Acute Intracranial Problems
Intracranial pressure = closed system

Cerebrospinal fluid 10%

Intravascular fluid 12%

Brain tissue 78%

Monro-Kellie doctrine states that they must remain in relative constant volume to mntn homeostasis
(normal pressure is 5-15, anything greater than 20 is worrisome)
Hydrocephalus – peds have open fontanels and suture lines that are not bonded together, which creates an
open system

don’t see the typical s/s bc of the expansion that can happen
Herniation – happens bc adults have closed system and there is nowhere for the pressure to go but down the
brain stem

complete devastation and grave danger
Increased ICP – tumors, edema, trauma

CM: headache, vomiting, seizures
o LOC- any alteration of mental status, can be quick
o Cushing’s triad- ↑ systolic BP (widening of pulse pressure), bradycardia, irregular RR

Medical ER d/t brainstem compression and impending death
o Ocular signs- pupils may be dilated, fixed, sluggish, pinpoint, unequal
o Posturing changes- decorticate vs decerebrate

Diagnostics:
o CT/MRI of brain- used to discern the many conditions that can cause increased ICP and assess
the effect of trmt
o MRA of brain
o EEGs

Assessment:
o Glascow coma scale- assess LOC w/pts ability to open the eyes when a verbal/painful stimulus
is applied, speak, and obey commands (3-15, at 8 we intubate!)
o NIH stroke scale
o Vital signs- Cushing’s triad
o Focused neuro exam
o Ventriculostomy- gold standard for monitoring ICP, catheter inserted directly into ventricle that
measures ICP and facilitates removal/sampling of ICP

Nursing mgmt.:
o Airway- monitor ABGs (bc differences in O2 and CO2 levels can impact pressure), suctioning as
needed
o HOB at least 30- lying flat increases the pressure
o Seizures- pressure can mess w/the firing of neurons

Seizure precautions- padded siderails, suction ready, ambo bag, antiseizure meds, time
seizure
o Decrease stimulation- cluster care, minimize touch, darken room

Increased pressure can be d/t increased stimulation
o Nutritional- if intubated put in OG tube

Medical mgmt.:
o Shunts- hydrocephalus
o Craniotomy- brain bleeds
o Temp regulation
o Fluid regulation- too much fluid can cause increase in pressure
o Meds
Corticosteroids (dexamethasone)- help w/inflammatory cascade

Diuretics (mannitol)- works by plasma expansion and osmotic effect

Antiseizure meds

Sedatives/paralytics- especially for intubated pts

Pain meds- usually for HA
Bacterial Meningitis – infection of meningeal tissues

Bacteria introduced w/URI or bloodstream, 95% of cases are caused by strep, flu, or meningitis

VERY FATAL AND CONTAGIOUS

Increase in incidence in the fall/winter and crowded conditions like college dorms

CM:
o Fever
o Nuchal rigidity- looking up causes pain
o Positive Kernig sign- pushing the leg up from the knee causes neck/back pain
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o Purpura rash (specific to meningococcal)
o Severe HA
o Altered mental status- confused, not making sense
o Seizures in about 1/3 of pts
o Biggest complication is increased ICP

Diagnostics:
o CT scan of brain- prior to lumbar puncture to establish ICP
o Blood cultures
o Lumbar puncture w/analysis of CSF- very purulent/sticky CSF w/high pressure

Label – 123, one will be latex panel which can tell if it is one of the big organisms
o Blood work- CBC, CMP, INR, Pt, Ptt

Nursing mgmt.:
o Assessment- VS, neuro status, fluid I/Os, skin/lung eval
o Decrease lighting
o Minimize stress
o HOB at 30 degrees
o Isolation and respiratory precautions

Medical mgmt.:
o HA mgmt.
o Seizure control
o Meds-


Antibiotics- ASAP after cultures

Steroids for inflammation

Temp control (Tylenol)

Mannitol for ICP control
Nursing goals:
o Return to maximal neuro function
o Resolve infection
o Control pain and discomfort
o Pt expresses understanding of disease process

Prevention:
o Meningococcal vaccine- MCV4 for people under 55
o Influenza vaccine
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o Pneumonia vaccine
o Prophylactic antibiotic for exposure
Viral Meningitis – viral infection caused by enteroviruses, HSV, HIV, arboviruses and spread by respiratory
secretions

Diagnostics:
o CT
o Lumbar puncture- usually comes out not pressurized and clear w/lymphocytosis

CM:
o Fever
o HA
o Photophobia
o Nuchal rigidity

Nursing mgmt.:
o Low lighting
o Head of bed up
o Symptom control- pain meds, steroids, no antibiotics

Medical mgmt.:
o Symptom mgmt.
o Self-limiting
o Meds- acyclovir for reducing viral load
Encephalitis – acute inflammation of the brain tissues, serious to fatal disease process

spread by direct contact and ticks and mosquitos in some cases

viral- west nile virus, hepatitis, HIV, chicken pox, measles, mumps
o West Nile Virus – spread through infected mosquitos, can cause meningitis, encephalitis, febrile
illness


Incubation is 2-6d but can be longer if person has lower immunity

Less than 1% of people will develop serious illness

Most people 70-80% will have no s/s

Most cases occur June-September

No trmt, pvtn only
CM: starts very nonspecific then as it progresses it increases in s/s and can include virtually any CNS s/s
o Fever
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o HA
o n/v
o altered mental status- only slight change like affect or can present in a coma
o seizures

diagnostics:
o CT
o MRI
o PET
o PCR (HSV and west nile)
o may see lumbar puncture to rule out meningitis

nursing mgmt.:
o seizure precautions
o low lighting
o HOB up at 30 degrees
o Education on pvtn
o If we can identify a specific viral cause, we may have an antiviral to give

Medical mgmt.:
o Symptom control
o Seizure pvtn
o Meds- Acyclovir for HSV
Chronic Neuro Problems
Headaches –

Types:
o Tension- most common type, feels like a band, neck involvement, lasts hours to days, “stress”
HA, bilateral
o Migraine- n/v, unilateral or bilateral, throbbing, something usually triggers it, females 20-30,
familial tendency, triggers include anxiety/menstruation/certain foods/ weather/meds, lasts 472hrs

Classical- migraine has an aura

Common- do not have aura
o Cluster- suicidal, 0.1% of pop, weeks to months at a time, alcohol is main trigger, men

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Diagnostics: most important is health history and HA history
o CT
o MRI

Nursing mgmt.:
o Low lighting
o Decrease noise and disruption
o Education for pt and family
o Neuro assessment

