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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

Abruptio placentae, or placental abruption, is when the placenta partially or completely detaches prematurely from the uterus, causing a risk for hemorrhage. This is most often seen at 24-26 weeks gestation and is considered a serious complication. In mild cases, the patient may remain on restricted activity or bed rest for the duration of the pregnancy, but in more severe cases where there is maternal or fetal compromise, delivery is required. While placental abruption generally happens suddenly, chronic abruption may occur in which there is a small separation that causes slow bleeding behind the placenta.

Etiology

Etiology is generally unknown, but risk factors include abdominal trauma, vascular disorders, hypertension (chronic or gestational), PROM or other rapid loss of amniotic fluid, infection, prior history of placental abruption, advanced maternal age (>35 yrs old)  and maternal use of tobacco or cocaine. Complications of abruptio placentae include fetal growth restriction, distress or death, maternal blood loss and shock, blood clotting issues (DIC) and maternal kidney and organ failure.

Desired Outcome

Patient will have no or minimal bleeding; pain will be controlled, fetus will show no signs of distress

Subjective and Objective Data

Subjective Data
  • Abdominal pain
  • Uterine tenderness
  • Back pain
  • Constant uterine contractions
Objective Data
  • Vaginal bleeding
  • Back to back uterine contractions
  • Firmness of uterus on palpation

Advanced abruption and severe blood loss may lead to shock

  • Tachycardia
  • Hypotension

Nursing Interventions and Rationales

  1. Assess and monitor vaginal bleeding
    • Excessive bleeding may result in shock. Amount of obvious blood may not fully indicate severity due to possible internal bleeding
  2. Obtain history from patient
    • Determine time bleeding began, any history of pregnancy complications or abdominal/uterine trauma
  3. Place patient on bed rest in lateral position
    • This position helps avoid pressure on the vena cava to avoid decreased cardiac output
  4. Initiate IV access with large bore line
    • IV fluids will be given to manage hypovolemia and blood transfusion may be required
  5. Assess abdomen for uterine tenderness and contractions
    • Uterus may be tender upon palpation, tense and rigid.

      Fundal massage may help to slow bleeding from uterine wall.
  6. Monitor maternal vitals for signs of shock
    • Watch for signs of hypovolemia to include tachycardia, tachypnea and hypotension
  7. Place and observe external fetal monitoring for signs of fetal distress
    • This allows you to monitor fetal heart rate and contractions to observe for variability and responsiveness of the fetal heart rate. A lack of variability or decelerations indicate fetal distress.
  8. Assess and manage pain: Massage, Guided imagery, Cool compresses to the forehead, Deep breathing techniques
    • Abdominal, back and uterine pain may accompany bleeding and at times may be severe, especially with contractions.

      Provide alternative options for pain relief if able
  9. Administer medications: Corticosteroids, Analgesics as appropriate, Oxytocin
    • In addition to IV fluids, corticosteroids may be given to speed up fetal lung development if delivery is necessary.

      Oxytocin may be given after delivery to decrease hemorrhage.
  10. Provide patient education
    • Help patient to feel more informed and lessen anxiety and stress

Pathophysiology

Acute kidney injury, also known as acute renal failure,  is when the kidneys stop working over the period of a few hours or a few days. People at risk for AKI are those who have high blood pressure, a chronic illness such as heart or liver disease or diabetes, or those who have peripheral artery disease. AKI requires immediate treatment but is usually reversible if treated quickly.

Etiology

Acute kidney injury is a result of direct kidney damage, decreased blood flow or blockage of the urinary tract. Direct damage may be a result of sudden trauma to the kidneys, sepsis, scleroderma or allergic reaction. Other, more common, causes include a blockage in the ureters such as kidney stones, blood clots, enlarged prostate or multiple myeloma. Hypotension, severe diarrhea, infection, overuse of NSAIDs, dehydration or severe burns may cause decreased blood flow.

Desired Outcome

Restore kidney function to optimal state, patient will maintain hydration and be free from infection or chronic kidney damage.

Subjective and Objective Data

Subjective Data
  • Feeling tired
  • Feeling confused
  • Nausea
  • Pain or pressure in the chest
  • Shortness of breath
Objective Data
  • Dependent edema
  • Periorbital edema
  • Seizures
  • Tachycardia with hypertension
  • Decreased urine output
  • Electrolyte abnormalities
    • ↑ Potassium
    • ↓ Sodium
    • ↑ Phosphate
    • ↓ Calcium
  • ↑ BUN/Creatinine
  • ↓ GFR

Nursing Interventions and Rationales

  1. Monitor vitals: Heart rate, Blood pressure
    • Tachycardia and hypertension may occur because of the kidneys’ inability to excrete urine
  2. Perform 12 lead EKG
    • To assess for arrhythmias
  3. Asses heart and lung sounds for adventitious breath sounds or extra heart sounds
    • Fluid overload may lead to pulmonary edema and heart failure and may be manifested by shortness of breath and chest pain
  4. Monitor mentation and changes in level of consciousness
    • Changes in LOC may indicate fluid shifts and electrolyte imbalance
  5. Assess dependent and periorbital edema
    • Evaluate and report degree of edema (+1 - +4)
      There may be a gain of up to 10lbs of fluid before pitting is noticed
  6. Monitor diagnostic studies Radiology: Chest x-ray, ultrasound or CT of kidneys, Lab: urine, blood
    • Chest x-ray may show increase in cardiac size, pleural effusion or pericardial congestion due to fluid overload

      Urinalysis- urine creatinine usually decreases as serum creatinine increases

      Serum- BUN, creatinine - monitor ratio, if >10:1, dialysis may be indicated
      Sodium- may indicate hyponatremia (fluid overload) or hypernatremia (total body fluid deficit)

      Potassium- elevation indicates kidney disease from lack of excretion or selective retention and leads to hyperkalemia
  7. Insert indwelling urinary catheter unless contraindicated for infection
    • Indwelling catheter will provide for more accurate measurement of urine output
  8. Monitor I & O for fluid retention
    • Measure for decreased output <400 mL/24 hr period may be evident by dependent edema

      Daily weights at the same time on the same scale each day, >0.5kg/day is indicative of fluid retention

      Note changes in characteristics of urine to include odor, blood, mucus or sediment present
  9. Administer medications as ordered
    • IV Fluids- may be given for lack of fluid volume, but may be withheld in cases of fluid overload

      Diuretics- furosemide, mannitol may be given to flush kidneys of debris and reduce fluid overload, reducing hyperkalemia

      Calcium channel blockers-given early can help reduce influx of calcium in kidney cells to maintain cell integrity - if calcium level is too low, calcium may be infused

      Antihypertensives- clonidine, methyldopa may be given to counteract the effects of decreased renal blood flow

      Cation-exchange resins- sodium polystyrene sulfonate (Kayexalate) help reduce levels of potassium and treat hyperkalemia
  10. Nutrition management and education
    • Limit intake of excess fluids

      Limit sodium intake - avoid adding salt to foods and limit processed or canned foods that contain hidden sodium

      Increase fresh fruits and vegetables

      Limit foods high in potassium such as beans, rice, bananas, oranges, potatoes and tomatoes

      Limit intake of whole grain breads, bran cereals, nuts and sunflower seeds due to their high phosphorus content

      Refer patient to dietitian if further counseling is required
  11. Prepare patient for dialysis if indicated: Peritoneal, Hemodialysis, Continuous Renal Replacement Therapy
    • Elevate the head of the bed to reduce pressure on the diaphragm and aid in respiration

      Monitor for signs and symptoms of clot or infection at shunt site

      Assess for thrill/bruit of shunt for patency

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

The adrenal glands, located above the kidneys, fail to produce an adequate amount cortisol, aldosterone or androgens. Cortisol is a glucocorticoid that influences the body’s ability to respond to stress and produce energy. Aldosterone is a mineralocorticoid that maintains the sodium-potassium balance that regulates blood pressure. Androgens are responsible for sexual development of men and the influence of muscle mass and sense of well-being in men and women.

Etiology

A decrease in adrenal gland function may be caused by an autoimmune disease that damages the adrenal glands in which the body attacks the adrenal glands as if they were a foreign body. Damage to these glands may also be a result of severe infection of the adrenal glands, tuberculosis, or the spread of cancer.

Desired Outcome

maintain adequate hormone levels for optimized ability to create energy and respond to stress and electrolyte balance to regulate blood pressure

Subjective and Objective Data

Subjective Data
  • Fatigue
  • Lower back / leg pain
  • Abdominal pain
  • Irritability / depression
  • Reports significant weight loss
Objective Data
  • Decreased blood pressure
  • Electrolyte imbalance
    • Decreased sodium
    • Increased potassium
  • Severe vomiting, diarrhea
    • Dehydration
  • Loss of consciousness

Nursing Interventions and Rationales

  1. Monitor weight
    • Lack of appetite due to decreased levels of cortisol may cause significant decrease in body weight
  2. Encourage oral fluids
    • Deficiency of cortisol may lead to anorexia and impaired GI function. Encourage oral fluids to help maintain adequate sodium levels and avoid dehydration.
  3. Minimize stress and assist with activities / provide rest periods
    • Simple stress and overexertion can cause a life-threatening Addisonian crisis due to lack of corticosteroids that help the body react to and manage stress.
  4. Monitor nutrition
    • Aldosterone deficiency causes the kidneys to excrete sodium which may result in salt cravings. Encourage patients to increase salt intake and supplements as necessary to prevent hyponatremia. Encourage patients to eat high protein / low carb snacks and meals as tolerated followed by rest periods to prevent fatigue due to hypoglycemia and to facilitate digestion.
  5. I & O – monitor intake and output
    • Monitor urine for decreased output (desired >30ml/hr), concentration and color which may be darker
  6. Assess vitals; temperature, blood pressure and heart rate - watching for orthostatic changes and hyperpyrexia
    • A decrease of 15 mm Hg or more and increase in heart rate (normal <100bpm) may indicate reduced circulation of fluids such as with dehydration

      Increased temperature may be a sign of Addisonian crisis due to hormonal and fluid imbalance
  7. Monitor EKG for signs of hyperkalemia
    • Lack of Aldosterone means increased sodium excretion and increased potassium retention.

      Signs of hyperkalemia will include peaked T waves and prolonged QRS complex.
  8. Monitor for signs of dehydration by noting mucus membranes and skin turgor
    • Tenting of the skin and dry mucous membranes indicate dehydration., which is common due to vomiting and anorexia.
  9. Administer Medications: Kayexalate, Cortef or Cortone, Prednisone, Florinef
    • Kayexalate - Can be given orally or by enema to reduce potassium levels

      Cortef or Cortone and prednisone may be given orally or IV to increase cortisol levels

      Florinef – Given orally to promote replacement and retention of sodium and water

Pathophysiology

Alzheimer’s disease, sometimes called Alzheimer’s Dementia, is a progressive and irreversible neurological disorder that causes loss of memory and cognitive function. Symptoms begin gradually, with signs that are easily attributed to other factors such as misplacing items, forgetting appointments or getting lost in a familiar area. The disease may actually begin occurring in the fifties and sixties, but symptoms may not present until the client is in their eighties or nineties. Studies have shown that clients who reside in smaller living spaces, avoid social interaction or rarely leave their homes are twice as likely to have Alzheimer’s disease. Since Alzheimer’s is an irreversible disease, treatment is geared toward management of symptoms and promoting support and the best quality of life possible.

Etiology

Diagnostic Criteria:    Diagnosis of Alzheimer’s disease should not be applied when symptoms began following a stroke, traumatic brain injury (TBI),  there is another known neurological disorder or when client is being treated with medications for other neurological disorders that would produce similar symptoms. The following characteristics must be met for diagnosis:

  • Gradual onset (may take months or years)
  • Clear observation of cognitive decline
  • Decline in memory or learning and one other cognitive area (based on history of testing)
    • Speech
    • Visual-spatial (recognition of objects or faces)
    • Reasoning or judgement
  • Steady cognitive decline without periods of stability

Desired Outcome

Client will maintain optimal level of independent or assisted functioning. Client will remain free from injury. Client will have minimal wandering behaviors. Client’s family will have adequate resources and support for coping with client’s disease.

Subjective and Objective Data

Subjective Data
  • Difficulty finding words during a conversation
  • Difficulty remembering names
  • Poor short-term memory
  • Forgetting details of personal history (life events, phone number, etc.)
  • Inability to recognize faces
Objective Data
  • Difficulty dressing or performing ADLs
  • Loss of bladder and bowel control
  • Personality changes
  • Inappropriate behaviors (aggression, sexual gestures, etc.)
  • Wandering or pacing

Nursing Interventions and Rationales

  1. Perform complete nursing assessment
    • Get a baseline for interventions and monitor progression of disease
  2. Assess neurological status and level of confusion routinely, per facility protocols
    • Help determine necessary interventions and progression of disease.
  3. Assess for depression or reclusiveness
    • Clients in the earlier stages who are still able to understand that they are losing their sense of reality may become depressed and withdrawn.
  4. Routinely assess client for organic contributors to behavior: Dehydration, Poor nutrition, Infection (systemic, urinary)
    • Many organic factors may contribute to an increase in client’s confusion or changes in mental status. It is important not to ignore them, since it could be related to infection or dehydration, which is treatable.
  5. Communicate effectively: Speak in a slow and low, comforting voice, Call client by name, Speak face-to-face
    • Helps increase the possibility of the client understanding what is being communicated. Repeating the name helps the client maintain a sense of self-identity.
  6. Limit choices for independent decisions appropriate to stage of disease progression
    • Progressively reducing the client’s need for decision making helps reduce frustration and stress.
  7. Avoid allowing client to watch television or violence on television
    • Clients often have difficulty distinguishing fiction from reality and may cause aggressive or violent behaviors or unwarranted fears.
  8. Monitor for non-verbal cues and anticipate client’s needs Grimacing, Crying, Pointing
    • As the disease progresses, clients have more difficulty communicating verbally. Anticipating needs helps reduce stress and prevent frustration and anxiety.
  9. Orient client to environment as often as needed: Calendars, Pictures, Signs
    • Helps client feel safer and reassured of their surroundings. Promotes awareness of environment.
  10. Provide structured and guided activities that client can accomplish with minimal challenge
    • This helps to keep the mind active, and incorporate a sense of accomplishment. Make sure the activity is not sp challenging so as to cause frustration or stress.
  11. Maintain schedule and routine
    • Helps the client maintain an awareness of time of day and offers a sense of security and reality.
  12. Assist with ADLs as needed
    • Advanced stages of the disease may diminish the client’s ability to perform simple tasks like dressing, bathing, combing hair and feeding. Provide whatever assistance the client needs to maintain a sense of dignity.
  13. Provide an opportunity for clients to interact with others, but avoid forcing interaction
    • Helps prevent clients from feeling isolated or alone. Gives them an opportunity to share stories or memories and maintain or develop social relationships. Forced interaction may cause aggression or inappropriate behaviors.
  14. Monitor client’s wandering habits and determine specific reasons, if any, for wandering
    • Clients may wander because they are thirsty or hungry, or are looking for a bathroom. Assess needs and provide assistance or direction within a safe environment.
  15. Educate family about disease process and resources for coping: Therapy or counseling for families, Support groups for families or caregivers, Respite care options, Home modifications
    • Help families cope and be prepared for the changes in their loved one.

      Help families adapt to the needs of the clients.

      Help reduce stress and anxiety that may be transferred to the client.
  16. Administer medications appropriately and as needed: Cholinesterase inhibitors (donepezil), NMDA receptor antagonist (memantine), Antipsychotics (olanzapine, quetiapine), Benzodiazepines (lorazepam, temazepam), SSRI antidepressants (citalopram, paroxetine)
    • Some medications may be given regularly for management of memory loss and delay progression of the disease.

      Other medications may be given PRN to treat behaviors and symptoms such as depression, anxiety or loss of appetite.
  17. Minimize environmental hazards and make pathways clear and illuminated
    • Promote safety and prevent injury.

Pathophysiology

Anaphylaxis is an acute, multiorgan,  life threatening allergic reaction. Initial symptoms may look like a normal allergy with runny nose or rash and usually occur within minutes of exposure to an allergen.  Within a few minutes, symptoms get more severe and can be deadly if not treated. Anaphylaxis requires immediate medical attention.

Etiology

Anaphylaxis is caused by an overreaction of the immune system to a particular allergen. Triggers may be different for each person, but the most common triggers are peanuts, insect stings, latex, shellfish and eggs, and medications such as penicillin.

Desired Outcome

Restore effective breathing pattern and improved ventilation and maintain hemodynamic stability

Subjective and Objective Data

Subjective Data
  • Chest tightness
  • Difficulty swallowing
  • Stomach cramping
  • Shortness of breath
  • Dizziness
  • Feeling of impending doom
Objective Data
  • Rash, hives (usually itchy)
  • Weak, rapid pulse
  • Hypotension
  • Swollen throat
  • Hoarse voice
  • Coughing
  • Vomiting
  • Diarrhea
  • Pale or red color to the face and body

Nursing Interventions and Rationales

  1. Administer epinephrine or EpiPen autojector if available
    • Antihistamines are not adequate to treat true anaphylaxis. Administer epinephrine or EpiPen immediately.
  2. Remove antigen/causative allergen
    • If medication is the trigger, discontinue medication immediately; remove, but do not squeeze the stinger of an insect
  3. Initiate IV access and maintain patency
    • Medications and fluids will need to be given quickly. IV access allows uniform and quick dosing.
  4. Monitor airway and oxygenation status; prepare for intubation or tracheostomy if necessary to maintain airway
    • Swelling of the throat may be caused by acute inflammation. Airway obstruction is the most common manifestation of anaphylaxis and can be fatal. Monitor ABG and oxygen saturation.
  5. Perform CPR if necessary
    • Anaphylaxis may occur quickly and result in cardiac or respiratory arrest. Provide CPR or rescue breathing as necessary
  6. Position patient upright in high-Fowler’s position if conscious
    • Positioning is to lessen airway obstruction and encourage optimal gas exchange by promoting maximum chest expansion.
  7. Monitor vital signs; assess for signs of shock
    • A drop in blood pressure and elevation of heart rate are signs of shock.
  8. Administer medications as appropriate: Epinephrine, Diphenhydramine, Albuterol
    • Medications are given for vasoconstriction and to reverse the effects of histamine. Albuterol may be given to reverse histamine-induced bronchospasm.
  9. Educate patient regarding avoidance of allergens; how to use EpiPen
    • Teach patient to read nutrition labels and the importance of wearing a Medic Alert bracelet to prevent future anaphylactic reactions. Patient should have EpiPen available and be aware of how to use it.

Pathophysiology

Anemia is the lack of enough healthy red blood cells (RBC) or hemoglobin (HGB), which is the part of the red blood cell that binds oxygen to the blood. This lack of HGB restricts the amount of oxygen available to create energy within the cells (ATP). This decrease in oxygenation (hypoxia) results in altered pH and can lead to damage of organ systems including cardiac, respiratory and renal disease.

Etiology

There are many causes for anemia to develop including bone marrow disorders and chronic diseases.

  • The most common type of anemia is iron-deficiency anemia which is caused by pregnancy, significant blood loss over time as with heavy menstruation.
  • In aplastic anemia, the bone marrow fails to produce an adequate amount of red blood cells.
  • Hemolytic anemia develops when RBCs are destroyed, often by infection or autoimmune disorders
  • Sickle Cell anemia is a genetic disorder in which the RBCs are misshapen (sickle-shaped) causing clots and poor perfusion.

Desired Outcome

Treat the underlying cause of anemia and return to normal counts of RBCs and HGB.

Subjective and Objective Data

Subjective Data
  • Fatigue / weakness
  • Dizziness
  • Shortness of breath
  • Chest pain
  • Headache
Objective Data
  • Pale or yellowish skin
  • Bleeding / hemorrhage
  • Syncope
  • Hypotension
  • Tachycardia
  • Abnormal labs (CBC = decreased RBC and HGB)

Nursing Interventions and Rationales

  1. Assess for and control obvious signs of bleeding: External bleeding, Heavy menstruation (>1 pad per hour), GI bleed
    • Excessive loss of blood results in decreased oxygenation and poor perfusion.
  2. Perform 12-lead ECG
    • Decreased blood volume causes tachycardia and arrhythmias. Monitor for ST depression and QT prolongation.
  3. Replace fluid volume per facility protocol: IV fluids, Blood transfusion for HGB <8 (per protocol and provider)
    • For blood loss of >40% volume, immediate transfusion is required
  4. Monitor diagnostic testing: Lab values, CT scans for possible liver or spleen lacerations, Fecal occult blood - non-invasive test to determine if there is a potential GI bleed
    • Abnormal lab values help determine the cause of anemia and a plan of treatment.
      Lab values to monitor closely:

      HGB (Normal 12-15 g/dL females; 13.5 - 16.5 g/dL males)

      B12 (Normal 2 - 20 ng/mL)

      Ferritin (Normal 20-300 ng/mL) - the protein that stores iron

      Iron (Normal 50-175 ug/dL)
  5. Monitor oxygen saturation and administer oxygen as necessary: If SpO2 is <94%, deliver oxygen via nasal cannula at 2L/min and increase as needed
    • Lack of HGB reduces oxygenation and leads to hypoxia which causes damage to tissues and vital organs.
  6. Administer medications
    • Pantoprazole (GI bleed) - helps reduce acid and stop bleeding of peptic ulcers

      IV fluids and electrolytes as necessitated by lab values

      B12 injections or oral supplements - for B12 deficiency

      Erythropoietin is a hormone that may be given to treat anemia caused by chemotherapy or chronic kidney disease that stimulates production of red blood cells in the bone marrow
  7. Provide nutritional education: Increase green leafy vegetables, Incorporate foods high in vitamin C, Intake of red meat, lamb, poultry and venison as well as fish and shellfish Intake of seafood and shellfish, Limit or avoid intake of foods high in calcium
    • Leafy greens such as spinach, kale and chard are high in iron and folate

      Vitamin C assists in the absorption of iron. Good choices include oranges, red peppers and strawberries

      All meats and most fish and shellfish contain heme iron

      Calcium-rich foods such as raw milk, yogurt, cheese and broccoli are high in calcium, which binds with iron and prevents absorption

Pathophysiology

Appendicitis is the obstruction and inflammation of the inner lining of the appendix.  If left untreated, increasing inflammation and infection can lead to necrosis, gangrene or perforation of the appendix in which the infectious materials spill out into the abdominal cavity causing peritonitis. Appendicitis is considered a medical emergency and requires surgery to remove the appendix (appendectomy).

Etiology

Obstruction of the appendix may result from fecal material, infection, a foreign body or cancer blocking the opening of the appendix. The bacteria from the collection of fecal matter or infection multiply rapidly which causes the appendix to become inflamed, distended and filled with pus, creating an obstruction.

Desired Outcome

Optimal pain relief and patient will be free from infection.

Subjective and Objective Data

Subjective Data
  • Abdominal pain – periumbilical that migrates to RLQ
  • Nausea
  • Chills
  • Anorexia
  • Diarrhea or constipation reported
Objective Data
  • Fever, diaphoresis
  • Vomiting
  • Fetal position to reduce pain
  • Rebound tenderness at McBurney’s Point
  • Inflamed hemiscrotum (male infants and children)
  • Abnormal labs
    • ↑ WBC
    • ↑ CRP

Nursing Interventions and Rationales

  1. Place in semi-Fowler’s position
    • This position allows gravity to assist by reducing abdominal stress and relieves discomfort
  2. Monitor Labs
    • Abnormal labs are indications of illness progression. Monitor for:

      CRP >1 mg/dL - indicates inflammation. Very high levels may indicate gangrene

      WBC >10,500 - indicates infection
      Neutrophils >75%
  3. Monitor vital signs
    • Fever, chills and diaphoresis are signs of infection, developing sepsis, abscess or peritonitis

      Hypotension with tachycardia may indicate dehydration if vomiting or diarrhea is severe
  4. Prep for surgery to remove appendix (appendectomy)
    • Initiate IV access
      Informed Consent obtained
  5. Provide Post-Op care after appendectomy
    • Maintain NPO status to empty gastric contents and remain NPO post surgery until gag reflex has returned to reduce the risk of aspiration

      Clear liquids, advance diet as tolerated
  6. Assess and manage pain
    • Note location, severity and quality of pain and any changes in characteristics which may signify abscess or peritonitis

      Administer analgesics as ordered for pain management

      Place ice pack on RLQ to aid in pain relief - avoid using heat as it may cause the appendix to rupture
  7. Encourage abdominal splinting
    • Education the patient on ways to protect abdomen before and after surgery by splinting with a pillow- this will aid in pain management and prevent dehiscence of incision.

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

Cardiogenic shock is a state in which the organs are not receiving adequate oxygenated blood because of severe pump (heart) failure. It is an acute, sudden, extreme version of heart failure and is a medical emergency.

Etiology

A myocardial infarction can cause cardiogenic shock because the heart muscle cannot pump effectively. Things that obstruct the flow of blood to the body can also cause cardiogenic shock – that includes cardiac tamponade (fluid build up around the heart that compresses it and prevents pumping) and pulmonary embolism (blood clot in the pulmonary arteries that prevent forward flow and prevent oxygenation of the blood).

Desired Outcome

The goal is to reverse the cause and restore sufficient cardiac output to the tissues. The hope would be to prevent any permanent damage from tissue ischemia and to prevent recurrence of cardiogenic shock.

Subjective and Objective Data

Subjective Data
  • Crushing Chest Pain
  • Anxiety or restlessness
  • Sudden, severe, SOB
  • Weakness
  • Nausea
Objective Data

Patient may have any combination of these signs depending on the cause of their cardiogenic shock

  • Evidence of MI or 12-Lead and Cardiac Enzymes
  • ↑ HR
  • ↑ RR
  • ↓ BP
  • ↓SpO2
  • ↓ Temp
  • ↑ CVP
  • ↓ CO
  • ↑ SVR
  • ↓ LOC
  • ↓ Urine output
  • Skin is cold, pale, possibly dusky or mottled
  • Pulses rapid and thready
  • Diaphoretic
  • JVD
  • Crackles in lungs
  • Heart sounds muffled
  • S3, S4 present

Nursing Interventions and Rationales

  1. Assess for Risk: History of Myocardial Infarction, Coronary Artery Disease, Obesity, Hyperlipidemia, Pulmonary Embolism Risk, Blunt Chest Trauma
    • Nurses should assess their patient for the risk of developing cardiogenic shock.

      History of MI - previous damage to heart muscle means more susceptible to shock with a recurrent MI.

      CAD, Obesity, HLD all contribute to risk for MI

      Pts on prolonged bedrest, postpartum mothers, and those with DVTs are at highest risk of developing a pulmonary embolism

      Blunt Chest Trauma means patient may be at risk of developing pericardial tamponade.

      Either way, the more aware the nurse is of the risk, the more likely it can be prevented or caught early.
  2. Assess and monitor: VS - apply oxygen as needed, LOC Lung Sounds, Edema, Urine Output
    • Monitoring VS could help to prevent decompensation and cardiac arrest if caught early, but will also help to determine the patient’s response to treatment.

      Level of consciousness should be assessed because it may decrease as the patient loses oxygenation of their brain. Decreasing LOC is a sign of advancing shock.

