NURS 363 Final Exam Overview

BPH signs and symptoms

Focus on QofL: obstructive causing: frequency, nocturia, urgency, hesitancy, straining, dribbling, stasis - UTI

TURP syndrome

Monitor and assess for TURP syndrome (a complication), N/V, confusion, HTN and bradycardia
From google: occurs when too much of the fluid used to wash the area around the prostate during the procedure is absorbed into the bloodstream
Monitor for TURP syndrome or severe hyponatremia (water intoxication) caused by excessive CBI absorption

continuous bladder irrigation

A three-way (lumen) irrigation to decrease bleeding and to keep the bladder free from clots
One lumen for inflating the balloon (30mL)
One lumen for outflow
One lumen for instillation (inflow)

continuous bladder irrigation for TURP post-op

Run CBI solution at rate to keep urine pink: rapidly if bright red drainage or clots present (then about 40 gtt/minute when bright red drainage clears)
If catheter obstructed, turn off CBI, irrigate with 30-50mL NS and notify MD if obstruction is unresolved

peritoneal dialysis

A type of renal replacement therapy
Goals
Remove toxic substances and metabolic wastes
Reestablish normal F&E balance
Appropriate for pts who cannot tolerate hemodialysis or have severe HTN, HF, and pulmonary edema that does not respond to hemodialysis

peritoneal dialysis procedure

Sterile dialysate is introduced into the peritoneal cavity through an abdominal catheter at intervals. Waste products move from an area of higher concentration (blood) to an area of lower concentration (dialysate) through a semipermeable membrane (peritoneum)
Takes 36-48 hours to achieve what hemodialysis accomplished in 6-8 hours

acute intermittent peritoneal dialysis

Nurse warms, spiked, and hangs each container of dialysate
Common routine: hourly exchanges the involve 10-minute infusion, 30-minute dwell time, and 20-minute drain time
Requires strict aseptic technique
Assessments: VS, weight, I&O, labs, and patient status
Additional assessments: skin turgor and mucous membranes to evaluate fluid status; presence of edema
If dialysate does not drain properly, the nurse facilitates draining by turning the pt from side to side or raising the head of the bed. NEVER push the catheter further into the peritoneal cavity

continuous ambulatory peritoneal dialysis

Performed at home 4-5 times per day EVERY day
Longer dwell time - better results
Managed by the pt or a trained caregiver

continuous cyclic peritoneal dialysis

Uses a machine called a cycler
Combines overnight intermittent PD with a prolonged dwell time during the day
Lower infection rates d/t fewer bag changes and tubing disconnections
Greater freedom to work

urinary stones nursing interventions

Monitor VS, I&O
Assess for fever, chills, and infection
Monitor for N/V and diarrhea
Force fluids up to 3000mL/day to facilitate stone passage and prevent infection
Strain all urine and send stones for laboratory analysis
Provide warm baths and heat to flank area
Administer analgesics regularly to relieve pain and assess response to pain medication
IV fluids to increase urine flow and facilitate passage of stone
Perform relaxation techniques to assist in pain relief
Instruct on diet specific to stone composition
Maintain urinary pH depending on type of stone
Turn and reposition immobilized clients
Prepare client for surgical procedures PRN

urinary stones assessment

Renal colic: pain originates in lumbar legion, radiates around side and down toward testicle (men) and down to the bladder (women)
Ureteral colic: pain radiates toward genitals and thigh
Sharp, severe, sudden onset pain
Dull, aching kidneys
N/V, pallor, and diaphoresis during acute pain
Urinary frequency with alternating retention
Signs of UTI: low-grade fever, RBCs, WBCs, and bacteria in urinalysis; hematuria

renal colic

pain originates in lumbar legion, radiates around side and down toward testicle (men) and down to the bladder (women)

ureteral colic

pain radiates toward genitals and thigh

acid ash foods

cranberries, plums, grapes, pruned, tomatoes, eggs, cheese, whole grains, meats and poultry

