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118 Cards in this Set
- Front
- Back
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5 Types of incontinence
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1. Stress
2. Urge 3. Overflow 4. Reflex 5. Functional |
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4 Types of Urinary Retention
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1. Obstruction
2. Detrusor Muscle 3. Neurogenic 4. Voluntary |
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Stress Incontinence
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PATHOPHYSIOLOGY/DEFINITION
Pelvic muscle relaxation weak urethra related to multiple pregnancies, <estrogen prostate surgery S/S loss of small amounts of urine sneezing, coughing, lifting NURSING ED Kegal's Avoid irritating foods: caffeine, NutraSweet, citrus juice |
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Urge Incontinence
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PATHOPHYSIOLOGY/DEFINITION
<bladder capacity bladder irritation CNS disorders S/S Can't reach toilet in time after urge felt. NURSING ED Anticholinergics Kegal's Toileting schedule; goal 300cc w/ each void Diurectics early in the day |
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Overflow Incontinence
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PATHOPHYSIOLOGY/DEFINITION
urinary retention S/S Dribbling urine NURSING ED check for residual urine cholinergics toileting schedule |
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Reflex Incontinence
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PATHOPHYSIOLOGY/DEFINITION
spinal cord injury hypereflexia of detrusor muscle S/S involuntary loss of moderate amt of urine no warning |
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Functional Incontinence
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PATHOPHYSIOLOGY/DEFINITION
Self care deficit interferes with ability to respond S/S Inability to get to toilet on time NURSING ED Toileting schedule reduce delay in toileting answer lights quickly |
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Obstruction Retention
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PATHOPHYSIOLOGY
BPH Infection/trauma scarring S/S overflow incontinence firm distended badder often displaced to the side. NURSING ED may require surgery difficult to cath coude tip |
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Detrusor muscle retention
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PATHOPHYSIOLOGY
Surgery (commone post-op complication) Medications (anitcholinergics) NURSING ED Don't allow 8hrs w/o void bladder scan straight cath run water, hands in water, AMBULATE cholinergic meds (Urecholine) |
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Neurogenic Retention
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PATHOPHYSIOLOGY
Spinal cord injury diabetes NURSING ED Trigger points crede valsalva +manual pressure teach self cath |
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Voluntary Retention
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PATHOPHYSIOLOGY
Voluntarily hold urine past urge to void teachers, nurses NURSING ED Go when you need too!!!! |
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Creatinine Clearance
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90-130
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specific gravity of urine
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1.005-1.030
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BUN
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5-20: slightly higher-up to 23 for people over 60
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serum creatinine
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0.5-1.2
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calcium
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9-11
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phosphorus
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1.7-2.6
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magnesium
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1.5-2.5
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normal WBC,
and name for high and low related to |
4,500-10,000
low- leukopenia high-leukocytosis fight infection |
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normal platelet level
name for high and low related to |
150,000-400,000
low- thrombocytopenia high-thrombocytosis clotting |
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RBC
name for high and low hemoglobin level hematocrit level |
low- anemia
high- polycythemia hemoglobin-12-18 hematocrit-36-54% |
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potassium level
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3.5-5.3
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sodium level
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135-145
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albumin level
physical sign albumin level is low |
3.5-5.0
edema |
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chloride level
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95-105
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Therapeutic Dig level
4 nusing interventions for high dig level |
0.5-2
1. monitor potassium levels 2. monitor for signs of toxicity (headache, nausea...) 3. monitor BP and HR 4. apical pulse |
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total cholesterol
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<200
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LDL cholesterol
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<100
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HDL choesterol
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>60
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triglycerides
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<150
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Therapeutic INR
concern high INR.. order? concern low INR. order? |
2-3
high- blood isn't clotting fast enough, bleeding risk. order- decr coumadin dose. low- blood clotting too fast, risk for clots, order- incr coumadin dose. |
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normal pH
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7.35-7.45
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Normal CO2
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35-45
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Normal HCO3
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22-26
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Lab that reflects severity of pt's HF
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BNP
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2 lab values that reflect damage to heart muscle after heart attack.
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CKMB and troponins
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List 3 signs of cystitis and 5 patient education points related to prevention.
