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Nursing School

Unit C Outline Adolescent/Young Adult
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Took me forever to get this up, I know...

                                                Unit C Outline

                                                Adolescent & Young Adult

 

 The Adolescent Growth & Development

            - physical growth spurt: girls = 9.5-14.5 years, boys = 10.5- 16 years

            - can cause aches & pains

            - girls tend to have more forethought, think more long term

            - boys tend to take more risks, pay less attention to consequences

 

            - Developing a sense of identity:

                        - Group Identity is extremely important

                                    - pressure to belong to a group, based on similarities, should I conform or not?

                                    - looking for differences between self & parents because parents suck

                                    - adolescent culture is extremely self-centered

                                    - conformity vs. nonconformity?

                                    - this is tough for parents to deal with

                        - Individual Identity

                                    - quest for “who am I?” part of developmental task

                                    - body image (really effected by media, pop culture)

                                    - societal influence

                                    - #1 reason for adolescent suicide is homosexuality

                        - Sex-role identity

                                    - influences: culture, geographic area, socioeconomic groups, peers, adults

                                    -hetero/homo sexual relationships

                        - adolescent conflicts

                        - depression - not always textbook w/adolescents

 

            -Sexuality: education: need to know what to expect, school nurses need to be available/openminded

                        - education must be based on: biology

                                    - social pressures

                                    - health issues

                                    - personal attitudes

                                    - peers/pressures

                                    - values, different value systems

 

            - Adolescent Pregnancy, declining for last 20 years

                        - pay attention to special needs, education, resources

                        - risk should not be greater for teens w/adequate nutrition & prenatal care

                        - risk of pre-eclampsia is higher for teens, otherwise same as adults

                        - middle class is more likely to choose abortion

                        - variables: peer pressure, knowledge, emotional maturity, socioeconomic status

 

Nutrition; females 2000 cal/day (44/46g protein), males 2500-3000 cal/day (45-59g protein)

                        - need increased Ca+, Fe, Zn - usually don’t get it

                        - need Zinc for bone growth (major physiological event for teens)

                        - food habits often suck, need education

                        - boys have increased metabolism & bone growth

                        - boys have more muscle than girls

                        - food habits: teens will do what they’ve grown up doing... they learn habits early

 

            - Obesity: 11% of US children/adolescents

                        - Adipose Cell theory - some kids have bigger/more fat cells than stay larger

                        - Set point theory - programmed weight level, like thermostat, body wants to stay there

- Causes: high fat diet, not enough fruits & veggies, food as a coping mechanism, parental obesity, sedentary lifestyle (25% of kids have no regular activity r/t unsafe neighborhoods, apartment living, lack of leisure time with families)

 

            - Anorexia Nervosa - self-imposed starvation, intense phobia of obesity

                        - distorted body image, most female, 1st occurrence in adolescence

            - often about control, often really driven kids, perfectionists, goal oriented, overachievers

                        - introverted, reserved, ritual personal hygiene, intensive work/study, excessive exercise

                        - often very rigid, OCD type tendencies

- may experience amenorrhea d/t decrease fat, hormone imbalance, fatigue, dehydration, metabolic acidosis/alkalosis, electrolyte/mineral imbalances, hypotension, increased HR, cardiac dysrhythmias can be life threatening, anemia d/t decreased Fe intake, hormone imbalance, hypothermia, vitamin/mineral/protein deficiency

                        - starvation symptoms: lanugo/edema (late stage)

                        - albumin is a good indicator of overall health

                        - mortality rate = 5-10%

- treatment: regain weight to 90% of norm, psych tx for whole family, nutrition therapy, antidepressant therapy, SSRI’s: Desyrel, Paxil, Zoloft, Celexa

 

            - Bulemia Nervosa - can be harder to identify than anorexia because these kids eat

            - uncontrollable binging & purging, happens often, mostly female 15-30 y/o

            - mostly in late adolescence (18-19) is when it starts

            - happens equally in all socioeconomic & ethnic groups

            - very similar to anorexia nutritionally

            - high cholesterol & fat stimulate insulin production & hunger

            - feelings of abdominal discomfort, guilt, lack of control, anxiety

            - happens many times a day

            - treatment: similar to anorexia

            - dentist may notice d/t tooth decay or discoloration

            - may develop esophagitis

            - behavior modification may be used

            - psychotherapy is an option, individual, group, & family

            - dietary counseling is necessary

           

Health Problems of the Adolescent

            - Infectious Mononucleosis (“the kissing disease”)