      If a patient’s SpO2 falls below 92% (or prescribed threshold), apply supplemental oxygen via nasal cannula to improve overall oxygenation ability.
  3. Assess and manage pain
    • Patient may have severe chest pain because of myocardial ischemia. Pain should be assessed every 4 hours or more often as needed, and reassessed 30 minutes after administration of pain medication.
  4. Monitor Hemodynamics: MAP, CVP, CO, SVR, VO2
    • Hemodynamic measurements will tell us the severity of the shock and how well the patient is responding to treatment.

      MAP = Mean Arterial Pressure - this is the average pressure within the arteries. It can be calculated with a non-invasive blood pressure, but is more accurate when measured by an Arterial Line. Decompensated shock will show a decreasing MAP below 60 mmHg

      CVP = Central Venous Pressure. This measures Preload. In a patient with cardiogenic shock, it will be high (>12 mmHg). The goal would be to see this number return closer to normal, but ultimately the CO measurement is more important.

      CO = Cardiac Output. In cardiogenic shock, the overall CO takes the biggest hit. The body cannot compensate. The goal of therapy is to increase cardiac output, so it needs to be monitored closely. This is assessed using a FloTrac or Pulmonary Artery catheter.

      SVR = Systemic Vascular Resistance. This measures afterload. We will expect this to be high because of the body’s attempts to compensate through vasoconstriction. If treatment is effective, we will see this number return back down to normal. Dobutamine can also help to decrease this number through vasodilation.

      VO2 Oxygen consumption - the rate at which oxygen is taken up into the tissues. In cardiogenic shock, we will see this number decrease significantly because the tissues are not getting the oxygen they need. This is a classic sign of cardiogenic shock versus heart failure (normal VO2)
      (Marino, 2007)
  5. Calibrate all hemodynamic monitoring transducers: Level and Zero CVP and A-line to the phlebostatic axis
    • The phlebostatic axis is located at the 4th intercostal space, mid-axillary line and is the most accurate reference point for the right atrium. This is where a CVP is measured using a central line. It is also the most accurate reference point of the aorta for MAP measured by an arterial line.

      Levelling and zeroing ensures that the measurements are calibrated correctly so that readings are accurate.
  6. Prepare for procedures: Arterial Line or Central Line Placement, Gather all supplies, Ensure consent is obtained by provider, Explain procedure to patient/family, Prep fluids or tubing, Ensure all monitoring equipment is available Intubation Notify Respiratory Therapist and Charge Nurse for support, Suction and Ambu Bag at the bedside, Gather supplies, Ensure all monitoring equipment is available, Surgical Intervention, Follow facility procedures, Remove all personal clothes, jewelry, etc., Ensure informed consent is obtained by provider, Facilitate transport
    • Arterial lines are placed for invasive hemodynamic monitoring. They can measure MAP, but can also measure other hemodynamic values such as CO/CI, SVR, SV, etc. when using a FloTrac machine.

      Central lines are placed for administration of fluids and medications as well as hemodynamic monitoring of CVP, CO/CI, and SVR. Patients with cardiogenic shock may also receive a Pulmonary Artery catheter (also called a Swan-Ganz catheter) for more detailed invasive hemodynamic monitoring.

      Patients whose airway and/or ventilation has been compromised due to ↓ LOC or pulmonary edema may need to be intubated and placed on a ventilator.

      Patients may need to be taken to the OR to repair the injury or internal bleeding that caused the hypovolemia in the first place.

      **Informed consent MUST be obtained by the provider. You can explain procedures to patients/family, but the provider must give the reason, risks, benefits, etc. and obtain the informed consent.
  7. Maintain HOB >30°
    • Lowering the head of bed or laying the patient flat can be detrimental for two reasons:

      It brings blood towards the heart and baroreceptors, which will now believe that the problem has been fixed and will stop working to compensate. While lowering the head and raising the legs can be useful in the absence of other interventions, it should be avoided once more advanced therapies are available.

      The patient likely has pulmonary edema because of this acute cardiogenic shock. Laying them flat will compromise their oxygenation because of all the fluid in their lungs.
  8. Elevate legs on pillows Apply SCD’s SCD’s are contraindindicated if the patient already has a DVT
    • The goal with these interventions is to decrease peripheral edema in the patient’s legs and facilitate some venous return in order to prevent development of a DVT. DVT’s are the #1 cause of pulmonary embolism.
  9. Prepare for and manage Intra-Aortic Balloon Pump (IABP): Prep like any other procedure Leg used should be kept straight at all times, Patient on bedrest - reposition every 2 hours, Follow facility policy for documentation of pressures
    • This is an advanced technique that would be seen in a cardiovascular ICU. IABP is used to decrease the workload/afterload on the heart and assist with forward circulation. It is inserted via the femoral artery into the descending aorta. The balloon inflates during diastole to help with filling pressures and deflates with systole to help with forward pressure.

      Advanced cardiogenic shock may require LVAD or Transplant.

Pathophysiology

Cardiomyopathy is an abnormality of the cardiac muscle that leads to functional changes or impairment. There are three types: Dilated, Hypertrophic, and Restrictive.

Etiology

Cardiomyopathy is typically caused by prolonged, uncontrolled hypertension, congestive heart failure, or congenital diseases. In each case the heart is having to work extra hard – the ventricles begin to change shape (or remodel) in response to the extra work.

Desired Outcome

To control HTN and manage symptoms and prevent long-term complications of low cardiac output. The only “cure” is heart transplant.

Subjective and Objective Data

Subjective Data
  • Symptoms of Heart Failure
    • Fatigue
    • Chest Pain
    • Shortness of Breath
  • Dyspnea on exertion
Objective Data
  • Signs of Heart Failure
    • Extra Heart Sounds (S3, S4)
    • Poor peripheral perfusion
    • Dysrhythmias
    • JVD
    • Crackles in lungs
  • Enlarged heart on imaging
  • ↓ Stroke volume
  • ↓ CVP (preload)

Nursing Interventions and Rationales

  1. Monitor CV status & VS
    • Cardiomyopathy can mimic heart failure and is often caused by hypertension. It’s important to monitor the patient’s cardiovascular status and vital signs to be alert to any evidence of decompensation.
  2. Assess Oxygenation, Apply O2 as needed
    • Because cardiac output is compromised, oxygenation may be compromised as well due to poor perfusion and fluid backing up in the lungs. Assess SpO2 and give supplemental oxygen
  3. Administer antihypertensives
    • Controlling hypertension is important to control symptoms as well as to prevent any further damage to the heart muscle.

      Beta Blockers
      ↓ workload of heart

      ACE Inhibitors
      ↓ afterload

      ARBs
      ↓ afterload

      Diuretics
      ↓ preload
  4. Encourage rest and minimize stress
    • Because of the poor cardiac output, patients will be short of breath and easily fatigued. Encourage frequent rest periods and clustered activities.

      Minimizing stress can decrease blood pressure and workload on the heart, as well as decrease inflammatory chemicals within the heart muscle (↓ cortisol).
  5. Monitor for s/s heart failure
    • Cardiomyopathy can mimic heart failure. The patient may experience signs of poor perfusion such as weakness, pale, clammy skin, and diaphoresis, as well as shortness of breath and pink frothy sputum due to pulmonary edema.
  6. Educate patient on low-sodium diet (DASH diet)
    • A low sodium diet should be followed to help decrease hypertension and water retention (volume overload). This involves avoiding processed or canned foods, not adding salt to food, and avoiding sodas.

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

Cholecystitis is the inflammation of the gallbladder, which holds bile, a digestive juice, that is released into the small intestine. When the path (bile duct) between the gallbladder and small intestine is blocked, bile becomes trapped, builds up and causes inflammation. Surgical removal of the gallbladder is commonly required.

Etiology

The cause of obstruction of the bile duct may vary. The majority of cases are caused by gallstones (calculi) that get trapped in the bile duct. Biliary sludge is the mixture of bile, cholesterol and salt that can build up and form a blockage. Other obstructions may develop from infection, tumors, or edema from compression of the blood vessels.

Desired Outcome

Patient will be free of pain and resume and maintain optimal diet and nutrition.

Subjective and Objective Data

Subjective Data
  • Nausea
  • Loss of appetite
  • Severe abdominal pain, RUQ or center
Objective Data
  • Fever
  • Vomiting
  • Jaundice (severe cases)
  • Abnormal labs
  • Clay-colored stools

Nursing Interventions and Rationales

  1. Assess vital signs
    • Monitor for signs of cardiopulmonary stress and signs of infection
      Tachycardia
      Fever
  2. Assess Gastrointestinal status
    • Look- for distention

      Listen- for frequent belching

      Feel- for abdominal rigidity and palpable gallbladder, note tenderness
  3. Initiate IV access and administer fluids
    • IV access will be required for medication administration and for anesthesia if surgery or diagnostic procedures are being performed. Patient will need to be on bowel rest program and IV hydration is essential.
  4. Assess and manage pain
    • Severe pain is the most common and worrisome symptom. Patients may report pain that radiates from the RUQ to the back

      Administer medications

      Assist with positioning, place in semi-Fowler’s following meals to aid in digestion

      Promote bedrest for comfort
  5. Administer medications: Monitor for effectiveness, Monitor for side effects / adverse reactions
    • Antibiotics (levofloxacin, cephalosporins, metronidazole) - in cases of infection and for prophylaxis during surgery or procedures

      Antiemetics (ondansetron, promethazine) - to control nausea and prevent electrolyte imbalances

      Analgesics (oxycodone, acetaminophen)- to manage pain

      Cholecystokinin may be given to prevent gallbladder sludge in patients receiving TPN
  6. Monitor diagnostic testing: Labs, Imaging (Ultrasound, CT, MRI, x-rays)
    • Labs: labs may not always be reliable, but the following are often noted:
      AST/ALT - may be elevated due to liver dysfunction in cases of obstruction

      Elevated bilirubin may indicate common bile duct obstruction/liver dysfunction

      Urinalysis- can be used to rule out pyelonephritis and renal calculi as source of pain

      Pregnancy test should be done on all women of childbearing age to prevent fetal demise

      Imaging: Ultrasound is the diagnostic choice as it allows visualization of acute disease without excessive radiation exposure

      Ultrasound

      CT, MRI- may be done for more detailed evaluation or when ultrasound is inconclusive
  7. Prepare patient for diagnostic procedures: ERCP (Endoscopic Retrograde Cholangiopancreatography) - allows visualization of the biliary system to help diagnose and treat problems with the bile and pancreatic ducts. HIDA scan (Hepatobiliary Iminodiacetic Acid)- performed by injecting a radioactive dye into the bloodstream and visualizing the flow through a special camera placed on the abdomen
    • Place patient on clear liquids only for 6-12 hours prior to procedure

      Withhold NSAIDS and anticoagulants prior to procedure to avoid excess bleeding and interference with the test

      Assist patient with ambulation after the tests as medication (often morphine) given during the procedure may cause drowsiness
  8. Nutrition and Lifestyle education
    • Obesity is often related to gallbladder disease- encourage diet and exercise to control weight

      Avoid foods high in fat such as pork, gravies, fried foods, butter

      Avoid gas producing foods such as cabbage, beans, carbonated drinks

      Limit or avoid gastric irritants such as alcohol, coffee, tea, caffeine

Pathophysiology

Chronic kidney disease includes conditions that  damage the kidneys and decrease their ability to effectively filter waste products from the blood. Chronic kidney disease (CKD) develops slowly over time and often presents with no symptoms. Progressed kidney disease may lead to kidney failure which may require dialysis and lead to death.

Etiology

The two most common causes of CKD are uncontrolled hypertension and diabetes mellitus.  Long term elevated pressure of hypertension within the artery walls and damage to the blood vessels from excess glucose can reduce the blood flow to the kidneys causing improper filtration of waste. Prolonged obstruction, as with kidney stones, or recurrent urinary tract infections may also damage the kidneys and inhibit their ability to filter and remove waste products into the urine.

Desired Outcome

Maintain optimal control of blood pressure and blood glucose, avoid further progression of disease to cardiac involvement, maintain optimal fluid balance,  and prevent complications.

Subjective and Objective Data

Subjective Data
  • Loss of appetite
  • Nausea
  • Fatigue and weakness
  • Muscle twitches and cramps
  • Peripheral edema
  • Persistent itching
  • Urinary frequency, nocturia
  • Chest pain
  • Shortness of breath
Objective Data
  • Decreased mental agility
  • Swelling of feet and ankles
  • Weight gain
  • Poorly controlled hypertension
  • Elevated serum creatinine

Nursing Interventions and Rationales

  1. Monitor vitals
    • Maintain reasonable blood pressure to help protect the kidneys from further damage

      Tachycardia may indicate

      Fever may indicate infection and further disease progression
  2. Monitor and manage blood sugar
    • Keeping blood sugar in the optimal range if diabetic can help reduce the stress on the kidneys
  3. Assess cardiopulmonary system: Auscultate heart and lungs for abnormal sounds
    • Fluid retention from improper glomerular filtration may collect in the myocardium resulting in stress on the heart and in the lungs. Listen for friction rub and pulmonary crackles or congestion
  4. Monitor lab/diagnostic studies: Glomerular Filtration Rate (GFR) <60 indicates kidney disease, <15 indicates kidney failure, CT / Ultrasound Kidney biopsy (if necessary), Chest x-ray - if indicated
    • GFR- is a blood test that can show the degree of kidney function available. It is a calculation of creatinine levels, race, age, gender and other factors.

      Albumin- urine albumin test- healthy kidneys do not allow albumin into the urine. Albumin in the urine may indicate decreased kidney function.

      CT / Ultrasound- this imaging may be helpful to view the kidneys to determine if there are tumors or other unusual characteristics of the kidneys
  5. Evaluate mental status
    • Notice changes in mental status and confusion. Cerebral edema and stroke are possible complications.
  6. Monitor I & O
    • Monitor kidney function and calculate fluid retention.
      Daily weights at the same time each day on the same scale can also help determine amount of fluid being retained.

      Measure for decreased output <400 mL/24 hr period may be evidenced by dependent edema
  7. Insert indwelling catheter as appropriate
    • To help monitor fluid balance and characteristics of urine
  8. Palpate abdomen
    • To assess for fluid retention
  9. Restrict fluids
    • Closely monitor fluid intake to prevent overload and help reduce retention and promote emptying of the bladder.
  10. Nutrition education
    • A renal diet is low in protein and sodium. The kidneys are compromised and unable to remove the waste produced by processing proteins (BUN).

      Choose foods low in saturated and trans fat to prevent and lower fat deposits in the blood vessels.

      Choose lower potassium foods to avoid hyperkalemia caused by excess potassium retention.

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. Since the liver is responsible for making many of the chemicals required by the body to function, breaking down and detoxifying substances and storing vitamins and minerals, many of the body’s systems fail to function when the liver is damaged.

Etiology

Liver cirrhosis is primarily caused by diseases that damage the liver and leave scar tissue in place of healthy tissue. Alcoholic liver disease (26%) and Hepatitis C (21%) are the cause behind 47% of liver cirrhosis cases in the United States. Other factors such as nonalcoholic fatty liver disease, Hepatitis B and D, autoimmune disease and chronic heart failure with liver congestion may also result in cirrhosis.

Desired Outcome

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

Subjective and Objective Data

Subjective Data
  • Patient may not have symptoms
  • RUQ abdominal pain
  • Fatigue
  • Poor appetite
  • Nausea
  • Itchy skin
Objective Data
  • Bruising and bleeding easily
  • Confusion or memory loss
  • Dependent edema
  • Ascites
  • Jaundice
  • Dark colored urine
  • Spider-like blood vessels on the skin
  • Clay colored stool
  • Asterixis (flapping hand tremor)
  • Decreased reflexes
  • Anemia
  • Malaise
  • Hepatomegaly
  • Splenomegaly

Nursing Interventions and Rationales

  1. Complete vitals and respiratory assessment
    • Note impaired gas exchange and compromised respiratory function
      Assess for decreased or labored breathing
  2. Monitor fluid and electrolyte balance: Daily weights, Assess for JVD
    • Liver impairment may also affect renal function. Ascites and dependent edema may be indicators of hyponatremia.

      Increasing weight and blood pressure may indicate vascular congestion

      Decrease in weight and blood pressure may indicate effectiveness of interventions
  3. Initiate bleeding precautions per facility protocol: No straight razors, Use soft toothbrush and good oral hygiene, Use stool softeners to avoid straining with bowel movements
    • Coagulation chemicals such as prothrombin and fibrinogen. Damage to the liver may alter the production of these chemicals and increase risk of bleeding.
  4. Promote rest to conserve energy
    • Impaired liver function can cause the patient to be easily fatigued. Encourage rest periods and cluster care to conserve energy for nutrition and self-care.
  5. Assist with paracentesis as necessary
    • If ascites progresses, it may be necessary to perform paracentesis to drain the abdominal fluid. Assist with set-up and positioning of patient, post-procedure site assessments and monitoring.
  6. Administer medications appropriately: Diuretics, Lactulose, Analgesics, Blood products, Vitamin K
    • Diuretics- are often given to manage the accumulation of fluid and edema

      Lactulose- a man-made sugar that is given to help reduce the amount of ammonia in the blood and prevent hepatic encephalopathy

      Analgesics- given to manage pain; avoid acetaminophen

      Blood products- excessive bleeding and complications following surgery may require blood transfusions

      Vitamin K- helps to promote clotting and avoid complications from bleeding
  7. Provide adequate nutrition and education, encourage lifestyle changes
    • Malnutrition is often a complication of liver disease but may go unnoticed due to increase in weight. Encourage and education patient to maintain diet low in sodium and fat.
      Avoid alcohol, seek treatment for alcohol dependence.

Pathophysiology

Orofacial clefts, individually known as cleft lip and cleft palate, are the most common birth defects. These defects happen early in pregnancy when the lips and palate do not form properly. Cleft lip is characterized by a slit or opening that goes through the lip and into the nose on one or both sides of the lip. Cleft palate is an opening in the roof of the mouth, called the palate. Cleft lip and cleft palate may occur together or individually.

Etiology

During the early part of pregnancy, around week 7 or week 8, the tissues of the mouth and lips begin to form and join. Genetic and environmental factors are believed to be the cause of these tissues not joining correctly which leaves an opening in the lip or palate. Studies have shown that pregnant women who use certain medications to treat epilepsy and those who have diabetes or smoke are at increased risk of having a baby with orofacial clefts.

Desired Outcome

Patient will have normal breathing pattern; patient will have adequate nutrition; patient will have optimal hearing and speech

Subjective and Objective Data

Subjective Data
  • Difficulty feeding
  • Hearing loss
Objective Data
  • Cleft / opening in lip or palate
  • Aspiration of food/secretions
  • Frequent ear infections
  • Speech difficulty

Nursing Interventions and Rationales

  1. Assess infant’s respiratory status, including rate, depth and effort before and after surgery
    • Clefts can often cause aspiration of milk or secretions due to incomplete closure of palate or lip. This can cause infants to develop pneumonia and respiratory distress.
  2. Assess infant for skin color and capillary refill
    • Decreased oxygenation is often an issue with the defect due to possible aspiration. Assess for cyanosis and decreased tissue perfusion.
  3. Assess infant’s sucking ability; Provide special nipples and feeding devices with one-way valve
    • Depending on severity and location of cleft, infant may have difficulty sucking from a bottle.

      Special devices can help infant feed on formula or expressed breast milk with a reduced risk of aspiration and air intake
  4. Perform oral and nasal suction as necessary
    • To remove excess fluid or secretions and clear airway
  5. Monitor infant’s caloric intake and weight
    • Determine if feeding method is adequate or if other interventions should be initiated. Make sure patient is receiving adequate nutrition
  6. Prepare patient and family for surgery
    • Patient will likely need surgery to correct the defect. Prepare patient per facility protocol and help provide support for patient’s family
  7. Provide referral information for dental, speech and audiology consults
    • Patient may have frequent ear infections as a result of eustachian tube blockages that result in hearing loss, consult audiology.

      Difficulty with hearing can lead to speech delays, consult speech therapy.

      Dental issues are likely to arise from defect of palate and lip, consult dentist.
  8. Provide education and resource information for parents and caregivers
    • Provide demonstrations for cleaning suture site following surgery.

      Provide assistance with proper feeding, especially if using assistive feeding devices.

      Educate family regarding diet as child matures according to limitations

Pathophysiology

The heart fails to pump effectively, causing decreased perfusion forward of the failure and fluid back behind the failure. Heart failure can be left sided, right sided or both. When both sides are failing, it is called congestive heart failure (CHF). Heart failure is measured by ejection fraction. Normally functioning hearts have an ejection fraction of 55-75%. Anything less than 50% 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, valve disorders, 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
  • Heart palpitations or feeling like the heart is racing.
  • Weakness
  • Fatigue
  • Reports significant weight gain or loss
Objective Data
  • Peripheral edema
  • JVD
  • Crackles in the lung bases
  • Coughing
  • Pink, frothy sputum
  • SOB with exertion
  • ↓ SpO2
  • Tachycardia
  • Possible Atrial Fibrillation on ECG
  • ↓ LOC
  • Signs of decreased perfusion
    • ↓ pulses
    • Cool, clammy skin
    • Diaphoretic
    • Slow cap refill
    • Possible cyanosis or dusky skin

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.

      Patients may also have Atrial Fibrillation - a condition in which the atria quiver instead of contracting - this can lead to the development of heart failure.

      May also see signs of current or previous ischemia or infarction.
  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.

      300-600 mg of salt per serving.

      Avoid processed foods or lunch meats

      Do not add salt to meals

      Caution with salt substitute in renal insufficiency - it is made with potassium chloride and can raise the patient’s 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, Apply O2 as needed
    • 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 - usually above 92% or as ordered by the provider.
  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 an independent 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, too...

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

      Loop: works on the loop of henle and excretes Na+, K+, and Ca-. Water follows. (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 every 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 only 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.

      Strict I&O means measuring every drop that goes in or out of that patient.

      Teach patient to drink one cup at a time and to report how many they’ve had

      Put a hat in the toilet if the patient has bathroom privileges

      Be familiar with common beverage options and their volumes (juice, milk, coffee cup, etc.)
  7. Monitor swelling/edema
    • Edema is caused by volume overload due to congestion within the system. Worsening edema can indicate worsening heart failure.

      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).
      Non-pitting - doesn’t stay pitted

      +1: mild indent, 2mm

      +2: Moderate indent, 4mm

      +3: Deep indent, 6mm

      +4: Very deep indent, 8mm
  8. Daily Weights
    • Daily weights should be done at the same time of the day, same clothes (or none), same scale. A weight gain of 1 kg is equivalent to 1 L of fluid - notify HCP for gain of 2 lbs in a day or 5 lbs in a week.

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

Similar to Cushing’s syndrome which is much more common, Cushing’s disease is a condition where the pituitary gland secretes too much hormone (ACTH) causing an overproduction of cortisol (stress hormone). It causes weight gain around the trunk and waist with fat loss in the less and arms. Patients may also develop a hump on the upper back  that is caused by abnormal fat deposits. This disease weakens the immune system and can cause mood disorders such as anxiety and depression.

Etiology

Cushing’s disease is caused by a tumor or excess growth (hyperplasia) on the pituitary gland. Cushing’s syndrome is similar in its production of excess cortisol, but is usually a result of other disease processes.  As the pituitary secretes more hormone (ACTH), it stimulates the adrenal glands to produce more cortisol (stress hormone).  Cortisol controls blood sugar levels, how the body uses carbohydrates, fats and proteins and reduces the immune system’s response to inflammation, therefore making the patient more susceptible to infection.

Desired Outcome

Manage symptoms, maintain normal blood pressure and a blood glucose level within appropriate range

Subjective and Objective Data

Subjective Data
  • Back pain
  • Weakness
  • Irregular menstrual cycles
  • Shortness of breath
  • Poor concentration
Objective Data
  • Red, ruddy face
  • Upper body obesity with thinning arms and legs
  • Acne or skin infections
  • Hypertension
  • Uncontrolled diabetes
  • Tachycardia
  • Tachypnea

Nursing Interventions and Rationales

  1. Assess and monitor cardiac and respiratory status; perform 12-lead EKG to rule out cardiac involvement
    • Shifts in fluid balance and electrolytes may cause arrhythmias and difficulty breathing.
  2. Monitor fluid and electrolyte balance; I & O, fluid restrictions as necessary
    • Overproduction of cortisol causes the body to retain sodium and water which can cause cardiac stress and hypokalemia.
  3. Administer medications as appropriate to manage symptoms
    • Antihypertensives- monitor blood pressure closely as changes in cortisol levels may cause rapid changes in blood pressure

      Diuretics- to treat fluid retention and prevent excess strain on the heart
  4. Monitor vital signs for hypertension
    • Excess stress hormone (cortisol) causes an increase in blood pressure. Monitor closely and administer medications as necessary
  5. Manage blood glucose level
    • Excess cortisol can cause blood sugar to fluctuate. Monitor blood glucose levels regularly and notify MD if outside patient’s target area. Treat hypoglycemia with juice and crackers, but watch for rapid spikes afterwards.
      Treat hyperglycemia by having the patient drink water and notify MD if necessary.
  6. Promote rest
    • Long term stress and elevated cortisol levels can weaken the immune system and increase the risk of developing bacterial infections.
  7. Monitor for signs of infection: Fever, Wounds that are not healing, Changes in appetite or bowel habits, Nausea / vomiting
    • Cortisol suppresses the immune system and increases the risk of infection. Obvious signs of infection may be masked, so take note of subtle signs.
  8. Prepare patient for surgery to treat disease
    • Medication can help manage the symptoms, but there is currently no medication that can fully treat the disease. Surgery to remove the pituitary tumor(s) or adrenal glands is the most common treatment for the disease.
  9. Reduce risk of infections
    • Avoid unnecessary exposure to people with infections; stress the importance of good hand hygiene to patient and family members / caregivers
  10. Educate and encourage positive body image
    • Changes in the appearance can give the patient a negative self-image and lead to anxiety and depression. Reassure patient and educate them about the changes in fat distribution associated with the disease. Promote an atmosphere of acceptance and encourage the patient to verbalize feelings.
  11. Nutrition and lifestyle education: Quit smoking, Limit or avoid alcohol, Low sodium diet
    • Incorporate and educate patient about good dietary and lifestyle choices. Low sodium diet may be supplemented with high potassium foods and low protein to promote a stronger immune system. Encourage exercise as tolerable.

Pathophysiology

Cystic fibrosis (CF) is an autosomal recessive genetic disorder which causes abnormalities in the secretory glands that produce mucus and sweat and mostly affects the lungs, pancreas, liver, intestines and sex organs. The mucus that is produced in the body becomes thick and sticky. Instead of lubricating the lungs and other organs, it clogs the airways in the lungs and the ducts, most frequently in the pancreas and liver. Almost all males with CF are sterile and most females have a hard time getting pregnant. Symptoms can range from mild to severe. CF can lead to other diseases such as diabetes and osteoporosis. Screening for CF is routinely done on newborns and diagnosis is generally made before symptoms are evident, often within the first month of life.

