Adult Heath II -- Test 3 Flashcards
Parkinson’s S/S
bradykinesia, resting tremor; rigidity; mental status (depression), postural instability
excess ACh – constipation, ortho HOTN, diaphoresis, flusing
Parkinson’s Rx
Levodopa (dopamine precursor) and Carbidopa (inhibits peripheral conversion of levodopa = more for brain)
Parkinson’s Rx A/E
dyskenisa, dystonia, on/off
Drugs that cause PD-like Sx
antipsychotics (ie Haldol, lithium & others), antiemetics (ie Compazine), Reglan, antiHTN (ie reserpine, aldomet), illicit drugs (ie methamphetamines)
Fall Precautions
PT for balance, low & locked bed, fall bracelet, don’t get up alone, bed alarm, non-skid footwear, no throw rugs, furniture w/ open pathways to walk
Aspiration Precautions
HOB elevated before & after meal, lung sounds before & after eating, ensure not pocketing food in mouth, thickened liquids if needed, soft foods
Paraplegia
injury occurring from T1 through L4 w/ paralysis of lower extremities
Quadraplegia
– injury occurring from C1 through C8 w/ paralysis of all 4 extremities
Emergency Care for SCI
maintain patent airway, immobilize on spinal backboard w/ head in neutral position w/ a C-collar to prevent an incomplete injury from becoming complete, prevent head flexion/rotation/extension, if severe cervical injury skeletal traction should be placed in the ER; always suspect SCI until ruled out, improper handling can cause further neurological damage/loss of function
Edema can extend up cord extending deficits, tx w/ methylprednisolone w/i 8hrs of SCI (not for penetrating injuries); enormous dosages
Cervical traction
ALWAYS CONTINOUS, requires pin site care, assess for alignment, amount (lbs) will depend on level of injury, alignment & reduction obtained via x-ray, various types of tongs; in for 5 days then sx
Halo traction
– high to mid cervical fractures w/o cord injury; teaching – 10-12 weeks, post op don’t raise HOB until ordered, walker, swivel chair, low heeled shoes, straws for drinking, sponge bath (no showers/baths), don’t use bars to move pt, don’t lift more than 10lbs, button up shirts
C collar
post-sx: 2 collars (wear one wash the other), change collar in front of mirror, snug but not tight, should prevent nodding yes/no, complication: pressure ulcers
Neurogenic spinal shock
acute SCI complication, ischemic event (lack of circulation) 30 min – 6 weeks; s/s – hypotension (tx w/ dopamine), bradycardia, warm/dry extremities, inability to regulate temp, areflexia below injury, no sensation/movement
Hyperkalemia
acute SCI complication assess during first couple of weeks; loss of K from paralyzed muscle; tx w/ Kayexylate, diuretics if tolerated by hypotension, insulin
Autonomic dysreflexia
potentially chronic massive sympathetic response to visceral stimulation that occurs after spinal shock resolved & reflex activity has returned, more likely w/ injuries above T5-6, disconnect b/w PNS & SNS, intact lower motor neurons sense painful stimuli below level of injury (ie full bladder); message trying to get to brain is blocked so looks for another route
Autonomic dysreflexia S/S
sudden & severe HTN (250/180), pounding h/a, bradycardia, arterial dilation/flushed skin/sweating above T6, nasal congestion, cool skin/goose bumps below injury
Autonomic dysreflexia Etiology
bladder/bowel distention, tight dressings, decubitus ulcers, anything that normally causes pain below lesion, PG
Autonomic dysreflexia Tx
sit pt up (they are orthostatic), monitor BP, look for cause & alleviate it, vasodilators (apresoline, Procardia, nitroglycerin); teach pt to prevent
Immobility hazards
pneumonia, DVT & decubitus ulcers – every system is compromised by bed rest; turn/cough/deep breathe often, meds, early mobility
