APNA 25th Annual Conference October 19, 2011

Transcription

1 Managing Acute and Chronic Illnesses: What Every Psych Nurse Needs to Know SARA BARR GILBERT, RN, CEN, MACP, SANE-A CHESHIRE MEDICAL CENTER, KEENE NH Chest Pain/MI MONA (Morphine, Oxygen, Nitroglycerin, Aspirin) greets every chest pain at the door (of the ER). Objectives Chest Pain/MI Recognize signs of acute medical illness Review red flag vital signs Identify exacerbations of chronic diseases List strategies t for reducing impact of co-morbid medical problems Acute onset, left sided Radiation into left axilla, arm SOB, diaphoresis Nausea, dizziness Syncope Gray color Not worsened by deep breathing, change in position Chest not tender to palpation Acute Medical Illnesses Chest pain/mi Stroke Respiratory distress Altered mental status Injuries Acute pain Giving report: EKG reading (STEMI) Onset, hx of symptoms Treatment given (IV access) Recent surgeries, falls, GI bleeds Lab results Medical history with pertinent medications Code status Chest Pain/MI Stat EKG, vital signs ASA 325 mg. PO Easy access to crash cart IV access (2 for acute MI); KVO O2 if SOB CXR No exertion No NTG if BP is low Blood work (Troponin, coags) Consider other causes (PE, pneumothorax, pneumonia, anxiety) Gilbert 1

2 Stroke Respiratory Distress The most important thing to note about stroke symptoms is: A. Presence of facial droop B. Time that symptoms began C. If headache is relieved with medication D. Onset of altered mental status If a patient is experiencing worsening shortness of breath, it is important for the nurse to avoid: A. Administering oxygen B. Keeping the patient still C. Assessing lung sounds D. Laying the patient flat Stroke Sudden onset of symptoms Facial droop, slurred speech Hemiparesis, difficulty walking Pronator drift Sudden, thunderbolt HA LOC, change in mental status BP significantly higher than normal Possible causes: Exacerbation of chronic illness (COPD, CHF, asthma) PE Pneumothorax Pneumonia Anaphylaxis Flash pulmonary edema Respiratory Distress Tachypneic Retractions Tripoding, pursed lips Unable to speak more than one word Diaphoretic HX of needing intubation Giving report: Time of symptom onset (resolution?) Recent surgeries, injuries, GI bleeds Medical history, with pertinent meds Most recent VS Lab results Treatment given Stroke Bedside glucose Stat head CT Immobilize c-spine if fall involved Elevate head of bed EKG, vital signs IV access (saline lock x 2) Begin neuro checks, document GCS Blood work (troponin, coags, type and screen, electrolytes) No narcotics Giving report: Recent history e.g. cough, fever Interventions and response HX of breathing difficulties Blood work, EKG, CXR findings Pertinent medications (e.g. Lasix) Respiratory Distress Complete set of VS 02 via NC, NRB EKG, CXR Physical assessment, including lung sounds Blood work (ABG s) Minimize exertion Elevate head of bed Assess for possible causes (e.g. chronic illnesses, acute illness) Consider IV access Gilbert 2

3 Altered Mental Status Altered mental status is always indicative of a serious medical condition. Falls: Head CT if on coumadin or LOC Assess head/neck before moving pt. Be suspicious of distracting injuries Look for underlying causes Ask pt. for recall of event Assess orientation Know HCG status for xray Injuries No tourniquets Ice, elevation for sprains/bruises Assess pulses, color, temp of skin Monitor for increasing i pain Altered Mental Status Possible causes: Electrolyte imbalances Head injuries Infection Post-ictal Cardiac/neurological Adverse medication effects Abnormal vital signs Diaphoresis Unable to stay still (abdominal) Vomiting AMS Change in baseline Don t notice IV Acute Pain Physical assessment Blood work, UA Monitor vital signs NPO until cleared by MD if red flags present Know surgical hx Altered Mental Status Red Flag Vital Signs Know baseline orientation Assess level of confusion Review onset of symptoms Consider chronic medical illnesses or adverse drug effects Vital signs, blood work, FSBS, EKG, UA Monitor pt. until dispo Vital signs: HR > 140 or <40 BP > 200 or < 70 systolic RR > 35 Temp > 104 not responsive to meds 02 sat < 90% FSBS >400 or <50 More concerning if: Symptomatic e.g dizzy More than one red flag VS significantly different from baseline Not relieved with interventions Gilbert 3

