Med Surg Final Exam Questions PDF

Questions: 8 GI 8 CVA 4 liver 3 seizures 11 ortho 10 head injury 6 spinal injury 6 resp 5 cardio 5 endo 5 renal 4 shock Ortho Soft tissue injuries RICE ○ Rest 48 hrs ○ Ice 20 min at a time 4-8x a day...

Questions: 8 GI 8 CVA 4 liver 3 seizures 11 ortho 10 head injury 6 spinal injury 6 resp 5 cardio 5 endo 5 renal 4 shock Ortho Soft tissue injuries RICE ○ Rest 48 hrs ○ Ice 20 min at a time 4-8x a day ○ Compress ○ Elevate 6-10 in above heart - Ex. sprain (injury to ligament around joint) and strain (excessive stretching of muscle) Dislocation Bone separates from joint s/s ○ Deformity limb ○ Shorter or rotated ○ Pain ○ Edema ○ Vascular injury ○ Xray for fx Closed reduction Restrict mvmnt Sling, splint Dislocation can reoccur Valium (pain killer)  ○ Pain and sedation Fx Open ○ Broken through skin Closed ○ Not through skin Complete ○ Broken entire width Incomplete ○ Slightly broken Displaced ○ Moved out of alignment Nondisplaced ○ Still aligned Transverse ○ Across Linear ○ Up and down Oblique non displaced ○ Diagonal in alignment Oblique displaced ○ Diagonal not in alignment Spiral ○ Bone broken in twisting motion Greenstick ○ On side of bone Comminuted (shattered) ○ Multiple crushed fragments Falls Fracture manifestations Bruising Crepitation Deformity Edema Loss of function Muscle spasm Pain Tenderness Cant bear wt on fx extremity Traction Buck traction ○ Pulling force w wts  Hanging off of floor ○ Reduce pain ○ Muscle spasms ○ Immobilize joint ○ Short term Until surgery ○ Skin breakdown ○ Clean around rods Fracture immobilization Casts ○ Above and below fx ○ After closed reduction External fixation device ○ Wires in bone attach to rods ○ Pin care ○ Infection ○ Loose pins Internal fixation device ○ Pins ○ Rods ○ Surgically align and stabilize Fx therapy Pain meds Robaxin ○ Muscle spasms (relaxant) Tetanus ○ Open fracture Fluids Calcium and vit D3 and B12, protein, protein, fruits, veggies 5 P’s Pain Pulse Pallor Paresthesia Paralysis Fx nursing interventions Immobility ○ Constipation ○ Incr activity and fluids ○ Stool softeners ○ Renal stones  ○ Orthostatic hypotension ○ DVT, VTE ○ Atelectasis ○ Skin breakdown ○ Pneumonia Traction ○ Skin breakdown ○ Pin care ○ Position changes ○ ROM ○ cough/deep breathe ○ T: temp ○ R: ropes hang freely ○ A: alignment ○ C: circulation check (5 Ps) ○ T: type and location of fracture ○ I: increase fluid intake ○ O: overhead trapeze ○ N: No weights on bed or floor Casts ○ 5 p’s ○ Neurovascular checks ○ Edema ○ elevate/ice ○ Dont put anything in, take padding out, or get wet Ambulation ○ Pt mobility training ○ Wt and non wt bearing ○ Exercise joints Wiggle fingers and toes ○ Use of cane, crutch, walker ○ COAL Cane Opposite Affected Leg Infection Open fx Tissue and blood vessel injury Surgical debridement ○ Bone ○ Muscle ○ Tissue  ○ Fat Clean w saline irrigation Antibiotics Skin graft Compartment syndrome Swelling puts pressure on nerves and blood vessels Cut off blood supply ○ Ischemia ○ Necrosis Long bone fx Can lead to rhabdomyolysis ○ Dark urine means impending organ failure 5 p’s Tx ○ Neurovas checks ○ Don't elevate ○ No ice Constricts blood vessels more ○ Cut cast, loosen dsg ○ Fasciotomy Surgical decompression ○ Left open to drain ○ Amputation in severe cases VTE: Venous thromboembolism (VTE) is a condition that occurs when a blood clot forms in a vein. VTE can include deep vein thrombosis (DVT) and pulmonary embolism (PE) Hip fx, pelvic fx Lovenox Compression device ROM Fat embolism Long bones, pelvis Fat released from bone marrow ARDS, pulm edema s/s ○ Chest pain ○ Cyanosis ○ Dyspnea ○ Tachycardia ○ Loc change  - When you have low oxygen you will most likely have a higher heart rate because the heart is trying to pump faster to compensate Fluids, resp support, manage symptoms Prevention ○ Careful handling of long bones ○ Decr risk of fat droplets ○ dislodging Rhabdomyolysis Breakdown of muscle Release of myoglobin Obstructs renal tubules Leads to Acute Kidney Injury Low urine output Dark urine Elevated CK levels Post op care hip fx Incision for bleeding, infection Neurovas assessment ○ Color ○ Temp ○ Cap refill ○ Pulse ○ Edema ○ Sensation ○ Motor function ○ Pain Elevation Abduction ○ Pillow between legs Overhead trapeze PT for transfers and ambulation OT dressing self, socks, shoes Early ambulation ○ Day of surgery or first post op day Post op complications Pulm emboli DVT Pneumonia Muscle atrophy Infection Nonunion of bone  Mental deterioration Bed sores Femoral fx Blood loss Deformity Shortening Stabilize and immobilize Rod placement External fixation for open fx Compartment syndrome Health promo Manage DM Foot care No foot infections Smoking HTN management Amputation Preserve greatest extremity length Preserve function Disarticulation ○ Amputation through joint Home care amputation Clean and dry Dont shave skin No sunlight for 6 months Gentle massage once healed ○ Reduce scar tissue tightness Shrinker sock ○ decr swelling ○ Shape limb into prosthetic Dont soak in water Dont prop up when sitting or laying ○ Keep straight and flat Neurontin ○ Phantom limb pain Phantom limb pain Mixed signals from brain ○ Lose input from missing limb Mirror therapy  ○ Illusion that missing limb is moving Osteomyelitis Bone infection Causes ○ Open wound ○ Foreign body ○ Diabetic ulcers Bone death s/s ○ Bone pain ○ Swelling ○ Tenderness ○ Warmth ○ decr mvmnt ○ Fever ○ Chills ○ Nausea Leads to ○ Septicemia ○ Septic arthritis ○ Pathological fx Dx ○ Bone biopsy ○ Blood C&S ○ Wound C&S ○ CBC ○ C reactive protein ○ Bone scan ○ X ray Care ○ IV antibiotics 4-6 wks ○ Surgical removal of dead bone, tissue ○ Hyperbaric o2 ○ Amputation HBOT Hyperbaric o2 therapy Enhances body’s natural healing process by providing 100% pure o2 ○ Atmospheric pressure is incr and controlled Speed up healing of carbon monoxide poisoning, gangrene, stubborn wounds, and infections ○ Tissues starved of o2 Osteomalacia Bone loss Soft bones Vit d deficiency Bone pain Muscle weakness Pain worse at night decr serum, calcium, vit d Vit d, calcium, phosphorus supplements Osteoporosis Chronic, progressive Metabolic bone disease Low bone mass Fragile bones More common in women Pregnancy Breast feeding Menopause Bone scan for bone loss More common in hips, spine, wrists