Exam 2 med surg Flashcards
1
Q
clinical manifestations of urinary tract calculi
A
- sudden severe pain
- common sites include: ureteropelvic junction (dull pain in costovertebral flank and renal colic)
- mild shock with cool, moist skin
- pain moves to lower quadrant
- UTI symptoms
2
Q
how do you treat an acute attack of urinary tract calculi?
A
treat pain with opioids, look for infection
3
Q
lithotripsy
A
sends extracorporeal shock-wave lithotripsy (ESWL) throughout the kidneys to break up stones
4
Q
functional unit of the kidney
A
nephron
5
Q
functions of the kidney
A
- RBC production (erythropoietin)
- BP regulation
6
Q
capacity of the bladder
A
600-1000 mL
7
Q
between what ages do the size and weight of kidneys decrease and by how much?
A
between 30-90 and by 20-30%
8
Q
how much glomerular function is lost by the seventh decade of life?
A
30-50%
9
Q
what does atherosclerosis do in terms of kidneys?
A
accelerates the decrease of renal size with age
10
Q
what does decreased renal BF result in?
A
decreased GFR
11
Q
what is an important consideration in the gerontologic group concerning meds and renal function?
A
make sure their kidneys can handle some meds
12
Q
CVA tenderness
A
- kidney punch
- where vertebrae meets ribs
13
Q
what would you not want to hear at CVA with the bell of your stethoscope?
A
any bruits
14
Q
is it normal for the urinary tract to have bacteria?
A
no, the bladder and its contents are free of bacteria in majority of healthy persons
15
Q
most common pathogen in a UTI
A
escherichia coli
16
Q
where does E. coli come from?
A
the GI tract
17
Q
patients at risk for UTIs
A
- immunosuppressed
- diabetic
- having undergone multiple antibiotic courses
- have traveled to developing countries
18
Q
what parts are involved in an upper UTI?
A
kidneys, pelvis, and ureters
19
Q
signs of upper UTI
A
fever, chills, flank pain/CVA, pyelonephritis
20
Q
signs of lower UTI
A
usually there are no systemic manifestations, cystitis
21
Q
uncomplicated UTI
A
occurs in otherwise normal urinary tract and usually involves only the bladder
22
Q
complicated UTI
A
coexists with presence of obstruction/stones, catheters, diabetes/neurologic disease, pregnancy-induced changes, recurrent infection
23
Q
how are organisms introduced in a UTI?
A
via the ascending route from urethra and originate in the perineum
24
Q
what percentage do HAUTIs account for nosocomial infections?
A
31%
25
manifestations of UTI
- urinary frequency (more than every 2 hours)
- urgency (sudden strong desire to void immediately)
- incontinence
- nocturia
- nocturnal enuresis
- weak stream
- hesitancy
- intermittency
- postvoid dribbling
- urinary retention
- dysuria
26
manifestation of UTI in older adults
- symptoms are often absent
- nonlocalized abdominal discomfort rather than dysuria
- cognitive impairment possible
- fever less likely
27
what's important to determine from a urine culture?
need to determine susceptibility to antibiotics - sensitive or resistance
28
when should you start antibiotics in someone with a UTI?
AFTER obtaining a culture
29
what is important to teach a patient that is put on phenazopyridine (pyridium) for a UTI?
it stains the urine a reddish-orange that can be mistaken for blood and may stain clothing
30
objective findings in someone with a UTI
- fever
- hematuria, foul-smelling urine, tender, enlarged kidney
- leukocytosis, + bacteria, WBCs, RBCs, pyuria, US, CT scan IVP
31
acute pyelonephritis
inflammation of renal parenchyma and collecting duct caused by bacteria ~ infection/bacteria goes up into the kidneys
32
if left untreated, what can acute pyelonephritis lead to?
urosepsis which can lead to septic shock which can result in death
33
what preexisting factors might be present in a pt. with pyelonephritis?
