GASTROINTESTINAL by DUKE TRILLANES August 20, 2011

GASTROINTESTINAL I. Anatomy & Physiology A. Upper gastrointestinal tract 1. Mouth: teeth and salivary glands 2. Esophagus 3. Stomach B. Lower gastrointestinal tract 1. Small intestine - digests and absorbs, mixes via peristalsis, receives secretions from liver, gallbladder and pancreas a. duodenum - joins pylorus of the stomach, is about ten inches long b. jejunum - middle section, is about eight feet long c. illeum - lower section, is about 12 feet long 2. Colon - approximately six feet long, absorbs water and sodium a. ascending b. transverse c. descending d. sigmoid e. rectum - last seven - eight inches of intestines C. Accessory digestive organs 1. Liver - largest gland of the body a. lobes dived into lobules by blood vessels and fibrous material b. ducts - hepatic duct from liver; cystic duct from gallbladder; common bile duct formed by hepatic duct and cystic duct and drains into duodenum c. functions: Metabolism of fat, carbohydrates and protein i. converts glucose to glycogen for storage ii. converts glycogen to glucose and releases into blood iii. forms glucose from fats or proteins iv. breaks down fatty acids into ketones v. stores fat vi. synthesizes triglycerides, phospholipids, cholesterol, and choline (B complex factor) vii. synthesizes various proteins viii. converts amino acid to ammonia ix. converts ammonia to urea d. other functions i. secretes bile, which is important in the emulsifying of fats ii. detoxifies substances such as drugs, hormones iii. metabolizes vitamins 2. Pancreas a. fish-shaped organ extending from duodenal curve to the spleen b. both an endocrine and exocrine gland i. pancreatic cells - empty into duodenum at the hepatopancreatic papilla; secrete enzymes which digest fats, carbohydrates and proteins ii. islet of Langerhans a) alpha cells secrete glucagon to promote liver glycogenolysis and gluconeogenesis which ultimately increases blood glucose level b) beta cells secrete insulin 3. Gallbladder a. similar size and shape as a pear b. made up of smooth muscle and lined with rugae-arranged mucosa

c. only purpose is to store bile d. empties bile into duodenum when fat is present there D. Process of digestion 1. Purpose - converts foods into a form which can be absorbed and used by the body 2. Digestive enzymes 3. Basic processes a. absorption - accomplished by active transport via intestinal cells. Water and solutes move through the intestinal mucosa in opposite direction expected in osmosis and diffusion b. metabolism - consists of the sum of all physical and chemical changes that take place within an organism c. catabolism - series of chemical reactions that take place within the cell; breaks down food molecules to produce energy i. anabolism - synthesis of compounds from simpler compounds II. Disorders of Stomach and Colon A. Pernicious anemia - anemia caused when tissues fail to absorb enough vitamin B12 1. Definition/etiology/risk a. mucosa and parietal cells of stomach atrophy; stomach fails to produce intrinsic factor, thus cannot properly absorb vitamin B12 b. possibly an autoimmune disease c. may follow gastric resection 2. Pathophysiology a. large RBCs - macrocytic normochromic b. hydrochloric acid 3. Findings a. anemia - findings depend on severity b. tissue hypoxia producing fatigue, weakness, dyspnea, pallor, palpitations c. GI symptoms: sore tongue, anorexia, nausea, vomiting, abdominal pain, neurological symptoms d. neurological symptoms: paresthesia in hands and feet, weakness, impaired coordination, changes in LOC. 4. Complications: GI symptoms are reversible, but neurological changes are not 5. Diagnostics a. CBC b. bone-marrow biopsy c. lack of free hydrochloric acid in stomach d. Schilling test 6. Management a. lifelong vitamin B12 therapy b. adequate nutrition c. blood transfusions as needed 7. Nursing interventions a. monitor for impaired gas exchange b. manage fatigue c. risk of injury from depressed LOC and impaired coordination d. knowledge deficit- need to understand chronic illness B. Peptic ulcer diseases - include disorders that ulcerate any part of stomach or intestines. 1. Gastric ulcers a. definition/etiology i. incidence higher in the middle-aged and elderly; most common in men ages 45-55 ii. risk factors: aspirin, NSAIDs, steroids, caffeine, and alcohol intake; stress iii. pathogen: H. pylori b. pathophysiology

i. something disrupts mucosal layer and acid diffuses back into mucosa ii. commonest site: junction of fundus and pylorus iii. normal gastric acid secretion c. findings i. pain, burning or gas, worse with food ii. pain in left upper epigastric area iii. nausea/vomiting iv. bleeding; hematemesis 2. Duodenal ulcers a. etiology/risk factors i. excess production of hydrochloric acid ii. more rapid gastric emptying iii. familial tendency iv. stress v. more frequent in people with type O blood vi. more common in men ages 25 to 50 b. pathophysiology i. located 0.5 to 2 cm below pylorus ii. arteriosclerotic changes in adjacent blood vessels iii. vagus nerve stimulation causes tissues to release gastrin, which increases secretion of hydrochloric acid c. findings i. pain, heartburn occur during night or when stomach is empty ii. pain relieved by food intake iii. melena (tarry stool; black with digested blood) d. diagnostic studies i. endoscopy - esophagogastroduodenoscopy ii. complete blood count (CBC) iii. test stool for occult blood e. complications i. hemorrhage a) treat with tap water lavage to control bleeding b) administer Intra-arterial vasopressin c) administer Intravenous fluids and blood replacement ii. perforation and peritonitis a) finding: severe abdominal pain b) finding: board-like abdomen iii. paralytic ileus (obstruction): scarring may obstruct pylorus f. management i. NPO (nothing by mouth) ii. nasogastric tube iii. antibiotics: clarithromycin (Biaxin); metronidazole (Flagyl) iv. H2 receptor antagonists: cimetidine (Tagamet); rantidine hydrochloride (Zantac); famotidine (Pepcid); nizatidine (Axid) v. anticholinergics: dicyclomine hydrochloride (Bentyl) vi. antacids; aluminum hydroxide (Amphogel); aluminum-magnesium combinations (Maalox, Mylanta, Gelusil); calcium carbonate (Tums) vii. cytoprotective: sucrulfate (Carafate) viii. proton pump inhibitors: omeprazole (Prilosec), iansoprazole (Prevacid) ix. anxiolytics x. blood administration xi. surgical Intervention a) vagotomy: eliminates stimulation of gastric cells b) pyloroplasty: widening pylorus to improve gastric emptying c) subtotal gastrectomy

d) billroth I (gastroduodenostomy) e) billroth II (gastrojejunostomy) f) total gastrectomy 3. Postoperative complications a. dumping syndrome - from rapid emptying of the stomach i. tachycardia, palpitations, syncope, diaphoresis, diarrhea, nausea, abdominal distention ii. more common with Billroth II iii. subsides after several months iv. decrease with slow eating, lowcarbohydrate, high-protein and fat diet v. avoid liquids with meals b. pernicious anemia secondary to loss of intrinsic factor 4. Nursing interventions a. pain relief b. assess for bleeding c. discuss life-style changes: stop smoking, decrease stress d. teaching - medications, diet e. assess for post-operative complications infection, bleeding, respiratory complications f. maintain patency of NG tube g. observe drainage for signs of bleeding (drainage should be dark red after 24 hours) h. mouth care III. Disorders of Intestines A. Inflammatory intestinal diseases - chronic, recurrent inflammation; etiology unknown 1. ulcerative colitis a. definition/etiology i. affects young people ages 15 to 40 b. pathophysiology i. ulceration and inflammation entire length of colon ii. involves mucosa and submucosa iii. begins in rectum and extends to distal colon iv. abscess and ulcers lead to bleeding and diarrhea v. colon cannot absorb, so fluids and electrolytes go out of balance vi. protein is lost in stools vii. scarring produces narrowing, thickening, and shortening of colon viii. remissions and exacerbations c. findings i. bloody diarrhea ranging from two to three per day to ten to 20 per day ii. stools may also contain pus and mucus iii. abdominal (tenderness and cramping) pain iv. fever, weight loss, anemia, tachycardia, dehydration v. impaired absorption of fat-soluble vitamins such as E, K vi. systemic manifestations a) skin lesions - erythema nodosum b) joint inflammation c) inflammation of the eyes - uveitis d) liver disease d. diagnosis i. sigmoidoscopy ii. colonoscopy iii. barium enema - definition iv. complete blood count (CBC) e. management i. rest ii. fluid, electrolyte, and blood replacement iii. steroids as anti-inflammatories iv. immunosuppressives

v. anti-infectives: sulfasalazine (Azulfidine) primary drug of choice vi. anticholinergics vii. antidiarrheals viii. dietary restrictions - high calorie and high protein ix. surgical management a) total proctolectomy and ileostomy b) ileorectal anastomosis c) total proctolectomy with continent ileostomy (Kock pouch) d) total colectomy with ileal pouch (reservoir) f. complications i. increased risk of colon cancer ii. fluid and electrolyte imbalances g. nursing interventions i. manage pain ii. manage diarrhea iii. teach weight loss and nutrition iv. teach coping v. remedy knowledge deficit vi. reduce anxiety 2. Crohn's disease a. definition/etiology i. young people 15 to 30 years old ii. inflammation of segments of bowel, especially ileum, jejunum, and colon, with areas of normal bowel between inflamed bowel cobblestone appearance iii. inflammation involves all layers of bowel wall - transmural iv. ulceration, fissures, fistula, and abscess formation v. bowel wall thickens and narrows, producing strictures vi. slowly progressive b. findings i. diarrhea with steatorrhea (fats not processed) ii. abdominal pain - right lower quadrant (illustration) iii. fatigue, weight loss, dehydration, fever iv. systemic manifestations a) arthritis, clubbing of fingers b) skin inflammations c) nephrolithiasis c. complications i. obstruction from strictures ii. fistula formation iii. bowel may perforate and infect: peritonitis iv. medical management a) rest b) nutritional support c) hyperalimentation d) diet high in calories and protein, low in roughage and fat e) steroids as anti-inflammatories f) immunosuppressives g) anti-infectives: sulfasalazine (Azulfidine) primary drug of choice h) anticholinergics i) antidiarrheals j) loperamide (Imodium) drug of choice k) balloon dilation of strictures l) surgery will not cure Crohn's disease; may limit damage 1. colectomy with ileostomy 2. subtotal colectomy with ileostomy or ileorectal anastomosis d. nursing interventions i. after surgery, monitor

a) diarrhea b) fluid balance and nutrition c) skin integrity d) coping and self-care e) sexuality f) medications B. Diverticular disease - outpouching of the intestinal mucosa 1. Definition/etiology a. most common in sigmoid colon b. constipation, low fiber diet, obesity c. colon wall thickens with increased pressure in bowel d. stool and bacteria retained in diverticulum become inflamed and small perforations occur e. inflammation of surrounding tissue 2. Findings a. frequently asymptomatic b. crampy, lower, left abdominal pain c. alternating constipation and diarrhea d. low grade fever, chills, anorexia, nausea e. leukocytosis 3. Diagnosis a. barium enema b. complete blood count, urinalysis, stool for occult blood c. colonoscopy 4. Management a. diverticulosis (outpouching) i. high fiber diet ii. bulk laxatives iii. stool softeners iv. anticholinergics b. diverticulitis (inflammation) i. NPO ii. rest bowel iii. antibiotics iv. surgery a) bowel resection b) temporary colostomy 5. Complications a. abscess formation b. perforation with peritonitis c. fistula d. bowel obstruction 6. Nursing interventions a. teach appropriate diet b. avoid straining, coughing, lifting c. avoid increased abdominal pressure C. Constipation 1. Definition/etiology a. change in normal bowel habits characterized by i. decreased frequency ii. stool is hard, dry, difficult to pass iii. stool is retained in rectum b. etiology/risk factors i. insufficient dietary fiber ii. insufficient fluid intake iii. medications, especially opiates iv. lack of activity v. ignoring urge to defecate vi. chronic laxative abuse vii. lack of privacy/psychological factors viii. pregnancy ix. neuromuscular impairment x. hypothyroidism 2. Findings a. hard, dry stool b. abdominal distention c. decreased frequency of usual patterns

d. straining e. nausea/anorexia f. palpable mass g. hemorrhoids h. fecal impaction with diarrhea 3. Complications a. obstruction/perforation b. cardiovascular alterations 4. Management a. cathartics i. saline laxatives - milk of magnesia ii. stimulant laxatives - bisacodyl (Dulcolax) iii. bulk-forming laxatives - psyllium (Metamucil) iv. lubricant-emollient - mineral oil v. stool softeners - docusate sodium (Colace) b. enemas i. cleansing - saline, soap solution ii. softening - oil retention 5. Nursing interventions a. teach nutrition, increased fiber, and increased fluids b. teach: obey urge to defecate c. provide privacy and comfort d. increase activity D. Diarrhea 1. Definition/etiology - loose stools due to a. fecal impaction b. ulcerative colitis c. intestinal infections d. increased fiber e. medications 2. Finding - loose watery stools 3. Complications - dehydration, electrolyte imbalance 4. Management a. mild diarrhea - oral fluids to replace lost fluid b. moderate diarrhea - drugs that decrease motility (Lomotil, Imodium) c. severe diarrhea - due to infection, antimicrobials and fluid replacement 5. Nursing interventions a. monitor for fluid and electrolyte imbalance b. prevent skin excoriation c. teach client about foods that may affect bowel elimination, e.g., fruits, vegetables E. Bowel obstruction 1. Definition/etiology a. mechanical: adhesions, hernias, neoplasms, volvulus, intussusception b. nonmechanical: paralytic ileus, occlusion of vascular supply c. distended abdomen from accumulation of fluid, gas, intestinal contents d. fluid shifts due to increased venous pressure with hypotension and hypovolemic shock e. bacteria proliferate 2. Findings a. abdominal pain b. distention (more with large bowel obstruction) c. nausea/vomiting (more with small bowel obstruction) d. hypoxia e. metabolic acidosis f. bowel necrosis from impaired circulation 3. Complications a. perforation and peritonitis b. shock c. strangulation of bowel 4. Diagnosis

a. upper-GI and lower-GI series b. abdominal X rays show air in bowel c. low fluid volume increases white blood cells, hemoglobin & hematocrit, BUN 5. Management a. decompress the abdomen b. nasointestinal tube c. surgical bowel resection 6. Nursing interventions a. manage pain, but avoid morphine or codeine, which slow bowel motion b. measure abdominal girth c. with nasogastric or nasointestinal tubes, provide oral care d. nasogastric tubes: Salem sump (double lumen), Levin (single lumen) e. nasointestinal tubes i. cantor tube - single lumen, mercury filled weight on tip ii. miller-Abbott - double lumen with mercury weighted tip iii. advance two inches per hour f. maintain fluid and electrolyte balance F. Colon cancer 1. Definition/etiology a. may develop from adenomatous polyps b. risk factors - low residue diet, high-fat diet, refined foods 2. Pathophysiology a. adenocarcinoma is the most common type b. most common locations are sigmoid rectum and ascending colon c. often metastasizes to the liver d. classification (staging) systems: TNM or Duke's 3. Findings a. rectal bleeding b. change in bowel habits - constipation, diarrhea c. change in shape of stool d. anorexia and weight loss e. abdominal pain, palpable mass 4. Diagnostics a. colonoscopy b. sigmoidoscopy c. digital examination d. stool for occult blood e. barium enema f. CT scan g. carcinoembryonic antigen (CEA) h. alkaline phosphatase and AST (aspartate aminotransferase) 5. Complications - obstruction 6. Management a. radiation b. chemotherapy c. treatment of choice is surgery - bowel resection, colostomy i. right hemicolectomy - involves ascending colon ii. left hemicolectomy - involves descending colon iii. abdominal-perineal resection: removal of sigmoid colon and rectum with formation of a colostomy 7. Nursing interventions a. manage pain b. monitor for complications i. wound infection ii. atelectasis iii. thrombophlebitis

