Osteoporosis Interventions/Teachings

(ati 927 )
-take medications as prescribed
- Instruct the client and family regarding dietary calcium food sources.
- Provide information regarding calcium supplementation (take with food).
-Instruct the client of the need for adequate amounts of protein, magnesium, vitamin
K, and other trace minerals needed for bone formation.
- Reinforce the need for exposure to vitamin D (sunlight, fortified milk).
- Encourage weight-bearing exercises to improve strength and reduce bone loss.
-Assess the home environment for safety (remove throw rugs, provide adequate
l ighting, clear walkways).
- Reinforce the use of safety equipment and assistive devices.
- Instruct the client to avoid inclement weather (ice, slippery surfaces).
-Clearly mark thresholds, doorways, and steps.
Osteoporosis Manifestations
(ati 926-927)
Subjective Data (symptoms)
Reduced height (postmenopausal)
Acute back pain after lifting or bending (worse with activity, relieved by rest)
Restriction in movement
History of fractures
●Objective Data
Thoracic (kyphosis)
Pain upon palpation over affected area
AT-RISK POPULATIONS:
Nurses
Construction Workers
Athletes
Poor Posture - Cubicle Workers
Osteoporosis Risk Factors

Age-related bone demineralization causing loss of bone tissue and decreased bone
mass resulting in fragile porous bone mass. Risk for fractures.

(slides)
-Age / Family Hx / Smoking
-Menapause- Primary osteoporosis most frequently occurs in postmenopausal women.
-Medication tx: Corticosteroids; Diuretics, Convulsant
-High Alcohol or Caffiene Intake
-Sedentary Lifestyle / Immobility
-Poor calcium absorbtion
-Hyperparathyroidism - pulling Calcium from bones / Cushings / Hyperthyroidism
Older adult clients have an increased risk of falls related to impaired balance,
generalized weakness, gait changes, and impaired vision and hearing. Medication side
effects can cause orthostatic hypotension, urinary frequency, or confusion, which can
also raise the client's risk for falls.
Musculoskeletal Pain Contraindications
** No ice Directly on JOINT, Stiffness Joints (Total Knee is the exception)
· Fracture Interventions
Open Reduction and Internal Fixation (ORIF)
Surgical realignment of the open fractured bones, with placement of pin(s) or rod(s) to
stabilize the fracture with a subsequent cast and/or traction.
Rationale for continuous passive motion (CPM) machine and frequency of use 8-12
hours/day.

