- Endocarditis--strep, staph. Vegetative lesions. Flu like symptoms. Fever high as 103F Roth spots. Petechiae. Splinter hemorrhages. Numbness tingling. Oslers nodes are small and painful on fingers toes. Janeway lesions not tender. Heart murmur, enlargement, failure. Hemiparesis or change in LOC. PE. Splenic Embolization pain in LUQ radiates to left shoulder. Rigid Abdomen. Blood cultures + for causative organsism. Elevated WBC and ESR. Anemia. IV antibiot for 4-6 weeks--penicillin, amphotericin B. Arthralgia. Amox before dental work, childbirth.
- AAA 1 ½ times the stretch. 6:1 risk w/ first degree relative. Check yearly. Silent but may have prominent pulse in the abdomen when supine. Dx usually made when looking for something else. Rupture is Coming if---low back pain, abdominal pain, flank pain. Ruptured--intense low back pain. Lower abd pain, collapse, shock, mottling of lower extremities, decreased Hgb. Sx= resection of aneurysm. Low mortality stats if repaired before rupture, 5%. 50-80% mortality stat if repaired after rupture. Pre Op--compare peripheral pulses. Skin for color and temp, Mark pulses. During Sx- emboli risks from clamped aorta. Risks= MI, CHF, CVA, Kidney damage. Post Op= OUTPUT measured hourly. Assess for bleeding b/c heparin used during Sx. Check for Distal Arterial Perfusion= check for color pain level, motion sensation, temp. Check for distal arterial occlusion==darkened patches in soles/toes of feet. S/s of hemorrhage…drop in CV pressure. Drop in arterial pressure. Decreased urine output. Assess for spinal cord ischemia--assess motor and sensory function. Assess for pain from long incision. Assess for ischemic colitis--bloody diarrhea before bowel function is expected to return--normal return is 4-5 days post op. Assess mobility--OOB 1-2 days post op. discharge plan in 5-7 days. Lifting only to 5lbs. No driving. Showers ok. Assess family members after age 50.
- Hepatitis--pt hospitalized for dehydration or a prolonged PT. Rest, hydration. NO ETOH. Low fat high CHO diet. Corticosteroids. Need Vitamins B--liver can not absorb. K--for coags--C for healing. Education---Gamma globulin indirect contact for Hep A. Hep A vaccine for travelers. Hep B vaccine for health care workers, newborns, and adolescents. Prevention for Hep C. No vaccine for E.
- Cirrhosis--Early signs=vague, flu like. General weakness. Fatigue. Anorexia. Indigestion. Consitpation/diarrhea. Late signs= Jaundice, dry skin, pruitus. Edema. Ascites. Anemia. Bleeding. Infections (lost Kupfer cells). Menstrual irregular. Impotence. Gynecomastia. Renal failure. Dark amber urine. Clay colored stools.
The Fs of distention= fluid, flatulence, fat, feces, fibroid tumors.
- Rupture of Esophageal varicies. Med emergency. IV fluids, lytes, volume expanders. Sengstaken-Blakemore tube to stop the hemorrhage. Meds= Vasopressin.--constricts the arterial bed. Somatistatin--decreases bleeding w/out vasocontriction. Propranolol--beta blocker to decrease portal pressure.
- Increased intracranial pressure--Bp up. Pulse down. Resps down.= cushings triad.
- Shock--BP down. Pulse up. Resps up.
- Tx for Hyperkalemia in ARF--Insulin +glucose IV. Sodium bicarb. Calcium gluconate IV. Dialysis. Kayexalate.
- Diet for ARF= decrease protein. Increase calories. Low K+ and low phosphorus (bananas, citrus, coffee). Low Na+. Increase iron.
- Colon Cancer locations of lesions= R. sided lesions--dull abd pain. Black tarry stools. L. sided lesions---bright red blood in the stool. Rectal lesions--tenesmus. Rectal pain. Constipation/diarrhea. Bloody stool.
- Hyperflexion of the neck--chin to chest
- Hyperextension of the neck--think falling down stairs chin first. Head back
Monday, December 18, 2006
Sunday, December 17, 2006
Late clinical manifestations= non specific= weight loss, anorexia, fatigue, n/v/ and hoarseness. Persistent pneumonitis. Hoarseness. Hemoptysis. Unilateral paralysis of the diaphragm. Dysphagia. Palpable lymph nodes in the neck. Medistinal involment will show cardiac signs and symptoms. Clinically silent, and the symptoms appear late. Persistent productive cough. Chest pain, dyspnea, wheezing. Unexplained fever.
CT scan is the single most effective non invasive technique for diagnosis.
Large cell undifferentiated.
2 functions of the pancreas= endocrine--insulin and glucagon production and exocrine--digestive. Secretes 500-1000cc digestive juices/day.
Pancreatic Enzymes= Amylase breaks down starches. Chymotripinsinogent, elastase, trypsinogen break down proteins. Lipase, phospolipase A & B break down fats.
Pancreatitis is acute or chronic inflammation of the pancreas. Auto digestion (it is eating itself). The enzymes are activated BEFORE being secreted into the pancreatic duct. The cause may be----
Gall bladder disease 80%
Cysts, tumors, viral infection, trauma, surgery, mumps, steroids, thiazide, diuretics, oral contraceptives.
Pain--extreme abdominal pain umbilical pain that radiates to the back. Abd distention and decreased bowel sounds. N/v. chronic steatorrhea. Low grade fever. Tachycardia. Dyspnea. Hypotension, restless confused.
Sign of hemorrhage
Cullen’s sign= bluish color around the umbilicus.
Turners sign= bluish color on the flank.
Just remember that everything is going to be up EXCEPT the serum calcium.
What is up
***Amylase is going to be up
WBC--tissue damage inflamation
SGOT, SGPT, LDH--tissue destruction
Down is the Ca+….hypocalcemia leads to Tetany so watch for signs.
Reduce the anxiety. Anxiety stimulates the vagus nerve which will increase the secretions.
NPO--NO ICE CHIPS
IV therapy w/ I&O and daily weights.
Anticholinergics--reduction of enzymes. Decrease spasms of Oddi.
Calcium gluconate IV
Diet is progressed from NPO to low fat bland diet high in CHO after inflammation is over.
NO Coffee. NO ETOH
Avoid heavy spicy meals.
Give pancreatic enzymes with meals.
- Tricuspid Atresia
This is a failure of the tricuspid valve development. There is no communication between the RA and the RV. There is no opening where the tricuspid should be. The blood is going to flow…into the Vena Cava then through an ASD or PDA to the left side of the heart. Then goes through a VSD to the RV to the lungs. You will see cyanosis. Palliative Sx is the same for TETs. Corrective Sx= Convert the RA into an outlet for the pulmonary artery called Fontan procedure. Survival stats= 80-90% w/ complications.
- Tetralogy of Fallot TOF. Remember the aorta is riding the septum. Cyanotic.
Ventricular Septal Defect. Pulmonic Stenosis. Overriding aorta. Right ventricular hypertrophy.
Unoxygenated blood enters the aorta.
The shunting in TOF varies.
Right to Left shunt….unoxygenated blood enters the aorta when the pulmonary vascular resistance is higher than the vascular resistance.
Left to right shunt….if systemic resistance is higher than the pulmonary vascular resistance.
S/S= Blue, cyanotic, squatting, clubbing, syncope.
Blue Spells, hyper cyanotic spells, TET spells. The O2 needs are not med by the blood supply usually during crying, feeding or defecation. The cause is an infundibular spasm which decreases the pulm blood flow and increases R to L shunt. The risks from these spells are brain damage, death, neuro complications, polycythemia and increased blood viscosity which increases the risk for CVA. To treat these spells the infant is placed in the knee chest position. Stay calm. 100% O2 via mask. Morphine SQ or IV to reduce the spasm. IV fluids and expanders to decrease the viscosity. More morphine.
Sx= Palliative= Blalock Taussig shunt. But not preferred treatment.
Complete repair= First year of life. Closes the VSD…resection of the infundibular stenosis with pericardial patch to enlarge the right ventricular outflow tract. This is open heart and post op complications include dysrhythmia and CHF. Survival stats are at 95%.
- CHF in children.
The heart is not meeting the demand of the body. Seen a lot when there is increased blood flow to the lungs or problems w/ the left side of the heart .
The subtle signs= poor feeding, irritable, tired when feeding and lethargy.
2 things happen
I. Impaired myocardial function…Seeing tachycardia, weak pulses, decreased BP and a gallop rhytm. Fatigue restless, anorexia, pale cool mottled extremites. Diaphoresisi. Cardiomegaly. Decreased urinary output.
II. Systemic Venous congestions…seeing weight gain. Hepatomegaly. Peripheral edema, per orbital edema. Ascites. Neck vein distention. Rales, resp distress…retractions, nasal flaring.
Therapeutic Management Goals
- Improve cardiac function by increasing the contractility and decreasing the after load. Decrease the preload…remove accumulated fluid and sodium retention.
- Decrease the cardiac demands…control the work of the pt.prevent cold stress. Treat infections. Semi fowlers position. Sedation. Rest.
- Decrease O2 consumption to improve tissue oxygenation.
Digitalis is a Cardiac glycoside--improves contractility. Increases the force of contraction--positive inotropic. Decreases the heart rate--negative chronotropic. Slows the conduction of impulses through the AV node--negative dromotropic. Enhances duresis indirectly by increases renal perfusion…..
Concerning Digoxin and Pediatrics.
The dose is calculated in micrograms. 1000ug=1 mg. The digitalizing dose is given to bring the serum dig into a therapeutic range. The maintenance dose is 1/8 of the digitalizing dose.
