Medsurg Exam 2 PDF - Galen College of Nursing

lOMoARcPSD|48573418 Medsurg EXAM 2 Medical/Surgical Nursing Concepts (Galen College of Nursing) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 Medsurg Exam 2 Prof Milhome 11/03/22 Yellow on Exam Chapters 13 (pages 237-260), Chapter 14(pages 261-274); Chapter 48 (1057-1072); Chapter 49 ( 1081-1085; 1085-1088) Chapter 50 (page 1094- Chapter 56( page 1218-1229) ,Chapter 59( page 1265-1300) Chapter 60 (page 1301-1323), 61( page 1325-1336; 1336-1343; 1343-1344; 1344-1349) Chapter 62 (1363-1366; 1355-1359; 1359-1361; 1361-1362; 1366-1367; 1362-1363; 1367-1368; 1370-1370), chapter 64 (1413-1428),Chapter 67(1469-1479; 1488) Chapter 13 Fluid and electrolyte page 240 -1L of water= weighs 1 kg -Normal Osmolarity= 270- 300mOsm/L -Risk of electrolyte imbalance= older adults, chronic kidney disorder, endocrine disorder= ALL ILL ADULTS ARE AT RISK FOR ELECTROLYTE IMBALANCE -Women of any age have less total body water and higher risk for dehydration than men of similar sizes and ages. This difference is because men tend to have more muscle mass than women and because women have more body fat. ( muscles cells contain muscle mostly water and fat cells have little water. Excretion of Fluids Measurable= oral fluid thru urine; Parenteral fluids thru emesis; enemas thru feces; irrigation fluids thru drainage from body cavities Excretion of Fluids NOT measurable= solid foods thru perspiration; metabolism thru vaporization thru the lungs Fluid volume and electrolyte balance includes= regulation of body fluids and electrolytes (body fluid body volume, osmolarity, composition = electrolytes, (filtration, diffusion, osmosis and selective secretion EFC extracellular fluid is 1/3 of of total body water -filtration- movement of fluid thru hydrostatic pressure Osmosis- movement of fluid thru seleceltive semipermeable membrane -The min amt of urine output per day needed to excrete toxic waste is 400ml- 600mL if less than this amount of urine is excreted then lethal electrolyte imbalances, acidosis and toxic build of nitrogen occur, Insensible water loss- no mechanism controls (skin, lungs, GI tract) Isotonic= 0.9% saline, 5%dextrose in.2255 SALINE, ringers' lactate Hypotonic-.45% saline, Hypertonic- 10% dextrose in water, 5% dextrose in saline, 5% dextrose in 0.45 saline, Page 245 Potassium K+ cation= 3.5-5.0 (arrythmias) “ comes from any orifices” Most K= Found in meat, fish, some veggies, fruits Lowest K = eggs, bread, cereal grains Typical intake 2/20grams/daily Low mg= Low Potassium Before giving potassium make sure urine output is 30ML / hour High= Hyperkalemia= dehydration, kidney disease, acidosis, adrenal insufficiency, crush injuries Low= Hypokalemia= fluid overload, diuretic therapy. Alkalosis, insulin admin, hyperaldosteronism =Exactilate, insulin, duiretic to treat hyperkalemia Page 246 Calcium- Ca2+= 9.0-105 (found in bone matric) (arrythmias Absorption of Calcium requires Vitamin D Calcium found in bone matrix High= hypercalcemia- hyperthyroidism, hyperparathyroidism Low= Hypocalcemia- Vit D deficiency, hypothyroidism, hypoparathyroidism, kidney disease, fluid overload, excessive vomiting and diarrhea, adrenal insufficiency, diuretic therapy Page 246 Magnesium-Mg2+ ion= 1.8-2.6 9 ( arrythmias Mg found in bones and cartilage Importance in skeletal muscle contraction, carbohydrate metabolism, generation of energy stores, vitamin activation, blood coagulation, cell growth High= hypermagnesemia= kidney disease, hypothyroidism, adrenal insufficiency, Low= Hypomagnesemia= malnutrition, alcoholism, ketoacidosis ------------------------------------------------------------------------------------------------------------------------------------- -Muscles cells carry more water -Fat cells carry very little water -Kidney is the organ most sensitive to water loss / gain -3 Hormones that help regulate Aldosterone, Antidiuretic ADH, Natriuretic peptide hormone NP Aldosterone= prevents water and Na loss; promotes excretion of potassium Antidiuretic hormone aka vasopressin- retains water (indirectly regulates electrolyte retention or excretion) Natriuretic peptides- kidney reabsorption of Sodium ----------------------------------------------------------------------------------------------------------------------------- Page 246 Dehydration (fluid volume deficient) 1 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 causes- hemorrhage, vomiting, diarrhea, profuse salivation, fistulas, ileostomy, Profuse diaphoresis, burns, severe wounds, long term NPO status, diuretic therapy, GI suction, hyperventilation, diabetes insipidus, difficulty swallowing, impaired thirst, unconsciousness, fever, impaired motor function, weight loss, hyperemesis gravida, NV, draining wound,heat stroke Signs& symptoms= Poor skin turgor, hypotensive, tachycardia, flat neck and hand veins, dry skin “tenting”, dry mucous membranes, hypovolemia, deep furrow tongue, low grade fever, concentrated urine (dark amber color , strong odor ) Usual labs for dehydration= elevated hemoglobin, hemocrit, serum osmalority, glucose protein BUN, electrolytes; increase in blood concentration Treatment: Oral rehydration with electrolyte ( gatorade), if cannot handle PO give IV Teaching= Drink more water, reduce caffeine (increases fluid loss), reduce avoid alcohol Priority problems for patient w/ dehydration =1. poor profusion,2. potential injury (muscle weakness, pressure changes) Nursing priority= fluid replacement, drug therapy, patient safety (orthostatic hypotension, dysrthmias, muscle weakness, confusion OLDER ADULTS' CONSIDERATION: DUE TO LESS TOTAL BODY MASS, DECREASED THIRST SENSATION, LESS MOBILITY TO OBTAIN FLUIDS, DUIRETICS, ANTIHYPERTENSIVES, LAXATIVES Isotonic dehydration is the most common type of fluid loss problem u Items that are liquid at body temp are considered liquids= ice cream gelatin, ice 1 L of water = 2.2 lbs changes in daily weights are the best indicator of fluid volume loss of gains, (1LB =500mL of fluid loss) Provide fluids PO, fluid needed in 24hr period, give fluid every 2 hours, infuse iv FLUIDS, MONITOR EVERY 2 HOURS, (PULSE, bp, OUTPUT, Weight every 8 hours) monitor for overload also, IV site check hourly, Give Rx 2 most important areas to monitor during rehydration are PULSE QUALITY and URINE OUTPUT (30ml an hour) OLDER ADULT ASSESS SKIN TURGOR BY PINCHING SKIN OVER STERNUM OR FOREHEAD RATHER THAN BACK OF HAND ( on hand tenting can occur even if well hydrated because of lack of elasticity.) For every degree Celsius increase in body temperature above normal, a min of about 500mL of body fluid is lost URINE OUTPUT BELOW 500ML/ DAY FOR PATIENT WITHOUT KIDNEY DISEASE IS CAUSE FOR CONCERN. Page 248 Best Practice Patient with dehydration= oral fluids (consider restrictions sugar frere, low NA, thickened; ensure fluids(60-120mL ever hr) given on even schedule every 2 hrs throughout 24 hours; do not withhold fluid to prevent incontinence; infuse IV fluids at rate consistent with needs ( consider heart, lung ,kidney issue); monitor patient response every 2 hours ( consider pulse, difficulty breathing, neck veins distension in uprght position, presence of DEPENDENT EDEMA); assess IV infusion site hourly for signs pf infiltration and phlebitis (swelling pain, cordlike veins, reduced drip rate) Give prescribed rx for correct underlying case of dehydration ( antiemetics, antidiarrhea , antibiotics, antipyretics) When dehydration is severe patient cannot tolerate PO fluids = give IV THE 2 MOST IMPORTANT AREAS TO MONITOR DURING REHYDRATION ARE PULSE RATE AND QUALITY AND URINE OUTPUT Indications fluid balanced properly managed: fluid intake maintained at 1500mL ( or drinks at least 500mL more than daily urine; normal BP, moist mucous membranes; doesn’t fall; asks for assistance when ambulating, states indications of dehydration, correctly follows treatment plans. Insensible water loss= sweat, salivation, diarrhea, vomit, wound drainage Page 249 Fluid overload causes- excessive fluid replacement, kidney failure (late phase), heart failure, long term corticoid therapy, too much SIADH, Psychiatric disorders with polydipsia (thirst), water intoxication; CHF, IV hydration high rate, renal disease, Siadh Older adults are most at risk for dehydration, less muscle mass, less thirst sensation, less motor skills needed to obtain fluids, take diuretics, antihypertensives, laxatives Nursing interventions= safety, prevent worsening fluid overload, (n pulmonary edema, heart failure complication of electrolyte dilution Assess- food and liquid intake, intake and output daily weights, kidney and endocrine diseases Signs and symptoms= BP high, tachycardia, distended jugular veins,S3 gallop, crackles, hypertensive Treatment- dialysis, diuretics, fluid restriction -1L of water weighs 2.2lbs / weight change of 1lb corresponds to a fluid volume change about 500mL Fluid overload aka overhydration- most common type id hypervolemia (EXCESSIVE FLUID IN VASCULAR SPACE) Causes – CHF, renal failure, cirrhosis, SAIDH Page 250 Cardiovascular changes- - increased pulse bounding, elevated BP, elevated Central venous pressure, ^ weight gain, bounding pulse, decrease pulse pressure, distended neck veins and hand veins, engorged varicose veins, Respiratory changes- increased resp rate, SOB, moist crackles, shallow respirations Skin changes- pitting edema, skin pale and cool to the touch Nuero changes- Altered LOC, headache, visual disturbances, skeletal muscle weakness, paresthesia Gi changes- increased motility (acute fluid overload) (chronic =decreased motility), enlarged liver Labs- specific gravity – low, H&H falsely decrease, Serum osmolarity- decrease Patient safety, restore normal fluid balance, supportive care, prevent future fluid overload, fluid restriction ASSESS PATIENT WITH FLUID VOLUME OVERLOAD EVERY 2 HOURSTO RECOGNIZE PULMONARY EDEMA (OCCURS QUICKLY; CAN CAUSE DEATH) WORSENING OVERLOAD SIGNS = bounding pulse; increased neck veins, lung crackels, increased peripheral edema, reduced urine output, REPORT TO DR IMMEDIATELY Weight – is the