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Concepts 2 > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

GI Diagnostics: Esophagogastroduodenoscopy (EGD)

Purpose (2)
Nursing Care (3)

A

Purpose
* Viewing of the upper GI tract from the esophagus to the upper duodenum
* Used to find upper GI bleeding, PUD, biopsy

Nursing Care
* Keep NPO until gag reflex returns
* Monitor for perforation (pain, bleeding, fever)
* NPO 6-8 hr prior to procedure

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2
Q

GI Diagnostics: Magnetic resonance enterography (MRE)

Purpose
Patient Education (3)

A

Purpose
- visualize bowel (lumen, wall, mesentery, and surrounding abdominal organs) in pts w/ chronic IBD

Patient education
- NPO 4-6 hrs before test
- Must drink large amount of contrast medium (may cause abdominal discomfort and diarrhea so allowed to use restroom after)
- Patient will lie prone and get two subQ glucagon doses to slow bowel activity and motility

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3
Q

GI Diagnostics: Purposes

  • Endoscopic retrograde cholangiopancreatography (ERCP)
  • Abdominal ultrasound
  • Abdominal X-ray
A

Endoscopic retrograde cholangiopancreatography (ERCP)
* Visualize the liver, gallbladder, bile ducts, and pancreas

Abdominal ultrasound
* Visualize gallbladder, biliary system, liver, spleen, and pancreas

Abdominal X-ray
* Visualize bowel obstruction and perforation

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4
Q

GI Diagnostics: Purposes

  • MRI (2)
  • Fibrotic endoscopy
  • Angiography
A

MRI
* Identify tumors, abscesses, hemorrhages, and vascular abnormalities
* shows fluid and gas in small intestine and absence of gas in colon if small intestine obstruction

Fibrotic endoscopy
* Direct visualization and evaluation of GI tract

Angiography
* Evaluate status of GI circulation and control bleeding

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5
Q

GI diagnostics: Purposes

  • GI bleeding scan (2)
  • Hepatobiliary scan (2)
A

GI bleeding scan
* Evaluate presence and location of active GI bleed
* Assess need for arteriogram

Hepatobiliary scan
* Visualize the gallbladder
* Determine patency of the biliary
system

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6
Q

Lab tests for Peptic Ulcer Disease

Urea Breath Test (3)
Stool Antigen Test
Serologic Test

A

Urea breath test
* Exhales in collection container (baseline) after NPO
* Swallow capsule, liquid or pudding w/ urea and special carbon atom
* patient exhales after a few minutes and if CO2 released, bacterium is present

Stool antigen test
- tool sample tested for H. pylori; positive if occult blood

Serologic testing (most common but others more accurate)
- detects H pylori via antibody assays

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7
Q

Types of Mechanical Intestinal Obstructions (6)

A
  • Ulcerative colitis (adhesions/scar tissue outside bowel)
  • Crohn’s disease (strictures in bowel wall)
  • Tumors and hernias in intestinal lumen
  • Fecal impactions
  • Intussusception (telescoping of intestine into itself)
  • volvulus (twisting)
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8
Q

Types of non-mechanical intestinal obstructions (3)

A
  • Postoperative ileus r/t handling bowel in surgery, peritonitis
  • Intestinal ischemia ileus r/t thrombosis or embolism (risk for sepsis)
  • Oral opioid analgesic
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9
Q

Signs of small bowel obstruction (6)

A
  • Tachycardia
  • Abdominal discomfort or pain possibly accompanied by visible peristaltic waves in upper and middle abdomen
  • Upper or epigastric abdominal distention
  • Nausea and early, profuse vomiting (may contain fecal material, be orange brown)
  • Obstipation (no passage of stool) or diarrhea if partial obstruction
  • Metabolic alkalosis (due to obstruction high in small intestine causing loss of gastric HCl)- (not always present)
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10
Q

S/s of all bowel obstructions (5)

A
  • Peristaltic waves
  • Borborygmi (high pitched bowel sounds) – seen in early process w/ cramping as intestine tries to push obstruction
  • Absent bowel sounds distal the obstruction
  • Minimal tenderness and rigidity
  • Pain aggravated by food or oral fluids
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11
Q

Signs of large bowel obstruction (6)

A
  • Intermittent colicky lower abdominal cramping
  • Lower abdominal distention
  • Minimal or no vomiting
  • Obstipation or ribbon-like stools
  • Blood in stools
  • Metabolic acidosis -(due to obstruction at end of small intestine and lower in intestinal tract leading to loss of alkaline fluids) - (not always present)
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12
Q

Diagnostics and labs for bowel obstruction (5)

A
  • Abdominal CT/MRI scan
  • Endoscopy (Sigmoidoscopy or Colonoscopy)
  • Exploratory laparotomy (Ex-Lap)
  • WBC - normal unless infarction, gangrene or strangulated
  • Electrolytes (low Na, Cl, K; high hct and BUN in small bowel; no major imbalances in large bowel obstruction)
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13
Q

Management of bowel obstruction (8)

A
  • NPO
  • NGT to decompress the bowel
  • IVF replacement b-c risk for f/e imbalance
  • TPN if bowel nonfunctional
  • Comfort/pain (Opioids can worsen so avoid if possible)
  • Enema (hydrostatic enema for intussusception
  • digital Impaction removal if lower colon (order needed to remove)
  • Colectomy may be needed
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14
Q

Failure to rescue problems for Intestinal obstruction (4)

A
  • Fecal Impaction
  • Peritonitis (infection of peritoneal cavity)
  • Septic shock
  • Intra-abdominal pressure (Acute compartment syndrome)- esp if strangulated
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15
Q

NGT Decompression: Nursing Care (8)

A
  • Monitor drainage and gastric output q4h
  • Ensure NGT patency (function and irrigate w/ NS) q4h
  • Verify tube placement: X-ray, pH strips q4h
  • Maintain the patient on NPO status
  • frequent mouth and nares care
  • semi-Fowler’s position
  • Secure tube to gown
  • DO NOT USE TUBE FOR ORAL INTAKE
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16
Q

Risk factors for colon cancer (7)

A
  • High-fat diet (Red meats)
  • Low-fiber diet (High fiber diet = prevention)
  • Family history of colorectal cancer
  • History of Crohn’s, Ulcerative Colitis, H. Pylori, Irritable bowel syndrome
  • smoking
  • obesity and inactivity
  • heavy alcohol use
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17
Q

Colorectal Cancer: Physical Assessment signs (7)

A
  • Anemia
  • Rectal bleeding
  • Change in bowel habits (Constipation, Diarrhea, stool texture, stool size, melena)
  • Vomiting
  • Abdominal discomfort or fullness
  • unintentional weight loss
  • Abdominal mass (late finding)
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18
Q

Colorectal Cancer: Diagnostics (3)

A
  • CBC (low hct/hgb = anemia)
  • Imaging (CT, MRI)
  • Tumor, nodes, metastasis classification (staging)
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19
Q

Colorectal Cancer Screening

Sigmoidoscopy -1
Colonoscopy - 4

A

Sigmoidoscopy
*Visualization and removal of lesions/polyps of the lower colon using a fiberoptic scope

Colonoscopy
*High sensitivity & specificity so definitive for colorectal cancer
*pre-cancerous polyps/lesion can be removed and biopsy done during procedure
*Start at 50 yrs if no family hx
* clear liquids prior to test (no red, purple, or orange dyes)

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20
Q

Double-contrast Barium Enema

Indication (2)
Procedure (3)
Nursing Care (3)

A

Indication: Colon cancer screening, differentiate UC and crohn’s disease

Procedure
*Examines the entire length of the bowel (detects half of all large polyps)
*Barium is swallowed as liquid or solid
* if abnormal, may need colonoscopy for suspected colon cancer

Nursing care
- Need to void afterwards for elimination of contrast dye
- NPO prior to procedure
- Expect light colored stools (barium is light chalk colored)

