week 3-5 medsurg.pdf

NCMB 312 – MEDSURG PRELIMS DISTURBANCES IN OXYGEN EXCHANGE AND 5. Pulse Oximeter UTILIZATION OBSTRUCTIVE DISORDERS (WEEK 3) - Non-invasive device that estimates a client’s arterial blood...

NCMB 312 – MEDSURG PRELIMS DISTURBANCES IN OXYGEN EXCHANGE AND 5. Pulse Oximeter UTILIZATION OBSTRUCTIVE DISORDERS (WEEK 3) - Non-invasive device that estimates a client’s arterial blood oxygen saturation and pulsations Obstructive Disorder - Factors affecting oxygen saturation readings: - A category of respiratory disease characterized by airway ✓ Hemoglobin saturation obstruction. Many obstructive diseases of the lung result from ✓ Impaired circulation narrowing (obstruction) of the smaller bronchi and larger bronchioles, often because of excessive contraction of the ✓ Activity/movements smooth muscle itself. It is generally characterized by inflamed ✓ Carbon Monoxide poisoning and easily collapsible airways, obstruction to airflow, problems - Normal o2 sat: exhaling and frequent medical clinic visits and hospitalizations. ✓ 95-100% ✓ 1000 mL for the first 30 - The size of the effusion, the speed of its formation, and the mins underlying lung disease determine the severity of symptoms. - Post-procedure: Apply vaselinized or petrolatum gauze a. Large effusion: shortness of breath to acute respiratory - Position post-procedure: Side-lying on the unaffected side distress. - Emergency! b. Small to moderate effusion: Dyspnea may not be ✓ If the client expectorates blood (may mean accidental present. puncture of the lungs) NOTIFY the MD! c. Dullness or flatness to percussion over areas of fluid, ✓ Rule-out pneumothorax: Chest X-Ray minimal or absence of breath sounds, decreased fremitus, - Health teaching post procedure: and tracheal deviation away from the affected side. ✓ Avoid coughing Assessment and Diagnostic Methods ✓ Deep breathing - Physical examination - Chest x-rays (lateral decubitus) ✓ Straining - Chest CT scan - Thoracentesis - Pleural fluid analysis (culture, chemistry, cytology) - Pleural biopsy Medical Management - Objectives of treatment are to discover the underlying cause; to prevent reaccumulation of fluid; and to relieve discomfort, dyspnea, and respiratory compromise. Specific treatment is directed at the underlying cause. - Thoracentesis is performed to remove fluid, collect specimen for analysis, and relieve dyspnea. - Chest tube and water-seal drainage may be necessary for C. Pulmonary Edema drainage and lung reexpansion. - The abnormal accumulation of fluid in the interstitial spaces of - Chemical pleurodesis: Adhesion formation is promoted when the lungs that diffuses into the alveoli. drugs are instilled into the pleural space to obliterate the space - Acute event that results from left ventricular failure. With and prevent further accumulation of fluid. increased resistance to left ventricular filling, blood backs up - Other treatment modalities include surgical pleurectomy into the pulmonary circulation. (insertion of a small catheter attached to a drainage bottle) or - The patient quickly develops pulmonary edema, sometimes implantation of a pleuroperitoneal shunt. called “flash pulmonary edema,” from the blood volume Nursing Management overload in the lungs. - Implement medical regimen: Prepare and position patient for - Can also be caused by noncardiac disorders, such as renal thoracentesis and offer support throughout the procedure. failure and other conditions that cause the body to retain fluid. - Monitor chest tube drainage and water-seal system; record amount of drainage at prescribed intervals. - Administer nursing care related to the underlying cause of the pleural effusion. - Assist patient in pain relief. Assist patient to assume positions that are least painful. Administer pain medication as prescribed and needed to continue frequent turning and ambulation. - If the patient is to be managed as an outpatient with a pleural catheter for drainage, educate the patient and family about management and care of the catheter and drainage system. Thoracentesis - Removal of excess air and fluid from the pleural cavity - Prevent infection: Sterile technique 6|A.N.D.S.  NCMB 312 – MEDSURG PRELIMS Pathophysiology - Give frequent, simple, concise information about what is being - Similar to that seen in HF, in that the left ventricle cannot done to treat the condition and what the responses to treatment handle the volume overload and blood volume and pressure mean. build up in the left atrium. The rapid increase in atrial pressure - Monitor effects of medications. Observe patient for excessive results in an acute increase in pulmonary venous pressure, respiratory depression, hypotension, and vomiting. Keep a which produces an increase in hydrostatic pressure that forces morphine antagonist available (eg, naloxone hydrochloride). fluid out of the pulmonary capillaries into the interstitial spaces - Insert and maintain an indwelling catheter if ordered or provide and alveoli. Lymphatic drainage of the excess fluid is bedside commode. ineffective. - The patient receiving continuous IV infusions of vasoactive Clinical Manifestations medications require ECG monitoring and frequent - As a result of decreased cerebral oxygenation, the patient measurement of vital signs. becomes increasingly restless and anxious. - Along with a sudden onset of breathlessness and a sense of D. Pulmonary Embolism suffocation, the patient’s hands become cold and moist, the nail - PE refers to the obstruction of the pulmonary artery or one of beds become cyanotic (bluish), and the skin turns ashen (gray). its branches by a thrombus (or thrombi) that originates - The pulse is weak and rapid, and the neck veins are distended. somewhere in the venous system or in the right side of the heart. - Incessant coughing may occur, producing increasing quantities - Gas exchange is impaired in the lung mass supplied by the of foamy sputum. obstructed vessel. Massive PE is a life- threatening emergency; - As pulmonary edema progresses, the patient’s anxiety and death commonly occurs within 1 hour after the onset of restlessness increase; the patient becomes confused, then symptoms. stuporous. - It is a common disorder associated with trauma, surgery - Breathing is rapid, noisy, and moist-sounding; the patient’s (orthopedic, major abdominal, pelvic, gynecologic), oxygen saturation is significantly decreased. pregnancy, HF, age more than 50 years, hypercoagulable states, - The patient, nearly suffocated by the blood-tinged, frothy fluid and prolonged immobility. filling the alveoli, is literally drowning in secretions. The - It also may occur in apparently healthy people. situation demands emergent action. - Most thrombi originate in the deep veins of the legs. Assessment and Diagnostic Methods Clinical Manifestations - Diagnosis is made by evaluating the clinical manifestations - Symptoms depend on the size of the thrombus and the area of resulting from pulmonary congestion. the pulmonary artery occlusion. - Abrupt onset of signs of left-sided HF (eg, crackles on - Dyspnea is the most common symptom. auscultation of the lungs) may occur without evidence of right- - Tachypnea is the most frequent sign. sided HF (eg, no jugular venous distention [JVD], no - Chest pain is common, usually sudden in onset and pleuritic in dependent edema). nature; it can be substernal and may mimic angina pectoris or a - Chest x-ray reveals increased interstitial markings. myocardial infarction. - Pulse oximetry to assess ABG levels. - Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, Medical Management hemoptysis, syncope, shock, and sudden death may occur. - Goals of medical management are to reduce volume overload, - Clinical picture may mimic that of bronchopneumonia or HF. improve ventricular function, and increase respiratory - In atypical instances, PE causes few signs and symptoms, exchange using a combination of oxygen and medication whereas in other instances it mimics various other therapies. cardiopulmonary disorders. Oxygenation Assessment and Diagnostic Methods - Oxygen in concentrations adequate to relieve hypoxia and - Because the symptoms of PE can vary from few to severe, a dyspnea diagnostic workup is performed to rule out other diseases. - Oxygen by intermittent or continuous positive pressure, if signs - The initial diagnostic workup may include chest x-ray, ECG, of hypoxemia persist ABG analysis, and ventilation– perfusion scan. - Endotracheal intubation and mechanical ventilation, if - Pulmonary angiography is considered the best method to respiratory failure occurs diagnose PE; however, it may not be feasible, cost-effective, or - Positive end-expiratory pressure (PEEP) easily performed, especially with critically ill patients. - Monitoring of pulse oximetry and ABGs - Spiral CT scan of the lung, D-dimer assay (blood test for Pharmacologic Therapy evidence of blood clots), and