APPENDECTOMY NURSING PROCESS: UNDERGOING AMPUTATION
 surgical removal of the appendix which is done
ASAP to decrease the risk of perforation
 performed using GA or spinal anesthesia with a
laparotomy or by laparoscopy (faster recovery)
Nursing Management
 relieve pain, prevent FVD, reduce anxiety,
eliminate infection, maintain skin integrity, and
attain optimal nutrition
 prepare for surgery, infuse IV to replace fluid loss
and promote renal function and antibiotic
therapy
 with increased risk of paralytic ileus, NGT is
inserted and an enema is no given – perforation
 after surgery, place in a high-Fowler’s position to
reduce tension on incision & abdominal organs
 opioid (morphine sulfate) is given to relieve pain
 when normal bowel sounds are present, food is
provided as desired and tolerated on the day of
the surgery
 instruct to make an appointment to have
surgeon remove sutures between the 5th-7th
days after surgery
 normal activity can be resumed within 2-4 weeks
 discharge teachings must include incision care
and dressing changes and irrigations, as needed
BELOW-KNEE AMPUTATION
 preferred because of the importance of the knee
joint and the energy requirements for walking
Complications
 hemorrhage, infection, skin breakdown,
phantom limb pain (d/t severing of peripheral
nerves), and joint contracture (d/t positioning
and a protective flexion withdrawal pattern)
 bleeding, infection, and skin break down
Medical Management
 healing is enhanced by gentle handling of the
residual limb, control of residual limb edema
through rigid or soft compression dressings, and
use of aseptic technique in wound care
 after surgery, a sterilized residual limb sock is
applied to the residual limb
 cast is changed in about 10-14 days and a
removable rigid dressing may be placed over a
soft dressing to control edema, prevent joint
flexion contracture, and protect residual limb
 residual limb wound hematomas are controlled
with wound drainage devices to avoid infection
RLE SEMIFINALS
Assessment
 neurovascular and functional status of extremity
 assess function and condition of residual limb
 check circulatory status and function of
unaffected extremity
 C&S test is obtained to determine appropriate
antibiotic therapy
 diet: protein and vitamins to promote healing
 assess psychological status and emotional
reaction to amputation
Diagnosis
Nursing Diagnoses
 Acute pain r/t amputation
 Disturbed sensory perception: phantom limb
pain r/t amputation
 Impaired skin integrity r/t surgical amputation
 Disturbed body image r/t amputation
 Grieving or risk for complicated grieving r/t loss
of body part and resulting disability
 Self-care deficit: feeding, bathing/hygiene,
dressing/ grooming, or toileting, r/t loss of
extremity
 Impaired physical mobility r/t loss of extremity
Potential Complications
 Postoperative hemorrhage
 Infection
 Skin Breakdown
Planning and Nursing Interventions
1. Relieving pain
 controlled with opioid analgesics that may be
accompanied with evacuation of hematoma or
accumulated fluid
 changing position and placing a light sandbag
on residual limb to counteract muscle spasm
2. Minimizing Altered Sensory Perceptions
 when patient describes phantom pains,
acknowledge feelings as real and encourage
verbalization when in pain
 keeping patient active helps decrease incidence
 distraction techniques, TENS, UTZ, or local
anesthesia may provide relief
 beta-blockers may relieve dull, burning pain
 anti-seizures control stabbing or cramping pain
 TCAs alleviate phantom pain and improve mood
LYNETTESKIE
3. Promoting Wound Healing  explain s/s to be reported to the physician