Medical mgmt.:
o Meds
Tension- NSAID, muscle relaxer, sedative

Migraine- NSAID, ASA, caffeine combo, triptans (Imitrex), topiramate (Topamax) for
prophylactic trmt



Imitrex CI- uncontrolled HTN, cardiac/vessel disease

Topamax teaching- increase fluids (can cause kidney stones), do not dc abruptly,
can’t have in pregnancy
Cluster- oxygen 6-9L for 15mins, triptans, intranasal lidocaine, verapamil, and lithium for
prophylactic trmt
Teaching:
o Avoid triggers
o Stress mgmt. techniques
o Regular exercise and good nutrition
o Med use
Seizure – paroxysmal, uncontrolled electrical discharge of neurons in brain that interrupt normal function

May accompany other disorders or be spontaneous w/o apparent cause

Common causes during the first 6mo of life = severe birth injury, congenital birth defects involving CNS,
infections, errors of metabolism

Epilepsy – condition in which a person has spontaneous recurring seizures caused by underlying chronic
condition, 3 million people in US
o RF- males, strokes, genetic, Alzheimer’s

Phases of seizures:
o Prodromal- differences in behavior or mvmts when service animal can sense seizure is about to
happen
o Aural- consistent cue, smell/visual/something that tells the pt seizure is coming
o Ictal- during the seizure itself
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o Postictal- where the brain is recovering, can be incontinent

Types: determined by site of electrical disturbance
o Generalized- alterations in consciousness

Absence- “petit mal”, occur in children rarely beyond adolescence, may cease or
develop into another type, can be precipitated by flashing lights and hyperventilation

Tonic- involve sudden onset of mntn increased tone in the extensor muscles but pt may
still be awake and lasts less than 20sec, pts often fall

Clonic- begin w/loss of consciousness and sudden loss of muscle tone followed by limb
jerking, rare

Grand mal- both tonic and clonic where pt loses consciousness, falls to the ground, body
stiffens (tonic) for 10-20sec, extremities jerk (clonic) for another 30-40sec

Accompanied by some loss of airway, cyanosis, tongue biting, tongue blocks
airway, cheek biting, incontinence
o Focal- caused by focal irritations, begin in a specific region of cortex, produce s/s related to
function of portion of brain affected

Simple- remain conscious, may have unusual emotions

Complex- altered or dreamlike experience, may have lip smacking, repetitive emotions,
fumbling with clothes/objects
o Psychogenic- “pseudo seizures”, psychiatric in nature, resemble epileptic seizures, accurate
diagnosis requires EEG

Complications:
o Status epilepticus- any seizure lasting longer than 5min, debilitating, pt loses airway, can lose IQ
points

Neuro ER
o Respiratory insufficiency
o Cardiac dysrhythmias
o Systemic acidosis
o Trauma/injury
o Lifestyle disruptions- no longer drive/swim

Diagnostics:
o EEG
o Blood tests
o CT
o MRI
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o PET

Medical mgmt.:
o
Surgical interventions- if pt doesn’t respond well to meds, especially w/focal seizures
o Vagal nerve stimulation- doesn’t cure but it reduced the amnt of meds
o Ketogenic diet- low carb/fat
o Meds- anticonvulsants

Nursing mgmt.:
o Seizure precautions
o Observe and record description
o Protect head
o Mntn patent airway
o Ease to floor if standing
o Recovery position- side lying

Teaching:
o Identify triggers
o Medication and importance
o Medic alert bracelet
o Avoid ETOH and meds that decrease seizure threshold, loss of sleep
o Family teaching- care during seizure and when to call 911 (prolonged, injury, recurrent)
Multiple Sclerosis – chronic and progressive degenerate of the CNS, segmental demyelination of the nerve
fibers of brain and spinal cord

Onset is btwn 20-50yrs and usually slow/gradual

RF- women, colder temps, familial tendency

CM:
o Blurred vision- early sign
o Intermittent generalized weakness
o Vertigo
o Tinnitus
o Nerve root pain
o Lhermitte’s sign- transient sensory perception that feels like a lightning bolt down the back
o Nystagmus
o Incontinence
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
Diagnostics: to be diagnosed, must have at least 2 demyelinating lesions in at least 2 locations found on
one of the imaging tools
o History and CM
o Clinical manifestations
o CSF analysis
o CT scan
o Evoked potential scanning- test the reaction to visual, auditory, and muscular stimulants

Assessment:
o Health history
o Functional health patterns
o Skin/neuro/musculoskeletal assessment

Nursing mgmt.:
o Education on triggers and disease process
o Pvtn of complications especially immobility
o Bladder control issues
o Constipation

Medical mgmt.:
o PT/OT
o Meds- teaching for each

Immunomodulators- perform self-injecting techniques, treat flu-like s/s w/NSAIDs and
acetaminophen, avoid pregnancy, follow cancer screening guidelines, avoid large
crowds, monitor LFTs

Immunosuppressants- avoid pregnancy, avoid large crowds

Corticosteroids- restrict salt intake, do not dc abruptly, know drug interactions

Cholinergic- consult HCP before taking other drugs especially sleep aids and
antihistamines

Muscle relaxants- avoid driving, do not dc abruptly, do not use w/other CNS depressants

Nerve conductor enhancers- may cause seizures at higher doses, take tablet whole and
do not take more than 2 in 24hrs
Parkinson’s Disease – chronic progressive neurodegenerative disorder characterized by slowness in the
initiation of mvmt

CM:
o Tremor- often the first sign
o Rigidity- often jerky
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o Bradykinesia- slowness of mvmts

Diagnostics: diagnosis is made when 2/3 of the triad is present and a positive response to
antiparkinsonian drugs, no specific test available
o History and physical
o Present classic triad and response to Parkinson drugs
o MRI
o Rule out meds and other causes

Assessment:
o Health history
o Functional health problem- mvmt problems, depression mood swings, fatigue, facial
expressions, rigidity, shuffling gait, contractures, pin wheel tremor

Nursing mgmt.:
o Aspiration pvtn
o Nutritional imbalance- smaller more frequent meals (6), strong taste, soft texture
o ADLs
o Risk for falls
o Education for pt and family

Medical mgmt.:
o Meds- aimed at increasing dopamine levels

Anticholinergic drugs

Antiviral agent- Symmetrel

Antidepressant- Elavil
Amyotrophic Lateral Sclerosis – “Lou Gehrig’s disease”, rare progressive neurological disorder which is
characterized by loss of motor neurons

