Download - MS Lecture Notes
Centro Escolar UniversityMendiola Manila
College of Nursing
NCM 106-RLE
Lecture Notes in MS Concept
HYPERTENSION
Definition: a systolic blood pressure above 140 mmhg or a diastolic pressure above 90 mmhg based on two or more measurements.
Classification:1. Optimal- systolic 120 mmhg diastolic 80 mmhg2. Normal- systolic 130 mmhg diastolic 85 mmhg3. High normal- systolic 130 to 139 mmhg diastolic 85 to 89 mmhg4. Stage 1- systolic 140 to 159 mmhg diastolic 90 to 99 mmhg5. Stage 2- systolic 160 to 179 mmhg diastolic 100 to 109 mmhg6. Stage 3- systolic 180 mmhg or higher diastolic 110 mmhg or higher
Hypertension is a major RISK FACTOR for atherosclerotic cardiovascular disease, heart failure, stroke and kidney failure
I. ESSENTIAL (PRIMARY) HYPERTENSION
It accounts to 90-95% in the adult population have essential HPN Affects more women than men, African- American men
Pathophysiology:
There is increased in peripheral resistance and or cardiac output secondary to increased sympathetic stimulation, increased renal sodium reabsorption, increased rennin angiotensin aldosterone system activity, decreased vasodilation of the arterioles or resistance to insulin action.
RISK FACTORS:
Obesity, excessive alcohol intake, overstimulation with coffee, smoking and drug intake.
II. SECONDARY HYPERTENSION
Characterized by elevation in BP with a specific cause such as arterial disease, renal disease, certain medications, tumors and pregnancy hypertension.
DIAGNOSTIC PROCEDURE:
- History and physical examination- Retinal examination- Laboratory studies:urinalysis, blood chemistry (sodium, potassium, creatinine, FBS, total and high density lipoprotein), ECG and echocardiography to assess left ventricular hypertrophy- Special studies: intravenous pyelography, renal arteriography, split renal function studies, rennin levels, 24 hour urine protein, creatinine clearance.
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COMPLICATIONS:
Renal Hemorrhage Heart failure Renal insufficiency and Failure Cardiovascular Accident (CVA) Transient Ischemic Attack (TIA) Myocardial Infarction (MI) Left Ventricular Hypertrophy
Medical management:
Goal- to prevent death and complications by achieving and maintaining an arterial BP below 140/90 mmhg (130/85 mmhg for people with DM or proteinuria> 1 g/24 hrs. whenever possible.
NURSING MANAGEMENT:
I. ASSESSMENT Assess BP at frequent intervals , know baseline and note changes in pressure Note the apical and peripheral pulse rate , rhythm and character Assess symptoms such as nose bleeds, angina pain, shortness of breath,
alterations in vision, speech or balance (vertigo), headache or nocturia Assess extent to which HPN has affected patient personally, socially and
financially
II. NURSING DIAGNOSIS1. Deficient knowledge regarding the relationship between the treatment regimen
and control of the disease process2. Noncompliance related to side effects of prescribed therapy
III. PLANNING AND GOALS
The major goal of the patient include understanding the disease process and its treatment, compliance with the self care program and absence of complications.
IV. INTERVENTIONS
1. Increasing Knowledge Emphasize the concept of controlling HPN ( with lifestyle changes and
medications) rather than curing it Arrange a consultation with a dietitian to help patient plan a weight loss Obtain patient education materials Advise patient to limit alcohol intake and avoid use of tobacco (smoking)
2. Monitoring and Managing Complications Assess all body systems when patient returns for follow up care Question patient about blurred vision, spots or diminished visual acuity Report any significant findings promptly to determine whether additional
studies or changes in medications are required.
V. EVALUATION
Expected Patient outcomes: Maintains adequate tissue perfusion Complies with self-care program
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Experiences no complications
RHEUMATIC HEART DISEASE
DEFINITION: Endocarditis associated with rheumatic fever caused by group A beta-hemolytic streptococcal infection.
