Exam 2 Flashcards
multiple sclerosis
Myelin sheath destroyed (like rubber outside of phone charger)
Nerves not making smooth changes into muscle
parkinson’s disease
Center of balance and sensation are off
Rigidity
Can’t spontaneously put one foot in front of the other
Lots of concentration and thinking for simple tasks
CNS function
controls most body functions, including awareness, movements, sensations, thoughts, speech and memory
peripheral nervous system
broken down into somatic and autonomic
somatic nervous system
controls body movements that are under our control such as walking.
autonomic nervous system (and major organ)
further divided into sympathetic and parasympathetic
ADRENALS!
chain ganglia vs collateral ganglia
chain: spinal nerves and nerves in thoracic cavity
collateral: abdomen and pelvis
cerebrovascular disorder
functional abnormality of the CNS that occurs when blood flow to the brain is disrupted
Stroke is a major example
financial impact is profound
What is agnosia?
A. Failure to recognize familiar objects perceived by the senses
B. Inability to express oneself or to understand language
C. Inability to perform previously learned purposeful motor acts on a voluntary basis
D. Impaired ability to coordinate movement, often seen as a staggering gait or postural imbalance
A
nonmodifiable risk factors of cerebrovascular disorders
age (>55), male, black
manifestations of an ischemic stroke
Symptoms depend on the location and size of the affected area
Numbness or weakness of face, arm, or leg, especially on one side
Confusion or change in mental status
Trouble speaking or understanding speech
Difficulty in walking, dizziness, or loss of balance or coordination
Sudden, severe headache
Perceptual disturbances
hemiplegia vs hemiparesis
hemiplegia: complete paralysis
hemiparesis: partial weakness
dysarthria
difficulty speaking due to weak speech muscles
hemianopsia
only seeing on one side
TIA
Temporary neurologic deficit resulting from a temporary impairment of blood flow
“Warning of an impending stroke”
how to treat and prevent irreversible deficits
diagnostic workups
how to diagnose TIA
CT scan, cerebral angiography, lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage
what to treat with TIA
vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding
Deliberate CALM care!!
cardiac endarterectomy
removes buildup from carotids
carotids feed brain with blood supply
hemorrhage is bad
can mess up shoulder
what to do for carotid stenosis and afib
carotid: carotid endarterectomy
afib: anticoags and antihypertensives
medical management in acute phase of stroke
prompt diagnosis and treatment
thrombolytic therapy
pt monitoring
watch for bleeding
elevate HOB unless contraindicated
maintain airway and ventilation
continuous hemodynamic monitoring and neuro assessment
hemorrhagic stroke caused by
spontaneous rupture of small vessels r/t hypertension
ruptured aneurysm
intracerebral hemorrhage r/t amyloid angiopathy
arterial venous malformations (AVMs)
intracranial aneurysms
medications such as anticoagulants
ICP increases caused by blood in subarachnoid space
Compression or secondary ischemia from perfusion & vasoconstriction causes injury to brain tissue
manifestations of hemorrhagic stroke
similar to ischemic
severe HA
early and sudden changes in LOC
vomiting
bleeding
assessment of pt recovering from ischemic stroke (acute phase)
ongoing frequent monitoring of systems esp neuro (CHECK AROUSAL LEVEL)
LOC
symptoms
speech
pupil changes
I&O
BP maintenance
bleeding
O2 sat
nursing care after acute phase
Mental status
Sensation/perception
Motor control
Swallowing ability
Nutritional and hydration status
Skin integrity
Activity tolerance
Bowel and bladder function
Get men ready to pee again once they’re stable enough to stand
preventing joint deformities in stroke pts
turn and position in correct alignment q2h
use splints
passive or active ROM 2-5x/day
prevention of flexion contractures
prevention of shoulder abduction
do not lift by flaccid shoulder
quad setting and glute exercises
assist patient OOB ASAP
ambulation training
nutrition for stroke pts
Consult with speech therapy or nutritional services
Have patient sit upright, preferably out of bed, to eat
Chin tuck or swallowing method
Use of thickened liquids or pureed diet
Ice chips bad!!