 aseptic technique for wound dressing changes Evaluation

 if cast/dressing comes off, immediately wrap the
Expected outcomes may include:
limb with an elastic compression bandage to
prevent development of excessive edema 1. Experiences no pain
 ace wraps are discouraged because they may 2. Experiences no phantom limb pain
apply inconsistent pressure 3. Achieves wound healing
4. Demonstrates improved body image and
4. Enhancing Body Image
effective coping
 encourage to look at, feel, and care for residual 5. Exhibits resolution of grieving
limb and identify strengths and resources to 6. Achieves independent self-care
facilitate rehabilitation 7. Achieves maximum independent mobility
8. Exhibits absence of complications of
5. Helping the Patient to Resolve Grieving
hemorrhage, infection, or skin breakdown
 create an accepting and supportive atmosphere DIABETES MELLITUS
in which they are encouraged to share feelings
Epidemiology
6. Promoting Independent Self-care
 risk factors
 practicing an activity with consistent supervision  family history
in a relaxed environment  obesity
 independence in dressing, toileting, and bathing  race/ethnicity
depends on balance, transfer abilities, and  ≥ 45 years old
physiologic tolerance  impaired fasting glucose or impaired
7. Helping the Patient to Achieve Physical Mobility glucose tolerance
 HPN (≥ 140/90 mmHg)
 proper positioning and avoid placing on a pillow  HDL ≤ 35 mg/dL and/or triglyceride ≥
to prevent hip/knee joint contracture 250 mg/dL
 abduction, external rotation, and flexion are  history of gestational diabetes of
avoided and residual limb is placed in an delivery of babies > 9 lb
extended position or elevated for a brief period  leading cause of non-traumatic amputations,
 encourage turning to sides and assume prone blindness, and ESRD
position to prevent flexion contracture of the hip  3rd leading cause of disease d/t high rate of CVD
 ROM exercises include hip and knee exercises among people with DM
 patient must practice position changes and
transfer techniques, as well as good posture Pathophysiology
 assist to stand between parallel bars to allow  insulin is secreted by beta cells and when a
extension of temporary prosthesis person eats, secretion increases and moves
 teach members of family the bandaging method glucose from the blood into muscle, liver, and fat
8. Monitoring and Managing Potential Complications cells
 other roles of insulin include
 reestablish homeostasis and prevent  transports/metabolizes glucose for
complications r/t surgery, anesthesia, and energy
immobility  stimulates storage of glucose (glycogen)
 monitor for s/s of bleeding, VS, suction drainage  signals liver to stop release of glucose
 administer antibiotics and monitor incision,  enhances storage of fat in adipose tissue
drainage, and dressing for infection  accelerates transport of amino acids
 careful skin hygiene to prevent skin breakdown  inhibits breakdown of stored glucose,
 healed residual limb is wash & dried ≥ 2x a day protein, and fat
 insulin and glucagon maintain a constant level
9. Promoting Home and Community-based Care
of glucose in the blood by stimulating its release
 give ongoing instructions and practice sessions from the liver

RLE SEMIFINALS LYNETTESKIE

Type 1 DM Clinical Manifestations

 acute onset, usually before 30 years of age and
is characterized by destruction of pancreatic
beta cells
 genetic tendency to develop T1DM is found in
people with HLA types (human leukocyte
antigen)
 there is an evidence of an autoimmune response
 destruction of beta cells results in decreased
insulin production, unchecked glucose
production, and fasting hyperglycemia
Assessment and Dx Findings
 osmotic diuresis – excess glucose is excreted in
urine accompanied by excessive loss of F&E
 diabetic ketoacidosis – accumulation of ketones
d/t fat breakdown and may cause abdominal
pain, N/V, hyperventilation, and a fruity breath
 polyuria, polydipsia, and polyphagia
 the first 2 Ps occur d/t excess fluid loss with
osmotic diuresis and polyphagia results from the
catabolic state induced by insulin deficiency
 fatigue, weakness, sudden vision changes,
tingling or numbness, dry skin, lesions/wounds
that are slow to heal, and recurrent infections
 T1DM onset: sudden weight loss, N/V, or
abdominal pains, if DKA has developed
 fasting plasma glucose, random PG, and glucose
level 2 hrs. after receiving glucose may be used
 OGTT and IV GTT are no longer recommended

Type 2 DM

 occurs more commonly among people who are

older than 30 years of age and obese
 insulin resistance – decreased insulin sensitivity
 to overcome IR, increased amounts of insulin
must be secreted to maintain the glucose level
and is called metabolic syndrome
 hypertension
 hypercholesterolemia
 abdominal obesity
 DKA does not typically occur in T2DM because
there is enough insulin to prevent the
breakdown of fat and production of ketones
 slow, progressive glucose intolerance; onset may
go undetected for many years
 mild symptoms including fatigue, irritability,
polyuria, polydipsia, poor healing skin wounds,
vaginal infections, or blurred vision Medical Management

Gestational DM  intensive treatment: 3-4 insulin injections per

day or continuous subcutaneous insulin infusion,
 onset: during pregnancy d/t secretion of
insulin pump therapy plus frequent monitoring,
placental hormones, causing insulin resistance
and weekly contacts with diabetes educators
 if pt. is high-risk and does not have GDM at 1st
 management: nutritional therapy, exercise,
screening, must be retested bet. 24-28 wks. AOG
monitoring, pharmacologic therapy, education
 initial management: dietary changes and blood
glucose monitoring and if hyperglycemia Nutritional Therapy
persists, insulin is preseribed
 control of total caloric intake to attain or
 goal: ≤ 105 mg/dL before meals and ≤ 130
maintain a reasonable body weight, control of
mg/dL 2 hours after meals
blood glucose levels, and normalization of lipids
Prevention and BP to prevent CVD
 for obese patients, weight loss is key treatment
 standard lifestyle recommendations, metformin,
 meals should not be skipped but intake must be
placebo, or an intensive program of lifestyle
controlled
modifications