Etiology

Cystic Fibrosis is caused by a recessive defect in the CFTR gene. The CFTR  gene makes a protein that regulates the movement of salt and water through the cells. The mutation causes the protein to either not work very well, or not be produced at all. When this happens, there is no regulation of salt and water across the cell membranes and mucus that the body produces becomes dehydrated and salty.  The hallmark sign for this disease is a salty taste to the skin.

Desired Outcome

Patient will maintain adequate ventilation and respiratory status; patient will have optimal nutritional status; patient will be free from infection.

Subjective and Objective Data

Subjective Data
  • Exercise intolerance
  • Nasal congestion
  • Constipation
  • Abdominal pain
Objective Data
  • Coughing, non-productive or with thick sputum
  • Meconium ileus
  • Failure to thrive
  • Salty taste to skin
  • Oily stools
  • Abdominal distention

Nursing Interventions and Rationales

  1. Assess respiratory status; note rate, rhythm and quality of breathing; auscultate lungs
    • CF patients get frequent respiratory infections because the thick mucus in the lungs traps bacteria and becomes infected.
  2. Review growth charts, assess changes or decrease in height or weight
    • Children may fail to thrive and lose weight or not grow properly because of malabsorption. The body does not absorb nutrients well enough to feed the cells adequately.
  3. Assess abdomen: Look for distention, Listen for active bowel sounds and gas pattern, Feel - palpate for mass or signs of constipation
    • Lack of water regulation in the cells prevents adequate lubrication in the colon and often results in constipation. Newborns may have a meconium ileus that prevents the infant from passing meconium stools.
  4. Insert and monitor nasogastric feeding tubes
    • Feeding tubes may be placed to help with nutrition and absorption.
  5. Monitor nutritional status: Caloric intake, Excessive thirst or hunger, Fiber intake Use of feeding tube
    • Children may have adequate diet, but the body cannot absorb the nutrients. A blockage of the pancreas prevents digestive juices from being released into the intestines which aids in absorption of nutrients.
  6. Monitor blood glucose
    • CF related diabetes is common due to the impairment of the pancreas
  7. Assess for signs of infection: Monitor temperature, Note cough with or without sputum, Obtain sputum culture and sensitivity
    • Lung infections are common in patients with CF. Culturing the sputum can help determine bacteria involved and course of treatment.

      Educate patients and caregivers that they should avoid sick contacts and stay away from other CF patients who may be ill, due to susceptibility to infections.
  8. Monitor for signs of dehydration and encourage fluid and salt intake
    • Patients with CF lose excess amounts of fluid and salt and can become dehydrated or develop hyponatremia quickly.
  9. Assess for bone malformation, deformity or fractures
    • Bones may become thin, patient develops osteoporosis or osteopenia in the later stages. Fractures are common.

      Note clubbing, or widening, around the tips of the fingers and toes due to poor oxygenation of tissues
  10. Administer medications and supplements appropriately
    • IV antibiotics may be given to treat infections.

      Antipyretics may be used to manage fever.

      Anti-inflammatories help to reduce swelling in the airways

      Inhaled steroids and bronchodilators may be used to decrease inflammation and open airways.
  11. Suction secretions as necessary per facility protocol
    • Thick mucus in the lungs and weakened muscles make it difficult for patients to expel secretions. Suctioning may be required.
  12. Perform chest physical therapy or vest therapy 2 - 4 times per day per facility protocol
    • This technique helps loosen mucus within the lungs making it easier to expel or suction
  13. Provide education for home treatment and resource information for patients and parents
    • Educate parents on how to spot signs of infection and when to seek medical help.

      Encourage nutrition with high fiber foods and adequate fluid intake to prevent constipation.

      Teach the importance of supplements to ensure adequate absorption of nutrients.

      Provide information for support groups and resources as available.

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

Diabetes insipidus refers to the condition where the kidneys are unable to retain water. Even though the patient may be dehydrated, the kidneys cannot balance the fluid and produce large amounts of insipid urine (dilute and odorless). The kidneys normally produce 1-2 quarts of urine per day, but with diabetes insipidus, they may produce 3 – 20 quarts per day. This results in the patient feeling very thirsty and have the urge to drink large amounts of liquid.

Etiology

The hypothalamus produces a hormone called vasopressin, an antidiuretic hormone (ADH) that tells the kidneys how much fluid to absorb from the bloodstream. This normally results in a lower amount of urine produced.  When there is damage to the hypothalamus (Central diabetes insipidus, or CDI) or the kidneys are not able to respond to the vasopressin (Nephrogenic diabetes insipidus or NDI), the kidneys do not know when to stop removing fluid from the body, even if the body is already dehydrated. This results in the patient feeling extremely thirsty, which prompts them to drink more fluids, and therefore, secrete more dilute urine.

Desired Outcome

Prevent dehydration, manage symptoms and prevent complications

Subjective and Objective Data

Subjective Data
  • Excessive thirst
  • Polyuria, excessive urination
  • Headache
  • Fatigue
  • Nausea
  • Dry mouth
  • Loss of appetite
  • Muscle cramps
  • Confusion
Objective Data
  • Dry mucous membranes
  • Tachycardia
  • Weight loss
  • Hypotension
  • Hypernatremia
  • Decreased skin elasticity

Nursing Interventions and Rationales

  1. Monitor I & O, daily weights, and polydipsia
    • Weight loss will occur with excessive fluid loss. Thirst can be an indicator of fluid balance.
  2. Monitor for signs / symptoms of hypovolemia
    • Excess fluid loss results in decreased circulatory volume. Early detection and intervention can prevent hypovolemic shock from occuring.
  3. Monitor for signs of hypotension and provide education and assistance with ambulation
    • Dehydration and hypernatremia can cause the blood pressure to drop which may result in dizziness or weakness with position changes. Assist patient when standing or walking to prevent falls and injury. Educate patient to make slow changes in position.
  4. Encourage hydration and provide easy access to fluids; administer IV fluids if necessary: Hypotonic- D5W or 0.45% sodium chloride, Isotonic - NS (0.9% sodium chloride) if hemodynamically unstable
    • If the patient has intact thirst, offer plenty of fluids to prevent dehydration. If the patient cannot orally tolerate fluids, initiate IV fluids.
  5. Monitor labs / electrolyte balance: Serum and urine osmolality, Serum and urine sodium levels, Serum potassium
    • Excess fluid loss results in the body excreting potassium and retaining sodium. This results in too much sodium and too little potassium in the blood.
  6. Administer medications appropriately: Chlorpropamide or carbamazepine - stimulates the release of vasopressin (ADH), Hydrochlorothiazide- may be used for nephrogenic DI, Aqueous vasopressin - used for short term DI, Pitressin tannate is a long-acting vasopressin
    • Depending on the type of diabetes insipidus, medications may be given to stimulate the production of vasopressin, or it may be given as a supplement. When giving medications, monitor for effectiveness and changes in blood pressure due to changes in fluid balance.
  7. Provide easy access to bathroom
    • Frequent urination can be frustrating for the patient. Provide easy access for voiding including urinal or bedside commode as appropriate.
  8. Prevent injury and initiate fall precautions
    • Frequent trips to the bathroom can increase the risk of falls. Provide assistance as needed with ambulation, especially if patient has confusion, muscle cramps or muscle weakness from electrolyte imbalance.
  9. Assess for skin integrity, apply skin barriers as needed
    • Polyuria may lead to bouts of incontinence and increase the risk of skin breakdown. Apply barriers and precautions as necessary to avoid redness or excoriation.

Pathophysiology

Diabetes Mellitus (DM) occurs when the body is unable to move glucose (sugar in the blood) into the cells to produce ATP (energy). Insulin is a hormone made by the pancreas that allows glucose to move across the cell wall. There are two types of diabetes mellitus, Type I and Type II.

Type I is an autoimmune disorder in which the immune system attacks the insulin-producing cells in the pancreas resulting in very little or no insulin being produced. This prevents the cells from receiving glucose and they begin to starve.

Type II is called insulin resistance diabetes because the cells no longer respond to insulin. Again, the glucose cannot enter the cells so it stays in the bloodstream and the cells starve.

Etiology

The cause of diabetes is not known, but it is believed to be genetic or triggered by a virus. Sugar intake does not cause diabetes, but many factors may increase the risk of developing the disease. Factors include autoimmune disease, high blood pressure, overweight and obesity, physical stress (such as injury or surgery), heavy alcohol use, smoking and a history of gestational diabetes.

Desired Outcome

Maintain blood glucose levels within normal limits and prevent complications and progression of disease

Subjective and Objective Data

Subjective Data
  • Increased thirst
  • Increased hunger (especially after eating)
  • Dry mouth
  • Frequent urination
  • Fatigue, weakness
  • Unexplained weight loss
  • Numbness or tingling of hands and feet
  • Dry, itchy skin
  • Blurred vision
  • Confusion
  • Headaches
  • Nightmares
Objective Data
  • Slow healing wounds
  • Hypoglycemia
  • Hyperglycemia
  • Sweaty
  • Tachycardia
  • Slurred speech

Nursing Interventions and Rationales

  1. Blood sugar monitoring Normal range 70-180 mg/dL (Patients may have different target blood sugar levels): Fasting - upon waking up, Before each meal, At bedtime
    • The physician will determine the target blood glucose range for each patient.

      Teach patient how to use glucometer and when to test blood sugar level.

      Encourage patient to contact physician if blood glucose readings are higher than their target or if they have two readings >300 mg/dL
  2. Monitor feet and educate patient of importance for foot monitoring. Encourage proper foot care.
    • Decreased blood flow to the feet and neuropathy cause a reduction in sensation.

      Because of decreased sensation and slow wound healing, injuries to the feet, even as small as a blister, may progress rapidly and become serious wounds.

      Encourage daily foot care to include cleaning and inspecting the feet for injuries and trimming toenails straight across.

      Encourage patient to routinely visit a podiatrist.
      Monitor existing wounds and provide wound care as necessary.
  3. Monitor vitals / blood pressure
    • Diabetic patients are at higher risk of hypertension. Vascular strain can affect vision, kidney function or lead to stroke and heart attack.
  4. Administer Insulin: Rapid Acting Humalog Novalog, Fast/Short Acting Regular Insulin, Intermediate Acting NPH Insulin, Long Acting Lantus Levemir Educate patient on how to self-administer insulin at home
    • Administer insulin per facility and provider guidelines. Make yourself familiar with the types of insulin and how they work. You should know the onset, peak and duration of each insulin.

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

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

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

      Long Acting:
      Onset: 1 - 4 hours
      Peak: 4 - 12 hours
      Duration: Up to 24 hours

      Educate patient to self-administer, cleaning the site with alcohol prior to inserting needle, rotating injection sites and angle of injection.
  5. Encourage annual diabetic retina exams by opthamologist
    • Vascular changes can lead to deterioration of the retina. Encourage patient to have a dilated retinal exam at least once per year by an opthamologist.
  6. Educate patient on how to handle blood glucose fluctuations: Hyperglycemia (Hot and dry, sugar high), Hypoglycemia (Cold and clammy, give candy)
    • Hyperglycemia: If the glucose reading is higher than the target range, encourage patient to increase water intake

      Hypoglycemia: If the glucose reading is below the target range (<70 mg/dL) and the patient is awake and able to eat or drink, give orange juice, crackers and peanut butter to raise the glucose level.
  7. Nutrition and Lifestyle Education: Exercise - increase circulation, lose weight, Diet - make healthy diet choices, Avoid smoking Limit or avoid alcohol
    • Educate the patient on how to count carbs and what foods / beverages are to be avoided.

      Encourage patient to consult dietitian for counseling and meal preparation ideas

      Educate patient on the glycemic index of foods and how to read nutrition labels.

Pathophysiology

Diabetic ketoacidosis is a serious complication of diabetes mellitus that occurs when uncontrolled blood sugar rises and the body can’t produce enough insulin to use the glucose. When this happens, the body begins to break down fat as energy which produces a build-up of acid in the bloodstream called ketones.  This is a serious life-threatening condition that occurs most often in Type I diabetics

Etiology

Ketoacidosis can occur when diabetic patients experience emotional or physical stress such as with bacterial infections (UTI, etc), prolonged vomiting, surgery or when they miss doses of insulin. Alcohol and drug abuse in a diabetic patient can also cause the body to produce ketones that poison the blood.

Desired Outcome

Maintain blood glucose level within the target range, maintain normal fluid balance

Subjective and Objective Data

Subjective Data
  • Excessive thirst
  • Nausea
  • Abdominal pain
  • Weakness / fatigue
  • Shortness of breath
  • Reports of:
    • Blurry vision
    • Excessive urination
Objective Data
  • Frequent urination
  • Vomiting
  • Fruity-scented breath
  • Confusion
  • Hyperglycemia, usually >400 mg/dL
  • High urine ketone levels
  • Kussmaul respirations
  • Metabolic Acidosis with elevated Anion Gap

Nursing Interventions and Rationales

  1. Monitor blood glucose levels and administer insulin as appropriate
    • Consistently high blood glucose levels, over 400 mg/dL, are the primary indicator of ketone production. Monitor glucose and intervene with prescribed insulin as appropriate to reduce glucose levels and prevent further ketone production.
  2. Monitor fluid and electrolyte balance to prevent dehydration and complications such as decreased sodium, potassium, calcium and magnesium
    • Excess blood glucose can cause nausea and vomiting resulting in electrolyte imbalances. These electrolyte deficiencies can lead to further complications and cardiac arrhythmias.
  3. Monitor for and treat signs / symptoms of infection
    • DKA is often the result of an underlying infection such as a common cold, flu or bacterial infection like pneumonia or urinary tract infections. Assess for fever and other symptoms of infection and administer antibiotics as necessary.
  4. Administer medications as appropriate: Insulin as necessary, Antibiotics, IV fluids, Electrolyte replacement, Antiemetics
    • Medications may be given to lower the blood glucose level in order to prevent further production of ketones or to manage symptoms of vomiting and underlying infection.
  5. Monitor vitals for signs / symptoms of hypovolemia
    • Vomiting and frequent urination can cause a deficiency in fluid volume, thus leading to a decreased circulatory volume. This will be evident by low blood pressure and tachycardia
  6. Prevent injury and falls; assist with ambulation
    • Fatigue and weakness are common due to the cells inability to use glucose to produce energy, also following vomiting, and in cases of dehydration.
  7. Nutrition and lifestyle education: Avoid alcohol / illicit drug use, Choose foods that are high in fiber and low in fats, sugars and simple carbs, Eat regular meals and snacks, don’t miss meals, Check for urine ketones when you have symptoms, Do not exercise when urine shows positive for ketones, Maintain compliance with medication and insulin therapy
    • Maintaining a high blood glucose level, missing doses of insulin or being sick can cause ketones to form in the blood. Educate patients on healthy diet and lifestyle to prevent DKA. Teach patients and caregivers of the warning signs / symptoms of DKA.

Pathophysiology

Diverticulosis: A benign condition where pouches form along the intestine wall. These pouches may form anywhere along the intestine, but are most commonly found at the end of the descending and sigmoid colons on the left side of the abdomen. They are also commonly found in the first section of the small intestine, but diverticula in this area rarely cause problems.

Diverticulitis: involves small abscesses or infection in one or more of the diverticula, or perforation of the bowel.

Etiology

Diverticulosis- The thickening of the outer wall of the intestine causes narrowing of the inner space. This narrowing causes stool to move more slowly. Hard stools, produced from a low fiber diet, and slower transit time through the intestine create pressure on the intestinal wall, thus forming pockets called diverticula. These pockets are most often asymptomatic.

Diverticulitis- Stool passing slowly through the intestine deposits fecal material in the diverticula. Over time, bacterial overgrowth causes an inflammatory response and may form an abscess or infection in the diverticula. Advanced diverticular disease can result in perforations of the intestine and peritonitis if infection is leaked through the perforations into the abdominal cavity.

Desired Outcome

Patient will be free from pain and infection and will be compliant with appropriate diet and medication regimen.

Subjective and Objective Data

Subjective Data
  • Severe abdominal pain / cramping in LLQ
  • Abdominal bloating
  • Nausea / vomiting
  • Constipation
  • Abdominal tenderness
Objective Data
  • Fever / chills
  • Vomiting
  • Leukocytosis
  • Guarding of abdomen
  • Evidence of diverticula on colonoscopy
  • Possible bloody stools

Nursing Interventions and Rationales

  1. Monitor vital signs
    • Fever / chills are signs of infection and possibly early peritonitis
  2. Provide Bowel Rest
    • Maintain NPO status during initial phase of antibiotic treatment to kill infection and help bowel rest

      As symptoms decrease, advance diet to clear liquids and then increase fiber slowly.
  3. Assess abdominal pain
    • Detailed abdominal assessments will indicate if inflammation or infection may be developing. For example, a rigid abdomen may indicate peritonitis.
  4. Monitor hydration status
    • Maintain optimal hydration for improved intestinal motility to prevent constipation
  5. Administer medications
    • Antibiotics - for infection

      Analgesics - for pain

      IV Fluids - for hydration and bowel motility

      Psyllium - (bulk-forming laxative) absorbs water from the intestine and makes stool easier to pass
  6. Provide nutrition education
    • Hydrate (2-3L fluids daily, unless contraindicated for renal or cardiac disease) to avoid constipation

      Probiotics - to help regulate the intestinal bacteria

      Avoid foods that trigger flare up (low-fiber foods)

Pathophysiology

Eczema is a chronic condition that causes inflammation of the skin. There are several types of eczema. The most common form is atopic dermatitis which can be triggered by foods, skin irritants, or environmental exposures. Eczema normally appears during infancy and often resolves by the teenage years. It most often affects the face, hands, feet, inner elbows and the back of the knees and causes an itchy rash to develop.

Etiology

While it is believed to be genetic, eczema is also more common among infants who are formula-fed or received solid foods prior to 6 months of age and those with a family history of asthma or allergies.  Atopic dermatitis, is thought to be due to a deficiency of a skin protein. Without this protein, the skin becomes more sensitive to environmental factors and irritants.

Desired Outcome

Patient will be free of rash and pain; patient’s skin will be free from excoriation and infection

Subjective and Objective Data

Subjective Data
  • Itching
  • Irritability
Objective Data
  • Rough, scaly patches of skin
  • Redness or blotchiness of skin
  • Fluid-filled blisters
  • Dry, cracked skin

Nursing Interventions and Rationales

  1. Assess patient’s skin, noting open areas, drainage, or signs of infection; observe for effectiveness of interventions
    • Bacterial skin infections are common due to excoriation from scratching. Crusting of broken blisters may be present.

      Routinely monitor skin to determine effectiveness of interventions.
  2. Obtain history from patient and parents/caregivers to determine triggers
    • Most flare-ups are related to sensitivities to foods, items that contact the skin, hygiene products, changes in weather and immune response.
  3. Encourage proper skin care including bathing and regular use of emollient creams (petroleum jelly, etc.)
    • Overwashing and using harsh soaps can make symptoms worse. Dry skin is prone to cracks and infection.

      Encourage fragrance and dye free soaps when bathing.

      Avoid frequent baths. Infants do not need daily baths unless visibly dirty.

      Apply emollient creams frequently to keep skin soft and hydrated.
  4. Assist with allergy testing, including patient/parent education
    • Allergy patch testing may be done to determine allergens and triggers for atopic dermatitis. Education should be provided on how to prepare for the patch test (no lotions, creams) and when to return to be evaluated.
  5. Apply topical medications and bandages as appropriate.
    • Topical corticosteroids are the first line of treatment for eczema flare ups.

      Wet-wrap bandages are sometimes used for more severe cases of childhood eczema, but must be done carefully to avoid serious side effects.
  6. Administer oral medications as required
    • Oral antihistamines may be given to help relieve symptoms of itching and manage allergies. Be mindful of sedative effects of antihistamines.

      Oral steroids may be given short-term for severe symptoms.
  7. Provide resources and referral information and education for prevention
    • Parents must be educated to be aware of triggers (often foods) and avoid them.

      Diligence must be given to ridding the home of other allergens such as pet dander and dust mites.
  8. Make sure child’s nails are short and clean; use mittens or socks on infants hands
    • Itching is the most prevalent symptom. Long, sharp or dirty nails can cause secondary infections to develop on the skin.

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

Endocarditis is inflammation of the lining and valves of the heart. It is often from an infectious source and can cause disorders of the valves and life threatening arrhythmias. Vegetations can form because of bacteria adhering to valves, which can then become embolic – causing heart attacks or strokes.

Etiology

The two most common causes are IV drug use (because of the introduction of bacteria into the vascular system) and artificial valve replacement (because the bacteria tend to adhere to the artificial device).

Desired Outcome

To treat the cause and remove the source of infection while preserving cardiac output and preventing any major (or minor) complications.

Subjective and Objective Data

Subjective Data
  • Chest Pain
  • Symptoms of Heart Failure
Objective Data
  • ↑ Temperature
  • ↑ WBC
  • Signs of Heart Failure
  • Heart murmurs
  • ↓ SpO2
  • Embolic complications
    • Splinter hemorrhages in nail beds
    • Janeway lesions on fingers, toes, nose
    • Clubbing of fingers

Nursing Interventions and Rationales

  1. Assess Heart Sounds
    • Patients with endocarditis may develop valve disorders - listen for heart murmurs or extra sounds.
  2. Assess and Address Oral Hygiene
    • There is a significant connection between oral health and pericarditis. Bacteria can travel to the heart easily from the oral cavity. Patients should brush their teeth twice daily to prevent complications.
  3. Administer IV Antibiotics
    • Endocarditis is almost always a bacterial source, therefore, IV antibiotics will be required to treat the infection. Be sure to obtain blood cultures prior to initiating antibiotics.
  4. Administer and Monitor Anticoagulant Therapy
    • The provider may order anticoagulant therapy to prevent further collection of platelets or clots around the valves and to prevent major complications from emboli.

      Depending on the medication, the therapy may require monitoring. For example IV Heparin requires PTT monitoring.
  5. Apply SCDs or TED hose
    • Patients are at risk for embolic complications. SCD’s or TED hose can help prevent DVT’s from developing. This can help to prevent pulmonary embolism.
  6. Assess for s/s emboli
    • The vegetation on the valves is at risk for breaking off and becoming lodged in smaller vessels. This includes risk for Stroke, MI, Pulmonary Embolism, but also damage to the smaller vessels in the extremities, hands, and feet.
  7. Educate patient on s/s infection
    • Endocarditis is an infectious process, therefore infection control is imperative. They need to be taught hand hygiene as well as other infection precautions. They should also be taught s/s of infection to report to their provider.
  8. Educate patient to inform other providers before procedures: May need prophylactic antibiotics, No dental procedures for at least 6 months
    • Because the patient is at high risk for recurrence and complications, it’s important that they notify other providers of their history of endocarditis. They may require prophylactic antibiotics prior to any invasive procedures and they should avoid dental procedures for at least 6 months after their hospitalization.

Pathophysiology

A fever is the rise in body temperature above what is considered a normal range. Most physicians consider a fever to be a temperature over 100° when taken orally, 99° when taken under the arm and over 100.4° when taken rectally. The purpose of a fever is to help the body fight off infection. Fevers can be mild and benign, but they can also alert to more serious disease. Not all fevers need treatment. It is recommended that, unless the child is visibly uncomfortable or in pain, fevers under 102° should not be treated.

Dehydration is an excessive loss of fluid from the body and is another common issue among children. Most children get enough water from eating and drinking, but fluid loss in a child can be dangerous, leading to brain damage or even death.

Etiology

The body’s temperature is controlled by the hypothalamus in the brain. When the body temperature rises, it is because the hypothalamus is resetting the temperature in response to some illness or infection. A higher temperature makes it more difficult for germs that cause infection to live. This is a normal defense system of the body and is not a disease in itself, but usually a symptom of some illness or infection. Alternatively, infants who are over bundled or in a very warm environment may develop a fever because the hypothalamus is not yet able to fully regulate temperature.

Dehydration occurs more often in infants and toddlers as they lose fluid much faster than older children and adults, and may occur from having an illness that causes vomiting or diarrhea or from fever. As the body temperature rises, the tissues use more water. If the child does not take in enough fluid when running a fever or with vomiting and diarrhea, they can dehydrate more quickly. Children who have other diseases such as diabetes may experience excessive urination that results in dehydration. In older children, sweating after play may contribute to fluid loss, but is not usually the only factor.

Desired Outcome

Patient will maintain optimal fluid balance; patient will exhibit vital signs within normal range; patient will be free from infection

Subjective and Objective Data

Subjective Data

Fever

  • Fussiness of infant or toddler or irritability
  • Lethargy
  • Changes in sleep habits
  • Decreased appetite
  • Headache
  • Body aches

Dehydration

  • Report of dry diapers or no urine output for 4-6 hours
  • Report of vomiting more than 24 hours
  • Lethargy
  • Irritability, fussiness (maybe inconsolable)
  • Abdominal pain
Objective Data

Fever

  • Feel hot to touch
  • Elevated temperature
  • Tachypnea

Dehydration

  • Fever
  • Sunken eyes
  • Dry mouth or no tears when crying
  • Vomiting
  • Sunken soft spot on head (infants)
  • Tachycardia
  • Tachypnea
  • Decreased urine output

Nursing Interventions and Rationales

  1. Assess vitals
    • Note presence of fever. Elevated heart rate and breathing may indicate fever or dehydration. Get baseline to determine if interventions are effective
  2. Assess skin for signs of dehydration
    • Skin may be dry, hot or flushed; note capillary refill and observe for dry mouth, cracked lips or crying without tears. Assess skin turgor for tenting.
  3. Obtain history from parent or caregiver to determine cause
    • The cause and time of onset of symptoms helps to determine the appropriate course of action.
  4. Monitor intake and output
    • Determine fluid balance; monitor for and measure vomiting or diarrhea; note amount and color of urine (darker with dehydration)
  5. Remove excess clothing or blankets, educate parents/caregivers
    • Infants are especially sensitive to over-bundling as they are unable to regulate temperature.

      Often when infants are ill, parents will bundle them up, but don’t realize they are making things worse.
  6. Encourage oral fluid intake; administer IV fluids if necessary
    • Oral fluid intake may be in the form of breastfeeding or bottle feeding in infants. Offer snacks and liquids frequently and monitor patient’s response, especially with vomiting and diarrhea.

      Children may be more responsive to frozen juice bars, ice pops or flavored gelatin. IV fluid replacement may be required if patient is resistant to or cannot tolerate oral intake.
  7. Apply cool compresses to patient’s forehead, hands and feet or place in tepid bath
    • Do not apply ice packs to skin, but cool moist cloths and tepid baths help reduce fever through evaporative cooling; monitor for shivering which may indicate cooling too quickly
  8. Administer medications as required
    • Anti-nausea medications may be given to children experiencing vomiting

      Antipyretic medications (acetaminophen) are often given to reduce fever

      Antibiotics may be given if fever is related to infection
  9. Provide education and counseling for patients, parents and caregivers
    • Help families understand treatment methods and ways to treat patient at home

      Provide demonstrations as necessary for accurate thermometer use and guidance regarding intake and output.

Pathophysiology

GERD is the return (reflux) of stomach acid and contents into the esophagus, past the Lower Esophageal Sphincter (LES) causing irritation and thinning of the lower esophagus.  Regurgitation often occurs without effort, such as when lying down or bending over. Frequent recurrences without treatment may lead to erosion of the mucus membranes of the lower esophagus.

