1.

Review Ericksons stage of development

- Infancy (birth till 18mons) Trust Vs mistrust. Task: Attachment to mother
- Early adulthood (18mons to 3 years): Autonomy vs shame. Task: Gaining basic control
- ate childhood (3!") : Initiative vs #uilt. Task : ecoming p!rposef!l and directive
- $chool a%e ("!1&) : Industry vs Inferiority. Task: "eveloping social# ph$sical skills
- Adolescence (1&!&'): %dentit$ vs role conf!sion.
- Early adulthood (&'!3(): Intimacy vs Isolation. Task: establishing intimate bonds
- )iddle adulthood (3(!"(): #enerativity vsd sta%nation. Task: &!lfilling life goals
- ater ("(*) Inte%rity vs des+air
.
&. Elder abuse and assessments
- 'h$sical: (prain# dislocation# fract!res# br!ises# p!nct!re wo!nds# b!rns# press!re sores
- (e)!al: "iscomfort*bleeding in the genital area.
- Emotional: +onf!sion# fearf!l and agitated# changes in appetite and weight# withdrawn
- ,eglect: "eh$dration and maln!trition# disheveled appearance# lacking ph$sical needs# meds
overdose# economic e)ploitation
3. ,evie- a%e related chan%es (affectin% nutrition. hydration. medications in the elderly)
- "ec skin t!gor# elasticit$# dr$ skin# inc resp. rate - decrease o)$gen intake#
- "ecrease: need for calories-appetite-thirst-lean bod$ weight# stomach empt$ing time# metabolic
rate#
- "ecrease capacit$ of bladder# inc resid!al !rine# incidence of incontinence and infection
- .edication doses are prescribed at one half or 1*/ of ad!lt doses. +ommon sign of AE is ac!te
changes in mental stat!s
4. Review care of patients with chest t!bes 0Remove or drain air from int intraple!ral space# to e)pand the
l!ng after s!rger$# and to restore s!batmospheric press!re to the thoracic cavit$1 /e%ative +ressure
a. 0ee+ all tubin% coiled loosely belo- chest level. -ith connections ti%ht and ta+ed
b. 2eep water seal and s!ction control chambers at appropriate water levels
c. .onitor the fl!id drainage and mark the time of meas!rements and fl!id level
i. 1 to 3 ho!rs intervals !sing a piece of tape
d. 1bserve for air bubblin% in the -ater seal chamber and fluctuations (tidalin%1
i. %f fluctuation cease# chec2 for 2in2ed tubin%. acc!m!lation of fl!id in the t!bing#
occl!sions# or change in the client4s position# b*c e)panding l!ng tiss!e ma$ be
occl!sions the t!be opening
ii. 2now 3neumothora4. intermittent bubblin% in the water seal chamber is
e)pected as air is drained from the chest# b!t cont. b!bbling indicates an air leak in the
s$stem
,otif$ the ph$sician if there is a cont. b!bbling in the water seal chambers
e. .onitor the client4s clinical stat!s
f. +heck the position of the chest drainage s$stem
g. Enco!rage the client to breathe dee+ly +eriodically
h. "o not empt$ collection container. "o not strip or mild chest t!bes
i. +hest t!bes are not clamped ro!tinel$. %f the drainage s$stem breaks# place the distal end of the
chest t!bing connection in a sterile water container at a 5 cm level as an emergenc$ water seal
6. .aintain dr$ occl!sive dressing
Interventions for 5hest tubes
.onitor drainage7 notif$ the ph$sician if drainage is more than 188 m9*hr or if
drainage becomes 6,I#7T ,E8 or I/5,EA$E8 s!ddenl$
Assess res+iratory status and ausculate lun% sounds
.onitor for sings of e)tended pne!mothora) or hemothora)
:hen removed ask the client to deep breath and hold it# and the t!be is removed7
a dr$ sterile dressing# petrole!m ga!;e dressing# or Telfa dressing is taped in place after
removal of the chest t!be
Valsalva9s maneuver
(. :se of anti!inflammatories for treatment of +ain (/onnarcotics)
Acts b$ means of peripheral mechanism at level of damaged tiss!e b$ inhibiting prostaglandin
and other chemical mediator s$ntheses involved in pain
,(A%"s relive inflammation and pain to treat rhe!matoid arthritis# b!rsitis# tendinitis#
osteoarthritis# and ac!te go!t
(low antip$retic activit$ thro!gh action on the h$pothalamic heat-reg!lating center to red!ce
fever 0a$er# nonsalic$lates# acetaminophen 0T$lenol1# ib!profen 0.otrin1
Analgesic and can be s!ed with other agents
Teach s*s 6EE8I/## avoid ET17# observe for TI//IT:$. admin corticosteroids for server
rhe!matoid arthritis# /$AI8s reduce the effects of A5E inhibitors in h$pertensive clients
3t ta2en anticoa%ulant should not ta2e as+irin or /$AI8$
A$3I,I/ and /$AI8$ sho!ld not be taken together b*c A$3,I/ 8E5,EA$E the blood
level and the effectiveness of /$AI8$ and can I/5,EA$E the ris2 of bleedin%
<igh risk of T1;I5IT< e)ists if ib!profen is taken conc!rrentl$ with 5AI5:) 6150E,$
<$pogl$cemia can res!lt if ib!profen 0.otrin1 is taken with I/$:I/ or 1,A 7<31#<5E)I5
)E8IATI1/
Enco!rage ro!tine appt to chec2 liver=renal labs and 565
Adverse reactions
G% irritation# bleeding# ,*=*+onstipation# Elevated liver en;$mes# 'rolonged coag!lation time#
tinnit!s# thromboc$topenia# fl!id retention# nephroto)icit$ and blood decrease 0plasma cells1
". Endocrine
a. 7y+othyroid (*(0 Th$roid gland disorder1 7ashimoto disease and )y4edema
%ns!fficienc$ of th$roid hormones T/ and T3
"ecreased rate of bod$ metabolism
Treated with hormone replacement
Endemic goiters occ!r in individ!als living in areas where there is a 8E>I5IT of
I18I/E
Iodi?ed salt has hel+ed to +revent this +roblem
b. Assessments
&atig!e# letharg$
:eakness# m!scle aches# paresthesias
%ntolerance to 518
Thin# dr$ hair# dr$ skin
Thick# brittle nails
+onstipation
6radycardia. hy+otension
#oiter
'eriorbital edema# facial +uffiness (my4edema)
@ei%ht %ain
8ull emotions and mental +rocesses
&orgetf!lness# loss of memor$
.enstr!al dist!rbances
5ardiac enlar%ement. tendency to develo+ 57>
c. /ursin% interventions and +t teachin%
)1/IT1, VITA$ $I#/$. 7, and ,7<T7)
)AI/TAI/ 3ATE/T AI,@A< thro!gh $:5TI1/ and ventilator$ s!pport
"ail$ dose of prescribed hormone
+heck 63 and +ulse re%ularly
@EI#7T 8AI<
AV1I8 I18I/E
9evoth$ro)ine sodi!m 0$ynthroid1
%ncrease metabolic rates. ($nthetic T/
An4iety. Insomnia. tremors. tachycardia. +al+itations. an%ina.
dysrhythmias
>ngoing follow-!p to determine ser!m hormone level
Th$roid replacement therap$ and abo!t the clinical manifestations of both
7<31T7,1I8I$) and 7<3E,T7,1I8 r*t :/8E,,E3A5E)E/T >R
1VE,,,E3A5E)E/T of the hormones
3revent consti+ation
&l!id intake to be 3*da$
7i%h!fiber. includin% fresh fruits and ve%etables
%ncrease activit$
ittle or no use of enemas or la4atives
Avoid $E8ATI/# client# ma$ lead to ,E$3I5,AT1,< 8I>>I5:TIE$
$=$ my4edema coma
7y+otension# hy+o%lycemia# res+iratory failure. bradycardia. hy+onatremia.
