Adult Medical Surgical Notes For Nursing Part 2

ADULT MEDICAL SURGICAL ASTHMA CHRONIC DISORDER OF THE AIRWAYS THAT RESULTS IN INTERMITTENT AND REVERSIBLE AIRFLOW OBSTRUCTION OF THE BRONCHIOLES. MEDICATIONS: BRONCHODILATORS ¥ ALBUTEROL: watch for TREMORS AND TACHYCARDIA ¥ IPATROPIUM: observe for DRY MOUTH. SCUCK ON HARD CANDY TO HELP RELIEVE THE DRY MOUTH; INCREASE FLUID INTAKE, AND REPORT HEADACHE, BLURRED VISION, OR PALPITATIONS, WHICH CAN INDICATE TOXICITY. ¥ THEOPHYLLINE: monitor blood levels for toxicity. Adverse effects include TACHYCARDIA, NAUSEA, AND DIARRHEA. ¥ SALMETEROL: use to prevent an asthma attack and not the ONSET of the attack. DO NOT use during acute exacerbations. ANTI-INFLAMMATORY AGENTS ¥ Corticosteroids such as FLUTICASONE & PREDNISONE (TAKE WITH FOOD) ¥ Leukotriene inhibitors such as MONTELUKAST ¥ Mast cell stabilizers such as CROMOLYN ¥ Monoclonal antibodies such as OMALIZUMAB CLIENT EDUCATION: ¥ ¥ ¥ ¥ ¥ ¥ REPORT BLACK TARRY STOOLS DRINK PLENTY OF FLUIDS TO PROMOTE HYDRATION Avoid people who has respiratory infections Use good mouth care and hand washing regimen DO NOT DISCONTINUE medications abruptly. Rinse mouth and gargle after inhaled glucocorticoids to minimize dysphonia and candidiasis. ADULT MEDICAL SURGICAL TUBERCULOSIS Is an infectious disease caused by MYOBACTERIUM TB. “AIRBORNE” EXPECTED FINDINGS: ¥ ¥ ¥ ¥ ¥ PERSISTENT COUGH LASTING LONGER THAN 3 WEEKS PURULENT SPUTUM, POSSIBLY BLOOD STREAKED FATIGUE AND LETHARGY WEIGHT LOSS & ANOREXIA NIGHT SWEATS AND LOW GRADE FEVER IN THE AFTERNOON LAB TESTS: ¥ NUCLEIC ACID AMPLIFICATION TEST (RESULTS IN LESS THAN 2 HOURS) ¥ QUANTIFERON-TB GOLD (RESULTS AVAILABLE WITHIN 24 HOURS) ¥ ACID-FAST BACILLI SMEAR AND CULTURE ¥ INTRADERMAL INJECTION: RESULTS ARE TO BE READ WITHIN 48-72 HOURS PATIENT CENTERED-CARE: ¥ Administer humidified oxygen therapy as prescribed. ¥ WEAR N-95 MASK!!! ¥ PLACE THE CLIENT IN A NEGATIVE-AIRFLOW ROOM & IMPLEMENT AIRBORNE PRECAUTIONS. ¥ PROMOTE ADEQUATE NUTRITION (Encourage fluid intake, and well-balanced diet, encourage foods high in PROTEIN, IRON, AND VITAMIN C&B. MEDICATIONS: ISONIAZID – commonly referred to as INH, is bactericidal and inhibits growth of myobacteria by preventing synthesis of mycolic acid in the cell wall. ¥ ¥ ¥ ¥ ¥ Taken on an empty stomach Monitor for hepatoxicity (jaundice, anorexia, malaise, fatigue, and nausea) and NEUROTOXICITY (tingling in the hands or feet) Vitamin b6 (PYROXIDINE) is often prescribed concurrently to prevent neurotoxicity. Liver function testing should be completed prior to and monthly after starting INH. DO NOT DRINK ALCOHOL RIFAMPIN – commonly referred to as RIF, is a bacteriostatic and bactericidal antibiotic that inhibits DNA-dependent RNA polymerase activity in susceptible cells. ¥ ¥ ¥ ¥ ¥ Observe for hepatoxicity Liver function testing prior and monthly URINE AND OTHER SECRETIONS WILL BE ORANGE REPORT JOINT SWELLING, LOSS OF APPETITE, JAUNDIE, AND MALAISE CAN EFFECT EFICACY OF ORAL CONTRACEPTIVES ADULT MEDICAL SURGICAL IMMUNE AND INFECTIOUS DISORDERS DIAGNOSTIC PROCEDURES The most accurate and definitive way to identify micro-organisms and cell characteristics is by examining blood, body fluids, and tissue samples under a microscope. WHITE BLOOD CELLS: ¥ Stimulate the inflammatory response and offer protection against various types of infection and foreign antigens. ¥ There are 5 types of WBC’s USED IN THE LAB ANALYSIS. NEUTROPHILS – PERCENTAGE OF CIRCULATING NEUTROPHILS: 55-70%. LYMPHOCYTES (T-CELLS AND B-CELLS) – PERCENTAGE OF CIRCULATING LYMPHOCYTES: 20-40%. MONOCYTES – PERCENTAGE OF CIRCULATING MONOCYTES: 2-8%. EOSINOPHILS – PERCENTAGE OF CIRCULATING EOSINOPHILS: 1-4%. BASOPHILS – PERCENTAGE OF CIRCULATING BASOPHILS: 0.5-1%. BLOOD ALLERGY TEST: can determine sensitivity to various allergens. ADVANTAGES: ¥ Will not precipitate a dangerous allergic reactions ¥ Quicker than skin testing DISADVANTAGES: ¥ Usually, only tests for a small amount of allergens at a time, such as a panel for meat allergens, or panel for fruit allergens. ¥ Can be less sensitive than skin testing REPORT OF HYPERSENSITIVITY REACTIONS: HIVES, EDEMA, GI DYSFUNCTION, RHINITIS, DERMATITIS, ANGIOEDEMA. TAKING CORTICOSTEROIDS PRIOR TO TESTING CAN ELEVATE IgE LEVELS. SKIN TESTING FOR ALLERGENS: is for allergens involves the use of INTRADERMAL injections or scratching the SUPERFICIAL layer (scratch for prick test) of the skin with small amounts of potential allergens. POTENTIAL DIAGNOSES: environmental and food allergies. EXPECTED FINDINGS: hives, asthma, GI dysfunction, rhinitis, dermatitis, angioedema. INTERPRETATION OF FINDINGS: ¥ A localized reaction (wheal and flare) to an allergen is a POSITIVE REACTION to that allergen. ¥ The LARGER the reaction, the more severe the allergy. CONSIDERATIONS: ¥ ¥ Prepare the skin: use alcohol to remove any oil. Prior to testing, withhold corticosteroids and antihistamines for 48 hr to 2 weeks, as instructed by PCP. ADULT MEDICAL SURGICAL HIV/AIDS Retrovirus that is transmitted through blood and body fluids (semen, vaginal secretions). HIV TARGETS CD4+ LYMPHOCYTES, ALSO KNOWN AS T-cells, or T-lymphocytes. HIV IS FOUND IN FECES, URINE, TEARS, SALIVA, CEREBROSPINAL FLUID, CERVICAL CELLS, LYMPH NODES, CORNEAL TISSUE, AND BRAIN TISSUE. ALL PATIENTS WHO ARE PREGNANT SHOULD BE SCREENED FOR HIV. PROGRESSION OF HIV INFECTION: ¥ Manifestations occur within 2 to 4 weeks of infection. ¥ Manifestations are similar to those of influenza and can include a rash and sore throat. ¥ Manifestations of acute HIV infection can include the following: FEVER, NIGHT SWEATS, CHILLS, HEADACHES, MUSCLE ACHES, SORE THROAT, AND RASH. ¥ ¥ ¥ AIDS This stage is characterized by life-threatening opportunistic infections. This is the END STAGE of HIV infection. Without treatment, death can occur within 5 YEARS. ALL PEOPLE WITH AIDS HAVE HIV, BUT NOT ALL PEOPLE WHO HAVE HIV HAVE AIDS. HEALTH PROMOTION AND DISEASE PREVENTION ¥ Providers should use STANDARD PRECAUTIONS when caring for the client. ¥ Encourage the client to maintain up-to-date immunizations, including yearly influenza and pneumococcal polysaccharide vaccine. RISK FACTORS ¥ Unprotected sex, (vaginal, oral, anal) ¥ Multiple sex partners ¥ Occupational exposure (healthcare workers) ¥ Perinatal exposure ¥ Blood transfusions ¥ IV drug use with a contaminated needle EXPECTED FINDINGS ¥ Chills, rash ¥ Anorexia, nausea, weight loss ¥ Weakness and fatigue ¥ Headache and sore throat ¥ Night sweats LAB TESTS: ¥ CBC and differential: Abnormal (anemia, thrombocytopenia, leukopenia) ¥ Platelet count: decreased less than 150,000/mm3 A POSITIVE WESTERN BLOT OR IFA TEST MEANS THAT THE CLIENT HAS BEEN EXPOSED TO AND HAS THE AIDS VIRUS IN THEIR BODY BUT DOES NOT