CLINICAL MANIFESTATIONS
Heart murmurs characteristic of valvular stenosis, egurgitation or both become audible on auscultation
Cardiac symptoms defend on which side of the heart is involved. Severity of symptoms depends on size and location of the lesion
The mitral valve is mostly affected, producing symptoms of left sided heart failure, shortness of breath, crackles and wheezes
DIAGNOSTIC PROCEDURES
Throat culture for accurate diagnosis of streptococcal infection of the throat
MEDICAL MANAGEMENT Eradication of causative organism and prevention of additional complications
such as thromboembolitic event Long term antibiotic therapy-Penicillin
NURSING MANAGEMENT Teaching patient about the disease its treatme nt and the steps needed to avoid
complications Educate patient and community regarding recognition of streptococcal infections
and the need to treat them Teach susceptible patients that may require long term oral antibiotic therapy and
may be required to take prophylactic antibiotics Emphasize that less common diagnostic procedures such as cystoscopy, also
require prophylactic antibiotic therapy
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
DEFINITION: Is a disease state in which airflow is obstructed by emphysema, chronic bronchitis or both. The airflow obstruction is usually progressive, irreversible, and associated with airway hyperactivity, resulting in narrowing of peripheral airways, airflow limitation and changes in the pulmonary vasculature.
RISK FACTORS: cigarette smoking, air pollution and occupational exposure(coal, cotton and grain)
CLINICAL MANIFESTATIONS: Dyspnea, cough and increased work of breathing Dyspnea on mild exertion advancing to dyspnea at rest Weight loss Symptoms are specific to disease: Bronchitis and Emphysema
SYMPTOMS:
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BRONCHITIS-
Chronic cough and production of copious purulent sputum which has a quality of layering out into three layers on stranding, a frothy top layer, a middle clear layer and a dense particular layer,
hemoptysis, clubbing of the fingers and repeated episodes of pulmonary infection.
EMPHYSEMA- Dyspnea with insidious onset progressing to severe dyspnea with slight exertion. Chronic cough, wheezing, dyspnea, fatigue, and tachypnea On inspection “barrel chest” due to air traping, muscle wasting and pursed lip
breathing On auscultation, diminished breath sounds with crackles, wheezes, rhonchi and
prolonged expiration Hyperresonance with percussion and a decrease in fremitus Anorexia, weight loss, weakness and inactivity Hypoxemia and Hypercapnia, morning headache in advance stages Inflammatory reactions and infections from pooled secretions.
COMPLICATIONS: Respiratory insufficiency or failure Atelectasis Pneumonia Pneumothorax Pulmonary HPN
Medical management: Bronchodilators Oxygen Therapy including nighttime oxygen Varied treatment specific to disease
NURSING MANAGEMENT:
I.ASSESSMENT
Assess risk factors Obtain health history such as duration of respiratory difficulty, dyspnea,
shortness of breath, wheezing, exercise, tolerance, fatigue, effects on eating and sleeping habits
Perform physical examination to obtain baseline data:- Pulse, RR, and rhythm- Contraction of abdominal muscles during inspiration- Use of accessory muscles to breathe, prolonged expiration- Cyanosis, neck vein engorgement- Peripheral edema- Cough, color, amount and consistency of sputum- Status of sensorium, increasing stupor, apprehension
II. NURSING DIAGNOSIS Impaired gas exchange related to ventilation perfusion inequality
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Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough and bronchopulmonary infection.
Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstiction and airway irritants
Self- care deficit related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation.
Activity intolerance due to fatigue, hypoxemia and ineffective breathing pattern Ineffective coping related to less socialization, anxiety, depression, lower activity
level and inability to work Deficient knowledge related to risk of smoking as evidenced by continuing at risk
behaviors.
