NSRG 250 QUIZ 7

Exophthalmos

• Abnormal protrusion of the eyes

• Nursing Concepts

  • Exclusively occurs with Graves Disease

  • AKA proptosis

• Interventions

  • Artificial tears, including drops or gel, to relieve dry eyes and protect your corneas.

  • Antibiotics if you have an infection.

  • hyperthyroidism medications (thionamides, methimazole)

  • Intravenous (IV) medications like corticosteroids (anti-inflammatory medication) or teprotumumab (Tepezza®) for thyroid eye disease.

  • Double vision treatments: These treatments include prisms that attach to your glasses and redirect light as it enters your eyes.

  • Immunosuppressive drugs

  • Corticosteroids (Prednisone, methylprednisolone)

Goiter

• Visibly enlarged thyroid gland

• Nursing Concepts

  • Formed by TSH binding to thyroid cells causing thyroid gland enlargement

  • Common in several thyroid issues and does not definitively indicate either hypothyroidism or hyperthyroidism

• Interventions

  • No treatment/“watchful waiting”: monitor your thyroid for any changes.

  • Medications: Levothyroxine (Levothroid®, Synthroid®) is a thyroid hormone replacement therapy.

    • Other medications include methimazole (Tapazole®) and propylthiouracil.

    • Your provider might prescribe a corticosteroid (Prednisone, methylprednisolone)  

  • Radioactive iodine therapy: 

  • Surgery to remove all or part of your thyroid gland (thyroidectomy).

Graves disease

• Autoimmune disorder in which the production of autoantibodies (thyroid-stimulating immunoglobulins [TSI's] that attach to the thyrotropin (TRAb) receptor on the thyroid gland greatly increases thyroid hormone production

• Nursing Concepts

  • Increases number of glandular cells, enlarging gland, forming goiter, and overproduces thyroid hormones

  • Hyperthyroidism symptoms present

  • Exclusive symptoms:

    • Exopthalamos

    • Pretibial myxedema

  • Can be aggravated by COVID-19

  • Thyroid storm may occur

• Interventions

  • NOTE: shared with hyperthyroidism

  • Antithyroid medication (preferably thionamides, methimazole)

    • Propylthiouracil - has toxic effects on liver

    • Iodine preparation for surgery

  • Radioiodine ablation

  • Measure apical pulse, B/P, temp every 4 hours

  • Report palpitations, dyspnea, vertigo, chest pain

  • Report increase in temperature of 1F or more

  • Reduce stimulation

  • Promote comfort and decrease discomfort

  • Beta-adrenergic blocker drugs (atenolol, propanolol)

  • Radioactive iodine therapy

  • Surgery

Hyperthyroidism

• Excessive thytoid hormone secretion from the thyroid gland

• Nursing Concepts

  • Graves Disease is most common form

  • Can be caused by multiple thyroid nodules

    • AKA toxic multinodular goiter

    • Nodules may be enlarged thyroid tissues or benign tumors

    • Milder symptoms than graves disease

      • No exopthalamos or pretibial myxedema

  • Common endocrine disorder

  • Measure blood levels for (triiodothyronine [T3], Thyroxine [T4], and thyroid-stimulating hormone [TSH])

  • RAIU is increased

  • Ask about previous thyroid surgery or neck radiation therapy

  • Includes:

    • Heat intolerance

    • Fatigue and insomnia (changes to energy level and ability to perform ADLs)

    • Libido changes

• Interventions

  • NOTE: shared with Graves Disease

  • Antithyroid medication (preferably thionamides, methimazole)

    • Propylthiouracil - has toxic effects on liver

    • Iodine preparation for surgery

  • Radioiodine ablation

  • Measure apical pulse, B/P, temp every 4 hours

  • Report palpitations, dyspnea, vertigo, chest pain

  • Report increase in temperature of 1F or more

  • Reduce stimulation

  • Promote comfort and decrease discomfort

  • Beta-adrenergic blocker drugs (atenolol, propanolol)

  • Radioactive iodine therapy

  • Surgery

Hypothyroidism

• Reduced or absent hormone secretion from the thyroid gland that results in whole-body decreased metabolism from inadequate cellular regulation