MEAN THE CLIENT HAS CLINICAL AIDS. ADULT MEDICAL SURGICAL HIV/AIDS CONT… PATIENT-CENTERED CARE: ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ Collect data on risk factors (sexual practices, IV drug use) Monitor fluid intake/urinary output Obtain daily weight to monitor weight loss Monitor nutritional intake Monitor electrolytes Monitor skin integrity Monitor pain status Check neurologic staus Provide analgesia PRN MEDICATIONS FUSION INHIBITORS à ENFUVIRTIDE BLOCK THE FUSION OF HIV WITH THE HOST CELL. ENTRY INHIBITORS à MARAVIROC BLOCKS THE CCR5 RECEPTOR OF THE CD4 T CELL TO PREVENT FURTHER PROGRESSION OF THE INFECTION. NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS à ZIDOVUDINE INTERFERES WITH THE VIRUS’S ABILITY TO CONVERT RNA TO DNA. NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS à DELAVIRDINE AND EFAVIRENZ INHIBIT VIRAL REPELICATION IN CELLS PROTEASE INHIBITORS à ATAZANAVIR, NELFINAVIR, SAQUINAVIR, AND INDINAVIR INHIBIT AN ENZYME NEEDED FOR THE VIRUS TO REPLICATE INTEGRASE INHIBITORS à RALTEGRAVIR AND DOLUTEGRAVIR INHIBIT VIRAL REPLICATION BY STOPPING THE HIV ENZYME INTEGRASE FROM INSERTTING INTO THE HOST CELL DNA. ANTINEOPLASTIC MEDICATION à INTERLUKIN IS AN IMMUNOSTIMULANT THAT ENHANCES THE IMMUNE RESPONSE AND REDUCES THE PRODUCTION OF CANCER CELLS (USED COMMONLY WITH KAPOSI’S SARCOMA) NURSING ACTIONS/CLIENT EDUCATION ¥ ¥ ¥ ¥ ¥ ¥ ¥ MONITOR LAB RESULTS (CBC, WBC, AND LIVER FUNCTION) BE AWARE OF THE ADVERSE EFFECTS OF THE MEDICATIONS AND WAYS TO DECREASE THE SEVERITY OF THE EFFECTS. TAKE MEDICATIONS ON A REGULAR SCHEDULE AND DO NOT MISS DOSES. MISSED DOSES CAN CAUSE DRUG RESISTANCE. PRACTICE GOOD HYGIENE, BATHE DAILY USING ANTIMICROBIAL SOAP WASH DISHES IN HOT WATER AVOID RAW FOODS (FRUITS, VEGGIES, AND UNDERCOOKED FOODS (MEAT, FISH, EGGS) AVOID CROWDS ADULT MEDICAL SURGICAL LUPUS ERYTHEMATOSUS Is an autoimmune disorder in which an atypical immune response results in chronic inflammation and destruction of healthy tissue. ¥ Lupus varies in severity and progression. It is generally characterized by periods of exacerbations (FLARES) and remissions. o Discoid lupus erythematosus (DLE) – only affects the SKIN. o Systemic lupus erythematosus (SLE) – affects the connective tissues of multiple organ systems and can lead to major organ failure. o Medication-induced lupus erythematosus – can be caused by medications (procainamide, hydralazine, minocycline). Findings resolve when the medication is discontinued. RISK FACTORS ¥ FEMALE AGE 15 TO 40 YEARS OLD ¥ Asian, Hispanic, African EXPECTED FINDINGS ¥ ¥ ¥ ¥ ¥ ¥ ¥ Fatigue/Malaise Alopecia Blurred vision Pleuritic pain Depression Joint pain, swelling, tenderness Anemia NURSING CARE ¥ ¥ ¥ ¥ ¥ ¥ Monitor the following: pain, mobility, and fatigue Vital signs (especially blood pressure) Provide small frequent meals) Offer between-meal supplements Limit salt intake for fluid retention secondary to steroid therapy Provide emotional support Avoid crowds MEDICATIONS NSAIDS – used to reduce inflammation and arthritic pain. Contraindicated for clients who have impaired kidney function. CORTICOSTEROIDS – PREDNISONE: used for immunosuppression and to reduce inflammation. ¥ ¥ ¥ Monitor for fluid retention, hypertension, and impaired kidney function. DO NOT stop taking abruptly, gradually taper the dosage as prescribed. Older adults are at an increased risk