Final Exam Flashcards
Dka prority
A) insulin
B) administer 0.9% sodiumnchloride
B); metabolic acidosis-> risk of hypovolemia and arrhythmias due to hypokalemia
Prioritize fluid resuscitation with isotonic fluid. then IV insulin with potassium (even if normal)** with hourly bs checks
In dka, hyperglycemia, lots of sugar in urine brings fluid with it. Also fat is broken into ketones and there is deep and labored breathing as a result. Initially there in hyperkalemia but later Insulin administration will cause hypovolemia/hypokalemia. Monitor serum potassium while giving it.
DKA vs HHNS
dka is type 1 and acidic; faster onset. Sugar is greater than 300 and kussmaul’s breathing with ketones and abd pain.
Hhs is type 2 and not ketones. Dehydration is more prominent and confusion.
Hhs treatment when bs is 350
Give normal saline 0.9%
Give iv insulin until 300 and then subcutaneously and then manage electrolytes
Reassess blood sugar hourly and rehydration (bp and cap refill, urine 30 ml/hr; specific gravity of 1.005-.030 and warm skin/color)
Monitor for edema, blood sugar, lung sounds, ecg,kidney function, I/O.
Patient has DI, what to do and monitor after giving medication?
Lack of adh-Desmopression and should urinate every 3-4 hours.
Siadh
What are some interventions? -meds/independent actions
What do you watch out?
What is bp?
In SIADH, there is too much absorbtion of water by adh (increased bp) and low urine output. Sodium is low due to lots of water->seizures/confusion. 7s’s
Stop urination
Sticky thick urine (1.03+)/concentrated
Soaked inside (hypoosmolality and natremia)
Sodium low
Seizures
Severely high bp
Stop fluids and give salt (3% saline) with diuretic
Caused by small lung cancer severe brain trauma and sepsis
Daily weights
DI
Die ADH or Dehydrated (low adh)
Diuresis
Diluted urine (low specific gravity less than .005)
Dry (hyperosmolality-thick blood and hypernatremia
Drinking a lot
Dehydrated skin and mucosa
Decreased bp
Desmopressin decrease urine output and can also cause death by seizures
Caused by brain damage (tumors, trauma, surgery)
When caring for a patient with siadh, what does the nurse implement select all:
Iv 0.9 NS
Fluid restriction
Sodium restriction
Seizure precuations
Monitor I/O
Measure weight weekly
Fluid restriction, seizure precautions, I/O,
In a patient with DI and a brain tumor what does nurse expect to find: dark urine with high sepcific geavity
High blood serum osmolality
Weight gain withe edema
Increased thirst
Sodium of 134
Urine output below 30 ml/less
High serum osmo
Increase thirst
Lack of adh
A client is prescribed desmospressin what is wrong teaching:
Frequent headaches are normal
I will make sure to restrict water
This drug is used to decrease frequent urine
I am glad it can treat siadh
I will record output closely while using drug
I will weight myself weekly
Frequent headaches are normal (headaches are sign of hypomatremia causing seizures)
I will restrict water
It will treat siadh
Weekly weight
Hyperthyroidism
What is diet like? Physical manifestations. Bowels? Gi? Monitor for what?
High energy/Nervous/Tremors/Palpitations
and hot or graves disease
High t3/t4
Monitor for thyroid storm (agitation and confusion)
Grape eyes; exothalamus
High bp/hr; weight loss and hungry due to high energy burn
heat intolerance & sweaty
Tx: Beta blockers, Methimazole, PTU, Radiactive 131 (Family planning/take preg test b4; can give hypothyrodism)
Risk of A fib (clots-stroke) & HF (hypertrophy)
-monitor vision changes: liver function, cbc (thyroid storm), and t3/t4
_give sedatives; avoid stimulants; provide rest
High gi (diarrhea)
Need high calories and proteins (frequent meals-6/8 per day)
No fiber, caffeine (soda or tea), or spicy food
Hypothyroidism
Caused by what? Complications/what to monitor? Nails? Excretion?
Weight/fluid? Blood? Hair? Tx? Temp?
