exam 3 medsurg

Chapter 47: Assessment of Kidney & Urinary Function

  • 2 partial-credit select all that apply questions.
  • 5 questions related to gerontologic considerations in renal function and GFR changes.

Renal Function & GFR Changes

  • GFR Decline:
      - Definition: The Glomerular Filtration Rate (GFR) begins to decrease between ages 35 and 40.
  • Injury Risk:
      - Older adults have a significantly higher susceptibility to both Acute Kidney Injury (AKI) and Chronic Kidney Injury (CKI) due to structural and functional changes in the kidneys.

Fluid & Electrolyte Balance

  • Diminished Thirst Mechanism:
      - Aging leads to a decreased osmotic stimulation of thirst, meaning older adults do not feel thirsty even when they require water.
  • Dehydration Risk:
      - Older adults are highly prone to hypernatremia (high sodium levels in the blood) and fluid volume deficit due to the diminished thirst response.
  • Nursing Priority:
      - Educate older adults to drink fluids throughout the day, even if they do not feel thirsty.
      - Promote easy bathroom access and scheduled toileting when necessary.

Behavioral Adaptations

  • Intentional Dehydration:
      - Some patients may purposely limit fluid intake to avoid frequent voiding or the embarrassment of incontinence.
  • Nurse’s Role:
      - It is critical for nurses to educate patients about the dangers of inadequate fluid intake and encourage them to hydrate adequately despite concerns about frequency of urination.

Health History

  • Urinary Symptoms:
      - Dysuria: Painful urination.
      - Hematuria: Presence of red blood cells in urine.
      - Anuria: Urine production decreases to less than 50 mL in 24 hours.
  • Risk Factors:
      - Urinary Tract Infection (UTI) in older patients leads to higher mortality rates (urosepsis).
      - Complicated UTIs in older adults can result in serious complications such as fever and changes in level of consciousness.
  • Common Issues with Voiding:
      - Frequency: Voiding more than every 3 hours.
      - Oliguria: No urine output at all; these signs could indicate urinary retention.

Urinary Retention

Diagnostic Evaluation
  • Urinalysis & Urine Culture:
      - Urine culture determines bacterial presence in urine; remember that urinalysis and culture are distinct tests performed on the same sample.
      - Urinalysis:
        - Shows blood, WBCs, protein, signs of infection.
        - Limitation: Does not specify exact bacteria present.
      - Urine Culture:
        - Identifies the type of bacteria and the appropriate antibiotics for treatment.
        - Takes 2 days to return; patients can be started on broad-spectrum antibiotics in the meantime.
      - Procedure: Perform a bladder scan followed by straight catheterization if necessary.
Renal Function Tests (serum levels)
  • Used to evaluate the severity of kidney disease and assess kidney function status.
  • BUN & Creatinine: Key indicators of renal function.

Diagnostic Imaging

  • X-ray: Reveals size, shape, and position of kidneys.
  • Ultrasound:
      - Requires a full bladder.
      - Used to detect masses and obstructions in the kidney.

Chapter 49: Urinary Disorders

  • 8 questions covering urinary disorders and urologic endoscopic procedures.

Urologic Endoscopic Procedures

  • Cystoscope:
      - Used to visualize the urethra and bladder and obtain urine specimens from each kidney for functional assessment.
  • Nursing Interventions:
      - Key management goal is to alleviate discomfort related to the procedure.
      - Monitor for signs and symptoms of UTI and urinary retention post-procedure.
      - Burning upon voiding, blood-tinged urine, and urinary frequency may be normal post-op experiences.