Rest Ice Compress Elevate

** No ice Directly on JOINT, Stiffness Joints (Total Knee is the exception)

Musculoskeletal
Knee & Hip Arthroplasty Interventions
•Pulses and circulation checks should be done every one (1) to two (2) hours
postoperatively.
•Weight-bearing limits on the affected leg. Knee with an immobilizer on the affected joint
to provide stability.
•Elevated while the patient is sitting in the chair to minimize edema.
•Do not encourage range of motion until the surgeon gives permission for flexion of the
knee. . . . Then
•Continuous Passive Motion (CPM) is used only while the patient is in bed and ordered
with support from Physical Therapy.
Knee & HIP Post -op Joint Repl. Interventions
•Pain control management with PCA Morphine or Hydromophone (Dilaudid).
•Continuous infusion local anesthetic into joint with catheter - "baby bottle" Fentyl
infusion.
•Abduction pillows / wedge for hip replacement pts.
•Rationale for continuous passive motion (CPM) machine and frequency of use 8-12
hours/day.
•Cryopac therapy or Ice packs to reduce swelling and inflammation.
•Hemovac to negative pressure drain - JP drain or accordion drain.
**1st Line intervention is Ice Not directly on joints
Musculoskeletal
Knee & Hip Arthroplasty Discharge Teaching
Discharge teaching plan for a patient after having a total hip replacement:
-Weight-bearing limits
-Use of assistive devices
-Gradual increase in activity
-Medication therapy
-Periods of rest
Shower after first few days
Glaucoma S/Sx
Pharmacological treatments for glaucoma center on reduction of or draining or the
aqueous humor, thus reducing intra-optical pressure, not increasing it. Repair or
replacement of lenses is done with cataracts and there is no pharmacological treatment
for macular degeneration.
S/SX of flaucoma (ati 143)
Subjective and Objective Data
Open-angle glaucoma
■ Loss of peripheral vision
■ Decreased accommodation
■ Elevated IOP (> 21 mm Hg)
Angle-closure glaucoma
■ Rapid onset of elevated IOP
■ Decreased or blurred vision
■ Seeing halos around lights
■ Pupils are nonreactive to light
■ Severe pain and nausea
■ Photophobia
Glaucoma interventions
Monitor the client for increased IOP (> 21 mm Hg).
Monitor the client for decreased vision and light sensitivity.
Assess the client for aching or discomfort around the eye.
Explain the disease process to the client and allow him to express his feelings.
Treat severe pain and
Cataracts risk factors
Risk factors for Cateracts (sides)
-Lighting
-Trauma
-Smoking
-Age
-Hereditary
-Diabetes
-Excessive exposure to the sun
-Chronic corticosteroid use
Cataracts Interventions
* use patch at night / never lift more than 5 lbs
Interventions post-op for cataracts (slides)
•The patient is instructed to wear a metal or plastic shield to protect the eye from
accidental injury and is instructed not to rub the eye.
•Glasses may be worn during the day, and an eye shield is worn at night.
•Aspirin or medications containing aspirin are not to be administered or taken by the
patient; the patient is instructed to take acetaminophen (Tylenol) as needed for pain.
•The patient is instructed not to sleep on the side of the body that was operated on
because this action will cause edema and increased intraocular pressure.
•The patient is not to lift more than 5 pounds
Hearing Loss prevention
Prevention of hearing loss
-Use ear protection devices when involved with exposure to high-intensity noise.
-Keep the volume as low as possible when using headphones for listening.
-No objects should be placed in the ear.
-Have a physician remove any foreign objects that may get in the ear.
Hearing Assessment
assessment of hearing loss
•The nurse should stand 1 to 2 feet away from the patient and ask the patient to block
one external ear canal. The nurse quietly whispers a statement and asks the patient to
repeat it. Each ear is tested separately.
Hyperthyroid
thyroid is palpable on geriatric population- she said will be a multiple choice
(lecture/final)
•Hyperthyroidism: too much hormone - Graves Dx
LABS - Hyperthyroidism
1) decreased TSH, or thyroid stimulating hormone comes from the pituitary gland, trys
to bring T3 and T4 to normal range
2) increased T3, or triiodothyronine
3) increased T4, or thyroxine
Hyperthyroid Tx
TREATMENT: Hyperthyroidism
•Medications: Importance for timely dosing and Side effect of drossiness
-Methimazole
-Propylthiouracil
•Radioactive Iodine: only gland to absorb iodine
•Surgery removal of thyroid tissue with thyroid hormone supplement taken for life
Hypothyroidism
too little hormone - Hashimoto Dx
LABS - Hypothyroidism
1) elevated TSH, or thyroid stimulating hormone comes from the pituitary gland, trys to
bring T3 and T4 to normal range
2) decreased T3, or triiodothyronine
3) decreased T4, or thyroxine
Hypothyroidism Tx
TREATMENT: Hypothyroidism
Medication: Synthroid or Levothyroxine
Diabetes Mellitus / DKA
Diabetes Mellitus is chronic disorder characterized by hyperglycemia and glycosuria
manifested by inadequate production or utilization of insulin.
risk fators
•Obesity, family history, and higher than normal levels of blood glucose, a condition
called pre-diabetes, also called impaired glucose tolerance.
•
The results of the Diabetes Prevention Program (DPP) showed that weight loss through
moderate diet changes and physical activity can delay and prevent type 2 diabetes
Addison Disease:hyperglycemic complication
risk for hyperglycemia with medications (lecture/final)
Addison's disease - Hypocortisol: Decreased cortisol levels
*Addison's disease is a result of too little cortisol and corticosteroids. These patients
need to be given steroids to help normalize their bodies. These patients also need to
remain well hydrated. Dehydration could lead to an Addisonian Crisis.

*need vitamin D supplements

Cushings Syndrome S/Sx
S/Sx of Cushing's
•Altered fat metabolism: face/neck/trunk / buffalo hump
•Muscle wasting extremities; Bone demineralization
•Ruddy complexion with moon face
•Abdominal striae and thin, easily bruised skin
•Hyperglycemia
•Excess hair growth in women
•Hypertension electrolyte imbalances
•Prolonged use of corticosteroids: prednisone
Cushings Syndrome Manifestations
Manifestations
Weight gain is a common symptom of Cushing's syndrome, a condition in which you are
exposed to too much of the hormone cortisol, which in turn causes weight gain and
other abnormalities. Cushing's syndrome can occur if you take steroids for asthma,
arthritis, or lupus. It can also occur when your adrenal glands produce too much of the
hormone, or be related to a tumor. The weight gain may be most prominent around the
face, neck or upper back, or waist.
Neurology
Seizure Interventions
Priority nursing intervention during a seizure:
Protect the head and the rest of the body during the seizure, safety is the primary
concern. Afterwards, reduce stimuli and allow rest.
Neurology
Seizure Interventions During a Seizure
Priority nursing intervention during a seizure:
**Protect the head and the rest of the body during the seizure, safety is the primary
concern. Afterwards, reduce stimuli and allow rest.

•Characterized by abnormal cell firing in the brain.

Risk Factors for seizures

head injuries put a person at risk for seizures
Multiple Sclerosis & Dx
A progressive central nervous system disease, MS is characterized by exacerbations
and remissions of widespread, varied neurologic dysfunction resulting in slowed
transmission and conduction of impulses. Symptoms reflect gradual demyelination of
the white matter of the brain and spinal cord, a major cause of chronic disability in
young adults.

