Use Textbook of Medical- Surgical Nursing Janice L. Hinkle Kerry H. Cheever 14th edition PLEASE COPY AND PASTE do not paraphrase 1. Laboratory Results: Normals vs Abnormals CBC (WBC HGB HCT Platelets) BMP (BUN Creatinine Na Potassium) Cholesterol Triglycerides 2. ECG Rhythms Normal vs Code Blue Effect Potassium high/low on ECG strip 3. Math conversions 4. Locations of heart sounds on chest Aortic Pulmonic Tricuspid Mitral/Apical 5. Hypertension Risk Factors Stages of HTN Orthostatic Pressures Patient education Treatment 6. PVD: Arterial vs Venous Disease: Causes/Signs and Symptoms Risk factors for development 7. Glaucoma: Two types Risk factors for development 8. Hypertension prevalence and long term effects. 9. Risk factors associated with peripheral venous disorders. 10. Visual impairment related to macular degeneration and cataracts. 11. Macular degeneration diagnostic testing, type of vision impairment, and role of antioxidants. 12. The care of patients with peripheral arterial insufficiency. 13. Multiple sclerosis: underlying cause, common symptoms, areas affected, diagnostic tests, treatments, and nursing management. 14. UTI: classifications, frequency, signs and symptoms (upper vs. lower), nursing interventions and education. 15. Types of urinary incontinence. Treatment strategies. 16. CAUTI: actions to help prevent. 17. Nephrolithiasis: most common composition, signs and symptoms, diagnosis, prevention.
 

1. Laboratory results:

Normal values:

CBC:

White blood cells: 4,500 to 11,000 cells per microliter (cells/mcL)

Red blood cells: 4.5 million to 5.9 million cells/mcL for men; 4.1 million to 5.1 million cells/mcL for women

Hemoglobin: 14 to 17.5 grams per deciliter (gm/dL) for men; 12.3 to 15.3 gm/dL for women

Hematocrit: 41.5% to 50.4% for men; 35.9% to 44.6% for women

Platelets: 150,000 to 450,000 platelets/mcL

BMP:

BUN : 6 to 20 mg/dL (adults 18-60 years old) , 8-23 mg/dL (adults over 60 years old)

Creatinine: 0.9-1.3 mg/dL( adults 18-60 years old)  , 70-99 mg/dL (adults over 60 years old)

Na+ : 136-145 mE/L  (adults 18-60 years old) , 132-146 mEq/L   (adults over 60 years old)

Potassium: 3.5-5.1 mEq/L  adults 18-60 years old) , 3.5-5.1 mEq/L (adults over 60 years old)

Abnormal values:

Values lower or higher than the normal values.

 

2. ECG rhythm:

The rhythm is often identified at the same time the rate is determined. The RR interval is used to determine ventricular rhythm and the PP interval to determine atrial rhythm. If the intervals are the same or if the difference between the intervals is less than 0.8 seconds throughout the strip, the rhythm is called regular. If the intervals are different, the rhythm is called irregular

Potassium plays an important role in changing the ECG. There is rather a strong correlation between plasma potassium level and ECG changes. ECG may be used to estimate the severity of hyperkalemia

 

 

4. Location of heart sounds on the chest:

Mitral area - left fifth intercostal space, mid-clavicular line. This is where the mitral valve sounds are best auscultated;

Tricuspid area - left fourth intercostal space, just lateral to the sternum. This is where the tricuspid valve sounds are best auscultated;

 Pulmonary area - left second intercostal space, just lateral to the sternum. This is the area where sounds from the pulmonary valve are best auscultated;

Aortic area -  right second intercostal space, just lateral to the sternum. This is where the aortic valve sounds are best auscultated.

 

5. Hypertension:

Risk factors:

1. Elevated Blood Pressure

2. Diabetes.

3. Unhealthy Diet.     

4. Physical Inactivity.

5. Obesity.

6. Too Much Alcohol.

7. Tobacco Use.

8. Genetics and Family History.

Stages of HTN

Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.