• Nursing Concepts

  • Can be missed early on due to gradual onset and symptoms being similar to other disease processes

  • Thyroid cells fail to produce sufficient TH

  • Myxedema coma is rare but serious complication if untreated or poorly treated

  • Most cases caused by Hashimoto thyroiditis

    • Other causes include: thyroid surgery, radioactive iodine

  • Congenital ver indicates condition being present at birth

  • Common where soil and water have little natural iodine, which causes endemic goiter

• Interventions

  • No known way to prevent

  • Observe rate/depth of respiration and gas exchange

  • Pulse ox measurement

  • Auscultate for breath sounds or crackles

  • Ventilatory support if necessary

  • Be careful with sedation

  • Monitor heart related values

  • Lifelong thyroid hormone replacement (levothyroxine)

  • Prevent myxedema coma

Myxedema coma

• A serious complication of untreated or poorly treated hypothyroidism with dangerously reduced cardiopulmonary and neurologic functioning, although few affected adults become comatose

• Nursing Concepts

  • Mortality rate is extremely high

  • Life-threatening emergency

  • Can be caused by variety of events, drugs, or conditions

    • Factors include: acute illness, surgery, chemo, discontinue of thyroid replacement therapy, sedatives, opioids

  • Concurrent issues: Reduced consciousness and cognition, respiratory failure, hypotension, hyponatremia, hypothermia, hypoglycemia, bradycardia

• Interventions

  • Maintain patent airway

  • Replace fluid with IV normal or hypertonic saline as per order

  • Replace T3 and/or T4 intravenously as prescribed

  • Give IV glucose as prescribed

  • Check temp hourly

  • Check B/P hourly

  • Cover with warm blankets

  • Check for mental changes

  • Turn every 2 hours

  • Insititute aspiration precautions

Thyroid storm

• threatening event that occurs in patients with uncontrolled hyperthyroidism. most often with graves disease

• Nursing Concepts

  • Presents with symptoms of hyperthyroidism that are more intense than normal

  • Characterized by high fever and tachycardia

  • Indicated by increases in temperature

  • Symptoms develop quick and can be fatal if left untreated

  • Triggered by stressors: trauma, infection, diabetic ketoacidosis, pregnancy, vigorous palpation of goiter, iodine exposure, radioactive iodine therapy

  • Symptoms caused by excessive thyroid hormone release

    • Increases metabolic rate

    • May also include: abdominal pain, nausea, vomiting, diarrhea, anxiety, tremors

    • May later become: restless, confused, psychotic, seizrures, coma

  • Death risk always present

• Interventions

  • Immediately report temp increase of even 1F

  • Asses cardiac status if elevated

  • Maintain patent airway and adequate ventilation

  • Oral antithyroid drugs (methimazole, propylthiouracil)

    • Or bile acid sequestrant (cholestyramine)

  • oral propanolol for heart rate control

  • Monitor vitals 15-30 min

  • Cooling blanket for comfort and fever reduction

  • Normal saline infusions for dehydration

Acute Cystitis

• Sudden inflammation of bladder

• Nursing Concepts

  • Related to infection of bladder

    • However can be caused by inflammation without infection (EX: drugs, chemicals, local radiation therapy, irritants (such as feminine hygiene spray, spermicidal jellies), long term cathether use)

  • Can occur as complication of other disorders such as:

    • Gynecologic cancers, pelvic inflammatory disorders, endometriosis, Crohn’s disease, diverticulitis, lupus, tuberculosis

  • Most common bacterial causes are E.coli and Candidda

    • Some others include Enterococcus and Klebsiella

  • Urine may be cloudy, foul smelling, blood tinged

  • May do urinalysis or cytoscopy

  • Closely tied in with UTIs

• Interventions

  • Antiseptics, antibiotic, analgesics, and antispasmodics

    • Isopropyl alcohol, Penicillins, Acetaminophen, Dicyclomine

  • Drink enough fluid for about 1.5 L of urine

    • Cranberry products may help

Dysuria

• Pain or burning with urination

• Nursing Concepts

  • A hallmark symptom of UTI

• Interventions

  • Urinary tract infections are most commonly treated with antibiotics. If your pain is severe, you may be prescribed phenazopyridine.