DIAGNOSIS
•Symptoms of MS may mimic those of many other nervous system disorders. The
disease is diagnosed by ruling out other conditions.
Multiple Sclerosis & Interventions
•Long-term medications used to slow the progression:
Interferons , glatiramer acetate, mitoxantrone (Novantrone), and natalizumab (Tysabri),
Fingolimod (Gilenya ) Methotrexate, azathioprine (Imuran),
•Intravenous immunoglobulin (IVIg) and cyclophosphamide
•Steroids, Methylprednisone, may be used to decrease the severity of attacks and
exacerbations.
MS may suffer muscle spasticity, difficulty chewing/swallowing, urine retention and
urinary tract infections, constipation, joint contractures, pressure ulcers, rectal
distension, and pneumonia. As the disease advances, it may cause blurred vision, eye
pain, blindness, ataxia, incontinence, muscle atrophy, spastic paraplegia, hemiplegia,
and complete paralysis.
Parkinson's Disease
•Dopamine inhibits and acetylcholine excites the muscles. When the patient does not
produce enough dopamine, acetylcholine is allowed to over stimulate the basal ganglia,
leading to the physical manifestation effects of tremors and shaking.
1st: Unilateral shaking and tremors in one limb.
2nd: Bilateral limb involvement and difficulty with walking and balance
3rd: Physical movements slow significantly, affecting walking more
4th: Tremors may decrease, but akinesia and rigidity begin to develop
5th: Unable to stand / walk, dependent for care, may exhibit dementia
FAST pneumonic 4 "Stroke Assessment"
F - Facial Weakness, one-sided drooping or smile
fallen to one side.
A - Arms when both raised manifests one-sided
weakness or numbness; can't hold both.
S - Speech slurred; confusion, no understanding
blurred vision.
T - Time noted of last normal assessment, Call 911
Alzheimer's Disease care plan
patient will remain free of injury
client will navigate home environment with modifications as needed
client will participate in grooming and hygiene with prompting supervision
client will utilize memory aids( alarm clocks, ect)
Benign Prostatic Hyperplasia
Manifestations/Intervention
Condition found in all geriatric males in some degree

Male > 50yo

Difficulty starting urine stream
Frequent urination, especially nocturia
Urinary retention
Hematuria
INTERVENTION
Transurethral Resection Procedure (TURP) with CBI
SURGERY
TransUrethral Resection of the Prostate (TURP)
During transurethral resection of the prostate (TURP), an instrument is inserted up the
urethra to remove the section of the prostate that is blocking urine flow. TURP usually
requires hospitalization and is done using a general or spinal anesthetic.
Benign Prostatic Hyperplasia S/Sx
•Frequency
•Nocturia
•dribbling
•hard to start
•hard to stop
• incontinence
•small amounts of urine at a time.
SURGERY
TransUrethral Resection of the Prostate (TURP)
•During transurethral resection of the prostate (TURP), an instrument is inserted up the
urethra to remove the section of the prostate that is blocking urine flow. TURP usually
requires hospitalization and is done using a general or spinal anesthetic.
Phases of Renal Failure
Renal Insufficiency / Failure
•HTN leads to damage of the afferent and efferent arterioles of the renal vascular
system, leading to poor perfusion of the kidney and poor kidney function.

•Chronic renal failure may involve a bridge to a kidney transplant with hemodialysis
and/or peritoneal dialysis.
Phases of Renal Failure Stages
ACUTE - Intrarenal Catagory
Diuretics (Lasix) are used to increase urinary output. As a result, it may be able to assist
in flushing out some of the toxins that have contributed to the acute renal failure.

CHRONIC
Phases of Chronic Renal Failure
Each stage involves increasing loss of nephron function and less glomerular filtration
rate
Renal Impairment - 40-75% nephron loss; no s/sx
Renal Insufficiency - 75-85% nephron loss with polyuria/ nocturia
Renal Failure - 15% nephrons remaining
End-stage Renal Failure/Dx< 15% nephrons < 10% glomerular rate
Acute pyelonephritis Manifestations
Kidney infection (pyelonephritis) is specific type of urinary tract infection(UTI) that
generally begins in your urethra or bladder and travels up to your kidneys

•Acute pyelonephritis is a potentially organ- and/or life-threatening infection that

