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105 Cards in this Set

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Key Features of Hyperthyroidism
Cardiovascular - Palpitations - Chest pain - Systolic hypertension - Tachycardia - Dysrhythmias
Respiratory - Dyspnea, at rest or exertional
Neurological - Visual changes - Eye fatigue - Eyelid retraction, global lag - Exophthalmus (bulging eyes) - Tremors
Gastrointestinal - Increased appetite - Diarrhea - Weight loss
Metabolic - Increased BMR - Heat intolerance - Low grade fever
Psychological - Decreased attention span - Restlessness - Irritability - Manic, labile behavior
Muscle weakness, wasting. and fatigue
Thyroid Storm/Crisis
Fever > 102 (can be as high as 105.3)
Systolic hypertension
Heart failure
N & V
Agitation confusion, seizures
Emergency Care of Client During Thyroid Storm
Maintain patent airway and adequate ventilation
Medications that lower thyroid levels including:
Propylthiouracil (PTU), Methimazole (Tapazole)
Iodine (blocks release and inhibits T3/T4 synthesis—also decreases vasculature of thyroid gland prior to surgery)
Inderal/beta blockers (to decrease heart activity)
Glucocorticoids (hydrocortisone, prednisone)
Antipyretics (non-aspirin based)
Cardiac monitor for dysrhythmias
Monitor vitals frequently
IV fluids
Provide comfort measures (ie. Cooling blanket)
Hyperthyroidism Nursing Interventions
Monitor vital signs
Assess respiratory effort
Asses energy levels and activity tolerance
Diet is important (make sure they are getting enough calories during hyper metabolic state)
Exophthalmos education
Need for regular eye exams
Report changes in vision
Protect eyes with tinted glasses
Moisten eyes frequently
Sleep with head of bed elevated to decrease pressure on optical nerve
Complications From Thyroid Surgery
Respiratory distress (due to swelling)
Parathyroid gland injury resulting in hypocalcemia and tetany
Damage to laryngeal nerves
Post Surgical Nursing Interventions
Monitor for symptoms of respiratory distress including tachypnea and stridor
Inspect neck dressing every hour and then every 4 hours
Monitor amount of drainage (bleeding), notify MD for bleeding
Maintain client in semi-Fowler´s position, with ice to neck
Assess for numbness, tingling, voice quality (dysphonia), dysphagia, signs of hypocalcemia
Keep emergency tracheostomy kit at bedside
Hypothyroidism : characterized by
Decreased production of hydrochloric acid by stomach
Reduced gastrointestinal motility
Decreased heart rate and cardiac output
Impaired neurological function
Decreased heat production
Decreased lipid metabolism  cholesterol, lipids
Increased interstitial fluids leading to pleural and cardiac effusions
Key Features of Hypothyroidism
Cardiovascular - Hypotension - Bradycardia - Dysrhythmias - Periobital edema - Facial puffiness
Respiratory - Dyspnea - Hypoventilation - Pleural effusion
Metabolic - Decreased BMR - Decreased body temp. - Cold intolerance
Neurological - Slow, slurred speech - Decreased memory, concentration - lethargy, somnolence - paresthesias
Gastrointestinal - Anorexia, weight gain - constipation - Abdominal distention
Psychological - Apathy - Depression - Paranoia - Withdrawal
Care of the Client With Myxedema Coma
Maintain patent airway
Replace fluids as ordered
Give replacement thyroid hormone (levothyroxine sodium) IV as ordered
Administer IV glucose as ordered
Administer corticosteroids as ordered
Assess vitals, temperature and blood pressure
Cover with warm blankets
Monitor for mental status changes
Nursing Interventions for Hypothyroidism
Monitor cardiac status including blood pressure and heart rate frequently
Assess hemodynamic function including urine output and blood pressure frequently
Monitor for mental status & neurologic changes
Administer hypothyroid medications as ordered: - Synthroid
Give 1 hour prior to meals or 2 hours after to facilitate absorption
Withhold if heart rate >100 or at least notify physician
Adjust environment with blankets as needed to temperature and comfort
Encourage fluids of at least 2 L and diet high in fiber to promote regular bowel movements
Key Features of Hyperparathyroidism
Polyuria and renal calculi
Generalized bone pain
Pathological fractures
Confusion and drowsiness
Lethargy and confusion
Depressed deep tendon reflexes
Depression , psychosis
Flank pain
Muscle weakness
GI disturbance
N & V
Heart block
Shortened QT interval and ST segment
Cardiac arrest
Note: All of the above may be caused by excessive PTH or by hypercalcemia
Non-Surgical Management of Hyperparathyroidism
Promote safety and comfort (prevent falls)
Strain urine to detect calcium-based urinary stones
Hydration 2-3 L /day and high fiber diet
Paced activity with rest periods
Diuretics (Lasix, Uritol) an NS IV, to increase calcium excretion
Analgesics to control pain
Phosphates (oral or IV, only when rapidly lowering of calcium is necessary)
Calcitonin given with glucocorticoids, increases renal excretion of calcium
Mithramycin (chelating agents) - Cytotoxic agent that rapidly lowers serum calcium level within 48 hours, but causes thrombcytopenia, hepatic toxicity, renal toxicity
Care of the Client Receiving Non-Surgical Treatment HYPERPARATHYROIDISM
Administer IV hydration as ordered
Monitor intake and output strictly
Assess renal status Q 2-4 hours
Continuous cardiac monitoring, usually indicated
Assess for numbness and tingling in muscles
Monitor labs - CBC - Ca++ - BUN - LFTs - Creat
Care of the Client Post-Parathyroidectomy
Assess for bleeding
Monitor respiratory status, compression of trachea by hemorrhage or swelling
Emergency airway management tray at bedside
Monitor serum calcium levels Q4hrs, may be hypocalcemic until levels stabilize
Monitor for signs of hypocalcemia (Chvostek´s, Trousseau´s, twitching, tetany)
Assess for voice quality and hoarseness
Key Features of Hypoparathyroidism
Tingling and numbness around mouth
Laryngospam with possible respiratory arrest
Hyperactive deep tendon reflexes
Muscle cramps/spasms
Chvostek’s and Trousseau’s sign
Hyperactive bowel sounds
Abdominal cramping with diarrhea
Dry brittle nails and hair
Decreased myocardial contractility
Prolonged QT interval and lengthened ST segment
Cardiac arrest
Care of the Client With Hypoparathyroidism
Education regarding importance of adherence to medication regime, lifelong
Education regarding dietary modification including: - Foods high in Ca++ but low in PO4
(i.e., yogurt, processed cheeses)
Monitor for signs and symptoms of hypocalcemia
Monitor labs including those mentioned for hyperparathyroidism
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
SIADH is an excessive amount of serum ADH resulting in water intoxication and hyponatremia
ADH is released despite normal or low plasma osmolarity (feedback mechanism does not work)
Excess ADH increases permeability of renal distal tubules which leads to reabsorption of water into the plasma and suppression of the renin-angiotensin mechanism causing renal excretion of sodium leading to……...