Back Tx
– brief bed rest (2 days – longer bedrest results in greater disability), PT including exercises (after acute pain subsides), ice/heat/massage, body mechanics, traction; meds – NSAIDs, opioids, muscle relaxants, steroids
Myelogram – intro
– specialized x-ray; lumbar puncture below L3 & injection of contrast into subarachnoid space (can show bony overgrowth, spinal cord tumors/abscesses, HNP/pinched nerve)
Myelogram – pre
allergies to contrast, kidney/thyroid/liver problems (inhibit excretion of contrast – BUN & creatinine), permit signed, pre-op drug, NPO at least 4-8hrs, d/c drugs that lower seizure threshold including: (phenothiazines ie Phenergan, TCA (ie Elavil), CNS stimulants, Glucophage, Demerol shouldn’t be ordered; d/c drugs that cause blood thinning ie ASA, NSAIDs, Plavix, Anticoagulants
Myelogram – post
force fluids, low to semi-fowler’s, assess for voiding, assess LE movement, assess for spinal h/a, if outpatient need a driver
Laminectomy – post
removal of entire lamina (sm bony plate on the back of the vertebrae) to relieve pressure on the spinal canal; post-op – always log roll, don’t ambulate or raise HOB w/o an order, always have draw sheet on bed, report any neuro deficit (ie motor loss, urinary retention, sensory loss), stool softener as ordered, assess wound, TCDB q2h, antibiotics ordered, avoid drugs that increase bleeding, pain mgmt., NSAIDs may not be ordered b/c want inflammation, don’t drive/check w/ MD, TLSO (thoracic lumbar sacral orthodesis ie brace) q3-6mos; complications – neuro deficit, retroperitoneal hemorrhage, CSF leak
Cauda equina syndrome
complete/bilateral compression of lower lumbar & sacral roots (below conus medullaris) causing sensory & motor loss below level of lesion (flaccid LE, decreased DTRs, urinary & fecal incontinence or retention); sx emergency
Five Ps
pain, pallor, polar, paresthesia, pulselessness, paralysis, perception, pressure
Trigeminal neuralgia
unilateral facial pain d/t disease of sensory branches of trigeminal nerve (CN 5); s/s – burning, knifelike/lightninglike shock in trigeminal branches including lips, upper/ lower gums, cheek, forehead or side of nose, pain is abrupt & intense w/ unpredictable duration & recurrences; cause unknown but may be r/t trauma of jaw or ear/teeth infection; triggers – minimal stimulation by eating, brushing teeth, talking, cold blast of air
Trigeminal neuralgia Tx
Meds - antiepileptic meds (ie carbamazepine, oxcarbazepine), antidepressants (ie Amitriptyline), muscle relaxants (ie baclofen)
Sx – glycerol rhizotomy (chemical ablation), percutaneous rhizotomy (radiofrequency ablation), microvascular decompression, gamma knife radiosurgery (targeted radiation to site)
Trigeminal neuralgia – Nx
pain mgmt., response to drug tx, nutritional status, oral hygiene, teaching for sx prep, post-op care if residual deficits after sx (loss of sensory on that side), social isolation r/t uncertainty of pain events
Bell’s palsy
steroids for inflammation; antivirals if viral & doxycycline if Lyme’s disease
Peripheral neuropathy
DM, vascular abnormalities, renal/liver failure, B12 deficiency, AIDS/other immune disorders, drug toxicity, infection, toxic substances (ie heavy metals), trauma
Peripheral neuropathy S/S
muscle weakness w/ or w/o atrophy, pain that’s described as stabbing/cutting/ searing, paresthesia (ie tingling, burning, numbness), loss of sensation, impaired reflexes
Peripheral neuropathy Tx
removal/tx underlying cause, neuropathic pain use: antiepileptic tx (ie gabapentin), antidepressants (ie nortriptyline), opioids; teaching – smoking worsens, elastic stockings to facilitate venous return, caution re extremity care (ie protect from burns/trauma/temp changes)