best indictor of fluid retention and overload When weighing patient Same time ( before breakfast, same clothes, on same scale) 2 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 Instruct patient to call PCP if weight gain is more than 3lbs (1.5kg) in 1 week or more than 2lbs ( 1kg) gain in 24 hours 1kg – 1L water retained / 55% percent of total weight Diuretics- SIADH- ADH antidiuretic hormone- (Syndrome of inappropriate = homeostasis is not working holding on too much fluid/ high amount of SIADH Opposite Diabetes insipidus- low amount of ADH- deficient dehydration Water specific gravity of 1.000 KNOW DUIRETICS---------------------------------------------------------------------------------------------------------------------------------------------------------------- Loop Diuretic aka high ceiling diuretics- Furosemide (losing Magnesium) Bumex (lose potassium) Thiazide Duiretic – hydrochlorothiazide (causes hyper calciumia) Osmotic Diuretic– mannitol ( cerebral edema) IV only K sparing Diuretic- Spironolactone (hypercalcemia) K, Ca, Mg – can cause arrythmias-= if there is an imbalance ; REQUIRES continuous cardiac monitors!!!!!!!! Hyperkalemia– too much Potassium- loop diuretic- HypoKalema less than 3.4 shallow respiration check respiration every 2 hours 3.5 to 5 Normal saline 40MEq 500mL Page 254 HYPOkalemia ( this imbalance is life threatening because every body system is affected ) causes- loop/ thiazide diuretics, anything from any orifice, NG suctioning, Diaphoresis, urination, laxative, fluid overload, diuretic therapy, alkalosis, insulin administration, hyperaldosteronism, corticoid steriods Complications – Dysrthymia (monitor EKG), respiration low shallow breathing (assess every 2hours), muscle weakness, hypo reflexes, flaccid pyrolysis, Signs / Symptoms– Dysrhythmia thready and weak pulse, altered LOC, lethargy, confusion, GI paralysis, NV abd distention, paralytic ileus, constipation, hypo active bowel sounds, shallow respiration, muscle weakness, HYPOREFLEXIA, ( if severe flaccid paralysis), orthostatic postural hypotension, altered mental status, acute confusion, coma, GI : decreased peristalsis or paralytic ileus, decreased respiration, Treatment- Imodium (if not infectious only), antiemetic N/V, treat underlying cause, PO oral tabs, diet, IV form; continuous EKG monitoring Food w/ potassium- bananas, citrus juices, raisins,red meat, chicken, fish salmon, cod, flounder, sardines, soy products, veggies ( broccoli, peas, lima beans, tomatoes, potatoes, sweet potatoes, winter squash,) Fruits ( citrus cantaloupe, bananas, kiwiw , prunes, dried apricot), milk, yogurt PRIORITY NURSING ACTION- ENSURE ADEQUATE GAS EXCHANGE, SAFETY FROM FALLS, AND k ADMINISTRATION, MONITOR PATIENT RESPONSE SAFETY PRIORITY: Assess respiratory status every 2 hours because respiratory insufficiency is major cause of death w/ hypokalemic patient -Before infusing any IV solution containing K (potassium) check and recheck dilution of drug in IV solution container; MAX INFUSION RATE IS 5-10Ml MEq PER HOUR(NEVER EXCEED 20mEq PER HOUR) -POTASSIUM IV IS A SEVERE TISSUE IRRITANT AND IS never GIVEN im OR sUBq If infiltration occurs= stop IV remove venous access, notify HCP, or Rapid response team, document action and photograph area. PO potassium – give with or after meals l DON’T take on empty stomach Page 255 Potassium IV administration- monitor area (extravasation) (check blood return every few hours, never give bolus, subQ,, IM and don’t give more than rate of 10-20 MEQ an hour ( recommended is 5meq-10meq) CHECK IV SITE HOURLY; ASK IF THEY FEEL BURNING? Problem example= 0.9% normal saline 1000mL + 60 MEQ of potassium in bag…Bag at 100ml/ hr…..it will take 10 hr to finish this bag 60mEQ/ 10 hrs getting 6mEq/ 1 hr 500cc; 40meQ with 125mL= 500mL/125mL= 4 hours....40mEq /4 = 10mEq per hour........safe to give Page 254 BEFORE INFUSING ANY IV SOLUTION CONTAINING POTASSIUM CHLORIDE CHECK AND RECHECK DILUTION OF DRUG IN IV SOLUTION CONTAINER. JOINT COMMISION MANDATE: concentrated potassium by diluted and added to iv solutions only in pharmacy by registeried pharmasist ( concentrated potassium should not be in patient care areas. Page 255 IF INFILTRATION OF POTASSIUM CONTAINING SOLUTION 1. STOP IV IMMEDIATELY 2. REMOVE VENOUS ACCESS, 3. NOTIFIY HCP OR RRT. 4. DOCUMENT AND PHOTOGRAGH SITE Page 255 HYPERkalemia- PRIORITY- NURSING ACTION- ASSESS CARDIAC COMPLICATIONS (if HR below 60 rapid response team), SAFETY FROM FALLS, MONITOR RESPONSE AND TEACHING Cardiovascular changes are the most severe problems(most common cause of death) Complications- dysrhythmias-(very severe) = heart block; v fib, asystole Causes- medications (Ace inhibitor PRILS, and arbs SARTANS, renal failure, old blood, dehydration, kidney disease, acidosis, adrenal insufficiency, crush injuries, use of salt substitutes, potassium chloride; rapid infusion of IV potassium; transfusion of whole blood / packed cells; adrenal insufficiency, kidney failure; potassium sparring diuretics (spironolactone), tissue damage, acidosis, hyperuricemia, uncontrolled diabetes mellitus Risk factors= decreased kidney function, older adults, ill patients, debilitated, potassium sparing diuretics Signs/ Symptoms- palpitations, (phase 1) hyperactive1st twitching legs, tingling, burning, numb hands feet; around mouth ( paresthesia) (phase 2), muscle twitching, hyper reflexes then numbness, then paralysis late flaccid paralysis , increase motility, watery diarrhea, (bradycardia, hypotension; when lethal levels reached= respiratory muscles affected. 3 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 Treatment- remove potassium in diet or from meds, dialysis ( renal failure) , diuretic ( loop ), monitor EKG, FAST acting Insulin* but give with glucose dextrose) check blood sugar, no Aldactone, give diuretics that excrete K, continous cardiac monitoring , kexsalate, Teaching- diet, drugs, recognize indicators of hyperkalemia, avoid foods high in K Priority nursing action= assess cardiac complications, patient safety from falls, monitor response to therapy, teaching ASSESS ANYONE W/ OR AT RISK OF HYPERKALEMIA TO RECOGNIZE CARDIAC CHANGES. IF HR FALLS BELOW 60BEATS/MIN; OR T WAVES ARE SPIKED WITH DX OF HYPERKALEMIA CALL RAPID RESPONSE Calcium range 9-10.5 – stored in bones, absorbed thru gut Parathyroid 4 control calcium release) and phosphorous Page 256 HYPOparathyroidism aka HYPOcalcemia- Calcium low and phosphorus high Causes- low calcium intake,lactose intolerance, malabsorption syndrome (celiac disease; crohns) lack of Vit D, end stage kidney disease, GI wound drainage, diarrhea , Steatorrhea aka fatty stools, excess phosphorous in foods, drinks, hypothyroidism, thyroid surgery, acute pancreatitis, hyperphosphatemia, immobility, removal of parathyroid Signs/ symptoms- 1st hands /feet paraethesis 2nd muscle twitching, cramps spasms ; tetany, Chvostek sign ( tap on facial nerve/ cheek twitching), Trousseau sign ( 1-4 mins BP cuff =palmer flexion ; gang signs) , laryngeal stridor, dysphagia, fatigue, anxiety, depression, hyperreflexia, muscle spasm, tingling of extremities, Charlie horse, dysthymia, Hyperactive bowel sounds, increased motility, diarrhea, painful muscle spasms / “Charlie horse”, weak thready pulse, hyperactive bowel sounds, ( chronic: osteoporosis), risk of bleeding Complications- osteoporosis, loss of height, Dysthymias, seizures, Vtach, Treatment- 2 ways >>>treat calcium or phosphorous= increase calcium diet and D, administer IV calcium gluconate check ECG, IV site, weight bearing exercise, Some meds calcitonin, pamidronate, furosemide (antiacids have calcium) Post menopausal women are at risk of chronic calcium loss caused by reduced weight bearing activities; decreased estrogen) Teach older women to continue walking and other weight bearing exercises Foods w/ calcium= dairy, tofu, green leafy veggies (broccoli, kale mustard, turnip, bok choy), salmon, sardines, almonds, Brazil nuts, sunflower seeds, tahini, dried beans , blackstrap molasses HYPERParathyroid aka HYPERcalcemia= calcium high and phosphorate low Causes- too much calcium ( in antiacids or diary) , gluco steroid, kidney disease/ failure, glucocorticoids, dehydration , immobilization ( bedfast) vit D overdose, and fractures ( calcium leaves bone and goes to blood), bone mastisis, milk alkali syndrome, Hyperparathyroidism (lithium), Thiazides diuretic, hyperthyroidism, kidney disease, Signs- at 1st increase HR BP, overtime decrease HR, monitor ECG changes, blood clots more likely, lethargy, weakness, confusion, decreased reflexes, constipation, anorexia, abd distention, N/V, bone pain, polyuria, kidney stones ( flank pain), risk of clotting, Treatment- Always monitor ECG, discontinued thiazide diuretics,stop antiacids; stop lactated ringers; low calcium diet, increase weight bearing exercising, dialysis, isotonic or oral hydration, 3000ml/day , biphorous( end in dronate ( sit 30 mins after taking it avoid esophagitis), RX :plicamycin, penicillamine (low Ca levels Page 245 Sodium- changes in level of consciousness (BRAIN) Regulated by kidneys under influences of aldosterone, antidiuretic hormone ADH “Water follows sodium” Food high in sodium= processed/ preserved /smoked/pickled foods, snacks, condiments, Foods low in sodium- fresh fish, poultry, fresh veggies and fresh fruits Sodium NA cation= 136-145 >>>effects muscle contractions, cardiac contraction, nerve impulse transmission High = Hypernatremia= dehydration, KIDNEY disease, Hypercortisolism Low= Hyponatremia= = fluid overload, dehydration, liver disease, acidosis, adrenal insufficiency Page 251 Hyponatremia- (brain) Causes- not enough sodium in diet, excessesive diaphoresis , high ceiling diuretic, kidney disease, low salt diet, wound drainage(GI), decreased secretion of aldosterone (loss too much H20 and Na), Hyperlipidemia, heart failure, NPO, Cerebral wasting system, hyperglycemia, fluid overload, liver disease, adrenal insufficiency, overuse of diuretics, SIAPH hormone secretion, freshwater submergion accident, npo Signs/ symptoms cerebral changes, behavior