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300 Cards in this Set

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A 56-year-old client who has abused alcohol for the past 15 years. He was brought into the emergency department by his wife because of his increased confusion and coughing up blood. His primary medical diagnosis is cirrhosis of the liver. He has ascites and esophageal varices. Assessment of Mr. Santara would reveal all of the following changes except:
a. Bulging flanks
b. Protruding umbilicus
c. Abdominal distention
d. Bluish discoloration of the umbilicus
d. Bluish discoloration of the umbilicus
A 56-year-old client who has abused alcohol for the past 15 years. He was brought into the emergency department by his wife because of his increased confusion and coughing up blood. His medical diagnosis is cirrhosis of the liver. He has ascites and esophageal varices. The major dietary treatment for ascites calls for:
a. High protein
b. Increased potassium
c. Restricted fluids
d. Restricted sodium
d. restricted sodium
3. A 40-year-old client was brought to the emergency department by his wife because of increased confusion. His medical history includes cirrhosis, alcoholism. He has ascites and esophageal varices. Which laboratory value would the nurse expect to find in Mr. Santoro as a result of liver failure?
a. Decreased serum creatinine
b. Decreased sodium
c. Increased ammonia
d. Increased calcium
c. increased ammonia
4. A nurse is caring for a client with end-stage renal disease (ESRD). The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse should be alert for which of the following? (Select all that apply)
a. Trousseau’s sign
b. Cardiac arrhythmias
c. Constipation
d. Decreased clotting time
e. Fractures
A, B, and E
5. When instructing the clients wife on providing continuous ambulatory peritoneal dialysis (CAPD) for her husband, the nurse would teach them to:
a. Add an antibiotic to the dialysate
b. Warm the solution before instillation
c. Suction the fluid out after instillation
d. Instill the solution at least twice a day
b. warm the solution before instillation
For a central line to be a true central line, the tip needs to be in the:
superior vena cava
Is heparin needed to flush a Groshong catheter?
Loop Diuretics

Furosemide (Lasix)

Bumetanide (Bumex)
Increase the amount of urine excreted. Inhibit electrolyte reabsorption in the loop of Henle, thereby promoting the excretion of sodium, water, chloride, and potassium
Thiazide Diuretics

Chlorothiazide (Diuril)

Hydrochlorothiazide (Hydrodiuril)
Increases sodium and water by inhibiting sodium reabsorption in the cortical diluting tubule of kidney
Potassium-sparing Diuretics

Amiloride (Midamor)
Spironolactone (Aldactone)

Triamterene (Dyrenium)
Act directly on the distal convoluted tubule to increase sodium excretion and decrease potassium secretion
Beta-adrenergic blockers

Block beta-adrenergic receptors mainly found in cardiac muscle. Reduce renin activity, with resulting suppression of the renin-angiotension-aldosterone system; resulting in reduction of systolic and diastolic BP.
A negative inotrope (force of contraction) and chronotrope (heart rate) effect; results in reduction in HR and force of contraction
Calcium Channel blockers

Amlodipine (Norvasc)

Diltiazem (Cardizem, Tiazac)

Nifedipine (Adalat)

Verapamil (Calan, Covera HS)
Class IV antiarrhythmic drugs that inhibit calcium ion influx through slow channels into cells of myocardial and arterial smooth muscle, negative dromotrope (decreases conduction rate).
Dilate coronary arteries, resulting in an increased myocardial O2 delivery (preventing angina).
Reduce BP
(ACE) Inhibitors

Inhibit the angiotensin-converting enzyme, responsible for converting angiotensin I to angiotensin II, and inactivates bradykinin and prevent peripheral vasoconstriction
Reduce aldosterone levels causing vasodilation and lower BP
The nurse is caring for a client who is diagnosed with diabetes insipidus. A nurse performs an assessment on the client, knowing that which symptom is indicative of this disorder?
a. Diarrhea
b. Polydipsia
c. Weight gain
d. Fatigue
A client admitted to a hospital with a diagnosis of diabetic ketoacidosis. The initial blood glucose level was 950 mg/dL. A continuous intravenous infusion of regular insulin is initiated an long with iv rehydration with normal saline. The serum glucose level is now 240. The nurse would next prepare to administer which if the following?
Iv fluids containing 5% dextrose
Used to prevent hypoglycemia.
A client w/ a dx of dka is being treated in an er. Which finding would a nurse expect to note as foncirming this dx?
a. Elevated blood glucose level and a low plasma bicarb
b. Decreased urine output
c. Increased respirations and an increase in pH
d. Comatose state
elevated blood glucose level and low plasma bicarb
After hypophysectomy, a client complains of being thirsty and having to urinate frequently. The initial nursing action is to?
a. Document the complaints
b. Increase fluid intake
c. Assess urine specific gravity
d. Assess for urinary glucose
assess urine specfic gravity
A nurse is caring for a client with pheochromocytoma. As part of the nursing care plan, the nurse monitors for hypertensive crisis. In the event that hypertensive crisis occurs, the nurse would anticipate that the most likely medication to be prescribed would be ?
