Common disorders
Treating and preventing diseases
Treating and preventing diseases
Alzheimer’s disease
Overview
♦ Degenerative disorder of the cerebral cortex (especially the frontal lobe). Alzheimer’s disease accounts for more than 50% of all cases of dementia
♦ Poor prognosis
♦ No cure or definitive treatment
Causes
♦ Unknown
Risk factors
Neurochemical
♦ Deficiencies of the neurotransmitters
Environmental
♦ Aluminum and manganese
♦ Repeated head trauma
♦ Genetic abnormality on chromosome 21
♦ Slow-growing central nervous system viruses
Assessment
History
♦ History obtained from a family member or caregiver
♦ Insidious onset
♦ Initial changes almost imperceptible
♦ Forgetfulness and subtle memory loss
♦ Recent memory loss
♦ Difficulty learning and remembering new information
♦ General deterioration in personal hygiene
♦ Inability to concentrate
♦ Tendency to perform repetitive actions and experience restlessness
♦ Negative personality changes (irritability, depression, paranoia, hostility)
♦ Nocturnal awakening
♦ Disorientation
♦ Suspicious and fearful of imaginary people and situations
♦ Misperceives own environment
♦ Misidentifies objects and people
♦ Complains of stolen or misplaced objects
♦ Labile emotions
♦ Mood swings, sudden angry outbursts, and sleep disturbances
Physical findings
♦ Impaired sense of smell (usually an early symptom)
♦ Impaired stereognosis
♦ Gait disorders
♦ Tremors
♦ Loss of recent memory
♦ Positive snout reflex
♦ Organic brain disease in adults
♦ Urinary or fecal incontinence
♦ Seizures
Diagnostic tests
♦ Diagnosis is made by exclusion; tests are performed to rule out other diseases.
♦ Positive diagnosis is made on autopsy.
Imaging
♦ Positron emission tomography shows metabolic activity of the cerebral cortex.
♦ Computed tomography scan shows excessive and progressive brain atrophy.
♦ Magnetic resonance imaging rules out intracranial lesions.
♦ Cerebral blood flow studies show abnormalities in blood flow to the brain.
Diagnostic procedures
♦ Cerebrospinal fluid analysis shows chronic neurologic infection.
♦ Electroencephalogram evaluates the brain’s electrical activity and may show slowing of brain waves in late stages of the disease.
Other
♦ Neuropsychologic tests may show impaired cognitive ability and reasoning.
Treatment
General
♦ Behavioral interventions (patientcentered or caregiver training) focused on managing cognitive and behavioral changes
♦ Well-balanced diet (may need to be monitored)
♦ Safe activities, as tolerated (may need to be monitored)
Medications
♦ N-methyl-D-aspartate antagonist
♦ Cerebral vasodilators
♦ Psychostimulators
♦ Antidepressants
♦ Anxiolytics
♦ Neurolytics
♦ Anticonvulsants (experimental)
♦ Anti-inflammatories (experimental)
♦ Anticholinesterase agents
♦ Vitamin E
Nursing interventions
♦ Provide an effective communication system.
♦ Use soft tones and a slow, calm manner when speaking to the patient.
♦ Allow the patient sufficient time to answer questions.
♦ Protect the patient from injury.
♦ Provide rest periods.
♦ Provide an exercise program.
♦ Encourage independence.
♦ Offer frequent toileting.
♦ Assist with hygiene and dressing.
♦ Give prescribed drugs.
♦ Provide familiar objects to help with orientation and behavior control.
♦ Monitor fluid intake, nutritional status, and safety.
Patient teaching
♦ Be sure to cover:
– the disease process
– the exercise regimen
– the importance of cutting food and providing finger foods, if indicated
– the need to use plates with rim guards, built-up utensils, and cups with lids
– promotion of independence.
♦ Refer the patient (and his family or caregivers) to the Alzheimer’s Association.
♦ Refer the patient (and his family or caregivers) to a local support group.
♦ Refer the patient (and his family or caregivers) to social services for additional support.
Arterial occlusive disease
Overview
♦ Obstruction or narrowing of the lumen of arteries
♦ May affect any artery; commonly affects the aortic, iliac, carotid, vertebral, femoral, popliteal, anterior tibial, posterior tibial, renal, mesenteric, and celiac arteries
♦ Prognosis depends on the location of the occlusion and the development of collateral circulation that counteracts reduced blood flow
♦ Ninety percent of acute peripheral arterial occlusions occur in the lower extremities
Causes
♦ Atherosclerosis
♦ Immune arteritis
♦ Embolism
♦ Thrombosis
♦ Thromboangiitis obliterans
♦ Raynaud’s disease
♦ Fibromuscular disease
♦ Atheromatous debris (plaques)
♦ Indwelling arterial catheter
♦ Direct blunt or penetrating trauma
Risk factors
♦ Smoking
♦ Hypertension
♦ Dyslipidemia
♦ Diabetes mellitus
♦ Advanced age
Assessment
History
♦ One or more risk factors
♦ Family history of vascular disease
♦ Intermittent claudication
♦ Pain on resting
♦ Poor healing of wounds or ulcers
♦ Impotence
♦ Dizziness or near syncope
♦ Symptoms of transient ischemic attack
Physical findings
♦ Trophic changes of the involved arm or leg
♦ Diminished or absent pulses in the carotid artery, arm, or leg
♦ Ischemic ulcers
♦ Pallor with elevation of the arm or leg
♦ Dependent rubor
♦ Arterial bruit
♦ Hypertension
♦ Pain
♦ Pallor
♦ Pulselessness distal to the occlusion
♦ Paralysis and paresthesia in the affected arm or leg
♦ Poikilothermy
Diagnostic tests
Imaging
♦ Arteriography shows the type, location, and degree of obstruction and the establishment of collateral circulation.
♦ Duplex ultrasonography shows decreased blood flow distal to the obstruction.