alkaline ash foods

legumes, milk and milk products, green vegetables, rhubarb

high calcium foods

milk and other dairy products, beans, lentils, dried fruits, flour, chocolate, cocoa, canned/smoked fish (not tuna)

high oxalate foods

asparagus, beets, celery, cabbage, nuts, tea, fruits, tomatoes, green beans, chocolate, beer, cola, dark green leafy vegetables

high purine foods

organ meats, sardines, herring, venison, goose

pyelonephritis

Inflammation of the renal pelvis
Acute - chills, fever, leukocytosis, bacteriuria, pyuria, low back pain, flank, pain, nausea, vomiting, headache, malaise, painful urination
Chronic - frequently diagnosed accidentally when being evaluated for hypertension → fatigue, headache, poor appetite, polyuria, excessive thirst, weight loss, poor urine concentrating ability, pyuria, azotemia, proteinuria, anemia, acidosis
Encourage fluids up to 3000 mL

cystitis

Inflammation of the bladder often caused by infection
½ of clients are asymptomatic
Frequency, urgency and voiding in small amounts
Burning upon urination and inability to void
Incomplete bladder empty and spasm
Lower abdominal or back discomfort
Cloudy, dark foul smelling urine
Hematuria
Malaise, chills, fever, N/V
Nocturia
Incontinence
Suprapublic, pelvic, or back pain
Acid ash diet, discourage caffeine products and avoid alcohol, heat to abdomen or sitz bath, avoid bubble baths and perfumed hygiene products, avoid tight clothing

renal failure risk factors

For chronic kidney disease: diabetes mellitus, hypertension, cardiovascular disease, and obesity
For geriatric population: aging, HTN, atherosclerosis, HF, DM, and cancer predispose elders to kidney disease

nephrostomy tube nursing intervetions

Monitor nephrostomy attached to drainage bag for free flow or urine and foley with strict I&O
Assess nephrostomy tube (may be placed 1-5 days for chemical irrigations to break up stone

urinary retention signs and symptoms

Inadequate bladder emptying
Residual urine remains in the bladder after voiding and can result in overflow incontinence

urosepsis

Gram-negative bacteremia originating in the urinary tract
Most common organism: E. coli
Most common cause: presence of indwelling catheter or untreated UTI in medically compromised pt
Major problem: bacterium's ability to develop resistant strains
Urosepsis can lead to septic shock if not treated aggressively
Assessment
Fever: most common and earliest manifestation
Urine for C&S
Interventions
Administer IV antibiotics as prescribed
Usually 3-5 days, or until afebrile, of IV antibiotics and then oral

what is the most common and earliest manifestation of urosepcis?

fever

nephrotic syndrome

Glomerular disease characterized by proteinuria, hypoalbuminemia, diffuse edema, high serum cholesterol, and hyperlipidemia
Salt and water retention contribute to edema
Thromboemboli are common
Prognosis is poor (< 50% experience complete remission and at least 30% develop ESRF)

24 hour urine test

Obtain specimen container with preservative (lab)
Provide clean receptacle to collect urine (unless indwelling urinary catheter)
Post signs in client's room, on chart, and in bathroom
Have client void and discard the first urine at the beginning of the collection period. During the collection period, save all urine in the container. Place on ice and do not contaminate. Instruct client to empty bladder at the end of the collection period and save this urine
gold standard test for renal function - creatinine clearance

hyperthyroidism signs and symptoms

Increased basal metabolic rates. Rates among women > men
Clinical manifestations vary depending on the amount and time
Assessment: health history, VS, neck (goiter), eyes (exophthalmos), respiratory effort, energy level, irritability, weight pattern, sleep pattern
Assess for thyroid storm/crisis/thyrotoxicosis (treatment includes acetaminophen, hypothermia mattress, ice packs, cool environment, IV fluids, beta blocker propranolol.Inderal, antithyroid med/propylthiouracil/PTU)*
From google: nervousness, anxiety, irritability, hyperactivity, mood swings, difficulty sleeping
Elevated serum T3, T4, free T4; decreased TSH; positive RAI uptake scan and thyroid scan

