exams 3 study guide Flashcards
Addisons Disease clinical manifestation
addison = adrenal insufficiency
- Bronze light pigmentation
- hyperkalemia
- hyponatremia
- anorexia
- nausea
- vomiting
- progressive weakness
- fatigue
- weight loss
- abdominal pain
- diarrhea
- headache
- Orthostatic hypotension
- salt craving
- joint pain
Addisons Disease health teaching
o If they feel sick, tell provider immediately
Flu like symptoms should be reported
o Corticosteroids, do not stop them—needs to be tapered
o Medical alert bracelet
o Signs and symptoms of too little or too many steroids
o Emergency kit—100mg hydrocortisone
Addisonian crisis
LIFE THREATENING
- insufficient or sudden sharp decrease in hormones
CAN SEE Hypotension Tachycardia Dehydration Fever Weakness Vomiting and diarrhea Pain
o Worry about irreversible shock—this can happen if you don’t address the above
NA down, K UP
- fatigue
- dehydration
- vascular collapse ( LOW BP)
- renal shut down
Lab findings of Addisons Disease
o Decreased sodium
o Increased potassium
o Decreased glucose
Cushings Disease loss of bone density
opposite of addisons - TOO MUCH HORMONES
o Make sure patient is safe
- Prevent falls
o Monitor calcium levels
o Weight-bearing exercise
Clinical manifestations of cushings disease
o Trunk obesity o Hirsutism—abnormal growth of hair on a person’s face and body o Buffalo hump o Face o Extremities would be thin o Muscle atrophy o Slow wound healing = ecchymosis, bruises, striae o Weight gain—Addison’s is loss o Acne o Back pain
diagnostics of cushings disease
o Urinary cortisol level
o Serum blood cortisol level
Both are increased
o ACTH level—abnormal
o Dexamethasone Suppression test—abnormal
o Electrolytes = Hyperglycemia, dyslipidemia, hypokalemia
nursing interventions of cushings disease
o Monitor vital signs o Daily weights o Monitor labs o Assess for S&S o Monitor things that upset the patient—stress is a problem o Rest! o Observe for mood swings o Protect for trauma o Monitor fluid balance
medical management of cushings disease
o Did they have surgery for pituitary?
- Hemorrhage
- Fluid and electrolyte imbalance
- Make sure patient has right amount of corticosteroid + knows side effects
o Body image
o Monitor for infection = they are prone because of disease and steroids
Kidney disease assessments of patients
- Abnormal vital signs—priority over other patients
- Labs: focus on potassium (3.4-5.9 mEq)
Nursing interventions: Acute Kidney Injury
o Fluid intake—intake and output o Anemic—monitor blood levels o Hyperkalemia—monitor labs o Dialysis—check the site o Vital signs—check skin and mouth
PERITONEAL DIALYSIS: worry about peritonitis, infection( catheter) -RISK FOR SEPSIS
teachings Acute Kidney Injury
Nephrotoxic drugs
- NSAIDS
- Antibiotics
- OTC medications—tell doctor (may be high in salt or other ingredients)
Chronic kidney disease teachings
o Keep a journal of Is and Os o Try not to get too fatigued o Walk around to prevent blood clots o Daily weights o Take meds as directed o Keep all medical appointments o May have HTN and diabetes—take meds
Chronic kidney disease labs
o Hyperkalemia o Hyperphosphatemia o Hypermagnesemia o Increased creatinine o Increased BUN o Sodium (increase, decrease or normal)—not on exam o GFR (glomerular infiltration rate)—DECREASED o Increased triglycerides cholesterol o ↑ BUN/creatinine o ↑ cholesterol, TRIG o ↓ RBCs (prone to anemia) o ↓ GFR
Chronic kidney disease medical management
o kayexalate—decrease K levels (NG or rectal, PO is preferred) o Fluid overload or deficit o Proper nutrition o Anemia—blood transfusion
- Careful with transfusion because of fluid overload
- Iron
o Calcium supplements