when to perform neuro checks for pt with hemorrhagic stroke
q2-4h
assessment of pt with hemorrhagic stroke
Altered LOC
Sluggish pupillary reaction
Motor and sensory dysfunction
Cranial nerve deficits
Speech difficulties and visual disturbance
Headache and nuchal rigidity
Other neurologic deficits
3 complications of hemorrhagic stroke
Decreased cerebral blood flow
Inadequate oxygen delivery to brain
Pneumonia
5 complications of ischemic stroke
Vasospasm
Seizures
Hydrocephalus
Rebleeding
Hyponatremia
goals of hemorrhagic stroke
Improved cerebral tissue perfusion
Relief of anxiety
The absence of complications
aneurysm precautions
Provide a non-stimulating environment, prevent increases in ICP, prevent further bleeding:
Absolute bed rest with HOB 30 degrees
Avoid all activity that may increase ICP or BP; Valsalva maneuver, acute flexion or rotation of neck or head
Stool softener and mild laxatives so they don’t bear down
Non-stimulating, non-stressful environment; dim lighting, no reading, no TV, no radio
Visitors are restricted
early identification of stroke (interventions)
Call RRT (neuro)
Initiating stroke algorithm
The National Institutes of Health Stroke Scale (NIHSS)
labs prior to CT (CBC, BMP, coags, T&S)
stroke scale values
0 = no stroke
1 to 4 = minor stroke
5 to 15 = moderate stroke
16 to 20 = moderate to severe stroke
21 to 42 = severe stroke
Airway in pts with decreased LOC and interventions
Patients with decreased LOC have increased risk of airway compromise due to loss of protective reflexes and oral-pharyngeal reflexes
Nursing Interventions:
HOB > 30 degrees
Suction prn
O2 saturation assessment
S&S of dysphagia
ASPIRATION RISK
Weak or absent gag reflex
Drooling
Excessive chewing
Difficulty pushing food to back of mouth
Dysarthria (difficulty speaking)
Listen to the voice
Gurgle, wet, weak, hoarse, strident
Paresthesia of face, lips, tongue
what is aspiration
Aspiration is defined as the inhalation of either oropharyngeal or gastric contents into the lower airways
modified massey bedside swallow test
must be completed and documented w date and time for all rule out strokes and TIAs prior to any oral intake
complete within 24hrs of admission or new onset TIA/CVA
can’t just document +/-
nurses do this test
when in doubt, keep pt NPO
aspiration PNA
Aspiration of colonized oropharyngeal material (food, secretions)
Often polymicrobial
Pulmonary inflammation
pts look very sick
CXR shows what in aspiration pts
infiltration of dependent portion of lungs
cloudy, can’t identify outline of lobes
effective oral care does what 5 things
Reduces bacteria
Increases appetite
Increases alertness
Increases salivary flow
Reduces pneumonia incidence
diagnosis of aspiration PNA
Fever >100 F
WBC > 10,000 (know normal WBC)
Rales
+ sputum culture
Productive cough
PaO2 <70 mmHg
CXR + for new infiltrate
how to manage reflux
positioning
feeding/diet changes
meds such as antacids, PPIs, histamine blockers, prokinetics, physical barriers
nursing interventions for dysphagia
NPO
Swallow evaluation
Ensure appropriate diet (puree, mechanical soft)
Feed in upright position
For pts with hemiplegia or paresis, place food on unaffected side
If “pocketing” of food occurs, have patient sweep mouth with finger to remove
when can tPA be given
within 3hrs of stroke onset
5 assessment for tPA
monitor for bleeding
maintain BP
neuro status (for re-embolization or bleed)
no SCD or BP cuff for 24h
no heparin for 24h
what to use for non-tPA eligible pts
Early ASA therapy is recommended (150- 325mg)
Pts w/ restricted mobility
Prophylactic low-dose SQ Heparin or LMWH or IPC (intermittent pneumatic compression)
blood pressure management for stroke pts
aggressive efforts to lower blood pressure may decrease perfusion pressure and may prolong or worsen ischemia
hypertension in the setting of hemorrhagic stroke should always be managed
Parameters for BP management can vary depending on if patient is a candidate for t- PA
fever in stroke pts
mild hypothermia in the brain is neuroprotective, hyperthermia accelerates ischemic neuro injury
give antipyretics and find source of fever
antithrombotics for day 2 post CVA/TIA
ASA
Aggrenox
ASA & dipyridamole
Coumadin
Plavix
Ticlid
IV Heparin
LMWH – full dose
afib and ischemic CVA meds
long term coumadin (INR 2.5 [2-3])
ASA 75-325 mg/day if coumadin contraindicated
first thing we look at with people with impaired LOC
verbal response and alertness
lethargy
drowsy, awakens to stimulation
obtunded
difficult to arouse, needs constant simulation to FOLLOW SIMPLE COMMAND
stupor
arouses to vigorous, continuous stimulation
CAN’T FOLLOW A SIMPLE COMMAND
can be from increased ICP
severe impairment to brain circulation
immediate intervention
may become comatose and exhibit abnormal motor responses
if goes to irreversible coma, brainstem reflexes are absent, respirations are impaired, may be braindead)
akinetic mutism
Unresponsiveness to the environment, makes no movement or sound, sometimes opens eyes
PVS
no cognitive function but has sleep-wake cycles
locked in syndrome
inability to move or respond except for eye movements (up and down not side to side)
lesion in the pons!