c. maintain fluid and electrolyte balance d. care of ostomy IV. Disorders of the Liver A. Hepatitis 1. Definition/etiology - acute inflammatory disease of the liver caused by viral, bacterial, or toxic ingestion 2. Pathophysiology a. inflammation of liver, enlargement of Kupffer cells, bile stasis b. regeneration of cells with no residual damage c. types i. hepatitis A a) transmitted from infected food, water, milk, shellfish b) fecal-oral route of infection common in poor sanitation/overcrowding c) higher incidence in fall and winter d) new vaccine available ii. hepatitis B a) blood-borne and sexually transmitted b) may become a carrier iii. hepatitis C a) transmitted parenterally (post-transfusion hepatitis) and possibly fecal-oral route b) may become a carrier iv. hepatitis D a) blood borne b) coexists with hepatitis B v. hepatitis E a) water borne b) contaminated food or water; rare in the United States B. Hepatitis B 1. Risk factors/infection route a. homosexuality b. iv drug use c. health professionals d. hemodialysis e. transmission routes i. sexual ii. fecal-oral route: incubation 12 to 14 weeks or longer f. pathophysiology i. hepatitis B has three distinct antigens a) HBsAg - surface antigen b) HBcAg - core antigen c) HBeAg - e antigen ii. damage to the hepatocytes causes inflammation and necrosis iii. liver function decreased in proportion to damage iv. healing takes three - four months 2. Findings a. jaundice if liver fails to conjugate bilirubin or excrete it b. clay-colored stools from lack of urobilin c. urine is dark from urobilin excreted in urine rather than stool d. urine foams when shaken e. pruritus from bile salts excreted through skin f. right upper quadrant pain from edema and inflammation of liver g. anorexia, nausea, vomiting, malaise, weight loss h. prolonged bleeding from impaired absorption of vitamin K i. anemia from decreased RBC lifespan 3. Diagnostics - serologic markers of HBV a. HBsAg - hepatitis B surface antigen

b. anti-Hbc - antibodies to B core antigens c. elevated alanine aminotransferase (ALT previously SGPT) d. elevated bilirubin e. elevated aspartate aminotransferase (AST; previously SGOT) f. elevated alkaline phosphatase g. prolonged prothrombin time 4. Management - nonspecific and supportive a. symptomatic treatment of pain b. antiemetics as needed 5. Nursing interventions a. fatigue - provide rest periods; may require bed rest initially b. maintain skin integrity c. client will tolerate less activity d. nutrition needs: i. increase carbohydrates and proteins; decrease fat ii. avoid alcohol iii. eat frequent, small meals e. remedy knowledge deficit f. arrange for home care needs g. teach infection control i. use disposable utensils and dishes or keep separate from others ii. good handwashing iii. do not share razors, toothbrush, etc. 6. Prevention a. hepatitis B vaccine provides active immunity b. hepatitis B immune globulin provides passive immunity c. observe Standard and Enteric Precautions d. good handwashing C. Cirrhosis 1. Definition/etiology - irreversible, chronic, progressive degeneration of the liver, with fibrosis and areas of nodular regeneration a. types i. Laennec's cirrhosis - related to alcohol abuse ii. post-necrotic - associated with viral hepatitis or exposure to hepatotoxin iii. biliary cirrhosis - associated with inflammation or obstruction of gallbladder or bile duct iv. cardiac cirrhosis - associated with congestive heart failure 2. Pathophysiology a. nodular liver with fibrosis and scar tissue b. destroys hepatocytes and kills tissue (necrosis) c. necrosis, nodules, and scar tissue obstruct flow of blood, lymph, and bile d. impaired bilirubin metabolism 3. Findings a. weakness, fatigue, weight loss, hepatomegaly b. right upper quadrant pain c. jaundice, pruritus, steatorrhea (decreased absorption of fat and fat-soluble vitamins) d. clay-colored stools e. increased bilirubin in urine, producing dark colored urine f. impaired aldosterone metabolism resulting in edema g. impaired estrogen metabolism: gynecomastia, menstrual changes, changes in distribution of body hair, vascular changes spider angiomas, palmar erythema h. impaired metabolism of protein, carbohydrate, and fat

i. produces less plasma protein, resulting in edema and ascites ii. produces less of proteins needed for clotting (fibrinogen and prothrombin) iii. absorbs less vitamin K, resulting in prolonged bleeding iv. liver fails to convert glycogen to glucose, resulting in hypoglycemia 4. Diagnostics a. liver function studies - ALT, AST, alkaline phosphatase b. prothrombin time, CBC c. decreased cholesterol because liver synthesis impaired d. elevated serum bilirubin and urine bilirubin e. ERCP to examine bile duct f. CTscan of liver g. liver biopsy 5. Management a. steroids for post-necrotic cirrhosis b. replace B vitamins and fat-soluble vitamins c. diet i. increased carbohydrates ii. protein may be restricted, depending on amount of damage and symptoms iii. no alcohol 6. Nursing interventions a. monitor for bleeding b. alteration in nutrition i. 2,000-3,000 calories daily ii. low fat c. provide rest periods; client will not tolerate strenuous activities d. remedy any knowledge deficit about cirrhosis and its therapies e. changes in LOC i. confusion ii. avoid sedation f. impaired skin integrity, from edema and pruritus g. monitor fluid balance h. measure abdominal girth daily i. weigh daily j. measure I & O 7. Complications a. portal hypertension b. ascites c. hepatic encephalopathy D. Portal hypertension 1. Definition/etiology - increased pressure in the portal 2. Pathophysiology: normal blood flow is altered producing an increased resistance to flow through the liver. Congestion in the portal system dilates veins, especially in esophagus and rectum. 3. Findings a. prominent abdominal-wall veins (caput medusa) b. hemorrhoids c. enlarged spleen d. anemia from increased destruction of RBCs e. esophageal varices and GI bleeding 4. Diagnostics: endoscopy 5. Management a. sclerotherapy - injection of a sclerosing agent into varices b. balloon tamponade i. sangstaken-Blakemore tube is inserted into the stomach ii. gastric balloon is inflated and presses on

lower esophagus while allowing suctioning iii. esophageal balloon places pressure on varices iv. pressure is released as ordered to prevent necrosis v. traction for increased pressure added by attaching tube to football helmet vi. assess for bleeding and signs of shock vii. assess for respiratory distress - aspiration or displacement of tube, suction PRN viii. keep head of bed elevated c. medications i. vasopressin a) constricts veins and decreases portal blood flow b) given IV or into superior mesenteric artery c) side effects include hypothermia, myocardial ischemia, acute renal failure ii. nitroglycerin will decrease myocardial effects iii. beta-adrenergic neuron-blocking agents may decrease risk of recurrent bleeding by decreasing pressure in portal system iv. cathartics to remove blood from GI tract and decrease absorption of ammonia d. surgical intervention i. shunt to decrease blood flow to liver and therefore pressure Splenorenal shunt a) mesocaval shunt b) portacaval shunt ii. TIPS (transjugular intrahepatic portosytsemic shunt) - shunt placed between hepatic and portal vein 6. Nursing interventions a. prevent bleeding b. avoid intake of alcohol, irritating or rough food c. avoid increased pressure in abdomen d. if bleeding occurs - administer transfusions, fresh frozen plasma, vitamin K e. monitor for infection E. Ascites 1. Definition/etiology - accumulation of fluid in the peritoneum 2. Pathophysiology a. portal hypertension causes increased plasma and lymphatic hydrostatic pressure in portal system b. hypoalbuminemia causes decreased colloid osmotic pressure c. hyperaldosteronism due to liver's inability to metabolize aldosterone causes body to retain sodium and water 3. Findings a. abdominal distention, protruding umbilicus, dull sound on percussion of abdomen, fluid wave b. bulging flank c. dyspnea 4. Diagnostics a. abdominal x-ray b. CT scan c. ultrasound 5. Medical management a. diuretics - spirnolactone (Aldactone) aldosterone antagonist, spares potassium b. iv albumin c. paracentesis to remove fluid d. diet low in sodium e. peritoneal venous shunt - allows drainage of fluid from the peritoneum to superior vena cava

6. Nursing interventions a. abdomen will have excess fluid, blood vessels too little b. measure I & O, daily weight, abdominal girth, skin turgor c. restrict fluids d. monitor for ineffective breathing patterns e. semi-Fowler's position f. monitor for impaired skin integrity g. remedy knowledge deficit F. Hepatic encephalopathy - mental dysfunction associated with severe liver disease 1. Definition/etiology a. impaired ammonia metabolism in liver poisons brain tissue b. ammonia produced in bowel from action of bacteria on protein 2. Findings a. changes in LOC from confusion to coma b. changes in sleep pattern c. memory loss d. asterixis - flapping tremor e. impaired handwriting f. hyperventilation with respiratory alkalosis g. fetor hepaticus - musty, sweet odor to breath 3. Diagnostics - serum ammonia level 4. Management a. neomycin sulfate (Mycifradin) - inhibits action of intestinal bacteria b. lactulose (Cephulac) - absorbs ammonia and produces evacuation of the bowel c. low protein diet 5. Nursing interventions a. tremor, confusion can lead to injury: maintain safety b. ascites and low intake decrease fluid volume c. diarrhea from medications V. Disorders of Pancreas and Gallbladder A. Acute pancreatitis 1. Definition/etiology - inflammation of the pancreas a. alcohol ingestion b. gall stones c. drug ingestion d. viral infections e. trauma 2. Pathophysiology a. autodigestion from premature activation of pancreatic enzymes b. proteases and lipases, normally active in small intestine, are activated in the pancreas c. phospholipase A digests adipose and parenchymal tissues d. elastase digests elastic fibers of blood vessels, producing bleeding e. amylase digests carbohydrates f. inflammation response occurs from enzyme release 3. Findings a. left upper quadrant abdominal pain b. pain worsens after eating and when lying flat c. nausea and vomiting d. fever, agitation, confusion e. hypovolemia and shock f. hemorrhage into retroperitoneal space may

produce ecchymosis in flank or around umbilicus g. tachypnea, pulmonary infiltrates, atelectasis from circulating enzymes 4. Diagnostics a. elevated enzymes: serum amylase, serum lipase, and urinary amylase b. elevated WBCs, decreased hemoglobin and hematocrit c. elevated LDH and AST (SGOT) d. hyperglycemia e. hypocalcemia f. chest x- ray, CT scan, ultrasound, ERCP 5. Complications a. respiratory problems - atelectasis, pneumonia from the immobility imposed by pain b. tetany from decreased calcium levels c. abscess or pseudocyst 6. Management a. treat cause b. pain relief - meperidine (Demerol) c. fluid maintenance to prevent shock d. insulin for hyperglycemia e. calcium replacement f. decrease stimulation of pancreas i. NPO-TPN (nothing by mouth; total parenteral nutrition) ii. NG tube iii. anticholinergics iv. h2-receptor antagonists 7. Nursing interventions a. manage pain b. monitor alteration in breathing patterns c. monitor nutritional status d. oral care when NPO e. if eating is allowed, diet high in proteins and carbohydrates and low in fat f. monitor fluid and electrolyte balances B. Cholecystitis 1. Definition/etiology - inflammation of the gallbladder a. usually due to gallstones (Cholelithiasis) b. types i. cholesterol - most common ii. pigment - unconjugated bilirubin c. bile is blocked, and infects tissue d. more common in women, especially those over 40 and those who use birth control pills 2. Pathophysiology a. common bile duct is obstructed by a gallstone b. bile cannot be excreted, some is reabsorbed c. remaining bile distends and inflames gall bladder d. may scar gallbladder, resulting in less storing of the bile from the liver e. can perforate gall bladder 3. Findings a. colicky pain in right upper quadrant with possible radiation to right shoulder and back b. indigestion after eating fatty foods c. nausea and vomiting d. jaundice (if the liver is involved or inflamed or the common duct obstructed) e. low grade fever 4. Diagnostics

a. endoscopic retrograde cholangiography (ERCP) b. endoscopic retrograde catheterization of the gallbladder (ERCG) c. ultrasound 5. Management a. rest b. low-fat diet c. removal of stone in common duct by endoscopy d. to dissolve cholesterol stones i. chenodeoxycholic acid (Chenodiol) - side effects are diarrhea and hepatotoxicity ii. ursodeoxycholic acid (UDCA) e. control pain - meperidine (Demerol) is drug of choice f. replace vitamin K if bleeding time is prolonged g. extracorporeal shock wave lithotripsy - may have hematuria after procedure, but not longer than 24 hours h. choledocholithotomy - to remove or break up stones i. laparoscopic laser cholecystectomy j. cholecystectomy 6. Nursing interventions a. monitor vital signs b. monitor pain and medicate as needed c. teach client - dietary restriction of fatty foods POINTS TO REMEMBER! Most obstructions occur in the small bowel. Most large bowel obstructions are caused by cancer. Onset of cirrhosis is insidious with symptoms such as anorexia, weight loss, malaise, altered bowel habits, nausea and vomiting. Management of cirrhosis is directed towards avoiding complications. This is achieved by maintaining fluid, electrolyte and nutritional balance. A client with esophageal varices must be monitored for bleeding (e.g., melena stools, hematemesis, and tachycardia.) The rupture of esophageal varices is life threatening and associated with a high mortality rate. Pancreatitis is often associated with excessive alcohol ingestion. Pancreatic cancer is an insidious disease that often goes undetected until its later stages. Diverticula are most common in the sigmoid colon. Clients with diverticulosis are often asymptomatic. A deficiency in dietary fiber is associated with diverticulitis. Colostomies: an ascending colostomy drains liquid feces, is difficult to train and requires daily irrigation; a descending colostomy drains solid feces and can be controlled. Frequent liquid stools can be indicative of a fecal impaction or intestinal obstruction. Bowel sounds tend to be hyperactive in the early phases of an intestinal obstruction.