for fractures if corticosteroid tx. is used. IMMUNOSUPPRESSANT AGENTS ¥ METHOTEXTRATE and AZATHIOPRINE are used to suppress the immune response. o Monitor for toxic effects ADULT MEDICAL SURGICAL o Avoid live vaccine administration for 30 days before beginning immunosuppressant therapies. Lupus cont… CLIENT EDUCATION o Wear a wide-brimmed hat, long-sleeve shirt, and long pants when outdoors o AVOID UV and prolonged sun exposure. Use sunscreen. o Use mild protein shampoo and harsh hair treatments o Use steroid creams for rash o Avoid crowds and people who are sick o Apply lotion to dry skin o Cleanse skin with mild soap, and inspect for open areas and rashes daily. GOUT or gouty arthritis is the most common inflammatory arthritis. Gout is a systemic disease caused by a disruption in purine metabolism in which uric acid crystals are deposited in joints in joints and body tissues. GOUT IS CLASSIFIED AS EITHER PRIMARY OR SECONDARY PRIMARY GOUT: o o o o MOST COMMON Primary gout has 3 stages: asymptomatic hyperuricemia, acute gouty arthritis, and chronic gout. URIC ACID production is greater than excretion of it by the kidneys. Can have genetic component SECONDARY GOUT: o o o Caused by another disease or condition (chronic kidney failure, some carcinomas, excessive diuretic use) that causes excessive uric acid in the blood. Treatment is based on treating the underlying condition Can affect people of any age RISK FACTORS: o o o o o o Obesity Heredity Alcohol ingestion Starvation dieting Diuretic use CKD EXPECTED FINDINGS: o o o o Severe joint pain, especially in the metatarsophalangeal joint of the GREAT TOE. Redness, swelling, and warmth of affected joint Painful, swollen joint that is very painful if touched or moved Appearance of TOPHI (deposits of sodium urate crystals under the skin) with CHRONIC GOUT LAB TESTS: o Erythrocyte sedimentation rate (ESR): ELEVATED ADULT MEDICAL SURGICAL o o SERUM URIC ACID: repeated measurements obtained due to the effect of dietary intake on results. Consistent elevation above 6.8 mg/dL is associated with gout. BLOOD UREA NITROGEN (BUN): ELEVATED GOUT cont… DIAGNOSTIC PROCEDURE: o Aspiration of SYNOVIAL FLUID for analysis or uric acid crystals in affected joints. NURSING CARE: o Pain, redness, swelling of the affected joint o SERUM URIC ACID LEVELS MEDICATIONS: ACUTE GOUT – ANTIGOUT AGENTS o COLCHICINE (PO) – is used to decrease pain and inflammation. (Use cautiously in clients who have impaired kidney function.) NSAIDs o INDOMETHACIN or IBUPROFEN is used to decrease pain and inflammation. (Contraindicated for clients who have impaired kidney function) o DO NOT TAKE ON AN EMPTY STOMACH CORTICOSTEROIDS o PREDNISONE is used to treat inflammation. o MONITOR FOR FLUID RETENTION, HYPERTESNION, AND IMPAIRED KIDNEY DYSFUNCTION o DO NOT STOP TAKING MEDICATION ABRUPTLY. GRADUALLY TAPER CHRONIC GOUT – XANTHINE OXIDASE INHIBITOR o ALLOPURINOL or FEBUXOSTAT is used as a maintenance medication to promote uric acid excretion and decrease its production o TAKE AFTER MEALS AND WITH A FULL GLASS OF WATER. INCREASE FLUID INTAKE. URICOSURIC o PROBENECID is used as a maintenance medication to promote uric acid excretion. o MONITOR URIC ACID LEVELS o DO NOT USE ASPIRIN BECAUSE IT WILL DECREASE THE EFFECTIVENESS OF THE MEDICATION ENZYMES o Enzyme treatment is used with refractory gout, when acute or