GCS score interpretations
9-15: mild-mod injury
3-8: major injury
GCS eye
4- Spontaneous
3- Loud voice
2- Pain
1- None
GCS verbal
5- Normal conversation
4- Disoriented conversation
3- Non coherent
2- No words, only sounds
1- None
GCS motor
6- Normal
5- Localized to pain
4- Withdraws to pain
3- Flexion
2- Extension
1- None
changes in LOC can indicate what 7 things?
Hypoxia
Hypercarbia
Hypotension
Drug related
Hypothermia
Postictal state
Hypoglycemia
complications of change in LOC
resp distress/failure
PNA
aspiration
pressure ulcers
DVT
contractures
fixed and dilated pupils
herniation syndrome
posturing in relation to PVS
high potential for PVS in pts who posture and have adequate perfusion and oxygenation
spastic muscles
generally accompanied by rigidity, muscle is in a state of contraction, muscle spasm may be present
decorticate (plantar, legs, arms, hands)
plantar flexed (outward)
legs internally rotated
arms flexed and adducted
hands flexed
BETTER PROGNOSIS
decerebrate (plantar and arms/hands)
plantar flexed (outward)
arms adducted, extended, pronated, and hands flexed outward
DTRs and which is superficial
triceps, biceps, brachioradialis, patellar, and achilles tendon
plantar is superficial
in who is Babinski normal
children <2
cushing’s triad
Increased SBP with a widening pulse pressure
Bradycardia
Bradypnea
cushing’s triad caused by?
increased ICP
late sign of herniation syndrome
normal ICP
1-15 mmHg
herniation syndrome
Occurs when cerebral pressure is not exerted evenly
One portion of the brain herniates into another
Supratentorial and infratentorial
Caused by cerebral edema or mass
Neuro changes can be slow or rapid
Call family to establish baseline
maintenance of clear airway for altered LOC patient
may be orally or nasally intubated, can cause accumulation of secretions which need to be removed
frequent monitoring and lung sounds
positioning to accumulate secretions and prevent obstruction
HOB elevated 30, lateral or semi-prone
suctioning, oral hygiene, CPT
how to protect eyes in pt with altered LOC
clean with saline-soaked cotton balls
artificial tears
cautious w eye patches because cornea may contact patch
fluid status and body temp with altered LOC
watch fluid status, turgor, INO, labs, IV and tube feedings
adjust temp and cover pt
monitor temp frequently
diarrhea may result from what 3 things
infection
meds
hyperosmolar fluids (TPN)
mood if patient arouses from coma
may have period of agitation (low stimulation)
monro-kellie hypothesis
Dynamic equilibrium of intracranial pressure
Limited space in skull, so increase in any components causes change in volume of others
compensation by displacing or shifting CSF
increasing absorption or minimizing production of CSF
minimizing blood volume
increased ICP causes what
decreased cerebral perfusion, ischemia, cell death, and further edema
may result in herniation
autoregulation in the brain
the brain’s ability to change the diameter of blood vessels to maintain cerebral blood flow
decreased and increased CO2 in relation to blood vessels
decreased: constriction
increased: dilation
early manifestations in increased ICP
changed in LOC
change in condition
Restlessness, confusion, increased drowsiness, increased respiratory effort, purposeless movements (loss of spontaneous movement), hemianopsia, lost taste for sweet and salty, pulse and pulse pressure changes
Pupillary changes and impaired ocular movements
Weakness in one extremity or one side
Headache: constant, increasing in intensity, or aggravated by movement or straining
late manifestations of increased ICP
Respiratory and vasomotor changes
Cushing triad: bradycardia/pnea, HTN
Projectile vomiting
Further deterioration of LOC
Going from stupor to coma
Hemiplegia, decortication, decerebration, or flaccidity
Respiratory pattern alterations including cheyne-stokes breathing and arrest
Loss of brainstem reflexes: pupil, gag, corneal, and swallowing
diabetes insipidus
Decreased secretion of ADH
Excessive urine output
Decreased urine osmolality
Serum hyperosmolality
Give IV fluids, electrolyte replacement and desmopressin (synthetic vasopressin)
SIADH fluid restriction
<800ml/day
interventions for increased ICP
resp status and lung sounds
head in neutral position and elevated 0-60 to promote venous drainage
avoid hip flexion, valsalva, abd distention, or stimuli
