FINAL
Perioperative:
● Informed consent○ active, shared decision making process between the HCP and recipient of care.
Three things must happen in order to get a valid consent
○ Adequate disclosure of : 1. Diagnosis, 2. Nature and purpose of proposed
treatment, 3. Risks and consequences of treatment, 4. Probability of success, 5.
Availability, benefits, and risks of alternative treatments, 6. Prognosis if treatment
doesn’t work.
○ Pt must have a clear understanding of information being provided before getting
sedative drugs.
○ Pt must consent voluntarily
○ ***If pt is a minor, unconcious, or mentally incompetent, a legally appointed
representative or responsible family member may give written permission
● Getting the patient ready for surgery
○ Legal Consent: informed consent in presence of witness, surgeon is ultimately
responsible, nurse is witness.
○ Day of Prep: pre op teaching, assessment, communication of pertinent findings,
preop orders complete, charting complete.
● Patient teaching
● Safety: sterile field, medical counts correct, give drugs, positions patient to ensure correct
alignment and marks correct surgical spot.
● Possible complications: malignant hyperthermia, DVT, pneumonia
○ Pneumonia: immobility
○ DVT: surgery and immobility
○ Malignant Hyperthermia
■ disorder characterized by hyperthermia with rigidity of skeletal muscles
which could result in death. Leads to muscular contracture, hyperthermia,
hypoxemia, lactic acidosis and alterations in circulation
and respiratory systems.
---Treat with Dantrium!!!!
● Types of anesthesia.
○ Epidural block: involves injection of a local anesthetic into the epidural space
via a throacic or lumbar approach. The anesthetic agent doesn’t enter the
cerebrospinal fluid but binds to nerve roots as they enter and exit the spinal cord.
○ General anesthesia: technique of choice for patients who are having surgical
procedures that are significant duration, require muscular relaxation, require
uncomfortable operative positions bc of the location of incision site, or require
control of ventilation.
○ Local anesthesia: interrupts the generation of nerve impulses by altering the flow
of sodium into nerve cells. Local anesthetics are topical, ophthalmic, nebulized, or
injectible.
○ Regional anesthesia: (block) using a local anesthetic is always injective. It
involves a central nerve (spinal) or group of nerves (plexus) that innervate a site
remote to the point of injection.
○ Spinal anesthesia: involves injection of a local anesthetic into cerebrospinal fluid
in the subarachnoid space, usually below L2.
Cardiovascular:
● Cardiac enzymes lab test
○ Cardiac Specific troponin: heart muscle protein that is released into circulation
after injury or infarction, these subtypes are specific to heart muscle and are
detectable within hours of MI or injury. (Detectable within 4-6 hours, peak at 1024 hours)
■ Troponin (cTnT): biomarker of choice in diagnosis of ACS
■ Cardiac Specific Troponin I (cTnI):
○ Creatinine Kinase (CK-MB): Heart specific enzyme that peaks 4-6 hours after an
MI
○ Myoglobin: successful indicator of early MI but lacks specificity
● Cardiac procedures (heart cath):
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● CHF: inability of the heart to provide sufficient blood to meet O2 needs of tissues
and organs
● BNP: the marker of choice from distinguishing dyspnea from cardiac or respiratory origin
● Typical assessment findings: Acute decompensated HF, fatigue, dyspnea, paroxysmal
nocturnal dyspnea, tachycardia, edema, nocturia, skin changes, behavioral changes, chest
pain, weight change
● Primary Risk Factors: HTN, CAD
● How to manage dyspnea: place in high fowler's position, provide O2,
● Differences between Right-sided and Left-sided.
○ Right Sided: THINK POOLED EDEMA
■ Results from failing RV, leading to backed up fluid in the extremities.
■ Usually happens secondary to Left sided failure
■ S&S: Fatigue, increased peripheral venous pressure, ascites, enlarged liver
and spleen, JVD, anorexia, EDEMA
○ Left Sided: THINK FLUID IN LUNGS
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■ Results from inability of LV to empty during systole or fill during diastole,
most common form of HF
■ S&S: cyanotic, pink sputum, fluid in lungs, fatigue
● Coughing, wheezing, crackles
Medication used to treat, how they work to help CHF and assessment data needed to
administer
○ Diuretics: pee off excess fluids
○ Vasodilators: reduces preload and afterload, allows heart to work better
Nursing Care of CHF patient
○ Treat underlying cause, daily weights, sodium/fluid restrictions,
Dietary needs/restrictions
HTN: high blood pressure (>140/90)
Risk factor:
○ increased age, alcohol, tobacco, DM, elevated serum lipids, excess sodium, male,
genetics, obesity, ethnicity, sedentary lifestyle, socioeconomic status, stress
Medication types, how to safely administer
○ Diuretics:
■ Thiazides: may potentiate cardiotoxicity of digoxin by producing
hypokalemia. Supplement with potassium rich foods.
■ Loop: Monitor for hypotension and electrolyte abnormalities
■ Potassium Sparing: contraindicated in patients with renal failure, Use with
caution in patients on ACE inhibitors or ang II receptor blockers
■ Aldosterone Receptor Blockers: Use with caution in patients on ACE
inhibitors or ang II receptor blockers.
○ Adrenergic Inhibitors:
■ Central Acting Adrenergic agonist: Sudden discontinuation may cause
withdrawal, Dry mouth
■ Peripheral acting adrenergic agonist: Contraindicated in patients with
history of depression
■ A1 adrenergic blocker
■ B-Blocker: Monitor BP and pulse regularly, use with caution with patients
with DM
Dietary restriction and teaching:
○ Weight reduction
○ DASH eating plan
○ Sodium Restriction
○ Moderation of alcohol/Avoid tobacco
○ Regular physical activity
○ Management of psychosocial risk factors
Complications resulting from HTN
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○ CAD, Left ventricular hypertrophy, heart failure, stroke, PVD, nephrosclerosis,
retinal damage
CAD: blood vessel disorder, atherosclerosis (fatty deposits in the vessels and harden
over time, causing occlusions and blockage)
Risk factors
○ Nonmodifiable
■ Increase in age
■ Gender: greatest risk in middle aged men, however more deathly for
women because they get it later on.
■ Ethnicity
■ Family history
■ Genetics
○ Modifiable
■ Increased serum lipid levels, homocysteine, increased salt
■ Hypertension
■ Tobacco
■ DM
■ Stress
■ Metabolic syndrome
Labs usually watched
○ CRP: C-reactive protein, marks inflammation in the body (atherosclerosis-causes
inflammation). Patients with elevated levels of CRP have an increased risk for
heart attack, stroke, sudden death, and vascular disease.
Statins: inhibit the synthesis of cholesterol in the liver, therefore the liver is able to
remove more LDLs from the blood. Statins also increase HDLs and lower CRP.
Collateral Circulation: new blood vessels are developed due to blockages, therefore even
if the occluded vessel gets very blocked, the heart will still be nourished from the new
vessels formed. This normally happens if the blockages happen slowly over time, that
way new vessels have time to grow.