Water intoxication
Cellular edema
Dilutional hyponatremia
SIADH Clinical Manifestations
Fluid retention (fluid volume excess)
Increase B/P
Crackles in lung fields
Distended jugular veins
Taut skin
Imbalanced I/O (more coming than going out)
Dilutional hyponatremia muscle cramps and weakness
Concentrated urine with low output
Cerebral edema
Changes in LOC
Weight gain without edema (So putting someone in high fowlers would not assist)
DI Manifestations
Polyuria (5-20 L in a day)
Polydipsia (drink huge amounts to keep up)
Dry tenting skin
Muscle fatigue
Muscle twitching, agitation, hallucinations, seizures, coma
N & V
Dry mucous membranes
Fluid volume deficits occur if one cannot keep up with fluid loss resulting in
Weight loss
Shock due to hypovolemia
DI Nursing Interventions
Water replacement-encourage fluids
Oral preferred or IV D5W (hypotonic solution) to keep lab values normal
Weigh daily
Monitoring Fluid status if HUGE
Monitor urine specific gravity and report if it decreases
Monitor serum osmolality and sodium for increases
Hormones replacement primary treatments for central DI
Desmopressin Acetate nasal spray
In nephrogenic DI kidneys are unable to respond to ADH so patient will need to be put on thiazide diuretics, low sodium and low protein diet
Cushing’s Syndrome
Hyperfunction of adrenal gland cortex resulting in elevated serum cortisol or ACTH
Incidence grater in women
Usual onset 30-40 years of age
Prednisone use
ACTH secreting pituitary tumor or adrenal tumors
Usually occur between the ages of 20-40
Cushing’s Syndrome Manifestations
Fluid overload
Weight gain
Truncal obesity
Moon face
Thinning hair
Increased body and facial hair (hirsutism)
Purple striae on abdomen
Emotional lability (mood swings)
Edema in lower extremities
Skin infection and slow wound healing
Muscle wasting and weakness
Thin skin with easy bruising
Cushing syndrome: nursing priorities
Assess client to achieve fluid, electrolyte, glucose, and calcium balance.
Daily weights
Monitor I/O
Promote safety (uncluttered walking areas, adequate lighting, etc.)
Pace activities
Prevent infection
Help client cope with changes in physical appearance
Cushing syndrome: post op care
Promote effective breathing (cough and deep breath/IS use)
Explain mouth breathing due to nasal packing
Turn every 2 hours (use SCDs or encourage dorsiflexion)
Keep HOB elevated 30 degrees
Examine pituitary surgical wound for Cerebrospinal fluid leak (how would you do this?)
Addison’s Disease
Hypofunction of adrenal cortex or lack of ACTH secretion by pituitary
Body lacks corticosteroids
More common in women
Happens to those under the age of 60
Industrialized countries—autoimmune condition where adrenal tissue is destroyed (will not notice symptoms until most of the tissue is destroyed)
AIDS or its treatments
Anitcoagulant therapy
Sudden stoppage of long-term high does steroid medications
Addison’s crisis
Can occur when steroids are abruptly stopped or exposure to stress.
Hypotension leading to shock
Plus other manifestations mentioned on the previous page
Addison’s Disease
Steroid replacement therapy
Treating underlying cause
Addison’s Disease Nursing Interventions
Monitor vital signs
Assess LOC frequently
Monitor energy level and activity tolerance
Assess orthostatic hypotension
Monitor fluid and electrolyte imbalances
Monitor I/O
Nutritional status (watch for low blood sugar)
Encourage 3L of fluid intake
May need added sodium in diet
Promote a safe environment
Protect from infection
Asthma: after exposure to trigger
Wheezing with expiration
Dyspnea (may be severe)
Chest tightness
Prolonged expiration
Increased RR
Tachypnea with possible use of accessory muscles
Mild to greatly diminished breath sounds
Increased heart rate and blood pressure
Restlessness and anxiety
Asthma – Nursing Management & Interventions
Assess respiratory and oxygenation status
Administer supplemental oxygen as needed
ID/Avoid/Remove precipitating factors
Allergy desensitization therapy if appropriate
Educate on PEFR monitor to promote self management
Administer medications as prescribed and instruct on their appropriate use
Provide education and resources on how to manage exacerbations
Chronic Bronchitis-Manifestations
Frequent cough with foul smelling sputum
Frequent pulmonary infections
Blue Bloater
Bluish skin from cyanosis and polycythemia
Dyspnea and activity intolerance as disease progresses
Increased anterior-posterior chest diameter
Risk for deep vein thrombosis as H &H increases
Emphysemia: Manifestations
Pink Puffer
Barrel chest
Pursed lip breathing (forced exhalation)
Maintain oxygenation by hyperventilating
Use of accessory muscles when breathing
Under weight appearance
Central cyanosis & finger clubbing
Progressive exertional dsypnea
Persistent tachycardia due to inadequate oxygenation
Diminished breath sounds (wheezes and crackles may be present)
COPD Nursing Interventions 1
Smoking cessation!!!!!!!!!!
