Manifestations / Interprofessional Care

Manifestations / Interprofessional Care 150 150 Tony Guo
Manifestations Interprofessional Care
  • Agitation
  • Anxiety
  • Increased Heart rate
  • Increased BP
  • Sweating
  • Nausea
  • Tremors
  • Insomnia
  • Hyperactivity
  • Benzodiazepines e.g. lorazepam (Ativan) or midazolam (Versed) to prevent seizures and delirium
  • Thiamine to prevent Wernicke-Korsakoff syndrome
  • Multivitamins e.g. folic acid, B vitamins
  • Magnesium sulfate to treat low serum magnesium
  • IV glucose solution to treat hypoglycemia
  • β-blockers (e.g. propranolol) or α2 -agonists (e.g. clonidine) to stabilize VS
  • Respiratory support

 

  • Alcohol Withdrawal Delirium
    • Serious complication
    • Can occur 2-3 days after the last drink
    • Lasts 2-3 days
    • Risk increases with greater alcohol dependence

 

Manifestation Interprofessional Care
  • Disorientation
  • Visual, tactile, or auditory hallucinations
  • Seizures
  • Continued use of benzodiazepines
  • Carbamazepine (Tegretol) or valproate (Depakote) to treat seizures 
  • Antipsychotic agents e.g. chlorpromazine (Thorazine), haloperidol (Haldol)
  • Chlordiazepoxide (Librium) if psychosis persists after benzodiazepine administration

 

Body System Effects of Alcohol
Cardiac Hypertension, atrial fibrillation, cardiomyopathy, stroke, coronary artery disease, sudden cardiac death
Neurologic  Alcoholic dementia, Wernicke-Korsakoff syndrome. 

Impaired cognitive function, psychomotor skills, abstract thinking, and memory. 

Depression, anxiety, attention deficit, labile moods, seizures, insomnia, peripheral neuropathy, chronic headache

Immunologic Increased susceptibility to infections, depressed immune function
Hematologic Bone marrow depression, anemia, leukopenia,  thrombocytopenia, blood clotting abnormalities
Hepatic Alcoholic hepatitis, cirrhosis, liver cancer
Musculoskeletal Myopathy, osteoporosis, gout
Gastrointestinal Gastritis, gastroesophageal reflux disease (GERD), peptic ulcer, esophagitis, esophageal varices, gastrointestinal bleeding, pancreatitis, oropharyngeal cancer, colorectal cancer
Urinary  Diuretic effect from inhibition of antidiuretic

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Nutrition Diabetes mellitus, anorexia, malnutrition, vitamin deficiencies (especially thiamine)
Reproductive Breast cancer, testicular atrophy, decreased beard growth, decreased libido, decreased sperm count, gynecomastia
Integumentary Palmar erythema, spider angiomas, rosacea, rhinophyma

 

Stimulants

  • Highly addictive
  • Increase cardiac activity
  • Excite CNS by increasing neurotransmitters
    • Norepinephrine
    • Serotonin
    • Dopamine
  • Toxicity
    • Sympathetic overdrive
      • Can be fatal
      • No antidote
      • Emergency management is based on clinical manifestations
      • Supportive care for agitation and cardiovascular symptoms
  • Withdrawal
    • Not an emergency
    • Supportive care
      • Quiet environment
      • Sleeping and eating at will
      • Suicide precautions if indicated
Assessment findings Interventions
Cardiovascular
  • Ensure patent airway.
  • Establish IV access and initiate fluid replacement as appropriate.
  • Obtain a 12-lead ECG and initiate ECG monitoring.
  • Treat ventricular dysrhythmias as appropriate with lidocaine, bretylium (Bretylol), or procainamide (Pronestyl).
  • Hypertension and chest pain may require administration of nitroprusside (Nipride) or phentolamine (Regitine).
  • Aspirin may be administered to lower the risk of myocardial infarction.
  • Administer IV diazepam (Valium) or lorazepam (Ativan) for seizures.
  • Administer IV antipsychotic drugs for psychosis and hallucinations.
  • Monitor vital signs and level of consciousness.
  • Initiate cooling measures for hyperthermia.
  • Palpitations
  • Tachycardia
  • Increased BP
  • Dysrhythmias
  • Myocardial ischemia or infarction
Central Nervous System
  • Feeling of impending doom
  • Euphoria
  • Agitation
  • Combativeness
  • Seizures
  • Hallucinations
  • Confusion
  • Paranoia
  • Fever

