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ATI med surg Final

Terms in this set (672)

What is normal range for cholesterol, HDL, LDL

Less than 200, above 40, less than 130

What is the desired INR range for people taking warfarin

What is an indicator of cardiac tamponade

Blood pressure is 10 MM HG or higher on expiration then on inspiration

Patients scheduled for a coronary artery bypass graft should not take anticoagulants for at least blank prior to the surgery to prevent excessive bleeding

A patient is admitted with a diagnosis of Bradydysrhythmia. What assessment finding requires immediate intervention?

The patient reports weakness and fatigue

Following insertion of a permanent pacemaker, a patient states they cannot get rid of these hiccups. Why is this potentially a problem?

Hiccups may indicate that the pacemaker is stimulating the chest wall or diaphragm. This could indicate a complication such as lead wire perforation

What is the normal range for creatine kinase? When are elevated levels first detectable after myocardial injury and what is expected duration of the elevated levels?

30 to 170 units/L, 4 to 6 hours, 3 days

What is the normal range for troponin T? When are elevated levels first detectable after myocardial injury and what is expected duration of the elevated levels?

Less than 0.2 ng/L, 3 to 5 hours, 14 to 21 days

What is normal range for troponin I? When are elevated levels first detectable after myocardial injury and what is expected duration of the elevated levels?

Less than 0.03, three hours, 7 to 10 days

What is normal range for myoglobin? When are elevated levels first detectable after myocardial injury and what is expected duration of the elevated levels?

Less than 90 mcg/L, two hours, 24 hours

While an echocardiogram is being performed what side should the patient lie on?

Left side and remain still

What are indications for an echocardiogram

Cardiomyopathy
Heart failure
Angina
Myocardial infarction

What are indications for stress test

Dysrhythmias
HF
Angina
MI

What are two medications that are prescribed for pharmacological stress test

Dobutamine
Adenosine

What do you instruct the patient to do 2 to 4 hours before a stress test

Avoid tobacco, alcohol and caffeine

Hemodynamic monitoring involves special indwelling catheters that provide information about blood volume and perfusion, fluid status and how well the heart is pumping. Arterial lines are placed in the radial (most common), brachial or femoral artery. What should you Monitor for?

Monitor circulation in the limb with the arterial line. Such as capillary refill, temperature, color. Arterial lines are not used for IV fluid administration

The pulmonary artery (PA) catheter is inserted into a large vein (internal jugular, femoral, subclavian, brachial) and threaded through the right atria and ventricles into a branch of the pulmonary artery. PA catheters have multiple lumens, ports and components that allow for various hemodynamic measurements, blood sampling and

Infusion of IV fluids

What are the different lumens used for?

What is the expected reference range for CVP (Central venous pressure)

What is the expected reference range for pulmonary artery systolic (PAS)

What is the expected range for pulmonary artery diastolic (PAD)

What is expected range for pulmonary artery wedge pressure (PAWP)?

What is the expected range for cardiac output

4 to 7 L/minute

What is expected range for mixed venous oxygen saturation

When should a nurse anticipate lower hemodynamic values?

In older patients especially if dehydration is a complication

What position should the patient be in with hemodynamic monitoring

Supine or Trendelenburg

What are post procedure nursing interventions for hemodynamic monitoring

1. Obtain chest x-ray to confirm catheter placement
2. Continually monitor vitals
3. Compare NIBP to arterial blood pressure
4. Observe and document waveforms. Report changes in waveforms to the provider
5. Document catheter placement each shift and as needed
6. Place the patient in supine position prior to recording hemodynamic values ( HOB can be elevated 15° to 30°)

What are complications of hemodynamic monitoring

What are nursing actions preprocedure before an angiography

1. Patient is NPO for at least eight hours before
2. Assess for iodine/shellfish allergy
3. Assess renal function
4. Teach the client that the affected leg must remain straight after the procedure
5. The other normal stuff like ensure informed consent blah blah

What are post procedure nursing interventions for an angiography

1. Assess vitals every 15 minutes for One hour, every 30 minutes for one hour, every hour for four hours and then every four hours
2. Assess the site for bleeding and hematoma with every vital sign check
3. Maintain bed rest for 4 to 6 hours after the procedure
4. Monitor urine output and administer IV fluids for hydration (contrast media acts as an osmotic diuretic)

How long do patients receive anticoagulation therapy that have stent placement

What is cardiac tamponade

Fluid accumulation in the pericardial sac

What are manifestations of cardiac tamponade

hypotension
JVD
Muffled heart sounds
Paradoxical pulse

What are nursing actions for cardiac tamponade

1. Notify the provider immediately
2. Administer IV fluids to combat hypotension as prescribed
3. Obtain a chest x-ray or echocardiogram to confirm diagnosis
4. Prepare the client for pericardiocentesis

What is retroperitoneal bleeding

Bleeding into the abdominal cavity behind the peritoneum can occur due to femoral artery puncture (after an angiography)

What are nursing actions for retroperitoneal bleeding

1. Assess for flank pain and hypotension
2. Notify the provider immediately
3. Administer IV fluids and blood products as prescribed

What are central catheter's appropriate for

Any fluids due to rapid hemodilution in the superior vena cava

What is post procedure care for a PICC

What should you do if there's an occlusion in the access device that impedes flow

1. Flush the line at least every 12 hours to maintain patency (3 mL for peripheral & 10 mL for central lines)
2. Administer urokinase to lyse obstructions per facility protocol
3. Flush implanted port after every use and at least once a month while implanted

What are nursing actions for a catheter thrombosis/emboli

1. Flush the line per facility protocol
2. Do not force fluid if resistance is encountered
3. Use a 10 mL or larger syringe to avoid excessive pressure

What is treatment for infiltration and extravasation

1. Remove using direct pressure with gauze sponge until bleeding stops
2. Apply cool compress
3. Elevation is optional
4. Avoid starting a new IV site in the same extremity

What are nursing interventions to prevent an air embolism in a vascular access device

1. Leave central lines clamped when not in use
2. Have the patient hold breath while the tubing is changed
3. If the patient has sudden SOB, place in Trendelenburg on left side, give oxygen and notify the provider

What are nursing interventions to prevent accidental dislodgment of a catheter

1. Cover the extremity site with stretch netting
2. Wrap a washcloth folded into thirds around the arm before applying a needed restraint
3. When removing the dressing, pull from distal to proximal

Hemodynamic pressure lines should be calibrated to read atmospheric pressure as blank.

Zero. Zero transducer to room air

What kind of medication would you use for vasodilation secondary to sepsis

Dopamine (vasopressors)

What are medications/electrical management for bradycardia

1. Atropine and isoproterenol (antiarrhythmic and bronchodilator)
2. Pacemaker

What are medications/electrical management for a fib, SVT or VT with pulse

1. Amiodarone, adenosine, verapamil (CCB)
2. Synchronized cardioversion

What are medications/electrical management for VT without a pulse or ventricular fibrillation

1. Amiodarone, lidocaine and epinephrine
2. Defibrillation

What is cardioversion

Delivery of a direct countershock to the heart synchronized to the QRS complex

What is defibrillation

Delivery of an unsynchronized, direct countershock to the heart. Stops all electrical activity of the heart, allowing the SA node to take over and reestablish a perfusing rhythm

What is held 48 hours prior to elective cardioversion

What is indicative of an MI

Chest pain and ST segment depression or elevation

What is an arthrectomy

Used to break up and remove plaques within cardiac vessels

What is a stent

Placement of a mesh wire device to hold an artery open and prevent restenosis

What is a percutaneous transluminal coronary angioplasty

Involves inflating a balloon to dilate the arterial lumen and the adhering plaque, therefore widening the arterial lumen

What are indications for a PCI (angioplasty)

What are preprocedure nursing actions for a PCI (besides allergies, informed consent, blah blah)

1. NPO at least eight hours if possible
2. Assess renal function prior to introduction of contrast dye
3. Administer antiplatelet medications as prescribed

What are two medications that are administered during the intraprocedure for PCI

Midazolam (Versed) and fentanyl

What is post procedure nursing actions after a PCI

1. Assess vitals every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours and then every four hours.
2. Assess the groin site at the same intervals for bleeding and hematoma formation
3. Assess for signs of thrombosis
4. Maintain bed rest in a supine position with the leg straight for 4 to 6 hours ( or prescribed time)
5. Monitor urine output

How long does a client with a stent replacement receive anticoagulation therapy

6 to 8 weeks after

Perforation of an artery by the catheter may cause blank

Cardiac tamponade

What are clinical manifestations of anaphylaxis

chills
Fever
Rash
Wheezing
Tachycardia
Bradycardia

What are two medications that might be prescribed in the event of anaphylaxis

Diphenhydramine or epinephrine

A coronary artery bypass graft is most effective when a patient has sufficient ventricular function such as an EF greater then

What are preprocedure medications for a CABG

1. Anxiolytics: lorazepam and diazepam
2. Prophylactic antibiotics
3. Anticholinergic such as scopolamine

What are some important preprocedure teachings for a patient that is going to undergo a CABG

1. Endotracheal tube and mechanical ventilator for airway management for several hours following the surgery
2. Inability to talk while endotracheal tube is in place
3. Sternal incision and possible leg incision
4. 1 to 2 mediastinal chest tubes
5. Indwelling urinary catheter
6. Pacemaker wires
7. Hemodynamic monitoring devices

What are two medications that are discontinued before a CABG

1. Diuretics 2 to 3 days before surgery
2. Aspirin and other anticoagulants one week before surgery

What are medications that are often continued for CABG

Potassium supplements
Antidysrhythmic's
Antihypertensives
Insulin

Post procedure: what should you do with the patient within two hours following extubation

Dangle and turn the client from side to side as tolerated

What should you do within 24 hours after CABG

Assist the patient to a chair. Ambulate the patient 25 to 100 feet by first postoperative day

How often should you assess neurological status after CABG

Every 30 to 60 minutes until the client awakens from anesthesia, then every 2 to 4 hours or per facility policy

Monitor chest tube patency and drainage. Measure drainage at least once an hour. Volume exceeding blank could be a sign of possible hemorrhage and should be reported to the surgeon

What kind of manifestations of pain might an older female patient show instead of chest pain

Dyspnea, indigestion

What is a heart healthy diet

Low-fat, low cholesterol, high-fiber, low-salt

What should the patient's activity level be after a CABG

What can hypothermia cause

Vasoconstriction, metabolic acidosis and hypertension

What are indications of cardiac tamponade after a CABG

1. Sudden decrease of chest tube drainage following heavy drainage
2. JVD with clear lung sounds
3. Equal PAWP & CVP values