III. PLANNING Improved gas exchange Smoking cessation Improved breathing pattern Maximal self- management Improved activity tolerance Achievement of airway clearance Impaired coping ability Improved health related quality of life Adherence to the therapeutic programs and home care
IV NURSING INTERVENTIONS:
Improving Gas Exchange Monitor Dyspnea and Hypoxia Administer Medications and be alert for potential side effects Assess relief of bronchospasm through patient report of less dyspnea Monitor prescribed oxygen effectiveness with pulse oximetry or arterial blood
gas (ABG ) analysisAchieving Airway Clearance
Encourage high fluid intake to liquefy secretions Instruct patient in directed or controlled coughing Provide chest physiotherapy with potential drainage and intermittent passive
pressure (IPPB) when ordered Instruct patient in effective breathing techniques Measure expiratory flow rates
Preventing Bronchopulmonary Infections
Instruct patient to report signs of infection and report any worsening of symptoms Advise patient to avoid outdoor exposure during high pollen counts or significant
air pollution because there may increase bronchospasm Encourage immunization against hemophilus Influenzae and streptococcus
pneumonia and pneumococcal vaccine every 5 to 7 yrs.
IV. EVALUATION:
Expected patient outcomes: Demonstrates improved gas exchange Achieves maximal airway clearance Improves breathing pattern Maintains maximal level of self-care and physical functioning Achieves activity tolerance and exercises and performs activities with less
shortness of breath
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Develops effective coping mechanisms and participates in a pulmonary rehabilitation program
Adheres to the therapeutic program
ASTHMA
DEFINITION: Is a chronic inflammatory disease of the airways characterized by hyperresponsiveness, mucosal edema and mucus production. Inflammation leads to obstruction from mucosal edema, reducing airway diameter and contraction of bronchial smooth muscle> Acute exacerbations last from minutes to hours to days and are interspersed with symptom- free period.
RISK FACTORS: Allergy Chronic exposure to airway irritants or allergens(e.g. grass, weed, pollens, mold,
dust or animals) Common triggers for asthma symptoms and exacerbations includes airway
irritants (pollutants, cold, heat, strong odors, smoke, perfumes)
CLINICAL MANIFESTATIONS:
Most common symptom is cough frequently occur at night and early morning (with or without mucus production), dyspnea, and wheezing
Chest tightness An asthma exacerbation is frequently preceded by increasing symptoms over
days, but it may begin abruptly Expiration requires effort and becomes prolonged As exacerbation progresses, central cyanosis secondary to severe hypoxia may
occur Additional symptoms: diaphoresis, tachychardia, and a widened pulse pressure
may occur
DIAGNOSTIC PROCEDURES; Sputum and blood test Pulse oximetry, ABG Pulmonary function tests (FEV &FVC)
MEDICAL MANAGEMENT: Leukotrine modifiers inhibitors/antileukotrines block receptors to prevent
bronchoconnstrictors Beta-adrenergic agonists Methylxanthines Anticholenergics Corticosteroids: metered dose inhales (MDI) Mast cell inhibitors
NURSING MANAGEMENT:
I. ASSESSMENT:
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Evaluate and Identify substances that precipitate attacks (obtain history of exacerbations, family environment and health history)
Monitor respiratory status for progression or resolution of asthma attack (e.g. breath sounds, pulse oximetry, vital signs, peak flow)
Obtain medical history and history of medications allergy
II. NURSING DIAGNOSIS Ineffective airway clearance related to airway obstruction related to
airway constriction and excess mucus production Anxiety related to fear of death Risk for ineffective management of treatment regimen
III. PLANNING Goals may include the ff:
Unlabored breathing Clear breath sounds Pulmonary studies within normal limits Knowledge of self-care regimen for prevention and treatment
IV. NURSING INTERVENTIONPromoting airway clearance
Administer prescribed therapy and monitor patient responses Administer fluids and antibiotics (if infection present) Assist with intubation and respiratory support if needed
Minimizing Anxiety Provide nursing care using a calm approach Keep patient and family informed about procedures
V. EVALUATIONExpected patient outcomes:
Breathes freely and clearly Experiences no respiratory failure or other complications Carries out self-care measures effectively
PANCREATITIS
DEFINITION: Inflammation of the pancreas an dis a serious disorder that can range in severity from a relatively mild self limiting disorder to a rapidly fatal disease that dose not respond to any treatment.