RLE SEMIFINALS LYNETTESKIE

  thorough review of diet history, eating habits,
and lifestyle – first step for meal planning
 total cholesterol intake < 300 mg/day
 decreased protein and increased fiber intake
 food classification systems include exchange
lists, nutritional labels, healthy food choices,
food guide pyramid, and glycemic index
 alcohol consumption must be moderated: 1
beverage/day for women and 2/day for men
 moderation in the amount of sweetener to avoid
potential adverse effects
Exercise
 lowers blood glucose levels by increasing uptake
of glucose by body muscles and improving
insulin utilization
 regular daily exercise at the same time and in the
same amount each day is recommended
 those with blood glucose > 250 mg/dL and
ketouria must not begin exercising until urine
test results are negative and closer to normal
Gerontologic Considerations
 use of proper footwear, avoid exercise in
extreme temperatures, inspect feet after
exercise, and avoid exercise during poor
metabolic control periods
 gradual, consistent exercise (with resistance)
should be planned as tolerated by the elderly
Monitoring Glucose Levels and Ketones
 self-monitoring of blood glucose allows for
detection and prevention of hypo or
hyperglycemia
 SMBG is recommended for the following
 unstable diabetes (severe swings)
 tendency to develop severe ketosis or
hypoglycemia
 hypoglycemia without warning
symptoms
 recommended 2-4 times daily before meals and
at bedtime
 continuous glucose monitoring uses a sensor
attached to an infusion set and is inserted
subcutaneously in the abdomen (72 hours)
 testing for glycated hemoglobin is a blood
test reflecting ave. BG levels over a period of
approx. 2-3 months
 testing for ketones using a urine dipstick to
detect ketonuria
RLE SEMIFINALS
Pharmacologic Therapy
 insulin therapy
 T1DM: life-long exogenous insulin
 T2DM: long-term to control glucose
 insulin regimens vary from 1-4 injections/day
and there is usually a combination of short and
longer-acting insulin
 conventional
 intensive: reduced risk of complications
 contraindications for intensive insulin regimen
 nervous system disorders
 recurring severe hypoglycemia
 irreversible diabetic complications
 cerebrovascular of CV disease
 ineffective self-care skills
 complications of insulin therapy
 local allergic reactions
 systemic allergic reactions
 insulin lipodystrophy
 resistance to injected insulin
 morning hyperglycemia
 methods of insulin delivery
 insulin pens
 jet injectors
 insulin pumps (risk for ketoacidosis)
 future insulin delivery
 transplantation of pancreatic cells
 oral antidiabetic agents
 sulfonylureas, biguanides, and alpha-
glucose inhibitors
 non-sulfonylurea insulin secretogogues
 thiazolidinediones
 dipeptide-peptidase-4
 other pharmacologic therapy
 pramlintide: synthetic analogue of
human amylin for T1 and T2 DM
 exenatide: derived from a hormone
produced in the small intestine for T2
DM only
Nursing Management
Providing Patient Education
 reinforcement of self-management skills
 teaching survival skills (simple pathophysiology,
treatment modalities, recognition/treatment
and prevention of acute complications,
pragmatic information)
 preventive measures (foot/eye care, general
hygiene, and risk factor management)
 self-administration of insulin: storing, selecting
syringes, mixing insulins, withdrawing, selecting
LYNETTESKIE
 and rotating injection site, skin preparation,
needle insertion, and disposing of sharps
Promoting Home and Community-based Care
 patient empowerment, behavior change, self-
efficacy, and health beliefs r/t insulin regimen
CORONARY ARTERY DISEASE
 most prevalent type of CVD in adults
I. CORONARY ATHEROSCLEROSIS
 atherosclerosis – abnormal accumulation of lipid
and fibrous tissue in the lining or arterial blood
vessels
Pathophysiology
 genetics and environmental factors are involved
in the progression of these lesions
 involves an inflammatory response which begins
with injury to the vascular endothelium
 atheromas or plaques protrude into the lumen
of the vessel, narrowing it and obstructing blood
flow
 vulnerable plaque – thin cap with inflammation
 ruptured plaque – focus for thrombus formation
 may lead to acute coronary syndrome (ACS)
resulting in an acute myocardial infarction (MI)
 proinflammatory state (high levels of C-
reactive protein)
 prothrombic state (high fibrinogen)
 to det. overall CV risk, hs-CRP test results with
other screening tools are viewed
Prevention
Controlling Cholesterol Abnormalities
 LDL < 100 mg/dL
 total cholesterol < 200 mg/dL
 HDL > 60 mg/dL
 triglyceride < 150 mg/dL
 weight loss, cessation of tobacco use, and
increased physical activity (30 min. moderate
exercise on most days)
 lipid-lowering agents can reduce CAD mortality
with elevated lipid levels
Promoting Cessation of Tobacco Use
 those who stop smoking reduce their risk of
heart disease within the first year and the risk
continues to decline as long as they refrain
 meds such as nicotine patch or the
antidepressant bupropion may assist with
stopping use of tobacco
Managing Hypertension

