Professional Documents
Culture Documents
Final 48 HouCram Full PDF
Final 48 HouCram Full PDF
BRAIN TUMOR
48 Hour Cram
Sheets for Med Surg
Table of Contents
1. CANCER (ONCOLOGY) ...................................................................................................................... 7
BRAIN TUMOR...................................................................................................................................... 7
COLON CANCER.................................................................................................................................... 8
LEUKEMIA............................................................................................................................................. 9
OVARIAN CANCER .............................................................................................................................. 11
PROSTATE CANCER ............................................................................................................................ 12
PANCREATIC CANCER ......................................................................................................................... 13
2. NEURO: CNS ................................................................................................................................... 15
ALZHEIMERS ....................................................................................................................................... 15
BRAIN TUMORS .................................................................................................................................. 17
CEREBERAL VASCULAR ACCIDENT (CVA) ........................................................................................... 18
EPILEPSY ............................................................................................................................................. 20
HEAD INJURY ...................................................................................................................................... 23
MULTIPLE SCLEROSIS (MS)................................................................................................................. 24
MENINGITIS........................................................................................................................................ 25
PARKINSON’S ..................................................................................................................................... 26
SEIZURE .............................................................................................................................................. 27
SPINAL INJURY.................................................................................................................................... 30
3. NEURO: PNS ................................................................................................................................... 32
GUILLAIN-BAR SYNDROME ................................................................................................................ 32
MYASTHENIA GRAVIS ......................................................................................................................... 33
4. GASTRO INTESTINAL (Lower) ......................................................................................................... 36
APPENDICITIS ..................................................................................................................................... 36
SBO (SMALL BOWEL OBSTRUCTION) ................................................................................................. 37
CONSTIPATION ................................................................................................................................... 38
HERNIA ............................................................................................................................................... 39
PARALYTIC ILEUS ................................................................................................................................ 40
ISCHEMIC BOWEL/COLITIS ................................................................................................................. 41
VOLVULUS .......................................................................................................................................... 42
DIVERTICUITIS .................................................................................................................................... 43
RESECTION OF INTESTINES ................................................................................................................ 44
With over 8 years in the medical field, Mike Linares has worked both out in
the field on an Ambulance in the dangerous streets of Los Angeles County
and the in crazy busy the Emergency Rooms. Coupled with his passion for
teaching & desire to help other students and mixed with his chronic typpos
and bad grammmer, SIMPLEnursing.com was born to not only help his
fellow RN students, but nursing students worldwide.
"I hope you enjoy the valuable jewels that Simplenursing.com has to offer.
If so please let me know! I am a real person & I´d love to hear your
thoughts good or bad on Face book, Twitter, or Youtube."
Mike Linares
Student Nurse Mentor & Certified EKG Instructor
Before Helping Hundreds of Struggling Nursing Students Reach Graduation Day & Before Becoming a
Student Nurse Mentor & Certified EKG Instructor, I Myself Was A Struggling "At Risk" Student Nurse
Drowning In My Books & Lost In Clinical.
I was that struggling student working full time in the Emergency Room at one of those
MEGA hospitals in Orange, California. I worked as an EMT aka a "medic" for 8 years
prior to failing out. I knew how to take care patients, I knew the basics of the ABCs of
basic life support, I knew how to take vital signs and how to fix minor injuries. I thought I
had enough experience to skate right through nursing school, I remember thinking "how
hard can it be" right?
After two semesters, I FAILED out of the Program.
I felt defeated, depressed and like a loser. It was one of the lowest points of my life.
Sitting in my room practically bawling my eyes out, I remember quotes my mom and
dad used to encourage me with, "son, whatever doesn´t kill you, Makes you Stronger" &
" Failing is Not a Bad Thing, As long as learn, become better, and NEVER EVER QUIT"
Ending with:
"able to return next semester contingent upon demonstrating INCREASED
COMPETANCIES in these core areas."
"NEVER GIVE UP!!" my mom & dad used to tell me, so I set out on a Quest
to develop a system to make Simplify Nursing School!
In a systematic way to put all the "core competencies" of nursing school that instructors look for to
pass students. My quest was to make it SIMPLE first and foremost, by cutting out the fluff and getting
down to the nitty critty making it easier.
At that moment I realized there are better, more predictable, and more low cost ways to get higher test
scores and have more critical thinking skills than the money I had been spending on dead end study
books that claimed to help but really just confuse me more.
I needed simplicity!!!
Within the next six months I had created over 27 different student help systems, strategies and tactics
that produced better results for me - some better than others.
Then over the next few semesters I tracked, tested, and tweaked each system until my students were
passing with a 82% or better on each and every test, 2 students being out of School for over 25 years
& coming back to score 94% on their EKG cardiac test! Truly amazing & truly making me proud to be
their mentor.
1. CANCER (ONCOLOGY)
DIAGNOSIS/PATHO DATA ACTION RESPONSE
BRAIN TUMOR Assess: Neurological status, ALOC, Nursing Interventions: Nursing Dx:
worsening symptoms/impairment, Pharm: **DEPENDS ON -Disturbed Body Image r/t
↑ICP SIZE & TYPE OF TUMOR, AS changes in the structure and
Patho: Defined as an intracranial solid
Vitals: Normal, until near death WELL AS OVERALL HEALTH function of the brain/body
neoplasm, or an abnormal growth of
S/S & PHYS. EXAM: STATUS: -Fear r/t recent diagnosis and
cells in brain or central spinal canal. No
- Headache - Chemotherapy unknown future
known cause or risk factor.
-Nausea/Vomiting Targeted therapy:
Graded as: low, intermediate or high
-ALOC/Changes in speech, vision or -Avastin/bevacizumab (for Pt. Goals/ Evaluation:
Can be located in several areas of the
hearing glioblastoma) -Pt will verbalize concerns and
brain: - Afinitor/everolimus (used
-Issues with gait, balance or walking fears about body, self
to treat a benign brain tumor)
-Changes in mood, personality, perception and change of
Alternative Medicine:
ALOC lifestyle
-Acupuncture
-Memory problems/inability to -Pt will verbalize anxiety as well
-Hypnosis
concentrate as ways to reduce it/minimize
-Music Therapy
- Seizures/Convulsions with it.
-Relaxation Techniques
-Muscle twitching/jerking
-Numbness/Tingling in extremities
Pt. Ed: Referral to OT, PT,
ST (Speech therapy) and
Labs: Spinal tap, biopsy
tutoring (if child, and
Dx Tests: Neurological exam, MRI,
learning/memory problems
CT Scan, Angiogram
-Healthy cells transform/mutate into Surgery: Removal of
malignant cells upon exposure to certain tumor (If able to)
etiologic factors such as: Viruses,
Chemicals, and Physical agents. When
cells are malignant, they can metastasize
into tissues surrounding the area, to the
lymph nodes and lymphatic system, the
etiologic factors such as: Viruses, - Change in your bowel habits status and demonstrate
Chemicals, and Physical agents. When (diarrhea, constipation, utilization of support systems
cells are malignant, they can metastasize consistency) and therapy as prescribed
into tissues surrounding the area, to the - Blood in your stool
lymph nodes and lymphatic system, the - Persistent abdominal discomfort,
blood, and system wide to other such as cramps, gas or pain
organs/cavities. All cancers are staged - Feeling your bowel doesn't empty
between I-IV, with Stage I being the least completely
severe and Stage IV being the most - Weakness/fatigue
severe. - Unexplained weight loss
blood, and system wide to other S/S & PHYS. EXAM: including ERECTILE
organs/cavities. All cancers are staged - Urinary problems DYSFUNCTION, and
between I-IV, with Stage I being the least - Decreased force in the urine encourage them to utilize
severe and Stage IV being the most stream support system/
severe. - Blood in semen affection/coping skills.
- Erectile dysfunction Refer to support group.
- Pelvic Discomfort Also ambulation and
- Pain in Bone catheter care after surgery.
lymph nodes and lymphatic system, the I – Indigestion/Difficulty swallowing (duodenum), gallbladder
blood, and system wide to other O – Obvious change in wart/mole and part of your bile duct.
organs/cavities. All cancers are staged N - Nagging, coughing or Part of stomach may be
between I-IV, with Stage I being the least hoarseness removed in addition. The
severe and Stage IV being the most remaining parts of your
severe. pancreas are reconnected
Vitals: Normal unless distressed to the Patient’s stomach
S/S & PHYS. EXAM: and intestines to allow the
(**Can be asymptomatic) digestion of food.
- Yellowing of your skin and the -Also, removal of cancer on
whites of your eyes (jaundice) tail of Pancreas if possible
- Upper abdominal pain (can
radiate to back)
- Weight Loss/ Anorexia
- Depression
- Blood clots
2. NEURO: CNS
DIAGNOSIS/PATHO DATA ACTION RESPONSE
ALZHEIMERS Assess: Use GLASCOW/COMA SCALE (see Nursing Interventions: Nursing Dx:
below), LOC, Advancement of disease, ADL Pharm: -Altered urinary
Patho: The most common cause of
issues (speak to caretaker if any) Degree of Cholinesterase Inhibitors: and bowel
Dementia in older adults. This disease is
Memory loss, Motor function, reflexes, -Donepezil elimination r/t
progressive and is marked by impaired
speech, cognition, affect -Galantamine cognitive
memory and thinking skills. The classic
NMDA Antagonist: impairment and
neuropathology findings in AD include
-Memantine loss of muscle
amyloid plaques, neurofibrillary tangles,
Selective Serotonin Reuptake tone
and synaptic and neuronal cell death.
Inhibitors (SSRI’s): - Self-care deficit
-Citalopram r/t cognitive
-Paroxetine impairment and
Anti-Anxiety Meds: physical
-Lorazepam limitations
- Oxazepam
Pt. Goals/
Vitals: ↑BP & ↑Pulse (May indicate ↑ Pt. Ed: **Education is better Evaluation:
Cranial pressure) absorbed by the Caretaker; as -Pt will identify
S/S & PHYS. EXAM: the patient may not be a need to
STAGES: reliable source to remember urinate/defecate
1. Mild – Slow and gradual progression of Have clocks, calendars and and/or understand
decline of intellectual activity; loss of personal items in clear view. the need for
energy/drive, difficulty learning Speak in short phrases/words. assistance with
2. Moderate – Evident deterioration. Speak slowly. Assess vital these activities
Client can’t remember address/phone signs/Neuro status. Identify -Pt will identify
number. Memory gaps, decreased threats to patient’s safety. need to
hygiene, memory gaps, mood swings, Review all meds patient is urinate/defecate
paranoia, anger, jealousy and apathy. Full- taking, use family to obtain and/or understand
time care needed. history. the need for
BRAIN TUMORS Assess: Neuro exam, Head to toe Nursing Interventions: Nursing Dx:
assessment, Assess coordination Pharm: (Depends on size and -Acute pain r/t
Patho: Brain tumors may be classified
Vitals: location of the tumor) tumor and
into several groups: those arising from the
Severe headache in the morning, Radiation Therapy, increased
coverings of the brain (e.g., Dural
increased when coughing, bending Chemotherapy, Medications to intercranial
meningioma), those developing in or on
Convulsions reduce ICP (Mannitol), Anti- pressure
the cranial nerves (e.g., acoustic
convulsants, Analgesics -Anxiety r/t
neuroma), Signs of increased intra-cranial pressure: (**All prn, depending on unknown future
Those originating with in brain tissue and blurred vision, nausea, vomiting, decreased situation) after surgery,
metastatic lesions originating elsewhere in Auditory function, changes in vital signs,
Pt. Ed: Caregiver information cognitive
the body. Tumors of the pituitary and aphasia.
about assistance with ADL’s, impairment and
pineal glands and of cerebral blood vessels Changes in personality
keeping up with check-ups, health issues.
are also types of brain tumors. Relevant Impaired memory options of care/symptom relief, Pt. Goals/
clinical considerations include the location
Natural disturbance of taste support groups, Evaluation:
and the histology character of the tumor.
communication with medical -Pt will verbalize
Tumors may be benign or malignant. A Classic triad:
personnel and sources pain level using
benign tumor CAN BE SERIOUS!! If occurs o Headache
o Papilledema (intra-ocular pressure)
Surgery: Surgery if possible to numeric chart or
in a vital area and can grow large enough
o Vomiting remove tumor (Depends on “FACES” chart, as
to have effects as serious as those of a
S/S & PHYS. EXAM: size, location and degree of well as ways to
malignant tumor.