Weak bones lead to spontaneous fxs Management ○ Proper nutrition ○ Calcium, vit d ○ Exercise, wts build muscle strength ○ Prevent falls, fxs ○ No smoking ○ decr ETOH ○ Fosamax Daily or weekly ○ Reclast IV yearly ○ Evista Estrogen therapy Head trauma TBI: traumatic brain injury External force applied to the head and brain Causes disruption of physiologic stability locally and globally ○ At point of injury Incr in ICP  Changes in blood flow within and to brain Diffuse axonal injury: brain shifts/ rotates inside skull, causing long nerve fibers to tear ○ Shearing injury Swelling = compression ○ Can't expand ○ Ischemia Neg result may not stay neg ○ Slow bleeds dont show up immediately Hrs after injury ○ Internal bleed Wks after injury ○ Multisystem failure Cushing's triad (HTN, bradycardia, irregular breathing) Types of head injury Scalp laceration Skull fx ○ Test nasal and ear drainage for glucose ○ Pos = blue CSF test strip Diffuse head injury ○ Concussion N+V Confusion Vision change Post concussive syndrome ○ s/s last longer than they should ○ HA ○ Lethargy ○ Personality changes Diffuse axonal injury ○ Can result in vegetative state ○ Damage to axons Edema Disconnection ○ decr LOC ○ Incr ICP ○ Cerebral edema ○ Decoration Arms in ○ Decerebration Arms out Focal head injury ○ Lacerations of brain tissue from open/closed skull fx ○ Contusions bruising of brain  ○ Hematomas ○ Cranial nerve injuries ○ Local injury ○ Hematoma ○ Injury on opp side of trauma site Intracerebral bleed ○ Bleeding into brain tissue ○ Watch for sz size and location of bleed ○ Aneurysms ○ subarachnoid bleed Skull fx open/closed Basil fx Battle sign ○ Bruising around ears Raccoon eyes ○ Bruising around eyes Rhinorrhea ○ Thin ○ Mostly clear ○ Nasal drainage Otorrhea ○ Liquid from ear Test liquids for glucose ○ CSF Primary injury MVA Falls Recreational Blunt force trauma Damage to any part of brain ○ Tissue, blood, CSF Secondary injury hrs/days after injury Hypoxia Ischemia Hypotension Edema Incr ICP Slow brain bleed  ○ N+V ○ Severe HA ○ Monitor closely Brain hematoma Epidural ○ Skull and dura ○ s/s LOC HA N+V ○ Evacuate hematoma ○ Manage ICP ○ Insert catheter for constant ICP reading Subdural ○ Skull and outside of brain ○ Acute ○ s/s LOC Ha PERRLA High ICP Intracerebral ○ Subarachnoid ○ Death ○ Perm brain damage ○ Brain herniation Blood pushes brain Damages brainstem Dilated pupils Resp distress Head trauma Diffuse injury ○ Concussion Change in LOC ○ HA ○ Post concussive syndrome ○ 2 wks-2 months Nursing management GCS Neuro status CSF leak Primary survey Airway ○ Assume cervical spine injury w any suspected head and neck injury ○ Cervical collar ○ Relieve airway obstruction ○ CAT scan to visualize C7 Breathing ○ O2 PRN ○ RR, rhythm, depth ○ Symmetry of breath sounds ○ Arterial blood gas ○ O2 sat Circulation ○ Pulse ○ BP ○ Urine output ○ LOC ○ Check and control hemorrhage ○ Shock Disability ○ Quick neuro exam LOC Pupils GCS Exposure ○ Wounds ○ Prevent hypothermia ○ Quiet and calm environment ○ Head midline and in cervical collar GCS Eye opening response ○ 1-4 1 = no 4 = spontaneous Verbal response ○ 1-5 1 = no 5 = oriented x3 Motor response ○ 1-6 1 = no 6 = obeys commands  Total score ○ 15 = best ○ 8 or < = comatose ○ 3 = unresponsive Nursing assessment Oculocephalic reflex ○ Tilt head ○ Neg is eyes stay forward Brainstem affected CN 3 (oculomotor), 6 (abducens), 8 (vestibulocochlear) Oculovestibular ○ Ice water in ears ○ Causes nystagmus ○ Normal Eyes move away from cold water and slowly back ○ Abnormal Eyes dont move Unilateral dilated pupil ○ Compressed oculomotor nerve (3) Bilateral dilated and fixed pupils ○ Ominous sign Pinpoint pupils ○ Pons damage ○ Drugs Motor strength ○ Squeeze hands ○ Pronator drift test Arms out ○ Raise foot off bed ○ Bend knees Motor response ○ Spontaneous or to pain VS Neuro assessment Lacerations or soft tissue injury on skull Cleanse lacerations and cover w dsg Dont remove protruding objects Battle sign ○ Ecchymosis behind ear Raccoon eyes ○ Periorbital ecchymosis CSF leaks from ears  ○ Halo effect = glucose ○ Dont check for nuchal rigidity until spinal cord injury is ruled out PERRLA Nystagmus, dolls eyes Sensory and motor changes Cerebral perfusion pressure CPP ○ 80-100 ICP ○ 5-15 Inc CPP = inc ICP Net pressure gradient causing blood flow to the brian ○ Maintained w narrow limits ○ Too little pressure can cause ischemia ○ Too much can raise ICP s/s of ICP decr LOC ○ Restlessness ○ Disorientation ○ Lethargy ○ Drowsiness HA N+V Diplopia ○ Double vision Blurred vision Sz Behavior changes Memory changes Amnesia Late signs of ICP decr LOC ○ To coma level decr motor and sensory response Alterations in pupil size and response Cushings triad ○ Incr systolic BP ○ decr pulse ○ Widened pulse pressure ○ Incr RR Elevated temp  Papilledema ○ Optic disc swells Posturing Cheyne stokes resp Diagnostic testing skull/neck radiographs CT scan/MRI ABG ○ Hypoxia and hypercapnia EEG Cerebral angiography ICP and brain tissue oxygenation measurement ○ Licox catheter Doppler and evoked studies No lumbar puncture ○ Causes herniation Tx Maintain airway Maintain spinal cord precautions ○ Back board ○ Roll pt in one piece Continuous monitoring of neurological status prevent/treat incr ICP ○ Mannitol ○ decr HTN ○ decr temp ○ HOB elevated 30 degree ○ decr stimulation ○ Barbituate come ○ Catheter Maintain cerebral perfusion Sz precaution Surgical management ICP monitoring devices ○ Intraventricular catheter ○ Subarachnoid screw or bolt ○ Epidural catheter ○ Subdural catheter Monitors pressure Craniotomy ○ Extreme instances of incr ICP Drug therapy Mannitol, furosemide ○ Diuretic and vasoconstriction ○ decr ICP Glucocorticoids ○ decr inflammation and ICP Opioids, naloxone Neuromuscular blocking agents Antiepileptics Antipyretics Barbituate coma/sedatives Hyperventilation ○ decr cerebral blood flow and blood volume 0.9% NaCl ○ Hypertonic solution ○ decr ICP ○ Incr BP and CO ○ Pulls fluid from brain ○ D5 = incr ICP Tx and prevention of ICP Head midline and elevated 15-30 deg decr stimulation Analgesics and short acting sedatives Close monitoring of fluids Osmosis and diuresis Mild to moderate hyperventilation Controlled hypothermia Hematoma removal Sz precautions and anticonvulsants Barbiturate