hypothyroidism signs and symptoms

Decreased BMR, decreased heat production, and effects on all body systems
s/sx depend on severity of condition
Goiter
*Myxedema crisis: life-threatening crisis of hypothyroidism. Precipitated by trauma, infection, etc. Non-pitting edema in connective tissue. High mortality if untreated*

hyperparathyroidism nursing managament

Mild: increase fluids, avoid thiazide diuretics, weight bearing activity, avoid vitamin A and vitamin D and calcium supplements
Acute: decrease serum calcium with IV NS, diuretics and phosphate replacement, surgery to remove PT glands
Medications
Analgesics
Diuretics and IV NS to excrete calcium
Phosphate, calcitonin

hypoparathyroidism signs and symptoms

Hypoglycemia
GI symptoms
Signs of hypocalcemia (anxiety, headache, tremors, spasms, tetany, seizures)
Decreased serum PTH, total calcium, free calcium, increased serum phosphate

SIADH nursing diagnosis

Fluid overload
Alteration in thought process
Insufficient nutrients
Fatigue

central (neurogenic) diabetes insipidus definition and nursing management

From google: central diabetes insipidus is a rare condition in which your body doesn't have enough antidiuretic hormone (ADH, or vasopressin), which causes you to pee large volumes of urine and become very thirsty
Nursing management
Monitor I&O hourly
Weight daily: report weight loss
Monitor urine labs
Encourage fluid intake greater than urine output
Skin protection PRN

neurogenic diabetes insipidus definition and nursing management

From google: nephrogenic diabetes insipidus occurs when there's a defect in the structures in your kidneys that makes your kidneys unable to properly respond to ADH
Nursing management
Monitor I&O
Daily weights
Monitor urine labs

addison's disease diet

Hypofunction of adrenal glands cause hyponatremia and hypovolemia
Consume adequate fluid, sodium, potassium
Need high protein and high carbohydrate diet
Excessive weight gain or edema may indicate the Cortisol replacement is too high, needs to visit with Medical Provider for evaluation

addisonian crisis

Life threatening
Precipitated by: stress, decreased salt intake, dehydration, not taking prescribed steroid replacement therapy, adrenalectomy, removal of pituitary gland or tumor

addisonian crisis signs and symptoms

Mental status changes (confusion, lethargy, agitation)
Muscle weakness
Headache, abdominal pain, nausea, weakness
Postural hypotension or shock
Hyperthermia (as high as 105 degrees F, 45.6 C)
Labs: hyponatremia, hyperkalemia, hypoglycemia

addisonian crisis treatment

Priority: prevent irreversible shock
Five S's:
Support
Search for precipitating illness
Salt
Sugar
Steroids: IV corticosteroid
Antibiotics
IV fluids

addisonian crisis nursing interventions

From google: providing and monitoring response to fluid and cortisol therapies, providing a safe environment, evaluating and maintaining nutritional needs, monitor labs especially sodium levels

cushing syndrome signs and symptoms

Hyperglycemia
Central-type obesity with "buffalo hump"
Heavy trunk and thin extremities
Fragile, think skin
Ecchymosis
Striae
Weakness
Lassitude
Sleep disturbances
Osteoporosis
Muscle wasting
Hypertension
"Moon face"
Acne
Infection
Slow healing
Virilization in women
Loss of libido
Mood changes
Increased serum sodium
Decreased serum potassium

cushing syndrome nursing diagnosis

Risk for injury
Risk for infection
Self-care deficit
Impaired skin integrity
Disturbed body image
Disturbed thought process

cushing syndrome nursing management: Risk for injury r/t weakness

Accident proof environment, concern falls and fractures
Ambulation assistive devices
Diet: high in protein, calcium, vitamin D, low sodium, watch calorie intake

cushing syndrome nursing management: Risk for infection r/t altered protein metabolism and inflammatory response (increase susceptibility to injury or infection secondary to immunosuppression cause by excessive cortisol)