Labs: Blood & Urine tests, Biopsy damage if removed) reduce/treat pain
Dx Tests: MRI, Functional MRI (fMRI) CT -Pt will verbalize
Scan, Angiogram, Brain Scan, Diffusion anxiety as well as
Tensor Imaging (DTI), Positron Emission ways to reduce
technology (PET Scan), Bone Scan it/minimize with it.
CEREBERAL VASCULAR Assess: Assess for ALOC, change in Nursing Interventions: Nursing Dx:
ACCIDENT (CVA) speech/mental status, aphagia, dysphagia, Pharm: (Depends on type/ -Ineffective
visual disturbance, loss of balance, cause) Cerebral Tissue
Patho: *Commonly referred to as
coordination, sudden SEVERE headache -Aspirin Perfusion
Stroke or “Brain attack”. In a stroke, the
Vitals: ↑Pain -TPA (“Clot Buster”): Given -Impaired physical
sudden interruption of blood supply to
S/S & PHYS. EXAM: within first 3-4.5 hours as mobility r/t
areas of the brain results in cerebral
Stroke indicated. ***TPA neuromuscular
necrosis and impaired cerebral -Hemiplegia and sensory deficit CONTRAINDICATIONS involvement:
metabolism, which permanently damages -Aphasia (impairment may be in speaking, Intercranial hemorrhage, cognitive
brain tissues and produces focal listening, writing, or comprehending,
internal bleeding, recent impairment,
neurologic deficit of varying severity. A Most cases are mixed expressive and
receptive). trauma/surgery in last 3 mos., perceptual
cerebral aneurysm is prone to rupture,
-Hemipoeis – weakening of one side uncontrolled hypertension impairment,
which causes blood to leak into the sub-
-Unilateral neglect of paralyzed side -Anticoagulants/Anti-platelets paresthesia,
arachnoid space (and sometimes into
-Bladder impairment Pt. Ed: Watch for signs of weakness
brain tissue, where it forms a clot), -Possibly respiratory impairment bleeding/hemorrhage/Stroke,
resulting in increased intracranial pressure -Impaired mental activity and psychological blood tests as requested, Pt. Goals/
(ICP) and brain tissue damage deficits/ALOC
control Hypertension & Evaluation:
-In a TIA, there is a temporary decrease in -STROKE: F-A-S-T – Face, affect, smile,
diabetes, maintain diet low in -Pt will maintain
blood flow to a specific region of the -Transient Ischemic Attack
saturated fat, and exercise as improved/usual
brain, but there is no necrosis of brain -Temporary loss of consciousness or advised. QUIT SMOKING! Drink cognition, LOC and
tissue. The symptoms (lasting seconds to dizziness
-Paresthesias
moderately/stop drinking. If motor/sensory
hours) produce transient neurologic
-Garbled speech trouble communicating, utilize function
deficits that completely clear within 12 to
-Cerebral aneurysm props/tools, If physical -Pt will
24 hours.
-Blurred vision and headache ailments, utilize tools to assist maintain/increase
in mobility, join a support function, of
Signs and symptoms of ICP group/obtain emotional affected body part
-Nuchal rigidity and pain on neck support. or compensatory
movement
-Photophobia
Surgery: body part
FOR CLOTS:
Labs: Urinalysis, Lumbar Puncture, brain Mechanical removal of clot,
biopsy Carotid endarterectomy
FOR HEMHORRAGING:
-Coiling
HEAD INJURY Assess: Perform Neuro assessment, Nursing Interventions: Nursing Dx:
Assess for ALOC, Signs of confusion, Pharm: Analgesics, Mannitol, -Ineffective
Patho: brain injuries can be classified
as traumatic or acquired, with additional
bleeding/CSF in ears (halo sign), Assess Lasix, barbiturates, Cerebral Tissue
types under each heading. All brain injuries intracranial pressure (Shouldn’t exceed 20- corticosteroids Perfusion
are described as either mild, moderate, or 25mmHg) Monitor MAP (Keep above Pt. Ed: Inform patient of signs -Impaired physical
severe. 90mmHg), Elevate HOB to 30°, Monitor and symptoms of ICP, confirm mobility r/t
Traumatic Brain Injury vital signs/ABG’s understanding of treatment neuromuscular
Traumatic brain injury is a result of an Vitals: ↑PAIN, may have ↑TEMP and/or regimen including medication, involvement:
external force to the brain that results in a
↑↓BP (depending on Injury) drains, etc. Communicate with cognitive
change to cognitive, physical, or emotional
functioning. The impairments can be family for signs of worsening impairment,
temporary or permanent S/S & PHYS. EXAM: condition and allow them to perceptual
(Symptoms depend on the severity and voice concerns. impairment,
Acquired Brain Injury distribution of brain injury) Surgery: To relieve excessive paresthesia,
An acquired brain injury is an injury to the -A common manifestation is loss of fluid/ICP (May install a drain), weakness
brain that is not hereditary, congenital, consciousness, ranging from a few minutes
to 1 hour or longer
“Bone Flap” removed to relieve
degenerative, or the result of birth trauma.
-Ecchymosis may be seen over the mastoid pressure, Removal of Pt. Goals/
Acquired brain injury generally affects cells
throughout the entire brain. (Battle’s sign) hematoma Evaluation:
-CT scan may reveal the area that is -Pt will maintain
contused or injured X-Rays may reveal skull improved/usual
fractures cognition, LOC and
Bloody spinal fluid suggests brain motor/sensory
laceration or contusion
-Brain injury may have various signs,
function
including altered level of conscious-ness, -Pt will
pupil abnormalities, altered or absent gag maintain/increase
reflex or corneal reflex, neurologic deficits, function, of
change in vital signs (e.g. respiration affected body part
pattern, hypertension, bradycardia), or compensatory
A. Direct injury: Depression of skull, hyperthermia or hypothermia, and sensory,
body part
Direct injury or skull fracture vision or hearing impairment
B. Blow to head: Blow to the skull -Signs of a post-concussion symptoms may
that may move the brain to a point include headache, dizziness, anxiety,
which can cause damage to irritability, and lethargy
vessels or veins, contusion or -In acute or sub-acute subdural hematoma,
hematoma changes in level of consciousness, papillary
MULTIPLE SCLEROSIS (MS) Assess: Assess for cognitive, sensory and Nursing Interventions: Nursing Dx
physical impairment, pain, Pharm: -Impaired physical
Patho: REMEMBER! MS, Myelin Sheath!!
Demyelination of nerve fibers within long
numbness/paresthesia, extreme fatigue -Immuno-suppressants to mobility r/t
conducting pathway of spinal cord and and inflammation. Also assess for reduce exacerbation: (Avonex neuromuscular
brain. medication adherence IM weekly), Betaseron involvement:
Impaired transmission of never Vitals: (Subcut), Copaxone (Subcut) cognitive
impulses. S/S & PHYS. EXAM: -For muscle spasicity/tremors: impairment,
-Spastic weakness – the most common Neurontin, Baclofen, perceptual
Degenerative changes myelin sheath
sign Clonazapam impairment,
are scattered irregularly throughout the
central -Charcots Triad: A combination of -For Urinary Problems: parasthesia,
nervous system. Nerve axon also symptoms that includes nystagmus,
Ditropan, Detrol weakness
deteriorates. The areas involved are not intention tremor (motor weakness in -For sexual Dysfunction: Viagra -Ineffective
consistent when it comes to deterioration coordination), scanning speech which is -Depression: Zoloft. Prozac individual coping
thereby showing the signs and symptoms elicited by slowing enunciation with -Fatigue: Provigil, Symmetrel r/t uncertainty of
appear whenever the nerve conduction is tendency to hesitate at beginning of a course of MS
interrupted word. Pt. Ed:
-There are periods of remission also,
Hyper-emotions as well as euphoria 1. Self-Injection techniques Pt. Goals/
however there are cases that symptoms are
exacerbated especially when nerve impulse Visual disturbances 2. Promote independence Evaluation:
travel through the patchy never fibers. 3. Self-Catheterization -Pt will maintain/
Nausea/Vomiting
4. Promote exercise daily, with increase function,
Urinary retention or urinary incontinence fall precautions of affected body
Dysphagia (difficulty in swallowing) 5. Injury Prevention part or
Ataxia (decreased coordination)
6. Stress reduction and immune compensatory
support to avoid infection body part
Labs: CSF Analysis
PARKINSON’S Assess: Assess for the 4 Cardinal signs of Nursing Interventions: Nursing Dx:
Parkinson’s: Pharm: Depends on -Impaired physical
Patho: Parkinson’s disease is a slowly
1. Resting tremor age/severity: mobility r/t
progressive degenerative neurological
2. Rigidity - Carbidopa/Levodopa neuromuscular
disorder caused by the loss of nerve cell
3. Bradykinesia therapy involvement:
function in the basal ganglia. Loss of nerve
4. Postural instability - Dopamine Agonists tremors, muscle
cells in the substantia nigra causes a
*PATIENT IS A FALL RISK! - Anticholinergics rigidity, weakness
reduction of dopamine production.
Vitals: Normal, unless distressed - MAO-B Inhibitors -Self care deficit
Dopamine is the neurotransmitter
S/S & PHYS. EXAM: - COMT Inhibitors r/t neuromuscular
essential for such functions as control of
weakness,
posture, supporting the body in an upright
Pt. Ed: Assistance with ADL’s, decreased
position and voluntary motions.
Caretaker info, important strength and loss
information regarding the of muscle control/
disease and depression, coordination,
Surgery: None at this time cognitive changes
& postural
changes
FOCAL SEIZURES
1. Simple Focal Seizure: During these
seizures, you remain conscious although
some people can't speak or move until the
seizure is over. Uncontrolled movements,
such as jerking or stiffening, can occur
throughout your body. You also may
experience emotions such as fear or rage
or even joy; or odd sensations, such as
ringing sounds or strange smells.