Stage 2 hypertension: More-severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.

Hypertensive crisis: A blood pressure measurement higher than 180/120 mm Hg is an emergency situation that requires urgent medical care.

Orthostatic hypotension:

Orthostatic hypotension is a condition in which your blood quickly drops when you stand up from a sitting or lying position. This low blood pressure (also called postural hypotension) can make you feel dizzy or faint.

 

7.  PVD:

Arterial disorders: 

Arterial disorders cause ischemia and tissue necrosis. These disorders may occur because of chronically progressive pathologic changes to the arterial vasculature (e.g., atherosclerotic changes) or due to an acute loss of blood flow to tissues (e.g., aneurysm rupture)

 Arteriosclerosis (hardening of the arteries) is the most common disease of the arteries. It is a diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and arterioles become thickened. Atherosclerosis involves a different process, affecting the intima of large and medium-sized arteries. These changes consist of the accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery. These accumulations are referred to as atheromas or plaque.

Signs and symptoms:

• hair loss on your legs and feet
• .numbness or weakness in the legs.
• brittle, slow-growing toenails.
• ulcers (open sores) on your feet and legs, which do not heal.
• changing skin colour on your legs, such as turning pale or blue.
• shiny skin.
• in men, erectile dysfunction.

Risk factors:

Modifiable Risk Factors • Nicotine use (i.e., tobacco smoking or chewing) • Diet (contributing to hyperlipidemia) • Hypertension • Diabetes (speeds the atherosclerotic process by thickening the basement membranes of both large and small vessels) • Hyperlipidemia • Stress • Sedentary lifestyle • Elevated C-reactive protein • Hyperhomocysteinemia Nonmodifiable Risk Factors • Increasing age

• Female gender • Familial predisposition/genetics

 

 

Venous disorders:

Venous disorders cause reduction in venous blood ow, causing blood stasis. This may then cause a host of pathologic changes, including coagulation defects, edema formation and tissue breakdown, and an increased susceptibility to infections.

Deep vein thrombosis (DVT) and pulmonary embolism (PE) collectively make up the condition called venous thromboembolism. The incidence of VTE is 10% to 20% in general medical patients and up to 80% in critically ill patients. Studies suggest that 5% to 10% of all in-hospital deaths are a direct result of PE (Qaseem, Chou, Humphrey, et al., 2011). VTE is frequently not diagnosed, however, because DVT and PE are often clinically silent. It is estimated that as many as 30% of patients hospitalized with VTE develop long-term postthrombotic complications. Hospital lengths of stay are shorter, which means that the majority of symptomatic thromboembolic complications in surgical patients occur after hospital discharge.

Signs and symptoms:

• Swelling in your legs or ankles.
• Tight feeling in your calves or itchy, painful legs.
• Pain when walking that stops when you rest.
• Brown-colored skin, often near the ankles.
• Varicose veins.
• Leg ulcers that are sometimes hard to treat.

 

Risk factors:

Endothelial Damage • Trauma • Surgery • Pacing wires • Central venous catheters • Dialysis access catheters • Local vein damage • Repetitive motion injury Venous Stasis • Bed rest or immobilization • Obesity • History of varicosities • Spinal cord injury • Age (>65 years) Altered Coagulation • Cancer • Pregnancy • Oral contraceptive use • Protein C deficiency • Protein S deficiency • Antiphospholipid antibody syndrome • Factor V Leiden defect • Prothrombin G20210A defect • Hyperhomocysteinemia • Elevated factors II, VIII, IX, XI • Antithrombin III deficiency • Polycythemia • Septicemia

 

 

 

 

 

8. Glucoma:

Types:

There are several types of glaucoma. Although glaucoma classification is changing as knowledge increases, current clinical forms of glaucoma are identifed as open-angle glaucoma; angle-closure glaucoma (also called pupillary block); congenital glaucoma; and glaucoma associated with other conditions, such as developmental anomalies or corticosteroid use. Glaucoma can be primary or secondary, depending on whether associated factors contribute to the rise in IOP. The two common clinical forms of glaucoma encountered in adults are primary open-angle glaucoma (POAG) and angle closure glaucoma, which are differentiated by the mechanisms that cause impaired aqueous outflow (Porth & Mat?n, 2009).

