Nursing Exam 1 Review Completed A

Diabetes Mellitus Concept Map • Type 1- Insulin dependent (born with it) • Type 2 – Insulin Resistant (can be reversible) • Risk Factors: increased BMI, poor diet, HTN, decreased perfusion • Assessment: Polyuria, pol ...

Diabetes Mellitus Concept Map • Type 1- Insulin dependent (born with it) • Type 2 – Insulin Resistant (can be reversible) • Risk Factors: increased BMI, poor diet, HTN, decreased perfusion • Assessment: Polyuria, polydipsia, polyphagia, weight loss, fatigue • Complications: retinopathy, nephropathy (urine =30ml/hr, BUN, creatinine), neuropathy, CVD—stroke, Slow wound healing (skin, wbc, temp) • Nursing Diagnosis: ineffective tissue perfusion, risk for ineffective wound healing • Medications: insulin, oral meds • Labs and Diagnostic: FBS, A1C, urine, o Fasting BG: 70-110 <126 o Postprandial BG (2hr) <200 o Random BG: <200 o HA1C: < 6.5 – gives 8-12 week average o 2 hr plasma glucose: give pt sugar and check blood 60 min-2 hrs later to make sure it’s getting insulin and being used correctly • Nursing Interventions: monitor diet [stay away from simple carbs], exercise, specialists (eye doc), walking o When exercising make sure to check BG before, during and after, especially when starting a new regimen o Monitor skin integrity, especially feet o No lotion between toes Make sure you know the different types of Insulin • Know Onset, peak, duration • Rapid Acting: lispro, aspart, glulsine o Onset: 10-30min o Peak: 30min-3hr o Duration 3-5 hr • Short Acting: Regular Humulin R, Novolin o Onset: 30min-1hr o Peak: 2-5 hr o Duration: 5-8 hr • Intermediate: NPH Humulin R, Novalin o Onset: 1.5-4hr o Peak 4-12 hr o Duration 12-18 hr • Long Acting: glargine, determir o Onset: 0.8-4hr o Peak: no pronounced peak o Duration: 24+ hr Hypoglycemia: Cold, Clammy, changes in LOC • Good test question! Always assess situation if patient presents these signs and symptomsDawn Phenomenon (Insulin injection complication) • Normal levels of glucose followed by an elevation of blood glucose between 5am & 9am due to sudden surges of growth hormone secretion • Change time of injection from dinner time to bedtime Somogyi effect • Nocturnal hypoglycemia followed by rebound hyperglycemia due to release of epinephrine, cortisol, glucagon. Elevated earyl glucose level. Most common in children and type 2 diabetics • Decrease evening insulin or increase bedtime snack Insulin Pen • Prime needle, check expiration date, double check with another RN If you have diabetes and they are sick, they need to check their blood glucose levels every 4 hours. • If sugar levels are above 300 two times in a row, come in and see PCP Acute Complications • Diabetic Ketoacidosis o Assessment: thirst, confusion, flushed skin, poor skin turgor [dehydration], tachycardia, kussmaul respirations, fruity breath [from ketones] Metabolic Acidosis, pH <7.35, low HCO3, low CO2, ketones in urine and blood  BG > 250mg/dL  Ketones moderate to high  Concerned about safety o Management: insulin drip, airway, IV Fluids, VS, LOC, cardiac rhythm, I&O, breath sounds, glucose monitoring, electrolyte replacement [check potassium and heart]  Treatment Regular insulin through IV drip  Monitor for fluid overload due to all the fluids with ECG  Check for crackles when monitoring breath sounds  You are not monitoring breath sounds because of the kussmaul respirations o KNOW THIS • Hyperosmolar Hyperglycemic Syndrome (HHS) o Assessment: coma, seizures  Blood glucose level >600 mg/dL  Ketones absent or minimal o Management: IV, insulin drip, electrolyte replacement, VS, I&O, lab values, cardiac, monitoring, LOC, treat cause  Typically normal saline is given  A good test question would be what would be a good fluid to give to someone who has HHS? • NO D5 given!!! Typically 0.9% normal salineo Know difference between blood glucose of DKA and HHS  DKA is ketones HHS is not. You do not go into metabolic acidosis with HHS o HHS can happen due to any reason, can be caused by lots of different things; • Hypoglycemia: Cold, clammy, changes in LOC o Assessment: diaphoresis, pallor, tremors, loss of consciousness, seizures, coma o Management: glucose administration, safety  > 70mg/dL: look for other causes  < 70mg/dL: begin treatment for hypoglycemia • 15g fast-acting carb (pb and crackers), recheck in 15 minutes and if