monitor fluid status, I&O every hr in acute phase
strict asepsis
craniotomy
opening of the skull
craniectomy
excision of portion of the skull
cranioplasty
repair of cranial defect with metal or plastic plate
burr holes
circular openings for exploration or diagnosis to provide access to ventricles or shunting procedures, aspirate a hematoma or abscess, or make a bone flap
preop meds for increased ICP
corticosteroids, fluid restriction, hyperosmotic (mannitol), diuretics
antibiotics
diazepam for anxiety
care of pt undergoing intracranial surgery
Assess dressing and for evidence of bleeding or CSF drainage from nares or intracranial drain, may look orange or yellow
monitor fluid status and labs
how often to check VS and neuro for intracranial patients
every 15 mins to an hour
when does cerebral edema peak
24-36 hours
HOB to maintain cerebral perfusion
0-30
turning and repositioning/breathing intracranial patients
q2h
use incentive spirometer
humidify oxygen
interventions for intracranial pts
Monitor I&O, weight, blood glucose, serum and urine electrolyte levels, and osmolality, and urine specific gravity
prevent infection by assessing incision site, CSF leak, don’t do anything to increase ICP, asepsis!
causes of seizures
Cerebrovascular disease
Hypoxemia
Fever (childhood)
Head injury
HTN
CNS infections
Metabolic and toxic conditions
Brain tumor
Drug and alcohol withdrawal
Allergies
assessment of HA
Include medication history and use
Persons undergoing a headache evaluation require a detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes
Diagnostic testing may be used to evaluate underlying cause if there are abnormalities on the neurologic exam
Find out about predecessors, new meds being used, history of drug abuse
meds for migraines and cluster headaches
abortive medications instituted as soon as possible with onset
heat and cold for what type of headache
heat for tension
cold for migraine
CN I
olfactory (smell)
offer patient something to smell
CN II
optic (vision)
snellen chart with and without aids
ask when patient sees you wiggling your fingers at side of their head
ishihara plates for color blindness
ask which finger is moving in each quadrant
PERRLA
CN III
oculomotor (eyelid movement, pupil reflex, coordinated movement of eyes)
6 cardinal points in H pattern without moving head
PERRLA
look for failure to move, nystagmus, drooping, double vision
CN IV
trochlear (eyelid movement, pupil reflex, coordinated movement of eyes)
6 cardinal points in H pattern without moving head
PERRLA
look for failure to move, nystagmus, drooping, double vision
CN V
trigeminal (face sensation, corneal reflexes, chewing)
sensory: cotton and pin near jawline, cheek, and forehead; cotton on cornea should make pt blink
motor: open mouth against resistance or pretend to chew, left index finger on pt chin and strike with tendon hammer, slight protrusion of jaw
CN VI
abducens (eyelid movement, pupil reflex, coordinated movement of eyes)
6 cardinal points in H pattern without moving head
PERRLA
look for failure to move, nystagmus, drooping, double vision
CN VII
facial (face movement, taste, salivation)
raise eyebrows, close eyes, keep closed against resistance
puff cheeks and show teeth
taste
CN VIII
vestibulocochlear/acoustic (hearing and balance)
whisper test
rinne test (tuning fork on mastoid and next to ear, ear should be louder)
weber test: fork on center of forehead, should sound same in each ear
CN IX
glossopharyngeal (throat sensation, taste, movement of tongue for swallowing/gag reflex, phonation)
swallow or elicit gag reflex
phonation by listening to vocal sounds
assess taste
CN X
vagus (throat sensation, taste, movement of tongue for swallowing/gag reflex, phonation)
swallow or elicit gag reflex
phonation by listening to vocal sounds
assess taste
CN XI
spinal accessory (some neck movement and shoulder)
shrug shoulders and turn head against resistance
CN XII
hypoglossal (tongue movement)
stick out tongue and check for deviations
right sided CVA
left paralysis
spacial difficulties
impulsive behavior
poor judgment
time blindness
left sided CVA
right paralysis
difficulty knowing left and right
slow cautious movements
impaired cognition
dep and anxiety
warning signs of chemo toxicity
loss of appetite
fatigue
SOB
what med to give before chemo
benadryl corticosteroids
platinum based chemo
neuropathy!!
