Professional Documents
Culture Documents
BRAIN TUMOR
48 Hour Cram
Sheets for Med Surg
Page 1 of 106
Table of Contents
1.
2.
3.
4.
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6.
7.
RESPIRATORY ................................................................................................................................. 60
ASTHMA ............................................................................................................................................. 60
BRONCHITIS ....................................................................................................................................... 61
COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE) ................................................................... 62
EMPHYSEMA ...................................................................................................................................... 63
HEMOTHORAX ................................................................................................................................... 64
PNEUMOTHORAX............................................................................................................................... 65
PNEUMONIA ...................................................................................................................................... 66
PULMONARY EMBOLISM ................................................................................................................... 67
RESPIRATORY FAILURE ....................................................................................................................... 68
TUBERCULOSIS ................................................................................................................................... 69
URI (UPPER RESPIRATORY INFECTION) ............................................................................................. 70
8.
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ENDOCRINE .................................................................................................................................... 81
DIABETES TYPE I ................................................................................................................................. 81
DIABETES TYPE II ................................................................................................................................ 82
HYPOGLYCEMIA ................................................................................................................................. 83
HYPERGLYCEMIA ................................................................................................................................ 84
DIABETIC KETOACIDOSIS (DKA).......................................................................................................... 86
10.
APPENDICITIS ..................................................................................................................................... 87
CHOLECYSTITIS ................................................................................................................................... 88
HEPATITIS ........................................................................................................................................... 89
PANCREATITIS .................................................................................................................................... 90
CIRRHOSIS .......................................................................................................................................... 91
11.
KIDNEY (RENAL).......................................................................................................................... 93
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Mike Linares
Student Nurse Mentor & Certified EKG Instructor
Before Helping Hundreds of Struggling Nursing Students Reach Graduation Day & Before Becoming a
Student Nurse Mentor & Certified EKG Instructor, I Myself Was A Struggling "At Risk" Student Nurse
Drowning In My Books & Lost In Clinical.
I was that struggling student working full time in the Emergency Room at one of those
MEGA hospitals in Orange, California. I worked as an EMT aka a "medic" for 8 years
prior to failing out. I knew how to take care patients, I knew the basics of the ABCs of
basic life support, I knew how to take vital signs and how to fix minor injuries. I thought I
had enough experience to skate right through nursing school, I remember thinking "how
hard can it be" right?
After two semesters, I FAILED out of the Program.
I felt defeated, depressed and like a loser. It was one of the lowest points of my life.
Sitting in my room practically bawling my eyes out, I remember quotes my mom and
dad used to encourage me with, "son, whatever doesnt kill you, Makes you Stronger" &
" Failing is Not a Bad Thing, As long as learn, become better, and NEVER EVER QUIT"
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Then over the next few semesters I tracked, tested, and tweaked each system until my students were
passing with a 82% or better on each and every test, 2 students being out of School for over 25 years
& coming back to score 94% on their EKG cardiac test! Truly amazing & truly making me proud to be
their mentor.
Page 6 of 106
1. CANCER (ONCOLOGY)
DIAGNOSIS/PATHO
BRAIN TUMOR
Patho: Defined as an intracranial solid
neoplasm, or an abnormal growth of
cells in brain or central spinal canal. No
known cause or risk factor.
Graded as: low, intermediate or high
Can be located in several areas of the
brain:
DATA
ACTION
Nursing Interventions:
Pharm: **DEPENDS ON
SIZE & TYPE OF TUMOR, AS
WELL AS OVERALL HEALTH
STATUS:
- Chemotherapy
Targeted therapy:
-Avastin/bevacizumab (for
glioblastoma)
- Afinitor/everolimus (used
to treat a benign brain tumor)
Alternative Medicine:
-Acupuncture
-Hypnosis
-Music Therapy
-Relaxation Techniques
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RESPONSE
Nursing Dx:
-Disturbed Body Image r/t
changes in the structure and
function of the brain/body
-Fear r/t recent diagnosis and
unknown future
Pt. Goals/ Evaluation:
-Pt will verbalize concerns and
fears about body, self
perception and change of
lifestyle
-Pt will verbalize anxiety as well
as ways to reduce it/minimize
with it.
COLON CANCER
Patho: Colon cancer occurs in the
lower part of the digestive system.
Cancer in the colon can begin as small
benign clumps in the colon, known as
adenomatous polyps.
In time, these polyps can develop into
colon cancer.
Page 8 of 106
Nursing Interventions:
Pharm: Chemotherapy,
Radiation therapy, and
Targeted drug therapy
(bevacizumab/Avastin,
cetuximab/ Erbitux,
panitumumab/Vectibix and
regorafenib/Stivarga)
Pt. Ed: Maintenance of
Colostomy bag/care if
needed, returning for
testing, side effects of
meds/ colostomy bag,
support system
Surgery: Removal of
polyps (If possible), Partial
Colostomy, Full
colostomy/surgical removal
Nursing Dx:
-Anticipated loss of
physiological well-being r/t loss
of body part, change in body
function, change in lifestyle and
perceived potential death of
patient
-Situational low self-esteem r/t
disfiguring surgery,
chemotherapy or radiotherapy
side effects, e.g., loss of hair,
nausea/vomiting, weight loss,
anorexia, impotence, sterility,
overwhelming fatigue,
uncontrolled pain
Pt. Goals/ Evaluation:
-Pt will continue daily activities,
identify feelings and fears
towards lifestyle change and
diagnosis, Pt will understand
and verbalize the grieving and
death process
- Pt will verbalize acceptance of
diagnosis, control over health
Nursing Interventions:
(**Depends on type of
Leukemia, severity and Age
of Patient)
Pharm: Chemotherapy,
Radiation, Biological
therapy, Targeted Therapy
(Imatinib/Gleevec &
dasatinib/ Sprycel), Stem
Cell Transplant
Pt. Ed: DONT WAIT TO
GET TREATMENT! TIMING
IS IMPORTANT! Know the
side effects of medication
as well as supportive
measures:
- Vaccines
- Blood/Platelet
Transfusions
Page 9 of 106
Nursing Dx:
- Pain r/t enlarged organs/
lymph nodes and treatment for
diagnosis
-Risk for infection r/t
compromised immune system
Pt. Goals/ Evaluation:
- Pt will report pain at tolerable
level and verbalize ways to
manage it
- Pt will identify signs and
symptoms of infection and
verbalize ways to minimize
chances of infection
T Thickening/lumps in
breast/body
I Indigestion/Difficulty swallowing
O Obvious change in wart/mole
N - Nagging, coughing or
hoarseness
- Antibiotics
- Analgesics for Pain
- Immunoglobulins
- Red & White cell growth
factors
Surgery: Removal of
spleen (if inflamed)
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OVARIAN CANCER
Patho: Cancer of the ovaries:
Assess:
Assess for menstrual
cycle/ovulation history of patient
and family
Most At Risk:
-Staring period at young age
-Ending period (Menopause) at
older age
-Never been pregnant (nulliparity)
-Frequent cycles
**10% are genetic and can be
tested for BRCA1 and BRCA2 gene
changes (mutations)
Nursing Interventions:
Pharm: Chemotherapy
(carboplatin and paclitaxel)
Pt. Ed: Educate patient on
side effects of
chemotherapy, changes in
hormone levels due to
diagnosis and possible
hormonal side effects, as
well as ways to prevent
infection as patient will be
immunocompromised.
Surgery: Surgical
Debulking, where the
abdomen is cleared of all
masses, with NONE over
the size of 1 cm. Removal
of Ovaries/Fallopian tubes
(Salpingo-oophorectomy),
removal of uterus
(hysterectomy) or
omentum (omenectomy)
and Lymph node dissection
may be needed based on
Page 11 of 106
Nursing Dx:
- Pain r/t enlarged organs/
lymph nodes and treatment for
diagnosis
-Risk for infection r/t
compromised immune system
Pt. Goals/ Evaluation:
- Pt will report pain at tolerable
level and verbalize ways to
manage
- Pt will identify signs and
symptoms of infection and
verbalize ways to minimize
chances of infection
N - Nagging, coughing or
hoarseness
PROSTATE CANCER
Patho:
Cancer of the prostate gland:
Page 12 of 106
Assess:
Assess for Risk Factors: Pt/Family hx
of BPH and prostate cancer, MEN
OVER 40, African American, Obese
The American Cancer Society 7
WARNING SIGNS for Cancer:
C Change in bowel/bladder habits
A A sore that that doesnt heal
U Unusual Bleeding/Discharge
T Thickening/lumps in
breast/body
I Indigestion/Difficulty swallowing
O Obvious change in wart/mole
N - Nagging, coughing or
hoarseness
Vitals: Normal unless distressed
Nursing Interventions:
Pharm: Chemotherapy,
Biological therapy,
Hormone therapy:
Luteinizing Hormone
Release Hormone/LH-RH
(To Stop the release of
testosterone, such as
LUPRON, TRELSTAR,
ZOLIDEX)
Pt. Ed: Encourage
medication compliance, as
well as the importance of
check-ups/colonoscopy as
recommended by doctor.
Inform patient of side
effects of prostate cancer,
Nursing Dx:
-Altered urinary elimination r/t
enlarged prostate and bladder
distension
-Risk for infection r/t surgical
procedure/immunocompromise
Pt. Goals/ Evaluation:
-Patient will maintain effective
voiding measures within limits
of his/her condition
- Pt will identify signs and
symptoms of infection and
verbalize ways to minimize
chances of infection
PANCREATIC CANCER
Patho:
Cancer of the Pancreas, NO KNOWN
CAUSE!
including ERECTILE
DYSFUNCTION, and
encourage them to utilize
support system/
affection/coping skills.
Refer to support group.
Also ambulation and
catheter care after surgery.
Assess:
Assess for Risk Factors:
- Chronic pancreatitis
- Personal or family history of
pancreatic cancer
- Smoking/Excessive drinking
- Obese
- Diabetes
- African-American
- Family history of genetics that
can increase cancer risk
Nursing Interventions:
**THIS CANCER IS
USUALLY DIAGNOSED AT
VERY LATE STAGES DUE TO
ITS ASYMPTOMATIC
NATURE
Pharm: Analgesics for
pain, Chemotherapy,
Targeted therapy,
Radiation therapy
Page 13 of 106
Nursing Dx:
-Fear r/t recent diagnosis and
unknown future
-Risk for infection r/t surgical
procedure/immunocompromise
Pt. Goals/ Evaluation:
-Pt will verbalize anxiety as well
as ways to reduce it/minimize
with it.
- Pt will identify signs and
symptoms of infection and
verbalize ways to minimize
chances of infection
I Indigestion/Difficulty swallowing
O Obvious change in wart/mole
N - Nagging, coughing or
hoarseness
(duodenum), gallbladder
and part of your bile duct.
Part of stomach may be
removed in addition. The
remaining parts of your
pancreas are reconnected
to the Patients stomach
and intestines to allow the
digestion of food.
-Also, removal of cancer on
tail of Pancreas if possible
Page 14 of 106
2. NEURO: CNS
DIAGNOSIS/PATHO
ALZHEIMERS
Patho: The most common cause of
Dementia in older adults. This disease is
progressive and is marked by impaired
memory and thinking skills. The classic
neuropathology findings in AD include
amyloid plaques, neurofibrillary tangles,
and synaptic and neuronal cell death.
DATA
ACTION
Nursing Interventions:
Pharm:
Cholinesterase Inhibitors:
-Donepezil
-Galantamine
NMDA Antagonist:
-Memantine
Selective Serotonin Reuptake
Inhibitors (SSRIs):
-Citalopram
-Paroxetine
Anti-Anxiety Meds:
-Lorazepam
- Oxazepam
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RESPONSE
Nursing Dx:
-Altered urinary
and bowel
elimination r/t
cognitive
impairment and
loss of muscle
tone
- Self-care deficit
r/t cognitive
impairment and
physical
limitations
Pt. Goals/
Evaluation:
-Pt will identify
need to
urinate/defecate
and/or understand
the need for
assistance with
these activities
-Pt will identify
need to
urinate/defecate
and/or understand
the need for
Page 16 of 106
assistance with
these activities
BRAIN TUMORS
Patho: Brain tumors may be classified
into several groups: those arising from the
coverings of the brain (e.g., Dural
meningioma), those developing in or on
the cranial nerves (e.g., acoustic
neuroma),
Those originating with in brain tissue and
metastatic lesions originating elsewhere in
the body. Tumors of the pituitary and
pineal glands and of cerebral blood vessels
are also types of brain tumors. Relevant
clinical considerations include the location
and the histology character of the tumor.
Tumors may be benign or malignant. A
benign tumor CAN BE SERIOUS!! If occurs
in a vital area and can grow large enough
to have effects as serious as those of a
malignant tumor.
Nursing Interventions:
Pharm: (Depends on size and
location of the tumor)
Radiation Therapy,
Chemotherapy, Medications to
reduce ICP (Mannitol), Anticonvulsants, Analgesics
(**All prn, depending on
situation)
Pt. Ed: Caregiver information
about assistance with ADLs,
keeping up with check-ups,
options of care/symptom relief,
support groups,
communication with medical
personnel and sources
Surgery: Surgery if possible to
remove tumor (Depends on
size, location and degree of
damage if removed)
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Nursing Dx:
-Acute pain r/t
tumor and
increased
intercranial
pressure
-Anxiety r/t
unknown future
after surgery,
cognitive
impairment and
health issues.
Pt. Goals/
Evaluation:
-Pt will verbalize
pain level using
numeric chart or
FACES chart, as
well as ways to
reduce/treat pain
-Pt will verbalize
anxiety as well as
ways to reduce
it/minimize with it.
