facebook_pixel

The Ultimate Nursing Care Plan Database

Helping You Take Care of Your Patients

Want a FREE Nursing Care Plan Template?

Nursing care plans can be a pain to write… especially as a new nurse. Grab this two page (editable) template and guide for creating perfect nursing care plans.

Grab Free CheatsheetFree PDF - Instant Delivery

Like this? Share With Your Fellow Nursing Students and Be Loved Forever!

Share on Facebook Share on Pinterest

Pathophysiology

Abdominal pain can be a very minor issue that is easily resolved, or a medical emergency.  There are many different things that can cause abdominal pain, whose pathophysiology can differ widely. Abdominal pain can be classified as either acute or chronic. When a patient presents to the emergency department or outpatient environment with abdominal pain, it generally constitutes a lengthy workup to determine the cause, and therefore the pathophysiology. Additionally, abdominal pain can be referred pain, which can complicate the clinical picture even further.

Etiology

Abdominal pain can be the result of pregnancy, ectopic pregnancy, trauma, a long list of gastric issues (gastroenteritis, constipation, diarrhea, irritable bowel syndrome, GERD, Chron’s disease, appendicitis, to name a few), hernias, allergic response, endometriosis, gallstones, severe menstrual cramps, hepatitis, miscarriage, and many more. Many disease processes result in abdominal pain, and some may present with abdominal pain even though it is not the typical clinical picture.

Desired Outcome

Cease painful stimuli, resolve underlying cause, minimize any subsequent damage.

Subjective and Objective Data

Subjective Data

Abdominal pain

Decreased appetite

Nausea

Rebound tenderness

Muscle tension

Restlessness

Objective Data

Constipation

Diarrhea

Electrolyte imbalances

Guarding

Vomiting

Nursing Interventions and Rationales

  1. Assess pain
    • We must have a detailed baseline so we not only know how to treat appropriately, but also to know if it has changed. (For example, a sudden relief of pain in a patient with appendicitis indicates rupture and an emergency.)
  2. Control pain: repositioning, heat/cold, medications (muscle relaxants, analgesics), and so forth (all as clinically appropriate)
    • Patients who are in pain have trouble participating in care, relaxing, sleeping, and healing. Do what is necessary to proactively treat the patient’s pain, and notify the MD as appropriate of changes or an inability to provide adequate relief.
  3. Assess bowel movements (color, consistency, frequency, amount)
    • This will aid the provider in making clinical decisions significantly. It is essential to report bowel movement characteristics and frequency accurately to aid in this important decision making. This also ensure accurate intake and output recording.
  4. Ensure adequate hydration; may require intravenous fluids
    • Patients with abdominal pain may have a diminished appetite, be NPO, or not want to drink fluids. Assess and promote appropriate fluid balance, which may requiring notifying the provider of a decreased oral intake and need for intravenous fluids to maintain fluid balance.
  5. Assess bowel sounds
    • Essential to know their quality as a baseline and to routinely reassess to detect changes. If a patient had bowel sounds, but now does not, it is essential to detect that and notify the provider, as the patient may not experience any symptoms.
  6. Facilitate normal bowel patterns
    • Abdominal pain can be due to issues with the GI tract. Therefore, it’s essential to proactively address issues like nausea, vomiting, constipation, and diarrhea as clinically appropriate. This can lessen
  7. Record intake and output
    • Patients with abdominal pain may not be taking in appropriate fluids or foods, or their urinary and/or bowel output may be lacking. Accurate I&O is essential for appropriate clinical decision making.
  8. Prevent infection
    • Abdominal pain may have been caused by a pathogen (gastroenteritis, for example). It is essential to promote adequate hand hygiene and infection prevention to prevent the spread to others or preventing the issue from resolving.
  9. Assess abdominal distention, report changes in size and quality as appropriate
    • Patients may be experiencing abdominal distention as part of the underlying disease process

Pathophysiology

Also known as acute kidney injury (AKI), is measured by the buildup of waste in your body and altered fluid levels because the kidneys are failing to do their job. The cause of the renal failure can also change the pathophysiology. There are three main causes: 1) decreased blood flow to the kidneys, 2) direct injury to the kidney/tissues, and 3) blockage of urine excretion. Inflammation to the kidneys or their structures (nephrons) can cause the kidneys to fail. Blockage of urine can cause a backup in the kidney, not allowing them to continue to filter out waste from the body or manage fluid levels.

Etiology

There are many causes of kidney failure. For example, low blood perfusion to the kidneys can cause acute kidney failure from causes such as an infection/antibiotic use, hypotension potentially from blood loss (hemorrhage) or fluid loss (vomiting/ diarrhea), or even other organ failure (heart attack, liver failure). Another reason for kidney failure could be direct damage to the structures of the kidney itself. The biggest offender of kidney damage is sepsis, but also anything that can cause inflammation in the vessels of the kidneys (Vasculitis) as well as the attempt to treat it with too many NSAIDs can cause direct damage to the kidneys. Lastly, if the urine cannot be excreted, this can cause kidney failure. Kidney stones, enlarged prostates and some cancers can present problems for the urinary tract’s ability to excrete urine.

 

Desired Outcome

Return normal functioning of the kidney’s, including the nephrons, blood vessels, urethra, and ureters. Have the kidney labs be within normal limits and hopefully not have the patient on dialysis.

Subjective and Objective Data

Subjective Data
  • Increased thirst
  • Dizziness
  • Flank pain
  • Hematuria
  • Oliguria
  • Recent antibiotic usage
  • Over usage of NSAIDs
  • Recent blood transfusion
  • Chest pain/pressure
  • Confusion
Objective Data
  • Hypertension
  • Orthostatic Hypotension
  • Atrial fibrillation
  • JVD
  • Pulmonary Edema/Rales
  • Edema

Nursing Interventions and Rationales

  1. Strict intake and output measurement
    • It is important if the kidney’s are not functioning to measure the patient’s I&Os. Notify the physician if there is a deficit greater than 5-10%.
  2. Medications to watch: Statins, NSAIDS, Aspirin
    • Be mindful of medications that can become toxic when the kidneys aren’t functioning at their prime.

      Try to limits these drugs, watch labs and antibiotic troughs. Look out for signs
  3. Statins NSAIDS Aspirin Acetaminophen Insulin Some antibiotics Herbal supplements
    • Be mindful of medications that can become toxic when the kidneys aren’t functioning at their prime.

      Try to limits these drugs, watch labs and antibiotic troughs. Look out for signs and symptoms of overdose.

      Here are the most common signs and symptoms of overdose. *note this is not a comprehensive list*

      Statins: muscle pain and weakness.

      NSAIDS: N/V, headache, dizziness and blurred vision.

      Aspirin: ringing in the ears (tinnitus), decreased hearing.

      Acetaminophen: N/V/D, irritability, convulsions, coma.

      Insulin: Hyperinsulinemia from the body building up resistance to insulin.

      Some antibiotics: Neuro symptoms like seizures, confusion, neuropathy.

      Herbal supplements: Various, depends on the herbal supplement.
  4. Monitor lung sounds and edema
    • You want to make sure fluid balance is carefully monitored. A backup in the lungs would cause crackles and a back up systemically would cause pitting edema in the legs.
  5. Diuretic administration: Furosemide (Lasix) Bumetanide (Bumex) Spironolactone (Aldactone)
    • This is very important… diuretics are going to make the patient PEE… lots and lots of PEE. Do not under any circumstances administer a diuretic without a bathroom plan. And a word to the wise, have a backup plan. Meaning if you have a walkie talkie patient with functioning arms and a strong call light finger, I still would set up a bedside commode just.in.case. I walk them to the bathroom or assist them in any way needed, but it is possible that they do not know how urgent their situation is and I can clean up pee, but you can’t clean up that patients dignity.

      Diuretics work on different parts of the nephrons. The goal of diuretics is to help the kidneys rid the body of salt (notice I didn’t say sodium (Na+)?) and fluids. It is important to note for every Na+ molecule there is a compound of one water (H20) that follows it. Psssst: potassium is a salt...

      There are three kinds of diuretics: Loop, Thiazide, and potassium sparing.

      Loop: works on the loop of henle and excretes Na+, K+, and Ca-. (Yikes! Watch your patient’s electrolytes!)

      Thiazide: Works on the distal convoluted tubule and blocks the Na+/Cl- symporter (which reabsorbs...you guessed it Na+ and Cl-). This symporter is responsible for about 5% of Na+ reabsorption. So monitor your patient’s sodium and chloride. Oh, and your K+...Why? Because K+, Cl- and Na+ have direct relationships!

      Potassium-Sparing: Works on the Na+/K+ pumps in the collecting ducts of the kidney by blocking the effects of aldosterone at that site. Aldosterone has the collecting ducts reabsorbing Na+ and thus water, and for ever Na+ absorbed, one molecule of K+ is excreted. So this diuretic does the opposite of that, saves a K+ and excretes a Na+ and H20.

      Most commonly used diuretics in acute kidney failure:
      -Furosemide: Loop
      -Bumetanide: Loop
      -Spironolactone: Potassium-Sparing
  6. Monitor Potassium Potassium (K+) Normal range: 3.5 - 5.0 mEq/L
    • As Furosemide is the front line and best treatment for kidney failure, nurses must be careful to watch the patient’s potassium levels (Remember: Furosemide is potassium wasting).

      Potassium (K+): is the most abundant intracellular cation and plays a vital role in the transmission of electrical impulses in cardiac and skeletal muscle. It plays a role in acid base equilibrium. In states of acidosis hydrogen with enter the cell as this happens it will force potassium out of the cell, a 0.1 decrease in pH will cause a 0.5 increase in K+
  7. Diet changes and control Fluid restriction Salt restriction
    • Educating the patient on decreased sodium intake as well as strict fluid intake is vital when in any sort of kidney failure.

      However, if patient is on a potassium wasting diuretic, educate about potassium (bananas, sweet potatoes, etc.)
  8. Monitor Kidney Labs Blood Urea Nitrogen (BUN) Normal Range: 7-20 mg/dL Creatinine (Cr) Normal Range: 0.7-1.4 mg/dL
    • This measures how well treatment is working, you want the labs to be moving back to normal limits.

      Blood Urea Nitrogen (BUN): measures the amount of urea in the blood. When protein is broken down ammonia is formed. Ammonia is converted to urea in the liver and is eventually excreted in the kidneys.

      Creatinine (Cr): is a byproduct of creatine metabolism, and it is excreted by the kidneys. Creatinine is created in proportion to muscle mass and usually stays stable.

Pathophysiology

A decrease in red blood cells (RBC) or hemoglobin (HGB). The body uses the RBCs to transport Oxygen via HGB (HGB binds oxygen to the RBC). The oxygen is then bussed around the body and dropped off to the cells for the cell to perform cellular respiration creating ATP AKA energy. With oxygen (aerobic cellular respiration) the cells produce their ATP and have a byproduct of CO2, which we breath out. Without oxygen (anaerobic respiration) the cells use fatty chains to get their energy which has the byproduct of ketones (super acidic). Having the body be in a state of low oxygenation (hypoxia) creates an unbalanced pH which then denatures proteins making cells not be able to read their code/instructions because the code (DNA/RNA) is made out of proteins… While being anemic for short term is easier for the body to bounce back, long term anemic or rapid severe anemia is a bicycle kick to the body… AKA no good. It is important to note that you need BOTH RBCs and HGB for a working system of oxygenation.

Etiology

There are many causes of anemia, the most life threatening is massive hemorrhage, but other causes such as lack of iron, severe burns, cancers, bone marrow disorders like multiple myeloma or leukemia can be just as detrimental.

 

Some of the types of anemia:

  • Iron Deficiency Anemia: Usually caused by hemorrhage or lack of Iron (or lack of ability to absorb iron). Treated with iron supplements/diet changes and blood transfusions.
  • Vitamin Deficient Anemia: Due to Folic Acid (vitamin B12) deficiency or lack of ability to absorb B12. Treated with B12 supplements and diet changes.
  • Aplastic Anemia: The bone marrow is not producing enough RBCs. Treated with blood transfusions and also bone marrow biopsies to diagnose specific issue with the bone marrow.
  • Hemolytic Anemia: Due to RBCs being destroyed. What is causing the lysing of the RBCs can be from a range of problems including infection, autoimmune disorders, etc. Treatment is dependant on the cause. If due to infection, treatment is antibiotics, if autoimmune treatment may be medications that suppress the autoimmune system. Cardiac and vascular specialists should be consulted for this condition in case it is due to a mechanical factor like the heart valves.
  • Sickle Cell Anemia: This is a genetic disorder where the blood cells become sickle shaped, causing clots, hemolysis, and poor perfusion. Treatment is focused on pain control, fluid resuscitation and sometimes blood transfusions.

Desired Outcome

Stopping the cause of the anemia and returning the blood counts (RBC/HGB) back to normal limits.

Subjective and Objective Data

Subjective Data
  • Fatigue/weakness
  • Dizziness
  • Lightheadedness
  • Shortness of Breath (SOB)
Objective Data
  • Bleeding/Hemorrhaging
  • (internal and external)
  • ***consider stroke like symptoms, patient may be have a hemorrhagic stroke!***
  • Pale skin
  • Shortness of Breath (SOB)
  • Potential ECG changes
  • Hypotension (from blood loss)
  • Tachycardia (from hypotension/blood loss)
  • Syncope (also from hypotension/blood loss)
  • Low lab values: HGB/RBC.

Nursing Interventions and Rationales

  1. Assess for bleeding/Hemorrhage and stop source if found. GI bleed: Give pantoprazole (Protonix), potential surgical intervention to stop the bleeding. External hemorrhage: Don’t forget about menstruation for females, soaking more than 1 pad in an hour is very concerning for too much blood loss! Internal hemorrhage: outside of the GI tract but inside the skin.
    • GI bleeding: This entails my least favorite thing to do, and the nurse doesn’t even do it, but the nurse usually needs to be present because it invades the patient’s self respect and dignity. Therefor you get to be in the patient’s visual field while they are being pillaged in their back end.

      The provider will place a gloved finger into the rectum and needs to have feces on it when it comes out. The feces is placed on a hemoccult card where a developing solution is married with the stool giving the provider insight of whether or not there is blood in the stool. If the card turns blue it is positive for blood.

      As a nurse you will ask the patient if they have black/tarry stools (upper GI bleed) or bright red blood (lower GI bleed) in their stools.

      Give pantoprazole (Protonix), a proton pump inhibitor (PPI) that decreases the amount of acid in the GI lining. This reduces the ulceration which could be (and most likely is) causing the GI bleed.