Clinical Manifestations  early detection and serious adherence to

therapy can prevent the serious consequences
 ischemia – deprivation of cardiac muscle cells of
with untreated elevated BP
oxygen needed for survival
 angina pectoris – pain brought by myocardial Controlling DM
ischemia
 treatment with insulin and metformin and other
 a decrease in blood supply from CAD may cause
therapeutic interventions that lower plasma
sudden cardiac death
glucose levels can lead to improved endothelial
 dyspnea, nausea, and weakness, prodromal
function
symptoms, or a major cardiac event
Gender
Risk Factors
 in women > 55 years of age, the incidence of
 CAD risk equivalents: CAD, diabetes, PAD, AAA,
CAD is approx. equal to that in men
or carotid artery disease
 women also tend to have a higher incidence of
 age (M: > 45 y/o; W: > 55 y/o), systolic
complications from CVD and a higher mortality
BP/hypertension, DM, obesity/physical inactivity,
 menopause is a milestone in the aging process
smoking history, level of total cholesterol, level
during which risk factors tend to accumulate
of LDL, and level of HDL
 women continue to have poorer outcomes, with
 metabolic syndrome (major risk factor for CVD)
increased morbidity and mortality after MI,
whose diagnosis includes 3 of the ff. conditions
CABG, and PCI
 insulin resistance
 central obesity II. ANGINA PECTORIS
 dyslipidemia
 episodes or paroxysms of pain or pressure in the
 BP persistently > 130/85 mmHg
anterior chest

RLE SEMIFINALS LYNETTESKIE

Pathophysiology
 caused by atherosclerotic disease and assoc.
with a significant obstruction of at least one
major coronary artery
 types of angina include stable angina, unstable
angina, intractable or refractory angina,
variant/Prinmental’s angina, and silent ischemia
 factors associated with angina are the following
 physical exertion ( oxygen demand)
 exposure to cold (vasoconstriction and
elevated BP)
 eating a heavy meal (decreases blood
supply to the heart)
 stress/emotion-provoking situation
(releases catecholamines)
Clinical Manifestations
 pain or other symptoms such as mild
indigestion, choking or heavy sensation in the
upper chest accompanied by severe
apprehension and a feeling of impending death
 weakness or numbness in the arms, wrists, and
hands, SOB, pallor, diaphoresis, dizziness, N/V
 important characteristics: subsides with rest or
nitroglycerin
Gerontologic Considerations
 earliest sign: dyspnea, sometimes there are no
symptoms
 stress testing and cardiac catheterization may be
used to diagnose CAD in the elderly
Assessment and Dx Findings
 history r/t clinical manifestations of ischemia
 12-lead ECG (T-wave inversion), laboratory
studies such as CRP and cardiac biomarkers to
rule out an ACS, nuclear scan, or invasive
procedure
Medical Management
Pharmacologic Therapy
 nitroglycerin – short and long term reduction of
myocardial oxygen consumption through
vasodilation
 beta-blockers – reduction of myocardial oxygen
consumption by blocking beta-adrenergic
stimulation of the heart
 CI include hypotension, bradycardia,
advanced AV block, and acute HF
RLE SEMIFINALS
 calcium channel blockers – negative inotropic
effects; for those not responsive to beta-
blockers; primary TOC for vasospasm
 increase myocardial oxygen supply
 1st gen. CCBs must be avoided in people
with HF (reduce myocardial contractility)
 antiplatelet – prevention of platelet aggregation
 aspirin, clopidogrel
 heparin: effective when aPTT is 2-2.5
times the normal aPTT value
 apply bleeding precautions
 glycoprotein IIb/IIIa agents: unstable
angina and adjunct for PCI
 anticoagulants – prevention of thrombus
formation
Nursing Interventions for Patient with Angina
1. Treating Angina
 during an attack, patient must stop all activities,
sit or rest in bed in a semi-Fowler’s position to
reduce oxygen requirements
 measure VS and observe for respiratory distress
 nitroglycerin is given SL and patient’s response
is checked and administration is repeated up to
3 doses, if needed
 oxygen is given at 2 L/min by nasal cannula, even
without evidence of respiratory distress
2. Reducing Anxiety
 stress reduction methods must be done and
spiritual needs are addressed
3. Preventing Pain
 alternate rest and activity periods
4. Promoting Home and Community-Based Care
 discuss the disease process, s/s, actions to take,
and methods to prevent chest pain and
advancement of CAD
 any pain unrelieved within 15 min. by the usual
methods (nitroglycerin) should be treated at the
closest emergency center
III. ACUTE CORONARY SYNDROME (ACS) AND
MYOCARDIAL INFARCTION (MI)
 emergent situation characterized by an acute
onset of myocardial ischemia that results in
myocardial death
LYNETTESKIE
Pathophysiology 3. NSTEMI (Non-STEMI)

