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180 Cards in this Set

  • Front
  • Back
With which symptoms of hypoglycemia can a patient self treat?
*Adrenergic/autonomic
What should a pt experienceing adrenergic symptoms of hypoglycemia do?
*Make sure RN is aware of signs and symptoms
*Can self treat by eating CHO or drinking OJ
What do neurologlycopenic symptoms of hypglycemia mean?
*There is to little glucose going to the brain
Neuroglycopenic symptoms of hypoglycemia
*H/A
*confusion
*lethargy
*Slurred speech
*Coma
*Seizure
*Death
How do you treat a pt with neuroglycopenic symptoms of hypoglycemia?
*Give glucose (D50)
What order do the symptoms of hypoglycemia normally present?
*Adrenergic
*Neuroglycopenic
How is mild hypoglycemia defined?
*By symptoms, not by blood sugar
Symptoms of mild hypoglycemia
*Nervousness
*Irritability
Treatment of mild hypoglycemia
*10-15 gm CHO
*4 oz of juice OR 4 tsp. sugar (not both)
*6-8 oz of 2% milk (works longer)
*6 oz regular soda
*Be sure to give something to sustain the increased BS because if not it will just drop again
*Recheck in 15-30 minutes and retreat if BS <100
Symptoms of moderate hypoglycemia
*Slurred speech
*Confusion
Treatment of moderate hypoglycemia
*As long as pt is still awake they can have PO even though they have neuro symptoms if not the need SQ or IM
*20-30gm CHO
*Glucagon 1mg IM or SQ
Adverse effect of Glucagon
*Nausea and vomiting
*Be cautious of aspiration because as pt starts to wake up they may vomit--lay pt on their side to prevent aspiration
Considerations with glucagon
*Type 1 DM should always have glucagon incase of a hypoglycemic attack
*Glucagon must be diluted--comes with a vial so educate pt how to dilute
Symptoms of severe hypoglycemia
*Unresponsiveness
Treatment of severe hypoglycemia
*D50W (25gm) IV (resistance)
*Glucagon 1mg IV or IM
Where is D50W located?
*In the crash cart and pyxus
Prevention of hypoglycemia
*Pt education
Pt education about prevention of hypoglycemic emergencies
*Recognize s/s
*When reaction is most likely to occur (insulin peak, after exercise, not enough food)
*Person with newly dx DM should keep a food/insulin diary
*Medic-alert identification
Hypoglycemic unawareness
*Absent s/s of hypoglycemia when b/s < 55
*Blunted epi response (counter regulatory hormones)
*Normally in type I
What should be done for a pt with hypoglycemic unawareness?
*Increase monitoring of BS
*Higher blood glucose target (110ish)
*Avoid beta-blockers (-olols)
Why should pts with hypoglycemic unawareness avoid beta-blockers?
*Slow HR
*B/P
*These things further impair epi effects
Somogyi effect
*Rebound hyperglycemia
*Rare
*Results from evening insulin dose
*Pt becomse hypoglycemic between 2-4 AM but they don't know it because they are asleep
*Counterregulatory hormones raise BS by 7am and pt will be hyperglycemic
Management of Somogyi effect
*>food at bedtime
*Intermediate insulin at bedtime and decrease dose
Dawn phenomenon
*Similar to somogyi but doesn't have the hypoglycemic episode
*Early AM (4-8am) hyperglycemia
*possibly due to altered counterregulatory hormone levels
Management of Dawn phenomena
*Be careful not to cause hypoglycemia
*May change insulin to Ultralente so that it is continuously acting
Chronic Macrovascular complications of DM
*Dz of large arteries r/t deposit of lipids
*Begins with pre-diabetes (syndrome X)
*CAD
*TIA/CVA
*HTN
*PVD
*Infection
*Foot complications
Risk of CAD with DM
*2-4 times greater
TIA/CVA with DM
*2-3 times greater risk
*Platelet adhesiveness (clots)
*HTN r/t increase resistance in the circulatory system
*Diabetic nephropathy
HTN with DM
*40% increase with DM
Why are there so many chronic macrovascular complications with DM?