            - usually younger than 25 y/o, caused by Epstein-Barr virus

            - communicable via oral secretions? Not exactly certain of transmission

            - sx: headache, fatigue, lowgrade fever, anorexia

            - as progresses, fever increases, sore throat, cervical lymph nodes enlarge (key sign)

            - possible splenomegaly, petechiae, exudative pharyngitis/tonsilitis

            - Monospot test - finger stick test to dx

            - no specific tx because it’s viral, treat symptoms

            - po PCN for sore throat if Strep B

            - usually symptoms are gone in 7-10 days

            - fatigue subsides in 2-4 weeks

            - teaching: be alert for dyspnea, abdominal pain, sore throat, hydration is key

            - enlargement of lymph nodes, tonsils, pharyngitis can cause dyspnea

            - use APAP for symptoms instead of ASA d/t danger of Rye’s Syndrome

            - if sx don’t get better in 7-10 days call Dr.

 

            - Altered Growth & Maturation

            - Gynecomastia - fairly common in boys, usually grow out of it

            - Substance Abuse - fairly common to experiment

            - Suicide

            - traumatic injury = MVA #1 killer of teens

            - AIDS - HIV is a retrovirus, infects CD4 T-lymphocytes & turns them into HIV making machines & destroys them

- HIV in kids: lymphadenopathy, hepatosplenomegaly, thrush, diarrhea, FTT, developmental delays, Parotitis

- AIDS in kids: PCP, LIP, bacterial infections, wasting syndrome, HIV encephalopathy, candidal esophagitis, CMV disease, MAC (mycobacterium avium-intracellular complex infections), severe herpes, pulmonary candidiasis, cryptosporidiosis

- can also lead to short stature, malnutrition, cardiomyopathy, neurological defects, decreased motor ability, developmental delays

- Tx: antiretroviral drugs - suppress viral replication for years & years

            - Severe Combined Immunodeficiency Disease (SCID) (bubble boy)

            - absence of humoral & cell-mediated immunity

            - chronic infection, FTT, unusual illness

            - hard to dx d/t delayed Ig in infants & maternal transfer for IgG

            - poor prognosis

            - Wiskott-Aldrich Syndrome - X linked recessive disorder

            - 1. Thrombocytopenia 2. Eczema 3. Immunodeficiency of selective function of B & T lymphocytes

            - bloody diarrhead d/t thrombocytopenia, recurrent infection d/t eczema

            - chronic herpes infection is problem - loss of vision d/t karatitis of eye

            - chronic pulmonary disease, sinusitis, otitis media

            - poor prognosis

           

 

            - Sex Chromosome Abnormalities

            - Turner Syndrome: females; absence of X - can be identified at birth

            - webbed neck, low rear hairline, widely spaced nipples, edema of hands/feet

            - puberty - short stature, sexual infantilism, amenorrhea = infertile

            - behavior problems, immature, socially inept, isolated

            - tx w/hormone therapy, psychological counseling (growth hormone when young, estrogen therapy at puberty)

            - Triple X: “Super Female” - normal looking, tall, risk for impaired language

            - learning difficulties, fertile, variable mental capacity & behaviors

            - Klinefelter Syndrome: male; MOST COMMON, extra X, seldom dx before puberty

            - absence of sperm in semen (azoospermia), small testes, defective development of secondary sex characteristics

            - cognitive impairment, decreased gross motor skills, developmental language delay, poor verbal skills, decreased auditory memory, shyness, passivity, behavior problems

            - tall, long legs, gynecomastia possible

            - XYY Male- tendency to be tall, long head, poor coordination, aberrant behavior?

            - normal sexual development

 

 Young Adults

            - Adulthood - 20-40 years, defined many ways (age of alcohol consumption...), independence, maturity

- career establishment, building relationships, start family

- independent thinking, idea of who we want to be, more established values

                        - Erikson’s Intimacy vs Isolation - decrease in egocentrism, spiritual development

- focus on reality, religious teaching may be accepted or redefined

- spirituality is broad - who/what I am in the universe, not just religion

           

Thrombophlebitis - clot irritating vein, foreign body causing inflammation

            - also known as DVT

            - can be superficial or deep

            - Virchow’s triad - venous stasis, damage to the endothelium, hypercoagulability, sluggish circulation may be even backup of blood

            - signs/symptoms - may be asymptomatic, edema of affected extremity, most often in legs d/t their dependent position