coma Craniectomy Prevention of resp comps Aggressive pulm hygiene Aspiration precautions Preventing incr ICP while suctioning ○ Hyperoxygenate before and after each pass ○ Pass no longer than 10 sec each ○ Fewest passes necessary ○ Avoid unnecessary airway stim Secure ET tube Dont touch carina w suction catheter Acute care post head injury Neuro assessments Monitor ICP Lubricate eyes ○ Loss of corneal reflex Loose pad under nose No sneezing/blowing nose No NTG Monitor sz Rehab Nutrition Prevent protein calorie malnutrition Monitor serum albumin Initiate feedings in 72 hrs post injury Maintain normoglycemia Assess gag reflex Use enteral tube feedings Prevent bleeding Monitor coagulation studies Prevent GI bleed ○ Use H2 inhibitors and antacids Suspect GI bleed with unexplained anemia ○ Hgb and Hct decr Suspect GI bleed Avoid ASA and NSAIDS CVA TIA Resolves in few hrs ○ Mini stroke s/s depend on location Loss of vision temporarily Transient hemiparesis ○ Slurred speech ○ Unilateral weakness Numbness Loss of sensation Ischemic stroke Thrombotic  ○ Most common cause of stroke ○ Vessel narrows Occluded then infarction ○ Older adults ○ DM, high chol, HTN ○ Pattern Single attack s/s occur over several hrs Intermittent progression over hrs or days Partial stroke w permanent neuro deficits Series of TIA’s followed by a stroke w permanent neuro deficits Embolic stroke ○ Embolus occludes vessel ○ Most originate from heart ○ AFIB, MI ○ Sudden symptoms ○ HA ○ Neurologic deficits Can be temp TPA in 3-4 hrs of onset Hemorrhagic stroke Intracerebral ○ Ruptured vessel ○ Most death within 48 hrs ○ HTN common cause ○ Sudden s/s HA N+V decr LOC 1 side weakness Face Arm Leg Hemiparesis Fixed dilated pupils Resp distress Posturing Coma Subarachnoid ○ Intracranial into CFS ○ Ruptured cerebral aneurysm ○ Trauma  ○ Silent killer s/s right CVA Left side hemiplegia Spacial perceptual deficit Minimizes problems Short attention span Visual field deficits Impaired judgment Impulsive Impaired time concept s/s let CVA Right side hemiplegia Impaired speech and language Slow performance Aware of deficits Depression, anxiety Impaired comprehension s/s CVA Sudden numbness/weakness in arms, face, legs Sudden confusion, trouble speaking, understanding speech ○ Aphasia Cant understand or express speech ○ Receptive aphasia Loss of comprehension ○ Expressive aphasia Inability to produce language ○ Global aphasia Total inability to communicate ○ Dysphasia Impaired ability to communicate ○ Dysarthria Problem w muscle control of speech Slurred, slow Sudden trouble seeing Sudden dizziness, inability to walk Sudden severe HA ○ This is the worst headache of my life FAST ○ Facial drooping ○ Arm weakness ○ Speech difficulty  ○ Time to call Affect ○ Cant control emotions Intellectual ○ Impaired memory, judgment Elimination ○ Constipated ○ Incontinent Dx Rapid head CT ○ Ischemic vs hemorrhagic MRI CTA Prevention Diet Exercise Manage risk factors decr sodium Low fat Normal BG ASA Coumadin and other coags ○ AFIB decr clots in atrium Statins Ischemic stroke acute care Onset of s/s time Unresponsive ABC’s O2, ETT, vent Neuro assessment Stroke center Code stroke HTN Fluids and electrolyte balance Ischemic stroke therapy TPA ○ IV bolus or into clot ○ Within 3-4 hrs of onset ○ Rule our hemorrhagic first  Monitor VS Monitor neuro status Heparin after TPA ○ Prevents more clots Stent placement in artery Hemorrhagic stroke acute care HTN< 160 sys Sz prophylaxis Remove hematoma surgically Clip or coil aneurysm CVA nursing management Card, resp, neuro assessment Current illness Onset of s/s Meds Hx of risk factors Family hx, med/surg hx Aspiration pneumonia risk Oral care Positioning Suctioning Cough and deep breathe PERRLA ICP Card rhythm I&O heart/lung sounds VTE/ROM Prevent contractures G tube, PPN, swallow study ○ In first 24 hrs NIH stroke scale 0 = no 1-4 = minor 5-15 = moderate 16-20 = moderate to severe 21-42 = severe Bacterial meningitis At risk  ○ College dorm students and institutionalized pts Causes ○ Streptococcus pneumoniae Incr CSF and ICP Highly contagious ○ Resp transmission ○ Cough, sneezem droplet Bacterial meningitis s/s HA Fever N+V Nuchal rigidity decr LOC Sz Skin rash Bacterial meningitis comp High ICP Altered mental Residual neurologic dysfunction ○ Cranial nerves Hemiparesis Dysphasia HA Sz Coma Death Bacterial meningitis dx Blood C+S CT Labs ○ Bacteria ○ WBC MRI H&P Neuro assessment Bacterial meningitis interprofessional care Antibiotics after CS ○ Ampicillin ○ Penicillin ○ Vanco  ○ Ceftin Health promo ○ Flu and pneumonia vax ○ Meningococcal vax Bacterial meningitis acute care VS Neuro I&O Resp assessment Pain relief ○ HA ○ Neck pain HOB sl elevated Dark room Minimize stimuli Treat sz ○ Kepra ○ Dilantin Treat fever ○ ASA ○ Cooling blanket Resp isolation - droplet Viral meningitis Causes ○ Enteroviruses ○ HIV ○ Herpes ○ Direct contact w resp secretions s/s ○ HA ○ Fever ○ Stiff neck ○ Photophobia GI GERD Affects LES ○ Opens to let food into stomach ○ Closes to prevent food and acid up into esophagus  LES is weak ○ Lets stomach contents into esophagus GERD risk factors Obesity Smoking Hiatal hernia Pregnancy Fried, fatty foods ETOH Coffee Peppermint Drugs decr LES pressure ○ Antidepressants ○ Asthma meds ○ Sedatives GERD s/s Heart burn Dyspepsia ○ Pain in epigastric area Regurgitation Cough Dyspnea Wheezing Sore throat Chest pain ○ Maalox ○ Pain goes away = GERD Not angina GERD complications Esophagitis Barretts esophagus ○ Precancerous lesion Resp complications GERD dx H&P ○ Nutrition s/s ○ Depends on what relieves pain Drugs Upper GI endoscopy w biopsies ○ NPO and sedated  ○ Tube into mouth to somach to biopsy stomach lining pH monitoring ○ 24 hrs Barium swallow GERD care Avoid trigger foods and drugs Low fat Small frequent meals Sit up after eating No eating 65 yrs Prolonged immobility URI Head injury Sz Anesthesia Stroke Immunosuppressive disease Tube feeding Smoking Intubation Tracheostomy Pneumonia types Community acquired ○ Streptococcus pneumoniae ○ Resp virus ○ Legionella ○ Staphylococcus aureus ○ Fungi Hospital acquired ○ Pseudomonas ○ Klebsiella ○ Staph aureus ○ Strep pneumoniae Vent associated pneumonia Aspiration pneumonia Trigger inflammatory response Stomach acid Bacterial Aspiration pneumonia