pulmonary arteriogram may be - Morphine given intravenously in small doses to reduce anxiety warranted. and dyspnea; contraindicated in cerebral vascular accident, Prevention chronic pulmonary disease, or cardiogenic shock; have - Ambulation or leg exercises in patients on bed rest naloxone hydrochloride (Narcan) available for excessive - Application of sequential compression devices respiratory depression - Anticoagulant therapy for patients whose hemostasis is - Diuretics (eg, furosemide) to produce a rapid diuretic effect adequate and who are undergoing major elective abdominal or - Vasodilators such as IV nitroglycerin or nitroprusside (Nipride) thoracic surgery may enhance symptom relief Medical Management Nursing Management - Immediate objective is to stabilize the cardiopulmonary - Assist with administration of oxygen and intubation and system. mechanical ventilation. - Nasal oxygen is administered immediately to relieve - Position patient upright (in bed if necessary) or with legs and hypoxemia, respiratory distress, and central cyanosis. feet down to promote circulation. Preferably position patient - IV infusion lines are inserted to establish routes for with legs dangling over the side of bed. medications or fluids that will be needed. - Provide psychological support by reassuring patient. Use touch - A perfusion scan, hemodynamic measurements, and ABG to convey a sense of concrete reality. Maximize time at the determinations are performed. Spiral (helical) CT or pulmonary bedside. angiography may be performed. 7|A.N.D.S.  NCMB 312 – MEDSURG PRELIMS - Hypotension is treated by a slow infusion of dobutamine Minimizing Chest Pain, Pleuritic (Dobutrex), which has a dilating effect on the pulmonary - Place patient in semi-Fowler’s position; turn and reposition vessels and bronchi, or dopamine (Intropin). frequently. - The ECG is monitored continuously for dysrhythmias and right - Administer analgesics as prescribed for severe pain. ventricular failure, which may occur suddenly. Managing Oxygen Therapy - Digitalis glycosides, IV diuretics, and antiarrhythmic agents - Assess the patient frequently for signs of hypoxemia and are administered when appropriate. monitors the pulse oximetry values. - Blood is drawn for serum electrolytes, complete blood cell - Assist patient with deep breathing and incentive spirometry. count, and hematocrit. - Nebulizer therapy or percussion and postural drainage may be - If clinical assessment and ABG analysis indicate the need, the necessary for management of secretions. patient is intubated and placed on a mechanical ventilator. Alleviating Anxiety - If the patient has suffered massive embolism and is - Encourage patient to express feelings and concerns. hypotensive, an indwelling urinary catheter is inserted to - Answer questions concisely and accurately. monitor urinary output. - Explain therapy, and describe how to recognize untoward - Small doses of IV morphine or sedatives are administered to effects early. relieve patient anxiety, to alleviate chest discomfort, to improve Monitoring for Complications tolerance of the endotracheal tube, and to ease adaptation to the - Be alert for the potential complication of cardiogenic shock or mechanical ventilator. right ventricular failure subsequent to the effect of PE on the Anticoagulation Therapy cardiovascular system. - Anticoagulant therapy (heparin, warfarin sodium [Coumadin]) Providing Postoperative Nursing Care has traditionally been the primary method for managing acute - Measure pulmonary arterial pressure and urinary output. DVT and PE (numerous specific options for treatment are - Assess insertion site of arterial catheter for hematoma available). forma+tion and infection. - Patients must continue to take some form of anticoagulation for - Maintain blood pressure to ensure perfusion of vital organs. at least 3 to 6 months after the embolic event. - Encourage isometric exercises, antiembolism stockings, and - Major side effects are bleeding anywhere in the body and walking when permitted out of bed; elevate foot of bed when anaphylactic reaction resulting in shock or death. Other side patient is resting. effects include fever, abnormal liver function, and allergic skin - Discourage sitting; hip flexion compresses large veins in the reaction. legs. Thrombolytic Therapy - Thrombolytic therapy may include urokinase, streptokinase, E. Pneumonia and alteplase. It is reserved for PE affecting a significant area - An ordinary infection, if it is not treated at an initial stage, it and causing hemodynamic instability. may spread to others. - Bleeding is a significant side effect; nonessential invasive - Also, it may cause lot of complications to the infected person procedures are avoided. which may be sometimes fatal. Hence it is always better to Surgical Management identify the cause of infection and get it treated. - A surgical embolectomy is rarely performed but may be - General term that refers to an infection of the lungs, which can indicated if the patient has a massive PE or hemodynamic be caused by a variety of microorganisms, like viruses, instability or if there are contraindications to thrombolytic bacteria, fungi, and parasites. therapy. - Pneumonia is a common illness, occurs in all age groups, and - Transvenous catheter embolectomy with or without insertion is a leading cause of death among the elderly and people who of an inferior vena caval filter (eg, Greenfield). are suffering from long time illness. It is a very old disease well Nursing Management Minimizing the Risk of PE known to our ancestors. - The nurse must have a high degree of suspicion for PE in all - Hippocrates, the ancient Greek physician known as the father patients, but particularly in those with conditions predisposing of Medicine had described the signs and symptoms of to a slowing of venous return. pneumonia accurately as early as 4th century B.C. Preventing Thrombus Formation - Encourage early ambulation and active and passive leg exercises. - Instruct patient to move legs in a “pumping” exercise. - Advise patient to avoid prolonged sitting, immobility, and constrictive clothing. - Do not permit dangling of legs and feet in a dependent position. - Instruct patient to place feet on floor or chair and to avoid crossing legs. - Do not leave IV catheters in veins for prolonged periods. Monitoring Anticoagulant and Thrombolytic Therapy - Advise bed rest, monitor vital signs every 2 hours, and limit invasive procedures. Types of Pneumonia: - Measure international normalized ratio (INR) or activated 1. Acute pneumonia: It is a type which usually develops rapidly partial thromboplastin time (PTT) every 3 to 4 hours after and lasts for 2 to 3 weeks. It is spread easily and can cause thrombolytic infusion is started to confirm activation of symptoms very soon. fibrinolytic systems. 2. Chronic pneumonia: These develop gradually over a period - Perform only essential ABG studies on upper extremities, with of weeks to months. This type pneumonia does not spread manual compression of puncture site for at least 30 minutes. easily. 8|A.N.D.S.  NCMB 312 – MEDSURG PRELIMS 3. Community acquired pneumonia is a common seen in people infection usually occurs 2 to 10 weeks after exposure. The with an underlying pathology. Streptococcus is the most patient may then develop active disease because of a common bacterial cause of community- acquired pneumonia. compromised or inadequate immune system response. The This occurs most commonly in very young and very old people. active process may be prolonged and characterized by long 4. Hospital-acquired pneumonia is an infection that patients get remissions when the disease is arrested, only to be followed by while they’re in the hospital. This means the infection is not periods of renewed activity. present at the time a patient is admitted to the hospital. - TB is a worldwide public health problem that is closely 5. Aspiration pneumonia is an inflammation of the lungs and associated with poverty, malnutrition, overcrowding, bronchial tubes caused by inhaling foreign material, usually substandard housing, and inadequate health care. Mortality and food, drink, vomit, or secretions from the mouth into the lungs. morbidity rates continue to rise. 6. Severe Acute Respiratory Syndrome (SARS): SARS is a - TB is transmitted when a person with active pulmonary disease highly contagious and deadly type of pneumonia which first expels the organisms. A susceptible person inhales the droplets occurred in 2002 after initial outbreaks in China. SARS is and becomes infected. Bacteria are transmitted to the alveoli caused by a virus called as coronavirus. and multiply. An inflammatory reaction results in exudate in 7. Chemical pneumonia: Chemical pneumonia is caused by the alveoli and bronchopneumonia, granulomas, and fibrous chemical toxins such as pesticides, which may enter the body by tissue. Onset