CEREBERAL VASCULAR
ACCIDENT (CVA)
Patho: *Commonly referred to as
Stroke or Brain attack. In a stroke, the
sudden interruption of blood supply to
areas of the brain results in cerebral
necrosis and impaired cerebral
metabolism, which permanently damages
brain tissues and produces focal
neurologic deficit of varying severity. A
cerebral aneurysm is prone to rupture,
which causes blood to leak into the subarachnoid space (and sometimes into
brain tissue, where it forms a clot),
resulting in increased intracranial pressure
(ICP) and brain tissue damage
-In a TIA, there is a temporary decrease in
blood flow to a specific region of the
brain, but there is no necrosis of brain
tissue. The symptoms (lasting seconds to
hours) produce transient neurologic
deficits that completely clear within 12 to
24 hours.
Page 18 of 106
Nursing Interventions:
Pharm: (Depends on type/
cause)
-Aspirin
-TPA (Clot Buster): Given
within first 3-4.5 hours as
indicated. ***TPA
CONTRAINDICATIONS
Intercranial hemorrhage,
internal bleeding, recent
trauma/surgery in last 3 mos.,
uncontrolled hypertension
-Anticoagulants/Anti-platelets
Pt. Ed: Watch for signs of
bleeding/hemorrhage/Stroke,
blood tests as requested,
control Hypertension &
diabetes, maintain diet low in
saturated fat, and exercise as
advised. QUIT SMOKING! Drink
moderately/stop drinking. If
trouble communicating, utilize
props/tools, If physical
ailments, utilize tools to assist
in mobility, join a support
group/obtain emotional
support.
Surgery:
FOR CLOTS:
Mechanical removal of clot,
Carotid endarterectomy
FOR HEMHORRAGING:
-Coiling
Nursing Dx:
-Ineffective
Cerebral Tissue
Perfusion
-Impaired physical
mobility r/t
neuromuscular
involvement:
cognitive
impairment,
perceptual
impairment,
paresthesia,
weakness
Pt. Goals/
Evaluation:
-Pt will maintain
improved/usual
cognition, LOC and
motor/sensory
function
-Pt will
maintain/increase
function, of
affected body part
or compensatory
body part
-Surgical Clipping
-Surgical AVM removal
-Intracranial bypass
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EPILEPSY
Patho: A disorder involving abnormal,
sudden discharge of electrical activity in
the brain. Epilepsy is not a singular
disease, but is heterogeneous in terms of
clinical expression, underlying etiologies,
and pathophysiology . As such, specific
mechanisms and pathways underlying
specific seizure types may vary. Epileptic
seizures are broadly classified according to
their site of origin and pattern of spread.
Nursing Interventions:
Pharm: Dilantin,
Phenobarbital, Tegretol,
Depakote, Valium, Klonopin,
Pt. Ed: Adherence to
medication regimen as well as
contra-indications and side
effects!
Surgery: Removal of anterior
temporal lobe (For partial
epilepsy/seizures), Usually in
children: hemispherectomy,
corpus callosotomy (separating
of nerve fibers that connect the
two sides of the brain)
Emotional:
o Fear/Panic
o Pleasant feeling
Physical:
o Chewing movements
o Convulsion
o Difficulty talking/Drooling
o Eyelid fluttering/rolling
o Falling down
o Foot stomping
o Hand waving
o Inability to move
o Incontinence
o Lip smacking/Making sounds
o Shaking
Page 20 of 106
Nursing Dx:
-Low self-esteem
r/t social role
changes, loss of
control and stigma
associated with
disease
-Risk for
Trauma/Suffocatio
n r/t loss of
consciousness,
coordination,
weakness and
reduced
muscle/sensation
Pt. Goals/
Evaluation:
-Pt will verbalize
concerns and fears
about body, self
perception and
change of lifestyle
-Pt will verbalize
understanding of
factors that
contribute to
trauma during a
seizure, pt will be
aware of seizure
precautions that
should be utilized,
especially by
o Staring
o Stiffening
o Swallowing
o Sweating
o Teeth clenching/grinding
o Tongue biting
o Twitching movements
o Breathing difficulty
o Tachycardia
o Bruising
o Difficulty talking
o Injuries
o Sleeping
o Exhaustion
o Headache
o Nausea
o Pain
o Thirst
o Weakness
o Urge to urinate/defecate
caretaker, family
or friend
Page 21 of 106
"drop attacks"
FOCAL SEIZURES
1. Simple Focal Seizure: During these
seizures, you remain conscious although
some people can't speak or move until the
seizure is over. Uncontrolled movements,
such as jerking or stiffening, can occur
throughout your body. You also may
experience emotions such as fear or rage
or even joy; or odd sensations, such as
ringing sounds or strange smells.
2. Complex Focal Seizure: During these
seizures, you are not fully conscious and
may
appear to be in a dreamlike state. Typically,
they start with a blank stare. You may
involuntarily chew, walk, fidget, or perform
other repetitive movements or simple
actions, but actions are typically
unorganized or confused
3. Secondarily Generalized Seizure:
These seizures begin as a focal seizure and
develop
Into generalized ones as the electrical
abnormality spreads throughout the brain.
When the seizure begins, you may be fully
conscious but then lose consciousness and
Experience convulsions as it develops.
Page 22 of 106
HEAD INJURY
Patho: brain injuries can be classified
as traumatic or acquired, with additional
types under each heading. All brain injuries
are described as either mild, moderate, or
severe.
Traumatic Brain Injury
Traumatic brain injury is a result of an
external force to the brain that results in a
change to cognitive, physical, or emotional
functioning. The impairments can be
temporary or permanent
Acquired Brain Injury
An acquired brain injury is an injury to the
brain that is not hereditary, congenital,
degenerative, or the result of birth trauma.
Acquired brain injury generally affects cells
throughout the entire brain.
Nursing Interventions:
Pharm: Analgesics, Mannitol,
Lasix, barbiturates,
corticosteroids
Pt. Ed: Inform patient of signs
and symptoms of ICP, confirm
understanding of treatment
regimen including medication,
drains, etc. Communicate with
family for signs of worsening
condition and allow them to
voice concerns.
Surgery: To relieve excessive
fluid/ICP (May install a drain),
Bone Flap removed to relieve
pressure, Removal of
hematoma
Page 23 of 106
Nursing Dx:
-Ineffective
Cerebral Tissue
Perfusion
-Impaired physical
mobility r/t
neuromuscular
involvement:
cognitive
impairment,
perceptual
impairment,
paresthesia,
weakness
Pt. Goals/
Evaluation:
-Pt will maintain
improved/usual
cognition, LOC and
motor/sensory
function
-Pt will
maintain/increase
function, of
affected body part
or compensatory
body part
C. Rebound/Contrecoup Injury:
Rebound of cranial contents an
cause an injury of the head on the
OPPOSITE side of injury. Also
known as contrecoup injury
Page 24 of 106
Nursing Interventions:
Pharm:
-Immuno-suppressants to
reduce exacerbation: (Avonex
IM weekly), Betaseron
(Subcut), Copaxone (Subcut)
-For muscle spasicity/tremors:
Neurontin, Baclofen,
Clonazapam
-For Urinary Problems:
Ditropan, Detrol
-For sexual Dysfunction: Viagra
-Depression: Zoloft. Prozac
-Fatigue: Provigil, Symmetrel
Pt. Ed:
1. Self-Injection techniques
2. Promote independence
Visual disturbances
3. Self-Catheterization
Nausea/Vomiting
4. Promote exercise daily, with
Urinary retention or urinary incontinence fall precautions
5. Injury Prevention
Dysphagia (difficulty in swallowing)
6. Stress reduction and immune
Ataxia (decreased coordination)
support to avoid infection
Labs: CSF Analysis
Hyper-emotions as well as euphoria
Nursing Dx
-Impaired physical
mobility r/t
neuromuscular
involvement:
cognitive
impairment,
perceptual
impairment,
parasthesia,
weakness
-Ineffective
individual coping
r/t uncertainty of
course of MS
Pt. Goals/
Evaluation:
-Pt will maintain/
increase function,
of affected body
part or
compensatory
body part
MENINGITIS
Patho: Meningitis is the inflammation of
the protective membranes covering the
central
nervous, known collectively as the
meninges.
Meningitis can be caused from a direct
spread of a severe infection such as an ear
infection or sinus infection. In some cases,
meningitis is noted after head trauma or
an injury to the head or brain. There are
several causes of meningitis: Bacterial
Nursing Interventions:
Pharm: IV Antibiotics
(Rifampin/Vancomycin)
Pt. Ed: Sit patient in
comfortable position with
adequate neck support, reduce
environmental stimuli/stress,
monitor hydration, antibiotics,
seizure precautions
Surgery: N/A
Page 25 of 106
Nursing Dx:
-Pain r/t acute
condition
- Risk for infection
transmission r/t
contagious nature
of organism
Pt. Goals/
Evaluation:
-Pt will verbalize
pain level using
numeric chart or
FACES chart, as
well as ways to
reduce/treat pain
-Initiate infection
precautions and
antibiotic therapy
as ordered
PARKINSONS
Patho: Parkinsons disease is a slowly
Nursing Interventions:
Pharm: Depends on
age/severity:
- Carbidopa/Levodopa
therapy
- Dopamine Agonists
- Anticholinergics
- MAO-B Inhibitors
- COMT Inhibitors
Pt. Ed: Assistance with ADLs,
Caretaker info, important
information regarding the
disease and depression,
Surgery: None at this time
Page 26 of 106
Nursing Dx:
-Impaired physical
mobility r/t
neuromuscular
involvement:
tremors, muscle
rigidity, weakness
-Self care deficit
r/t neuromuscular
weakness,
decreased
strength and loss
of muscle control/
coordination,
cognitive changes
& postural
changes
Pt. Goals/
Evaluation:
-Pt will maintain/
increase function,
of affected body
part or
compensatory
body part
-Pt and caretaker
will verbalize
understanding of
physical, cognitive
and emotional
limitations due to
diagnosis
SEIZURE
Patho: A disorder involving abnormal,
sudden discharge of electrical activity in
the brain. Epilepsy is not a singular
disease, but is heterogeneous in terms of
clinical expression, underlying etiologies,
and pathophysiology. As such, specific
mechanisms and pathways underlying
specific seizure types may vary. Epileptic
seizures are broadly classified according to
their site of origin and pattern of spread.
Nursing Interventions:
Pharm: Dilantin,
Phenobarbital, Tegretol,
Depakote, Valium, Klonopin,
Pt. Ed: Adherence to
medication regimen as well as
contra-indications and side
effects!
Surgery: Removal of anterior
temporal lobe (For partial
epilepsy/seizures), Usually in
children: hemispherectomy,
corpus callosotomy (separating
of nerve fibers that connect the
two sides of the brain)
Nursing Dx:
-Low self-esteem
r/t social role
changes, loss of
control and stigma
associated with
disease
-Risk for Trauma/
Suffocation r/t loss
of consciousness,
coordination,
weakness and
reduced
muscle/sensation
Pt. Goals/
Evaluation:
Page 27 of 106
Page 28 of 106
Physical:
o Chewing movements
o Convulsion
o Difficulty talking/Drooling
o Eyelid fluttering/rolling
o Falling down
o Foot stomping
o Hand waving
o Inability to move
o Incontinence
o Lip smacking/Making sounds
o Shaking
o Staring
o Stiffening
o Swallowing
o Sweating
o Teeth clenching/grinding
o Tongue biting
o Twitching movements
o Breathing difficulty
o Tachycardia
o Bruising
o Difficulty talking
o Injuries
o Sleeping
o Exhaustion
o Headache
o Nausea
o Pain
o Thirst
o Weakness
o Urge to urinate/defecate
"drop attacks"
FOCAL SEIZURES
1. Simple Focal Seizure: During these
seizures, you remain conscious although
some people can't speak or move until the
seizure is over. Uncontrolled movements,
such as jerking or stiffening, can occur
throughout your body. You also may
experience emotions such as fear or rage
or even joy; or odd sensations, such as
ringing sounds or strange smells.
Page 29 of 106
SPINAL INJURY
Patho: Spinal cord injuries cause myelopathy or damage to white matter or
myelinated fiber tracts that carry signals to
and from the brain. It also damages gray
matter in the central part of the spine,
causing segmental losses of interneurons
and motorneurons. Spinal cord injury can
occur from many causes, including:
-Trauma such as automobile crashes, falls,
gunshots, diving accidents, war injuries,
etc.
-Tumors such as right, ependymomas,
astrocytomas, and metastatic cancer.
-Ischemia resulting from occlusion of
spinal blood vessels, including dissecting
aortic aneurysms, emboli, arteriosclerosis.
Page 30 of 106
Nursing Interventions:
Pharm: None at this time to
TREAT, but
methylprednisolone/Solumedr
ol may be given as medication
to treat ACUTE spinal injury
Pt. Ed: Assistance with ADLs
as needed, PT to become
adjusted to
wheelchair/prosthesis,
Psychological care to deal with
mental aspect of the loss,
catheter care as needed,
avoiding pressure ulcers/self
care
Nursing Dx:
-Impaired physical
mobility r/t
neuromuscular
involvement:
sensory/
perceptual
impairment,
parasthesia,
weakness
-Low self-esteem
r/t social role
changes, loss of
control and recent
diagnosis
Labs: N/A
Dx Tests: CT Scan, MRI, X-Ray
Page 31 of 106
Pt. Goals/
Evaluation:
-Pt will maintain
function, of
unaffected body
parts or
compensatory
body parts as well
as correctly
utilizing support
and assistive
devices
-Pt will verbalize
concerns and fears
about body, self
perception and
change of lifestyle
3. NEURO: PNS
DIAGNOSIS/PATHO
GUILLAIN-BAR SYNDROME
DATA
Patho: Guillain-Barr syndrome is the result of a cellmediated and humoral immune attack on peripheral
nerve myelin proteins that causes inflammatory
demyelination. With the autoimmune attack, there is an
influx of macrophages and other immune-mediated
agents that attack myelin, cause inflammation and leave
the axon unable to support nerve conduction
Other Symptoms:
-Dyskinesia (inability to
executive involuntary
movements)
-Weakness usually begins in
the legs and progress upward
(ascending paralysis)
-Hyporeflexia (decreased
DTRs)
-Paresthesia (numbness),
clumsiness
-Blindness
-Inability to swallow
(dysphagia) or clear secretions
Page 32 of 106
ACTION
RESPONSE
Nursing Interventions:
Pharm: Plasmapheresis, IVIG
(IV Immunoglobulin),
Analgesics as needed
Pt. Ed: Healing/recovery time
may take up to 2 years.