 unstable/pre-infarction angina – reduced blood
flow in a CA, often d/t rupture of an
atherosclerotic plaque, but artery is not
completely occluded
 MI – area of myocardium is permanently
destroyed leading to complete occlusion of the
artery
 vasospasm of CA, ↓ O2 supply, and  demand
for oxygen are other causes of MI as cells are
deprived of oxygen, ischemia develops, cellular
injury occurs, and the lack of oxygen results in
infarction
 ECG usually identifies type and location of MI
 Q-wave and pt. history identify the timing
 elevated cardiac biomarkers but no definite ECG
evidence of acute MI
Laboratory Tests
 CK-MB is the cardiac-specific isoenzyme:
increases only when there has been damage to
cardiac cells (acute MI)
 myoglobin – negative results are an excellent
parameter for ruling out an acute MI
 troponin – regulates contractile process
 troponins I and T are biomarkers which
are reliable and critical markers of
myocardial injury

Clinical Manifestations Medical Management

 chest pain (sudden and continues with rest and
medication) with ACS
 SOB, indigestion, nausea, anxiety
 cool, pale, moist skin
 HR and RR are faster than normal
 stimulated sympathetic nervous system
 re-perfuse the area with the emergency use of
thrombolytic medications or by Percutaneous
Coronary Intervention
 reducing myocardial O2 demand and increasing
O2 supply with medications, O2 administration,
and bed rest

Assessment and Diagnostic Findings

 12-lead ECG to clarify whether unstable angina,

NSTEMI, or STEMI
 ECG should be obtained within 10 minutes from
the time a patient reports pain or arrives in the
emergency department
 T-wave inversion, ST-segment elevation, and
development of an abnormal Q wave
 first ECG signs of an acute MI occur as a result of
myocardial ischemia and injury
 key diagnostic indicator for MI: elevation in the
ST segment in two contiguous leads
 decreased urinary output may indicate
cardiogenic shock
 echocardiogram is used when ECG is non-
diagnostic

1. Unstable Angina

 clinical manifestations of coronary ischemia, but

ECG and cardiac biomarkers show no evidence
of acute MI
2. STEMI
 ECG evidence of acute MI with characteristic
changes in 2 contiguous leads on a 12-lead ECG
 significant damage to the myocardium
Pharmacologic Therapy
 given aspirin (162 to 325 mg), nitroglycerin,
morphine, an IV beta-blocker, and other
medications as indicated while the diagnosis is
being confirmed
 long-term therapy with beta-blockers can
decrease the incidence of future cardiac events

