Patho Phlash of Pathophysiology Flash Cards

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Patho Phlash!
Pathophysiology Flash Cards
Valerie I. Leek, MSN, RN, CMSRN
F. A. DAVIS COMPANY • Philadelphia

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F. A. Davis Company As new scientific information becomes available through basic and clinical
1915 Arch Street research, recommended treatments and drug therapies undergo changes.
The author(s) and publisher have done everything possible to make this
Philadelphia, PA 19103 book accurate, up to date, and in accord with accepted standards at the
www.fadavis.com time of publication. The author(s), editors, and publisher are not responsi-
ble for errors or omissions or for consequences from application of the
book, and make no warranty, expressed or implied, in regard to the con-
Copyright © 2012 by F. A. Davis Company tents of the book. Any practice described in this book should be applied by
the reader in accordance with professional standards of care used in regard
Copyright © 2012 by F. A. Davis Company. All rights reserved. to the unique circumstances that may apply in each situation. The reader is
This book is protected by copyright. No part of it may be repro- advised always to check product information (package inserts) for changes
and new information regarding dose and contraindications before adminis-
duced, stored in a retrieval system, or transmitted in any form or tering any drug. Caution is especially urged when using new or infrequently
by any means, electronic, mechanical, photocopying, recording, ordered drugs.
or otherwise, without written permission from the publisher.
Authorization to photocopy items for internal or personal use, or the inter-
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Dedication
To my husband, David, and my sons, Jeffrey and Zachary, thank you for your love and
support.
To my family and friends, thank you for giving me latitude when I seemed glued to my computer
screen.
To my granddaughter, Cadence, just keep growing healthy and strong. Nona loves you.
In remembrance of my Uncle Tommy and my friends Reuel and Sharon.
Acknowledgments
Thank you to all my past and present students. It is such a privilege to teach. I learn
something new every day by the interesting inquiries from all of you that stimulate my
thinking!
Thank you to all the wonderful people at F. A. Davis Company, including Tom, Meghan,
and Julie. You have the gift of making hard work seem pleasant!
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Reviewers
Joyce B. Ceresini, ADN, BSN
Anatomy/Med-Surg Instructor
Lebanon County Career & Technical School
Lebanon, Pennsylvania
Gary Gudlin RN, MSN, Ed. M

Senior Program Manager PSU Outreach
Pennsylvania State University
Bethlehem, Pennsylvania
JoEllen Kubik, RN, MA, LMSW

Assistant Professor
Allen College
Waterloo, Iowa
Andrea R. Mann, MSN, RN

Instructor, Third Level Chair
Frankford Hospital School of Nursing
Philadelphia, Pennsylvania
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Debra Morrison, RN, BScn, MN (c)

Academic Coordinator: Practical Nursing Program
Faculty: Practical Nursing, Critical Care E-learning, online Patho.Anatomy and Physiology
Durham College
Oshawa, Ontario
Mary J. Sletten, DM(c)m MSN, RN

Associate Professor
Dona Ana Community College
Las Cruces, New Mexico
Janet C. Stradtman, MSN, RN, CCRN, CNE, CNS

Assistant Director
Firelands Regional Medical Center School of Nursing
Sandusky, Ohio
Debbie Tavernier MSN, RN, BSN, School Nurse Credential

Associate Professor of Nursing
California State University Stanislaus
Turlock, California
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Icons
Gastrointestinal System Disorders Cardiovascular System Disorders
Endocrine System Disorders Respiratory System Disorders
Urologic System Disorders Sensory System Disorders
Immune System Disorders Dermatologic System Disorders
Musculoskeletal System Disorders Mental Health Disorders
Nervous System Disorders Women’s Health and Perinatal

Disorders
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Abbreviations
AAA abdominal aortic aneurysm AML acute myelogenous BCP birth control pills
ABG arterial blood gases (myeloblastic) leukemia BD Buerger’s disease
ABI ankle-brachial index ANA antinuclear antibody BHS beta-hemolytic streptococci
ac before meals ANP atrial natriuretic peptide bid two times a day
ACE angiotensin-converting enzyme anti-CCP anticyclic citrullinated BMI body mass index
AChE acetylcholinesterase peptide BMS bone marrow suppression
AChR acetylcholine receptor APAP acetaminophen BMT bone marrow transplant
ACLS advanced cardiac life support aPTT activated partial BNP brain natriuretic peptide
ACTH adrenocorticotropic hormone thromboplastin BP blood pressure
ADH antidiuretic hormone ARDS acute respiratory distress BPH benign prostatic hyperplasia
ADHD attention-deficit/hyperactivity syndrome bpm beats per minute
disorder AS aortic stenosis BRM biologic response modifier
ADLs activities of daily living ASA acetylsalicylic acid BROW barley, rye, oats, and wheat
AED antiepileptic drug ASC atypical squamous cells BSA body surface area
AF atrial fibrillation ASCA anti–Saccharomyces cerevisiae BSE breast self-examination
AFB acid-fast bacillus antibody BUN blood urea nitrogen
AGC atypical glandular cells ASC-US ASC of undetermined BUN blood urea nitrogen
AIDS acquired immunodeficiency significance BX biopsy
syndrome AST aspartate aminotransferase C&S culture and sensitivity
ALL acute lymphocytic leukemia AV atrioventricular CA coronary artery
ALP alkaline phosphatase AVM arteriovenous malformation Ca+ serum calcium
ALS amyotrophic lateral sclerosis AVP arginine vasopressin Ca++ calcium
ALT alanine aminotransferase BBB bundle branch block CABG cardiac artery bypass graft
AMI acute myocardial infarction BCG bacille Calmette-Guérin CAD coronary artery disease
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cap capsule CPK creatine phosphokinase D5W 5% dextrose in water

CBC complete blood count CPM continuous passive motion DBP diastolic blood pressure
CBI continuous bladder irrigation CPR cardiopulmonary Derm dermatology
CBT cognitive behavioral therapy resuscitation DEXA dual-energy x-ray
CD4 T-helper cells CR controlled release absorptiometry
CD8 cytotoxic cells CREST calcinosis, Raynaud’s DFV Doppler flow velocimetry
CEA carcinoembryonic antigen phenomenon, esophageal DHT dihydrotestosterone
CFTR cystic fibrosis transmembrane dysfunction, sclerodactyly, DI diabetes insipidus
regulator telangiectasia (cluster of DIC disseminated intravascular
CHF congestive heart failure features of systemic sclerosis coagulation
CIN cervical intraepithelial scleroderma) DISIDA diisopropyl iminodiacetic
neoplasia CRP c. reactive protein (scan) acid (cholescintigraphy)
CK creatine kinase CRS-R Conners Rating Scales–Revised DJD degenerative joint disease
CK-MB serum creatine kinase, CS cardiogenic shock DKA diabetic ketoacidosis
myocardial bound CS cesaerean section dL deciliter
CLL chronic lymphocytic CSF cerebrospinal fluid DMARD disease-modulating
leukemia CSF colony-stimulating factor antirheumatic drug
CML chronic myelogenous CT computerized tomography DNA deoxyribonucleic acid
leukemia CV cardiovascular DRE digital rectal examination
CNS central nervous system CVA cardiovascular accident DSM-IV-TR Diagnostic and Statistical
CO cardiac output CVC central venous catheter Manual of Mental Disorders,
COMT catechol-O-methyltransferase CVP central venous pressure 4th Edition, Text Revision
COPD chronic obstructive pulmonary CXR chest x-ray DTR deep tendon reflexes
disease D5/0.9 5% dextrose and normal DTs delirium tremens
COX-2 cyclooxygenase 2 inhibitors NaCl saline solution (0.9% NaCl) DVT deep vein thrombosis
CPHSS Cincinnati Prehospital D5/1/2/NS 5% dextrose and half normal ECG electrocardiogram
Stroke Scale saline solution (0.45% NaCl) ECHO echocardiography
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ECMO extracorporeal membrane F and E fluid and electrolyte GVHD graft-versus-host disease
oxygenation FAP familial adenomatous H&H hematocrit and hemoglobin
ECT electroconvulsive therapy polyposis H1N1 hemagglutinin type 1 and
EEG electroencephalogram FBS fasting blood sugar neuraminidase type 1
EENT eye, ear, nose, and throat FDA U.S. Food and Drug H2 histamine 2
EF ejection fraction Administration H5N1 hemagglutinin type 5 and
EGD esophagogastroduodenoscopy FFP fresh frozen plasma neuraminidase type 1
ELISA enzyme-linked immunosor- FHT fetal heart tone HAART highly active antiretroviral
bent assay FISH fluorescence in situ therapy
EMA-IgA immunoglobulin A hybridization HAV hepatitis A
antiendomysial G, g, gm gram HBV hepatitis B
EMG electromyography GABA gamma-aminobutyric acid HCP health-care professional
EMS emergency medical services GABAB gamma-aminobutyric acid Hct hematocrit
Endo endocrine type B HCV hepatitis C
EP extrapyramidal GABRB3 GABAA receptor gene HDL high-density lipoproteins
EPS extrapyramidal symptoms GB Guillain-Barré HDV hepatitis D
ER extended-release GERD gastroesophageal reflux HELLP hemolysis, elevated liver
ERCP endoscopic retrograde disease enzymes, low platelets
cholangiopancreatography GFR glomerular filtration rate HEPA high-efficiency particulate
ESR erythrocyte sedimentation GGT gamma-glutamyl transferase air
rate GH growth hormone HER2 human EGF (epidermal
ESRD end-stage renal disease GI gastrointestinal growth factor) receptor 2
ESWL extracorporeal shock wave GnRH gonadotropin-releasing HEV hepatitis E
lithotripsy hormone Hgb hemoglobin
ET-1 endothelin-1 GTT glucose tolerance test HGSIL high-grade squamous
ETOH ethal alcohol GU genitourinary intraepithelial lesion
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HIDA hepatobiliary iminodiacetic IVP intravenous pyelogram MI myocardial infarction

(scan) acid (cholescintigraphy) JNC 7 The Seventh Report of the Joint MM multiple myeloma
HIV human immunodeficiency National Committee on Prevention, MRgFUS MR-guided focused ultra-
virus Detection, Evaluation, and sound surgery
HLA human leukocyte antigen Treatment of High Blood Pressure MRI magnetic resonance imaging
HOB head of bed K+ potassium NAA nucleic acid amplification
HPV human papillomavirus KOH potassium hydroxide NG nasogastric
HR heart rate KS Karposi’s sarcoma NGT nasogastric tube
HRT hormone replacement therapy KUB kidney-ureter-bladder NK natural killer
HTN hypertension LDH lactate dehydrogenase NMDA N-methyl D-aspartate
HSIL high-grade squamous LDL low-density lipoprotein NMJ neuromuscular junction
intraepithelial lesion LEEP loop electrosurgical excision NMS neuroleptic malignant
HSV herpes simplex virus procedure syndrome
I&O intake and output LFT liver function tests NPO nil per os (nothing by mouth)
ICD implantable cardioverter LLQ left lower quadrant NSAIDs nonsteroidal anti-
defibrillator LOC level of consciousness inflammatory drugs
ICP intracranial pressure LP lumbar puncture O2 oxygen
ICS intercostal space LR lactated Ringer’s (solution) OCD obsessive-compulsive
IDM infants of diabetic mothers LSIL low-grade squamous disorder
IgE immunoglobulin E intraepithelial lesion OmpC outer membrane porin C
IgG immunoglobulin G LVAD left ventricular assist device ORIF open reduction with internal
IL-1 interleukin 1 MAO-B monoamine oxidase-B fixation
IL-8 interleukin 8 MELD Model for End-Stage Liver OSHA Occupational Safety and
INR international normalized Disease Health Administration
ratio MG myasthenia gravis OTC over-the-counter
IOL intraocular lens Mg+ magnesium PA placenta abruption
IOP intraocular pressure MgSO4 magnesium sulfate PABA para-aminobenzoic acid
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PaCO2 partial pressure of carbon PRBCs packed red blood cells SCI spinal cord injury
dioxide in alveolar gas PSA prostate-specific antigen SDAT senile dementia of the
PAD peripheral arterial disease PSV peak systolic velocity Alzheimer type
P-ANCA perinuclear antineutrophil PT prothrombin time SERM selective estrogen receptor
cytoplasmic antibody PUBS percutaneous umbilical modulator
PAO2 alveolar oxygen partial blood sampling SGA small-for-gestational-age
pressure PUVA psoralen ultraviolet A SIADH syndrome of inappropriate
Pap Papanicolaou PVC premature ventricular diuretic hormone
PCOS polycystic ovarian syndrome contraction SJS Stevens-Johnson syndrome
PCR polymerase chain reaction PVR peripheral vascular resistance SLE systemic lupus erythematosus
PD Parkinson’s disease QFT-G QuantiFERON-TB Gold SNS sympathetic nervous system
PD peritoneal dialysis R/O rule out SOB shortness of breath
PDA patent ductus arteriosus RA rheumatoid arthritis SPECT single-photon emission
PE pulmonary embolism RAIU radioactive iodine uptake computed tomography
PEEP positive end-expiratory RBC red blood cell SPF skin protection factor
pressure RD Raynaud’s disease SSRI selective serotonin reuptake
PET positron emission tomography RF rheumatoid factor inhibitor
PFT pulmonary function test RFT renal function tests STD sexually transmitted disease
pH potential of hydrogen RLQ right lower quadrant T3 triiodothyronine
PIH pregnancy-induced ROM range of motion T4 tetraiodothyronine
hypertension RSV respiratory syncytial virus T6 thoracic nerve pair 6
PIPIDA 99mTc-para-isopropylac- RUQ right upper quadrant TB tuberculosis
(scan) etanilido-iminodiacetic acid SA sinoatrial TEE transesophageal
(cholescintigraphy) SAD seasonal affective disorder echocardiogram
PND paroxysmal nocturnal SARS severe acute respiratory TEN toxic epidermal necrolysis
dyspnea syndrome TENS transcutaneous electrical
PP placenta previa SBP systolic blood pressure nerve stimulation
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TG thyroglobulin TPO thyroid peroxidase TURP transurethral resection of

THR total hip replacement TRAP tremor, rigidity, akinesia the prostate
TKR total knee replacement criteria or postural instability UC ulcerative colitis
TN trigeminal nerve bradykinesia, and US ultrasound
TNF tumor necrosis factor postural instability UTI urinary tract infection
TNF-I tumor necrosis factor TSH thyroid-stimulating UV ultraviolet
inhibitors hormone V/Q ventilation/perfusion
TNF-α tumor necrosis factor alpha tTG antitransglutaminase VF ventricular fibrillation
TNM tumor-node-metastasis TUMA transurethral microwave VT ventricular tachycardia
TPN total parenteral nutrition antenna WBC white blood cell
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Introduction
Students who study alterations in health states interventions are listed in drug classes, ideally
must learn to link assessment data, laboratory used with Pharm Phlash Pharmacology Flash
and diagnostic studies, medical and surgical Cards. Using these cards gives the learner all
treatment, possible complications, client of the important information necessary to ade-
teaching, and important findings in order to quately prepare for care of any client.
develop a comprehensive understanding of Key memory aids are “Clue” boxes for self-
specific disease management. After many years assessment of knowledge and “Remember” or
of health instruction, watching learners mnemonics to help identify important assess-
attempt to synthesize and integrate client infor- ment or care information. Fifty NCLEX style
mation, I noticed that the novice learner in questions formatted self-tests on the DavisPlus
health care had difficulty connecting all the Web site are available for knowledge application
pieces of the puzzle. It is for this reason that I by students and assignments by faculty.
developed Patho Phlash. These cards make the The cards include body system icons to
connection between all the aspects of disease remind the learner which system is affected, and
management. a list of common abbreviations for easy refer-
Each card is a brief but comprehensive snap- ence. The front of each card has the name of
shot of an alteration in health. Pharmacological the disorder with its phonetic spelling along
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with a Clue box. On the back of each card you This learning system does not replace a com-
will find prehensive medical-surgical book or pharmacol-
1. Pathophysiology ogy text. It is a tool that integrates all aspects of
2. Assessment and Diagnostic Findings medical and nursing inquiry and treatment of
3. Complications disease states. Students who utilize these cards
4. Medical and Surgical Treatment with Pharm Phlash will have at their fingertips
5. Keep in Mind (includes information to be completely integrated information to deal with
taught to the client) diseases. Best of all, the cards can be easily
6. Make the Connection, which is crucial carried in their pocket! Best of luck to all!
information to remember about assess-
ment and treatment for that disorder
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GASTROINTESTINAL
Celiac Disease, 1 Pancreatitis, 13

Gastritis, 2 Cholecystitis, 14
Gastroesophageal Reflux Disease, 3 Pancreatic Cancer, 15
Histal Hernia, 4 Bowel Obstruction, 16
Peptic Ulcer Disease, 5 Ulcerative Colitis, 17
Gastric Cancer, 6 Colon Cancer, 18
Obesity, 7 Diverticulosis, 19
Hepatitis, 8 Appendicitis, 20
Abdominal Hernias, 9 Crohn’s Disease, 21
Laënnec’s Cirrhosis, 10 Peritonitis, 22
Liver Cancer, 11 Hemorrhoids, 23
Esophageal Varices, 12
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Gastrointestinal Disorders 1
Celiac Disease
(se-le-ak di-zez)
Clue: Diagnostic or Clinical Findings

Bloating, diarrhea, rashes, anemia,
malnutrition, and failure to thrive.
+ Hydrogen breath test.
Pathophysiology Complications
• Malabsorption disorder caused by antibody • Anemia due to B-vitamin and iron deficiency.
response to gluten or gliadin proteins in barley, • Osteoporosis and osteopenia (calcium
rye, oats (some), and wheat (BROW) affecting malabsorption).
up to 1% of U.S. population. • Hemorrhage (vitamin-K deficiency related to
• Damages small intestinal villi; prevents fat, iron, decreased B-vitamin activity in bowel).
calcium, and B-vitamin absorption. • Neuropathies and mental status changes
• Genetic link that is not well understood, but (Remember: B vitamins are for Brain/Blood).
human leukocyte antigen (HLA), of which the cell • Bowel cancers and autoimmune organ destruction.
surface receptor type protein human leukocyte Medical Care and Surgical Treatment
antigen (HLA-DQ) is one, is found in family • Antirheumatics and tumor necrosis factor inhibitors.
members with a high incidence of celiac disease; • Monoclonal antibodies.
pediatric and adult clients affected. • Corticosteroids and other immunosuppressants.
Assessment and Diagnostic Findings Keep in Mind
• Diarrhea, steatorrhea, cramps, hyperactive bowel • Awareness of BROW-containing foods, food
sounds, dermatitis herpetiformis (rash).
fillers, and pharmaceutical agents is important.
• Complete blood count (CBC) with differential,
vitamin and iron profile, and antibody tests
(immunoglobulin A antiendomysial [EMA-IgA], Make the Connection
IgA/IgG, antitransglutaminase antibodies [ATA]) • Monitor I&O, calories, and stools.
elevation. • Assess for development of vesicular rash on
• Screening with endoscopic biopsy, hydrogen knees, elbows, and buttocks.
breath test, and DEXA scan. • Monitor for SOB, pallor, poor pulse oximetry
(anemia), and bleeding tendencies (vitamin K).
Gastritis
(gas-tri-tis)

Epigastric burning or discomfort
associated with tobacco use,
alcohol ingestion, stress, or
NSAID use.
Pathophysiology (Remember: B vitamins are for Brain/Blood),
• Gastric mucus forms a physical and chemical especially in the elderly.
barrier, protecting the epithelial cells lining the Medical Care and Surgical Treatment
stomach and trapping bicarbonate between the • Proton pump inhibitors, Pepto-Bismol, H2 block-
mucus and the cells. ers, and antibiotics.
• Hydrogen production outpaces bicarbonate pro- • Antacids, coating agents, prostaglandin-containing
duction during physiologic or psychological stress. agents may be utilized.
• Common gastric irritants include alcohol, stress, • PRBC cell infusion and vasopressin in cases of
tobacco, caffeine, NSAIDs, Helicobacter pylori hemorrhage.
(H. pylori) bacteria, and shock. • Perforation may require gastric reduction surgery.
Assessment and Diagnostic Findings
• Complaints of epigastric pain or burning, hyper- Keep in Mind
acidity of the stomach, eructation, pressure, nau- • Avoid gastric mucosal irritants.
sea and vomiting, or hematemesis in severe cases. • Avoid and channel psychological and physiologic
stress.
• CBC with differential to screen for pernicious
anemia.
• Endoscopy with direct visualization of inflammation Make the Connection
with biopsy urease testing, urea breath test, and
IgG antibody test for H. pylori. • Assess intake/use of gastric irritants.
Complications
• Chemotherapy and radiation treatments over the
stomach are atypical causes of severe gastritis.
• Upper gastric bleeding, peptic ulcer disease with • Chronic use of over-the-counter medications for
possible perforation and peritonitis. gastritis may lead to alteration in absorption
• Mental status changes and pernicious anemia of other medications and nutrients (↑pH).
are common with vitamin-B12 deficiencies
Gastroesophageal Reflux
Disease (GERD)
(gas-tro-e-sof-a-je-al re-fluks di-zez)

Chest pain or severe burning
occurring within an hour of
eating. Discomfort is worse when
lying down after meals and may
occur during the night.
Pathophysiology Medical Care and Surgical Treatment
• Meals that are large, high-fat, spicy, or consumed • Antacids, H2 blockers, proton pump inhibitors,
concurrently with alcohol cause relaxation of the coating agents, prostaglandins, antiemetics that
lower esophageal sphincter, allowing hydrochloric increase emptying.
acid and pepsin present in gastric contents to • Dilation of the esophagus if narrowing occurs.
reflux, or pass back, into the esophagus. • Nutritional and lifestyle changes.
• The esophagus is easily damaged by acidic gastric
Keep in Mind
contents, resulting in inflammation, edema, and
scarring over time. • Avoid large, fatty meals; alcohol use; and tobacco
use.
• Chest pain and burning within an hour of meals. • Clothing should be loose around the waist.
• Endoscopy with biopsy and pH measurement. • Sit upright for 2 hours after eating; don’t eat
within 3 hours of retiring; elevate the head of the
• Barium swallow. bed (HOB) 6–8 inches using shock blocks.
Complications • Consume liquids separately from meals to avoid
• Scarring of the esophageal tissue that can cause stomach distention.
narrowing of the esophagus and noncompliance
of the lower esophageal sphincter.
• Chronic irritation of the esophagus may lead to Make the Connection
Barrett’s esophagus (a dysplastic change of nor- • Assess lifestyle choices for clients with
mal squamous cells to columnar epithelial cells in GERD and teach accordingly.
areas of irritation), and esophageal CA. • Rule out cardiac problems that mimic GERD.
• Respiratory difficulties related to aspiration of • Monitor for signs of chemical pneumonia and
acidic gastric contents; pain with respiration. respiratory problems, especially in very young and
very old or debilitated clients.
Hiatal Hernia
(hi-a-tal her-ne-a)

Burning, chest pain, heartburn,
dysphagia, GERD, a feeling of
fullness.
Pathophysiology • Dilation of the esophagus if narrowing occurs.
• A weakness in the hiatus of the diaphragm • Fundoplication, a surgical procedure in which the
coupled with intra-abdominal pressure forcing fundus is wrapped around the lower esophagus,
protrusion of the stomach and esophagus stabilizes the upper stomach, preventing herniation.
upward through the hiatus.
• Nutritional counseling.
• Hiatal hernias include the “sliding” type and the
“rolling” type. Keep in Mind
Assessment and Diagnostic Findings • Clothing should be loose around the waist.
• Discomfort increases when lying down and decreases • Sit upright for 2 hours after eating; don’t eat
when standing or sitting upright after meals. within 3 hours of retiring; elevate the head of the
• Endoscopy; barium swallow with x-ray, fluo- bed (HOB) 6–8 inches using shock blocks.
roscopy, and swallowing studies can show the • Consume several small meals daily instead of
upward displacement of the stomach. three large meals.
Complications • Consume liquids separately from meals to avoid
stomach distention.
• Scarring and narrowing of the esophagus with
noncompliance of the lower esophageal sphincter.
• Chronic irritation of the esophagus may lead to Make the Connection
Barrett’s esophagus and esophageal CA. • Rule out cardiac problems that mimic
• Respiratory difficulties related to aspiration of hiatal hernia symptoms.
acidic gastric contents, pain with respiration. • Monitor for signs of chemical pneumonia and
Medical Care and Surgical Treatment respiratory problems, especially in very young and
• Antacids, H2 blockers, proton pump inhibitors, very old or debilitated clients.
coating agents, prostaglandins, antiemetics that
increase gastric motility and emptying.
Peptic Ulcer Disease

(pep-tik ul-ser di-zez)

Gnawing, burning pain in either the
midepigastric area 2–4 hours after
meals or the left epigastric area
with meals.
Weight loss and presence of melena.
Low H&H.
• Eighty percent of all peptic ulcer disease is caused • Bleeding, anemia, perforation with peritonitis or
by Helicobacter pylori (H. pylori) infection that causes pancreatitis (severe back pain) or obstruction
inflammation and erosion of the mucosal barrier (pyloric scarring), upper gastrointestinal (GI) bleed.
in the stomach. • Gastric cancer (chronic irritation and regeneration
• Gastric mucus provides a physical and chemical of cells).
barrier, protecting the epithelial cells lining the • Dumping syndrome after subtotal gastrectomy.
stomach and trapping bicarbonate between the Medical Care and Surgical Treatment
mucus and the cells.
• Antibiotics, proton pump inhibitors, H2 blockers,
• Hydrogen production outpaces bicarbonate coating agents, antacids.
production during physiologic or psychological
stress.
• Vagotomy.
• Subtotal gastrectomy.
• Common gastric irritants or contributors to
gastritis include alcohol, stress, tobacco, NSAIDs, Keep in Mind
H. pylori bacteria, and shock. • Avoid spicy foods, alcohol, tobacco, and caffeine;
Assessment and Diagnostic Findings manage stress; eat small, frequent bland meals.
• Duodenal ulcer: Midepigastric pain 2–4 hours
after meals, relieved with food intake.
Make the Connection
• Gastric ulcer: Left epigastric pain that increases
• Monitor CBC for anemia.
with food intake, especially 1–2 hours after
meals; hematemesis is more common than • Assess patterns of pain and weight loss.
melena. • Assess emesis for frank bleeding or coffee-ground
appearance; test stools for melena.
• Urea breath test, IgG antibody test for H. pylori,
• In the acute stage, the client will be NPO.
H. pylori culture, barium swallow with x-ray, EGD.
Gastric Cancer
(gas-trik kan-ser)

Indigestion, anorexia, weight loss,
nausea and vomiting, anemia,
melena. Pain relieved
by antacids.
• Epithelial cells undergo mutation related to • Subtotal or total gastrectomy.
chronic irritation or exposure to carcinogens. • Dumping syndrome related to subtotal or total
Cells that are damaged must be replaced. The gastrectomy.
chance of a mutation occurring is proportional • Chemotherapy and radiation, biological therapies.
to the rate of new cell growth.
• Implicated causes are chronic or autoimmune Keep in Mind
gastritis; exposure to lead dust, grain dust, glycol • Manage stress.
ethers, or leaded gasoline; or a diet high in • Pain medication should be taken before the pain
smoked fish or meats. is severe.
Assessment and Diagnostic Findings • Teach pre- and postoperative therapies (nasogas-
tric [NG] tube will be in place after gastrectomy).
• Indigestion that responds to antacids. • Teach the side effects of chemotherapy and radia-
• Anorexia and weight loss, nausea and vomiting, tion and how to mitigate them.
gastric distention.
• Complete blood count (CBC) reveals anemia.
Stool is positive for occult blood. Make the Connection
• Barium swallow with x-ray, gastric fluid analysis • Monitor nutritional status with daily or
for cytology, serum gastrin levels. weekly weights and laboratory values like total
• Positive diagnosis is made by gastroscopy and biopsy. protein, CBC, and blood chemistries.
Complications • If client is on chemotherapy, monitor for
• Nutritional deficit. hyperuricemia.
• Metastasis. • Assess for excessive diarrhea or nausea, and cold
• Bleeding, perforation, and peritonitis. sweats (dumping syndrome).
• Death. • Assist with psychosocial needs.
Obesity
(o-be-si-te)

BMI >30 kg/m2, degenerative joint
disease, type 2 diabetes, total
cholesterol >200 mg/dL.
Pathophysiology • Bariatric surgery:
• Behavioral, genetic, medication, or hormonal • Roux-en-Y.
etiology.
• Gastric banding.
• Imbalance between food energy consumed and
energy expended. Keep in Mind
Assessment and Diagnostic Findings • Reduction of 500 kilocalories (kcal) per day
• Overweight is defined as a body mass index results in weight loss of 1–2 lb/wk.
(BMI) of 25 to <30 kg/m2. • Walking for 30–60 minutes daily is the safest
• Obesity is defined as a BMI of >30 kg/m2. method of exercise.
Complications • Prevention of obesity is the goal. Eat a variety of
colorful foods and exercise 35 minutes daily.
• Degenerative joint disease (DJD).
• Cardiovascular, renal, and neural damage related
to hypertriglyceridemia and hypercholesterolemia, Make the Connection
resulting in atherosclerosis. • Monitor I&O carefully following bariatric
• Enlargement and infiltration of the liver with fat. surgery. Once gastric leaking is ruled out, the
• Type 2 diabetes mellitus. client may begin taking 1–2 ounces of liquids
• Dumping syndrome related to bariatric surgery. per meal.
• Intertriginous skin breakdown. • Rupture of the gastric pouch after bariatric
• Dyspnea. surgery may occur with excessive food intake.
Medical Care and Surgical Treatment • Behavioral interventions must be coupled with
• Total hip, knee, and ankle replacement. surgical intervention.
• Angioplasty or coronary bypass surgery. • Monitor cardiac and respiratory status when an
• Oral antidiabetic agents or insulin therapy. approved diet and exercise regimen is prescribed.
• Dialysis.
Hepatitis
(hep-a-ti-tis)

Lethargy, malaise, headache,
anorexia, low-grade fever, right
upper quadrant pain, jaundice.
Elevated ALT and AST levels.
• Inflammation of the liver caused by direct cellular • Avoid hepatotoxic medications like acetaminophen.
injury and secondary injury by the immune • Bedrest; avoid injections to prevent hemorrhage.
response; those with a lesser immune response • Small, frequent meals that contain high calories,
may become carriers rather than infected. high protein (titrate protein to ammonia levels),
• Hepatitis A (HAV): Spread by the oral-fecal route. low sodium, and moderate fluid intake.
• Hepatitis B (HBV; often coexistent with hepatitis D • Immunoglobulin therapy on exposure; hepatitis A
[HDV]): Spread by blood and body fluids. and B vaccination for prevention.
• Hepatitis C (HCV): Spread by contact with con-
Keep in Mind
taminated blood, IV drug use, unprotected sex.
• Hepatitis E (HEV): Spread by contaminated water. • Teach client dietary regimen, to rest, and avoid
hepatotoxic substances.
• Preicteric phase: Weeks to months depending on • Report confusion, asterixis, abdominal disten-
tion, or edema of legs/feet.
type; characterized by malaise, lethargy, nausea,
vomiting.
• Icteric phase: Characterized by jaundice, pale Make the Connection
stools, dark tea-colored urine, and rashes. • Monitor ALT, AST, bilirubin, stool and
• ↑ ALT and AST, ↑ bilirubin, presence of virus- urine color, mental status, and presence of
specific antigen, prothrombin time >11.6 seconds, ascites.
↑ ESR, ↑ serum ammonia levels, abnormal
hepatocytes revealed through liver biopsy.
Complications
• Acute or chronic liver failure and encephalopathy.
• Hemorrhage; liver cancer.
Abdominal Hernias
(ab-dom-i-nal her-ne-a)

Abdominal area that bulges out,
especially when intra-abdominal
pressure is ↑. Gentle pressure can
cause reduction or popping back
of the abdominal contents.
Pathophysiology resonance imaging (MRI), or direct
• A weakness in the abdominal wall allows the endoscopy.
bowel or omentum, along with peritoneal tissue, Complications
to herniate outward. Weakened areas include the • Incarcerated or strangulated hernia results in
umbilical area, along the linea alba, incisional necrosis of the bowel or omentum, which is a
areas, and areas that have not completely closed surgical emergency.
after birth (the inguinal rings).
Medical Care and Surgical Treatment
• Umbilical hernias are caused by incomplete
• Stool softeners or bulk laxatives to prevent strain-
closure of the umbilical orifice and commonly
ing at stool.
occur in children and obese clients.
• Ventral hernias are caused by weakness in the • Herniorrhaphy or hernioplasty (open or closed
surgical procedure).
linea alba and are aggravated by obesity.
• Inguinal hernias are caused in both males and Keep in Mind
females by incomplete closure of the inguinal rings.
• Incisional hernias occur after underlying muscle is
• Postsurgical care includes avoidance of coughing
or straining.
cut and scar tissue forms, weakening the area.
• Males need to use ice packs and elevate the
Assessment and Diagnostic Findings scrotum.
• May be reducible. • Avoid lifting, driving, and sexual activity as
• Straining causes the hernia to protrude. prescribed.
• Inguinal hernias may cause a dragging feeling or
occasional discomfort.
• May be present in newborn males with hydrocele. Make the Connection
• Diagnosed through physical examination, • Assess ventral hernias for bowel sounds.
computerized tomography (CT) scan, magnetic • Assess for pain that may be a sign of strangulation.
Laënnec’s Cirrhosis
(la-e-neks si-ro-sis)

Chronic condition associated with
alcohol consumption. Elevated ALT
and AST, ascites, and edema
in the lower extremities.
Pathophysiology • Portal hypertension, ascites, edema.
• Chronic heavy consumption of alcohol causes • Hepatorenal syndrome.
inflammation of the cells of the liver.
• Hemorrhage, bleeding esophageal varices.
• Fatty infiltration of the liver occurs related to Medical Care and Surgical Treatment
decrease in fatty acid oxidation and increase in
gluconeogenesis. The liver enlarges first. • Nutritional assessment and dietary intervention:
• The stellate cells to produce fibrous connective • Small, frequent high-calorie, low-sodium meals.
tissue and becomes resistant to blood flow from • Protein is titrated according to the serum
the portal vein; portal HTN and ascites result. ammonia levels.
• Lactulose for high ammonia levels; diuretics
and/or albumin for ascites.
• ↑ GGT and ALP, abnormalities in hepatocytes • Alcohol cessation program.
revealed by liver biopsy.
• Paracentesis to remove ascitic fluid if respiratory
• ↑ ALT, AST, and bilirubin levels. embarrassment occurs.
• Anorexia, nausea, vomiting, right upper quadrant • Transjugular intrahepatic portosystemic shunt.
discomfort, presence of ascites and lower extremity
edema, enlarged liver, pruritus. Keep in Mind
• Presence of alcohol withdrawal symptoms. • Teach client to avoid hepatotoxic substances.
• Pale stools, dark tea-colored urine, jaundice.
• History of alcohol abuse; starburst hemorrhages
Make the Connection
under the skin.
• B-vitamin deficiency, (Remember: B vitamins • MELD score indicates the likely survival of
are for Blood/Brain), as in wet beriberi. the client for 90 days (score ranges from 6 to 40).
Complications • Assess laboratory values, respiratory and mental
status; assess.
• Chronic liver failure, encephalopathy, and death.
Liver Cancer
(liv-er kan-ser)

Elevated ALT and AST, ascites,
edema in the lower extremities,
↑ bilirubin.
Pathophysiology • Lactulose for high ammonia levels; diuretics
• Chronic irritation of hepatocytes or surrounding and/or albumin for ascites.
parenchyma causes mutation of cells.
• Alcohol cessation program.
• The liver is a common site of mastastasis. • Paracentesis to remove ascitic fluid, if respiratory
Assessment and Diagnostic Findings embarrassment occurs.
• ↑ ALT and AST, ↑ ALP and ↑ bilirubin level. • Transjugular intrahepatic portosystemic shunt.
• Anorexia, nausea, vomiting, right upper quadrant Keep in Mind
discomfort, presence of ascites and lower extremity
edema, enlarged liver, pruritus. • Avoid hepatotoxic substances as much as
• Presence of alcohol withdrawal symptoms. possible.
• Pale stools, dark tea-colored urine, jaundice. • Manage stress with counseling.
• Liver biopsy is positive for carcinoma. • Teach the side effects of chemotherapy and radia-
tion therapy.
Complications
• Chronic liver failure, encephalopathy, and death.
• Portal hypertension, ascites, edema. Make the Connection
• Hepatorenal syndrome. • Offer pain medication and antiemetics
• Hemorrhage; bleeding esophageal varices. around the clock or by patient-controlled system.
Medical Care and Surgical Treatment • Monitor laboratory values, respiratory ease, and
• Chemotherapy, radiation, biologic therapies, and, signs of bleeding.
rarely, liver transplantation. • Intra-arterial chemotherapy is shown to be less
• Nutritional assessment and dietary intervention: toxic to the body.
• Small, frequent high-calorie, low-sodium meals.
• Protein is titrated according to the serum
ammonia levels.
Esophageal Varices
(e-sof-a-je-al var-i-sez)

Oral hemorrhage in the presence
of portal hypertension.
Pathophysiology • Transfusion of packed red blood cells (PRBCs),
• Dilation of the veins of the esophagus occurs related volume expanders (e.g., albumin), and fresh frozen
to portal hypertension from chronic liver disease. plasma (FFP) for clotting factors (if necessary).
• The walls of the veins become thin and can spon- • Sclerotherapy done with an esophagogastroduo-
taneously rupture and cause massive bleeding. denoscopy (EGD).
• Ingestion of fibrous or fried foods can scratch
and rupture the varices. Keep in Mind
Assessment and Diagnostic Findings • Avoid hard, fried, or fibrous foods if diagnosed
• Endoscopic examination for dilated areas of the with enlarged esophageal varices.
esophagus. • After sclerotherapy, chest pain may occur for
• Portal hypertension (resistance to blood flow 72 hours. Report worsening pain not responding
through the liver). to the prescribed analgesic.
Complications
• Hemorrhage. Make the Connection
• Fluid and electrolyte imbalance. • Monitor the airway carefully when using
Medical Care and Surgical Treatment tamponade. Be ready to quickly deflate or cut the
• Infusion of vasopressin to stop the hemorrhage. lumens of the esophageal balloon in cases of res-
• Tamponade (pressure) on the varices with a piratory distress.
Sengstaken-Blakemore tube, which has three • Assess the complete blood count (CBC), blood
lumens. One drains the stomach contents, another pressure, and pulse for hypovolemia and anemia.
inflates a balloon in the fundus of the stomach, • Start venous access.
and the last inflates a long balloon in the esopha- • Unrelieved pain after sclerotherapy could indicate
gus. The esophageal balloon pressure should be esophageal perforation.
maintained between 20 and 25 mm Hg.
Pancreatitis
(pan-kre-a-ti-tis)

Severe midline abdominal pain that
radiates to the flank, spine, and back,
worsening with extension of the legs
or ingestion of food. Elevated ALT and
AST, amylase, lipase, and glucose.
Pathophysiology • Signs of hemorrhage: Turner’s sign (a purple
• The outlet of the pancreas may become blocked discoloration in the flanks) and Cullen’s sign
due to inflammation, mechanically (gallstones), (a purple discoloration around the umbilicus).
or by the digestive enzymes being prematurely
activated while they are still in the pancreas. Medical Care and Surgical Treatment
• Protease causes dilation and permeability of • IV infusion of fluids, volume expanders, and
the capillaries, allowing fluid to move from the PRBCs.
pancreas to the retroperitoneal space. If fluid • Oxygen, IV analgesics (meperidine rather than
loss is severe, shock may occur. morphine to lessen spasm of the sphincter of
Oddi), and antiemetics.
• Protease initiates a chain reaction of inflamma-
• NPO to avoid worsening autodigestion.
tion that results in conversion of prothrombin to
thrombin, causing DIC. Keep in Mind
Assessment and Diagnostic Findings • Chronic alcohol ingestion is a causative factor in
• ↑ ALT and AST, amylase, lipase, ALP, bilirubin, pancreatitis.
LDH, potassium, and glucose. • Cholelithiasis may cause mechanical obstruction.
• CT scan and US to show infiltrates in the
retroperitoneal and pleural spaces.
• Pain in the abdomen with guarding. Pain is less- Make the Connection
ened by drawing the knees up and worsened by • Monitor pain level and medicate as needed.
extension. • Assess vital signs for ↑ pulse and ↓ blood
• Low blood pressure and ↑ pulse indicate shock. pressure.
Complications • Monitor amylase and lipase levels and F and E
levels.
• Shock, respiratory distress. • Assess for Turner’s or Cullen’s sign.
• Renal failure.
Cholecystitis
(ko-le-sis-ti-tis)

Right upper quadrant pain that
radiates to the right scapula.
Murphy’s sign is present.
↑ Amylase and bilirubin.
Pathophysiology • Ultrasound of the gallbladder.
• Presence of gallstones causes mechanical • Endoscopic retrograde cholangiopancreatography
obstruction of bile from the gallbladder. Stasis (ERCP) with contrast.
of bile attracts bacteria, which adds to the
inflammation. Complications
• Small gallstones enter the cystic duct and cause • Sepsis, gallbladder perforation, peritonitis.
severe colicky pain as the duct’s peristaltic waves • Adenocarcinoma of the gallbladder.
press on the stone. Medical Care and Surgical Treatment
• The gallbladder becomes fibrotic and does not • Low-fat diet, meperidine for pain, antispasmodics,
release bile effectively into the duodenum. antiemetics, oral gallstone dissolution medications.
• Pressure of gallstones on the gallbladder walls • Laparoscopic or classic cholecystectomy.
can cause necrosis. • Extracorporeal shock wave lithotripsy (ESWL).
• Severe right upper quadrant (RUQ) pain (biliary • Avoid high-fat meals preoperatively. Postoperatively,
colic) radiating to the right scapula, especially reintroduce fats into the diet gradually.
after a fatty meal, and lasting for 4–6 hours;
nausea and vomiting. • A T tube may be inserted temporarily after
cholecystectomy for drainage of bile if the cystic
• Murphy’s sign, in which the client is unable to duct was explored.
take a deep breath when the examiner places
pressure over the lower liver border.
• Low-grade temperature elevation, elevated WBC Make the Connection
count. • Assess pain patterns and medicate as needed;
• ↑ Serum amylase levels, ↑ bilirubin, jaundice. assess for Murphy’s sign.
• PIPIDA, DISIDA, or HIDA nuclear medicine scans. • Monitor laboratory values and vital signs.
Pancreatic Cancer
(pan-kre-at-ik kan-ser)

Weight loss, anorexia; ↑ amylase,
lipase, and bilirubin. ↑ vitamin D
intake may be preventative.
Pathophysiology • Postoperative infection, fistula formation,
• Mutation of cells in the pancreas occurs from peritonitis, paralytic ileus, malabsorption
genetic factors or chronic irritation. disorder.
• Tumors are most commonly found in the head of • Death: pancreatic cancer has a poor prognosis.
the pancreas and are large.
• Metastasis by direct extension to the stomach, • Total or partial pancreatectomy when the tumor
gallbladder, liver, and duodenum occurs rapidly.
is located in the head of the pancreas.
• Tumors in the body of the pancreas metastasize • Whipple’s procedure, which involves removal of
rapidly via blood and lymph.
the head of the pancreas, the duodenum, and
Assessment and Diagnostic Findings parts of the stomach. Chemotherapy and/or
• ↑ ALP, glucose, and bilirubin. radiation.
• If the cancer causes obstruction, ↑ amylase and
lipase levels are seen. Keep in Mind
• Needle biopsy guided by ultrasound revealing • Manage pain and stress of illness.
cancer cells. • Monitor glucose level; report bruising.
• ERCP. • Take digestive enzymes as ordered.
• CT scan and MRI.
Complications Make the Connection
• DVT and CVA are commonly associated with • Monitor pain level and medicate as needed.
pancreatic cancer. The tumor secretes substances
similar to trypsin or protease that convert pro- • Assess laboratory values, electrolytes, albumin,
vital signs, weight and nutritional status.
thrombin to thrombin and increase clotting
factors in the blood.
• Diabetes mellitus.
Bowel Obstruction
(bow-el ob-struk-shun)