      External hemorrhage: Found by examining the patient’s full body (front and back). Apply pressure to any hemorrhage. Replace lost volume if hemoglobin is below 8 (this number is different per hospital, per doctor and per situation, but 8 is a general number that you don’t want people’s hemoglobin to be below).

      Internal hemorrhage: Can be from a laceration to the liver or the spleen. Assess for abdominal pain and swelling.

      Don’t forget about hemorrhaging in the brain- look for signs and symptoms of stroke.
  2. HGB Normal Value: Male: 13.5 - 16.5 g/dL | Female: 12.0 - 15.0 g/dL RBC Normal Value: Male: 4.5 - 5.5 x106/cells/mm3 Female: 4.0 - 4.9 x106/cells/mm3 Folic Acid (B-12) Normal Value: 2 - 20 ng/mL Ferritin Normal Value: 20-300 ng/mL Iron Normal Value: 50-175 ug/dL
    • There are many blood lab values a nurse can monitor while treating a patient with anemia. Here are the most important.

      HGB: Hemoglobin (Hbg), an iron containing compound, is the main protein in Red Blood Cells (RBCs). It enables oxygen and carbon dioxide (CO2) to bind to RBCs for transport throughout the body.

      This is the most commonly looked at lab value to assess need for a blood transfusion. Every institution, Doctor, and person is different but as a general rule, a hemoglobin below 8 requires a blood transfusion.

      RBCs: Red Blood Cells (RBCs) contain hemoglobin which is responsible for oxygen transport throughout the body. RBCs are primarily produced in the bone marrow, they have a life span of 120 days and are destroyed in the spleen and liver. RBC production is regulated by erythropoietin (EPO) which is produced and released from the kidneys.

      Folic Acid (B12): Folic acid is an essential water soluble B vitamin. It is stored in the liver and is an important part of Red Blood Cell (RBC) and White Blood Cell (WBC) function, DNA replication, and cell division.

      Ferritin: Ferritin is a protein that stores iron. It is formed in the liver spleen and bone marrow. Ferritin in the blood is usually proportional to stored ferritin. Ferritin is a more sensitive and specific test for identifying iron-deficiency anemia, however, it is usually measured in conjunction with total iron binding capacity and iron.

      Iron: Iron (Fe) is an element that is an important component of hemoglobin in red blood cells. Hemoglobin transports oxygen from the lungs to all the cells of the body. Most of the iron in the body is located in hemoglobin, but some iron is located in myoglobin as well as some iron is stored in the liver, bone marrow, and spleen. The storage form of iron is ferritin. Iron is transported in the blood by a protein called transferrin.
  3. Blood product administration: Packed Red Blood Cells (PRBC) Fresh Frozen Plasma (FFP)- one unit for every 4 units of PRBC
    • If the source of the anemia is blood loss, you want to stop the source if possible and replace the blood. If you are unable to stop the source and the patient losses greater than 40% of their blood, give a massive blood transfusion rapidly.
  4. Cardiac Monitoring: 12-lead ECG 5-lead monitoring
    • Decreased blood volume is problematic for the heart, so make sure the heart is still kicking it the proper way (normal sinus rhythm) or as proper as it can. Monitor for any changes in ECG, tell the patient to inform you of any new symptoms like chest pain or shortness of breath.

      Anemic patients are more likely to experience ST depression, QT prolongation, T wave depression, and R wave difference.
  5. Fall Precautions
    • High risk of syncope, especially if the patient is hemorrhaging. Keep the patient lying flat or in trendelenburg position if hypotensive.
  6. Oxygenation monitoring/Administration
    • The purpose of your RBCs binding hemoglobin and oxygen is to deliver oxygen to your cells so they can perform aerobic respiration, giving you the energy to perform ADLs.

      If you limit the number of RBCs or HGB, you limit the O2 in your blood.

      Check for oxygen saturation, monitor it, and if it falls below 94% give 2L NC to start with, increase as needed. Oh and call your Respiratory Therapist because they are your best friends and need to monitor the patient too. Friends don’t let friends drive drunk monitor oxygenation alone.
  7. Iron or B12 Supplements/Diet changes
    • Educate the patient on foods that are high in iron (red meats, dark leafy vegetables, etc) or high in folic acid AKA B12 (rice, pasta, beans) and if the patient is unable to get enough through their diet, they may have to use supplements.

      Review the patient’s medication list.

      Iron supplements are likely to decrease absorption of Quinolone and Tetracycline Antibiotics as well as Levodopa, Levothyroxine, Methyldopa, CellCept, Penicillamine, and Bisphosphonates.

      Folic Acid supplements are likely to increase side effects of 5-Fluorouracil and Capecitabine. It might also decrease the efficacy of Fosphenytoin, Methotrexate, Phenobarbital, Phenytoin, Primidone, and Pyrimethamine.

Pathophysiology

Aspiration occurs when something enters into the lungs that is not air. This sometimes causes aspiration pneumonia, but not always. For example, the patient has a gag reflex, causing coughing, or the cilia lining the lungs are able to sweep out the aspirated item. If the patient aspirates a secretion that has a high bacterial count they will likely get aspiration pneumonia. The difference physiologically speaking is that pneumonia will be treated with antibiotics.

Etiology

This is likely caused by someone losing their gag reflex, but can also be caused by inability to clear secretions/emesis, as well as from a position or medication (such as a sedative medication). Someone with dysphagia, no matter the cause is at high risk for aspiration.

Desired Outcome

Patent airway, oxygenation maintenance, prevention of further complications such as pneumonia.

Subjective and Objective Data

Subjective Data

Shortness of breath

 

Difficulty breathing

 

Chest pain

Objective Data

Coughing

 

Low oxygen saturation

 

Tachypnea/Dyspnea

 

Blue lips/fingers

 

Lung sounds: Crackles and/or diminished

 

Putrid or frothy sputum

Nursing Interventions and Rationales

  1. AIRWAY PROTECTION Maintain a patent airway

    • Legit the number one thing. Everything else in this care plan is good too but this trumps it all when it comes to priorities.

      Prevention is key, but since this patient has already slipped substances past the epiglottis (AKA royal lung guard) everything that applies to prevention (NPO, head of bed greater than 30 degrees, oral hygiene, etc.) is even more important to prevent further complications.

      Intubation: Be prepared to intubate, not because the patient will for sure be intubated, but because not being prepared is costly (like someones life kind of cost).

      Suction: Lastly have suction ready. You should always have suction ready no matter the patient’s chief complaint, but especially for a patient with aspiration.

      Oxygen: Have all the stuff for oxygen ready. Monitor their oxygen levels. If they dip low (<94%) help them out with oxygen. Key note here: have a full tank of oxygen ready to go on their bed incase you need to rush them off somewhere due to emergent situations. These patients are high risk for low oxygenation.

  2. Suction when necessary
    • Have the suction ready to go to help keep the airway clear and increase the surface area for oxygen absorption.
  3. Perform a Swallow Screen

    • This is a simple, nurse initiated test that should really be performed on any patient that is not NPO.

      Checking the patient’s ability to swallow gives the nurse so much information about how to proceed with the plan of care.

      For example: That fever they have, is not going to be treated via oral Tylenol if they cannot swallow. Doctors WILL order this- you will not give it because you are awesome and have checked the patient’s ability to swallow. Then you will beg for IV Tylenol and get an order for rectal Tylenol because it is cheaper and the standard of care. After you and the patient cry it out for a minute, you will administer the Tylenol in the no go zone with the promise of blankets as a reward for breaking the fever.

      If they do not pass the swallow screen the patient will be NPO, or they should be anyway.
  4. Acquire a chest X-ray
    • A chest x-ray helps to differentiate the patient with aspiration as to whether they have acquired pneumonia or not.

      The results of the x-ray determine the patient’s plan of care (meaning pneumonia treatment or not).

      As a nurse, it is important to monitor for s/s of aspiration and to inform the doctor if you suspect aspiration has occurred so the team can assess the need for an x-ray.
  5. Laboratory testing: Venous or Arterial Blood gas Complete Blood Count (CBC) Sputum culture/Blood culture
    • The goal of the blood gas is to monitor the patient PaCO2/PCO2 and their PaO2/PO2

      The goal of the CBC is to monitor White Blood Cells (WBC)

      Sputum culture/blood cultures will be not helpful right away but after they result can change the antibiotics that the patient is receiving.
  6. Antibiotics- if indicated (Clindamycin or Metronidazole)
    • This may be used as prophylaxis, or because the patient developed pneumonia.

      Clindamycin: most commonly used for aspiration pneumonia.

      Metronidazole: used in conjunction with clindamycin to offer further coverage.
  7. Assess respiratory function: Auscultate lung sounds Monitor O2 saturation Assess skin color (are they blue?) Assess depth, rate, regularity of breathing as well as symmetry of chest rise and fall
    • This should be done on every patient. But just like for a patient who has stroke like symptoms, you will be checking neuro function more frequently, a patient with aspiration needs to have their respiratory functions assess more frequently. The frequency is based on each patient and the situation-use clinical judgement here.

Pathophysiology

Bronchoconstriction and increased mucus production decreases the ability to bring air into the alveoli, decreasing the amount of oxygenation red blood cells are able to exchange. This can also lead to increased amounts of carbon dioxide (CO2) retention due to lack of ability to exhale the CO2.

Etiology

Swelling and mucus aggregated from an irritant or “trigger” cause difficulty in breathing, wheezing lung sounds and hypoxia. Triggers include dust, pollen, smoke, infection, etc. Asthma can also be genetic, environmental, triggered by exercise or from allergies.

 

Desired Outcome

Decreased work of breathing and proper oxygenation to tissues.

Subjective and Objective Data

Subjective Data
  • “I can’t breath”
  • Chest Pressure
  • Chest Pain
  • Chest Tightness
  • Cough (both objective and subjective depending on if the cough is happening now or if they are reporting a cough)
Objective Data
  • Pursed lip breathing
  • Low pulse oximetry (< 90)
  • Blue lips/fingers
  • Tachypnea
  • Wheezing
  • Tripod position

Nursing Interventions and Rationales

  1. Check pulse oximetry Apply oxygen if O2 saturation is less than 90%, start at 2 liters nasal cannula (2L NC)
    • Get subjective data to determine if patient is receiving proper amounts of oxygen.

      This is both a comfort measure as well as physiologically helpful. In other words, it can’t hurt the patient (at higher amounts and flows it could hurt the patient!). Eliminate hypoxia, move up by 1L if not improving after re-checking every few minutes, call respiratory therapy if they require more than 6L NC.
  2. Educate about triggers/make sure the patient's room does not have any triggers
    • Dust is near impossible to completely get rid of, however, other triggers like pollen (no flowers), animal dander (no visiting puppies), etc. can be eliminated.

      Make sure the patient knows about their asthma triggers and help them problem solve how to eliminate the trigger from their life.
  3. Auscultate lung sounds
    • If wheezy they may need a breathing treatment
      If you hear crackles they may have pneumonia and potentially could use suctioning.
  4. Positioning patient in an upright position
    • Opens lung bases and airway
  5. Have the patient perform a peak flow meter
    • Peak flow meters tell us how much air that patient can exhale. The smaller the number the less amount of air they are moving.
  6. Breathing treatments and medication therapy
    • Beta-Agonists: Such as albuterol work as bronchodilators

      Anticholinergics: Such as Ipratropium work to relax bronchospasms

      Corticosteroids: Such as Fluticasone work as an anti-inflammatory
  7. If the patient is a child or the patient has been working very hard to breath for a long period of time and is getting worse, be prepared with an airway cart. And for the love of the airway, have your respiratory therapist aware of the patient
    • Safety! Plus you do not want to wait until the impending airway closure happens to try to secure their airway. Sometimes the patient will be sedated and intubated to try to correct any respiratory acidosis or alkalosis.

Pathophysiology

An electrical activity disturbance in the heart that causes an irregular and often rapid heartbeat. The atria quiver sending confusing electrical signals to the ventricles, leaving them unsure of when to contract thus beating irregularly. During atrial fibrillation, the heart is a less effective pump because of the quivering as well as not emptying completely. This causes the blood to pool and a clot can form. The clot can venture out of the heart into the lungs (PE), brain (stroke) or extremities (DVT).

Etiology

The specific cause of atrial fibrillation is unknown but there are risk factors that put someone at higher risk of developing afib. Risk factors such as smoking, hypertension, and obesity as well as conditions such as diabetes or heart disease increase the likelihood that a patient may get atrial fibrillation. Post surgical interventions present a major risk for atrial fibrillation as well. Approximately 30%-40% of cardiac surgery patients develop atrial fibrillation.

Desired Outcome

Decreasing risks of clot formation, a heart rate within normal limits and rhythm control. The ultimate outcome is converting back to normal sinus rhythm, however, many people live with atrial fibrillation, especially if rhythm control doesn’t work or isn’t necessary.

Subjective and Objective Data

Subjective Data
  • Heart Palpitations
  • Feeling like the heart is beating out of the chest
  • Feeling a fluttering sensation in the chest
  • Nausea
  • Lightheadedness
  • Weakness
  • ***Patient may not have any symptoms at all***
Objective Data
  • Irregular heartbeat
  • Tachycardia

Nursing Interventions and Rationales

  1. Obtain a 12 lead ECG
    • Used to diagnose atrial fibrillation

      The waves are more chaotic and random

      The beat is irregular

      You can see the atria quivering between the QRS (ventricles pumping)

      No discernible P waves The ventricular rate is often 110-160 bpm and the QRS complexes is usually less than 120 ms.
  2. Potential rhythm control: Electrocardioversion, Ablation, Pacemaker
    • -Electrocardioversion: AKA cardioversion, is used to “reset” the heart’s electricity.

      The patient will be shocked on the outside of the chest wall. This treatment is used for patients who have infrequent episodes of atrial fibrillation because if the patient has it frequently, they have a high probability of the afib returning after being cardioverted.

      ***If there is a blood clot in the atria, cardioverting may send the clot out of the heart to the brain, lungs, or extremities. The chance of a blood clot increases the longer the patient is in afib, consider anticoagulation prior to cardioversion***

      Ablation: used for patient’s that have not been able to control their afib for a long time with medications or cardioversion. A catheter is inserted into the patient’s heart and destroys cardiac muscle cells so they scar, causing the electrical activity to stop in those cells, thus eliminating the passing of chaotic electrical activity.

      Pacemaker: This is placed under the skin and is a device that sends electrical signals to the heart to help it beat with the right rhythm and pace.
  3. Heart rate control: Beta Blockers: -Propranolol -Metoprolol -Atenolol Calcium Channel Blockers: -Diltiazem -Verapamil Cardiac Glycosides: -Digoxin
    • A heart can only sustain rapid beating for so long before it tires out. Using beta blockers, calcium channel blockers and cardiac glycosides will help control the rate of the heart beat.