♦ Magnetic resonance angiography and computed tomography scan may show arterial abnormalities.
Other
♦ Segmental limb pressures and pulse volume measurements show the location and severity of the obstruction.
♦ Ophthalmodynamometry indirectly helps determine the degree of obstruction in the internal carotid artery.
♦ Electrocardiogram and echocardiogram may show cardiovascular disease.
Treatment
General
♦ Smoking cessation
♦ Control of hypertension, diabetes, and dyslipidemia
♦ Foot and leg care
♦ Weight control
♦ Low-fat, low-cholesterol, high-fiber diet
♦ Regular walking program
Medications
♦ Antiplatelets
♦ Lipid-lowering agents
♦ Hypoglycemic agents
♦ Antihypertensives
♦ Thrombolytics
♦ Anticoagulation
♦ Niacin or vitamin B complex
Surgery
♦ Embolectomy
♦ Endarterectomy
♦ Atherectomy
♦ Laser angioplasty
♦ Endovascular stent placement
♦ Endovascular stent graft
♦ Percutaneous transluminal angioplasty
♦ Laser surgery
♦ Patch arterioplasty
♦ Bypass graft
♦ Amputation
♦ Bowel resection
Nursing interventions
For chronic arterial occlusive disease
♦ Use preventive measures, such as minimal pressure mattresses, heel protectors, a foot cradle, or a footboard.
♦ Avoid restrictive clothing such as antiembolism stockings.
♦ Give prescribed drugs.
♦ Allow the patient to express fears and concerns.
For preoperative care during an acute episode
♦ Assess the patient’s circulatory status.
♦ Give prescribed analgesics.
♦ Give prescribed heparin or thrombolytics.
♦ Wrap the patient’s affected foot in soft cotton batting, and reposition it frequently to prevent pressure on any one area.
♦ Strictly avoid elevating or applying heat to the affected leg.
For postoperative care
♦ Watch the patient closely for signs of hemorrhage.
♦ If the patient has mesenteric artery occlusion, connect a nasogastric tube to low intermittent suction.
♦ Give prescribed analgesics.
♦ Assist with early ambulation, but don’t allow the patient to sit for an extended period.
♦ If amputation has occurred, check the stump carefully for drainage and note and record the color and amount of drainage as well as the time.
♦ Elevate the stump, as ordered.
♦ Perform neurovascular checks, as ordered.
Patient teaching
♦ Be sure to cover:
– the disorder, diagnosis, and treatment
– medications and potential adverse reactions
– when to notify the physician
– dietary restrictions
– the regular exercise program
– foot care
– signs and symptoms of graft occlusion
– signs and symptoms of arterial insufficiency and occlusion
– the need to avoid crossing the legs and wearing constrictive clothing or garters
– modification of risk factors
– the need to avoid temperature extremes.
♦ Refer the patient to a physical and occupational therapist, as indicated.
♦ Refer the patient to a podiatrist for foot care, as needed.
♦ Refer the patient to an endocrinologist for glucose control, as indicated.
♦ Refer the patient to a smokingcessation program, as indicated.
Asthma
Overview
♦ A chronic reactive airway disorder that involves episodic, reversible airway obstruction caused by bronchospasms, increased secretion of mucus, and mucosal edema
♦ Signs and symptoms that range from mild wheezing and dyspnea to life-threatening respiratory failure
♦ Signs and symptoms of bronchial airway obstruction that may persist between acute episodes
Causes
♦ Sensitivity to specific external allergens
♦ Internal, nonallergenic factors
Extrinsic asthma (atopic asthma)
♦ Pollen
♦ Animal dander
♦ House dust or mold
♦ Kapok or feather pillows
♦ Food additives that contain sulfites or other sensitizing substances
Intrinsic asthma (nonatopic asthma)
♦ Emotional stress
♦ Genetic factors
Bronchoconstriction
♦ Hereditary predisposition
♦ Sensitivity to allergens or irritants such as pollutants
♦ Viral infections
♦ Drugs, such as aspirin, betaadrenergic blockers, and nonsteroidal anti-inflammatory drugs
♦ Tartrazine
♦ Psychological stress
♦ Cold air
♦ Exercise
Assessment
History
♦ Intrinsic asthma is commonly preceded by severe respiratory tract infections, especially in adults.
♦ Irritants, emotional stress, fatigue, endocrine changes, temperature and humidity variations, and exposure to noxious fumes may aggravate intrinsic asthma attacks.
♦ An asthma attack may begin dramatically, with simultaneous onset of severe, multiple symptoms, or insidiously, with gradually increasing respiratory distress.
♦ Exposure to a particular allergen is followed by sudden onset of dyspnea, wheezing, and tightness in the chest accompanied by a cough that produces thick, clear, or yellow sputum.
Physical findings
♦ Visible dyspnea
♦ Ability to speak only a few words before pausing for breath
♦ Use of accessory respiratory muscles
♦ Diaphoresis
♦ Increased anteroposterior thoracic diameter
♦ Hyperresonance
♦ Tachycardia, tachypnea, and mild systolic hypertension
♦ Inspiratory and expiratory wheezes
♦ Prolonged expiratory phase of respiration
♦ Diminished breath sounds
♦ Cyanosis, confusion, and lethargy, which indicate onset of life-threatening status asthmaticus and respiratory failure
Diagnostic tests
Laboratory
♦ Arterial blood gas analysis shows hypoxemia.
♦ Increased serum immunoglobulin E levels are caused by an allergic reaction.
♦ A complete blood count with differential shows an increased eosinophil count.
Imaging
♦ Chest X-rays may show hyperinflation, with areas of focal atelectasis.
Diagnostic procedures
♦ Pulmonary function tests may show decreased peak flow and forced expiratory volume in 1 second, low-normal or decreased vital capacity, and increased total lung and residual capacities.
♦ Skin testing may identify specific allergens.
♦ Bronchial challenge testing shows the clinical significance of allergens that are identified by skin testing.
