3611 Final Study Guide

Inflammation and immune response: Chp 19 Self-tolerance- ability to recognize normal body cells so they arent destroyed along with invaders, only immune cells are capable of determining self by proteins on membrane 5 manifestations of inflammation- natural immunity, provides immediate protection against the effects of tissue injury and invading foreign proteins, immediate but short-term, nonspecific; start antibody-mediated and cell-mediated actions to activate a full immune response; infection is accompanied by inflammation but infection can occur without it and inflammation does not always mean infection is present. 1) Pain 2) Erythema 3) Swelling 4) Warmth 5) Loss of function All is caused by the three steps of the inflammatory response Stage I- constriction of vessles Stage II- (basophils)- increased blood flow, neutrophil production, edema and tenderness, formation of puss Stage III- repair Types of immunity: o Innate- born with- natural killer cells, mucous, skin o Acquired is active or passive Active- natural through exposure (chicken pox) & artificial (from vaccines) Passive- through breast milk, lasts 3 to 6 months Immunizations- artificial active immunity, created from dead and live viruses Immunoglobulin shots- artificial passive immunity, from antibodies produced by another person or animal; tetanus, rabies, snake bites Transplant medicationso Maintenance therapy- continuous immune suppression after transplant Cyclosporine/Sandimune, azathioprine/Imuran, mycophenolate/CellCept, plus a steroid such as prednisone o Rescue therapy- treats acute rejection episodes Antilymphocyte globulin, Muromonab

HIV/AIDS and End of Life: Precautions- The best prevention for health care providers is the consistent use of standard precautions for all clients as recommended by the CDC. Assessment findings in HIV + patients- n/v/d/weight loss, cough, night sweats, lymph, fatigue, fever, mental status change, dry skin, rashes, lesions, pain, discomfort

o May not have any s&s or may have flu-like or lymph node swelling How to prevent spread- Maintain standard precautions, Consider all blood and bodily fluids to be contaminated, Avoid contaminating outside of container when collecting specimens, Do not recap needles and syringes, Cleanse work surface areas with appropriate germicide, Clean up spills of blood and body fluid immediately, Follow CDC recommendations for immunization of health care workers Patient teaching to prevent infections in AIDS patients- opportunistic infections take advantage of suppressed immune systems; teach pt to wash hands, a Physical symptoms of impending death- pain, dyspnea, angina, nausea, vomiting, fatigue, weakness, distress, constipation, anorexia, delirium Advanced directives- A document prepared by a competent individual specifying what, if any, extraordinary actions the person would want when no longer capable of decisions about personal health care

Blood Transfusion: Checks before administering blood- compare the physicians prescription with another RN and check the pts armband, examine the blood bag and compare to orderscheck Rh, expiration date, inspect color, for bubbles, cloudiness Types of transfusionso Red Blood Cell- anemia, trauma, surgery; for hemoglobin less than , check for compatibility, infuse for 2-4 hours, Rh + pts can receive Rh- but not the other way o Platelet- for pts who are actively bleeding, scheduled for invasive surgery, have thrombocytopenia, and below 20,000 platelet, dont use standard transfusion sets, vital signs before at 15 min and after, pre-treat with Benadryl and Tylenol o Plasma- fresh to replace blood volume, ABO compatibility required, infuse over 30-60 minutes, pooled or single donors (single with history of febrile or allergy) Needles less than 19 gauge with normal saline 0.9 NaCl When complications occur stop transfusion immediately, attend to the pt and call dr

Oncology: Biologic characteristics of normal cells: Have limited cell division Undergo apoptosis- death, 90-120 days Show specific morphology Have a small nuclear-to-cytoplasmic ratio Perform specific differentiated functions Adhere tightly together Are non-migratory

