400 Exam 5 Flashcards
1
Q
ϖ Gallbladder is not essential for life because ?
A
because liver produces the fats
2
Q
but it helps to store bile so that when person eats it can respond to the amount of food ingested and let out bile as needed.
A
gallbladder
3
Q
ϖ Gallbladder’s main function is to
A
store and concentrate bile that is formed in the liver (“considered a store house for bile”)
4
Q
ϖ Acute or chronic inflammation of the gallbladder—can occur with or without stones or obstruction
A
cholecystitis
5
Q
symptoms of cholecystitis
A
fever leukocytosis jaundice RUQ/back/shoulder pain fullness abd. distention anorexia N/V dark urine pale poop
6
Q
labs with cholecystitis
A
elevated ALT, AST, and bilirubin
7
Q
ϖ Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile—
A
CHOLELITHIASIS (GALLSTONES)
8
Q
mostly made of cholesterol
A
cholelithiasis
9
Q
risk factors for gallstones?
A
women over 40 Oral contraceptives GI disease T-tube fistula hypercholesterolemia anticholestrol meds rapid weight loss type 1 DM
10
Q
sx of gallstones
A
no pain
mild GI symptoms
epigastric distress
11
Q
acute sx of gallstones
A
RUQ pain
N/V
fever
increased WBCs
12
Q
chronic sx of gallstones
A
“flare ups”
pain
dyspepsia
13
Q
simplified sx of gallstones
A
RUQ pain that radiates jaundice clay stool fever WBC elevation N/V murphy's sign dark urine vit. def. (ADEK)
14
Q
♣ Palpate under right subcostal area—when pushed on and released they will do a preinspirtory arrest (like a gasp) causes pain to that area
A
murphy’s sign
15
Q
what is avoided because it could cause spasm of sphincter of Oddi with gallstone patients?
A
o Morphine
16
Q
instead of morphine use _____.
A
meperidine (Demerol)
17
Q
• Occurs in a few patients with gallbladder disease—usually with obstruction of common bile duct (biliary obstruction)
A
jaundice
18
Q
dx of CHOLECYSTITIS and CHOLELITHIASIS
A
Abd. x-ray
Abd. Ultrasound
Endoscopic Retrograde Cholangiopancreatography (ERCP)
19
Q
o least invasive
Can rule out other causes (Ex. paralytic ileus)—not helpful in dx gallbladder disease
A
abdominal XRAY
20
Q
• Normally can’t see gallstones on x-ray, if we can it means ?
A
it’s really bad
21
Q
o most commonly done
• Diagnostic procedure of choice—95% accuracy
A
Abdominal ultrasound
22
Q
education before abdominal ultrasound
A
NPO after midnight before test to give the gallbladder time to fill up with bile
23
Q
• Provides direct visualization into hepatic biliary system with side-viewing fiberoptic camera introduced into esophagus to the descending duodenum
A
Endoscopic Retrograde Cholangiopancreatography (ERCP)
24
Q
pre op education with ERCP
A
multiple position changes are used beginning in left semi-prone position
NPO several hours before and until gag reflex returns
25
• Not just done for cholisisthiasis helpful to determine reason patient is jaundice (Ex. From liver disease or a stone)
o PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
26
o Water soluble contrast agent (dye) injected directly into biliary tract outlines visual of whole biliary tract on a radiologic instrument—shows any obstruction
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
27
pre op PTC
fasting
check H and H
check platelet count
28
post op PTC
monitor for bleeding, infection, and peritonitis
29
IV dye. bile duct and liver problems are seen with X-ray.
Need IV and fast for 4 hours!!
Hida Scan
30
intra op with PTC:
administer broad spectrum ATB
31
when pt comes into hospital with acute cholecystitis what do we do?
```
NPO
IV fluids
NG tube
pain meds
IV ATB
consider for surgery
```
32
diet education when they're sent home without surgery
low fat liquids first
gradually progress to a low fat diet with high protein
avoid fatty foods and alcohol
33
chronic cholecystitis patients
monitor diet
keep log of triggers
OTC pain meds
surgery referral for gallbladder removal
34
non surgical removal of gallstones
oral dissolution therapy
stone removal by instrumentation
intracorporeal lithotripsy
ESWL
35
meds used with oral dissolution therapy
ursodeoxycholic acid (actual)
chenodeoxycholid acid (Chenix)
36
o May be used as therapy, before surgery, or during surgery—remove the stones in the tracts
• Stone Removal by Instrumentation
37
2 ways for Stone Removal by Instrumentation to be completed?
