Anemia NUR 330 Exam 4 PDF

Focus on Anemia Anemia - A deficiency in the - Number of erythrocytes (red blood cells (RBCs)) - Quantity of hemoglobin - Volume of packed RBCs (hematocrit) - Anemia is not a specific disease state but a sign of an underlying disorder. It is by far the most common hem...

Focus on Anemia Anemia - A deficiency in the - Number of erythrocytes (red blood cells (RBCs)) - Quantity of hemoglobin - Volume of packed RBCs (hematocrit) - Anemia is not a specific disease state but a sign of an underlying disorder. It is by far the most common hematologic condition - Diverse causes such as - Blood loss - Impaired production of erythrocytes - Increased destruction of erythrocytes Causes of Anemia - Decreased RBC Production - Deficient nutrients - Iron - Cobalamin - Folic acid - Decreased erythropoietin - Decreased iron availability - Blood loss - Chronic hemorrhage - Bleeding duodenal ulcer - Colorectal cancer - Liver disease - acute trauma - rupture aortic aneurysm - GI bleeding - Increased RBC Destruction - Hemolysis - Sick cell disease - Medication (e.g., methyldopa (Aldomet)) - Incompatible blood - Trauma (e.g., cardiopulmonary bypass) Anemia - RBC function - Transport oxygen (O2) from lungs to system tissues - Erythrocyte disorders can lead to tissue hypoxia, accounts for many of the s/s of anemia - Carry carbon dioxide from the tissues to the lungs - NOT A SPECIFIC DISEASE - Manifestation of a pathologic process - Identified through history and physical exam and classified by laboratory review Anemia---Clinical Manifestations - Caused by the body's response to tissue hypoxia (not having enough oxygen) - Hemoglobin (Hb) levels are used to determine the severity of anemia - s/s - pallor - low hemoglobin - low blood flow to the skin - weakness & fatigue - SOB - Tachycardia - Microcytic (small) red blood cells - Jaundice - Higher concentration of serum bilirubin - Pruritus - High serum and skin bile salt concentrations - Severe symptoms - Glossitis - Inflammation & burning of the tongue - Cheilitis - Inflammation of the lips - Brittle & ridged nails Anemia---integumentary Manifestations - In addition to the skin, the sclerae of the eyes and mucous membranes should be evaluated for jaundice because they reflect the integumentary changes more accurately, especially in a dark-skinned individual Anemia---Cardiopulmonary Manifestations - Additional attempts by the heart and lungs to provide adequate O2 to the tissues - Cardiac output maintained by increasing the heart rate and stroke volume - In extreme cases, or when concomitant heart disease is present, angina pectoris and MI may occur if myocardial O2 needs cannot be met Anemia---Nursing Assessment - Subjective Data - Important health information - Past health history - Medications - Surgery or other treatments - Dietary history - Functional health patterns - Health perception---health management - Nutritional---metabolic - Elimination - Activity---exercise - Cognitive---perceptual - LOC decreased because of lack of oxygen - Sexuality---reproductive - Objective Data - General - Health exam - Integumentary - Respiratory - Cardiovascular - Gastrointestinal - Neurologic Anemia---Nursing Diagnoses - Fatigue - Altered nutrition: less than body requirements - Ineffective self-health management Anemia---Nursing Management - Goals - Assume normal activities of daily living - Maintain adequate nutrition - Healthy diet - Develop no complications related to anemia - Nursing interventions can focus on assisting the patient to prioritize activities and to establish a balance between activity and rest that is acceptable to the patient - Patients with chronic anemia need to maintain some physical activity and exercise to prevent the deconditioning that results from inactivity. It is also important to assess for other conditions that can exacerbate fatigue, such as pain, depression, and sleep disturbance - Stay active Anemia---Nursing Implementation - Blood or blood product transfusions - Drug therapy - Volume replacement - Dietary and lifestyle changes - Oxygen therapy - Patient teaching - Nutrition intake - Protein - Compliance with safety precautions to prevent falls and injury - Correcting the cause of the anemia is the ultimate goal of therapy Anemia---Gerontologic Considerations - Common in older adults - Chronic disease - Nutritional deficiencies - s/s may go unrecognized or may be mistaken for normal aging changes - among older adults with anemia, about one third have a nutritional type of anemia (e.g., folate, cobalamin, iron), another third have renal insufficiency and/or chronic inflammation, and the remaining third have anemia that is unexplained. - s/s - pallor - confusion - ataxia - fatigue - worsening angina - HF Erythrocyte Production - Erythropoietin (EPO) is a glycoprotein primarily produced in the kidneys (10% in the liver) - Higher number of stem cells committed to RBC production - Shortens the time to mature RBCs - **Life span of an RBC is 120 days** - Three alterations in erythropoiesis may decrease RBC production - Decreased hemoglobin synthesis - Defective DNA synthesis in RBCs - Diminished availability of erythrocyte precursors Iron-Deficiency Anemia - One of the most common chronic hematologic disorders - Iron is present in all RBCs as heme in hemoglobin and in a stored form - Heme accounts for two thirds of the body's iron - In addition, those most susceptible to iron-deficiency anemia are the very young, those on poor diets, and women in their reproductive years Etiology - Inadequate dietary intake - 5% to 10% of ingested iron is absorbed - Malabsorption - Blood loss - Hemolysis - As iron absorption occurs in the duodenum, malabsorption syndromes may involve disease of the duodenum in which the absorption surface is altered or destroyed. - Major sources of chronic blood loss involve the GI and genitourinary (GU) systems. Common causes of GI blood loss are peptic ulcer, gastritis, esophagitis, diverticuli, hemorrhoids, and neoplasia. GU blood loss occurs primarily through menstrual bleeding. - In addition to anemia of chronic renal failure, dialysis treatment may induce iron-deficiency anemia as the result of blood lost in the dialysis equipment and frequent blood sampling. Clinical Manifestations - General manifestations of anemia - Pallor is the most common finding - Severe symptoms - Glossitis - Inflammation & burning of the tongue - Cheilitis - Inflammation of the lips - In addition, the patient may report headache, paresthesia, and a burning sensation of the tongue, all of which are caused by lack of iron in the tissues Diagnostic Studies - Laboratory findings - Hb, Hct, MCV, MCH, MCHC, reticulocytes, serum iron, TIBC, bilirubin, platelets - Stool guaiac test - Endoscopy - Colonoscopy - Bone marrow biopsy Collaborative Care - Goal is to treat the underlying disease - Increased intake of iron - Nutritional therapy - Oral or occasional parenteral iron supplements - Transfusion of packed RBCs Drug Therapy - Oral iron - Inexpensive - Convenient - Factors to consider - Enteric-coated or sustained-release capsules are counterproductive - Best absorbed from the duodenum and proximal jejunum - Daily dose is 150 to 200mg - Ingested in three or four daily doses, with each tablet or capsule of the iron preparation containing between 50 and 100mg of iron - Best absorbed as ferrous sulfate in an acidic environment - Hour before meals - Liquid iron should be diluted and ingested through a straw - Side effects - Black stool - Constipation - Four aftertaste - Heartburn - Parenteral iron - Indicated for malabsorption, oral iron intolerance, need for iron beyond normal limits, poor patient compliance - Can be given IM or IV - IM may stain skin Nursing Management - At-risk groups - Premenopausal women - Pregnant women - Persons from low socioeconomic backgrounds - Older adults - Individuals experiencing blood loss - Diet teaching - Supplemental iron - Discuss diagnostic studies - Emphasize compliance - Iron therapy for 2 to 3 months after hemoglobin levels return to normal \*\*Patients who require lifelong iron supplementation should be monitored for potential liver problems related to iron storage\*\* Urinary Incontinence & Bowel Alterations & Pressure Ulcers Risks/Etiologies - **Urinary incontinence is uncontrolled leakage of urine** - Risks/Etiologies - Anything that interferes w/bladder or urethral sphincter **Risks** - **Age-related changes in the urinary tract** - **Caregiver or toilet unavailable** - **Cognitive disturbances---dementia, Parkinson disease** - **Diabetes** - **Genitourinary surgery** - **High-impact exercise** - **Immobility** - **Incompetent urethra due to trauma or sphincter relaxation** - **Medications---diuretic, sedative, hypnotic, and opioid agents** - **Menopause** - **Morbid obesity** - **Pelvic muscle weakness** - **Pregnancy---vaginal delivery, episiotomy** - **Stroke** - **Women** - **Stress incontinence** - **Urge incontinence** - **Men** - **Prostatic hypertrophy** - **Overflow from urinary retention** Urinary Incontinence---Diagnosis - Focused history - Physical exam - Mobility - Cognitive function - Pelvic examination - Urination journal---1 week - Factors producing urine leakage - Frequency of noctura - Urinalysis (u/a) - UTI? - DM? - Urodynamic testing---evaluates storage of urine & outflow of urine - Imaging---ultrasound---may show urinary retention Urinary Incontinence---types - Stress incontinence - Urge incontinence - Overflow incontinence - Functional incontinence Stress Incontinence - **Sudden increase in intraabdominal pressure\>involuntary leakage of small amounts of urine** - **Can occur during coughing, laughing, sneezing, or physical activities such as heavy lifting, or exercising** - Leakage usually in small amounts and may not be daily - **[Treatment]** - **[Pe]lvic floor exercises---Kegels** - **Weight loss of pt obese** - **Cessation of smoking** - Surgery - Females: - Topical estrogen - Vaginal pessary - Males - External condom catheter - Penile clamp - Incontinence Aids [Urge Incontinence] - **Overactive bladder & occurs randomly when involuntary urination is proceeded by urgency** - Urinary urgency precedes