Final Flashcards
What is the primary function of ADH
to regulate fluid balance by regulating serum osmolality
Where does ADH come from?
Posterior pituitary
What happens to a pts serum osmolality if they become dehydrated?
It increases, above 300. Blood becomes thick/sludgey
What is a normal serum osmolality
275-295
What takes place when ADH is released?
water is reabsorbed into the renal tubules and urine becomes concentrated
What are three reasons ADH would be released in a normal person?
increased plasma osmolality
decreased fluid osmolality
hypotension
What are three reasons ADH would be INHIBITED?
decreased plasma osmolality
increased fluid volume
alcohol
What is the general idea of SIADH
overproduction of ADH - “cell swell”
A pt is admitted and the report you get includes a h/o malignant bronchogenic oat cell carcinoma. Which ADH impairment do you expect the pt to exhibit?
SIADH
What are causes of SIADH
severe head trauma, CNS tumors
meds (nicotine, tricyclic antidepressants, tegratol)
extended time on PEEP
oat cell carcinoma
What is the patho behind SIADH
the posterior pituitary releases ADH in spite of normal serum osmolality causing overhydration and low serum osmolality
What happens to serum osmolality & sodium with excessive ADH as in SIADH
they are both low.
What are some s/s of hyponatremia and when might you see them?
confusion, seizure, coma, death
SIADH as a result of overhydration
What findings do you expect to see from urine testing in a pt w SIADH
high osmolality, sodium, and specific gravity (> 1.030)
What are some clinical manifestations of SIADH
lethargy, anorexia, confusion, personality changes
really bad abdominal cramps
[seizure, coma, death from hyponatremia]
weight gain, N/V, decreased urine output
What finding would prompt you to advocate for your pt and request seizure precautions be initiated?
serum sodium levels less than 110
A 40y.o male pt p/w wt gain and confusion. The family reports that the he just isn’t acting like himself and can’t recall the last time he urinated. What do you suspect is going on?
SIADH
A student nurse is getting ready to hang normal saline for an SIADH pt at 100mL/hr for fluid resuscitation. What should the nurse do?
Stop the student nurse. pts w SIADH are to be on fluid RESTRICTION of 800-1000mL/day.
What replacement should the nurse anticipate for an SIADH pt and what does that entail?
Sodium replacement w hypertonic solution (3%NSS) 2 RN signature admin very slow infusion freq v/s & BMP q1hr neuro checks
What medication would the nurse anticipate administering for a pt p/w extreme lethargy, USG of 1.042, and a serum osmolality of 268
pt has SIADH
nurse would administer demeclocycline to increase renal water excretion
What would a pt p/w if they were experiencing overhydration as in SIADH?
Tachycardia
increased weight gain
crackles in lungs
not always Edemetous, swelling is intravascular
What should you do if you have a pt w SIADH who is AAO?
have them drink milk, tomato juice, or beef/chicken broth
A deficiency of production, excretion, or function of ADH is what condition?
Diabetes Insipidus
A pt c/o urinating non stop. After observation the nurse documents copious amounts of dull, tasteless urine. What is the pt experiencing?
Diabetes Inspidus
Tumors or Trauma that causes D.I is considered what type of cause?
secondary, Neurogenic/Central DI
What might be an indicator of Neurogenic/Central DI?
Rapid LOC and pt covered in urine
What is the patho of nephrogenic DI?
it has a slower progression
The hypothalamus is producing ADH but the kidneys can’t respond
What is the result of DI?
free water is excreted in the urine causing extracellular dehydr.
hypernatremia
decreased cerebral perfusion
can present like hypovolemic shock
What are the blood levels occurring with DI?
hypersolute/high osmolality
> 295
really high serum sodium…. >145
What are the urine levels with DI
hyposolute/dilute/low osmolality
< 300
A pt p/w serum osmolality of 341, serum sodium of 160, and urine osmolality of 262. Which endocrine issue might you expect?