4 Chronic Medical Illnesses COPD COPD CHF Diabetes mellitus Seizure disorders Encourage smoking cessation Drink water, get exercise, avoid cold weather Get vaccinated Medication usage depends on stage of disease Complications: HTN, depression, respiratory infections, CAD Exacerbation: Acute onset of worsening SOB, coughing SX: wheezing, pursed lip breathing, retractions, cyanosis Caused by infection, air pollution, poor compliance Managed by abx, nebs, steroids, 02 via NC AMS: think C02 retention Chronic Obstructive Pulmonary Disorder Congestive Heart Failure COPD cannot be reversed, even if the patient stops smoking. Risk factors for CHF include: A. History of MI B. Addiction to chocolate C. Family history D. Allergy to Lasix Chronic Obstructive Pulmonary Disease Congestive Heart Failure Major cause of mortality worldwide (Mayo Clinic, 2011) Caused by emphysema and/or chronic bronchitis Exchange of 02 and C02 interrupted Chronic sx: SOB, cough, wheezing, chest tightness Progressive illness, not reversible Caused by damage to heart muscle Heart unable to pump blood effectively Leads to fluid retention in lungs, extremities Progressive disease Risk factors: history of MI, CAD, cardiomyopathy, kidney disease Gilbert 4

5 Limit fluid and salt intake Diuretics (e.g. Lasix) Manage co-morbid conditions e.g. HTN, DM Stop smoking, start walking Limit ETOH, NSAIDS Daily/weekly weights Early recognition of exacerbation CHF Exacerbation: Slower onset of SOB Increased edema in legs Fatigue or weakness Hypertensive Blood work includes BNP Elevate legs; IV Lasix; measure I&O; CXR and EKG No IV fluids Hypoglycemia: FSBS < 50 or symptomatic Give oral agents Orange juice, meal Glucose IM or IV Recheck q 30 IV if unable to take oral, or BS persistently low D50 IV, transfer? Diabetes Type I Formerly known as juvenile diabetes Body does not produce insulin Without insulin, glucose stays in blood Excess blood sugar damages organs 1 in 400 children diagnosed (ADA, 2011) Onset at any age AMS: think hypoglycemia or DKA Diabetes Mellitus The main difference between Type I DM and Type II is: A. Type II diabetics do not have to take insulin B. Type I diabetics do not make insulin C. Type I diabetics are typically diagnosed in middle age D. Pre-diabetes does not occur in Type II diabetics New onset symptoms: Extreme thirst Frequent urination Abdominal pain Weight loss Hunger Fatigue Blurred vision Diabetes Type I Complications: DKA Hypo/hyperglycemia CAD, stroke, HTN, kidney damage Neuropathy, loss of sensation in extremities Gastroparesis Amputations Depression, anxiety Diabetes Mellitus Seizure Disorders Prediabetes: Fasting glucose mg/dl 50% greater risk of heart disease, stroke More likely to develop diabetes within 10 years DM onset can be delayed or prevented ADA recommends loss of 10-15% body weight Checked every 1-2 years Diabetes Type II: Fasting glucose >126 mg/dl Body becomes insulin resistant Progressive disease Need CCD diet, oral meds Exercise reduces blood glucose levels FSBS checks may vary Depression, anxiety common sequalae (ADA, 2011) A distinguishing characteristic of tonic-clonic seizures is loss of bladder control. Gilbert 5

6 Diabetes Mellitus Reducing Impact of Co-morbid Illnesses Resource team (dietician, medical provider etc) Manage co-morbid illnesses (e.g. COPD) Frequent conversations about illness Encourage CCD diet, exercise Ask about interaction of medical/psych illnesses Exacerbation (DKA): May be first onset in Type I Other causes: infection, missed insulin, stress, trauma Critical high FSBS, vomiting, confusion, weakness, signs of dehydration DKA needs transfer to ICU IV x 2, vital signs ABG s, CBC, CMP, UA Adopt a heart and lungs attitude Educate co-workers, including physicians Recognize impact of medical illness on psychiatric issues Obtain accurate medical history Assess and reassess throughout hospitalization Identify knowledge deficits Tonic-clonic: FKA grand mal Abnormal activity in both hemispheres May begin with shriek Involves falls, loss of bladder control, injury LOC No spontaneous breathing May last 1-3, followed by post-ictal period Seizure Disorders Two main types: focal (aka partial) and generalized Tonic-clonic most dangerous Causes: TBI, stroke, infection, tumor, drug withdrawal, eclampsia, epilepsy, electrolyte abnormalities Psychogenic nonepileptic seizures: conversion disorder New onset seizures need head CT, blood work Reducing Impact of Co-morbid Illnesses Encourage self-monitoring of symptoms Educate re: early recognition of exacerbation Ask about supports, management, barriers to care Recommend specific support groups Arrange appts. during hospitalization Provide education to family Problem-solve around medication issues etc Seizure Disorders Summary Side rail padding Check medication levels Ask about causes (e.g. epilepsy, TBI) Know seizure history (e.g. onset, type, date of last seizure) Prevention and preparation, (have PR Valium) Pt. education: ID alert, management of illness/stress, medications Exacerbation (tonic-clonic): Note length of seizure Nasal airway, give 02; loosen clothing at neck Protect from injury: remove objects, place padding Place IV asap Post-seizure: recovery position, assess for injury, no food or water Status Epilepticus: prepare for transfer to ICU (www. Epilepsy.com) Be prepared for medical emergencies Emphasize management of medical illnesses Educate patients about exacerbations Advocate for cohesive approach Gilbert 6

7 References American Diabetes Association, Mayo Clinic, Gilbert 7