Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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Oxygen therapy to support breathing.
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Insert endotracheal tube to maintain airway.
NURSING DIAGNOSES
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Decrease cardiac output
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Risk for suffocation
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Anxiety
NURSING INTERVENTION
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Maintain airway to facilitate breathing.
•
Monitor for hoarseness and difficulty breathing to check for symptoms of
decreased respiration.
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Explain to the patient:
•
Avoid exposure to allergens to prevent future occurrences.
•
Seek medical help immediately if exposed to allergens to prevent ana-
phylaxis.
Ankylosing Spondylitis
WHAT WENT WRONG?
Ankylosing spondylitis (AS) is a progressive form of arthritis that affects <1 per-
cent of the population. Joints between the spine and pelvis become inflamed, as
do some of the ligaments, resulting in instability of the joints. Heredity factors play
an important role in the development of AS. The disease is strongly associated
with the presence of histocompatibility antigen HLA-B27 on the chromosomes of
affected individuals. It begins in the sacroiliac joints and spreads up the spine.
PROGNOSIS
The course of the disease may vary in each case and from individual to individual.
Some have episodes of transient back pain while others have more chronic severe
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back pain that leads to varying degrees of spinal stiffness over time. The disease
is characterized by acute painful exacerbations and remissions.
HALLMARK SIGNS AND SYMPTOMS
•
Severe lower back pain after a period of inactivity due to inflammation and
stiffness
•
Reduced motion of the lumbar area of the spine due to the pain of inflam-
mation
INTERPRETING TEST RESULTS
•
Spinal x-ray: joints show the characteristic Bamboo spine that is a late sign.
Early x-rays may show arthritic erosion.
•
Blood serum contains the HLA-B27 antigen, which is present in about 90 per-
cent of those with AS.
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Elevated ESR.
TREATMENT
Nonpharmacologic measures include patient education, family education, genetic
counseling, positioning, extension exercises, and physical therapy. The primary
goals are to relieve pain, decrease inflammation, begin strengthening exercises, and
maintain good posture and function. Medications take an empiric approach. If one
NSAID is not effective for that particular patient, another is tried. Corticosteroids
should not be utilized for long-term management due to the systemic effects.
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Stretching exercises—to maintain flexibility.
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Back brace—to maintain posture.
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Administer nonsteroidal anti-inflammatory agent—to decrease inflammation
and for the analgesic effect.
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aspirin
•
ibuprofen
•
indomethacin
•
sulfasalazine
•
sulindac
•
Physical therapy.
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NURSING DIAGNOSES
•
Activity intolerance
•
Impaired physical mobility
•
Chronic pain
NURSING INTERVENTION
•
Administer intermittent heat to the lumbar area of the spine for symptom relief.
•
Massage the lumbar area of the spine for symptom relief.
•
Provide comfort to the patient.
•
Explain to patient:
•
It is best to sit in a high back chair for posture.
•
Repeated attempts to maintain erect posture.
Kaposi’s Sarcoma (KS)
WHAT WENT WRONG?
Overgrowth of blood vessels that leads to malignant tumors and cancer of lym-
phatic tissue and skin commonly found in patients with AIDS. Usually seen in
cases of advanced AIDS.
PROGNOSIS
Kaposi’s sarcoma is often associated with AIDS. The treatment of AIDS with anti-
retrovirals usually helps the symptoms of KS.
HALLMARK SIGNS AND SYMPTOMS
•
Red, brown, and purple lesions on the buccal mucosa, lips, gums, tongue,
and palates because it is a malignancy affecting the skin and mucosa.
•
Difficulty breathing (dyspnea) if the malignancy invades the pulmonary system.
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INTERPRETING TEST RESULTS
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Biopsy to look for the HIV virus, and B-lymphocytes.
•
CT scan to determine metastasis of the lesion to ascertain the severity of the
disease.
TREATMENT
The treatment for KS is often specific for the individual lesion, using radiation.
Treatment for AIDS will also ameliorate, to some degree, the effects of AIDS.
•
Radiation in the affected tissue to shrink and treat tumors. Laser surgery may
be utilized to remove some lesions.
•
Administer antiemetic medication to counter effects of chemotherapy and
radiation:
•
trimethobenzamide
•
Administer chemotherapy medication to slow or halt the disease:
•
doxorubicin
•
etoposide
•
vinblastine
•
vincristine
NURSING DIAGNOSES
•
Disturbed body image
•
Ineffective protection
•
Risk for infection
NURSING INTERVENTION
•
Monitor skin for lesions to determine new lesions and/or metastasis.
•
Daily weighing to determine changes in weight from baseline.
•
Explain to the patient:
•
The need for dietary changes, such as a high-protein, high-calorie diet.
•
How to conserve energy.
•
Hospice care.
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Lymphoma
WHAT WENT WRONG?
Functionless and damaged cells of the lymphatic system undergo overgrowth,
decreasing the effectiveness of the lymphatic system. There are two main types of
lymphoma, characterized by painless lymph node swelling:
•
Hodgkin’s disease is malignant lymphoma characterized by presence of
Reed-Sternberg cells. There are four stages of Hodgkin’s disease:
•
Stage I—Reed-Sternberg cells appear in one lymph node region.
•
Stage II—Reed-Sternberg cells appear in multiple lymph node regions on
the same side of the diaphragm.
•
Stage III—Reed-Sternberg cells appear in multiple lymph node regions
on both sides of the diaphragm.
•
Stage IV—Reed-Sternberg cells appear throughout the body.
•
Non-Hodgkin’s lymphoma (NHL) are cancers of the B-lymphocytes and are
characterized by the absence of Reed-Sternberg cells.
The lymphomas are caused by a disruption of cells during differentiation. Diag-
nosis is made on lymph node biopsy.