ENDOCRINE I. Anatomy and Physiology A. The endocrine system, together with the neurological system, functions as the communication system for the body B. Endocrine glands secrete hormones 1. Secreted in very small amounts 2. Alters the rate of many physiologic activities a. reproduction b. metabolism c. growth and development d. neurological and mental functions 3. Secreted into the blood 4. Regulated by several methods a. autonomic nervous system b. changes in concentrations of specific substances in plasma c. feedback system C. Glands D. Pituitary 1. Lies in sella turcica above the sphenoid bone 2. Consists of two lobes connected by the hypothalamus 3. Regulates the other endocrine glands by stimulating target organs 4. Controlled by releasing and inhibiting hormones from the hypothalamus E. Thyroid gland 1. Located at the level of the cricoid cartilage in front of the trachea 2. Two highly vascular lobes 3. Controls the rate of the body metabolism F. Parathyroid glands - parathormone (PTH) 1. Four small glands located near the thyroid gland 2. Controls calcium and phosphorus metabolism G. Adrenal glands 1. Two small glands lying in the retroperitoneal region 2. Functions a. cortex - promotes organic metabolism, regulates sodium and potassium, response to stress, preadolescent growth spurt b. medulla - stimulation of sympathetic nervous system, responds to stress H. Pancreas - insulin, glucagon secretion into the blood, an endocrine function 1. Lies retroperitoneally, with the head of the gland in the duodenal cavity and the tail lying against the spleen 2. Excretion of enzymes and bicarbonate that aid digestion and controls carbohydrate metabolism as an exocrine function I. Gonads - ovaries, estrogen, progesterone, inhibin - decreases secretion of folliclestimulating hormone (FSH); testes, testosterone 1. Located: two ovaries are situated in the lower abdomen on each side of the uterus. The testes are the pair of male sex organs that form within the abdomen but descend into the scrotum 2. Responsible for secondary sex characteristics and reproductive function II. General Concepts A. Endocrine glands must maintain homeostasis of about 50 billion cells. B. Endocrine glands are ductless, and secrete many hormones directly into the blood or

lymph. C. These hormones regulate growth; maturation; reproduction; metabolism; the balances of electrolytes, water, and nutrients; and the balances of behavior and energy D. Concentration in the bloodstream of most hormones is maintained at a constant level. If the hormone concentration rises, further production of that hormone is inhibited (also known as "feedback control") E. Unlike the endocrine, exocrine glands secrete their products through duct(s) into the body's cavities or onto its surface. Exocrine glands produce sweat (sweat glands), skin oils (sebaceous glands), mucus (mucous membranes), and digestive juices (for example, the pancreas in its exocrine function). III. Disorders of the Anterior Pituitary A. Hypopituitarism 1. Definition - underactivity of the front (anterior) pituitary gland a. classifications of pituitary tumors i. functioning: hormone present in insufficient quantities ii. non-functioning: hormone absent 2. Etiology - most common cause: neoplasms, usually benign 3. Findings - result from hormone deficiency (hypogonadism) a. hypogonadism, female: i. amenorrhea ii. infertility iii. decreased libido iv. breast and uterine atrophy v. loss of axillary and pubic hair vi. vaginal dryness b. hypogonadism, male i. decreased libido ii. impotence iii. small, soft testicles iv. loss of axillary and pubic hair c. hypothyroidism (because pituitary regulates thyroid glands by thyroid stimulating hormone (TSH)) d. hypoadrenalism (because pituitary regulates adrenal glands by ACTH production) e. may see signs of increased intracranial pressure (ICP) 4. Diagnostics a. history and physical exam b. neuro-ophthalmological exam c. x-rays of pituitary fossa d. radioimmunoassays of anterior pituitary hormones e. computerized tomogram (CT) scan 5. Management a. expected outcome: hormone deficiency corrected b. hormone replacement therapy i. corticosteroid therapy ii. thyroid hormone replacement iii. sex hormone replacement c. surgical removal of tumor 6. Nursing interventions a. provide for i. care of the client with increased ICP ii. care of the client undergoing surgery b. monitor for desired effects of administered medications as ordered c. provide emotional support with referral to support groups

d. teach client i. medications desired effects and side effects ii. need for lifelong hormone replacement therapy and regular checks of sirum levels B. Hyperpituitarism 1. Definition - anterior pituitary secretes too much growth hormone and/or ACTH 2. Etiology a. usually caused by benign neoplasm b. growth hormone overproduction: acromegaly c. ACTH overproduction leads adrenal gland to overproduce cortisone: Cushing's syndrome 3. Findings a. may see signs of increased ICP b. acromegaly: excess longitudinal bone growth c. prognathism d. coarse facial features e. prominent forehead and orbital ridge f. large, broad, spade-like hands g. arthritis, kyphosis 4. Diagnostics a. history and physical exam b. computerized tomogram (CT) scan c. plasma hormone levels: increased growth hormone, ACTH 5. Management a. expected outcome: remove tumor and restore hormonal balance b. surgical removal of tumor c. irradiation of gland d. pharmacologic: growth hormone suppressant: bromocriptine (parlodel) 6. Nursing interventions a. provide i. care of the client with increased ICP ii. care of the client undergoing surgery iii. care of the client undergoing radiation therapy iv. emotional support b. assess for signs of diabetes insipidus, since removal of a pituitary tumor may injure the posterior pituitary glands and decrease antidiuretic hormone (ADH) secretions c. teach client that treatment usually produces hypopituitarism so lifelong hormone replacement therapy with regular check-ups are required IV. Disorders of the Posterior Pituitary A. Diabetes insipidus 1. Posterior pituitary gland makes too little antidiuretic hormone (ADH). Body loses too much water in the urine; plasma osmolality and sodium levels increase. 2. Etiology can include tumor, trauma, inflammation, or psychogenic causes. 3. Findings a. excessive thirst (polydipsia) b. polyuria: as much as 20 liters per day with specific gravity below 1.006 c. nocturia d. signs of dehydration e. constipation 4. Diagnostics a. water deprivation tests: inability to concentrate urine b. osmotic stimulation c. administration of vasopressin (pitressin) or desmopressin acetate (stimate) d. computerized tomogram (CT) scan

5. Management a. expected outcomes: to correct underlying cause and restore hormonal balance b. pharmacotherapy i. desmopressin acetate (stimate) ii. vasopressin (pitressin) - antidiuretic hormone iii. lypressin (diapid) iv. chloropropamide (chloronase) v. clofibrate (claripex) vi. carbamazapine (mazepine) c. IV fluid replacement therapy d. surgical removal of tumor 6. Nursing interventions a. monitor for findings of dehydration; measure urine; specific gravity b. administer medications as ordered c. monitor fluids and give IV fluids as ordered d. measure intake and output e. weigh client daily f. care of the client with increased ICP g. care of the client undergoing surgery h. teach client i. to record intake and output ii. about medications and side effects iii. to check urine specific gravity iv. the need to wear disease identification jewelry V. Disorders of the Thyroid Gland A. Hypothyroidism 1. Definition - an underactive thyroid resulting in a lessened secretion of thyroid hormone a. deficiency of thyroid hormones causing decreased metabolic rate i. affects more women ii. age group: 30 to 50 years of age b. classifications i. cretinism: hypothyroidism in children ii. hypothyroidism without myxedema: mild thyroid failure iii. hypothyroidism with myxedema: severe thyroid failure; usually seen in older adults iv. myxedema coma a) most severe type of hypothyroidism b) precipitated by stress c) findings include: i. hypothermia ii. bradycardia iii. hypoventilation iv. altered LOC leading to coma d) potentially life threatening condition 2. Etiology a. thyroid surgery b. treatment for hyperthyroid condition c. overdosage of thyroid medications d. deficiency in dietary iodine 3. Findings a. cognitive impairment b. constipation, fatigue, depression c. intolerance to cold d. coarse, dry skin; periorbital edema; thick, brittle nails e. bradycardia; increased diastolic pressure f. menstrual changes - increased menstrual flow g. loss of the outer one-third of eyebrows h. weight gain i. fluid retention 4. Diagnostics a. history and physical exam b. increased TSH

c. decreased serum T3 and T4 d. anemia e. decreased basal metabolic rate (BMR) f. elevated cholesterol and triglycerides g. hypoglycemia 5. Management a. expected outcomes: to restore hormonal balance and prevent complications b. administer synthetic thyroid hormone: levothyroxine sodium (levothroid) c. myxedema coma: i. IV fluids as ordered ii. correct hypothermia iii. give synthetic thyroid hormone 6. Nursing interventions a. give medications as ordered b. watch client for signs of myxedema c. provide restful environment d. teach client i. how to conserve energy ii. how to avoid stress iii. about the medications and side effects synthyroid is to be taken in the morning on an empty stomach at least one hour before any other medications or vitamins or ingestion of milk iv. the importance of lifelong therapy e. protect client from cold B. Hyperthyroidism (Graves' disease, thyrotoxicosois) 1. Definition - overactive thyroid over secretes hormones, and causes increased basal metabolic rate or hyperactivity of thyroid as a primary disease state 2. Etiology - considered autoimmune response a. women affected more than men b. age group: 30 to 50 years 3. Findings a. hyperphagia, weight loss, diarrhea b. heat intolerance c. exophthalmos d. tachycardia e. palpitations f. increased systolic BP g. difficulty concentrating h. irritability i. hyperactivity j. thin, brittle hair, pliable nails: plummer's nails k. diaphoresis l. insomnia m. reduced tolerance for stress 4. Diagnostics a. history and physical exam: palpable thyroid enlargement: (goiter) b. elevated serum T3 and T4 levels c. elevated radioactive iodine uptake d. presence of thyroid autoantibodies e. decreased TSH (thyroid-stimulating hormone; comes from pituitary) levels 5. Complication: thyrotoxic crisis (thyroid storm) a. rare but potentially fatal b. breakdown of body's tolerance to chronic hormone excess c. state of extreme hypermetabolism d. precipitating factors: stress, infection, pregnancy e. findings include: i. systolic hypertension ii. hyperthermia iii. angina

iv. infarction or heart failure v. extreme anxiety vi. even psychosis 6. Management a. expected outcomes: to reduce the excess hormone secretion and to prevent complications b. pharmacologic i. sodium131I ii. antithyroid agents: propylthiouracil (PTU) iii. beta-adrenergic blocking agents: propranolol (inderol) iv. iodides: useful adjunct c. surgical: thyroidectomy: partial or total removal of thyroid gland d. diet high in calories, protein, carbohydrates 7. Nursing interventions a. monitor vital signs, especially blood pressure and heart rate b. provide quiet, restful, cool environment c. monitor diet therapy d. provide extra fluids e. provide emotional support f. administer medications as ordered g. teach client i. about medications and side effects ii. stress avoidance measures iii. energy conservation measures h. care of the client undergoing surgery VI. Disorders of the Parathyroid Gland A. Hypoparathyroidism 1. Definition - parathyroid produces too little parathormone; results in hypocalcemia 2. Etiology unknown a. possibly an autoimmune disorder b. most often results from surgical removal of parathyroid glands 3. Findings (mild to severe order) a. neuromuscular i. irritability ii. personality changes iii. muscular weakness or cramping iv. numbness of fingers v. tetany vi. carpopedal spasms vii. laryngospasms viii. seizures b. dry, scaly skin c. hair loss d. abdominal cramping 4. Diagnostics a. history and physical exam b. positive Chvostek's sign c. positive Trousseau's sign (carpopedal spasm as inflated BP cuff is released) d. decreased serum calcium e. increased serum phosphate 5. Management a. expected outcomes: to restore hormonal balance and prevent complications b. calcium replacement therapy: ideal serum calcium level 8.6mg/dl c. vitamin D preparations facilitate uptake of calcium d. calcium-rich diet 6. Nursing interventions a. monitor carefully for signs of tetany b. place airway, suction and tracheotomy tray at bedside c. institute seizure precautions d. administer medications as ordered

e. teach client i. about medications and side effects ii. signs of vitamin D toxicity iii. to consume more calcium and get vitamin D from sun exposure to skin iv. to reduce phosphorus intake: minimize intake of fish, eggs, cheese and cereals B. Hyperparathyroidism 1. Definition - parathyroid secretes too much parathormone; results in increased serum calcium (hypercalcemia) 2. Etiology a. benign growth in parathyroid b. secondarily as result of kidney disease or osteomalacia c. incidence increases dramatically in both sexes after age 50 3. Findings a. many clients are asymptomatic b. gastrointestinal: constipation, nausea, vomiting, anorexia c. skeletal: bone pain and demineralization d. irritability e. muscle weakness and fatigue 4. Diagnostics a. history and physical exam b. elevated serum calcium c. decreased serum phosphate level d. x-rays reveal bone demineralization 5. Management a. expected outcomes: to restore hormonal balance and prevent complications b. surgery: removal of parathyroid glands parathyroidectomy 6. Nursing interventions a. care of the client undergoing surgery b. after surgery observe for signs of hypocalcemia c. after surgery, teach client to consume diet rich in calcium VII. Disorders of the Adrenal Gland A. Addison's disease 1. Definition a. adrenal cortex secretes too little adrenocorticotropic hormone (ACTH) b. decreases secretion of other adrenal products: mineralocorticoid, glucocorticoids, and sex hormones c. relatively rare 2. Etiology - autoimmune adrenalitis 3. Findings a. acute adrenal insufficiency (Addisonian crisis) i. severe headache or back pain ii. severe generalized muscle weakness iii. diarrhea or constipation iv. confusion v. lethargy vi. severe hypotension vii. circulatory collapse b. adrenal insufficiency i. vague complaints or findings ii. fatigue iii. muscle weakness iv. vague abdominal complaints: anorexia, nausea, vomiting v. personality changes vi. skin pigmentation 4. Diagnostics a. history and physical exam b. ACTH stimulation test: low cortisol level

c. low blood levels of sodium and glucose and high levels of potassium d. 24-hour urine collection: decreased levels of free cortisol 5. Management a. expected outcome: to return to hormonal balance b. Addisonian crisis i. emergency management of circulatory collapse ii. intravenous hydrocortisone c. chronic insufficiency i. glucocorticoid replacement therapy: hydrocortisone (cortef) ii. mineralocorticoid replacement therapy: fludrocortisone acetate (florinef acetate) iii. diet high in protein, carbohydrates, and sodium 6. Nursing interventions during hospitalization a. administer medications as ordered b. manipulate the environment to reduce stressors c. preserve the client's energy by assisting with ADL as indicated d. monitor diet therapy e. measure intake and output and observe for signs of hyponatremia, hyperkalemia, and hypoglycemia. f. teach client i. about medications and side effects ii. the need for lifelong hormone-replacement therapy iii. the need for medical-alert jewelry iv. how to conserve energy v. how to avoid or minimize stress vi. guidelines for diet: high sodium B. Cushing's syndrome 1. Definition: adrenal gland secretes too much cortisol 2. Etiology a. average age of onset 20 to 40 years of age b. affects women more often than men c. primary syndrome caused by tumor of adrenal cortex d. secondary syndrome caused by an ACTHproducing tumor of pituitary e. long term steroid therapy 3. Findings a. personality changes b. hypertension c. metabolic alkalosis d. weight gain, buffalo hump, truncal obesity e. change in libido f. moon face g. muscle weakness h. virilization in women, amenorrhea, or menstrual irregularities i. osteoporosis j. acne or hyperpigmentation 4. Diagnostics a. history and physical exam b. blood tests show i. increased levels of cortisol, ii. increased sodium and glucose, iii. decreased potassium c. 24-hour urine collection: i. elevated free cortisol ii. elevated 17-ketosteroids iii. elevated 17-hydroxycorticosterone 5. Management a. expected outcome: to restore hormonal

balance b. surgery for adrenal or pituitary tumor c. irradiation therapy d. pharmacologic e. adrenal enzyme inhibitors that block enzymes needed for cortisol synthesis i. aminogluthemide ii. metyrapone iii. mitotane f. potassium supplements g. high protein diet with sodium restriction 6. Nursing interventions a. administer medications as ordered b. monitor diet therapy c. monitor for signs of hypokalemia, hypernatremia d. teach client i. the need for lifelong treatment ii. about medications and side effects iii. the need for medical alert jewelry e. surgical treatment may cause adrenal or pituitary insufficiency C. Pheochromocytoma 1. Definition Adrenal medulla secretes too much epinephrine and norepinephrine (called the catecholamines). Causes excessive stimulation of the sympathetic nervous system 2. Etiology a. generally benign tumor of the adrenal medulla b. curable, but fatal if untreated 3. Findings a. severe stress response b. panic metabolic state c. hypertensive crisis d. headache, usually severe e. orthostatic hypotension f. tachycardia g. pallor or flushing h. diaphoresis i. palpitations j. anxiety, high and sustained k. hyperglycemia l. dysrhythmias 4. Diagnostics a. increased BMR b. computerized tomogram (CT) scan c. 24-hour urine collection: increased urinary catecholamines 5. Management a. expected outcomes: to remove the tumor and correct the imbalance b. surgical removal of the tumor: scheduled only after client has been normotensive for at least one week c. antihypertensive agents as needed preop d. alpha-adrenergic blocking agent and beta adrenergic blocking agent (beta blockers): phentolamine (regitine), nitroprusside (nitropress), propranolol (inderal) e. tyrosine inhibitors: alphamethylparatyrosine decreases circulating catecholamines f. antidysrhythmic agents as needed preop 6. Nursing interventions a. monitor vital signs, especially blood pressure b. administer medications as ordered c. provide care of the client undergoing surgery d. if bilateral adrenalectomy performed, lifelong steroid therapy required