Avoid precipitating irritants
Monitor oxygenation status frequently
Goal is to improve ventilation and promote patent airway by mobilizing secretions
Adequate fluid status (at least 2L to thin secretions)
Adequate nutrition to fight infections and meet increased energy needs
Bronchodilator therapy to reduce dyspnea and attempt increase FEV1
Beta adrenergic agonists (used as bronchiodialtors and administered by MDI or nebulizers)
Corticosteroid therapy (useful for those with asthma or exacerbations unresponsive to therapy with beta-agonists)
COPD Nursing Interventions 2
Sitting patient up in bed in fowlers or high fowlers may help dyspnea.
Chest Physiotherapy
Oral care to reduce chance of infection
Antibiotic therapy and importance of completing the prescribed regimen
Prepare for possible surgical interventions
Flu and pneumonia vaccines are very important
Physiologic Factors Affecting Oxygenation
Anemia (decreased oxygen carrying capacity)
Toxic gas inhalation (ie. carbon monoxide)
Cardiovascular conditions
Airway obstruction
High altitudes (decreased oxygen conc.)
Fever (increased metabolic & oxygen demands
Musculoskeletal impairments
Airway Management
Head tilt/chin lift
Oropharyngeal airway (maintaining airway by preventing posterior tongue displacement)
Use only on unconscious patient due to risk of vomiting and should be sized to individual
Nasopharyngeal airway
Airway for semi-conscious patient or whom placement via oropharygeal is not feasible
Long cuffed tube is inserted with laryngoscope for long-term airway management
Must be sized for individual
Must be confirmed by x-ray
Tracheostomy (many types)
Surgical placement of cuffed airway into the trachea
Obturator needs to be at bedside with replacement Trach-tube sized for that patient
CPAP (continuous positive airway pressure) or BiPAP (bi-level….)
Nasal mask that is attached to high-flow blower
Blower is adjusted to maintain sufficient positive pressure in the airway to prevent airway collapse
Used to treat sleep apnea (partial or complete upper airway obstruction during sleep)
Signs and symptoms (frequent waking, insomnia, daytime sleepiness, witnessed apneic episodes, loud snoring, other symptoms related to inadequate sleep-irritability, inability to concentrate, depression)
Affects 2-10% of population
Tracheostomy Complications
Obstruction with secretions - C & DB, humidified oxygen - Periodic suctioning and trach. care
Tube dislodgment/decannulation - Secure cannula with trach. ties - Have emergency tube with obturator at bedside
Pneumothorax - Monitor for sx and notify MD
Subcutaneous emphysema - Inspect and palpate for air under tissues at trach site, notify MD
Bleeding - Small amount ok for first few days, if constant oozing, notify MD
Cuff pressure too high---what could happen?????
Assess stoma, keep trach. dressings C, D & I
Special Considerations When Suctioning
Assess respiratory status before suctioning
Hyper-oxygenate prn before suctioning
Position client accordingly
Aseptic technique for nasopharyngeal, nasotracheal suctioning
No more than three passes per session!!! WHY?
Do not apply suction as you insert the catheter—Why???
Apply intermittent suction coming out—Why
Care of the Client with Oxygen
Assess order for oxygen rate (assess when in room for first time)
Monitor respiratory status Q 4hrs & prn
Assess oxygen saturation Q shift & prn
Elevate HOB at least 30 degrees
Encourage TC & DB Q 2- 4 hrs Around the clock
Humidify oxygen whenever possible (> 2L/NC)
Assess nares at least Q shift
Remove oxygen, cleanse nares, apply lubricant Q 4 hrs.
Document findings Q shift & prn
Thoracic Surgery Nursing Care
Get base line vitals, oxygenation status, and cognitive status and monitor patient for changes
Monitor urine output <30ml/hr should raise concerns
Maintain airway
Position for optimal ventilation (noting any specific order)
Maintain water seal if patient has chest tube and closely monitor drainage for acceptable amount which would be specified in orders
Monitor operative site for bleeding/hemorrhage
Administer post-op antibiotics if ordered
Administer analgesics
Encourage position change, incentive spirometer use, coughing and deep breathing to decrease atelectasis development
Pneumonia Manifestations
Fever:low grade
Cough: non-productive
White blood count: normal to low elevation
Chest X-ray: minimal change evident
Clinical course: less severe than bacterial
Fever: high
Cough: productive
White blood count: high elevation
Chest x-ray: infiltrates
Clinical course: more severe
Pneumonia Nursing Care
Maintain Airway
Administer Antibiotics if bacterial or antifungals if fungal
Monitor respiratory and oxygenation status and administer O2 if indicated
Provide analgesics for pain
Provide fluid and nutritional support (why: fluids help mobilize secretions and when infection occurring you have higher metabolic needs)
Provide adequate periods of rest between activities
Prevention of pneumonia in hospital setting is worth a pound of cure
ID high risk patients
Flu/pneumonia vaccines updated
Maintain adequate nutrition and hydration
Encourage activity and mobility after surgery
Pulmonary Embolism: signs and sxs
Restlessness, anxiety, agitation
Changes in LOC
Lung crackles
Pulmonary Embolism: nursing interventions
Maintain airway
Supplemental oxygen
Maintain IV access
Pain management
Anticoagulants (heparin, coumadin)
SCDs after surgery
Movement after surgery
Care of the Patient With Chest Tubes Chest tube facts
When your patient has a pneumothorax, expect little if any output because the tube is draining air, not fluid.
