Medical-surgical nursing

Cardiovascular System

1. Coronary Artery Disease (CAD), Hypertension, Heart Failure, and Dysrhythmias

A. Coronary Artery Disease (CAD)

1. Overview
CAD refers to reduced blood flow in the coronary arteries due to plaque buildup, which can limit oxygen to the heart muscle and potentially result in chest pain or a heart attack.

2. Contributing Factors

  • Can be changed: Things like smoking, poor diet, high blood pressure, diabetes, being inactive, excess weight, and chronic stress.
  • Cannot be changed: Age, gender (men more prone before menopause), genetic factors, and ethnicity.

3. How It Happens
Fatty substances, mainly cholesterol, stick to artery walls. Over time, this narrows the space for blood to pass through, leading to lower oxygen delivery. This may result in chest pain (angina) or even tissue death (heart attack) if prolonged.

4. Signs and Symptoms

  • Predictable Angina: Chest discomfort during activity, goes away with rest or meds.
  • Unstable Angina: More serious; can occur while resting and signals risk of a heart attack.
  • Heart Attack: Persistent chest pain due to blocked blood supply, leading to permanent damage.

5. Nursing Role and Actions

  • Check and Monitor: Pain details, ECG patterns, vital signs, lab work.
  • Promote Healthier Habits: Quit smoking, follow a heart-healthy diet, exercise regularly.
  • Medications:
    • Nitroglycerin for chest pain relief.
    • Beta-blockers like metoprolol to reduce heart strain.
    • Aspirin or clopidogrel to prevent clot formation.
    • Statins to control cholesterol levels.
  • Patient Education: Explain the need for consistency with meds and lifestyle changes; refer to cardiac rehab when necessary.

B. Hypertension

1. Definition
A chronic condition where blood pressure readings stay at or above 130/80 mmHg on multiple checks.

2. Risk Factors

  • Modifiable causes: Poor diet (salty foods), smoking, alcohol, stress, extra weight, not moving enough.
  • Fixed risks: Genetics, race (more common in African American populations).

3. Types

  • Primary: Develops gradually without a clear cause.
  • Secondary: Results from another illness, like kidney disease.

4. Symptoms
Often goes unnoticed (hence the term “silent killer”), but in severe cases, it can cause headaches, blurred vision, or dizziness.

5. Long-Term Impact
If not managed, it can damage vital organs—heart, kidneys, brain, and eyes.

6. Nursing Responsibilities

  • Monitor: Accurate BP checks; look for organ issues.
  • Encourage Changes: Use the DASH diet, reduce salt, move more, manage stress, lose weight.
  • Medications:
    • Diuretics to flush excess fluid.
    • ACE inhibitors or ARBs to relax blood vessels.
    • Beta-blockers to ease heart’s workload.
    • Calcium channel blockers to widen arteries.
  • Patient Teaching: Stress the need to take meds on time, check BP regularly, and attend follow-ups.

C. Heart Failure

1. What It Means
A condition where the heart doesn’t pump or fill properly, leading to insufficient oxygen delivery to the body.

2. Variants

  • Left-sided: Affects the lungs (shortness of breath, coughing).
  • Right-sided: Causes fluid buildup in the body (swelling, enlarged neck veins).

3. What’s Going On in the Body
As the heart weakens, the body tries to compensate by activating hormones and the nervous system—but this can make things worse over time.

4. Symptoms

  • Left HF: Trouble breathing with activity, wheezing, pink sputum, low energy.
  • Right HF: Swollen legs, belly bloating, weight gain, decreased appetite.

5. Nursing Care Plan

  • Ongoing Checks: Daily weights, listen for lung sounds, monitor fluids, check for swelling.
  • Health Habits: Cut back on salt, limit fluids if advised, stay active within limits.
  • Medications:
    • ACE inhibitors/ARBs to ease the heart’s work.
    • Beta-blockers to reduce nerve system stress.
    • Diuretics to manage fluid retention.
    • Digoxin to boost heart strength (watch for side effects).
  • Patient Guidance: Spot early signs of overload, like sudden weight gain; reinforce routine with meds and checkups.

D. Dysrhythmias

  1. Overview
    o Refers to disturbances in the electrical impulses that coordinate heartbeats, resulting in irregular or abnormal heart rhythms (e.g., atrial fibrillation, ventricular tachycardia).
  2. Frequently Encountered Dysrhythmias
    o Sinus Bradycardia: Heart rate falls below 60 bpm; can be normal in well-conditioned individuals or triggered by increased vagal tone.
    o Atrial Fibrillation (AF): Disorganized electrical activity in the atria causes a highly irregular rhythm, increasing stroke risk due to possible clot formation.
    o Ventricular Tachycardia (VT): Rapid rhythm from the ventricles that can compromise perfusion and may be fatal without intervention.
    o Ventricular Fibrillation (VF): Disorganized, ineffective contractions of the ventricles resulting in zero cardiac output—requires urgent defibrillation.
  3. Signs & Symptoms
    o Can range from subtle to severe: palpitations, fainting spells, lightheadedness, chest discomfort, or even no symptoms.
    o Inadequate cardiac output may present as hypotension or cognitive changes due to poor cerebral perfusion.
  4. Nursing Actions & Priorities
    o Evaluation: Continuous ECG monitoring for rhythm deviations; assess circulatory status via blood pressure, pulse, and mental state.
    o Pharmacologic Support:
    ▪ Antiarrhythmic agents (e.g., amiodarone, lidocaine) especially for ventricular types.
    ▪ Rate-control meds like beta-blockers or calcium channel blockers (e.g., diltiazem) for atrial fibrillation.
    ▪ Anticoagulation (e.g., warfarin, DOACs) to reduce embolic risk in AF.
    o Urgent Measures:
    ▪ Synchronized cardioversion for unstable AF or VT with a pulse.
    ▪ Defibrillation for pulseless VT or VF.
    ▪ Device therapy, such as pacemakers or ICDs, for ongoing rhythm stabilization.

2. Diagnostic Testing (ECG and Cardiac Enzymes)
Accurate identification of cardiac conditions relies heavily on two diagnostic pillars: ECGs and biochemical markers.

A. Electrocardiogram (ECG)

  1. Function
    o Visualizes the heart’s electrical activity to help identify arrhythmias, conduction blocks, or signs of ischemia and infarction.
  2. Nursing Involvement
    o Before the test: Ensure good electrode-skin contact—may need to prep skin.
    o During/after: Monitor for changes in waveforms, such as ST segment shifts or rhythm anomalies.
    o Analysis: Note heart rate, PQRST characteristics, and patterns that might suggest cardiac enlargement or injury.

B. Cardiac Biomarkers

  1. Troponin (I or T)
    o The most sensitive and specific indicator of myocardial damage; rises early and stays elevated for days.
  2. CK-MB
    o Formerly widely used; levels increase several hours after myocardial injury and normalize within a few days.
  3. Myoglobin
    o Elevates early but is not heart-specific—occasionally used as an early warning.
  4. Nursing Role
    o Timing: Blood draws are spaced over time to observe enzyme trends.
    o Interpretation: Elevated markers suggest cardiac tissue injury and must be considered with ECG data.
    o Education: Explain the rationale behind serial blood sampling to patients.