is usually insidious. inhalation or by skin contact. Risk Factors Causative organisms: - Close contact with someone who has active TB - It is caused by different types of microorganisms, including - Immunocompromised status (eg, elderly, cancer, corticosteroid bacteria, viruses, fungi, and parasites. therapy, and HIV) 1. Viruses: Some viruses that cause pneumonia are adenoviruses, - Injection drug use and alcoholism rhinovirus, influenza virus (flu), respiratory syncytial virus - People lacking adequate health care (eg, homeless or (RSV), and parainfluenza virus. impoverished, minorities, children, and young adults) 2. Bacteria: The bacterium Streptococcus pneumoniae, a - Preexisting medical conditions, including diabetes, chronic common cause of pneumonia. Bacteria typically enter the lung renal failure, silicosis, and malnourishment when airborne droplets are inhaled, but they can also reach the - Immigrants from countries with a high incidence of TB (eg, lung through the bloodstream when there is an infection in Haiti, southeast Asia) another part of the body. Many bacteria live in parts of the - Institutionalization (eg, long-term care facilities, prisons) upper respiratory tract, such as the nose, mouth and sinuses, - Living in overcrowded, substandard housing and can easily be inhaled into the alveoli. - Occupation (eg, health care workers, particularly those 3. Fungi: Fungal pneumonia is uncommon, but it may occur in performing high-risk activities) individuals with reduced immune system due to AIDS or other Clinical Manifestations medical problems. - Low-grade fever, cough, night sweats, fatigue, and weight loss 4. Parasites: A variety of parasites can affect the lungs. These - Nonproductive cough, which may progress to mucopurulent parasites typically enter the body through the skin or by being sputum with hemoptysis swallowed. Once inside the body, they travel to the lungs, Assessment and Diagnostic Methods usually through the blood and cause disease. - TB skin test (Mantoux test); QuantiFERON-TB Gold (QFT-G) Inflammation of LUNG PARENCHYMA test Etiology: - Chest x-ray - Strep. Pneumoniae - Acid-fast bacillus smear - H. influenza - Sputum culture - E. coli Gerontologic Considerations - Klebsiella - Elderly patients may have atypical manifestations, such as S/Sx: unusual behavior or disturbed mental status, fever, anorexia, - RUSTY/PRUNE JUICE-colored sputum (pathognomonic and weight loss. TB is increasingly encountered in the nursing sign) home population. In many elderly people the TB skin test - Dyspnea produces no reaction. - Fever Medical Management - Pleuritic chest pain - Pulmonary TB is treated primarily with antituberculosis agents - Crackles for 6 to 12 months. A prolonged treatment duration is necessary Dx: to ensure eradication of the organisms and to prevent relapse. - CXR Pharmacologic Therapy - CBC (leukocytosis) - First-line medications: isoniazid or INH (Nydrazid), rifampin Mngt: (Rifadin), pyrazinamide, and ethambutol (Myambutol) daily - ANTIBIOTICS for 8 weeks and continuing for up to 4 to 7 months - Oxygen - Second-line medications: capreomycin (Capastat), - Force fluids ethionamide (Trecator), para aminosalicylate sodium, and - CPT cycloserine (Seromycin) - Nebulization - Vitamin B (pyridoxine) usually administered with INH - Semi-fowler’s position Nursing Management Promoting Airway Clearance F. Pulmonary Tuberculosis - Encourage increased fluid intake. - Tuberculosis (TB), an infectious disease primarily affecting the - Instruct about best position to facilitate drainage. lung parenchyma, is most often caused by Mycobacterium Advocating Adherence to Treatment Regimen tuberculosis. - Explain that TB is a communicable disease and that taking - It may spread to almost any part of the body, including the medications is the most effective way of preventing meninges, kidney, bones, and lymph nodes. The initial transmission. 9|A.N.D.S.  NCMB 312 – MEDSURG PRELIMS - Instruct about medications, schedule, and side effects; monitor ✓ If lying on the affected side (put a rolled towel beside the for side effects of anti-TB medications. tubing) - Instruct about the risk of drug resistance if the medication regimen is not strictly and continuously followed. - Carefully monitor vital signs and observe for spikes in temperature or changes in the patient’s clinical status. - Teach caregivers of patients who are not hospitalized to monitor the patient’s temperature and respiratory status; report any changes in the patient’s respiratory status to the primary health care provider. Promoting Activity and Adequate Nutrition - Plan a progressive activity schedule with the patient to increase activity tolerance and muscle strength. - Devise a complementary plan to encourage adequate nutrition. A nutritional regimen of small, frequent meals and nutritional supplements may be helpful in meeting daily caloric requirements. - Identify facilities (eg, shelters, soup kitchens, Meals on Wheels) that provide meals in the patient’s neighborhood may increase the likelihood that the patient with limited resources and energy will have access to a more nutritious intake. Preventing Spreading of TB Infection - Carefully instruct the patient about important hygiene measures, including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and handwashing. - Report any cases of TB to the health department so that people who have been in contact with the affected patient during the infectious stage can undergo screening and possible treatment, if indicated. - Instruct patient about the risk of spreading TB to other parts of the body (spread or dissemination of TB infection to nonpulmonary sites of the body is known as miliary TB). - Carefully monitor patient for military TB: Monitor vital signs and observe for spikes in temperature as well as changes in renal and cognitive function; few physical signs may be elicited on physical examination of the chest, but at this stage the - Remember: Keep the collection device below the client’s chest patient has a severe cough and dyspnea. Treatment of miliary level TB is the same as for pulmonary TB. - Oscillations or fluctuations on water seal: NORMAL G. Pneumothorax ABSENCE: Re-expansion of the lungs & Obstruction - Accumulation of atmospheric air in pleural space which results Mngt: in rise in intra- thoracic pressure - Notify the MD for CXR Types: - Obstruction: (no milking and stripping) SQUEEZE (hand-over- 1. Simple pneumothorax - Breach in the visceral or parietal hand) pleura - Presence of bubbling: 2. Tension pneumothorax - Laceration or hole in the lungs a. Drainage Bottle: NO BUBBLING S/Sx: b. Water Seal Bottle: INTERMITTENT BUBBLING - Dyspnea c. Suction Control Bottle: CONTINOUS GENTLE - Dec. or Absent breath sound on the affected side BUBBLING - Dec. chest expansion - Abnormal bubbling: - Tracheal deviation to the unaffected side (CXR) - Exclusive for a. Water Seal Bottle: CONTINOUS BUBBLING TENSION pneumothorax b. Suction Control Bottle: VIGOROUS BUBBLING Mngt: ALERT: LEAKAGE!!! - Thoracentesis Management: Chest Tubes and Drainage System - CLAMP the tube and TAPE the leak (allowed for short - Aims to restore negative pressure of the pleural cavity and drain periods) collected fluid/blood - PROLONGED CLAMPING: can cause tension - Components: pneumothorax a. Suction control chamber - Absence of bubbling b. Water seal chamber a. Water Seal Bottle c. Closed collection chamber b. Suction Control Bottle - Assessment of the site: At least every 4 hours for: ✓ May mean: Lung Re-expansion & Obstruction ✓ Excessive or abnormal drainage ✓ Mngt: The same ✓ Cracking sound upon palpation for subcutaneous emphysema - Points to remember: TUBE PULLED FROM THE SITE 10 | A. N. D. S.  