changes from cerebral edema, changes in LOC and cognition, muscle weakness (worse in legs and arms), low deep tendon reflexes, low respiration, increased motility, Rapid/weak thready pulses, not palpable peripheral pulses decrease BP< orthostatic hypotension, (acute confusion in older adults); Complications, seizures, coma, death Treatment- cardiac solutions-nutrition (processed food), IV sodium ( saline), 3% hypertonic solution), / DUIRETICS ( conivaptan / tolvaptan); if caused by abnormal ADH secretion (lithium, demeclyocline; continueing cardiac monitoring IF MUSCLE WEAKNESS IS PRESENT, IMMEDIATELY CHECK RESPIRATION EFFECTIVENESS BECAUSE VENTILATION DEPENDS ON ADEQUEATE STRENGTH OF RESPIRATION MUCLES PRIORITY NURSING INTERVENTION WITH HYPONATREMIC PATIENT= MONITOR RESPONSE TO THERAPY AND PREVENT HYPERNATREMIA AND FLUID OVERLOAD Foods w NA= table salt, milk, beets, celery, some water, food products (Worcestershire sauce, soy sauce, onion salt, garlic salt, bouillon cubes), processed meats (bacon, sausage, ham), canned soups, canned veggies, processed baked goods, fast food Page 252 HYPERatremia-(brain) Causes- Cushing’s syndrome, hyper aldosterone, corticoid steroids, high sodium diet, dehydration, kidney disease, hypercortisolism, NPO, increased rate of metabolism, fever, hyperventilation, excessive diaphoresis, watery diarrhea, dehydration 4 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 Signs/ symptoms- “irritable" (makes excitable tissues more excited example nerves, skeltal and cardiac function), cognitive deficit, (short attention span/ agitated/confused) lethargy, stuporous, comatose; muscle twitching, progress and deep tendon reflexes gone, lethargy, stuporous, comatose, muscle weakness bilaterally, pulse increase, hypovolumia, hypotension, neck vein distension, Complication- Treatment- Diuretic (loop Bumetanide (bumex), furosemide), change diet, Isotonic solution(9%SALINE) and dextrose5% in 0.45% sodium, -Assess deep tendon reflex tapping knee and Achilles tendon with reflex hammer PRIORITY NURSING INTERVENTION= ENSURE SAFETY AND PREVENT HYPONATREMIA AND DEHYDRATION; assess deep tendon reflexes patellar and Achilles Magnesium-1.5-2.5 (hand in hand with potassium) Page 258 HYPOmagnesium- Causes: Steria (fatty stools), aminoglycosides, cisplatin, amphotericin, cyclosporine, citrate blood products ethol ingestions, malnutrition, starvation, diarreah, steatorrhea, celiac disease, Crohn's disease, alcoholism, ketoacidosis, loop , osmotic, aminoglycoside, loop diuretics, thiazide diuretics, Signs- dysthymias (premature contractures, a fib, v fib), hypertension, arteriosclerosis, hypertrophic left ventricles, can lead to MI, hyperactive deep tendon reflexes, numbness, tingling, positive Chovek , trouse signs, (worsening hypo MG tetany, seizures), reduced motility, constipation, Decreased muscle contraction, anorexia, Complication – A fib, v fib, premature contracture Treatment- remove meds, no loop diuretics, no osmotic diuretics, no aminoglycosides, avoid phosphorous meds, Use Magnesium sulfate MgSo4 for replacement Nursing interventions- assess deep tendon reflexes hourly, heart monitoring Foods w/ MG= dark green leafy greens, fruits (bananas, dried apricot, avocados), nuts (almonds, cashews), Peas, beans (legumes), seeds, soy products, Tofu, whole grains ( brown rice millet), milk Page 259 Hypermagnesemia- Patient with severe HYPERmagnesia= great risk of CADIAC ARREST Causes – increased mg intake, antiacids and laxatives w/mg, iv mag replacement, kidney disease, adrenal insufficiency, Signs – bradycardia, hypotension, absent tendon reflexes, respiratory muscle weak, peripheral Vaso dilation, drowsy, lethargic, absent deep tendon reflexes, Complications- cardiac arrest CNS dépression, coma, respiratory Failure, death Treatment – loop diuretics furosemide, can give CA to help reveres hypercalcemia effects Chapter 14: Concepts of Acid base Balance It is critical to obtain and interpret other lab data ABG and electrolytes Numbers: Respiratory opposite metabolic Equal PH: normal blood PH is 7.35-7.45 can tell you its acid or alkaline Less than 7.35 acidosis; More than 7.45- alkalosis co2 normal= 35-45 less than 35 is alkalosis; more than 45 acidosis HC03 =Bicarb metabolic(kidneys)-21-28 Less than 22 acidosis; more than 26 alkalosis PaO2= normal 80-100 Acidosis: hypotension, thready peripheral pulses; lethargy, confusion, stupor, coma, hyporeflexia, skeletal muscle weakness, flaccid paralysis, Kussmaul respiration, variable respirations ASSESS heart can lead to cardiac arrest from acidosis and hyperkalemia Bicarb only given if SERUM BICARB levels are low and pH is less than 7.2 Acidosis causes- excessive acidosis of fatty acids, hypermetabolism, excessive ingestion of acids, kidney failure, diarrhea, opioids, inadequate chest expansion Acidosis signs and symptoms= 1st sign – Cognitive changes; bradycardia heart block, hypotension, thready peripheral pulses, depressed CNS activity, Hyporeflexia, flaccid paralysis, Kussmaul respirations, variable respirations, warm flushed skin, , pale to cyanotic in resp acidosis “ Hallmark of resp acidosis are decreasing Pao2 coupled with rising pa CO2 Assess cardiovascular system 1st!!!if patient at risk of acidosis; can lead to cardiac arrest from accompanying hyperkalemia, report changes to HCP Alkalosis- increased activity, anxiety, irritability, positive chosvek sign, positive trousseau sign, parathesis, hyperlexia, muscle cramping/ twitching, skeletal muscle weakness, increased HR, normal/low BP, increased digoxin tox,hyperventilation, decreased respiration Alkalosis causes- antacids, blood transfusion, sodium bicarb, TPN, vomiting, suctioning, hypercortisolism, hyperaldosteronism , high loop Resp alkalosis causes- diuretics, hyperventilation, mechanical vent, salicylate toxicity, high altitudes, early stage acute pulmonary probs Alkalosis Signs and symptoms= increased activity, anxiety irritability, tetany, seizures, + Chvostek sign, + trousseau sign, parathesias, hyper flexia, muscle cramping twitching, skeletal muscle weakness, increased HR, normal or low BP, increased digoxin toxicity, hyperventilation Acid base imbalance (signs and symptoms looking for ) metabolic acidosis = key= 1. PH down 2. Hc03 down; 5 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 Conditions: metabolic acidosis= ketosis, renal failure, starvation, diarrhea, hyperthyroidism, diabetic acidosis, hypermetabolism (heavy exercise, seizure, fever, hypoxia, ischemia) too much acids= ethanol intox, salicylate intoxication, kidney failure, pacretitus, liver failure, dehydration, Over elimination of bicarb (diarrhea) metabolic alkalosis- loss of gastric fluids, decreased potassium, diuretic therapy, fever, respiratory alkalosis, hyperventilation Conditions: anta cids ingestion, blood transfusion, sodium bicarb admin, TPN, prolonged vomiting , NG suctioning, hypercortisolism, hyperaldosteronism, loop diuretics, thiazide diuretics respiratory acidosis= 1. PH down 2. Co2 up Conditions-respiration depression; anesthesia, drugs( opiods), electrolyte imbalance, Not enough chest expansion ( muscle weakness, airway obstruction, alveolar capillary block) COPD Respiratory alkalosis= Conditions=hyperventilation, fear, anxiety, mechanical ventilation, salicylate intox, high altitudes, early stage acute pulmonary problems Diseases Chapter 56: Assessment of endocrine system -Major endocrine glands- hypothalamus, pituitary, adrenal, thyroid, islet of pancreas, parathyroid, gonads Endocrine system is responsible for homeostasis and regulation of metabolism, nutrition, elimination, temp, fluid and electrolyte, growth, reproduction Decreased ADH- patient at risk of dehydration ( offer fluids every 2 hours while patient is awake Physical assessment – abnormalities of face features, expressions and =structures= prominent forehead, round puffy face, dull flat expression exophthalmos (protruding eyes); enlarged thyroid, juglar vein distention, hyperpigmentation, vitiligo, edema, buffalo hump, gynecomastia (men with breast)straie on chest, AVOID APPLYING PRESSURE ON THYRODI OF PATIENT WITH OR SUSPECTED OF HYPERTHYROIDISM (this can stimulate sudden release of thyroid hormones and cause thyroid storm) Labs= when drawing blood for catecholamines place on ice; Urine test throw away first urine then begin to collect, 1. Endocrine function and hormones- all tissues and organs are effected by endocrine system; hormones require receptor ; nervous system works closely with endocrine system to maintain homeostasis 2. First outcome of hormone binding correctly to receptor of target tissue= increased specific function of target tissue 3. Removal of posterior pituitary gland would cause deficiency in oxytocin and testosterone 4. Excessive production of MSH or melanocyte stimulating hormones= skin darkening 5. Reduced catecholamine levels and decreased cardiac excitability caused =decreased in Cortisol 6. Age related changes in endocrine function= decreased core temp, dehydration, hyperglycemia, polyuria 7. Condition that would stimulate RAAS aka renin angiotensin aldosterone system= hypoxemia and alkalemia 8. If vasopressin levels are lower than normal nurse should= check skin turgor and urine output 9. Lower than normal thyroid hormones to increase in diet of = cheese, protein, seafood, iodized salt 10. Electrolyte to monitor after removal of thyroid gland= CALCIUM 11. Decreased estrogen levels – suggestions to patient= skin moisturizer; intake calcium and Vit D, walk 1 mile 4 times a week, urinate after sexual intercourse, weigh yourself daily same time and wearing same amount of clothing Chapter 59 Diabetes Alpha cells= secrete glucagon PREVENT HYPOGLYCEMIA Beta cells = produce insulin and amylin PREVENT HYPERGLYCEMIA Glucose is stored as Glycogen in the liver. Fasting state= not eating for 8 hours; insulin secretion suppressed Classic symptoms of diabetes = 3 p’s polyuria ( frequent urination, polydipsia (thirst), polyphagia (excessive eating) Hormones that increase glucose=epinephrine, norepinephrine, growth