Etiology

Weakness or incompetence of the LES may be related to excessive pressure being placed on the abdomen such as in the case of obesity or pregnancy. Certain medications such as calcium channel blockers, sedatives, antidepressants and antihistamines relax the smooth muscle of the LES, which weakens the ability of the sphincter to fully close, thus allowing food and digestive acids to enter the esophagus. Patients who smoke or have a hiatal hernia are at increased risk of developing GERD.

Desired Outcome

Eliminate pain of the esophagus and regurgitation while  maintaining normal function of lower esophageal sphincter and preservation of the esophageal tissue.

Subjective and Objective Data

Subjective Data
  • Burning sensation behind breastbone (heartburn)
  • Chest pain
  • Nausea, often with  vomiting
  • Dysphagia (difficulty swallowing)
Objective Data
  • Vomiting
  • Coughing
  • Wheezing
  • Weight loss
  • Erosion of tooth enamel

Nursing Interventions and Rationales

  1. Perform a detailed pain assessment (PQRST or OLDCARTS)
    • Pain may be associated with eating or lying flat. It is also typically burning. Getting details about the pain can help rule out possible cardiac etiology of chest pain
  2. Obtain 12-lead EKG
    • To rule out possible cardiac etiology of chest pain.
  3. Prepare for and assist with upper endoscopy
    • Endoscopy is a procedure that is done by a doctor using a scope that is placed orally to visualize the upper GI tract including the esophagus, stomach, and upper portion of the small intestine. Tissue samples may be taken during this procedure if necessary.

      Patients must be fasting, no food or drink for 4-8 hours prior to the procedure

      Administer conscious sedation

      Monitor vitals while patient is sedated per facility policy

      Assist with ambulation immediately following procedure until sedation is fully worn off

      NPO until gag reflex returns
  4. Education of Lifestyle changes
    • Encourage patients to stop smoking - nicotine relaxes the LES

      Maintain a healthy weight - obesity and belly fat create stress and pressure on the abdomen and stomach

      Avoid tight fitting clothes - clothes that are tight around the waist put extra pressure on the stomach and esophageal sphincter

      Elevate the head of the bed by 6-9 inches with risers, boards or blocks to allow gravity to help reduce reflux. Using pillows is not effective because it only raises the head and can become disarranged throughout the night
  5. Diet and nutrition education
    • Avoid highly acidic foods such as citrus, tomatoes and spicy foods

      Avoid carbonated beverages and alcohol that cause the stomach to expand and increase pressure on the LES

      Eat meals at least 2 hours prior to bedtime or lying down to allow the stomach to fully empty

      Avoid foods that trigger reflux such as fried foods, fatty foods, caffeine, garlic, onions and chocolate

      Encourage adequate hydration (drink water)
  6. Encourage good oral hygiene
    • Tooth enamel erosion often occurs in patients with severe vomiting due to GERD. Encourage patients to maintain good oral health to reduce the risk of infection and protect teeth
  7. Administer medications as ordered
    • Proton pump inhibitors- reduce the amount of acid produced in the stomach

      Antacids- are alkaline substances that counteract the acid in the stomach

      Antibiotic- Erythromycin can help empty the stomach

Pathophysiology

Gestational hypertension is having high blood pressure during the second half of pregnancy in women who have never had high blood pressure before. This is diagnosed when blood pressure exceeds 140/90. Gestational hypertension normally resolves within about 6 weeks after delivery.

Preeclampsia is high blood pressure during pregnancy that damages other organs, usually the kidneys and liver. Preeclampsia can be a serious complication and is often characterized by swelling of the face and hands and protein in the urine.

Eclampsia results when preeclampsia is left undiagnosed or treated and can be fatal. Eclampsia is diagnosed when patients with preeclampsia begin having seizures. These seizures can occur, even if the patient does not have a history of them.

Etiology

Gestational hypertension The cause is generally unknown, but is more common in patients who have kidney disease or diabetes prior to pregnancy, or those who have had gestational hypertension in previous pregnancies. Other risk factors include being pregnant with twins (or triplets), maternal age younger than 20 years old or older than 40 years old and being African American.

Preeclampsia– The blood vessels within the placenta do not develop properly and are narrower than normal. This extra pressure within the blood vessels puts stress on the maternal liver and kidneys.  Certain genetic factors, immune system response and damage to the blood vessels may contribute to this abnormal development. This complication can result in growth restriction of the fetus, placental abruption or even preterm birth.

Eclampsia  Eclampsia is basically severe preeclampsia that results in seizures. When preeclampsia becomes severe and is not treated, it can result in seizures and could be fatal to mother and fetus. This usually results in having to terminate the pregnancy and deliver the fetus, regardless of gestational age.

Desired Outcome

Patient will have controlled blood pressure at or below 140/90; patient will have optimal functioning of organ systems without chronic damage; patient will carry pregnancy to term

Subjective and Objective Data

Subjective Data
  • Headache
  • Vision changes
  • Nausea
  • Stomach pain (upper right side of abdomen)
Objective Data
  • BP over 140/90
  • Swelling of face, hands, feet
  • Sudden weight gain
  • Vomiting
  • Decreased urine output
  • Proteinuria

Nursing Interventions and Rationales

  1. Monitor vital signs, particularly blood pressure
    • Blood pressure may fluctuate and spike quickly; monitor for changes and elevations
  2. Assess for edema; note location and determine degree of pitting
    • Some swelling is normal in pregnancy, but pitting edema is different and can be a significant sign of decreased cardiac output.
  3. Weigh patient regularly
    • Sudden increase in weight indicates fluid retention and may signify progression of disease and impaired renal function
  4. Auscultate heart and lungs; note rate and rhythm; administer oxygen as necessary
    • Monitor for signs of fluid overload and pulmonary edema which puts strain on the cardiopulmonary system

      Listen for crackles and note presence of dyspnea

      Oxygen supplementation may be given to relieve dyspnea and improve maternal-fetal oxygenation and tissue perfusion
  5. Administer IV fluids and medications as appropriate
    • Antihypertensives(hydralazine) may help decrease diastolic pressure and increase blood flow to vital organs

      Antiepileptic drugs and magnesium sulfate for seizures
  6. Monitor fetal heart rate
    • Observe for signs and symptoms of fetal distress due to maternal blood pressure, decreased placental blood flow and lack of oxygenation
  7. Assess for vision disturbances and cognitive function
    • Preeclampsia may progress over time or suddenly to eclampsia and result in seizures.

      Note any changes in mentation or vision as an exacerbation of preeclampsia.
  8. Monitor labs and diagnostic test results
    • Observe for proteinuria, blood glucose level, elevated liver enzymes and decreased renal function.
  9. Provide nutrition and lifestyle education
    • Low sodium diet to help reduce edema

      Bedrest and elevation of the feet to reduce blood pressure

      Encourage patient to rest on left side to prevent compression of vena cava

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 common and painful form of arthritis that causes swollen, hot and stiff joints. When uric acid crystallizes, it settles into the joints and body tissues, most frequently affecting the big toe and, if not treated,  progresses to the ankles, heels, wrists and hands. This results in severe pain, stiffness and redness at the joint. Gout attacks often occur in the middle of the night when the joint is immobile. Once the initial pain has subsided, general discomfort of the area can last for several weeks.

Etiology

Excessive amounts of uric acid in the blood is the primary cause of gout. Other factors include genetics, dietary factors, use of diuretics and the inability of the kidneys to excrete uric acid. As the uric acid accumulates, crystals of monosodium urate form in the joints and tissues. 90% of cases are caused by the underexcretion of uric acid. Dietary factors as a cause for gout only comprise about 12% of cases, but changes to the diet help reduce the risk.

Desired Outcome

Relieve acute attack, prevent future attacks, promote optimal excretion of urates

Subjective and Objective Data

Subjective Data
  • Sudden pain in joints, often the big toe
  • Stiffness in joint
  • Tenderness of the joint
  • Limited range of motion
  • Itching
Objective Data
  • Tophi (nodules in skin)
  • Renal calculi
  • Joint inflammation
  • Joint edema
  • Erythema

Nursing Interventions and Rationales

  1. Assess and manage pain: Administer medications, Apply cool cloths as tolerable, Assist with positioning to avoid pressure on the affected joint
    • An acute attack can cause intense pain for the first 36 hours. Offer options to help manage pain.
  2. Assist with mobility
    • Due to pain and inflammation, patients may require assistance with mobility for safe ambulation and transfer.
  3. Monitor signs of joint inflammation
    • Evaluate erythema and joint edema to determine if interventions are effective at reducing inflammation.
  4. Administer medications: NSAIDS / Corticosteroids, Colchicine, Xanthine, Oxidase, Inhibitors (XOIs), Uricosurics
    • Medications can help relieve the immediate symptoms while others are for long term management and prevention of flare-up recurrence.

      NSAIDS and corticosteroids help reduce swelling and can relieve immediate pain

      Colchicine can be given for acute pain specific to gout attacks

      XOIs (allopurinol)- medications that block the production of uric acid and help prevent future attacks

      Uricosurics (probenecid)- help the kidneys more effectively excrete uric acid
  5. Promote hydration and increase fluid intake
    • Prevents dehydration and helps the kidneys excrete uric acid
  6. Assist with AROM or PROM
    • Prevents joint stiffness and increases mobility
  7. Nutrition Education: Limit or avoid animal proteins (liver, kidney, beef, lamb and pork), Limit intake of seafood, especially those high in purine such as shellfish, sardines and tuna, Avoid alcohol as it greatly increases the risk of gout attacks, Encourage foods that reduce the risk of attacks including: coffee, cherries and foods high in vitamin C, Limit or avoid foods/drinks sweetened with fructose
    • Dietary changes reduce the risk of recurrent gout attacks and lessen the severity of future attacks.

      Patients should avoid foods high in purines as these will cause a buildup of uric acid within the body.

Pathophysiology

Mitral Regurgitation – mitral valve cannot close completely, therefore blood back-flows into the LA

Mitral Stenosis – mitral valve cannot open fully or is narrowed, therefore blood can’t go into the LV

Aortic Regurgitation – aortic valve cannot close completely, therefore blood back-flows into the LV

Aortic Stenosis – aortic valve cannot open fully or is narrowed, therefore blood can’t get out of LV

When the blood can’t flow the direction it’s supposed to flow, cardiac output is compromised.

Etiology

The most common cause of valve disorders is rheumatic fever or endocarditis which cause damage, vegetation, or thickening and scarring of the heart valves. An acute, emergent situation could be caused by mitral valve prolapse or papillary muscle rupture.

Desired Outcome

Preserve cardiac output where possible, and proceed to valve repair or replacement if cardiac output is compromised. Prevent post-op complications from valve repair or replacement.

Subjective and Objective Data

Subjective Data

May be asymptomatic except heart murmur. If cardiac output is compromised, may see these symptoms:

  • Chest pain
  • Shortness of breath
  • Weakness
  • Fatigue
Objective Data
  • Heart Murmur
    • Systolic Murmur – Aortic Stenosis or Mitral Regurgitation
    • Diastolic Murmur – Aortic Regurgitation or Mitral Stenosis

May be asymptomatic except heart murmur. If cardiac output is compromised, may see these signs:

  • ↓ BP
  • ↑ HR
  • Skin – cool, diaphoretic, pale, dusky
  • Weak pulses
  • Slow cap refill

Nursing Interventions and Rationales

  1. Assess Heart Sounds To identify murmur: Is it an S1 or S2 murmur?, Which valve are you listening to?, What should the valve be doing at that time?
    • The easiest way for a nurse to determine the presence of a valve disorder is to listen for murmurs. A murmur indicates abnormal or turbulent blood flow through the valve.

      If the valve should be open, but doesn’t open fully - stenosis

      If the valve should be closed, but doesn’t close fully - regurgitation
  2. Assess and Monitor CV status: Pulses, Capillary refill, Skin color, temperature, Heart rate, Blood Pressure, Arrhythmias (ECG)
    • Valve disorders can compromise cardiac output. Assess cardiovascular status to determine if there is decreased perfusion to the tissues. If BP is dropping, HR may increase to compensate.
  3. Assess respiratory status: Lung sounds, SpO2, Shortness of Breath, Sputum
    • If blood is not going forward or backing up, it can cause pulmonary congestion leading to pulmonary edema. This would cause decreased SpO2, crackles in the lungs, and possibly even pink-frothy sputum
  4. Notify provider of new or sudden onset or murmurs, especially if accompanied by signs of poor perfusion or pulmonary edema
    • Papillary muscle rupture and mitral valve prolapse may occur suddenly. They are most often accompanied by chest pain, shortness of breath, or other signs of heart failure. This is an emergency that requires surgical intervention immediately. Don’t hesitate to call for help.
  5. Educate patient about post-op requirements after valve replacement surgery: Prophylactic antibiotics prior to any invasive procedures, Bleeding Precautions (anticoagulant therapy), Use soft bristle toothbrush, Maintain good oral hygiene, Avoid dental procedures for 6 months post-op
    • Patients who receive artificial valve replacements will require lifelong anticoagulant therapy. They need to be taught precautions for anticoagulant therapy, including using electric razors and soft bristle toothbrushes and how often they will require monitoring, if at all.

      Patients with artificial heart valves are at high risk of developing endocarditis. They need to be taught about preventative measures, including receiving prophylactic antibiotics prior to any invasive procedures.

      Oral hygiene is imperative to prevention of endocarditis after valve repair. This may seem silly but it is a HUGE deal. The evidence has shown that bacteria from the oral cavity are highly likely to translocate (move) to the heart and become lodged in/on the valves. This is also why patients should avoid dental procedures for 6 months after valve surgery. It is so important that you, as the nurse, educate them on why this is so important.

Pathophysiology

Hemophilia is a genetic bleeding disorder that is characterized by a deficiency of clotting protein. Patients with hemophilia experience longer bleeding time than others because their blood clots much slower. The amount of clotting protein available in the blood determines the severity of hemophilia and categorizes it into three levels: mild, moderate and severe. Complications of the disease include bleeding into the joints, hemorrhage into the central nervous system or vital organs, and aspiration from bleeding into the airways.

Etiology

Hemophilia is genetically (X) linked with females being the carriers, and males being affected by the disease. There are two types of hemophilia. Type A (classic) is caused by a deficiency of Factor VIII (8) clotting protein and is the most common, affecting 1 in every 10,000 males.  Type B (Christmas disease) is caused by a deficiency of Factor IX (9) and affects 1 in every 30,000 males.

Desired Outcome

Patient will be free from bleeding complications; patient will be educated on how to prevent injury and bleeding; patient will have optimal physical mobility

Subjective and Objective Data

Subjective Data
  • Irritability (infants)
  • Pain or tightness in the joints
  • Sleepiness or lethargy
  • Double vision
Objective Data
  • Large or deep bruises
  • Unexplained nosebleeds
  • Blood in urine or stool
  • Excessive bleeding from cuts or after dental work

Nursing Interventions and Rationales

  1. Assess patient for signs of bleeding; cuts, scrapes, bruises, swollen joints
    • Patients often experience deep bruising from minimal contact or minor injuries. The deep bruising may lead to bleeding into joint spaces and vital organs.
  2. Assess patient for evidence of pain (non-verbal cues)
    • Patients may report painful joints or aching muscles; younger children may not know how to express pain and exhibit symptoms through guarding or irritability and fussiness.
  3. Provide passive ROM exercises
    • This is not advised during acute phase or with active bleeding, but encouraged when patient’s condition is stable to maintain or improve joint and muscle mobility
  4. Provide assistive devices as required
    • Physical deformity of joints may occur due to bleeds into joint, which may cause limited mobility. Provide assistance and devices as necessary.
  5. Initiate bleeding precautions per facility protocol
    • Small and simple injuries may cause excessive bleeding. Client should avoid blade razors (use electric razors), use soft-bristle toothbrush, and avoid blowing nose during nosebleeds
  6. Monitor coagulation tests; hemoglobin and hematocrit levels
    • Monitor for effectiveness of interventions and therapeutic levels of medication and supplements

      Expect bleeding times to be reduced from the client’s baseline
  7. Anticipate need and administer blood products as required
    • Excessive blood loss may require transfusions; have O-neg blood immediately available in case of hemorrhage
  8. Avoid unnecessary invasive tests and techniques
    • Avoid heel or finger sticks and IM injections if possible

      Be prepared for excessive bleeding with administration of vaccines (opt for subcutaneous routes if available).

      Apply pressure to site for several minutes to allow time to clot
  9. Administer medications orally as available; administer replacement clotting factors as necessary
    • Replacement of clotting factors is the primary treatment for hemophilia; other supplements, antibodies and antifibrinolytics may be required
  10. Educate patient and caregivers on safety and prevention of injury
    • Prevention of injury is most important; patient should avoid physical contact sports and high risk activities; use soft toothbrush, give appropriate (not sharp-edged) toys, use helmets and padding for sports, supervise playtimes

Pathophysiology

The inflammation of the liver is called hepatitis and may be the result of lifestyle factors, chronic or autoimmune disorders or viral agents. Some forms of hepatitis are curable while other forms last a lifetime. Management and treatment of the disease depends on the causative factor.  The widespread inflammation results in degeneration and necrosis of the liver. 70% of hepatitis cases (B and C) progress to a chronic state, cirrhosis or become fatal.

Etiology

About half of all hepatitis cases are attributed to hepatitis viruses A, B and C. Chronic alcohol use, drugs and excessive use of some medications (acetaminophen, statins)  as well as infection such as Epstein-Barr (mononucleosis), can impair the liver’s ability to filter toxins, produce and store metabolic chemicals and store vitamins and minerals.

Desired Outcome

Minimize progressive degeneration and necrosis of the liver, improve healthy lifestyle habits, maintain optimal nutrition and functionality of liver

Subjective and Objective Data

Subjective Data
  • Loss of appetite
  • Fatigue
  • Muscle / joint aches
  • Nausea
  • RUQ abdominal pain
  • Itchy skin
Objective Data
  • Dark colored urine
  • Pale colored stools
  • Diarrhea
  • Jaundice
  • Vomiting
  • Fever

Nursing Interventions and Rationales

  1. Initiate bleeding precautions per facility protocol: No straight razors, Use soft toothbrush and good oral hygiene, Use stool softeners to avoid straining with bowel movements
    • Coagulation chemicals such as prothrombin and fibrinogen. Damage to the liver may alter the production of these chemicals and increase risk of bleeding.
  2. Monitor fluid and electrolyte balance: Monitor I & O, Daily weights, Assess skin turgor
    • Liver impairment may also affect renal function. Ascites and dependent edema may be indicators of hyponatremia. Diarrhea and vomiting may cause fluid imbalances.
  3. Provide routine oral care before meals with soft toothbrush
    • Bleeding gums and lack of oral hygiene can lead to infection and poor appetite. Provide oral care prior to meals to enhance flavor and encourage adequate nutrition.
  4. Encourage and assist with positioning
    • Recommend patient eat sitting upright to reduce abdominal fullness and encourage dietary intake.
  5. Administer medications appropriately and monitor for effectiveness and adverse reactions. Monitor lab values prior to administration.
    • Medications may be given to manage electrolytes, and symptoms of nausea or to assist with alcohol or drug detox.
      Avoid giving acetaminophen.
      Antiviral medications may be given to treat certain types of hepatitis.
  6. Provide and monitor supplemental feedings and TPN as necessary
    • In chronic disease it may be necessary to provide adequate nutrition and caloric intake
  7. Nutrition and Lifestyle education, prevention and protection: Avoid alcohol and illicit drugs, Avoid exposure to dirty needles, Avoid contact with bodily fluids such as semen, blood, stool and vomit, Encourage vaccines for high risk patients and their families
    • High risk behavior and lifestyle modifications may be necessary. Encourage patients to avoid alcohol and drug use and unprotected sex as viral hepatitis is easily transmitted.

      Provide nutrition education to promote low fat, low sugar diet. Wheat, gluten, dairy and artificial sweeteners are difficult for the liver to digest.

Pathophysiology

Bilirubin is the yellow pigment that is left over when red blood cells break down. The liver normally absorbs and processes bilirubin, but in the newborn there are not enough enzymes present yet for the liver to absorb and metabolize the bilirubin. Therefore, about the second to fourth day after birth, the skin and eyes become yellow-tinted. If the jaundice is not treated, high levels of bilirubin can lead to brain damage.

Etiology

In the newborn, the liver is not mature enough to have adequate levels of enzymes present to metabolize the bilirubin fast enough. Premature infants are at higher risk of jaundice as well as those who have had bruising during birth (as with forcep or vacuum assisted delivery), when there is a blood type difference between mother and baby, and in cases of neonatal sepsis. Breastfeeding infants will often develop jaundice as a result of dehydration or not enough calorie intake if they are having difficulty nursing.

Desired Outcome

Patient will have decreased yellowing of the skin and eyes; patient will have adequate nutritional intake; patient will have bilirubin level within normal range

Subjective and Objective Data

Subjective Data

Patient’s mother/caregiver reports:

  • Difficulty with breastfeeding
  • Loss of color in stools
  • Fussiness
Objective Data
  • Yellowing of the skin and/or eyes (sclera)
  • Greater than expected weight loss
  • High-pitched cries
  • Infant is difficult to awaken
  • Serum indirect bilirubin >5mg/dL

Nursing Interventions and Rationales

  1. Assess infant for skin abnormalities; note color (yellowing) of skin or eyes
    • Yellowing of the skin can be determined by lightly pressing on the skin of a baby’s forehead. This is the most common indicator of neonatal jaundice.
  2. Assess infant for neurological involvement
    • Infant will likely be very fussy when awake, and difficult to awaken from sleep. Many mothers inadvertently delay waking the baby to feed.

      More advanced stages include hyperreflexia (twitching, over-excitability, sensitive reflexes, and convulsions)
  3. Obtain history of pregnancy and delivery
    • A stressful delivery, including the use of assistive devices such as forceps or vacuum, can increase the risk of neonatal jaundice.

      Also, determine if there is any family medical history that could affect the infant like spleen and liver disease or hypothyroidism.
  4. Obtain serum or transcutaneous bilirubin level
    • Transcutaneous method is preferred due to non-invasive nature of test. Levels greater than 12 mg/dL usually require treatment;

      Serum bilirubin may be required and is obtained by heel stick per facility protocol.
  5. Observe breastfeeding and offer assistance to improve latch and encourage frequent feedings every 2 hours; supplement with formula as appropriate
    • Jaundice may be present in infants if they are having difficulty breastfeeding.

      Frequent feedings promote good hydration of the infant and increase milk supply in the mother.

      Breast milk may be insufficient; infant may require additional nutrients from formula
  6. Begin phototherapy per facility protocol
    • Baby will be placed under bili lights or blanket. Phototherapy helps improve the solubility of bilirubin for faster excretion through the stool and urine. This is non-invasive treatment.
  7. Monitor infants skin and eyes every 2 hours during phototherapy
    • To prevent damage to skin, cover infant’s genitalia and eyes during phototherapy

      Assess skin and eyes every two hours when patient is removed from lights for feedings.
  8. Monitor for increased temperature / fever
    • Patient may experience higher temperature with bili lights; note signs of fever that may indicate infection or sepsis
  9. Administer medication or blood transfusion as appropriate
    • Hyperbilirubinemia that is related to Rh incompatibility or severe anemia may require blood transfusions

      Medications (phenobarbital) may be given to stimulate liver enzymes to metabolize bilirubin
  10. Provide education for patient’s parents/caregivers regarding care for infant with jaundice
    • Discuss home management, return visits for evaluation and treatment, and possible long-term effects.

      Provide information for resources and referral for home therapy as needed.

Pathophysiology

Hyperemesis gravidarum is extreme morning sickness that causes long-lasting intense nausea, vomiting and weight loss. While many pregnant women experience morning sickness, hyperemesis gravidarum develops between the 4th – 6th weeks of pregnancy and may last longer than week 20.  Symptoms may be so severe that they interrupt the patient’s daily activities.

Etiology

While the exact cause is still unknown, many believe hyperemesis gravidarum is caused by a rapid rise in hormone (hCg) levels.  This condition may last several weeks or throughout the majority of the pregnancy. Complications that may arise from excessive vomiting include dehydration, renal impairment, malnutrition and electrolyte imbalance.

Desired Outcome

Reduce and manage symptoms of nausea and vomiting; maintain appropriate nutrition and hydration; avoid complications and injury to patient and fetus

Subjective and Objective Data

Subjective Data
  • Nausea
  • Dizziness
  • Weakness
  • Fatigue
  • Food/smell aversions
  • Headache
  • Confusion
Objective Data
  • Vomiting
  • Dehydration
  • Fainting
  • Jaundice
  • Hypotension
  • Tachycardia

Nursing Interventions and Rationales

  1. Assess vital signs: Heart rate, Blood pressure, Respirations
    • Note vital signs to get a baseline
  2. Assess for signs of dehydration: Dry mucous membranes, Skin tenting, Confusion
    • Fluid loss from vomiting and inability to tolerate oral fluids may result in dehydration.
  3. Monitor diagnostic labs BUN/creatinine Metabolic panel
    • Monitor labs to determine if patient has electrolyte imbalance or renal impairment from excessive vomiting.
  4. Administer medications and IV fluids
    • IV fluids will be necessary to help manage electrolyte balance and maintain adequate hydration.

      Medications may be administered to help relieve nausea.
  5. Monitor input and output
    • Monitor urine and emesis for blood; also note dark urine and decreased output that indicate renal function impairment
  6. Monitor weight
    • Patients often lose approx 5% of their weight. Monitor weight to ensure interventions are effective.
  7. Assess for and treat constipation as necessary
    • Decreased intestinal motility from dehydration can cause uncomfortable constipation.

      Encourage oral intake as tolerated to increase intestinal motility and relieve constipation.

      Administer stool softeners as appropriate.
  8. Promote bed rest
    • Patients are often weak and may become dizzy or lightheaded upon standing.

      Encourage patient to conserve energy with bed rest and assist with ambulation to prevent injury.
  9. Monitor nutrition status to prevent further weight loss: Encourage oral intake as tolerated, Provide frequent snacks, Insert and maintain nasogastric feeding as appropriate
    • Excessive vomiting and food/smell aversions make it difficult to maintain proper nutrition and tube feedings may be necessary to provide adequate nutrition for patient and fetus.
  10. Provide comfortable environment: Loose fitting garments, Decrease environmental stimulation (light/noise), Avoid foods or odors that trigger nausea
    • Avoid known triggers such as foods or smells. Take note of offending hygiene products and offer alternatives. Toothpaste is often a trigger.
  11. Promote safety: Emesis basin within easy reach, Clear access to toilet, Non-slip socks/shoes
    • Avoid accident or injury by providing a safe environment.

      Introducing IV fluids and medications may cause bowel or bladder urgency and result in incontinent episodes.

      Provide assistance and supplies as necessary to promote skin integrity and avoid falls.

Pathophysiology

HHNS occurs in Type 2 diabetics when the body is unable to excrete excess sugar in the blood. The blood becomes very concentrated (hyperosmolar), but does not produce ketones. Initially, it causes polyuria, frequent urination, but as it progresses, the urine becomes more concentrated and takes on a dark appearance and frequency is decreased. Dehydration often occurs and can lead to seizures, coma and death.  HHNS is a serious condition that generally affects the elderly population.