No change in the pts mental ability and no cognitive impairment

CM:
o Limb weakness
o Dysarthria
o Dysphagia
o Muscle wasting
o Depression

Nursing mgmt.:
o Facilitating communication
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o Reducing risk of aspiration- might opt for a GT tube
o Facilitating early identification of respiratory illness
o Decreasing pain
o Decrease risk of injury from falls
o Provide diversional activity such as reading and companionship

Medical mgmt.: no cure available
o Artificial ventilation
o Meds- Riluzole (Rilutek) slows the progression
Stroke
Classic CM – FAST = facial drooping, arm drift, speech slurred or unintelligible, time to get help
Diagnostics:

CT w/in 45mins no contrast- determines whether stroke is result of a bleed

MRI- can see ischemic areas immediately

MRA

tans esophageal echocardiogram- can visualize the valves of the heart to see if there are any underlying
conditions like valvular bacterial growth or endocarditis

carotid doppler- identify plaques in the carotids

fasting lipid profile- to see if that is a modifiable RF
Modifiable RF- HTN, diabetes, smoking, atherosclerosis, A-fib, heart disease, sleep apnea, obesity, lack of
physical exercise, poor diet, drug, and alcohol use
Non modifiable RF- increasing age, women are more likely to die, more common in blacks/Hispanics
complications:

aspiration pneumonia- importance of speech therapy and bedside swallow study

impaired mobility- PT/OT

altered mental status

impaired communication
bed side swallow screen- done prior to anything by mouth

if pt fails = nothing by mouth including medicines
o speech therapy should be considered if impaired

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if pt’s s/s have resolved since original screening = may be repeated
golden hour- all eligible pts receive TPA w/in 1hr of arrival to hospital

time goals:
o door to eval/team activation – 15mins
o door to CT – 25mins
o door to EKG, labs, and chest Xray – 45mins
o door to CT results – 45mins
o door to TPA – 60mins
Transient Ischemic Attack – “mini stroke”, usually resolve w/in 1hr but may have effects that last for up to
24hrs

May cause any of the symptoms of an ischemic stroke and may be severe or mild

Puts people at risk for more TIAs and strokes in the future
Ischemic Stroke – occurs when a blood clot blocks an artery, cutting off the flow of oxygen-rich blood to part
of the brain

Embolic- fewer warning signs, usually severe and sudden
o Non-cardiac- pulmonary embolism and DVT
o Cardiac- A-fib and patent foramen ovale

Thrombotic- occlusion in the cerebral blood supply, more common, about 60%, occurs in association
w/plaques and the narrowing of arteries

Trmtso TPA (tissue plasminogen activator)- drug of choice to bust clots and restore blood flow to
damaged area

CI- systolic below 185, diastolic below 100, no recent surgeries/traumatic brain
injuries/hemorrhagic strokes, INR greater than 2
o Retrieval devices- large artery, surgery that takes out the clot, may be used up to 6hrs after
symptom onset
o Carotid endarterectomy- surgery where they pull away some of the plaques to dilate the
carotids

Some pts have bilateral involvement (do one side at a time) and might have strokes
during the procedure
Hemorrhagic Stroke – more prone to cause increased ICP

Trmts:
o Craniotomy- go in and take a piece of skull out to evacuate the hematoma and let the brain
swell
12
o Coiling and clipping

sub-arachnoid hemorrhage- most often caused by rupture of a cerebral aneurysm, arteriovenous
malformation, neoplasm (outside the brain tissue)
o CM:


Headaches- pt experiences sudden onset of a severe HA

Prodromal (warning) HA from minor blood leakage

n/v

symptoms of meningeal irritation- neck stiffness, low back pain, bilateral leg pain

photophobia and visual changes

loss of consciousness- about ½ of pts experience this at the time of bleeding onset
intracranial hemorrhage- caused by the rupture of a vessel in the brain tissue
o more likely to present w/manifestations of increased ICP
o onset of symptoms is usually during daytime activity w/progressive dvmt of the CM:

alteration of the LOC

n/v

HA

Seizures

Focal neurological deficits

History of HTN, trauma, illicit drug abuse
o Causes:
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
HTN

Arteriovenous malformation

Aneurismal rupture

Intracranial neoplasm coagulopathy

Hemorrhagic transformation of an ischemic infarct

Cerebral venous thrombosis

Sympathomimetic drug abuse

Sickle cell disease

Eclampsia or postpartum vasculopathy

Infection

Trauma
Male Reproductive Diseases
Hypospadias – literally “below the fleshy spike”, a condition in which the external urinary meatus (opening)
opens anywhere below the tip of the penis rather than at the tip
Hydrocele – a fluid filled sac partially surrounding the testis

CM: swelling on the side of the scrotum, may cause discomfort

Trmt: can be surgically corrected
Varicocele – dilated and twisted veins of the testis, sort of “hemorrhoids” of the scrotum

CM: swelling on the side of the scrotum which may look and feel like a “bag of worms”
o Can also cause reduced sperm count and male sterility d/t sluggish blood flow elevating
testicular temp

Trmt: may be surgically corrected if causing discomfort
Cryptorchidism – literally “hidden testicle” or undescended testicle

A condition of lack of descent of one or both testes into scrotum

Trmt: surgery
o If not correct can lead to sterility and ↑ risk of testicular cancer
Assessment of prostate –

Asymptomatic or may have BPH s/s = urinary frequency, dysuria, incontinence, nocturia, ↓ urine stream
or dribbling at end of urination

Current recommendations = annual DRE (digital rectal exam), PSA starting at age 50
o Abnormal prostate feels hard, nodular, and asymmetric
BPH (benign prostatic hypertrophy) – swelling of the prostate gland which surrounds the base of the male
bladder and urethra

CM: difficulty urinating, dribbling, nocturia
o Diminished size and force of urinary stream – early sign
o Feelings of incomplete bladder emptying

14
RF: occurs in 50% of men >age 50, occurs in 90% of men by age 80, family hx, obesity esp. ↑ waist,
circumference, ETOH, smoking, diabetes

Complications:
o Acute urinary retention w/pain
o Residual urine which ↑ risk of UTI
o Bladder caliculi r/t alkaline pH of urine
o Pyelonephritis and renal failure r/t hydronephrosis

Trmt:
o Noninvasive- meds to help reduce size (Avodart, Flomax)
o Minimally invasive surgeries
Transurethral microwave technology (TUMT)

Transurethral needle ablation (TUNA) – heat through needle

Laser prostatectomy – removal w/laser

Intraprostatic urethral stents – “opens up” urethra
o Invasive surgeries – TURP and prostatectomy (major sx)