Grow in an orderly and well-regulated manner Are contact inhibited Are euploid

Biologic characteristics of embryonic cells: Have rapid and continuous cell division Do not respond to signals for apoptosis Show anaplastic morphology- no differentiation Have large nuclear-to-cytoplasmic ratio Perform no specific (differentiated) functions Adhere loosely together Are able to migrate Are not contact inhibited Are euploid Commitment- day 8 in gestation Benign cell growth: Continuous or inappropriate growth Show specific morphology Have a small nuclear-to-cytoplasmic ratio Perform specific differentiated functions Adhere tightly together Are non-migratory Grow in an orderly and well-regulated manner Are euploid Malignant cell growth: Demonstrate rapid or continuous cell division Do not respond to signals for apoptosis Show anaplastic morphology Have large nuclear-to-cytoplasmic ratio Lose some or all differentiated functions Adhere loosely together Are able to migrate Grow by invasion Are not contact inhibited Are aneuploidy Risk factors for developing cancer: 80% of cancers are caused by external factors (also carcinogens) Chemical Carcinogenesis- air pollution, 30% tobacco use, drugs Physical Carcinogenesis- radiation, chronic irritation, sunlight Virus Carcinogenesis very few Dietary factors- high in red meat and fat, low in fiber; preservatives and nitrates

Internal factors- immunosuppression, age, genetic predisposition

Primary intervention- removal or avoidance of causative factors; smoking cessation, removal of both breasts when only one is effected, vaccination, chemoprevention Secondary intervention- screening for cancer or gene alteration; mammography, colonoscopy, CBE, PSA Tertiary prevention- preventing secondary diseases/infections that are related to primary diagnosis Grading: Describes how malignant the tumor is On the basis of cell appearance and activity compared to normal tissue lowest-close to normal highest- G4 Gx- cannot be determined G1- well differentiated and closely resemble normal cells they arose from G2- moderately differentiated and have few malignant characteristics G3- poorly differentiated but tissue origin can be established, few normal characteristics G4- retain no normal characteristics, difficult to determine origin Staging: Exact location of cancer and degree of metastasis at time of diagnosis Clinical, surgical and pathologic- must have biopsy, tissue is the issue TNM System- tumor nodes metastasis Tumor growth= Doubling time- time it takes for tumor to double & Mitotic index% of dividing cells w/in tumor Metastasis is always stage 4 TNM- tumor nodes metastasis describe the anatomic extent of cancers, used for prognosis and treatment Immune system during chemo: Nadir is the peak, when the WBC and bone marrow is the lowest; pt should watch for infection and avoid crowds; dont give next chemo dose until WBC is back up, if getting multiple chemos you dont want nadirs at same time Side effects of chemo: can give cytoprotectants to protect healthy cells Bone marrow suppression o Bone Marrow Depression is the MOST serious side effect!!!!! o Neutropenia- 5,000-10,000 o Thrombocytopenia- 150,000-400,000 o Anemia- fatigue, sob, weakness- hgb- 14-18 RBC- 4.7-6.1 & 4.2-5.4 o Know drugs for colonization

Biologic response modifiers (BRMs) are defined as agents that modify the clientss biologic responses to tumor cells with beneficial results Cytokines and interlukens Nausea and vomiting o zofran, give 30 minutes before to allow time to work Mucositis/Stomatitis o Adequate oral hygiene with soft bristle brushes and rinsing in between o Run toothbrush through the dishwasher daily Alopecia- 4-6 weeks to grow back o Disturbed body image- plan ahead with wigs and scarfs; teach pt to avoid sun Changes in cognitive function o More common with aggressive treatment, support the pt, warn the pt before Peripheral neuropathy o Priority- prevent injury and falls Fatigue is biggest complaint o Teach pt to spread out activities and rest between

Chemo on child-bearing years: The pt should avoid becoming pregnant during treatment Chemo is a teratogen Men can sperm bank and women can freeze eggs Extravasation- when a line with chemo becomes infiltrated, STOP THE IV Causes pain, infection, and tissue loss Prevention is a priority, monitor the IV site Nurse needs to protect herself when giving chemo and when handling excreta Vesicantso Antitiumor antibiotics- Dantiomycin, Mitoxantrone (end in icin) o Antimitotics- Vincristine (stat with vin) Nursing care of immunosuppressed: Place the client in a private room Use good hand-washing before touching the client or belongings Room and bathroom cleaned at least daily No supplies from common areas Limit personnel caring for client Monitor V/S qhr for 4 hrs; temperature elevation Inspect mouth q 8 hrs Inspect skin & mucous membranes (especially anal area) for fissures & abcesses at least q 8 hrs Inspect open areas, such as IV sites, q4 hrs for signs of infection Change IV tubing daily