Tetanus
severe polyradiculitis & polyneuritis affecting spinal & cranial nerves; causes – traumatic wound, dental infection, chronic OM, heroin injection, human & animal bites, open fractures; 100% fatal in severe form
Tetanus S/S
stiffness in jaw (trismus) or neck, fever, tonic convulsions (opisthotonos), laryngeal & resp spasm causing apnea, overstimulation of sympathetic nervous system (diaphoresis, labile HTN, tachycardia, arrhythmias, hyperthermia);
Tetanus Tx
– tetanus toxoid booster & tetanus immune globulin before onset of symptoms, control spasms w/ deep sedation (ie valium, barbituates, neuromuscular blocking agents ie vecuronium), penicillin or other antibiotics to tx infection; nursing mgmt. – prevention w/ Td booster q10yrs, immediate cleansing of wound w/ soap & H2O, acute – pain mgmt., quiet/dark room to prevent spasms/seizures, trach w/ mechanical vent, rehab; READ BOX IN BOOK ABOUT TETANUS
Botulism
most serious type of food poisoning but also can be contracted through open wounds/ nasal inhalation, neurotoxin destroys/inhibits transmission of ACh leading to disturbed muscle movement;
Botulism S/S
n/v, abdominal cramping, neurologic manifestations (difficulty in convergence of eyes, photophobia, ptosis, paralysis of extraocular muscles, blurred/double vision, dry mouth, sore throat, difficulty swallowing), other symptoms (paralytic ileus, muscle weakness, seizures, resp problems/resp arrest);
Botulism Tx
botulism antitoxin IV, GI tract purges (non-Mg laxatives, enemas, lavage w/ charcoal); nursing mgmt. – prevention w/ proper food prep, vent support if needed, care of pt w/ altered mobility
Functions of kidney
Regulatory – maintain body fluid vol & composition, filter waste products for elimination, acid-base regulation
Hormonal – regulate BP (through Renin), Erythropoietin (RBC Synthesis), metabolize Vit D to active form
Kidney terms
Oliguria – decreased urine output to b/w 100-400mL/24hr; 30mL/hr or 720mL/24hrs is normal
Anuria – no urination (total output less than 100mL/24hr)
Dysuria – painful urination
Nocturia – waking from sleep d/t need to urinate
Polyuria – output greater than 2000mL/24hr
Uremia – full blown renal failure; collection of metabolic wastes in the bloodstream
Urinalysis
ideal is 1st morning void, color/odor/turbidity, specific gravity; normal = amber yellow, pH 4-8 (average 6), specific gravity 1.003-1.030, RBC 0-4, WBC 0-5, no glucose/ ketones/bilirubin, few casts, bacteria less than 10k/mL; urinalysis doesn’t have to be sterile
Urine culture
done when urinalysis is abnormal (ie WBC, leukoesterase or nitrites) or symptoms of UTI, needs to be clean catch or catheter derived specimen
BUN
measures renal excretion of urea nitrogen (by-product of protein metabolism in liver); elevation may or may not indicate renal disease (other factors taken into account ie varies according to hydration, trauma can elevate); normal 6-20
Serum creatinine
end product of muscle & protein metabolism filtered by kidneys & excreted in urine (muscle mass & metabolism are usually constant so this is a good indicator of kidney function); normal less than 1.3 (any elevation is important)
KUB
kidneys/ureter/bladder x-ray (shows structures of urinary tract system but it’s a flat plate of whole abdomen)
IVP
contrast x-ray of kidneys to look at renal system
Bladder scan
portable u/s to see how much urine is in the bladder to determine if catheterization is necessary; verify empty bladder, post void residual (over 150mL after voiding will probably cath them)
24 Hr Urine Collection