Levothyroxine (whatnot to take it with); 4 things to look out for
Low and slow
Priority: myxedema coma (post thuroidectomy or abruptly stopping levothyroxine)
Puffy face/weight gain (low metabolism), Low hb/anemia
Numbness/tingling, high cholestrol-> left ventricle dysf
Low temp and cold intolerance
Low digestion/constipation
Low hair or alopecia not hirutism and brittle nails
Low mental status and energy
Amen no period
Treat: Rest and levothyroxine at 6am without magnesium antiacids; It will decrease the function of anticoagulants and digoxin (monitor for bleeding annd heart)
There is a risk of angina and arrhythmias due to increase o2 demand to myocardium
Caused primary:not enough t3/4
Seondary: thyroidectomy or pituitary not tsh
Hashimoto’s thyroidits is mostly
Copd patient has 85% o2 sat, would increase oxygen up to 3L on norebreather or increase o2 and get abg
increase o2 and get abg to determine effectiveness. Copd patients use nc 2-4 or venturi 40%
Addison’s
What is diet like? What is high? Does it cure? What causes it?
Lack of cortisol and aldosterone
*Low bp, tanned skin and mucosa (especially knuckles and elbows), low glucose, low sodium, high potassium, & Low weight
Causes: Autoimmune or disease (tb) or overuse of corticosteroids (COPD/Lupus)
Watch for Addison’s crisis
Tx: Prevent circulatory shutdown
Monitor orthostatic bp (administer iv fluids with sodium). If severly hypotensive-give vasopressors. Administer IV Dextrose.
Monitor glucose and electrolytes (Na, K, Ca). I/O and daily weights. High protein and carbohydrate diet with salt. Monitor cortisol and acth.
Administer IV Solu-corkf (hydrocortisone).
Avoid stress
Cushing’s
What is bp like? What mark do they have? Hair? Bones? Causes?
Big huge cushion of steroids
Big, round, and heavy
Big bp, glucose/sodium
Big belly/trunchal obesity/moon face/buffalo hump/hirutism
Big purple striae/butterfly mark/rosy cheeks
Slow wound healing/brittle bones
Causes: high steroids (prednisone)
Tumor (pituitary or adrenal)
Small cell lung cancer
Tx: cut causes; tumor or slowly decrease steroids
Steroid precautions
Swollen:report l lb a day or 2-3 lb in few days
Sepsis: report low wbc;low grade fever (100) is srs
Sugar increased; increase insulin for diabetics
Skinny (osteoporosis)
Sight (cataracts)
What is the purpose of pursed lip breathing?
Helps the airway stay open and provides positive pressure and releases trapper air
Patient is obtunded and responding to only painful stimuli. Blood glucose is 38
Protocols/types of _____
Usually less than 70; severe is less than 40;
Mild: sweating and tachycardia, tremors
Moderate: confusion/slurred speech, drowsy
Severe: seizures, loc, death
In this case give IM/sq glucagon or 25-50 ml 50% dextrose
If awake: gice 15 g carb: 4-6 oz juice ir 3-4 glucose tablets
Recheck sugar in 15 if les than 70; if greater than 70 give protein and carb (pb&j unless they plan to eat in 1 hr)
A diabetic comes in with a foot injury what do you assess? Cap refill
Temperature
Sharp/dull
Two point doscrimination
Light touch
Pulses
Reflexes
Rom
Sharp/dull, two point disc…
Cap refill & pulses
Temperature
Educate patient: not to go to salon and to cut nails straight across; shake shoes before wearing; never go barefoot and get annual foot exams; no moisture between toes and inspect foot daily
Lispro onset and duration
15 min; 2-4 hours
Dawn phenomenon vs somoyagi effeect
Dawn phenomenon occurs in all people; sugar spikes at dawn
Somoyagi: in diabetics if they take too much insulin before bed or if they don’t eat before bedtime, they get hypoglycemic and that causes rebound hyperglycemia
How often do you change insulin pump needles? How do you calibrate it? What should u keep on hand ? Where and when should a non insulin user test blood sugar?
Every 3 days; enter the number of carbs eaten per meal; a spare pen; post-prandial or fasting on the pads of their fingers (smbg or cgms)
Hypoglycemia manifeststions
Diaphoresis, palpitations, shaky, dizzy/hungry, confusion
A nurse is caring for a patient who is dehydrated and is receiving continous tube feeding through a pump at 75 ml/hr. When the nurse assess the client at 800, what requires an intervention?