The therapeutic range is from 0.8-2ug/L
Check the apical pulse for one full min is a must. For infants hold the med for pulse below 90-110 bpm. For older children do not give if apical is less than 70 bpm.
Signs of Dig Toxicity= bradycardia. Anorexia. Nausea. Vomit often unrelated to feedings. No interest in eating. Decreased oral intake.
Other meds and treatments.
ACE inhibitors Vasotec and Capoten to reduce the after load on the heart which makes it easier to pump.
For severe CHF other inotropic meds given IV in the ICU = dopamine, dobutamine, Amrinone to improve contractility.
Diuretics= to remove fluid and sodium…but CAUTION a fall in the serum K+ can potentiate the effects of digoxin and there is then an inceased risk of toxicity.
Cancer of the Larynx
At risk= smoking and ETOH. Pollution. Nutritional deficiency. Family predisposition. Vocal straining.
Early signs= hoarseness. lump in neck, pain in throat when drinking hot fluids or juice.
Late Signs= Dysphagia, Dyspnea, Foul breath. Chronic cough. Hemoptysis. Sore throat or sores in throat.
Signs of Metastasis= Enlarged cervical lymph nodes. Weight loss. General debility. Otalgia.
Most are squamous cell.
Partial--½ or more of the larynx removed. High cure rate stats. It is a vertical midline incision. Trached first few days. VOICE HOARSE. No dysphagia.
Supraglottic--removes hyoid bone. Epiglottis and false cords. It is radical neck dissection. Tracheotomy. NG tube for 2 weeks. Voice is preserved. Post op dysphagia because some muscles removed.
Total--removes hyoid bone. Epiglottis, cricoid cartilage and 2-3 rings of the trachea. Permanent tracheal stoma. NO VOICE. It is radical neck dissection.
Complications= resp distress. Hemorrhage. Infection.
Post op--be alert for serious complication of rupture of carotid artery. If it happens apply direct pressure. Call for help. And provide emotional support until it can be ligated.
- Spinal Cord injuries
4 types of injury. Hyperflexion&Hyperextension (think car wreck). Axial Loading (think fall from ladder). Excessive Rotation.
Complete (total cord transection) or Incomplete (partial cord transection).
Injuries affect motor & sensory fx at and below the level of the injury.
Spinal shock= areflexia (loss of reflex fx). Decrease in BP & bradycardia. Below the injury paralysis and no sensation and no diaphoresis. Check for distended bladder. Lasts days or months.
Paraplegia= paralysis of lower body. Injury level in the thoracic spine or lower.
Tetraplegia= Quad= injury in the cervical spine=arms, legs, trunk and pelvic paralysis.
Maintain patent airway. Cervical injury edema.
High does Corticosteroids within 8 hours.
Mannitol to decrease edema around the spinal cord
Baclofen=muslce relaxer to reduce plasticity
Dextran= prevents BP from dropping and improves the capillary blood flow.
Traction= tongs such as the Gardner Wells or Crutchfield. Halo.
Weights hang free.
Do not remove.
Clean tongs with betadine
Assess for infection.
Surgical immobilization….via anterior/posterior decompression and fusion w/ bone grafts. Decompression w/ laminectomy will remove bony fragments that cause compression…remove the foreign body causing compression. Fusion-anterior/posterior using Harrington rods.
SOMI=sterno occipital mandibular immobilizer
CTLSO= cervical thoracic lumbar sacral orthotic.
Complications may include= DVT. Orthostatic hypotension. Autonomic Dysreflexia.
- Promote Adequate Breathing and airway clearance--I am not going into this as we should know this by now! But I will say that if suctioning is needed--be careful because this can stimulate the vagus nerve which can lead to bradycardia and cardiac arrest.
- Improving mobility--maitain proper body alignment at all times. Feet are prone to foot drop. Use splints removing and reapplied q 2 hours. Trochanter rolls to prevent external rotation of the hip. If the pt is not on a rotating bed do not turn unless the spine is stable and the MD must order. PROM to avoid contractures.
- Promote adaptation to sensory and perceptual alterations.
- Maintain skin integrity--Prevent pressure ulcers. They can happen very quickly.
- Maintain Urinary Elimination--intermittent cath. Teach family. Neurgenic bladder. Prevent UTI--increase fluid, high acid fluids, no ETOH, avoid alkaline fluids.
- Improve Bowel function--paralytic ileus from Neutrogena paralysis of the bowel. NG tube to relieve distention and prevent aspiration. Bowel activity usually returns in a week. After BS are heard pt given high calorie, high protein, high fiber diet.
Remember Again that the Emergency Autonomic Dysreflexia
1. Immediately the head of bed up and BP q 5 min,
2. Rapid Assess to find the cause and alleviate
3.Urinary Cath but never drain more than 700cc--can lead to Hypovolemic shock.
4. Check for fecal mass. Topical anesthetic for 10-15 min…then remove.
5. Check skin for pressure
6. Remove all stimulus.
7. Report to MD immediately if BP does not drop.
Meds for Autonomic Dysreflexia.
Arfonad IV / Apresoline IV--ganglionic blocker to lower BP fast. relaxes arteriolar smooth muscle.
Low spinal anesthetic at L4 in nothing works.
- Burns- Some nursing Care. NG tube to decompress. Foley Cath for I&O--HOURLY! Putting a lot of fluids in so we need to see what is coming out. Urine glucose levels. Pain relief. Continuous assessment of extremity pulses and ventilation. Emotional support. Check for GI bleed--stool for OB, coffee ground emesis.
Nursing care for pt w/ grafts
Occlusive dressing. Check for infection and foul smell. If the graft is dislodged cover w/ sterile saline dressing. Keep the pressure off and elevate. The donor site is more painful than the burn site!
Pain is severe and may need PCA pump w. morphine.
For Rehab…..help the pt set realistic goals and include the pt in decision making…give them some control.
S/S of smoke inhalation damage from burns
Focus on signs of resp and cardiac involvement. Burned nasal hair. Cyanotic lips. Hard time talking, facial burns, Dyspnea, Tachypnea, Cough, Stridor, Hoarseness, Sooty sputum. Rales, Wheezes, Rhonchi.
Monday, December 11, 2006
Superficial Partial Thickness Burn= First degree burn=Epidermis and maybe some dermis. soothed by cooling. reddened, blanches with pressure. no scar. peeling. recovery in 1 week. ie: sun burn, or low intensity flash.
Deep Partial Thickness=Second Degree burn=epidermis and upper dermis, portion of deeper dermis. Pain! Blistered, mottled red base, weeping surface, edema. Infection may convert this to full thickness. ie: scalds, flash flame.
Full-Thickness= Third Degree burn= epidermis, all of dermis and some SQ and may involve muscle or bone. Symptoms= NO PAIN! shock, hematuria. Wound may look dry, pale white, leathery or charred. Fat may be exposed. Edema. Need grafting.
Rescuer should stay safe.
Breathing- 100% O2
Neuro-may be very alert w/ deficits later. So gather information now.
Deal with the wounds last.
Then find out how they were burned and Med history
MED History includes
E=events that preceded injury
Stop the burning process= flush chemical burns, remove contacts, cool water to stop the burning.
Airway management= humidified O2 @100%. Smoke inhalation is the leading cause of death in burn pt. The hemoglobin loves CO better than O2. it creates carboxyhemoglobin which competes with the O2.
Next to the respiratory system fluid and lytes are next in line.
The body is going to try and conserve fluids and can lead to kidney failure. A decreased BP+decreased cardiac output leads to shock.
LR is infused via a large bore IV.
Most common formula is the Parkland/Baxter formula=4ml pf LR x body weight in kg x % of BSA burned= the fluid replacement. 1/2 of that is given the first 8 hours. Then 1/4 for the next 8 hours. And then again 1/4 of that for the next 8 hours. Of course this depends also on the clinical picture. Assess--heart rate, BP, urine output HOURLY.
This is what is happening during the emergent phase... concerning fluids
General dehydration as plasma leaks through the damaged capillaries. Blood volume is reduced secondary to plasma loss, decrease in BP, and decreased cardiac output. Decreased urinary output secondary to fluid loss, decreased renal blood flow, Na+ and water retention. To much K+ because of massive cellular trauma releases K+ into the extracellular fluid. Na+ deficit because it is trapped in edema fluid and because of the K+ shift. Metabolic Acidosis because of a loss of bicarbonate ions that goes with sodium loss. Hemoconcentration-elevated hematocrit because liquid blood component is lost into the extracellular space.
Monday, December 04, 2006
The problem is with neurotransmission, a defect in acetylcholine receptors sites. Fatigue of the voluntary muscles. Dry eye corneal abrasion. Eyes droop. Fatigue of the resp muscles and limb muscles. The pt eventually choke on food because of difficulty swallowing. The tensilon test= pt given short acting anti-cholinesterase (tensilon or edrophonium chloride) this enhances neurotransmission and improves symptoms, this is short term. Atropine is given to reduce the side effects of the tensilon which is bradycardia, sweating, and cramping. If the pt has a positive test, the pt may be ordered drug therapy with anticholinesterase meds. Mestinon, Prostigmin. MUST be given on time. Side effects=abd pain, diarrhea, increased Oropharyngeal secretions. Other treatments=Corticosteroids given. Cytotoxic meds may be given, such as Imuran and cytoxan…why they work is still unknown. IVIG. Plasmapheresis. No cure. Surgical Tx= thymectomy results in clinical improvement. Produces antigen specific immunosuppression. It takes a year to start working because of the life span of the circulating T cells.