e. teach client i. about medications and side effects ii. need for lifelong followup VIII. Disorders of the Pancreas A. Diabetes mellitus 1. Definition - a condition in which the pancreas produces too little insulin, or cells stop responding to insulin; results in hyperglycemia a. type 1 diabetes mellitus: genetic, autoimmune respones; severe insulin deficiency from beta cells stop production of insulin b. type 2 diabetes mellitus: obesity; cells stop responding to insulin 2. Diagnostics a. history and physical exam b. fasting blood sugar: elevated serum glucose levels c. oral glucose tolerance test (GTT) d. after meal, serum glucose is elevated - postprandial glucose e. glycosylated hemoglobin test (A1c test) 3. Data collection a. hyperglycemia b. the 3 "polys" of diabetes mellitus: polydipsia, polyuria, polyphagia c. additional findings: fatigue, hunger, weight loss d. blurred vision e. slow wound healing 4. Management a. diet therapy and weight loss i. the total number of calories is individualized according to the client's weight ii. as prescribed by the care provider, the client may be advised to follow dietary guidelines for Americans (food guide pyramid) or individualized food exchanges from the American Diabetic Association b. exercise i. lowers glucose level and improves circulation ii. decreases total cholesterol and triglycerides iii. instruct client to monitor glucose before exercising iv. before exercise, clients who require insulin should eat a carbohydrate snack with protein to prevent hypoglycemia c. insulin i. used in type 1 diabetes mellitus (DM) and type 2 DM, if needed for better control of blood glucose levels ii. regular insulin, the only insulin that is given IV, is used for ketoacidosis iii. check other medications the client is taking iv. illness, infections, and stress increase the need for insulin v. instruct client about the importance of rotating injection within one region (the abdomen absorbs insulin the most rapidly) vi. insulin administration: see Pharmacology section of this course vii. insulin pens, jet injectors, and insulin pumps are used to administer insulin d. oral antidiabetic medications i. prescribed for clients with type 2 DM ii. monitor blood glucose levels iii. check other medications the client is taking iv. instruct the client to recognize manifestations for hypoglycemia and hyperglycemia v. pancreas transplant vi. islet cell transplant

vii. blood glucose monitoring - with different self-check systems 5. Medications a. type 1 DM: insulin therapy b. type 2 DM: oral hypoglycemic agents 6. Complications a. hypoglycemia (insulin shock) i. blood sugar falls below 50 mg / dl ii. caused by too much insulin, too little food, or excessive physical activity iii. may result from delayed meals, exercise, or vomiting iv. rapid onset v. findings of insulin shock a) diaphoresis; cold, clammy skin b) anxiety, tremor, slurred speech c) weakness d) nausea e) mental confusion, personality changes, altered LOC f) headache vi. management of hypoglycemia a) if client is conscious, give oral sugar: hard candy, honey, Karo syrup, jelly, cola b) if unconscious: give one mg glucagon IM, IV or subcutaneous (SC); or 20 to 50 ml 50% dextrose IV push b. diabetic ketoacidosis (DKA) - an acute complication i. results from severe insulin deficiency ii. findings a) blood sugar levels > 350 mg/dl b) elevated ketone levels: sweet odor to breath may also have odor of someone drinking alcohol c) metabolic acidosis: Kussmaul's respirations, flushed appearance, dry skin d) thirst e) polyuria f) drowsiness g) anorexia, vomiting h) may lead to shock and coma i) usual causes: i. undiagnosed diabetes mellitus ii. inadequacy of prescribed therapy for diabetes mellitus iii. physical stress such as surgery, illness, or trauma in person with diabetes mellitus iv. caused by increased gluconeogenesis from amino acids and glycogenolysis in the liver j) management: i. correct fluid depletion - IV fluids ii. correct electrolyte depletion - replacement particularly of potassium iii. correct metabolic acidosis - insulin IV c. hyperglycemic, hyperosmolar nonketotic coma (HHNKC) i. potentially fatal ii. findings a) severe hyperglycemia; usually > 600 mg/dl b) plasma hyperosmolarity c) dehydration d) altered LOC - decreased e) absence of ketoacidosis iii. usually precipitated by physical stress such as an infection; iv. in non-diabetics can be due to tube feedings without supplemental water, or too rapid rate of infusion for parenteral nutrition v. occurs more often in the elderly, typically vi. expected: to correct fluid depletion, insulin

deficiency, and electrolyte imbalance d. other chronic complications i. diabetic triopathy a) retinopathy b) nephropathy c) neuropathy ii. macrovascular disease in the a) coronary artery b) peripheral vascular 7. Nursing interventions a. give medications as ordered b. monitor for findings of hyperglycemia or hypoglycemia c. help client monitor blood glucose d. refer client to dietician for planing of meals e. support client emotionally f. teach client i. the importance of balanced, consistent daily focus of diet, medication and exercise ii. self blood-glucose monitoring iii. dietary exchange system or refer to appropriate resources iv. about medications and side effects v. foot care vi. early reporting of complications of a) ketoacidosis b) insulin shock c) long term issues vii. about insulin administration viii. about the need to: a) eat more before strenuous exercise b) carry extra rapid-absorbing carbohydrate on person at all times c) wear medical-alert jewelry d) have regular eye exams e) consider emergency care for insulin shock POINTS TO REMEMBER! About Insulin In the pancreas's islets of Langerhans, beta cells secrete insulin-the islet-cell hormone of major physiological importance; Without sufficient insulin, the body develops diabetes mellitus. Exploration of a number of new delivery systems for insulin is ongoing. Implanted insulin delivery systems, in combination with a glucose sensor may create an "artificial pancreas." Exercise increases the body's metabolic rate to result in a decrease in blood sugar and an increase in insulin sensitivity. Signs of hypoglycemia often occur. Illness can disrupt metabolic control and raise blood sugar, which results in an increased need for insulin. Insulin-dependent clients should be well controlled for at least one week prior to any surgery. Special care for any client with either type of diabetes mellitus should be taken to monitor blood glucose during and after surgery and adjust insulin accordingly. About the Thyroid Following neck surgery, potentially lifethreatening complications such as laryngeal edema and tracheal obstruction can occur. Monitor for respiratory distress. Following thyroid surgery, many clients suffer transient hypocalcemia from hyporfunction or removal of the parathyroids. Monitor for signs

of tetany for up to three days after surgery. About the Parathyroid Positive Chvostek's sign: contraction of facial muscle near mouth occurs when light tap is given over facial nerve in front of ear. Positive Trousseau's sign: carpopedal spasm results during the deflation of a blood pressure cuff that has been inflated for at least one minute. ONCOLOGY I. Epidemiology, Etiology, Terms A. Sites in men associated with greatest mortality: lung, colon, rectum and prostate B. Sites in women with greatest mortality: breast, lung, colon, and rectum C. Familial risk for certain cancers: lung, stomach, breast, colon, rectum and uterus D. Etiology 1. Generally unknown but may be caused by interacting factors 2. Theories include predisposing factors: a. constant irritation b. history of cancer c. environmental carcinogens d. radiation 3. Cancer terminology a. primary site of neoplasm is its site of origin b. secondary sites represent metastasis c. types of neoplasms: benign and malignant d. four types of malignant neoplasms i. carcinomas: usually solid tumors arising from epithelial cell ii. sarcomas: from muscle, bone, fat and other connective tissue iii. lymphomas: originate in the lymphatic system iv. leukemias: originate in the blood system 2. Diagnostics and Staging A. History and physical exam - depends on location of tumor B. Biopsy: obtaining tissue for histological examination C. Imaging: CT scan, MRI D. Tumor markers: biochemicals made and released by tumor cells E. Staging and grading 1. Staging: describe and classify extent of a malignancy when it is diagnosed 2. Grading: describe the degree of malignancy according to the type of tumor cell 3. Treatment in General A. Objective: to remove all traces of the cancerous tissue B. Treatment plan based on stage and grade of tumor C. Surgery: specific to site of malignancy D. Chemotherapy E. Radiation therapy 4. Metastatic Disease A. Spread of malignancy beyond the primary site; means of metastasis: a. Tumor invades adjacent tissue b. Tumor sheds cells into body cavities c. Tumor cells spread via the lymphatic system or blood stream B. Major cause of death from cancer a. Most common sites: a. to lung from primary sites in colon,

rectum, breast, renal system, testes and bone b. to liver from primary sites in lung, colon, rectum, breast and renal system c. to CNS from primary sites in lung and breast d. to bone from primary sites in lung, breast, renal system and prostate 5. Cancer Pain Management A. Although clients with cancer may experience pain at any time during their disease, pain is usually a late symptom of cancer B. Use a variety of pain relief measures. 6. Acquired Immune Deficiency Syndrome (AIDS) A. Definition/etiology 1. Infection with human immunodeficiency virus (HIV) resulting in a dysfunction of cell-mediated immunity 2. Characterized by recurrent, opportunistic infections or unusual malignancies 3. Methods of transmission a. parenteral b. sexual c. perinatal d. Incubation period ranges from six months to ten years e. Antibodies can generally be detected in blood within two weeks to three months after infection with virus B. Findings 1. Most common manifestations a. Kaposi's sarcoma i. malignant tumor of the endothelium lining the heart, blood vessels, lymphatic system, and serous cavities ii. most benign form limited to the skin particularly the lower extremities iii. characterized by diffuse cutaneous lesions b. pneumocystis carinii pneumonia (PCP) i. etiology: opportunistic protozoa ii. characterized by low-grade fever, nonproductive cough, shortness of breath iii. may progress to respiratory failure 2. Other findings a. fatigue, shortness of breath b. weight loss, nausea and vomiting, diarrhea c. cough d. chest pain e. fever, night sweats f. mental changes g. infections i. protozoal infections: toxoplasmosis, giardiasis ii. fungal infections: candidiasis, histoplasmosis iii. viral infections: cytomegalovirus, herpes, Epstein-Barr iv. bacterial: salmonellosis, mycobacterium tuberculosis C. Diagnostics 1. History and physical exam 2. Bronchoscopy for PCP (pneumocystis carinii pneumonia) 3. Enzyme-linked immunoabsorbent assay (ELISA) 4. Polymerase chain reaction (PCR) 5. CBC: decreased WBC, decreased lymphocytes, anemia, thrombocytopenia

6. Tissue biopsy for Kaposi's 7. T4 lymphocyte count D. Management 1. Objective: to detect and treat opportunistic infections and any sign of Kaposi's sarcoma and to prevent complications 2. No known cure at present 3. Pharmacologic a. antiviral agents: azidothymidine (Zidovudine) b. pneumocystis: trimethoprim/sulfomethoxazole (Septra), pentamidine (NebuPent) c. Kaposi's: vinblastine (Velsar), Vincristine (Oncovin),interferon Alph-2A (Roferon-A) E. Nursing care of HIV-positive client 1. Initiate standard precautions 2. Use postural drainage and percussion only when secretions are present and coughing does not adequately clear lungs 3. Administer oxygen as ordered 4. Provide restful environment 5. Monitor for signs of dehydration 6. Maintain diet high in calories and protein, low in residue 7. Encourage fluids 8. Provide supplemental feedings as ordered 9. Administer medications as ordered 10. Provide skin care as indicated 11. Weigh client daily 12. Care of the client on mechanical ventilation 13. Assess how much the disease has impaired cognition. 14. Provide emotional support 15. Care of the cancer client undergoing chemotherapy. 16. Maintain body-substance isolation according to CDC guidelines for HIV. 17. Care of the client on TPN 18. Teach client a. avoid persons with known infections b. safe sex guidelines c. energy conservation techniques d. need to wear disease identification jewelry e. to report infections immediately to physician f. not to donate blood, serum or semen g. not to share toothbrushes, razors, or other items that may draw blood POINTS TO REMEMBER! Radiation has local effects; chemotherapy is more systemic. Only certified nurses may administer chemotherapeutic agents. Ionizing radiation will damage both normal and cancerous cells, and cause side effects. Clients who receive external radiation are not radioactive at any time. Clients receiving internal radiation are not radioactive: the implant or injection is. If the source of radiation is metabolized, the client's secretions and excretions may be radioactive for a time, based on the half-life of the isotope.

CARDIOVASCULAR

1. CARDIOVASCULAR I. Anatomy and Physiology A. Anatomy 1. Layers a. pericardium: fibrous b. epicardium: covers surface of heart c. myocardium: muscular portion of the heart d. endocardium: lines cardiac chambers and covers surface of heart valves 2. Chambers of heart a. right atrium: collecting chamber for incoming systemic venous system b. right ventricle: propels blood into pulmonary system c. left atrium: collects blood from pulmonary venous system d. left ventricle: thickwalled, high-pressure pump that propels blood into system 3. Heart valves: membranous openings that allow one way blood flow a. atrioventricular valves: prevent backflow from ventricles to atria during systole b. tricuspid - right heart valve c. mitral - left heart valve d. semilunar valves prevent backflow from aorta and pulmonary arteries into ventricles during diastole i. pulmonic ii. aortic 4. Blood supply to heart a. arteries i. right coronary artery supplies right ventricle and part of left ventricle ii. left coronary artery supplies mostly left ventricle b. veins i. coronary sinus veins ii. thebesian veins 5. Conduction system a. SA (sinoatrial) node b. junctional tissue c. bundle branch Purkinje system B. Physiology 1. Function of the heart is the transport of oxygen, carbon dioxide, nutrients and waste products 2. Cardiac cycle consists of: a. systole - the phase of contraction during which the chambers eject blood b. diastole - the phase of relaxation during which the chambers fill with blood. When heart pumps, myocardial layer contracts and relaxes. 3. Blood flow: a. deoxygenated blood enters the right atrium through the superior and inferior vena cava b. enters the right ventricle via the tricuspid valve c. travels through the pulmonic valve to pulmonary arteries and lungs d. oxygenated blood returns from lungs through the pulmonary veins into left atrium and enters the left ventricle via bicuspid (mitral) valve. e. from the left ventricle, through the aortic valve through the aorta to the systemic circulation 4. The heart itself is supplied with blood by the left and right coronary arteries 5. The vascular system is a continuous network of blood vessels. a. the arterial system consists of arteries,