Change wound dressings daily Culture suspicious areas Cough & deep breathing exercises Keep frequently used equipment in the room for use by client only Limit visitors to healthy adults Wear a mask to enter room Strict aseptic technique for invasive procedures Monitor WBCs: especially the ANC, daily Avoid the use of indwelling catheters Keep fresh flowers and potted plants out of the clients room Teach the client to eat a low-bacteria diet

Types of radiation: External radiation/teletherapy Internal radiation/brachytherapy- pt is radioactive o Unsealed- eliminated in waste products for 48 hours o Solid- implanted within or near a tumor, 2 to 3 days o Nurses need to protect their self and limit time in room Types of biopsies: Hormone cancer treatment: Some hormones make tumors grow faster, decrease the amount of hormones to slow growth Can cause opposite sex traits to grow- gynecomastia in men, hair in women Tissues? Cancer Emergencies: Sepsis and DIC- in leukemia, adenocarcinomas in lung, pancreas, stomach, prostate SIDH- carcinoma in lung, brain tumors Hypercalcemia- bone metastasis Tumor lysis syndrome- leukemia, lymphoma, lung, multiple myeloma

Breast Cancer: Testicular- 15 to 34 Breast- over 65 BSE- The goal of screening for breast cancer is early detection because breast selfexamination cannot prevent breast cancer.

Early detection reduces mortality rate. Teach breast self-examination. Most breast lumps are found by the women themselves or by their sexual partner Best time is a week after period ends (5-10 days after menses ends) If not having regular periods, then BSE should be on the same day of the month

CBE every 3 years for women 20-39 every year for women 40 and over & for mammogram American Cancer Society/Reach to Recover- breast cancer survivors that meet with people going through similar experiences, women whove had mastectomy Psychosocial/Emotional support Is there someone to assist her with treatment choices, the pt should not go alone Is the patient in pain? 1) Fear of cancer 2) Threats to body image, sexuality, intimacy 3) Decisional conflict related to treatment options 4) Uncertainty about treatment outcome and survival Breast reconstruction: Breast expanders- saline or gel used after surgery to lead to implants Autologus- uses the pts own skin, fat, and muscle flap Mastectomy Modified radical- muscle left intact; tissue, nipple, nodes removed Simple- tissue and nipple removed; nodes left Lumpectomy with node dissection- only tumor and nodes are removed

HTN: Types of htn Malignant- > 200/150 rapid, morning ha, blurred vision, dyspnea, 30-50 yr old Primary- no known cause; risk factors- family, ^ Na & calories, sedentary, African American, hyperlipidemia, caffeine, alcohol Secondary- renal problems, primary aldosteronism, cushings, pheochromocytoma, aorta contraction, brain tumors, pregnancy, drugs- steroids, estrogen, decongestants Pre-hypertension: 120-139/80-89 Stage 1: 140-159/90-99 Stage 2: >160/ >100 Lifestyle changes/diet to decrease HTN: Sodium restriction- reduce packaged meals and fast food

Weight maintenance Reduce alcohol and stress Stop smoking Exercise

Diet instructions in pts with hyperlipidemia: Low cholesterol, including cholesterol found in muffins and pastries Types of blood pressure meds: Calcium channel blockers- cardiazem & verapamil; Beta Blockers- anteolol & metoprolol; erectile dysfunction, depression ACE inhibitors- lisinopril; cough Diuretics- hctz- dehydration and hypokalemia; adolactone- hyperkalemia Monitoring fluid volume in CHF: Weight is the best indicator