Treatment of cardiac tamponade after a CABG involves

1. Volume expansion
2. Emergency sternotomy (Pericardiocentesis is avoided because blood may have clotted)

What is maximum potassium administration rate IV

10 to 20 mEq/hour

How long should a patient remain NPO before a peripheral bypass graft

What are two client education points for a peripheral bypass graft

1. Advise the patient not to cross legs
2. Explain that pedal pulses will be checked frequently

What are post procedure nursing interventions for a peripheral bypass graft

1. Assess vitals every 15 minutes for one hour and then every hour after the first hour
2. Administer anticoagulant therapy/antiplatelet therapy
3. Maintain bed rest for 18 to 24 hours. The leg should be kept straight during this time

What are teaching points for foot inspection and care

The graft may occlude due to reduced blood flow and clot formation. This occurs primarily in the first

24 hours post operative

What kind of procedure is used for graft occlusion

Thrombectomy or thrombolytic therapy

What procedure is used for compartment syndrome

What are physical assessment findings for peripheral artery disease

1. Bruit over femoral and aortic artery's
2. Decreased capillary refill of toes
3. Decreased or non-palpable pulses
4. Loss hair on lower calf, ankle and foot
5. Dry, scaly, mottled skin
6. Thick toenails
7. Cold/cyanotic extremity
8. Pallor of extremity with elevation
9. Dependent Rubor
10. Muscle atrophy
11. Ulcers and possible gangrene

What are nursing actions for arteriography

1. Observe for bleeding and hemorrhage
2. Palpate pedal pulses to identify possible occlusions

How does a plethysmography diagnose PAD

A decrease in pulse pressure of the lower extremity indicates a possible blockage in the leg

A Doppler probe is used to take various blood pressure measurements for comparison. In the absence of peripheral arterial disease, pressures in the lower extremities are

Higher than those in the upper extremities

What is nursing care for a patient with PAD

1. Encourage collateral circulation
2. Avoid crossing legs
3. Avoid restrictive garments
4. Elevate the leg to reduce swelling, but not to elevate them about the level of the heart
5. Provide a warm environment
6. Avoid exposure to cold
7. Avoid stress, caffeine and nicotine and anything that causes vasoconstriction

What are medications for PAD

1. Antiplatelet medications - aspirin, Plavix, trental
2. Statins - can relieve manifestations associated with PAD such as intermittent claudication

What are two surgical procedures for PAD

1. Percutaneous transluminal angioplasty
2. Laser assisted angioplasty

What are nursing interventions for these two procedures

1. Observe for bleeding/vitals
2. Keep client on bed rest with limb straight for 6 to 8 hours before ambulation
3. Antiplatelet therapy for 1 to 3 months

What is arterial revascularization surgery used for

Patients who have severe claudication and/or limb pain at rest, or patients who are at risk for losing a limb due to poor arterial circulation

What are nursing actions for arterial revascularization surgery

1. Maintain adequate circulation in the repaired artery. The location of the pedal or dorsalis pulse should be marked and its strength compared with the contralateral leg on a scheduled basis using a Doppler
2. Assess color, temperature, sensation and capillary refill compared with the contralateral extremity on a scheduled basis
3. Monitor BP!!!!
4. No bending of the hip and knee

One complication of graft is compartment syndrome what are manifestations of it

Tingling
Numbness
Worsening pain
Edema
Pain on passive movement
Unequal pulses
(prepare patient for Fasciotomy)

What are risk factors for peripheral venous disease

1. Venus thromboembolism associated with Virchow triad
2. Hip surgery, total knee replacement, open prostate surgery
3. Heart failure
4. Immobility
5. Pregnancy
6. Oral contraceptives
7. Family history

Patients with venous disease most often complain of limb pain that feels like

Aching pain and feeling of fullness or heaviness in the legs after standing

What are signs of DVT and thrombophlebitis

What are signs of Venous insufficiency

1. Stasis dermatitis is a brown discoloration on the ankles that extends at the calf relative to the level of insufficiency
2. Edema
3. Stasis ulcers ( typically found around ankles)

What are clinical manifestation of varicose veins

1. Distended, superficial veins that are visible just below the skin and are torturous in nature
2. Patients often report muscle cramping and aches, pain after sitting and pruritus

What are laboratory tests for PVD

D dimer test measures fibrin degradation products present in the blood produced from fibrinolysis. A positive test indicates that thrombus formation has possibly occurred

What are diagnostic procedures for DVT and thrombophlebitis

1. Venus duplex ultrasonography
2. Impedance plethysmography
3. If the above test are negative for a DVT, but one is still suspected a venogram, which uses contrast material or MRI may be needed for accurate diagnosis

For varicose veins Trendelenburg test is used. What are the nursing actions for this test

1. Place the patient in the supine position with legs elevated
2. When the patient sits up, the veins will fill from the proximal and if varicosities are present

What should you encourage the patient to do if they have DVT or thrombophlebitis

What should you teach the patient to do if they have venous insufficiency

What are medications for DVT and thrombophlebitis

How long does it take for warfarin to take affect

DVT and thrombophlebitis both can use thrombolytic therapy. What are the details of this therapy?

For varicose veins, sclerotherapy may be performed. What are the details of this therapy?

What should the nurse monitor for postoperatively after varicose veins - vein stripping

What are two other surgical interventions that can be performed for varicose veins

1. Endovenous laser treatment
2. Application of radiofrequency energy

Venous stasis ulcers often form over the medial malleolus. Venous ulcers are chronic, hard to heal and often recur. They can lead to amputation and/or death. What are nursing interventions for venous ulcers

What are patient teachings for patients that have venous ulcers (diet and DVT prevention)

1. Recommend a diet high in zinc, protein, iron and vitamins A & C
2. Instruct patient on the use of compression stockings

A pulmonary embolism occurs when a thrombus is dislodged, becomes an embolus and lodges into a pulmonary vessels. What are manifestations of a pulmonary embolism's

1. Sudden onset of dyspnea, pleuritic chest pain, restlessness and apprehension, feelings of impending doom, cough and hemoptysis

What are clinical findings of a pulmonary embolism's

Tachypnea
Crackles
plural friction rub
Tachycardia
S3 or S4 heart sounds
Diaphoresis
Low-grade fever
Petechia over chest and axillae
Decreased arterial O2 sat

What should you do if you suspect that a patient has a pulmonary embolism

1. Notify the health care provider immediately, reassure the client, and assist with position of comfort with the head of the bed elevated.
2. Prepare for oxygen therapy and ABGs while continuing to monitor and assess the patient for other manifestations

When should Venus compression stockings be removed

Before going to bed. Legs should be elevated before the stockings are reapplied

What is secondary hypertension caused by

Certain disease states or medications

How does hypertrophia of the left ventricle develop

As the heart pumps against resistance caused by the hypertension

What is the maximum BMI a person should have in regards to health promotion and disease prevention for hypertension

What are risk factors for secondary hypertension

Blank, can occur with verapamil hydrochloride, so encourage intake of foods that are high in fiber

What kind of juice should not be taken with CCB medications

Grapefruit juice

What are two side effects of ARBs

Angioedema, hyperkalemia

Aldosterone receptor antagonists such as blank, block aldosterone action. They promote the retention of potassium and excretion of sodium and water

What are Side effects of aldosterone receptor antagonists

Hypertriglyceridemia, hyponatremia, hyperkalemia

What should you teach the patient that is taking aldosterone receptor antagonists

No grapefruit juice or St. John's wort. Do not take salt substitutes with potassium or foods rich in potassium

What do central alpha antagonist such as clonidine do

Reduce peripheral vascular resistance and decrease blood pressure by inhibiting the reuptake of norepinephrine

What are side effects of central alpha antagonist

Sedation, orthostatic hypotension, impotence

Alpha adrenergic antagonist, such as blank, reduce blood pressure by causing vasodilation

When is prazosin given

Usually at Night and Monitor BP for two hours after initiation of treatment

What are dietary approaches to stop hypertension

1. Diet high in fruits, vegetables, and low-fat dairy
2. Avoid foods high in sodium and fat
3. Consume foods rich in potassium, calcium and magnesium

What are clinical manifestations of a hypertensive crisis

1. Severe headache
2. Extremely high blood pressure - greater than 240/120
3. Blurred vision, dizziness and disorientation
4. Epistaxis

What are two medications that are given IV for a hypertensive crisis

Nitroprusside
Nicardipine

Before, during and after administration of IV antihypertensive what should you do

Monitor BP every 5 to 15 minutes and assess neurological status and monitor ECG

How long should a patient abstain from smoking before a pulmonary function test

6 to 8 hours prior to testing

If a patient uses inhalers how long should they withhold use before a pulmonary function test

Four to six hours prior to testing

The partial pressure of oxygen

Percentage of oxygen bound to hemoglobin as compared with the total amount that can be possibly carried

What is normal bicarbonate according to ATI

What are preprocedure nursing actions for an arterial puncture

What are intraprocedural nursing actions while performing an arterial puncture

What are postprocedural nursing actions while performing an arterial puncture

What are two complications from an arterial puncture

Hematoma and air embolism

What should you do if the patient has a hematoma

1. Observe the patient for changes in temperature, swelling, color, loss of pulse or pain
2. Notify the provider immediately if symptoms persist
3. Apply pressure to the hematoma site

What should you do if a patient exhibits symptoms of an air embolism

1. Place the patient on his left side in the Trendelenburg position
2. Monitor the patient for a sudden onset of SOB, decrease in SaO2, chest pain, anxiety and air hunger
3. Notify the provider immediately if symptoms occur, administer oxygen and obtain ABGs

Why is a bronchoscopy performed

1. Visualization of abnormalities such as tumors, inflammation and strictures
2. Biopsy
3. Removal of foreign bodies and secretions
4. Treat post operative atelectasis

What is preprocedure nursing interventions for a bronchoscopy

What are intraprocedural nursing interventions for a bronchoscopy

What are post procedure nursing interventions for a bronchoscopy

The patient is not discharged from the recovery room until adequate cough reflex and respiratory effort are present

What are three complications that can occur from a bronchoscopy

Laryngospasm, pneumothorax, aspiration

What are nursing interventions for Laryngospasm spasm and what can decrease the likelihood of laryngeal edema

1. Monitor the patient for signs of respiratory distress
2. Maintain a patent airway by repositioning the patient or inserting an oral/nasopharyngeal airway as appropriate
3. Administer oxygen therapy to the patient as prescribed. Humidification can decrease the likelihood of laryngeal edema

What are nursing interventions for a pneumothorax

1. Assess patient's breath sounds and O2 sat and obtain a follow-up chest x-ray

What are nursing interventions for aspiration

1. Prevent aspiration and the patient by withholding oral fluids or food until the gag reflex returns
2. Perform suctioning as needed

What is a thoracentesis

Performed to obtain specimens for diagnostic evaluation, instill medication into the plural space, and remove fluid or air from the plural space

What are preprocedure nursing interventions for a Thoracentesis

1. Obtain preprocedure x-ray as prescribed
2. Position the patient sitting upright with his arms and shoulders raised and supported on pillows and/or on an overbed table and with his feet and legs well supported
3. Instructed patient to remain absolutely still during the procedure and not to cough or talk unless instructed by the primary care provider