for Creatinine of other collections ie NaCl, Ca, other electrolytes; 24hr urine collection; throw away 1st void at 10am then collect all specimens until 10am next day & save that last urine, may need to store on ice, start over if contaminated
Creatinine clearance
better indicator of kidney function (approximates GFR); normal = 70-135mL/min
Cystoscopy
looks into bladder for infections, tumors, sources of bleeding, structural problems, etc; post-procedure will have pink tinged urine so increase fluids; contraindications – acute UTI, severely enlarged prostate
Cystitis
inflammation or infection of bladder; s/s – frequency, urgency & dysuria are prime symptoms but can also have cloudy/foul smelling/blood tinged urine, older adults may present w/ confusion
Cystitis Dx
urinalysis (100k+ organisms, positive for leukoesterase & nitrites, presence of WBC & RBC, urine culture/sensitivity confirms organism & antibiotics needed)
Cystitis Tx
urinary antiseptics or antibiotics X3days (ie cipro, Bactrim), analgesics (ie pyridium which stains body fluids), antispasmodics (ie anaspaz)
Pyelonephritis
acute/active infection of kidneys (often can be ascending infection); s/s – low-grade fever, chills, N&V, flank pain or CVA tenderness, cystitis symptoms
Pyelonephritis Dx
urinalysis & culture, elevated WBC, blood cultures, KUB, u/s for anomalies
Pyelonephritis Tx
Bactrim or Cipro usually 14-21 days, f/u culture after tx, sx repair of anomalies
Glomerulonephritis Intro
immune complex deposition (antibody-antigen & complement) w/i glomeruli leads to inflammation & ineffective renal filtration ability ie SLE, post-strep infection; s/s – proteinuria, hematuria, generalized edema & other symptoms of fluid overload, elevated BP, elevated BUN & Creatinine (not infection symptoms!!!!); best way to evaluate pt’s fluid status = BP & daily weights
Glomerulonephritis Dx
assess for previous often Group A Strep infection, urinalysis, BUN & creatinine, testing for immunological reactions (ie ANA, IgG, C3 complement levels), renal biopsy
Glomerulonephritis Tx
symptomatic/supportive care, antibiotics if infection, mg fluid overload w/ Na & H2O restriction/diuretics, diet restriction of protein & Na, oliguria can lead to increased K which needs tx, antihypertensives, may need plasmaphoresis to remove immune complexes or short-term dialysis
Renal cancer
may have no symptoms, early sign = painless hematuria, palpable mass, dull flank pain, general malignancy symptoms (weight loss, anemia, fatigue)
Renal cancer Dx
urinalysis (r/o other urinary problems), CT/MRI/US, renal biopsy
Renal cancer Tx
nephrectomy (remove kidneys, adrenal gland, fat & lymph nodes), radiation, chemo (if metastatic), immunotherapy (biologic response modifiers)
Bladder cancer S/S
may have no symptoms, early sign = painless hematuria, palpable mass, dull flank pain, general malignancy symptoms (weight loss, anemia, fatigue)
Bladder cancer Dx
urinalysis (r/o other urinary problems), CT/MRI/US, renal biopsy
Bladder cancer Tx
nephrectomy (remove kidneys, adrenal gland, fat & lymph nodes), radiation, chemo (if metastatic), immunotherapy (biologic response modifiers)
Renal / Urinary calculi
stones in urinary tract (a lot of stones contain Ca), strong family & personal hx
Renal / Urinary calculi Dx
severe flank/abdominal pain aka renal colic, N&V, pallor, diaphoresis; dx – urinalysis usually shows hematuria & crystals, KUB/CT/US; nursing mgmt. – pain, hydration, strain urine for stones
Renal / Urinary calculi Tx
different procedures for stone removal
Causes of ARF
inadequate kidney perfusion ie shock, PE, anaphylaxis (prerenal failure #1 cause), damage to glomeruli/interstitial tissue or tubules ie infection/drugs/cancer (intrarenal failure), obstruction of urine flow ie ureter stone (postrenal failure)