RLE SEMIFINALS LYNETTESKIE

  unfractionated heparin or an LMWH is
prescribed along with platelet-inhibiting agents
to prevent further clot formation
 analgesic of choice for acute MI is morphine in
IV boluses to reduce pain and anxiety
 decreases workload of the heart and
enhances oxygenation
 ACE-inhibitors – decreases BP, facilitates
diuresis, and decreases O2 demand of heart
 ensure patient is not hypotensive,
hyponatremic, hypovolemic, or
hyperkalemic
 BP, urine output, and Na, K, and
creatinine levels are closely checked
 thrombolytics – given to dissolve the thrombus
in a CA, allowing reperfusion, minimizing the size
of the infarction and preserving ventricular
function
Emergent PCI
 usually for patients with STEMI, may also be
indicated in patients with unstable angina and
NSTEMI who are at high risk due to persistent
ischemia
 procedure treats the underlying atherosclerotic
lesion
Cardiac Rehabilitation
 important continuing care program for patients
with CAD that targets risk reduction by means of
education, individual and group support, and
physical activity
 target heart rate during hospitalization is an
increase of less than 10% from the resting heart
rate, or 120 bpm
Phases of Cardiac Rehabilitation
 Phase 1 – diagnosis of atherosclerosis
 Phase 2 – after discharge
 attends sessions three times a week for
4 to 6 weeks but may continue for as
long as 6 months
 supervised, often ECG-monitored,
exercise training
 Phase 3 – long-term outpatient program which
focuses on maintaining cardiovascular stability
and long-term conditioning; self-directed phase
Nursing Interventions for Patient with ACS
1. Relieving pain and other s/s of ischemia
RLE SEMIFINALS
 O2 administration along with meds (2-4 L/min)
 physical rest in bed with backrest elevated or in
a supportive chair to decrease chest discomfort
and dyspnea
2. Improving Respiratory Function
 monitor fluid volume status to prevent
overloading the heart and lungs
 encourage the patient to breathe deeply and
change position frequently
3. Promoting Adequate Tissue Perfusion
 bed or chair rest during the initial phase of
treatment helps reduce myocardial oxygen
consumption
 check skin temperature and peripheral pulses
frequently to monitor tissue perfusion
4. Reducing Anxiety
 decreased sympathetic stimulation decreases
the workload of the heart, which may relieve
pain and other s/s
5. Monitoring and Managing Potential Complications
 monitor the patient closely for changes in
cardiac rate and rhythm, heart sounds, BP, chest
pain, respiratory status, urinary output, skin color
and temperature, sensorium, ECG changes, and
laboratory values
6. Promoting Home and Community-Based Care
 teaching patients self-care
 continuing care: home-care or follow-up
PLEURAL EFFUSION
 a collection of fluid in the pleural space, rarely a
primary disease process; usually secondary to
other diseases
Pathophysiology
 effusion can be relatively clear fluid, or it can be
bloody or purulent
 transudative (clear) effusion implies that pleural
membranes are not diseased and most
commonly results from HF
 exudative effusion results from inflammation by
bacterial products or tumors in the pleural space
Clinical Manifestations
 pneumonia causes fever, chills, and pleuritic
chest pain
LYNETTESKIE
  malignant effusion may result in dyspnea,
difficulty lying flat, and coughing
Assessment and Dx Findings
 decreased or absent breath sounds, decreased
fremitus, and a dull, flat sound on percussion
 extremely large PE: acute respiratory distress and
tracheal deviation away from affected side
 physical examination, CXR, chest CT, and
thoracentesis confirm the presence of fluid
Medical Management
 thoracentesis – remove fluid, obtain specimen,
and relieve dyspnea and respiratory compromise
 pleurodesis – chemically irritating agent is
instilled or aerosolized into the pleural space
 surgical pleurectomy – insertion of small
catheter attached to a drainage bottle
 implantation of pleuroperitoneal shunt
Nursing Management
 prepare and position patient for thoracentesis
and offer support throughout the procedure
 record and send fluid amount to the laboratory
 monitor water-seal system’s function and record
drainage amount at prescribed intervals
 if chest tube is inserted, pain management is a
priority and help patient assume positions that
are least painful
TOTAL ABDOMINAL HYSTERECTOMY AND
BILATERAL SALPINGO-OOPHORECTOMY
 surgical removal of the uterus to treat cancer,
dysfunctional uterine bleeding, endometriosis,
nonmalignant growths, persistent pain, pelvic
relaxation and prolapse, and previous injury to
the uterus
 total hysterectomy involves removal of the
uterus and the cervix
 TAHBSO is usually required in malignant
conditions
Pre-operative Management
 discontinue anticoagulant medications, NSAIDs,
and vitamin E to reduce the risk of bleeding
 prophylactic antibiotics are given prior to
surgery and discontinued the next day
 prevention of thromboembolic events: heparin,
anti-embolism stockings, intermittent
pneumatic compression device
RLE SEMIFINALS
Post-operative Management
 major risks: infection and hemorrhage
 an indwelling catheter may be inserted d/t
edema or nerve trauma causing temporary loss
of bladder tone
Nursing Interventions for Patient Undergoing
Hysterectomy
1. Relieving Anxiety
 provide explanations about preparations and
procedures to be performed
 address outcomes of surgery, possible feelings
of loss, and options for management of
symptoms of menopause
2. Improving Body Image
 provide reassurance regarding sexual
relationships, function, and satisfaction
3. Relieving Pain
 assess intensity and assist with analgesia as
prescribed
 fluids and food may be restricted for 1-2 days
 passage of flatus indicates peristalsis (facilitated