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21
Q

Colon Cancer Screening: Fecal Occult Blood test

Procedure (2)
Patient education (2)
Next steps

A

Procedure
- collected on card or in cup
- 2-3 separate stool samples needed on 3 consecutive days

Patient Education
- Avoid aspirin, vitamin C, iron, red meat for 48 hrs before test
- Avoid NSAIDs, corticosteroids, anticoagulants before test

Next steps
- if positive, need colonoscopy to diagnose b-c simply says GI bleeding present

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22
Q

Colostomy

What is it?
Indications (3)
Nursing care (4)

A
  • removes the sigmoid colon, rectum, and anus through combined abdominal and perineal incisions

Indications: tumor, diverticulitis, bowel obstruction

Nursing Care
- NGT decompression until peristalsis returns post-op
- examine stoma, skin around stoma
- Assess the pouch system for proper fit and signs of leakage
- Assess for signs of complications (unusual bleeding OR ischemia/necrosis (dark red, purplish, or black color; dry stoma)

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23
Q

Stomas: Expected Findings (5)

A
  • should be red pink, painless (black or purple = bad)
  • Protrudes 3 cm from abdominal wall (prolapse if more and treat like evisceration)
  • Functions in 2-3 days
  • heals in 2 months
  • Surrounding skin around should be intact, smooth, w/o redness or excoriation (no folliculitis or dermatitis)
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24
Q

Stomas: Patient education (4)

A
  • Use barrier skin cream
  • Empty pouch when 1/3 to 1/2 full
  • Assess stoma and change wafer and pouch weekly (wafer 1/8th wider than stoma)
  • Caution w/ high fiber foods b-c can cause gas and odor
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25
Q

Ulcerative Colitis: Drug Therapy

Aminosalicylates (5-ASA) – Sulfasalazine

Action
Patient education (3)

A

Action: metabolized by intestinal bacteria into 5-ASA which provides antiinflammatory effects and sulfapyridine

Patient education
* Take folic acid supplement b-c Sulfasalazine reduces its absorption
* Thiazide diuretic may be contraindicated
* Avoid if sulfa allergy

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26
Q

Ulcerative Colitis: Drug Therapy

Glucocorticoids (ex. prednisone, prednisolone, budesonide (preferred))

Use
Side effects (5 w/ long-term)

A

Use: antiinflammatory during acute flares

Side effects of long-term use: hyperglycemia, osteoporosis, PUD, increased infection risk, adrenal insufficiency

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27
Q

Ulcerative Colitis: Drug Therapy

Biologic response modifiers (BRMs) (ex. infliximab)

Action
Side effect

A

Action: synergistic effect w/ steroids via igG monoclonal antibody to reduce activity of tumor necrosis factor (TNF) to decrease inflammation

Side effects: immunosuppression (pt should report any s/s of infection and avoid large crowds)

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28
Q

Ulcerative Colitis: Drug Therapy

Antidiarrheal drugs (ex. diphenoxylate hydrochloride, atropine sulfate, loperamide)

Use
Side effect

A
  • Use: symptomatic management w/ caution b-c can have opposite effect
  • Side effect: toxic megacolon (massive dilation of colon and colonic ileus leading to gangrene and peritonitis)
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29
Q

Ulcerative Colitis: Nutrition Therapy

What to do (2)
What to avoid (4)

A
  • If severe, NPO and then TPN if severely ill and malnourished
  • If less severe, drink elemental formulas (have components which reduce bowel stimulation)

Avoid
- caffeine and alcohol (may cause diarrhea and cramping)
- raw veggies and high fiber (can cause GI symptoms)
- lactose containing foods (poorly tolerated)
- GI stimulants ( carbonated beverages, pepper, nuts, corn, dried fruits, smoking)

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30
Q

Complications of Ulcerative Colitis

  • Acute (6)
  • Long-term (3)
A

Acute
- Abscesses in ulcers (pockets of infection)
- Peritonitis
- Bowel Perforation (stool goes in abdominal cavity)
- Bowel Obstructions due to edema, hyperemia, and mucosal thickening
- Toxic megacolon (massive dilation of colon leads to colonic ileus)
- GI Bleeds

Long-term
- Malabsorption leads to anemia and malnutrition
- Pernicious anemia (B12 deficiency)
- Colorectal Cancer (if > 10 yrs of UC)

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31
Q

Signs of GI Bleeding (6)

A
  • Hematochezia (bright red stools) – lower GI bleed
  • Melena (black, tarry, or dark red sticky stools)
  • Upper GI Bleed (Dark blood)
  • shock (low hct/hgb, low BP, high HR, weak pulses)
  • dizziness, confusion, syncope
  • vertigo
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32
Q

Peptic Ulcer Disease

What is it?
Transmission

A
  • Erosion of the mucosa of the stomach, esophagus or duodenum due to H. pylori neutralizing stomach acidity then exposing epithelium to gastric acid

Transmission
- via oral-oral OR fecal-oral route (water, food, saliva)

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33
Q

Signs of stomach perforation (3)

A
  • sudden sharp mid-epigastric pain spreads over abdomen (often radiates to right shoulder
  • peritonitis (infection w/ tender, rigid, boardlike abdomen AND rebound tenderness)- fetal position for relief
  • Shock manifestations (hypotension, tachycardia, dizziness, confusion)
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34
Q

Signs of PUD

General (5)
Failure to rescue (3)

A
  • Dyspepsia (sharp, burning or gnawing pain at epigastric or back; heartburn, NV)
  • GI bleedings (melena and hematemesis)
  • Sensation of abdominal pressure or fullness or hunger
  • Weight loss
  • pernicious anemia (r/t decreased intrinsic factor)

Failure to rescue
- Perforation
- hemorrhage
- pyloric obstruction (s/s metabolic alkalosis, NV due to stasis and gastric dilation)

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35
Q

Drug Therapy for PUD

Antacids (ex. Aluminum hydroxide and Magnesium hydroxide)

Actions
Precaution
Side effects (2)
Nursing Care (2)

A

Action: increase pH of gastric contents

Precautions
- CKD and CHF increase chance of toxicity w/ magnesium hydroxide

Side effects
- diarrhea w/ magnesium
- constipation w/ aluminum

Nursing Care
- give 1-2 hrs after meals and at bedtime
- give other drugs 2 hrs before or after

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36
Q

Histamine blockers (ex. Famotidine, Ranitidine)

Use (2)
Action
Nursing Care (2)

A

Use: PUD, heartburn,

Action: decrease gastric acid secretions via blocking H2 receptors in stomach

Nursing Care
- give w/ or w/o food
- give at bedtime

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37
Q

Drug Therapy for PUD

Proton pump inhibitors (ex. Omeprazole, Pantoprazole, Esomeprazole)

Action
Side effects (3)
Nursing Care (3)

A

Action: decreases production of gastric acid

Side effects (long term): fractures, pneumonia, C. diff

Nursing Care
- give 30 minutes before meals unless rabeprazole (for duodenal ulcers so give prior to morning meal)
- do not give IV PPIs w/ other drugs
- taper to prevent rebound activation w/ withdrawal

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38
Q

Antibiotics used for H. pylori (4)

A
  • Clarithromycin (monitor BUN)
  • Amoxicillin (monitor for NVD)
  • Tetracycline (take w/o meals; avoid dairy products and sunlight)
  • metronidazole (monitor for Nausea; avoid alcohol b-c disulfiram-like reaction
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39
Q

General Effects of HIV on host (2)

A
  • high viral load (>200) leads to infections
  • low T cell/CD4 count (<800) and poor functioning T-cells leads to opportunistic infections, leukopenia, lymphocytopenia
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40
Q

cART therapy: Immune reconstitution inflammatory syndrome (IRIS)