Other
♦ Pulse oximetry measurements may show decreased oxygen saturation.
Treatment
General
♦ Identification and avoidance of precipitating factors
♦ Desensitization to specific antigens
♦ Establishment and maintenance of a patent airway
♦ Fluid replacement
♦ Activity as tolerated
♦ In patients who are unresponsive to drug therapy, possible admission for further treatment, which may include intubation or mechanical ventilation
Medications
♦ Bronchodilators
♦ Corticosteroids
♦ Histamine antagonists
♦ Leukotriene antagonists
♦ Anticholinergic bronchodilators
♦ Low-flow oxygen
♦ Antibiotics
♦ Trial of heliox (helium-oxygen mixture) before intubation
♦ I.V. magnesium sulfate (controversial)
Nursing interventions
♦ Give prescribed drugs.
♦ Place the patient in high Fowler’s position.
♦ Encourage pursed-lip and diaphragmatic breathing.
♦ Administer prescribed humidified oxygen.
♦ Adjust oxygen administration according to the patient’s vital signs and arterial blood gas values.
♦ Assist with intubation and mechanical ventilation, if appropriate.
♦ Perform postural drainage and chest percussion, if tolerated.
♦ Suction an intubated patient, as needed.
♦ Treat the patient’s dehydration with I.V. or oral fluids, as tolerated.
♦ Anticipate bronchoscopy or bronchial lavage.
♦ Keep the room temperature comfortable.
♦ Use an air conditioner or a fan in hot, humid weather.
Patient teaching
♦ Be sure to cover:
– the disorder, diagnosis, and treatment
– medications and potential adverse reactions
– when to notify the physician
– the importance of avoiding known allergens and irritants
– the use of a metered-dose inhaler or dry powder inhaler
– pursed-lip and diaphragmatic breathing
– the use of a peak flow meter
– effective coughing techniques
– the importance of maintaining adequate hydration.
♦ Refer the patient to a local asthma support group.
Breast cancer
Overview
♦ Malignant proliferation of the epithelial cells that line the ducts or lobules of the breast
♦ Prognosis considerably affected by early detection and treatment
Causes
♦ Unknown
Risk factors
♦ Family history of breast cancer, particularly in first-degree relatives, including the patient’s parents and siblings
♦ Positive results on tests for genetic mutations (BRCA 1)
♦ Older than age 45 and premenopausal
♦ Long menstrual cycles
♦ Early onset of menses, late menopause
♦ Nulliparous or first pregnancy after age 30
♦ High-fat diet
♦ History of endometrial or ovarian cancer
♦ History of unilateral breast cancer
♦ Radiation exposure
♦ Estrogen therapy
♦ Antihypertensive therapy
♦ Alcohol or tobacco use
♦ Preexisting fibrocystic disease
Breast cancer is the leading cause of cancer deaths among women ages 35 to 54.Assessment
History
♦ Detection of a painless lump or mass in the breast
♦ Change in breast tissue
♦ History of risk factors
Physical findings
♦ Clear, milky, or bloody nipple discharge, nipple retraction, scaly skin around the nipple, and skin changes, such as dimpling or inflammation
♦ Edema of the arm
♦ Hard lump, mass, or thickening of breast tissue
♦ Lymphadenopathy
Diagnostic tests
Laboratory
♦ Elevated alkaline phosphatase levels and liver function test results may indicate distant metastases.
♦ A hormonal receptor assay determines whether the tumor is estrogenor progesterone-dependent and guides decisions to use therapy that blocks the action of the hormone estrogen that supports tumor growth.
Imaging
♦ Mammography can show a tumor that’s too small to palpate.
♦ Ultrasonography can distinguish between a fluid-filled cyst and a solid mass.
♦ Magnetic resonance imaging can show very small tumors.
♦ Chest X-rays can show metastases to the lung.
♦ Scans of the bone, brain, liver, and other organs can detect distant metastases.
Diagnostic procedures
♦ Fine-needle aspiration and excisional biopsy provide cells for histologic examination that may confirm the diagnosis.
Treatment
General
♦ The choice of treatment usually depends on the stage and type of disease, the woman’s age and menopausal status, and the disfiguring effects of surgery.
♦ Therapy may include any combination of surgery, radiation therapy, chemotherapy, and hormone therapy.
♦ Some patients benefit from preoperative breast irradiation.
♦ The patient may require armstretching exercises after surgery.
♦ The patient may need primary radiation therapy.
Medications
♦ Chemotherapy such as a combination of drugs, including cyclophosphamide, fluorouracil, methotrexate, doxorubicin, vincristine, paclitaxel, and prednisone
♦ Antiestrogen therapy, such as tamoxifen, or anastrozole
♦ Hormonal therapy, including estrogen, progesterone, androgen, or antiandrogen aminoglutethimide therapy
Surgery
♦ Lumpectomy
♦ Partial, total, or modified radical mastectomy
♦ Sentinel node biopsy or axillary node dissection
Nursing interventions
♦ Provide information about the disease process, diagnostic tests, and treatment.
♦ Give prescribed drugs.
♦ Provide emotional support.
Patient teaching
♦ Be sure to cover:
– all procedures and treatments
– activities or exercises that promote healing
– breast self-examination
– the risks and the signs and symptoms of recurrence
– the need to avoid venipuncture or blood pressure monitoring on the affected arm.
♦ Refer the patient to local and national support groups.