Risk factors:

Family history of glaucoma

• Thin cornea

• African American race

• Older age

• Diabetes

• Cardiovascular disease

• Migraine syndromes

• Nearsightedness (myopia)

• Eye trauma

• Prolonged use of topical or systemic corticosteroids

 

9. Hypertension long-term effects:

• Heart attack or stroke.
• Aneurysm.
• Heart failure.
• Weakened and narrowed blood vessels in your kidneys.
• Thickened, narrowed or torn blood vessels in the eyes.
• Metabolic syndrome.
• Trouble with memory or understanding.
• Dementia.

 

10. Risk factors associated with peripheral vision disorder:

Family history of heart disease, high blood pressure, high cholesterol, or stroke

Older than 50 years

Overweight or obesity

Inactive (sedentary) lifestyle

Smoking

Diabetes

High blood pressure

High cholesterol or LDL (the “bad cholesterol”), plus high triglycerides and low HDL (the “good cholesterol”)

 

11.  Vision impairment and cataract

Vision impairment is defined as having best corrected visual acuity of 20/40 or worse in the better-seeing eye. Low vision describes visual impairment that requires the use of devices and strategies to perform visual tasks. Blindness is defined as having best corrected visual acuity that can range from 20/400 to no light perception. The clinical definition of absolute blindness is the absence of light perception. Legal blindness is a condition of impaired vision in which a person has best corrected visual acuity that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less (Prevent Blindness America, 2012). This definition neither equates with functional ability nor classifies the degrees of visual impairment. Legal blindness ranges from an inability to perceive light to having some vision remaining. A person who meets the criteria for legal blindness may be eligible for government financial assistance through disability.

Cataracts:

A cataract is a lens opacity or cloudiness (Fig. 63-8). Cataracts aect nearly 24.4 million Americans who are 40 years or older, or about 1 in 6 people in this age range. By 80 years of age, more than half of all Americans have cataracts. Cataract is a leading cause of blindness in the world (Prevent Blindness America, 2012).

A cataract is a lens opacity or cloudiness (Fig. 63-8). Cataracts aect nearly 24.4 million Americans who are 40 years or older, or about 1 in 6 people in this age range. By 80 years of age, more than half of all Americans have cataracts. Cataract is a leading cause of blindness in the world (Prevent Blindness America, 2012).

 

12.  Types of vision impairments

Loss of Central Vision

The loss of central vision creates a blur or blindspot, but side (peripheral) vision remains intact. This makes it difficult to read, recognize faces and distinguish most details in the distance. Mobility, however, is usually unaffected because side vision remains intact.

Loss of Peripheral (Side) Vision

Loss of peripheral vision is typified by an inability to distinguish anything to one side or both sides or anything directly above and/or below eye level. Central vision remains, however, making it possible to see directly ahead. Typically, loss of peripheral vision may affect mobility and if severe, can slow reading speed as a result of seeing only a few words at a time. This is sometimes referred to as "tunnel vision."

Blurred Vision

Blurred vision causes both near and far to appear to be out of focus, even with the best conventional spectacle correction possible.

Diagnostic Testing

 Assessment of vision impairment includes a thorough history and examination of distance and near visual acuity, visual field, contrast sensitivity, glare, color perception, and refraction. Specially designed, low vision visual acuity charts are used to evaluate patients.

