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180 Cards in this Set
- Front
- Back
With which symptoms of hypoglycemia can a patient self treat?
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*Adrenergic/autonomic
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What should a pt experienceing adrenergic symptoms of hypoglycemia do?
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*Make sure RN is aware of signs and symptoms
*Can self treat by eating CHO or drinking OJ |
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What do neurologlycopenic symptoms of hypglycemia mean?
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*There is to little glucose going to the brain
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Neuroglycopenic symptoms of hypoglycemia
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*H/A
*confusion *lethargy *Slurred speech *Coma *Seizure *Death |
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How do you treat a pt with neuroglycopenic symptoms of hypoglycemia?
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*Give glucose (D50)
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What order do the symptoms of hypoglycemia normally present?
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*Adrenergic
*Neuroglycopenic |
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How is mild hypoglycemia defined?
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*By symptoms, not by blood sugar
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Symptoms of mild hypoglycemia
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*Nervousness
*Irritability |
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Treatment of mild hypoglycemia
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*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 |
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Symptoms of moderate hypoglycemia
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*Slurred speech
*Confusion |
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Treatment of moderate hypoglycemia
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*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 |
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Adverse effect of Glucagon
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*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 |
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Considerations with glucagon
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*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 |
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Symptoms of severe hypoglycemia
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*Unresponsiveness
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Treatment of severe hypoglycemia
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*D50W (25gm) IV (resistance)
*Glucagon 1mg IV or IM |
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Where is D50W located?
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*In the crash cart and pyxus
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Prevention of hypoglycemia
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*Pt education
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Pt education about prevention of hypoglycemic emergencies
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*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 |
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Hypoglycemic unawareness
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*Absent s/s of hypoglycemia when b/s < 55
*Blunted epi response (counter regulatory hormones) *Normally in type I |
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What should be done for a pt with hypoglycemic unawareness?
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*Increase monitoring of BS
*Higher blood glucose target (110ish) *Avoid beta-blockers (-olols) |
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Why should pts with hypoglycemic unawareness avoid beta-blockers?
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*Slow HR
*B/P *These things further impair epi effects |
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Somogyi effect
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*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 |
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Management of Somogyi effect
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*>food at bedtime
*Intermediate insulin at bedtime and decrease dose |
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Dawn phenomenon
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*Similar to somogyi but doesn't have the hypoglycemic episode
*Early AM (4-8am) hyperglycemia *possibly due to altered counterregulatory hormone levels |
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Management of Dawn phenomena
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*Be careful not to cause hypoglycemia
*May change insulin to Ultralente so that it is continuously acting |
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Chronic Macrovascular complications of DM
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*Dz of large arteries r/t deposit of lipids
*Begins with pre-diabetes (syndrome X) *CAD *TIA/CVA *HTN *PVD *Infection *Foot complications |
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Risk of CAD with DM
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*2-4 times greater
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TIA/CVA with DM
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*2-3 times greater risk
*Platelet adhesiveness (clots) *HTN r/t increase resistance in the circulatory system *Diabetic nephropathy |
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HTN with DM
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*40% increase with DM
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Why are there so many chronic macrovascular complications with DM?
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*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 |
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PVD with DM
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*Poor healing r/t poor circulation of nutrients and O2 to wounds
*Neuropathy *Increased amputation incidence |
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Infection with DM
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*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 |
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Foot complications with DM
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*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 |
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Microvascular Complications with DM
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*Retinopathy
*Nephropathy *Neuropathy *Gastroparesis *Neurogenic bladder |
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*Retinopathy with DM
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*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 |
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*Nephropathy with DM
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*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 |
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Nephrotoxic meds
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*Really strong ABX such as the mycins
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Function of Glomeruli
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*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 |
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Neuropathy with DM
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*1/2 DM experience it
*Transmission slows r/t poor nutrient supply to axons and dendrites *Numbness, tingling, burning *sensory loss |
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Gastroparesis with DM
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*20-30% of ppl with DM will experience
*slows stomach emptying r/t decreased nerve innervation *Reglan may help |
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Neurogenic Bladder with DM
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*Urinary stasis leads to more UTI's
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Pre-op considerations with DM pts
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*Usual labs
*Early morning OR to disrupt BS mgmt as little as possible *IV insulin for type I DM *Monitor BS immediatly before OR |
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Why do DM surgical pts need IV insulin
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*Because anasthesia decreases the metabolic rate so it won't be absorbed as quickly
*Surgery stresses body which increases BS |
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Intraoperative considerations with DM pts
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*IV insulin if necessary
*No sub-q insulin in OR |
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Post-operative considerations with DM pts
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*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 |
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What is the most common thing we see in the hospital?