arterioles and capillaries and delivers oxygenated blood to tissues b. oxygen, nutrients and metabolic waste are exchanged at the microscopic level c. the venous system, veins and venules, returns the blood to the heart II. Failures of the Heart Muscle A. Myocardial infarction (MI) 1. Definition insufficient oxygen supply kills (causes necrosis of) myocardial tissue. MI may be sudden or gradual. total event takes 3 to 6 hours. 2. Epidemiology a. almost equal for men and women b. client history of smoking, obesity, high cholesterol/low density lipoprotein diet, physical/emotional stress c. mortality about 25%. Of the sudden deaths from MI, more than half happen within an hour d. of those who survive the initial MI and recover, up to 10% die within the first year 3. Findings a. persistent, crushing substernal chest pain b. pain that may radiate to the left arm, jaw, neck and shoulder blades, with a feeling of impending doom c. pain may persist for 12 hours or more d. some clients report no pain, or call it mild indigestion e. fatigue, nausea, vomiting and shortness of breath f. sudden death g. within the first hour after an anterior MI, about 25% of clients experience tachycardia or hypertension. h. up to 50% of clients with an inferior MI experience the opposite: bradycardia or hypotension. i. women may experience fatigue, achiness, flu-like symptoms 4. Management a. cardiac monitoring for arrythmias b. oxygen - to prevent tissue hypoxia c. bed rest - to decrease the workload of the heart d. pharmacologic agents - to stabilize client e. stool softeners - to decrease the workload of the heart caused by straining, which can cause vagal stimulation producing bradycardia and arrythmias f. narcotic analgesics - to reduce pain, anxiety and fear and decrease the workload of the heart g. betablocking agents - to slow heart rate h. sedatives - to decrease anxiety and fear and to decrease the workload of the heart i. antiarrhythmic - to prevent arrythmias which are the most common complications after an MI j. thrombolytic agents - to dissolve the thrombus in the coronary artery and reperfuse the myocardium k. nitrates - to decrease pain and decrease preload and afterload while increasing the myocardial oxygen supply l. anticoagulants - to prevent blood clots m. Swan-Ganz catheter to

monitor pressure in pulmonary artery (measure functioning of left ventricle) n. intra-aortic balloon counterpulsation may be used for cardiogenic shock o. cardiac catheterization may be performed for PTCA p. surgery - coronary atherectomy or graft of a coronary artery bypass 5. Diagnostic studies a. history and physical b. EKG monitor for changes, arrythmias c. serum cardiac markers (CK - MB) rises 4-6 degrees after acute MI; Returns to normal in three to four days. Troponin - rises quickly but remains elevated for two weeks. 6. Nursing interventions a. monitor the following to prevent heart failure, infections and complications i. temperature ii. daily weight iii. intake and output iv. respiratory rate v. breath sounds vi. blood pressure vii. serum enzyme levels viii. EKG readings ix. heart sounds, especially S3 and S4 b. assess pain and give analgesics as ordered. Record the severity, location, type, and duration of pain. c. do not give IM injections, or CK will be falsely elevated. d. watch for crackles, cough, tachypnea, and edema which may predict left ventricle is failing. e. use antiembolism stockings to prevent venostasis and thrombophlebitis. f. assistance with range-of-motion exercises g. client and family teaching i. explain the ICU or Coronary Care Unit, routine and machinery ii. ask dietitian to speak with the client and family to reinforce teaching iii. encourage client to join the cardiac rehab exercise program iv. counsel gradual resumption of sexual activity; taking nitroglycerin before sex may prevent chest pain v. advise the client to report typical or atypical chest pain vi. describe postmyocardial infarction syndrome; have client report it to physician vii. stress that client must modify high-risk behaviors B. Congestive heart failure 1. Definition/etiology a. heart fails to pump enough blood to support the body's functions b. types of CHF depend on which part of the heart fails: the left half that pumps to the body, or the right half that pumps to the lungs. c. etiology i. coronary artery disease ii. myocarditis iii. cardiomyopathy iv. infiltrative disorders: amyloidosis, tumors, sarcoidosis v. collagen-Vascular disease: systemic lupus erythematosus, scleroderma vi. dysrhythmias that reduce cardiac filling time vii. disorders that increase cardiac workload:

hypertension, valve disease, anemia, hyperthyroidism viii. cardiac tamponade 2. Findings of Left CHF and Right CHF 3. Management a. objective: to restore balance between myocardial oxygen supply and demand b. treatments include oxygen, digitalis, vasodilators, nitrates antihypertensives, cardiac glycosides, diuretics, intra-aortic balloon counterpulsation, ventricular assist pumping, etc. 4. Nursing interventions a. administer medications as ordered b. administer oxygen as ordered - to prevent tissue hypoxia c. monitor hemodynamic indicators d. monitor for findings of hyponatremia, hypokalemia e. restrict fluids and assess for findings of fluid retention f. client and family teaching i. medications and side effects ii. how to conserve energy and thus oxygen iii. teach client to report weight gain of more than two pounds in 24 hours (equals 1 liter) dyspnea decreased exercise tolerance iv. importance of sodiumrestricted diet 5. Diagnostic findings - the primary goal is to determine the underlying cause of the heart failure a. history and physical exam b. CXR - to determine heart size and pleural effusions c. EKG for changes, arrythmias d. echocardiogram to measure valvular abnormalities e. nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injury f. hemodynamic monitoring of arterial blood pressure, pulmonary artery pressure, pulmonary artery wedge pressure and cardiac output C. Cardiac tamponade 1. Definition/etiology a. fluid quickly fills pericardial sac and limits cardiac output; cardiac tamponade is a medical emergency b. etiology i. acute pericarditis ii. post-op after cardiac surgery iii. pericardial effusions iv. chest trauma v. myocardial rupture vi. aortic dissection vii. anticoagulant therapy 2. Findings: classic triad of findings a. hypotension with b. muffled heart sounds with c. high jugular venous pressure (increased CVP) 3. Diagnosis (above) 4. Management a. pericardiocentesis: needle aspiration of pericardial sac 5. Nursing interventions a. bed rest with elevated head of bed b. prepare client for pericardiocentesis c. provide emotional support

III. Disorders of the Circulatory System: Hypertension 1. Definitions a. hypertension - systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater, or taking antihypertensive medication b. chronic hypertension of pregnancy high blood pressure already present before week 20 of gestation c. accelerated hypertension - a hypertensive crisis: blood pressure rises very rapidly, threatening the brain 2. Etiology and epidemiology a. essential hypertension: cause unknown. b. possible factors include: i. family history- immediate family: mother, father, siser, brother ii. raceAfrican American, Hispanic, Native American, more susceptible iii. stress iv. obesity- 20% more than ideal weight v. a diet high in sodium or saturated fat vi. use of tobacco vii. use of hormonal contraceptives viii. sedentary life-style ix. aging c. besides hypertension, most individuals have other risk factors for cardiovascular disease (CVD). d. secondary hypertension may result from i. renovascular disease ii. renal parenchymal disease iii. cushing's syndrome iv. diabetes mellitus v. dysfunction of the thyroid, pituitary, or parathyroid vi. coarctation of the aorta vii. pregnancy viii. neurologic disorders 3. Findings a. may be asymptomatic b. findings reflect the effect of hypertension on organ systems c. occipital headache, blurred vision, dizziness d. dizziness, palpitations, weakness, fatigue, and impotence e. nosebleeds f. bloody urine g. chest pain and dyspnea, if heart is involved 4. Diagnosis a. based on the average of two or more blood pressure readings, two minutes apart, at each of two or more visits after an initial screening visit b. classification of adult hypertension b. hypertension is classified according to its cause: i. primary or essential hypertension (about 90% of clients) ii. secondary hypertension (results from another disease; about 5% to 10% of clients) iii. accelerated hypertension - a hypertensive crisis 5. Management a. pharmacological i. initial therapy - for uncomplicated hypertension, it is recommended to start with a diuretic or Betaadrenergic blocking agent ii. oxygen PRN in acute crisis iii. angiotensinconverting enzyme (ACE) inhibitors are used to treat left-sided heart failure and preferred if client is diabetic iv. antilipemics b. goals of treatment a. BP <130/85 mm Hg b. control dyslipidemia, obesity,

inactivity c. control diabetes mellitus, if indicated 6. Nursing interventions: reinforce client and family teaching regarding: a. client to use self-monitoring blood pressure cuff b. client to record readings at least twice weekly in a journal or calendar for review by care provider during visits c. client to set up routine for taking antihypertensive medications d. the need to warn against high-sodium antacids, and cold or sinus remedies with vasoconstrictors such as antihistamines e. diet low in sodium, cholesterol and saturated fat f. when client is to report extremely high blood pressure readings g. lifestyle modifications i. optimize body weight ii. drink alcohol based on current guidelines iii. moderate dietary sodium (two gm sodium diet) iv. exercise: regular moderately intense aerobic activity v. avoid tobacco products vi. manage stress triggers and responses to triggers Coronary artery disease 1. Definition - fatty deposits in coronary arteries (atheroma or plaque) narrow the artery (by 75% or more) and cut flow of blood and oxygen to the heart muscle. 2. Epidemiology and etiology a. CAD is epidemic in the western world. b. more than 30% of men age 60 or older show signs of CAD on autopsy. c. most common cause: Atherosclerosis d. risk factors: i. over 40 white male ii. family history of CAD iii. high blood pressure iv. high cholesterol v. smokers are twice as likely to have a myocardial infarction and four times as likely to die suddenly. The risk drops sharply within one year after smoking ceases. vi. obesity (waist predominance); [added weight increases the risk of diabetes, hypertension and high cholesterol] vii. sedentary life style 3. Findings: angina 4. Management a. pharmacology i. nitrates such as nitroglycerin, isosorbide dinitrate (Isordil), or beta-adrenergic neuronblocking agents ii. oxygen - to prevent hypoxia iii. diuretics and beta-adrenergic blocking agents iv. aspirin - decreases platelet aggregation v. antilipemics - to decrease circulating lipids b. diet: reduce calories, salts, fats, cholesterol c. cardiac catheterization i. after cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA), maintain heparinization; observe for bleeding systemically at the site, and keep the

affected leg straight and immobile for six to 12 hours. ii. check for distal pulses. iii. to counter the diuretic effect of the dye, increase IV fluids and make sure client drinks plenty of fluids. iv. assess potassium levelobserve for dysrhythmias v. observe findings of hypotension, bradycardia, diaphoresis, dizziness; give atropine and lay the client flat. d. Rotational ablation i. after rotational ablation, monitor the client for chest pain, hypotension, coronary artery spasm and bleeding from the catheter site. ii. provide heparin and antibiotic therapy for 24 to 48 hours or as ordered. d. laser coronary angioplasty e. surgical treatment coronary artery bypass graft (CABG) 5. Nursing interventions a. help client with ADL (activities of daily living) b. partial bed rest c. reassure client d. assist with turning, deep breathing and coughing exercises e. relieve chest pain by oxygen and medication as ordered f. during angina attacks, monitor bp, heart rate, pain, meds, symptoms; get electrocardiogram g. keep nitroglycerin available for immediate use h. client and family teaching i. risks 1. teach the risk factors for CAD (coronary artery disease) 2. encourage client to lose excess weight; review low-fat, lowcholesterol diet 3. teach smoking cessation 4. teach side effects of drugs for CAD 5. stress - teach stress reduction techniques ii. avoid 1. activities known to cause angina 2. physical activities for two hours after meals 3. very cold and very hot weather 4. alcohol and caffeine drinks 5. diet pills, nasal decongestants, or any remedy that can raise heart rate or blood pressure iii. use 1. nitroglycerin tablets; carry at all times 2. if necessary nitroglycerin patch iv. report 1. angina 2. angina >15 minutes, go to clinic or hospital IV. Dysrhythmias and Lesser Vascular Disorders A. Dysrhythmias 1. Definition: disturbance in heart rate or rhythm 2. Types of dysrhythmia a. supraventricular: sinus, atrial, and junctional i. sinus tachycardia ii. sinus bradycardia iii. sinus arrhythmia iv. premature atrial complexes v. atrial tachycardia vi. atrial flutter vii. atrial fibrillation viii. premature junctional complex ix. junctional tachycardia b. ventricular i. premature ventricular contraction ii. ventricular tachycardia iii. ventricular fibrillation iv. asystole v.

atrioventricular block: vi. first degree A-V block (no treatment) vii. second degree A-V block (no treatment) viii. third degree A-V block c. Nursing interventions i. supraventricular dysrhythmias A. asymptomatic - no nursing interventions indicated B. symptomatic A. administer medications as ordered B. provide emotional support C. teach client A. medications and side effects B. to wear dysrhythmia identification jewelry ii. ventricular dysrhythmias A. administer medications as ordered B. monitor C. monitor hemodynamic indicators as ordered D. administer oxygen as ordered E. provide a restful environment F. prepare the client for cardioversion G. initiate cardiopulmonary resuscitation as indicated H. provide emotional support I. teach client A. medications and side effects B. importance of dysrhythmia identification jewelry iii. atrio-ventricular (AV) conduction disturbances A. asymptomatic: no nursing interventions indicated B. symptomatic A. administer medications as ordered B. prepare client for pacemaker insertion C. care of the client undergoing surgery D. provide emotional support E. provide a restful environment B. Aneurysms 1. Definition, four types, two locations a. dilation of an artery due to a weakness in the arterial wall b. four types of aneurysms 1. saccular: outpouching of one wall in a circumscribed area 2. fusiform: involves complete circumference of artery 3. dissecting: accumulation of blood separating the layers of the arterial wall 4. pseudoaneurysm: tear of the full thickness of the arterial wall, leading to a collection of blood contained in the connective tissue c. two locations: abdominal aorta and thoracic aorta 1. location one: abdominal aortic aneurysm a. findings of abdominal aortic aneurysm i. usually asymptomatic ii. vague abdominal or back pain iii. tenderness on palpation iv. hypotension v. diminished pulses in lower extremities vi. commonest site: just below renal arteries and above iliac arteries b. treatment - surgical repair c. nursing interventions d. care of the client undergoing surgery e. after surgery, watch for back pain, a sign of retroperitoneal hemorrhage f. monitor perfusion g. provide comfort measures h. provide emotional support i. teach client - to avoid prolonged sitting and lifting of heavy objects 2. location two: thoracic aortic aneurysm 3. findings of thoracic aortic aneurysm a. may

be asymptomatic b. vague chest pain c. dyspnea d. distended neck veins 4. management - surgical repair 5. nursing interventions a. care of the client undergoing surgery b. care of the client undergoing cardiac surgery Etiology - atherosclerosis C. Arterial occlusive disease 1. Definition: insufficient blood supply in the arteries; usually in legs. may be acute or chronic. 2. Acute arterial occlusive disease a. etiology i. embolism, thrombosis, and trauma ii. femoral artery most often affected b. findings i. pain in affected limb ii. cyanosis in affected limb iii. paresthesia in affected limb iv. if untreated, gangrene c. management i. pharmacology anticoagulants ii. surgical treatment embolectomy bypass of affected artery amputation of limb percutaneous transluminal coronary angioplasty 3. Chronic arterial occlusive disease a. etiology i. arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco use ii. slow, progressive arteriosclerotic changes give collateral circulation a chance to form iii. collateral circulation cannot give tissues enough oxygen; result is hypoperfusion iv. hypoperfusion leads to ischemia v. usually affects legs b. findings i. intermittent claudication indicates mild to moderate obstruction ii. pain at rest indicates severe obstruction iii. affected limb will show edema paresthesia weak or absent pulses skin: waxy, hairless, cool, pale, cyanotic iv. in men, impotence c. management i. pharmacologic anticoagulants - to prevent blood clots vasodilators antiplatelet drugs - to prevent platelet aggregation pentoxifylline (Trental): increases blood flow by thinning blood ii. surgical treatment endarterectomy femoral-popliteal bypass (illustration) sympathectomy amputation of affected limb for gangrene laser coronary angioplasty (LTA) peripheral angioplasty 4. Both acute and chronic arterial occlusive disease a. nursing interventions iii. administer medications as ordered iv. monitor peripheral pulses and blanch test v. provide comfort measures vi. help client develop an exercise program vii. care of the client undergoing surgery viii. provide foot care ix. teach client to change positions frequently to avoid crossing legs to avoid any constrictive clothing on legs to avoid trauma to lower extremities foot care to place legs in dependent

position to increase blood flow D. Raynaud's phenomenon (arteriopastic disease) 1. Definition: disorder of small cutaneous arteries causing vasospasm. usually affects the fingers bilaterally. 2. Etiology a. unknown b. frequently occurs in women c. may be triggered by stress, cold 3. Findings 4. Management a. pharmacologic agents b. antihypertensive agents: reserpine (Serpasil) c. alpha-adrenergic blocking agents: phenoxybenzamine (Dibenzyline), tolazoline (Piscoline) d. vasodilators e. surgery i. sympathectomy in advanced stages ii. amputation of fingers showing gangrene 5. Nursing interventions a. administer medications as ordered b. care of the client undergoing surgery c. teach client i. to manage stress ii. to stop smoking, avoid caffeine iii. to avoid temperature extremes iv. protection from cold v. medications and their side effects E. Thromboanginitis obliterans (Buerger's disease) 1. Definition: blocking of the medium and small arteries, usually in the legs and feet. 2. Etiology a. affects men more than women b. 25 to 40 age group who smoke c. the disease only occurs in smokers 3. Findings a. intermittent claudication b. numbness and tingling of toes c. weak or absent peripheral pulses d. ischemic ulcerations may occur e. can lead to gangrene 4. Management a. smoking cessation b. other treatment, see arterial occlusive disease c. analgesics d. surgery in late stages, amputation 5. Nursing interventions a. assist client with smoking cessation b. see nursing interventions for arterial occlusive disease: i. administer medications as ordered ii. monitor peripheral pulses and blanch test iii. provide comfort measures iv. help client to develop an exercise program v. care of the client undergoing surgery vi. provide foot care vii. teach client how stopping smoking can relieve symptoms F. Varicose veins 1. Definition: dilation of superficial veins of the legs and feet. 2. Etiology a. usually found in greater saphenous vein (leg) b. incompetent valves (incompetence, vavular) in the superficial veins c. increased pressure in veins causing them to distend d. risk factors: standing for long periods, pregnancy 3. Findings a. pain after period of standing b. foot and ankle swelling at end of day c. distended leg veins 4.