What are intraprocedural nursing interventions for a thoracentesis

1. Monitor the patient's vitals, skin color and O2 sat throughout the procedure
2. Measure and record the amount of fluid removed from the patient's chest
(The amount of fluid removed is limited to one L at a time to prevent cardiovascular collapse)
3. Label and send specimens to the Laboratory

What are post procedure nursing interventions for a thoracentesis

1. Apply a dressing over the puncture site and assess dressing for bleeding/drainage
2. Monitor vitals and respiratory status hourly for the first several hours after
3. Encourage the patient to deep breathe to assist with lung expansion
4. Obtain a chest x-ray (check resolution of effusions, rule out pneumothorax)

What are complications of a thoracentesis

Mediastinal shift, pneumothorax, bleeding, infection

What is a mediastinal shift

Shift of thoracic structures to one side of the body (Monitor VS, auscultate lungs for a decrease in or absence of breath sounds)

What is a symptom of pneumothorax

Diminished breath sounds

What are indications of a pneumothorax

1. Deviated trachea
2. Pain on the affected side that worsens upon exhalation
3. Affected side does not move in and out upon inhalation/exhalation
4. Increased HR
5. Rapid shallow respirations
6. Nagging cough or feeling of air hunger

How long does it take for a patient to exhibit symptoms when exposed to healthcare acquired pneumonia

What is rhinitis

Inflammation of the nasal mucosa

What is objective data for rhinitis

1. Red, inflamed, swollen nasal mucosa
2. Low-grade fever

What are nursing interventions for rhinitis

1. Encourage rest, 8 to 10 hours a day and increase fluid intake to at least 2000 mL/day
2. Encourage use of home humidifier or breathing steamy air
3. Proper disposal of tissues and use of cough etiquette

What are medications for rhinitis

What are holistic or complementary therapies for rhinitis

Echinacea, large doses of vitamin C and zinc

What is sinusitis

Inflammation of the mucous membranes of one or more of the sinuses

What is sinusitis associated with

1. Deviated nasal septum
2. Occurs after rhinitis
3. Nasal polyps
4. Inhaled pollutants or cocaine
5. Facial trauma
6. Dental infections
7. Loss of immune function

What are symptoms of sinusitis

Nasal congestion
Headache
Facial pressure/pain (worse when head is tilted forwards)
Cough
Bloody/Purulent nasal drainage
Tenderness to palpitation
Low-grade fever

What are diagnostic tests for sinusitis

1. CT scan or sinus x-rays
2. Endoscopic sinus cavity lavage or surgery to relieve the obstruction and promote drainage of secretions may be done as a diagnostic procedure

What are nursing interventions for sinusitis and what should you discourage

1. Encourage the use of steam, sinus irrigation, nasal spray
2. Increase fluid and rest
3. Discourage air travel, swimming and diving

What are medications for sinusitis

1. phenylephrine: used to reduce swelling of the mucosa
2. Patients should be encouraged to begin OTC decongestant at the first manifestation of sinusitis
3. Signs of rebound nasal congestion may occur if decongestions are used for more than 3 to 4 days
4. Amoxicillin if there is bacteria
5. NSAIDs, Tylenol, aspirin

What is patient education for sinusitis and what should the patient report

1. Sinus irrigation and saline nasal spray's are an effective alternative to antibiotics for relieving nasal congestion
2. Contact the provider for manifestations of a severe headache, neck stiffness and high fever (meningitis/encephalitis)

What are complications of sinusitis

Meningitis and encephalitis can occur if pathogens enter the bloodstream from the sinus cavity

When are adults contagious when infected with the flu

24 hours before manifestations develop and up to five days after

What are three extra symptoms of the avian flu compared to the flu

Severe diarrhea and cough, hypoxia

What is nursing care for hospitalized patients infected with influenza

What are antivirals that may be prescribed for treatment and prevention of the flu

1. Amantadine
2. Rimantadine
3. Ribavirin

What antivirals may be prescribed to shorten the flu

1. Relenza
2. Tamiflu

When should patients begin antiviral medications

24 to 48 hours after the onset of manifestations

Vaccination for the flu is encourage for everyone over six months of age. However high-risk patients include

1. History of pneumonia
2. Chronic medical conditions
3. Over the age of 65
4. Pregnant women
5. Health care Providers

What is a complication of the flu

What is the most common manifestation of pneumonia in older adults

How does the sputum look with pneumonia

Purulent, blood tinged or rust colored sputum

Elevated wbc's are normally elevated in pneumonia with the exception of

May not be present in older patients

What are diagnostic procedures for pneumonia

1. Chest x-ray will show consolidation of lung tissue
2. Pulse oximetry may show less than expected range

What are nursing interventions for pneumonia

1. Position the patient in high Fowlers unless contraindicated
2. Encourage coughing or suctioning
3. Oxygen therapy/breathing treatments as prescribed
4. Incentive spirometer
5. Structure activity to include periods of rest
6. Encourage fluid intake of 2 to 3 L/day

It is important to obtain a culture specimen before antibiotic therapy. What are two common antibiotics given

Penicillins and cephalosporins

What are nursing considerations regarding medications for pneumonia

1. Observe patients taking cephalosporins for frequent stools
2. Monitor her kidney function, especially older adults who are taking penicillins and cephalosporins
3. Take medication with food. Some penicillins should be taken one hour before meals or two hours after

Bronchodilators are given to reduce bronchospasms and reduce irritation. What is a short acting Beta two agonist bronchodilator

Anti-cholinergic medications such as blank, block the parasympathetic nervous system, allowing for increased bronchodilation and decreased pulmonary secretions

Methylxanthines such as blank, require close monitoring of serum medication levels due to narrow therapeutic range

What are adverse effects of Theophylline

Nausea, tachycardia, diarrhea

What should you watch for in patients taking albuterol

Tremors, tachycardia

Observe for dry mouth in patients taking ipratropium and monitor heart rate. Adverse effects include

Headache, blurred vision and palpitations which may indicate toxicity

What should you encourage patients to do while taking ipratropium

Suck on hard candies to help moisten dry mouth

Anti-inflammatories such as glucocorticosteroids such as fluticasone and prednisones are prescribed to reduce inflammation. Monitor for

Immunosuppression, fluid retention, hyperglycemia, hypokalemia and poor wound healing, black/tarry stools

What are other nursing considerations for anti-inflammatories

What are complications from pneumonia

Atelectasis, bacteremia, acute respiratory distress syndrome

What are manifestations of atelectasis

1. Patient reports SOB and exhibits findings of hypoxemia
2. Patient has diminished/absent breath sounds over the affected area
3. Chest x-ray shows area of density

What are manifestations of acute respiratory distress syndrome (ARDS)

1. Hypoxemia persists despite oxygen therapy
2. Patients dyspnea worsens as bilateral pulmonary edema develops that is non-cardiac related
3. Chest x-ray shows an area of density with a "ground glass "appearance
4. Blood gas findings demonstrate hypercarbia even though pulse oximetry shows decreased saturation

Patient with pulmonary tuberculosis is being discharged with a prescription for rifampin. The nurse should plan to include which of the following in the patient's discharge teaching plan

Urine and other secretions orange in color

A nurse is caring for a patient with COPD. What assessment finding should the nurse report to the primary care provider regarding the color of sputum

Productive cough with green sputum

What kind of diet should a patient with COPD be on

High calorie and protein

What are some things that may trigger asthma attacks

1. Changes in temperature and humidity
2. Perfume
3. Air pollutants
4. Seasonal allergies
5. Stress
6. Medications (aspirin, NSAIDs, beta blockers, cholinergics)
7. enzymes in laundry detergent
8. Sinusitis with post nasal drip
9. Viral respiratory tract infection

When a patient has asthma what temperature of water should be used to eliminate dust mites in bed linens?

What is something that should be encouraged as part of asthma therapy for a patient

Regular exercise because it promotes ventilation and perfusion

There are many risk factors for asthma, most of them are common sense. What are two risk factors that you may not think of?

1. GERD
2. The older patient is more susceptible to infection and therefore they're at bigger risk for complications

What are some physical assessment findings of asthma

1. Dyspnea
2. Anxiety or stress
3. Coughing
4. Wheezing
5. Mucus production
6. Use of accessory muscles
7. Prolonged exhalation
8. Poor O2 sat
9. Barrel chest or increased chest diameter

What diagnostic test is most accurate for diagnosing asthma and its severity?

Pulmonary function test

What are some things that you can do as a nurse to maximize patient comfort in a patient that has asthma

1. Hi Fowler's
2. Oxygen
3. Monitor cardiac rate and rhythm for changes during an acute attack
4. Initiate and maintain IV access
5. Encourage prompt medical attention for infections and appropriate vaccinations

What are some things that a nurse should monitor when a patient is using Theophylline

Monitor the patient's serum levels for toxicity. Side effects will include tachycardia, nausea and diarrhea

What are some things that a nurse should monitor the patient for when the patient is using albuterol

Tremors and tachycardia

What is something that a nurse should monitor the patient for when the patient is using Ipratropium

If a patient was showing symptoms of ipratropium toxicity what would the symptoms be?

Headache, blurred vision or palpitations

What kind of asthma attack is salmeterol used for

Is used to prevent an asthma attack and not at the onset of an attack

What are things that a nurse should watch for when a patient is taking corticosteroids, leukotriene antagonist (singulair), mast cell stabilizer (Cromolyn), or monoclonal antibodies (omalizumab)

1. Decreased immune function
2. Hyperglycemia
3. Black, tarry stools
4. Fluid retention/weight gain (common)
5. Hypokalemia with corticosteroids such as prednisone

How should prednisone be taken?

What is status asthmaticus

Life-threatening episode of airway obstruction that is unresponsive to common treatment

What are symptoms of status asthmaticus

1. Extreme wheezing
2. Labored breathing
3. Use of accessory muscles
4. Distended neck veins
5. Creates a risk for cardiac/respiratory arrest

What are nursing interventions for status asthmaticus

1. Prepare for emergency intubation
2. As prescribed, administer oxygen, bronchodilators, epinephrine and initiate systemic steroid therapy

What is emphysema characterized by

Loss of lung elasticity and hyperinflation of lung tissue

What is a genetic risk for COPD

Alpha-1 antitrypsin deficiency

What are some physical assessment findings of COPD

1. Barrel chest
2. Hyperresonance on percussion
3. Thin extremities and enlarged neck muscles
4. Clubbing of fingers and toes
5. Dependent edema secondary to right-sided heart failure (increase in pulmonary pressure)

Would hematocrit be low or high in a patient that has COPD?

