Intracranial Pressure
Head Injury
Stroke
vs
R/CVA
LCVA
seizures
Spinal surgery
Alzheimer's
*
Manifestations:Severe vs Moderate
A D U L T H E A L T H 2 – Quiz 3
Altered Intracranial
Regulation
***Extras
- Healthy brain with normal perfusion requires 50mL/min of blood
- Cerebral Perfusion Pressure: force driving blood into the brain.
Normal CCP: 60-100mmHg
- Mean Arterial Pressure: measures perfusion pressure present in vascular system.
Increased MAP = Increased ICP
Normal MAP: 70-150mmHg
- Intracranial Pressure: pressure inside the skull. Changes whenever brain tissue,
cerebrospinal fluid, or blood volume is increased or decreased (for example: brain
tumor, meningitis, encephalitis, head injury, and stroke). Any increase in the amount
of brain tissue, cerebrospinal fluid, or blood can increase the intracranial pressure in
the brain.
Normal ICP: ≤15mm/Hg
Altered Intracranial Regulation
Causes
- Medical History
o Head injury
o Brain hematoma (epidural, subdural, subarachnoid)
o Cerebral Vascular Accident (resulting in brain edema dead brain tissue)
o Ruptured blood vessel in brain (cerebral hemorrhage)
o Overproduction of cerebral spinal fluid
o Inflammation/Infection of meninges (lining of brain and spinal cord)
o Prolonged global anoxia (near drowning, overdose, cardiac/resp arrest)
o Traumatic injury of head or neck
o Hypertension
o Stroke
o Hydrocephalus
- Surgical History
o Brain/Spinal surgery
- Family History
o Seizures
o Parkinson’s
o Huntington’s Chorea
- Social History
o Occupation/Environmental exposure to toxins (lead, arsenic)
o Risk-taking behaviors (no helmet, no seatbelt)
o Contact sports
o Motor vehicle crashes
o Use of substances that suppress the breathing center (chronic or episodic)
o Lack of insurance (reluctance to seek care for head injury)
Signs & Symptoms
- Early signs of ↑ ICP
o Changes in mental status (lethargy, irritability, slow decision-making,
abnormal social behavior)
o Vomiting without nausea
o Pupil changes (irregularity of dilation of one eye, unilateral ptosis)
be the cause
- Late signs of ↑ ICP hemorrhagic stroke
o Changes in mental status (stupor, coma, death)
o Projectile vomiting
o Pupil changes (ophthalmoplegia, loss of vestibulocochlear reflexes)
o Motor changes (hemiparesis)
o Cardiovascular changes (hypertension, widened pulse pressure, slow
irregular pulse)
can
A D U L T H E A L T H 2 – Quiz 3
-
Cushing’s Triad
o Respiration: down and irregular
o Blood Pressure: elevated, Pulse Pressure: widening
o Heart Rate: down
Diagnostic Tests
- Blood Tests
o CBC: Increased white blood cells can signal infection. Decreased red blood
cells, hemoglobin, and platelets can suggest anemia or hypoxemia.
*NI: antibiotics, blood transfusion, oxygen
o CMP: High or low electrolyte levels can cause confusion. Elevated liver
function can suggest liver failure. Decreased protein levels can mean
malnutrition.
*NI: electrolyte correction, liver failure treatment, improved nutrition
o Magnesium/Phosphorus: Not included in combination panels.
These electrolyte levels can be decreased in renal failure, dehydration, or
alcohol misuse.
*NI: electrolyte correction
o Ammonia Level: During liver insufficiency and failure, ammonia levels can
increase. Increased ammonia levels can cause acute confusion resulting from
altered intracranial regulation.
*NI: Reduce ammonia levels in liver failure
o ABG’s: Measure levels oxygen and carbon dioxide levels which can affect pH
and lead to increased cerebral edema (swelling of the brain).
*NI: reduce CO2/increase O2
- Diagnostic Tests (non-invasive)
o CT Scan with/without contrast: detailed pics of bones/organs in slices of xray
*NI: for contrast: iodine/shellfish allergies. Hold metformin 48 hours
before/after. Hydrate after.
o MRI: powerful magnets to take “slice” images – no radiation. Clearest image
of bones/organs/nerves/tendons/ligaments
*NI: before procedure, assess for metal/implant devices (pacemakers). Meds
for anxiety or claustrophobia
o PET scan: measures metabolic activity of brain using radioactive isotope.
Useful in identifying malignancies
*NI: no sedatives/tranquilizers before. Empty bladder. During procedure,
may have to do different activities
o EEG: records electrical activity in the brain from different angles.
*NI: Tranquilizers/Anti-seizure drugs (lorazepam) may be held. Paste in hair.
o Transcranial Doppler: ultrasound to evaluate blood flow of the intracranial
blood vessels. By measuring the speed of the blood flow, or identifying
narrowing in a vessel, potential blockages can be identified.
*NI: none - no prep needed
- Diagnostic Tests (invasive)
o Cerebral Angiography: Moving x-rays (fluoroscope) are used to visualize the
veins and arteries of the brain to look for emboli, bleeding, or aneurysm.
*NI: large vein/artery used. Monitor puncture sites for bleeding. Contrast
may be used (kidney function, metformin, iodine/shellfish allergy)
o Continuous ICP & Brain Tissue Oxygenation Measurement: measure
intracranial pressure, brain tissue oxygen level, and may offer an opportunity
to drain excessive spinal fluid or blood buildup. Temperature should be
checked frequently (every 1-2 hours), to ensure no infection develop
*NI: assess entry site for infection. Blood coagulation studies and CBC prior
A D U L T H E A L T H 2 – Quiz 3
o
o
Evoked Potential Studies: assesses for large nerve conduction speed and
signal. Abnormal tests can suggest paralysis, paresthesias, nerve
impingement or damage to the extremities.
*NI: can be painful from needles. Check for blood clotting abnormalities or if
taking blood thinners to prevent complications
Lumbar Puncture: Injecting a needle into the lumbar area of the spinal cord
allows for the collection of cerebral spinal fluid which can be tested for the
presence of blood or infection.
*NI: must lay flat after to avoid headache from CSF loss. Sterile procedure as
risk of infection (meningitis) is high
Nursing Interventions
- Vital Signs (apply cardiac monitor with automated BP cuff)
- Pain: analgesic (monitor response), comfort measures
- Impaired mobility: mobility assistance, safety precautions (rails up, call light)
- Altered gas exchange/Impaired airway clearance: HOB elevated at 30°, emergency
airway equipment available (intubation kit)
*Reducing cerebral edema: raise HOB to 30°
- Altered cognition: seizure precautions, restraints for self-injury protection, quiet
non-stimulating environment
- Imbalanced body temperature: temperature control measures
- Fall risk: ADL assistance, mobility assistance, bed alarm
- Impaired swallowing: dietary eval, feeding assistance, alternative feeding (NG/TPN),
daily weight, I&O
- Administer MEDS:
o Neuro (cues: restlessness, headache, seizures, hyperthermia)
 Opioids (morphine): pain
 Propofol/Dexmedetomidine: sedation, decrease ICP
 Non-depolarizing agent: paralyze client, decrease ICP
 Mannitol/Hypertonic saline: decrease cerebral edema
 Corticosteroid therapy (methylprednisolone): decrease cerebral
edema
 Lorazepam IV: seizures
 Acetaminophen: hyperthermia, reduce fever
 Antibiotics (ceftriaxone): meningeal infections
o Respiratory (cues: difficulty breathing)
 Oxygen therapy: increase cerebral oxygenation
o Cardiovascular (cues: ↑systolic BP, widened pulse pressure, bradycardia)
 IV fluids: low BP
 Beta blocker/vasodilator/Diuretic: high BP
o GI (cues: epigastric pain)
 Antacids/Histamine H2 receptor blockers/PPI: decrease gastric acid
 Enteral/Parenteral nutrition
o GU (cues: polyuria)
 Fluids & Electrolytes: replace imbalances
A D U L T H E A L T H 2 – Quiz 3
Cranial Nerves
*Sensory Deficit -defined as a
change in the amount of patterning
of incoming stimuli, accompanied by
a diminished, exaggerated,
distorted, or impaired response to
such stimuli.
*Motor Deficit -deficit means a
disturbed or changed function of a
muscle, nerve, or center that affects
movements.
*Some CN are only one, some are
both(mixed).
*CN 111, 1V, V1, can be assessed
together (3, 4, 6)
*CN 1X, X, X11, can be assessed
together (9, 10, 12)
CN I: Olfactory (Sensory)
- Put a scent on a cotton ball as the client to smell it, see if they can identify it.
o Abnormal: Anosmia- decrease loss of smell. Can occur with head trauma or
brain lesion.
CN II: Optic (Sensory)
- Visual acuity, the Snellen chart.
o Abnormal: visual field loss.
CN III: Oculomotor (Motor)
- Six fields of gaze
o Abnormal: Ptosis: such as with myasthenia gravis. Deficit of motor function.
Nystagmus occurs with disease of the vestibular system, cerebellum, or
brainstem
CN IV: Trochlear (Motor)
- Six fields of gaze
o Abnormal: Ptosis: such as with myasthenia gravis. Deficit of motor function.
Nystagmus occurs with disease of the vestibular system, cerebellum, or
brainstem
CN V: Trigeminal (Sensory & Motor)
- Face sensation, chewing. With patients’ eyes closed, test sensation over several
areas of the face using a cotton ball. Palpate temporal and masseter muscles as
patient clenches teeth. Ask the client to open their mouth against resistance.
o Abnormal: Decrease strength in one or both sides, asymmetry and jaw
movement, pain with clenching teeth, unilateral weakness occurs with lesion
of the pons and cancer metastasis to the skull.
CN VI: Abducen (Motor)
- Six fields of gaze
o Abnormal: Ptosis: such as with myasthenia gravis. Deficit of motor function.
Nystagmus occurs with disease of the vestibular system, cerebellum, or
brainstem
CN VII: Facial (Sensory & Motor)
- Taste: anterior two-thirds of the tongue. Have the patient smile, frown, puff out
their cheeks, and raised eyebrows. Movement should be symmetrical on both sides
of the face.
o Abnormal: Decreased or unequal sensation with a stroke, sensation of face
and body is lost on the opposite side of the lesion. Hemiparesis and Aphasia
are often associated. Loss of movement and asymmetry of movement occur
with both CNS lesions and peripheral nervous system lesions, example Bell's
Palsy that affects the upper and lower face on one side.
CN VIII: Vestibulocochlear/Acoustic (Sensory)
- Hearing and balance. Whisper test, Rinne test, Romberg test.
o Abnormal: Inability to hear or problems with coordination and balance.
***Priority Nursing Diagnosis: Risk for falls
A D U L T H E A L T H 2 – Quiz 3
CN IX: Glossopharyngeal (Sensory and Motor)
- Taste posterior one third of tongue. Gag reflex. Have the patient open their mouth
and say “ahhh”, note that the palate rises symmetrically. Test for gag reflex by
touching the posterior pharyngeal wall with a tongue blade. Assess the sound of the
patient's voice should be smooth and not strained. Assess swallowing.
o Abnormal: Absence of symmetry of soft palate movement of tonsillar pillar
movement following a stroke, dysfunction in swallowing increases risk for
aspiration. Hoarse or brassy voice occurs with vocal cord dysfunction.
***Withhold oral fluids and food immediately.
CN X: Vagas (Sensory and Motor)
- Sensory: thoracic and abdominal viscera(organs).
- Motor: gag reflex, pharyngeal and laryngeal muscles swallowing and speech. This
cranial nerve can be assessed with cranial nerve 1X. Test for gag reflex by touching
the posterior pharyngeal wall with a tongue blade.
o Abnormal: Absence of symmetry of soft palate movement of tonsillar pillar
movement following a stroke, dysfunction in swallowing increases risk for
aspiration. Hoarse or brassy voice occurs with vocal cord dysfunction.