Left Sided Heart Failure: respiratory symptoms, usually begins with left First system could be dyspnea on exertion, having to stop while walking up stairs o Poor CO o Resp- usually more than 20 breaths/min o Pulmonary congestion o Decreased tissue profusion o Fatigue (decreased O2) o Weakness (decreased O2) o Oliguria- nocturia o Angina (decreased O2) o Pallor o Weak peripheral pulses o Cool extremities o OVERALL PULMOARY CONGESTION o Hack/cough- worse at night o Dyspnea o Crackles/wheezes o Pulmonary edema- frothy pink sputum o S3/S4 gallop Right Sided Heart Failure: systemic symptoms Right sided w/o left is usually a result of COPD or pulmonary hypertension o Increased systemic venous pressures o JVT, hepatomegaly/splenomegaly, ascites o Dependent edema- feet/ankles- not best indicator of fluid retention. Weight is. o Bed rest edema- sacrum o Swollen hand/fingers- rings are tighter/ socks leave imprints o Weight gain- DW are best indicators

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Poss. Increased BP- FVE/ poss. Decreased BP- due to failure Anorexia/nausea Polyuria- nocturia OVERALL SYSTEMIC CONGESTION

Patient teaching CHF: MAWDS: Medications: o Take meds as prescribed keep refills filled o Know why the drug is taken and side effects of each o Avoid NSAIDs Activity: o Stay as active as possible/ dont overdo it o Know your limits o Be able to keep a conversation while exercising Weight: o Weigh each day at same time/ same scale/ same clothes o Monitor for fluid retention Diet: o Limit sodium to 2-3 g/day omit table salt and dont cook with it, dont use condiments, dont eat pickled or smoked food o Limit fluid to 2L/day Symptoms: o New or worsening symptoms/ notify physician immediately

Respiratory: Oxygen therapy: 4 mL requires humidifier Nasal canula for 1-2L, venturi mask is more precise Will stop drive to breathe on pts who have emphysema or chronic hypoxemia Thorancentesis: A thoracentesis is the removal of pleural fluid/air from the pleural space. Done for diagnosis or treatment. Inform the pt. of a stinging upon administration of the anesthetic. Stress the importance of NOT MOVING DURING PROCEDUCRE- risk for lung puncture. Ask about allergies to any anesthetics betadine/ shellfish etc. Procedure is generally performed at the bed side and a consent is imperative prior to Doc is responsible for getting that consent No more than 1000ml of fluid is pulled to prevent re-expansion pulmonary edema If having a biopsy a second needle will be inserted.

Follow up care: a chest x-ray is done to rule out pneumothorax or medialstinal shift(THORACIC STRUCTURES SHIFT TOWARD ONE SIDE) Monitor vitals, auscultate esp the affected side. Monitor dressings and site. Promote deep breathing and coughing promoting expansion of lung. Monitor for a PNEUMOTHORAX: lung collapse usually within first 24 hours. o Pain on affected side- worse at end of inhalation/exhalation. o Rapid heart rate, shallow respirations, air hunger, affected side doesnt move o Trachea pulled to affected side

Suctioning: Wear protective gear/standard precautions THIS IS A STERILE PROCEDURE Check suction and occlude till 80-120mm Hg is obtained Pre-oxygenate for 30sec-3 mins- need at least 3 hyperinflations/sync with inhalation Insert suction till resistance Withdraw at a rate of 1-2cm and apply suction intermittently with a twirl motion Only go 10-15 seconds Then hyperoxygenate for 1-5 mins Repeat only up to 3 times Reassess breath sounds post suctioning SUCTIONING IS ONLY DONE UPON ADVENTAGEOUS SOUNDS/PRN Pack year- # of packs X # of years

Fluid and Electrolyte: fluid sheet Normal values: Na+- 135 to 145 K+- 3.5 to 5 Ca+- 8.5 to 10.5 Phos- 3 to 4.5 Mg+- 1.5 to 2 Cl100 to 106 Most reliable indicators for fluid loss or fluid gain: Weight! Fluid overload- bounding and increased pulse Dehdryation- fluids V/D, decreased intake, fever, infection, diabetes insidious, diaphoresis, surgery, NG

