Acute Illness

• - Health Promotion activities
• - Appropriate technology
• - Accessibility
• - Public Participation
• - Interdisciplinary/Intersectoral Collaboration

• Family Health teams
• Community Health Centers
• NP-Led Clinics
• Solo physician practices

• Healthcare provider
• Educator
• Facillitator/Communicator
• Community developer
• Social marketer
• Researcher/Evaluator
• Resource manager/Planner/Coordinator

• Assessment
• Planning
• Implementing
• Evaluating

• Data Collection
• - History and physical assessment from the client
• -Documentation
• -Other people (social worker, family)
• - Gordon's Functional Review pattern

• Statment of a client's response which is actually or potentially unhealthful
• -Actual or potential

• Set priorities
• Set goals (short and long term)
• Identify elements of care

• Isotonic
• Hypotonic
• Hypertonic
• Additives

• Angiocath
• PICC line
• Central Venous Line

• Primary
• Drip Chamber (macro or micro)
• Roller Clamp
• Secondary ports
• Q72 Hours

• Continuous analgesia (Requires less drug to maintain pain control, Small, Mobility and independence)
• Insulin
• Reservior (preloaded cassette)

• Infiltration
• Phlebitis
• Peripheral IV infection with bacteremia and sepsis
• Air in tubing
• Piece of Cath. in vein
• Allergic reaction to cath.

• Arm swollen, cool to touch
• Fluid leaking from site
• Tenderness around site
• Elderly client
• Site near a joint

Tip of cannula remains in the vein but vessal wall does not seal around it

Cannula slips out of the veinFluid infuses into surrounding tissue

• Length of time cannula has been in place
• Harshness of medication

• Dilute medications
• Slower infusion rate
• Rotating sites Q48 to 72 hours
• Using a central line

Occurs 2-3 days after discharge

• Vein is hard, skin is red, swollen and warm, but good infusion and blood return
• Induration (becoming hardend)
• Red line/ bump above IV site

• Infusion is sluggish, looks phlebitic
• Aspirate before you flush
• May accompany Phlebitis
• Inflammation of vein, blood flow has slow and clot is suspected.
• Remove Cannula and call MD
• Elevated WBC, fever, chills, and +tive blood cultures
• Treat with IV antibiotics and vien excision

• Infusion is sluggishIV site is hot, red and painfull, but not hard or swollen
• Chills, rapid pulse, T 39.4
• Blood, urine and sputum cultures
• Heat compress and elevate arm(dialates vessels to allow bld flow)

• Poor aseptic technique
• Failure to maintain a clean site or closed delivery system
• Failure to change tubing or cannulas at regular intervals
• Malnourished, immunocompromised, over 60, or if the client has an infection at another site

• Bp drops quickly and pulse increases after tubing change
• - Air embolism
• - Place client on left side, lower head of bed.
• Clamp IV and check tubbing for disconnection or air leakNotify physician, oxygen, monitor client closely

• IV site turns red,
• Pt complains of icthing and devlopes rash
• SOB

• Stop the infusion
• KVO with NS
• Administer oxygen
• Notify Physician
• Document reaction

• New IV,
• Red streak over vein,
• Pain at site
• Inform physician
• Use cath. of different material

• Alarm
• Site monitoring
• Mobility
• Written instructions
• S/S of allergic reation

HTN, CAD, Acute coronary artery syndrome, heart failure, Cardiomyopathy, Arrhythmias, inflammatory and valvular Heart disease, Vascular disorders

• Chest pain
• Palpitations Dyspnea
• Syncope
• Fatigue
• Dependant edema
• Hemoptysis (coughing up blood)
• Cyanosis

• Retrosternal,
• diffuse pressure
• Left arm, Jaw, Back pain
• "Aching, dull, pressing, squeezing, Vice-like"
• Mild to severe
• Minutes
• Increases with effort, emotion, eating, cold
• Relieved with rest and nitroglycerin

• Left inframammary localized pain (able to pinpoint)
• Radiates to right arm
• "Sharp, shooting, cutting"
• Excruciating
• Seconds, hours, days,
• Increases with respiration, posture, and motion
• Nonspecific relief measure

• "Fluttering"
• "Skipped beats"
• Several underlying causes, such as thyroid, dehydration

• Paroxysmal Nocturnal Dyspnea
• Orthopnea
• Dyspnea on exertion

• Occurs at night
• Supine (lying down)
• Increased intrathoracic blood volume when in supine
• Runs to window for air
• Most common with CHF

• Pt has to sit up to breath
• # of pillows can be used to quantify orthopnea

• DOE
• "How long are you walking before you lose your breath?"