Avoid others who are ill
Infection and inflammation are masked
Monitor for changes that may indicate infection
Offer age appropriate vaccinations particularly influenza, herpes zoster, and pneumococcal vaccinations d/t increased risk for infections

cushing syndrome nursing management: Self care deficit r/t weakness, fatigue, muscle wasting, altered sleep patterns

Encourage rest and consistent sleep patterns
Moderate activity
Relaxing, quiet environment for rest and sleep

cushing syndrome nursing management: Impaired skin integrity r/t edema, impaired hearing, and thin and fragile skin

Meticulous skin care
Avoid adhesive tape
Frequent position change
Frequent assessment of bony prominences
Monitor for DVT

cushing syndrome nursing management: Disturbed body image r/t altered physical appearance, impaired sexual functioning, decreased activity level

Weight gain and edema modified by low-carbohydrate, low sodium diet
High protein diet may decrease other bothersome symptoms

cushing syndrome nursing management: Disturbed thought process r/t mood swings, irritability, and depression

Explain disease to pt and family members
Coping methods to deal with mood swings, irritability, depression
Report psychotic behavior
Encourage pt and family to verbalize feelings and concerns

cushing syndrome nursing management

Can have "addisonian crisis" or shock from sudden corticosteroid withdrawal
Monitor blood glucose
Monitor hypertension, hyperglycemia, weight gain
Self monitoring BP, BG, weight
Medic alert bracelet
Keep adequate supply of corticosteroid medication (avoid running out)

pheochromocytoma symptoms

Classic symptom triad
Headache
Diaphoresis
Palpitations
Anxiety
Light headed getting up

pheochromocytoma signs

Attacks or symptoms may be paroxysmal
5 "H's"
Hypertension
Headache
Hyperhidrosis (sweating)
Hypermetabolism (fever)
Hyperglycemia
TIAs
Tremor
Flushing
Postural hypotension
Cafe au lait spots

thyrotoxicosis signs and symptoms

Life threatening emergency occurrence in hyperthyroidism occurs with long term untreated hyperthyroidism or during stress (pregnancy, trauma, etc.)
s/sx
Elevated temperature, extreme tachycardia, exaggerated symptoms of hyperthyroidism

thyrotoxicosis teaching

Treatment - acetaminophen and working to decrease temperature, replace IV fluids, beta blockers, hypothermia mattress, PTU
NO ASPIRIN

paracentesis NI before

Check consent
Have pt void
Monitor VA
Obtain weight and abdominal girth

paracentesis NI during

Position as upright as possible
Monitor VS
Monitor for s/s of hypovolemia (pallor, tachycardia, hypotension)

paracentesis NI after

Monitor for s/s of hypovolemia
Obtain weight and abdominal girth
Measure, describe, and document fluid collected
Assess puncture site for drainage (pressure dressing may be applied)
Monitor neuro status
Limit of activity
Fluid/electrolyte replacement therapy (albumin)

ascites nursing assessment

Percussion → shifting dullness
Flank edema
Fluid wave

ascites education

Definition of ascites
Rationale for low sodium diet, bed rest
Medications (diuretics)
Major complication (spontaneous bacterial peritonitis)
Paracentesis and TIPS

organ transplantation education

Education about long-term measures to promote health
Adhere closely to the therapeutic regimen, with special emphasis on administration, rationale, and side effects of immunosuppressive agents
Education about the signs and symptoms that indicate problems necessitating consultation with the transplant team
Emphasize the importance of follow-up laboratory tests and appointments with the transplant team

liver biopsy NI

After a liver biopsy
Right side
Pillow
2-3 hours
Avoid coughing or straining
Vital sign protocol
Dressing
Heavy lifting

carcinoembryonic antigen (CEA)

used to r/o types of cancer including liver cancer. Cancer sheds certain proteins in the blood, so the presence of this antigen can indicate cancer