High-pitched bowel sounds,
abdominal distention and pain.
Pathophysiology • Mental status changes or cardiovascular abnor-
• Mechanical obstruction occurs when a tumor or malities related to electrolyte imbalance.
hard stool lodges in the intestine or when the
bowel twists (volvulus) or telescopes within itself Medical Care and Surgical Treatment
(intussusception). Pressure builds on the walls of • NPO.
the intestine, decreasing perfusion, which can • Decompression with an NGT.
lead to necrosis of the bowel. • Bowel resection.
• Adhesions from prior abdominal surgeries • F and E replacement.
cause scar tissue causing mechanical • Antibiotics, antiemetics, and analgesics.
obstruction. Keep in Mind
• Paralytic obstruction results from a temporary
• The NGT is used until the obstruction is resolved
cessation in nerve conduction. (self-resolution or with surgery).
Assessment and Diagnostic Findings • Report nausea immediately, because the NGT
• Abdominal pain, thirst, and malaise. may be occluded.
• Abdominal distention and visible loops of bowel.
• Intractable vomiting, eventually of fecal material; Make the Connection
no stools.
• F and E imbalance (dehydration). • Monitor all clients with past abdominal
• CT scan. surgeries for signs of bowel obstruction.
• ↑ WBC and H&H. • Bowel sounds are more active and high pitched
at the area of obstruction.
Complications
• Necrosis and perforation of the bowel. • Assess vital signs, pain level, and laboratory
values for infection; assess F and E status.
• Peritonitis.
Ulcerative Colitis
(ul-ser-a-tiv ko-li-tis)

Daily passage of six or more bloody
mucus stools associated with
abdominal pain.
Pathophysiology • Bowel perforation, peritonitis, and CA.
• Inflammation and hemorrhage in small areas of • Bowel cancer.
the mucosal layer of the colon cause abscesses to
form (crypt abscesses). The necrotic areas slough Medical Care and Surgical Treatment
off, causing ulcer formation that extends to the • Antirheumatics, tumor necrosis factor (TNF)
submucosal layer of the bowel. inhibitors, anti-inflammatory medications;
corticosteroids and immunosuppressants; bulk
• Blood in the colon causes hypertonicity of the
laxatives (gel the stool, ↓ diarrhea).
bowel contents and acts as a laxative.
• Pseudopolyps (ragged edges of the mucosal layer). • Partial bowel resection or colectomy.
• Incidence is greatest in the second, third, and • NPO during the acute phase; IV or TPN.
sixth decades of life, a genetic link exists; proba- Keep in Mind
ble autoimmune disease.
• Lesions begin in the rectum and spread proximally. • Avoid spicy foods and high-residue foods.
• Expect remissions and exacerbations; avoid stress.
Assessment and Diagnostic Findings • Avoid persons with infections while on anti-
• Weight loss, diarrhea with blood and mucus, inflammatories, antirheumatics, TNF inhibitors,
cramping and abdominal pain. or corticosteroids; teach care of ostomy.
• F and E imbalance. • Support groups for ulcerative colitis are helpful.
• CBC, colonoscopy with bowel biopsy, presence of
fissures, fistulas.
• Arthritis, skin lesions, inflammatory eye disorders, Make the Connection
altered liver function studies. • Monitor number and characteristics of
• P-ANCA, ASCA, OmpC testing. stools; assess laboratory values for anemia and
electrolyte imbalances.
Complications
• Anemia. • Assess vital signs and pain level frequently.
Colon Cancer
(ko-lon kan-ser)

Stool is positive for blood.
A change in bowel habits
has occurred.
• Mutation of epithelial cells of the colon from the • Bowel resection with or without ostomy creation.
chronic irritation of inflammatory bowel disease, • Chemotherapy and/or radiation.
familial adenomatous polyposis (FAP; early onset • Analgesics, antiemetics.
of polyps in the colon that become malignant),
removal of the gallbladder, increased fat in the Keep in Mind
diet, and ingestion of carcinogens. • Provide preoperative teaching concerning naso-
gastric tube (NGT), deep breathing, incentive
Assessment and Diagnostic Findings spirometer, exercise, use of antiemetics and anal-
• Change in bowel habits (constipation or diarrhea). gesics, and early ambulation.
• Change in shape of stool due to obstructing • Awareness of the side effects of chemotherapy
lesion.
and/or radiation and their mitigation is important.
• Virtual colonoscopy by computed tomographic • Support groups for colon cancer are helpful;
(CT) scan, colonoscopy with biopsy, barium
teach ostomy care.
enema revealing polyps or tumors; stool for
occult blood is positive (polyps and tumors tend
to bleed). Make the Connection
Complications • Monitor laboratory tests for elevated liver
• Bleeding. enzymes to detect metastasis.
• Obstruction, necrosis, bowel perforation with • Assess vital signs and pain level.
peritonitis. • Teach ostomy care and assess ability of the client
• Metastasis to the lymph system and liver, result- for self-care.
ing in death. • Assess complete blood count (CBC) for immuno-
• After bowel resection, anastomotic leak, and suppression related to chemotherapy or radiation.
peritonitis.
Diverticulosis
(di-ver-tik-u-lo-sis)

History of constipation and
poor bowel habits.
Pathophysiology • Diverticulitis (acute phase): Nothing by mouth
• Small herniations of the sigmoid and descending (NPO); rest the gut; intravenous fluids.
colon that occur when pressure within the bowel
and abdomen is high.
• Diverticulitis (surgical intervention): Bowel resection.
• Diverticulitis (convalescent phase): Increase to a
• Related to poor bowel habits, constipation, and soft, low-fiber, low-residue diet and avoid all
straining at stool. foods with nondigestible seeds or shells; once
• When diverticula become inflamed by seeds or healed, slowly resume normal diet, adding fiber.
other residue entering them, diverticulitis results.
• Diverticulosis is asymptomatic. • When the signal comes for a bowel movement,
• Barium enema or computed tomographic (CT) do not ignore it because doing so causes water
scan shows multiple small pouches, usually on loss from the stool and promotes constipation.
the sigmoid colon. • Use bulk laxatives; eat raw vegetables and fruits,
• Diverticulitis presents with pain in the left lower fiber-containing grain; increase fluid intake and
quadrant (LLQ); bleeding may be present and exercise for healthy bowel habits.
necessitate transfusion with packed red blood • Do not strain at stool.
cells (PRBCs) or surgery (bowel resection).
• Stool for occult blood may be positive.
Make the Connection
Complications • Assess for rebound tenderness at the LLQ
• Infection, colon perforation with peritonitis. if diverticulitis is suspected.
Medical Care and Surgical Treatment • Monitor complete blood count (CBC); monitor
• Diverticulosis: High-fiber diet; adequate fluid and stool for occult blood.
exercise to encourage healthy bowel habits. • Teach proper dietary habits for the presenting
condition.
Appendicitis
(a-pen-di-si-tis)

Rebound tenderness at McBurney
point, ↑ WBC.
Pathophysiology Keep in Mind
• Inflammation of the appendix by obstruction, • A nasogastric tube (NGT) may be in place briefly
usually by fecalith. The small stones may enter, until bowel function returns to prevent nausea
causing more inflammation by exerting pressure and vomiting; diet is increased once bowel
and abrasiveness on the walls of the appendix. function returns to normal.
Assessment and Diagnostic Findings • Pain medication should be taken only after diag-
Temperature elevation, ↑ white blood count (WBC). nosis; no enemas should be used prior to coming
• to the emergency department.
• Guarding, limping on ambulation, rebound ten-
derness at McBurney point (midpoint between • Take nothing by mouth (NPO).
the umbilicus and the right iliac crest). • Lying in side-lying or semi-Fowler’s position will
decrease pain.
• Computed tomographic (CT) scan and ultra-
sound show enlargement of the appendix.
• Rectal examination reveals enlarged appendix. Make the Connection
• If appendix has ruptured, abdominal rigidity is
• Monitor complete blood count (CBC) for
evident; if appendix is abscessed, no bowel WBC elevation.
sounds are heard over the right lower quadrant
(RLQ), and pain increases. • Assess pain patterns, including rebound tender-
ness at McBurney point.
Complications • Watch for any increase in pain and decreased
• Rupture and peritonitis. bowel sounds in the RLQ.
• Abscess.
• Laparoscopic resection.
• Drainage of abscess.
• Antibiotics, analgesics.
Crohn’s Disease
(kronz di-zez)

Diarrhea, weight loss, cobblestone
appearance in the small bowel.
• Inflammatory bowel disease affecting mostly • Antirheumatics and TNF inhibitors,
women from adolescence to the third decade corticosteroids, immunosuppressants,
of life. anti-inflammatories.
• Cobblestone appearance of the bowel wall related • Ileostomy or bowel resection. Surgery is not a
to interspersed areas of inflammation and healthy cure; the enteritis will spread.
tissue; also called regional enteritis. • Dietary intervention with folate, calcium,
• Inflammation occurs mainly in the small intestine flaxseed, and fish oil.
above the cecum and spreads proximally.
• Affects the submucosa, causing strictures, Keep in Mind
scarring, fissures, and fistulas. • Avoid spicy foods and high-residue foods.
• Disease involves both genetic and autoimmune • Expect remissions and exacerbations; avoid stress.
factors. • Avoid persons with infections.
• Crohn’s disease affects the entire bowel wall. • Support groups for Crohn’s disease are helpful.
• Cramps and diarrhea that occur with food intake. Make the Connection
• Remissions and exacerbations. • Monitor I&O, calories, and characteristics
• F and E imbalance. and number of stools.
• CBC, bowel biopsy, presence of fissures, fistulas. • Assess laboratory values for anemia and inflam-
• P-ANCA, ASCA, OmpC testing. matory markers.
Complications
• Anemia and malnutrition.
• Fissures, fistulas, stricture/obstruction, bowel per-
foration with peritonitis.
Peritonitis
(per-i-ta-ni-tis)

Rebound tenderness and rigidity
over the abdominal wall.
Decreased bowel sounds.
Pathophysiology • Intravenous antibiotics, analgesics.
• Inflammation of the sterile peritoneal cavity by • Organ repair if caused by a perforation; place-
introduction of bacteria via invasive procedures, ment of a nasogastric tube (NGT) if bowel is
open bowel surgeries, or perforation of intra- perforated.
abdominal organs whose normal flora contain
bacteria. Keep in Mind
Assessment and Diagnostic Findings • Teach pre- and postoperative care and expecta-
• Generalized abdominal pain and rigidity. tions (early ambulation, deep breathing, leg
• If perforation is the cause, pain localizes to the exercises).
area of the perforation and leak. • Explain the illness and the use of antibiotic
• ↑ White blood count (WBC), temperature therapy.
increase, tachycardia.
• Absence of bowel sounds (peristalsis) over the Make the Connection
affected area.
Complications
• Assess for return of bowel sounds.
• Monitor CBC for normalization of WBC levels.
• Septicemia. • Assess function of all organ systems.
• Hypovolemia with fluid shifts into the • Support cardiorespiratory functions as needed.
peritoneum.
• Shock and death.
• Nothing by mouth (NPO).
• Exploratory surgery; abscess drainage and infiltra-
tion with antibiotic solution.
Hemorrhoids
(hem-o-roydz)

History of constipation. Frank
blood on the stool. Painful
anal lesions.
• Varicosities of the veins of the anus related to • Prevent straining at stool and constipation.
increased intra-abdominal pressure. • Nutritional consultation.
• Occur during pregnancy as the weight of the • Anti-inflammatory topical medication, analgesics.
fetus compresses the inferior vena cava, causing • Sitz baths, side-lying positions, ice packs.
congestion of the veins in the anus (as well as • Sclerotherapy.
the legs). • Rubber-band ligation.
• Poor bowel habits and constipation contribute to • Laser, cryotherapy, or surgical removal.
the etiology.
• Internal hemorrhoids occur above the internal Keep in Mind
sphincter; external hemorrhoids occur below the • Avoid constipation by eating adequate fiber-rich
external sphincter. foods; increase fluids and exercise.
Assessment and Diagnostic Findings • Encourage good hygiene.
• Frank red blood on stools.
• External hemorrhoids are visible. When inflamed, Make the Connection
they are large and red and usually encircle the • Monitor affected site for improvement.
anus. Careful examination should be done of • Sitz baths can lower blood pressure and cause
these lesions to determine whether they are blue, syncope, so monitor the client carefully.
light-colored, or black, which could indicate • Assess stools for bright red blood.
ischemia or necrosis of the overlying skin. • Assess hemorrhoids for color.
Complications • Postoperatively, monitor for bleeding, infection,
• Pain, bleeding, and infarction of the skin above and pain.
the lesions.
ENDOCRINE
Hyperpituitarism, 24 Addison’s Disease, 29

Hypopituitarism, 25 Hyperthyroidism, 30
Diabetes Insipidus, 26 Hypothyroidism, 31
Syndrome of Inappropriate Diabetes Mellitus Type 1, 32
Antidiuretic Hormone, 27 Diabetes Mellitus Type 2, 33
Cushing’s Syndrome, 28
Endocrine Disorders 24
Hyperpituitarism
(hi-per-pi-tu-i-tar-ism)

Excess growth hormone, abnormal
lipid level, high blood glucose
levels. Adults experience arthritis,
visual changes, and enlarged
hands and feet.
Pathophysiology • Enlarged feet and hands, deep voice, arthritis,
• Hyperfunction of the pituitary is almost insulin resistance, headache, sleep apnea.
always caused by an adenoma.
• CT scan and MRI to detect pituitary tumor.
• GH, from the anterior pituitary, is secreted in Complications
large amounts, resulting in gigantism in children
and acromegaly in the adult. • MI, CHF, DM.
• Acromegaly is characterized by growth of bone, • Sleep apnea, dysphagia.
connective, and soft tissue. • Arthritis, osteoporosis, and chronic bone pain.
• Hands and feet become enlarged; larynx • Cancer from GH.
enlarges; vertebral growth often results in Medical Care and Surgical Treatment
kyphosis; teeth become displaced; enlargement • Dopamine agonists, GH inhibitors (somatostatin).
and erosion of the sella turcica causes visual • Radiation therapy or hypophysectomy.
changes and headache.
Keep in Mind
• Metabolic alteration causes fats to become
• Monitor the glucose level, report excessive
the initial energy burned, resulting in ketosis.
GH–induced insulin resistance, along with snoring, and report difficulty swallowing.
glycogen release by the liver, causes DM.
• Other anterior pituitary hormones are inhibited. Make the Connection
• Fatty acid metabolism is altered causing
• Remember: Following transsphenoidal
atherosclerosis. hypophysectomy, assess all drainage for glucose,
• Excess soft tissue of the soft palate cause sleep indicating CSF leak.
apnea.
• ↑ GH, ↑ LDL. Uploaded by MEDBOOKSVN.ORG
Hypopituitarism
(hi-po-pi-tu-i-ta-rizm)

Short stature in children accompanied
by weakness, low blood glucose, and
delayed sexuality and stunted growth
of sexual organs.
• Growth hormone (somatropin) is deficient • Somatropin.
related to an ablative pituitary tumor or failure • Hypophysectomy.
of the gland to develop. • Hypoglycemia treated with dietary intervention.
• Dwarfism, in the child, and mental slowness.
Keep in Mind
• In adults, decreased GH leads to central accumu-
lation of body fat and related problems with • Report any bone pain or limping after starting
cardiovascular health. somatropin therapy.
Assessment and Diagnostic Findings • Growth is possible as long as the epiphyseal disks
are not closed.
• Growth of a child well below the 25th • Adults should be under the care of a health pro-
percentile.
fessional if GH or secretagogues are used.
• Developmental delay.
• Weakness, hypoglycemia, “apple fat,” and skin
changes in adults. Make the Connection
• GH levels, GH stimulation test in response to • Monitor glucose levels, growth patterns,
induced hypoglycemia. sexual organ development, and thyroid function
• MRI and CT scan to detect presence of pituitary tests.
tumor. • Measure long-bone growth bilaterally; note any
Complications change in gait, which may be a sign of a slipped
• Cardiovascular disease in adults and untreated epiphyseal disk, in which growth is occurring only
in one area of the disk.
children.
• Short stature, mental retardation.
• Headache and visual changes in cases of pituitary
tumor. Uploaded by MEDBOOKSVN.ORG
Diabetes Insipidus
(di-a-be-tez in-si-pi-dus)

Low specific gravity of urine <1.005.
Urinary output in excess of
5–15 liters daily.
• ADH or AVP is secreted by the posterior pitu- • Hypovolemic shock.
itary gland and is responsible for reabsorption • Electrolyte imbalances.
of water by the kidney. • Enlarged bladder.
• DI is caused by a deficiency of ADH and excess Medical Care and Surgical Treatment
loss of water through urination. Urinary output
can be in excess of 5–15 L daily.
• Hypophysectomy in presence of pituitary tumor.
• Replacement of ADH.
• DI can be caused by drugs like lithium; surgical
• Hypotonic fluid replacement (0.45% sodium
removal of the pituitary; and nephrogenic DI. chloride solution).
• Psychogenic DI (not true DI) is caused by a desire
• Sulfonylureas that increase sensitivity to ADH
to drink large amounts of fluids (water intoxica- and thiazide diuretics (slow urine output in the
tion); alcohol ingestion causes a temporary DI absence of ADH).
resulting in dehydration.
• Polyuria, nocturia, excessive thirst, poor skin turgor. • Monitor daily weight (report an increase of
• Hypovolemia, dehydration, and electrolyte greater than 2 lb in 1 day), and keep a diary of
imbalance. intake and output (I&O) after start of therapy.
• Specific gravity of urine of <1.005; ↓ urine • Take extra fluids if thirst occurs.
osmolality. • Comply with medication regimen.
• ↓ ADH levels following administration of hyper-
tonic saline solution or fluid restriction (should ↑).
Make the Connection
• Water deprivation test.
• Monitor vital signs, I&O, urine specific
• CT scan and MRI to detect presence of a
gravity, and serum electrolytes.
pituitary tumor.
Syndrome of Inappropriate
Antidiuretic Hormone
(sin-drom uv in-a-pro-pree-et
an-ti-di-u-ret-ik hor-mon)

High blood pressure, low serum
osmolality, bounding pulse,
seizures.
Pathophysiology • Seizures, coma, cerebral and pulmonary edema,
• SIADH occurs when ADH does not decrease in and death.
response to a low serum osmolality, leading to
fluid overload. Medical Care and Surgical Treatment
• Frequently, SIADH is associated with cancers of • Oral salt, hypertonic solutions, loop diuretics,
the lung, pancreas, and Hodgkin’s disease. and fluid restriction (1,000 mL/24 hr).
• ADH may hypersecrete in the presence of head • Demeclocycline.
trauma or tumor or as a complication of diabetes • Treatment of underlying cancer.
insipidus treatment. Keep in Mind
Assessment and Diagnostic Findings • Monitor fluid restriction adherence, monitor daily
• Weight gain, bounding pulse, increased blood weight (report gain of >2 lb/24 hr), encourage
pressure, crackles. fluids high in sodium (ice chips may satisfy thirst
• Dilutional hyponatremia with signs and symp- without adding to fluid intake), maintain diary
toms of headache, personality changes, nausea, of I&O.
diarrhea, seizure, and coma (cerebral edema).
• Serum osmolality <275 mOsm/kg; serum ADH ↑.
• Lethargy, muscle cramps and weakness. Make the Connection
• History of cancer, especially oat cell cancer of the • Monitor for change in mental status
lung. (Glasgow Coma Scale may be used in severe
• Water load test. cases).
Complications • Monitor serum osmolality, urine output, daily
weight, and urine specific gravity.
• Mental status changes, weakness, lethargy, muscle • Monitor serum electrolytes (135–145 mEq/L).
cramps related to dilution of electrolytes.
• Auscultate lungs for crackles or diminished
breath sounds in the bases.
Cushing’s Syndrome
(koosh-ingz sin-drom)

Moon face, buffalo hump,
truncal obesity, ↑ serum glucose,
↓ potassium (K+), ↑ serum sodium.
• Hormones secreted by the adrenal cortex are • Hypophysectomy or adrenalectomy if indicated.
the body’s stress hormones (glucocorticoids and • Treatment for secondary diabetes and insulin
mineral corticoids). resistance.
• Cushing’s disease is caused by excess cortisol • Exogenous cortisol dosage change or given every
secretion related to excess ACTH secretion, while other day.
Cushing’s “syndrome” is related to consumption
of exogenous cortisol. Keep in Mind
• May be caused by secreting tumor of the lungs or • Teach client to monitor blood glucose; modify
adrenal glands. dietary intake to low calorie, high protein,
high K+, and low Na+.
• Weight gain, moon face, buffalo hump, truncal • Report any signs of infection (e.g., sore throat).
obesity, osteoporosis, glucose intolerance and
secondary diabetes, slow wound healing, striae, Make the Connection
bruising, bone marrow suppression and hyper- • Monitor cardiac rhythm strip, serum
pigmentation of the skin. potassium, and serum sodium.
• ↑ Serum sodium and ↓ serum potassium. • Monitor daily weights and I&O; administer potas-
• Plasma and urine cortisol and plasma ACTH are sium supplements, if ordered.
elevated. • Encourage weight-bearing exercise.
Complications • Monitor CBC and for any signs of infection.
• Masked infection, WBC activity, ↓ platelets. • Monitor wound healing.
• Cardiac arrhythmias; atherosclerosis.
• Pathologic bone fracture.
• Diabetes mellitus. Uploaded by MEDBOOKSVN.ORG
Addison’s Disease
(ad-i-sonz di-zez)

Tanned appearance to skin, low
blood pressure, ↓ serum glucose,
↓ serum sodium (Na+), ↑ serum
potassium (K+).
• The adrenal cortex secretes hormones necessary • Replacement of corticosteroids and aldosterone
to react to stress (physical or psychological). given daily in divided doses in times of stress.
They include glucocorticoids, aldosterone, and
sex hormones (sugar, salt, and sex). Keep in Mind
• In primary hypofunction of the adrenal gland, • Teach compliance with medication regimen;
+
rest
the adrenal hormones are not secreted in ade- as needed; and high-calorie, moderate-Na , and
quate amounts; in secondary hypofunction of ↓K+ diet.
the adrenal glands, insufficient pituitary secretion • Client must learn to assess his or her BP.
of ACTH occurs. • Wear a MedicAlert bracelet.
• Primary Addison’s disease may be autoimmune.
• Adrenalectomy may cause Addison’s.
Make the Connection
Assessment and Diagnostic Findings •+ Monitor BP, blood glucose, serum Na+,
• Hyperpigmentation of the skin, ↓ BP, ↓ serum and K levels; weight, Addisonian crisis.
Na+, ↑ K+, ↓ serum glucose levels. • Monitor cardiac rhythm strip data.
• Anorexia, weight loss, confusion, psychosis.
• Low urine sodium and cortisol levels; ↑ pituitary
output of serum ACTH (primary); ↑ blood urea
nitrogen (BUN) related to dehydration.
Complications
• Inability to respond to stress; Addisonian crisis.
• Arrhythmias.
• Coma and death from hypoglycemia.
Hyperthyroidism
(hi-per-thi-royd-izm)

Restlessness, irritability,
heat intolerance, ↓ TSH,
↑ T3 and T4.
Pathophysiology pressure, restlessness, decreased mental acuity,
• The thyroid gland hormones are responsible for and delirium.
carbohydrate, protein, and fat metabolism • Goiter (enlargement of the thyroid gland).
required by the body cells and for calcium regula- • Hypothyroidism after treatment.
tion (in tandem with the parathyroid glands). • Visual changes related to exophthalmos.
• Primary hyperthyroidism (Graves’ disease) is Medical Care and Surgical Treatment
caused by excess thyroid hormone secretion • Subtotal thyroidectomy.
(T3 and T4). • Radioactive iodine treatment.
• Secondary hyperthyroidism is caused by hyper- • Thyroid-suppressing medications.
secretion of thyroid-stimulating hormone (TSH)
by the pituitary gland. Keep in Mind
• A thyroid tumor may also cause hypersecretion of • Report temperature increase, increased blood
thyroid hormones or TSH. pressure, or change in mental status; manage
• Exposure to radiation is another causative factor. stress, maintain nutritional status, and take rest
Assessment and Diagnostic Findings breaks.
• Weight loss despite increased appetite, heat intol-
erance, irritability, nervousness, tremor, tachycar- Make the Connection
dia, palpitations, inability to sit still or rest.
• ↓ Serum TSH, ↑ serum T3 and T4. • Monitor vital signs, serum TSH, and
cardiac rhythm strip data.
• Thickening of the skin on the anterior legs.
• Assess for nodules palpated on the thyroid.
• Exophthalmos.
• In the case of radioactive iodine treatment,
Complications remind the client he or she will have to be in
• Thyrotoxic crisis (thyroid storm) characterized by isolation.
very high temperature, tachycardia, high blood
Hypothyroidism
(hi-po-thi-royd-izm)

Lethargy, mental slowness, heavy
menstrual periods in women,
↑ TSH, ↓ T3 and T4.
Pathophysiology temperature, decreased respiration, decreased
• The thyroid gland is responsible for metabolism cardiac output, renal failure, nonpitting edema
of carbohydrates, fats, and protein according to of extremities, death from respiratory failure.
body requirements. Medical Care and Surgical Treatment
• Primary hypothyroidism (myxedema) occurs when • Synthetic thyroid hormone replacement therapy.
the thyroid gland does not secrete adequate
thyroid hormone. Keep in Mind
• Secondary hypothyroidism is related to hypose- • Teach that full effects of the hormone
cretion of thyroid-stimulating hormone (TSH) replacement may take from days to a week.
by the pituitary gland or overtreatment of • Report palpitations or shortness of breath after
hyperthyroidism. hormone replacement therapy.
• Low levels of thyroid hormone decrease metabo-
lism in the body.
• Hashimoto’s thyroiditis is an autoimmune Make the Connection
disorder that destroys thyroid tissue. • Monitor TSH level.
Assessment and Diagnostic Findings • Assess cardiac rhythm strip data when beginning
synthetic hormone replacement.
• Fatigue; weight gain; lethargy; mental slowness; • Teach client to report signs and symptoms of
bradycardia and heart failure; dry skin; coarse, hyperthyroidism or myxedema.
dry hair; feeling cold all the time; menorrhagia in
women; shortness of breath; decreased sweating.
• ↑ TSH and ↓ T3 and T4 in primary disease.
Complications
• Myxedema coma triggered by physical or psy-
chological stress and resulting Uploaded
in subnormal by MEDBOOKSVN.ORG
Diabetes Mellitus Type 1

(di-a-be-tez mel-i-tus type 1)

Polyuria, polydipsia, polyphagia,
↑ serum glucose levels that
persist.
Pathophysiology • Synthetic or animal-derived insulin given
• The pancreas secretes insulin from the beta cells subcutaneously.
(islets of Langerhans) in response to elevated
blood glucose levels.
• Treatment of DKA with intravenous hypotonic
saline solution with regular insulin added. Once
• In primary diabetes mellitus type 1, the beta cells the glucose begins to normalize, potassium
are destroyed by an autoimmune reaction. replacement is necessary.
• In secondary diabetes mellitus type 1, the beta
• Pancreas transplant; transplantation of beta cells
cells are damaged by cancer of the pancreas or into the liver via the portal vein.
other diseases like pancreatitis and cystic fibrosis.
• Elevated fasting blood glucose levels, elevated • Monitor glucose level before meals and at bed-
postprandial glucose levels. time. Report hypoglycemia in the middle of the
• Weight loss, polyuria, polydipsia, polyphagia. night (Somogyi effect) or increase in the morning
• Elevated glycohemoglobin levels, acetone breath (dawn phenomenon).
(smells like alcohol/fermented fruit). • Encourage client to carry a simple sugar or glu-
Complications cose at all times, wear a MedicAlert bracelet,
• Neuropathy, nephropathy, retinopathy. examine his or her feet for lesions, and report
• Diabetic ketoacidosis (DKA). visual problems or pain in arms/legs.
• Hypoglycemia (the most common complication
after treatment with insulin is begun).
Make the Connection
• Infertility related to sexual dysfunction. • Teach the client to rotate sites for insulin
Medical Care and Surgical Treatment administration and to follow dietary regimen.
• Carbohydrate counting; dietary regimen should • Monitor glycosylated hemoglobin and serum
be similar day to day with increase in calories if glucose levels; monitor for complications.
physical activity is increased. Uploaded by MEDBOOKSVN.ORG
Diabetes Mellitus Type 2

(di-a-be-tez mel-i-tus type 2)

Sedentary lifestyle. Polyuria,
polyphagia, and polydipsia.
Elevated serum glucose levels.
Pathophysiology increases in the blood glucose level without
• Type 2 diabetes increases in incidence with ketosis.
obesity, poor diet, and sedentary lifestyle as • Death.
the cells of the body become resistant to Medical Care and Surgical Treatment
insulin. • Oral hypoglycemic agents and drugs to lower
• Genetic link (10 new gene variants that affect insulin resistance; insulin may be required if these
blood glucose and insulin levels have been medications are ineffective or if the client is ill
identified); type 2 diabetes is affecting more (increases glucose levels).
children related to poor diet and obesity. • Nutritional consult and exercise regimen.
Assessment and Diagnostic Findings • Assessment of cardiac status with stress testing,
• Elevated fasting blood glucose levels, elevated lipid profile, cardiac rhythm strip.
postprandial glucose levels. • Renal tests.
• Weight loss, polyuria, polydipsia, polyphagia. Keep in Mind
• Elevated glycohemoglobin levels.
Complications • Monitor blood glucose level ac and hs. Learn the
symptoms of low blood glucose and report if it
• Neuropathy, nephropathy, retinopathy. occurs.
• Metabolic syndrome (syndrome X), character- • Follow dietary, exercise, and medication regimen.
ized by elevated waist circumference (apple
fat), reduced high-density lipoprotein levels, • Check feet for sores.
elevated blood pressure, fasting glucose levels • Report sensation or vision changes.
of >100 mg/dL. This syndrome is related to
atherosclerosis and cardiac events. Make the Connection
• Hyperosmolar nonketotic syndrome, in • Monitor HgbA1c and serum glucose levels;
which stress from illness causes extreme
Uploaded monitor for complications.
by MEDBOOKSVN.ORG
UROLOGIC
Urinary Tract Infection, 34 Acute Renal Failure, 43

Urethritis, 35 Chronic Renal Failure, 44
Pyelonephritis, 36 Overactive Bladder, 45
Glomerulonephritis, 37 Renal Artery Stenosis, 46
Nephrotic Syndrome, 38 Epididymitis, 47
Polycystic Kidney Disease, 39 Benign Prostatic Hyperplasia, 48
Hydronephrosis, 40 Bladder Cancer, 49
Renal Calculus, 41 Prostate Cancer, 50
Rhabdomyolysis, 42
Urologic Disorders 34
Urinary Tract Infection

(u-ri-nar-e trakt in-fek-shun)

Urinary frequency, urgency, dysuria,
bacterial count of >100,000/mL
of urine.
Pathophysiology • Residual urine of >50 mL immediately after
• Occurs more frequently in women because of voiding (bladder scans).
anatomy and age-related structural changes.
• Voiding cystourethrogram or KUB x-ray showing
• UTIs can also occur as a result of obstructive dis- obstruction.
ease, invasive therapies, and incontinence issues.
Complications
• Most UTIs (95%) are caused by contamination • Ascending infection.
and ascension in the urethra by normal flora
from the rectum. • Urosepsis.
• Causative agents are Escherichia coli; Staphylococcus Medical Care and Surgical Treatment
saprophyticus; and to a lesser extent Klebsiella • Antibiotics and urinary analgesics.
species, Proteus mirabilis, Staphylococcus aureus, and • Transurethral resection of the prostate or lithec-
Pseudomonas aeruginosa. tomy for obstructions.
• The normal mucin-surface glycosaminoglycans • Complementary ingestion of cranberry capsules,
are overwhelmed and bacteria become adherent which are shown to prevent adherence of
to bladder surfaces. bacteria.
• Soap in bathwater causes UTIs in children.
Keep in Mind
• Chills, temperature elevation, dysuria, frequency, • Increase fluid intake when on treatment, and com-
plete all antibiotics as ordered.
urgency, frank blood in urine, urethral spasm,
and pyuria or strong ammonia smell of urine.
• Urine culture showing bacterial count of Make the Connection
>100,000/mL indicates infection. The presence • Recurrent infections or those caused by
of RBCs, WBCs, hyaline casts, and positive leuko- unusual organisms must be investigated.
cyte esterase and nitrite in urinalysis.
Urethritis
(u-re-thri-tis)

Dysuria, blood in the urine or ejaculate
in a male. Discharge from the urethra.
History of unprotected sex. In women,
pelvic pain.
• More common in men but can occur in women; • Infertility.
also characterized by inflammation and coloniza- • Diffuse infection that spreads to joints, heart
tion of the urethra by Escherichia coli, Neisseria valves, and meninges.
gonorrhoeae, Chlamydia trachomatis, herpes simplex, • Spread to other sexual partners.
or cytomegalovirus. Medical Care and Surgical Treatment
• Infectious agents may ascend and affect the
• Ceftriaxone, azithromycin, or penicillin.
prostate and infiltrate the lymph nodes in the
groin area. In women, these agents can ascend
• Sexual counseling and reporting to public health
department as indicated.
to infect the pelvic area and may be a cause of
infertility.
• Urinary analgesics.
• Culture and sensitivity and treatment with anti- • Men may not become symptomatic for 1 month
infective to which the organism is sensitive. after contact with infectious agents.
• In males, symptoms are dysuria, blood or pus in
urine and semen, swollen lymph nodes in the
groin area, swollen testicles, purulent discharge
Make the Connection
from the penis, sore throat, and fever. • It is important to diagnose this condition
early to prevent systemic infection and infertility.
• In women, symptoms include dysuria, dyspareunia,
vaginal discharge, pelvic pain, sore throat, and
fever.
• Cervical cultures, rectal culture, penile cultures,
joint fluid culture, Gram stain, and throat
culture.
Pyelonephritis
(pi-e-lo-ne-fri-tis)

Chills, fever, tenderness over the
costovertebral angle, dysuria,
elevated WBCs.
• Usually an ascending urinary tract infection (UTI) • Recognize signs and symptoms of UTI so that
caused by a failure of the “washout” mechanism spread to the kidneys may be avoided.
of urine and protective mucin gel. Causative • Use complementary agents, like cranberry juice or
agents are usually Escherichia coli and, to a lesser capsules, to prevent adherence of bacteria to
extent, Staphylococcus aureus. bladder area (trigone is most easily breached).
• Kidney pelvis structures may be damaged by • Take entire antibiotic prescription as directed.
ongoing infection, leading to nephron damage • Ensure that urine culture is collected properly
and renal failure. (midstream).
• Pyuria. Make the Connection
• Urinalysis and culture findings showing white • Monitor for dysuria.
blood cells singly, in clumps, or in casts.
• Bacteria count of >100,000/mL of urine. • Assess costovertebral angle for tenderness.
• Low specific gravity and osmolarity. • Assess urinalysis and urine culture.
• Slightly alkaline urine pH. • Identify risk factors for UTI.
• Proteinuria, glycosuria, and ketonuria. • Remember: The kidneys are inextricably linked to
the bloodstream, so infections in the kidney may
Complications quickly become overwhelming infections of the
• Chronic renal failure. blood, and the reverse is also true.
• Antibiotics (e.g., sulfonamides, fluoroquinolones,
nitrofurantoin, penicillins) and urinary analgesics.
If drugs are given intravenously (IV), hospitaliza-
tion is required.
Glomerulonephritis
(glo-mer-u-lo-ne-fri-tis)

Hypertension; oliguria; smoky, frothy
urine. Urinalysis shows RBCs, casts,
and protein.
Pathophysiology • High BUN, creatinine, and creatinine/BUN ratio
• The glomerulus is formed from tufts of arteriolar (>20:1); elevated antistreptolysin O titer.
capillaries fed by an afferent arteriole and drained
by an efferent arteriole that have thin basement
• US of the kidney, renal biopsy, or CT scan.
membrane composed of a proteinous matrix Complications
and a layer of epithelial cells with footlike out- • Renal failure.
pouches. Blood plasma is forced through these Medical Care and Surgical Treatment
thin structures by a pressure gradient into • Steroidal and nonsteroidal anti-inflammatory
Bowman’s capsule and the renal tubule. agents; antibiotics, if indicated.
• A number of toxins, diseases, and organisms • Sodium and fluid restriction, antihypertensive
can cause inflammation and damage to this agents, and diuretics.
basement membrane. • Dialysis may be necessary; bedrest.
• In poststreptococcal infection, antigens are
Keep in Mind
deposited in the basement membrane of the
glomerulus. When antigen/antibody complexes • All suspected streptococcal infections require cul-
form, the immune system destroys them, setting ture specimen analysis, completion of treatment,
up large areas of inflammation and damage to and verification of negative culture.
surrounding structures.
Assessment and Diagnostic Findings Make the Connection
• Hypertension; smoky, frothy urine from RBCs and • Monitor laboratory values, pulse oximetry,
protein; oliguria; edema; periorbital edema tender- BP urinalysis results; serum chemistry for worsen-
ness over the costovertebral angle; and flank pain. ing azotemia.
• Adventitious lung sounds or absent lung sounds • Monitor level of consciousness and daily weights;
and generalized edema. maintain strict I&O measurements.
Nephrotic Syndrome
(ne-frot-ik sin-drom)

Elevated LDL cholesterol and
triglycerides, proteinuria, frothy urine
from protein and lipids, decreased
immunoglobulins lost in urine.
Massive edema.
Pathophysiology • Generalized edema, CHF, pleural effusion, and
• Nephrotic syndrome is an umbrella term encom- HTN.
passing disorders that result from glomerular
damage. Damage to the basement membrane
• Atherosclerosis.
results in loss of blood components that would
• Renal failure.
otherwise remain in circulation.
• Infections from loss of immunoglobulins.
• Large amounts of protein and immunoglobulins
• Antihypertensive agents, lipid-lowering drugs,
are lost in the urine. Hyperlipidemia and hyper-
triglyceridemia occur as the liver responds to the diuretics.
low protein levels. Triglycerides and LDL are also • Anticoagulant therapy, corticosteroids.
lost in the urine, to some extent adding to the • Sodium and water restrictions; protein is titrated
frothy appearance. based on serum nitrogenous wastes and estimate of
protein loss in the urine (low to moderate amount).
• Protein loss causes loss of intravascular fluid
• Dialysis.
into the interstitial spaces, but low glomerular
filtration rate still results in hypertension. Keep in Mind
Assessment and Diagnostic Findings • Report sudden weight gain or change in mental
• Hypertension, hyperlipidemia, hypertriglyc- or urinary status.
eridemia, loss of antibodies (immunoglobulins).
• Foamy urine. Make the Connection
• Azotemia (increased nitrogenous wastes).
• Hypercoagulability. • Monitor I&O, daily weights, abdominal
circumference, and vital signs.
Complications
• Thrombosis and embolism. • Monitor laboratory values for worsening
azotemia and complications of thrombosis.
Polycystic Kidney
Disease
(pol-e-sis-tik kid-ne di-zez)

Hypertension, headaches, and
hematuria. Ultrasound shows
fluid-filled cysts.
Pathophysiology • Aneurysm in the brain.
• Hereditary disorder causing cystic formation in • Diverticulosis in the colon.
the cortex or medulla of the kidney.
• Cyst formation in other organs.
• Cysts may develop from pressure buildup in the Medical Care and Surgical Treatment
tubules and can progress to the entire kidney.
• Glomerular filtration rate (GFR) decreases. • Antibiotic therapy and antihypertensives.
• Stasis of fluid in the cysts predisposes to repeated • Dialysis or renal transplant.
urinary tract infection (UTI). Keep in Mind
• Persons with this hereditary disease are at high • Report signs and symptoms of UTI (frequency,
risk for aneurysms in the brain and diverticulosis urgency, pyuria, and hematuria).
related to body system formation during the
embryonic period. • Report change in mental status and prolonged,
severe headache.
• Elevated blood pressure, UTIs and hematuria. Make the Connection
• Ultrasound revealing cysts in the kidney.
• Subjective findings of discomfort in the flank and • Remember: Decrease in GFR will result in
lower back. hypertension.
Complications • Because this disease is associated with brain
aneurysm, it is important to keep hypertension
• Urosepsis. under control.
• Hypertension.
• Renal failure.
Hydronephrosis
(hi-dro-nef-ro-sis)

Obstruction of urine outflow from
the kidney related to lithiasis, tumor,
outflow obstruction from the bladder.
Pathophysiology removal of tumor, lithectomy, dilation of stric-
• Unilateral or bilateral swelling of the renal cap- tures, careful monitoring of urinary output during
sule from regurgitant urine related to outflow CBI or when an indwelling Foley catheter is in
obstruction. Because the renal capsule is fibrous, place).
internal functional structures (nephrons) are • Nephrostomy tubes and/or stent placement.
destroyed. • Nephrectomy, if necessary.
• Causes may include renal system lithiasis; tumors • Antibiotics for repeated UTI.
of the kidneys, ureters, or bladder; enlargement
of the prostate; or stricture of the urethra. Keep in Mind
• May occur with continuous bladder irrigation • Report repeated UTI symptoms to the health-care
(CBI) if a clot obstructs outflow of irrigant and professional.
urine or with an obstructed Foley catheter. • Report flank pain, especially if post-TURP.
• Flank and back pain. Make the Connection
• If insidious onset, urinary tract infections (UTIs) • Remember: Monitor intake and output
begin to occur because of urine stasis. carefully during CBI.
Complications • As they grow, renal system cancers can physically
• Renal failure. obstruct kidney outflow at any point from the
• Urosepsis. hilus of the kidney to the urethra.
• Removal or mitigation of the obstruction
(transurethral resection of the prostate [TURP],
Renal Calculus
(re-nal kal-ku-lus)

KUB or US shows one or more masses
in the kidneys, ureters, or bladder.
Renal colic in the flank that radiates
downward, nausea, vomiting, and
costovertebral tenderness.
Pathophysiology • Hydronephrosis and hydroureter.
• Men are affected more than women, and stone • Renal failure with repeated stone formation.
formation is usually unilateral. Once stones have
formed, repeated formation is likely. Medical Care and Surgical Treatment
• Irritation of the epithelial cells that line the tubules. • Nephrolithotomy, pyelolithotomy, lithotripsy,
chemolysis, and nephrostomy tubes.
• Dehydration causes more solute to be present
• Pain medication.
in the urine.
• Persons prone to stone formation may lack • Dietary changes: increase fluid intake. Acid-ash
inhibitor proteins and stones may recur. diet for calcium, struvite, and calcium oxalate
stones. Calcium added to the diet binds with
• Small stones (<5 mm) usually are passed in the
oxalates and is eliminated in the stool. Struvite
urine.
stones are formed in the presence of infections
Assessment and Diagnostic Findings and an alkaline environment. Alkaline-ash diet for
• Repeated urinary tract infection (UTI), hematuria uric acid stones.
from stasis of urine.
• Calculi, hydronephrosis, and hydroureter can be Keep in Mind
diagnosed by KUB x-ray, retrograde pyelography, • Stone formation seems to be hereditary. Alter diet
or ultrasound (US). as necessary and force fluids.
• Renal colic, genital pain, nausea, vomiting, and
diarrhea.
• 24-hour urine for creatinine clearance. Make the Connection
• Urinalysis and urine pH. • Monitor for characteristic pain,
hematuria, and repeated UTI.
Complications
• Hemorrhage and hypovolemic shock.
• Urosepsis.
Rhabdomyolysis
(rab-do-mi-ol-i-sis)

Azotemia, edema, hypertension,
hematuria, arrhythmias. Common
causative drugs are cholesterol-
lowering agents.
Pathophysiology with hydration, loop and osmotic diuretics are
• Results from crush injuries (compartment syn- prescribed to promote diuresis.
drome), the toxic effect of drugs or chemicals on • Dialysis may be needed if renal failure develops.
skeletal muscle, extremes of exertion, sepsis, • Urinary alkalinization with sodium bicarbonate
shock, electric shock, and severe hyponatremia. increases myoglobin solubility in the urine and
• Lipid-lowering drugs (e.g., statins, niacin, and/or assists its elimination from the body. The patient
fibrates) are among the commonly prescribed with rhabdomyolysis should also be monitored
drugs that cause damage to skeletal muscle fibers closely for electrolyte disturbances (hypocal-
that are released into the bloodstream and accu- cemia, hyperkalemia) and dysrhythmias, with
mulate in renal tubules. corrections being made as quickly as possible.
Assessment and Diagnostic Findings • Bedrest throughout the acute illness phase.
• Elevated levels of serum or urine myoglobin or Keep in Mind
creatine kinase (CK).
• Hematuria, elevated potassium levels, low • Report any muscle tenderness immediately if tak-
ing a cholesterol-lowering drug.
calcium levels, and metabolic acidosis.
• Arrhythmias related to altered electrolyte levels.
• Azotemia and decreased glomerular filtration rate Make the Connection
(GFR). • Monitor closely for electrolyte disturbances
Complications (hypocalcemia, hyperkalemia) and dysrhythmias.
• Renal failure and death. • Remember: Crush injuries may cause renal
failure.
• Hydrate to achieve urine output of between 200
and 300 mL/hr. If urine output does not increase
Acute Renal Failure

(a-kut re-nal fal-yer)