• Fainting
• Transient loss of cerebral blood flow
• Hearts inability to pump blood to the brain
• Affected by position, activity and palpitations

• How long have you been tired? (new or chronic)
• Was the onset abrupt? Do you feel tried all day? (in the morning or evening)
• When do you feel the least tired?
• Do you feel more tired at home or work? (stress related)
• Is the fatigue relieved by rest?
• PEDS: Can they keep up with the other kids?

• Swelling of the legsCHF: Symmetric, worse at the end of
• the day
• Bilateral: Systemic cause
• One foot: Localized, DVT

• Look around mouth (circumoral)
• Lips and chest more serious than blue toes and fingers
• Dark skin: Look under lip and between fingers

• Where is the pain?
• How long have you had the pain
• Do you have reacurrent episodes of the pain?
• How often do you get the pain?
• What makes the pain worse?
• How would you describe it? (dull, presure, sharp?)
• Does the pain occur at rest, with exertion, after eating, when moving arms or with emotion?
• Is the pain associated with SOB, palpitations, nausea or vomiting, coughing, fever, coughing up blood or leg pain?

Hand over chest

• Elevated serum lipids
• HTN
• Cigarette smoking (Pack years)
• Sedentary Lifestyle
• Obesity
• Stress
• Diabetes
• Alcohol or drug abuse (cocaine causes tachycardia)
• Allergies
• Family history

• Weight history (going up and down stresses heart)
• Diet recall
• Salt and fat intake
• Ethnic influences (in terms of intake)

• Diuretic use
• Constipation (straining can cause CVA)Incontinence

• Type,
• Duration and frequency
• Unwanted effects (of meds. or condition)ADL limitations

• PND
• Orthopnea
• Nocturia (fluid is redistrubuted at night),
• take diuretic in morning

• Pain
• Language
• Memory

• Body image concerns
• Effect of illness on client

• Marital status
• Role in household
• # of children
• Living environment
• Significant others
• Satisfaction with role

• Fear of sudden death
• Fatigue
• SOB
• Impotence (Erectile dysfunction is one of the earliest signs of CAD b/c of decreased bld flow)
• No viagra if on nitroglyercin

• Marital relationships, family ,occupation, church, friends, finances, housing
• Coping mechanisms
• Support systems

• "higher power"
• Crisis
• Plan of care and conflict with belief system

• Health perception/health management
• Nutritional/metabolic
• Elimination
• Activity/exercise
• Sleep/rest
• Cognitive/perceptual
• Role/relationships
• Sexuality/reproductive
• Coping-stress tolerance
• Values/beliefs

• General appearance
• Skin
• Nails
• Facies
• Eyes
• Mouth
• Neck
• Chest
• Extremities

• Changes in HR (tachycardia, Bradycardia, Fibrillation)
• Arrythmia/Dysrhythmia
• Changes in character of pulse
• Changes in pulse pressure (diff. b/w systolic and diastolic)
• Alteration in peripheral pulses
• Jugular vein distension

• Changes in Bp (HTN, HPTN, Postural hypotension)
• Changes in skin (pallor, central (more serious) or peripheral cyanosis)Diaphoresis
• Decreased Cap. refill (less than 2 sec.)Changes in temp. (use back of hand)

• Bleeding
• - Frank (can see it)
• - Occult (hidden, in stool)
• - Bruising/ Ecchymosis
• - Petechiae (sm. vascular lesions - will disappear when touched)
• - Decreased cognition (bleeding in brain)