o Phosphate binders
o Vitamin D, Antihypertensive, Statins—if needed
Chronic kidney disease contraindcation medications
o IV Motrin—tell doc
- procaine
BOTH A NO NO
Chronic kidney disease electrolyte imbalances
o Hyperkalemia
o Hyperphosphatemia
o Hypermagnesemia
Peritoneal Dialysis: Assessment
o Look for infection
- Check catheter site for redness, swollen, warm
- Peritonitis won’t show on outside
o Monitor for hernia
o Lower back pain
o Bleeding
o If the patient has drainage that is smelly, cloudy—not a good sign
Hemodialysis: Nursing interventions
o Baseline weight = WEIGHT BEFORE AND AFTER
o Some meds need to be held = HTN meds, cardia (with dialysis may have hypotention)
o Give patient more protein (urea and creatinine removed)
Hemodialysis: patient concerns
o Are reserved and sad
They know it will help, but listen to them and answer questions and reassure them
o Understand this is a patient’s way of life
o Talk, talk, talk
Hemodialysis: meds patient taking/ diet
o They can take a lot of meds—some they can’t
o Antihypertensive drugs are held because they can make the patient more hypertensive
DIET: PROTEIN, EGGS HOEM TOAST
AV Fistula: Nursing care
o Ensure patency of av fistula = BRUITS (hear) or THRILL (feel) = teach patient how to feel them
o Auscultate for bruit/thrill
o No BP where fistula is
o Not to wear bracelets—may restrict blood flow to arm
o Do not carry bags—use shopping cart = NO PRESSURE ON ARM WITH FISTULA
o Do not sleep on the affected side
AV Fistula: complications
o Infection
o AV fistula may clot
o May bleed
o Let doctor know if any of the above happens
o Fingers are cold, hot, cyanotic—concerning
Kidney Transplant: Assessments
o Urinary output
o Cognizant about infection
o Pain management
Kidney Transplant: medication teaching
o How are they managing meds?
o Cannot skip
o Lifetime meds
o Cyclosporine/Neoral = Take it with chocolate milk!
use of glucocorticoids
o They may need to increase if surgery occurs, patient is in distress,
o Muscle atrophy and weakness
o Peptic ulcer disease
o Trunk Obesity
o Mood and behavior changes
o Steroids can increase glucose—fingerstick
Pulmonary Embolism:
RISK FACTORS
- DVT & Previous History of DVT
- Immobility or reduced mobility
- Surgery
- Malignancy
- Oral contraceptives/hormones
- Pregnancy/delivery
- Obesity
- Smoking
- Heart failure
- Clotting disorders
A Fib - Central Venous - Catheters
- Fractured long bone
Remember that it is highly related and associated with? DVT
This knowledge will need to be incorporated
Pulmonary Embolism: CLINICAL MANIFESTATION
- Varied and nonspecific! → Dependent on size and extent of emboli
- DYSPNEA → most common
- Tachypnea & Tachycardia
- Cough
- Chest pain
- Hemoptysis
- Crackles
- Wheezing
- Fever
- Syncope
- LOC changes
Diagnostic tests: pulmonary embolism
- ABG
- Chest X-Ray
- ECG
- Observing
- Troponin levels
- B-Type Natriuretic peptide
D-Dimer
- Elevated with any clot degradation
- False negs w/ small PE
Spiral (Helical) CT Scan:
- Most frequently used
- Requires IV contrast media
pulmonary embolism Treatment – considerations during treatmen
- pulmonary toilet = exercises to help clear airways of mucus and secretions
- Oxygen → mechanical ventilation
- Fluids
once resolved, patient will need to be on LONG TERM THROMBOLYTIC THERAPY FOR 3 MONTHS
Drug Therapy: for pulmonary embolism
- Analgesics
- Diuretics
- Anticoagulants (LMWH, IV Heparin, Warfarin)
- Fibrinolytics (Tissue plasminogen activator (tPA), Alteplase (Activase)
- Surgical interventions for pulmonary embolism
Pulmonary Embolectomy =
hemodynamic patients for whom thrombolytic therapy is contradindicated
- Inferior Vena Cava Filter = prevents migration of clots in pulmonary system