*When cells cant get enought glucose they are damaged because they aren't getting enough nutrients or O2
*this begins with "syndrome X" AKA pre-diabetes
PVD with DM
*Poor healing r/t poor circulation of nutrients and O2 to wounds
*Neuropathy
*Increased amputation incidence
Infection with DM
*Infection=increased need for insulin because the bacteria feeds off of the glucose
*UTI's are comon because DM often have neuropathy so they don't feel the need to void as soon as others so they hold the urine in the bladder for longer
Foot complications with DM
*Must educate pt
*Can get would on foot without even knowing it because of the neuropathy
*Small wound can get infected very quickly r/t to poor circulation
Microvascular Complications with DM
*Retinopathy
*Nephropathy
*Neuropathy
*Gastroparesis
*Neurogenic bladder
*Retinopathy with DM
*Retina needs most O2 in the body
*Major cause of blindness
*Decreased O2 to the retina causes damage
*Laser therapy can be used to slow the vision loss
*Nephropathy with DM
*Most common cause of ESRD (End Stage Renal Disease)
*Damage capillaries to the glomeruli
*Avoid nephrotoxic meds
*control HTN because the kidney effects renin-angiotensin system
Nephrotoxic meds
*Really strong ABX such as the mycins
Function of Glomeruli
*Filters things through kidneys
*If blood flow is decreased then the kidney cant function and things wil begin to build up leading to Renal failure
Neuropathy with DM
*1/2 DM experience it
*Transmission slows r/t poor nutrient supply to axons and dendrites
*Numbness, tingling, burning
*sensory loss
Gastroparesis with DM
*20-30% of ppl with DM will experience
*slows stomach emptying r/t decreased nerve innervation
*Reglan may help
Neurogenic Bladder with DM
*Urinary stasis leads to more UTI's
Pre-op considerations with DM pts
*Usual labs
*Early morning OR to disrupt BS mgmt as little as possible
*IV insulin for type I DM
*Monitor BS immediatly before OR
Why do DM surgical pts need IV insulin
*Because anasthesia decreases the metabolic rate so it won't be absorbed as quickly
*Surgery stresses body which increases BS
Intraoperative considerations with DM pts
*IV insulin if necessary
*No sub-q insulin in OR
Post-operative considerations with DM pts
*Monitor BS frequently (4-6 times/day)
*Monitor food/fluid intake and BS
*monitor wound for infection
*Avoid catherization to decrease UTI risk
*Return to normal diet, activity, med regimen as quickly as possible
What is the most common thing we see in the hospital?
*Urinary Tract Infection
Cystitis
*Bladder infection
Uretheritis
*Uretheral infection
How is a UTI diagnosed?
*Culture and Sensitivity to ID what microorganism
*Dx with >100,000 organisms/ml
Why are UTI's more common in females?
*Shorter urethra
*m/o doesn't have to travel as far
*location of urethra to the rectum
What M/O is most often the cause of UTI?
*E. Coli
When are men at most risk for UTI?
*> age 50 r/t prostate problems that cause urinary retention
Etiology/Risk factors for UTI
*Sexually active females r/t "honeymoon cysts"
*chemical irritants like bubble bath because it changes the pH
*moisture (wearing bathing suit all day)
*Pregnancy- hormones change pH
*Urinary stasis
*foley catheter
*increased age
*diabetes
Clinical manifestations of UTI
*Dysuria
*Hematuria
*Frequency of urination
*Urinary Urgency
*Low back pain
*Cloudy, foul smelling urine
*fever, chill, N/v
*Malaise
*10% may be asymptomatic
Dysuria
*Pain with urination
Reason for low back pain in pts with UTI
*Usually higher in the ureters and kidneys
*It's also more severe
What pts are most likely to be asymtomatic with UTI
*The elderly
*Mostly will present with confusion
Ideal specimen for urine specimen?
*Mid stream clean catch
*Can get from foley by using sterile needle and aspirating from the port.
*NEVER from the bag because it is not a fresh specimen
Management of UTI
*ABX
*Urinary analgesics
*Modify diet
*Increase fluid intake
*Prevent complications
ABX for UTI
*Sulfonamides
*Cipro
*Macrobid
*Educate pts that will effect birth control
*broad spectrum abx untill m/o is identified then more m/o specific abx
Urinary analgesics for UTI
*Pyridium
*What does pyridium do for UTI?
*Decrease bladder spasms
Side effect of Pyridium
*Turns urine bright orange
Diet modifications for UTI
*Bladder irritants increase acidity :(
*Cranberry juice (without sugar) changes pH lower and prevents m/o from sticking to the bladder
*Ascorbic acid
*Cranberry tabs need more study
Bladder irritants
*Increase aciditiy
*Caffine
*Tomatoes
*ETOH
*Chocolate
How much fluid should someone drink for MAINTENANCE with UTI?