Referral to PT, OT, RT & ST
(Speech therapy), educate
patient on strategies to
prevent
complications/immobility
Surgery: Laminectomy
(Remove portion of the
vertebrae) Diskectomy
(Removal of herniated disk),
Spinal Fusion (Fusion of
vertebrae via the spinal
process by using a bone graft)
Nursing Dx:
-Ineffective
breathing
pattern r/t
respiratory
muscle weakness
or paralysis,
decreased cough
reflex and
immobilization
-Impaired
physical mobility
r/t
neuromuscular
involvement:
cognitive
impairment,
perceptual
impairment,
paresthesia,
weakness
Pt. Goals/
Evaluation:
-Pt will maintain
patent airway,
demonstrate
effective
-Alternate
hypotension/hypertension Arrhythmias
Labs: Lumbar Puncture
Ganglioside Antibody tests
Dx Tests: MRI, Pulmonary
Function tests, Nerve
conduction test, EMG
(Electromyography)
MYASTHENIA GRAVIS
Patho: In myasthenia gravis, antibodies directed at the
acetylcholine receptor sites impair transmission of
impulses across the myoneural junction. Therefore, fewer
receptors are available for stimulation, resulting in
voluntary muscle weakness that escalates with continued
activity 80% of people with myasthenia gravis have
either thymic hyperplasia or a thymic tumor, and the
thymus gland is believed to be the site of antibody
production
breathing
pattern and
show evidence
of adequate
oxygenation
-Pt will maintain/
increase
function, of
affected body
part or
compensatory
body part
Nursing Interventions:
Pharm: Anticholinesterase
medications (Atropine is the
antidote), Pyridostimine,
IMMUNOSUPPRESANTS:
Prednisone, Azathioprine (A
cytotoxic med),
Plasmapheresis, IVIG (IV
Immunoglobulin), Analgesics
as needed
Pt. Ed: Importance
medication compliance,
Aspiration precautions
Watch amount and
consistency of food as well
scheduling feedings during
peak times of medication
effect. Grouping ADLs and
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Nursing Dx:
-Impaired gas
exchange, r/t
ineffective
breathing
pattern and
muscle weakness
-Risk for
aspiration r/t
difficulty
swallowing
Pt. Goals/
Evaluation:
-Pt will maintain
patent airway,
demonstrate
effective
-Double vision
-Mask like facial expression
-Weakened laryngeal muscles
leads to dysphagia (difficulty
of swallowing, without food)
-Hoarseness of voice
-Respiratory muscle weakness
leads to respiratory arrest
-Extreme muscle weakness
especially during activity or
exertion in AM
Page 34 of 106
breathing
pattern and
show evidence
of adequate
oxygenation
-No aspiration
will occur.
Patient and
patients family
will verbalize
understanding of
aspiration risk
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Page 36 of 106
DATA
ACTION
RESPONSE
Nursing Interventions:
Pharm: PAIN MANAGEMENT
& ANTIBIOTICS UNTIL
SURGERY!! Continue after
surgery as well. Possibly blood if
lost in surgery.
Pt. Ed: Avoid applying heat to
the area, Monitor for
signs/symptoms of infection,
mobility after surgery
Surgery: APPENDECTOMY!
**Must remove before
appendix perforation CAN
CAUSE SEPTIC SHOCK!! Patient
will notice a Sudden relief of
pain which is a BAD SIGN!!
Abdomen will become rigid,
fever will SPIKE!
Nursing Dx:
-Acute pain r/t inflammation
of tissues
-Risk for infection r/t
Inadequate primary
defenses/surgery/perforation
of tissues
Vitals: TEMP
S/S & PHYS. EXAM: Aching
pain that begins around your
navel and often shifts to your
lower right abdomen. The pain
occurs when you apply pressure
to your lower right abdomen
THEN, release the pressure on
that area. When released, the
Pt. will feel A LOT of pain!!
(REBOUND TENDERNESS!!) Pain
that worsens if you cough, walk
Nursing Interventions:
Pharm: Stool Softener,
STIMULANT Laxative
Pt. Ed: eat foods high in fiber,
drink lots of liquids
Surgery: Laparoscopy, or
Surgical Removal (For complete
strangulation)
Nursing Dx:
-Deficient Fluid
Volume related to
nausea/vomiting, fever or
diaphoresis
-Acute Pain related to
intestinal blockage, distention
and rigidity
Pt. Goals/ Evaluation:
-Pt will demonstrate normal
vital signs, balanced input and
output
- Pt will report pain at
tolerable level and verbalize
ways to manage it
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CONSTIPATION
Patho:
Constipation, costiveness, or
irregularity, is a condition of the
digestive system in which a person
experiences hard feces that are difficult
to expel. This usually happens because
the colon absorbs too much water from
the food. If the food moves through the
gastro-intestinal tract too slowly, the
colon may absorb too
much water, resulting in feces that are
dry and hard. Defecation may be
extremely painful, and in severe cases
(fecal impaction) lead to symptoms of
bowel obstruction
Causes of constipation:
-Diet
-Hormones
-Anatomical a side effect of medications
(Opiates/Narcotics)
-An illness or disorder
Page 38 of 106
Nursing Interventions:
Pharm: Stool softeners,
Laxatives
Pt. Ed: Stick to diet high in
fiber, Know/PREVENT CAUSES:
-Anal fissure
-Bowel Obstruction
-Colon Cancer
-Bowel Stricture (Narrowing of
Colon)
-Abdominal/Rectal Cancer
Surgery: Bowel obstruction
removal if needed
Nursing Dx:
-Altered bowel elimination r/t
low-fiber diet/inactivity
-Alteration in Nutrition: Less
Than Body
Requirements related to loss
of appetite/pain
Pt. Goals/ Evaluation:
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
-Pt will report desire to eat,
achieves an adequate
Nutritional intake, Avoidance
of irritating foods, increased
awareness of dietary
management and relief of
pain.
HERNIA
Patho: When part of an internal organ
bulges through a weak area of muscle.
There are several types of hernias,
including:
Nursing Interventions:
Pharm: Analgesics for pain,
stool softeners
Pt. Ed: Hernias are common.
They can affect men, women
and children. A combination of
muscle weakness and straining,
such as with heavy lifting, might
contribute. Some people are
born with weak abdominal
muscles and may be more likely
to get a hernia.
Surgery: Surgical repair of
hernia a.k.a. Minimally Invasive
Inguinal Hernia Repair (MIIHR),
Herniorraphy laparoscopic
repair
Page 39 of 106
Nursing Dx:
-Pain r/t abdominal swelling
and pressure
-Risk for infection r/t
abdominal mass/obstruction
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and verbalize
ways to manage it
-The patient will remain free
from signs or symptoms of
infection
-Pressure in abdomen
Labs: WBCs
Dx Tests: Barium Swallow w/
Flouroscopy, X-RAY, Physical
exam
PARALYTIC ILEUS
Patho: Paralytic ileus is the occurrence
of intestinal blockage in the absence of
an actual physical obstruction. This type
of blockage is caused by a malfunction in
the nerves and muscles in the intestineimpairing digestive movement. Causes
include: Electrolyte imbalances,
gastroenteritis, appendicitis,
pancreatitis, surgical complications, and
obstruction of the mesenteric artery,
which supplies blood to the abdomen.
Certain drugs and medications, such as
opioids/sedatives, can cause ileus by
slowing peristalsis (contractions that
propel food through the
digestive tract)
Page 40 of 106
Nursing Interventions:
Pharm/TX: NG Tube w/
Continuous suction, Fluid and
Electrolyte replacement,
Pt. Ed: Avoid opiods and
anticholingergics.
Common causes of Paralytic
Ileus:
-Appendicitis
-Botulism
-Certain medications, such as
opiates/ sedatives
-Diabetic ketoacidosis (DKA)
-Electrolyte imbalance
-Gastroenteritis
-Neonatal necrotizing
enterocolitis (disease that
causes death of intestinal tissue
in newborns)
Nursing Dx:
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
-Risk for shock r/t lack of body
fluid volume
Pt. Goals/ Evaluation:
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
-Pt will exhibit stable vital
signs, consistently stable
input and output, as well as
satisfactory fluid and
nutritional intake to meet the
patients specific needs and
avoid shock
ISCHEMIC BOWEL/COLITIS
Patho: Ischemia occurs secondary to
hypo-perfusion of an intestinal
segment. When hypo-perfusion occurs,
collateral blood flow may preclude or
minimize ischemia; however, the regions
of the intestine with a solitary arterial
supply, and the watershed areas, are
both at increased risk of developing
ischemia. The degree of intestinal injury
is dependent on the duration and
severity of ischemia.
-In turn, Ischemia can cause Acute or
sub-acute mucosal sloughing and
ulcerations. The loss of the mucosal
barrier allows for bacterial translocation
and toxin absorption. Re-perfusion injury
can also occur if blood supply is reestablished after a prolonged
interruption. Segments of bowel which
do not cause acute necrosis or
perforation can heal with stenosis or
stricture. These can cause ischemic
bowel disease with long-term effects
Page 41 of 106
Nursing Dx:
-Risk for shock r/t inadequate
tissue perfusion
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
VOLVULUS
Patho: A volvulus is a bowel
obstruction with a loop of bowel that has
abnormally twisted on itself
Page 42 of 106
o Rectal bleeding
o Red stools
o Maroon stools
o Constipation
o Indigestion
o Diarrhea
o Nausea/Vomiting
o Anorexia
Labs: WBC, Blood in GI Tract
Dx Tests: Cinical Assessment,
Endoscopy, Angiogram, Doppler
Ultrasound or CT Scan of
Abdomen
Assess: Auscultate for highpitched bowel sounds, rushing
sounds or absence of bowel
sounds
Vitals: BP, HR, TEMP
(Signs of infection/Shock)
S/S & PHYS. EXAM:
-Severe abdominal pain
-Nausea
-Vomiting (A lot of Bile)
-Bloody Stools
-Abdominal Distension
-Palpable Mass
Nursing Interventions:
Pharm: Analgesics for pain,
antibiotics for infection, IV Fluid
replacement to facilitate
perfusion and prevent shock
Pt. Ed:
-Smaller feedings are
recommended, because large
quantities of food overload the
stomach and promote gastric
reflux.
-Encourage to eat slowly and
to chew all food thoroughly so
that it can pass easily into the
stomach
Nursing Dx:
-Ineffective breathing pattern
r/t abdominal distension
interfering with normal lung
expansion
-Ineffective tissue perfusion:
GI r/t bowel obstruction
Pt. Goals/ Evaluation:
-Pt will exhibit normal
breathing pattern, effective
depth, and report little to
know difficulty breathing as
well as Sp02 within normal
limits for patient
-Pt will exhibit stable vital
signs, consistently stable
input and output, as well as
satisfactory fluid and
nutritional intake to meet the
DIVERTICUITIS
Nursing Interventions:
Pharm: Analgesics/Pain
Management, Bulk Laxatives,
Stimulant Laxatives, Saline
Laxatives, Stool softeners,
Antibiotics such as
Metronidazole (FLAGYL),
Antisposmodics
Pt. Ed:
Risk Factors for Dicerticula:
Low-fiber diet
Chronic constipation
Obesity
Risk Factors for Diverticulitis:
Bacteria / food trapped in
diverticula
Infection/Inflammation
Most common site for
diverticulitis is the Sigmoid
colon, because of fecal masses
that irritate and increase
pressure in the colon.
Page 43 of 106
Nursing Dx:
-Pain r/t inflamed bowel and
possible peritonitis
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and verbalize
ways to manage it
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
RESECTION OF INTESTINES
Page 44 of 106
Nursing Interventions:
Pharm: Enema, Antibiotics,
Analgesics for pain, IV Fluids,
Anesthesia
Pt. Ed: BOWEL PREP!!
If you have laparoscopic
surgery:
-You will have 3 - 5 small cuts in
your lower belly. The surgeon
will pass a camera
and medical instruments
through these cuts
-You may also have a cut of
about 2 to 3 inches if your
surgeon needs to put a hand
inside your belly to feel the
intestine or remove the
diseased segment
-Your belly will be filled with gas
to expand it. This makes it easy
for the surgeon to see
and work
Nursing Dx:
-Pain r/t inflamed bowel and
possible peritonitis
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and verbalize
ways to manage it
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
-The patient will remain free
from signs or symptoms of
infection
Page 45 of 106
INFLAMMATORY BOWEL
DISEASE
Patho:
CROHNS!!
Ulcerative colitis
Is an inflammatory disease of the
submucosal layer of the colon and
rectum characterized by continuously
occurring ulcerations and shedding of
intestinal epithelium. Fat deposits and
muscular hypertrophy result in a narrow,
short, and thickened bowel.
COLORECTAL CANCER
Patho: Colorectal cancer is a disease in
which normal cells in the lining of the
colon or rectum begin to change, start to
grow uncontrollably, and no longer die.