Phentolamine mesylate (regitine)
what kind of diet is important for a pt. with cushing's syndrome?
high potassium diet
A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of nph insulin and exercise?
a. The best time for me to exercise is every afternoon.
b. The best time for me to exercise if is after I eat lunch
c. The best time for me to exercise is after I eat breakfast
d. The best time for me to exercise is after I eat morning snack
the best time for me to exercise is every afternoon
A community health nurse visits a client at home. Prednisone (Deltasone), 10mg PO daily, has been prescribed for the client. The nurse teaches the client about the medication. Which statement, if made by the client, indicates that further teaching is necessary?
a. I need to take the med every day at the same time
b. I can take the aspirin or my antihistamine if I need it
c. If I gain more than 5lbs in a week, call the doctor
d. I need to avoid coffee, tea, cola, and chocolate in my diet
I can take the aspirin or my antihistamine if I need it
A nurse provides instructions to a client taking fludrocortisones (Florinef). The nurse instructs the client to notify the physician if which of the following occurs?
a. Weight loss
b. Nausea
c. Swelling of the feet
d. fatigue
swelling of the feet
what is the sheet-like connection that connects the parietal peritoneum and abdominal organs?
intraperitoneal organs include:
liver, stomach, and intestines
retroperitoneal organs include:
kidneys, pancreas
what are some common sources of peritonitis?
perforations of stomach, intestines, gallbladder, or appendix; gunshot or stab wound; pelvic inflammatory disease
perforation may exhibit signs such as:
rigid, board-like abdomen; severe abdominal and shoulder pain; diminished or absent bowel sounds
what do you want to do first and then second if a perforation is suspected?
1st-notify physician so that proper testing can be done to diagnose perforation.
2nd-place the pt on NPO status
what are a couple ways to diagnose a perforation?
x-ray, CT scan, CBC, peritoneal aspiration C&S
what are some medical managements of a perforation?
iv fluid and electrolyte replacement, oxygen, antibiotics, NG tube, surgical treatment
what type of medications can be used for nausea/vomiting caused be perforation?
what are some important assessments for a pt with perforation?
GI is most important, VS (temp), BP trending down, HR trending up
what type of bleed takes priority?
the most common sites for GI bleed are:
esophagus, stomach, and duodenum
bleeding that has esophageal origin is caused by:
esophagitis, Mallory-Weiss tear, esophageal varices
what are esophageal varices?
Engorged and distended blood vessels in the esophagus and proximal stomach
what is the most common cause for esophageal varices?
Portal HTN occurs secondary to cirrhosis. The liver has high pressures and the blood needs (collateral circulation) to go somewhere of lower pressure. Common area that the blood will flow to is the esophagus. The veins in the esophagus are thin and fragile. The veins become engorged. Esophageal varices rupture and bleed easily
what type of treatment can be done if relief of stress related mucosal disease can't be managed?
total or partial gastrectomy
when does pain occur with gastric ulcers, and duodenal ulcers?
gastric is 1-2 hours after meals and duodenal is 2-4 hours after meals. there is usually pain relief with food or antacids for duodenal
what is important to know about Hct and blood loss?
Hematocrit will help show the severity of the pt’s blood loss. After IV fluids begin, h&h will be low. Checking hematocrit will help determine blood loss
some assessment findings of a pt with acute GI bleed?
hypovolemic shock, hematemesis, hematochezia, melena, hypotension, tachycardia, rigid board-like abdomen
how often are vital signs taken for acute gi bleed?
q15-30 minutes
some of the therapeutic interventions for acute gi bleed:
stop the bleeding, restore blood volume, oxygen, NG tube, lavaging
how many IV lines are in for acute GI bleed and what type of solution is infused?
2 lines with Isotonic crystalloid solution (NS, Lactated Ringers (LR))
-Whole blood, packed red blood cells (PRBCs), and fresh frozen plasma (FFP)
why is it good to infuse fresh frozen plasma?
it has clotting factors that will help stop or control the bleeding
what should be done before endoscopy is to be performed regarding acute gi bleed?
insert a large NGT and lavage with RT water or NS until clear
what are the two types of intervention that can be done endoscopically for GI bleeding?
endoscopic thermal therapy (heat probes, sclerotherapy) and endoscopic injection therapy (epinephrine, vasopressin)
what is the drug of choice when given IV for GI bleeds? What does it do?
octreotide; Decreases splanchnic blood flow and decreases HCl acid secretion via decrease in release of gastrin
what are some acute interventions for acute GI bleed?
maintain IV line, measure urine output (0.5mL/kg/hr), specific gravity urine
what type of position in bed should an acute GI bleed patient be in?
semi-fowlers or high fowlers
what is dumping syndrome?
when the food that is consumed is sent to the intestines before being digested in the stomach
post-op care for acute GI bleed is:
Monitor for complications:
Dumping syndrome
Postprandial hypoglycemia
buildup of ammonia in the blood will yield:
hepatic encephalopathy
what are the fat-soluble vitamins?
A, D, E, and K
cirrhosis is:
Chronic progressive disease of the liver characterized by extensive destruction of the liver
common causes of cirrhosis are:
Alcoholic liver disease
Chronic viral hepatitis
Chronic biliary obstruction
Chronic severe right-sided heart failure
clinical manisfestations of cirrhosis include:
-General: Fatigue, gen. weakness, malaise
Abdominal ascites, esophageal varices
Shortness of breath
Hepatic encephalopathy
what color will the BM's be with cirrhosis pts?
jaundice is caused by hyperbilirubinemia, which may be from one of 2 things:
Indirect (unconjugated) – related to increased RBC destruction
Direct (conjugated) – related to cirrhosis, biliary obstruction, hepatitis
the yellowish coloring of the eyes is:
what is portal hypertension?