Hemothorax, a lack of drainage may indicate a clot obstructing the tube. If that occurs, try milking the tube (only if ordered to do so): Starting at the proximal end, gently squeeze and release it between your fingers along the length of the tubing.
However, don't “strip” the chest tube, which means squeezing the length of the tube without releasing it. Once a common practice, stripping the tube causes a dangerous increase in intrathoracic pressure and doesn't lead to any significant increase in output.
Air Leak: Continuous bubbling is seen in water-seal bottle/chamber, indicating that leak is between patient and water seal
Locate leak
(b)        Tighten loose connection between patient and water seal
(c)        Loose connections cause air to enter system.
d)        Leaks are corrected when constant bubbling stops
   Problem:  Bubbling continues, indicating that air leak has not been corrected
(a)        Cross-clamp chest tube close to patient’s chest, if bubbling stops, air leak is inside the patient’s thorax or at chest tube insertion site
(b)        Unclamp tube and notify physician immediately!
(c)        Reinforce chest dressing 
air leak 3
  Problem:  Bubbling continues, indicating that leak is not in the patient’s chest or at the insertion site
(a)        Gradually move clamps down drainage tubing away from patient and toward suction-control chamber, moving one clamp at a time
(b)        When bubbling stops, leak is in section of tubing or connection distal to the clamp
(c)        Replace tubing or secure connection and release clamp
(4)        Problem:  Bubbling continues, indicating that leak is not in tubing
(a)        Leak is in drainage system
(b)        Change drainage system
Q: When should I change the CDU?
A: Change it if it breaks or it's full:
* Prepare the new CDU according to the manufacturer's instructions.
* Remove the current CDU from suction, clamp the chest tube with a rubber-tipped hemostat, and disconnect the connecting tube from the CDU.
* Quickly connect the new CDU, unclamp the tube, and secure all connections according to your unit's policy.
* Resume suction and assess the CDU chambers for normal function.
Pinpointing Subcutaneous Emphysema
A collection of air or gas under the skin, subcutaneous emphysema—crepitus—is usually painless and feels spongy on palpation. Small amounts of subcutaneous emphysema around the tube insertion site are commonly absorbed. However, if the tube is improperly placed or has an air leak, air may move from the insertion site into the neck, chest, and face and cause pain. In this case, notify the clinician.
infection stone or triple phosphate stone, develops when a urinary tract infection (e.g., bladder infection) affects the chemical balance of the urine. Bacteria in the urinary tract release chemicals that neutralize urinary acid, which enables bacteria to grow more quickly and promotes struvite stone development.
stones are more common in women because they have urinary tract infections more often than men. The stones usually develop as jagged structures called "staghorns" and can grow to be quite large.
Uric acid
Digestion and metabolism of meat protein produces uric acid. If the acid level in the urine is high (i.e. low pH), the uric acid may not dissolve and uric acid stones will form.
Cystine (least common)
Cystine is an amino acid in protein that does not dissolve well. Some people inherit a rare, congenital (i.e., present at birth) condition that results in large amounts of cystine in the urine. This condition (called cystinuria) causes cystine stones that are difficult to treat and requires life-long therapy.
Renal Calculi: Risk factors
Dehydration: concentrates calculus-forming substances
Infection: damaged tissue and changing pH provide environment for calculi to develop
Obstruction: urine stasis allows solid material to collect, which promotes infections
Congenital disorders and arthritis (inflammation)
High blood pressure
Metabolic factors: hyperthyroidism, renal tubular acidosis, elevated uric acid levels (gout), defective oxalate metabolism, excessive vitamin D or calcium intake.
renal calculi Signs and symptoms
excrutiating pain that begins in the lower back and radiates to the groin (spasm of ureter)
Blood in the urine (hematuria)
Increased frequency of urination (urinary urgency)
Nausea and vomiting
Pain during urination (stinging, burning)
Tenderness in the abdomen and kidney region
UTI (fever, chills, loss of appetite)
renal calculi nursing interventions
Treatment of symptoms especially pain
Monitor serum levels for calcium, phosphorous, and uric acid
24 urine
Prepare for KUB, IVP, renal ultrasound, CT-scan, MRI or cystoscopy
Removal of calculi
Prevention of future stone development
Assess urinary function (monitor I/O)
Strain urine for stones to be analyzed
Encourage ambulation and vigorous fluid intake
Renal Calculi Treatments with Nursing Care
Lithotripsy (Extracopeal shock wave lithotripsy )
High energy shock waves to break up calculi
Takes 30min -1 hr
Patient will get general or epidural anesthetic
Nursing care
Baseline vitals
Monitor I/O
Maintain patency of catheter
Strain urine for calculi and send fragments to lab
Encourage ambulation and increase fluid intake as ordered to aide passage of calculi
Medicate for pain as needed
Slight hematuria is common
Renal Calculi Treatments with Nursing Care 2
Ureterolithotomy/pyelolithotomy/neprolithotomy (surgery to remove calculi)
Baseline assessments (vitals, B/P, LOC)
Monitor I/O
Monitor consistency of urine (color, clarity, etc)
Maintain patency of catheter
Assess and medicate for pain
Increase fluid intake for passage of calculi fragments
Strain urine
Urinary Retention Nursing Interventions
Palpate bladder for distension at regular intervals
Monitor I/O
Monitor for signs of UTI
Attempt to stimulate relaxation of urethral sphincter by running water, poor warm water over perineum
Straight catheterization if ordered
Evaluate medication to see if any medication could be the cause
May need surgery to remove BPH obstruction
Urinary Incontinence Causes
Causes of temporary urinary incontinence
Alcohol. Beer, wine and spirits are all diuretics..