Prevention
○ Changing modifiable risk factors, early detection and treatment
PVD: thickening of artery walls
Risk factors: tobacco, CKD, DM, HTN, high cholesterol
Compare difference between arterial vs. venous, what patients look like
○ Arterial: intermittent claudication or rest pain, thin/shiny/taut skin, thickened
nails, cool temp down leg, peripheral pulses decreased/absent, black eschar on
toes, ulcers on tips of toes or lateral malleolus, loss of hair, no edema, worsens
with activity, dangling feet helps relieve pain.
○ Venous: dull ache, or heaviness in leg, medial malleolus ulcers with drainage and
yellow/red slough, bronze pigmentation with varicose veins, warm temp, thick
skin with edema present, worsens with rest, elevating feet may relieve pain.
● Intermittent claudication: ischemic muscle pain is caused by exercise, resolves within 10
min or less with rest, and is reproducible. Ischemic pain is a result of buildup of lactic
acid from anaerobic metabolism.
● Nursing management
○ Change modifiable risk factors (tobacco cessation, physical exercise, healthy
body weight, DASH, DM controlled, lipids controlled, treat claudication,
nutrition, PT/OT, proper foot care.
● Treatment
○ Surgery, antiplatelet therapy, exercise, nutrition, leg/foot care
Respiratory:
● ABG’s: assesses the efficiency of gas transfer in the lung and tissue oxygenation, ABGs
are used to determine oxygenation status as well as acid-base balance. Blood can be
obtained from arterial puncture or arterial catheter
○ pH: 7.35-7.45
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○ Pa02: 65-100 (based on sea level)
○ PaC02: 35-45
○ SaO2: >95%
○ HC03-: 22-26
Asthma: heterogeneous disease characterized by a combination of clinical manifestations
along with reversible expiratory airflow limitation or hyperresponsive bronchi.
Meds -bronchodilators and steroids
○ Long term: inhaled/oral corticosteroids, leukotriene modifiers
(Montelukast/Singulair), Anti-IgE
○ Short term: Short Acting bronchodilator (Albuterol), inhaled anticholinergic
(Atrovent)
○ Bronchodilators: LABA, Methylxanthine
Symptoms: wheezing, cough, dyspnea, chest tightness, prolonged expiration.
Triggers: allergens, air pollutants, viral/bacterial infections, drugs, occupational exposure,
food additives, stress, exercise, GERD, hormones
Teaching:
○ Postmenopausal women taking corticosteroids should be on a calcium and vit D
supplement as well as do weight bearing exercise
○ Rinse mouth after corticosteroids to prevent bacterial infection
○ Pursed Lip breathing
COPD: preventable and treatable disease characterized by persistent airflow limitation
that is usually progressive. Chronic inflammation of the airways, lung parenchyma, and
pulmonary blood vessels
Differences between chronic bronchiolitis vs emphysema
○ Chronic Bronchitis: Blue Bloater
■ Presence of cough and sputum production for at least 3 months in each of
2 consecutive years
○ Emphysema: Pink Puffer
■ Destruction of alveoli
● What do these patients look like and present when in crisis
○ Chronic Bronchitis: productive cough, sputum, cyanotic, peripheral edema,
prolonged expiration, obese
○ Emphysema: barrel chest, pursed lip breathing, frail, accessory muscle use, quiet
chest
● CO2 acts a trigger for normal person trigger to breath, In COPD hypoxia triggers their
brain to breath
○ Because of this, you want to limit their O2 (give 2L max, intermittently)
● Major problems for these patients: nutrition, managing SOB, fatigue, etc.
○ when it's hard to breathe you don't think about eating as much, tire easily, and
stresses you out
● Chronic Bronchiolitis: chronic inflammation, increased mucous, what do they look like
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○ Cyanotic, obese, sputum, noisy chest sounds
Both have exacerbations, what triggers them and how is it treated?
○ Smoking, allergies, air pollution
○ Treatment: Bronchodilators (short and long acting), inhaled anticholinergics,
corticosteroids (short term)
Cor pulmonale occurs when the blood pressure in the pulmonary
artery—which carries blood from the heart to the lungs—increases and
leads to the enlargement and subsequent failure of the right side of
the heart
TB: infectious disease caused by mycobacterium involving the lungs (can include any
organ tho). Gram positive and airborne.
Testing: Skin test, blood test, chest xray
Symptoms: 2-3 weeks after infection, bad cough, chest pain, blood sputum from cough,
weakness/fatigue, weight loss, no appetite, chills, fever, night sweats
Screening
Medications (hard on liver)
○ Lengthy and lots of meds (2 month initial period, and then continuation period)
○ Hard on liver bc different types of microbial drugs all at once to kill the tubercle
and avoid resistance
Endocrine:
● Thyroid: secretes T3, T4, calcitonin; T3 and T4 control metabolism, calories, and growth
development; calcitonin is released when Ca levels are HIGH; problems diagnosed by looking
at TSH, T4, and T3 levels
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Hypo vs hyper
○ Hyper- a lot of T3 and T4 and not enough TSH; hyperactivity of the thyroid gland with
sustained increase in synthesis and release of thyroid hormone
■ Graves’ disease (75%) – gouter and their eyes pop out (exophthalmos)
■ Thyrotoxicosis is hypermetabolism that results from circulating T3 and T4 or
both; hyperthyroidism and this usually happen together
■ Subclinical: serum TSH = <0.4 and normal T3 and T4 levels
■ Overt: low of undetectable TSH;
○ Hypo- too much TSH and not enough T3 and T4;
■ General slowing of metabolic
■ TSH > 4.5, low T3 and T4
● What do patients typically present like
○ Hyper- hypertension, high HR, cardiac hypertrophy, systolic
murmurs, dysrhythmias, angina, dyspnea, increased RR, increased appetite,
weight loss, diarrhea, splenomegaly, hepatomegaly, warm/smooth/moist skin,
thin and brittle nails, hair loss, fine silky hair, premature graying
○ Hypo- low HR, low RR, high risk for HF, dyspnea, decreased appetite, n/v, weight gain,
constipation, thick brittle nails, pallor, muscle aches, fatigue, lethargy, amenorrhea,
mentally sluggish, cold intolerance
● Myxedema
○ Due to accumulation of hydrophilic and mucopolysaccharides in the dermis and other
tissues
○ Happens with pts who have severe long-standing hypothyroidism
○ Puffiness, facial and periorbital edema, and a mask like effect
○ Individuals may describe an altered self-image related to their disabilities and altered
appearance
● Thyroid storm
○ Thyrotoxicosis- excessive amounts of hormones are released. Can result from stressors
(trauma, surgery, infection). Manifestations are tachycardia, shock, hyperthermia,
agitation, seizures, abdominal pain, vomiting, diarrhea, delirium, coma
● How is it treated
○ Hyper- radioactivity, surgery, diet; put pt in low-stimuli environment; change linen
frequently, encourage exercise involving large muscle groups; if they have
exophthalmos, you need to protect their eyes; elevate HOB
○ Hypo- diet and medications
● What do you need to know about medications used
○ Hyper- Methimazole, iodine, beta blockers, radioactivity (bcan result in hypo-)
○ Hypo- Levothyroxine (Synthroid) (take in the morning on an empty stomach)
● Teaching for patient.