chemo and thrombocytopenia
noooo!
supportive care for palliative
Insertion of gastric feeding tube
Placement of central venous access device
Prophylactic surgical fixation of bones at risk for pathologic fracture
intrathecal chemo
injected in spinal column
Central vascular access device (VAD) administration
Placement in large blood vessels
Frequent, continuous, or intermittent administration
Can be used to administer other fluids (blood, electrolytes, etc.)
Minimize discomfort and emotional distress!
Avoid continuous punctures through peripheral lines
intraarterial regional chemo
Delivers drug through arteries supplying tumor
intraperitoneal regional chemo
Delivers drug to peritoneal cavity for treatment of peritoneal metastases with 1-2L of fluids for 1-4 hours then drained. Heated intraperitoneal chemotherapy (HIPEC), done for liver or colon cancer that metastasized into peritoneal cavity
intrathecal/ventricular regional chemo
Involves lumbar puncture & injection of chemo into subarachnoid space
intravesical bladder regional chemo
Agent added to bladder by urinary catheter and retained for 1 to 3 hours
acute chemo toxicity
Anaphylaxis, hypersensitivity, extravasation (comes out of the blood vessel and goes into tissue), anticipatory nausea, vomiting, dysrhythmias
delayed effects of chemo toxicity
Nausea and vomiting, mucositis (mucus membranes break down), alopecia, skin rashes, bone marrow depression, altered bowel function, neurotoxicities (especially with platinum-based chemo)
chronic chemo toxicity
Damage to heart, liver, kidneys, and lungs
Can immediately develop after treatment and manifest months later
SE can be in more than one category, long lasting ones can have effects on patient’s survival
platinum based chemo for what types
bladder, lung, testicular, and ovarian
topoisomerase inhibitors for what type of cancer
ovarian, colon, small cell lung
vinca alkaloids for what type of cancer
solid tumors
leukemia, lymphoma, hodgkin lymphoma
antifolates for what type of cancer
sarcomas, carcinoma, ALL lymphoma, non-neoplastic like immunosuppression
treatment induced effects of chemo (bone marrow suppression)
monitor CBC, neutro, PLT, RBC, nadir in 7-10 days so space out chemo q2w, neutropenia, anemia, fatigue, thrombocyto, infection, sepsis, hemorrhage
treatment induced effects of chemo (mucosal lining disturbances)
stomatitis, mucositis, esophagitis, N/V/D/C, dysgeusia, hepatotoxicity)
treatment induced effects of chemo (skin changes)
erythema, flushing, hyperpigmentation
acral erythema, alopecia
rashes, dryness, finger and toenail discoloration
peeling (macerated) skin
caused by normal RBCs being destroyed
Especially the ones rapidly proliferating like bone marrow, GI lining, bone, skin, and nails
when is nutritional counseling indicated after chemo
when 5% weight loss noted
diet for chemo pts
Soft, non irritating, high-protein & high-calorie foods should be eaten throughout the day.