Increased pressure in the liver veins from obstruction
complications of portal hypertension may include:
Esophageal varices
Hepatorenal syndrome
what are some causes of ascites?
Decreased colloidal oncotic pressure from impaired liver synthesis of albumin and increased portocaval pressure from portal hypertension
Hyperaldosteronism – can lead to hypokalemia
aldosterone will retain:
Na, causing retention of water
Fector hepaticus:
musty, sweet odor on the breath from buildup of toxins
Asterixis- liver flap:
high ammonia levels will produce this symptom (hold arms and hands right out in front of you and if hand flap then it could be high ammonia levels)
encephalopathy can occur secondary to cirrohsis of the liver. this occurs because of:
accumulation of ammonia, which will cause mental status changes
A complication of cirrohsis is:
hepatorenal syndrome
True or False: A patient that is in cirrhosis, will most likely go into renal failure too.
what are some diagnostic findings to diagnose cirrhosis?
elevated liver enzymes (AST and ALT), low serum albumin, ALP, high bilirubin, prolonged PT
If a pt has a liver biopsy, what position do you want to have the pt in?
lying on the right side to help stop potential bleeding
administration of albumin may be needed for cirrohsis pts, what is important to remember about infusion of albumin?
it is thick and a large gauge needle is needed.
If a pt has cirrohsis with ascites, what are some interventions that can be implemented?
sodium restriction, IV albumin, diuretic therapy (potassium sparing, loop, thiazide)
assessment for ascites caused by cirrohsis:
auscultate lung sounds, I&O, monitor electrolytes, assess for edema
If a pt has esophageal or gastric varices, what are the three things to teach pts?
avoid alcohol, aspirin, and irritating foods
What is TIPS and how does it help?
Transjugular intrahepatic portosystemic shunt (TIPS) and it helps with collateral flow
what is the main goal of hepatic encephalopathy?
reduction of ammonia
what pharmacologic agent is used to help reduce the ammonia levels in the blood?
lactulose; causes an acidic environment in the intestine which traps the ammonia. it promotes stooling
nursing considerations for ascites:
Measure abdominal girth
Monitor for edema – elevate if present
Daily weights, I & O
Monitor respiratory function
Administer diuretics (as prescribed)
Hob elevated
esophageal varices monitoring:
monitor balloon tamponade, monitor for aspiration, elevate HOB
Nutrition for pt with cirrhosis:
High carbohydrate, low protein
Soft diet if varices present
Low sodium diet and fluid restriction if edema and ascites present
Diet supplements
Avoid alcohol
Provide oral care
what kind of medications need to be avoided with cirrhosis?
ones that cause liver toxicity, acetaminophen
jaundice is first seen _______ on light skinned people and _________ on dark skinned peopel:
skin; mouth and eyes
Fulminant Hepatic Failure (acute liver failure) is:
A clinical syndrome characterized by severe impairment of liver function
causes for fulminant hepatic failure are:
drugs or viral hepatitis
the only organ that has endocrine and exocrine function is:
Glucagon is released from the alpha cells of the pancreas and helps:
release stored glucose into the blood stream
Insulin is released from the beta cells of the pancreas and help:
control the blood sugar within the body
what are the primary contributing factors to acute pancreatitis?
Chronic alcohol abuse
what is one of the theories of acute pancreatits?
When trypsin is activated in the pancreas, it destroys the pancreatic cells. Trypsin shouldn’t be activated until the small intestine.
One theory as to why enzymes are activated is from gall stones. A reflux of bile acid into the pancreas can cause the activation of these enzymes.
what is the #1 clinical manisfestation of acute pancreatitis?
pain, left or midepigastric
objective clinical manisfestations of acute pancreatitis:
Abdominal rigidity and guarding
Abdominal distention
Low-grade fever
pancreatitis causes:
if a pt has hypocalcemia from pancreatitis, what may be seen in the pt?
Muscle twitching
Changes in the client’s level of consciousness
Signs of tetany
pancreatic hemorrhage may cause one of two things:
-Cullen’s sign- pt will have ecchymosis around belly button
-Turner’s sign (Grey Turner’s spots or sign)- ecchymosis in the flank areas
complications of pancreatitis:
Pleural effusion, atelectasis, pneumonia
-Hypovolemia- if not resolved, pt can develop hypovolemic shock
diagnosis of pancreatitis includes:
Serum amylase
Urinary amylase
Serum lipase
Fecal fat
in pancreatitis, when will the amylase rise and how long will it stay increased for?