○ Hyper- diet high in protein (at least 6 meals a day)
○ Hypo- side effects of medications like cardiovascular (chest pain, dysrhythmias) and
that it’s a life-long therapy, regular follow-up care, keep a comfortable warm
environment, prevent skin breakdown, constipation (inc. exercise, fiber in diet)
● Parathyroid :4 little things on the back of thyroid
● Calcium levels
○ Hyper- increased Ca levels!! Secretes PTH, which takes calcium out of the bones
(osteoporosis) and puts it in the blood
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○ Hypo- decreased Ca levels!!
Hyper increased calcium levels, lower phos. levels
Hypo increase phos. levels and decreased calcium levels
How is each treated
○ Hyper- is treated with surgical removal and loop diuretics
○ Hypo- is treated with activated vitamin D (cacltriol) and Ca supplements, high Ca diet
Diabetes:
DM 1 vs DM 2
○ Type 1 is autoimmune where the body develops antibodies against insulin. Results in
not enough insulin to survive. There is a genetic link and it cannot be reversed. Take
insulin daily and taking blood sugars is important. Most of the time, diagnosed as kids.
■ -Weight loss, polyuria, polydipsia, polyphagia
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Type 2 is the most prevalent type. Risk factors include overweight, obesity, advanced
age, family history. Pancreas produces some insulin, but it’s not enough or the body
doesn’t use it effectively. It’s a gradual process and can be reversed. Based on family
history, diet, sedentary lifestyle. Common in African Americans. They need to monitor
their blood sugar.
■ -weight gain, polyuria, polydipsia, polyphagia
● Labs
○ Hemoglobin A1C level: 6.5% or higher- used to diagnose and monitor response to
therapy
○ Blood glucose level (normal is about 70-100)
○ Fructosamine- reflects glycemia in previous 1-3 weeks
● PO meds:
○ metformin, sulfonylureas
● Insulin types, peak action, length of action
Names
Onset
Peak
Duration
Rapid
Humalog
10-30 mins
30-3 hr
3-5 hr
Short
Humulin R
30mins-1hr
2-5 hr
5-8 hr
Intermediate
NPH, humalin N
1.5-4 hr
4-12 hr
12-18 hr
Long
Levemir
.8-4hr
No peak
16-24 hr
○ 15 mins feels like an hour during 3 rapid responses
○ Short-staffed nurses went from 30 patients to (2) 8 patients
○ Nurses play hero to (2) 8 16 year-olds
○ The two long nursing shifts never peaked but lasted 24 hours.
● Physical consequences of uncontrolled diabetes
○ Stroke, obesity, kidney failure, retinal damage, peripheral neuropathy
● DKA vs HHNS (S&S, differences, treatment)
○ DKA: Diabetic ketoacidosis
■ Mostly seen in type 1. They have to insulin at all. Ketones are present.
■ Hyperglycemia greater than 300
■ Kussmaul respirations (deep rapid breathing)
■ Fruity breath
■ Tx: IV fluids, insulin, electrolyte replacement
○ HHNS: hyperglycemic hyperosmolar nonketotic syndrome
■ They have some insulin, but not enough; no ketones; high blood glucose;
extreme hyperglycemia and dehydration. They will show mental changes from
the dehydration. Blood glucose can be 600 or higher.
■ Tx: IV fluids, IV insulin, monitor serum potassium and replace as needed, as
glucose falls to about 250 use dextrose to prevent hypoglycemia.
● Dawn phenomena
○ Blood sugar gradually goes up throughout the night. They wake up with hyperglycemia
○ Treated by giving more insulin at night or controlling bedtime snacking
● Symogoyi Effect
○ Overdose on insulin at night, so your blood sugar gets too low; other hormones kick in
and raise your blood glucose
○ Fixed by taking less insulin at night or have a nighttime snack.
● Hypoglycemia: how to treat/recognize
○ If conscious, give them a complex carb and wait 15 mins and do it again if their sugar is
still low. After the third time, ER.
○ If they are not conscious, take them to the ER.
○ They’re pale, cold, clammy, confused, dizzy, rapid HR.
● Teaching
○ TAKE YO BLOOD SUGAR!!
○ DASH diet
○ Exercise
○ No smoking
Gastrointestinal:
● Hernias: When are they problematic and how treated
○ Hiatal Hernia: herniation of a portion of the stomach into the esophagus through
an opening or hiatus, in the diaphragm.
■ Risk Factors: old age, female, weakened muscles in the diaphragm around
esophagogastric opening, obesity, pregnancy, ascites, tumors, intense
physical exertion, continual heavy lifting.
■ Nurse priority: teach changes in lifestyle, elevating head of bed, reduce
intra-abdominal pressure
■ Call the doc: hemorrhage, tracheal aspiration
■ Pt worse: ulcerations
○ Inguinal Hernia: most common hernia, where weakness in wall where
spermatic cord or round ligament is in men/women.
■ Risk Factors: heavy lifting, repetitive straining, chronic cough, pregnancy
■ Nurse priority: may need surgery, educate on post-op (don’t strain, splint
incision and keep mouth open when coughing or sneezing).
● GERD: chronic symptom of mucosal damage caused by reflux of stomach acid into
lower esophagus.
● Signs and symptoms: heartburn (pyrosis), dyspepsia and regurgitation, wheezing,
coughing, dyspnea, angina.
● Complications: esophagitis (inflammation of esophagus), esophageal ulcers
● Barrett’s Esophagus: precancerous lesion that increases the patient's risk for esophageal
cancer. A surveillance endoscopy is needed every 2 years to rule it out.
● Medication used to treat:
○ PPI and H2 receptor blockers, cholinergic drugs, and antacids
● Causes: incompetent LES, obesity, smoking, hiatial hernia
● Diverticulosis: bulging noninflamed pouches form in the large intestine or colon.
● Diverticulitis: inflammation of the diverticula (bulging pouches) resulting in perforation
into the peritoneum.
● Symptoms: most patients with diverticulosis have no symptoms, but may have abdominal
pain, bloating, gas, changes in bowel habits. In diverticulitis the most common symptom
in LLQ pain, a palpable mass, n/v, and systemic symptoms of infection.
● Teaching: explain the condition, preach high fiber diet, lots of fluids (2L a day), weight
reduction, lower intra abdominal pressure
● Complications: Diverticulitis, Peritonitis
● Treatment: high fiber diet, stool softeners, anticholinergics, weight reduction, lots of
physical activity, colon rest in acute diverticulitis (also orla antibiotics and clear liquid
diet),
● Hepatitis: inflammation of the liver, commonly caused by viruses, also caused by
substances, autoimmune or metabolic abnormalities.
● How transmitted/contracted:
● A: Fecal/Oral (poor sanitation/hygiene, contaminated food, etc). Similar to flu conditions,
infectious two weeks before onset of symptoms, and one week after onset of jaundice.
Vaccine and hand washing are the best ways to avoid.
● B: Blood Borne (contaminated needles, sexual activity with dirty partners, tattoos with
dirty needles, HBV-infected mother during birth). Sexual transmission (MSM) is the most
common way to get this. Most adults who contract HBV usually resolve without any
lifelong complications. Infectious for 4-6 months, carriers infectious for life.