            - pain/tenderness - maybe redness d/t inflammation

            - warm to touch

            - elevated temperature

            - may have + Homan’s sign - dorsiflexion to plantar flexion = pain in calf

            - often obvious to see in superficial vein

            - risk increases w/ disrupting bone marrow (& platelet creation) in hip, knee surgery (also prone to PE), bedrest, & pregnancy

            - dx: venous doppler - irregular, louder above phlebitis

- blood tests: D-dimer (fragment resulting from fibrin degradation, increased w/fibrin clot lysis; Coagulation studies to show risk, to check appropriateness of heparin tx - helps determine heparin dose

-venogram (visualize clot)

- Plethysmography - used when extremity is edematous to dx, not used often, BP cuff attached proximal, medial, & distal areas of extremity; distal cuff records pulse volume, there’s no increase in volume if DVT present

            - Interventions: PREVENTION

            - low dose heparin SQ, Lovenox SQ

            - lose dose coumadin po (based on pt)

            - early mobilization post-op (WALK!!!!!)

            - TED’s

            - SCD’s (for any surgery longer than 1 hour)

            - exercise legs & feet - muscles pump blood back up legs

            - If DVT already present: elevate affected extremity above heart level, warm moist compresses

            - TED hose (MEASURE THEM!!!)

            - strict bedrest initially, mild analgesics (NSAIDS for discomfort)

            - anticoagulant therapy (coumadin & heparin work on different clotting proteins)

 

Heparin - 5000 Units is a low dose, often comes in prefilled syringe

            - IV usually given as continuous infusion after initial bolus dose

            - inhibits conversion of fibrinogen to fibrin

            - heparin dose regulated by PTT (or APTT), sliding scale based on PTT

            - PTT will increase as heparin gets more effective, tx value 1.5-2.5 times the normal value, want result higher than normal

            - Can decrease platelet counts

            - protamine sulfate is an antidote: overdose may also be treated by stopping heparin

            - OD can cause bleeding anywhere

            - calculation of infusions as weight/hour

            - know how much med is in 1mL, know how much med/hour

            - DO NOT PUT MEDS in w/HEPARIN!!!!

            - some low molecular weight heparins (Lovenox) have been approved for tx of some cases of DVT, especially if PE is not present

            - administered SQ

            - usually do not require daily labs

            - given deep SQ (lateral abdomen - toward love handles)

 

Oral Anticoagulants - given to maintain anticoagulation

            - example: warfarin (Coumadin)

            - usually started while on IV heparin

            - takes 3-5 days for maximum effect

            - regulated by Prothrombin time (PT) & INR

            - aim for INR of 2-3 for tx effect

            - vitamin K is antidote to Coumadin

            - teach pt to take med same time every day, wear/carry ID showing what anticoagulant pt is taking, keep appointments for blood tests, be aware of interactions w/other meds (aspirin), avoid marked changes in eating (consistant intake of vitamin K), no using straight razors

            - Control of peripheral edema - TED’s, SCD’s, elevation of legs

            - Surgical intervention - thrombectomy, inferior vena cava interruption

            - use soft toothbrush

            - be careful of brusing/bleeding

            - Greenfield filter (in superior vena cava)

 

- Vericose Veins - distended, protruding veins

            - vein wall weakens & dilates, venous pressure increases & valves become incompetent

            - c/o pain & “fullness” in the legs

            - dx test: trendelenberg test

            - interventions: conservative meausres - TED’s, elevate legs

            - sclerotherapy, laser therapy, surgery (vein ligation, vein stripping)

            - nursing dx: knowledge deficient, pain, altered peripheral tissue perfusion, impaired skin integrity (or high risk)

 

- Respiratory System - Asthma - usually begins in young adulthood - 1st sign of hypoxia - restlessness

            - characterized by usually reversible airway obstruction

            - intermittent airway narrowing caused by 3 processes:

            -bronchospasm & bronchoconstriction

            - excess production of mucus (part of inflammatory response)

            - airway edema

                        - narrowing can be so bad as to make intubation difficult

           

            - Triggers: allergens, resp infections, nose/sinus problems, exercise, cold/dry air, GERD, stress, air pollutants, cigarette smoke

            - classification: mild intermittent, mild persistent, moderate persistent (symptoms interrupt daily life), severe persistent (pt needs medical attention now)

           

            - Signs/Sx - cough (may be nonproductive initially & become productive as airways open)

            - dyspnea (use of accessory muscles to breathe, gets progressively worse)

            - wheezing (usually on exhalation, worse when both inhale & exhale; pt who stops wheezing has probably gotten worse & doesn’t breathe forcefully enough to make a sound anymore...this pt is in trouble!!!)