      Beta Blockers: They block beta 1 receptors from being stimulated. Stimulation of Beta 1 causes positive inotropic (force of contraction) and chronotropic (pace of heart beat) effects. If you block beta 1 you will have decreased force of contraction and decreased heart rate.

      Calcium Channel Blockers: They block calcium channels… Duh. When calcium enters the cell in causes the cell to contract, thus when the channels are blocked, it decreases the production of electrical activity innately decreasing the heart rate.

      Cardiac Glycosides: This medication stimulates the Vagus nerve, which when stimulated slows the heart rate down. The vagus nerve is a CNS nerve that also works with the PNS- specifically the autonomic parasympathetic system… AKA rest and digest… So if this is stimulated your body will rest/slow down, thus decreased heart rate.


      It also blocks the Na+/K+ channel in cardiac myocytes. When this channel is open, K+ moves into the cell and Na+ moves out of the cell, called repolarization and is the relaxation part of a heart beat. When it is blocked it causes increased contractility of the heart. If your heart is beating stronger it will inherently slow down.
  4. Anticoagulant Therapy: Coumadin Aspirin Lovenox Plavix Eliquis
    • Thinning the blood helps to disintegrate and break up the clot as well as increasing flow of blood. There are many options for blood thinners each with their own pro’s and con’s. The most common are listed to the left.
  5. Fall education
    • Being on a blood thinner, the patient needs to be informed of their risk of bleeding out especially if they fall and hit their head.

      Make sure to go over environmental hazards such as good lighting and eliminating throw rugs.

      If a patient does fall and hit their head they need to go to the ER immediately, even if they are not experiencing any adverse effects.
  6. Stroke education Use the FAST Mnemonic: F: Facial drooping A: Arm weakness S: Slurred speech T: Time to call 911
    • The risk of a blood clot forming and moving to the brain is fairly high. It is important to teach the patient and their family members the signs and symptoms of stroke.

      Teach the patient that if they feel confused or feel weakness on one side to call for help.
  7. Cardiac enzyme monitoring: Troponin I Creatine Kinase MB
    • Initial measurement of the cardiac enzymes is important because it helps with any trending information, the sooner you get this information the better. Also getting trending results over specific periods of time is helpful.

      Troponin I: Is an enzyme that helps the interaction of myosin and actin in the cardiac muscle. When necrosis of the myocyte happens, the contents of the cell eventually will be released into the bloodstream.

      Troponin can become elevated 2-4 hours after in ischemic cardiac event and can stay elevated for up to 14 days.

      Creatine Kinase MB: This enzyme is found in the cardiac muscle cells and catalyses the conversion of ATP into ADP giving your cells energy to contract. When the cardiac muscle cells are damaged the enzyme is eventually released into the bloodstream.

      CKMB levels should be checked at admission, and then every 8 hours afterwards.

Pathophysiology

Fluid back up in the heart causing the heart to fail its’ functionality and pump ineffectively. Heart failure can be in the left side, right side or both. When both sides are failing, it is called congestive heart failure. Heart failure is measured by ejection fraction. Normally functioning hearts have 50% or higher ejection fractions. Anything less is concerning for heart failure.

Etiology

Any issue with the cardiovascular system could potentially cause CHF (or put the patient at a much higher risk for CHF), such as myocardial infarction, coronary artery disease, hypertension, cardiomyopathy, heart arrhythmias, etc. Also any other comorbidities such as diabetes, thyroid issues, HIV, etc. contribute to heart failure occurring. If the CHF is acute in nature, it may have been caused by a virus, infection, or blood clot.

Desired Outcome

maximized cardiac functionality as well as decreased stress on the cardiovascular system.

Subjective and Objective Data

Subjective Data

Difficulty in Breathing

 

Coughing (produces a white or pink tinged mucus)

 

Heart palpitations or feeling like the heart is racing.

Objective Data

Leg edema

 

Crackles in the lung bases

 

Shortness of breath upon exertion

 

Confusion

Nursing Interventions and Rationales

  1. Monitor heart rhythm Get a 12 lead ECG
    • Patients with CHF will have a low voltage ECG, after peripheral edema is resolved the ECG gains voltage again and becomes more of a normal looking ECG.
  2. Restrict sodium intake
    • Water follows salt! The patient has too much fluid on board and needs to get rid of it, restricting the sodium helps with this.

      This means educating the patient on dietary changes that need to happen and be adhered to. Try to stay between 300-600 mg of salt in a serving. Also be aware of salt substitute and the patients K+!
  3. Monitor BNP Normal range: <100 pg/mL
    • Brain natriuretic peptide (BNP): is a hormone made by the heart. When the heart is stressed or working hard to pump blood, it releases BNP.
  4. Assess respiratory function: Listen to breath sounds Monitor O2 saturation
    • Fluid can back up into the lungs and cause shortness of breath, especially upon exertion. Be careful about laying these patients flat as you can put them in respiratory distress.

      Place the patient on O2 as needed to help them keep their O2 levels adequate.
  5. Administer diuretics: Furosemide (Lasix) Bumetanide (Bumex) Hydrochlorothiazide (Microzide) Spironolactone (Aldactone)
    • We need to get all this fluid out of the patient… The best way to do this is administer diuretics.

      The FIRST thing you do BEFORE you administer a diuretic is have a pee plan. Do not under any circumstances administer a diuretic without a bathroom plan. And a word to the wise, have a backup plan. Meaning if you have a walkie talkie patient with functioning arms and a strong call light finger, I still would set up a bedside commode just.in.case. I walk them to the bathroom or assist them in any way needed, but it is possible that they do not know how urgent their situation is and you can clean up pee, but you can’t clean up that patients dignity.

      Diuretics work on different parts of the nephrons. The goal of diuretics is to help the kidneys rid the body of salt (notice I didn’t say sodium (Na+)?) and fluids. It is important to note for every Na+ molecule there is a compound of one water (H20) that follows it. Psssst: potassium is a salt...

      There are three kinds of diuretics: Loop, Thiazide, and potassium sparing.

      Loop: works on the loop of henle and excretes Na+, K+, and Ca-. (Yikes! Watch your patient’s electrolytes!)

      Thiazide: Works on the distal convoluted tubule and blocks the Na+/Cl- symporter (which reabsorbs...you guessed it Na+ and Cl-). This symporter is responsible for about 5% of Na+ reabsorption. So monitor your patient’s sodium and chloride. Oh, and your K+...Why? Because K+, Cl- and Na+ have direct relationships!

      Potassium-Sparing: Works on the Na+/K+ pumps in the collecting ducts of the kidney by blocking the effects of aldosterone at that site. Aldosterone has the collecting ducts reabsorbing Na+ and thus water, and for ever Na+ absorbed, one molecule of K+ is excreted. So this diuretic does the opposite of that, saves a K+ and excretes a Na+ and H20.

      Most commonly used diuretics in congestive heart failure are loop and sometimes thiazides are used with loop diuretics:
      -Furosemide: Loop
      -Bumetanide: Loop
      -Hydrochlorothiazide: Thiazide
  6. Strict intake and output (I&O’s)
    • These patients should have around 8 cups of fluid or just slightly under 2 liters of fluid per day. This can change per patient and per doctor recommendation, so make sure to get a goal from the physician.
  7. Monitor swelling/edema
    • Edema is measured by pressing over a bony prominence, usually the top of the foot or the tibia and is charted by a number and whether the skin bounces back or stays pitted (called pitting edema).
      +1: mild indent
      +2: Moderate indent
      +3: Deep indent
      +4: Very deep indent

Pathophysiology

Liver cirrhosis is a chronic, irreversible liver disease. Inflammation and fibrosis of liver cells (hepatocytes) lead to formation of scar tissue within the liver, which causes obstruction of hepatic blood flow and impedes proper liver function.  This impaired blood flow leads to edema, ascites, esophageal varices, hemorrhoids, and varicose veins, among many other things.  The liver is responsible for carrying out many functions for the body, and therefore the list of potential signs and symptoms is quite lengthy.

Etiology

Alcoholic liver disease (26%) and Hepatitis C (21%) are the cause behind 47% of liver cirrhosis cases in the United States. An additional 15% of cases are due to a combination of Hepatitis C and alcoholic liver disease, making these disease processes responsible for 62% of all cases in the United States. Additional causes include non-alcoholic fatty liver disease, Hepatitis B, Hepatitis D, autoimmune hepatitis, and many more.

Desired Outcome

Minimize continued liver damage, optimize nutrition, maximize hepatic circulation, minimize and prevent respiratory complications.

Subjective and Objective Data

Subjective Data

Pain in RUQ

Objective Data

Malaise

Jaundice with scleral icterus

Edema

Anorexia

Clay-colored stool

Hepatomegaly

Aplenomegaly

Ascites (positive fluid wave test)

Hepatic encephalopathy

(disorientation, altered LOC, fatigue)

Asterixis (flapping hand tremor)

Decreased reflexes

Anemia

Dark urine

Nursing Interventions and Rationales

  1. Promote nutrition
    • Many who suffer from cirrhosis have impaired nutrition and require nutritional support with specific vitamins and minerals; enteral or parenteral feedings may be ordered
  2. Assist with paracentesis, if needed
    • Patients may require the abdominal fluid that has built up (ascites) to be drained. Assist in set-up, positioning, and post-procedure site assessments, and monitoring as needed.
  3. Daily weights
    • This indicates if fluid has been accumulating, or if patient is losing weight
  4. Dietary adjustments: decrease protein, decrease sodium, restrict fluids
    • This will decrease the amount of fluid that may accumulate
  5. Initiate bleeding precautions
    • Coagulation factors are created in the liver, and if the liver is compromised it can effect these factors, and therefore put the patient at a higher risk for bleeding
  6. Administer meds appropriately (diuretics, lactulose, analgesics, blood products,vitamin K)
    • Various meds may be ordered, ensure to check labs as ordered prior to giving or initiating meds
  7. Conserve energy
    • Patients with cirrhosis tire easily; cluster care and conserve energy so they can prioritize energy use to mealtimes and self care.
  8. Monitor for excess fluid volume (assess daily weight, JVD, blood pressure)
    • Increasing values indicate vascular congestion
  9. Note and address electrolyte imbalances
    • Fluid and electrolyte imbalances are common and can result in dysrhythmias
  10. Promote oral care
    • Patients are at a higher risk for bleeding gums and mouth sores, which can cause a decreased appetite in an already malnourished individual
  11. Complete a careful and comprehensive respiratory assessment (vitals, labs, auscultation)
    • Essential to note impaired gas exchange and compromised respiratory function early

Pathophysiology

Less air flow is able to flow into and out of the alveoli both trapping CO2 as well as restricting O2 entering.

Etiology

There are two types of COPD: Chronic Bronchitis and Emphysema. The most common cause of COPD is smoking of any form: cigarette, pipe, cigar, second hand. Any lung irritant can cause COPD and also exacerbate it.

Desired Outcome

Clear, even, non-labored breathing while maintaining optimal oxygenation for patient.

Subjective and Objective Data

Subjective Data

Difficulty in Breathing

 

Chest tightness

 

“I can’t breath”

Objective Data

Wheezing

 

Shortness of Breath

 

Oxygen saturation

 

Blue/Gray lips/fingernails

 

Inability to speak full sentences (have to stop to breath)

 

Swelling/edema

 

Tachycardia

Nursing Interventions and Rationales

  1. Avoid irritants: Quit smoking or being around smoke Be mindful of the weather (very cold can aggravate the bronchi) Allergens like dust or pollen
    • The key to avoiding a flare up of COPD is to avoid things that make it worse.

      If the patient is smoking still this is a priority, they need to quit smoking. Provide education on smoking with COPD and the benefits of quitting.
  2. If the patient has been working very hard to breath for a long period of time and is getting worse, be prepared with an airway cart. And for the love of the airway, have your respiratory therapist aware of the patient!
    • Safety! Plus you do not want to wait until the impending airway closure happens to try to secure their airway. Sometimes the patient will be sedated and intubated to try to correct any respiratory acidosis or alkalosis.
  3. Breathing Treatments and medications
    • Beta-Agonists: Such as albuterol work as bronchodilators

      Anticholinergics: Such as Ipratropium work to relax bronchospasms

      Corticosteroids: Such as Fluticasone work as an anti-inflammatory
  4. Monitor Oxygen saturation
    • This is subjective as you need to make sure to understand the patient’s baseline. Plan the oxygen monitoring with the physician.

      Give oxygen as ordered and needed. Be careful about turning their drive to breath off by giving too much O2, as a general rule, COPD patients should be kept around 88%-92%.
  5. Obtain an ECG
    • The lungs and the heart are in the same general area, if someone is having problems breathing, make sure their heart is ok. Sometimes people having a heart attack can feel like they can’t breath due to the pressure or pain on their chest.

      Also, COPD is stressful on the heart, so even if the main problem is breathing, monitoring the heart, especially during an episode/exacerbation is important.
  6. Encourage a healthy weight Can be either overweight or underweight
    • Having access weight on the patient decreases the space for the lungs to expand. Plus, generally those who lose weight are also moving more to lose the weight, double win.

      Some patients (especially those with emphysema) can be very thin (barrel chested) and it is important to make sure they are getting the proper nutrition so their body is at optimal performance (for that patient).
  7. Encourage movement/activity
    • Sedentary lifestyle causes increased shortness of breath and less tolerance for movement. Helping the patient move more often helps improve breathing abilities.
  8. Assess for/Administer influenza vaccine and pneumococcal vaccine
    • Preventing complications such as influenza or pneumonia is important because the lungs are already working harder to keep the body balanced with oxygen and CO2, an increased risk of infection only complicates the patient’s ability to breathe.

Pathophysiology

Blood clots formed from any source, lodging in the patient leg or arm, impeding blood flow. This backup of blood pools in the extremity causing swelling, redness, warmth and pain.

Etiology

Narrowing or occlusion of the vessels in an extremity. If caused by plaque (cholesterol and other substances) this could be from poor diet, lack of exercise, or genetics. However, blood stasis can cause aggregation of platelets and other blood products forming a clot that travels to the extremity (or heart, lungs or brain!). The most common cause of blood pooling (stasis) is Atrial Fibrillation (AFib). Other major causes are prolonged sitting, pregnancy, smoking, and birth control.

Desired Outcome

Stabilization of the blood clot or disintegration of the blood clot as well as prophylaxis treatment for future blood clots.