Kidney Biopsy

  • Purpose:
      - Conducted to evaluate injuries to the kidney, cancer testing, or to clarify other diagnostic concerns.
  • Preoperative Considerations:
      - Check coagulation labs, as there is a risk of bleeding during the biopsy.
      - Patients must be NPO for 6-8 hours prior to the procedure.
  • Nursing Interventions:
      - Monitor vital signs for the first 24 hours to detect any signs of bleeding or infection—look for pallor, dizziness, flank pain, tachycardia, and low blood pressure.
      - Assess the biopsy puncture site for signs of infection.
      - Ensure bed rest post-biopsy.
      - Note that blood in urine after biopsy is NOT NORMAL and must be reported to the healthcare provider (HCP).

UTI (Urinary Tract Infection)

  • A common nosocomial infection.
Clinical Manifestations of Uncomplicated Lower UTI
  • Symptoms include burning, urinary frequency, urgency, strong odor, cloudy sediments, and nocturia (nighttime urination).
Urosepsis
  • The spread of infection from the urinary tract to the bloodstream.
  • Early manifestation of a UTI in older patients can present as delirium (cognitive impairment).

Medical Management of a UTI

  • Antibiotic treatment typically lasts 7 days.
      - Patients must be educated about the importance of completing the full course of antibiotics and not stopping treatment even if they feel better to prevent recurrence of the infection.
  • Encourage hydration: recommend 8-10 glasses of fluids daily.
  • Education should include prevention strategies, such as proper personal hygiene (wiping front to back to prevent E. coli infection).
  • Signs of recovery include relief of pain, absence of infection symptoms, and normal kidney function.

Upper Urinary Tract Infections

Pyelonephritis
  • The most common form of upper UTI.
  • Symptoms: Flank pain.
  • Medical Management:
      - 14-day course of antibiotic treatment.
      - A follow-up urine culture should be obtained two weeks after completion of the antibiotics to ensure the infection has cleared (only done for pyelonephritis).

Types of Urinary Incontinence

Medical Management for Incontinence
  • Implementing a voiding schedule every 2 hours can assist patients.
  • Pelvic Muscle Exercises: Recommended for strengthening pelvic floor muscles.
  • Types of Incontinence:
      - Stress Incontinence: Leakage with coughing or sneezing, often seen in postpartum mothers.
      - Urge Incontinence: A strong urge to urinate followed by inability to reach the toilet in time; commonly observed in patients with neurologic dysfunction.
      - Functional Incontinence: The urinary tract is intact, but severe cognitive impairment, such as in Alzheimer’s patients, makes it difficult to identify the need to void or reach a toilet in time.

Urinary Retention

  • Defined as the inability to empty the bladder completely; assessment is critical prior to diagnosis.

Method of Treating Renal Stones

  • Lithotripsy: A procedure generating shock waves to break up kidney stones.

Urinary Diversions

  • After bladder removal, urine is rerouted to a new exit, typically through a stoma on the skin.
Nursing Management
  • Monitor urine output to detect any issues.
  • Stoma and skin care responsibilities are crucial; wound care specialists may be involved.
  • Control odor and assist with changing of appliances.

Chapter 34: Rheumatic Disorders

  • 6 questions on rheumatic diseases.

Rheumatic Diseases Overview

  • Definition: Refers to diseases affecting joints, muscles, and bones.
  • Causes:
      - Inflammation, autoimmune response, degeneration of tissues.
  • Common Symptoms:
      - Symmetric joint pain and swelling, stiffness, reduced movement.
      - The goal of treatment is to control inflammation.
Assessment Findings of RA (Rheumatoid Arthritis)
  • Key Findings: Presence of rheumatoid nodules and swan neck deformities in fingers.
Lupus (Systemic Lupus Erythematosus)
  • Nature: Autoimmune disease that affects multiple body systems.
  • Key Signs:
      - Butterfly rash, fatigue, joint pain, fever.
  • Nursing Interventions:
      - Educate to avoid sun exposure and use sunscreen.
      - Monitor for signs of infection.
      - Dietary consultation is crucial as these patients have an increased risk of cardiovascular diseases like hypertension and atherosclerosis.
      - Screening for osteoporosis due to long-term steroid use is essential.
Osteoarthritis (OA)
  • Pathophysiology:
      - Often referred to as “wear and tear” arthritis, which is NOT autoimmune.
  • Key Signs:
      - Pain worsens with movement but improves with rest.

