I just want to double check that this is correct and that nothing…

Medical Dx

Brief Patho & S/S

Nursing Care Priorities (5)

Nursing Interventions (3)

Renal Failure

-Kidneys stop functioning normally (GFR <15) 

-Kidneys can’t retain water as well and can’t excrete wastes as well = F/E imbalances (FVO overload, Na, K, Phos retained, FVO also leads to HTN) 

Edema, FVO, crackles, low GFR, diluted urine, possible comorbidities that lead to renal failure, elevated electrolytes, HTN

-Fluid / electrolyte balance (FVO priority) (Phos, K, Na, C, BUN, C)

-HTN

-Impaired Skin integrity (edema along with possible immobility if weak can lead to skin breakdown when laying in bed) 

-Impaired Oxygenation (depending on how bad FVO is)

-Deficient knowledge (need good education in order to prevent potentially deadly complications) 

-Assess fluid and electrolyte status (lung sounds, edema, monitor daily electrolyte labs especially Na and K, are they on any fluid restrictions)

-Prepare/Perform Hemodialysis or Peritoneal Dialysis 

-Administer medications as ordered (diuretics and antihypertensives to lower BP from FVO, may need K supplement depending on which diuretic they are on)

-Educate about importance of renal diet and managing HTN = low Na, K, Phos, limit fluid intake (until dialysis, kidneys cannot excrete the extra electrolytes and that can lead to severe consequences, especially with K, and non-managing HTN can make kidney function even worse and renal perfusion decreases even further)

Lower GI Bleed

Could be from diverticulosis, IBD, polyps, tumors, Crohn’s hemorrhoids

Black/tarry stool or occult stool, abdominal pain, possible blood in emesis (coffee ground), lightheaded, dizzy, anemia, pallor, depending on severity s/s of shock 

-Impaired Perfusion/circulation (FVD/shock)

-Fluid/Electrolyte correction with IV therapy due to fluid loss

-Safety (weakness can occur from blood loss and anemia, don’t want them trying to get out of bed and fall bc they are weak or confused)

-Monitor Hgb/Hct to identify potential blood transfusion

-Pain (depending on cause like diverticulosis or hemorrhoids, the bleed can be painful)

-Bowel Rest (keep NPO for stomach lining to heal and prep for exams) 

-Culture and sensitivity on stool to identify organisms such as parasites, E. coli, C. diff, etc. 

-Assess for s/s of shock (hypotension, tachycardia, tachypnea, hypovolemic shock from too much blood loss is a possibility and catching the early signs like slight increase in HR, oliguria, weaker peripheral pulses, will lead to better outcome)

-Monitor CBC and oxygenation status (RBC, Hct, Hgb, will they need a blood transfusion, especially with Hgb because low Hgb can lead to low oxygen carrying capacity and their oxygenation can become impaired, also will help prevent shock if you see Hct become too low, monitor their O2 sat and any reports of dizziness or SOB incase they need supplemental oxygen)

-Educate patient about fall precautions (use call light ANY TIME they need to get out bed)

-Make sure type & crossmatch of blood has been completed and consent has been obtained in case blood transfusion is needed 

Urosepsis

Gram-negative bacteremia originating in the urinary tract.  Most common causative organism is E.coli.  Client who is immunocompromised, a common cause of infection from indwelling urinary catheter or untreated urinary tract infection (UTI). Major problem is the ability of this bacterium to develop resistant strains.

s/s: fever, pain in lower sides of back, n/v, tired, decreased urine output, difficulty breathing, abnormal heart function, inability to think clearly.

-Complete full dose of antibiotic therapy 

-Continuous monitoring of temperature for fever, altered mental status

-Prevent progression into Septic shock; check lactate levels

-Maintain adequate tissue perfusion and circulatory volume 

-Avoid unnecessary procedures to avoid infection 

-Obtain a urine specimen for urine culture and sensitivity before administering antibiotics

-Administer antibiotics intravenously as prescribed, usually until the client has been afebrile for 3-5days.

-Switch to oral antibiotics as prescribed after 3-5 days afebrile period.

-Check BUN/Creatinine for kidney function

Cholecystitis

Inflammation of the gallbladder that may occur as an acute or chronic process. Chronic cholecystitis results when inefficient bile emptying and gallbladder muscle wall disease cause a fibrotic and contracted gallbladder.  Acalculous cholecystitis occurs in the absence of gallstones and is cause by bacterial invasion via the lymphatic or vascular system.

s/s: pain in upper right part of belly, shoulder pain, n/v, yellow skin/eyes, loose, light colored BM, belly bloating.