hormone, cortisol Page 1273 A1c Normal (4-6); Pre diabetes( 5.7-6.4) Diabetes 6.5 or greater; Poor diabetes control greater than 8% (older adult less than7) Fasting glucose Normal 100 ( older adults rise 1mg per decade of age); 100-126mg/dl impaired fasting glucose;greater than 126= dx DM Glucose tolerance normal( 140 or less); impaired glucose tolerance 140-200 mg/dL; 200mg/dL indicates provisional dx diabetes 200 and up Normal blood sugar range- 74-106mg/dL ( 4.1-5.9 mmol/L) Page 1270 Type 1- have no insulin; ketosis prone; autoimmune, onset younger than 30, abrupt onset, (usually after viral infection) Idiopathic; clients usually thin, no insulin-S/S pronounced treatment is only insulin >>> no PO meds; Patho (pancreatic beta cell destruction) Symptoms of type 1 – weight loss, thirst hunger, increased urine output, weight loss; thin (they are using fat for energy; cant breakdown carb) Type 2- onset usually after 50; ketosis resistant; inherited, insulin required, potential of DKA; life changes, weight loss and diet can help (insulin Resistance, dysfunctional beta cells, life changes (diet, exercise correlate to obesity) Symptoms type 2- thirst, fatigue, blurred vision, vascular, neuropathy S/S not always obvious Treatment- oral or SUbq meds- be mindful of peaks – hypoglycemia, check sugar every 4 hours, Glucagon- (hormone ) prevents HYPOglycemia, aka hormone of starvation; secreted from liver when food levels are low to regulate sugar - Insulin- prevents HYPERglycemia aka hormone of plenty; secreted when food intake is high moves glucose to cells Chronic HYPERglycemia-= Diabetes Diet for Diabetic - low carb 6 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 Diabetic medication= ONSET, PEAK, Duration Diabetes most common in Blacks, Hispanics American Indian, Alaska Indians, Page 1272 Indicators for possible diabetes – high BMI more than 25 kg , relative with Diabetes, inactive, hypertensive 140/90, high HDL, A1C more than 5.7%, gave birth to baby weighing more than 9lbs or dx GDM, low \HDL less than 35; tryglceride greater than 250, dx polycyctic ovary syndrome, hx of vascular disease, If Patient tests normal for blood glucose and has any of the risk factors repeat every 3 years Diagnosing Diabetes-A1C greater than 6.5% and Fasting blood glucose greater AND equal to 126 mg/Dl (no food for 8hrs) OR 2hr glucose = or greater to 200mg/dl during oral glucose tolerance test (using 75g g anhydrous glucose dissolved in water) OR for patient with classic hyperglycemia crisis manifestations, random blood glucose concentration of 200mg/dl ( 3 p’s and unexplained weight loss Page 1274 Nonsurgical management- A1C maintained @ 7% or below or as prescribed; majority of premeal blood glucose levels are 70-130 mg/dl, Peak after meal bloods glucose levels are less than 180 Page 1275=RX alert= Metformin (biguanides) can cause lactic acidosis patients w/ kidney impairment; Contraindicated for kidney disease pts; DRug should be withheld before and 48 hrs after using contrast medium or surgery w/ anesthesia ( establish kidney function first) Don’t drink alcohol while taking this med, side effects: upset GI ANTI- Diabetes Drugs= ARE NOT A SUBSTITUTE FOR DIET AND EXERCISE Extended release exenatide and dulaglutide are injected subQ ONCE WEEKLY. Do not mix pramlintide and insulin pH of 2 drugs not compatible= Page 1279 Somegee- phenomenon- blood sugar is low then giving meds then low and high again (check 3-5AM check blood sugar Treatment: bedtime snack,or decrease insulin) ; Dawns phenomenon High in Am ( hypoglycemia episode 0 cortisode released and that why they are high the morning overnight hormones are released steroids making blood sugar read high(check 3-5am blood surge will be normal) treatment : increase insulin or give at later time. Blood sugar rises with the sun Page 1281 SubQ insulin administration= fasted in abdomen (2 in radius around umbilicus); rotate within 1 anatomic site, inject at 90 degree angle (but 45 degree angle for thin elderly); do not rub after administration Lipodistrophy=loss of subQ fat around site of repeated insulin injection (scar tissuse) DO NOT MIX ANY INSULIN GLARGINE OR DETEMIR OR HUMALOG 75/25 ( THEY ARE PREMIXED FORMULAS) Page 1292 HYPERglycemia- blood glucose greater than 106mg/dl (greater than 5.9 mmol/L); KETONES in urine, warm dry vasodilated, dehydrated, becomes DKA; -Signs and Symptoms of HYPERglycermia- Cold, clammy/ change of mental status, eventual coma, diaphoresis, ,3 P’s polyuria, polyphagia, polydipsia *exercise, illness, steroids, lowers blood glucose levels, blurred vision; blood is viscous (thick) -Patho- pancreas- exocrine function and endocrine functions- alpha beta cells (glucagon (increase) and insulin (lowers) Page 1292 HYPOglycemia- blood glucose less than 70 mg/dl (less than 4.1 mmol/L); cool clamy, sweaty, HYPOglycemia symptoms- weakness, fatigue, confusion, behavior changes, emotional, LOC, brain damage, death, Sweaty hungy, tingling Treating MODERATE hypoglycemia- (cold clammy, pale, rapid pulse, shallow respirations, Glucose less than 40= 30g of rapid carb, retest glucose in 15 mins, check glucose if less than 60mg, eat additional food low fat milk after 10-15 mins Treating SEVERE hypoglycemia LESS THAN 50 blood glucose is less than 20 unconscious, risk convulsions can't swallow= give Glucagon IM or SubQ, ; give 2nd dose in 10 mins, (if unconscious) Call Provider and follow instructions, take to ED, 4 Causes of HYPOglycemia- excess insulin, insufficient intake absorption of food, exercise when insulin is peaking, alcohol intake , too much insulin, insulin before food Acute Complication of Diabetes= DKA ( no insulin and too much ketoacids) Hyperglycemic Hyperosmolar state ( deficiency insulin and dehydration, HYPOglycemia ( too much insulin or too little glucose) Chronic complications of Diabetes- macrovascular and microvascular+= Diabetic retinopathy, visual sensory perception, Macrovascular-Coronary heart disease, cerebrovascular disease peripheral vascular disease and microvascular- poor tissue perfusion and ischemia, sexual dysfunction, dementia, Diet- low calorie, increasing physical activity and weight loss Secondary diabetes- alcoholic- pancreatitis ( amylase , lipase don’t work) Causes- NPO ( fluids with dextrose), too much insulin, insulin before food, Onset -peak- duration Complications- wound healing inspect feet daily, podiatrist to cut nails, immunity, Page 1280 Insulin storage varies- refrigerate unused vails of insulin, no exposure to sun, temp above 36 F and below 86F; Insulin in use kept at room temp discard after 28 days; inspect vial before use, avoid excess shaking, don’t freeze insulin, discards any unused insulin after 28 days, NPH is cloudy (roll do not shake); Pen-type injectors are not designed for independent use by visually impaired or cognitively impaired TEACH PATIENT WITH A HISTORY OF HYPOGLYCEMIC UNAWARENESS not TO TEST AT ALTERNATIVE SITES Page 1283 Alcoholic beverages – 2 for men / 1 women 12 oz or 5oz wine, 1.5 of distilled spirit. POTENTIAL OF DELAYED ALCOHOL INDUCED HYPOglycemia only ingest alcohol with or shortly after meals PAGE 1285 Exercise= perform exercise (appropriate exercise, examine feet, hydrate, no extreme weather, don’t exercise during peak or 1 hours after insulin injection, prevent hyperglycemia Atleast 80 and less than 250 carb snack before or high intensity, carry simple sugar, 7 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 carry ID, check glucose levels. (Exercise will lower blood sugar) 150 mins per week, aerobic activity divided into 3 days.don’t exercise within 1 hour of insulin injection, Don't exercise same area of injection, IF GLUCOSE KETONES PRESENT DO NOT EXERCISE If patient who had controlled diabetes in hospital has unexpected rise in blood glucose = may be WOUND INFECTION Page 1288 Foot care- inspect feet daily, wash with luke warm water, pat dry, clean soc Everday, dont wear shoes 2 days in a row, ( leather cloth shoes, trim nails straight across, use Emory board, do not be barefoot, no open toe sandals, clean cotton socks, no thong sandals, don’t soak feet, try on shoes later in the day, No hot pads or portable heaters on feet, moisturizer on foot but NOT BETWEEN toes. Page 1290 Symptoms of Hypo Glycemia= weakness, fatigue, difficulty thinking, confusion, behavior changes, emotional instability, seizures, loss of consciousness, brain damage, death, shaky tremulous, heart pounding, nervous anxious, sweaty, hungry, tingling Treat Mild Hypoglycemic less than 70=use 15g of carbohydrate, ½ cup of fruit juice,6-10 candies, I tablespoon of honey; retest blood glucose in 15 mins, repeat treatment of glucose remains less than 70, eat small carb and protein if next meal is more than 1 hour away Treat Moderate Hypoglycemia less than 40- S/S cold clammy skin, pale , rapid pulse, shallow respiration, marked change in mood, drowsy; Blood glucose less than 40 , 30 grams of carb; retest in 15 mins , repeat treatment of remains less than 60; drink low fat milk after 10-15mins Treat Severe Hypoglycemia less than 20= unable swallow, unconsciousness, convulsions, Blood glucose less 20; give glucagon IM, SubQ, give second does in 10 mins; if still consciousness 911; give small meal if they wake and not longer have N/V Prevent hypoglycemia- avoid excess insulin, deficient intake or absorption of food, avoid exercising when insulin peaks, avoid alcohol without meal BEFORE GIVING iv K CONTAINING SOLUTIONS , ENSURE URINE OUTPUT IS ATLEAST 30ML/HR Page 1294 Sick days- monitor sugar every 4 hours, test urine for ketones if blood glucose greater 240, continue to take insulin, drink 8oz-12oz of water every hour, eat meals regular times plenty of rest. CALL HCP= n/v, moderate/high ketones, temp over 101.5 more than 24 hrs, Accu check –once everyday – blood glucose level at that QHS, and before meals+ blood sugar at the bedtime ON EMPTY STOMACH Low blood glucose is more concerning- will go into a coma=> glucagon, or dextrose IV in emergency 1. IF low= Draw blood complete metabolic panel; look at number and patient; dextrose