leakage of urine - **Uncontrolled contraction or overactivity of detrusor muscle** - CNS alteration---tumor, Parkinson's - Bladder alteration---radiation - **Urge incontinence---treatment** - **Rx of underlying cause** - **Bladder retraining** - **Bowel regularity** - **Kegel exercises** - **[Anticholinergics; calcium channel blockers]** - **Oxybutynin---relaxes the bladder muscles** - **Beta-3 adrenergic agonists** - **Mirabegron (myrbetriq)** - **Absorbent pads---disposable** Overflow Incontinence - **Overfull bladder** - **Bladder distended & palpable** - **Leaking urine day & night** - **Underactive detrusor muscle---DM** - **Bladder or urethral outlet obstruction** - **Neurogenic factors** - **Anesthesia** - Overflow incontinence---Rx - **A adrenergic blockers** - **Tamsulosin (Flomax)---treat enlarged prostate** - **Bethanechol---enhance bladder contractions** - **Treat urinary and bladder problems by emptying the bladder and increasing urination** - **Crede maneuver---direct pressure over bladder** - **Urinary catheterization** - **Vaginal pessary to support pelvic organs** **How do we care for patients with catheters?** - **Peri-care** - **Change linens** - **Emptying every shift (half full)** - **Bag needs to be below the bladder** - **Check for kinks** - **Never disconnect catheter** Functional Incontinence - **Leakage of urine due to cognitive, functional or environmental factors** - **Demetia, older adults that have balance and mobility problems** - Functional incontinence---treatment - **Regular toileting---every 2-3 hrs.** - **Easy access to toilet** - **Lighting at night** - **Mobility aids** - **Clothing alterations** Instrumentation - Urethral catheterization - Ureteral catheters - Suprapubic catheters - Nephrostomy tubes - Intermittent catheterization Diarrhea - **Passage of \>3 loose or liquid stools/day** - **Acute diarrhea is self-limiting, lasting 1 or 2 days; persistent diarrhea typically lasts between 2 and 4 weeks; and chronic diarrhea persists for more than 4 weeks and may return sporadically. Acute and persistent diarrheas are frequently caused by viral infection** - **Danger in immunosuppressed patients** Diarrhea Etiology and Pathophysiology (causes) - **Viral**---1-8 days depending on virus; monitor associated sx: fever, abdominal cramping, n/v - **Parasitic**---may last up to 2-3 weeks - Giardia---most common; may interfere w/nutrient absorption - **Bacterial**---24hr. to 7 days; monitor other sx: fever, abdominal cramping, n/v, watery or bloody diarrhea - **Staphylococcus---30min. to 1-3 days; mild sx** - **E. coli---average 60 hr.; watery/bloody diarrhea, fever, n/v, abdominal cramping** - **Clostridium diffficile---watery diarrhea, fever, nausea, anorexia, abdominal pain (very contagious lives on surfaces for 90 days)** - **Bleach is the only thing that will kill the spores** - **Contact isolation** - **\*\*If you suspect that your patient has c. diff wash hands then gown and glove\*\* implement precautions right away, stool cultures may take 1-3 days to come back** - **What would make a patient high risk?** - **Previous antibiotic use** - **Chemo** - **Salmonella---fever, abdominal cramps** Diarrhea Pathophysiology - Ingestion of organism---varies w/cause - Alter secretion and/or absorption of enterocytes of small intestine w/o inflammation - Impair absorption by destroying cells and causing inflammation - Damage intestine cells and produce toxins - Susceptibility to organism varies: - Immunosuppression - Genetic - Gastric acidity - Elderly - Hospitalized patients receiving antibiotics - C. difficile---mild to severe with fulminate colitis and intestinal perforation **[Diarrhea]** - Acute---typically from infections - May be infectious up to 2 weeks after symptoms gone - Most often, self-limiting - May occur from pancreatic insufficiency - Problems - Perianal skin excoriation - Malabsorption\>malnutrition - Anemia - Severe dehydration---may be life-threatening - Electrolyte alterations (K+=dysrhythmias) - Acid-base alterations **Diarrhea---Diagnostic Studies** - H&P; Hgb & Hct; WBC w/differential - Recent travel; personal contacts; foods eaten - Stool specimens for WBCs, bacteria, fat, blood, mucus - Endoscopy, colonoscopy may be needed w/bx taken from intestinal mucosa Diarrhea Nursing Management: Acute Infectious - **Nursing assessment** - Thorough history; assess for dehydration; assess abdomen, pain, duration, vomiting, stool pattern - Nursing diagnoses - Diarrhea r/t acute infectious process aeb frequent loose, liquid stools and cramping---resume normal bowel activity - **Wash hands** - **Obtain stool spec for c&s; other** - **Actions for bowel rest---NPO, liquid diet** - **Instruct pt. to inform staff of each stool** - **Instruct pt. to monitor time, color, consistency, amount each stool** - **Teach pt. to take ordered medications; do not take OTC drugs w/o MD approval** \*\*Antidiarrheal agents like loperamide are contraindicated in some infectious diarrheas because they prolong exposure to the organism \*\*If your patient is having multiple loose stools, would you give