3. Nursing Care & Medication Approaches

A. Fundamental Nursing Measures

  1. Monitoring
    o Keep close watch on vital signs and assess for heart/lung sounds, signs of fluid overload or poor perfusion, and ECG abnormalities.
  2. Positioning
    o Use elevated positions (semi- or high-Fowler’s) for breathing difficulty.
    o Following a cardiac event, restrict activity initially, then increase gradually.
  3. Supplemental Oxygen
    o Administer if there are signs of oxygen deprivation or acute cardiac events.
  4. Rest & Stress Management
    o Combine care tasks to allow longer rest periods; limit stimulation as needed.
  5. Diet and Fluid Guidelines
    o May include fluid restriction for heart failure, sodium reduction for hypertension, and cholesterol control for CAD.

B. Medications

  1. Core Cardiac Drugs
    o Includes antihypertensives, antianginals, diuretics, anticoagulants, antiplatelets, and cardiac glycosides.
  2. Monitoring and Teaching
    o Adverse effects: Watch for drops in blood pressure, arrhythmias, or electrolyte imbalances.
    o Education: Emphasize medication adherence and the risks of abrupt discontinuation.
    o Lab Tracking: Regular checks of kidney function, electrolytes, digoxin levels, and clotting times depending on the medication.
  3. Emergency Use Drugs
    o Thrombolytics (e.g., alteplase) used promptly in heart attacks or strokes.
    o Advanced antiarrhythmics for serious rhythm issues.
    o Vasopressors/inotropes (e.g., dopamine) for shock states or severe low blood pressure.

C. Heart Failure

  1. Definition
    ▪ A condition where the heart cannot pump or fill efficiently, resulting in insufficient blood flow to meet the body’s needs.
  2. Types
    ▪ Left-Sided: Presents mainly with respiratory symptoms such as difficulty breathing (especially when lying down), crackles on auscultation, and a persistent cough.
    ▪ Right-Sided: Characterized by systemic symptoms including swelling in the legs, visible neck vein distention, and liver enlargement.
  3. Pathophysiology
    ▪ When the heart’s output falls, the body activates compensatory systems like the RAAS and the sympathetic nervous system. These initially help but eventually strain the heart further, worsening the condition.
  4. Clinical Manifestations
    ▪ Left-Sided HF: Shortness of breath with activity, wheezing, fatigue, and in severe cases, coughing up pink, frothy sputum.
    ▪ Right-Sided HF: Swelling in the lower limbs, abdominal bloating (ascites), unexpected weight gain, and reduced appetite.
  5. Nursing Considerations & Interventions
    ▪ Assessment: Monitor daily weight, lung auscultation for crackles, intake and output, peripheral swelling, and vital signs.
    ▪ Lifestyle Adjustments: Limit salt intake, restrict fluids if necessary, and encourage light activity as tolerated.
    ▪ Medications:
     ▫ ACE inhibitors or ARBs to ease the heart’s workload and reduce long-term damage.
     ▫ Beta-blockers to moderate sympathetic nervous system effects.
     ▫ Diuretics (loop or thiazide) to manage fluid buildup.
     ▫ Positive inotropes like digoxin to support heart function (monitor closely for toxicity).
    ▪ Patient Education: Teach patients to watch for early fluid retention (e.g., sudden weight gain), maintain medication routines, attend regular check-ups, and track daily weights.

D. Dysrhythmias

  1. Definition
    ▪ Irregularities in the heart’s electrical impulses that cause abnormal heart rhythms, such as atrial fibrillation or ventricular tachycardia.
  2. Common Types
    ▪ Sinus Bradycardia: Slower than normal heartbeat (<60 bpm); can be normal in some individuals, like athletes, or result from vagal tone.
    ▪ Atrial Fibrillation: Disorganized electrical signals in the atria, causing an irregular rhythm and increasing the risk of clot formation.
    ▪ Ventricular Tachycardia (VT): Rapid heartbeat originating in the ventricles; may be dangerous if it continues for a prolonged period.
    ▪ Ventricular Fibrillation (VF): Disorganized ventricular activity with no effective contraction; a medical emergency requiring immediate action.
  3. Clinical Manifestations
    ▪ Symptoms may include fluttering in the chest, fainting, dizziness, chest pain, or there may be no symptoms at all.
    ▪ Reduced cardiac output can lead to low blood pressure and confusion.
  4. Nursing Considerations & Interventions
    ▪ Assessment: Monitor heart rhythm via ECG, assess circulation (blood pressure, pulses, mental status).
    ▪ Medications:
     ▫ Antiarrhythmics like amiodarone or lidocaine to correct ventricular rhythms.
     ▫ Beta-blockers or calcium channel blockers (e.g., diltiazem) for slowing the heart rate in atrial fibrillation.
     ▫ Blood thinners (e.g., warfarin or DOACs) to prevent stroke in atrial fibrillation.
    ▪ Emergency Interventions:
     ▫ Synchronized cardioversion for unstable AF or VT with a pulse.
     ▫ Defibrillation for VF or pulseless VT.
     ▫ Use of implanted devices like pacemakers or ICDs for ongoing rhythm control.

2. Diagnostic Tools: ECG and Cardiac Biomarkers

Accurate assessment is critical in managing cardiovascular conditions. Two important diagnostic tools include the electrocardiogram (ECG) and measurement of cardiac-specific enzymes.

A. Electrocardiogram (ECG)

  1. Purpose
    ▪ Measures the heart’s electrical signals to identify rhythm issues, blocked pathways, decreased blood flow, or signs of heart muscle damage.
  2. Nursing Responsibilities
    ▪ Before the Test: Make sure skin is clean and dry for electrode placement; shaving may be necessary for better contact.
    ▪ During Monitoring: Watch for abnormalities in the ECG, especially changes in the ST segment or irregular rhythms.
    ▪ Analysis Focus: Assess heart rate and rhythm, look at wave patterns (P wave, QRS, T wave), and evaluate for signs of heart enlargement, reduced oxygen supply (like ST depression), or heart attack (ST elevation).

B. Cardiac Biomarkers

  1. Troponin I/T
    ▪ Considered the most reliable indicator of heart muscle damage. Levels increase a few hours after a heart attack and stay elevated for several days.
  2. CK-MB (Creatine Kinase-Muscle/Brain subtype)
    ▪ Previously used as a primary marker. Begins to rise within hours after cardiac injury, peaks around one day later, and returns to baseline within 48–72 hours.
  3. Myoglobin
    ▪ One of the earliest markers to rise following muscle damage, but it lacks specificity for cardiac tissue, making it less definitive for heart injury.
  4. Nursing Role
    ▪ Timing of Tests: Serial blood draws may be required over a 24-hour period to monitor enzyme levels for trends.
    ▪ Interpreting Results: Elevated enzyme values typically indicate damage to heart tissue and should be considered alongside ECG results.
    ▪ Patient Communication: Help patients understand the importance of repeated testing to monitor for ongoing heart injury.