Over-hydration. Drinking a lot of water or other beverages, particularly in a short period of time, increases the amount of urine your bladder has to deal with and may result in an occasional accident.
Dehydration. If you have urge incontinence, you may try to limit your fluids to reduce the number of trips to the toilet. However, if you don't consume enough liquid to stay hydrated, your urine can occasionally become very concentrated. This collection of concentrated salts can irritate your bladder and worsen your urge incontinence.
Caffeine. Caffeine also is a diuretic.
Bladder irritation. Carbonated drinks, tea and coffee — with or without caffeine — may irritate your bladder and cause episodes of urge incontinence. Citrus fruits and juices and artificial sweeteners also can be sources of aggravation.
Medications. Sedatives, such as sleeping pills, can sometimes interfere with your ability to control bladder function. Other medications — including water pills (diuretics), muscle relaxants and antidepressants — can cause or increase incontinence. Some high blood pressure drugs, heart medications and cold medicines also can affect bladder function. After surgery, some people experience temporary overflow incontinence from the lingering effects of anesthesia.
Other illnesses or injuries. Any serious illness, injury or disability that keeps you from getting to the toilet in time also is a potential cause of incontinence.
Urinary tract infection. Infectious agents — usually bacteria — can enter your urethra and bladder and start to multiply. The resulting infection irritates your bladder, causing you to have strong urges to urinate. These urges may result in episodes of incontinence, which may be your only warning sign of a urinary tract infection. Other possible signs and symptoms include a burning sensation when you urinate and foul-smelling urine.
Constipation. The rectum is located near the bladder and shares many of the same nerves. Hard, compacted stool in your rectum causes these nerves to be overactive and trigger urine frequency.
Urinary Incontinence Causes
Causes of persistent urinary incontinence
Pregnancy and childbirth. Pregnant women may experience stress incontinence because of hormonal changes and the increased weight of an enlarging uterus and weakened pelvic floor muscles
Changes with aging. Aging of the bladder muscle affects both men and women, leading to a decrease in the bladder's capacity to store urine and an increase in overactive bladder symptoms.
Hysterectomy. In women, the bladder and uterus (womb) lie close to one another and are supported by the same muscles and ligaments. Any surgery that involves a woman's reproductive can lead to incontinence.
Enlarged prostate. In older men, incontinence often stems from enlargement of the prostate gland.
Prostate cancer. In men, stress incontinence or urge incontinence can be associated with untreated prostate cancer. However, more often, incontinence is a side effect of treatments — surgery or radiation — for prostate cancer.
Bladder cancer or bladder stones. Incontinence, urinary urgency and burning with urination can be signs and symptoms of bladder cancer and also of bladder stones. Other signs and symptoms include blood in the urine and pelvic pain.
Neurological disorders. Multiple sclerosis, Parkinson's disease, stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing urinary incontinence. Also changes caused by Diabetes or vascular diseases
Obstruction. A tumor anywhere along your urinary tract can obstruct the normal flow of urine and cause incontinence, usually overflow incontinence. Urinary stones — hard, stone-like masses that can form in the bladder — may be to blame for urine leakage.
Urinary Incontinence dx tests
Urine diary
Post void residuals
Blood tests
Stress test (not the cardiac kind-coughing)
Pelvic ultrasound
Urinary Tract Infection UTI
Generic term that covers any bacterial infection that affects the urinary tract
Classified according to region and primary site affected
Bladder (cyctisis)
Urethra (urethritis)
Kidney (pyelonephritis)
Note above urethra the urinary tract is sterile
Pathogens enter via the perineal area or from blood stream
Most commonly the ascending route
Body has natural defense against bacteria *****
Urine flow (think about diseases that impede urine flow-BPH, kidney stones)
Large urine output
Ecoli major culprit causiing 80-85% of cases
Remaining cases caused by staphylococcus
Signs and Symptoms of Cystitis
Frequent urination
Burning or pain with urination
Pain in the midline suprapubic region.
Pyuria: Pus in the urine or discharge from the urethra.
Hematuria: Blood in urine.
Mild fever
Cloudy and foul-smelling urine
Increased confusion and associated falls are common presentations to Emergency Departments for elderly patients with UTI.
Protein found in the urine.
Signs and Symptoms of Pyelonephritis
Same as cystitis plus
Abdominal pain or pressure.
Shaking chills and high spiking fever.
Night sweats
Extreme fatigue
A group of kidney diseases caused by inflammation of capillary loops in the glomeruli of the kidney.
Caused by immunologic reaction to an antigen
Endogenous-antigens already in kidney or other body tissues
Exogenous-infections occurring in the body
Antigen-antibody complexes trapped within glomeruli produce an inflammatory response that damages the glomeruli
Upper respiratory infection
Skin infection
Autoimmune processes
**Symptoms occur 2-3 weeks after original infection
Occurs in men more than women
Glomerulonephritis Signs and symptoms
Cola-colored or diluted iced-tea-colored urine from red blood cells in your urine (hematuria)
Foam in the toilet water from protein in your urine (proteinuria)
High blood pressure (hypertension)
Fluid retention (edema) with swelling evident in your face, hands, feet and abdomen
Weakness and fatigue from anemia or kidney failure
Less frequent urination than usual
REMEMBER symptoms develop 2-3 weeks after underlying/precipitating infection (UTI, Respiratory infection, pericarditis or endocarditis.