High due to low oxygenation levels

Does COPD increase or decrease caloric demands

Increase because work of breathing has increased

Patients that have COPD may need blank of oxygen via nasal cannula or up to blank via Venturi mask

2 to 4 L/min, 40%

Patients who have chronically increased PaCO2 levels usually require blank of oxygen via nasal cannula

A positive expiratory pressure device assist patients to remove airway secretions. The patient inhales deeply and exhales through the device. While exhaling, a ball moves causing

A vibration that results in loosening the clients secretions

How often should a patient with COPD do exercise conditioning (walking until dyspnea occurs, resting and then walking again)

20 minutes, 2 to 3 times weekly

How much fluids should a patient who has COPD drink

Most of the medications for COPD are the same as asthma. With the exception of Mucolytic's. What are two kinds of mucolytic's?

Mucomyst, dornase alpha

How long does it take for the risk of transmission to decrease regarding TB

2 to 3 weeks after anti-tuberculin therapy

A patient will have a positive intradermal TB test within blank weeks of exposure to the

How often should patients who live in high-risk areas be screened for tuberculosis

On a yearly basis

What are risk factors for TB

In addition, recent travel outside of the US, substance use and health care occupation

What are symptoms of TB

1. Persistent cough lasting longer than three weeks
2. Purulent sputum, possibly blood streaked
3. Fatigue and lethargy
4. Weight loss and anorexia
5. Night sweats
6. Low-grade fever in the afternoon

When should the Mantoux test to be read

Within 48 to 72 hours

What is a positive Mantoux test?

1. 10 mm or greater
2. 5 mm is considered positive for immunocompromised patients

What kind of diet should a patient with TB be on?

Foods that are rich in protein, iron and vitamin C

How does isoniazid work

By preventing synthesis of mycolic acid in the cell wall

How should isoniazid be taken

On an empty stomach

What should you monitor for any patient that is taking isoniazid

Hepatotoxicity and neurotoxicity, such as tingling of the hands and feet (vitamin B6 is used to prevent neurotoxicity)

How does rifampin work

Inhibits DNA dependent RNA polymerase activity

What are side effects of rifampin

1. Hepatotoxicity (they should report yellowing of the skin, pain or swelling of joints, loss of appetite or malaise)
2. Orange color of urine and other secretions
3. May interfere with oral contraceptives

What is a side effect of pyrazinamide

How should pyrazinamide be consumed?

Instruct the patient to drink a glass of water with each dose and increase fluids during the day

How does ethambutol work

By inhibiting protein synthesis

What are two things that you need to obtain before administering ethambutol to a patient

1. Baseline visual acuity
2. Determine color discrimination ability

(this medication should not be given to children younger than 13 years of age)

What is the most important thing to teach a patient that is on ethambutol

To report vision changes immediately

What is streptomycin sulfate

Aminoglycoside antibiotic that potentiates the efficacy of macrophages during phagocytosis

What kind of patients are put on streptomycin

Those who have multi drug-resistant TB because of this medications high level of toxicity

What are two side effects of streptomycin

Ototoxicity
Renal function decline

How often are sputum samples needed during tuberculosis therapy

Every 2 to 4 weeks to monitor therapy

What is miliary TB

Where the infection invades the bloodstream and can lead to MODS

What are symptoms/complications of miliary TB

Headaches
Neck stiffness
Drowsiness
Pericarditis

What is the only condition that increases serum creatinine levels

What is the purpose of a VCUG

To detect whether urine refluxes into ureters as an x-ray is taken while the patient is voiding

What should you do as a nurse after a patient has a VCUG

1. Monitor the patient for infection for the first 72 hours after
2. Encourage increased fluid intake
3. Monitor urine output

What are preprocedure nursing interventions for a patient that is going to have a kidney biopsy

1. Review coagulation studies
2. NPO for 4 to 6 hours before

What are post procedure nursing interventions for a patient that has had a kidney biopsy

1. Monitor vitals
2. Assess dressings and urinary output (hematuria)
3. Review HGB and HCT values
4. Administer PRN pain medication

A cystography or cystourethrography are used to discover abnormalities of bladder wall and/or a occlusions of ureter or urethra. What are pre-procedure nursing interventions for these procedures?

1. NPO after midnight
2. Administer laxative/enema for bowel preparation the night before the procedure

What position should a patient be in for a cystography or Cystourethrography

Lithotomy position

What color urine may come out after a cystography or cystourethrography

Urine maybe pink tinged

What should you do if blood clots are present or urine output is decreased or absent after a cystography or Cystourethrography

Irrigate urinary catheter with NS

What are a retrograde pyelogram, Cystogram, or urethrogram used for

To identify obstruction or structural disorders of the ureters and renal pelvis of the kidneys by instilling contrast dye during a cystoscopy

What is a renography used for

To assess renal bloodflow and estimate GFR after IV injection of radioactive material to produce a scanned image of the kidneys

What should you assess frequently during and after A renography if captopril is given to change blood flow to the kidneys

What is an excretory urography used for

To detect obstruction, assess for a parenchymal mass, and assess size of the kidney. IV contrast dye is used to enhance images

What are preprocedure nursing interventions for a patient that is having an excretory urography

1. Increased fluids the day before the procedure
2. Bowel prep
3. NPO after midnight
4. Hold Metformin for 24 hours before procedure

What are post procedure nursing interventions for a patient that has had an excretory urography

1. Administer parenteral fluid or encourage oral fluids to flush dye
2. Diuretics may be administered to increase dye secretion
3. Follow up creatinine and bun serum levels before Metformin is resumed

A nurse is reviewing a patient's laboratory findings for urinalysis. The findings indicate the urine is positive for leukoesterase and nitrates. Which of is an appropriate nursing action?

Obtain a clean catch urine specimen for culture and sensitivity because this determines the antibiotic that will be most effective for treatment of the urinary tract infection

Why would a patient with a history of asthma be at risk for a complication when undergoing excretory urography?

A patient who has a history of asthma has a higher risk of having an asthma attack as an allergic response to the contrast dye used during the procedure

How do you estimate a patient's amount of fluid removed after dialysis

By comparing the patients preprocedure weight to the post procedure weight

How long should invasive procedures be avoided after dialysis

4 to 6 hours due to the risk of bleeding related to an anticoagulant

How do you check an AV fistula or AV graft for patency

By checking for thrill or bruit

When should you contact the provider after dialysis

1. If bleeding from the insertion site last longer than 30 minutes
2. Absence of thrill/bruit
3. Signs of infection

What kind of diet should a patient be on after dialysis

high folate, high protein diet

What is disequilibrium syndrome

Caused by too rapid of a decrease in BUN and circulating fluid volume. It may result in cerebral edema and increased ICP

What are signs/symptoms of disequilibrium syndrome

nausea
Vomiting
Change in LOC
Seizures
Agitation

Blank, is a risk factor for dialysis disequilibrium and hypotension due to rapid changes in fluid and electrolyte status

What can a nurse do to decrease the risk of disequilibrium syndrome

1. Use a slow dialysis exchange rate, especially for older adults and those being treated with hemodialysis for the first time
2. Administer anticonvulsants/barbiturates if needed

What is something that a nurse should do for a patient experiencing hypotension from dialysis other than administer IV fluids

Lower the head of the patient's bed

What is peritoneal dialysis

Involves instillation of a hypertonic solution into the peritoneal cavity. The solution dwells in the peritoneal cavity as ordered by the provider. Drain the solution that includes the waste products. The peritoneum serves as the filtration membrane

What color should the dialysate solution be

Clear, light yellow is expected

How much should the outflow be compared to the inflow

Expected to equal or exceed amount of dialysate inflow (insufficient outflow could mean infection)

If a fibrin clot has formed in the peritoneal dialysis catheter what should you do?

Carefully milk the catheter

What are two conditions caused by dialysis

Hyperglycemia and hyperlipidemia

Blank, is a common cause of poor inflow or outflow

What position should a patient be in during CCPD and APD treatment

Supine with head slightly elevated

If medications are held before dialysis can they be administered after it is done

Yes, medications that can be partially dialysed during the treatment should be withheld. After the treatment, the nurse should administer the medication.

Why should a patient that is experiencing shortness of breath not receive peritoneal dialysis

Because they may not be able to tolerate excessive fluids being instilled into their abdomen

What are patient indications of end-stage kidney disease necessitating kidney transplant

1. Anuria
2. Proteinuria
3. Marked azotemia
4. Severe electrolyte imbalance
5. Fluid volume excess conditions (heart failure, pulmonary edema)
6. Uremic lung

What are subjective signs/symptoms of end-stage kidney disease

Anorexia
Fatigue
Paresthesia
SOB
Dry, itchy skin
Metallic taste
Muscle cramping

What are object of signs/symptoms of end-stage kidney disease

Decreased attention span, seizures, tremor, HF, Edema, dyspnea, hypertension, distended jugular vein's, anemia, vomiting, pulmonary edema, cardiac dysrhythmias, pallor, dry itchy skin, bruising, halitosis and diminished or dark colored urine

What is methylprednisone sodium succinate

An anti-inflammatory and immunosuppressant used to decrease the immune system response of inflammation and rejection of donor kidney

What is another immunosuppressant medication used to prevent rejection of the donor kidney

A patient has had a kidney transplant is usually dialyzed within blank of the surgery

What are some things you should assess/monitor the patient for after a kidney transplant

1. Vital signs every 15 minutes initially and advance to every hour
2. Report urine output less than 30 mL/HR
3. Urine appearance and older should be checked hourly (initially pink and bloody)
4. Daily weights
5. Maintain continuous bladder irrigation as prescribed (to prevent clots from forming)

What diuretic is preferred when oliguria is present after a kidney transplant

What kind of diet should a patient be on after a kidney transplant

Low-fat, high-fiber, increased protein, low-sodium, avoid sugars or carbohydrates

When taking cyclosporine what are two things you need to do

1. Magnesium supplements because it reduces magnesium levels
2. Avoid grapefruit

What is hyper acute rejection

Rejection that occurs within 48 hours after surgery caused by an anti-body mediated response that causes small blood clot to form in the transplanted kidney

What are symptoms of a hyper acute rejection

Fever, hypertension, pain at the transplant site

What is treatment for hyper acute rejection

Immediate removal of the donor kidney

What is acute rejection

Occurs one week to two years after surgery. An antibody mediated response causing vasculitis in the donor kidney and cellular destruction starts with inflammation that causes lysis of the donor kidney

What are symptoms of an acute rejection

Oliguria
Anuria
Low-grade fever
Hypertension
Tenderness over the transplanted kidney
Lethargy
Azotemia
Fluid retention

What is treatment for acute rejection

Involves increased doses of immunosuppressive medications

What is chronic rejection

Occurs gradually over months to years. Blood vessel injury from overgrowth of the smooth muscles of the blood vessels causing fibrotic tissue to replace normal tissue resulting in a nonfunctioning donor kidney