-Detailed pain assessment: pain in right upper quadrant, guarding, rigidity and rebound tenderness

-Food diary: exasperated by high fat or high-volume foods

-Murphy’s sign: cannot take a deep breath when the examiner’s fingers are passed below the hepatic margin 

-Monitor for signs of dehydration

-Monitor for signs of biliary obstruction (choledolithiasis): jaundice, dark orange/foamy urine, clay feces, pruritus 

-Maintain NPO status when n/v

-Maintain NG decompression as Px for severe vomiting

-Admin antiemetics, analgesics (reduce spasms), antispasmodics (anticholinergics-relax SM)

-Instruct client to eat small low-fat meals

-Instruct client to avoid gas-forming foods

-Prepare client for nonsurgical and surgical procedures as prescribed.

Left CVA

In general stroke can be ischemic (most common) or hemorrhagic. 

Ischemic = blockage, usually from a clot, in cerebral blood flow = damage brain tissue.

Hemorrhagic = rupture of cerebral artery 

Stroke on the left side of brain will affect the right side of the body.

s/s: 

-paralysis/weakness and decreased sensation on R side of body

-speech & language problems (dysphasia) bc language center in left hemisphere 

-right homonymous hemianopia (vision loss on R side)

-memory loss

*Broca’s area motor speech (pt will have difficulty expressing thoughts)

*Wernicke’s area sensory speech (pt will have difficulty processing speech)

Impaired swallowing (can lead to aspiration)

Altered sensory perception 

Impaired physical mobility (from hemiparesis)

Impaired verbal communication (damage to speech areas in brain)

Risk for impaired skin integrity (from immobility and impaired urinary elimination) 

Assess neuro status and VS (changes in LOC indicate ICP, if tPA given assess q15min for 6hrs, high BP can increase ICP)

Reposition q2hrs and assess skin, elevate paralyzed or weak limbs to minimize edema, ROM, hygiene care

Aspiration and bleeding precautions (HOB 45deg, get a swallow screen) (if on tPA use electric razor, fall precautions)

Pneumonia

Inflammation of the lung parenchyma (functional lung tissue) from a bacterial, viral, or fungal infection. Can be a result of aspiration. Inflammation impairs the exchange of O2 and CO2. If bacteria gets into the bloodstream can = sepsis.

s/s: 

-Fever

-Tachypnea/dyspnea

-Tachycardia

-Chills

-Cough, productive or nonproductive

-Pleuritic chest pain

-Fatigue

-Myalgia/arthralgia

severe s/s:

-Purulent or blood-streaked sputum 

-Hypotension 

-Dysrhythmias

Impaired oxygenation (related to inflammation causing impaired gas exchange)

Antibiotics to treat infection

Assess respiratory status (crackles, wheezing, SOB, dyspnea) 

Safety (fall precautions: call light w/in reach, bed locked and in lowest position, bed alarm, falling star, yellow or red socks, continue to check on, room near nursing station)

Activity intolerance (from hypoxia and decreased tissue perfusion) 

Skin breakdown (from immobility and decreased activity, turn every two hrs)

Risk for FVD (from fever, diaphoresis, mouth breathing, decreased oral intake)

Assess O2 stat and other VS; low O2 stat from decreased oxygenation, pt may have a fever, chills, fatigue, tachypneic & tachycardic (body compensating for hypoxia), labored breath sounds

Administer meds (antibiotics, antipyretics) per dr orders, ensure C/S have been done and monitor renal labs bc antibiotics are hard on the kidneys 

Teach pt importance of incentive spirometer for deep breathing (10 every hr), coughing and drinking fluids to help clear secretions

Encourage rest and adequate nutrition for healing

Liver Cirrhosis

Chronic liver disease that causes cell destruction and fibrosis or scarring of hepatic tissue. This is irreversible.

Functional liver cells die and damaged liver cells regenerate into nodules surrounded by fibrous tissue.

Blood flow, normally 85% through portal vein, is now dependent on hepatic artery. 

This chronic injury and liver cell necrosis and altered blood flow leads to hepatic insufficiency and portal hypertension (increase in pressure in vein carrying blood through liver) and shunting of blood around liver. This increases pressure to surrounding vessels causing:

• Esophageal varicies, upper GI bleed, water retention, coagulopathy, ascites, bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome (rapid deterioration of kidney function)

Risk for injury: bleeding from portal hypertension and varices, also liver failure impacts clotting factor synthesis.

Risk for acute confusion d/t increase in ammonia levels.