CLINICAL MANIFESTATIONS Severe abdominal pain in the mid-epigastrium may be accompanied by
abdominal distention Poorly defined palpable abdominal mass and decreased peristalsis Frequently acute in onset (24 to 48 hrs after a heavy meal or alcohol ingestion)
maybe severe after meals and unrelieved by antacids Patient appears acutely ill Abdominal guarding rigid or board like abdomen Soft abdomen in the absence of peritonitis Ecchymosis in the flank or around the umbilicus which may indicate severe
hemorrhagic pancreatitis Hypotension related to hypovolemia and shock
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Acute renal failure Tachycardia, cyanosis and cold clammy skin Respiratory distress and hypoxia Dyspnea Tachypnea Abnormal blood gas values Diffuse pulmonary infiltrates Myocardial depression, hypocalcemia, hypercalcemia and DIC
Diagnostic procedures: Urine amylase level White blood cell count Hypocalcemia, transient hyperglycemia :glucosuria and increased serum bilirubin
levels in some patients X-rays of abdomen and chest Ultrasound and CT scan Serum amylase and serum lipase levels are most indicative (rises to more than
normal within 24 hrs. Amylase returns to normal elevated within 7 to 14 days Peritoneal fluid is evaluated for increase in pancreatic enzymes
MEDICAL MANAGEMENT: acute phase Oral intake is withheld to inhibit pancreatic stimulation and secretion of
pancreatic enzymes Parenteral nutrition (PN) Nasogastric suction is used to relive nausea and vomiting, decrease painful
abdominal distention and paralytic ileus Cimetidine (tagamet) is given to decrease hydrochloric acid secretion Pain medication (morphine) Correction of fluid and blood loss an dlow albumin levels Antibiotics for infection Insulin for hyperglycemia Aggressive respiratory care Biliary drainage (drain and stents) to decreased pain and increased weight gain Surgical intervention, drainage, resection or debridement
MEDICAL MANAGEMENT: POSTACUTE PHASE
Antacids Oral feedings low in fat and proteins Caffeine and alcohol are eliminated Medications: thiazide, diuretics, glucocorticoids or oral contraceptives are
discontinued
COMPLICATIONS: Fluid and electrolyte imbalances Necrosis of the pancreas Shock and multiple organ failure
NURSING MANAGEMENTI. ASSESSMENT
Assess presence and character of pain its relationship to eating and to alcohol consumption
Assess nutritional fluid status and history of gallbladder attack and alcohol use
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History of gastrointestinal problems: fatty stools, diarrhea, nausea and vomiting
Assess respiratory status including rate, pattern and breath sounds Assess abdomen for pain, tenderness, guarding and bowel sounds more
board like or soft abdomen
II. NURSING DIAGNOSIS Pain and discomfort related to edema, distention of the pancreas and
peritoneal irritation Imbalance nutrition: less than body requirements related to inadequate
dietary intake, impaired absorption, reduced food intake and increased metabolic demands
Ineffective breathing pattern related to severe pain, pulmonary infiltrates, pleural effusion and atelectasis
Impaired skin integrity resulting from poor nutritional status, bed rest, surgical wound
III. PLANNING Relief of pain and discomfort Improved fluid and nutritional status Improved respiratory function Absence of complications
IV. NURSING INTERVENTIONRelieving Pain and discomfort
Administer meperidine (demerol) Avoid morphine sulfate Withhold oral fluids to decrease formation and secretion of secretin Use nasogastric suctioning to remove gastric secretions and relieve
abdominal distention Maintain patient on bed rest to decrease metabolic rate and reduce
secretions of pancreatic enzymes Provide explanation about treatment
Improving nutritional status Monitor lab results, daily weights and anthropometric measures Assess nutritional status and increased metabolic requirement Provide mouth care, patient should receive nothing by mouth during attack Administer fluids, electrolytes and parenteral nutrition Monitor serum glucose levels and give insulin Introduce oral feedings gradually Avoid heavy meals, alcoholic beverages, excessive use of coffee and spicy
foodsProviding wound care
Assess the wound, drainage sites and skin carefully for signs of infection, inflammation and breakdown
Carry out wound care Turn patient every 2 hrs.