1. catheter and instrument with basket attached are threaded through T-tube or fistula
2. ERCP endoscope is inserted, a cutting instrument is passed through the endoscope into the common bile duct
38
o Go in with endoscope breaks up stones with laser pulse technology breaks up stones so they can pass
• Intracorporeal Lithotripsy
39
o Non-surgical fragmentation of gallstones – no incision – treated as outpatient
Sends repeated shock waves directed over the gallbladder to break up stones
o Very painful—not used often anymore
o Usually requires more than one treatment
• Extracorporeal shock wave lithotripsy (ESWL)
40
how are waves transmitted with ESWL?
through water
| fluid-filled bag or by immersing the patient in a water bath
41
surgical management for gallstones
laparoscopic cholecystectomy
open cholecystecomy
42
o Usually same-day surgery go home that afternoon or next day
o 3-4 ½ inch incisions (1 to umbilicus, 1 to RUQ of abdomen, and few on sides) used to blow belly up with CO2 gas for better visualization
laparoscopic cholecystectomy
43
main post op intervention with laparoscopic
get up and moving or roll side to side to break up gas
44
open cholecystectomy is used when they can't have laparoscopic due to
inflammation
perforation
other complications
45
they may come back with a ______ with open cholecystectomy
T-tube
46
Looks like T and fits into common bile duct to keep it open so that inflammation doesn’t cause an obstruction or remaining stones don’t cause an obstruction
♣ T-tube
47
high risk for what with open cholecystectomy
DVTs, bleeding, infection
48
o In pre-op you want consents for both ???? just incase
laparoscopy and open surgery
49
o Soft diet is started after bowel sounds return, which is usually the ___ ___ if laparoscopic approach is used.
next day
50
o With laparoscopy patient does not experience _____ _____ that occurs with open abdominal surgery less postop abdominal pain
paralytic ileus
51
post op with open??
```
improve respiratory status
pain control
skin integrity
diet
diarrhea
education
```
52
post op cholecysteomy low fat diet for how long?
4-6 weeks
53
o Gas usually lasts about a ____; will be a problem for a little while
week
54
o Produces digestive enzymes in an inactive state. Once in the ________ the enzymes are activated.
duodenum
55
3 pancreatic enzymes
amylase
trypsin
lipase
56
o Amylase aids in digestion of _______
carbohydrates.
57
o Trypsin aids in the digestion of ______.
proteins
58
o Lipase aids in the digestion of ____.
fats
59
ϖ Inflammation of the pancreas and is very painful.
PANCREATITIS
60
causes of acute pancreatitis
alcohol
| cholithiasis
61
sx of acute pancreatitis
pain
NV
Abd distention
62
if acute pancreatitis patients develop a rigid board-like abdomen they may be developing ______
peritonitis
63
complications of acute pancreatitis
ecchymosis
DIC
Hypotension (hypovolemia and shock)
cardiac ischemia
64
* Advanced form of pancreatitis
* Fluid shift albumin and proteins that are not in the right space; not in the vasculature
* Abdominal distention
* Hypovolemiadue to the fluid and electrolyte imbalance
* Can occur in advance liver disease
o Ascites
65
bruising around the flank area
o Grey-Turner’s sign
66
bruising around the umbilicus (belly area)
o Cullen’s sign
67
Diagnosis of pancreatitis
serum amylase and lipase
CT scan of abdomen
Ultrasound/MRI
Hypocalcemia
68
is usually elevated within hours of symptom onset best indicator of acute pancreatitis combined with signs and symptoms.
♣ Amylase
69
is drawn takes a lot longer to elevate. It stays elevated longer after the episode is over but acutely the lipase may not be elevated.
♣ Lipase
70
medical management for pancreatitis
NPO
TPN
NG tube
71
meds for pancreatitis
histamine 2 antagonists
PPIs
Pain management
72
diet after acute pancreatitis
clear liquids then advance as tolerated
73
If you can't get pain under control for pancreatitis?
call DR
74
ϖ The pancreas continues to get scarring, inflammation, and gets fibrous.
ϖ Eventually the endocrine and exocrine functions become damaged and the pancreas can no longer function as it should.
Chronic Pancreatitis
75
ϖ Most common cause of chronic pancreatitis is
Chronic alcohol abuse
76
sx of Chronic Pancreatitis
pain all the time or when they eat
N/V
steatorrhea stools
vitamin deficiencies
77
issues with chronic pancreatitis related to nutrition
malnutrition
malabsorption
weight loss
78
are not useful in chronic pancreatitis because it is a chronic disease.