The client is lying on the right side with a visible dependent loop in the feeding tube
The patient’s tube is about to be dislodged
The disposable bag is from 10 on the previous day and contains 200 ml of feed
The hob is 20
The nurse hears crackles upon assessment
Patient is constipated
What to monitor? Ph? Interventions
The hob is 20, the nurse hears crackles or if tube number decreases: shows tube is dislodged-> stop feed; check pH of aspirate-shld b less than 5; get cxr if not;
Constipation: check if theres a lack of fiber/opioids/dehy
To avoid dislodging: pin to gown
Monitor blood glucose, electrolytes, and BUN; assess spo2, rr, lung sounds, I/o (even flushes/aspirate); give oral care and monitor for pressure injuries
Organize the following into tubes for decompression/lavage and tubes for enteric feeding:
Corpak
Gastric salem sump
Dobhoff
Ng
Levin
Orogastric
Nj
Peg/pgj
Decompression/lavage: ng/orogastric (large bore)
Levin (single lumen)
Gastric salem sump-double luken
Feeding:
Ng/nd/nj/percutaneous gastrostomy/jejunostomy (peg/pgj)-small bore
Dobhoff
Corpak
You are placing a pgj what is the patient education
Expect gagging
Sit upright and drink water upon insertion
We will confirm placement with an cxr and before meals check aspirate and use warm water or digestive enzymes to clear the tube of obstruction ; flush before/after meals and as scheduled
Nursing care of gastrostomy or jejunostomy-site csre
Wash site with chg bid or soap and water
Monitor for skin breakdown, infection, or bleeding
Scant serous drainage is normal a few days after insertion
Rotate tube daily for gastrostomy? Not pgj
Which one should the nurse question?
A. 0.45% NS for patient with SIADH
b. 0.9% Nacl for patient with GI bleeed and decreased hematocrit
c. 1,000 ml bolus 0.9% Nacl for patient in septic shock and increased wbc
d. LR for patient with decreased hematocrit and burns
- A. SIADH is characteristized by hyponatremia and hypervolemia. A 0.45% Nacl is hypotonic. When infused fluid will shift out of blood and into the cells. **A hypertonic (3%) solution will have fluid shift out of cells and into blood. ** For hypovolemia in shock or hypovolemia due to evaporation in burns, an isotonic solution (9%) will help reduce the hypervolemia and increase bp.
A patient with hx of Cystic Fibrosis is being admitted due to exacerbation. What requires immediate intervention?
A) decrease in spo2 from 92 baseline to 88 on room air
B) expectorating blood tinged sputnum
C) no bowel movement for 2 days and right quadrant discomfort
D) no appetite and 5 lb recent weight loss
A) it can mean mucus plug. Bloody sputnum is expected. Gross hemoptysis or frank blood is life threatening. Patients with cf can have intestinal obstruction syndrome that can be relieved with rehydrating stool.
Upper GI tract study
Barium swallow study
Npo at midnight
Hold essential meds in the AM
Avoid smoking and chewing gum
Encourage fluids after test
Esphagogastroduodenoscopy
Used to dx ulcers, tumors, varices, esophageal motility, biopsys, inflammatory disorders
-can do ablation, banding, stent placement
Sedation
Interventions: consent
Npox8 hrs
Assess: Loc, vs, spo2, gag reflex
Signs of perforation: unusual difficulty swallowing, rapidly elevated T, bleeding
A patient is experiencing dyspepsia, pyrosis and odynophagia what disorder do they have? Other symptoms and complications
How is it diagnosed?
Gerd. They can also have esphogitis, hypersalivation, and regurgitation. Complications include barret’s esophagus, respiratory problems, adenocarcinoma, strictures, ulcerations and dental erosins.
Through endoscopy, barium swallow study, h pylori testing, trial of lifestyle changes/surgey, and gerd-q.
Whay are some gerd rf? What it is it?
Age, ibs, h pylori, copd, asthma. The les is unable to close/injured: due to alsl pyloric stenosis, hiatal hernia, or motility disorder m.