Effects of edema on skin: More likely to develop pressure ulcers, risk for decreased skin integrity IV solutions: Normal saline- expand volume, KVO, dilute med, isotonic Lactated ringers- fluid resuscitation, isotonic D5W- hypotonic, metabolizes glucose; not for peds or head injury D51/2W- Na and volume replacement, hypertonic, go slow and monitor Assessment for F & E imbalances: Daily weight, DTR, check lungs, edema, I&O

Thyroid/Parathyroid/Adrenal/Pituitary: Thyroid storm: LIFE THREATENING Acute exacerbation of S & S: maintain airway Fever Heart failure Shock Hyperthermia Tachycardia, Hypertension Confusion Seizures Coma Hyperthyroid: manifestations are called thyrotoxicosis Diaphoresis, thinning of hair, chest pain, tachycardia, weifht loss, increased appetite, muscle wasting and weakness, blurred vision, tremors, insomnia, increased metabolic rate, heat intolerance, low-grade fever, decreased attention span, restlessness, manic behavior, increased libido, amenorrhea, goiter, decreased WBC, enlarged spleen Txthionamides and beta-adrenergic blocking drugs, radioactive iodine for more severe cases (decrease blood flow), thyroidectomy when drug therapy is unsuccessful Hypothyroid: manifestations are a result of decreased metabolism from low levels of thyroid hormone, most cases are a result of tx of hyperthyroid Cool & dry skin, poor wound healing, bradycardia, decreased metabolism and cold tolerance, apathy, depression, decreased libido and prolonged menstrual periods, anemia, periorbital edema

Thionamides- reduces manifestations of hyperthyroidism by inhibiting the formation of new thyroid hormones Propylthiouracil -prevents T4 to T3 and inhibits binding of iodide -q8h

avoid ill ppl report dark urine, jaundice, and bruising check for weight gain, brady, cold intolernace -reduce blood cell counts and immune response liver toxicity Methimazole-Inhibits thyroid binding of iodide -q8h notify if become preg. possible joint & muscle pain check weight gain, brady, cold intolerance causes birth defects Lithium (when pt cant take thionamide) Inhibits release of hormones temporarily -q8h -drink 3-4 qts -check for weight gain, brady, cold int. -increase urine output and can cause dehyd. Iodine containing agents Rapidly inhibits thyroid hormone release temp. resolves cardiac problems. Not for long term 1h after thionamide check for fever, rash, metallic taste, mouth sores, sore throat, gi distress thionamide prevents initial hormone increase I31- kills thyroid, will need synthroid Iodine deficiency: causes hypothyroid; iodine added to salt Removal of parathyroid: Sometimes accidently removed during total thyroidectomy, damaged, or blood supply is impaired. Causes PTH levels to decrease and hypocalcemia. Hypocalcemia- Tetany,Chvosteks Sign, Trousseaus Sign, circumoral paransthesia Addisons: primary, secondary- sudden cessation of long-term high-dose steroids, the bodies need for steroid becomes greater than what it can produce Clinical- bronze pigmentation, hypoglycemia, postural hypotension, weight loss, weakness, changes in body hair distribution Adrenal crisis- severe fatigue, dehydration, vascular collapse, renal shutdown, hyponatremia, hyperkalemia Tx- steroid therapy and fluid replacement Cushings: caused by over use of steroids Clinical manifestations- hyperglycemia, thin skin, purple striae, GI distress from increase acid, moon face, gynecomastia, osteoporosis, fat deposits, increased

susceptibility to infection, irritable, personality changes, edema from fluid and Na+ retention, amenorrhea and hirsutism in women Tx- adrenalectomy, hypophysectomy