o Blood test
79
treatment for chronic pancreatitis
```
NPO
bed rest
NG tube
opioid administration
same diet as acute
diabetes education
```
80
with a side-to-side anastomosis or joining of pancreatic duct to jejunum allows drainage of pancreatic secretions into jejunum—pain relief occurs in 6 months; usually returns
o Pancreaticojejunostomy
81
ϖ Controlled diabetes can result in long-term damage of
many tissues and organs
82
ϖ Affects 29.1 million people 8.1 million undiagnosed
| ϖ 3rd leading cause of death in U.S
DM
83
DM is the leading cause of new cases of ______ ages 20-74
blindness
84
DM is a disorder of ____, _____, and ____ metabolism
carb, protein, and fat metabolism
85
risk factors for Diabetes
```
family history
obesity
race
age above 45
HTN
HDL cholesterol <35
Hx of gestational diabetes
insulin deficiency
impaired release of insulin by pancreas
inadequate receptors to insulin
```
86
acute complications of DM
hyperglycemia
DKA
HHNS
87
chronic complications of DM
```
diabetic neuropathy
renal insufficiency
cardiovascular risk (stroke and heart attack)
retinopathy
wounds
```
88
o Diabetes Mellitus associated with other conditions and syndromes such as
pancreatitis, overuse of corticosteroids
89
insulin dependent
| usually before 30 years old
type 1 diabetes
90
with type 1 diabetes the body's immune system does what?
destroys the beta cells and they can no longer produce insulin
91
what causes keotacidosis with type 1 diabetes
hyperglycemia and breakdown of body fat and protein
92
type 1 DM patients need ____ to survive
insulin
93
risk factors of type 1
genetic problem
autoimmune problem
environmental risk factors
94
sx of type 1 DM
```
3Ps
blurred vision
weight loss
ketoacidosis
fatigue
hungry/thirsty
```
95
2 things that mean its most likely type 1 DM
ketoacidosis
| rapid onset
96
ϖ Body can still make insulin, but impaired function, usually resistance in tissue
ϖ Usually those older than 30 and obese – incidence is increasing in those younger than 30 though because of the growing epidemic in obesity
TYPE 2 DIABETES
97
how does TYPE 2 DIABETES occur?
liver produces too much glucose and they can't keep up with balancing insulin and glucose
98
ϖ Two main problems related to insulin in type II
insulin resistance and impaired insulin secretion
99
risk factors for type 2
```
sedentary lifestyle
familial tendency
age
gestational diabetes
HTN
hyperlipidemia
```
100
sx of type 2 dm
```
slow progressive onset
damage to eye
neuropathy
recurrent infections
fatigue
decrease energy
```
101
ϖ Combination manifestations of type 2 diabetes and heart disease
metabolic syndrome
102
metabolic syndrome is at least 3 of the following:
```
increased waist circumference
triglycerides above 250
HDL lower than 35
high BP
Fasting Plasma Glucose greater than 110
```
103
– haven’t been fasting, just checking sugar
♣ Casual glucose
104
♣ Fasting plasma glucose greater than ____ on two separate occasions to diagnose diabetes
126
105
education for fasting plasma glucose
NPO 8 hours before
106
* Large dose of sugary drink
| * Blood sugar remains elevated – body not producing enough insulin to return to normal range
♣ OGTT (oral glucose tolerance test)
107
ϖ Normal AIC is usually between
4-6 %
108
Long-term glycemic controls in pts with diabetes is best achieved by monitoring glyscosylated hemoglobin (HAIC) which reflects the:
ϖ Average blood glucose level over a period of time (2-3 months)
109
ϖ Often use AICs for people with _______ or to diagnose earlier to prevent complications
metabolic syndrome or those with family history
110
treatment of type 1 dm
insulin
111
treatment of type 2 dm
oral hypoglycemic
diet
insulin
112
o Pancreas works in two different phases–determine whether person will need rapid or long-acting insulin
Phase I bolus phase
Phase II basal phase
113
during phase 1 (bolus phase) what happens?
♣ release of insulin in response to glucose (food)
| o Prevents postprandial hyperglycemia (after eating)
114
during Phase II basal phase what happens?
body releases insulin b/w meals to keep blood glucose stable b/w fasting times (purpose of long-acting)
115
U100 means
100 unites per mL
116
how to mix insulin
clear to cloudy
117
what type of insulin in used in pumps?
short acting (regular insulin)
118
how often to change locations with pump?
q 3 days
119
o Should check BS at least ____ times a day with insulin pumps
3
120
what is the only insulin that could be used in an IV
regular
121
education on insulan storage
can be stored in the fridge while unopened
can stay at room temp for 4 weeks once open
122
don't shake insulin _____ it
roll
123
only cloudy insulin =
intermediate
124
how to clean site before insulin admin at home
soap and water
125
where does insulin absorb the fastest at?
in the abdomen
126
TRIANGLE OF DIABETES MANAGEMENT
meds
diet
exercise
127
ADA goals
o Maintain glucose levels in near normal range
o Reduce risk of CV disease
o Modify lifestyle as appropriate to prevent/treat obesity, hyperlipidemia, CV disease and nephropathy
o Respect personal and cultural preferences
128
carbs should be what % of daily diet
50-60%
129
what type of protein
non animal
130
fiber helps diabetic patients do what?