● C: Blood Borne (blood, needles and syringes, sexual activity with positive partners).
Infectious 1-2 weeks before symptoms appear, and while it runs its course, 75%+ go on
to develop chronic hep C and are continuously infectious. *Most common cause of liver
failure*
● D: HBV must precede HDV, chronic carriers of HBV are always at risk. Can only cause
infection while HBV is present
● E: Fecal/Oral: outbreaks common in contaminated water and developing countries.
Common in Asia, Africa, and Mexico. May be similar to HAV.
● Labs watched:
AST elevated, ALT elevated, GGT increased, Alkaline phosphate increased,
Serum proteins globulin increased, albumin decreased, Bilirubin increased, pTT:
prolonged.
● Vaccines:
○ The hepatitis A vaccine protects infants, children, and adults
from hepatitis A.
○ The hepatitis A and B combination vaccine protects adults from
both hepatitis A and hepatitis B.
● Complications: Chronic hepatitis, acute liver failure, acute hepatitis
● Isolation precautions? Enteric precautions
● Cirrhosis: end stage of diseased liver, massive destruction of liver cells, replacement of
fibrous tissue and nodules
■ Risk Factors: chronic liver disease, years of drinking, chronic hep C,
extreme dieting, malabsorption, obesity, environmental factors, genetics
■ S&S:
● early: fatigue, enlarged liver, abnormal liver tests.
● Late: results from liver failure and portal hypertension (jaundice,
peripheral edema, ascites, skin lesions, hematologic disorders,
endocrine disorders {loss of pubic/axillary hair, testicular atrophy,
vaginal bleeding or loss of bleeding}, peripheral neuropathy).
■ Call the doc: Hepatic encephalopathy, coma, asterisk (flapping of arms
and hands)
■ Pt worse: hepatic encephalopathy, hepato renal syndrome (treat with liver
transplant)
■ Meds used to treat: rest, banana bag (b complex vitamins), avoid alcohol,
aspirin, acetaminophen, and NSAIDS.
■ How to treat ascites: sodium restriction, give albumin infusion, diuretics,
Vasopressin (tolvaptan (samsca), paracentesis if indicated
■ Diagnostic tests: liver enzyme, protein, albumin, bilirubin, globulin,
cholesterol, prothrombin, ultrasounds, liver biopsy
■ Liver function test labs
● Total bilirubin: 0.2-1.2: high
● Protein: 3.5-5.0
● Ammonia: 15-45: high
● AST: 10-30: high
● ALT: 10-40: high
● GGT: 0-30
● Cholesterol: <200
● albumin : low
● Hepatic encephalopathy, how treated
○ Neurotoxic effects of ammonia build up
○ Characteristic manifestation: flapping tremors (asterixis)
○ Treatment: Antibiotics (rifaximin) and lactulose (to poop it out)
● Protein-Caloric Malnutrition: pt will need to be high in calories (3000) with high carb and
moderate/low levels of fat. Protein restriction may be initially started as well.
○ Alcoholic cirrhosis commonly has protein-calorie malnutrition
■ Treat with protein supplements and possible enteral/parenteral nutrition
● Decreased BMI, Decreased albumin level
● Typically, elderly… why
● Esophageal Varices: **most life threatening complications of cirrhosis and should be
treated as an emergency.
○ Treat with endoscopic band ligation, balloon tamponade, TIPS
● What does this patient look like?
○ Impaired consciousness, flapping tremors, fetor hepaticus (sweet musty breath)
● IBS: chronic abdominal pain and alteration of bowel patterns
● Causes? No known organic cause:
● Crohns’ VS Ulcerative Colitis, what are the differences?
○ Crohns: can involve any segment in the GI tract from mouth to anus
■ Onsets teens to mid 30s, and after 60, diarrhea, cramping abdominal pain,
fever, weight loss, nutritional deficiencies. Healthy tissue with areas of
inflammation, includes entire thickness of bowel wall, cobblestone
mucosa, perianal abscesses, fistulas, strictures, c. diff, perforation,
increased risk of S.Intestine cancer
○ Ulcerative Colitis: usually limited to the colon
■ Onsets teens-mid 30s and after 60, diarrhea, constant abdominal pain,
fever during attacks, rectal bleeding, tenesmus, starts in rectum and
spreads to colon, continuous areas of inflammation, mucosa depth,
pseudopolyps common, c. diff, perforation due to toxic megacolon,
increased risk for colorectal cancer.
● Treatments: rest the bowel, control the inflammation, combat infection, correct
malnutrition, alleviate stress, provide systematic relief, improve quality of life, surgery
● Medications: aminosalicylates, antimicrobials, corticosteroids, immunosuppressants,
biologic therapy.
● Gastritis: an inflammation of the gastric mucosa, can be chronic or acute. The back
diffusion of HCL results in tissue edema, disruption of capillary walls, and possible
hemorrhage.
○ Risk Factors: Drugs: aspirin, corticosteroids, iron supplements, NSAIDS. Diet:
alcohol, large quantities of spicy irritating foods. Microorganisms, Environment:
radiation, smoking. , Diseases: burns, hiatal hernia, stress, crohns, reflux, renal
failure, sepsis, shock.
○ Nurse priority: eliminating cause of gastritis, antiemetics if needed, NG tube
○ Call the doc: dehydration leads to neuro changes
○ Pt worse: loss of intrinsic factor→ pernicious anemia
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○ Pt better: self limiting and gets better
○ Meds used to treat: antiemetics, PPI’s, H2 receptor blockers, antibiotics if H.
pylori.
○ CBC to diagnose and endoscopic
Causes: meds, smoking, stress, bacteria
Exams/tests: endoscopy, blood, and stool test
Pineal Cyst
Fistulas: abnormal tract between two hollow organs or a hollow organ and skin.
○ Manifestations: fever and abdominal pain, pus, intestinal contents draining
through cavity
○ Management: appropriate fluid and electrolyte replacement, surgery, fixing
malnutrition, maintaining skin integrity
Immune:
● Immune Response:
● Review the worksheet
● Humoral: antibody-mediated immunity. B lymphocytes, produces antibodies, memory
cells present, protects against viruses (extracellular), bacteria, and respiratory and GI
pathogens. (Examples: anaphylactic shock, atopic diseases, transfusion reactions,
bacterial infections).
● Cell Mediated: T lymphocytes, and macrophages. Produces sensitized t-cells and
cytokines. Memory cells present, protects against fungus, intracellular viruses, chronic
infections, tumor cells (Examples: TB, contact dermatitis, graft rejection, and destruction
of cancer cells).
● Lymphocytes: produced in the bone marrow and differentiate into B and T cells.
○ B cells are formed in the bone marrow and differentiate into plasma cells which
produce antibodies (immunoglobulins)
○ T cells are formed in the Thymus and differentiate into T cytotoxic and T helper
cells
■ T cytotoxic: attack antigens on the cell membrane and destroy pathogens,
these will then remain as “memory” cells for the next invasion
■ T helper: involved in regulation of cell-mediated immunity and humoral
antibody response. They differentiate to display different cytokines.