            - diminished/absent breath sounds (if airflow is restricted from obstruction)

            - Dx studies - screening for severity - peak flow tests & ABG (asthmatics should have their own peak flow meter at home to use regularly and monitor their own personal norms)

            - ABG’s show change early because arterial blood is usually highly oxygenated

                        - asthma can induce respiratory acidosis

            - Methacholine challenge test (looks at triggers, will try to induce attack)

            - chest x-ray - probably will be normal

           

            - Interventions: ask pt what they normally do!

            - O2 therapy! Administer as ordered, especially if possibility of CO2 retention

            - maintain airway patentcy - positioning (high fowler’s, leaning over a table, sitting on side of bed), ensuring adequate fluid intake (to think mucus)

            - space activities to allow for rest

            - control anxiety

            - chest physiotherapy (cupped hands, no bare skin) & postural drainage - more helpful when asthma complicated by chronic bronchitis or other chronic resp condition

            - health teaching - pursed lip breathing, controlled coughing, teaching about inhaler use

            - drug therapy - includes maintenance meds & rescue meds

           

            - Maintainence Medications:                

            - NSAIDS - most useful for prevention, not useful during attack

            - cromolyn (Intal)

            - nedocromil (Tilade)

            - Corticosteroids - reduce inflammation in the throat & lungs - inhaled route is used for maintenance

            - beclomethasone (Vanceril) (older but works)

            - triamcinolone acetonide (Azmacort)

            - Leukotriene inhibitors/receptor antagonists - have both antiinflammatory & bronchodilator effects  - prevents inflammatory response/edema - oral meds - not used in acute attacks

            - zafirlukast (Accolate)

            - montelukast sodium (Singulair)

            - zileuton (Zyflo)

            - Theophylline derivatives - increase production of cAmp - oral bronchodilators - chronic lung disease, not usually asthma maintenance, IV Aminophylline may be used IV in an acute asthma attack; side effects: increased HR, increased anxiety

            - Aminophylline

            - Theo-Dur

            - Slo-bid (long acting)

            - Anticholinergic medications - side effects lessened when inhaled

            - ipratropium (Atrovent)

            - Beta-2 agonists (sympathomimetics) - most useful for maintenance

            - salmaterol (Serevent)

            - Advair (combination of Serevent & corticosteroid)

 

            - Rescue Medications:

            - Corticosteroids - when used for rescue they are usually given orally or parenterally - many systemic side effects

            - methylprednisolone (Solu-Medrol)

            - prednisone

            - Beta-2 agonists - (sympathomimetics)

            - albuterol (Proventil)

            - metaproterenol (Alupent)

            - terbutaline

            - epinephrine

 

            - Nursing dx:impaired gas exchange, ineffective breathing pattern, ineffective airway clearance, altered nutrition: less than body requirements, anxiety, activity intolerance, powerlessness, high risk for infection, risk for decreased immune response (side effect of meds)

 

- Respiratory System - Acute Bronchitis - inflammation of the bronchi & usually the trachea, usually viral, can be bacterial

            - signs/sx: cough w/sputum (clear = no bacteria, cloudy = bacteria, usually), low-grade fever, malaise, abnormal breath sounds

 

            - tx: usually sumptomatic, ensure adequate fluid intake ( to thin sputum), analgesics, antipyretics, antibiotics only if appropriate

 

- Respiratory System - Sinusitis - inflammation of the mucous membranes of one or more of the sinuses, acute or chronic

            -signs/sx: headache, c/o pressure, drainage, ear aches, toothaches

 

            - Nonsurgical interventions:

            - antibiotics (cause often bacterial)

            - decongestants (to break up mucous)

            - expectorants (to help cough up/out mucous)

            - nasal corticosteroid inhalers

            - antihistamines

            - adequate hydration

            - saline nasal sprays, steam, humidifier, netti pot

 

            - Surgical interventions:

            - endoscopic sinus surgery

            - Caldwell-Luc sinus surgery (only done as last resort)

            - Ethmoidectomy

            - Sphenoid sinus surgery

            - Frontal sinus surgery

           

            - Post-op care:

            - assess for hemorrhage (often very bloody, look at how much swallowing pt is doing)

            - ice compresses

            - change drip pad as ordered

            - frequent oral care

            - keep mucosal lining moist after removal of packing

            - avoid blowing nose for at least 48 hours after packing removal (hard for pt)