Management a. objective: to reduce pain and halt underlying condition b. medical: sclerotherapy (injection of sclerosing agent that causes vein thrombosis) c. surgical: vein ligation (Vein stripping) 5. Nursing interventions a. care of the client undergoing surgery b. post-operative care includes i. application of elastic stocking or bandages ii. elevation of leg c. teach client i. not to cross legs ii. to elevate legs as much as possible iii. to avoid prolonged sitting or standing G. Thrombophlebitis 1. Definition: A clot inflames the wall of a superficial blood vessel. 2. Etiology a. trauma b. intravenous catheters c. prolonged immobility d. IV drug use 3. Findings a. redness b. swelling c. tenderness d. warmth 4. Management a. bed rest, with elastic stockings b. elevation of affected extremity c. anticoagulants - to prevent clot formation d. analgesics to control discomfort 5. Nursing interventions a. keep leg elevated b. monitor i. for findings of pulmonary embolism (sudden pain, cyanosis, hemoptysis, shock) ii. vital signs, including peripheral pulses iii. for findings of vascular impairment (pallor, cyanosis, coolness) c. administer analgesics as ordered d. client teaching i. avoid tight or constricting clothing ii. stop cigarette smoking iii. avoid maintaining one position for long periods H. Deep venous thrombosis 1. Definition: clotting in a deep vein 2. Etiology and risk a. immobilization b. sepsis c. hematological disorders and clotting disorders d. malignancies e. congestive heart failure f. myocardial infarction g. obesity h. pregnancy i. fractures j. venipuncture k. surgeries: orthopedic, neurologic, urologic and gynecologic l. risk of pulmonary embolus 3. Findings unilateral edema of extremity 4. Management a. objective: to eliminate the clot and prevent complications b. bed rest c. anticoagulant therapy - to prevent new clots d. thrombolytic therapy - to dissolve thrombus e. compression stockings f. surgery - thrombectomy 5. Nursing interventions a. monitor for findings of pulmonary embolus b. maintain bed rest c. administer medications as ordered d. teach client i. medications and side effects ii. to avoid prolonged immobility iii. to maintain adequate fluid intake I. Venous stasis ulcers 1. Definition: chronic skin and subcutaneous ulcers usually found on legs, ankles or feet. 2. Etiology a. chronic venous insufficiency b. incompetent valves

(vavular, incompetence) in perforating veins or deep veins cause venous stasis c. pressure of blood pooling causes capillaries to leak d. ulcer begins as small, inflamed, tender area e. any trauma causes tissue to break or it may break spontaneously f. site: pretibial and medial supramalleolar areas of ankle 3. Findings a. open skin lesion with irregular border b. skin around ulcer usually brown and leathery c. pain in affected area 4. Management a. objective: to correct venous hypertension and both prevent and correct ulceration b. local wound care c. antibiotics and analgesics as indicated d. surgery i. debridement ii. skin grafting iii. removal of veins with incompetent valves 5. Nursing interventions a. keep legs elevated, with feet above level of heart at all times b. apply elastic bandages as ordered c. cleanse and dress ulcer as ordered d. administer drugs as ordered e. teach client i. to report any signs of inflammation immediately ii. to avoid trauma to affected limb iii. to provide skin care iv. to apply elastic bandages V. Heart infections A. Pericarditis 1. Definition and related terms a. in pericarditis, an infection (from a bacterium, a fungus, Systemic Lupus Erythematosus (SLE), etc.) inflames the pericardium. b. there may or may not be pericardial effusion or constrictive pericarditis. c. dressler's Syndrome, also called postmyocardial infarction syndrome, is a combination of pericarditis, pericardial effusion and constrictive pericarditis. It occurs several weeks to months after a myocardial infarction. Etiology unclear. 2. Epidemiology a. may be acute or chronic and may occur at any age. b. pericarditis occurs in up to 15% of persons with a transmural infarction. 3. Findings a. sharp chest pain often relieved by leaning forward b. pericardial friction rub c. dyspnea d. fever, sweating, chills e. dysrhythmias f. pulsus paradoxus g. client cannot lie flat without pain or dyspnea 4. Management a. antibiotics to treat underlying infection b. corticosteroids: usually reserved for clients with pericarditis due to SLE, or clients who do not respond to NSAID c. NSAIDS/Asprin for pain and inflammation d. oxygen: to prevent tissue hypoxia e. surgical emergency pericardiocentesis if cardiac tamponade develops for recurrent constrictive pericarditis, partial pericardiectomy (pericardial window) or total pericardiectomy 5.

Nursing interventions a. manage pain and anxiety b. the cardio-care six c. maintain a pericardiocentesis set at the bedside in case of cardiac tamponade. d. assess respiratory, cardiovascular, and renal status often. e. observe for findings of infiltration or inflammation at the venipuncture site, a possible complication of long-term IV administration. Rotate the IV sites often. f. client and family teaching teach the cardio five 6. Diagnostic studies a. EKG changes, arrythmias b. echocardiography to determine pericardial efusion or cardiac tamponade c. history and physical exam B. Myocarditis 1. Definition an inflammatory condition of the myocardium caused by a. viral infection b. bacterial infection c. fungal infection d. serum sickness e. rheumatic fever f. chemical agent g. as a complication of a collagen disease, i.e. SLE 2. Epidemiology a. may be acute or chronic and may occur at any age. b. usually an acute virus and self-limited, but it may lead to acute heart failure. 3. Findings a. depends on the type of infection, degree of myocardial damage, capacity of myocardium to recover, and host resistance b. may be minor or unnoticed: fatigue and dyspnea, palpitations, occasional precordial discomfort manifested as a mild chest soreness and persistent fever c. recent upper-respiratory infection with fever, viral pharyngitis, or tonsillitis d. cardiac enlargement e. abnormal heart sounds: murmur, S3 or S4 or friction rub f. possibly findings of congestive heart failure such as pulsus alternans, dyspnea, and crackles g. tachycardia disproportionate to the degree of fever 4. Diagnostic studies a. EKG for changes and arrythmias b. labs increases ESR increases myocardial enzymes such as: o AST o CK o LDH c. endomyocardial biopsy (EMB) d. myocardial imaging 5. Management a. antibiotics to treat underlying infection b. corticosteroids to decrease inflammation c. analgesics for pain d. oxygen to prevent tissue hypoxia 6. Nursing interventions a. the cardio-care six with modified bedrest and less help with ADLs b. assess for edema; weigh daily; record intake and output c. assess cardiovascular status frequently d. observe for findings of left-sided heart failure (dyspnea, hypotension and tachycardia) e. check often for changes in cardiac rhythm or conduction; auscultate heart sounds

f. evaluate arterial blood gas levels as needed to ensure adequate oxygenation g. client and family teaching physical activity may be slowly increased to sitting in chair, walking in room, then outdoors. avoid pregnancy, alcohol, and competitive sports. immunize against infections. teach client about anti-infective drugs. Stress importance of taking drugs as ordered. teach clients taking digitalis at home to: o check pulse for one full minute before taking the dose, and withhold the drug if heart rate falls below 60 beats/minute. o observe for findings of digitalis toxicity (anorexia, nausea, vomiting, blurred vision, cardiac arrhythmias) and for factors that may increase toxicity, such as electrolyte imbalance and hypoxia. teach client to report rapidly beating heart. C. Endocarditis 1. Definition and related terms a. an infection of the endocardium, heart valves, or cardiac prosthesis resulting from bacterial or fungal invasion. b. endocarditis can be classified as native valve endocarditis endocarditis in I.V. drug users prosthetic valve endocarditis 2. Epidemiology a. with proper treatment about 70% of clients recover. b. the prognosis is worse when endocarditis damages valves severely or involves a prosthetic valve. c. infective endocarditis occurs in 50 to 60% of clients with previous valvular disorders. d. systemic lupus erythematosus (SLE) often leads to nonbacterial endocarditis. e. in 12% to 35% of clients with subacute endocarditis, lesions produce clots that show the findings of splenic, renal, cerebral or pulmonary infarction, or peripheral vascular occlusion. 3. Findings of endocarditis a. cardiac murmurs in 85 to 90% of clients b. fever c. especially, a murmur that changes suddenly, or a new murmur that develops in the presence of a fever d. pericardial friction rub e. anorexia f. malaise g. clubbing of fingers h. neurologic sequelae of embolus i. petechiae of the skin (especially on the chest) j. splinter hemorrhage under the nails k. infarction of spleen: pain in the upper left quadrant, radiating to the left shoulder, and abdominal rigidity l. infarction in kidney: hematuria, pyuria, flank pain, and decreased urine output m. infarction in brain: hemiparesis, aphasia, and other neurologic deficits n. infarction in lung: cough, pleuritic pain, pleural friction rub, dyspnea and hemoptysis

o. peripheral vascular occlusion: numbness and tingling in an arm, leg, finger, or toe, or signs of impending peripheral gangrene 4. Management - clients at risk for prosthetic valves a. prophylaxis - to prevent endocarditis; i.e. MVP, cardiac lesions b. antibiotics - to treat underlying infection c. antipyretics - to control fever d. anticoagulants - to prevent embolization e. oxygen - to prevent tissue hypoxia f. surgical - possible valve replacement 5. Nursing interventions a. the cardio-care six b. observe for findings of infiltration or inflammation at venipuncture site; rotate sites often. c. client and family teaching explain all procedures in a simple and culturally sensitive manner. involve the client and family in scheduling the daily routine activities. Allow client and family to participate in care. teach client relaxation techniques (meditation, visualization, or guided imagery) to cope with stress, pain, or insomnia. explain endocarditis and the need for long-term therapy. explain the need for prophylactic antibiotics before dental work and other invasive procedures. teach client to report fever, tachycardia, dyspnea and shortness of breath. 6. Diagnostic studies a. health history b. lab data CBC blood cultures ESR c. CXR - to detect CHF d. EKG transesophageal echocardiogram to detect vegetation and abscess on valves D. Rheumatic heart disease (rheumatic endocarditis) 1. Definition and related terms a. rheumatic heart disease is damage to the heart by one or more episodes of rheumatic fever. Pathogen is a group A streptococci. b. rheumatic endocarditis is damage to the heart, particularly the valves, resulting in valve leakage (regurgitation) and/or stenosis. To compensate, the heart's chambers enlarge and walls thicken. 2. Epidemiology a. worldwide, 15 to 20 million new cases of rheumatic fever are reported each year. b. rheumatic fever follows a group A streptococcal infection. We could prevent it by finding and treating streptococcal pharyngitis. c. where malnutrition and crowded living are common, rheumatic fever is commonest in children between ages 5 and 15. d. rheumatic fever strikes most often during cool, damp weather. In the U.S., it is most common in the northern states. e. it is unknown how and why group A streptococcal infections cause the lesions called Aschoff bodies. f.

damage depends on site of infection: most often the mitral valve in females and the aortic valve in males. g. malfunction of these valves leads to severe pericarditis, and sometimes pericardial effusion and fatal heart failure. Of those who survive this complication, about 20% die within ten years. 3. Findings a. streptococcal pharyngitis sudden sore throat throat reddened with exudate swollen, tender lymph nodes at angle of jaw headache and fever to 104 degrees Fahrenheit b. polyarthritis manifested by warm and swollen joints c. carditis d. chorea e. erythema marginatum (wavy, thin red-line rash on trunk and extremities) f. subcutaneous nodules g. fever to 104 degrees Fahrenheit h. heart murmurs pericardial friction rub and pericardial rub i. no lab test confirms rheumatic fever, but some support the diagnosis. 4. Management a. give antibiotics steadily to maintain level in blood. b. provide analgesics - for pain/inflammation c. oxygen to prevent tissue hypoxia. d. surgical commissurotomy, valvuloplasty, prosthetic heart valve 5. Nursing interventions a. the cardio-care six b. help the client with chorea to grasp objects; prevent falls. c. encourage family and friends to spend time with client and fight boredom during the long, tedious convalescence. d. client and family teaching explain all tests and treatments nutrition hygienic practices to resume ADLs slowly and schedule rest periods to report penicillin reaction: rash, fever, chills to report findings of streptococcal infection o sudden sore throat o diffuse throat redness and oropharyngeal exudate o swollen and tender cervical lymph glands o pain on swallowing o temperature of 101 to 104 degree Fahrenheit o headache o nausea keep client away from people with respiratory infections explain necessity of long-term antibiotics arrange for a visiting nurse if necessary help the family and client cope with temporary chorea 6. Diagnostic studies a. antistreptolysin 0 titer - increased b. ESR - increased c. throat culture positive for streptococci d. WBC count - increased e. RBC parameters - normocytic, normochromic anemia f. C-reactive protein - positive for streptococci VI. Valve Disorders A. Mitral stenosis 1. Definition - mitral valve thickens and gets narrower, blocking blood flow from the left atrium to left ventricle. a. physiology i. function of the heart is the