complications of pulmonary embolism
Pulmonary infarction
- Alveolar necrosis & hemorrhage
- Abscess
- Pleural effusion
Pulmonary hypertension
- Results from Hypoxemia associated w/ massive or recurrent emboli
- Right ventricular hypertrophy
Tuberculosis: transmission/precautions include
- Spread via airborne particles
- Transmission requires close, frequent or prolonged exposure
AIRBORNE ISOLATION
TUBERCULOSIS DIAGNOSTIC TESTS
- Tuberculin skin test (Mantoux test) → injected intradermally & assess in 48-72 hours
- POSITIVE > 15 mm induration in low risk individuals
- POSITIVE: 5 mm induration in
- Interferon-γ gamma release assays (IGRAs): = DETECT T CELLS
- chest x rays
- biological studies
Clinical manifestations of Tuberculosis
- Latent tuberculosis infection (LTBI) → asymptomatic
Pulmonary TB
- Takes 2-3 weeks to develop symptoms
- initial dry cough that becomes productive
- Constitutional symptoms: fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats
Late symptoms:
Dyspnea (unusual)
Hemoptysis (not common but advanced disease)
TREATMENT OF TUBERCULOSIS
Active disease: aggressive treatment
• Four drug regimen: isoniazid, rifampin (rifadin), pyrazinamide, ethambutol
Directly observed therapy (DOT)
• Noncompliance = main reason in treatment failure + multidrug resistance
• Requires watching patient swallow drugs
• Preferred strategy to ensure adherence
Latent TB infection: usually isoniazid for 6-9 months
Vaccine: not recommended except for very select individuals
o Interventions OF TUBERCULOSIS
Drug therapy to prevent/treat active disease
Monitor for compliance
Health promotion
Acute care = airborne isolation
Teach patient to prevent spread (hand hygiene + cover mouth)
clinical manifestation of COPD
Chronic cough or sputum production Dyspnea (usually prompts medical attn) Chest breathing (use of accessory & intercostal muscles + inefficient breathing) Underweight with anorexia Chronic fatigue Paroxysmal coughing (patient may faint or fracture ribs) Prolonged expiratory phase Wheezes Decreased breath sounds Barrel chest (increased A-P diameter) Tripod position Pursed lip breathing Polycythemia & cyanosis • Hypoxemia • Increased RBC production • Bluish-red color of skin
o Treatment – pharmacological and other interventions COPD
Drugs
• Short-acting bronchodilators (relax smooth muscles; improve ventilation in lungs)
o COPD with FEV < 60% LABA & inhaled corticosteroids
• Oral systemic corticosteroids
• Antibiotics
o Azithromycin (Zithromax)
• Severe COPD and chronic bronchitis = roflumilast (Daliresp)
Supplemental oxygen therapy
• Oxygen therapy to keep O2 sat >90%
• Complications: combustion, CO2 narcosis, O2 toxicity, absorptions atelectasis, infection
Surgical therapy
• Lung Volume Reduction Surgery
• Bronchoscopic lung volume reduction surgery
• Bullectomy
• Lung transplant
o Nursing interventions COPD
Health promotion • Smoking cessation • Evaluate for environmental or occupational irritants • Early detection, diagnosis, and treatment • Awareness of family hx. Acute care • Acute exacerbations, pneumonia, cor pulmonale, acute respiratory failure • Degree and severity of underlying respiratory problem should be assessed Ambulatory care • Teaching o Pulmonary rehab improve quality of life o Activity considerations Walk 15-20 mins a day 3x week o Sexual activity o Sleep o Psychosocial considerations Influenza virus vaccine Pneumococcal vaccine Respiratory & physical therapy • Breathing retraining • Effective coughing • Chest physiotherapy Postural drainage Percussion to move mucus Nutritional therapy • (eat 5-6 small meals a day) • Avoid foods that require a lot of chewing • Avoid exercise 1hr before and after eating