 

- Neuromuscular System - Multiple Sclerosis - progressive degenerative disease that effects the myelin sheath - unknown etiology, suggested underlying viral infection? - characterized by remission & exacerbations

 

            - exacerbations triggered by:

            - fatigue, stress, overexertion

            - temperature extremes

            - moist heat (hot showers, hot tubs, steam baths, saunas)

            - pregnancy - remission may occur during gestation, but increased risk for exacerbation in postpartum

 

            - assessment: thorough history is important!!!! (previous illness, surgeries, triggers)

            - symptoms often vague/nonspecific

            - symptoms classified as sensory, motor, cerebellar, spinal cord involvement, neurobehavioral

            - sensory: numbness/tingling (where? duration?), blurred vision (triggers? duration?), paresthesias (burning, prickling sensation), decreased sense of temperature, tinnitus, decreased hearting

            - motor: weakness or feeling of heaviness in lower extremeties, paralysis, spasticity, diplopia

            - cerebellar: incoordination, nystagmus (crazy eye movements periodically), dysphagia, slurred speech

            - spinal cord involvement: abnormalities in bowel & bladder function (urinary or bowel incontinence, urinary retention, constipation), sexual dysfunction

            - neurobehavioral: emotional lability, depression, irritability, apathy, loss of short-term memory (also happens in Alzheimer’s)

 

            - Dx studies: no single reliable dx study

            - based primarily on hx & clinical manifestations

            - MRI, CT scan, visual/auditory evoked responses, lumbar puncture w/CSF analysis

 

- Interventions: Medications: used to treat acute attack, decrease the # & frequency of relapses, & for symptoms management

            - basic goal is to decrease the inflammation & destruction of the myelin sheath therefore reducing the frequency & severity of relapses.

 

            - Medications:

            - Corticosteroids - useful for exacerbations, antiinflammatory, many side effects, especially w/long term use - daily maintenance

            - ACH, SoluMedrol, Prednisone

            - Immunosuppressants - may be helpful in decreasing exacerbations, side effects may outweigh the benefits - daily maintenance

            - cyclosporine (Sandimmune)

            - azithioprine (Imuran)

            - cyclophosphamide (Cytoxan)

            - Beta-interferons - help decrease relapses & seems to help to control the disease, not just relieve symptoms - daily maintenance or as symptoms recur

            - interferon beta-1b (Betaseron) - (SQ injection)

            - Copaxone - unrelated to beta-interferons, but also decreases exacerbations & number of new lesions (given SQ)

            - Medications given for symptom management:

            - Spasticity - muscle relaxants, baclofen (Lioresal), dantrolene (Dantrium), diazepam (Valium)

            - Spastic bladder & urge incontinence, oxybutynin (Ditropan), propantheline (Pro-Banthine), tolterodine (Detrol)

            - urinary retnetion, bethanechol (Urecholine)

            - antidepressants, amitriptyline (Elavil), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)

 

            - Nursing Interventions:

            - diplopia - eyepatch alternated from eye to eye every few hours

            - if decreased sensation, protect from injury (teach to use a thermometer to check H2O tempature)

            - encourage maintenance of indepence - adaptive equipment (occupational therapy consult!)

            - encourage exercise - swimming, ambulation w/wide base of support, stationary bike

            - manage discomfort, facial pain, paresthesias in feet

            - prevent constipation

            - prevent complications such as contractures, decubitus ulcers

            - sexual/marital counseling

            - goal of interventions is to maintain as much independence as possible, while keeping fatigue to a minimum

 

            - Nursing dx: impaired physical mobility, self-care deficit, knowledge deficient, constipation, activity intolerance, body image disturbance, high risk for injury, urinary incontinence or urinary retention

 

- GI/GU System - Peptic Ulcer Disease - common in young adults, erosion of GI mucosa resulting from the digestive action of HCL & pepsin. The stomach is protected by a gastric mucosal barrier - agents destroying that barrier include: H. pylori, aspirin, NSAIDS (prostaglandin inhibitors), & corticosteroids (should be given w/food to prevent this problem); Pain is major symptom!