characteristically causes scarring of the kidney.
SYMPTOMS
Pyelonephritis is an infection and inflammation of the renal pelvis, calyces, and medulla.
The infection usually starts in the lower urinary tract and moves up into the renal pelvis.
Chronic pyelonephritis leads to damage of the kidney, resulting in chronic renal failure.
At-Risk Populations
- Pregnancy
History of:
- Chronic kidney stones
- Benign Prostate Hypertrophy
- Diabetes Mellitus
GERD manifestations
GastroEsophageal reflux disease (GERD) is a condition in which the stomach contents
(food or liquid) leak backwards from the stomach into the esophagus (the tube from the
mouth to the stomach). This action can irritate the esophagus, (Reflux esophagitis);
causing heartburn and other symptoms.
Contributing factors: diet excessive ingestion of foods that are fatty, fried, chocolate,
caffeinated beverages, spicy foods, citrus, alcohol.
Distended abdomen from overeating or delay emptying
NSAID's stress that increses gastric acids
Lying Flat
TX: Primary tx is diet and lifestyle change
advances to antacids, H2 receptor antagonists, proton pump inhibitors, last is surgery
Laparoscopic Cholecystectomy Post-op
Post-laparoscopic Cholecystectomy
Thoracic pain in the shoulder or upper back pain after a laparoscopic abdominal surgery
is a result of the free air that is placed in the abdomen during surgery to make room for
the instruments and to complete the surgery. Ambulation is usually helpful for this type
of pain.
Sigmoidoscopy manifestations
A sigmoid colostomy is the most common permanent colostomy performed, particularly
for cancer of the rectum. It is usually created during an abdominoperineal resection.
Other colostomies
•Duodenal
•Double-barrel
•Transverse loop
Ostomy Interventions / Teaching
Radical surgery that results in a drastic change in the way waste products may be
dispelled by the body affects body image. A fear of smell or other accidents may alter
the patient's ability to feel attractive or effective in work or social roles. Patients may
defer this life saving surgery to postpone this disfiguring intervention or therapy.
Teaching:
Empty ostomy bag when it's ¼- ½ full
Foods that can cause odor fish, eggs, asparagus, garlic or gas leafy veggies, beer,
carbonated drinks
Avoid high fiber foods for first 2months
Do not put anything in bag to mask odor/ keep clean
Interventions:
Assess type of ostomy the higher up in small intestine, the more liquid and acidic output
Apply skin barrier creams when applying wafers to protect skin
Assess integrity of stoma you want pink appearance and moist.
Inflammatory Bowel Disease-- Ulcerative Colitis
A chronic inflammatory bowel disorder of the large intestine, colon and rectum.
treatment
•The patient would be NPO to put the bowel at rest, which is the rationale for
administering TPN
•TPN is high in dextrose, which is glucose; therefore the patient's blood glucose level
must be monitored very closely. The patient may be on sliding-scale regular insulin
coverage for the high glucose level.
•TPN must be administered through a central line because of the high glucose levels.
Appendicitis
Pain located on right side, very painful, if no pain (resolves) means it burst, now at risk
for sepsis
Peptic Ulcer Disease
Most common ulcer of an area of the gastrointestinal tract that has breaks in the
gastrointestinal mucosa and is usually acidic and thus extremely painful. It is defined as
mucosal erosions equal to or greater than 0.5 cm. As many as 70-90% of such ulcers
are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic
environment of the stomach; however, only 40% of those cases go to a doctor. Ulcers
can also be caused or worsened by drugs such as aspirin, ibuprofen, and other
NSAIDs.
•Use of NSAIDs places the patient at risk for peptic ulcer disease and hemorrhage. Any
patient suspected of having peptic ulcer disease should be questioned specifically about
the use of NSAIDs.
•If a patient has an extensive peptic ulcer disease, they may develop pernicious anemia.
Pernicious anemia (vitamin B12 anemia) is a result of the lack of intrinsic factor
secreted by the gastric mucosal cells.
Findings for Asthma
ETIOLOGY
Air flow into lungs is unobstructed, however mucus holds stale air in the bases forcing
air out of the upper respiratory passages only.
PREVENTION
•Lifestyle Changes
•Relaxation Techniques
•Seek Treatment or Professional Counseling
•Prophylactic Inhalers: Albuterol 10-15min before Exercise (EIA)

Stridor breath sounds are heard with acute asthma and reactive airway diseases.
COPD Tx
COPD Tx (slides)
Immunizations
Antibiotics
Bronchodilators
Corticosteroids - Oral and Inhaled
Beta-Adrenergic Agonists

Oxygen Therapy - Low flow rate:

Normally, CO2 stimulated breathing b/c it initiates Hypoxic Drive.
Chronic COPD patients have chronic elevated carbon dioxide levels. They "retain" their
bodies to breath when they are low in oxygen. High rate flow may actually stop
breathing. This will increase PaC02 leading to somulence and respiratory failure.
COPD S/Sx
S/Sx
Dyspnea upon exertion
■Productive cough that is most severe upon rising in the morning
■Respiratory acidosis and compensatory metabolic alkalosis
■Crackles and wheezes
■Rapid and shallow respirations
■ Use of accessory muscles
■ Barrel chest or increased chest diameter (with emphysema) Hyperresonance on
percussion due to "trapped air" (with emphysema)
■ Irregular breathing pattern
■ Thin extremities and enlarged neck muscles
■ Dependent edema secondary to right-sided heart failure
■ Clubbing of fingers and toes
■ Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease)
■ Decreased oxygen saturation levels (expected reference range is 95% to 100%)
■ In clients who have dark-colored skin or in older adults, oxygen saturation levels can
be slightly lower
COPD Interventions
Position the client to maximize ventilation (high-Fowler's is 90.).
◯ Encourage effective coughing, or suction to remove secretions.
◯ Encourage deep breathing and use of an incentive spirometer.
◯ Administer breathing treatments and medications as prescribed.
◯ Administer oxygen as prescribed. (low flow drive for need for oxygen)
LECTURE/FINAL
◯ Monitor for skin breakdown around the nose and mouth from the oxygen device.
◯ Promote adequate nutrition.
■ Increased work of breathing increases caloric demands.
■ Proper nutrition aids in the prevention of infection.
■ Encourage fluids to promote adequate hydration.
■ Dyspnea decreased energy available for eating, so soft, high-calorie foods should be
encouraged.
◯ Monitor current weight and note any changes.
Aspiration Intervention
suctioning (lecture/final)
Cyanosis Nursing Diagnosis
-Impaired gas exchange
-Decreased cardiac output r/t stroke vol and tissue perfusion decreases
Intervention for Hypoxia
1. Oxygenate - nasal cannula or mask (low O2 for copd)
2. Place in high fowler's position
3. Rest
4. Medicate as ordered
Findings for decreased cardiac output
Finding for decreased cardiac output
changes such as decreased renal functions may occur, causing other system to
compensate so decreased cardiac output . when produce renin, which eventually
increases blood pressure and sodium retention. gradually changes are benign but lead
to decreased cardiac and renal function and to fluid overload.
Findings for decreased valvular disease
May involve any valve and wither stenosis(stiff, narrow opening, reducing blood flow) or
insufficiency (incomplete closing of valves, allowing blood to regurgitate and reducing
cardiac output) symptoms depend of severity, shortness of breath, palpitations, edema
of lower extremities, weakness, dizziness, weight gain and chest pressure changes in
organ function results from compromised blood flow, Example: decreased blood flow to
the brain presents as LOC change
S/Sx of CHF "Chronic"
Chronic heart failure S/Sx
Shortness of breath (dyspnea) when you exert yourself or when you lie down
Fatigue and weakness
Swelling (edema) in your legs, ankles and feet
Rapid or irregular heartbeat
Reduced ability to exercise
Persistent cough or wheezing with white or pink blood-tinged phlegm
Swelling of your abdomen (ascites)
Sudden weight gain from fluid retention
Lack of appetite and nausea
Difficulty concentrating or decreased alertness
S/Sx of CHF "Acute"
Acute heart failure S/Sx
Symptoms similar to those of chronic heart failure, but more severe and start or worsen
suddenly
Sudden fluid buildup
Rapid or irregular heartbeat (palpitations)
Sudden, severe shortness of breath and coughing up pink, foamy mucus
Chest pain, if your heart failure is caused by a heart attack
Geriatric cardiac changes
decreased cardiac output as they age body fluid becomes less
DVT S/Sx
Deep Vein Thrombosis dislodges from bilateral lower extremities, following Surgery,
Thromboplebitis, or Immobility, and travels to the right side of the heart, circulates, and
lodges in the branches of the Pulmonary Artery causing partial or complete occlusion
Always Life Threatening
signs and symptoms
-Dyspnea
-Tachypnea
-Sudden Onset of Chest Pain
-Tachycardia
-Anxiety
-Cough
-Hemoptysis
-Diaphoresis
FEELING OF DOOM
DVT Interventions/ Pt Teaching
Interventions:
•Elevate legs
•Heat or Compression Stockings, as ordered
•Encourage ambulation
•Avoid trauma - needle sticks
•Monitor lab results
•Prevent complications of immobility
•Anxiety intervention
NO MASSAGE! No ASPIRATION
LMWH - Low Molecular Weight Heparin (used at hospital) lecture/final
•MEDICATION interventions:
-Administer Warfarin (Coumadin) - prevention
-Administer Enoxaparin (Lovenox) - prevention keep blood thin (used at home)
-Administer pain medication
-Monitor for therapy effectiveness and complications of bleeding
S/Sx of Anemia
•Tachycardia
•Grey Skin Pallor
•Fatigue
•Dizziness
•Glossitis - inflammation of tongue
Cheilitis - inflammation of lips
Plan of Care Anemia (Iron deficiency)
•Take with orange juice or other high VIT C drink; take on empty stomach (1 hour before
or 2 hours after meal); stools dark green and tarry; (she said is driving point on lecture)
*For better absorption is best practice
•Avoid Tetracycline ABX, antacids, allopurinol, VIT E; may cause nausea at first until
body use to it.