feel full
and
lower serum lipid levels
131
alcohol can cause ______
hypoglycemia
132
o How much of that particular food is expected to increase BS
o Good whole foods, raw vegetables actually lower glycemic response
Eating whole fruit instead of drinking fruit juice also lowers this
glycemic index
133
BENEFITS OF EXERCISE
```
ϖ Improves insulin sensitivity
ϖ Decreases blood glucose during and after exercise – get your patient moving
ϖ Improves circulation and muscle tone
ϖ Assists with weight loss
ϖ Improves lipid profile and BP
```
134
ϖ Good glucose control before, during and after surgery! why?
o Promote healing
o Will be sedated in surgery will be hard to determine hypo and hyperglycemia
o Fluid and electrolyte imbalance
o Prevent complications
135
may need more insulin after surgery
o Type 1’s
136
o Oral hypoglycemic usually held __-___ days before surgery (renal function)
1-2
137
o Can occur in both—exact cause is unknown
o Rise in early morning blood sugar
o May be level of cortisol or growth hormone during the day
ϖ Dawn phenomenon
138
o Sugar goes high at night and crashes in the morning but can happen anytime during the day
o Alternating b/w hyper/hypoglycemia – yoyo effect on BS
o Insulin resistance several hours after event
ϖ Somogyi phenomenon
139
o Non-ketotic – no breakdown of fats/proteins
o Can occur in Type I or Type II, most common in Type II
o Many things can cause stress, illness, infection, MI, stroke
o More prevalent in older adult
o Usually more of a gradual onset
o Extreme rise in glucose (600-800)
ϖ Hyperosmolar Hyperglycemic State (HHNS)
140
Common in Type I
o Could be related to illness, infection, stroke, heart attack
o Sudden onset of hyperglycemia—usually over 250
o Get acidosis because of the presence of ketones
DKA
141
hypoglycemia is a blood sugar around ___ or less
70
142
ϖ
Causes of Hypoglycemia
o May result when a diabetic omits a meal, takes excessive insulin, vomits a meal/meals, over exercises
o May also be precipitated by the overproduction of insulin due to an insulin producing tumor or autoimmune disease
143
what to do if your patient has hypoglycemia if they can swallow
admin 15 g of carbs:
fast acting carbs
sugar packet
OJ
glucose tablets
144
if they can't swallow?
1 mg glucagon SQ/IM
| IVP 50 ml of 50% dextrose
145
ϖ Notify health care professional when:
diarrhea more than 5 times or longer than 6 hours
unable to eat for 24 hours
difficulty breathing
BG higher than 300 two times
146
when glucose gets around __-___ start checking for urine ketones
240-250
147
chronic complications with DM
```
peripheral neuropathy
nephropathy
retinopathy
macrovascular
infection
```
148
damage to peripheral nerves resulting in miscommunication with the brain and other body parts
ϖ Peripheral neuropathy
149
ϖ Peripheral neuropathy can be _____ or ____
somatic or autonomic
150
feeling of touch; may just be decreased sensation overall, or some complain of a burning/stinging feeling
♣ Somatic –
151
– things that happen inside of body that they don’t feel; GI motility, bladder problems, cardiovascular problems
♣ Autonomic
152
leading cause of ESRD
| Presence of albumin in the urine
nephropathy
153
at risk for cardio disease because of neuropathy and atherosclerotic changes
ϖ Macrovascular
154
microvascular can lead to:
CAD
CVD
PVD
155
most common complication leading to hospitalization among diabetics
Diabetic foot ulcers
156
o Full foot exam ____ by physician or practitioner
yearly
157
(anti-inflammatory/ immunosuppressive properties): secreted during times of stress; helps to maintain BP and heart function; slows immune process down; assists in balancing effects of insulin to break down sugars for energy;
o Cortisol
158
o Cause glycogenesis, protein catabolism, and immobilizes fatty acids
corticosteroids
159
ϖ Hypersecretion of adrenal medulla
PHEOCHROMOCYTOMA
160
with Pheochromocytoma there is a small tumor that does what?
secretes large amounts of epic (vasoconstriction)
161
Pheochromocytoma is more common in who?
women 40-50
162
sx of Pheochromocytoma
```
HTN
HA
Hyperdiaphoresis
hyperglycemia
heart palpitations
```
163
diagnosis of Pheochromocytoma by?