Azotemia, anuria, or oliguria.
Precipitated by severe hypotension,
use of diagnostic contrast dyes, or
structural damage to nephrons.
Elevated K+ and decreased Na+ in
serum. Elevated creatinine and BUN.
• Acute damage to nephrons associated with severe • Azotemic encephalopathy; acute renal failure
hypotension, use of contrast dyes, or damage to becomes chronic renal failure.
skeletal muscle fibers that accumulate in the • Hypertension, CHF, anemia, osteomalacia or
nephron tubules. osteoporosis with spontaneous fracture, and pul-
• Three stages: The oliguric stage (less than 400 mL/ monary edema.
24 hr), lasting 2 weeks (better prognosis) to several Medical Care and Surgical Treatment
months (poor prognosis).
The diuretic phase, characterized by a normal
• Bedrest; treatment of the underlying cause.
output of low-quality urine lasting up to a
• Restriction of protein intake, fluid, sodium,
potassium, and phosphorus while in renal
month. The recovery phase, which may last up to failure.
1 year. The quality of urine in this phase
improves, but full recovery is not guaranteed.
• Erythropoietin injections, antihypertensives,
diuretics, vitamin D supplementation, and
• Prerenal conditions are those that decrease per- calcium supplements with meals.
fusion of the kidneys. Intrarenal failure includes
incidents that damage the nephrons.
• Dialysis or transplant.
• Postrenal failure is caused by obstruction, result- Keep in Mind

ing in hydronephrosis. • Hydrate well prior to and following studies using
Assessment and Diagnostic Findings contrast dyes; report changes in voiding.
• Hypertension, azotemia, change in LOC,
nausea, vomiting, fatigue, anemia.
Make the Connection
• Low urine sodium level (<10 mEq/L). • Renal failure carries with it the
• CBC showing anemia and platelet dysfunction, 3 Ds—dialysis, donor, or death.
azotemic pericarditis, and acidosis.
Chronic Renal Failure

(kron-ik re-nal fal-yer)

History of diabetic nephropathy,
hypertension, glomerulonephritis, or
an autoimmune disease (systemic
lupus erythematosus [SLE]).
Pathophysiology frost, sexual dysfunction, and accumulation of
• Gradual destruction of the nephrons and reduc- drugs in the body.
tion of GFR. Acute renal failure, diabetic Medical Care and Surgical Treatment
nephropathy, and hypertension are the most • Diet+ high in calories+and ++low in phosphorus,
common causes, but abnormalities of the kidney, Na , protein, and K ; Ca supplements (PhosLo)
autoimmune disorders, and chronic infection or with meals, vitamin D; fluid restriction (titrated).
cancer are also causes. • Hemodialysis or PD-insertion of peritoneal
Assessment and Diagnostic Findings catheter.
• Hypertension, worsening azotemia, change in • Erythropoietin injections, iron supplements.
LOC, nausea, vomiting, fatigue, anemia, elec- • Antihypertensives and diuretics.
trolyte imbalances, and abnormal DEXA scan. • Kidney transplant.
• Low urine sodium level (<10 mEq/L).
Keep in Mind
• CBC showing anemia and platelet dysfunction,
azotemic pericarditis, and acidosis. • It is important to know the blood glucose level
and blood pressure to avoid renal complications.
Complications
• Increasing azotemia, ESRD, uremic
encephalopathy, and sites for hemodialysis Make the Connection
becoming exhausted. • Monitor laboratory results; monitor for
• Infection from peritoneal dialysis (PD) from peritonitis (cloudy peritoneal return). Check graft
peritoneal catheter access (peritonitis). for bruit/thrill.
• Infected or clotted hemodialysis shunt or
graft.
• HTN, arrhythmias, azotemic pericarditis, peptic
ulcers, change in LOC/coma, pruritus, uremic
Overactive Bladder
(o-ver-ak-tiv blad-der)

Urgency, frequency, and stress
incontinence related to autonomic
and structural anomalies of
the bladder.
• Overactive bladder is thought to be caused by • Anticholinergics to block parasympathetic
excessive parasympathetic impulses to the detru- impulses.
sor muscle of the bladder, initiating the micturi- • Behavioral modification exercises for bladder
tion response. retraining and Kegel exercises.
• Also, structural anomalies resulting from pelvic • Dietary changes to reduce fluids that cause
relaxation syndrome decrease the angle of the diuresis; decreased fluid intake prior to bed.
bladder, causing undue pressure on the neck of the
bladder and abnormal stretch of the transitional Keep in Mind
cells, which again triggers the micturition response. • Anticholinergic medications may cause drowsi-
• Neurogenic causes may include chronic neurologic ness; dry mouth; warm, flushed skin; changes in
illnesses (e.g., multiple sclerosis) that unintention- vision; and, in some clients, changes in mental
ally stimulate motor function and the micturition status. Troublesome side effects should be
reflex arc, making the bladder more active. reported.
Assessment and Diagnostic Findings • Side effects may diminish with time.
• Ultrasound (US) examination of the bladder for • Behavioral modification exercises and Kegel
exercises are very effective for this condition.
residual urine.
• Endoscopic examination of the bladder.
• Subjective history of stress incontinence, frequency, Make the Connection
and urgency. • Monitor frequency and urgency.
Complications • Monitor for side effects of anticholinergic
• Incontinence and social inhibition. medications (blind as a bat, mad as a hatter,
• Urinary tract infections, especially if the bladder dry as a bone, red as a beet, and hot as a hen).
is at an abnormal angle due to pelvic relaxation.
Renal Artery Stenosis

(re-nal ar-ter-e ste-no-sis)

Onset of severe hypertension in the
absence of glomerular disease, renal
failure, or pheochromocytoma.
• Hypertension occurs when the renal artery • Renal artery angioplasty.
becomes narrowed and incapable of transmitting • Medications, especially angiotensin-converting
blood to the kidney. The response is activation of enzyme (ACE) inhibitors.
the renin-angiotensin-aldosterone mechanism to
increase vasoconstriction, further increasing the Keep in Mind
blood pressure. • Report headache or changes in vision immediately.
• Young women usually develop renal stenosis from • Have blood pressure assessed at every health-care
fibromuscular dysplasia; older adults develop it visit.
from chronic atherosclerotic disease.
• Computed tomography (CT) scan or magnetic • Structural anomalies must be ruled out
resonance imaging (MRI) of the kidney with before standard treatment with antihypertensive
contrast. agents is begun.
• Duplex ultrasound of the kidney.
• Renal artery angiography.
Complications
• Cerebrovascular accident (CVA), retinopathy,
heart disease, vascular disease, and nephropathy
of the uninvolved kidney (if unilateral).
Epididymitis
(ep-i-did-i-mi-tis)

Painful inflammation of the back
of the testes. The scrotum is
erythematous.
• Infection and inflammation of the epididymis, the • Sexually transmitted diseases (STDs) may persist
tube along the back side of the testes in which and cause infertility and abnormalities in other
sperm mature and are stored, can be the result of organ systems (valvular disease, neurologic deficits).
several events. Medical Care and Surgical Treatment
• In older men, regurgitation of urine from exces-
• Antibiotic therapy.
sive bladder pressure when trying to urinate in
the presence of an enlarged prostate can force
• Bedrest, scrotal elevation, and ice pack application.
urine into the vas deferens to the epididymis,
• Oral analgesics and antipyretics.
causing infections with bacteria such as
• Sexual counseling.
Escherichia coli. Keep in Mind
• Infections with sexually transmitted organisms occur • Appropriate protection from STD must be used
with frequency in young, sexually active males. (condoms).
• Congenital structural abnormalities in young chil- • Difficulty urinating must be reported to the
dren predispose them to infection. health-care provider.
• Trauma results from excessive pressure exerted on • Scrotal protection should be worn when strenuous
the epididymis. activity resulting in scrotal pressure is planned.
• Scrotum is painful to touch; usually unilateral Make the Connection
involvement. Ambulation is difficult.
• Urinalysis, Gram stain, and urine culture showing • Assess laboratory results.
infection. • Maintain bedrest in the acute phase, with scrotal
elevation and intermittent use of ice packs.
• Possible pyuria and penile discharge. • Counsel the person with an STD that the sexual
partner must be treated as well.
Benign Prostatic
Hyperplasia
(be-nin pros-tat-ik hi-per-pla-ze-a)

Difficulty starting or maintaining urinary
stream, dribbling of urine, urgency
and frequency in men approaching or
in the fifth decade of life.
• Enlargement of glandular tissue in the periurethral • Alpha-adrenergic antagonists.
area of the prostate under the influence of testos- • DHT- and testosterone-blocking medications.
terone, particularly DHT. • Herbals like saw palmetto.
• Estrogen is also implicated, as it makes the gland • TUMA.
more susceptible to DHT. • Prostatic balloon dilation.
• The prostatic urethra narrows as the prostate • Transurethral resection of the prostate (TURP).
gland enlarges, causing partial, or eventually total,
obstruction of urine outflow from the bladder. Keep in Mind
Assessment and Diagnostic Findings • Report difficulty passing urine to the health-care
provider.
• Decrease in urinary stream, difficulty starting the • Medications used for benign prostatic hyperplasia
flow of urine, frequency and urgency, incomplete
emptying of the bladder, dribbling of urine, (BPH) can cause significant side effects like ↓ BP
overflow incontinence, and nocturia. or feminization (DHT blockers).
• Urinary tract infections from urine stasis; epi-
didymitis from pressure in the bladder forcing Make the Connection
urine into the ejaculatory ducts.
• Digital rectal examination for assessment of • If untreated, prostatic enlargement can
cause hydronephrosis and renal failure.
enlargement, urinalysis, prostate-specific antigen
(PSA), and serum creatinine level to determine • The PSA test is done serially from age 40.
the level of obstruction. • If a TURP is done, monitor I&O from the CBI
carefully to prevent postoperative hydronephrosis;
Complications output should exceed instillation amount.
• Hydronephrosis, hydroureter, and diverticular
lesions of the bladder from pressure of attempted
voidings.
Bladder Cancer
(blad-der kan-ser)

Painless hematuria, pelvic pain,
lower back discomfort, and changes
in voiding patterns.
Pathophysiology • Metastasis and death.
• More common in middle-aged males than in females. Medical Care and Surgical Treatment
• Strong association with cigarette smoking. • Surgery, radiation, chemotherapy, bacille
• Exposure to industrial pollutants (e.g., aniline dyes). Calmette-Guérin (BCG) bladder instillations to
• The tumor-node-metastasis (TNM) method of stag- prevent return of cancer cells.
ing the cancer determines prognosis and treatment.
• Over time, dysplastic changes occur in the • Surgeries after cystectomy include incontinent uri-
urothelium. With chronic irritation, these areas nary diversion, continent urinary diversion using a
of dysplasia are replaced by malignant cells. The Kock pouch, or formation of a neobladder (or
cells may form small cancers that remain in the new bladder) using a part of the intestines.
urothelium or may become invasive and metasta- Keep in Mind
tic to the liver, lungs, and bones.
• Report blood in the urine immediately.
Assessment and Diagnostic Findings • If surgery for bladder cancer has been performed
• Urine for cytology; urine culture. and a urinary diversion is done, care for area
• Intravenous pyelogram (IVP) to assess invasion of aseptically.
other urinary structures.
• Cystoscopy with biopsy is the only definitive diag- Make the Connection
nostic method.
Complications • Monitor laboratory and urinalysis results
for infections and nitrogenous waste levels.
• Hydronephrosis, hydroureter, renal failure, and • Teach client how to care for urinary diversions.
hemorrhage.
• Removal of the bladder with urinary diversion • Explain that incontinence is sometimes a problem
with orthotopic or neobladder formation.
may result in urinary tract infection or sepsis if
not cared for properly.
Prostate Cancer
(pros-tat kan-ser)

Late symptoms include signs of urinary
obstruction, pain in the lumbar or hip
area, weight loss, and weakness. Urine
outflow may be impaired.
Pathophysiology • Metastatic disease.
• Prostatic glandular cells mutate and grow under • Tumors that obstruct urinary outflow and may
the influence of testosterone and DHT. result in hydronephrosis and renal failure.
• Prostate cancer late in life is usually slow Medical Care and Surgical Treatment
growing (↓ testosterone levels).
• Metastatic spread into other urinary and repro- • Testosterone-suppressing medications.
ductive structures is through lymph and blood • Radiation therapy (external beam or implanted
vessels. radioactive seeds) and/or chemotherapy.
• The TNM system is used to grade the cancer and • Radical prostatectomy; TURP.
make a prognosis. • Orchiectomy to decrease testosterone levels.
• Symptoms are usually late in the disease, so PSA • Early detection is key.
and DRE should be done in males older than 40. • Medications and surgeries may cause feminiza-
• Elevated prostatic acid phosphatase. tion and permanent erectile dysfunction.
• Late symptoms include hematuria, signs of
urinary obstruction, weight loss, anemia, and
pain in the boney structures of the pelvic girdle. Make the Connection
• Definitive diagnosis is made by a transrectal • Monitor I&O, calorie count, and stool
ultrasound-guided prostatic biopsy. characteristics.
Complications • Assess for development of vesicular rash on
knees, elbows, and buttocks.
• Complications of chemotherapy include nausea, • Monitor for anemia and bleeding tendencies.
vomiting, alopecia, hyperuricemia, and bone
marrow suppression; radiation causes burns, skin
breakdown, and scarring of internal tissue.
IMMUNE SYSTEM
Anaphylaxis, 51 Sjögren’s Syndrome, 55

Scleroderma, 52 Acquired Immunodeficiency
Systemic Lupus Erythematosus, 53 Disease, 56
Hashimoto’s Thyroiditism, 54 Kaposi’s Sarcoma, 57
Immune Disorders 51
Anaphylaxis
(an-a-fi-lak-sis)

Sudden onset of wheezing, edema
of airway, hypotension, tachycardia,
feeling of impending doom and
anxiety.
Immune Disorders 51
• Severe type I hypersensitivity reaction in which • Emergency care includes use of an EpiPen.
IgG antibodies attached to mast cells, previously • IV fluids, IV vasopressors, corticosteroids,
sensitized to an antigen, are reactivated. The epinephrine, antihistamines, and histamine 1
most common antigenic material is derived from (H1)-receptor and H2-receptor blockers.
foods or insect stings. • Supplemental oxygen will be needed and airway
• Chemical mediators are released, the most support.
common of which are histamine, proteases, • Electrocardiogram (ECG) monitoring.
chemotactic factors, leukotrienes, prostaglandin D,
cytokines, and interleukins 1, 3, 4, 5, and 6). These Keep in Mind
mediators cause vasodilation and fluid shift from • Teach that severe allergy an occur at any time after
the intravascular to the interstitium. first occurance.
Assessment and Diagnostic Findings • Families with a member who has food or other
allergies should have an EpiPen on hand.
• Erythema, angioedema, urticaria (hives),
stridor, wheezing, decrease in BP, and
increase in pulse. Make the Connection
• Change in level of consciousness, drowsiness. • Anaphylaxis causes shock. Remember:
Complications shock = ↓ BP, ↑ pulse.
• Shock, respiratory and cardiac failure. • Remember: ↓ HOB, ↑ legs. Keep client warm.
• Renal ischemia. • Start an IV for fluid and drug administration.
Immune Disorders 52
Scleroderma
(skler-a-der-ma)

Taut face without wrinkles. Calcium
deposits. + ELISA for ANA and
other antibodies. Raynaud’s
phenomenon.
Immune Disorders 52
• An autoimmune disease. • CREST syndrome: calcinosis (calcium deposits),
• Women are affected more often than men; Raynaud’s phenomenon, esophageal immotility,
disorder often has periods of exacerbation and sclerodactyly, and telangiectasia.
remission. • Dysphagia and aspiration risk; pneumonia and
• The skin, connective tissue, and internal organs desaturation of blood from lung noncompliance;
are affected. Insoluble collagen is overproduced arrhythmias; and necrosis of fingertips, toes, and
and deposited in the skin and other organs, caus- nose from Raynaud’s vasculitis.
ing inflammation. Inelastic rather than supple Medical Care and Surgical Treatment
edema results. A common finding is “stone face,” • Immunosuppressants.
which is the result of this hardening of the skin. • Vasodilating agents.
• There is a strong association (95%) with • Careful and consistent physical therapy and
Raynaud’s phenomenon. occupational therapy.
Assessment and Diagnostic Findings • Extremities must be kept warm.
• Pitting edema of the upper extremities followed Keep in Mind
by tightening of the tissue.
• The face will have no wrinkles. • Report any signs of illness (e.g., sore throat) immediately.
• Arthritis and decreased range of motion occur. • Physical activity helps to keep the body supple. Be as
independent as possible.
• The kidneys, lungs, heart, and gastrointestinal
tract are also affected.
• Skin biopsies and ELISA testing for anti-Scl-70 Make the Connection
and anticentromere antibodies. • Scleroderma presents a body image
• Kidney function tests, pulmonary function tests, problem, so psychological counseling is essential.
electrocardiogram, and x-ray studies.
Uploaded by • Monitor lung, renal, and cardiac function.
MEDBOOKSVN.ORG
• Passive and active ROM.
Immune Disorders 53
Systemic Lupus
Erythematosus
(sis-tem-ik lu-pus er-i-the-ma-to-sis)

Butterfly rash, arthritis, malaise,
Raynaud’s phenomenon, peripheral
neuropathy, change in vision and
renal status; round lesions on head
cause hair loss.
Immune Disorders 53
Pathophysiology • Peritonitis from chronic inflammation and scar-
• Immune system antibodies attack “self.” Females ring of abdominal and intestinal vasculature.
are affected more than males. A hereditary pre-
disposition exists.
• Visual changes or blindness.
• Severe arthritic changes.
• Discoid lupus causes skin plaques that tend to
occur on the face, ears, and hair. Wherever they
appear, the area is inflamed and becomes scarred. • Antirheumatics and tumor necrosis factor
Alopecia results in affected areas in the hair. inhibitors.
• Systemic lupus erythematosus (SLE) causes • Corticosteroids and other immunosuppressants.
changes in the dermatologic, cardiovascular, Keep in Mind
musculoskeletal, hematologic, gastrointestinal,
renal, and ophthalmologic systems—all related to • Teach signs of heart disease, like SOB.
inflammation from overreaction of the immune • Teach signs of kidney inflammation.
system. • Eat a healthy diet, stay active, get adequate rest,
and wear a MedicAlert bracelet.
• ELISA for SLE-specific antibodies; antinuclear Make the Connection
antibody (ANA); and nonspecific inflammatory
studies, like complete blood count with differen- • Monitor laboratory results and clinical
tial (CBC with diff), erythrocyte sedimentation condition. Refer to a rheumatologist if butterfly
rate, and kidney function tests. rash and arthritis occur.
Complications • Immunosuppressant therapy puts the client at
risk for infection and pseudodiabetes.
• Myocarditis, myocardial infarction, and pericarditis.
• Renal failure.
• Thrombocytopenia, anemia. Uploaded by MEDBOOKSVN.ORG
Immune Disorders 54
Hashimoto’s Thyroiditis
(ha-she-mo-toz thi-royd-i-tis)

Goiter, periods of insomnia, anxiety,
muscle and joint aches, weight
changes, hair loss, and fertility
problems that are mixed symptoms
of hyper- and hypothyroidism.
TSH may be normal or elevated.
T3 and T4 are low.
Immune Disorders 54
Pathophysiology • Fatigue, depressive illness, and mental dullness.
• Usually a disease of older women with a history • Anorexia, constipation, facial puffiness, and
of autoimmune disease. dry skin.
• Autoantibodies are produced to fight TSH. TSH Medical Care and Surgical Treatment
is not destroyed and instead binds with its recep-
tors in the thyroid gland, causing symptoms of • Evidence shows that low-dose thyroid hormone
hyperthyroidism. therapy may reduce destruction of the thyroid
gland.
• As the thyroid gland becomes infiltrated with
lymphoid tissue and plasma cells it enlarges and Keep in Mind
hypothyroidism occurs.
• Episodic hyperthyroidism can occur, so symp- • Report any signs of chest pain when therapy
begins. It takes a few weeks for the drug to
toms may swing back and forth from hyperthy- reduce symptoms.
roidism to hypothyroidism.
• Report any thoughts of suicide.
Assessment and Diagnostic Findings • Stay active and follow a low saturated-fat diet.
• Elevated levels of serum TG antibodies and TPO
using immunofluorescent assay. TSH may be
elevated or normal. T3 and T4 levels ↓. Make the Connection
• Needle biopsy of the thyroid. • Remember: Starting thyroid replacement
• ↑ RAIU. hormones with a sluggish heart can precipitate an
• Visible goiter or enlarged thyroid gland on US. angina attack or myocardial infarction. Monitor
the client’s electrocardiogram.
Complications
• Atherosclerosis, bradycardia, hypotension, and • Adjust dietary regimen as condition changes.
chest pain.
Immune Disorders 55
Sjögren’s Syndrome
(sho-grenz sin-drom)

Blurred vision, thick secretions,
decreased sense of taste, dysphagia,
xerostomia, and dry nasal membranes.
Antiribonucleoprotein serum antibodies
and + rheumatoid factor in the absence
of rheumatoid arthritis.
Immune Disorders 55
• Autoimmune illness in which the lacrimal and • Corneal abrasion, choking, pneumonia,
salivary glands are attacked by autoantibodies anorexia, non-Hodgkin’s lymphoma, dyspareu-
and T lymphocytes. nia, tachycardia, and primary biliary cirrhosis.
• Can occur alone or with other autoimmune Medical Care and Surgical Treatment
diseases.
• Artificial tears, cyclosporine eye drops, effective
• Occurrence is mainly seen in older women. and thorough mouth care, sugarless gum or
• Sjögren’s syndrome is associated with a 40%–60% candies, sips of water, a cholinergic preparation
increase in the chance of developing non-Hodgkin’s to induce salivation, and artificial saliva.
lymphoma.
• Antimalarials and immunosuppressants.
• Blurred vision, burning and itching of the eyes, Keep in Mind
Schirmer’s test (ability to wet a test strip placed • Report xerostomia, dysphagia, and chronic
under the eyelid). dry eye.
• Decreased sense of taste; thick secretions; dys-
phagia; dry, cracked oral mucous membranes;
enlarged parotid glands; lower lip salivary
Make the Connection
biopsy. • Observe ability to swallow.
• Dry nasal membranes, thick secretions in the • Protect eyes from excessive dryness to prevent
corneal abrasion.
bronchi and lungs.
• Synovitis, vaginal dryness with frequent Candida
infection, and vasculitis.
• Anemia, leukopenia, and elevated ESR.
Immune Disorders 56
Acquired
Immunodeficiency Disease
(a-kwird im-u-no-de-fish-en-se di-zez)

Lymphadenopathy, night sweats, and
presence of rare opportunistic illness.
T-helper (CD4) cells <500 cells/mm3,
T-killer (cytotoxic) (CD8) cells
<375 cells/mm3, change in the
CD4/CD8 ratio (normal 0.9–1.9),
and measurable viral load.
Immune Disorders 56
• Macrophages process foreign antigens and pres- • Kaposi’s sarcoma and lymphomas, AIDS
ent antigenic material to the T-helper cells (CD4). dementia, fungal meningitis, and tuberculosis.
• The CD4 transfer this information to the T and • Pneumocystis carinii pneumonia, Mycobacterium
B lymphocytes. In HIV, a retroviral particle avium complex, and other pneumonias.
(RNA strand) wrapped in a glycoprotein coat • Septicemia, toxoplasmosis, cytomegalovirus
(gp120 receptor) with p24 viral protein invades retinitis, cervical cancer and Candida infections,
the CD4 cell. The CD4 cell and macrophage are GI infections, and wasting.
the immune cells affected and destroyed. Medical Care and Surgical Treatment
• Once the CD4 cell count drops below
• HAART, fusion inhibitors (injectable only), and
200 cells/mm3, the client is diagnosed with integrase inhibitors. Monotherapy with a nucleo-
AIDS. Other diagnostic criteria include the side transcriptase inhibitor is administered only
presence of an opportunistic infection. during pregnancy and the neonatal period.
Assessment and Diagnostic Findings • Once an opportunistic infection occurs, prophylac-
• CD4 and CD8 counts, CD4/CD8 ratio abnormality, tic treatment is added to the daily medical regimen.
and viral load.
• GI wasting through opportunistic diarrheal Keep in Mind
infection and by alterations in enteral epithelial • Avoid smoking, unprotected sex, and organic
function by the viral particles. foods, and take medications as ordered.
• AIDS dementia complex.
• Opportunistic disease; ELISA is repeated after one
Make the Connection
positive result and confirmed by Western blot
analysis. • Monitor CD4/CD8 ratios, viral load, and
presence of opportunistic infection.
Immune Disorders 57
Kaposi’s Sarcoma
(kap-o-sez sar-ko-ma)

Red-to-purple macules, papules,
and nodules seen in persons with
AIDS. First seen usually on the
mucous membranes.
Immune Disorders 57
• A rare lymphatic malignancy of the endothelial, • Chemotherapy and radiation treatment, biotherapy
rather than connective, tissue characterized by (interferon alfa-2b), cryotherapy, and hormone
red-to-purple macules, papules, or nodules. therapy.
• Lesions are first seen on the skin or mucous • Treatment with HAART.
membranes but may involve the internal
organs. Keep in Mind
• A rare cancer commonly related to AIDS. • Do not have unprotected sex, as this cancer may
• In patients with AIDS, KS is believed to be be spread in this way and there are many strains of
sexually acquired by infection with the human human immunodeficiency virus that can be spread.
herpesvirus 8. • Do not smoke, as many infective organisms can
be present in cigarette paper.
• Classic form is found on the lower extremities
and dorsal area of the feet. The type associated Make the Connection
with AIDS is found on the upper extremities and • Monitor complete blood cell count and
on the mucous membranes. uric acid level during chemotherapy to assess for
• Biopsy provides the only definitive diagnosis. bone marrow suppression and hyperuricemia.
Complications • Assess the skin (portal of entry and portal of exit)
• Damage to organ systems by metastasis. during radiation therapy.
• Overgrowth and blockage of lymph, blood • Provide reverse isolation if leukopenic; avoid fresh
vessels, gastrointestinal and accessory tract, flowers and organic foods.
and organ exocrine function. • Counseling.
MUSCULOSKELETAL
Osteoarthritis, 58 Paget’s Disease, 64

Gouty Arthritis, 59 Sprain, 65
Rheumatoid Arthritis, 60 Fracture, 66
Osteoporosis, 61 Compartment Syndrome, 67
Osteomalacia, 62 Total Joint Replacement, 68
Osteomyelitis, 63 Herniated Nucleus Pulposus, 69
2693_Tab05_Card_58-69.qxd 7/13/11 12:01 PM Page 58
Musculoskeletal Disorders 58
Osteoarthritis
(os-te-o-ar-thri-tis)

Pain and stiffness in the weight-
bearing joints and the vertebral
column due to wear and tear
or obesity.
Pathophysiology • Heberden’s and Bouchard’s nodes, which are
• The matrix of cartilage is composed of chondro- painful nodes in the fingers.
cytes imbedded in proteoglycan molecules, which
are large and osmotic, drawing fresh synovial
• Vertebral osteoarthritis can result in muscle
spasm and pressure on nerves.
fluid into the joint.
• With excess wear and tear, the chondrocytes
• Anti-inflammatory and immunosuppressants like
become inflamed and release inflammatory medi-
ators (cytokines), causing a cascade of events that DMARDs and TNF-I.
includes formation of protease, which break down • Muscle relaxants and application of cold and
the proteoglycan molecules. Eventually, the carti- heat therapy.
lage becomes worn and misshaped. Streaks and • Joint replacement surgery, if necessary.
dents in the cartilage become cracks. Synovial Keep in Mind
fluid leaks into the underlying bone, causing cysts.
The underlying layer of the cartilage can no longer • Walking and swimming can replace high-impact
exercise. Weight loss is necessary if obese.
be an effective shock absorber. Bone spurs form.
• Take anti-inflammatory agents with food, and
Assessment and Diagnostic Findings report any signs of infection immediately.
• Pain with or following activity that subsides with
rest. More likely to occur after age 40.
• CT scan or MRI scan are diagnostic. Make the Connection
• Arthroscopy may be done to both diagnose and • Inactivity should never be advocated.
treat articular and bony malformations. Clients should know that if you don’t use it, you
lose it.
Complications
• Ankylosis of joints, with resulting immobility and
chronic pain.
Gouty Arthritis
(gowt-e ar-thri-tis)

Acute pain and swelling in a joint,
usually the great toe (unilaterally).
High serum uric acid levels.
Pathophysiology • Soft nontender tophi can occur on the extremities
• In gouty arthritis, uric acid crystals are deposited near joints. These may become open sores (ulcers)
in the joints and other connective tissues. The if the skin is not cared for properly.
concentration in synovial fluid is higher than in
plasma, so the crystals cause excessive inflamma-
• Possible uric acid kidney stone formation.
tion in the joint. Joints affected are usually those Medical Care and Surgical Treatment
at the distal area of the body, as uric acid crystals • Anti-inflammatory agents, uricosuric agents,
are affected by gravity. Called “the rich man’s dis- and probenecid; increasing daily fluid intake to
ease” because many of the foods that contain 2,000–3,000 mL.
purines are considered those consumed by the Keep in Mind
wealthy.
• Avoid aspirin and diuretics as well as high-purine
Assessment and Diagnostic Findings foods.
• Hyperuricemia, high-purine diet, painful joints, • Consume alcohol in small amounts, if at all.
and possible gouty lesions near joints. • Find healthy outlets for stress.
• Attacks of gout precipitated by excessive alcohol
ingestion, dehydration, illness/stress, and medica-
tions like diuretics, aspirins, cyclosporine, lev- Make the Connection
odopa, aminophylline, niacin, and antibiotics • Remember: Gouty arthritis is very painful. Give
used to treat tuberculosis. anti-inflammatory drugs, such as colchicine.
• Arthroscopy with joint fluid aspiration for uric • Force fluids, and teach the client the importance
acid crystals and white blood cells. of remaining hydrated.
Complications • Monitor uric acid levels, and assist the client in
choosing low-purine foods and drugs.
• Pain and immobility during acute attacks.
Rheumatoid Arthritis
(roo-ma-toyd ar-thri-tis)

Swan neck deformity or ulnar
deviation of the metacarpophalangeal
joints. Fatigue, flu-like symptoms
may accompany exacerbations of
the disease. Elevated ESR; RF and
CCP antibodies present.
• Rheumatoid arthritis is a systemic disease known • Pain, joint deformity, ankylosis, and immobility.
to be genetic and autoimmune in nature. Women • Vasculitis, scleritis, pulmonary and cardiac
are affected more than men. inflammation, and leukopenia.
• Rheumatoid factor (RF) antibodies react with Medical Care and Surgical Treatment
IgG, forming immune complexes in the body
and in the synovial joints.
• Salicylates, NSAIDs, gold salts, TNF inhibitors,
DMARDs, and corticosteroids.
• Granulocytes phagocytize the immune complexes
• Surgery for joint replacement.
and release toxins into the tissue and into the
joints.
• Physical and occupational therapy to maintain
function.
• Synovitis occurs as well as increased formation of
blood vessels in the synovial walls, which con- Keep in Mind
tributes to production of vascular pannus. • Take all anti-inflammatory agents with food.
• The area of inflammation is “walled off” in an Report any signs of infection immediately.
attempt to heal injured tissue causing more
immobility and destruction.
• Presence of RF, anti-CCP antibodies, • Monitor CBC for signs of infection while
on anti-inflammatory agents.
WBC elevation, and ↑ ESR.
• Synovial fluid examination reveals a significant • Assist with ROM exercises to maintain function.
number of neutrophils.
• Low-grade temperature, flu-like symptoms,
bilateral joint inflammation, joint deformities
like swan neck deformity, and nodal formation.
Osteoporosis
(os-te-o-por-o-sis)

Loss of bone density (by DEXA scan)
seen mainly in females who weigh
less than 140 lb at menopause and
have never used estrogen-replacement
therapy. The mnemonic is ABONE
(A = age, B = bulk, ONE = one never
on estrogen).
Pathophysiology and prolonged immobility.
• Healthy bone is living tissue that is dynamic in • DEXA scan of the hip, spine, and first four verte-
nature. Osteoclasts resorb bone, while osteoblasts brae; serial heights; US of bone; and CT scan.
lay down new bone. In this way, healthy bone is Complications
always remodeled. Bone remodeling occurs under • Falls resulting in hip fracture.
the influence of hormones and from normal body • Pathologic fractures.
movement and weight-bearing activities.
• At menopause, estrogen withdrawal causes
• SERMs, biphosphonates, calcitonin hormone,
inflammatory mediators and immune cells that
and recombinant human parathyroid hormone.
encourage the differentiation of osteoclasts and
increase their life span. Osteoblasts, or bone • HRT Weight-bearing exercise.
creators, are less active. • Calcium and vitamin D supplements.
• As osteoporosis progresses, this trabecular frame- Keep in Mind
work is diminished and may be totally resorbed.
Bone density decreases.
• The client with confirmed osteoporosis should
wear well-fitting shoes (no slip-ons) and clear all
Assessment and Diagnostic Findings clutter (e.g., throw rugs) from walking areas.
• Risk factors include Caucasian or Asian ancestry, • Assistive devices (e.g., walkers) may decrease the
postmenopausal status, weight of less than 140 lb chance of falls and fractures.
at menopause, sedentary lifestyle, history of
rheumatoid arthritis, low calcium and vitamin D
• Teach importance of DEXA scan.
consumption, excessive alcohol consumption,

smoking and caffeine intake. Secondary risks are Make the Connection
associated with endocrine imbalance, steroid use, • Give calcium with meals. Observe for
sleeping tablets, cancer treatment, kidney disease, esophagitis related to SERM therapy.
Osteomalacia
(os-te-o-mal-a-she-a)

Softening of bone causing bowed
legs in children and soft or brittle
bones in adults. Bone pain is often
present with muscle weakness.
• Bone mineralization is diminished because of lack • Treatment of the underlying condition.
of calcium or vitamin D. • Biliary disease may require that pancreatic
• Vitamin D absorbed by exposure of the skin to enzymes be given to absorb vitamin D and
sunlight must be activated by two organs, first calcium from the diet.
the liver and then the kidney. Any disorders of • In renal disease, supplemental calcium, phos-
these organs decreases vitamin D availability. phate binders, and vitamin D supplements are
• The disease is more prevalent in women because used.
of their increased need for calcium.
• Osteomalacia is seen more frequently in persons Keep in Mind
with low sun exposure. • Moderate exposure to the sun with skin SPF 15
sunscreen.
• X-ray (sometimes showing transverse pseudo- • Dietary intake of supplemented foods, like dairy
products and dark green leafy vegetables. Visit
fractures believed to be stress fractures that
choosemyplate.gov
have not been remodeled), laboratory tests for
serum calcium and phosphorus, bone scan, and
bone biopsy. Make the Connection
Complications • Monitor laboratory values; do serial
• Deformity of bone and teeth. height and gait assessment.
• Change or closure of the epiphyseal growth plate • Bracing of upper and lower extremities may be
in children, resulting in stunted growth. necessary in severe cases.
• Muscle weakness. • Monitor for scoliosis and other vertebral
abnormalities.
Osteomyelitis
(os-te-o-mi-el-i-tis)

Increased temperature with pain and
inflammation over the affected bone;
elevated WBC and ESR. Bone biopsy
positive for infection.
• Bone infection with microorganisms that can • Amputation of the affected limb to decrease the
occur in compound fracture as well as in surgical chance of death from septic shock.
intervention (direct inoculation), spread from • Repeated surgical procedures to remove diseased
surrounding tissue (e.g., cellulitis [contiguous bone (sequestrectomy).
spread]), and infection of the bone from sepsis Medical Care and Surgical Treatment
(hematogenesis).
• IV and oral antibiotic therapy for long periods of
• When the bone becomes infected, the inflamed time.
area forms an abscess that impairs blood flow to
the intramedullary area. Bone death occurs, the
• Sterile wound dressing changes.
periosteum peels away from the ostium, and
• Sequestrectomy.
dead bone (sequestrum) forms. The sequestrum Keep in Mind
can fall from the bone, causing more pressure
and decreased blood flow to other boney areas.
• Avoid osteomyelitis by carefully controlling blood
glucose levels and checking the feet each evening
• Sinuses commonly form that allow pus and for pressure areas.
debris to escape from the bone to the outer skin. • Report any sore areas where a soft tissue injury
Assessment and Diagnostic Findings has occurred.
• History and physical, x-ray, complete blood count
(CBC), elevated erythrocyte sedimentation rate
(ESR), positive bone biopsy for infection, positive
Make the Connection
blood culture, magnetic resonance imaging • Teach clients the importance of tight
glycemic control and to check for ill-fitting shoes,
(MRI), and computed tomography (CT) scan.
dentures, and other prosthetics.
• A history of diabetic foot ulcers and cellulitis is
• Assess sites of infection carefully; monitor CBC
considered a risk factor.
and ESR.
Paget’s Disease
(paj-ets di-zez)

Enlarged bone mass and deformity of
the femur, skull, vertebrae, or pelvis,
usually in older adults. Increased
serum ALP, increased urine
hydroxyproline (measured by Pyrilinks
and Osteomark), increased urine
and serum calcium.
Pathophysiology • Nerve palsies.
• A disease of older adults in which osteoclastic • Calcified aortic stenosis.
activity is followed by an exaggerated response by
osteoblasts resulting in enlargement of bone.
• Decreased rib cage compliance and
pneumonia.
• There are three phases: (1) the active phase
(reabsorption); (2) the mixed phase (osteoblast
activity); and (3) the inactive phase, in which the • Calcitonin, biphosphonates, and
osteoblastic phase has exceeded the osteoclastic anticancer/antibiotic agents (e.g., plicamycin) to
activity. suppress osteoclasts and osteoblasts.
• Increased vasculature around the bones. • Anti-inflammatory agents.
• The femur, skull, vertebrae, and pelvis are most • Analgesics.
often affected. Keep in Mind
Assessment and Diagnostic Findings • Report pain level on a 0–10 scale and any
• X-ray showing enlargement and deformity of dizziness or dyspnea.
bone. • Report any bleeding of the gums or from any ori-
• Nuclear bone scans showing “hot spots” of fice while under treatment.
abnormally rapid bone cell turnover that appear
overgrown or have a mosaic pattern; increased
ALP. Pyrilinks and Osteomark urine tests, which Make the Connection
measure markers of bone resorption, are elevated • Monitor CBC for low platelet level with
in Paget’s disease. plicamycin therapy.
Complications • Titrate analgesic levels to keep pain level <3.
• ↓ cardiac output related to vasodilation. • Monitor serum and urine studies to assess
effectiveness of therapy.
• Pain and deformities.
Sprain
(sprane)

Pain, swelling, and heat around
a recently injured joint, usually
the ankle.
Pathophysiology extremity by using an ACE wrap, cast, or brace;
• The ligaments, the strong connective tissue bands and elevate the extremity to decrease tissue
that secure bone to bone, are affected. The most edema.
likely joint is the ankle. • Assistive devices are necessary for mobility.
• The ligaments may be slightly torn or completely • Muscle relaxants or anti-inflammatory agents may
torn with disconnection from and a piece of the be used.
bone attached to the torn ligament.
Keep in Mind
• Rapid swelling and pain of the joint. • Keep the injured area elevated as much as
possible and avoid weight bearing.
• Limited ability to function. • Allow time for adequate repair.
• X-ray, necessary to differentiate a sprain from a
fracture, is done usually after the extremity
swelling has diminished. Make the Connection
Complications • Sprains have to be assessed for a fracture
• Poor healing with change in range of motion. being present.
Medical Care and Surgical Treatment • Remember: Ligaments hold bone to bone;
tendons hold muscle to bone (more involved
• RICE method: rest the extremity; apply ice to in strains).
decrease swelling; confine or compress the
Fracture
(frak-chur)

Tenderness, pain, or deformity over
an area of injury. Crepitation may
be heard or felt; range of motion
is decreased.
Pathophysiology • Infection, neurologic damage, compartment
• Healthy bone is living tissue that is dynamic in syndrome, and thrombophlebitis.
nature. Osteoclasts resorb bone, while osteoblasts
lay down new bone. In this way, healthy bone is Medical Care and Surgical Treatment
always remodeled. • Analgesics, skin traction using balanced traction
or an external fixator.
• A fracture is a disruption in the bone structure
• ORIF.
caused by trauma or pathology.
• Closed fractures do not disrupt the integrity of the • Closed reduction.
skin; open fractures are called compound because • Electrical stimulation and bone grafting in cases
they break through the skin as well as disrupt the in which the bone does not mend.
integrity of the bone. Keep in Mind
• Fracture types are comminuted, impacted, green-
• If a fall involves the hip, report deep groin pain in
stick, oblique, longitudinal, and transverse. the absence of x-ray data (a positive sign).
• Fractures heal by forming a blood clot at the site and
• Report any unusual smells from a cast; do not
attracting cells to the site. The fracture site is known scratch under the cast.
as a callus at week 1, and by week 6, osteoclasts have
resorbed dead bone and osteoblasts have remodeled
the site. Complete healing is usually in 1 year. Make the Connection
Assessment and Diagnostic Findings • Monitor vital signs for signs of infection,
• X-ray, CT scan, and MRI. petechial hemorrhage, or dyspnea.
• CBC++ to assess blood loss internally or externally. • Watch for color, motion, and sensitivity and
• CA and ESR to assess tissue damage. “palm” cast.
Complications • Encourage mobility exercises for the unaffected
side to combat thromboembolism.
• Fat embolism.
Compartment Syndrome
(com-part-ment sin-drom)

Neurovascular assessment of injured
area, usually by crush injury or
fracture, includes severe pain,
pallor, pulselessness, paresthesia,
paralysis, and coolness to
the touch.
Pathophysiology • Rhabdomyolysis and renal failure.
• In a traumatic injury (e.g., fractures caused by • Infection.
automobile accident or crush injury), soft tissue
swelling occurs. The soft tissue in this case is the Medical Care and Surgical Treatment
muscle. Every muscle compartment is surrounded • Restoring blood flow by performing a fasciotomy.
by connective tissue called fascia. Once pressure is relieved and the swelling goes
down, the fascia and skin are closed. Skin graft-
• Fascia compresses the swelling tissue, causing
ing may be required.
loss of vascularity to tissue and nerves. The mus-
cle tissue is essentially being strangled in its own Keep in Mind
covering.
• Less problematic compartment syndrome is seen • Report excessive pain after any sports injury.
in exertional compartment syndrome and stress • Report skin that is cool to the touch distal to any
wrap or cast.
fracture.
• Neurovascular assessment of injured area, usually Make the Connection
by crush injury or fracture, includes severe pain, • Time is muscle. Is it important to
pallor, pulselessness, paresthesia, paralysis, and recognize compartment syndrome to prevent
coolness to the touch. complications and deformity.
• Excessive pain is the first clue. • Remember: When muscle fibers are injured, they
may gain access to the bloodstream and filter
Complications into the nephrons, causing renal failure.
• Necrosis of the affected tissue. • Watch for signs of infection in the area of the
• Paralysis of the extremity. fasciotomy or graft.
• Volkmann’s contracture.
Total Joint Replacement

(to-tal joint re-plas-ment)

Replacement of the femoral head
and placement of an acetabular cup
(THR) (hip), or replacement of the
femoral and tibial ends of the knee
by metal and the knee cap by a
button (TKR).
Pathophysiology • Sepsis in the joint or blood.
• Persons with problems like chronic osteoarthritis • Skin breakdown.
pain, avascular necrosis of the femoral head, or
systemic lupus erythematosus (SLE) cannot per-
• Hemorrhage.
form activities of daily living (ADLs) and require Medical Care and Surgical Treatment
the joint be replaced by prosthetic devices. • Prophylactic antibiotics.
• Blood transfusion if necessary (autologous
replacement if possible).
• Preoperatively, the client exhibits severe decrease • Analgesia.
in range of motion and increased pain with ADLs.
• Assessment of neurovascular status.
• Baseline neurovascular assessment is performed. • Assessment of neurologic status in the elder adult.
• Postoperatively, the complete blood count (CBC) • Flowtron boots or compression stockings; early
is monitored for blood loss and infection; neu- ambulation (non–weight-bearing).
rovascular assessments are done every 4 hours.
• Total hip replacement (THR) clients have legs Keep in Mind
abducted and may not sit with hips flexed at • Teach THR clients to not cross their legs or sit at
greater than a 90-degree angle. Total knee greater than a 90-degree angle.
replacement (TKR) clients have the affected leg • Report pain or chills immediately.
(legs) in continuous passive motion (CPM)
machines, which move the knee to greater angles
as directed by the orthopedist. Make the Connection
Complications • Monitor CBC for hemorrhage and infection.
• Thrombophlebitis and embolism. • Monitor and report the neurovascular status of
the affected leg distal to the surgery.
• Infection. • Remember that orthopedic surgery is very bloody,
• Hip or knee dislocation. so the need for transfusion exists.
Herniated Nucleus
Pulposus
(her-ne-at-ed nu-kle-us pul-po-sis)

Pain and numbness in the arm or
headaches on the affected side
(cervical), or pain and numbness
radiating down the sciatic nerve
in the leg (lumbar).
Pathophysiology • Infection after surgery.
• The vertebrae have cushions or intervertebral Medical Care and Surgical Treatment
disks between them to absorb shock and to keep
the nerve roots away from the boney areas. • Analgesics, muscle relaxants, physical therapy,
minimally invasive balloon vertebroplasty, TENS
• Disks can herniate out of the normal position,
unit, skin traction, and corticosteroid injections
and the annulus fibrosus tears. The inner portion
(nucleus pulposus) pushes outward and places directly into the disk area.
pressure on a nerve root. • Surgical laminectomy (frontal approach for
cervical, posterior approach for lumbar).
• The most common sites are the cervical and
lumbar areas. Keep in Mind
Assessment and Diagnostic Findings • Report any numbness or problems with mobility
• Cervical disk herniation causes numbness and tin- after surgery.
gling in the affected arm, neck spasm, pain, and • Report chills or other signs of infection.
(in some cases) migraine headache. • Spinal fusions will limit range of motion.
• Lumbar disk herniation causes numbness, pain,
and tingling in the affected leg. Muscle spasm is
common. Heel-toe walking is not possible Make the Connection
because of discomfort. Severe herniation is the • Monitor neurovascular status of the
only type that would cause incontinence. arms (cervical surgery) or of the legs, bladder,
• MRI, with and without contrast, will show and bowel (lumbar surgery).
herniation of the disk. • Log-roll the client after surgery.
Complications • Monitor CBC and ability to perform ADLs
without pain.
• Hemorrhage, nerve root damage, and rehernia-
tion, and altered mobility after surgery.
NERVOUS SYSTEM
Meningitis, 70 Simple Partial Seizures, 83

Concussion, 71 Complex Partial Seizures, 84
Skull Fracture, 72 Cerebrovascular Accident, 85
Epidural and Subdural Hematoma, 73 Multiple Sclerosis, 86
Huntington’s Disease, 74 Myasthenia Gravis, 87
Spinal Cord Injury, 75 Trigeminal Neuralgia, 88
Autonomic Dysreflexia, 76 Parkinson’s Disease, 89
Spinal Shock, 77 Alzheimer’s Disease, 90
Cerebral Aneurysm, 78 Bell’s Palsy, 91
Tonic-Clonic Seizures, 79 Amyotrophic L ateral Sclerosis, 92
Absence Seizures, 80 Guillain-Barré Syndrome, 93
Myoclonic Seizures, 81 Encephalitis, 94
Atonic Seizures, 82 Malignant Hyperthermia, 95
Nervous System Disorders 70
Meningitis
(men-in-ji-tis)

Nuchal rigidity and pain as the
meninges are stretched by moving the
legs or flexing the neck to the chin.
Turbid CSF with low glucose and
high protein.