- vesicoureteral reflux: backward movement of urine from lower to upper urinary tract
- dysfunction of lower urinary tract from obstruction from BPH, stricture, urinary stone
34
manifestations of pyelonephritis
- mild fatigue
- chills
- fever
- vomiting
- malaise
- flank pain
- lower urinary tract symptoms characteristic of cystitis
35
parts of upper respiratory tract
- nose
- mouth
- pharynx
- epiglottis
- larynx
- trachea
36
parts of lower respiratory tract
- bronchi
- bronchioles
- alveolar ducts
- alveoli
37
where would a chest tube go if there is pneumothorax?
chest tube is up because air goes up
38
where would a chest tube go if there is a hemothorax?
chest tube goes down because blood sits down
39
what does a ventilation-perfusion (V/Q) scan look for?
a pulmonary embolism (PE)
40
why might a person need a trach?
- throat cancer
- impaired airway
- trauma
- anaphylaxis
41
what are trachs used for?
to bypass obstruction, facilitate secretion removal, permit long-term mechanical ventilation
42
advantages of trach vs. endotracheal tube
- more secure airway
- increased mobility
- less risk of long-term damage to airway
- easier breathing
- increased comfort
- patient can eat and speak
43
how should trach tie strings be put changed?
one side at a time
44
what does an obturator of a trach do?
used to put it back in if it falls out
45
what is a trach tube with an inflated cuff used for?
risk of aspiration or in mechanical ventilation (inflate cuff with min. volume required to create an airway seal ~ should not exceed 20mm Hg in order to prevent necrosis)
46
what is important to know before deflating a trach cuff?
deflate only if patient is not at risk for aspiration
47
what does deflating a trach cuff allow?
talking and makes swallowing easier
48
when is dislodgement the most dangerous?
during the first 5-7 days
49
retention sutures
free ends taped to skin and left accessible in case tube is dislodged you can just rip them opened if lost airway
50
precautions to prevent with dislodgement
- have replacement tube at bedside
- do not change ties for 24 hours
- physician performs first tube change
51
how might minor dyspnea be alleviated
put patient in semi-fowler's
52
if a trach cannot be replaced what should you do with the stoma?
cover with a sterile dressing and ventilate with bag mask until help arrives
53
how often should a trach tube be changed?
monthly
54
how should a person with a trach receive oxygen?
should be humidified
55
can patients change their trach tubes at home?
yes, using a clean technique
56
what is important to know with decannulation of a trach?
- take out when patient can adequately exchange air and expectorate
- close stoma with tape and occlusive dressing
- splint the incision when coughing, swallowing, speaking
- should close in 4-5 days
57
most common facial fracture
nasal fracture
58
what does a nasal fracture occur as a result of?
blunt trauma
59
complications of nasal fracture
airway obstruction, epistaxis, CSF leak (clear or pink tinged nasal drainage), hematomas, deformity
60
treatment of nasal fracture
maintain airway, reduce pain and edema, prevent complications, upright position, ice, analgesic, nasal decongestants or nasal sprays, no smoking
61
what could occur from a rhinoplasty
swelling, so elevate the head
62
treatment of epistaxis
keep patient quiet, sitting, and pinch entire lower portion of the nose for 10-15 minutes
63
what can treatment of epistaxis cause?
can impair respiratory status
64
treatment of allergic rhinitis
identify and avoid allergens
65
treatment of acute viral rhinitis (common cold)
relieve symptoms, gargles, saline nasal sprays, antihistamines and decongestants, cough suppressants
66
complications of the common cold
pharyngitis, sinusitis, otitis media, tonsillitis and lung infections - need to mobilize secretions
67
manifestations of secondary bacterial infection
higher temperature, tender swollen glands, sinus pain, ear pain, green drainage
68
can acute viral rhinitis be treated with antibiotics?
yes they may be treated with them
69
treatment of influenza
antivirals (zanamivir-relenza and oseltamivir-tamiflu), prevention, vaccination (inactivated and live, attenuated)
70
what would you caution someone with sinusitis using topical decongestant?
don't use for longer than 3 days to prevent rebound congestion caused by vasodilation ~ dry mucosa
71
nasal polyps
benign growths in sinus or nasal mucosa
72
manifestations of acute pharyngitis
fever, anterior cervical node enlargement and tonsillar exudate (yellow-green), absence of cough-bacterial, irregular white patches-candida albicans
73
how is TB spread?