3-6 hours and 30 hours
in pancreatitis, when does lipase rise and how long does it stay high for?
doesn't rise until later and stays elevated for about 14 days.
what is a better indicator of pancreatitis, amylase or lipase?
lipase. a pt may not present to the ER until after the amylase has risen, peaked, and decreased. Therefore, the lipase is a better indicator since it doesn't rise until later.
what are the two best drugs to give to a pt with acute pancreatitis?
morphine and meperidine (demerol)
Pharmacologic management for acute pancreatitis:
what are some side effects of anticholinergics for the acute pancreatitis?
very dry, dry mouth, dry skin, brittle hair
a pt with pancreatitis can begin to eat again when:
the pain goes away. if the pain comes back, the pt should be placed on NPO status again
the diet for a pancreatitis pt may include:
small, frequent meals low in fat, protein, fiber, and high in carbohydrates (consult dietician)
If a pt has pancreatitis, there may be some changes in _____ _______. So, _____ _____ ____should be monitored as ordered
blood glucose; blood glucose levels
what is one of the differences between acute and chronic pancreatitis?
steatorrhea increases in chronic pancreatitis
what is delegation?
assigning or designating a competent individual the responsibility of carrying out a specific group of nursing tasks in the provision of care for certain clients
what is supervision of delegation?
the initial direction and periodic evaluation of a person performing an assigned task to ensure that he or she is meeting the standard of care
If a nurse delegates a task, is he/she still responsible for that task?
what is important for any nurse to do before delegation?
Assess the patient
If an RN is going to delegate a task to a UAP, it is important for the RN to:
demonstarte the task, explain expected outcomes, and be available for questions
what are the five rights of delegation?
-Right task
Do the tasks delegated follow written policy guidelines?
-Right person
Does the person have the proper qualifications for the tasks?
-Right direction or communication
Are the instructions and outcomes clearly stated? When should the person report changes?
-Right supervision or feedback
How can the delegation process be improved? Are the client goals for care being achieved?
-Right circumstances
Are the tasks that are being delegated free from requiring independent nursing judgments?
The RN should always ______ the delegatee?
The RN should avoid delegating which type of tasks?
-Tasks that are highly invasive or have the potential to cause significant physical harm to clients
-Assigning tasks that are under the scope of practice belonging exclusively to an RN
-Assigning tasks the person is not trained for or lacks the knowledge to safely complete
-Assign tasks when there is inadequate time to safely monitor or evaluate the practice of the person performing the task
LPN's may not be delegated what tasks?
-Cannot do admission assessments
-Cannot give IV push medications
-Cannot write nursing diagnoses
-Cannot do most teaching
-Cannot do complex skills
-Cannot take care of clients with acute conditions
-Cannot take care of unstable clients
For questions concerning UAPs, CNAs, and aides on the NCLEX:
-Look for the lowest level of skill required for the task
-Look for the least complicated task
-Look for the most stable client
-Look for the client with the chronic illness
the parathyroid gland releases parathyroid hormone in response to:
low calcium levels in the blood. it will pull calcium from the bones to increase blood levels
hypothalamus is part of the brain and is considered the:
command center
how many lobes does the pituitary gland have?
3; anterior, posterior, and intermediate
why is the thyroid gland important?
metabolism and growth
why is the pancreas important?
it plays a major role in insulin production
what is another name for the pituitary gland?
what are two things that the posterior pituitary secretes?
oxytocin and antidiuretic hormone (ADH, vasopressin)
because the pituitary hormone secretes ADH, it causes:
sodium retention, which causes water retention
the pituitary consists of 3 lobes: anterior, posterior, and intermediate. The anterior is also known as ______ and the posterior is also known as the ________:
adenohypophysis; neurohypophysis (oxytocin and ADH)
if blood osmolality is high, what do the kidneys do to help dilute the blood?
they are stimulated to retain water. this is done by the release of ADH from the post. pituitary
syndrome of inappropriate antidiuretic hormone (SIADH) is caused by:
an increase in ADH secretion
causes of SIADH may include:
malignant tumors, drug induced (thiazide diuretics, opioids), CNS infections, and miscellaneous
what is a major problem with SIADH?
water intoxication
clincical manisfestations of SIADH include:
fluid retention, increased urine SG (>1.032), nausea/vomiting, low urine output w/ high urine osmolality, decreased serum osmolality, and hyponatremia (dilutional: muscle cramps, weakness, ALOC)
diagnosis of SIADH is done by:
Based on analysis of urine and serum electrolytes and osmolality
Low serum osmolality
High urine osmolality
High urine specific gravity
what is the initial goal of SIADH management?
restore normal fluid volume and osmolality
-Fluid restriction to 800 – 1000 mL per day
-IV hypertonic saline solution (3% - 5%)
-monitor urine and sodium osmolality, electrolytes
Diuretics: ex. furosemide (Lasix)
physicians don't like to order lasix with SIADH patients unless the serum sodium is at least:
125 or higher
Demeclocycline blocks the effects:
of ADH on the kidneys
Lithium blocks the effects of:
the kidneys
what are some nursing implementations for SIADH?
-Fluid restriction
-HOB flat
-Seizure precautions
-Monitor VS, I & O, weights, urine specific gravity, neurologic status, lab values
fluid sources are considered:
anything that melts at RT
Diabetes Insipidus (DI) results from:
decreased secretion or response to ADH
what are the three types of DI?