These changes usually take years to
develop; however, in some cases of
hereditary disease, changes can occur
within months to years. Both genetic and
Page 46 of 106
Ulcerative colitis
Severe diarrhea containing
pus, blood and mucosa
Abdominal cramping and
tenderness, fever
Anorexia and weight loss
Usually occurs in the
descending colon and rectum
Labs: H&H, C-Reactive protein,
WBC,
Dx Tests: Abdominal X-Ray
Nursing Interventions:
Pharm: Anti-Diarrheals,
Aminosalicyates (5-ASAs),
Immune Modulators (Humira),
TPN, Corticosteroids,
Multivitamin and supplemental
Iron,
Pt. Ed: Refrain from foods that
can be irritating to the bowel!
Oral fluids,
Surgery: IF needed,
Proctolectomy with Ileostomy/
Colectomy with ileostomy
Nursing Dx:
-Pain r/t inflamed bowel
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
Nursing Interventions:
Pharm: Analgesics for pain
Pt. Ed: Dont miss your annual
checkups!! Use of colostomy
bag, avoid food that cause odor
and gas, Medical supply stores
locally to obtain bags/materials
Nursing Dx:
-Anticipatory grieving r/t
change in body function and
perceived potential death of
patient
- Disturbed body image r/t
loss of diseased body
part/loss of good health
Surgery: Colostomy
Page 47 of 106
5. ORTHOPEDICS (BONES)
DIAGNOSIS/PATHO
HIP FRACTURE
DATA
Page 48 of 106
Assess: For
Hemhorrage and
SHOCK!! **ALSO
ASSESS for distal
pulses to ensure
circulation! Observe
for signs of thrombophlebitis, report
immediately
Vitals: PAIN, BP,
HR,
S/S & PHYS. EXAM:
-Inability to move
immediately after a fall
-Severe pain in your
hip or groin
-Inability to put weight
on your leg on the side
of your injured hip
-Stiffness, bruising and
swelling in and around
your hip area
-Shorter leg on the side
of your injured hip
-Turning outward of
your leg on the side of
your injured hip
ACTION
Nursing Interventions:
Pharm: Analgesics for pain, Antibiotics
for surgery prep, FLUIDS/BLOOD as
necessary, ***
Pt. Ed: Instruct client regarding
fracture
healing process, diagnostic procedures,
treatment and its complications, home
care, daily activities, diet, restrictions
and follow-up. Encourage fluid intake
and high protein, high vitamin, highcalcium diet. Teach the client
appropriate crutch walking
techniques
RESPONSE
Nursing Dx:
-Pain r/t injury
-Risk for Shock r/t
blood loss/Injury
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Pt will show signs of
adequate tissue
perfusion including
stable vital signs and
fluid status
Assess: Assess
wound/surgical
incision for signs and
symptoms of infection
following surgery and
for signs of shock, for
pain, extreme
shortening, circulation/
neurovascular status
Vitals: PAIN, HR,
RR
S/S & PHYS. EXAM:
Signs/Symptoms of
whatever injury is
causing the need for
surgery! For Example
-Pain
-Inflammation
-Difficulty moving your
knee
-Popping/Clicking of
knee
-Joint Pain/Stiffness
Nursing Interventions:
Pharm: Anti-Coagulants,
NSAIDS/Analgesics for pain (Including
Morphine PCA)
Pt. Ed: The operation typically involves
substantial postoperative pain, and includes
vigorous physical rehabilitation. The recovery
period may be 6 weeks or longer and may
involve the use of mobility aids (e.g. walking
frames, canes, crutches) to enable the
patient's return to preoperative mobility. Use
of helpful items such as toilet seat extender,
Exercises to reduce risk of DVT
Page 49 of 106
Nursing Dx:
-Pain r/t surgical
procedure
-Impaired mobility r/t
injury/recent surgery
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Patient will show signs
and verbalize effective
ways to properly
mobilize using
tools/physical
assistance provided
-Lack of range of
motion
Page 50 of 106
Nursing Interventions:
Pharm: Analgesics for pain
Pt. Ed: Instruct client about restrictions
like not bending at waist or sitting with
Buck traction and not turning below the
waist with Russell traction. Encourage
client verbalize feelings and problems
regarding fracture.
Nursing Dx:
-Pain r/ injury
- Risk for peripheral
Neurovascular
dysfunction
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Pt will maintain
adequate tissue
perfusion AEB palpable
pulses, skin warm and
dry, normal sensation,
stable vital signs, and
adequate urinary
output for patient.
OSTEOARTHRITIS (OA)
Patho: The most common form of arthritis.
It causes the deterioration of the joint cartilage
and formation of reactive new bone at the
margins and subchondral areas of the joint. This
chronic degeneration results from a breakdown
of chondrocytes, most often in the hips and
knees. Osteoarthritis occurs equally in both
sexes after age 40.
The earliest symptoms appear in middle age
and progress with advancing age. Depending on
the site and severity of joint involvement,
Assess: For
contributing factors
such as:
-Female
-Aging
-Metabolic Disease
-Smoker
-Obesity
-Repetitive use/abuse
of Joints
Vitals: PAIN
S/S & PHYS. EXAM:
Page 51 of 106
Nursing Dx:
-Acute Pain r/t
distension of tissues
-Impaired physical
mobility r/t skeletal
deformity
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
Page 52 of 106
-Joint pain
-Joint stiffness
-Joint tenderness
-Limited range-ofmotion
-Crepitus (crackling,
grinding noise with
movement)
-Joint effusion
(swelling)
-Local inflammation
-Bony enlargements
and osteophyte
formation
Labs:
Dx Tests: Bone scan,
Dual Energy X-Ray
Absorptiometry Scan
(DEXA-Scan)
Assess: For
contributing factors
such as:
-Female
-Physical and
Emotional Stress
-Young to middle age
-Family History
Vitals: PAIN
S/S & PHYS. EXAM:
-Tender, warm,
swollen joints
Nursing Interventions:
Pharm: NSAIDS, Corticosteroids,
Disease Modifying Anti-Rheumatic
drugs (DMARDs) like METHOTREXATE,
LEFLUNOMIDE, BIOLOGIC RESPONSE
MODIFIERS (BRM) administered
parenterally HUMIRA, ENBREL
Pt. Ed: Use of mobility devices and
safety, prevention of
infection/complications, Physical therapy
exercises/Rehab,
Surgery: Total Joint arthroplasty, total
joint replacement as required
Nursing Dx:
-Acute Pain r/t
distension of tissues
-Impaired physical
mobility r/t skeletal
deformity
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Pt will maintain a
position with absence r
Labs: Positive
Rheumatoid factor,
synovial fluid analysis,
antinuclear antibody
test, Erythrocyte
sedimentation rate, CReactive protein
Dx Tests: X-Ray, MRI
Assess:
GOUT
Vitals:
Patho: Gout is a disorder of purine metabolism
S/S & PHYS. EXAM:
characterized by elevated uric acid levels with
-Intense joint pain.
deposition of urate crystals in joints and other
Gout usually affects
tissues. High uric acid levels result from
the large joint of your
decreased excretion of uric acid (90% of cases)
big toe, but it can
due to a wide variety of causes. The disorder
occur in
may progress from an asymptomatic stage
your feet, ankles,
through acute gouty arthritis, to chronic
knees, hands and
tophaceous gout.
wrists. The pain is likely
to be most severe
within the
first 12 to 24 hours
after it begins.
limitation of
contractures, and
display
techniques/behaviors
that enable
continuation of
activities
Nursing Interventions:
Pharm:
Short-Term Relief: Corticosteroids,
Ibuprofen/ NSAIDS, Colchicines **DO
NOT TAKE ASPIRIN, AS IT CAN RAISE
URIC ACID LEVELS IN THE BLOOD!
Uricosuric agents (Help to increase
elimination of uric acid by the kidneys)
Xanthine oxidase inhibitors (decreases
uric acid production by the body)
Colchicine (prevents flare-ups during the
first months you have gout and are
taking other medicines to lower uric acid
levels)
Page 53 of 106
Nursing Dx:
-Impaired Physical
Mobility r/t pain
Pt. Goals/ Evaluation:
-Patient will show signs
and verbalize effective
ways to properly
mobilize using
tools/physical
assistance provided
-Lingering discomfort.
After the most severe
pain subsides, some
joint discomfort may
last from a few days to
a few weeks. Later
attacks are likely to last
longer and affect more
joints.
-Inflammation and
redness. The affected
joint or joints become
swollen, tender and
red.
Page 54 of 106
6. VASCULAR DISORDERS
DIAGNOSIS/PATHO
DATA
DX:
ACTION
Assess: Assess skin
for: Dependent
rubor, cyanosis,
ulcers, gangrene,
decreased sensation
or pulses
Vitals: Cap Refill,
Unequal/Weak
Pulses, Pain
S/S & PHYS. EXAM:
Painful cramping in
your hip, thigh or calf
muscles after
activity, such as
walking or climbing
stairs (inter-mittent
claudication), Leg
numb-ness or
weakness, Cold
feeling in your lower
leg or foot, especially
when compared with
the other leg, Sores
on your toes, feet or
legs that won't heal,
A change in the color
of your legs, Hair loss
or slower hair
growth on your feet
Nursing
Interventions:
Pharm: Anticoags: (Heparin,
Lovenox, Aspirin,
Coumadin), AntiPlatelets (Trental,
Plavix), Vasodilators
(Isoxsuprine,
papaverine)
Pt. Ed: Good foot
care, do not cross
legs, stop smoking,
regular exercise,
healthy diet,
monitor/report
symptoms
Surgery:
Angioplasty, Arterial
revasculartization,
artherectomy,
arterial bypass (at
arterial blockage),
thrombectomy
Page 55 of 106
RESPONSE
Nursing Dx:
-Chronic pain r/t
intermittent
claudication/ischemia
-Activity intolerance r/t
peripheral oxygen supply
and demand
- Risk for impaired skin
integrity r/t altered
circulation/sensation
Pt. Goals/ Evaluation:
-Client will report
increased comfort level
and adequate pain
control
- Client will demonstrate
increased tolerance to
physical activity and
utilize the use of rest
periods
-Client will be free from
signs of impaired skin
integrity during their
hospital stay.
Page 56 of 106
Nursing Interventions:
Pharm: Anti-coags: (Heparin,
Lovenox, Aspirin, Coumadin),
Pt. Ed: Good foot care, do not
cross legs, stop smoking, regular
exercise, healthy diet,
monitor/report symptoms, avoid
extreme temperatures, Use TED
hose/Compression stockings
Surgery: thrombectomy,
Angioplasty, Arterial
revasculartization,
artherectomy, arterial bypass (at
arterial blockage)
Nursing Dx:
- Ineffective Tissue Perfusion:
peripheral r/t interruption of
vascular flow
-Ineffective health maintenance r/t
deficient knowledge regarding
disease process
walking or climbing
stairs and stops when
you rest. This is because
the muscles' demand for
blood increases during
walking and other
exercise. The narrowed
or blocked arteries
cannot supply more
blood, so the muscles
are deprived of oxygen
and other nutrients. This
pain is called
intermittent (comes and
goes) claudication. It is
usually a dull, cramping
pain. It may also feel like
a heaviness, tightness,
or tiredness in the
muscles of the legs.
Cramps in the legs have
several causes, but
cramps that start with
exercise and stop with
rest most likely are due
to intermittent. When
the blood vessels in the
legs are completely
blocked, leg at night is
very typical, and the
individual almost always
hangs his or her feet
down to ease the pain.
Hanging the legs down
allows for blood to
passively flow into the
distal part of the legs
Page 57 of 106
Labs: Total
Cholesterol, LDL
(Lousy Cholest.), HDL
(Happy Cholest.),
Lipids, Triglycerides
Dx Tests: Isotope
Studies, Ultra-Sonic
flow detection
Doppler Studies,
Venous Pressure
measurements
Assess: For
increasing severity of
symptoms, **SUDDEN
Dx:
ANEURYSMS
Patho: An aneurysm is a permanent localized dilation
of an artery. This can enlarge the artery. The locations
can differ, as well as the type and how they form, with
DISSECTING being the most life-threatening:
Types/Location:
1. AORTIC
2. CEREBERAL
3. PERIPHERAL
Page 58 of 106
RELIEF OF A PAINFUL
ANUERYMS IS A BAD
SIGN!! LIKELY MEANS
THAT THE ANUERYSM
HAS RUPTURED AND
IMMEDIATE SURGERY
IS REQUIRED!!
Vitals: HR (Weak
pulses distal to
aneurysm), BP,
RR
S/S & PHYS. EXAM:
1. AORTIC: AAA
(Abdominal Aortic
Aneurysm) w/
gnawing pain/pulsing
in abdomen/back,
Thoracic Aortic
Nursing Interventions:
Pharm: Pre-surgical
Meds/Antibiotics, AntiHypertensives (to reduce blood
pressure and decrease a chance
of rupture), Beta Blockers,
Calcium Channel Blockers,
Vasodilators, Anti-Lipid/Plaque
meds (STATINS!)
Pt. Ed: Reduce stress, STOP
SMOKING!! Lower BP, Healthy
Diet/Lifestyle, Monitor changes
to doctor, adhere to medication
regimen.
Surgery: Open abdominal
Chest repair, Endovascular
Repair (Aneurysm not removed
but strengthened):
Nursing Dx:
-Risk for deficient fluid
volume r/t potential
hemorrhage
-Fear/Anxiety r/t
emergency condition
Pt. Goals/ Evaluation:
-Pt will show no signs of
hypovolemia/shock, and
maintain fluid and
electrolytes within
acceptable levels for
Patient
-Pt will verbalize fears
and Anxiety and ways to
cope with such fears
Aneurysm : Pain
radiates up to jaw,
neck,
coughing/hoarseness,
shoulder blade pain.