Etiology

Most commonly, HHNS is triggered by periods of illness such as a common cold or bacterial infection. The inflammation process raises blood glucose levels. When the glucose level stays elevated, often over 600 mg/dL, for extended periods of time, polyuria occurs as the body pulls water from inside the cells to try to rid itself of the extra glucose through the urine. As the urine is expelled and the cells dehydrate, electrolytes become imbalanced as sodium, potassium and chloride are lost. Since some insulin is present in Type 2 diabetes, ketones are not produced. Severe dehydration leads to extreme thirst, confusion, seizures, coma and death.

Desired Outcome

Maintain blood glucose levels within target range for patient, attain optimal hydration and fluid balance.

Subjective and Objective Data

Subjective Data
  • Extreme thirst
  • Drowsiness
  • Confusion
  • Loss of vision
  • Weakness on one side of the body
  • Hallucinations
Objective Data
  • Blood glucose level >600 mg/dL
  • Dry mucous membranes
  • Warm, dry skin that does not sweat
  • High fever

Nursing Interventions and Rationales

  1. Monitor blood glucose levels
    • The hallmark of HHNS is extremely elevated blood glucose levels >600 mg/dL
  2. Encourage optimal hydration and administer IV fluids (Normal Saline) to maintain fluid balance.
    • Excessive urination can cause dehydration. Encourage oral fluids as tolerated and administer IV fluids to re-establish tissue perfusion and maintain electrolyte balance.
  3. Insulin (Regular) infusion to reduce blood glucose level. Monitor for hypokalemia.
    • Monitor blood glucose levels and serum potassium. As insulin is administered, potassium is lost. Initiate potassium supplementation as necessary.
  4. Frequently assess level of consciousness and mentation
    • The brain is an insulin-dependent tissue. With elevated glucose levels, there is not enough insulin to normalize and the patient becomes confused, dizzy and may have changes in level of consciousness. Patients often experience drowsiness.
  5. Monitor for hyperthermia and treat with antipyretics (fever reducers), cool compresses and cooled IV fluids
    • Thermoregulation is impaired as urine production decreases; sweating decreases and electrolytes become imbalanced.
  6. Monitor vitals for hypotension and tachycardia
    • Most likely related to dehydration and hypovolemia. Patient is at risk for hypovolemic shock.

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

  • Headaches
  • Shortness of breath
  • Visual changes
  • Dizziness
  • Chest Pain/Angina
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.**

  • Epistaxis
  • Kidney failure
  • ↓ LOC
  • Evidence of Stroke

Nursing Interventions and Rationales

  1. Assess and monitor BP Use accurate size of blood pressure cuff: Width = 40% arm circumference, Length of bladder = 80% of arm circumference
    • You must know what the level is to know how to treat it.

      If we’re going to treat patients based on this number, it’s got to be accurate!

      If the cuff is too small, think about a tight pair of jeans and what that would do to the pressure - you’ll get a falsely elevated pressure.
      If the cuff is too large, it will be loose and you’ll get a false low blood pressure.

      The general rule is that the width should be about 40% of the arm circumference and the length of the bladder (that’s the part that actually inflates) should be about 80% of the arm circumference.

      A lot of blood pressure cuffs these days actually have indicators printed on them so you can make sure you’re using the right cuff - so always double check!
  2. Fluid restriction (if clinically appropriate)
    • More blood volume generally means a higher blood pressure, assuming the patient is not in heart failure. Offloading this fluid can help reduce preload and therefore reduce overall blood pressure.
  3. Perform a comprehensive cardiopulmonary assessment: Heart sounds, Lung sounds, Pulses, 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 symptoms.
  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

      Yoga

      Meditation

      Relaxation/Breathing Exercises
  6. Administer BP lowering agents at appropriate time. May need to adjust timing 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. It’s better to have consistent control throughout the day and night.

      You can speak with a pharmacist about optimal medication timing and notify the provider if you feel changes are needed.
  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. Assess and control pain
    • Pain will increase blood pressure. Control as much as possible and time appropriately with activity.

      Patient may also experience angina - be sure to do a full pain assessment and intervene as appropriate.
  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.

      Medication Instructions
      Continue meds even if you feel better

      Diet - DASH
      Low Sodium
      No processed/canned foods
      Limit caffeine/alcohol

      Lifestyle changes
      Exercise
      Smoking cessation
      Reduce weight

      Follow-Up
      Annual check-ups
      Cardiology visits
      At-Home BP monitoring

Pathophysiology

Impetigo is the most common bacterial skin infection in children. Impetigo is highly contagious and normally appears around the nose, mouth and extremities. It is characterized by blisters with yellow fluid that rupture and leave a honey-colored crust. Impetigo is spread through direct contact with sores and scratching may cause the lesions to spread.  The normal course of infection typically lasts 2-3 weeks without treatment. Systemic complications, including rheumatic fever and glomerulonephritis are rare, but can occur.

Etiology

Impetigo is caused by common bacteria, usually Group A beta-hemolytic streptococcus or Staphylococcus aureus that enters through breaks in the skin.  It often accompanies poor hygiene and is more prevalent in warm temperatures. The condition is considered contagious as long as lesions are present.

Desired Outcome

Patient will be free from infection and exhibit an absence of skin lesions; patient will not have systemic complications

Subjective and Objective Data

Subjective Data
  • Generalized weakness
  • Malaise
  • Itching
Objective Data
  • Multiple lesions or bullae around the mouth and nose or extremities
  • Honey-colored crust around lesions
  • Fever
  • Diarrhea

Nursing Interventions and Rationales

  1. Assess skin for lesions; note color and presence of crusting
    • Open sores or blisters may form around mouth and nose, but may also be located on trunk and extremities. Ruptured blisters and sores may have yellow crusting on or around the lesions.
  2. Assess vitals; note fever
    • Monitor for signs of systemic infection or complication
  3. Maintain contact precautions
    • Disease is spread through direct contact with lesions. Use PPE and sanitize equipment or tools (or use disposable equipment if available)
  4. Apply topical antibiotics with sterile, individual applicators
    • Topical antibiotics may be appropriate when a small area is affected. A 7 day course is generally required.

      Make sure to avoid contamination of container and other areas when applying topical treatments.
  5. Administer oral antibiotics
    • Oral antibiotics may provide better treatment of infection than topical treatments alone. There should be signs of improvement after 2-3 days of treatment.
  6. Make sure patient’s fingernails are trimmed and clean; use mittens or socks on the hands of infants as appropriate
    • Itching is a common symptom. Scratching lesions will cause the disease to spread to other parts of the body, or other people.
  7. Educate patient and caregivers about how to prevent the spread of disease to others
    • Infected child should use their own towels and linens which should be washed alone.

      Ensure good hand washing habits;
      Avoid contact with others who may have depressed immune system.

      Avoid outside play, high temperatures that will make the sores worse.

Pathophysiology

Increased pressure within the cranial cavity (or skull) is caused by an increase in the volume of either the brain tissue, blood, or cerebrospinal fluid, or by the presence of another space-occupying lesion. This increased pressure will compress the brain tissue, causing damage to the neurons and leading to neuro changes and eventually herniation and brain death.

Etiology

Anything that causes increased volume of brain tissue, blood, or cerebrospinal fluid within the skull – cerebral edema, hemorrhage, hydrocephalus, hypertension, cerebral vasodilation. Could also be caused by a space-occupying lesion such as a tumor or mass.

Desired Outcome

Minimize intracranial pressure to prevent any damage to nerve tissue and prevent long-term neurological deficits.

Subjective and Objective Data

Subjective Data
  • Confusion
  • Memory Loss
Objective Data
  • Altered LOC
  • Pupil changes
  • Babinski Reflex
  • Posturing
  • Seizures
  • Cushing’s Triad (impending herniation)
    • Abnormal Resps
    • Wide pulse pressure
    • Bradycardia
  • Elevated Temp

Nursing Interventions and Rationales

  1. Frequent neuro checks (q1h)
    • Neurological changes related to increasing ICP may be subtle or may occur rapidly. Frequent detailed neuro checks allow changes to be recognized quickly so that interventions can be initiated.
  2. Monitor Temperature and hemodynamics, including MAP and CPP
    • With a loss of autonomic regulation, a patient’s temperature could become very elevated (104°+).
      Monitor hemodynamics to assess for Cushing’s Triad and to evaluate Cerebral Perfusion Pressure (MAP - ICP).
  3. Avoid sedatives or CNS depressants if possible
    • These medications could alter our neuro checks, so we avoid them whenever possible in order to get an accurate neuro exam.
  4. Administer ordered medications: Osmotic Diuretics, Hypertonic Saline, Corticosteroids
    • Osmotic Diuretics (Mannitol) - decrease edema

      Hypertonic Saline (3% saline) - decrease edema

      Corticosteroids - decrease inflammation

      These medications help to decrease the circulating CSF volume as well as to decrease any cerebral edema. This decreases the pressure within the cranial cavity based on the Monro-Kellie Hypothesis.
  5. Prepare patient for surgical intervention: Craniectomy, External Ventricular Drain
    • A craniectomy is used to remove a portion of the skull (bone flap) in order to allow space for cerebral swelling.

      External Ventricular Drain (EVD) is a catheter placed into the ventricle to drain blood or CSF in the event of an elevated ICP.
  6. Level and Zero EVD to tragus (external auditory meatus). Maintain open per orders (i.e. open at 10 cm H2O)
    • EVD should be leveled to the tragus to be approximately in line with the 4th ventricle in the brain. 10 cmH2O correlates to approximately 7-8 mmHg ICP - therefore any increase in the ICP above 7-8 would cause CSF to drain. If the EVD is not leveled appropriately, too much or too little CSF could drain. Too little drainage could cause increased ICP and possible brain herniation.
  7. Monitor Electrolytes and Urine Output
    • If the patient is on mannitol or hypertonic saline, this could cause fluctuations in sodium levels, which could lead to seizures.

      Urine output should be monitored to ensure diuresis with mannitol, but also to monitor for the possible development of diabetes insipidus.
  8. Perform interventions to minimize ICP: Maintain HOB 30-45°, Decrease stimuli, Avoid valsalva maneuvers
    • Maintain HOB 30-45°

      HOB < 30 = increased blood flow to brain → Increased ICP

      HOB > 45 = increased intrathoracic pressure → decreased venous outflow from brain → increased ICP


      Decrease stimuli

      Agitation or stress can cause increased ICP

      Avoid valsalva maneuvers

      Coughing or bearing down can cause increased ICP

Pathophysiology

Leukemia is cancer of the blood forming tissues and usually involves the white blood cells. The bone marrow produces abnormal white blood cells that do not function properly. The life cycle of the white blood cells is changed and the cells do not die when they should, thus accumulating and taking up space. They eventually crowd out the good cells which impairs the growth and function of healthy cells.  There are many types of leukemia. Some types can be cured while others cannot. Treatment is highly dependent upon the type of leukemia

Etiology

Scientists don’t fully know the exact etiology of leukemia , but believe that it may come from a combination of genetic and environmental factors.  Genetics, radiation or chemical exposure, viruses (HIV), previous chemotherapy, and those with Down Syndrome appear to have a higher incidence of leukemia.

Desired Outcome

Minimize complications and resolve if possible. Maximize the normal blood cells and minimize the abnormal cells.

Subjective and Objective Data

Subjective Data
  • Loss of appetite, weight loss
  • Tendency to bruise or bleed
  • Fatigue, weakness
  • Bone pain
Objective Data
  • Frequent infections
  • Fever
  • Swollen lymph nodes
  • Enlarged liver / spleen
  • Petechiae
  • Recurrent nosebleeds
  • Prolonged clotting factors
  • Elevated WBC
  • Pallor

Nursing Interventions and Rationales

  1. Initiate bleeding precautions
    • Clotting factors are impaired and patients are at a higher risk of bleeding and bruising
  2. Assess and manage pain appropriately: Massage, Positioning, Cool/heat therapy, Aromatherapy, Guided imagery, Medications as necessary
    • Pain can be difficult to control and manage and medications may be scheduled with PRN measures for breakthrough pain. Make sure the intervention is appropriate for the patient and avoid extra stressors such as movement. Encourage patient to try non-pharmacological interventions and balance those with medication for more comprehensive pain control.
  3. Monitor for signs / symptoms of infection or sepsis
    • Especially during treatment, patients are at higher risk of developing sepsis. Monitor closing for signs and symptoms and notify MD as necessary.
  4. Promote normothermia
    • Progressive hyperthermia may occur as the body’s response to disease and effects of treatment. Monitor temperature closely, especially during chemotherapy.
  5. Anticipate needs
    • Time pain and nausea medications at their peak according to therapy, chemo and meal times to increase their effectiveness
  6. Monitor Intake & Output and signs/symptoms of dehydration: Skin turgor Dry mucous membranes, Capillary refill
    • Dehydration and kidney compromise is a potential complication of disease and treatment. Encourage hydration and monitor closely.
  7. Patient and family education: Symptoms and disease process, Infection prevention, Plan of care
    • Patients and family members must be knowledgeable of process and what to expect to help reduce anxiety and be prepared for complications as they arise. Educate family members and caregivers of the importance to help reduce risk of infection for the patient by practicing good hand hygiene.
  8. Avoid risk of infection from procedures: Foley catheter insertion, Injections, Lines and tubes
    • Lack of sufficient white blood cells damages the immune system and patients are more prone to infections. Weight risk versus benefit.
  9. Promote self care, independence and ADLs
    • Fatigue is a common symptom and can prevent the patient from participating in self care. Provide assistance with ADLs as needed and cluster care to reduce fatigue and promote rest. Prioritize activities to help conserve energy for self care.

Pathophysiology

Lymphoma refers to cancer of the lymphatic system. This system includes the lymph nodes (glands located throughout the body), spleen, thymus gland and bone marrow. There are two main types of lymphoma: Hodgkin’s and Non-Hodgkin’s lymphoma, and they are classified as such depending on the type of cell involved.  Treatment depends on the type and severity. Lymphoma is characterized by painless, swollen lymph nodes.

Etiology

Lymphoma begins when a disease-fighting white blood cell (lymphocyte) develops a genetic mutation. Doctors are still unclear as to what causes this change, but have found that the mutation causes the cells to multiply rapidly and go on living when normal cells would die. The accumulation of these diseased lymphocytes causes swelling of the lymph nodes.  Certain risk factors increase the chance of developing lymphoma, including being male, over 55, having an impaired immune system or taking immunosuppressants, and certain infections such as Epstein-Barr virus and Helicobacter pylori.

Desired Outcome

Maintain adequate ventilation, prevent infection, manage pain and symptoms of side effects related to treatments

Subjective and Objective Data

Subjective Data
  • Persistent Fatigue
  • Shortness of breath
  • Cough
  • Itching
  • Night sweats
  • Lack of appetite
Objective Data
  • Swollen, painless lymph glands / nodes
  • Fever, without infection
  • Weight loss

*Symptoms are not always present*

Nursing Interventions and Rationales

  1. Monitor respiratory status and provide supplemental oxygen as necessary.
    • If lymph nodes of the neck and chest are involved, patient may experience shortness of breath, dyspnea and airway obstruction due to obstruction of the trachea or superior vena cava.
  2. Note changes to the skin color; pallor or cyanosis
    • As the WBCs multiply rapidly, it can reduce the oxygen carrying capacity of the red blood cells, resulting in hypoxemia.
  3. Observe for neck vein distention, headache, dizziness, facial edema, dyspnea and stridor
    • Lymphoma patients are at higher risk for vena cava syndrome in which the superior vena cava is obstructed from enlarged lymph nodes. This constitutes a life-threatening emergency and MD should be notified. Emergency radiation treatment may be ordered.
  4. Assess and manage pain; teach relaxation techniques, administer analgesics as necessary
    • While the enlarged lymph nodes are usually painless, patients may experience pain with radiation or chemotherapy treatments. Management of pain and reduction of stress is essential to patients to promote healing and conserve energy.
  5. Nutrition education; monitor daily weight and caloric intake; encourage patients to eat small frequent meals and increase protein intake.
    • Patients may experience lack of appetite and diminished nutrition. Increasing caloric intake promotes healing, provides fuel for energy and prevents gastric distention. Offer more palatable options frequently.
  6. Provide supportive comfort measures following radiation or chemotherapy treatments.
    • Patients often experience extreme fatigue, nausea and vomiting following treatment. Assist with ADLs, offer ice chips and antiemetics as appropriate for nausea.
  7. Assist with positioning and monitor for skin breakdown
    • Fatigue and impaired nutrition cause muscle weakness. Assist patients to positions of comfort for optimal air exchange and monitor skin for signs of breakdown due to prolonged bed rest.

Pathophysiology

The meninges surround both the brain and the spinal cord to provide cushion and protection as well as create cerebrospinal fluid.  In meningitis, these meninges get infected and inflamed, causing symptoms that range from altered level of consciousness (due to inflammation in the brain) to nuchal rigidity or numbness & tingling (because of the effect on the spinal cord).

Etiology

Meningitis can be caused by bacteria or viruses, which can be introduced via the bloodstream as well as through invasive procedures or fractures of the skull.  Transmission is via droplets and usually occurs in areas of population density or crowded living spaces such as college dorms, prisons, and homeless shelters.

Desired Outcome

Treat the underlying infection, decrease inflammation and swelling in the brain, and prevent long-term neurological deficits.

Subjective and Objective Data

Subjective Data
  • Confusion
  • Lethargy
  • Photophobia
  • Headache
Objective Data
  • Fever
  • Increased ICP
  • Seizures
  • Nuchal rigidity

Nursing Interventions and Rationales

  1. Place patient in droplet isolation
    • Meningitis is spread via droplets, therefore a mask, gown, and gloves should be worn at all times and all surfaces should be cleaned thoroughly
  2. Administer analgesics and/or anti-inflammatories
    • To alleviate headache or nuchal rigidity caused by inflammation.
  3. Administer antimicrobials
    • Many antibiotics cannot cross the blood brain barrier, but will be given to treat any bloodstream infection. Antivirals can be given as well.
  4. Assess LOC and neuro status q2-4 hours
    • Inflammation of the meninges can cause irritation of the brain tissue and swelling, which can cause decreased LOC.
  5. Monitor ICP and CPP if available
    • If there is enough hydrocephalus or edema, providers may place an EVD for ICP monitoring. If so, monitor ICP and CPP hourly and manage EVD.
  6. Initiate seizure precautions
    • Inflammation of the meninges can cause irritation of the nerves and brain tissue, leading to development of seizures.
  7. Educate patient and family on infection control measures and s/s to report to provider
    • Handwashing is imperative, considering droplet transmission. Family members should also wash their hands on the way in and out of the room. Patients should report any s/s infection

Pathophysiology

Mood disorders are a category of mental illnesses that affect a person’s emotional state over a long period of time. Emotions, or moods, may fluctuate frequently and seemingly without any reason. The most common of these are Major Depressive Disorder and Bipolar Disorder.  Depression may be a common feature of other mental illnesses, but can occur independently as well. Clients with mood disorders are at higher risk for substance abuse and suicidal tendencies. Research has shown that there is a high incidence of depression among clients that also have chronic medical conditions such as heart disease, cancer, Alzheimer’s disease and hypertension. Treatment is geared toward managing symptoms through the use of medications and psychotherapy.

Etiology

Diagnostic Criteria:

Diagnoses do not include symptoms related to other medical conditions or substance use, does not meet the criteria for another mental illness or psychotic disorder.

Major Depressive Disorder (MDD):  

  • Five or more of the following new symptoms present in the same 2-week period.
    • Depressed mood, most days
    • Loss of interest or pleasure in most activities
    • Significant weight loss or weight gain
    • Insomnia or hypersomnia, most days
    • Slow or aggravated psychomotor function
    • Fatigue or loss of energy, most days
    • Feelings of worthlessness or inappropriate guilt, most days
    • Inability to think or concentrate, indecisiveness, most days
    • Recurrent thoughts of death, without a specific plan or attempt
  • Symptoms significantly affect social or occupational functioning
  • Never had a manic or hypomanic episode

Bipolar Disorder (BPD):

  • One or more manic episodes; or one hypomanic and one major depressive episode
  • Distinct period of abnormally elevated mood lasting more than 1 week
  • More than 3 of the following occur during mood disturbance
    • Inflated self-esteem
    • Decreased need for sleep
    • Racing thoughts
    • Easily distracted
    • Increased activity
    • Excess risky or pleasurable activity

Desired Outcome

Client will remain safe. Client will not cause harm to self or others. Client will demonstrate coping techniques. Client will identify appropriate actions for managing emotions.

Subjective and Objective Data

Subjective Data
  • Prolonged sadness
  • Change in appetite
  • Change in sleep patterns
  • Irritability
  • Feelings of guilt
  • Inability to concentrate
  • Inability to feel pleasure in former interests
  • Suicidal ideations
  • Grandiose delusions
  • Unexplained aches and pains
  • Increased fatigue (MDD)
  • Decreased need for rest (BPD)
  • Significant mood swings
Objective Data
  • Pessimism
  • Reckless behavior
  • Easily distracted
  • Racing speech
  • Tearfulness
  • Restlessness

Nursing Interventions and Rationales

  1. Assess for level of suicide precautions necessary: Verbalizes desire to commit suicide, Has a suicide plan, Previous / recent suicide attempts
    • Determine if client is an active risk to self or others and what safety precautions need to be initiated. Always ask if there is a specific plan.
  2. Initiate suicide precautions as necessary per facility protocol: Do not leave client unattended, Remove unnecessary items from room that may be used as a weapon (sharp instruments, belts, etc.)
    • Provide for the safety of client and others. Follow your facility’s specific protocol regarding supervision and documentation.
  3. Implement a written “no-suicide” contract with client
    • Clients who agree to a written contract are often less likely to carry out a suicide plan. It shows the client that they have value.
  4. Obtain history from client or family members regarding any current or a history of substance abuse. Labs may be necessary.
    • Determine if client’s symptoms are caused by or exacerbated by use of drugs or alcohol.
  5. Remove client valuables and send home with trusted family member or lock in facility safe.
    • Clients experiencing suicidal behaviors or manic episodes may give away valuables or money indiscriminately and may become victims of theft.
  6. Encourage client to talk about feelings and emotions
    • Helps client verbalize and identify the cause of their actions. Builds trust and rapport.
  7. Provide activities that do not require concentration or competition (drawing, walking, exercise, music, etc.)
    • Clients who are depressed have difficulty concentrating. Allows client time to calm down. Competition (games) can cause aggression - no card games except solitaire.
  8. Provide calm, relaxing environment
    • Overstimulation during manic episodes may cause an exacerbation of symptoms
  9. Teach client visualization techniques that replace negative images with positive images
    • Help improve client’s self-image and confidence
  10. Minimize environmental stimuli: Close blinds/curtains, Keep door closed to reduce noise, Limit visitors, Cluster care
    • Reduce chance of overstimulation to minimize aggression or agitation.
  11. Observe for destructive or manipulative behaviors
    • Clients experiencing mania often have poor impulse control and may become hostile.
  12. Offer and arrange religious counseling as appropriate per client preference and facility protocol
    • Religious services may be offered, but are not required. Clients often have deep cultural or religious views and may benefit from these services.
  13. Encourage bedtime routine that may include warm bath, soothing music and lack of stimulation. Avoid caffeine.
    • Promote healthy sleep hygiene and encourages rest and relaxation which can decrease mania and improve mood.
  14. Assist with ADLs by giving short, one-step instructions
    • Promotes independence while minimizing the stress of complex instructions. Clients often have difficulty concentrating, so using one-step directions is important.
  15. Administer medications appropriately
    • Antidepressants and antimanic medications may be given to improve client functioning and effectiveness of interventions.

      Antidepressants - SSRI’s, SNRI’s, MAOI’s, TCA’s

      Anti-manic - Haloperidol, Benzodiazepines, Lithium

Pathophysiology

Chronic, progressive disorder characterized by decreased acetylcholine activity in the synapses. This is due to insufficient acetylcholine secretion and excessive secretion of cholinesterase, the enzyme that inactivates acetylcholine. This causes a decrease in effective transmission of nerve impulses in the muscles, causing weakness and fatigue, especially in respiratory muscles.

Etiology

MG is an autoimmune disorder which is often exacerbated by precipitating factors known as triggers. This includes stress, infection, hormone disturbances, trauma, and extreme temperatures.

Desired Outcome

Preserve functional ability, protect airway, and prevent complications such as myasthenic crisis or cholinergic crisis.

Subjective and Objective Data

Subjective Data
  • Double vision
  • Weakness/fatigue
  • Dysphagia
  • Dyspnea

Cholinergic Crisis

  • Muscle cramps
  • Nausea

Myasthenic Crisis

  • Sudden, severe weakness
Objective Data
  • Ptosis (drooping eyelid)
  • Tachypnea
  • Abnormal ABG
  • Diminished breath sounds or crackles due to atelectasis

Cholinergic Crisis

  • Vomiting, diarrhea
  • Bradycardia
  • Bronchial spasm
  • Hypotension

Myasthenic Crisis

  • Increased HR, RR, BP
  • Hypoxia and cyanosis
  • Bowel and Bladder incontinence

Nursing Interventions and Rationales

  1. Administer cholinesterase inhibitors (Physostigmine) and ensure proper dosing/timing
    • The goal is to have a net increase of acetylcholine activity at the nerve synapses. This should help improve the conduction of impulses within the muscles.
  2. Monitor respiratory status
    • Patients are at high risk for respiratory distress due to muscle weakness and dysphagia (aspiration)
  3. Provide eye care
    • Ptosis and weakness of eye muscles can cause dryness and irritation of the eyes. Provide eye drops or an eye patch as appropriate.
  4. Monitor feeding and ensure proper nutrition. Schedule meds 30-45 minutes before meals
    • Weakness and dysphagia make preparing and eating meals more and more difficult as the disease progresses. Scheduling meds 30-45 minutes before meals helps to minimize their symptoms as much as possible during meal times.
  5. Maintain suction and emergency equipment.
    • Because of risk of respiratory depression - this is especially important to have at the bedside when administering a Tensilon test because it can send the patient into V-Fib or cardiac arrest, or can make cholinergic crisis worse, leading to respiratory distress or respiratory arrest. Ensure suction regulator is functioning and ambu bag is available.
  6. Educate patient to identify and avoid triggers
    • This may include temperature extremes, stress, drugs, alcohol, infection, or caffeine. They should avoid any known triggers as much as possible.
  7. Educate patient on s/s of cholinergic and myasthenic crisis to report to provider.
    • Both cases can cause severe muscle weakness and respiratory depression. Early intervention to protect the patient’s airway is imperative.
  8. Cholinergic Crisis: Withhold medication, Administer antidote - anticholinergic medication, Ventilatory support
    • Cholinergic crisis can be caused by taking too much medication or can occur after a dose adjustment.

      Atropine may help, but isn’t always enough - patients often need ventilatory support until the medication is out of their system.
  9. Myasthenic Crisis: Increase medication dose, Ventilatory support
    • having too little medication and is essentially an exacerbation of the disease.

      Administer the missed dose or increase the dosage per provider orders. Patients often still require ventilatory support until the medication is at a therapeutic level again.