What are symptoms of chronic rejection

Gradual return of azotemia
Fluid retention
Electrolyte imbalance
Fatigue

What is treatment for chronic rejection

Monitor kidney status, continue immunosuppressive therapy until dialysis is required

What is acute tubular necrosis

Caused by a delay in transplanting the donor kidney after harvesting may result in hypoxic injury of the donor kidney

What are symptoms/signs of renal artery stenosis

Hypertension
Bruit over artery anastomosis site
Decreased kidney function
Peripheral edema

What is the most common cause of first transplant year morbidity and mortality

What are the four phases of acute kidney injury

1. Onset: begins with the onset of the event, ends when oliguria develops and lasts for hours to days
2. Oliguria: begins with the kidney insult, urine output is 100 to 400 mL/24 hour with or without diuretics and lasts for 1 to 3 weeks
3. Diuresis: begins when the kidneys start to recover, diuresis of a large amount of fluid occurs and can last for 2 to 6 weeks
4. Recovery: continues until kidney function is fully restored and can take up to 12 months

What is prerenal acute kidney injury

Occurs as a result of volume depletion and prolonged reduction of blood flow to the kidneys which leads to ischemia of the nephrons

What is treatment for prerenal acute kidney injury

1. Administer IV fluid if no fluid restrictions
2. Administer calcium channel blocker to prevent the movement of calcium into the kidney cells and to increase GFR
3. Monitor I and O's
4. Monitor for decreased cardiac output

Intrarenal acute kidney injury occurs as a result of direct damage to the kidney from lack of oxygen (acute tubular necrosis). What are causes of intrarenal acute kidney injury

1. Physical injury
2. Hypoxic injury - renal artery or vein stenosis or thrombosis
3. Chemical injury - acute nephrotoxins (antibiotics, NSAIDs, contrast dye, heavy metal, blood transfusion reaction)
4. Immunologic injury - infection, vasculitis, acute glomerulonephritis

What are two complications of intrarenal acute kidney injury

Heart failure or pulmonary edema

What are signs/symptoms of acute intrarenal kidney injury

ECG dysrhythmias (tall T waves)
Flank pain
N/V
Lethargy
Tremors
Confusion

Post renal acute kidney injury occurs as a result of bilateral obstruction of structures leaving the kidney. What are causes

1. Stone, tumor, bladder atony
2. Prostate hyperplasia, urethral stricture
3. Spinal cord disease or injury

How do laboratory values look in post renal acute kidney injury

Gradually increases in serum creatinine, BUN, urine specific gravity

What is nutrition for post renal acute kidney injury

Restrict potassium, phosphate and magnesium during oliguric phase and increase protein

What are the five stages of chronic kidney disease

Stage one: minimal kidney damage with normal GFR (greater than 90 ML/min)
Stage two: mild kidney damage with GFR 60 to 89 mL/min
Stage III: GFR 30 to 59 mL/min
Stage 4: GFR is 15 to 29 mL/min
Stage five: GFR less than 15 mL/min

How much fluids are patients with chronic kidney disease encouraged to drink

At least 3 L of water daily

If a patient has diabetes or hypertension and chronic kidney disease what should you encourage them to come in for regarding yearly tests

Yearly testing for albumin in the urine

What are some signs and symptoms of chronic kidney failure

Fatigue
Lethargy
Involuntary movement of the legs
Depression
Intractable hiccups

How do you serum electrolytes look in chronic kidney disease

Decreased sodium and calcium; increased potassium, phosphorus and magnesium

Why is hemoglobin and hematocrit decreased in chronic kidney disease

From anemia secondary to the loss of erythropoietin

What are complications of CKD

Electrolyte imbalance
Dysrhythmias
Fluid overload
Hypertension
Metabolic acidosis
Secondary infection
Uremia

What kind of diet should a patient be on that has chronic kidney disease

High in carbohydrates and moderate in fat

What medications are considered nephrotoxic

Aminoglycosides
Amphotericin b
NSAIDs
Ace inhibitors
Arbs
Contrast dye

If a patient is on digoxin when should you administer it

After receiving dialysis

Why is aluminum hydroxide given to patients with chronic kidney disease

Taken with meals to bind phosphate in food and stop phosphate absorption (take two hours before or after digoxin)

What kind of diuretic should be avoided in patients that have end stage kidney disease

What kind of Antacids should a patient with kidney disease avoid

Those containing magnesium

If a patient has a high creatinine level what should you assess for in the urine

Who is more at risk for urosepsis women or men

Aging women due to decreased estrogen which promotes atrophy of the urethral opening towards the rectum

What are subjective signs/symptoms of a urinary tract infection

1. Lower back/abdominal discomfort
2. Urinary frequency/urgency
3. Nausea
4. Dysuria, cramping
5. Urinary retention
6. Perineal itching
7. Hematuria
8. Pyuria (greater than four wbc in urine sample)

What are objective signs/symptoms of a urinary tract infection

1. Fever
2. Vomiting
3. Voiding in small amounts
4. Nocturia
5. Urethral discharge
6. Cloudy/smelly urine

What are older adult clinical manifestations of a UTI

1. Mental confusion
2. Incontinence
3. Loss of appetite
4. Nocturia and dyslexia
5. Signs of urosepsis

What are signs of urosepsis

Hypotension
Tachycardia
Tachypnea
Fever

If a patient has a urinary tract infection what are some things you'd expect to find in the urine

Bacteria, sediment, WBCs, RBCs, positive leukocyte esterase and nitrates

If a patient has a urinary tract infection what are some things you can encourage the patient to do to relieve symptoms

1. Promote fluid intake up to 3 L a day
2. Encourage urination every 3 to 4 hours instead of waiting until the bladder is completely full
3. Recommend warm sitz Bath 2 to 3 times a day to promote comfort

What are two medications that are prescribed less frequently for UTIs because the medicine is less effective and tolerated

Penicillins and cephalosporins

If a sulfonamide is prescribed for a patient with a UTI what should you ask the patient about?

Allergy to sulfa

What is a bladder analgesic that is used to treat UTIs

Phenozopyridine (take with food)

When a patient has a UTI they are encouraged to drink cranberry juice because a compound in cranberries may stop certain bacteria from adhering to the mucosa of the urinary tract. Patients who have blank should avoid cranberry juice, which irritates the bladder

Chronic cystitis

What are risk factors for pyelonephritis

1. Men over 65 who have prostatitis and hypertrophy of the prostate
2. Chronic urinary stone disorders
3. Spinal cord injury
4. Pregnancy
5. Bladder tumors
6. Urine pH increases
7. Chronic illnesses (DM, HTN)

Chills, nausea, malaise, fatigue, burning/urgency/frequency with urination are all subjective signs and symptoms of pyelonephritis. What are two more less obvious symptoms?

Colicky type abdominal pain and costovertebral tenderness

What are objective signs/symptoms of pyelonephritis

Fever
Tachycardia
Tachypnea
Hypertension
Flank/back pain
Vomiting
Nocturia
Asymptomatic bacteremia
Inability to concentrate urine or conserve sodium

What are 4 lab values that will be increased with pyelonephritis nephritis

C-reactive protein, ESR, Creatinine and BUN

What are complications of chronic pyelonephritis

Septic shock
Chronic kidney disease
Hypertension

Although penicillin antibiotics are rarely used to treat urinary tract infections with kidney infections this type of penicillin may be used

Does a diet high in calcium increase the risk for kidney Stones. Since the majority of stones are composed of calcium phosphate or calcium oxalate

No not unless there is a pre-existing metabolic disorder or renal tubular defect

Who is more at risk for urolithiasis? Males or females

There is an increased incidence of urolithiasis in males

What are four things that contribute to an environment favorable for stone formation

Urinary stasis, urinary retention, immobilization and dehydration

What is something that you might see in a urinalysis of a patient that has a kidney stone

What does KUB stand for

X-ray of kidney, ureters and bladder

What are things that a nurse should assess/monitor for any patient that has kidney stones

1. Pain
2. I and O's
3. Urinary pH
4. Strain all urine
5. Encourage ambulation to promote passage of the stone

According to ATI what should respiration rate be

12 to 20 breaths per minute

What are medications given for kidney stones

Opioids, nSAIDs, oxybutynin chloride

What are side effects of oxybutynin chloride

1. Increased intraocular pressure (Contraindicated if there's a history of glaucoma)
2. Dizziness
3. Dry mouth
4. Tachycardia
5. Urinary retention

Antibiotics such as gentamicin and cephalexin are used to treat UTIs. Administer the medication with food to decrease G.I. distress. What else should you monitor for

Nephrotoxicity and ototoxicity. Also inform the patient that urine may have a foul odor related to the antibiotic

What are two things that are common after a patient has had extracorporeal shockwave lithotripsy

Bruising at the site where the waves are applied and hematuria

If a patient keeps having calcium phosphate stones what kind of diet should they be on

Limit intake of food high in animal protein, limit sodium, reduce calcium

What are medications that are given for calcium phosphate stones

Thiazide diuretics,
Orthophosphates,
Sodium cellulose phosphate

If a patient has calcium oxalate stones what should their diet be

Avoid: spinach, black tea, rhubarb, cocoa, beats, pecans, peanuts, okra, chocolate, wheat germ, lime peel, Swiss chard and limit sodium intake

What are medications for uric acid stones

Allopurinol, potassium or sodium citrate or sodium bicarbonate

What is hydronephrosis

When a stone has blocked a portion of the urinary tract causing the urine to back up into the kidneys causing distention of the kidney

Which ethnicities is diabetes more prevalent in

African-American, American Indians and Hispanics

What are risk factors for diabetes

Obesity
Hypertension
Inactivity
Hyperlipidemia
Cigarette smoking
Genetic history
Elevated CRP
Ethnic group
Women who have delivered infants weighing more than 9 pounds
BMI greater than 24

What are two things that the patient can add to their diet to decrease the risk of developing diabetes

Omega-3 fatty acids and fiber

What are clinical manifestations of diabetes

Hyperglycemia (blood glucose level usually greater than 250)
Polyuria
Polydipsia
Polyphagia
Fruity breath
Decreased LOC
Headache
N/V
Seizures leading to coma

Diagnostic criteria for diabetes include 2 findings (on separate days) of one of the following

1. Manifestations of diabetes plus casual blood glucose concentration greater than 200
2. Fasting blood glucose greater than 126
3. Two hour glucose greater than 200 with an oral glucose tolerance test

How long is a patient instructed to not eat or drink (other than water) before a fasting blood glucose test

How long should a patient fast for before an oral glucose tolerance test

What is normal hemoglobin A-1 C range

How often should the needle in a continuous infusion pump be changed

Every 2 to 3 days

Are insulin pens used if more than one insulin is given anytime

What kind of insulin is Humalog and NovoLog

Rapid acting, onset is 10 to 30 minutes

What kind of insulin is Humulin N and detemir insulin

Intermediate acting, administered for control between meals and at night

What kind of insulin is glargine

Long acting, administered once a day because it dissipates slowly over 24 hours

What are manifestations of hypoglycemia

Mild shakiness
Mental confusion
Sweating
Palpitations
Headache
Lack of coordination
Blurred vision
Seizures
Coma