and glucagon 2. If too high ; get blood draw/ get order >>>> sliding scale order needed STAT insulin drip Less than ( average is 106) 6.5 % less than 7% -Glucose tolerance test for PG.5 is 30 mins = peak 2-4 hours duration 5-12 hours Given at *800 am – onset is 8:30 peak at 10-12 til 1pm to 8pm Don’t give insulin til food is there DKA – 1st- Airway, LOC, hydration, electrolytes, blood glucose, 2nd check every 15 mins, 3rd urine output…after stable check every 4 hours LABS= protein in urine ( red flag) , ketones in urine (red flag), GFR, A1C, (Ace inhibitor Pril protect renal system) Pancreatic transplantation option for diabetic with end stage kidney disease ( kidney transplant Give 7 units of NPH and 10 units of regular insulin = draw up 17 units of air= Regular then NPH (finish with RN) type onset peak duration color given Rapid acting 15-30 mins 0.5-2.5 hrs 3-6hrs Eat immediately clear subQ Humalog after taking Short acting 30 mins-1 hr 1-5 hours 6-10hrs clear SubQ/ IV regular Intermediate 1-2 hours 6-14 hrs 16-24 hrs cloudy subQ NPH Long lasting 70 mins none 18-24 hrs clear SubQ Lantus Chapter 60 renal and Urinary system REPORT PRESENCE OF GLUCOSE OR PROTEINS INURINE OF PATIENT UNDERGOING A SCREENINGEXAM TO PCP THIS IS ABNORMAL ARE REQUIRES FURTHER ASSESSEMENT Lose fluid BP goes down/ gain fluid Bp goes up Kidneys=FILTERS Left kidney is longer and Narrower than right; work as regulatory and hormonal functions Fluid and electrolyte function, and RBC formation Abnormal in urine- glucose and protein Bladder- muscular sac; in med in front of rectum, in women in front of vagina, Continence- voluntarily control emptying of bladder, Micturition aka voiding, urinating Page 1308 Renal system changes in Aging adults- kidney regulation goes down, dehydration, falls, excessive fluid at night, some drugs increase urinary output, anticholinergic drugs promote retention of urine; GFR decreases with age ( assess hydration status), nocturia (offer urinal /toiler every 2 hrs), decreased bladder capacity , weak urinary sphincter (provide perineal care after voiding), tendenct to retain urine ( assess for UTI, retention) DO NOT palpate patient with suspected abd tumor and aneurysm!!!!!! Blood test labs= creatine indicator of kidney function; BUN is also but can be affected by hydration status 8 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 SERUM creatine- 0.6 -1.2 males; 0.5-1.1 females; high = kidney impairment / low= muscle decreased BUN 10-20 = high = kidney disease dehydration, ; low decreased malnutrition fluid volume excess, severe haptic damage BUN : creatine ratio= increased = fluid volume deficit; decreased= fluid volume deficit -High protein diet can cause calculi Listen for bruit in renal artery on midclavicular line NO OTHER PATHOLOCGIC CONDITION OTHER THAN KIDNEY DISEASE INCREASES SERUM CREATINE LEVEL ; only excreted by kidneys BUN = measure effectiveness of kidney excretion. Can be influenced by kidney, steroids, cancer treatment, injured body tissues, Gi bleeding Page 1314 Collection of urine specimens Voided urine- collect first specimen in AM, send to lab ASAP, if delay refrigerate Clean catch= selfclean before void, clean 3 wipes w/ sponge and solution, start void then stop and begin to void in container, anantimy should not touch container, only 1 oz needed Catheterized- (str8 cath)-sterile technique, apply clamp to drain tube 15=30mins, clean injection port cap, iodine or alcohol, use 5mL syringe to port and aspirate amt required, inject sample into sterile specimen cup, remove clamp continue drainage, dispose of syringe 24 hour urine collection- place signs, ( may require ice, fridge, preservative),first void will be discarded, ; ( if foley discard tubing and drainage bag and start), collect for 24 hours, (do not use of this specimen for any other exam) ENSURE PATIENT PRESCRIBED METFORMIN DOESN NOT RECIEVE DRUG AFTER A PROCEDURE REQUIRING IV CONTRAST MATERIAL UNITL ADEQUATE KIDNEY FUCNTION HAS BEEN DETERMINED RENAL SCAN IS CONTRAINDICATED FOR PG WOMEN UNLESS BENIFIT OUTWEIGHS RISK Hydrate before and after contrast Diabetes ( metformin ) with contract= lactic acidosis (try to hold metformin for 24 hours) and 48 hours after procedure = gives contrast to get our out of system. KUB ,CT, renal biopsy, serum creatine, BUN elevated with injury, GFR goes down , ( 40= dialysis) Frequency, urgency dysuria hallmark of uti at all sites ‘ Colins sign- bruising around umbilicus area Turners Sign- bruising around flank area Nephrosclerosis – ( hardening)-of blood vessels Try to keep/ to see BP less than 160/110 Leg bag has to be on affected side Reposition , fluid restricted at fits then slowly increased , if tube placements lost tell HCP ASAP 1. Increased production of renin = patient with blood loss 2. Abnormal finding in routine urine sample= proteins, RBC, Albumin, glucose, WBC, blood, nitrates,bacteria 3. Compromised kidney function would cause low BP= 68/40 4. AP proper handling of urine analysis= ensure tightly closed, take sample to lab within 1 hr, put sample in plastic bag, refrigerate if cannot be taken to lab right away, start with first moring void 5. Increased noctura nursing actions= adequate lighting, availability of bedpan, discourage excessive fluid s 2-4 hours before going to bed, respond ASAP to client need to void 6. Symptoms of enlarged prostate= difficulty starting urine stream 7. Ask patient with changes in urination patterns= hx diabetes hypertension, toxins or illecit substances, recent travel, previous kidney or urologic probs, ( tumors infections stones) 8. oTC that can affect kidney function= Acetaminophen 9. Most common symptoms prob with kidney or Urinary tract= pain in flank, abdomen or pain when urinating 10. Client with chronic kidney disease develops anorexia , n/v complication that can occur= uremia 11. Renal system assessment- nurse should 1st= observe flank region for asymmetry or discoloration 12. Renal artery ( renal artery stenosis client ) = swishing sound 13. Assessing for bladder distenion= gently palpate outline of bladder and percuss lower abdomen toward umbilucs unto dull sounds are no longerheard 14. Lab value nurse monitor specific to cient kidney function- creatine, Cystatin c, blood osmalrity, BUN creatine ratio 15. Postprocedural after renal scan= encourage oral fluids to excrete isotope 16. Preprocedure Ultrasound= drink 500- 1000mL of water 2-3 hours before test 17. Priority after kidney biopsy= perform frequent checks for hemorrhage(SUPINE POSITION_…..avoid lifting heavy objects 1-2 weeks aft er procedure 18. Why would nurse choose male icon for female e client when doing bladder scan= female had hysterectomy Chapter 61 Patients with urinary problems Stress incontinence= involuntary loss of urine ( cough, physical exertion, sneeze, Treatment= loss weight, pelvic muscle therapy, vaginal cone therapy, bladder training, estrogen therapy, electrical simulation, MR therapy , pessary device, surgical sling, Page 1330 Pelvic muscle exercise Kegels= tighten pelvic muscles for a slow count of 10 then relax for 10 secsm do exercise 15 times while laying down , sitting up or standing, 45 exercises, NO more than 10 or 12MINs, Urge incontinence= overactive bladder , urgency, nocturia Treatment – bladder training, weight reduction, avoid bladder irriatnct, electrical simulation device TURP Overflow incontinence- bladder distention, dribbling of urine Treatment- bladder training, Crede method ( press on bladder), intermittent self cath, Bethanechol chloride, Functional incontinence- leakage of urine by factors other than disease=timing varies; anatomy of urinary tract Treatment- habit training, applied device, penile clamps, condom Cath, intermittent long term cath 9 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 TEACH PATIENTS TAKING EXTENDED RELEASE FORMS OF ANTICHOLINERGIC DRUGS TO SWALLOW TABLET OR CAPSULE WHOLE WITHOUT CHEWING OR CRUSHING. (DESTROYS EXTENDED RELEASE FEATURE INCREASES SIDE EFFECTS) HABIT TRAINING IS UNDERMINED WHEN ABSORBENT BRIEFS ARE USED IN PLACE OF TIMED TOILETING. DO NOT TELL PATIENTS TO “JUST WET THE BED” A COMMON CAUSE OF FALLS IN HEALTH CARE FACILITES IS RELATED TO PATIENT EFFORT TO GET OUT OF BED UNASSITED TO USE THE TOILET. CONSITSTENTLY IMPLEMENT TOILETING SCHEDULE FOR HABIT TRAIING bladder training = assess 24 hr elimination= 2-3 days; 45 mins intervals, for 1 st day, reduce be 15 if patient cannot hold urine, when consistent increase intervals by 15mins. For URGE and OVERFLOW Habit training- asses 24 hours 2-3 days, base 2 hours, cues to remind to go, if incident occurs reduce by 30 mins, don’t leave patient on toilet more than 5 mins, if constant extend intervals to 30 mins, AVOID DIAPERS; FUCNCTIONAL Page1336 Cystitis-inflammatory condition of the bladder; doesn’t have to be because of infection causes- drugs , chemicals, local radiation, irritants, feminine hygiene spray, spermicidal sprays, long term cath use; gynelogical cancer, PID, endometriosis, Crohn's, diverticulitis, lupus, TB. (e.coli from GI, staphylococcus, Klebsiella pneumonia, proteus, Enterobacter species) DX** leukocytes and nitrites****, WBC, hematuria Risk factors of cystitis- females (shorter urethra), catheter (dwell time), not able to empty bladder, (prostate), obstruction (Kidney stones, BPH), poor immune system, synthetic underwear and pantyhose (cotton loose) fitted, remove bath suits, shower vs bath, Diabetes concentrated (glucose urine), sexual activity, antibiotics, pregnancy (), nuero disorder, gout, urinary procedures, UTI- uncomplicated cystitis= bladder only; no signs symptoms of any other involvement; UTI complicated cystitis= more than bladder involved= fever, flank, chills, rigors, malaise pelvis and perineal pain, UTI – can happen anywhere in urinary tract (location is key) Page 1337 UTI Risk factors- obstruction, stones (calculi), vesicoureteral reflux (backward flowing urine), diabetes mellitis (glucose =bacterial growth), characteristics of urine (pH), gender (women- coliform bacteria) (men- prostate enlargements), age, sexual activity, recent