Patient Interview During history taking, the cause and duration of the patient’s visual impairment are identifed. Patients with retinitis pigmentosa, for example, have a genetic abnormality. Patients with diabetic macular edema typically have fluctuating visual acuity. Patients with macular degeneration have central acuity problems that cause difficulty in performing activities that require near vision, such as reading. People with peripheral field defects have more difficulties with mobility. The patient’s customary ADLs, medication regimen, habits (e.g., smoking), acceptance of the physical limitations brought about by the visual impairment, and realistic expectations of low vision aids are identified and included in the plan of care, as well as provision of guidelines for safety and referrals to social services. Contrast-Sensitivity Testing and Glare Testing Contrast-sensitivity testing measures visual acuity in different degrees of light and dark contrast to determine visual function. Glare testing is also used to determine visual function. Glare can reduce a person’s ability to see, especially in patients with cataracts. Those aspected by loss of contrast sensitivity and glare have difficulty functioning in low light, or driving at night or in foggy conditions. People with a loss of contrast sensitivity may benefit from better illumination.

Role of antitoxidants:

One or two drops of proparacaine hydrochloride (Ophthaine 0.5%) and tetracaine hydrochloride (Pontocaine 0.5%) are instilled before diagnostic procedures such as tonometry and minor ocular procedures such as removal of sutures or conjunctival or corneal scrapings. Topical anesthetic agents are also used for severe eye pain to allow the patient to open his or her eyes for examination or treatment (e.g., eye irrigation for chemical burns). Anesthesia occurs within 20 seconds to 1 minute and lasts 10 to 20 minutes.

 

 

14.  MS is an immune-mediated, progressive demyelinating disease of the CNS. Demyelination refers to the destruction of myelin—the fatty and protein material that surrounds certain nerve fibers in the brain and spinal cord; it results in impaired transmission of nerve impulses.

Underlying cause:

The cause of MS is an area of ongoing research. Autoimmune activity results in demyelination, but the sensitized antigen has not been identified. Multiple factors play a role in the initiation of the immune process.

Areas affected:

 The areas most frequently affected are the optic nerves, chiasm, and tracts; the cerebrum; the brain stem and cerebellum; and the spinal cord. The axons themselves begin to degenerate, resulting in permanent and irreversible damage (Porth & Matfin, 2009)

Signs and symptoms:

The signs and symptoms of MS are varied and multiple, reflecting the location of the lesion (plaque) or combination of lesions. The main symptoms most commonly reported are fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, spasticity, and pain (AANN, 2011). Visual disturbances due to lesions in the optic nerves or their connections may include blurring of vision, diplopia (double vision), patchy blindness (scotoma), and total blindness.

Diagnostic tests:

The diagnosis of MS is based on the presence of multiple plaques in the CNS observed with MRI (Halper & Holland, 2011). Electrophoresis of CSF identifies the presence of oligoclonal banding (several bands of immunoglobulin G bonded together, indicating an immune system abnormality). Evoked potential studies can help to the extent of the disease process and monitor changes. Underlying bladder dysfunction is diagnosed by urodynamic studies. Neuropsychological testing may be indicated to assess cognitive impairment. A sexual history helps identify changes in sexual function.

Treatment:

No cure exists for MS. An individual treatment program is indicated to relieve the patient’s symptoms and provide continuing support, particularly for patients with cognitive changes, who may need more structure and support. The goals of treatment are to delay the progression of the disease, manage chronic symptoms, and treat acute exacerbations. Many patients with MS have a stable disease course and require only intermittent treatment, whereas others experience steady progression of their disease. Symptoms requiring intervention include spasticity, fatigue, bladder dysfunction, and ataxia. Management strategies target the various motor and sensory symptoms and effects of immobility that can occur.

Nursing interventions and education:

An individualized program of physical, occupational, and speech-language therapy, rehabilitation, and education is combined with emotional support. An educational plan of care is developed to enable the person with MS to deal with the physiologic, social, and psychological problems that accompany chronic disease. The presence of depression, pain, fatigue, and walking di?culty all decrease physical activity. Assisting patients with management of these symptoms may help increase the level of physical activity and overall sense of well-being (Halper & Holland, 2011).