***Withhold oral fluids and food immediately.
CN XI: Spinal Accessory (Motor)
- Sternocleidomastoid trapezius muscles. Controls head-turning and shoulder
shrugging. place your hand on the patient's cheek. Have the patient turn their head
towards your hand while you hold resistance. Firmly place your hand on the patient's
shoulders and ask them to raise their shoulders against resistance.
o Abnormal: Atrophy, weakness of muscles or paralysis occurs with a stroke or
following an injury to the peripheral nerve. Surgical removal of lymph nodes.
CN XII: Hypoglossal (Motor)
- Tongue movement. Have the patient stick their tongue out and move it side to side.
o Abnormal: Tongue deviates to the side when stroke affects the hypoglossal
nerve when this occurs deviation is towards the paralyzed size.
Stroke
Causes
- Ischemia (lack of perfusion)
o Thrombotic strokes: blood vessel injured, causing clot formation. Clot gets
lodged in vessel that has been narrowed by atherosclerotic plaque, causing
ischemia and later infarction. Develop slowly. Caused by: HTN, high
cholesterol, atherosclerosis, diabetes mellitus
o Embolic strokes: embolism (originating in heart) occludes a cerebral artery,
resulting in ischemia and infarction. Occur suddenly and mostly during
activity. Caused by: CAD, a-fib
*Most patients with ischemic strokes don’t have ↓LOC in first 24 hours.
- Hemorrhage (brain bleed)
o Intracranial Hemorrhage (ICH): bleeding inside brain tissue caused by
ruptured blood vessel. 50% of deaths in first 48 hours. Sudden onset
worsening in minutes to hours. Caused by: HTN, aneurysms, vascular
malformations, illicit drugs, trauma, anticoagulant/ thrombolytic drugs.
o Subarachnoid Hemorrhage (SAH): bleeding in cerebrospinal fluid-filled space
between arachnoid and pia mater (meninges) lars covering brain. Silent
killers – no warning signs or symptoms until aneurysm ruptures. Immediate
death. Caused by: cerebral aneurysms, illicit drugs (cocaine), trauma
- Modifiable Risk Factors
o Hypertension
o Heart disease (CAD, A-fib)
o Overweight/Obesity
A D U L T H E A L T H 2 – Quiz 3
-
o Use of tobacco (vasoconstriction)
o Sedentary lifestyle
Non-Modifiable Risk Factors
o Age (risk doubles after 55)
o Ethnicity (African-Americans twice the risk and higher death rate)
o Gender (men higher risk than women)
o Genetics
o History of transient ischemic attacks (TIA)
Signs & Symptoms
- Warning Signs
o Balance: loss of balance (gait or mobility affected), dizziness
o Eyes: blurred vision (or irregular eye movements)
o Face: one side of face is drooping or numb (uneven smile)
o Arms: arm or leg weakness (one arm drift downward when raising both
arms)
o Speech: speech difficulty (slurred speech, unable to speak, hard to
understand)
o Time: time to call (call immediately note time signs first started!)
- Clinical Manifestations
o Motor Function: impairment of swallowing, mobility, respiratory function,
self-care abilities.
 Akinesia: loss of voluntary movement
 Lesion (or injury) on one side of brain affects motor function of
opposite side of body (contralateral manifestation).
o Communication: (especially if left hemisphere where language skills
involved)
 Aphasia: communication deficits
 Receptive aphasia: inability to comprehend
 Expressive aphasia: inability to produce language
 Global aphasia: inability to communicate at all
 Dysarthria: deficit in muscular control of speech (pronunciation,
articulation, phonation)
o Memory & Judgement:
 Elimination: urine and bowel
A D U L T H E A L T H 2 – Quiz 3
Nursing Interventions
- Preventative Interventions
o Healthy lifestyle: healthy diet, regular exercise, routine health checks
o Management of modifiable risks: weight control, no smoking/drugs, limited
alcohol, BP management, diabetic disease control, low cholesterol
management
o Drug therapy for high-risk: antiplatelet/anticoagulant (aspirin/warfarin)
- Ischemic Stroke Acute Care
o Determine onset of symptoms: allows provide to eliminate interventions
from options.
o Control BP: HTN common immediately after stroke
 If no fibrinolytic therapy received, meds to ↓BP is recommended if
systolic 220 or diastolic over 120
 If fibrinolytic therapy is received, BP must be less than 185/110 and
then maintained at or below 180/105 for 24 hours after fibrinolytic
therapy concludes. IV antihypertensives (labetalol, nicardipine)
o Maintain Fluid & Electrolyte Balance: Keep electrolytes controlled as
imbalances mimic or mask neurologic changes
o Fibrinolytic Therapy: If meet criteria, don’t delay! tPA must be administered
withing 3-4.5 hours of onset of symptoms. Closely monitor for signs of
hemorrhagic transformation or intracranial hemorrhage. Critical: BP control
***PRIORITY NURSING ACTIONS for patient with ischemic stroke signs:
1. Administer oxygen to keep O2 sats above 92%
2. Obtain CT scan without contrast
3. Obtain weight
4. Administer tissue plasminogen activator (tPA) – tPA breaks up the clot
blocking blood from getting to the brain.
***PRIORITY ASSESSMENT for patient with ischemic stroke signs:
-Ask when symptoms first started
-Ask if she has any allergies to medications
-Evaluate orientation/LOC
- Hemorrhagic Stroke Acute Care (treatment of ruptured aneurysm)
o Metal clip: Neurosurgeon placed a metallic clip on neck of aneurysm to block
blood flow and prevent rupture. For life.
o Coiling: platinum coil inserted into the aneurysm. Winds around the inside,
reducing blood pulsations within it. Body recognizes coil as foreign, creating
thrombus to form within and seal aneurysm and connective tissue.
*Vasospasm: risk is high with clipping/coiling. Reduces cerebral perfusion
pressure – treatment: nimodipine (calcium channel blocker). Assess BP and
pulse before administering, hold if pulse below 60bpm or systolic below 90
***PRIORITY NURSING ACTIONS for patient with hemorrhagic stroke signs:
1. Perform neurologic evaluation – If pupils fixated at 6mm and no longer
following commands, call provider for possible further bleeding or ↑ICP!
2. Prepare for CT scan
3. Gather informed consent form for surgery
4. Administer seizure precautions
- Nurse Management of a Stroke
o Neuro: Assess speech patterns, comprehension to instruction. Give them
time to respond. Use short simple sentences, ask yes/no questions, minimize
background noise. Coping and emotional support. Speech therapy.
o Respiratory: Priority – managing airway and respiratory system. Swallowing
evaluation before taking off NPO status. Reduce coughing and suctioning
(↑ICP) while maintaining proper airway
o Musculoskeletal: Positioning. Splints for contractures. Physical and
Occupational therapy. Assistive devices (walkers)
A D U L T H E A L T H 2 – Quiz 3
o
o
o
Glasgow Coma Scale
-Standardized, objective assessment
that defines the level of consciousness
by giving it a numeric value.
Integumentary: Prevent skin breakdown and pressure ulcers. Air mattress,
frequent repositioning, good skin hygiene. Shorten duration they are on
paralyzed side (30min instead of 2hr)
GU: increase fluid intake, adding fiber, laxatives, suppositories, stool
softeners, and mobility for constipation. Bedpan, bedside commode,
ambulating to bathroom at regular time daily to establish patten.
GI: may have incontinence. Bladder retraining: adequate fluids, scheduled
toileting, good assessments. Check postvoid residuals with bladder US.
Eye Response
- 4: spontaneous
- 3: on command
- 2: to pain
- 1: no response
Verbal Response
- 4: alert and oriented
- 3: confused
- 2: inappropriate
- 1: incomprehensible
Motor Response
- 6: follows direction
- 5: localizes pain
- 4: withdrawal from pain
- 3: abnormal flexion
- 2: abnormal extension
- 1: no response
Scores
- 15 = fully conscious (best)
- Less than 7 = coma!
- 3 = completely unresponsive (worst)
A D U L T H E A L T H 2 – Quiz 4
Altered Hepatobiliary
Function
***Extras
- Positive Murphy’s sign: The client experiences pain or tenderness that causes an
abrupt halt in inspiration when pressure is applied in the right upper quadrant of the
abdomen, below the ribs.
Altered Hepatobiliary Function
Causes
-
Sedentary lifestyle
Obesity
Family history of hepatobiliary dysfunction
Alcohol abuse
Drug abuse
Signs & Symptoms
- Jaundice
- Abdominal distention
- Abdominal pain or tenderness
- Clay-colored stools
- Pruritus
- Nausea/Vomiting
- Fatigue
- Weight loss
- Positive Murphy’s sign
- Hepatomegaly
- Steatorrhea fatty stool caused by
- Petechiae
- Pitting edema
chronic
common
obstruction
bile duck
-
Diagnostic Tests
- Blood tests
- Alanine aminotransferase (ALT): marker for liver damage and inflammation
- Aspartate aminotransferase (AST): marker for liver damage and inflammation
- Alkaline phosphatase (ALP): an enzyme that originates from bone and the liver
*ALP rises when excretion of the enzyme is impaired because of obstruction of
the biliary tract
- Serum Bilirubin: measures liver’s ability to conjugate and excrete bilirubin
o Total bilirubin: measures direct and indirect bilirubin
o Direct bilirubin: measures conjugated bilirubin (value would be high with
obstructive jaundice)
o Indirect bilirubin: measures unconjugated bilirubin (value would be high with
hepatocellular or hemolytic jaundice)
- Liver Biopsies
- Open Biopsy: an incision is made, and a wedge of liver tissue is removed
surgically in the operating room under anesthesia
- Closed (Needle) Biopsy: provider inserts a long biopsy needle to obtain a
specimen of hepatic tissue with ultrasound guidance under local anesthesia
*Nursing considerations:
o Check coagulation and clotting times prior to biopsy
*Normal PT: 10-12 seconds
o Ensure informed consent is signed
o After biopsy, need to remain lying in right lateral position for min of 2 hours
o Notify provider for any dyspnea, cyanosis, or restlessness (possible
pneumothorax)
- Diagnostics
- Hepatobiliary Iminodiacetic Scintigraphy Scan: used to identify any obstructions
in the bile ducts (stones, tumors), gallbladder diseases, and bile leaks. The client
is given an intravenous (IV) injection of a radioactive tracer and positioned under
A D U L T H E A L T H 2 – Quiz 5
Altered Male Reproduction
***Extras
- PSA: <50: less than 2.5, >50: less than 4.0
Altered Male Reproduction
Causes
- Past Medical History
o Prostate cancer
o Testicular cancer
o Infections: prostatitis
o Priapism
o STI’s
o Diabetes
o Hypertension (modifiable)
o Obesity (modifiable)
o Cardiovascular disease (modifiable)
- Drugs/Medication
o Antihypertensives
o Tricyclic antidepressants
o Alcohol abuse (modifiable)
o Smoking (modifiable)
o Illicit drug use (modifiable)
- Psychosocial concerns
o Depression
o Anxiety
o Stress
Prostatitis
- Inflammation of prostate caused by irritation or infection.
- S/S: pain from sitting or bowel movement
- Treatment: antibiotics, can last more than a month
Epididymitis
- Inflammation of epididymis
- S/S: red/swollen scrotum with testicular pain/tenderness on one side, pain from
urination, discharge from penis, blood in semen, painful ejaculation
Testicular Torsion
*Medical emergency!
- Spermatic cord is twisted above testicle. Testicle has reduced/no blood supply.
- S/S: severe pain and swelling
- Treatment: immediate surgery. Without immediate treatment, death in testicular
tissue can occur
Paraphimosis and Phimosis
- Foreskin of uncircumcised male is neither retractable (phimosis) nor retracted
(paraphimosis) and not movable
- S/S: painful decrease in circulation of the glans penis, penile pain in uncircumcised
- Treatment: surgery
A D U L T H E A L T H 2 – Quiz 5
Diagnostic Tests
- Screenings
- Testicular self-exam: early detection of testicular cancer. Performed monthly
after puberty. Educate to examine testicles for changes in shape, size,
consistency. During bath or shower when skin of scrotum relaxed.