PROGNOSIS
Prognosis depends on what stage the patient was in upon diagnosis, and on response
to treatment. Survival is generally <10 years for non-Hodgkins; may be more for
Hodgkins, with an optimistic staging.
HALLMARK SIGNS AND SYMPTOMS
•
B symptoms (night sweats, fever, and weight loss)
•
Enlarged, painless lymph nodes in cervical region, mesentery, abdomen, and
pelvis.
INTERPRETING TEST RESULTS
•
Lymph node biopsy contains Reed-Sternberg cells, which typify Hodgkin’s disease.
•
Bone marrow biopsy contains follicular type cells (Non-Hodgkin’s lymphoma).
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TREATMENT
Treatment depends on the staging, which is based on the number of involved
lymph nodes, and the number of cavities, and bone marrow involvement.
•
Radiation in the affected tissue to shrink the nodes.
•
Administer Hodgkin’s disease medication:
•
vincristine
•
doxorubicin
•
bleomycin
•
dacarbazine
•
Administer non-Hodgkin’s lymphoma medication:
•
cyclophosphamide
•
vincristine
•
doxorubicin
•
rituximab
•
prednisone
•
radiation
NURSING DIAGNOSES
•
Impaired tissue integrity
•
Risk for infection
•
Ineffective protection
NURSING INTERVENTION
•
Monitor vital signs to determine variations from baseline.
•
Monitor for complications such as new palpable lymph nodes and fever.
•
Increase fluid intake.
•
Increase calories, protein, iron, calcium, and vitamins and minerals to counter-
act weight loss.
•
Administer prescribed antiemetic medication for nausea.
•
Monitor laboratory results for blood counts in response to chemotherapy.
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Explain to the patient:
•
Consult with physician before using over-the-counter medication.
Rheumatoid Arthritis
WHAT WENT WRONG?
Antibodies from the bloodstream move into the synovial lining of joints, causing
joints to swell. The swelling affects the functionality of tendons, bones, and liga-
ments that move the joint, resulting in pain with movement. Etiology is unknown,
although genetics plays a part. The usual age of onset is 20 to 40 years, and it
affects about 2 percent of the population. Inflammation and nodules around joints
are common, usually involving the wrists, hands, knees, and feet.
PROGNOSIS
Prognosis is variable. Some patients go into remission and need only moderate
treatment. Others progress with decreased functioning, with cardiac, renal, and
respiratory disease. Life expectancy is greatly lessened for this group.
HALLMARK SIGNS AND SYMPTOMS
•
Morning stiffness in joints due to the inflammation
•
Enlarged joints from swelling
•
Pain when moving due to the stiffness
•
Limited range of motion because of the inflammation and pain
•
Fever, malaise, and weight loss
INTERPRETING TEST RESULTS
•
Rheumatoid factor is positive in blood test.
•
Positive antinuclear antibody (ANA).
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Positive ESR.
•
Gamma globulins.
•
X-rays show changes in the affected joints.
TREATMENT
Reduction of pain and inflammation is the goal of treatment, along with preserv-
ing range of motion of the joint. Treatment is divided into nonpharmacological and
pharmacological methods.
•
Administer nonsteroidal anti-inflammatory (NSAID) medication to decrease
inflammation and pain:
•
ibuprofen
•
indomethacin
•
flurbiprofen
•
naproxen
•
sulindac
•
diflunisal
•
Administer disease-modifying antirheumatology agents (DMARDS):
•
methotrexate is an antimetabolite
•
TNF1—tumor necrosis factor increases lymphocytes and leukocytes found
in the joint fluids
•
etenercept
•
infliximab
•
adalimumab
•
antimalarials
•
hydroxychloroquine
•
Administer corticosteroids:
•
prednisone
•
Administer antacids to coat the stomach:
•
magnesium hydroxide
•
aluminium hydroxide
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Physical therapy and occupational therapy to maintain ADL and independ-
ence.
•
Cold and heat therapy for pain relief, anti-inflammatory effect, to help mus-
cles and joints.
•
Splints to maintain joints in positions that are most used.
•
Exercises to maintain flexibility and ROM (range of motion).
NURSING DIAGNOSES
•
Chronic pain
•
Activity intolerance
•
Disturbed body image
NURSING INTERVENTION
•
Assist patient in placing a splint on affected joint.
•
Weight loss to place less stress on joints.
•
Explain to the patient:
•
Get a full night’s sleep.
•
Avoid the cold.
•
Reduce stress.
Scleroderma
WHAT WENT WRONG?
Antibodies attack connective tissues in an autoimmune response. This results in
scar tissue (fibrosis) forming on skin, organs, GI tract, blood vessels, and muscles,
causing systemic sclerosis.
It is a chronic disease of unknown etiology, usually seen in 30-to-50-year-olds.
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PROGNOSIS
Scleroderma is a progressive disease causing early death, especially in those patients
with diffuse disease. Organ damage indicates an earlier demise; those with limited
organ involvement have longer life expectancies.
HALLMARK SIGNS AND SYMPTOMS
•
Stiffness and pain due to the fibrosis
•
Skin thickens
•
Edema, malaise, and fever
INTERPRETING TEST RESULTS
•
Positive antinuclear antibody.
•
Dermis appears thickened in skin biopsy.
TREATMENT
Treatment is based on treating the patient’s symptoms to ensure comfort. No known
medications are able to stop the disease. Various medications may be used to treat
the symptoms of the affected organs caused by scleroderma.
•
Physical therapy to maintain joint mobility.
NURSING DIAGNOSES
•
Impaired physical mobility
•
Impaired skin integrity
•
Pain
NURSING INTERVENTION
•
Monitor for increasing blood pressure, which is the leading cause of death to
scleroderma patients due to the renal effects of the disease.