Copy of Exam 2 Theory MedSurg Chapters 18, 19, 20, 38, 39, 40 PDF

Chapter 18: Assessing the Endocrine System THE GLANDS OF THE ENDOCRINE SYSTEM -​ Pituitary gland, thyroid gland, parathyroid glands, adrenal glands, pancreas, and gonads (reproductive glands). PITUITARY GLAND: -​ Also known as hypophysis, located in the skull bene...

Chapter 18: Assessing the Endocrine System THE GLANDS OF THE ENDOCRINE SYSTEM -​ Pituitary gland, thyroid gland, parathyroid glands, adrenal glands, pancreas, and gonads (reproductive glands). PITUITARY GLAND: -​ Also known as hypophysis, located in the skull beneath the hypothalamus of the brain. -​ Called the “Master gland” because its hormones regulate many body functions. -​ Two parts: the anterior pituitary (or adenohypophysis) and the posterior pituitary (or neurohypophysis). -​ ANTERIOR PITUITARY: secretes 6 major hormones. 1.​ Somatotropic cells secrete Growth hormone (GH), also called somatotropin. -​ GH stimulates growth of the body by signaling cells to increase protein production and stimulating the epiphyseal plates of the long bones. 2.​ Lactotrophic cells secrete Prolactin (PRL). -​ Prolactin stimulates the production of breast milk. 3.​ Gonadotropic cells secrete the Gonadotropin hormones → Follicle-stimulating hormone (FSH) and Luteinizing hormone (LH). -​ These hormones stimulate the ovaries and testes (the gonads). 4.​ Thyrotropic cells secrete Thyroid-stimulating hormone (TSH). -​ TSH stimulates the synthesis and release of thyroid hormones from the thyroid gland. 5.​ Corticotropic cells secrete Adrenocorticotropic hormone (ACTH).  -​ ACTH stimulates release of hormones, especially glucocorticoids, from the adrenal cortex. -​ POSTERIOR PITUITARY: primary function is to store and release antidiuretic hormone and oxytocin, produced in the hypothalamus. 1.​ Antidiuretic hormone (ADH), also called vasopressin, decreases urine production. 2.​ Oxytocin induces contraction of the smooth muscles in the reproductive organs. -​ In women, oxytocin stimulates the myometrium of the uterus to contract during labor - and induces milk ejection from the breasts. THYROID GLAND -​ Cells within the glandular follicles secrete Thyroid hormone (TH), a general name for two similar hormones: Thyroxine (T4) and Triiodothyronine (T3). -​ Primary role of thyroid hormones in adults is to increase metabolism. -​ TH secretion is initiated by the release of TSH (thyroid-stimulating hormone) by the pituitary gland and is dependent on an adequate supply of iodine. -​ The thyroid gland also secretes Calcitonin, a hormone that decreases excessive levels of calcium in the blood by slowing the calcium-releasing activity of bone cells.  -​ Serves as a marker for sepsis and is believed to be a mediator of inflammatory response. PARATHYROID GLANDS -​ They secrete Parathyroid hormone (PTH), or parathormone. -​ When calcium levels in the plasma fall, PTH secretion increases. -​ PTH also controls phosphate metabolism. -​ It acts by increasing renal excretion of phosphate in the urine, by decreasing the excretion of calcium, and by increasing bone reabsorption to cause the release of calcium from bones. -​ Normal levels of vitamin D are necessary for PTH to exert these effects on bone and kidneys. ADRENAL GLANDS -​ Sit on top of the kidneys. -​ Each gland consists of two parts, an inner medulla and an outer cortex. -​ ADRENAL MEDULLA: produces two hormones, also called Catecholamines: Epinephrine (adrenalin) and Norepinephrine (noradrenalin). -​ NOT ESSENTIAL TO LIFE. -​ Epinephrine increases blood glucose levels and stimulates the release of ACTH from the pituitary. -​ Epinephrine also increases the rate and force of cardiac contractions; constricts blood vessels in the skin, mucous membranes, and kidneys; dilates blood vessels in the skeletal muscles, coronary arteries, and pulmonary arteries. -​ Norepinephrine increases heart rate, increases the force of cardiac contractions, and vasoconstricts blood vessels throughout the body. -​ ADRENAL CORTEX: secretes all corticosteroids. -​ They are classified into two groups: Mineralocorticosteroids and Glucocorticoids. -​ These hormones are ESSENTIAL TO LIFE. -​ Release of Mineralocorticoids is controlled primarily by Renin (an enzyme).  -​ When a decrease in blood pressure or sodium is detected, specialized kidney cells release renin to act on angiotensinogen. -​ Angiotensinogen is modified by Renin to become angiotensin, which stimulates the release of aldosterone from the adrenal cortex. -​ Aldosterone prompts the distal tubules of the kidneys to release increased amounts of water and sodium back into the circulating blood to increase circulating blood volume/ pressure. -​ Glucocorticoids include cortisol and cortisone. -​ These hormones affect carbohydrate metabolism by regulating glucose use in body tissues, mobilizing fatty acids from fatty tissue, and shifting the source of energy for muscle cells from glucose to fatty acids. -​ Glucocorticoids are released in times of stress. -​ EXCESS of glucocorticoids in the body depresses inflammatory response and inhibits the effectiveness of the immune system. PANCREAS -​ The pancreas is both an endocrine gland (producing hormones) and an exocrine gland (producing digestive enzymes). -​ The endocrine cells of the pancreas produce hormones that regulate carbohydrate metabolism. -​ They are clustered in structures called pancreatic islets (or Islets of Langerhans). -​ Pancreatic islets have at least 4 different cell types: 1.​ Alpha cells: produce Glucagon, which decreases glucose oxidation and promotes increase in blood glucose level. 2.​ Beta cells: produce Insulin, it decreases blood glucose levels. 3.​ Delta cells: secrete Somatostatin, which inhibits the secretion of glucagon and insulin by the alpha and beta cells. 4.​ F cells: secrete pancreatic polypeptide, which is believed to inhibit the exocrine activity of the pancreas. GONADS -​ The gonads are the Testes in men and the Ovaries in women. -​ These organs are the primary source of steroid sex hormones in the body.  -​ The hormones of the gonads are important in regulating body growth and promoting the onset of puberty. AN OVERVIEW OF HORMONES -​ Hormones are chemical messengers secreted by endocrine organs and exert their action on specific cells called target cells. -​ Hormones regulate tissue responses. -​ Hormones levels are controlled by the pituitary gland and by feedback mechanisms. -​ In positive feedback mechanisms, increasing levels of one hormone cause another gland to release a hormone. -​ Stimuli for hormone release may be classified as Hormonal, Humoral, or Neural. -​ In Hormonal release, hypothalamic hormones stimulate the anterior pituitary to release hormones. -​ In Humoral release, fluctuations in the serum levels of certain ions and nutrients stimulate specific endocrine glands to release hormones to bring these levels back to normal. -​ In Neural release, nerve fibers stimulate the release of hormones. HEALTH ASSESSMENT INTERVIEW -​ If a patient has a problem with endocrine function, the nurse analyzes its onset, characteristics and course, severity, precipitating and relieving factors, and any associated symptoms, noting the timing and circumstances. -​ EXAMPLE: 1.​ “Describe the swelling you noticed in the front of your neck. When did it begin? Have you noticed any changes in your energy level? If so, describe them.” 2.​ “When did you first notice that your hands and feet were getting larger?” 3.​ Have you noticed that your appetite has increased even though you have lost weight?” -​ Explore changes such as → difficulty swallowing, increased or decreased thirst, appetite, and/or urination; visual changes, sleep disturbances; altered patterns of hair distributions (such as increased facial hair in women); changes in menstruation; changes in memory or ability to concentrate; and changes in hair and skin texture.  PHYSICAL ASSESSMENT -​ The only endocrine organ that can be palpated is the thyroid gland: -​ Palpate the thyroid gland for SIZE AND CONSISTENCY. (stand behind the patient). -​ May be enlarged in patients with Graves disease or a Goiter (enlarged thyroid gland). -​ Multiple nodules may be seen in metabolic disorders, WHEREAS, only ONE nodule may indicate cyst or a benign/malignant tumor. HOWEVER, other assessments that provide information about endocrine function include: 1.​ Inspection of the skin, hair, nails, facial appearance, reflexes, and musculoskeletal system. 2.​ Measuring and monitoring trends in height/ weight and vital signs. ASSESSMENT OF SPECIAL POPULATIONS -​ Type 2 diabetes is the most common endocrine problem in older adults. -​ The treatment of diabetes and prevention of hyperglycemia is important to decrease debilitating complications such as renal failure, stroke, heart disease, disability, and premature death.  -​ In order to identify and treat diabetes early, the ADA recommends that all patients over the age of 45 be screened every 3 years for diabetes and those with prediabetes be screened annually. -​ Low levels of vitamin D and deficient calcium in older adults = (loss of vitamin D → dementia, deterioration of cognitive abilities) (loss of calcium from bones → risk for hip fractures, osteoporosis) -​ Veterans with PTSD → endocrine system has a role in creating vivid memories. -​ Endocrine changes increase the stress response and cause the brain to store vivid memories of traumatic events. -​ LGBTQ!!!!!! GENETIC INFLUENCES 1.