Cause (2)
S/s
Treatment

A

Cause
- Seen when CD4+ T-cell count rises, and immunity normalizes then becomes exaggerated
- Result of T-cell recognizing opportunistic infections (esp TB) and sounding alarm about them

s/s: inflammatory reaction (high fever, chills, maybe worsened disease)

Treatment: short-term therapy w/ corticosteroids (Ideally treat Opportunistic infections prior to starting cART)

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41
Q

CART therapy in HIV

Therapeutic Effect - 2
Preparation - 1

A

Therapeutic Effect
- controls viral replication to reduce viral load in 4 weeks and increases T-cell count
- U=U (undetectable viral load (< 200 for > 6 months) = untransmittable via sex)

Preparation
- genosure resistance paneling (determine hypersensitivity to drugs to determine what to use

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42
Q

CART therapy in HIV

Patient Education (5)

A
  • Do not stop taking drugs or change therapy once viral load decreases b-c drugs are not a cure
  • Must take drugs correctly 90% of time (9 out of 10 doses on time and correct) - Do not miss, delay, or take lower than prescribed dose
  • Drug resistance r/t missed doses causing new resistant viral particles (Once resistant to a drug, that drug no longer able to be used b-c resistant virus is archived indefinitely in body)
  • many drugs cause liver toxicity (report to HCP any jaundice, NV, abdominal pain)
  • If pregnant, check w/ HCP because some drugs cause birth defects but other drugs can help reduce transmission to baby
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43
Q

S/s of symptomatic HIV (9)

A
  • persistent fever
  • sore throat
  • rash
  • night sweats, chills
  • diarrhea
  • weight loss
  • fatigue
  • headache, muscle aches
  • lymphadenopathy
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44
Q

Stages of HIV (5)

A

Initial Exposure

Primary HIV (acute): flu-like symptoms within 4 weeks; antibodies in 1-6 months

Asymptomatic HIV (seropositive): infectious but no evidence except positive HIV antibody test

Symptomatic HIV: can be 10 yrs after initial exposure

AIDS: diagnosis made if T-cell count is ever < 200 OR less than 14% OR opportunistic infection (diagnosis remains forever)

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45
Q

HIV testing

3 generations of ELISA
Notes (3)

A

ELISA
1st generation (1980s): IgG
2nd generation (1991): IgG
3rd generation (1992): IgM & IgG

Note
* 1st-3rd gen need western blot after if positive b-c can indicate influenza as well
* takes 3 months for antibodies to appear after antigen
* takes 14-21 days for antibody to be detected and then 7 days for western blot to confirm

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46
Q

HIV testing: 4th Generation Testing (2010)

Process (3)
Timing (2)

A

Process
- Detects ANTIGEN & ANTIBODY via antigen/antibody immunoassay
- If positive, use antibody differentiation immunoassay
- If antibody differentiation immunoassay is negative or indeterminate, use nucleic acid test to determine if acute HIV infection (RNA present)

Timing
- detects HIV-IgM and IgG antibodies (positive in 21 days)
- detects presence of p24 antigen (HIV capsid protein which is positive in 14 days)

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47
Q

HIV Transmission

Routes (3)

A
  • Parenteral (needle sharing; contaminated equipment w/ blood)
  • Perinatal (vertical; from placenta due to contact w/ maternal blood and body fluids or breast milk)
  • sexual (genital, oral or anal b-c exposure to mucous membranes) - esp. anal or male-to-female
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48
Q

Secondary prevention: HIV (3)

A
  • one time screening for all adults b/w 15-65
  • annual screening for adults at high risk for HIV (man/man sex, nonmonogamus, parenteral drug users, relationships w/one HIV positive and one HIV negative partner; anyone diagnosed with STIs in the past 6 months)
  • prenatal screening for pregnant people
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49
Q

Primary Prevention: HIV (5)

A
  • If drug user, clean used needle w/ bleach for 30-60 seconds OR partake in needle-exchange program
  • Abstinence or mutually monogamous sex w/ noninfected partner
  • Wear dental dam
  • Use Water based lube w/ condom
  • Latex gloves for finger or hand contact w/ vagina or rectum
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50
Q

Pre Exposure Prophylaxis (PrEP) – ex. Truvada (tenofovir/emtricitabine) AND Discovy (emtricitabine/tenofovir)

Indication
Routine (2)
Concern
Testing (3)

A

Indication: use of HIV Antiretroviral drugs by HIV-uninfected adult to prevent infection

Routine
- once daily w/ prescription
- Protection starts after 7 days of consistent dosing (can miss one and be okay; if miss > 2, need to wait 7 days for protection again)

Concern: Black box warning for severe acute exacerbation of hep B

Testing
* Blood and urine testing plus liver and kidney function (test kidney q3 months)
* other STI tests, hepatitis test
* 4th gen HIV antigen/antibody testing to ensure HIV negative b-c not for HIV positive

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51
Q

Recommendations for Preventing HIV Transmission by Healthcare Workers (3)

A
  • Standard Precautions (gloves for body fluids)
  • If sharps related; first wash wound for 1 full minute then contact employee health
  • If you perform exposure-prone procedures, know your HIV antibody status.
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52
Q

Postexposure Prophylaxis (PEP)

Indication (2)
Routine (2)
Testing (2)

A

Indication: occupational exposure (sharps, body fluids of HIV positive pt w/ blood, broken skin or mucus membranes of HCP), nonoccupational exposure (consensual sexual exposure w/ person of unknown HIV status OR sexual assault)

Routine
- 3 drug regimen within 2-36 hrs of exposure for 28 days OR until HIV status negative
- no prescription needed

Testing
- Periodic HIV testing at 1, 3, and 6 months
- CBC, electrolytes, creatinine tests done 2 weeks after starting cART

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53
Q

HIV Complications: Neurological (4)

A

Neurological (HIV-associated neurocognitive disorder (HAND) and HIV-associated dementia complex (HADC)

  • s/s cognitive, motor, and behavioral impairments (confusion to dementia)
  • peripheral neuropathy (paresthesia and burning sensations, reduced sensory perception, pain, gait changes)
  • myopathy (leg weakness, ataxia, and muscle pain)
  • increased ICP (pupil size or reactivity change
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54
Q

HIV Complications

Cardiovascular
Skin (3)
Kidney

A

Cardiovascular: Disordered fat metabolism (elevated triglycerides and cholesterol) and diabetes increase risk for hypertension and atherosclerosis

Skin changes
* dry, itchy, irritated skin
* folliculitis, eczema, psoriasis possible
* petechiae or bleeding gums if low platelets

Kidney changes (minor glomerular injury to AKI to CKD or HIV-associated nephropathy (HIVAN)

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55
Q

HIV complications: Endocrine (5)

A

AIDS wasting syndrome (s/s diarrhea, malabsorption, anorexia, oral and esophageal lesions)

Gonadal dysfunction (Low testosterone in men and Irregular menses in women)

Body shape changes
* Lipodystrophy w/ old cART (s/s buffalo hump, large belly fat)
* Lipoatrophy (s/s wasted arms, face, legs; sunken cheeks)

Adrenal insufficiency – life-threatening (s/s fatigue, weight loss, NV, low BP, electrolyte disturbance)

Diabetes

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56
Q

HIV complications: malignancies (5)

A

Kaposi’s sarcoma
* r/t coinfection of HIV and human herpesvirus 8
* S/s: small, purplish-brown, raised lesions on skin and mucous membranes (mouth, throat, intestinal tract, lungs, lymph nodes) that are not painful or itchy
* Nursing care: assess #, size, location, if intact

Non-Hodgkin’s or Hodgkin’s lymphoma
* s/s: swollen lymph nodes, weight loss, fever, night sweats

Invasive cervical carcinoma and anal cancer
* r/t HPV leading to cervical and anal dysplasia
* Prevention: Cervical Pap testing q6 months or anal Pap test

Lung cancer
GI cancer

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57
Q

HIV: Viral load testing

Process (3)
Results (3)
Concern

A

Process
- Measures actual amount of HIV viral RNA particles in 1 mL of blood to measure therapy effectiveness
- positive within 10 days of exposure
- takes 14 hrs for test to process