  • Inflammation caused by irritation to your skin is usually treated by avoiding the cause of the irritant.

  • addressing the underlying condition.

  • There are several steps you can take to reduce the discomfort of painful urination, including drinking more water or taking an over-the-counter aid (such as Uristat® or AZO®) to treat painful urination. Other treatments need prescription medications

Frequency

• Urge to urinate frequently in small amounts

• Nursing Concepts

  • A hallmark symptom of UTI

• Interventions

  • Antibiotics to treat a UTI

  • Changing what kinds of fluids you drink and how much you drink on a daily basis

  • Managing diabetes, prostate conditions or other conditions

  • Pelvic floor physical therapy to treat an overactive bladder

  • A provider may recommend Kegel exercises to strengthen your pelvic floor if you also have urine leakage (urinary incontinence).

  • Avoiding fluids two hours before going to sleep

  • Limiting the amount of alcohol and caffeine you drink, including soda pop, tea, coffee and other caffeinated drinks

  • If you have leaks, a healthcare provider may recommend wearing absorbent pads or underwear to protect your clothing, furniture and bedding.

  
  

Hydronephrosis

• Enlargement of the kidney caused by blockage of urine lower in the track and filling the kidney with urine

• Nursing Concepts

  • Kidney enlarges as urine collects in renal pelvis and kidney tissue

  • Obstruction in renal pelvis or at the point where ureter joins renal pelvis quickly distends renal pelvis

    • Renal pelvis can only hold 5 to 8 mL

  • Kidney pressure increases as volume of urine increases

  • Overtime, maybe in hours, blood vessels and kidney tubules can be damaged extensively

• Interventions

  • Remove obstruction like a kidney stone using cytoscopic or retrograde urogram

  • Nephrostomy

hydroureter

• Enlargement of the ureter

• Nuring concepts

  • Similar effects to hydronephrosis but obstruction is in ureter rather than kidney

  • ureter is easily obstructed where iliac vessels cross or where ureters enter bladder

  • Ureter dilation occurs above obstruction and enlarges as urine collects

• Interventions

  • Remove obstruction like a kidney stone using cytoscopic or retrograde urogram

  • Nephrostomy

Lithotripsy

• the use of sound, laser, or dry shock waves to break stones into small fragments

• Nursing Concepts

  • AKA Extracorporeal shock wave lithotripsy (ESWL)

  • Device is aimed at stone

  • Stone located via fluoroscopy

  • High-energy shock waves pass through body, hit stone into small pieces

  • Bruising may occur on flank of affected side

  • May place stent in ureter before SWL to ease stone fragment passage

• Interventions

  • Patient should be moderately sedated and lying supine

  • Monitor ECG for dysrhythmia

  • Post-op

    • Strain urine to monitor passing of stone fragments

Nephrolithiasis

• Formation of stones in kidney

• Nursing Concepts

  • Caused by particles in urine occurring in too high amounts to stay dissolved, becoming supersaturated in urine

  • Particles precipitate and collect to form calculi

  • Usually caused by dehydration

  • Increased risk if: family history, obese, diabetes, gout, poor diet

  • Can lead to hyronephrosis

• Interventions

  • around 80% of kidney stones can pass on their own

  • Relax your ureter to help stones pass.

    • Commonly prescribed medicines include tamsulosin (Flomax®) and nifedipine (Adalat® or Procardia®).

  • Manage nausea and vomiting.

  • Manage pain.

  • Shockwave lithotripsy.

  • Ureteroscopy.

  • Percutaneous nephrolithotomy.

  • Laparoscopic surgery.

Renal colic

• Term used to describe the severe flank pain resulting from stones

• Nursing Concepts

  • Suggests stone is in kidney or upper ureter

  • If extending to abdomen or scrotum and testes or vulva suggests stones are in ureters or bladder

  • Most intense when stone is moving or ureter is obstructed

  • Begins suddenly

  • Unbearable pain

  • Accompanied by nausea, vomiting, pallor/ash grey skin, diaphoresis

• Interventions

  • Expulsion of stone can occur without surgery

  • Opioid analgesics

    • NSAIDs (Ketorolac)

  • Urinary antispasmodic (oxybutynin)