docusate sodium? - No, you would not Diarrhea: Nursing Diagnoses - **Deficient fluid volume r/t excessive fluid loss secondary to diarrhea aeb dry skin & mucous membranes, orthostatic hypotension, skin tenting, tachycardia, e u/o, electrolyte imbalance** - Risk for impaired skin integrity r/t perianal exposure to chemical irritants & excretions Fecal Incontinence - **Leakage of feces; involuntary passage of stool when normal structures are disrupted** - Etiology and Pathophysiology (causes/occurs) - **Weak or disrupted internal or external anal sphincter** - **Damage to pudendal or other nerves that innervate anal/rectal area** - **Weaknesses or trauma to puborectalis muscle** - [Childbirth trauma, surgery, radiation rx, aging, fecal impaction, diabetic neuropathy, neurological alterations, impaired mobility)] - **Diagnostic studies** - History\--\# stools, consistency, volume + - Physical---rectal exam - Abdominal x-ray or CT, sigmoidoscopy, colonoscopy - **Collaborative Care** - If fecal impaction, remove - Bowel management program - Regular toileting; Kegel exercises - High fiber diet - **Avoid caffeine, spicy foods, dried fruit, onions, mushrooms, green vegetables, fruit w/ peels** - Increased fluid intake - 2 to 3L - Bulk-forming laxatives Fecal Incontinence: Nursing Management - Nursing diagnoses - Social isolation r/t inability to control bowel function---participate in work and social activities - Bowel incontinence r/t inability to control bowel function---have predictable bowel elimination - Self-care deficit (toileting) r/t inability to manage bowel evacuation voluntarily---manage bowel evacuation voluntarily Constipation - **Difficult-to-pass stools, decrease in stool volume, retention of feces in rectum** - Etiology and Pathophysiology (causes) - **Insufficient dietary fiber, fluid, exercise** - Ignoring urge to defecate - Tumor blocking stool passage - Chronic laxative use\>lack of muscle tone of colon - Drugs (opioids) - **[ALWAYS assess the patient for individual risk factors for constipation ]** - **Clinical Manifestations** - Fewer than three bowel movements per week - Abdominal distention - Pain and bloating - A sensation of incomplete evacuation - Straining at stool - The elimination of small-volume, lumpy, hard, dry stools - **Complications**: - Valsalva maneuver can be fatal - Hemorrhoids - Fecal impaction\>bowel perforation Assessment Rome IV Diagnostic Criteria for Functional Constipation - Reported s/s must be present for the past 3 months with onset at least 6 months prior to diagnosis; these must include 2 or more of the following: - Straining during at least 25% of bowel movements - Lumpy or hard stools from at least 25% of bowel movements - Sensation of incomplete evacuation during at least 25% of bowel movements - Sensation of anorectal obstruction or blockage during at least 25% of bowel movements - Manual maneuvers (e.g., digital stimulation, support of pelvic floor) needed to facilitate at least 25% of bowel movements - less than three spontaneous bowel movements weekly - In addition to these, loose stools are rarely present w/o the use of laxatives, and there must be insufficient suspicion of irritable bowel syndrome Constipation - Diagnostic studies - History---defecation patterns, diet, exercise, use of laxatives - Physical exam---abdominal distention - Abdominal x-ray; colonoscopy; sigmoidoscopy - **Collaborative care** - Laxatives - Enemas---fast acting and beneficial for immediate treatment but use cautiously - Laxative---read drug information in Lehne (Look in book) - Bulk-forming (Metamucil) - Mix with intestinal fluids, swell, and stimulate peristalsis - Stool softeners (docusate) - Increases the wetting efficiency of intestinal water - Lubricants (mineral oil, glycerin suppository) - Increases the wetting efficiency of intestinal water - Saline (magnesium hydroxide) - Osmotic laxatives (polyethylene glycol) - Stimulants (bisacodyl, senna) Constipation---nursing management - **Nutritional Therapy** - Increase dietary fiber: fruits and vegetables, grains, prunes, wheat bran - Increase fluids to 2L-3L/day (unless restricted) - **Teach patient that increasing fiber at first will lead to increased gas production but will decrease over several days** Constipation - Nursing diagnosis example - Constipation r/t inadequate intake of dietary fiber and fluid; decreased physical exercise - **Goal/outcome:** will increase fiber in diet; will increase fluid intake to 2-3L/day, will exercise daily, such as 30 minutes of walking per day; will pass soft, formed stools with regularity; will not have complications - Sit pt. upright on bedpan or toilet - Footstool in front of patient to keep knees flexed and up - Privacy - Instruct on walking 30 minutes daily (use of indoor mall or gym if inclement weather); keep exercise journal - Instruct on foods high in fiber Pressure Ulcers **Pressure Ulcer** - A localized injury to the skin and/or underlying tissue due to pressure with or w/o shear/friction - Generally fall under the category of healing by secondary intention Incidence - Most common sites - Sacrum - Heels Influencing Factors - Amount of pressure (intensity) - Length of time pressure is exerted (duration) - Ability of tissue to tolerate externally applied pressure Contributing Factors - Shearing force---pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement - Friction---two surfaces rubbing against each other - Excessive moisture **Risk factors** - Prolonged pressure on tissue - Immobility, compromised mobility - Loss of protective reflexes, sensory deficit/loss - Poor skin perfusion, edema - Malnutrition, hypoproteinemia, anemia, vitamin deficiency - Friction, shearing forces, trauma - Incontinence of urine or feces - Altered skin moisture: excessively dry, excessively moist - Advanced age, debilitation - Equipment: casts, traction, restraints - Skin problems on admission Clinical Manifestations - Ulcers are graded or staged according to deepest level of tissue damage: - Stage 1 (minor) to stage IV (severe) - Slough or eschar may have to be removed for accurate staging of some ulcers - A pressure ulcer may also present as a blood-filled blister - Stable (dry, adherent, intact) eschar on the heels serves as "the body's natural (biologic) cover" and should not be removed Clinical Manifestations: **Stage 1** - Intact skin with non-blanchable redness - Possible indicators---skin temperature, tissue consistency, pain - May appear with red, blue, or purple bues in darker skin tones Clinical Manifestations: **stage 2** - Partial-thickness loss of dermis - Shallow open ulcer with red pink wound bed - Presents as an intact or ruptured serum-filled blister - No slough tissue or bruising Clinical Manifestations: **stage 3** - Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia - Presents as a deep crater with possible undermining of adjacent tissue - Depth of ulcer varies by anatomic location - The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue, and stage 3 ulcers can be shallow - In contrast, areas of significant adiposity can develop extremely deep stage 3 pressure ulcers - Bone/tendon is not visible or directly palpable Clinical Manifestations: **stage 4** - Full-thickness loss can extend to muscle, bone, or supporting structures - Bone, tendon, or muscle may be visible or palpable - Slough or eschar may be present on some parts of the wound bed - Undermining and tunneling may also occur - High risk for osteomyelitis Unstageable pressure injury - Full thickness wound, depth cannot be determined due to slough tissue and/pr eschar tissue - This will be either a stage 3 or stage 4 pressure ulcer when wound is clean Suspected Deep Tissue Injury - Purple or maroon in color - Blood filled blister - Painful, firm, mushy, boggy Clinical Manifestations: Infection - Signs - Leukocytosis - Fever - Increased ulcer size, odor, or drainage - Necrotic tissue - Pain - Untreated ulcers may lead to cellulitis, chronic infection, or osteomyelitis Clinical Manifestations: Complications - Most common---recurrence - Cellulitis - Chronic infection - Osteomyelitis **Assessment** - Assess pressure ulcer risk on admission and at periodic intervals based on care setting and patient's condition - Assess total skin condition at least twice a day - Inspect each pressure site for erythema - Assess areas of erythema for blanching response - Palpate the skin for increased warmth - Inspect for dry skin, moist skin, and breaks in skin - Not drainage and odor - Care of a patient with a pressure ulcer requires local care of the wound and support measures for the whole person such as adequate nutrition, pain management, control of other medical conditions, and pressure relief - Assessment: for example, in acute care, a patient should be reassessed every 24 hours; in long-term care, a resident should be reassessed weekly for the first 4 weeks after admission and then minimally monthly or quarterly; in home care, a person should be reassessed every nurse visit Assessment Tools - Use risk assessment tools such as the Braden scale for systematic skin inspection - Activity, moisture, nutrition, friction & shear, sensory perception, mobility Assessment of Patients with Dark Skin - Look for areas of skin darker (purplish, brownish, bluish) than surrounding skin - Use natural or halogen light for accurate assessment (fluorescent light casts a blue color that can skew results) - Touch the skin to feel its consistency - Boggy or edematous tissue may indicate a stage 1 pressure ulcer - Ask about pain or an itchy sensation Planning - **Overall goals** - No deterioration - Reduce contributing factors - Not develop an infection - Have healing! - Have no recurrence **Prevention---Education** - Prevention is the best treatment - Identify risk factors and implement prevention strategies - Devices such as alternating pressure mattresses, foam mattresses with adequate stiffness and thickness, wheelchair cushions, padded commode seats, boots (foam, air), and lift sheets are useful in reducing pressure and shearing force. However, they are not adequate substitutes for frequent repositioning. **Prevention---Skin care** - Remove excessive moisture - Avoid