Ineffective breathing patterns d/t intra-abdominal fluid collection (ascites)

FVE d/t decrease in plasma proteins (albumin affecting plasma oncotic pressure)

Infection r/t bacterial infection in ascites fluid

Vital signs: an increase in B/P bc FvE or decreased d/t fluid shifts r/t decrease in oncotic pressure

Respiratory status monitoring r/t to FVE or inability to lower diaphragm d/t ascites

Administer diuretics and antibiotics and vit K, FFP (r/t coagulation disorder d/t inability to produce clotting factors.

Right Leg Cellulitis

I’m not sure why it says RIGHT LEG, so I’m just doing cellulitis.

This is a diffuse infection of the dermis and subcutaneous tissue that usually occurs through breaks in the skin. Mostly caused by gram (+) bacteria like Streptococcus pyogenes, MRSA, or Staph. Aureus.

Either non-necrotizing

    Erythema, warmth, edema, and localized pain.

 or Necrotizing (very serious, potentially life threatening spreading further throughout fascia and muscle destroying tissue)

Blood infection and septicaemia (blood gets contaminated and from bloodstream affects surrounding tissues, should do blood test to rule out sepsis/ systemic infection) 

Culture the wound (to determine cause of infection and best antibiotic) 

Antibiotic therapy (effective treatment in over 90% of patients)

Obtain history (if it has happened before, pt can tell what worked and what didn’t) 

Since it is in the leg, safety is a priority bc if they are in pain, they are a fall risk. 

Establish baseline of the appearance to see potential spread.

Obtain blood and specimen for bloodwork and cultures. Early diagnostics will result in prompter effective treatment.

Assess/monitor vital signs for signs of worsening infection or complications leading to sepsis. 

Teach the patient to keep leg elevated higher than the heart during rest in order to reduce swelling. 

Wound care to protect wound/ clean area to prevent infection from spreading. 

Implement safety precautions, such as pt should call nurse if getting up, so that they don’t fall. 

Pain meds if in pain, hot compress if non pharmacological

Diabetes Mellitus Type II

-Defects at the cell membrane that prevent the normal action of insulin; even though insulin is present, the cell “resists” its effect in transporting glucose into the cell

-B/c of this, insulin resistance develops & requires increased levels of insulin in order to drive glucose into the cells

-Eventually pancreas can’t keep up with the increased demand for insulin; beta-cell failure appears and progresses

-S/s include: 

-3 Ps: Polyuria, polydipsia, polyphagia 

-Fatigue, CVD 

-Poor wound healing, recurring infection

-Visual disturbances

-Renal insufficiency

-Yeast infection in women if diabetes is uncontrolled

Risk for skin and soft tissue infection→ related to macrovascular vessel changes secondary to hyperglycemia

Risk for ineffective renal perfusion→ Renal failure

Risk for microvascular effects: diabetic retinopathy, periodontal disease, PVD 

Risk for diabetic peripheral neuropathy and diabetic neuropathy

-Assess: 

V/S, I/O, serum glucose, WBC count, BUN/ creatinine levels, carb intake at meals, capillary refill in lower extremities 

decreased perfusion, skin assessment of lower extremities and feet

Pancytopenia

Pancytopenia is a condition that occurs when a person has low counts for all three types of blood cells: red blood cells, white blood cells, and platelets. Pancytopenia is usually due to a problem with the bone marrow that produces the blood cells. 

Altered Tissue Perfusion related to a decrease in cellular components required for the delivery of oxygen / nutrients to the cells.

Risk for infection related to decreased WBC count

IV access (if need abx or transfusion)

Bleeding precautions(electric razor, soft toothbrush)

VS (fever, hypotensive, tachycardic) 

Admin meds(prophylactic abx, iron, EPO, etc.)

Neutropenic precautions

Assess v/s for increased fever, tachycardia, hypotension

Assess CBC (RBC, H/H, WBC, PLT)

Prevent injury (bed lowest position, bed alarm on, etc.)

Educate s/s infection, hand hygiene, avoid sick ppl

Colitis (ulcerative colitis?)

Affects the large intestine and involves only the mucosa and submucosa 

-spreads uniformly beginning at the rectum and spreads upward toward the cecum 

S/S: 

-diarrhea (>20 stools daily), blood, mucus and pus are common 

-abdominal pain and tenderness that are worse in left lower quadrant 

-tenesmus- spasms of the anal sphincter

-persistent desire to empty the bowl 

-crypt abscess- releases secretions that result in purulent discharge from the bowl mucosa

-scar tissue is common but it interferes with nutrient absorption 

Control inflammation (to prevent it from getting worse)

Rest bowel (to promote healing)

Combat infection(so it doesn’t spread to the blood or turn to sepsis)

Correct nutritional deficits (since exacerbation was likely caused by diet unless it’s IBD or Crohn’s)

Fluid and electrolyte management (due to losses from diarrhea)

Assess vitals for signs of infection such as fever, elevated heart rate and decreased blood pressure.