Transurethral resection of the prostate (TURP): the surgical cure of BPH, an instrument
inserted through the penile urethra is used to partially cut away the prostate to relive
obstruction of the urinary tract
Post op care and NI:
o Pt will have catheter w/continuous bladder irrigation – need to mntn catheter patency
o Pain control
o Adequate bladder irrigation for 24hrs
o Accurate I/Os
o Discuss sexual concerns- erectile dysfunction, may take >1yr to be as active as preop
o Encourage perineal exercise to ↑ sphincter tone
o Meds- stool softeners, antibiotics
PSA (prostate specific antigen) = a marker specific protein for prostate cell secretions which can be detected
in a simple blood sample, a rising PSA may be an early sign of prostate cancer – although there may be other
causes including false + tests
Prostate Cancer - #1 cancer among men, #2 cancer killer in men behind lung cancer

Prognosis: varies widely and depends on many factors like age, health of the client, stage of the cancer at
diagnosis, cancer responsiveness to trmt

CM: asymptomatic mostly which is why the PSA test is so important along w/yearly DRE and a prostate
risk calculator, symptoms are more likely if cancer is advanced like…
15
o Difficulty w/an erection
o Straining to pass urine
o Leaking/bloody urine
o Bone pain that radiates down the hips/legs may indicate metastasis

Trmt: watchful waiting
o Surgery to remove prostate
o Radiation/cyro/hormonal/chemo/immune/other targeted therapies
o Research techniques include high-intensity focused US (HIFU)
o Meds- bisphosphonates, denosumab, radiopharmaceuticals (radioactive substances used as
drugs)
Priapism – a persistent, often painful, erection lasting more than 4hrs, not associated w/sexual activity

Trmt: medical ER bc a prolonged erection can scar the penis and result in a long-term complication of
erectile dysfunction if not treated
o Goal of trmt is to relieve the erection and preserve normal penile function
o In most cases, draining the blood using a needle placed in the side of the penis

Causes:
o Alcohol or drug abuse (esp. cocaine)
o Certain meds, including some antidepressants and BP meds
o Spinal cord problems
o Injury to the genitals
o Anesthesia
o Penile injection therapy (also a trmt for erectile dysfunction)
o Blood diseases including leukemia and sickle cell anemia
Erectile Dysfunction – the inability to achieve/sustain an erection suitable for sexual intercourse

Problems getting/keeping an erection can be a sign of a health condition that needs trmt, such as heart
disease or poorly controlled diabetes

Treating an underlying problem may be enough to reverse erectile dysfunction

Causes:
o Meds
o Chronic illnesses
o Poor blood flow to the penis
16
o Drinking too much ETOH
o Prostate problems

Complications:
o Unsatisfactory sex life
o Stress/anxiety
o Embarrassment or low self-esteem
o Marital/relationship problems
o Infertility

Trmt: oral meds are successful ED trmt for many men they include
o Sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra, Staxyn)
o CI- hx of cardiac disease, CVA, taking nitrates or anticoagulants, HTN, uncontrolled diabetes,
hypotension
Peyronie’s Disease – a condition in which a plaque, or hard lump, forms on the penis

CM:
o General pain
o Painful erections
o Penis will have a significant bend

Etiology: exact cause is unknown, in most cases it develops quickly, lasts a short time, and goes away w/o
trmt (In some cases, it develops slowly and is severe enough to require surgical trmt)

Trmt: none, wait and watch…
o Most HCPs suggest waiting 1-2yrs or longer before attempting to correct it w/sx
o Penile implants can be used in cases where it has affected the man’s ability to achieve or mntn
an erection
Phimosis – a condition in which the foreskin of the penis is so tight that it cannot be pulled back/retracted to
reveal the head of the penis (children and adults)

Etiology: seen most often children and may be present at birth, can also be caused by an infection or by
scar tissue that formed because of injury or chronic inflammation
o Another cause is balanitis (infection of the head of the penis) which leads to scarring and
tightness of the foreskin
o Sometimes nursing staff can be the cause of the problem w/o proper foley cath care and mntn

17
Trmt: circumcision is often used to treat it
o Preputioplasty involves separating the foreskin from the glans which preserves the foreskin and
is less traumatic than circumcision

Complications: immediate medical attn is necessary if the condition makes urination difficult/impossible
Penile Cancer – rare form of cancer that occurs when abnormal cells in the penis divide and grow
uncontrolled, certain benign tumors may progress and become cancer

CM:
o Growths and sores on the penis
o Abnormal discharge beneath the foreskin
o Bleeding

Trmt: sx to remove the cancer is the most common trmt for penile cancer, doctor may take out the cancer
using one of the following operations…
o Wide local excision takes out only the cancer and some normal tissue on either side
o Electrodessication and curettage, cryosurgery, microsurgery, laser surgery, circumcision, or
penectomy (amputation of the penis)
o Trmt w/radiation and chemotherapy
Testicular Cancer – a very rare disease that most commonly occurs in younger men ages 15-39, may affect
men at any age, accounts for 1% of all cancers in men, very treatable especially if it is detected in its early
stages

CM:
o Hard lumps or nodules on either testicle
o Change in how the testicle looks or feels
o Swelling in the scrotum sometimes caused by a sudden buildup of fluid
o Dull ache in the lower abd or scrotum
o Pain/discomfort/feeling of heaviness in the scrotum
o Enlarged/swollen breasts caused by the secretion of hormones that stimulate breast growth by
the testicular tumor

Diagnostics:
o Lab testing
o Imaging
o Biopsy of the testicular mass or nodule

Trmt: can cause infertility (sperm banking should be considered prior to trmt)
o Surgery
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o Radiation
o Chemotherapy
o Pt education for routine follow-up physical exams after trmt are very important
Vasectomy: procedure in which the 2 tubes that carry sperm from the 2 testicles to the urinary tract are
surgically altered so sperm cannot pass through and be released to fertilize a woman’s egg during sexual
intercourse

Safest and easiest form of surgical sterilization and Performed under local anesthesia