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*Urinary Tract Infection
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Cystitis
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*Bladder infection
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Uretheritis
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*Uretheral infection
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How is a UTI diagnosed?
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*Culture and Sensitivity to ID what microorganism
*Dx with >100,000 organisms/ml |
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Why are UTI's more common in females?
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*Shorter urethra
*m/o doesn't have to travel as far *location of urethra to the rectum |
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What M/O is most often the cause of UTI?
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*E. Coli
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When are men at most risk for UTI?
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*> age 50 r/t prostate problems that cause urinary retention
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Etiology/Risk factors for UTI
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*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 |
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Clinical manifestations of UTI
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*Dysuria
*Hematuria *Frequency of urination *Urinary Urgency *Low back pain *Cloudy, foul smelling urine *fever, chill, N/v *Malaise *10% may be asymptomatic |
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Dysuria
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*Pain with urination
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Reason for low back pain in pts with UTI
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*Usually higher in the ureters and kidneys
*It's also more severe |
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What pts are most likely to be asymtomatic with UTI
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*The elderly
*Mostly will present with confusion |
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Ideal specimen for urine specimen?
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*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 |
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Management of UTI
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*ABX
*Urinary analgesics *Modify diet *Increase fluid intake *Prevent complications |
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ABX for UTI
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*Sulfonamides
*Cipro *Macrobid *Educate pts that will effect birth control *broad spectrum abx untill m/o is identified then more m/o specific abx |
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Urinary analgesics for UTI
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*Pyridium
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*What does pyridium do for UTI?
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*Decrease bladder spasms
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Side effect of Pyridium
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*Turns urine bright orange
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Diet modifications for UTI
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*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 |
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Bladder irritants
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*Increase aciditiy
*Caffine *Tomatoes *ETOH *Chocolate |
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How much fluid should someone drink for MAINTENANCE with UTI?
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*0.5 ounces/lbs of body weight
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Complication prevention with UTI
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*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 |
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Cells that are effected with bladder CA
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*Cells in bladder wall
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Etiology of bladder CA
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*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) |
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Decreasing risk of bladder CA
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*0.5/ounce/lb of fluid
*Quit smoking *no artificial sweetner |
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Clinical manifestations of bladder CA
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*Similar to UTI
*Painless hematuria *dysuria, frequency, urgency as CA progresses |
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Classic sign of bladder CA
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*Painless hematuria (pt usually goes to see healthcare provider when they have trouble voiding)
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Dx of bladder CA
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*Cystoscopy
*IVP *CT/MRI *CEA |
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What is a cystoscopy?
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*go in through the ureter to the bladder to visualize it.
*Wash it out and gather the washings for biopsy |
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What is a CEA?
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*Carcinoembryonic Antigen--tumor marker
*not specific to organ--just that tumor is present |
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What is IVP?