%enerali?ed edema. coma
.aintain patent airwa$
Admin 51,TI51$TE,1I8$ as prescribed
Assess temp ho!rl$
0EE3 5IE/T @A,)
)1/IT1, EE5T1,<TE A/8 #:51$E EVE$
Admin %lucose intravenously as prescribed
d. 7y+erthyroid (#raves 8isease. #oiter) $=$
E)cessive activit$ of th$roid gland and EEVATE8 EVE$ of 5I,5:ATI1/
T<7,1I8 71,)1/E$
Res!lt from !se of ,E3A5)E/T 71,)1/E T7E,A3< or E;5E$$
T7<,1I8!$TI):ATI/# 71,)1/E 0T(<1 T/# T3
#,AVE$ a!toimm!ne process
e. Assessments
Enlar%ed thyroid %land
Acceleration of bod$ process
1. @ei%ht loss
2. Increased appetite
/. "iarrhea
A. 7eat Intolerance
(. Tachycardia. +al+itations. increased 63. a!fib
?. "iaphoresis# wet or most skin
B. /ervousness. insomnia. fine tremors of hands
8. $mooth soft s2in and hair
@. 'ersonalit$ change s!ch as irritabilit$# agitation and mood swings
1'. E4o+hthalmos (+rotrudin% eyeballs)
f. /ursin% interventions
'rovide A8EC:ATE ,E$T
Admin $edatives as prescribed
3rovide cool. and Duite environment
>bserve for sings of T7<,1I8 $T1,)
(!dden oversecretion of th$roid hormones or !ncontrolled is life threatening d*t #raves
disease
(*( >EVE,. TA57<. AI#ITATI1/. A/;IET<. and 7<3TE,TE/$I1/
'rimar$ n!rsing interventions )AI/TAI/ AI,@A< and A8EC:ATE AE,ATI1/ (A%R
+%R+A9ATE" T<R>AG<1
1btain daily -ei%ht
3rovide hi%h!calorie diet
Admin A/TIT7<,1I8 meds# 0'rop$lthioracil# 'TA1 block th$roid s$nthesis as prescribed
Admin I18I/E preparations that inhibits the release th$roid hormone as prescribed
Admin +ro+ranolol (I/8E,A) for tachycardia and to decrease e)cessive s$mpathetic
stim!lation
,adiation iodine thera+y to destroy thyroid cells
Radiation preca!tions 0Time# distances and shielding as means of protection against
radiation1
g. 3atient teachin%
After treatments# res!lting 7<31T7<,1I8I$) will reB!ire dail$ hormone replacement
:ear .ediAlert 6ewelr$ in case of emergenc$
(igns of hormone-replacement 1VE,81$A#E are the signs for 7<3E,T7<,1I8I$) and
:/8E,81$A#E 7<31T7,1I8I$)
"iet: 7I#7!5A1,IE. 7I#7!3,1TEI/. 1@!5A>>EI/E. 1@!>I6E, 8IET if 8IA,,7EA
3T: and )ethima?ole sho!ld take medication e)actl$ as prescribed so that desired affect
can be achieved
'erform e$e care for e)ophthalmos
Artificial tears to maintain moisture
$un%lasses when in bri%ht li%ht
Ann!al e$e e)ams
h. 8iabetes $=$ )ETA61I5 8I$1,8E, in which there is an absence of an insufficient
+roduction in insulin
". affects metabolism of +rotein. carbohydrate and fat
"iagnostic parameter is a fasting gl!cose level# $E,:) or 5A3IA,< of %reater than 1&"
m%=dl
T<3E 1: Insulin!de+endent 8)
3olydi+sia. +oly+ha%ia. +olyuria. weight loss and weakness
T<%, and 0etosis
I/$:I/ reB!ired b$ A99
Go into 0ET1A5I81$I$
5I/I5A 57A,A5TE,I$TI5$
ser!m gl!cose of /C8 >R above
0etonuria in large amo!nts
=eno!s p< of ?.D to E.5# (er!m bicarbonate below 1CmEg*dl
T,EAT)E/T
Treat with I$1T1/I5 IV >:I8$
$1@ IV inf!sion b$ IV +um+ of ,E#:A, I/$:I/ with %. or (+ bol!s
+aref!ll$ replacement of 31TA$$I:)
T<3E &: /on insulin!de+endent 8)
>ften !nnoticed# same as t$pe 1 and 6:,,E8 VI$I1/
16E$E rare 0ET1A5I81$I$
1,A h$pogl$cemics or ins!lin
develop /1/0ET1TI5 7<3E,1$)1A, 7<3E,#<5E)IA with e)treme
<F'ERG9F+E.%A
5I/I5A 57A,A5TE,I$TI5$
<F'ERG9F+E.%A
'9A(.A <F'ER>(.>9A9%TF
"E<F"RAT%>,
+<A,GE" .E,TA9 (TATA(
T,EAT)E/T$
I$1T1/I5 IV fl!ids replacements and caref!ll$ monitoring of '>TA((%A. and #:51$E
EVE$
%,TRA=E,>A( %,(A9%, 0,ot alwa$s necessar$1
i. Assessments
6rea2s in s2in# infections on skin
8IA6ETI5 8E,)13AT7< 0skin spots1
Anhealed in6ection sites
1ral cavity
+arries# 'eriodontal disease# +andidiasis 0raised# white patch$ areas on m!co!s membranes1
Eyes
+ataracts# retinal problems
5ardio+ulmonary system
Angina# "$spena
3eri+hery
<air loss on e)tremities# indicating poor perf!sion
+oolness# skin shininess and thinness
:eak or absent of peripheral p!lses
Alcerations of e)tremities
'allor
Thick nails with ridges
0idneys
Edema of face# hands and feet
s$mptoms of AT%: &AT%GAE# 'A99>R A," :EA2,E((
AR%,ARF RE,TAT%>,
/euromusculature
Atroph$ of hands and feet
,e!ropathies and s$mptoms of n!mbness tingling# pain b!rning
#I disturbances
,ighttime diarrhea
Emesis falling into patterns 0vomits ever$ night 1 ho!r after dinner
Gastroparesis 0fa!lt$ absorption1
,e+roduction
.ale impotence
=aginal dr$ness# freB!ent vaginal infections
.enstr!al irreg!larities
#<51$<ATE8 7E)1#16I/ A15 0presence confirms e)istence of h$pergl$cemia in previo!s 3
mo!ths1
Gl!cose control over 1&' days (lift of ,651
=al!able meas!rement of diabetes control
j. /ursin% interventions
8etermine baseline labs
(er!m gl!cose# electrol$tes# creatinine# A, and AGs
k. 3atient teachin%
9ift skin !se @8 degree angle
Rotate in6ection site 0abdomen for t$pe 11
8ra- re%ular insulin into syrin%e first -hen mi4in% insulin
5arb count and !se of e)change list when dinning o!t
)eals sho!ld be timed according to medication +ea2 times
CCG-?8G carboh$drates
15-15G protein
/8G fat or less
&oods high in comple) carbs# high in fiber and low in fat
ET>< beverages: acceptable if proper e)change are made
I/E$$ ,I$E I/$:I/
618< response to illness and stress is to prod!ce gl!cose (7<3E,#<5E)IA)
(nack ma$ be needed before or d!ring e)ercise
.onitor blood gl!cose before# d!ring and after e)ercise when beginning a new regimen
:EAT<ER a +9%E,T is 7<3E,#<5E)I5 or 7<3E,#<5E)I5 treat
7<3E,#<5E)IA
7y+er%lycemia
31<8I3$IA. 31<:,IA. 31<37A#IA. 6:,,E8 VI$I1/. @EA0/E$$. @EI#7T 1$$
A/8 $</513E
Enco!rage water intake and check ( freB!entl$
Asses for 0etoacidosis
Arine 2ET>,E( and G9A+>(E
A".%, ins!lin as directed
7y+o%lycemia
7A. /A:$EA. $@EATI/#. T,E)1,$. ET7A,#<. 7:/#E,. 51/>:$I1/. $:,,E8
$3EE57. TI/#I/# A,1:/8 )1:T7. A/;IET<. /I#7)A,E$
/ursin% Action
>cc!rs rapidl$ and is potentiall$ life-threatening treat with 51)3E; 571
graham crackers and pean!t b!tter twice# and if no response seek medical attention
+heck blood gl!cose is H 38
Teach feet care
&eet sho!ld be check dail$ for changes7 signs of in6!r$ and breaks in skin sho!ld be reported to
<+'
&eet sho!ld be washed dail$ with mild soap and warm water7 soaking is to be A=>%"E"# feet
sho!ld be "R%E" well# especiall$ ET:EE, T>E(
&EET ma$ be moist!ri;ed with a lanolin prod!ct# b!t not T: T>E(
:E99 fitted leather shoes sho!ld be worn7 going 6A,E>11T and -earin% $5A/8E$ are to
be avoided
5EA/ $7150$ sho!ld be worn dail$
Garters and tight elastic-topped socks $718 /1T 6E @1,/
+orns and call!ses sho!ld be removed b$ professional
,ails sho!ld be c!t or filled straight across
@A,) socks sho!ld be worn if feet are 518
l. Addisons A!toimm!ne con6!nction with other E/815,I/E 8I$EA$E of A:T1I)):TE
/AT:,E
(!dden withdrawal from 51,TI51$TE,1I8$ and lack of 51,TI$1#
A81$TE,1/E# and A/8,1#E/$
8isease interventions
.onitor VITA $I#/$ C1( min if in crisis# 63. @EI#7T and IE1
%nstr!ct client to ,I$E $1@< b*c of the possibilit$ of post!ral h$potension
6118 #:51$E and 31TA$$I:) EVE$
Admin #:5151,TI51I8 and )I/E,A151,TI51I8 medication
>bserve for A88I$1/IA/ 5,I$I$ ca!sed b$ $T,E$$. I/>E5TI1/. T,A:)A or
$:,#E,<
Admin %= gl!cose with parenteral gl!cocorticoids. 0A,#E >:I8 V1:)E
,E3A5E)E/T1
3atient teachin%
Avoid individ!als with I/>E5TI1/$
"iet: 7I#7!3,1TEI/# and 7I#7 5A,617<8,ATI1/
I>E1/# #:5151,TI51I8 therap$
Avoid 1T5 )edications
:ear .edic-Alert bracelet
s*s R*T :/8E,,E3A5)E/T and 1VE,,E3A5E)E/T of 71,)1/E$
m. 5are of the +atient s=+ thyroidectomy
+heck for aryn%eal edema b$ watching for 71A,$E/E$$ or I/A6IIT< to $3EA0 5EA,
'!t tracheostom$ set at the beside with >5 and s!ction machine# 5alcium %lucose sho!ld be
easil$ accessible
+heck freB!entl$ for 6EE8I/#
(!pport the /E50 when )1VI/# 5IE/T 0do not h$pere)tend1
"etermine I of 'ARAT<FR>%" G9A,"( that have been removed
3arathyroid problems is decreased in the client4s 5alcium compared to the preoperative
val!e
+hances of TETA/< I/5,EA$E8
+heck for TI/#I/# 1> T1E$ and >I/#E,$ and A,1:/8 the )1:T7
57V1$TE0 $I#/ 0twitching of lip after a tap over the parotid gland mean it is positive1
T,1:$$EA: $I#/ 0carpopedal spasm after ' c!ff is inflated above s$stolic press!re
means positive1
2eep 8,AI/A#E 8EVI5E$ 51)3,E$$E8 and E)3T<
B. Electrolytes
a. 5alcium: 7y+ocalcemia! F8."