Results
* Uninfected adult: no viral load
* Positive load: as little as 20 particles/mL or > 1 million particles/mL
* Higher the load, higher risk of transmission

Concern: some immune systems may suppress viral replication and cause false low; so 4th gen testing needed alongside viral load testing

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58
Q

HIV opportunistic infections: Protozoal (2)

A

Toxoplasma gondii (Toxoplasmosis encephalitis)
* Transmission: contact w/ cat feces or ingestion of infected undercooked meat
* S/s: subtle changes in mental status (confusion, speech), neurologic deficits (vision, seizures, gait), headaches, fever

Cryptosporidium (cyptosoporidiosis) ¬ - protozoal
* Intestinal infection w/ mild diarrhea to severe wasting (> 5 lb unplanned weight loss w/ electrolyte imbalance)

59
Q

HIV opportunistic infections: Viral (3)

A

Cytomegalovirus
- S/s: nonspecific (fever, malaise, weight loss, fatigue, swollen lymph nodes)
- For eye, impaired vision to blindness
- For GI, diarrhea, abdominal bloating and discomfort, and weight loss; adrenalitis, hepatitis, disseminated infection
- For CNS, encephalitis
- For respiratory, pneumonitis

Herpes simplex virus
* s/s: more widespread, longer duration, numbness or tingling 24 hrs prior to blisters in oral, perirectal, or genital area
* blisters rupture; fever, headache, pain, enlarged lymph nodes, malaise

Varicella-zoster virus (shingles)
* Seen in adults who had chickenpox previously
* S/s: chickenpox w/ rash and fever; pain and burning along nerve tract; headache; low fever; blisters w/ or w/o crusting

60
Q

HIV opportunistic infections: Bacterial (3)

A

Mycobacterium avium complex (MAC)
* Systemic infection of respiratory or GI tract
* s/s: fever, physical weakness, weight loss, malaise, swollen lymph glands or organ disease

Mycobacterium tuberculosis (Tuberculosis)
* Usually extrapulmonary disease sites
* s/s: cough, dyspnea, chest pain, fever, chills, night sweats, weight loss, anorexia
* Note: If T cell < 200 may not have positive PPD test (anergy) so need blood analysis w/ NAAT (automated nucleic acid amplification test) – results in 2 hrs

Pneumonia
* 2 or more bacterial pneumonia cases in 12 months is diagnostic for AIDS progression
* s/s chest pain, productive cough, fever, dyspnea

61
Q

HIV Opportunistic Infections: Fungal (4)

A

Pneumocystis jivorevi pneumonia (PCP) – fungal
* s/s: SOB, tachypnea, persistent dry cough, persistent low-grade fever, fatigue, weight loss, breath sounds (crackles)

Candida albicans
- Stomatitis or esophagitis (funny tasting food, mouth pain, difficulty swallowing, pain behind sternum)
- cottage cheese-like yellowish white plaques and inflammation
- vaginal (severe pruritus, perineal irritation; thick, white vaginal discharge)

Cryptococcus neoformans (Cryptococcosis)
* Debilitating meningitis
* s/s: fever, headache, blurred vision, NV, neck stiffness, confusion, seizures, malaise

Histoplasma capsulatum (Histoplasmosis)
* s/s: dyspnea, fever, cough, weight loss TO enlarged lymph nodes, spleen, liver

62
Q

Care of the Patient with Reduced Immunity (10)

A
  • Place the patient in a private room whenever possible.
  • clean bathroom at least once each day.
  • Limit the number of personnel entering the patient’s room.
  • Monitor vital signs, including temperature, every 4 hours.
  • Inspect the patient’s mouth and skin and mucous membranes (including the anal area) for the presence of fissures and abscesses; lungs sounds at least every 8 hours.
  • Inspect open areas such as IV sites every 4 hours for signs of infection and assess w/ strict aseptic technique
  • Change gauze-containing wound dressings daily.
  • Help the patient perform coughing and deep-breathing exercises.
  • Keep frequently used equipment in the room for use with this patient only (e.g., blood pressure cuff, stethoscope, thermometer).
  • Limit visitors to healthy adults.
63
Q

HIV: When to notify HCP (5)

A
  • Temperature > 100° F (37.8° C)
  • Persistent cough (with or without sputum)
  • Pus or foul-smelling drainage from any open skin area or normal body opening
  • Presence of a boil or abscess
  • Urine that is cloudy or foul smelling or that burns on urination
64
Q

HIV: Patient education w/ low WBC (T-cell < 800) - 11

A
  • Avoid crowds and other large gatherings of people.
  • Do not share personal articles such as toothbrushes, toothpaste, washcloths, or deodorant sticks.
  • If possible, bathe daily, using an antimicrobial soap. If total bathing is not possible, wash the armpits, groin, genitals, and anal area twice a day with an antimicrobial soap.
  • Clean your toothbrush at least weekly by either running it through the dishwasher or rinsing it in liquid laundry bleach (and then rinsing out the bleach with hot running water)
  • Wash your hands w/ antimicrobial soap before you eat or drink, after touching a pet, after shaking hands with anyone, as soon as you come home from any outing, and after using the toilet.
  • Avoid eating or touching undercooked meat, fish, and eggs.
  • Wash dishes between use with hot, sudsy water or use a dishwasher.
  • Do not change pet litter boxes or play in gardens. If unavoidable, use gloves and wash hands immediately.
  • Avoid turtles and reptiles as pets.
  • Take your temperature at least once a day and whenever you do not feel well.
  • Avoid travel to areas with poor sanitation or primitive health care facilities
65
Q

Transient ischemic Attack

What is it?
Time
Implications (3)

A
  • Brief interruption in cerebral blood flow which when artery is blocked for short period of time;

Time
- Symptoms resolve within 30-60 minutes but may last up to

Implications
- no permanent deficits w/ TIA vs permanent deficits w/ stroke
- management for TIA is the same as for stroke b/c initial symptoms are the same as stroke
- TIA is a warning sign for stroke

66
Q

Transient ischemic Attack: ABCD tool for stroke risk

A
  • Age greater than or equal to 60 (risk increases with age)
  • BP > or equal to 140/90 mm Hg (either systolic or diastolic or both)
  • Clinical TIA features which increase stroke risk
    (unilateral weakness; carotid artery stenosis > 70%; new onset a-fib
  • Duration of symptoms (longer the TIA symptoms (> 4 minutes), greater the risk of stroke)
67
Q

Stroke

What is it?
Two main types

A
  • Interruption of perfusion to any part of the brain leading to permanent disabilities from infarction (inability of brain to get oxygen and glucose or dispose of CO2 and lactic acid)

Types
- ischemic strokes: due to occlusion or blockage of cerebral or carotid artery (Thrombotic (by clot) or emboli (dislodged clot))
- hemorrhage (ruptured vessel causes intracerebral, subarachnoid or subdural bleeding))

68
Q

Thrombotic vs embolic ischemic stroke

Location
Onset

A

Thrombotic
- Location: atherosclerosis of carotid and cerebral arteries esp bifurcation of carotid
- Onset: slow and gradual w/ gradual progression of deficits

Embolic
- Location: clot breaks off and travels to cerebral arteries esp. due to a-fib
- onset: sudden w/ immediate neurologic deficits

69
Q

Risk of Hemorrhagic stroke: vasospasm (3)

A

Vasospasms
- causes constriction of cerebral artery leading to decreased blood flow at distal areas
- can lead to subsequent strokes or seizure activity due to ischemia to cerebral tissue
- within 4-14 days after stroke occurrence