**Toxicity: nausea, diarrhea, or constipation.

Best location to hear all Heart Sounds?
S1- best heard at the apex of the heart, located at 4-5 intercostal on the left fourth heart
sound- abnormal heart sound just prior to S1 "document"
· Rhuematoid arthritis interventions
Highest priority when caring for a client diagnosed with rheumatoid arthritis?
•Pain is priority over psychological problems and activity.
•Simple exercises, a warm shower and maintaining a regular medication regimen are all
good things to do to help decrease morning stiffness and soreness.
•Ice will increase pain in a stiff and sore joint NO ICE ON JOINT. alternate hot/cold not
directly (lecture)
(Only used to help decrease swelling / edema by causing vasoconstriction)
Autoimmune disease is a long-term disease that the body's immune system mistakenly
attacks healthy tissue and leads to inflammation of the joints and surrounding tissues. It
can also affect other organs.
S/Sx
•Inflammation
•Bilateral and systemic
•Multiple joints
•Affects upper extremities first then systemic, sparing joints of the hands
•Elevated rheumatoid factor, ANA, ESR
Ice Pack Contraindications / Interventions
never put ice directly on injury, except for knee. Alternate hot/cold
PQRST pneumonic
P Provoking factors: What brought on the symptoms? What were you doing when it
started?
Q Quality. Is the pain stabbing, burning, sharp? Is it a gnawing feeling?
R Radiation. Does the pain go anywhere or does it just stay in one place?
S Severity/Symptoms. How bad is it? Are there any other symptoms associated with it?
T Triggers/Timing. When did it come on? Is it continuous or intermittent? What makes it
worse?
· Physiologic Manifestations
Acute pain is temporary, usually has a known cause, is generally treatable, and serve
the purpose of alerting the person to possible harm.