Corticosteroid therapy: take with food, weigh daily or 3 X a week, monitor bp for hypertension, report s&s of weight gain, round face, fluid retention, edema, and report illness such as severe diarrhea, vomiting, and fever because they may need an increased dose. Causes hyperglycemia and must taper off. Cortical hormones: Anterior pituitary o Growth hormone o TSH- synthesis and release of thyroid hormones Hyperthyroid hypothyroid o ACTH-release of steroids (adrenal cortex) Hypo- addisons Hyper- cushings Posterior pituitary o Vasopressin/ADH Hypo- diabetes insipidus Hyper- SIADH Parathyroid Adrenal glands o Adolsterone (mineralcorticoids) Hyperaldosteronism o Adrenal medulla- catecholamines Pheochromocytoma Removal of gland = will need hormones for life Diabetes inspidious: water metabolism problem caused by insufficient ADH S&S- dehydration, thirst, dilute urine Medication monitoring- IM or IV ADH can cause ulceration of the mucous membranes, chest tightness, pulmonary inhalation. Priority nursing- aimed at early detection of dehydration and maintaining hydration monitor I&O, weight, specific gravity Teaching- lifelong desmopressin/vasopressin therapy for those with severe DI, teach that polyuria and polydipsia are signals of needing another dose. Drugs can cause fluid overload and water toxicity. Teach pts to weight themselves daily and report weight gain. Wear medical alert bracelet and notify provider of acute confusion or persistant headache.

SIADH: vasopressin is secreted even when plasma osmolarity is low or normal, inhibits ADH production and secretion. Water is retained resulting in hyponatremia. Causes- head trauma, cancer, tb, cerebrovascular disease Tx- fluid restriction, monitor for overload, diuretics Nursing- check for thrush as a result of antibiotic o Provide safe environment when Na levels fall o Neurological assessment Pituitary surgery: Hypophysectomy- surgical removal of the pituitary gland and tumor to treat hyperpituitarism Pre-op- do not brush teeth, cough, sneeze, blow nose, lean forward Post-op- teach pt to report postnasal drip o Observe for CSF, LOC, ICP, and diabetes insipidus, decreased o Vision and strength of extremities o ICP- straining during bowel, bending over, coughing o CSF- halo effect, yellow/clear drainage o Decreased sensation and loss of smell for 3 to 4 months o No tooth brushing for 2 weeks

Diabetes: Diabetes mellitus: chronic hyperglycemia resulting from problems with insulin secretion, insulin action, or both. Diabetes Type 1: Autoimmune- beta cell destruction NO insulin, must take insulin, no oral meds S&S- weight loss, thirst, abrupt Younger than 30 Ketones Diabetes Type 2: Insulin resistance, relative deficiency, secretory deficiency Polyuria, polyphagia, polydipsia 15 % familial Patho- dysfunctional beta cells 50, obese, no exercise May take orals and/or insulin Syndrome X- weight in midsection, high bp, cholesterol, sugar Glucagon- counter regulator to insulin, causes release of glucose from cells when glucose levels are low, prevents hypoglycemia

Insulin- key to membranes for glucose, reaches liver first to promote the production and storages of glycogen and inhibits glycogen breakdown into glucose (glycogenesis); increases protein and lipid synthesis; inhibits liver glycogenolysis, ketogenesis, and glucogenosis Polyuria-results from osmotic diuresis caused by excess glucose in the urine Polydipsia- resulting from dehydration caused by polyuria Polyphagia- cell starvation from lack of glucose Insulin: Rapid acting- 15 min onset, 2 hour peak, 5 hr duration Short acting- 30-60 min onset, 2-4 hr peak, 5-7 duration Intermediate acting- 1-2 hour onset, 4-12 hr peak, 16-24 duration Long acting- no peak, 2-4 onset, 24 duration Insulin teaching: Rotate site every week but never in the same exact area Dont give in legs before exercising Clear before cloudy Oral antidiabetics: med sheet Exercise: Check blood sugar before, if over 250 check ketones Ketones- no exercise Sugar less than 80 or greater than 250- no exercise When blood sugar is excessive or when there is lack of insulin, sugar will increase No insulin within 1 hour Stay hydrated Will need extra snacks and carbs to compensate Modifications of exercise: Retinopathy- avoid valsalva maneuver Neuropathy- non-weigh bearing exercise to prevent injury Autonomic neuropathy- be mindful of impaired temp control, impaired thirst, orthostatic hypotension Glucosuria: Excretion of glucose in the urine Must be over 220 Diet: Protein- 15 to 20% (10% in nephropathy) Carbs- 45 to 65% minimum of 130g a day