massage over bony prominences - **Turn every 1 or 2 hours (with care to avoid shearing**) - **Use lift sheets** - Position with pillows or elbow and heel protectors - Use specialty beds - Cleanse skin if incontinence occurs - Use pads or briefs that are absorbent **Prevention---Nutrition** - A high-protein diet with protein supplements - Iron preparations may be necessary to raise the hemoglobin concentration so that tissue oxygen level can be maintained within acceptable limits - Ascorbic acid (vitamin C) is necessary for tissue healing - Other nutrients associated with healthy skin include vitamin A, B vitamins, zinc, and sulfur - With adequate nutrition and hydration, the skin can remain healthy, and damaged tissues can be repaired **Treatment---Ulcer Care** - **[Offload Area]** - Document and describe size, stage, location, exudate, infection, pain, and tissue appearance - Keep ulcer bed moist - Cleanse with nontoxic solutions - Saline ONLY - Debride - Careful documentation should be made of the size of the pressure ulcer. A wound-measuring card or tape can be used to note the ulcer's maximum length and width in centimeters. To find the depth of the ulcer, gently place a sterile cotton-tipped applicator into the deepest part of the ulcer - Some agencies require that pictures of the pressure ulcer be taken initially and at regular intervals during the course of treatment - Solutions such as Dakin's solution (sodium hypochlorite solution), acetic acid, povidone-iodine, and hydrogen peroxide (H2O2) are cytotoxic and therefore should not be used to clean pressure ulcers - It is also important to use enough pressure to adequately clean the pressure ulcer (4 to 15 psi) w/o causing trauma or damage to the wound. To obtain this pressure, a 30-mL syringe and a 19-gauge needle can be used - Use adhesive membrane, ointment, or wound dressing - Verify good nutrition - Teach self-care and signs of breakdown - Initiate specialty services - Multiple agents and protocols are used to treat pressure ulcers; however; consistency is an important key to success. Objective evaluation of the pressure ulcer (e.g., measurement of the size and depth of the pressure ulcer, inspection of granulation tissue) for response to the treatment protocol must be made every 4 to 6 days Operative Repair - Skin grafts - Skin flaps - Musculocutaneous flaps - Free flaps Seizures Seizures - Abnormal episodes of motor, sensory, autonomic, or psychic activity resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons - Associated with - Loss of consciousness, - Excessive movement or loss of muscle tone or movement - Disturbances of behavior, mood, sensation, or perception - Epilepsy---medical condition of unprovoked, recurring seizures **Causes of Seizures** - Cerebrovascular disease - Hypoxemia - Fever (childhood) - Head injury - Central nervous system infections - Metabolic and toxic conditions - Brain tumor - Drug and alcohol withdrawal **Seizures: Classification** - Focal: originates in one hemisphere - Generalized: both hemispheres involved - Primary: idiopathic (unknown origin) - Secondary: known cause or underlying condition (such as brain tumor) Types of Generalized Seizures - Tonic---stiffening - Clonic---jerking - **Tonic-clonic---stiffening/jerking** - Also known as grand mal seizures - Most dramatic form - Includes loss of consciousness - Stiffening/shaking - Incontinence - Postictal state may last minutes or hours - **Absence---subtle movement, staring** - Also known as petit mal seizures - **More common in children** - Children may outgrow them - Last seconds - May be mislabeled as **"day dreaming"** - **May include blinking, lip smacking, or chewing motions** - **Atypical absence seizures may include peculiar behavior followed by confusion in postictal state** - Atonic---drop attacks - Myoclonic---sudden twitches/jerks Focal Seizures - Disruption of electrical impulses in one part of the brain, also known as Partial seizures - Patient may remain aware/conscious - May include motor symptoms - May include non-motor symptoms involving changes in emotions, thinking, and sensations Simple focal seizures - A person remains conscious and experiences unusual feelings, thought processes or sensations that can take many forms, may include motor symptom, brief-less than one minute Complex focal seizures - Person has a change or loss of consciousness, has dream like experience, and display's unusual behavior, lasts longer than one minute Status Epilepticus - Series of generalized tonic-clonic seizures w/o full recovery in-between - Medical emergency---untreated, may result in permanent or fatal brain damage - Treatment - IV diazepam - Often requires intensive care/intubation Status Epilepticus - Series of seizure w/o full recovery in-between - Medical emergency-may require intubation - May result in permanent or fatal brain damage - IV medications indicated - Diazepam - Lorazepam - Phosphenytoin Diagnosis of Seizures - Based on description of symptoms - History - EEG - MRI to rule out structural lesions/tumors/CVA - Labs to rule out metabolic imbalances - ABGs, electrolytes, BMP including glucose, UA to rule out metabolic disorders - Medications, compliance, illicit drugs use Plan of Care for a Patient Experiencing a Seizure - **Observation and documentation DURING seizure** - How long did it last - Did patient lose consciousness - What body parts were involved - What type of movement - Was patient incontinent - When the seizure ended, how did patient respond - **Intervention for patient safety DURING seizure** - Pad head - Remove tight clothing - Remove objects that may injure patient - Turn onto side if possible - DO NOT put anything in patient's mouth - DO NOT try to restrain patient - IV access - Stay until seizure passes - Suction as needed - **Intervention for patient safety AFTER seizure** - At risk for vomiting, aspiration - Assist to side lying position - Suction, oxygen available - May have bitten tongue - Side lying position - Suction, oxygen available - Reorient, emotional support - Ongoing monitoring---VS, LOC, O2 sat, neuro assessment, IV access Common medications for seizures **Tonic-clonic and focal seizures** - **Phenytoin** - **Carbamazepime** - **Phenobarbital** - **Valproic acid/Divalporex** - Many different seizure medications including - Carbamazepime - Divalproex - Levetiraxetam - Phenytoin - Phenobarbital - Valproic acid - Gabapentin - Pregabalin - **Some seizure medications may be used for other reasons (such as neuropathic pain)** Medications - Monitor blood levels - Med compliance - Safety considerations - Side effects may include - Drowsiness - Fatigue - Dizziness - Sedation Nursing Diagnoses - Risk for injury - Deficient knowledge - Fear - Ineffective coping **Teaching** - Med compliance - Lab compliance - Med alert bracelet - Driving restrictions - Minimize stress - Proper sleep - Follow up appointments - Report changes - Caregiver education---emergency management - Eat regular meals/snacks Seizures---evaluation - Compliance with meds/therapeutic drug levels - Prevention of injuries - Verbalizes knowledge of condition and recommendations - Acceptance of disorder Headaches Headache - Also known as cephalalgia - One of the most common physical complaints - Primary headaches have no known organic cause and includes migraine, tension headache, and cluster headache - Secondary headache is a symptom with an organic cause such as a brain tumor or aneurysm - Headaches may cause significant discomfort for the person and can interfere with activities and lifestyle Types of Headaches - **Tension** - Most common - Less severe - Pressure or bandlike pain - May be triggered by emotional or physical stress - Acetaminophen/NSAIDs/sometimes muscle relaxants used or sedative - Heat massage may be effective - Minimizing stressors - May last 30 minutes to days - PT may be beneficial for recurrent headaches - Cluster - Rare - Unilateral - Pathophysiologic mechanism is unknown - Naps can induce the cluster headache - Excruciating pain around eye, can radiate to the temple, forehead, cheek, nose, or gums - Stabbing pain - Last 15 min-3hours, occur in clusters - May be treated with 100% oxygen - 10 to 20 min - Drug therapy is not as effective as for other headaches - Triptan - Cranial Arteritis - More common\>age 70 - Severe pain around in temporal region - Biopsy of artery may be needed for diagnosis - Commonly treated with steroids Types of headaches---Migraine - Migraine - Periodic, recurrent severe headache lasting hours or days - Familial tendencies - More common in women than men - May be preceded by aura---sensory, motor or psychic - May be associated with photophobia/phonophobia/ or N/V - Patients often desire sleep afterwards - May be triggered by - Hormone fluctuation - Stress - Sleep deprivation - Odors - Certain foods - Bright lights - Oral contraceptives - Weather - Chocolate (caffeine), MSG - First line treatment is with **[triptans]**---Sumatriptan - **[Decreases inflammation, causes vasoconstriction, decreases pain transmission]** - **[Contraindicated in patients with ischemic heart disease]** - Mild to moderate---NSAIDs, combination aspirin-acetaminophen-caffeine - Ergotamine-terminate or prevent migraines, variations of migraines, or cluster headaches - Use with caution with patient with hypertension, PVD, cerebral vascular disorders - Tablets, injections, sprays, inhaled - **[Use at onset of headache, dose may be repeated 2 hours afre 1 st (max 200mg/24hours]** **What are some prophylactic daily meds for migraines?