NCMB 312 – MEDSURG PRELIMS Cover with DRY STERILE dressing 9. Induration: an abnormally hard lesion or reaction, as in a If air is leaking ensure that the dressing is not occlusive positive tuberculin skin test If not available in the choices: 10. Nosocomial: pertaining to or originating from a a. Vaselinized gauze hospitalization; not present at the time of hospital admission b. Petrolatum gauze 11. Open lung biopsy: biopsy of lung tissue performed through a - TUBE DISCONNECTED or WATER SEAL BOTTLE limited thoracotomy incision BREAKS: 12. Orthopnea: shortness of breath when reclining or in the supine a. Submerge the end in 1 in. of sterile saline or water position b. Reconnect 13. Pleural effusion: abnormal accumulation of fluid in the pleural space 14. Pleural friction rub: localized grating or creaking sound caused by the rubbing together of inflamed parietal and visceral pleurae 15. Pneumothorax: partial or complete collapse of the lung due to positive pressure in the pleural space 16. Pulmonary edema: increase in the amount of extravascular fluid in the lung 17. Pulmonary embolism: obstruction of the pulmonary vasculature with an embolus; embolus may be due to blood clot, air bubbles, or fat droplets 18. Purulent: consisting of, containing, or discharging pus 19. Restrictive lung disease: disease of the lung that causes a decrease in lung volumes H. Chest Injuries 20. Tension pneumothorax: pneumothorax characterized by - Major chest trauma may occur alone or in combination with increasing positive pressure in the pleural space with each multiple other injuries. Chest trauma is classified as either blunt breath; this is an emergency situation and the positive pressure or penetrating. needs to be decompressed or released immediately - Blunt chest trauma results from sudden compression or positive 21. Thoracentesis: insertion of a needle into the pleural space to pressure inflicted to the chest wall. remove fluid that has accumulated and decrease pressure on the - Penetrating trauma occurs when a foreign object penetrates the lung tissue; may also be used diagnostically to identify chest wall. potential causes of a pleural effusion. Rib Fracture - Fracture resulting from direct blunt chest trauma DISTURBANCES IN OXYGEN TRANSPORT - S/Sx: Pain at the site (increases with respiration) HEMATOLOGIC DISORDERS/VASCULAR - Mngt: Unite spontaneously & High fowler’s position DISORDERS (WEEK 5) Flail Chest - Fracture or 3 or more ribs resulting from direct blunt chest A. Anemia trauma - A condition in which the hemoglobin concentration is lower - S/Sx: PARADOXICAL BREATHING than normal; it reflects the presence of fewer than the normal - Mngt: Oxygen, WOF respiratory distress & High fowler’s number of erythrocytes within the circulation. As a result, the position amount of oxygen delivered to body tissues is also diminished. - Anemia is not a specific disease state but a sign of an Terminologies: underlying disorder. I 1. Acute lung injury: an umbrella term for hypoxemic, - t is by far the most common hematologic condition. There are respiratory failure; acute respiratory distress syndrome is a several kinds of anemia. severe form of acute lung injury - A physiologic approach classifies anemia according to whether 2. Acute respiratory distress syndrome: nonspecific pulmonary the deficiency in erythrocytes is caused by a defect in their response to a variety of pulmonary and nonpulmonary insults production (hypoproliferative anemia), by their destruction to the lung; characterized by interstitial infiltrates, alveolar (hemolytic anemia), or by their loss (bleeding). hemorrhage, atelectasis, decreased compliance, and refractory Clinical Manifestations hypoxemia - Aside from the severity of the anemia itself, several factors 3. Asbestosis: diffuse lung fibrosis resulting from exposure to influence the development of anemia- associated symptoms: asbestos fibers the rapidity with which the anemia has developed, the duration 4. Atelectasis: collapse or airless condition of the alveoli caused of the anemia (ie, its chronicity), the metabolic requirements of by hypoventilation, obstruction to the airways, or compression the patient, other concurrent disorders or disabilities (eg, 5. Consolidation: lung tissue that has become more solid in cardiac or pulmonary disease), and complications or nature due to collapse of alveoli or infectious process concomitant features of the condition that produced the anemia. (pneumonia) - In general, the more rapidly an anemia develops, the more 6. Empyema: accumulation of purulent material in the pleural severe its symptoms. space Pronounced symptoms of anemia 7. Hemoptysis: the coughing up of blood from the lower - Dyspnea, chest pain, muscle pain or cramping, tachycardia respiratory tract - Weakness, fatigue, general malaise 8. Hemothorax: partial or complete collapse of the lung due to - Pallor of the skin and mucous membranes (conjunctivae, oral blood accumulating in the pleural space; may occur after mucosa) surgery or trauma - Jaundice (megaloblastic or hemolytic anemia) - Smooth, red tongue (iron-deficiency anemia) - Beefy, red, sore tongue (megaloblastic anemia) 11 | A. N. D. S.  NCMB 312 – MEDSURG PRELIMS - Angular cheilosis (ulceration of the corner of the mouth) Nursing Interventions - Brittle, ridged, concave nails and pica (unusual craving for Managing Fatigue starch, dirt, ice) in patients with iron- deficiency anemia - Assist patient to prioritize activities and establish a balance between activity and rest. Assessment and Diagnostic Methods - Encourage patient with chronic anemia to maintain physical - Complete hematologic studies (eg, hemoglobin, hematocrit, activity and exercise to prevent deconditioning. reticulocyte count, and red blood cell (RBC) indices, Maintaining Adequate Nutrition particularly the mean corpuscular volume [MCV] and RBC - Encourage a healthy diet. distribution width [RDW]) - Teach patient to avoid or limit intake of alcohol. - Iron studies (serum iron level, total iron-binding capacity - Plan dietary teaching sessions for patient and family; consider [TIBC], percent saturation, and ferritin) cultural aspects of nutrition. - Serum vitamin B12 and folate levels; haptoglobin and - Discuss nutritional supplements (eg, vitamins, iron, folate) as erythropoietin levels prescribed. - Bone marrow aspiration Maintaining Adequate Perfusion - Other studies as indicated to determine underlying illness - Monitor vital signs and pulse oximeter readings closely, and Medical Management adjust or withhold medications (antihypertensives) as - Management of anemia is directed toward correcting or indicated. controlling the cause of the anemia; if the anemia is severe, the - Administer supplemental oxygen, transfusions, and IV fluids as erythrocytes that are lost or destroyed may be replaced with a ordered. transfusion of packed RBCs (PRBCs). Promoting Compliance with Prescribed Therapy - Discuss with patients the purpose of their medication, how to Nursing Process take the medication and over what time period, and how to Assessment manage any side effects; ensure patient knows that abruptly - Obtain a health history, perform a physical examination, and stopping some medications can have serious consequences. obtain laboratory values. - Assist the patient to incorporate the therapeutic plan into - Ask patient about extent and type of symptoms experienced and everyday activities, rather than merely giving the patient a list impact of symptoms on lifestyle; medication history; alcohol of instructions. intake; athletic endeavors (extreme exercise). - Provide assistance to obtain needed insurance coverage for - Ask about family history of inherited anemias. expensive medications (eg, growth factors) or to explore - Perform nutritional assessment: Ask about dietary habits alternative ways to obtain these medications. resulting in nutritional deficiencies, such as those of iron, Monitoring and Managing Complications vitamin B12, and folic acid. - Assess patient with anemia for heart failure. - Monitor relevant laboratory test results; note changes. - Perform a neurologic assessment for patients with known or - Assess cardiac status (for symptoms of increased workload or suspected megaloblastic anemia. heart failure): tachycardia, palpitations, dyspnea, dizziness, Evaluation orthopnea, exertional dyspnea, cardiomegaly, hepatomegaly, Expected Patient Outcomes: peripheral edema. - Reports less fatigue - Assess for GI function: nausea, vomiting, diarrhea, melena or - Attains and maintains adequate nutrition dark stools, occult blood, anorexia, glossitis; women should be - Maintains adequate perfusion questioned about their menstrual periods - Experiences no or minimal complications - (eg, excessive menstrual flow, other vaginal bleeding) and the use of iron supplements during pregnancy. B. Aplastic Anemia - Assess for neurologic deficits (important with pernicious - A rare disease caused by a decrease in or damage to marrow anemia): presence and extent of peripheral numbness and stem cells, damage to the microenvironment within the paresthesias, ataxia, poor coordination, confusion. marrow, and replacement of the marrow with fat. Diagnosis - The precise etiology is unknown, but it is hypothesized that the 1. Fatigue related to decreased hemoglobin and diminished body’s T cells mediate an inappropriate attack against the bone oxygen-carrying capacity of the blood marrow, resulting in bone marrow aplasia. Significant 2. Altered nutrition, less than body requirements, related to neutropenia and thrombocytopenia (ie, a deficiency of inadequate intake of essential nutrients platelets) also occur. 