2. CEREBERAL:
Aneurysm in brain,
Worst headache of
your life,
nausea/vomiting,
pain behind eyes,
,
3. PERIPHERAL:
Pulsations, pains and
sores in extremities,
also gangrene (due to
lack of circulation)
Labs: Blood work
such as Hg and Hct,
Coags, checking for
bleeding, monitoring
for signs of
hypovolemia
Dx Tests:
Ultrasound,
Echocardiogram,
Angiogram, MRI, CT
Scan
Page 59 of 106
7. RESPIRATORY
DIAGNOSIS/PATHO
ASTHMA
Patho: Bronchial asthma is a
chronic inflammatory disease of the
airways, associated with recurrent,
reversible airway obstruction with
intermittent episodes of wheezing
and dyspnea. Bronchial hypersensitivity is caused by various
stimuli, which innervate the vagus
nerve and beta adrenergic receptor
cells of the airways, leading to
bronchial smooth muscle
constriction, hypersecretion of
mucus, and mucosal edema.
Page 60 of 106
DATA
ACTION
RESPONSE
Nursing Interventions:
Pharm: PREVENTATIVE THERAPY:
(Flovent, Serevent, Singulair) RESCUE
DRUGS (Albuterol, Atrovent,
Theophylline)
Pt. Ed: STOP SMOKING!! Adhere to
medication regimen as prescribed,
Reduce stress, monitor symptoms daily
especially signs of an attack, report
increasing symptoms to doctor.
Surgery: N/A
Nursing Dx:
-Activity Intolerance r/t
energy shift to meet muscle
needs for breathing to
overcome airway
obstruction
-Anxiety r/t inability to
breathe effectively
-Ineffective breathing
pattern r/t anxiety
BRONCHITIS
Patho: Bronchitis is an
inflammation of the air passages
within the lungs. It occurs when the
trachea (windpipe) and the large and
small bronchi (airways) within the
lungs become inflamed because of
infection or other causes.
Nursing Interventions:
Pharm: Antibiotics for infection, Cough
meds/Expectorants, NSAIDS
Pt. Ed: STOP SMOKING!! Adhere to
medication regimen as prescribed,
Reduce stress, monitor symptoms daily
especially signs of an attack, report
increasing symptoms to doctor.
Surgery: N/A
Page 61 of 106
Nursing Dx:
-Ineffective airway
clearance r/t excessive
thickened mucus secretion
-Anxiety r/t potential
chronic condition
Pt. Goals/ Evaluation:
-Client will demonstrate
effective coughing and clear
breath sounds
-Client will identify,
verbalize, and demonstrate
techniques to control
anxiety.
COPD (CHRONIC
OBSTRUCTIVE PULMONARY
DISEASE)
Page 62 of 106
Nursing Interventions:
Pharm: Short and long acting
Bronchodilators (tiotropium (Spiriva)
salmeterol (Serevent) formoterol
(Perforomist), OXYGEN!
Pt. Ed: STOP SMOKING!! Adhere to
medication regimen as prescribed,
Reduce stress, monitor symptoms daily
especially signs of an attack, report
increasing symptoms to doctor.
*Alternate activity and rest periods to
prevent fatigue
Surgery: Lung Reduction, Lung
Transplant **For selected cases only,
end-stage COPD
Nursing Dx:
-Activity intolerance r/t
imbalance between oxygen
supply and demand
-Ineffective Health
Maintenance r/t deficient
knowledge regarding care
of disease
Pt. Goals/ Evaluation:
-Client will participate in
physical activity and
demonstrate appropriate
changes in heart rate,
breathing rate and blood
pressure
-Client will follow mutually
agreed health maintenance
plan
EMPHYSEMA
Patho: Decreased pulmonary
elastic recoil. At any pleural pressure,
the lung volume is higher than
normal. Additionally, the altered
relation between pleural and
alveolar pressure facilitates
expiratory dynamic compression of
airways. Such compression limits
airflow during forced expiration and,
in severe instances, during tidal
expiration. Another factor
contributing to airflow limitation is
disease of the airways,
both large and small. In general,
patients with relatively pure
emphysema maintain blood gases in
or near the normal range until very
late in their course. PaO2 is
maintained because of the preserved
matching of ventilation and
perfusion as alveolar walls are
destroyed. PaCO2 is maintained
because the ventilatory response to
CO2 is not usually impaired. It is not
clear why patients who are
categorized clinically as "chronic
bronchitics" are more likely to
respond to an increased flowresistive work of breathing by
hypoventilating. Physical findings in
emphysema are not specific.
Radiologic changes are insensitive
Nursing Interventions:
Pharm: Bronchodilators, Expectorants,
Corticosteroids, Oxygen
Pt. Ed: STOP SMOKING!! Adhere to
medication regimen as prescribed,
Reduce stress, monitor symptoms daily
especially signs of an attack, report
increasing symptoms to doctor.
*Alternate activity and rest periods to
prevent fatigue
Surgery: Lung Reduction, Lung
Transplant **For selected cases only,
Emphysema NOT caused by smoking
Page 63 of 106
Nursing Dx:
-Activity intolerance r/t
imbalance between oxygen
supply and demand
-Ineffective Health
Maintenance r/t deficient
knowledge regarding care
of disease
Pt. Goals/ Evaluation:
-Client will participate in
physical activity and
demonstrate appropriate
changes in heart rate,
breathing rate and blood
pressure
-Client will follow mutually
agreed health maintenance
plan
HEMOTHORAX
Patho: Roughly Translated,
HEMOTHORAX means blood (HEMO)
in the pleural cavity (THORAX). This
condition can be caused by a number
of factors, when anything penetrates
the pleural wall causing blood to
enter the pleural space, including a
gun shot wound or stabbing. A
hemothorax is managed by removing
the source of bleeding and by
draining the blood already in the
thoracic cavity. Blood in the cavity
can be removed by inserting a drain
(chest tube) in a procedure called a
tube thoracostomy. Usually the lung
will expand and the bleeding will
stop after a chest tube is inserted.
The blood in the chest can thicken as
the clotting cascade is activated
when the blood leaves the blood
vessels and is activated by the
pleural surface, injured lung or chest
wall, or contact with the chest tube.
Page 64 of 106
Nursing Interventions:
Pharm: Oxygen, Morphine/ analgesics
for pain, Antibiotics for infection
Pt. Ed: Sit in High-Fowlers, Monitor
chest tube/dressing
Surgery: Chest tube insertion/
drainage system
Nursing Dx:
-Deficient Fluid Volume r/t
blood in pleural space
-Ineffective breathing
pattern r/t chest pain/lung
injury
Pt. Goals/ Evaluation:
-Patient will maintain blood
pressure, pulse, body
temperature and breathing
patterns within acceptable
range for patient
-
PNEUMOTHORAX
Patho: Pneumothorax refers to gas
within the pleural space. Normally,
the alveolar pressure is greater than
the intrapleural pressure, while the
intrapleural pressure is less than
atmospheric pressure.
Therefore, if a communication
develops between an alveolus and
the pleural space or between the
atmosphere and the pleural space,
gases will follow the pressure
gradient and flow into the pleural
space. This flow will continue until
the pressure gradient no longer
exists or the abnormal
communication has been sealed.
Since the thoracic cavity is normally
below its resting volume, and the
lung is above its resting volume, the
thoracic cavity enlarges and the lung
Nursing Interventions:
Pharm: Oxygen, Morphine/ analgesics
for pain, Antibiotics for infection, O2
Pt. Ed: Sit in High-Fowlers, Monitor
chest tube/dressing, verbalize signs of
infection, medication compliance
Surgery: Chest tube insertion
Nursing Dx:
-Ineffective Breathing
pattern r/t decreased lung
expansion
- Risk for Suffocation r/t
dependence on external
device (Chest Tube)
Pt. Goals/ Evaluation:
-Pt will establish a normal
and effective breathing
pattern with ABGs within
normal range for patient
-Pt will recognize need for
assistance to prevent
complications
Page 65 of 106
PNEUMONIA
Patho: Pneumonia is an acute
inflammatory disorder of lung
parenchyma that results in edema of
lung tissues and movement of fluid
into the alveoli. These impair gas
exchange resulting in hypoxemia.
Pneumonia can be classified in
several ways. Based on microbiologic
etiology, it may be viral, bacterial,
fungal, protozoa, myobacterial,
mycoplasmal, or rickettsial in origin.
Based on location, pneumonia may
be classified as broncho-pneumonia,
lobular pneumonia, or lobar
pneumonia. Broncho-pneumonia
Page 66 of 106
Nursing Interventions:
Pharm: Antibiotics, Antipyretics, antiinflammatory, bronchodilators
Pt. Ed: Medication
Administration/compliance,
Pneumonia/Influenza vaccine
Surgery: chest tube/Thoracentesis
Nursing Dx:
-Impaired gas exchange r/t
changes in alveolar
membrane
-Ineffective airway
clearance r/t inflammation
and secretion build-up
Pt. Goals/ Evaluation:
-Pt will show improved
ventilation and gas
exchange,
-Pulmonary Ventilation is
adequate with no secretion
build-up
PULMONARY EMBOLISM
Patho: A thrombus that has
separated from its site of origin
travels through the circulation to the
inferior vena cava. The right ventricle
pumps this thrombus to the
pulmonary arteries where the
thrombus
finally lodges. PE may occur singly or
multiply. They can be microscopic in
size or be big enough to occlude the
major branches of the pulmonary
artery. Recurrent PE may gradually
obstruct the pulmonary vasculature
and ultimately lead to chronic
obstructive pulmonary hypertension
and cor pulmonale.
Nursing Interventions:
Pharm: Anti-thrombolytics/clotbusters (tPA if within 3 Hour time
frame) , Anticoagulants, OXYGEN
Pt. Ed: Follow up on labs (PT/INR),
Report new symptoms/worsening pain.
Preventative measures/ medication ,
Dietary precautions (Vitamin K),
Bleeding Precautions, Follow up on
PT/INR
Surgery: Embolectomy, Vena Cava
filter
Page 67 of 106
Nursing Dx:
-Impaired gas exchange r/t
decreased pulmonary
perfusion
-Acute Pain r/t pulmonary
flow obstruction
Pt. Goals/ Evaluation:
-Pt will demonstrate
improved ventilation and
adequate oxygenation as
evidenced by ABGs within
normal limits for patient
-Pt. will report pain at a
comfortable and tolerable
level
RESPIRATORY FAILURE
Page 68 of 106
Nursing Interventions:
Pharm: Oxygen, Diuretics (Lasix),
Nitroglycerin (To reduce preload/
afterload), Morphine
(Pain/Venodilation), Beta2 Agonists
(Albeuterol, Terbutaline), Atrovent,
Corticosteroids (Methylprednisolone)
Pt. Ed: Sit in a position of comfort
(one that promotes effective breathing)
such as High Fowlers, medication
compliance, Oxygen use and need,
report new/worsening symptoms.
Surgery: Tracheotomy/Ventilator if
needed, (AIRWAY IS ALWAYS #1!!),
Lung Transplant (if eligible)
Nursing Dx:
-Ineffective breathing
pattern r/t decreased lung
compliance
-Impaired respiratory
function r/t inability to
maintain adequate
oxygenation of the
respiratory tract and
perfusion of oxygen
Pt. Goals/ Evaluation:
-Pt will report ability to
breathe comfortably and
-Client will exhibit positive
signs of perfusion including
O2 Sat. levels and ABGs
within normal patient limits
TUBERCULOSIS
Patho: Tuberculosis is an infectious
disease caused by the Myobacterium
Tuberculosis. Transmission occurs
when droplet nuclei are produced
form an infected persons coughs or
sneezes. (AIRBORNE ROUTE). If
inhaled, tubercle bacillus settles in
the alveolus and infection occurs,
with alveolocapillary dilation and
endothelial swelling. The incubation
time for TB is 4 to 8 weeks. TB is
usually asymptomatic in primary
infection. The risk of TB is a higher in
older people who have close contact
with a newly diagnosed TB
patient, those who have TB before,
gastrectomy patients, and those
affected with diabetes mellitus. The
aging process weakens the immune
system, further increasing the
likelihood of tubercular infection in
older adults.
Assess: *AIRBORNE
ISOLATION PRECAUTIONS!!
Assess Lung sounds,
Hemoptysis, Monitor
Liver/Kidney function
Vitals: TEMP (low grade)
S/S & PHYS. EXAM: Cough,
Hemoptysis, Low grade
fever/NIGHT SWEATS,
Anorexia/Weight-loss,
Malaise/Fatigue
Labs: POSITIVE Sputum
Culture for for acid-fast
bacillus (AFB), Serum analysis,
Serum Analysis QFT-G
(Quantiferon Tuberculosis Gold)
Dx Tests: Chest X-RAY,
Mantoux Tuberculin skin test
(TST)
Nursing Interventions:
Pharm:
COMBINATION DRUG THERAPY:
Isonazid (INH), Rifampin, Pyrazinamide,
Streptomycin, Ethambutol
Pt. Ed: Prevent the spread of this
airborne infection! Practice good hand
hygiene, cover mouth when coughing or
sneezing, ensure medication
compliance as well as diligent follow up
appointments
*AS A MEDICAL PROFESSIONAL, ALL
DIAGNOSED CASES OF TB MUST BE
REPORTED TO LOCAL/STATE HEALTH
DEPARTMENT!