Improving respiratory function Maintain patient in semi-fowlers position to decrease pressure in diaphragm Change position frequently to prevent atelectasis and pooling of respiratory
secretions Administer anticholinergic medications to decrease gastric and pancreatic
secretions Assess respiratory status frequently and teach patients coughing techniques
and deep breathing
V. EVALUATION9
Expected patient outcomes: Report relief of pain and discomfort Experiences improved respiratory function Achieves nutritional and fluid and electrolyte balance Exhibits intact skin Remains free of complications
LIVER (HEPATIC) CIRRHOSIS
DEFINITION: Is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver.
Types:1. Alcoholic- most frequent due to alcoholism2. Late result of previous acute viral hepatitis3. Biliary- a result of chronic biliary obstruction and infection, less common type
Clinical Manifestations:
Compensated cirrhosis usually found secondary to routine physical examination Decompensated Cirrhosis: symptoms of decreased protein, clotting factors and
other substances and of portal hypertension. Liver enlargement early in the course ( fatty liver) later to course liver size
decreases from scar tissue Portal obstruction and ascites: chronic dyspepsia, constipation or diarrhea,
splenomegaly, spider telangiectasis Gastrointestinal varices, distended abdominal blood vessels, varices or
hemorrhoids, hematemesis, profuse hemorrhage from the stomach and esophageal varices
Edema Vitamin deficiency (Vit ACK) and anemia Mental deterioration with impending hepatic encephalopathy and hepatic coma
Diagnostic Procedures:
Liver function tests ( serum alkaline phosphatase, AST, SGOT, ALT, SGPT, GGT and Bilirubin, Prothrombin time, ABGs, Laparoscopy in conjunction with biopsy
Ultrasound scanning Computed tonography (CT) scan Magnetic Resonance Imaging (MRI) Radioscopic Liver scan
COMPLICATIONS: Bleeding and hemorrhage Hepatic encephalopathy Fluid volume excess
Medical Management
Treatment includes Antacids, vitamins, balanced diet, and nutritional supplements, potassium sparing diuretics (for ascites), avoidance of alcohol
Colchicine may increase the length of survival in patients with mild and moderate cirrhosis
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Nursing Management:I. ASSESSMENT
Focus on dietary intake, nutritional status, onset of symptoms, history of precipitating factors, including long term alcohol abuse, exposure to toxic agents, medications.