3. Nursing Care Strategies and Pharmacologic Management

A. Core Nursing Responsibilities

  1. Ongoing Evaluation
    ▪ Consistent observation of vital signs and targeted assessments, including cardiovascular and respiratory status, peripheral circulation, and any signs of fluid retention or lab/electrocardiographic abnormalities.
  2. Patient Positioning
    ▪ Use upright positions like Semi-Fowler’s or High-Fowler’s to ease breathing in patients experiencing dyspnea.
    ▪ After a heart attack or worsening heart failure, initial rest is encouraged with a gradual return to physical activity based on tolerance.
  3. Oxygen Administration
    ▪ Provided when there’s reduced oxygen supply, acute chest discomfort, or signs of heart failure to enhance oxygen delivery.
  4. Supporting Recovery & Minimizing Stressors
    ▪ Schedule care in clusters to promote rest, offer stress-reducing activities or techniques, and manage the environment (e.g., limiting stimulation or visitors as needed).
  5. Managing Fluids and Nutrition
    ▪ In select heart failure cases, limit fluid intake.
    ▪ For hypertension and heart failure, sodium intake should be restricted.
    ▪ In coronary artery disease, a heart-healthy diet low in saturated fat and cholesterol is encouraged.

B. Pharmacologic Therapy and Nurse-Led Monitoring

  1. Standard Cardiac Medications (previously discussed):
    ▪ Medications may include those that manage blood pressure (e.g., ACE inhibitors, beta-blockers, calcium channel blockers), relieve chest pain (nitrates), control fluid overload (various diuretics), reduce clot risk (antiplatelets and anticoagulants), or improve heart pumping ability (digoxin).
  2. Nursing Surveillance & Patient Education
    ▪ Adverse Effects: Monitor for low blood pressure, changes in electrolytes, and slow heart rates.
    ▪ Medication Adherence: Stress the importance of taking medications as directed to avoid symptom recurrence or worsening.
    ▪ Laboratory Monitoring: Keep track of kidney function (BUN, creatinine), electrolyte levels (especially potassium and magnesium), therapeutic drug levels (e.g., digoxin), and clotting parameters for anticoagulants (INR for warfarin, aPTT for heparin).
  3. Urgent Pharmacologic Interventions
    ▪ Thrombolytics: Administered promptly in stroke or myocardial infarction within strict timing protocols.
    ▪ Antiarrhythmic Drugs: Used for critical rhythm disturbances.
    ▪ Hemodynamic Support Agents: Drugs like dopamine or dobutamine may be used in cases of severe blood pressure drops or when the heart is failing to pump adequately.

Respiratory System

4. Respiratory Conditions: COPD, Asthma, Pneumonia, and Tuberculosis (TB)

A. Chronic Obstructive Pulmonary Disease (COPD)

  1. Definition
    ▪ COPD is a progressive, irreversible lung disease involving obstructed airflow. It includes chronic bronchitis (excessive mucus and chronic cough) and emphysema (destruction of lung tissue and loss of lung elasticity).
  2. Risk Factors
    ▪ Smoking (the leading cause), exposure to workplace hazards (dust, chemicals), air pollution, and genetic factors (e.g., alpha-1 antitrypsin deficiency).
  3. Symptoms
    ▪ Chronic Bronchitis: Persistent cough with mucus production for at least 3 months per year for two consecutive years, frequent lung infections, and signs of cyanosis and swelling (blue bloater).
    ▪ Emphysema: Shortness of breath with physical exertion, barrel-shaped chest, minimal cyanosis, pursed-lip breathing, and a pinkish appearance (pink puffer).
  4. Nursing Interventions
    ▪ Assessment: Regular monitoring of respiratory rate, oxygen levels, lung sounds, blood gas results, and the patient’s tolerance to activity.
    ▪ Lifestyle Adjustments: Smoking cessation is essential; encourage pulmonary rehab and exercise within the patient’s capability.
    ▪ Medications:
     ▫ Bronchodilators (e.g., beta-2 agonists, anticholinergics) to ease airflow.
     ▫ Corticosteroids to reduce inflammation in the airways.

B. Asthma

  1. Definition
    ▪ A chronic inflammatory condition of the airways, causing episodic airflow obstruction, which can often be reversed with treatment or spontaneously.
  2. Triggers
    ▪ Environmental allergens (pollen, dust mites), exercise, cold air, respiratory infections, emotional stress, and work-related irritants.
  3. Symptoms
    ▪ Wheezing, difficulty breathing, chest tightness, and a cough (particularly at night or in the early morning). During flare-ups, prolonged exhalation and wheezing are common.
  4. Nursing Interventions
    ▪ Assessment: Monitor peak expiratory flow rates (PEFR), breathing status, and any signs of respiratory distress.
    ▪ Medications:
     ▫ Short-acting beta-2 agonists (e.g., albuterol) for acute attacks.
     ▫ Long-acting beta-2 agonists and inhaled corticosteroids (e.g., fluticasone) for long-term management.
     ▫ Leukotriene inhibitors (e.g., montelukast) for managing specific triggers.
    ▪ Patient Education: Teach proper inhaler use, avoidance of triggers, and the importance of tracking peak flow readings.

C. Pneumonia

  1. Definition
    ▪ Pneumonia is an infection of the lung tissue, often caused by bacteria (e.g., Streptococcus pneumoniae), viruses, or atypical organisms (e.g., Mycoplasma).
  2. Risk Factors
    ▪ Age (the very young and elderly), chronic lung diseases (like COPD), diabetes, weakened immune systems, malnutrition, and smoking.
  3. Symptoms
    ▪ Fever, chills, productive cough (with pus-like sputum), sharp chest pain (pleuritic pain), and crackling sounds in the lungs. In elderly patients, mental confusion or disorientation may be the first sign.
  4. Nursing Interventions
    ▪ Assessment: Monitor body temperature, respiratory function, sputum appearance, and lung sounds.
    ▪ Medications:
     ▫ Antibiotics tailored to the suspected microorganism and local resistance patterns.
     ▫ Antipyretics to manage fever, and oxygen therapy for patients with low oxygen levels.
    ▪ Supportive Care: Ensure adequate hydration, encourage rest, and implement respiratory treatments such as incentive spirometry, deep breathing, and coughing.