Pathophysiology • CBC, procalcitonin testing, MRI.
• The meninges include the dura matter, arachnoid • Eye fundus examination showing papilledema.
layer, and pia matter; and surround the brain and
spinal cord. Complications
• Causative agents include bacteria, viruses, • Seizures; residual hearing, vision, or cognitive
mycobacteria, fungi, amebas, cancer, and nonin- defects; and death.
fectious sources. Entrance via the respiratory Medical Care and Surgical Treatment
system is most common. • Quiet, darkened, nonstimulating environment.
• Infections that occur close to the CNS, basilar frac- Cooling blanket for high temperature.
ture, CNS surgery or presence of an indwelling • Antimicrobials, antipyretics, steroids, pain
shunt, and blood-borne illnesses cause meningitis. medication, and (rarely) surgical drainage of
• TNF-α and IL-1 are major mediators of inflamma- abscesses.
tion that increase permeability and transit of the
causative agent through the blood–brain barrier. Keep in Mind
• Inflammation causes ↑ ICP in meningitis. • Vaccines are recommended for the most common
forms of bacterial meningitis (Haemophilus influenzae
Assessment and Diagnostic Findings type b in infants and children, and Neisseria meningi-
• Fever and symptoms of ICP, including change in tidis in college-aged children).
LOC, headache, nausea, vomiting, nuchal rigidity
(positive Kernig’s and Brudzinski’s signs), lethargy,
photophobia, seizures, pupil dilation, decorticate or Make the Connection
decerebrate posturing, and pulse pressure changes. • Change in LOC is often the first sign.
• LP shows turbid CSF, and ↓ glucose and ↑ protein • Monitor CBC and Glasgow Coma Scale assess-
levels. Infectious cell count, Gram stain or C&S. ments; elevate the head with neck straight.
Concussion
(kon-kush-un)

A blow to the head resulting
in changes in LOC.

• Also known as traumatic brain injury, concussion • ICP, brain herniation, diabetes insipidus, and vital
is caused by a nonpenetrating, or closed, head sign instability.
injury. Mechanisms of injury include acceleration • Posttraumatic syndrome characterized by a perma-
injury, deceleration injury, or a combination nent impairment of cognitive or motor function.
of both. Rotational injuries cause traumatic Medical Care and Surgical Treatment
shearing of the brain tissue. Most injuries are
related to automobile accidents, but playing
• Control ICP by pharmacologic means or by
mechanical hyperventilation with barbiturate-
contact sports and falls are also frequent induced coma and temperature control.
causes.
• Initiate invasive ICP monitoring and ventricular
• After injury, the compromised cells require drainage; elevate head and keep neck straight.
increased glucose in order to remain alive.
However, with the onset of cerebral edema, the Keep in Mind
capillary bed may become displaced from the
cells by fluid. With decreased blood flow,
• Head trauma is cumulative, so repeated blows
to the head can cause irreversible damage.
neuronal loss can continue to occur. • Teach clients that prevention is the best
Assessment and Diagnostic Findings approach. Wear appropriate headgear when
• Change in LOC that may include confusion, engaging in activities such as bike riding, skating,
difficulty concentrating, amnesia, brief loss of skiing, or playing contact sports. Helmet use does
conciousness, ICP (direct or MRI measurement of not guarantee that brain trauma will not occur.
≥15 mmHg), widening pulse pressure, and decorti-
cate or decerebrate posturing.
CT scan, MRI ICP measurement >15 mm Hg,
Make the Connection
• • Any change in LOC after head injury
and PET.
warrants medical care and monitoring.
Skull Fracture
(skul frak-chur)

Severe head trauma resulting in an
area of open-skull injury that presents
as crepitus, CSF leak, or a depressed
area in the skull.

• Loss of integrity of the cranial bones and/or • Control ICP by pharmacologic means or by
meninges causing damage to the underlying brain mechanical hyperventilation with barbiturate-
tissue and creation of an avenue of infection to induced coma and temperature control.
the CNS. • Initiate invasive ICP monitoring and ventricular
• Types include linear, comminuted, depressed, drainage; elevate head and keep neck straight.
compound, and basilar. • Reduction of fracture, including removal of
• Acute cerebral edema and ICP occur from penetrating bone.
neuronal damage, hemorrhage, inflammation,
infection, potassium leaking to the extracellular Keep in Mind
space, and lactate buildup from glycolysis. • After head trauma, an area that is depressed
rather than swollen requires immediate care.
• Amnesia, brief loss of consciousness, or signs of
increased ICP. Make the Connection
• CT scan, or skull x-ray to detect fracture, MRI ICP • Monitor CT, MRI, or PET imaging.
reading. • Maintain a record of vital signs and Glasgow
• Leakage of CSF from cranial orifices. Coma Scale readings.
• Battle’s sign or raccoon sign. • Monitor ICP reading.
Complications • Check any clear drainage for glucose or
• ICP, brain herniation, diabetes insipidus, and vital concentric circles forming on a dressing.
sign instability.
• Permanent impairment of cognitive or motor
function.
Epidural and Subdural

Hematoma
(ep-i-dur-al and sub-du-ral he-ma-to-ma)

Head injuries that may be arterial
or venous in nature, causing ICP and
change in LOC. May cause rapid
ICP or be insidious, chronic, or
become fatal.

• Traumatic brain injury that is nonpenetrating and • Control ICP by pharmacologic means, steroids, or
caused by rotational injury, acceleration injury, by mechanical hyperventilation with barbiturate-
deceleration injury, or both. induced coma and temperature control.
• Epidural hematomas are arterial, so symptoms • Initiate invasive ICP monitoring and ventricular
are more severe due to rapid accumulation of drainage; elevate head and keep neck straight.
blood above the dural layer. • Surgical evacuation of hematoma and repair of
• Subdural hematomas are venous, so symptoms bleeding vessels.
may be more insidious.
• These hematomas may occur together. Keep in Mind
Assessment and Diagnostic Findings • Teach clients that prevention is best approach.
Wear appropriate headgear when engaging in
• CT scan, MRI scan, and x-ray of the skull. activities such as bike riding, skating, skiing, or
• Increased ICP with decreased LOC, headache, playing contact sports. Helmet use does not
dizziness, nausea, vomiting, vital sign changes
guarantee that brain trauma will not occur.
like temperature increase, hemiparesis, unequal
pupil dilation, decorticate or decerebrate
posturing, ICP measurement by invasive or Make the Connection
noninvasive MRI measurement of ≥15 mm Hg. • Monitor CT, MRI, and ICP measurements.
Complications Maintain Glasgow Coma Scale assessments.
• ICP, brain herniation, diabetes insipidus, and vital • Monitor vital signs; keep head elevated and neck
sign instability. straight to lessen ICP.
• Hemiparesis, chronic neurologic injury, or • Elderly clients and alcoholics may develop
death. insidious subdural hematoma.
Huntington’s Disease
(se-le-ak di-zez)

Onset of jerking movements of the
upper extremities, face, and neck
progressing to the rest of the body
accompanied by progressive psychotic
behavior. Genetic testing reveals
mutation of the IT15 gene resulting
in huntingtin protein.

• A disorder that causes a mutation in the IT15 • Antipsychotic medications, antidepressants, and
gene that results in transcription of an abnormal antichoreic medications.
protein called huntingtin protein. Abnormalities • Research is ongoing regarding fetal nerve tissue
in DNA trigger cellular death. Cells affected are transplant, but there is no cure.
those that control motor and cognitive function.
• An autosomal dominant disorder; each offspring Keep in Mind
of an affected parent has a 50% chance of • Teach clients and caregivers that soft foods and
inheriting the disorder. thickened liquids will be substituted in the diet to
• Onset may be in childhood or in midlife. assist in swallowing effectively.
Assessment and Diagnostic Findings • Teach caregivers that jerking movements are not a
sign of aggression but that aggression can occur.
• Personality changes, inappropriate behaviors,
labile moods, depression, and suicidal
tendencies. Make the Connection
• Paranoia with irritability, anxiety, and aggressive • The client with Huntington’s disease must
behavior. make end-of-life decisions at the onset of
• Choreiform movements. symptoms.
• Video swallowing test for dysphagia. • Genetic counseling and testing must be available
Complications to anyone with a history of Huntington’s disease.
• Aspiration pneumonia. • Assess respiratory function, breath sounds, and
• Choking. ability to swallow.
• Progressive loss of social and physical skills,
leading to debilitation and death.
Spinal Cord Injury

(spi-nal kord in-jur-e)

Loss of sensation, movement, or
both after trauma to the neck,
thorax, lumbar, or sacral area.

Pathophysiology substance abuse, skin breakdown, and autonomic
• Nerve fibers of the spinal cord are nonregenerative. dysreflexia.
• Central cord syndrome results in weakness or Medical Care and Surgical Treatment
paralysis that affects the upper extremities more • Immobilize the client, apply traction, and support
than the lower extremities. the respiratory and vital functions. IV access
• Anterior cord syndrome, caused by trauma or required for fluids and medications. Injuries above
ischemia results in weakness and decreased pain C4 will result in respiratory depression.
and temperature sensation below the damaged • Support bowel and bladder function.
area. • Surgically stabilize the vertebrae.
• Posterior cord syndrome causes ataxia, but
strength and sensation are preserved. Keep in Mind
• Brown-Séquard syndrome results in paralysis • Teach clients that they must remain immobile.
on the affected side and sensation loss on the • Clients need to know that there is a “wait and
opposite side of injury. see” time frame for some types of injuries, but
• Cauda equina syndrome results in bowel and they must be kept apprised and participate in the
bladder dysfunction and some leg paresthesia. plan of care.
• Abnormalities in sensation, temperature sense, Make the Connection
or motor function that occur in patterns that
suggest the type of injury. • Monitor all vital functions and oxygenation;
assess CBC.
• MRI scan.
• Maintain immobilization; check sensation/motor
Complications function; assess skin, bowel, and bladder.
• Infection, deep vein thrombosis, orthostatic
hypotension, spinal shock, depression and/or by MEDBOOKSVN.ORG
Uploaded
Autonomic Dysreflexia
(aw-to-nom-ik dis-re-flek-se-a)

In spinal cord injuries above T6,
sudden onset of headache, nasal
stuffiness, high BP, and flushed skin
above the level of injury.

• SCI above T6 receive peripheral sensory impulses • Cerebrovascular accident or hemorrhage; retinal
from below the injury via the spinothalamic tract hemorrhage.
that stimulates a large sympathetic release of • Myocardial infarction.
norepinephrine, dopamine β-hydroxylase, and Medical Care and Surgical Treatment
dopamine. These neurotransmitters cause vaso-
constriction (↑ BP) and skin pallor below the area
• Antihypertensive medications as needed.
of injury.
• Remove the noxious stimuli to stop the dysreflexia.
• The brainstem reacts to the ↑ BP by parasympa- Keep in Mind
thetic nervous innervation above the level of
injury.
• Teach clients with SCI above T6 about symptoms
and to report them immediately.
• Relieving the noxious stimuli stops the sensory • If clients are capable, they should self-catheterize
signal and therefore the sympathetic response. if symptoms begin.
• Blood pressure elevation that can be as high as Make the Connection
300 mm Hg systolic.
• Flushing of skin above the thoracic SCI, nasal • Monitor vital signs.
stuffiness, headache, and bradycardia. • Assess for full bladder or rectal impaction first,
and then conduct systematic assessment for
• Pallor of the skin below the thoracic SCI with stimuli.
piloerection.
• Bladder distention, bowel impaction, UTI, • Monitor CBC, I&O, and urine C&S.
ingrown toenail, pressure sores, wrinkled bed • Turn client every 2 hours.
linen, or pain below the level of the SCI are • Teach and assess bladder and bowel training
activities.
causes.
Spinal Shock
(spi-nal shok)

Period of time after SCI in which
there is no motor or sensory
transmission. Can last a day to
several months.

Pathophysiology • Depression of the client with spinal shock waiting
• SCI causes a concussion-like injury to neurons to know the extent of injuries.
known as spinal shock in which neurons below
the level of the SCI are incapable of any sensory
• Respiratory infection; hemodynamic fluctuation.
or motor transmission.
• Spasticity; autonomic dysreflexia.
• Cytokines cause an inflammatory condition in the
• Immobilization to prevent any further injury.
affected neurons.
• Phase 1 spinal shock is characterized by the • Steroids and other anti-inflammatory agents.
absence of all reflex arcs below the SCI. Keep in Mind
• Phase 2 spinal shock is characterized by the return
• Teach clients that the extent of their injuries
of some of the reflex arcs, which signals the begin- cannot be assessed until spinal shock ends.
ning of the end of spinal shock.
• Phase 3 and 4 are characterized by strong reflexes
that occur with minor stimulation and may be Make the Connection
followed by autonomic dysreflexia, hyperreflexia, • Monitor for return of reflexes, spasticity,
and clonus. or clonus.
Assessment and Diagnostic Findings • Assess breath sounds and institute a respiratory
• Hypotonia, areflexia, and paralysis below the level care program.
of SCI. • Monitor blood chemistry for F&E and CBC for
• Bulbocavernosus reflex elicitation and assessing infection.
for anal sphincter contraction. • Assess skin and utilize pressure-relieving methods
while maintaining immobilization for SCI.
Complications
• Skin breakdown; osteoporosis. • Support the client psychologically.
Cerebral Aneurysm
(ser-a-bril an-u-rizm)

Sudden onset of a severe headache,
ICP, change in LOC, and motor
dysfunction and dilation of pupil
on affected side.

• The endothelial lining of vessel walls become • Rebleeding after surgical repair.
damaged, lose elasticity, and become vulnera- • Vasospasm leading to widespread ischemia.
ble to rupture. Contributing conditions include • Hydrocephalus.
HTN, atherosclerosis, natural presence of arte- Medical Care and Surgical Treatment
rial bifurcation, and congenital high-pressure
areas such as AVMs.
• Antihypertensives.
• Smoking cessation program.
• Ruptured aneurysms have abnormally high levels
• Catheterization and placement of a coil or other
of inflammatory cell infiltration. material to fill a small aneurysm.
Assessment and Diagnostic Findings • The stalk of a berry aneurysm can be clipped
• Cerebral angiography can precisely diagnose an surgically; others may be wrapped to prevent
aneurysm by outlining the abnormal dilation or rupture; some are resected and reanastomed.
outpouching of vessels.
• MRI with contrast is diagnostic and shows Keep in Mind
abnormal outpouching of vessels. • Teach clients to report severe headaches,
• Dilation of the pupil on the affected side, especially accompanied by nausea/vomiting;
headache, nausea and vomiting, change in LOC, have yearly physicals; stop smoking; and limit
and other signs of ICP. alcohol consumption.
• Motor dysfunction of cranial nerve VI resulting in
abnormal gaze.
Make the Connection
• Motor dysfunction of one or both limbs on the
• Monitor ICP, Glasgow Coma Scale score,
side opposite the ruptured aneurysm.
and vital signs.
• Abnormal Glasgow Coma Scale score.
• Assess psychological status.
Tonic-Clonic Seizures
(ton-ik klon-ik se-zhurz)

Presence of an aura followed by loss
of consciousness with alternating
cycles of stiffness and jerking
movements lasting 1–2 minutes.

• Tonic-clonic seizures are generalized seizures. • Status epilepticus and death.
• Pathology includes an area of hyperexcitable • Injury to the head or body, biting of the lips or
neurons. This is the epileptogenic focus. tongue, vertebral compression fractures.
Assessment and Diagnostic Findings • Interpersonal relationship interruption.
• EEG identifies the epileptogenic focus and Medical Care and Surgical Treatment
seizure threshold. • AEDs; ketogenic diet.
• Client reports having a sensory warning prior to • Resection or ablation of the epileptogenic focus.
onset of a seizure (aura). • Vagal nerve stimulation; corpus callosotomy.
• The tonic phase is accompanied by laryngeal Keep in Mind
spasm, autonomic reaction with increase in
pulse and BP, and increased mucus secretion. • Teach clients they may drive again when seizures
This phase lasts approximately 20 seconds. are certified as being controlled.
• The clonic phase is characterized by alternating • Stress may increase the need for AEDs.
atonia and spasm and lasts approximately • Comply with serum AED levels.
30 seconds; the client may be incontinent as
the urinary sphincter relaxes.
Make the Connection
• The entire seizure usually does not exceed
• Protect the client from injury; never insert
1–2 minutes.
anything into the mouth during the seizure.
• The postictal phase follows the seizure and
• Time the seizure; monitor serum level of AEDs;
is characterized by amnesia of the seizure,
monitor CBC for ↓ WBC.
confusion, lethargy, muscle pain, and
embarrassment.
Absence Seizures
(ab-sens se-zhurz)

Usually a disease of children; the
child appears to be daydreaming
and has no recall of the event.
Abnormal EEG.

• Generalized seizures that may be due to alternat- • Teach clients, caregivers, and teachers about the
ing gamma-aminobutyric acid type B (GABAB) illness.
receptor–mediated inhibition alternating with • Medication regimens must be followed to prevent
glutamate-mediated excitation. further seizures.
• Calcium channel abnormalities are also implicated • Teach that serum blood levels of AEDs will be
in the genesis of absence seizures. measured.
Assessment and Diagnostic Findings • Teach side effects (lethargy, sleepiness) of AEDs.
• Electroencephalogram (EEG) showing abnormal • The need for AEDs increases with stress.
spikes alternating with slow-wave patterns.
• Staring episodes that look like daydreaming. Make the Connection
• Mutation in the GABAA receptor gene (GABRB3). • Monitor serum AED levels.
Complications • Monitor vital signs.
• Educational and behavioral problems related to • Provide emotional support to the family; impress
unrecognized seizures. upon the family that this illness can be controlled
Medical Care and Surgical Treatment with little risk to or interruption of the develop-
• Antiepileptic drugs (AEDs). ment of the child.
Myoclonic Seizures
(mi-o-klon-ik se-zhurz)

Brief, sudden jerking motion
bilaterally, with EEG showing
abnormal waveforms.

Pathophysiology • Some forms of myoclonic seizure can be associa-
• A generalized seizure with juvenile onset. The ted with cognitive delay and progressive brain
cerebral cortex, subcortical, and spinal areas are dysfunction.
believed to be involved in the development of
myoclonic seizures. The electrical discharge from Medical Care and Surgical Treatment
the cortex produces stimulation of the muscles • AEDs; ketoginec diet.
through the motor centers. • Vagal nerve stimulation.
• Acetycholine (excitatory), serotonin (inhibitory), • Focal resection; corpus callosotomy.
and GABA (inhibitory) neurotransmitters are Keep in Mind
present in mismatched amounts in this disorder.
• The mechanism of myoclonic seizure disorder is • Teach clients and family members that myoclonic
seizure activity can occur during sleep or immedi-
related to restless leg syndrome. ately after awakening.
Assessment and Diagnostic Findings • Loss of consciousness is rare, but a period of
• Involuntary jerking motion of limbs, soft palate, confusion may occur.
and other areas that occurs bilaterally.
• CT scan and MRI to rule out physiologic abnor- Make the Connection
malities of the brain.
• EEG identifies the epileptogenic focus. • Monitor serum concentrations of AEDs to
• Loss of consciousness cannot be determined due assure therapeutic levels.
to the brevity of the seizure; however, myoclonic • Monitor CBC to assess for BMS.
seizures can progress to tonic-clonic seizures.
Complications
• Falls and injury from tripping.
• May progress to tonic-clonic seizures.
Atonic Seizures
(a-ton-ik se-zhurz)

Sudden loss of muscle tone
causing a “drop attack.”

• Classified as a generalized seizure, with juvenile • Antiepileptic drugs (AEDs).
onset lasting into adulthood. The cerebral cortex, • Vagal nerve stimulation.
subcortical, and spinal areas are believed to be • Focal resection; corpus callosotomy.
involved in the development of generalized • Ketogenic diet.
seizures. The electrical discharge from the cortex
produces stimulation of the muscles through the Keep in Mind
motor centers. • Teach clients and family members about the
• Evidence indicates that an abnormality exists nature of the disorder and its treatments.
among neurotransmitters (e.g., gamma- • Blood tests will be done to monitor serum AED
aminobutyric acid [GABA]) or in calcium, levels.
potassium, or sodium channel activity.
• May experience an aura and have sweating and • Monitor serum concentrations of AEDs to
piloerection. assure therapeutic levels.
• Electroencephalogram (EEG) showing abnormal • Monitor complete blood count (CBC) to assess
wave patterns. for bone marrow suppression.
• Computed tomography (CT) scan and magnetic • Assess CT scan and MRI for abnormalities in
resonance imaging (MRI) to rule out other brain brain structure.
pathology. • Provide emotional support; refer to support
Complications group.
• Injury related to loss of tone and falls.
Simple Partial Seizures

(Focal)
(sim-pl par-shul se-zhurz fo-kal)

Lip smacking, picking at clothing,
or chewing behaviors of which the
client is unaware. Consciousness
is not lost.

• Simple partial seizures, or focal seizures, arise • Psychosocial implications if automatisms are
from one hemisphere of the brain, usually in the present.
temporal lobe. • May spread and become a generalized seizure.
• May spread to the parietal lobe, causing transient Medical Care and Surgical Treatment
paresthesias of the body on the opposite side of
the epileptogenic focus, usually beginning in the
• Antiepileptic drugs (AEDs).
finger, arm, and hand and then spreading to the
• Vagal nerve stimulation.
leg and face.
• Focal resection.
• Corpus callosotomy is controversial.
• Neurotransmitter abnormalities, especially in
• Ketogenic diet.
gamma-aminobutyric acid (GABA), as well as cal-
cium, potassium, or sodium channel abnormali- Keep in Mind
ties, may produce the abnormal electrical charge. • Teach clients and family members about the
• Simple partial seizures may spread and become a nature of the disorder and its treatments.
generalized seizure. • Blood tests are done to monitor serum AED levels.
• Juvenile onset lasting into late adulthood. Make the Connection
• Electroencephalogram (EEG) showing abnormal • Monitor serum concentrations of AEDs to
wave patterns.
assure therapeutic levels.
• Computed tomography (CT) scan and magnetic • Monitor complete blood count (CBC) to assess
resonance imaging (MRI) to rule out other brain
for bone marrow suppression.
pathology.
• Automatisms (e.g., fondling oneself, chewing, • Assess CT scan and MRI for abnormalities in
brain structure.
lip smacking).
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Complex Partial Seizures

(Psychomotor)
(kom-pleks par-shul se-zhurz si-ko-mo-tor)

Staring, running away, picking at
clothing, or standing still with
lip smacking or other socially
awkward behavior. May lose
consciousness.

• Complex partial seizures arise from one hemi- • Antiepileptic drugs (AEDs).
sphere of the brain, usually in the temporal lobe. • Vagal nerve stimulation.
• May spread and become a generalized seizure. • Focal resection.
• Neurotransmitter abnormalities, especially in • Corpus callosotomy is controversial.
gamma-aminobutyric acid (GABA), as well as • Ketogenic diet.
calcium, potassium, or sodium channel abnor-
malities, may produce the abnormal electrical Keep in Mind
charge. • Teach clients and caregivers the nature of these
• Loss of consciousness occurs and may last seizures and that they may spread.
2–15 minutes. • Teach caregivers not to yell at the client or tell the
client to stop the behavior because doing so is
Assessment and Diagnostic Findings not helpful; rather, keep the client safe.
• Electroencephalogram (EEG) showing abnormal
wave patterns.
• Computed tomography (CT) scan and magnetic Make the Connection
resonance imaging (MRI) to rule out other brain • Monitor serum concentrations of AEDs to
pathology. assure therapeutic levels.
• Automatisms (e.g., fondling oneself, chewing, • Monitor complete blood count (CBC) to assess
lip smacking, running away, screaming, for bone marrow suppression.
masturbating). • Assess CT scan and MRI for abnormalities in
Complications brain structure.
• Psychosocial implications if automatisms are • Provide emotional support; refer to support group.
present. • Do not attempt to restrain the client unless he or
• May spread and become a generalized seizure.by
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Cerebrovascular
Accident
(ser-e-bro-vas-ku-lar ak-si-dent)

Inability to form words, drooping
of the face, or inability to see out
of one eye.

• Result of a thrombotic block to blood flow or • Death.
bleeding into the brain that drastically diminishes • Permanent loss of function; unilateral neglect.
blood flow to the neurons, causing the cere- • Depression, poor judgment, seizures, and PE.
brovascular accident (CVA). • Increased ICP and respiratory insufficiency.
• Injured cells fill up with free zinc ions that are Medical Care and Surgical Treatment
believed to hasten their demise.
• Thrombolytic therapy.
• Production of glutamate increases the metabolic
• Antiplatelet therapy; antidysrhythmic medica-
needs of the already depleted neurons. tions; oxygenation; cardiac monitor.
• Inflammation causes cerebral edema.
• Suction as necessary; liquids are thickened.
Assessment and Diagnostic Findings • Surgical intervention for hemorrhagic stroke.
• CT scan (first) and MRI to determine if the CVA Keep in Mind
is a result of ischemia related to a thrombus or a
hemorrhage. • Teach clients to have their BP and blood lipids
• Hemianopsia and facial droop on affected side, checked and to report any CVA signs.
aphasia or dysphasia, and paresthesia or paraly-
sis on the opposite side of the CVA.
Make the Connection
• The CPHSS is performed, and if any one of the
• Closely monitor laboratory tests and
three criteria is positive, the client is brought to
hemodynamic status in the acute phase.
the hospital for assessment.
• ECG to rule out atrial fibrillation; ↑ BP. • Provide physical and occupational therapy; assess
ability to swallow effectively.
• A severe headache will be present in hemorrhagic
stroke.
Multiple Sclerosis
(mul-ti-pl skle-ro-sis)

Exacerbating and remitting periods
of degenerating motor function.
The MRI shows demyelination of
the white matter of the brain.

• Exacerbating and remitting disease characterized • Immobility issues.
by demyelination of brain white matter, damage to • Accidents and risk for falls; decreased cognitive
axons, and decreased number of oligodendrocytes function; alteration in family relationships.
in the CNS affecting young adults (ages 20–40) • Respiratory infections; death.
and women more than men. Medical Care and Surgical Treatment
• Autoimmune inflammatory disease involving
• Beta-interferons, corticosteroids, or adrenocorti-
cell-mediated (T-cell) and antibody (B-cell) cotropic hormone.
activity.
• Antidepressants, antispasmodics, and anticholin-
• Exacerbation of symptoms can be caused by ergics.
extreme heat or cold, fatigue, infection, stress, or
pregnancy.
• Plasmapheresis.
• Physical therapy and rest periods.
• Visual problems (one eye at a time), with eye pain Keep in Mind
during eye movement; diplopia; slurred speech • Teach clients to avoid stress and extremes of
and dysarthria; vertigo; tinnitus; nystagmus; temperature and to report respiratory infections.
ataxia; and dysphagia.
• Numbness and weakness of limbs, spastic or
Make the Connection
flaccid bladder, urinary incontinence, constipation,
and sexual dysfunction. • Evaluate respiratory status; have client use
incentive spirometry.
• Mood lability.
• Encourage self-care and stress reduction; provide
• CSF assessment for oligoclonal IgG.
emotional support.
• Magnetic resonance imaging (MRI) reveals
sclerotic plaques.
Myasthenia Gravis
(mi-as-the-ne-a gra-vis)

Ptosis of one eyelid.

• Meaning “grave muscle weakness,” MG is an • Cholinesterase-inhibiting drugs; steroids;
autoimmune disease that produces antibodies plasmapheresis.
that attack AChR in the NMJ of skeletal muscles.
• ACh molecules are inactivated by the enzyme Keep in Mind
AChE, which is abundantly present at the NMJ. • Teach clients to take their medication on arising
• The disease involves periods of exacerbation and and before eating breakfast.
remission. • Report excessive weakness, nausea, vomiting,
constriction of pupils, and dyspnea.
• Antibodies to muscle striations in serum.
• Weakness with activity and return of muscle Make the Connection
strength after rest. • Avoid medications that interfere with
• Ptosis of eyelids when asked to gaze upward for therapy.
2 minutes; weakness in chewing and swallowing, • Monitor clients on calcium channel blockers,
speaking, and breathing. beta blockers, antibiotics, and antidysrhythmics,
• Exacerbations caused by stress. as these may interfere with muscle contraction.
• EMG to rule out nerve damage. • Assess muscle function; auscultate lungs and
• Tensilon test. review pulmonary function tests.
• Respiratory function tests.
Complications
• Cholinergic crisis; myasthenic crisis.
• Aspiration and choking.
• Respiratory failure; death.
Trigeminal Neuralgia
(tri-jem-in-al nu-ral-je-a)

Severe knife-like facial pain unilaterally
in response to movement of the
musculature of the face, a touch,
or cool breeze.

• Vascular compression or other structural disor- • Anticonvulsants and benzodiazepines.
ders of the vasculature cause inflammation of the • Nerve block with a local anesthetic.
fifth cranial nerve, or TN. • Radiofrequency ablation to destroy some of the
• Inflammation and compression cause demyeli- nerve branches.
nation and remyelination of the nerve. This • Gamma knife therapy.
abnormal myelination causes abnormal sensory
discharge, felt by the client as intense pain. Keep in Mind
• Trigger zones include the lips, upper or lower • Teach clients to protect their eyes if corneal sen-
gums, cheeks, forehead, and side of the nose. sation is lost as a result of treatment. Artificial
tears and an eye patch should be used (eye patch
Assessment and Diagnostic Findings during sleep).
• Burning, jabbing or knife-like pain in the face on
one side.
• Triggers include a slight touch, a cold breeze, Make the Connection
chewing, talking, face washing, teeth brushing, • Encourage normal activity.
shaving, and eating. • Report attacks and implement pharmacologic
• Tearing and frequent blinking on the affected side. intervention as necessary.
• Attacks are rare during sleep. • Assess corneal sensation after ablative therapies.
• CT scan and MRI to rule out other disorders.
Complications
• Avoidance behaviors.
• Bone marrow suppression from drugs to treat
TN; loss of corneal sensation from nerve blocks
and ablative therapies. Uploaded by MEDBOOKSVN.ORG
Parkinson’s Disease
(par-kin-sonz di-zez)

Mask-like facial expression, soft and
monotonous voice, drooling,
dysphagia, and shuffling gait.

Pathophysiology • Parkinsonian crisis triggered by physical or
• Under the cerebral cortex are interconnected emotional stress.
areas of gray matter (basal ganglia), which are
involved in controlling voluntary movement. Medical Care and Surgical Treatment
Adjacent to the basal ganglia are cells of the sub- • Dopamine agonists, MAO-B inhibitors, COMT
stantia nigra that produce the neurotransmitter inhibitors, and anticholinergics.
dopamine necessary to produce smooth and • Pallidotomy; embryonic stem cell therapy.
coordinated muscle movement. Death of cells Keep in Mind
in the substantia nigra leads to decreased levels
of dopamine production, and impairment of • Teach clients tricks to overcome “freezing”; add
fiber and liquids to the diet; report any psycho-
EP tract. logical problems (hallucinations or depression).
• As dopamine levels decrease, acetylcholine levels
• Avoid tyramine-containing foods.
increase.
• MRI to rule out other conditions. Make the Connection
• Lewy bodies, found in the cortex. • Monitor side effects of medication.
• TRAP criteria. • Avoid meperidine (fatal interaction with MAO-B
inhibitors).
Complications
• Orthostatic hypotension, falls, constipation, • Assess ability to chew and swallow.
painful joints from stiffness and tremor, and • Assess for worsening of symptoms.
communication problems. • Provide emotional support, assess for pain.
• Loss of quality of life, depression, swallowing
difficulty, and dementia in later stages related to
the disease or treatment. Uploaded by MEDBOOKSVN.ORG
Alzheimer’s Disease
(alts-hi-merz di-zez)

Short-term memory loss, forgetfulness,
confusion, and inability to recognize
loved ones or self.

Pathophysiology incontinence, decreased appetite, and respiratory
• Neuropathologic findings in SDAT include amy- compromise.
loid plaques, neurofibrillary tangles, and synaptic • MRI, PET scan, and SPECT scans may reveal
and neuronal cell death. areas of tangles, plaques, and decreased cell
• Degeneration occurs first in the hippocampus, metabolism respectively.
(short-term memory), then damage spreads to Complications
the temporal area. Frontal damage causes • Inability to achieve caloric needs.
personality changes and incontinence. • Respiratory compromise leading to pneumonia.
• Acetylcholine levels in the cerebral cortex become • Incontinence and skin breakdown.
deficient. • Immobility resulting in death.
• Ventricles of the brain become larger as the
brain tissue is destroyed. The brain shrinks in
size. • Acetylcholinesterase inhibitors; NMDA receptor
antagonists.
Assessment and Diagnostic Findings • Cognitive therapy, reality orientation, pet therapy,
• Stage 1 (the forgetfulness stage) is characterized validation therapy, reminiscence therapy.
by episodes of losing personal items, forgetting
appointments, and jealousy. Keep in Mind
• Stage 2 (the confusional stage) is characterized • Teach family to assist clients with ADLs.
by transient loss of recognition of loved ones and • Arrange for respite care services.
self, inability to do simple mathematic calcula-
tions, depression, anxiety, and hyperorality.
• Stage 3 (the dementia stage) is characterized by Make the Connection
psychosis, permanent loss of memories of loved • Utilize recall of past events in order to
ones, severe sleep disorders and “sundowning,” communicate with those with severe dementia;
monitor I&O and dietary intake.
Bell’s Palsy
(bellz pawl-ze)

Unilateral drooping of the face;
inability to blink the eye.

• Inflammation thought to be caused by autoim- • Steroids, antibiotics, antiviral medications, and
mune, viral, bacterial, or traumatic processes of B-vitamin supplements.
the seventh cranial nerve (facial nerve), causing • Eye patch and frequent application of artificial
interruption of nerve transmission. tears.
• Motor control is lost usually on one side of the
Keep in Mind
face, although it can occur bilaterally (1%).
• More likely to occur in pregnancy, immune dys- • Teach the client to gently massage the face and
function (e.g., human immunodeficiency virus), ear to ease pain.
or diabetes. • Teach the client to use analgesics as needed and
as prescribed.
• Drooping of the face unilaterally; inability to • Disorder may be self-limiting or become a chronic
condition.
blink the eye.
• Electromyogram (EMG) may be done to confirm
nerve dysfunction. Make the Connection
• Computed tomography (CT) scan to rule out • Medicate the client for pain based on a
cerebrovascular accident. scale of 0–10 when pain level is at 4 or above.
Complications • Assess the affected eye for inflammation, which
• Damage to the cornea of the eye through drying could be a sign of corneal irritation.
or rubbing against the pillow during sleep. Pain
described as burning or “cold” in the eye and
facial area.
Amyotrophic Lateral
Sclerosis
(a-mi-o-tro-fik lat-er-al skle-ro-sis)

Fasciculations and atrophy of muscle
groups with progressive weakness; a
degenerative neuromuscular disease.

Pathophysiology • Incontinence.
• Also known as Lou Gehrig’s disease, ALS is a pro- • Immobility issues; death.
gressive neurodegenerative disease.
• The upper and lower motor neurons degenerate • Muscle relaxants and benzodiazepines for spasticity.
and form scar tissue, disrupting nerve transmis-
sion and leading to muscle atrophy. • Quinine for muscle cramps.
• Results in swallowing and breathing difficulty. • Riluzole to reduce motor neuron destruction.
• A genetic link is suspected as the cause. Onset is • Physical and occupational therapy, massage,
usually between ages 40 and 70 years and more mobility aids, and enteral feedings.
prevalent in men than in women; survival varies • Air mattresses to reduce skin breakdown.
from 3–10 years or more. • Respiratory suctioning and supplemental oxygen.
• Fasciculation and atrophy of muscle, with • Teach the client and caregivers how to preserve
progressive weakness. the skin, respiratory function, and activity level.
• Intellect is intact. • Provide information regarding mobility devices
• Difficulty chewing and swallowing. and computer-assisted communication devices.
• Difficulty clearing respiratory secretions.
• CSF analysis, EEG, nerve biopsy, and EMG may Make the Connection
be done to rule out other disorders.
• Blood enzymes may be increased due to muscle • Assess respiratory function and ability to
atrophy. clear secretions.
Complications • Provide a method of communication.
• Aspiration; respiratory compromise. • Monitor for skin breakdown; institute a turning
schedule.
Guillain-Barré Syndrome
(ge-yan ba-ra sin-drom)

Paralysis of the legs, ascending to
the upper body. May affect the ability
to breathe on one’s own.

Pathophysiology • Immobility, skin breakdown, PE, muscle atrophy,
• GB syndrome (inflammatory polyneuritis), is an and DVT.
inflammatory disorder characterized by a distinct
progression of paralysis. GB often follows a viral Medical Care and Surgical Treatment
infection. Occurs in those older than age 45 years • Plasmapheresis.
and with higher frequency in Caucasians than in • Ventilation and supplemental oxygen.
African Americans. • Steroids.
• Peripheral nerves are infiltrated by immune cells Keep in Mind
that lead to inflammation and demyelination of
the axon. Paralysis begins in the legs and ascends. • Teach clients and caregivers measures will be
taken to mitigate symptoms; temporary ventilator
If the disease reaches the lungs, respiratory sup- support may be needed.
port is required. The plateau stage is the most
severe, but it signals the end of the progression; • Teach about the normal progression of the
disease.
remyelination occurs and the symptoms regress.
• A descending form of the disease exists.
• Miller-Fisher syndrome causes ataxia and extra Make the Connection
ocular paralysis but no respiratory or sensory loss. • Provide emotional support and diversion.
Assessment and Diagnostic Findings • Manage pain; assess for skin integrity, nutritional
• LP for CSF. Shows ↑ protein. status.
• EMG and nerve conduction velocity tests.
• Pulmonary function tests.
Complications
• Respiratory failure, infections, depression, and
anxiety. Uploaded by MEDBOOKSVN.ORG
Encephalitis
(en-sef-a-li-tis)

Inflammation of the brain leading to
ICP, most frequently caused by viruses
(e.g., West Nile virus), parasites,
toxins, bacteria, vaccines, or fungi.

• Neurons are damaged and inflamed, leading to • AEDs, antipyretics, analgesics, sedatives, and cor-
cerebral edema and increased ICP. ticosteroids.
• Causative agents are viruses, ticks, mosquitoes, • ICP monitoring through invasive methods or
parasites, toxins, bacteria, vaccines, or fungi. noninvasive MRI.
Those with a compromised immune system, • Antiviral medications IV.
the very young, and the very old are especially
at risk. Keep in Mind
• Herpes simplex virus may be the most common • Teach client and family members about the
non-insect-borne cause of the disease. disorder.
Assessment and Diagnostic Findings • To decrease cerebral edema, maintain a calm
environment with little stimuli.
• Elevated temperature, headache, nausea, vomiting, • Teach that the goal of ventilator and medication
and general malaise.
therapy is to reduce ICP.
• Ataxia, altered sleep patterns, tremors, and
hemiparesis.
• CT scan, MRI, and LP to assess CSF. CT scan and Make the Connection
MRI diagnose cerebral edema. CSF shows an • ICP is made worse by noxious stimuli;
increased WBC and protein level, and normal keep the client calm and the environment quiet.
glucose levels. • Monitor CBC, ABGs, and ICP measures.
Complications • Assess for skin breakdown.
• Seizures, motor deficits, personality changes, • Monitor ventilation; clear respiratory passages
blindness, and cognitive deficits. only when needed to reduce ICP increases.
• Brain herniation and death.
Malignant Hyperthermia
(ma-lig-nant hi-per-ther-me-a)

Temperature increase and muscle
rigidity following exposure to
anesthetics. Creatinine and BUN
levels increase. Urine is brown
in color.

• Autosomal dominant disorder in which exposure • Discontinue the anesthetic immediately.
to a certain anesthetic agent causes temperature • Cooled intravenous dantrolene and IV fluids to
increase and muscle rigidity. clear myoglobin from the kidneys.
• Affects skeletal muscle tissue primarily. Free • Cooling blanket; antipyretics.
ionized calcium concentration can increase
to damaging levels and cause multiple contrac- Keep in Mind
tions of skeletal muscle. The temperature may • Teach client to report any personal or family
rise to over 105°F from repeated contractions. history of side effects with anesthesia.
• The hypermetabolic state causes lactate forma-
tion, resulting in acidosis.
Make the Connection
Assessment and Diagnostic Findings • Muscle tissue is destroyed by rapid
• Familial link. contraction due to excess calcium. As muscle is
• Temperature increase following exposure to an destroyed, myoglobin is released and flows via
anesthetic. the bloodstream to the kidneys, which may
• Muscle rigidity and sore muscles. cause acute tubular necrosis; adequate
• Dark brown urine (myoglobin in urine); renal hydration is necessary to flush the kidneys.
insufficiency due to rhabdomyolysis. • Monitor blood chemistry for elevated levels of
• Blood chemistry. enzymes, creatinine, and BUN.
Complications • Temperature must be reduced to normal by
• Arrhythmia; death. antipyretics and cooled intravenous fluid.
• Renal failure.
• Destruction of brain tissue; seizure.
CARDIOVASCULAR
Coronary Artery Disease, 96 Venous Stasis Ulcer, 110

Angina Pectoris, 97 Varicose Veins, 111
Myocardial Infarction, 98 Peripheral Artery Disease, 112
Congestive Heart Failure, 99 Buerger’s Disease, 113
Cardiogenic Shock, 100 Raynaud’s Disease, 114
Atrial Fibrillation, 101 Aortic Aneurysm, 115
Ventricular Tachycardia, 102 Hypertension, 116
Ventricular Fibrillation, 103 Leukemia, 117
Pericarditis, 104 Multiple Myeloma, 118
Myocarditis, 105 Graft-Versus-Host Disease, 119
Rheumatic Endocarditis, 106 Metabolic Acidosis, 120
Cardiomyopathy, 107 Metabolic Alkalosis, 121
Deep Vein Thrombosis, 108 Respiratory Acidosis, 122
Aortic Stenosis, 109 Respiratory Alkalosis, 123
Cardiovascular System Disorders 96
Coronary Artery Disease

(kor-o-na-re ar-ter-e di-zez)

Shortness of breath with activity in
a client with risk factors for heart
disease such as a history of elevated
blood lipids, smoking, poor dietary
habits, sedentary lifestyle, and obesity.