Chronic pain persists over time, might or might not have a known cause, respond to
treatment, and serve no useful purpose.
Epicutaneous Test
Definitions:
Literally, on the skin, referring to introduction of biologic material or drugs into the skin
by shallow, bloodless piercing with small-gauge needles through drops of solution, used
in allergy testing, tuberculosis skin tests, smallpox immunization, and in many other
procedures.
Allergic reaction interventions
Anaphylaxis is life threatening allergic reaction. Requiring immediate emergency
medical treatment.
S/Sx: Wheezing sounds, labored breathing
n/v/d, Weakness, light headedness, dizziness
Blue skin result no O2, Hives, low BP, abnormal heart rhythm
Epinephrine is 1st line of treatment-given subcutaneous or intramuscular. epinephrine
dilates airway, and narrows blood vessels....essentially counteracting allergic reaction.
· Pruritis intervention
**Psoriasis manifests silvery patches. Typically seen on the scalp.
-Over production of keratin, it' autoimmune disorder w/ periods of exacerbations &
remissions.
Painful rash could be shingles, a result of the herpes zoster virus. It usually manifests
hemispherically (one side or the other).
Herpes simplex would be a cold sore or fever blister.
Pemphigus vulgaris are blisters in the mouth
Seborrheic dermatitis is "cradle crap" or white, flakey skin on the head.
Pruritis intervention Interventions
Medications:
-Topical corticosteroids -Triamcinolone acetonide (kenalog) Reduces inflammatory
response of lesions
-Nurse should observe skin for thinning, strai w/high potency corticosteroids
-Tar Preparations - Coal Tar (Balnetar)
-Repress cell division/decrease inflammation
-Nurse teach proper application & how to assess for cancerous lesions
-Topical epidermopoiesis suppressive medication Calcipotriene (Dovonex)
-Monitor signs of hypercalemia
-Teach avoid product on face/skin folds not use concurrently w/corticosteroids.
-Advice sunscreen and limit sun exposure
-Therapeutic Procedures-
**PUVA Psoralen (photosensitizing medication) & Ultraviolet Light
Psoralen given 2hrs before light treatment.
Treatment given 2-3x's per week, avoiding consecutive days.
· Pressure Ulcers
Stage 1- intact skin w/areas of persistent, non blanching redness over bony
prominence, may feel warm to touch.
Stage 2- Partial thickness skin loss involving epidermis and dermis. Ulcer visible and
superficial, blister, shallow cavity.
Stage 3- Full thickness tissue loss w/damage or necrosis of subcutaneous tissue. Ulcer
appears deep crater w/o exposure to bone.
Stage 4- Full thickness tissue loss w/destruction, tissue necrosis, damage to muscle,
bone, deep pockets of infection, tunneling, eschar or slough scab (tan, yellow or green
may appear)
Wounds
**GREEN & WHITE discharge = INFECTION It is emergent
**Wound that has dehiscence ....Intervention-Never close wound, vac would not work it
has to heal from the inside-out
Inflammation
Inflammation is one of the complex defense mechanisms the human body has
developed in order to defend itself by containing the injury and destroying the invading
microorganisms. Inflammation allows repair of the injured area to proceed at a faster
pace.
FIRST STAGE: Vascular and cellular responsesInvolving blood vessel constriction at
site of injury / infection. Tissues release histamines, kinins, and prostaglandins in
response to injury / infection that dilate blood vessels and contract smooth muscle to
increase blood flow to the site responsible for the redness and heat in inflammation.
Fluid, proteins and leukocytes (WBCs) leak into the interstitial spaces causing pain on
nerve endings
SECOND STAGE: Exudate production
Fluid exudes or "oozes" from the blood vessels and dead tissue cells. Types of exudate
are serous (thin-watery straw-colored), purulent (opaque or milky), and hemorrhagic
(sanguinous - is red and thick). Collegan adds strength, then granulation tissue adds
capillary network leading to epithelialization.
THIRD STAGE: Reparative phase
When underlying tissue support structures are intact, the epithelial tissues of the skin,
digestive and respiratory tracts will have good regenerative capacity, as well as
osseous, lymphoid, and bone marrow.
No epithelialization = scab/crust/eschar. Replacement of destroyed tissue cells by cells
that are identical or similar in structure and function and provide fibrous tissue (scar)
formation. However, not with nerves, muscular and elastic tissues.
· Hypomagnesaemia
Increased: renal failure, hypothyroidism, severe dehydration, lithium intoxication,
antacids, Addison's disease.
Decreased: hyperthyroidism, aldosteronism, diuretics, malabsorption,
hyperalimentation, nasogastric suctioning, chronic dialysis, renal tubular acidosis, drugs
(aminoglycosides, cisplatin, ampho B), hungry bone syndrome, hypophosphatemia,
intracellular shifts with respiratory or metabolic acidosis.
*Hypomagnesaemia due to chronic alcohol use *Interventions: Mag Riders Below
S/Sx: HypoNatremia
Muscle Cramps / Twitching - Muscle twitching is a sign of early sodium imbalance and if
not treated could progress to seizures
Headache
Lethargy / Generalized Weakness
Confusion / Stupor / Coma / Seizures
Anorexia
Nausea / Vomiting
Abdominal Cramping
CAUSES: Hyponatremia
Total body water loss proportionately lower than Na loss
An increase in total body water (oral) that is not accompanied by an increase in sodium.
A decrease in dietary intake of sodium or an excess of sodium excretion.
Excessive use of hypotonic IV solutions / Diuretics
Nausea / Vomiting / Diarrhea / Nasogastric suctioning
Chronic Renal or Adrenal Insufficiency; CHF; SIADH; Ascites
Hyperlipidemia and Hyperglycemia
Define HypoNatremia/ Values
<135 meq/L Severe < 120 meq/L
The interstitial tissue pulls fluid from the bloodstream to areas of higher solute found in
the cells with Risk of brain damage secondary to brain cell injury resulting from swelling,
edema, and increased ICP, intracranial hemorrhage, and neuro deficit.
People at Risk for HypoNatremia
Older adults greater risk due to increased incidence of chronic illness, use of
diuretic medications and insufficient Na+ intake *(Mostly seen in Older Pt's More
Common!) (lecture)
Excessive water intake
Excessive hypotonic IV
GI losses n/v/d, nasogastric suctioning
Water enemas
Adrenal insufficiency
Ascites (related to cirrhosis)
Sweating, burns, wound drainage
S/Sx: HyperNatremia
Thirst / Dry Mucous Membranes
Fever
Lethargy / Generalized Weakness
Confusion / Irritability / Seizures
Weight Loss
Tachycardia
Orthostatic Hypotension
Oliguria (decreased urine)
CAUSES: HyperNatremia
Inadequate Fluid Intake evidenced/by Decreased Turgor
Altered Thirst Mechanism
Abnormal Hormone Secretions
Decreased pituitary: ADH - Diabetes Insipidis
Increased: Cortisol - Cushing's Syndrome
Aldosterone - Kohn's Syndrome
Rapid Breathing / Diaphoresis(sweating) / Fever
Renal Water Losses - diuretic therapy
Too Much Sodium Dietary Intake
Define HyperNatermia /Value
Value > 145 meq/L
Hyperosmolality results in Risk of Fluid Volume Deficit with a Total Body Water Deficit.
In response, the bloodstream pulls fluid from the brain's interstitial tissue to the vascular
compartment of higher solute by the process of osmosis. Risk of brain damage
secondary to brain cell injury resulting in shrinkage and /or intracranial hemorrhage and
neuro deficit.
People at Risk for Hypernatremia
Infancy or Advanced age
Insensible Water Losses: Tachypnea / fever / diaphoresis
Third-spacing Water Losses: Fluid Volume Deficit
Diabetes Insipidus
Osmotic Diuresis
Diuretic Therapy
Excess ingestion of OTCs / Drug Therapy
Cushing's Syndrome
Hyperaldosteronism
Fluid Vol Excess:
Before you hang any IV fluid, know what you're hanging, why it's been ordered, and
what complications may occur. Since fluid overload is common to all IV solutions, be
alert for its signs: neck vein distention, increased blood pressure, adventitious lung
sounds, and respiratory distress.
Excess fluid is both intracellular fluid (ICF) & Extracellular fluid (ECF) 2nd to Increase
TOTAL body Sodium =Water Retention
Risk Factors for Fluid Vol Excess
At Risk for Vol Excess
Abnormal kidney function reduced secreation of Na+ and water (renal failure)
Interstitial plasma fluid shifts (hypertonic fluids, burns)
Water replacement without electrolyte replacement (excess exercise w/o diaphoresis)
S/Sx of Extra Cellular Fluid Volume Excess
S/Sx of Extra Cellular Fluid Volume Excess
Dyspnea / Cough / Crackles / Rales
Hypoxemia
Pulmonary Edema / Peripheral Edema / Sacral Edema
Weight Gain
Hypertension / JVD
Heart gallops - S3 and S4 (Always document abnormal sound as extra sound herd)
Severe HyperVolemia lead to Heart Failure
Bounding peripheral pulses
Ascites
Pleural Effusion
LABS for Fluid Vol Excess
LABS: Decreased
Serum Protein
Serum Sodium (135-145)
Hematocrit (M:40-54, W:38-47)
Hemaglobin (M:13.0-18.0, W:12.0-16.0)