● Anaphylactic reaction – how to treat it
○ 1. Early recognition of signs and symptoms
○ 2. Maintain patent airway
○ 3. Prevent spread of allergen by using a tourniquet
○ 4. Administer drugs
■ Epinephrine
■ High flow O2 via face mask
■ Nebulized albuterol for bronchospasms
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■ Diphenhydramine for itching and urticaria
■ Corticosteroids IV
○ 5. Treat shock
■ Place recumbant and elevate legs
■ IV normal saline rapid bolus
■ Maintain BP with fluids, volume expanders, vasopressors
○ Ongoing monitoring: VS, respirations, 02 sat, LOC, cardiac rhythm, urine output
Psoriasis vs Eczema:
○ Psoriasis: autoimmune chronic dermatitis that involves excessively rapid turnover
of epidermal cells
■ Treatment: reduce inflammation, corticosteroids, tar, salicylic acid, UVB,
antimetabolite, immunosuppressant, biologic therapy
○ Eczema: condition where patches of skin become inflamed, itchy, red, cracked,
and rough. Blisters may sometimes occur.
■ Treatment: lubricate skin, topical immunomodulators, reduction of stress
flare ups, corticosteroids, phototherapy, antibiotics for secondary infection
PRN
Autoimmune vs hypersensitivity
○ Autoimmune: a type of hypersensitivity response, occur when the body fails to
recognize self-proteins and begins to react against self-antigens
○ Hypersensitivity: immune response is over active against foreign antigens or
reacts against own tissue
Osteoarthritis: slowly progressive noninflammatory disorder of the synovial joints.
Involves gradual loss of articular cartilage with formation of bony outgrowths at the joint
margins.
○ Risk factors: aging, trauma, mechanical stress, joint instability, neurologic
disorder, skeletal deformities, hematologic or endocrine disorders, drugs
○ Manifestations: mild discomfort to significant disability. Joint pain is the primary
symptom, pain worsens with joint use. In early stages, pain will be relieved by
rest, but later stages may have more pain upon rest. Pain usually worsens with
activity, but joint stiffness usually worsens after periods of rest.
○ Treatment: Manage pain, reduce inflammation, prevent disability, maintain and
protect joint function. Balance rest and activity, use heat and cold applications,
weight reduction and exercise program, Capsaicin cream topically,
acetaminophen, camphor, eucalyptus oil, menthol, topical salicylates, NSAIDS,
surgery.
Rheumatoid Arthritis: chronic, systemic autoimmune disease characterized by
inflammation of connective tissue in the synovial joints. Typically marked by periods of
remission and exacerbation.
○ Risk factors: increased age, genetics, an antigen triggering formation of abnormal
immunoglobulin (IgG), autoantibodies are known as rheumatoid factor and
combine with IgG to form immune complexes that initially deposit on synovial
joints, also leading to activation of complement and inflammatory response.
Neutrophils are then attracted to the site of inflammation where they release
proteolytic enzymes that damage articular cartilage and cause the synovial lining
to thicken.
○ Without treatment, pt may develop functional impairment within 20 years.
○ S&S: fever, fatigue, anorexia, weight loss, and generalized stiffness may precede
onset of joint problems. Stiffness becomes more localized in the following weeks.
Joint movement is marked by pain, stiffness, little movement, and inflammation.
Patients usually have joint stiffness after periods of inactivity. Joints are tender,
painful, warm.
○ Small joints (fingers and toes) affected first
○ Pain may decrease with use
○ Bony overgrowths
○ Treatment
■ Management: nutritional/weight management, therapeutic exercise,
emotional support, rest and joint protection, use of devices, heat/cold,
herbals, acupuncture, surgery
■ Drugs: DMARDs- antirheumatic drugs, intraarticular or systemic
corticosteroids, NSAIDS, Biologic response modifiers.
● Medication types and things to watch for on these medications
● Women’s Health:
● Menopause: physiologic cessation of menses associated with declining ovarian function.
It is usually considered “complete” after a year without bleeding (amenorrhea)
■ Postmenopause: cessation of menses, hot flashes and night sweats, atrophy
of genital epithelium, stress and urge continence, osteoporosis
● Who is a candidate for HRT?
○ menopausal symptoms are severe including headaches, sleep
problems, painful intercourse, and night sweats. You have a
family history of osteoporosis or colon cancer. You have had early
menopause before age 40
● Uterine Prolapse: downward displacement of the uterus into the vaginal canal.
○ RF: childbirth, age, obesity, chronic constipation and having a
hysterectomy
○ First degree: cervix rests in the lower part of vagina
○ Second degree: cervix is at vaginal opening
○ Third degree: uterus protrudes out of vagina.
○ Treatment
■ Kegel exercises, Pessary, surgery
● Rectocele and Cystocele: S&S, treatment
○ Rectocele: weakening between vagina and rectum
■ Treatment: kegel exercises or a pessary or surgery (anterior colporrhaphy)
○ Cystocele: support between the vagina and bladder is weakened.
■ Treatment: kegel exercises or a pessary or surgery (anterior colporrhaphy)
● Fistula: Who is at risk? Treatment? Identifying
○ Fistulas: abnormal opening between internal organs or between an organ and the
exterior of the body. Gynecologic procedures cause most urinary tract fistulas, or
injury during childbirth, disease. If the fistula doesn’t heal on its own, there may
need to be surgery done.
○ RF:
● Musculoskeletal:
● Fractures: most common is hips and femurs. Who typically gets them?
○ Hip/femur Fracture: fracture of the proximal upper third of the femur.
■ 95% of these happen from falls
■ Leading cause: osteoporosis
■ If they occur within the hip joint capsule=intracapsular fractures (Capitalin head of femur. Subcapital- below head of femur. Transcervical- femoral
neck)
■ If they occur outside joint capsule=extracapsular fracture
(intertrochanteric: in between greater and lesser trochanter.
Subtrochanteric: below lesser trochanter) These are usually caused by
severe trauma or fall.
■ Manifestations: external rotation, muscle spasms, tenderness around
fracture site, displaced femoral neck, avascular necrosis, immobilized.
■ Care: Bucks traction (relieves muscle spasms), early mobilization post op,
meds pre-op, POST OP- assess VS, intake and output, resp function, pain
meds, observe incision site for bleeding. Assess color, temp, cap refill,
distal pulses, edema, sensation, motor function, and pain.
■ Teaching: DO NOT BEND PAST 90 DEGREES OR CROSS MIDLINE
(CROSS LEGS)
● Elevated toilet seat, chair in shower, pillow between legs for 6
weeks, keep hip in neutral, notify surgeon if pain or loss of
function occurs.
● Complications:
○ compartment syndrome: swelling causes increased pressure within a limited space
(muscle compartment), swelling compromises blood flow in the fascia, causing a
muscle group (compartment) to swell and not get nourished.
■ Treatment: fasciotomy: surgeon opens up skin and fascia to relieve the
pressure.
○ fat embolism
○ PR d/t DVT: Deep Vein thrombosis: formation of clot within a deep vein
■ Treatment: anticoagulant drugs (warfarin, low molec heparin), TED hose,
ROM exercises
○ How are they ID’s, prevented, and treated/
● Neurovascular assessment
● Low Back Pain: most often due to a musculoskeletal problem, can be localized or diffuse,
radicular (nerve root) or referred.