 

            - Gastric Ulcer - normal/low secretion of gastric acid, normal stomach emptying rate, increased diffusion of gastric acid back into the stomach (local mucosal inflammation from NSAIDS), pain in left upper/epigastric area, pain 1-2 hrs after meals & rarely at night, pain NOT relieved by eating

 

            - Duodenal Ulcer - increased gastric acid secretion, increased rate of gastric emptying, normal diffusion of gastric acid back into the stomach, pain in right upper/epigastric area, pain 2-4 hrs after meals & often at night, pain relieved by eating

 

            - Contributing factors: NSAIDS (prostaglandin inhibitors), alcohol abuse (irritating to stomach), smoking (nicotine increases HCL production), O blood type, diet? May contribute to development/may exacerbate existing ulcers, Stress response (increased HR/BP, gastric emptying slows, resps increase, parathormone release, epinepherine/norepinepherine release, corticosteroid release, blood flow shunted to extremities/flows to vital organs, immune system depression, inflammatory response delayed)

 

            - Symptoms - PAIN!!! usually described as gnawing, aching, burning, confined to small area of upper abdomen

 

            - Dx studies: EGD, Endoscopy, GI series (upper GI), Testing for H. pylori (blood test, breath test, biopsy of mucosa w/culture), gastric analysis (questionable value, involves insertion of NG tube & testing stomach contents in stimulated & fasting state); pts are NPO before many tests

 

            Medications:

            - Antacids - (can disrupt pH balance) provide symptomatic relief, not healing, must give frequently, most effective when given 1-3 hours after meals, wide variety available, Aluminum hydroxide can be constipating (Amphojel); Magnesium can cause diarrhea; Calcium preparations (Tums, Rolaids) can be constipating; Systemic antacids (Sodium bicarb) may lead to systemic alkalosis if used long term; these may be initial drug of choice in treatment of PUD

 

            - Histamine (H2) receptor antagonists - block histamine stimulated gastric secretions, give 1 hour from antacids, few side effects, often single dose HS; Tagamet, Zantac, Pepcid, Axid

 

            - Proton Pump Inhibitors - suppresses the enzyme system of gastric acid production, mainly used for GERD, may be used w/duodenal ulcers, may have antibacterial effect on H. pylori; Prevacid, Protonix, Prilosec

 

            - Mucosal Protective Agents - Carafate: helps heal ulcer & decrease pain by coating ulcer, prevents irritation from pepsin & gastric acid, increases prostaglandin synthesis, should be separated from antacids by at least 30 mins-1 hour, take on empty stomach; Cytotec: prostaglandin analog, replaces gastric prostaglandin & appears to have some antisecretory effects, used in people who MUST take NSAIDS/helps prevent ulcers occurring w/use of NSAIDS

 

            - H. pylori treatment: several recommendations, most combine Proton Pump Inhibitors or H2 Receptor Antagonists w/antiinfective (often use Flagyl clarithromycin, or amoxicillin)

 

            - Diet modifications: avoid foods that increase acid secretions/foods that cause discomfort, bland diet may be started initially in 6 small feedings, no clear indication that this promotes healing, avoid alcohol & tobacco

 

            - Complications: Pyloric obstruction (gastric outlet obstruction) caused by edema, spasm, or scar tissue, usually treated conservatively, surgery usually vagotomy

 

- Hemorrhoids - swollen/distended veins, can be internal/external, risk increases w/obesity, straining w/stools, occupations that require long standing/sitting, heredity, pregnancy

            - tx w/sitz bath, cold packs, witch hazel (Tucks pads), local anesthetic ointment, high fiber diet, stool softeners; Invasive tx: sclerotherapy, elastic band ligation, cryosurgery, hemorrhoidectomy

 

- Urinary Tract Infection - higher risk for females, pts w/structural abnormalities, obstruction, impaired bladder innervation, chronic disease, cystoscopy, catheterization, pregnancy, sexual activity, delayed postcoital urination, wiping from back to front after urination

            - Cystitis - lower UTI

            - Pyleonephritis - upper UTI

 

            - Dx: urinalysis, C&S (identifies bacteria & what kills it), IVP, CT scan

                        - Ss/Sx - urinary frequency/urgency, dysuria, cloudy/foul smelling urine, fever/chills, lower back pain

 

            - Tx: antibiotics: Bactrim, Macrodantin; increased fluids (3-4 liters/day), cranberry juice may help, teaching regarding perineal hygiene

 

- Inflammatory Bowel Disease - young adult nutrition: decreased Ca+ & Phosphorus needs (males 700mg/day, females 1000mg/day), caloric needs: males 2900kcal/day, females 2200kcal/day; protein needs: males 53gm/day, females 50gm/day