Severe generalized weakness and respiratory failure. After stress such as infection, high temp, surgery. Need Ventilatory support. ADLs, chest PT, suctioning.
From overmedicating with Anticholinergics. Can mimic the s/s of myasthenic crisis. It is differentiated by the tensilon test…ie…the pt in myasthenic crisis will improve after the tensilon. Stop all anticholinesterase med! Atropine sulfate to reduce increased, excessive secretions.
Nsg Care= teaching….use of meds on time and to keep a diary. .s/s of crisis. How to save energy, space activity, organize the house.…how to avoid aspiration soft food, neck slightly flexed
Reduced amount of dopamine. Signs and symptoms= rigid, resting tremor, bradykinesia, a loss of postural reflexes. Bradyphrenia. Memory problems. Drooling dysphagia, speech problems, constipation, urinary frequency. Treatment= Eldepryl--protects the neurons and reduces the need for Levodopa till later. Levodopa--provides the missing dopamine. Amantadine--Anticholinergics that is given to reduce the symptoms and increases the release of dopamine from the storage sites. Sometimes pt need a drug holiday to find other drugs that may work when the current treatment not working.
Nsg care= routine for personal care. Safety. AROM, PROM, rigid facial expressions may hide true feelings. Thicken liquids. Eat sitting up…..
Demyelinating disease…nerve fibers of brain and spinal cord. Lesions throughout the white matter…some in the grey matter. There is an inflammatory response that attacks the myelin. Could be an autoimmune problem with a viral trigger…unknown. Exacerbations and remissions. MRI will demonstrate white matter lesions. New drug therapy= Avinex--interferon beta-1a--weekly IM
Betaseron--interferon beta 1b recombinant every other day SQ. Major side effect = suicidal tendency, depression. Older drug therapy= Corticosteroids. Cytoxan may produce temporary remission. Signs and symptoms= blurry vision, double vision, dysphagia, facial weakness, numbness, pain, paralysis, abnormal gait, tremor, vertigo, incontinence, short term memory loss, trouble finding words. Other meds to reduce the symptoms.
Nsg Care= self care balance. Urinary retention--straight cath or texas. Bowel routine. Skin integrity.
Wednesday, November 29, 2006
1. Increasing temp, increasing pulse, increasing respirations, decreasing blood pressure.
2.Increasing temp, decreasing pulse, decreasing resps, increasing bp
3.decreasing temp, decreasing pulse, increasing resps, decreasing bp
4.decreasing temp, increasing pulse, decreasing resps, increasing bp
To promote the venous drainage…head neutral..cervical collar, keep the head of the bed up.
Compression of the jugular vein increases the ICP so…avoid rotation and flexion.
Avoid hip flexion to avoid…intrabdominal pressure which raises the intrathoracic pressure which increases the ICP.
Use turning sheets and pt should exhale when turning..
Colace and NO enemas
Space the care…ICP should not rise above 25mmHg and should return to baseline in 5 min.
NO isometric muscle contractions because this will raise the systemic BP and again therefore raise the ICP
Closed or open
Grade I= Mild. Not admitted. Short loss of consciousness.
Grade II= loss of consciousness. Lethargy, confusion, hemi paresis, admitted and require surgery.
Grade III= unable to follow even simple commands. Serious damage. Dilated pupils. Without rapid attention may die.
Concussion.--mechanical force and release enzymes. Contusion--brain bruise. Blunt object like a baseball bat. Hematoma.
Epidural or extradural Hematoma= arterial blood between the dura and the skull. Pt loss of consciousness and regains it. Vomit. hemi paresis. Pupil changes. all leading to rapid worsening. The Tx is to remove the Hematoma by craniotomy.
Subdural Hematoma.= venous bleeding below the dura. ICP.
Complications of head injury= cerebral edema, DI, SIADH, Stress ulcer from use of steroids. Epilepsy. Meningitis. Hyper/hypothermia.
MEDICAL Tx of HEAD INJURY
Mannitol and steroids. Antibiotics.
KEEP DEHYDRATED TO AVOID INCREASE IN FLUID LEVEL.
SURGICAL Tx of HEAD INJURY
Craniotomy--supratentorial or infratentorial.
Burr holes--used to remove clots.
Nutrition following head injury
May need TPN…stress and steroids increase catabolism.
Airway. LOC. Pupils. Movement. Sensation. Hand grasps. ICP. Resp changes. VS. headache. Glasgow coma scale.
POST OP Craniotomy care
Resp. Deep breath q 2. NO COUGHING! Neuro checks. Suction. Strict I&O. Seizure precaution. CSF leaks. S&S of meningitis.
Supratentorial--head of bed up 30 degrees. On back or unoperative side.
Infratentorial--FLAT on either side.
Assess for bleeding. GI bleeds, assess for emotional response or knowledge deficit.
Brain death--irreversible loss of brain function. EEG will confirm no activity. Cerebral blood flow studies. MD will determine.
Remember Diabetes Insipidus…caused by a decrease in ADH---increased urine output…anticipate to give VASOPRESSINS….give fluids and lytes.
SIADH--restrict fluids….caused by increase ADH. Volume overload and a decreased urine output.
Tuesday, November 28, 2006
Hydrocephalus. Abnormal amount of fluid accumulates in the ventricles of the brain.
INTERNAL NON COMMUNICATING
Blockage--the CSF can not get to the subarachnoid space. Causes: malformations, neoplasms, infections, trauma.
Obstruction in the subarachnoid cistern at the base of the brain or in the space.
No blockage! Fluid paths are open….but not absorbed.
Early signs= increased head circumference. Bulging fontanels. Cranial sutures separated. Signs of ICP.
Late signs= Cracked pot head….;}….which is of course Macewen’s sign! Setting sun sign, arched back (opisthtonus) frontal bossing.
Treatment= correction of cause of obstruction. Ventricular shunting.
VP= ventriculoperitoneal= method of choice.
Older versions= ventriculpleural, ventriculoatrial.
Problems= infection…tubing issues, replacements
POST OP Nsg CARE
Position on unoperated side to prevent the pressure on shunt valve. Keep flat….prevent rapid reduction of fluid….to fast the cerebral cortex can pull away from the dura and produce a subdural Hematoma.
Gradually raise the head of bed as ordered.
Shunt obstruction will need to return to OR.
Infection---IV and Intraventricular antibiotics.
Infection of the pia mater…arachnoid membrane…and CSF fills the subarachnoid space. Because of bacteria, virus, or fungal organism. The organisms can get there by…..nasal pharynx, lumbar puncture, penetrating wounds, fractures, spina bifida.
S & S
Neonate= hypothermia or fever….not eating, poor muscle tone.
Infants= fever, high pitch cry, headache, bulging fontanel.
Children/Adolescents= fever, photophobia, headache, nuchal rigid, +Kernigs, + Brudzinski’s signs.
All= Irritable, Seizures, vomiting.
Pressure is measured--the normal is 0-15mmHg. Increased ICP is greater than 15mmHg.
The CSF is sent to the lab…Grain Stain to identify the shape of the organism…Blood cell count--increased WBC…Glucose--decrease in glucose….Protein--increase in protein…within the hour…C and S will take longer….
Antibiotics AFTER sending CSF to the lab…penicillin, cephalosporins, vancomycin alone or with Rifampin. Dexamethasone given 15-20 min before the first dose and q 6 hours for next 4 days.
Isolation for first 24 hours of antibiotics
Control seizures, fever, strict I & O to avoid edema…..
Shhhh….no pillow! Seizure precautions, be careful with the neck…VS, neuro checks, LOC q 1-2 hours. NPO if decreased LOC.
If you are exposed the CDC recommends treatment with Rifampin.
Rifampin side effects: n/v/d…headache, dizzy orange urine, contact lenses will turn orange, Cannot be given to pregnant women. Or Tx w/ Cipro or rocephin.
Skull volume= brain tissue + blood + CSF.
There is a limited space inside the skull for expansion and an increase in any of the components will lead to a change in the volume of the other components.
There will be an increased absorption of the CSF and a decreased cerebral blood volume.
The ICP will rise leading to decreased cerebral perfusion which will lead to edema. Then the brain tissue will shift through openings in the rigid dura leading to herniation and death.
Remember that an increased ICP leads to decreased cerebral blood flow…leading to ischemia and cell death.
The systemic response---vasomotor centers are stimulated which increase the BP
***Slow bounding pulse and irregular respirations***
How the body deals with cerebral edema…..The goal is to maintain blood flow and prevent tissue damage. 2 ways the body deals= Auto regulation of blood vessel diameter, and decreasing production of the CSF.
Seen with pressure on the medulla from brain stem herniation.
- Pathological Conditions that can cause ICP
Head injury, CVA, brain tumor, intracranial Sx, meningitis, encephalitis, subarachnoid hemorrhage.
- Early symptoms of ICP= a change in the LOC= slow speech, delayed responses, irritable, restless and increased effort of resps. Change in pupils, weakness on one side, headache that increases.
- Late symptoms of ICP= Worsening LOC leading to coma. Sluggish pupil response, decreased HR, decreased RR. Bradycardia to tachycardia. BP and temp will rise. The pulse pressure widens, Cheyne stokes resps, PROJECTILE VOMITING, hemiplegia, decorticate or decerebrate posture, flaccid before death. Loss of brain stem function. Increased systolic pressure.
LOC, pupil response, VS, motor activity
VS=pulse decreases, resps decrease, BP increases, Temp increases.