○ Use proper body mechanics when moving, lifting, bending.
○ Maintain healthy body weight, and exercise.
○ Acute care: give NSAIDS and muscle relaxants, brief rest period, massage,
chiropractic, acupuncture, hot and cold compresses.
● Rotator Cuff Repair:
○ Rotator cuff has 4 muscles: supraspinatus, infraspinatus, teres minor, and
subscapularis
○ Injury may occur from aging/repetitive stress, falling, overhand sports
(swimming, baseball, tennis)
○ Manifestations: weakness, pain, decreased ROM, severe pain at abduction 60-120
degrees, positive drop arm test
○ Tests: drop arm test, xray, MRI
○ Treatment: Surgery, sling/swathe, acromioplasty
● Fibromyalgia: widespread musculoskeletal pain accompanied by fatigue, sleep, memory
and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by
affecting the way your brain processes pain signals
● Target points
● Depression: The stress from fibromyalgia's pain and fatigue can cause anxiety and social
isolation. The chronic deep muscle and tender point pain can result in less activity. That
causes you to become more withdrawn and can also lead to depression
● Treatment: meds and non-pharm therapy
○ the antidepressants duloxetine (Cymbalta) and
milnacipran (Savella), plus the anti-seizure medicine
pregabalin (Lyrica)
○ movement therapy, mindfulness, dietary changes, or talk
therapy
● Osteoporosis: Osteoporosis: chronic progressive metabolic bone disease marked by
low bone mass and deterioration of one tissue leading to increased bone fragility.
■ Risk factors: female, over 65, sedentary, smoker, low body weight,
estrogen deficient, family history, low testosterone, excessive alcohol
■ Manifestations: occurs commonly in bones of spine, hips, and wrists.
Early signs are back pain or spontaneous fractures. Falls, fractures.
■ Diagnostics: Quantitative ultrasounds and dual energy xray
absorptiometry is used to determine BMD (bone mineral density). Serum
calcium, phosphorus, alkaline phosphatase, Vit D, H&P
■ Care: Adequate dietary calcium, calcium supplements, sun exposure or
vit D, exercise
■ Drug therapy:
● Bisphosphonates (-dronate)
○ Take with full glass of water and 30 minutes before meals
or any other meds
○ Remain upright for 30 minutes
● Salmon calcitonin
● Selective estrogen receptor modulator
● Recombinant parathyroid hormone
● Monoclonal antibody
● Problems resulting from this disease.
● Osteomyelitis: severe infection of the bone, bone marrow, and surrounding soft tissue. S.
Aureus is usually the microorganism behind this.
○ Causes: Indirect: entry: effects boys younger than 12 that are growing and is
associated with blunt trauma. Adults with genitourinary or respiratory tract
infections or diabetes are at higher risk to spread infection from blood to bone.
Direct: when an open wound (fracture) allows microorganisms into the bone or an
implant or prosthetic device.
○ Infection pressures non expanding bone and compromises the vascular structure
of the periosteum, therefore causing ischemia, leading to dead bone forming a
sequestra. Antibiotics and WBC cannot easily reach the sequestra, therefore
leading to a reservoir for microorganisms to reproduce, which could then spread
to other organs of the body.
○ Acute Osteomyelitis: initial infection or an infection that is less than 1 month in
duration.
■ Clinical manifestations: Local: constant bone pain that worsens with
activity and is not relieved by rest. Swelling, tenderness, warmth,
restricted movement. Systemic: fever, night sweats, chills, restlessness,
nausea, malaise, drainage from sinus tracts.
■ Chronic Osteomyelitis: bone infection that lasts longer than 1 month or
that has failed to respond to initial antibiotic treatment. This can be a
chronic or persistent problem or can be exacerbation/remission. Systemic
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manifestations are lessened, local manifestations are more common
(constant bone pain, swelling, warmth. )
■ Diagnostics: bone or soft tissue biopsy, blood and wound cultures,
elevated WBC and ESR, and CRP. CT, MRI, Bone scans
■ Care:
● aggressive and lengthy IV (usually central line) antibiotics if bone
ischemia hasn’t occurred.
● Surgical debridement and decompression may be needed.
● Antibiotics will continue for 4weeks-6mo.
● Adults with chronic osteomyelitis will usually get oral
fluoroquinolone (ciprofloxacin) for 6-8weeks and then IV
antibiotics after that.
● Continued ESR and bone scans are needed to test effectiveness of
treatment.
● Chronic: surgical removal, extended use of antibiotics, suction
irrigation system, hyperbaric O2, remove prosthetics if causing
infection, amputation if needed.
● Role of Nurse: administer antibiotics and teach about side effects
and adhering to antibiotic treatment plan, assess wound for
worsening infection, assess for muscle spasms and administer
muscle relaxants as ordered, assess pain and administer pain meds
and assess response, assess neurovascular condition and
immediately inform HCP if anything changes.
IV antibiotics, IV and high dose
No weight bearing
Typical patients?
End result?
Gout: acute arthritis due to elevation of uric acid and the deposit of uric acid in one or
more joints. Gout is marked by painful flare ups that last days to weeks and then
remission.
○ Risk factors: excessive red/organ meat, alcohol, shellfish, fructose drinks. Usually
triggered by trauma, surgery, alcohol ingestion, or systemic infection. .
○ S&S: affected joints may seem dusky/cyanotic and very tender. Inflammation of
the great toe is the most common initial problem. Low grade fever.
○ Attacks usually last 2-10 days with or without treatment.
○ Diagnostics: serum uric acid is usually about 6mg/dL or synovial fluid aspiration.
○ Treatment: Colchicine and NSAIDS. Management: diet and drug therapy
○ Allopurinol
Uric acid levels: Normal values for women are 2.5 to 7.5
milligrams/deciliter (mg/dL) and for men 4.0 to 8.5 mg/dL. However,
the values may vary based on the lab doing the testing. According to
the American College of Rheumatology (ACR), your target level if you
have gout is a blood uric acid level of less than 6.0 mg/dL.
● Neurological:
● How to assess neuro system
● Alzheimer’s: Alzheimer’s Disease: chronic, progressive, neurodegenerative disease of the
brain. Most common form of dementia (60-80%). 1. Amyloid plaques, neurofibrillary
tangles, loss of connections between neurons, neuron death.
■ Risk Factors: AGE, Family History, heart health, head trauma
■ Diagnostics: diagnosis of exclusion (when all other things can be ruled
out, they will diagnose AD). H&P, neuropsychological testing, brain
imaging tests, CBC, electrocardiogram, serum glucose, creatinine, BUN,
serum levels of vit B, thyroid function tests, liver function tests, screening
for depression.
■ Manifestations: memory loss, mild disorientation, trouble with
words/numbers, agitation and aggression, dysphasia (difficulty
comprehending language and oral communication, apraxia (inability to
recognize objects by sight, dysgraphia (difficulty communicating during
writing). Eventually long term memories cannot be recalled and they no
longer recognize family members.
■ Care: 1. Controlling undesirable behavior manifestations, 2. Providing
support for the caregiver.