Surgery: N/A
Page 69 of 106
Nursing Dx:
-Ineffective breathing
pattern related to
acute infection and
decreased lung
capacity
-Risk for infection (spread)
r/t lowered
resistance/suppressed
inflammatory process
Pt. Goals/ Evaluation:
- Pts breathing will return
to rate and pattern within
their normal limits
-Pt will exhibit minimal or
no signs of infection.
Page 70 of 106
Nursing Interventions:
Pharm: Treat the cause! If infection
(strep throat, epiglottitis & bacterial
sinusitis): Antibiotics, Common cold
(Can only treat symptoms) with
Tylenol/NSAIDs for fever/body aches,
Steriods for broncho-inflammation, &
Decongestants for nasal issues.
Pt. Ed: Decongestants are NOT
recommended for Pts w/ high BP.
Surgery: N/A
Nursing Dx:
-ineffective Airway
Clearance related to
thick secretions and airway
obstructions
-Acute pain r/t swelling in
throat
Pt. Goals/ Evaluation:
-Pt will be able to cough
effectively and
clear own secretions, and
maintain patency of airway
and had clear breath
sounds
-Patient will report relief of
pain with analgesic
administration
8. CARDIAC (HEART)
DIAGNOSIS/PATHO
ANGINA
Patho: Basic term for Chest Pain.
Commonly assoc. w/ CAD,
cholesterol & plaque in vessels.
Triggered by phys. Activity/stress. SNS
sys. Activates vasoconstriction of
vessels smaller tube brings more O2
back to heart, brain and lungs, where it
is needed most. 2 types:
Stable: caused by phys. Activity, but
stops when activity stops. STABLE
STOPS!
Unstable: Even after stopping activity,
pain is still there. May be due to
blockage/clot in artery, or a clot that
becomes loose as the vessels shrink
and expand. Lack of O2 to heartCan
lead to MI/ Ischemia!!
DATA
Assess: Vital signs/pain such as
facial grimacing, rubbing of neck or
jaw, reluctance to move, increased
blood pressure, and tachycardia.
Vitals: BP, HR, O2 SAT
S/S & PHYS. EXAM: pain (May
radiate down L arm), SOB,
Diaphoresis/Cool/Clammy skin,
Syncope, anxiety
Labs: Cardiac Enzymes,
Cholesterol/Lipids, H&H
Dx Tests: EKG, Echocardiogram,
Stress test, Angiogram
ACTION
Nursing Interventions:
Pharm: M O N A
MORPINE (Pain mgmt, last resort,
can numb Pt./mask symptoms)
OXYGEN (O2 to left ventricle)
NITROGYLCERIN ( vasodilation)
**Contraindicated in Pts on
Vasodilators/Viagra!
Page 71 of 106
RESPONSE
Nursing Dx:
-Acute Pain r/t
decreased
myocardial blood
flow
-Activity Intolerance
r/t acute
pain/dysrhythmias
Pt.
Goals/Evaluation:
-Patient will be free
from pain, maintain
stable vital signs and
show no visual signs
of pain
-Pt. will demonstrate
tolerance to
activity. Assess
effectiveness of nitro;
assess vital signs,
pain control, as well
as Pt. S/S and EKG for
any sign of
infarction/
arrhythmias.
ARRHYTHMIAS
Patho: Disturbance in impulse
formation/conduction/communication.
4 TYPES: Suppressed Automaticity (SA
node doesnt fire effectively/up to
speed, can lead to Pacemaker
Placement), Enhanced Automaticity
(Can result in multiple arrhythmias,
ATRIAL & FIB. due to increased
rate/impulse) Triggered Activity (An
early or late depolarizations can
trigger/ precipitate Ventricular
arrhythmias EX: torsades de pointes,
Digoxin Toxicity) & Re-entry (Current or
past MI/infarction/scarring or a block
at a node can conceal accessory
pathways and cause the re-entry of the
conduction signal in the heart.
Page 72 of 106
Nursing Interventions:
Pharm: OXYGEN! Nitro
(Vasodilator)
RX Depends on the Arrhythmia:
PSVT/WPW Synd/A-Flutt: Diltiazem,
Adenosine (Slows Vent. Rate by
AV Block). Digoxin (Supraventricular
Arrhythmias)
Pt. Ed: Report S/S to Physician,
Limit salt intake, Monitor B/P, Follow
up with meds as prescribed, DO NOT
take nitro w/ other Vasodilators like
Viagra, Monitor BP/HR/Daily weights
Surgery: Pacemaker to regulate
heart rate, Cardio-aversion, Vagal
Stimulation (Temporary)
Nursing Dx:
-Activity intolerance
r/t decreased cardiac
output
-Decreased cardiac
output r/t altered
electrical conduction
Pt.
Goals/Evaluation:
-Patient will
participate in phys.
Activity with
appropriate changes
in vital signs.
-Patient will
demonstrate
adequate cardiac
output AEB: BP, HR
and Rhythm within
normal parameters
for Patient and
without pain.
Nursing Interventions:
Pharm: Depends on the lipid levels,
but most commonly used are the
Statins (ex. Atorvastatin/Lipitor,
Rosuvastatin/Crestor)
Pt. Ed: Modify common risk factors,
including: Smoking, Tobacco use,
Diet, Exercise, Stress, Alcohol Use
Surgery: Angioplasty, Stent/Balloon
placement, CABG if necessary.
Page 73 of 106
Nursing Dx:
-Decreased cardiac
output r/t ischemia
-Acute pain r/t
myocardial issue
damage r/t
inadequate blood
supply.
Pt.
Goals/Evaluation:
-Patient will
demonstrate
adequate cardiac
output AEB: BP, HR
and Rhythm within
normal parameters
for Patient and
without pain.
-Pt. will report that
pain management
regimen is
satisfactory to pain
tolerance standards.
Page 74 of 106
Assess: Pulses, urine output, bloodtinged sputum, EKG strip & SIGNS of
STROKE (ALOC, changes in speech,
motor function, or facial droop)
Vitals: HR (Up to 350-600 Atrial
BPM) BP (r/t Cardiac output)
S/S & PHYS. EXAM: Palpitations,
Dyspnea, Pulmonary edema, Signs of
cerebrovascular insufficiency,
fatigue, distended jug. veins,
Labs: PT, PTT, INR, H&H, EKG
Dx Tests: Trans-esophageal
electrocardiogram (TEE) to assess for
signs of clots BEFORE cardioversion.
Physiologic Mapping Studies (Before
MAZE procedure)
Nursing Interventions:
Pharm: Calcium Channel Blockers
(Diltiazem), Antidysrhythmics
Amioderone (Unlabeled use), &
Anticoagulants (Heparin, Coumadin,
Lovenox)
Pt. Ed: Advise Pt on blood thinners
that regular blood tests may be
required, to take caution as excessive
bleeding may occur.
Surgery: Cardioversion, Radiofrequency Catheter Ablation (Creates
scar tissue to defer abnormal
pathways/rhythms of A-fib) & Maze
Procedure (usually performed with
CABG, sutures are strategically placed
to prevent electrical circuits from
causing AF) & Pacemaker implant.
Nursing Dx:
-Decreased Cardiac
Output r/t altered
electrical conduction
-Activity intolerance
r/t decreased cardiac
output
Pt. Goals/
Evaluation:
-Patient will display
adequate cardiac
output AEB Pts
BP/HR/Rhythm are in
normal parameters
for the client.
-Patient will
participate in phys.
Activity with
appropriate changes
in vital signs.
CARDIOGENIC SHOCK
Patho: Signs and symptoms of
cardiogenic shock reflects the nature of
the circulation/
patho of heart failure.
MI/Dysrrhythmias and
Cardiomyopathies cause heart damage
resulting in decreased cardiac output,
BP out of artery to the vital organs.
Blood flow to coronary arteries
Oxygen to the heart leading to
ischemia and Heart's ability to
pump, thus causing inadequate
perfusion of body tissues = SHOCK
Nursing Interventions:
Pharm: Meds to reverse shock:
Dopamine and dobutamine (to
improve cardiac
contractility), Vasopressors (Nitro),
Epinepherine, Norepinepherine,
Fluids
(Blood/Plasma/Platelets/Crystalloids/
Colloids), Diuretics (Lasix, HCTZ),
Oxygen
Pt. Ed: Teach Pt. how to reduce
controllable risk factors for heart
disease. Encourage attendance
Ensure the patient understands the
medication prescribed.
Surgery: Immediate re-perfusion (Pt
is taken to Cardiac Cath. Lab and
immediate Left sided heart
catheterization, PCI (Percutaneaous
Coronary Intervention) stent/balloon.
*Pt. may be intubated/on ventilator
for O2 support
Page 75 of 106
Nursing Dx:
-Altered tissue
perfusion
(cardiopulmonary)
r/inadequate cardiac
output
Pt.
Goals/Evaluation:
Circulation status;
Cardiac pump
effectiveness; Tissue
perfusion:
Cardiopulmonary,
Cerebral, Renal,
Peripheral; Vital sign
status *Evaluate for
signs of
arrhythmia/MI/Shock
to prevent relapse.
Assess Pts vital signs
for values within
acceptable limit.
Page 76 of 106
Nursing Interventions:
Pharm: O2, Aspirin, Heparin/
Lovenox/Coumadin, Nitro for chest
pain
Nursing Dx:
- Risk for reduced
cardiac output r/t
depressed cardiac
function
- Risk for bleeding r/t
incision site/surgery
- Anxiety r/t
surgery/hospital stay.
Pt. Goals/
Evaluation : Patient
will be able to
demonstrate
hemodynamic
stability such as
stable blood pressure
and adequate cardiac
output
Nursing Interventions:
Pharm: O2, Diuretics, as indicated
Pt. Ed: Fluid/Sodium restriction,
Combine ADLS/Alternate breaks,
Relaxation/ Stress,
Surgery: Heart Transplant is
ULTIMATE CHOICE, but if not, VAD
(Ventricular Assist Device *usually
used as a bridge until surgery), PLV
(Partial Left Ventriculectomy),
Endoventricular Circular Patch, Acorn
Cardiac Support Device, Myosplint
Pt. Goals/
Evaluation :
- The patient will be
able to display vital
signs within
acceptable limits,
dysrhythmias
controlled and no
symptoms of failure.
Nursing Dx:
- Decreased cardiac
output r/t impaired
cardiac function
- Excessive fluid
volume r/t impaired
excretion of sodium
and water
- Impaired gas
exchange r/t
excessive fluid in
interstitial space of
lungs/alveoli
Page 77 of 106
Nursing Interventions:
Pharm: Cholesterol meds (STATINS),
Nitro for Chest Pain, Antiplatelets/Anti-Coagulants
Pt. Ed: Healthy diet, exercise as
directed by doctor
Surgery: Angioplasty, Stent/Balloon
placement, CABG
Nursing Dx:
- Acute pain related
to the imbalance o
myocardial oxygen
supply and demand.
- Ineffective tissue
perfusion related to
myocardial ischemia
and decreased
cardiac output.
- Anxiety related to
pain, feeling of
impending doom,
lifestyle
changes/diagnosis of
CAD.
Pt. Goals/
Evaluation: Reduce
pain, Prevent angina
episodes by
balancing
rest/activity, achieve
and maintain a
suitable blood
pressure for patient.
Page 78 of 106
HTN (Hypertension)
Patho: Chronic High Blood pressure
due to some or a combination of many
factors/Imbalances in the body. When
blood volume falls or blood flow to the
kidneys decreases, juxtaglomerular
cells in the kidneys secrete renin into
the bloodstream. In sequence, renin
and angiotensin converting enzyme
(ACE) act on their substrates to
produce the active hormone
angiotensin II, which raises blood
pressure in two ways. First, angiotensin
II is a potent vasoconstrictor; it raises
blood pressure by increasing systemic
vascular resistance. Second, it
stimulates secretion of aldosterone,
which increases re-absorption of
sodium ions and water by the kidneys.
The water reabsorption increases total
blood volume, which increases blood
pressure.
Assess: Headache
Vitals: HR BP:
Nursing Interventions:
Pharm: Beta Blockers (Metropolol,
Atenolol, Carvedilol *BETA BLOCKERS
like to LOL!! ) Diuretics (Aldactone,
Furosemide, HCTZ), ACE Inhibitors,
Calcium Channel Blockers,
Vasdilators
Pt. Ed: Monitor Blood Pressure
Daily, Daily weights, side effects of
meds, Modifiable risk factors
Surgery: May need surgery to repair
damage caused by chronic
hypertension, such as aneurysm
repair, kidney transplant/Dialysis,
CABG
Page 79 of 106
Nursing Dx:
-Ineffective health
maintenance r/t
deficient knowledge
of disease process
- Risk for prone
behavior r/t lack of
knowledge about the
disease
Pt. Goals/
Evaluation:
-Pt will verbalize
understanding of
disease process
-Pt will check BP daily
and report significant
changes
-Pt will adhere to
medication regimen
-Pt will adhere to
ordered low salt diet
and exercise regimen
-Pt will change
modifiable risk
factors
HYPERLIPIDEMIA (High
Cholesterol)
Patho: Hyperlipidemia is an excess of
fatty substances called lipids, largely
cholesterol and triglycerides, in the
blood. It is also called hyperlipoproteinemia because these fatty
substances travel in the blood attached
to proteins. This is the only way that
these fatty substances can remain
dissolved.
Page 80 of 106
Nursing Interventions:
Pharm: Statins! STATINS, STOP!
(Atorvastatin, Simvastatin,
Lovastatin) Fibric Acids (Advicor,
Tricore)
Pt. Ed: Modify diet/exercise,
compliance with medication, report
new symptoms immediately.
Surgery: Stent/Balloon, CABG,
angioplasty
Nursing Dx:
-Inadequate
perfusion of body
tissues r/t
interruption of
vascular flow
- Insufficient
knowledge r/t
disease process
Pt.