Phases of ARF – Onset
Onset – begins w/ precipitating event (ie blood loss = hypotension from trauma) & continues until oliguria, may see elevated BUN & creatinine; can occur over several hrs-days
Phases of ARF – Oliguric
output less than 400mL/24hr that doesn’t respond to fluid challenges or diuretics; elevated BUN & creatinine, hyperkalemia, hyperphosphatemia, hypermagnesemia
Phases of ARF – Diuretic
high output phase occurs after correction of precipitating event when renal tubular function is reestablished; BUN begins to normalize; usually occurs 2-6 weeks after onset
Phases of ARF - Recovery
renal function continues to improve although may never reach pre-illness levels
ARF Dx
creatinine & BUN elevated & continue to increase at same pace (can get really high ie creatinine 6mg & BUN 100), K & phosphorus increased, Ca decreased, specific gravity usually decreased & fixed at 1.010 (inability of tubules to produce concentrated or dilute urine), creatinine clearance, alteration in ABGs (ie metabolic acidosis is the main thing)
ARF Tx
correct cause then tx major problems of compromised fluid vol regulation & electrolyte imbalances w/ drugs (diuretics, dopamine gtt, Ca channel blockers to promote renal blood flow), diet, renal replacement tx w/ dialysis, fluid challenge w/ NS
ARF dialysis
temporary hemodialysis (using temp access port in subclavian or jugular vs fistula used for CRF), peritoneal dialysis, continuous renal replacement therapies (pts are too hemodynamically unstable for HD)
ARF and CRF diet
restrict protein, Na, K & fluids; admin Fe/Ca/Vit D, may need to tube feed/TPN if to ill for oral
ARF risk factors
– DM, HTN, glomerulonephritis, PKD, systemic disease (ie Lupus), ARF that doesn’t resolve
CRF risk factors
– DM, HTN, glomerulonephritis, PKD, systemic disease (ie Lupus), ARF that doesn’t resolve
CRF Stages – diminished renal reserve
diminished renal reserve – no accumulation of metabolic wastes b/c nephrons in overdrive to compensate but creatinine clearance may show some changes
CRF Stages – renal insuffiiciency
unaffected nephrons damaged by increased pressure leading to symptoms w/ elevated BUN & creatinine; end stage renal disease (ERSD) – no functioning nephrons = need dialysis
ESRD – renal insufficiency
BUN & Creatinine increasing, kidneys lose ability to concentrate, polyuria & nocturia, h/a, mild anemia, weakness & fatigue
ESRD S/S
BUN & creatinine significantly increased, specific gravity fixed at plasma level (1.010), oliguric, dialysis necessary, sallow/yellow discoloration of skin, uremic frost, pruritus, CNS depression, peripheral neuropathy, psychological changes (withdrawal, depression, psychosis), elevated BP, CHF, pericarditis, anorexia, N&V, GI bleeding, PUD, constipation, hyperglycemia, hyperlipidemia, anemia-bleeding, hyperparathyroid, amenorrhea, infertility, impotence, gout, GFR less than 10%, renal osteodystrophy; uremia – collection of metabolic wastes in bloodstream w/ development of clinical symptoms
ESRD – uremic syndrome
hyperparathyroidism, glucose intolerance, pulmonary edema, Kussmaul’s respirations, proteinuria, hematuria, nocturia, oliguria, fixed specific gravity, anorexia, N&V, gastroenteritis, hiccups, abdominal pain, GI bleeding, PUD, osteodystrophy, bone pain, spontaneous fractures, diminished leukocyte count & increased susceptibility to infection, apathy, lethargy, h/a, impaired cognition, insomnia, restless leg syndrome, gait disturbances, paresthesias, seizures, decreased LOC, coma, HTN, CAD, dysrhythmias, pericarditis, pericardial effusion, cerebrovascular disease, CHF, anemia, impaired clotting, amenorrhea, impotence, spontaneous abortion, pallor, uremic skin color & frost (yellow green), dry skin, poor turgor, pruritus, ecchymosis, azotemia (big time uremia), edema, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesia, acidosis, hyperlipidemia, hyperuricemia, malnutrition