-Ex: 13y.o. male just starting puberty
- Digital Rectal exam: Detection of prostate cancer and BPH. Physical exam done
by provider to estimate size, symmetry, consistency of prostate.
-Ex: 50y.o. male with slow urine stream
*Abnormal: prostate enlarged, rubbery, smooth
- Blood tests
- Prostate-specific antigen (PSA): screens for prostate cancer. Can be elevated for
BPH.
o Begin at age 50 for average risk.
o Begin at 45 for high-risk (African Americans, first-degree relative diagnosed
with prostate cancer under 65y.o.)
o Begin at 40 for higher-risk (more than one first-degree relative diagnosed
with prostate cancer before 65y.o.)
-Ex: 40y.o. African American male with family history of prostate cancer
- Diagnostics
- Transrectal ultrasound: Diagnosis of prostate tumors. Accurate assessment of
prostate size and distinguishing between prostate cancer and BPH.
-Ex: 65y.o. male with unexplained PSA elevation
- Vaccinations
- Human Papilloma Virus (HPV) vaccine series: Protect against HPV-related
infections and cancers. Recommended through the age of 26.
-Ex: 16y.o. male at yearly wellness visit
Nursing Interventions
- Impaired sexual function
o Identify stress factors
o Establish therapeutic and trusting patient/nurse relationship
o Educate to promote informed decision making
o Assist patient/their partner alternative ways of sexual expression
- Acute pain
o Assess pain
o Encourage diversional activities (TV, music)
o Provide comfort measures
o Review procedures/expectations to decrease fear of unknown and muscle
tension
- Anxiety
o Review medications (OTC and prescription) as some heighten anxiety
o Listen to patient
o Acknowledge anxiety/fear. Don’t provide false hope or reassurance
o Provide nonpharmacologic comfort measures
- Situational low self-esteem
o Identify/create support systems
o Assess negative attitude/self-talk
o Use active listening without judgement
o Help patient problem solve and develop plan to enhance commitment
- Disturbed body image
o Encourage patient and their partner to communicate feelings
o Acknowledge patients grief, hostility, anxiety
o Assist in treatment of underlying problem
A D U L T H E A L T H 2 – Quiz 5
Erectile Dysfunction
Causes
- Drug-induced: alcohol, marijuana, nicotine, antihypertensives, tricyclic
antidepressants
- Endocrine: obesity, diabetes
- Previous cerebrovascular disease
- Psychosocial: anxiety, stress, depression
- Peripheral vascular disease
- Aging
- Renal failure
- Post radical prostatectomy
Nursing Interventions
- Treat underlying cause
- Therapy for patient and partner to achieve a satisfying sexual relationship and stress
- Emotional support for patient and partner
- Medication therapy:
o Erectogenic drugs (sildenafil) cause smooth muscle relaxation and increased
blood flow into the corpus cavernosum, promoting penile erection
o Taken orally before sexual activity
o Remind patient not to take nitrates with erectogenic medications as they
increase hypotensive effects
Benign Prostatic Hypertrophy
-Prostate gland enlarges from
hormonal changes, causing
significant urinary problems
Causes
-
Age greater than 50y.o.
Smoking/Alcohol use
Sedentary lifestyle, Obesity
Diet (High fat, High protein, Low fiber)
Chronic disorders (diabetes mellitus, cardiovascular disease)
Signs & Symptoms (gradual onset)
- Obstructive symptoms
o Dribbling at end of urination
o Difficulty starting stream of urine
o Stopping the stream several times during voiding
- Irritative symptoms
o Nocturia (usually noticed first)
o Urinary frequency and urgency
o Incontinence
o Frequent UTI’s
o
o Dysuria
o Bladder pain
Complications
- UTI: urine accumulation in bladder can grow bacteria
- Pyelonephritis: infection ascends to kidneys
- Sepsis: infection reaches the bloodstream
- Stones: develop due to residual urine in bladder
- Acute urinary retention: need catheter (to empty) or surgery (to relieve constriction)
Diagnostic Tests
- Screenings
- International Prostate Symptom Score (IPSS): 8 questions to diagnose/track
symptoms of BPH
- Digital Rectal Examination (DRE): detection of prostate cancer and BPH. Physical
exam done by provider to estimate size, symmetry, consistency of prostate.
A D U L T H E A L T H 2 – Quiz 5
-
-
Blood tests
- Prostate-specific antigen (PSA): screens for prostate cancer. Can be elevated for
BPH.
o Begin at age 50 for average risk.
o Begin at 45 for high-risk (African Americans, first-degree relative diagnosed
with prostate cancer under 65y.o.)
o Begin at 40 for higher-risk (more than one first-degree relative diagnosed
with prostate cancer before 65y.o.)
-Ex: 40y.o. African American male with family history of prostate cancer
- Creatinine & BUN: assess renal insufficiency and kidney function
Diagnostics
- Renal Ultrasound: assess for hydronephrosis (if BUN and creatinine elevated)
- Transrectal Ultrasound: accurately measures prostate (if DRE is abnormal and
PSA is elevated). Biopsy can be taken during exam to distinguish BPH from
prostate cancer
- Uroflowmetry: Measures volume of urine expelled from the bladder.
- Cystoscopy: Visualization of the urethra and bladder
Nursing Interventions
- Restore bladder drainage
- Relieve symptoms
- Prevent/treat complications
- Lifestyle changes
o Decrease bladder irritants (caffeine, alcohol)
o Avoid certain medications (decongestants, anticholinergics ((ipratropium))
o Restricting evening fluid intake
o Timed voiding schedule
- Pharmacology:
o Dihydrotestosterone (DHT) lowering agents: finasteride, dutasteride: block
conversion of testosterone to DHT, which decreases prostate size
*May take 6 months for full effect.
*Decrease libido and may cause impotence
*Pregnant women should not touch finasteride tablets or semen when on
this medication: potential risk for birth defects in male fetus
o Alpha-blocking agents: tamsulosin, alfuzosin: block a specific receptor in
prostate that are increased in BP, which relaxes smooth muscle surrounding
urethra, allowing increased urine flow
*May cause tachycardia and hypotension
*Avoid cimetidine with tamsulosin: worsens hypotension
- Minimally Invasive Therapy
o Transurethral needle ablation (TUNA): Low-wave frequency to heat prostate,
causing necrosis
o Transurethral microwave thermotherapy (TUMT): microwave therapy to
produce coagulative necrosis of prostate
o Transurethral electrovaporization of prostate (TUVP): electrosurgical
vaporization to destroy prostate tissue
o Prostatic stent: placed to keep urethra patent
- Invasive Therapy
Indications: painful decreased urine flow, acute urinary retention, hydronephrosis
o Transurethral incision of prostate (TUIP): incision into prostate to relieve
compression of urethra
o Prostatectomy: option for large prostates and associated bladder damage
o Transurethral resection of prostate (TURP): tissue excision and cauterization
used to remove prostate tissue via cystoscopy ***standard BPH treatment
*Nursing Priority: monitor for bleeding and clot retention
-Avoid intercourse for 2 weeks
A D U L T H E A L T H 2 – Quiz 5
-Constipation must be prevented to avoid straining (stool softeners, fluids,
high-fiber diet). No enema.
-No heavy lifting for 2 weeks
-Bloody urine = stop activity, drink 8-12oz of water. If persists, notify
provider.
-No stimulants (caffeine, alcohol, tea, citrus juices)
-No aspirin
-3-Way indwelling catheter with 30mL balloon is inserted to prevent
bleeding and facilitate urine drainage
 Allows for bladder irrigation using normal saline continuously or
intermittently for first 24-72 hours
 Rate of infusion is managed to keep urine light pink without clots
 Monitor closely irrigation inflow and outflow
 If outflow less than inflow, assess for kinks or clots
 Strict aseptic technique to prevent infection
 Record irrigation instilled and total outflow. The difference is
amount of urine documented
 Catheter is secured to leg using traction to prevent bleeding and
urethral irritation
Altered Female
Reproduction
***Extras
- Luteinizing hormone: 5-25
- Follicle-Stimulating hormone: 1.5-17.2
- Estrogen: 30-400
- Prolactin: 3-27
Altered Female Reproduction
Causes
-
-
Polycystic ovary syndrome (PCOS) *most common cause of infertility
Diminished ovarian reserve
Improper function of hypothalamus and pituitary glands
Premature menopause
Nonmodifiable Risks
o Age (1/3 of women over 35)
o Ovulation disorders
o Endometriosis
o Uterine fibroids
Modifiable Risks
o Obesity
o Inactivity
o Smoking
o Excessive alcohol use
o Excessive physical or emotional stress resulting in amenorrhea
o Salpingitis (caused by STI)
Signs & Symptoms
- Amenorrhea (absence of menstrual flow)
- Menorrhagia (excessive menstrual bleeding)
- Metrorrhagia (bleeding in between periods)
- Dysmenorrhea (pain during or shortly before menstruation
Reproductive Health Problems
- Endometriosis: growth of endometrial tissue outside of the uterus
- Premenstrual syndrome: physical/psychological in luteal phase of menstrual cycle,
symptoms so severe that they affect lifestyle
- Abnormal uterine bleeding: not related to menstrual cycle. Uterine bleeding
irregular in amount, duration, timing
A D U L T H E A L T H 2 – Quiz 5
Diagnostic Tests
- Screenings
- Mammogram: detects lumps before they are palpable. 40-44: 1 during this time
as a baseline, 45-54: annually, >55: 1-2 years
- Pap test: detects cancerous cervical cells. 25-65y.o., every 3 years, can stop at 65
if normal for 10 years
- Pelvic exam: early detection of reproductive disease
- Breast exam: monthly self-exams, annual clinical exams by provider
- STI test: 13-64: at least once for HIV, <25: annual for chlamydia & gonorrhea,
pregnant women: syphilis, HIV, Hep B, chlamydia, gonorrhea
- Cholesterol screening: starting at 45y.o., every 5 years
- Bone density scan: detect bone-related problems for women at risk of
osteoporosis (menopause is most common cause of osteoporosis)
- Vaccinations
- Human Papilloma Virus (HPV) vaccine series: Protect against HPV-related
infections and cancers. Recommended through the age of 26.
- MMR: prior to pregnancy
- Influenza: during pregnancy
- Tdap: between 27-36 weeks of pregnancy, and every 10 years
- Pneumococcal Pneumonia: >65
- Shingles: >65 to prevent herpes zoster
Nursing Interventions
- Adequate calcium intake (to prevent osteoporosis
- Condom usage with multiple sex partners
- Avoid excessive sun exposure
Breast Disorders
Breast Cancer
(second leading cause of death from
cancer in women)
Causes
- Modifiable Risks
o First pregnancy after 30
o Nulliparity (never pregnant)
o No breastfeeding
o Hormone replacement therapy
o Smoking
o Sedentary lifestyle
o Obesity
o Exposure to ionizing radiation
- Nonmodifiable Risks
o Age over 50
o Early menarche before 12 and menopause after 55
o History of benign breast disease with atypical epithelial hyperplasia
o Breast cancer 1 and breast cancer 2 gene mutations
o Family history of breast cancer
Signs & Symptoms
- Hard, irregular shaped, poorly delineated, nonmobile, nontender lump/mass in
upper outer quadrant
- Unilateral, clear, or bloody nipple discharge may be present
- Peau d’orange may occur
- Most common sites of metastasis: bone, liver, lung, brain
A D U L T H E A L T H 2 – Quiz 5
Diagnostic Tests
- Screenings
- Mammogram: detects lumps before they are palpable. 40-44: 1 during this time as a
baseline, 45-54: annually, >55: 1-2 years
- Breast exam: monthly self-exams, annual clinical exams by provider
- Diagnostics
- Ultrasound: assess specific area found during mammogram
- Fine needle aspiration: needle inserted into breast cyst to collect fluid sample. Local
anesthesia is used.
- Core needle biopsy: small sample of breast tissue is removed using a hollow “core”
needle.