Goals/Evaluation:
-Pt will verbalize
understanding of
healthy diet and
exercise
-Pt. will be able to
state modifiable
factors
-Pt. will adhere to a
specific medication
regimen to reduce
cholesterol levels in
body
9. ENDOCRINE
DIAGNOSIS/PATHO
DIABETES TYPE I
Patho: Diabetes Mellitus (DM)
is a chronic metabolic disorder
caused by an absolute or relative
deficiency of insulin, an anabolic
Hormone. Type 1 diabetes
mellitus can occur at any age and
is characterized by the marked
and progressive inability of the
pancreas to secrete insulin
because of autoimmune
destruction of the beta cells. It
commonly occurs in children,
with a fairly abrupt onset;
however, newer antibody tests
have allowed for the
identification of more people
with the new-onset adult form of
type 1 diabetes mellitus called
latent autoimmune diabetes of
the adult (LADA). These patients
are dependent on exogenous
insulin. Type 1 diabetes
(formerly called juvenile-onset
or insulin-dependent diabetes),
accounts for 5% to 10% of all
people with diabetes. In Type 1
diabetes, the bodys immune
DATA
ACTION
RESPONSE
Nursing Interventions:
Pharm: Insulin!
Pt. Ed: Insulin compliance (maintain normal
range!), Do not stop taking insulin if within normal
range! Diet management, education on the signs of
hypo/hyperglycemia, long term education for
complications, foot care, med-alert bracelet, SICK
DAY RULES:
Nursing Dx:
-Risk for infection r/t
high glucose levels
-Lack of knowledge
r/t disease process
Page 81 of 106
Pt. Goals/
Evaluation:
-Pt. will take proper
precautions and
verbalize signs and
symptoms of
infection
-Pt will be able to
verbalize
understanding of
disease process and
daily management
regimen
DIABETES TYPE II
Patho: Type 2 diabetes mellitus
occurs when the pancreas
produces insufficient amounts of
the hormone insulin and/or the
bodys tissues become resistant
to normal or even high levels of
insulin. This causes high blood
glucose (sugar) levels, which can
lead to a number of
complications if untreated. Type
2 diabetes is a chronic medical
condition that requires regular
monitoring and treatment.
Treatment, which includes
lifestyle adjustments, self-care
measures, and sometimes
medications, can control blood
glucose levels in the near-normal
range and
Minimize the risk of diabetesrelated complications. Type 2
diabetes accounts for around
85% of all people with diabetes.
Page 82 of 106
Assess: Sign of
Hyperglycemia, HHS
(Hyperglycemic
Hyperosmolar State)
Vitals: HR, BP (Longterm)
S/S & PHYS. EXAM: Any
symptoms of DM Type 1,
recurring or hard-to heal skin,
gum or urinary tract
infections, drowsiness,
tingling of hands and feet,
itching of skin and genitals.
Labs: Fasting plasma
glucose of 126 mg/dL or
greater, Random plasma
glucose of 200 mg/dL greater,
Glucose tolerance test,
HbA1c, ABGs, electrolytes,
Urine glucose tests, Thyroid
function
Dx Tests: N/A
Nursing Interventions:
Pharm: Anti-diabetic drugs, insulin as needed
Pt. Ed: Teach strategies to prevent HHS, Regular
monitor blood glucose, adherence to insulin
regimen, regular blood tests, monitor for long term
effects
Surgery: N/A
Nursing Dx:
-Risk for infection r/t
high glucose levels
-Lack of knowledge
r/t disease process
Pt. Goals/
Evaluation:
-Pt. will take proper
precautions and
verbalize signs and
symptoms of
infection
-Pt will be able to
verbalize
understanding of
disease process and
daily management
regimen
HYPOGLYCEMIA
Patho: Hypoglycemia, also
called low blood glucose or low
blood sugar, occurs when blood
glucose drops below normal
levels. Glucose, an important
source of energy for the body,
comes from food. Carbohydrates
are the main dietary source of
glucose. Rice, potatoes, bread,
tortillas, cereal, milk, fruit, and
sweets are all carbohydrate-rich
foods. After a meal, glucose is
absorbed into the bloodstream
and carried to the body's cells.
Insulin, a
hormone made by the pancreas,
helps the cells use glucose for
energy. If a person takes in more
glucose than the body needs at
the time, the body stores the
extra glucose in the liver and
muscles in a form called
glycogen. The body can use
glycogen for energy between
meals. Extra glucose can also be
changed to fat and stored in fat
cells. Fat can also be used for
energy. When blood glucose
begins to fall, glucagon-another
hormone made by the pancreassignals the liver to break down
glycogen and release glucose into
Nursing Interventions:
Pharm: Glucose Tabs/Glucagon! 15g of fast- acting
Carbs (fruit juice, candies, honey)
Pt. Ed: Knowledge of signs and symptoms of
hypoglycemia, ways to alleviate, Dietary
recommendations
Surgery: N/A
Nursing Dx:
-Risk for
complications r/t
low glucose levels
-Risk for Infection r/t
altered body
functions
Pt. Goals/
Evaluation:
-Pt will be free from
complications and
verbalize signs of
hypoglycemia
-Pt will be free from
infection and
verbalize signs of
infection, as well as
proper hand hygiene
Page 83 of 106
HYPERGLYCEMIA
Patho: High levels of serum
glucose are excreted in the
kidneys, causing glycosuria which
can lead to excessive osmotic
diuresis (polyuria). The impact of
polyuria would cause excessive
fluid loss, and
followed the loss of potassium,
sodium and phosphate. Due to
lack of insulin the glucose cannot
be converted into glycogen to
increase blood sugar levels and
hyper-glycemia occurs. The
kidneys cannot resist
hyperglycemia, and cannot filter
out and absorb the amount of
glucose in the blood. The sugar,
which absorbs all the excess
Page 84 of 106
Nursing Interventions:
Pharm: Depends on need!! Can take anti-diabetic
pills (Glyburide, Metformin) also INSULIN, as
prescribed, many also be given in a insulin pump.
Pt. Ed: Diet and exercise regimen should be
followed as prescribed by doctor.
Surgery: N/A
Nursing Dx:
-Ineffective
management of
therapeutic regimen
r/t deficient
knowledge of
disease process
-Risk for unstable
blood glucose r/t
deviation from
normal range
Pt. Goals/
Evaluation:
-Pt will verbalize
understanding of
proper care and
testing of blood
sugar as well as the
prescribed
medications to
manage it
-Pt will maintain
blood glucose level
within healthy limits
of the patients
condition.
Page 85 of 106
DIABETIC
KETOACIDOSIS (DKA)
Page 86 of 106
Nursing Interventions:
Pharm: REGULAR INSULIN! (IV @ 0.1 mg/kg/hr)
Saline/Fluids (To make up for body losses),
ELECTROLYTES as needed (ex. Potassium)
Pt. Ed: Proper testing of blood sugar, verbalization
on signs/symptoms of DKA. Sick Day Rules , Teach
strategies to prevent DKA
Surgery: N/A
Nursing Dx:
-Imbalanced
nutrition less than
body requirements
r/t biological factors
-Knowledge
deficient (learning
need) r/t condition/
treatment regimen,
self-care,
Pt. Goals/
Evaluation:
-Pt will maintain
homeostasis and be
free from signs of
malnutrition
-Pt will verbalize
understanding of
condition/disease
process and
signs/symptoms of
complications
APPENDICITIS
Patho: Appendicitis is usually
caused by blockage of the lumen
of the appendix. Obstruction
causes the mucus produced by
mucous appendix suffered dam.
The longer the mucus is more and
more, but the elastic wall of the
appendix has limitations that lead
to increased intra-luminal
pressure. These pressures will
impede the flow of lymph
resulting in mucosal edema and
ulceration. At that time there was
marked focal acute appendicitis
with epigastric pain. If the flow is
disrupted arterial wall infarction
will occur followed by gangrene
appendix. This stage is called
appendicitis gangrenosa. If the
appendix wall fragile, there will be
a perforation, called perforated
appendicitis.
DATA
Assess: For guarding, with pain in RLQ,
Positive McBurneys sign (Pain located the
right side of abdomen, located 1/3 the
distance from the anterior superior iliac spine
to the umbilicus):
Vitals: TEMP
S/S & PHYS. EXAM: Aching pain that begins
around your navel and often shifts to your
lower right abdomen. The pain occurs when
you apply pressure to your lower right
abdomen THEN, releases the pressure on that
area. When released, the Pt. will feel A LOT of
pain!! (REBOUND TENDERNESS!!) Pain that
worsens if you cough, walk or make other
jarring movements, also Nausea, Vomiting,
Loss of appetite, Low-grade fever,
Constipation, Inability to pass gas, Diarrhea,
Abdominal swelling
ACTION
RESPONSE
Nursing Interventions:
Pharm: PAIN
MANAGEMENT &
ANTIBIOTICS UNTIL
SURGERY!! Continue
after surgery as well.
Possibly blood if lost in
surgery.
Pt. Ed: Avoid applying
heat to the area,
Monitor for
signs/symptoms of
infection, mobility after
surgery
Surgery:
APPENDECTOMY!
**Must remove before
appendix perforation
CAN CAUSE SEPTIC
SHOCK!! Patient will
notice a Sudden relief
of pain which is a BAD
SIGN!! Abdomen will
become rigid, fever will
SPIKE!
Nursing Dx:
-Acute pain r/t inflammation
of tissues
-Risk for infection r/t
Inadequate primary
defenses/surgery/perforation
of tissues
Page 87 of 106
Page 88 of 106
Nursing Interventions:
Pharm: Analgesics,
Antiemetics,
Anticholinergics,
Antibiotics,
Ursodeoxyxholic Acid
(Urso) to internally break
up stones if possible
Pt. Ed: Manage a lowfat diet & exercise
program, Care of T-Tube
if sent home with one,
Prevent Dumping
Syndrome:
Surgery:
Sphinterectomy with
stone removal with
ERCP, Extracorporeal
Shock Wave Lithotripsy
Nursing Dx:
-Acute pain r/t
obstruction/spasm
-Risk for deficient fluid
volume r/t excessive losses
due to vomiting
Pt. Goals/ Evaluation:
-Pt will report pain at
tolerable level and verbalize
ways to manage it
-Pt will show evidence of
adequate fluid volume by:
stable vital signs, moist
mucus membranes, good
skin turgor, and urine output
within normal level for
patient
Dx:
HEPATITIS
Patho: Inflammation that
spreads to the liver (hepatitis) can
be caused by infection by viruses
and toxic reactions to drugs and
chemicals. Basic functional units
of the liver are called lobules, and
these units are unique because
they have their own blood supply.
Disruption of the normal blood
supply to the cells causes hepatic
necrosis and damage to liver cells.
After passing his time, the liver
cells become damaged &
eliminated from the body by the
immune system response and
replaced by new cells of a healthy
liver. Therefore, most clients who
have hepatitis recovered with
normal liver function.
Nursing Interventions:
Pharm:
*SPECIFIC TO TYPE AND
SYMPTOMS:
-Treat Symptoms for
TYPE A
-Anti-viral drugs for TYPE
B & C: Penginterferonalpha 2B (PEGLNTRON)
Pt. Ed: PREVENT
SPREAD OF INFECTION!
Wash hands, Vaccines
for Types A & B, Avoid
High-Risk Behaviors
such as unprotected sex,
sharing/using unclean
needles, blood-to-blood
contact, *NOT ELIGIBLE
TO DONATE BLOOD
Surgery: Liver
transplant if eligible
(Type C)
Page 89 of 106
Nursing Dx:
-Fatigue r/t decreased
metabolic energy production
-Risk for deficient fluid r/t
altered clotting factors (Hep
C) or vomiting/anorexia (HEP
A) and altered body
chemistry
Pt. Goals/ Evaluation:
-Pt will report increased
energy and is able to
participate in ADLs
- Pt will show evidence of
adequate fluid volume by:
stable vital signs, moist
mucus membranes, good
skin turgor, and urine output
within normal level for
patient
PANCREATITIS
Patho: Pancreatitis is an
inflammatory disease, which
varies in severity from mild to
severe. Factors determining the
severity of pancreatitis are not
known. It is generally believed
that the earliest events in the
evolution of acute pancreatitis
lead to premature intra-acinar cell
activation
Page 90 of 106
Nursing Interventions:
Pharm: Antibiotics,
Opiod analgesics/Pain
meds (Demorol is
CONTRAINDICATED!),
Anticholinergics,
Pancreatic enzymes,
Proton pump inhibitors
(Omeprozole/Prilosec),
TPN
Pt. Ed:
Nursing Dx:
-Acute pain r/t obstruction of
pancreatic bile
ducts/inflammation
-Risk for deficient fluid
volume r/t loss of fluid from
vomiting/gastric suction
Pt. Goals/ Evaluation:
-Patient will report
controlled/relief of pain, and
adhere to medication
regimen
Dx:
CIRRHOSIS
Patho: A CHRONIC liver disease
characterized by an irreversible
scarring of the liver. This extensive
scarring causes a disruption in the
normal function of the liver. The liver
is a very important organ that
functions in the body to help:
-Store Blood Sugar (as GLYCOGEN)
-Produce Bile (TO DIGEST FOOD)
-Filter out toxins/wastes in blood
stream (INCLUDING
DRUGS/ALCOHOL)
-Take Pancreatic
enzymes before meals
and snacks
-High caloric diet/needs
-NO ALCOHOL! (Refer to
program as needed)
-Limit fat intake
-Follow up with all
appts/lab work
Nursing Interventions:
Pharm: Diuretics (Lasix,
Aldactone), Flagyl (to
reduce bacteria in
intestine), Lactulose to
Ammonia, supplemental
vitamins, PPIs
(Prevacid), Albumin (to
decrease ascites)
Nursing Dx:
-Imbalanced Nurtrition: less
than body requirements r/t
poor nutrition and
nausea/vomiting
-Fluid volume excess r/t
compromised regulatory
mechanism and excessive
fluid/ sodium intake
Pt. Ed:
-NO ALCOHOL!