 

Depressants

  • Rapid development of tolerance and dependence
  • Commonly used with alcohol
  • Commonly types used:
    • Sedative-hypnotics
      • Barbiturates
      • Benzodiazepines
      • Barbiturate-like drugs
  • Depress CNS
  • Tolerance develops to drug’s effects but not brainstem-depressant effects
  • Opioids
    • Misuse of illegal street drugs and prescription opioids
  • Cause sedation and analgesia
  • Frequently abused
  • Toxicity
    • Unintentional overdose occurs frequently
    • Death can occur from CNS and respiratory depression
    • Care includes support of respiratory and cardiovascular function
    • Sedative-Hypnotics toxicity
      • Benzodiazepine antagonist (flumazenil)
      • No antagonists for barbiturates or other sedative-hypnotics
      • Promote drug elimination
  • Dialysis – used to decrease the drug level and to prevent irreversible CNS effects and death
  • Gastric lavage with activated charcoal
  • Opioids – reverse effect 
    • Naloxone (opioid antagonist)
      • Reverses respiratory depression and coma
      • Monitor closely
      • May need repeated doses
  • Withdrawal
    • Sedative-Hypnotics
      • May be life threatening
      • Manifestations mimic alcohol withdrawal
        • Delirium, seizures, respiratory and cardiac arrest within 24 hours of last dose
    • Opioids
      • Symptoms depend on opioid used, route of administration, duration of use
      • Uncomfortable but not life threatening
      • Can occur within hours after last dose
      • Treatment often requires medications

Inhalants

  • Household and workplace products contain chemicals with psychoactive properties when inhaled
  • Rapidly absorbed and reach CNS quickly
  • Most are depressants
  • Long-term use can result in brain damage

Cannabis

  • THC (tetrahydrocannabinol) a key ingredient in cannabis causes psychoactive effects
    • Low to moderate doses produce alcohol-like effects
    • Long-term use has cardiopulmonary and mental health effects
  • Legalization for medical and recreational use is controversial
    • Medical uses
      • Nausea and vomiting from chemotherapy
      • Appetite stimulant in AIDS patients
    • Illegal synthetic THC derivatives
      • Unpredictable effects
      • More toxic
  • Toxicity
    • Causes:
      • Acute psychotic episodes
      • Tachycardia, hypertension, dysrhythmias, MI (myocardial infarction)
      • Panic and flashbacks
    • Care includes quiet environment and benzodiazepines
  • Withdrawal
    • Heavy cannabis use
    • Irritability, anxiety, anorexia, chills, disturbed sleep, fever, tremors
    • Peaks about 48 hours after cessation
    • Lasts 3-4 days
    • No drug therapy is effective

Caffeine

  • Most widely used psychoactive substance in the world
  • Weak stimulant
    • Increases wakefulness
    • Facilitate motor activity
    • Treat headaches
  • Toxicity
    • Cause cardiac dysrhythmias 
    • Hypertension
    • Disturbed sleep
    • Seizures, and anxiety.
  • Dependence
    • Muscle pain or stiffness,
    • Drowsiness, irritability, and headaches after general anesthesia

 