by ambulation) and is a sign for permission of a
soft diet
4. Monitoring and Managing Potential Complications
 hemorrhage – to detect early, count perineal
pads used, assess saturation with blood, and
monitor VS
 abdominal dressings are monitored for
drainage
 give prescribed guidelines for activity
restrictions to promote healing and
prevent bleeding
 DVT – caused by positioning, post-op edema,
and decreased post-op activity
 anti-embolism stockings
 frequent position changes
 legs and feet exercises while in bed
 assist in early ambulation
 assess for DVT/phlebitis and PE
 avoid prolonged sitting with pressure at
the knees and inactivity
 bladder dysfunction – after catheter is
removed, urinary output and abdominal
distention is monitored and assessed
5. Promoting Home and Community-Based Care
LYNETTESKIE
  provide information tailored to patient’s needs
such as limitations or restrictions to be expected
 instruct to check incision daily and contact
primary HC provider if redness/purulent
drainage/discharge occurs
 remind about importance of adequate oral
intake and maintaining bowel and UT function
Complications
 encourage to resume activities gradually
 instruct to avoid straining, lifting, sex, or driving
until surgeon permits
 remind about the different s/s to be reported
HEMOPNEUMOTHORAX
 hemothorax – collection of blood in pleural
space resulting from torn intercostal vessels,
laceration of the great vessels, or laceration of
the lungs
 hemopneumothorax – collection of blood and
air in the chest cavity
 most often occurs as a result of a wound to the
chest (traumatic pneumothorax) and can also
occur spontaneously without an apparent cause
(spontaneous pneumothorax)
 to treat this condition, blood and air must be
drained from the chest using a tube and a
surgery may be needed to repair a wound/injury
Clinical Manifestations
 pain which is usually sudden and/or pleuritic
 if pneuomothorax is large, the lung collapses
totally, resulting in acute respiratory distress
 anxiety, agitation, hypotension, tachycardia,
profuse diaphoresis, dyspnea, air hunger,
increased use of accessory muscles, and central
cyanosis from severe hypoxemia
Position
 sudden chest pain which gets worse after
coughing or taking a deep breath, chest
tightness
Medical Management
 in an emergency, anything may be used that is
large enough to fill the chest wound
Pre-operative Teaching
 patient is instructed to inhale and strain against
a closed glottis to re-expand lungs and eject air
from the thorax
 in the hospital, the opening is sealed with gauze
impregnated with petrolatum
 pleural cavity can be decompressed by needle
aspiration (thoracentesis) or by chest tube
drainage (thoracostomy) of the blood ad air
RLE SEMIFINALS
 thoracotomy (surgery) is done if > 1500 mL of
blood is aspirated by thoracentesis or if chest
tube output continues > 200 mL/hr
 before the procedure, prophylactic antibiotics
may be given and also pain medications, as
prescribed
 serious infections such as pneumonia
 hemorrhagic shock
 cardiac arrest
 empyema – pus gathers in pleural space
 respiratory failure
THYROIDECTOMY
 total thyroidectomy is indicated for certain
carcinomas and to relieve tracheal or
esophageal compression
 needs lifelong thyroid replacement
therapy because hypocalcemia may
occur (no more production of PTH
which stimulates calcium production)
 surgical removal of about 5/6 of the thyroid
tissue/gland (subtotal thyroidectomy) results in
a prolonged remission with exophthalmic goiter
 beta-adrenergic blockers may be used to reduce
HR and other s/s of hyperthyroidism
 iodine may be given to reduce blood loss
 medications that could prolong clotting are
stopped several weeks prior to surgery
 nursing priorities: managing hyperthyroid state
pre-op, relieving pain, providing info about the
surgery, prognosis, and treatment needs, and
prevent complications
 supine with rolled towel or sandbag between the
scapulae, hyperextending the neck
 if table is in reverse Trendelenberg position, a
padded foot board should be used to prevent
the patient from slipping down
 nausea and vomiting may be present 24 hours
post-op due to general anesthetic agents
 anti-emetics will be ordered on a PRN basis
 post-op diet will begin with clear liquids and
advance as tolerated when N/V resolves
 head of the bed will be elevated by 30 degrees
 ambulation and sitting in chair is encouraged
when awake and alert
LYNETTESKIE
  support head and back of neck when rising to
sitting position or lying down
 pain medication will be given (IV) on PRN basis
 drain is surgically placed under skin and
attached to suction to facilitate healing
 suture line care 2-4 times/day when dressing is
not in place and continued until sutures are
removed
 inform of the s/s of hypocalcemia: (+) Chvostek’s
and Trousseau’s sign and decreased serum
calcium levels
 avoid constrictive clothing around neck
Potential Complications
 hypocalcemia, vocal cord paralysis
 hematoma, bleeding, and infection
 transverse neck scar
Post-operative Teachings/Interventions
Wound Care
 place ice bag on the neck wound to reduce
swelling and pain
 frequently check wound dressing and skin near
and on the wound site for any bleeding
 support neck when changing positions or sitting
 speak as little as possible during first few days
Diet
 cold liquid food may be given when fully aware
and if N/V subsides and peristalsis returns, soft
diet may be given as prescribed
 include high-protein in diet to promote healing
 avoid ingesting irritants such as coffee and cola
Activity and Movement
 elevate head of bed 25-35 degrees to keep
respiratory tract unobstructed and for sputum to
be expelled
 massage back of neck every 1-2 hours for
relaxation
 patient may get out of bed on the 2nd day postop
Home Care
 report s/s such as spasms from any extremity