Gerd management
1) lifestyle: low fat, weight, avoid peppermint, milk, tobacco, beer, or soda. Stop eating 2 hrs before bedtime. Elevate hob by 30
2) calcium carbonate, famotidine, ranitidine (recall), metocloprmaide, pantoprazole, bethanechol, or sulfracte
3) nissen fundiplication for refractory gerd or hiatal hernia. Clear diet 24 hr postop then full liquids for 1-2 wks. Avoid strenous sctivity for 2 weeks
Hiatal hernia symptoms and diagnotics
Treatment and complications
Opening of the esophagus where the upper stomach passes is enlarged.
Sliding hernia and paraesophageal hernia.
Pyrosis, dysphagia, and intermittent epigastric pain after eating
Complication: hemorrhage, obstruction, or strangulation
Dx: barium swallow/esophageal memometry (motility), xray/ct, endoscopy
Management of hiatal hernia
Complications
Slowly advancing diet after nissen. Monitor nutritional intake and manage n/v.
Belching, gagging, abdominal distention, and epigastric chest pain->surgery
Gastritis chronic vs acute
Cause/rf/dx
Acute: rapid onset caused by dietary indiscretion or ingestion of strong acid/alkali its self limiting
Other risk factors: alcohol,
Bile, radiation
Chronic: prolonged inflammation due to ulcers or h pylori. It can lead to b12 deficiency, pernicious anemia.
Other risk factors include: autoimmune disease (hashimoto’s, graves, and addison’s) meds (nsaids), alcohol, smoking, or bile
Dx: endoscopy, cbc (anemia), h pylori testing
Acite vs chronic gastritis symptoms management and tx
Acute: anorexia, rapid epigastric pain, hematemesis, hiccups, hematochezia/melena, shock
Tx: refrain from alcohol, tobacco, and caffeine
and NPo until symptoms subside and iv fluids
Avoid emetics and lavage
Chronic: bleching, early satiety, sour taste, anemia, epigastric discomfort relieved by eating, pyrosis, intolerance of spicy
Tx: treat h pylori
modify diet, acoid alcohol and nsaids, , rest/reduce stress and
Meds:take antacids (calcium carbonate/magnesium hydroxide)/h2 blockers( famotidine) or ppis (pantoprazole)
Surgery: gastric resection or gastrijejynostomy for obstruction
Assessment of gastritis
Monitor I/O
Monitor for signs of dehydration (vs, skin turgor,
Watch out: tachy/hypotension/diaphoresis/loc/coolness/pallor
Manage pain and educate
Pud rf and symptoms
Erosion of mucosa
Zollinger-ellison syndrome (tumor secreting acid)
Nsaids/Alcohol/Smoking
Excess acid production/hereditary
Sour eructation, dull/gnawing epigastric pain, constipation/diarrhea, bleeding/vomitting/heartburn
Gastric: pain immediately after esting
Duodenal: pain 2-3 hrs after meals; relieved by eating or antacid/more likely to be awake at night
Peptic ulcer perforation: severe sharp upper abdominal pain, tacy/hypo, abd tenderness,n/v
Pid dx
Upper endoscopy with biopsy
H pylori: urea breath test, serum ab test, or stool antigen
Cbc and fecal occult
Tx: h pylori: 2 abx, ppi, bismuth salts for 10-14 days
Non-h pylori:h2 histamines, ppi, avoid aspirin and nsaids
Stop smoking and stop triggers
Surgery for intractable ulcers-vagotomy or antroctomy
Monitor I/o, dehydration, complication-hemorrhage: hematemesis/melena; monitor h&h; urine output, vs: hypo/tachy and loc and pallor/cool temp (diaphoresis)
Tx: ng/transfusion/endoscopy ablation/surgery
Perforation
Gastric outlet obstruction
Sudden severe abdominal pain around right shoulder
Rigid abomen
Shock
Perforation, a complication of pud
Go to or
Constipation, epigastric fullness, anorexia, n/v
Gastric outlet Obstruction
Ng decompression
Iv fluids
Endoscopy/surgery
Gastric cancer rf
Rf: men, older adults, hispanics/aa/asians
Diet high in smoked, salted and pickled foods & low in fruits/veg
Chronic gastritis/h pylori
Pernicious anemia
Smoking/achlorydiria
Gastric ulcers/subtotal gastrectomy/genetics
Gastric cancer symptoms
Dyspepsia, abdominal pain relieved by antacids, early satiety, weight loss/decreased appetite, bloating after meals, n/v
Tx: chemo/surgery if possible and chemo/palliative care (metastasis)
Radiation is given for advanced cancer
Functions of the thyroid gland
Regulate metabolism
Growth and devlopment
Tissue function
Sexual function
Reproduction
Sleep and mood
Anterior vs posterior pituitary gland
Anterior: fsh
Lh
Acth
Tsh
Posterior: adh
Oxytocin
What does the thyroid look like? Where is it located? What is an essential component of thyroid hormones? In hyperthyroidism what hormone is high? What are diagnostics? What meds are contraindicated?