risks Sz ETOH Head injury Stroke Anesthesia NG tube Pneumonia s/s Cough Fever Chills SOB Tachypnea Pleuritic chest pain Sputum Confusion Hypothermia ○ Older pt Anorexia HA PE ○ Crackles ○ Egophony ○ Increased fremitus Pneumonia comp Atelectasis Pleurisy Pleural effusion Bacteremia Pneumothorax Meningitis Acute resp failure Sepsis Lung abscess Pneumonia dx h&p C&S Chest x ray Pulse ox ABGs Incr WBC Blood culture Pneumonia care Antibiotics ○ Zithromax ○ Levaquin ○ Augmentin  ○ Zosyn O2 Analgesics Antipyretics Hydration Rest Resp assessment Oral hygiene Pneumonia management Prevent aspiration Positioning Ambulation HOB 30 w meals, NG feeds ○ Assess gag reflex Oral hygiene Infection control C&S Chest PT TB risks HIV Minorities Homeless IV drug abuse Foreign born TB Airborne precaution ○ Neg airflow Primary ○ Have organism ○ No disease Latent ○ Pos skin test ○ Has organism ○ No active TB ○ Not infectious ○ No s/s ○ Can develop any time Active ○ Infectious ○ Pos chest x ray ○ Pos sputum TB s/s 2-3 post infectious Dry cough ○ Secretions Fatigue Anorexia Low grade fever Night sweats Flu s/s Crackles SOB late symptom Hemoptysis TB comp Lung scarring Effects other organs TB dx Skin test Mantoux test Purified protein derivative Implanted intradermal forearm ○ Results in 48-72 hrs by inspection/palpation ○ Induration and exposure > or equal to 10mm = + Measure the area to see Interferon y release assays ○ Finds t cell lymphocytes Response to mycobacteria ○ quantiFERON TB and T SPOT.TB tests ○ Rapid results ○ More expensive Chest x ray ○ Cant make dx only on this ○ Upper lobe infiltrates ○ Pleural effusion Sputum specimen ○ 3 specimen ○ 3 days early mornin ○ 8 wks for results ○ Start tx if suspected TB tx  Active TB ○ Initial phase 2 month/8 wks Isoniazid QD Rifampin QD SE ○ Orange color sputum, tears, urine Pyrazinamide QD Ethambutol QD ○ Continuous phase Isoniazid and rifampin QD for 18 wks Latent TB ○ Isoniazid QD for 9 months Prevent active Adverse effects of meds Infectious 2 wks after tx Strict adherence ○ Relapse DOT Avoid ETOH ○ Hepatotoxicity ○ Hepatitis Closed chest trauma Rib fracture ○ Blunt trauma ○ Chest pain Inspiration ○ Cough ○ Splinting at site Flail chest ○ Mult rib fx/sternum ○ Incr RR, HR ○ Paradoxical chest ○ O2 ○ Pain meds ○ Vent  ○ Surgery Open chest wound GSW Stabbing Leave object in place ○ Taken out in OR Chest tube Cover wound on 3 sides ○ 1 side open so air can escape Pleural effusion Accumulation of fluid in pleural space Empyema ○ Collection of purulent fluid Pneumonia, TB, abscess SOB Chest pain on inspiration Diminished breath sounds Fever Night sweats Cough Wt loss Thoracentesis ○ Remove fluid VS Pulse ox Resp assessment SE of rapid removal ○ Low BP ○ Hypoxemia ○ Pulm edema Pulm embolism Thrombus blockage in pulm artery DVT A fib Ft emboli ○ Fx CT scan Rapid assessment ○ O2 ○ ABG ○ Intubation Pulm embolism risk factors Immobility Post op Obesity Smoking Clotting disorder Pulm embolism s/s Depends on size SOB Hypoxic Tachycardia Chest pain LOC change Feeling of doom Low BP Hgh HR Crackles Pulm embolism comp Infarction of lung tissue Pulm embolism tx Anticoagulation ○ Lovenox ○ Coumadin ○ Activase Surgery ○ Pulm embolectomy ○ Inferior vena cava filter Rhinitis causes Inflammation of mucus membranes in nose Allergic Nonallergic Seasonal Rhinitis s/s Sneezing Runny nose Watery eyes Rhinitis tx Tx cause Fluids Expectorants ○ Mucinex Antihistamines Tylenol Antibiotics if bacterial Rhinosinusitis Pharyngitis Inflammation throat or tonsils Strep throat Pain Swelling Exudate Fever Malaise Throat culture Antibiotics ○ PCN Pharyngitis management Pt teaching Ret Saline gargles Ie collar Full course of antibiotics Hand hygiene Obstructive sleep apnea Upper airway obstruction Apnea episodes Obese Male Age Structural changes Snoring Sleep study Position therapy CPAP BiPAP Pulm edema  Non cardiac causes ○ Lung injury ○ Aspiration ○ Sepsis ○ Infection ○ Smoke inhalation ○ Mult blood transfusions Pulm edema s/s Cough Dyspnea Anxiety Cool moist skin Tachycardia JVD Frothy bloody sputum O2 Diuretics NTG ARDS Hypoxemia decr pulm compliance Dyspnea Noncardiogenic bilateral pulm edema Dense pulm infiltrates Alveolar cap interface becomes damages and more permeable to intravascular fluid Alveoli fill w fluid Usually after acute catastrophic event ARDS risks Pneumonia Lung contusion Aspiration Shock Sepsis Mult trauma O2 toxicity Pancreatitis ARDS phases Exudative ○ 1-7 days after lung injury ○ Damage to vascular endothelium  ○ Incr cap permeability ○ Hypoxemia ○ Excess fluid in lungs Proliferative ○ 1-2 wks after injury ○ Incr neutrophils, monocytes, lymphocytes ○ Fibrolast proliferation ○ Lung is dense and fibrous ○ Lung compliance decor Stiff and shock Fibrotic ○ 10-14+ days ○ Inflammation resolves ○ Oxygenation improves and extubation possible ARDS s/s Hyperpnea Grunting resp Cyanosis Pallor Chest pain Retraction intercostally and suprasternal Diaphoresis Changes in mental status Fatigue Fever Hypotension Tachycardia Dysrhythmias Decor PaO2 ARDS dx H&P Wheezing Rhonchi Rales Crackles ABGs Chest x ray Blood work Sputum C&S Bronchoscopy Chest CT  ECG ARDS management O2 ○ High flow ○ SpO2 continuous monitoring ○ Give lowest concentration = >90 PaO2 ○ Toxicity if FiO2 >60% for 48 hrs ○ Mechanical vent with PEEP Positioning ○ Prone Reduce inspired O2 or PEEP ○ Chest PT ○ Turn frequently ○ Nebulizer Asthma classification Intermittent ○ Symptoms < 2x/wk ○ Night < 2x/month ○ SABA < 2x/wk Albuterol Ventolin Proventil Atrovent Xopenex Moderate ○ Daily s/s ○ > 1/wk night ○ SABA daily Severe ○ Continuous s/s ○ 7/wk night ○ SABA mult/day ○ Progress rapidly Status asthmaticus ○ Not responding to tx Asthma physical Audible wheeze on exhalation Incr resp rate and cycle Accessory muscles Round chest Cyanosis  Decr pulse ox Asthma dx Chest x ray r/o pneumonia FB Asthma tx Intermittent SABA ○ Rescue inhaler ○ Albuterol ○ Ventolin ○ Caution w cardiac disorders ○ SE HA Heart palpitations Nervousness Persistent asthma LABA ○ Daily long acting therapy ○ Advair ○ Dulera ○ Symbicort ○ Spirvia ○ Theophylline Corticosteroids inhaled ○ Inflammation ○ Pulmicort ○ Flovent ○ Symbicort ○ SE Sore throat Cough Thrust Decr bone density Leukotriene modifiers ○ Block leukotriene ○ Singulair Acute exacerbation ○ Assessment ○ RR ○ HR ○ Lung sounds COPD risk  Cigarette smoking Second hand smoking Occupation chemicals Air pollution Infection Genetics ○ Antitrypsin deficiency Aging Asthma COPD s/s Chronic cough SOB on exertion Chest heaviness/tightness Wheezing Fatigue Wt loss Barrel chest Tripod position Sit up 90 deg Pursed lip breathing Comp of COPD Cor pulmonale Pulm HTN SOB Crackles Decr LS Use of accessory and intercostal muscles Right HF Distended neck veins Wt gain Bronchodilator Diuretics Endocrine Hormone regulation Neg feedback ○ Most common ○ Decr reaction to slow it down Pos feedback ○ Less common ○ Incr reaction to make it happen faster  NS control ○ Pain ○ Emotion ○ Stress Glands Anterior pituitary ○ TSH ○ Growth hormone ○ ACTH ○ Adrenocorticotropic Adrenal cortex to release corticosteroids Posterior pituitary ○ ADH ○ Oxytocin Pineal ○ Melatonin Thyroid ○ T4 thyroxine ○ T3 triiodothyronine ○ Calcitonin Parathyroid ○ PTH Reg blood calcium Adrenal ○ Upper kidneys ○ Adrenal medulla Catecholamines Epinephrine Norepinephrine Dopamine Fight or flight ○ Adrenal cortex Steroids Cortisol Aldosterone Pancreas ○ Islets of Langerhans Glucagon Low glucose Protein intake Exercise Insulin Metabolism  Storage of carbs, fats, proteins Helps glucose transfer into cells Complaint and likely condition Nocturia, night sweats, sleep apnea ○ Diabetes HA ○ Abnormal pituitary growth Menstrual dysfunction ○ Ovaries ○ Pituitary ○ Thyroid ○ Adrenal heat/cold intolerance ○ hyper/hypothyroidism Constipation ○ Hypothyroidism ○ Hypoparathyroidism ○ Hypopitutarism Facial hair in women - hirsutism ○ Too much testosterone ○ Adrenal medulla ○ Cushings syndrome ○ Excessive prolactin Hyperpigmentation ○ Addisons disease Wt loss and incr appetite ○ Hypethyroidism ○ DM Wt gain and leathery skin ○ Hypothyroidism Trunk obesity, thin extremities, incr body hair, purple striae, moon face ○ Hypercortisolism Cushing syndrome Obesity, incr thirst, urination ○ Pancreas disorder Diabetes T2 Enlarged thyroid, difficulty swallowing ○ Thyroid goiter SNS activity: nervousness, palpitations, sweating, tremors ○ Thyroid dysfunction ○ Adrenal medulla tumor Gynecomastia ○ Hypogonadism Dx Pituitary ○ Growth hormones Fasting blood test ○ Gonadotropins FSH LH LMP Menopause ○ MRI ○ CT to r/o tumors Thyroid ○ TSH most sensitive 0.5-4.5 ○ T4 and T3 levels ○ Thyroid antibodies Autoimmune disease ○ Ultrasound Cyst Tumors ○ Thyroid scan and uptake Radio iodine uptake Parathyroid ○ PTH Fasting blood drawn and on ice ○ Calcium Bone and parathyroid disorders ○ Phosphate ○ Parathyroid scan Imaging Adrenal ○ Cortisol Adrenal cortex function Drawn in morning ○ Aldosterone AMbloon draw Hyperaldosteronism ○ ACTH Adrenal cortex secretion ○ MRI to r/o tumors ○ CT Pancreatic ○ Fasting blood sugar  Fast 8-12 hrs ○ Oral glucose tolerance test Fast 8-12 hrs Abnormal FBG that doesnt indicate DM Drink 75g of test at 30, 60, 120 min ○ HG a1c Glycemic control over 3 months Amt of glucose linked to hgb ○ Urine glucose and ketones Diabetic acidosis ○ CT r/o tumors and cysts Acromegaly Incr GH Rare Both genders Onset 40-45 yrs Caused by benign pituitary tumor ○ Adenoma Overgrowth of soft tissues and bone Hands, feet, face Acromegaly s/s Big hands, feet, face Joint pain Carpel tunnel syndrome Thick bones and soft tissue Big tongue ○ Speech problems Sleep apnea ○ Upper airway narrowing Thick leathery oily skin Muscle weakness Menstrual disturbances Visual changes ○ Pressing on optic nerve HA s/s of DM ○ Affects insulin ○ Leads to hyperglycemia Atherosclerosis ○ Incr fatty acid levels Acromegaly dx GH levels IGF 1 ○ Insulin like growth factor 1 GH response to OGTT ○ Incr GH = incr IGF 1 MRI ○ r/o tumors CT Acromegaly tx Depends on age, onset, tumor size Surgery ○ Hypophysectomy ○ Endoscopic transsphenoidal Radiation Drugs ○ Sandostatin (octreotide) decr GH levels SQ 3x wk or IM every 4 wk GH levels guide dosage every 2 wks ○ Permax decr GH tumor Bone growth stops, not reverses Sleep apnea, diabetic and card comp may continue Acromegaly intervention post op HOB 30 and bed rest ○ decr stimuli Neuro assessment Post op hemorrhage No brushing teeth ○ Protect suture site Mouth care No sneezing, coughing, straining ○ Avoid CSF leak ○ Test for glucose ○ Risk for meningitis Spinal tap Hormone replacement ○ GH ○ ADH ○ Thyroid ○ FSH  ○ LH Assess for DI ○ Due to loss of ADH I&O SG of blood and urine High risk ○ Colorectal ca ○ Colonoscopy q 3-4 yr Hypopituitarism 1+ hormone deficiencies ○ GH ○ LH ○ FSH Causes ○ Radiation ○ Pituitary tumor ○ Autoimmune ○ Infection ○ AA prone Hypopituitarism s/s HA Visual changes Loss of smell N+V Sz Hypopituitarism dx H&P MRI/CT ○ r/o tumor TSH T3 and T4 GH ACTH Hypopituitarism tx Surgery to remove tumor Radiation Lifelong hormone therapy Somatropin ○ HG ○ SQ daily in evening  GH, corticosteroids, thyroid hormones ○ Sometimes need estrogen and progesterone SIADH High ADH Older adults Causes ○ Malignancy ○ Small cell lung cancer ○ Brain cancer ○ Head injury ○ Drugs Chemo ○ Adrenal insufficiency ○ Chronic if cancer is the cause SIADH s/s Fluid retention ○ Wt gain w/o edema decr plasma osmolality Delusional hyponatermia ○ Below 120 Hypochloremia Concentrated urine GFR incr Low UO Initial s/s ○ Thirst ○ SOB on exertion ○ Fatigue Progressive s/s ○ Vomit ○ Muscle twitchin ○ Sz ○ Cerebral edema ○ Coma SIAD dx Serum sodium < 134 Urine sg > 1.025 Serum osmolality < 280 ○ Norm: 278-300 SIADH tx  Monitor I&O, VS, heart and lung sounds Hyponatremia s/s Fluid restriction ○ 800-1000/day Daily wts Sz precaution Lasix, samsca ○ Treat low sodium Declomycin ○ Block effects of ADH DI decr ADH or renal response to ADH Causes ○ Central DI Most common Brain tumor Head injury Brain surgery ○ Nephrogenic DI Drug therapy Lithium Renal damage ○ Primary DI Too much water DI s/s Polyuria ○ 2-20L/day Polydipsia ○ Excessive thirst Urine SG < 1.005 Urine osmolality < 100 Serum osmolality > 295 Hypernatremia Dehydration Low BP Tachycardia Poor skin tugor Hypovolemic shock DI dx SG < 1.005 Central DI w water deprivation test ○ No water 8-12 hrs then give DDAVP  Desmopressin acetate Central DI ○ Incr in urine osmolality ○ decr in UO Measure ADH DI tx Central DI ○ Fluid and hormones ○ DDAVP ○ Pitressin IV fluids for UO ○ d5W Electrolytes VS LOC BP I&O Urine SG UO