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*Intravascular pylogram
*Done in xray with dye to look for CA |
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Medical Managment of bladder CA
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*Intravesical chemotherapy-
BCG *Systemic Chemotherapy |
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Intravesical chemotherapy BCG
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*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) |
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Surgical managment of Bladder CA
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*Tumor excision through urethra (TUR)
*Partial cystectomy *Radical cystectomy & urinary diversion |
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Partial cystectomy
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*Remove part of the bladder
*bladder will have decreased capasity at first... as little as 60mls |
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Indication of partial cystectomy
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*Tumor must be contained
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Radical cystectomy & urinary diversion
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*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 |
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Indication of Radical cysectomy & urinary diversion
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*If CA is invaisive-spread
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Transurethral resection
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*TUR
*Remove tumor *pretty good method and fairly common |
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Indication for Transurethral resection
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*Tumor must be contained
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Conduit
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*tube
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Ways for urinary diversion
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*Ileal conduit
*Continent pouch |
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Ileal conduit
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*Segment of intestine (ileum) is used
*Ureters are attached to conduit *Must wear bag |
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Contraindications of ileal conduit
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*Pts who have small bowel disease
*Crohns disease *colitis |
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Pro's for continent pouch
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*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
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Continent pouch
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*Ascending colon/terminal ileum are used to make a bladder
*Will have a nipple valve *Catheterize stoma |
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Capacity of reservoir with continent pouch
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*60ml at first
*will expand to possible 600ml |
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Frequency of catheterizing continent pouch
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*may be as often as Q1H at first
*after 8-10 weeks may be as little as 4 times a day |
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Who is candidate for continent pouch?
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*Someone who can TAKE CARE OF IT!
*someone who has a decent life expectancy *not someone with METS |
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Similarites between the ileal conduit and the continent pouch
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*Urine characteristics
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Urine characteristics after urinary diversion
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*May have mucus present r/t using bowel for conduit
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Differences between ileal conduit and continent pouch
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*Method of urine collection
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Urinary drainage managment post-op urinary diversion
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*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 |
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What would cause a decrease or all together hault of urine output after urinary diversion?
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*Obstruction
*Dehydration |
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Stoma characteristics
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*Red beefy = good circulation
*Dusky=purple=poor circulation and hypoxia *Stoma will be large immediatly post-op r/t edema from OR |
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Peritonitis after urinary diversion
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*If suture line ruptures and spills contents into the sterile periteneum pt will get very sick
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S/S of peritonitis
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*distended abdomen
*Fever *Lots if pain *Increased WBC's |
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Urinary calculi
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*Kidney stones
*Forms in the kidney or in lower urinary tract *more common in males |
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Etiology of urinary calculi
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*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 |
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Cause of pain with urinary calculi
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*When stone moves.
*no pain when stone is stationary |
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Types of kidney stones?
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*Calcium phosphate or calcium oxalate
*Oxalate *Uric acid |
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Calcium phosphate or calcium oxalate stones
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*Males in early 20's
*gravel or stone size (can be bigger than 5mm) *Hypercalciuria |
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Causes of hypercalciuria
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*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 |
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Oxalate stones
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*Dietary
*Inflammatory bowel disease *Vit C excess |
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Foods that increase risk for oxalate stones
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*Tea
*Cola *Tomatoes *Instant coffe *cereal |
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Uric Acid kidney stones
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*People with gout
*Increase urate excretion *avoid protein excess |
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What do you do with a kidney stone once it is passed?
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*Send to pathology to find out what kind of stone it is
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What is colic?
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*Pain
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Clinical manifestations
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*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 |
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Ureteral colic
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*Pain in the front of the body and down through groin
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Renal colic
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*Pain in lubar & with men maybe testicles
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What causes pain with kidney stones?
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*Size of stone
*Mov't of stone |
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Medical managment of kidney stones
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*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) |
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Dietary changes for medical managment of kidney stones
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*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 |
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Ditropan
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*antispasmodic
*Decreases spasms to relax bladder |
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Surgical managment of kidney stones
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*Normally greater then 5mm stone
*20% require surgical intervention *Cystoscopy *Lithrotripsy *Open surgery |
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Calcium phosphate or calcium oxalate stones
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*Males in early 20's
*gravel or stone size (can be bigger than 5mm) *Hypercalciuria |
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Cystoscopy
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*Insert urethral catheter and try to remove stone
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Causes of hypercalciuria
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*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 |
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Oxalate stones
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*Dietary
*Inflammatory bowel disease *Vit C excess |
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Lithotripsy
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*VERY PAINFUL
*Put pt in a body of H2O *Deliver extracorporeal shock wave *pt will be very bruised along lumbar |
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When is open surgery used for kidney stones?