3. Altered tissue perfusion related to inadequate hemoglobin and - Can be congenital or acquired, but most cases are idiopathic. hematocrit Infections and pregnancy can trigger it, or it may be caused by 4. Noncompliance with prescribed therapy certain medications, chemicals, or radiation damage. Agents that may produce marrow aplasia include benzene and benzene Collaborative Problems/Potential Complications derivatives (eg, paint remover). Certain toxic materials, such as - Heart failure inorganic arsenic, glycol ethers, plutonium, and radon, have - Angina also been implicated as potential causes. - Paresthesias Clinical Manifestations - Confusion - Infection and the symptoms of anemia (eg, fatigue, pallor, Planning and Goals dyspnea). - The major goals for the patient may include decreased fatigue, - Retinal hemorrhages. attainment or maintenance of adequate nutrition, maintenance - Purpura (bruising). of adequate tissue perfusion, compliance with prescribed - Repeated throat infections with possible cervical therapy, and absence of complications. lymphadenopathy. - Other lymphadenopathies and splenomegaly sometimes occur. 12 | A. N. D. S.  NCMB 312 – MEDSURG PRELIMS Assessment and Diagnostic Methods - Have patient continue iron preparations for 6 to 12 months. - Diagnosis is made by a bone marrow aspirate that shows an Nursing Management extremely hypoplastic or even aplastic (very few to no cells) - Administer IM or IV iron in some cases when oral iron is not marrow replaced with fat. absorbed, is poorly tolerated, or is needed in large amounts. Medical Management - Administer a small test dose before IM injection to avoid risk - Those who are younger than 60 years, who are otherwise of anaphylaxis (greater with IM than with IV injections). healthy, and who have a compatible donor can be cured of the - Advise patient to take iron supplements an hour before meals. disease by a bone marrow transplant (BMT) or peripheral blood If gastric distress occurs, suggest taking the supplement with stem cell transplant (PBSCT). meals and, after symptoms subside, resuming between-meal - In others, the disease can be managed with immunosuppressive schedule for maximum absorption. therapy, commonly using a combination of antithymocyte - Inform patient that iron salts change stool to dark green or globulin (ATG) and cyclosporine or androgens. black. - Supportive therapy plays a major role in the management of - Advise patient to take liquid forms of iron through a straw, to aplastic anemia. Any offending agent is discontinued. The rinse the mouth with water, and to practice good oral hygiene patient is supported with transfusions of PRBCs and platelets after taking this medication. as necessary. - Teach preventive education, because iron-deficiency anemia is Nursing Management common in menstruating and pregnant women. - Assess patient carefully for signs of infection and bleeding, as - Educate patient regarding foods high in iron (eg, organ and patients with aplastic anemia are vulnerable to problems related other meats, beans, leafy green vegetables, raisins, molasses). to erythrocyte, leukocyte, and platelet deficiencies. - Instruct patient to avoid taking antacids or dairy products with - Monitor for side effects of therapy, particularly for iron (diminishes iron absorption). hypersensitivity reaction while administering ATG. - Provide nutritional counseling for those whose normal diet is - If patients require long-term cyclosporine therapy, monitor inadequate. them for long-term effects, including renal or liver dysfunction, - Encourage patient to continue iron therapy for total therapy hypertension, pruritus, visual impairment, tremor, and skin time (6 to 12 months), even when fatigue is no longer present. cancer. - Carefully assess each new prescription for drug–drug D. Anemia Megaloblastic (Vitamin B12 and Folic Acid interactions, as the metabolism of ATG is altered by many other Deficiency) medications. - In the anemias caused by deficiencies of vitamin B12 or folic - Ensure that patients understand the importance of not abruptly acid, identical bone marrow and peripheral blood changes stopping their immunosuppressive therapy. occur because both vitamins are essential for normal DNA synthesis. C. Iron-Deficiency Anemia Pathophysiology Folic Acid Deficiency - Typically results when the intake of dietary iron is inadequate - Folic acid is stored as compounds referred to as folates. The for hemoglobin synthesis. folate stores in the body are much smaller than those of vitamin - The most common type of anemia in all age groups, and it is B12, and they are quickly depleted when the dietary intake of the most common anemia in the world. folate is deficient (within 4 months). - The most common cause of iron-deficiency anemia in men and - Folate deficiency occurs in people who rarely eat uncooked postmenopausal women is bleeding from ulcers, gastritis, vegetables. inflammatory bowel disease, or GI tumors. - Alcohol increases folic acid requirements; folic acid - The most common causes of iron-deficiency anemia in requirements are also increased in patients with chronic premenopausal women are menorrhagia (ie, excessive hemolytic anemias and in women who are pregnant. Some menstrual bleeding) and pregnancy with inadequate iron patients with malabsorptive diseases of the small bowel may supplementation. not absorb folic acid normally. - Patients with chronic alcoholism often have chronic blood loss Vitamin B12 Deficiency from the GI tract, which causes iron loss and eventual anemia. - A deficiency of vitamin B12 can occur in several ways. Other causes include iron malabsorption, as is seen after Inadequate dietary intake is rare but can develop in strict gastrectomy or with celiac disease. vegetarians who consume no meat or dairy products. Clinical Manifestations - Faulty absorption from the GI tract is more common, as with - Symptoms of anemia conditions such as Crohn’s disease or after ileal resection or - Symptoms in more severe or prolonged cases: smooth, sore gastrectomy. tongue; brittle and ridged nails; angular cheilosis (mouth - Another cause is the absence of intrinsic factor. ulceration) - A deficiency may also occur if disease involving the ileum or Assessment and Diagnostic Methods pancreas impairs absorption. The body normally has large - Bone marrow aspiration stores of vitamin B12, so years may pass before the deficiency - Laboratory values, including serum ferritin levels (indicates results in anemia. iron stores), blood cell count (hemoglobin, hematocrit, RBC Clinical Manifestations count, MCV), serum iron level, and total iron-binding capacity - Symptoms of folic acid and vitamin B12 deficiencies are Medical Management similar, and the two anemias may coexist. Symptoms are - Search for the cause, which may be a curable GI cancer or progressive, although the course of illness may be marked by uterine fibroids. spontaneous partial remissions and exacerbations. - Test stool specimens for occult blood. - Gradual development of signs of anemia (weakness, - People aged 50 years or older should have periodic listlessness, and fatigue). colonoscopy, endoscopy, or x-ray examination of the GI tract - Possible development of a smooth, sore, red tongue and mild to detect ulcerations, gastritis, polyps, or cancer. diarrhea (pernicious anemia). - Administer prescribed iron preparations (oral, intramuscular - Mild jaundice, vitiligo, and premature graying. [IM], or IV). 13 | A. N. D. S.  NCMB 312 – MEDSURG PRELIMS - Confusion may occur; more often, paresthesias in the E. Disseminated Intravascular Coagulation (DIC) extremities and difficulty keeping balance; loss of position - A coagulation disorder that prompts overstimulation of the sense. normal clotting cascade and results in simultaneous thrombosis - Lack of neurologic manifestations with folic acid deficiency and hemorrhage. alone. - The formation of micro clots affects tissue perfusion in the - Without treatment, patients die, usually as a result of heart major organs, causing hypoxia, ischemia, and tissue damage. failure secondary to anemia. - Coagulation occurs in two different pathways: intrinsic and Assessment and Diagnostic Findings extrinsic. These pathways are responsible for the formation of - Schilling test (primary diagnostic tool) fibrin clots and blood clotting, which maintains homeostasis. - Complete blood cell count (Hgb value as low as 4 to 5 g/dL, - In the intrinsic pathway, endothelial cell damage commonly WBC count 2,000 to 3,000 mm3, platelet count fewer than occurs because of sepsis or infection. 