*0.5 ounces/lbs of body weight
Complication prevention with UTI
*Eat yogurt to increase norma flora and decreas Candida
*ABX decrease effectivness of B/C so use back up method
*Urolithiasis, pyelonephritis-will have systemic infections and is more severe
Cells that are effected with bladder CA
*Cells in bladder wall
Etiology of bladder CA
*Directly linked to cigarette smoking
*Industrial chemical exposure (asbestos)
*artificial sweeteners could be link
*Coffee possible but there are confounding variables (coffe drinkers use artificial sweetner and smoke)
Decreasing risk of bladder CA
*0.5/ounce/lb of fluid
*Quit smoking
*no artificial sweetner
Clinical manifestations of bladder CA
*Similar to UTI
*Painless hematuria
*dysuria, frequency, urgency as CA progresses
Classic sign of bladder CA
*Painless hematuria (pt usually goes to see healthcare provider when they have trouble voiding)
Dx of bladder CA
*Cystoscopy
*IVP
*CT/MRI
*CEA
What is a cystoscopy?
*go in through the ureter to the bladder to visualize it.
*Wash it out and gather the washings for biopsy
What is a CEA?
*Carcinoembryonic Antigen--tumor marker
*not specific to organ--just that tumor is present
What is IVP?
*Intravascular pylogram
*Done in xray with dye to look for CA
Medical Managment of bladder CA
*Intravesical chemotherapy-
BCG
*Systemic Chemotherapy
Intravesical chemotherapy BCG
*Kills CA cells
*Chemo drug is injected to bladder via foley (often with cystoscopy)
*Stays in for 2 hours (may stay in procedure area-will either remove foley or clamp it)
*Change position q 15 minutes
*Drained via voiding or foley
*Protect self, others, and pt from where the chemo goes as far as toilet and stuff (bleach)
Surgical managment of Bladder CA
*Tumor excision through urethra (TUR)
*Partial cystectomy
*Radical cystectomy & urinary diversion
Partial cystectomy
*Remove part of the bladder
*bladder will have decreased capasity at first... as little as 60mls
Indication of partial cystectomy
*Tumor must be contained
Radical cystectomy & urinary diversion
*Women-Remove bladder, urethra, part of vagina, and more
*Men-remove urethral seminal vesicals, bladder, and more
*Both will no longer be able to reproduce
Indication of Radical cysectomy & urinary diversion
*If CA is invaisive-spread
Transurethral resection
*TUR
*Remove tumor
*pretty good method and fairly common
Indication for Transurethral resection
*Tumor must be contained
Conduit
*tube
Ways for urinary diversion
*Ileal conduit
*Continent pouch
Ileal conduit
*Segment of intestine (ileum) is used
*Ureters are attached to conduit
*Must wear bag
Contraindications of ileal conduit
*Pts who have small bowel disease
*Crohns disease
*colitis
Pro's for continent pouch
*Gives a little more of a normal life because the pt doesn't have to wear a bag and they can empty it on their own
Continent pouch
*Ascending colon/terminal ileum are used to make a bladder
*Will have a nipple valve
*Catheterize stoma
Capacity of reservoir with continent pouch
*60ml at first
*will expand to possible 600ml
Frequency of catheterizing continent pouch
*may be as often as Q1H at first
*after 8-10 weeks may be as little as 4 times a day
Who is candidate for continent pouch?
*Someone who can TAKE CARE OF IT!
*someone who has a decent life expectancy
*not someone with METS
Similarites between the ileal conduit and the continent pouch
*Urine characteristics
Urine characteristics after urinary diversion
*May have mucus present r/t using bowel for conduit
Differences between ileal conduit and continent pouch
*Method of urine collection
Urinary drainage managment post-op urinary diversion
*Prolly will have a drain immediatly post op to keep pressure off of suture line
*Report <0.5ml/kg/hr or no output for 15 minutes
*Inspect stoma
*Watch for peritonitis
What would cause a decrease or all together hault of urine output after urinary diversion?
*Obstruction
*Dehydration
Stoma characteristics
*Red beefy = good circulation
*Dusky=purple=poor circulation and hypoxia
*Stoma will be large immediatly post-op r/t edema from OR
Peritonitis after urinary diversion
*If suture line ruptures and spills contents into the sterile periteneum pt will get very sick
S/S of peritonitis
*distended abdomen
*Fever
*Lots if pain
*Increased WBC's
Urinary calculi
*Kidney stones
*Forms in the kidney or in lower urinary tract
*more common in males
Etiology of urinary calculi
*Dehydration-causes urinary stasis which can form crystals
*Excess of crystaloid materials
*Obstruction
*Infection that decreases mov't
*Some ppl just are more prone to get them
Cause of pain with urinary calculi
*When stone moves.
*no pain when stone is stationary
Types of kidney stones?