Post op:
o Apply ice pack wrapped in towel to scrotum for the first 24hrs (do not place directly on skin)
o Avoid walking/standing as much as possible for 1-2days
o Wear snug cotton briefs or an athletic supporter to help apply pressure against the procedure
area and for support of the scrotum for the first 1-2wks
o Avoid heavy lifting or exercise for at least 2-3days
o Wait at least 1wk before resuming sexual activity and use other birth control methods
o Semen testing will be collected 6-12wks after to make sure that no sperm remain
Renal and Urologic Disease
renal disease causes: glomerular injury, tubulointerstitial injury, hereditary disease, autoimmune disease,
systemic disease, malformations, obstructions
kidney functions: filter blood, mntn electrolyte balance, mntn acid/base balance, synthesize vitamin d,
stimulates RBC pdtn, regulates BP, excrete waste products
diagnostics: renal biopsy is definitive diagnosis

Urinalysis (24hr urine)

CBC- H/H specifically

BMP/CMP- electrolytes and BUN/creatinine
o Creatinine = muscle breakdown byproduct, can be caused by other things besides kidney injury
but in normal person it tells us how well the kidneys are functioning (more muscle mass 
more creatinine)

GFR

Renal US- detects masses, defects, cysts
19
nephron – functional unit of the kidney

Glomerulus: filters the blood

Tubules: absorb/secrete electrolytes, amino acids, water, urea based on the bodies need
Glomerulonephritis – group of diseases that affect both kidneys equally causing inflammation of the
glomerulus and small blood vessels

Third leading cause of renal failure

Main complication is nephrotic syndrome

CM: asymptomatic
o Proteinuria
o Hematuria
o HTN
o Azotemia (↑ BUN/creatinine)
o Edema
o Oliguria/anuria

Acute poststreptococcal nephritis (ASPGN) – most common cause, 5-21days after an infection of the
tonsils, pharynx, or skin
o Not a group a strep infection of the kidneys, but instead is a result of the body’s immune
system fighting off the group A strep throat/skin infection
o CM: has a 1-2 wk incubation period btw strep and glomerular infection

Dark, reddish-brown urine

Edema especially around the face/eyes and in the hands/feet

↓ need to pee or ↓ amnt of urine

Feeling tired d/t low iron levels in the blood (anemia)
o Diagnostics:

Throat culture

Skin culture

Kidney biopsy
o Medical mgmt.: usually self-limiting after 4wks

Manage symtpoms- edema, HTN

Treat any active strep infection identified
o NI: symptomatic relief of symptoms

20
Low sodium diet


HTN control and monitoring

Teach early trmt of throat and skin infections

Good personal hygiene to pvtn the spread

Meds- diuretics for edema
Lupus nephritis – secondary cause, inflammation and scarring of small vessels of the kidney
o CM: may manifest as nephrotic syndrome

Edema

HTN

Proteinuria

Hematuria
o Complications: may cause complete renal failure
o Trmt: Transplant is possible after dialysis for 3mo disease w/reoccurrence of disease in 5-30%
(most that have ESRD have resolution of lupus extrarenal symptoms)

Benign prostate hypertrophy (BPH) – obstruction, swelling of prostate that obstructs urine flow causing
hydronephrosis
o Trmt:


Catheter placement

TURP surgery
Nephrolithiasis – obstruction, kidney stones
o More common in men than women, 20-55yrs, higher in persons w/FHX, reoccurrence common
50%, more common in summer
o Complications: can cause obstruction (hydronephrosis)

Sepsis- lethal if obstruction w/kidney infection

Abscess formation

Ureteral scarring and stenosis

Ureteral perforation

Chronic kidney disease
o CM:
21

Back/flank/abd pain

Guarding

Fever

Dehydration

n/v
o diagnostics: CT abd/pelvis w/o contrast

↑ BUN/creatinine

UA – RBCs, WBCs, pyuria, crystals, casts, minerals, bacteria

24hr urine - ↑ uric acid, calcium, phosphorus oxalate or cystine levels
o Medical mgmt.: confirm size w/imaging greater than 5mm

Pain control

Treat any infection

Kidney function assessment

Cystoscopy w/stent placement

Nephrostomy tube

Lithotripsy – use sonic waves to bust up kidney stones

Meds- tamsulosin (Flomax) which dilates the ureters
o NI: pain mgmt.

Teaching

Adequate fluid intake

Dietary restrictions

Low purine (meats and fish) or low oxalate (dark greens, tomatoes, beets) or low
calcium

Urine strainer

Ambulation

Lithotripsy- hematuria, urethral stent (remove about 2wks)

Vesicourethral Reflux – malformation, congenital defect in ureters where every time the bladder
contracts to release urine, the urine shoots back up the ureters into the kidneys

Renal Fusion – “horseshoe kidney”, malformation, makes one conjoined kidney and contain 2 excretory
system and 2 ureters
o Both malformations are prone to more UTIs, scarring, chronic kidney disease, proteinuria
Pyelonephritis – kidney infection of the renal parenchyma and collecting system including the penal pelvis

Usually starts from infection of the lower urinary tract

Bacteria commonly found- E coli, proteus, enterobacteria

Pre-existing problems: vesicourethral reflux, BPH, stone, stricture

Main complication is chronic kidney disease
22

CM:
o Chills
o Fever
o Vomiting
o Malaise
o flank pain
o Lower UTI symptoms- dysuria, urgency, frequency
o Costovertebral angle tenderness
o Chronic pyelonephritis- fatigue, HA, polyuria, weight loss, anorexia, polydipsia

Diagnostics:
o UA- pyuria, bacteriuria, hematuria, WBC, casts
o CBC- leukocytosis
o Urine and blood culture (before antibiotics)
o Imaging studies


IVP or CT w/contrast are avoided to stop the spread of the infection

US- abnormalities, hydronephrosis, renal abscess/stone
Medical mgmt.:
o Fluids
o F/u culture and imaging
o Severe or complicates cases maybe hospitalized
o Meds-


Broad spectrum antibiotics when culture returns switch to sensitivity guided meds

Antipyretics

Fluoroquinolones (cipro, Levaquin)
NI:
o Drink 8 glasses of water daily
o Rest
o Teaching-
23

Take all antibiotic prescription

Follow up urine culture after antibiotic

Recognize symptoms/relapse
Tubulointerstitial Injury – injury or infection of the tubules are where all the homeostasis takes place like
mgmt. of electrolytes, reabsorption of water/sodium (impacts K/Na/Ca/Cl)

CM: asymptomatic
o Polyuria
o Nocturia
o Proteinuria
o Electrolyte imbalance

Acute tubular necrosis – damage to the tubule cells can be drug induced, sepsis, hypotension (ischemia),
rhabdomyolysis, seizures
o CM:

↓ consciousness, coma, delirium/confusion, drowsiness, lethargy

↓ urine output or no urine output

General swelling and fluid retention

n/v
o diagnostics: history

↑ FENa (>2%)
o Trmt: 80% will recover if initial insult can be reversed


Mntn of euvolemia w/diuretics, IVF

Avoidance of hypotension and nephrotoxic meds (NSAIDs and ACE-I)

Dialysis

Goal is to pvtn of acute kidney failure
Acute tubular nephritis – tubular damage leads to renal tubular dysfunction, w/wo renal failure
o Regardless of the severity of the damage to the tubular epithelium, the renal dysfunction is
generally reversible- possibly reflecting the regenerative capacity of the tubules w/preserved
basement membrane
o 95% of cases are caused by infection or an allergic drug reaction
o CM: polyuria and nocturia (d/t a defect in urinary concentration and Na reabsorption)
o Medical mgmt.:

Meds- antibiotics if caused by infection and steroids for allergic reaction
Chronic Kidney Disease – result of permanent kidney damage defined as GFR <60 for greater than 3mo

Causes: long term med use, DM, HTN, autoimmune disease, recurrent UTIs, malformations

Depression is frequent and disabling
24

Overall medical mgmt.:
o Frequent follow ups checking F/E levels and med changes

Potassium- less than 5.5, teach low potassium foods, role of Kayexalate

Phosphorus- keep below 4.5, binders (renvela, renagel, PhosLO) used when too high,
low phosphorus foods

Albumin- 4.0 or above, low protein intake for CKD and ESRD
o Manage systemic effects of CKD-


Secondary parathyroid

Anemia

Uricemia

Metabolic acidosis
NI: pvtn is best intervention!
o Catch them early before CKD develops
o BP below 130/80
o Keep BS levels under control
o Dietary restrictions
o Monitor F/E imbalances

Complications of kidney disease:
o Nephrotic syndrome –



25
CM:

Massive proteinuria- greater than 3gm (PCR) or 300mg (MCR)

Edema

Serum hypoalbuminemia

Hypercoagulability- blood clots can form in renal vein
Primary causes:

Glomerulus disease

Paraproteinemia (multiple myeloma)
Secondary causes:

DM

Lupus erythematosus

Viral infections

Amyloidosis


Preeclampsia
NI: control primary disease

Mgmt. of edema

Dietary education

Lipid trmt

Blood thinners

Avoiding infections

Support for altered body image
o Kidney Cancer –

CM: usually asymptomatic



Later manifestations- hematuria, flank pain and palpable mass in flank/ abd,
weight loss, fever, HTN, anemia
Diagnostics:

MRI

CT scan

Biopsy

US
Medical mgmt.: partial or radical nephrectomy
o End stage renal disease – CKD stage 5

GFR is less than 15

Assess placement referrals

Replacement therapy options

Hemodialysis

Peritoneal dialysis

Kidney transplant

Pt always has the option to do nothing

Dialysis is started based on pt symptoms


Uremia symptoms- tremor anorexia, n/v, severe body aches
Polycystic Kidney Disease (PKD) – hereditary kidney disease, 10-15% of chronic kidney disease, most
common life-threatening genetic disease in the world, adult form is an autosomal dominant disorder,
occurs in men and women
o Involves both kidneys (can also include liver, heart, intestines)
26
o Loss of kidney function to the point of end-stage renal disease occurs by age 60 in 50% of pts
o CM:

HTN

Hematuria- from rupture of cysts

Feeling of heaviness in the back, side, abd

UTI and/or urinary caliculi

Chronic pain

Physical exam, palpable bilateral enlarged kidneys are often found
o Diagnostics:

CM

FHX

US- best screening measure

CT scan
o Medical mgmt.:


Pvtn infections of the urinary tract

Nephrectomy may be necessary if pain, bleeding, or infection

Kidney transplants remain only cure

Diet modification depending on labs

Fluid restriction

Meds like antihypertensives
Sickle Cell Nephropathy – hereditary kidney disease, caused by glomerular hypertrophy,
glomerulosclerosis, ingestion of analgesics that can independently induce interstitial nephropathy
o
Complication is nephrotic syndrome
o CM:

Proteinuria

Hematuria

HTN

Renal tubular acidosis

Renal failure
o NI: Monitor kidney functions
27

Pain mgmt.

Hydration
Renal replacement therapies –

Hemodialysis access
o Arteriovenous fistula: a permanent access that is created surgically by connecting an artery to a
vein, forearm
o Arteriovenous graft: a permanent access created surgically by using a synthetic material
tunneled under the skin

Shorter maturation time than fistula, site can be used in 3-6wks
o NI: protect the access, no BPs or needle sticks in that arm, no tourniquets

Remember it is pts lifeline

Try to limit the number of needle sticks in the upper extremities of people w/CKD

Catheters- a temporary access in which a catheter is placed into a large central vein such as the internal
jugular vein or subclavian vein

Fluid gains- pt teaching
o ESRD w/no residual urine output- approx. 1L daily is retained
o More weight that is gained hard it is to pull the fluid off safely in dialysis
o If BS is high- you cannot control fluid intake
o Decrease sodium intake
o Methods to decrease thirst

Peritoneal dialysis- dialysis fluid (dialysate) is infused into the abd cavity through a catheter
o Pt teaching: infection is a serious problem

Follow standard precautions

Wash your hands often and always btwn pts

Keep yourself well-groomed and clean
Urethritis – difficult to diagnose in women

Causes:
o Bacterial or vaginal infection
o Trichomonas
o Monilial infection (yeast)
o Chlamydial infection
o Gonorrhea

CM:
o Dysuria
28
o Reluctance to void
o Vulvar irritation and erythema
o Perineal pain
o Asymptomatic

Medical mgmt.: depends on what it is and what meds to give
o Bacterial- trimethoprim/sulfamethoxazole or nitrofurantoin
o Trichomonas- metronidazole (flagyl), clotrimazole (Mycelex)
o Monilial- nystatin (mycostatin), fluconazole (Diflucan)
o Chlamydial- azithromycin or doxycycline
Cystitis – E coli (80-86%) is main infective agent

CM:
o Dysuria
o Urinary frequency
o Hematuria
o Urinary urgency
o Suprapubic pain

Medial mgmt.: Based on pathogen
o Meds
Nitrofurantoin

Fluoroquinolones

Trimethoprim/sulfamethoxazole
Urinary incontinence – higher in women (50% older women)

Not natural consequences of aging

Complications:
o Confusion/depression
o Infection, atrophic vaginitis, urinary retention, restricted mobility, fecal impaction, or drugs