protein studies

the liver manufactures proteins so levels are decreased

liver enzymes

liver cell damage → release of enzymes into blood

pigment studies (bilirubin)

reflect liver's ability to break down and excrete bilirubin

cholesterol

typically elevated in biliary obstruction; decreased in liver disease that affects liver cells

ammonia

liver converts ammonia to urea so ammonia levels increase

serum aminotransferases

indicators of injury to the liver cells; useful in detecting hepatitis

alanine aminotransferase (ALT)

levels increase primarily in liver disorders; used to monitor the course of hepatitis, cirrhosis, the effects of treatments that may be toxic to the liver

aspartate aminotransferase (AST)

not specific to liver diseases however levels of AST may be increased in cirrhosis, hepatitis, and liver cancer

Gamma-glutamyl transferase (GGT)

levels are associated with cholestasis; alcoholic liver disease

hepatitis A

Spread by poor hand hygiene; fecal-oral
Incubation: 2-6 weeks
Illness may last 4-8 weeks
Mortality rate is 0.5% for those younger than 40 and 1-2% for those older than 40
Manifestations: mild flu-like symptoms, low-grade fever, anorexia, later jaundice and dark urine, indigestion and epigastric distress, enlargement of liver and spleen

hepatitis A NI

Prevention
Good handwashing, safe water, proper sewage disposal
Vaccine
Immunoglobulin for contacts to provide passive immunity
Bed rest during acute stage
Nutritional support

hepatitis B

Transmitted through blood, saliva, semen, and vaginal secretions; sexually transmitted; transmitted to infant at time of birth
A major worldwide cause of cirrhosis and liver cancer
Lon incubation period: 1-6 months
Manifestations: insidious and variable; similar to HAV, loss of appetite, dyspepsia, abdominal pain, generalized aching, malaise, and weakness
Jaundice may or may not be evident

hepatitis B NI

Medications
Bed rest and nutritional support
Vaccine: for persons at high risk, routine vaccination of infants
Passive immunization for those exposed
Standard precautions and infection control measures
Screening of blood and blood products

hepatitis C

Transmitted by blood and sexual contact; including needle sticks and sharing of needles
The most common bloodborne infection
A cause of ⅓ of cases of liver cancer and the most common reason for liver transplant
Incubation period is variable ranging from 15-160 days
Symptoms are usually mild
Chronic carrier state frequently occurs

hepatitis C NI

Antiviral medications
Alcohol potentiates disease: medications that affect the liver should be avoided
Prevention: public health programs to decrease needle sharing among drug users
Screening of blood supply
Safety needles for healthcare workers

hepatitis D

Only persons with hepatitis B are at risk
Blood and sexual contact transmission
Use of IV or injection drugs, pts undergoing hemodialysis, and recipients of multiple blood transfusions
Likely to develop fulminant liver failure or chronic active hepatitis and cirrhosis
Incubation period 30-150 days
Interferon alfa is the only licensed drug available in the treatment for HDV infection

hepatitis E

Transmitted by fecal-oral route, contaminated water
Incubation period of 15-65 days
Resembles hepatitis A; self-limiting, abrupt onset, not chronic
Prevention: good hygiene, handwashing

live disease signs and symptoms

Pallor, jaundice, muscle atrophy, edema, vitamin deficiencies, skin excoriation r/t itching, petechiae, ecchymosis areas, spider angiomas, palmar erythema, males - gynecomastia and testicular hypertrophy, neuro changes (cognition, tremors, asterixis, weakness, slurred speech), unstable blood glucoses

liver disease education

s/sx of complications
Proper skin care
Reducing risk of injury

cirrhosis education

Take medications as directed
Talk with provider before taking vitamins, OTCs, and herbal supplements
Avoid NSAIDs

hepatic encephalopathy

Portosystemic encephalopathy (PSE)
Occurs with profound liver failure
Not physical but neuropsychiatric manifestations
Patho
Ammonia
Portosystemic shunting
Things that can precipitate encephalopathy