DI SIADH High UO Low UO Low ADH High ADH Hypernatremia Hyponatermia Dehydrated Over hydrated Lose too much fluid Retain too much fluid Both present w excessive thirst Goiter Enlarged thyroid Hyper or hypothyroidism Cause ○ Low iodine Broccoli Cabbage Kale Peanuts Iodized salt  Nodules on gland usually benign TSH, T4, thyroid antibodies Goiter tx Hormone to prevent further enlargement Surgery to remove large goiters Thyroiditis Abrupt onset Thyroid pain Fever’chills Sweats Fatigue Hashimotos thyroiditis ○ Hypothyroidism ○ Thyroid tissue destroyed by antibodies At risk ○ White ○ Female ○ Family hx ○ Older Tx ○ Hormones ○ Antibiotics Hyperthyroidism Females > males 20-40 yr Smoking Stress Graves disease Causes ○ Toxic nodular goiter ○ Thyroiditis ○ Excess iodine ○ Pituitary tumors ○ Thyroid cancer Graves disease Autoimmune ○ Unknown cause Thyrotoxicosis ○ Incr T3 and T4 Destroyed thyroid causing hypothyroidism Graves s/s Palpable goiter Abnormal eyes ○ Exophtalmos Dry irritated cornea Ulcers Loss of vision Diplopia Wt loss Incr metabolism Incr appetite and third Nervous Incr SNS Cardio s/s ○ Tachycardia ○ HTN Intolerance to heat Menstrual irregularities Clubbed fingers Graves comp Thryotoxicosis ○ Thyroid storm/crisis ○ Cause Infection Trauma Surgery Thyroidectomy ○ Hyperthyroid s/s more severe ○ Tachycardia ○ Hyperthrmia ○ Shock ○ Sz ○ Coma Graves dx H&P Labs Low TSH High T3, T4 Free T4 Radioactive iodine uptake Graves vs other thyroiditis forms Graves tx Drugs ○ PTU (propylthiouracil), Tapazole 4-6 wks ○ Iodine, SSKI (potassium iodine) ○ Propranolol, atenolol ○ Radioactive iodine therapy ○ Thyroidectomy ○ Subtotal thyroidectomy ○ Nutrition Graves interventions Acute thyrotoxicosis ○ ICU ○ Drugs ○ Cardiac monitoring Dysrhythmias ○ O2 ○ IV fluids for electrolytes ○ Rest ○ quiet/cool room ○ Passive ROM exercises Exophthalmos ○ Pain meds ○ Artificial tears ○ Saltrestiction decr edema ○ HOB elevated ○ Dark glasses Thyroidectomy comp ○ Hypothyroidism ○ Hypoparathyroidism ○ Hemorrhage ○ Infection ○ Laryngeal nerve damage Vocal paralysis ○ Spastic airway obstruction Immediate trecheostomy Have trach at bedside O2 suction Laryngeal stridor ○ Swelling neck Asses pt every 2 hrs x 24 hrs  ○ Bleedin ○ Breathing ○ Swelling ○ VS Avoid neck flexion Semi fowlers Calcium ○ Hypoparathyroidism ○ Tingling toes and fingers Pain meds Complete thyroidectomy hormone replacement ○ Synthroid Hypothyroidism Slow metabolic rate Women > men Primary ○ Destruction of thyroid tissue Hashimotos Secondary ○ Pituitary disease w incr TSH Iodine deficiency Hypothyroidism s/s Fatigue, lethargy Impaired memory Depression decr CO SOB on exertion Anemia Bruising Cold intolerance Incr cholesterol Myxedema ○ Severe hypothyroidism ○ Dry, coarse, sparse hair ○ Thin lateral eyebrows ○ Periorbital edema ○ Puffy dull face ○ Dry skin Hypothyroid comp Myxedema coma ○ Prolonged hypothyroidism  Causes ○ Infection ○ Trauma ○ Cold exposure Hypothermia Hypotension Hypoventiltion Cardiovascular collapse Tx s/s and IV thyroid hormones Hypothyroidism dx H&P TSH and T4 Cholesterol and triglycerides levels incr Anemia Hypothyroid tx Synthriod Low calorie diet Levothyroxine (synthroid) Start w low dose Monitor for cardio SE ○ Chest pain ○ Dysrhythmias ○ HR Report anything over 100 beats/min or irregular HB Wt loss Nervousness Tremors Insomnia Incr in dose in 4-6 wk intervals Lifelong tx Frequent MD followups AM before breakfast Hypothyroidism tx Pt teaching Life long therapy Regular follow ups Myxedema ○ ICU care ○ Cardiac monitoring ○ Mechanical vent  ○ Monitor core temp ○ VS ○ Daily wt ○ I&O ○ Neuro status ○ Good skin IV thyroid hormones ○ Paralytic ileus is common Hyperparathyroidism Hypercalcemia Hypophophatemia Women > men 1% of pop decr bone density Hyperparathyroidism s/s Hypercalcemia Muscle weakness Loss of appetite Constipation Fatigue Osteoporosis Fx Kidney stones Renal failure Card changes ○ Dysrhythmias ○ HTN Hyperparathyroidism classification Primary ○ PTH incr ○ Cause Benign tumor Radiation to head and neck Long term lithium Secondary ○ Low calcium Vit d deficiency Malabsorption Chronic kidney disease Tertiary ○ After kidney transplant  ○ Long periods of dialysis For CKD and ESRD Hyperparathyroidism dx PTH high High calcium Low phosphorus Bone density test MRI/CT to r/o tumor Normal serum calcium: 8.5-10.2 Normal serum phosphorus: 2.4-4.1 Hyperparathyroidism tx Surgical ○ partial/complete removal of gland Endoscopy Nonsurgical ○ Mild symptoms Drugs ○ Decr calcium levels Fosamax Aredia Sensipar ○ Phosphate supplements Incr fluids Serum PTH Calcium Phosphorus Creatinine BUN levels Hyperparathyroidism interventions Post op parathyroidectomy Hemorrhage Fluid and electrolyte I&O Tetany ○ Low calcium Chvosteks and trousseaus sign ○ Low calcium Teach s/s of hyper and hypocalcemia Hypoparathyroidism Uncommon  Low PTH and calcium Cause ○ Genetic ○ Iatrogenic Damage of gland by neck surgery ○ Tumors ○ Heavy metal poisoning ○ Chronic alcoholism Hypoparathyroidism s/s Hypocalcemia ○ Tetany Pos chvosteks and trousseaus ○ Dysphagia ○ Muscle spasms ○ Laryngeal spasms Resp distress Labs ○ Decr calcium and PTH ○ Incr serum phosphate levels Hypoparathyroidism interventions Emergency treatment of tetany ○ IV calcium chloride ○ Calcium gluconate ○ Given slowly Can cause necrosis of tissue check Check IV infiltration Cardiac and BP monitoring ○ Hypotension ○ Dysrhythmias ○ Cardiac arrest from IV calcium Long term PO calcium supplements Deity high in calcium Follow up care and monitor calcium Cushing syndrome Excessive corticosteroids Cause ○ Iatrogenic corticosteroids Prednisone ACTH secreting pituitary adenoma Adrenal tumor First signs  ○ Truncal obesity ○ Generalized obesity Moon face Purple red striae ○ Abd ○ Breasts ○ Butt Menstrual disorders HTN Hypokalemia Hyperglycemia Osteoporosis Back pain Anxiety Cushing syndrome dx High cortisol High urine cortisol ○ 24hr collection ○ Higher than 80-120 Abnormal ACTH CT or MRI to r/o tumors Cushing syndrome tx Depends on severity Pituitary adenoma ○ Remove pituitary ○ Radiation Adrenalectomy ○ Adrenal tumors ○ laparoscopic/open is malignant Drugs ○ Nizorol ○ Cytadream ○ Lysodren ○ Prednisone Must be tapered off Pos self image Physical changes resolved w tx Cushing syndrome interventions Assess