1-medical-surgical_compress.pdf

1. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* CARDIOVASCULAR Ischemia: lacking Blood supply Infarcted: Absence of blood supply; tissue damage (Infarcted cardiac tissue releases enzymes) 1. DIAGNOTICS: 1.1 CARDIAC ENZYMES: 1.1.1 CK-MB: elevation indicates myocardial damage: elevates within 24 4-6 hrs; peaks in 18- hrs 1.1.2 LDH: occurs in 24 hrs and peaks in 48-72 hrs 1.1.3 TROPONIN I: 0-0.4 ng/mL; EARLIEST in 2-4 hrs; most sensitive 1.2 COMPLETE BLOOD COUNT: WBC RBC, H&H, HDL, LDL, Triglyceride Level 1.3 Electrolytes: K, Na, Ca, Phosphorus (In renal), Mg 1.4 BUN & CREATININE: the heart stops, stops the perfusion to other organs especially the kidney 1.5 CXR: enlarged heart 1.6 ECG: electrical activity of the heart; Simply remove metals but in reality no real effect *ADD: NCLEX ECG; Written and what to do with it 1.7 Coagulation Tests: In pharmacology 1.8 CARDIAC CATHERTERIZATION: assess the obstruction in the blood vessels or coronary arteries 1.8.1 FEMORAL ARTERY: you don’t insert the whole catheter; place dye to determine where the obstruction starts 1.8.2 NOW predisposed to bleed: Pressure dressing and Sand bag (10 pounds of pressure) unto the area: HIGH PRESSURE ARTERY; The client may complain of bed wetting but may refer to bleeding; 1.8.3 It can also form Hematoma (Due to the pressure and moving around) in the inguinal artery (LOWER EXTREMITIES) so monitor the peripheral pulses (Pedal Pulses: Dorsalis Pedis. Posterior Tibialis) ’ ; if you can t palpate, you use a DOPPLE; 4-6 hrs immobilized on bed 1.8.4 Ask patient if allergic to Dye CORONARY ARTERY DISEASE 1. AGINA: is the symptom of CAD; Chest pain results from Myocardial Ischemia: most common symptoms of CAD; Concept: DEMANDS EXCEEDS SUPPLY 1.1 TYPES 1.1.1 STABLE: Pain goes away when precipitating factors are removed; pain relieved by REST and NTG 1.1.2 UNSTABLE: Increased activity severity, duration and frequency; might not be relieved by NTG (2 capsules); May proceed to MI 1.1.3 PRINZMETAL/ VARIANT/ VASOSPASTIC: may occur at rest (usually secondary to VASOCONSTRICTION ie Cold environment) 1.2 CAUSE: Anything that increases the HR, Increases oxygen Demand (Anything that causes Stress, Stimulation or Excitement) 1.3 3E’s: EXERTION, EMOTION, EATING 1.3.1 Increase metabolism increases HR; SFF 1.3.2 Walking is the only possible exercise 1.3.3 Overjoyed can cause increase HR 1.3.4 Sexual Activity 1.3.5 Artherosclerosis (MOST COMMON CAUSE); Thromboembolism 1.4 ASSESSMENT 1.4.1 Pain: SUBSTERNAL, Crushing or compressing; may radiate to the LEFT arms, jaws or back also in shoulder; ; usually after exertion, excitement or exposed to cold 1.4.2 MEN: Substernal pain 1.4.3 WOMEN: Lower/ Epigastric region pain; May be diagnosed as GERD not Angina; Higher cause of death in women due to Misdiagnosis 1.4.4 Anxiety: Diaphoresis, dyspnea, tachycardia, palpitations, epigastric distress (ATYPICAL/ uncommon manifestation; Mostly for women) 1.5 DX 1.5.1 Increased Cholesterol, LDL and triglycerides 1.5.2 CARDIAC ENZYMES: usually WITHIN NORMAL LEVELS 1.5.3 Coronary arteriography shows narrowing coronary arteries 1.5.4 ECG: ST segment depression, T-wave inversion *In NON-STEMI and ANGINA: both are Non ST elevated and may become depressed; so you don’t know the difference; The only thing that will tell you that it is MI is CARDIAC EZYMES that show presence of infarction 1.6 MANAGEMENT 1.6.1 Low fat, Low cholesterol; SFF 1.6.2 Administer 02 to decrease 02 demand 1.6.3 Maintain Bed rest and SEMI FOWLER’s position: Reduce cardiac workload (with bathroom privilege: may walk but until bathroom only) 1.6.4 Encourage weight reduction and smoking cessation (vasoconstriction) 1.7 MEDICATION 1.7.1 NTG: 3 Months; Take 5 minutes max of three then go to the ER or call 911 1.7.2 Anticoagulants: Heparin (APTT, Protamine Sulfate); Coumadine (PT, Vit K) 1.7.3 Ca Channel Blockers (VND) 0 0

2. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* 1.7.4 Beta Blockers (propranol) 1.8 TREATMENT 1.8.1 Percutaneous Transluminal Corornary Angioplasty (PTCA) 1.8.2 Intravascular Stenting: Done to prevent restenosis after PTCA; Given Coumadin, ASA (prevent clotting; lifetime medication for stents) 2. MI *Loose circulation to whole body: Brain and Kidneys (U/O monitor) 2.1 CAUSES 2.1.1 Total occlusion of one of the coronary arteries causing ischemia, injury and NECROSIS 2.1.2 Infarction most common to the LV 2.1.3 RF: same risk of Angina 2.1.4 Not relieved by rest or NTG 2.2 LEVINE’S SIGN: clutching at the chest due to Pain; Most likely having an MI 2.3 ASSESSMENT 2.3.1 Crushing substernal pain (radiate to jaw, back and arms; unrelieved by rest and NTG) 2.3.2 Dyspnea, Diaphoresis 2.3.3 Hypoxia causes Arrhythmias (V Fibrillation: MC cause of Death) *PULSELESS V- - TACH and V FIB: Shockable rhythm 2.4 DX 2.4.1 Diagnostic evaluation: ECG shows deep, wide Q wave (All layers are infarcted: epi, myo and endocardium), Elevated or depressed ST-segment, T- wave inversion 2.4.2 Coupled with Cardiac Enzymes, you will be able to determine the presence of MI; Increased Cardiac Enzymes 2.5 MANAGEMENT 2.5.1 Bedrest with Bedside Commode (used as a chair and makes it easier to defecate and urinate; just beside the bed) 2.5.2 CABG: Saphenous Vein (Contraindicated with varicose Veins); Internal Mammary Artery (may be used); The number CBG x5 meaning 5 vessels were bypassed 2.5.3 Angioplasty 2.5.4 Low calorie, low cholesterol, low fat diet 2.5.5 Monitor labs (ABG, CK, electrolyte and Troponin) 2.5.6 02 2.5.7 CPR (if patient becomes unconscious and defibrillate when ECG shows V Fibrillation) *CPR within um of 15 minutes 5-10 minutes; Brain maxim anoxic; Longer, becomes stroked-out (vegetable) 2.6 CPR 2.6.1 Assess consciousness: hey hey are you ok: Unresponsive 2.6.2 Check the Pulse: Carotid Pulse for at least 10 seconds 2.6.3 Assess Respiration: rise and fall [New: MONITOR for absence of breathing or abnormal breathing {GASPING for breath}] 2.6.4 Call for help: CODE 2.6.5 Start Chest Compression: 30:2 Compression to Breathe; ; 2 INCHES HIGH QUALITY CPR Adequate rate and Adequate Depth: 100-120 compressions per minute; 2.6.6 Advance Airway (Ambubag): 1 breathe every 6 seconds; Avoid excessive ventilation; REMEMBER TO COUNT 2.6.7 ABC: Compression, Airway, Breathing 2.6.8 New: 2 minutes of Full compression not unless someone brings the Defibrillator 2.6.9 Defibrillator: Apex and Sternum (for the paddles and lubricate); Once placed on the chest, APPLY 10 lbs of pressure; Setting must be on MODE: ASYNCHRONIZED (It does not matter where it will hit; the rhythm is chaotic; No need to be careful; Shock will hopefully go back to any rhythm good for perfusion); JOULES: It depends on the defibrillator being used; 2.6.9.1 MONOPHASIC: One way and does not travel back to the heart; 360 Joules 2.6.9.2 BIPHASIC: Goes back and forth with an AC Current with lesser joules or damage to the muscles; 200 Joules *CARDIOVERSION: SYNCHRONIZED 2.6.9 if does not wake up: KEEP CPR and Inject needed meds: EPINEPHRINE; Then Continue Defibrillation with same joules 2.7 MEDICATION 2.7.1 MONA 2.7.2 MORPHINE: vasodilator and analgesics (reduces Myocardial 02 demand) 2.7.3 O2 2.7.4 NTG 0 0

3. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* 2.7.5 ASA: Anti-Platelet 2.7.6 Beta Blocker and CA Channel 2.7.7 Thrombolytics: Given 3 4 hrs - after S/SX 2.7.8 Anticoagulant 2.8 VENTRICULAR FIBRILLATION: Chaotic Discharge; rate >300/min, may result to clinical death; IMMEIDIATE DEFIBRILATION and EPINEPHRINE CARDIAC ARRYTHMIAS - Abnormal electrical conduction or automaticity that changes cardiac rhythm rate - PROPERTIES: [1] Automaticity (initiating its own heart beats); [2] Conductivity (Traveling from one point to another); [3] Contractility (the ability to empty the content of the heart) - SA NODE: the intrinsic pacemaker of the heart IMPULSE WAVE ACTIVITY SA NODE HR: 60-100 bpm P-wave Atrial Depolarization: Contraction AV NODE HR: 40-60 bpm Time travel & Impulse from SA to AV: PR interval: 0.12- 20 seconds BUNDLE OF HIS PURKINJE FIBERS: 20 40bpm - QRS: 0.4-0.12 Seconds Ventricular Depolarization T-Wave Ventricular Repolarization: Resting Heart CARDIAC DYRRYTHMIAS TYPES LABEL BPM MGMT SINUS Normal Sinus Rhythm All the available waves (PQRST) Sinus Bradycardia Still from SA Node; But slower; Sleeping Asymtomatic: No tx Symptomatic: Atropine S04 Sinus Tachycardia Exertion ATRIAL Atrial Flutter P-wave Jagged Saw teeth 250- 350 Quinidine (Na channel Blocker) Atrial Fibrillation Jiggling; Beating to fast, shaking atrium; Presence of Blood clot >350 Anti- coagulants PAC Ectopic Heart beat VENTRICULAR Ventricular Tachycardia All QRS 101- 250 Lidocaine; VTach Pulse: Cardioversion VTach w/o Pulse: Defibrillation Ventricular Fibrillation Chaotic HEART BLOCK First Degree Heart Block Prolonged PR interval HR at 40 50 - No treatment Second Degree Type 1: Wincklebach PR interval: Long, longer, longest drop No treatment Type 2 PR Interval: Norma, normal, normal, drop If requires tx if VR falls too low to maintain adequate CO Third Degree No impulse form SA node reaches the ventricles; no association; cant determine which wave is which Pace makers *IMPAIRED TISSUE PERFUSION: all Cardiac Dysrhythmias 1. CAUSES 1.1 Congenital, Drug toxicity, Electrolyte imbalances (HYPOKALEMIA: most dangerous; Sister is Magnesium so also low); Heart Disease (MI, CHF) 2. TREATMENT 2.1 Anti arrhythmic card , Synchronized ioversion, CPR, Defibrillation 2.2 ICD (Implanted Cardiac Defibrillator; detects fibrillation and shocks; for post VFIb/MI patients), Transcutaneous pacing 3. CARDIOVERSION: 50-200 Joules only 3.1 Synchronized mode: you wait for a particular or certain wave; WAIT FOR THE R-WAVE 3.2 DON’T HIT the T-WAVE (the heart is resting) 0 0

4. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* 4. MANAGEMENT: 4.1 Monitor hypoperfusion: to prevent cardiac anoxia and renal failure 4.2 Initiate CPR 4.3 If trained, defibrillate VFIB and Pulseless VTACH 5. PACEMAKER 5.1 Atrium or Ventricles inserted 5.2 Electronic device that causes cellular depolarization and cardiac contraction 5.3 MODES 5.3.1 Fixed: 60-100 bpm no matter what 5.3.2 Demand: Shocks if below the setting (will only work if higher or lower) 5.4 INDICATIONS: 5.4.1 Tachyarrythmia 5.4.2 Symptomatic Bradyarrythmias 5.4.3 Heart Blocks 5.5 PACING 5.5.1 Single Chamber: one chamber atrium or ventricular 5.5.2 Double Chamber: Both 5.5.3 A paced: the wave at the Atrial 5.5.4 V paced: before the QRS; ventricular 5.5.5 AV pace: if both the atrium and the ventricle 5.6 NX MGMT 5.6.1 Monitor ECG following implantation and VS 5.6.2 5-10 year battery Life; The symptoms returns with arrhythmia (the battery is dying) 5.6.3 Signs of pacemaker failure: DIZZINESS AND FAINTING 5.6.4 Sterile technique in changing the dressing 5.6.5 Avoid going near an electric device: NO MRI, NO Microwaves (6 feet away); Use cellphone on the unaffected side; NO CONTACT SPORTS; No tight clothes CHF - Inability of the heart to pump adequate blood into the systemic circulation to meet metabolic demands: CONGESTION - The Heart can’t pump the blood forward, then will cause back-up - RCHF: Systemic Signs; Cardiac Cirrhosis - LCHF: Pulmonic Signs 1. CAUSES 1.1 Atherosclerosis in the Descending Aorta 1.2 MI 1.3 COPD: Damaged and fibrotic; the blood cannot enter due to damage so causing back-up to the RV; this causes COR PULMONALE: the heart got damaged due to the lungs (very specific to RIGHT SIDED HEART FAILURE) 1.4 HTN 1.5 Fluid Overload 1.6 Pulmonary HTN 1.7 Valvular Insufficiency: this will result to CHF due to Endocarditis 2. MANAGEMENT 2.1 Low sodium; I&O, weights, restrict fluid (1L a day) 2.2 Assess CV status and VS to detect decreased cardiac output 2.3 Keep in Semi-fowler’s position 3. MEDICATION 3.1 Inotropic: (Best Dug; Initial DIGOXIN medication) Normal Level: 0.5-2 mg/mL; Check BANDAV; Check for toxicity; Antidote DIGIBIND 3.2 Analgesics (morphine for pulmo edema) 3.3 Beta Blockers 3.4 Diuretics: FUROSEMIDE ENDOCARDITIS - All layers of the heart can get infected; You also damage the heart - MC cause: Bacteria; GABHS; From Strept throat - Risk for Clots and CHF: MANAGE as CHF - TX: Give antibiotics PERICARDITIS - Inflammation of the pericardium - SPACE: has fluid to decrease fluids - Inflammation and Histamine causes the movement from Intravascular to the Interstitial Space: BP goes down causing CARDIAC TAMPONADE - Viral, Fungal, Bacterial - MGMT: ATB, Steroids, Salicylate (the inflammatory effect); But if the heart contains blood, do not give Aspirin (causes more bleeding) - Pain on respiration CARDIAC TAMPONADE - Rapid unchecked rise in intrapericardial pressure due to blood or fluid accumulating in pericardial sac 1. ASSESSMENT 1.1 Anxiety 1.2 Dyspnea, tachycardia, 1.3 REDUCED ARTERIAL BP; Narrow pulse pressure 1.4 Distended neck vein 1.5 Pallor or cyanosis 2. DX: CXR shows cardiomegaly and widened mediastinum 3. MANAGEMENT: PERICARDIOCENTESIS (needle aspiration) of the pericardial sac *PLEURAL EFFUSION: Pleural: parietal and visceral: has a space where pleura has fluid; Thoracentesis 0 0

5. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* VALVULAR HEART DISEASE - Can result from endocarditis and inflammation then HF 1. TYPES 1.1 STENOSIS or NARROWING: does not open due to or hardening (CHF) stiffening 1.2 INSUFFICIENCY: Incomplete closure of the valve (CHF) 1.3 PROLAPSE OF THE VALVE: protrudes into the La (MC in Mitral/ Bicuspid valve) 2. FORMS 2.1 Aortic insufficiency: Left Sided CHF 2.2 Mitral insufficiency: Left Sided CHF 2.3 Mitral Stenosis 2.4 Mitral Valve Prolapse 2.5 Tricuspid Insufficiency 3. MANAGEMENT 3.1 PORCINE: Pork grafting for valves; Temporary 3.2 Prosthetic: Permanent 3.2.1 HANCOC: Tricuspid HTN 1. CLASSIFICATION OF BP FOR ADULTS SYSTOLIC DIASTOLIC Optimal 120 80 Normal <130 <85 High 130 139 - 85 89 - STAGE 1 140 159 - 90 99 - STAGE 2 (+20) 160 179 - 100 109 - STAGE 3 (+10) >180 >110 *To diagnose with HTN; 2 Consecutive reading over a 2-week period 2. ASSESSMENT 2.1 Essential: no particular reason 2.2 Asymptomatic 2.3 Elevated BP 2.4 Dizziness 2.5 H/A 2.6 L Ventricular Hypertrophy 2.7 HF 2.8 Cerebral Ischemia 2.9 RENAL FAILURE *Renal ischemia: low blood supply; It will release RENIN à Angiotensin I ACE à à ANGIOTENSIN II: High BP 2.10Visual Disturbances inc. Blindness: in the FRONTAL LOBE 2.11Epistaxis : Pressure in the BV 3. DX 3.1 Increased BUN, creatinine, Na and cholesterol 4. ANEURYSM: GOAL: maintain NORMAL BP; Don’t make it rupture 4.1 TYPES 4.1.1 Saccular: one side pouch 4.1.2 Fusiform: Both sides 4.1.3 Dissecting 4.1.4 False Aneurysm 4.2 SURGERY: Clipping of Aneurysm; Coiling (did not treat just block not really stop the aneurysm) 5. MANAGEMENT 5.1 Regular exercise to reduce weight 5.2 Low sodium diet and limitation of alcohol 5.3 Assess CV status and VS; Take an average of 2 or more readings to establish HTN 5.4 Assess neurologic Disorders and observe for changes that may indicate alteration in cerebral perfusion (CVA) 5.5 Monitor I&O and weight 6. MEDICATION 6.1 Maintain quiet environment to reduce stress: AWAY FROM NX station and elevator ARTERIAL DISEASES 1. REYNAUD’S DISEASE: Vasospasms of the arterioles and arteries of the extremities (Oxygenated Blood); Ischemic à NECROSIS 1.1 ETIOLOGY 1.1.1 Cold [ICE]; Stress; Smoking 1.2 UPPER EXTREMITIES 1.3 ASSESSMENT 1.3.1 Blanching of ext. followed by cyanosis: WHITE à à BLUE RED 1.3.2 Reddened tissue 1.3.3 Numbness, tingling sensation (Paresthesia: Impaired circulation) 1.4 MANAGEMENT 1.4.1 Stop Smoking 1.4.2 VASODILATORS 1.4.3 Avoid Precipitating factors 1.4.4 Warm Clothing 1.4.5 Avoid injuries to hands and fingers 2. BUERGER’S DISEASE/ THROMBO ANGINITIS OBLITERANS: occlusive disease of the median and small arteries and veins by clot formation 2.1 RF: 30-35 y/o; Males; Men who SMOKE 2.2 ETIOLOGY: 2.2.1 Unknown, smoking, males 2.3 LOWER EXTREMITIES 2.4 ASSESSMENT 2.4.1 Intermittent Claudication 2.4.2 Ischemic Pain occurring in the digits while at rest 2.4.3 Cool, Numb, tingling sensation 2.4.4 Diminished pulse at distal extremities 2.4.5 Ulceration 2.5 Amputation 2.6 MANAGEMENT 2.6.1 Instruct to stop smoking 2.6.2 Monitor Pulses 0 0

6. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* 2.6.3 Avoid injury to extremities 2.6.4 Administer vasodilators as prescribed 3. VARICOSE VEINS - Distended protruding veins that appears darkened and tortuous; Vein walls weaken and dilate, the valves become incompetent - VARICOSE: Veins full of blood - In the RECTUM: Hemorrhoids - In the ESOPHAGUS: Esophageal varices 3.1 ETIOLOGY 3.1.1 Prolonged standing (Pooling of blood) / sitting (impede the circulation especially when the popliteals are at the edge of the sit) 3.1.2 PREGNANT Obesity and : Increase abdominal pressure 3.1.3 Congenital absence of valves 3.1.4 Constrictive Clothing 3.2 INCIDENCE 3.2.1 Female, Pregnant 3.2.2 35-40 y/o 3.2.3 Not necessarily Hereditary 3.3 S/SX 3.3.1 Rare to Have pain 3.3.2 MC Heaviness in the Lower Extremities; Leg edema (due to pooling) 3.4 MANAGEMENT 3.4.1 elevation 15-30 minutes 3.4.2 Compression with support stockings: Has a gradient that has pressure; Measured circumference of the calves 3.4.3 SCLEROTHERAPY: it involves injection of a sclerosing agent in to the varicose vein: Scleroses the vein 3.4.4 SURGERY: vein stripping and ligation to relive pain, reduce swelling or provide cosmetic results 3.4.5 EARLY AMBULATION: prevent thrombophlebitis HEMATOLOGIC BLOOD COMPONENTS STEM CELL: An originating cell; Capable of becoming another type of cell ↓ ↓ Lymphoid Myeloid ↓ ↓ ↓ B-CELL T-CELL RBC, PLATELET, WBC Plasma Cells: Antibodies or immuno- globulins 1. Helper: Activate B and Killer T-Cells 2. Cytotoxic/ Killer 3. Suppressor: not working: Immune diseases Differentiated: has functions and trasnsforms into another cell 1. ANEMIA - Decrease in the number of RBC 1.1 TYPES 1.1.1 BLOOD LOSS: Hemorrhagic (>500 ml) 1.1.2 HEMOLYTIC: increased destruction 1.1.2.1 Sickle Cell 1.1.2.2 Thallacemia 1.1.3 MANUFACTURING Pernicious IDA Aplastic Anemia 1.2 CONCEPT: Tissue Hypoxia: Underlying cause of all manifestations accompanying anemia 1.3 S/SX: 1.3.1 Pallor, Easy fatigability, Dyspnea, H/A APLASTIC ANEMIA (PANCYTOPENIA) - Damage to the bone marrow: Chemotherapy or radiation - Decrease in or damage to the marrow stem cells - RENAL FAILURE: due to loss of erythropoietin - Results in anemia, leukopenia, Thrombocytopenia 1. CAUSES: medications, chemicals, radiation 2. MANAGEMENT: 2.1 Remove the cause Supportive 2.2 BONE MARROW TRANSPLANT: from the marrow; SITE OF ASPIRATION: Iliac Crest *BONE MARROW REJECTION: Graft vs Host Disease (GVHD); The one rejecting is the BONE MARROW or the marrow *ORGAN REJECTION: the body rejects the organ 2.3 PERIPHERAL BLOOD STEM CELL TRANSPLANTATION *NEUPOGEN: ; Filgrastin WBC production *EPOGEN production : RBC LEUKEMIA - Malignant disorder of hematopoietic system that involves the bone marrow and the lymph nodes - Characterized by uncontrolled proliferation of immature WBC - TOO MUCH WBC PRODUCTION: Anemia and Thrombocytopenia; due to decrease RBC and platelets 1. TYPES: classified by onset and severity and by precursor cells 1.1 Acute ML: MC in Adults; Aplastic Anemia 1.2 Acute LL: MC in Children; Dangerous; Very prone to infections; No defense 1.3 Chronic ML 1.4 Chronic LL 2. DX: BONE MARROW BIOPSY: Leukemic Blast Cells 0 0

7. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* 3. MANAGEMENT 3.1 Chemotherapy 3.2 Radiation 3.3 Bone Marrow Transplantation: GVHD *ADD: Study Blood Transfusion LYMPHOMA - Lymphatic problems - LYMPHADENPATHY (Kulani): Phagocytosis; Inflammation of the Lymph Node - Lymphatic System: goes to the heart and turns systemic A. HODGKINS • Proliferation of REED-STERNBERG cells in a single lymph node then travel to other lymph nodes: AFFECT B-CELLS 1. CAUSE: EPSTEIN BARR VIRUS (Transmitted through Saliva by Kissing; KISSING’S DISEASE); Starts as INFECTIOUS MONOCLEOSIS (15-20 y/o); FLU LIKE SYMPTOMS since it is viral; May cause CA and needing Chemotherapy; HIGHER CHANCE OF CURE 2. PROGRESSION 2.1 STAGE 1: Single Lymph Nodes/ Cervical Lymph Nodes 2.2 STAGE 2: 2 or more lymph nodes on the same side of the diaphragm (Still Good Prognosis) 2.3 STAGE 3: Both sides of the Diaphragm 2.4 STAGE 4: Disease disseminated, spreads to other extralymphatic organs like SPLEEN (POOR PROGNOSIS) 3. S/SX 3.1 EARLIEST: Bone Pain and cyanosis of face and neck; Enlarged, painless, Non tender, firm, and movable lymph nodes 3.2 LATE: Hepatomegaly; Splenomegaly; Difficulty of breathing; facial edema; enlargement of the LE *EXTRA-LYMPHATIC ORGANS: LIVER AND THE SPLEEN 4. DX: Swab test B. NON-HODGKINS • Affects B and T-cells • Tumors occurs throughout the lymph nodes and lymphatic organs in an unpredictable pattern 1. S/SX: Prominent, painless generalized lymphadenopathy 2. DX: Lymph Node Biopsy 3. MANAGEMENT: Radiation/ Chemotherapy; Transfusion RBS; Admin 02 and Rest *MC Lymphoma in AIDS: NON-HODGKINS *MC Cancer in AIDS: KAPOSI’S SARCOMA MULTIPLE MYELOMA - Abnormal proliferation of plasma cells (Precursors to Antibodies) - Immature and malignant WBC invade the bone marrow, Lymph nodes and liver, spleen and kidneys (HIGHLY VASCULAR, through the blood); THE BONE MARROW IS INVADED and leads to blood destruction throughout the body: Multiple fractures, Increased Serum Ca & Kidney Stones (RF) - BENCE JONES CHON in urine, Increased BUN, Creatinine Hypercalcemia 1. S/SX: pancytopenia; pathologic fracture (fracture secondary to another disease); hepatomegaly, renal Calculi, Severe Bone pain 2. MANAGEMENT 2.1 Bone Marrow Transplant 2.2 HD, Chemotherapy, Radiation 2.3 Encourage Fluid intake 2.4 Maintain seizure precaution due to hypocalcemia *PROTATE SPECIFIC ANTIGEN: for prostate cancer RESPIRATORY 1. DIAGNOSTIC 1.1 Skin testing: Mantoux Testing (test of the person is Exposed to the Client); 48 to 72 hrs; Positive: Indolation (SWOLLEN AND HARD): Measure 10 mm or more; AIDS or Immunocompromised: 5 mm *Once exposed, always exposed, no ne d to repeat Mantoux e test 1.2 CXR: preliminary only 1.3 SPUTUM EXAM: To determine positive for TB; early AM, Cough, rinse mouth with water; Gargle and Don’t swallow *FOR THOSE WHO CAN’T COUGH: CPT, Bronchodilators 1.4 THORACENTESIS: position upright at side of the bed, lean on overhead table; NEED FOOT STOOL, to stabilize legs; IF not Pneumothorax 1.5 BRONCHOSCOPY: NPO before and after until the gag reflex returns; or else ASPIRATION 2. INTERVENTION 2.1 OXYGEN THERAPY: Nasal Cannula (2-3); Face mask (3L); Humidify if high concentrations, tracheobronchial suctioning 2.2 CHEST PHYSIOTHERAPY 2.3 INCENTIVE SPIROMETRY: Done 10x every hour, waking hours 2.4 CLOSED CHEST TUBES (THORACOSTOMY) 0 0

8. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* EPISTAXIS - Don’t hyperextend; no ice compress - Sit-up lean forward and head tilted down - Pressure over the soft tissue of the nose - Cold Compress - Avoid Nose Blowing - Nasal pack with Neosynephrine (Vasoconstrictor; 3-5 days; A1 Agonist) TONSILITIS - Inflammation of the tonsils; GABHS - S/SX: sore throat, difficulty or pain in swallowing, fever - MGMT: ATB, Anti-pyretic, Saline Gargles - Surgery: Tonsillectomy: POST-OP CARE: HOB to 450 elevate to reduce swelling; avoid citrus and carbonated drinks: irritate the incision; Ice chips, small sips of cold fluid, popsicle (First day); Soft foods on (Second day) *PEDIA: Prone position to facilitate drainage of blood due to risk of aspiration and they do not have good swallowing LARYNGITIS *ADD: Laryngeal Cancer and Surgery of the Larynx - inflammation and swelling of mucous membrane of the larynx - CAUSE: infection, improper use of voice, smoking - S/SX: hoarse voice, throat irritation, dry non productive cough - MGMT: ATB, stop smoking, Removal of cause (don’t speak, don’t whisper) COPD - A group of diseases that include: Chronic Bronchiectasis; Chronic Asthma; Chronic Bronchitis, Emphysema - Causes: Airborne irritants and pollution, SMOKING, allergens; Chronic RT infection - ASSESSMENT 1. Barrel Chest (Antero-posterior Diameter increased) and clubbing (excessive trapping of air and cyanosis) 2. Cough, evectional dyspnea 3. Wheezing and crackles 4. Weight loss (unable to eat due to SOB); SFF only, Increased myocardial oygen demand 5. Sputum production (amount, color consistent) 6. Use of accessory muscles: Main muscle is DIAPHRAGM but extra: sternocleidomastoid, scalene, trapezius, intercostal muscles 7. Posturing (leaning forward): better to breathe leaning forward since it displaces the heart, less pressure on the lungs 8. Pursed lip breathing (remove C02) 9. Can cause COR PULMONALE (R-CHF) - DIAGNOSTICS 1. CXR: congestion and hyperinflation 2. ABG: respiratory acidosis and hypoxemia - TREATMENT 1. CPT, Postural Drainage, Incentive Spirometry 2. FLUID INTAKE to 3L/ day if not contraindicated (Contraindicated: If you have COR PULMONALE/ CHF) 3. 02 at 2 3 L/day - 4. Diet high in CHON, Vit C, Calories, Nitrogen (CHO yields C02 so not much on these food item) 5. Instruct diaphragmatic or abdominal and pursed lip breathing ( inhale and Instruct Consciously, feel the / increase out; abdomen go out The diaphragm at the same time goes down; to relax and decrease C02) 6. Suction 7. Encourage SFF to prevent dyspnea 8. Stop Smoking 9. Avoid person infection 10. RECEIVE IMMUNIZATION: Pneumonia vaccine (Pneumovax: Only every 5 years); Flu or Influenza (every year since viruses are faster to mutation) - MEDICATION 1. Bronchodilators: instruct oral and inhalants 2. Steroids 3. Anti-Leukotrienes 4. Mast Cell Stabilizers 5. Mucolytic 6. Expectorant I. CHRONIC BRONCHITIS 1. Persistent cough for at least 3 MONTHS a year for 2 successive years; *IMPAIRED AIRWAY CLEARANCE: Bronchitis 2. S/SX: Edema of the mucous membrane; Hyper- secretion of mucus; BLUE BLOATERS (cyanosis; BLOATING: it can cause COR PULMONALE, passageway is too narrow) 3. PREDIPOSING FACTORS: Cigarette smoking & Bacterial infection II. EMPHYSEMA 1. Level of the alveoli, the air went in and not out the inelastic alveoli: OVER distended and non- functional alveoli leading to rupture; Retaining C02 and Carbonic Acid (respiratory acidosis); BULLAE: air trapped alveoli *IMPAIRED GAS EXCHANGE: Emphysema 2. S/SX: PINK PUFFER (vasodilation on the face; carb on dioxide retention; PUFFER: due to PURSED LIP breathing, prolonged expiration to blow off all C02); Chronically Hypoxic 0 0

9. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* 3. NORMAL: Stimulus to breathe is increased C02 4. COPD: Stimulus to breathe is low p02 5. MGMT: 02 = 1-2 L/min III. ASTHMA - HYPERSENSITIVITY REACTION: Edema of the mucous Membrane, Hypersecretion of mucus & Bronchoconstriction (More dangerous than Bronchitis since the muscle constrict the airway + mucus production = AIRWAY OBSTRUCTION & Respiratory Acidosis) - Retention of C02 and air trapping - Hypoxia - Avoidance of the triggers IV. BRONCHIECTASIS - MC cause: Bacterial infection - The bronchioles are over distended; No bronchoconstriction - Hypersecretion of mucus and edema formation STATUS ASTHMATICUS - Type of asthma not relived by normal bronchodilator - High Fowler’s position; Monitor VS; Monitor respiratory status; EPINEPHRINE/ AMINOPHYLLINE (Xanthine) IV; If not epi then use aminophylline PNEUMONIA - Refers to bacterial, viral, parasitic or fungal infection that cause inflammation of alveolar spaces and increase in alveolar fluids. Ventilations decrease as secretion the thicken - CAUSES: Aspiration, Chemical irritants and Various organisms - ASSESSMENT 1. Chills, fever SOB, tachypnea, Accessory muscle use 2. Sputum (rusty, green or bloody pneumococcal pneumonia and yellow green with bronchopneumonia); 3. Crackles, Ronchi, Pleural friction Rub (rubbing sand paper) on auscultation; Cough and malaise - DX: CXR: Consolidation; Diffuse patches; Sputum Culture to determine what microorganism (bacterial or other wise); WBC and ESR (due to inflammation) are elevated - MGMT: CPT, PD, IS; Diet high CHN, High calorie, Force Fluids; Admin 02, Semi fowlers to facilitate breathing and lung expansion; Change position frequently and ambulate as tolerated to mobilize secretions - LOBAR PNEUMONIA: only one lobe of the lungs - BRONCHOPNEUMONIA: patches of consolidation all over the lungs - HANDWASHING and proper disposal of secretion PNEUMOCYSTIS CARINII PNEUMONIA - MC cause of death in AIDs and form of pneumonia; opportunistic to HIV - MICROOGANISM: Pneumocystitis jiroveci - Leading cause of death among HIV patient - ASSESSMENT: fatigue, low grade, intermittent fever, non-productive cough, dyspnea, anorexia, weight loss - MGMT: Pentamidine and Bactrim; monitor I&O; Anti-pyretic; Administer 02, monitor hypoxemia PLEURAL EFFUSION AND EMPYEMA - Pleural Effusion: excess of fluids in the pleural space - Empyema: accumulation of pus and necrotic tissue in the pleural space - CAUSE: bacterial or fungal infection, RF, Hepatic Disease with ascites - ASSESMENT: 1. Pleuritic Chest Pain that is sharp and increases with inspiration; 2. Decreased breathe sounds (lung is being compression; Absent: if too much fluid; ATELECTASIS), Dyspnea, fever, malaise; DRY non productive cough caused by bronchial irritation or mediastinal shifting to unaffected side - TX: Thoracentesis & Thoracotomy; Chest tube Drainage - MGMT: tell the pt. to expect stinging sensation from the insertion PNEUMOTHORAX - SPONTANEOUS: The rupture of bleb (Bullae), MV (mechanical ventilator; OVERINFLATION and rupture; positive pressure MV), Internal cause *Negative Pressure: MG; Iron Lung Machine: POLIO - OPEN: Came from a source outside: Gunshot; opening through the chest allows air to flow between pleural space and outside of the body - - TENSION: Build up of air in pleural space that can’t escape *Stab wound: remove, if ever, cover with a VENTED gauze (3 sides closed but one side open; this will let air out as well; may cause TENSION PNEUMOTHORAX if completely sealed) - MEDIASTINAL SHIFTING: The HR is increased, BP is low and the RR low; The heart trachea and lungs to the unaffected side are moved - The difference with open and close VS Tension: . When inspiring it’s the same (the lungs and heart move to unaffected side and affected lung is small or not inflated); When the lung is expiring, this will normally inflate the affected but in tension, the heart 0 0

10. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* and lung will still continue being in mediastinal shifting - ASSESSMENT: Dyspnea, decreased 02 at; Diminished or absent breath sound; Sharp chest pain that increases with exertion; tracheal shift to unaffected side (tension); SUCKING SOUNDS WITH OPEN CHEST WOUND - MGMT: apply vented dressing; Position in High Fowlers; Prepare for chest tube placement until the lungs has fully expanded; Monitor hypotension, tachycardia and tachypnea (mediastinal shifting); Administer 02 and Monitor chest tube drainage system CHEST TUBE - Returns negative pressure to intrapleural space - Used to remove abnormal accumulation of air and fluid from pleural space - CHAMBERS 1. COLELLCTION CHAMBER: Drainage 2. WATER AND SEAL CHAMBER: Tip of the tube under water (2cm) allowing fluid and air from entering the pleural space; Immersed so that the air will not go back; Water will show INTERMITTENT BUBBLING 3. SUCTION CONTROL CHAMBER: gentle bubbling normal high ; only used when there are amounts of mucous but does not drain; Attached to suctioning apparatus; Expected to have CONTINOUS BUBBLING - WATER OCCILATES/ TIDALING: moves up when the patient inhales and moves down as the patient exhales; To see if the bottle system is moving - NO OSCILLATION or TIDALING: [1] obstruction in the system (kinked or pt. is lying down on the tube; Thick secretions like pus); [2] lung has expanded meaning to more secretions to suck; To determine if not effusion subsided: CXR *ONE BOTTLE: Drainage and water sealed into one *TWO-BOTTLE: Drainage and Water seal - MGMT: Monitor the drainage; Keep tubes free of leaks, dependent loops or other obstructions; Do not strip or milk tubes unless specified by the doctor (Milking: Pressing; Stripping: continual pressing from start for bubbling until end); Check : Intermittent bubbling is normal while continuous bubbling is air leak; If water is used in the suction chamber, check the continuous bubbling which indicates the system is working *If the bottle brakes, immerse the tube unto water; A BOTTLE OF STERILE WATER: must be placed on the bed side; Clamping will cause pressure then TENSION PNEUMOTHORAX *if pulled out: use Vented gauze and call MD *if removed after use: use occlusive dressing; take a deep breath and pull; use petrolatum dressing or dry dressing LUNG CANCER - The lungs are highly vascular since it oxygenates the body - TYPES: 1. NON SMALL CELL: MC; 1.1 Adenocarcenoma 1.2 Squamous- Cell Carcinoma 1.3 Large Cell Carcinoma 2. SMALL CELL - CAUSES: Smoking (pack/year/history; Exposure to environmental and occupational pollutants); MINERS: Mineral deposits into the lung tissue PACK YEARS: # packs per day X Number of years smoked 1 PACK = 20 cigarettes - EARLIEST MANIFESTATION: Productive Cough - LATE MANIFESTATION: hemoptysis: eroding lung tissues - S/SX: Dyspnea, hoarseness, chest pain, anorexia, and weight loss, weakness - SURGERY: SIZE matters PNEUMONECTOMY SECTION DESCRIPTION Wedge resection / Segmentectomy Only near the part of the tumor Lobectomy Entire lobe has been infiltrated *These surgeries WILL have CHEST TIUBES *UNAFFECTED SIDE: position, there is a chest tube and make the lung re-inflate properly Pneumonectomy Whole side of the lung *NO CHEST TUBE: no lung no bleeding, no anything * AFFECTED SIDE: position; allow the remaining lung to expand *TB: 2 weeks of RIPES and then can now socialize; no more isolation *EMPHYSEMA: alveoli; DYPNEA ON REST *Bronchitis: Chronic productive cough *Asthma: WheezingMUSCULOSKELETAL DISORDERS *ADD: proper body mechanics TRAUMA - All signs of trauma will cause inflammations SPRAIN: ; tendons overstretching STRAIN: Over twisting; joints and ligaments Dislocated: when outside; total Subluxation: partial dislocation 0 0

11. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* FRACTURE - the move it the more it will brake - SIGNS: Injury will cause inflammation; Loss of motion; edema, crepitus (rubbing against another bone), shortening of the extremity - IMPACTED: one bone is rubbing on another (Sound is called Crepitus) - STAGES OF BONE HEALING 1. HEMATOMA: immobilize, the only thing that is keeping it together is blood clots; Inflamed (First 3 days; don’t place a cast since it will compress the site; PLACE a POSTERIOR MOLD: which is a hard board and bandages wrapped around it) 2. GRANULATION TISSUE STAGE: Osteoblasts go to the site; Bones are made of protein and at this stage protein will be laid down; WHOLE CAST are now placed here since inflammation has decreased 3. CALLUS STAGE Calcium deposition : START of ; partial weight bearing can now be done (PROM; only the done for fractures on joints; the more sedentary you are; the more calcium will go out the body) 4. REMODELING: ossification and remodeling MANAGEMENT *SPLINT: it is above and below the JOINT; ex if radial fracture: long arm cast STIFFNES OF THE JOINT: Contracture - MGMT: immobilize ( ) SPLINT : the more you move, the more you break; NECK (cervical: IMMOBILIZE THE NECK, ASAP); Cervical Collar: prevent injury to phrenic nerve *PHRENIC NERVE: C2 C3 - - RICE (educe inflammation; Rest Ice, Compression, Elevation) - Reduction: Realignment of the bone 1. OPEN: surgery to realign the bone 2. CLOSE: Casting/ traction CAST CARE - Types: 1. PLASTER OF PARIS: it looks like gauze but chalky in consistency; place in water then squeeze then mold it in place; DRIES: 24-48 hrs: Do not touch the cast when wet; USE THE PALM of the hand when molding or moving it around; Cement/ heavy 2. FIBERGLASS: it is plastic, synthetic; Wet the gauze and little bit of water; DRIES: 20 min; Plastic/ Light - MGMT: Monitor the extremities for circulatory impairment inserted (1-2 fingers must be to determine if the cast is not too tight): COMPARTMENT SYNDROME 5P’s 1. PAIN 2. PALLOR 3. PARESTHESIA 4. PULSELESSNESS 5. PARALYSIS - Monitor for any drainage on the cast; Instruct to keep the cast clean and dry; DO NOT WET THE PLASTER OF PARIS CAST, will make it soft; For Fiberglass, you can wet it but it is discouraged, the outside can be cleaned but the inside cannot dry properly; Instruct not to insert anything in the cast; do not write anything on the cast - INFX: 1. Monitor for Drainage 2. Monitor HOTSPOTS: touch the cast it must be cold but when it feels warm that is the infected are *NO POWDER: will contribute to infection - Instruct to do ISOMETRIC EXERCISES (alternate contraction and relaxation) TRACTION: Act of pulling into the proper location 1. Ensure the weights are hanging freely 2. Maintain continuous traction (once you pull it don’t let it go; misaligned: will heal into that position [MALUNITED/ MALUNION] or does not stick together [NO UNION]) 3. Must always have a counter-traction: the need for balance (ONLY 10% of the patient’s Body weight) - BRYANT’S TRACTION: for children <3y/o; the feet are held up; The buttocks of the baby must be off the mattress, not touching the bed meaning NO PULL; Place a mobile to stimulate the baby - SKIN TRACTION 1. CERVIVCAL TRACTION: Skin type; cervical 2. PELVIC TRACTION: for lumbar spine - SKELETAL TRACTION 1. CRUTCHFIELD TONG: Drilled into the skull for traction 2. BST: Clean the pin since there is an entry for microorganisms; 2.1 PIN CARE: Do not clean with hydrogen peroxide: will cause anaerobic infection; No betadine: this will oxidize and rust the pins; Apply ATB; place antiseptic *SKIN TRACTIONS: are temporary, for minor injuries *SKELETAL TRACTION: severe injuiries CRUTCHES - The crutches not up to the AXILLA: this will cause BRACHIAL PLEXUS COMPRESSION (paresthesia of the fingers) - MEASUREMENT: 1. 2 INCHES below axilla 2. 2-3 INCHES into the side; 6-12 inches into the front 3. ELBOW FLEXION (20-30 degrees) - Exercises to prepare for CW: 0 0

12. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* 1. Hand muscles exercise (all the weight in the palm of your hands to stabilize) 2. Arm muscle exercise - Stair Climbing 1. UP: good leg with bad leg à crutches 2. DOWN : bad leg à crutches with good leg “UP WITH THE GOOD, DOWN WITH THE BAD” *If the patient is non-weight bearing: 3-point gait, may also use Swing to (crutch forward and swing to the point of the crutch) & Swing Through (crutch forward and pass the crutches) *If patient is partial weight bearing: 4-point gait *2-point Gait: as if walking; faster version of 4-point gain CANE - Cane held on the stronger side or unaffected side - Cane walks together with the weak leg COMPLICATION OF FRACTURES 1. FAT EMBOLISM: systemic fat lobules into the circulation; As the bone fractures, the fat is adhered unto by platelets and becomes a blood clot, then an embolism; MC in long bone fractures (ribs, tibia, pelvis) 1.1 S/SX: Chest pain, CHANGE IN LOC; Tachypnea, Tachycardia, Petechae on neck and the anterior chest (INTRAVASCULAR THROMBOSIS) 1.2 MGMT: DBE and CE; 02 Supplementation; Intubation 2. INFECTION/ OSTEOMYELITIS 2.1 TYPE: Acute and Chronic 2.2 Signs of infection: Fever and chills 2.3 Infection may turn the bone necrotic: SEQUESTRUM (Surgery: Sequestrectomy: A type of debridement of necrotic bone) 2.4 MGMT: NOT UNTIL YOU REMOVE THE NECROTIC BONE, will the bone heal; IV ATB: 6-8 weeks then to ORAL switch 3. COMPARTMENT SYNDROME 3.1 Tight cast; Neurovascular compression 3.2 MGMT: 5P’s; Monitor for ATN (Acute Tubular Necrosis: may lead to RF; MYOGLOBIN: Any single time that the muscle is hurt, myoglobin is released; Myoglobin is very small and can go to the renal tubules and cause damage) 3.3 SURGERY: Faciotomy (Straight into the fascia to relieve the compression) HIP FRACTURE - Proximal 3rd fracture of the femur - Common among elderly women - HIP REPLACEMENT TYPES: 1. Total Hip Replacement: all parts 2. Partial Hip replacement: except acetabulum - POST-OP 1. DISLOCATION: Always Abducted (place pillows between the legs); Abduction will displace prosthesis for 8 weeks; When asleep 2. Avoid bending or cross legs 3. Use trochanter roll to prevent external rotation AMPUTATION - Surgical removal of the part of the limb; LIMB is very vascular and bleeds after; PRESSURE DRESSING must be in place - POST-OP 1. Monitor VS for BLEEDING 2. Evaluate for Phantom Limb Sensation and pain; explain to the patient’; “Its is no longer there but it will take some time to go away” 3. During the FIRST 24hrs, elevate the stump; After the 48 hr, flat on bed to prevent FLEXION HIP CONTRACTURES 4. After 48 hrs, instruct also to be on PRONE POSITION, several times a day (PRONE: 3x a day; 5-10 minutes) 5. Maintain application of ACE WRAP to promote stump shrinkage (FINGURE OF 8) - POST OP COMPLICATION; hemorrhage, Infection and Contracture - *DISARTCULATION: removal of the entire joint with the extremities RHEUMATOID ARTHRITIS - Autoimmune and hereditary (IMMUNE COMPLEX); The Cytotoxic T- - Cell & B Cells attack the Synovial membrane - Can occur in children; Juvenile Rheumatoid Arthritis (JRA) - Bilateral and symmetrical, inflammatory; SYSTEMIC - Usually affects the joints symmetrically (on both sides equally), may initially begin a couple of joints only and most frequently attacks the WRIST, HALNDS, ELBOWS, SHOULDERS, KNEES AND ANKLES - Progressive, Lifetime disorder - SYNOVITIS: formation of scar tissue and BONY ANKYLOSES (causing contractures due to stiffness) (permanent) - Remission and Exacerbation (FLARE UP: stressed or ill; the body will release these T-Cells to defend) - IMMUNE COMPLEXES: RH Factor (Auto- Antibodies) - PANNUS FORMATION: highly vascular granulation - On and off then damage at area à healing à healed but keep on fracturing à scar formation à Ankylosis and Pannus Formation - JOREN’S SYNDROME: Systemic effect of RA; Dryness of the eyes and the vagina - S/SX: painful warm, swollen joints with limited motion; STIFF in the morning after periods of 0 0

13. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* inactivity; SWAN NECCK deformity; Bouteniere’s Deformity; Ulnar Deviation - DX: Increased WBC, RF + (Auto Antibodies); Elevated ESR; effusion in the joint (Arthrocentesis) - MANAGEMENT 1. Bed Rest 2. PROM 3. Heat stiffness and cold for inflammation; Warm Shower in the AM 4. PT 5. Splint painful joints - MEDICATION: Aspirin (the 4 effects); NSAIDS (Ibuprofen); Corticosteroids; DMARDS (Disease Modifying Anti Rheumatic Drugs): Immunosuppressants, Methotrexate, Sulfasalazine, GOLD therapy - SURGERY: Synovectomey & Arthroplasty *SLE: you it is damage anything with COLLAGEN ( found everywhere; SYSTEMIC; Butterfly Rash) OSTEOARTHRITIS - Degeneration of articular cartilage - MC in Obese Clients - Involves weight bearing: HIPS; Knees; Fingers; Vertebra (Lower Back) - S/SX 1. Joint pain aggravated by use; relieved by rest 2. Stiffening of joints 3. Formation of bony outgrowths (OSTEOPHYTES); HEBERDEN’S (Distal IP) and BOURCHARD’S NODES (Proximal IP) 4. Decreased ROM and CREPITUS - MANAGEMENT 1. Relieve strain and further trauma to joints 2. Cane or walker, if indicated 3. Joint replacement as needed 4. Proper Body Mechanics 5. Avoid Excessive weight bearing and standing 6. PT 7. Relief of pain (NSAIDS) 8. CHONTROTIN: repairs the cartilage AND GLUCOSAMINE - TYPES OF HIP REPLACEMENT 1. TOTAL HIP: All parts 2. patella PARTIAL: except - PASSIVE ROM MACHINE: for continuous movement and stop contracture of the knee replacement GOUT - Disorder of purine metabolism - Uric acid crystals in the JOINT: TOPHI - S/SX: Joint pain, redness, ankle and great toe (MC) - MANAGEMENT 1. Rest 2. Low purine and increase fluids 3. PHARMACOTHERAPY 3.1 Acute Attack: Colchicine and NSAIDS 3.2 Uricosuric Drugs: Excretes Uric acid: Probenecid (Benemid) 3.3 Allopurinol (Zyloprim): Inhibits the formation of uric acid HERNIATED NUCEUS PULPOSUSU/ SLIP DISK - NUCLEUS PULPOSIS: the jelly inside the vertebral disk - ANNULUS FIBROSUS: this holds the nucleus fibrosis - CAUSES: lifting, degeneration of the disc (loses water content); also caused by sitting down - AREAS 1. Cervical: Shoulder pain radiating to the hand; Weakness and Paresthesia; Weight bearing on the NECK/ HEAD; On cervical Traction 2. Lumbosacral: back pain radiating across buttocks and down the leg (SCIATIC NERVE; Sciatica); weakness ad paresthesia; Muscle spasm in the Lumbar region; on pelvic Traction - MANAGEMENT 1. Bed rest on firm mattress with board 2. Traction 3. Local Application of het 4. Lumbosacral corset (BACK BRACE) 5. Prevent complication of Immobility - SURGERY: Laminectomy with Discectomy; SURGICAL FUSION (Spinal fusion with rod insertion) - POSTOP: 1. Turn the patient as a whole (LOG ROLLING TECHNIQUE) 2. LUMBAR: HOB, flat, supine with legs slightly flexed 3. CERVICAL: HOB elevated, with neck immobilized with collar or sandbag GASTROINTESTINAL HEPATOBILLIARY & - Mouth into the Anus; Unsterile GERD - The food is refluxing up to the esophagus; Gastric contents flow upwards to esophagus - Common for obese and pregnant women - Any activity that increase intra abdominal pressure (Overeating, bending, tight clothing), Foods that relax the cardiac sphincter (Alcohol, peppermint, caffeine, high fat diet [fats are not easily digestible, stays longer in the stomach]), lying down after eating - ASSESSMENT: Dyspepsia; Dyspepsia; ODYNOPHAGIA (painful swallowing); Esophagus; Eaophagitis - MANAGEMENT: 1. Avoid alcohol, peppermint, caffeine, high fat diet; 2. 15-30 minutes High Fowler (Supine opens the sphincter due to pressure) 3. Lose weight 4. Avoid over-eating and tight fitting clothes 0 0

14. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* *SWALLOW AIR: carbonated drinks, chewing gum and eating fast *HERNIA: protrude; Can also cause GERD due to opening of the sphincter *Ambulation increases Peristalsis PEPTIC ULCER - GASTRITIS: inflamed only but later forms ulceration causing GI bleeding; The deeper it gets then erodes the mucosa - PERITOTINITIS: from the contents of stomach will cause septicemia à SEPTIC SHOCK - STRESS, STIMULATED or EXCITED (SNS): Gastric Ischemia; CURLING’S ULCER (for GI) and CUSHINGS (inc. ICP); Both are still related to gastric ischemia - Increases release of gastric acid or HCL: hot and spicy; Food with MILK (It is rich in protein; You need pepsin to breakdown CHON, pepsin stimulates the parietal cells to release HCL); Alcohol, Cigarette Caffeine, Drugs: NSAIDS, ASA, Steroids; NUMBER 1 CAUSE IS H. PYLORI (90 %) - KINDS 1. DUONDENAL: Hyperacidity; MC Duodenal and most acidic 2. GASTRIC: Decreased Mucous; Hyposecretion of HCL *Don’t give reduced; H2; PPI and antacids to GASTRIC ULCERS, it will not help - DUODENAL: Nothing buffers the food; no food makes it painful; 2-4 hours after eating; Wakes up in the middle of the night due to pain - GASTRIC: no mucous and more painful when you eat; 1-2 after eating - MGMT 1. Relieve the pain 2. Lifestyle modification - MEDICATION: 1. ANTACIDS: Neutralize Gastric Acids 1.1 Magnesium, Aluminum, Calcium *Magnesium Based Antacid: Diarrhea *Aluminum Based Antacid: Constipation 2. DECREASE ACID PRODUCTION 2.1 Proton Pump inhibitors (Esomeprazole): Most effective for DUODENAL! 2.2 H2 Blocker (Cimetidine, Ranitidine) 3. PROVIDE PROTECTIVE COATING OVER ULCERATIVE SITE 3.1 Sucralfate (Carafate) 4. INCREASE MUCOUS PRODUCTION 4.1 Misoprostol (Cytotec): GATRIC! 5. ANTIBIOTICS 5.1 Amoxicillin 5.2 Metronidazole (Flagyl) - SURGERY: VAGOTOMY (Sever the vagus nerve which enervates the parietal cells; Inhibits release of HCl) 1. BILROTH I (Cut the stomach and attach to the duodenum) & II (cut the stomach and attach to the jejunum; Shorter; Very Prone to DUMPING SYNDROME): Ga tric resection s 2. TOTAL GASTRECTOMY (Pernicious Anemia: loss of intrinsic factor for B12) - POST OP: 1. Maintain on NPO; TPN (Pure glucose 50 %; Check CBG every 6 hours; DO NOT D/C abruptly stop; only good for 24 hrs [Wait longer and may cause SEPTICEMIA and change the whole tubing system]; make sure to infuse D10% to wait for next TPN) *72 hours: for normal IV VS TPN is 24 hrs *D50: is for UNCONSCIOUS HYPOGLYCEMIC 2. Maintain on fowler’s position for comfort and to promote drainage 3. NGT for drainage 4. Monitor dressing for drainage (bleeding) 5. Assess bowel sounds DUMPING SYNDROME - Prevent dumping syndrome: rapid emptying gastric content contents into the small intestines which has been anastomosed to the gastric stump - The fluid goes to the stomach which decreased INTRAVASCULAR VOLUME and goes to the stomach; Majority of blood to the stomach and causes Dizziness (decreased cerebral perfusion); Tachycardia and LOW BP - CAUSE: ingestion of food HIGH in CHO and electrolytes, which must be diluted in the Jejunum; Ingestion of Fluids at mealtimes (DIET: low CHO or simple sugar; Drink after meals) - ONSET: 15-30 minutes after meals so lie down! - S/SX: 3D’s; Diarrhea, Dizziness, Diaphoresis; N/V, palpitations MGMT: SFF; Chew food thoroughly; Lie down after meals; Low CHO diet; Do not drink fluids during meals; APPENDICITIS - Obstruction of the VERMIFORM APPENDIX; FECALITH (MC cause of Appendicitis; small piece of feces; since it should not contain anything); BARIUM (drink fluids after or it may dislodge in this area) - S/SX 1. Acute abdominal pain (RIQ); McBurney’s Point 2. N/V/A 3. Rigid Abdomen with guarding 4. Rebound Tenderness 0 0

15. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* 5. Elevated WBC count, Fever 6. Sudden cessation of pain means rupture: NO ANALGESICS if there are no DX for it *PALPATION of the LEFT lower abdomen causing pain in RIQ *BLUMBERG’S SIGN: rebound Tenderness; Peritonitis *ROVSING’S SIGN: palpate on the Left it hurts more on the RIGHT - MANAGEMENT: 1. Bed rest 2. NPO 3. NO NARCOTICS initially will mask the pain 4. NO ENEMA/ Laxatives: can cause perforation; High pressure into the intestinal tract and cause rupturing 5. ATB TX 6. Surgery: Appendectomy INFLAMMATORY BOWEL DISEASES - AUTOANTIBODIES to the GI CROHN’S DISEASE ULCERATIVE COLITIS (ulcer: Bleeding, Colitis: Inflammation of COLON) Autoimmune Autoimmune Ileum & Ascending: Digestion, Metabolism and Partly elimination; FAT is metabolized in the illeum; They cannot absorb FAT (STEARRHOEA); Also Fat soluble ADEK deficiency; No Vitamin K (Bleeding) Rectosigmoid: Elimination problem only RIGHT Lower quadrant pain Left Lower Quadrant Pain 3-5 watery stools 15-20 BLOODY Diarrhea (Shock and F&E Balance) TRANSMURAL INVOLVEMENT: All layers have already been involved SHALLOW ULCERATION: few layers only Ileostomy Colostomy COBBLESTONE APPEARANCE/ SKIP LESIONS: not all segment, there are parts without CONTINOUS PATTERNS: all the parts of the rectosigmpoid are inflamed STEROIDS & FLAGYL STEROIDS & FLAGYL *CHEMOTHERAPY: is used also for their immunosuppressant effect - MANAGEMENT: 1. Rest the bowel 2. Control the inflammation 3. TX INFX 4. Correct Malnutrition: Chron’s: ADEK 5. Alleviate Stress: causes exacerbation 6. Provide Symptomatic Relief - MEDICATIONS: DMARDS: AMINOSALICYLATE(Sulfazaline), ATB, Steroids, Immunosuppresants - SURGERY 1. CHRON’S PROCTOCOLECTOMY: total removal of the Intestines; Liquid stools Large and may irritant incision 2. CONTINENT ILEOSTOM/ KOCK’S POUCH: the bag is inside: the intestines are used to create the pouch; there is a whole; Continent (Can be manually drained through CATHERTER); With a flat stoma on the right side of the abdomen (Drained every 2-4 hours) 2.1 ADVANTAGE 2.1.1 No need to wear an external pouch 2.1.2 Minimal kin Problems 2.1.3 No flatus or leakage of stool - PRE-OP 1. Reduce the bacteria in the intestinal tract to prevent infection: NEOMYCIN 2. Reduce colon content: low residue diet, laxatives, enema 3. Decompress GI tract - COLOSTOMY CARE 1. Skin Care: cleanse with mild soap and water 2. Odor control: no gassy foods or smelly (asparagus) 3. Control gas: no eggs; place charcoal or baking soda to deter scent 4. Colostomy Irrigation: to stimulate peristalsis; to establish a regular pattern; Almost the same as enema but inserted into the colostomy; can only be done ONCE a DAY or may cause diarrhea - COLOSTOMY IRRIGATION 1. DO NOT INSERT NO MORE THAN 4 inches 2. Do not force catheter into the stoma 3. Elevate solution 12-18 inches 4. 500 Irrigate only with -1000ml of warm tap water 5. Do not irrigate more than once a day - STOMA CARE: 1. COLOR: pinkish, reddish with slight edema for 5-7 days 2. PURPLE: is cyanotic 3. Beefy red: inflamed infected LIVER CIRRHOSIS - Scarring if the liver; irreversible damage to the liver - CAUSES: 1. Laennec (Alcohol); 2. post Hepatitis (VIRAL): Fibrosis; 3. Biliary Obstruction (chronic bile obstruction causes cirrhosis); 4. Cardiac (R-CHF) - LIVER CIRCULATION: 1. Lymphatic artery: BLOOD is 20% oxygenated 0 0

16. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* 2. Portal Vein: From the GI tract 80% unoxygenated Blood (needs more of unoxy) - Once the liver is damage, causes PORTAL HYPERTENSION because the blood cannot enter. - S/SX: GI Symptoms: N/V, Anorexia, decreased energy (cannot metabolize and Glucose CHO properly); HEPATOMEGALY (Fatty Liver; caused by the loss of the liver to metabolize fats); Decrease albumin (CHON) (shifting due to production: edema decreased colloidal pressure) ascites; decreased production of clotting, bleeding anemia *ANTIBODIES are made out of CHON, since you can’t metabolize proteins, you will be prone to Infections * CLOTTING FACTORS ARE ALSO MADE OF CHON - Obstruction of Bile flow: Decreased absorption of fats and ADKEK; VITAMIN K is for clotting: THEY DIE of HEMMORHAGIC STROKE - Decreased conjugation of Bilirubin: ACHOLIC stools, tea Colored Urine • RBC (120 days) à HEME + BILIRUBIN à Unconjugated bilirubin à not water soluble (cannot be excreted) à Glucoronyl Transferase • In the Liver converts it into CONJUGATED BILIRUBIN: goes to the liver to be recycled and the remaining becomes STERCOBILIN (gives the color or the liver); Which in turn causes ACHOLIC STOOLS • The one left with the liver and goes to the blood HYPERBILIRUBENEMIA; then to the kidneys causing HYPERBILIRUBINEMIA which is TEA COLORED URINE - Decreased deamination of CHON Ammonia - can’t be converted to urea • AMMONIA is toxic to the Nervous System; Deamination in the Liver to converts it into water soluble UREA • This will increase the BUN - S/SX OF HEPATIC ENCEPALOPATHY 1. Confusion 2. Forgetfulness 3. Peripheral: ASTERIXIS - Liver also has something to do with Sex Hormone use: Males (gynecomastia) and Females (hirsutism); The Sex hormones are destroyed - MANAGEMNT 1. Correct electrolyte imbalance 2. Reduction of ammonia formation: 2.1 NEOMYCIN, LACTULOSE 2.2 CHON restriction, tap water enema *MODERATE CHON but lower with hepatic Encephalopathy *HIGH BIOLOGICAL CHON: MEAT *LOW BIOLOGICAL CHON: Beans or monngo in CHN *If you use LOW biological, you will eat a lot and cause more feces so you use High biological to decrease stool 3. NGT to suction 4. Potassium Sparring: Spirinololactone (CIRRHOSIS has increased sodium and Hypokalemia) 5. Paracentesis 6. BEDREST: to reduce metabolic demands to the liver 7. High CHO, High Calorie Diet ESOPHAGEAL VARICES - When the client eats the varices can be hit and cause bleeding without chance of clotting - STEGSTAKEN BLAKEMORE TUBE: it puts pressure on the esophagus and stomach; there are two balloons; No blood supply and causes ESPHAGEAL VARICES (Deflate 5 minutes 10 hrs per day in 8- ); if ever the patient pulls out cut the balloons SCISSORS on bed side *what do you need in BED SIDE Thyroidectomy: Trachesotomy Set - MANAGEMENT 1. IV FLUIDS 2. Anti Emetics 3. Stegstaken-Blakemore PANCREATITIS - Inflammation: AUTODIGESTION by the trapped enzymes; Obstruction and edema; Interstitial hemorrhage and tissue necrosis - CAUSES 1. Chronic Alcoholism 2. Gallstone 3. Infection 4. DRUGS: Chlorothiazine, Glucocorticods – PROVOKE PANCREATITIS - May hurt due to the trapped pancreatic enzyme - S/SX: 1. Steady, severe epigastric pain: back, aggravated by fatty meal and recumbent position 2. Vomiting which does not relieve epigastric pain 3. Fever 4. Abdominal pain 5. Elevated lipase and amylase: Characteristic Indicator 6. Elevated WBC, blood sugar (since the pancreas creates the insulin; causing DM) and bilirubin - SIGNS OF PERITONEAL BLEEDING 1. CULLEN’S SIGN: discoloration of abdomen and peri-umbilical region 2. TURNER’S SIGN: Bluish discoloration of the flanks - SIGNS OF PERITONITIS: Blumberg’s Sign (rebound tenderness) - MANAGEMENT 1. Client will be free from pain or less: NPO: prevents auto-digestion; ANALGESIS: Demerol (drug of choice); NO Morphine causes spasm of 0 0

17. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* the sphincter of oddi; ANTICHOLINERGIC: Probanthine: decrease secretion and relax sphincter of Oddi 2. Client will be free form shock: IV FLUIDS 3. TPN and Insulin as needed and Vitamins 4. Stop drinking alcohol - SURGERY: WIPOL’S SURGERY: head of pancreas and and part duodenum *ADD: Pancreatic CA CHOLELITHIASIS - Stone formation in the gall bladder - CHOLECYSTITIS: inflammation of the gall bladder usually precipitated by gallstones (Cholelithiasis) - CHOLEDOCHOLITHIASIS: Stone formation at the common bile duct (CHOLEDOCHOLTITHOTOMY) - Incidence (5Fs) 1. Female 2. Forty (age: 40 and above) 3. Fair Complexion 4. Fertile 5. Fat - Fatty Foods and Dehydration: Liquid bile but becomes dehydrated due to low fluids - The COMMON BILE DUCT: cannot be removed but only remove the stone (T-TUBE) - MANIFESTATION: Epigastric distress; Abdominal Distention; RUQ pain after fatty meal; REFERRED PAIN to Shoulder - MURPHY’S SIGN: with pain when palpated during DB - MANAGEMENT: Pain: DEMEROL (drug of choice): Do not give Morphine: causes spasm of the sphincter of oddi - NON SURGICAL 1. DISSOLUTION TX: Chemodeoxycholic Acis (chenosiol), Ursodiol PO: 4-6 months to take effect and dissolve and few could be dissolve 2. ESWL: followed by oral dissolution; 1500 shockwaves delivered in 1 2 hours done on - selective basis; <3 stones; Instruct to remain motionless for 20 minutes-1 hour; ABDOMINAL AREA WILL BE BRUISED; Also for Kidney stones *HIGH INCISION OF OPEN CHOLE: does not promote DBE and will cause Pneumonia and Atelectasis; Open: monitor for respiratory distress - - POST OP 1. Maintain a patent NGT 2. Assess T-Tube if common bile duct is manipulated (500mL/ dy for 1st few days): Drains the bile until the COMMON BILE DUCT IS NOLONGER INFLAMMED; green discharge *How to know if the CBD is no longer inflamed: Clamp the T- Tube and let the patient eats; He will be able to tolerate the feeding; So if the client cannot tolerate (N/V), clamp automatically 3. Position: Low to SF 4. Monitor dressing 5. Clamp Tube as ordered: open ready ti eat 6. DBE 7. EARLY ambulation 8. FAT FREE DIET for 6 weeks GENITOURINARY KIDNEYS: Urine formation; Excretion of waste products - URINE is the vehicle to remove waste ; products Waste Product: CHON metabolites (in metabolizing CHON: UREA (80%; BUN), Creatinine, Phosphate, Sulfates, Uric Acid); ALL OF WHICH WILL CAUSE METABOLIC ACIDOSIS - REGUALTION of electrolytes: Sodium and Potassium; 80% of K is by the kidneys (this excreted is the reason why diuretics loose all the K in the body) *30-60 mL/Hr is the normal U/O; 720 ml Minimum amount of urine per day; Less than that is Oliguria; None is Anuria - Regulates Acid Base Balance - : Deep and Rapid breathing (KUSSMAUL’S RESPIRATION: anytime you have metabolic acidosis not only DKA or HHNS) - Control of water balance: ADH (Vasopressin): Edema - Control of BP: RAAS; Increased BP with kidney damage; HTN - Regulation of RBC Production: Anemic DIAGNOSTICS 1. Labs 1.1 Routine Urinalysis 1.2 Creatinine Clearance 1.3 Blood studies: BUN (8-25 mg/dL), Serum Creatinine (0.6-1.3 mg/dL), Creatinine Clearance (85-135 ml/min), serum electrolytes 1.4 Cystoscopy 1.5 Abdominal X-ray (KUB) *ADD: all Laboratory procedures and Diagnostic Procedures RENAL FAILURE 1. TYPES: 1.1 Acute: can be reversed; sudden loss of functioning 1.2 Chronic: more dangerous; gradual, progressive 2. CAUSES: 2.1 PRERENAL: is decreased or perfusion decreased blood supply 2.2 RENAL: damage directly to the kidneys; Renal Calculi or medications 2.3 POSTRENAL: obstr the uction nd up flow a kidney 0 0

18. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* ACUTE RENAL FAILURE 1. PHASES 1.1 OLIGURIC/ ANURIC PHASE (Chronic is stuck here) - : 8 15 days output <400ml/day; - Toxins accumulate: METABOLIC acidosis; Increased BUN, Crea, Hyperkalemia 1.1.1 Decreased: pH, bicarb and Na anad Ca 1.1.2 AZOTEMIA: elevated serum level of UREA, creatinine and uric Acid 1.2 DIURETIC PHASE: extends from the time daily output >400 mL/day; BUN stops increasing, U/O >3-5L/day, hyponatremia you ( are now urinating Na and K), change in LOC; hypokalemia, changes in LOC 1.3 RECOVERY (Chronic RF will never go to this phase): extends from the first day BUN falls to the day it returns to normal 2. MANAGEMENT 2.1 Dialysis monitor F7E, Acids and bases observe for fluid overloads 2.2 Moderate protein restriction, high on calories, CHO, Low K *KAYEXELATE (Sodium Polystyrene Sulfonate): hyperkalemia, exchange Na for K ions in GIT 2.3 Monitor cardiac status, I&O, weigh daily 2.4 Fluid restriction 2.5 Diuretic Therapy CHRONIC RENAL FAILURE STAGES OF CRF 1. DIMISHED RENAL RESERVE 1.1 Normal serum BUN and Creatinine 1.2 No symptom 1.3 Other kidney Compensates 2. RENAL INSUFFICIENCY 2.1 GFR is only 25% normal 2.2 Azotemia: mild; Anemia 2.3 Decreasing Creatinine Clearance 3. END STAGE RENAL DISEASE 3.1 GFR <10% 3.2 SEVERE AZOTEMIA MANIFESTATIONS 1. Azotemia; Metabolic Acidosis 2. ALOC due to accumulation of waste 3. Irregular HR 4. Yellow to bronze skin due to altered metabolic process 5. Dry and scaly skin with severe itching due to uremic frost 6. Proteinuria, Glycosuria 7. Diminished erythropoietin secretion: Anemia 8. Renal Phosphate excretion and VIT D synthesis are diminished; K secretion increases 9. Heart Failure; Pulmonary edema 10. Kussmaul’s Respiration MANAGEMNT 1. Kidney transplant 2. Dialysis, Monitor I&O, F&E 3. Low CHON Diet: Limit accumulation of end products of CHON metabolism 4. Fluid restriction 5. Ant Diuretics iHTN and 6. EPOGEN 7. Antipuritics; Good skin Care DIALYSIS HD 1. Access Site: takes 4-6 weeks to mature so use an central Venous Catheter 1.1 AV Fistula 1.2 Av Graft 1.3 Central Venous Catheter (IJ, Subclavian, Femoral) 2. MANAGEMNT 2.1 Monitor venous access 2.2 Weigh before and after the procedure *DRY WEIGHT: the weight of the patient without excess water; based by the physician; so ex. Dry weight of 5 L and simply remove 5kg from the real weight and place that into the machine 3. Monitor Disequilibrium Syndrome: too fast removal of waste causes Confusion and weakness 4. Monitor for Shock and hypovolemia 5. Auscultate for Bruits and palpate for thrills 6. Don’t use arm for BP, IVT or venipuncture PD - Introduction of specially prepared dialysate solution into the abdominal cavity where the peritoneum acts as a semi-permeable membrane - CHON may leak out - MANAGEMENT: Assess Vs every 15 minutes then after every hour; Weigh; Let patient void before procedure; Warm dialysate to prevent cramps 1. Access Site: [1] STERILE INSERTION (if not peritonitis); [2] Concepts: INFLOW (10 minutes), DWELLING TIME (20 min - 30 minutes) & OUTFLOW (15-20 minutes) 2. Drainage is less than infused: Turn side to side or Ambulate UTI - Stasis of the urine in the bladder and of urine reflux back into the bladder - UPPER UTI = SUPRAPUBIC PAIN: Urethritis - LOWER UTI = FLANK PAIN: cystitis, urethritis - MC is ASCENDING TYPE - Females > Males (shorter urethra) - Instrumentation and obstruction also common causes; Also sexual intercourse promotes development of UTI 0 0

19. MEDICAL-SURGICAL NURSING UNIVERSITY*OF*SANTO*TOMAS*–*COLLEGE*OF*NURSING*|*FJCP*2017*| α α α α α*NOTES* - MANIFESTATIONS: 1. Frequency, Urgency, Dyuria 2. Hypogastric Pain 3. Malaise 4. Fever, Chills 5. N/V 6. Low back pain 7. Urinalysis Findings - MANAGEMENT 1. C and S before ATB 2. Increase Fluid intake 3. Acidify the urine *ACID ASH: CPP: Cranberry, Plums & Prunes *Buco Juice is only a DIURETICS *ALKALINE ASH: Citrus fruits 4. Perineal Hygiene 5. Regular Bladder emptying 6. Hot sitz bath UROLITHIASIS/ NEPHROLITHIASIS - Formation of stones in the urinary tract - RF: 1. Calcium: Diets high in calcium; immobilization (if you don’t move, the calcium is removed from the bones into the serum) 2. Urinary Stasis 3. Dehydration 4. Uric Acid - TYPE OF STONE 1. URIC ACID CALCIUM OXALATES, PHOSPHATES - MANIFESTATION 1. Hematuria: late sign 2. Colicky pain 3. N/V; Dysuria - MANAGEMENT 1. Fluids 2. Strain urine * STRAIN the urine and send it to the lab to determine the stone 3. Encourage ambulation 4. Pain Control 5. DIET 5.1 Calcium: Acid Ash 5.2 Cystine: Alkaline Ash 5.3 Uric Acid: Low purine *Vegetables: contain oxalates so don’t give to calcium OXALATE stones! 6. SURGERY: Urolithotomy/ Nephrolithotomy; NEPHROSTOMY TUBE: At the flank to drain the urine while it is healing/ inflamed; Same idea as a T TUBE; ESWL BPH - Slow enlargement of the prostate; 40 y/o and above - Nocturnal: number 1 reason; - CAUSES: hormonal changes or factors; age related changes - Urethral compression occurs with sign of urinary obstruction urinary stasis à à UTI - INTERFERENCE IN URINATION - MANIFESTATIONS 1. Urinary frequency 2. Nocturia 3. Bladder distention 4. Bladder Calculi - MANAGEMENT: 1. Terazosin: to promote urination; ALPHA BLOCKER 2. ATB for UTI 3. Administer Finasteride (Proscar: reduces size) - SURGERY 1. TURP 1.1 Suprapubic: incision in the abdomen and blader 1.2 Retropubic: abdominal incision 1.3 Perineal: near the rectum; highest risk of contamination and incontinence *1% Impotent after surgery - POST-OP 1. Cystoclysis: to remove the clots; Maintain urine to pinkish red; if red, too little, too little, too fast; 3 WAY CATHERTER: infusion, balloon and drainage bag 2. Normal to have bladder spasms PROSTATE CANCER - Slow malignant in the prostate gland that spreads by direct invasion of the tissue and can metastasize to bony pelvis and spine - Elevated serum acid phosphatrase and serum PSA (Prostate Specific Antigen) and CEA (Carcinoembryonic Antigen) - BIOPSY: Reveals malignancy, MRI-CT - Give: Diethystilbrstrol (estrogen) to reduce testosterone - Radiation and Radical Prostectomy - ORCHIECTOMY: to also decrease production of testosterone α α α α α! 0 0

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