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*if lithotripsy doesn't work
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Foods that increase risk for oxalate stones
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*Tea
*Cola *Tomatoes *Instant coffe *cereal |
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Uric Acid kidney stones
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*People with gout
*Increase urate excretion *avoid protein excess |
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Decreasing injury with kidney stones
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*3-4 L of fluid/day
*monitor urine output (0.5ml/kg/hour) *Possible ureteral catheter *Strain all urine |
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Calcium phosphate or calcium oxalate stones
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*Males in early 20's
*gravel or stone size (can be bigger than 5mm) *Hypercalciuria |
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Ureteral catheter
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*Usually with open surger r/t inflammation
*Sometimes will need to be irrigated--need an order |
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Causes of hypercalciuria
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*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 |
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What do you do with a kidney stone once it is passed?
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*Send to pathology to find out what kind of stone it is
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Oxalate stones
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*Dietary
*Inflammatory bowel disease *Vit C excess |
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What is colic?
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*Pain
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Foods that increase risk for oxalate stones
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*Tea
*Cola *Tomatoes *Instant coffe *cereal |
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Clinical manifestations of kidney stone
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*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 |
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Ureteral colic
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*Pain in the front of the body and down through groin
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Uric Acid kidney stones
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*People with gout
*Increase urate excretion *avoid protein excess |
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Renal colic
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*Pain in lubar & with men maybe testicles
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What do you do with a kidney stone once it is passed?
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*Send to pathology to find out what kind of stone it is
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What is colic?
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*Pain
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Clinical manifestations
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*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 |
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Ureteral colic
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*Pain in the front of the body and down through groin
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Renal colic
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*Pain in lubar & with men maybe testicles
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Irrigation of ureteral catheters
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*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 |
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Urine decrease or stop with foley catheter
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*Worry about renal issues
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Nursing conciderations with kidney stones
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*Treat pain
*Monitor urine output *strain urine *teach about prevention |
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Urinary retention
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*functional problem
*Bladder is not emptying but the kidneys are still making urine |
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*Oliguria
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*Kidney's aren't making urine
*Kidney failure |
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Causes of urinary retention
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*BPH
*Surgery/anesthesia *Neuro deficits *DM |
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BPH
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*benign prostatic hypertrophy
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What does surgery have to do with urinary retention?
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*Takes time for the bladder to empty
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*What do neuro deficits have to do with urinary retention?
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*Brain doesn't let pt know that they have to void and so they hold it
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Concern with urinary retention
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*infection
*kidney stone |
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Nursing managment of urinary retention
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*Assess amounts and patterns
*Simulate indepentant voiding *Catheterization when post void residual is >300ml *prevent infection *prevent injury from catheter |
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How to assess amounts and patterns of voiding
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*Post void residual
*Bladder scanner |
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Post void residual
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*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 |
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Reason to take catheter out if post void residual is <300ml
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*to see if pt will eventually be able to empty bladder completely on their own
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Fluids or no fluids with urinary retention?
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*continue fluids
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Urinary incontinence
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*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 |
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Meds that can cause urinary incontinence
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*ETOH
*Cold meds *Antihistamines |
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Stress incontinence
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*Usually trauma to bladder (stomach surgery)
*Bladder goes into spams |
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Urge incontinence
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*Overactivity of muscles leads to weak bladder
|
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*Overflow incontinence
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*Does not empty bladder completly--retention
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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
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*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
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*Filters stuff in kidneys
|
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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
|
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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! |
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How to reduce inflammation with glomerulonephritis
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*Plasmapheresis
*Steroids *Anti-rejection meds |
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Plasmapheresis
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*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 |
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Diet changes with glomerulonephritis
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*High calorie for body repair
*Low protein if protein uria *Moderate protein and sodium restriction |
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Fluids with glomerulonephritis
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*Don't restrict but don't overload
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