Nursing Management Substance Use

  • Nursing Assessment
    • Screening, Brief Intervention, and Referral to Treatment (SBIRT)
      • Screening for problems using standardized screening tools
      • Brief intervention or teaching about consequences of use and abuse
      • Referral for further treatment
    • Determine when substance last used
    • Assess for withdrawal
    • Notify HCP of polysubstance use
    • Mental health disorders
    • Blood work
  • Nursing Diagnosis
    • Acute confusion related to toxicity or withdrawal
    • Disturbed sensory perception related to toxicity or withdrawal
    • Risk for injury related to altered mental status
    • Ineffective health maintenance related to substance use
  • Planning
    • Overall goals
      • Normal physiologic functioning
      • Acknowledge a problem exists
      • Explain the negative effects of use
      • Abstain from substance use
      • Cooperate with treatment

Health Promotion

  • Prevention
    • Teach about negative effects 
    • Provide support
  • Early detection
    • Initiate brief interventional techniques
    • Refer for treatment

Gerontologic Considerations

  • Older adults are often unaware of their substance use problems
  • Difficult to recognize
    • Don’t fit the image of users
    • Symptoms can mimic medical conditions i.e. liver damage and cardiovascular, GI, and endocrine problems
      • Use may cause confusion, delirium, memory loss, and neuromuscular impairment
    • At greater risk for medical problems associated with substance use
  • Screening
    • Use all information resources
    • Discuss drug and alcohol use 
    • Assess current medication knowledge
    • The Short Michigan Alcoholism Screening Test – Geriatric Version

 

Inflammation

  • Sequential response to cell injury that:
    • Neutralizes and dilutes inflammatory agent
    • Removes necrotic materials
    • Establishes an environment suitable for healing and repair
  • Inflammatory response can be divided into 
    • Vascular response
    • Cellular response
    • Formation of exudate
    • Healing

 

Vascular response

  • After cell injury, arterioles in area briefly undergo transient vasoconstriction
  • After release of histamine and other chemicals by injured cells, vessels dilate, resulting in hyperemia
  • Vasodilation chemical mediators 
    • Increased capillary permeability
    • Movement of fluid from capillaries into tissue spaces
  • Fluid in tissue spaces
    • Initially composed of serous fluid
    • Later contains plasma proteins, primarily albumin
      • Proteins exert oncotic pressure that further draws fluid from blood vessels
      • Tissue becomes edematous
  • As plasma protein fibrinogen leaves blood, it is activated to fibrin by products of injured cells
  • Fibrin strengthens blood clot formed by platelets
  • In tissues, clot traps bacteria to prevent spread

 

Cellular response

  • Blood flow through capillaries in area of inflammation slows as fluid is lost and viscosity increases
  • Neutrophils and monocytes move to inner surface of capillaries and then migrate through capillary wall to site of injury
    • Chemotaxis
      • Directional migration of WBCs along concentration gradient of chemotactic factors
      • Mechanism for accumulating neutrophils and monocytes at site of injury
    • Neutrophils
      • First leukocytes to arrive at site of injury (6 – 12 hours) 
      • Phagocytize bacteria, other foreign material, and damaged cells 
      • Short life span (24 – 48 hours)
      • Pus is composed of
  • Dead neutrophils accumulated at site of injury
  • Digested bacteria
  • Other cell debris
  • Bone marrow releases more neutrophils in response to infection, resulting in elevated WBC
  • Monocytes
    • Second type of phagocytic cells to migrate to site of injury from circulating blood
    • Attracted to the site by chemotactic factors
    • Arrive within 3 to 7 days after onset of inflammation
    • On entering tissue spaces, monocytes transform into macrophages
    • Assist in phagocytosis of inflammatory debris
    • Macrophages have a long life span and can multiply
  • Macrophages
    • Important in cleaning area before healing can occur
    • May stay in damaged tissues for weeks
    • Cells may fuse to form multinucleated giant cell
  • Lymphocytes 
    • Arrive later at the site of injury
    • Primary roles of lymphocytes involve 
      • Cell-mediated immunity
      • Humoral immunity