Subjective and Objective Data

Subjective Data
  • Painful extremity
  • Numbness and tingling on affected extremity
  • Potential subjective data to be concerned about and monitor for: (this is if the clot moves)!
  • Pulmonary Embolism (PE): Difficulty in Breathing (DIB)/Shortness of Breath (SOB), Chest Pain (CP)
  • Myocardial Infarction (MI): Chest Pain (CP)
  • Stroke: facial asymmetry, confusion, one sided deficit,  
Objective Data
  • Warm, red, firm and swollen leg
  • Decreased peripheral pulse on affected extremity

Nursing Interventions and Rationales

  1. Assess a full neuro exam, assess breathing-Pulse oximetry, difficulty in breathing, chest pain, obtain an EKG.
    • Assess and monitor for potential complications d/t the blood clot moving into another area such as the lungs (PE), heart (MI), or brain (CVA).
  2. Heparin- initial therapy to break up clot. Transition into a SubQ or oral anticoagulant to prevent future clots.
    • This is an anticoagulant that breaks up blood clots (as well as prevents them).

      Monitor aPTT or Anti-Xa Q6H to adjust and maintain therapeutic levels.

      Bolus: 80 units/kg

      Initial dose: 18 units/kg/hr
      -Adjust according to your organization's nomogram (Q6H- based on results of aPPT or Anti-Xa)
  3. Enoxaparin (Lovenox)/Warfarin (Coumadin)
    • Both SubQ and oral anticoagulant therapy use as prophylaxis (prevention) therapy.

      Patient will need to have frequent blood draws to monitor their INR. Therapeutic range is between 2 and 3.

      Enoxaparin: 1-1.5 mg/kg

      Warfarin: initial dose is 2-4 mg, and typically can range up to 10 mg.
  4. Educate about avoiding vitamin K (both supplements as well as food)
    • Vitamin K works to help increase clotting, this is opposite of what we are trying to do for this patient, unless of course they are bleeding out, in which case the treatment may be vitamin K with Fresh Frozen Plasma (FFP)
  5. Continuous monitoring: 3 or 5 lead cardiac monitoring pulse oximetry monitoring
    • This monitors for changes in the heart and allows for quick intervention if the clot moves and is stuck in the heart.

      This monitors for changes in oxygenation if the clot moves to the lungs.
  6. Bleeding/fall precautions because of anticoagulant therapy
    • This isn’t just for in the hospital, it is also for when the patient goes home. The patient is at major risk for bleeding out, thus educating about s/sx of internal bleeding as well as educating about fall precautions is vital.

      GI bleeding: Dark, tarry stool (Upper GI bleed) OR bright red bloody stools (lower GI bleed)

      Epistaxis: Nosebleeds are obvious, however, inform the patient that if they bleed through nasal packing for longer than 15 minutes they should go to the ER. Also they they feel dizzy, faint, or are losing color in their face they should go to the ER.

      Cuts that don’t stop bleeding: if the cut has had pressure applied for longer than 15 minutes and the gauze is being soaked through the patient should go to the ER.

      Brain bleed: Have patients and the people who are around them look for S/Sx such as confusion, facial droop, one-sided weakness.

Pathophysiology

Diabetes Mellitus is when blood glucose (sugar in the blood) is unable to move into the cells and help in the making of ATP…AKA energy. The body makes insulin to assist with this process. Insulin is a hormone that allows the sugar in the blood to move across the cell wall so the body can use to to produce ATP. There are two types of diabetes. Type I and Type II.

 

Type I is an autoimmune disorder where the cells attack the insulin producing cells in the pancreas. Thus the body is producing very little or no insulin leaving the sugar in the blood and the cells starve.  

 

Type II is when the cells don’t respond to the insulin trying to get sugar into them, called insulin resistance. Thus the sugar stays in the blood and the cells starve.

Etiology

The cause for Type I diabetes is unknown, but hypothesized to be potentially genetic or triggered by a virus. The cause for Type II diabetes is caused by a storm of events culminating such as weight gain, lack of activity, genetics, and stress levels.

Desired Outcome

Blood sugar control with minimal side effects.

Subjective and Objective Data

Subjective Data

Hyperglycemia: BG >180 mg/dL

Polydipsia

Polyphagia

Polyuria

Blurred vision

Dry mouth

Increased tiredness

Leg pain

Nausea/Vomiting

 

 

Hypoglycemia: <70 mg/dL

Confusion

Weakness

Numbness around the mouth

Nervousness/Anxiety

Hungry

Headaches

Nightmares

Groggy

Objective Data

Hyperglycemia:

-Hot and Dry, Sugar High.

 

Hypoglycemia:

-Cold and clammy give them some candy!

 

Sweaty

 

Tachycardia

 

Irritability

 

Slurring words

Nursing Interventions and Rationales

  1. Blood sugar monitoring: Normal range 70-180 mg/dL *patient may have a different target blood sugar level, make sure to know what each patient’s target is.
    • The physician will make a target blood glucose level. Teach the patient that they need to monitor their blood glucose.They need to call their primary care physician if they have blood glucose levels higher than their target for multiple days or if they have 2 readings of greater than 300 mg/dL.

      Teach the patient how to use their glucometer and record their results.
  2. Insulin administration -Rapid Acting: Humalog Novolog -Fast/short Acting: Regular -Intermediate Action: NPH -Long Acting:’ Lantus Levemir
    • It is important to know which insulin to give and how they work. Each institution has guidelines and each insulin has guidelines. Following the guidelines, make sure you know the onset, peak and duration of each type of insulin.

      -Rapid Acting
      Onset: 10-30 minutes
      Peak: 30 minutes- 3 hours
      Duration: 3-5 hours

      -Fast/short Acting
      Onset: 30 minutes-1 hour
      Peak: 2-5 hours
      Duration: Up to 12 hours

      -Intermediate Action
      Onset:1.5-4 hours
      Peak: 4-12 hours
      Duration: Up to 24 hours

      -Long Acting
      Onset:1-4 hours
      Peak: minimal peak
      Duration: Up to 24 hours

      To administer insulin, teach the patient to rotate injection sites and to clean the site with alcohol prior to inserting needle.
  3. Educate about nutritional changes and monitoring
    • This would be a good time to get the dietician involved. The patient needs to learn at a minimum, how to count carbs and which foods to avoid such as beer.

      A patient’s glucose should be checked once when the patient wakes up, before meals, and before going to bed.

      If the patient is hypoglycemic, and they are able to eat or drink, give them some OJ and graham crackers with peanut butter.

      Increase water intake if the patient has hyperglycemia
  4. Monitor feet and educate about monitoring feet
    • Both decreased blood flow to the feet as well as neuropathy occur to make the feet something the patient really needs to watch. Wounds are hard to heal so if they are having a hard time feeling their feet and they become injured, the wounds will be worse than with someone without diabetes.

      Teach the patient to check their feet everyday. Washing their feet, cutting their toenails straight across, and scrubbing off calluses gently are a couple of points to make with the patient.

      The patient may have a podiatrist involved in their care as well.

      As a nurse, you will need to be checking the patient’s feet as well and monitor any wounds.
  5. Monitor Blood Pressure (BP) Normal Blood Pressure: 120/80 mmHg
    • It is vital to keep someone with diabetes within normal limits for their blood pressure.

      Placing strain on the cardiovascular system wrecks havoc on other organ systems. Being diabetic makes the chances of that system having issues worse. A patient can lose their vision, kidney function, have a stroke or heart attack.
  6. Educate about maintaining a healthy weight and keeping active
    • With a healthy weight, the patient is likely also implementing a healthy diet as well as implementing more movement. These three things (weight, diet, exercise) can help to manage or even reverse diabetes.

      Healthy weights are calculated based on height and sex of the patient. Other ways to monitor the size of the patient is to use a BMI calculator or measure waist circumference.

Pathophysiology

Destruction of the alveoli shapes and functionality. Normally alveoli are little pouches of springy grapes, but patients with emphysema have misshapen pouches that are not springy. This causes CO2 to stay in the alveoli and not exhale out of the body as well as making it harder for O2 to enter into the alveoli. High levels of CO2 (which is acidic) can cause complications such as respiratory alkalosis.

Etiology

Exposure to lung irritants in the air: smoke, air pollutants, chemicals, dust, etc. for prolonged periods of time and with repeated exposure.

Desired Outcome

Clear, even, non-labored breathing while maintaining optimal oxygenation for patient.

Subjective and Objective Data

Subjective Data

Subjective Data:

 

Chronic cough

 

Difficulty in breathing

 

May notice they are avoiding certain activities that they used to participate in and now cannot due to breathing difficulties… “I used to play with the grandkids, now I can’t”

 

Chest tightness/pain

Objective Data

Wheezing

 

Shortness of Breath- especially upon exertion

 

Oxygen saturation

 

Blue/Gray lips/fingernails- especially upon exertion

 

Inability to speak full sentences (have to stop to breath)

 

Swelling/edema

 

Tachycardia

 

Barrel chest

Nursing Interventions and Rationales

  1. Auscultate lung sounds
    • If wheezy they may need a breathing treatment
      If you hear crackles they may have pneumonia and potentially could use suctioning.
  2. Monitor ABGs
    • Blood gases help to determine if the patient is in respiratory acidosis.

      To interpret the ABG you must know normal ABG values.

      pH: 7.35-7.45
      PaCO2: 35-45
      Bicarbonate: 22-26

      Respiratory acidosis is when the pH is below 7.35 and the PaCO2 is above 45.
  3. Encourage a healthy weight Early stages of emphysema: overweight Late stages of emphysema: underweight
    • Having access weight on the patient decreases the space for the lungs to expand. Plus, generally those who lose weight are also moving more to lose the wieght, double win.

      In later stages of emphysema, the patient can be very thin (barrel chested) and it is important to make sure they are getting the proper nutrition so their body is at optimal performance (for that patient).
  4. Monitor Oxygen saturation
    • This is subjective as you need to make sure to understand the patient’s baseline. Plan the oxygen monitoring with the physician.

      Give oxygen as ordered and needed. Be careful about turning their drive to breath off by giving too much O2, as a general rule, emphysema patients should be kept around 88%-92%.
  5. Prepare for the worst: If the patient has been working very hard to breath for a long period of time and is getting worse, be prepared with an airway cart. And for the love of the airway, have your respiratory therapist aware of the patient!
    • Safety! Plus you do not want to wait until the impending airway closure happens to try to secure their airway. Sometimes the patient will be sedated and intubated to try to correct any respiratory acidosis or alkalosis.
  6. Breathing treatments and medications
    • Beta-Agonists: Such as albuterol work as bronchodilators

      Anticholinergics: Such as Ipratropium work to relax bronchospasms

      Corticosteroids: Such as Fluticasone work as an anti-inflammatory
  7. Assess for/Administer influenza vaccine and pneumococcal vaccine
    • Preventing complications such as influenza or pneumonia is important because the lungs are already working harder to keep the body balanced with oxygen and CO2, an increased risk of infection only complicates the patient’s ability to breathe.

Pathophysiology

The repeated assault of stomach acid and bile into the esophagus. This assault can sometimes cause esophagitis and eventually the thinning of the lining of the esophagus.

Etiology

A weakened esophageal sphincter allowing the acid or bile up into the esophagus from the stomach. Also increased amount of  acid or bile can cause a patient to have GERD signs and symptoms. Patients at high risk include: Obese patients, pregnant patients, patients who smoke, and those with a hiatal hernia. Some medications can place a patient at higher risk too, such as antihistamines, pain medications, calcium channel blockers, and antidepressants.

Desired Outcome

Maintain a normal amount of acid in the stomach, eliminate or decrease burning in the esophagus from acid splashing up and protect the GI tract from bleeding.

Subjective and Objective Data

Subjective Data

Chest burning/pain

 

Dysphagia

 

Regurgitation

 

Sore throat

 

‘Heartburn’

 

Nausea

Objective Data

Holding or pressing on the chest due to discomfort

 

Normal ECG

 

Normal vital signs

 

Non-reproducible chest pain

 

Weight-loss

 

Vomiting

 

Erosion of teeth enamel

 

Wheezing

 

Laryngitis

Nursing Interventions and Rationales

  1. Educate on the benefits of lifestyle changes: Quitting smoking Wear loose fitting clothing Keeping active
    • Quitting smoking: Nicotine relaxes the esophageal sphincter. Teaching the patients about the connection helps give them another reason to quit.

      Wear loose fitting clothing: Having the midsection squeezed puts pressure on the stomach-this is the same concept as being overweight.

      Keeping active: Helps the patient lose weight, which is important since excess weight pushes on the stomach.
  2. Medications! Proton Pump Inhibitors: Esomeprazole Lansoprazole Omeprazole Pantoprazole Antacids: Maalox Mylanta Rolaids H2 Blockers: Cimetidine Famotidine Nizatidine Ranitidine Prokinetics: Bethanechol Metoclopramide Antibiotics: Erythromycin
    • Proton Pump Inhibitors:
      Decreases the amount of acid made in the stomach
      -Prevents the transport of H ions into the gastric lumen by binding to gastric parietal cells, ↓ gastric acid production

      Antacids:
      Neutralizes stomach acid


      H2 Blockers:
      Decreases the amount of acid made in the stomach
      -Inhibits action of histamine leading to inhibition of gastric acid secretion

      Prokinetics:
      Helps to empty the stomach faster.
      -Accelerates gastric emptying by stimulating motility

      Antibiotics:
      Helps to empty the stomach faster (watch out for diarrhea though!)
  3. Educate on nutritional changes
    • Nutritional changes such as not over eating, avoiding acidic foods like orange juice or spicy foods such as salsa.

      Also after eating, be sure to have the patient sitting in an upright position for at least 2-3 hours. Also, having a patient sleep with their HOB greater than 30 degrees helps.
  4. Prepare the patient for a Barium Swallow Test
    • An X-Ray tech will perform this test, your job as a nurse is to prepare the patient for this appointment. Generally the patient has been NPO but check with the hospital policy or through the X-Ray tech as to how long they would like the patient to be NPO prior to the test.
  5. Assist with Endoscopy
    • This procedure allows the visualization of the esophagus and the esophageal sphincter.

      The nurse will be administering sedative medications, maintaining the airway and monitoring vital signs.
  6. Obtain an ECG
    • The symptoms of chest burning and pain are similar to that of a heart attack. It is always important to eliminate the heart as a problem, and not to just assume that the patient is experiencing GERD symptoms.
  7. Encourage a healthy weight
    • Access fat on a patient usually shows up in their abdomen and the displaces their stomach, increasing the risk of acid or bile deviously sneaking into the supposed off limits zones.

Pathophysiology

Bleeding along the lining of the Gastrointestinal Tract is hard to recognize because it is not something you can see immediately, or necessarily get imaging or laboratory test work to discover the cause of bleeding right away. Upper GI bleeds will come out as dark tarry stools and lower GI bleeds will come out as bright red bleeding. Also, monitor for blood in the vomit, and be aware of coffee ground emesis because blood can curdle in the acidic stomach environment.

