Final Exam 366

• Coronary Artery Disease

  (inflammation/damage to blood vessels → fat deposits → atherosclerosis of the blood vessels → vasoconstriction → plaques form and can rupture → thrombus can form → block blood flow → angina/MI)
• Mgmt of CAD 


  Reduce blood pressure (beta blockers, calcium channel antagonists, ace inhibitors, diuretics), reduce inflammation, manage HTN and DM, reduce triglycerides, eliminate smoking/drinking/ substance abuse, manage obesity and stress
• Myocardial Infarction MI


  heart attack often caused by CAD, and when blood flow to the heart is blocked--> myocardial ischemia--> myocardial death
• MI s/s


  True chest pain, pain in shoulders/neck/stomach/back, weakness, N/V, tachypnea, dyspnea, tachycardia, dysrhythmias, BP changes
• MI mgmt

  MONA, stress testing, PCI/Stent, CABG, anticoagulants (Heparin, Warfarin), antiplatelets, thrombolytics, oxygen therapy PRN
• CHF


  myocardium unable to provide adequate CO to meet the body's demands [decreased contractility/SV] --> low EF -->low CO
• Right sided HF


  failure to pump blood into the lungs--> systemic venous congestion
• right sided MI manifestations


  Peripheral edema, weight gain, ascites, hepatomegaly/splenomegaly, jugular veins distended
• Left sided HF

  Failure to pump blood into the systemic circulation--> pulmonary congestion
• Left sided HF manifestations

  Pulmonary edema, crackles, wheezes, dyspnea, blood tinged sputum/SOB, fatigue, restless/confused/anxious/cyanosis (SIGNS of HYPOXIA)
• Left sided HF mgmt


  Fluid/sodium restriction, daily weights, monitor fluid levels (edema, pulmonary congestion), small meals, ease work of the heart, manage bp, continue exercise
• HTN


  increase blood pressure due to vasoconstriction or CAD

  Factors include: obesity, sedentary lifestyle, smoking, alcohol, DM, high lipids, family hx, substance abuse
• HTN mgmt non-pharmacologic

  Monitor bp at home/office, improve diet (reduce unhealthy diet fats/excessive sodium/processed sugar), manage weight with exercise/activity, no alcohol (increases BP), or smoking (vasoconstrictor), manage stress
• HTN pharmacologic mgmt

  Beta 2 adrenergic agonists (SNS- vasodilation), Nitric oxide (vasodilator), ACE inhibitors (stop RAAS, lower bp), ARB (block angiotensin, lower BP), calcium channel blockers (decrease contractility of heart vessels), diuretics (excretion of excess fluid--> decrease blood volume and BP)
• Post-OP care

  Ambulation, incentive spirometer, hydration, pain mgmt w/medications, TCDB, freqeuntly assess ABC, assess skin color/temp, assess surgical site, assess I&O, promote early ambulation, VS, cardiac rhythm, educate on how to identify post-op complications
• Post-op complications

  Shock--> replace fluids and blood volume with IV, administer O2, monitor BP

  
  

  Hemorrhage--> administer blood/platelets/ clotting factors, replace fluids with IV, administer O2

  
  

  DVT/ pulmonary embolism --> may need oxygen, anticoagulant medications (heparin, warfarin), or thrombolytics, can elevate leg, NO MASSAGE OR SCDs because it could dislodge it

  
  

  CVA/stroke--> oxygen, thrombolytics/anticoagulants, assess neuro

  
  

  Pneumonia/ atelectasis --> TCDB, IS, promote hydration (oral/IV), elevate HOB, reposition, encourage ambulation, potentially abx if bacterial
• Post-op complications continued


  Urinary retention/ intestinal obstruction --> promote hydration (oral/ IV), encourage fiber-rich foods and early ambulation, may need laxative, diuretic, or foley catheter

  
  

  Risk of DIC --> be prepared for blood/platelet/ plasma transfusions
• S/S of Pulmonary Embolism

  Chest pain, dyspnea, SOB, cough up blood, fever, wheezing, crackles, hypoxia, mental changes, hypotension, pallor, cardiac arrest,