24 hour urine test for catecholamines
MRI/CT scan
Vanillymandelic
164
education before vanillymadelic
no vanilla, caffeine, chocolate, aspirin prior to test
165
treatment of Pheochromocytoma
treat symptoms
or
removal of tumor
166
♣ Careful monitoring of BP after _____ or ___ _____ d/t hypotensive shift that usually occurs
surgery or after acute event
167
after an acute even to pre-op with Pheochromocytoma
ICU on continuous ECG monitoring
Nipride drip
CCB
BB
168
how do they remove the tumor?
unilateral/bilateral adrenalectomy
169
ϖ Hypofunction of adrenals
| ϖ Most commonly seen in women
Addison's Disease
170
causes of Addison's?
autoimmune problem that results in the destruction of the adrenal cortex
sudden corticosteroid discontinuation
TB of adrenals
CA of adrenals
Adrenaectomy
HIV/AIDs
171
labs with Addison's
low aldosterone/cortisol
high ACTH
172
sx of Addison's
```
bronze skin
changes in distribution of body hair
GI disturbances
decreased cortisol
(hypoglycemia)
postural hypotension
```
173
what causes the postural hypotension with addison's?
low aldosterone --> low sodium, high potassium and volume depletion (dehydrated)
174
o Vascular collapse from severe hypotension
ϖ Adrenal (Addisonian) Crisis:
175
sx of Adrenal (Addisonian) Crisis:
```
o Profound fatigue
o Cyanosis
o Fever
o N/V
o Signs of shock—cold, pallor, clammy
o Headache
o Abdominal pain
o Diarrhea
o Confusion/Restlessness
o Dehydration
o Renal shut down
o Decreased serum sodium
o Increased serum potassium
```
176
o Slight overexertion to extreme cold, infection, or decrease Na intake may lead to:
♣ Circulatory collapse
♣ Shock
♣ Death (if untreated)
177
o The patient in addisonian crisis requires immediate treatment with
IV fluids,
glucose and electrolytes, especially Na,
replacement of missing steroids and
vasopressors.
178
how to dx Addison's dx
```
cortisol levels
low sodium
high potassium
low glucose
high plasma ACTH
high WBCs
```
179
when to check cortisol levels
(check in the morning because they should be high but they will still be low with them)
180
tx for addison's
o Preventing or reversing hypovolemic/circulatory shock
monitor VS
D5W
corticosteroid replacements lifelong
monitor sodium and potassium
181
encourage sodium in diet with Addison's to prevent
arrhythmias and weakness
182
diet for Addison's
o Increase salt (especially during GI disturbances and hot weather)
o Low potassium (too much=heart arrhythmias and weakness)
o Increase protein
o Stay hydrated
183
what can decrease K+
exelate
184
meds for Addison's
corticosteroids
| vasopressors
185
o NEVER stop medications abruptly bc what will happen
addisonian crisis
186
Addison's patients should wear
medic alert bracelet
187
ϖ Adrenal cortex hyperfunction
cushing's syndrome
188
what else could cause cushion's
long term corticosteroid use
COPD
adrenal tumorr
189
cushing's labs
elevated cortisol
decreased ACTH
decreased K+
190
sx of cushing's
```
round trunk area
think extremities
think skin
moon face
buffalo hump
hyperglycemia
infection
sodium and fluid retention
GI distress
osteoporosis
```
191
dx of cushing's
o Serum or urine cortisol level
o 24 hour urine to check for free cortisol
o If tumor is suspected CT or MRI for visualization
192
o Medications with cushing's are used to treat conditions that are
inoperable or if it is not a tumor of the pituitary or adrenals.
193
o Meds revolve around inhibition of ____ production (controls symps/manifestations not the syndrome or disease)
cortisol
194
examples of meds that inhibit cortisol production
```
ketoconazole
mitotane
metyrapone
aminoglutethemide
somatostatin
sandostatin
```
195
o If Cushing’s is caused by prolonged administration of corticosteroids
o Attempt to reduce or taper the dose
o Gradually discontinue the use all together
o alternate-day therapy .
196
post-op adrenalectomy! at risk for
hemorrhage
197
o Can dump excessive amounts of hormones into the blood stream during surgery so we need to monitor for?
BP
Fluid and electrolytes
hormone fluctuations
198
o High doses of IV _____ are given after surgery for the first 24-48 hours then titrate down
steroids
199
To decrease the chance of an addisonian crisis monitor for:
```
hypotension
vomiting
weakness
dry tenting skin
tachycardia
dehydration
changes in LOC
```
200
o Promote wound healing and minimize stress on the incision by?