Diagnostics= CT scan, MRI, PET
Goal is to relieve the ICP by decreasing edema, decrease volume of CSF, decrease cerebral blood volume while still maintaining adequate perfusion.
Monitoring the ICP
Intraventricular catheter= ventriculostomy.into lateral ventricle. Allows for drainage. Meds can be instilled. Risks are infection and ventricle collapse.
Subarachnoid bolt=or screw…hollow device through the skull and dura mater into the cranial subarachnoid space. No ventricle puncture. Negative aspect = blockage leading to decreased accuracy of reading.
Epidural/subdural catheter= non electrical basis. Low incidence of infection. Can not withdrawal CSF for analysis.
***Remember the ventricles are the storage tanks for CSF***
To decrease the cerebral edema
Mannitol=and osmotic diuretic to dehydrate the brain tissue. This works by drawing the water across intact membranes. Need strict I&O
Corticosteroids--dexamethasone is given to reduce the edema
Fluid restrictions--- to lead to dehydration and hem concentration which is again drawing fluid across the osmotic gradient which will decrease the edema.
Maintain the cerebral perfusion
Manipulate cardiac output to provide enough perfusion to the brain. Improve Cardiac output. This is done by fluid volume and inotropic agents= dobutamine hydrochloride. This is checked by monitoring the cerebral perfusion pressure and it should be maintained at 70mmHg or greater.
Reduce the CSF and intracranial blood volume with drains…but be careful of over drainage can lead to collapse. Hyperventilation of patients is only used for patients that do not respond to the other therapies.
Control the fever….shivering increases ICP…fever increases cerebral metabolism and edema.
Reduce metabolic demands
Barbiturates= Nembutal, pentothal, diprivan. When administering paralyzing agents…..require intubation, arterial pressure monitoring…ICP monitoring.
ASSESSMENTS based on location in the brain
ICP on the frontal lobes will lead to Cheyne stokes resps
ICP in midbrain will lead to hyperventilation
ICP in stem (pons, medulla) leads to irregular resps and apnea.
Elevate the head of the bead 30-40 degrees as prescribed.
Avoid Trendelenburg’s position
Prevent flexion of neck and hips
Monitor resp status and hypoxia
Avoid morphine sulfate
Maintain PaCO2 at 30-35mmHg. This will result in vasoconstriction of the cerebral blood flow vessels, decreased blood flow and a decreased ICP.
Maintain body temp--anti pyretics ,
Decrease environmental stimuli
Monitor lyte and fluid balance
Limit fluid intake 1200mL/day--decrease edema
Avoid straining, coughing sneezing
Avoid valsalva maneuver.
Seizure precautions--pad rails, have O2 and suction.
- Avoid straining, coughing sneezing
Avoid valsalva maneuver.
Seizure precautions--pad rails, have O2 and suction.
Monday, November 27, 2006
- Acute renal review. Some…alot of work for kidneys.
Think about the kidney…waste and water balance, acid base balance, controlling BP, controlling anemia.
- 3 f(x)= glomerular filtration, reabsorption and secretion.
- How does the kidney exrete nitrogenous waste ? Conserve electrolytes? and concentrate urine?
- Standard renal f(x) test= the GFR. Creatinine clearance test done over 24 hours. Normal rate is 80-125ml/min.
- Streptomycin--is nephrotoxic…be careful…
- Hypotension, extreme bleeding associated with pre renal failure.
- Oliguric phase--10-14 days….anticipate, urinary changes decreased output decreased GFR, cant concentrate urine. fluid volume excess, assess edema, neck vein distention, pulm. Edema, CHF, bounding pulse. Metabolic acidosis…see increased rr. Sodium balance…excreting to much Na+. Supposed to excrete K+ …but it is not. Anemia decreased platelets, RBC. Calcium deficit + Phosphate excess.
- What to expect to do….treat Hypovolemia w/ albumin IV. (remember 3rd spacing?) Treat HTN with meds, Treat hyperkalemia…R insulin IV + glucose. To help K+ into cells. Sodium bicarbonate to Tx acidosis. Calcium gluconate IV. Dialysis, to get rid of K+ for arrhythmias. Kayexalate to get rid of K+ in through stool excretion. Restrict dietary K+. to 40mEq.
Decrease the protein to 1gm/kg
Increase the calories
Decrease K+ and phosphorous (banana, citrus, coffee)
Increase the Fe
Access = AV shunt, fistula, graft.
Assess for change in BP, disequilibrium reaction, alterations in clotting from heparin solution.
Major concern=rejection. Rx given to immunosuppressive=Imuran, Prednisone, cyclosporin.
Next concern is infection
Assess for increased temp. pain. Tenderness over grafted area. Decreased output, edema, sudden weight gain. Assess for rise in serum creatinine and BUN values. in essence the s/s of ARF.
Sunday, November 26, 2006
Drugs that change the T4 labs--
Heparin, Lithium and ASA DECREASE the T4 levels. Contraceptives increase the T4 levels.
TH supplements--Syntroid is given to treat hypothyroidism. Thyroid hormone supplements increase blood glucose. TH supplements INCREASE the effects of Digitalis glycosides---Check for Dig toxicity.Anticoags--watch for bleeding, hemorrhage. Indomethacin (for RA)..ulcer issues. .AVOID hypnotics...call MD to decrease dosage of hypnotics to 1/2...or increase somnolence may occur.
Digoxin Toxicity--Therapeutic levels range from 0.5-2ng/mL. Usually drawn before the next dose. Or 4-10 hours after dose. Signs and symptoms = abd pain, anorexia, n/v, visual disturbances, bradycardia, arrhythmias. If signs are not severe just hold the dose. If arrhythmias….treatment will follow. Life threatening--may include administration of Digibind (digoxin immune Fab) which binds to the dig in the blood and is excreted by the kidneys.
Transphenoidal hypophysectomy. Removal of the pituitary gland. Sx treatment for removal of pituitary tumor. HOB up. CSF leak--glucose check. Antibiotics to prevent meningitis. Replacement therapy for hormones needed. NO bending. No straining for BM for 2 months. No brushing teeth for 10 days (suture removal). If the whole gland is removed…permanent diabetes insipidus.
Thyroidectomy. Pre-op--Antithyroid meds. Lugols solution prep.
Post op--semi fowlers position. Support head. Avoid tension on sutures. Pain control. Humidified O2/suction. Ice--soft diet. Shhhhh….assess voice changes. Check for hemmorage. Report complaints of pressure. Check for resp. distress---edema of glottis, Hematoma, nerve damage. Have trach set and airway at bedside. Call MD for extreme hoarseness. Check for thyroid storm--fever, tachy, agitation, delirium, coma, heart failure, shock.
Pheochromocytoma. Usually a benign tumor on adrenal medulla. Causes hypertension. Tremor headache, flushed, anxious, hyperglycemia. Check urine and plasma levels of catecholamines. 24 hour urine VMA--for test--NO coffee, tea, bananas, chocolate, ASA, vanilla. Adrenalectomy--removal of tumor may cause release of epi & norepi---increased BP & HR. If both adrenals removed….Corticosteroids needed.
Addisons Crisis. Hypotension/shock. Severe. Fever headache. -n/v/d. cyanosis. With slight overexertion or exposure to cold or infections or decrease in salt==circulatory collapse, shock, death. To prevent a crisis= replace Corticosteroids. No exertion.
Saturday, November 25, 2006
- Celiac Disease
- Gluten Intolerance…found in wheat, barley, rye, and oats.
- Early Stages
Fat absorption effected. Large quantities of steatorrhea. Frothy and foul smelling.
- Late Stages Impaired--Absorption of Protein, Calcium, Iron, Folic Acid, Vit D, K B12.
What happens when….Malabsorption of…
Fats---Steatorrhea. Proteins and CHO---peripheral edema, malnutrition. Vit D and Calcium--Osteomalacia and osteoporosis. Vit K--blood coag problem. Iron, folic acid and vit B12---anemia.
Growth failure will result if not stopped.
- First Evidence of Disease
Failure to gain weight. Poor appetite, bout of diarrhea, constipation/vomiting, abdominal pain, irritability.
As disease progresses
General wasting. Some children to not show signs until 5 years.
- Celiac Crisis
Acute--child has profuse, pale, bulky, stools…vomiting..wasted appearance. Dependent edema. Smooth tongue. Crisis precipitated by GI infections, prolonged fasting, and of course…eating gluten.
Stool for fat. Serum albumin. CBC for anemia.. PT for hypothrombinemia. Serum iron. Folic acid level. B12 levels. Immunoglobulin levels. Bowel studies for dilated flaccid bowel loops. Pancreatic function studies. Sweat test to rule out CF. Small bowel biopsy.
Remove gluten from diet. Give corn, hominy, rice, potato instead. Treat malnutrition. High calorie diet. May need TPN.
- Treat Crisis
Life threatening. Correct dehydration, metabolic acidosis. NG tube to decrease abd distention. IV fluids with K+, Ca+, and magnesium. Albumin to treat low protein. IV steroids to decrease the bowel inflamation.
Avoid cereals and baked goods. Hydrolyzed vegetable oils, processed food fillers. NO bread, cakes, cookies, spagetti, pizza, lunch meat, meat gravy, They CAN have Tacos and Mexican food.
Very hard….must follow diet for life. Increased risk for lymphoma or GI cancer if diet not followed. Teach patient and family--Anticholinergic drugs precipitate crisis: Inform MDs and Dentists.
1.Chloride level of 20mEq/L
2.Chloride level of 30mEq/L
3. Chloride level of 40mEq/L
4.Chloride level of 70mEq/L
1."the schedule will need to be altered."