50,000 mm3; very high MCV, usually exceeding 110 _m3) - The extrinsic pathway is initiated by tissue injury such as from - Serum levels of folate and vitamin B12 (folic acid deficiency malignancy, trauma, or obstetrical complications. DIC may and deficient vitamin B12) present as an acute or chronic condition. Medical Management: Folic Acid Deficiency - An essential medical management of DIC is primarily aimed at - Increase intake of folic acid in patient’s diet and administer 1 treating the underlying cause, managing complications from mg folic acid daily. both primary and secondary cause, supporting organ function, - Administer IM folic acid for malabsorption syndromes. and stopping abnormal coagulation and controlling bleeding. - Prescribe additional supplements as necessary, because the Morbidity and mortality depend on underlying cause and amount in multivitamins may be inadequate to fully replace severity of coagulopathy. deficient body stores. Signs and Symptoms of Excessive Blood Clotting - Prescribe folic acid for patients with alcoholism as long as they - In DIC, blood clots form throughout the body's small blood continue to consume alcohol. vessels. These blood clots can reduce or block blood flow Medical Management: Vitamin B12 Deficiency through the blood vessels. This can cause the following signs - Provide vitamin B12 replacement: Vegetarians can prevent or and symptoms: treat deficiency with oral supplements with vitamins or Chest pain and shortness of breath if blood clots form in fortified soy milk; when the deficiency is due to the more the blood vessels in your lungs and heart. common defect in absorption or the absence of intrinsic factor, Pain, redness, warmth, and swelling in the lower leg if replacement is by monthly IM injections of vitamin B12. blood clots form in the deep veins of your leg. - A small amount of an oral dose of vitamin B12 can be absorbed Headaches, speech changes, paralysis (an inability to by passive diffusion, even in the absence of intrinsic factor, but move), dizziness, and trouble speaking and understanding large doses (2 mg/day) are required if vitamin B12 is to be if blood clots form in the blood vessels in your brain. replaced orally. These signs and symptoms may indicate a stroke. - To prevent recurrence of pernicious anemia, vitamin B12 Heart attack and lung and kidney problems if blood clots therapy must be continued for life. lodge in your heart, lungs, or kidneys. These organs may Nursing Management even begin to fail. - Assess patients at risk for megaloblastic anemia for clinical Signs and Symptoms of Bleeding manifestations (eg, inspect the skin, sclera, and mucous - In DIC, the increased clotting activity uses up the platelets and membranes for jaundice; note vitiligo and premature graying). clotting factors in the blood. As a result, serious bleeding can - Perform careful neurologic assessment (eg, note gait and occur. DIC can cause internal and external bleeding. stability; test position and vibration sense). 1. Internal Bleeding - Assess need for assistive devices (eg, canes, walkers) and need - Internal bleeding can occur in your body's organs, such as the for support and guidance in managing activities of daily living kidneys, intestines, and brain. This bleeding can be life and home environment. threatening. - Ensure safety when position sense, coordination, and gait are - Signs and symptoms of internal bleeding include: affected. Blood in your urine from bleeding in your kidneys or - Refer for physical or occupational therapy as needed. bladder. - When sensation is altered, instruct patient to avoid excessive Blood in your stools from bleeding in your intestines or heat and cold. stomach. Blood in your stools can appear red or as a dark, - Advise patient to prepare bland, soft foods and to eat small tarry color. (Taking iron supplements also can cause dark, amounts frequently. tarry stools.) - Explain that other nutritional deficiencies, such as alcohol Headaches, double vision, seizures, and other symptoms induced anemia, can induce neurologic problems. from bleeding in your brain. - Instruct patient in complete urine collections for the Schilling 2. External Bleeding test. Also explain the importance of the test and of complying - External bleeding can occur underneath or from the skin, such with the collection. as at the site of cuts or an intravenous (IV) needle. - Teach patient about chronicity of disorder and need for monthly - External bleeding also can occur from the mucosa. (The vitamin B12 injections even when patient has no symptoms. mucosa is the tissue that lines some organs and body cavities, Instruct patient how to self-administer injections, when such as your nose and mouth.) appropriate. - May cause purpura (PURR-purr-ah) or petechiae (peh-TEE- - Stress importance of ongoing medical follow-up and screening, key-ay). Purpura are purple, brown, and red bruises. This because gastric atrophy associated with pernicious anemia bruising may happen easily and often. Petechiae are small red increases the risk of gastric carcinoma. or purple dots on your skin. Assessment and Diagnostic Findings - Clinically, the diagnosis of DIC is often established by a drop in platelet count, an increase in PT and activated partial thromboplastin time (aPTT), an elevation in fibrin degradation 14 | A. N. D. S.  NCMB 312 – MEDSURG PRELIMS products, and measurement of one or more clotting factors and - Use services from behavioral medicine and clergy, if desired. inhibitors (eg, antithrombin [AT]). - The International Society on Thrombosis and Haemostasis has F. Idiopathic thrombocytopenic purpura (ITP) developed a highly sensitive and specific scoring system using - A disease affecting all ages but is more common in children the platelet count, fibrin degradation products, PT, and and young women. Although the precise cause remains fibrinogen level to diagnose DIC. This system is also useful in unknown, viral infection sometimes precedes the disease in predicting the severity of the disease and subsequent mortality. children. Other conditions (eg, systemic lupus erythematosus, Medical Management pregnancy) or medications (eg, sulfa drugs) can also produce - The most important management issue is treating the ITP. underlying cause of DIC. - In patients with ITP, antiplatelet autoantibodies that bind to the - A second goal is to correct the secondary effects of tissue platelets are found in the blood. When the platelets are bound ischemia by improving oxygenation, replacing fluids, by the antibodies, the reticuloendothelial system (RES) or correcting electrolyte imbalances, and administering tissue macrophage system ingests the platelets, destroying vasopressor medications. them. The body attempts to compensate for this destruction by - If serious hemorrhage occurs, the depleted coagulation factors increasing platelet production within the marrow. and platelets may be replaced (cryoprecipitate to replace - There are two forms: acute (primarily in children) and chronic. fibrinogen and factors V and VII; fresh-frozen plasma to Clinical Manifestations replace other coagulation factors). - Many patients have no symptoms. - A heparin infusion, which is a controversial management - Petechiae and easy bruising (dry purpura). method, may be used to interrupt the thrombosis process. Other - Heavy menses and mucosal bleeding (wet purpura; high risk of therapies include recombinant activated protein C and AT intracranial bleeding). infusions. - Platelet count generally below 20,000/mm3. Nursing Management Maintaining Hemodynamic Status - Acute form self-limiting, possibly with spontaneous - Avoid procedures and activities that can increase intracranial remissions. pressure, such as coughing and straining. Assessment and Diagnostic Findings - Closely monitor vital signs, including neurologic checks, and - Usually the diagnosis is based on the decreased platelet count assess for the amount of external bleeding. and survival time and increased bleeding time and ruling out - Avoid medications that interfere with platelet function, if other causes of thrombocytopenia. Key diagnostic procedures possible (eg, beta-lactam antibiotics, acetylsalicylic acid, include platelet count, complete blood cell count, and bone nonsteroidal anti-inflammatory drugs). marrow aspiration, which shows an increase in megakaryocytes - Avoid rectal probes and rectal or intramuscular injection (platelet precursors). Many patients are infected with medications. Helicobacter pylori. To date, effectiveness of H. pylori - Use low pressure with any suctioning. treatment in relation to management of ITP is unknown. - Administer oral hygiene carefully: use sponge-tipped swabs, Medical Management salt or soda mouth rinses; avoid lemon-glycerine swabs, - Primary goal of treatment is a safe platelet count. Splenectomy hydrogen peroxide, commercial mouthwashes. is sometimes performed (thrombocytopenia may return months - Avoid dislodging any clots, including those around IV sites, or years later). injection sites, and so forth. Pharmacologic Therapy Maintaining Skin Integrity - Immunosuppressive medications, such as corticosteroids, are - Assess skin, with particular attention to bony prominences and the treatment of choice. The bone mineral density of patients skin folds. receiving chronic corticosteroid therapy needs to be monitored. - Reposition carefully; use pressure-reducing mattress and These patients may benefit from calcium and vitamin D lamb’s wool between digits and around ears and soft absorbent supplementation or bisphosphonate therapy to prevent material in skin folds, as needed. significant bone