Etiology

The bleeding along the GI tract is from a perforation somewhere in the intestines or stomach. Can be caused by too much acid (ulcer), an abnormal formation in the colon (tumor, polyp, hemorrhoids), inflammation of the lining (diverticulitis, colitis) or any sort of trauma to the GI tract.

Desired Outcome

Controlling and stopping of the bleeding, vital signs back to baseline, normal blood counts such as hemoglobin.

Subjective and Objective Data

Subjective Data

Subjective Data:

 

Weakness

 

Dizziness

 

Abdominal pain

Objective Data

Pale skin

 

Lethargy

 

Hypotension

 

Tachycardia

Nursing Interventions and Rationales

  1. Monitor Hemoglobin (HGB)
    • HGB: Hemoglobin (Hbg), an iron containing compound, is the main protein in Red Blood Cells (RBCs). It enables oxygen and carbon dioxide (CO2) to bind to RBCs for transport throughout the body.

      This is the most commonly looked at lab value to assess need for a blood transfusion. Every institution, Doctor, and person is different but as a general rule, a hemoglobin below 8 requires a blood transfusion.
  2. Monitor heart rate and blood pressure
    • When the heart is low on fluids to fill it, it will start beating faster and your pressure gets lower. If the patient’s BP gets too low, they will start to shunt blood to their vital organs.

      If patient becomes hypotensive, put them in reverse trendelenburg, give them fluids, and get the physician.

      A patient’s heart can only beat fast for so long so monitor the heart rhythm while you work on getting the volume back into their cardiovascular system.
  3. Administer blood products
    • This requires a blood match (Remember your ABO compatibility and Rh factor).

      When administering the blood, remember to have the blood product double checked with another nurse. Vital signs every
  4. Administer pantoprazole (Protonix) Potential surgical intervention to stop the bleeding
    • Give pantoprazole (Protonix), a proton pump inhibitor (PPI) that decreases the amount of acid in the GI lining. This reduces the ulceration which could be (and most likely is) causing the GI bleed.

      If it is not able to stop the bleeding, potential surgical intervention may be needed to stop the bleed.

      Also-To be noted is the use of anticoagulants (warfarin, aspirin, heparin, etc.). Ask all your patients if they take an anticoagulant regardless of their issues, it is important to know.
  5. 12 lead ECG
    • Having low amounts of blood most definitely affects the heart. Make sure that the heart is still lub-dubbing as it should be.
  6. Assess for bleeding in stool GI bleed:
    • This entails my least favorite thing to do, and the nurse doesn’t even do it, but the nurse usually needs to be present because it invades the patient’s self respect and dignity. Therefore you get to be in the patient’s visual field while they are being pillaged in their back end.

      The provider will place a gloved finger into the rectum and needs to have feces on it when it comes out. The feces is placed on a hemoccult card where a developing solution is married with the stool giving the provider insight of whether or not there is blood in the stool. If the card turns blue it is positive for blood.

      As a nurse you will ask the patient if they have black/tarry stools (upper GI bleed) or bright red blood (lower GI bleed) in their stools.
  7. Fall precautions
    • The patient is at an increased risk for fall. This means that it is super important to educate the patient on using the call light if they need to get up and assisting with any mobilization of the patient.

Pathophysiology

Glaucoma is group of diseases in which the pathophysiology is not fully understood. It is also a condition which remains largely asymptomatic until it is in its advanced stages. At its most basic level of understanding, the pressure in the eye on the optic nerve increases, which leads to cellular death and ultimately vision loss. The mechanisms in which the pressure increases differs between the different kinds of glaucoma. We will discuss the two most common.  

 

Open-angle and angle-closure are the most common kinds. Open-angle accounts for approximately 90% of cases. It occurs over a long period of time. Slowly, drainage canals become clogged, which results in higher pressure. This can happen so slowly that the patient doesn’t even realize the visual deterioration is occurring until it’s quite advanced.

 

The second most common kind of glaucoma, angle-closure, is a sudden condition that comes on quickly and requires immediate treatment. It is usually related to some sort of eye trauma. This must be treated immediately and is considered a medical emergency, as permanent blindness can occur without appropriate treatment.

 

Because the most common kind of glaucoma occurs slowly over years without symptoms, screenings are essential. This is why a glaucoma test is routine in eye exams, even for young adults.

Etiology

The exact cause of glaucoma is unknown.  As far as the most common type of glaucoma, open-angle, the theory is that the drainage system of the eye becomes insufficient over time and subsequent pressure builds up.

 

Age (over 60), race, genetics/family history, eye injury, other eye pathology, as well as corticosteroid use are all risk factors for glaucoma.

Desired Outcome

Decrease intraocular pressure as quickly as possible, prevent further visual damage.

Subjective and Objective Data

Subjective Data

**May be asymptomatic

 

Hazy vision

Seeing bright lights

Sudden sight loss

Severe eye pain

Slow visual changes

Nausea

Objective Data

**May be asymptomatic

 

Vomiting

Nursing Interventions and Rationales

  1. Prevent further compromised vision
    • Must report changing assessment findings to the provider promptly, especially with angle-closure glaucoma because timing is a factor in preventing permanent blindness.
  2. Prevent injury: initiate fall precautions, remove any tripping hazards
    • Due to compromised vision, patients may not be able to see tripping hazards or objects in their way. Remove as much clutter, cords, rugs, etc. as possible to make the area as safe as it can be. This is especially important in the patient with sudden visual changes, as they have not slowly adapted over years as one may have with progressive loss.
  3. Appropriately assess vision
    • You must know the degree of visual compromise so that you are able to tell if it has changed.
  4. Educate about appropriate eye drop administration
    • Post-procedure or during long-term management, patients are frequently on various various eye drops. It’s essential they understand thoroughly which drops to administer when, how to do so appropriately. They may need additional intervention with color-coding bottles because they may not be able to clearly read labels. Ensure support systems are equally aware of regimen.
  5. Educate about importance of follow-up care
    • Compliance is key! Patients must follow be compliant with their treatment regimen to prevent further deterioration.
  6. Manage pain
    • Patients can have sudden pain, which will increase their intraocular pressure, making the problem even worse.
  7. Manage anxiety
    • A sudden inability to see or the new knowledge that you will have a degree of blindness is upsetting. Provide as much education and emotional support as possible, and if necessary, administer medications.

Pathophysiology

Gout is a metabolic disorder and form of arthritis. Uric acid crystallizes and deposits into joints and body tissues, most frequently in the big toe. This results in pain, inflammation, stiffness, and redness.  An acute attack can occur, which includes sudden severe pain, frequently in the middle of the night.

Etiology

Essentially, gout is caused by too much uric acid in the blood. This can occur because of genetics, dietary factors, and/or an inability to excrete uric acid at a normal rate. Use of diuretics can also be the cause. Underexcretion of uric acid is the cause in approximately 90% of cases. While gout caused by diet is only comprised of 12% of cases, dietary changes do seem to lower the overall risk.

Desired Outcome

Treat the acute attack, prevent future flare ups/attacks, lower excess stores of urate.

Subjective and Objective Data

Subjective Data

Pain

Sudden pain in great toe

Itching

Blurry vision

Objective Data

Tophi (nodules in skin)

Renal calculi

Joint inflammation

Joint edema

Redness

Scratching

Nursing Interventions and Rationales

  1. Treat pain: administer meds, apply warm or cool compresses, positioning
    • Patients in an acute attack will experience pain and require appropriate pain control and interventions
  2. Assist with mobility
    • Patients may have an impaired ability to mobilize due to inflammation and pain; assist for safe ambulation and transfer
  3. Closely monitor amount of inflammation at joint
    • Enables you to know if symptoms are worsening or resolving (therefore telling you if interventions are working)
  4. Promote fluids
    • Prevents dehydration and aides in the excretion of uric acid
  5. Assist with AROM or PROM
    • Prevents joint stiffness and immobility
  6. Cluster care; maximize rest

    • Prevents fatigue; enables patient to participate inasmuch self-care as possible
  7. Educate about dietary and lifestyle changes (decreasing alcohol intake, foods high in purines, foods/drinks sweetened with fructose, weight reduction, adequate hydration)
    • Doing so decreases the likelihood of future flare ups and/or attacks
  8. Initiate fall precautions/prevent injury
    • Joint pain, particularly in the foot, will put them at higher risks for fall and injury due to their impaired mobility.

Pathophysiology

The pathophysiology of HTN is quite complex. Blood pressure is essentially the amount of blood the heart pumps, as well as the resistance to blood flow in the actual arteries. If there is more blood and/or smaller arteries, naturally the pressure will be higher.  When someone has higher pressure for an extended period of time, it begins to cause problems. HTN is called the silent killer because it can begin to cause problems without any symptoms. Some don’t realize this is happening until end-organ damage occurs, like kidney failure.  Many times it has been happening for years undetected. The way it is detected is with a simple blood pressure screening, hopefully done at an annual physical.  However, if someone does not regularly visit a physician and get checkups, then this may go undetected for a long period of time.

 

There is primary and secondary HTN.  Primary HTN is caused by a combination of genetic and environmental factors.  Secondary HTN comes from an identifiable cause (for example, sleep apnea or hyperthyroidism).

 

Keep in mind, higher blood pressure for a short period of time is normal. Your blood pressure will naturally increase during times of stress or pain, but the HTN we are discussing is chronically elevated even during times of relaxation.

Etiology

Primary HTN can be caused by many different factors. Certain ethnicities have a higher incidence of HTN (African Americans). The older a person is, the higher the likelihood of HTN. Family history, body weight, sedentary lifestyle, not enough of certain vitamins (like Vitamin D), not enough potassium, too much sodium, or excessive stress can all be a causative factor of primary HTN.

 

Secondary HTN arises from various conditions like kidney/adrenal/thyroid issues, congenital blood vessel defects, sleep apnea, various meds (decongestants are a big one!), street drugs (cocaine, methamphetamines), tobacco and excessive alcohol use, and more, can all cause secondary HTN.

Desired Outcome

Control blood pressure down to a safe level appropriately. Please note, if a patient has had chronically elevated blood pressure for years or is in a hypertensive crisis , they may need their blood pressure lowered slowly, as they can have symptoms of hypotension at even normal blood pressure levels. Make sure you’re following orders very specifically and not decreasing the blood pressure too quickly in these instances.

Subjective and Objective Data

Subjective Data

**HTN frequently presents without symptoms, therefore the listed symptoms are not the typical presentation. If symptoms present, that means the disease process has most likely progressed significantly.**

 

Headaches

Shortness of breath

Visual changes

Cognitive changes

Objective Data

**HTN frequently presents without symptoms, therefore the listed symptoms are not the typical presentation. If symptoms present, that means the disease process has most likely progressed significantly.**

 

Epitaxis

Kidney failure

Nursing Interventions and Rationales

  1. Assess and monitor BP
    • You must know what the level is to know how to treat it
  2. Fluid restriction (if clinically appropriate)
    • More blood volume = higher pressure
  3. Perform a comprehensive cardiac assessment: auscultate lung sounds, note edema
    • We need to know if there are any abnormalities, s/s fluid overload, edema, new murmurs or other changes as they can present without the patient feeling any different
  4. Promote rest, cluster care
    • We want to avoid blood pressure spikes and promote rest, especially if the blood pressure is very high
  5. Decrease stress
    • Lowering stress levels will help bring down blood pressure
  6. Administer BP lowering agents at appropriate time (may need to alter to avoid larger drops in BP)
    • BP meds may need to be spaced out so they all don’t peak at the same time and cause a drop in blood pressure, rather than consistent control throughout the day and night. You may want to speak with a pharmacist about optimal medication timing.
  7. Assess BP and HR before and after BP lowering meds are administered
    • Important to ensure that the BP is stable before administering a medication. Many BP meds also will impact the HR, so it’s essential to understand where you are before you drop the pressure.
  8. Control pain
    • Pain will increase blood pressure. Control as much as possible and time appropriately with activity.
  9. Educate about disease process, treatment regimen, dietary changes
    • Education is key because you cannot feel HTN. Patients must understand how important compliance is to prevent major events in the future.

Pathophysiology

Leukemia is a cancer of the blood.  There are many kinds of leukemia, however the basic pathophysiology is that somehow the DNA of immature blood cells is damaged.  This causes those blood cells to develop and divide abnormally. Because their development is impaired, these cells don’t die when they normally should (normally cells develop and die within a certain amount of time). This presents quite a problem, as the abnormal blood cells begin to accumulate and take up a lot of space, eventually crowding out the good and healthy cells.  This impairs the function and growth of healthy cells.

Etiology

The exact etiology of leukemia is unknown, but there seems to be higher likelihood of it developing when certain environmental and genetic factors are present. Genetics, radiation or chemical exposure, viruses (HIV), previous chemotherapy, and also those with Down Syndrome appear to have a higher incidence of leukemia.

Desired Outcome

Minimize complications, resolve and recover from leukemia if possible. (Some types of leukemia can be cured, while others cannot.)  Maximize the normal blood cells and minimize the abnormal ones.