What are some preventative measures to avoid hypoglycemia

Avoid excess insulin, exercise and alcohol consumption on an empty stomach

Blood glucose increases approximately blank over 30 minutes following ingestion of blank grams of absorbable carbohydrate

If a patient is unconscious or any able to swallow how can you administer glucagon to them

By SQ or IM and repeat in 10 minutes is still unconscious

If the patient is in an acute care setting the nurse should administer blank if IV access is available and consciousness should occur within 20 minutes

When a patient has a blood glucose level greater than 250 mg/DL they should restrict

What are two things you should monitor for any patient taking Metformin

G.I. effects and lactic acidosis

When should Metformin be discontinued before anything with contrast dye

What kind of supplements should a patient be taking that is on Metformin

Vitamin B12 and folic acid

When should glipizide be taken

30 minutes before meals

What medication can mask tachycardia typically seen during hypoglycemia

Should diabetic patients use lotion between the toes after they wash their feet with mild soap and water

When is the best time to perform nail care

After a shower or bath

What kind of socks should diabetic patients wear

Socks made of cotton or wool

How should a diabetic patient clean a cut on their foot

With warm water and mild soap, gently dry and apply a dry dressing

How often should a diabetic patient monitor their blood glucose when they're sick

Every 3 to 4 hours

What is the recommended blood pressure of a patient with diabetes

Less than 130/80

How often should a diabetic patient get eye and foot exams

What is hyperglycemic - hyperosmolar State

An acute, life-threatening condition characterized by profound hyperglycemia (above 600) osmolarity that leads to dehydration and an absence of ketosis

What are risk factors for HHS

1. Older adult who has residual insulin secretion
2. Older adult who has an adequate fluid intake
3. Older adults who have decreased kidney function and are unable to excrete excess of glucose into the urine
4. MI, cerebral vascular injury or sepsis
5. Infection/stress
6. Glucocorticoids, diuretics, Dilantin, propranolol, CCB

What are clinical manifestations of HHS

blurred vision
Headache
Weakness
Polyuria
Polydipsia
Orthostatic hypotension
Change in LOC
Seizures/myoclonic jerking
Reversible paralysis

How does serum osmolarity look in HHS

Greater than 320 mOsm/L

How does your pH look in DKA

What is the pH look like in HHS

Greater than 7.4

What kind of fluids should be administered to patients with DKA or HHS

Isotonic fluid's such as normal NS followed with a hypotonic fluid (IV bolus of insulin)

What should you do when serum glucose levels approach 250 mg/DL

Add glucose to IV fluids to minimize the risk of cerebral Edema associated with drastic changes in serum osmolarity and prevent hypoglycemia

What else should you monitor a patient for when they are in a diabetic crisis

Hyperkalemia and then hypokalemia as potassium follows insulin into the cells

How often should an older adult patient monitor blood glucose when they are sick

Every 1 to 4 hours

If a patient who has diabetes would like to consume alcohol what should you tell them

Consume carbohydrates while drinking alcohol will help prevent hypoglycemia

Medication given to suppress the thyroid hormone and will allow for weight gain

When assessing a patient diagnosed with diabetes insipidus, the nurse should expect which of the following laboratory findings

Increased hematocrit due to dehydration

A nurse is monitoring a patient's status 24 hours after a total thyroidectomy. What kind of breath sound would you immediately report to the provider

Laryngeal stridor

How should the patient take their medication if they are on thyroid hormone replacement therapy

On an empty stomach to promote proper absorption

Why is an arthroscopy performed

To visualize the internal structures of a joint, most commonly the knee or shoulder joints

When can an arthroscopy not be performed

If there is an infection or if the patient is unable to bend the joint at least 40°

How often should you assess the patient's neurovascular status and dressing after an arthroscopy

Every hour or per hospital protocol

How often should a patient ice and elevate extremity after an arthroscopy

Ice and elevation should be applied for 24 hours

Bone scans are done when a patient entire skeletal system is to be evaluated. A radionucleotide test involves radioactive material injected blank before scanning

Blank and blank scans are more sensitive to detecting bone problems than a bone scan. When is in radionucleotide injected before the scans

Gallium, Thallium, 4 to 6 hours

During a bone scan does the patient need to be sedated

Only if they are unable to lie still for 30 to 60 minutes

Following the procedure does the patient need to take any special radioactive precautions

No but the patient should be encouraged to drink plenty of fluids to increased excretion of radioisotope

What kind of scan is done to estimate the density of a patient's bone mass, usually in the hip or spine, and the presence/extent of osteoporosis

DXA (dual x-ray absorptiometry)

Is contrast material used with a DXA scan

At what age might a baseline DXA scan be performed

Why would an electromyography (EMG) and nerve conduction studies be performed

To determine the presence and cause of muscle weakness

How is an EMG performed

Thin needles are placed in the muscle under study and attach it to an electrode, which is attached to oscilloscope. Electrical activity is recorded during a muscle contraction

How is a nerve conduction study performed

Flat electrodes are taped on the skin. Low electrical currents are sent through the electrodes and muscle response to the stimulus is reported

What are two medications that must be avoided before receiving an EMG or nerve conduction study

Anticoagulants or muscle relaxants

What are two things that the patient should report to the provider after receiving an EMG or nerve conduction study

Swelling or tenderness

What kind of pain medication can be used for patients after an arthroscopy

How long does a DXA scan last for

Several hours. The radionucleotide substance is injected and must be absorbed by the bone prior to the procedure. The patient must wait several hours after the injection before the scan can be completed

During an EMG what should you ask the patient to do for an easier insertion of the needle into the muscle

To flex their muscles

What is an arthroplasty

The surgical removal of a diseased joint due to osteoarthritis, osteonecrosis, rheumatoid arthritis, trauma or congenital anomalies and replacing it with prosthetics or artificial components made of Metal and/or plastic

What are contraindications to an arthroplasty

1. Recent or active infection
2. Arterial impairment to the affected extremity
3. The patient's inability to follow the post surgery regimen
4. A comorbid condition such as uncontrolled diabetes or hypertension, osteoporosis, progressive inflammatory condition, unstable cardiac/respiratory conditions

What should a patient do to prepare for arthroplasty the night before the surgery

1. Scrub the surgical site with a prescribed anti-septic soap
2. Wear clean clothes and sleep on clean linens

What should a patient do in the morning to prepare for an arthroplasty

1. Scrub at the surgical site with a prescribed anti-septic soap
2. Take antihypertensive medications as well as other medications that the surgeon allows with a sip of water

Prosthetic components may or may not be cemented in place. Components that do not use cement allow the bone to grow into

The prosthesis to stabilize it

If the components are not cemented when should weight-bearing occur

Weight bearing is delayed several weeks until the femoral shaft has grown into the prosthesis

A CPM machine may be prescribed after surgery to promote motion in the knee and

Prevent scar tissue formation

When is a CPM turned off

What position of the patient should you avoid after an arthroplasty

Positions of flexion of the knee are limited to avoid flexion contractures. Avoid knee gatch and pillows placed behind the knee

How should you position small blankets or pillows to keep heels off the bed in efforts to avoid pressure ulcers

Slightly above the ankle area

After an arthroplasty opioids as well as a continuous peripheral nerve block may be initiated for a patient. What should you monitor the patient for in regards to a continuous peripheral nerve block

Monitor the patient for systemic effects of local anesthetic, such as hypotension, bradycardia, restlessness or seizure

Ice or cold therapy may be applied to reduce post operative swelling. Monitor the patients neurovascular status of the surgical extremity every blank

2 to 4 hours (movement, sensation, color, pulse, capillary refill and compare with the contralateral extremity)

After a patient has had a hip arthroplasty what kind of range of motion exercise should you encourage

Plantar flexion, dorsiflexion, and circumduction to prevent clot formation

Early ambulation after a hip arthroplasty is important. How should you transfer the patient out of bed

From the unaffected side into a chair or wheelchair

What should you apply to the surgical site following ambulation

What is patient positioning after a hip arthroplasty

Place the patient supine with the head slightly elevated and the affected leg in a neutral position. Place a pillow or abduction device between the legs when turning to the unaffected side. The patient should not be turned to the operative side, which could cause hip dislocation

What are four do's after an arthroplasty

1. Use elevated seating/raised toilet seat
2. Use straight chairs with arms
3. Use an abduction pillow, or a pillow, if prescribed between the patients legs while in bed
4. Externally rotate a patient's toes

What are four don'ts after an arthroplasty

1. Avoid flexion of hip greater than 90°
2. Avoid low chairs
3. Do not cross a patients legs
4. Do not internally rotate a patient's toes

After a knee arthroplasty when can a patient kneel and deep knee bend

Unfortunately those are limited indefinitely

How often should a patient clean their incision after a total hip arthroplasty

Daily with soap and water

Upper extremity amputation's are usually the result of a traumatic injury however lower extremity amputation's are usually the result of

Peripheral vascular disease as a result of arteriosclerosis

What are signs of inadequate peripheral circulation

Edema
Reduced cap Refill time
Necrosis
Lack of hair distribution

What is the ankle brachial index

Measures difference between ankle and brachial systolic pressures

What is a closed amputation

The most common technique used. Skin flap is sutured over end of residual limb, closing site

What is open amputation

This technique is used when an active infection is present. Skin flap is not sutured over end of residual limb allowing for drainage of infection. Skin flap is closed at a later date

When your palpating the residual limb for warmth what might heat indicate

What do patients often describe the pain associated with phantom pain as

Deep and burning, cramping, shooting or aching

What are two classes of medications that some patients may feel relief from phantom pain

Anti-spasmodic's and antidepressants

Other than medications what are four alternative treatments for phantom limb pain

Massage, heat, biofeedback or relaxation therapy

What should you teach a patient to do to reduce phantom limb pain and prepare the limb for a prosthesis

To push the residual limb down toward the bed while supported on a soft pillow

How should you position that affected extremity to promote bloodflow/oxygenation

Dependent position

What are three things that you can do to assist in shrinking the residual limb for a prosthesis fitting

1. Wrapping the stump, using elastic bandages to prevent restriction of blood flow and decrease edema (figure 8)
2. Use a stump shrinker suck
3. Use an air splint inflated to protect and shape the residual limb

What are four things that a nurse could do to prevent the patient from developing flexion contractures after an amputation

1. Range of motion exercises and proper positioning immediately after surgery
2. Avoid elevating the stump on a pillow after the first 24 hours following surgery
3. Have the patient lie prone for 20 to 30 minutes several times a day
4. Discourage prolonged sitting in a chair