- Excisional biopsy: performed in operating room
- Surgical prevention
- Prophylactic removal of ovaries (removes main source of estrogen)
- Prophylactic bilateral mastectomy (very high risk)
- Chemo Prevention: blocking effects of estrogen on breast tissue
- Tamoxifen: attaches to hormone receptors on cancer cells and prevents natural
hormones from attaching to receptors. Used to prevent and treat breast cancer.
-Teratogenic effects on unborn fetus (use non hormonal contraception)
-Can be taken on empty stomach or with food
-Take missed doses ASAP but no double doses
-Side effects: hot flashes, night sweats, vaginal bleeding, mood swings, DVT,
endometrial cancer
- Raloxifene: agonist & antagonist to estrogen receptor sites. Used treat/prevent
osteoporosis and reduce risk of invasive breast cancer in postmenopausal
-Can be taken on empty stomach or with food
-Take missed doses ASAP but no double doses
-Side effects: hot flashes, peripheral edema, joint pain, sweating, DVT,
pulmonary embolism
-Contradiction: history of venous thromboembolism
Staging of Breast Cancer
- Tumor size (T)
- Nodal involvement (N)
- Presence of metastasis (M)
- Stages 0 to IV:
o Stage 0 is in situ with no lymph node involvement and no metastasis
o Stage IV is metastatic spread, regardless of size or lymph node involvement
Nursing Interventions
- Assess psychologic readiness for surgery. Support groups may be needed.
- Avoid taking BP, giving injections, taking blood from arm of affected side
- Post-op drains from incision site need to be assessed and emptied. Education on
management of drains prior to discharge.
- Acute lymphedema requires decongestive therapy (compression bandaging)
- Breast conservation surgery (lumpectomy)
- Mastectomy with/without reconstruction
*Priority: elevate affected arm on pillow above heart level
 Hand hygiene before and after touching incision or drains
 Arm exercises as directed
 Empty drains at least twice a day
 Take medication as soon as pain begins
 Avoid heavy lifting or reaching above head
 Avoid tight clothing or jewelry on affected arm
 Self-breast exams
 Breast cancer support groups
A D U L T H E A L T H 2 – Quiz 5
-
-
Benign Breast Disorder: Fibrocystic
Breast Changes
(most common benign condition of
breast)
Causes
-
Radiation (stage I or II)
o Brachytherapy (internal) allows for partial-breast radiation through catheter
into cavity left after tumor is removed
o Palliative radiation therapy: used to reduce tumor mass or treat
symptomatic metastatic lesions
Drug Therapy (chemotherapy, hormone therapy, immunotherapy, targeted therapy)
o Neoadjuvant therapy is given before surgery. Adjuvant therapy is used after
surgery.
o Chemotherapy uses a combination of cytotoxic drugs to destroy cancer
cells.
 Doxorubicin causes cardiotoxicity and heart failure. Monitor for SOB,
pedal edema, dysrhythmias, decreased activity tolerance
 Cyclophosphamide: increase fluid intake to 2-3L daily
 Avoid contact with others recently received live virus vaccine/sick
 Side effects: nausea, anorexia, weight loss, anemia, hair loss
 Cognitive changes: loss of concentration, memory, focus, attention
 Increase protein intake and calories (dip chicken in eggs before
cooking, use peanut butter on crackers, cheese on baked potato, top
fruit with Greek yogurt and granola)
o Hormone therapy with tamoxifen, an estrogen agonist, is recommended for
women over 50 years old for at least 5 years.
Ages 30-50
Menstrual cycle abnormalities
Absence of pregnancy or pregnancy after 40
History of spontaneous abortion
Early menarche
Late menopause
Lack of breastfeeding
Obesity
Smoking and excessive alcohol use
Genetic predisposition
Signs & Symptoms
- Palpable (round, well-defined, freely movable) lump in upper outer quadrant
- Dull, heavy pain from chronic inflammation, edema, and nerve irritation in upper
outer quadrant
- Dark brown nipple discharge
- 1 week before menstruation begins and subside 1 week after menstruation ends
Nursing Interventions
- Educate patient of routine breast screenings
- Demonstrate correct breast self-examination techniques
Benign Breast Disorder:
Fibroadenoma
Causes
- Most common in adolescent and young adults
Signs & Symptoms
- Small, unilateral, painless, round, well-defined, mobile, and solid lumps
- No nipple discharge
- Slow growth and not affected by menstruation
Diagnostic Tests
- Mammogram
- Ultrasound
A D U L T H E A L T H 2 – Quiz 5
-
Fine needle aspiration or biopsy to exclude breast cancer
Nursing Interventions
- If lump greater than 3cm or client is symptomatic  surgically remove lump
Other Benign Breast Disorders
Mammary Duct Ectasia
- Not associated with breast cancer
- Itching and burning behind nipple
- Thick, sticky dark green fluid
- Inflammation with bloody discharge  abscess may develop
- Treatment of abscess: antibiotics and warm compresses (surgical excision of duct)
Intraductal Papilloma
- Associated with a slightly increased risk of developing breast cancer
- More common in ages 30-50
- Wart-like, nonpalpable growth in mammary ducts near nipple
- Blood discharge from breast
- Core biopsy should be performed
- If abnormal cells found, surgically excise mass and involved duct
Sexually Transmitted
Infections
Chlamydia trachomatis
Male Gynecomastia
- Transient, noninflammatory enlargement of one or both breasts
- During puberty, transient imbalance of estrogen and testosterone occurs leading to
gynecomastia, resolving by age 20
- Treatment: none, reassurance its benign and resolves on its own
- Could be symptom of another problem: testicular tumor, adrenal cancer, pituitary
tumor, hyperthyroidism, liver disease, medications (digitalis, isoniazid, ranitidine,
spironolactone), marijuana uses
***Extras
- ?
Causes
- ?
Signs & Symptoms
- ?
Diagnostic Tests
- Blood tests
- ?
- Diagnostics
- ?
Nursing Interventions
- ?
Gonorrhea
Causes
- ?
Signs & Symptoms
- ?
Diagnostic Tests
- Blood tests
- ?
A D U L T H E A L T H 2 – Quiz 5
-
Diagnostics
- ?
Nursing Interventions
- ?
Syphilis
Causes
- ?
Signs & Symptoms
- ?
Diagnostic Tests
- Blood tests
- ?
- Diagnostics
- ?
Nursing Interventions
- ?
Trichomoniasis
Causes
- ?
Signs & Symptoms
- ?
Diagnostic Tests
- Blood tests
- ?
- Diagnostics
- ?
Nursing Interventions
- ?
Genital Herpes
Causes
- ?
Signs & Symptoms
- ?
Diagnostic Tests
- Blood tests
- ?
- Diagnostics
- ?
Nursing Interventions
- ?
Genital Warts
Causes
- ?
Signs & Symptoms
- ?
A D U L T H E A L T H 2 – Quiz 5
Diagnostic Tests
- Blood tests
- ?
- Diagnostics
- ?
Nursing Interventions
- ?
Blood Levels
-
Potassium: 3.5-5.0
Sodium: 135-145
Calcium: 8.5-10.5
Magnesium: 1.3-2.1
Hemoglobin: 12-18 *Below 7 = transfusion
Hematocrit: 37-52%
RBC: 4.2-6.1
Platelets: 150,000-400,000
WBC: 5,000-10,000
BUN: 10-20
Creatinine: 0.5-1.3 *Over 1.3 = Bad Kidney
Blood Osmolality: 275-295
Urine Specific Gravity: 1.005-1.030
ALT: 4-36U/L
ALP: 30-120U/L
AST: 0-35U/L
Total Bilirubin: 0.3-1.0mg/dL
Direct Bilirubin: 0.1-0.3mg/dL
Indirect Bilirubin: 0.2-0.8mg/dL
Albumin: 3.5-5.0g/dL
Vitamin K: 0.1-2.2ng/mL
PT: 11-12.5 seconds
aPTT: 30-40 seconds
INR: 0.8-1.1
Normal Urine Output
-
Per day: 1,500ml
Per hour: at least 30mL
*Patients should urinate every 6 hours.
*Oliguria: decreased urine output
*Anuria: no urine output
A D U L T H E A L T H 2 – Quiz 4
a camera. The radioactive tracer will travel through the bloodstream and into
the client's liver, then flows with the bile into the gallbladder, and lastly goes
through the bile ducts into the small intestine.
*Nursing considerations:
o Remind patient to remain perfectly still during procedure so camera can
track movements accurately
o Tracer contains only traces of radioactivity and poses little to no danger
Nursing Interventions
- GI: risk for imbalanced nutrition
o Discuss eating habits, food preferences/requirements (religion/culture)
o Assess potential drug interactions increasing nausea/decreased appetite
o Administer antiemetic prior to eating
- Hepatobiliary: impaired liver function
o Assist with medical treatment for underlying condition
o Encourage proper diet adherence (avoiding alcohol or fatty foods)
o Identify complications that could arise with impaired liver function
- Musculoskeletal: acute pain
o Assess pain (location, characteristics, severity)
o Provide comfort measures (pharmacological and non-pharmacological)
- Immune: risk for infection
o Proper hand hygiene by caregivers and visitors
o Encourage early ambulation, cough/turn/deep breathing exercises, incentive
spirometer
o Review nutritional needs and consult with dietitian/nutritionist
- Sensory: fatigue
o Assess response to activity
o Identify if cluster care or spreading out interventions is best
o Encourage use of assistive devices
Jaundice
Nursing Interventions
- Assess hard palate of mouth
- Assess sclera/inner canthus of the eye
- Assess changes in urine color
- Assess skin
 Hemolytic Jaundice
- Causes
o Blood transfusion
o Sickle cell
- Signs & Symptoms
o High indirect bilirubin
 Obstructive Jaundice
- Causes
o Cancerous tumor blocking bile ducts
o Pancreatitis
- Signs & Symptoms
o High direct bilirubin
 Hepatocellular Jaundice
- Causes
o Chronic hepatitis C
- Signs & Symptoms
o Elevated indirect bilirubin
A D U L T H E A L T H 2 – Quiz 4
Hepatitis
Hepatitis
Causes
- Hepatitis A (HAV): transmitted fecal-oral
- Contaminated food or water
- Poor personal hygiene (not washing hand after using restroom)
- Poor sanitation (military personnel, visiting or living in areas where prevalent)
- High-risk sexual activity, IV drugs misuse
- Workplace risk (daycare, laboratory, or institutional care employees)
- Hepatitis B (HBV): transmitted blood-borne
- Prenatal transmission (from mom)
- Percutaneous (accidental needle stick, IV drug use)
- Small cuts on mucosal surfaces with exposure to contaminated blood, bodily
fluids, blood products
- Unprotected sex with infected partner
- Employment exposes you to human blood
- Hepatitis C (HCV): transmitted blood-borne
- Percutaneous (sharing contaminated needles and equipment among injection
drug users)
- Blood transfusion prior to 1992
- Snort cocaine
- Work with blood or needles
- Renal dialysis
- Unprotected sex
- Care for, or have close contact with infected individual
- Born to a mother with Hep c
- Incarceration
Signs & Symptoms
- Acute
- Affected bile production
- Affected coagulation
- Affected blood glucose
- Affected drug and protein metabolism
- No symptoms
- Flu-like symptoms (fatigue, anorexia, joint pain)
- Right upper quadrant tenderness (liver inflammation)
- Jaundice
- Pruritis
- Chronic
- Scar tissue  fibrosis, compromised liver function
- Ascites
- Jaundice
- Bleeding abnormalities
- Asterixis (liver flap)
- Elevated ALT or AST
- Spider angiomas
- Palmar erythema
- Hepatic encephalopathy (neurologic and motor disturbances)
Diagnostic Tests
- Antigen blood test: positive antigen means virus is currently active
- Antibody blood test: positive antibody means patient has been exposed to the virus
at some point but body has mounted appropriate immune response (had virus in the
past and recovered OR had Hep A or Hep B vaccinations)
A D U L T H E A L T H 2 – Quiz 4
Nursing Interventions
***Place client on contact precautions!
- Rest: promotes hepatocyte regeneration
- Adequate nutrition: small frequent meals, antiemetics, adequate fluid intake (23L/day
- Assess for complications: bleeding, encephalopathy, increased weight/abdominal
girth, bloody/tarry stools, vomiting blood, elevated liver enzymes
- Prevent transmission: no sharing personal items, hang hygiene, dispose of needles,
avoid unsafe behaviors
- Hepatitis A (HAV):
- Education regarding proper sanitation and hand washing
- Hep A vaccine series (2 doses - all children at 1 year of age and adults at risk)
- No drug therapy for HAV, supportive measures only
- Hepatitis B (HBV):
- Education on reducing risk of transmission if at risk for HBV (good hygiene,
condom use, not sharing razors/toothbrushes/needles
- Hep B vaccine series for prevention (3 doses from birth to 18 months)
- Administer antivirals if chronic HBV
- Hepatitis C (HCV):
- Educate on reducing risk of transmission if at risk (screen blood/organ/tissue
donors, good hygiene, modify risk behaviors)
- No vaccine available.