%nadeB!ate oral intake of +A and vit "
9actose intolerance
.alabsorption s$ndromes s!ch as celiac spr!e or +rohn4s disease
E/8 $TA#E ,E/A 8I$A$E
Increased 5a e4cretion
Renal fail!re# pol$ric phase
"iarrhea# (teatorrhea
:o!nd drainage# especiall$ G%
5onditions that decrease the ioni?ed fraction of 5a
<$perproteinemia
A0A1$I$
)E8I5ATI1/$ s!ch as +a chelators or binders
Ac!te pancreatitis
7<3E,31$3ATE)IA
%..>%9%TF
,E)1VE8 or 8E$T,:5TI1/ 1> 3A,AT7<,1I8 #A/8$
A$$E$$)E/T
5ardiovascular
8E5,EA$E8 7,
7<31TE/$I1/
8I)I/I$7E8 3E,I37E,A 3:$E$
3,11/#E8 $T and CT interval
,es+iratory
,es+iratory failure or arrest can res!lt from 8E5,A$E8 respirator$ movement b*c muscle
tetany or sei?ures
/euromuscular
%rritable skeletal m!scles: T@IT57E$. 5,A)3$. TETA/<. $EIG:,E$
3AI/>: ):$5E $3A$)$ in the calf or foot d!ring periods of inactivit$
'aresthesias followed b$ /:)6/E$$ that ma$ affect I3$. /1$E# and EA,$ in addition
to limbs
'ositive Tro!ssea!4s and +hvostek4s sign
7<3E,A5TIVE 8EE3 TE/81/ ,E>E;E$
An)iet$# irritabilit$
#I
I/5,EA$E8 #A$T,I5 )1TIIT<. 7<3E,A5TIVE 61@E $1:/8$
abd cramping# diarrhea
7y+ercalcemia: $erum 5a H1'm%
%ncreased +a absorption
E)cessive oral intake of +a and =it "
"ecreased +a e)cretion
,enal failure
Ase of thia?ide diuretics
%ncreased bone resorption of +a
7<3E,3A,AT7,1I8I$)
7<3E,T7,1I8I$)
.alignanc$ 0bone destr!ction from metastatic t!mors1
%mmobilit$
Ase of %lucocorticoids
7emoconcentration
deh$dration# !se of lithi!m
A8,E/A I/$:>>I5IE/5<
Assessments
+ardiovasc!lar
Increase in 7, in early +hase. bradycardia that can lead to cardiac arrest in late sta%e
Increase in 63
o!nding# f!ll peripheral p!lses
,es+iratory
%neffective respirator$ movements as a res!lt of profo!nd skeletal m!scle weakness
/euromuscular
'rofo!nd m!scle weakness
8iminished or absent dee+ tendon refle4es
"isorientation# letharg$# coma
,enal
%ncreased !rinar$ o!tp!t leading to deh$dration
>ormation of renal calcui
#I
8E5,EA$E8 )1TIIT< and 7<3A5TIVE 61@E $1:/8$
A,>REJ%A# ,AA(EA# A">.%,A9 "%(TE,%>,# +>,(T%'AT%>,
b. 7y+o2alemia: 31TA$$I:) F3.(
I>E!T7,EAT7I/# b*c VE,< 618< $<$TE) I$ A>>E5TE8
A5T:A T1TA 618< 31TA$$I:) 1$$
E4cessive use of medications such as diuretics or corticosteroids
%ncreased secretion of aldosterone# s!ch as in 5:$7I/# $</8,1)E
=omiting# diarrhea
@ound draina%e# partic!larl$ G%
'rolonged ,G s!ction
E)cessive diaphoresis
Renal disease impairing reabsorption of 2
%nadeB!ate 2 intake: /31
.ovement of 2 from e)tracell!lar fl!id to the intracell!lar fl!id
Al2alosis
7y+erinsulinisum
"il!tion of ser!m 2
:ater into)ication
%= therap$ with 2-poor sol!tions
Assessment
5ardio
Thready. -ea2. irre%ular +ulse
3eri+heral +ulse -ea2
>rthostatic h$potension
,es+iratory
(hallow# ineffective# respirations that res!lt from profo!nd weakness of the skeletal m!scles
of respirations
"iminished breath so!nds
/euromuscular
An4iety. lethar%y. confusion. coma
$0EETA ):$5E$ @EA0/E$$. EVE/T:A >A55I8 3A,A<$I$
oss of tactile discrimination
8ee+ tendon hy+orefle4ia
#I
"ecreased mortilit$# h$poactive to absent bowel so!nds
,enal
,*=
+onstipation# abd distention
'arla$tic ile!s
7y+er2alemia 0H(
>veringestion of 2 containing foods or medications s!ch as 31TA$$I:) 571,I8E or $AT
$:6$TIT:E$
,a+id infusion of 0!containin% IV solution
"ecrease 2 e)cretion
31TA$$I:)!$3A,I/# 8I:,ETI5$
,E/A >AI:,E
A8,E/A I/$:>>I5IE/5< s!ch as A88I$I1/9$ 8I$EA$E
.ovement of 2 from intracell!lar fl!id to e)tracell!lar fl!id
Tiss!e damage
Acidosis
<$per!ricemia
7<3E,5ATA61I$)
Assessment
5ardio
$1@. @EA0. I,,E#:A, 7,
8ecreased 63
,es+iratory
'rofo!nd weakness of the skeletal m!scle leading to respirator$ fail!re
/euromuscular
Earl$: )uscle t-itches# cramps# paresthesias 0tingling and b!rning followed b$ n!mbness in hands
and feet and aro!nd mo!th1
9ate: 'rofo!nd -ea2ness. ascendin% flaccid +aralysis in the arm and le%s 0dr!nk# head and
respirator$ m!scles become affected when the ser!m 2 levels reaches a lethal level1
#I
%ncreased motilit$# h$peractive bowel so!nds
"iarrhea
c. 7y+onatremia $odium F13(
%mbalances !s!all$ ass with fl!id vol!me imbalances
Increased /a e4cretion
E)cessive diaphoresis
"i!retics
=omiting*"iarrhea
:o!nd drainage# G%
Renal disease
8ecreased secretion of aldosterone
%nadeB!ate ,a intake
/31
lo- salt diet
"il!tion of ser!m ,a
E)cessive ingestion of h$potonic fl!ids or irrigation with h$potonic fl!ids
Renal fail!re
&resh water drowning
($ndrome of inapp. Antidiuretic hormones secretions
7y+er%lycemia
+<&
Assessment
5ardio
($mptoms var$ with change in vasc!lar vol!me
/ormovolemic: Rapid p!lse# rate normal bp
7y+ovolemic: Thread$# weak# rapid p!lse rate# h$potension# flat neck veins# normal or low +='
7y+oervolemic: Rapid# bo!nding p!lse# bp normal or elevated# normal or elevated +='
,es+iratory
(hallow# ineffective respirator$ movements as a late manifestation R*T skeletal m!scle weakness
/euromuscular