avoid extreme temps, tobacco, alcohol, spicy/rough foods
nutritional supplements
biweekly weights
10lb weight loss=hard to maintain nutritional status
monitor albumin and prealbumin
causes for fatigue in chemo pts
anemia
accumulation of toxic substances after cells are killed
need for extra energy to repair and heal body tissue
lack of sleep from drugs
pulmonary effects of chemo
immediate effects can be alarming because they mimic symptoms that precipitated the cancer diagnosis
Pneumonitis, pulmonary fibrosis, pulmonary edema, hypersensitivity pneumonitis, interstitial fibrosis & pneumonitis produced by an inflammatory reaction or destruction of alveolar-capillary endothelium are all possible
Cough, dyspnea, pneumonitis, pulmonary edema
treatment of pulmonary effects of chemo
bronchodilators
expectorants/cough suppressants
bed rest
oxygen
primary cause of death of chemo
infection in lungs, GU, mouth, rectum, peritoneal, blood
occurs from ulceration, compression of vital organs, and neutropenia
3 obstructive emergencies of chemo
SVC syndrome
spinal cord compression
third space syndrome
SVC syndrome and S&S
obstruction by tumor or thrombus by lung cancer, non-hodgkins lymphoma, and breast cx
Facial and periorbital edema
Distention of veins of head, neck, and chest
Seizures
Headache
Confusion and disorientation
mediastinal mass seen on chest xray
what increases risk of SVC syndrome and treatment
presence of a central venous catheter & previous radiation therapy to the mediastinum
radiation therapy or chemo to site of obstruction
spinal cord compression and S&S
tumor in epidural space of spinal cord
Intense, localized, persistent back pain
Motor weakness
Sensory paresthesia and loss
Change in bladder or bowel function
third space syndrome, S&S, and treatment
Shifting of fluid from vascular to interstitial space
Signs of hypovolemia including hypotension, tachycardia, low central venous pressure, and decreased urine output
Treatment: replacement of fluids, electrolytes, and plasma protein
hypervolemia can occur from treatment
5 metabolic emergencies by production of ectopic hormones
SIADH
hypercalcemia
tumor lysis syndrome
septic shock
DIC
SIADH
abnormal or sustained production of ADH
cancer cells manufacture, store, and release it
chemo agents stimulate release
SIADH S&S
Weight gain without edema, weakness, anorexia, N/V, personality changes, seizures, oliguria, decreased reflexes, coma, hyponatremia
SIADH treatment
Treat underlying malignancy & correct the sodium- water imbalance (fluid restriction, oral salt tablets or isotonic [0.9]) saline and IV administration of 3% sodium chloride solution.
Furosemide (Lasix) may also be a helpful treatment in the initial phases.
Demeclocycline (Declomycin) may be needed on an ongoing basis
Monitor sodium level because sometimes SIADH…? I’m assuming SIADH causes hyponatremia
what 2 things contribute to or exacerbate hypercalcemia
immobility and dehydration
S&S of hypercalcemia
Apathy, depression, fatigue, muscle weakness
ECG changes, polyuria, nocturia, anorexia, N/V
tumor lysis syndrome
rapid destruction of large numbers of cells
increased serum phosphate causes decreased calcium
can cause biochem changes resulting in renal failure
can be fatal
prevent renal failure and serious electrolyte imbalance
usually 24-48h after chemo and lasts a week
hallmark signs of tumor lysis syndrome
hyperuricemia
hyperphosphatemia
hyperkalemia
hypocalcemia
infiltrative emergencies in chemo pts
cardiac tamponade and cardiac artery rupture
sometimes in head and neck cancer, risk
S&S of cardiac tamponade
heavy feeling in chest, SOB, tachycardia, coughing, difficulty swallowing, hoarse, perspiring a lot, uncomfy and anxious
cardiac artery rupture
Invasion of artery wall by tumor
Erosion following surgery or radiation
Bleeding can manifest as
minor oozing or spurting of blood in case of a blowout pressure should be applied
surgical management of carotid artery rupture
ligation of the carotid artery above and below the rupture site and reduction of local tumor
what hormones do the renal system release (what do the hormones help with)
RBC production
bone metabolism
BP control
physical structure of ureters
wide then thinner, where stones get stuck
gerontological considerations of renal and urinary
GFR decreases (causing more effects of meds bc they can’t excrete them as well)
diminished osmotic stimulation (hypernatremia and FVD)
structural (tumor) or functional changes to bladder (incontinence or BPH)
FEWER NEPHRONS
lining of bladder is?
VERY VASCULAR
hallmark sign of upper UTIs like pyelonephritis
fever or chills
when would a patient be on a long term catheter
paralyzed, BPH, PVS or coma, MS, any neuro problem that interferes with message telling brain “I have to void”
how do drugs affect urine output
tobacco/nicotine vasoconstricts, alcohol suppresses ADH
nephrotic syndrome is what kind of defect
structural
gout and urinary
buildup of uric acid crystals, very painful when they lodge in a joint, can get it anywhere
kidney pain physical exam and clini manifestations
CVA tenderness (dull, severe, sharp, colicky)
N/V, diaphoresis, shock -> obstruction, stone, blood clot, pyelonephritis, trauma
bladder pain physical exam and clini manifestations
suprapubic (intense with voiding and full bladder)
urgency, pain at the end of void, straining ->infection, tumor, interstitial cystitis, overdistended bladder
uteral pain physical exam and clini manifestations
CVA, flank, lower abd, labium (severe, sharp, stabbing, colicky)
N/V, paralytic ileus -> ureteral stone, stricture, blood clot
prostate pain physical exam and clini manifestations
perineum, rectum (vague discomfort, feeling of fullness, back pain)
suprapubic tenderness, obstruction, hesitancy, frequency, urgency, nocturia -> prostate ca, prostitis
urethral pain physical exam and clini manifestations
MALES: from penis to meatus
FEMALES: urethra to meatus
frequency, urgency, dysuria, nocturia, urethral discharge -> infection, irritation of bladder neck, foreign body
interstitial cystitis
not a bladder infection, inflammation of lining of bladder that comes and goes, resembles infection but cultures are (-). Bleeding and pain when urinating, looks like pyelonephritis. Treated with steroids.