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
  • Shortness of Breath
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)
  • Elevated Cardiac Enzymes

Nursing Interventions and Rationales

  1. MONA: Morphine Oxygen Nitroglycerin Aspirin (ASA) *note - this is only a mnemonic and not the correct order of administration - see rationale for details*
    • 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 initial 12-lead ECG indicates inferior 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. **Inferior MI’s need to be treated differently!**
  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. Insert Large Bore IV and draw initial Cardiac Enzymes
    • IV access is important for administration of medications, possible interventions if angina worsens, and any scans that may be needed to rule out thrombosis.

      Cardiac enzymes further serve to rule out Myocardial Infarction and can give an indication to the extent of myocardial damage.
      Troponin I
      CK
      CK-MB
      Myoglobin
  8. 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

Osteoarthritis (OA), a common degenerative joint disease, is the wearing down of the protective cartilage between the joints. The tendons, ligaments and ends of the bones also wear down, often developing spurs, that produce pain, inflammation and swelling.  OA is the top cause of disability in the older population, but can affect people of any age, even in their 20s and 30s. Joint pain and stiffness are the hallmarks of osteoarthritis. It cannot be cured or reversed, but treatment is available to help relieve pain and improve mobility.

Etiology

Several factors contribute to the development of OA, not just aging. People who have inherited defects in the genes responsible for making cartilage or who are born with joint deformities (i.e. scoliosis) are more likely to develop OA. Fractures or injuries to the joints or near the joints, especially back and knee injuries, increase the risk of degenerative disease. Overuse of the joints, like repeated bending, and obesity cause stress on the joints and cartilage and can lead to early development of OA.

Desired Outcome

Reduce and manage pain, improve functionality of joints and prevent further joint damage

Subjective and Objective Data

Subjective Data
  • Pain
  • Tenderness
  • Stiffness
  • Loss of flexibility
  • Grating sensation
Objective Data
  • Bone spurs
  • Swelling around the joint
  • Limited ROM
  • Crepitus

Nursing Interventions and Rationales

  1. Assess chronic pain
    • Pain is the most common and long-standing symptom of OA. Assess the patient’s description of pain and what has worked for them in the past. They may describe the pain as a constant ache while at rest that worsens with movement.
  2. Assess acute, breakthrough pain
    • Patients often become accustomed to constant pain of OA, but will experience a sharp or exacerbated pain when applying full weight to the joint or with movement such as walking.
  3. Monitor joint swelling and RICE
    • Joints often swell with stress such as with walking or with injury. Remember RICE:
      Rest, Ice, Compression, Elevation
  4. Apply heat/cold as appropriate; heat may help reduce pain as it increases blood flow, but can also cause increased inflammation. Cold helps reduce pain and inflammation
    • Alternate between warm and cold compresses, allowing only 20-30 minutes of each with 20-30 minute rest periods in between. Make sure the warm compresses are not to hot and avoid using arthritis creams with heat to prevent burns. Monitor the skin to avoid cold damage to tissues.
  5. Assist with ROM exercises, AROM and PROM; coordinate physical / occupational therapy as appropriate
    • Encourage ROM activity to loosen joints and prevent stiffness. Consider medicating prior to exercise to reduce pain.
  6. Administer medications as appropriate to relieve pain and reduce inflammation.
    • Acetaminophen is safe and effective analgesic

      NSAIDs provide pain relief and help reduce inflammation

      Corticosteroids- relieve inflammation in severe cases or when NSAIDs are not indicated as with history of GI bleed, peptic ulcers or allergies.

      Duloxetine may be given to treat chronic OA pain

      Diclofenac helps relieve pain and inflammation; it comes in oral and topical applications for target areas
  7. Provide adaptive equipment as necessary to encourage self care: Walkers, canes, Large handled eating utensils and grooming products (toothbrush or hairbrush)
    • Patients with OA of the hands, wrists and elbows often have difficulty performing self care and feeding themselves. Offer tools and encouragement to promote as much independence as possible.
  8. Initiate fall precautions: Non-slip shoes/socks, Clear walkways, Ensure adequate lighting, Provide handrails
    • Joint damage causes weakness and increases the risk of falls and injuries.
  9. Assist with ambulation and ADLs as required
    • Patients are often unsteady and nervous about ambulation. Provide assistance with transfers and walking, use gait belts and assist with ADLs as necessary.

Pathophysiology

Bone is a living tissue that is constantly breaking down and being replaced. Osteoporosis happens when growth of new bone does not keep up with the breaking down of old bone. This makes the bones very brittle and fragile. Primary osteoporosis is a result of the normal aging process, while secondary osteoporosis is a result of another disease process.  

Etiology

Bone regeneration normally takes place much faster than the deterioration process and the bones grow in mass reaching a peak in a person’s 20s. As people age, the breaking down process becomes faster than the regeneration process. The amount of bone mass at the peak can partly determine the likelihood of developing osteoporosis. There are many risk factors. It is most common in older women, due to a decrease in estrogen, as well as people taking corticosteroids or with a decreased dietary intake of calcium.

Desired Outcome

The goal of treatment is to address the underlying causes and prevent fractures.

Subjective and Objective Data

Subjective Data
  • Bone Pain

There are typically no symptoms in the early stages of bone loss

Objective Data
  • Loss of height over time
  • Stooped posture
    • Kyphosis of the spine
  • Bone fractures, especially hip/pelvis
  • Pathologic fractures
    • Occur without trauma

Nursing Interventions and Rationales

  1. Assess and manage pain
    • Patients often complain of back pain as the vertebra collapse or pain from a fracture. Pain control is essential for the patient to participate in rehab.
  2. Initiate fall precautions to prevent injury
    • Falls and injuries are more difficult to heal with osteoporosis as the bone takes longer to regenerate. Provide assistance with ambulation, remove rugs or fall hazards and maintain a clear and well-lit path.
  3. Support fracture stabilization
    • If patient is in cast or splint, make sure the device fits properly and assess for skin integrity and circulation.
  4. Administer medications appropriately: Bisphosphonates (alendronate, ibandronate), Hormone therapy, Biologic drugs (denosumab)
    • Medications to slow bone loss may be given as an oral medication daily, weekly or monthly. Some medications require weekly, monthly or quarterly injections.
  5. Monitor respiratory status and signs of fat embolism
    • Fat embolism is a complication of fractures and can lead to respiratory insufficiency.
  6. Assist with repositioning
    • Pain and injury make positioning difficult for some patients. Assist in repositioning every 2 hours as needed to prevent skin breakdown and assist with mobility.
  7. Assist with ROM activities
    • Immobility can cause atrophy of muscles. Assist as necessary with ROM activities to prevent injury.
  8. Consult physical and occupational therapy as appropriate
    • Consult with PT/OT for evaluation and rehab to maintain functionality and mobility.
  9. Nutrition and lifestyle education: Healthy diet, increase calcium intake, Exercise as tolerable in safe environment, Quit smoking, Limit or avoid alcohol
    • A healthy diet high in calcium and vitamin D can help prevent skin breakdown and exercise promotes circulation and healing.

      Weight-bearing exercises can improve the strength of muscles around weak bones/joints as well as increase bone density to reduce the risk of fractures.

      Smoking increases the rate of bone loss.

      Limit alcohol to two drinks per day as it can decrease bone formation and increase the risk of falls.

Pathophysiology

Otitis media (OM) is an infection of the middle ear behind the tympanic membrane  and is one of the most common illnesses in children, accounting for approximately 20% of primary care visits. OM may be viral or bacterial and, depending on cause,  is generally treated with antibiotics.

Etiology

In young children, the eustachian tube that connects the middle ear to the back of the throat is shorter and more horizontal than in older children and adults, making it easier for fluid to get trapped and become infected. Congestion from allergies, a cold, or sinus infection are common reasons for fluid to become trapped. Other causes include exposure to cigarette smoke and drinking while lying down. Untreated infections can lead to complications such as ruptured eardrum, cholesteatoma and delays in speech.

Desired Outcome

Patient will be free from pain and infection; patient will have optimal hearing; patient will be afebrile

Subjective and Objective Data

Subjective Data
  • Ear pain
  • Fussiness / irritability
  • Feeling of fullness in the ear
  • Hearing loss or distortion
  • Headache
Objective Data
  • Fever
  • Pulling at ears
  • Fluid drainage from the ear
  • Vomiting
  • Diarrhea
  • Lack of balance

Nursing Interventions and Rationales

  1. Assess vitals
    • Get baseline to determine if interventions are effective.

      Fever is a common symptom.

      Pain and fever may cause increase in heart rate, respiratory rate and blood pressure
  2. Observe ears and throat for signs of drainage or discharge
    • Congestion, post-nasal drip and drainage of the ears may be present.

      Co-infections such as strep throat, a cold or the flu may also be present
  3. Assess pain with appropriate pain scale
    • Wong Baker FACES and FLACC scales may be used to assess pain in young children and infants. Pulling at the ears and tilting the head are also signs of ear pain.
  4. Assess for hearing loss or changes in speech
    • Sounds may be distorted or muffled in the affected ear.

      Toddlers learning to talk may have changes in speech due to impaired ability to hear
  5. Position patient for comfort; sitting up or lying on side of unaffected ear
    • Lying flat or on the side of the affected ear can cause more swelling and fluid accumulation in the eustachian tube, resulting in increased pain. Encourage the parent to hold infants and young children upright to reduce discomfort
  6. Manage pain with medications and non-pharmacologic interventions
    • Analgesics such as acetaminophen may be given. Other methods include applying warm (not hot) moist compresses to the ears
  7. Administer medications as required
    • Antibiotics are usually given for bacterial infections. A full 10-day course is generally required
  8. Recommend follow-up after treatment
    • Some infections may be resistant to certain antibiotics. Encourage follow-up after treatment to determine if infection has cleared, even if symptoms seem to subside or resolve.
  9. Provide education for parent / caregiver: Avoid giving bottles or sippy cups while lying down, Avoid exposure to cigarette smoke, Practice good hand hygiene to prevent spread of bacteria that cause ear infections
    • Teach parents how to prevent future infections and prevent complications

Pathophysiology

Self-digestion of the pancreas by its own proteolytic enzymes (trypsin) causes acute inflammation of the pancreas. Enzymes within the pancreas may be prematurely activated by obstruction of gallstones in the bile duct. The enzymes then reflux back into the pancreatic duct causing inflammation, erosion and necrosis. There is an elevated risk of mortality due to hypovolemic shock, hypotension or multiple organ dysfunction. Acute pancreatitis is a sudden inflammation that only lasts a short time. Chronic pancreatitis is long-lasting and usually occurs after an acute episode.

Etiology

Acute:  In the US, 80%-90% of acute pancreatitis cases are the result of gallstones followed by alcohol intake. Other etiology includes infections, hypercalcemia, hypertriglyceridemia, trauma, pancreatic cancer, autoimmune disease and certain medications.

Chronic:  Long-term alcohol use is the major contributor to chronic pancreatitis, in addition to gallstones, hereditary disorders, cystic fibrosis and hypertriglyceridemia

Desired Outcome

The desired outcome of pancreatitis is the absence of obstruction, inflammation or infection of the pancreas and bile duct. Patient will be free from pain and vomiting.

Subjective and Objective Data

Subjective Data
  • Abdominal pain – mid-epigastric pain that radiates to the back
  • Anorexia
  • Nausea / vomiting
Objective Data
  • Vomiting
  • Fever
  • Dry mucous membranes
  • Rigid abdomen
  • Tachycardia
  • Hypotension
  • Bruising in the flank and around the umbilicus
  • Elevated serum lipase/amylase levels

Nursing Interventions and Rationales

  1. Assess and monitor vitals
    • Temperature – fever is a sign of infection and stress response

      Hypotension (decreased blood pressure) with tachycardia (elevated heart rate): a sign of hypovolemia and can lead to shock
  2. Assess and manage pain
    • Administer medications as ordered: opioid or non-opioid medications for pain

      Positioning: place in semi-Fowler’s to decrease pressure on abdomen and diaphragm
  3. Monitor labs
    • Serum lipase - may stay elevated for up to 12 days

      Serum amylase - usually returns to normal within a few days of treatment

      CRP - 24-48 hours after presentation - higher levels may indicate possible organ failure

      WBC- >12,000/uL (leukocytosis) may = inflammation or infection

      Hematocrit - >47% may indicate more severe disease
      Serum glucose - monitor for hyperglycemia due to lack of insulin secretion
  4. Administer Medications as ordered
    • Cimetidine (Tagamet) - often given to decrease secretion of hydrochloric acid

      Antibiotics - as necessary for primary infection

      Insulin - as necessary for significant hyperglycemia
  5. Nutrition Monitoring and Education
    • Maintain NPO status during acute phase of illness

      Provide clear liquid diet for a few days once inflammation is under control

      Parnteral nutrition - in severe cases may be given to inhibit stimulation of pancreatic enzymes and to decrease metabolic stress
  6. Assess fluid/electrolyte balance
    • Monitor
      Skin turgor- tenting is a sign of moderate to severe dehydration
      Mucous membranes- lips and mouth should be moist and shiny
      I & O monitor for retention or excess output of fluid

      Administer
      Aggressive IV hydration is recommended within the first 12-24 hours of onset, unless contraindicated (cardiac or renal comorbidities)
  7. Encourage lifestyle changes
    • Counsel patient on healthy lifestyle choices to include:
      Stop smoking

      Cessation of drinking alcohol

      Healthy diet and exercise to maintain appropriate weight.

      Lower fat intake to improve hypertriglyceridemia

      Optimal hydration - pancreatitis can cause dehydration, encourage patient to drink more water throughout the day

Pathophysiology

Some paranoid disorders such as paranoid personality disorder and paranoid schizophrenia may have more bizarre behavior and have intense feelings of distrust or fear. These clients will not confide in others and may be difficult to talk to as they often misinterpret harmless conversation or behavior.

Etiology

Diagnostic Criteria:   Criteria and symptoms must persist for one month or more, and cannot be attributed to substance use or another medical or mental condition.

  • Extreme distrust and suspiciousness of others, misinterpreting motives as malevolent, begins early in adulthood
  • Presents by at least four of the following:
    • Suspects, without reason, that others are exploiting, harming or deceiving him or her
    • Is preoccupied with unjustified doubts about the trustworthiness of friends or associates
    • Is reluctant to confide in others because of fear that information will be used against him or her
    • Misinterprets threatening meanings into harmless remarks or events
    • Bears grudges or is unforgiving of insults, injuries
    • Perceives attacks on his or her character or reputation
    • Recurrent, unjustified suspicions about partner’s fidelity
  • Does not occur only during the course of, but may be diagnosed prior to,  schizophrenia

Desired Outcome

Client will be able to identify appropriate coping techniques. Client remains safe and free from harm.

Subjective and Objective Data

Subjective Data
  • Suspicion
  • Fear of being deceived
  • Feelings of being persecuted
  • Poor self image
Objective Data
  • Argumentative
  • Hostility
  • Detachment
  • Social isolation
  • Easily offended
  • Self-righteous attitude
  • Rigid behaviors and beliefs
  • Perfectionism

Nursing Interventions and Rationales

  1. Assess client’s neurological status
    • To determine if there are other issues that may be causing symptoms or if disorder has progressed to another serious conditions such as schizophrenia
  2. Monitor behaviors and interactions with staff and other clients
    • Determine how client interacts with others. Paranoid clients may exhibit aggressive behaviors for no apparent reason.
  3. Talk openly with client about their beliefs and thoughts, showing empathy and support
    • Help build trust and rapport with clients. Paranoid clients may be more reluctant to trust anyone, but open communication generally offers more cooperation
  4. Explain all procedures clearly and carefully, and their purpose, before starting them
    • Prevents aggressive behavior and suspicion. Promotes cooperation and compliance. Helps develop trust.
  5. Remain aware of client’s personal space. Avoid startling the client, sudden movements or touching the client unnecessarily
    • Even the best of intentions, such as a handshake, tidying the room, or body language may be misinterpreted as threatening and may lead to aggressive behavior.

      Showing respect for client’s space and possessions helps build trust.
  6. Discuss feelings and help client identify behaviors that cause conflict or alienate others
    • Helping clients see the reality of their own behaviors can help treatment progress and lead to more appropriate behaviors and interactions.
  7. Discuss and have client demonstrate (through role play if appropriate) more acceptable responses and reactions to behaviors and stressors
    • Helps client develop more positive coping skills for dealing with delusions, suspicions and fears
  8. Minimize environmental stimuli
    • Overstimulation from loud noises, excessive talking, television or radio may increase paranoia and prompt erratic or aggressive behaviors.
  9. Encourage socialization with others, but do not force participation in activities
    • Help client develop relationships and more positive interactions with others. Helps reorient client to reality. Forcing them to participate may trigger paranoia that you are trying to trick or trap them.
  10. Set behavior boundaries and enforce per facility protocols with medications or restraints as necessary
    • Promote the safety of client during agitated moments and the safety of others from aggressive behaviors.

      Follow your facility’s specific protocol regarding supervision, restraint, and documentation.
  11. Administer medications appropriately and monitor for reactions to medications
    • Antipsychotic medications may be given to manage delusions and behaviors. Monitor for adverse reactions.
  12. Offer praise and encouragement for accomplishments of tasks
    • Promote a sense of self-worth and improves self-esteem
  13. Consider any cultural concerns or impacts of treatment
    • Depending on their culture, some behaviors and beliefs may be considered acceptable to the client. Take these into consideration when implementing interventions.
  14. Provide reorientation as appropriate, but avoid direct confrontation of the delusions
    • Client may need to be refocused to reality at times, but avoid confrontation that may be interpreted as argumentative to avoid noncompliance and uncooperative behaviors.
  15. Provide education, resources and support for client’s family and loved ones
    • Help family members understand the nature of the client’s illness and avoid conflict that could exacerbate the client’s symptoms.
      Encourages coping skills of family members through each other and support groups.
  16. As client agrees, and per facility protocol, incorporate client’s family or loved ones in ongoing treatment plan
    • Help develop trust between client and loved ones, and promotes positive management of illness going forward. Help client and family members stay on track with treatment.

Pathophysiology

A degenerative neurological disorder characterized by a lack of controlled movement, caused by a depletion in circulating dopamine levels in the brain. Dopamine is a neurotransmitter responsible for controlled muscle movements.

Etiology

A genetic component is suspected, but the true cause is not entirely understood. The depletion of dopamine results from atrophy of the substantia nigra – the structure within the midbrain that is responsible for secretion of dopamine.

Desired Outcome

Optimize independence and ability for self-care as long as possible. Improve dopamine levels within the brain to minimize symptoms. There is no cure.

Subjective and Objective Data

Subjective Data
  • Weakness
  • Fatigue
  • Feeling “heavy”
  • Feeling “stiff”
  • Difficulty swallowing
Objective Data
  • Pill-rolling tremor
  • Shuffling gait
  • Lip smacking
  • Bradykinesia – slow movements
  • Akinesia – loss of voluntary movement
  • Blank facial expression
  • Drooling
  • Dysphagia

Nursing Interventions and Rationales

  1. Assess swallow prior to giving anything by mouth - involve Speech Therapy as appropriate
    • Due to muscle weakness, patients may experience difficulty swallowing. It may be appropriate to have ST assess for appropriate interventions to prevent aspiration.
  2. Encourage PT/OT and the use of assistive devices for ambulation multiple times a day
    • Improving range of motion and muscle strength can help patient to maintain independence. If they do not participate in these activities, muscle atrophy is likely.
  3. Educate patient on activity and energy conservation options
    • Patients fatigue easily. Teach to cluster care and provide for periods of rest.
  4. Use rocking motion to initiate movement, especially from sit to stand
    • This momentum can help assist with initiating movements when weakness is present.
  5. Encourage small, frequent, nutrient-dense meals to get proper caloric intake: Increase fluid intake, High protein, High fiber, Avoid foods high in, Vit B6
    • As the disease progresses, weakness and dysphagia make preparing and eating meals more difficult. Smaller meals can be easier to consume before getting fatigued. Encourage nutrient dense foods.
      Vitamin B6 can interfere with antiparkinsonian drugs.
  6. Administer medications: Dopaminergics, Dopamine agonists, Levodopa-Carbidopa, Anticholinergics
    • The goal is to increase the levels of available dopamine within the central nervous system.

      Anticholinergics are given to decrease drooling and secretions.
  7. Encourage independence as long as possible
    • As the disease progresses, patients will lose their independence. Encourage them to remain an active participant in their care as long as possible.
  8. Provide resources for community support (i.e. groups)
    • Progressive, degenerative diseases can take their toll on patients and their families emotionally. Having community support is helpful.

Pathophysiology

Pediculosis capitis is more commonly known as “head lice” and is a common, very contagious, infestation of the human head louse in the patient’s hair. It generally infests the hair on the head and causes extreme itching. The itching is often a result of an allergic reaction to the louse saliva after it bites the skin. The louse feeds on human blood in order to survive. Head lice is most prevalent in schools, day care centers and nurseries.

Etiology

Head lice are spread from person to person through direct contact with someone who already has an infestation. The easiest contact is during play such as sports activities, playgrounds and slumber parties, but can also be transmitted by sharing combs, brushes, hats and scarves, sports uniforms or using blankets or towels that were used by an infested person. Lice can only crawl and create a tickling sensation on the skin; they are not able to fly or jump from person to person.

Desired Outcome

Patient will be free from active lice infestation; patient will verbalize ways to prevent future reinfestation

Subjective and Objective Data

Subjective Data
  • Extreme itching on the scalp
  • Irritability
  • Difficulty sleeping
Objective Data
  • Small red bumps or sores on the scalp, neck or shoulders
  • Swollen lymph nodes behind the ears
  • Red, irritated eyes (if lice present in eyelashes)
  • Small bugs noted on scalp or found on pillow or sheets

Nursing Interventions and Rationales

  1. Assess the scalp for nits or active lice; common behind the ears, at the base of the neck and on the crown of the head
    • Nits will be small and firmly attached to the hair shaft. Shells of nits will still be present after they hatch, but will appear more yellow. Adult lice may be more difficult to see as they are darker and crawl quickly.
  2. Use PPE for examining patient
    • Lice are easily transmitted in clothing and on skin; use gloves to examine patient and change gloves between patients to prevent further transmission
  3. Use Wood’s lamp (black light) to determine presence of lice or nits
    • This method involves less chance of transmission of lice and is done by shining the black light on the patients head. Lice and nits will look like glowing yellow or green dots.
  4. Apply pediculicide shampoo to patient’s scalp and hair
    • Over the counter and prescription strength shampoos are available. Hair should not be washed again for 1 -2 days following treatment.
  5. Comb hair with nit comb
    • This is a long and tedious process, but it required to remove lice and nits from the hair and prevent reinfestation. Some shampoos only kill adult lice and nymphs, so nits (eggs) must be manually removed.
  6. Administer oral medication as a last option (Ivermectin)
    • This medication is given orally when all other treatments have failed.

      There may be significant side effects to this medication, so monitor for signs of liver damage, joint or muscle pain, weakness, vision changes or rash.
  7. Assess skin for signs of infection
    • Itching is the most worrisome symptom, but introducing bacteria into excoriated skin can lead to skin infections.
  8. Ensure patient’s nails are trimmed and clean
    • Scratching to relieve itching is a normal response, and often is done during sleep. Make sure nails are trimmed and clean to reduce likelihood of infection.
  9. Address patient or caregivers’ emotional distress
    • Many people feel that lice is a reflection of poor hygiene. Reassure families that anyone can have lice and provide guidance on how to cope. Try to help them view the situation as a medical condition and avoid scolding or punishing the child.
  10. Provide education for patient and caregivers on ways to prevent further infestation
    • Treatment must be reapplied within 7-10 days to ensure that all newly hatched lice and nymphs have been removed.

      Wash all bed linens, towels and clothes belonging to the patient separately in hot water.

      Vacuum carpets, rugs, furniture and mattresses to remove lice that may be hiding there

      For items that cannot be washed, such as toys or stuffed animals, seal them in a plastic bag for 4-5 weeks to kill any remaining lice or nymphs.

Pathophysiology

Defects (open sores) in the protective lining of the stomach and upper small intestine. Gastric ulcers occur on the inside of the stomach and duodenal ulcers occur on the inside of the upper portion of the small intestine (duodenum). Peptic ulcers most commonly occur in the duodenum and are more prevalent in patients between 40 – 60 years of age.

Etiology

Chronic use of NSAIDS (aspirin, ibuprofen, naproxen) weakens and thins the mucosal lining of the stomach and duodenum and greatly contributes to the formation of breaks in the protective lining. The primary cause of peptic ulcer disease (approx. 90%) is Helicobacter pylori bacterial infection. Heavy alcohol use and smoking increase the risk of PUD in patients with H. pylori infection. Other contributing factors include various illnesses such as Crohn’s disease, gastritis, hepatic disease and pancreatitis. Complications of peptic ulcers may include anemia, profuse bleeding, perforation, obstruction and certain cancers.

Desired Outcome

Relief of pain, absence of complications, maintain adequate nutrition

Subjective and Objective Data

Subjective Data
  • Epigastric pain (gnawing or burning) after meals
  • Heartburn
  • Constipation
  • Patient reports tarry stools
  • Feeling full
  • Unexplained weight loss
  • Dysphagia
Objective Data
  • Bleeding, tarry stools
  • Anemia
  • Vomiting
  • Hypovolemia

Nursing Interventions and Rationales

  1. Assess and Monitor vitals
    • Monitor for signs and symptoms of infection / inflammation to include:
      Fever
      Tachypnea
      Tachycardia

      Monitor for signs and symptoms of hypovolemia to include:
      Hypotension
      Tachycardia
  2. Perform detailed pain assessment
    • The most common symptom of peptic ulcers is burning stomach pain that may be worse between meals and at night.
  3. Evaluate lab test
    • The pathogen Helicobacter pylori (H. pylori) is responsible for approx 90% of all peptic ulcers reported.

      CBC - anemia or blood loss

      Coagulation panels (aPTT, PT, INR) for patients who are on anticoagulants or have active bleeding

      Electrolytes, BUN, creatinine - to determine if patient requires fluid resuscitation
  4. Prepare patient for and assist with upper GI Endoscopy
    • Endoscopy is a procedure that is done by a doctor using a scope that is placed orally to visualize the upper GI tract including the esophagus, stomach, and upper portion of the small intestine. Tissue samples may be taken during the procedure if necessary.

      Withhold anticoagulants for several days prior to procedure if possible to avoid excessive bleeding during procedure

      Patient must be fasting, no food or drink for 4-8 hours prior to procedure to ensure gastric emptying and to reduce risk of aspiration during sedation

      Administer conscious sedation

      Monitor vitals while patient is sedated per facility policy

      Assist with ambulation immediately following procedure until sedation is fully worn off

      Maintain NPO status post procedure until return of gag reflex to avoid aspiration
  5. Administer medications as ordered
    • Proton pump inhibitor (Omeprazole) - to reduce stomach acid

      H2 Histamine blockers (Famotidine) - to reduce stomach acid

      Antacids - may be given for symptom relief, but do not heal the ulcer

      Cytoprotective agents (Sucralfate) - to protect the lining of the stomach and intestine

      Antibiotics - commonly given to treat H. pylori infection

      AVOID NSAIDS (aspirin, ibuprofen, naproxen)
  6. Nutrition Education
    • Limit or avoid foods that cause excess acid production or irritation to the peptic lining:
      Coffee, tea
      Carbonated drinks
      Alcohol
      Citrus
      Peppers, all
      Spicy foods
      Red meat
      Dairy

      Reduce salt intake - Increased risk of developing stomach cancer

      Monitor food labels carefully and make choices that are lower in fat and sodium.