Generali;ed skeletal m!scle weakness that is worse in the e)tremities
"iminished deep tendon refle)es
+erebral f!nction
7A. 3E,$1/AIT< 57A/#E$. 51/>:$I1/. $EIG:,E$ 51)A
#I
%ncreased motilit$ and h$peractive bowel so!nds
,a!sea
Abd cramping and diarrhea
,enal
8ecreased urinary s+ecific %ravity
%ncreased !rinar$ o!tp!ts
7y+ernatremia $odiumH1A(
"ecreased ,a secretions
5orticorosteroids
5ushin%9s syndrome
,enal failure
7y+eraldosteronim
%ncrease ,a intake
E)cessive oral ,a in6ection or e)cessive admin of ,a containing %= fl!ids
"ecrease water intake: /31
%ncreased water loss: %ncreased rate of metabolism# fever# h$perventilation# infection# e)cessive
diaphoresis# water$ diarrhea# diabetes inspid!s
Assessment
5ardio
7, and 63 that respond to vasc!lar vol!me stat!s
Respirator$: 3ulmonary edema if h$pervolemia presentation
/euromuscular
Early: (pontaneo!s m!scle twitches# irreg!lar m!scle contractions
ate: (keletal m!scles weakness# deep tendon refle) diminished or absent
5entral nervous system
Altered cerebral function is the most common manifestation of hy+ernatuermia
,ormovolemia or h$povolemia: Agitation# conf!sion# sei;!res
<$pervolemia: 9etharg$# st!por# coma
,enal
Increased urinary s+ecify %ravity
8ecreased urinary out+ut
Inte%umentary
"r$ skin
'resence or absence of edema# depending on fl!id vol!me change
5ardiac
7y+ertension +atient teachin% and evaluation
%nformation abo!t the disease process
Risk factors# ca!ses# long-term complications# lifest$le modification
Relationship of treatment to prevention of complications
%nformation abo!t treatment plan
Reason for each medication
<ow to take own 63
<ow and when to take each medication
,ecessit$ of consistenc$ in medications regiment
,eed to o!tgoing assessment while taking antihy+ertensive

<E(% <%,T
The n!mber 1/E ca!se of a $T,10E in <T, clients is noncompliance with medication regimen
<T, is often s$mptomless and antih$pertensive medications are e)pensive and have side effects
d. <eart &ail!re inabilit$ of the heart to 3:)3 eno!gh blood to meet the TI$$:E demands
5ause
%schemic heart disease# .%# +ardiom$opath$# =alv!lar heart disease and <T,
e. eft!sided 7>
3:1)A/A,< E8E)A 09& ventric!lar fail!re1
'!lmonar$ congestion d*t the inabilit$ of the 9f ventricle to p!mp blood to the peripher$
(*(
"F(',EA
>RT<>',EA
I@ETJ :/# $1:/8$
+>AG<# &AT%GAE
TA57<5A,8IA
A/;IET<. ,E$TE$$/E$$
+>,&A(%>,
f. ,i%ht!$ided 7>
3eri+heral con%estion d*t inabilit$ of the ,I#7T VE/T,I5E to +um+ blood out of the
lun%sK often results from left!sided failure or +ulmonary disease
$=$
'ER%'<ERA9 E"E.A
:E%G<T GA%,
"%(TE,"E" ,E+2 =E%,(
A,>REJ%A# ,AA(EA# :EA2,E((
,>+TAR%A
3lannin% and Interventions
.onitor vitals B3 ho!rs for changes
.onitor apical heart rate with vital signs to detect d$srh$thmias# (/ or (3
Asses for 7y+o4ia
RE(T9E((,E((
TA+<F+AR"%A# A,G%,A
Auscultate lun%s for indications of +ulmonary edema
@ET $1:/8$ and 5,A50E$
Admin 1& as needed
Elevate 716 to assist with breathing
>bserve for signs of edema
@ei%h daily
)onitor IE1
.eas!re abd girth observed ankles and fingers
imit /a inta2e
EEVATE 1@E, E;TE,)ITIE$ while $ITTI/#
+heck a+ical 7, prior to admin of di%italis
@IT718 medication and call ph$sician if rate is F"' bm+
Admin di!retics in the A.
3rovide +eriods of ,E$T after +eriods of activities
%. An%ina
5hest discomfort or +ain that occ!rs when myocardial 1& demands e)ceed s!ppl$
5ause
Atherosclerotic heart disease
<T,
+oronar$ arter$ spasm
<$pertrophic cardiom$opath$
h. Assessments
.ild to severe intensit$# described as 7EAV<. $C:EEGI/#. 3,E$$I/#. 6:,/I/#.
57150I/#. A57I/## and feeling of A33,E7E/$I1/
$:6$TE,/A. ,A8IATI/# to f arm and or shoulder. La-. ri%ht shoulder
Transient or prolonged# with %radual or sudden onset7 t$picall$ of short duration
>ften 3,E5I3ITATE8 b$ E;E,5I$E. E;31$:,E to 518# a 7EAV< )EA. )E/TA
TE/$I1/# $E;:A I/TE,51:,$E
,EIEVE8 b$ ,E$T and or /IT,1#<5E,I/
"$spnea# tach$cardia# palpitations
,*=# &atig!e# "iaphoresis# pallor# weakness
($ncope
"$shr$thmias
(T-segment depressed and T-wave inversion
i. Interventions= 3t teachin%
.onitor medication and instr!ct client with proper administration
"etermine factors precipitation pain# and assist client and famil$ in ad6!sting lifest$le to
decrease these factors
Teach ris2 factors. and identify clients o-n ris2 factors durin% attac2
'rovide I))E8IATE ,E$T
Take vital signs
Record an E+G
Admin no more than 3 /IT,1#<5E,I/ tables for ( )I/$ a+art
(eek emergenc$ treatments if no relief has occ!rred after taking nitrogl$cerin
3hysical activity
Teach avoidance of I$1)ET,I5 A5TIVITE$
%mplement an E;E,5I$E 3,1#,A)
(e)!al activit$ ma$ be res!med after e)ercise is tolerated# !s!all$ when able to climb &
>I#7T$ 1> $TAI,$ -ithout E;E,TI1/
/IT,1#<5E,I/ can be taken proph$lacticall$ before intercourse
'rovide n!tritional information abo!t modif$ing &AT 0sat!rated1 and (>"%A.