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cystitis- inflammation of the bladder from infection or obstruction.
s/s- dysuria, urgency, nocturia, pyuria, hematuria, suprapubic discomfort, tired, anorexic. elderly confused and incontinent. Pt Teaching points. 1. encourage fluids 2-2.5 quarts/day 2. void when urge is felt. empty bladder every 3-4 hours 3. wipe front to back 4. females void before and after intercourse. 5. women avoid bubble baths, feminine sprays, and douches 6. wear cotton underwear 7. drink 2 glasses of cranberry juice/day 8. avoid excess milk and milk products, and sodium bicarb. |
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list s/s of chronic renal failure
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s/s - headache, lethargy, metallic taste, anorexia, pruritis, anuria, muscle cramps, dusky color, <LOC, proteinuria, anemia, fluid overload, CHF
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renal failure- 3 dietary modifications to teach pts prior to dialysis.
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high carb
low K low phosphorus restrict fluids and NA |
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2 Major causes of chronic renal failure
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Diabetes
Hypertention |
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kidneys effect
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Fluid balance
electrolytes BP erythropoietin-RBC production |
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2 major signs of acute renal failure
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-oliguria (urine output less than 400ml/day
-rising BUN or serum creatinine levels |
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Major categories of causes of acute renal failure (3)
give 2 examples of each |
PRERENAL
-Impaired blood flow to kidney hemorrhage, dehydration, HF, shock INTRARENAL FAILURE -acute tubular necrosis (ATN): -tubular cell damage due to prolonged ischemia and/or exposure to nephrotoxins; acute kidney disease. ischemia, nephrtoxic drugs or substances, heatstroke POSTRENAL FAILURE obstruction of urine outflow urethral obstruction by enlarged prostate or tumor, ureteral or kidney pelvis obstruction by calculi |
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3 classifications of nephrotoxic drugs that can cause acute renal failure
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Aminoglycosides
NSAIDS chemotherapy cox 2 inhibitor cocaine venom |
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Compare Hemodialysis with Peritoneal Dialysis
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HEMODIALYSIS
-3x per wk for 4-6hr -pt blood in one compartment , dilysate in another -clients blood into dialyzern(movement from blood to dialysate by diffusion, osmosis ACCESS subclavian and femoral catheter (short-term) AV shunt- external arteriovenous shunt AV fistula/AV graft- internal arteriovenous fistula PERITONEAL DIALYSIS -done at home; different schedules (usually at night), uses gravity. -pertoneum is dialyzing membrane and substitues for kidney function. ACCESS surgical insertion of a catheter into the abd cavity 3-5cm below umbilicus. BETTER TOLERATED |
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Steps of RAAS system
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RENIN ANGIOTENSIN ALDOSTERONE SYSTEM
1.Decr. Blood flow to kidneys cause kidneys to secrete renin 2. Renin Converts angiotensinogen to angiotensin I 3. Angiotensin I goes to lungs where ACE converts it to angiotensin II 4. Angiotensin II causes a) thirst mechanism stimulated (incr blood volume and CO) b)adrenal gland to release aldosterone (NA retention, H20 retention, and K excretion) c) vasoconstriction (incr BP) |
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Decr BP causes the pituitary to release
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ADH
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vital sign to monitor related to RAAS system and ADH
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BP
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What is BPH?
list 2 manifestations? |
Benign Prostatic Hyperplasia
enlargement of the prostate gland Nocturia Diminished force of urinary stream Hesitency in starting voiding Dribbling after voiding Incomplete bladder emptying frequency, urgency urge incontinence dysuria, hematuria |
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what drug manages symptoms of BPH?
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Finasteride (Proscar) causes gland to shrink
Alpha1 blockers terazosin (Hytrin), doxazoin (Cardura), and tamsulosin (Flomax) - relax smooth muscle reducing obstruction. |
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TURP (Transurethral Resection of the Prostate) NURSING CARE
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BEFORE SURGERY
-provide routine pre-op care and teaching -inform pt they will return from surgery w/ a urinary catheter. AFTER SURGERY -provide routine post-op care -assess and manage pain (urethral discomfort, bladder spasms, and abdominal cramping due to gas) -use aseptic technique when managing urinary drainage and irrigation. -maintain accurate I&O -encourage fluids when allowed -frequently asses catheter patency, record color and characteristics of urine. monitor for hemorrhage for first 24-48 hours. |
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TURP - 2 things related to urine output post-op
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1st 24hrs - light red urine w/ small clots
24-48hrs - light pink to yellow urine |
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ABCs of trauma care
A-E primary survey (list 2 things to assess for for each) |
A - AIRWAY W/ SPINAL STABILIZATION
-Jaw thrust -Secretions, Vomitus, edema, bleeding, loose teeth, debris B - BREATING -Rate, rhythm, spontaneous, vocalization, color of skin, breath sounds equal bilaterally, trachea, subq emphysema -non-rebreather mask C - CIRCULATION -Pulses, pressure on external bleed, type and cross match, 2 #14IV, run one LR and NS w/blood tubing. -beeding, capillary refill, pupils, D - DISABILITY -Pain, broken bones, LOC, PERRL, AVPU E - EXPOSE/ENVIRONMENT -remove clothing, keep warm |
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ABCs of trauma care
F-I secondary survey |
F - FIVE INTERVENTIONS
-NG, cath, pulse-ox, EKG, full set of vitals -lab tests -family support G - GIVE SUPPORT Control pain/anxiety H - HISTORY -Head to toe exam -Splint as necessary I - INSPECT POSTERIOR SURFACE |
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types of shock (5)
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Hypovolemic
Anaphylactic shock Septic shock Neurogenic shocl Cardiogenic shock |
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Hypovolemic Shock
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-not enough blood, low-volume shock, lack of circulating blood volume.
