lOMoARcPSD|8965719 Advanced Medsurg EXAM 2 Study Guide Advanced Med Surg (West Coast University) StuDocu n'est pas sponsorisé ou supporté par une université ou école Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 INTRACRANIAL REGULATION/MOBILITY: 1. How to prevent DVT after Stroke - Measures to prevent development of a thrombus or embolus are used in patients at risk for stroke - Antiplatelet drugs are used in patients who have had a TIA related to atherosclerosis - Aspirin is the most frequently used antiplatelet agent - Sequential compression device (SCD) should be implemented post stroke to decrease DVT formation 2. Stroke (Difference between right and left S/S, Safety and Fall prevention, Residual Deficits following Stroke, Contraindications for Treatment following a Stroke=Medication, Priority Interventions) - - Stroke occurs when there is ischemia or hemorrhage into the brain that results in death of brain cells Also known as brain attack or cerebrovascular accident Loss of function varies according to the location and extent of brain tissue involved - Physical, cognitive, and emotional impact on patient and family Several conditions are associated with stroke risk: - Atrial fibrillation - Cardiac valve abnormalities - DM RIGHT AND LEFT BRAIN STROKE: - - Stroke on the right side of the brain is more likely to cause problems in spatialperceptual orientation - Incorrect perception of self and illness Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 - - - - Unilateral neglect Agnosia: the inability to recognize an object by sight, touch or hearing Apraxia: the inability to carry out learned sequential movements on command COLLABORATIVE CARE FOR STROKE PREVENTION: - Goals include management of modifiable risk factors - Healthy diet - Weight control - Regular exercise - No smoking - Limited alcohol consumption - Routine health assessments Postoperative care is important - Neurovascular assessment - BP management (Labetalol) - Assessment of stent occlusion or retroperitoneal hemorrhage as complications - Minimize complications at insertion site Baseline neurologic assessment - Monitor closely for - Signs of increasing neurologic deficit - Increased ICP - Patient with resolved issues and a history of multiple stroke should be sent to a neuro/telemetry unit for observation and tx. - Elevated BP is common immediately after a stroke - May reflect body’s attempt to maintain cerebral perfusion - As a nurse you should question an order for an IV BP medication gtt - Carefully work to control fluid and electrolyte balance - Goal is to keep patient adequately hydrated to promote perfusion and decrease further brain injury - Manage ICP - Use interventions that improve venous drainage - Anticoagulants and platelet inhibitors are contraindicated - Should be aware if a patient is taking a blood thinner for a pre-existing condition - Management of HTN is the main focus - Oral and IV agents are used to maintain BP within a normal to high-normal range - Seizure prophylaxis is situation-specific ● Nutrition ○ Nutritional needs require quick assessment and treatment ○ May initially receive IV infusion to maintain fluid and electrolyte balance ○ May require nutrition support ● Communication: ○ Your role in meeting psychological needs of the patient is primarily supportive ○ Assess the patient for both the ability to speak and the ability to understand ■ Speak slowly and calmly, using simple words or sentences Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 ■ Gestures may be used to support verbal cues ■ If patient is experiencing initial aphasia, use short yes or no questions. ● Sensory-perceptual alterations ○ Related to the hemisphere of the brain in which the stroke occurred ○ Virtual problems may include ■ Diplopia ■ Loss of the corneal reflex ■ Ptosis (drooping eyelid) ■ Homonymous hemianopsia (make sure to place items on the unaffected side for patient use) ■ Patients are high fall risk-what precautions should be in place 3. Neurological Assessment (Priority=what’s the most important aspect to assess for first, Cranial Nerves Assessment (How do you assess each one) - Physical examination: - Mental status (most important aspect of the neurological assessment if LOC) Cranial nerves: - Oculomotor (CN III), trochlear IV and abducens (CNVI) nerves - Extraocular movement - Pupillary constriction and accommodation - PERRL - PERRLA - Eyelid drooping - Ask the patient to follow a finger through full range of motion to assess