Subjective and Objective Data

Subjective Data

Dyspnea

Nausea

Chills

Night sweats

Fatigue

Bone pain

Headache

Objective Data

Petechiae

Bleeds easily

Bruises easily

Prolonged clotting factors

Elevated WBC

Pallor

Anemia

Weight loss

Hepatomegaly

Splenomegaly

Fever

Persistent or frequent infections

Vomiting

Nursing Interventions and Rationales

  1. Prevent infection
    • Patients with leukemia have an impaired ability to fight infection and therefore we must be diligent in preventing infection. This includes strict hand hygiene, which is the most effective infection prevention measure.
  2. Promote normothermia
    • Progressive hyperthermia may occur, therefore it's essential to monitor body temp closely, especially if patient is receiving chemotherapy.
  3. Sepsis surveillance
    • Patients undergoing leukemia treatment are at higher risk for developing sepsis, so make sure to monitor them closely and notify the MD when needed.
  4. Educate patient and loved ones about infection prevention
    • The patient and support system must be compliant with infection prevention measures for this to be successful, not just the health care team. They must understand its importance and be equally as diligent.
  5. Educate patient and loved ones about plan of care, symptoms to expect, and when to get concerned
    • The more the patient and family can predict or be aware of, the better. This helps to decrease anxiety and increase compliance if people can anticipate what may happen, why we’re initiating certain interventions, as well as their importance.
  6. Prevent skin breakdown
    • Due to various meds and/or compromised immune response and/or malnutrition, patients with leukemia are at a higher risk for skin breakdown and delayed wound healing. Therefore, it is essential to take extra care to prevent breakdown
  7. Avoid procedures that would increase infection risk: inserting foley catheters, injections, lines, and tubes.
    • Must weigh risk versus benefit, and patients with leukemia are at a much higher risk for infection, so the benefit of said procedures may not outweigh the risk.
  8. Initiate bleeding precautions
    • Clotting factors are impaired and therefore patients with leukemia are at an increased risk for bleeding.
  9. Cluster care and conserve energy
    • Energy conservation is essential. We must maximize the time in which the patient is able to care for themselves. Feedings, ambulating and toileting is the priority. Therefore, do not disturb their sleep unnecessarily. Cluster labs, vitals, and other aspects of care as clinically appropriate.
  10. Assess and address pain appropriately; promote non-pharmacological interventions (massage, pillow support, cool/heat therapy, aromatherapy, guided imagery, and so forth)
    • Pain is very common and can be difficult to control. Pain medications may be ordered scheduled rather than PRN. Ensure you’re assessing what works for the patient, promoting a calm and restful environment, and avoiding any movements that would exacerbate pain. Assess appropriately (type, severity, precipitating and aggravating factors, what relieves the pain, and so forth). Leverage non-pharmacological interventions to complement pharmacological interventions by timing appropriately.
  11. Promote assistive devices to conserve energy
    • Walkers, wheelchairs, canes, shower chairs, are all things that can help the patient conserve energy while still participating in their own care. Make sure to educate and visualize a return demonstration before allowing independent use.
  12. Time pain medications and antimetics to be at their peak for therapy, chemo, and meals.
    • By timing these meds to be at their peak when anticipating increased pain and nausea, you can increase intake and their ability to participate in therapy. Therefore, be proactive with these medications rather than reactive to maximize their benefit and the patient’s response.
  13. Promote self-care, independence, and ADL’s
    • Increased fatigue can prevent patients from participating in their own care. Patients will most likely need assistance in caring for themselves. Prioritize their activities to promote those that are involved in their own care (conserve energy to feed self over walking up and down halls).
  14. Closely monitor intake and output, assess for signs of dehydration (skin turgor, mucous membranes, cap refill).
    • Dehydration and kidney compromise is a potential complication, therefore we must watch for it diligently.
  15. **A note about “neutropenic precautions” // “protective isolation” // “reverse isolation”**
    • Years ago, the standard in practice for patients with neutropenia was to put the patient on isolation, however evidence does not support this practice. Please see the quote below:

      “Evidence does not support the use of reverse isolation in hospitals…the use of reverse isolation procedures should be discouraged as they are unlikely to be of benefit, and commonly cause anxiety and confusion for patients, families, and healthcare workers” Sheshadri and Baumann 2008.

      Essentially, what puts the neutropenic patient at greatest risk for infection is their own body, so putting on gowns and masks doesn’t reduce that risk. It does increase cost and makes the patient feel isolated, straining their mental health unnecessarily.

Pathophysiology

Cardiac muscle tissue death from lack of blood flow. The blood carries oxygen and nutrients to the cells. When this is decreased, cells die also called necrosis. Cardiac muscle cells dying is problematic as they do not regenerate (although there is some debate of this topic: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042154/ )

Etiology

Narrowing or occlusion of the cardiac vessels that perfuse the heart. The plaque that causes this could be from poor diet, lack of exercise, or genetics. It can also be from a deep vein thrombosis (DVT) that has broken free (embolus) and landed in the heart.

Desired Outcome

Re-perfusion to cardiac muscle and return of cardiac muscle functionality, or as much as possible.

Subjective and Objective Data

Subjective Data
  • Chest Pain
  • Chest Pressure/Squeezing
  • PQRST pain assessment
  • P- provoke, precipitate, palliate
  • Q- quality
  • R- radiate
  • S- severity, symptoms
  • T- time
  • Patient may report a feeling of impending doom
Objective Data
  • ST elevation on the ECG- Called an STEMI
  • Decreased oxygenation
  • Signs of left ventricular failure such as crackles in the lungs or S3 heart sound
  • Tachycardia (Bradycardia can be seen if patient is having an inferior MI)

Nursing Interventions and Rationales

  1. MONA: Morphine Oxygen Nitroglycerin Aspirin (ASA)
    • Initial treatment for acute coronary syndrome.

      Morphine: given if aspirin and nitroglycerine do not relieve chest pain. Initial dose is 2-4 mg IV.

      Oxygen: helps for you to remember to check oxygenation for chest pain- if under 94% or if patient is short of breath give 2L NC initially. Evidence based research has left the use of oxygenation and its helpfulness in these situations inconclusive. Oxygen can cause vasoconstriction thus worsening the situation and decreasing blood flow. Administer oxygen when clinically relevant.

      Nitroglycerin: This is the initial medication given, along with aspirin. This medication dilates the blood vessels to help allow any blood flow that might be impeded. Give 0.4 mg sublingual tab, wait 5 minutes, if the chest pain is not relieved administer another dose. This can happen 3 times total. Monitor a patient’s blood pressure, hold for a systolic BP of less than 90 mmHg.

      Aspirin: given to thin the blood. A total of 4 baby aspirin (81 mg each) can be given for a total of 324 mg.
  2. 12 lead ECG If inferior wall MI- do a right sided 12 lead ECG.
    • Assess a 12 lead ECG immediately on anyone complaining of chest pain to determine if an ST elevated MI is occurring. If it is-Take the patient to the cath lab STAT! If the ECG is a normal sinus or otherwise non-concerning rhythm, place them on a 3 or 5 lead cardiac monitor for frequent re-assessing.

      Right sided 12 lead ECG shows the right side of the heart to assess for right ventricular ischemia.
  3. 3 or 5 Lead monitoring
    • No matter the outcome of the 12 lead ECG, placing a patient on a form of cardiac monitoring is key. You are worried about a worsening condition such as cardiac arrest.
  4. Cardiac Catheterization with Percutaneous Coronary Intervention (PCI)
    • A patient who has an ST elevated MI (STEMI) will be rushed to the cath lab so they can locate the clot and place a stent to regain blood flow to the heart.

      A patient may also go to the cath lab without having a STEMI, and they may still find a clot. Most NON-STEMI’s are treated without catheterization.
  5. BP Monitoring The measurement is determined by the doctor, who is determining this based on evidence based research married with patient factors. It can be measured by the systolic BP or the Mean Arterial Pressure (MAP). This can also be monitored by an arterial line.
    • This is important because the higher the blood pressure, the more pressure is on a clot. It isn’t out of the question for someone to have more than one clot, and increased pressure could break free a clot lodge itself somewhere else either in the heart, lungs, brain, or extremity.
  6. Heparin
    • This is an anticoagulant that breaks up blood clots (as well as prevents them).

      Monitor aPTT or Anti-Xa Q6H to adjust and maintain therapeutic levels.

      For STEMI
      Bolus: 60 units/kg (max 4,000 units)
      Continuous infusion: 12 units/kg/hr
      -Adjust according to your organization's nomogram (Q6H- based on results of aPPT or Anti-Xa)

      For N-STEMI
      Bolus: 60-70 units/kg (max 5,000 units)
      Continuous Infusion: 12-15 units/kg/hr
      -Adjust according to your organization's nomogram (Q6H- based on results of aPPT or Anti-Xa)
  7. Monitor Cardiac Enzymes: Troponin I Creatine Kinase-MB (CKMB)
    • The values of these enzymes are based on your institutional laboratory technique. If they are elevated it indicates that the cardiac muscle is stressed out or injured.

      Troponin I is an enzyme that helps the interaction of myosin and actin in the cardiac muscle. When necrosis of the myocyte happens, the contents of the cell eventually will be released into the bloodstream.

      Troponin can become elevated 2-4 hours after in ischemic cardiac event and can stay elevated for up to 14 days.

      Creatine Kinase MB: This enzyme is found in the cardiac muscle cells and catalyses the conversion of ATP into ADP giving your cells energy to contract. When the cardiac muscle cells are damaged the enzyme is eventually released into the bloodstream.

      CKMB levels should be checked at admission, and then every 8 hours afterwards.

Pathophysiology

Neutropenia is an abnormally low count of neutrophils, which is a type of white blood cell. Neutrophils are made in the bone marrow, so anything that inhibits or disrupts that process can result in neutropenia. It also can result if neutrophils are destroyed (by medications, for example) Neutropenia can be congenital or acquired.

Etiology

Congenital neutropenia can result from conditions like Kostmann’s syndrome or myelokathexis.

 

Acquired neutropenia result from nutritional deficiencies, infections (Hep A, B, C, HIV, and more), medications, chemotherapy, leukemia, alcohol use disorder, rheumatoid arthritis, and more.

Desired Outcome

Restore neutrophil count, prevent additional destruction, prevent infection

Subjective and Objective Data

Subjective Data

**Neutropenia itself will typically not elicit symptoms, but its cause or subsequent infections may, which differ. Many patients are unaware until the lab is drawn and the diagnosis is made.

Objective Data

absolute neutrophil count < 1500 cells/mm3

Nursing Interventions and Rationales

  1. Prevent infection
    • Patients with neutropenia are at an increased risk for infection already and will have a decreased ability to be able to fight infection appropriately, therefore it’s essential to prevent this by avoiding unnecessary lines/drains/tubes, appropriate care and cleaning, and discontinuing lines as soon as they are no longer medically indicated.
  2. Promote oral care
    • The mouth is a place that can get infected easily, especially if a patient is on antibiotics, which destroys some of the good bacteria there. It’s ideal if someone who is about to endure treatment that may cause neutropenia (like chemo) can get a dental exam prior. Brushing and flossing regularly is essential.
  3. Promote hygiene
    • Proper hygiene reduces the risk for infection, which is our main concern with neutropenia.
  4. Prevent skin breakdown
    • Skin is an essential aspect of our body that prevents infection. Therefore, if it is compromised, it can be quite a problem for a patient with neutropenia. Prevent ulcers and breakdown, as they may not be able to heal properly and prevent healing and recovery.
  5. Promote nutrition and ensure food is prepared and stored appropriately
    • Food that is not stored or prepared properly could cause infection. Listeria is a food-borne illness that could be quite detrimental to a neutropenic patient.
  6. Educate on signs and symptoms of infection
    • Patients must know when to alert their healthcare team when/if signs and symptoms of infection present themselves when they are neutropenic, as
  7. **A note about “neutropenic precautions” or “protective isolation” or “reverse isolation”
    • Years ago, the standard in practice for patients with neutropenia was to put the patient on isolation, however evidence does not support this practice. Please see the quote below:

      “Evidence does not support the use of reverse isolation in hospitals…the use of reverse isolation procedures should be discouraged as they are unlikely to be of benefit, and commonly cause anxiety and confusion for patients, families, and healthcare workers” Sheshadri and Baumann 2008.

      Essentially, what puts the neutropenic patient at greatest risk for infection is their own body, so putting on gowns and masks doesn’t reduce that risk. It does increase cost and makes the patient feel isolated, straining their mental health unnecessarily.

Pathophysiology

Even after bone are done growing after childhood, bones are constantly being broken down and replaced. Bone truly is living tissue. Osteoporosis occurs when the production of new bone isn’t keeping up with what’s being broken down. There is primary and secondary osteoporosis. Primary osteoporosis is from the normal age-related bone loss, while secondary osteoporosis is due to some other disease process.

Etiology

During younger years, bone is regenerated faster than old is broken down. Therefore, the overall bone mass will increase. Typically, bone mass peaks in the early 20’s.  As individuals age they continue to break down bone, but the rate in which they produce new bone can’t keep up.  If the patient had a high amount of bone mass when they peaked in their 20’s, they have more stored up, therefore the likelihood of developing osteoporosis with aging decreases.

There’s quite a bit that can put someone at a higher risk for developing osteoporosis. See the table below for a comprehensive list.

Desired Outcome

Address any underlying causes and prevent fractures

Subjective and Objective Data

Subjective Data
  • Pain
Objective Data
  • Fractures
  • Stooped posture
  • **The challenge with osteoporosis is that there typically is no sign of it until a fracture occurs, and a subsequent bone density test is performed

Nursing Interventions and Rationales

  1. Prevent injury (initiate fall precautions)
    • Injury can be catastrophic for patients with osteoporosis, as a fall could much more easily cause major fractures
  2. Control pain
    • Patients with fractures typically experience pain; pain control is essential to participating in rebab
  3. Consult physical and occupational therapy as appropriate
    • Establishing rehab needs and plan for nursing to assist with implementation; also safely evaluates their max functional level
  4. Assist with ROM activities
    • Patients may require assistance to ensure appropriate movement occurs to prevent atrophy from immobility
  5. Try to avoid using restraints if possible
    • A patient is much more likely to cause a fracture from restraints if they have osteoporosis and confusion. It is especially important to avoid restraints in these patients.
  6. Assist with repositioning every 2 hours if needed
    • Repositioning skin breakdown; assist patient with this if they are unable to do so themselves
  7. Promote appropriate bowel habits
    • Decreased mobility, pain, medications, and so forth all contribute to constipation. Being proactive rather than reactive will safe the patient discomfort, additional pain, and increase compliance with treatment regimen.
  8. Promote nutrition
    • Prevents skin breakdown, promotes healing. Increasing calcium intake and supplementation as appropriate
  9. Support fracture stabilization
    • Whether cast or splint, ensure it is on appropriately and evaluate for skin irritation and breakdown. Assess for appropriate circulation.
  10. Monitor for fat embolism
    • Fat embolism is a complication from a fracture (respiratory insufficiency, rash

Pathophysiology

Pneumonia is essentially when fluid or pus gets trapped in the alveoli of the lungs (pictured below) and impaired gas exchange results. This can impact one or both lungs.

 

Below are the important differentiations of pneumonia (these definitions, except the first one, are from Cleveland Clinic). Establishing the kind of pneumonia is essential, in that the treatment course can differ.

 

    • Community-acquired pneumonia (CAP): pneumonia acquired out in the community, not in a healthcare facility (source)
    • Hospital-acquired pneumonia (HAP): pneumonia diagnosed 48 hours or more after hospital admission
    • Health-care acquired pneumonia (HCAP): pneumonia that presents within 90 days of a hospitalization, nursing-home or long-term care facility stay, or received chemo, wound

 

  • Ventilator-associated pneumonia (VAP):  pneumonia acquired 48 hours or more after endotracheal mechanical ventilation

 

 

The first picture below is normal, unobstructed gas exchange.  If you look to the second picture, you see the alveoli have an accumulation of fluid in them, which impairs the gas exchange that should occur to provide appropriate oxygenation into circulation. What results is coughing (many times producing phlegm), fever, chills, chest pain or pain when coughing, or cold/flu like symptoms. Inflammation can also occur.  Antibiotics are administered, and the choice of which is dependent upon the offending pathogen, any other medical conditions going on with the patient, and if there are any antibiotic resistances present . Oral antibiotics are given typically for community-acquired pneumonia, however if the patient is hospitalized, they will most likely receive IV antibiotics. Steroids are typically administered to address inflammation.