  • Avoid overhydration and underhydration during acute phase

  • Strain urine

  • Antibiotics may be used (Penicillins)

  • Alpha blocker tamsulosin for medical expulsive therapy

Bacteriuria

• Presence of bacteria in the urine

• Nursing Concepts

  • May occur with cystitis or any UTI

  • Colonization/asymptomatic - has condition but no symptoms of infection

    • Common in older adults

  • Can lead to acute infection or renal insufficiency when patient has no other conditions where it would then require treatment

  • Body produces mucin which helps prevent infection and cellular damage

  • Men have prostate gland secreting protective protein

• Interventions

  • Void frequently

  • Antibiotics

Acute glomerulonephritis

• Inflammation of the glomerulus that develops suddenly from an excess immunity response within the kidney stones

• Nursing Concepts

  • Develops suddenly from excessive immunity response within kidney tissues

  • Usually infection is noticed before kidney symptoms are present

  • Onset of symptoms is about 10 days from time of infection

  • Recovery is quick

  • Causes are mostly infective

    • Secondary can be caused by multisystem diseases and can manifest as acute or chronic disease

• Interventions

  • Antibioitc therapy (penicillin, erythromycin, azithromycin)

  • Corticosteroids and cytotoxic drugs (cyclosporine, cyclophosphamide)

  • Prevent complications involving fluid overload or dehydration

  • Dialysis if uremic symptoms or fluid volume excess can’t be controlled with nutrition therapy or fluid volume management

    • Plasmapheresis can be used

  • measure weight and Bp daily at same time each day

Nephrotic syndrome

• Immunologic kidney disorder in which glomerular permeability increases so that larger molecules pass through the membrane into the urine and then excreted; causes massive loss of protein into the urine and decreased plasma albumin levels

• Nursing Concepts

  • Also causes edema formation

  • Minimal change disease is most common cause

    • Can be detected using light miscropy and transmission electron microscopy utilizing standard procedures

  • Can be caused by altered immunity

  • Altered liver function may also occur causing increased lipid production and hyperlipidemia

  • Renal thrombosis often also occurs either as cause or effect

  • Can progress to end-stage kidney disease

  • Low serum albumin, high serum lipids, fat and increased protein in urine, edema, and hypertension

• Interventions

  • Steroids

  • Cytotoxic or immunosuppressive agents

  • Angiotensin-converting enzyme inhibitors can reduce proteinuria

  • Heparin can reduce vascular defects and improve kidney function

  • lower protein intake if GFR low

  • Mild diuretics and sodium restriction

Polycystic kidney disease

• Genetic disorder in which fluid-filled cysts develop in the kidneys (nephrons)

• Nursing Concepts

  • Caused by relentless development and growth of cysts from loss of cellular regulation and abnormal cell division

  • Kidney enlargement

  • Experiences hypertension, abdominal and flank pain, ruptured cysts, infections

    • Can lead to kidney failure and reduced quality of life

  • Cysts look like grape clusters

  • Cystic kidney enlarges becoming size of football

  • More fluid filling of cysts = larger and less kidney function

  • High BP usually occurs

  • Cerebral aneurysm can also occur

  • Kidney stones may occur

  • Heart valve problems (mitral valve proplapse) left ventricular hypertrophy, and colonic diverticula can occur

• Interventions

  • Reduce sodium intake

  • Angiotensin-converting enzyme inhibitors (Lisinopril) for BP control

  • Opioids and acetaminophen

  • NSAIDs (Ibuprofen) in caution

  • Aspirin-containing drugs

  • Vasopressin-suppressors (tolvaptan)

Acute Pyelonephritis

• An active bacterial infection in the kidney and renal pelvis

• Nursing Concepts

  • Complication of ascending UTI spreading from bladder to kidneys

  • Interferes with urinary elimination

  • Bacterial infection causes local and systemic inflammatory symptoms

  • Organisms move up from UTI to kidney

  • Involves acute tissue inflammation, local edema, tubular cell necrosis, and possible abscess formation

• Interventions

  • Acetaminophen over NSAIDs

  • antibiotics for UTI

  • Cathether replacement if using catheter for 2 or more weeks

  • Nutritional therapy

  • Pyelolithotomy, nephrectomy, urethral diversion, or reimplantation of ureter