all three - Vestibulocochlear (acoustic) nerve CN VIII - Hearing test - Vestibular test - Glossopharyngeal (CN IX) and vagus (CN X) - Gag and cough reflex - Accessory nerve (CN XI) Shoulder movement - Hypoglossal nerve (CN XIII) - Tongue movement 4. Glasgow Coma Scale Interpretation Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 - The patient opens the eyes to noxious stimuli, makes incomprehensible verbalizations, and shows extension in response to painful stimuli This patient would be a 6 on the scale 5. Bacterial Meningitis Clinical Manifestations and Priority Interventions - - - - Leading causes of bacterial meningitis - Streptococcus pneumoniae - Neisseria meningitidis - Vaccine for Hemophilus has greatly diminished most common cause of the past - Organisms enter CNS from respiratory tract or bloodstream - May enter through wounds of skull or fractured sinuses KEY SIGNS OF MENINGITIS - Fever - Severe headache - Nausea, vomiting - Nuchal rigidity - Kernigs Sign (Cannot extend the leg when the hip is flexed) Other symptoms: - Photophobia - Decreased LOC - Signs of increased ICP - Seizures occur in ⅓ of all cases - Headache becomes progressively worse and may be accompanied by vomiting and irritability INTERVENTIONS: - Revolve around the nursing diagnosis of - Decreased intracranial adaptive capacity - Risk for ineffective cerebral perfusion - Increased fever - Acute pain - Minimize environmental stimuli - Mental distortion and hypersensitivity are typical - Convey caring and unhurried gentleness while providing efficient Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 - care Provide safety Observe and record seizures - Prevent injury - Administer anti seizure medications Vigorously manage fever - Fever increases cerebral edema and the frequency of seizures - Neurologic damage may result from high, prolonged fever Assess for dehydration - Evaluate fluid intake and output - Compensate for diaphoresis in replacement fluids Maintain therapeutic blood levels of antibiotics Respiratory isolation until cultures are negative (Droplet, everyone entering room should have on a mask) 6. Spinal Cord Injury Location and Clinical Manifestations ( Priority Assessment and Intervention depends on location of injury, Patient Education) CLINICAL MANIFESTATIONS OF RESP SYSTEM: - Above level of C4 - Total loss of respiratory muscle function → mechanical ventilation Below level of C4 - Diaphragmatic breathing → respiratory insufficiency Cervical and thoracic injuries - Paralysis of abdominal and intercostal muscles → ineffective cough → atelectasis or pneumonia Increase risk for infection Risk for neurogenic pulmonary edema Any cervical spine injury needs to be constantly monitored for changes in respiratory status CLINICAL MANIFESTATIONS OF CARDIO SYSTEM: - Injury above level T6 decrease of sympathetic nervous system Bradycardia, peripheral vasodilation → hypotension Relative hypovolemia because of increased in venous capacitance Cardiac monitoring necessary Atropine to increase HR Peripheral vasodilation - Decrease venous return of blood to heart - Decrease cardiac output IV fluids or vasopressor drugs to increase BP CLINICAL MANIFESTATION OF URINARY SYSTEM ● Acute phase ○ Urinary retention ○ Bladder atonic and overdistended Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 ○ Indwelling catheter ● Postacute phase ○ Bladder may become hyperirritable. ○ Loss of inhibition from brain ○ Reflex emptying ○ Pt may develop Diabetes Insipidus from trauma (check specific gravity) CLINICAL MANIFESTATION FOR GI ● Above T5→ hypomotility ● Paralytic ileus ● Gastric distention ○ Nasogastric tube ○ Metoclopramide (Reglan) ● Stress ulcers ● Intra-abdominal bleeding ● Neurogenic bowel ○ Injury level of T12 or below ■ Bowel initially areflexic with ↓ sphincter tone ● When reflexes return ○ Sphincter tone is enhanced. ○ Reflex emptying occurs. ● Regular bowel program ○ Coordinate with gastrocolic reflex CLINICAL MANIFESTATIONS OF INTEGUMENTARY SYSTEM ● Potential for skin breakdown ● Poikilothermism ○ Interruption of SNS ○ Decrease ability to sweat or shiver ○ More common with high cervical injury CLINICAL MANIFESTATIONS FOR METABOLIC NEEDS - NG suctioning → metabolic alkalosis - Decrease tissue perfusion → acidosis - Electrolyte imbalances - Increased nutritional needs - high protein diet NURSING INTERVENTION: - - Immediate goals - Patent airway - Adequate ventilation - Adequate circulating blood volume - Prevent extension of cord damage Initial care - Ensure patent airway. - Stabilize cervical spine. Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 - - - - Administer oxygen. - Establish IV access. - Assess for other injuries. - Control external bleeding. Ongoing monitoring - VS, LOC, O2 sat, cardiac rhythm, urine output - Keep warm. - Monitor for urinary retention, hypertension. - Anticipate need for intubation if no gag reflex. Acute care - To stabilize and decompress injured spinal segment - Traction or realignment - Eliminate damaging motion - Prevent secondary damage - Early surgery indicated if - Evidence of cord compression - Progressive neurologic deficit - Compound fracture - Bony fragments - Penetrating wounds - Laminectomy NURSING ASSESSMENT: - General - Poikilothermism (unable to regulate body heat) - Integumentary - Warm, dry skin below level of injury (neurogenic shock) - Respiratory - Injury at C1-3: apnea, inability to cough - Injury at C4: poor cough, diaphragmatic breathing, hypoventilation - Injury at C5-T6: decreased respiratory reserve - Cardiovascular - Injury above T5: bradycardia, hypotension, postural hypotension, absence of vasomotor tone - Gastrointestinal - Decreased or absent bowel sounds (paralytic ileus in injuries above T5), abdominal distention, constipation, fecal incontinence, fecal impaction - Urinary - Retention (for injuries between T1 and L2); flaccid bladder (acute stages); spasticity with reflex bladder emptying (later stages) - Reproductive - Priapism, loss of sexual function - Neurologic - Complete: Flaccid paralysis and anesthesia below level of injury resulting in tetraplegia (for injuries above C8) or paraplegia (for injuries below C8), hyperactive deep tendon reflexes, bilaterally positive Babinski test (after resolution of spinal shock) - Incomplete: Mixed loss of voluntary motor activity and sensation - Musculoskeletal - Muscle atony (in flaccid state), contractures (in spastic state) 7. Lumbar Puncture (Priority Assessment and Contraindications) Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 - Lumbar puncture is the most common method of sampling CSF - A lumbar puncture is contraindicated in the presence of increased intracranial pressure or infection at the site of puncture - Before the procedure, have the patient void. Most commonly, the patient is sidelying. However, a seated position may also be used. - Inform the patient that as a sterile needle is passed between the first and second lumbar vertebrae, temporary pain may be felt radiating down the leg - Suspect an infection if the fluid is cloudy or purulent - All fluid from a head injury should be checked for glucose to determine if it is CSF - Monitor for headache intensity, meningeal irritation (nuchal rigidity) or signs and symptoms of local trauma (e.g hematoma, pain) 8. ICP (Clinical Manifestations, Priority Assessments, and Priority Interventions, Normal Values for ICP, Decerebrate Vs Decorticate Posturing) - - Factors that influence ICP - Arterial pressure - Venous pressure - Intraabdominal and intrathoracic pressure - Posture - Temperature - Blood gases (CO2 levels) ICP can be measured in the ventricles, subarachnoid space, subdural space, epidural space, or brain tissue using a pressure transducer Normal intracranial ICP ranges from 5-15 mm Hg A sustained pressure greater than 20 mm Hg is considered abnormal and must be treated - CLINICAL MANIFESTATIONS: - Change in LOC - Change in vital signs (Cushing’s triad (HTN, bradycardia, with changes in respiratory status) - Compression of oculomotor nerve - Unilateral pupil dilation - Sluggish or no response to light - Inability to move eye upward - Eyelid ptosis - Decreased in motor function - hemiparesis/hemiplegia - Decerebrate posturing (Extensor) - Indicates more serious damage - Decorticate posturing (flexor) PRIORITY ASSESSMENT: - The normal ICP waveform has three phases It is important to monitor the ICP waveform, as well as the mean CPP - When ICP is normal, P1, P2, and P3 will resemble a staircase Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 - As ICP increases, P2 will rise above P1, indicating poor ventricular compliance PRIORITY INTERVENTION: - - - - Treat underlying cause Adequate oxygenation - PaO2 > 100 mm Hg - PaCO2 35-45 mm Hg - Intubation - Mechanical ventilation Surgery Drug therapy: - Mannitol (Osmitrol) - Plasma expansion - Osmotic effect - Monitor fluid and electrolyte status - Hypertonic saline - Moves water out of cells and into blood - Monitor BP and serum sodium