At what age does the remodeling of bone stop occurring at equal rates (osteoblastic versus osteoclastic activity)

What is the grading scale for open fractures

Grade 1: minimal skin damage
Grade 2: damage includes skin and muscle contusion but without extensive soft tissue injury
Grade 3: damage is excessive to skin, muscles, nerves and blood vessels

What is a comminuted fracture

Has multiple fracture lines splitting the bone into multiple pieces

What is the most common fracture found in children

Greenstick: Fracture occurring on one side but does not extend completely through the bone

What are the three biggest risk factors for osteoporosis

1. Excessive exercising/weight loss from dieting and malnutrition
2. Women who do not use estrogen replacement therapy after menopause
3. Patients on long-term corticosteroid therapy

What are five physical assessment findings of a fracture

Crepitus, deformity, muscle spasms, edema, ecchymosis

What position should a limb be in after a fracture

Elevated above the heart and apply ice

How often should neurovascular checks be performed when a patient has a fracture

Every hour for the first 24 hours and then every 1 to 4 hours after

What is a closed reduction

When a pulling force (traction) is applied manually to realign the displaced fractured bone fragments

What is an open reduction/internal fixation

When a surgical incision is made and the bone is manually aligned and kept in place with plates and screws

What is more effective than splints or immobilizers because they cannot be removed by the patient

What is a spica cast

A portion of the trunk and one or two extremities

How should you handle a plaster cast until it is dry? It can take up to 24 to 72 hours to dry

With the palms, not fingertips

Look at skin traction, bucks traction and balanced suspension skeletal traction

How often should you insure that pulley ropes are free of knots, fraying, loosening and improper positioning

Every 8 to 12 hours

What are two things you can do to treat muscle spasms if it is prescribed

What is a normal standard pin care protocol (if the patient has pins in place)

1. Pin care is provided usually once a shift, 1 to 2 times a day
2. Chlorhexidine is usually used and only one cotton tipped swabs per a pin to avoid cross-contamination

What is external fixation

Involves fracture immobilization using percutaneous pins and wires that are attached to a rigid external frame

What are advantages to external fixation

1. Immediate fracture stabilization
2. Minimal blood loss occurring in comparison with internal fixation
3. Allows for early mobilization and ambulation
4. Permitting wound care with open fractures

What is a disadvantage to external fixation

Risk of pin site infection leading to osteomyelitis

What is open reduction and internal fixation

Refers to visualization of a fracture through an incision in the skin and internal fixation with plates, screws, pins, rods and prosthetics as needed

How often should you inspect bony prominences with an open reduction and internal fixation

Every shift and ensure heels are off the bed at all times

What are the six p's associated with compartment syndrome

Pain, paralysis, paresthesia, pallor, pulselessness and poikilothermia

Who is at greatest risk for developing a fat embolism

Adults between the age of 70 and 80

Fat embolism's usually occur within blank hours following a long bone fracture or with total joint arthroplasty

What are clinical manifestations of a fat embolism

Dyspnea
Chest pain
Decreased O2 sat
Decreased LOC
Respiratory distress
Tachycardia
Tachypnea
Fever
Cutaneous petechiae (late sign)

What is treatment for a fat embolism

1. Maintain the patient on bedrest
2. Oxygen for respiratory compromise
3. Corticosteroids for cerebral edema
4. Vasopressors and fluid replacement for shock
5. Pain and anti-anxiety medications as needed

What is the most common complication following trauma, surgery or disability related to immobility

What are ways to prevent DVT

1. Encourage early ambulation
2. Apply antiembolism stockings
3. Administer anticoagulants
4. Encourage intake of fluids to prevent hemoconcentration
5. Instruct the patient to rotate feet at the ankles and perform other lower extremity exercises as permitted by the particular immobilization device

What is treatment for osteomyelitis

1. Long course of IV and oral antibiotic therapy (3 months)
2. Surgical debridement
3. Hyperbaric oxygen treatment
4. Surgically implanted antibiotic beads
5. Amputation

If a wound from osteomyelitis is left open to heal, standard precautions are adequate and blank technique can be used during dressing changes

What is avascular necrosis

Bloodflow is disrupted to the fracture site and the resulting ischemia leads to tissue/bone necrosis

Who is at greater risk for developing avascular necrosis

Patients receiving long-term corticosteroid therapy

A nurse is completing an assessment of a patient who had an external fixation device applied two hours ago for a fracture of the left tibia and fibula. What are four things that the nurse might find that would indicate compartment syndrome?

1. Intense pain when the left foot is passively moved
2. Hard, swollen muscle in the left leg
3. Burning and tingling of the distal left foot
4. Minimal pain relief following a second dose of opioid medication

A nurse in the emergency department is planning care for a patient who has a right hip fracture. What kind of immobilization device should the nurse anticipate in the plan of care?

Bucks traction because it is a temporary immobilization device applied to diminish muscle spasms and immobilize the affected extremity until surgery is performed

The posterior pituitary gland secretes the hormone blank which causes the kidneys to reabsorb water

ADH (vasopressin)

A deficiency of ADH causes

Diabetes insipidus, which is characterized by the excretion of a large quantity of diluted urine

Excessive secretion of ADH causes

Syndrome of inappropriate antidiuretic hormone. In SIADH, the kidneys retain water, urine becomes concentrated, urinary output decreases and extracellular fluid volume is increased

What is the water deprivation test

Measures the kidneys ability to concentrate urine in light of an increased plasma osmolality and a low plasma vasopressin level.

The water deprivation test is performed for patients who have a diagnosis of diabetes insipidus. It should only be conducted if the patient's baseline serum sodium level is blank and The osmolality of the urine is below blank

Within the expected range, 300

What is a positive result for diabetes insipidus with the water deprivation test

The kidneys are unable to concentrate urine despite increased plasma osmolality

What are preprocedure nursing actions for the water deprivation test

1. No smoking/caffeine or alcohol prior to test
2. Withhold fluids for 8 to 12 hours
3. Obtain IV access

What position is the patient in during the test

Recumbent position for 30 minutes however The patient may sit or stand during voiding.

What is a complication of the water deprivation test

What is Cushing's disease (Hypercortisolism)

Hyper functioning of the adrenal cortex and an excessive production of cortisol

What is Addison's disease

Hypo functioning of the adrenal cortex and a consequent lack of adequate amounts of serum cortisol

What is a diagnostic test they can use to determine if a patient has Cushing's disease

Dexamethasone suppression test

What is a positive result for Cushing's disease after doing the dexamethasone test

There is no decrease in the production of ACTH and cortisol

Disorders of the adrenal medulla may cause

Hypersecretion of catecholamines (pheochromocytoma)

The vanillylmandelic acid test is used to diagnose pheochromocytoma. How does this test work

VMA testing is a 24 hour urine collection for VMA, a breakdown product of catecholamines

What is the expected range for VMA in a 24-hour period

What is a positive result for the VMA test that indicates pheochromocytoma

Elevated levels

What kind of food and medications may be restricted 2 to 3 days before the test

Caffeine, vanilla, bananas, chocolate, aspirin and Antihypertensive medications

A clonidine suppression test is where the patients plasma catecholamine levels are taken prior to and three hours after administration of clonidine. What is a positive result for pheochromocytoma

The clonidine has no effect and no decrease in blood pressure

What is normal reference range for fasting blood glucose

Less than 110 mg/dL

How long does the patient need to abstain from food or fluids other than water before a fasting blood glucose test

What is a normal reference range for the oral glucose tolerance test

How long does a patient need to fast before the oral glucose tolerance test

How often are blood samples taken during the oral glucose tolerance test

Every 30 minutes for two hours

What is normal range for HBA1C, what level indicates pre-diabetes and what level indicates diabetes

Normal: 5% or less
Pre-diabetes: 5.7% to 6.4%
Diabetes: 6.5% or higher

What is normal range for T3

What is normal range for T4

What are risk factors for diabetes insipidus

1. Head injury/tumor/infection (meningitis, encephalitis)
2. Lithium

What are signs/symptoms of diabetes insipidus

Polyuria
Polydipsia
Nocturia
Fatigue
And other symptoms of dehydration

How is the urine chemistry in diabetes insipidus (PH, sodium, potassium, specific gravity, osmolality)

Everything is decreased, think dilute

How is the serum chemistry in diabetes insipidus

Think concentrated everything is increased

What would a radioimmunoassay show you

What kind of drink would a patient with diabetes insipidus went to avoid

Anything with caffeine

What should be done daily with the patient that has diabetes insipidus

What is an anticonvulsant that stimulates the release of ADH

What are three side effects of Tegretol

Dizziness, drowsiness, thrombocytopenia

What are symptoms of thrombocytopenia

Sore throat, fever, bleeding

Should Tegretol be taken with or without food

Who should vasopressin be given cautiously to

Patients who have coronary artery disease because it can cause vasoconstriction

What are four teaching points to a patient that has diabetes insipidus

1. Weigh daily
2. Eat a diet high in fiber
3. Wear a medical alert wristband
4. Monitor fluid intake

What are risk factors for syndrome of inappropriate antidiuretic hormone

Malignant tumors
Increased intrathoracic pressure (PPV)
Meningitis
Cardiovascular accident
Medications
Trauma
Pain
Stress
Diuretics due to increased sodium losses

Early manifestations of SIADH include

Headache
Anorexia
Muscle cramps
Weakness
Weight gain

As a serum sodium level decreases in SIADH, the patient begins to experience personality changes, hostility, sluggish deep tendon reflexes and

Nausea, vomiting, diarrhea and oliguria

Later manifestations of SIADH include

Confusion
Lethargy
Cheyne-stokes respirations
Seizures
Coma
Death

What are manifestations of fluid volume excess

Tachycardia
Possible hypertension
Crackles in the lungs
Distended neck veins
Taut skin

What is urine chemistry in SIADH

Think concentrated

What is blood chemistry in SIADH

What should oral fluids be restricted to any patient that has SIADH

500 to 1000 mL/day

What is Demeclocycline

Tetracycline derivative. Used for SIADH

With patients taking demeclocycline monitor for indications of a yeast infection in the mouth. What can you do to decrease the likelihood of this happening?