- Administer antivirals if chronic HCV (Those medications block the proteins that
are needed for HCV replication. Clients complete a 12-week medication regimen
with oral drugs. Almost all who complete treatment are now able to cure their
chronic HCV infection! Some of these agents may cause severe birth defects, so
it’s important to educate clients to avoid pregnancy).
Hepatitis Exposure
- Hepatitis A (HAV):
- Hep A vaccine is used for postexposure prophylaxis
- Effective if given with 2 weeks of exposure
- Hepatitis B (HBV):
- Hep B vaccine and hepatitis B immunoglobulin (HBIG) administered
- HBIG should be given within 24 hours of exposure
- Hepatitis C (HCV):
- Immunoglobulin or antiviral agents not recommended post exposure
- Anti-HCV testing should be done
- Assessments and testing done at 4-6 months follow-up
Cirrhosis (end-stage liver disease)
Causes
- Hepatitis C
- Alcohol-induced liver disease
Signs & Symptoms
- Early
- Fatigue
- Enlarged liver
- Late
- Jaundice
- Skin lesion, spider angiomas
- Portal hypertension and Esophageal/Gastric Varices
- Peripheral edema and Ascites
- Hepatic encephalopathy
- Hepatorenal syndrome
- Hematologic problems: anemia, leukopenia, coagulation disorders
A D U L T H E A L T H 2 – Quiz 4
Pancreatitis
Pancreatitis
***Extras
- Pancreas location: retroperitoneal
- Top nursing priorities for acute pancreatitis:
o acute pain (goal: relief of pain)
o fluid and electrolyte imbalance (goal: normal fluid and electrolyte balance
o impaired nutritional intake (goal: minimize the risk of complication and
prevent recurrent attacks)
Causes
- Gallbladder disease (gallstones)
- Chronic alcohol use
- Other health conditions (diabetes, cystic fibrosis, elevated triglycerides)
- Autodigestion
- African Americans higher risk
- Men higher risk than women
Signs & Symptoms
- Acute (mild: edematous or interstitial, severe: necrotizing)
- Sudden, severe abdominal pain (left upper quadrant - epigastric)
- Pain radiates to back
- Pain feels worse after eating
- Low-grade fever
- Hypotension
- Tachycardia
- Nausea and vomiting
- Jaundice
- Decreased/absent bowel sounds
- Paralytic ileus  abdominal distention
- Lung crackles
- Ecchymoses (gray-blue skin discoloration) of flanks (Grey Turner sign)
- Ecchymoses of periumbilical area (Cullen’s sign)
- Severe cases: shock
- Systemic complications (pleural effusion, atelectasis, pneumonia, ARDS,
pulmonary embolism, DIC, hypocalcemia  tetany, abdominal compartment
syndrome)
- Chronic
- Pain (chronic heavy or gnawing)
- Malabsorption
- Weight loss
- Constipation
- Jaundice with dark urine
- Steatorrhea
- Diabetes
- Complications: pseudocyst, abscess, bile duct/duodenal obstruction, pancreatic
ascites, pleural effusion, splenic vein thrombosis, pseudoaneurysms, pancreatic
cancer
Diagnostic Tests
- Blood tests
- Serum amylase: elevated (main test for pancreatitis)
- Serum lipase: elevated (main test for pancreatitis)
- Blood glucose: elevated
- Serum calcium: low
- Serum triglycerides: elevated
- Diagnostics
- CT scan: best for imaging pancreatitis
- Chest x-ray: may show atelectasis and pleural effusion
A D U L T H E A L T H 2 – Quiz 4
Nursing Interventions
- Assess vitals, pain, fluid & electrolytes, bowel sounds, lung sounds, oxygen
saturation, chvostek’s & trousseau’s signs
- Frequent position changes and turning, coughing, and deep breathing exercises
- Frequent oral care (NPO or vomiting)
- Reduce pain *priority of treating pancreatitis*
o Position client on side with head of bed elevated at 45°
o IV opioid analgesics (morphine sulfate)
o Avoid anticholinergic medications
- Prevent infections *another priority – leading cause of death with pancreatitis*
o Inflamed, necrotic pancreatic tissue is a good medium for bacterial growth
o Enteral feeding reduced risk
o Monitor for infection and early treatment is critical
- Minimize aggressive dehydration
o Lactated Ringer’s to correct fluid & electrolyte imbalances
o Calcium gluconate to treat hypocalcemia
o Dopamine to increase systemic vascular resistance if BP low
o Blood volume replacements (plasma volume expanders – dextran/albumin)
if shock is present
- Manage metabolic complications
o Insulin to lower BG if hyperglycemia is severe
o Pancreatic enzyme products (pancrelipase) to replace pancreatic enzymes.
For chronic pancreatitis, pancrelipase is taken with every meal and snack
with a full glass of water.
- Minimize pancreatic stimulation
o NPO status
o NG suction to prevent gastric contents from entering duodenum
o Antispasmodics (epicycloid) to decrease pancreatic outflow and motility
o Antacids to neutralize gastric secretions
o PPI’s (omeprazole) to decrease hydrochloric acid secretion
o Supplemental O2 to maintain O2 saturation above 95%
- Nutrition to prevent acute attacks for chronic illness:
o Eat easy-to-digest foods with limited spice
o Low-fat, high-carb diet (skim milk)
o Small, frequent meals
o Avoid caffeine and alcohol
o Supplemental fat-soluble
- Prevention includes:
o Stop alcohol intake
o Smoking cessation
o Early diagnosis and management of gallstones
- Surgical treatment
o Gallstones: endoscopic retrograde cholangiopancreatography (ERCP) and
sphincterotomy are performed.
 Sphincterotomy severs muscle layers of the sphincter of Oddi
 May need laparoscopic cholecystectomy to prevent reoccurrence
o Acute pancreatitis: CT-guided draining of necrotic fluid.
 If a pseudocyst is drained percutaneously, a Jackson-Pratt (JP)
drainage tube is left in place.
 JP drains prevent accumulation of fluid after abscess drainage by
creating suction in the tube. The bulb is opened and squeezed flat
(compressed) and closed and connected to the tube protruding from
the body. The bulb expands as it fills with fluid. Bulb should be
emptied every 8-12 hours.
o Obstruction or pseudocysts: Roux-en-Y pacreatojejunostomy to open
pancreatic duct and anastomose with the jejunum.
A D U L T H E A L T H 2 – Quiz 4
Gallbladder Disease
***Extras
- Obstructed Bile Flow:
o Bleeding tendencies: lack of absorption of vitamin K
o Clay-colored stools: lack of bilirubin in small intestine
o Dark-colored urine: bilirubin excreted in urine
o Steatorrhea: no bile in small intestine to emulsify food for digestion
o Jaundice: no bile flows into duodenum and bilirubin accumulates in the
blood
o Pruritus: bile salts deposited in tissue
Cholelithiasis (gallstones)
Causes
-
Age over 40y.o.
More common in women
Women that have had multiple children
Oral contraceptives
Postmenopausal women taking hormone replacement therapy
Obesity
Family history of gallbladder disease
Changes in cholesterol metabolism
Infection
Signs & Symptoms
- Spasms
- Severe steady pain
- Tachycardia
- RUQ tenderness
- Acute attacks: typically last 3-6 hours after high-fat meal or lying down after eating
- Total obstruction: bilirubin excreted through kidneys, urine is dark brown
Diagnostic Tests
- Blood tests
o WBC: elevated due to inflammation
o Liver enzymes (ALT & AST): elevated if obstructed
o Bilirubin: elevated if obstructed
o Amylase: elevated if pancreas is involved
- Diagnostics
o Ultrasound: used to diagnose gallstones
o Endoscopic retrograde cholangiopancreatography (ERCP): allows for
visualization of gallbladder, cystic duct, common hepatic duct, common bile
duct
o Percutaneous transhepatic cholangiography: insertion of a needle into
gallbladder duct followed by injection of contrast to reveal an obstruction
o Percutaneous transhepatic cholangiography with sphincterotomy: used to
remove stone. Stent may also be placed.
Nursing Interventions
- Bile acids (ursodeoxycholic acid, chenodeoxycholic acid): used to dissolve stones.
Does not prevent recurrence
- Percutaneous transhepatic cholangiography with sphincterotomy: used to remove
stone. Stent may also be placed.
- Laparoscopic cholecystectomy *most common treatment
o Gallbladder is removed through 1-4 small puncture sites in abdomen
o CO2 gas is placed into abdomen to expand it for visualization
o Laparoscope with camera and forceps extract gallbladder
o Same-day procedure
o Can return to normal activity within one week
A D U L T H E A L T H 2 – Quiz 4
o
-
-
Cholecystitis
Causes
-
Complication: damage to bile duct. Patients with peritonitis, cholangitis,
gangrene of bladder, portal hypertension, or serious bleeding disorders can’t
have this procedure
o Postop discharge teaching:
 Remove bandages on puncture sites day after in shower
 Notify provider with signs of infection, severe abdominal pain,
nausea or vomiting
 Gradually resume activities one week postop
 Low-fat diet for 4-6 weeks postop
Nutrition Therapy
o Before cholecystectomy:
 Small frequent meals
 Some fat to promote gallbladder emptying
 Low saturated fats
 High fiber and calcium
 Maintaining healthy weight
 Calorie reduction
 Avoid rapid weight loss
o After Cholecystectomy:
 Low-fat diet for 4-6 weeks after surgery
 No special diet after
 Nutritious meals
 Avoid excessive fat intake
Extracorporeal shock-wave lithotripsy: used when endoscopic measures cannot
remove stones. High-energy shock waves are used to disintegrate stones. After they
are broken up, the fragments pass easily through the common bile duct into the
small intestine.
Obstruction from cholelithiasis
Older age
Critically ill
Prolonged immobility
Fasting
Signs & Symptoms
- History of loose, fatty stools
- Recent tendency to bruise easily
- Dry, itchy skin
- Positive Murphy’s sign
- Indigestion
- Severe RUQ pain and refers to right shoulder/scapula
- Fever
- Chills
- Nausea and vomiting
- Feeling of indigestion
- Jaundice
Diagnostic Tests
- Blood tests
o WBC: elevated due to inflammation
o Liver enzymes (ALT & AST): elevated if obstructed
o Bilirubin: elevated if obstructed
o Amylase: elevated if pancreas is involved
A D U L T H E A L T H 2 – Quiz 4
-
Diagnostics
o Ultrasound: used to diagnose gallstones
o Endoscopic retrograde cholangiopancreatography (ERCP): allows for
visualization of gallbladder, cystic duct, common hepatic duct, common bile
duct
o Percutaneous transhepatic cholangiography: insertion of a needle into
gallbladder duct followed by injection of contrast to reveal an obstruction
o Percutaneous transhepatic cholangiography with sphincterotomy: used to
remove stone. Stent may also be placed.