levels - Corticosteroids - Vasogenic edema - Monitor fluid intake, serum sodium and glucose levels - Concurrent antacids, H2 receptor blockers, proton pump inhibitor - Antiseizure medications - Antipyretics - Sedatives - Analgesics - Barbiturates Nutritional therapy: - Hypermetabolic and hypercatabolic state, increased need for glucose - Enteral or parenteral nutrition - Early feeding (within 3 days of injury) - Keep patient normovolemic - IV 0.9% NaCl preferred over D5W or 0.45% NaCl Overall Goals: - Maintain a patient airway - ICP within normal limits - Normal fluid and electrolyte balance - Prevent complications secondary to immobility and decreased LOC - Keep patient head/neck in a neutral position - Elevate HOB 30 degrees to help reduce ICP and promote adequate cerebral blood flow DECORTICATE AND DECEREBRATE POSTURING: - Decorticate response - Flexion of arms, wrists, and fingers with adduction in upper Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 extremities. Extension, internal rotation and plantar flexion in lower extremities Decerebrate response - All four extremities in rigid extension with hyperpronation of forearms and plantar flexion of feet Decorticate response on right side of body and decerebrate response on left side of body Opisthotonic posturing - - 9. Intracerebral Hemorrhage Risk Factors and Priority Intervention ● Intracerebral hemorrhage ○ Bleeding within brain caused by rupture of a vessel ○ Sudden onset of symptoms ○ Progression over minutes to hours because of ongoing bleeding ○ Prognosis is poor with a 30-day mortality rate of 40-80%. ● Hypertension is most common cause. ● Hemorrhage occurs during activity. ● Extent of symptoms varies and depends on amount, location, and duration of bleeding. ● Manifestations ● Neurologic deficits ● Sudden Headache ● Nausea and/or vomiting ● Decreased levels of consciousness ● Hypertension Subarachnoid hemorrhage (SAH) ○ Intracranial bleeding into cerebrospinal fluid–filled space between the arachnoid and pia mater ○ Commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse ● Characterized usually with a sudden excruciating headache Cerebral aneurysm ● Majority of aneurysms are in the Circle of Willis. ● Silent killer ○ Loss of consciousness may or may not occur. ○ Survivors often suffer significant complications and deficits. ○ Biggest risk factor is HTN METABOLISM AND FLUID REGULATION: 1. Hypothyroidism (High TSH, what would be a desirable outcome of administering Levothyroxine) Myxedema Coma concerns and priority ● Is a deficiency of thyroid hormones that causes a general slowing of the metabolic rate ● Primary hypothyroidism is caused by destruction of thyroid tissue ● Secondary hypothyroidism is caused by pituitary disease with decreased TSH hormone Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 ● Iodine deficiency is the most common cause worldwide ● S/S include lethargy, fatigue, impaired memory, weight gain, decreased cardiac contractility, SOB on exertion ● Patients will have an increased thyroid stimulating level due to the negative feedback system ● Myxedema Coma is a complication and medical emergency for this, involves extreme tiredness, facial edema, and lethargy leading to coma and death ● The diagnostic tests including testing TSH and free T4 levels ● Drug Treatment may involve giving levothyroxine (synthroid), desirable outcome of medication will be a decrease in level of thyroid stimulating hormone MYXEDEMA COMA: ● •The mental sluggishness, drowsiness, and lethargy of hypothyroidism may progress gradually or suddenly to a notable impairment of consciousness or coma. This situation, termed myxedema coma, is a medical emergency. ● •Myxedema coma can be precipitated by infection, drugs (especially opioids, tranquilizers, and barbiturates), exposure to cold, and trauma. ● •It is characterized by subnormal temperature, hypotension, and hypoventilation. ● •Cardiovascular collapse can result from hypoventilation, hyponatremia, hypoglycemia, and lactic acidosis. ● •For the patient to survive a myxedema coma, vital functions must be supported, and IV thyroid hormone replacement must be administered. NURSING MANAGEMENT: ● ● ● ● ● ● ● ● The overall goals for this patient include Experiencing relief of S/S Maintaining a euthyroid state (normal) Maintain a positive self image Maintain a positive self image Comply with thyroid therapy Stress the importance of taking medication Provide written information related drug therapy 2. Hyperthyroidism (Low TSH, Graves Disease) ● Hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones ● Occurs more in women more than men ● Most common form of disease, is called Graves Disease ● Causes include toxic goiter, thyroiditis, excessive iodine, tumors, and Ca ● Graves disease is thought to be autoimmune of origin and is precipitated by the development of thyroid-stimulating antibodies that cause growth and overproduction of the thyroid gland ● S/S may include presence of a large goiter, exopthalmos (bulging eyes), Increased HR, Weight loss, and excessive thirst ● Thyroid storm is a deadly complication which includes HF, shock, hyperthermia, coma, and death ● Diagnostics include testing thyroid hormone levels ● Patients will have a decreased thyroid stimulating hormone level due to the negative feedback system (Graves) ● Nutrition for this patient should include a high calorie diet due to high energy Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 expenditure THYROTOXICOSIS ● In thyrotoxicosis, all the symptoms of hyperthyroidism are prominent and severe. ● Manifestations include severe tachycardia, heart failure, shock, hyperthermia (up to 105.3º F [40.7º C]), restlessness, irritability, seizures, abdominal pain, vomiting, diarrhea, delirium, and coma). ● Treatment is aimed at reducing circulating thyroid hormone levels and the clinical manifestations with appropriate drug therapy. ● Supportive therapy is directed at managing respiratory distress, fever reduction, fluid replacement, and elimination or management of the initiating stressor(s). NURSING MANAGEMENT: •The overall goals for this patient include Experiencing relief of S/S Have no serious complications related to disease Maintain nutritional balance Cooperate with therapeutic plan Post-surgery promote leg exercises and range of motion exercises for the neck’ Keep head stable and support with hands when turning in bed Monitor for S/S of airway obstruction due to post-surgical hemorrhage and swelling Monitor Trousseau’s sign ( carpal spasm) and Chvostek’s sign (twitching of the facial nerve) could indicate hypocalcemia and damage to the parathyroid glands ● Assess sleep patterns ● Monitor respiratory status following a thyroidectomy, patient may make harsh breathing or have vibration upon assessment indicating a potential bleed ● Monitor serum calcium levels ● ● ● ● ● ● ● ● A patient is admitted to the hospital with thyrotoxicosis. On physical assessment of the patient, what should the nurse expect to find? a. Hoarseness and laryngeal stridor b. Bulging eyeballs and dysrhythmias c. Elevated temperature and signs of heart failure d. Lethargy progressing suddenly to impairment of consciousness 3. Thyroidectomy considerations and Implications for Hypocalcemia ● Monitor respiratory status following a thyroidectomy, patient may make harsh breathing or have vibration upon assessment indicating a potential bleed ● Monitor serum calcium levels 4. Modifiable Risk Factors for Diabetes Type 2, S/S of hypoglycemia, What to monitor for if patient receives too much insulin, Peak time Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 and significance with Insulin (Short Acting, Intermediate, and Long acting), Dietary sources for Diabetes patients, DKA S/S and preferred Tx - - Risk factors: - Overweight, obese - Having a family history of type 2 DM Clinical manifestation: - The s/s of type 2 DM are often nonspecific - Including polyuria, polydipsia, polyphagia - Most common manifestations: - Fatigue, recurrent infections - Recurrent vaginal yeast or candidal infections - Prolonged wound healing - Visual changes Interprofessional care - The goals of diabetes management are to reduce symptoms, promote wellbeing, prevent acute complications related to hyper-hypoglycemia, or delay the onset of complications - Nutritional therapy, drug therapy, exercise, and self-monitoring of blood glucose are the tools used in the management of diabetes - There are three major types of glucose-lowering agents such as insulin, oral agents, and noninsulin injectable agents - Some people may be able to control their Type 2 diabetes with diet and exercise, but eventually medication management may be needed due to progression of disease - A newly diagnosed patient should reduce their cholesterol, increase physical activity, and enroll in a smoking cessation program if still smoking, maintain a good blood pressure to reduce kidney damage - - ● MEAL TIME INSULIN (BOLUS) Rapid-acting synthetic