still low give 15g more (2-3 doses) o If patient is unconscious do not give them anything, use other means to treat o Avoid milk and orange juice in renal patients-it increases potassium levels  Orange juice with added sugar is not appropriate when managing low blood sugar  For renal patients – substitute cranberry juice, ginger ale, graham crackers, skin milk • dextrose IVP • glucagon IM or SQ • Hyperglycemiao Assessment: tachycardia, decresed LOC, palpatations, nervousness, lightheadedness, tremors, cold-clammy skin, glucose <70 Endocrine Problems • Acromegaly o Assessment: large face, hands, and feet, speech problems (typically gargled sounding, (pharyngeal tissue), thick skin, hyperglycemia, bobolus nose, neuropathy, muscle weakness, visual changes, headaches, hyperglycemia o Nursing Care: post-op care—airway, bleeding, elevate HOB, neuro check, oral care- sutures are on roof of mouth. Do not brush teeth for ten days to protect sutures. Avoid vigorous coughing, sneezing and straining. o Goal is to get growth hormone to return to normal levels. If it’s due to a tumor-remove it. If it is too big to remove they will radiate it to shrink it and then remove it. o Test: OGTT, IGF 1, MRI, CT (to visualize tumors) • Syndrome of Inappropriate Antidiuretic Hormone (SIADH) o Assessment: hyponatremia, muscle cramps, confusion, seizure o Nursing Care: weight, I&O, fluid restriction [they have too much fluid in their system, so monitor], NA (monitor brain), VS, heart and lungassessment, seizure precautions, flat or HOB at 10*, IV fluid [given slowly to help pull out the extra fluid] o Do not put these patients near nurses station, you want to prevent overstimulation because you do not want to cause a seizure • Diabetes Insipidus (DI) o Assessment: polydipsia, polyuria, thirst, hypernatremia, hypovolemia o Nursing Care: I&O, VS, LOC, hydration, monitor glucose (D5W), hormone therapy  Monitor for seizures, especially whenever sodium levels are out of range o • Hyperthyroidism (Grave’s Disease)—everything elevated o Assessment: HTN, tachycardia, tachypnea, increased appetite, weight loss, warm skin, diaphoresis, hair loss, tremors, exophthalmos, goiter  TSH, free thyroxine (free t4) • KNOW TSH LEVELS o Complications: thyrotoxicosis [thyroid storm, everything is elevated, medical emergency] o Nursing Care: cardiac monitoring, O2, IV fluid, rest, cool room, quiet area, ROM, eye comfort, elevate HOB, meds, high calorie foods [frequent meals that are high in calories], no caffeine  Post op care: VS, respirations, bleeding, semi-fowler’s, pain management, hypocalcemia Ca levels, trousseau’s and chvostek’s signo Treatment: remove thyroid gland (monitor ABC’s) o KNOW DIFFERENCE BETWEEN HYPERTHYROIDISM AND HYPOTHYROIDISM o • Hypothyroidism ----everything is slow o Assessment: fatigue, cold and dry skin, hair loss, slowed speech, constipation, depression, weight gain, decreased cardiac output, anemia, myxedema [swelling in face and eyes]  TSH, free thyroxine (fre t4) o Complications: myxedema coma, cardiovascular collapse o Nursing Care: meds, low calorie diet, VS, cardiac assessment, warm environment, skin care  No heating pad or heating blanket because they can’t sense that, they are at risk for burns  Levothyroxine lifelong medication take before meals on empty stomacho • Cushing’s Syndrome – too much steroid use o Assessment: central obesity, moon face, straie, HTN, hyperglycemia  In women- hirsutism, amenorrhea, buffalo hump  In men- “man boobs”, thickened area around abdomen, thin skin, petechiae o Nursing Care: VS, weight, glucose, prevent infection, meds, radiations, surgery (adrenalectomy)  Post-op care: airway, bleeding, VS, I &O, Bed rest, prevent infection o If on long term steroid use, monitor BG levels constantly due to hyperglycemia • Cushing’s Disease o A tumor is present on the pituitary or adrenal gland so the body releases too many too many glucose corticosteroids o Remove ito • Addison’s Disease o Assessment: weight loss, N/V, bronze-colored skin, hyponatremia (brain), hyperkalemia(heart), hypoglycemia  Know normal ranges for Na and K o Complications: Addisonian crisis o Nursing Care: hormone therapy, VS, weight, monitor glucose, NA, K, quiet environment fluids, I&O, LOC o Good snack foods: turkey and cheese sandwich. Addison’s pts need a diet high in protein, carbs, and sodiumo