Glomerulonephritis Complications
Acute kidney failure
May require dialysis
Chronic kidney failure
Kidney function at less than 10 percent of normal capacity indicates end-stage kidney disease, which usually requires dialysis or a kidney transplant to sustain life.
High blood pressure
Damage to your kidneys and the resultant buildup of wastes in the bloodstream can raise your blood pressure.
Nephrotic syndrome
characterized by high protein levels in the urine, resulting in low protein levels in the blood (** note low oncotic presuure), high serum cholesterol, and swelling of the eyelids, feet and abdomen.
Acute renal failure signs and symptoms
Since no treatment leads to end stage renal failure
Glomerulonephritis Nursing Care
Treat underlying infection or condition
Provide appropriate diet
Protein restriction if oliguria is severe
High carbohydrate to provide energy
Potassium usually restricted
Sodium restricted for hypertension and edema
Fluid restriction
Bedrest during acute stage
Monitor vitals frequently watching for hypertension
Monitor I/O and daily weights
Monitor for signs of renal failure (oliguria, azotemia-abnormal nitrogen containing wastes like BUN and creatinine, acidosis
Polycystic Kidney Disease
Hereditary disease characterized by cyst formation and massive kidney enlargement affecting both children and adults
Autosomal dominant form affects adults
Autosomal recessive for usually diagnosed in children
Renal cysts are fluid filled sacs develop in the tubular epithelium affecting nephron function leading to enlarged kidneys.
Disease is progressive and cysts are usually found in other organs such as liver, spleen, pancreas, and brain
Polycystic Kidney Disease: manifestations
Flank pain
Signs of UTI
Signs of renal Calculi
Palpable enlarged kidney
Signs of chronic renal failure as client approaches 50-60 years of age
Polycystic Kidney Disease: dx tests
Postive findings on
CT scan
Polycystic Kidney Disease Nursing Care
Largely supportive to cope with symptoms
Encourage fluid intake to prevent UTI and calculi
Pain medications
Diet restrictions when signs of renal failure occur
Eventually will require dialysis or transplant
Intra-renal acute renal failure
Damage to the kidney itself
Caused by
Toxin or medications (NSAIDS/certain antibiotics-gentamicin/contrast dyes)
Ischemia for greater than 2 hours (severe vascular disorders)
Glomerulonephritis and other infections
Blood transfusion reactions or allergies
Autoimmune diseases like lupus
Obstruction of urine flow
BPH/Trauma (including spinal cord injuries)
Renal or urinary tract calculi
Pre-renal (55%)
Decreased blood flow to kidneys
Reversible if caught early
May be caused by
Severe dehydration (GI loss, Vomiting and diarrhea)
Excess diuretic therapy
Vascular problems/heart failure/thrombosis
Acute Renal Failure Manifestations
3 Phases
Time of insult until symptoms develop
Maintenance/Oliguric phase
Oliguria due to reduction in GFR which can last 10-14 days but can last up to months.
Note difference in symptoms if cause if prerenal versus intra-renal
Occurs within 1 to 7 days of causative agent
Note 50% of patients may not present with this symptom
Acute Renal Failure Oliguric Phase Manifestations
Urinary (urinary output decreased to 400 ml/day or less)
Muscle weakness & Fatigue
GI symptoms (N & V)
Fluid volume excess (due to fluid retention)
Metabolic acidosis (kidneys cannot synthesize ammonia which is needed for H+ ion secretion)
Sodium imbalance (tubules cannot conserve sodium so may have low serum sodium)
Potassium excess (kidneys cannot do there job of excreting 80-90% of body’s potassium.
Hematologic (decreased renal function results in impaired RBC production)
Calcium deficit and phosphate excess (why because kidneys needed to activate vitamin D so that calcium can be absorbed in the GI tract) but remember PTH will cause bones to demineralize so calcium is released)
Elevated BUN and creatinine (because kidneys not getting rid of the nitrogen wastes from protein metabolism) can also lead to neurologic changes (agitation, confusion)
NOTE creatinine single most important serum indicator of renal failure since it cannot be altered by other factors or disease processes
Diuretic phase
may last 1- 3 weeks
Urine output begins to increase gradually but nephrons still not fully functional so still have metabolic (uremia) problems.
Watch out for hypotension and hypovolemia due to fluid loss
Chronic Renal Failure Diagnostics
BUN and creatinine clearance rise and urine specific gravity fixed at 1.01 (normal is 1.025)
Uremia-urine in the blood
Decreased platelets
Loss of erythropoieten (what will this lead to ?)
Inadequate clearance of fluid and electrolytes
Metabolic acidosis
Chronic Renal Disease Manifestations
Psychologic-denial, depression, anxiety
Cardiovascular-hypertension, heart failure, dsyrhythmias
GI-anorexia, N & V, uremic fetor, GI Bleeds, peptic ulcer, gastritis
Endocrine-hyperparathyroidism, thyroid abnormalities, infertility
Metabolic-carbohydrate intolerance hyperlipidemia, gout
Hematologic-anemia, bleeding (platelet dysfunction), infection
Neuro-fatigue, headache, confusion, lethargy, seizures, coma
Pulmonary-uremic lung, pulmonary edema, dyspnea, pneumonia
Integumentary-pallor, pruitus, yellow grey discoloration (absorption of urinary pigments), dry scaly skin.