Pathophysiology • Cardiac catheterization is the gold standard for
• CAD results in interruption of blood flow that diagnosis.
can cause ischemia or infarction as a result of
atherosclerosis. Complications
• The inflammation attracts low-density lipopro- • Activity intolerance with angina pectoris; myocar-
teins (LDL) and binds them to the site. The dial infarction that can result in permanent heart
triglyceride core of the LDLs is spilled into the muscle damage and heart failure.
underlayer of the intima. Macrophages envelop • Arrhythmias because of loss of perfusion to the
these fats and are now termed “foam cells.” conduction system.
• This is the “fatty streak” seen in early stages of Medical Care and Surgical Treatment
atherosclerosis. As the area enlarges, more LDL, • Dietary changes; lipid-lowering drugs.
macrophages, platelets, and smooth muscle • Cardiac catheterization with balloon angiography
fibers are drawn to the site and accumulate and stent placement, depending on severity.
under the intima, narrowing the vessel. • CABG.
• This causes reduced blood flow and higher blood
Keep in Mind
pressure in the small coronary vessels.
Assessment and Diagnostic Findings • Teach clients that CAD may be genetic, but there
are modifiable risk factors (e.g., cessation of
• Crp to diagnose inflammation in the body; serum smoking, healthy diet, exercising).
lipid profile to assess cholesterol and LDL.
• Stress test with thallium nuclear imaging (areas
not well perfused are seen as “cold spots”). Make the Connection
• Stress echocardiography; ECG abnormalities. • Lifestyle changes can reverse CAD. Assess
• Ultrafast CT scan to detect calcium deposits in shortness of breath with activity.
the arteries.
Angina Pectoris
(an-ji-na pek-tor-is)

Chest pain referred to the jaw, neck,
upper arms, and scapulae that is
usually associated with activity, cold
weather exercise, or smoking. Usually
subsides with rest.

• The coronary arteries that feed the heart muscle • MI; permanent heart muscle damage leading to
become occluded with atherosclerotic plaque. heart failure.
Increased oxygen demands cannot be met Medical Care and Surgical Treatment
because of narrowing and noncompliance to
dilation. Ischemic pain results and is referred to
• Cardiac catheterization with balloon angioplasty
and stent placement.
the jaw, inner upper arms, sternum, and between
the scapulae.
• CABG.
• Vasodilators, calcium channel blockers, beta-
• Causative events include the 4 Es—eating a large adrenergic blockers, angiotensin-converting
meal, excitement, environment (very cold or very enzyme inhibitors, angiotensin II receptor blockers,
hot), and exercise—as well as smoking. lipid-lowering drugs, and antiplatelet drugs.
• Types include stable angina; variant angina
(Prinzmetal’s), unstable angina, which can easily Keep in Mind
lead to MI; and silent ischemia, usually experi-
enced by older adults, that damages the heart
• Teach the client about healthy diet, exercise, and
avoiding triggers of angina.
without pain. • Teach the client about use of nitroglycerin.
• ECG, exercise ECG, graded testing exercise, and Make the Connection
chemical stress testing with radioisotope imaging
(showing “cold spots” or areas of diminished • Anginal attacks and MI must be differ-
entiated. Cardiac enzymes and ECG assist in
cellular metabolism).
diagnosis. Until an MI is ruled out, angina
• Stress ECHO.
should be treated as an MI.
• Crp ↑; cardiac enzymes.
Myocardial Infarction
(mi-o-kar-de-al in-fark-shun)

Severe chest pain that refers to the
jaw, upper arms, neck, and scapula
and is described as “crushing.”
Accompanied by shortness of breath,
elevated BP, and sweating.

• When blood flow diminishes to the heart muscle, • Thrombolytics, antiplatelet drugs, antidysrhyth-
the sympathetic nervous system is activated, mic agents, oxygen, morphine sulfate, nitrates,
raising the blood pressure and heart rate. This vasodilators, beta blockers, and angiotensin-
increases the oxygen and glucose needs of the converting enzyme inhibitors.
cardiac cells. • Cardiac catheterization with stent placement;
• Cardiac necrosis from lack of perfusion occurs CABG.
centrally, surrounded by varying levels of ischemic
tissue radiating outward from the site. Keep in Mind
• Necrotic cardiac tissue will never resume its prior • Prevention of atherosclerosis by healthy lifestyle is
ability to contract but rather will form scar tissue. best; some people are genetically predisposed.
• Damage can occur to the pacing system of the • Teach clients the signs and symptoms of MI so
heart, causing lethal arrhythmias. they will seek treatment in time.
• ECG changes (ST segment elevation). Make the Connection
• Abnormalities in a 12-lead ECG. • Women have atypical signs and symptoms
• Elevation of cardiac enzymes. (nausea, indigestion, and maybe no pain), but if
• Elevated pulse and blood pressure; decreased they present with shortness of breath or other
oxygen saturation. symptoms, diagnostic tests should be performed.
• CBC showing an elevation of white blood cells; • There is a 6-hour window for thrombolytic therapy,
electrolyte abnormalities. but following “60 minutes to treatment” guideline
Complications is best. “Time is muscle.”
• Lethal dysrhythmias, cardiogenic shock, valvular • Defibrillator access in public areas saves lives of
insufficiency, heart failure, and sudden death. those with arrhythmia.
Congestive Heart Failure

(kon-jes-tiv hart fal-yer)

Elevated BNP, edema in the
extremities, shortness of breath,
crackles and pleural effusion,
jugular vein distention,
hepatomegaly, and
splenomegaly.

• The heart is a double pump. Any structural • PND related to pleural effusion, hepatomegaly
damage to the pump will cause heart failure. and splenomegaly, left ventricular thrombus/
• Left-sided heart failure causes backup of fluid in embolus, and cardiogenic shock.
the lungs. Medical Care and Surgical Treatment
• Right-sided heart failure causes backup of fluid in • Oxygen, high Fowler’s position, bedrest,
the inferior and superior venae cavae. IV opioids, IV inotropic agents, IV vasodilators,
• Preload becomes extensive and afterload is difficult IV human B-type natriuretic peptide, ventricular
to overcome because of ↑ PVR. assist device, hemodynamic monitoring, and
Assessment and Diagnostic Findings daily weights.
• SOB; crackles or diminished breath sounds at the Keep in Mind
lung bases; presence of third and fourth heart
sounds; orthopnea; cough; pale, clammy skin; • Yearly physical examinations, proper diet,
anxiety; and restlessness. exercise, and medications can prevent heart
• CXR revealing pleural effusion and/or atelectasis, failure.
increased pulmonary wedge pressures, trans-
esophageal echocardiogram (TEE) showing
decreased ejection fraction and low cardiac
Make the Connection
output, exercise or pharmacologic stress test • Monitor daily weights, urinary output,
breath sounds, and BNP for improvement.
demonstrating poor myocardial perfusion
pattern, ECG abnormalities.
• ABG showing a decreased PaO2; elevation of
endothelin 1 (ET-1), a vasoconstrictor, and ANP
and BNP elevation.
Cardiogenic Shock
(kar-de-o-jen-ik shok)

Following MI, sudden onset of low
BP, poor perfusion, tachycardia,
and arrhythmias.

• AMI leads to decreased contractility of either the • Cardiopulmonary arrest, fatal arrhythmias, renal
right or left ventricle, decreasing cardiac output failure, thromboembolus, and stroke.
to all body organ systems. Medical Care and Surgical Treatment
• CS may be caused by pericarditis and resulting
• Inotropic agents, phosphodiesterase enzyme
cardiac tamponade. inhibitors, platelet aggregation inhibitors,
• Stenosis of heart valves or sustained arrhythmia vasodilators, natriuretic peptides, vasopressors,
can cause CS. and opioid analgesics.
• Drugs, used for preexisting hypertension, angina,
• Hemodynamic monitoring.
or arrhythmias, may reach toxic levels and
cause CS.
• LVAD; intra-aorta balloon pump.

• Jugular venous distention, cyanosis, muffled heart • Teach clients the early signs and symptoms of
sounds, crackles and wheezes in the lung bases, AMI and to seek care immediately.
and extra heart sounds.
• BP of less than 90 mm Hg lasting more than
Make the Connection
30 minutes; ECG showing ST-segment elevation
that indicates AMI. • Monitor urine output, BP, cardiac output,
pulse oximetry, and ECG.
• Cold extremities; change in mental status.
• Keep the environment calm; reassure the client to
• Urine output of less than 20–30 mL/hr.
decrease sympathetic outflow.
• Increased cardiac enzymes.
• CBC indicating inflammation, electrolyte levels,
ABG for acidosis, BNP, and coagulation studies.
Atrial Fibrillation
(a-tre-al fi-bril-a-shun)

Irregular R-R intervals
Palpitations, skipping heartbeats,

or vertigo perceived.

• Atrial fibrillation (AF), or quivering of the atria, • Stasis of blood causes formation of thrombi,
is caused by repeated reentry of stimuli to the which can lead to CVA, MI, or pulmonary
atrioventricular (AV) node. embolism (PE).
• Loss of atrial kick. • Left ventricular failure.
• Stimulation of the sympathetic nervous system, Medical Care and Surgical Treatment
as well as increasing age, illness (e.g., hyperthy-
roidism), and the stress of surgery may initiate AF.
• Intravenous anticoagulants, antiarrhythmic
agents, cardiac glycosides, beta-adrenergic
• Types of AF include paroxysmal, persistent, blockers, and calcium channel blockers.
permanent, and lone.
• Electrical cardioversion, pacemaker, implantable
Assessment and Diagnostic Findings cardioverter defibrillator (ICD), ablation or maze
• ECG shows no P waves, and the rhythm is irregu- procedure (cardiac catheterization approach), or
larly irregular with shortened QRS complex. open-heart maze procedure.
PR interval cannot be measured.
• Client may complain of palpitations, skipped Keep in Mind
heartbeats, and anxiety. • Teach clients, especially those with preexisting
• CBC, cardiac enzymes, thyroid function tests, cardiac conditions, to report palpitations.
serum drug levels, serum toxicology, and blood • Teach clients the importance of monitoring
chemistry to assess for infection, MI, thyrotoxico- laboratory values.
sis, toxicity of prescribed cardiac drugs or side
effects of over-the-counter or street drugs, renal
failure, or abnormalities of electrolytes.
Make the Connection
• CXR or TEE to evaluate for structural or inflam- • Monitor ECG and INR and PT levels
carefully. Report any SOB that may indicate PE.
matory disease.
Ventricular Tachycardia
(ven-trik-u-lar tak-e-kar-de-a)
Client may be lightheaded or

unconscious and pulseless.

• In ventricular tachycardia (VT), the ventricles • Defibrillation; administration of antiarrhythmics,
replace the sinoatrial (SA) node as the pacemaker vasopressors, and oxygen according to ACLS
of the heart. protocol.
• PVCs often precede VT. • Replacement of electrolytes; magnesium adminis-
• VT may be caused by MI, myocardial irritability, tration to relax ventricular myocardium.
and cardiomyopathy.
• Abnormally low levels of K+, Ca++, and Mg+; Keep in Mind
digoxin toxicity; RA, SLE, and respiratory acidosis. • Teach clients to seek emergency medical services
• Cardiac catheterization and pacing wires. for any incidence of chest pain, dizziness, or
syncope because prehospital stabilization can
Assessment and Diagnostic Findings increase chances of survival.
• ECG shows rapid ventricular rhythm, absent
P waves, no PR interval, and QRS complex
greater than 0.11 seconds. Make the Connection
• Client may become diaphoretic and report • Clients with severe preexisting cardiac
sudden dyspnea, palpitations, lightheadedness, conditions may have VT and should be on
nausea, and chest pain. The client may lose telemetry.
consciousness and become pulseless. • Remember: check the client not only the ECG.
• Blood chemistry, cardiac enzymes, ABGs, and • Monitor electrolyte levels, serum drug levels, and
serum digoxin levels are assessed. cardiac enzymes.
Complications
• Sustained VT can progress to ventricular
fibrillation and death.
• CHF following repeated episodes.
Ventricular Fibrillation
(ven-trik-u-lar fi-bril-a-shun)
Loss of consciousness, no peripheral

pulses or blood pressure.

• VF is associated with CAD, MI, and structural or • Immediate defibrillation, oxygen therapy, intuba-
inflammatory cardiac conditions. It may be precip- tion, and administration of antiarrhythmics,
itated by antiarrhythmic drug administration, atrial anticholinergics, and vasopressors according
fibrillation, cardioversion, and hypoxic states. to ACLS protocol.
• VF causes include hyperkalemia and hypomagne- • CABG for perfusion problems.
semia, cardiac catheterization and placement of • ICD for those with known risk.
pacemaker wires.
• Congenital conditions that predispose to VF Keep in Mind
include Marfan’s syndrome, tetralogy of Fallot, • Encourage all clients and family members to learn
Kawasaki’s disease, long QT syndrome, and CPR and to use AEDs for personal safety and
Wolff-Parkinson-White syndrome also predispose promotion of public health.
to VF. • Teach clients to activate emergency services if
experiencing any chest pain.
• ECG shows an irregular rhythm with no P wave,
PR interval, or QRS complex. Make the Connection
• Clients lose consciousness immediately, are pulse- • Follow ACLS protocols and algorithms to
less, and have no BP. increase the likelihood of client survival.
• Cyanosis, respiratory arrest, circulatory collapse, • Defibrillate immediately; monitor oxygen satura-
and pupil dilation occur. tion, ECG, and vital signs continuously.
Complications • Follow safety protocols for use of defibrillators.
• Death.
• Cerebral anoxia, aspiration pneumonia, defibrilla-
tion injury, and repeated VF episodes.
Pericarditis
(per-i-kar-di-tis)

Pericardial friction rub. Substernal
radiating chest pain that increases in
intensity with deep inspiration or lying
flat. Pain is somewhat relieved by
sitting upright and leaning forward.
CBC and ESR may indicate inflammation
or infection is present.

• Pericarditis is an inflammation of the pericardial • Pericardial effusion (an accumulation of fluid in
sac. The pericardial sac is a fibrous tissue layer the pericardium).
that surrounds the heart. Under normal circum- • A large pericardial effusion impairs cardiac filling,
stances, it contains and is bathed with approxi- causing shock or death.
mately 25–50 mL of serous fluid. In pericarditis, • Constrictive pericarditis leads to heart failure.
the volume may increase to 1,500 mL. Medical Care and Surgical Treatment
• Many diseases, conditions, and drugs can inflame
• Drug therapy depends on the causative factor.
the pericardial sac.
• Pericardiocentesis; creation of a pericardial
• Hemopericardium may be caused by trauma and window or use of a balloon pericardiotomy for
in-hospital procedures. chronic or persistent pericarditis.
• Radiating substernal chest pain that increases Keep in Mind
with deep inspiration or lying flat and is some- • Teach clients to seek emergency medical care if
what relieved by sitting upright and leaning experiencing dyspnea or chest pain.
forward, dyspnea, low-grade fever, cough, and
pericardial friction rub.
Make the Connection
• CBC and ESR to detect infection and inflamma-
• Monitor ECG, oxygen saturation, and
tion; ECG shows ST-T wave elevation; echocar-
ease of breathing after pericardiocentesis.
diogram shows pericardial effusions; CT scans
and MRI can show the status of the pericardial • Assess clients undergoing invasive cardiac
procedures for postprocedure pericarditis.
tissue and effusions; blood chemistries to
detect uremia; pericardiocentesis fluid analysis
to determine the causative agent.
Myocarditis
(mi-o-kar-di-tis)

Fever, chest pain, and activity
intolerance.

• The myocardium is infiltrated by inflammatory cells • Pericarditis, arrhythmias, chronic dilated
leading to necrosis of muscle cells and fibrosis. cardiomyopathy, and heart failure.
• Causes include viral, bacterial, protozoan, and Medical Care and Surgical Treatment
fungal infections.
• Anticoagulants for thromboembolus development.
• Inflammatory and autoimmune causes or • Angiotensin-converting enzyme inhibitors,
exposure to chemicals or toxins, and radiation beta-adrenergic blockers, loop diuretics, and
therapy. cardiac glycosides.
• Women who are pregnant, those undergoing
• Temporary pacemaker or heart transplant.
radiation therapy to the chest area, and the
elderly are also at risk. Keep in Mind
Assessment and Diagnostic Findings • Teach clients to report new onset of dyspnea or
• CBC and ESR to detect infection and inflamma- swelling of ankles immediately.
tion; cardiac troponin I is elevated; ECG shows • Activity will be limited after diagnosis, maybe
ST-segment elevation and Q-wave development, permanently.
and may show complete heart block and BBB; • Teach about heart transplantation.
ECHO shows ↓ CO and ↓ EF.
• MRI shows areas of inflammation.
Make the Connection
• Temperature elevation and chest pain.
• Monitor for worsening signs of heart failure
• Signs of heart failure.
and for pericarditis (pericardial friction rub) and
• Endomyocardial biopsy to examine the cells of
chest pain.
the myocardium for damage and causative agent.
• PCR identification of a viral infection in myocar-
dial biopsy tissue.
Rheumatic Endocarditis
(roo-mat-ik en-do-kar-di-tis)

Fever, chest pain, dyspnea, cough,
arthritic symptoms, chorea, and ankle
edema develop 2–3 weeks after strep
throat (beta-hemolytic streptococci).

• BHS that cause throat infection or impetigo travel • Thromboemboli.
to the bloodstream, causing bacteremia. The BHS • Mitral or aortic valve stenosis; CHF.
infect the heart typically 2–3 weeks after the initial Medical Care and Surgical Treatment
infection. May occur in clients in childhood and
recur as rheumatic endocarditis at any age.
• Antipyretics as needed and long-term antibiotic
therapy.
• All layers of the heart are affected, with
• Treatment of heart failure.
generalized inflammation of all heart structures.
• Mitral valvulotomy, percutaneous balloon
• The endocardium is affected by vegetation valvuloplasty, or mitral valve replacement.
deposited on the valves.
• The end result of cardiac structural anomalies Keep in Mind
is CHF. • Teach clients that any sore throat or outbreak of
Assessment and Diagnostic Findings impetigo must be examined by culture, treated,
• Tachycardia, heart murmur, pericardial friction and reexamined by culture to ensure the infection
rub, chest pain, fever, polyarthritis, subcuta- has been cured.
neous nodules, arthralgia, dyspnea, cough, and
abdominal pain.
Make the Connection
• ECG shows PR interval lengthening.
• Monitor CBC for improvement.
• ECHO shows abnormal movement of the mitral
• Monitor client for pericardial friction rub and
valve.
symptoms of heart failure.
• Antistreptolysin O titer greater than 250 IU/mL
• Monitor oxygen saturation and activity tolerance;
and throat culture positive for BHS; CBC and
offer restful activities.
ESR indicating infection and inflammation.
Cardiomyopathy
(kar-de-o-mi-op-a-the)

Dyspnea, fatigue, edema of the
ankles, and possible atypical chest
pain occurring with rest and not
relieved with nitrates. MRI shows
enlargement of the heart muscle
or chambers.

• Enlargement of the heart muscle or chambers of • Anticoagulants and antiarrhythmias.
the heart that causes heart failure. • Medications and procedures are related to type.
• Major types: dilated and restrictive. Keep in Mind
• Causes: Heredity, myocarditis, chronic alcohol or
cocaine use, HIV, thiamine or zinc deficiencies, • Teach family members how to perform CPR and
infections; or autoimmune disease. to seek emergency medical care if the client
experiences dyspnea, chest pain, or syncope.
• Angina, arrhythmias, dyspnea, fatigue, syncope,
and S3 gallop rhythm. Make the Connection
• ECHO, shows abnormal myocardial thickness or • Monitor vital signs, oxygen saturation,
large chamber size. and for worsening signs of congestive heart
• ECG shows arrhythmias. failure and monitor ECG for arrhythmias.
• Cardiac catheterization to visualize chamber size • Remember: PE, MI, or CVA can occur if throm-
and contractility. boemboli are produced. Monitor INR and PT.
• Cardiac MRI to visualize heart wall and chamber
size.
Complications
• Congestive heart failure.
• Hypertrophic type may cause enlargement of the
septum that blocks the aortic valve resulting in
abnormal heart rhythms and sudden death.
• Thromboemboli.
Deep Vein Thrombosis

(dep van throm-bo-sis)

Positive Homans’ sign, redness or
warmth in an area of pain in the leg,
and edema unilaterally in the arm
or leg.

• Causes of DVT include venous stasis, vessel wall • Massive PE, MI, or CVA from thromboembolus.
injury, and hypercoagulability. Perinatally, women Medical Care and Surgical Treatment
are at increased risk because of excess clotting
factors.
• Anticoagulants and thrombolytics, followed by
outpatient warfarin treatment.
• Areas where blood flows more slowly, usually
• Compression stockings and early ambulation.
where veins are bending are more prone to DVT.
Postsurgery clients are at greater risk due to ↓
• Thrombectomy; vena caval filter placement.
•
activity. Keep in Mind
• Septicemia resulting in hemolysis and dehydra- • Teach the client to report swelling, pain, or
tion can contribute to DVT. warmth in an extremity.
Assessment and Diagnostic Findings • Seek immediate medical attention if sudden
• Unilateral pitting edema in the affected extremity, dyspnea occurs.
with pain and erythema over the site. • Teach the client to move about on airplanes and
• Positive Homans’ sign. long car rides.
• D-dimer test showing fibrin degradation
products.
Make the Connection
• Duplex ultrasonography detects the occlusion • Never repeat a positive Homans’ assessment.
and changes in venous flow.
• Impedance plethysmography shows slowed • Monitor platelets and clotting time.
venous outflow from the affected area. • Have client maintain bedrest; as ordered.
• MRI to image iliac or inferior vena caval sites.
• CT venography shows DVT.
Aortic Stenosis
(a-or-tik ste-no-sis)

Presence of a loud, harsh midsystolic,
crescendo–decrescendo murmur that
radiates to the side of the neck and
down the left sternal border or apex.
Heard loudest at the second right
ICS. Low BP, fatigue, dizziness,
and chest pain.

• AS develops from thickening, scarring, calcifica- • Prophylactic antibiotic therapy; anticoagulant
tion, vegetation, or fusing of the flaps of the valve. therapy.
• Left ventricular hypertrophy occurs as the sympa- • Valvotomy for young adults; valve replacement in
thetic nervous system is activated to compensate older adults.
for low cardiac output. When compensatory
mechanisms fail, heart failure results. Keep in Mind
Assessment and Diagnostic Findings • Teach clients to report any episodes of chest
pain, vertigo, or syncope immediately.
• Presence of a loud, harsh midsystolic, crescendo– • Teach clients to seek immediate medical care
decrescendo murmur that radiates to the side of
for chest pain.
the neck and down the left sternal border or
apex. Heard loudest at the second right ICS. • If a valve replacement is performed, teach the
client the importance of maintaining anticoagu-
• Low BP, fatigue, vertigo or syncope, palpitations,
lant therapy and keeping laboratory appoint-
and angina chest pain.
ments to assess effectiveness of therapy.
• CXR and ECG show enlargement of the left
atrium and ventricle.
• Two-dimensional and Doppler echocardiography Make the Connection
show impaired movement of the aortic valve, • Monitor the INR and PT in clients with
decreased cardiac output, and lowered ejection valve replacement and on warfarin therapy.
fraction. • Assess for bleeding, assess platelet count, and
• Cardiac catheterization shows increased ventricular assess CBC for anemia.
pressure and decreased cardiac output. • Remember: Microorganisms can grow on the
Complications valves, forming vegetation that can embolize.
• CHF; pulmonary edema.
Venous Stasis Ulcer

(ve-nus sta-sis ul-ser)

Ulcer that occurs on the lower
extremities in the presence of edema
and brown, leathery skin. Described
as “wet” and exudes a large amount
of serous fluid.

• Blood is not returned efficiently to the heart and • Unna’s boot compression bandage is wrapped
venous pressure ↑ in the lower extremities. The with the leg elevated.
↑ venous pressures cause backflow of blood into • Pentoxifylline therapy.
the capillary exchange beds and leakage of serous • Skin grafts and artificial cultured skin.
fluid containing wastes into the interstitial space. • Clients are instructed to walk, as tolerated.
• Edema in the interstitial space prevents capillary
Keep in Mind
access for all cells and can be severe.
• Increased pressure in a vein causes a small rup- • Teach the importance of elevating the legs;
ture that becomes a deeper wound that cannot walking as tolerated to ↑ use of skeletal muscle
heal because of poor capillary access to inflam- pump.
matory agents, oxygen, and glucose. The wound
ulcerates because of inflammatory substances
trapped in the subcutaneous tissue, damaging the
Make the Connection
valves in the veins and exuding serous fluid. • Assess for healing when the compression
boots are removed (every 2–7 days).
Assessment and Diagnostic Findings • If skin grafts are used, the area should not be
• Edema of the extremities, with brown, leathery disturbed until skin buds are seen.
skin.
• Culture of the ulcer obtained.
• CBC to R/O infection.
Complications
• Infection, nonhealing chronic ulcerations that
affect the client’s quality of life; reulceration.
• Permanent damage to the valves in the veins.
Varicose Veins
(var-i-kos vanz)

Visible, tortuous, bulging veins that
cause discomfort in the leg and
changes in body image.

• Venous return in the body is dependent on the • Sclerosing agents.
muscular contractions of the skeletal muscle • Endovenous laser therapy, radiofrequency abla-
pump. Competency of the valves within the veins tion, ambulatory phlebectomy, and the traditional
cause forward flow that is eventually returned to saphenectomy with saphenofemoral ligation.
the heart. • Corticosteroids and other immunosuppressants.
• In pregnancy, the pressure of the fetus causes
Keep in Mind
venous hypertension, and hormones make the
valves less competent, which ↑ incidence of vari- • Teach clients to utilize compression stockings if
cose veins of the legs and anus to occur. they stand in one place for a prolonged period
• Superficial varicosities are more visible than more of time; teach them to plantar flex and dorsiflex
deeply located varicosities. the foot and ankle, and shift their weight from
leg to leg.
• Visible tortuous veins seen on the legs or hemor- • Teach pregnant clients to elevate the legs
frequently.
rhoids seen around the anus. Varicosities can
also occur in the esophagus because of portal
hypertension. Make the Connection
• Contrast venography, MRI, and color-flow duplex • Assess whether the client who has
US that show blood pooling. undergone treatment is using compression
• Clients complain of pain, pressure, or a dragging stockings.
sensation in the legs.
Complications
• Thromboembolisms, venous ulcerations, and
bleeding varicosities.
Peripheral Arterial
Disease
(per-if-er-al ar-te-re-al di-zez)

Symptoms occur late in the disease
and include intermittent claudication
in the calves associated with activity.
Color changes in the legs, with hair
loss and dry, flaky skin, may occur.

• PAD is caused by progressive narrowing of the lumen • Thromboembolism, CVA, and MI.
of the arteries by atherosclerotic plaque buildup. • Necrosis, arterial ulcerations, gangrene, and
• If arteries are totally occluded, necrosis and amputation.
ulceration (gangrene) develop, and the limb is Medical Care and Surgical Treatment
no longer viable.
• Anticoagulants; pentoxifylline.
Assessment and Diagnostic Findings • Vasodilators and calcium channel blockers.
• The 5 Ps: pulselessness, paralysis, paresthesia, • Amputation.
pain, and pallor.
• Heaviness and pain in the legs after a short Keep in Mind
period of exertion that are relieved by rest. • Teach client to have yearly physicals and blood
• ABI measures BP in the upper and lower extremi- work to detect risks for atherosclerosis.
ties. The BP taken after a brief period of exercise in • Eat a healthy diet and exercise daily.
the client with PAD shows a drop in the ankle BP,
indicating constriction and decreased perfusion.
Make the Connection
• Doppler US measures the velocity of blood flow.
• Monitor dependent and elevated extremities
• MRI shows images of plaque in arteries.
in the client with PAD. Palpate for pulses; report
• Plethysmography and angiography to visualize
loss of pulse, mottling, or cold extremities.
blood flow through the extremity.
• Lipid panel and a total blood chemistry to assess • Monitor anticoagulant therapy and glucose levels.
electrolytes and nitrogenous wastes.
• D-dimer test to assess for fibrin degradation
products; Crp and interleukin 6 to assess for
inflammatory markers.
Buerger’s Disease
(burg-erz di-zez)

A disease of young men who
smoke. Thrombi develop in the
legs, occluding circulation. “Your
cigarettes or your legs” is often
the choice.

• BD also known as thromboangiitis obliterans is a • Necrosis, arterial ulcerations, gangrene, and
disease of recurrent inflammation of the small amputation.
and medium arteries of the legs that results in Medical Care and Surgical Treatment
thrombus formation.
• Anticoagulants; pentoxifylline to increase red
• Young men (aged 25–40) who smoke are affected. blood cell flow.
It is thought that substances in the tobacco prod-
ucts trigger an autoimmune response in these
• Vasodilators and calcium channel blockers.
young men. Vasospasm and loss of arterial blood
• Amputation.
flow occurs.
• The 5 Ps: pulselessness, paralysis, paresthesia, • Teach the client the importance of smoking
pain, and pallor. cessation.
• Heaviness and pain in the legs after a short • Refer client to a support group for those with
period of exertion that are relieved by rest. Buerger’s disease.
• ABI measures BP in the upper and lower extremi-
ties. The BP taken after a brief period of exercise
in the client with PAD shows a drop in the
Make the Connection
ankle BP, indicating constriction and decreased • The legs will be purple-red when
dependent and show pallor when elevated;
perfusion.
palpate for pulses.
• Doppler US measures the velocity of blood flow.
• Maintain anticoagulant and vasodilator therapy.
• MRI shows images of plaque in arteries.
• Assess the effectiveness of smoking cessation
• Plethysmography and angiography to visualize
program and support group interactions.
blood flow through the extremity.
Raynaud’s Disease
(re-noz di-zez)

Vasospasm and vasoconstrictive
ischemia of the tips of the nose,
fingers, hands, feet, and toes when in
contact with cold objects or cold
temperatures.

• A disease of women, RD causes vasospasm and • Digital ulceration, tissue loss, and gangrene.
vasoconstrictive ischemia of the tips of the nose, Medical Care and Surgical Treatment
fingers, hands, feet, and toes when in contact
with cold objects or cold temperatures. Ischemia
• ACE inhibitors, angiotensin-receptor antagonists,
vasodilators, SSRI, analgesics, and local infiltra-
is followed by a period of hyperemia. Diagnosis is tion with lidocaine.
made when the ischemic attacks occur for 2 or
more years.
• Digital sympathectomy.
• Pharmaceutical-grade omega-3 fatty acid.
• Endothelin 1 and angiotensin may be causative
• Biofeedback; avoiding contact with cold; smoking
agents. cessation.
• Secondary RD is associated with autoimmune/
collagen disorders and persons with occupations Keep in Mind
that involve vibratory tools like jackhammers. • Teach the client to insulate the hands, feet, and
Assessment and Diagnostic Findings face from cold temperatures and to never smoke.
• CBC to assess for blood disorder, BUN and • Report ischemic events immediately.
creatinine to assess renal and hydration status,
PT and aPTT to assess the clotting cascade;
serum glucose; and thyroid panel to assess for
Make the Connection
metabolic disorders. Diagnostics for autoim- • Assess color, sensation, and temperature
in digits and nose; smoking cessation program.
mune and collagen disorders are also ordered.
• Calcitonin gene-related peptide, which is a
vasodilator, is found to be decreased in RD.
• Neuropeptide Y, a vasoconstrictor, is found in
high levels in secondary RD.
Aortic Aneurysm
(a-or-tik an-u-rizm)

Abdominal pain, nausea, or fullness
relieved by position change. Pulsating
mass in the abdomen. Auscultation
with the bell of the stethoscope for a
bruit adjacent to the umbilicus.

• Bulging or ballooning of the aorta due to athero- • Monitoring of the size of the aneurysm.
sclerosis, hypertension, chronic obstructive pul- • Antihypertensive agents for BP management.
monary disease, smoking, trauma, or congenital • Smoking cessation program.
anomaly. Commonly found in the abdominal • Surgical intervention with open surgical repair or
aorta (abdominal aortic aneurysm [AAA]). Tends endovascular grafting.
to run in families with Marfan’s syndrome.
• Types include fusiform, saccular, and dissecting. Keep in Mind
• May be completely asymptomatic until it • Teach clients with a first-degree relative with AAA
ruptures. the risk factors and symptoms to report, and
encourage screening by ultrasound.
• Abdominal pain, nausea, or fullness relieved by • Teach clients at risk to maintain therapy with
antihypertensive agents, avoid smoking, and have
position change. Pulsating mass in the abdomen.
yearly examinations.
• Auscultation with the bell of the stethoscope for
a bruit adjacent to the umbilicus.
• US screening for men aged 50 or older or those Make the Connection
with a family history. • The rate of rupture increases with age
• MRI showing a enlarged black mass; aortography or surgery.
showing the outline of the aortic abnormality. • Assess BP and advise clients undergoing surgical
• Spiral CT scan with contrast revealing the repair to avoid lifting heavy objects.
calcified rim of the aneurysm.
Complications
• Rupture of the aneurysm, cardiac arrest,
hemorrhage, shock, and death.
Hypertension
(hi-per-ten-shun)

BP readings of greater than 119 mm Hg
systolic or greater than 79 mm Hg
diastolic classify the client as
prehypertensive. The client may have
no symptoms or, in severe cases,
headache and nosebleed.

• BP is determined by CO, which is determined by • Atherosclerosis and vessel damage; cerebrovascu-
heart rate multiplied by the stroke volume. The lar accident (CVA) and myocardial infarction
heart rate can be affected by stimulation of the (MI), and resulting congestive heart failure (CHF).
SNS responding to arterial baroreceptors that • Nephropathy and retinopathy due to poor
measure BP and by chemoreceptors that measure perfusion.
CO2 levels. Other mechanisms that alter BP Medical Care and Surgical Treatment
include the renin-angiotensin-aldosterone system,
exercise, emotions, and taking medications that
• Diuretics, antihypertensives, and lifestyle changes.
cause vasoconstriction. High blood pressure dam-
ages the intima of arteries, making way for infiltra- Keep in Mind
tion of macrophages, muscle fibers, cholesterol,
and fatty acids that form atherosclerotic plaque.
• Teach clients to change modifiable risk factors,
avoid added salt, decrease caffeine intake, drink
• PVR is the resistance to blood flow through alcohol modestly, take prescribed medications
arterioles creating a high afterload. regularly, and manage stress through exercise or
Assessment and Diagnostic Findings meditative means.
• Systolic BP should ideally be less than 120 mm Hg
and diastolic BP should be less than 79 mm Hg
(JNC 7).
Make the Connection
• Hypertension is diagnosed if the average BP • Assess BP carefully in the correct way with
the correctly sized cuff, the client seated, and the
readings taken on two separate occasions is
sphygmomanometer at heart level. Take the BP
greater than 139 mm Hg systolic and
after 5 minutes of rest.
greater than 89 mm Hg diastolic.
Leukemia
(loo-ke-me-a)

Low-grade fever, lymphadenopathy,
bleeding tendency, infections, and
anemia. Bone marrow biopsy shows
many immature WBCs.

• Leukemia can be acute or chronic and affect • Thrombocytopenia, petechiae and bleeding,
lymphocytes, monocytes, granulocytes, erythro- infection, GVHD, and severe anemia.
cytes, and platelets. Due to a mutation in the Medical Care and Surgical Treatment
stem cells of the bone marrow, immature WBCs
(blasts), proliferate uncontrollably in the bone
• Chemotherapy, radiation therapy, stem cell
transplant, and bone marrow transplant.
marrow, lymph tissue, and spleen. In the bone
marrow, the immature and ineffective WBCs Keep in Mind
crowd the normal WBCs, RBCs, and platelets,
greatly reducing their number.
• Teach clients that ALL in children has a high cure
rate (cancer-free for 5 years or more).
• Types include ALL, AML, CLL, CML. • Clients with leukemia should use soft toothbrushes,
Assessment and Diagnostic Findings eat foods of moderate temperature, avoid organic
• CBC showing many immature WBCs, low RBC vegetables, take frequent rest periods, and report
count, and low platelet count. fever immediately.
• Bone marrow aspiration, with cell count showing
many immature blasts.
Make the Connection
• Genetic testing for the Philadelphia chromosome
• Monitor the CBC, vital signs, and oxygen
(CML).
saturation levels frequently.
• LP for identification of blasts in CSF to determine
• Maintain reverse isolation in the client undergoing
CNS involvement.
BMT.
• Low-grade fever, pallor, weakness, SOB, bone pain,
headache, and confusion.
Multiple Myeloma
(mul-ti-pl mi-e-lo-ma)

Pathologic fractures from severe
osteoporosis, bleeding tendency,
infections, and anemia affecting those
in the fifth to seventh decades of life.

• Mutation of plasma cells (type of B-lymphocyte) • High-dose steroids, IV biphosphonates, thalido-
that infiltrate the bone marrow, bone tissue, liver, mide, and analgesics.
spleen, lymph nodes, lungs, adrenal glands, • Treatment of hypercalcemia, hyperuricemia,
kidneys, skin, and GI tract. dehydration, respiratory infection, renal calculi.
• MM has a poor prognosis. • High-dose chemotherapy with stem cell trans-
Assessment and Diagnostic Findings plant and external beam radiation therapy.
• Bone pain, especially in the back or ribs, joint Keep in Mind
pain, low-grade fever, and general malaise.
• Pathologic fractures and spinal cord compres- • Teach the client to drink plenty of fluids, walk as
tolerated, and avoid injury.
sion, hypercalcemia, and pneumonia.
• CBC shows anemia, WBC fluctuation, and • Report fever, pain, or paresthesias immediately.
decreased platelets.
• X-ray, CT scan, bone scans, and MRI show severe Make the Connection
osteoporosis. • Monitor the CBC, vital signs, oxygen
• Urine is positive for M-type gamma globulins saturation, and breath sounds frequently.
known as Bence-Jones protein (24-hour urine). • Ambulation as tolerated.
• Bone marrow biopsy confirms the presence of • Lift the client with a lift sheet gently; provide
immature plasma cells. passive and active range of motion.
Complications • Encourage fluid intake of up to 4 liters daily;
• Bone destruction, pathologic fracture, spinal cord medicate for pain as needed.
compression with loss of bowel and bladder con-
trol, and renal calculi from hypercalcemia; GVHD.
• Recurrent infections, pneumonia, and sepsis.
Graft-Versus-Host
Disease
(graft vur-sus host di-zez)

Approximately 31/2 months following
solid organ, bone marrow, or stem
cell transplant, damage to the
epithelial cells of the skin, GI tract,
and hepatocytes occurs from an
immune attack initiated by the
transplanted tissue.

Pathophysiology • Endoscopic examination of the GI tract.
• GVHD can occur following solid organ, bone Complications
marrow, or stem cell transplant. The graft cells
recognize the host cells as foreign. • Graft failure, hemorrhage, infection, and liver
failure that may lead to death.
• Phase 1 of GVHD involves the host tissue that
• Permanent scarring of epithelium of skin and
has been prepared for transplant by use of
chemotherapy and radiation therapy. The injured GI tract.
tissue releases cytokines, which stimulate the Medical Care and Surgical Treatment
host’s CD4+ cells. • Removal of graft T cells.
• In phase 2 of GVHD, activated CD4+ cells cause • Immunosuppressive agents, DMARDs, and
the graft to activate T killer cells and NK cells that anti-TNF agents.
mount an immune response against susceptible • Plasmapheresis of host CD4+ cells.
tissues of the host (epithelial tissue, GI tract, and
hepatocytes). Keep in Mind
• In phase 3 of GVHD, immune cells and cytokines • Teach the client that prior to bone marrow or
begin to damage host tissues. stem cell transplant, immunosuppressive and
steroid drugs may be given.
• CBC shows anemia, thrombocytopenia, and an
elevation in eosinophils; Howell-Jolly bodies are Make the Connection
identified in the peripheral blood smear. • Monitor serial CBC, liver enzymes, and
• Elevated serum levels of IL-2 receptor alpha, TNF blood chemistries. Remember: This disease
receptor 1, IL-8, and hepatocyte growth factor; occurs 3 1/2 months after graft.
elevated LE and liver biopsy.
• US, CT scan, and Doppler studies to assess the liver.
Metabolic Acidosis
(met-a-bol-ik as-i-do-sis)

ABG shows pH of less than 7.35,
PCO2 in the range of 35–45 mm Hg
or decreasing
_ to compensate, and
HCO3 of less than 22 mEq/L.

Pathophysiology • Serum osmolality; blood chemistry analysis for
• Normal pH of the body is 7.35–7.45. ABG analy- azotemia, electrolytes, and high fasting glucose
sis diagnoses metabolic acidosis; pH is low, CO2 levels; Kussmaul’s respirations; change in mental
is within normal_range or decreasing to compen- status; ECG changes.
sate, and HCO3 is low.
Complications
• Buffering systems are initiated by the body when
• Prolonged acid-base imbalance will lead to death.
the pH goes out of range. The first to react are
cellular buffers. In metabolic acidosis, H+ are Medical Care and Surgical Treatment
absorbed into the cells, causing a shift of K+ into • IV administration of sodium bicarbonate; correc-
the extracellular area. tion of electrolytes.
• The lungs are the second buffering system to
Keep in Mind
activate. When pH is low, CO2 is released
through rapid and deep respirations. • Teach the client about toxic materials in the
environment.
• The kidneys are the last buffering system to
• Teach the client the signs and symptoms of
activate; and it may take as long as 1–2 days
for them to begin to affect pH. In metabolic diabetes mellitus and the importance of
acidosis, the kidneys secrete H+. maintaining a normal blood glucose level.
• Causes include diarrhea (loss below the waist-
lose base), CRF, lactic acidosis, salicylate poison- Make the Connection
ing, methanol and alcohol poisoning, paralde-
hyde poisoning, and diabetic ketoacidosis. • Monitor laboratory values, mentation,
acetone breath, and ECG.
Assessment and Diagnostic
_
Findings
• Low pH and low HCO3 . The value of the anion gap
may be high, low, or normal; guides further testing.
Metabolic Alkalosis
(met-a-bol-ik al-ka-lo-sis)

ABG shows pH of greater than 7.45,
PCO2 in the range of 35–45 mm Hg
or rising
_ to compensate, and
HCO3 of greater than 26 mEq/L.

Pathophysiology • Abnormalities on electrocardiogram (ECG).
• Normal pH of the body is 7.35–7.45. The ABG Complications
diagnoses metabolic alkalosis, pH is high, CO2 is
within normal range or increasing to compensate, • Prolonged changes in pH level of the body.
_
and HCO3 is high. • Tetany, seizures, change in mentation, hypoventila-
+
tion and hypoxemia, and lethal arrhythmias (K ).
• Buffering systems are initiated by the body when
cellular buffers. In metabolic alkalosis, H+ are • Carbonic anhydrase inhibitors, IV hydrochloric
released from the cells, causing a shift of potassi- acid preparations, potassium-sparing diuretics,
um ions (K+) into the cells. ACE inhibitors, K+ and Ca supplements, corticos-
• The lungs are the second buffering system to teroids, nonsteroidal fluid replacement, and fluid
replacement.
activate. When pH is high, CO2 is held by slow,
shallow respirations.
Keep in Mind
• Teach clients about metabolic alkalosis, especially
activate, and it may take as long as 1–2 days
for them to begin to affect pH. In metabolic in the case of vomiting for prolonged periods, and
alkalosis, the kidneys hold H+. to seek medical care if mental status changes occur
or if they have tremors.
• Causes include persistent vomiting; gastroin-
testinal suction; diarrhea; and use of loop
diuretics, antacids, licorice, glucocorticoids, Make the Connection
and mineralocorticoids.
• Monitor ABGs and other laboratory
Assessment and Diagnostic Findings values. Check both Chvostek’s and Trousseau’s
• Urine chloride less than 20 mEq/L; hypocalcemia signs to detect low calcium levels and ECG for
and hypokalemia; ABG analysis. arrhythmias related to low K+ levels.
Respiratory Acidosis
(res-pir-a-to-re as-i-do-sis)

ABG shows pH of less than 7.45,
PCO2 of greater
_ than 45 mm Hg,
and HCO3 within range or rising
to compensate.

• Normal pH of the body is 7.35–7.45. The ABG • Chronic hypoxemia leading to polycythemia,
analysis diagnoses respiratory
_
acidosis; pH is low, pulmonary hypertension, and cor pulmonale;
CO2 is high, and HCO3 is within normal range mental status changes; cerebral edema; and
or rising to compensate. papilledema. Death may occur.
• Buffering systems are initiated by the body when Medical Care and Surgical Treatment
cellular buffers. In respiratory acidosis, H+ are
• Bronchodilators, ventilation support, mechanical
or, naloxone or flumazenil for opioid and benzo-
absorbed into the cells, causing a shift of K+ out diazepine overdosages, and theophylline.
of the cells.
• Surgical interventions for obesity and sleep
• The lungs are the second buffering system to apnea.
activate. When pH is low, CO2 is released
through rapid and deep respirations. Keep in Mind
• The kidneys are the last buffering system, and it • Teach the client to avoid smoking, use oxygen
may take as long as 1–2 days for them to begin as directed, and maintain a healthy weight.
to affect pH. In respiratory acidosis, the kidneys
secrete H+.
• Teach the client about sleep study programs.
• Causes include COPD, hypoventilation, sleep
Make the Connection
apnea, and drug use that suppresses respiratory
function. • Monitor ABGs, ventilation status, and
CBC for polycythemia.
• ABG analysis, CBC for polycythemia, drug • Assess Glasgow Coma Scale score for cerebral
edema; assess for papilledema.
screens, and CXR.
Respiratory Alkalosis
(res-pir-a-to-re al-ka-lo-sis)

ABG shows pH of greater than
7.45, PCO2 of_ less than 35 mm Hg,
and HCO3 within the range of
22–26 mEq/L or decreasing to
compensate.