airborne droplet: transmission requires close, frequent, or prolonged exposure, not spread by touching, kissing, or other physical contact
74
what does ghon focus develop into?
a granuloma - infection is walled off and further spread is stopped
75
classification of TB
0 = no TB exposure
1 = exposure, no infection
2 = latent TB, no disease
3 = TB, clinically active
4 = TB, not clinically active
5 = TB suspected
76
discuss pulmonary TB
- takes 2-3 weeks to develop symptoms
- initial dry cough that becomes productive
- symptoms of fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats
- dyspnea and hemoptysis late symptoms
77
how does LTBI present?
it is asymptomatic
78
positive response in TST
- >= 15mm induration in low-risk individuals
- >= in immune-compromised patients (a waning immune response can cause false negative results
79
what kind of study is required for TB diagnosis
bacteriologic
80
bacteriologic studies
- sputum samples obtained usually on 2-3 consecutive days
- culture can take up to 8 weeks
81
how long is TB infectious for after starting treatment?
first 2 weeks
82
how to treat active disease TB
- treatment is aggressive
- in two phases: initial (8 weeks) and continuation (18 weeks)
- four-drugs: INH, rifampin, pyrazinamide, ethambutol
- liver function should be monitored
83
how is latent TB infection treated?
- usually treated with INH for 6-9 months
- HIV should take INH for 9 months
- alternative 3 month regimen of INH and rifapentine OR 4 months rifampin
84
physical symptoms of TB
- productive cough - color of sputum
- night sweats
- afternoon temperature elevation
- weight loss
- pleuritic chest pain
- crackles over apices of lungs
85
how can a patient prevent spread of TB?
- wear mask if outside negative-pressure room
- identify and screen close contacts
- hand hygiene
86
when can airborne isolation for a patient with TB be discontinued?
after three consecutive acid-fast bacillus smears are negative
87
three ways organisms can reach lungs
1. aspiration
2. inhalation of microbes present in the air
3. hematogenous spread from primary infection elsewhere in body
88
community-acquired pneumonia (CAP)
- occurs in patient who have not been hospitalized or resided in LTC facility within 14 days of the onset of symptoms
89
medical-care associate pneumonia (MCAP)
- HAP: occurring 48 hours or longer after admission and not incubating at time of hospitalization
- VAP: occurring more than 48 hours after endotracheal intubation
- HCAP: new onset pneumonia in pt. who was hospitalized for 2 days or longer within 90 days of infection OR resided in LTC facility OR received recent IV antibiotic therapy, chemo, or wound care within past 30 days OR attended a hospital or hemodialysis clinic
90
how to we determine the probable organism in pneumonia?
culture of sputum
91
what is opportunistic pneumonia caused by?
microorganisms that do not normally cause disease ~ sneak in when someone is down and they find an opportunity
92
manifestations of pneumonia
- cough
- fever, shaking chills
- dyspnea, tachypnea
- pleuritic chest pain
- green, yellow, or rust-colored sputum
- change in mentation for older or debilitated patients
93
physical findings of pneumonia
- rhonchi and crackles
- bronchial breath sounds
- egophony
- fremitus
- dullness to percussion if pleural effusion present
94
c-reactive protein (CRP)
a protein made by liver and released into the blood within a few hours after tissue injury, the start of infection, or other cause of inflammation
95
when is pneumococcal vaccine suggested?
for those at risk! age 65 or older, age 2-64 with LT health problem or immunosuppression, age 19-64 who smoke or have asthma, live in nursing homes or LTC facility
96
how does drug therapy work with pneumonia?
- shart with IV and switch to PO as soon as patient is stable
- min. of 5 days of therapy (should see improvement in 3-5 days)
97
what would you want to know in someone with pneumonia?
- past health history of lung cancer, COPD, diabetes, malnutrition, chronic debilitating disease
- use of antibiotics, corticosteroids, chemo, or immunosuppressants
- recent abdominal or thoracic surgery (not willing to cough)
- recent intubation
- tube feedings
98
what does COPD include?
chronic bronchitis and emphysema
99
what percentage of smokers develop airway obstruction?