insulin analogs, which include lispro (Humalog), aspart (Novalog) and glulisine (Apidra), have an onset of action of approximately 15 minutes and should be injected within 15 minutes of mealtime (peak 1-2 hrs, duration 4-6 hrs) Patient must have food present with this type of insulin, (Novalog), due to the peak initiating in 15 minutes of injection of pen Short-acting regular insulin has an onset of action of 30 to 60 minutes and is injected 30 to 45 minutes before a meal to ensure that the onset coincides with the absorption of the meal - ● LONG OR INTERMEDIATE-ACTING (BASAL) - In addition to mealtime insulin, people with type 1 diabetes use a long-or intermediate-acting basal insulin to maintain blood glucose levels in between meals and overnight Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 - - The long acting insulin includes glargine (Lantus, Toujeo), detemir (Levemir), and degludec (Triseba) - There is no peak for the long acting insulin, so the risk for hypoglycemia is greatly decreased - Intermediate-acting insulin (NPH cloudy) is also used as a basal insulin, has a duration 12 to 18 hrs, and has a peak ranging from 4-12 hrs which can result in hypoglycemia Anytime too much insulin has been given or there is a mistake, the nurse must monitor patient for S/S of hypoglycemia Insulin vials and insulin pens currently in use may be left at room temperature for up to 4 weeks after this it must be discarded Hypoglycemia: - s/s: shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, and pallor, vertigo, moist clammy skin, tachycardia If patient found unconscious, check blood sugar immediately and administer drugs intravenously if levels are severely low Check blood sugar if s/s of hypoglycemia are suspected ■A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to: a. use only the lispro insulin until the symptoms are resolved. b. limit intake of calories until the glucose is less than 120 mg/dL. c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%. A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 10:00 AM (rapid-acting insulins peak in 1 to 3 hours) b. 12:00 AM c. 2:00 PM d. 4:00 PM A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 a. Lispro (Humalog) b. Glargine (Lantus) c. Detemir (Levemir) d. NPH (Humulin N) The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a. "If I overeat at a meal, I will still take the usual dose of medication." b. "Other medications besides the Glucotrol may affect my blood sugar." c. "When I am ill, I may have to take insulin to control my blood sugar." d. "My diabetes won't cause complications because I don't need insulin Many type 2 diabetics take oral medications versus insulin, but can still experience serious ailments and complications from the disease process The primary action of metformin is to reduce glucose production by the liver, it also enhances insulin sensitivity at the tissue level and improves glucose transport into the cells SULFONYLUREAS glipizide (Glucotrol), glyburide (Diabeta, Glynase), and glimipride (Amarly) - These drugs are thought to stimulate insulin release from the pancreas and increase sensitivity to insulin at receptor sites Meglitinides Repaglinide (Prandin) and nateglinide (Starlix) - When they are taken just before meals, pancreatic insulin production increases during and after the meal, mimicking the normal response to eating Food consumption: - Should eat more calories from complex carbohydrates ■A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a. The patient always carries hard candies when engaging in exercise. b. The patient goes for a vigorous walk when his glucose is 200 mg/dL. c. The patient has a peanut butter sandwich before going for a bicycle ride. Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 d. The patient increases daily exercise when ketones are present in the urine. ■A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to: a. check glucose level before, during, and after swimming. b. delay eating the noon meal until after the swimming class. c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin. d. time the morning insulin injection so that the peak occurs while swimming Nursing management of DM: ■ Routine care includes regular bathing, with particular emphasis on foot care, advise patients to inspect their feet daily, avoiding going barefoot, wear shoes that are appropriate, and supportive Diabetic ketoacidosis: - An insulin deficit promotes metabolism of fat stores, which will produce large