Bronchitis, chronic
Overview
♦ Inflammation of the lining of the bronchial tubes
♦ A form of chronic obstructive pulmonary disease
♦ Characterized by excessive production of tracheobronchial mucus with a cough for at least 3 months each year for 2 consecutive years
♦ Severity linked to the amount of cigarette smoke or other pollutants inhaled and the duration of inhalation
♦ Exacerbation of the cough and related symptoms by respiratory tract infections
♦ Development of significant airway obstruction in few patients with chronic bronchitis
Causes
♦ Cigarette smoking
♦ Possible genetic predisposition
♦ Environmental pollution
♦ Exposure to organic or inorganic dusts and noxious gas
Assessment
History
♦ Longtime smoker
♦ Frequent upper respiratory tract infections
♦ Productive cough
♦ Exertional dyspnea
♦ Cough, initially prevalent in winter, but gradually becoming year-round
♦ Increasingly severe coughing episodes
♦ Worsening dyspnea
Physical findings
♦ Cough that produces copious gray, white, or yellow sputum
♦ Cyanosis, also called a blue bloater
♦ Use of accessory respiratory muscles
♦ Tachypnea
♦ Substantial weight gain
♦ Pedal edema
♦ Jugular vein distention
♦ Wheezing
♦ Prolonged expiratory time
♦ Rhonchi
Diagnostic tests
Laboratory
♦ Arterial blood gas analysis shows decreased partial pressure of oxygen
and normal or increased partial pressure of carbon dioxide.
and normal or increased partial pressure of carbon dioxide.
♦ Sputum culture shows many microorganisms and neutrophils.
Imaging
♦ Chest X-ray may show hyperinflation and increased bronchovascular markings.
Diagnostic procedures
♦ Pulmonary function test results show increased residual volume, decreased vital capacity and forced expiratory flow, and normal static compliance and diffusing capacity.
Other
♦ Electrocardiography may show atrial arrhythmias; peaked P waves in leads II, III, and aVF; and right ventricular hypertrophy.
Treatment
General
♦ Smoking cessation
♦ Avoidance of air pollutants
♦ Chest physiotherapy
♦ Ultrasonic or mechanical nebulizer treatments
♦ Adequate fluid intake
♦ High-calorie, protein-rich diet
♦ Activity, as tolerated, with frequent rest periods
Medications
♦ Oxygen
♦ Antibiotics
♦ Bronchodilators
♦ Corticosteroids
♦ Diuretics
Surgery
♦ Tracheostomy in advanced disease
Nursing interventions
♦ Give prescribed drugs.
♦ Encourage the patient to express his fears and concerns.
♦ Include the patient and his family in care decisions.
♦ Perform chest physiotherapy.
♦ Provide a high-calorie, protein-rich diet.
♦ Offer small, frequent meals.
♦ Encourage energy-conservation techniques.
♦ Ensure adequate oral fluid intake.
♦ Provide frequent mouth care.
♦ Encourage daily activity.
♦ Provide diversional activities, as appropriate.
♦ Provide frequent rest periods.
Patient teaching
♦ Be sure to cover:
– the disorder, diagnosis, and treatment
– medications and possible adverse reactions
– when to notify the physician
– infection control practices
– the importance of influenza and pneumococcus immunizations
– the importance of home oxygen therapy, if required, including a demonstration, if needed
– postural drainage and chest percussion
– coughing and deep-breathing exercises
– inhaler use
– high-calorie, protein-rich meals
– adequate hydration
– avoidance of inhaled irritants
– prevention of bronchospasm.
♦ Refer the patient to a smokingcessation program, if indicated.
♦ Refer the patient to the American Lung Association for information and support.
Colorectal cancer
Overview
♦ Malignant tumors of the colon or rectum are almost always adenocarcinomas (About half are sessile lesions of the rectosigmoid area; all others are polypoid lesions.)
♦ Slow progression
♦ Five-year survival rate of 50%; potentially curable in 75% of patients if early diagnosis allows resection before involvement of nodes
♦ Third most common type of cancer in Europe and North America
Causes
♦ Unknown
Risk factors
♦ Excessive intake of saturated animal fat
♦ Smoking
♦ Older than age 50
♦ History of ulcerative colitis
♦ History of familial polyposis
♦ Family history of colon cancer
♦ High-protein, low-fiber diet
♦ Excessive alcohol intake
Assessment
History
♦ Tumors of the right side of the colon: no signs and symptoms in the early stages because stool is liquid in that part of the colon
♦ Black, tarry stools
♦ Abdominal aching, pressure, or dull cramps
♦ Weakness
♦ Diarrhea, anorexia, obstipation, weight loss, and vomiting
♦ Rectal bleeding
♦ Intermittent abdominal fullness
♦ Rectal pressure
♦ Urgent need to defecate on arising
Physical findings
♦ Abdominal distention or visible masses
♦ Enlarged abdominal veins
♦ Enlarged inguinal and supraclavicular nodes
♦ Abnormal bowel sounds
♦ Abdominal masses (Tumors on the right side usually feel bulky; tumors of the transverse portion are more easily detected.)
♦ Generalized abdominal tenderness
Diagnostic tests
Laboratory
♦ A fecal occult blood test may show blood in the stools, a warning sign of rectal cancer.
♦ The carcinoembryonic antigen test permits patient monitoring before and after treatment to detect metastasis or recurrence.
Imaging
♦ Excretory urography verifies bilateral renal function and allows inspection to detect displacement of the kidneys, ureters, or bladder by a tumor pressing against these structures.
♦ Barium enema studies use dual contrast of barium and air to show the location of lesions that aren’t detectable manually or visually. This test shouldn’t precede colonoscopy or excretory urography because barium sulfate interferes with these tests.
♦ A computed tomography scan allows better visualization if a barium enema test yields inconclusive results or if metastasis to the pelvic lymph nodes is suspected.
Diagnostic procedures
♦ Proctoscopy or sigmoidoscopy permits visualization of the lower GI tract. It can detect up to 76% of colorectal cancers.
Other
♦ Digital rectal examination can be used to detect one-third of malignant tumors of the distal colon and rectum; specifically, it can be used to detect suspicious rectal and perianal lesions.