SPINAL INJURY Assess: ABC’s!! For reflexes, response to Nursing Interventions: Nursing Dx:
stimuli and level of injury, Neuro-exam! Pharm: None at this time to -Impaired physical
Patho: Spinal cord injuries cause myelo-
pathy or damage to white matter or
TREAT, but mobility r/t
myelinated fiber tracts that carry signals to (GLASCOW COMA SCALE): methylprednisolone/Solumedr neuromuscular
and from the brain. It also damages gray ol may be given as medication involvement:
matter in the central part of the spine, to treat ACUTE spinal injury sensory/
causing segmental losses of interneurons Pt. Ed: Assistance with ADL’s perceptual
and motorneurons. Spinal cord injury can as needed, PT to become impairment,
occur from many causes, including: adjusted to parasthesia,
-Trauma such as automobile crashes, falls,
gunshots, diving accidents, war injuries,
wheelchair/prosthesis, weakness
etc. Psychological care to deal with -Low self-esteem
-Tumors such as right, ependymomas, mental aspect of the loss, r/t social role
astrocytomas, and metastatic cancer. catheter care as needed, changes, loss of
-Ischemia resulting from occlusion of avoiding pressure ulcers/self control and recent
spinal blood vessels, including dissecting care diagnosis
aortic aneurysms, emboli, arteriosclerosis.
-Developmental disorders such as spina Surgery: None at this time for Pt. Goals/
bifida, meningomyolcoele, and other parasthesia, but surgery may be Evaluation:
Neurodegenerative diseases, such as required to remove bone -Pt will maintain
Friedreich’s ataxia, spinocerebellar ataxia,
fragments (if any), or further function, of
etc.
-Demyelinative diseases, such as secure the spine to prevent unaffected body
Multiple Sclerosis. deformity. parts or
-Transverse myelitis, resulting from spinal compensatory
cord stroke, inflammation, or other causes body parts as well
-Vascular malformations, such as arterio- as correctly
venous malformation (AVM), dural utilizing support
Arteriovenous fistula (AVF), spinal
and assistive
hemangioma, cavernous angioma and
Aneurysm. devices
-Pt will verbalize
concerns and fears
about body, self
perception and
Vitals: DEPENDS ON THE INJURY!! change of lifestyle
S/S & PHYS. EXAM:
-Impaired physical mobility
-Disturbed sensory perception
-Acute pain
-Anticipatory grieving
-Low self-esteem
-Constipation or bowel incontinence
-Impaired urinary elimination
Labs: N/A
Dx Tests: CT Scan, MRI, X-Ray
3. NEURO: PNS
DIAGNOSIS/PATHO DATA ACTION RESPONSE
GUILLAIN-BAR SYNDROME Assess: Asses for S/S of Nursing Interventions: Nursing Dx:
ARDS! Assess respiratory Pharm: Plasmapheresis, IVIG -Ineffective
Patho: Guillain-Barré syndrome is the result of a cell-
status, monitor VS and ECG, (IV Immunoglobulin), breathing
mediated and humoral immune attack on peripheral
Monitor for infection and Analgesics as needed pattern r/t
nerve myelin proteins that causes inflammatory
signs of progression Pt. Ed: Healing/recovery time respiratory
demyelination. With the autoimmune attack, there is an
Vitals: HR, B P may take up to 2 years. muscle weakness
influx of macrophages and other immune-mediated
S/S & PHYS. EXAM: Referral to PT, OT, RT & ST or paralysis,
agents that attack myelin, cause inflammation and leave
Autonomic changes: (Speech therapy), educate decreased cough
the axon unable to support nerve conduction o Tachycardia, bradycardia, patient on strategies to reflex and
hypertension, or orthostatic prevent immobilization
hypotension
complications/immobility -Impaired
o Increased sweating
o Increased salivation Surgery: Laminectomy physical mobility
o Constipation (Remove portion of the r/t
vertebrae) Diskectomy neuromuscular
Other Symptoms: (Removal of herniated disk), involvement:
-Dyskinesia (inability to Spinal Fusion (Fusion of cognitive
executive involuntary vertebrae via the spinal impairment,
movements) process by using a bone graft) perceptual
-Weakness usually begins in impairment,
the legs and progress upward paresthesia,
(ascending paralysis) weakness
-Hyporeflexia (decreased
DTRs) Pt. Goals/
-Paresthesia (numbness), Evaluation:
clumsiness -Pt will maintain
-Blindness patent airway,
-Inability to swallow demonstrate
(dysphagia) or clear secretions effective
-Alternate breathing
hypotension/hypertension - pattern and
Arrhythmias show evidence
Labs: Lumbar Puncture of adequate
Ganglioside Antibody tests oxygenation
Dx Tests: MRI, Pulmonary -Pt will maintain/
Function tests, Nerve increase
conduction test, EMG function, of
(Electromyography) affected body
part or
compensatory
body part
SBO (SMALL BOWEL Assess: Observe and palpate Nursing Interventions: Nursing Dx:
OBSTRUCTION) abdomen for swollen/tender Pharm: Stool Softener, -Deficient Fluid
areas and lump, Listen to bowel STIMULANT Laxative Volume related to
Patho: Intestinal contents, fluid and gas
sounds (or absence of), Assess Pt. Ed: eat foods high in fiber, nausea/vomiting, fever or
accumulative above the intestinal
for signs of perforation and drink lots of liquids diaphoresis
obstruction. The abdominal distention
sepsis/septic shock -Acute Pain related to
and retention of fluid reduce the
Vitals: TEMP Surgery: Laparoscopy, or intestinal blockage, distention
absorption of fluids and stimulate more
S/S & PHYS. EXAM: Surgical Removal (For complete and rigidity
gastric secretion. With increasing
- Cramping intermittent strangulation)
distention, pressure within the intestinal
abdominal pain Pt. Goals/ Evaluation:
lumen increases, causing a decrease in
- Nausea -Pt will demonstrate normal
venous and arteriolar capillary pressure.
- Vomiting vital signs, balanced input and
This causes edema, congestion,
- Diarrhea output
necrosis and eventual rupture or
- Constipation
perforation of the intestinal wall, with - Pt will report pain at
- Inability to have a bowel
resultant peritonitis. Reflux vomiting tolerable level and verbalize
movement/ pass gas
may be caused by abdominal distention. ways to manage it
- Swelling of the abdomen
Vomiting results in a loss of hydrogen
(distention)
ions and potassium from the stomach,
-Bad breath
leading to a reduction of chlorides and
Labs: Serum chemistry, BUN,
potassium in the blood and to metabolic
Creatinine, CBC, WBC,
alkalosis. Dehydration and acidosis
Urinalysis
develop from loss of water and sodium.
-Pressure in abdomen
Labs: WBC’s
Dx Tests: Barium Swallow w/
Flouroscopy, X-RAY, Physical
exam
obstruction can progress to infarction Dx Tests: Upper GI X-ray WILL patients specific needs and
and gangrene in as little as SHOW “COFFEE BEAN SIGN → ) avoid shock
6 h. Barium enema, CT scan
RESECTION OF INTESTINES Assess: For signs of infection, Nursing Interventions: Nursing Dx:
peritonitis, shock Pharm: Enema, Antibiotics, -Pain r/t inflamed bowel and
Patho: Small bowel resection is surgery
Vitals: TEMP Analgesics for pain, IV Fluids, possible peritonitis
to remove part or all of your small
S/S & PHYS. EXAM: Depends Anesthesia -Impaired bowel elimination
bowel. It is done when part of your small
on the reason for bowel Pt. Ed: BOWEL PREP!! r/t constipation and
bowel is blocked or diseased. The small
resection surgery! Many If you have laparoscopic decreased dietary intake
bowel is also called the small intestine.
diseases or ailments can lead to surgery:
Most digestion (breaking down and
this surgery s an option -You will have 3 - 5 small cuts in Pt. Goals/ Evaluation:
absorbing
(Cancer? Polyp Groths? your lower belly. The surgeon - Pt will report pain at
nutrients) of the food you eat takes place
Tumors?) will pass a camera tolerable level and verbalize
in the small intestine.
Labs: CBC and medical instruments ways to manage it
Dx Tests: Abdominal through these cuts -Bowel Elimination as
Ultrasound, CT Scan, EKG, Chest -You may also have a cut of evidenced by Comfort of
X-Ray, about 2 to 3 inches if your passage of stool, stool is soft
surgeon needs to put a hand and formed, passage of stool
inside your belly to feel the is achieved without aids
intestine or remove the -The patient will remain free
diseased segment from signs or symptoms of
-Your belly will be filled with gas infection
to expand it. This makes it easy
for the surgeon to see
and work
COLORECTAL CANCER Assess: Risk factors of colon Nursing Interventions: Nursing Dx:
cancer, Recently changed bowel Pharm: Analgesics for pain -Anticipatory grieving r/t
Patho: Colorectal cancer is a disease in
habits Pt. Ed: Don’t miss your annual change in body function and
which normal cells in the lining of the
Vitals: Normal unless infection, checkups!! Use of colostomy perceived potential death of
colon or rectum begin to change, start to
possibly TEMP bag, avoid food that cause odor patient
grow uncontrollably, and no longer die.
S/S & PHYS. EXAM: and gas, Medical supply stores - Disturbed body image r/t
These changes usually take years to
Ascending (Right) Colon Cancer locally to obtain bags/materials loss of diseased body
develop; however, in some cases of
-Occult blood in stool part/loss of good health
hereditary disease, changes can occur
-Anemia
within months to years. Both genetic and
-Anorexia and weight loss Surgery: Colostomy
environmental factors can cause the -Abdominal pain above Pt. Goals/ Evaluation:
changes. Initially, the cell growth appears umbilicus -Pt will identify and express
as a benign (noncancerous) polyp that -Palpable mass feelings appropriately,
can, over time, become a cancerous Distal Colon/Rectal Cancer verbalize understanding of
tumor. If not treated or removed, a -Rectal bleeding the dying process, and
polyp can become a potentially life- -Changed in bowel habits support to cope
threatening cancer. Recognizing and -Constipation or Diarrhea - Client will discuss concerns,
removing -Pencil or ribbon – shaped stool what to expect after
precancerous polyps before they - Tenesmus chemo/surgery, and ways to
become cancer can prevent colorectal -Sensation of incomplete bowel limit anxiety about body
cancer! emptying image
Dukes’ Classification of
Colorectal Cancer
-Stage A: Confined bowel
mucosa, 80-90% 5-year survival
rate
-Stage B: Invading muscle wall
-Stage C: Lymph node
involvement
-Stage D: Metastases or locally
unresectable tumor, less than
5% 5-year survival rate
Labs:
Dx Tests: Colonoscopy
5. ORTHOPEDICS (BONES)
DIAGNOSIS/PATHO DATA ACTION RESPONSE
HIP FRACTURE Assess: For Nursing Interventions: Nursing Dx:
Hemhorrage and Pharm: Analgesics for pain, Antibiotics -Pain r/t injury
Patho: Fracture pathophysiology includes
SHOCK!! **ALSO for surgery prep, FLUIDS/BLOOD as -Risk for Shock r/t
cortical disruption, peri-osteal damage, and
ASSESS for distal necessary, *** blood loss/Injury
damage to the intra-medullary and cancellous
pulses to ensure Pt. Ed: Instruct client regarding
architecture. Histomorphometric studies have
circulation! Observe fracture Pt. Goals/ Evaluation:
shown that cortical thinning and some decrease
for signs of thrombo- healing process, diagnostic procedures, - Pt will report pain at
in trabecular bone mass and connectivity can be
phlebitis, report treatment and its complications, home tolerable level and
seen especially in Osteoporosis suggesting a
immediately care, daily activities, diet, restrictions verbalize ways to
lower quality of bone, and thus decreased
and follow-up. Encourage fluid intake manage it
mechanical strength resulting in fracture. An
Vitals: PAIN, BP, and high protein, high vitamin, high- -Pt will show signs of
age-related decline in osteocyte viability has
HR, calcium diet. Teach the client adequate tissue
also been observed in experimental studies. An
S/S & PHYS. EXAM: appropriate crutch walking perfusion including
inflammatory response also occurs following
-Inability to move techniques stable vital signs and
fractures of the proximal femur.