Fat- less than 7% Cholesterol- less than 200 mg Fish twice a week Increase fiber gradually to 14 g per 1000 cals, sudden increase can cause hypoglycemia, fiber improves carb metabolism and lowers cholesterol

Emotional stress, sickness, and injury can raise a persons need for insulin. Type 2 can have ketones during stress or infection

Acute complications: Diabetic ketoacidosis- sudden, kussmaul resp, sugar over 300, ketones, N/V/ab pain HHS- gradual, elderly type 2, dehydration, sugar over 600, confusion Hypoglycemia Hypoglycemia: occurs when there is an abrupt decline in glucose levels either from too much insulin or lack of good, can occur when glucose drops a very high level to a high level (250 to 180) S&S- sudden onset of hunger, diaphoresis, weakness, nervousness, heart pounding, headache, confusion, slurred speech, irritable, coma Mild- < 60 o Give 10-15 g of carbs o Repeat in 10 minutes if still have symptoms, eat within 15-30 min. Moderate- <40 o Give 15-30 g of readily absorbed carbs o More food after 10-15 min Severe- <20 o IM or SC glucagon or 50% dextrose (teach family) o Second dose if pt does not respond o Give a small meal when the pt awakens and is not nauseas Lab values: Pre-meal- 90 to 130 Post-meal- 180 HS- 100 to 140 Fasting- 70 to 110 A1C- should be kept below 7 Macrovascular complications: related to risk factors of hypertension, sedentary lifestyle, hyperlipidemia, and smoking more than hyperglycemia Cardiovascular- most common, risk for MI is the leading cause of deaths with pts who have diabetes, 66% death is from heart failure. Blood pressure should be kept below 130/80. Renal disease increases the risk for heart disease and death from MI. Women have higher excess risk and more than half of pts diagnosed

with dm have cardio disease. Prevent by reducing weight, intake of cholesterol, and saturated fats. Cerebrovascular disease- Damages cerebrovascular circulation and is a risk factor for stroke, hypertension, and other complications. Elevated glucose at the time of stroke lead to greater brain injury and higher mortality. Keep glucose within normal ranges.

Microvascular complications: more directly related to hyperglycemia Eye and vision- legal blindness is 25 X more likely, retinopathy with neovascularization leads to hemorrhage and more vision loss due to poor eye circulation. Hyperglycemia causes blurred vision. Hypoglycemia causes double vision. Increased risk for glaucoma and cataracts. Hyperglycemia and hypertension increases rate of retinopathy in pts with type 1. o Should have eye exams every year because retinopathy is directly related to duration of dm. Diabetic neuropathy- progressive deterioration of nerves that result in loss of nerve function. Sensory nerve damage can lead to chronic pain or loss of sensation. Damage to motor nerves results in weakness. Damage to autonomic nerve fibers can cause dysfunction in every part of the body. o Keeping glucose in normal ranges can delay the onset of neuropathy. o Medications- anti-seizure meds like Neurontin prevent nerve pain o Proper foot care, shoes, and proper treatment for wounds. Nephropathy- pathologic change in the kidney that reduces kidney function and leads to kidney failure. DM is the leading cause of renal failure. Earliest sign is microalbuminuria. Chronic hyperglycemia can cause hypertension in kidney blood vessels and excess kidney perfusion. Hypertension greatly speeds the process of nephropathy. o Low protein diet, teach importance of diet and compliance with meds Erectile dysfunction- occurs faster than in the general population; most men with diabetic neuropathy have ED. Foot care: Inspect feet daily Lotion to feet but not between toes Leather closed toed shoes, alternating days Dont smoke See dr asap for blisters, sores, infection Check water with wrist (decreased sensation in feet) Do not cross legs, wear garters or tight socks, soak feet