Chapter 47: Diabetes Management

  • 20 questions on diabetes management and complications.

Diabetes Definition

  • Diabetes: A condition characterized by high blood sugar levels.
  • Causes:
      - Decreased insulin production or ineffective insulin action.
  • Normal Blood Glucose Range:
      - 70-110 mg/dL
  • Risk Factors:
      - Obesity and family history of diabetes are major risk factors.

Acute vs. Chronic Complications of Diabetes

Acute Complications
  • Types:
      - Hypoglycemia or hyperglycemia.
      - Morning stiffness lasting less than 30 minutes.
  • Nursing Treatment:
      - Emphasize exercise (aerobic and strength training), weight loss, and use of orthotic devices (e.g., splints, braces, canes).
      - The major goal is managing pain and maintaining optimal functional ability.
Gout
  • Pathophysiology:
      - Caused by high levels of uric acid in the body.
  • Key Signs:
      - Sudden, severe joint pain often felt in the big toe, resulting in a red, swollen joint.
  • Nursing Teaching:
      - Advise to limit intake of purine-rich foods (red meat), reduce alcohol consumption, and encourage weight loss.

Chronic Complications

  • Types:
      - Heart disease, eye damage, kidney damage (nephropathy), nerve damage (neuropathy).
Type 1 Diabetes
  • Nature: An autoimmune disease where patients require insulin (no endogenous production).
  • Risk for DKA (Diabetic Ketoacidosis):
  • Symptoms:
      - Fruity breath, ketosis, metabolic acidosis, nausea, vomiting, fatigue; also known as the "3 P's": polyuria, polydipsia, polyphagia.
  • Treatment: Insulin therapy.
Type 2 Diabetes
  • Nature: Characterized by insulin resistance; the body produces insulin but not in adequate amounts.
  • Complications: Can progress to Hyperglycemic Hyperosmolar State (HHS).
  • Treatment Protocol:
      - Begins with lifestyle changes, followed by medication if changes fail.
      - NO ketosis present in patients.

Diagnostic Tests for Type 2 Diabetes

  • Fasting Blood Sugar:
      - Patients must refrain from eating for 8 hours.
  • Glucose Tolerance Test:
      - A sugary drink is ingested, with blood glucose checked after 2 hours; a result equal to or greater than 200 mg/dL indicates diabetes.
  • Hemoglobin A1c (A1C):
      - Measures average blood glucose over the past 3 months; a level of 6.5% or higher indicates diabetes.

Management Overview

  • Goals:
      - Control and maintain blood sugar levels consistently over time.
      - Strategies include diet modification, exercise, medication adherence, monitoring, and patient education.
  • Nutrition:
      - Reduce daily caloric intake by 500 to 1000 calories as part of weight management in obese patients.
      - Carbohydrate intake raises blood glucose most significantly.

Exercise Monitoring

  • Blood Sugar Checks:
      - Recommend finger sticks for self-monitoring of blood glucose (SMBG) with defined trends tracked.
      - A fasting blood sugar greater than or equal to 126 mg/dL signifies diabetes.
      - Patients should check their blood glucose three times each week without skipping two consecutive days, ideally at the same time of day.
      - Elderly patients may face challenges due to technological issues; consistency and tracking are crucial for effective management.