Nursing Interventions
- Pain management (analgesics - morphine)
- Prevent infection with antibiotics
- Maintain fluid and electrolyte balance (IV Lactated Ringer’s)
- NPO status & NG tube suctioning for gastric decompression to decrease gallbladder
stimulation if severe nausea and vomiting present
- Administer antiemetics for nausea/vomiting
- Anticholinergic meds (atropine) to decrease GI secretions and counteract smooth
muscle spasms
- Fat-soluble vitamins: replace vitamins A, D, E, K
- Bile salts: aid digestion and vitamin absorption
- Cholestyramine: resin that binds with bile salts in the intestine and increases
excretion in feces and provides relief from pruritus. Mixed with milk/juice
- Cholecystostomy to drain purulent material from obstructed gallbladder
- Laparoscopic cholecystectomy *most common treatment
o Gallbladder is removed through 1-4 small puncture sites in abdomen
o CO2 gas is placed into abdomen to expand it for visualization
o Laparoscope with camera and forceps extract gallbladder
o Same-day procedure
o Can return to normal activity within one week
o Complication: damage to bile duct. Patients with peritonitis, cholangitis,
gangrene of bladder, portal hypertension, or serious bleeding disorders can’t
have this procedure
o Postop discharge teaching:
 Remove bandages on puncture sites day after in shower
 Notify provider with signs of infection, severe abdominal pain,
nausea or vomiting
 Gradually resume activities one week postop
 Low-fat diet for 4-6 weeks postop
- Nutrition therapy
o Before cholecystectomy:
 Small frequent meals
 Some fat to promote gallbladder emptying
 Low saturated fats
 High fiber and calcium
 Maintaining healthy weight
 Calorie reduction
 Avoid rapid weight loss
o After Cholecystectomy:
 Low-fat diet for 4-6 weeks after surgery
 No special diet after
 Nutritious meals
 Avoid excessive fat intake
A D U L T H E A L T H 2 – Quiz 4
Blood Levels
-
Potassium: 3.5-5.0
Sodium: 135-145
Calcium: 8.5-10.5
Magnesium: 1.3-2.1
Hemoglobin: 12-18 *Below 7 = transfusion
Hematocrit: 37-52%
RBC: 4.2-6.1
Platelets: 150,000-400,000
WBC: 5,000-10,000
BUN: 10-20
Creatinine: 0.5-1.3 *Over 1.3 = Bad Kidney
Blood Osmolality: 275-295
Urine Specific Gravity: 1.005-1.030
ALT: 4-36U/L
ALP: 30-120U/L
AST: 0-35U/L
Total Bilirubin: 0.3-1.0mg/dL
Direct Bilirubin: 0.1-0.3mg/dL
Indirect Bilirubin: 0.2-0.8mg/dL
Albumin: 3.5-5.0g/dL
Vitamin K: 0.1-2.2ng/mL
PT: 11-12.5 seconds
aPTT: 30-40 seconds
INR: 0.8-1.1
Normal Urine Output
-
Per day: 1,500ml
Per hour: at least 30mL
*Patients should urinate every 6 hours.
*Oliguria: decreased urine output
*Anuria: no urine output
A D U L T H E A L T H 2 – Quiz 3
Altered Chronic Neurologic
Function
Seizure Disorder (Epilepsy)
Causes
- Metabolic issues (electrolyte imbalances, acidosis, alcohol withdrawal)
- No apparent cause
Phases
-
Prodromal: sensation or behavioral change hours/days before seizure
Aura: sensory warning that comes before a seizure (similar each time)
Ictal: seizure activity
Postictal: recovery period after seizure activity
Types
- Generalized-Onset (Tonic-Clonic): impacts wide areas of both sides of brain.
Impaired awareness for a few seconds to several minutes. Tonicity (stiffness) and
clonus (jerking).
- Focal-Onset: limited to one hemisphere of the brain.
- Status Epilepticus: Emergency! continuous seizure activity (5 minutes or longer) or
happen in rapid succession to one another without regaining consciousness in
between.
Signs & Symptoms
- Generalized-Onset (Tonic-Clonic)
o Loss of consciousness
o Cyanosis
o Tongue/Cheek biting
o Excessive drooling/saliva
o Postical phase: fatigue, sore
- Focal-Onset (based on function of involved area of brain)
o Sensory
o Motor
o Cognitive (some alert, some in dreamlike state – loss of consciousness with
eyes remaining open)
o Emotional (joy, anger, sadness, nausea)
- Status Epilepticus
o Continuous seizures
Nursing Interventions
- Regular follow ups with Neurologist
- Antiseizure meds (phenytoin, carbamazepine, diazepam, divalproex, lamotrigine
- Avoid potential triggers
- Medical alert identification
- Seizure precautions
o PRIORITY: Protect airway
o Observe & record details of even (what time it started, how long it lasted,
what patient doing before it started, what are they doing after)
o Suction and oxygen equipment readily available
o Cords up and out of the way
o Bed rails and floor next to bed are padded
o Specialty low bed that is close to/sits on the ground
- During a seizure
1. Turn to side and tilt head forward
2. Loosen restrictive clothing
3. Observe time activity started
4. Document the seizure activity in medical record
A D U L T H E A L T H 2 – Quiz 3
Multiple Sclerosis
Causes
- Myelin sheath (covering) of nerve fibers of brain and spinal cord is destroyed
- No exact cause
Signs & Symptoms (slow and gradual process)
- Issues with short-term memory/retentions
- Visual perception
- Unstable mood
- Hearing loss
- Blurred/Double vision (often first symptom)
- Red-green color distortions
- Dysphagia
- Deteriorating motor function (difficulty walking, ataxia, tremors, spasms)
- Extreme muscle weakness
- Generalized numbness and tingling
- Bladder/Bowel dysfunction
Nursing Interventions
- Avoid triggers (stress, childbirth, trauma, change in climate)
- Drug therapy: Immunomodular drugs to modify progression
o Interferon-B
o Immunosuppressants
o Corticosteroids
o Muscle relaxants
- Physical and Speech therapy
- Maintain independence with ADLs
***Cause of death is usually an infectious complication of immobility (pneumonia).
Illness causes exacerbations, symptoms are worse while ill.
Myasthenia Gravis
Causes
- Autoimmune
-Disease of neuromuscular junction
Signs & Symptoms
- Weakness of skeletal muscles including those used to:
o move the eyes and eyelids (ptosis is common)
o chew
o swallow
o speak
o breathe
- No sensory loss occurs
- Reflexes are normal
- Muscle atrophy is rare
Diagnostic Tests
- History & Physical assessment (muscle weakness that progresses with use)
- Electromyography (EMG): muscle contractions
- Tensilon test: IV dose of tensilon (anticholinesterase agent, that blocks enzyme that
breaks down Ach. Positive: client rapidly improves after administration of tensilon.
Nursing Interventions
- Drug therapy
o Anticholinesterase agents (pyridostigmine): enhance transmission at
neuromuscular junction
o Corticosteroids
o Immunosuppressants
*Schedule drug doses of drugs to reach peak at mealtime.
A D U L T H E A L T H 2 – Quiz 3
Huntington’s Disease
-Progressive neurodegenerative
brain disorder
Plasmapheresis
Neurological deficits that affect ADLs
Dietary alterations (semisoft foods instead of liquids or solids)
Rest periods after activity
***PRIORITY: Respiratory assessment
Causes
- Genetic: child of person with HD has 50% chance of inheriting autosomal dominant
disorder
- Excess of dopamine and deficiency of acetylcholine (opposite of Parkinson’s)
Signs & Symptoms
- Abnormal & Excessive involuntary movements (chorea)
o Writhing & twisting movements of face, limbs, body
o Movements get worse with progression
- Aspiration, Malnutrition (due involuntary movements affecting chewing/swallowing)
- Gait deteriorations
- Impaired ability to eat and talk
- Depression
- Behavior concerns (social withdrawal, impulsivity, agitation, obsessiveness)
Nursing Interventions
- No cure. Treatment is palliative.
- Drugs to control movements and behavioral problems.
- Nondrug therapy: counseling, memory books, group activities
- High calorie diet (4000-5000 a day): chorea burns energy quickly
- End of life issues and desires
- Establish goals of nursing management
- Provide comfortable environment
- Most common causes of death: pneumonia, suicide
Parkinson’s
Causes
- Deficit in dopamine, creating imbalance between dopamine and acetylcholine, an
excitatory neurotransmitter
- Onset of manifestations from 40-70y.o.
- More common in males
- Genetic predisposition
- Exposure to environmental toxins and chemical solvents
- Chronic use of antipsychotic medication
Signs & Symptoms
- Tremors at rest: pill rolling
- Rigidity: jerk-like movement causing pain and muscle soreness
- Akinesia (absence of voluntary muscle movements) and Bradykinesia (slowness of
muscle movement): blinking, swinging arms, gesturing, swallowing, posture
adjustments are all affected, resulting in  Mask-like face, Drooling, Shuffling gait
- Postural instability: swaying forward and backward (assessment: pull test)
Complications
- Motor symptoms: dyskinesia (spontaneous involuntary movements, weakness,
neurologic issues, neuropsychiatric concerns (depression, hallucinations)
- Dementia
- Malnutrition (weakness affects safe swallowing)
- Dysphagia (can lead to aspiration)
- Skeletal muscle weakness  immobility  pressure ulcers, UTI, pneumonia
- Orthostatic hypotension
A D U L T H E A L T H 2 – Quiz 3
Nursing Interventions
- Thorough history & physical assessment
- Nutrition: malnutrition and constipation occur. Six small meals a day. Ample time to
eat. Cut food into smaller pieces.
- Activity & Exercise: Occupational therapy, ROM
- Safe environment: fall risk -remover carpets and excess furniture to reduce risk of
stumbling. Elevated toilet seats. Simple clothing.
- Psychosocial well-being: depression, anxiety. Provide therapeutic communication,
listening, encouragement.
- Drug Therapy
o Dopaminergic meds (enhance release of dopamine)
 Levadopa with Carbadopa is primary treatment
 Levadopa: chemical precursor of dopamine and converted to
dopamine in basal ganglia of the brain.
o Anticholinergic meds (block effect of overreactive cholinergic neurons)
o Nursing Interventions:
 Take several weeks to see improvement
 Many side effects and drug interactions
 Monitor for wearing off phenomenon and dyskinesias – indicates
dose/time adjustments needed or drug holiday.
 Paradoxical intoxication: symptoms can worsen with excessive use.
- Surgical Options
o Deep Brain Stimulator (most common): implanting an electrode into brain.
Delivers specific current to brain to treat tremors and uncontrolled
movements. Can improve motor function and reduce dyskinesia.
o Ablation: destroying area of brain that is affected.
o Transplantation: transplanting fetal neural tissue into basal ganglia to
increase production of dopamine.
Spinal Cord Injury (SCI)
Causes
-
Sports-related injury
Motor vehicle collision
Falls
Violence
Classifications
- Mechanism of injury: what happened? What was physical injury? How did spine
rotate? (ex: flexion-rotation, hyperextension, vertical compression)
- Level of injury: what level of vertebrae is involved? (cervical, thoracic, lumbar, sacral)
- Degree of injury: how much of spinal cord is involved/damaged? (Complete cord
involvement: total loss of sensory and motor function below level of injury.
Incomplete cord involvement: partial/mixed loss of voluntary motor activity and
sensation, and leaves some tracts intact)
Signs & Symptoms
- Neuro: Poikilothermia (inability to maintain a constant core temperature)
- Integumentary: Skin breakdown
- Cardiovascular: SCI Above T6  dysfunction of sympathetic nervous system
(bradycardia, vasodilation, hypotension, decreases in cardiac output)
- Respiratory: Cervical injuries above C3 involve total loss of respiratory muscle
function. Requires immediate intubation.
- GI: gastric distention, potential paralytic ileus, weight loss, nutritional support
(enteral/parenteral).
- GU: neurogenic bladder (urinary dysfunction), spasticity of the bladder muscle,
incontinence, reflex of urine back into kidney.
- Venous thromboembolism is common complication.