immediately after a fall fluid status
-Severe pain in your Surgery: Hip Fracture repair, specific to
hip or groin injured site:
-Inability to put weight
on your leg on the side
of your injured hip
-Stiffness, bruising and
swelling in and around
your hip area
-Shorter leg on the side
of your injured hip
-Turning outward of
your leg on the side of
your injured hip
TOTAL KNEE REPLACEMENT (TKR) Assess: Assess Nursing Interventions: Nursing Dx:
wound/surgical Pharm: Anti-Coagulants, -Pain r/t surgical
Patho: Knee replacement, or knee
incision for signs and NSAIDS/Analgesics for pain (Including procedure
arthroplasty, is a surgical procedure to replace
symptoms of infection Morphine PCA) -Impaired mobility r/t
the weight bearing surfaces of the knee joint to
following surgery and Pt. Ed: The operation typically involves injury/recent surgery
relieve the pain and disability of osteoarthritis.
for signs of shock, for substantial postoperative pain, and includes
It may be performed for other knee diseases
pain, extreme vigorous physical rehabilitation. The recovery Pt. Goals/ Evaluation:
such as rheumatoid arthritis and psoriatic period may be 6 weeks or longer and may
shortening, circulation/ - Pt will report pain at
arthritis. In patients with severe deformity from involve the use of mobility aids (e.g. walking
neurovascular status tolerable level and
advanced rheumatoid arthritis, trauma, or long frames, canes, crutches) to enable the
Vitals: PAIN, HR, verbalize ways to
standing Osteo- arthritis, the surgery may be patient's return to preoperative mobility. Use
RR of helpful items such as toilet seat extender,
manage it
more complicated and carry higher risk. Osteo-
S/S & PHYS. EXAM: Exercises to reduce risk of DVT -Patient will show signs
porosis does not typically cause knee pain,
Signs/Symptoms of Surgery: TKR is the surgery! and verbalize effective
deformity, or inflammation and is not a reason
whatever injury is ways to properly
to perform knee replacement.
causing the need for mobilize using
Other major causes of debilitating pain include
surgery! For Example… tools/physical
meniscus tears, cartilage defects, and ligament
-Pain assistance provided
tears. Debilitating pain from osteoarthritis is
-Inflammation
much more common in the elderly. Knee
-Difficulty moving your
replacement surgery can be performed as a
knee
partial or a total knee replacement. In general,
-Popping/Clicking of
the surgery consists of replacing the diseased or
knee
damaged joint surfaces of the knee with metal
-Joint Pain/Stiffness
disability can range from minor limitation of the -Joint pain -Pt will maintain a
fingers to near immobility in persons with hip or -Joint stiffness position with absence r
knee disease. Progression rates vary; joints may -Joint tenderness limitation of
remain stable for years in the early stage of -Limited range-of- contractures, and
deterioration. motion display
-Crepitus (crackling, techniques/behaviors
grinding noise with that enable
movement) continuation of
-Joint effusion activities
(swelling)
-Local inflammation
-Bony enlargements
and osteophyte
formation
Labs:
Dx Tests: Bone scan,
Dual Energy X-Ray
Absorptiometry Scan
(DEXA-Scan)
RHUMATOID ARTHRITIS (RA) Assess: For Nursing Interventions: Nursing Dx:
contributing factors Pharm: NSAIDS, Corticosteroids, -Acute Pain r/t
Patho: Rheumatoid arthritis (RA) is a chronic,
such as: Disease Modifying Anti-Rheumatic distension of tissues
systemic inflammatory disorder that may affect
-Female drugs (DMARDs) like METHOTREXATE, -Impaired physical
many tissues and organs, but principally attacks
-Physical and LEFLUNOMIDE, BIOLOGIC RESPONSE mobility r/t skeletal
the joints producing an inflammatory synovitis
Emotional Stress MODIFIERS (BRM) administered deformity
that often progresses to destruction of the
-Young to middle age parenterally HUMIRA, ENBREL
articular cartilage and ankylosis of the joints.
-Family History Pt. Ed: Use of mobility devices and Pt. Goals/ Evaluation:
Rheumatoid arthritis can also produce diffuse
safety, prevention of - Pt will report pain at
inflammation in the lungs, pericardium, pleura,
Vitals: PAIN infection/complications, Physical therapy tolerable level and
and sclera, and also nodular lesions, most
S/S & PHYS. EXAM: exercises/Rehab, verbalize ways to
common in subcutaneous tissue under the skin.
-Tender, warm, manage it
Although the cause of rheumatoid arthritis is
swollen joints Surgery: Total Joint arthroplasty, total -Pt will maintain a
unknown, autoimmunity plays a pivotal role in
joint replacement as required position with absence r
its
6. VASCULAR DISORDERS
DIAGNOSIS/PATHO DATA ACTION RESPONSE
disease may manifest acutely when walking or climbing -Pt. will verbalize understanding of
thrombi, emboli, or acute trauma stairs and stops when the disease process and adhere to
compromises perfusion. Thromboses often you rest. This is because the prescribed medication regimen
occur in the lower extremities more the muscles' demand for
blood increases during
frequently than in the upper extremities.
walking and other
Multiple factors pre-dispose patients for exercise. The narrowed
thrombosis. These factors include sepsis, or blocked arteries
hypotension, low cardiac output, cannot supply more
aneurysms, aortic dissection, bypass grafts, blood, so the muscles
and underlying atherosclerotic narrowing of are deprived of oxygen
the arterial lumen. Emboli, the most and other nutrients. This
common cause of sudden ischemia, usually pain is called
are of cardiac origin (80%); they also can intermittent (comes and
originate from proximal atheroma, tumor, goes) claudication. It is
usually a dull, cramping
or foreign objects. Emboli tend to lodge at
pain. It may also feel like
artery bifurcations or in areas where vessels a heaviness, tightness,
abruptly narrow. The femoral artery or tiredness in the
bifurcation is the most common site (43%), muscles of the legs.
followed by the iliac arteries (18%), the Cramps in the legs have
aorta (15%), and the popliteal arteries several causes, but
(15%). cramps that start with
exercise and stop with
rest most likely are due
to intermittent. When
the blood vessels in the
legs are completely
blocked, leg at night is
very typical, and the
individual almost always
hangs his or her feet
down to ease the pain.
Hanging the legs down
allows for blood to
passively flow into the
distal part of the legs
Labs: Total
Cholesterol, LDL
(Lousy Cholest.), HDL
(Happy Cholest.),
Lipids, Triglycerides
Dx Tests: Isotope
Studies, Ultra-Sonic
flow detection
Doppler Studies,
Venous Pressure
measurements
Aneurysm : Pain
radiates up to jaw,
neck,
coughing/hoarseness,
shoulder blade pain.
2. CEREBERAL:
Aneurysm in brain,
“Worst headache of
your life”,
nausea/vomiting,
pain behind eyes,
3. PERIPHERAL: ,
Pulsations, pains and
sores in extremities,
also gangrene (due to
lack of circulation)
Labs: Blood work
such as Hg and Hct,
Coags, checking for
bleeding, monitoring
for signs of
hypovolemia
Dx Tests:
Ultrasound,
Echocardiogram,
Angiogram, MRI, CT
Scan
7. RESPIRATORY
DIAGNOSIS/PATHO DATA ACTION RESPONSE
ASTHMA Assess: Assess for change in Nursing Interventions: Nursing Dx:
skin color/cyanosis, use of Pharm: PREVENTATIVE THERAPY: -Activity Intolerance r/t
Patho: Bronchial asthma is a
accessory muscles/labored (Flovent, Serevent, Singulair) RESCUE energy shift to meet muscle
chronic inflammatory disease of the
breathing (Is this an attack or DRUGS (Albuterol, Atrovent, needs for breathing to
airways, associated with recurrent,
emergency?) Also changes in Theophylline) overcome airway
reversible airway obstruction with
mentation/ALOC Pt. Ed: STOP SMOKING!! Adhere to obstruction
intermittent episodes of wheezing
Vitals: Shallow RR medication regimen as prescribed, -Anxiety r/t inability to
and dyspnea. Bronchial hyper-
(Commonly with Audible Reduce stress, monitor symptoms daily breathe effectively
sensitivity is caused by various
Wheezing), HR during especially signs of an attack, report -Ineffective breathing
stimuli, which innervate the vagus
attacks increasing symptoms to doctor. pattern r/t anxiety
nerve and beta adrenergic receptor
S/S & PHYS. EXAM: Surgery: N/A
cells of the airways, leading to
Feeling of tightness in the Pt. Goals/ Evaluation:
bronchial smooth muscle
chest, difficulty in breathing or -the patient will be able to
constriction, hypersecretion of
shortness of breath, wheezing, demonstrate
mucus, and mucosal edema.
coughing (particularly at behaviors to improve
night). airway clearance
Labs: O2/cap. Refill, -Client will report ability to
hypoxemia breathe comfortably
Dx Tests: Chest X-Rays, &
Pulmonary Fx tests:
Forced Vital Capacity/FVC
(Volume of air exhaled from
full inhalation to full
exhalation), Forced Expiratory
Volume in the first
Second/FEV1 (Vol. of air blown
out as hard as possible in the
first SECOND of the most
-A tension Pneumothorax is a
medical emergency and occurs when
the intrapleural pressure exceeds
atmospheric pressure, especially
during expiration, and results from a
ball valve mechanism that promotes
inspiratory accumulation of pleural
gases. The build-up of pressure
within the pleural space eventually
results in hypoxemia and respiratory
failure from
compression of the lung.