D. Tuberculosis (TB)

  1. Definition
    ▪ TB is a contagious bacterial infection primarily affecting the lungs, caused by Mycobacterium tuberculosis.
  2. Transmission
    ▪ TB spreads through airborne particles released when an infected person coughs or sneezes. It requires airborne precautions (e.g., N95 respirator, isolation in a negative-pressure room).
  3. Symptoms
    ▪ Persistent cough lasting over 3 weeks, night sweats, low-grade fever, unexplained weight loss, and coughing up blood (hemoptysis) in advanced stages.
  4. Nursing Interventions
    ▪ Screening & Isolation: Administer the PPD skin test, chest X-ray, and sputum culture. Isolate patients suspected of TB and initiate airborne precautions immediately.
    ▪ Medications:
     ▫ RIPE therapy: Rifampin, Isoniazid (INH), Pyrazinamide, and Ethambutol for active TB.
     ▫ Long-term treatment, typically 6–9 months, with Directly Observed Therapy (DOT) for medication adherence.
    ▪ Monitoring for Toxicity: Watch for signs of liver toxicity (check liver function tests) and eye issues (especially from ethambutol).

5. Airway Management (Oxygen Administration, Suctioning)

Maintaining a clear airway is essential for patients with respiratory issues. Nurses must be adept at safely administering oxygen and performing suctioning when needed.

A. Oxygen Administration

  1. Oxygen Delivery Methods
    ▪ Nasal Cannula: Provides 1–6 L/min of oxygen; comfortable for the patient, allows speaking and eating but offers limited oxygen concentration.
    ▪ Simple Face Mask: Delivers 5–8 L/min of oxygen; typically used for short-term or moderate oxygen needs.
    ▪ Venturi Mask: Offers precise oxygen concentration (24–50%), ideal for patients with COPD who require controlled oxygen levels.
    ▪ Non-Rebreather Mask: Delivers the highest oxygen concentration (60–90%) without the need for intubation; used in emergencies.
  2. Safety Considerations
    ▪ Watch for skin irritation around the ears or nostrils during prolonged oxygen use.
    ▪ Avoid smoking or open flames near the oxygen supply.
    ▪ Regularly assess for improvements in oxygen saturation, mental clarity, and respiratory rate.

B. Suctioning

  1. Indications for Suctioning
    ▪ When there is an accumulation of secretions, the inability to effectively clear the airway, gurgling sounds, or decreased oxygen levels due to airway blockage.
  2. Suctioning Techniques
    ▪ Oropharyngeal Suctioning: Using a Yankauer suction device to clear the mouth and throat.
    ▪ Nasopharyngeal Suctioning: Inserting a flexible catheter through the nose into the throat for suctioning.
    ▪ Endotracheal/Tracheal Suctioning: Performed on patients with an artificial airway (intubated or with a tracheostomy); requires sterile technique.
  3. Suctioning Procedure
    ▪ Pre-oxygenate the patient if necessary, especially before performing endotracheal suctioning.
    ▪ Limit suctioning to 10–15 seconds per pass to prevent oxygen depletion.
    ▪ Continuously monitor the patient’s vital signs and oxygen levels, and discontinue suctioning if the patient shows signs of severe distress.

6. Interpreting Arterial Blood Gases (ABGs)

Arterial blood gases (ABGs) are crucial in assessing a patient’s oxygenation, ventilation, and acid-base status. Key values commonly measured include pH, partial pressure of carbon dioxide (PaCO2), partial pressure of oxygen (PaO2), bicarbonate (HCO3–), and oxygen saturation (SaO2).

ParameterNormal Range
Meaning
pH7.35–7.45Measures the blood’s acidity or alkalinity
PaCO235–45 mmHgIndicates carbon dioxide levels (respiratory)
HCO3–22–26 mEq/LReflects bicarbonate concentration (metabolic)
PaO280–100 mmHgAssesses oxygen concentration in the blood
SaO295–100%Percentage of hemoglobin bound to oxygen

B. Basic Steps in Interpretation

  1. Assess pH
    • If the pH is below 7.35, it indicates acidosis.
    • If the pH is above 7.45, it suggests alkalosis.
  2. Identify the Primary Cause
    • PaCO2 reflects the respiratory component, with an inverse relationship to pH.
    • HCO3– represents the metabolic component, with a direct relationship to pH.
  3. Determine Compensation
    • Uncompensated: One of the parameters (either PaCO2 or HCO3–) stays within the normal range.
    • Partially Compensated: Both PaCO2 and HCO3– are abnormal, but the pH remains outside the normal range.
    • Fully Compensated: Both parameters are abnormal, but the pH has returned to the normal range (7.35–7.45).
  4. Evaluate Oxygenation
    • Assess PaO2 and SaO2 to evaluate oxygenation and check for signs of hypoxemia.

Neurological System

7. Stroke (CVA), Seizures, Increased Intracranial Pressure, Head/Spinal Cord Injuries

A. Stroke (Cerebrovascular Accident, CVA)

  1. Definition
    A stroke refers to an acute neurological event that occurs due to a disruption in the brain’s blood supply. It can be classified as ischemic (caused by a blocked artery) or hemorrhagic (resulting from a ruptured blood vessel).
  2. Types of Stroke
    • Ischemic Stroke (most common):
      Caused by a clot (thrombus) blocking a cerebral artery or an embolus (a clot that travels). Treatment may involve thrombolytic therapy (tPA), if administered within a critical time frame (usually 3–4.5 hours from symptom onset).
    • Hemorrhagic Stroke:
      Caused by bleeding in the brain due to conditions like an aneurysm rupture or trauma. Key risk factors include hypertension.
  3. Clinical Manifestations
    Sudden onset of symptoms such as facial drooping, one-sided weakness (arm or leg), speech difficulties, confusion, and vision problems. Use the FAST mnemonic for quick identification: Face drooping, Arm weakness, Speech difficulties, and Time to seek emergency care.
  4. Nursing Interventions
    • Immediate Action: Record the time symptoms began, perform a rapid neurological assessment, and check the blood glucose to rule out hypoglycemia.
    • Monitoring: Keep track of vital signs, neurological status (using stroke scales like the NIH Stroke Scale), and ensure the airway remains open.
    • Medication:
      • For ischemic stroke: Consider tPA (if applicable), antiplatelets (like aspirin), and sometimes anticoagulants or statins.
      • For hemorrhagic stroke: Focus on blood pressure control and possible surgical interventions (e.g., aneurysm clipping or coiling).
    • Long-Term Care: Rehabilitation (including physical, occupational, and speech therapy) and education on preventing future strokes through managing hypertension, diabetes, and lifestyle changes.

B. Seizures

  1. Definition
    A seizure is an abrupt, abnormal electrical discharge in the brain, leading to temporary changes in behavior, sensation, or consciousness.
  2. Types of Seizures
    • Generalized Seizures (e.g., Tonic-Clonic): Affect both hemispheres of the brain, often resulting in loss of consciousness and convulsions.
    • Focal Seizures: Involve a localized part of the brain, which may result in either simple (conscious) or complex (impaired awareness) symptoms.
  3. Clinical Manifestations
    • Tonic-Clonic Seizure: Starts with muscle rigidity (tonic phase), followed by rhythmic jerking (clonic phase), and may include incontinence and postictal confusion.
    • Absence Seizures: Brief loss of consciousness, often accompanied by subtle movements like eye blinking.
  4. Nursing Interventions
    • During Seizures:
      • Safety: Protect the patient’s head, clear the area of hazards, never restrain the patient, and avoid placing anything in their mouth.
      • Timing: Record the start and end time of the seizure for assessment.
    • Post-Seizure:
      • Place the patient on their side to prevent aspiration if unconscious.
      • Reorient them upon waking, then perform a thorough assessment of vital signs and neurological status.
    • Medication:
      • Use antiepileptic drugs (e.g., phenytoin, levetiracetam) to prevent seizures.
      • Use benzodiazepines (e.g., lorazepam) for acute seizures or status epilepticus.
    • Patient Education: Emphasize the importance of medication adherence, avoiding known seizure triggers, and having a plan for seizure management.