70
Q

6 Causes of Hemorrhagic stroke

A
  • cocaine (spasms of cerebral artery)
  • HTN
  • aneurysm (abnormal blister or ballooning of an artery causing excessive pressure and weakening of wall causing vulnerability to bleeding)
  • congenital arteriovenous malformation (angled collection of malformed, thin-walled, dilated vessels w/o capillary network which may rupture and cause bleeding in subarachnoid space)
  • Head trauma
  • Increased ICP
71
Q

9 Risk factors for stroke

A
  • a-fib r/t decreased perfusion causing clot
  • other Heart conditions (MI, prosthetic heart valve, heart valve disease, endocarditis, atherosclerosis, hyperlipidemia)
  • Diabetes mellitus
  • Hypercoagulability
  • Smoking
  • Heavy alcohol use
  • Oral contraceptives
  • Obesity
  • High fat diet
72
Q

Diagnostics for Stroke (3)

A
  • Cerebral angiography (arteriography)
  • Imaging: CT, MRI
  • Coagulation Studies: Prothrombin time/ international ration (PT/INR); Promboplastin (PTT)
73
Q

Medical Management: Stroke

Anticoagulants (ex. heparin, enoxaparin, warfarin, clopidogrel, aspirin)

Implications (2)

A

Implication
- high risk drugs that can cause bleeding included IC hemorrhage
- aspirin (325 mg enteric coated) given within 24-48 hours of onset of stroke

74
Q

Medical Management: Stroke

Nimodipine (CCB)
- Implication (2)

A

Implication
- relaxes smooth muscles of vessel walls
- given to reduce incidence and severity of vasospasm rather than for HTN

75
Q

Medical management: Stroke

Surgical (2)

A
  • for AVM/Aneurysm, Surgical resection, Clip, or Coil
  • for Clot Removal, Embolectomy
76
Q

Medical management: stroke

Alteplase (TPA; fibrinolytic)
- Nursing care (6)

A
  • informed consent needed
  • given within 45 min of ED arrival
  • nurse monitor vitals before, during, and after admin (esp. BP) - q10-15 min during; q30 for 6 hrs after; q1h for 24 hr
  • If BP > 185/110 mm Hg, give IV antihypertensive (labetolol) before and throughout alteplase admin to maintain BP < 185/110 mm HG
  • avoid other invasive tubes (NG or catheters) until pt stable to prevent bleeding - 24 hrs
  • discontinue if NV, severe headache or severe HTN
77
Q

Medical management: stroke

Alteplase (TPA; fibrinolytic)
- Time (2)
- Risk

A

Time
- give within 3 hrs of initial stroke symptoms to reduce severity of neurological deficits in ED
- can be given in 4.5 hrs sometimes

Risks
- bleeding esp IC hemorrhage

78
Q

6 groups that cannot get fibrinolytics within 4.5 hrs

A
  • Age older than 80 years
  • Anticoagulation therapy regardless of INR
  • Imaging evidence of ischemic injury w/ > 1/3 of the brain tissue supplied by the middle cerebral artery
  • Baseline NIHSS score > 25
  • History of both stroke and diabetes
  • Evidence of active bleeding
79
Q

FAST for Stroke

A

Facial Drooping
Arm Weakness
Speech Difficulty
Time to call 911

80
Q

Acute management of stroke (3)

A
  • seen within 10 minutes in ED for stroke like symptoms (hx should not delay treatment)
  • glasgow and NIHSS assessments done routinely for patients admitted w/ stroke
  • Rule out pathophysiological causes (hypoxia and hypoglycemia)
81
Q

Acute symptoms of Stroke (7)

A
  • confusion (trouble speaking or understanding others)
  • numbness or weakness of the face, arm
  • trouble seeing in one or both eyes
  • dizziness, trouble walking, or loss of balance or coordination
  • severe headache with no known cause (esp. aneurysm r/t)
  • embolic stroke: new-onset heart murmur, dysrhythmias, HTN
  • hemorrhage subarachnoid: NV, photophobia, stiff neck, CN deficits
82
Q

Symptoms of right-sided Stroke (5)

A
  • Unilateral neglect or inattention r/t hemianopsia
  • Lack of proprioception/body sense (unable to distinguish left/right or up/down)
  • problems w/ depth and distance perception
  • Disoriented to time and place
  • Personality changes (impulsivity and poor judgment)
83
Q

Symptoms of Left-sided Stroke (4)

A
  • deficits in analytical skills
  • speech deficits (Aphasia (receptive, expressive or mixed), Dysarthria)
  • Apraxia (slow, cautious, hesitant behavior style)
  • personality changes (lacks initiative and anxious)
84
Q

Neurological Status: When to notify HCP (4)

A
  • decreases of 2 or more points on Glasgow coma scale
  • posturing (flaccid or extension)
  • pinpoint, dilated or nonreactive pupils
  • sudden changes in mental status (earliest sign of change in neurological status)
85
Q

Glasgow Coma Scale: Eye opening

A

Spontaneous (4)
To sound (3)
To pain (2)
None (1)

86
Q

Glasgow Coma Scale: Motor response

A

Obeys commands - 6
Localizes pain - 5
Normal flexion (withdrawal) - 4
Abnormal flexion (decorticate) - 3
Extension (decerebrate) - 2
None - 1

87
Q

Glasgow Coma Scale: Verbal response

A

Oriented (5)
Confused conversation (4)
Inappropriate words (3)
Incomprehensible sounds (2)
None (1)

88
Q

Stroke: Communication deficits (4)

A
  • facial drooping
  • expressive/Broca’s aphasia- understands spoken and written words, but unable to speak or write (can read)
  • receptive/Wernicke’s - unable to understand spoken or written word; can talk but no logical meaning
  • dysarthria (slurred speech r/t muscle weakness or paralysis)
89
Q

Stroke: Nursing care for Communication deficits (7)

A
  • Present one thought in a complete sentence
  • give one-step command
  • Face client and speak slowly NOT loudly
  • Repeat names of objects used on routine basis
  • Avoid yes/no questions b-c - patients may give automatic but incorrect responses to yes/no question
  • Use alt communication (flash cards, computer, picture or communication board)
  • do not rush patient when speaking
90
Q

Stroke: Motor deficits (5)

A
  • right hemisphere = hemplegia to left side of body
  • left hemisphere = hemiplegia to right side of body
  • decreased blood flow to brainstem = total paralysis (quadriparesis)
  • Weakness (facial droop, arm or leg drift, hand grasp)
  • Ataxia (lack of muscle control and coordination affecting gait, balance, and ability to walk)
91
Q

Stroke: Nursing care for mobility deficits (5)

A
  • VTE protocol (SCDs, position changes, ambulation)
  • assess patient’s ability to perform ADL in home-setting
  • be aware of patient’s extremities (do not pull)
  • position arm on pillow to prevent shoulder dislocation/subluxation
  • instruct all staff working with patient about any deficits in mobility to prevent harm to patient (no pulling affected extremity)
92
Q

Stroke: Nursing Care for Swallowing deficits (8)

A
  • Maintain NPO until SLP screen
  • Assess for gag reflex w/ small liquid
  • Assess mouth for increased drooping/drooling
  • Position patient upright before feeding/eating
  • Check diet orders (soft, mechanical soft thickened liquids) b-c thin cause more coughing)
  • Place food in back of mouth to prevent trapping in cheek
  • Monitor for s/s of aspiration (coughing, dyspnea, crackles)
  • stop feeding if patient coughs
93
Q

Stroke: Sensory deficits

Sensation - 3
Visual - 6

A

Sensation
- Numbness (Decreased sensation)
- Unilateral Neglect (unaware of affected side)
- vertigo

Visual (r/t brainstem damage)
- Ptosis (eyelid drooping)
- Hemianopsia (blindness in half of visual field)
- Nystagmus
- tunnel vision
- diplopia (double vision)
- blurred

94
Q

Stroke: Nursing care for sensory deficits

Visual - 4
Memory - 2

A

Visual
- If pt has diplopia (double vision), patch over affected eye and change q2-4 hrs
- place objects in visual field including yourself
- If hemianopsia, patient should turn head back and forth to scan full visual range
- patient should dress affected side first