A D U L T H E A L T H 2 – Quiz 3
Nursing Interventions
- Neuro: use appropriate bed linens for comfort and temperature control
- Integumentary: repositioning, skin hygiene, prophylactic dressings, air mattress
- Cardio: continuous cardiac monitoring
- Respiratory: assess for respiratory compromise, watch breathing pattern, use of
accessory muscles, skin color, ABG’s, clear secretion.
- Fluid/Nutrition: NG tube. High-protein, high-calorie diet within 72 hours. Swallow
evaluation.
- GI: bowel retraining regimen including rectal stimulant (suppository/enema) at same
time every day. Add fiber, increase fluids, mobilize as permitted for constipation.
- Stress Ulcers: assess and test stool and gastric content. Prophylactic administration
of H2 receptor blockers (ranitidine) or PPI (omeprazole)
- GU: indwelling catheter insertion and care
- Early surgical intervention (within first 24 hours) to decompress spinal cord
- Nonoperative therapy: stabilizing injured spinal segment and decompression
through traction or realignment.
- Medications to decrease issues that arise (DVT)
***PRIORITY:
1. Maintaining airway/breathing/circulation
2. Prevention of further injury (secondary injury): immobilize head, neck, spine with
rigid cervical collar and “log rolling” client as a unit
3. Administer oxygen via nonrebreather mask
4. Assess BP and HR
5. Prepare for CT scan.
Autonomic Dysreflexia
*Medical Emergency
Causes
- Major complication of spinal cord injury at 6 th thoracic vertebrae or higher
- Massive, uncompensated cardiovascular reaction mediated by SNS
- Precipitating factors
o Distended bladder
o Distended rectum
o Any sensory stimulation
Signs & Symptoms
- Severe hypertension (systolic up to 300)
- Throbbing Headache
- Bradycardia (low HR from PNS)
- Facial flushing/Diaphoresis
- Nasal congestion
- Vasoconstriction below level of injury
- Vasodilation above level of injury
Nursing Interventions
- Notify provider
- Correct the cause
o Bladder assessment (palpate, bladder scanner, check foley for kinks)
o Bowel assessment
o Remove constrictive clothing
o Obtain BP
o High fowlers position
- BP meds AFTER assessment
A D U L T H E A L T H 2 – Quiz 3
Altered Cognition
Altered Cognition
Causes
- Advanced age
- Medical History
o Dehydration/Fluid & Electrolyte imbalances
o Heart failure
o Kidney failure
o COPD
o Cerebral Edema
o Dementia
o Alzheimer’s
o Encephalopathy
o Sensory impairment
o Polypharmacy
- Social History
o Alcohol/Substance use disorder
o Malnutrition/Unhealthy diet
o Environmental exposure
- Medications
o Chemotherapy agents
o Abuse of diuretics
o Benzodiazepines
o Sedatives
- Triggers
o Change in environment
o Change in sleep patterns/lack of sleep
o Acute illness
o Trauma
o Stress
Signs & Symptoms
- Confusion
- Agitation
- Lethargy
- Disorientation
- Memory loss
- Potential incontinence
- Emotional changes
- Impaired judgement
- Decreased problem solving ability
Nursing Interventions
- Ensure a safe, quiet environment with minimal distractions
- Reorient the client as needed
- Assistive devices within reach
- Safety mechanisms in place (bed locked, lowest position, call light within reach)
- Assess ability to chew, swallow, taste food
- Involve Nutritionist/Dietitian
- Encourage to express feelings and needs
- Monitor behavior and use distractions/stress relieving management
- Provide sameness and consistency in environment
- Use memory-training techniques/aids
- Keep communication simple. Give time to respond.
A D U L T H E A L T H 2 – Quiz 3
Delirium
Causes
-
HOB elevated during and 30-45 minutes after eating
Suction mouth if needed
Provide analgesics or antiemetics to increase comfort
Provide good oral hygiene
Options to support the client and family with care
Dementia, dehydration
Electrolyte imbalances, emotional stress
Lung, liver, heart, kidney, brain issues
Infection, ICU stay
Rx (medications)
Injury, immobility
Untreated pain, unfamiliar environment
Metabolic disorders
Signs & Symptoms
- State of confusion
- Decreased ability to direct/sustain focus, attention, awareness
- Deficit in memory, orientation, language, perception
- Hypoactive (lethargic, fatigue)
- Hyperactive (agitated)
Nursing Interventions
- Treatment is centered around eliminating precipitating factors (due to medication,
discontinue med. Due to fluid & electrolyte imbalance, fix imbalance)
- Provide calm, nonthreatening environment
- Family at bedside to reorient and have familiarity
- Strategies of redirecting and reorienting
- Drug Therapy
o Antidepressant
Alzheimer’s Disease
(most common form of dementia)
Causes
-
Age (65 and over)
Family history/Genetics
Poor cardiovascular health
Past head injuries
Signs & Symptoms
- Frequent forgetfulness
- Unexplainable confusion
- Lack of motivation/interest/initiative
- Lack of self-care
- Less emotional response
- Personality/Mood changes
- Problems with abstract thinking (numbers, basic calculations)
- Forgetting simple words
- Difficulty doing familiar tasks
- Misplacing things
- Poor/Decreased judgement
- Sundowning (specific type of agitation found in dementia clients. Client becomes
more confused/agitated in late afternoon or evening)
A D U L T H E A L T H 2 – Quiz 1
Altered Glucose Regulation
***Extras
- Glucagon: alpha cells – glycogenolysis and gluconeogenesis
- Insulin (endogenous): beta cells – transports glucose from the blood into cells
- Patients should monitor blood glucose:
o before meals
o two hours after meal
o anytime symptoms of hypoglycemia are present
o before and after exercise
Metabolic Syndrome
Diagnosis = 3 or more components
- Increased glucose levels (blood sugar 100+)
- Abdominal obesity (females: 35+, males: 45+)
- Hypertension (systolic: over 130)
- Elevated lipids (high cholesterol/LDL/triglycerides)
- Decreased high-density lipoproteins (HDL) “good cholesterol”
HYPOglycemia
(low blood sugar – less than 70)
“cold and clammy = need some
candy”
Causes
- Too much insulin
- Not enough food intake
Signs & Symptoms (rapid onset)
- Slurred speech
- Tachycardia
- Tremors
- Irritability
- Restless
- Blurred vision
- Excessive hunger
- Diaphoresis (sweating), cold clammy skin, pallor
- Dizziness
- Numbness in fingers and toes
- Headaches
- Seizures and Coma if not corrected
Nursing Interventions
- Conscious Patient
o Consume 15g of simple carbs (fruit juice, milk, hard candies, soda) or glucose
gel/tablets. *Avoid carbs with fat as they slow glucose absorption.
o Check blood glucose 15 minutes after carb ingestion
o If still less than 70:
 Consume another 15g of simple carbs and recheck in 15 minutes
 Contact healthcare provider
- Unconscious Patient
o Sub-Q or IM injection of 1mg glucagon or IV admin of 20-50mL 50% glucose
solution
o If vomiting occurs, turn patient on side to prevent aspiration
A D U L T H E A L T H 2 – Quiz 1
HYPERglycemia
(high blood sugar – over 115)
“high and dry = sugar high”
Causes
- Insufficient insulin
- Acute causes: sepsis, stress, skipped insulin, steroids)
- Chronic causes: diet
Signs & Symptoms (gradual onset)
- Polydipsia
- Polyuria
- Polyphagia
- Dry mouth
- Weakness
- Headache
- Blurred vision
- Nausea
- Abdominal cramps
Nursing Interventions
- Sugar: check blood glucose at least every 3-4 hours
- Insulin: always take insulin (could lead to diabetic ketoacidosis if not taken)
- Carbs: drink fluids frequently (30-60min)
- Ketones: check urine/blood ketones every 4 hours when blood glucose>240
A D U L T H E A L T H 2 – Quiz 1
Diabetes
***Extras
- Diabetes diagnosed using 1 of 4 methods:
o Glycosylated hemoglobin (A1C) 6.5% or higher
o Fasting blood glucose 126 or higher
o Oral glucose tolerance test (OGTT) 2-hour blood glucose 200 or higher
o Casual blood glucose 200 or higher AND symptoms of hyperglycemia
- Complications:
o Kidney – Renal failure: creatinine over 1.3
o Eye: retinopathy (blind)
o Nerves: neuropathy (no nerve sensations in extremities)
o Heart: hypertension & atherosclerosis
***Diabetics should regularly see ophthalmologist and podiatrist.
DM Type 1 “Insulin none”
*Autoimmune disorder
*Insulin dependent for life
*More common in children,
adolescents, and young adults
Causes (pancreas can no longer make sufficient insulin to maintain normal glucose)
- Genetic predisposition
- Exposure to a virus
Signs & Symptoms (acute and rapid onset)
- Polyuria (excessive urination)
- Polydipsia (excessive thirst)
- Polyphagia (excessive hunger)
- Sudden, dramatic weight loss
- Fatigue
- Blurry vision
- Nausea and vomiting
Nursing Interventions
- Reduction of symptoms
- Promotion of well-being
o Annual flu vaccine
o Daily brushing, flossing, regular dental visits
o Regular bathing and meticulous foot inspection/care daily, no flip flops/bare
feet, supportive shoe, cotton socks, nails trimmed straight, no lotion, no
cold/hot, notify provider of non-healing wounds
- Nutrition/Diet:
 Healthy simple carbs (fruits)
 Complex carbs (grains)
 Fiber: 25-30g per day
 Cholesterol: up to 200mg per day
 Minimize trans-fat and saturated fat
 At least two servings of fish per week
 High-protein diet not recommended
o Medication (insulin)
o 150 minutes per week of Moderate Intensity Exercise (walking briskly,
housework, mowing lawn, dancing, swimming, biking, sports)
o Self-monitoring blood glucose
- Prevention of acute/chronic complications
- During times of illness or stress:
o Sugar: check blood glucose at least every 3-4 hours
o Insulin: always take insulin (could lead to diabetic ketoacidosis if not taken)
o Carbs: drink fluids when sick.