where is the labium
right above the hip
frequency
urinating > q3h
hesitancy
difficulty initiating voiding
enuresis
involuntary voiding during sleep
oliguria
urine output <500 ml/day
anuria
urine output < 50ml/day
encopresis
stool at night
urine specific gravity range
1.010-1.025
normal serum creatinine
0.6-1.2
normal BUN
7-18
8-20 in pts >60
cystoscopic examination
metal rod with clip at the end goes in penis for biopsy
leads to hematuria
interventions before urinary tract testing
use correct terminology in a way pt will understand
encourage fluid intake unless contra
reduce discomfort like sitz baths
analgesics and antispasmodics
assess voiding and hygiene
pyridium
antispasmodic
turns urine orange/red
very potent
same as uristat but higher concentration
postop management of kidney surgery
Potential hemorrhage and shock
Widening pulse pressure
HR increases then decreases
Pallor
Nausea
potential abd distention from bleeding and paralytic ileus (use blakemore sengsten tube [black and weighted])
potential infection and thrombus that can turn into PE
complications of kidney surgery
bleeding , pneumonia, infection, and DVT
drains after kidney surgery
pt goes home with them
hand suction on JP drain, should first be blood, then serosang, then sero
tubes sutured in
causes of uro and nephrolithiasis
hyperparathyroidism
renal tubular acidosis
cancers
granulomatous (sarcoid, TB) increase Vit D
Excessive Milk and dairy
myeloproliferative disease
diagnosis of uro an nephrolithiasis
x-ray, blood chemistries, and stone analysis; strain all urine and save stones
possible reasons for stone development
-deficiency of citrate, Mg, nephrocalcin, and uropontin (prevents crystallization)
-dehydration (binging alcohol)
-certain conditions like infection, urinary stasis, periods of immobility
-increased calcium concentrations in blood and urine
Causes of Hypercalcemia and Hypercalciuria
hyperparathyroidism
renal tubular acidosis
cancers
granulomatous (sarcoid, TB) increase Vit D
Excessive Milk and dairy
same as causes of uro and nephrolithiasis
med management of kidney stones
allow stone to pass
pain management
hot bath or moist heat to flank
ten 8oz glasses of water a day
urine output 2L/day
strain urine
NO OPIOIDS, use toridol (antiinflammatory)
gerontologic consideration for kidney stones (temperature)
normal looking temperature like 99 is bad
normally they’re a bit colder like 97 so 99 can be sepsis
not good outcome
dietary teaching for uric stones
low purine diet, no shellfish, mushrooms
dietary teaching for cystine stones
low protein
dietary teaching for oxalate stones
no spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran
bladder cancer risk factors
> 55
male
smoking (tobacco)
environmental carcinogens
recurrent or chronic UTIs
high urinary pH
bladder stones
high cholesterol
pelvic radiation therapy
cancers of nearby areas
S&S of bladder cancer
Visible painless hematuria (most common symptom)
Frequency and urgency secondary to infection
Any alteration in voiding pattern
Pelvic or back pain with metastatic
surgery for bladder cancer
transurethral resection or fulguration, cystectomy (simple or radical)
Conduit to bypass bladder (connects kidneys to skin)
urinary diversion reasons
Bladder cancer or other pelvic malignancies
Birth defects, trauma, strictures, neurogenic bladder, chronic infection or intractable cystitis
Used as a last resort for incontinence
types of urinary diversion
Cutaneous urinary diversion: ileal conduit, cutaneous ureterostomy, vesicostomy, nephrostomy
Continent urinary diversion: Indiana pouch, Kock pouch, ureterosigmoidostomy
pt teaching of urinary ostomy
changing appliance, controlling odor, managing the ostomy appliance, cleaning and deodorizing the appliance, continuous care
BPH manifestations
those of urinary obstruction, urinary retention, and urinary tract infections (due to urinary stasis)
treatment of BPH and SE
alpha-adrenergic blockers, alpha- adrenergic antagonists, antiandrogen agents (-zosins)
Finasteride
Catheterization if unable to void
Prostate surgery
antiadrogen causes gynecomastia and facial feminization
risk factors of BPH
Estrogen and testosterone play a role
smoking, Etoh, obesity, sedentary lifestyle, HTN, CVD, DM, Western diet; increase fat, animal protein, refined carb
S&S of BPH
Frequency, urgency, nocturia, hesitancy, decreased force of stream, incomplete void, straining, dribbling, urinary retention, recurrent UTI
fatigue, anorexia, nausea, vomiting, pelvic discomfort
diagnosis of BPH
voiding diary
health/family hx
DRE: large, rubbery, non-tender, gloved hand goes in to feel for prostate
PSA: prostatic specific antigen
American urological association scoring to help grade severity of symptoms
UA, culture
Ultrasound
management of BPH
Meds: alpha-adrenergic blockers alfuzosin, terazosin
5-alpha-reductase inhibitor finasteride
saw palmetto (can mask serious problem) little data to support but often taken by pt.