Treatment
General
♦ Radiation preoperatively and postoperatively to induce tumor regression
♦ High-fiber diet
♦ After surgery, avoidance of heavy lifting and contact sports
Medications
♦ Chemotherapy for metastasis, residual disease, or recurrent inoperable tumor
♦ Analgesics
Surgery
♦ Resection or right hemicolectomy for advanced disease (Surgery may include resection of the terminal segment of the ileum, cecum, ascending colon, and right half of the transverse colon with corresponding mesentery.)
♦ Right colectomy that includes the transverse colon and mesentery corresponding to the midcolic vessels, or segmental resection of the transverse colon and associated midcolic vessels
♦ Resection usually limited to the sigmoid colon and mesentery
♦ Anterior or low anterior resection (A newer method that uses a stapler allows for much lower resections than were possible in the past.)
♦ Abdominoperineal resection and permanent sigmoid colostomy required
Nursing interventions
♦ Provide support and encourage the patient to express his concerns.
♦ Give prescribed drugs.
Postoperative
♦ Vital signs
♦ Intake and output
♦ Hydration and nutritional status
♦ Electrolyte levels
♦ Wound site
♦ Postoperative complications
♦ Bowel function
♦ Pain control
♦ Psychological status
Patient teaching
♦ Be sure to cover:
– the disease process, treatment, and postoperative course
– stoma care
– the need to avoid heavy lifting
– the need to keep follow-up appointments
– risk factors and signs of reoccurrence.
♦ Refer the patient to resource and support services.
Coronary artery disease
Overview
♦ Heart disease that results from narrowing of the coronary arteries over time as a result of atherosclerosis
♦ Primary effect: loss of oxygen and nutrients to myocardial tissue because of decreased coronary blood flow
Causes
♦ Atherosclerosis
♦ Dissecting aneurysm
♦ Infectious vasculitis
♦ Syphilis
♦ Congenital defects
♦ Coronary artery spasm
Assessment
History
♦ Angina that may radiate to the left arm, neck, jaw, or shoulder blade
♦ Angina that commonly occurs after physical exertion but may also follow emotional excitement, exposure to cold, or a large meal
♦ May develop during sleep (Symptoms wake the patient.)
♦ Nausea
♦ Vomiting
♦ Fainting
♦ Sweating
♦ Stable angina (predictable and relieved by rest or nitrates)
♦ Unstable angina (increased frequency and duration, more easily induced, generally indicates extensive or worsening disease and, untreated, may progress to myocardial infarction)
♦ Crescendo angina (effort-induced pain that occurs with increasing frequency and with decreasing provocation)
♦ Prinzmetal’s or variant angina pectoris (severe, non-effort-produced pain that occurs at rest without provocation)
Physical findings
♦ Cool extremities
♦ Xanthoma
♦ Arteriovenous nicking of the eye
♦ Obesity
♦ Hypertension
♦ Positive Levine sign (holding the fist to the chest)
♦ Decreased or absent peripheral pulses
Diagnostic tests
Imaging
♦ Myocardial perfusion imaging with thallium 201 during treadmill exercise shows ischemic areas of the myocardium. These are visualized as “cold spots.”
♦ Pharmacologic myocardial perfusion imaging in arteries with stenosis shows a decrease in blood flow that’s proportional to the percentage of occlusion.
♦ Multiple-gated acquisition scanning shows cardiac wall motion and reflects injury to cardiac tissue.
Diagnostic procedures
♦ Electrocardiographic findings may be normal between anginal episodes. During angina, the findings may show ischemic changes.
♦ Exercise testing may be performed to detect ST-segment changes during exercise, which indicate ischemia, and to determine a safe exercise prescription.
♦ Coronary angiography shows the location and degree of coronary artery stenosis or obstruction, the collateral circulation, and the condition of the artery beyond the narrowing.
♦ Stress echocardiography may show abnormal wall motion.
Treatment
General
♦ Stress reduction techniques are essential, especially if known stressors precipitate pain
♦ Lifestyle modifications, such as smoking cessation and maintaining ideal body weight
♦ Low-fat, low-sodium diet
♦ Possible restrictions on the patient’s activity
♦ Regular exercise
Medications
♦ Aspirin
♦ Nitrates
♦ Beta blockers
♦ Calcium channel blockers
♦ Antiplatelets
♦ Antilipemics
♦ Antihypertensives
Surgery
♦ Coronary artery bypass graft
♦ “Keyhole,” or minimally invasive surgery
♦ Angioplasty
♦ Placement of an endovascular stent
♦ Laser angioplasty
♦ Atherectomy
Nursing interventions
♦ Ask the patient to grade the severity of his pain on a scale of 1 to 10, with 10 being the most severe.
♦ Keep nitroglycerin available for immediate use. Instruct the patient to call the nurse immediately whenever he feels pain and before he takes nitroglycerin.
♦ Monitor the patient’s electrocardiogram for ST-T segment changes.
♦ Observe the patient for signs and symptoms that may signify worsening of his condition.
♦ Perform vigorous chest physiotherapy and guide the patient in pulmonary self-care.
♦ Monitor abnormal bleeding and distal pulses after interventions or procedures.
♦ Monitor drainage of the chest tube after surgery.
Patient teaching
♦ Be sure to cover:
– risk factors for coronary artery disease
– the need to avoid activities that precipitate episodes of pain
– effective coping mechanisms for dealing with stress
– the need to follow the prescribed drug regimen
– the importance of following a lowsodium, low-calorie diet
– the importance of regular, moderate exercise.
♦ Refer the patient to a weight-loss program, if needed.
♦ Refer the patient to a smokingcessation program, if needed.
♦ Refer the patient to a cardiac rehabilitation program, if indicated.
