ENDOCRINE CONDITION Who is at risk? Signs/Symptoms Lab/Diagnostics Nursing Management Hyperthyroid Primary vs secondary Graves, goiter, amiodarone-induced Family history of thyroid/AI disease Recent pregnancy Excess iodine Meds (amioadarone) Tachycardia, a-fib Tremors Goiter Warm, moist skin Hair falls out Irritability Heat intolerance Hyperactiviy Weight loss Diarrhea Proptosis/exophthalmos Serum antibodies Decreased TSH Increased T3 & T4 Uptake/suppression Tapazole, PTU Beta-blockers 131I Thyroidectomy Thyroid storm Assess for fever, diaphoresis, S/S Antithyroid drugs Hormones Post-op Respiratory distress Hemorrhage Hypocalcemia Thyroid storm Hypothyroid (Myxedema) Primary vs secondary Hashimoto – hyper then hypo Family history of thyroid disease History of autoimmune disease (women) Aging Inadequate dietary iodine Previous tx for hyperthyroidism Dry skin Cold extremities Hair breakage, dry hair Bradycardia Peripheral edema Delayed DTR relaxation Carpal tunnel Tiredness Amenorrhea Weakness Cold intolerance Difficulty concentrating Weight gain Constipation Hoarse voice T4 and TSH Antibodies (Hashimoto) Levothyroxine (1º) TSH stimulation (2º) Myxedema crisis Cardiac – IV fluids Neuro Respiratory – monitor; ventilator Rewarm Hypoparathyroid Family hx, heredity Neck sx/radiation Comorbidity Hypocalcemia Hyperphosphatemia Numbness, tingling Muscle cramps Chvostek’s Trousseau’s Ca and P levels Ca: decreased P: increased Ca, calcitrol, vit. D Fall and fracture prevention Hyperparathyroid Primary: gland enlargement; hyper-Ca Menopause Prolonged Ca/vit. D deficiency Neoplasm Bone fx/weakness Oliguria, kidney stones, acidosis Weakness, fatigue, Increased PTH Ca: increased Bone density test = Osteopenia: weak bones Parathyroidectomy + Ca supplements (1500-2000 mg/day) Hemorrhage
decreased libido, impotence Kidney stones CARDIOVASCULAR CONDITION Who is at risk? Signs/Symptoms Lab/Diagnostics Nursing Management CAD Increasing age Genetic predisposition Gender - male Diet Sedentary lifestyle - obesity Smoking High LDL Low HDL High total cholesterol HTN DM High CRP Atherosclerosis Angina pectoris Unstable angina Myocardial infarction Sudden cardiac death Supply & demand of myocardial tissue Ischemia – ECG changes; angina pectoris Lipid panel CRP – inflammation Homocysteine – inflammation Intravascular US Cardiac cath and percutaneous coronary intervention (PCI) Coronary angiography CV modifiable risk factor reduction Physical activity Dietary changes Monitor weight, exercise, food intake Support groups Catheterization and PCI Balloon or stent Angina Pectoris Stable – predictable, goes away with rest Unstable – unpredictable, may involve clot, vasoconstriction, risk for MI Prinzmetal or vasospastic Same as above Sudden onset of discomfort in chest, jaw, shoulder, back, or arm Ca-channel blockers Nitrates Beta-blockers Activity restriction Remove precipitating factors Supplemental O2 during pain Assess: PQRST, hx, physical findings, VS, ECG changes Myocardial Infarction Complications of angina (high MI risk): Increased angina duration, frequency or at rest (unstable) ST or T wave changes Signs of HF Pulmonary edema Tachycardia Hypotension Acute: chest pain more intense than angina Diaphoresis SOB Generalized weakness May mistake S/S for indigestion Troponin – 4-6 h post up to 4-7 days; serial pattern Creatine kinase – (CK-NB) h to 48-72 h Myoglobin – damage to heart muscle EKG changes – place in tele MONA - Dilate coronary arteries Thrombolytics CABG Prevent ACS: O2, vasodilate, reperfuse, prevent thrombus, blood flow IHI: early admin of aspirin aspirin @ d/c 325 mg beta-blocker @ d/c