A,T%9%'E.%+ medications ma$ be prescribed to lower cholesterol levels
j. 5VA-sudden loss of brain function resultin% from a disru+tion in the blood su++ly to a
+art of the brain. T7,1)61TI5 or 7E))1,7A#I5A
$tro2e assessments
57A/#E in 15
'aresthesia# paral$sis
Aphasia# agraphia
.emor$ loss
=ision impairment
ladder and bowel d$sf!nction
behavioral changes
Abilit$ to swallow# eat and drink witho!t aspiration
Assessment of client9s functional abilities
)16IIT<. A89$. EI)I/ATI1/. 51)):/I5AT1/
k. interventions=+atient teachin%
5ontrol 7T/ to help prevent f!t!re strokes
)aintain +ro+er body ali%nment -hile client is in bed
Ase s+lints or other assistive devices 0 bed rolls and pillows1
'osition client to minimi;ed edema# prevent contraction and maintain skin integrit$
'erform >: ,1) e4ercises A times a day
Enco!rage client to participate in or manage own personal care
(et realistic goals# add new tasks dail$
l. +are of patients with hemiplegia
m. +are of patients with hemianopsia
Appropriate self-care activities for pt
athing# br!shing teeth# shaving and electric ra;or
Eating# combing hair
Enco!rage client with assist with dressing activities and modif$ them as necessar$0wear
street clothes d!ring waking ho!rs1
Analy?e bladder or elimination
>ffer bedpan or !rinal according to client4s partic!lar pattern of elimination
Reass!re client that bladder control tends to be regained B!ickl$
>ollo-!u+ s+eech +ro%rams initiated by s+eech and lan%ua%e thera+ist
Ens!re consistenc$ with program
Reass!re the client that regaining speech is VE,< $1@ 3,15E$$
Give 1/E set of I/$T,:5TI1/$ at a time
Enco!rage total famil$ involvement in rehab
Enco!rage client and famil$ to 6oin s!pport gro!p
Enco!rage famil$ members to allow the client to perform self-care activities as o!tlined
b$ rehab team
Teach swallowing modifications ma$ incl!de soft diet 0p!reed foods# thickened liB!ids1
and head positions
7E$I 7I/T
$teroids are administered after a stroke to decrease cerebral edema and retard permanent
disabilit$
7& inhibitors are admin to +revent +e+tic ulcers
8. ,es+iratory
a. A6# inter+retation! )easurement of the dissolved o4y%en and carbon dio4ide in the arterial
blood hel+s indicate the acid!base state and ho- -ell 1;<#E/ is bein% carried to the body
3re+ro
'erform AE/9$ TE$T before drawing radial arter$ specimens
Assist with the specimen draw b$ preparing a he+arini?ed syrin%e
<ave pt rest for 3' )I/ before s+ecimen collection to ens!re acc!rate meas!rement of bod$
o)$genation
Avoid $:5TI1/I/# before dra-in% the A6# sam+le. 8o not turn off o4y%en !nless the AG
sample is ordered to drawn with the clients breathing room
3ost+rocedure
3lace s+ecimen on ice
/ote clients tem+ on the lab form
/ote the o4y%en and ty+e of ventilation that the client is receivin% on the lab form
A++ly +ressure on the p!nct!re site for ( to 1' min or lon%er if the client is taking
anticoa%ulant thera+y or has a bleeding disorder
Transport specimen to the laborator$ within 1( min
/1,)A A,TE,IA 6118 #A$ VA:E$
p<: E./C-E.3C
'co5- /C to 3C mm <g
<co/- 55-5E
'>5- @?-188G
Asthma: 5hronic inflammatory disorders of the air-ays that causes VA,<I/# 8E#,EE 1>
16$T,:5TI1/ in the air-ays. AI,@A< I/>A))ATI1/ and 7<3E,,E$31/$IVE/E$$ to
stimuli or tri%%ers
b. Risk factors 0triggers1
%nfections
Allergies
E)ercise
%rritants
I%E!mast cell medicated res+onse
>bstr!ction of large and small airwa$s
Air trapping
,E$3I,AT1,< A5I81$I$
7<31;E)IA
Asthma ca!ses rec!rrent episodes of @7EEGI/#. 6,EAT7E$$/E$$. 57E$T TI#7T/E$$# and
51:#7I/# associated with AI,>1@ 16$T,:5TI1/ that ma$ be resolved spontaneo!sl$# often reversible
with treatment
(tat!s asthmatic!s is severe life-threatening A(T<.A episode that is refractor$ to treatment and ma$ res!lt in
',EA.>T<>RAJ# ac!te cor p!lmonale or respirator$ arrest
c. Assessments
,E$TE$$/E$$ 0 earl$ signs of cerebral h$po)ia# brain is not receiving eno!gh 851
@7EEGI/# 1, 5,A50E$
A6$E/T 1, 8E)I/I$7E8 :/# $1:/8$
7<3E,,E$1A/5E$
A(E >& A55E$$1,< ):$5E$ >1, 6,EAT7I/#
TA57<3/EA (ra+id breathin%) with 7<3E,VE/TIATI1/
3,1/1/#E8 E;7AATI1/
TA57<5A,8IA. 3:$E 3A,A81;:$ 0($stemic arterial press!re normall$ falls by
less than 1' mm7% durin% ins+iration. b!t this decline is not palpable at the
peripheral p!lse1
8IA371,E$I$. 5<A/1$I$. 8E5,EA$E8 1;<#E/ $AT
f. Treatments
A".%,%(T 6,1/5718IAT1,$. >:I8$ and 7:)I8I>I5ATI1/
<$dration enables liB!efactions of m!c!s trapped in the bronchioles and alveoli# facilitating
e)pectoration
Essential for clients e)periencing fevers
3''!A''ml of fluid is lost daily by the lun%s throu%h eva+oration
/ursin% Interventions
3,1)1TE AI,@A< 5E,A/5E 0fl!ids# antibiotics1
.onitor vital signs# p!lse o)# peak flow
'osition pt in 7I#7T >1@E,M$ 31$TI1/ or $ITTI/# to aid in breathing
Admin o4y%en as prescribed
Admin bronchodilator as prescribed
"ilate the airwa$s of the respirator$ tree# making air e)change and respiration easier for the
client# and rela) the smooth m!scle of the bronchi
C:I50 ,EIE> )E8I5ATI1/
%f taken T7E137<I/E monitor thera+eutic level 1' to &' mc%
,ecord color. amount and consistency of s+utum if an$
Admin corticosteroids as prescribed 0.etered-dose inhaler1 ."%
Anti-inflammator$ agent and red!ce edema of the airwa$s
1/# TE,) control
A!sc!late l!ng so!nds before# d!ring and after treatment
)inimi?in% an4iety
,!rsing care# calm approach. 2eep pt and famil$ informed abo!t proced!res
3t. Education
I/TE,)ITTE/T /AT:,E >& $<)3T1)$ and /EE8 for 1/#!TE,) mana%ement
%nstr!ct client to identif$ possible triggers and meas!res to prevent episodes
management of medication and proper administration
+orrect !se of peak flow meter
Asthma action plan with primar$ care provider and teach the client what to do if asthma
episodes occ!r
I/7AE,
<A=E +9%E,T E;7AE 51)3ETE<
#,I3 )1:T73IE5E (I/ )1:T7) 1/< I> T7E,E I$ A $3A5E,. other-ise. 0EE3 T7E
)1:T7 13E/ T1 6,I/# I/ V1:)E 1> AI, @IT7 )I$TE8 )E8I5ATI1/. @7IE
I/7AI/# $1@<. 3:$7 81@/ >I,)< 1/ T7E I/7ATE, T1 ,EAA$E
)E8I5ATI1/
A(E 6,1/5718IAT1, I/7A1, E&>RE $TE,1I8 I/7AE,
:A%T AT 9EA(T 1 )I/ 6E>1,E 3:>>$ 0%,<A9E" ">(E(1
d. 5138! 57,1/I5 16$T,:5TIVE :/# 8I$EA$E and 57,1/I5 AI,>1@ I)ITATI/$.
57,1/I5 51:#7. $3:T:) 3,18:5TI1/. and I/5,EA$E8 @1,0 of 6,EAT7I/# as -ell as
81E
e. "iagnostic tests
3ulmonary function Test
EVA:ATE :/# )E57A/I5$. #A$ E;57A/#E# and A5I8!6A$E
8I$T,:6A/5E$ thro!gh $3I,1)ET,I5 )EA$,)E/T$. :/# V1:)E$ and A6#
EVE$
"etermine whether an analgesic that ma$ depress the respirator$ f!nction is being
administered
<old 6,1/5718IAT1, before test 0cons!lt with ph$sician1
=oid before the proced!re and wear loose clothing
%nstr!ct client to refrain from smo2in% or eatin% heavy foods A to " hours before
the test
3ost+rocedure:
+lient ma$ res!me normal diet and an$ bronchodilators and respirator$ treatments that
were held before the proced!re
7E$I 7I/T
+>'" worsens# the amo!nt of 1& in the blood decreases 07<31;E)IA1 and amo!nt of carbon
dio4ide 0+>51 in blood increases 07<3E,5A,6IA1
ca!se 57,1/I5 ,E$3I,AT1,< A5I81$I$ 0%,+REA(E" ARTER%A9 +AR>,
"%>J%"E1 'a+>5
)ETA61I5 A0A1$I$ 0increase arterial bicarbonate1
,ot all +>'" pt are +>5 retainers# even when h$po)emia is present# b*c +>5 diff!se
more easil$ across l!ng membranes than >5
f. Assessment
l!e bloater 0c$anosis1
Right sided heart fail!re# distended neck veins
+>AG<
">E
5,A50E$
E4+iratory @7EEGE$
$3:T:) 3,18:5TI1/
:E%G<T 9>((
'R>9>,GE" EJ'%RAT%>,
>RT<>',EA
+AR"%A+ "F(R<FT<.%A(
7<3E,I/>ATI1/ 1> :/#$ and >AT 8IA37,A#)
AG levels that indicate ,E$3I,AT1,< A5I81$1$ and 7<31;E)IA
%. 3lannin%
%.'R>=E GA( EJ+<A,GE# A+<%E=.E,T >& A%R:AF +9ERA,+E
(.>2%,G +E((AT%>,
%.'R>=E" REAT<%,G 'ATTER,
.AJ%.A9 (E9&-.A,AG.E,T
%.'R>=E" A+T%=%TF T>9ERA,+E
%.'R>=E" +>'%,G A%9%TF
%.'R>=E" <EA9T<-RE9ATE" KAA9%TF >& 9%&E
h. /ursin% Interventions
I)3,1VI/# #A$ E;57A/#E
.onitor for d$spnea and h$po)ia
Admin medications and be alter for potential side affects
Assess relief of bronchos+asm thro!gh pt report of less dys+nea
.onitor prescribed o)$gen effectiveness with p!lse o)imetr$ or AG4s
*+ 7<31;E)IA I$ A $TI)::$ >1, ,E$3I,ATI1/ I/ T7E 3T -ith 5138.