Referral to TX Program if
needed
-Follow Dietary
guidelines for condition
Page 91 of 106
CONTRIBUTING FACTORS:
-Excessive Alcohol (Laennecs)
-Post Necrotic (r/t
Hepatitis/chemicals)
-Billiary Disease
-SEVERE Right-sided heart failure
Page 92 of 106
- Bleeding
precautions/Risk for
bleeding
Surgery: Transplant
(*ONLY IF ELIGIBLE!! Will
not be a candidate if
alcoholic/drug related)
DATA
ACTION
Nursing Interventions:
Pharm: TREAT THE CAUSE!!
Electrolyte ImbalancesHYPERKALEMIA: Kayexalate (Usually
given by enema)
ANEMIA: EPOGEN (Procrit)
PHOSPHATE / CALCIUM: PHOSLO,
CALCUM ACETATE
Diuretics (as directed)
Pt. Ed:
Adhere to diet:
OLIGURIC PHASE: Protein,
Potassium, Carb
DIURESIS PHASE: Protein, Calorie,
Restricted Fluids (As indicated), Bed
rest in Oliguric Phase, Dialysis as
ordered.
Also. Daily weights, Monitor I&Os
Page 93 of 106
RESPONSE
Nursing Dx:
-Fluid Volume excess
related to compromised
regulatory mechanism
(renal failure)
-Risk for infection r/t
altered immune
functioning
Pt. Goals/ Evaluation:
-Fluid volume will be
within normal limits for
patient and homeostasis
will be achieved.
-Pt will show no signs or
symptoms of infection
prior to discharge
Page 94 of 106
Nursing Interventions:
Pharm: ANEMIA: EPOGEN (Procrit)
PHOSPHATE / CALCIUM: PHOSLO,
CALCUM ACETATE, also: BLOOD
TRANSFUSION if necessary
HEMODIALYSIS!! (Can be in hospital, or
at home/Peritoneal)
Nursing Dx:
-Impaired urinary
elimination r/t effects of
disease, need for dialysis
-Fatigue r/t effects of
chronic anemia and
uremia
DIALYSIS:
Page 95 of 106
Assess:
Vitals:
S/S & PHYS. EXAM:
(aka, END STAGE RENAL FAILURE/
-anemia (may begin earlier than
END-STAGE RENAL DISEASE)
this) easy bleeding and bruising
Patho: This is a long-term
-Headache
condition caused by several factors!!
-Fatigue (more than normal or
Diabetes is a common one
usual )and weakness
Remember the washing machine that
-Mental symptoms such as
is your kidneys? Chronic high blood
ALOC/confusion, inability to
sugar increases the bloods viscosity,
concentrate
much like putting cement in a
-Nausea, vomiting, anorexia &
washing machine and expecting it to
thirst
work the same! This syrupy blood
-Muscle cramps, muscle
can reduce blood flow, oxygen
twitching
transport, and necrosis. Very similar,
-Nocturia
HYPERTENSION can cause the same
-Numb sensation in the
problem. If there is too much water
extremities
filtering through your
-Diarrhea
Glomeruli/washing machine, it
- Itchy skin/Eyes
CANNOT work the way it needs to!!
-Grayish complexion, can also be
Thus causing LOW GLOMERULAR
yellowish-brownish tone
FILTRATION RATE (GFR).
-Generalized Edema (more than
Remember, ONCE THESE
you had while in advanced renal
GLOMERULI DIE, THEY CANNOT
failure, and most likely in the
HEAL AND RETURN TO NORMAL!
feet and/or ankles)
Causes kidney death!!
-SOB (due to fluid in the lungs,
anemia)
End Stage Renal Disease is technically
-Hypertension
that last phase of the above renal
CHRONIC RENAL
INSUFFICIENCY
Page 96 of 106
Nursing Interventions:
Pharm: ANEMIA: EPOGEN (Procrit)
PHOSPHATE / CALCIUM: PHOSLO,
CALCUM ACETATE, also: BLOOD
TRANSFUSION if necessary
HEMODIALYSIS!! (Can be in hospital, or
at home/Peritoneal)
Nursing Dx:
-Impaired urinary
elimination r/t effects of
disease, need for dialysis
-Fatigue r/t effects of
chronic anemia and
uremia
NEPHROTIC SYNDROME
Nursing Interventions:
Pharm: Corticosteroids (Prednisone),
Diuretics (LASIX), Salt-poor Albumin
Vitals: BP
S/S & PHYS. EXAM:
-Hypoalbuminemia (low level of
albumin in the blood)
-Proteinuria (Protein in urine)
-Edema (Starts w/ eyes, then
systemic, called ANASARCA)
-Hypercholesterolemia (high
level of cholesterol in the blood)
-Hematuria (blood in urine)
- Ascities
- Oiliguria
- Anorexia
- Malaise
- Nausea
Surgery: N/A
Page 97 of 106
Nursing Dx:
-Excess fluid volume r/t
compromised regulatory
mechanism
-Activity intolerance r/t
generalized edema
Pt. Goals/ Evaluation:
-Patient was able to
display stable weight, vital
signs within patients
normal range, and nearly
absence/ reduction of
edema.
KIDNEY STONES
Patho: Kidney stones (renallithiasis) are small, hard deposits that
form inside your kidneys. The stones
are made of mineral and acid salts.
Kidney stones have many causes and
can affect any part of your urinary
tract from your kidneys to your
bladder. Often, stones form when
the urine becomes concentrated,
allowing minerals to crystallize and
stick together.
Page 98 of 106
Nursing Interventions:
Pharm: NARCOTICS for PAIN
MANAGEMENT!! Also FLUIDS to help
Flush/Pass stone, Corticosteroids for
Inflammation, as well as Antisposmotics
Pt. Ed: Report increasing pain, or
feeling of Passing Stone. Drink LOTS
of fluids to promote passing. Refrain
from foods that may contribute to
stone formation, Foods that contain
high levels of OXYLATE, including:
Peanuts, rhubarb, spinach, beets, choc
olate and
sweet potatoes
Surgery: Surgical removal of stones as
needed
Nursing Dx:
-Acute pain r/t
Inflammation/obstruction,
and abrasion of urinary
tract by migration of
stones.
-Altered urinary
Elimination
Pt. Goals/ Evaluation:
-Pt will report pain as
tolerable and verbalize
ways to distract
themselves from pain
-Pt will show an adequate
urinary output for their
status/condition
GLOMERULONEPHRITIS
Patho: Antibody reaction
SECONDARY to infection else ware
inside the body. SAME
INFLAMMATION, DIFFERENT CAUSE!
The initial reaction is usually either
an upper respiratory infection or skin
infection due to group A betahemolytic Streptococcus. This leads
to the formation of an antigenantibody reaction. It is followed by
the release of a membrane-like
material from the organism into the
bodys circulation. Antibodies
produced react against the
glomerular tissue, thus forming
immune complexes. The immune
complexes become trapped in the
glomerular loop and cause an
inflammatory reaction in the affected
Nursing Interventions:
Pharm:
-Penicillin (For Strep)
-Corticosteroids (For inflammation)
-Anti-hypertensives (For BP)
Pt. Ed: Bed rest during acute phase,
Patient can resume normal
activities gradually as symptoms
subside. Diet: Calories, Protein,
Sodium, Potassium, Fluids.
Hand hygiene, prevent contact with
infected people.
-Monitor intake and output/daily
Weight
-Teach Pt. to report peripheral edema
or the formation of ascites.
-Explain to the patient taking diuretics
They may experience orthostatic
hypotension and dizziness when
changing positions quickly
Page 99 of 106
Nursing Dx:
- Acute pain r/t edema of
kidney
-Imbalanced Nutrition,
Less than body
requirements r/t
anorexia/restrictive diet
Surgery: N/A
Nursing Interventions:
Pharm: Narcotics for pain and to
prevent/decrease bladder spasm,
FOR BPH:
Urinary Antibiotics, Alpha-Blocker
Meds (To promote urinary flow, such as
FLOMAX), Enzyme inhibitors (To
decrease size of Prostate, such as
AVODART / PROSCAR
Pt. Ed: TURP rarely causes erectile
dysfunction, but may trigger retrograde
ejaculation because removal of the
prostatic tissue at the bladder neck can
cause seminal fluid to flow backward
into the bladder rather forward
through the urethra during ejaculation.
Surgery: THIS IS THE SURGERY!
Nursing Dx:
-Acute pain r/t incision,
bladder irrigation, bladder
spasms
-Risk for urinary retention
r/t Obstruction of urethra
catheter with clots
Pt. Goals/ Evaluation:
-Pt will report pain as
tolerable and verbalize
ways to distract
themselves from pain
-Pt will show an adequate
urinary output for their
status/condition
Nursing Interventions:
Pharm: Antimicrobial (Sulfonamides,
UNLESS ALERGIC!! THEN, Bactrim or
Macrodantin)
Pt. Ed: FLUIDS!! Also cranberry juice,
WIPE FROM FRONT TO BACK!! Just
think of my song I GOT ANOTHER
UTI!... DONT SAY I DONT KNOW HOW
TO WIPE!! Women (You have shorter
Urethras): Avoid bubble baths, VOID
AFTER SEX, Wear cotton underwear.
Surgery: N/A
Nursing Dx:
-Acute Pain r/t
inflammation of urinary
tract
-Urinary retention r/t
acute condition
Pt. Goals/ Evaluation:
-Pt will report pain as
tolerable and verbalize
ways to distract
themselves from pain
-Pt will show an adequate
urinary output for their
status/condition
Nursing Interventions:
Pharm: Urinary Antibiotics, AlphaBlocker Meds (To promote urinary flow,
such as FLOMAX), Enzyme inhibitors (To
decrease size of Prostate, such as
AVODART / PROSCAR
Nursing Dx:
- Acute pain r/ t mucosal
Irritation: bladder
distention
& urinary infection
-Urinary retention r/t
mechanical obstruction/
enlarged prostate
Pt. Goals/ Evaluation:
-Pt will report pain as
tolerable and verbalize
ways to distract
themselves from pain
-Pt will show an adequate
urinary output for their
status/condition
DATA
ACTION
Nursing Interventions:
Pharm: Analgesics for pain,
Hormone therapy as needed,
Antibiotic if surgery
Pt. Ed: Common in young
African American women,
Family history of fibroids,
Obese, Age 30+, and eating a
lot of red meat/pork
Surgery: To remove
mass/part of reproductive as
necessary per patients
situation (Myoectomy,
Hysterectomy), Endometrial
Ablation, Fibroid Ablation,
Uterine Fibroid Embolisation
RESPONSE
Nursing Dx:
-Acute Pain r/t
Inflammation of
Uterus
-Anxiety r/t changes
in health status
Pt. Goals/
Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Client will report
reduced anxiety level,
ways to reduce
anxiety, and
understanding of
diagnosis/health
process
OVARIAN CANCER
Patho: Cancerous growth, originating from different
parts of the ovary:
Contributing Factors:
-Over 40
-Never been Pregnant OR
-First pregnancy after 30 years of age
-Family hx of ovarian, breast, or colon cancer
-Hx of Dysmenorrhea or heavy breathing
-Hormone replacement therapy
-Infertility medication use
Nursing Interventions:
Pharm: Chemotherapy and
Radiation as needed
Pt. Ed: Genetic testing for
risk, Check-up for
reoccurrence (CA-125 Blood
test/HE-4) , signs and
symptoms of reoccurrence,
side effects of
chemo/medications
Surgery: Surgery to remove
diseased parts as needed
Nursing Dx:
-Anxiety r/t
prognosis, lack of
knowledge of disease
process and threat of
malignancy
- Disturbed body
image r/t loss of
diseased body
part/loss of good
health
Pt. Goals/
Evaluation:
-Client will report
reduced anxiety level,
ways to reduce
anxiety, and
understanding of
diagnosis/health
process
- Client will discuss
concerns, what to
expect after
chemo/surgery, and
ways to limit anxiety
about body image
13. Bibliography
Ebersole, P., Hess, P., Touhy, T.A., Schmidt Logan, A., & Jett, K. (2008) Toward healthy aging: Human
needs and nursing response ( 7th ed.). St. Louis, MO: Mosby.
Eliopoulous C. (2009). Gerontological nursing. ( 7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Grodner, M., Long, S., & Walkingshaw,B.C. (2007). Foundations and clinical application of nutrition: A
nursing approach ( 4th ed.). St. Louis, MO: Mosby.
Ignatavicius, D. D., & Workman, M. L. (2010). Medical-Surgical nursing (6th ed.). St. Louis, MO: Saunders.
Lowdermilk, D.L.,& Perry, S.E. ( 2007) . Maternity & womens health care (9th ed.). St. Louis, MO: Mosby.
Lehne, R.A. (2010). Pharmacology for nursing care (7th ed.). St. Louis, MO: Saunders.
Lilley, L. L., Harrington, S., & Snyder, J.S. (2007). Pharmacology and the nursing process (5th ED.). St.
Louis, MO: Mosby.
Roach, S. S.,& Ford, S. M. (2008). Introductory clinical pharmacology. Philadelphia, PA: Lippincott Williams
& Wilkins.
Smeltzer, S. C., Bare, B.G., Hinkle, J. L., & Cheever, K.H. ( 2008). Brunner and Suddarths textbook of
medical-surgical nursing ( 11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.