      Include probiotics in regular diet - yogurt, aged cheeses and sauerkraut have healthy probiotics that help restore the natural bacteria in the GI tract

      Eat regular, small meals - complete emptying of the stomach for prolonged amounts of time may cause acid build up in the stomach and increase pain and erosion of tissues

      Avoid overeating - excess pressure from overeating or bloating may cause pressure on the stomach and increase pain
  7. Encourage lifestyle changes
    • Reduce stress - although stress has not been proven to cause peptic ulcers, it may result in overeating or skipping meals which will irritate the peptic lining

      Stop smoking - nicotine increases stomach acid and thins the mucous membranes

      Limit or avoid alcohol - excessive alcohol increases acid production and can irritate and erode the peptic lining

Pathophysiology

Pericarditis is inflammation of the pericardium – the outer layer of the heart and pericardial sac. Fluid and inflammation build up around the heart inside the pericardial sac, putting pressure on the heart and making it harder for the heart to fully relax and contract. It can cause heart failure or cardiac tamponade.

Etiology

Pericarditis is caused by an infectious source, either viral, bacterial, or fungal. Fungal is the least common, while the Coxsackie virus is a common source.

Desired Outcome

To treat the cause and remove the source of infection while preserving cardiac output and preventing any major (or minor) complications.

Subjective and Objective Data

Subjective Data
  • Chest Pain
    • Aggravated by breathing, coughing, swallowing
    • Worse when supine
  • Symptoms of Heart Failure
Objective Data
  • ↑ Temperature
  • ↑ WBC
  • Signs of Heart Failure
  • ST Elevation possible
  • ↓ SpO2
  • S/S Cardiac Tamponade
    • Muffled heart sounds
    • Narrow Pulse Pressure
    • Pulsus Paradoxus
    • JVD with clear lungs
    • ↓ Cardiac Output

Nursing Interventions and Rationales

  1. Assess Heart and Lung Sounds
    • May hear a pericardial friction rub, muffled heart sounds, or extra sounds because of the pressure being placed on the heart. It’s possible, but unlikely that you will hear fluid in the lungs - in cardiac tamponade the lungs will be clear.
  2. Assess and Address Oral Hygiene
    • There is a significant connection between oral health and pericarditis. Bacteria can travel to the heart easily from the oral cavity. Patients should brush their teeth twice daily to prevent complications.
  3. Administer IV Antibiotics
    • If the source is bacterial, IV antibiotics will be required to treat the infection. Be sure to obtain blood cultures prior to initiating antibiotics.

      If the source is viral - providers may order anti-inflammatory medication since antibiotics aren’t effective. If the virus is known and susceptible, an antiviral medication could be used.
  4. Perform 3-5 lead ECG monitoring and/or 12-lead ECG
    • Pericarditis could cause arrhythmias or ST elevation as the fluid puts pressure on the heart.

      Cardiac tamponade is a risk - in which case we’ll see the QRS amplitude decrease with inspiration.
  5. Assess and Manage Pain
    • Patients will have significant chest pain that is worse with breathing or when supine. Perform OLDCARTS pain assessment and administer pain medication as ordered.

      Positioning the patient in High-Fowler’s position can also relieve pressure on the heart and be more comfortable for the patient.
  6. Assess for s/s Cardiac Tamponade
    • Assess for Beck’s Triad - JVD, ↓ BP, muffled heart sounds. May also see Pulsus Paradoxus and narrowing pulse pressures.

      This is a medical emergency and needs to be treated as such.
  7. Prepare patient for emergent pericardiocentesis
    • A physician will insert a large, long needle into the pericardial sac, using ultrasound as a guide, to drain off the fluid that is collecting around the heart. This will allow the heart to beat more freely and should improve cardiac output rapidly.
  8. Educate patient on s/s infection
    • Pericarditis is an infectious process, therefore infection control is imperative. They need to be taught hand hygiene as well as other infection precautions. They should also be taught s/s of infection to report to their provider.
  9. Educate patient to inform other providers before procedures: May need prophylactic antibiotics, No dental procedures for at least 6 months
    • Because the patient is at high risk for recurrence and complications, it’s important that they notify other providers of their history of pericarditis. They may require prophylactic antibiotics prior to any invasive procedures and they should avoid dental procedures for at least 6 months after their hospitalization.

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

Postpartum hemorrhage is the excessive bleeding following delivery of a baby. For vaginal delivery, excessive bleeding would be more than 500ml and for cesarean delivery, more than 1000ml.  This may happen with vaginal or cesarean delivery and occurs in 1-5 out of 100 women. The hemorrhage may occur immediately after birth, or over several hours following delivery.

Etiology

Normally, the uterus continues to contract after the delivery of the baby and placenta. These contractions actually help close the vessels that supplied blood from the mother to the baby. When these contractions do not continue, or are not strong enough, hemorrhage occurs. Sometimes, a tear in the cervix, placenta or the blood vessels within the uterus may cause the hemorrhage.  Risk factors include obesity, multiple births (twins or more), many previous pregnancies, blood clotting disorders, infection, prolonged labor or use of assistive devices such as forceps or vacuum to delivery the baby.

Desired Outcome

Patient will maintain optimal fluid balance and vital signs within normal limits

Subjective and Objective Data

Subjective Data
  • Pain in vaginal area (if due to hematoma)
  • Dizziness
Objective Data
  • Uncontrolled bleeding
    • Excessive saturation of perineal pads
  • Hypotension
  • Tachycardia
  • Low hematocrit

Nursing Interventions and Rationales

  1. Assess vital signs and monitor for signs of shock
    • Decreased fluid volume will cause blood pressure to drop and patient will go into shock
  2. Monitor blood loss
    • Amount of blood loss and presence of blood clots can help determine treatment.
  3. Assess for vaginal hematoma
    • If bleeding is due to vaginal hematoma, rest and application of an ice pack may be sufficient treatment
  4. Monitor intake and output for 30ml - 50 ml/hr urine output; may require indwelling catheter insertion for accurate measurement
    • Decreased urine output may be a sign of hematomas that put pressure on the urethra, or may be a late sign of hypovolemic shock.
  5. Monitor lab values to determine need for transfusions or signs of complications
    • Watch hematocrit and clotting levels to know if blood transfusion is necessary and for signs and severity of DIC.
  6. Administer IV fluids, medications and blood products as necessary
    • Watch hematocrit and clotting levels to know if blood transfusion is necessary and for signs and severity of DIC.
      Fluid replacement may be necessary and, depending on amount of blood lost and hematocrit level, a blood transfusion may be required.
      Oxytocin is sometimes given to initiate contractions that will help stop bleeding.
  7. Perform uterine massage to stimulate contractions following delivery
    • Begin fundal massage and educate patient on how to massage abdomen to stimulate contractions. These contractions may help stop bleeding.
  8. Monitor and manage pain
    • Continued, unrelieved pain may be due to hematomas or lacerations within the vagina
  9. Place patient on bed rest with legs elevated
    • Rest and elevation of legs helps venous return and slows bleeding
  10. Prepare patient for surgery if indicated; remain on NPO status
    • If bleeding can’t be managed otherwise, surgery may be required

Pathophysiology

The rupture of fetal membranes (water breaks) before the beginning of labor is considered a complication of pregnancy known as premature rupture of membranes. This can happen at any gestational age, even full term.  Despite what movies may depict, this sudden gush or steady trickle of fluid only occurs in about 10% of term pregnancies and 4% of preterm pregnancies. When the membranes rupture prior to 37 weeks gestation, it is considered preterm premature rupture of membranes (PPROM). Regardless of gestational age, when the membranes rupture, the protective barrier between the vagina and the fetus is lost and increases the risk of maternal and fetal infection.

Etiology

There is no specific cause, but there are many factors that may increase the risk of PROM. Maternal or intra-amniotic infection and chronic disease, such as systemic lupus erythematosus, direct abdominal trauma, nutritional deficiencies, smoking and placenta abruption all increase the risk of PROM.  Multiple pregnancy (twins or more) and a history of previous PROM also indicate an increased risk.

Desired Outcome

Patient will be free from infection (maternal and fetal); viable birth

Subjective and Objective Data

Subjective Data
  • Sudden gush or steady  trickle of clear fluid from vagina
Objective Data
  • Blue nitrazine paper test – turns dark  blue if positive for amniotic fluid
  • Visual pooling of amniotic fluid in vagina

Nursing Interventions and Rationales

  1. Assess for signs of infection
    • Maternal and fetal infection may prompt PROM and must be treated quickly to avoid fetal compromise.
  2. Perform single digital or sterile speculum vaginal exam
    • Vaginal exam may be required to confirm diagnosis, but avoid multiple digital vaginal exams to reduce the risk of infection. Reserve these exams for when delivery is imminent.
  3. Obtain history from patient regarding complications and status of pregnancy.
    • Treatment depends on gestational age and existing complications

      Patient may need to remain on bed rest to continue pregnancy if preterm, or labor may be induced.
  4. Initiate fetal monitoring
    • PROM may be an indicator of fetal distress. Monitor for signs of fetal compromise to include changes in fetal heart rate.
  5. Administer medications and IV fluids as appropriate: Prophylactic antibiotics, Corticosteroids, Tocolytics, Magnesium sulfate
    • PPROM may indicate a need for corticosteroids to speed up the fetal lung maturity

      Antibiotics are given prophylactically to prevent infection

      Tocolytics may be given to stop preterm labor

      Magnesium sulfate may be given if prior to 32 wks gestation to prevent fetal neurological dysfunction
  6. Prepare patient for induction of labor and delivery
    • If indicated, labor will likely be induced if it does not spontaneously begin within 12-24 hours. Explain process to patient to reduce fears.
  7. Provide patient education if preterm: Pelvic rest, Avoid tampons and intercourse, Avoid tub baths (showers ok)
    • If delivery is not indicated(<34 wks gestation), patient will likely remain in the hospital until delivery is an option.

      Regardless of location, patient will be required to remain on bed rest and antibiotics will continue prophylactically until delivery.

Pathophysiology

Pressure ulcers are also called decubitus ulcers or bedsores. These are injuries to the skin and underlying tissues that develop after prolonged pressure in a particular area. Bedsores are common on the heels, sacrum and over bony prominences such as the elbows and shoulder blades. Pressure ulcers can develop and progress very quickly, but are preventable and treatable.

Etiology

Pressure ulcers are caused by three main factors.  

Pressure:  Constant or prolonged pressure that restricts blood flow to any part of the body.  If blood is restricted to an area, nutrition, oxygenation and tissue perfusion cannot take place. Without these essentials, the skin and nearby tissue is damaged and may eventually become necrotic.

Friction: As skin rubs against clothing or bedding, it can make weakened areas in the skin that are vulnerable to injury. This occurs often if the skin is consistently moist.

Shear:  When skin slides against a surface, such as sliding down in the bed when the head only is elevated or transferring or positioning a patient by allowing the skin to move across the bedding. Fragile skin is easily ripped or torn this way.

Desired Outcome

Patient will experience healing of current pressure wounds, prevention of further skin injury and maintain optimal skin integrity

Subjective and Objective Data

Subjective Data
  • Tender areas of skin
  • Pain, burning of skin
  • Itching
Objective Data
  • Changes in skin color or texture
  • Swelling
  • Drainage from wounds
  • Stage 1 – non-blanchable redness
  • Stage 2 – open skin, pink/red, blister
  • Stage 3 – Exposed subcutaneous tissue
  • Stage 4 – Exposed muscle/bone

Nursing Interventions and Rationales

  1. Assess skin for signs of hydration pressure injury, and note areas of increased risk
    • Get a baseline of skin status to compare changes; note areas that are at risk for developing pressure injury such as heels, sacrum or shoulder blades
  2. Monitor for signs of infection: Note odor and appearance of exudate, Fever, Warmth to touch, Obtain wound cultures as needed, Monitor white blood count (WBC), Administer antibiotics as required
    • Not all pressure ulcers are infected. Know and monitor for signs and symptoms of developing infection. Treat current infections appropriately to avoid systemic complications.
  3. Reposition patient at least every 2 hours or more frequently as needed: Use and reposition pillows under arms, between knees (if side-lying) and behind back to reduce pressure and friction, Place rolled sheet or towel under ankles (not heels) to reduce pressure of heels against bedding, Provide cushions and padding on assistive devices such as wheelchairs, walkers, crutches, etc.
    • Redistribute weight to remove pressure and prevent tissue injury. Provide for comfort.
  4. Assess patient’s level of sensation
    • Patients with pre-existing conditions, such as diabetes, will be at greater risk of developing pressure ulcers, but may have decreased sensation. Assess sensation to know if patient will be able to feel pain or discomfort before a pressure injury occurs.
  5. Assess for incontinence of bowel or bladder: Provide perineal care, Assistance with toileting, Apply barrier cream
    • Incontinence increases risk of skin breakdown and risk of pressure injury. Protective devices such as diapers and incontinence pads/liners withhold moisture which can speed up breakdown.
  6. Assess patient’s mobility and provide assistance as necessary
    • Patients with limited mobility require extra assistance to relieve pressure points
  7. Assess and manage pain: Positioning, Administer analgesics, opioids
    • Prophylactic pain management may be necessary
  8. Provide appropriate wound care: Cleaning, Debridement, Dressings, Emollients, Skin barriers, Negative pressure wound therapy
    • Treat current wounds and prevent localized or systemic infection. Promote wound healing.
  9. Promote nutrition and education: Consult dietitian, Offer high-protein, high-calorie diet, Encourage hydration
    • Optimal nutrition helps aid in wound healing and strengthens tissues to prevent further injury; hydrated skin is at slightly less risk for injury than dry, dehydrated skin.

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

RA is an autoimmune disease where the immune system mistakenly targets and attacks the joint linings causing uncontrolled inflammation of the synovium.  Joints on both sides of the body (bilateral) are affected, primarily the hands, wrists and knees. RA is characterized by bone erosion and joint deformity. As the disease progresses other joints may be affected symmetrically.  Chronic inflammation and degenerative changes are the hallmark aspects of RA.

Etiology

Doctors are still unsure as to what triggers RA, but it appears to be at least partially genetic in nature. This genetic predisposition makes the patient more susceptible to environmental factors like viruses and bacteria that may trigger the initial inflammation. Once the inflammation begins, the synovial fluid thickens and the tendons and ligaments weaken and stretch, resulting in the joint losing its shape and alignment.

Desired Outcome

While there is no cure, the goal of treatment is to manage the symptoms and slow disease progression. Medication, physical or occupational therapy and possibly surgery may be necessary.

Subjective and Objective Data

Subjective Data
  • Fatigue
  • Joint stiffness, symmetrical
  • Joint pain
Objective Data
  • Warmth of joints
  • Joint edema
  • Dislocations
  • Deformity of joints
    • Ulnar deviation of hands
  • Fever
  • Weight loss

Nursing Interventions and Rationales

  1. Assess and manage chronic and acute pain: Pillow supports, Warm compresses to loosen stiff joints/relax muscles, Cold compresses to numb pain and reduce swelling, Administer PRN pain meds
    • The primary complaint of patients with RA is the intense pain and stiffness of the joints. Manage chronic pain and breakthrough pain as necessary.
  2. Administer medications appropriately
    • NSAIDs are given to reduce inflammation and ease pain

      Steroids (prednisone) is often given to reduce inflammation and slow joint damage

      DMARDs (methotrexate, hydroxychloroquine) are disease-modifying antirheumatic drugs that are given to slow the progression of RA and save the joints and tissues from permanent damage

      Biologic agents (rituximab, adalimumab) are biologic response modifiers and work by targeting parts of the immune system that trigger inflammation.
  3. Promote self care
    • As the disease progresses, it may be difficult for patients to perform ADLs such as feeding themselves or combing their hair; provide tools such as eating utensils or toothbrushes with larger grips to encourage patients to remain independent.
  4. Cluster care, promote rest
    • Fatigue is a common symptom of RA. Cluster care and promote rest as necessary
  5. Promote positive self-image
    • Patients with joint deformities may experience a negative body image
  6. Encourage activity / exercise
    • Patients fatigue easily, but daily exercise can help loosen joints. Encourage activity as tolerated.
  7. Nutrition and lifestyle education: Healthy diet, Avoid alcohol, Quit smoking
    • When patients are in pain, they often want to turn to comfort foods. Help patients make healthy diet choices, avoiding alcohol and smoking.
      Encourage hydration.

      Patients can also consult with a nutritionist regarding an anti-inflammatory diet.

Pathophysiology

Schizophrenia is a serious mental disorder that affects how a person thinks, feels and behaves. Patients often have difficulty distinguishing between reality and imagination and have difficulty communicating with others. Schizophrenia tends to run in families, but most frequently appears to be related to an imbalance of neurotransmitters (dopamine, glutamate and serotonin) that change the way the brain reacts to stimuli.  Patients are not normally violent, but may react defensively to even the most well-intended gestures or stimuli.

Etiology

Diagnostic Criteria:   The patient must have experienced at least two of the following symptoms, one of which must be a positive symptom.

  • Positive symptoms
    • Delusions
    • Hallucinations
    • Disorganized speech
    • Disorganized (or catatonic) behavior
  • Negative symptoms
    • Flat affect
    • Decrease in emotional range
    • Loss of interest in activities
    • Reduced speaking

Symptoms must be present for at least 6 months with at least one month of active symptoms. Symptoms are not related to substance use/abuse or any other medical condition.

Desired Outcome

Patient will communicate effectively. Patient will demonstrate reality-based thought processes. Patient will demonstrate ability to distinguish between reality and hallucinations.

Subjective and Objective Data

Subjective Data
  • Hallucinations
  • Feeling of being watched (paranoia)
  • Change in personality
  • Inability to sleep
  • Inability to concentrate
  • Feelings of  indifference
Objective Data
  • Awkward body positioning
  • Decreased or impaired speech
  • Decline in academic or work performance
  • Inappropriate behavior
  • Extreme preoccupation with religion or the occult
  • Flat affect
  • Unprovoked outbursts or uninhibited actions
  • Tense, anxious or erratic movements
  • Wandering

Nursing Interventions and Rationales

  1. Obtain history and assess patient for hostile or self-destructive behaviors
    • Determine risk of harm to patient or others and what precautions may be required. Stress response often triggers hallucinations.
  2. Provide encouragement in a non-judgemental, compassionate way, understanding that symptoms are real to patient
    • Develop trust between patient and nurse to improve effectiveness of interventions and cooperation.
  3. Encourage patient to communicate (verbal, drawing, written) how hallucinations make them feel
    • Helps understand and anticipate behaviors and help identify stressors such as fear or helplessness. Reduce anxiety.
  4. Ask if hallucinations are instructing them to harm themselves or others. Provide safety for patient and others per facility protocol if needed.
    • Patients may be inclined to obey commands given by hallucinations that instruct them to harm themselves or others. Notify security or police if necessary.

      Follow your facility’s specific protocol regarding supervision, restraint, and documentation.
  5. Provide redirection for inappropriate behaviors, maintain boundaries and guidelines.
    • Avoids need for intervention and exacerbated behaviors. Redirecting patient helps remove the focus from the current perceived threat to a more positive activity.

      Boundaries and guidelines should be held consistently among caregivers to prevent splitting (turning one caregiver against another).
  6. Encourage reality-based activities (music, art, playing cards, etc.)
    • Help redirect patient to acceptable activities and behaviors and reduce the risk of hallucinatory distractions.
  7. Explain all procedures slowly and carefully before beginning
    • Reduces paranoia and encourages cooperation. Patients are less likely to feel “tricked” if they understand what is happening to them. Even taking a blood pressure can be frightening if not fully explained first.
  8. Avoid using large gestures or touching the patient except when necessary
    • Patient’s distortion of reality may interpret the touch or gesture as an aggressive or threatening action.
  9. Gently reorient patient as necessary
    • Reorienting patient helps them differentiate between reality and hallucination.
  10. Avoid arguing with a patient regarding delusions or hallucinations
    • If reorienting is initially ineffective, avoid persistent attempts or arguing as it can agitate the patient or cause feelings of isolation.

      Never confirm a delusion or hallucination (“I see Jesus, too!”) - this can exacerbate agitation or confusion.
  11. Teach patient coping skills to help manage hallucinations or delusions: Exercise, Singing / listening to music, Writing, Drawing, Talking with someone they trust
    • Help patient learn how to cope with and manage symptoms to improve daily functioning and behaviors.
  12. As symptoms improve, allow patient to make small decisions such as what to eat, wear or choice of activities
    • Allows patient to feel that they have more control of themself and their care. Promotes independence.
  13. Administer medication appropriately
    • Routine medications may be given to help improve symptoms.
      Atypical antipsychotics

      IM medications may be given PRN for acute exacerbations.
      Diphenhydramine
      Haloperidol
      Lorazepam

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
  • Pt may report aura before seizure
  • A postictal state (drowsiness, nausea, vomiting, headache)
Objective Data
  • Rhythmic twitching
  • Stiff contraction
  • Loss of consciousness
  • Staring off blankly
  • Repetitive behavior (lip smacking, laughing)

Nursing Interventions and Rationales

  1. Initiate seizure precautions for patients at-risk for seizures: Suction set up and working, Ambu-bag in room, Padding side rails, All side rails up
    • 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.
  3. Maintain safety during any seizure activity: Turn pt to side, NOTHING in mouth Do NOT restrain
    • Patients may be vomit during a seizure, therefore turning them to their side can help to prevent aspiration (in addition to having suction available).

      Putting things in the mouth can cause the patient injury as they tend to clench their teeth during seizures

      Restraining the patient may cause injury because of the unpredictable muscle movements
  4. 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.
  5. 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)
  6. 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
  7. 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.
  8. Provide emotional support
    • Seizures are serious and upsetting to witness. The more empathy and support you can provide patients and loved ones, the better.
  9. Help the patient develop a seizure action plan for after discharge
    • The patient and family need to know what to do should a seizure occur at home. Not all seizures are emergencies. They should know what to do to keep the patient safe and when to call 911:

      Cyanosis or not breathing

      Back to back seizures

      Seizure lasting > 5 minutes

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

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 to septic shock. Time is of the essence in sepsis recognition and treatment.

Etiology

Essentially, the cause of septic shock 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 of cellular death, resolution of infection, minimizing damage from cellular oxygen deprivation and lactic acid build up, maximizing cardiac output and resolution of condition.  

Subjective and Objective Data

Subjective Data
  • Pain
  • Difficulty breathing
  • Reports of s/s infection (burning with urination, frequent cough, green mucus, etc.)
Objective Data
  • ↑ temp (over 101° F)
  • ↓ temp (below 96.8° F)
  • HR over 90 bpm
  • RR over 20 bpm
  • Respiratory distress
  • ↓ urinary output
  • Hypotension
  • ↓ platelet count
  • Edema
  • Hyperglycemia (no hx diabetes)
  • Altered LOC
  • Mental status changes
  • ↑ WBC, bands
  • ↓ SVO2
  • ↑ lactic acid
  • ↑ creatinine

Nursing Interventions and Rationales

  1. Prompt lab draws: CBC - WBC count, Lactate - ↓ O2 to tissues, BMP - kidney function, ABG - shows acidosis, Blood Cultures
    • 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.

      Blood cultures must be drawn prior to the initiation of antibiotics to ensure the appropriate pathogen is identified.
  2. Appropriate administration of IV antibiotics
    • Drawing the labs, then starting antibiotics as ordered is the nurse’s responsibility.

      The goal is to initiate broad spectrum antibiotics within 1 hour of recognition of sepsis.
  3. Optimize fluid-volume status
    • Patients suffering from sepsis usually require massive fluid resuscitation. This helps to increase their preload and therefore their cardiac output.

      30 mL/kg in the first 6 hours

      100 kg man = 3 L fluid
  4. Assess, monitor, and optimize cardiac output MAP, CO, Signs of perfusion, Lactic Acid
    • Cardiac output is compromised in septic shock. 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.

      MAP should be monitored with an arterial line when administering vasopressors

      Lactic acid levels are elevated with decreased tissue perfusion - following lactic acid levels helps to determine if therapy is being successful.
  5. Assess, monitor, and support oxygen status: SpO2, Lung sounds, SOB, ABG
    • 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. Follow CLABSI and CAUTI protocols to prevent infection
  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

Hypovolemic shock is a loss of blood volume leading to decreased oxygenation of vital organs. The body’s compensatory mechanisms fail and organs begin to shut down.

Etiology

Any condition causing loss of circulating blood or plasma volume. Hemorrhage from any large source. Traumatic injuries. Burns (plasma loss due to capillary permeability). Prolonged vomiting or diarrhea.

Desired Outcome

The goal is to restore circulating blood volume, preserve hemodynamics, and prevent any damage to vital organs.

Subjective and Objective Data

Subjective Data
  • Weakness
  • Anxiety or restlessness
  • Report of vomiting or diarrhea
  • Report of rectal or vaginal bleeding
Objective Data
  • Measured fluid loss > 1500 mL
  • Hemorrhage or Burn
  • ↑ HR
  • ↑ RR
  • ↓ BP
  • ↓ CVP
  • ↓ CO
  • ↑ SVR
  • ↓ LOC
  • ↓ Urine output
  • Cool, pale, clammy skin

Nursing Interventions and Rationales

  1. Assess for Risk
    • Causes of shock include:

      Blood loss from:

      Traumatic injuries
      Internal bleeding, such as a GI bleed or surgical complication
      Postpartum hemorrhage

      Fluid loss from:

      Burns
      Diarrhea
      Vomiting

      Nurses should assess their patient for the risk of developing hypovolemic shock. The patient may have lost some fluid already, or maybe they’re at risk for bleeding. Either way, the more aware the nurse is of the risk, the more likely it can be prevented or caught early.
  2. Assess and monitor VS and LOC
    • Patient may develop tachycardia and tachypnea in the early stages, then hypotension in later stages. It’s important to note these changes in the patient. Monitoring VS could help to prevent hypovolemic shock if caught early, but will also help to determine the patient’s response to treatment.

      Level of consciousness should be assessed because it may decrease as the patient loses oxygenation of their brain. Decreasing LOC is a sign of advancing shock.

      Notify the provider for:

      ↓ blood pressure, not responding to fluids. If the blood pressure continues to drop, the patient will lose perfusion to vital organs.

      ↓ LOC - if the patient is more difficult to arouse or confused, this could be a sign of advancing shock. They may also begin to have difficulty protecting their own airway - the provider needs to be notified
  3. Monitor Hemodynamics
    • Hemodynamic measurements will tell us the severity of the shock and how well the patient is responding to treatment.

      MAP = Mean Arterial Pressure - this is the average pressure within the arteries. It can be calculated with a non-invasive blood pressure, but is more accurate when measured by an Arterial Line.