● Drug therapy: Cholinesterase inhibitors (inhibit the breakdown of
AcH), Namenda (protects the brain against large amounts of
glutamate), treat depression with zoloft, luvox, celexa, prozac
■ Teaching: Early recognition and treatment, avoid harmful substances,
challenge the mind, exercise regularly, stay socially active, avoid trauma
to the brain, take care of mental health, treat diabetes, take care of your
heart, get enough sleep, get the right fuel.
● Stages
● Treatment and mgmt.
○ Drug therapy for cognitive problems, behavioral modification, moderate exercise,
assistance with functional independence, assistance and support for caregiver
○ Drugs: cholinesterase inhibitors, NMDA, SSRIs, atypical antidepressants,
antipsychotics, benzodiazepines
● Common problems and how to treat them:
○ Safety: supervision and caregiver is needed, think of watching a toddler (takes
time and patience).
○ Nutritional defects: small, frequent, high calorie meals
○ Sundowning: pt becomes more irritated and confused in late afternoon
■ Create quiet and calm environment, maximize exposure to daylight,
evaluate meds, limit naps and caffeine, consult HCP for drug therapy
● Parkinson’s: chronic progressive neurodegenerative disorder characterized by slowness in
initiation and execution of movement, increased muscle tone, tremor at rest, gait
disturbance. LACK OF DOPAMINE IN BRAIN.
○ Risk Factors: well water, genetics, pesticides, chemicals, family history.
○ Clinical Manifestations: gradual and insidious.
■ TRAP: Tremors, Rigidity, Akinesia, Postural instability
○ Diagnostics: Pt history and clinical features
○ Care
■ Surgery: DBS
■ Nutrition: appetizing foods that can be easily chewed and swallowed,
eating 6 small meals a day may be less exhausting than eating 3 large
meals.
■ Preventing falls, safety first, nutrition
■ Drug therapy: correcting imbalance of neurotransmitters within CNS
● Levodopa with carbidopa is the primary treatment
○ Complications: depression, constipation, dementia
● Carbidopa/Levodopa
○ Levodopa changes into dopamine in the brain, helping to control movement.
Carbidopa prevents the breakdown of levodopa in the bloodstream so more
levodopa can enter the brain. Carbidopa can also reduce some of levodopa's side
effects such as nausea and vomiting.
○ Dizziness, lightheadedness, nausea, vomiting, loss of appetite, trouble sleeping,
unusual dreams, or headache may occur
● Stroke: Ischemic Stroke: inadequate blood supply to the brain by way of clot formation.
○ Long term disabilities: partial paralysis, inability to walk, complete or partial
dependence for ADL’s, aphasia, and depression. A stroke is a lifelong change for
pt and caregiver.
○ Risk Factors: Age, gender, race, family history. Hypertension, heart disease, DM,
smoking, obesity, sleep apnea, metabolic syndrome, lack of exercise, poor diet,
drug/alcohol abuse, contraception. TIA: neurologic dysfunction caused by focal
brain, spinal cord, or retinal ischemia but without acute infarction of the brain
(symptoms usually last <1 hour).
● Testing: MRI
● tPA (tissue plasminogen activator): who is the candidate? How to give it?, Labs to watch
○ Candidate: 3 to 4.5 hours after onset of stroke symptoms, pt have to have a
noncontrast CT/MRI to rule out hemorrhagic, blood tests for glucose level and
coagulation disorders, screening for history of GI bleeds, strokes, or head trauma
within 3 months, major surgery within 14 days, or recent internal bleeding within
22 days.
○ How to give: administered IV, can be given arterially within 6 hours of onset (via
catheter)
○ Labs: VS, neuro status, control of BP, pTT, WBC
● Review Glasgow coma scale and NIH Stroke: what are they, what do they tell you?
○ GCS: shows LOC, 15 is best lower # is worse condition. Usually performed after
traumatic brain injury
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○ NIH stroke: The NIH Stroke Scale is a widely used tool that was
built to assess the cognitive effects of a stroke. In more
scientific terms, it “provides a quantitative measure of strokerelated neurologic deficit
Post stroke: long term care, dysphagia, safety issues, psychosocial issues
○ Long term care: options and caregiver teaching
○ Dysphagia: Dysphagia is the medical term for swallowing difficulties. Some
people with dysphagia have problems swallowing certain foods or liquids, while
others can't swallow at all. Other signs of dysphagia include: coughing or
choking when eating or drinking. bringing food back up, sometimes through the
nose
○ Safety: oral feeding, house changes, ADLs
○ Psychosocial: may be apathetic, depressed, angry, frustrated, etc.
Chapter 16: Fluid, Electrolyte and Acid-Base Balance
1.Review: Fluid Volume Imbalance Nursing Mgmt.
2.Electrolyte Imbalances:
Sodium Imbalance:
○ Hypernatremia: inadequate water intake, excess water loss, or sodium gain.
■ Cellular dehydration
■ Change in mental status (agitation, restlessness, confusion, lethargy,
coma), intense thirst, flushed skin, weight gain, peripheral and pulmonary
edema, increased BP.
○ Hyponatremia: loss of sodium containing fluids, excess water gain
■ Cellular edema
■ Headache, irritability, difficulty concentrating. Can lead to: confusion,
vomiting, seizures, coma.
Potassium Imbalance:
○ Hyperkalemia: impaired renal excretion, a shift of K+ from ICF to ECF, a
massive intake of potassium.
■ Fatigue, irritability, muscle weakness/cramps, loss of muscle tone,
paresthesias, decreased reflexes, abdominal cramping/diarrhea/vomiting,
confusion, irregular pulse, tetany
○ Hypokalemia: increased loss of potassium, shift of K+ from ECF to ICF,
deficient dietary intake of K+.
■ Fatigue, muscle weakness, leg cramps, soft/flabby muscles, paresthesias
and decreased reflexes, constipation, nausea, paralytic ileus, shallow
respirations, weak/irregular pulse, hyperglycemia
Calcium Imbalance:
○ Hypercalcemia: hyperparathyroidism and malignancies, thiazide diuretic use,
prolonged immobilization, increased calcium intake.
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■ Lethargy, weakness, fatigue, decreased memory, depressed reflexes,
increased BP, confusion/psychosis, anorexia, n/v, bone pain/fractures,
polyuria, dehydration, nephrolithiasis, seizures/coma
○ Hypocalcemia: any condition associated with PTH deficiency, multiple blood
transfusions, sudden alkalosis.
■ Weakness, fatigue, depression, irritability, confusion, hyperreflexia,
muscle cramps, decreased BP, numbness and tingling, chvostek's sign,
trousseau's sign, laryngeal and bronchospasms, tetany, seizures.
Phosphate Imbalance:
○ Hyperphosphatemia: acute kidney injury or CKD, phosphate containing laxatives
or enemas
■ Hypocalcemia, numbness and tingling, hyperreflexia, tetany and seizures,
calcium-phosphate precipitates in skin, soft tissue, cornea, viscera, blood
vessels.
○ Hypophosphatemia: decreased intestinal absorption (diarrhea, malabsorption),
increased urinary secretion, or ECF/ICF shifts, malnourished pt or parentally
nourished.