AV1I8 8E3,E$$I/# the ,E$3I,AT1,< 8,IVE with A8)I/$TE,I/# 1;<#E/
to 51,,E5T 7<31;E)IA
Interventions
.onitor vital signs
Admin lo- concentration of 1& (1 to &=min) stim!l!s to breathe is a low arterial '>5
instead of an increased '+>5
)1/IT1, 3:$E 1;I)ET,<
%n 8IA37,A)ATI5 1, A681)I/A TE57/IC:E$ and 3:,$E8!I3 6,EAT7I/#
,E51,8 511,. A)1:/T# and 51/$I$TE/5< 1> $3:T:)
(A+T%>, &9A%"( from the +9%E,T4( 9A,G(# if ness. To +9EAR the A%R:AF( and
'RE=E,T %,&E+T%>,
.>,%T>R :E%G<T and E/51:,A#E $)A >,EC:E/T )EA$ to )AI/TAI/
/:T:,TI1/ and 3,EVE/T 8<$3/EA
7I#7!5A1,IE. 7I#7!3,1TIE/ 8IET
)a%nesium and 5alcium b=c of their role in ):$5E 51/T,A5TI1/ and
,EA;ATI1/
.onitor .g and 'hosphor!s levels b*c role to bone mineral densit$ 0osteoprosis1
E,+>ARAGE &9A%" %,TA2E A' T> 3''' ml=day to keep $E5,ETI1/$ T7I/# !nless
contraindicated
.>,%T>R for (*( of fl!id overload
7E$I 7I/T
%f breath so!nds are clear# b!t client is c$anotic and lethargic# adeB!ate 1;<#E/ATI1/ is
not 155:,I/#
0ey to ,es+iratory $tatus is assessment of 6,EAT7 $1:/8$ as well as
VI$:AIGATI1/ of the client
5rac2les. -hee?in%. or hi%h!+itched -histlin% sounds rather than ,AE$ or
,71/57I
>5 m!st b!bble thro!gh some t$pe of water sol!tion so it can be humidified if %iven at
HA=min or delivered directly to trachea
i. 3atient teachin%
Rela)ation techniB!es when not in distress
'9A+E +9%E,T %, 7I#7 >1@E,9s 31$ITI1/ and EA/ >1,@A,8 to aid in 6,EAT7I/#
TEA57 5IE/T to $IT :3,I#7T and 6E/8 $I#7T< >1,@A,8$ to 3,EVE/T
6,EAT7I/#
3:,$E8!I3 and 8IA37,A#)ATI5 6,EAT7I/#
3,1/1/#E8 E;3I,AT1,< 37A$E to 5EA/ T,A33E8 AI,
j. health +romotion
.E+<A,%+A99F soft 8IET. which do not reB!ire as m!ch chewing and digestion
'revent secondar$ infections: AV1I8 5,1@8$. 51/TA5T -ith 3E13E -ho have
I/>E5TI1:$ 8I$EA$E and ,E$3I5,AT1,< I,,A/T$ (tobacco smo2in%1
+lient report an$ changes in characteristics of $3:T:)
7<8,ATE 3=day and decrease caffeine d!e to di!retic effects
I)):/IGATI1/$ when needed 0fl! and pne!monia1
>lder ad!lt ?C $ear older with h) chronic illness once a lifetime
%mm!nios!ppression clients or clients with h) of pne!monia revaccination is sometimes
reB!ired
%nform smoking with nor near o)$gen is e)tremel$ dangero!s
2. 3neumonia dia%nostic testin%
+hest )-ra$ show lobar or segmental consolidation +ulmonary infiltrates# or +leural
effusions
lood and sp!t!m c!lt!res identif$ organism
gram stain
:+ co!nt and Er$throc$tes sedimentation rates are elevated

l. Assessments
,es+iratory al2aloids
+$anosis and cold and clamm$ skin
Enco!rage cou%h dee+ breathin%. and !se of I$ D &hours
$emi!fo-ler9s pt to facilitate breathing and l!ng e)pansion
5han%e +ositions freDuently and ambulates as tolerated to mobili?e secretions
'erform nasotracheal s!ctioning if client is !nable to clear secretions
'!lse >)imetr$
hi%h!calorie. hi%h!+rotein diet -ith small freDuent meals
/ 9*da$ to thin secretions !nless contraindicated
Abr!pt onset of EEVATE8 >EVE, with shaking and 57I$
TA+<F',EA: $hallo- res+irations use of accessory muscles
,71/57I and @7EEGE$. use of A55E$$1,,< ):$5E$ for breathin%. )E/TA
$TAT:$ 57A/#E$
('ATA. 'R>"A+T%>,
,e+roductive cou%h -ith +leuritic +ain
Rapid# bo!nding p!lse
>lder ad!lts
+>,&A(%>,# 9ET<ARGF# A,>REJ%A# RA'%" RE('%RAT>RF RATE
'A%, and "!llness to perc!ssion over the affected l!ng field
m. characteristics of lun%s sounds
6ronchial breath sounds are heard over areas of density or consolidation# crac2les
n. bronchial secretions
Amo!nt# color and color of secretions 0#reen. ,usty and ,ed1
o. medication administration
Antip$retics# bronchodilators# co!gh s!ppressants# m$col$tic agents# and e)pectorants
+. +atient teachin%
%nstr!ct the importances of rest# proper n!trition and adeB!ate fl!id intake
Avoid chilling and e)pos!re to individ!als with respirator$ infections or vir!s
,otif$ the ." if chills# fever# d$spnea# hemopt$sis# or increased fatig!e occ!rs
q. health +romotion
>lder ad!lts: &l! and pne!monia imm!ni;ations
%mm!nos!ppressed and debilitated persons: infection avoidance# sensible n!trition#
adeB!ate intake# balance and rest and activit$
avoid so!rces of infection and indoor poll!tants 0d!st# smock# and aerosis1 ,> (.>2%,G
51)AT1$E and I))16IE 3E,$1/$: elevation of 716 to feed and for & hours after
feedin%s. >reDuent turnin%
5. .!sc!lo skeletal
a. Assessment and care of +atients -ith fractures
)aintainin% and ,estorin% function
/. Red!ction and immobili;ation are maintained as prescribed to promote bone and soft tiss!e healing
3. Edema is controlled b$ elevating the in6!red e)tremit$ and appl$ing ice as prescribed
C. ,e!rovasc!lar stat!s 0+irc!lating# .ovement# (ensation1 is monitored and the orthopedic s!rgeon is
notified immediatel$ if sings of ne!rovasc!lar compromise are identified
?. Restlessness# an)iet$ and discomfort are controlled with a variet$ of approaches# s!ch as reass!rance#
position change and pain relief strategies# incl!ding !se of analgesics
E. 'articipation in A"9s is enco!raged to promote independent f!nctioning and self-esteem
D. %nternal fi)ation the s!rgeon determines the amo!nt of movement and weight-bearing stress the
e)tremit$ can withstand and prescribes the level of activit$
/ursin% )ana%ement (3atients -ith closed fractures)
@. ,!rses enco!rages pt with closed simple fract!res to ret!rn to their !s!al activities as rapidl$ as
possible.