  Labs: eℓevated BNP/ troponin
• Tuberculosis


  caused by mycobacterium, various infections, spread airborne

  Starts by infecting the lungs, but can spread through lymphatic system (active or latent)
• Active phase of tuberculosis


  Present and growing in the body, symptomatic, infectious and spreadable can also lead to death
• Latent phase of tuberculosis


  Present but not growing in the body, asymptomatic, can't be spread but can advance to active Tb

  *pt may be asymptomatic for years b4 showing s/s
• Proper mgmt of Continuous Bladder Irrigation (CBI)

  Sterile technique w/insertion of catheter to prevent infection, secure to leg

  Monitor flow of irrigant (in and out of the bladder)

  Assess for bleeding or clots

  Assess catheter for patency

  May manually irrigate catheter if outflow decreases or clots are present

  Analgesics as needed

  Keep drainage system closed, and remove if there is an obstruction

  *kegal exercises after removal
• S/S End Stage Renal Disease


  Signs: weakness, fatigue, confusion, depression, increased BP (poor urine output), edema , SOB, cough, ammonia breath, metal taste, N/V, pruritus, dry skin, bruising, purpura, cramps (from imbalanced electrolytes), bone pain, anemia (decreased EPO), increased potassium (reduced excretion)

  • GFR <15mL /min
  • urine: very low output, very dilute (kidneys cannot concentrate urine well)
• Nursing interventions for maintaning a fistula for hemodialysis vascular access

  • Evaluate fistula for s/s of infection, patency
  • Listen for bruits/thrills coming form the location of the fistula (if none, important to notify the provider)
  • Do not take BP or draw labs from the arm that has the fistula
  • Hold meds prior to hemodialysis (filtering of the blood will inactivate the med)
  • Monitor I/O, weights, vital signs (esp during hemodialysis)
• Medication mgmt of pts w/ Renal dysfunction

  • Iron, folate, B12- help w/ RBC production and to prevent anemia
  • Kayexalate- for hyperkalemia
  • Calcium supplements: for hypocalcemia
  • Phosphate binding agents: for hyperphosphatemia
  • Bicarbonate solution: for metabolic acidosis
  • EPO: for anemia (kidneys not producing enough)
  • Diuretics: for fluid retention
• Communicate with other disciplines when

  • Pt struggling with ADLs, has issues with consciousness, neurological deficits, severe chronic/end stage disease
  • Pt w/ developmental delays or cognitive impairments
  • Pt who can't tolerate PO nutrition
  • Pt w/ dysphagia, sensory impairment
  • Pt high risk for falls
  • Pt not responding well to tx or declining
  • Errors with medication orders
  • Question a physician order
  • collaborate with nutrition/dietary, PT/OT/ST, surgeon, physician, pharmacy, palliative care, social workers, RT, child life
• Gero Med-Polypharmacy


  Older adults take many different meds, that may be prescribed by different providers

  • risk for adverse medication interactions/ or medication errors (miss one or take too many doses etc.)
  • DO A FULL MEDICATION RECONCILIATION
  • drugs should be organized~easier to understand, identify incorrect doses, avoid omission or duplications of meds
  • properly withdraw unecessary meds
  • be aware of reduced absorption, metabolism, excretion! --> increased risk for toxicity and side effects
  • STOPP screening for potential inappropriate prescription use in older adults
• S/S of pruritus, eczema, dermatitis, psoriasis vulgaris

  Pruritus: Itching caused by medication, reaction

  Eczema: itchy, red- brownish patches, sall raised bumps that leak/crust, cracked/scaly/ raw sensitive skin

  Dermatitis: swollen red itchy lesions (often from allergic reaction or from contact with an irritant)

  Psoriasis vulgaris: itchy red plaques covered in loose silvery scales
• S/S of acne vulgaris, skin tears, pressure ulcers, sunburn, cellulitis

  Acne vulgaris: swollen sebaceous glands causing whiteheads, blackheads, pustules

  Skin tears: separation of the dermis and epidermis (more common in elderly due to loss of elasticity)