RESPIRATORY FAILURE Assess: Chest Pain, SOB, Nursing Interventions: Nursing Dx:
Restless, anxiety, confusion, Pharm: Oxygen, Diuretics (Lasix), -Ineffective breathing
Patho: Respiratory failure can arise
**ASSESS FOR SIGNS OF Nitroglycerin (To reduce preload/ pattern r/t decreased lung
from an abnormality in any of the
SHOCK afterload), Morphine compliance
components of the respiratory
Vitals: RR, HR, O2, (Pain/Venodilation), Beta2 Agonists -Impaired respiratory
system, including the airways,
BP (Albeuterol, Terbutaline), Atrovent, function r/t inability to
alveoli, central nervous system (CNS),
S/S & PHYS. EXAM: Corticosteroids (Methylprednisolone) maintain adequate
peripheral nervous system,
Bluish coloration of the lips or Pt. Ed: Sit in a position of comfort oxygenation of the
respiratory muscles, and chest wall.
fingernail, Confusion or loss of (one that promotes effective breathing) respiratory tract and
Patients who have hypoperfusion
consciousness, Fainting or such as High Fowlers, medication perfusion of oxygen
secondary to cardiogenic,
change in level of compliance, Oxygen use and need,
Hypovolemic, or septic shock often
consciousness or lethargy report new/worsening symptoms. Pt. Goals/ Evaluation:
present with respiratory failure.
Fatigue, Irregular heart rate Surgery: Tracheotomy/Ventilator if -Pt will report ability to
(arrhythmia), Rapid breathing needed, (AIRWAY IS ALWAYS #1!!), breathe comfortably and
(tachypnea) or shortness of Lung Transplant (if eligible) -Client will exhibit positive
breath signs of perfusion including
Labs: CBC, Chem Panel, O2 Sat. levels and ABG’s
Serum Creatinine Kinease & within normal patient limits
Troponin (To rule out MI) and
TSH (To rule out
hypothyroidism)
Dx Tests: Monitor location of
embolism if any, Chest X-Ray,
URI (UPPER RESPIRATORY Assess: Lung breath sounds, Nursing Interventions: Nursing Dx:
INFECTION) labor of breathing, cough, Pharm: Treat the cause! If infection -ineffective Airway
related symptoms (strep throat, epiglottitis & bacterial Clearance related to
Patho: A URI is a common infection
Vitals: Temp sinusitis): Antibiotics, Common cold thick secretions and airway
that affects the nose, throat and
S/S & PHYS. EXAM: Itchy, (Can only treat symptoms) with obstructions
airways. Caused by Bacteria and
watery eyes, nasal discharge, Tylenol/NSAID’s for fever/body aches, -Acute pain r/t swelling in
Viruses, this type of infection is very
nasal congestion, Steriods for broncho-inflammation, & throat
common and contagious as well.
Sneezing, sore throat, cough, Decongestants for nasal issues.
Examples include:
head- ache, fever, malaise, Pt. Ed: Decongestants are NOT Pt. Goals/ Evaluation:
Sinus infection, Common Cold (aka
fatigue, weakness, muscle recommended for Pt’s w/ high BP. -Pt will be able to cough
Rhinitus) nasopharyngitis,
pain Surgery: N/A effectively and
Laryngitis, Laryngotracheitis, and
Labs: Sputum/Culture clear own secretions, and
Tracheitis
Dx Tests: Sputum/Culture, maintain patency of airway
The common time of occurrence is in
Rapid strep test (if suspected), and had clear breath
the winter months, from September
Monospot test (If enlarged sounds
to March.
lymphnodes/Mono -Patient will report relief of
suspected), and pain with analgesic
Allerfy/Asthma evaluation administration
8. CARDIAC (HEART)
DIAGNOSIS/PATHO DATA ACTION RESPONSE
ANGINA
Assess: Vital signs/pain such as Nursing Interventions: Nursing Dx:
Patho: Basic term for “Chest Pain”.
facial grimacing, rubbing of neck or Pharm: M – O – N – A -Acute Pain r/t
Commonly assoc. w/ CAD,
jaw, reluctance to move, increased MORPINE (Pain mgmt, last resort, decreased
cholesterol & plaque in vessels.
blood pressure, and tachycardia. can numb Pt./mask symptoms) myocardial blood
Triggered by phys. Activity/stress. SNS
Vitals: BP, HR, O2 SAT OXYGEN (O2 to left ventricle) flow
sys. Activates vasoconstriction of
S/S & PHYS. EXAM: pain (May NITROGYLCERIN ( vasodilation) -Activity Intolerance
vessels… smaller tube brings more O2
radiate down L arm), SOB, **Contraindicated in Pts on r/t acute
back to heart, brain and lungs, where it
Diaphoresis/Cool/Clammy skin, Vasodilators/Viagra! pain/dysrhythmias
is needed most. 2 types:
Syncope, anxiety ASPIRIN (Breaks up congregating plts)
Stable: caused by phys. Activity, but
Labs: Cardiac Enzymes, *Position Pt. in Semi-Fowlers Pt.
stops when activity stops. STABLE
Cholesterol/Lipids, H&H position. Goals/Evaluation:
STOPS!
Dx Tests: EKG, Echocardiogram, Pt. Ed: NO smoking, healthy diet, -Patient will be free
Unstable: Even after stopping activity,
Stress test, Angiogram limit sodium, exercise program, from pain, maintain
pain is still there. May be due to
stress, cholesterol, BP stable vital signs and
blockage/clot in artery, or a clot that
Surgery: Angioplasty/Stent, CABG show no visual signs
becomes loose as the vessels shrink
to check for and clear blockage if of pain
and expand. Lack of O2 to heart…Can
present. -Pt. will demonstrate
lead to MI/ Ischemia!!
tolerance to
activity. Assess
effectiveness of nitro;
assess vital signs,
pain control, as well
as Pt. S/S and EKG for
any sign of
infarction/
arrhythmias.
ACUTE CORONARY SYND. Assess: Reported Pain, BP, Apical Nursing Interventions: Nursing Dx:
(ACS) HR & Urinary output. Pharm: Depends on the lipid levels, -Decreased cardiac
Vitals: Pain, BP, HR & O2 but most commonly used are the output r/t ischemia
Patho: Acute coronary syndrome is a
(may lead to bradycardia/inadequate “Statins” (ex. Atorvastatin/Lipitor, -Acute pain r/t
term used for any condition brought on
perfusion) Rosuvastatin/Crestor) myocardial issue
by sudden, reduced blood flow to the
S/S & PHYS. EXAM: Chest pain, Pt. Ed: Modify common risk factors, damage r/t
heart. Can be chest pain you feel
Referred pain, N/V, SOB, Diaphoresis including: Smoking, Tobacco use, inadequate blood
during a heart attack, or chest pain you
& Anxiety Diet, Exercise, Stress, Alcohol Use supply.
feel while you're at rest or doing light
Labs: Cholesterol, Triglycerides, Surgery: Angioplasty, Stent/Balloon
physical activity (unstable angina). It is
Blood Glucose, Serum Lipid levels placement, CABG if necessary. Pt.
believed that atherosclerotic plaque
Dx Tests: EKG (To rule out MI), Goals/Evaluation:
ruptures in the artery, resulting in clot
Computed tomography coronary -Patient will
formation and vasoconstriction, thus
angiography (CTCA), Angiogram (To demonstrate
leading to decreased cardiac output.
determine blockage, if any) adequate cardiac
The “Freeways”/ Arteries of your heart
output AEB: BP, HR
become blocked or Jammed.
and Rhythm within
normal parameters
for Patient and
without pain.
-Pt. will report that
pain management
regimen is
satisfactory to pain
tolerance standards.
CARDIOGENIC SHOCK Assess: Signs of inadequate tissue Nursing Interventions: Nursing Dx:
perfusion, including: Pulse, muscle Pharm: Meds to reverse shock: -Altered tissue
Patho: Signs and symptoms of
weakness, metabolic acidosis, Dopamine and dobutamine (to perfusion
cardiogenic shock reflects the nature of
shallow respirations, tachycardia, improve cardiac (cardiopulmonary)
the circulation/
cool, clammy skin. contractility), Vasopressors (Nitro), r/inadequate cardiac
patho of heart failure.
Vitals: HR, BP, RR, Epinepherine, Norepinepherine, output
MI/Dysrrhythmias and
O2/Cap. Refill, Temp. Fluids
Cardiomyopathies cause heart damage
S/S & PHYS. EXAM: Anxiety, (Blood/Plasma/Platelets/Crystalloids/ Pt.
resulting in decreased cardiac output,
restlessness, altered mental state Colloids), Diuretics (Lasix, HCTZ), Goals/Evaluation:
BP out of artery to the vital organs.
due to decreased cerebral perfusion Oxygen Circulation status;
Blood flow to coronary arteries
and Pt. Ed: Teach Pt. how to reduce Cardiac pump
Oxygen to the heart leading to
subsequent hypoxia. Hypotension controllable risk factors for heart effectiveness; Tissue
ischemia and Heart's ability to
due to decrease in cardiac output. disease. Encourage attendance perfusion:
pump, thus causing inadequate
Rapid/weak/thready pulse, Ensure the patient understands the Cardiopulmonary,
perfusion of body tissues = SHOCK
tachycardia, Cool/clammy/mottled medication prescribed. Cerebral, Renal,
skin, Distended jugular veins. Oliguria Surgery: Immediate re-perfusion (Pt Peripheral; Vital sign
Labs: ABG’s (For signs of acidosis) is taken to Cardiac Cath. Lab and status *Evaluate for
as well as CVP (Central Venous immediate Left sided heart signs of
Pressure) Hemodynamic monitoring, catheterization, PCI (Percutaneaous arrhythmia/MI/Shock
H&H, CK-MB/Cardiac panel to rule Coronary Intervention) stent/balloon. to prevent relapse.
out MI. *Pt. may be intubated/on ventilator Assess Pt’s vital signs
Dx Tests: EKG, Echocardiogram for O2 support for values within
acceptable limit.
CABG (Coronary Artery Assess: Signs of anxiety, decreased Nursing Interventions: Nursing Dx:
Bypass Graft) cardiac output/Hemodynamics, chest Pharm: O2, Aspirin, Heparin/ - Risk for reduced
pain, and feeling of impending doom. Lovenox/Coumadin, Nitro for chest cardiac output r/t
Patho: Essentially Building a “SIDE-
Assess pulses, heart rate, EKG and O2 pain depressed cardiac
STREET” The occluded coronary arteries
perfusion, Pre/Post Op. Pt. Ed. and function
are bypassed with the client’s own venous
or arterial blood vessel or synthetic grafts. allergies. Pt. Ed: Schedule uninterrupted - Risk for bleeding r/t
The internal mammary artery (IMA) is the rest/sleep periods, assistance incision site/surgery
best choice for success over a long period Vitals: O2, BP, Peripheral with/Early ambulation, Turn, Cough, - Anxiety r/t
of time for patency. Recommended for pulses, RR Deep breath as ordered, monitor site surgery/hospital stay.