      Decompensated shock will show a decreasing MAP below 60 mmHg
      CVP = Central Venous Pressure. This measures Preload. In a patient with hypovolemic shock, it will be low (<4 mmHg). The goal would be to see this number as well as the CO increase with fluid resuscitation

      CO = Cardiac Output. As the patient’s preload decreases, so does their cardiac output. The body will attempt to compensate, so you may see a normal cardiac output for a while - then it will begin to drop as the body’s compensatory mechanisms fail. This is assessed using a FloTrac or PA catheter

      SVR = Systemic Vascular Resistance. This measures afterload. We will expect this to be high because of the body’s attempts to compensate through vasoconstriction. If fluid resuscitation is effective, we will see this number return back down to normal
  4. Prepare for procedures
    • Arterial lines are placed for invasive hemodynamic monitoring. They can measure MAP, but can also measure other hemodynamic values such as CO/CI, SVR, SV, etc. when using a FloTrac machine.

      Central lines are placed for administration of fluids and medications as well as hemodynamic monitoring of CVP, CO/CI, and SVR. Patients who have severe hemorrhages may receive a large bore (12g) central catheter called a Cordis so they can receive large volumes of fluids rapidly.

      Patients whose airway has been compromised due to ↓ LOC may need to be intubated to protect their airway, and placed on a ventilator.

      Patients may need to be taken to the OR to repair the injury or internal bleeding that caused the hypovolemia in the first place.

      **Informed consent MUST be obtained by the provider. You can explain procedures to patients/family, but the provider must give the reason, risks, benefits, etc. and obtain the informed consent.
  5. Insert 2 Large Bore IV’s
    • The patient will need large bore IV access in order to administer fluid resuscitation. This should be done with a pressure bag or rapid infuser.

      The highest possible rate on an infusion pump is 999 mL/hr. At this rate, 1 L of fluids takes 1 hour to infuse. Shorter and thicker catheters will provide for faster fluid administration.
  6. Administer Blood Products
    • For patients who have lost significant amounts of blood due to trauma or hemorrhage, they should receive transfusions of blood products.

      Be sure that consent is obtained and that the patient is aware of possible reactions. Send a type and crossmatch to determine the patient’s blood type. Verify the blood product with another nurse prior to administering and monitor per facility protocol for transfusion reactions. Usually this is q15min x 2, q30 min x 1, and q1h after that for standard infusions. However, in hypovolemic shock, even blood products are given via rapid infusion.

      Packed Red Blood Cells (PRBC’s) do not contain clotting factors, platelets, or plasma - therefore patients may have trouble clotting after receiving multiple units of PRBC’s. During massive transfusion protocol, units of plasma, platelets, and clotting factors are given at certain intervals to prevent this clotting problem.

Pathophysiology

A hereditary disease that destroys red blood cells by causing them to become rigid and “sickle” shaped. Occurs mainly in persons of African descent. When red blood cells release oxygen to the tissues and O2 concentration is reduced, the red cells and become rigid, assuming a sickle shape. As the cells are re-oxygenated the sickle-shaped cells become clogged in the small blood vessels causing obstruction of the circulation. This results in damage to the various tissues.

Etiology

A single genetic mutation of the hemoglobin molecule. Inheritance of the mutated gene from both parents results in sickle cell disease. A person who inherits the mutated gene from only one parent is a carrier of the trait. There is no cure for this condition.

Desired Outcome

Manage pain of SC crisis, promote optimal perfusion and prevention of complications

Subjective and Objective Data

Subjective Data
  • Fatigue
  • Pain crisis
    • Severe pain
    • All over body
  • Shortness of breath
  • Chest pain
  • Irritability
Objective Data
  • Swelling of hands / feet
  • Fever
  • Jaundice
  • Cyanosis
  • Presence of sickled cells on histologic exam

Nursing Interventions and Rationales

  1. Assess respiratory status: Rate, Use of accessory muscles, Cyanosis
    • During a SC crisis, red blood cells cannot effectively deliver oxygen to the tissues resulting in poor perfusion. Frequent infections often result in pneumonia and cause shortness of breath and chest pain.
  2. Monitor cardiac status: Perform 12-lead ECG
    • Changes in respiratory status and hypoxia may lead to arrhythmias
  3. Assess for and manage pain: Administer medications, Apply warm compresses
    • Poor perfusion results in damage to the tissues and organs which causes intense throbbing pain that may change location from one body part to another.

      Avoid using cold compresses as cold causes further vasoconstriction and exacerbates pain and crisis. Warm compresses dilate vessels to promote circulation and reduce pain and muscle tension.
  4. Administer medications / blood products as necessary: IV fluids (prevent or treat dehydration), Analgesics for pain - opioids may be used, Antibiotics for infections, Hydroxyurea - prevents sickling of red blood cells to reduce the number of crisis episodes
    • Medication is given to manage the symptoms of a crisis event and treat any underlying infections that may cause a crisis.
      In some cases, blood transfusions may be necessary to manage crisis events and increase perfusion to vital organs.

      Monitor vital signs carefully

      Monitor respiratory status and breath sounds
  5. Assess for signs of infection: Fever
    • Bacterial infections may be severe and often result in pneumonia. Frequent infections weaken the organ systems and may lead to organ failure.
  6. Assess for and manage dehydration
    • Stress on the organ systems from dehydration can exacerbate the pain of a crisis. Encourage adequate hydration and administer IV fluids to promote adequate blood viscosity.
  7. Provide wound care as necessary
    • Decreased peripheral circulation often results in changes in the skin and delayed wound healing.
  8. Encourage routine eye exams
    • Sickling of red blood cells can damage the vessels in the eyes over time and cause blindness.
  9. Monitor vital signs closely
    • Decreased circulating blood volume can occur resulting in tachycardia and hypotension
  10. Minimize stress: Teach guided imagery techniques, Encourage deep breathing exercises, Provide resources for stress management
    • Stress and physical activity increase the body’s metabolic need for oxygen. Reducing stress helps preserve fluid balance and provides better individual pain control.
  11. Assess for changes in consciousness and mentation
    • The brain is sensitive to fluctuations in oxygen balance. Decreased perfusion of brain tissue may result in confusion, loss of consciousness or stroke.

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 subtherapeutic 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

SIADH is diagnosed as a collection of symptoms that take place with otherwise normal function. This syndrome is characterized by hyponatremia, concentration of urine and dilution of blood. The patient has an adequate amount of blood, but it is more dilute than normal. SIADH causes the body to retain fluid resulting in decreased electrolyte balance.

Etiology

SIADH is caused as an effect of other disorders, often nervous system disorders such as epilepsy, Guillain-Barre syndrome or head trauma, or cancers of the pulmonary, brain, GI and genitourinary systems. It is caused when the hypothalamus is stimulated to produce excess amounts of AVP (arginine vasopressin) which is an antidiuretic hormone (ADH) that triggers the kidneys to retain fluid in the tubules and excrete sodium. As the amount of fluid builds up in the cells and tissues, it creates an imbalance of electrolytes, specifically sodium, causing hyponatremia.  The excess fluid dilutes the blood instead of being excreted causing the urine to become concentrated.

Desired Outcome

Patient will maintain normal electrolyte and fluid balance

Subjective and Objective Data

Subjective Data
  • Nausea
  • Muscle cramps
  • Depression, irritability
  • Fatigue
Objective Data
  • Vomiting
  • Hypothermia
  • Tremors
  • Confusion
  • Seizures
  • Coma
  • Edema
  • Signs of Volume Overload

Nursing Interventions and Rationales

  1. Monitor I & O, daily weights
    • Patients may be on fluid restrictions to help balance intake and output. Monitor for retention through calculated intake and output and with daily weights at the same time on the same scale each day.
  2. Continuous ECG monitoring
    • Changes in electrolyte balance can disrupt the electrical conduction in the heart causing dysrhythmias.
  3. Assess and monitor vital signs every 1-2 hours
    • Fluid shifts can occur quickly causing changes in blood pressure and heart rate. Most often patients will experience hypotension.
  4. Assess and monitor respiratory status; note changes in respiration, auscultate lungs
    • Excess fluid volume can settle in and around the lungs and heart. Monitor for signs of congestion, difficulty breathing. SIADH can also be triggered by pneumonia, so monitor for the underlying cause as well.
  5. Administer medication and electrolyte supplements appropriately: Electrolyte supplements (potassium), Demeclocycline or lithium - stops the kidneys from responding to extra ADH
    • Supplements may be given to regulate electrolyte imbalance. Carefully administer supplements to avoid overloading too quickly
  6. Monitor lab / diagnostic values: Serum potassium, Serum sodium, Serum chloride, Serum osmolality (concentration), Urine specific gravity
    • Hyponatremia is the hallmark of SIADH. Monitor lab values to determine if treatment is effective.

Pathophysiology

Lupus is a chronic autoimmune disease in which the immune system attacks different parts of the body causing inflammation and damage to various body tissues. Lupus can affect the skin, joints, heart, lungs, kidneys, blood vessels and brain. Patients with lupus may have phases of worsening symptoms called “flares” and other periods of milder symptoms. Lupus symptoms may mimic other disorders and may go undetected for several years. Management by a rheumatologist is recommended.

Etiology

The exact cause of SLE is not known, but scientists believe it may be in part related to genetics.  Environmental factors that seem to trigger lupus include sunlight, stress, viruses, trauma and some medications.  

Desired Outcome

Reduce inflammation, regain optimal mobility, reduce organ dysfunction, reduce number and frequency of “flares”

Subjective and Objective Data

Subjective Data
  • Joint pain
  • Chest pain with deep breathing
  • Extreme fatigue
  • Sensitivity to sun
Objective Data
  • Butterfly or malar rash on face
  • Swollen joints
  • Unexplained fever
  • Hair loss
  • Swelling in legs or around eyes
  • Mouth ulcers
  • Swollen lymph glands
  • Raynaud’s phenomenon (pale or purple fingers or toes)

Nursing Interventions and Rationales

  1. Assess and monitor skin for rash
    • The hallmark sign of SLE is a malar butterfly rash across the cheeks and bridge of the nose; rash may develop on the face, neck, chest or extremities
  2. Assess mucous membranes; encourage oral hygiene; rinse mouth with half-strength peroxide three times per day
    • Oral lesions and ulcers are common symptoms; peroxide helps to keep oral lesions clean and promote healing
  3. Assess and manage pain: Analgesics, AROM/PROM, Positioning for comfort and to prevent contractures, Apply warm/cool compresses to painful joints, Recommend non-pharmacological alternatives
    • Inflammation and SLE related arthritis can cause significant pain and stiffness of joints; Medication may be necessary, but encourage other alternatives as well.
  4. Encourage deep breathing exercises to promote adequate gas exchange and prevent lung diseases: Splinting, Incentive spirometer, Relaxation
    • Patients may report chest pain with deep breathing. Encourage breathing exercises to open airways, reduce pain and relieve anxiety. Incentive spirometers and splinting with pillows may be beneficial.
  5. Cluster care and schedule activity
    • Fatigue is a common complaint for patients with lupus. Encourage activity as tolerated but discourage patients from overexertion. Cluster care to reduce fatigue and conserve energy.
  6. Monitor lab / diagnostic tests: ANA (antinuclear antibody), ESR (erythrocyte sedimentation rate), RF (rheumatoid factor), CMP / liver function tests
    • Lab tests can help determine the extent, if any, of organ failure or dysfunction and therefore determine progression of disease and response to treatments.
  7. Administer medications appropriately: Antimalarials (chloroquine), Corticosteroids (prednisone), NSAIDs, Immunosuppressants (cyclophosphamide), Opioids
    • Medications are often given to suppress immune system, treat existing inflammation and manage symptoms such as pain. Monitor for GI discomfort or irritation when giving medications; prevent constipation if opioids are given.
  8. Nutrition and lifestyle education: Healthy diet (fruits, grains, vegetables), Regular exercise, Avoid sun exposure, Adequate rest
    • Maintaining a healthy lifestyle and staying active can help improve immunity and reduce the number and frequency of flares. Sun exposure often triggers rash and flare, try to avoid; Rest helps promote healing and reduces inflammation.

Pathophysiology

Thrombocytopenia is when there is a low platelet count and an increased risk of bleeding. This is usually a side effect of another disease process such as leukemia and some immune system disorders, or the use of certain medications. Platelets, also called thrombocytes,  are essential to the body as they clump together and form clots that seal blood vessels when injury or damage occurs. If bleeding does occur, it may be internal or external.

Etiology

Many factors influence the development of thrombocytopenia such as cancers, autoimmune diseases, infections, surgery, alcohol use and certain medications. The condition can be inherited or acquired. Generally, a low platelet count develops when the bone marrow fails to produce enough thrombocytes, the bone marrow makes enough, but the body destroys them or uses them too quickly, or when the spleen holds on to too many platelets.

Desired Outcome

Increase platelet production and availability, minimize risk of excessive bleeding, treat underlying cause

Subjective and Objective Data

Subjective Data
  • Easily bruises
  • Bleeding gums when brushing teeth

** Patients may be completely asymptomatic **

Objective Data
  • Petechiae or purpura
  • Abnormal vaginal bleeding
  • Epistaxis
  • Low platelet count on CBC (<100,000)

Nursing Interventions and Rationales

  1. Assess for signs of internal or external bleeding; blood in urine or stool, bleeding of mucous membranes such as gums, and skin
    • Observe skin for petechiae, purpura and open wounds. Bleeding may be minimal, non-existent or severe.
  2. Administer medications and blood or platelet transfusions as indicated: Immunosuppressants, Androgens (males only), Vinca alkaloids (vincristine)
    • Despite low platelet count, administering platelets may not be indicated if there are no signs of active bleeding.

      Treatment depends on the cause of thrombocytopenia; immunosuppressants may be given if the underlying cause is autoimmune disease; androgens are not given to females as they have been known to cause unwanted hair growth; vinca alkaloids may be given if all other measures have failed
  3. Educate patient to avoid NSAIDs
    • NSAIDs such as ibuprofen and aspirin can increase the risk of bleeding and should be avoided. If pain relief is necessary, recommend acetaminophen or non-pharmacological alternatives.
  4. Initiate bleeding precautions; use only electric razors, limit needlesticks, use soft toothbrush, provide safety devices to prevent injury (non-skid shoes/socks, etc.)
    • Decreased platelet counts do not always indicate bleeding, but may lead to excessive bleeding if injury occurs.
  5. Nutrition and lifestyle education: Avoid activities that could cause injury (contact sports, martial arts, etc), Limit or avoid alcohol, Avoid NSAIDs, Increase intake of leafy greens
    • Avoid high risk activities that may result in injury to reduce the risk of bleeding; alcohol slows the production of platelets; NSAIDs increase the likelihood of bleeding; leafy greens are high in vitamin K which helps promote clotting.
  6. Monitor for signs of infection if splenectomy is required
    • Removing the spleen may be necessary to treat thrombocytopenia. If so, it increases the risk of infection. Monitor for fever, rash and other signs of infection.

Pathophysiology

Blood clots formed from any source, lodging in the patient leg or arm, impeding blood flow and causing inflammation. This backup of blood pools in the extremity causing swelling, redness, warmth and pain. These clots can dislodge and become embolic, lodging in the heart, lungs, or brain.

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.  Virchow’s triad explains the 3 major contributors to the development of thrombophlebitis: venous stasis, damage to the inner lining of the vessel, and hypercoagulability.

Desired Outcome

Stabilization of the blood clot or disintegration of the blood clot as well as prophylaxis treatment for future blood clots. Prevention of complications such as embolic strokes, myocardial infarction, or pulmonary embolism.

Subjective and Objective Data

Subjective Data
  • Unilateral findings on affected extremity:
    • Painful
    • Numbness
    • Tingling
  • Symptoms of Embolism
    • Lungs → Pulmonary Embolism (PE)
      • Anxiety
      • Shortness of Breath (SOB)
      • Chest Pain (CP)
    • Heart → Myocardial Infarction (MI)
      • Chest Pain (CP)
    • Brain → Stroke
      • Facial asymmetry
      • Confusion
      • One sided deficit
Objective Data
  • Unilateral findings on affected extremity:
    • Warmth
    • Redness
    • Swelling (firm)
    • Decreased peripheral pulse
  • Positive D-Dimer
  • Evidence of Clot on Ultrasound
  • Possible Positive Homan’s Sign (pain with dorsiflexion of the foot) *caution – this maneuver may dislodge the clot*

*Note – the evidence shows that Homan’s Sign is an unreliable and nonspecific finding. It is only present in 33% of those with a DVT and should not be used as standard practice in isolation.

Nursing Interventions and Rationales

  1. Assess for evidence of embolus: Neuro Status, Respiratory Status, Chest Pain / ECG
    • A potential complication of thrombophlebitis and DVT is thrombi can break of and become emboli to other vital organs such as the lungs (PE), heart (MI), or brain (CVA). Monitor for signs of these occurrences.
  2. Administer Heparin- Transition into a SubQ or oral anticoagulant to prevent future clots.
    • This is an anticoagulant that prevents worsening of clots or development of new clots. It does not breakdown clots, but allows the body’s natural fibrinolysis to occur without new clots forming.

      Monitor aPTT q6h to adjust and maintain therapeutic levels.

      Follow your facility protocols for administration of bolus and dosing. Refer to the Pharmacology course for more details of this drug.
  3. Administer Enoxaparin (Lovenox) and/or Warfarin (Coumadin)
    • Both SubQ and oral anticoagulant therapy are used as prophylactic (prevention) therapy.

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

      Follow your facility protocols for administration and dosing. Refer to the Pharmacology course for more details of these drugs.
  4. Encourage ambulation / Compression socks / SCDs (Prevention)
    • The sooner you get a patient moving the less likely they are to form anymore blood clots.

      Compression socks and SCDs encourage blood flow back to the heart and prevent blood stasis.

      *Caution - as soon as the patient has a confirmed DVT, ll three of these should be held until an IVC filter can be placed
  5. 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.

      The only time Vitamin K is used therapeutically is if the patient is bleeding out, in which case the treatment may be vitamin K with Fresh Frozen Plasma (FFP).

      Vitamin K is also the antidote for Coumadin (warfarin)
  6. 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.
  7. 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

The tonsils are oval-shaped masses of tissue found on both sides of the back of the throat and help the immune system fight off bacteria and viruses that enter through the mouth. Tonsillitis occurs when the tonsils become inflamed or infected. Many cases resolve on their own, but some bacterial infections require treatment. Repeated bacterial infections, or those that do not respond to treatment, may result in surgery to remove the tonsils.

Etiology

Viruses account for the majority of cases of tonsillitis and are usually seen in young children, under the age of five. The most common bacterial infection is Streptococcus pyogenes (strep throat). This is easily spread by being in close contact with other affected individuals and is especially common in school aged children.  As the tonsils become swollen, the airway may become blocked which is an emergency. Complications of untreated tonsillitis include rheumatic fever and inflammation of the kidneys (poststreptococcal glomerulonephritis). Practicing good hand hygiene can help prevent the spread of viruses and bacteria that cause tonsillitis.

Desired Outcome

Patient will be free from pain and infection; patient will have adequate nutritional intake and hydration; patient will maintain adequate respiratory status

Subjective and Objective Data

Subjective Data
  • Pain in the throat > 24-48 hours
  • Irritability
  • Refusing food or drink
  • Difficulty swallowing
Objective Data
  • Drooling
  • Bad breath
  • Fever
  • Palpable lymph glands in neck
  • Swollen tonsils
  • Erythema or pustules in the throat

Nursing Interventions and Rationales

  1. Assess vital signs
    • Get baseline to determine if interventions are effective. Assess for fever which can lead to tachycardia, tachypnea and elevated blood pressure
  2. Assess mouth and throat
    • Look for erythema, pustules or petechiae that may indicate infection. Assess for adequate airway. Note any post-nasal drip that could cause throat pain.
  3. Assess for signs of dehydration
    • Throat pain in children often causes them to refuse food and drink because swallowing is painful. Note mucous membranes.
  4. Assess for pain using appropriate pain scale for age (FLACC / FACES) and provide non-pharmacological pain relief methods
    • Throat pain is the most common symptom of tonsillitis, but patients may not be able to verbalize complaints.

      Note nonverbal cues such as crying, mouth breathing, irritability or refusal to eat or drink.
  5. Administer medications as appropriate
    • Viral tonsillitis requires only symptom management and will resolve on its own.

      Bacterial tonsillitis (strep) will require antibiotics.

      Give analgesics such as acetaminophen orally or rectally as appropriate for age, for pain relief.
  6. Prepare patient for and assist with surgery as required
    • Repeated infections or those that are resistant to treatment may require surgical removal of the tonsils.
  7. Encourage patient to eat and drink; avoid dairy products
    • It is important to maintain adequate nutrition to help the immune system fight off disease.

      Dairy products coat the throat and may cause the patient to cough which will further irritate the throat and cause pain, especially after surgery
  8. Provide patient and parent education for home care and prevention
    • Demonstrate and educate parents and patient about good hand hygiene to avoid spread of germs.

      Encourage patient to avoid playing with other children when they feel sick.

      Encourage rest to help the immune system work.
      Parents should keep child home from school or daycare while running a fever.

Pathophysiology

The urine is normally sterile, but exposure to bacteria at the distal urethra (meatus) may lead to colonization of bacteria within the urinary tract. Infection may take place anywhere within the urinary tract, including the lower urinary tract (cystitis), or the upper urinary tract (pyelonephritis).  Cystitis refers to inflammation and infection of the bladder, Pyelonephritis refers to inflammation and infection of the kidneys.

Etiology

The bacteria associated with 80% – 90% of urinary tract infections is Escherichia coli. Other bacteria that commonly cause infections include klebsiella, Enterococcus and Staphylococcus. Bacteria may be introduced to the urinary tract through the use of indwelling catheters. Antibiotic use disrupts the normal flora of the vagina and allows bacteria to grow and spread to the urethra, as does  frequent or recent sexual intercourse. Difficulty voiding and inability to empty the bladder are also causes for the development of bacterial infections in the urinary tract.

Desired Outcome

Patient will be free from pain and symptoms of UTI and will be free of infection.

Subjective and Objective Data

Subjective Data
  • Lower back pain
  • Dysuria
  • Frequent urination
  • Urethral discharge (primarily in men)
  • Nocturia
  • Suprapubic pain
  • Nausea / vomiting
Objective Data
  • Hematuria (may be microscopic)
  • Fever / chills
  • Oliguria
  • Foul smelling urine

Nursing Interventions and Rationales

  1. Monitor vital signs for infection
    • Symptoms that indicate worsening infection or progression of disease include :
      Tachycardia
      Fever / chills
      Elevated blood pressure
  2. Assess / palpate the bladder every 4 hours
    • Assess for bladder distention to determine if there is urinary retention.
  3. Assess hydration status and encourage increased fluids
    • Increasing fluid intake will help the kidneys to flush excess waste and increase blood flow. This will also prevent dehydration with can complicate UTI.
  4. Administer medications to treat: Infection, Pain, Fever
    • Infection- Most UTIs can be treated with common antibiotics such as nitrofurantoin, cephalexin and sulfamethoxazole/trimethoprim, depending on urine culture & sensitivity test results.

      Pain- Analgesics for urinary pain include phenazopyridine, which is a dye that helps numb the pain within the urinary tract.

      Fever- Ibuprofen or acetaminophen may be given in case of fever and chills per facility protocol
  5. Provide education regarding hygiene and prevention of future infections
    • Wipe from front to back when urinating and defecating to prevent bacteria being introduced to the vagina and urethra

      Avoid scented hygiene sprays, douches and bath products to prevent infection and irritation

      Cleanse genital area before and after sex

      Empty bladder frequently and completely to avoid build up of toxins in the bladder

      Drink lots of water

      Wear cotton underwear and avoid tight fitting clothing
  6. Apply heating pad for comfort
    • Application of heat to lower back or abdomen may help relieve pain and cramping. Avoid prolonged exposure to heating pad, using only 15 minutes per session with at least 15-30 minutes in between to prevent burns.

Pathophysiology

The forceful emptying of the stomach contents is known as throwing up (vomiting). Two or more loose, watery stools constitutes diarrhea. Vomiting and diarrhea without fever is common in children. Vomiting and diarrhea often occur together, but may happen independently of each other and at any time. The symptoms, while frustrating and worrisome, may serve as the body’s natural method to rid itself of the offending cause. Extended periods of vomiting or diarrhea may lead to dehydration.

Etiology

A child’s gastrointestinal system is sensitive and may react to certain medications or foods that are hard to digest, such as sweets or undercooked meats. Other causes of vomiting and diarrhea may be virus, bacteria or parasites. Viral gastroenteritis is the most common cause of vomiting and diarrhea, specifically Rotavirus and Norovirus.

Desired Outcome

Patient will have soft, formed stools; patient will vomit less than 2 times in 24 hours; patient will maintain adequate hydration

Subjective and Objective Data

Subjective Data
  • Abdominal pain
  • Nausea
  • Irritability (infants and toddlers)
  • Decreased appetite
Objective Data
  • Vomiting
  • >2 loose, watery stools in 24 hours

Nursing Interventions and Rationales

  1. Assess patient for degree of vomiting: mild (1-2x/day), moderate (3-7x/day) or severe (8 or more or vomits everything consumed)
    • Understanding the severity of symptoms can help determine course of treatment.
  2. Obtain history and information from patient’s parent or caregiver
    • Determine when symptoms began, any contributing factors and if other family or household members are experiencing similar issues. This can help determine etiology and guide treatment. Other sick family members should be isolated from the patient.
  3. Assess vital signs
    • Monitor for fever or signs of dehydration including tachycardia and tachypnea.

      Rapid respiratory rate may indicate possible aspiration of emesis.
  4. Assess for blood in stool or emesis
    • The presence of blood in vomitus or stools may indicate a more severe infection or issue in the GI system.
  5. Assess abdomen for distention, hyperactive bowel sounds and cramping
    • Patient may be guarding if unable to verbally express pain; note hyperactive sounds that may accompany diarrhea
  6. Monitor Intake and Output
    • Determine fluid balance and need for rehydration intervention; prevent dehydration. Decreased wet diapers may be a sign of dehydration.
  7. Obtain samples of stool for culture
    • Determine if the cause of symptoms is due to a parasitic or bacterial infection; helps determine course of treatment
  8. Provide perineal care following diarrhea
    • Help patient clean perineal area following stools to prevent skin breakdown and rash; apply barrier cream such as zinc oxide as needed
  9. Encourage oral hydration; Administer oral rehydration solution (ORS) as necessary or IV fluids as appropriate
    • Encourage parents to continue offering normal diet.

      Patients are often more responsive to frozen juice bars, ice pops and flavored gelatin.

      Supplementation of electrolyte solution may be required.

      Breastfed infants should continue to breastfeed with ORS supplementation
  10. Educate patient and family on BRAT diet (Bananas, Rice, Applesauce, and Toast)
    • This diet is easy on the digestive system and helps to decrease diarrhea and replace nutrients lost.
  11. Administer medications as appropriate
    • Typically, antidiarrheal medications
      are not recommended, as diarrhea usually resolves spontaneously once the virus or bacteria has been flushed out of the body.

      Anti-nausea medication may be given depending on the severity of vomiting.

      Antibiotics may be given if symptoms are related to bacterial infection
  12. Provide patient and family education to manage and prevent symptoms
    • Encourage good handwashing to prevent spread of infection.

      Avoid sugary or high fat foods that can make diarrhea worse.

      Encourage older children (>2yrs old) to drink chicken broth or sports drinks to help rehydration