2."the child will recieve all immunizations except polio"
3."the child will revieve the recommended basic series of immunizations plus a yearly pneumococcus and influenza vaccine."
4. "the child should not receive any hepatitis vaccines."
- Cystic fibrosis
Affects mucus producing (exocrine glands) Inherited autonomic recessive trait. On chromosome #7. The mucus is thick (increased viscosity) causes obstruction in small passages in organs. Sodium and Chloride is increased 2-5 times in these children.
- Resp. Changes=Reduced gas exchange from the mucus leads to hypoxia, hypercapnia and acidosis. Lots of infections, (s. aureus, h. influenzae, pseudomonas aeruginosa). Become resistant to drugs. Fibrotic areas. Pneumothorax and hemostasis. Symptoms--wheezing, dry cough, barrel shaped chest, dyspnea, cyanosis, clubbing of fingers/toes, repeated bronchitis, bronchopneumonia. Manage= prevent. Remove secretions. Antibiotics. Chest PT. Play…hang upside down!! Use O2 carefully…remember chronic hypercapnia and breathing stimulus. Hemoptysis greater than 300cc/24 hours is life threatening.
- GI changes= Secretions block the ducts lead to fibrosis. Pancreatic enzymes can not reach the duodenum. Results in: steatorrhea, azotorrhea. DM may develop. Biliary obstruction--leads to biliary cirrhosis--leads to portal hypertension. Dry mouth. Infection. Symptoms= in infants--meconium ileus. Signs of intestinal obstuction= abdominal distention, vomit, failure to pass stools, dehydration. Increased amount of frothy stools, failure to thrive related to malabsorption, thin extremities. Easy bruising, anemia. Deficiency of fat soluble vitamins(A,D,E,K). Manage= sprinkle capsules of pancreatic enzymes with meals. Diet= high calories. Vit K. TPN for failure to thrive. Salt supplements in hot weather. Reproductive changes= females--fertility inhibited. Male--mostly sterile.
- Integument changes= salty. Risk for hyperthermic conditions
Sweat Test Stimulate sweat production and measure sweat electrolytes. Normal sweat chloride=less than 40mEq/L. Greater than 60mEq/L diagnosis of CF. Test is done twice, separately.
- Tune Up --q 6 months--chest PT--antibiotics (inhaled and IV)--prophylactic prevention of serious infections. Done at Dupont Hospital for Children. Antibiotics= The order will appear as an unsafe dose. This is anticipated with CF…but the nurse still needs to call MD to clarify. CF children metabolize the antibiotics quickly.
- Give Psychological support--refer to CF Foundation.
- Diabetes Mellitus
800,000 new cases in US each year
Leading cause of non traumatic amputations, end stage renal disease and blindness among adults.
3rd leading cause of death by disease mostly due to cardiovascular complications
The primary goal is controlling glucose and preventing complications.
Physiology and Pathophysiology
Insulin is an anabolic…storage hormone. It moves glucose from the blood into the muscles, liver, and fat cells. Once inside those little cells the insulin will…transport and metabolize glucose for energy, stimulate the storage of glucose in the liver and muscle…yes in the form of glycogen. Tells the liver to stop the release of glucose. Helps the storage of dietary fat in adipose tissue. Speeds up the transport of amino acids from dietary protein into the cells. It also stops the breakdown of stored glucose, protein and fat.
Glucagon is secreted by the alpha cells in the islets of Langerhans and this is released when the blood glucose is to low, and it stimulates the liver to release some of that stored up glucose.
Insulin + Glucagon so happy together to maintain a constant level of glucose in the blood.
How does the liver produce glucose? At first it does this by the breakdown of glycogen=glycogenolysis. Then after 8-12 hours without food …breakdown of non carbohydrate substances…including amino acids=gluconeogenesis.
- Type One--Destruction of the beta cells results in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. And with this impaired function of above stated role of insulin.
- Type Two--Impaired insulin secretion and insulin resistance. Not only is there a problem with making insulin the tissues have a decreased sensitivity to it.
- What is the Dawn Phenomenon?
It is a normal blood sugar till about 3am with a gradual rise in the early morning hours. This is a common problem. The treatment= patient controlled by changing the time and dose of insulin-NPH-by 1-2 units.
- What is the Somogii Phenomenon?
It is hypoglycemia at night with hyperglycemia in the morning. Caused by to much insulin or an increase in sensitivity to insulin. The treatment = a gradual lowering of the insulin dose and increase in diet at the time of the hypoglycemic reaction.
Risk Factors we should already have beaten into our brains.
- The 3 Clinical Manifestations--ppp
- Other Signs/Symptoms
Weight loss, fatigue, weakness, tingling or numbness in the hands or feet, dry skin, slow healing sores, recurrent infections
- Diagnosing DM--Of course high blood glucose levels…Fasting plasma glucose levels of 115mg/dL on more than one test.
Management--Diet, weight control, exercise. The ADA recommends 50% from CHO, 30% from fats, 10-20% from proteins. Recommend high complex carbs, high soluble fiber foods, few simple sugars, limit fats.
- To lower the glycemic response--combine starch foods w/ protein and fat to slow the absorption of the starch. Eat raw foods, and eat whole fruit. The goal is to slow down the response.
- Remember to educate about the effects of ETOH and oral anti- diabetic meds. Side effects may include--facial flushing, warmth, headache, nausea, vomiting, sweating, thirst.
- Why walk? It increases the uptake of glucose by muscles and improves the utilization of insulin.
- Insulin Therapy
Short acting--Regular. Onset= ½ to 1 hour. Peak=2-3 hours. Duration=4-6 hours. Given 20-30 minutes before meal.
Intermediate--NPH, Lente. Onset=3-4 hours. Peak=4-12 hours. Duration=16-20 hours.
Long acting--Lantus. Peakless. Slow sustained action. Onset= 6-8 hours. Peak= 12-16 hours. Duration=20-30 hours. Used to control fasting glucose levels.
Absorbed faster when injected into the abdomen. Do not inject in a limb that will be exercised. (increases speed of absorption)
Insulin pumps are the most effective at maintaining blood glucose levels.
- Oral Antidiabetics
Cannot be used during pregnancy. Sulfanylurias--stimulate the pancreas to secret insulin and improves action at the cellular level. Should not be combined w/ ETOH. Biguanides--glucophage.(metformin). Can only be used w/ presence of insulin. Watch for drug interaction:Corticosteroids, diuretics, anti-coagulants, oral contraceptives.
Blood sugar level less than 50-60. Mild--sympathetic nervous system stimulated; A surge of adrenalin, causing sweating, tremor, tachycardia, palpitations, hunger, nervous. Moderate--brain cells deprived of food, impaired function of the CNS, can not concentrate, headache, light head, confusion, numb lips and tongue, slurred speech, emotional/irritable, double vision, drowsy. Severe---CNS change so impaired they need help. Disorientated, seizures, may not arouse.
To prevent---Feed the Peak. Know insulin/med peak times, and give food at that time.
Treatment--2-4 glucose tabs, 4-6oz fruit juice, 6-10 life savers, 2-3tsp of honey, love the frosting!
Caused by no insulin, illness, infection, and undiagnosed DM. This leads to a disorder in metabolism of CHO, protein, fat. 3 HUGE problems: Dehydration, electrolyte loss, acidosis.
- Here it is….There is not enough insulin…decreased amount of glucose are getting to the cells…which makes the liver make lots of glucose. Resulting in hyperglycemia. The kidneys try and try to secrete the extra glucose…and there goes the water and the Na+ and K+….
Lots of urination leads to dehydration and extreme lyte loss. Because of the decreased insulin Fats breakdown into fatty acids and glycerol.
Then the liver converts the free fatty acids into Ketone bodies which are acids…and lead to metabolic acidosis.
The blood glucose may be 300-800 or 1000 or more!
- Ketoacidosis--will see….
Low serum bicarb --0-15
Low PCo2--10-30 reflecting respiratory COMPENSATION for Metabolic acidosis.
Depending on the water loss Na+ and K+ may be high low or normal.
With dehydration will see---High creatinine, high BUN, high Hgb, high Hct.
Treatment As Ordered may be….
Dehydration--may need 6-10liters normal saline solution. 1liter/hour for 2-3 hours then switched to ½ NS.
Lyte loss--initially loss of K+ with dehydration. May need 40mEq/hour for several hours.
Acidosis--insulin IV at slow rate of 5units/hour. Hourly blood glucose checks.
- Insulin Drip Math
Convert hourly rates of insulin infusion to IV gtt rates.
Example= 100 unit of R insulin mixed in 500cc of 0.9NS.
Order= 5 units/hour
Math= 5 units x 5cc= 25cc/hour
Infuse separate. When mixing insulin drip, flush solution through the entire set and waste the first 50cc. Why is that?? Insulin molecules adhere to the glass and plastic infusion sets so the initial fluid has a decreased amount of insulin.
Always run the insulin continuously or the Ketone bodies will return.
Complications to come another day!
Friday, November 24, 2006
Grief is the personal feelings that go with the loss.
Mourning is the expression of grief.
Bereavement is the period of time of mourning.
"Although the pain of the loss may be tempered by the passage of time, recent conceptualizations of loss as an ongoing developmental process maintain that time does not heal the bereaved individual completely(Silverman, 2001); that is, the bereaved do not get over a loss entirely, nor do they return to who they were before the loss. Rather, they develop a new sense of who they are and where they fit in a world that has changed dramatically and permanently." (Bare, Smeltzer)
Grief vs. Depression--Normal vs. Maladaptive Grieving
Grief--feelings of loss but self esteem intact.