Diabetes mellitus
Overview
♦ Chronic disease of absolute or relative insulin deficiency or resistance
♦ Characterized by disturbances in the metabolism of carbohydrates, proteins, and fats
♦ Two primary forms:
– Type 1, which is characterized by absolute insufficiency of insulin
– Type 2, which is characterized by insulin resistance with varying degrees of insulin secretory defects
Causes
♦ Genetic factors
♦ Autoimmune disease (type 1)
Risk factors (Type 2)
♦ Family history of diabetes
♦ Race
♦ Sedentary lifestyle
♦ Obesity (BMI ≥ 25 kg/m2)
♦ History of gestational diabetes, glucose intolerance, or delivery of a > 9 pound baby
♦ HDL ≤ 35 mg/dl or triglygeride level ≥ 130 mg/dl
♦ Hypertension
♦ Age ≥ 45 years
Unless a diabetic woman’s glucose levels are well controlled before conception and during pregnancy, her neonate has two to three times the risk of congenital malformations and fetal distress.Assessment
History
♦ Polyuria, nocturia
♦ Dehydration
♦ Polydipsia
♦ Dry mucous membranes
♦ Poor skin turgor
♦ Weight loss and hunger
♦ Weakness and fatigue
♦ Vision changes
♦ Frequent skin and urinary tract infections
♦ Dry, itchy skin
♦ Sexual problems
♦ Numbness or pain in the hands or feet
♦ Postprandial feeling of nausea or fullness
♦ Nocturnal diarrhea
Type 1
♦ Rapidly developing symptoms
Type 2
♦ Vague, long-standing symptoms that develop gradually
♦ Family history of diabetes mellitus
♦ Pregnancy
♦ Severe viral infection
♦ Other endocrine diseases
♦ Recent stress or trauma
♦ Use of drugs that increase blood glucose levels
Physical findings
♦ Retinopathy or cataract formation
♦ Skin changes, especially on the legs and feet
♦ Muscle wasting and loss of subcutaneous fat (type 1)
♦ Obesity, particularly in the abdominal area (type 2)
♦ Poor skin turgor
♦ Dry mucous membranes
♦ Decreased peripheral pulses
♦ Cool skin temperature
♦ Diminished deep tendon reflexes
♦ Orthostatic hypotension
♦ Characteristic “fruity” breath odor in ketoacidosis
♦ Possible hypovolemia and shock in ketoacidosis and hyperosmolar hyperglycemic state
Diagnostic tests
Laboratory
♦ Fasting plasma glucose level is 126 mg/dl or greater on at least two occasions.
♦ Random blood glucose level is 200 mg/dl or greater along with symptoms of diabetes.
♦ Two-hour postprandial blood glucose level is 200 mg/dl or greater.
♦ Glycosylated hemoglobin value is increased.
Diagnostic procedures
♦ Ophthalmologic examination may show diabetic retinopathy.
Treatment
General
♦ Exercise and diet control
♦ Tight glycemic control for prevention of complications
♦ Modest calorie restriction for weight loss or maintenance
♦ American Diabetes Association recommendations to reach target glucose, hemoglobin A1c lipid, and blood pressure levels
♦ Regular aerobic exercise
Surgery
♦ Pancreas transplantation
Nursing interventions
♦ Give prescribed drugs.
♦ Give rapidly absorbed carbohydrates for hypoglycemia or, if the patient is unconscious, give glucagon or I.V. dextrose, as ordered.
♦ Administer I.V. fluids and insulin replacement for hyperglycemic crisis, as ordered.
♦ Monitor electrolytes and administer replacements, as ordered.
♦ Provide meticulous skin care, especially to the feet and legs.
♦ Treat all injuries, cuts, and blisters immediately.
♦ Avoid constricting hose, slippers, or bed linens.
♦ Encourage adequate fluid intake.
♦ Encourage the patient to express his feelings.
♦ Offer emotional support.
♦ Help the patient to develop effective coping strategies.
Patient teaching
♦ Be sure to cover:
– the disorder, diagnosis, and treatment
– medication and potential adverse reactions
– when to notify the physician
– the prescribed meal plan
– the prescribed exercise program
– signs and symptoms of infection, hypoglycemia, hyperglycemia, and diabetic neuropathy
– self-monitoring of blood glucose level
– complications of hyperglycemia
– foot care
– the importance of annual regular ophthalmologic examinations
– safety precautions
– management of diabetes during illness.
♦ Refer the patient to a dietitian.
♦ Refer the patient to a podiatrist if indicated.
♦ Refer the patient to an ophthalmologist.
♦ Refer adult diabetic patients who are planning families for preconception counseling.
♦ Refer the patient to the Juvenile Diabetes Research Foundation, the American Association of Diabetes Educators, and the American Diabetes Association, as appropriate, to obtain additional information.
Emphysema
Overview
♦ Chronic lung disease characterized by permanent enlargement of air spaces distal to the terminal bronchioles and by exertional dyspnea
♦ One of several diseases usually labeled collectively as chronic obstructive pulmonary disease or chronic obstructive lung disease
Causes
♦ Genetic deficiency of alpha1-antitrypsin
♦ Cigarette smoking
Assessment
History
♦ Smoking
♦ Shortness of breath
♦ Chronic cough
♦ Anorexia and weight loss
♦ Malaise
Physical findings
♦ Barrel chest
♦ Pursed-lip breathing
♦ Use of accessory muscles
♦ Cyanosis
♦ Clubbed fingers and toes
♦ Tachypnea
♦ Decreased tactile fremitus
♦ Decreased chest expansion
♦ Hyperresonance
♦ Decreased breath sounds
♦ Crackles
♦ Inspiratory wheeze
♦ Prolonged expiratory phase with grunting respirations
♦ Distant heart sounds
Diagnostic tests
Laboratory
♦ Arterial blood gas analysis shows decreased partial pressure of oxygen; the partial pressure of carbon dioxide is normal until late in the course of disease.
♦ The red blood cell count shows an increased hemoglobin level late in the course of disease.
Imaging
♦ Chest X-ray may show:
– a flattened diaphragm
– reduced vascular markings at the lung periphery
– overaeration of the lungs
– a vertical heart
– enlarged anteroposterior chest diameter
– a large retrosternal air space.