amounts of acidic ketones Acetone odor to breath s/s: dehydration causes poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension Kassmaul respirations (rapid deep breathing associated with dyspnea) the body’s attempt to reverse metabolic acidosis through exhalation of excess CO2 Nursing management: - Patients with DKA require hospitalization for tx Management of fluid and electrolytes (NS bolus) Administration of short acting insulin ECG monitoring Correcting dehydration status Assessment of mental status - 5. Diabetes Insipidus (Neurogenic Causes), Expected outcomes of administering Vasopresson (Desmopresson) what will happen to urine specific gravity and serum sodium, and urine output - Caused by a deficiency of production of secretion of ADH or a decreased renal response to ADH Primary Neurogenic DI may be caused by trauma (MV, Spinal cord injury) The decrease in ADH results in fluid and electrolyte imbalances caused by increased urine output and increased plasma osmolality DI is characterized by polydipsia and polyuria, excreting large amounts of urine is the primary characteristic of DI The patient will have a very low specific gravity (less than 1.005) and a serum sodium greater than 145 due to the large fluid depletion. Water deprivation test diagnosis this , pt is deprived of water for 8 to 12hrs and then given desmopression (synthetic form of ADH) Serum osmalilty and sodium Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 - are measured as well Early detection, maintaining adequate hydration, and balancing fluid and electrolyes is key to treatment goals •Desirable effects of administering desmopressin will include a decreased urine output and and an increased specific gravity 6. SIADH expected outcomes and preferred treatment, what will happen to urine specific gravity and serum sodium, and urine output - Is the release of ADH despite normal or low plasma osmolarity ADH increases permeability of distal renal tubules and collecting ducts leading to water reabsorption causing fluid retention This disorder has various causes and the most common is Small Cell Lung Ca The patient with SIADH experiences decreased urine output and increased body weight Hyponatermia less than 120mEq/L can cause further serious S/S such as lethargy, confusion, seizures,muscle weakness and coma This is diagnosed is made by simultaneous measurements of urine and serum osmolality Monitor I’s and O’s Demeclocyline and Lasix may be given to promote diuresis resulting in an increased urine output and less fluid retention Maintain the HOB at 10 degrees to enhance venous return to the heart to increase atrial filling Restrict fluids The patient is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What manifestation should the nurse expect to find? a. Decreased body weight b. Decreased urinary output c. Increased plasma osmolality d. Increased serum sodium levels During care of the patient with SIADH, what should the nurse do? a. Monitor neurologic status at least every 2 hours. b. Teach the patient receiving treatment with diuretics to restrict sodium intake. c. Keep the head of the bed elevated to prevent antidiuretic hormone (ADH) release. d. Notify the health care provider if the patient's blood pressure decreases more than 20 mm Hg from baseline. 7. Cushing/s S/S, Addison’s S/S and preferred TX, Education for Addison’s and Cushing’s patients CUSHING SYNDROME: ● A clinical condition that results from chronic exposure to excess corticosteroids, Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 particularly glucocorticoids ● S/S include weight gain, fluid retention, rounded face (moon face), fat deposits in the back, neck, and shoulders (buffalo hump) ● Severe acne and purple striae can be found on the skin as well ● Diagnostic studies include 24hr urine cortisol test ● Truncal obesity is very common in these patients The primary goal of treatment is to normalize hormone secretion ● If the underlying cause is a pituitary adenoma, then removal of the tumor is appropriate ● Drug therapy to suppress the secretion and synthesis of cortisol from the gland is preferred if the patient is not a candidate for surgery ● If steroid therapy is the cause, gradually taper off the medications ● The overall goals of treatment include ○ a)Reducing risk of infection due to lowered resistance to stress and suppression of immune system ○ b)Monitor side effects of steroid therapy ○ c)Acceptance of body image ○ d)Monitor for signs of bleeding and swelling post-surgical removal of any adrenal tumors ADDISON’S DISEASE: ● In this disease all hormones previously listed are reduced ● Most cases of Addison’s disease are autoimmune of nature ● S/S include bronze colored skin hyperpigmentation, ABD pain, diarrhea, salt craving, and joint pain ● Complications include Adrenal Crisis in which the patient experiences a sudden drop in all hormones and can have S/S such as tachycardia, fever, and shock ● The ACTH stimulation test is a common test to diagnose adrenal insufficiency NURSING MANAGEMENT: ● Lifelong hormonal therapy ● Overall patients that take their medications consistently can expect a long-life expectancy ● Correcting fluid and electrolyte imbalances are important when a patient is experiencing crisis ● Hormone adherence is the mainstay of teaching • A patient with Addison's disease comes to the emergency department with complaints of nausea, vomiting, diarrhea, and fever. What collaborative care should the nurse expect? a. IV administration of vasopressors b. IV administration of hydrocortisone c. IV administration of D5W with 20 mEq KCl d. Parenteral injections of adrenocorticotropic hormone (ACTH) Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 NCLEX QUESTIONS: Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a. Spasticity b. Flaccidity c. No sensation d. Hyperactive reflexes The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for a. sensation on the left side of the body. b. voluntary movements on the right side. c. reasoning and problem-solving abilities. d. understanding written and oral language. To assess the functioning of the trigeminal and facial nerves (CNs V and VII), the nurse should a. shine a light into the patient's pupil. b. check for unilateral eyelid drooping. c. touch a cotton wisp strand to the cornea. d. have the patient read a magazine or book. A 68-year-old man with suspected bacterial meningitis has just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? a. Codeine b. Phenytoin (Dilantin) c. Ceftriaxone (Rocephin) d. Acetaminophen (Tylenol) Nurse on clinical unit is assigned to four patients. Which patient should she assess first? Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had continued vomiting A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input. When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? a. "This type of monitoring system is complex and highly skilled staff are needed." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage." A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30 Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? a. Hematocrit Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 b. Blood pressure c. Oxygen saturation d. Intracranial pressure After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Check the nasal drainage for glucose. c. Assure the patient that rhinorrhea is normal after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity. After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A patient whose cranial x-ray shows a linear skull fracture b. A patient who has an initial Glasgow Coma Scale score of 13 c. A patient who lost consciousness for a few seconds after a fall d. A patient whose right pupil is 10 mm and unresponsive to light Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? a. Hypertension b. Hyerlipidemia c. Alcohol consumption d. Oral contraceptive use The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? a. Impulsivity b. Impaired speech Téléchargé par adir adina (filona@mailto.plus) lOMoARcPSD|8965719 c. Left-side neglect d. Short attention span Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? a. Present several thoughts at once so that the patient can connect the ideas. b. Ask open-ended questions to provide the patient the opportunity to speak. c. Finish the patient's sentences to minimize frustration associated with slow speech. d. Use simple, short sentences accompanied by visual cues to enhance comprehension. Which is most important to respond to in a patient presenting with a T3 spinal injury? a. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute b. Deep tendon reflexes of 1+, muscle strength of 1+ c. Pain rated at 9 d. Warm, dry skin The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do? a. Determine if the patient lost consciousness. b. Assess the Glasgow Coma Scale (GCS) score. c. Obtain a set of vital signs. d. Use a logroll technique when moving the patient. Téléchargé par adir adina (filona@mailto.plus)