 

Etiology

Pneumonia can be caused by a virus, bacteria, fungus, or from inhaling something (a chemical, inhalant, or aspirating on food or fluid). This can be of particular risk to those with a weakened immune system or unable to keep your own airway clear (for example, unable to cough or maintain consciousness due to neurological or other injury).

Desired Outcome

Resolve the infection, optimize gas exchange, minimize impact from impaired gas exchange.

 

Subjective and Objective Data

Subjective Data
  • Chills
  • Pain
  • Shortness of breath
  • Increased work of breathing
  • Nausea
Objective Data
  • Cough
  • Phlegm
  • Elevated temperature
  • Low temperature (not as common)
  • Vomiting
  • Loose stool
  • Mental status changes
  • Increased or decreased RR

Nursing Interventions and Rationales

  1. Obtain appropriate labs (antibiotic troughs, sputum cultures, ABGs, etc.)
    • Gives us a baseline; identifies pathogens, and enables us to evaluate if interventions are effective
  2. Complete a full respiratory assessment to detect changes or further decompensation as early as possible, and notify MD as indicated
    • Enables quicker interventions and may change them (for example, wheezing noted on auscultation would potentially indicate steroids and a breathing treatment, while crackles could require suctioning, repositioning, and potential fluid restriction)
  3. Promote normothermia (warm patient if hypothermic, cool patient and administer antipyretics if hyperthermic)
    • Normothermia optimizes oxygen consumption
  4. Cluster care
    • Activity intolerance is common because of decreased gas exchange; cluster your care to conserve your patient’s energy for essential tasks like ambulation, coughing and deep breathing, and eating
  5. Promote airway clearance
    • We want to encourage coughing to remove phlegm; do not suppress cough unless clinically indicated. If patient is able to clear their own airway, continue to encourage this. If not, suction frequently and consider an advanced airway to ensure a patent airway, which ultimately maximizes gas exchange. Getting phlegm out is important.
  6. Optimize fluid balance
    • Patients with pneumonia may not be consuming adequate oral intake due to fatigue or not feeling well, but hydration is essential to healing. Patients may need IV fluids if PO intake is inadequate.
  7. Assess and treat pain
    • If patients are not coughing because of pain, it will only allow fluid to continue to build. Treat pain appropriately and encourage them to cough to clear phlegm.
  8. Encouraging coughing and deep breathing
    • Coughing and deep breathing encourages expectoration, which enables better gas exchange
  9. Promote nutrition
    • Patients with pneumonia typically tire easily and have poor appetites, but need appropriate nutrition and hydration to heal
  10. Administer supplemental oxygen as appropriate
    • Due to the impaired gas exchange, oxygen doesn’t make it into circulation as easily. Providing additional oxygen supports this as much as possible. Use caution in patients with underlying lung conditions.
  11. Ensure patent airway
    • If a patient has unmanageable secretions or is unable to maintain consciousness and keep their airway clear, they must be supported (positioning, advanced airway, etc) to ensure adequate oxygen delivery
  12. Promote rest
    • Energy conservation is essential; patients should focus on breathing, providing self care, coughing/deep breathing, and ambulation. Patients cannot adequately participate in these important activities if they are not maximizing their time to rest. Appropriate sleep promotes healing.
  13. Administer antibiotics in a timely fashion, draw troughs appropriately
    • Patients may be on antibiotics, therefore it’s essential to ensure they are administered at the appropriate time and not delayed, as this will impair their efficacy. Also, trough levels will most likely to be ordered to assess if the patient is getting too much, too little, or just enough of the antibiotic. The timing of these labs related to administration times are essential for accuracy.
  14. Prevent further infection
    • Patients may have invasive lines like a internal urinary catheter, central venous catheter, endotracheal tube, and so forth. It is essential to care for these devices properly to prevent further infection.
  15. Educate patient and loved ones on the importance of energy conservation, effective airway clearance, nutrition, as well as coughing and deep breathing
    • Patients must be aware of how these aspect of recovery are pertinent so they will be more likely to participate and remain compliant.

Pathophysiology

Essentially, at its most basic level, respiratory failure is inadequate gas exchange. Not enough oxygen is being exchanged in your lungs, and therefore it’s not getting into circulation.  

There are three main types:

  • Type I is low levels of oxygen in the blood (hypoxia) – also called hypoxemic respiratory failure
  • Type II is hypoxia with high levels of carbon dioxide (hypercapnia)  – also called hypercapnic respiratory failure
    • High levels of carbon dioxide result when your lungs can get rid of it (breathe out) and it begins to build up
  • Type III is also called perioperative respiratory failure is basically when patients get atelectasis after general anesthesia or shock
    • Type III is a subset of Type I

Your body desperately needs oxygenated blood to function. Therefore, if you’re not getting good gas exchange in the lungs and oxygenating your blood, your organs will suffer.

Etiology

Many situations and/or conditions can result in respiratory failure.  Trauma, medication (oversedation, for example), various disease processes (COPD, asthma, PE, pneumonia), damage to the actual lungs/surrounding tissue/spinal cord or nerves supporting the lungs/brain, and inhalation injuries are the major ones.

Desired Outcome

Restore oxygen levels of blood as appropriate and remove excess carbon dioxide

Subjective and Objective Data

Subjective Data
  • Feeling SOB
  • Respiratory distress
  • Confusion
  • Lethargy
Objective Data
  • Hypoxia
  • Hypercapnia
  • Blue skin, lips, nail beds, etc.
  • Arrhythmias
  • Increased RR
  • Decreased RR
  • Increased breathing workload
  • Low Sp02
  • Decreasing level of consciousness

Nursing Interventions and Rationales

  1. Maintain patent airway
    • Some patients with trauma or neurological injury may require frequent suctioning and/or oropharyngeal airway/nasopharyngeal airway/intubation to ensure adequate oxygen delivery
  2. Obtain and evaluate labs (ABG)
    • This will reveal the level of decompensation as well as if interventions are effective
  3. Complete a full respiratory assessment to detect changes or further decompensation as early as possible, and notify MD as indicated
    • Enables quicker interventions and may change them (for example, wheezing noted on auscultation would potentially indicate steroids and a breathing treatment, while crackles could require suctioning, repositioning, and potential fluid restriction)
  4. Provide supplemental oxygen as appropriate
    • Supplemental oxygen will ideally increase their oxygen levels. (Use caution with COPD patients, as they cannot breathe out the CO2 adequately, so over-oxygenation is a concern, and they also may have a lower baseline SpO2 level)
  5. Ensure patient is in optimal position to decrease work of breathing
    • Sitting up in bed to enable appropriate lung expansion allows for adequate inspiration and expiration, which facilitates better gas exchange (if clinically appropriate to be sitting up)
  6. Prepare for rapid sequence intubation, if necessary
    • Helpful to be prepared, as this can progress quickly. Know where the necessary meds and equipment are and how to get ahold of assistive personnel.
  7. Remove any negative/distracting stimuli: turn the TV off, encourage family members to be calm
    • When patients are anxious or cannot focus it can increase their work of breathing and exacerbate the issue. Promote a calming environment so all the patient has to worry about is breathing.
  8. Prevent ventilator acquired pneumonia (VAP) if patient is intubated
    • If the patient becomes intubated, prevent this major further complication
  9. Provide oral care
    • If a patient is intubated or receiving oxygen via nasal cannula/face mask or tent, or other method of delivery, oral care is essential to protect mucous membrane and prevent infection
  10. Cluster care
    • Decreases oxygen demands if patient’s rest can be maximized
  11. Promote appropriate nutrition
    • Malnourishment is common with chronic lung disease, and appropriate nutrition provides the patient support for healing
  12. Assist to treat underlying cause. If the patient has pneumonia, administering antibiotics is essential to healing, if the patient has a PE, administer appropriate blood thinners, if the patient has asthma, you’re auscultating lungs sounds before and after to evaluate effectiveness.
    • The underlying cause must be treated and routinely reevaluated for the patient to progress.
  13. Monitor for conditions that can increase the oxygen demands (fever, anemia)
    • Frequently other things are going on, so make sure you’re being diligent in addressing them to give the patient the best opportunity to maximize their gas exchange (treat the fever, administer blood products, etc.)
  14. Prevent aspiration pneumonia in patients who cannot maintain their own airway
    • Hypoxia can cause lethargy and a decreasing LOC; should they aspirate on their own secretions this will put them at a significantly increased risk for aspiration pneumonia, which would further impair gas exchange and respiratory failure
  15. Manage secretions
    • Tough to allow appropriate gas exchange in a patient if they cannot handle their own secretions and are using effort to cough/clear their airway, or if it is getting down into their trachea.
  16. Assess ability to swallow safely post-intubation
    • Vocal cords may be irritated and have edema if a patient has been intubated and if give oral intake too quickly too early, patients can easily aspirate. Many facilities require patients to wait 12-24 hrs post intubation to resume regular oral intake as well as a swallow evaluation.

Pathophysiology

Essentially, skeletal muscle is destroyed (for various reasons) and their intracellular contents (in particular myoglobin) leak into the bloodstream. The kidneys can’t handle this large amount of myoglobin and it can damage them, and in some cases (roughly 30-40% of patients with this develop acute renal failure) can cause kidney failure.

Etiology

Quite a few things can cause this. One that has been discussed more frequently recently is due to the increase in people engaging in high-intensity workouts (like CrossFit). This causes intense muscle breakdown, which can result in this condition. Trauma can also be a cause, as well as conditions of genetic origin, seizures, metabolic issues, temp-regulating issues, and many medications.  A few medications that can cause this to occur include statins, diuretics, aspirin overdose (salicylate toxicity), recreational drugs like cocaine and amphetamines, and narcotics.

Subjective and Objective Data

Subjective Data
  • Muscle pain*
  • Generalized weakness*
  • Nausea
  • Tender muscles
Objective Data
  • Dark urine*
  • Vomiting
  • Fever
  • Edema
  • Skin changes (may even look like necrosis)
  • Tense muscles

Nursing Interventions and Rationales

  1. Ensure fluid resuscitation
    • “Expansion of extracellular volume is the cornerstone of treatment and must be initiated as soon as possible.” (Source)
  2. Record I&O
    • The amount of urine output, or lack thereof, may dictate various treatment regimens. Patients may need dialysis if oliguria is present.
  3. Insert Foley and prevent infection
    • Enables nurse to closely and accurately monitor urine output, foley is a source of infection and must be cared for diligently
  4. Monitor labs
    • Labs can and will dictate treatment regimens, especially because symptoms can vary widely. CK, serum and urine pH, bicarb, and electrolytes to name a few
  5. Correct electrolytes per orders
    • Electrolyte imbalances are common (K, Ca, P are of particular importance)
  6. Monitor for compartment syndrome
    • If significant muscle injury occurred, compartment syndrome is a risk. Muscle injury is typical due to decreased perfusion.
  7. Discharge education r/t diet, activity level/prevention
    • Diet changes can prevent this in the future when there is a metabolic cause, patients who are active athletes need to ensure they are hydrated appropriately and use caution with intense exercise, and note if they’re experiencing heat stroke. If a medication was noted to cause this, it and alternatives should be evaluated with the prescriber. Prevention is key!

Pathophysiology

The exact patho of RA is not fully understood, although there is thought to be a genetic component leading to more susceptible individuals. Essentially, something triggers the immune response (that something could be an infection, trauma, or something of that nature) and this leads to synovial hypertrophy (synovial lining of the joint) and chronic inflammation of the joint(s).

Basically, this inflammation becomes uncontrolled and leads to the destruction of bone, cartilage, and even tendons, ligaments, and blood vessels.

Chronic inflammation and degenerative changes are the hallmark aspects of RA.

Etiology

Like the pathophysiology, the etiology is unknown. However there are some factors that seem to contribute to its occurrence. These factors include genetics, various infections, sex hormones, as well as immunological factors.

Desired Outcome

There is no cure for RA, therefore the goal is to manage symptoms and slow the disease progression. NSAIDs, steroids and DMARD’s are used, physical and occupational therapy are key, and in severe cases surgery and joint replacement may be necessary. Some alternative therapies like fish oil, tai chi, and various plant oils have demonstrated improvement in RA symptoms.

Subjective and Objective Data

Subjective Data
  • Fatigue
  • Joint stiffness
Objective Data
  • Warm joints
  • Swelling
  • Deformity
  • Rheumatoid nodules
  • Various deformities
  • Weight loss
  • Periarticular osteoporosis
  • Decreased ROM

Nursing Interventions and Rationales

  1. Manage both chronic and acute pain: use pillow supports and even specialty mattresses, administer PRN and scheduled meds
    • RA is painful and you must have a plan to address the chronic level that accompanies RA as well as the breakthrough and acute pain
  2. Promote self care
    • It may become difficult for patients to care for themselves, especially if they begin to have deformities of their hands
  3. Cluster care, promote rest
    • RA patients experience fatigue frequently
  4. Promote positive self-image
    • Patients experience joint deformities, which can produce a negative body image.

Pathophysiology

Seizures are a very complex neurological issue. Here is the definition from Medscape of a seizure: “a seizure results when a sudden imbalance occurs between the excitatory and inhibitory forces within the network of cortical neurons in favor of a sudden-onset net excitation” (source).  Basically, abnormal electrical discharges are occurring in the brain.  There are different kinds of seizures (epileptic, focal-onset, general-onset).

Etiology

The exact cause of a seizure can be extremely difficult to pinpoint. John Hopkins Epilepsy Center divides seizures into two categories: provoked and unprovoked.  

The etiology of provoked seizures can include: trauma, drugs or alcohol, tumors, medications, drug withdrawal, progressive brain disease, and more.

The etiology of unprovoked (or “natural”) seizures can include: fever, infection, metabolic issues, genetics, Alzheimer’s disease, and more. (Source link listed below)

Desired Outcome

Stop any current seizure activity as soon as possible, minimize damage, and prevent it from occurring in the future.