right sided heart failure fluid overload and body has already been compromised. Left
sided happens more often and fights against aorta pressure.
· Fluid Vol Deficit:
less fluid higher osmosility (LABS) for everything (lecture final)
The pathophysiologic consequences of fluid volume deficit range from mild
abnormalities to hypovolemic shock
CAUSES: Extracellular Fluid Volume Deficit
Fluid losses from the GI tract: n/v/d/suctioning
Inadequate fluid Intake: abnormal thirst mech / swallowing
Renal losses: diuretics / Addison's / hypoadosteronism
Insensible losses: fever / sweating / deep wounds / bleeding (hemorrhage)
3rd-space losses: edema /ascites / peritonitis / burn injury /SBO
**With Fluid Loss: Dehydration #1 Risk factor for Vol Deficit
· Fluid Vol Deficit: At Risk
**At Risk are aging adults...Prevention is encourage fluids regardless of thirst
perception
Hypovolemia
Metabolic acidosis
Hypokalemia
Hypernatremia
S/Sx of Extra Cellular Fluid Volume Deficit
VS: Hypotension, tachycardia,thready pulse, tachypneic (increased respirations)
GI: Thirst, dry tongue, n/v, anorexia, acute weight loss
Diminished cap refill
coool clammy skin
diaporesis
sunken eyeballs
flattened neck vein (ATI pg558)
Vol Deficit May Result From: Third Spacing or Compartment Syndrome
A fluid shift from the vascular space into a trapped area where this fluid represents a
volume loss with no support of normal physiologic processes. Areas like the abdomen,
bowel, pleural or peritoneal space. Third spacing may not be apparent until after organ
malfunction. **Bladder scan will detect 3rd spacing!
LABS for Fluid Vol Deficit
LABS: INcreased Decreased:
Urine Sodium (urine)
ABG's
HCO-3 = Metabolic Alkalosis
Alkalosis
pCO2 = Respiratory Alkalosis

pH

HCO-3 = Metabolic Acidosis

Acidosis pCO2 = Respiratory Acidosis

NORMAL VALUES
pH = 7.35 - 7.45
pCO2 = 35 - 45 (Respiratory)
pO2 = 80 - 100
HCO-3 = 22-26 (Metabolism)
Base Excess = -5 to +3
· Delegation to Unlicensed Assistive Personnel
The purpose of delegation is to share tasks as appropriate by decreasing the overall
workload of the primary nurse.
When the nurse delegates nursing care activities to another person, that person is
authorized to act in the place of the nurse, while the nurse retains the responsibility and
accountability for the activities performed. The nurse is accountable for reviewing the
data collected by another person and ensures it is done appropriately.
When delegating a skill, it must be within the scope of the RN to delegate it, the
unlicensed nursing assistant (UNA) or unlicensed assistive personnel (UAP) must be
qualified to perform the skill. Nurses should not delegate skills just because they don't
want to do them; nor do they need to do everything themselves.
* It is appropriate to delegate. *Task must be in the CNA's scope of practise!!
Intervention for Warfarin (Coumadin) toxicity
Protamine sulfate- is a drug that reverses the anticoagulant effects of heparin by binding
to it.
Protamine was originally isolated from the sperm of salmon and other species of fish but
is now produced primarily through recombinant biotechnolog (internet)
assess for petechiae, no razors blades, soft toothbrush, and complications of
bleeding(Maritza)

Vitamin K- can decrease the therapeutic effects of warfarin (Coumadin) and place
clients at risk for developing blood clots. Clients taking warfarin should include a
consistent amount of vitamin K in their diet.
Sliding Scale Insulin calculation / Best Practice
Sliding Scale Insulin calculation / Best Practice
lecture it was said, that we need to check glucose levels first and everyone has a
different chart for their sliding scale. When they go home they will not be on a sliding
scale. (lecture)
CVA care plan
■ Assess the ability to understand speech by asking the client to follow simple
commands.
-Assist with the client's communication skills if his speech is impaired.
■ Assess swallowing and gag reflexes before feeding. Speech therapy may be
requested to do this during a swallowing study that can involve swallowing a
barium substrate and radiography of the peristaltic activity of the esophagus.
Monitor for changes in the client's level of consciousness (increased ICP sign).
-Assist with safe feeding.
If a swallowing deficit is identified, the client's liquids may need to be thickened
with a commercial thickener to avoid aspiration.
-Maintain skin integrity.
■ Reposition the client frequently and use padding.

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