during the 1st week, fever, restlessness,
irritability, palpitations, cyanosis, DOB, neck
muscle tightness, and wound swelling
PULMONARY TUBERCULOSIS
 infectious disease primarily affecting the lung
parenchyma and may be transmitted to other
RLE SEMIFINALS
parts of the body (meninges, kidneys, bones, and
lymph nodes)
 M. tuberculosis is an acid-fast aerobic rod that
grows slowly and is sensitive to heat and UV light
Transmission
 airborne transmission; infected person releases
droplet nuclei through talking, coughing,
sneezing, laughing, or singing
Risk Factors
 close contact with someone who has active TB
 immunocompromised status
 substance abuse
 without adequate health care
 preexisting medical conditions or special
treatment
 immigration from countries with a high
prevalence of TB
 institutionalization
 living in overcrowded, substandard housing
 being a health care worker performing high-risk
activities
Pathophysiology
 begins when a susceptible person inhales
mycobacteria and becomes infected
 bacteria are transmitted through the airways to
the alveoli, deposited and begin to multiply
 body’s immune system responds with an
inflammatory reaction
 phagocytes engulf many of the bacteria, and TB-
specific lymphocytes lyse the bacilli and normal
tissue
 results in accumulation of exudate in the alveoli
– bronchopneumonia
 initial infection: 2-10 weeks after exposure
 granulomas are surrounded by macrophages,
forming a protective wall
 material becomes necrotic, forming a cheesy
mass which may become calcified and form a
collagenous scar
 bacteria become dormant and there is no further
progression of active disease
 Ghon tubercle ulcerates, releasing cheesy
material into the bronchi, the bacteria then
become airborne
 ulcerated tubercle heals and forms scar tissue
and infected lung becomes more inflamed
LYNETTESKIE
Clinical Manifestations  class 3: disease; clinically active
 class 4: disease; not active
 low-grade fever, cough, night sweats, fatigue,
 class 5: suspected disease; pending
and weight loss
 hemoptysis may occur and both systemic & Gerontologic Considerations
pulmonary symptoms are chronic and may have
 symptoms may include unusual behavior and
been present for weeks to months
altered mental status, fever, anorexia, and
Assessment and Dx Findings weight loss
 tuberculin skin test produces no reaction or
 history, PE, tuberculin skin test, chest x-ray, acid-
delayed reactivity for up to 1 week; a 2nd skin test
fast bacillus smear, and sputum culture
is done in 1-2 weeks
 CXR reveals lesions in the upper lobes and acid-
fast bacillus smear contains mycobacteria Pharmacologic Therapy
 assess lungs for consolidation by evaluating
 anti-tuberculosis agents for 6-12 months
breath sounds, fremitus, and egophony
 INH, rifampin, pyrazinamide, and ethambutol
Tuberculin Skin Test  capreomycin, ethionamide, para-aminosalicylate
sodium, and cycloserine are second-line drugs
 Mantoux method – standardized intracutaneous
 initial phase: intensive-treatment given daily for
injection procedure and should be performed
8 weeks
only by those trained in its administration and
 continuation phase: additional 4 or 7 months
reading
 7-month period: recommended for those with
 TB extract and purified protein derivative are
cavitary pulmonary TB whose sputum culture
injected into the intradermal layer of the inner
after the initial 2 months of treatment is positive,
aspect of the forearm, 4 inches below the elbow
those initial phase did not include PZA, and
 test result is read 48-72 hours after injection and
those treated once weekly with INH and
tests read after 72 hours tend to underestimate
rifapentine whose sputum culture is (+) at the
the true size of induration/hardening
end of the initial phase
 a reaction occurs when both induration and
 non-infectious: after 2-3 weeks of continuous
erythema are present
medication therapy
 0-4 mm: insignificant
 prophylactic INH treatment involves taking daily
 ≥ 5 mm: significant in people at risk
doses for 6 to 12 months
 a significant reaction indicates past exposure to
M. tuberculosis or vaccination with BCG vaccine Nursing Management
 the more intense the reaction, the greater the
Promoting Airway Clearance
likelihood of an active infection
 increase fluid intake and correct positioning to
QuantiFERON-TB Gold Test
facilitate airway drainage
 ELISA that detects the release of interferon-
Advocating Adherence to Treatment
gamma by WBCs when the blood of a patient
with TB is incubated with peptides similar to  teach patient that TB is communicable and
those in M. tuberculosis taking medications is the most effective way to
 results are available in < 24 hours prevent transmission
 a (+) QFT-G only indicates that a person has  instruct to take meds either on an empty
been infected with TB and does not indicate stomach or at least 1 hour before meals
whether or not the disease is active  monitor for other side effects of anti-TB drugs
 inform about risk of drug resistance
Classification
Promoting Activity and Adequate Nutrition
 data from the history, PE, TB test, CXR, and
microbiologic studies are used to classify TB  plan progressive activity schedule that focuses
 class 0: no exposure/infection on increasing activity tolerance and muscle
 class 1: exposure; no infection strength
 class 2: latent infection; no active
disease

RLE SEMIFINALS LYNETTESKIE

  a nutritional plan that allows small, frequent
meals may be required

Preventing Spread of Infection

 instruct about hygiene measures: moth care,

covering mouth and nose when coughing and
sneezing, proper disposal of tissues, and
handwashing
 military TB is the spread of TB infection to
nonpulmonary sites of the body and has the
same treatment regimen with pulmonary TB

RLE SEMIFINALS LYNETTESKIE