            - Ulcerative Colitis & Crohn’s Disease: chronic acute inflammations & remissions, no specific cause, may be autoimmune reaction, may be d/t infectious agents, may be food allergies or heredity

 

            - Ulcerative Colitis - inflammed upper colon & rectum, peaks between age 15-40, both sexes but women more often, may be cultural - more common in Jews & the upper middle class. Starts in the rectum & spreads up continuously; pt develops abscesses which pop open, break into the sub-mucosa which causes bleeding/damage to mucosal epithelial tissue = diarrhea, fluid/e-lyte imbalance; loss of absorption area/cell breakdown = protein loss in stool, granulation tissue develops causing contracture of some surrounding tissue = usually tough tissue, not elastic - colon shortens & musculature gets thicker

            - sx: pt can suffer from hypovalemia leading to tachycardia; 2-3 bloody diarrhea/day = mild case; 10-20 bloody mucousy stools/day = severe case; during acute exacerbations pt will be NPO w/TPN & lipids, then move to high calorie high protein low residue diet w/vitamin & iron supplementation

            - Megacolon - d/t thick musculature, colon dilates

            - Dx: can do biopsy w/a colonoscopy, barium enema (nurse must eyeball stool, should be gray/white)

            - Management: REST BOWEL w/NPO status, HAL/TPN, antibiotics may be used

            - Sulfasalazine - antibiotic w/antiinflammatory effects, po or retention enema in pt w/ left sided colitis = drug of choice

            - Steroids: prednisone (methylprednisone IV), cortisone (solumedrol IV), can be retention enema

            - anticholinergics = decrease GI motolity - ProBanthine

            - immunosuppressives = cyclosporine

            - Surgeries: in 15-20% of all cases, last resort, if massive bleeding suggesting dysplasia (when cells become precancerous)

            - Total Proctocolectomy w/Permanent Ileostomy - remove colon, rectum, anus, ileum = stoma RLQ below belt line

            - Total Proctocolectomy w/Continent Ileostomy - Kock pouch - diminishes need for pouch/bag, pouch made in distal ileum & one way valve created & sutured to abdomen, pouch holds contents & is drained regularly by inserting catheter; Valve has HIGH failure rate - during recovery pouch must be irrigated w/NS regularly to flush mucous.

            - Total Colectomy w/Rectal Mucosal Stripping w/Ileoanal Reservoir - 2 separate surgeries 8-12 weeks apart, high risk for complications but most preferred surgery; 1st remove colon & create ileoanal anastamosis w/temporary stoma created to heal sutures - temporary ileostomy & then closure of ileostomy which becomes a reservoir; 3-6 months for reservoir to heal/mature & person’s Bms become more controlled - must be able to care for self w/no risk of CA or disease

            Post-Op care: assess for hemorrhage, abdominal abscess, small bowel obstruction, teach regarding dehydration, monitor ileostomy oupout - 1500-2000mL/day, keep surrounding skin clean/dry; JP drain - 100-150mL serosanguinous fluid, drain when half full (should not be bloody drainage), Foley cath 2-5 days; Pt MUST walk!!

 

- Crohn’s Disease - ages 15-30, high incidence in women, Jewish people & upper middle class; occurs slightly less than Ulcerative Colotis; “mouth to anus disease” Inflammation of segments of the GI tract w/normal areas between diseased areas, ulcerations are deep & long & widely penetrate mucosa, musculature thickens/narrows = strictures develop, abscesses burst & fistulas develop, people develop bowel obstructions; can occur anywhere in GI tract, usually found in ileum, jejunum, & colon

            - Dx: same studies as ulcerative colotis

            - Management: Drug therapy - Sulfasalazine (effective w/colon), corticosteroids, Flagyl

            - Diet: elemental diet (pre-digested nutrients) during exacerbations, low fat/residue/roughage, high calories/protein, lactose free, may have HAL through central line; Procalamine -peripherally infused TPN (not as irritating as HAL)

            - Surgery only happens when people have fistulas/problems/symptoms & life threatening complications, surgery is not curative for this disease (surgery can lead to “short gut syndrome” leading to lifetime TPN - these pts often die of malnutrition)

 

- Woman’s Health

            - Fibrocystic Breast Disorder - thickening of normal breast tissue & formation of cysts, appears to improve during pregnancy & lactation & resolve w/menopause; probably caused by imbalance of progesterone & estrogen, can be very painful; consists of one or more palpable lumps that are usually round, freely movable, usually bilateral, can be made worse by caffeine & during PMS week; avoid caffeine, excess sodium, maybe take a mild diuretic - especially during PMS week