Pharmacological Therapy

Insulin Types
  • Insulin therapy is classified by onset and peak action times, which dictate the timing of administration.
  • Rapid-Acting Insulin:
      - Lispro:
        - Onset: 10-15 minutes
        - Peak: 1 hour
      - Aspart:
        - Onset: 5-15 minutes
        - Peak: 40-50 minutes
      - Glulisine:
        - Onset: 5-15 minutes
        - Peak: 30-60 minutes
      - Memory Aid: “LAG = Lispro, Aspart, Glulisine (rapid)”
Short-Acting Insulin
  • Regular Insulin (Humulin R, Novolin R):
      - Onset: 30-60 minutes
      - Peak: 2-3 hours
      - Memory Aid: “Regular = R’s of insulin names”
Intermediate (NPH) Insulin
  • NPH:
      - Onset: 2-4 hours
      - Peak: 4-12 hours
  • Humulin N, Novolin N:
      - Onset: 3-4 hours
      - Peak: 4-12 hours
Very-Long-Acting Insulin
  • Glargine:
      - Onset: 1 hour
      - Peak: NO PEAK
  • Detemir & Degludec:
      - Both have onset: 6 hours & NO PEAK.

Acute Complications of Diabetes

Hypoglycemia
  • Definition: Low blood glucose levels below 50-60 mg/dL
  • Caused by: Excess insulin or inadequate food intake.
  • Symptoms:
      - Tachycardia, sweating, shakiness, confusion, headache, drowsiness.
  • Treatment:
      - If the patient is alert and oriented (A&Ox4), administer 15g of sugar and recheck blood glucose in 15 minutes.
      - If blood sugar remains low (<70 mg/dL), administer more sugar.
Insulin Waning
  • Definition: A progressive rise in blood glucose from bedtime to morning.
  • Treatment: Increase the evening insulin dose or provide insulin before the evening meal.
Dawn Phenomenon
  • Definition: Normal blood glucose levels until early morning hours, when levels begin to rise.
  • Treatment: Administer insulin later (at bedtime instead of dinner).
Somogyi Effect
  • Definition: Normal/elevated glucose levels at bedtime followed by early morning hypoglycemia.
  • Treatment: Decrease evening insulin or increase bedtime snacks.
Oral Antidiabetic Agents
  • Awareness that these can still lead to hypoglycemia, and treatment should be initiated if necessary.
  • Dosing and Administration:
      - In cases of unmonitored symptoms, treat symptoms even if blood glucose cannot be checked.
      - 15g of sugar equates to about 4-6 ounces of juice or regular soda.
      - A snack containing both protein and carbohydrates is beneficial.
      - For emergencies where the patient is unconscious or unable to swallow, administer subcutaneous or intramuscular glucagon and 25-50 mL of 50% Dextrose IV.
Diabetic Ketoacidosis (DKA) (Type 1)
  • Causes: Lack of insulin, missed insulin doses, or undiagnosed diabetes.
  • Symptoms:
      - Severe hyperglycemia (>300 mg/dL), metabolic acidosis, presence of ketones in blood/urine, fruity breath, dehydration, and electrolyte imbalances (increased creatinine, hematocrit, BUN).
  • Treatment:
      - Start with IV fluids to rehydrate, followed by a continuous infusion of insulin, and monitor and correct electrolyte imbalances.
      - Potential complications such as hypokalemia should be closely watched.
Hyperglycemic Hyperosmolar State (HHS) (Type 2)
  • Causes: Insulin resistance under stress (e.g., illness, infection) resulting in high glucose.
  • Symptoms: Severe dehydration presented as dry mucous membranes, poor skin turgor, and neuro changes.
  • Treatment:
      - Administer fluids first, then insulin.
      - It's common for diabetic patients to have IVs for easier access to treat complications.
      - Unlike DKA, respiratory compensation won't occur in HHS.

Long-Term Chronic Complications

Diabetic Nephropathy

  • Description: Kidney damage from prolonged high blood sugar levels.
  • High blood sugar compromises the kidney's filtering capability, causing protein (albumin) leakage into urine.
  • Diagnosis Indicators:
      - Presence of protein in urine, elevated creatinine and BUN levels, along with high blood pressure.
  • Management Strategies:
      - Maintain tight control of blood sugar levels and adhere to dietary recommendations, along with fluid management.