Diagnostic procedures
♦ Pulmonary function tests typically show:
– increased residual volume and total lung capacity
– reduced diffusing capacity
– increased inspiratory flow.
♦ Electrocardiography may show tall, symmetrical P waves in leads II, III, and aVF; a vertical QRS axis; and signs of right ventricular hypertrophy late in the course of disease.
Treatment
General
♦ Chest physiotherapy
♦ Possible transtracheal catheterization and home oxygen therapy
♦ Adequate hydration
♦ High-protein, high-calorie diet
♦ Activity, as tolerated
Medications
♦ Bronchodilators
♦ Anticholinergics
♦ Mucolytics
♦ Corticosteroids
♦ Antibiotics
♦ Oxygen
Surgery
♦ Insertion of a chest tube for pneumothorax
♦ Lung volume reduction surgery for patients who meet criteria
Nursing interventions
♦ Give prescribed drugs.
♦ Provide supportive care.
♦ Help the patient adjust to lifestyle changes that are necessitated by a chronic illness.
♦ Encourage the patient to express his fears and concerns.
♦ Perform chest physiotherapy.
♦ Provide a high-calorie, protein-rich diet.
♦ Give small, frequent meals.
♦ Encourage daily activity and diversional activities.
♦ Provide frequent rest periods.
Patient teaching
♦ Be sure to cover:
– the disorder, diagnosis, and treatment
– medication and potential adverse reactions
– when to notify the physician
– the importance of avoiding smoking and areas where smoking is permitted
– the need to avoid crowds and people with known infections
– home oxygen therapy, if indicated
– transtracheal catheter care, if needed
– coughing and deep-breathing exercises
– the proper use of handheld inhalers
– the importance of a high-calorie, protein-rich diet
– adequate oral fluid intake
– avoidance of respiratory irritants
– signs and symptoms of pneumothorax.
Urge the patient to notify the physician if he has sudden onset of worsening dyspnea or sharp pleuritic chest pain that’s exacerbated by chest movement, breathing, or coughing.♦ Refer the patient to a smokingcessation program if indicated.
♦ Refer the patient for influenza and pneumococcal pneumonia immunizations as needed.
♦ Refer the family of a patient with familial emphysema for screening for alpha1-antitrypsin deficiency.
Gastroenteritis
Overview
♦ Self-limiting inflammation of the stomach and small intestine
♦ Intestinal flu, traveler’s diarrhea, viral enteritis, and food poisoning
Causes
♦ Bacteria, such as Staphylococcus aureus, Salmonella, Shigella, Clostridium botulinum, Clostridium perfringens, and Escherichia coli
♦ Amoebae, especially Entamoeba histolytica
♦ Parasites, such as Ascaris, Enterobius, and Trichinella spiralis
♦ Viruses, such as noroviruses, echoviruses, and coxsackieviruses
♦ Ingestion of toxins, such as poisonous plants and toadstools
♦ Drug reactions from antibiotics
♦ Food allergens
♦ Enzyme deficiencies
Assessment
History
♦ Acute onset of diarrhea
♦ Abdominal pain and discomfort
♦ Nausea and vomiting
♦ Malaise and fatigue
♦ Exposure to contaminated food
♦ Recent travel
Physical findings
♦ Slight abdominal distention
♦ Poor skin turgor (with dehydration)
♦ Hyperactive bowel sounds
♦ Decreased blood pressure
Diagnostic tests
Laboratory
♦ Gram stain, stool culture (by direct rectal swab), or blood culture shows the causative agent.
Treatment
General
♦ Supportive treatment for nausea, vomiting, and diarrhea
♦ Rehydration
♦ Initially, clear liquids as tolerated
♦ Electrolyte solutions
♦ Avoidance of milk products
♦ Activity, as tolerated (Encourage mobilization.)
Medications
♦ Antidiarrheal therapy
♦ Antiemetics
♦ Antibiotics
♦ I.V. fluids
Nursing interventions
♦ Allow uninterrupted rest periods.
♦ Replace lost fluids and electrolytes through diet or I.V. fluids.
♦ Give prescribed drugs.
Patient teaching
♦ Be sure to cover:
– the disorder, diagnosis, and treatment
– dietary modifications
– all prescribed drugs, including administration and possible adverse effects
– preventive measures
– how to perform warm sitz baths three times per day to relieve anal irritation.
Gastroesophageal reflux disease
Overview
♦ Backflow of gastric or duodenal contents, or both, into the esophagus and past the lower esophageal sphincter (LES), without associated belching or vomiting
♦ Reflux of gastric acid, causing acute epigastric pain, usually after a meal
♦ Commonly called heartburn
♦ Also called GERD
Causes
♦ Pyloric surgery (alteration or removal of the pylorus), which allows reflux of bile or pancreatic juice
♦ Hiatal hernia with an incompetent sphincter
♦ Any condition or position that increases intra-abdominal pressure
Risk factors
♦ Any agent that lowers LES pressure: acidic and fatty food, alcohol, cigarettes, anticholinergics (atropine, belladonna, propantheline) or other drugs (morphine, diazepam, calcium channel blockers, meperidine)
♦ Nasogastric intubation for more than 4 days
Assessment
History
♦ Minimal or no symptoms in onethird of patients
♦ Heartburn that typically occurs 1½ to 2 hours after eating
♦ Heartburn that worsens with vigorous exercise, bending, lying down, wearing tight clothing, coughing, constipation, or obesity
♦ Relief obtained by using antacids or sitting upright
♦ Regurgitation without associated nausea or belching
♦ Sensation of accumulation of fluid in the throat without a sour or bitter taste
♦ Chronic pain radiating to the neck, jaws, and arms that may mimic angina pectoris
♦ Nocturnal hypersalivation and wheezing
Physical findings
♦ Odynophagia (sharp substernal pain on swallowing), possibly followed by a dull substernal ache
♦ Bright red or dark brown blood in the vomitus
♦ Laryngitis and morning hoarseness
♦ Chronic cough
Diagnostic tests
Imaging
♦ Barium swallow with fluoroscopy shows evidence of recurrent reflux.