Memory
- Establish structured, repetitious, and consistent routine
- If memory problems, orient pt to month, year, day of week, and circumstances surrounding hospitalization

95
Q

Stroke: Major complication

Increased ICP
- General Signs and symptoms - 7

A
  • Increased restlessness, irritability, and confusion
  • Headache
  • Projectile NV
  • Systolic BP >180 mm Hg /Diastolic BP > 110 mm Hg (OR sudden increase in BP
  • Change in speech pattern, dysarthria, aphasia
  • Sensorimotor changes (CN dysfunction, Ataxia)
  • Seizures (usually within first 24 hours after stroke)
96
Q

Stroke: Major complication

Increased ICP
- earliest sign - 1
- Late signs - 3

A

Earliest sign
- Decreased LOC– earliest indicator

Late signs
- Pupillary changes: dilated and nonreactive pupils (“blown pupils”) or constricted and nonreactive pupils (very late sign)
- Cushing triad (very late sign): Severe HTN, Widened pulse pressure, Bradycardia
- Abnormal posturing (very late sign): Decerebrate or Decorticate

97
Q

Stroke: Major complication

Increased ICP
- Management - 7

A
  • Elevate HOB to 30 degrees
  • Maintain head and body in midline position (hip or neck flexion = increased ICP_
  • Avoid clustering activities
  • Maintain quiet environment
  • Decrease light esp if photophobia
  • give oxygen if hypoxic esp prior to suctioning
  • Monitor LOC, BP, heart rhythm, O2, glucose, temp and notify HCP of sig. changes
98
Q

Stroke: TJC core measures (7)

A
  • VTE prophylaxis
  • Discharge with antithrombotic therapy
  • Discharge with anticoagulation therapy for atrial fibrillation/flutter
  • Antithrombotic therapy re-evaluated by end of hospital day 2
  • Discharge on statin medication
  • Stroke education provided and documented
  • Assessment for rehabilitation based on individual needs and functional status
99
Q

Nursing Care during seizure (8)

A
  • stay with patient and remain calm
  • prevent aspiration and keep airway clear (side-lying)
  • Make note of seizure (date, time, duration; characteristics)
  • call for another RN to get the antiepileptic drugs
  • Do not force anything into the patient’s mouth.
  • Remove any objects or restrictive clothes that might injure the patient.
  • Suction oral secretions if possible without force.
  • Do not restrain or try to stop the patient’s movement; guide movements if necessary.
100
Q

Antiepileptic drugs (ex. phenytoin, carbamazepine, valproic acid, gabapentin, levetiracetam)

  • major side effects (4)
  • things to monitor (4)
A

Major side effects
- liver dysfunction
- leukopenia
- gingival hyperplasia and damage (need frequent oral care)
- osteoporosis (esp. postmenopausal

Monitoring
- CBC, BMPs, liver enzymes, and blood levels of drugs regularly (tolerance develops w/ age)

101
Q

Antiepileptic drugs (ex. phenytoin, carbamazepine, valproic acid, gabapentin, levetiracetam)

Patient education (5)

A
  • ask HCP before taking any drugs (Oral contraceptives, OTC drugs)
  • wear medical identification bracelet, necklace, ID card
  • Avoid alcohol and excessive fatigue.
  • Avoid warfarin and phenytoin
  • Avoid grapefruit juice b-c can increase chance of drug toxicity
102
Q

Seizure precautions (3)

A
  • Oxygen/suctioning w/ airway at bedside
  • IV access for PRN AEDs (diazepam, lorazepam, phenytoin)
  • Never insert tongue blade into patient’s mouth (b-c can lead to chipped teeth and aspiration of fragments
103
Q

Seizure: Major complication

Status Epilepticus
- what is it?
- treatment (6)

A
  • prolonged seizure lasting longer than 5 minutes OR repeated seizures over 30 minutes (can lead to death if > 10 minutes)

Treatment
- Oxygen
- airway
- large bore catheter IV for NS (only fluid compatible w/ phenyotin)
- IV push lorazepam or diazepam
- IV phenytoin and fosphenytoin to prevent further seizures or cardia arrests
- rapid response team, provider notified and put in ICU

104
Q

Negative Feedback of Adrenal Gland (2 pathways)

A

Stress -> CRH (from hypothalamus) -> ACTH (pituitary gland) -> cortisol (adrenal gland) -> Immune system function, metabolism

Low blood volume -> Angiotensin II -> Aldosterone (Adrenal gland) -> Na and water reabsorption, K reabsorption

105
Q

Adrenal Insufficiency: S/s

Neuromuscular - 2
GI - 4
Skin - 3
Cardiovascular - 3

A

Neuromuscular
- Profound fatigue/weakness
- joint/muscle pain

Gastrointestinal
- Weight loss/anorexia
- decreased gastric acid production
- NVD, constipation
- salt craving (dehydration)

Skin
- Bronze pigmentation
- decreased hair, axillary, body (r/t loss of androgens)
- vitiligo (primary autoimmune) r/t destruction of melanocyte

Cardiovascular
- Vascular collapse
- anemia
- hypotension

106
Q

Labs: Adrenal Insufficiency (8)

A
  • cortisol (decreased)
  • ACTH (varies- may be decreased or normal)
  • hypoglycemia (sweating, headaches, tachycardia, tremors)
  • hyponatremia
  • hyperkalemia (dysrhythmias w/ irregular HR)
  • hypovolemia
  • hypercalcemia
  • Kidney: decreased GFR, high BUN
107
Q

Medical management: Glucocorticoids

Ex. Cortisone, Hydrocortisone, Prednisone, Fludrocortisone (mineralocorticoid))

Nursing Implications (7)

A
  • take w/ meals to avoid gastric irritation.
  • increase dose when ill or stressed
  • Divided doses given (2/3 in morning and 1/3 at 6pm to mimic normal release of hormone)
  • Do not confuse prednisone w/ prednisolone which is more potent
  • may need sodium restriction
  • Weigh yourself daily and keep a record to show your primary HCP
  • wear your medical alert bracelet or necklace.
108
Q

Emergency care: Adrenal Insufficiency

  • Hormone replacement - 3
  • Hyperkalemia management - 5
  • Hypoglycemia - 3
A

Hormone Replacement
- Start rapid infusion of NS or D5NS
- corticosteroids (cortisone, hydrocortisone, prednisone) bolus then continuous
- H2 histamine blocker (e.g., cimetidine) IV for ulcer prevention.

Hyperkalemia Management
- Administer insulin in units equal to the same number of mg of extra dextrose in NS IV to shift potassium into cells.
- Give potassium binding and excreting resin.
- Give loop or thiazide diuretics.
- Avoid potassium-sparing diuretics, as prescribed.
- Monitor for hyperkalemia (slow heart rate; heart block; tall, peaked T waves; fibrillation; asystole).