Have the patient rinse their toothbrush with a diluted bleach solution and increase consumption of yogurt

How does lithium work in SIADH

Blocks the renal response to ADH

What are signs of lithium toxicity

Nausea, diarrhea, tremors ataxia

Should lithium be taken with or without food

During treatment for SIADH if a patient is receiving hypertonic saline or loop diuretics how often should their serum sodium level be monitored

Every 2 to 4 hours

What do the hormones T3 and T4 do

They affect all body systems by regulating overall body metabolism, energy production, fluid and electrolyte balance and controlling tissue use of fats, proteins and carbohydrates

What is the most common cause of hyperthyroidism

Graves disease. Autoimmune antibodies result in hypersecretion of thyroid hormones

What are two other causes of hyperthyroidism

Toxic nodular goiter: caused by overproduction of thyroid hormone due to the presence of thyroid nodules
Exogenous hyperthyroidism: caused by excessive dosage of thyroid hormone

What are some clinical manifestations of hyperthyroidism other than ones you would already think of such as insomnia, tachycardia, irritability and so on

1. Menstrual irregularities (Amenorrhea/decreased menstrual flow)
2. Libido is initially increased and then followed by a decrease
3. Exophthalmos (Graves disease only)
4. Vision changes
5. Bruit over the thyroid gland

If someone was given the thyrotropin-releasing hormone stimulation test, what would be a positive result for hyperthyroidism

Failure of expected rise in TSH

In the radioiodine uptake and thyroid scan test, iodine is administered orally 24 hours prior to the test, and then it is measured. What is a positive result?

An elevated uptake

One week prior to the radioiodine uptake test what should patients avoid regarding food

Anything that contains iodine

Thionamides such as blank and blank are used to inhibit the production of thyroid hormone

Methimazole, propylthiouracil

What are side effects of thionamides

Hypothyroidism
Leukopenia
Thrombocytopenia
Hepatotoxicity

What is the medication that can be administered one hour after anti-thyroid medication and is only used for short term

Iodine solutions (mixed with juice, use a straw and take the food)

How does radioactive iodine therapy work

It is taken up by the thyroid and destroys some of the hormone producing cells

How long after radioactive iodine therapy does a patient need to stay away from infants and small children and avoid becoming pregnant

2 to 4 days and avoid becoming pregnant for six months following therapy

What are four other precautions that a patient needs to take after radioactive iodine therapy

1. Do not use the same toilet as others for two weeks and flush the toilet three times after use
2. Take a laxative for 2 to 3 days after treatment
3. Wear clothing that is washable and wash clothes separate from others
4. Do not share a toothbrush and use disposable food service items such as paper plates

What should a patient receive 10 to 14 days before a thyroidectomy to reduce gland size and prevent excess bleeding

After a thyroidectomy what position should the patient be in

Hi Fowler's and avoid neck extension

After thyroidectomy how do you check for laryngeal nerve damage

By asking the patient to speak as soon as they awake from the anesthesia and every two hours there after

If the parathyroid gland gets damaged during a thyroidectomy what will the patient be needing

Calcium supplements

What is usually given after a thyroidectomy to reduce postoperative edema

How much drainage should you expect in the first 24 hours after a thyroidectomy

50 mL (after the first 24 hours there should only be scant drainage)

Thyroid storm/crisis results from a sudden surge of large amounts of thyroid hormones into the blood stream, causing an even greater increase in body metabolism. Precipitating factors include

Infection
Trauma
Emotional stress
Diabetic ketoacidosis
Digitalis toxicity
Thyroidectomy

What are clinical manifestations of a thyroid storm/crisis

Hyperthermia
Hypertension
Delirium
Vomiting
Abdominal pain
Hyperglycemia
Tachydysrhythmias
Dyspnea

If a patient is having a thyroid storm you can administer propylthiouracil to prevent further release of thyroid hormones. You can then administer iodine one hour after. Why not give it before

Because if it is given before it can exacerbate manifestations in susceptible clients

What are two things to look for as an indicator of hypocalcemia

Chvosteks and trousseau sign

A nurse in a providers office is reviewing the health record of a patient who is being evaluated for graves disease. What is an expected laboratory finding for this patient?

Decrease in TSH because the pituitary gland decreases the production of TSH when thyroid hormone levels are elevated

What are risk factors for hypothyroidism

1. Women between the ages of 30 to 60
2. Lithium and amiodarone
3. In adequate intake of iodine

What are some early findings of hypothyroidism

Fatigue/lethargy
Intolerance to cold
Constipation
Weight gain
Pale skin
Thin, brittle nails
Depression
Thinning hair
Joint and/or muscle pain

What are late manifestations of hypothyroidism

Bradycardia
Hypotension
Dysrhythmias
Slow thought process/speech
Hypoventilation
Thickening of the skin
Dry flaky skin
Swelling in face, hands and feet
Decrease acuity of taste and smell
Horse, raspy speech
Abnormal menstrual periods

What kind of diet should a patient with hypothyroidism be on

Low-calorie, high bulk diet and encourage activity to prevent constipation and promote weight loss

What is the medication of choice for thyroid hormone replacement therapy

What are three medications that Synthroid increases the effects of

Coumadin
Insulin (need for it)
Digoxin

What type of medications decrease the absorption of Synthroid

PPI's and H2 antagonist

When should Synthroid be taken

1 to 2 hours before breakfast

What is a severe complication of hypothyroidism

A nurse any providers office is reviewing the laboratory findings of a patient who's being evaluated for primary hypothyroidism. What is expected a laboratory finding for this patient?

Hematocrit 34% which indicates anemia, which is an expected result for patient who has hypothyroidism

What kind of laxative can a patient not take when they are on Synthroid

Fiber laxatives because it interferes with absorption

What are causes of Cushing's syndrome

Organ transplant
Chemotherapy
Autoimmune diseases (rheumatoid arthritis)
Asthma
Long-term use of glucocorticoids

What are some signs/symptoms of Cushing's disease

Weakness/fatigue
Back/joint pain
Decreased immune system
Bruising/petechiae
Hypertension
Tachycardia
Gastric ulcers
Weight gain
Hypervolemia
Hirsutism

What are expected findings in laboratory test associated with Cushing's disease

ATCH: increased
Cortisol: increased
Serum K/Ca: decrease
Serum glucose: I
Serum sodium: I
Lymphocytes: D

What is Addison's disease

An adrenocortical insufficiency. The production of mineralocorticoids and glucocorticoids is diminished resulting in decreased aldosterone and cortisol

What are some risk factors for Addison's disease

Autoimmune dysfunction
TB
Cancer
Adrenalectomy
Sepsis
Trauma
Steroid withdrawal

What are some clinical manifestations of Addison's disease

Weight loss
Craving for salt
Hyperpigmentation
Severe hypotension
Dehydration
Hyponatremia
Hyperkalemia
Hypoglycemia
Hypercalcemia

What would laboratory values be in a patient that has Addison's disease

Bun/creatinine: I
Serum glucose: D
Serum cortisol: D

Hydrocortisone, prednisone and cortisone are all glucocorticoids used for Addison's disease. How should this medication be taken?

What is a potential adverse side effects of the mineralocorticoid fludrocortisone

Hypertension and dosage may need to be increased during periods of stress or illness (One the patient to expect mild peripheral Edema)

What is addisonian crisis

An acute adrenal insufficiency occurs when there is an acute drop in adrenocorticoids due to sudden discontinuation of glucocorticoid medications or when induced by severe trauma, infection or stress

What is treatment for addisonian crisis

1. Administer insulin to move potassium into the cell
2. Administer calcium and kayexalate to counteract the effects of hyperkalemia
3. Establish an IV line and initiate a rapid infusion of NS
4. Loop or thiazide diuretics are used to manage hyperkalemia
5. Administer hydrocortisone as replacement therapy

In the presence of primary adrenal insufficiency, plasma cortisol levels blank in response to the administration of ACTH

What is the best possible score for the Glasgow coma scale

What do the other possible scores for the Glasgow coma scale indicate

1. Less than eight: associated with severe head injury and coma
2. 9 to 12: indicate a moderate head injury
3. Greater than 13: reflect minor head injury

What are the three things that the Glasgow coma scale uses to determine the score

Eye-opening, verbal and motor response

What is the positioning for a lumbar puncture

Either the cannonball position or have the patient stretch over and over bed table if sitting is preferred

What kind of meningitis is common among patients who have AIDS

What is the haemophilus influenza type B vaccine

A vaccine for infants against bacterial meningitis

What is pneumococcal polysaccharide vaccine

For adults 65 years and older who have not been previously vaccinated nor have history of the disease (for adults or immunocompromise, have a chronic disease, who smoke cigarettes or live in a long-term care facility)

What is the meningococcal vaccine

For adolescence to receive prior to living in a residential setting in college and for those in the military

What are risk factors for viral meningitis? Also there's no vaccine against viral

Mumps, measles, herpes and west Nile virus

What are some subjective signs of meningitis

Excruciating, constant headache
Nuchal rigidity
Photophobia

What are some objective physical assessment findings of meningitis

Fever and chills
N/V
Altered LOC
Positive Kernig's sign
Positive Brudzinski's sign
Hyperactive deep tendon reflexes
Tachycardia
Seizures
Red macular rash
Restlessness/irritability

What is the most definitive diagnostic procedure for meningitis

What results from the CSF analysis and lab values would be indicative of meningitis

1. Appearance of CSF: cloudy (bacterial) or clear (viral)
2. Elevated WBC
3. Elevated protein
4. Decreased glucose (bacterial)
5. Elevated CSF pressure

What kind of precautions is a patient with meningitis placed on

Isolation/droplet precautions, which requires a private room

What position should a patient with meningitis be in, in bed

Head of bed elevated 30°

What is a myoclonic seizure

A brief jerking or stiffening of the extremities which may be symmetrical or asymmetrical

What is an atonic seizure

Characterized by a few seconds in which muscle tone is lost. The seizure is followed by a period of confusion

What is one anti-elliptic drug

Phenytoin (decreases effectiveness of oral contraceptives)

What is a medication that should not be given with phenytoin

What is a vagal nerve stimulator

A device implanted into the left chest wall and connected to an electrode placed on the left vagus nerve

How does a vagal nerve stimulator work

It is programmed to administer intermittent stimulation of the brain via stimulation of the vagal nerve, at a rate specific to the patients needs

In addition to routine stimulation, the patient may initiate vagal nerve stimulation by holding a blank over the implantable device, at the onset of seizure activity. This either aborts the seizure or lessons it's severity

What is status epilepticus characterized by

A prolonged seizure activity occurring over a 30 minute time frame

Parkinson's disease is a progressively debilitating disease that grossly affects motor function. It is characterized by four primary symptoms which are

Tremor, muscle rigidity, Bradykinesia and postural instability (dopamine is decreased)

How's your patience Parkinson's eat their food

1. Provide smaller, more frequent meals
2. Add commercial thickener to thicken food
3. Patients should be weighed at least weekly

Medications such as blank, are converted to dopamine in the brain, increasing dopamine levels in the basal ganglia

Dopaminergics May be combined with blank, to decrease peripheral metabolism of levodopa requiring a smaller dose to make the same amount available to the brain. Side effects are subsequently less

What is stereotactic pallidotomy

Destruction of a small portion of the brain within the Globus pallidus through the use of brain imaging and electrical stimulation

Any patient that receives deep brain stimulation should be monitored for what afterwards

Infection, brain hemorrhage, neurological impairment or stroke like symptoms

What are two complications of Parkinson's disease

Aspiration pneumonia and altered cognition such as dementia

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