disease. - Perform skin care every 2 hours; administer oral hygiene - Intravenous gamma globulin (very expensive) and the carefully. chemotherapy agent vincristine are also effective. - Use prolonged pressure (5 minutes minimum) after essential - Another approach involves using anti-D (WinRho) for patients injections. who are Rh(D) positive. Monitoring for Imbalanced Fluid Volume - Thrombopoiesis-stimulating protein AMG 531 has been - Auscultate breath sounds every 2 to 4 hours. successfully used to treat patients with chronic ITP. - Monitor extent of edema. - Epsilon aminocaproic acid (EACA; Amicar) may be useful for - Monitor volume of IV medications and blood products; patients with significant mucosal bleeding who are refractory decrease volume of IV medications if possible. to other treatment modalities. - Administer diuretics as prescribed. - Platelet infusions are avoided except to stop catastrophic Assessing for Ineffective Tissue Perfusion Related to bleeding. Microthrombi Nursing Management - Assess neurologic, pulmonary, and skin systems. - Assess patient’s lifestyle to determine the risk of bleeding from - Monitor response to heparin therapy; monitor fibrinogen levels. activity. - Assess extent of bleeding. - Obtain history of medication use, including over-the counter - Stop epsilon-aminocaproic acid if symptoms of thrombosis medications, herbs, and nutritional supplements; recent viral occur. illness; or complaints of headache or visual disturbances Reducing Fear and Anxiety (intracranial bleed). Be alert for sulfa-containing medications - Identify previous coping mechanisms, if possible; encourage and medications that alter platelet function (eg, aspirin or other patient to use them as appropriate. nonsteroidal anti-inflammatory drugs [NSAIDs]). Physical - Explain all procedures and rationale in terms that the patient assessment should include a thorough search for signs of and family can understand. bleeding, neurologic assessment, and vital sign measurement. - Assist family in supporting patient. 15 | A. N. D. S.  NCMB 312 – MEDSURG PRELIMS - Teach patient to recognize exacerbations of disease (petechiae, - Symptoms usually indicate vascular damage related to organ ecchymoses); how to contact health care personnel; and the systems served by involved vessels. names of medications that induce ITP. - Coronary artery disease with angina or myocardial infarction is - Provide information about medications (tapering schedule, if the most common consequence. relevant), frequency of platelet count monitoring, and - Left ventricular hypertrophy may occur; HF ensues. medications to avoid. - Pathologic changes may occur in the kidney (nocturia and - To minimize bleeding, instruct patient to avoid all agents that increased BUN and creatinine levels). interfere with platelet function. Avoid administering - Cerebrovascular involvement may occur (stroke or transient medications by injection or rectal route; rectal temperature ischemic attack [TIA] [ie, alterations in vision or speech, measurements should not be performed. dizziness, weakness, a sudden fall, or transient or permanent - Instruct patient to avoid constipation, the Valsalva maneuver, hemiplegia]). and tooth flossing Assessment and Diagnostic Methods - Encourage patient to use electric razor for shaving and soft - History and physical examination, including retinal bristled toothbrushes instead of stiff- bristled brushes. examination; laboratory studies for organ damage, including - Advise patient to refrain from vigorous sexual intercourse urinalysis, blood chemistry (sodium, potassium, creatinine, when platelet count is less than 10,000/mm3. fasting glucose, total and high- density lipoprotein); ECG; and - Monitor for complications, including osteoporosis, proximal echocardiography to assess left ventricular hypertrophy. muscle wasting, cataract formation, and dental caries. - Additional studies, such as creatinine clearance, renin level, urine tests, and 24-hour urine protein, may be performed. G. Hypertension Medical Management - Defined as a systolic blood pressure greater than 140 mm Hg - The goal of any treatment program is to prevent death and and a diastolic pressure greater than 90 mm Hg, based on two complications by achieving and maintaining an arterial blood or more measurements. Hypertension can be classified as pressure at or below 140/90 mm Hg (130/80 mm Hg for people follows: with diabetes mellitus or chronic kidney disease), whenever - Normal: systolic less than 120 mm Hg; diastolic less than possible. 80 mm Hg - Nonpharmacologic approaches include weight reduction; - Prehypertension: systolic 120 to 139 mm Hg; diastolic 80 restriction of alcohol and sodium; regular exercise and to 89 mm Hg relaxation. A DASH (Dietary Approaches to Stop - Stage 1: systolic 140 to 159 mm Hg; diastolic 90 to 99 mm Hypertension) diet high in fruits, vegetables, and low-fat dairy Hg products has been shown to lower elevated pressures. - Stage 2: systolic _160 mm Hg; diastolic _100 mm Hg - Select a drug class that has the greatest effectiveness, fewest - Hypertension is a major risk factor for atherosclerotic side effects, and best chance of acceptance by patient. Two cardiovascular disease, HF, stroke, and kidney failure. classes of drugs are available as first-line therapy: diuretics and Hypertension carries the risk for premature morbidity or beta- blockers. mortality, which increases as systolic and diastolic pressures - Promote compliance by avoiding complicated drug schedules. rise. Prolonged blood pressure elevation damages blood vessels in target organs (heart, kidneys, brain, and eyes). Nursing Process 1. Essential (Primary) Hypertension Assessment - In the adult population with hypertension, between 90% and - Assess blood pressure at frequent intervals; know baseline 95% have essential (primary) hypertension, which has no level. Note changes in pressure that would require a change in identifiable medical cause; it appears to be a multifactorial, medication. polygenic condition. - Assess for signs and symptoms that indicate target organ - For high blood pressure to occur, an increase in peripheral damage (eg, anginal pain; shortness of breath; alterations in resistance and/or cardiac output must occur secondary to speech, vision, or balance; nosebleeds; headaches; dizziness; or increased sympathetic stimulation, increased renal sodium nocturia). reabsorption, increased renin– angiotensin–aldosterone system - Note the apical and peripheral pulse rate, rhythm, and activity, decreased vasodilation of the arterioles, or resistance character. to insulin action. - Assess extent to which hypertension has affected patient - Hypertensive emergencies and urgencies may occur in patients personally, socially, or financially. whose hypertension has been poorly controlled, whose Diagnosis hypertension has been undiagnosed, or in those who have 1. Deficient knowledge regarding the relationship between the abruptly discontinued their medications. treatment regimen and control of the disease process 2. Secondary Hypertension 2. Noncompliance with therapeutic regimen related to side effects - Secondary hypertension is characterized by elevations in blood of prescribed therapy pressure with a specific cause, such as narrowing of the renal Collaborative Problems/Potential Complications arteries, renal parenchymal disease, hyperaldosteronism - Left ventricular hypertrophy (mineralocorticoid hypertension), certain medications, - Myocardial infarction pregnancy, and coarctation of the aorta. Hypertension can also - HF be acute, a sign of an underlying condition that causes a change - TIA in peripheral resistance or cardiac output. - CVA Clinical Manifestations - Renal insufficiency and failure - Physical examination may reveal no abnormality other than - Retinal hemorrhage high blood pressure. Planning and Goals - Changes in the retinas with hemorrhages, exudates, narrowed - The major goals for the patient include understanding of the arterioles, and cotton–wool spots (small infarctions), and disease process and its treatment, participation in a selfcare papilledema may be seen in severe hypertension. program, and absence of complications. 16 | A. N. D. S.  