Depression--feelings of guilt, worthlessness precipitates depression.
Delayed or Inhibited Grief
Can be pathological. The person does not deal with the reality. Fixed in the denial stage. Failure of the mourning process.
Care Plan for the Grieving Person
Nursing Diagnosis:Risk For Dysfunctional Grieving;
Related to: loss of loved one;
Evidenced by: Feelings of sadness, anger, guilt, self-reproach, anxiety, lonliness, fatigue, helplessness, shock, yearning, and numbness.
Outcome Criteria: Patient will progress through the grief process in a healthful manner toward resolution.
Nursing Interventions w/ rationales
1.Assess the patient's stage in the grief process.
2. Devolop trust. Show empathy, concern and positive regard. Provides the basis for a therapeutic relationship.
3.Help patient actualize the loss by talking about it. Reviewing the events can help full awareness of the loss.
4.Help the patient identify and express feelings. Such as anger, guilt, anxiety and helplessness. until these feelings are recognized and accepted the grief work can not progress
5.Provide adequate time to grieve and help patient to understand the grief process to help prevent the feelings of guilt.
6.Provide continuing support, if the nurse can not then offer referals to support groups. This facilitates the grief process.
7.Identify pathological defense that the patient may be using such as drug/alcohol, somatic complaints, and social isolation. Help the patient understand that these are not healthy defenses and delay the process of grieving. The bereavement process is impaired by behaviors that mask the pain of loss.
8. Encourage the patient to make an honest review of the relationship that has been lost. Keeping a journal is a good way. To see the positive and negative aspects related to the loss.
GRIEF Greif Recovery Institute Education Foundation, Inc.= www.grief.net
Thursday, November 23, 2006
3.Coronary Artery Disease
1. Cold intolerance
3. Excessively dry skin
1.elevated blood glucose levels and a low plasma bicarbonate
2.decreased urine output
3.increased respirations and an increase in pH
1. Difficulty in voiding
2. Abdominal cramps
3. Laryngeal stridor
4. Mild to moderate incisional pain
A patient is admitted to emergency room and diagnosis of myxedema coma is made. Which action will the nurse prepare to do first?
1. Warm the patient
2. Give fluid replacement
3.Maintain and airway
4. Administer thyroid hormone.
1. Continue to observe the drainage.
2. Test the drainage for glucose
3.lower the head of the bed
4. Obtain a culture of the drainage
From: Comprehensive review for the NCLEX-RN examination, (Saunders)p.664
Wednesday, November 22, 2006
(Minimally) Adrenal Sex hormones= Androgens- like male sex hormones. Estrogen--secretes small amounts of this.
DYSFUNCTION OF ADRENAL GLANDS (4)
In the Medulla--PHEOCHROMOCYTOMA--catecholamines are increased. The severity depends on how much epinephrine and norepinephrine are secreted. Causes hypertension (I mean really high) Tumor usually on the adrenal medulla. Clinical s/s= tremor, headache flushing, anxiety, hyperglycemia (remember what epinephrine does) Liver and muscle glycogen turning into glucose. Diagnostics= check urine and plasma levels of catecholamines. The most direct and conclusive test for over activity of the adrenal medulla is t he 24 hour urine for VMA (vanillylmandelic acid) Test.--levels of VMA in the urine will be increased. Diet for this test is no coffee, tea, bananas, chocolate, vanilla, (Oh No!!!) and aspirin prior to the test. ADRENALECTOMY--removal of the tumor. Manipulating the tumor may cause a release of stored epi/norepi….which may increase the heart rate and blood pressure. If both adrenals are removed, Corticosteroids replacement is needed. Hypotension or hypoglycemia may occur because of the sudden withdrawal of catecholamines. Check plasma and urine levels (of catecholamines)! To see if the surgery has been successful.
On to the Cortex…..ADDISONs DISEASE not enough adrenocortical hormones. Caused by TB destroying the gland. Or maybe autoimmune atrophy. Clinical s&s= muscle weakness, fatigue, wasting, anorexia, GI--nausea, vomit, diarrhea leading to dehydration, weight loss. Increased melanocyte hormone causes bronze darkening of mucus membranes, skin, knuckles, knees. Hypotension from hyponatremia--low Na+ craving salt. K+ may be elevated leading to cardiac arrhythmias. *******Hypoglycemia--tired and weak*********
Addisons Crisis---severe hypotension and shock, cyanosis, fever, headache, GI symptoms. On slight overexertions, cold temp, infections or decrease in salt. Leading to shock, circulatory collapse and death. To prevent all this would be Corticosteroids replacement. Labs= low blood sugar, low sodium, high K+, high white blood cells, low levels of adrenocortical hormones, low cortisol levels. Management= fight the shock. Restore blood circulation, fluids, Corticosteroids replacement, treat infections, Provide IV therapy with Na+. Glucose, lytes. Rest. TEACHING= patient should be taught to prevent hyponatremia to increase sodium intake, to prevent illness, stress. Lifelong hormone replacement, to increase CHO and protein.
CUSHINGS SYNDROME has increased production of ACTH. The problem is from to much Corticosteroids being secreted by the adrenal cortex. Caused by adrenocortical tumor or pituitary tumor secreting ACTH which then causes increased secretion of glucocorticoids. If the cause is a pituitary hormone…..treatment of choice is removal of the pit gland. Signs/symptoms= cortisol levels are increased, hypernatremia leading to fluid retention, hypocalcemia, hyperglycemia. Nursing Care= protect from infection, skin care, decrease stress, check edema, accuchecks and insulin as ordered, diet--low calorie, low Na+, high K+, high Ca+, high vit D. daily weights, I&O.
PITUITARY GLAND (covered)
HYPOPITUITARISM disease of pit gland or hypothalamus…tumor, trauma or radiation. Treatment= replace the hormones! Corticosteroids, thyroid hormone, sex hormones, gonadotropins. Diagnose= x ray, CT scan. (to see tumor)
HYPOPHYSECTOMY--partial or complete. 2 approaches. To gain access to the pituitary gland the common approach transsphenoidal. The surgeon makes an incision beneath the upper lip to get inside the nasal cavity. The surgical site is the sella turcica. . Post operative nursing care=Increase head of bed to ease pressure on the sella turcica, and to promote normal drainage. Assess for clear drainage from the nose, constant swallowing, check for glucose in drainage--if positive= CSF Leak. Leak usually resolves in 72hr. May need spinal tap to decrease pressure. Anticipate antibiotics to prevent meningitis. Reduce Cerebral Edema- expect meds to reduce edema- mannitol (draws free water) Decadron may be given IV q6 hours for 24-72 hours….then tapered off. Relieve pain and reduce seizures= Acetaminophen for temp greater than 99.6 F (37.5C) and for pain. Codeine or morphine may be ordered for pain. Monitor the ICP. I&O . Urine specific gravity after each voiding. Check nasal packing frequently for blood and CSF. Oral Care every four hours…they are dry from mouth breathing. Teaching=No bending, no straining, for 2 months post op, no tooth brushing until sutures are out and heal--10days. If whole gland removed patient will have permanent diabetes insipid is.
ABSENCE OF PITUITARY GLAND
Menstruation ceases, Infertility occurs. Need Replacement hormone therapy. Testosterone for me, estrogen for women and HPG may restore fertility in women.
DIABETES INSIPIDIS hypofunction of the posterior pituitary. Leads to deficiency of ADH or Vasopressin. Cause= brain tumor, head trauma, inflammation, removal of the pit gland. S/s= thirst for cold water. Can drink up to 20 Liters a day. Dehydration, polydipsia, low specific gravity of urine ( 1.001-1.005) Large volumes of dilute urine. Diagnosis of DI is the fluid deprivation test. =withhold fluids for 8-12 hours or until 3-5% of body weight is lost. During test= frequent weights, plamsa and osmality of urine, specific gravity of urine. Stop Test if patient becomes tachycardia, weight loss greater than 5 %, If hypotension. Treatment= fluid and lyte replacement. I&O, weights. Administer hormone replacement as ordered= vasopressin (Pitressin) and vasopressin tannate IM, Lypressin nasal spray.
So there it is...I am studying instead of drawing. I have alot more to do.
some covered elsewhere...ie: islets of langerhans covered in DM...not going beat a dead horse with a stick....I am sick. More and more of endocrine to come.
The Endocrine Glands= pituitary-thyroid-parathyroid-adrenals-islets of langerhans-ovaries-testes
The system works with the nervous system…to maintain homeostasis.
The glands secrete directly into the bloodstream. (as opposed to the exocrine glands.)
This system is a negative feedback system.
Hypothalmus- The link between the nervous and endocrine system. Controls the pituitary.
Pituitary- HYPOPHYSIS= The master gland. Secretes hormones that control secretion of other hormones. (pretty cool.)
Posterior Pituitary--secretes Vasopressin (ADH). This is stimulated in response to…increase in blood osmolality…decrease in blood pressure. To control the excretion of water by the kidney. Secretes Oxytocin. Stimulated by pregnancy, childbirth. Function is to --milk ejection during lactation, increase force of uterine contractions.
Anterior Pituitary--secretes FSH, LH, Prolactin, ACTH, TSH, GH, MSH. (Only covering Growth hormone here, have the others covered elsewhere)--What GH does for you= increases protein synthesis, breakdown of fatty acids, increases the glucose levels in the blood. Secretion of this hormone increases when you: exercise, have stress (like now for exams!…I must be secreting a lot of this hormone) have a low blood sugar, starvation. Decreased secretion with hyperglycemia. If you do not have enough secretion= limited growth and dwarfism. Over secretion during childhood= Gigantism. Over secretion during adult hood leads to Acromegaly (think Abe Lincoln) deformities develop of bone, soft tissue, enlargement of viscera, large broad spade like hands…will not grow taller.