o Ketones: check urine ketones or blood ketones every 4 hours
A D U L T H E A L T H 2 – Quiz 1
Diabetic Ketoacidosis
(Hyperglycemic > 400)
Causes (predominately DM type 1)
- Inadequate insulin dosing
- Illness/Infection (cellulitis, pneumonia)
- Inflammation (cholecystitis, pancreatitis)
- Intoxication (ETOH, cocaine, speed)
- Infarction (MI, CVA)
- Iatrogenic (steroids, surgery)
- Skipping meals
- Patients who lack understanding/education/resources or neglectful of self-care
Signs & Symptoms (happens suddenly)
- Ketones present in blood and urine
- Metabolic Acidosis (pH less than 7.30 & bicarb less than 16)
- Kussmaul respirations (fast, deep breathing)
- Acetone fruity breath
Nursing Interventions
- PRIORITY: Maintain airway and oxygen saturation (administer oxygen)
- IV fluids (0.9% NS) at least 30mL/hour (monitor for fluid overload)
- Regular insulin IV at continuous rate of 0.1 units/kg/hour
- Monitor for hypokalemia/hyperkalemia (and other electrolytes)
- Once blood glucose falls to 250, administer 5% dextrose IV
- Monitor cardiopulmonary continuously
- Assess mental status
- Hourly I&O
- Hourly blood glucose levels
DM Type 2 “Few and You”
*Few insulin receptors
*Change your lifestyle
*More common in adults over 45
Causes (pancreas secretes inadequate insulin or body develops resistance to insulin)
- Genetic predisposition (first-degree relative with diabetes)
- Lifestyle behaviors
- Metabolic syndrome
- Obesity (main risk factor)
- Women with polycystic ovary syndrome
Signs & Symptoms (gradual)
- Polyuria (excessive urination)
- Polydipsia (excessive thirst)
- Polyphagia (excessive hunger)
- Fatigue
- Recurrent infections
- Prolonged wound healing
- Vision problems
Nursing Interventions
- Reduction of symptoms
- Diet: weight loss and healthy BMI
o Nutrition/Diet:
 Primarily complex carbs (grains, legumes, vegetables)
 Some healthy simple carbs (fruits)
 Fiber: 25-30g per day
 Cholesterol: up to 200mg per day
 Minimize trans-fat and saturated fat
 At least two servings of fish per week
 High-protein diet not recommended
 Limit alcohol intake
A D U L T H E A L T H 2 – Quiz 1
-
Hyperosmolar Hyperglycemia
Syndrome (HHS)
(Hyperglycemic > 600)
150 minutes per week of Moderate Intensity Exercise (walking briskly, housework,
mowing lawn, dancing, swimming, biking, sports)
Self-monitoring glucose, tracking trends
Oral meds: maintain normal blood glucose levels
Insulin (last line)
Prevention of acute/chronic complications
Promotion of well-being
o Annual flu vaccine
o Daily brushing, flossing, regular dental visits
o Regular bathing and meticulous foot inspection/care daily, no flip flops/bare
feet, supportive shoe, cotton socks, nails trimmed straight, no lotion, no
cold/hot, notify provider of non-healing wounds
o Promoting self-care, minimal stress
*Routine Diabetes Screening: fasting blood glucose beginning at 45y.o. and every 3
years
Causes (predominately DM type 2)
- Sepsis (insulin resistance)
Signs & Symptoms (gradual onset)
- No ketones or acidosis
- Dehydration (due to hyperosmolarity - concentrated)
- Somnolence (intense drowsiness)
- Seizures
- Hemiparesis
- Aphasia
Nursing Interventions
- PRIORITY: Maintain airway and oxygen saturation (administer oxygen)
- IV fluids (0.9% NS) at least 30mL/hour (monitor for fluid overload)
- Regular insulin IV at continuous rate of 0.1 units/kg/hour
- Monitor for electrolyte imbalances
- Once blood glucose falls to 250, administer 5% dextrose IV
- Monitor cardiopulmonary continuously
- Assess mental status
- Hourly I&O
- Hourly blood glucose levels
Oral Anti-Diabetic Agents
Metformin (Biguanides)
*most effective – 1st line
***Extras
- No iron  prevent absorption
- No calcium  prevent absorption
- No antacids (tums/rolaids)  prevent absorption
Indications
- DM type 2
- Enhances insulin sensitivity (low blood glucose)
Side Effects
- GI upset (diarrhea)
Nursing Implications
- Hold 1-2 days before and at least 48 hours after IV contrast (cath lab)
- Take with food
- Lactic Acidosis
- Liver & Kidney toxic
- High risk for acute kidney injury and cervical intraepithelial neoplasia
A D U L T H E A L T H 2 – Quiz 1
Glipizide, Glyburide (Sulfonylureas)
Indications
- Increases insulin production from pancreas
Side Effects
- Hypoglycemia
- Weight gain
Nursing Implications
- Risk for hypoglycemia
- Take 30 minutes before breakfast
- Slow position changes
- Avoid alcohol
Acarbose, Miglitol (α-Glucosidase
Inhibitors)
Indications
- Delays absorption of complex carbs from GI tract
Side Effects
- GI upset (gas, abdominal pain, diarrhea)
Nursing Implications
- Take with first bite of morning meal
- Not for liver failure (liver function tests)
Injectable Insulin
***Extras
- Peaks + Plates = Give food during peaks
- Deadly Hypoglycemia (70 or less)
- NO peak No mix = long-acting in separate syringes
- IV push/IV bag only = Regular insulin
- Draw up: clear before cloudy… RN = Regular before NPH
- Rotate locations: abdomen, arms, thighs (best on abdomen near umbilicus or naval)
- DKA – Type 1 – sick days: still give insulin without food… monitor closely
- Opened and in use insulin stored at room temperature for up to 4 weeks. No
extreme temperatures. Unopened insulin kept in fridge until expiration.
- Mixing insulin (ex: 10 units of regular and 20 units of intermediate):
o Inject 20 units of air into intermediate
o Inject 10 units of air into regular
o Flip vial upside down and withdraw 10 units
o Withdraw 20 units
Long-Acting (Detemir/Glargine)
Onset
- 1 - 4 hours
Peak
-
None
Duration
- 16 - 24 hours
Nursing Interventions
- No mix: draw in separate syringes
- Never IV
A D U L T H E A L T H 2 – Quiz 1
Intermediate-Acting (NPH)
Onset
- 90 minutes - 4 hours
Peak
-
4 - 12 hours
Duration
- 12 - 18 hours
Nursing Interventions
- Gently roll vial in hand to mix before administration
- Mix clear before cloudy. RN= Regular before NPH.
- Never IV
- Given 2 times a day (maintains blood glucose between meals and overnight)
Short-Acting (Regular)
*Only insulin that can be given IV
Onset
- 30 - 60 minutes
Peak
-
2 - 5 hours
Duration
- 5 - 8 hours
Nursing Interventions
- Only IV insulin
- Give 30 minutes before meals, not before food is delivered
- Risk for hypoglycemia
Rapid-Acting
(Aspart/Lispro/Glulisine)
Onset
- 10 - 30 minutes
Peak
-
30 - 90 minutes
Duration
- 3 - 5 hours
Nursing Interventions
- Must eat immediately with injection
- Most deadly – greatest risk for hypoglycemia
- Never IV
A D U L T H E A L T H 2 – Quiz 1
Blood Levels
-
Potassium: 3.5-5.0
Sodium: 135-145
Calcium: 8.5-10.5
Magnesium: 1.3-2.1
Hemoglobin: 12-18 *Below 7 = transfusion
Hematocrit: 37-52%
RBC: 4.2-6.1
Platelets: 150,000-400,000
WBC: 5,000-10,000
BUN: 10-20
Creatinine: 0.5-1.3 *Over 1.3 = Bad Kidney
Blood Osmolality: 275-295
Urine Specific Gravity: 1.005-1.030
ALT: 7-55
AST: 8-48
Albumin: 3.5-5.0
PT: 11-12.5 seconds
aPTT: 30-40 seconds
INR: 0.8-1.1
Normal Urine Output
-
Per day: 1,500ml
Per hour: at least 30mL
*Patients should urinate every 6 hours.
*Oliguria: decreased urine output
*Anuria: no urine output
Cholesterol Levels
-
Total Cholesterol: 200 or less
Triglycerides: 150 or less
LDL (bad): 100 or less
HDL (good): 40 or more
Sugar
-
Glucose (random): 70-115
Glucose (fasting): 70-99
Hemoglobin A1C: under 5.7
Pre-DM: 100-125
Pre-DM: 5.7-6.4
DM: 200+
DM: 126+
DM: 6.5+
Quiz 2-Renal
Pre-Renal
(before
any condition
blood flow
there is
AK1)
that is external to the
and GFR
no
to renal tissue
damage
reversible with treatment
Pre-renal is
Conditions
that
cause
pre-rend
hypovolemia
Impaired perfusion:
AKI
cardiac failure
sepsis
·HF, M1
severe
condition that
mostly
prolonged
caused
by
·vascular occlusion
Kidney)
causes
Prevenal
kidney's
damage to
direct
AKI will cause
drugs/meds
of
eipirasartana
condition that causes obstruction
urinary
Conditions
>BDH
>
-
outflow (Iry. of
cause
that
in
cases)
A. Amphotericin
N- NSAIDS
post-renal AK1
cancer
> Renal Calculi(in uterer, bladder
cause
hydromephorsis
ignostics
·BMP
or
(backed up
I
test for
urethra)-bilateral
wine in the
albumin
in
the
electrolytes
·
*
ace
S.CR?
GFR (Rifle criterial
·VA/
Sp.
gravity
Kidney
CT/Renall
US/biopsy
inhibitors
Kidneys
utever obstruction will
kidneys)
the
>microalbuminea is
·BUN
toxic
M- Metaformin
benign prostatic hypertropy
3 tumors
> UTI
Intra-Renal
CAKEMAN:kidney
Post-Renal AKI (after kidney)
any
dehydration
output
Intra-Renal AK1 (within
>
blood loss
dehydration (snock sepsis
decreased cardiac
any
renal
decreases
that
kidneys:condition
yearly (dm/nth)
lst sign of
kidney damage
wine
like
lisinopril protects
the
Potassium (serum)
more
or less
Warning!
can be
life
threatening!
Watch potassium levels
·Renal Failure
hydration Imbalances
Acid-Balt Imbalance
·
Cellular
damage
>burn's
> accidents
3
surgery
diabetes
AK1 is
pt's
in
mined
inDigia"in
potentially reversible: primary goals
manage S/S
and
prevent complications
> Medications
loop
diretic
> For
-
furosimide
·
Fittin
2-calcium
B Bicarborate
can be
usedinemergein
eliminate cause,
kidneys
recover.
Hyperkalemia:
gluconate:Stabalize
Calcium
insulin
dextrose:redistribute
polystyrene
sulfonate:eliminate
sodium bicarbonate:Redistribute
Memodyalists (fastest):eliminate
C "see" BIGK!!
albuterol
are to
while the
antihypertensives:ACEI
*
with:
i redistribute
albuterol hiduse
AKI
Management
Monitor
>VS, cardiac monitor;daily wt;
same
scale
time
assesment
(1k 12 fluid)
complete
110
=
·Labs, BMP, FBE,
avoid
ABG
(metacidosis
nephrotoxins!!!
·Diet
↳ Protein intake
>
high
0.8-1g/day
fat
carbs, moderate
> limitsalt
substitutes,
many
> limit intake of potassium,
have *Kt
phosphate
and
magnesiv
CKD
Chronic kidney
-
progressive, irreversible
Disease
kidney function
loss of
causes:DM 50% and Hth 25%
of nephrons
Decreased GFR
loss
gradual
kidneys
are unable to excrete
regulate FIE
Who is
aging
and
greatest
-
balance.
acid-base
maintain
at
metabolic waste,
Risk for
10 +
CID?
heart problems
AK1
autoimmune disease
Fire
obesity
family
DM
nX
tobacco
often age
use
glomerulonephritis
medications:NSAIDS
hypertension
control htn,
·CBC;Chem7 electrolytes
I
gene
Management
Diagnostics
-
stroke
or
parathyroid
disease, CKD-MB, anemia,
dyslipidemia
and
hyperkalemia
>
correction
hyperphosphatemia
hypocalcemia
overload
of extracellular fluid volume
or
deficit
BUN, S. CReatnine, GFR, UA,
Urine Studies, Renal VS,
biopsy
CKD
Nutrition
fluid
restriction
may
->
need
kidney
supplements
iron, VitD,
Iphosphate
Drug
and
Diet:high
and
CHO, sodium, potassium,
phosphate
lower
for
therapy
I
protein
DASH diet
binders
Nutritional
diet
may
be
helpful
th
Monitor
Vital
signs, 10, daily weights, fluids,
electrolytes (K, Mg, Pros, S.cr, BUN)
CBC
anemia
-
Teach
MieRAST
DYES
frequent
rest periods
skin from breakdown
protect
diet, medication, importance of
dialysis (schedule)
Catheter
and
maintaining
A D U L T H E A L T H 2 – Quiz 3
Nursing Interventions
- Maintain functional ability
- Be in safe environment
- Have personal care needs met (oral care)
- Have dignity maintained
- Undernutrition (remind to chew and swallow, don’t rush them, enteral/parenteral)
- Pain management
- Drug therapy
o Cholinesterase inhibitor (donepezil, rivastigmine)
o Memantine
o Antidepressant - SSRI (fluoxetine, citalopram, trazodone)
Dementia
Causes
- Decline from previous level of function in one or more cognitive domain
o Attention
o Language
o Learning and memory
o Executive function
o Social cognition
o Perceptual-motor
- Alzheimer’s
- Down syndrome
- Parkinson’s
- Medication usage
- Autoimmune diseases (MS, meningitis, AIDS)
- Head injuries
- Hydrocephalus
- Brain tumors
- Alcohol use disorder
Signs & Symptoms
- Same as Alzheimer’s
Nursing Interventions
- Consistent care approach
o Assures routine that reduced anxiety and confusion
o Increases orientation
o Provides consistency
o Allows patient to relate to staff in a consistent manner