patients that do not respond to other S/S & PHYS. EXAM: Pt may be for signs of infection/bleeding
forms of medication and treatment Other grimacing, chest pain, SOB, Tacypnea, Surgery: CABG is the surgery! Pt. Goals/
indications include: Angina with 50% or arrhythmias/elevated ST wave, JVD, AFTER CABG: Observe for ALOC, Evaluation : Patient
more occlusion of main Coronary artery ALOC will be able to
that cannot be stented, Acute
demonstrate
MI/Cardiogenic shock, Ischemia with heart
Labs: Cardiac enzymes, ABG, hemodynamic
failure, Valvular disease, coronary arteries
not suitable for Percutaneaous Cholesterol, Lipids stability such as
transluminal coronary angioplasty (PTCA), Dx Tests: EKG, PTCA, Echo- stable blood pressure
or those who have signs of ischemia or cardiogram, Stress test and adequate cardiac
pending MI after PTCA. output
CHF (Congestive Heart Failure) Assess: Apical pulses for Rate/Rhythm, Nursing Interventions: Nursing Dx:
Assess skin for pallor/cyanosis, Monitor Pharm: O2, Diuretics, as indicated - Decreased cardiac
Patho: Heart failure means the tissues of urine output for decrease, and dark
the body are temporarily not receiving as
Pt. Ed: Fluid/Sodium restriction, output r/t impaired
concentrated urine. ALOC Combine ADL’S/Alternate breaks, cardiac function
much blood and oxygen as needed. Vitals: O2, HR,
Whether acute or chronic, there is much Relaxation/ Stress, - Excessive fluid
S/S & PHYS. EXAM: Dysrhythmias
risk associated with Heart Failure, each set Left-sided heart failure
Surgery: Heart Transplant is volume r/t impaired
of systems assoc. w/ a side of the heart *Dyspnea on exertion or orthopnea ULTIMATE CHOICE, but if not, VAD excretion of sodium
(see next column) Think ANATOMICALLY: *Moist crackles on lung auscultation (Ventricular Assist Device *usually and water
The two upper chambers are called atria *Frothy, blood-tinged sputum used as a bridge until surgery), PLV - Impaired gas
and the two lower chambers are called *Tachycardia with S3 heart sound (Partial Left Ventriculectomy), exchange r/t
ventricles. The right atrium and right *Pale, cool extremities Endoventricular Circular Patch, Acorn excessive fluid in
ventricle receive blood from the body * Peripheral and central cyanosis Cardiac Support Device, Myosplint interstitial space of
through the veins (DE-OXYGENATED) and *peripheral pulses, capillary refill
then pump the blood to the lungs. The left
lungs/alveoli
time * urinary output (<30 ml/hour)
atrium and left ventricle receive blood *Fatigue* Insomnia/restlessness
from the lungs and pump it out through Pt. Goals/
Right-sided heart failure
the aorta into the arteries (OXYGENATED), * Dependent pitting edema (peripheral
Evaluation :
which feed all organs and tissues of the and sacral) * Weight gain * Nausea/ - The patient will be
body with oxygenated blood. Because the anorexia Jugular vein distention (JVD) able to display vital
left ventricle has to pump blood to the * Hepatomegaly, ascites or weakness signs within
entire body, the LEFT VENTRICLE a Left and right-sided heart failure: acceptable limits,
stronger pump than the right ventricle. *Cardiomegaly dysrhythmias
*Vascular congestion of lung fields controlled and no
*Electrocardiogram identifies symptoms of failure.
hypertrophy or MI/damage
ABG (Arterial blood gas) studies reveal
decreased partial pressure of arterial
oxygen (95%),
Labs: ABG, Cardiac Enzymes
Dx Tests: EKG, PTCA, Echo-
cardiogram, Stress test
CAD (Coronary Artery Assess: Pain, anxiety, Activity Nursing Interventions: Nursing Dx:
Disease) intolerance, Pharm: Cholesterol meds (STATINS), - Acute pain related
Vitals: BP, HR , Cap. Refill Nitro for Chest Pain, Anti- to the imbalance o
Patho: Chronic disease of the
time/Oxygenation platelets/Anti-Coagulants myocardial oxygen
Coronary arteries, where over time
S/S & PHYS. EXAM: Pt. Ed: Healthy diet, exercise as supply and demand.
plaque has built up and hardening has
-Angina directed by doctor - Ineffective tissue
occurred causing a “narrowing” of the -Nausea and vomiting Surgery: Angioplasty, Stent/Balloon perfusion related to
artery walls, similar to a “TRAFFIC JAM” -Dizziness and syncope placement, CABG myocardial ischemia
on the freeway… LESS LANES ARE -Diaphoresis clammy skin and decreased
OPEN! Because of this, the built-up -Apprehension or a sense of impending
cardiac output.
plaque can occlude partially (causing doom
- Anxiety related to
stable angina) or completely (Causing Labs: Lipids, Cholesterol
pain, feeling of
UNSTABLE angina). Dx Tests: Echocardiogram, Stress
impending doom,
test, Angiogram
lifestyle
changes/diagnosis of
CAD.
Pt. Goals/
Evaluation: Reduce
pain, Prevent angina
episodes by
balancing
rest/activity, achieve
and maintain a
suitable blood
pressure for patient.
HYPERLIPIDEMIA (High Assess: What is the Pt.’s diet? Any Nursing Interventions: Nursing Dx:
Cholesterol) past problems/family Hx of high Pharm: Statins! STATINS, STOP! -Inadequate
cholesterol? Is the Pt. Taking (Atorvastatin, Simvastatin, perfusion of body
Patho: Hyperlipidemia is an excess of
medication for it? Associated Lovastatin) Fibric Acids (Advicor, tissues r/t
fatty substances called lipids, largely
Diseases/Dx… Palpate pulses, assess Tricore) interruption of
cholesterol and triglycerides, in the
distal pulses for circulation, assess Pt. Ed: Modify diet/exercise, vascular flow
blood. It is also called hyper-
pulses for bruit compliance with medication, report - Insufficient
lipoproteinemia because these fatty
Vitals: BP new symptoms immediately. knowledge r/t
substances travel in the blood attached
S/S & PHYS. EXAM: Surgery: Stent/Balloon, CABG, disease process
to proteins. This is the only way that
Cholesterol/Lipid levels, May be angioplasty
these fatty substances can remain
obese, may have associated chest Pt.
dissolved.
pain, SOB, Cap. Refill/ Goals/Evaluation:
Circulation, Unequal pulses -Pt will verbalize
Labs: Total Cholesterol, HDL, understanding of
LDL, Lipid Panel, Triglycerides healthy diet and
Dx Tests: Angiogram, exercise
Echocardiogram, Stress test -Pt. will be able to
state modifiable
factors
-Pt. will adhere to a
specific medication
regimen to reduce
cholesterol levels in
body
9. ENDOCRINE
DIAGNOSIS/PATHO DATA ACTION RESPONSE
DIABETES TYPE I Assess: For signs of Nursing Interventions: Nursing Dx:
hyperglycemia & Pharm: Insulin! -Risk for infection r/t
Patho: Diabetes Mellitus (DM)
hypoglycemia! Pt. Ed: Insulin compliance (maintain normal high glucose levels
is a chronic metabolic disorder
Vitals: HR, BP (Long- range!), Do not stop taking insulin if within normal -Lack of knowledge
caused by an absolute or relative
term) range! Diet management, education on the signs of r/t disease process
deficiency of insulin, an anabolic
S/S & PHYS. EXAM: The 3 hypo/hyperglycemia, long term education for
Hormone. Type 1 diabetes
P’s! POLURIA, POLYPHAGIA, complications, foot care, med-alert bracelet, “SICK Pt. Goals/
mellitus can occur at any age and
POLYDIPSIA! Extreme thirst, DAY RULES”: Evaluation:
is characterized by the marked
frequent urination, -Pt. will take proper
and progressive inability of the
drowsiness, lethargy, precautions and
pancreas to secrete insulin
increased appetite, sudden verbalize signs and
because of autoimmune
weight loss for no reason, symptoms of
destruction of the beta cells. It
sudden vision changes, sugar infection
commonly occurs in children,
in urine, ketones in urine, -Pt will be able to
with a fairly abrupt onset;
heavy or labored breathing, verbalize
however, newer antibody tests
unconsciousness understanding of
have allowed for the
Labs: Fasting plasma *EXAMPLE of Insulin Times (See you School/Hospital disease process and
identification of more people
glucose of 126 mg/dL or book/policy): daily management
with the new-onset adult form of
greater, Random plasma regimen
type 1 diabetes mellitus called
glucose of 200 mg/dL greater,
latent autoimmune diabetes of
Glucose tolerance test,
the adult (LADA). These patients
HbA1c, ABG’s, electrolytes,
are dependent on exogenous
Urine glucose tests, Thyroid
insulin. Type 1 diabetes
function
(formerly called juvenile-onset
Dx Tests: Same as labs
or insulin-dependent diabetes),
accounts for 5% to 10% of all
Surgery: N/A, unless organ
people with diabetes. In Type 1
complication as needed
diabetes, the body’s immune
water removed with the urine is Labs: Blood Glucose, A1c, prescribed
called glycosuria. In glycosuria, Glucose tolerance test medications to
some water is lost in the urine, Dx Tests: Same as above manage it
called POLYURIA. Polyuria results -Pt will maintain
in intracellular dehydration, blood glucose level
which will stimulate the thirst within healthy limits
center so that patients will feel of the patient’s
constantly thirsty, so the patient condition.
will continue to drink and have
POLYDIPSIA. The lack of insulin
production will cause a decrease
in glucose transport into the cells
so the cells are starved of food
and stores carbohydrates, fats
and proteins to be depleted.
Because it is used to burn as fuel
the body, then the client will feel
hungry and eat, known as
POLYPHAGIA. Failure to restore
the body's homeostasis situation
will lead to hyper-glycemia,
hyperosmolar, excessive osmotic
diuresis and dehydration. Central
nervous system dysfunction due
to transport
oxygen to the brain disorder can
result in a coma.
Hemoconcentration increases
the blood viscosity (Thickness)
which may lead to the formation
of blood clots, thrombo-
embolism, cerebral infarction,
heart.