log rolling to sit them up
201
3 main nursing dx with cushing's
fluid vol excess
risk for injury
risk for infection
202
diet for cushing's
low calorie
low sodium
high protein
take vitamins B,C, D and calcium
203
ϖ Master gland
ϖ Located at the base of the brain adjacent to the hypothalamus
ϖ Responsible for regulating endocrine function by producing hormones that affect body systems and stimulate other endocrine gland to secrete hormones
Pituitary Gland
204
major hormones of the Pituitary Gland
```
FSH
LH
Prolactin
ACTH (Adrenocorticotropic hormone)
TSH
GH
```
205
hormones secreted by post. pituitary
ADH
| Oxytocin
206
* Controls excretion of water by kidney
| * Secretion is stimulated by an increase in the osmolality of the blood or by a decrease in blood pressure
o Antidiuretic hormone (ADH)—vasopressin
207
* Stimulated during pregnancy and at childbirth
| * Facilitates milk ejection during lactation and increases the force of uterine contractions during labor and delivery
* Stimulated during pregnancy and at childbirth
| * Facilitates milk ejection during lactation and increases the force of uterine contractions during labor and delivery
208
ϖ Most common conditions deal with the anterior pituitary that deals w/ growth and development
ϖ A result of over secretion of GH, prolactin and ACTH
Hyperpituitarism
209
Deficiency in secretion of pituitary hormones
Hypopituitarism –
210
Hypopituitarism can be caused by:
tumors of pituitary
surgical removal or pituitary
pituitary infarction
211
− Postpartum pituitary necrosis
− Uncommon cause of failure of the anterior pituitary
− Most commonly occurs when there is a traumatic birth and mother goes into shock and has decreased vascularity to pituitary gland
• Sheehan’s Syndrome
212
removal of pituitary tumor
treatment of choice
Hypophsectomy—
213
Hypophsectomy is most often done through the ____ approach
transphenoidal approach
214
o go up through lip and palate and through the skull, then use an instrument to retract tumor
transphenoidal approach
215
worry about what with Hypophsectomy
increased ICP since its brain surgery
and infection
216
pre op Hypophsectomy
ATB
teach them how to prevent increased ICP
tell them about the meds they will be on (hormone replacement)
217
how to prevent increased ICP
• Avoid bending over, straining, sneezing (do through mouth), blowing nose, elevate HOB, may be placed on stool softeners so not straining to have a BM
218
post op Hypophsectomy
```
frequent vitals/neuro checks
monitor for infection
HOB at 30 degrees
mustache dressing
shouldn't have active bleeding
assess for clear drainage
assess for post nasal drip
strict I and Os
good oral care
```
219
how to see if the clear fluid is CSF
if it has glucose in it
220
after surgery they may be at a temporary risk for
diabetes insipidus
221
ϖ Otherwise known as “tasteless urine” great volumes and so diluted it has no color or taste
Diabetes Insipidus
222
____ insufficiency leading to large amounts of urine = polyuria; also have problems with nocturia
ϖ ADH
223
ϖ If putting out a lot of diluted urine – _____ level increases
sodium (hypernatremia)
224
ϖ Can have____ or more liters of urine in 24 hour period
12
225
diabetes insidious can be caused 2 ways
neurogenic
| nephrogenic
226
o Absence of production or secretion of ADH
| Often results from some type of head trauma, cerebral injury, brain surgery like the hypophysectomy, tumors, chronic
NEUROGENIC
227
o ADH levels are normal in body, but renal tubules are not working so kidneys don’t respond to ADH
o Renal disease, disease of renal tubules – May be related to hypokalemia, hypercalcemia, variety of medications
NEPHROGENIC
228
sx of diabetes insipidus
large amounts of dilute urine
extreme thirst
sx of dehydration
tachycardia
229
o Dumping out a lot of fluid – can go into _____/______ shock if fluid is not replaced in a timely manner
cardiovascular collapse/hypovolemic shock
230
dx of diabetes insipidus
specific gravity low
| urine osmolality less than 300
231
* One of the most common tests – often used to identify the cause of polyuria
* Administer ADH & hold fluids for 8-12 hours or until 3-5% of body weight is lost
* Patient weighed frequently during the test
* Combination of blood and urine tests (at beginning and end of the test)
o Water deprivation test
232
• What would you assess for if sodium is high?
− Changes in vitals, poor skin turgor, thirsty, LOC, seizures, tremors, orthostatics, strict I/O’s, daily weights
233
#1 priority of care for diabetes insipidus
replacement of fluids
234
with Diabetes Insipidus you will dminister IV fluids. Then monitor hydration status by ?
I/Os
Daily weights
monitor IV solutions
235
if the DI is neurogenic you will admin _____ to treat it
admin analogue of ADH
| desmopressin
236
− Can be given orally, nasally, IV
| − Monitor for opposite symptoms and report to doctor
desmopressin
237
what to assess for with desmopressin
excessive weight gain
headaches
restlessness
chest pain
238
− Giving vasopressin which causes ________ – so want to monitor cardiac findings such as chest pain
vasoconstriction
239
if DI is nephrogenic what do we treat them with
low sodium diet
thiazide diuretics
prostaglandin inhibitors (NSAIDs)
240
SIADH has too much _____
ADH (Vasopressin)
241
o Results from failure of negative feedback system – ADH is released despite normal or low serum osmolality
SIADH
242
what will SIADH patients have
```
retained fluid (fluid overload)
concentrated urine (high specific gravity)
diluted blood (low serum level)
```
243
causes of SIADH
```
Stress,
pituitary surgery,
small cell lung cancer
certain medications (barbiturates, some antidepressants),
anesthesia,
head injury,
diuretics
```
244
SIADH is Characterized by dilutional _____ from water retention (a lot of water, little salt in body)
hyponatremia
245
what will SIADH patients look/feel like?