Assess mental status through interview and intervention with patients, note orientation to time, place and person
Note relationships with family and friends and co-workers regarding incapacitation secondary to alcohol abuse and cirrhosis
Note abdominal distention and bloating, gastrointestinal bleeding, bruising and weight changes
Document exposure to toxic agents such as hepatotoxic medicationsII. NURSING DIAGNOSIS
Activity intolerance related to fatigue, general debility muscle wasting and discomfort
Imbalanced nutrition: Less than body requirements, related to chronic gastritis, decreased gastrointestinal motility and anorexia
Impaired skin integrity related to compromised immunologic status, edema, and poor nutrition
Risk for injury related to altered clotting mechanismsIII. PLANNING
Goals may include: Independence in activities Improved nutritional status Improved skin integrity Decreased potential for injury Improved mental status Absence of complications
IV. NURSING INTERVENTIONS
Providing rest Position bed for maximal respiratory efficiency: provide oxygen if
needed Initiate efforts to prevent respiratory, circulatory and vascular
disturbances Encourage patient to increase activity gradually and plan rest with
activity and mild exercise
Improving Nutritional status Provide a nutritious high protein diet supplemented B-complex vitamins
and others, including AC and K and Folic acid if there is no indication of impending coma
Provide small, frequent meals, consider patient preferences and encourage patient to eat, provide protein supplements if indicated
Provide nutrients by feeding tube or total parenteral nutrition(TPN) Provide patients with fatty stools (steatorrhea) with water soluble forms of
fat- soluble vitamins AD and E and give folic acid and iron to prevent anemia
Provide a low-protein diet temporarily if patient shows signs of impending or advancing coma: restore protein intake to moderate (1-1.5 kg) when patient’s condition permits
Providing Skin Care Change position frequently Avoid using irritating soaps and adhesive tapes
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Provide lotion to soothe irritated skin< take measures to prevent patient from scratching the skin
Reducing Risk for Injury Use padded side rails if patient becomes agitated or restless Orient to time, place, and procedures to minimize agitation Instruct patient to ask for assistance to get out of bed Provide safety measures to prevent injury or cuts (electric razor, soft toothbrush) Apply pressure to venipuncture sites to minimize bleeding
V. EVALUATIONExpected patient outcomes:
Demonstrates ability to participate in activities Increases nutritional intake
DIABETES MELLITUS
DEFINITION: Is a group of metabolic disorders characterized by elevated levels of blood glucose. (hyperglycemia) resulting from defects in insulin production and secretion, decreased cellular response to insulin or both.
TYPES:TYPE I (FORMERLY INSULIN- DEPENDENT DM)
About 5 to 10% of diabetic patients Beta cells of the pancreas that normally produced insulin are destroyed by an
autoimmune process Insulin injections are needed to control blood glucose levels Has sudden onset, before the age of 30 yrs.
TYPE II (FORMERLY NON-INSULIN DEPENDENT DM) About 90-95% of diabetic patients It results from decreased sensitivity to insulin (insulin resistance) or from
decreased amount of insulin production Treated with diet and exercise, then oral hypoglycemic agents are needed Most frequent in patients older than 30 yrs of age and obese patients
GESTATIONAL DIABETES MELLITUS Characterized by any degree of glucose intolerance with onset during pregnancy
(2nd or 3rd trimester) It occurs in women 25 yrs of age or older, obese and with history of diabetes in
first degree relatives or members of certain ethnic groups
CLINICAL MANIFESTATIONS Polyuria, polydipsia, polyphagia Fatigue and weakness, sudden vision changes, tingling, numbness in hands or
feet, dry skin, sores that heal slowly and recurrent infection Onset may be associated with nausea, vomiting or stomach pains Results from a slow progressive glucose intolerance and results in long term
complications if diabetes goes undetected for many yrs.DIAGNOSTIC PROCEDURES
BLOOD GLUCOSE LEVELS Fasting blood glucose levels 126mg/dl or more Random plasma glucose levels more than 200 mg/dl or more than one occasion
COMPLICATIONS HYPOGLYCEMIA
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DKA HHNS Macrovascular disease (large vessel) Microvascular disease (small vessel e.g. eyes and kidneys) Neuropathic diseases: affects sensory, motor and autonomic nerves
MEDICAL MANAGEMENT Main goal of treatment is normalize insulin activity and glucose levels and to
reduce the development of vascular and neuropathic conditions Primary treatment of DM type I is insulin Primary treatment of DM type II is weight loss Exercise is important in enhancing the effectiveness of insulin Use of oral hypoglycemic agents if diet and exercise are not successful in
controlling blood glucose levels, insulin injections may be used in acute situations
NUTRITIONAL MANAGEMENT Meal plan should be based on patient’s usual eating habits and lifestyle and
should provide all essential food constituents Goals are to achieve and maintain ideal weight, meet energy needs, prevent
fluctuate of blood glucose level For patients with insulin to maintain blood glucose levels consistency is required