Dx: Assess: For RUQ Epigastric pain, jaundice, Nursing Interventions: Nursing Dx:
contributing factors: Pharm: Analgesics, -Acute pain r/t
CHOLECYSTITIS THE 5 F’S!! Female, Forty, Fat, Fertile, Family Antiemetics, obstruction/spasm
Hx Anticholinergics, -Risk for deficient fluid
Patho: “INFLAMMATION OF THE Vitals: Temp, BP/HR (r/t Pain) Antibiotics, volume r/t excessive losses
GALLBLADDER” One of the most S/S & PHYS. EXAM: Nausea/ vomiting, Ursodeoxyxholic Acid due to vomiting
common types of cholecystitis is Tenderness in the right abdomen, Fever, Pain (Urso) to internally break
acute cholecystitis. This is when that gets worse during a deep breath, Dark up stones if possible Pt. Goals/ Evaluation:
the onset of inflammation of the colored urine, Pain for more than 6 hours, Pt. Ed: Manage a low- -Pt will report pain at
gallbladder is sudden and intense, particularly after meals. fat diet & exercise tolerable level and verbalize
with fast progression of the Labs: CBC, WBC, Liver Fx Tests, program, Care of T-Tube ways to manage it
disease. More often than not, the Amylase/Lipase Levels if sent home with one, -Pt will show evidence of
inflammation is caused due to Dx Tests: Ultrasound, Hepatobiliary scan, Prevent “Dumping adequate fluid volume by:
obstruction of the bile duct, which Endoscopic Retrograde Syndrome”: stable vital signs, moist
is known as calculous Cholangiopancreatography (ERCP), mucus membranes, good
cholecystitis, as they are caused Cholangiography, Abdominal X-RAY skin turgor, and urine output
due to gallstones, or cholelithiasis. within normal level for
There are other causes of acute patient
cholecystitis as well, such as
ischemia, chemical poisoning,
motility disorders, infections with
protozoa, collagen disease,
allergic reactions, etc. The
obstruction results in gallbladder Surgery:
distension, which results in edema Sphinterectomy with
of the cells lining the gallbladder. stone removal with
The lining wall of the gallbladder ERCP, Extracorporeal
may eventually undergo necrosis Shock Wave Lithotripsy
Dx: Assess: Depends on the type! Type B & C Nursing Interventions: Nursing Dx:
may be ASYMPTOMATIC, Type A can cause Pharm: -Fatigue r/t decreased
HEPATITIS “Flu-like” Symptoms, *SPECIFIC TO TYPE AND metabolic energy production
Vitals: Fever most common SYMPTOMS: -Risk for deficient fluid r/t
Patho: Inflammation that S/S & PHYS. EXAM: Circulation problems -Treat Symptoms for altered clotting factors (Hep
spreads to the liver (hepatitis) can (only toxic/drug-induced hepatitis), Dark urine, TYPE A C) or vomiting/anorexia (HEP
be caused by infection by viruses Dizziness (only toxic/drug-induced hepatitis), -Anti-viral drugs for TYPE A) and altered body
and toxic reactions to drugs and Drowsiness (only toxic/drug-induced hepatitis), B & C: Penginterferon- chemistry
chemicals. Basic functional units Enlarged spleen (only alcoholic hepatitis), alpha 2B (PEGLNTRON)
of the liver are called lobules, and Headache (only toxic/drug-induced Pt. Ed: PREVENT Pt. Goals/ Evaluation:
these units are unique because hepatitis),Hives, Itchy skin, Light colored feces, SPREAD OF INFECTION! -Pt will report increased
they have their own blood supply. the feces may contain pus, Yellow skin, whites Wash hands, Vaccines energy and is able to
Disruption of the normal blood of eyes, tongue (jaundice) for Types A & B, Avoid participate in ADL’s
supply to the cells causes hepatic “High-Risk” Behaviors - Pt will show evidence of
necrosis and damage to liver cells. such as unprotected sex, adequate fluid volume by:
After passing his time, the liver sharing/using unclean stable vital signs, moist
cells become damaged & needles, blood-to-blood mucus membranes, good
eliminated from the body by the contact, *NOT ELIGIBLE skin turgor, and urine output
immune system response and TO DONATE BLOOD within normal level for
replaced by new cells of a healthy Surgery: Liver patient
liver. Therefore, most clients who transplant if eligible
have hepatitis recovered with (Type C)
normal liver function.
Dx: Assess: For contributing factors such as: Nursing Interventions: Nursing Dx:
1. Excessive alcohol/drug use Pharm: Antibiotics, -Acute pain r/t obstruction of
PANCREATITIS 2. Gallstones Opiod analgesics/Pain pancreatic bile
3. Infection meds (Demorol is ducts/inflammation
Patho: Pancreatitis is an 4. Blunt Abdominal Trauma CONTRAINDICATED!), -Risk for deficient fluid
inflammatory disease, which 5. Surgical trauma/manipulation Anticholinergics, volume r/t loss of fluid from
varies in severity from mild to Also… TURNER’s SIGN (Bruising between the Pancreatic enzymes, vomiting/gastric suction
severe. Factors determining the last rib and the top of the hip) & CULLEN’s Proton pump inhibitors
severity of pancreatitis are not SIGN (Bruising of fatty tissue around umbilicus) (Omeprozole/Prilosec), Pt. Goals/ Evaluation:
known. It is generally believed TPN -Patient will report
that the earliest events in the Vitals: TEMP, HR, Sometimes BP controlled/relief of pain, and
evolution of acute pancreatitis S/S & PHYS. EXAM: Pt. Ed: adhere to medication
lead to premature intra-acinar cell regimen
activation
of digestive zymogens and that Signs and symptoms of acute pancreatitis -Take Pancreatic - Pt will show evidence of
those enzymes, once activated include: enzymes before meals adequate fluid volume by:
cause acinar cell injury. Recent -Abdominal pain to the upper quadrants, and snacks stable vital signs, moist
studies have suggested that the radiates to the clients back and worsens after -High caloric diet/needs mucus membranes, good
ultimate severity of resulting meals -NO ALCOHOL! (Refer to skin turgor, and urine output
pancreatitis may be determined -Nausea and vomiting program as needed) within normal level for
by -Tenderness on the abdomen -Limit fat intake patient
events which occur subsequent to Signs and symptoms of chronic pancreatitis -Follow up with all
acinar cell injury. These include include: appts/lab work
inflammatory cell recruitment and -Upper abdominal pain
activation as well as the -Indigestion
generation and release of -Sudden weight loss Surgery: N/A (Unless
cytokines and other chemical -Steatorrhea (oily, foul smelling stools) eligible for transplant,
mediators of inflammation. ALCOHOL & DRUG
Labs: Liver enzymes, Bilirubin, Pancreatic RELATED NOT ELIGIBLE)
enzymes
Dx Tests: CT w/ contrast
Dx: Assess: For signs of Jaundice/Liver failure, Nursing Interventions: Nursing Dx:
ALOC, Contributing factors Pharm: Diuretics (Lasix, -Imbalanced Nurtrition: less
CIRRHOSIS Vitals: RR, Aldactone), Flagyl (to than body requirements r/t
S/S & PHYS. EXAM: reduce bacteria in poor nutrition and
Patho: A CHRONIC liver disease EARLY STAGE: intestine), Lactulose to nausea/vomiting
characterized by an irreversible -Enlarged Liver Ammonia, supplemental -Fluid volume excess r/t
scarring of the liver. This extensive compromised regulatory
-GI Disturbances vitamins, PPI’s
scarring causes a disruption in the
-Jaundice (Prevacid), Albumin (to mechanism and excessive
normal function of the liver. The liver
is a very important organ that -Weight Loss decrease ascites) fluid/ sodium intake
functions in the body to help: LATE STAGE:
-Store Blood Sugar (as GLYCOGEN) -Small/Nodular Liver Pt. Ed: Pt. Goals/ Evaluation:
-Produce Bile (TO DIGEST FOOD) -Ascites -NO ALCOHOL! -Pt will exhibit no further
-Filter out toxins/wastes in blood -Splenomegaly Referral to TX Program if signs of malnutrition and
stream (INCLUDING -Esophogeal Varices/Coughing up blood needed show weight gain
DRUGS/ALCOHOL) - Dyspnea -Follow Dietary appropriate for body.
- Pruitis guidelines for condition
-Manufacturing proteins in the blood - Clay colored stools, TEA colored Urine - Bleeding -Patient will maintain stable
that assist in clotting and oxygen precautions/Risk for fluid volume AEB vital signs
transport Labs: Liver enzymes, Bilirubin, H&H, bleeding within normal range,
-Helps to break down fat/produce hematologic testing, WBC, PLT’s, CBC, PT, INR balanced I&O
cholesterol
& AMMONIA (Could indicate hepatic Surgery: Transplant
encephalopathy) (*ONLY IF ELIGIBLE!! Will
CONTRIBUTING FACTORS:
Dx Tests: MRI/ULTRASOUND for Liver size not be a candidate if
-Excessive Alcohol (Laennec’s)
(EARLY stages will be LARGE, Later stages of alcoholic/drug related)
-Post Necrotic (r/t
Hepatitis/chemicals)
cirrhosis will be small/nodular) Remember:
-Billiary Disease “If SIR ‘ROHSIS’ gets to a party EARLY, then
-SEVERE Right-sided heart failure he’s LARGE and in charge… if he gets there
LATER, he will be NODDED at and SMALL”
STAGES:
Phase 1. Onset
ARF begins with the underlying
clinical condition leading to tubular
necrosis (Ex. hemorrhage, which
Phase 2. Maintenance
A persistent decrease in GFR and
tubular necrosis characterizes this
phase. Oliguria is often present
during the beginning of this phase.
Efficient elimination of metabolic
waste, water, electrolytes, and acids
from the body cannot be performed
by the kidney during this phase.
Therefore, azotemia, fluid retention,
electrolyte imbalance and metabolic
acidosis occurs. The patient is at risk
for heart failure and pulmonary
edema during this phase because of
the salt and water retention.
Phase 3. Recovery
Renal function of the kidney
improves quickly the first five to
twenty-five days of this phase. It
begins with the recovery of the GFR
and tubular function (BUN and serum
Creatinine stabilize). Improvement in
renal function may take up to a year
as more nephrons regain function.
CHRONIC RENAL FAILURE Assess: For contributing factors Nursing Interventions: Nursing Dx:
(CRF) such as: Diabetes (Leading Pharm: ANEMIA: EPOGEN (Procrit) -Impaired urinary
Cause), Uncontrolled HTN, PHOSPHATE / CALCIUM: PHOSLO, elimination r/t effects of
Patho: Progressive, long-term
Chronic Glomerularnephritis, CALCUM ACETATE, also: BLOOD disease, need for dialysis
failure of kidney function. This is an
Congenital Kidney Disease, TRANSFUSION if necessary -Fatigue r/t effects of
IRREVERSIBLE condition that can only
Pyelonephritis, Ethnicity (African HEMODIALYSIS!! (Can be in hospital, or chronic anemia and
be corrected by regular dialysis or
American, Native American & at home/Peritoneal) uremia
kidney transplant, or will be terminal.
Asian).
Chronic renal failure can be present
Pt. Ed: Monitor electrolyes, BP (For Pt. Goals/ Evaluation:
for many years before you notice any
Vitals: BP HTN), Strict I&O’s, RENAL DIET, -Patient will maintain
symptoms. If your doctor suspects
S/S & PHYS. EXAM: increased Meticulous skin care. Dialysis effective voiding
that you may be likely to develop
urination (especially at night), Education! Based on the type, measures within limits of
renal failure, he or she will probably
decreased urination, blood in schedule, at home or in facility. his/her condition
catch it early by conducting regular
the urine (not a common -Pt will state that he/she
blood and urine tests. If regular
symptom of chronic renal Surgery: Kidney Transplant (if is able to accomplish
monitoring isn't done, the symptoms
failure) urine that is cloudy or needed/eligible) ADL’s with minimal
may not be detected until the
tea-colored assistance by utilizing rest
kidneys have already been damaged.