transport of oxygen, carbon dioxide, nutrients and waste products ii. cardiac cycle consists of: systole the phase of contraction during which the chambers eject blood diastole - the phase of relaxation during which the chambers fill with blood. When heart pumps, myocardial layer contracts and relaxes. iii. blood flow: deoxygenated blood enters the right atrium through the superior and inferior vena cava enters the right ventricle via the tricuspid valve travels through the pulmonic valve to pulmonary arteries and lungs oxygenated blood returns from lungs through the pulmonary veins into left atrium and enters the left ventricle via bicuspid (mitral) valve. from the left ventricle, through the aortic valve through the aorta to the systemic circulation iv. the heart itself is supplied with blood by the left and right coronary arteries (illustration) v. the vascular system is a continuous network of blood vessels. the arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood to tissues oxygen, nutrients and metabolic waste are exchanged at the microscopic level the venous system, veins and venules, returns the blood to the heart (illustration) 2. Epidemiology a. of clients with mitral stenosis, 2/3 are female b. most cases of mitral stenosis are caused by rheumatic fever 3. Findings a. mild - no findings b. moderate to severe dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea weakness, fatigue, and palpitations c. peripheral and facial cyanosis in severe cases d. jugular vein distention e. with severe pulmonary hypertension or tricuspid stenosis ascites f. edema g. hepatomegaly h. diastolic thrill at the cardiac apex i. when client lies on left side, loud S1 or opening snap and a diastolic murmur at the apex j. crackles in lungs 4. Management a. antiarrhythmics if needed b. if medication fails, atrial fibrillation is treated with cardioversion. c. lowsodium diet - to prevent fluid retention d. oxygen if needed - to prevent hypoxia e. surgery - mitral commissurotomy or valvotomy 5. Nursing interventions a. the cardiocare six b. observe closely for findings of heart failure, pulmonary edema, and reactions to drug therapy. c. if client has had surgery, watch for hypotension, arrhythmias, and thrombus formation. d. monitor

the cardio seven e. client and family i. explain the need for long-term antibiotic therapy and the need for additional antibiotics before dental care. ii. report early findings of heart failure such as dyspnea or a hacking, nonproductive cough. 6. Diagnostic studies/findings a. history and physical exam b. EKG- for changes of left atrial enlargement and right ventricle enlargement c. echocardiogram - for restricted movement of the mitral valves and diastolic turbulance B. Mitral insufficiency (or regurgitation) 1. Definition and related terms a. a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during systole. b. to handle the backflow, the atrium enlarges. So does the left ventricle, in part to make up for its lower output of blood. 2. Epidemiology a. follows birth defects such as transposition of the great arteries. b. in older clients, the mitral annulus may have become calcified. c. cause unknown; may be linked to a degenerative process. d. occurs in 5 to 10% of adults. 3. Findings a. client may be asymptomatic b. orthopnea, dyspnea, fatigue, weakness, weight loss c. chest pain and palpitations d. jugular vein distention e. peripheral edema 4. Management a. low-sodium diet - to prevent fluid retention b. oxygen as needed - to prevent tissue hypoxia c. antibiotics - to treat infection d. prophylactic antibiotics to prevent infection e. surgery mitral valvuloplasty or valve replacement 5. Nursing interventions a. the cardio-care six b. monitor the cardio seven c. monitor for left-sided heart failure, pulmonary edema, adverse reactions to drug therapy, and cardiac dysrhythmias especially atrial and ventricular fibrillation d. if client has surgery, monitor postoperatively for hypotension, arrhythmias and thrombus formation e. client and family teaching i. diet restrictions and drugs ii. explain tests and treatments iii. prepare client for long-term antibiotic and follow-up care. iv. stress the need for prophylactic antibiotics during dental care. v. teach client and family to report findings of heart failure: dyspnea and hacking, nonproductive cough. 6. Diagnostic findings a. EKG for arrythmias and changes of left atrial enlargement b. echocardiogram - to visualize regurgitant jets and flail chordae/leaflets c. cardiac cath shows regurgitation of blood from left

ventricle to left atrium C. Tricuspid stenosis 1. Definition: narrowing of the tricuspid valve between right atrium and right ventricle 2. Epidemiology a. relatively uncommon b. usually associated with lesions of other valves c. caused by rheumatic fever 3. Findings a. dyspnea, fatigue, weakness, syncope b. peripheral edema c. jaundice with severe peripheral edema and ascites can mean that tricuspid stenosis has led to right ventricular failure d. may appear malnourished e. distended jugular vein 4. Management: surgery - valvulotomy or valve replacement; valvuloplasty 5. Nursing interventions a. the cardio-care six b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy d. post valve surgery, monitor client for hypotension, arrhythmias and thrombus formation e. when client sits, elevate legs - to prevent dependent edema f. client and family teaching i. teach the cardio five ii. client must comply with long-term antibiotic and follow up care iii. emphasize the need for prophylactic antibiotics during dental care 6. Diagnostic findings a. EKG - for arrythmias b. echocardiogram - right ventricular dilation and paradoxic septal motion D. Tricuspid insufficiency (regurgitation) 1. Definition - tricuspid valve lets blood leak from the right ventricle back into the right atrium 2. Epidemiology a. results from dilation of the right ventricle and tricuspid valve ring b. most common in late stages of heart failure from rheumatic or congenital heart disease 3. Findings a. dyspnea, fatigue, weakness and syncope b. peripheral edema may cause discomfort 4. Management: surgical valve replacement 5. Nursing interventions a. the cardio-care six b. monitor for cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy d. postop monitor client for hypotension, arrhythmias and thrombus formation e. when sitting, client should raise legs - to prevent dependent edema f. client and family teaching i. the cardio five ii. emphasize the need for prophylactic antibiotics during dental care iii. instruct client to raise legs when sitting - to prevent dependent edema E. Pulmonic stenosis 1. Definition obstructed right ventricular outflow resulting in right ventricular hypertrophy 2. Epidemiology a.

usually congenital, often with other birth defects such as tetralogy of Fallot b. rare among the elderly c. may result from rheumatic fever 3. Findings a. dyspnea, fatigue, chest pain and syncope b. peripheral edema may cause discomfort 4. Management: surgical - replace the valve via balloon and cardiac catheter 5. Nursing interventions a. same as tricuspid stenosis and tricuspid insufficiency b. monitor for findings of heart failure, pulmonary edema, and adverse reactions to to the drug therapy c. post-op: monitor client for hypotension, dysrhythmias and thrombus formation d. monitor the cardio seven e. client and family teaching - same as tricuspid stenosis and tricuspid insufficiency. F. Pulmonic insufficiency (regurgitation) 1. Definition pulmonary valve fails to close, so that blood flows back into the right ventricle 2. Epidemiology a. a birth defect, or a result of pulmonary hypertension b. rarely, result of prolonged use of a pressuremonitoring catheter in the pulmonary artery 3. Findings a. dyspnea, fatigue, chest pain and syncope b. peripheral edema may cause discomfort c. if advanced: jaundice with ascites and peripheral edema d. possible malnourished appearance 4. Management a. diuretics - to mobilize edematous fluid to reduce pulmonary venous pressure b. sodium-restricted diet to control underlying heart disease c. anticoagulants - to prevent blood clots d. digitalis - to increase the force or strength of cardiac contractions (inotropic action) e. surgery for severe cases: valvulotomy or valve replacement 5. Nursing interventions a. the cardio-care six b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to drug therapy d. post-op: monitor client for hypotension, arrhythmias and thrombus formation e. provide rest periods f. when client sits, raise legs g. client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, and pulmonic stenosis) i. the cardio five ii. client's dentist must give client prophylactic antibiotics to prevent infection iii. instruct client to raise legs when sitting to prevent dependent edema G. Aortic stenosis 1. Definition aortic valve narrows. left ventricle must work harder, so needs more oxygen, and may suffer ischemia and heart failure. 2. Epidemiology a.

most significant valvular lesion seen among elderly people. It usually leads to left-sided heart failure b. incidence increases with age c. occurs in 1% of the population d. about 80% of these people are male e. 20% of them die suddenly, around age 60 3. Findings a. classic triad: dyspnea, syncope, angina (see Assessing Clients with Cardiovascular Disorders) b. fatigue c. palpitations d. left-sided heart failure may bring on orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema 4. Management a. nitroglycerin to relieve chest pain b. low-sodium diet - to prevent fluid retention c. diuretics - to mobilize edematous fluid and to reduce pulmonary venous pressure d. digitalis - to increase the force or strength of cardiac contractions (inotropic action) e. oxygen - to prevent hypoxia f. surgery - percutaneous balloon valvuloplasty, then valve replacement 5. Nursing interventions a. the cardio-care six b. monitor the cardio seven c. monitor for findings of heart failure, pulmonary edema, and adverse reactions to the drug therapy d. postop: monitor client for hypotension, arrhythmias and clots e. when client sits, raise legs to prevent dependent edema f. client and family teaching: (same as tricuspid stenosis, tricuspid insufficiency, pulmonic stenosis and pulmonic insufficiency) i. the cardio five ii. client's dentist must administer prophylactic antibiotics iii. client should raise legs when sitting H. Aortic insufficiency (regurgitation) 1. Definition a. blood flows back into the left ventricle during diastole overloading the ventricle and causing it to hypertrophy. b. extra blood also overloads the left atrium and, eventually, the pulmonary system. 2. Epidemiology a. by itself, most common among males b. with mitral valve disease, more common among females c. may accompany Marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a defect of the ventricular septum 3. Findings a. uncomfortable awareness of heartbeat b. palpitations along with a pounding head c. dyspnea with exertion d. paroxysmal nocturnal dyspnea, with diaphoresis, orthopnea and cough e. fatigue and syncope with exertion or emotion f. anginal chest pain unrelieved by sublingual nitroglycerin g. heartbeat that seems to jar the client's entire body h. client's nailbeds appear to be pulsating i. if nail tip is pressed, the

root will flush and then pale (Quincke's sign) j. if left ventricle fails, client may show ankle edema and ascites k. pulsus biferiens 4. Management a. digitalis - increases the heart's contractility (inotropic action) b. diuretics - to mobilize edematous fluids and to reduce pulmonary venous pressure c. sodium-restricted diet - to prevent fluid retention d. anticoagulant agents - to prevent blood clots e. surgical - valve replacement. however, aortic insufficiency often damages the ventricle before it is detected. 5. Nursing interventions a. same as all other valve disorders the cardio-care six except don't need to elevate head unless pulmonary problems have begun. b. monitor the cardio seven c. monitor for signs of heart failure, pulmonary edema, and drug reactions. d. post-op: monitor client for hypotension, arrhythmias and clots. e. client and family teaching i. same as all other valve disorders - the cardio five ii. emphasize the need for prophylactic antibiotics during dental care iii. instruct client to raise legs when sitting POINTS TO REMEMBER TEACH THE CARDIO FIVE: TDDDS 1. Tests and treatments: explain them in simple, culturally sensitive ways. 2. Drugs, their side effects, and how long client will take them. 3. Diet: good nutrition and restrictions (such as low sodium). 4. Disease, its treatment, and what signs to report promptly: the 'watch-fors'. 5. Smoker? Teach and encourage 'stop smoking' THE CARDIO-CARE SIX: A,B,C,D,E,F 1. ADL: Help the client with activities of daily living. 2. Bed rest 3. Commode at bedside (it stresses the heart less than using a bedpan does). 4. Diversions: offer diversions that don't stress the heart. 5. Elevate head of bed, or sit client up. 6. Feelings: Let clients express concern; reassure when activity will resume. RESPIRATORY

RESPIRATORY I. General Respiratory Anatomy and Physiology A. The respiratory system is comprised of the upper airway and lower airway structures. B. The upper respiratory system filters, moistens and warms air during inspiration. C. The lower respiratory system enables the exchange of gases to

regulate serum PaO2, PaCO2 and Ph. II. Upper Respiratory A. Nose and sinuses 1. Filters, warms and humidifies air 2. First defense against foreign particles 3. Inhalation for deep breathing is to be done via nose 4. Exhalation is done through the mouth B. Pharynx 1. Behind oral and nasal cavities 2. Nasopharynx a. behind nose b. soft palate, adenoids and eustachian tube 3. Oropharynx a. from soft palate to base of tongue b. palatine tonsils 4. Laryngopharynx a. base of tongue to esophagus b. where food and fluids are separated from air c. bifurcation of larynx and esophagus C. Larynx 1. Between trachea and pharynx 2. Commonly called the voice box 3. Thyroid cartilage - Adam's apple 4. Cricoid cartilage a. contains vocal cords b. the only complete ring in the airway 5. Glottis - opening between vocal cords III. Epiglottis - covers airway during swallowing IV. Lower Respiratory and Other Structures A. Trachea 1. Anterior neck in front of esophagus 2. Carries air to lungs B. Mainstem bronchi 1. Right and left 2. Right is more vertical, so right middle lobe is more likely to receive aspirate into it with the result of aspiraton pneumonia, which is more commonly found in elderly populations C. Conducting airways 1. Lobar bronchi a. surrounded by blood vessels, lymphatics, nerves b. lined with ciliated, columnar epithelial cell c. cilia move mucus or foreign substances up to larger airways 2. Bronchioles a. no cartilage; collapse more easily b. no cilia c. do not participate in gas exchange D. Alveolar ducts and alveoli 1. Lungs contain approximately 300 million alveoli 2. Alveoli surrounded by capillary network 3. Gas exchange area (blood takes O2, gives off CO2) 4. Gas exchange happens at alveolar-capillary membrane (al-cap memb) 5. Held open by surfactant which decreases surface tension to minimize alveolar collapse E. Accessory muscles of respiration 1. Scalene muscles elevate first two ribs 2. Sternocleidomastoid raise sternum 3. Trapezius and pectoralis stabilize shoulders 4. Abdominal muscles - puts power into cough and used most often with chronic respiratory problems and acute severe respiratory distress V. Physiology A. Basic gasexchange unit of the respiratory system is the alveoli. B. Alveolar stretch receptors respond to inspiration by sending signals to inhibit inspiratory neurons in the brain stem to prevent lung over distention. C. During expiration stretch receptors stop sending signals to inspiratory neurons and inspiration is ready to start again. D. Oxygen and carbon dioxide are exchanged across the alveolar capillary membrane by process of diffusion. E. Neural control of respirations is located in the medulla. The respiratory center in the medulla is stimulated by the concentration of carbon dioxide in the blood. F. Chemoreceptors, a secondary feedback system, located in the carotid arteries and aortic arch respond to hypoxemia. These chemoreceptors also stimulate the medulla. G. Ph regulation 1. Blood Ph (partial pressure of hydrogen in blood): a decrease in blood Ph stimulates respiration hyperventilation, both through the neurons of the brain's respiratory center and

through the chemoreceptors in carotid arteries and aortic arch. 2. Blood PaCO2 (partial pressure of carbon dioxide in arterial blood): an increase in the PaCO2 results in decreased blood Ph, and stimulates respiration as described above. 3. Blood PaO2 (partial pressure of oxygen in arterial blood): a decrease in the PaO2 results in a decreased blood Ph, stimulating respiration as described above. 4. When arterial Ph rises or the arterial PaCO2 falls, hypoventilation occurs. VI. Disorders of the Upper Respiratory System A. Allergic rhinitis (hay fever) - sensitivity to allergens with whitish or clear nasal discharge B. Sinusitis 1. Medical condition a. inflammation of mucus membranes in the sinuses b. may be followed by infection with a yellowish-green discharge 2. Management a. treatment with antibiotics, decongestants, antihistamines b. surgery to drain and open sinuses c. antral irrigation (sinus irrigation) d. Caldwell-Luc procedure C. Upper airway obstruction (choking) 1. Findings a. stridor (harsh, vibrating breath) b. no sound of air c. both hands of client around the throat d. management: emergency treatment i. Heimlich maneuver ii. cricothyrotomy (cut cricoid cartilage) iii. tracheotomy/tracheostomy D. Pharyngitis 1. Inflammation of mucous membranes of pharynx 2. Bacterial, viral, environmental causes 3. Treat findings; if culture shows bacteria, use antibiotics E. Tonsillitis 1. Inflammation and/or infection of tonsils 2. Acute form is usually bacterial 3. Treat findings; if culture shows bacteria, use antibiotics F. Peritonsillar abscess 1. Complication of acute tonsillitis 2. Infection spreads to surrounding tissue 3. If swelling is massive, can endanger airway 4. Treat findings; if culture shows bacteria, use antibiotics G. Vocal cord disorders 1. Laryngitis a. inflammation of vocal cords and surrounding mucous membranes b. cause: something irritates the larynx c. occurs in viral and bacterial infections d. in children, called croup (larynx blocked by edema, spasm or both) e. treat findings, rest voice, remove irritants, gargle with warm salt water 2. Vocal cord paralysis a. injury, trauma or disease of larynx, laryngeal nerves or vagus nerve b. may result as a complication after thyroidectomy surgery c. assess how well client can protect airway d. can sometimes be surgically treated with Teflon injection H. Cancer of the larynx 1. Etiology a. most tumors of the larynx are squamous cell carcinoma b. more common among men, age 50 to 65 c. cigarette smoking and alcohol consumption are related 2. Findings a. persistent sore throat b. dyspnea c. dysphagia d. increasing persistent hoarseness e. weight loss f. enlarged cervical lymph nodes 3. Management a. radiation therapy b. chemotherapy c. surgery: removal of all or part of larynx to treat cancer i. total laryngectomy: no voice, permanent stoma in neck with no risk of aspiration from oral cavity ii. radical neck dissection: when cancer has metastasized to surrounding tissues 4. Nursing interventions a. arrange for clients with larnygectomies to meet with members of support groups b. establish a method for communication before surgery c. maintain airway; have suction equipment at