CRF ABNORMAL LAB VALUES
creatinine < 1.3 BUN 6-20 Hgb/Hct (11-17/35-50%) Na, K, Mg (1.5-2.5) Ca (8.6-10.2) Phosphorus (2.4-4.4) Bicarb (22-26) Urine proteins (should be none)
CRF Tx
control of HTN/anemia/electrolyte imbalances – diuretics for fluid retention & HTN early on in renal insufficiency (not ESRD), dialysis, renal transplant; anemia – colony stimulating factors (Epogen/Procrit)
Assess AV fistula
(aka shunt) – auscultate bruit & palpate for thrill to ensure adequate circulation; also no BP/blood draw in fistula arm
Peritoneal dialysis – Nx
daily weight, strict aseptic technique (mask & sterile gloves), hand washing, monitor I&O; after draining: assess color (should be yellow like urine), consistency of flow (if decreasing elevate HOB/turn), if cloudy/fibrinous clots notify MD, check catheter site, assess for pain; complications
Peritoneal dialysis – peritonitis
fever, persistent abdominal pain & cramping, slow/cloudy dialysis drainage, increased WBC, swelling/tenderness around catheter
Dialysis – DRUGS TO AVOID
usually don’t give AM meds b/c will get dialyzed out, give after dialysis; avoid drugs that cause hypotension prior to dialysis
Exclusions for Renal Transplant
older than 70, unresolved malignancies, active infectious process, HIV+, cirrhosis/hepatitis, substance abusers, COPD, LVEF less than 20%, BMI greater than 35, psychosocial/behavioral abnormalities
BPH S/S
voiding symptoms including: difficulty initiating stream, reduced force of urinary stream, intermittency, dribbling urine, sensation of incomplete bladder emptying, frequency, urgency, nocturia; potential complications: acute urinary retention, UTI: phyleonephritis (inflammatory or infectious), sepsis, backflow leading to hydronephrosis & renal failure
BPH Dx vs prostate cancer
DRE – BPH presents as uniform, elastic, non-tender enlargement vs cancer presents as stony-hard nodule
PSA – elevated in both BPH & Prostate Ca; normal = 4-10ng/mL, greater the # larger the tumor
Creatinine & BUN – renal complications
If Abnormal DRE & PSA: KUB – to evaluate renal system; IV pyelogram – contrast x-ray of kidneys to look at renal system; Cystourethroscopy – cystoscope to view urethra, bladder neck & bladder; Bladder scan – to assess postvoid residual
BPH conservative care Nx
watch & wait to see if causing urinary difficulties; dietary changes – avoid ETOH/caffeine/lg amounts of fluids in short time/drinking fluids 2-3hrs before bedtime; avoid meds that can cause urinary retention (decongestants, anticholinergics ie scopolamine, atropine)
TURP transurethral resection of prostate
post op care w/ continuous bladder irrigation – tissue is removed & coagulated (to reduce pressure on urethra), irrigation solution carries out debris; bleeding is a common complication (assess clotting factors pre-op); post-op – clots normal 24-36hrs, hematuria
CBI continuous bladder irrigation
NS irrigation 24hrs after TURP adjusted to maintain colorless or light pink drainage return, tape cath to leg to provide gentle traction, balloon at end of catheter is pulled down into prostatic tissue removal area to put pressure on area & maintain hemostasis; complications – potential hemorrhage, bladder spasms (tx w/ antispasmodics ie oxybutynin/Ditropan)
Hormonal therapy for Prostrate Cancer
estrogens inhibit release of LH from pituitary which stops hormone stimulation to prostate (ie Megace or Depo-Provera)