** - **Goal is to decrease frequency and intensity** - **[Beta blockers-decrease frequency and intensity]** - **[Everyday ]** - Antidepressants may help - Anticonvulsants may also be used Assessment of Headaches - Detailed description of the headache is obtained - Location - Quality - Frequency - Precipitating factors - Duration - Associated symptoms - Medication history and use - Emotional factors/stress - Sleep habits - Family history - Chemical exposure - History and physical assessment with neurologic exam to rule out various physical and psychological causes - Diagnostic testing may be used---CT, MRI, angiography, EMG, labs Nursing Management of Headache: Pain - Provide individualized care and treatment - Prophylactic medications may be used for recurrent migraines - Migraines and cluster headaches requires PRN medications instituted as soon as possible with onset - Provide medications as prescribed - Provide comfort measures - Quiet, dark room - Massage - Local heat for tension Nursing Management of Headache: Education - **Help patient identify triggers and develop a preventive strategies and lifestyle changes for headache prevention** - Medication instruction and treatment regimen - Stress reduction techniques - **Nonpharmacologic therapies** - **Hold and cold** - Follow-up care - Encouragement of healthy lifestyle and health promotion activities Parkinson's Disease Parkinson's Disease - Slow. Progressive neurological movement disorder - Associated with ***[decreased levels of dopamine]*** in the brain - Usually diagnosed after age 50 - Affects men more than women Pathophysiology of Parkinson's Disease Parkinson's Disease: Cardinal Signs - Tremor - Usually starting in forearm or hand - Noted at rest - Stops with sleep or purposeful movement - Rigidity - Noted in arms, legs, face, posture - Cogwheel rigidity: tension in a muscle which gives away in little jerks - Bradykinesia - Slowing of active movement - Postural instability - Head bent forward - Shuffling gait **Parkinson's Disease: Other Signs and Symptoms** - Autonomic - Sweating - Drooling - Flushing - Orthostatic hypotension - Constipation - Urinary retention - Sexual dysfunction - Dysphagia---malnutrition and aspiration - Mask like expression - Voice impairment - Psychiatric and cognitive changes - Depression - Anxiety - Dementia, delirium - General debilitation---pneumonia, UTIs, And skin breakdown Parkinson's Disease: Medical Diagnosis & Management - Diagnosis based on - **History** - **Presenting with 2 out of 4 cardinal signs** - **Positive response to medication-Levodopa** - Treatment directed toward controlling symptoms and maintaining functional independence - Pharmacologic treatment - **Levodopa---'gold standard'** - **Converts to dopamine** - May take weeks for response to be noted - Best effect usually lasts 1-2 years - ***[Best absorption 30 minutes prior to or 2 hours after eating]*** - Eventually leads to confounding side effects - Orthostatic hypotension - Dyskinesia including facial grimacing, jerking, head bobbing, lip smacking - **Carbidopa---may eventually be added to enhance effectiveness of Levodopa** - Other medications may be added - Pramipexole, Rasagiline Parkinson's Disease: Medical Management - Deep Brain stimulator---surgical procedure - Battery powered pulse generator implanted - Increases dopamine release/blocks anticholinergic release - Decreases tremors and decreases rigidity - May lead to being able to decrease dose of levodopa - Other surgical procedures/neural transplantation-ongoing research What are some nutritional therapy for PD patients? - Sitting upright - Malnutrition and constipation can be serious consequences - Adequate roughage, BM medications - High protein Parkinson's Disease Nursing Process: Assessment - Focus on the function of the patient including ADLs - Cognitive function - VS including orthostatic BP's - Medications and responses and individual/family coping - Manifestations of disease and potential complications - Swallowing impairment-risk for aspiration - Speech - Falls - Muscle related-Tremors, rigidity, posture, gait, jerking/grimacing - **Fall risk assessment** - Home care and education needs Parkinson's Disease Nursing Process: Nursing Diagnoses - Impaired physical mobility - Activity intolerance - Risk for falls - Self-care deficits - Imbalanced nutrition - Constipation - ***[Risk for infection---associated with urinary retention and aspiration pneumonia]*** - Impaired verbal communication - Disturbed thought processes - Ineffective coping and compromised family coping - Deficient knowledge Parkinson's Disease Nursing Process: Planning - Major goals may include: - **Improved functional ability** - **Maintaining independence in ADLs** - **Controlling symptoms** - Achieving adequate bowel elimination - Attaining and maintaining acceptable nutritional status - Avoiding complications - Achieving effective communication - Developing positive individual and family coping skills Parkinson's Disease Nursing Process: Implementation - Enhancing self-care - Encourage, educate, and support independence - Environmental modifications - Use of assistive and adaptive devices - Collaborate with Occupational therapy - Improve mobility - Exercise program - Collaborating with physical therapy - Safety/fall prevention - Assistive devices - Prevention of complications - Collaborate with speech therapy for swallowing and speech issues - Thickened liquids may be indicated - Sit upright for eating and drinking - Teaching regarding medications/follow up care - Support of coping - Set achievable, realistic goals - Encourage socialization, recreation, and independence - Referral to supportive services: counselors, social workers, home care