NF 216 Midterm notes./COMPLETE SOLUTION

NF 216 Midterm notes ABG-taken from a A-line which is also good for monitoring blood pressure. A-line should be at phlebostatic axis • PH o Normal 7.35-7.45 o Acidosis below 7.35 o Alkalosis • PaO2 o Normal 80-1 ...

NF 216 Midterm notes ABG-taken from a A-line which is also good for monitoring blood pressure. A-line should be at phlebostatic axis • PH o Normal 7.35-7.45 o Acidosis below 7.35 o Alkalosis • PaO2 o Normal 80-100 • SaO2 o Normal 95-99 • PaCO2 o Normal 35-45 o Acidosis greater than 45 o Alkalosis less than 35 • HCO3 o Normal 22-26 o Acidosis less than 22 o Alkalosis greater than 26 BELLS PALSY • Assessment o Inability to close eye o Decreased corneal reflex o Increased lacrimation o Speech difficulty o Loss of taste o Disorientation of one side of the face • Analysis o Peripheral involvement of the seventh cranial nerve o Predisposing factors ▪ Vascular ischemia ▪ Viral disease ▪ Edema ▪ Inflammatory reactions • Nursing considerations o Protect head from cold or drafts o Administer analgesics o Assist with electric stimulation o Teach isometric exercises for facial muscles (blow and suck from a straw) o Massage o Warm packs URINARY ELIMINATION • Assessment o Color-yellow o Consistency-clear, transparent o Specific gravity-1.010 to 1.030 o pH-4.5 to 8 o 24 hour production is 1,000 to 2,000. 50ml per hour or 1 mL/kg/hr o BUN normal 10-20 or 3.6 to 7.1 o Creatinine normal 0.7 to 1.4 or 62-124 • Definitions o Anuria-total urinary output less than 100 mL/24 hours o Oliguria-total urinary output 100-400 mL/24 hours o Polyuria-total urinary output greater than 2000 mL/hours o Dysuria-painful or difficult voiding • Predisposing factors o Bedrest o Tumors o Prostatic hypertrophy, anticholinergic medications o Decreased bladder tone-previous use of indwelling catheter or childbirth o Cancer o Neurogenic-CVA, spinal injuries o Calculi o Stress o Urinary tract infection BRACHYTHERAPY o Internal radiation like cesium, radium and gold o Seal source like cesium is mechanically position source of radioactive material place in the body cavity or tumor o Lead container and long handled forceps in room in the event of dislodged source o Save all dressings, bed linens until the source is removed then discard dressings and liens as usual o Urine, feces not radioactive o Do not stand close or in line with radioactive source o Client on bedrest while implant is in place o Position of source verified by radiography o Unsealed source of radiation-unsealed liquid given orally or instilled in the body cavity o All body fluids contaminated o Greatest danger from body fluids during first 24-96 hours o Nursing care o Assign client to private room o Place caution radioactive material sign on door o Wear dosimeter film badge at all times when interacting with client. Offers not protection but measures amount of exposure. Each nurse has an individual badge o Do not assign a pregnant nurse to client o Rotate staff caring for client. Limit close contact to 30 minutes per 8-hour shift o Organize tasks so limited time is spent in client’s room o Limit visitors o Encourage client to do own care o Provide shield in room o Use antiemetics for nausea o Consider body image like alopecia-loss of hair o Provide comfort measures, analgesics for pain o Provide good nutrition o Skin care o Avoid use of soaps and powders o Wear cotton, loose fitting clothing o Mouth care o Stomatitis-develops 5-14 days after chemo begins o Symptoms-erythema, ulcers, bleeding o Rinse with saline or chlorhexidine. Avoid hard-bristled toothbrush, dental floss, lemon glycerin swabs. o Avoid hot or spicy foods o Topical antifungals and anesthetics o Hair care o Alopecia commonly seen, alters body image o Assist with wig or hair piece o Scarves, hats o Nutritional changes o Anorexia, nausea and vomiting commonly seen with chemo o Malabsorption and cachexia (wasting) common o Make meals appealing to senses o Conform diet to client preference and nutritional needs o Small frequent meals, high calorie, high protein o Encourage fluids but limit at mealtimes o Perform oral hygiene and provide relief of pain before meals o Neutropenia precautions-prevent infection among clients with immunosuppression. Absolute neutrophil count less than or equal to 1000 cells o Assess skin every 8 hours. Auscultate breath sounds, presence of cough, sore throat, check temp every 4 hours, report if higher than 101. Monitor CBC and differential daily o Private room when possible o Thorough hand washing o Allow no staff with cold or sore throat to care for client o No fresh flowers or standing water o Clean room daily o