use of antibiotics, virulence UTI- causes=routine use of urinary caths, use wiping incorrectly, douching, bubble baths, Page 1340 Teachings Fluid 2-3L a day, go to bathroom ; do not hold urine (cranberry juice bacteria doesn’t adhere to epithelium of urinary tract), pee 30ml an hour, Enough sleep rest ,nutrient, for immune health, Spermicide if causing issues stop using, Perineum wipe front to back Avoid using douches, lubricant , bubble bath , scented bath tissue, don’t delay urination, Take entire course of antibiotics , wash perinium before and after sex, go to bathroom every 2-3 hours , (institual due to food)avoid coffee , tea and colas, avoid spices, soy , tomato products Cystitis- Signs of UTI- (burning )dysuria, frequency, urgency, cloudy urine, hematuria (bloody urine), nocturia, low back pain, pyuria(puss in urine) , feeling of incomplete bladder emptying Older adult's symptoms of UTI- changes in LOC, unexplained falls, fever, anorexia, tachycardia, tachypnea, nocturia Complications- pyelonephritis, urosepsis, sepsis Med management- pharm therapy Peridium phenazopyridine (urinary analgesic) changes color of urine, stains contact red or orange) antibiotics, 2000-300ml of fluids, ENSURING THAT URINARY CATHETERS ARE USED APPROXIMATELY AND DISCONTINUED AS EARLY AS POSSIBLE IS REQUIRED. DO NOT ALLOW CATHETERS TO REMAIN IN PLACE FOR STAFF CONVIENCE; Asepetic technique, stat locked (cath must be below bladder, bag shouldn’t touch floor), SULFAMEYHOAZOLE,/ TRIMETHOPRIM – STOPPED IF RASH OCCURS= INDICATE STEVEN JOHNSONS SYNDROME (CAN CAUSE SUNBURN IF in sun) Page 1343 Urethritis-aka pyuria-dysuria syndrome inflammation of urethra results from infectious or non infectious factors Causes- STI, (gonorrhea, urea plasma, chlamydia, trichomonas vaginalis, post menopause ; high urine acidity, Obstruction (hypercalcemia), diuretics, dehydration, super saturation of element like uric acid, calcium, S/S= discharge (purulent)dysuria, itchy, urethral pruritus, , frequency, fever Treatment- antibiotic if STI, estrogen vag cream (post menopause) Page 1344 Urolithiasis=calculi stones in urinary tract., no symptoms til they are in lower Uriniary tract Causes- dehydration, supersaturation of urine( Ca), formation nidus S/S- hematuria (rust color, turbid/cloudy), pain aka renal colic, n/.v pallor diaphoresis, hydronephrosis = perm kidney damage Risk factors- fam hx, dehydration, obesity, diabetes, gout, Diet (high NA intake), diet high in Ca, high purines, Dx: helitical Ct scan, KUB (xray); strain urine and send any stone to lab!!! Treatment – diet change, antibiotic pain meds (NSAIDS), Lithoscope-anesthetic cream , cardiac monitor, shock waves to break stone Page 1345 Teaching diet: ================================ renal lithiasis – strain the urine ( see what stone is made of ) ( if calcium decrease ca intake) Symptoms – renal cholic pain, frequency, dysuria, hematuria, blood in urea, oliguria, (scant urine output), renal colic, (unbearable pain), N/V diaphoresis and severe pain, ( BP high,) -1st thing to do – medication for pain NSAID; ketorolac, opioids LABS: UA ( urine analysis,), PH 5-6 normal, Serum WBC, Xray, biopsy, cytoscopy, CT without contrast, Ultrasounds Risk factors- diet high in calcium, dehydration, vit d, vit c, immobilization, uric acid, hyper parathyroid, IBS, history of GI, Crohn disease, osteoporosis patients 10 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 Treatment-drink water mobility if less than 5mm; Extracorporeal shock wave lithotripsy (break stones but patient still has to urine local anesthesia normal bruises,) flush with fluids ( strain urine ), lithotomy, nephrostomy tube (drainage bag on pelvis, check amt and color, strict I &o) Post procedure care- pain management, prevent infection (antibiotics), monitor I and O (200L-300L) urinary analgesic, give opioids, Thiazide ( get rid of uric acid) Complication: Hydronephrosis- enlargement of kidneys (backflow of urine) =perm kidney damage Nursing diagnosis- acute pain, impaired urinary elimination, risk fluid volume deficit, risk for infection Urine PH normal = 5-6 Type of stones- calcium oxalate, calcium phosphate, struvite, uric acid, cystine URINARY TRACT OBSTRUCTIONIS AN EMERGENCY AND MUST BE TREATED IMMEDIATELY TO PRESERVE KIDNEY FUCTION Labs- UA ( urine analysis) not normal leukocytes, nitrates, RBC abnormal, culture and sensitivity (type of bacteria and antibiotics that can be used), cystoscope, CT , Nursing diagnosis- acute pain, impaired urinary elimation, deficient knowledge Why are women at risk? Women – urethra shorter in women than men Complication- Urosepsis- urinary tract to blood ( risk for death), renal failure, 1. Type of incontinence loss of small amts of urine when coughing g, sneezing, jogginf=g, lifting= stress incontinence 2. Best nurse action for obese , older, incontinence, dementia client= provide assistance with toileting every 2 hours 3. Rx with contributing to urinary incontinence= diuretics, opioid analgesics, anticholinergics 4. Non-surgical action for patient with stress incontinence= make diary of urine leakage, food s eaten; Kegel exercise, drink adequate fluid water, dietitian for diet and weight loss 5. Best advice to client with urge incontinence= drink 120ml everhr or 240ml every 2 hours and limit fluid intake after dinner 6. Overflow incontinence with patient with heart disease avoid = Valsalva maneuver, 7. Contributors to dx complicated UTI= PG, obstruction, diabetes, chronic kidney disease, decreased immunity 8. Most common sign of urinary tract infection= frequency, urgency, Dysuria 9. Essential nursing intervention post shock wave lithotripsy= Strain urine monitor for passage of stone frags 10. After lithotripsy= finish antibiotics, balance reg exercise and rest, drink 3L of fluids everyday, urine will be bloody afew days after procedure Chapter 62 Patient with Kidney disorders (remember kidneys affect BP) Page 1356 Pyelonephritis is bacterial infection ESCHERICHIA COLI that starts in bladder and moves up to infect kidneys Acute pyelonephritis- comes from bacterial infection; common in women young sexually active Acute pyelonephritis symptoms= fever, chills, tachycardia, tachypnea, flank back, loin pain, CVA tenderness, N/V, malaise , fatigue, burning urgency, frequency, nocturia, recent cystitis or UTI infection, gfr down Chronic pyelonephritis – comes from repeated continued upper UTI infections (anatomic issues) structural deformiites Chronic pyelonephritis= hypertension, cant conserve sodium, decrease urine concentration, nocturia, hyperkalemia or acidosis Assessments= LAB ( WBCS, nitrate dipstick, blood cultures) Imaging ( xray, KUB, CT, Treatment= Tylenol for pain, antibiotics, high calories diet fluid intake of 2L / day or surg nephrectomy, pyelithotomy Page 1359 Acute glomerulonephritis- (job filter blood) inflammation for glomerulus; excess immunity response within kidneys (10 days from time of infection) occurs after infection (post streptococcus infection) Diagnose: biopsy Causes- 10 days after infection of streptococcus syphilis, hepatitis, HIV, strep Treatment: manage infection=antibiotics, immunity suppressant drugs, prevent complications, reduces sodium intake , fluid restriction, strict I&O Complication- scarring of tissue, At risk – children 90% of cases Signs- edema, (anascara) fluid volume overload, SOB, Crackels, s3, smoking reddish brown urine, hypertension, hematuria and proteinuria, dialysis Surgical treatment- Pyelolithotomy (stone removal), Nephrectomy (remove kidney), ureteral diversion, Urethroplasty Don’t Give – Spirnerlactone Ace (pril), Arbs, (Sartans) Page 1361 Chronic Glomerulonephritis- over years or decades Page 1362 Nephrotic syndrome= glomerular permeability increases so larger molecules pass thru membrane into urine and are excreted (protein loss, edema, decreased plasma albumin) mostly occurs in children 90% Signs of Nephrotic syndrome-SUDDEN ONSET massive proteinuria (3.5g in 24 hr urine), hypoalbuminemia, edema (face), lipid Uria, hyperlipidemia, delayed clotting reduced kidney function Complication- End stage renal disease Page 1362 Nephrosclerosis- degenerative disorder resulting from changes in kidney thicken of blood vessels At risk of Nephrosclerosis- hypertension, atherosclerosis, diabetes treatment- ace inhib, diuretics- no spirnolactone Page 1363 Polycystic kidney disease- genetic disorder fluid filled cysts (grape-like) develop in nephrons. ( at risk- hypertension, ) GO TO GENETISIST; no treatment / only transplant ( by age 30) Polycystic signs symptoms- abdominal, flank pain; hypertension, nocturia, increased ab girth, constipation, hematuria, sodium wasting, progression of kidney failure, headache (aneurysms), UTI, 11 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 Polycystic management- measure BP daily; check temp if fever is suspected tell hcp, weight self everyday, limit salt intake, notify foul smelly urine , headache that doesn’t go away call HCP, monitor bowel movement for constipation Complication- Dialysis need transplant, chronic kidney disease, cyst rupture sign= urine cloudy, smells, painful Avoid Nephrotoxic- blood thinner, contrast, NSAIDS, PREVENT CONSTPATION IDEAL BP= 160/110 Page 1366 Hydronephrosis- kidney enlarges as urine collects in renal pelvis and kidney tissue. (cause: obstruction renal pelvis) Page 1366 Hydroureter- enlargement of ureter (cause: obstruction in ureter) Causes= obstructions such as kidney stones, tumors, fibrosis, structural abnormalities, trauma, abscess, cyst Complication- after 48 hours or several weeks; necrosis, acid base imbalance, AKI Labs= blood creatine=up, BUN=up, GFR reduced Treatment= nephrostomy-drain urine out to bag (NPO, prone position, nephrostomy tube stays in place til obstruction resolved AFTER NEPHROSTOMY, MONITOR PATIENT INDICATIONS OF COMPLICATIONS ( DECREASED/ ABSENT DRAINAGE, CLOUDY, FOUL SMELLING DRAINAGE, ELAKAGE OF BLOODOR URINE FROM SITE, BACK PAIN) IF ANY OF THESE SIGNS TELL SURGEON ASAP Page 1363Renovascular disease- includes renal vein thrombosis renal artery