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Anaphylactic Shock
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BP tanks, immune reaction triggers abnormal dilation of blood vessels.
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Septic Shock
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Overwhelming infection, usually gram-negative; cause dilation of blood vessels
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Neurogenic Shock
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when nerves are cut which causes less venous constriction due to absent nerve stimulation; also spinal anesthesia and barbiturate overdose.
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Cardiogenic Shock
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Volume overload, not volume deficit; caused by faiure of hearts pumping action.
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Shock
3 things every cell needs |
body isn't able to provide the cell with a constant supply of O2 and removal of wastes.
3 things every cell needs -adequate blood flow -correctly functioning heart -normal blood vessel diameter |
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3 stages of shock
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Compensatory Stage
Progressive Stage Irreversible Stage |
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Manifestations of Compensatory stage of Shock
(LOC, BP, P, R, Skin, Urine) |
LOC -oriented but restless
BP -Normal to slightly decreased P - >100bpm R - >20/min Skin - pale, cool, moist Urine- Less than 30mL/hr |
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Manifestations of Progressive stage of Shock
(LOC, BP, P, R, Skin, Urine) |
LOC - confused; decr response to pain
BP - <90mmHg P - >150bpm R - >30/min, shallow, possible crackles Skin - Cold, clammy; possible cyanosis Urine - Less than 20mL/hr |
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Manifestations of Irreversible stage of Shock
(LOC, BP, P, R, Skin, Urine) |
LOC - Lethargy to coma, no relfex response
BP - Falling to unobtainable P - Slow and Irregualr R - Slow w/ Chayne-Stokes respirations Skin - Cold, cyanotic, mottled Urine - Anuria |
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alcoholism can cause both
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low magnesium and low phosphorus
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Fluid volume deficit
-manifestations - lab values |
MANIFESTATIONS
fatigue postural hypotension tachycardia weak, thready peripheral pulse weight loss flat neck veins, decr central veous pressure dry skin, poor turgor decr urine output, concentrated urine LAB VALUES Incr osmolality Incr Hematocrit Incr Urine Specific Gravity |
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Fluid Volume Excess
-manifestations -lab values |
MANIFESTATIONS
Hypertension Tachycardia Full, bounding peripheral pulses Incr respiratory rate cough, dyspnea, orthopnea moist crackles, wheezes weight gain distended neck veins, incr CVP Dependent edema LAB VALUES Decr serum osmolality Decr Hematocrit Decr Urine specific gravity |
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prehospital emergency care of the client experiencing hemorrhage
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1. scan environment for hazards
2. call for help 3. ensure adequate airway 4. assess for cause of hemorrhage 5. control external bleeding with direct pressure and pressure points. 6. turniquet as LAST RESORT 7. assess for shock 8. if no head injury keep head and back flat and elevate legs. 9. cover client for warmth 10. NPO 11. use touch and verbal communication to reduce anxiety. |
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Nursing responsibilities for a blood transfusion
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ID client and blood.
monitor for febrow reaction (occurs w/in the 1st 15 minutes) |
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waste products removed by kidneys
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creatinine and BUN
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positioning for dyspnea
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high fowlers
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renal calculi prevention
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drink 8-10 gasses of water a day
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manifestations of fluid volume deficit
(HR, BP, Skin) |
incr HR, decr BP, dry skin
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lab results post hemodialysis
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decr serum creatinine
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normal body temp in deg celcius
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37.0 deg celcius
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indication of peritonitis during peritoneal dialysis
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cloudy dialysate
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secreted by kidney, resonsible for RBC production
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erythropoietin
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edema assessment of a pt on bed rest
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sacral area
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manifestations of peritonitis
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absent bowel sounds, rigid board like abdomen, cloudy dialysate
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periorbital edema
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nephrotoxic syndrom
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healthy adults feel the urge to void when how much urine has collected in the bladder?