bedside d. observe for signs of hemorrhage or infection e. teach about trach and stoma care f. assist with period of grieving VII. Disorders of Lower Respiratory System (LRS): Obstructive A. General facts: process in chronic obstructive pulmonary diseases 1. Block airflow out of lungs 2. Trap air, with impairment of gas exchange 3. Increase the work of breathing B. Emphysema 1. Destroys alveoli 2. Narrows and collapses small airways 3. Overall lung loses elasticity 4. Traps air 5. As alveolar walls die, there is less surface for vital gas exchange C. Chronic bronchitis 1. Definition a. inflammatory response in the lung b. affects few alveoli, mostly airways 2. Findings a. lungs chronically produce fluids b. inflammation and mucus narrow the airways D. Asthma 1. Definition/etiology a. reversible obstruction of airways b. inflammation of airways c. airways hypersensitive to variety of stimuli d. bronchospasm is a minor component e. disease waxes and wanes, remissions and exacerbations 2. Findings a. orthopnea, expiratory wheezing b. barrel chest, cyanosis, clubbing of fingers c. distention of neck veins d. edema of extremities e. increased PCO2 and decreased PO2 f. polycythemia 3. Diagnostics a. physical examination with history of findings b. arterial blood gases c. chest x-ray 4. Complications a. hypoxemia b. hypercapnia c. variety of respiratory infections d. cor pulmonale e. dysrhythmias E. Management for obstructive disease 1. Antibiotics and corticosteroids for infection or chronic inflammation 2. Bronchodilators 3. Mucolytics 4. Expectorants F. Respiratory program: postural drainage, exercise, nebulizer, high protein diet G. Nursing interventions common to obstructive diseases 1. Assess client's risk of respiratory failure 2. Assess for degree of respiratory effort for an increased work of breathing or dyspnea 3. Assess oxygenation with pulse oximeter if hemoglobin level is within normal limits 4. Measure arterial blood gases (ABG) to evaluate gas exchange 5. Administer oxygen as indicated 6. If risk of respiratory failure, anticipate ventilation 7. Assist with secretion removal as indicated 8. Pace client activities to reduce oxygen demand 9. Teach diaphragmatic breathing and pursed-lip breathing 10. Position in a high Fowler's to ease breathing effort 11. Provide for nutritional consults as indicated 12. Reinforce the plan for small, frequent high carbohydrate meals 13. Provide referrals for: a. depression associated with disease b. pulmonary rehabilitation c. stop smoking support groups 14. For asthma, teach clients that aspirin or peanuts may stuimulate an asthma attack VIII. LRS Disorders: Restrictive A. In general: these disorders prevent full lung expansion via three mechanisms 1. Lung stiffening 2. External compression 3. Muscle weakness B. Pulmonary fibrosis- lung stiffening 1. Occupational lung diseases a. coal worker's pneumoconiosis - risk increases with length of exposure to coal dust (>15 years), intensity of exposure, and silica content of dust b. silicosis: workers who will have inhaled silica dust 2. Asbestosis a. inhalation of asbestos fibers b. disease may develop 15 to 20 years after

exposure C. Pulmonary sarcoidosis - lung stiffening 1. Etiology a. unknown origin b. characterized by formation of tubercles, most often in the lungs c. may progress to fibrosis 2. Findings a. dyspnea b. anxiety 3. Diagnostics a. chest x-ray b. biopsy of affected tissue 4. Management a. antitussives b. oxygen therapy c. removal of toxic substances D. Nursing interventions common to all types of pulmonary fibrosis 1. Prevent infection or exposure to infection 2. Pace clients' activities to reduce oxygen demands and dyspnea 3. Reinforce the need for small, frequent meals 4. Encourage daily activities within pulmonary tolerance a. provide referrals for: i. depression associated with disease ii. stop smoking support groups iii. occupational rehabilitation E. Disorders of fluid in pleurae 1. Pleural fluid disorders - all treated with water seal chest drainage systems 2. Pneumothorax: air between the pleurae a. open pneumothorax: hole in the chest wall, communicates with the lung b. closed pneumothorax: hole in lung, chest wall intact c. tension pneumothorax - a nursing and medical emergency i. closed pneumothorax ii. air is forced into the pleural space with a continued pressure build up iii. shifts mediastinum away from affected side with results of a compressed heart iv. treated with chest tube insertion v. cardiac and respiratory arrest if not treated d. examples of the above 3. Pleural effusion a. fluid (transudate or exudate) in the pleural space b. if small, no treatment c. if larger, treated with chest tube insertion 4. Hemothorax a. blood in the pleural space b. treated with thoracentesis or chest tube 5. Empyema a. purulent drainage in the pleural space b. often from a chronic condition such as lung cancer c. treated with chest tube inserton 6. Chylothorax a. lymphatic fluid in pleural space b. treated with thoracentesis or chest tube F. Musculoskeletal diseases associated with difficulty breathing 1. Guillain-Barre syndrome follows a viral infection a. ascending paralysis that may affect muscles of respiration as paralysis ascends b. muscles so weak that client cannot breathe deeply, a nursing and medical emergency c. may progress to respiratory failure a. may require intubation b. mechanical ventilation c. course of illness varies from a few months to years 2. Myasthenia gravis a. sporadic, progressive weakness of skeletal muscle b. cause: lack of acetylcholine with results of a myoneural junction malfunction c. may not be able to chew and swallow well a. may aspirate b. may lose protective airway reflexes d. repeated muscle movements, especially towards days end, can exacerbate acute respiratory failure 3. Poliomyelitis a. viral infection b. if disease strikes the respiratory muscles the result may be respiratory failure c. may not swallow well a. may aspirate b. may lose protective airway reflexes 4. Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease) a. affects motor neurons; autonomic, sensory and mental function unchanged b. manifests as a chronic, progressive irreversible disorder c. begins usually in distal ends of upper extremities d. often leads to respiratory failure within two to five years e. results in ethical issue a. whether

clients want mechanical ventilation b. whether nutritional support is desired c. if they would rather die when disease becomes this severe f. results in clients' inability to communicate or physically move from voluntarily and/or clients lack involuntary reflexes, such as blinking or gag reflex 5. Muscular dystrophies a. progressive symmetrical wasting of voluntary muscles with no nerve effect b. as thoracic muscles weaken, breathing becomes more difficult c. may not swallow well; risk for aspiration with loss of protective airway reflexes 6. Interventions common to musculoskeletal disorders a. monitor carefully for changes in condition b. assess regular swallowing and ability to protect the upper airway c. discuss chances of mechanical ventilation or nutritional support: does client wish it? d. assist with coughing and secretion clearance as indicated e. prevent infection f. assess for with appropriate referrals for depression that is often associated with these diseases g. administer medications specific to the disease condition h. assist/provide occupational or/and physical rehibilitation as indicated i. maintain adequate nutrition j. with terminal disorders, provide for referrals for family IX. LRS Disorders: Infectious A. Pneumonia 7. Definition/etiology a. acute infection of lung parenchyma b. cause: bacterium, virus, protozoan, mycobacterium, mycoplasma, or rickettsia c. pneumonia is the leading cause of death from infectious causes d. may affect only a region of lung: lobar pneumonia, bronchopneumonia e. may be the result of: a. primary infection b. secondary to other lung damage c. aspiration 8. Risk factors for pneumonia a. pre-existing pulmonary disease b. abdominal and thoracic surgery c. mechanical ventilation d. advanced age e. decreased ability to protect airway or cough effectively f. artificial airway g. chronic illness and debilitation h. depressed immune function i. cancer 9. Diagnostics a. chest radiograph b. sputum culture, sensitivity and microscopic analysis, Gram stain, cytology c. ABG as indicated by clinical condition 10. Management a. antimicrobials, depending on pathogen b. antipyretic c. expectorants d. antitussives e. supplemental oxygen, as indicated f. IV fluids to treat dehydration 11. Nursing interventions a. monitor finger oximeter if hemoglobin levels within normal limits b. promote hydration to liquify secretions c. teach effective coughing techniques to minimize energy expenditure d. suction if necessary e. teach the need to continue entire course of antimicrobial therapy which is usually seven to ten days f. teach that findings are expected to be less within 48 to 72 hours of initial therapy B. Pulmonary tuberculosis (PTB) 1. Etiology a. mycobacterium tuberculosis b. bacilli lodge in alveoli c. pulmonary infiltrates d. can spread throughout body via blood e. multi-drug resistant PTB is becoming more prevalent f. PTB incidence is rising with increasing homelessness and AIDS 2. Findings a. weakness with fatigue b. anorexia with weight loss c. night sweats d. chest pain e. productive cough 3. Diagnostics a. sputum and gastric contents, analysis for the presence of acid-fast bacilli b. chest x-ray for presence of active or

calcified lesions, "coin" lesions c. tuberculin testing 1. tine, mantoux tests i. checked 48 to 72 hours for induration ii. positive if >10 mm induration in healthy persons iii. establishes if there is an antibody response to the tubercle bacillus iv. if positive, indicates prior exposure to bacillus, not an active disease 4. Management a. long-term, six to 24 months, antimicrobial therapy with isoniazid (INH) (Hyzyd) or rifampin (Rifadin), with ethambutol HCL (Etibi) in some cases b. bed rest or chair rest until findings abate c. surgical resection of involved lung if medication is not effective d. high carbohydrate, high protein diet with frequent small meals 5. Nursing interventions a. with active infection, client must be isolated with airborne precautions when in the hospital b. teach client i. proper techniques to prevent spread of infection: hand washing, etc. ii. to report bloody sputum iii. not to use over the counter (OTC) medications without health care provider's approval iv. importance of taking medications as prescribed adherence to treatment regimen return at scheduled times for lab testing of liver enzymes an increase in B6 to minimize peripheral neuropathies, a common side effect of drug therapy C. Lung abscess 1. Localized area of lung infection 2. Usually follows pneumonia, TB or aspiration 3. Treatment consists of draining and culturing abscess and antimicrobial therapy X. LRS Disorders: Miscellaneous A. Pulmonary embolism 1. Definition/etiology a. clot blocks blood from the "bed" of arteries that feed the lung b. client is breathing but gases are not exchanged - ventilation without perfusion c. hypoxemia results d. can be mild or immediately fatal, based on the size and location of clot(s) e. usually clot has traveled from deep veins in the leg or pelvis 2. Diagnostics a. ventilation/perfusion (V/P) scan, also called V/Q scan b. ABG c. EKG 3. Management a. oxygen via mask b. anticoagulation - heparin in acute and coumadin for chronic risk c. thrombolytics d. filter surgically placed in vena cava for long term care B. Acute respiratory distress syndrome (ARDS) 1. Definition/etiology a. alveolar capillary membrane becomes more permeable to fluids b. increased extravascular lung fluid c. pulmonary compliance decreases d. intrapulmonary shunt increases e. refractory hypoxemia f. usually seen after lung injury or massive multi-system organ disease 2. Findings a. restlessness, anxiety b. dyspnea c. tachycardia d. cyanosis e. intercostal retractions 3. Diagnostics a. clinical presentation and history of findings b. hypoxemia on ABG despite increasing inspired oxygen level c. chest x-ray shows diffuse infiltrates 4. Management a. optimize oxygenation i. mechanical ventilation ii. sedation may be required iii. paralytic agents may be necessary b. antibiotics, as indicated c. corticosteroids 5. Nursing interventions a. plan for frequent rest periods b. monitor trends in oxygenation status, ABGs, respiratory effort c. observe for behavioral changes and vital signs; confusion and hypertension may indicate cerebral hypoxia C. Lung cancer 1. Definition/etiology a. types of lung cancer i.

squamous cell carcinoma ii. small-cell (oat cell) carcinoma iii. adenocarcinoma iv. large cell carcinoma b. prognosis is generally poor c. largely preventable if smokers stop and nonsmokers avoid second hand smoke 2. Findings a. hoarse voice b. changes in breathing c. persistent cough or change in cough d. blood-streaked or bloody sputum e. chest pain or tightness in chest wall f. recurring pneumonia, pleural effusion g. weight loss 3. Diagnostics a. medical imaging examinations b. cytological sputum analysis c. bronchoscopy d. biopsy 4. Management a. nonsurgical i. chemotherapy ii. radiation therapy iii. laser therapy to de-bulk tumor iv. thoracentesis and pleurodesis b. surgical i. thoracotomy a) wedge resection - part of a lobe b) segmental resection- part of a lobe c) lobectomy - one or more lobes d) pneumonectomy - entire right or left lung 5. Nursing interventions a. postoperative care i. chest drainage ii. routine post operative care a) monitor respiratory status frequently b) teach effective deep breathing and cough techniques c) refer to physical therapy for exercises for shoulder on affected side d) relieve pain iii. optimize oxygenation iv. provide opportunities for the client to talk about cancer; as needed, refer to support groups v. teach information as based on treatment plan and prognosis vi. optimize nutritional status D. Cor pulmonale 1. Definition/etiology a. right ventricular hypertrophy and subsequent chronic heart failure b. cause: heart must pump against great resistance from lung's blood vessels: called increased pulmonary vascular resistance (PVR) c. increased PVR results from chronic lung disease d. may be due to primary pulmonary hypertension as well 2. Diagnostics a. pulmonary artery pressure readings via a catheter b. echocardiogram c. chest radiograph d. ABG e. EKG 3. Management a. administer oxygen as ordered b. if hemoglobin within normal limits (WNL), monitor oxygenation with finger or pulse oximeter c. bed rest, as needed d. monitor effects of medications i. cardiac glycosides ii. pulmonary artery vasodilator iii. diuretics iv. restricted fluid intake as indicated e. nursing interventions i. monitor for changes in oxygenation status ii. pace activities in clients who tire easily E. Respiratory failure 1. Definition: lungs cannot maintain arterial oxygen levels or eliminate carbon dioxide a. PaCO2 > 50 mm Hg b. PaO2 < 50 mm Hg c. clients with chronic lung disease precautions i. look for drop from baseline function ii. this is a nursing and medical emergency iii. clients are always hypoxemic 2. Etiology a. lung diseases that harden the alveolar-capillary membrane to trap O2 b. neuro-muscular or musculoskeletal disorders i. respiratory drive dulled or blunted ii. muscles too weak to breathe 3. Diagnostics: ABG 4. Management a. oxygen per mask b. mechanical ventilation c. monitor for improvement in the underlying cause for the respiratory failure