Hypoglycemia Management
- Administer IV glucose
- Prepare to administer glucagon as needed and prescribed
- Monitor blood glucose level hourly

109
Q

Hypercortisolism: S/s

GI - 2
Integumentary - 5
Cardiovascular - 2

A

GI
- Increased appetite
- GI distress r/t increased acid

Integumentary
- Bruises and Petechiae (r/t fragile capillaries)
- Reddish-purple striae r/t destruction effect on collagen
- Thin or translucent skin
- acne
- Hirsutism (increased body and facial hair) or male-pattern baldness

Cardiovascular
- HTN
- dependent edema

110
Q

Hypercortisolism: S/s

Musculoskeletal - 3
Immune - 3

A

Musculoskeletal
- Bone density loss (osteoporosis; decreased height and vertebral collapse)
- Muscle atrophy (thin extremities)
- aseptic necrosis of femur

Immune
- Increased risk for infection (reduced WBC, macrophage activity, antibody synthesis)
- poor wound healing
- reduced inflammatory chemicals (histamines) and cytokines (less reaction)

111
Q

Hypercortisolism: S/s

Reproductive - 2
Psychosocial -2
General - 5

A

Reproductive
- For males, gynecomastia
- For females, oligomenorrhea, clitoral hypertrophy

Psychosocial
- Personality changes
- CNS irritability

General
- Thin arms r/t increased tissue breakdown
- Weight Gain r/t increased total body fat (dependent edema)
- Truncal Obesity
- Moon Face
- Buffalo Hump

112
Q

Labs: Hypercortisolism/Cushing (5)

A
  • cortisol (increased)
  • ACTH (excess if pituitary)
  • hypervolemia (bounding pulse, JVD, crackles, peripheral edema, reduced urine output, urine specific gravity < 1.005, Pulmonary edema, HF)
  • hypernatremia
  • hyperglycemia
113
Q

Hypercortisolism: Nutrition Therapy (4)

A
  • High calorie diet, high protein
  • Increased amount of calcium and vitamin D (for bone density) (Ex. Milk, cheese, yogurt, green leafy and root vegetables)
  • Avoid caffeine and alcohol which increase GI ulcer risk and reduce bone density.
  • Avoid smoking, fasting, NSAIDs, salicylates b-c cause gastric irritation.
114
Q

Hypercortisolism: Restoring fluid volume balance (4)

A
  • Monitor for hypervolemia q2h
  • Fluid and Na restriction (usually no added salt)
  • Monitor I & O, weight (1 lb. of weight after first ½ lb. = 50 mL of retained water)
  • Weight at same time w/ same clothes each day prior to breakfast
115
Q

Drug management: Cushing

  • Steroidogenesis inhibitors (1)
    Ex. Metyrapone, aminoglutethimide, ketoconazole, mitotane, etomidate, cyproheptadine
  • Mifepristone (3)
  • Pasireotide (2)
A

Steroidogenesis inhibitors
- Action: interfere w/ ACTH production or adrenal hormone synthesis for temp relief

Mifepristone
- Indication: pts w/ increased ACTH production, type 2 DM, and no response to other drugs
- Action: synthetic steroid that blocks glucocorticoid receptors
- Contraindicated in pregnancy b-c blocks progesterone receptors.

Pasireotide
- Indication: pts w/ hypercortisolism r/t pituitary adenoma
- Action: subQ admin which binds to somatostatin receptors on adenoma to inhibit tumor production of corticotropin -> decreases cortisol production in adrenal gland

116
Q

Surgical Care: Adrenalectomy

  • Preoperative (5)
A
  • Correct f/e balance and hyperglycemia
  • Cardiac monitoring r/t potassium imbalance
  • To prevent falls, raise top side rails, encourage pt to ask for assistance when getting out of bed.
  • High-calorie high protein diet
  • Glucocorticoids given before and throughout surgery to prevent adrenal crisis.
117
Q

Surgical Care: Adrenalectomy

  • Postoperative (4)
A
  • Monitor ICU for VS, central venous pressure, pulmonary wedge pressure, I & O, daily weights, serum electrolytes
  • Assess q15 for shock (hypotension, rapid, weak pulse, decreased urine output)
  • Lifelong glucocorticoid r/t bilateral adrenalectomy w/ glucocorticoid and mineralocorticoid
  • Two yrs of glucocorticoids if unilateral adrenalectomy to give remaining adrenal gland time to increase hormone production.
118
Q

Hypercortisolism: Prevent skin breakdown

Nursing care (5)

A
  • Prevent skin breakdown (pressure-relieving devices, turn q2h, pad bony prominences)
  • assess pressure areas daily (coccyx, elbows, hips, heels)
  • Assess skin for redness, excoriation, breakdown, edema.
  • Keep skin clean, dry thoroughly after washing,moisturize
  • Use soft toothbrush and electric shaver.
  • Use tape sparingly and remove carefully.
119
Q

Hypercortisolism: GI ulcers

Causes (3)
Drugs (3)

A

Cause of GI bleeding
* Cortisol inhibits production of thick, gel-like mucus that protects stomach lining.
* Cortisol decreases blood flow to stomach.
* Cortisol triggers release of excess hydrochloric acid

Drugs
* Antacids- buffer stomach acids (take around the clock not PRN)
* H2 blockers (cimetidine, famotidine, nizatidine) – decreases secretion of hydrochloric acid.
* PPIs (omeprazole, esomeprazole) – inhibit gastric proton pump to prevent formation of hydrochloric acid.

120
Q

Hypercortisolism: Preventing Infection

Nursing care (7)

A
  • Anyone w/ URI needs mask prior to entering pt.’s room.
  • Assess for s/s of infection (may be masked w/ only low-grade fever or urinary symptoms)
  • Monitor CBC w/ diff esp. neutrophils daily.
  • Inspect mouth every shift for lesions and mucosa breakdown.
  • Assess lungs for crackles, wheezes, reduced breath sounds q8h.
  • Perform pulmonary hygiene 2-4 hrs (deep breaths and incentive spirometer hourly when awake)
  • Take vitals q4h (a temp change of > 1F or 0.5C is significant)
121
Q

S/s: Hypothyroidism

Reproductive - 3
Cardiovascular - 4
CNS - 4

A

Reproductive
- Menstrual disturbances (amenorrhea, prolonged, anovulation)
- impotence in men
- decreased libido

Cardiovascular
- Bradycardia
- dysrhythmias
- enlarged heart
- hypotension

CNS
- Decreased LOC (Slow intellectual functions, lethargy, somnolence)
- Apathy (dull-blank expression); depression
- hearing loss
- paranoia

122
Q

S/s: Hypothyroidism

Pulmonary - 3
GI - 4
Muscular - 4

A

Pulmonary Symptoms
- Hypoventilation
- Pleural effusion
- Dyspnea and decreased activity tolerance

GI
- Weight gain (decreased urine output)
- Constipation
- anorexia
- abdominal distention

Muscular
- Muscle aches and weakness
- Extreme fatigue
- decreased DTRs
- paresthesia (numbness and tingling)

123
Q

S/s: Hypothyroidism

Integumentary - 7
Metabolic - 2

A

Integumentary
- Myxedema (Non-pitting edema of hands/feet; facial puffiness, periorbital edema)
- Thick tongue and skin (slow speech and hoarseness)
- Dry skin (coarse and scaly)- cool, pale, yellow
- Hair loss (eyebrow hair loss) and receding hairline
- Thick dry, brittle nails and hair
- goiter (if TSH binds to thyroid cells)
- poor wound healing

Metabolic
- Decreased metabolism
- Cold intolerance (decreased body temp)

124
Q

Labs: Hypothyroidism (2)

A
  • Decreased T3 and T4
  • Elevated TSH (may be decreased or normal in secondary hypothyroidism)
125
Q

Medical management: hypothyroidism

Levothyroxine sodium (synthroid)
- Adverse effects (3)
- Patient education (4)

A
  • Adverse effects of high dose: severe HTN, heart failure, MI

Patient education
* Report chest pain or chest discomfort immediately (* Start on lowest dose possible esp. if severe hypothyroidism to prevent cardiac problems)
* Take levothyroxine exactly as prescribed.
* Monitor for s/s of hyperthyroidism.
* Take on empty stomach w/o food or drink for 30-60 mins

126
Q

Hypothyroidism: Nursing care

  • Improving gas exchange (4)
  • Preventing hypotension (2)
A

Improving Gas Exchange
- Observe and record rate and depth of respirations, O2 sat, breath sounds
- Apply oxygen if patient hypoxemic (ventilatory support if severe)
- Avoid sedating b-c can worsen gas exchange.
- If sedation needed, reduce dose b-c increased sensitivity to opioids and tranquilizers w/ hypothyroidism.