Chemicals Alcohol use Nosocomial infections Chest radiation SCD Endocarditis Acute: rapid onset, virulent Subacute: low virulent organism Recent dental sx Illegal drug use Weakened valves Previous hx PNA Valve dysfunction Nosocomial infections Chest trauma Septal defects Bleeding gums Long-term central line Prosthetic valves Congenital heart disease Cellulitis Rheumatic fever Marfan’s syndrome HIV Fever Chills, Night sweats Tachycardia Fatigue Malaise Anorexia Weight loss Headache Arthralgias Myalgias Back pain Abdominal discomfort Clubbing Splinter hemorrhages on nails Petechiae Osler’s nodes (painful lesions)) Janeway’s lesions Roth’s spots on retina Mild elevation of WBC in IE Elevated Erythrocyte Sedimentation Rate (ESR) in IE Elevated CRP in IE Elevated CK-MB, Troponin Conduction delay, ST changes CHF symptoms of ECG CXR – septic pulmonary emboli Cardiac tamponade Pericarditis Thoracic surgery Trauma Chest pain worsened by deep breathing or coughing Difficulty breathing Discomfort, sometimes relieved by sitting upright or leaning forward Pale, gray, or blue skin - cyanosis Palpitations - tachycardia Rapid breathing Dizziness Drowsiness Weak or absent pulse Anxiety Decreased LOC Elevated venous pressure Decreased CO Decreased BP Loss of tissue perfusion Narrowed pulse pressure <30 mmHg Beck’s triad – low BP, muffled heart sounds, JVD Weak peripheral pulses Pulsus paradoxus - >10 drop in SBP during inspiration ECG – low QRS Pericardiocentesis Hemodynamic monitoring ECG monitoring Fluid replacement Pericardiectomy or pericardial window Surgical resection Mitral valve disease Pulmonary hypertension Decreased CO Increased pulse pressure Stenosis: Regurgitation: Dyspnea, weakness, fatigue Orthopnea, paroxysmal nocturnal dyspnea, peripheral Murmurs Echocardiogram Transesophageal echocardiography (TEE) ECG monitoring for a-fib Monitor for cardiomegaly Maintain CO and activity tolerance
ventricular tissue remodeling CAD Genetic Idiopathic Inherited disorders Pregnancy HTN CAD Viral myocarditis Cocaine Calcium overload Hyperlipidemia Obesity DM Idiopathic Chemotherapy Genetic Neuromuscular disorders Endocrine (DM, Cushing’s) Abnormal electrolytes Antiviral meds Cardiac valve disease Congenital heart disease Sleep apnea Radiation therapy Amyloidosis, sarcoidosis Smoking Familial cardiomyopathies Cardiac surgery Bacterial/parasitic infections Stress, sedentary lifestyle Toxins Pregnancy, PP period Connective tissue disorders Nutritional deficiency Mitral/tricuspid insufficiency Endomyocardial biopsy Radionuclide study Palliative Heart transplant Permanent mechanical assist devices Detailed hx ADLs Paced/reduced activity Positioning O2 therapy Hypertrophic obstructive cardiomyopathy Usually <30 y/o Sudden death Disorder of sarcomere Genetic HTN, hypoparathyroidism Idiopathic LV hypertrophy Hypertrophy in septum Sudden death, severe HF Dyspnea Chest pain Presyncope, syncope Paroxysmal nocturnal dyspnea Echo CXR ECG, resting & ambulatory Cardiac catheterization Endomyocardial biopsy Radionuclide study Find/treat underlying cause Control S/S Prevent progression Improve QOL Genetic testing Meds Activity restriction Fluid stabilization Restrictive cardiomyopathy Endocardial scarring Fibrosis & thickening Impaired diastolic stretch Ventricular stretch Cocaine use Sarcoidosis Restrictive pulmonary disease Pulmonary/systemic congestion Dyspnea Palpitations, fatigue, syncope, angina, weakness, exercise intolerance R or L sided HF S3, systolic murmur CXR ECG Echo Cardiac catheterization Endomyocardial biopsy Radionuclide study Decrease cardiac workload Teach to avoid situations that impair venous filling or lower CO Arrhythmogenic Right Ventricular Cardiomyopathy Electrical disturbance because of scarring in RV Genetic Palpitations, light-headedness, fatigue Sudden cardiac death RV: prominent neck veins, liver distention, swollen legs and ankles LV: (advanced stage) fatigue, SOB Good family hx Heart transplant NO OTHER CURE Antidysrhythmic Decrease workload Energy conservation
May involve LV Peripheral arterial disease Older age Male gender African American Smoking DM Hyperlipidemia HTN Intermittent claudication Muscle/limb weakness Absent/diminished pulses Poor hair growth Resting limb pain Paresthesia Poor healing Ankle-brachial index Treadmill exercise arterial studies Duplex US Segmental arterial pressures Angiography CT MRI/MRA Lifelong aspirin tx Meds Angioplasty Stenting Radiation tx Percutaneous transluminal angioplasty Arterial bypass Amputation Acute arterial ischemia: immediate heparin tx or embolectomy Peripheral venous disease Swelling, tightness, discomfort in one or both Les Unilateral = DVT Stasis dermatitis, stasis ulcers Streptokinase (not for DVT) Vena cava filters – prevents