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Pathophysiology Varicose veins may be considered primary (without involvement of deep veins) or secondary (resulting from obstruction of deep veins) symptoms pink eye cheap hydrea on line. If only the superficial veins are affected treatment thesaurus buy hydrea toronto, the person may have no symptoms but may be troubled by the appearance of the dilated veins symptoms nicotine withdrawal cheap 500mg hydrea overnight delivery. Clinical Manifestations Symptoms treatment 1st degree burns buy hydrea 500 mg without prescription, if present, may take the form of dull aches, muscle cramps, and increased muscle fatigue in the lower legs. When deep venous obstruction results in varicose veins, patients may develop the signs and symptoms of chronic venous insufficiency: edema, pain, pigmentation, and ulcerations. Assessment and Diagnostic Findings Diagnostic tests for varicose veins include the duplex scan, which documents the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux. When it is used, however, it involves injecting an x-ray contrast agent into the leg veins so that the vein anatomy can be visualized by x-ray studies during various leg movements. Discusses with family members dietary modifications that need to be made at home. Plans, with the family, a diet that is nutritionally sound Prevention the patient should avoid activities that cause venous stasis, such as wearing tight socks or a constricting panty girdle, crossing the legs at the thighs, and sitting or standing for long periods. Changing position frequently, elevating the legs when they are tired, and getting up to walk for several minutes of every hour promote circulation. The patient should be encouraged to walk 1 or 2 miles each day if there are no contraindications. Walking up the stairs rather than using the elevator or escalator is helpful in promoting circulation. Most commonly, this condition occurs in the lower extremities, the saphenous veins, or the lower trunk; however, it can occur elsewhere in the body, such as esophageal varices (see Chap. It is estimated that varicose veins occur in up to 60% of the adult population in the United States, with an increased incidence correlated with increased age (Johnson, 1997). The condition is most common in women and in people whose occupations require prolonged standing, such as salespeople, hair stylists, teach- Medical Management Surgery for varicose veins requires that the deep veins be patent and functional. The vein is ligated high in the groin, where the saphenous vein meets the femoral vein. The wire is then withdrawn, pulling (removing, "stripping") the vein as it is removed. This treatment may be performed alone for small varicosities or may follow vein ligation or stripping. After the sclerosing agent is injected, elastic compression bandages are applied to the leg and are worn for approximately 5 days. After sclerotherapy, patients are encouraged to perform walking activities as prescribed to maintain blood flow in the leg. The patient is instructed to dry the incisions well with a clean towel using a patting technique rather than rubbing. Application of skin lotion is to be avoided until the incisions are completely healed to decrease the chance of developing an infection. If the patient underwent sclerotherapy, a burning sensation in the injected leg may be experienced for 1 or 2 days. The nurse may encourage the use of a mild analgesic (eg, propoxyphene napsylate and acetaminophen [Darvocet N], oxycodone and acetaminophen [Percocet], oxycodone and acetylsalicylic acid [Percodan]) as prescribed by a physician or nurse practitioner and walking to provide relief. Exercises of the legs are necessary; the development of an individualized plan requires consultation with the patient and the health care team. Nursing Management Surgery can be performed in an outpatient setting, or patients can be admitted to the hospital on the day of surgery and discharged the next day, but nursing measures are the same as if the patient were hospitalized. Bed rest is maintained for 24 hours, after which the patient begins walking every 2 hours for 5 to 10 minutes. Dressings are inspected for bleeding, particularly at the groin, where the risk of bleeding is greatest. It is often misdiagnosed, usually as recurrent thrombophlebitis or chronic venous insufficiency. Cellulitis occurs when an entry point through normal skin barriers allows bacteria to enter and release their toxins in the subcutaneous tissues. The acute onset of swelling, localized redness, and pain is frequently associated with systemic signs of fever, chills, and sweating.