in maintaining calories and carbohydrates consumed at different meals. Consult dietitian for Diabetes management
NURSING MANAGEMENTI. ASSESSMENT
Focus on signs and symptoms of prolonged hyperglycemia and physical, social and emotional factors
Assess for description of symptoms that preceded the diagnosis Assess for signs of DKA, including ketonuria, Kusmmaul respirations,
orthostatic hypotension and lethargy Monitor laboratory signs for metabolic acidosis Assess patients with type 2DM for signs of HHNS, hypotension, altered
sensorium, seizures, decreased skin turgor, hyperosmolarity and electrolyte imbalance
Assess physical factors that impair ability to learn or perform self care skills, visual defects. Motor coordination defects and neurologic defects
Assess emotional status through observation of general demeanor Assess coping skills by asking patient how patient dealt with difficult
situations in the past
II. NURSING DIAGNOSIS Risk for fluid volume deficit related to polyuria and dehydration Imbalanced nutrition related to imbalance of insulin, food and physical
activity Deficient knowledge about diabetes self-care skills and information Potential self-care deficit related to physical impairments or social factors Anxiety related to loss of control, fear, inability to manage diabetes,
misinformation related to diabetes and fear of diabetes complications Risk for complications
III. PLANNING Attainment of fluid and electrolyte balance Optimal control of blood glucose Regaining weight lost Ability to perform basic diabetes skills and self care activities
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Reduction of anxiety Absence of complications
IV. Nursing INTERVENTIONMaintaining fluid and electrolyte Balance
Measure I and O Administer IV and electrolytes as ordered Encourage fluid intake Measure serum electrolytes ( NA & K) Monitor VS to detect dehydration, tachycardia, and orthostatic
hypotensionImproving Nutritional Intake
Plan the diet with glucose control as the primary goal Take considerations in patients lifestyle, cultural background, activity
level and food preference Encourage patients to eat full meals and snacks as per diabetic diet Make arrangements for extra snacks before increased physical activity Ensure that insulin orders are altered as needed for delays in eating
due to diagnostic and other procedures Reducing Anxiety
Provide emotional support set aside time to talk with patient Clear up misconceptions patient or family may have regarding diabetes Assist patient and family to focus on learning self-care behaviors Encourage patient to perform the skills feared most-injection or finger
stick for blood glucose monitoring Give positive reinforcement for self-care behaviors attempted
Teaching Patients about Self- care Teach preventive behaviors for long term diabetic complications and
patient survival skills Provide special equipment for instruction on diabetic survival skills Tailor information according to patients ability to understand Instruct family so that they may assist in diabetes management Recommend follow-up education with out- patient diabetic specialist Assist in identifying community resources for education and supplies Health education on the ff:
1. Nutrition Eating habits Use of exchange system reading labels of foods
2. Exercise Monitoring blood glucose levels before, during and after exercise Eating complex carbohydrates before exercise Watch out for signs of hypoglycemia after exercise Encourage regular exercise
3. Self-Monitoring of blood glucose levels Provide initial training for SMBG Keep record of blood glucose levels
4. Testing urine for ketones Provide instruction in the urine testing procedure
5. Administering Insulin Therapy 3 categories of insulin, short acting ( regular)- onset 30 mins to 1 hr; peak 2-4 hrs,
duration:- 6-8 hrs. intermediate – onset- 3-4 hrs; peak- 4-12 hrs; duration 16-20 hrs and long acting insulin- onset- 6-8 hrs, peak 12 to 16 hrs,
duration- 20 to 30 hrs.6. Recognizing Problems with Insulin
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Local allergic reaction may occur- redness,, swelling, tenderness and induration of up to 1 to 2 hrs after injection
Systemic allergic reactions are rare Clinical insulin resistance may occur because immune antibodies
develop and bind the insulin Morning hyperglycemia may be noted
7. Teaching about Hypoglycemic agents Hypoglycemia may occur when excessive dose is taken Avoid ingestion of alcohol If hyperglycemia occur due to infection, trauma or surgery
hypoglycemic agent may be discontinued temporarily
V. EVALUATION fluid and electrolyte balance Optimal control of blood glucose Regaining weight lost Ability to perform basic diabetes skills and self care activities Reduction of anxiety Absence of complications
MENINGITIS
DEFINITION: is an inflammation of the meninges, (membrane surrounding the brain and spinal cord)
TYPES: ASEPTIC- maybe viral or secondary to lymphoma, leukemia or brain abcess Septic-caused by bacteria such as Neisseria maningitides Tuberculosis
PATHOPHYSIOLOGY:Causative organism- Neiserria Meningitidis (meningococcal Meningitis), Streptococcus pneumonia (adults) and Haemophilus Influenzae (childrens and young adult)
Mode of transmission: direct contact including droplets and discharges from the nose and The causative organism enters into the bloodstream ---- causes the blood-brain barrier and triggers an inflammatory reaction in the meninges----- inflammation of of the subarachnoid and pia mater occurs----increased ICP.