29
NI: lifestyle modification (weight, smoking, caffeine, bowel regime), pelvic floor exercises, antiincontinence devices (pessaries, penile compression device), containment devices (external catheters,
undergarments, pads)
Gastrointestinal
Peptic ulcer disease – erosion of the GI mucosa from hypersecretion of HCl acid and pepsin

Causes: H Pylori is #1 cause, NSAIDs, aspirin, smoking, ETOH, genetic
o Encourages ulcer formation and inhibits the secretion of prostaglandins

Types: gastric (near pylorus), duodenal, esophageal, stress
o Stress ulcers can occur from hospitalization – a PPI may be prescribed to pvtn

CM: n/v/c/d
o Pyrosis
o “Sour burping” on empty stomach
o weight loss
o Burning, dull pain in epigastric region
o Gastric- pain immediately after meals
o Duodenal- pain 2-3hrs after meals

Complications:
o Hemorrhage- GI bleed, most common complication

Slow bleed that is passing through normal digestive passages will be black and tarry

Acute bleed will be bright red

NI: monitor their hemodynamic state, VS for hypotension/tachycardia, H/H, stool for
occult blood, endoscopic studies to locate bleeding, CBC to show anemia from ulcer,
mntn patency in NG tube
o Perforation- ulcer goes completely through the stomach, most lethal

Small one can heal on its own, but more complicated one may lead to s/s of peritonitis
(BS absent, rigid abd muscles)


If left untreated, bacterial peritonitis can occur in 6-12hrs
NI: monitor for shock, VS q15mins, put in NGT to suction contents, IVF, prep for
laparoscopic/open sx, broad spectrum antibiotics, pain meds
o Gastric outlet obstruction- caused by inflammation r/t the ulcer, blocks where the duodenum
and stomach meet, builds up scar tissue and impedes the flow of contents out of the stomach
into the duodenum

30
Diagnostics:

pain is worse after eating and relieved w/burping or vomiting

NI: decompress the stomach w/NGT, PPI, or sx if others were unsuccessful
o Endoscopy- most accurate tool to determine the presence and location of ulcer

Include biopsy to determine if H Pylori is present
o Stool and breath testing
o Serum antibodies to H Pylori
o CBC and occult blood

meds
o Aspirin and NSAIDs stopped for 4-6wks, when taken again they are given w/PPIs or H2 blockers
o Antibiotics
Gastroesophageal reflux disease (GERD) – mucosal damage d/t reflux of stomach acid into lower esophagus

RF: age, obesity, pregnancy, hiatal hernias, smoker, DM
o Commonly seen in pts w/IBS, COPD, Barret’s esophagus, PUD, angina

CM:
o Heartburn
o Dyspepsia
o Acid regurgitations
o Dysphagia
o Respiratory symptoms- wheezing, coughing, SOB
o Sore throat
o Difficulty sleeping

Complications:
o Esophagitis- inflammation of esophagus d/t contact w/HCl acid, leads to scar tissue (esophageal
stricture), can cause narrowing of the esophagus
o Barret’s esophagus- cells adapt and change to protect themselves, becoming precancerous

↑ risk of esophageal cancer
o Dental erosion
o Ulcers of pharynx and esophagus
o Laryngeal damage- chronic bronchitis or aspiration pneumonia

Diagnostics: usually diagnosed based on symptoms
o EGD- endoscopic procedure
o Barium swallow- see regurgitation
o pH monitor- seeing if pH in esophagus turns acidic
31

nutritional therapy:
o ↓ LES pressure- avoid chocolate, mints, tomatoes, high fat foods, caffeine
o No milk- ↑ gastric secretions
o Small frequent meals ↓ pressure on esophagus
o Chew gum and suck on lozenges
o Do not eat 2hrs before bed

Lifestyle changes:
o Avoid triggers
o Weight loss
o Don’t lay supine 2-3hrs after meals (elevate HOB 30 deg)
o Stop smoking and drinking
o Stress mgmt.

Meds:
o PPIs (prazoles)- stop gastric acid secretions

Take before first meal, ↑ risk for pneumonia, CDAD, CKD, bone fractures
o H2 blockers (tidines)- stop gastric acid secretion
o Sucralfate (Carafate)- protecting agent that will protect the stomach if there are ulcerations

Give antacids at least 2hrs after
o Cholinergic (bethanechol)- speed up gastric emptying
o Prokinetics (Reglan)- speed up gastric emptying
o Antacids (tums)- for heartburn


Take 1-3hrs before meals and 2hrs before/after other meds
Surgical trmts:
o Nissen fundoplication- take fundus and wrap around lower part of esophagus to
reinforce/repair the defective barrier
Peritonitis – inflammation of the peritoneum because of bacterial infection from the GI tract or internal
reproductive organs (in women)

Causes: injury, inflammation, bacteria

Primary- blood borne organisms enter the peritoneal cavity
o Cirrhosis w/ascites
o Genital organisms
32

Secondary- abd organs perforate/rupture and release their contents
o Appendicitis or diverticulitis rupture
o Blunt trauma, stab/gunshot wound

CM: at first there is diffuse pain which tends to become constant localized and more intense over the site
of the pathologic process
o Increased temp
o Tachycardia
o Mvmt exaggerates pain
o Tender and distended w/rigid abd
o May have rebound tenderness
o Hypoactive to absent BS
o n/v
o hypotension

diagnostics:
o xray- air, fluid, distended bowel loops
o abd US
o CT scan- show inflammation and what caused it
o Peritoneal aspiration and culture
o MRI
o CBC and F/E- ↑ WBCs, abnormal Cl/K, ↓ H/H

Complications:
o Acute respiratory distress
o Hypovolemic shock
o Sepsis
o Infection

Mgmt.:
o IVF (isotonic)
o Pain and antiemetic meds
o Broad spectrum antibiotics
o NGT- low intermittent wall suctioning
o Remove/repair the problem

33
Pvtn: hand hygiene, stop drinking/smoking, proper exercise
Inflammatory bowel disease – chronic inflammation of the GI tract characterized by periods of remission and
exacerbation; no cure d/t autoimmune

Usually occurs during adolescence and adulthood usually during the 60s

Diagnostics:
o Barium enema
o CT
o MRI
o Colonoscopy
o CBC - ↓ H/H from GI bleeds, ↑ WBC, ↓ electrolytes (NA, K, Cl, Mg, bicarb), hypoalbuminemia
r/t malnutrition, ↑ sed rate and c reaction protein from inflammation