RENAL CHAPTERS UTI • e.coli most common cause of UTI • Can have lower tract infection or upper tract infection • Lower Tract o Lower: Cystitis –inflammation of bladder o Dysuria, frequency, urgency, hematuria, confusion  Confusion is seen mainly in the elderly (check for LOC) • Safety is a big concern with this! • If elderly patient is confused, expect a UTI o Treatment: antibiotics, antispasmodic, fluids, preventative  You will first do a urinalysis to check for UTI, but to guarantee that they have a UTI, you must do a urine culture sensitivity test  ALWAYS do culture first!!! Then do antibiotics and whatever else is ordered  Antispasmodic-pyridium (turns urine orange, normal side effect) • Upper Tract o Upper: Pyelonephritis o Fever, chills, flank pain (CVA tenderness), n/vo Treatment: antibiotics (PO, IV), fluids, may be hospitalized, monitor for septic shock [low BP, increased HR]  Ex: if you are asked that a patient is admitted to the hospital for pyelonephritis, you will give them antibiotics IV, not PO • Pay attention to the order and what the patient came in for, most of the time the treatment is not orally, but IV • Neurogenic bladder catherization (2-3 hours) • DX: UA/ C&S • Glomerulonephritis • Assessment: edema, HTN, oliguria, hematuria, cola colored urine, proteinuria • Nursing Care: rest, sodium and fluid restriction, antihypertensive meds o Increase protein in the patient’s diet  Meats, beans, nuts, etc o Monitor BUN and Creatinine levels (typically high levels, know the levels) o Monitor for periorbital edema, or edema in legs (monitor everyday) • Patients who have untreated sore throat can develop glomerulonephritis, educate patient on early treatment• Nephrotic Syndrome • Assessment: peripheral edema, massive proteinuria, HTN o Diabetic patients more likely to get this o Massive protein loss • Nursing Care: corticosteroids, anti-hypertensive, diuretics, NSAIDS, lowsodium and moderate-protein diet, small and frequent meals, assess edema o Monitor glucose levels due to corticosteroids o Typically given ACE inhibitors o Check circumference of abdomen or legs in order to monitor edema • BIGGEST take away: lost of protein lost and a lot of edema (typically in legs) • Nursing DX: excessive fluid volume, fluid volume overload• Polycystic Kidney Disease • Cause is genetic • Assessment: enlarged kidneys • Nursing Care: prevent infection, dialysis, kidney transplant o Genetic counseling for those who want to have kids o NO bubble baths, void after sex o Typically have renal failure, so discuss dialysis o Discuss ways to monitor pain • Renal Calculi • Assessment: severe pain, dysuria, chills • Nursing Care: analgesics, anti-spasmodics, hydration, dietary restrictions, strain urine, post-lithotripsy care, education o Treat pain first because they are in excruciating pain o Drink lots and lots of fluids! Stay Hydrated!!! About 3000ml a day o Dietary restriction based on what kind of stone they pass (calcium, uric, etc) o Urine may be pinked tinge following procedure, call doctor right away if it is bright red• Renal Cancer • Assessment: hematuria, flank pain, HTN • Nursing Care: assist with treatment, post-nephrectomy care • Do biopsy in order to know if they have cancer • Types of Urinary Incontinence pg. 1088 table 46.17 • Stress: sudden increase in intraabdominal pressure causes involuntary passage of urine • Urgency: Involuntary urination is preceded by urinary insistence • Overflow:Pressure of urine in bladder overcomes sphincter control • Reflex: No warning or stress precedes periodic involuntary urination • Functional: From cognitive, functional, or environmental factors • Teach patients to do kegel exercises and pelvic floor exercises Types of Catheters • Urethral catheter • Ureteral catheter o Most risk at infection for UTI • Suprapubic catheter o Most risk at infection for UTI o Monitor for skin breakdown Urinary Diversion Types • Nephrostomy: drains urine from kidney• Ileal conduit: uses small intestine • Cutaneous ureterostomy: ureters detached, stoma formed Renal Failure • Diabetic patients most at risk for renal failure along with patients who have HTN • Types of Acute Renal Failure o Prerenal: reduced perfusion to the kidneys  Can be caused by uncontrolled HTN o Intrarenal: damage to renal paranchyma  Caused by medication like gentamycin  Caused by infection or