Diagnostic procedures
♦ An esophageal acidity test shows the degree of gastroesophageal reflux.
♦ Gastroesophageal scintillation testing shows reflux.
Factors affecting LES pressure
Various dietary and lifestyle factors can increase or decrease lower esophageal sphincter (LES) pressure. Take these factors into account when you plan the patient’s treatment program.
Factors that decrease LES pressure | Factors that increase LES pressure |
♦ Protein ♦ Carbohydrates ♦ Nonfat milk ♦ Low-dose ethanol | ♦ Fat ♦ Whole milk ♦ Orange juice ♦ Tomatoes ♦ Antiflatulent (simethicone) ♦ Chocolate ♦ High-dose ethanol ♦ Cigarette smoking ♦ Lying on the right or left side ♦ Sitting |
♦ Esophageal manometry shows abnormal LES pressure and sphincter incompetence.
♦ The result of an acid perfusion (Bernstein) test confirms esophagitis.
♦ The results of esophagoscopy and biopsy confirm pathologic changes in the mucosa.
Treatment
General
♦ Modification of lifestyle
♦ Positional therapy
♦ Removal of the cause
♦ Weight reduction, if appropriate
♦ Avoidance of dietary causes
♦ Avoidance of eating 2 hours before sleep (See Factors affecting LES pressure.)
♦ Parenteral nutrition or tube feedings
♦ No activity restrictions for medical treatment
♦ Lifting restrictions for surgical treatment
Medications
♦ Antacids
♦ Cholinergics
♦ Histamine-2 receptor antagonists
♦ Proton pump inhibitors
Surgery
♦ Hiatal hernia repair
♦ Vagotomy or pyloroplasty
♦ Esophagectomy
Nursing interventions
♦ Offer emotional and psychological support.
♦ Assist with diet modification.
♦ Perform chest physiotherapy.
♦ Use semi-Fowler’s position for the patient with a nasogastric tube.
Patient teaching
♦ Be sure to cover:
– the disorder, diagnosis, and treatment
– the causes of gastroesophageal reflux disease
– the prescribed antireflux regimen of medication, diet, and positional therapy
– development of a dietary plan
– the need to identify situations or activities that increase intra-abdominal pressure
– the need to avoid substances that reduce sphincter control
– signs and symptoms to watch for and report.
Heart failure
Overview
♦ Buildup of fluid in the heart that occurs when the myocardium can’t provide sufficient cardiac output
♦ Usually occurs in a damaged left ventricle, but may occur in the right ventricle primarily, or secondary to left-sided heart failure
Causes
♦ Mitral stenosis secondary to rheumatic heart disease, constrictive pericarditis, or atrial fibrillation
♦ Mitral or aortic insufficiency
♦ Arrhythmias
♦ Hypertension
♦ Atherosclerosis with myocardial infarction
♦ Myocarditis
♦ Ventricular and atrial septal defects
♦ Constrictive pericarditis
♦ Pregnancy
♦ Thyrotoxicosis
♦ Pulmonary embolism
♦ Infections
♦ Anemia
♦ Emotional stress
♦ Increased intake of salt or water
Assessment
History
♦ A disorder or condition that can precipitate heart failure
♦ Dyspnea or paroxysmal nocturnal dyspnea
♦ Peripheral edema
♦ Fatigue
♦ Weakness
♦ Insomnia
♦ Anorexia
♦ Nausea
♦ Sense of abdominal fullness (particularly in right-sided heart failure)
♦ Substance abuse (alcohol, drugs, tobacco)
Physical findings
♦ Cough that produces pink, frothy sputum
♦ Cyanosis of the lips and nail beds
♦ Pale, cool, clammy skin
♦ Diaphoresis
♦ Distention of the jugular veins
♦ Ascites
♦ Tachycardia
♦ Pulsus alternans
♦ Hepatomegaly and, possibly, splenomegaly
♦ Decreased pulse pressure
♦ S3 and S4 heart sounds
♦ Moist, bibasilar crackles, rhonchi, and expiratory wheezing
♦ Decreased pulse oximetry
♦ Peripheral edema
♦ Decreased urinary output
Diagnostic tests
Laboratory
♦ B-type natriuretic peptide immunoassay value is elevated.
Imaging
♦ Chest X-rays show increased pulmonary vascular markings, interstitial edema, or pleural effusion, and cardiomegaly.
Diagnostic procedures
♦ Electrocardiography shows heart strain, enlargement, or ischemia. It may also show atrial enlargement or fibrillation, tachycardia, or extrasystole.
Treatment
General
♦ Antiembolism stockings
♦ Elevation of the legs
♦ Sodium-restricted diet
♦ Fluid restriction
♦ Calorie restriction, if indicated
♦ Low-fat diet, if indicated
♦ Walking program
♦ Activity, as tolerated
Medications
♦ Diuretics
♦ Oxygen
♦ Inotropic drugs
♦ Vasodilators
♦ Angiotensin-converting enzyme inhibitors
♦ Angiotensin receptor blockers
♦ Cardiac glycosides
♦ Diuretics
♦ Potassium supplements
♦ Beta-adrenergic blockers
♦ Anticoagulants
Surgery
♦ For valvular dysfunction with recurrent acute heart failure, surgical replacement
♦ Heart transplantation
♦ Placement of a ventricular assist device
♦ Placement of a stent
Nursing interventions
♦ Place the patient in Fowler’s position, and give supplemental oxygen.
♦ Provide continuous cardiac monitoring during the acute and advanced stages of disease.
♦ Assist the patient with range-ofmotion exercises.
♦ Apply antiembolism stockings. Check for calf pain and tenderness.
♦ Monitor the patient’s weight daily to detect peripheral edema and other signs and symptoms of fluid overload.
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