■ CNS depression, muscle weakness, polyneuropathy, seizures, cardiac
problems, osteomalacia, rickets, rhabdomyolysis
Magnesium Imbalance:
○ Hypermagnesemia: renal insufficiency or failure, CKD who ingests magnesium
products.
■ Lethargy, drowsiness, muscle weakness, urinary retention, n/v, diminished
deep tendon reflexes, flushed warm skin, decreased pulse and BP
○ Hypomagnesemia: limited magnesium intake or increased GI/renal losses.
■ Confusion, muscle cramps, tremors, seizures, vertigo, hyperactive deep
tendon reflexes, chvosteks and trousseau's signs, increased pulse and BP
Know normal ranges, symptoms and orders that you would expect to treat condition
3.Acid-Base Imbalances: How Buffer, Respiratory and Renal Systems work to maintain
balance.
Respiratory Acidosis: caused by hypoventilation (buildup of CO2)
Respiratory Alkalosis: caused by hyperventilation (Release of too much co2)
Metabolic Acidosis: caused by DKA, lactic acid buildup, or diarrhea. Kussmaul
respirations are usually began to compensate.
Metabolic Alkalosis: caused by prolonged vomiting or gastric suction, or
ingestion of baking soda.
Know causes, expected lab findings, how body tries to compensate, symptoms, and
assessment findings both subjective and objective.
4. Know difference between Isotonic Hypertonic and Hypotonic IV solutions and when
would they be used.
● Chapter 44: Assessment of Renal System Review if you need to. Be sure to know
diagnostic studies, purpose and nursing responsibilities.
○ Diagnostic Studies:
■ Urinalysis: general exam of urine to establish baseline or tentative
diagnosis, need to wash perineal area, try to obtain first morning urine,
specimen needs to be examined 1 hour within obtaining.
■ Urine culture: confirms UTI and identifies organisms. Midstream
collection.
■ BUN: used to detect renal problems
■ Creatinine: more reliable than BUN to determine renal function
■ Uric Acid: screening disorders for purine metabolism and kidney disease.
● Chapter 45: Renal and Urologic Problems
● Urinary Tract Infection: most common bacterial infection in women. Inflammation of the
urinary tract is caused when bacteria gets into an otherwise bacteria-free zone (bladder).
○ E. Coli is the most common pathogen causing a UTI
○ Can be classified as “upper” or “lower”. Upper: renal parenchyma, pelvis, and
ureters, usually cause fever, chills, and flank pain. Lower: does not usually have
systemic effects
○ S&S: painful urination, hesitancy, intermittency, post-void dribbling, urinary
retention or incomplete emptying, dysuria, nocturia, urgency, incontinence,
frequency (more than 8 times in 24 hours).
○ RF: intrinsic/extrinsic obstruction, urinary retention, renal impairment, urinary
calculi, catheters, urinary tract instrumentation, congenital defects, fistula, shorter
urethra, obesity, aging, HIV, DM, constipation, voiding dysfunction, pregnancy,
menopause, multiple sex partners, use of spermicide agents, diaphragm, bubble
baths, poor hygiene, habitual delay of bladder emptying.
○ Diagnostics: H&P, clean catch urinalysis, urine C&S, imaging studies of urinary
tract if indicated
○ Treatment: adequate fluid intake, phenazopyridine, antibiotics
○ Teaching: Take all antibiotics as prescribed, carefully clean perineal area (separate
labia when cleaning), wipe from front to back, clean with warm soapy water after
BM, empty bladder before and after intercourse, urinate regularly throughout the
day (every 3-4 hours), maintain adequate fluid intake, avoid douching, report
recurrent UTIs to HCP, cranberry juice or tablets for prevention
● Pyelonephritis: inflammation of the renal parenchyma and collecting system (caused by
infection)
○ Acute: mild fatigue, chills, flank pain, dysuria, frequency, urgency.
■ Diagnostics: H&P, C&S, urinalysis, imaging studies, CBC with WBC
differential, blood culture, percussion for flank pain
■ Management: adequate fluid intake, NSAIDS, Broad spectrum antibiotics,
fluoroquinolones. If it gets severe: parenteral antibiotics, and then oral
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○ Chronic: due to recurrent infections
■ Diagnostics: radiologic imaging and biopsy.
■ Often progresses to end stage renal disease
Urinary Tract Calculi: kidney stones
○ RF: metabolic abnormalities, warm climates, large intake of dietary proteins,
excessive amounts of tea/fruit juices, excessive intake of calcium and oxalate, low
fluid intake, family history, lifestyle, sedentary
○ S&S: severe sudden pain (in flank, back, or lower abdomen), n/v, mild shock,
labial/testicular pain, dysuria, fever, chills,
○ Diagnostics: noncontrast CT, ultrasound, retrieval of stones, measurement of urine
pH.
○ Treatment: Administer opioids, tamsulosin (flomax), or alpha adrenergic blockers
to relax smooth muscle. Look into the reason for kidney stones. Adequate
hydration, sodium restrictions, endourology lithotripsy or open stone removal
may be needed if stone is too big, stone is associated with infection, it's causing
imparired renal function, its causing persistent n/v or paralytic ileus, pt has one
kidney or pt cannot be treated medically.
○ Teaching: reducing dietary purine, dosage/scheduling of drugs, self monitor
urinary pH and/or output.
Urinary Diversions: what are they, who gets them, nursing care of these patients, Life
after surgery.
○ Procedures performed to treat cancer of bladder, trauma to bladder, neurogenic
bladder, anomalies, and chronic infections.
○ Management:
■ Teach care of stoma, what to expect (odor, body image, sex, clothing, etc).
■ Post-op: increased risk for atelectasis, shock, thrombophlebitis, small
bowel obstruction, and UTI. Encourage a high fluid intake and that mucus
is common in the urine. Provide meticulous care for skin around stoma.
○ Life after surgery
■ Body image
■ Clean stoma habits
Chapter 54: Male Reproductive Problems
Benign Prostatic Hyperplasia: prostate gland increased in size, leading to disrupted urine
outflow.
○ S&S: occur gradually and may not be noticed until present for some time.
■ Irritative: [inflammation and infection]: nocturia, urinary frequency,
urgency, bladder pain, incontinence.
■ Obstructive: [caused by prostate enlargement]: decrease in the caliber and
force of urinary stream, difficulty in initiating a stream, intermittency, and
dribbling.
○ Dx: H&P, digital rectal exam, urinalysis, WBC, PSA blood test to look for cancer,
TRUS
○ Complications: urinary retention, kidney stones, UTI, renal failure
○ Meds: 5a-reductase inhibitors, a-adrenergic receptor blockers, erectogenic drugs
○ Nursing care (bladder irrigation): assess for bleeding and clots, assess catheter
patency, manually irrigate catheter if bladder spasms, Discontinue CBI and notify
physician if obstruction occurs, kegel exercises, care instructions
○ Teaching: caring for catheter, managing incontinence, maintaining fluid intake,
UTI/wound infection, prevent constipation, avoid heavy lifting, refrain from
driving or intercourse after surgery (may take up to 1 year for sexual function to
return).