Diabetic Neuropathy

  • Education on long-term complications is essential for prevention.
  • Type 2 uncontrolled diabetes can progress to CHD (Coronary Heart Disease), stroke, and PAD (Peripheral Arterial Disease).

Diabetic Retinopathy

  • Pathophysiology: Damage to retinal tissues due to high blood sugar obstructing vascular pathways in the eye.
  • Symptoms: Blurred vision, sudden vision changes, spotty vision, and potential complete vision loss.
  • Management: Regularly maintain blood glucose to near-normal levels, and patients with diabetes need annual eye exams for retina assessment.

Nerve Damage from High Blood Sugar

  • Predominantly affects lower extremities, causing symptoms such as paresthesias (tingling, burning, prickling) initially, advancing to numbness, loss of sensation, and balance difficulties.
  • Management:
      - Daily foot checks for signs of infection/injury are paramount due to loss of sensitivity and increased risk for undetected foot infections.

Chapter 38: Assessment of Gastrointestinal Function

  • 2 questions covering GI system functions and common symptoms.

Functions of the GI System

  • Main Site of Absorption: The small intestine.

Key GI Symptoms to Assess

  • Dyspepsia: The most common complaint involving indigestion, bloating, fullness, and heartburn.

Physical Assessment Methodology

  • Sequence: Inspect, auscultate, percuss, then palpate the abdomen.

Age-Related Changes

  • Decreased gastrointestinal motility leading to constipation.
  • Decreased saliva secretion causing dry mouth.
  • Increased risk of malnutrition in the aging population.

Diagnostic Tests (High-Yield)

  • Laboratory Tests:
      - Hemoglobin and hematocrit can indicate gastrointestinal bleeding.
      - Stool tests for occult blood, ova/parasites, and C. difficile infections.
      - Monitor potassium levels as they impact cardiac function.
      - Absence of bowel sounds indicates an obstruction, while normal bowel sounds are considered good.

Breath Test

  • Used to detect H. pylori presence in the stomach.

Ultrasound

  • Requires fasting for 8-12 hours as part of pretesting for gallbladder studies.

Imaging Studies

Upper GI (Barium Swallow)
  • Used to identify ulcers, tumors, or gastroesophageal reflux disease (GERD).
  • Protocol: NPO after midnight, increase fluids, and laxatives after the procedure.
      - Educate patients that their stool might look white, which is a normal reaction to the barium.
Lower GI (Barium Enema)
  • Used to detect polyps and tumors within the lower intestine.
  • Procedure Duration: 15-30 minutes.
  • Pre-testing Preparation: Clear liquids the night before, laxatives, and enemas.
      - Contraindicated in case of obstruction or perforation.
MRI
  • Caution: No metal implants allowed during the procedure.

Endoscopy

Colonoscopy
  • Used for visualizing the colon for cancer screening and polyp removal.
  • Prep: Bowel cleansing regimen; GoLYTELY or laxatives for two nights prior; entire colon must be clear of stool.
  • Post-Procedure Complications:
      - Watch for bleeding, report to HCP if noted.

Colon Cancer Screening

  • Recommended to start at age 45, with earlier screening for individuals with a family history, inflammatory bowel disease (IBD), or known polyps.

Chapter 40: Oral and Esophageal Disorders

  • 3 questions covering oral and esophageal diseases.

Oral Cancer Risk Factors

  • Primarily associated with tobacco use, alcohol consumption, and HPV infection.
Early Signs
  • Painless, non-healing sores, red/white patches that bleed easily.
Late Signs
  • Increased pain, difficulty chewing or swallowing, and enlarged lymph nodes.
Treatment
  • Surgery combined with chemotherapy.

Hiatal Hernia

Pathophysiology
  • Defined as a portion of the stomach herniating into the chest cavity.
Clinical Manifestations
  • Symptoms include regurgitation, fullness after eating, and dysphagia (difficulty swallowing).
Nursing Management
  • Recommendations include consuming small, frequent meals and avoiding reclining for one hour post-meal to prevent reflux.
  • Surgical intervention may be necessary for symptomatic relief.