Thyroid Gland--lower neck anterior to trachea. 2 lobes. Highly vascular. Hormones= thyroxin (T4) Triiodothyronine (T3)--these are controlled by TSH. Calcitonin not controlled by TSH. It is controlled by Ca+ levels in the blood. Secreted as a response to high serum Ca+ levels. Reduces Ca+ levels by increasing Ca+ deposition into bone. Need Iodine for hormone synthesis. Functions of the thyroid hormones= control cellular metabolic activity. Influence cell replication, brain development, normal growth.
TRH is secreted by the hypothalamus it influences the release of TSH from the pituitary. The environment….when the environmental temp falls--leads to an increased secretion of TRH which results in an elevated secretion of thyroid hormones.
Labs for the Thyroid function= Serum T4= 5-12ug/dl for normal range. Drugs that decrease T4 levels= Heparin, Lithium, Salicylates. Drugs that increase T4 levels= contraceptives. Serum T3= 110-230mg/dl. Accurate indicator of hyperthyroidism. Greater T3 rise than T4 rise. TSH assay= most useful single test to Dx hypothyroidism.
Radioactive iodine uptake= (not going there today!) elevated levels with hyperthyroidism.
Thyroid ScintiScan= evaluates the size and structure of the thyroid. Areas of hyperactivity are hot spots. Gray or black regions. Areas of hypoactivity are cold spots and will show as white or gray regions. Biopsy= Under general anesthesia, needle biopsy. Detects tumors. Complications= Bleeding (of course) respiratory difficulties coming from Hematoma and edema.
Common women 30-60 years. Causes: autoimmune, surgical removal, over treatment of hyperthyroidism. Assessments=bradycardia, general non pitting edema, anorexia, lethargy, slow mental process, clumsy, Intolerance to cold!!, dry skin, sleep a lot. Everything slows down. Nursing Care= VS. I&O. daily weights, decrease calorie in the diet, increase fluids/fiber, stool softener, keep environment warm, access edema (3rd spacing), thyroid replacement as ordered. Medical Treatment= Synthroid, Proloid, Cytomel. Effects of these: increase blood glucose levels. TH supplements increase the effect of Digitalis Glycosides, (watch for dig toxicity), Anticoagulants (watch for hemorrhage) Indocin. AVOID hypnotics sedatives. May produce profound somnolence. Give ½ to 1/3 dose. Call MD to clarify orders if not ordered this way.
MYXEDEMA= most severe stage of hypothyroidism. Pt. Hypothermic, increased lethargy leading to coma, cardiovascular collapse and shock, thyroid hormone given IV, Mortality rate is high.
HYPERTHYROIDISM or GRAVES DISEASE OR THYROTOXICOSIS
Over secretion of thyroid hormones. Metabolic rate GREATLY increased. Goiter seen with iodine deficiency . Mostly women 30-40s. May appear after emotional shock, stress, infection (unknown reasons) Assessments= nervous, insomnia, can not sit still, exophthalmus (bulging eyes), emotionally hyper excitable, apprehensive…tachycardia, palpitations, elevated systolic reading, flushed warm moist skin, Intolerance to heat!!! No menstrual periods, very thin and active. No weight gain even after eating, eating, eating. Thyroid gland is enlarged, soft and may pulsate. Thrill and Bruit over thyroid arteries. Nursing Care= VS- anti-thyroid meds as ordered, cool environment, decrease stress, increase in diet: CHO, protein, calories, vitamins/minerals. No coffee, tea, cola. Medical Treatment= Antithyroid meds= block synthesis of TH, Propacil, Tapazole. Radiation to destroy the gland, Thyroidectomy, Adrenergic blocking agents such as Inderal to decrease the sympathetic activity and alleviates tachycardia.
Pre-Operative Nursing= Antithyroid drugs to suppress function. Iodine prep= Lugols or K iodine to decrease size and vascularity of the gland to reduce the hemorrhage risk.
Post-Operative Nursing= Humidified O2. First fluids to soft diet. Limit talking. Assess voice changes injury to the laryngeal nerve, some hoarseness common. Check for hemorrhage= behind/side neck. If patient complains of fullness or pressure at insertion site call MD stat. Check for Respiratory distress= results of edema of glottis, Hematoma, or injury to the laryngeal nerve, have trach set/airway at bedside, Call MD for extreme hoarseness.
Tetany--from accidental removal of the parathyroid gland during surgery. Disturbs Ca+ metabolism. Assess= hyper irritability of nerves, spasms of hands, feet, muscle twitching. At risk for--Airway obstruction, laryngospasm. Treatment= IV calcium gluconate.
Thyroid Storm= results from release of excessive amounts of TH during surgery. Assess for fever, tachycardia, agitation leading to delirium, heart failure, shock.
Parathyroid glands in the neck posterior to the thyroid (4)
Parathyroid hormone regulates calcium and phosphorous metabolism. Vit D increases the actions of the Parathyroid hormone, (I will abbrev. PTH). PH lowers the phosphorus levels in the blood. An increase exaggerates normal bone function. (Remember osteoblasts and osteoclasts? Building up and Cleaning up. From way back when) PTH has 3 basic effects on the body. 1. To increase bone resorption causes Ca+ loss leading to bone demineralization, bone pain from pathological fractures. 2. Increases renal retention of Ca+. 3. To increase GI absorption of Ca+.
HYPERPARATHYROIDISM is a disorder of calcium, phosphate, and bone metabolism. Hyper secretion of PTH. Clinical signs= elevated Ca+ levels above 10.8mg/dl on 3 tests. Skeletal--easy bone fracture, diffuse bone pain. Kidney-- low urine specific gravity. Decreased filtration leading to stones, and renal failure. GI--constipation, anorexia, nausea, vomit. Cardio--dysrhythmia, hypertension. GOALS= increase the renal excretion of Ca+. Decrease GI absorption and bone resorption of Ca+. high volume isotonic saline IV to increase the glomerular filtration of Ca+. Limit oral Calcium. Nursing Care= walking to put the calcium (Ca+) back into the bones. Low calcium diet. Increase bulk/fiber. Stool softener. Avoid bed rest!!
HYPOPARTHYROIDISM caused by inadequate secretion of PTH, from accidental removal of the parathyroid gland during thyriodectomy leading to hypocalcemia. Diagnostics= low Ca+ levels, increased phosphate levels, x-rays may show increased bone density. Tetany-- A serum calcium below 6.5 and the patient will have symptoms. S/s= tingling of fingers, around lips, painful muscle spasm. Dysphasia, laryngospasm, seizures, cardiac arrhythmias. Chvostek’s sign. Trousseau’s sign. Medical Goal= raise the calcium level. 9-10mg/dl. Calcium gluconate IV for acute. Large doses of Vit. D to increase the absorption of Ca+. Aluminum hydroxide (Amphogel) with or before meals to decrease phosphate levels. Nursing Care= Seizure precautions, quiet, emergency trach and IM Calcium gluconate at the bedside. Check serum Ca+ and phosphate levels.
Not enough color to this.....
(f)x= to remove air/fluid from the pleural space. To re-expand the lungs.
Simple things to Remember
Normal breathing works on -neg- pressure.
Pressure in the chest cavity is lower than the pressure in the atmosphere--Air moves into the lungs during inspiration.
When the chest is open from surgery or trauma - pressure is lost and the lung can collapse.
Chest tubes drain fluid or gas. Normally 20mL in pleural space.
Pneumothorax= air in the pleural space. Common from surgery.
Hemothorax= blood or serous fluid in the pleural space. Both lead to a decrease in gas exchange.
The chest tube will restore the -neg-pressure needed.
Small bore chest tube--7F to 12F, has a one way valve that prevents the air from moving back to the patient.
Large bore tube--up to 40F. Usually connected to drainage.
Wet Water Seal- amount of suction made by the amount of water instilled in the suction chamber. The amount of bubbling tells how strong the suction is. The water seal prevents the water from being sucked back to the patient on inspiration.
When wall suction is off--must be open to air.
To prevent pneumothorax, tube can be placed in sterile water for a temporary water seal.
To check @ insertion site= clamp briefly at site with padded hemostats. If the bubbling stops in the water seal chamber= Leak at insertion site.
To check tubing= pinch rubber connecting tubing. If bubbling stops=leak at connecting site.
The water seal chamber should not be bubbling. Small amount of bubbling when- suction starts, drainage displacement, or a cough displaces air.
Check q 15min-1 hour first day post operative.
Water Seal chamber should have 2cm tidaling water.
Suction control= 20cm H2O regulates amount of suction
Document the drainage. Do not empty drainage (MD)
Dislodged tube: Have patient exhale. Compress site and provide a tight seal. Apply occlusive dressing. Notify MD
Chest tube disconnected from site: Clamp tube with padded hemostats near the insertion site. Create and underwater seal.
And we know that we will be using a pleur-evac...but since they are still testing us on this old 3 bottle system....anyway good to know the system to understand the concept of the pleur-evac drainage/suction system.