Peripheral neuropathies-motor weakness, restless legs syndrome
Chronic Renal Failure Nursing Interventions
Low protein with supplemental amino acids (urea nitrogen are metabolic byproducts)
Once dialysis begins can lessen protein restriction
Restrict fluids as ordered
Provide electrolyte replacement or restriction
Sodium restriction (canned soups, prepared foods, cured meats)
Potassium restriction (salt sustitutes, oranges, bananas, melons, tomatoes, prunes, legumes)
Replacement Bicarb to treat acidosis
Replacement of calcium (but need to restrict phosphate at the same time and food high in calcium also are high in phosphate-cheese, milk, ice cream
Monitor plan care for hypertension and heart failure
Prepare patient for dialysis or kidney transplant
Monitor I/O
Monitor Vital signs
Medications need to evaluated because of inability to excrete properly
Monitor lab results (pH, electrolytes, BUN , creatinine, CBC)
Medicate for N & V
Observe for signs of infection
Provide periods of rest between activities
Weigh daily
Dialysis complications and interventions
Catheter obstruction
Insufficient outflow (reposition client)
Hypotension and hypovolemia (excessive fluid removal)
Hyperglecemia from dialysate (watch closely in diabetic client and do not let dwell longer than ordered)
Make sure you warm fluid prior to adminstering
Arteriovenous fistula
dialysis care
Vascular access to a vein and artery for hemodialysis ( most commonly used are radial or brachial artery and cephalic vein)
Auscultate for bruits and palpating for thrills
Lack of thrill may mean there is a clot
Avoid arm for other procedures (i.e. IV starts , B/P, or venipuncture)
Home care (keep fistula clean and dry, watch for redness and swelling, exercise is beneficial for vein enlargement)
Bladder Cancer manifestations
*Painless* hematuria most common sign
Inflammation may mimic signs of bladder infection (frequency, urgency, dysuria)
Colicky pain
Diagnostic tests
Urine ctology for presence of cancer cell
MRI, CT, IVP, or cystoscopy
Post-op Care for Patient with Bladder or Kidney Cancer
Care after removal of bladder/kidney
Administer antiobiotics as ordered
Assess respiratory status
Administer pain medicine as ordered
Monitor urine output closely (<30ml/hr report ot MD)
Irrigate catheter as ordered
Observe for signs of hypovolemic shock (pallor, hypotension, and tachycardia)
Inspect stoma if urinary diversion
Monitor urine for bleeding or clots
Stoma should be red or bright red
Bluish or deep red stoma should be reported to MD
Monitor incision for signs of infection and change dressings per MD order
Kidney Transplant Nursing Considerations
Reducing anxiety (through teaching, medications, and just being there)
Rejection education is very important
Begin immunosuppressant therapy
Dialysis the day before suregery
Baseline assessments (VS, I/O, LOC)
Frequent position changes, TC & DB, incentive spitrometer use
Strict aseptic technique to minimize infection (why?)
Observe for signs of tissue rejection
Pain management
Expect blood tinged urine for several days
Live kidney (urine should be expected immediately, a cadaver kidney may take up to 2 days to 2 weeks for urine production
Weigh daily)
Kidney Transplant Nursing Considerations
Tissue rejection
Redness, tenderness, swelling at surgical site
Elevated WBC count
Decreased urine output with increased protein in urine
Sudden weight gain
Elevated BUN and creatinine
Hyperacute (within hours of surgery due to antibody reaction to donor antigens) *note rare now to checking of compatabilities
Acute (within days or months occurs due to body immune response against tissue in organ donor)
Chronic (within months to years)
Jaundice (icterus)
Extrahepatic (obstruction of common bile duct by gallstones or tumor)
Prevents transport of bile into the duodenum
Accumulation of bile in the liver which overflows into the blood
Liver cogugates this
Intrahepatic jaundice
disturbance of hepatocyte function and obstruction of bile canalicculi found with drug reactions or hepatitis)
Decreases flow of conjugated bilirubin into common bile duct and thus into the intestine.
If caused by hepatocyte failure there will be an increase in unconjugated bilirubin
Caused by excessive breakdown of red blood cells
Amount of bilirubin produced exceeds the ability of liver to conjugate so there is and increase in unconjugated bilirubin in the blood
Blood transfusion reaction, membrane defects of RBCs, severe infection, or toxic substances
Jaundice Diagnostic Tests
Hyperbilirubinemia (high levels of bilirubin in the blood)
Total bilirubin (nomal .1 to 1.2 mg/dL)
Direct (conjugated) bilirubin .1 to .3
Increased in obstructive jaundice
Indirect (uncongugated) bilirubin .2 to .8
increased in hepatocellur failure
Increased in hemolytic jaundice
Note congugated bilirubin is water soluble so may show up in urine (normal is 0 -0.2 mg/dL)
Increased in obstructive jaundice
Other tests
Alanine aminotransferase (ALT) increased in hepatocellular disease
Asparate aminotransferase (AST) elevated with hepatitis and gallstones
Alkaline phosphatase (ALP) increased in both types of obstructive jaundice
Radiologic procedures used
Abdominal ultrasound and CT scans
Jaundice Nursing Care
Symptom management
May have to keep NPO because introduction of food will increase pain
IV hydration and pain management
Treat underlying cause
Medications that sequester bile may be used
Tips to ease itching
Cool or tepid bath containing colloids (oatmeal, cornstarch, soybean powder) can reduce itching
Cool room (68-70)
Emollient lotion rather than alcohol based
Topical corticosteroids
Hepatitis A (HAV
Viral infection of liver causing inflammation of Hepatic tissue
Most common type of viral hepatitis
Causing 40% of cases worldwide
Transmitted by the fecal-oral route
Unsanitary conditions
Intimate contact with someone infected
Contaminated foods, water, and shellfish
Incubation period is 4-6 weeks
Most contagious 10 to 14 days prior to onset of symptoms
Can cause hepatic cell necrosis and swelling and inflammation
Hepatitis B
is caused by the virus HBV. It is spread by contact with an infected person's blood, semen, or other body fluid. And, it is a sexually transmitted disease (STD). You can get hepatitis B by:
Having unprotected sex (not using a condom) with an infected person.