15%
100
what percentage of COPD deaths are related to tobacco smoking?
80-90%
101
what does nicotine do?
- simulates sympathetic NS: inc. HR, causes peripheral vasoconstriction, inc. BP and cardiac workload
- dec. amount of functional Hgb: will be high when drawn b/c body is working a lot
- inc. platelet aggregation
- compounds problems in CAD
102
how does cigarette smoking affect the respiratory tract?
- inc. production of mucus
- lost of dec. ciliary activity
- chronic, enhanced inflammation
- carbon monoxide
- dec. O2 carrying capacity: inc. HR, impaired psychomotor performance and judgment
103
what can COPD result in?
pulmonary hypertension
104
manifestation of COPD
- develops slowly
- cough
- sputum production
- exposure to risk factors
- dyspnea on exertion - at rest with advanced
- chest breathing
- chest tightness
- underweight with adequate caloric intake
- chronic fatigue
- prolonged expiratory phase
- wheezes
- dec. breath sounds
- barrel chest
- tripod position
- pursed lip breathing
- bluish-red color of skin
105
complications of COPD
- cor pulmonale
- exacerbations of COPD
- acute respiratory failure
- peptic ulcer disease
- depression/anxiety
106
cor pulmonale manifestations
- dyspnea
- JVD
- hepatomegaly with RUQ tenderness
- peripheral edema
- weight gain
107
typical ABG findings in COPD later stages
- low PaO2
- inc. PaCO2
- dec. pH
- inc. bicarbonate level
108
CO2 narcosis
over time some COPD pts. develop tolerance for high CO2 levels
109
diet for COPD patients
high protein, high calorie, 3L of fluid per day
110
activity recommendations for COPD pts.
walk 15-20 minutes a day at least 3 times a week with gradual increase
111
is asthma reversible?
usually
112
risk factors in asthma
- genetic factors
- environment
- male gender in children
- obesity
- genetics
- immune response
113
exercise-induced asthma (EIA)
induced or exacerbated during physical exertion; pronounced with exposure to cold air
114
occupational lung disease
exposure to diverse agents, may take months or years of exposure, pt. will arrive at work well and then experience gradual decline
115
air pollutants
cigarette or wood smoke, vehicle exhaust, concentrated pollution
116
asthma triggers
- respiratory infections: inc. inflammation and hyperresponsiveness of the tracheobronchial system
- asthma triad: nasal polyps, asthma, and sensitivity to aspirin and NSAIDs
- GERD: reflux may trigger bronchoconstriction as well as cause aspiration and asthma medications may worsen GERD
- psychological factors: panic and anxiety
117
where are salicylates found?
foods, beverages, flavorings
118
primary response of asthma
chronic inflammation
119
what do inflammatory mediators cause in asthma?
- vascular congestion
- edema formation
- production of thick, tenacious mucus
- bronchial muscle spasm
- thickening of airway walls
120
what could occur in asthma if airway inflammation is not treated or does not resolve?
may leave to irreversible lung damage
121
structural changes in the bronchial wall is know as?
remodeling
122
do severe attacks have audible wheezing?
they may not
123
characteristics of severe and life-threatening exacerbations
- RR >30
- pulse >120
- PEFR is 40% at best
- seen in ED or hospital
124
life-threatening asthma characteristics
- too dyspneic to speak
- perspiring profusely, drowsy/confused
- require hospital care and often admitted to ICU
125
what does IV magnesium sulfate do in asthma?
given as a bronchodilator ~ relaxes smooth muscle
126
corticosteroids
- taken on a fixed schedule
- systemic form to control exacerbations and manage persistent asthma
127
what should you be careful for in those taking corticosteroids?
oropharyngeal candidiasis; teach pt. to gargle after each use
128
example of bronchodilator
albuterol ~ rescue not maintenance
129
what is ephedrine used for?
simulated CNS and CV system, used in emergency airway attacks
130
how much water should asthma patients drink?
2-3 L of fluid each day
131
what should asthma pts. avoid?
- cold air
- aspirin, NSAIDs, nonselective B-blockers
132
green, yellow, and red zone of PEFR
- green = 80-100% of best
- yellow = 50-80%
- red = 50% or less
133
how much does 1L of water weigh?