Musculoskeletal/connective tissue: Cast care: Neuro checks qhr for 24 hours, check for swelling, color, sensation

Elevate extremity above heart on pillows, ice for 24 to 48 hours Allows early mobilization and reduce pain by immobilizing the affected part Petaling- removes rough edges Window to care for open skin keep piece to cover

Traction- pulling force to provide reduction, alignment, and rest; weights are prescribed and should be off the floor and not handled by cna; skin checks q8; painful muscle spasms- try realigning pt first Osteoarthritis: Progressive deterioration of cartilage in one more joints, esp weight bearing Risk factors- aging, obesity, smoking, trauma Prevention- normal body weight, dont smoke, avoid stressful activities like jogging, wear supportive shoes, avoid risk seeking activities Tx- nsaids, joint replacement, steroid shots, glucosamine, etc. Hip replacement: Immobilize hip and align with thigh Keep hip at less than 90 degree angle Early ambulation to prevent dvt- day after Dislocation- acute pain, adduction, shortening Infection can occur years later- acute pain Check cap refill, distal pulses, sensation H&h checked 1-2 days after

Compartment syndrome: Assessment: swelling, erythema, disproportionate pain, decreased circulation Tx- fasciotomy; must be done w/in 4 to 6 hrs to prevent neuro damage Fat embolism: Confusion, tachypnea, petechiae on the chest, first sign is often decreased RR Check airway and apply O2! Osteomyelitis: Surgery- for pts with chronic infection, sequestrectomy to debride necrotic bone and allow revasularization; neuro checks frequently bc swelling is normal; amputation as a last resort May need PICC line Hyperbaric chamber to diffuse O2 into tissue to promote healing May need oral abx after IV, take all of it! Contact precautions for drainage Sterile dressing change and irrigation Abx must penetrate the bone to be effective, abx beads or picc

Osteoporosis: Chronic metabolic disease, bone loss cause decreased density of bones causing fractures High risk- women, white/Asian, slender, sedentary, alcohol, cigarettes, over 65, over 75 in men, low calcium, hormone deficiency Prevention- adequate calcium and walking 30 min 3-5X a week, baseline dxa at 35 Injury prevention- fall risk, move with bed sheet Meds: o All prevent bone loss and increase density o Evista- estrogen modulator, monitor liver function and teach signs of dvt (60 mg) o Calcium carbonate/os cal- cost effective, take 1/3 dose at night, take with full glass of water (1-1.5g) o Premarin (estrogen/progesterone)- can cause endo and breast cancer, teach importance of gyno and breast exams, observe for dvt (1.25 mg to 2.5 mg) o Calcimar/calcitonin- alternate nares, monitor renal function and vit D level, s.e.- n/v/ha/flushing (200 units) o Fosamax (bisophosphonates)- take on an empty stomach in the morning, stay upright for 30 minutes, no food or water for 30 minutes, can cause esophagus problems 5 mg for prevention 10 mg for treatment o Boniva is a bisophosphonate too- taken once a month Rheumatoid arthritis: Autoimmune disorder that attacks joints; joint stiffness in morning; Tx- nsaids o Dmards- slow progression; strict bc and no alcohol, immunosuppression SLE Chronic progressive ctd that can cause organs and sustems to fail Spontaneous remission and flares Vasculitis- caused by inflammation and damage from immune complexes forming serum in tissue Scaly, red, inflamed rash on face Pleural effusion/pneumonia, fever, fatigue, anorexia, joint inflammation, ab pain, nephritis Aggressive treatment with immunosuppressive drugs Teach sunscreen and skin care with mild products Bone cancer- increased calcium and ALP Carpal tunnel: Repetitive stress injury

Positive phalens and tinels sign Symptoms- numbness and tingling NSAIDs and splint Surgery- relieve pressure on median nerve by nerve decompression o When caused by RA- synovectomy- removal of excess synovium