-Central DI (neurogenic)
Interference of ADH production or release. Brain tumors, CNS infections, brain lesions
-Nephrogenic DI
Inadequate renal response to ADH despite presence of adequate ADH. Drugs that damage the kidneys (Lithium), renal damage
-Psychogenic DI
Excessive water intake. Lesion in the thirst center or psychiatric disorder
diabetes insipidus causes a massive urine output each day, 5L. What is a major problem with excessive output such as this?
what are some clinical manisfestations of DI?
extremely thirsty, extreme amounts of urine output, urine is very diluted, dehydration, weight loss, increased serum osmolality, Hypotension,
Increased temperature,
Electrolyte imbalances,
what diagnosis method is used for DI?
fluid deprivation test. Administer ADH or vasopressin intravenously or subcutaneously
30-60 minutes after administration, obtain urine and serum osmolality , compare to baseline
when is a fluid deprivation test considered positive?
when the urine osmolality is low or lower and serum osmolality is high or higher
what is the management for central (neurogenic) DI?
-Fluid and hormonal replacement
Intravenous hypotonic saline or dextrose 5% in water (D5W)
-Hormones- all the pressin drugs
what is important to remember about intranasal drugs?
spray into the nose and don't inhale. let the medication sit on the nasal mucosa and be absorbed
what type of diet should a nephrogenic DI pt be on?
low sodium, <3 gram/day
fluid sources are considered:
anything that melts at RT
Diabetes Insipidus (DI) results from:
decreased secretion or response to ADH
what are the three types of DI?
-Central DI (neurogenic)
Interference of ADH production or release. Brain tumors, CNS infections, brain lesions
-Nephrogenic DI
Inadequate renal response to ADH despite presence of adequate ADH. Drugs that damage the kidneys (Lithium), renal damage
-Psychogenic DI
Excessive water intake. Lesion in the thirst center or psychiatric disorder
diabetes insipidus causes a massive urine output each day, 5L. What is a major problem with excessive output such as this?
what are some clinical manisfestations of DI?
extremely thirsty, extreme amounts of urine output, urine is very diluted, dehydration, weight loss, increased serum osmolality, Hypotension,
Increased temperature,
Electrolyte imbalances,
what diagnosis method is used for DI?
fluid deprivation test. Administer ADH or vasopressin intravenously or subcutaneously
30-60 minutes after administration, obtain urine and serum osmolality , compare to baseline
when is a fluid deprivation test considered positive?
when the urine osmolality is low or lower and serum osmolality is high or higher
what is the management for central (neurogenic) DI?
-Fluid and hormonal replacement
Intravenous hypotonic saline or dextrose 5% in water (D5W)
-Hormones- all the pressin drugs
what is important to remember about intranasal drugs?
spray into the nose and don't inhale. let the medication sit on the nasal mucosa and be absorbed
what type of diet should a nephrogenic DI pt be on?
low sodium, <3 gram/day
what type of diuretics are used for nephrogenic DI?
Thiazide diuretics
Hydrochlorothiazide (Hydrodiuril)
Chlorothiazide (Diuril)
what do thiazide diuretics do to the kidneys?
slow the GFR to increase the amount of water that is reabsorbed
what are some nursing implementations for DI?
-Monitor VS, I & O, weights, urinary specific gravity, neurologic status, laboratory values
-Administer vasopressin as ordered
-Monitor for manifestations of water intoxication
-Monitor for manifestations of dehydration
-monitor for SIADH when administering ADH. DI can be flipped
low protein diet may be implemented because:
protein causes more fluid release
removal of the pituitary gland is called:
post-op care for a hypophysectomy includes:
-Instruct to avoid vigorous coughing, sneezing, valsalva, brushing teeth
-Monitor for post-nasal drip or nasal drainage
-HOB elevated at a 30-degree angle
-Monitor neurologic status
-Monitor VS
-Monitor electrolyte values
-Monitor I & O
-Mouth breathing
what are the two parts of the adrenal gland?
adrenal medulla and adrenal cortex
the adrenal cortex secretes what type of hormones?
adrenal cortex hormones include:
-Mineralocorticoids: aldosterone
-Glucocorticoids: cortisol (hydrocortisone) and corticosterone
-Adrenal Androgens- stimulate axillary hair and play a role in reproduction
aldosterone plays a role in:
sodium reabsorption and potassium excretion
cortisol has a major effect on:
glucose metabolism and cause blood sugars to increase
pts that are taking glucocorticoids are more prone to:
cushing's syndrome is when:
-Adrenal cortex hypersecretion-
Excess corticosteroids, particularly glucocorticoid
cushing's is usually caused by:
-Iatrogenic administration of exogenous corticosteroids
-Adrenocorticotropic hormone (ACTH)- secreting tumor
-Adrenal tumors
-Ectopic ACTH production by tumors
Lung or pancreas
clinical manisfestations of cushing's syndrome:
-Physical appearance
Weight gain
Centripetal (truncal) obesity
Moon facies
Purplish red straie
-Hyperglycemia, Hypokalemia
-Muscle wasting
-Mood fluctuations
-Menstrual disorders
clinical diagnosis of cushing's is:
-Clinical presentation
-24- hour urine collection for free cortisol
Levels of 50 – 100 mcg/day
-ACTH suppression (dexamethasone suppression test)
P. 1250 Table 48-8
-Plasma cortisol levels
-CT scanning or MRI- this looks for a tumor that may be secreting any hormones.