```
generalized weight gain (without edema)
muscle cramps
weakness
low urinary output
sodium below 120
```
246
hyponatremia sxs
```
restlessness/irritability
changes in LOC
lethargy
HA
vomiting
muscle twitches
seizure
```
247
complications of SIADH
cerebral edema and coma
248
diagnosis of SIADH
urine and serum osmolalit
249
ultimate goal for SIADH
to increase sodium level and increase serum osmolality so they’re not so diluted
250
treatment of SIADH
oral fluid restriction (800-1000 ml/day)
1/2 NS
Lasix
251
how to assess for fluid volume excess with SIADH
* Jugular vein distention
* Skin taut and shiny
* Possible increased BP
* Crackles in lungs
* Intake greater than output
* Headache
* Fatigue
* Nausea
* Muscle aches
* Weight gain without edema
* Progressive altered LOC
* Seizures, coma
* Small amount concentrated amber urine
252
Nurse is establishing a plan of care for a patient newly diagnosed with SIADH. Priority nursing diagnosis would most likely be:
a. Excess fluid volume
253
ϖ Butterfly-shaped organ located in lower neck – that area is very vascular
ϖ Consists of 2 lateral lobes connected by an isthmus
THYROID GLAND
254
the thyroid produces what 3 hormones
T4
T3
Calcitonin
255
_______ is essential to the thyroid gland for synthesis of its hormones
Iodine
256
how are the thyroid hormones regulated?
negative feedback loop
257
hyperthyroid levels
elevated T3/T4
| decreased or no TSH
258
hypothyroid levels
elevated TSH
| decreased T3/T4
259
Primary function of thyroid horomone is to maintain ______
metabolism
260
how to diagnosis thyroid disorders
```
H&P
Blood tests
Ultrasound
Thyroid Scan
24 hour radioactive iodine uptake (RAIU)
Look for nodules
Thyroid antibodies
```
261
(confirms how extreme the hyperthyroidism is)
• Free T4
262
ϖ RAI is given IV or orally and thyroid is scanned to see what?
how much iodine the thyroid took in
263
increased uptake of RAI means
hyperthyroid
264
decreased uptake of RAI
hypothyroid
265
warm nodule
benign
266
cold nodule
CA
267
• Serum test used to diagnose immune disorders of thyroid
ϖ Thyroid antibodies
268
Decreased amount of thyroid hormone which leads to a decreased metabolic rate
Symptoms can develop very slowly, months to even years
hypothyroidism
269
common causes of hypothyroidism
hashimoto's thyroiditis
thyroid dysfunction
pituitary dysfunction
270
sx of hypothyroidism
```
always cold
very tired
numbness and tingling of fingers
husky/hoarse voice
menstrual disturbances
loss of libido
weight gain
facial and eyelid edema
constipation
```
271
hypothyroidism more common in ?
women 40-70
272
late sx of hypothyroidism
```
subnormal temp
bradycardia
weight gain
decreased LOC
thick skin
cardiac complications
```
273
ϖ Really severe form of hypothyroidism is called ______ – Chronic untreated hypothyroid state
Myxedema
274
with myxedema there is edema as a result of?
water retention
| non-pitting edema around face/tibial area
275
• Tongue can become thick, speech slow, can have voice changes with ?
myxedema
276
is even more extreme – pt has prolonged hypothyroidism and they start to develop cardiac effects
ϖ Myxedema coma
277
• If myxedema coma is untreated for long period of time, will most likely have cardiac effects such as
– CAD, hypercholesterol
278
with myxedema coma they get severe metabolic disorders such as:
hypothermia
cardiovascular collapse
resp failure (bc of CHF from prolonged bradycardia)
279
• These symptoms along with cardiovascular collapse and shock require aggressive and intensive supportive and _______ therapy if the patient is to survive
(myxedema coma)
hemodynamic
280
Medical Management for Myxedema
ϖ In extreme state, can give thyroid meds IV until they can tolerate regular doses
281
primary goal for myxedema
replace thyroid hormone and reduce hypothyroidism effects
| might be fixing acid-base imbalances
282
ϖ Do not give ______ to patient’s with a severe form of hypothyroidism because their metabolic rate is already very slow – if we give sedatives, they could go into severe respiratory depression and could die
sedatives
283
when patient starts taking meds for hypothyroidism the symptoms usually resolve when?
within a few days
284
how are meds administered with hypothyroidism.