• Diagnostic testing
• Medical management (drug therapy, surgical intervention)
• Interdisciplinary Responsibilities (collaborative care, Independant nursing care - careplans, Discharge planning, community care)

• 24-48 hours
• Diary (to record symptoms)
• No bath or shower
• Skin irriatation may occur

• Ultrasound waves
• Blood flow through the heart (structure abnormalities)
• May be combined with exercise
• No contraindications
• Picks up the chambers of the heart

• Blood test
• Measures protiens released after MI
• Rapid bedside test, specifically related to the heart

• Written permission required
• Injection of dye
• No food or fluids 6-8 hours prior to procedure
• Post procedure care required (punture site - cath. goes into femoral artery)

• antihypertensives
• Antianginals
• Cardiotonics
• Antihyperlipidemics
• Decreasing the damage to the heart helps the heart work better also prevents any further damage

• Antiplatelet agents (coumadin -need INR)
• B-adrenergig blockers
• Nitrates
• Glycoprotien inhibitors
• Low molecular weight heparin
• Direct thrombin inhibitors
• ADP receptors antagonist
• Calcium Channel blockers
• Morphine
• ACE inhibitors
• Fibrinolytic therapy
• Pravex- blood thinner simular to coumadine but you don't need an INR H/E there is no antidote

• Cardiac Catherization
• Cardiopulmonary Bypass (bloodless feild during open heart surgery)
• Stent Placement (common-holds artery open)
• Heart transplant (criteria on heart transplant list)
• Pacemaker implant
• CABG(coronay artery bypass graph - go around blocked artery - use saphinous vein in leg)
• PTCA (Percutaneous transluminal coronary angioplasty)
• Laser angioplasty (use laser to detroy plaques)
• AED (automated external defibulator - if heart stops it puts it back on track)

• History & Physical
• Pt Fear and knowledge
• NPO after midnight
• Admin. sedative as ordered
• Teach cough and deep breathing
• explain use of pain meds. after surgery
• Explain Activity restrictions (6-8 wks after surgery)

• Immediate post op period (3-6 days in ICU)
• Post cardiac Rehabilitation (cardiac step down unit, telemetry, general medicine, or home)

Cardiac, resp., Hemmorage, Neurological, Renal failure, F/E imbalances, Coagulopathies, Poor wound healing, depression, Postpericardiotomy syndrome

• Monitor for complications
• Analgesics PRN
• Encouraged increased activity as tolerated
• Monitor incision
• Support client and family with recovery and in making required lifesyle modifications

• High risk for cardiovascular disease
• Decreased cardiac output
• Activity intolerance
• Knowledge deficit

Age, alcohol, cigarette smoking, Diabetes mellitus, Elevated serum lipids, Excess diatary sodium, Family history, Obesity ethnicity, sedentary lifesyle, Social economic status, Stress, Gender

• Hypertensive heart disease (CAD, left ventricular hypertrophy, which then leads to heart failure)
• Cerebrovascular disease (stroke)Peripheral vascular disease
• Nephrosclerosis (hardening of arteries in kidneys)
• Retinal damage

• Nutrional therapy
• Physical activity
• Medical managment
• Avoidance of tobacco products
• Modification in alcohol consumption
• Stress management

• Decrease serum cholesterol, obesity and DM
• <30%fat, <7%saturated fat, <200mg cholesterol
• 25-30g of soluble fibre (digestable)Fruits, vegetables and whole grains
• Fewer meats, refined starches and sugars
• Reduce sodium intake
• Dietician

• Shown to increase HDL
• Decrease Serum cholesterol, HTN, and obesity
• 3 to 4 times a week to 5 times 30 min a week.
• Progressive increase in activity

• Cost
• Instruction unclear or not given in writting
• Inadequate or no client teaching
• Lack of involvement of the client in the treatment plan
• Side effects
• Dementia (forgetful)
• Inconveinient dosing
• illiterate

• Encourage smoking cessation
• Refer to smoking cessation program
• Change routine associated with smoking
• Ask for family member support
• substitute with other activities