The thyroid is butterfly shaped. It is located anterior to pituitary. Iodine is essential. In hyperthyroidism, t3/t4 are higher than tsh.
Diagnostics: free t4
T3t4, tsh, thyroid ab (hashimotos or graves disease), raiu (inc in hyperthyroidism), fine needle biopsy, thyroid scan.
Meds: topical antiseptics
Amiodarone (antiarrhytmics)
Seaweed/kelp
Multivitamins
Contrast dye
Iodine/shellfish allergy
Myexedma coma
Severely low hypothyroidism, low RR/HR/BP/Temp/Glucose/Sodium
Give IV hydrocortisone, IV glucose, passively warm patient with blanket, ABGs, assess their neuro function every hour
A patient has a temperature of 101, confusion, and hr of 140. What should u do?
Thyroid storm
Maintain patient airway and reduce t and hr
Monitor abgs and titrate o2
Give propronol and digitalis for arrhytmias
Give cool packs
Give ptu and iodine
Give iv hydrocortisone and fluids with dextrose and tylenol
Avoid nsaids
In thyroidectomy what are pre and post op interventions
Preop: watch vs, wt, and electrolytes:
Potassium (potassium iodide and hypocalcemia)
Cough and deep breathing
Meds to prevent thyroid storm (high t and hr and confusion)
Post-op
Always have trach kit and suction-monitor resp function
Monitor electrolytes (chvstek and trosseau sign)
Assess surgical dressing anteriorly and posteriorly for edema and bleeding
Watch for stridor and dysphagia
Ask patient to neutral position: support neck when turning and to not flex neck and use semi fowler’s position
What hormones are secreted by the adrenal cortex and medulla
Medulla: catecholamines
Cortex: glucocorticoids and mineralocorticoids and androgens
Addisonian crisis
Causes by stress, trauma, or surgery or abrupt stop of steroids. Hypotension, cyanosis, fever, abdominal pain, confusion can lead to shock
Tx: iv glucocorticoids, iv fluid and electrolytes, iv glucose/dextrose, vasopressors, monitor I/o and vitals
Avoid cold exposure and exertion
Make sure they have prefilled syringes at home
Cushing’s syndrome symptoms and treatment
Moon facies, buffalos hump, trunchal obesity, stomach striae, poor wound healing, hyperglycemia, osteoporosis, thin skin
Resection of pituitary or transphenodial hypophysectomy
Adrenlectomy
Tapering corticosteroids used for crohns, autoimmune, or copd
Monitor electrolyte (Na/K) and glucose
Monitor I/o and cortisol
Encourage moderate activity
Skin: no adhesive tape, turn every 2 hours, and assess skin integrity
Talk about med age range and tapering
Adrenlectomy-pre intra and post
Bilateral removal means lifelong therapy. Preop : monitor electrolytes (k, na, ca)
Monitor ekg for arrhythmia , hyperglycemia, and administer glucocorticoids
Intraop:drop in catecholamine can cause shock
Post: hemorrhage, vs, urine output (foley), electrolytes, glucose
Educate abt hypo/hyper replacement and therapy
Treat pain, encourage cough/deep breathing/ ambulation
Corticosteroid therapy
Helps treat inflammation: autoimmune (rheumatoid arthritis, lupus), allergies, preventing transplant rejection, and adrenal insufficiency
Ae: increased bp and glucose
Risk of glaucoma/cataracts
Can suppress adrenal cortex; shld b tapered