If a pt. abruptly stops taking their steroids for cushing's synrdome, what can occur?
adisonians crisis
the drug mitotane, used for pt's with cancer, can suppress the production of what?
managment of cushing's syndrome is to:
normalize hormone secretion, fluid and electrolyte correction, prevent complications
an adrenalectomy (removal of adrenal gland) can cause what type of syndrome/condition?
cushing's syndrome
some exogenous causes for cushing's syndrome are:
-Gradual discontinuance of corticosteroid therapy
-Reduction of the corticosteroid dose
-Conversion to every-other-day regimen
Why are accuchecks implemented in a pt with cushing's syndrome?
because of the use of glucocorticoids
implementation for cushing's syndrome may include:
-Monitor VS (esp. BP), I & O, weight, respiratory status, electrolytes, and glucose
-Examine for presence of edema
-Administer diuretics
-Collaborate with dietary: balanced, low-sodium diet, K supplements
if a pt has an adrenalectomy, what would be important for the nurse to educate the pt about?
the life-long use of steroid replacement
when is the best time for mineralcorticoids to be taken and why?
in the morning because of circadian rhythms and the body's natural time of release
An Addisonian crisis is caused by:
Precipitated by a stressful event such as infection, trauma, surgery, sudden withdraw of corticosteroids (most common), after adrenal surgery
addisonian crisis is essentially the exact opposite of:
cushing's syndrome
what is the most common hormone replacement used for addisonian crisis?
hydrocortizone...it has both mineralcorticoid and glucocorticoid properties
clinical manisfestations of addisonian crisis include:
-Severe hypotension, tachycardia with weak pulse
-Hypoglycemia, hyponatremia
-Cardiac dysrhythmias – hyperkalemia
-Severe dehydration
addison's disease is the chronic hypofunction of:
the adrenal cortex
what three classes of adrenal corticosteroids are reduced?
glucocorticoids, mineralcorticoids, and androgens
clinical manisfestations of addisonian disease include:
-Muscular weakness and fatigue
-Altered pigmentation
-Sparse axillary and pubic hair
-Weight loss
what are some diagnosis tools for addison's disease?
-Decreased serum cortisol levels
-Hyperkalemia – ECG changes
-Increased BUN
-Low urine free-cortisol levels
What is the most common treatment for addison's disease?
hormone replacement that is typically done with hydrocortizone (has glucocorticoid and mineralcorticoid properties)
nursing implementation for addison's disease include:
-Monitor VS
-Maintain fluid and electrolyte balance
-I & O, daily weight, encourage intake 3 L/day, add Na in diet
what kind of diet will a pt with addison's disease include?
consume foods high in sodium, decrease potassium intake
what is pheochromocytoma?
Adrenal medulla hyperfunction
Excessive secretion of epinephrine and norepinephrine
what is pheochromocytoma caused by?
Tumor of adrenal medulla (unilateral or bilateral)
epinephrine and norepinephrine causes vasoconstriction, which can lead to:
high blood pressure (as high as 300/200)
why is pheochromocytoma considered a life threatening emergency?
The blood pressure is extremely high. It can get high enough and will send the pt into heart failure
primary symptoms of pheochromocytoma include:
-Headache (often pounding)
-Hyperhidrosis (excessive sweating)
-Hypermetabolism (increased basal metabolic rate with weight loss)
if a pt has pheochromocytoma, what should the pt avoid?
ephedrine, bananas, caffeinated drinks, chocolate
Vanilla, alcoholic beverages, citrus fruits affect urine levels of VMA
diagnosis of pheochromocytoma may include:
serum catecholimine assays, 24-hour urine collection (catecholimines), CT or MRI
in order to treat pheochromocytoma, what must be done?
tumor removal (if necessary), or treatment of symptoms
why is bed rest important with a pt with pheochromocytoma?
it will reduce the release of catecholamines (epi and norepi)
the drug of choice for a pt in a hypertensive crisis of pheochromocytoma is:
what is the most important thing to assess for post-op after a pheochromocytoma pt has had surgery?
what are some pre-op things that can be done for a pt that is having an adrenalectomy?
Hyperglycemia and hypertension controlled and
Hypokalemia corrected
post-op care of adrenalectomy includes:
-Monitor VS, laboratory values
-Administer corticosteroids as ordered
-Promote effective breathing pattern; CDB, IS
-Keep HOB elevated 30-degrees
hypoglycemia is considered what value for blood glucose levels?
50-60 mg/dL
what are some common causes of hypoglycemia?
often caused by inadequate carbohydrate intake at meals, missed meals, vomiting, accidental insulin overdose or
Unusual energy expenditure
why does unusual energy expenditure cause hypoglycemia?
during peak insulin times, increased amounts of glucose are being pushed into the cell
s/sx of hypoglycemia are:
Shakiness or tremors
Cold, clammy skin
Fast, thready pulse, Confusion or disorientation
treatment of hypoglycemia includes:
-If conscious and able to swallow
6 - 8 oz. of orange juice or low-fat milk
Hard candy or a sugar cube
-If have lost consciousness
Sugar or frosting under tongue
1 mg IM or SQ
Peaks 30 minutes after administration
-IV dextrose
how often should blood glucose be checked for a hypoglycemia pt?
Check blood glucose level 15 min. after treatment and again 45 minutes
hypoglycemia dietary:
carry hard candy, or commercial product, etc.
What is DKA and what causes it?