​ Endocrine disorders in the immediate family. -​ Include family members age of onset and gender. 2.​ Family history of diseases. 3.​ Women: problems with pregnancy, menstruation, and/or menopause.  HEALTH PROMOTION -​ Prevention of Type 2 diabetes: 1.​ Control weight and improve exercise to prevent type 2 diabetes. 2.​ Choosing healthy meals for the family. 3.​ Participate in diabetes screening at a community health fair. -​ Prevention of Bisphenol A (BPA): 1.​ Encourage families to identify containers in the home that contain BPA and are used to store foods, and encourage to dispose of the containers.  Older Adult Assessment Considerations ​ All pt over age 45 need to be screened every 3 yrs. for diabetes and pt with prediabetes screened annually. ​ Debilitating and common endocrine problem in older adults is ↓ levels of Vitamin D and deficient calcium. ○​ ↓ Vitamin D linked to dementia and deterioration of cognitive abilities  ○​ Loss of calcium from bone puts older adult at risk for hip fractures, often lead to disability and ↑ mortality ​ Treatment of osteopenia and osteoporosis to prevent complications and Death Assessing causes of hypocalcemia and severe hypertension Hypocalcemia: ​ Trousseau sign (Inflate BP cuff greater than systolic BP for 2-5 mins) ​ Chvostek sign (tap finger in front of pt ear at the angle of the jaw Chapter 19: Nursing Care of Patients with Endocrine Disorders KNOW ABOUT THYROIDITIS AND THYROID CRISIS THYROIDITIS: -​ Inflammation of the thyroid gland (often the result of a viral infection of the thyroid gland). -​ Acute disorder that may become chronic, resulting in a hypothyroid state as repeated infections destroy gland tissue. THYROID CRISIS (THYROID STORM): -​ An extreme state of hyperthyroidism that is rare today. -​ THOSE AFFECTED: 1.​ People with untreated hyperthyroidism (most often Graves disease) 2.​ People with hyperthyroidism who have experienced a stressor → infection, trauma, untreated diabetic ketoacidosis, or manipulation of the thyroid gland during surgery. -​ LIFE-THREATENING CONDITION. -​ Rapid treatment is essential to preserve life. TREATMENT: 1.​ Cooling without aspirin (which increases free TH) and prevention of shivering (which may further increase the temperature). 2.​ Replacing fluids, glucose, and electrolytes. 3.​ Relieving respiratory distress by administering oxygen. 4.​ Stabilizing cardiovascular function. 5.​ Reducing TH synthesis and secretion. HYPERTHYROIDISM (SIGNS & SYMPTOMS OF GRAVES DISEASE, AND THYROID STORM) GRAVES DISEASE: -​ Patients with Graves disease have a Goiter (an enlarged thyroid gland) and manifestations of hyperthyroidism.  -​ Proptosis (forward displacement) of the eye and Exophthalmos (the forward protrusion of the eyeballs) -​ Exophthalmos is usually bilateral, but it may involve only one eye. -​ Patients may experience blurred vision, diplopia, eye pain, lacrimation, and photophobia. -​ The inability to close the eyelids completely over the protruding eyeballs increases risk of corneal dryness, irritation, infection, and ulceration. -​ Other manifestations include: 1.​ Fatigue 2.​ Difficulty sleeping 3.​ Hand tremors 4.​ Changes in menstruation. -​ Older patients may present with atrial fibrillation, angina, or congestive heart failure. THYROID CRISIS (THYROID STORM): -​ MANIFESTATIONS: -​ Hyperthermia (body temperature of 102 to 106*) -​ Tachycardia -​ Systolic HYPERtension -​ Dyspnea -​ GI manifestations (abdominal pain, vomiting, diarrhea) -​ Agitation and restlessness -​ Psychosis -​ Delirium and seizures -​ Rapid treatment is essential to preserve life. TREATMENT: 6.​ Cooling without aspirin (which increases free TH) and prevention of shivering (which may further increase the temperature). 7.​ Replacing fluids, glucose, and electrolytes. 8.​ Relieving respiratory distress by administering oxygen. 9.​ Stabilizing cardiovascular function.  10.​Reducing TH synthesis and secretion. GRAVES DISEASE → WHAT LABS TO ASSESS FOR PATIENTS WITH GRAVES DISEASE. -​ Serum TA: (normal values: negative to 1:20) -​ INCREASED -​ Serum TSH: (< 3 g/mL) -​ DECREASED in primary hyperthyroidism -​ Serum T4: (5-12 mcg/dL) -​ INCREASED -​ Serum T3: (80-200 ng/dL) -​ INCREASED -​ T3 uptake: (25-35 relative percentage) -​ INCREASED -​ Thyroid suppression: INCREASED RAI uptake and T4 levels -​ Elevated levels of TH (both T3 and T4). -​ Increased radioactive iodine (RAI) uptake. TREATMENT OF HYPERTHYROIDISM → METHIMAZOLE (TEACHINGS) ANTITHYROID DRUG: METHIMAZOLE (Tapazole) -​ Antithyroid drugs inhibit TH production. -​ Several weeks may elapse before the patient experiences therapeutic effects.  -​ NOT RECOMMENDED DURING PREGNANCY. 1.​ Monitor for side effects: hypothyroidism, pruritus, rash, elevated temperature, anorexia, loss of taste, hair loss, changes in menstruation. 2.​ Administer drugs AT THE SAME TIME each day with meals to maintain stable blood levels. 3.​ Monitor for manifestations of hypothyroidism: fatigue, weight gain, periorbital edema. HEALTH EDUCATION FOR THE PATIENT AND FAMILY 1.​ Watch for unusual bleeding, redness, swelling, nausea, loss of taste, or epigastric pain. (report such manifestations to physician) 2.​ Take medication regularly and exactly as prescribed. DO NOT DISCONTINUE ABRUPTLY. 3.​ It may take up to 12 weeks before you experience the full effects of the drugs. PLAN OF CARE FOR PERSON WITH HYPERPARATHYROIDISM -​ Treatment of hyperparathyroidism focuses on decreasing the elevated serum calcium levels. -​ Patients with mild hypercalcemia are urged to drink fluids and keep active.  1.​ Avoid immobilization, thiazide diuretics, large doses of vitamins A and D, antacid containing calcium, and calcium supplements. 2.​ Medications to inhibit bone resorption and reduce hypercalcemia → pamidronate (Aredia), alendronate (Fosamax), and zoledronate (Zometa). 3.​ Calcitonin (nasal spray, IM, SQ) to decreased secretion of PTH and reduced serum calcium and phosphorus HYPOTHYROIDISM (DIET, SIGNS & SYMPTOMS) MANIFESTATIONS: -​ Goiter -​ Fluid retention and edema -​ Decreased appetite -​ Weight GAIN -​ Constipation -​ Dry skin -​ Dyspnea -​ Pallor -​ Hoarseness -​ Muscle stiffness -​ Decreased sense of taste and smell -​ Menstrual disorders -​ Anemias -​ Cardiac enlargement -​ Bradycardia IODINE DEFICIENCY: -​ Iodine is necessary for TH synthesis and secretion. -​ Iodine deficiency may result from certain goitrogenic drugs, lithium carbonate, and antithyroid drugs. HASHIMOTO THYROIDITIS: -​ Most common cause of goiter and primary hypothyroidism. -​ Autoimmune disorder → antibodies develop that destroy thyroid tissue. MYXEDEMA COMA: -​ Life-threatening complication of long-standing, untreated hypothyroidism. -​ Usually occurs in older people and precipitated by use of opioids, infections, stroke, trauma, or heart failure. -​ Patients present with severe hypothermia and severely slowed mental status. REDUCE RISK OF CONSTIPATION (DIET): 1.​ Encourage a fluid intake of up to 2000 mL/ day. -​ Discuss preferred liquids and the best times of day to drink fluids. 2.​ Discuss ways to maintain a high-fiber diet. -​ Beans, fruits, whole-grain breads, unprocessed brown rice. 3.​ Encourage activity such as walking as tolerated. LEVOTHYROXINE (for HYPOthyroid) (on empty stomach, first thing in the morning, take by itself, take medication FOR LIFE) -​ Levothyroxine sodium (T4) (Levothroid, Synthroid) is the treatment of choice. -​ Thyroid preparations INCREASE blood levels of TH, raising the metabolic rate. -​ As a result, cardiac output, oxygen consumption, and body temperature INCREASE. -​ NURSING RESPONSIBILITIES OF ADMINISTRATION: 1.​ Give 1 HOUR BEFORE meals or 2 HOURS AFTER meals for best absorption. -​ If levothyroxine is taken with food or antacids, its absorption is reduced and can even be totally ineffective. 2.​ Thyroid preparations potentiate the effect of anticoagulant drugs. -​ If a patient is also receiving an anticoagulant, monitor for bruising, bleeding gums, and blood in the urine.  3.​ Thyroid medications potentiate the effect of digitalis (treats certain heart conditions). -​ Monitor for signs of digitalis toxicity if a patient is receiving. 4.​ Monitor for manifestations of coronary insufficiency. -​ Chest pain, dyspnea, tachycardia. 5.​ If a patient has insulin-dependent diabetes, monitor the effects of insulin. -​ The effect of the insulin may change as thyroid function increases. 6.​ During dose adjustment, take pulse BEFORE administering the drug. -​ Report pulse greater than 100 bpm. IMPORTANT TO KNOW: 1.​ Medications must be taken FOR THE REST OF YOUR LIFE. 2.​ Report manifestations of excess thyroid hormone to the physician: excess weight loss, palpitations, leg cramps, nervousness, or insomnia. 3.​ DO NOT use iodized salt or over-the-counter drugs containing iodine. 4.​ Report changes in menstrual periods. 5.​ Avoid excessive intake of foods that are known to inhibit TH utilization such as walnuts and high-fiber foods. 6.