DI
What is Desmopressin and what is it used for?
it is a synthetic form of vasopressin used for DI
There are NO vasoconstrictive properties
Intranasal is most effective
What is the sx of choice for DI?
Transphenoidalhypophysectomy
watch for increase ICP and glucose drainage!
What is an imp piece of pt edu with a transphenoidalphypophysectomy?
They’ll need hormone therapy for life
What is phenochromocytoma
tumor of the adrenal medulla r/t the anterior pituitary gland
What is the patho of phenochromocytoma
it produces an increased secretion of catacholamines
ie. epi, norepi, and dopa
how does phenochromocytoma manifest
with fight or flight response (SNS)
What are clin mans of phenochromocytoma
classic triad: tachycardia severe HA diaphoresis also HTN & chest pain
What are possible complications of phenochromocytoma
severe hypertensive encephalopathy
DM
Cardiomyopathy
Death
What is the gold standard test for phenochromocytoma
24hr urine to measure catacholamines + methanephrine
What is the sx of choice for pheochromocytoma
adrenalectomy
What is a critical consideration prior to an adrenalectomy
Goal BP is < 160/90
What are possible meds for mgmt of pheochromocytoma
Alpha blockers(metyrosine) - dec HTN
BB - inderal
Nipride
Considerations for Post Op adrenalectomy
really labile BP - treat HTN conservatively
fluids/blood
postural HTN - avoid rapid changes
elevate LE when sitting
imp pt edu post adrenalectomy
life long steroids if it was B/L
General info about pancreas
digestive & hormonal functions
endocrine & exocrine glands!
What is the application of the word fulminant
incredibly rapid onset
associated w high mortality rate (10-15%)
Common causes of pancreatitis
alcohol & Biliary disease (gallstones) make up 80% of cases
Patho of pancreatitis
injury to asinar cells leads to inc infection and inc ischemia in pancreas causing leakage of enzymes into tissue
Which enzyme is activated first in pancreatitis
Trypsin, which triggers the secretion of other enzymes
Which enzyme is the most dangerous in pancreatitis
Elastase - it destroys the cells responsible for clotting
what is autodigestion in relation to pancreatitis
breakdown of the pancreas d/t the release of enzymes
How does pancreatitis initially manifest
as localized pancreatic inflammation!
what is the acronym CARS
Compensatory anti-inflam response syndrome
Body’s attempt to pull back inflam to prevent it from becoming systemic
inc r/f infection, SIRS, MODS, etc
What are the systemic comps of pancreatitis
hypoxemia ( >60 on ABG) hypovolemic shock - distributive d/t systemic inflam -h.v d/t vomiting and/or GI bleed increased intraabd pressure pancreatic abscess oliguria dysrhythmias
What are localized comps of pancreatitis
incredibly severe pain N/V Abd distension guarding fever
What is the definitive test for pancreatitis
elevated serum lipase
What are other associated test results for pancreatitis other than elevated lipase
elevated CONJUGATED bilirubin hypocalcemia elevated amylase hyperglycemia toward the end dec albumin & protein
What might you find during a physical assessment of a pt w pancreatitis
Grey Turner’s Sign
- side/flank ecchymosis
Cullen’s Sign
- Ecchymosis @ the umbilicus
What are the 2 most imp imaging studies for pancreatitis & what’s the difference
CECT is the gold standard
ERCP is used if A.P r/t gallstones so they can be removed during imaging study
What is the ranson criteria
a predictability test to assess for increased chance of morbidity/mortality for pts dx’d w acute pancreatitis
What are the stipulations for the ranson criteria
less than 3 = 1% mortality
more htan 7 = almost 100% mortality
Hypocalcemia assessment findings
prolonged QT interval
tetany
+ chvostek’s sign - muscle twitching in face
+ Trousseau’s - tetany in arm r/t BP cuff inflation
Hypokalemia assessment
dysrhythmias - inc r/f PVCs
muscle weakness
hypotension
decreased bowel sounds - ileus
What electrolyte imbalance would produce really peaked T waves?