-Life-threatening metabolic acidosis resulting from persistent hyperglycemia and breakdown of fats into glucose, leading to presence of ketones in blood
-Emotional stress, uncompensated exercise,
Infection, Trauma, Insufficient or delayed insulin administration
in a DKA pt, why does the pt. become hyperkalemic?
potassium being pushed out of the cell for hydrogen ions to be pushed into the cell
s/sx of DKA:
-Lethargy and weakness
-Fruity or acetone odor on the breath
diagnosis of DKA:
-Low pH
-High serum glucose (>250 mg/dL)
-Initially hyperkalemic
treatment of DKA:
-Fluid therapy
Normal saline solution, 1 – 2 L during first hour, then decrease to 500 mL/hr as tolerated,
When blood glucose levels reach 250 to 300, a 5% glucose solution is added to prevent hypoglycemia
Bolus of regular insulin followed by continuous IV drip until glucose levels normalize
BGM every 30 minutes to every 2 hours
what is a possible complication of treatment of DKA?
hypokalemia...as DKA is corrected, potassium goes back into the cell causing low levels in the blood
what is Hyperglycemia Hyperosmolar Nonketotic Syndrome (HHNS/HHNKS)?
Life-threatening metabolic disorder of hyperglycemia usually occurring with DM type II
what is HHNKS caused by?
-Acute illness
-Invasive procedure
-Chronic illness
-Excessive caloric intake
s/sx of HHNKS:
-High blood glucose levels (>600 mg/dL)
-Postural hypotension
how much fluid should be given to a pt with HHNKS and for how long?
1-2L for the first hour or two
what is the most abundant intracellular cation?
what is the normal range of potassium?
3.5-5.0 mEq/L (<3.5 is hypokalemia, >5.0 hyperkalemia)
what is our main source of potassium?
what kind of relationship do K and Na have?
inverse relationship
How does Mg play a role with K and Na?
it moves K out of the cell and Na into the cell
what is a classic sign of hyperkalemia?
tall and peaked T waves
what are some common reasons for hyperkalemia?
Renal insufficiency, crushing injuries, increased dietary intake, potassium sparing diuretic
how does aldosterone play a role in K?
Na is increased and K decreases
s/sx of potassium imbalances:
hypokalemia: Flat or inverted T waves, dysrhythmias, Vertigo, Muscular weakness
hyperkalemia: Tachycardia, (later bradycardia) and then cardiac arrest, Peaked, narrow T waves, muscle cramps
IV potassium replacement can be very painful through the peripheral IV. What is the best method for administration?
central line if possible. Always dilute your potassium!!
what should the urine output be if potassium replacement is to be done?
sodium bicarb can be used temporarily for treatment of hyperkalemia. How does this help?
sodium bicarb pushes the potassium back into the cell
what kind of drugs can cause potassium imbalances?
how does hypokalemia affect digitalis?
it enhances the action
what is the normal dose of IV potassium and should it be given as a bolus or diluted?
20-40 mEq/L; diluted (NEVER BOLUS)
Sodium is the cation mainly found where? what is it responsible for?
ECF, water retention
what is the normal values of sodium?
135-145 mEq/L
How does sodium work on the cellular level?
Na pump action. Na shifts into cells as K shifts out, repeatedly, to maintain water balance and NM activity.
what is responsible for diluting our sodium?
water retention or intoxication
what happens when there is Cellular swelling causing fluid to shift into the cells to try and dilute the Na
CNS changes such as headaches, lethargy, confusion, seizures.
s/sx of hyponatremia:
Tachycardia, hypotension
Headaches, lethargy, confusion, seizures
Muscular weakness
s/sx of hypernatremia:
Tachycardia, possible hypertension
Restlessness, agitation, stupor
Muscular twitching, tremor, hyperreflexia
what drugs cause sodium imblances?
diuretics (sodium excretion) and corticosteroids (promote sodium retention and potassium excretion)
what can occur if a pt has hyponatremia and the sodium levels are raised too quickly?
cerebral edema
treatment for hyponatremia and hypernatremia:
normal saline or salt solution; diuretics
how are sodium and chloride involved with each other?
sodium easily binds to chloride
where is calcium found in the blood?
what is the normal range for calcium?
9-11 mg/dL
what kind of relationship does calcium and phosphorus have?
inverse; Ca is up, Phos is down and vice versa
functions of calcium include:
transmission of nerve impulses and contraction of skeletal muscles
Contraction of myocardium
Coagulation of blood
Formation of teeth and bone
s/sx of hypocalcemia:
+Chvostek’s sign
+Trousseau’s sign
Impaired blood clotting
s/sx of hypercalcemia:
Muscles flabby
Cardiac arrest
Pathologic fractures
Calcium stones
Flank pain
if a pt is receiving calcium supplements, what else must they take?
Vitamin D
chronic alcoholism will cause:
renal failure will cause:
function of phosphorus is:
Bone and teeth formation
Normal nerve and muscle activity
If a pt is receiving IV phos, what can happen?
phlebitis (can be avoided with a rate of 10mEq/L
hyperphosphatemia can be treated with:
aluminum antacids
what is the normal range of Magnesium?