for hormone and drug toxicity ○ Prednisone  VS Daily wt Possible infections Thrombolytic events Pulm emboli Sudden chest pain SOB Emotional support Cushion syndrome care Pre op ○ Adrenalectomy Stabilize pt Optimal condition Post op ○ Most crucial period is 24-48 hrs after ○ Hemorrhage ○ BP ○ Fluid and electrolyte ○ IV solu cortef During and after Anti inflammatory glucocorticoid ○ Thrombolytic precaution ○ Infection control Addisons disease Adrenocortical insufficiency Hypofunction of adrenal cortex All corticosteroids reduced ○ Secondary cause Lack of pituitary ACTH Common cause ○ Autoimmune TB Fungal infection AIDS Metastatic cancer Adrenal hemorrhage Chemo Addisons s/s Not until 90% of adrenal cortex is killed Slow onset Weakness  Fatigue Wt loss Bronze skin Palmar creases Orthostatic hypotension Hyponatermia Hyperkalemia N+V, D Irritable Depression Addisons comp Addisonian crosis ○ Acute adrenal insufficiency ○ Insufficient or sudden decr in hormones ○ Life threatening ○ Triggered Stress Infection Sudden corticosteroid withdraw Adrenal surgery Addisons s/s Severe orthostatic hypo Tachycardia Dehydration Hyponatremia Hyperkalemia Hypoglycemia Faver Weakness Confusion Lead to shock circulatory collapse N+V, D Pain Addisons dx Low serum and urine cortisol ACTH high in primary ○ Low in secondary Hyperkalemia Low chloride Low NA Low glucose  Anemia High BUn MRI tumors Fungal infection TB Addisons tx Managing the cause Hormone replacement Hydrocortisone Florinef ○ Mineralocorticoids daily Increase salt Addison crisis ○ Manage shock w high dose of hydrocortisone replacement Addisons interventions Correct fluid and electrolytes VS Wt BP ○ Hypotension Serum gl NA and K levels Mental status Control infection Protect from noise, light ○ Cant cope due to decr corticosteroids Addisons home care Life long hormones Glucocorticoids in divided doses ○ Prednisone ○ ⅔ AM, ⅓ PM Mineralocorticoids ○ Fludrocortisone ○ Florinef ○ Acetate ○ Once in AM Avoid extreme temp, infection, stress Teach how to adjust meds s/s to call dr and adjust meds based on stress No emotional, physical stress Illness  Fever Incr exercise Dont abruptly dc meds DM ○ Monitor blood gl Renal Urine studies Urinalysis ○ First morning void ○ General exam ○ Wash perineal area ○ Color, clarity, odor ○ Protein ○ GL ○ Ketones ○ Bilirubin ○ SG ○ pH ○ RBC ○ WBC Creatinine clearance ○ 24 hr collection ○ GFR Amount of blood filtered per min ○ Discard first urine and keep on ice Urine culture ○ Confirms UTI ○ Identifies causative organism ○ Done when WBC detected in urine BUN ○ Amount of urea in blood is ○ Regulated by rate of excreted urea ○ Normal level 6-20 Creatinine ○ More reliable than BUN for renal function ○ Normal level 0.6-1.3 BUN:Creatinine ○ 12:1 to 20:1 ○ Increased ratio decr blood flow HF Dehydration  ○ Decreased ratio Liver disease Sodium ○ Normal level 135-145 ○ Late sign of renal failure Potassium ○ First electrolyte to become abnormal Radiologic procesures Renal arteriogram ○ Similar to card cath ○ Dye inserted to view blockages Assess for iodine, shellfish, dye allergy May become flushed w salty taste in mouth Force fluids after ○ Check BUN and creatinine before ○ Pressure dsg to groin Assess for bleeding, hematoma ○ Keep leg stragih ○ Check pedal pulse Cystoscopy ○ Obtain biopsy ○ Remove ○ Stones ○ Visualize mass ○ Camera inserted into bladder UTI (cystitis) Common cause ○ Bacteria that move from external urethra to bladder E coli Trauma Irritation Catheter related infections Can take place in 48 hrs Lower UTI (cystitis) Bladder and urethra Urethritis No symptomatic s/s Upper UTI (pyelonephritis) Kidneys, renal parenchyma, renal pelvis, ureters Fever  Chills Flank pain Urosepsis ○ Bacteremia ○ Women ○ DM ○ Immunosuppressed ○ Elderly ○ Leads to septic shock ○ MOF ○ death Lower UTI risks HAIs CAUTIs ○ Most common cause of HAIs Obstruction Calculi DM Alkalotic urine Gender Age Sex Poor hygiene Cystitis s/s Dysuria Frequency Urgency Suprapubic discomfort Sediment Cloudy Foul smelling Hemturia Fatigue Anorexia Cystitis dx h&p Urine dip stick Urinalysis Urine c&s Ct Renal ultrasound  ○ Masses ○ Stones ○ Strictures Cystitis tx Antibiotics ○ Bacterial Trimenthoprum and sulfamethoxazole (bactrim, Septra) Nitrofurantoin (Macrodantin) Ampicillin, amoxicillin, cephalosporins Cipro, Levaquin 1-3 days or 7-14 days ○ Fungal infection Diflucan Analgesic ○ Phenazopyridine (Pyridium) Turns urine and mucous membranes orange Lower UTI intervention Adequate fluids Perineal hygiene Empty bladder completely and regularly Avoid catheterizations Local heat Sitz bath Full course of antibiotics Report ○ Recurrent dysuria ○ Frequency ○ Fever ○ Urgency Earl removal of catheters Pyelonephritis causes Begins with lower UTI E coli Proteus Klebsiella Vesicoureteral reflux Obstruction Frequent catheterizations Pregnancy Pyelonephritis s/s  UTI Fever Chills N+V Flank pain CVA tenderness Pyuria Pyelonephritis dx h&p Urinalysis CBC Blood cultures CT Renal ultrasound Pyelonephritis tx Mild s/s ○ Antibiotics 14-21 days ○ Adequate fluids ○ NSAIDs ○ Antipyretics ○ Follow up urine culture Severe s/s ○ Hospitalization ○ IV antibiotics Pyelonephritis interventions Early tx Continue meds Follow up urine culture Adequate fluid intake ○ 8 8oz glasses a day Rest Chronic pyelonephritis Kidneys shrink and lose function Scarring From recurring infection Dx by renal biopsy and imaging Can lead to ESKF Glomerulonephritis 3rd leading cause of ESKD  Acute can be temp and reversible Chronic is irreversible Most common type ○ Acute post streptococcal glomerulonephritis Acute post streptococcal glomerulonephritis s/s Generalized edema decr GFR HTN Oliguria Hematuria Rust colored urine Proteinuria Abd or flank pain Acute post streptococcal glomerulonephritis dx h&p Renal biopsy Urinalysis Proteinuria BUN Serum creatinine Acute post streptococcal glomerulonephritis tx Symptomatic Rest decr sodium, protein, potassium decr fluids Strict I&O Daily wt Diuretics Antihypertensive Antibiotics ○ PCN Prevention ○ Treat sore throats and skin lesions early ○ Lead to chronic and ESKD Nephrotic syndrome Incr glomerular permeability ○ Lets big molecules through Severe loss of protein in urine Edema  decr plasma albumin Causes ○ Diabetes ○ Systemic lupus ○ Infections Strep Comp ○ Thromboembolism from hypercoagulability Nephrotic syndrome s/s Massive edema Ascites Massive proteinuria HTN Hyperlipidemia decr serum protein Hypocalcemia Hypercoagulability Nephrotic syndrome tx Treat cause CM Lupus Corticosteroids ○ Prednisone Mild diuretic for edema Fluid restriction Diet restriction ○ Low Na ○ High protein Hyperlipidemia meds HTN meds Heparin Urinary tract calculi Risks ○ Family hx ○ Climate ○ Warm Dehydration ○ High protein, calcium, tea, fruit juices ○ Metabolic factors Incr urine levels of calcium, uric acid, citric acid ○ Keep urine diluted and free flowing  Reduces stone formation Urinary calculi s/s Sudden severe flank, back, abd, groin pain Renal colic spasm Radiating to groin Morse intense when stone is moving N+V Diaphoresis Pale Hematuria Urinary calculi dx h&p KUB CT w no contrast Renal ultrasound IVP Urinalysis ○ Hematuria ○ pH ○ Type of stone 24 hr urine ○ Type of stone ○ Recurring calculi Urinary tract calculi tx Pain relief ○ Opioids Morphine Vicodin ○ NSAIDs Toradol Infection Antispasmolytics ○ Relaxes muscles in ureter ○ Flomax ○ Ditropan ○ Bentyl ○ Hytrin Antiemetics Cystoscopy Cytolitholapaxy Flexible ureteroscopes  Extracorporeal shock wave lithotripsy Ureteral stent ESWL Non invasive Sound, laser, dry shock ○ Breaks stone up Topical anesthetic EKG monitoring Post ○ Strain all urine ○ Place stent Facilitate passage of gravel Removed in 2 wks ○ Hematuria Common Urinary calculi surgery Depends on location Nephrolithotomy ○ Kidney Ureterolihotomy ○ Ureters Cystotomy ○ Bladder Post op ○ Hematuria ○ Infection prevention ○ Diet tx Type of calculi decr foods high in causative Calculi prevention Incr fluid intake 3L/day Output 2L/day Low sodium Exercise ○ Promote urine flow Renal artery stenosis Occlusion of one or both arteries Cause ○ Atherosclerosis  ○ Thrombus ○ Emboli s/s ○ Abrupt HTN Dx ○ Renal US ○ CT ○ MRI ○ Renal arteriogram Tx ○ Percutaneous transluminal renal angioplasty ○ Surgical revascularization Polycystic kidney disease Genetic Cortex fills w cysts ○ Fluid ○ Blood ○ Pus Compression on surrounding tissues Destroys tissues Polycystic kidney disease s/s HTN 1st Hematuria Enlarged palpable kidneys UTI Urinary calculi Heaviness in back Abd pain Incr abd girth Multisystem involvement ○ Heart ○ Blood vessels ○ Intestines ○ Liver Polycystic kidney disease dx Family hx s/s Renal US CT MRI High BUN and creatinine  Proteinuria UA Hematuria UA Polycystic kidney disease intervention No specific tx Prevent and tx infection Prevent calculi Pain management Fluid monitoring Med management ○ Antihypertensives Nephrectomy Dialysis Kidney transplant Genetic counseling AKI Rapid decr kidney function High creatinine, BUN, potassium Azotemia ○ High nitrogen in blood ○ Kidneys cant filter properly Low UO Can be reversible AKI - CKD - ESKD - death AKI causes Pre renal ○ External to kidneys ○ Hypovolemia ○ Dehydration ○ Hemorrhage ○ Burns ○ N+V, D ○ Decr CO ○ Cardiogenic shock ○ HF ○ MI ○ Septic shock ○ Renal artery emboli or thrombosis Intra renal ○ Nephrotoxic injury ○ Drugs Amphotericin  Antibiotics Gentamycin Contrast dye Blood transfusion reaction ○ Acute glomerulonephritis ○ Acute pyelonephritis ○ Crush injury Myoglobin release from muscle breakdown ○ Toxemia in pregnancy ○ Lupus ○ Acute tubular necrosis Most common cause Post renal ○ BPH ○ Bladder CA ○ Calculi ○ Infection ○ Stricture ○ Spinal trauma AKI causes Pre renal ○ Decr systemic circulation ○ Decr renal blood flow ○ decr GFR Norm 90-120 ○ Oliguria ○ Pre renal azotemia ○ Incr serum NA ○ Incr water retention ○ Treatable Intra renal ○ Damage to kidney Glomeruli Tubular ○ Impaire nephron function ○ Common cause ATN Acute tubular necrosis ○ Blood transfusion reaction ○ Treatable Post renal ○ Mechanical obstruction of urine ○ Reflux of urine ○ 10% of AKI cases  ○ Treatable AKI phases Oliguric ○ UO 65 Blood C&S Antibiotics in 1st hour Vasopressors, inotropes, anticoagulants (Lovenox) UO Temp monitor Collaborative care - neurogenic Care based on cause Stabilize spine Maintain airway O2 Hypotension, vasodilation Vasopressors (neo-synephrine) Bradycardia (atropine) Monitor temp Collaborative care - anaphylactic Prevention Epinephrine Benadryl Patent airway Nebulizer Intubation Fluids Corticosteroids Collaborative care - obstructive Early recognition/treatment Needle/tube aspiration Pericardial tamponade Tension pneumothorax Hemopneumothorax Thrombolytic therapy Pulmonary emboli Nursing management Assessment ABCs Assess tissue perfusion ○ VS ○ Peripheral pulses, cap refill ○ LOC ○ Skin Temp, color, moisture ○ UO History of events, chief complaint Health history Medications Health promo At risk ○ Elderly ○ Chronic illness ○ Immunocompromised ○ Trauma ○ Surgery ○ Severe allergies Monitor fluid balances IO Wts Infection Hand washing Invasive catheters Aseptic technique Acute interventions ADPIE Neuro status ○ Q1-2 hr Cardiovascular ○ HR ○ BP ○ CO ○ CVP ○ PA pressure  Monitor ○ EKG ○ Heart sound Assess fluid and medication response ○ Every 10-15 min Resp status ○ Assess O2 levels ○ ABGs Resp rate ○ Q15-30 min Breath sounds every hour Pulse ox ○ Ear, finger, nose, forehead UO every 1-2 hrs Monitor temp abnormal every hour Tylenol, motrin Skin color, turgor, temp, cyanosis Bowel sounds ○ Q4h ○ Distention ○ NG tube Skin care Turn Q1-2hrs Oral care Pain Home care Rehab center Evaluation Adequate tissue perfusion Normal ○ BP ○ Organ function ○ ECG ○ CVP ○ PAWP ○ Temp ○ RR Decreased fear/anxiety Warm, dry skin  UO >0.5mL/kg/hr SaO2 >90% Multiple organ dysfunction syndrome 2+ organs fail Complication of all shocks No known trigger ○ Cant predict who will get it ○ Usually begins in lungs, followed by liver and kidneys If pt has pulmonary insult and resp failure, can rapidly get MOF Survives 2-4 days Manifestations ○ Hypotension ○ Massive vasodilation ○ Tachycardia ○ Decreased perfusion to organs ○ Micro emboli ○ Resp system firs effected ○ Alveolar edema - ARDS ○ Confusion, agitation, lethargy, coma ○ Acute kidney injury Hypo perfusion to kidney ○ GI motility decreases Paralytic ileus Ulcers GI bleed ○ Liver failure ○ DIC ○ Hypokalemia/metabolic acidosis Treatment ○ Prevent progression ○ Sepsis protocol ○ Promote adequate organ perfusion ○ Provide nutritional support Responsibilities ○ Same as septic shock