nephrotoxic meds, aspirin o Postrenal: sudden blockage that stops urine form flowing out the kidneys  Occurs from tumor or cyst o • Stages of Acute Renal Failure o What would you expect to see in the oliguric phase  Decreased urine output, <400ml/day  Decrease in glomerular filtration rate (know normal level—90- 120ml/min) o What would you expect to see in the diuretic phase  Loosing a lot of urine, may loose up to 5L/day  Kidneys stop working, so everything just floods through it o What would you expect to see in the Recovery phase  Labs normalize (BUN and creatinine)  Glomerular filtration rate starts to go up Can take up to a year, most recover, if they don’t then it develops to CKD o Nursing interventions  Strict I/O, lab values (K, Na), mental status, daily weights  Insulin, glucose, sodium bicarbonate is given (table 47-4/5) pg. 1105  Know generic name for kayexalate—sodium polystyrene sulfonate Chronic Kidney Disease • Defined as presence of o Kidney damage o Glomerular filtration rate (GFR)  <60mL/min for 3 months or longer [know this] • Stages of CKD o Kidney damage with normal or elevated GFR o Kidney damage with mild decrease GFR o Moderate decrease GFR o Severe decrease GFR o Kidney failure o • Manifestations o Neuro—lethargy, seizures o Cardio—HTN, HF, edema o Respiratory—SOB, tachypnea, pulmonary edema, Kussmaul respirations o GI—Anorexia, N/V o Skin—pruritis, dry [keep nails short, and try not to scratch skin]o Musculoskeletal—pain, weakness [monitor safety] o Hematologic—anemia [know rbc, H&H levels] o Reproductive—menses o Urinary—polyuria, nocturia, oliguria, anuria, proteinuria, hematuria • Dialysis o Corrects fluid/electrolyte imbalances and removes waste products in renal failure o Two methods:  Peritoneal dialysis (PD)—goes into the abdomen • Complications—bleeding, dialysate retention, infection, may not come out [make sure tube isn’t blocked off, no kinks, turn and reposition patient] • Effective & Adaptation—more convenient than HD, short training program  Hemodialysis (HD) • Nursing Care o Before: Assess fluid status [daily weight], access (bruits and thrill), educate patient [length of time 2-6 hrs] o During: Monitor VS[pulse, bp], loss of blood o After: monitor changes in condition (VS, bleeding), No BP or venipuncture in affected arm, skin care, diet [monitor K, phosphors, Na, fluid Kidney Transplant Nursing Care • Postop care of recipient o Fluid and electrolyte balance o Urine output [1100ml/hr normal] o Catheter patency—check for kinks or blockage if output decreases o Immunosuppression medications o Complications—rejection, infection, reoccurrence of kidney disease [elevated BUN or creatinine] Sensory/Hearing Weber Test • Test bone conduction Rinne Test • Test Air conduction Technique for using otoscope • Children pull eye down • Adult pull eye up Types of hearing loss• Conductive; due to external or middle ear problem • Sensorineural; due to damage to the cochlea or vestibulocochlear nerve • Mixed; both conductive and sensorineural • Function (psychogenic); due to emotional problem • Presbycusis; due to aging Manifestation • Early symptoms include • Tinnitus: perception of sound; often”ringing in the ear” • Increased inability to hear in a group • Turning up the volume on the Tv • Impairment may be gradual and not recognized by the person experiencing the loss • As hearing loss increases, person may experience deterioration of speech, fatigue, indifference, social isolation, or withdrawal, and other symptoms Conditions of the External Ear • Cerumen impaction • Removal may be irrigation, suction, or instrumentation • Gentle irrigation should be used with lowest pressure, directing steam behind the obstruction. Glycerin, mineral oil, ½ strength H202, or peroxide in glyceryl may help soften cerumen • Foreign bodies • Objects that may swell (such as vegetables or insects) should not be irrigated • Foreign body removal can be dangerous & may replace extraction in the operating room- b/c you can tear the tympanic membrane. • External otitis • Inflammation most commonly due to bacteria Staphylococcus or pseudomonas, or fungal infection due to Aspergillus. • Manifes Dullness & redness is infection Bulging too much positive pressure Retraction too much negative pressure Impaction Give something to relax them Ask about allergies If a child get permission