Gastroesophageal Reflux Disease (GERD)

Pathophysiology
  • Characterized by stomach acid flowing back up into the esophagus, commonly recognized as heartburn.
Clinical Manifestations
  • Symptoms include heartburn, regurgitation (food returning from the esophagus into the mouth).
Nursing Management
  • Recommend a low-fat diet and avoid eating/drinking 2 hours before bedtime.
  • Patients should avoid foods like coffee, spicy foods, carbonated beverages, and milk that may exacerbate symptoms.

Gastrointestinal Intubation/ NG Tube

Pathophysiology

  • Tubes inserted through the nose and into the stomach or abdominal wall for various medical reasons.
Reasons for NG Tube Placement
  • Indicated for stomach decompression, removal of gas/fluid, and administration of medications & feedings.
Signs of Feeding Intolerance
  • Symptoms can include vomiting, abdominal distention, discomfort, pain, and diarrhea.
Position and Confirmation
  • Before initiating feedings, NG tube placement must be confirmed through an X-ray.
  • Patients should be positioned in semi-Fowler's with the NG tube; supine position is not recommended.

Parenteral Nutrition & TPN (Total Parenteral Nutrition)

Pathophysiology

  • PN provides essential nutrients directly into the bloodstream via IV or central line.

Goals

  • Aimed to improve nutritional status, promote weight gain, and maintain overall health.

Nursing Management

  • TPN must always be administered using an infusion pump and the TPN bag needs changing every 24 hours to minimize infection risks.

Chapter 40: Gastric and Duodenal Disorders

  • 3 questions related to gastric disorders.

Gastritis

Pathophysiology
  • Inflammation located in the gastric lining often caused by H. pylori infection.
Clinical Manifestations
  • Symptoms may include pain, dyspepsia (indigestion), and pyrosis (burning sensation in the stomach).
Nursing Management
  • Avoidance of alcohol and NSAIDs is vital.
  • Encourage increased fluid intake and a bland diet consisting of items like crackers and chicken.

Peptic Ulcer Disease

Pathophysiology
  • Defined as an open sore in the gastrointestinal lining.
Clinical Manifestations
  • Characterized by relief of pain after meals; possible complications include GI bleeding.
Nursing Management
  • Preventive measures include avoiding foods that are extremely hot or cold and reducing intake of alcohol, coffee, and spicy foods and drinks.

Perforation

  • Considered an abdominal emergency requiring immediate surgical intervention, marked by sudden and severe clinical symptoms.

Chapter 42: Intestinal and Rectal Disorders

  • 3 questions addressing intestinal and rectal issues.

Irritable Bowel Syndrome (IBS)

Pathophysiology
  • A long-term condition that leads to recurrent abdominal pain and changes in bowel habits (diarrhea, constipation, or both).
Nursing Management
  • Advising patients to avoid known food triggers, maintain a food diary for 1-2 weeks, eat meals at consistent times, and increase fluid intake yet refrain from mixing fluids with meals.

Appendicitis

Pathophysiology
  • Inflammation and swelling of the appendix.
Clinical Manifestations
  • Symptoms include pain in the right lower quadrant (notably McBurney’s point) and rebound tenderness (pain upon release).
Nursing Management
  • Postoperative care should involve positioning in semi-Fowler's with knees to the chest and advising patients to report any abdominal distension.

Diverticular Disease

Pathophysiology of Diverticulosis
  • Refers to pouch formation in the intestines often without symptoms.
Pathophysiology of Diverticulitis
  • Refers to the inflammation of these pouches, which may lead to pain and serious complications.
Nursing Management
  • Promote hydration, aiming for 2L of fluid daily, stimulating regular bowel movements, and identifying food triggers to avoid (such as popcorn and nuts).