Preventing Hypotension
- Monitor BP, HR, rhythm, shock (hypotension, decreased urine output, change in mental status)
- Give lifelong thyroid hormone replacement (levothyroxine)

127
Q

Complication of Hypothyroidism: Myxedema

Manifestations (7)

A
  • Hyponatremia
  • Hypotension -> shock
  • Hypothermia
  • Hypoglycemia
  • Respiratory failure (major cause of death)
  • Reduced LOC and cognition -> coma
  • flabby heart muscle and increased chamber size (decreased cardiac output)
128
Q

Emergency care of myxedema coma

3 nonpharmacological
4 meds

A
  • Maintain a patent airway, mental status changes, VS (BP and temp) hourly
  • Start treatment quickly according to symptoms vs wait for lab confirmation.
  • Cover the patient with warm blankets.

Meds
- Replace fluids with IV normal or hypertonic saline
- Give levothyroxine sodium IV as prescribed (given via IV due to reduced GI motility and absorption)
- Give glucose IV as prescribed.
- Give corticosteroids as prescribed

129
Q

S/s: Hyperthyroidism (Graves)

Metabolism - 3
Eyes - 6
Musculoskeletal - 4

A

Metabolism
- Increased Metabolism
- Heat intolerance (low grade fever)
- Enlarged gland (goiter)

Eyes
- Exophthalmos (bulging, startled)
- blurry or double vision r/t pressure on optic nerve
- increased tears
- photophobia
- red conjunctiva
- eyelid or globe retraction/lag -> corneal ulcers if dry

Musculoskeletal
- Muscle wasting r/t negative nitrogen balance from protein breakdown
- Weight loss r/t increased fat metabolism
- tremors
- fatigue

130
Q

S/s: Hyperthyroidism (Graves)

Integumentary -5
GI - 3

A

Integumentary
- Fine-straight, soft, silky hair
- Pretibial myxedema (dry, waxy swelling of front surfaces of lower legs)
- Finger clubbing
- facial flushing and diaphoresis
- goiter

GI
- diarrhea
- enlarged spleen
- increased appetite

131
Q

S/s: Hyperthyroidism (Graves)

Reproductive - 3
Cardiopulmonary - 5
Neurological - 3

A

Reproductive
- Amenorrhea and decreased fertility
- Breast enlargement
- increased libido

Cardiopulmonary
- Increased systolic BP (r/t increased cardiac output, blood flow, stroke volume)
- decreased diastolic so widened pulse pressure
- Facial flushing
- rapid, shallow respirations
- chest pain (palpitations, dysrhythmias, tachycardia)

Neurological
- insomnia
- decreased attention span
- manic (emotional instability, restless, irritability

132
Q

Labs: hyperthyroidism (4)

A
  • Increased T3 and T4
  • Decreased TSH (high in secondary hyperthyroidism)
  • Increased thyroid-stimulating immunoglobulins (TSIs) and Thyrotropin receptor antibodies (TRAbS)- Grave’s
  • hyperglycemia (decreased glucose tolerance)
133
Q

Drug Management: Hyperthyroidism

Thionamide (ex. Methimazole, propylthiouracil)
- Action
- Side effects (4)
- Notes (2)

A

Action: decrease thyroid Hormone production via preventing iodide binding to thyroid gland

Side effects
* increased risk for infection
* hypothyroidism ( weight gain, slow heart rate, and cold intolerance)
* liver toxicity (darkening of the urine or a yellow appearance to the skin or whites of the eyes) – Mainly PTU
* birth defects - methimazole

Notes
- Delayed response b-c large amounts of stored thyroid hormones usually need to be released first.
- higher dose needed for PTU

134
Q

Drug Management: Hyperthyroidism

Propranolol
- Action

A
  • Action: slows SNS down (no effect on thyroid hormone)- relieve diaphoresis, anxiety, tachycardia, palpitations
135
Q

Drug Management: Hyperthyroidism

Saturated solution of potassium iodine (SSKI)
- Action
- Side effects (2)
- Notes (2)

A
  • Action: stops synthesis of thyroid hormone via stopping blood flow to thyroid gland

Side effects
- hypothyroidism
- iodism (fever, rash, metallic taste, mouth sores, sore throat, GI distress)

Notes
- improvement in 2 weeks
- give thioamide first to prevent initial rise in thyroid hormone production

136
Q

Non Pharmacological nursing care: hyperthyroidism (8)

A
  • Measure apical pulse, BP, temp at least q4h.
  • Immediately report temp increase of 1 F or higher OR heart problems
  • Do not palpate goiter b-c can cause sudden release of excessive thyroid hormone and thyroid storm.
  • Quiet environment (rest, door closed, limit visitors, postpone nonessential care)
  • Reduce room temp b-c heat intolerance.
  • Ensure fresh pitcher of ice water.
  • Change bed linen whenever damp from diaphoresis.
  • Encourage patient to take cool sponge bath or shower several times a day.
137
Q

Medical Management: Hyperthyroidism

Radioactive iodine (RAI) Therapy - 3

A
  • RAI destroys some of cells that produce thyroid hormone
  • contraindicated in pregnancy b-c crosses placenta
  • internal radiation precautions (flush 3x, separate toilet)
138
Q

Complications of Thyroidectomy (5)

A
  • Hemorrhage esp 24 hrs post-op
    serosanguineous drainage = normal
  • Respiratory distress (s/s laryngeal stridor)
    need suction, emergency trach, oxygen
  • Laryngeal nerve damage (s/s hoarseness and weak voice)
  • Thyroid storm
  • Parathyroid gland injury (hypocalcemia and tetany) - need rescue calcium gluconate or calcium chloride
139
Q

Hypocalcemia symptoms (4)

A
  • Increased neuromuscular excitability; tingling, muscle spasm (particularly in hands, feet, and facial muscles), convulsions, tetany
  • intestinal cramping
  • hyperactive bowel sounds
  • prolonged QT interval -> cardiac arrest
140
Q

Total Thyroidectomy or Subtotal Thyroidectomy

Preoperative Care (5)

A
  • Monitor labs b-c treatment can induce hypothyroidism
  • Thionamide to induce euthyroid prior to surgery.
  • Iodine preparations to decrease thyroid size and vascularity (reduces risk of hemorrhage and thyroid storm)
  • Control HTN, dysrhythmias, tachycardia
  • High-protein, high-carbohydrate diet for weeks or days prior
141
Q

Total Thyroidectomy or Subtotal Thyroidectomy

Postoperative Care (6)

A
  • Monitor for complications (Monitor VS q15 minutes until stable then q30 minutes) – most important action (Temp increase of 1 F (1.8C) = thyroid crisis)
  • Assess level of discomfort and give pain meds.
  • Use pillow or hands to support neck and head (avoid neck extension)
  • Place in semi-fowler
  • Deep breath every 30 min to 1 hr.
  • Lifelong thyroid hormone replacement if total thyroidectomy
142
Q

Major complication of hyperthyroidism: Thyroid storm

Manifestations (5)

A
  • high fever
  • tachycardia
  • severe systolic hypertension
  • Other s/s: abdominal pain, NVD, anxious, tremors
  • Progressive s/s: restless, confused, psychosis, seizures, coma, death.
143
Q

Emergency care: Thyroid Storm

3 nonpharmacological
6 pharmacological

A
  • Maintain a patent airway and adequate ventilation.
  • Monitor vital signs every 30 minutes.
  • Provide comfort measures, including a cooling blanket.

Meds
- Give nonsalicylate antipyretics as prescribed.
- Correct dehydration with NS
- Give oral antithyroid drugs as prescribed: methimazole or propylthiouracil.
- Administer sodium iodide solution IV daily as prescribed.
- Give propranolol IV as prescribed, slowly over 3 minutes. The patient should be connected to a cardiac monitor, and a central venous pressure catheter should be in place.
- Give glucocorticoids as prescribed: hydrocortisone, prednisone, or dexamethasone.

Concepts 2 (4 decks)

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