stenosis, atherosclerosis ot thrombosis causing ischemia / atrophy of kidney tissue S/S= uncontrolled hypertension (w or w/o family hx), uncontrolled DM, elevated seum creatine, decreased GFR Dx= MRA, renal US, radionuclide imaging, renal arteriogram wil Ace (pril) Page 1370 Kidney trauma – trauma occuring to 1 or 2 kidneys Causes- penetrating wounds, blunt injuries to back, flank, abdomen Classification – grade 1( low garde injury ) to grade 5 ( most severe)shattered kidney Prevention- wear seat belt, safe walking habits, caution with riding bikes and motorcycles, wear protection when playing sports, avoid all contact sports, and high-risk activity if you only have 1 kidney Nursing action= bP and compare pulses bilaterally, RR, temp, fluid therapy, Assess VS if signs of shock every 5-15 mins, urine output every hr, should be greater than 0.5mL/kg/ hr EXPECTED ADULT URINE OUTPUT = 0.5 TO 1 ML/ KG/HR IF URETHERAL OPENING IS BLEEDING, CONSULT W/ UROLOGISTOR PCPBEFORE ATTEMPTING URINARY CATHERITIZATION, TO AVOID MAKING INJURY WORSE 1. Findings of acute pyelonephritis= pain/ burning during urination; back, flank, loin pain, cloudy foul-smelling urine; dark smokey colored urine 2. Priority question client at risk for pyelonephritis= have you recently been treated for UTI 3. Lab tests for client with ACUTE pyelonephritis= urine culture, CBC ( wbc), c-reactive protein and ESR, BUN, creatine, PG test ( if woman) 4. Highest risk of developing ACUTE pyelonephritis= female client with diabetes mellitus in 2 nd trimester of PG 5. Findings of chronic Pyelonephritis= not able to conserve sodium, decreased urine concentration and nocturia, hypertension, hyperkalemia/ acidosis 6. Best indication client fluid intake is sufficient to manage ACUTE pyelonephritis= urine output is clear yellow and dilute 7. Home care instructions for care of acute pyelonephritis = importance of nutrition, fluid intake; balance rest and activity; signs and symptoms of recurrence; proper coping mechanism; care of indwelling catheter; drug regiment 8. Priority finding in client with possible ACUTE glomerulonephritis= EDEMA of hands, face, eyelids 9. Nursing intervention of infection causing glomerulonephritis= antibiotic, personal hygiene, handwashing 10. Symptoms of client with chronic glomerulonephritis that develops uremia= ataxia, slurred speech, asterixis, itching 11. Rn delegates to AP for patients with ACUTE glomerulonephritis= weigh client every morning 12. Client with decreased kidney function, increased proteinuria , decreased serum albumin, lipid in blood and urine, increased aPTT and INR, facial edema, hypertension= Nephrotic syndrome 13. Nursing action for Nephrotic syndrome= admin mild diuretics, assess hydration status, admin angiotensin covers=ting enzyme inhibitor, assessment of periorbital swelling 14. Promoting factor of antihypertensive drug therapy DX of nephrosclerosis= once a day dosing low cost, minimal side effects 15. Questions to ask client with suspected polycystic kidney disease PKD= fam history; probs with headache, constipation or abd discomfort, changes in urine color and frequency 16. Early sign of autosomal dominant ADKPD= Nocturia 17. Teaching to prevent constipation for client with PKD= consume 2-3 liters a day; stool softener daily; maintain fiber; exercise daily 18. Minimal risk initial screening Dx test for polycystic kidney disease- renal ultrasonography 19. Polycystic disease sign to report to HCP= foul odor urine, headache that doesn’t go away, sudden weight gain 20. Priority concern for patient with hydronephrosis or hydroureter= OBSTRUCTION 21. Hydronephrosis specific finding= flank asymmetry 22. Signs and symptoms of renovascular disease= sudden hypertension, difficult to control HTN, sustained hyperglycemia, elevated serum creatine, decreased GFR 23. Post OP action of client who had nephrostomy and nephrotomy tube placed= monitor amount of drainage in collection bag 24. After nephrectomy to prevent adrenal complication = RX of steroid supplement 25. Finding of frenal cell carcinoma patient = flank pain, hematuria, palpable renal mass, renal bruit 26. Prevent kidney and genitourinary trauma= wear belt, safe walking habits, caution riding bike and motorcycle, protective clothing for contact sports, avoid contact sport if you only have 1 kidney, a. Signs and symptoms= turn her around (bruising in flank area, around colins sign (umbilicus) increased ab girth, urine hematuria, H&H, Chapter 64 Assessment of reproductive system -Low testosterone can cause= decrease muscle mass, reduce skin elasticity, lead to changes in sexual performance Page 1416-Changes in reproductive system related to aging= 12 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 WOMEN=graying /thinning pubic hair, decreased size of labia majora clitoris, decreased size of uterus, atrophy of endometrium, decreased size ovaries, loss tone, elasticity of pelvic ligaments, increased flabbiness /fibrosis of breast, decreased erection of nipples, MEN=graying and thinning of pubic hair, increased drooping of scrotum loss of rugae, prostate enlargement, increased likelihood of obstruction Women with menstruation and IUD may require iron supplement (heavy menstrual bleeding), needs calcium,) after menopause to prevent osteoporosis Preventative screening- mammogram, pap test, -anemia= can lead to fatigue, low libido AVOID Alcohol, tobacco and illicit drugs – men= can affect libido and sperm production, sustain erection; in females most no longer have meses Salpingitis- infection of uterine tubes caused by chlamydia Assessment of Patient with Reproductive health issues (not be confused with GI)> Pain, bleeding, discharge, masses Discharge causes= antibiotics, clothing, synthetic underwear, some STI, infection Page 1418 PAP smear test aka Papanicolaou test= (lithotomy position) scheduled between periods= don’t douche, no meds, no powders or deodorants or no sexual intercourse 24 hours before test Pap exam frequency –begin at age 21, ages 21-29 should do every 3 years f/u with HPV testing, ages 30-65 should have pap every 3 years, 65 and older with reg cervical cancer testing no longer need pap, hysterectomy clients no longer need pap unless hx of cancer, PAP assess- menstrual irregulars, unexplained abd, vag pain, vag discharge, infection, rape trauma or pelvic injury, physical changes in vagina cervix and uterus, PSA aka Prostate specific antigen= screening for prostate cancer for men, less than 2.5-4.0 are normal; PSA higher results can be altered by prostatitis, acute urinary retention, recent prostate biopsy, TURP, Page 1422 Mammograms recommended for 40-year-olds and up. -Pre-Mammogram instructions- no creams, no lotions, no powders, no deodorant (underarms or breast), NO Mammo if PG, Other tests- CT scan, MRI, Ultrasound, endometrial biopsy, breast biopsy Transvaginal ultrasound (allergy to latex, condom on device), Hysterosalpingogram (contrast is used) (contraindicated for PG, vag bleeds, pelvic infection and allergy to iodine, done 6-11 days from last period, Colonoscopy- no douching 24-48 hours before exam (iodine allergy) Page 1425 Laparoscopy- cath drains bladder, Transdendenburg position, abdomen inflated and deflated when done.> avoid strenuous activity afterward 1 week Page 1425 Hysteroscopy- diagnose issues in uterus, lithotomy position, (contraindicated for patient with cervical or endometrial cancer, PG, infection) Page 1426 Cervical Biopsy instructions- no lifting of heavy items 2 weeks, rest for 24 hours, report more than normal bleeding, report sign of infection, do not douche, use tampons or intercourse for 2 weeks, keep perineum dry and use antiseptic solution to rinse, change pads frequently Prostate biopsy- urinalysis done 1st, , bright red blood for a few days, semen may be rusty color, use Tylenol no NSAIDS, 1. When is normal flora disrupted for woman what condition is expected?> Vaginal infection 2. Male with hx of mumps with orchitis what common potential complication is> Testicular atrophy 3. Factors of decreased libido in men= use of Tabacco, consumption of alcohol, illicit substance abuse 4. Condition where female reports altered Nutrional intake which change metabolism- Amenorrhea 5. Priority for older male who has difficultly starting stream- teach signs of urethral obstruction and importance of prostate cancer screening 6. Older female physiologic changes= drying, smoothing thinning of vag walls, loss of tone and elasticity of pelvic ligaments, increased flabbiness and fibroids of breasts; decreased labia majora and clitoris 7. Health and lifestyle habit the nurse assesses when taking hx from client with reproductive health probs- Dietary intake, excersise pattern, , sleep pattern, sexual practices 8. Priority question to ask 40-year-old who is experiencing heavy menstrual bleeding= Are you feeling weak, dizzy, or lightheaded. 9. 