• Acute Respiratory Failure RISK FACTORS
Aging Smokers Poor nutrition Mismatch between ventilation and perfusion (V/Q mismatch) • COPD • Pneumonia • Asthma • Atelectasis • Result of pain • Pulmonary embolus Shunt • Anatomic shunt • Intrapulmonary shunt Diffusion limitation • Pulmonary fibrosis • ARDS • Lung disease • Hypoxemia present during exercise Alveolar hypoventilation • CNS disease • Chest well dysfunction • Neuromuscular disease CNS abnormalities • Drug overdose • Brainstem infarction • Spinal cord injuries Chest wall abnormalities • Flail chest • Kyphoscoliosis • Severe obesity • Fractures • Mechanical restriction • Muscle spasm Neuromuscular conditions • Muscular dystrophy • Guillain-Barre syndrome • Multiple sclerosis • Exposure to toxins • Muscle wasting
SIGN AND SYMPTOMS OF Acute Respiratory Failure
Mental status changes (often occur early) Tachycardia, tachypnea, mild HTN Cyanosis Rapid, shallow breathing pattern Tripod position Pursed-lip breathing Dyspnea Retractions Paradoxical breathing Diaphoresis Abnormal breath sounds
HOW TO TREAT Acute Respiratory Failure
Respiratory therapy
• oxygen therapy
• Mobilize secretion (effective coughing, chest physiotherapy, ambulation, airway suctioning, hydration, and humidification)
Augmented cough
Airway suctioning
Drug therapy
Nutritional therapy (maintain protein & energy stores)
ARDS risk factors
Direct or indirect lung injuries
sign and symptoms of ARDS
Dyspnea Tachypnea Cough Restlessness Decrease compliance Decreased lung volumes Decreased functional residual capacity Increasing work of breathing Tachycardia Diaphoresis Changes in mental status Cyanosis Pallor
o Red Flags to look out for ARDS
1.If the patient has systemic inflammatory response syndrome (SIRS)
2. Multiple organ dysfunction syndrome (MODS).
3. New or worsening respiratory symptom,
chest x-ray with new bilateral opacities, and a low PaO2/FIO2 (P/F) ratio
4.Hypercapnia which causes hypoventilation
5. ABGs indicates respiratory alkalosis caused by hyperventilation
WHAT TO DO? Endotracheal intubation and PPV
Chest tubes: What are they used for?
To remove air or fluid from pleural and/or mediastinal space
CHEST TUBE Assessment of different chamber, what’s good vs not good
Water-seal chamber
• Bubbling indicates air leak
• If air leak is a lot, intervention is needed
• Tidaling is normal (reflects change in pressure)
o If no tidaling suspect obstruction
Collection chamber
Suction chamber
This is an emergency
• Place distal end in sterile water to maintain water seal
We are concerned about respiratory distress
Measuring CHEST TUBE
Measure fluid level
Report >100mL/hr
Report fresh blood
If you drain more than 1.5L, obtain vitals to ensure patient is okay
Tracheotomy WHAT IS IT USED FOR
Surgically created stoma opening used to …
• Establish a patent airway
• Bypass an airway construction
• Facilitate secretion removal
• Permit long-term mechanical ventilation
• Facilitate weaning from mechanical ventilation
Patient limitations TRACHEOSTOMY
Speech limitation
• Alternative forms of communication (paper, pictures, visual alphabet)
Swallowing dysfunction
o Suctioning
Respiratory Acidosis
- pH under 7.35
- PaCo2 over 45
- Caused by: Hypoventilation & respiratory failure
Respiratory Alkalosis
- pH over 7.45
- PaCo2 under 35
- Causes: Hypoxemia & hyperventilation
Metabolic Acidosis
- pH under 7.35
- HCo3 under 22
- Caused by: Ketoacidosis, Lactic acid accumulation (shock), severe diarrhea, kidney disease
Metabolic Alkalosis
- pH over 7.45
- HcO3 over 26
- Causes: Prolonged vomiting or gastric suction
• First patient to see = Acute Respiratory Failure