​ Take drug in the morning 30 MINUTES BEFORE EATING to decrease insomnia. -​ Take other medications AT LEAST 4 HOURS BEFORE OR AFTER. SIGNS AND SYMPTOMS OF HYPOPARATHYROIDISM PRIMARY MANIFESTATION IS: -​ Hypocalcemia NEUROMUSCULAR MANIFESTATIONS: -​ Numbness and tingling around the mouth and in the fingertips. -​ Muscle spasms of the hands and feet. -​ Convulsions  -​ Laryngeal spasms -​ Tetany (Assessment for Tetany: Chvostek & Trousseau) INTEGUMENTARY MANIFESTATIONS: -​ Brittle nails -​ Hair loss -​ Dry, scaly skin GI MANIFESTATIONS: -​ Abdominal cramps and malabsorption CNS MANIFESTATIONS: -​ Paresthesias of the lips, hands, and feet. -​ Mood disorders such as irritability, depression, and anxiety. -​ Hyperactive reflexes -​ Psychosis -​ Increased intracranial pressure CUSHING'S SYNDROME (SIGNS AND SYMPTOMS, WHO IS AT RISK FOR CUSHING'S SYNDROME, FINDINGS THAT REQUIRE IMMEDIATE FOLLOW UP). SIGNS AND SYMPTOMS: -​ Obesity, fat deposits in the abdominal region. -​ Fat pads under the clavicle -​ Buffalo hump over the upper back -​ Round mood face -​ Muscle weakness and wasting -​ Thinning of skin -​ Abdominal striae (reddish purple stretch marks) -​ Easy bruising -​ Poor wound healing -​ Frequent skin infections -​ IN WOMEN → Hirsutism (excessive facial hair), Acne, Menstrual irregularities. WHO IS AT RISK:  -​ People who take corticosteroids for long periods of time (ex. For the treatment of arthritis, after an organ transplant, or as an adjunct to chemotherapy) -​ More common in women between the ages of 20 and 50 years. FINDINGS THAT REQUIRE IMMEDIATE FOLLOW UP: 1.​ A generalized feeling of malaise may be the primary manifestation of infection, especially in the older adult. 2.​ Present jugular vein distention or edema. 3.​ Increased white blood cells are indicative of infection. 4.​ Delayed wound healing ADDISON'S DISEASE (SIGNS AND SYMPTOMS, ASSESSMENTS, AND ADDISON'S CRISIS INTERVENTION) SIGNS AND SYMPTOMS: -​ hypoglycemia -​ Postural hypotension -​ Weight loss -​ Bronze pigmentation of the skin -​ Lethargy -​ Weakness -​ Anorexia, nausea, vomiting, diarrhea -​ LOW sodium -​ HIGH potassium ASSESSMENTS: -​ Health History: weight loss, changes in skin color, nausea and vomiting, anorexia, diarrhea, abdominal pain, weakness, amenorrhea, changes in sexual desire, confusion, and intolerance of stress. -​ Physical assessment: height and weight, vital signs, skin, hair quality, and distribution, muscle size and strength. ADDISONIAN CRISIS INTERVENTION: -​ Treatment of the crisis is rapid intravenous replacement of fluids and glucocorticoids. 1.​ Maintain Fluid Volume: -​ Monitor intake and output, assess for signs of dehydration → dry mucous membranes, thirst, poor skin turgor, sunken eyeballs, dark urine, increased urine specific gravity, weight loss, and increased hematocrit and BUN. -​ Monitor cardiovascular status -​ Weight patient daily, same time/clothing. -​ Encourage increased oral fluid intake and increased salt intake. -​ Teach to sit and stand slowly. SIGNS AND SYMPTOMS OF SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE. -​ Hyponatremia -​ Thirst -​ DECREASED urinary output but very concentrated -​ Changes in mental status or personality -​ Lethargy -​ Irritability -​ Seizures -​ Cerebral edema DIABETES INSIPIDUS = 3 P’S (POLYURIA, POLYPHAGIA, POLYDIPSIA) -​ Result of ADH insufficiency. -​ Two types: 1.​ Neurogenic diabetes insipidus  2.​ Nephrogenic diabetes insipidus -​ May result from brain tumors or infections, pituitary surgery, cerebrovascular accidents, and renal and organ failure. 3 P’S: 1.​ POLYURIA → excretion of large amounts of dilute urine. 2.​ POLYDIPSIA → extreme thirst 3.​ POLYPHAGIA → extreme hunger Treatments: -​ ADH replacement -​ Administer intravenous hypotonic fluids -​ Increase oral fluids -​ Correct underlying causes Chapter 20: Nursing Care of Patients with Diabetes Mellitus Type 1 diabetes = young people Type 2 diabetes = adults 30 mins before meals → oral hypoglycemic agents Cool & clammy = need some candy Hot & dry = sugar is HIGH DELEGATION -​ RN can delete nursing care activities such as → blood glucose checks, providing hygiene, assisting with feeding, and assisting with physical activity. DIABETIC FOOT CARE TEACHINGS -​ Most common sources of foot trauma: 1.​ Cracks and fissures caused by dry skin. 2.​ Infections (athletes foot, blisters caused by improperly fitting shoes, pressure from stockings or shoes, ingrown toenails). 3.​ Direct trauma (cuts, bruises, or burns). FOOT CARE TEACHINGS: 1.​ Don't be barefoot. 2.​ Cut toenails straight across. 3.​ Wash and dry feet properly. 4.​ Control your blood sugar. 5.​ Examine your feet daily.  TREATMENT FOR PERSON WITH LOW BLOOD SUGAR -​ 15g of rapid-acting sugar. EXAMPLE: -​ 3 glucose tablets -​ ½ cup (4oz) of fruit juice or regular soda -​ 8 oz of skim milk -​ 5 Life Savers candies -​ 3 large marshmallows -​ 3 tsp of sugar or honey. (ADDED SUGAR SHOULD NOT BE ADDED TO FRUIT JUICE) IF MANIFESTATIONS CONTINUE, the 15/15 rule should be followed: -​ Wait 15 minutes, monitor blood glucose, if low → eat another 15g of carbohydrate. (CAN BE REPEATED UNTIL BLOOD GLUCOSE LEVELS RETURN TO NORMAL) SEVERE HYPOGLYCEMIA: -​ If the patient is conscious and alert → 10 to 15g of oral carbohydrate. -​ Altered levels of consciousness → parenteral glucose or glucagon administration. -​ 50% dextrose by IV push (most rapid method). TREATMENT FOR PERSON WITH DIABETES AND HYPERTENSION ACE INHIBITORS → END IN “PRIL” , BLOCKS ALDOSTERONE, COMMON SIDE EFFECT IS A CONSISTENT COUGH, DO NOT TAKE WHEN YOU ARE PREGNANT)  TEACHING OF SICK DAY MANAGEMENT -​ When an individual with DM is sick or has surgery, blood glucose level increases due to high metabolic needs. -​ Person often mistakenly alters or omits the insulin dose in response to decreased food intake, causing hyperglycemia. -​ Guidelines for dietary management during illness focus on preventing dehydration and providing nutrition to promote recovery: 1.​ Monitoring blood glucose as much as every 2 to 3 hours. 2.​ Testing urine for ketones as often as every 4 hours. 3.​ Continuing to take insulin or oral hypoglycemic agents. 4.​ Consuming many clear liquids (without caffeine). 5.​ Calling healthcare provider if a patient has had a fever for 2 days, vomiting and diarrhea lasts for more than 6 hours or cannot keep fluids down, if glucose is way out of range, if urine ketones are moderate or large, or if there are signs of dehydration. HEMOGLOBIN A1C LEVELS NORMAL RANGE: -​ 2 - 5% Diagnostic screening for diabetes: -​ Hemoglobin A1C greater than or equal to 6.5%. PRE-diabetes: -​ A hemoglobin A1C level of 5.7% to 6.4% indicates a high risk for developing diabetes and vascular disease. ORAL ANTIDIABETIC MEDICATION OF CHOICE (Non-insulin) Hypoglycemic Agents: 1.​ Sulfonylureas: glipizide, glyburide.  2.​ Biguanides: metformin. 3.​ Alpha-Glucoside inhibitors 4.​ Incretin Mimetics 5.​ Dpp-4 inhibitors 6.​ Synthetic amylin hormone MIXING OF INSULINS -​ Mixing is recommended when a patient with DM requires more than one type of insulin. GENERAL GUIDELINES: 1.​ Glargine and Detemir insulin CANNOT be mixed with other insulins. 2.​ NPH insulin may be mixed with regular insulin or rapid-acting insulins (Humalog, Novalog). 3.​ ALWAYS withdraw regular or rapid-acting insulin FIRST to avoid contaminating the regular insulin with intermediate-acting insulin.  IF A PERSON IS GOING TO HAVE SURGERY WHAT DO THEY DO WITH THEIR INSULIN DOSE? -​ Screening for complications and regular blood glucose monitoring are part of preoperative preparation. -​ Oral hypoglycemic agents may be withheld for 1 to 2 days before surgery. -​ Regular insulin is often administered to the patient with T2D and those with prediabetes during the perioperative period. -​ Patients with diabetes who are critically ill in the perioperative period should receive IV glucose and insulin infusion in an intensive care unit. -​ The target blood glucose level during surgery is 110 - 140 mg/dL.  -​ The surgical procedure should be scheduled for as early as possible in the morning to minimize the duration of fasting. WHO IS AT RISK FOR HYPEROSMOLAR/ HYPERGLYCEMIC STATE -​ Occurs in people who have Type 2 diabetes. -​ Ages 57 - 70. -​ SERIOUS LIFE-THREATENING MEDICAL EMERGENCY. -​ Precipitating factors include: 1.​ Infection 2.​ Medications that cause hyperglycemia 3.​ Therapeutic procedures 4.​ Acute illness 5.​ Chronic illness DIET FOR TYPE 1 DIABETIC CARBOHYDRATES: -​ Plant foods such as (whole)grains, legumes, fruits, and vegetables, and dairy products. PROTEIN: -​ Low in saturated fat and cholesterol to reduce cardiovascular risk factors. -​ Healthy proteins include → fish, lean poultry, egg whites, and beans. (processed meats should be limited) FATS: -​ Limit saturated fat: animal meats (butter fats, lard, bacon), cocoa butter, coconut oil, palm oil, and hydrogenated oil.  -​ Avoid trans fatty acids: partially hydrogenated vegetable oils such as shortenings and animal fats. -​ Consume healthful fat: peanut oil, olive oil, and oils from other nuts and seeds, avocados, fish oils. FIBER: -​ Soluble fiber: dried beans, oats, barley, peas, corn, zucchini, cauliflower, broccoli, prunes, pears, apples, bananas, oranges. -​ Insoluble fiber: wheat, corn, carrots, brussels sprouts, eggplant, green beans, pears, apples, strawberries. Intake of 14g/1000 kcal per day is recommended. SODIUM: -​ Recommended daily intake is 1000mg. -​ Avoid table salt and processed foods high in sodium. SWEETENERS: -​ Commercially produced nonnutritive sweeteners: Saccharin (Sweet & Low), aspartame or neotame (NutraSweet, Equal), sucralose (Splenda), acesulfame potassium (Sunette), and stevia (Truvia. (produce very little or no changes in blood glucose levels). -​ Sugar free: Fructose, sorbitol, xylitol. ALCOHOL: (not totally prohibited) -​ Men with DM → no more than two drinks. -​ Women with DM → no more than one drink per day. -​ Light beer is the recommended alcoholic drink. -​ Alcohol should be consumed with meals and added to the daily food intake. DIET PLAN FOR INSULIN-DEPENDENT DM: 1.​ Glucose regulation requires correlating eating patterns with insulin onset and peak of action. 2.​ Meals, snacks and insulin regimens should be based on the person's lifestyle. 3.​ Snacks are an important consideration in relation to the amount and timing of exercise. 4.​ SMBG levels help the patient make adjustments for planned and unplanned changes in routines. Chapter 38: Assessing the Musculoskeletal System (6 questions) Bone Remodeling in Adults ​ Bones that are in use and subjected to stress, increase osteoblast activity to increase ossification ​ Bones that are inactive undergo increased osteoclast activity and bone resorption ​ Hormones and stress on the bones, along with osteocytes, osteoclasts, and osteoblasts, help bone regulation ​ Hormonal stimulus for bone remodeling is controlled by negative feedback, which in turn regulates blood calcium levels ○​ Involves PTH and calcitonin ○​ When blood calcium levels ↓, PTH is released to stimulate osteoclast activity and resorption so that calcium is released from the bone matrix ○​ The rising blood calcium stimulates the secretion of calcitonin, inhibits bone resorption, and causes the deposit of calcium salts in the bone matrix ​ Calcium ions are necessary for: ○​ Release of neurotransmitters ○​ Muscle contraction ○​ Blood clotting ○​ Glandular secretion ○​ Cell division ​ Bone remodeling is also regulated by the response of bones to gravitational pull and to mechanical stress from the pull of muscles ​ Bones that undergo increased stress are heavier and larger Cartilage ​ 3 types: ○​ Elastic cartilage ​ External ear ​ Larynx ○​ Hyaline cartilage ​ Joins the ribs to the sternum and vertebrae ​ Many cartilages in the respiratory tract ​ Articular cartilage ​ Epiphyseal plates ○​ Fibrocartilage ​ In the intervertebral disks ​ Symphysis pubis  ​ Areas where tendons connect to bones Skeletal Muscle ​ Promote body movement ​ Help maintain posture ​ Produce body heat ​ Can be moved consciously, voluntarily, or by reflex ​ Thick bundles of parallel multinucleated contractile cells called fibers ○​ Smaller structures within called myofibrils to even smaller units (sarcomeres) which consist of thick filaments of myosin and thin filaments of actin, proteins that contribute to muscle contraction ​ Functional Properties: ○​ Excitability ​ Receive and respond to a stimulus ○​ Contractibility ​ Response to stimulus by forcibly shortening ○​ Extensibility ​ Respond to a stimulus by extending and relaxing ○​ Elasticity ​ Resume its resting length after shortened or lengthened ​ Skeletal movement is triggered when motor neurons release acetylcholine (alters permeability of muscle fibers) ​ Sodium ions enter fiber, producing action potential that causes muscle contraction ​ The more the fiber contracts, the stronger the contraction of the entire muscle ​ Prolonged strenuous activity causes nerve impulses which build up of lactic acid and reduce energy in the muscle (muscle fatigue) ○​ Continuous impulses are responsible for muscle tone ○​ Lack of muscle use results in muscle atrophy Joints ​ Classified by function: ○​ Synarthroses ​ Immovable joints ○​ Amphiarthrosis ​ Slightly movable joints ○​ Diarthroses ​ Freely movable joints ​ Classified by structure: ○​ Fibrous ○​ Cartilaginous ○​ Synovial  Need to know phantom pain and the type of medication (Neuropathic medication) ​ Treatments include pain management, TENS, mirror therapy, and a variety of surgical procedures. 1401, 1402, 1403 - musculoskeletal assessment (Phalen test) Phalen Test ​ Assess for suspected abnormalities ​ Acute flexion for 60 seconds ​ Numbness and burning in fingers during test may indicate carpal tunnel syndrome 1404 - Genetic Considerations (muscle dystrophy and sclerosis) ​ Ask about family members with health problems affecting musculoskeletal structure or function: ○​ History of arthritis ○​ Abnormally long bones ○​ Children with muscular dystrophy ○​ Anyone with amyotrophic lateral sclerosis (ALS) ○​ Assess for any manifestations that might indicate genetic disorder ​ Ask about genetic testing and refer genetic counseling ​ Ex. of genetic basis: ○​ Myotonic dystrophy: (inherited disorder) muscles are weak, decreased ability to relax, and eventually waste away. ​ Manifestations: mental deficiency, hair loss, cataracts ○​ Duchenne muscular dystrophy: rapid muscle degeneration, most commonly found in men.  ○​ Others: Rheumatoid arthritis, osteoarthritis, gout, muscular dystrophy, ankylosing spondylitis, lupus erythematosus, and scleroderma 38.6 Age related changes in Musculoskeletal System ​ Bone and joints ○​ Decreased bone mass and minerals ○​ Decreased calcium reabsorption, a slow resorption of the interior long bones, and slower production of new bone on the outside surface of bones ○​ Thinning of intervertebral disks, erosion of vertebrae, and kyphosis often develop ○​ Cartilage on bone surfaces in joints deteriorates and bone spurs may occur ○​ Synovial fluid becomes less viscous ​ Muscles, Ligaments, and Tendons ○​ Muscle fibers atrophy and fibrous tissue slowly replaces muscle tissue ○​ Decreased muscle mass and strength ○​ Ligaments and tendons lose elasticity resulting in loss of joint ROM 1406 - EMG EMG: ​ Measures the electrical activity of skeletal muscles at rest and during contraction. ○​ Helps diagnosing neuromuscular disease.  ​ Normally no electrical activity at rest Related Nursing Interventions: ​ Tell pt NOT TO drink caffeine or smoke for 3 hrs before test ​ DON’T take meds like muscle relaxants, anticholinergics, or cholinergics. ​ If serum enzymes like SGOT, CPK, or LDH are ordered, they NEED to be drawn before the EMG or 5 to 10 days after. 1405 - DEXA, Arthrocentesis, and Arthroscopy infection prevention Dual-energy x-ray absorptiometry (DEXA): ​ The hip and lumbar spine can calculate the size and thickness of bone. Related Nursing Interventions: ​ Instruct pt to REMOVE all metal objects from the area to be scanned (like jewelry, belt buckles, zippers) Arthrocentesis: ​ After the procedure, apply a compression dressing and tell the pt to report any bleeding, leaking of fluid, or excessive pain to the healthcare provider. Arthroscopy: ​ Instruct pt about fasting and use of current mediation prior to the procedure ​ Following the procedure, assess for bleeding and swelling, apply ice to the area if prescribed, and instruct pt to avoid excessive use of the joint for 2 to 3 days.  Health Promotion ​ Young adults ○​ Face high risk for sustaining trauma ○​ Must be taught the importance of safety equipment ​ Seat Belts ​ Helmets ​ Football pads ​ Proper footwear ​ Protective eyewear ​ Hard hats ​ Older adults ○​ Regular screenings for: ​ Osteoporosis ​ Activity levels ​ Cognitive and affective disorders vision impairments ​ Assessment for risk for falls ○​ Reduce risk of falls by: ​ Increasing lower body strength and balance through regular exercise and a review of their meds ​ Adults ○​ Regular exercise to avoid obesity ○​ Adequate intake of calcium ○​ Women must ensure good bone health prior to menopause bc of loss of estrogen ​ Strong bones are formed by calcium intake and weight bearing exercise (good for postmenopausal women) Chapter 39: Nursing Care of Patients with Musculoskeletal Trauma (15 questions) ★​ Ankle Sprain ➔​ Most commonly sprained joint. ➔​ Caused by forced inversion of the foot. ➔​ Sprain → Is a stretch or tear of one or more ligaments surrounding a joint. ◆​ Forces going in opposite directions = overstretching & or tears. Manifestations: ​ Loss of functional ability of the joint. ​ Feeling a “pop” or tear ​ Discoloration ​ Pain ​ Rapid swelling Treatment ➔​ Goal of initial stage of treating tissue trauma = reduce edema & pain. ➔​ Follow RICE: ◆​ Rest (limit weight bearing on injured extremity/use cane or crutch on uninjured side) ◆​ Ice ◆​ Compression ◆​ Elevation (elevated @ heart level to reduce edema & pain) ➔​ Immobilization: (with cast or splint, with no limitations on weight bearing.) ◆​ Mild ankle sprain may require 3 to 6 weeks of rehab. ◆​ Severe sprains can take 8 to 12 months to return to full activities. ➔​ Surgery ➔​ Physical therapy Diagnosis -​ Musculoskeletal ultrasound -​ X-ray -​ MRI Nursing Care ​ Centers on the injured area & patient’s reaction to injury. ​ Post-injury assessment: for head injury & level of consciousness. ​ Stable pt focused assessment: Skin, neurovascular (if extremity is involved), musculoskeletal in area of injury, pain, & psychosocial. ❖​ Focus on reduction of inflammation, immobilization of joints, associated acute pain, impaired physical mobility, & the risks for impaired tissue perfusion & neurovascular compromise. Medications -​ NSAIDs -​ Acetaminophen Compartment syndrome ​ Complication of fracture: ○​ Pressure from edema/hemorrhage ○​ Can lead to → limb loss, sepsis, ARF (acute renal failure) ○​ Within 48 hrs of injury ​ Manifestations: ○​ Early: Pain, normal or decreased peripheral pulse ○​ Later: Cyanosis, Paresthesias, Paresis, Severe Pain ​ Treatments: ○​ Alleviate pressure ○​ Removal of cast ○​ Fasciotomy Fat embolism ​ Is a Neurological dysfunction ​ Pulmonary insufficiency ​ Petechial rash: chest, axilla, & upper arms. ​ Bone fracture results in rise of pressure in the bone marrow ​ Fat globules enter the bloodstream, combined with platelets. ​ Occlude small blood vessels, causing tissue ischemia. ❖​ Manifestations: ​ Confusion (changes in level of consciousness) ​ Symptoms of ARDS ​ Petechiae, soft palate, conjunctiva ❖​ Treatments: ​ Intubation, mechanical ventilation ​ Fluid balance ​ Corticosteroids Deep Vein Thrombosis ➔​ A blood clot along the intimal lining of a large vein. ➔​ DVT → to venous insufficiency & pulmonary embolism. ​ Manifestations: ○​ Swelling, pain, tenderness, or cramping of the affected extremity ○​ Can be asymptomatic ​ Treatments: ○​ Prevention is the best treatment of DVT. ○​ May be treated with anticoagulant therapy. Casts ➔​ Rigid plaster or fiberglass device ➔​ Immobilizes bones & joints above & below the fracture.  ★​ Box 39.2 Pain Management for the Pt with a Fracture The pain associated with the fracture & surrounding tissue damage is often severe & may be described as sharp, aching, or burning. Carefully assess any complaint of pain, including the location, character, & duration of pain: 1.​ Administer prescribed analgesics, including NSAIDs & opioid analgesics. For serious fractures or following orthopedic surgery, patient-controlled analgesia (PCA) or epidural analgesia may be used. Administer NSAIDs and analgesics at regular intervals, around-the-clock, for the first 24 to 48 hours, then instruct the patient to request or take the medication before the pain is severe. Most patients require only oral analgesics by the third or fourth day after orthopedic surgery. 2.​ ASSIST the pt to frequently change positions to relieve pressure and use pillows to provide support. 3.​ ELEVATE the involved extremity, and APPLY COLD (if prescribed) to help decrease edema. 4.​ Monitor and drain accumulated fluids in any drainage devices to ensure patency, reduce edema, and decrease the possibility of hematoma formation. 5.​ ENCOURAGE the patient to wiggle fingers or toes on an extremity in a cast or traction to improve venous return and decrease edema. 6.​ TEACH the pt adjunctive pain management techniques, such as relaxation and guided imagery. 7.​ NOTIFY THE PHYSICIAN of severe or unrelieved pain, which may indicate a serious complication such as compartment syndrome or neurovascular impairment.  1426 - pain medication, medication, nutrition, and treatment Pain Management ➔​ Antibiotics administered prophylactically (pts with open or complex fractures.) ➔​ Anticoagulants, can be prescribed to prevent DVT (If surgery or prolonged immobilization is necessary) ➔​ Stool softeners: given secondary to narcotics & immobility to prevent risk of constipation. ➔​ Antiulcer medications/antacids: to reduce risk of gastrointestinal bleeding if the pt sustained trauma. Nutrition ​ Promote high-protein diet with adequate calcium & vitamin D. ​ Hydration assists in healing, prevents constipation, & decreases risk of blood clots. Treatment -​ Fracture is reduced/ restored to its normal alignment. ❖​ Closed reduction: (bone is repositioned using external manipulation) -​ Local or regional anesthesia or conscious sedation is given before closed reduction. -​ After closed reduction → Fractured is immobilized with a splint, cast or traction. -​ X ray used to verify proper position. ❖​ Open reduction: Bone is exposed & realigned (done in surgery). ​ Plates, wires, nails & or screws can be used to maintain position. ❖​ Traction: Applies force to return/maintain fractured bones to normal anatomic position. ​ All traction needs a counter weight. (Pts own body is the counter weight used) ​ Suspend weights can also be used.  ★​ Box 39.3 Nursing Interventions for Pts in Traction ​ Maintain the pulling force and direction of the traction.​ -​ In most instances, the patient’s weight provides countertraction: A.​ Center the patient on the bed; maintain body alignment with the direction of pull. B.​ DO NOT WEDGE the patient’s foot or place it flush with the footboard of the bed. C.​ Ensure that weights hang freely and do not touch the floor. D.​ Ensure that nothing is lying on or obstructing the ropes. E.​ Do not allow the knots at the end of the rope to come into contact with the pulley. ​ Perform neurovascular assessments frequently. ​ ASSESS for common complications of immobility, including pressure ulcer formation, renal calculi, deep venous thrombosis, pneumonia, paralytic ileus, and loss of appetite. ​ If a problem is detected, assist in repositioning. Stabilize the fracture site during repositioning. ​ TEACH the patient and family about the type and purpose of the traction. ​ For skin traction:​ 1.​ Frequently assess skin, bony prominences, and pressure points for evidence of pressure, shearing, or pending breakdown. 2.​ Protect pressure sites with padding and protective dressings, as indicated. 3.​ Remove weights only IF intermittent traction has been ordered to alleviate muscle spasm. ​ For skeletal traction: 1.​ Never remove the weights. 2.​ Frequently assess pin insertion sites and provide pin site care per policy. 3.​ Report signs of infection at the pin sites, such as redness, drainage, and increased tenderness.  1427 - pic A fig 39.4 (Realignment) ​ Traction is the application of a pulling force to restore or maintain bone alignment or fracture healing. ​ Manual traction is applied to restore or maintain alignment during emergency treatment of a fracture 1430 - 1432 nursing care (compartment syndrome) Assessment: ​ Pain with movement, edema, pulses, range of motion, skin color and temp, and deformity. The five Ps (Pain, Pulses, Pallor, Paralysis/Paresis, Paresthesia) Priorities of Care: ​ Manage Acute Pain ➔​ Monitor vital signs ➔​ Ask the pt to rate pain on scale of 0-10 ➔​ For the pt with a hip fracture, apply Buck’s traction per provider orders, keep traction weights freely hanging ➔​ Move the pt gently and slowly ➔​ Elevate the injured extremity about the level of the heart ➔​ Encourage distraction and other adjunctive measures of pain relief ➔​ Administer NSAIDs ​ Reduce Risk for Impaired Peripheral Neurovascular Function ➔​ Support the injured extremity above and below injured site when moving pt ➔​ Assess five P’s every 1-2 hrs immediately post injury ➔​ Assess nails for capillary refill, if nails are too thick cheek skin around ➔​ Monitor exterity for edema or hematoma ➔​ Assess for deep, throbbing, unrelenting pain ➔​ Assess the ability to differentiate between sharp and dull touch and the presence of paresthesias and paralysis every 1-2 hrs immediately postinjury ➔​ Monitor tightness of cast  ➔​ If compartment syndrome is suspected, assist healthcare providers in measuring compartment pressure. Rises within 10-30 mmHg. ➔​ Elevate extremity about the level of the heart ➔​ Administer anticoagulant per physicians orders ​ Reduce Risk of Infection ➔​ Monitor vital signs and lab reports of ​WBC ➔​ Use sterile technique for dressing changes ➔​ Assess the wound for size, color, and presence of drainage ➔​ Administer antibiotics ​ Promote Physical Mobility ➔​ Teach or assist pt with ROM ➔​ Teach isometric exercises, and encourage the pt to perform them every 4 hrs ➔​ Encourage ambulations if able ➔​ Turn the pt on bed rest every 2 hrs 1436 - complication 2 questions - (DVT 3 questions) ​ Go up for compartment syndrome DVT: 1.​ Venous stasis, or decreased blood flow 2.​ Injury to blood vessel walls 3.​ Altered blood coagulation ★​ Pulmonary embolism is the leading cause of death in hip fracture surgeries  1440 complication for amputation ​ Infection, delayed healing, chronic stump pain and phantom pain, and contractures. 