*Calcium phosphate or calcium oxalate
*Oxalate
*Uric acid
Calcium phosphate or calcium oxalate stones
*Males in early 20's
*gravel or stone size (can be bigger than 5mm)
*Hypercalciuria
Causes of hypercalciuria
*From increased bone reabsorbtion
*Increase calcium absorbtion in the gut (men)
*Impair tubular renal absorbtion
*PPL that have to much vit. C that doesn't get absorbed
Oxalate stones
*Dietary
*Inflammatory bowel disease
*Vit C excess
Foods that increase risk for oxalate stones
*Tea
*Cola
*Tomatoes
*Instant coffe
*cereal
Uric Acid kidney stones
*People with gout
*Increase urate excretion
*avoid protein excess
What do you do with a kidney stone once it is passed?
*Send to pathology to find out what kind of stone it is
What is colic?
*Pain
Clinical manifestations
*Pain
*Ureteral colic
*renal colic
*N/V r/t pain
*Tachycardia r/t pain
*HTN r/t pain
*Fever r/t inflammation
*Elevated WBC r/t inflammation
Ureteral colic
*Pain in the front of the body and down through groin
Renal colic
*Pain in lubar & with men maybe testicles
What causes pain with kidney stones?
*Size of stone
*Mov't of stone
Medical managment of kidney stones
*Increase fluid intake at least to 3L a day
*Opoids
*NSAIDs
*Antispasmodics
*Prevention of stones with thiazides, Vit B6, allopurinol for pts with gout
*dietary changes (depends on type of stone)
Dietary changes for medical managment of kidney stones
*varies with type of stone
*Fluids
*Low protein
*Cranberry juice
*there is controversy over calcium intake (r/t calcium goes to blood, not urine)
*Decrease protein for pts with uric acid stone
Ditropan
*antispasmodic
*Decreases spasms to relax bladder
Surgical managment of kidney stones
*Normally greater then 5mm stone
*20% require surgical intervention
*Cystoscopy
*Lithrotripsy
*Open surgery
Calcium phosphate or calcium oxalate stones
*Males in early 20's
*gravel or stone size (can be bigger than 5mm)
*Hypercalciuria
Cystoscopy
*Insert urethral catheter and try to remove stone
Causes of hypercalciuria
*From increased bone reabsorbtion
*Increase calcium absorbtion in the gut (men)
*Impair tubular renal absorbtion
*PPL that have to much vit. C that doesn't get absorbed
Oxalate stones
*Dietary
*Inflammatory bowel disease
*Vit C excess
Lithotripsy
*VERY PAINFUL
*Put pt in a body of H2O
*Deliver extracorporeal shock wave
*pt will be very bruised along lumbar
When is open surgery used for kidney stones?
*if lithotripsy doesn't work
Foods that increase risk for oxalate stones
*Tea
*Cola
*Tomatoes
*Instant coffe
*cereal
Uric Acid kidney stones
*People with gout
*Increase urate excretion
*avoid protein excess
Decreasing injury with kidney stones
*3-4 L of fluid/day
*monitor urine output (0.5ml/kg/hour)
*Possible ureteral catheter
*Strain all urine
Calcium phosphate or calcium oxalate stones
*Males in early 20's
*gravel or stone size (can be bigger than 5mm)
*Hypercalciuria
Ureteral catheter
*Usually with open surger r/t inflammation
*Sometimes will need to be irrigated--need an order
Causes of hypercalciuria
*From increased bone reabsorbtion
*Increase calcium absorbtion in the gut (men)
*Impair tubular renal absorbtion
*PPL that have to much vit. C that doesn't get absorbed
What do you do with a kidney stone once it is passed?
*Send to pathology to find out what kind of stone it is
Oxalate stones
*Dietary
*Inflammatory bowel disease
*Vit C excess
What is colic?
*Pain
Foods that increase risk for oxalate stones
*Tea
*Cola
*Tomatoes
*Instant coffe
*cereal
Clinical manifestations of kidney stone
*Pain
*Ureteral colic
*renal colic
*N/V r/t pain
*Tachycardia r/t pain
*HTN r/t pain
*Fever r/t inflammation
*Elevated WBC r/t inflammation
Ureteral colic
*Pain in the front of the body and down through groin
Uric Acid kidney stones
*People with gout
*Increase urate excretion
*avoid protein excess
Renal colic
*Pain in lubar & with men maybe testicles
What do you do with a kidney stone once it is passed?
*Send to pathology to find out what kind of stone it is
What is colic?