1.5-2.5 mEq/L
function of Mg:
-Mediator for neural transmission in the CNS
-Contracts the myocardium
-Activates enzymes for carbohydrate and protein metabolism
-Transports Na and K across cell membranes
what is the treatment for a pt with hypermagnesemia?
IV saline or Calcium salts, dialysis
what are some basic functions of the kidneys?
reabsorption, secretion, vit D activation, renin-angiotensin aldosterone system (helps reabsorb water by retaining sodium)
chronic renal failure is:
Progressive , irreversible deterioration in renal function; uremia or azotemia
chronic renal failure is caused by:
Hypertension (HTN)
Obstruction of the urinary tract
Polycystic kidney
can acute renal failure be reversed?
it can be reversed and kidney function may be restored
what is the output for oliguria?
what is the output for anuria?
what are the three stages of chronic renal failure?
initial (75% nephron loss), second phase (90% nephron loss), and final stage-ESRD (GFR <10%, BUN and creat levels are increased)
what test determines the GFR?
creatinine clearance, both urine and serum
what is a common problem with kidney failure?
hyperkalemia, with tall peaked T-waves
what should never be given to a dialysis patient?
potassium or magnesium supplements
Since there is a lack of kidney function, hyperkalemia, hyperphosphatemia, and hypermagnesemia occur. Why is calcium low (hypocalcemia)?
Vitamin D is not being activated because the kidneys have decreased function.
why is sodium not very diagnostic in determing kidney failure or function?
it can be high, low, or normal. most pt's will be on low or restricted sodium though to prevent water retention
what are some common complications from chronic renal failure?
Anemia, platelet dysfunction, infection
Loss of muscle strength
Muscle cramping
Bone fractures
Renal osteodystrophy
Shortness of breath, tachypnea, Kussmaul’s breathing
what is a common, non life threatening, problem with pt's who stop their dialysis?
uremic frost. uremia deposits are all over the skin (little crystals all over the skin)
creatinine clearance (24-hour) is the best indicator of the kidney function. BUN helps, but why is it not as good?
BUN can be affected by other things in the body and isn't the best test to determine function
HTN is a common problem with renal failure patients. How can this be treated?
-Drug therapy
adrenergic blockers
Calcium channel blockers
Angiotensin-converting enzyme (ACE) inhibitors
-Dietary management
Water restriction
Sodium and Potassium restriction
what is something that should NOT be held for a dialysis pt?
Tums, it's used to help with the hypocalcemia
what drugs may be used for a pt with renal failure?
Calcium carbonate (Tums)
Calcium acetate (PhosLo) for hypocalcemia,
Calcitriol (Rocaltrol),
Sevelamer hydrochloride (Renagel)
Lanthanum carbonate (Fosrenol), for hyperphosphatemia
what are some key points to remember with renal failure pt's that have anemia?
Erythropoietin (epoetin alfa [Epogen, Procrit]
Darbepoetin alfa (Aranesp)
Monitor for hypertension
Iron deficiency
Folic acid
why should meperidine never be given to a pt with renal failure?
causes a buildup of normeperidine
what is the dietary management that must be implemented for renal failure pts?
-High carbohydrates
-Moderate fat
-Protein restriction – usually 1 g/kg
-Water restriction
-Sodium and potassium restriction
-Phosphate restriction
what are the three types of dialysis?
hemodialysis, peritonealdialysis, and continuous renal replacement therapy (CRRT)
who are the only people allowed/trained to do CRRT therapy?
ICU staff. Some staff nurses may perform if given the proper training
how often is CRRT, hemodialysis, and peritoneal dialysis done?
continuous for a few days to 5 or 6 weeks; a few days a week (MWF or T,Th,S schedule), typically everyday
what is generally happening with diaylsis?
Solutes and water move across semipermeable membrane from the blood to the dialysate or from the dialysate to the blood in accordance with concentration gradients
what dialysate solutions are used for peritoneal dialysis?
Glucose concentrations of 1.5%, 2.5%, 4.25%
Add medications
what is a general rule of thumb for PD?
-The higher the glucose concentration, the more fluid will be pulled from the patient’s body
-The lower the glucose concentration, the more toxins will be pulled from the patients body
what are some common complications of PD?
Exit site infections
Abdominal pain
peritoneal dialysis is contraindicated for which patients?
pts that have multiple abdominal surgeries
how is hemodialysis done?
Arteriovenous (AV) fistulas and grafts
Temporary vascular access
what should be felt and/or auscultated with an AV fistula/graft?
thrill and bruit
what are some nursing considerations for HD pts?
NEVER use HD catheter without a physician order
NO….. In affected extremity
Blood pressure measurements
Insertion of IVs
what is disequilibrium syndrome and why does it occur?
develops as a result of rapid changes in composition of the ECF.* the toxins are more rapidly removed from the periphery than in the CSF. Fluid will shift into the brain and cause cerebral edema.
what are some s/sx of disequilibrium syndrome?
s/sx-nausea, vomiting, seizures, confusion, headaches. Usually occurs in the first couple of runs for HD, but doesn’t typically happen much after that. The way to stop is to stop the dialysis or infuse hypertonic solutions.
what needs to be done before beginning HD treatment?
-full assessment-
Fluid status (weight, BP, peripheral edema, lung and heart sounds)
Condition of vascular access
what type of nurse is required for CRRT?
ICU nurse or specially trained staff nurse