hyperkalemia
What fluid replacement would be utilized for pancreatitis
isotonic crystalloids - NO Lactated Ringers if liver enzymes are elevated
What is the suggested nutritional support for someone w pancreatitis
early enteral feeds once they’re not vomiting
What is imp pain mgmt for pancreatitis
PCA or REGULARLY scheduled pain meds NOT just PRN
Pharm mgmt for pancreatitis
prevent ulcers w histamine blockers/antacids
antibiotics
What is the most common cause of hepatic failure
50% d/t meds
42% d/t tylenol alone
What is the patho of hepatic failure
pts usually healthy before sudden onset of acute liver failure
FHF occurs over 1-3weeks
Hepatic encephalopathy within 8weeks
What is the first sign of hepatic failure
jaundice or decreased MS
What are results of Kupfer cell destruction in hepatic failure
imp bilirubin conjugation = inc UNCONJUGATED bilirubin Dec clotting factor production - inc INR ( >1.5) - inc PT ( >14 can be up to 100) hypoglycemia metabolic acidosis & inc serum lactate
What is a critical assessment/dx finding of hepatic failure
increased serum ammonia!!!!!!
causes change in MS
What are other assessment findings of hepatic failure
resp alk or met acidosis
inc WBC
only thing dec is platelets and albumin
What is the characteristic of urine in a pt p/w hepatic failure
orange, dark, incredibly concentrated
Clin Mans of hepatic failure
HA & personality changes hyperventilation (early) jaundice palmar erythema spider nevi bruises asterixis/liver flaps
Pharm mgmt of hepatic failure
neomycin
lactulose
vitamin k & FFP/platelets to treat bleeds
How does lactulose assist with hepatic failure
creates acidic enviro which traps ammonia, and then the laxative effect excretes it
What multi-system effects does hepatic failure create
brain - cerebral edema
lungs - resp failure
CV - hemodynamic instability
What is the preferred tx for hepatic failure
ONLY tx is transplant
What is the role of the OPO?
in charge of donations
bereavement care to families
DETERMINES MEDICAL SUITABILITY FOR DONATION!
clinical determinants for brain death
2 physicians w separate assessments w SAME results
Apnea testing - NO respirations & ABG PaCO2 >60
Pupils non responsive, dolls eyes
EEG
Absence of gag reflex
GCS >3
What is the definition of brain death?
complete irreversible cessation of brain functioning
What is the criteria for live organ donation from non relative. aka benevolent donor
good overall health, no DM or CA, no heart or kidney disease
compatible blood type!
What is the criteria for brain dead donor
complete irreversible cessation of brain function
Organ donation after circulatory death (DCD)
complete irreversible cessation of heartbeats and respirations
no recovery from illness suspected
dependent on life sustaining measures
Who determines medical suitability for organ donation?
the OPO NOT the physician or hospital
What is the Major Histocompatability Complex
molecules on cell surface responsible for lymphocyte and antigen recognition.
determination of self vs non-self
initiates transplant rejection
Nursing Mgmt goals for organ transplant pt
oxygenate organs
maintain hemodynamic stability
maintain fluid & electrolyte balance
maintain temp regulation
Describe hyperacute transplant rejection
antibody acute rejection. not seen much anymore because we test for antibodies
Describe acute transplant rejection
most common. weeks to months after transplant. Body needs time for the upregulation (helper t cells recognize there’s a foreign body takes time to build up troops.)
Everyone experiences some degree of this. effects reduces w immunosuppressant meds
Describe chronic transplant rejection
both cell mediated and antibody (humeral) mediated.
always results in complete destruction of organ!
will eventually need another transplant
what is the purpose of induction therapy
to create a tolerance for the transplant graft
what is the goal of immunosuppressant therapy
to suppress the activity of helper T cells
What do you monitor for rejection surveillance
elevated liver function tests, especially ASTs & ALTs
decreased bile output
fever