chronic gout does not respond to other medication treatment. o MONITOR CLOSELY FOR ALLERGIC REACTION o REPORT IMMEDIATELY IF REACTION OCCURS COMBINATION MEDICATIONS à PROBENECID AND COLCHICINE ARE AVAILABLE AS COMBINATION. o o o o CLIENT EDUCATION: Stay on a LOW-PURINE DIET, which includes no ORGAN MEATS OR SHELLFISH Limit alcohol intake AVOID STARVATION DIETS, ASPIRIN, DIURETICS Limit physical or emotional stress ADULT MEDICAL SURGICAL o Practice medication adherence o Use stress-management techniques FIBROMYALGIA Also known, as fibromyalgia syndrome, is a chronic pain syndrome which manifests as pain, stiffness, and tenderness at trigger points in the body. RISK FACTORS o o o Females between ages 25 and 60 years History of stressors: trauma, infection, autoimmune disease, and family history Deep sleep deprivation EXPECTED FINDINGS o o o o o o Moderate to severe fatigue Sleep disturbances Numbness/tingling of extremities Sensitivity to noxious smells, loud noises, and bright lights Headaches, jaw pain Depression, Visual changes NURSING CARE o o Monitor pain, mobility, and fatigue Provide emotional support to the family MEDICATIONS – SNRI’s (serotonin-norepinephrine reuptake inhibitors and Anticonvulsants o PREGABALIN (anticonvulsant) and DULOXETINE (SNRI) are used to increase the release of serotonin and norepinephrine, resulting in decreased nerve pain. o DO NOT DRINK ALCOHOL WHILE TAKING THESE MEDICATIONS o SNRI’s can cause DROWSINESS AND SLEEPINESS NSAIDs o Used to decrease pain and inflammation o DO NOT TAKE ON EMPTY STOMACH TRICYCLIC ANTIDEPRESSANTS o AMITRIPTYLINE, NORTRIPTYLINE, (can cause confusion and orthostatic hypotension) AND TRAZADONE: are used to help induce sleep and decrease pain. CLIENT EDUCATION: o Limit intake of caffeine, alcohol, and other substances that interfere with sleep o Develop a routine for sleep o Engage in regular, LOW-IMPACT EXERCISE ADULT MEDICAL SURGICAL RHEUMATOID ARTHRITIS (AUTOIMMUNE) Is a chronic, progressive inflammatory disease that can affect tissues and organs but principally attacks the joints, producing an inflammatory synovitis. RISK FACTORS: o o o o o o Female sex Age 30 to 50 years Genetic predisposition Bacterial or viral infection Environmental factors Older age EXPECTED FINDINGS: o o o o o o o o Pain with movement Morning stiffness Pleuritic pain Xerostomia Anorexia/Weight loss Fatigue Paresthesia Joint pain LAB TESTS: o o Erythrocyte sedimentation rate (ESR) – elevated ESR is associated with the inflammation or infection in the body. C-reactive protein (CRP) – test that can be done in place of ESR. Useful for diagnosing disease or monitoring disease activity, and for monitoring the response for anti-inflammatory therapy. (ELEVATED LEVELS INDICATE INFLAMMATION) Expected reference range is less than 1.0 mg/dL. DIAGNOSTIC PROCEDURES: ARHTROCENTESIS o Is synovial fluid aspiration by needle. NURSING ACTIONS: o Monitor for bleeding or a synovial fluid leak from the needle biopsy site. CLIENT EDUCATION: o Take acetaminophen for pain o Apply ice o Avoid strenuous use of the joint for several days NURSING CARE: o o o o o Assist with and encourage physical activity to maintain joint mobility. Monitor for indications of fatigue. Monitor skin closely, Minimize pain Facilitate the use of assistive devices, physical therapy and occupational therapy Eat small, frequent meals