Monitor intake and output to monitor fluid balance since the patient will be losing lots of fluids and electrolytes via loose stools. Assess the characteristics of the stools as well in case there is blood. 

Teach the patient about adequate nutrition during the exacerbation, such as avoiding fiber, fat, and dairy until they improve. Or avoiding it in general if they have IBD.

Gastritis with PUD

PUD = ulcers or erosions in the stomach, duodenum or esophenal. Ulcer = breakdown in the lining of the mucosa. Erosion = breaks in the surface of epithelium. Can be cause by excess NSAIDs or HCl, H. pylori, illness (Crohn’s, pancreatitis, hepatic disease)

s/s:

-may have none (esp elderly)

-pain (dull, gnawing, pain or burning sensation midepigastric, worsens w/ eating)

-pyrosis (heartburn)

-vomiting

-C/D

-bleeding

Pain (Pain is most common symptom of PUD. Assess location, characteristics, what makes it better/worse. Rule out any indications of complications such as perforation or pancreatitis)

FVD due to diarrhea (Diarrhea is most common symptom in gastritis. Assess characteristics and note any blood)

Stool testing (rule out organisms such as parasites, E. coli, C. diff, H. pylori) 

Nutrition (assess their nutrition prior to look for triggers, and give only bland foods until they improve)

Supportive treatment (IV rehydration, Loperamide, perineal care, sequentials)

Monitor CBC (low H&H incase of bleeding, high WBC with inflammation) electrolytes (if vomiting) 

Teach patient about dietary modification (limit food intake in the evening, avoid spicy food, coffee, alcohol, dairy) and stress reduction to help with prevention of PUD flare-ups. 

Assess for fluid and electrolyte imbalance symptoms, especially if vomiting, in order to implement early interventions. 

Administer medications as ordered to help relieve symptoms (PPIs, antacids, pain meds) 

Pancreatitis

-Inflammation of the pancreas that occurs when digestive enzymes autodigest the pancreas and surrounding tissue for a prolonged period of time

-S/S: LUQ and epigastric pain often worse after eating/drinking, N/V/D, pale/clay-colored stools, steatorrhea stools, weight loss

-Acute pain r/t inflammation and obstruction of the pancreas

Monitor BG (bc of decreased insulin pumping)

Administer PERT (enzymes amylase, lipase, protease) & H2 blockers(omeprazole)

Weigh daily since risk of weight loss due to malabsorption.

Consult with dietician to ensure adequate nutrition

-Administer pancreatic enzymes: need to swallow WHOLE as typically extended release

-Administer analgesics

Assess characteristics of abdomen, presence and bowel sounds, abd distension, LUQ pain

Monitor color, consistency and amount of stool for Steatorrhea(incomplete digestion of fats)

Teach proper diet plan to avoid alcohol and low fat

Syncope with HTN

Stable Angina

“Exterional angina” occurs with activities that involve exertion or emotional stress; relieved with rest of nitroglycerin.  Usually has a stable pattern of onset, duration, severity, and relieving factors

s/s: chest pain, dyspnea, pallor, sweating, palpitations, tachycardia, dizzy, syncope, HTN, digestive disturbances

Stop all activity (since stable angina is associated with physical activity, which increases O2 demand, stop activity to decrease O2 demand)

Administer Nitroglyerin (Nitro usually given sublingually; med relaxes coronary arteries and reduces O2 demand)

Administer O2 (usually initiated at onset of chest pain to increase amount of oxygen delivered to myocardium and reduce chest pain) 

Assess pain (location, characteristics, pain scale, what brought it on, what makes it better/worse; can aid in diagnosis of cardiac chest pain and disease progress) 

Bedside EKG (often the initial test when CAD is suspected; look for ST depression or T wave inversion during pain- signifies ischemia) 

Stress test – changes in pain, ECG, VS during test = ischemia

Troponin/cardiac enzymes – should be normal in angina

Cardiac catheterization – definitive dx, info about the patency of coronary arteries

-Assess pain & institute pain relief measures

Stop all activity and sit them up to decrease O2 demand and make it easier for them to breathe

-Admin oxygen by NC to increase O2 delivery and perfusion

-Asses continuous VS, cardiac monitoring and nitro as Px

-Ensure the bed rest in maintained in semi-fowlers; fall precautions

-Obtain 12-lead ECG

-Establish an IV access route

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