Pathophysiology • CXR and VQ scans to identify pulmonary
• Normal pH of the body is 7.35–7.45. The ABG infection, pneumothorax, or PE.
analysis diagnoses respiratory alkalosis; pH is
_
high, CO2 is low, and HCO3 is within normal
• Brain MRI to R/O tumor.
range or decreasing to compensate. Complications
• Buffering systems are initiated by the body when • Cerebral vasoconstriction leading to seizures.
the pH goes out of range. The first to react are • Hyperventilation causing paresthesias, dyspnea,
cellular buffers. In respiratory alkalosis, H+ are and chest pain.
released from the cells, causing a shift of K+ into • ECG changes related to hypocapnia; BP changes.
the cells. Medical Care and Surgical Treatment
• The lungs are the second buffering system to • Rebreathing of CO2 and treatment of underlying
activate. When pH is high, CO2 is held by conditions.
slow, shallow respirations.
Keep in Mind
• Teach the client methods for relieving
activate, and it may take as long as 1–2 days
for them to begin to affect pH. In respiratory hyperventilation.
alkalosis, the kidneys hold H+.
• Causes include pain, anxiety, fever, CVA, tumor, Make the Connection
and trauma.
• Monitor ABG; assist to calm the client;
Assessment and Diagnostic Findings monitor CBC and imaging studies.
• ABG analysis;
+
serum chemistries for intracellular
+
• Institute seizure precautions if necessary; monitor
shifts of Na , K , and phosphates; and LFT, as res- the ECG and vital signs.
piratory alkalosis may be caused by liver failure.
• CBC showing a reduced hematocrit.
RESPIRATORY
Bronchiectasis, 124 Pulmonary Embolism, 132

Asthma, 125 Pneumonia, 133
Emphysema, 126 Pleural Effusion, 134
Chronic Bronchitis, 127 Influenza, 135
Pneumothorax, 128 Legionnaires’ Disease, 136
Cystic Fibrosis, 129 Lung Cancer, 137
Acute Respiratory Distress Syndrome Histoplasmosis, 138
(ARDS), 130 Sarcoidosis, 139
Severe Acute Respiratory Syndrome Mesothelioma, 140
(SARS), 131 Tuberculosis (TB), 141
Respiratory Disorders 124
Bronchiectasis
(brong-ke-ek-ta-sis)

Dyspnea, cyanosis, expectoration of
large amounts of foul-smelling mucus.
↓ RBC, weight loss. Rhonchi heard on
auscultation.

• Chronic dilation of the bronchi and bronchioles • Antibiotics, bronchodilators, mucolytics, expecto-
due to inflammation. rants, supplemental oxygen, leukotriene inhibitors.
• Inflammatory process destroys elasticity of • Postural drainage; limiting of activity level.
smooth muscle in the airways. • Bronchoscopy for palliative treatment.
• Chronic infections occur in dilated areas that • Segmental lobectomy.
retain mucus and obstruct airways.
• Can be localized or diffuse; associated with Keep in Mind
childhood diseases (e.g., measles), influenza, or • Teach importance of influenza and pneumonia
tuberculosis. vaccination.
Assessment and Diagnostic Findings • Postural drainage must be continued on an
outpatient basis; discontinue smoking.
• Recurrent respiratory infections, foul-smelling
mucus from accumulation of infected secretions,
rhonchi over bronchi and diminished breath Make the Connection
sounds in the lung bases. • Assess for oxygen saturation by pulse
• High-resolution CT scan, CBC with differential, oximetry as well as for worsening dyspnea.
ABG, oxygen saturation. • Auscultate lungs every 4 hours, and perform
• Bronchoscopy for diagnosis and palliative postural drainage.
treatment. • Assess characteristics of cough and mucus.
Complications • Remember: When there is collection and stasis
• Anemia due to poor dietary intake (dyspnea). of mucus, viruses and bacteria have a perfect
• Respiratory acidosis; atelectasis, pneumonia. medium in which to grow and cause infection.
• Chronic obstructive disease.
• Necrosis of bronchi and bronchioles.
Asthma
(az-ma)

Expiratory wheeze on auscultation,
rapid onset, difficult expiration,
nonproductive cough, “chest is tight,”
and ↓ O2 saturation.

Pathophysiology aminophylline drip.
• Reactive inflammatory disorder associated with • Small, frequent high-calorie, high-protein meals.
exposure to allergens, viral infection, pollution, • Limiting of activity level.
smoking, or extremes of temperature.
• Chronic inflammation results in fibrosis and Keep in Mind
narrowing of bronchiole passageways, leading • Environment should be free of allergen-laden
to air trapping, bronchospasm, and increased materials like carpets and drapes.
dead air space. • Stop smoking; have a rescue inhaler available at
all times (beta2-agonist).
• Mast cells, active in inflammation, release
histamine, prostaglandins, leukotrienes, and • Increase fluid intake; maintain a healthy diet.
bradykinin. • Monitor asthma with a peak flowmeter.
Assessment and Diagnostic Findings • Avoid temperature extremes.
• Sudden onset of nonproductive cough, expiratory • Vaccinate for influenza and pneumonia.
wheeze, dyspnea, “tight chest,” ↑ expiratory
effort and prolonged expiratory cycle, diaphore- Make the Connection
sis, and tachycardia. • Monitor for exacerbation of condition,
• ABG (acidosis), blood and sputum for eosinophils, respiratory failure, and status asthmaticus.
↑ serum IgE, abnormal PFTs, and CXR, allergy skin • Monitor breathing pattern, auscultate lungs every
testing. 4 hours, and monitor with pulse oximetry.
Complications • Remember: Daily assessment with the peak
• Status asthmaticus; acute respiratory failure. flowmeter is integral to treating exacerbations
early.
• Beta2-agonist bronchodilators, leukotriene
inhibitors, supplemental O2, corticosteroids,
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Emphysema
(em-fi-se-ma)

Barrel or pigeon chest, dyspnea, the
“pink puffer,” ↑ PaCO2, chronic
respiratory acidosis, and hypoxic
respiratory drive.

• A chronic disorder in which the alveolar struc- • Bronchodilators, expectorants, mucolytics,
tures distend, lose elasticity, rupture, or coalesce, supplemental O2, corticosteroids, antibiotics.
resulting in damage and destruction to the pul- • Lung volume reduction surgery.
monary capillary bed, air trapping, and increased • Limiting of activity level.
dead air space.
• Cigarette smoking and an inherited deficiency Keep in Mind
of α1-antitrypsin are cocontributors to the • Teach pursed lip breathing. O2 may be needed at
disease. ↓ α1-antitrypsin results in elastase secret- home.
ed from neutrophils that can digest elastin and • Vaccinate for influenza and pneumonia.
other alveolar structures. • Suggest small, frequent nutrient-dense meals.
↑ fluids.
• Pursed lip breathing, a prolonged expiratory
respiratory cycle, barrel or pigeon chest, and use Make the Connection
of accessory muscles to breathe; difficult inspira- • Monitor I&O, calorie count; offer small
tion and chronic cough with thick sputum. high-calorie, high-protein meals frequently.
• Abnormal CXR, and PFTs, sputum analysis, ABG. • Assess O2 saturation, ABG, breathing pattern;
• Clubbing of fingers, diminished breath sounds, clients may like a fan blowing on them.
orthopnea, dyspnea on exertion. • Remember: Keep O2 at low levels; hypoxic
Complications respiratory drive.
• Cor pulmonale, recurrent respiratory infections,
and respiratory failure.
• Hypoxia and confusion.
Chronic Bronchitis
(kron-ik brong-ki-tis)

A history of a chronic productive
cough of more than 3 months’ duration
for more than 2 consecutive years;
the “blue bloater.”

• Chronic Inflammation by IL-8 and cytokines of • Bronchodilators, mucolytics, diuretics, oxygen
the mucous membrane lining the bronchi and supplementation, anti-infective drugs, nebulizer
bronchioles. Excess mucus is produced, and the treatments, incentive spirometry, antihypertensives,
mucociliary pump ceases to function properly, ACE inhibitors, and inotropic drugs and beta-
causing chronic congestion. Common in smokers. adrenergic blockers.
• Chronic bronchitis results in a fibrotic, noncom- • Smoking cessation program.
pliant airway and pulmonary hypertension. • Lung-reduction surgery.
• Cough with expectoration for at least 3 months • Teach clients that the effects of smoking.
for more than 2 consecutive years, with dyspnea
and cyanosis. • Teach clients that vaccination against
influenza and pneumonia are necessary.
• The “blue bloater” related to cor pulmonale;
• Teach clients to report SOB, symptoms of infec-
clubbing of the fingernails.
tion, or sudden weight gain immediately.
• Fever, headache, fatigue, and nausea.
• Along with clinical findings, abnormal, CXR scans,
MRI, ABGs, and abnormal PFTs. Make the Connection
Complications • Monitor diagnostic chest x-rays, CT scan,
• Worsening right-sided CHF. or MRI for improvement.
• Chronic bouts of pneumonia and hospitalization. • Monitor ABGs and pulse oximetry.
• Colonization of antibiotic-resistant organisms. • Weigh the client daily during acute episodes of
• Development of oxygen dependency as pulmonary right-sided CHF.
function worsens. • Plan care according to activity tolerance.
• Death from pneumonia and/orUploaded
heart failure. by MEDBOOKSVN.ORG
Pneumothorax
(nu-mo-tho-raks)

Sudden sharp pain in the chest area,
SOB, ↓ O2 saturation, absent breath
sounds in the affected lung.

Pathophysiology • For lung collapse related to pathology (injury
• Potential space created by the visceral and pari- to the pleura from disease), a thoracotomy
etal pleura creates negative pressure in that area. with evacuation of accumulated fluid offers
Once breached by trauma or a pathologic event, relief.
negativity is lost and the potential space becomes
an actual space that fills with air (pneumothorax)
• Recurrent pneumothorax may require pleurodesis.
or blood (hemothorax). Keep in Mind
• Positive pressure in the pleural space presses • The chest tube may be in place for several days.
against the lung tissue, causing atelectasis ↓ gas • Bronchodilators, coughing and deep breathing
exchange. exercises, and frequent x-rays are needed.
• Sudden, sharp pleural pain; dyspnea; anxiety; SOB. Make the Connection
• Absent breath sounds in affected lung field, uneven • Monitor O2 saturation, auscultate lungs
chest movement, ↓O2 saturation, hemoptysis.
every 4 hours, and palpate thorax for subcuta-
• ABG abnormalities and CXR showing atelectasis. neous emphysema.
Complications • Remind client to ask for pain medication as needed,
• Mediastinal shift with respiratory distress. especially if the chest tube is being removed.
• Respiratory acidosis. • Remember: Monitor the blood pressure carefully
• Subcutaneous emphysema. for hypotension following evacuation of a
Medical Care and Surgical Treatment large amount of fluid from the pleural space.
• Depending on the size of the pneumothorax
(>30%), placement of a chest tube exerts suction
in the pleural space, restoring negative pressure.
Cystic Fibrosis
(sis-tik fi-bro-sis)

Meconium ileus at birth is the earliest
sign. Later, respiratory, gastrointestinal,
and reproductive dysfunction.

• Autosomal recessive disorder that affects chro- • Pancreatic enzymes.
mosome 7, which normally produces a protein • Antibiotics for respiratory episodes, chest percus-
CFTR that affects movement of Na+ and Cl– ions. sion, supplemental O2, ABG, CXR, CBC.
• All secretions of exocrine glands of the respiratory, • Lung transplant.
gastrointestinal, and reproductive tracts become • Genetic counseling.
thick and obstruct normal flow.
• Sweat glands do not reabsorb sodium, so salt Keep in Mind
depletion in sweat can occur. • The disease is chronic, and clients usually have
shortened life spans (3 or 4 decades).
• CXR, testing of sweat electrolytes, PFTs, fat absorp- • Chest percussion and pancreatic enzyme replace-
ment must be continued.
tion; pancreatic enzymes for infants who present
with a meconium ileus and children with repeated • Vaccination for influenza and pneumonia are
recommended for high-risk individuals.
or severe pulmonary disease.
• Genotype testing of the parents and child.
• Obstruction to pancreatic exocrine function. • Monitor PFTs and O2 saturation;
Chronic pancreatitis and secondary type 1 DM. auscultate lungs sounds every 4 hours.
• Potentially fatal recurrent respiratory episodes of • Monitor stools; assess for small-bowel obstruction.
infections and atelectasis; thorax may become • Assess labs for hypovitaminosis and low total
barrel-shaped due to respiratory effort. protein.
• Steatorrheic stools, malnutrition, hypovitaminosis; • Remember: Help families emotionally.
and bowel obstruction.
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Acute Respiratory Distress

Syndrome (ARDS)
(a-kut res-pir-a-to-re dis-tres sin-drom)

Rhonchi and crackles on auscultation,
↓ O2 saturation after sepsis,
near-drowning, or aspiration
of gastric contents.

• Destruction of alveolar walls and capillary beds • Intubation and ventilation with PEEP.
caused by stimulation of immune mediators that • Hemodynamic monitoring for CO; daily weigh-
↓O2 exchange by fibrosis and edema. ing to assess fluid retention; use of diuretics,
• Immune mediators are also stimulated by antibiotics, and inotropic agents; ECG
traumatic events. monitoring.
Assessment and Diagnostic Findings • Intravenous support; transfusion of PRBC for
oxygen transport.
• Rapid breathing; air hunger.
• CXR showing consolidation to complete “white • Enteral feedings; intermittent prone positioning
out”; symptoms of noncardiogenic right-sided for increased oxygenation.
CHF.
Keep in Mind
• ABG and pulse oximetry showing decreased
• Teach clients about mechanical ventilation.
oxygenation.
• Auscultation revealing rhonchi, crackles, and • Will require serial x-rays, laboratory tests, and
central IV catheters.
areas of absent breath sounds over areas of
consolidation.
• Cool skin, cyanosis, peripheral edema. Make the Connection
Complications • Monitor central venous pressure, lung
• Acute respiratory failure with a 50% or greater sounds, ABG, pulse oximetry, and ECG.
mortality rate. • Monitor I&O strictly.
• Respiratory acidosis. • Monitor for signs of shock, assess serial CXR, and
• Multisystem organ failure; shock. provide aseptic ventilator care.
Severe Acute Respiratory

Syndrome (SARS)
(se-ver a-kut res-pir-a-to-re
dis-tres sin-drom; sarz)

Cough, rhonchi, crackles, and
worsening respiratory symptoms
after exposure to the coronavirus.

Pathophysiology • Intubation and ventilation possibly required if the
• Exposure to the coronavirus by droplet inhalation client’s status worsens.
or contact. The SARS virus can live 6 hours on
the hands.
• Hemodynamic monitoring for cardiac output;
daily weighing to assess fluid retention; use of
• After contact with the SARS coronavirus, immune diuretics, antibiotics, and inotropic agents; con-
mediators cause inflammation, edema, and pneu- tinuous electrocardiogram (ECG) monitoring.
monia by blocking gas exchange and resulting in
filling of the alveoli with fluid.
• Intravenous support; transfusion of packed red
blood cells (RBCs) for oxygen transport.
• Auscultation revealing rhonchi, crackles, and Keep in Mind
diminished lung sounds in areas of consolidation; • Teach ventilator-dependent clients about intense
fever; myalgia; cough. physical and psychosocial care they will receive.
• Liver function tests (LFTs) showing elevation; • Serial x-rays, arterial blood gas (ABG), blood
complete blood count (CBC) for low white blood transfusion, central venous catheters, and inten-
cell (WBC) and platelet counts; chest x-ray and sive care are needed.
chest computed tomography (CT) for areas of
consolidation; electrolyte panel for low potassi-
um and low sodium; polymerase chain reaction
Make the Connection
(PCR) and antibody test for SARS. • Strict infection control must be followed.
• Recent trips to countries with SARS. • Monitor central venous pressure, lung sounds,
ABG, pulse oximetry, and electrocardiogram
Complications (ECG).
• Acute respiratory failure and death. • Monitor intake and output (I&O) strictly.
Medical Care and Surgical Treatment • Monitor for signs of shock, assess serial chest
• Antivirals, antibiotics, steroids, supplemental
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Pulmonary Embolism
(pul-mo-ne-re em-bo-lizm)

Rapid onset of dyspnea, chest pain,
anxiety, feeling of impending doom,
and hemoptysis.

• Thrombus formation in the deep veins from an • Right-sided CHF, shock, and sudden death.
ineffective cardiac pump; atrial fibrillation; the Medical Care and Surgical Treatment
presence of increased clotting factors; or lack of
movement of the musculoskeletal pump, delaying
• Supplemental O2, suctioning, frequent auscul-
tation of the lungs, hemodynamic support.
blood movement back to the heart.
• Anticoagulants, thrombolytics, inotropics,
• Emboli may also consist of air, fat, amniotic diuretics, antiarrhythmics, IV morphine.
fluid, and bacteria.
• Embolectomy.
• The thrombus occludes pulmonary circulation,
impairing gas exchange. Keep in Mind
Assessment and Diagnostic Findings • Identify and decrease risk factors for PE.
• Anxiety, dyspnea, diaphoresis, fear, feeling of • Prophylaxis of atrial fibrillation with warfarin.
impending doom, chest pain, abnormal auscul-
tatory findings, hemoptysis, syncope, and
hypotension.
Make the Connection
• CXR for obstruction, ECG for arrhythmias or • Remember: Assess extremities of
bed-bound clients every shift. Look for unilateral
signs of right ventricular hypertrophy, ABG
edema of the arms or legs to identify DVT
showing decreased oxygenation, V/Q scan
formation.
abnormality, peripheral Doppler studies for
DVT, spiral CT scan of the lung to visualize PE, • Assess vital signs for shock; support the anxious
client; be ready to support ventilation and
D-dimer test, and pulmonary angiography.
hemodynamic state.
Pneumonia
(nu-mo-ne-a)

Productive cough, chills, dyspnea,
pain on inspiration.

• Acute inflammation of lung tissue by inhalation • Antibiotics, bronchodilators, expectorants,
of droplets containing viral particles, bacteria, antipyretics, pulse oximetry.
fungi, parasites, or irritating chemicals.
• Inflammatory mediators in lung tissue cause Keep in Mind
edema and filling of alveoli with serous fluid • Vaccination for influenza and pneumonia reduces
and mucus. risk of pneumonia.
Assessment and Diagnostic Findings • Respiratory toileting and infection control
measures are necessary.
• Rhonchi, crackles, and wheezes on auscultation.
Auscultation over areas of consolidation are
diminished; over these areas, the spoken word is Make the Connection
clearly heard (not the case in air-filled areas). • Auscultate lungs every 4 hours; assess
Temperature elevation; productive cough charac- vital signs; monitor intake and output (I&O);
terized by green, yellow, or rusty sputum. position in semi-Fowler’s to high Fowler’s posi-
• Chest x-ray or computed tomography (CT) for tion; assess pulse oximetry reading every 4 hours.
consolidation, complete blood count (CBC) for • Assess breathing patterns; give supplemental O2
elevated white blood count (WBC), arterial blood (humidified if necessary).
gas (ABG) for ↓ O2 level, sputum analysis for • Teach infection control measures.
causative agent with culture and sensitivity (C&S)
test and Gram stain.
Complications
• Pulmonary edema.
• Respiratory failure and death.
Pleural Effusion
(ploo-ral e-fu-zhun)

Dyspnea, diminished breath sounds
over affected area, pleural friction
rub.

• The pleural space is the visceral and parietal • Thoracentesis or placement of chest tube.
lining of the outer lungs. Negative pressure or a • Antibiotics, steroids, and analgesics.
vacuum exists in this space. • Cancer-causing pleural effusions are assessed by
• If the lining becomes damaged or diseased, or the oncologist to determine the most efficacious
experiences oncotic pressure changes (lung cancer, treatment.
pulmonary tuberculosis [TB], lung abscess, • Pleurodesis (talc placed in pleural space to cause
congestive heart failure, ascites, chronic renal a scar to prevent further effusion).
disease, chest trauma), the space loses its
negative pressure and expands into a space Keep in Mind
that presses on the lung in that cavity. • Shortness of breath (SOB) should be reported
immediately, especially if diagnosed with chronic
Assessment and Diagnostic Findings lung disorders.
• Cough, dyspnea, diminished breath sounds • Vaccination for influenza and pneumonia is
over the affected area, asymmetric expansion
recommended for high-risk clients.
of the chest, presence of pleural friction rub on
inspiration. • Infection control and splinting the chest for
effective coughing are important.
• Complete blood count (CBC) with differential
showing an increase in white blood count (WBC)
(infection); chest x-ray; thoracentesis and cytology Make the Connection
to find the cause of the effusion; client history. • Remember: Carefully assess blood pressure
Complications (BP) after thoracentesis, as removal of fluid
• Mediastinal shift with pressure on unaffected depletes total circulating volume.
lung. • Place client in high-Fowler’s position, medicate
• Respiratory distress. Uploaded by
before chest tube removal, and limit activities.
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• Monitor for SOB and poor pulse oximetry.
Influenza
(in-floo-en-za)

Fever, myalgia, respiratory and
gastrointestinal symptoms.

• A viral syndrome that is spread as aerosolized • Antiviral medications, which must be started
particles (airborne) and causes systemic inflam- within 48 hours of onset of symptoms to be most
matory reactions of myalgia, fever, respiratory effective.
symptoms, and gastrointestinal symptoms. • Analgesics, bronchodilators (if necessary),
• Strains are varied, and influenza vaccine is culture, antibiotics for secondary infection,
developed anew each season on the basis of electrolyte solutions for gastrointestinal symp-
identified strains. H1N1 influenza (swine flu) toms, and resting of the gut.
and H5N1 (bird flu) are relatively new strains
causing concern. Keep in Mind
• Influenza can easily become pandemic without • Vaccination for influenza strains is essential in
vaccination. high-risk populations but contraindicated in
• The very young, very old, and those with persons allergic to eggs.
chronic disease are at most risk for death from
complications.
Make the Connection
Assessment and Diagnostic Findings • Monitor intake and output (I&O), vital
• History of contact with an infected person. signs, and breath sounds.
• Complete blood count (CBC) with differential, • Teach clients that vaccines are in forms with
vital signs, culture for strain (if necessary), breath either killed or weakened virus; therefore, they
sounds, visualization of postnasal drip by are unable to cause influenza.
oropharyngeal examination. • Vaccination may result in a low-grade tempera-
Complications ture or soreness at injection site related to local
• Pneumonia. and systemic inflammation and production of
antibodies.
Legionnaires’ Disease
(le-ju-nerz di-zez)

Dry cough, myalgia, abnormal lung
sounds. Exposure to contaminated
water droplets.

• Legionella bacteria is inhaled from contaminated • Erythromycin given early and throughout the
water supplies (e.g., from air conditioner vents, course of the disease is the treatment of choice.
spas, respiratory equipment), causing pneumonia- • Rifampin (used only with other antibiotics).
like symptoms. Thrives at temperatures from • Macrolides and fluoroquinolones are effective.
90°–105° F. • Penicillin, cephalosporins, and aminoglycosides.
• Headache, myalgia, fever, diarrhea. Incubation • Antiemetics for vomiting.
period of 2–10 days. • CBC, ABG, CXR.
• Results in Legionnaire’s disease or a lesser
Keep in Mind
influenza-like illness known as Pontiac fever.
Assessment and Diagnostic Findings • Maintain infection control practices.
• Persons at risk include middle-aged or older • Encourage coughing and deep breathing exercises;
use incentive spirometer.
adults who smoke cigarettes or have chronic lung
disease and those whose immune systems are
compromised by diabetes, renal failure, organ Make the Connection
transplantation, cancer, or AIDS. • Monitor intake and output (I&O) and
• Sputum culture, bronchial washings, blood character of stools; assess and treat emesis.
serology for antibody titer; or antigen testing of • Assess breath sounds every 4 hours; monitor ease
urine. of respiration, pulse oximetry, ABGs, and vital
Complications signs; perform chest percussion; and provide
• Pneumonia. frequent oral hygiene care.
• Respiratory failure leading to death. • Assess for neurologic deterioration.
• Use sterile water for humidification.
Lung Cancer
(lung kan-ser)

Persistent cough, weight loss, history
of or current cigarette smoking.

Pathophysiology • Hyperuricemia as a side effect of cancer treatment
• Exposure to chronic irritants or carcinogens cause and cancer cells killed.
cell mutation, resulting in oncogene stimulation
and loss of genetic material from chromosome 3. Medical Care and Surgical Treatment
• Cells in early differentiation that mutate are more • Radiation, chemotherapy, immunotherapy,
aggressive than more mature cells. corticosteroids, TomoTherapy.
• Cancers are evaluated using the TNM method. • Lobectomy or pneumonectomy.
• Cancer cells divide more rapidly and are more • CBC, electrolytes, serial CXRs or other imaging.
metabolic than normal body cells. Secreting can- Keep in Mind
cers cause damage to the body by hypersecretion.
• Cancer in the lung may be the primary site or a • Encourage smoking cessation, yearly checkups,
and learning the warning signs of cancer.
metastatic secondary site from a distant body
area.
• Persistent cough, wheezing, dyspnea, fever, weight • Monitor F and E, skin and underlying
loss, anorexia, pleural friction rub, hoarseness. structures (radiation); provide antiemetics
• CXR, bronchoscopy and biopsy, sputum for (chemotherapy).
cytology, MRI, CT scan, PET scan, US. • Monitor CBC for ↓ RBC, and ↓ WBC.
Complications • Support the psychosocial needs of the client and
family; medicate for pain as needed.
• Superior vena cava syndrome.
• Pleural effusions.
• Cardiac tamponade.
Histoplasmosis
(his-to-plaz-mo-sis)

Cough, fever.

Pathophysiology • Decreasing neurologic status.
• Systemic fungal disease caused by dimorphic Medical Care and Surgical Treatment
fungus Histoplasma capsulatum.
• Organism grows in soil enriched with bird drop- • Intravenous amphotericin B, ketoconazole,
pings. Fungal spores form that are then inhaled. itraconazole.
• Once at body temperature, fungal spores change • Immunosuppressed clients will be on fluconazole
to the yeast form in the alveoli. The yeast is then for life.
absorbed through the regional lymphatics and Keep in Mind
into the bloodstream. Cellular immunity occurs
2–3 weeks after infection. • Immunosuppressed clients who are human
immunodeficiency virus (HIV) positive or are
Assessment and Diagnostic Findings undergoing chemotherapy or radiation should
• Fever, cough. avoid exposure to soil that may be contaminated
• Fever, anemia, enlargement of the spleen and liver, with bird droppings.
leukopenia, pneumonia, adrenal necrosis, and • Encourage client to report cough or fever imme-
gastrointestinal tract ulcers in disseminated dis- diately.
ease. Chronic pulmonary histoplasmosis produces
lung cavitations similar to those in tuberculosis.
• Positive histoplasmin skin test or urine antigen Make the Connection
test, and rising complement fixation and aggluti- • Monitor breath sounds every 4 hours,
nation titers. Confirmed by stained tissue biopsy vital signs, liver function tests (LFTs), and gas-
or culture of H. capsulatum from sputum, blood, trointestinal pain indicating ulceration.
lymph nodes, or bone marrow. • Monitor chest x-ray for tuberculosis-like cavita-
tions; complete blood count (CBC) for anemia
Complications and blood chemistry for catecholamines.
• Pleural effusion, cardiac tamponade.
Sarcoidosis
(sar-koyd-o-sis)

Fever, myalgia, night sweats, anorexia,
weight loss, fatigue, with progressive
lung noncompliance and SOB.

Pathophysiology • Abnormalities on chest x-ray, electrocardiogram
• Granulomatous disorder primarily of the lungs, (ECG), histology; rule out histoplasmosis and
skin, eyes, and lymphatics thought to have a tuberculosis (TB).
genetic link. Other organs affected are the heart,
bones, joints, liver, and kidneys. Complications
• Genetic clusters include mainly African Americans • Cor pulmonale and progressive pulmonary
and Scandinavians. Environmental influences fibrosis leading to death.
are considered as genetic triggers. Affects those • Kidney, liver, and eye damage.
40 years of age and younger. Medical Care and Surgical Treatment
• Hilar lymphadenopathy occurs, then progresses • Corticosteroids and other immunosuppressants.
to lymphocytic alveolitis. Skin lesions, peripheral
lymphadenopathy, interstitial nephritis, iritis, Keep in Mind
hepatomegaly and splenomegaly can also occur. • Report dry cough that does not remit, night
sweats, and shortness of breath (SOB).
• Symptoms and complications are related to
• Teach client about the nature of the illness, its
malabsorption.
low mortality rate, and the use of corticosteroids.
• Can result in pulmonary fibrosis or associated
right-sided heart failure (cor pulmonale).
• Signs of inflammation, such as temperature • Monitor pulse oximetry reading, chest
elevation, and other flu-like symptoms. x-rays, ease of respiration, and signs of right-
• History of night sweats. sided heart failure.
• T-cell lymphocytopenia, increased monocyte • Assess for symptoms associated with cortico-
count, allergy panel testing for common steroid therapy and intervene when noted.
allergens.
Mesothelioma
(mes-o-the-le-o-ma)

Cough, SOB, history of asbestos
exposure.

• Mesothelia is a single layer of flat cells that line • Chemotherapy, radiation (external beam and
the pleural, peritoneal, and pericardial cavities. implanted).
Exposure to asbestos through inhalation causes • Lobectomy and pneumonectomy.
infiltration by the short asbestos fibers into • Pleurodesis for repeated pleural effusion.
these cells. Peritoneal infiltration is thought to
occur by coughing up and swallowing the Keep in Mind
asbestos fibers. • Follow the OSHA guidelines for working with
• Cells mutate causing changing DNA, and activat- asbestos products.
ing oncogenes. • Those with history of asbestos exposure should
have frequent health screenings.
• A good history assists with diagnosis.
• CT scan, CXR, MRI, bronchoscopy or thora- Make the Connection
coscopy with biopsy. • Monitor for SOB, vital signs, pulse
• Genotypes show abnormalities in chromosome oximetry, electrolytes, CBC, and pleural effusions.
22 and rearrangement of the arms of chromo- Auscultate the breath sounds every 4 hours.
somes 1, 3, 6, and 9. • Remember: If the client has had a pneumonectomy,
Complications there is no chest tube, and the affected lung is
• Spread to the peritoneal cavity, chest wall, and placed down or in semi- to high-Fowler’s posi-
tion. In the case of a lobectomy, a chest tube is
lymph nodes.
• Pleural effusion, dysphagia, superior vena cava in place. The client is placed in semi- to high-
Fowler’s position.
syndrome.
• Radiation may cause dysphagia, candidiasis of the
esophagus.
Tuberculosis (TB)
(tu-ber-ku-lo-sis)

Fatigue, weight loss, anorexia, night
sweats, low-grade fever, productive
cough, hemoptysis, chest pain,
anxiety.

• Mode of transmission: The tubercle bacilli are • Combination of four antibiotics. Based on immu-
spread by the airborne route. The mycobacterium- nity, 6–9 or more months of antibiotic therapy
containing droplet nuclei circulate in the air. A may be needed. Monthly AFB sputum test until
T-cell–mediated response occurs, walling off the two tests are negative in a row.
lesion (Ghon tubercle), inactivating the disease. • Adequate nutrition, weekly weights, bronchodila-
• The Ghon tubercle affects the hilar region first. If tors, chest percussion.
the client becomes immunosuppressed, the Ghon • Airborne isolation in a negative pressure room.
necrose cavitates then may release the organism
into the lung. Keep in Mind
Assessment and Diagnostic Findings • After exposure or vaccination with BCG, the
Mantoux test will always be positive, so CXR will
• History; chest x-ray (lesions more likely in the have to be done.
upper lobes); Mantoux test revealing TB or indura-
tion of >15 mm in clients with normal immune sys- • Expect health-care providers wear special masks
while in the room.
tem function; sputum smears and culture for AFB.
• NAA; QFT-G test done on blood specimen with • Compliance with the medical regimen is essential
for personal and public health. Teach about the
results given in 24 hours. The QFT-G test result is
side effects.
unaffected by having received the BCG vaccine.
• Auscultation of chest reveals adventitious breath
sounds. Make the Connection
Complications • Monitor for SOB, poor pulse oximetry,
• Obstructive respiratory disease, respiratory fail- presence of lymphadenopathy, vital signs, and
night sweats, wear fit-tested HEPA mask.
ure, and death.
SENSORY
Cataracts, 142 Otitis Media, 149

Acute Angle-Closure Glaucoma, 143 Otitis Externa, 150
Primary Open-Angle Glaucoma, 144 Mastoiditis, 151
Retinal Detachment, 145 Otosclerosis, 152
Macular Degeneration, 146 Labyrinthitis, 153
Diabetic Retinopathy, 147 Ménière’s Disease, 154
Conductive and Sensorineural Hearing Acoustic Neuroma, 155
Loss, 148
Sensory Disorders 142
Cataracts
(kat-a-rakts)

Difficulty driving at night because of
excessive glare. Opacity of the lens on
ophthalmologic examination.

• Opacity of the lens can occur at any age, including • Intraoperative floppy iris syndrome (α-blocker
congenitally. However, most cataract formation therapy), which can cause the iris to suddenly
occurs over age 40 years and most commonly in constrict during surgery.
the elderly. Types include subcapsular; nuclear; • Retinal detachment, macular edema, IOP, hemor-
and cortical. rhage; IOL implant dislocation.
• In nuclear (age-related) cataract formation, the Medical Care and Surgical Treatment
center and outer areas of the lens start to pro-
duce more protein strands that begin to aggre-
• Phacoemulsification of the old lens, with inser-
tion of an IOL.
gate in the center portion of the lens and form
strata by folding. As strata forms, the center Keep in Mind
portion of the lens opacifies and yellows as the • Discuss all daily medications with the surgeon,
protein fibers accumulate. especially α-adrenergic blockers.
• Women who take HRT are at a greater risk, and • Recovery time is very fast.
women who take HRT and consume significant
amounts of alcohol are at an even greater risk.
• Exposure to UV light is another risk factor. Make the Connection
Assessment and Diagnostic Findings • Monitor vital signs and visual acuity
pre- and postoperatively.
• Ophthalmoscope and slit lamp microscope
exams reveal opacity of the lens.
• Subjective reports include difficulty reading small
print, difficulty seeing in bright light, seeing halos
around objects, and difficulty driving at night
because of glare.
Acute Angle-Closure
Glaucoma
(a-kut ang-gl klo-shur glaw-ko-ma)

Unilateral redness and pain in the eye,
headache, nausea, and vomiting. Client
may see halos in the visual field around
lights. Tonometry measurement may
exceed 50 mm Hg.

• Highest risk group is Asian or Inuit women over • Partial or total blindness.
age 45 years or persons with nearsightedness. • Systemic effects of eye drops.
• In glaucoma, the anterior chamber experiences • Postsurgical infection.
outflow problems, with fluid and pressure increas- Medical Care and Surgical Treatment
es. Because it is an enclosed fibrous capsule, the
eye is unable to swell without causing pressure on
• Laser surgery that creates an opening from the
anterior chamber to posterior chamber; may be
important structures like the choroid retina and done on the unaffected eye as prophylaxis.
optic nerve.
• Miotic agents, carbonic anhydrase inhibitors,
• Causes the outflow area of the iris/corneal adrenergic agonists, or beta-adrenergic blockers.
angle to become narrow because of bunching
of the iris as the pupil dilates. Prolonged pupil
• In acute episodes, corticosteroids to reduce
inflammation, osmotic diuretics, analgesics,
dilation, can cause an episode of mild or emer- antiemetics, and bedrest.
gent severity. A mild episode may be relieved by
sleep and relaxation. Keep in Mind
• Trauma to the eye can also produce the same • Avoid long periods of time in the dark, stress,
type of symptoms, which create a medical and and any medication that may produce mydriasis.
surgical emergency.
• Tonometry that measures IOP. Gonioscopy that • Assess for eye redness, nausea, vomiting,
visualizes and assesses the angle of the anterior
and seeing rainbows around objects.
chamber during eye exam.
• Remember: This is a medical and surgical
emergency. Time is vision.
Primary Open-Angle
Glaucoma
(pri-ma-re o-pen ang-gl glaw-ko-ma)

Bilateral, usually painless loss of vision.
May see halos around objects and
experience mild aching in the eyes
or headaches. Tonometry measurement
⬎20 mm Hg.

• This is the most common type of glaucoma, with • Miotic agents, carbonic anhydrase inhibitors,
insidious onset in persons older than 35 years of adrenergic agonists, or beta-adrenergic blockers.
age. The only risk factors are black race, trauma • Argon laser trabeculoplasty, trabeculectomy, or
to the eye, and chronic use of corticosteroids by cyclocryotherapy.
any route.
• In glaucoma, the anterior chamber experiences Keep in Mind
outflow problems, with fluid and pressure • Eye examinations with tonometry must be
increases on the choroid layer, the retina, and continued on a regular basis.
optic nerve. • Eye drops must be continued for life; wear a
• In the darkly pigmented eye, iris pigment may MedicAlert bracelet and always carry medications.
flake off and occlude the iridocorneal angle. • Occlude the lacrimal duct for 1 full minute after
administration of eye drops to prevent systemic
Assessment and Diagnostic Findings effects.
• Tonometry measurements exceed 12–20 mm Hg.
• Gonioscopy to assess the anterior angle.
• Ophthalmoscopic examination with pupil dilation. Make the Connection
• GDx Access device scan, which utilizes an infrared • Tonometry is the most important aspect
laser to assess damage to retinal fibers. of diagnosis for most clients.
Complications • Monitor for systemic effects of eye drops, espe-
• Gradual visual loss and blindness. cially in the elderly.
• Systemic effects of eye drops. • Administration of eye drops is done with sterile
• Postsurgical infection. technique; the applicator does not touch the eye.
Retinal Detachment
(ret-i-nal de-tach-ment)

Visual abnormalities of seeing flashing
lights or sparks, floaters, loss of
peripheral vision, and eventually
nothing, like a curtain falling over
the visual field.

• Disorders in vision, like myopia, may predispose • Argon laser reattachment.
the peripheral retina to come away (traction) • Cryosurgery.
from the choroid layer. • Scleral buckling.
• Rhegmatogenous detachment can occur during • Less common procedures include pneumatic
intraocular surgery if traction is applied to the retinopexy.
retina, causing vitreous fluid to flow into a hole • Electrodiathermy uses heat to drain fluid from the
between the retina and choroid layer, resulting in area between the choroid and retina.
detachment. Trauma to the head and eyes may
cause this type of detachment. Keep in Mind
• Exudative or serous detachment occurs in persons • Report any sudden changes in vision, especially
with hypertension or intraocular tumors in which after trauma.
serous fluid leaks between the retina and choroid. • Be aware of the signs and symptoms of retinal
detachment after cataract surgery.
• Loss of peripheral vision, flashing lights, floaters,
or total loss of part of the visual field. Make the Connection
• Indirect ophthalmoscopic visualization of the • Retinal detachment will cause death of
retina. rods and cones in the area of detachment unless
Complications interventions are initiated quickly.
• Permanent visual loss in the area of detachment. • The client must comply with postsurgical limita-
• IOP. tions on activity in order to allow the procedure
• Recurrent detachment. to correct the detachment.
Macular Degeneration
(mak-yoo-ler de-jen-er-a-shun)

Most commonly, a gradual, age-related
loss of central, near, or color vision.

Pathophysiology • Color vision test.
• The central fovea of the retina is rich in cones • IV fluorescein angiography.
(color vision) and is responsible for clear central
vision.
• Amsler grid for initial and ongoing self-diagnosis.
Complications
• Risk factors include being an older (⬎75 years)
• Central blindness.
female, white, a smoker; having hyperlipidemia;
and consuming little antioxidant-containing Medical Care and Surgical Treatment
foods. • Dry type: few options other than low-vision
• Dry or atrophic age-related macular degeneration lenses.
causes pigmental changes in the fovea, which can • Wet type: argon laser therapy, vascular endothelial
be visualized on examination. Drusen (pale yellow growth factor inhibitors.
spots) appear on the macula, showing areas that
no longer function. This is the most common Keep in Mind
type. • Teach coping skills for clients with loss of central
vision.
• Wet or exudative age-related macular degenera-
tion occurs when vitreous fluid and/or blood leak
under the macula. The onset of this type is sud- Make the Connection
den, and it may be treated with an argon laser,
as in retinal detachment. • Monitor Amsler grid findings to assess
visual stability or loss.
Assessment and Diagnostic Findings • Monitor IOP and for infection following argon
• Progressive loss of central and near vision in the laser therapy.
dry type; sudden onset in the wet type.
• Visual acuity tests.
Diabetic Retinopathy
(di-a-bet-ik ret-in-op-a-the)

Those with a history of poorly controlled
diabetes experience gradual central
visual field changes that can progress
to flashing lights and cessation of
vision (retinal detachment). On
ophthalmoscopic examination,
cotton-wool spots and tortuous,
dilated vessels are seen.

• Background retinopathy is caused by microa- • Tight blood glucose control, especially during the
neurysms that form on the retinal capillaries and first 5 years following diagnosis of diabetes.
leak blood. The client may experience visual • Vitrectomy is done if leakage of blood has
changes caused by inflammation. occurred under the retina. The vitreous humor is
• The preproliferative stage of retinopathy is char- drained and replaced with saline or silicon oil.
acterized by edema of the retina with blocked and • Argon laser therapy or sclera buckling is needed
infarcted blood flow. if retinal detachment occurs.
• The proliferative stage of retinopathy is charac-
Keep in Mind
terized by twisting of vessels, with neovascula-
ture growing into the optic disk and obscuring • Retinopathy can be avoided with tight control
the retina. The neovasculature leaks easily. of blood glucose levels through diet, lifestyle
Traction may occur as a result of the twisting changes, and medication.
and leaking of these vessels and cause retinal
detachment.
Make the Connection
• Disorder has a genetic link.
• Teach diabetic clients how to keep their
Assessment and Diagnostic Findings blood glucose levels in the normal range.
• Change in visual acuity testing. • Teach diabetic clients to undergo a complete
• Ophthalmoscopic examination with dilation of visual examination with pupil dilation at least
the pupil. yearly.
• Retinoangiography. • Monitor blood glucose level and provide periodic
Complications visual acuity tests.
• Visual loss. • Listen to subjective complaints of the client or
• Retinal detachment. family about visual changes.
Conductive and
Sensorineural
Hearing Loss
(kon-duk-tiv and sen-so-re-nu-ral her-ing los)

Acquired or congenital inability to
discriminate sound, resulting in
impaired hearing. History of ototoxic
drug use. Weber’s and Rinne’s tests
are abnormal.

Pathophysiology Assessment and Diagnostic Findings
• Hearing loss is a common problem in the elderly, • Abnormal Weber’s and Rinne’s tests.
but it may occur at any age. • Hearing loss indicated by subjective methods as
• Efficient hearing is accomplished by appropriate well as audiometric testing.
conduction of sound into the inner ear. Complications
Conduction of sound is accomplished by vibra-
tion of the tympanic membrane that is connected
• Changes in family processes and relationships
with friends; safety issues.
to the malleus. The malleus, incus, and stapes
transmit the vibration to the oval window of the Medical Care and Surgical Treatment
inner ear. The oval window vibrates and causes • Use of cerumen-reducing topical solutions.
movement of endolymph within the cochlea that • Anti-infectives and anti-inflammatories.
stimulates sensorineural receptors within the • Hearing aids, cochlear implants.
cochlea. Transmission to the acoustic nerve sends • Stapedectomy for otosclerosis.
information to the brain for interpretation. Keep in Mind
• Conductive hearing loss can result from increased
• Lipreading can assist in hearing.
cerumen, foreign bodies in the ear canal, cysts,
tumors, otosclerosis, or stiffened or scarred tym- • Clean hearing aid and replace batteries as directed.
panic membrane.
• Sensorineural hearing loss occurs through dam- Make the Connection
age to sensory nerves caused by complications of
infections, use of ototoxic drugs, neuromas, arte-
• Face the person with hearing loss while
speaking; use gestures or word boards.
riosclerosis, chronic exposure to noise, and aging. • Assess if the client has heard you by writing a
question about the conversation.
Otitis Media
(o-ti-tis me-de-a)

Fever and pain in the ear. Otoscopic
examination reveals a reddened and
swollen tympanic membrane. Usually
associated with colds and allergies.