Meningeal infections generally originate in 1 or 2 ways1. Through the bloodstream from other infections (cellulitis) or by direct
extension( after a traumatic injury to the facial bones)2. The cause is iatrogenic or secondary to invasive procedures (lumbar puncture) or
devices (ICP monitoring devices) or to opportunistic infections such as AIDS or Lyme disease
Clinical manifestations: Bacterial Meninigitis Nuchal rigidity ( stiff neck) is an early sign Positive kernig’s sign: when lying with thigh flexed on abdomen, patient cannot
completely extend leg Positive brudzinskis sign: flexing parient’s neck produces flexion of the knees
and hips: passive flexion of lower extremity of one side produces similar movement for opposite extremity
Photophobia (extreme sensitivity to light)
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Seizures and increased ICP signs include widened pulse pressure and bradycardia, respiratory irregularity, headache, vomiting and de;pressed level of consciousness
Clinical manifestations: Meningococcal Meninigitis Abrupt onset of high fever Extensive purpuric lesions (face and extrimities) Shock and signs of disseminated intravascular coagulopathy (DIC) Death is possible within a few hrs of onset of infection In AIDS patients there are few if any symptoms because of the blunted
inflammatory response occurring in the immunocompromised patients.
DIAGNOSTIC PROCEDURES: Culture and gram straining of cerebrospinal fluid and blood
PREVENTION
People with closed contact must have antimicrobial prophylaxis (rifampin) Meningococcal vaccination Polysaccharide vaccine (Haemophilus B polysaccharide vaccine)
MEDICAL MANAGEMENT Antimicrobial therapy (penicillin or amplicillin) Vancomycin hydrochloride alone or in combination with rifampin Dexamethasone may be beneficial as adjunct therapy for H influenza type B
meningitis Fluid volume expanders use to treat dehydration and shock Diazepam or phenytoin is used to control seizures An osmotic diuretic such as mannitol to treat cerebral edema
NURSING MANAGEMENT Monitor vital signs Determine oxygenation from ABG values and ;pulse oximeter Insert cuffed ET or Traecheostomy and placed patient on mechanical ventilator Give oxygen to maintain partial pressure of oxygen Monitor central venous pressure (CVP) for incipient shock which precedes
cardiac or respiratory failure Note generalized vasoconstriction, circumoral cyanosis and cold extrimities Reduce high fever to decrease load on heart and brain from oxygen demands Rapid IVF may be prescribed If syndrome of inappropriate anti diuretic hormone (SIADH) is suspected monitor
closely for body weight, serum electrolytes, urine volume, specific gravity and osmolarity
Assess clinical status continuously, evaluate skin and oral hygiene, promote comfort and protect patient during seizures and while comatose
Implement droplet precautions and respiratory isolation until 24 hrs after start of antibiotic therapy
Inform family about patients condition and permit family to see patients at appropriate intervals
Reference: Johnson, Joyce et al, Handbook for Brunner & Suddarth’s textbook of Medical Surgical Nursing 10th Edition,Lipincott William and Wilkins, 2004
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