MORE SERIOUS S&S: periods
Some of the symptoms, such as
Puffy eyes, hands, and feet DIALYSIS:
fatigue - may have been present for
(edema), High BP, fatigue,
some time, but come on gradually,
shortness of breath
and may not be noticed or attributed
loss of appetite,
to kidney failure.
nausea/vomiting (common
symptom), thirst, bad taste in
TYPES:
the mouth or bad breath, weight
loss, persistent itchy skin,
muscle twitching or cramping,
yellowish-brown tint to the skin
Labs: BUN/Cr, Kidney Fxn
Tests, GFR
Dx Tests: Ultrasound/Biopsy
NEPHROTIC SYNDROME Assess: Edema, usually starts Nursing Interventions: Nursing Dx:
with eyes), Massive Proteinuria, Pharm: Corticosteroids (Prednisone), -Excess fluid volume r/t
Patho: auto-immune “Body is
Pallor, Anorexia Diuretics (LASIX), Salt-poor Albumin compromised regulatory
attacking itself”… The big “NERF
mechanism
BALLS OF PROTEIN” are let through
Vitals: BP Pt. Ed: Maintain Diet: -Activity intolerance r/t
the once tight-knit net of the
S/S & PHYS. EXAM: -SODIUM generalized edema
Glomeruli. This disorder consists of
-Hypoalbuminemia (low level of -POTASSIUM
PROTEIN WASTING (Proteinuria)
albumin in the blood) - CALORIE Pt. Goals/ Evaluation:
which occurs as a result of diffuse
-Proteinuria (Protein in urine) -Moderate PROTEIN -Patient was able to
glomelular damage. Proteinuria
-Edema (Starts w/ eyes, then Aeseptic techniques (To prevent display stable weight, vital
occurs because of changes to
systemic, called ANASARCA) infection) signs within patient’s
capillary endothelial cells, the
-Hypercholesterolemia (high -Bed rest to preserve renal function normal range, and nearly
glomerular basement membrane
level of cholesterol in the blood) -Daily Weights/ I&O’s absence/ reduction of
(GBM), which normally filters serum
-Hematuria (blood in urine) edema.
protein selectively by size and
- Ascities Surgery: N/A
charge:
- Oiliguria
- Anorexia
- Malaise
- Nausea
KIDNEY STONES Assess: For passing of stones Nursing Interventions: Nursing Dx:
(Strain Urine), Hx or Risk for Pharm: NARCOTICS for PAIN -Acute pain r/t
Patho: Kidney stones (renal-
Kidney stones, Pain Mgmt MANAGEMENT!! Also FLUIDS to help Inflammation/obstruction,
lithiasis) are small, hard deposits that
Vitals: BP, HR Flush/Pass stone, Corticosteroids for and abrasion of urinary
form inside your kidneys. The stones
S/S & PHYS. EXAM: Inflammation, as well as Anti- tract by migration of
are made of mineral and acid salts.
Severe pain in the side and back, sposmotics stones.
Kidney stones have many causes and
below the ribs, Pain that spreads -Altered urinary
can affect any part of your urinary
to the lower abdomen and groin, Pt. Ed: Report increasing pain, or Elimination
tract — from your kidneys to your
Pain that comes in waves and feeling of “Passing Stone”. Drink LOTS
bladder. Often, stones form when
fluctuates in intensity of fluids to promote passing. Refrain Pt. Goals/ Evaluation:
the urine becomes concentrated,
(SPOSMOTIC PAIN) Pain on from foods that may contribute to -Pt will report pain as
allowing minerals to crystallize and
urination, Pink, red or brown stone formation, Foods that contain “tolerable” and verbalize
stick together.
urine, Cloudy or foul-smelling high levels of OXYLATE, including: ways to distract
urine, Nausea/vomiting, Peanuts, rhubarb, spinach, beets, choc themselves from pain
Persistent urge to urinate, olate and -Pt will show an adequate
Frequent urination, Fever and sweet potatoes urinary output for their
chills (if infection is present) status/condition
Labs: Calcium, Uric Acid, Urine Surgery: Surgical removal of stones as
(For sediments/Minerals) needed
Dx Tests: Ultrasound, CT SCAN,
ABD X-ray
Page 100 of 106 Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
TURP (Trans urethral resection of prostate)
TURP (Trans urethral Assess: For signs of shock or Nursing Interventions: Nursing Dx:
resection of prostate) blockage, monitor and maintain Pharm: Narcotics for pain and to -Acute pain r/t incision,
indwelling catheter/Irrigation, prevent/decrease bladder spasm, bladder irrigation, bladder
Patho: The process by which the
also ASSESS FOR TURP FOR BPH: spasms
enlarged portion of the prostate
SYNDROME! (Cluster of Urinary Antibiotics, Alpha-Blocker -Risk for urinary retention
(BPH) is removed by an endoscopic
manifestations as the result of Meds (To promote urinary flow, such as r/t Obstruction of urethra
instrument.
absorbing fluids during irrigation FLOMAX), Enzyme inhibitors (To catheter with clots
through prostate tissue causing: decrease size of Prostate, such as
ALOC, Bradycardia, AVODART / PROSCAR Pt. Goals/ Evaluation:
Hyponatremia, N/V, Pt. Ed: TURP rarely causes erectile -Pt will report pain as
Hypo/Hyper- tension) dysfunction, but may trigger retrograde “tolerable” and verbalize
ejaculation because removal of the ways to distract
Vitals: TEMP prostatic tissue at the bladder neck can themselves from pain
S/S & PHYS. EXAM: cause seminal fluid to flow backward -Pt will show an adequate
-Urgency/Frequency of urination into the bladder rather forward urinary output for their
-Abdominal straining through the urethra during ejaculation. status/condition
-Nocturia
-Impairment of size and force of Surgery: THIS IS THE SURGERY!
TURP (Transurethral Resection of the stream/ Intermittent hesitancy
Prostate) is the most common procedure -Incomplete bladder emptying
used to treat BPH. It can be carried out -Terminal dribbling
through endoscopy. The surgical and -Dysuria
optical instrument is introduced directly -Eventual renal failure from
through the urethra to the prostate, urinary obstruction
which can then be viewed directly. The
Labs: PSA- Prostate Specific
gland is removed in small chips with an
Antigen to test for BPH
electrical cutting loop. This procedure,
which requires no incision, may be used Dx Tests: Digital Rectal Exam,
for glands of varying size and is ideal for Cytoscopy
patients who have small glands and for
those who are considered poor surgical
risks. Newer technology uses bipolar
electrosurgery and reduces the risk of
TURP syndrome (hyponatremia,
hypovolemia).TURP usually requires an
Simplenursing.com Less Study Time HIGHER test scores! Page 101 of 106
48 Hour Cram Sheets for Med Surg
URINARY TRACT INFECTION (UTI)
Page 102 of 106 Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
BPH (Benign Prostate Hypertrophy)
BPH (Benign Prostate Assess: DRE (Digital Rectal Nursing Interventions: Nursing Dx:
Hypertrophy) Exam) to check for enlargement Pharm: Urinary Antibiotics, Alpha- - Acute pain r/ t mucosal
of prostate, Assess for Blocker Meds (To promote urinary flow, Irritation: bladder
Patho: As males age, production
history/family hx of BPH such as FLOMAX), Enzyme inhibitors (To distention
of androgenic hormones decreases,
Vitals: ↑TEMP decrease size of Prostate, such as & urinary infection
causing an imbalance in
S/S & PHYS. EXAM: AVODART / PROSCAR -Urinary retention r/t
androgen and estrogen levels and
-Urgency/Frequency of urination mechanical obstruction/
high levels of dihydrotestosterone,
-Abdominal straining Pt. Ed: If you require TURP: Rarely enlarged prostate
the main prostatic
-Nocturia causes erectile dysfunction, but may
intracellular androgen.
-Impairment of size and force of trigger retrograde ejaculation because Pt. Goals/ Evaluation:
stream/ Intermittent hesitancy removal of the prostatic tissue at the -Pt will report pain as
-Other causes of Benign prostatic
-Incomplete bladder emptying bladder neck can cause seminal fluid to “tolerable” and verbalize
hyperplasia (BPH) include:
-Terminal dribbling /Dysuria flow backward into the bladder rather ways to distract
o Neoplasm
-Eventual renal failure from forward through the urethra during themselves from pain
o Arteriosclerosis
urinary obstruction ejaculation. -Pt will show an adequate
o Inflammation
Labs: PSA- Prostate Specific Surgery: TURP! urinary output for their
o Metabolic Imbalance
Antigen to test for BPH, Urine status/condition
o Nutritional disturbances.
culture, Blood test/Clotting
studies
Dx Tests: Digital Rectal Exam,
Cytoscopy, Ultrasound
Simplenursing.com Less Study Time HIGHER test scores! Page 103 of 106
48 Hour Cram Sheets for Med Surg
UTERINE FIBROIDS
Page 104 of 106 Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
OVARIAN CANCER
OVARIAN CANCER Assess: Assess for risk Nursing Interventions: Nursing Dx:
Factors- Pharm: Chemotherapy and -Anxiety r/t
Patho: Cancerous growth, originating from different
-Over 40 y/o Radiation as needed prognosis, lack of
parts of the ovary:
-Nulliparity/First Pt. Ed: Genetic testing for knowledge of disease
pregnancy age 30+ risk, Check-up for process and threat of
-Family history of ovarian, reoccurrence (CA-125 Blood malignancy
breast or colon cancer test/HE-4) , signs and - Disturbed body
-Dysmenhorrea/heavy symptoms of reoccurrence, image r/t loss of
bleeding side effects of diseased body
-Hormone replacement chemo/medications part/loss of good
therapy Surgery: Surgery to remove health
-Use of fertility diseased parts as needed
medications Pt. Goals/
Evaluation:
Vitals: Normal, unless -Client will report
septic reduced anxiety level,
Contributing Factors: S/S & PHYS. EXAM: ways to reduce
-Over 40 Labs: CA-125 Blood test anxiety, and
-Never been Pregnant OR (35 u/ml= ABNORMAL) understanding of
-First pregnancy after 30 years of age Dx Tests: Intra-Vaginal diagnosis/health
-Family hx of ovarian, breast, or colon cancer Ultrasound, Pelvic Exam process
-Hx of Dysmenorrhea or heavy breathing - Client will discuss
-Hormone replacement therapy concerns, what to
-Infertility medication use expect after
chemo/surgery, and
ways to limit anxiety
about body image
Simplenursing.com Less Study Time HIGHER test scores! Page 105 of 106
48 Hour Cram Sheets for Med Surg
OVARIAN CANCER
13. Bibliography
Ebersole, P., Hess, P., Touhy, T.A., Schmidt Logan, A., & Jett, K. (2008) Toward healthy aging: Human
needs and nursing response ( 7th ed.). St. Louis, MO: Mosby.
Eliopoulous C. (2009). Gerontological nursing. ( 7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Grodner, M., Long, S., & Walkingshaw,B.C. (2007). Foundations and clinical application of nutrition: A
nursing approach ( 4th ed.). St. Louis, MO: Mosby.
Ignatavicius, D. D., & Workman, M. L. (2010). Medical-Surgical nursing (6th ed.). St. Louis, MO: Saunders.
Lowdermilk, D.L.,& Perry, S.E. ( 2007) . Maternity & women’s health care (9th ed.). St. Louis, MO: Mosby.
Lehne, R.A. (2010). Pharmacology for nursing care (7th ed.). St. Louis, MO: Saunders.
Lilley, L. L., Harrington, S., & Snyder, J.S. (2007). Pharmacology and the nursing process (5th ED.). St.
Louis, MO: Mosby.
Roach, S. S.,& Ford, S. M. (2008). Introductory clinical pharmacology. Philadelphia, PA: Lippincott Williams
& Wilkins.
Smeltzer, S. C., Bare, B.G., Hinkle, J. L., & Cheever, K.H. ( 2008). Brunner and Suddarth’s textbook of
medical-surgical nursing ( 11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Simplenursing.com Less Study Time HIGHER test scores! Page 106 of 106