Tuesday, November 07, 2006
OXYGENATION Just a quick review.Deoxygenated blood goes into the Right Atrium to Right Ventricle-- to the lungs to pick up O2.Oxygenated blood then goes from the lungs into the RA to RV to Aorta to body--In other words…the RV pumps blood to the pulmonary circulation( to the lungs) .The LV pumps blood to the systemic circulation( to the body.)The pump, that is the myocardial pumping action of the heart is essential to maintaining oxygen delivery.The 4 chambers of the heart fill w/ blood during diastole and empty during systole.In other words…systole (contraction) is when the blood is ejected from the ventricles.The heart muscle fibers are stretchable…they have contractile properties. This is Starlings law..The stretch is related to the contraction…Think of the rubber band, the greater the stretch the farther it will go…The greater the stretch the greater the contraction…Remember…The more stretch the greater the contraction, the greater the stroke volume….In healthy hearts only.The pumps effectiveness is decreased by….CAD and CHF…these lead to diminished stroke volume.The LV does most of the pumping, most of the work.
Blood flow through the heart.Unidirection is maintained by the heart valves.Mitral valve is the left AV valve.Tricuspid is the right AV valve.S1 the first heart sound is heard because of the mitral and tricuspid valves open and blood then flows into the ventricles. So..the ventricles are filled with blood and the aortic and pulmonary semi lunar valves open letting the blood flow from the filled ventricles out to the aorta (goes to body, systemic) and to the pulmonary artery (goes to the lungs)…The valves Pulm. and aortic (semi lunar) valves then close- this is S2, the second heart sound.
Coronary Artery Circulation. This is a part of the systemic circulation.Coronary Arteries supply the heart with the O2 that it needs.The right and left coronary arteries stem from the aorta.Just as the left side of the heart does most of the pumping work….the left coronary arteries have the most blood supply and they feed the left ventricle part of the heart.Right Coronary Artery…supplies the posterior aspect of the septum, posterior papillary muscle, Sinus and AV nodes, and the inferior wall of the LV.Left Coronary Artery….LAD-left anterior descending, supplies the anterior LV wall, Anterior papillary muscle, Anterior interventricular septum which supplies the conduction system of the heart- bundle of his, and bundle branches……25% of MI ( heart attack) is a problem with LAD to the anterior wall of the LV. LAD also supplies the left ventricular apexCircumflex…Comes off of the left coronary arteries, wraps around the back, supplies the left atrium, posterior left ventricle, and posterior septum.
Systemic Circulation. Review.-O2 blood from the Left Ventricle to the Aorta to the body…..In the body it travels through arteries to the tissues and organs..it goes from big arteries to smaller arteries to arterioles to capillaries. This is all oxygenated blood.Then at the capillaries gases, nutrients are exchanged and the tissues become oxygenated. The waste product CO2 is carried off through the venues to veins to larger veins to the heart. This is all deoxygenated blood…it gets back to the heart to the RA….to the RV…to the lungs to drop of the CO2 and pick up O2..Then back to the heart again with now oxygenated blood to go to the LA to the LV to the Aorta to the body etc……..again and again and again….
Hemostasis: Process that prevents blood loss from vessels that are intact and stops blood loss from vessels that are severed or injured.Intact vessels are protected by platelets. These platelets nurture the endothelium and maintain the integrity of the vessel wall.
Primary Hemostasis: Constriction of the severed blood vessel. Platelets aggregate at the site-stick together forming an unstable hemostatic plug.
Secondary Hemostasis: coagulating factors are converted into active forms. This happens at the site of injury. The process in the end leads to the formation of fibrin. Fibrin reinforces the plug and anchors it. Factor X is activated-- Prothrombin-- Thrombin-- Fibrinogen -- Fibrin Clot.2 pathways that are needed: Intrinsic pathway is slow and it happens when collagen that lines blood vessels is exposed. The sequence of clotting is started and ends with a clot, which is fibrin. The extrinsic pathway is fast, it is activated by tissue injury and thromboplastin is released by the tissues.
2.Alcoholic myopathy= acute or chronic condition. Acute= sudden onset of muscle pain, swelling, weakness, a red tinge to the urine caused by a breakdown product of muscle, increase of muscle enzymes in the blood. Labs= increase of CPK, LDH, AST. The chronic symptoms= gradual wasting and weakness of skeletal muscles, no pain or elevation of enzymes. Caused by b vitamin deficiency. Treatment= abstinence and nutrion support.
3.Wernicke’s encephalopathy= serious thiamine deficiency. Signs and symptoms= paralysis of eye muscles, diplopia, ataxia, somnolence and stupor. Need thiamine replacement or death will follow.
4.Korsakoff’s psychosis=syndrome of confusion, loss of recent memory, and confabulation. Usually seen with wernickes, the two together. Treatment = parenteral or oral thiamine replacement.
5.Alcoholic cardiomyopathy= heart enlargement and weakness due to an accumulation on lipids in the heart muscle cells. Symptoms relate to CHF=decreased exercise tolerance, tachycardia, dyspnea, edema, palpitations, non-productive cough. Labs =increase enzymes CPK,AST,ALT, LDH. CHF may be seen on x ray. Treatment= total abstinence and treatment as CHF. Death rate is high not treated early.
6.Esophagitis= inflamation and pain in the esophagus. From toxic effect of alcohol and vomit.
7.Gastritis= inflamation of the lining of the stomach. Signs and symptoms= epigastric distress, nausea and vomiting, distention. The alcohol can break down the mucosal lining of the stomach, this lets the hydrochloric acid erode the stomach wall. If blood vessels get damaged, hemorrhage may occur.
8.Pancreatitis= acute or chronic. Chronic can lead to malnutrion, weight loss, and diabetes mellitus. Signs and symptoms= constant, severe epigastric pain, nausea vomiting, and distention.
9.Alcoholic hepatitis= follows severe long term drinking and usually affects an already damaged or weakened liver. Signs and symptoms= enlarged tender liver, nausea vomiting, lethargy, tiredness, anorexia, increased WBC count, jaundice. Ascites and weight loss. Treatment= strict abstinence of alcohol, proper nutrition, rest. Can lead to cirrhosis of the liver.
10.Cirrhosis of liver= the leading cause of cirrhosis of liver is alcohol abuse. It is the end stage liver disease for alcoholics; the result of long term chronic use of alcohol. The liver cells are destroyed and replaced by scar tissue. Signs and symptoms=nausea vomiting, lethargy, tiredness, anorexia, weight loss, abdominal pain, edema, anemia, blood coagulation abnormalities. Treatment= abstinence, nutrition and supportive care to prevent the complications of cirrhosis.
Alcohol withdrawal= within 4-12 hours of prolonged heavy use ( several days or longer). Signs and symptoms= coarse tremors of hands, tongue or eyelids, nausea and vomiting, sweating, increased blood pressure, weakness, tachycardia, anxiety, depressed mood or irritability, transient hallucinations or illusions, headache, insomnia. Delirium can happen on the 2nd or 3rd day or with a reduction of amount. This can be a very serious condition. Nursing Care=The nurse should be aware of own feelings or bias attitudes. The nurse should have a strong understanding of self and attitudes to be able to be empathetic toward the patient. The nurse should be able to accept the patient unconditionally and separate the past behaviors of the patient from who the patient is and accept the patient for themselves.
1.Ineffective denial related to weak, underdeveloped ego evidenced by statements such as, “ I do not have a problem.” Outcome=Patient will demonstrate acceptance of responsibility for behavior and verbalize the relationship between substance abuse and medical problems. Interventions= Develop trust. Ensure to patient that it is the behavior that is not acceptable, but the person is acceptable--unconditional acceptance leads to self-worth and dignity.Correct misconceptions about the problem in a way that is nonjudgmental.--this helps the patient see that it is an illness that needs help. To clear denial identify maladaptive behavior and how substances may have had a role in the problem. For example lab studies.--trying to decrease the role of denial.Do not allow the patient to rationalize or blame others for behaviors associated with abuse.--to decrease the denial time.
2.Ineffective coping related to inadequate coping skills as evidenced by the use of substances to cope. Outcomes=Verbalize adaptive coping mechanism to use instead of substance abuse in response to stress. Interventions= set limits on manipulative behavior/--may not be able to set own limits or delay gratification. Explore options to relieve stress other than substance abuse and practice these techniques--gratification is obtained and related to the oral stage of development (freud), and the patient may not know how to be more adaptive with coping strategies. Give positive reinforcement when the patient is able to delay gratification and respond to stress with adaptive coping methods--patient needs lots of positive feedback to increase self esteem and to promote ego development.
3.Imbalanced nutrition: less than the body requires; fluid volume deficit; related to drinking alcohol instead of eating evidenced by weight loss, poor skin turgor, pale mucus membranes, electrolyte imbalance, anemia, or other signs of poor nutrition or dehydration.Outcomes=Patient will be free of signs and symptoms of malnutrition/dehydration. Interventions=parenteral support may be needed initially-- to correct fluid and electrolyte imbalance, hypoglycemia, and vitamin deficiency. Encourage cessation of smoking--to help repair damage to GI tract. Consult dietician, find out how many calories the patient needs, document intake and output, calorie count, weigh daily--to maintain nutritional assessment for early interventions. Maintain adequate protein intake to maintain nitrogen equilibrium, but if hepatic problems protein should be eliminated or decreased--diseased livers can not metabolize protein and can cause a build up of ammonia in the blood which can lead to serious problems with consciousness. Sodium may be restricted--to decrease fluid retention- ascites and edema. Provide small frequent meals of favorite foods, supplement with vitamins and mineral supplements--to encourage intake and facilitate adequate nutrition.
4. Risk for infection related to malnutrition and altered immune condition.
5. Risk for injury related to withdrawal evidenced by the signs and symptoms of withdrawal.There is medical treatment protocol for the detox process of alcohol withdrawal.
The list could go on....