PE, stroke Varicose veins Older age Female Obesity Jobs w/ prolonged standing Low-fiber diet Smoking HTN Pregnancy Injury Dilated tortuous veins Often none Sensation of heaviness, tiredness, itching Visible during pregnancy or menstruation Recurrence Ligation Stripping Laser therapy Radiofrequency ablation of vein Wear compression stockings after venous sclerotherapy Avoid venous pooling Walking program, weight loss DVT Immobility – SCI, paresis Fx of pelvis, hip, long bones Multiple trauma, burns, sx, infection, inflammation Hypercoagulability states Previous DVTs, PE Malignancy MI, HF, respiratory failure, sepsis, ulcerative colitis ICU admission Age >40 Obesity Immobility 3 days or more Varicose veins Pregnancy, PP Oral contraceptive use Virchow’s triad: Venous stasis Damage of endothelium Hypercoagulability Asymptomatic until PE Unilateral pain, edema, warmth, tenderness Slightly puffier than other leg Homan’s sign Duplex US Venography CT and MRI Venous duplex imaging Photoplethysmography Ambulatory venous pressure Early ambulation as tolerated Elevate 10 to 20º above level of heart Moist heat AVOID MASSSAGING Graduated compression stockings Anticoagulants (heparin, thrombin inhibitors, warfarin) Venous thrombectomy Percutaneous interruption of vena cava AROM, PROM Avoid prolonged sitting, standing, crossing legs Intermittent pneumatic
Nutrition, fluid Avoid exposure to others with infections Meds S/S to watch out for Pulmonary tuberculosis HIV/AIDS Immunocompromised Dyspnea Weight loss Cough Sputum production Sleep disturbances Rust colored sputum Night sweats Low grade fever Advanced: Activity intolerance, fatigue Low grade fever, night sweats Blood-streaked sputum Dullness w/percussion over involved area Bronchial breath sounds, increased transmission of whispered sound Tuberculin skin test – read 48-72 hours, 10mm (5mm for immunocompromised) CXR – if BCG vaccinated Acid-fast bacillus smear – 3 positives on 3 different days Sputum culture Drug tx Negative pressure room Airborne isolation until 3 sputum cultures are neg Pain management Fatigue management Good nutrition Lung abscess Necrotizing PNA Bacterial, fungal, parasitic Pus in the lung itself Fever Chills High-dose antibiotics Pulmonary empyema Chest tube for pleural effusion Pus in pleural space Drainage of pus Re-expand the lung Control the infection COPD: Emphysema Dyspnea/wheezing Use of accessory muslces Vent/perfusion mismatch Decreased forced expiratory volume Involvement of alveoli Cachexia Barrel chest Changed muscle definition Clubbing – chronic hypoxia ABG: PaO2 <80-50 mmHg PaCO2 – increased to 50 Polycythemia vera – high H/H Sputum samples Serum electrolytes Serum AAT levels CXR: Emphysema = Lots of black space/air Assess O2 first Admin O2 Antibiotics - infection Bronchodilators – reduce airway resistance Anticholinergics – bronchodilate and decreases secretions Corticosteroids – decrease inflammation, decrease bronchoconstriction COPD: Chronic bronchitis Dyspnea/wheezing Use of accessory muslces
Bronchitis = not enough air, clouding over Pulmonary function test Impaired gas exchange; Airway Cough & DB O2 therapy Pulmonary rehab Ineffective breathing pattern Specific breathing techniques Positioning – dyspnea Energy conservation Diaphragmatic breathing Pursed-lip breathing Relaxation techniques Positioning Ineffective airway clearance Chest physiotherapy w/ postural drainage Suctioning Positioning Hydration RT – flutter valve Tracheostomy Imbalanced nutrition Activity intolerance Anxiety Potential for PNA Avoid large crowds PNA vaccine Flu vaccine Vent/perfusion mismatch Decreased forced expiratory volume Involves airway Inflamation, vasodilation, congestion, mucosal edema, bronchospasm Airway enlargement Large amount of thick mucus Hypoxemia Acidosis Respiratory infections Cardiac failure – cor pulmonale Cardiac dysrhythmias Clubbing – chronic hypoxia Pleural effusion CHF Bacterial PNA Malignancy Indwelling pleural catheter w/ intermittent drainage Pleural-peritoneal shunt Thoracentesis Pleurodesis Pleurectomy Chest tube – pleural space