ϖ Medications usually administered by themselves before meals
285
proper education is crucial for hypothyroidism:
* Educate to take 1 hour before meals or 2 hours after
| * Need to take at the same time every day to mimic the body’s normal cycle of hormone production
286
hypothyroidism medications May also increase the pharmacologic effects of
digitalis glycosides, anticoagulant agents , and indomethacin(Indocin)
287
• could be at risk for ______ and ________ – monitor for these more often
bleeding tendencies and dig toxicity
288
hypothyroidism meds can also exaggerate the effects of ____
sedatives
289
nursing diagnosis for hypothyroidism:
```
ϖ At risk for Decreased Cardiac Output
ϖ Activity Intolerance
ϖ Altered nutrition: more than body requirements
ϖ Ineffective therapeutic regimen
ϖ Risk for impaired skin integrity
ϖ Constipation Prevention
```
290
ϖ Increased metabolic rate from hypersecretion of T3/T4
HYPERTHYROIDISM
291
ϖ Most common type of hyperthyroidism we see is
Graves’ Disease
292
common causes of hyperthyroidism
thyroiditis
excessive ingestion of thyroid hormone/medications
Hashimoto's thyroiditis
293
sx of hyperthyroidism
```
intolerance to heat
fine-straight hair
bulging eyes
facial flushing
enlarged thyroid
tachycardia
increased systolic BP
weight loss
diarrhea
amenorrhea
localized edema
```
294
Extreme form of hyperthyroidism –
Thyroid Storm
295
ϖ Life threatening – attention needed quickly to avoid further complications and even death
thyroid storm
296
how to treat hyperthyroidism
anti-thyroid medications
297
nursing diagnosis for hyperthyroidism
risk for injury
risk for decreased cardiac output/activity intolerance
altered nutrition
body image disturbances
298
ϖ A patient with hyperthyroidism underwent three months of preoperative treatment with anti-thyroid medications and iodine preparations to establish a euthyroid state prior to her surgery – Why is it so important for the patient to be euthyroid (normal labs) prior to a thyroidectomy?
* To reduce complications of cardiac problems
* Decreases chance of thyroid storm after surgery—potentially fatal
* If not in euthyroid state – at higher risk for hemorrhage
* Use drug therapy and radioactive iodine prior to surgery to reduce size and put them in euthyroid state
299
ϖ The nurse is preparing for the patient’s return to the surgical floor. What should be the nurse’s top patient priorities?
(hyperthyroidism)
risk for thyroid storm
risk for hemorrhage
300
ϖ Risk for _______ if take out parathyroid gland – may be accidentally removed or on purpose w/ thyroidectomy
hypocalcemia
301
what to look for to assess for hypocalcemia?
chvostek's sign
| trosseau sign
302
BP cuff makes the arm turn in
Trousseau's sign
303
ϖ Sits on posterior side of the thyroid – can be removed on purpose when thyroid is removed or accidently
parathyroid glands
304
main function of parathyroid glands
regulate calcium and phosphate metabolism
305
ϖ Calcium level falls– parathyroid sends message to stimulates parathyroid stimulating hormone to get calcium – get calcium from 3 places:
* Pulls it out the bone
* Reabsorbs it from renal tubules
* Dietary in presents of vitamin D
306
ϖ Caused by overproduction of parathormone by the parathyroid glands
hyperparathyroidism
307
hyperparathyroidism labs
increased calcium
decreased phosphorus
308
hyperparathyroidism is characterized by:
renal damage
| bone decalcification
309
primary hyperparathyroidism can be cause by?
malignancy
| unknown cause
310
secondary hyperparathyroidism occurs in patients who have ?
chronic renal failure
311
• Renal patients often get high ______ levels and x-rays will show porous bones from calcium being pulled out of them
phosphorus
312
hyperparathyroidism symptoms:
```
older females
bone pain (especially in the back)
bone demineralization
polyuria
renal colic
kidney stones
muscle weakness/fatigue
irritability
GI symptoms
```
313
ϖ If having an acute hypercalcemic crisis– serum calcium level gets extremely high– high risk for ????
dehydration, cardiac arrhythmias and even cardiac arrest
314
diagnostic tests for hyperparathyroidism
assess serum calcium and parathyroid hormone level
bone scan
CT scan
X-ray
315
goal for hyperparathyroidism
decrease level of calcium
316
immediate focus for hyperparathyroidism
to decrease/prevent dehydration
317
ϖ If severe hypercalcemia – will probably be hospitalized and treated with:
• IV normal saline
Loop Diuretics – Lasix
318
______ diuretics are contraindicated because they promote the renal absorption of calcium
Thiazide
319
ϖ Medications to inhibit bone reabsorption therefore reducing hypercalcemia
calcitonin
biphosphonates
corticosteroids
320
increases calcium deposition in bone
• Corticosteroids –
321
inhibits bone reabsorption to keep calcium in the bone instead of in the bloodstream
• Bisphosphonates -
322
Bisphosphonates examples:
pamidronate
alendronate
zoledronate