1442 nursing care (for stump) ​ Manage acute pain ➔​ Pain scale before and after interventions ➔​ Slint and support the injured area ➔​ Elevate the stump on a pillow for the first 24 to 48 hrs ➔​ Move and turn pt gently and slowly, and support limb as the pt moves ➔​ Administer pain meds ➔​ Encourage deep breathing and relaxation exercises ➔​ Reposition pt every 2 hrs (side to side, and onto abdomen) ​ Reduce risk for infection ➔​ Assess wound for redness, drainage, temp, edema, and suture line ➔​ Take temp every 4 to 8 hrs ➔​ Monitor WBC ➔​ Use aseptic technique to change wound dressing ➔​ Administer antibiotics, as ordered ➔​ Teach pt stump wrapping technique (wrap from distal to proximal extremity) ​ Reduce Risk of Impaired Skin integrity ➔​ Wash stump with soap and warm water and dry thoroughly and inspect stump (mainly at night) ➔​ Message the end of stump, beginning 3 weeks after surgery ➔​ Expose any open areas of skin on the remaining part of the limb for 1 hr QID ➔​ Change stump socks and elastic wraps each day. Wash in mild soap and water. ​ Reduce risk of Psychosocial issues ➔​ Encourage verbalization of feelings, using open-ended questions ➔​ Active listening and eye contact ➔​ Reflect on the pt’s feelings ➔​ Allow the pt to have unlimited visiting hrs ➔​ If desired, provide spiritual support ​ Promote healthy body image ➔​ Encourage verbalization of feelings ➔​ Allow pt to wear clothing from home ➔​ Encourage the pt to look at the stump ➔​ Encourage the pt to care for the stump ➔​ Offer to have a fellow amputee visit ➔​ Encourage active participation in rehabilitation ​ Promote physical mobility ➔​ Perform ROM ➔​ Maintain postoperative shrinkage devices ➔​ Turn and reposition every 2 hrs ➔​ Reinforce teaching gy the physical therapist in crutch walking or the use of assistive devices ➔​ Encourage active participation in physical therapy Chapter 40: Nursing Care of Patients with Musculoskeletal Disorders (15 Questions) ★​The Patient with Osteoporosis (modifiable and nonmodifiable risk factors, symptoms) ➔​ Osteoporosis = porous bones; metabolic bone disorder characterized by: ◆​ Loss of bone mass ◆​ Increased bone fragility & risk of fractures. ➔​ Caused by imbalance of the processes that influence bone growth & maintenance. ➔​ Most often associated with AGING ◆​ Other causes: endocrine disorder or malignancy Risk Factors ➔​ Risk of developing osteoporosis depends: on how much bone mass is achieved between ages 25 & 35, & how much is lost later. ★​ Primary Risk Factors for Osteoporosis: ➔​ ACCESS ◆​ Alcohol ◆​ Corticosteroid ◆​ Calcium low ◆​ Estrogen low ◆​ Smoking ◆​ Sedentary lifestyle Nonmodifiable Risk Factors ➔​ Women have a higher risk for osteoporosis because their peak bone mass is 10 to 15% less than men. ➔​ Age-related bone loss starts earlier & faster in women. ◆​ Begins in 30s & accelerates before menopause. ➔​ Estrogen in women & Testosterone in men help prevent bone loss.  ➔​ Age related bone loss in men occurs 15 to 20 years later than in women & at a slower rate. ➔​ Smaller frame & thinner people are at higher risk for osteoporosis. ➔​ Caucasian & Asian women are more prone. ➔​ Caucasian men are more likely to develop osteoporosis than men of other ethnic backgrounds. ❖​ Pts with Endocrine disorders:(affect metabolism, & nutritional status & bone mineralization) ​ Hyperthyroidism, hyperparathyroidism ​ Cushing syndrome ​ Diabetes mellitus ❖​ Malabsorption disorders: (affect calcium absorption & increase risk for osteoporosis) ​ Celiac disease ​ Pancreatic disorders ​ Inflammatory bowel disease Modifiable Risk Factors ➔​ Calcium deficiency is a crucial modifiable risk factor that can lead to the development of osteoporosis. ◆​ Insufficient calcium intake = weakening bone tissue. ➔​ Acidosis (results from high-protein diet) contributes to osteoporosis: ◆​ Calcium is withdrawn from the bone as the kidney attempts to buffer the excess acid. ◆​ Acidosis may directly stimulate osteoclast function. ◆​ High intake of diet soda containing significant phosphate can also deplete calcium stores. ➔​ Estrogen ◆​ Premature osteoporosis is increasing in female athletes, who have a greater incidence of eating disorders & amenorrhea. ◆​ Poor nutrition & intense physical training can = deficient production of estrogen. ◆​ Decreased estrogen + lack of calcium & vitamin D = loss of bone density. ➔​ Testosterone  ➔​ Cigarette smoking & excess alcohol intake (>3 drinks per day) = risk for osteoporosis. ◆​ Smoking decreases blood supply to the bones. ◆​ Nicotine slows production of osteoblasts & impairs absorption of calcium = decreased bone density. ◆​ Alcohol has a direct toxic effect on osteoblast activity, suppressing bone formation during periods of alcohol intoxication. ➔​ Moderate alcohol consumption in postmenopausal women: ◆​ Increase bone mineral content, by increasing levels of estrogen & calcitonin. ➔​ Sedentary lifestyle: ◆​ Weight-bearing exercise (walking) influences bone metabolism. Increases blood flow to bones, brings growth-producing nutrients to cells. ◆​ Walking increases osteoblast growth & activity. ➔​ Glucocorticoid Medication (prednisone or dexamethasone) ◆​ Risk for glucocorticoid induced osteoporosis if taken for more than 3 months. ◆​ These meds are used to manage rheumatic diseases, directly affecting bone cells & slowing the rate of bone formation. ◆​ Also interfere with how the body uses calcium & affect levels of sex hormones, leading to bone loss. ➔​ Other medications: (increase risk for osteoporosis & fracture) ◆​ Anticonvulsants ◆​ Immunosuppressants Manifestations Most common: -​ Loss of height -​ Progressive curvature of the spine -​ fractures of the forearm, spine or hip. -​ Acute episodes of pain. Aging: (Dowager’s hump) -​ Dorsal kyphosis -​ Cervical lordosis ★​ Osteoporosis is called “the silent disease” because bone loss occurs without symptoms. ➔​ No obvious manifestations of osteoporosis until fractures occur.  ◆​ Some fractures are spontaneous; others can occur because of everyday activities. (bending, lifting, jumping) -​ As the condition progresses, height can be reduced as much as 18 cm (7 in). 1453 - alendronate - bisphosphonate (nursing intervention) (calcium and vitamin D) ➔​ Bisphosphonates (drugs of choice to prevent/treat osteoporosis). ◆​ Potent inhibitors of bone resorption that preserve bone mass & density in the hip & vertebrae. ​ Postmenopausal Osteoporosis: Alendronate, Risedronate, & oral Ibandronate ​ Glucocorticoid-induced osteoporosis: Alendronate, Risedronate ➔​ Adverse effects: (bc of long-term adherence to bisphosphonate therapy) ◆​ Heartburn ◆​ Difficulty swallowing ◆​ Gastric upset BISPHOSPHONATES (inhibit bone resorption by inhibiting osteoclast activity, increasing mineral density of bones, & reducing incidence of fractures.) -​ alendronate (Fosamax) -​ etidronate (Didronel) -​ ibandronate (Boniva) -​ pamidronate (Aredia)  -​ risedronate (Actonel) -​ tiludronate (Skelid) -​ zoledronic acid (Reclast, Zometa) Nursing Responsibilities -​ Administer oral forms with 6 to 8 ounces of water 30 minutes before food or other medications. Other liquids decrease absorption. -​ DO NOT CRUSH, BREAK, OR CHEW TABLETS. -​ DO NOT give foods high in calcium, vitamins with mineral supplements, or antacids within 2 hours of administering -​ Instruct pt to avoid lying down for 30 to 60 minutes after taking the drug. -​ Assess renal function studies before initiating therapy; alendronate is not recommended for use in patients with renal insufficiency. -​ Dilute the dose of IV preparations and administer by slow intravenous injection or infusion as recommended. Do not add to calcium-containing solutions such as Ringer or lactated Ringer solutions. -​ Monitor the IV site for signs of thrombophlebitis. -​ Assess the patient for signs of electrolyte imbalance or other adverse responses such as a drug fever. Health Education for the Patient & Family -​ Take the medication as directed with clear water only. Consuming other beverages or food within 30 minutes of taking the drug may interfere with its absorption and effectiveness. -​ DO NOT lie down until after you have eaten because the drug can irritate the esophagus. -​ REPORT symptoms such as new or worsening heartburn, difficult or painful swallowing, or jaw pain to your primary care provider. -​ Fever with or without chills and flu-like symptoms may occur while receiving intravenous bisphosphonates; this will subside without treatment. -​ Report any abnormal symptoms such as tingling around the mouth or numbness and tingling of the fingers or toes, which may indicate an imbalance of electrolytes in the blood. -​ Take calcium and vitamin D supplements as instructed by your primary care provider.  -​ Response to these medications is gradual and continues for months after the drug is stopped. -​ CALCITONIN (In postmenopausal osteoporosis [and treatment of Paget disease], calcitonin prevents further bone loss and increases bone mass if the patient consumes adequate amounts of calcium and vitamin D. Calcitonin may be used in combination therapy with a bisphosphonate or for patients who cannot use bisphosphonates.) -​ calcitonin (Fortical, Miacalcin) Nursing Responsibilities -​ Calcitonin is a protein in nature; both the parenteral and nasal spray forms may cause an anaphylactic-type allergic response. Observe the patient for 20 minutes after administration; have appropriate emergency equipment and drugs available to treat anaphylaxis. -​ Alternate nostrils daily when administering calcitonin nasal spray. Assess nasal mucosa daily for irritation. -​ Review medical history for conditions that contraindicate use of calcitonin products: hypersensitivity to calcitonin–salmon and lactation (calcitonin is secreted in breast milk and may inhibit lactation). -​ OBSERVE for side effects: Nausea and vomiting, anorexia, mild transient flushing of the palms of the hands and the soles of the feet, and urinary frequency. -​ Teach the patient the proper technique for handling and injecting the drug at home. Health Education for the Patient & Family -​ Take the medication in the EVENING to minimize side effects. -​ Warm nasal spray to room temperature before using. -​ Rhinitis (runny nose) is the most common side effect with calcitonin nasal spray. Other possible side effects include sores, itching, or other nasal symptoms. Report nosebleeds to your primary care provider. -​ Nausea and vomiting may occur during initial stages of therapy; they disappear as treatment continues.  -​ While taking the medication, be sure to consume adequate amounts of calcium and vitamin D. Nutrition (pg.1454) -​ Adequate intake of calcium & vitamin D beginning in childhood is critical to prevent & treat osteoporosis. -​ Food sources of calcium include dairy products (milk, yogurt, & cheese). -​ Milk & milk products are the best sources of calcium. ★​GOUT (risk factors and manifestations) (Pg.1460) -​ Acute inflammatory arthritis (caused by the deposition of urate crystals in synovial fluids) -​ Is triggered by urate crystallization within joints ◆​ Tophi ◆​ Deposits of crystals in kidneys can form urate kidney stones & result in kidney failure. -​ Develops in response to excess of uric acid in the body = high levels of uric acid in the blood (hyperuricemia) -​ Has abrupt onset, usually at night & often involves the first metatarsophalangeal joint (great toe). Risk Factors ➔​ Male gender at higher risk ➔​ Age, Hypertension, Obesity, Metabolic syndrome, Type 2 diabetes mellitus, & Chronic kidney disease. ➔​ Medications: Anti-flammatory, ◆​ {Diuretics, Aspirin} AVOID bc of gastrointestinal effects. Manifestations/Complications ➔​ Asymptomatic hyperuricemia (Early Gout, serum levels 9 to 10 mg/dL) ➔​ Acute gouty arthritis:  ​ triggered by trauma, alcohol ingestion, dietary excess, or stressor like surgery. ​ AFFECTED JOINT BECOMES: erythematous, hot, edematous, extremely painful & tender (mostly occurs in the great toe). ​ Other sites: foot, ankles, heels, wrists, fingers, & elbows. -​ Accompanied by: fever, chills, malaise, & elevated WBC & sedimentation rate. -​ Skin over joint becomes warm & dusky red. ◆​ Asymptomatic interval ◆​ Advanced gout (occurs when hyperuricemia is not treated) ​ Urate pool expands & urate crystal deposits (tophi) develop in cartilage, synovial membranes, tendons & soft tissue. ​ Pts will complain of joint stiffness & limited ROM, with deformity of joints evident. 1462 - Xanthine oxidase inhibitors (allopurinol [chronic medication]) Colchicine medication and anti inflammatory, also nutrition what to avoid ◆​ Acute attack : NSAIDs, colchicine, corticosteroids -​ CONTRAINDICATED for patients with active peptic ulcer disease, impaired renal function, or a history of hypersensitivity reactions to the drugs. -​ The use of colchicine is limited by significant side effects. Pts may develop abdominal cramping, diarrhea, or nausea and vomiting. Contraindicated for pts who have significant gastrointestinal (GI), renal, hepatic, or cardiac disease. -​ ◆​ Prophylactic therapy: Xanthine oxidase inhibitors, Uricosuric drugs -​ Because of their effectiveness in lowering serum uric acid levels, initiation of therapy may trigger an attack of acute gout. ➔​ Chronic medications: Xanthine Oxidase inhibitors : Alloprin ❖​ Nutrition: ○​ Pts with gout limit their intake of purine rich foods such as high amounts of meats & seafood, and drinks sweetened with high-fructose corn syrup. ○​ AVOID:Purine-rich vegetables: ​ Spinach, asparagus, cauliflower, and mushrooms.  ○​ Intake of low-fat or nonfat dairy products & vegetables are encouraged. nursing care and transition care Nursing Care -​ Pain is the primary focus for nursing interventions in patients experiencing an acute attack of gout. -​ (Pts mobility is impaired during acute attack because of pain & prescribed activity limitations.) -​ Diagnoses, Outcomes, & Interventions: ​ Relieve Acute Pain ○​ Position joint for comfort. Elevate joint or extremity on a pillow, maintaining alignment. Can use cold packs intermittently on joints. ○​ Protect joints from pressure, placing a foot cradle on the bed to keep bed covers off the foot or wearing a protective shoe to keep pressure off. ○​ Take anti-inflammatory and anti gout medications as prescribed. In the initial period, colchicine may be given several times a day. ○​ Take analgesics as prescribed. Avoid aspirin. ○​ Maintain joint rest. ​ Continuity of care: ○​ Disease & its manifestations ○​ Rationale for & use of prescribed medications ○​ Importance of a high intake of fluids each day; avoid alcohol. Transitions of Care Discuss the following topics with the patient: ​ Inform the patient that initial attacks cause no permanent damage but that recurrent attacks can lead to permanent damage and joint destruction. Discuss other potential effects of continued hyperuricemia, including tophaceous deposits in subcutaneous and other connective tissues. Discuss the potential for kidney damage and kidney stones. ​ Stress the need to continue the medication until the physician discontinues it, even though the patient is free of manifestations of gout. Tell the patient to avoid, if possible, drugs that increase uric acid blood levels: Hydro-chlorothiazide (HydroDIURIL), cyclosporine (Neoral, Sandimmune), furosemide (Lasix), and high doses of  aspirin. Patients who need to reduce their risk of heart attack may safely take one baby aspirin each day. ​ The importance of a high intake of fluids each day and avoiding the use of alcohol. ★​osteoartritis (manifestations, what makes it worse) nursing interventions and teaching ➔​ Degenerative joint disease ➔​ Most common type of arthritis. ➔​ Can be Idiopathic or secondary. ➔​ Characteristics: ◆​ Progressive loss of joint cartilage ◆​ Synovitis (inflammation of the synovium lining the joint) ◆​ Joint pain ◆​ Stiffness ◆​ Loss of joint motion ➔​ Women are more often affected by OA. ◆​ Men are more likely to have HIP OA ◆​ Postmenopausal women are more likely to have HAND OA. Risk factors ​ Increasing age ​ Genetics (Strong genetic linkage has been identified for OA of the hand & the knee) ​ Excessive or increasing body weight. ​ Inactivity ​ Repetitive joint use: ○​ Textile mill workers ○​ Sports participants Manifestations ​ Pain & stiffness in joints ​ Sciatic nerve pain ​ Decreased ↓ROM ​ Paresthesias (numbness, tingling) ​ Grating or crepitus present during movement. (ROM decreases as disease progresses) ​ Joint enlargement (because of bony overgrowth) ​ Flexion contractures ​ Pain, stiffness & limited ROM increase risk of falls & fractures in Older Adults. Nursing Care (Pg.1471) -​ Chronic process with no cure. -​ Provide comfort, help maintain mobility & ADls, teaching/assisting with adaptations to maintain life roles. ❖​ Assessment: ​ Health history: Fam history of OA; occupation; recreational activities; joint pain, stiffness; ability to carry out daily living activities. ​ Physical assessment: Height/weight; gait; joints (symmetry, size, shape, color, appearance, temperature, pain, crepitus, ROM, Heberden nodes, Bouchard nodes, muscle strength). ➔​ Diagnoses, outcomes, & interventions ◆​ (1)Manage Chronic pain ◆​ (2)Promote physical mobility ◆​ (3)Promote Readiness for enhanced self-care ❖​ Patient who has had Total Joint Replacement ​ Use & weight bearing of affected limb ​ Appropriate environmental modifications, such as overhead trapeze for getting out of bed, elevated toilet seat, & types of chairs to use & avoid when sitting. ​ Prescribed exercises ​ Use of assistive devices for ambulation, such as crutches or a walker. ​ Notify Provider if: Possible complications, including signs of infection or dislocation occur. hip and knee replacement Total Hip Replacement ➔​ Replacement of the articular surfaces of the acetabulum & femoral head. ➔​ Entire head of the femur & part of the femoral neck are removed & replaced with a prosthesis. ➔​ Potential problems of THR (total hip replacement): ◆​ Venous thromboembolic events ◆​ Dislocation within prosthesis ◆​ Loosening of joint components from surrounding bone ◆​ Infection Total Knee Replacement ➔​ Performed when the pt has intractable pain & x-ray shows evidence of arthritis of the knee. ➔​ Femoral side of the joint is replaced with a metallic surface, & the tibial side with polyethylene. ➔​ Joint failure is more common with knee replacement than with a total hip replacement. ◆​ Loosened joint components (on tibial side).  