• When assesing if they admit to 12 it is probably more
• GDT- Liver funtion test
• If they stop abruptly they can die

• Identify stress levels and possible strategies for reduction
• eg. imagery, education, relaxation exercises

• Collaborative effort
• Begins on admission
• Must include client and family

• Continue with progressive activity as tolerated
• Cough and deep breathing exercises
• Avoid lifting (4-6 wks)
• 2-4wks until sexual activity
• Monitor incision for S/S of infection or occulsion
• Perform necessary incisional care
• Comply with lab monitoring
• Arm bracelet (if on coumadin)
• take meds. as prescribed
• Follow dietary restrictions (2g of na)

Pneumonia, asthma, COPD, Cystic fibrosis, Lung cancer, Tuberculosis, ARDS, ARF(acute resp. failure), Atelectasis, bronchiectasis, pleural effusion, Pneumothorax, Pulmonary embolism (bld flow dosn't get to lungs)

• SOB
• Wheezing
• Pleuritic chest pain (b/w ribs)
• cough
• Sputum production
• Hemoptysis (coughing up blood)
• Voice change
• Fatigue

• Unexplained apprehension, restlessness, irritability confusion and/or lethargy
• Tachypnea/Tachycardia
• DOE
• Mild hypertension
• Arrhythmias
• Diaphoresis, decreased urinary output, unexplained fatigue

• Unexplained confusion or lethargy
• Combativness, coma
• Use of accessory muscles,
• ICS retraction (inspiration), pause for breath inbetween sentences/words
• Arrhythmias, hypotension, cyanosis, cool, clammy skin
• Diaphoresis, decreased urinary output, unexplained fatigue

• percieved change in health status
• Course of illness
• Degree of dypnea
• Characteristics of cough
• Family history
• Living arrangments and recent travel
• Current and past smoking
• Use of equipment (nebulizer, O2)
• Immunizations (flu/pneumonia vacc.)

• Weight loss (planned/unplanned)
• rapid weight change (fluid retension)Dehydration
• Obesity (to tired)

Activity intolerance (ability to get to the washroom in time, long enough cord)

• Dyspnea
• ADL's
• Self care strategies

• Night walking
• # of pillows
• Sweating (TB)

• Anxiousness (b/c can't breath, which increases HR, therefore more dyspnea)
• Ability to learn and retain
• Cooperation with treatment
• Discomfort

• Development of role functions
• Self esteem
• Personal body image
• Support groups or rehab programs come in to play (kingston is closest)

• Performance at work
• Impact of meds. O2, and special routines
• Environmental exposure

Teaching position strategies for sexual fulfillment

• Cycle of dyspnea and anxiety
• Physical and social isolation
• Coping strategies

• Adherence to management regimen
• Conflict with cultural beliefs, financial constraints, failure to note benefit, or other reasons

VS, Nose, Mouth and Pharynx, Neck, Thorax and lungs, skin colour

Nose - Patency (plug one nostrol (breath in out) then plug other), inflammation, deformities, symmetry and discharge, polyps

Mouth and pharynx - Colour, leisions, masses, gum retractions, poor dentition, bleedin, obvious dental caries, and pursed lip bleeding

• Neck - Symmetry, tender or swollen areas (trachea should be midline), Lymph nodes
• Cough, sputum, clubbing of digits

• Inspection
• Palpation
• Percussion
• Ausculation

• Alterations in rhythm and depth (apnea, tachypnea, bradypnea, hyperpnea, hyperventilation, arrthythmic resp.
• Colour (cyanosis, Cherry pink, Reddish blue)
• Dyspnea
• Use of accessory muscles, indrawing, retraction
• Splinting, guarding
• Prolonged expiratory phase

• Tracheal position (should be midline)
• Chest symmetry
• Fremitis

• Resonance
• Tell the size of the lung (have them exhale and percuss up, have them inhale and percuss up)

• Decreased or absent air entry
• Wheeze
• Crackles (fine, coarse)
• Friction rubs (Hold breath to tell if its cardiac or lungs)
• Stridor (obstruction) - High pitched
• Grunts, snores, hoarseness