Subjective and Objective Data

Subjective Data
  • Loss of awareness
  • Confusion
  • A postictal state (drowsiness, nausea, vomiting, headache)
Objective Data
  • Rhythmic twitching
  • Loss of consciousness
  • Staring off
  • Repetitive behavior (lip smacking)

Nursing Interventions and Rationales

  1. Ensure safety and initiate seizure precautions for patients at-risk for seizures. This includes having suction set up and working, having an ambu-bag in the room, padding side rails, not restrain them or putting anything in their mouth if a seizure occurs, having all side rails up, and so forth.
    • Seizures frequently happen without warning, therefore we must ensure safety in case it occurs. Once one begins, it’s too late to try to implement the safety precautions
  2. Maintain airway
    • During a seizure, the patient may not be able to maintain their own airway, or they may not be able to handle their oral secretions and aspirate (this is why it is essential to have suction set up)
  3. Assess, monitor and document seizure activity
    • It is essential to know the precipitating factors, what actually happened during the seizure (rhythmic twitching and specific location) and the specific timing (30 seconds vs. 2 minutes vs. 6 minutes) - you must be as specific as possible to enable the medical team to make appropriate clinical decisions
  4. Administer antiepileptics (PRN and scheduled) medications per orders
    • Many patients with seizures, or who are at-risk will have schedule antiepileptic medications. They must receive these promptly, as ordered. Also be aware of your PRN antiepileptics and when to administer them (typically for seizures lasting longer than 2 minutes)
  5. Reevaluate any medications that may lower the seizure threshold (some antibiotics, antidepressants, narcotics, and many more may do this)
    • We want to do all we can to prevent seizures from occurring, therefore the healthcare team must evaluate meds that may increase the seizure risk and closely look at them to decide if the benefit is worth the risk, or if an alternative is available that does not lower the seizure threshold
  6. Educate patient and family on hospital procedures, and when to notify staff
    • Some patients with a history of seizures can tell when one is coming on, which is helpful to communicate to the nurse. Also, it’s helpful to let them know what you as the nurse will do when/if a seizure occurs so that they are prepared mentally and emotionally, as it can be somewhat scary for families to witness and patients to experience.
  7. Provide emotional support
    • Seizures are serious and upsetting to witness. The more empathy and support you can provide patients and loved ones, the better.

Pathophysiology

Sepsis is essentially an overactive/uncontrolled immune response to an infection. The immune system kicks into overdrive, for whatever reason, and cannot be calmed down. It’s like someone turned the dial all the way up on the immune system and ripped the dial off the dashboard. As the healthcare team, we are trying to turn the immune response down as best we can… but it is VERY challenging. This is a very complex issue which affects many body systems, with an overall mortality rate anywhere from 27-36% (and higher in patients in intensive care settings). The challenge is that it can present with very subtle symptoms and progress quickly. Time is of the essence in sepsis recognition and treatment.

Etiology

Essentially, the cause of sepsis is the original infection. Examples include pneumonia, urinary tract infection, infection in the bloodstream (bacteremia), etc. It doesn’t have to be a bacterial infection, it can be a virus or a fungus as well.

Desired Outcome

Lessening the immune response, prevention cellular death, resolution of infection, minimizing damage from cellular oxygen deprivation and lactic acid build up, maximizing cardiac output and resolution of the condition.

Subjective and Objective Data

Subjective Data
  • Pain
  • Difficulty breathing
Objective Data
  • Elevated temp (over 101 F)
  • Low temp (below 96.8 F)
  • HR over 90
  • RR over 20
  • Respiratory distress
  • Decreasing urinary output
  • Hypotension
  • Decreasing platelet count
  • Edema
  • Hyperglycemia (no hx diabetes)
  • Altered LOC
  • Mental status changes
  • Increase in WBC, bands
  • Low SVO2
  • High lactic acid
  • Increasing creatinine

Nursing Interventions and Rationales

  1. Prompt lab draws
    • Labs in sepsis diagnosis and treatment are very time sensitive. It is imperative the nurse is drawing labs promptly, as this evaluates the effectiveness of treatment and determines next steps.
  2. Appropriate administration of IV antibiotics
    • Baseline blood cultures must be drawn prior to the initiation of antibiotics to ensure the appropriate pathogen is identified. Drawing the labs, then starting antibiotics as ordered is the nurse’s responsibility.
  3. Optimize fluid-volume status
    • Patients suffering from sepsis usually require massive fluid resuscitation.
  4. Assess, monitor, and optimize cardiac output
    • Cardiac output is typically compromised in sepsis. The nurse must communicate with the MD about this and how to treat it, as some may need more fluid, or vasopressors, or both. Non-invasive cardiac output monitoring (NICOM) or central venous pressure monitoring (CVP) are options.
  5. Assess, monitor, and support oxygen status
    • Septic patients may need significant respiratory support, depending on severity. Oxygen delivery and utilization is severely impaired, therefore the nurse must assess frequently (ABG’s, SpO2) and work with medical team on interventions
  6. Prevent infection
    • This patient already has a heightened inflammatory response, we don’t want to make it worse with another pathogen. Asepsis is KEY with all patient care but in particular the septic patient. Frequently septic patients will require a central venous catheter and foley catheter. These are invasive lines that can easily get infected but are necessary when a patient is that ill.
  7. Assess, monitor, and manage body temp
    • Their body temp may be high or low, and we want to warm them if they’re too cold (increase room temp, warming blankets) or cool them if their fever is too high (antipyretic, cooling blanket, decrease room temp). Many septic patients with fluctuating body temps may have continuous temperature monitoring (via foley, rectal tube, or endotracheal tube)
  8. Communicate with and educate patient and loved one
    • Sepsis is serious and scary. It is essential to educate the patient and their support system at every step of the way so they are able to let you know if they feel/act differently, if things change, and also to prevent them from unnecessarily worrying or interfering with very needed interventions.

Pathophysiology

A stroke is essentially a neurological deficit caused by decreased blood flow to a portion of the brain. They will be classified as either hemorrhagic or ischemic. An ischemic stroke is the result of an obstruction of blood flow within a blood vessel. A hemorrhagic stroke is when a weaken blood vessel ruptures and blood spills into the brain where it shouldn’t be. Both of these can cause edema and cellular death. Lack of blood flow for greater than 10 minutes can cause irreversible damage.

Etiology

Various things can cause an ischemic stroke, which comprises approximately 85% of all strokes. Some of those who are at highest risk are those on anticoagulation therapy. People are on anticoagulants therapy for various reasons (mechanical heart valves, atrial fibrillation, etc.) and if they become sub therapeutic and therefore their blood is too thick, a clot can easily form and end up in the brain, causing an ischemic stroke. Diabetes is also one of the major risk factors, in addition to atherosclerosis, hypertension, cardiac dysrhythmias, obesity, substances abuse, and oral contraceptives. Hemorrhagic strokes (the remaining 15% of strokes) can be caused by an aneurysm rupture (which are very difficult to predict… frequently noted increased incidence in smokers, drug abuse, and people with family history of a first-degree relative with one), high blood pressure, or the rupture of an arteriovenous malformation (which is genetic).

Desired Outcome

Restoring as much blood flow as possible as quickly as possible, and minimizing cellular death/damage is key. Clot-busting meds can be given to restore blood flow for ischemic strokes. Hemorrhagic strokes are managed by keeping the blood pressure controlled, controlling intracranial pressure, reversing any anticoagulants on board, and even very invasive procedures or surgery to relieve increased intracranial pressure. You want the patient to gain back as much function as possible. This is done slowly over time by the brain creating collateral circulation around the infarcted area. Physical, occupational, and speech therapy are essential aspects of stroke recovery. Some patients may make a complete recovery, while others may have profound deficits.

Subjective and Objective Data

Subjective Data
  • Numbness
  • Tingling
  • Decreased sensation
  • Difficulty swallowing
  • Headache
  • Pain
  • Nausea
  • Dizziness
Objective Data
  • Hemiparesis
  • Hemiplegia
  • Ataxia
  • Dysmetria
  • Facial droop
  • Paralysis
  • Aphasia
  • Dysphagia
  • Dysarthria
  • Vomiting
  • Increased secretions
  • Incontinence
  • LOC changes

Nursing Interventions and Rationales

  1. Use assistive ambulatory devices
    • Facilitates ambulation/transfers safely
  2. Frequent neurological assessments (per orders)
    • Alerts nurse to neurological changes as early as possible, enables them to notify MD and intervene when needed
  3. HOB at 30 degrees unless otherwise indicated
    • Increases venous return, decreases ICP
  4. Initiate DVT prophylaxis (mechanical and/or chemical)
    • Decreases risk for subsequent stroke, as patient most likely will not be as mobile as they are at baseline
  5. Ensure PT/OT/ST is ordered
    • Rehab is essential in stroke recovery; all must complete a baseline assessment and provide recommendations
  6. Fall prevention measures (non-skid socks, bed in lowest locked position, call bell within reach, and so forth)
    • Injury prevention; patient will most likely not be able to ambulate as they could prior to stroke and will require assistance
  7. Prevent contractions
    • Extremities that are now paralyzed are at risk for becoming contracted; ensure pillow supports are in place as well as rolled towels and adaptive devices
  8. Prevent aspiration: follow ST recommendations, keep HOB at 45 degrees during oral intake and keep patient upright after a meal, have suction available, assess lung sounds and body temp
    • Stroke patients frequently have impaired swallowing, and are at high risk for aspiration from their own oral secretions and oral intake.
  9. Cluster care; promote rest
    • Maximizes time with the patient so they can rest when care is not being provided
  10. Monitor vital signs appropriately; know BP limits
    • Closely monitoring BP is essential in managing ICP
  11. Prevent edema: elevate limbs, utilize compression stockings, promote ambulation, promote complete bladder emptying
    • Patients who are in bed more will have a harder time clearing fluid out, especially if they have any underlying heart condition causing a decreased cardiac output (like atrial fibrillation)
  12. Promote self-care
    • Patients will have a decreased ability to care for self due to new deficits; promote confidence and participation in caring for themselves as much as possible
  13. Promote cerebral tissue perfusion (interventions per orders, as this can differ depending on kind of stroke, location, and other factors)
    • This prevents additional neurological damage
  14. Facilitate safe swallowing: ensure bedside swallow screening completed and/or speech therapy assessment prior to oral intake
    • Frequently, brain injury results in an impaired ability to swallow safely. This is not always apparent as patients don’t always cough when aspirating and have silent aspiration.
  15. Promote adequate nutrition
    • Once a patient is cleared to eat, do what you can to encourage appropriate intake… as patients cannot heal if they don’t eat
  16. Initiate discharge planning
    • Stroke patients typically require multiple needs at discharge (follow up appts, rehab/therapy, and may need to go to long-term care or inpatient rehab, depending on the situation) begin getting your mind around their discharge needs at the beginning even if it’s not clear yet what their needs will be
  17. Prevent skin breakdown: turn q2hrs, ensure adequate protein intake, off-loading, pillow support, keep linen clean and dry
    • There are many reasons why a stroke patient will be at risk for skin breakdown… from an inability to feel or move extremities, incontinence, inability to communicate needs/pain/discomfort, decreased nutritional status.
  18. Facilitate communication; promote family coping and communication
    • Having a stroke is a major life event. Roles within families and support systems may change, especially if the patient played a caregiving role within their family structure

Pathophysiology

Syncope is essentially a loss of consciousness, which is typically caused by hypotension. The brain lacks adequate blood flow and a temporary loss of consciousness results.

Etiology

Syncope typically has a cardiac etiology, but can also be due to many other things (like a side effect from a med, neuro issue, psych issue, or lung problem). When a cardiac etiology is suspected, a cardiac workup is completed. This typically includes cardiac monitoring, labs, and routine vital signs (specifically blood pressure and heart rate).

Desired Outcome

No additional syncopal events, no injury, identification of cause and treatment to prevent further episodes

Subjective and Objective Data

Subjective Data
  • Nausea
  • Feeling cold, clammy, or warm
  • Tunnel vision
  • Blurred vision
Objective Data
  • Vomiting
  • Loss of consciousness
  • Arrhythmias
  • Hypotension
  • Pallor
  • Bradycardia
  • Confusion/disorientation

Nursing Interventions and Rationales

  1. Prevent injury (nonskid socks, doesn’t walk without assistance, bed in lowest locked position, necessary items within reach, call bell within reach, side rails up x3)
    • Sudden loss of consciousness puts patients at a higher risk for falls and injury, therefore it would be prudent to be with the patient when OOB
  2. Educate patient to change positions slowly
    • This enables the blood pressure to accommodate to position changes and hopefully prevent future episodes
  3. Reevaluate medications, review any that may cause syncope with MD
    • BP meds may need to be spaced out, or dosages may need to be adjusted; discuss
  4. Monitor for changes in level of consciousness.
    • Monitor appropriately and notify MD if needed, promote safety
  5. Promote adequate fluid intake
    • Prevents worsening hypotension

Pathophysiology

Infection within the genitourinary system, which then causes inflammation. The urinary tract is sterile above the urethra and pathogens gain entrance via the perineal area or the bloodstream.  When these pathogens enter this sterile environment, infection ensues.

One can acquire an infection in the bladder itself (cystitis), or the an infection in the urethra (urethritis), which is essential a urinary tract infection.

Etiology

Females are most prone to UTI’s due to their natural anatomy. Females have a shorter urethra and it has a close proximity to the anus (and therefore e. Coli, which is normally found in the GI tract). Males become more susceptible as they age due to urinary stasis. Urinary catheter use (particularly indwelling) significantly increase the risk for a UTI, sexual intercourse, certain birth control methods (spermicide, diaphragms), blockages in the urinary tract, abnormalities in the anatomy of the urinary tract, or a suppressed immune system can all increase the risk for a UTI.

Desired Outcome

Resolution of infection, restoration of normal bladder functioning

Subjective and Objective Data

Subjective Data
  • Painful urination
  • Burning
  • Lethargy, urinary urgency, pelvic pain, chills, back pain
Objective Data
  • Malodorous urine
  • Dark/cloudy/discolored urine
  • Sediment or pus in urine
  • Sediment in urine
  • Altered mental status
  • Positive urine culture
  • Increased WBC
  • Increased frequency
  • Fever
  • Discharge
  • Nausea and vomiting

Nursing Interventions and Rationales

  1. Assess pain, Assess urine color, clarity, odor Assess mental status Assess body temperature
    • Must obtain baseline assessment data
  2. Discontinue indwelling catheter if applicable
    • May be source of infection
  3. Draw appropriate labs (CBC, UA)
    • Identifies infection, follow ups can show if treatment is effective
  4. Encourage increased fluids (start IVF if necessary)
    • Increased urinary output helps flush out bacteria
  5. Promote routine voiding
    • Taking the patient to the bathroom on regular intervals will help facilitate emptying the bladder completely
  6. Educate on proper perineal cleansing techniques to decrease risk of infection
    • Improper wiping can cause infections
  7. Administer meds as ordered (antibiotics, antispasmodics, analgesics)
    • Decreases discomfort and kills bacteria causing infection