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300-500mL
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post IVP nursing actions
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1. monitor injection site
2. report signs of reaction to dye 3. monitor vitals and urine output |
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manifestations of hypocalcemia
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tetany, muscle cramps, tingling
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electrolyte imbalance, tall peaked T waves on ECG
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hyperkalemia
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manifestations of hyponatremia
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headache, anorexia, N/V
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3rd spacing
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fluid moves out of intervascular space into surrounding area
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low risk for third spacing
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diabetes mellitus - fluid moves into the blood
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high risk for fluid volume deficit
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ileostomy
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medication that lowers K levels in body
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kayexalate
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electrolyte that incr metabolic acidosis and decr metabolic alkosis
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potassium
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electrolyte effected by by thyroid and PTH gland
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calcium
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2 things that must be present before you can give high dose potassium
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adequate urinary output and a cardiac monitor.
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monitor for what after giving opiods
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respiratory depression
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medication frequently given pre-op to reduce oral secretions and prevent aspiration
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atropine sulfate
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L sided HF manifestations
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dyspnea, orthopnea, cough
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lab values for a client with hematuria, melena (back tarry stools), and purpura (subq bleeding) are likely to show
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thrombocytopenia
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sickle cell crisis triggered by
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dehydration, hypoxia, infection, excessive exercise
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in pernicous anemia deficiency of this results in malabsorption of Vit B12
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intrinsic factor
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if this was found in a chest tube drainage further action would be needed
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vigorous bubbling in H2O seal chamber
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breathing technique that prolongs exhalation, helping remove C02 from lungs
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pursed lip breathing
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impaired liver function will not effect
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production of amylase
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medication that decr serum ammonia by inhibiting ammonia absorption in the gut and promoting ammonia excretion in the stool
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lactulose (cephalac)
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new diagnosis of A fib monitor for
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irregular pulse
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pink frothy sputum is a sign of
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pulmonary edema
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nursing responsibility for plasmapheresis
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check for signed consent
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manifestations of pulmonary embolism
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chest pain, cough, anxiety, dyspnea
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pulmonary hypertension can cause this
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cor pulmonale
(R sided HF w/ or w/o HF) |
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flow of blood though the heart
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right atrium
tricuspid valve right ventricle pulmonic valve pulmonary trunk pulmonary arteries lungs pulmonary veins left atria bicuspid valve left ventricle aortic valve aorta arteries arterioles capilaries venules veins inferior and superior vena cava |
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hyponatremia
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LOW SODIUM
-affects function of voluntary and involuntary muscles. -brain cells swell leading to NEURO s/s s/s anorexia, N/V, abd cramping, diarrhea, mental status change, hyperreflexia, twitching, tremors, convulsions, coma LABS serum sodium<135 serum osmolality<280 |
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hypernatremia
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EXCESS SODIUM
-changes in LOC -brain cells shrink -dry, sticky, membranes s/s thirst, restlessness, weak, altered mental state, LOC changes, muscle irritability, dry sticky mucous membranes, postural hypotension, hot, dry skin, fever, decr sweating LABS serum sodium >145 serum osmolality >295 |
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hyper/hyponatremia effects:
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fluid shifting causes neuro changes
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Potassium Imbalance efects:
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the heart
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hypokalemia
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LOW POTASSIUM
s/s dysrythmia and EKG changes. FLATTENED T-WAVE; U WAVE; n/v, anorexia. <BS, muscle weakness, leg cramps. serum potassium <3.5 |
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hyperkalemia
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HIGH POTASSIUM
MOST DONGEROUS OF ALL ELECTROLYTE IMBALANCES!! s/s TALL< PEAKED T-WAVES, dysrythimia, heart block, cardiac arrest, nausea, abd cramping, muscle weakness, paresthesias, flacid paralysis. lab K>5.3 |
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hypo/hypercalcemia affect:
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muscle irritability
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hypocalcemia
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s/s
neuromuscular excitability increases. tetany, numbness, tingling. positive Chvostek's sign, positive Trousseau's sign. abd cramping, diarrhea <BP, <CO, dysrhythmia |
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hypercalcemia
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s/s
muscle weakness fatigue <tendon reflexes constipation anorexia, n/v >BP, dysrhythmias >urine output |