stage 1 hepatic encephalopathy

Normal LOC
Lethargy and euphoria
Sleep during the day, up at night
Asterixis
Impaired writing
Inability to draw line figures
Normal EEG

stage 2 hepatic encephalopathy

Increased drowsiness
Disorientation
Inappropriate behavior
Mood wings, agitation
Asterixis
Fetor hepaticus
Abnormal EEG

stage 3 hepatic encephalopathy

Suporus
Difficult to rouse
Sleeps of the time
Marked confusion
Incoherent speech
Asterixis
Increased DTRs
Rigid extremities
EEG markedly abnormal

stage 4 hepatic encephalopathy

Comatose
May not respond to painful stimuli
Absence of asterixis
Absence of DTRs
Flaccid extremities
EEG markedly abnormal
Possible seizures

esophageal varices education

Rupture → medical emergency
Manifestations: hematemesis, melena, general deterioration of physical and mental status, s/sx shock
Worsen varices: heavy lifting, straining, sneezing, aspirin, coughing, vomiting, reflux
Balloon tamponade tube, vasopressin, sclerotherapy, banding, TIPS (lowers portal hypertension)
Present with bloody vomit or black tarry stool

role of the nurse with vulnerable populations: education

Case finder
Health educator
Counselor
Direct care provider
Population health advocate
Community assessor and developer
Case manager
Advocate
Health program planner
Participant in developing health policies

individual level NI

Centered on improving access
Minimize the hassle
Culturally sensitive
Culturally competent
Education in terms of health promotion and prevention

community level NI

Public service announcements
Health fairs

general NI for vulnerable populations

Creating a caring environment
Show respect, compassion, and concern
Don't make assumptions
Coordinate a network of services and providers
Advocate for accessible health care services
Focus on prevention
Know when to walk beside the client and when to encourage the client to walk ahead
Know what resources are available
Develop a personal support network

adolescents developmental characteristics

12 - 18 year old - identity vs role confusion → an individual attempts to discover him / herself by taking into account his position in his family, where he originates from, and as a member of society where he belongs
Characteristics - invincibility, feeling unique or different, unrealistic attitudes that they can manage it all
Poverty, school failure, and limited life options

older adults - what makes them vulnerable?

Chronic illness causing disability
Abuse and neglect
Injury
Cognition may not allow for self advocacy
5 I's
Intellectual impairment
Immobility
Instability
Incontinence
Iatrogenic drug reactions (aka, adverse reactions)

older adults NI

Assess self-care abilities
Promote independence
Education
Medication reconciliation
Secondary prevention: asking or screening caregivers for role strain
Tertiary prevention: refer to respite; encourage support groups

infants and children - what makes them vulnerable?

Poverty/homelessness
Higher rates or: chronic illness, behavioral problems, school performance problems, developmental delays
5 H club: hungry, homeless, hopeless, hugless, without health care
Obesity
Communicable diseases
Injuries
Physically compromised
Abuse and neglect

intimate partner violence (IPV) NI

Provide a calm and comforting environment
Approach the pt with care and concern
Complete a physical examination looking for physical signs of abuse
Provide pt with resources to help escape the unhealthy situation

peptic ulcer disease

Definition: sores in the lining of the GI system that can erode past the mucosal layer at least ½ cm
Four locations: duodenum, gastric/stomach, pylorus, esophagus
Risk factors: chronic gastritis in the past caused by H. pylori, age 65 and older, family history, NSAID use, and diet
Main underlying cause: H. pylori and excessive secretion of HCl
Manifestations
Dull, gnawing burning pain in the mid epigastric area and back

what are the 4 locations for peptic ulcers?

duodenum (most common), gastric/stomach, pylorus, esophagus

gastric ulcer timing of pain

Immediately after a meal of 30-60 minutes after a meal
Rarely at night
Worse with food

gastric ulcer stomach acid secretion

Normal or hypo

gastric ulcer weight change

loss