• Otitis media is common in infants and children • Tympanosclerosis.
and results in accumulation of fluid in the middle • Cholesteatoma.
ear because their short, horizontal eustachian • Mastoiditis.
tubes allow exudates from colds and allergens • Hearing loss.
access to the inner ear. Medical Care and Surgical Treatment
• Causative microorganisms are viruses and bacteria.
• Vaccination against Streptococcus pneumoniae.
• Other risks include respiratory infections, day-
• Antibiotics, decongestants, analgesics,
care attendance, lower socioeconomic status, antipyretics, and heat or cold application.
exposure to secondhand smoke or wood-burning
stoves, allergies, excessive use of a pacifier, and
• Low-dose antibiotics.
feeding with a propped bottle.
• Myringotomy with ventilation tubes.
• Ear pain, drainage of fluid from the ear canal, • Do not smoke around children.
ear tugging, and hearing loss. • Vaccination can reduce the number and severity
• Elevated temperature, irritability, headache, of inner ear infections.
lethargy, anorexia, and vomiting. • Breastfeeding for at least 3 months ↓ incidence.
• History of a recent upper respiratory infection or
allergies.
Make the Connection
• Elevated WBC count, altered Weber’s and Rinne’s • Assess the tympanic membrane and ability
tests.
to hear (bilaterally). Assess tympanic membrane
for redness and swelling.
Otitis Externa
(o-ti-tis eks-tur-na)

Pain in the external auditory canal.
The canal may swell shut. Pain is
elicited by pressure on the tragus.
Often called “swimmer’s ear.”

• Infection or inflammation of the external auditory • Use a mild alcohol solution or an over-the-counter
canal caused by a contact allergy, an acute bacte- drying agent to dry water in the ear canal after
rial infection, or a fungal infection. swimming.
• Diabetics and immunosuppressed clients may • Report ear pain immediately to prevent otitis
experience invasion of the infection into the base media and severity of infection.
of the skull, resulting in deep bone infection.
• Pain in the auditory canal (elicited by pushing on • Bacteria and other organisms like to grow
the tragus of the ear), fever. in moist, warm, dark environments like the ear
• Otoscopic examination reveals a reddened, canal.
swollen ear canal. This infection may exist by
itself or with otitis media. • Assess the ears carefully in the adolescent or
adult who swims frequently.
• Elevated white blood cell (WBC) count shown on
• Teach the client to hold the head to one side to
complete blood count (CBC); altered Weber’s drain water from ears completely and to follow
and Rinne’s test. up with a drying agent.
Complications
• Otitis media.
• Mastoiditis.
• Hearing loss.
• Antibiotics, corticosteroid given by mouth or as
drops, and analgesics.
Mastoiditis
(mas-toyd-i-tis)

Pain behind the ear, with fever and
chills, usually after ear or sinus
infection.

• Inflammation of the mastoid sinuses, usually as a • Brain abscess.
result of the spread of infection from acute otitis • Meningitis.
media. Medical Care and Surgical Treatment
• Occurs rarely because of the availability of
• Intravenous (IV) antibiotics followed by PO out-
antibiotics for otitis media. patient medications and close follow-up.
• Causative organisms usually are the same as those
• Mastoidectomy or other neurosurgical procedures
causing otitis media (e.g., Streptococcus species, if infection has spread to beneath the periosteum
Haemophilus influenzae, Staphylococcus aureus), or if intracranial infection or thrombosis of neigh-
although on some occasions, mycobacteria or boring veins develops.
fungi may cause the disease.
• Chronic infection of the frontal sinuses may cause Keep in Mind
this secondary infection. • Treat sinus and ear infections when symptoms
Assessment and Diagnostic Findings occur to prevent complications and secondary
• Pain behind the ear and sometimes fever and infection.
systemic symptoms (e.g., malaise, chills).
• Physical examination may reveal redness and
Make the Connection
tenderness behind the affected ear, with swelling
of the external auditory canal. • Monitor level of consciousness in the
context of a comprehensive neurologic assessment.
• Magnetic resonance imaging (MRI) or computed
• Gain IV access and watch for irritability of the
tomography (CT) scan showing inflammation or
neurologic system.
abscess of the mastoid bone.
Otosclerosis
(o-to-skle-ro-sis)

Progressive hearing loss, especially with
low or soft tones. Rinne’s test for bone
conduction is normal, but Weber’s test
shows lateralization to the most affected
ear. Tinnitus may be evident.

• The cause of this condition is unknown, and is • Stapedectomy with prosthetic.
more common in women (worsens in pregnancy). • Postoperatively, the client is positioned with the
• The condition may begin in the adolescent years operative ear upward, perhaps with a plug or
and occurs bilaterally. dressing to prevent infection that could travel to
• Due to chronic inflammation in the inner ear, bone the brain.
remodeling by the osteoclasts and osteoblasts • Antiemetics are given as well as instructions not
occurs, causing excessive spongy bone growth to cough, sneeze, vomit, or travel by air for a
around the stapes and the oval window, resulting given time.
in ankylosis and conductive hearing loss.
Keep in Mind
• Whispered voice test shows decreased hearing; • Teach to notify the surgeon immediately if the
client develops a cold postoperatively.
low-tone deafness, tinnitus.
• Rinne’s test is normal for bone conduction,
but Weber’s test shows lateralization to the most Make the Connection
affected ear. • Conduct neurologic examinations
• Audiometric tests and CT scan and MRI periodically.
determine the extent of sclerosis. • Monitor vital signs frequently.
Complications • Position the client on the unaffected side.
• Progressive hearing loss. • Give antiemetics or other medications necessary
• Postsurgical brain infection, dizziness, nausea, to prevent loss of prosthetic.
vomiting, and movement of prosthetic inserted
after stapedectomy.
Labyrinthitis
(lab-i-rin-thi-tis)

Vertigo, tinnitus. Weber’s and Rinne’s
tests indicate conductive or sensorineural
hearing loss. Fever, elevation in WBCs,
nausea, and vomiting may occur.

• Inflammation of the inner ear caused by bacterial • Antibiotics or antiviral agents.
or viral microorganisms that enter the inner ear • Mild sedatives, antiemetics, and antihistamines.
from the middle ear, meninges, or bloodstream. • Bedrest.
• Serous labyrinthitis can occur after toxic intake of
Keep in Mind
alcohol or drugs.
• Diffuse suppurative labyrinthitis is caused by • Ringing in the ears should always be investigated
acute or chronic otitis media, mastoiditis, or by the health-care provider.
mastoid surgery.
• Complete blood count (CBC) to diagnose infec- • Counsel clients with tinnitus and hearing
tion (increased WBC count or shift to the left). loss on methods to mitigate problems that will be
• Nystagmus on the affected side. encountered.
• Weber’s and Rinne’s tests to assess for conduc- • Assess for dizziness, as this may be a safety issue
tive or sensorineural hearing loss. for the client and his or her family.
• Presence of tinnitus.
Complications
• Loss of cochlear function and hearing loss.
• Spread of infection to neurologic structures.
Ménière’s Disease
(man-e-arz di-zez)

Ear fullness, tinnitus, and vertigo.
Sweating, nausea, and vomiting may
occur. Movement of the head makes
symptoms worse.

• Excessive endolymph in the compartment of the • Bedrest and keeping the head still during acute
inner ear, possibly from a blockage of endolymph episodes is the most effective treatment.
reabsorption. • Antihistamines, sedatives, corticosteroids, and
• Recurring episodes of hearing loss, tinnitus, verti- diuretics.
go, and aural fullness, often resulting in gradually • A low-sodium diet.
progressive hearing loss. • Endolymphatic shunt.
• Exacerbations may occur suddenly and last for as • Balance training exercises.
long as 24 hours. • Discontinue smoking.
• When one ear is affected, the other ear will
Keep in Mind
become involved in approximately 50% of cases.
• Injury, infections, endocrine disorders, and vascu- • Report dizziness and tinnitus to the health-care
lar disorders may be causative. provider.
• Electronystagmography, caloric stimulation, Make the Connection
rotational tests, and Romberg’s test. • Monitor for balance and hearing problems.
• Auditory assessment, x-rays, CT scan, and MRI • Neurologic assessments, and monitor CBC.
studies are performed to assess quantity of • Counsel the client concerning balance training
endolymph in the inner ear and extent of hearing exercises, safety, and adherence to low-sodium
loss accompanying the disorder. diet.
Complications
• Postoperative brain infection.
• Hearing loss.
Acoustic Neuroma
(a-koos-tik nu-ro-ma)

Hearing loss, headache (wakes the client
or is worse with sneezing or coughing),
facial numbness, balance problems, and
tinnitus.

• Benign tumor of the Schwann cells of cranial • Surgery.
nerve VIII. • Stereotactic radiosurgery.
• Linked with neurofibromatosis type 2. • Treatment of inflammation with corticosteroids.
Assessment and Diagnostic Findings • Antihistamines for dizziness; analgesics for
headache.
• Drooling, facial drooping, and dilation of pupil
on affected side.
Keep in Mind
• Computed tomography (CT) scan, magnetic • Benign tumors will not metastasize but will
resonance imaging (MRI) to assess size and
grow and cause pressure on other structures,
location of lesion.
possibly resulting in serious problems (e.g.,
• Electronystagmography to assess extent of
hydrocephalus, hearing loss, and progressive
vertigo.
pain and dizziness).
• Test of hearing and brainstem function (brain-
stem auditory evoked response).
• Caloric stimulation test. Make the Connection
Complications • Monitor postsurgically for infection by
• Postoperative brain infection. watching the complete blood count (CBC).
• Radiation therapy after radiosurgery can result in • Assess hearing and facial movement after surgical
nerve damage and hearing loss. or radiosurgery procedures.
• Without treatment, the tumor can continue to • Monitor neurologic status.
press on structures, causing increasing discomfort • Counsel client on what to expect from treatment
and loss of function. or choosing not to have treatment.
• Hydrocephalus.
DERMATOLOGIC
Skin Cancer, 156 Pediculosis Capitis, 166

Contact Dermatitis, 157 Acne Vulgaris, 167
Eczema, 158 Stevens-Johnson Syndrome and Toxic
Cellulitis, 159 Epidermal Necrolysis, 168
Psoriasis, 160 Tinea, 169
Herpes Zoster, 161 Verruca, 170
Herpes Simplex, 162 Superficial and Partial-Thickness
Paronychia, 163 Burns, 171
Impetigo, 164 Full-Thickness Burns, 172
Scabies, 165 Rosacea, 173
Dermatologic Disorders 156
Skin Cancer
(skin kan-ser)

Skin lesion with asymmetry, irregular
borders, color changes, and >6 mm
diameter.

• Mutation of cells of the skin that occurs from • Metastasis to internal organs and death.
chronic exposure to the sun or other irritants. Medical Care and Surgical Treatment
• Basal cell cancer (the most common; cells in the • Excision and biopsy; Mohs’ chemosurgery for
lowest layer of the epidermis), squamous cell basal and squamous cell cancers.
(cells of the middle layer of the epidermis), or
melanoma (the most deadly form; melanocytes in
• Chemotherapy, radiation, TomoTherapy, inter-
leukin, interferon.
the bottom layer of the epidermis).
• Cells lose normal functional properties and can Keep in Mind
metastasize to other organs (melanoma). • Avoid prolonged sun exposure; wear SPF 30 or
Assessment and Diagnostic Findings greater sun block.
• Unusual lesion or change in a mole. • Maintain yearly skin checks with the dermatologist.
• ABCD criteria: Is it asymmetric? Are the borders
irregular? Is the color unusual (ranges from tan,
black, and brown to white, blue, and red). Is
Make the Connection
the diameter greater than 6 mm? • Monitor skin lesions and apply ABCD
criteria.
• Basal cell lesions are curled; squamous cell • If client is undergoing cancer treatment, assess
lesions reveal underlayer of tissue and are red,
for nausea, vomiting, CBC, electrolytes, site
scaly, or have drainage; melanomas are darkly
of radiation, and problems with underlying
pigmented.
structures.
• Diagnosis made by excision and biopsy of the
melanoma or Mohs’ chemosurgery technique, in
which thin layers of skin are shaved and examined
for cancerous cells (basal and squamous).
Contact Dermatitis
(kon-takt der-ma-ti-tis)

Patterned skin eruption after contact with
an irritant or allergen.

Pathophysiology • Respiratory distress, as in cases of severe latex
• Irritant contact dermatitis is caused by chemicals allergy.
like detergents; allergic contact dermatitis is a
cell-mediated type IV hypersensitivity reaction to Medical Care and Surgical Treatment
an allergen (poison ivy, tape, and jewelry are • Corticosteroids topically, orally, or intraocularly.
some examples). • Lesions should be lightly wrapped.
• Areas affected may show mild erythema or vesi- Keep in Mind
cles and bullae and are referred to as eczema.
• Allergy testing should be done to prevent further
Assessment and Diagnostic Findings outbreaks.
• Areas of erythema, vesicles, or bullae that appear • Avoid the allergen.
in a pattern.
• Allergy to the metal in a client’s watch will Make the Connection
result in a rash localized in that area.
• Exceptions: poison ivy leaves, in which the sap • Take a good history; look to see if the
may aerosolize if leaves are burnt, or photosensi- lesions have a distinct pattern.
tivity, which is a reaction to exposure to the sun, • Apply corticosteroids; watch for adrenal insuffi-
usually caused by use of drugs like diuretics, ciency (↓ Na, ↑ K, ↓ BP).
antipsychotics, or antibiotics, producing a more
extensive rash not occurring in area of clothing.
Complications
• Infection.
• Rash occurring in the eye.
Eczema
(ek-ze-ma)

Presence of a vesicular rash that may
occur on any skin surface, including
under the eyes. Asthma is often a
comorbid illness.

Pathophysiology than steroid creams except in severe outbreaks.
• Type I hypersensitivity disorder, genetically linked, Tacrolimus and pimecrolimus inhibit the actions
with a family history of hay fever, asthma, or of T lymphocytes, mast cells, dendritic cells, and
atopic dermatitis. keratinocytes. Ointment forms are preferable.
• Infantile forms are vesicular, cheeks are pale, and
Keep in Mind
Dennie-Morgan folds may be present under the
eyes. Adults usually have dry leathery areas that • Family histories of asthma or hay fever place
are either more or less pigmented than surround- other family members at greater risk.
ing tissue and appear in the antecubital and • Allergy skin testing should be done so contact
popliteal areas. with allergens can be avoided.
• The pruritic lichenified (dry, leathery) lesions can • Scratching the skin should be avoided to decrease
spread to the hands, feet, eyelids, and neck. the chance of secondary infection.
• Areas of vesicular eruption in infants; dry, leathery Make the Connection
areas in adolescents and adults. • Assess skin care habits and take a good
Complications family history.
• Secondary infection. • Assess discomfort and medicate with antihista-
mines to prevent scratching of the skin. Show
how to lightly tap the area rather than scratch for
• Warm water baths with a hypoallergenic soap or relief.
colloidal substances like oatmeal.
• Moisturizers. • Assess for adrenal insufficiency if topical or oral
steroids are used.
• Antihistamines for itching, topical immune mod-
ulators (tacrolimus and pimecrolimus) rather
Cellulitis
(sel-u-li-tis)

Patchy erythema and edema in the
extremities in the absence of DVT. May
be more prevalent in those with diabetes
or peripheral vascular disease.

• Bacteria infiltrate skin, bypassing normal skin • Educate clients at risk about proper skin and foot
barriers, and release toxins in the subcutaneous care.
tissue. Comorbid illnesses like diabetes and • Clients should not use heating pads if they have
peripheral vascular disease increase the incidence. decreased sensation in the extremities as they may
Assessment and Diagnostic Findings be burned.
• Acute onset of edema, patchy erythema, some-
times vesicles and pain with systemic signs and Make the Connection
symptoms of inflammation, like fever, pain, and
sweating. Lymph nodes in the region may be • Monitor the skin if client is using warm,
moist soaks, to prevent maceration.
swollen.
• Assess for allergy to antibiotics.
Complications • Teach clients that any injury (bruising, ulcerations,
• Possible deep vein thrombosis (DVT) forming due ingrown toenails, and hangnails) can result in
to inactivity. cellulitis.
• Spreading infection and possible necrosis of
tissue.
• Antibiotics.
• Elevate the limb.
• Warm, moist soaks.
Psoriasis
(so-ri-a-sis)

Patches of papules or plaques with silvery
scale. The underlying skin is
erythematous.

• T cell–mediated autoimmune disorder character- • Topical moisturizers, keratolytic agents, retinoids;
ized by silvery scale on an erythematous base. coal tar products; anthralin; corticosteroids (top-
• Abnormal growth of keratinocytes and dermal ical or PO); calcipotriene; and antihistamines.
blood vessels. • Psoralenscoupled with PUVA phototherapy.
• Precipitating factors may be any that stimulate • Disease-modifying antirheumatic drugs
the T-cell lymphocytes (e.g., trauma, stress, (DMARDs; e.g., methotrexate), biologic agents
infections, and medications). (e.g., etanercept), and intralesional cyclosporine.
• Histologic studies show increased epidermal cell
Keep in Mind
turnover; white blood cells (WBCs) are found in
the stratum corneum. • Support groups are in place because psoriasis
can be psychosocially disruptive.
• History, presence of typical lesions. Client may • Sun exposure and swimming in salt water will
help clear or reduce the severity of lesions, but
report improvement with sun exposure.
excess sun exposure increases risk for skin cancer.
• Histologic studies showing defects in keratinocyte
differentiation (filaggrin and involucrin gene
mutation), increased presence of plasma proteins Make the Connection
and Ig G. • Monitor the extent of the lesions.
Complications • Watch for bleeding or secondary infection.
• Secondary infections to skin shedding. • Watch for signs of adrenal insufficiency (↓ Na, ↑
• Adrenal insufficiency from corticosteroid use. K, ↓ BP).
Herpes Zoster
(her-pez zos-ter)

“Dew drops on a red leaf.” Painful
vesicular lesions unilaterally occurring
along sensory nerve pathways.

Pathophysiology • Scarring.
• Caused by varicella zoster virus, identical to that • Systemic infection.
which causes chickenpox.
• The herpes virus lies latent in the nerve tissue and • Antivirals orally, topically, or intravenously.
reactivates with stress or decreased immunity or
in clients with a malignancy or an injury to the • Analgesics, corticosteroids if no systemic
spine or cranial nerve. infection occurs.
• Breakouts follow the course of sensory nerves, der- • Antibiotics for secondary infection.
matomes, or cranial nerves and occur unilaterally. Keep in Mind
Eruptions last may last from 5 days to 5 weeks.
• Even when the lesions are gone, a postherpetic • Persons with risk factors should avoid persons
with varicella zoster infection.
neuralgia exists and persists.
• Antiviral medications will shorten the course of
Assessment and Diagnostic Findings the illness.
• Painful unilateral vesicular lesions following a • Lesions should not be scratched.
sensory nerve, dermatome, or cranial nerve. • The infectious period is 1–2 days prior to the
• Vesicles cause an erythema on the skin because of lesions erupting to when the lesions are dry.
the acute inflammation.
• Postherpetic neuralgia, persistent dermatomal • Clients with herpes zoster in the hospital
pain, and hyperesthesia, which can last for weeks
setting should be isolated for infection control.
or months.
• Ophthalmic herpes zoster can affect eyesight. • Monitor vital signs and skin for secondary
infection.
• Hearing loss, tinnitus, paralysis, and vertigo as
• Assess pain level and medicate as necessary.
postherpetic cranial nerve problems.
Herpes Simplex
(her-pez sim-plex)

Painful, itchy, vesicular lesion on the lips
or in the nose. May also occur in the
genital area.

Pathophysiology • Daily antiviral medication is given orally for
• Caused by the herpes simplex virus (HSV). There prevention of genital herpes outbreak.
are two types: HSV-I occurs above the waist, and
HSV-II occurs below the waist. Keep in Mind
• Occurs through direct contact, respiratory • Lesions are infectious a couple of days prior to
droplet, or fluid exposure. After exposure, the outbreak to the time the lesions are crusted.
virus lies dormant in the nerve ganglia where the • Herpes I and II cannot be cured, only suppressed.
immune system cannot destroy it. Stress of any • Genital herpes is spread most commonly by sexual
kind can cause the virus to reactivate. contact.
• Tingling sensation or itching as the vesicle erupts. Make the Connection
• Area is swollen and erythematous. • Teach the client about type I and
Complications type II HSV.
• Type II (genital herpes), if present during vaginal • Avoid contact with lesions; wear appropriate
birth, can cause blindness or acute neurologic protective gear.
problems in the newborn such as herpes • Teach about antiviral medication and its side
encephalitis. effects and action.
• A herpetic lesion on the eye requires ophthalmo-
logic care.
• Antiviral medication topically or orally, which will
shorten the duration of the outbreak.
Paronychia
(par-o-nik-e-a)

Erythema around the base of the nailbed
in persons who frequently, as a result of
employment, have their hands in water
or are nailbiters or thumb suckers.

• Acute or chronic condition in which the protec- • Keep nails moisturized, and care for cuticles
tive barrier between the nail and the nail fold is carefully.
breached by bacteria or fungus, causing erythema • Dry hands after thoroughly washing them.
and pain. • Do not bite the nails or cuticles.
• Can occur in persons whose hands are often in
water and in those who engage in thumb sucking
or nail/cuticle biting. Make the Connection
Assessment and Diagnostic Findings • Assess the site carefully; look for the nail
lifting from the nailbed.
• Erythema and pain around and at the nail fold, • Apply warm soaks and give medications as
which can spread. ordered.
• Antiretroviral drug use (indinavir) predisposes to • Teach the client to stop nail biting and use anti-
this illness in HIV+ persons. bacterial hand sanitizers as needed at places of
• Potassium hydroxide 5% smears; potassium employment.
hydroxide (KOH) wet mounts from scrapings or
discharge (hyphae). • Apply antibacterial moisturizers.
Complications
• A run-around infection of the nail.
• Loss of the nail.
• Warm soaks; a drain if necessary; antibiotics or
antiviral medications orally or topically.
Impetigo
(im-pe-ti-go)

Honey-colored crusts on the lips mouth,
nose, hands, or perineum; usually in
children. Shallow vesicles that
rupture easily.

• Superficial bacterial infection of the skin caused • Teach that the lesions are a bacterial infection, so
by staphylococci, streptococci, or both. medical regimen should be followed.
• Vesicles or bullae are preceded by discolored • Parents should teach their child not to scratch
spots. the lesions because the infection can spread.
• Vesicles or bullae rupture, leaving honey-colored • Child should not come in contact with other
crusts. children until crusts are dry and antibiotics have
• Infection spreads outward. been taken for 24 hours.
• Pruritus, weeping vesicles, bullae, and crusts. Make the Connection
• Cultures can be taken for confirmation. • Clean the area carefully.
Complications • Administer antibiotics and antibiotic ointment as
• Systemic infection, rarely necrotizing fasciitis, ordered.
or toxic shock syndrome. • Assess for diminution of lesions.
• Antibacterial soap; topical and systemic
antibiotics.
Scabies
(ska-bez)

Grayish brown pruritic threadlike lesions
with black dot at the end between fingers,
toes, axillae, groin, buttocks, and
abdominal areas.

• Impregnated female scabies mite burrows under • Scabicides do not have to be applied above the
the skin and lays eggs. An inflammatory response neck; keep on only for prescribed time, no longer.
occurs 30–60 days after initial contact. • Teach that infestations like scabies are common-
Assessment and Diagnostic Findings place among schoolchildren and discourage from
feeling judged.
• Grayish brown threadlike lesions with black dot
at the end found between fingers, toes, axillae, • Scabies are easily passed person to person, so all
groin, buttocks, and abdominal areas. persons in contact with the infected person are to
be treated.
• Pruritus.
• Skin scraping shows mite under microscope.
• Secondary infection from scratching. • Monitor lesions; wear protective gear.
• Spreads from person to person easily, so it can • Advise the infected person not to scratch the
become epidemic in school-aged children and lesions.
their families. • Support the family’s psychosocial needs.
• Application of a scabicide (e.g., Permethrin
topical cream or Lindane lotion).
• Wash clothing and other items with which the
infected person came into contact.
Pediculosis Capitis
(pe-dik-u-lo-sis ka-pi-tis)

Itching of the scalp. Magnifying glass
assessment reveals white or translucent
eggs adhered to hair shaft near the skin
or movement of insects in the hair.

Pathophysiology • Small-tooth comb to remove nits.
• Infestation of the head by Pediculus humanus capitis
(head louse). Keep in Mind
• Female louse lays eggs at night on a hair shaft • Wash all clothing, hats, and bedding in hot
close to the skin; eggs appear white or clear. water.
• Eggs hatch 7–10 days later. • Pediculicidal spray can be used on items that
• Itching of the scalp is produced by the insects cannot be laundered, like carpet or large pillows.
crawling and by their saliva on the scalp. Lice bite • Vacuum carpets and other surfaces.
and feed on human blood. They are approximately • Soak combs and other hair management items in
2 mm in length. the pediculicidal solution.
Assessment and Diagnostic Findings • Do not leave shampoo on longer than directed,
• Itching. as it is a toxic agent meant to kill insects.
• Nits observable on hair shaft by magnifying glass. • In the case of a child, report the infestation to
• Usually found in the hair at the occipital area the school nurse so anyone in contact can be
and nape of the neck, but can spread anywhere, treated.
even to eyebrows and eyelashes. • Support the child to prevent feelings of
embarrassment.
Complications
• Secondary infection from itching and scratching
the skin on the scalp. Make the Connection
• Spreads easily, so anyone with contact can • Use gloves and tongue blades when
become infected. looking for lice or nits.
Medical Care and Surgical Treatment • Nits are difficult to remove and are adhered tightly
• Shampoos and conditioners that contain pedi- to the hair shaft.
culicidal agents (e.g., Lindane, RID, NIX).
Acne Vulgaris
(ak-ne vul-ga-ris)

Whitehead, blackheads, or cysts on the
face, neck, upper back, chest, and
shoulders, usually in adolescents, but
can occur in adults.

Pathophysiology • Oral retinoids.
• Skin disorder of the sebaceous glands and their • Intralesional injections with corticosteroids.
hair follicles.
• Comedones extraction.
• Androgens, stress, strong soaps or cosmetics, • Chemical peels or collagen injections for scars.
or genetic factors cause an increase in sebum
secretion. Keep in Mind
• Pilosebaceous ducts are blocked with accumulated • Lesions should not be manipulated or
debris causing inflammation and bacterial “squeezed.”
infiltration. • Oral retinoids require that females use a reli-
• Lesions may be on face, neck, chest, upper back, able method of birth control and produce a
and shoulders. negative pregnancy test prior to the start of
Assessment and Diagnostic Findings therapy. Monthly LFTs will be performed. Skin
• Erythematous areas with open comedones structures will be very dry and will require a
(whiteheads) or closed (blackheads). moisturizer. Report depressive symptoms.
• Presence of papules, pustules, nodules, and in
severe cases, cysts.
Make the Connection
Complications • Acne causes psychosocial effects.
• Scarring, especially if the acne is cystic. • Assess for improvement once therapy is begun.
• Psychosocial implications. • If using oral retinoids, make certain adequate
Medical Care and Surgical Treatment teaching is done about prevention of pregnancy
• Topical antibiotics in combination with desqua- and monthly LFTs. Assess for signs of depression
in the client on these medications.
mation agents.
• Oral antibiotics in combination with desquama-
tion agents or retinoids.
Stevens-Johnson
Syndrome and Toxic
Epidermal Necrolysis
(ste-venz-jon-son sin-drom;
toks-ik ep-i-der-mal ne-krol-i-sis)

Flu-like symptoms or macular rash after
starting sulfa drugs, antibiotics, or
antiepileptics.

• Altered drug metabolism causes a T cell–mediated • Fluid loss and electrolyte imbalance.
reaction in the keratocytes. • Respiratory failure.
• A macular rash spreads rapidly and forms vesicles • Acute renal and hepatic failure.
and bullae in the epidermis and in the mucous Medical Care and Surgical Treatment
membranes, which necrose and slough.
• Transfer to a burn unit.
• Stevens-Johnson syndrome (SJS) involves 10%
• F & E replacement.
of body surface area, while toxic epidermal
necrolysis (TEN) involves 30%.
• Prophylaxis for infection.
• Corticosteroids.
• About 1–3 weeks after a drug is started, Keep in Mind
flu-like symptoms and conjunctivitis occur. • Report any flu-like symptoms or rash after start-
• Large bullae that are easily broken will slough ing therapy with any medication, seek immediate
over a period of 1–3 days. Nails, eyebrows, and medical care.
internal mucosal structures may be lost.
• Nikolsky’s sign. Painful oral crusts, erosions, and
Make the Connection
genital problems exist in most cases.
• Cough, pulmonary edema, and • Maintain strict monitoring of I&O; provide
fluid replacement based on total surface area.
hypoxemia.
• Glomerulonephritis and hepatitis may develop. • Monitor pulse oximetry, CBC, LFTs, RFTs, and
electrolyte panel.
• Histology shows necrotic epithelial tissue.
• If client is placed on a ventilator, provide aseptic
ventilator care and suctioning.
Tinea
(tin-e-a)

Reddened lesions that have a scaly
appearance. Lesions may form circular
areas, reddened raised areas, or, between
toes, crevasses that can be deep and
bloodless.

• Tinea infections or dermatophytoses occur • Secondary infection from altered skin integrity.
when skin is impaired by exposure to a moist • Alopecia.
environment. Medical Care and Surgical Treatment
• Infections may occur through direct contact with
• Topical and oral antifungal agents.
infected humans, animals, or objects.
• Corticosteroids for severe hypersensitivity
• Superficial mycotic infections include: reactions (kerion).
Tinea pedis.
Tinea capitis. Keep in Mind
Tinea corporis. • Teach clients to keep area clean and dry.
Tinea versicolor.
Tinea cruris.
• Tinea capitis and tinea pedis are easily spread
by direct contact; tinea capitis is also spread by
Tinea unguium. animals.
Tinea barbae. • Nonsynthetic or cotton socks and underwear
Assessment and Diagnostic Findings help decrease the incidence or severity of tinea
• Superficial types are characterized by scaling, infections.
slight itching, reddish or grayish patches, and
dry brittle hair that is easily extracted with the
hair shaft.
Make the Connection
• Deep lesions are flat, reddish, kerion-like areas • Assess for sites in moist areas that are
reddened, have a scaly appearance, or form a
studded with dead or broken hairs. Permanent
circular lesion.
alopecia may occur in these areas.
• Assess effectiveness of topical antifungals.
Verruca
(ver-roo-ka)

Pink or light pink growths that cluster on
skin structures. Occasionally, these
lesions are flattened and found on the
facial area.

• Benign papillomas, or warts, are caused by • Keratolytic agents, plaster that breaks down the
human papillomaviruses (HPVs) that are spread verruca, and freezing with liquid nitrogen.
through cracks in the skin; genital warts are • Intralesional bleomycin injections.
spread by sexual contact. • Laser surgery and electrosurgery.
• Various types are commonly seen: • Antiviral therapy.
Verruca vulgaris (common warts). • Duct tape (on for 6–7 days, off for 12 hours, and
Verruca filiformis are found on the eyelids, face, repeat).
and neck and project from the skin.
Verruca plana (flat warts). Keep in Mind
Verruca plantaris (plantar warts). • Teach females the connection between genital
Condyloma acuminata (genital warts). warts and cervical cancer.
• These growths usually clear in time, but the • Warts can be self-limiting, but removal methods
immune system reacts very slowly to their do exist.
presence. • Wart removal can cause scarring.
• Irregular thickening of the skin layers (stratum Make the Connection
spinosum and stratum corneum) in typical areas. • Assess areas affected by verrucae and
• Differentiated from other growths by biopsy. apply topical removal agents as ordered.
Complications • Assess effectiveness.
• Scarring. • Refer to dermatologist or gynecologist for
• Cervical cancer from condyloma acuminata. verrucae removal.
Superficial and
Partial-Thickness Burns
(soo-per-fish-al and par-shal thik-nes birns)

Redness of the skin resembling sunburn
or redness and mottling of the skin with
blister formation after contact with a
thermal source.

Pathophysiology the hand, the client will require referral to a burn
• Thermal or chemical injury to skin, the extent center for treatment, especially if the burn is a
of which is expressed as body surface area. deep second-degree burn.
• Superficial (first-degree) burns are likened to Medical Care and Surgical Treatment
sunburn and affect only the epidermis. Partial- • Silvadene or other antibiotic creams; analgesics
thickness (second-degree) burns involve the (usually morphine sulfate for severe pain).
epidermis and some portion of the dermis. • Original Biobrane or Integra Artificial Skin for
Second-degree burns are characterized by blister deep second-degree burns of the hands.
formation. • Assess respiratory status if the client was exposed
• Deep second-degree burns take longer to heal to smoke and heat.
and may cause scarring.
• First- and second-degree burns are painful Keep in Mind
because of intact free nerve endings for sensory • Teach the client about the extent of the burn and
pain transmission. what kind of treatment to expect.
Assessment and Diagnostic Findings • The client must maintain adequate fluid intake
and a nutritious diet.
• Redness of the skin resembling sunburn that is
very painful. • Any treatment regimen, like creams or occlusive
dressings, must be maintained.
• Red, mottled skin with blisters that blanch on
pressure and then refill; very painful.
• Edema, pain, and secondary infection with • Monitor I&O, pain level, electrolytes, and
second-degree burns. nutritional status.
• If burn occurs in the perineal area, over a large • Assess for healing or infection.
surface area, or involves the entire surface of
Full-Thickness Burns
(ful thik-nes birns)

Tough, leathery, or charred skin surface
that is brown, tan, red, or black. The skin
does not blanch and is painless.

Pathophysiology • Respiratory support.
• Thermal, chemical, or electrical source destroys • Allograft, autograft, xenograft or cultured skin
all layers of the skin (third-degree burns). that must not be disturbed.
• Severe edema from protein loss and increased • Antibiotics, morphine sulfate, TPN, and pressure
capillary permeability. suits to reduce scarring.
• Tough, leathery, or charred skin that is brown, Keep in Mind
tan, red, or black; does not blanch; and is • Client and family must be kept apprised of the
painless. situation to reduce anxiety.
• Progressive dyspnea from hot air burns. • Client will require reverse isolation when stable;
• Progressive edema, ↓ BP, ↑ HR; rule of nines to débridement is done with anesthesia.
assess BSA burned.
• CBC shows decreased RBCs.
Make the Connection
• Decreased renal output or hemoglobin in the
• Assess BSA affected by using the rule of
urine.
nines for adults and children.
Complications • Prepare to infuse a large volume of LR in the
• Shock from massive fluid loss to death. first 24 hours.
• Respiratory distress. • Monitor vital signs for shock; monitor I&O; and
• Secondary infection. monitor urine for color (must not be maroon).
Medical Care and Surgical Treatment • Medicate with morphine sulfate IV as needed.
• LR IV for fluid resuscitation with albumin infu- • Support the family and client.
sion based on BSA burned; transfer to burn • Apply splints or pressure suits as needed.
center; fluids must be sufficient to keep urine
clear of hemoglobin.
Rosacea
(ro-za-se-a)

Client’s skin appears flushed. States that
sun exposure, eating or drinking hot
foods or liquids, and alcohol make the
condition worse.

• Chronic inflammatory process that often coexists • Rhinophyma (thickening and bumpy deformity of
with acne that looks like blushing. the nose and cheeks).
• Thought to be caused by leakage of fluid and Medical Care and Surgical Treatment
inflammatory mediators into the dermis.
Inflammation may persist because of bacterial
• Metronidazole or azelaic acid topically.
infiltration in the area.
• Oral antibiotics.
• Rhinophyma requires laser treatment, dermabra-
• The main types of rosacea are the following: sion, cryosurgery, or excision of excess tissue by a
• Telangiectatic (marked by the appearance of plastic surgeon.
spidery blood vessels on affected skin).
• Papulopustular (bumpy/pustular lesions). Keep in Mind
• Phymatous (nasal scarring and deformity). • Clients with rosacea must be treated to prevent
• Ocular (involving the lids, lashes, or conjunctiva). worsening.
• The condition is common, especially in persons • Teach clients to avoid hot foods and liquids,
of Northern European ancestry. It usually is exposure to the sun, and alcohol.
noted first between the ages of 30 and 50.
• Women are affected more often than men.
Make the Connection
• Blushing or redness of the cheeks, nose, and • Monitor skin for improvement during
treatment.
eyelids, with acne-like outbreaks that are wors-
ened by sun exposure, ingestion of hot liquids • Reinforce teaching about foods, alcohol, and sun
exposure.
or foods, and alcohol (especially wine).
MENTAL HEALTH
Generalized Anxiety Disorder, 174 Depression, 182

Posttraumatic Stress Disorder, 175 Bipolar Disease, 183
Panic Disorder, 176 Schizophrenia, 184
Phobias, 177 Attention Deficit-Hyperactivity
Obsessive-Compulsive Disorder, 178 Disorder (ADHD), 185
Conversion Disorder, 179 Alcoholism, 186
Dissociative Amnesia, 180 Borderline Personality Disorder, 187
Mania, 181
Mental Health Disorders 174
Generalized Anxiety
Disorder
(jen-er-al-ized ang-zi-e-te dis-or-der)

Excessive worry or anxiety that cannot
be controlled, causing interference with
normal activities of daily living.
Symptoms must have occurred for
at least 6 months.

Pathophysiology • Disturbances in family processes.
• Anxiety is produced by stimulation of the • Loss of ability to function in society.
autonomic nervous system. Neurotransmitters
involved in the anxiety response include gamma-
• Depression that can lead to psychosis or suicide.
aminobutyric acid (GABA), serotonin, epineph- Medical Care and Surgical Treatment
rine, and norepinephrine. A prolonged, abnormal • Cognitive behavioral therapy, along with anxiolytic
fight-or-flight response occurs to normal stimuli. and antidepressive agents.
• Electroconvulsive therapy (ECT).
• Group therapy.
• According to the Diagnostic and Statistical Manual
of Mental Disorders, 4th Edition, Text Revision Keep in Mind
(DSM-IV-TR), symptoms must be associated • Exercise, diet, and social activity are part of
with the following: feeling easily fatigued, therapy.
irritability, sleep disturbances, difficulty concen-
trating, restlessness, and muscle tension.
• Autonomic activity causes cold sweats, sweaty Make the Connection
palms, dry mouth, nausea or diarrhea, urinary • “Offer yourself” to the client (“I will stay
frequency, difficulty swallowing and eating, an with you until you feel better”) and use empathy.
exaggerated startle response, and depressive Walk along with clients who need to pace.
symptoms. • Use open-ended questions (“Tell me about . . .”).
• PET and SPECT scans reveal increases in metabo- • Be aware of the defense mechanisms.
lism in the brain.
Complications
• Panic disorder and phobia development.
Posttraumatic Stress
Disorder
(post-traw-mat-ik stres dis-or-der)

Acute anxiety and distress related
to flashbacks or memories of a
traumatic event.

• Severe psychological distress after traumatic • Depression, suicide, and homicide.
events (e.g., war, criminal assault, accidents, • Loss of family processes and social withdrawal.
natural disasters, rape). Medical Care and Surgical Treatment
• The amygdala of the brain is hyperactive in PTSD.
• Treatment of substance abuse.
• Activation of the amygdala causes activation of
• Anxiolytic and antidepressant agents.
the autonomic nervous system, and the adrenal
system. The sympathetic nervous system
• ECT.
produces many of the symptoms of PTSD,
• Group therapy and cognitive behavioral therapy.
which are prolonged by the adrenal hormones. Keep in Mind
• According to the Diagnostic and Statistical Manual of • Family therapy will help enlist assistance for the
Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), client at home.
symptoms must last at least 1 month. Onset may
occur at any time after the traumatic event.
• Flashbacks or reexperiencing the horrifying event. • “Offer yourself” to the client
(“I will stay with you until you feel better”) and
• Avoidance behavior: use empathy. Walk along with anxious clients
Memory disturbances.
who need to pace and ensure they are safe.
Irritability.
Sleep disturbances. • Use open-ended questions (“Tell me about....”).
• Psychological or social withdrawal and substance • Be aware of the defense mechanisms.
abuse. • Reexperiencing traumatic events can be very
disturbing to the client.
• EEG changes, and PET scan showing ↑ in brain
metabolism. • Use crisis management theory.
Panic Disorder
(pan-ik dis-or-der)

Sudden feeling of impending doom,
going crazy, unreality, and fear
accompanied by palpitations,
numbness of the arms, chest
discomfort, and dizziness.

• Symptoms are recurrent. • Development of phobias,↑ functioning socially.
• The cycle of panic is attributable to “fear of the • Disturbances in family processes.
fear.” Dreading an attack brings one on. • Loss of ability to function in society.
• Physical symptoms are related to the sympathetic • Depression and substance abuse.
and adrenal systems. Medical Care and Surgical Treatment
• Several hypotheses exist as to cause: a disorder • Anxiolytic and/or antidepressant agents along
in serotonin sensitivity, hypersensitivity to with cognitive behavioral therapy.
catecholamines, sensitivity to lactate, decreased
inhibition to GABA, hypersensitivity in neu-
• Electroconvulsive therapy (ECT) for severe
depression.
roanatomy producing abnormal signals for fight
or flight, and genetics.
• Group therapy; treatment of substance abuse.
• Differential diagnosis must be made, especially to • Once stable, the client can use therapeutic tech-
rule out hypoglycemia and mitral valve prolapse. niques to recognize the self-limiting nature of a
• PET scan shows abnormalities of brain metabo- panic attack.
lism. Lactate infusion can precipitate a panic
attack.
Make the Connection
• Chest discomfort, palpitations, dyspnea, numb-
• Offer yourself to the client (“I will stay
ness and tingling of extremities, depersonaliza-
with you”). Walk along with clients who need to
tion and dizziness, feelings of impending doom,
pace.
nausea, choking, chills, cold sweats, and hot
flashes. • Use crisis theory to assure that the client knows
he or she is safe.
Phobias
(fo-be-az)

Irrational fear of an object, place,
situation, thing, or person that causes
avoidance behaviors.

• According to the Diagnostic and Statistical Manual • Cognitive behavioral therapy; group therapy.
of Mental Disorders, 4th Edition, Text Revision • Desensitization therapy (a long process).
(DSM-IV-TR), phobia development is strongly • Anxiolytic and antidepressant agents.
associated with anxiety disorders. A phobia
occurs when an object, place, situation, thing, Keep in Mind
or person causes a sympathetic nervous system • Once stabilized, the client can gradually be intro-
(autonomic) response that results in anxiety. duced to the phobic object or situation in a
The trigger of anxiety becomes a phobia. therapeutic setting.
• A phobia can become so severe that all social • Phobias can be overcome.
contact is lost.
• A simple phobia is one associated with fear of
Make the Connection
common things (e.g., spiders, heights).
• It is crucial to offer yourself to the client
(“I will stay with you until you feel better”) and
• Fear, anxiety, and panic when faced with the use empathy (“I understand your discomfort”).
object of the phobia. Walk along with anxious clients who need to pace.
• Tachycardia and dyspnea. • Use open-ended questions (“Tell me about....”).
• An intense desire to escape. • Be aware of the defense mechanisms that clients
Complications will use to ease their discomfort.
• Social phobia and agoraphobia result in loss • Use crisis management theory. Make certain the
of social contacts and isolation. client knows he or she is safe, especially if using
• Phobias are associated with anxiety and depres- desensitization therapy.
sion, so suicide can be a complication. • Utilize appropriate medication therapy to
decrease the client’s anxiety.
Obsessive-Compulsive
Disorder
(ob-sess-iv kom-pul-siv dis-or-der)

Rituals are performed a specific number
of times and in a specific sequence to
decrease unpleasant thoughts.

• According to the Diagnostic and Statistical Manual • Severe interruption in social and family processes.
of Mental Disorders, 4th Edition, Text Revision • Depression, suicide, or homicide.
(DSM-IV-TR), an obsession involves recurrent, Medical Care and Surgical Treatment
intrusive, and persistent thoughts, impulses, or
images that cause excessive anxiety. The obses-
• Selective serotonin reuptake inhibitors and
anxiolytic agents.
sion is known to be irrational yet cannot be
ignored. Attempts to suppress the obsession
• Cognitive behavioral therapy.
become rituals known as compulsions. Keep in Mind
• The DSM-IV-TR defines a compulsion as a repeti- • If behaviors are interfering with activities of daily
tive act or ritual. living, it is time to seek help.
• The client with obsessive-compulsive disorder • An obsession can be controlled with medication.
(OCD) spends a great deal of time on the
ritualistic behavior.
• There is a genetic predisposition for OCD. Make the Connection
Assessment and Diagnostic Findings • “Offer yourself” to the client (“I will stay
with you until you feel better”) and use empathy.
• Ritualistic hand washing, “checking for” safety,
Walk along with anxious clients who need to
opening and closing drawers a certain number
pace.
of times, and other repetitive, time-consuming
behaviors. • Use open-ended questions (“Tell me about....”).
• Severe anxiety is experienced if the compulsion is • Be aware of the defense mechanisms.
not completed. • Use crisis management theory.
• Some obsessions and compulsions are violent or • Monitor LFTs during antidepressant drug therapy.
sexual in nature.
• MRI may show increase in size of caudate nucleus.
Conversion Disorder
(kon-ver-zhun dis-or-der)

Somatization of anxiety that results in
paralysis, blindness, or other physical
symptoms for which no medical
explanation can be found. The client
seems indifferent to the loss of
function.