• Blunt or penetrating
• <20% of both lung: rest and limit activity it will go away on it's own
• 20-30% pt needs thoracentesis (needle though chest wall to draw fluids out)
• > 30% chest tube attached to underwater seal and suction (need to wait for lungs to re expand)

• Ensure patent airway
• Administer high flow O2 with non-rebreather mask
• Establish IV, begin fluids as appropriate
• Remove clothing to assess wounds
• Cover sucking wound with non-pourous dressing taped on 3 sides (don't want air in, need air to get out)
• Stablize impaled objects
• Assess for other signs of injurys
• Stablize flail rib segments (by hand or horizonal tape)
• Semi-fowlers, or on injured side after cervical spine injury has beed ruled out (allows for good expansion of lung)

Purpose is to remove air of fluid from the pleural space in order to reestablish subatmosphere intrapleural pressure which will reexpand the affected lung

• Bronchodilators
• Anticholinergics
• Anti-inflammatories
• Glucocorticoids
• Leukotriene receptor antagonsists
• Antibiotics
• Antituberculosis
• Expectorants
• Antitussives
• Opiates

• Used to prevent or relieve hypoxemia by increasing the amount of oxygen in the air
• Wall piped system, oxygen tanks, concentrators
• Equipment: Flow meter, humidifier, tubing, delivery device

• Comfortable, inexpensive, can eat with it on.
• Drying to nasal mucosa, can lead to nasal ulceration

• May or may not by humidified
• Holes on the side of the mask allow for entry of room air
• Permits higher O2 concentrations, inexpensive,
• Must be removed prior to eating, requires flow rate >5L/min. May cause facial irratation, not practical for long term

• Similar to simple mask, but has reservior bag
• Oxygen conserved, rebreath from resevoir.May lead to oxygen toxicity

• One way valve to prevent rebreathing of expired air
• 100%

• Connector or dial to deliver a specific amount of oxygen
• Set for each liter to be delivered with fixed amount of room air

• Over trach
• Must be humidified

• Fits under chin and loosely over face
• Oxygen and humidification for pt who cannot or will not keep a mask on

• Oxygen induced hypoventilation
• Atelectesis
• Oxygen toxicity

• pt loses stimulis to breath
• Do not admin > 3L/min w/o Doc order

• The collapes of alveoli.
• Occurs b/c O2 damages surfactant
• High concentrations should be limited to brief periods if possible.
• Encourage deep slow breaths

• greater concentration of21% - Potential for damage to aveolocapillary membrane increases
• >50% over 24 hours - sharp cheat pain, dry cough, decreased pulmonary function (ARDS).
• Avoid high concentrations for a long period of time.
• Use lowest setting possible to maintain oxygenation

• Combustion
• Infection transmission (ideal for growth (exhaled air and moisture) wash equipment, date equipment, change equipment)

• VS Q4H
• Bilateral chest expansion
• Palpate for SubQ emphysemia
• Auscultate for medastinal shift and breath sounds
• Colour and amount of drainage in chest tube
• Fluctuation of fluid in the drainage apparatus with each breath

• Check patency
• Check connection (sealed with water)Have client cough and change positions
• If not corrected, call physician (they will milk the tube)

• Keep above level of apparatisCoil tubes on bed and and pin to sheet using a tape tab
• No dependant loops
• Keep 2 rubber tipped Kelly forcepts at the bedside at all times to clamp a disconnected or broken tube
• Sterile vasoline gauze
• Never lift drainage apparatus above the level of insertion site

• Remove pets form home
• Remove carpeting from home
• Clean the house
• Ensure mattresses and pillows in allergen proof covers
• HEPA air cleaner
• Smoking cessation
• Air conditioner
• Avoid going outside on hot windy days (5-10am)
• Check pollen count
• Change clothing
• Remove plants that may be triggers
• Do not hang laundry out to dry

• Establish activity with HCP
• Take medication prior to exercise
• Start slowly
• Warm up and cool down
• Stop and rest with symptoms and take relieve RX
• Monitor temperature and pollution

• Asthma action plan
• Peak Flow meter