Low microbial diet. No fresh salads, unpeeled fresh fruits and vegetables. o Deep breathe every 4 hours o Meticulous body hygiene o Inspect IV site o Pain relief-three step ladder o Mild pain-nonnarcotic medication like acetaminophen along with antiemetics, antidepressants and glucocorticoids o For moderate pain-weak narcotics like codeine and nonnarcotic are used o For severe pain-strong narcotics like morphine are used o Give pain medication on regularly scheduled basis, preventative approach, additional analgesics given for breakthrough pain o Activity level o Alternate rest and activity o Maintain normal lifestyle o Psychosocial issues o Encourage participation in self-care and decision making o Provide referral to support groups, organizations o Hospice care CANCER o Assessment o Change in bowel, bladder habits o A sore that does not heal o Unusual bleeding or discharge o Thickening or a lump in the breast or elsewhere o Indigestion or difficulty in swallowing o Obvious change in a wart or mole o Nagging cough or hoarseness o Risk factors o Immunosuppression o Advancing age o Genetic predisposition o Causative factors o Radiation o Chronic irritation o Food additive-nitrates o Asbestos o Stilbesterol o Smoking o Alcohol o Epstein Barr virus o Burkitt’s lymphoma o Stress o Classifications o Carcinoma-epithelial tissue o Sarcoma-connective tissue o Lymphoma-lymphoid tissue o Leukemia-blood forming tissue. WBC and platelets o Plan o Avoid excessive intake of animal fat o Avoid nitrates o Decrease intake of red meat o Limit alcohol o Increase intake of bran, broccoli, cauliflower brussels sprouts, cabbage and foods high in vitamin A and C o Chemotherapy o Teletherapy (radiation)-like cobalt o Leave radiology markings intact on skin o Avoid creams, lotions, deodorants and or perfumes unless Rx o Use lukewarm water to cleanse area o Assess skin for redness, cracking o Administer antiemetics for nausea, analgesics for pain o Observe skin, mucous membranes and hair follicles for adverse effects o No hot water bottle, tape. Don’t expose area to cold or sunlight o Wear cotton clothing GASTRIC CANCER o Description o Malignant growth of the mucosal cells in the inner lining f the stomach with invasion to the muscle and beyond in advanced disease o No single causative agent has been identified but it is believed that H. pylori and a diet of smoke, highly salted, processed or spiced foods have carcinogenic effects. Other risk factors include smoking, alcohol and nitrate ingestion and a history of gastric ulcers o Complications include hemorrhage, obstruction, metastasis and dumping syndrome o The goal of treatment is to remove the tumor and provide a nutritional program o Assessment o Early ▪ Indigestion ▪ Abdominal discomfort ▪ Full feeling ▪ Epigastric, back or retrosternal pain o Late ▪ Weakness and fatigue ▪ Anorexia and weight loss ▪ Nausea and vomiting ▪ A sensation of pressure in the stomach ▪ Dysphagia and obstructive symptoms ▪ Iron deficiency anemia ▪ Ascites ▪ Palpable epigastric mass o Interventions ▪ Monitor vital signs ▪ Monitor hemoglobin and hematocrit and administer blood transfusion as prescribed ▪ Monitor weight ▪ Assess nutritional status, encourage small bland, easily digestible meals with vitamin and mineral supplements ▪ Administer pain mediation as prescribed ▪ Prepare the client for chemotherapy or radiation therapy ▪ Prepare the client for surgical resection of the tumor as prescribed o Post op ▪ Monitor vital signs ▪ Fowler’s position for comfort ▪ Administer analgesics and antiemetics ▪ Monitor I and O. ▪ Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns. Assess for bowel sounds ▪ Electrolyte replacement and parenteral nutrition ▪ Monitor nasogastric suction. Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours changes to brown tinged and then is yellow or clear ▪ Do not irrigate or remove the NG tube, but assist the PCP with irrigation or removal ▪ Advance the diet from NPO to sips of clear water to 6 small bland meals a day ▪ Monitor for complications such as hemorrhage, dumping syndrome, diarrhea, hypoglycemia, and vitamin B12 def. PANCREATIC CANCER o Most pancreatic tumors are highly malignant, rapidly growing adenocarcinomas originating from the epithelium of the ductal system. o Pancreatic cancer is associated with increased age, a history of diabetes mellitus, alcohol use, history of previous pancreatitis, smoking, ingestion of a high fat diet and exposure to environmental chemicals o Symptoms usually do not occur until the tumor is large, therefore the prognosis is poor o Endoscopic retrograde cholangiopancreatography for visualization of the