NCMB 312 – MEDSURG PRELIMS Nursing Interventions 6. Visceral aneurysm: This is a bulge of the arteries that supply Increasing Knowledge blood to the bowel or kidneys. Peripheral aneurysms are less - Emphasize the concept of controlling hypertension (with likely to rupture than aortic aneurysms. changes and medications) rather than curing it. Symptoms - Arrange a consultation with a dietitian to help develop a plan - Most aneurysms are clinically silent. Symptoms do not usually for improving nutrient intake or for weight loss. occur unless an aneurysm ruptures. However, an unruptured - Advise patient to limit alcohol intake and avoid use of tobacco. aneurysm may still obstruct circulation to other tissues. They - Recommend support groups for weight control, smoking can also form blood clots that may go on to obstruct smaller cessation, and stress reduction, if necessary. blood vessels. This is a condition known as - Assist the patient to develop and adhere to an appropriate thromboembolism. It can lead to ischemic stroke or other exercise regimen. serious complications. - Aneurysms are generally symptomless, but their complications H. Aneurysm can cause severe chest pain. - The enlargement of an artery caused by weakness in the arterial - Rapidly growing abdominal aneurysms are sometimes wall. Often there are no symptoms, but a ruptured aneurysm associated with symptoms. Some people with abdominal can lead to fatal complications. aneurysms report abdominal pain, lower back pain, or a - An aneurysm refers to a weakening of an artery wall that pulsating sensation in the abdomen. creates a bulge, or distention, of the artery. Most aneurysms do - Similarly, thoracic aneurysms can affect nearby nerves and not show symptoms and are not dangerous. However, at their other blood vessels, potentially causing swallowing and most severe stage, some can rupture, leading to life-threatening breathing difficulties, and pain in the jaw, chest, and upper internal bleeding. back. Symptoms can also relate to the cause of an aneurysm Types rather than the aneurysm itself. For example, in the case of an - The rupture of an aneurysm can be fatal. Aneurysms are aneurysm caused by vasculitis, or blood vessel inflammation, a classified by their location in the body. The arteries of the brain person may experience fever, malaise, or weight loss. and heart are the two most common sites of a serious aneurysm. Complications The bulge can take two main shapes: - The first signs of a previously undetected aneurysm could be 1. Fusiform aneurysms bulge all sides of a blood vessel complications upon rupture. Symptoms tend to result from a 2. Saccular aneurysms bulge only on one side The risk of rupture rather than the aneurysm alone. Most people living with rupture depends on the size of the bulge. an aneurysm do not experience any complications. However, in 1. Aortic Aneurysm addition to thromboembolism and rupture of the aorta, - The aorta is the large artery that begins at the left ventricle of complications can include: the heart and passes through the chest and abdominal cavities. Severe chest or back pain: Severe chest or back pain may The normal diameter of the aorta is between 2 and 3 centimeters arise following the rupture of an aortic aneurysm in the (cm) but can bulge to beyond 5 cm with an aneurysm. chest. - The most common aneurysm of the aorta is an abdominal aortic Angina: Certain types of aneurysm can lead to angina, aneurysm (AAA). This occurs in the part of the aorta that runs another type of chest pain. Angina can lead to myocardial through the abdomen. Without surgery, the annual survival rate ischemia and heart attack. for an AAA of over 6 cm is 20 percent. AAA can rapidly A sudden extreme headache: If a brain aneurysm leads to become fatal, but those that survive the transfer to a hospital SAH, the main symptom is a sudden, severe headache. have a 50 percent chance of overall survival. - Any rupture of an aneurysm may cause pain, low blood - Less commonly, a thoracic aortic aneurysm (TAA) can affect pressure, a rapid heart rate, and lightheadedness. Most people the part of the aorta running through the chest. TAA has a with an aneurysm will not experience any complications. survival rate of 56 percent without treatment and 85 percent Causes following surgery. It is a rare condition, as only 25 percent of - An aneurysm can happen in any part of the body. Blood aortic aneurysms occur in the chest. pressure can more easily distend a weakened arterial wall. 2. Cerebral Aneurysm Further research is necessary to confirm why an artery wall - Aneurysms of the arteries that supply the brain with blood are weakens to cause an aneurysm. Some aneurysms, though less known as intracranial aneurysms. Due to their appearance, they common, are present from birth as an arterial defect. are also known as “berry” aneurysms. A ruptured aneurysm of Aortic Dissection the brain can be fatal within 24 hours. Forty percent of brain - Aortic dissection is one identifiable cause of an aortic aneurysms are fatal, and around 66 percent of those who aneurysm. The arterial wall has three layers. Blood can burst survive will experience a resulting neurological impairment or through a tear in the weakened wall of the artery, splitting these disability. Ruptured cerebral aneurysms are the most common layers. It can then fill the cavity surrounding the heart. If the cause of a type of stroke known as subarachnoid hemorrhage tear occurs on the innermost layer of the arterial wall, blood (SAH). channels into and weakens the wall, increasing the risk of 3. Peripheral Aneurysm rupture. - An aneurysm can also occur in a peripheral artery. Types of - People with aortic dissection often describe abrupt and peripheral aneurysm include: excruciating chest pain. This pain can travel as the dissection 1. Popliteal aneurysm: This happens behind the knee. It is the progresses along the aorta. It may, for example, radiate to the most common peripheral aneurysm. back. Dissection leads to compression. Compression prevents 2. Splenic artery aneurysm: This type of aneurysm occurs near blood from returning to the heart. This is also known as a the spleen pericardial tamponade. 3. Mesenteric artery aneurysm: This affects the artery that Risk factors transports blood to the intestines. - Smoking tobacco 4. Femoral artery aneurysm: The femoral artery is in the groin. - Hypertension, or high blood pressure 5. Carotid artery aneurysm: This occurs in the neck. - Poor diet - Inactive lifestyle 17 | A. N. D. S.  NCMB 312 – MEDSURG PRELIMS - Obesity Relieving Sensory Deprivation - Smoking is by far the most common risk factor, especially in - Keep sensory stimulation to a minimum. cases of AAA. Tobacco use has been shown not only to - Explain restrictions to help reduce patient’s sense of isolation. increase cardiovascular disease and the risk of an aneurysm but Relieving Anxiety also increase the risk of rupture once an aneurysm has taken - Inform patient of plan of care. effect. - Provide support and appropriate reassurance to patient and Nursing Management- Preoperative Assessment family. - Assessment is guided by anticipating a rupture (signs include persistent or intermittent back or abdominal pain that may be I. Buerger’s Disease (Thromboangiitis Obliterans) localized in the middle or lower abdomen or lower back) and - Buerger’s disease is a recurring inflammation of the by recognizing that the patient may have cardiovascular, intermediate and small arteries and veins of the lower and upper cerebral, pulmonary, and renal impairment from extremities. It results in thrombus formation and segmental atherosclerosis. occlusion of the vessels and is differentiated from other vessel - Assess functional capacity of all organ systems. diseases by its microscopic appearance. - Implement medical therapies to stabilize patient. - Buerger’s disease occurs most often in men between 20 and 35 - If the aneurysm leaks blood and forms a clot, patient may show years of age, and it has been reported in all races and in many little neurologic deficit or may have severe bleeding, resulting areas of the world. There is considerable evidence that heavy in cerebral damage followed rapidly by coma and death. smoking or chewing of tobacco is a causative or an aggravating factor. Nursing Process Clinical Manifestations Assessment - Pain is the outstanding symptom (generally bilateral and - Perform a complete neurologic assessment: level of symmetric with focal lesions). Patients complain of cramps in consciousness, pupillary reaction (sluggishness), motor and the feet, particularly the arches, after exercise (instep sensory function, cranial nerve deficits (extraocular eye claudication). Pain is relieved by rest. movements, facial droop, ptosis), speech difficulties, visual - Burning pain aggravated by emotional disturbances, nicotine, disturbance or headache, and nuchal rigidity or other or chilling; digital rest pain (fingers or toes); and a feeling of neurologic deficits. coldness or sensitivity to cold may be early symptoms. - Document and report neurologic assessment findings, and - Color changes (rubor) of the feet progress to cyanosis (in only reassess and report any changes in patient’s condition. one extremity or certain digits) that appears when the extremity - Detect subtle changes, especially altered levels of is in a dependent position. consciousness (earliest signs of deterioration include mild - Various types of paresthesia may develop; radial and ulnar drowsiness and slight slurring of speech). artery pulses are absent or diminishe