Minimally invasive: transurethral microwave heat treatment (TUMT) transurethral needle ablation (TUNA)
surgery for BPH
Transurethral resection of prostate (TURP)
watch catheter
lots of bleeding, should look pinkish but not red red
if clots r there, should be small enough to pass
three way system for bladder irrigation
irrigating bladder wall, VERY vascular so try to minimize bleeding
risk factors of prostate cancer
increasing age, familial predisposition, and African-American race
manifestations of prostate cx
Early disease has few/no symptoms
Symptoms of urinary obstruction, blood in urine or semen, painful ejaculation
Symptoms of metastasis may be the first manifestations
Back pain usually brings person in to hospital
EARLY SCREENINGS VITAL
prostate cx treatment
Watchful waiting
Radiation Therapy
Brachytherapy: putting radioactive seeds into the site
Hormonal strategies
Chemotherapy
Regional: radioactive liquid in bladder, must hold it for 1.5-2 hours. Very uncomfortable because they want to urinate
Surgical- Prostatectomy
Radical prostatectomy
Cryosurgery
TURP
S&S of prostate cx
signs of obstruction:
Difficulty and frequency of urination
Urinary retention
Decrease force of stream
Painful ejaculation (prostate, not urinary!)
Blood in urine or semen
Hematuria if cancer of urethral or bladder
signs of metastasis:
back or hip pain, anemia, weight loss, spontaneous fractures
assessment of prostate cx
DRE: hard, fixed (not mobile) stony prostate
Elevated PSA or velocity of PSA
Usually presents with LUTS (lower urinary s/s)
Ultrasound, needle biopsy
Bone scan, MRI to look for mets
complications of prostate cx
Hemorrhage and shock
Infection
DVT
Catheter obstruction
Sexual dysfunction
what to watch w prostate cx surgery
fluid balance!
what do bladder spasms cause in prostate surgery pts
feelings of pressure and fullness, urgency to void, and bleeding from the urethra around the catheter
use meds and warm compresses/sitz baths
analgesics
walk dont sit!
prevent constipation
irrigate catheter
pt teaching after prostate surgery
Sometimes clamp off bladder so urine builds up, helps them regain sensation
Information that regaining control is a gradual process (dribbling may continue for up to 1 year depending upon type of surgery)
perineal exercises
avoid straining, heavy lifting, and long car rides for 6-8w
fluids! no coffee, alcohol or spice
urologist for sex questions
testicular cancer risk factors
undescended testicles, positive family history, cancer of one testicle, Caucasian-American race
manifestations of testicular cancer
painless lump or mass in the testes
(painful is infection)
treatment of testicular cancer
orchidectomy, retroperitoneal lymph node dissection (open or laparoscopic), radiation therapy, chemotherapy
Nitrates in urine
E.coli in pyelonephritis
How long should u fast before cerebral angio
8-10h
Hyperuricemia value
> 7
Hyperphosphate level
> 4.5
3 meds to dry secretions when dying
Scopolamine
Glycopyrrolate
Hyoscyamine
How to treat acute hypercalcemia
Hydration (3 L/day) and bisphosphonate therapy
Tumor lysis syndrome med
use allopurinol/zyloprim to decrease uric acid