 

            - Endometriosis - characterized by the presence of endometrial tissue outside the uterus, can be found in fallopian tubes, ovaries, colon, bladder, or more distant sites; this tissue responds to hormone changes of the menstrual cycle; Sx: dysmenorrhea, dyspareunia, backache, lower abdominal pain, pain is r/t site of implantation of the endometrial tissue, cause is unknown, can cause infertility

 

            - Ovarian Cysts - often asymptomatic, usually soft surrounded by a thin capsule & occur mainly during reproductive years, Dr’s 1st clue may be irregular menses; Dx by ultrasound, CT, laparoscopy; may resolve spontaneously, treated by oral contraceptives, surgery is cyst is large but surgery is not first choice

 

            - PMS - symptoms associated w/Luteal phase of menstrual cycle, symptoms vary from person to person/month to month - depends on physical health, coping mechanisms, personality; diary can be helpful to find triggers/patterns; Dx usually of exclusion; no single treatment - AVOID CAFFEINE, ALCOHOL, REFINED SUGARS & SALT! Increase intake of complex carbs, vitamin B complex & vitamin E & protein, exercise regularly, assess counseling/stress management needs; Medications: oral contraceptives, prostaglandin inhibitors, antidepressants, diuretics

 

            - Toxic Shock Syndrome - usually caused by Staph aureus, risk increases w/use of tampons - especially if tampons not changed every 1-4 hours! Also caused by contraceptive sponges & diaphragms; Symptoms - fever, chills, sore throat, headache, sunburn-like rash w/peeling of skin on palms/soles of feet, ulcerations of mucous membranes; fatalities occur from adult respiratory distress syndrome, uncontrollable hypotension, disseminated intravascular coagulopathy

 

            - Vaginal Candidiasis - yeast infection, thick white curd-like vaginal discharge, itching, dysuria, dyspareunia; treated w/oral or intravaginal antifungals: Gyne-Lotrrimin, Mycelex, Monistat

 

            - STD’s & STI’s - get a good sexual history - many people will not want to give specifics, both partners must be treated

           

            - TORCH infections - most commonly caused by toxoplasmosis, rubella, CMV - they can effect a growing embryo or fetus & cause spontaneous abortion, abnormal fetal development, severe congenital abnormalities, mental retardation, & fetal or neonatal death; mom may only have mild symptoms; 1st trimester is time of most risk; contracted by eating raw/partially cooked meat of infected animals, contact w/feces of infected cats; pregnant women CANNOT touch litterboxes

 

            - Abortion: Spontaneous: termination of pregnancy prior to viability

            - Threatened: cervix closed, minimal bleeding, fetus/placenta retained, mild cramping, size of uterus appropriate, tx w/bedrest, sedation, avoidance of stress

            - Inevitable/Imminent: cervix opened, moderate/heavy bleeding, placenta/fetus not yet passed, moderate cramping, size of uterus appropriate; will progress to incomplete or complete abortion

            - Incomplete: cervix opened, heavy bleeding, fetus passed, placenta retained, severe cramping, uterus smaller than expected, often need D&C

            - Complete: cervix usually closed, minimal bleeding, fetus/placenta passed, mild cramping, uterus smaller than expected; only tx to control bleeding if necessary

            - Missed: fetus dies but is retained, cervix closed, slight/no bleeding, no uterine cramping, uterus is smaller than expected; may need D&C or labor initiated

            - Habitual/ Recurrent Pregnancy Loss: abortion occurs consecutively in 3 or more pregnancies, determine cause & treat if possible

 

            - Hydatidiform Mole - abnormal development of placenta resulting in fluid-filled grapelike clusters; possible complication is choriocarcinoma (highly malignant cancer), vaginal bleeding almost universal w/molar preganancy, often brownish “like prune juice,” HCG level markedly elevated, treatment is removal of mole, need close follow-up to be able to identify if complication of choriocarcinoma is present; serum HCG weekly until normal level present 2 consecutive times; monitored monthly for 1 year, it’s important that woman doesn’t get pregnant for 1 year

 

            - Domestic Violence - myths: “only a small amount of violence exists” “battered women provoke the men who hit them,” “alcohol/substance abuse causes violence” (this is an excuse); domestic violence happens in all socioeconomic classes; it is a repeating cycle: tension building, acute battering incident, honeymoon period (men often buy gifts during this phase)

 

 

 

                                               

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