C. Increased Intracranial Pressure (ICP)

  1. Definition
    ICP refers to the pressure inside the skull from the brain tissue, blood, and cerebrospinal fluid. Normal ICP ranges from 5–15 mmHg.
  2. Causes
    Conditions like head injuries, brain edema (e.g., from stroke or infections), hydrocephalus, brain tumors, and meningitis can increase ICP.
  3. Clinical Manifestations
    • Early Signs: Decreased consciousness, headaches, vomiting (often without nausea), confusion, and restlessness.
    • Late Signs: Manifestations such as Cushing’s Triad (elevated systolic blood pressure with a widened pulse pressure, bradycardia, and irregular breathing), fixed and dilated pupils, and abnormal posturing (e.g., decerebrate or decorticate).
  4. Nursing Interventions
    • Positioning: Elevate the head of the bed to 30 degrees to encourage venous drainage, keeping the head and neck aligned.
    • Reducing Stimulation: Keep the environment quiet, limit visitors, and avoid actions like Valsalva maneuvers that could increase ICP.
    • Medication:
      • Use osmotic diuretics (e.g., mannitol) to reduce ICP.
      • Hypertonic saline in certain cases.
      • Sedatives or analgesics to reduce agitation and lower metabolic demand.
    • Monitoring: Regularly check neurological status (e.g., GCS), vital signs, and ICP readings if monitoring equipment is in place.

D. Head and Spinal Cord Injuries

  1. Head Injury
    • Types: Include concussion (mild traumatic brain injury), contusions, skull fractures, diffuse axonal injury, and hematomas (e.g., epidural and subdural).
    • Nursing Priorities:
      • Stabilize the cervical spine if trauma is suspected.
      • Watch for signs of increased ICP or changes in consciousness.
      • Educate post-concussion patients to monitor for worsening symptoms like headaches, confusion, vomiting, or weakness.
  2. Spinal Cord Injury
    • Causes: Often the result of trauma (e.g., car accidents, falls), hyperflexion, hyperextension, or compression injuries.
    • Levels of Injury:
      • Cervical injuries may cause tetraplegia (quadriplegia).
      • Thoracic or lumbar injuries may result in paraplegia.
    • Nursing Interventions:
      • Immobilization: Stabilize the spine, use cervical collars, and traction devices if needed.
      • Neuro Assessments: Monitor motor and sensory function below the injury site.
      • Monitor for Spinal Shock: Look for complete loss of reflexes below the injury.
      • Bowel/Bladder Care: Provide intermittent catheterization and bowel management programs.
      • Prevent Complications: Watch for pressure ulcers, infections, or autonomic dysreflexia (especially if the injury is above T6).

8. Neurological Assessment and Glasgow Coma Scale (GCS)

A thorough neurological assessment is crucial for identifying shifts in a patient’s condition and helping to direct appropriate care interventions.

A. Neurological Assessment

  1. Consciousness Level (LOC)
    • Use terms such as alert, drowsy, confused, stuporous, or unconscious.
    • Monitor for any deviations from the patient’s usual state, as even slight changes may signal increasing intracranial pressure (ICP) or deteriorating neurological function.
  2. Pupil Reaction
    • The PERRLA acronym is used to describe a normal pupil response: Pupils Equal, Round, Reactive to Light, and Able to Accommodate.
    • A pupil that is unusually dilated on one side may suggest elevated ICP or pressure on cranial nerve III.
  3. Motor and Sensory Evaluation
    • Test the strength of both arms and legs using a scale from 0 to 5 (5 indicates normal strength, 0 means no movement).
    • Look for signs of asymmetry, changes in reflex responses, and the ability to detect sensations like touch or temperature.
  4. Vital Signs
    • Watch for the onset of Cushing’s Triad, a late indicator of rising ICP, which includes high systolic blood pressure with a wide pulse pressure, bradycardia, and irregular breathing patterns.

B. Glasgow Coma Scale (GCS)
The GCS is an essential assessment tool used to measure a patient’s consciousness level by examining their eye-opening response, ability to speak, and motor skills.

CategoryScore RangeAssessment Criteria
Eye Opening1–44 = Opens eyes spontaneously, 3 = Opens eyes in response to speech, 2 = Opens eyes in response to pain, 1 = No eye opening
Verbal1–55 = Fully oriented, 4 = Confused speech, 3 = Inappropriate words, 2 = Unclear sounds, 1 = No verbal response
Motor1–6
6 = Follows commands, 5 = Localizes pain, 4 = Withdraws from pain, 3 = Flexion to pain (decorticate), 2 = Extension to pain (decerebrate), 1 = No movement

The Glasgow Coma Scale (GCS) is calculated by adding up the scores from three categories: Eye Response (1–4), Verbal Response (1–5), and Motor Response (1–6). Here’s how to interpret the total score:

  • A total score of 13–15 suggests a mild or minor head injury, indicating that the patient’s condition is near normal.
  • A score between 9–12 indicates a moderate injury, or a change in the level of consciousness (LOC).
  • A score of 8 or lower typically signals a severe injury, where intubation is often necessary to ensure the airway is protected.

Endocrine System

9. Diabetes Mellitus (Types, Management)

A. Definition

  • Diabetes mellitus is a metabolic condition where elevated blood glucose levels occur due to issues with insulin production, its action, or both. Over time, untreated hyperglycemia can lead to complications affecting organs like the eyes, kidneys, nerves, and blood vessels.