18. ,!rse teaches pt how to control edema and pain associated with the fract!re and with soft tiss!e
tra!ma and enco!rages the pt to active within the limits of the fract!re immobili;ation
11. %mportant to teach e)ercises to maintain the health of !naffected m!scles and to increase the strength
of m!scles needed for transferring for !sing assistive devices 0cr!tches# walker# special !tensils1
15. 'lans are made to help pt modif$ their home environment as needed and to sec!re personal assistants
if necessar$
13.'t teaching incl!de7 self!care. medication information. monitorin% for +otential com+lications and
the need for continuin% health care su+ervision
13. &ract!re healing and restoration of f!ll strength and mobilit$ ma$ take man$ months
3t -ith 1+en >ractures
1C. Risk for osteom$elitis 0infection of the bone1# tetan!s# and gas gangrene
1?. Goal is to prevent infection of the wo!nd# soft tiss!e# and bone and to promote healing of soft tiss!e
and bone
a. ,!rse admin.tetan!s proph$la)is if indicated
1E. (erial irrigation and debridement are !sed to remove anaerobic organism
a. %= antibiotics are prescribed to prevent or treat infections
b. :o!nd is c!lt!red and devitali;ed bone fragments are removed
1D. "amaged to blood vessels# soft tiss!e# m!scles# nerves# and tendons is treated
1@. >pen fract!re primar$ wo!nd clos!re is !s!all$ dela$ed
58. <eavil$ contaminated wo!nds are left !nsat!rated and dressed with sterile ga!;e to permit edema and
wo!nd drainage
21.After determined that infection is not present# the -ound is closed in ( to B days and all dead space
is obliterated b$ grafting of a!togeno!s skin or flap
55. ,!rse eval!ates the e)tremit$ to minimi;e edema and the importance to asses ne!rovasc!lar stat!s
freB!entl$
5/. .eas!ring temp at reg!lar intervals and monitors the pt for signs of infection
&A. >racture 7ealin% and 5om+lications
5C. :eeks to months are reB!ired for most fract!res to heal
5?. Affected bone m!st have an adeB!ate blood s!ppl$
5E. &ract!res at the ends of long bones# where the bone is more vasc!lar and cancello!s# heal more
B!ickl$ than do fract!res in areas where the bone is dense and less vasc!lar 0midshaft1
5D. %f fract!re healing is disr!pted# bone !nion ma$ be dela$ed or stopped completel$
a. &actors that can impair fract!re healing incl!de inadeB!ate fract!re immobili;ation# inadeB!ate blood
s!ppl$ to the fract!re side or ad6acent tiss!e# e)tensive space btw bone fragments# interposition of soft
tiss!e btw bone ends# infection and metabolic problems
&N. Enhance fracture healin%
/8. %mmobili;ation of fract!re fragments
/1. .a)im!m bone fragment contact
/5. (!fficient blood s!ppl$
//. 'roper n!trition
/3. E)ercise: weight bearing for long bones
/C. <ormones: grown hormone# th$roid# calcitonin# vit " anabolic steroids
/?. Electric potential across fract!re
3B. Inhibit >racture 7ealin%
/D. E)tensive local tra!ma
/@. one loss
38. %nadeB!ate immobili;ation
31. (pace or tiss!e btw bone fragments
35. %nfection
3/. 9ocal malignanc$
33. .etabolic bone disease 0'agets disease1
3C. %rradiated bone 0radiation necrosis1
3?. Avasc!alr necrosis
3E. %ntra-artic!lar fract!re 0s$novial fl!id contains fibrol$sis# which l$se the initial clot and retard clot
formation1
3D. Age 0elderl$ persons heal more slowl$1
3@. +orticosteroids 0inhibit the repair rate1
a. 1steoarthritis ris2 factors
"egeneration of cartilage# a wear-and tear process
!s!all$ affects >,E or T:> 6oints
A((F..ETR%+A9F
>E(%TF and >=ER(AE are 'RE"%('>(%,G factors
Assessments
O1I/T +ain that I/5,EA$E$ with A5TIVIT< and im+roves -ith ,E$T
)ornin% stiffness
Asymmetry of affected 6oints
+repit!s 0grating so!nd in the 6oint1
9imited .ovement
visible 6oint abnormalities indicted on radiographs and 6oint enlargement and bod$ nod!les
,A and 1A /ursin% Interventions
@ei%ht!,eduction diet
E)cessive !se of the involved 6oint aggravates pain and ma$ accelerate degenerations
%mplement pain relief meas!res
Ase moist heat
@A,). )1$T 51)3,E$$
:%R9'>>9 AT<(
7ot sho-er in the A)
3E,I18$ of ,E$T after 3E,I18$ of A5TIVIT<
3E,>1,) A5TIVITE$ d!ring 8A< when client feels most Energetic
Encoura%e avoid overe4ertion and to maintain +ro+er +osture and Loint +osition
Ase of assistive devices
Elevated toilet seat
(hower chair
+ain# walker and wheelchair
Reaches
Adaptive clothing with =elcro clos!res
(traight-backed chair with elevated seat
Teach client
5orrect +osture and body mechanics
$lee+ -ith rolled terry cloth to-el under cervical s+ine if nec2 +ain is a +roblem
2eep 6oint in f!nctional position
b. ,heumatoid arthritis ris2 factors
571,/I5. $<$TE)ATI5. 3,E1#E$$IVE 8ETE,I1,ATI1/ of the +>,,E+T%=E
tiss!e 0 s$novi!m1 of the 6oint
I/>A))ATI1/
I)):/E 51)3E; disorder
Loint involvement is bilateral and symmetrical
)ornin% stiffness
:eight loss
(welling of both hands and wrists
c. 8ia%nostic testin%
E9E=ATE" E(R
'ositive Rhe!matoid factor 0R&1
'resence of antin!clear antibod$ 0A,A1
L>,T-('A+E ,arrowing
Abnormal (F,>=%A9 fl!id 0fl!id in 6oint1
+-reaction protein 0+R'1 A+T%=E %,&9A..T%>,
7E$I 7I/T
EA,< detection of ,A can decrease the amount of bone and Loint destruction
Goes into ,E)I$$I1/
8E5,EA$I/# the amount of bone and Loint destruction reduces the amount of disability
d. Assessments
&AT%GAE
GE,ERA9%ME" :EA2,E((
:E%G<T 9>((
A,>REJ%A
.>R,%,G (T%&&%,E((
6IATE,A I/>A))ATI1/ of O1I/T$ with the following s$mptoms
"ecreased R>.
L>%,T 'A%,
:AR.T<
E"E.A
ERFT<E.A
L>%,T "E&>R.%TF
51,TI51$TE,1I8$ for I/>A))ATI1/. $3I/TI/#. I))16IIGATI1/ and ,E$T
for Loint deformity and /$AI8s for +ain
C8. (ensor$ disorders
a. 5are of the +atients -ith %laucoma
5hronic o+en!an%le %laucoma know as ad!lt 3,I)A,< gla!coma is 13E/ A/#E
Increased intraocular +ressure
grad!al# painless vision loss
+an lead to blindness if !ntreated
%ncreased in older ad!lts pop!lation
bilaterall$ in those who have a famil$ h) of gla!coma
AC:E1:$ >:I8 is I/A8AC:ATE< 8,AI/E8 from the eye
A$<)3T1)ATI5 especiall$ in earl$ stages
d) d!ring ro!tine vis!al e)amination
oss of +eri+heral vision and see 7A1$ around I#7T$
8E5,EA$E8 VI$:A A5:IT< not correctable with glasses
<A or EFE 'A%, that ma$ be so severe as to ca!se ,*= 0A+ATE >'E,-A,G9E gla!coma1
Interventions
Eye dro+s are used to cause 3:3I 51/$T,I5TI1/ b=c movement of muscles to
constrict the +u+il allo-s AC:E1:$ 7:)1, to >1@ 1:T. 8E5,EA$E 3,E$$:,E I/
E<E
3I15A,3I/ !sed. Vision may be blurred for 1 to & hours after admin and ada+tation
to 8A,0 E/V,1/)E/T is difficult b=c +u+illary constriction
A/TI7I$TA)I/E$ A/8 A/TI571I/E,#I5$ side affects
>rient client to s!rro!nds
Avoid nonverbal comm!nication that reB!ires =%(AA9 A+A%TF0facial e)pressions1
8evelo+ a teachin% +lain that includes:
+aref!ll$ adherence to e$e-drop regimen can prevent blindness
=ision alread$ lost cannot be restored
E<E 8,13$ are /EE8E8 for the ,est of I>E
'roper e$e-drop instillation techniB!e. 16TAI/ ,ET:,/ 8E)1$T,ATI1/
:ash hands and e)ternal e$e
Tilt head back slightl$
%nstill drop into lower lid# witho!t to!ching the lid with the tip of the dropper
Release the lid# a sponge e)cess fl!id from lip and check
51$E E<E #E/T< and EAVE 51$E 3!( )I/
A33< #E/TE 3,E$$:,E on I//E, 5A/T:$ to 8E5,EA$E $<$TE)I5
A6$1,3TI1/
,E)1VE throw r!gs
AdLust li%htin% to meet needs
Avoid activities that may I/5,EA$E I/T,A15:A, 3,E$$:,E
Emotional !psets