Chemical mediators

  • Histamine
    • Stored in granules of basophils, mast cells, platelets
      • Causes vasodilation and increased capillary permeability
  • Serotonin
    • Stored in platelets, mast cells, enterochromaffin cells of GI tract
      • Causes vasodilation and increased capillary permeability like histamine.
      • Stimulates smooth muscle contraction
  • Kinins (e.g., bradykinin)
    • Produced from precursor factor kininogen as a result of activation of Hageman factor (XII) of clotting system
      • Cause contraction of smooth muscle and vasodilation. 
      • Result in stimulation of pain
  • Complement system (C3a, C4a, C5a)
    • Anaphylatoxic agents generated from complement pathway activation
      • Stimulate histamine release and chemotaxis
      • Final components of complement system create holes in cell membrane, causing targeted cell death by membrane rupture
  • Prostaglandins and leukotrienes
    • Produced from arachidonic acid
      • PGs cause vasodilation. LTs stimulate chemotaxis
  • Cytokines

Exudate

  • Consists of fluid and leukocytes that move from circulation to site of injury
  • Nature and quantity depend on type and severity of injury and tissues involved
  • Types of inflammatory exudate
    • Serous
    • Serosangulneous
    • Fibrinous
    • Hemorrhagic
    • Purulent (pus)
    • Catarrhal

 

Clinical manifestations

  • Local response to inflammation
Manifestations Cause
Redness Hyperemia from vasodilation
Heat Increased metabolism at inflammatory site
Pain Change in pH. Nerve stimulation by chemicals (e.g., histamine, prostaglandins). 

Pressure from fluid exudate

Swelling Fluid shift to interstitial spaces.

Fluid exudate accumulation

Loss of function Swelling and pain

 

  • Systemic response to inflammation
    • Increased WBC count with a shift to the left
    • Malaise
    • Nausea and anorexia
    • Increased pulse and respiratory rate
    • Fever
  • Onset is triggered by release of cytokines
  • Cytokines cause fever by initiating metabolic changes in temperature-regulating center in hypothalamus
  • Epinephrine released from adrenal medulla increases metabolic rate
  • Patient then experiences chills and shivering
  • Body is hot, yet person seeks warmth until circulating temperature reaches core body temperature

Types of Inflammation

  • Acute
    • Healing occurs in 2 to 3 weeks, usually leaving no residual damage
    • Neutrophils are predominant cell type at site of inflammation
  • Subacute
    • Has same features as acute inflammation but persists longer
  • Chronic
    • May last for years
    • Injurious agent persists or repeats injury to site
    • Predominant cell types involved are lymphocytes and macrophages
    • May result from changes in immune system (e.g., autoimmune disease)

 

Nursing and Interprofessional management

  • Nursing Implementation
    • Health Promotion
      • Prevention of injury
      • Adequate nutrition
      • Early recognition of inflammation
      • Immediate treatment
    • Acute Intervention
      • Observation
      • Vital signs
      • Fever management
      • Drug therapy
  • Aspirin
  • Acetaminophen
  • NSAIDs
  • Corticosteroids
  • RICE
    • Rest
  • Helps the body use its nutrients and O2 for the healing process. 
  • The repair process is facilitated by allowing fibrin and collagen to form across the wound edges with little disruption.
  • Ice (Cold and Heat)
  • To promote vasoconstriction and decrease swelling, pain, and congestion from increased metabolism in the area of inflammation
  • Heat may be used later to promote healing by increasing the circulation to the inflamed site and subsequent removal of debris and localize inflammatory agents.
  • Compression and immobilization
  • Counters the vasodilation effects and development of edema.
  • Promotes healing by decreasing the tissues’ metabolic needs
  • Evaluate the patient’s circulation after application and at regular intervals. 
  • Swelling can occur within the closed space of a cast and compromise circulation.
  • Elevation
  • Elevating the injured extremity above the level of the heart reduces the edema at the inflammatory site by increasing venous and lymphatic return

 

Healing Process

  • The final phase of the inflammation process is healing
  • Healing includes two major components:
    • Regeneration
      • Replacement of lost cells and tissues with cells of the same type
    • Repair
      • Occurs by primary, secondary, or tertiary intention
  • Primary intention – When wound margins are neatly approximated, as in a surgical incision or a paper cut
  • Secondary intention – From trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss
  • Tertiary intention (delayed primary intention) – Contaminated wound is left open and sutured closed after the infection is controlled, and when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured

Complications of wound healing

  • Adhesions  
    • Bands of scar-like tissue that form between two surfaces inside the body and cause them to stick together
  • Contractions
    • Excessive fibrous tissue formation due to shortened muscle tissue
  • Dehiscence 
    • When a surgical incision reopens, either internally or externally, or when a primary healing site bursts open
  • Evisceration
    • When wound edges separate to the extent that intestines protrude through wound
  • Hypertrophic scars
    • Overabundance of collagen is produced during healing that results in large, raised red and hard scars
  • Keloid formation 
    • Extra scar tissue grows, forming smooth, hard growths without any tendency to subside
  • Hemorrhage
    • Abnormal internal or external blood loss caused by suture failure, clotting abnormalities, dislodged clot, infection, or erosion of a blood vessel by a foreign object (tubing, or drains) or infection process

 

Role of Nursing Personnel

  • Registered Nurse (RN) 
    • Assess patients for pressure ulcer risk and develop a plan of care to prevent the development of pressure ulcers.
    • Assess patients for factors that may delay wound healing and develop a plan of care to address these factors.
    • Assess and document initial wound appearance, including wound size, depth, color, and drainage.
    • Plan nursing actions to assist with wound healing, including wound care, positioning, and nutritional interventions.
    • Choose dressings and therapies for wound treatment (in conjunction with the HCP and/or wound care specialist).
    • Implement wound care for complex or new wounds, including negative-pressure wound therapy and hyperbaric O2 therapy.
    • Evaluate whether wound care is effective in promoting wound healing.
    • Provide teaching to patient and caregivers about home wound care and pressure ulcer prevention.
  • Licensed Practical/Vocational Nurse (LPN/LVN)
    • Perform sterile dressing changes on acute and chronic wounds.
    • Apply ordered topical antimicrobials and anti-bactericidals to wounds.
    • Apply prescribed dressings or medications for wound debridement.
    • Collect and record data about wound appearance.
    • Reinforce teaching that was provided by the RN.
  • Unlicensed Assistive Personnel (UAP)
    • Perform dressing changes for chronic wounds using clean technique (must consider state nurse practice act and agency policy).
    • Empty wound drainage containers and document drainage on intake and output record.
    • Report changes in wound appearance or drainage to RN.
  • Role of Other Team Members (Dietitian)
    • Assess and monitor patient’s nutritional status.
    • Establish an intervention together with the inter-professional team.
    • Monitor patient’s progress toward achieving the goals of care.

 

Pressure Ulcers

  • Localized injury to the skin and/or underlying tissue (usually over a bony prominence) as a result of pressure or pressure in combination with shear
  • Located at tailbone, heels, hips, shoulder blades, ankles, elbows, ears, and the back of your head.

Risk factors for pressure ulcers

  • Advanced age
  • Immobility
  • Anemia
  • Impaired circulation
  • Contractures
  • Incontinence
  • Diabetes mellitus
  • Low diastolic blood pressure (<60 mm Hg)
  • Elevated body temperature
  • Mental deterioration
  • Friction (rubbing of surfaces together)
  • Neurologic disorders
  • Obesity
  • Prolonged surgery
  • Pain
  • Vascular disease

Nursing Assessment

  • Conduct a thorough head-to-toe assessment on admission to identify and document any pressure ulcers. 
  • After admission, conduct periodic reassessment of the skin and wounds.
    • Assessment tool such as the Braden Scale

Nursing Diagnosis

  • Impaired skin integrity related to mechanical factors and physical immobilization
  • Impaired tissue integrity related to impaired circulation and imbalanced nutritional state

Planning

  • Have no deterioration of the ulcer
  • Reduce or eliminate the factors that lead to pressure ulcers
  • No developing infection in the pressure ulcer
  • Have healing of pressure ulcers
  • Have no recurrence

 

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