30-year-old female hx of blockages in fallopian tubes- difficulty conceiving 10. Expected to see in scrotum of a client= contracts with cold, suspend below pubic bone, sparse hair follicles, pouch skin is thin walled 11. Instruction to give before pelvic exam- empty bladder in the bathroom 12. Client most in need of pelvic exam= older female over 60 resumptions of menses 13. African American whose prostate specific antigen level is 2.5ng/mL= a PSA level less than 2.5 is generally considered normal 14. Mammograms are not recommended for women under 40 years old = in younger women there is little difference in density of normal tissue and malignant tumors 15. Patient most likely to require iron supplementation= 32 year old with heavy menstrual bleeding and intrauterine device 16. Pelvic exam and Pap test is indicated for = menstrual irregularities, rape trauma, pelvic injury, unexplained vag pain, vag discharge , itchy sores, physical changes to vag, cervix, uterus, pg and infertility 17. Post op care of laparoscopy client = admin oral analgesics for pain, instruct cleint to change bandage as needed, teaching cleint to observe incision for signs of infection and hematoma 18. Avoid harm Post colposcopy= Do not douche, use tampons, have sexual intercourse for 1 week after procedure 19. Post prostate biopsy= slight sorenessand light rectal bleeding bright red ecpecre for a few days Chapter 67 Male Reproductive problem -increased residual urine =stasis this can also cause over flow incontinence. - caused by- UTI, bladder calculi Page 1470 -BPH- benign prostatic hyperplasia- enlarged prostate (surround urethrae) ageing prostate increase in size, (starts to develop in 50’s) 13 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 Non modifiable factor: aging, race (black (under 65 more than white); Genetics (Gata3), family hx (of cancer); Modifiable factors- obesity/ metabolic syndrome, glucose intolerance, dyslipidemia, hypertension Signs/ symptoms incomplete emptying of bladder, frequency, nocturia, hesitancy, urine retention, dribbling, leaking straining to urinate, hesitancy, weak stream, ( BPH uniform non tender enlargement ) Labs- PSA aka prostatic specific antigen– (elevated BPH), tissue ultrasound, urine analysis, digital rectal exam (DRC) Treatment meds given at night - 5 alpha reductase inhibitor “tirade”- prostate shrink, Alpha blocking agents – decrease BP (ZIN) relax muscle. meds( tamosulin)/ surg = TURP, Open prostatectomy REMIND PATIENT TAKING 5ALPHA REDUCTASE INHIBIOR FOR BPH ( END IN ASTERIDE) MAY NEED TO TAKED FOR ATLEAST 6 MONTHS BEFORE IMPROVEMENT NOTED. LIVER DAMAGE CAN OCCUR. SIDE EFECTS ERRECTILE DYSFUNCTION, DECREASED LIBIDO, DIZZY, (CHANGE POSITIONS SLOWLY.) KEREP MED AWAY FRM PG (ABSROBED THRU SKIN AND ARE TEROGENIC. *5 ARI=(therapeutic effect in 6 months, liver damage, erectile dysfunction, decreased libido, dizzy) * med Risk of Gynecomastia (male breast cancer associated with 5 alpha reductase inhibitor for BPH * alpha blocker- orthostatic hypertension, ^HR, syncope, take at bedtime) Treatment- encourage fluids, avoid anticholinergics, avoid antihypertensives, A void decongestants surgery post op care TURP, prostatectomy (prostate cancer) other: SAW palmetto; Risk factors – Older men, Diabetes mellitus, hypertension, obesity, hyperlipidemia, (coffee and caffeine makes works) Surgical interventions- TURP Pre-op=discontinue anticoagulants days before surg, assess for hypoatremia Teaching for BPH-Avoid drinking large amounts fluids in short time. Avoid alcohol and caffeine (diuretic effect) avoid anticholinergic, antihistamines, antipsychotics, muscle relaxants (tell your HCP about BPH diagnosis), encourage sex Diagnosis – Digital rectal exam (hard / stiff abnormal, transrectal, CBC (infection), PSA (prostate specific antigen), serum acid phosphatase, , biopsy, transrectal ultrasound, cystoscopy, Instruction before DRE- aka digital rectal exam; physical exam (empty bladder, bend over exam table, fetal position) TURP: Transurethral resection of prostate: remove parts of prostate gland (bleeding precaution ( clots) irrigating is important run quickly, 3 way catheter like y tubing 2 3000mL bags, irrigating prevent blood clot formation ( no pump) clamp with slowly open and close manually, at nurses discretion (dark and bloody drainage bag) fluid need to be run faster, empty bag every PCT and nurse job, ( patient should not absorb fluid) I and O, Never open two bags at the same time Turp syndrome – irrigant is absorbed in body (headache dizzy, hypertension changes , confused, 70 cc / hr = 850/12 good urine output Page 1477 Care after Turp- monitor for infection, underlying chronic diabetes, bed to chair , assess pain 2-4 , temp LOC changes normal, tube secured, clear urine is wanted, isotonic normal saline, kinks or obstruction, bleeding and clots is major complications and infection After turp – 2-4 hours FOR vs and urine output, pain assess post op bleeding, (severe bleeding (first 24 hours) WHEN CARING FOR PATIENT AFTER SURGERY REORIENT FRQUENTLY AND REMIND NOT TO PULL CATH. IF PATIENT RERSTLESS AND TRIES TO PICK AT TUBING= PROVIDE FAMIIAR OBJECT AND DISTRACT. DO NOT RESTRAIN UNLESS ALL OTHER ALTERANTIVES HAVE FAILED COMPLICATION OF TURP = TURP SYNDROME RARE AND CRTICAL/ IF IRRIGATION FLUID IS OVER ABSORBED INTO BODY UN ADDITONAL TO BLOOD TRANSFUSIONS AND BLEEDING, STRESS CAN BE PLACED ON HEART. S/S HEADACHE, DIZZY, SOB, HYPERTENSION, BRADYCARDIA ALTERED LOC. NOTIFY SURGEON IMMEDIATLY WILL NEED INTENSIVE CARE WHILE DIURESING PATIENTS WHO UNDERGO TURP ARE ART RISK OF SEVERE BLEEDING AFTER SURGERY (MOST LIKELY WITHIN FIRST 24 HR. If Arterial bleeding urine ketchup W/clots ; irrigate cath w/ normal saline; Emergency; will need surgery to clear bladder of clots and stop bleeding If Venous blood burgundy urine (no changes of VS _ closely monitor H and H will go down Teaching post op = Stool softener (no straining, high fiber, no blood thinner, no heaving lifting 4-6 weeks, no sex 4-6 weeks, ( hypertension tachycardia = bleeding hemorrhaging) PSA ANALYSIS CAN BE USED AS A SCREENING TEST FOR PROSTATE CANCER. ITS NOT SPECIFICALLY DX FOR CANCER AFRICAN AMERICANS MEN BETWEEN 50-59 HAVE SLIGHTLYBHIGHER NORMAL VALUETHEN MEN WHO ARE CAUSASIAN OR ASIAN. BUT RESON FOR DIFFERENCE IS UNKNOWN Testicular self examination- exam testes monthly immediately after a bath or a shower, ( scrotal skin relaxed.); examine each testicle by rolling between thumb and finger. (deep in center of testes); look and feel for lumps, smooth rounded mass, or any change in shape or consistency of testes. Report any lump or swelling to your primary health care provider as soon as possible Page 1488 Erectile dysfunction aka impotence inability to maintain or achieve an erection for sexual intercourse. 2 types organic (gradual deterioration of function and psychogenic (sudden but still have normal pm and am erections; due to high stress) Dx- glycated hemoglobin, lipid panel, TSH, Serum total testosterone, doppler ultrasonography Treatment- smoking cessation, weight loss, management BP, stop some antidepressants, penile self-inject prostaglandin E1, PDE5 drug therapy, psychotherapy, surgery (prosthesis), vacuum assisted erection devices, INSTRUCT PATIENT TAKING PDE-5 INHIBITOR TO ABSTAIN FROM ALCOHOL BEFORE SEXUAL INTERCOURSE BECAUSE IT CAN IMPAIR THE ABILITY TO HAVE AN ERECTTION. COMMON SIDE EFFECTS DYSPEPSIA (HEARBURN) HEADACHE, FACIAL FLUSHING, STUFFY NOSE. IF MORE THAN 1 PILL LEG, BACK CRAMPS, N/V ALSO MAY OCCUR. TEACH MEN TAKING NITRATE TO AVOID PDE5 INHIBITOR BECAUSE VASODIALTION EFFECTS CAN CAUSE PROFOUND HYPOTENSION AND REDUCE BLOOD FLOW TO VITAL ORGANS 14 Downloaded by Maggie C. ([email protected]) lOMoARcPSD|48573418 1. Expected symptom of BPH= difficulty passing urine 2. Technique to best assess obese male client with symptoms of BPH= instruct client ot urinate, then using the bedside ultrasound bladder scanner 3. Questions to determine BPH = sensation of incomplete bladder emptying; dribbling or leaking after finishing to urinate, nocturia, increased force or size of urine stream 4. Action by nurse done after digital rectal exam- massage prostate to obtain a fluid sample for possible prostatitis 5. Teaching Behavioral modification for patient with BPH- limit alcohol, avoid caffeine, do not consume large amounts of fluid at once, avoid antihistamine drugs 6. Lab test for BPH suspected of prostate cancer- PSA prostate specific antigen, Serum acid phosphatase 7. How do we know Tamsulosin is reaching therapeutic affect= less difficulty passing urine 8. Diagnostic procedure for client with enlarged bladder; for bladder outlet obstruction= Urodynamic pressure flow study 9. Action that can help patient with PBH relieve obstructive symptoms- increase frequency of sexual intercourse 10. Criteria needed for BPH that indicates surgery is needed- Hydronephrosis, Hematuria, chronic UTI ( 2 nd to residual urine in bladder) , acute urinary retention due to obstruction 11. PSA lab test is done before = Digital rectal exam 12. Nursing actions included in care for TURP = help client to chair ASAP prevent immobility; Use saline solution for intermittent bladder irrigant unless otherwise ordered; monitor and document color, consistency, amount of urine , safe environment ( changes in mental status), assess reports of severe bladder spasms with decreased urinary output, check drainage for obstructions and kinks or blood clots 13. Highest risk for prostate cancer= 70 year old African American who father and brother have prostate cancer 14. LAB that suggest prostate cancer has metastasized to bone= elevated serum alkaline phosphatase 15. Patient with prostate cancer common sites of metastasize= liver, lungs, lumbar spine, bones of pelvis 16. Post Transrectal ultrasound with biopsy for prostate cancer Instructions= report fever, chills, bloody urine and diffuctly to void; biopsy with dx if there is prostate cancer,; drink fluids' in first 24 hours, avoid strenuous activity 17. When assess client with open rectal prostatectomy and finding scrotal and penile swelling= elevate scrotum , penis , then apply ice to area intermittently 18. Tumor marker that would confirm dx of testiculat cancer = LDH ( lactate dehydrogenase,), AFP Alpha fetoprotein ), hCH ( beta human chorionic gonadotropin 19. Testicular lump that is hard and painless= testicular cancer 20. Instructions teach client post Opens retroperitoneal lymph nose dissection ( RPLND) for testicular cancer- do not lift anything over 15lbs, don’t drive until HCP says, monthly testes check ( remaining testes), report fever drainage, tenderness around incision 21. Priority info for patient with RX – erectile dysfunction Sildenafil= Avoid meds for Nitrate drugs ( don’t take at same time) will cause hypotension reduces blood flow to vital organs 22. Causes of organic erectile dysfunction- kidney disease, thyroid disorders, diabetes mellites, penile trauma 23. Patient taking PDE5 inhibitor drugs for erectile dysfunction – NO Alcohol before sexual intercourse 24. Post vasectomy – when can sexual intercourse be resumed- Avoid sex for 1 week after surgery 15 Downloaded by Maggie C. ([email protected])

Medsurg Exam 2 PDF - Galen College of Nursing

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