*Pain
Clinical manifestations
*Pain
*Ureteral colic
*renal colic
*N/V r/t pain
*Tachycardia r/t pain
*HTN r/t pain
*Fever r/t inflammation
*Elevated WBC r/t inflammation
Ureteral colic
*Pain in the front of the body and down through groin
Renal colic
*Pain in lubar & with men maybe testicles
Irrigation of ureteral catheters
*Need an order
*catheters very small
*L and/or R catheter
*Sterile procedure
*Often a urologist does it
*Never push against resistance
*If meet resistance pull back to see if it comes unclogged
*3-5 ml MAX --ensure patency
Urine decrease or stop with foley catheter
*Worry about renal issues
Nursing conciderations with kidney stones
*Treat pain
*Monitor urine output
*strain urine
*teach about prevention
Urinary retention
*functional problem
*Bladder is not emptying but the kidneys are still making urine
*Oliguria
*Kidney's aren't making urine
*Kidney failure
Causes of urinary retention
*BPH
*Surgery/anesthesia
*Neuro deficits
*DM
BPH
*benign prostatic hypertrophy
What does surgery have to do with urinary retention?
*Takes time for the bladder to empty
*What do neuro deficits have to do with urinary retention?
*Brain doesn't let pt know that they have to void and so they hold it
Concern with urinary retention
*infection
*kidney stone
Nursing managment of urinary retention
*Assess amounts and patterns
*Simulate indepentant voiding
*Catheterization when post void residual is >300ml
*prevent infection
*prevent injury from catheter
How to assess amounts and patterns of voiding
*Post void residual
*Bladder scanner
Post void residual
*When pt doesn't feel like they are emptying their bladder all of the way
*Insert in and out cath after voiding
*100ml is significant
*300ml MD will prolly order a foley
Reason to take catheter out if post void residual is <300ml
*to see if pt will eventually be able to empty bladder completely on their own
Fluids or no fluids with urinary retention?
*continue fluids
Urinary incontinence
*When bladder can't control urination
*Stress incontinence
*Urge incontinence
*Overflow incontinence
*Many pts to embarressed to ask for help
*Can be related to surgery, pregnancy, meds
Meds that can cause urinary incontinence
*ETOH
*Cold meds
*Antihistamines
Stress incontinence
*Usually trauma to bladder (stomach surgery)
*Bladder goes into spams
Urge incontinence
*Overactivity of muscles leads to weak bladder
*Overflow incontinence
*Does not empty bladder completly--retention
Medical management of urinary incontinence
*Pelvic floor muscle exercise (Kegals)
*Bladder training
*Ditropan (anticholinergic)
*Fluid intake spaced more throughout day
*Decreased fluid intake before bed
*Less caffine and ETOH
*Voiding schedule
Bladder training & voiding schedule
*Training with Neuro dz (cord injury)
*Schedule when to empty bladder
Pyelonephritis
*When UTI goes to the kidney via the ureter
*Infection of renal pelvis and parenchyma causing scar tissue (if untreated)
*Decreased renal function
*often follows UTI
*Can be chronic
Clinical manifestations of pyelonephritis
*Similar to UTI but more severe and systemic
*Acute distress/infectious process
*Fever, chills, nausea, FLANK PAIN
*Dysuria, frequency, urgency
*Hematuria
*Foul smelling urine
Management of acute pyelonephritis
*ABX (culture urine)
*Urinary analgesic like pyridiam
*Increase fluid intake to 3-4 liters a day
*Follow up care
Glomerulonephritis
*Acute/Chronic
*Immunologic reaction
*Inflammatory changes in glomeruli
can be exogenous or endogenous
*Can lead to chronic renal failure but most recover if with exogenous
Glomeruli
*Filters stuff in kidneys
Clinical manifestations of glomerulonephritis
*Heaturia
*Proteinuria
*Low serum albumin and altered oncotic pressure r/t poor kidney function
*Fever, chills, n/v
*Edema, ascites, pleural effusion, heart failure
*HTN FIX FAST R/T RENIN-ANGIOTENSIN SYSTEM
*Abd/flank pain
*Oliguria or anuria
Why does oncotic pressure decrease with low serum albumin?
*Because albumin goes to the interstitial spaces
Managment of glomerulonephritis
*We want to stop the immune response to stop the inflammation
*ABX if infection is present
*Fluid and electrolyte balance
*Diet changes
*Manage HTN quickly
*Rest!
How to reduce inflammation with glomerulonephritis
*Plasmapheresis
*Steroids
*Anti-rejection meds
Plasmapheresis
*Looks like dialysis
*Removes plasma and try to get rid of the autoantibodies
*Protein (Albumin) may be given to pull fluid from the interstitial spaces into the intervascular and then give diuretics
Diet changes with glomerulonephritis
*High calorie for body repair
*Low protein if protein uria
*Moderate protein and sodium restriction
Fluids with glomerulonephritis
*Don't restrict but don't overload