Blurred vision, diplopia, nystagmus Tinnitus, vertigo Hypalgesia – decreased feeling Numbness, tingling, burning Bowel/bladder dysfunction Late cognitive changes in memory, concentration, judgment, depression metal poisoning, stroke, brain tumor Steroids for exacerbations Biological modifiers Antidepressants NO CURE Education: Avoid stress, extreme temps, infections Exercise & mobility program Amyotrophic Lateral Sclerosis (ALS) Genetic/family hx Men in their 30s Slurred speech - dysarthria Falling No cognitive defects, always motor Upper and lower motor weakness Muscle atrophy Dysphagia, fasciculations Spasticity, cramping, fatigue Twitching of limb, tongue Dyspnea EMG: fibrillations CBC outside normal Genetic markers R/O syphilis, HIV, heavy metal poisoning, stroke, brain tumor ADLs and muscle function Antispasticity meds Exercise & mobility program Periods of rest Manage swallowing, resp Support groups Guillain Barre Syndrome Previous viral infection Motor weakness Areflexia Flaccid paralysis Ascending (sometimes descending) symmetrical weakness progression Paresthesia and pain Autonomic changes No pupillary/cerebral S/S Changes in cardinal vision, diplopia CBC outside normal Comprehensive baseline assessment Ongoing monitoring Assess pain Provide support for fearful patients Antivirals – reversible Pain management NO CORTICOSTEROIDS IV immunoglobulin Plasmapheresis Ineffective Breathing Pattern Cardiac Dysfunction Myasthenia Gravis FACE – cranial nerves Thymoma Myasthenic crisis: increased droopy eye Cholinergic crisis: abdominal cramps, Younger women, older men Specific muscle weakness Voluntary muscle fatigue Ptosis (droopy eyelids) Diplopia Dysarthria (speech) Dysphagia (swallowing) Snarling look NO COGNITIVE Tensilon testing –increase Ach if improved, myasthenic crisis EMG: fibrillations CBC outside normal R/O syphilis, HIV, heavy metal poisoning, stroke, brain tumor Periods of rest around mealtimes Cholinergic crisis – overmedication; withhold meds; atropine, airway Myasthenic crisis – undermedication; maintain respiratory fxn; reintroduce meds little by little
diarrhea, bronchospasm, increased secretions Both muscle weakness Cholinesterase-inhibitors Immunosuppressants Plasmapheresis in crisis IV immunoglobulins in crisis Thymectomy Administer meds w/ food to prevent aspiration Monitor airway, swallowing Promote self-care Assist w/ communication Nutritional support Eye protection Avoid infection, stress, overheating Parkinson’s CPK levels: elevated Abnormal EEG Genetic markers R/O syphilis, HIV, heavy metal poisoning, stroke, brain tumor R/O hypo/hyperthyroid Alzheimer’s CPK levels: elevated MRI: brain atrophy CRP levels: elevated Genetic markers R/O syphilis, HIV, heavy metal poisoning, stroke, brain tumor R/O hypo/hyperthyroid Meningitis Bacterial is most dangerous Viral: self-limiting, more common, less fatal Bacterial: Immunocompromised Malnutrition Alcoholism DM Recent dental tx Bacterial sinus infections Meningismus (irritation) Photophobial Nuchal rigidity Kernig’s sign (bend hip) Brudzinski’s sign (bend neck) Severe headache High fever Seizures at onset Altered LOC late sign Hx of illnesses, dental tx, trauma Lumbar puncture PCR Prophylactic ABx, Mannitol Anticonvulsants Steroids Pain management Antipyretics Encephalitis Usually viral Mosquito bites Warmer climate Postviral from measles, mumps, chickenpox + Kernig’s & Brudzinski’s Brain hemorrhage/necrosis Severe headache Fever Lumbar puncture Low glucose High protein High WBCs Support respirations Manage ICP Nutritional support I&O
Long-term catheterization Loss of urge to urinate, control of sphincter Inability to sense fullness UTI Hydronephrosis Decline in renal fxn Renal calculi Constipation Incontinence Hemorrhoids Ileus Suprapubic catheter Intermittent cath Mitrofanoff (sx – use appendix between bladder and stoma) Meds for BM Scheduled BM Sexual SCI Loss of psychogenic erection Reflex (physical stimulation) may still be present Viagra Injection therapy Vacuum pump Surgical implant Psychosocial Loss of body image, independence, control, economic security Lifestyle changes Stress, strain on relationships Withdrawal from social Avoid eye contact Refuse to participate Monitor for inadequate coping Encourage to discuss feelings Allow to participate in decision-making