  Pressure ulcers: tissue ischemia (varying degrees non-blanchable erythema-->full thickness tissue loss)

  Sunburn: redness of the skin, may be dry, peeling, sore (heat/sun overpowers the melanin able to block the sun)

  Cellulitis: bacterial infection of SQ tissue, redness, swelling, warmth, tenderness, fever, chills, malaise
• S/S of Herpes Zoster

  Shingles, causing reddish maculopapular rash across the trunk, followed by burning or neuralgia (past hx of chicken pox?)
• Isotonic IV fluids


  Equal balance of fluid and ions, helps with hydrations replenishes electrolytes and blood volume

  -->Blood loss, dehydration, surgery

  Lactated ringers, Normal saline,
• Hypotonic IV fluids


  Lower osmolality, draws fluids into cells to increase hydration and blood volume, treats hyperosmolar states

  D5W, 0.45% NS, 0.25%NS
• Hypertonic IV fluids

  Higher osmolality, draws fluid out of the cells and into the vascularity, replenishes electrolytes and sodium

  --> burn, trauma pts, cerebral edema

  D5 1/2 NS, D5NS, hypertonic saline, D5LR
• Benign prostatic hypertrophy


  Enlarged transition zone of the prostate can obstruct the urethra and disrupt urine flow

  s/s: difficulty w/ urination, weaker stream, increased frequency and nocturia ~ NO INCREASED RISK FOR PROSTATE CANCER

  • Mgmt/education: yearly digital rectal exam, meds/saw palmetto for BPH, may need surgery, teach about complications (acute urinary retention, UTI, hydronephrosis)
• Prostate Cancer


  2nd most common type of cancer (after skin)

  s/s: often none at first, -->lumbosacral pain in hips/legs

  Mgmt: prostate specific antigen (PSA) testing, DRE Q2 yr

  sx to report: prostate becomes hard if cancer

  Risk factor edu: age, AA ethnicity, family hx, obesity, poor diet
• Normal changes throughout lifespan mgmt & edu for men

  GU changes with age: decreased testosterone, increase in prostate size, decrease in sperm and SQ fat, decreased erectile function/ejaculation, gynecomastia (enlarged male breasts)

  Mgmt: may receive testosterone supplements, digital rectal exam yearly to assess prostate (for BPH, infection, cancer), can take meds or saw palmetto for BPH, may need TURP surgery for BPH, may take meds for erectile function, teach testicular & breast self-exam at home

  Men <40 yr greater chance of prostate cancer

  Men >50 yr greater chance of BPH
• Necessary Preparation for Gender Affirming Surgery

  Ask pt what they wouℓd like to be called/ gender/ identity/ biological sex/ pronouns

  • considerate/polite w/questions
  • ask ab desires for future fertility
  • edu. ab proper injections and the use of high dose estrogen/testosterone
  • *needs to be long term gender dysphoria
  • need thorough explanations of benefits/risks-->informed consent!!!
  • assess emotional/mental health, provide support/resources/counseling as necessary
• Mgmt of joint replacement surgery (knee)

  Follow weight bearing restrictions as ordered, but usually can bear full weight 24 hours post-op.

  Increase walking/ambulation

  Increase hydration and fiber foods to minimize constipation and urinary retention,

  May need pain meds/laxatives/diuretics/anticoagulants/antibiotics, follow up with PT

  Monitor surgical site for s/s of bleeding, infections, proper care of surgical site, dressing changes as ordered
• Mgmt of joint replacement (Hip)

  Encourage light walking/ambulation,

  Movement limitations (can use abductor pillow, no more than 90 bend at waist, no internal/external rotations of the legs)

  Continue ordered meds, hydration, nutrition for healing, make sure pt has assistance needed at home, know how to use assistive devices
• Adult assessment


  HR: 60-100

  BP: <120/80

  RR: 12-20

  TEMP: 97.8-100.4F = 36.5-38C

  PULSE OX: >95%

  BG: 70-110 mg/dL

  *older adults may have a lower temp & ^bp (poor thermoregulation, stiffening of heart/blood vessels)