B. Types of Diabetes

  1. Type 1 Diabetes
    • Pathophysiology: The body’s immune system mistakenly attacks and destroys insulin-producing beta cells in the pancreas, leading to an absolute lack of insulin.
    • Onset: Generally diagnosed in childhood or early adulthood, though it can occur at any age.
    • Clinical Manifestations: Symptoms include increased urination (polyuria), excessive thirst (polydipsia), excessive hunger (polyphagia), weight loss, fatigue, and potentially diabetic ketoacidosis (DKA).
    • Management: Insulin administration is required for life. Patients should monitor blood glucose regularly, follow a balanced diet, engage in physical activity, and learn to manage hypoglycemia.
  2. Type 2 Diabetes
    • Pathophysiology: Characterized by insulin resistance, where the body’s cells don’t respond properly to insulin, often accompanied by a relative deficiency in insulin. This form is often linked to obesity and lack of physical activity.
    • Onset: Commonly seen in middle-aged or older adults, but increasing in younger populations due to rising obesity rates.
    • Clinical Manifestations: Often asymptomatic in the early stages. Symptoms may include fatigue, frequent infections, blurry vision, slow-healing wounds, and hyperosmolar hyperglycemic state (HHS).
    • Management: Treatment usually includes oral medications (like metformin and sulfonylureas), with insulin therapy if necessary. Lifestyle changes such as weight loss, physical activity, and dietary adjustments are crucial.
  3. Gestational Diabetes
    • Pathophysiology: This form of diabetes occurs during pregnancy when hormonal changes cause insulin resistance, leading to glucose intolerance.
    • Management: Blood glucose monitoring, dietary management, and insulin if required. Women diagnosed with gestational diabetes are at increased risk for developing type 2 diabetes later in life.

C. Nursing Considerations for Diabetes

  1. Medication Management
    • Insulin: Different types of insulin include rapid-acting (lispro), short-acting (regular), intermediate (NPH), and long-acting (glargine).
    • Oral Agents: Medications such as biguanides (e.g., metformin), sulfonylureas, thiazolidinediones, and newer agents like DPP-4 inhibitors and GLP-1 agonists.
  2. Monitoring
    • Blood Glucose: Regular self-monitoring or use of continuous glucose monitoring is essential.
    • Hemoglobin A1c: This test reflects average blood glucose levels over the past 2–3 months, with a common target of below 7% for adults.
    • Complications: Nurses should be vigilant for signs of hypoglycemia (tremors, sweating, confusion), hyperglycemia (excessive thirst, frequent urination), and long-term complications such as nerve damage (neuropathy), kidney damage (nephropathy), and eye damage (retinopathy).
  3. Patient Teaching
    • Diet & Exercise: Educate patients to match carbohydrate intake with insulin or medication doses. Encourage regular physical activity, which helps improve the body’s response to insulin.
    • Foot Care: Daily foot inspections are necessary to detect wounds early. Patients should wear protective footwear and seek timely care for any cuts to avoid infections or ulcers.
    • Sick Day Management: Advise patients to check blood glucose more frequently when ill. They should continue their medications, contact their provider if blood sugar remains high, or if vomiting occurs.

10. Thyroid and Parathyroid Disorders

A. Thyroid Disorders

  1. Hypothyroidism
    • Pathophysiology: Low levels of thyroid hormones (T3, T4), with elevated TSH if the problem is in the thyroid itself. This is often due to autoimmune diseases like Hashimoto’s thyroiditis or, globally, iodine deficiency.
    • Clinical Manifestations: Symptoms include weight gain, fatigue, sensitivity to cold, dry skin, slow heart rate (bradycardia), constipation, and, in severe cases, myxedema.
    • Management: Thyroid hormone replacement with levothyroxine is essential. TSH levels should be regularly monitored to ensure the proper dosage and prevent overtreatment, which can lead to hyperthyroidism.
  2. Hyperthyroidism
    • Pathophysiology: Excess thyroid hormone production, leading to suppressed TSH if the thyroid itself is the issue. The most common cause is Graves’ disease, an autoimmune disorder.
    • Clinical Manifestations: Symptoms include unintended weight loss despite increased appetite, heat intolerance, a fast heart rate (tachycardia), palpitations, sweating, anxiety, and bulging eyes (exophthalmos) seen in Graves’ disease.
    • Management:
      • Antithyroid medications such as methimazole or propylthiouracil (PTU) help reduce hormone production.
      • Beta-blockers, like propranolol, are used to control symptoms such as tachycardia.
      • In some cases, radioactive iodine therapy is used to destroy thyroid tissue, or a thyroidectomy may be performed.

B. Parathyroid Disorders

  1. Hypoparathyroidism
    • Pathophysiology: Insufficient secretion of parathyroid hormone (PTH), leading to low calcium levels (hypocalcemia) and high phosphate levels (hyperphosphatemia). It is commonly a complication following thyroid surgery.
    • Clinical Manifestations: Symptoms include muscle spasms, cramps, tetany (involuntary muscle contraction), and seizures due to low calcium levels. Positive signs like Chvostek’s and Trousseau’s may be present.
    • Management: Treatment involves calcium supplementation, vitamin D to aid calcium absorption, and possibly intravenous calcium gluconate in acute situations.
  2. Hyperparathyroidism
    • Pathophysiology: Excessive secretion of PTH, which results in elevated calcium levels (hypercalcemia) and low phosphorus levels. The most common causes are parathyroid adenomas or hyperplasia.
    • Clinical Manifestations: Symptoms often follow the classic “bones, stones, abdominal groans, and psychic moans” pattern, including bone pain, kidney stones, abdominal discomfort, and mental symptoms such as confusion or depression.
    • Management:
      • A parathyroidectomy may be necessary if an adenoma is present.
      • Hydration is crucial, and monitoring for signs of hypercalcemia is important.
      • In mild cases, bisphosphonates like alendronate may be used to decrease bone resorption.

11. Adrenal and Pituitary Disorders

A. Adrenal Disorders

  1. Addison’s Disease (Primary Adrenal Insufficiency)
    • Pathophysiology: This condition arises from autoimmune damage to the adrenal glands, leading to insufficient production of cortisol and aldosterone.
    • Clinical Manifestations: Symptoms include persistent fatigue, darkening of the skin (bronze or tan appearance), low blood pressure (hypotension), low sodium levels (hyponatremia), high potassium levels (hyperkalemia), and a strong craving for salty foods.
    • Addisonian Crisis: This is a sudden worsening of symptoms marked by severe hypotension and shock, often triggered by physical stress or sudden discontinuation of steroids.
    • Management:
      • Hormone Replacement: Treatment involves replacing cortisol with glucocorticoids such as hydrocortisone and possibly mineralocorticoids like fludrocortisone.
      • Nursing Care: Nurses should monitor the patient’s electrolytes and blood pressure and educate them on increasing steroid doses during stressful situations.
  2. Cushing’s Syndrome
    • Pathophysiology: This syndrome results from excess cortisol production, which can be caused by prolonged use of corticosteroids (iatrogenic) or an overproduction due to a pituitary tumor (Cushing’s disease).
    • Clinical Manifestations: Common symptoms include central obesity, “buffalo hump” (fat accumulation on the upper back), “moon face” (round face), high blood sugar (hyperglycemia), high blood pressure (hypertension), muscle wasting, fragile skin, and purple stretch marks (striae).
    • Management:
      • Steroid Reduction: If caused by prolonged steroid use, the reduction of steroids should be done gradually.
      • Surgical/Radiation Treatment: For tumors in the pituitary or adrenal glands, surgery or radiation may be necessary.
      • Monitor for Complications: Close observation for signs of infection, high blood sugar, skin issues, and electrolyte imbalances is essential.