2.2 lbs (1 kg)
134
cations
+ charge: sodium, potassium, calcium, and magnesium
135
anions
- charge: bicarbonate, chloride, and phosphate, most proteins
136
most prevalent cation and anion in ICF
cation: K+
anion: PO43-
137
most prevalent cation and anion in ECF
cation: Na+
anion: Cl-
138
diffusion
movement of molecules across a permeable membrane from high to low concentration
139
facilitated diffusion
uses carrier to move molecules
140
active transport
molecules move against concentration gradient - energy is required
141
osmosis
movement of water down concentration gradient from low solute concentration to high across a semipermeable membrane
142
osmotic pressure
amount of pressure required to stop osmotic flow of water
143
osmolarity
measures total milliosmoles/L of solution
144
osmolality
- measures number of milliosmoles/kg of water
- preferred measure to evaluate concentration of plasma, urine, and body fluids
145
isotonic
- equal
- NS or LR
146
hypotonic
- less solutes than fluid, "fat gummy bear"
- D5 1/2 NS
147
hypertonic
- more solutes than fluid
- D10W or 3% NS
148
plasma-to-interstitial fluid shift results in...
edema
149
interstitial fluid drawn into plasma...
decreases edema
150
first spacing
normal distribution
151
second spacing
abnormal (edema)
152
third spacing
fluid is trapped where it is difficult or impossible for it to move back into cells or blood vessels (peritoneal or pleural spaces)
153
primary organ for regulating fluid and electrolyte balance
renal system
154
manifestation of hypovolemia
restlessness, drowsiness, lethargy, confusion, postural hypotension, tachycardia, tachypnea, weakness, dizziness, weight loss, seizures, and come
155
what could cause hypovolemia?
diarrhea, vomiting, hemorrhage, polyuria
156
what would cause hypervolemia?
heart failure, renal failure, colloids
157
manifestation of hypervolemia
headache, confusion, lethargy, peripheral edema, JVD, bounding pulse, hypertension, dyspnea, crackles, pulmonary edema, muscle spasms, seizures, coma
158
most accurate measure of volume status
daily weights - an increase of 1 kg (2.2 lbs) is equal to 1000 mL (1L) of fluid retention
159
concentrated urine specific gravity
1.025
160
dilute urine specific gravity
1.010
161
normal ranges of sodium
135-145
162
manifestations of hypernatremia
thirst, postural hypotension, tachycardia, weakness, alterations in mental status
163
what would be considered too much sodium loss/gain?
more than 8-15 mEq/L in an 8 hour period
164
manifestations of hyponatremia
- mild: headache, irritability, difficulty concentration
- severe: confusion vomiting, seizures, coma
* clinical manifestations are result of cellular swelling and are first manifested in the CNS
165
main cause of hyponatremia
water excess - SIADH ~ fluid restriction needed and loop diuretics
166
in hyponatremia, what can you do with severe symptoms (seizures) in the ICU only?
give small amount of IV hypertonic saline solution (3% NaCl)
167
potassium normal ranges
3.5-5.0
168
sources of potassium
- fruits and vegetables (bananas and oranges)
- salt substitute
- potassium medications
- stored blood
169
where is potassium regulated?
in the kidneys and this is the only mechanism to clear excess
170
most common cause of hyperkalemia
renal failure
171
hyperkalemia causes
- impaired renal excretion
- shift from ICF to ECF (acidosis)
- massive intake
172
manifestations of hyperkalemia
- cardiac dysrhythmias
- cramping leg pain
- weak or paralyzed skeletal muscles
- abdominal cramping or diarrhea
173
urgent Rx to give someone with hyperkalemia
insulin and D50 IV, calcium, bicarbonate
174
hypokalemia causes
- loss of potassium via kidneys or GI tract (most common)
- increased shift of potassium from ECF to ICF (with DKA)
- dietary deficiency (rare)
- alkalosis causes shift if severe
175
manifestations of hypokalemia
- cardiac most serious
- skeletal muscle weakness (legs)
- weakness of respiratory muscles
- dec. GI motility
- hyperglycemia
176
what is important for anyone with a potassium problem to have?
cardiac monitor
177
what is important when administering potassium?