Complications of both:
o Hemorrhage
o C diff
o F/E imbalances
o Malnutrition
o Risk for osteoporosis

Trmt: intestinal transplant
o NPO to let bowel rest
o Good perineal care d/t ↑ BMs
o Pvtn/treat infection
o Pvtn/correct malnutrition
o Pain control
o Psychosocial support
o Reduce stress
o Meds- control the inflammation w/steroids (need Ca and vitamin d supplements)


Antidiarrheals and antiperistalsis

Aminosalicylates

Antibiotics

Immunosuppressants
Crohn’s disease – inflammation of the entire GI tract (common in distal ileum)
o “cobblestone” patches of ulcers separated by skip lesions of healthy tissue
o CM: insidious onset
34

Cramp-like RLQ pain

Diarrhea

Tenderness

Weight loss, anemia, malnutrition

Rectal bleeding

Steatorrhea
o Complications:


Fistulas/abscesses/fissures can form

Bowel walls thicken and become fibrotic, causing intestinal narrowing or strictures

More at risk for obstruction

Diseased bowel can attach to other sections of bowel

↑ risk of colorectal cancer
Ulcerative colitis – occurs in the colon and rectum with diffuse inflammation and ulcerations (continuous
lesions)
o Bowel narrowing, shortening, and thickening r/t hypertrophy and fat deposits
o Total proctocolectomy is curative
o CM:

Abd cramp-like LLQ pain

Blood, mucus, pus in diarrhea (6+ stools daily)

Weight loss

Anemia

Fatigue

Dehydration

Fever

n/v

anemia
o complications:
35

perforation

toxic megacolon- occurs when swelling/inflammation spread into the deeper layers of
colon, as a result the colon stops working and widens
colorectal cancer – arises polyps that can turn into adenocarcinomas

assessment and health promotion:
o assess bowel habits- constipation, diarrhea (leakage around obstruction)
o assess blood in stool- melena, hematochezia (closer to rectum)
o assess pain, n/v, anorexia, abd fullness
o promote screenings starting at age 45 and q10yrs after that
o psychosocial support
o preop and postop mgmt.- bowel prep, wound care, drain mgmt., diet/nutrition status

RF: male, older, FHX #1, obese, frequent red meat consumption, smoking, drinking, DM, chemical
exposure

Diagnostics: Colonoscopy is gold standard
o Entire colon is visualized
o Biopsies obtained
o Removed masses if needed

CM: no s/s until later stages
o Change in bowel habits
o Weight loss
o Fatigue
o Late stages- abd tenderness, palpable mass, hepatomegaly, ascites

Complications: colostomy, obstruction, bleeding, perforation, peritonitis, fistula

Trmt:
o Right/left hemicolectomy- may get temp colostomy
o Abd-perineal resection- permanent colostomy
o Chemotherapy- in addition to sx in high-risk stages 2-3 or preop w/radiation to shrink tumor
o Palliative care in stage 4
Hepatitis – inflammation of the liver d/t viruses

Virus  hepatocyte destruction  liver dysfunction  fibrosis

RF: chronic alcohol users, hepatically metabolized meds, ingested chemicals, metabolic disorders

Types:
o A – fecal oral, self-limiting, vaccine available
o B – blood and body fluids, baby, vaccine available
36
o C – blood and body fluids, usually chronic

CM:
o Spleen and hepatomegaly on palpation
o Jaundice
o Itching from bile salts under the skin
o Clay stools
o Dark urine
o Flu-like symptoms in acute phase
o HA – do not give Tylenol

Diagnostics:
o Liver biopsy
o Antibody/antigen testing

NI:
o Monitor the ↑ liver enzymes, bilirubin, PT times
o Look for ascites in chronic
o Bleeding protocols
o Encourage safe sex, vaccination, hand hygiene, no IV needle sharing, rest, fluid intake, small
frequent meals, regular F/U, avoid ETOH

Trmt:
o Acute – rest, diet w/adequate calorie consumption, vitamin K for bleeding problems, avoid
ETOH
o Chronic –

nucleoside/nucleotides/interferons ↓ viral load to slow disease progression in hep B

pt specific direct-acting antivirals in hep c
pancreatitis – inflammation of the pancreas caused by autodigestion by pancreatic enzymes

RF: gallbladder disease (biliary sludge), chronic ETOH intake, smoking, postop viral infections, drugs,
hypertriglyceridemia

CM:
o Sudden severe abd pain (LUQ)
o n/v
o low grade temp
o abd guarding/distention
37
o jaundice
o ↓ or absent bowel sounds
o Shock
o ↑ amylase, lipase, WBCs, glucose (may need insulin), bilirubin
o ↓ Ca

complications:
o F/E imbalances
o Pancreatic necrosis
o Can turn into chronic pancreatitis

Trmts and NI:
o NPO to let pancreas rest – then advance to low fat/protein
o NGT to suction out secretions (on low)
o Bedrest bc mvmt stimulates peristalsis
o IV infusion of normal saline
o Health promotion- encourage early trmt, weight loss, stop drinking, reduce reoccurring attacks
o Lap chole, ECRP w/endoscopic sphinectomy, drainage of necrotic fluid or pseudocysts,
pancreatomy
o Meds
H2 blockers or PPIs

Antiemetics, antibiotics, pain meds
C. Diff – spread fecal oral route

Alcohol based products do not kill bacteria, the most effective pvtn is soap and water, disinfect w/10%
bleach solution

Contact precautions- gown, glove, mask before entering room

Diagnostics: stool culture

CM: dehydration common d/t loss of F/E (can cause renal injury or failure)
o n/v
o foul-smelling loos frequent stools
o abd upset
o fever
o tachycardia (late bradycardia indicates sepsis)
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o shock
o ↑ WBCs

meds: antibiotics (vancomycin or Flagel)
Cholecystitis – inflammation of the gallbladder

RF: multiple pregnancies, female, age, hormone replacement, OCPs (estrogen)

common cause is cholelithiasis – may have no pain, epigastric distress/fullness, abd distention, vague
RUQ pain, fever, biliary cholic, n/v, jaundice, stool/urine color changes, vitamin deficiency
o biliary cholic – contractions of the gallbladder r/t obstruction to the duct

CM:
o Pain, tenderness, rigidity in the RUQ (can radiate midsternal area or the shoulder)
o n/v
o ↑ WBCs and bilirubin if obstruction present

diagnostics:
o Xray
o US
o ERCP

Trmt:
o NGT
o Removal of stones (lap chole)
o Low fat high carb diet
o Meds- pain, antibiotics, antiemetics
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