• A somatoform disorder in which neurologic • Comorbid depression and risk of suicide.
symptoms (e.g., blindness, paralysis, loss of • Deterioration of the personality.
touch) may occur as a result of anxiety. According • Failure to diagnose actual neurologic conditions.
to the Diagnostic and Statistical Manual of Mental Medical Care and Surgical Treatment
Disorders, 4th Edition, Text Revision (DSM-IV-TR),
symptoms cannot be intentional or explained by
• Anxiolytic and antidepressive agents.
any medical tests.
• Impulses to the brain are misinterpreted or Keep in Mind
rerouted by an anxiety response, resulting in
perceptual abnormalities. An anxiety- or stress-
• Teach clients methods for keeping stress under
control.
producing event precedes onset of the conversion
disorder. Women are affected more than men.
• Neurotransmitters affected in this disorder are Make the Connection
serotonin and norepinephrine. • “Offer yourself” to the client (“I will stay
with you”) and use empathy (“I understand your
Assessment and Diagnostic Findings discomfort”).
• Neurologic deficit with no medical explanation. • Never reveal doubt that the illness is real.
• MRI, CT scan, and other symptom-specific • Use open-ended questions (“Tell me about....”).
examinations are performed to rule out physical
causes. • Be aware of the defense mechanisms.
• “La belle indifference.” • Use crisis management theory.
• Primary gain (avoidance behavior) and secondary • Monitor LFTs during antidepressant therapy.
gain (attention).
Dissociative Amnesia
(dis-o-shi-a-tiv am-ne-ze-a)

Inability to remember stressful events.

Pathophysiology • Loss of family or social contacts.
• A dissociative disorder is caused by a traumatic
• Suicide or homicide.
occurrence. The areas of the brain associated
with memory recall and storage (the limbic and
• Self-medication (substance abuse).
hippocampal areas) may be traumatized by Medical Care and Surgical Treatment
childhood events or by unbearable events later • Cognitive behavioral therapy.
in life. • Crisis management.
• According to the Diagnostic and Statistical Manual • Anxiolytic and antidepressant agents.
of Mental Disorders, 4th Edition, Text Revision Keep in Mind
(DSM-IV-TR), the client must have experienced
at least two occurrences of amnesia for an • Teach coping skills once the client is stabilized.
event as well as impaired social or familial
processes. Make the Connection
• Repression. • Clients may become assaultive when
Assessment and Diagnostic Findings memory returns.
• After a traumatic event, the client cannot recall • If client is pacing, walk along with him or her to
any details of the event. This may be a temporary communicate and provide company.
or permanent loss of recall. • “Offer yourself” to the client (“I will stay with
• Early-life trauma may not be recalled later in life. you”) and use empathy.
• Imaging studies conducted to rule out physical • Use crisis theory and assure safety.
cause. • Monitor LFTs during antidepressant therapy.
Complications
• Overuse of repression; poor coping skills.
• Recall can cause severe trauma.
Mania
(ma-ne-a)

Mental disorder characterized by
excessive excitement, restlessness,
delusions of grandeur, and poor
judgment.

• According to the Diagnostic and Statistical Manual • Long-term treatment with mood stabilizers, anti-
of Mental Disorders, 4th Edition, Text Revision depressant agents, anticonvulsants, antipsychotic
(DSM-IV-TR), the client must have experienced agents, and calcium channel blockers.
at least three persistent episodes of grandiose • Cognitive behavioral therapy.
thoughts, excessive need to speak characterized
by flight of ideas, decreased need for sleep, poor Keep in Mind
judgment, and irritability. • Compliance with therapy is important to
• Imbalance in levels of norepinephrine, serotonin, success.
dopamine, and hormones.
• Hyperactivity, hypersexuality, hyperreligiosity, • “Offer yourself” to the client
impulsiveness, poor nutritional status, substance (“I will stay with you”) and use empathy.
abuse, and sleep disturbances. • If the client is pacing, walk along with him or her.
• MRI and PET scan may show disturbances in • Offer finger foods so the active client can walk
metabolic function of the brain (prefrontal and and eat.
temporal). • A one-on-one therapeutic setting is more
• Cortisol levels may be abnormal. effective.
Complications • Monitor CBC for low WBC, and monitor drug
• Severe interference with societal, familial, and levels and LFTs during mood stabilizer, antide-
pressant, and anticonvulsant therapy.
legal processes.
• Worsening substance abuse and decline of
nutritional status.
• Sexually transmitted disease.
Depression
(de-presh-un)

Persistent sadness, hopelessness, feelings
of guilt, inability to concentrate,
decreased interest in daily activities,
changes in appetite, insomnia or
excessive sleep, and recurrent thoughts
of death or suicide.

• Changes in brain tissue metabolism and blood • Psychosis, suicide attempts, and death.
flow, particularly in the prefrontal cortex • Severe interference with family and societal
(decreased) and the amygdala (increased). processes; self-medication (substance abuse).
• Changes in the ability of receptors to bind with Medical Care and Surgical Treatment
neurotransmitters (e.g., serotonin, norepineph-
rine); increase in reuptake of neurotransmitters
• Anxiolytic, mood stabilizing, antipsychotic, and
antidepressant agents.
before they can bind with receptors and
increased destruction of neurotransmitters by
• ECT; light therapy (if associated with SAD).
monoamine oxidase, which deaminates sero-
• Cognitive behavioral therapy with a one-on-one
structured therapeutic setting (until stable).
tonin and norepinephrine.
• Less ability to handle stress related to altered Keep in Mind
hypothalamus-pituitary-adrenal system. • Teach clients that side effects will lessen with
Assessment and Diagnostic Findings time, and some require dietary restrictions.
• MRI and PET scan abnormalities. ↓ blood flow • Persons with major depression can recover
and metabolism in the prefrontal cortex but ↑ in completely.
the amygdala.
• Low serum cortisol levels.
Make the Connection
• Sleep study abnormalities.
• “Offer yourself” to the client (“I will stay
• According to the Diagnostic and Statistical Manual
with you until you feel better”) and use empathy.
of Mental Disorders, 4th Edition, Text Revision
(DSM-IV-TR), symptoms of depression must rep- • Use open-ended questions (“Tell me about....”).
resent a significant deviance from normal activi- • Be aware of the defense mechanisms.
ty that is present for greater than 2 weeks. • Monitor LFTs during antidepressant therapy.
Bipolar Disorder
(bi-pol-ar dis-or-der)

Cycling through periods of depression
and mania. Rapid cycling (four episodes
per year) indicates a more severe illness.

Pathophysiology poor nutritional status, substance abuse, and
• Changes in brain tissue metabolism and blood flow, sleep disturbances.
particularly in the prefrontal cortex (decreased) and Complications
the amygdala (increased). Strong genetic link, and • Psychosis, suicide attempts, and death.
women are affected more than men. • Severe interference with family and societal
• Imbalance in neurotransmitters. Epinephrine and processes, self-medication, and substance abuse.
norepinephrine are increased in the manic phase,
and serotonin and norepinephrine are decreased
in the depressive phase. • Anxiolytic, mood stabilizing, antidepressant, and
antipsychotic agents.
• Less ability to handle stress (hypothalamus-
• ECT; light therapy (if associated with SAD).
pituitary-adrenal system).
• Sleep disturbances related to neurotransmitter • CBT with a one-on-one structured therapeutic
milieu.
imbalances.
• MRI and PET scan. • Teach the client about the disorder and the need
• Sleep study abnormalities. for periodic blood tests.
• According to the Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition, Text Revision (DSM-IV-
TR), symptoms of bipolar disorder such as per- Make the Connection
sistent sadness, hopelessness, feelings of guilt, • “Offer yourself” to the client (“I will stay
inability to concentrate, decreased interest in with you”) and use empathy (“I understand your
daily activities, changes in appetite, insomnia or discomfort”). A one-on-one therapeutic setting is
excessive sleep, and recurrent thoughts of death most effective. Offer nutrient-dense finger foods
or suicide alternate with periods of hyperactivity, during the manic phase.
hypersexuality, hyperreligiosity, impulsiveness, • If the client is pacing, walk along with him or her.
Schizophrenia
(skiz-o-fren-e-a)

Often described by the 4 As (autism,
avolition, anhedonia, and associative
looseness). Schizophrenia means “split
mind,” with a chasm occurring between
the client and the environment. High
dopamine levels are present.

• The neurotransmitter dopamine is excessively • Increasing anxiety, depression, and suicide.
abundant. Changes in brain metabolism. • Severe interference with social and family processes.
• Genetic links are not as strong as once thought • Substance abuse.
but still place relatives at greater risk of develop- Medical Care and Surgical Treatment
ing schizophrenia (onset adolescense; early
adulthood).
• Anxiolytic, mood stabilizing, antidepressant,
and antipsychotic agents; ECT with CBT.
• Alterations in perception and thought, including
delusions (fixed thoughts) and hallucinations Keep in Mind
(auditory is the most common but can involve all
the senses).
• Teach the client to report return of hallucinations
and types and how to cope.
• Difficulty with expression of thought. • Teach the client about side effects of medications
Assessment and Diagnostic Findings and to report movement problems.
• PET scans.
• High dopamine levels. Make the Connection
• The 4 As: autism, avolition, anhedonia, and • Monitor CBC for low WBC count.
associative looseness.
• Delusions, hallucinations, difficulty expressing • Check the blood glucose levels (atypical antipsy-
chotics).
oneself (associative looseness, neologisms,
echolalia, and word salad). • Assess the effectiveness of medication and CBT.
• Depersonalization. • Ensure the client’s safety by providing structure.
• Behavioral problems. • Watch carefully for signs of tardive dyskinesia,
akathisia, and pseudoparkinsonism. Clients with
movement disorders should be referred to a
movement specialist immediately.
Attention
Deficit-Hyperactivity
Disorder (ADHD)
(a-ten-shun def-i-sit hi-per-ak-tiv-i-te dis-or-der)

Child or adult with difficulty focusing,
finishing projects, listening to
instructions, and sitting still who
also shows emotional lability.

• PET scans show decreased metabolic activity in the • Poor self-esteem, difficulty with school work.
frontal lobes and basal ganglia; EEG readings show • Substance abuse (self-medication).
↓ wave activity in the same area. Medical Care and Surgical Treatment
• PET scans show ↑ metabolism in the primary
sensory and sensorimotor areas. There is no
• Psychostimulants.
specific lesion. ADHD is believed to be an error in
myelination.
• Social skills training.
• Affects boys and men more than girls and women. Keep in Mind
• Inability to wait, impatience, bursts of anger, and • Clients with ADHD may benefit from activities
an inability to sit still; difficulty finishing projects, like massage, music therapy, yoga, and
focusing, and following directions and often chiropractic manipulation.
appears to be staring off into space. • Dietary management is important.
• Abnormal PET scan and EEG showing ↓ activity, Make the Connection
particularly in the right frontal lobe, and
increased activity in the thalamus and sensorimo- • Monitor weight and sleep habits of clients
on medications.
tor areas.
• Diagnosis is often made by complaints of parents • Interview parents to assess the degree of improve-
ment seen in their child.
and teachers about behaviors.
• Developmental assessment.
• CRS-R are administered along with intelligence
and psychological tests to differentiate behavioral
problems from other mental or physical disorders.
Alcoholism
(al-ko-hol-izm)

Smell of alcohol on breath, ataxia,
slurred speech, and inappropriate affect;
or shaking if abstinent.

Pathophysiology • Dietary intervention.
• Alcoholism is genetically linked. • CBT with social coping skills and group session
• Alcohol is very lipid-soluble and enters the with community follow-up.
brain easily. Once there, it acts on GABA recep-
tors, promoting a depressant and pleasurable Keep in Mind
effect. The action of other drugs (e.g., heroin) • Teach that alcoholism adversely affects social, inti-
on the opioid and dopaminergic centers is mate, and financial aspects of an entire family.
similar to that of alcohol, cross-addictions • Alcohol adversely affects physiology, resulting in
occur. many health problems.
• Changes in mood, judgment, and sexual practices. Make the Connection
• May exhibit ataxic gait, slurred speech, and • Watch for DTs from several hours to
nystagmus; ETOH smell on breath.
several days after the last drink.
Complications • Monitor LOC and for seizure activity during acute
• Addiction. withdrawal.
• Severe interference with family and social processes. • Monitor blood chemistries for LFTs nutritional
• Withdrawal, Wernicke-Korsakoff syndrome, cir- assessment, GGT, and blood ETOH level. Check
rhosis of the liver, diabetes, metabolic syndrome, for cross-addictions.
and increased blood lipid levels. • Monitor the effectiveness of drug therapy.
Medical Care and Surgical Treatment • Check compliance with therapy. Most inpatient
• Antidepressant agents (tricyclic), opioid-receptor facilities provide 28 days of treatment for alcohol
withdrawal and then facilitate follow-up with
inhibitors, acamprosate, disulfiram, folic acid,
thiamine, anticonvulsants, magnesium sulfate, Alcoholics Anonymous in the community.
and sedatives.
Borderline Personality
Disorder
(bor-der-lin per-sun-al-i-te dis-or-der)

Substance abuse; impulsive, “needy”
behavior. Self-destructive behavior
(suicide attempts) for attention.

• The personality develops as a normal part of • Antidepressant, antipsychotic, and mood stabiliz-
neurophysiology, coupled with environmental ing agents.
factors. Components of the client’s genetic • CBT with clearly delineated boundaries.
framework react to what is external, creating
the outer and inner persona. Keep in Mind
• Changes in the prefrontal cortex may be responsi- • Teach the client about the importance of medica-
ble for the personality changes exhibited by those tions and about possible side effects.
with personality disorders. Affects women more • Develop a contract with the client to report any
than men. thoughts of suicide.
Assessment and Diagnostic Findings • Tell the client of the boundaries of the therapeutic
relationship.
• MRI may show reduction in size of the prefrontal
cortex.
• Splitting. Make the Connection
• Self-destructiveness, inappropriate affect, atten- • Monitor the CBC for WBC depletion
tion seeking; difficulty maintaining relationship, during anticonvulsive therapy.
manipulation, and impulsiveness with angry • Monitor the drug levels of mood stabilizers and
outbursts. anticonvulsants.
Complications • Monitor the LFTs during antidepressant therapy.
• Substance abuse. • Set limits and restate them frequently.
• Psychosis with paranoia. • Realize that the client will show desired behaviors
• Depression. in order to attain favors.
• Suicide attempts and death.
WOMEN’S HEALTH
Leiomyomas, 188 Persistent Fetal Circulation, 195

Cervical Cancer, 189 Patient Ductus Arteriosus, 196
Polycystic Ovarian Syndrome, 190 Neonatal Sepsis, 197
Breast Cancer, 191 ABO Blood Type Incompatibility, 198
Pregnancy-Induced Hypertension, 192 Rh Incompatibility, 199
Placenta Previa, 193 Meconium Aspiration Syndrome, 200
Placenta Abruption, 194
Women’s Health and Perinatal Disorders 188
Leiomyomas
(li-o-mi-o-maz)

Heavy menstrual periods with resulting
low H&H. May feel pressure, heaviness,
or pain in the pelvis.

• Estrogen is dominant in the proliferative phase • Torsion and ischemia of pedunculated tumors.
of the menstrual cycle and acts on the endometrial • Hypermenorrhea with chronic anemia.
layer and is also responsible for proliferation of • Dyspareunia, infertility.
abnormal uterine cells that grow under its • Pain on voiding or defecation.
influence. Medical Care and Surgical Treatment
• Benign tumors or growths that usually occur
• Antiestrogen medications, GnRH agonist.
in the corpus of the uterus. Subserosal myoma
(forms under the outer serous layer of the
• Hysterectomy; myomectomy.
uterus and may become pedunculated); intra-
• MRgFUS.
mural myomas (grow within the myometrium)
• Uterine artery embolization.
and submucosal myomas (endometrial layer Keep in Mind
and may cause excessive menstrual bleeding). • Teach clients that uterine fibroids rarely become
• Fibrous connective tissue surrounds the body of cancerous and will shrink in menopause.
the tumor. • Report excessively heavy periods, dyspnea,
Assessment and Diagnostic Findings fatigue, or pain.
• Pelvic examination showing enlargement of the
uterus, or the mass may be felt.
Make the Connection
• Ultrasound, CT scans, and MRI.
• Monitor CBC for anemia, as well as US,
• Menorrhagia, which may lower the H&H
CT scan, and MRI results.
significantly.
• Uterine fundus examination after childbirth may • Pelvic examination.
reveal irregular and bumpy feel of the uterine
fundus.
Cervical Cancer
(ser-vi-kal kan-ser)

History of recurrent STD, especially HPV
infection. Abnormal Pap smear. Late
signs are vaginal bleeding, dyspareunia,
and pelvic pain.

• Squamous cells on the outer cervix, chronically • Infertility after treatment.
irritated, undergo dysplasia from antigenic or • Metastasis and death.
infectious material from STD, especially HPV, or Medical Care and Surgical Treatment
multiple sexual partners. Glandular cells on the
uterine side of the cervix can undergo dysplasia
• Gardasil, a vaccine that prevents infection with
four types of HPV that cause the majority of
from chronic irritation of smoking, infection cervical cancers and HPV outbreaks.
with HIV that lowers immunity, or having sever-
al pregnancies.
• LEEP cryotherapy, laser therapy, conization of the
cervix, and hysterectomy.
• LSIL, and HSIL are squamous cells (afffected by
HPV) that are likely to progress to cancer. CIN Keep in Mind
followed by the numbers 1, 2, or 3 describes the
thickness of the lining of the cervix that contains
• Gynecologic visits are advised in the early
teenage years. Pap smears and vaccination
abnormal cell growth. against HPV can prevent cervical cancer.
• Pap smear results and grade (low or high) guide Teach client to use barrier methods to prevent
treatment regimen. pregnancy and STDs.
Assessment and Diagnostic Findings • Do not start smoking, or try to quit.
• Pap smear reports are classified as negative, intraep-
ithelial lesions, or malignancies.
Make the Connection
• Possible reports of serosanguineous bleeding or • Early detection is essential for favorable
pelvic pain during or after sex.
outcome.
• Presence of risk factors, e.g., HPV. • Remember: High-grade lesions contain less differ-
entiated cells and are more likely to be cancerous.
Polycystic Ovarian
Syndrome
(pol-e-sis-tik o-va-re-an sin-drom)

US or CT scan shows multiple ovarian
cysts. Clinically irregular menstrual
periods, hirsutism, high FBS, and
infertility.

• PCOS is a genetically linked female endocrine • Insulin sensitivity drugs and oral hypoglycemic
disorder that results in chronic anovulation, agents.
hyperinsulinemia that triggers androgen hormone • Lipid-lowering agents, along with diet and weight
release, type 2 DM, lipid abnormalities, hirsutism reduction regimens.
and thinning scalp hair, infertility, and ovarian • Calcium and vitamin D for oocyte maturation
cysts. and prevention of osteoporosis.
• Etiology is unknown. Also known as Stein- • BCP and GnRH agonists.
Leventhal syndrome.
Keep in Mind
• Irregular menstrual periods, anovulation, and • Teach the client not to smoke.
infertility. • Teach how to manage type 2 DM.
• High FBS; type 2 DM; elevated LDL and ↓ HDL; • Although it is more difficult, it is possible to
become pregnant with medical assistance.
↑ testosterone levels; and ovarian cysts on US or
CT scan.
• Obesity, acne, hirsutism, and male-pattern Make the Connection
baldness. • Monitor FBS, lipid panel, bone density
Complications scans, hormone levels, and weight.
• Metabolic syndrome and heart disease. • Assess effectiveness of insulin sensitivity drug.
• Endometrial cancer. • Assess effectiveness of BCP.
• Complications of diabetes.
• Infertility; osteoperosis.
Breast Cancer
(brest kan-ser)

Firm, painless, fixed, irregularly shaped
lump usually found in the upper outer
quadrant of the breast. Mammogram
reveals a mass, usually with
calcification.

• Overstimulation of estrogen. • Metastasis to bone, lungs, liver, and other distant
• TP53 mutation, (protection against tumor sites.
growth). • Side effects of radiation, chemotherapy, SERMs,
• Genetic anomalies (e.g., BRCA1, BRCA2, TP53) and BRMs.
increase the risks of developing breast cancer and • Body image disturbances as a result of surgery.
ovarian cancer. Medical Care and Surgical Treatment
• Women develop cancer more than men.
• Surgery (curative, palliative, or prophylactic).
• Risk factors are ↑ age, ↓ immunity, HRT,
personal or family history of breast cancer,
• Radiation, chemotherapy, BMT.
high-fat diet, alcohol intake, early menarche,
• Trastuzumab (Herceptin), which blocks HER2
receptors, aromatase inhibitors, and SERMs.
late menopause, no pregnancy or late pregnancy,
and no or short breastfeeding. Keep in Mind
Assessment and Diagnostic Findings • BSE monthly, yearly professional examinations,
• Breast examinations done by a professional. and mammograms as directed.
• Mammograms, US, MRI, and PET scans.
• Fine-needle biopsy, surgical excision and BX,
Make the Connection
ductal lavage, and sentinel lymph node exami-
nation. • Early detection increases survival rate.
• Tumor markers: CA 15.3, TRUQUANT, CA 27.29, • Monitor blood chemistries, tumor markers, and
CBC for anomalies.
CA 125, and CEA.
• FISH testing for excessive HER2-positive
receptors.
Pregnancy-Induced
Hypertension
(preg-nan-se in-dusd hi-per-ten-shun)

Hallmark signs include elevated blood
pressure, nondependent edema, and
proteinuria in the second or third
trimester of pregnancy.

Pathophysiology • SBP ↑ of 30 mm Hg or DBP ↑ of 15 mm Hg, the
• PIH, also known as preeclampsia, may be caused presence of protein in the urine (5 g/24 hr or
by a vasospastic disorder of the placenta leading more), retinal changes, and oliguria.
to a endothelial dysfunction and placental release
of factors such as sFlt-1.
• Oligohydramnios (by US), nonreassuring fetal
heart tones, or small-for-dates fetus.
• Endothelial dysfunction leads to capillary per-
Complications
meability, resulting in nondependent edema,
weight gain, pulmonary edema, hemoconcen- • HELLP syndrome.
tration, edema in the retina, and edema in the • Renal failure, coma, and seizures.
brain tissue. • Placental insufficiency leads to a SGA neonate.
• BP ↑ is caused by an abnormal response to Medical Care and Surgical Treatment
angiotensin II and epinephrine, and an imbal- • Delivery of the fetus; continued treatment with IV
ance among prostaglandins, prostacyclin, and Mg SO4; environmental control; and blood work
thromboxane A2, resulting in vasoconstriction for LFT, platelets, and RBCs.
and vasospasm.
Keep in Mind
• Proteinuria is the result of HTN and
• Teach clients the importance of prenatal visits
subsequent damage to vessel walls.
and that PIH may require hospitalization.
• Severe PIH is characterized by HELLP syndrome.
• The risk of PIH is increased in adolescence and Make the Connection
primigravidas older than 35, diabetics, and • Continuous monitoring of DTR, blood
women with preexisting vascular problems or pressure, and FHR are necessary while on MgSO4.
multiple pregnancies.
Placenta Previa
(pla-sen-ta pre-ve-a)

Painless, frank red vaginal bleeding at
or after 20 weeks’ gestation.

Pathophysiology • Premature delivery or cesarean section.
• In PP, the placenta implants in the lower rather • Placenta accreta.
than the upper uterine area. When the cervix
begins to dilate and move up the uterine wall in Medical Care and Surgical Treatment
preparation for delivery of the fetus, the placenta • Less extensive previa may require conservative
may dislodge due to traction, causing bleeding treatment (e.g., rest, avoidance of sexual inter-
and decreased oxygen delivery to the fetus. course, no vaginal examinations).
• There are three types: PP centralis (total or • Severe vaginal bleeding necessitates hospitaliza-
complete PP) in which the placenta has been tion, blood replacement, cesarean section, and
implanted in the lower uterine segment and com- monitoring of fetal well-being.
pletely covers the internal cervical os; PP lateralis • Double setup operating room.
(low marginal implantation) and PP marginalis Keep in Mind
(partial or incomplete PP).
• Risk factors include uterine scarring, previous • Teach clients to report any vaginal drainage.
pregnancy or cesarean section, Asian ethnicity, • Encourage clients to attend all prenatal and US
examinations.
smoking, and age over 35 years.
• Transabdominal and intravaginal US. Make the Connection
• Painless vaginal bleeding around the time of • Vaginal bleeding can result in both
delivery. maternal shock and fetal/neonatal hypoxia.
Complications • Monitor FHR and scalp potential of hydrogen
(pH).
• Placenta abruption or vasa previa.
• Hemorrhage.
Placenta Abruption
(pla-sen-ta a-brup-shun)

Rigid, painful abdomen. Nonreassuring
fetal heart tones with late decelerations.
Maternal signs of shock or DIC.

• Placenta abruption (PA), the sudden dislodgment • Maternal and/or fetal death.
of the placenta from the uterine wall, is classified • Maternal shock; DIC.
according to type and severity: • Possible hysterectomy.
• Grade 1 PA (vaginal bleeding with mild uterine Medical Care and Surgical Treatment
tenderness and mild uterine tetany, where only
10%–20% of the placenta is detached).
• Delivery may be vaginal or by emergency CS.
• Blood replacement.
• Grade 2 PA (uterine tenderness and uterine • Treatment of DIC.
tetany, with or without uterine bleeding, fetal
distress, or maternal shock where 20%–50% Keep in Mind
of the placenta is detached). • Teach client to report any vaginal drainage, pain,
• Grade 3 PA (severe uterine tetany and maternal dizziness, or shortness of breath.
shock, fetal demise is imminent or has occurred,
maternal or fetal DIC, and more than 50% of
• Report absence of fetal movement.
the placental surface is detached).
• A history of PIH, cocaine use, automobile accident, • Remember: PA can be present without
visible bleeding if the abruption is central.
or domestic violence.
• Painful, rigid abdomen with or without visible • Monitor the FHT tracing, fetal scalp pH, and
maternal vital signs.
vaginal bleeding.
• Signs of maternal shock. • IV to replace fluids and/or blood, administer
oxygen, and assist in cesarean delivery.
• Nonreassuring FHTs, with prolonged late decel-
erations of the fetal heart rate and low scalp pH.
Persistent Fetal
Circulation
(per-sis-tint fe-tal sir-ku-la-shun)

Shunting of blood from the right to
the left side of the heart through the
foramen ovale and ductus arteriosus
after birth, causing hypoxemia.

• Antenatal blood circulation includes three shunts. • Without intensive care, the neonate will not
The lungs are bypassed by two shunts, the fora- survive.
men ovale, and the ductus arteriosus. The last is Medical Care and Surgical Treatment
the ductus venosus that bypasses the liver.
• Supplemental 100% oxygen by endotracheal
• Following birth and adequate ventilation pres- tube and ventilator. May use a high-frequency
sures, the foramen ovale closes and the ducts ventilator.
collapse.
• Neuromuscular paralyzing agents and nitric oxide
• Hypoxia and high carbon dioxide levels increase inhalation.
vasoconstriction in the lungs causing pulmonary
hypertension that interferes with closure of the
• ECMO.
shunts and PFC occurs in small-for-gestational- Keep in Mind
age (SGA) neonates, infants of diabetic moth-
ers (IDM), and those with a traumatic delivery.
• Apprise the parents tactfully of the neonate’s
condition, the causes, and the required equip-
Assessment and Diagnostic Findings ment. Encourage visits to the neonatal intensive
• Onset of respiratory distress at or shortly care unit.
following delivery, with cyanosis, tachypnea, • Teach parents that diaphragmatic hernia requires
tachycardia, and low oxygen saturation levels surgical intervention.
with administration of 100% oxygen.
• Meconium aspiration syndrome.
Make the Connection
• Abnormal chest x-ray.
• Carefully monitor the bilateral breath
• Diaphragmatic hernia.
sounds, CXR (should reveal 9–10 “ribs of air”),
ABG, pulse oximetry, pulse, respiration, and
blood pressure.
Patent Ductus Arteriosus

(pat-ent duk-tus ar-ter-e-o-sis)

Persistent murmur. Weight loss,
difficulty with feedings, and
desaturation of oxygen with
activity.

• Antenatal blood circulation includes three shunts • Prostaglandin therapy.
one of which is ductus arteriosus, which shunts • Transcatheter device closure.
oxygenated blood from the pulmonary artery to • Direct surgical ligation.
the aorta (a right-to-left shunt).
• A PDA following birth will become a left-to-right Keep in Mind
shunt related to pulmonary vascular resistance • Reinforce teaching about PDA repair.
causing excessive blood flow to the pulmonary • Teach clients that the child with PDA repair will
area and left atria, as well as left ventricle conges- be able to resume normal activity levels.
tion and decreased systemic flow via the aorta. • Preterm children will “catch up” developmentally
• Occurs in preterm infants; girls are affected more based on the level of prematurity at birth.
often than boys; more likely to occur in neonates
with Downs syndrome or those exposed to rubella
during gestation.
Make the Connection
• Assess for murmurs in neonates carefully.
Perform a four-extremity blood pressure assess-
• Murmur on auscultation. ment and carefully grade and report to the
• Echocardiogram shows left-to-right shunt. neonatal cardiologist. Provide continuous moni-
• Tachypnea, difficulty feeding, sweating, and toring of vital signs and oxygen saturation levels.
weight loss. • Monitor weight daily.
Complications • Assess feeding problems and sweating.
• Ventilator assistance for breathing.
• Pulmonary hypertension.
• Infective endocarditis.
Neonatal Sepsis
(ne-o-na-tal sep-sis)

Temperature instability, tachypnea, and
cyanosis. Amniotic fluid may have
an abnormal odor.

• Usually an ascending infection caused by • Neonatal death.
Escherichia coli, Listeria monocytogenes, or group B Medical Care and Surgical Treatment
streptococci related to premature rupture of
membranes, maternal chorioamnionitis, or pre-
• Sepsis work-up.
mature birth in which immunity is severely limited.
• Temperature, respiratory, and nutritional support
(IV TPN).
• Sepsis may occur as a result of invasive therapies
(e.g., umbilical catheters; fetal surgery). Keep in Mind
Assessment and Diagnostic Findings • Clients must report any vaginal drainage and be
• Amniotic fluid may have a foul odor. assessed for rupture of membranes.
• CBC may show a high WBC count and the • Comply with recommendations regarding neona-
presence of bands (immature WBC). tal visits and testing for infection with group B
• Gastric fluid analysis shows a high neutrophil streptococci and other infectious organisms.
count.
• Blood and urine cultures are positive. Make the Connection
• CSF may be cloudy or have a high protein and • Subnormal temperature, bulging fontanel,
low glucose level and culture positive for bacteria.
abnormal flexion or limpness, tachypnea,
• Possible temperature instability (subnormal tem- cyanosis, or other signs and symptoms must be
peratures), tachypnea, tachycardia, and possible
reported and acted upon immediately.
need for supplemental oxygen administration.
• CXR may show infiltrates.
• ↑ CRP; erythrocyte sedimentation rate is high.
ABO Blood Type

Incompatibility
(a-b-o in-kom-pa-ti-bil-i-te)

Jaundice that occurs in the first
24 hours of life. Maternal blood type
is type O.

• Mothers with type O blood carrying fetuses with • Phototherapy.
type A, B, or AB blood are at risk for having a • Exchange transfusion.
neonate with an ABO incompatibility problem if
their antibodies are IgG antibodies. Keep in Mind
• IgG antibodies readily cross the placenta and begin • Keep prenatal appointments and comply with all
to hemolyze the fetal red blood cells (RBCs). laboratory testing.
• The fetal/neonatal liver is too immature to • Explain the work-up associated with early-onset
process the bilirubin produced from the RBC jaundice.
breakdown, and this results in early-onset • Teach parents about phototherapy and exchange
jaundice. transfusion.
Assessment and Diagnostic Findings • Teach parents how to care for the neonate during
treatment.
• Yellow/orange coloration to the sclera and skin.
• Serum bilirubin levels are elevated within the first
12–24 hours. Make the Connection
• Indirect Coombs’ test on maternal blood detects • Early onset of jaundice requires a
antibodies to the fetus’s blood type. differential diagnosis of blood incompatibilities,
• Fetal anemia can be monitored noninvasively by neonatal sepsis, or trauma at birth with
Doppler flow velocimetry (DFV), which measures hematoma formation.
the peak systolic velocity (PSV) in the middle • Serial bilirubin levels are measured by heel-stick
cerebral artery. method approximately every 6–8 hours to assess
Complications effectiveness of treatment.
• Kernicterus.
• Anemia. Uploaded by MEDBOOKSVN.ORG
Rh Incompatibility
(r-h in-kom-pa-ti-bil-i-te)

Rh-negative woman carrying an
Rh-positive fetus.

Pathophysiology • Direct Coombs’ testing will indicate that antibod-
• A pregnant woman with no Rh antigen, known as ies are attached to RBCs, destroying them.
Rh0(D), on her RBCs is Rh negative. Additionally,
there are no antibodies against the Rh antigen in Complications
her serum. If the fetus she is carrying is Rh posi- • Neonatal heart failure, high bilirubin levels,
tive, there should not be antibodies produced that kernicterus, edema (hydrops), and renal failure.
cross the placenta. However, at delivery of the Medical Care and Surgical Treatment
fetus, when maternal and fetal bloods finally mix, • RhoGAM must be given to the woman within
the maternal immune system is activated to pro- 72 hours after delivery to prevent sensitization
duce anti-Rh antibodies. If no treatment is provid- problems with subsequent pregnancies.
ed, the next Rh-positive fetus the woman carries • If the neonate survives, aggressive therapy with
will have its RBCs attacked by the anti-Rh anti- phototherapy, hydration, and other sympto-
bodies, producing a condition called erythroblas- matic treatment in an intensive care nursery is
tosis fetalis, a potentially fatal condition in which necessary.
most or all of the fetal RBCs are destroyed.
Keep in Mind
• Blood and Rh factor typing, along with a screen • Teach clients to keep all prenatal appointments.
for antibodies, are done at the first prenatal • Explain the significance of being Rh negative.
visit. The antibody screen is performed again at
28 weeks. Rh0(D) immune globulin (RhoGAM) Make the Connection
is given to prevent sensitization. • There will be no problem with this
• PUBS may be done to assess the fetal blood type, disorder if the fetus is also Rh negative; the
degree of hemolysis, and bilirubin levels. mother must be Rh negative and the fetus
• Amniocentesis.
Rh positive for this disorder to occur.
Meconium Aspiration
Syndrome
(me-ko-ne-um as-pi-ra-shun sin-drom)

Amniotic fluid, stained with meconium,
is aspirated by the fetus/neonate,
causing acute respiratory distress.

• Causes include intrauterine stress, such as PIH, • Immediate suction when the fetal head is delivered.
postmaturity (aging placenta), intrauterine • Suction of meconium below the vocal cords.
hypoxia and asphyxia, and infection. • Ventilator, high-frequency ventilator, or ECMO
• Fetal stress may produce increased intestinal therapy.
peristalsis, anal sphincter relaxation, and expul- • Nitric oxide inhalation therapy and surfactant
sion of meconium into the amniotic fluid. therapy.
• Fetus breathing in utero, or with the first few • Administration of prophylactic antibiotic therapy,
breaths of air after delivery, causes aspirated IV TPN.
meconium-stained fluid to enter the lungs.
• Alveoli of the lungs can be infiltrated by the Keep in Mind
meconium, causing atelectasis or the blockage • Teach client to report rupture of membranes and
of bronchiolar passages. the color and character of the fluid.
Assessment and Diagnostic Findings • Apprise the client of the condition of the neonate
and encourage visitation to the nursery.
• Rupture of membranes reveals meconium-stained
fluid.
• Often meconium-stained fluid is accompanied by Make the Connection
nonreassuring FHTs. • Nonreassuring FHTs (late decelerations
• Laryngoscopic examination reveals meconium and variable decelerations) are signs of fetal
below the level of the vocal cords. distress.
• Acute respiratory distress develops. • Staff present at deliveries must be trained to
Complications suction and visualize vocal cords and to begin
• Low oxygen saturation levels. respiratory support in cases of meconium-stained
• Respiratory acidosis, atelectasis.Uploaded fluid.
by MEDBOOKSVN.ORG
• Death.
INDEX
References
Index
Leek_Ref_201-204.qxd 7/14/11 2:17 PM Page 201
201
References
Texts
Deglin, J., Vallerand, A., & Sanoski, C. (2010). Davis’s Drug Venes, D. M. (Ed.) (2010). Taber’s Cyclopedic Medical
Guide for Nurses (12th ed.). Philadelphia: F.A. Davis. Dictionary (21st ed.). Philadelphia: F.A. Davis.
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Index Atrial fibrillation, 101

Attention deficit-hyperactivity
Chronic bronchitis, 127
Chronic renal failure, 44
Encephalitis, 94
Epididymitis, 47
A disorder (ADHD), 185 Colon cancer, 18 Epidural hematoma, 73
Abdominal hernias, 9 Autonomic dysreflexia, 76 Compartment syndrome, 67 Esophageal varices, 12
ABO blood type Complex partial seizures, 84
incompatibility, 198 B F
Bell’s palsy, 91 Concussion, 71
Absence seizures, 80 Conductive hearing loss, 148 Fracture, 66
Acne vulgaris, 167 Benign prostatic hyperplasia, Full-thickness burns, 172
48 Congestive heart failure, 99
Acoustic neuroma, 155 Contact dermatitis, 157
Acquired immunodeficiency Bipolar disorder, 183 G
Bladder cancer, 49 Conversion disorder, 179
syndrome, 56 Gastric cancer, 6
Borderline personality Coronary artery disease, 96
Acute angle-closure Gastritis, 2
disorder, 187 Crohn’s disease, 21
glaucoma, 143 Gastroesophageal reflux
Bowel obstruction, 16 Cushing’s syndrome, 28
Acute renal failure, 43 disease, 3
Breast cancer, 191 Cystic fibrosis, 129
Acute respiratory distress Generalized anxiety disorder,
syndrome (ARDS), 130 Bronchiectasis, 124 D 174
Addison’s disease, 29 Buerger’s disease, 113 Deep vein thrombosis, 108 Glomerulonephritis, 37
Alcoholism, 186 C Depression, 182 Gouty arthritis, 59
Alzheimer’s disease, 90 Cardiogenic shock, 100 Diabetes insipidus, 26 Graft-versus-host disease,
Amyotrophic lateral Cardiomyopathy, 107 Diabetes mellitus 119
sclerosis, 92 Cataracts, 142 type 1, 32 Guillain-Barré syndrome, 93
Anaphylaxis, 51 Celiac disease, 1 type 2, 33
H
Angina pectoris, 97 Cellulitis, 159 Diabetic retinopathy, 147
Hashimoto’s thyroiditis, 54
Aortic aneurysm, 115 Cerebral aneurysm, 78 Dissociative amnesia, 180
Hemorrhoids, 23
Aortic stenosis, 109 Cerebrovascular accident, Diverticulosis, 19
Hepatitis, 8
Appendicitis, 20 85 E Herniated nucleus pulposus, 69
Asthma, 125 Cervical cancer, 189 Eczema, 158 Herpes simplex, 162
Atonic seizures, 82 Cholecystitis, 14 Emphysema, 126 Herpes zoster, 161
2693_Index_205-207.qxd 7/14/11 2:16 PM Page 206
206
Hiatal hernia, 4 Meconium aspiration P Primary open-angle
Histoplasmosis, 138 syndrome, 200 Paget’s disease, 64 glaucoma, 144
Huntington’s disease, 74 Ménière’s disease, 154 Pain disorder, 176 Prostate cancer, 50
Hydronephrosis, 40 Meningitis, 70 Pancreatic cancer, 15 Psoriasis, 160
Hyperpituitarism, 24 Mesothelioma, 140 Pancreatitis, 13 Pulmonary embolism, 132
Hypertension, 116 Metabolic acidosis, 120 Parkinson’s disease, 89 Pyelonephritis, 36
Hyperthyroidism, 30 Metabolic alkalosis, 121 Paronychia, 163
R
Hypopituitarism, 25 Multiple myeloma, 118 Partial-thickness burns, 171
Raynaud’s disease, 114
Hypothyroidism, 31 Multiple sclerosis, 86 Patent ductus arteriosus, 196
Renal artery stenosis, 46
Myasthenia gravis, 87 Pediculosis capitis, 166
I Renal calculus, 41
Myocardial infarction, 98 Peptic ulcer disease, 5
Impetigo, 164 Respiratory acidosis, 122
Myocarditis, 105 Pericarditis, 104
Influenza, 135 Respiratory alkalosis, 123
Myoclonic seizures, 81 Peripheral arterial disease, 112
Retinal detachment, 145
K Peritonitis, 22
N Rh incompatibility, 199
Kaposi’s sarcoma, 57 Persistent fetal circulation,
Neonatal sepsis, 197 Rhabdomyolysis, 42
195
L Nephrotic syndrome, 38 Rheumatoid arthritis, 60
Phobias, 177
Labyrinthitis, 153 Rheumatoid endocarditis,
O Placenta abruption, 194
Laënnec’s cirrhosis, 10 106
Obesity, 7 Placenta previa, 193
Legionnaires’ disease, 136 Rosacea, 173
Obsessive-compulsive Pleural effusion, 134
Leiomyomas, 188
disorder, 178 Pneumonia, 133 S
Leukemia, 117
Osteoarthritis, 58 Pneumothorax, 128 Sarcoidosis, 139
Liver cancer, 11
Osteomalacia, 62 Polycystic kidney disease, 39 Scabies, 165
Lung cancer, 137
Osteomyelitis, 63 Polycystic ovarian syndrome, Schizophrenia, 184
M Osteoporosis, 61 190 Scleroderma, 52
Macular degeneration, 146 Otitis externa, 150 Posttraumatic stress disorder, Sensorineural hearing loss,
Malignant hyperthermia, 95 Otitis media, 149 175 148
Mania, 181 Otosclerosis, 152 Pregnancy-induced Severe acute respiratory
Mastoiditis, 151 Overactive bladder, 45 hypertension, 192 syndrome (SARS), 131
2693_Index_205-207.qxd 7/14/11 2:16 PM Page 207
207
Simple partial seizures, 83 Superficial burns, 171 Toxic epidermal necrolysis, V
Sjögren’s syndrome, 55 Syndrome of inappropriate 168 Varicose veins, 111
Skin cancer, 156 antidiuretic hormone, 27 Trigeminal neuralgia, 88 Venous stasis ulcer, 110
Skull fracture, 72 Systemic lupus Tuberculosis (TB), 141 Ventricular fibrillation, 103
Spinal cord injury, 75 erythematosus, 53 Ventricular tachycardia, 102
U
Spinal shock, 77 Verruca, 170
T Ulcerative colitis, 17
Sprain, 65
Tinea, 169 Urethritis, 35
Stevens-Johnson syndrome,
Tonic-clonic seizures, 79 Urinary tract infection, 34
168
Total joint replacement, 68
Subdural hematoma, 73

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F. A. DAVIS COMPANY • Philadelphia

Gary Gudlin RN, MSN, Ed. M

JoEllen Kubik, RN, MA, LMSW

Andrea R. Mann, MSN, RN

Debra Morrison, RN, BScn, MN (c)

Mary J. Sletten, DM(c)m MSN, RN

Janet C. Stradtman, MSN, RN, CCRN, CNE, CNS

Debbie Tavernier MSN, RN, BSN, School Nurse Credential

Gastrointestinal System Disorders Cardiovascular System Disorders

Endocrine System Disorders Respiratory System Disorders

Urologic System Disorders Sensory System Disorders

Immune System Disorders Dermatologic System Disorders

Musculoskeletal System Disorders Mental Health Disorders

Nervous System Disorders Women’s Health and Perinatal

cap capsule CPK creatine phosphokinase D5W 5% dextrose in water

HIDA hepatobiliary iminodiacetic IVP intravenous pyelogram MI myocardial infarction

TG thyroglobulin TPO thyroid peroxidase TURP transurethral resection of

Celiac Disease, 1 Pancreatitis, 13

Clue: Diagnostic or Clinical Findings

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Clue: Diagnostic or Clinical Findings

Peptic Ulcer Disease

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Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Hyperpituitarism, 24 Addison’s Disease, 29

Clue: Diagnostic or Clinical Findings

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Clue: Diagnostic or Clinical Findings

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Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Clue: Diagnostic or Clinical Findings

Diabetes Mellitus Type 1

Clue: Diagnostic or Clinical Findings

Diabetes Mellitus Type 2

Clue: Diagnostic or Clinical Findings