1470 - Box 40.3 nursing care of the patient having total joint replacement (pre and post op) Pre-Operative Care: ​ Assess the pt’s knowledge and understanding of the planned operative procedure. ​ Obtain a health history and physical assessment, including ROM of the affected joints. ​ Explain necessary postoperative activity restrictions. ​ Provide or reinforce teaching of postoperative exercises specific to the joint on which surgery is to be performed. ​ Teach respiratory hygiene procedures such as the use of incentive spirometry, coughing, and deep breathing. Post-Operative Care ​ Monitor vital signs, including temp and level of consciousness, every 4 hours or more frequently as indicated. Perform neurovascular checks (color, temperature, pulses and capillary refill, movement, and sensation) on the affected limb hourly for the first 12 to 24 hours, then every 2 to 4 hours. ​ Monitor incisional bleeding by emptying and recording suction drainage every 4 hours and assessing the dressing frequently. ​ Reinforce the dressing as needed. ​ Maintain IV infusion and accurate intake and output records during the initial postoperative period. ​ Maintain prescribed position of the affected extremity using a sling, abduction splint, brace, immobilizer, or other prescribed device. ​ Remind the patient to use the incentive spirometer, to cough, and to breathe deeply at least every 2 hours. ​ Assess the patient’s level of comfort frequently. ​ Help pt out of bed as soon as allowed. Teach and reinforce the use of techniques to prevent weight bearing on the affected extremity, such as the overhead trapeze, pivot turning, and toe touch. ​ Initiate physical therapy and exercises as prescribed for the specific joint replaced, such as quadriceps setting, leg raising, and passive and active ROM exercises. ​ Use sequential compression devices or antiembolism stockings as prescribed. ​ For pt with a total hip replacement, prevent hip flexion of greater than 90 degrees or adduction of the affected leg.  ​ Assess the patient with a total hip replacement for signs of prosthesis dislocation, ​ For pt with a total knee replacement, use a continuous passive range-of-motion (CPM) device or ROM exercises as prescribed. ​ Maintain fluid intake and encourage a high-fiber diet. ​ Encourage consumption of a well-balanced diet with adequate protein. ​ Teach or reinforce postdischarge exercises and activity restrictions. ​ For pts needing additional direct care after discharge, arrange placement in a long-term care or rehabilitation facility. ​ Make referrals as needed to home health agencies and physical therapy. 1475 - Rheumatoid Arthritis (interventions, medications, nutrition) ➔​ Chronic systemic autoimmune disease ➔​ NO CURE ➔​ Causes inflammation of connective tissue ➔​ Course & severity are variable ➔​ Cause unknown. Characteristics/Manifestations: ​ Joint manifestations: ○​ Swelling with stiffness, warmth, tenderness, pain ○​ Polyarticular, symmetric involvement ○​ Synovial edema ○​ Limited ROM, weakness ​ RA-associated deformities: ○​ Ulnar deviation of fingers ○​ Subluxation at MCP joints ○​ Swan-neck deformity ○​ Boutonniere deformity. ​ Wrist involvement: ○​ Deformity ○​ Carpal tunnel syndrome ​ Knee involvement: ○​ Swelling, instability ○​ Quadriceps atrophy, contractures, valgus deformities. ​ Foot/toe involvement: ○​ Subluxation, hallux valgus, lateral deviation of the toes, cock-up toes. ​ Extra-articular manifestations: ○​ Fatigue, weakness, anorexia, anemia, weight loss, low-grade fever ○​ Skeletal muscle atrophy  ○​ Rheumatoid nodules ○​ Pleural effusion, vasculitis, pericarditis, splenomegaly. Nutrition: ➔​ Ordinary, well-balanced diet is recommended. ➔​ Some pts benefit from fish oils, when taking three DMARDs. ➔​ Active RA can cause anorexia ◆​ Encourage hydration, helps prevent malnutrition & dehydration. ➔​ Bananas (antioxidants & potassium) = strengthen bones. ★​1476 - 40.5 Comparison of the Manifestations of Rheumatoid Arthritis and Osteoarthritis Feature Rheumatoid Arthritis Osteoarthritis Onset Usually insidious, can be Insidious abrupt. Course Generally progressive, SLOWLY progressive Characterized by remissions & exacerbations Pain & Stiffness -Predominant on arising, Pain with activity lasting >1h Stiffness after periods of -Occurs after prolonged immobility (relieved within activity minutes) Affected joints -Appear red, HOT, swollen -Joints may appear swollen; - “boggy” & tender to COOL & bony-hard on. palpation -One or Several Joints -decreased ROM, weakness affected: -Symmetric pattern : PIP, Hips, knees, lumbar/cervical MCP, wrists, knees, ankles & spine, PIP & DIP, & first MTP toes. joint. Systemic Manifestations -Fatigue, Fatigue - weakness -Anorexia -weight loss, Anemia -Fever -Rheumatoid nodules  1478 - RA joint manifestations -​ Proximal interphalangeal (PIP) -​ Metacarpophalangeal (MCP) ​ Usually affected: ○​ PIP, MCP, wrists, knees, ankles, & toes. ​ Stiffness is strongest in the morning. ➔​ Swan-neck deformity ◆​ Hyperextension of the PIP joint with compensatory flexion of the DIP joints.  1479 - Medications ​ Anti-Inflammatory medications ​ NSAIDs: aspirin(lowers risk for cardiovascular disease),other meds increase risk. ○​ [gastric irritation, ulceration, & bleeding = common toxic effects of NSAIDs) ○​ COX-2 inhibitor celecoxib does not inhibit platelet function. ​ Mild analgesics ​ Corticosteroids (Pay attention to glucose levels, ABGs, & Potassium [risk for hypokalemia]) ​ Disease-modifying antirheumatic drugs (DMARDs) ○​ Nonbiologic ○​ Biologic 1482 - Nursing care and treatment Nursing Interventions: →Newly diagnosed pt who is just starting treatment = reduce disease activity with the goal of achieving remission. -​ Different care needs for the pt experiencing a treatment complication such as infection or gastrointestinal bleeding or the patient who has undergone a total joint arthroplasty. ➔​ Promote Self-Health Management ◆​ Assess the patient’s understanding of RA, its manifestations and effects, and the anticipated course of the disease. ◆​ Initiate an interprofessional care conference with the patient and family. ◆​ Encourage the patient and family members to discuss the effect of the disease on their lives. ◆​ Refer the patient and family to community and social service agencies and local support groups. ➔​ Manage Chronic Pain ◆​ MONITOR the level of pain and duration of morning stiffness. ◆​ Teach the use of heat and cold applications to provide pain relief. ◆​ During periods of acute inflammation, cold packs may relieve pain more effectively. (helps relieve associated muscle spasms.) ◆​ Teach about the use of prescribed anti-inflammatory medications and the relationship of pain and disease activity. ➔​ Reduce Fatigue ◆​ Encourage a balance of periods of activity with periods of rest. ◆​ Help patients to prioritize activities, performing the most important ones early in the day. ◆​ Encourage dynamic (aerobic) physical activity IN ADDITION to prescribed ROM exercises.  ◆​ Refer to counseling or support groups. ➔​ Facilitate Role Changes ◆​ Discuss the effects of the disease on the patient’s career and other life roles. (Encourage the patient to identify changes brought on by the disease.) ◆​ Encourage the patient and family to discuss their feelings about role changes and grieve lost roles or abilities. ◆​ Listen actively to concerns expressed by the patient and family members; acknowledge the validity of concerns about the disease, prescribed treatment, and the prognosis. ◆​ Help the patient and family identify strengths they can use to cope with role changes. ◆​ Encourage pt to make decisions and assume personal responsibility for disease management. 1497 - osteomyelitis (how to antibiotic managing - teach pt) ➔​ Infectious Musculoskeletal Disorder ➔​ Osteomyelitis, infection of the bone. ​ The importance of careful hand hygiene, especially after toileting and dressing changes. ​ Take all antibiotics as prescribed. Include info about helping prevent the yeast infections (of the mouth or vagina) and diarrhea often associated with prolonged antibiotic therapy by eating 8 oz of live-culture yogurt each day. ​ The need to take pain medications on a regular basis to PREVENT PAIN from becoming severe. ​ How to perform wound care and sources for needed equipment and supplies. ​ Rest or limited weight bearing for the affected extremity or body part. ​ The importance of maintaining good nutrition. An adequate supply of kilocalories, protein, and other nutrients is necessary for immune function and healing. Suggest frequent, small meals and use nutritional supplements such as Ensure to help maintain nutritional intake.  1504 - low back pain (factors associated box 40.6) ❖​ Mechanical Injury or Trauma ​ Muscle strain or spasm ​ Compression fracture ​ Lumbar disk disease ❖​ Degenerative Disorders ​ Spondylosis ​ Spinal stenosis ​ Osteoarthritis ❖​ Systemic Disorders ​ Osteomyelitis ​ Osteoporosis or osteomalacia ​ Neoplasms,primary or metastatic ❖​ Referred Pain: ​ Gastrointestinal disorders ​ Genitourinary disorders ​ Abdominal aortic aneurysm ​ Hip pathology ❖​ Other: ​ Fibromyalgia ​ Psychiatric syndromes ​ Chronic anxiety ​ Depression 1506 - Nursing care and treatment ➔​ Nursing care for pt with low back pain focuses on educating patients. ❖​ Teach Self-Health Management. ​ Teach appropriate comfort measures, such as use of nonprescription analgesics or NSAIDs. ​ Discuss use of nonprescription analgesics & NSAIDs for lower back pain. ​ Encourage staying active & continue daily living activities as allowed by symptoms. ​ Instruct pt about appropriate use of heat to relieve back pain. ​ Teach about the “rebound phenomenon” of prolonged heat or ice therapy. ​ Teach use of appropriate body mechanics in lifting & reaching. ​ Instruct the patient to modify the workplace or environment to minimize stress to the lower back. ​ Encourage weight loss for obese patients. ​ Discuss the use of integrative therapies for treating acute low back pain.