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Prolonged diuretic therapy may also produce hyponatremia (deficiency of sodium in the blood) medicine jewelry hydrea 500 mg overnight delivery, which results in apprehension medicine 79 hydrea 500 mg visa, weakness symptoms bladder infection buy hydrea 500 mg on line, fatigue treatment centers for alcoholism buy hydrea 500 mg low cost, malaise, muscle cramps and twitching, and a rapid, thready pulse. Serum levels are assessed frequently when the patient starts diuretic therapy and then usually every 3 to 12 months. It is important to remember that serum potassium levels do not always indicate the total amount of potassium within the body. Nursing Management the nurse is responsible for administering the medications and for assessing their beneficial and detrimental effects to the patient. It is the balance of these effects that determines the type and dosage of pharmacologic therapy. Elderly people may present with atypical signs and symptoms: fatigue, weakness, and somnolence. Decreased renal function makes the elderly patient resistant to diuretics and more sensitive to changes in volume, especially with diastolic dysfunction. The administration of diuretics to elderly men requires nursing surveillance for bladder distention caused by urethral obstruction from an enlarged prostate gland. Signs and symptoms of pulmonary and systemic fluid overload are recorded and reported immediately so that adjustments can be made in therapy. The nurse also asks about the number of pillows needed for sleep (an indication of orthopnea), activities of daily living, and the activities that cause shortness of breath. The nurse helps patients to identify things that they have lost because of the diagnosis, their emotional response to that loss, and successful coping skills that they have used previously. Crackles, which are produced by the sudden opening of small airways and alveoli that have adhered together by edema and exudate, may be heard at the end of inspiration and are not cleared with coughing. The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume remains in the ventricle with each beat. As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. If the patient is sitting upright, the feet and lower legs are examined for edema; if the patient is supine in bed, the sacrum and back are assessed for edema. The patient is asked to breathe normally while manual pressure is applied over the right upper quadrant of the abdomen for 30 to 60 seconds. If neck vein distention increases more than 1 cm, the test finding is positive for increased venous pressure. If the patient is hospitalized, the nurse measures output carefully to establish a baseline against which to measure the effectiveness of diuretic therapy. It is important to know whether the patient has ingested more fluid than he or she has excreted (positive fluid balance), which is then correlated with a gain in weight. The patient must be monitored for oliguria (diminished urine output, <400 mL/24 hours) or anuria (urine output <50 mL/24 hours). The patient is weighed daily in the hospital or at home, at the same time of day, with the same type of clothing, and on the same scale. If there is a significant change in weight (ie, 2- to 3-lb increase in a day or 5-lb increase in a week), the patient is instructed to notify the physician or adjust the medications (eg, increase the diuretic dose). Prolonged bed rest, which may be selfimposed, should be avoided because of the deconditioning effects and hazards, such as pressure ulcers (especially in edematous patients), phlebothrombosis, and pulmonary embolism. An acute event that causes severe symptoms or that requires hospitalization indicates the need for initial bed rest. Otherwise, a total of 30 minutes of physical activity three to five times each week should be encouraged (Georgiou et al. The nurse and patient can collaborate to develop a schedule that promotes pacing and prioritization of activities. The schedule should alternate activities with periods of rest and avoid having two significant energy-consuming activities occur on the same day or in immediate succession. Discussing the timing of medication administration is especially important for patients, such as elderly people, who may have urinary urgency or incontinence. A single dose of a diuretic may cause the patient to excrete a large volume of fluid shortly after administration. Chart 30-4 Facts About Dietary Sodium Because some patients may be severely debilitated, they may need to perform physical activities only 3 to 5 minutes at a time, one to four times per day.

Beta-adrenergic receptors are further classified as beta1- and beta2-adrenergic receptors natural pet medicine purchase hydrea 500mg amex. When alpha-adrenergic receptors are stimulated treatment zone lasik discount hydrea 500 mg line, blood vessels constrict in the cardiorespiratory and gastrointestinal systems symptoms vitamin b deficiency purchase discount hydrea on-line, skin medicine 877 cheap hydrea online american express, and kidneys. When beta1-adrenergic receptors are stimulated, heart rate and myocardial contraction increase. When Dosages of vasoactive medications should be tapered and the patient should be weaned from the medication with frequent monitoring (every 15 minutes) of blood pressure. Table 15-1 presents some of the commonly prescribed vasoactive medications used in treating shock. Increased metabolic rates during shock increase energy requirements and therefore caloric requirements. The release of catecholamines early in the shock continuum causes glycogen stores to be depleted in about 8 to 10 hours. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Parenteral or enteral nutritional support should be initiated as soon as possible, with some form of enteral nutrition always being administered. The integrity of the gastrointestinal system depends on direct exposure to nutrients. Additionally, glutamine (an essential amino acid during stress) is important in the immunologic function of the gastrointestinal tract, providing a fuel source for lymphocytes and macrophages. Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore, antacids, histamine-2 blockers (eg, famotidine [Pepcid], ranitidine [Zantac]), and antipeptic agents (eg, sucralfate [Carafate]) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. Physiology/Pathophysiology Decreased blood volume Decreased venous return Decreased stroke volume Hypovolemic Shock In addition to caring for the patient through different stages of shock, the nurse needs to tailor interventions to the type of shock, whether it is hypovolemic, cardiogenic, or circulatory shock. Hypovolemic shock, the most common type of shock, is characterized by a decreased intravascular volume. The extracellular body fluid is found in one of two compartments: intravascular (inside blood vessels) or interstitial (surrounding tissues). The volume of interstitial fluid is about three to four times that of intravascular fluid. Hypovolemic shock occurs when there is a reduction in intravascular volume of 15% to 25%. This would represent a loss of 750 to 1,300 mL of blood in a 70-kg (154-lb) person. Medical Management Major goals in treating hypovolemic shock are to (1) restore intravascular volume to reverse the sequence of events leading to inadequate tissue perfusion, (2) redistribute fluid volume, and (3) correct the underlying cause of the fluid loss as quickly as possible. This may involve applying pressure to the bleeding site or surgery to stop internal bleeding. If the cause of the hypovolemia is diarrhea or vomiting, medications to treat diarrhea and vomiting are administered as efforts are made simultaneously to identify and treat the cause. At least two large-gauge intravenous lines are inserted to establish access for fluid administration. Two intravenous lines allow simultaneous administration of fluid, medications, and blood component therapy if required. Because the goal of the fluid replacement is to restore intravascular volume, it is necessary to administer fluids that will remain in the intravascular compartment and thus avoid creating fluid shifts from the intravascular compartment into the intracellular compartment. Pathophysiology Hypovolemic shock can be caused by external fluid losses, such as traumatic blood loss, or by internal fluid shifts, as in severe dehydration, severe edema, or ascites (Chart 15-3). Intravascular volume can be reduced both by fluid loss and fluid shifting between the intravascular and interstitial compartments. The sequence of events in hypovolemic shock begins with a decrease in the intravascular volume. This results in decreased venous return of blood to the heart and subsequent decreased ventricular filling. Decreased ventricular filling results in decreased stroke volume (amount of blood ejected from the heart) and decreased cardiac output. When cardiac output drops, blood pressure drops and tissues cannot be adequately perfused.

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The nurse assesses for signs of dehydration (eg medicine 20 cheap hydrea 500mg without a prescription, thirst treatment xanthelasma eyelid purchase genuine hydrea on-line, decreased skin turgor treatment 3rd nerve palsy hydrea 500mg generic, decreased central venous pressure) and reports these findings to the physician immediately treatment of diabetes order cheap hydrea line. It is es- sential to monitor blood glucose levels, because hyperglycemia can cause diuresis and excessive fluid loss. With a catheter in the subclavian vein, the patient is free to move the extremities and should be encouraged to maintain good muscle tone. If applicable, the teaching and exercise program initiated in the occupational and physical therapy departments should be reinforced. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Troubleshooting Mechanical Difficulties Mechanical problems usually arise from technical complications in the infusion pump or catheter site. The patient needs to know how to measure the length of the external portion of the catheter; this measurement is used as a comparison if the line is pulled or if dislodgement is suspected. The patient also needs to know how to recognize catheter problems (eg, leakage, loose cap, blood clot, dislodgement) and should receive a list of instructions explaining what to do for each problem. Recognizing Metabolic Complications the patient is given a list of symptoms that indicate metabolic complications (neuropathies, mentation changes, diarrhea, nausea, skin changes, decreased urine output) and directions on how to contact the home health care nurse or physician if any of these complications occurs. The patient is instructed to have weekly serum chemistry and hematology tests as well. Patients must cope with the loss of eating and with changes in lifestyle brought on by sleep disturbances (frequent urination during infusions, usually two or three times during the night). Major psychosocial reactions include depression, anger, withdrawal, anxiety, and impaired self-image. Patients and families need to know which support groups are available in the community to help them cope with the transition and to minimize disruption of lifestyle. The financial costs of such programs, although high, are less than those incurred in a hospital. Initiation of a home program may be the only way the patient can be discharged from the hospital. Teaching begins in the hospital and continues in the home or in an ambulatory infusion center. Continuing Care the home care nurse should be aware that the average patient needs about 2 weeks of instruction and reinforcement. Shows improved and stabilized nutritional status Journals Asterisks indicate nursing research articles. Microbial contamination of low-profile balloon gastrostomy extension tubes and three cleaning methods. Evidencebased practice for enteral feedings: Aspiration prevention strategies, bedside detection, and practice change. Use of residual volume as a marker for enteral feeding intolerance: Prospective blinded comparison with physical examination and radiographic findings. Detection of inadvertent respiratory placement of small-bore feeding tubes: A report of 10 cases. Visual characteristics of aspirates from feeding tubes as a method for predicting tube location. Cost savings and improved patient care with the use of a flush enteral feeding pump. The patient responds that she is accustomed to this and that the other nurses "check the tube by placing the end of it in a cup of water;" the patient also states that the nurses then "put air in the tube and use a stethoscope to listen for bubbles in my stomach. What research findings guide your actions in confirming the placement of the tube What follow-up actions would you take to ensure that there is consistency among the nursing staff in the procedure used for confirmation of tube placement A patient who is receiving gastrostomy tube feedings is to be discharged from the hospital to return home within the next few days.

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