B. Pituitary Disorders

  1. Diabetes Insipidus (DI)
    • Pathophysiology: This condition occurs when there is insufficient secretion of antidiuretic hormone (ADH) from the pituitary (central DI) or when the kidneys do not respond properly to ADH (nephrogenic DI).
    • Clinical Manifestations: Symptoms include excessive urination (polyuria) with very dilute urine, excessive thirst (polydipsia), and a low urine specific gravity (below 1.005). Dehydration is a common risk.
    • Management:
      • Desmopressin (DDAVP): This synthetic hormone is used for central DI to replace the missing ADH.
      • Fluid Replacement: Adequate fluid intake is essential to prevent dehydration, and electrolytes should be monitored regularly.
      • Nephrogenic DI: For this type, a low-sodium diet and diuretics like thiazides may help manage symptoms.
  2. SIADH (Syndrome of Inappropriate ADH Secretion)
    • Pathophysiology: In SIADH, there is excessive release of ADH, leading to water retention and dilution of sodium levels in the blood (dilutional hyponatremia). The condition can be triggered by cancers, central nervous system (CNS) disorders, or certain medications.
    • Clinical Manifestations: Symptoms include low urine output despite high urine specific gravity, confusion, muscle cramps, weight gain without swelling (edema), and low sodium levels in the blood.
    • Management:
      • Fluid Restriction: Limiting fluid intake is crucial to prevent further dilution of sodium in the blood.
      • Medications: Diuretics or hypertonic saline (3% NaCl) may be used to treat severe hyponatremia.
      • Monitoring: Continuous monitoring of the patient’s neurological status and serum sodium levels is essential.

Gastrointestinal System

12. Peptic Ulcer Disease, GERD, Inflammatory Bowel Diseases (Crohn’s, Ulcerative Colitis)

A. Peptic Ulcer Disease (PUD)

  1. Definition
    PUD refers to the damage of the gastrointestinal lining caused by the corrosive effects of stomach acid and pepsin. It commonly affects the stomach (gastric ulcers) and the upper part of the small intestine (duodenal ulcers).
  2. Etiology
    • Helicobacter pylori infection is a primary cause.
    • Chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen.
    • Excessive gastric acid production and stress-related injury to the mucosa.
  3. Clinical Manifestations
    • Gastric Ulcers: Pain typically worsens after eating, and the patient may experience weight loss.
    • Duodenal Ulcers: Pain tends to improve after eating, and patients may experience symptoms during the night.
  4. Complications
    • Potential complications include bleeding (e.g., hematemesis or melena), perforation (severe pain and rigid abdomen), and gastric outlet obstruction.
  5. Nursing Interventions & Management
    • Medications: Proton pump inhibitors (e.g., omeprazole), H2 blockers (e.g., ranitidine), antacids, and antibiotics for H. pylori infection.
    • Lifestyle Changes: Avoid irritants like alcohol and spicy foods, quit smoking, and manage stress.
    • Monitoring: Look for signs of bleeding (e.g., black, tarry stools or coffee-ground vomit), and monitor vital signs and laboratory results (hemoglobin/hematocrit).

B. Gastroesophageal Reflux Disease (GERD)

  1. Definition
    GERD occurs when gastric contents flow back into the esophagus due to dysfunction of the lower esophageal sphincter (LES), leading to irritation and inflammation of the esophageal lining.
  2. Risk Factors
    Factors that contribute to GERD include obesity, hiatal hernia, pregnancy, smoking, and consumption of trigger foods like caffeine, chocolate, and fatty foods.
  3. Clinical Manifestations
    Symptoms of GERD include heartburn (pyrosis), acid reflux, indigestion (dyspepsia), chronic coughing, and sore throat. Symptoms tend to worsen when lying down or bending over.
  4. Nursing Interventions & Management
    • Lifestyle Modifications: Encourage weight loss, elevate the head of the bed, avoid eating close to bedtime, and limit trigger foods.
    • Medications: Use proton pump inhibitors (PPIs), H2 blockers (e.g., famotidine), antacids, and prokinetic drugs (e.g., metoclopramide) if necessary.
    • Monitoring for Complications: Watch for esophagitis, the development of Barrett’s esophagus (which is precancerous), and potential for strictures.

C. Inflammatory Bowel Diseases (IBD)
IBD includes chronic conditions like Crohn’s disease and ulcerative colitis, both of which involve long-lasting inflammation of the digestive tract. However, they differ in the locations affected and the nature of the inflammation.

  1. Crohn’s Disease
    • Location: Can affect any part of the gastrointestinal tract from the mouth to the anus, but it most commonly involves the terminal ileum.
    • Characteristics: The disease is marked by “skip lesions” (areas of healthy tissue interspersed with inflamed areas), transmural inflammation (affecting all layers of the bowel wall), and potential for fistulas and strictures.
    • Clinical Manifestations: Symptoms include non-bloody diarrhea, crampy abdominal pain, weight loss, malnutrition, and fatigue.
  2. Ulcerative Colitis
    • Location: Usually starts in the rectum and progresses proximally in a continuous pattern through the colon.
    • Characteristics: Inflammation is limited to the mucosa and submucosa, and there are no skip lesions.
    • Clinical Manifestations: The hallmark symptoms are bloody diarrhea, urgency to defecate, abdominal pain, and tenesmus (the sensation of incomplete bowel evacuation).
  3. Nursing Interventions & Management
    • Medications: Aminosalicylates (e.g., sulfasalazine), corticosteroids, immunomodulators, and biologics (e.g., infliximab) are commonly used.
    • Nutrition: A high-calorie, high-protein diet is recommended, along with vitamin and mineral supplements, especially in cases of malabsorption or following surgery.
    • Monitoring: Be vigilant for dehydration, electrolyte imbalances, and anemia, particularly if there’s chronic blood loss in ulcerative colitis.
    • Surgical Interventions:
      • Crohn’s Disease: Resection of the affected bowel segments may be necessary, but recurrence of the disease is common.
      • Ulcerative Colitis: Colectomy may be curative, potentially resulting in the need for an ileostomy.

13. Liver Disorders (Hepatitis, Cirrhosis)

A. Hepatitis

  1. Definition
    Hepatitis is liver inflammation, primarily caused by viral infections (such as Hepatitis A, B, and C), but it can also result from exposure to toxins, medications, or autoimmune diseases.
  2. Clinical Manifestations
    • Acute Phase: Symptoms include fatigue, loss of appetite, nausea, discomfort in the right upper quadrant (RUQ), jaundice, dark urine, and pale stools.
    • Chronic Infection (especially Hepatitis B and C): These conditions can lead to the development of cirrhosis or liver cancer (hepatocellular carcinoma).
  3. Nursing Interventions & Management
    • Supportive Care: Encourage rest, provide a high-calorie, high-protein diet (if tolerated), ensure hydration, and avoid hepatotoxic substances like excessive acetaminophen.
    • Antiviral Treatment: Chronic hepatitis B or C can be managed with antivirals (e.g., tenofovir, interferon, or direct-acting antivirals for hepatitis C).
    • Education & Prevention: Recommend vaccination for Hepatitis A and B, practice safe sex, avoid sharing needles, and adhere to standard infection precautions.