Sharing drug needles (for illegal drugs like heroin and cocaine or legal drugs like vitamins and steroids).
Getting a tattoo or body piercing with dirty (unsterile) needles and tools that were used on someone else.
Getting pricked with a needle that has infected blood on it (health care workers can get hepatitis B this way).
Sharing a toothbrush, razor, or other personal items with an infected person.
An infected woman can give hepatitis B to her baby at birth or through her breast milk.
Through a bite from another person.
With hepatitis B, the liver also swells. Hepatitis B can be a serious infection that can cause liver damage, which may result in cancer. Some people are not able to get rid of the virus, which makes the infection chronic, or life long. Blood banks test all donated blood for hepatitis B, greatly reducing the risk for getting the virus from blood transfusions or blood products.
is caused by the virus HCV. It is spread the same way as hepatitis B, through contact with an infected person's blood, semen, or body fluid (see above). Like hepatitis B, hepatitis C causes swelling of the liver and can cause liver damage that can lead to cancer. Most people who have hepatitis C develop a chronic infection. This may lead to a scarring of the liver, called cirrhosis. Blood banks test all donated blood for hepatitis C, greatly reducing the risk for getting the virus from blood transfusions or blood products.
Hepatitis D is caused by the virus HDV. You can only get hepatitis D if you are already infected with hepatitis B. It is spread through contact with infected blood, dirty needles that have HDV on them, and unprotected sex (not using a condom) with a person infected with HDV. Hepatitis D causes swelling of the liver.
Hepatitis E is caused by the virus HEV. You get hepatitis E by drinking water infected with the virus. This type of hepatitis doesn't often occur in the U.S. It causes swelling of the liver, but no long-term damage. It can also be spread through oral-anal contact.
Hepatitis A Nursing Care
Proper handwashing!!!
Patient will be put on contact precautions
90% of cases avoided with HAV vaccine!!!
Usually managed as outpatients
Abstinence from alcohol
Diet low in fat and high in carbohydrates (why?)
Need for good breakfast because nausea worse later in the day
Provide IV fluids as ordered
Analgesics for pain
Monitor for signs of dehydration
Monitor activities due to fatigue
Monitor for signs of bleeding (in stool, urine, gums if liver is severely compromised)
Hepatitis Manifestations and Nursing Care
Safe sex practices
No sharing needles
Need for vaccinations
Don’t give blood
Cirrhosis Nursing Care
Clients with Ascites are fluid restricted to prevent further fluid accumulation and decreased protein and salt intake
Administer antiemetics and diuretics
Weigh daily and monitor I/O
Measure abdominal girth
Place in high fowlers and use supplemental O2 and encourage deep breathing
Maintain skin integrity (lotion and antihistamine and turn every 2 hours
May need to institute bleeding precautions (avoid injections and observe for signs and symptoms of bleeding)
Monitor labs
Small frequent meals
Hepatorenal syndrome nursing interventions
Monitor fluid and electrolytes
Eliminate drugs that are nephrotoxic or hepatotoxic
Will likely need liver transplant and hemodialysis
Cholelithiasis nursing care
Patient kept NPO and given IV fluids for hydration until pain subsides
Opiods are used to control pain
IV antibiotics are administered
Acute Pancreatitis Diagnosis
Blood tests
During acute pancreatitis, the blood contains at least three times the normal amount of amylase and lipase, digestive enzymes formed in the pancreas.
Changes may also occur in other body chemicals such as
Glucose (hyperglycemia as high as 500-900
Diagnosing acute pancreatitis is often difficult because of the deep location of the pancreas. The doctor will likely order one or more of the following tests:
Abdominal ultrasound.
Abdominal x-ray
Computerized tomography (CT) scan.
Endoscopic ultrasound (EUS).
Magnetic resonance cholangiopancreatography (MRCP).
Acute Pancreatitis Nursing care
Goal prevent further autodigestion of pancreatic tissue and systemic complications
Patient maintained on NPO status
May have NG tube if ileus or extreme vomiting occur
IV hydration to prevent hypovolemia or shock
TPN may be needed for prolonged episodes
Surgical removal of gallstones
Possible peritoneal lavage to remove toxic exudates from abdomen
Adminsiter pain medications (demerol)
May need insulin if hyperglycemic
Antibiotics if infection present
Monitor vital signs and I/O
Weigh daily
Monitor bowel sounds and chart stool.
Monitor respiratory status
Limit high fatty foods, alcohol, and smoking
Cirrhosis nursing care biopsy
Biopsy only definitive way to diagnose cirrhosis type
Nursing care post biopsy
Monitor VS q 15 minutes X 4, q30 X 2, q60 min X 2, q4 hrs X 4, then routine
Observe dressing same intervals for oozing
Monitor for signs and symptoms of bleeding
Apply direct pressure to biopsy site after procedure
Position on right side for compression of biopsy site
Maintain NPO for 2 hours after biopsy
Bed rest for 24 hours
Avoid activities that increase intrabdominal pressure for 1 to weeks (coughing, lifting, straining)
No lab test will diagnose cirrhosis
Monitor many labs because cirrhosis affects so many organ systems
nursing 300
rock it