 

15. Types of Urinary incontinence:

Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sneezing, coughing, or changing position (Meiner, 2011; Miller, 2012). It predominantly a?ects women who have had vaginal deliveries and is thought to be the result of decreasing ligament and pelvic ?oor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base. In men, stress incontinence is often experienced after a radical prostatectomy for prostate cancer because of the loss of urethral compression that the prostate had supplied before the surgery, and possibly bladder wall irritability.

Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed (Meiner, 2011; Miller, 2012). The patient is aware of the need to void but is unable to reach a toilet in time. An uninhibited detrusor contraction is the precipitating factor. This can occur in a patient with neurologic dysfunction that impairs inhibition of bladder contraction or in a patient without overt neurologic dysfunction

Functional incontinence refers to those instances in which lower urinary tract function is intact but other factors, such as severe cognitive impairment (e.g., Alzheimer’s dementia), make it di?cult for the patient to identify the need to void or physical impairments make it di?cult or impossible for the patient to reach the toilet in time for voiding (Specht, 2011).

 Iatrogenic incontinence refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alpha-adrenergic agents to decrease blood pressure. In some people with an intact urinary system, these agents adversely a?ect the alpha receptors responsible for bladder neck closing pressure; the bladder neck relaxes to the point of incontinence with a minimal increase in intra-abdominal pressure, thus mimicking stress incontinence. As soon as the medication is discontinued, the apparent incontinence resolves.

Mixed urinary incontinence, which encompasses several types of urinary incontinence, is involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing (Miller, 2012).

 

Treatment:

Behavioral Therapy

Behavioral therapies are the first choice to decrease or eliminate urinary incontinence (Chart 55-8). In using these techniques, health care professionals help patients avoid potential adverse effects of pharmacologic or surgical interventions. Pelvic poor muscle exercises (sometimes referred to as Kegel exercises) represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence (Agency for Healthcare Research and Quality [AHRQ], 2012). Other behavioral treatments include the use of a voiding diary, biofeedback, verbal instruction (prompted voiding), and physical therapy (Ling Man & Le Low, 2010).

Pharmacologic Therapy

Pharmacologic therapy works best when used as an adjunct to behavioral interventions. Anticholinergic agents inhibit bladder contraction and are considered ?rst-line medications for urge incontinence. Several tricyclic antidepressant medications (e.g., amitriptyline [Endep], amoxapine [Asendin]) can also decrease bladder contractions as well as increase bladder neck resistance (Karch, 2012). Pseudoephedrine sulfate (Sudafed), which acts on alpha-adrenergic receptors, causing urinary retention, may be used to treat stress incontinence; it needs to be used with caution in men with prostatic hyperplasia and patients with hypertension. Hormone therapy (e.g., estrogen) taken orally, transdermally, or topically was once the treatment of choice for urinary incontinence in postmenopausal women because it restores the mucosal, vascular, and muscular integrity of the urethra. However, research suggests incontinence increases in women taking estrogen alone compared to placebo (Weinstein, 2012).

 Surgical Management

Surgical correction may be indicated in patients who have not achieved continence using behavioral and pharmacologic therapy. Surgical options vary according to the underlying anatomy and the physiologic problem. Most procedures involve lifting and stabilizing the bladder or urethra to restore the normal urethrovesical angle or to lengthen the urethra.

 

16. UTI

Classification:

Urinary tract infections (UTIs) are classified by location:

The lower urinary tract (which includes the bladder and structures below the bladder) or the upper urinary tract (which includes the kidneys and ureters). They can also be classified as uncomplicated or complicated UTIs. Lower UTIs Cystitis, prostatitis, urethritis

Upper UTIs Acute pyelonephritis, chronic pyelonephritis, renal abscess, interstitial nephritis, perirenal abscess

UncomplicatedNo file attached.

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