- PO or IV
- always dilute IV KCl
- NEVER give KCl via IV push or as a bolus
- should not exceed 10 mEq/hr via pump
- except in severe deficiencies, KCl is not given unless there is urine output of at least 0.5 mL/kg of body weight per hour
178
normal calcium levels
8.5-10.2
179
what is calcium balance controlled by?
PTH and calcitonin
180
hypercalcemia causes
- hyperparathyroidism
- malignancy
- thiazide diuretic use, prolong immobilization, and increased calcium intake
181
manifestations of hypercalcemia
* excess calcium acts like a sedative
- fatigue, lethargy, weakness, confusion
- hallucinations, seizures, coma
- cardiac dysrhythmias
- bone pain, fractures, nephrolithiasis
- polyuria, dehydration
182
hypocalcemia causes
- dec. PTH
- multiple blood transfusions - citrate used to anticoagulate the blood binds with calcium *Ca and citrate go together
- alkalosis
- inc. calcium loss
- surgical removal of parathyroid glands
183
manifestations of hypocalcemia
* tetany
- + trousseau's or chvostek's sign
- laryngeal stridor ~ losing airway!
- dysphagia
- tingling around mouth or in extremities
- cardiac dysrhthmias
184
normal phosphate levels
2.5-4.5
185
hyperphosphatemia causes
- AKI or chronic disease
- chemo
- excess intake of phosphate or vitamin D
- hypoparathyroidism
186
maintenance of phosphate requires what?
adequate renal functioning
187
manifestations of hyperphosphatemia
- NM irritability and tetany (hypocalcemia)
- calcified deposition in soft tissue such as joints, arteries, skin, kidneys, corneas
188
describe the relationship between calcium and phosphate
if Ca is high, phosphate will be low and vise versa
189
what kind of foods contain phosphorus?
dairy
190
hypophosphatemia causes
- malnourishment/malabsorption
- diarrhea
- use of phosphate-binding antacids
- inadequate from parenteral nutrition
191
manifestations of hypophosphatemia
* impaired cellular energy and O2 delivery
- CNS depression
- muscle weakness and pain
- respiratory and heart failure
192
normal magnesium levels
1.5-2.5
193
what is magnesium important for?
normal cardiac function
194
where is magnesium excreted?
the kidneys
195
hypermagnesemia causes
- inc. intake or ingestion of products containing Mg when renal insufficiency or failure is present
- excess IV Mg administration
196
manifestations of hypermagnesemia
- lethargy
- nausea and vomiting
- impaired reflexes
- muscle paralysis
- respiratory and cardiac arrest
197
what drug reverses out Mg?
IV CaCl or calcium gluconate
198
hypomagnesemia causes
- prolonged fasting or starvation
- chronic alcoholism
- fluid loss from GI tract
- prolonged parenteral nutrition without supplementation
- diuretics
- hyperglycemic osmotic diuresis
199
manifestations of hypomagnesemia
- hyperactive deep tendon reflexes
- muscle cramps
- tremors
- seizures
- cardiac dysrhythmias - torsade de pointes and ventricular fibrillation
- corresponding hypocalcemia and hypokalemia causes symptoms
200
too rapid administration of magnesium can lead to...
hypotension and cardiac or respiratory arrest
201
hypotonic fluids
0.45% NaCl
202
isotonic fluids
0.9 NS
LR
D5W
NS
203
what is the preferred fluid for immediate response?
NS
204
what fluid is compatible with most meds and is the only fluid used with blood?
NS
205
what do LRs do?
expands ECF - treats burns and GI losses
206
why would LRs be contraindicated?
those with hyperkalemia and lactic acidosis
207
hypertonic fluids
D5 1/2 NS
D10W
208
use of hypertonic fluids
to provide calories as part of parenteral nutrition
209
colloids
- contain large molecules that inc. oncotic pressure and pull fluid into the blood vessels
- also called volume expanders or plasma expanders
- includes: human plasma products (albumin, fresh frozen plasma, blood) and semisynthetics (dextran and starches, [hespan])