E)ertion: p!shing# heav$ lifting# shoveling
+o!ghing severel$ or e)cessive snee;ing 0get medical attention before !pper respirator$
infections worsens1
81 /1T @EA, 51/$T,I5TIVE 51T7I/#
$T,AI/I/# at $T11 and 51/$I3ATI1/
>lder clients prone to constipation
The n!rse sho!ld A((E(( these clients for constipation and postoperative
complications associated with constipation and sho!ld implement a plan of care directed
at prevention of and treatment
b. 5are of the +atients -ith cataracts
>pacit$ of the lens
9ens of the e$e is responsible or pro6ection light onto the Retina so that images can be
discerned
witho!t the lends# opaB!e with cataracts# light cannot be filtered and vision is bl!rred
Earl$ signs: 6lurred vision. 8E5,EA$E8 511, 3E,5E3TI1/
9ate (igns: 8i+lo+ia. ,educed visual acuity. +ro%ression to blindness
5louded +u+il. +ro%ressin% to a mil2y!-hile a++earance
'reoperative: 8emonstrate and reDuest a return demonstration of eye
medication instillation from clients or family member
'ostoperative: @arnin% not to rub or +ut +ressure on eye
Teachin% that %asses or shaded lens should be -orn durin% @A0I/# 71:,$
AV1I8 I>TI/# obLects over 1(lbs. bendin%. strainin%. cou%hin%. or an y other
activity that can I/5,EA$E I13
$T11 $1>T/E, to +revent $T,AI/I/# at $T11
Teaching to AV1I8 <I/# on 13E,ATIVE $I8E
2EE' :ATER &R>. GETT%,G %,T> EFE while showering or washing hair
Report s*s of increased %>' and %,&E+T%>, 0pain# changes in vital signs1
:hen the cataract is removed# the lens is gone# .A2%,G 'RE=E,T%>, of &A99(
%.'>RTA,T
:hen lens is replaced with an implant# vision is ETTER
c. 5are of the +atients -ith hearin% im+airment
'rior to starting conversation# red!ce distraction as m!ch as possible
T!rn the T= or radio down or 1>>. 51$E the 811,. or )1VE to a Duieter location
"evote f!ll attention to the conversation7 do /1T try to do T@1 thin%s at once
9ook and 9isten d!ring the conversation
"o not switch topics abr!ptl$
9ip reader# face him or her directl$
$3EA0 $1@E< and 8I$TI/5T<. determine whether $o! are being !nderstood
A1@ A8EC:ATE time for the conversation to take place7 tr$ to avoid h!rried
conversations
Ase active listening techniB!es
e s!re to into inform the health care staff of the client4s hearing loss
<E9' &A99 A%"(
A)3I>IE, earphone attachments for the radio and T=# and lights or b!;;ers that
indicate the doorbell is ringing# located in the most commonl$ !sed room of the ho!se
<E(% <%,T
$3EA50 in a lo-!+itched voice. slo-ly and distinctly
$tand in front of the +erson. -ith the li%ht source behind the client
:se visual aids if available
C1. (kin "isorders
a. Im+eti%o
51/TA#I1:$ 6A5TE,A I/>E5TI1/ of the skin ca!sed b$ beta-hemol$tic streptococci
>cc!r from 311, 7<#IE/E
+ommon aro!nd the )1:T7# and then on the 7A/8$. /E50 A/8 E;TE,)ITEI$
9esions begin as VE$I5E$ or 3:$T:E$ $:,,1:/8E8 by E8E)A and ,E8/E$$
=E(%+9E( fl!id becomes clo!d$ and vesicles rep!tes# leaving hone$-colored cr!sted covered
!lcerated based
Interventions
5ontact isolations
lesions dr$ b$ air e)pos!re
:arm saline to lesions two or three times a da$ followed b$ soap and water to remove cr!sted
and allow for healing
A++ly emollients to +revent s2in crac2in%
.ethods to prevent the spread of the infection# especiall$ caref!ll$ hand washing
Ase separate towel# lines and dishes
@ash clothes -ith 8ETE,#E/T in 71T -ater
b. 5ontact dermatitis
I/>A))AT1,< res+onse of the s2in that +roduces s2in chan%es after contact -ith
$3E5I>I5 A/TI#E/
Assessments
'r!rit!s and b!rning
E"E.A
ERT<E.A at the '>%,T of +>,TA+T
(ign of %,&E+T%>,(
=E(%+9E( A," "RA%,AGE
Interventions
EEVATE8 and E;T,E)IT< to ,E8:5E E8E)A
A++ly cool. -et dressin%s and TE3I8 baths as +rescribed
)aintain a cool environment
'rotect the affected area from tra!ma
'revent scratching and r!bbing of the affected area
Assisted with skin test as prescribed to determine allergens
%nstr!ct the client to avoid contact with the A99ERGE, when determined
Avoid hard soaps
Avoid !sing heating pads or blankets
3soriasis
57,1/I5. noninfectious $0I/ inflammation involvin% 0E,ATI/ $</T7E$E$ that result in
3$1,IATI5 3AT57E$
'ossible ca!se $T,E$$. T,A:)A. I/>E5I1/ and chan%es in climate
.a$ be E;A5E,6ATE8 b$ the !se of certain medications
2oebner phenomenon is the development of '>(>%AT%+ 9E(%>,(
Assessments
'r!rit!s
$7E88I/#. $IVE,<. @7ITE $5AE$ on a ,A$IE8. ,E88E/8E8. ,1:/8 3AC: that
usually affects the $5A3. 0/EE$. E61@$. E;T,$1/$ surfaces of A,)$ and E#$
and $A5,A ,E#I1/$
Interventions
Assist with client to remove the scales 8:,I/# the $1A0 and $1>T @A$751T7 and
#E/TE. 5I,5:A, )1TI1/$K E)1IE/T 5,EA) or $AI5<I5 A5I8
keep the skin :6,I5ATE8 to minimi?e IT57I/#
@EA, li%ht 51TT1/ clothin% over affected areas
c. 7er+es Goster infection
5hic2en+o4. shin%les is caused by the reactivation of the varicella?oster virusK
shin%les can occur durin% any immunocom+romised state in a client -ith a h4 of
chic2en+o4
"ormant vir!s in located in the 81,$A /E,VE ,11T #A/#I1/ of the $ensory
cranial and s+inal nerves
+ontagio!s to individ!als who have not had chickenpo)
Assessments
:/IATE,A< 5:$TE,E8 s2in VE$I5E$ lon% 3E,I37E,A $E/$1,< /E,VE$
on the T,:50. T7,1A;. or face
&EA=ER
AR,%,G or ,EARA9G%A
'RAR%T%(
'ARE(T<E(%A
Interventions
Isolate the client b=c e4udate from the lesions contains the virus (maintain standard
and other +recaution such as contact +recaution
Assess neurovascular status and B
th
cranial nerve function
s*s infection and 2eep blisters intact if formed
Assist the client with acetic acid compressions# cool# wet compressions and tepid baths
/erve bloc2 usin% lidocaine (;yocaine)
Ase air mattress and bed cradle on the clients bed and keep the environment cool# warmth
and to!ch aggravate pain
'revent client from scratching and r!bbing the affected arm
%nstr!ct the client to wear lightweight# loose cotton clothing and to avoid wool and s$nthetic
clothing
,e!rological
$ei?ures. care of +atients -ith sei?ures. assessments. interventions. +otential com+lications
- (ei;!res are an abnormal discharge of electrical activit$ within the brain.
- Assessment: (ei;!re histor$# t$pe and occ!rrence of sei;!re# presence of a!ra
- %nterventions: ,ote time and d!ration# place client on floor# head to side and protect
head# maintain patent airwa$# administer >5# dont restrain. As for meds administer: =ali!m#
"ilantin. Tell client to avoid alcohol# stress# and fatig!e.
- Tonic +lonic sei;!re begins with an a!ra# followed b$ stiffness and rigidit$ of m!scles
and legs that lasts 18-58sec. Absence sei;!re lasts seconds and victims appear to be da$
dreaming. .$oclonic sei;!res involve generali;ed 6erking.
6ellMs +alsy $=$. assessments. +atient teachin%
- 9esion of the seventh cranial nerve# res!lting in paral$sis in one side of the face
- Assessment: &laccid facial m!scles# inabilit$ to raise e$ebrows# frown or smile loss of taste.
- %nterventions: Enco!rage facial e)ercises# protects e$es from dr$ness# freB!ent oral care#
instr!ct client to chew on !naffected side.
Review instr!ments to assess ne!rological stat!s 0interpretation of res!lts1
Glasgow come scaleN..
7e+atic
5irrhosis. assessments
- <istor$ of alcohol and street dr!gs# e)pos!re to to)ic chemicals# hepatoto)ic dr!gs# famil$
histor$ of liver abnormalities.
- 'h$sical findings: weakness# malaise# anore)ia# weight loss# 6a!ndice# fetor hepatic!s