pancreatic duct and biliary system and collection of tissue and secretions may be done o Assessment o Nausea and vomiting o Jaundice o Unexplained weight loss o Clay colored stools o Glucose intolerance o Abd pain o Interventions o Radiation o Chemo o Whipple procedure, which involves a pancreaticoduodenectomy with removal of the distal third of the stomach, pancreatojejunostomy, gastrojejunostomy and choledochojejunostomy o Post op care measure and complications are similar to those for the care of a client with pancreatitis and the client following gastric surgery. Monitor blood glucose levels for transient hyperglycemia or hypoglycemia resulting from surgical manipulation of the pancreas. LUNG CANCER o Description o Malignant tumor of the bronchi and peripheral lung tissue o Common target for metastasis from other organs o Assessment o Cough o Wheezing, dyspnea o Hoarseness o Hemoptysis, blood-tinged or purulent sputum o Chest pain o Anorexia and weight loss o Weakness o Diminisher or absent breath sounds, respiratory changes o Interventions o monitor for hemoptysis o monitor for tracheal deviation o place in a Fowler’s position o administer bronchodilators o provide a high calorie, high protein, high vitamin diet o nonsurgical interventions o radiation therapy may be prescribed for localized intrathoracic lung cancer and for palliation of hemoptysis, obstructions, dysphagia, superior vena cava syndrome and pain. o Chemotherapy may be prescribed for treatment of nonresectable tumors or as adjuvant therapy o Surgical interventions o Laser therapy ▪ To relieve endobronchial obstruction o Thoracentesis and pleurodesis ▪ To remove pleural fluid and relieve hypoxia o Thoracotomy-opening into the thoracic cavity, with pneumonectomy ▪ Surgical removal of 1 entire lung o Thoracotomy with lobectomy ▪ Surgical removal of 1 lobe of the lung for tumors confined to a single lobe o Thoracotomy with segmental resection ▪ Surgical remove of a lobe segment HEART DISEASE o Angina pectoris o Chest pain cause by myocardial ischemia o Quick or slow in onset o Indications ▪ Retrosternal chest pain that radiates usually to the left shoulder and upper arm and proceed down the arm into the fingers ▪ May also radiate to right shoulder, neck, jaw or epigastrium ▪ Usually lasts less than 5 minutes ▪ May describe pain as mild or moderate in severity as squeezing, burning, aching or bursting pressure. ▪ May say pain is like gas, indigestion or heartburn ▪ Dyspnea, pallor, palpitations, dizziness and diaphoresis ▪ Pain that is aggravated buy activity and relieved by rest and nitro o Interventions ▪ Medications • Antiplatelet agents • Vasodilators • Beta blockers • Calcium channel blockers ▪ Pain relief • Nitrates given sublingually ▪ Teach about nitro purpose and appropriate usage ▪ Encourage control of modifiable risk factors such as high cholesterol, smoking, hypertension, diabetes mellitus, obesity, lack of exercise and stress o CAD o Most prevealent form of cardiovascular disease in adults o Non-modifiable risk factors ▪ Age ▪ Gender ▪ Family history of heart disease o Modifiable ▪ Smoking ▪ Hypertension ▪ Elevated serum cholesterol levels ▪ Inactivity ▪ Obesity ▪ Diabetes mellitus o Atherosclerosis causes ischemia which results in angina, myocardial infarction and sudden cardiac death o Focus is to prevent disease by modifying modifiable risk factors o Ineffective endocarditis o Infection of heart lining and valves o Signs and symptoms ▪ Fever ▪ Malaise ▪ Back and joint pain ▪ Splinter hemorrhages under fingernails and toenails ▪ Petechiae in conjunctiva and mucous membranes ▪ Heart murmur o Care ▪ IV antibiotics for 4-6 weeks may need surgery for heart valve replacement o Cardiomyopathy o Disease of the heart muscle which can lead to heart failure, dysrhythmias and death o Most common form is dilated cardiomyopathy, significant dilation of the ventricles without hypertrophy of the muscle o Other form includes restrictive, arrhythmogenic right ventricular o Indications ▪ Signs of symptoms of heart failure o Tamponade o Excessive fluid accumulates in the pericardium causing decreased venous return to heart which decreases cardiac output causing compression of the heart o Cardinal signs ▪ Decreased systolic blood pressure ▪ Narrowing pulse pressure ▪ Increased venous pressure ▪ Muffled heart tones o Caused by penetrating injuries, metastasis, cardiac surgery, advance heart failure o Treatment ▪ Removal of the fluid in the pericardial sac o Care ▪ Assess for pulses paradoxus-systolic blood pressure is lower during inhalation than exhalation ▪ Hemodynamic status ▪ Assist with pericardiocentesis BLOOD PRESSURE