B. Cirrhosis

  1. Definition
    Cirrhosis is a long-term liver condition marked by ongoing liver damage, fibrosis (scar tissue formation), and the development of abnormal nodules, which ultimately disrupt liver function.
  2. Common Causes
    Cirrhosis can be caused by chronic alcohol use, long-term viral hepatitis (types B and C), nonalcoholic fatty liver disease, autoimmune conditions, and genetic disorders like hemochromatosis.
  3. Clinical Manifestations & Complications
    • Portal Hypertension: Leads to complications such as esophageal varices, enlargement of the spleen (splenomegaly), and fluid accumulation in the abdomen (ascites).
    • Hepatic Encephalopathy: Elevated ammonia levels in the blood can cause confusion and asterixis (a flapping tremor).
    • Jaundice: A yellowing of the skin and eyes due to the liver’s inability to process and excrete bilirubin.
    • Coagulopathy: The liver’s reduced ability to produce clotting factors increases the risk of bleeding.
  4. Nursing Interventions & Management
    • Monitoring: Track the patient’s mental status (for signs of encephalopathy), monitor abdominal circumference (for ascites), and keep an eye on lab values (Liver Function Tests, coagulation, ammonia levels).
    • Medications: Administer lactulose to reduce ammonia levels, use diuretics like spironolactone and furosemide to manage ascites, and prescribe beta-blockers (e.g., propranolol) to prevent bleeding from varices.
    • Nutrition: If hepatic encephalopathy worsens, consider a low-protein diet and restrict sodium intake to manage ascites.
    • Procedures: Perform paracentesis to remove excess fluid from the abdomen, and conduct endoscopic variceal ligation to treat bleeding varices.

14. NG Tube, Ostomy Care, Nutrition Considerations

A. NG (Nasogastric) Tube

  1. Indications
    NG tubes are used for decompressing the stomach (e.g., in cases of paralytic ileus or bowel obstruction), providing nutrition, or administering medications when oral intake is not possible.
  2. Nursing Responsibilities
    • Insertion: Measure the tube length from the tip of the nose to the earlobe, then to the xiphoid process. Lubricate the tube and guide the patient to swallow as the tube is advanced.
    • Verification: The gold standard for confirming placement is an X-ray. Alternatively, check the pH of the aspirate and observe the external tube markings for accurate placement.
    • Maintenance: Keep the tube clear by flushing with water as per the doctor’s orders, ensure it’s securely fastened, and watch for any signs of skin irritation or breakdown around the nares.

B. Ostomy Care

  1. Types
    • Colostomy: An opening created from the colon to the abdominal wall. The stool consistency varies based on the location of the stoma (ascending, transverse, descending colon).
    • Ileostomy: An opening created from the ileum. Output tends to be more liquid and acidic, so extra care with skin protection is necessary.
  2. Nursing Considerations
    • Stoma Assessment: The stoma should be pink or red and moist. A pale or discolored stoma may indicate poor blood circulation.
    • Appliance Fitting: Ensure that the pouch is securely attached to prevent leakage and avoid skin irritation.
    • Patient Teaching: Teach the patient how to empty and replace the pouch, recognize signs of infection, and make gradual dietary adjustments while monitoring for any changes in gas or odor.

C. Nutrition Considerations

  1. Therapeutic Diets
    • Low-Residue: Often used for conditions like Crohn’s disease or ulcerative colitis during flare-ups to reduce irritation.
    • High-Protein/High-Calorie: Beneficial for patients with liver disease (like cirrhosis) or those recovering from surgery, unless encephalopathy is present.
    • Small, Frequent Meals: Recommended for chronic gastrointestinal disorders to minimize discomfort and reduce the workload on the stomach.
  2. Enteral vs. Parenteral Nutrition
    • Enteral Nutrition: The preferred method if the gastrointestinal tract is functional, typically delivered through an NG tube, G-tube, or J-tube.
    • Parenteral Nutrition (TPN): Given intravenously when the GI tract is nonfunctional or when the patient is severely malnourished. This requires meticulous sterile technique to prevent infection.

15. Renal Failure (Acute vs. Chronic)

A. Acute Renal Failure (Acute Kidney Injury, AKI)

  1. Definition
    AKI refers to a rapid decline in kidney function, resulting in the kidneys’ inability to maintain proper fluid, electrolyte balance, or eliminate nitrogenous waste products. It is often reversible if detected early and managed effectively.
  2. Causes
    • Prerenal: Reduced blood flow to the kidneys, often due to hypovolemia, shock, or heart failure.
    • Intrarenal: Direct damage to the kidney tissue, commonly caused by nephrotoxic drugs or severe infections.
    • Postrenal: Obstruction of urine flow, such as from kidney stones, tumors, or benign prostatic hyperplasia.
  3. Phases of AKI
    • Onset/Initiation: The initial injury occurs, leading to decreased urine output.
    • Oliguric: Significant reduction in urine output (<400 mL/day), leading to fluid retention, electrolyte imbalances, metabolic acidosis, and elevated BUN/creatinine.
    • Diuretic: Gradual increase in urine output, but there is a risk of dehydration and electrolyte disturbances.
    • Recovery: Kidney function begins to normalize, though full recovery can take up to 12 months.
  4. Clinical Manifestations
    Symptoms can include oliguria or anuria, fluid retention (edema and hypertension), electrolyte imbalances (e.g., hyperkalemia, elevated phosphate, low sodium and calcium), metabolic acidosis, fatigue, and confusion.
  5. Nursing Interventions & Management
    • Identify and Treat the Cause: Improve renal perfusion in prerenal causes, remove toxins or adjust nephrotoxic medications in intrarenal causes, or relieve obstructions in postrenal causes.
    • Monitor Fluid Balance: Keep track of input and output, monitor daily weights, and watch for signs of hypervolemia during the oliguric phase.
    • Electrolyte Management: Use treatments like Kayexalate or IV insulin and glucose for high potassium, phosphate binders, or sodium bicarbonate for severe acidosis.
    • Nutritional Support: Ensure adequate calorie intake, potentially reduce protein intake initially to minimize uremic symptoms, while balancing to prevent malnutrition.
    • Dialysis: Required when potassium is dangerously high, fluid overload persists, or when BUN/creatinine levels are significantly elevated and the patient is symptomatic.

B. Chronic Renal Failure (End-Stage Renal Disease, ESRD)

  1. Definition
    Chronic renal failure involves the progressive and irreversible decline in kidney function, resulting in the inability to maintain homeostasis, leading to uremia and requiring renal replacement therapy.
  2. Common Causes
    Diabetes, hypertension, chronic glomerulonephritis, polycystic kidney disease, and recurrent pyelonephritis are the most common causes of ESRD.
  3. Clinical Manifestations

Posted

in

by

angelicasale08

Tags: