MEDSURG II FINAL EXAM STUDY GUIDE RATED A

1 Crohn's basic info: - Crohn’s disease is a type of IBD (most common in the distal small intestine or proximal colon) - Causes major inflammation and ulceration in the GI tract. - It is found through the whole GI tract but is most prominent in the terminal ileum and beginning of the colon. - Chronic inflammatory Disease that can involve the entire GI tract (most common in the distal small intestine or proximal colon) and all layer of the. Bowelwall. Characterized by periods pf remissions and exacerbations. RF: Autoimmune disorders, genetics, smoking, NSAID use. S/S: Diarrhea (5-6 loose stools/day) steatorrhea, RLQ pain, weight loss, anemia, fever, fatigue. Diagnostic test ● CT scan ● Magnetic resonance eterography (MRE) is performed to determine bowel activity and motility ● Barium enemas with air contrast can show differences between UC and Crohn’s disease. Colonoscopy: Pre-procedure: ● Clear liquid diet, laxatives (Polyethylene Glycol) ● Educate the patient NPO after midnight and avoid any time of food red, orange or purple in color as their residue can appear to be blood. ● Unlicensed assistive personnel (UAP) can Reinforce “NPO” status. Post-procedure: ● Patient in left lateral position to less discomfort and quicker passage of flatus. ● Assess VS every 15 to 30 minutes until the client is alert, assess for rectal bleeding or severe pain. ● Confirm the client has arranged for another person to drive home to get rest. ● After a colonoscopy with a biopsy, a small amount of bleeding is normal. . Crohn’s disease. Diagnostic test. Colonoscopy ● IF symptoms of fever, bleeding, severe pain, dizziness, tachycardia, tachypnea, and abdominal distention (rigid board like abdomen) PERITONITIS=Perforated bowel. Question: The nurse receives the following information about a 51-yr-old female patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient has a permanent pacemaker to prevent bradycardia. b. The patient is worried about discomfort during the examination. c. The patient has had an allergic reaction to both shellfish and iodine in the past. d. The patient declined to drink the prescribed polyethylene glycol (GoLYTELY). ● ANS: D If the patient has had inadequate bowel preparation, the colon cannot be visualized, and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient’s anxiety about discomfort. 2. Review risk factor of acute renal failure – prerenal AKI is caused by: decreased renal perfusion: Sudden loss of kidney function; usually reversible. Patho: Three general underlying causes: Prerenal AKI: low flow to kidneys (related to shock, sepsis, hypovolemia, renal vascular obstruction) Intrarenal AKI: Direct damage to the kidneys (physical trauma, hypoxic injury, chemical injury due to toxins or medications. Postrenal AKI: Mechanical obstruction to urine outflow (stone ,tumor, BPH) causes urine to back up to the kidneys , impairing kidney function. Causes: - obstruction/vessel occlusion - Low blood pressure - Hemorrhage (trauma or surgery) - Decreased cardiac output (Cardiogenic Shock) - Hypovolemia ● Decreased peripheral vascular resistance ● Use of aspirin, Ibuprofen, or NSAIDs/ glomerulonephritis ● Liver failure ● Decreased renovascular blood flow (Heart failure can lead to prerenal failure, which is due to decreased blood flow to the kidneys. ) ● Dehydration Question: The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history? R: Myocardial infarction Rationale: Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. 3. Total gastrectomy. Nursing education post procedure - Vitamin B 12 IM injection for life to avoid pernicious anemia (Pernicious anemia is a type of vitamin B12 anemia.)because there is not intrinsic factor - Folic acid replacement - Provide iron supplements for the client. Rational: The gastric mucosa secretes the intrinsic factor which is required for the absorption of the extrinsic factor (Vitamin B12) that is used in the maturation and release of erythrocytes from the bone marrow. Following gastrectomy, a client should be prepared to take a maintenance dose of an injectable Vitamin B12 (D) for the rest of his life to prevent pernicious anemia Postoperative interventions a. Monitor vital signs. b. Place in a Fowler’s position for comfort and to promote drainage. c. Administer fluids and electrolyte replacements intravenously as prescribed; monitor intake and output. d. Assess bowel sounds. e. Monitor NG suction as prescribed. f. Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns. g. Progress the diet from NPO to sips of clear water to 6 small bland meals a day, as prescribed when bowel sounds return. h. Monitor for postoperative complications of hemorrhage, dumping syndrome, diarrhea, hypoglycemia, and vitamin B12 deficiency. Following gastric surgery, do not irrigate or remove the NG tube unless specifically prescribed because of the risk for disruption of the gastric sutures. Monitor closely to ensure proper functioning of the NG tube to prevent strain on the anastomosis site. Contact the surgeon if the tube is not functioning properly. 4. Acute Kidney Injury. Nursing education about requires diet - Restrict potassium and sodium - High calories - Restrict protein specifically during oliguric phase Many clients with AKI are too ill to meet caloric goals and require tube feedings with renal-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas. According to Saunders: Administer the prescribed diet, which is usually a low to moderate protein (to decrease the workload on the kidneys and higher) 5. Hypoglycemia. Clinical manifestation. Nursing assessment Expected Ranges: - Casual : below 200 - Fasting: Below 100 - HgbA1c: below 6% - GTT: Below 140 Diagnostic Criteria Fasting >126 mg/dL Casual>200 mg/dL HgbA1c > 6.5% S/S of hypoglycemia: Cool, pale, sweaty, clammy, diplopia (double vision)→ please give me some sugary candy HIWASH - Headache - Irritable - Weakness - Anxious/trembling - Sweating (diaphoresis) - Seizures (severe) - Hunger Neuroglycopenic Symptom • Weakness • Fatigue • Difficulty thinking • Confusion • Behavior changes • Emotional instability • Seizures • Loss of consciousness • Brain damage • Death Neurogenic Symptoms Adrenergic: • Shaky or tremulous • Heart pounding • Nervous or anxious • Cholinergic: • Sweaty • Hungry • Tingling 6. Acute pyelonephritis. Clinical manifestation Pyelonephritis: Bacterial infection in the kidney PATHO: With acute pyelonephritis, a UTI spreads from the bladder- ureters – kidneys. Chronic pyelonephritis occurs due to a urinary tract defect and/or reflux from the bladder. RF: BPH, Kidney stones, pregnancy, high urine pH, incomplete bladder emptying, chronic disease. Main differentiating S/S from UTI: - Dull flank pain (Costovertebral tenderness) - (Extending toward the umbilicus) - Other s/s: - fever/chills - Dysuria (burning/painful urination) - Urinary frequency/urgency - cloudy/dark/foul smelling urine - Hematuria - WBC count x>10,000 - confusion/ALOC - tachycardia/tachypnea - Flank pain on the affected side - Costovertebral angle tenderness Labs: Blood High WBCs, creatinine, BUN, ESR, CRP Urine: positive for leukocyte esterase, nitrites, WBCs, bacteria. A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? a b ANS: B . U rinary urgency c . In termittent hematuria . Left-sided flank pain d. Bu rning with urination The nurse is assessing a client with acute pyelonephritis. What assessment findings would the nurse expect? (Select all that apply.) A. fever/ b. Chills/ c. Tachycardia/ d. Tachypnea/ e. Flank or back pain/ f. Fatigue ANS: A,B,C,D,E,F All of these assessment findings commonly occur in clients who have acute pyelonephritis because this health problem is a kidney infection. Which assessment data would the nurse anticipate in a client with acute pyelonephritis? Select all that apply. A. Urinary frequency B. Dysuria C. Oliguria D. Heart rate 120 beats/min E. Uremia F. Costovertebral angle tenderness Ans: a,b,d,f 7. Review: Menorrhagia, Metrorrhagia, oligomenorrhea concepts. Menorrhagia: Excessive menstrual bleeding in duration or amount. Lasts more than 7 days • Causes: Hormonal disturbances, systemic disease, benign or malign neoplasm, infection, and contraception (IUD). • Important: check Hb and Hto. Use of Aspirin is contraindicated Metrorrhagia: Intermenstrual bleeding. It is frequent in women taking contraceptive pills, or using progestin contraceptive injection, IUD Oligomenorrhea: Alteration in cyclic bleeding, infrequent menstrual periods, intervals of 40 to 45 days or longer 8. Diabetes insipidus. Clinical manifestation before and after Treatment. DI s/s: - High urine output - Diluted urine (high and dry labs) - High sodium (hypernatremia → over 145 mEq/L) - Hyperosmolality - Polydipsia - Dehydration (dry mucosa and poor skin turgor) - Decreased BP due to fluid loss After treatment: - Increases urinary osmolarity and urinary gravity Rational: Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolarity, as evidenced by a low specific gravity. Effective treatment results in decreased urine output that is more concentrated, as evidenced by an increased specific gravity. 9. Somogyi phenomenon. Clinical manifestation. Treatment options - Also called “rebound hyperglycemia” - Causes high levels of blood sugar in the morning - Clinical manifestations = s/s of hyperglycemia - Due to: - Too much/little insulin at night - Skipping bedtime snack - Is the bodies response to low periods of low blood sugar; causes body to release hormones that work against insulin - Treatment options: ● Check patients blood glucose level at 2-3 AM and intervene whether hyper/hypo glycemic ● adjusting the timing of insulin administration ● lowering the dose of insulin before bed ● changing the type of insulin ● eating a snack with the evening insulin dosage ● taking into account lifestyle factors, such as stress and exercise 10. Compartment syndrome. Clinical manifestation Compartment Syndrome: high pressure within the muscle compartment of an extremity that impairs circulation. - Diminished pulse - Deep, throbbing, unrelenting pain which is not controlled with opioids. - Unrelieved or increased pain in the limb - Tissue that is distal to the involved area becomes pale, dusky, or edematous. - Pain with passive movement - Loss of sensation (paresthesia) - Pulselessness (a late sign) S/S: 5Ps 1. Intensive pain (unrelieved by drugs and/or pain within passive movement), 2. Paresthesia (Pins and needles) 3. Paralysis 4. Pallor 5. Pulselessness A nurse caring for a client with a fracture of the femur, the nurse should be alert for compartment syndrome. What symptom is characteristic of this complication? Select one: a. Tachycardia and petechiae over the chest wall and buccal membranes. b. Acute anxiety, diaphoresis, and elevated blood pressure. c. Deep, throbbing, unrelenting pain which is not controlled with opioids. d. Positive Homan's sign with calf tenderness and warmth. Feedback: Ischemic necrosis of distal tissues produces the severe pain characteristic of compartment syndrome The correct answer is: Deep, throbbing, unrelenting pain which is not controlled with opioids. 11. Hyperthyroidism. Clinical manifestation. Complication of treatment Hyperthyroidism = Increased T3 and T4 (Together, these hormones regulate your body's temperature, metabolism, and heart rate) and low calcitonin GRAVES DISEASE Main complication: Thyroid Storm Clinical manifestations: HIGH AND HOT - High Blood pressure (can lead to hypertensive crisis) - Tachycardia - Heat intolerance - High heart rate - Exophthalmos (bulging eyes) - Goiter (enlarged thyroid gland) - High weight loss → skinny patient - High temperature (Heat intolerance and diaphoresis) - High GI → Diarrhea - shaking/tremors - Irregular menstruation in women - Smooth soft skin and hair TREATMENT: Surgery: thyroidectomy Medication: Propylthiouracil, iodine solutions, beta blockers(hypertension). Complication of treatment: Treatment option may cause hypothyroidism, requiring lifelong hormone replacement therapy (levothyroxine). Skipping doses of Levothyroxine may cause myxedema coma (welling of the skin and underlying tissues giving a waxy consistency, typical of patients with underactive thyroid glands. The more general condition associated with hypothyroidism, including weight gain, mental dullness, and sensitivity to cold.) Myxedema coma: Severe life-threatening hypothyroidism. Causes: Untreated hyperthyroidism, infection, illness, abrupt discontinuation of levothyroxine S/S: Hypoxia, low cardiac output , low LOC, bradycardia, hypotensi0on, hypothermia. Nursing care: maintain patent airway, monitor EKG, administer large doses of levothyroxine, warm patient. Assist with intubation and mechanical ventilation. Too much levothyroxine can cause Thyroid storm Thyroid storm: Excessive high levels of thyroid hormones. High mortality rate. Causes: infection, stress, DKA, Thyroidectomy S/S: severe hypertension, chest pain, dysrhythmias, dyspnea, delirium, fever, nausea/vomiting. TX: medicatio0ns: beta blockers, anti-thyroid medicatio0ns, antipyretics. Surgery: thyroidectomy Nursing care: maintain patient airway, monitor for dysrhythmias. While assessing a client with Graves disease, the nurse notes that the client’s temperature has risen 1° F (1° C). What does the nurse do first? a. Turn the lights down and shut the patient’s door. b. Call for an immediate electrocardiogram (ECG). c. Calculate the client’s apical-radial pulse deficit. d. Administer a dose of acetaminophen. ANS: A A temperature increase of 1° F (5/9° C) may indicate the development of thyroid storm, and the primary health care provider or RRT needs to be notified. But before notifying the provider, the nurse should first take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and acetaminophen is not needed because the temperature increase is due to thyroid activity. 12. Graves’ Disease. Clinical manifestation. Nursing action to alleviate the symptoms. - Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). - S/S: Refer to #11 - Interventions to alleviate eye symptoms: (due to exophthalmos = bulging eyes) tape the eyelids and provide eye lubricant. - Elevate HOB - Use eye patch/tape eyelids for sleeping - Use lubricating eye drops - Restrict salt intake( decrease risk of dehydration ) 13. Graves’ disease. Complication. First line of Treatment Patients need to rest, high protein and calorie diet, cool environment IV propranolol (lower BP) - Thyroid storm: - Occurs in patients with uncontrolled hyperthyroidism, most often with Graves’ disease. It presents with uncontrolled hyperthyroidism and is characterized by high fever and severe hypertension. Immediately report a temperature increase of even 1°F.If temperature is elevated, immediately assess the patient’s cardiac status Emergency Care of the Patient During Thyroid Storm (life-threatening event) • Maintain a patent airway and adequate ventilation. • Give oral antithyroid drugs as prescribed: methimazole or propylthiouracil. • Administer sodium iodide solution IV daily as prescribed. • Give propranolol IV as prescribed, slowly over 3 minutes. The patient should be connected to a cardiac monitor, and a central venous pressure catheter should be in place. • Give glucocorticoids as prescribed: hydrocortisone, prednisone, or dexamethasone. • Monitor continually for cardiac dysrhythmias. • Monitor vital signs every 30 minutes. • Provide comfort measures, including a cooling blanket. • Give non salicylate antipyretics as prescribed. • Correct dehydration with normal saline infusions. • Apply a cooling blanket or ice packs to reduce fever. 14. Type 1 diabetes. Most common complication: DKA: Diabetic Ketoacidosis: Life-threatening condition with high blood glucose levels and ketones in the blood and urine. Rapid onset. More common with type 1 DM. RF: Infection, stress/illness, untreated or undiagnosed type 1 D, missing insulin dose. S/S: 3Ps (Polydipsia, Polyuria, Polyphagia) weight loss, fruity breath odor, Kussmaul respirati0ons, GI upset, dehydration (resulting in hypotension, headache, weakness). Labs: Blood glucose > 300mg,dl, Ketones in the blood and urine, metabolic acidosis, hyperkalemia. DKA: blood glucose >300 mg/dL, with ketons in blood and urine. HHS: Blood Glucose >600 mg/dL. No ketons. The K in DKA will remind you to monitor K ! Other complications: (of hyperglycemia - type 1 and 2 diabetes) - Atherosclerosis - Diabetic nephropathy - Neuropathy - Diabetic feet - Slow wound healing - Acanthosis Nigricans - Cataracts / Retinopathy - Hypertension /Angina - CVA / Aneurysm - Periodontal disease / oral thrush - Thick nails with ridges 15. Review and recognize: Hydroceles, varicoceles and hemocoels. Hydroceles: Swelling in the scrotum where fluid has collected around one or both testicles. Painless, often the sensation is described as “heaviness” of the scrotum Teach: • Treatment is usually not needed unless the condition becomes painful or too large for comfort; at that time, surgery may be recommended. • If pain does occur, acetaminophen or ibuprofen can be taken. • Report any changes involving pain, fever, redness, or swelling. Varicoceles: Vein enlargement inside the scrotum (usually on the left side), which can cause low sperm production Is often asymptomatic; pain, if experienced, may be dull or sharp, and worsens with activity and throughout the day. Teach: • Treatment is usually not needed unless the condition becomes painful or too large for comfort; at that time, surgery may be recommended, particularly if the condition has left the patient infertile. Hematocele: Accumulation of blood in between the layers of the tunica vaginalis and can reach large volumes. Question: When conducting an initial assessment on a 10-year-old male patient, the nurse assesses a mass in the left testicle that on transillum ination glows red. The nurse notes the presence of: d. hydrocele. Feedback :A hydrocele will glow red on transillumination, but a hematocele will not. Phimosis is a foreskin that will not retract over the glans and varicocele are dilated veins in the spermatic cord. 16. Spironolactone (Aldactone) -related side effects HYPERKALEMIA Spironolactone = potassium sparing diuretic It prevents the body from absorbing too much salt and keep potassium levels from getting too low - It is used to treat: - Heart failure - High blood pressure - Hypokalemia - Edema - Ascites due to cirrhosis - Side effects: - Hyperkalemia (may cause cardiac dysrhythmias) - Oliguria / anuria - vomiting - Muscle pain - Slurred speech - Severe weakness - Breast swelling/tenderness (Gynecomastia) - Teratogenic - Menstrual irregularities Question: A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. The nurse will monitor for a. increased serum sodium. c. elevated serum potassium. b. decreased urinary output. d. evidence of fluid overload. ANS: C Because aldosterone increases the excretion of potassium, a medication that blocks aldosterone will tend to cause hyperkalemia. Aldosterone also promotes the reabsorption of sodium and water in the renal tubules, so spironolactone will tend to cause increased urine output, a decreased or normal serum sodium level, and signs of dehydration. 17. Hypothyroidism. Clinical manifestation. Complications of treatment Hypothyroidism: Inadequate production of thyroid hormones (T3/T4) by the thyroid gland. Patho: Primary: Thyroid gland injury/damage low T3/T4 production. Hashimoto’s disease (most common cause, autoimmune issue) causes antibodies to attack and destroy thyroid cells. Other cause: Thyroidectomy, radiation therapy Secondary: Anterior pituitary gland tumor & TSH secretion (which & T3/T4 production). Tertiary: Hypothalamic dysfunction & TRH secretion (which ¿ TSH secretion and T3/T4 production). Causes: - Hashimoto (autoimmune) - Low dietary iodine - Thyroidectomy - Pituitary tumor Complication: Myxedema coma = extreme low Myxedema coma: Severe life-threatening hypothyroidism. Causes: Untreated hyperthyroidism, infection, illness, abrupt discontinuation of levothyroxine S/S: Hypoxia, low cardiac output , low LOC, bradycardia, hypotensi0on, hypothermia. S/S: Low respiratory rate → respiratory failure Nursing care: maintain patent airway, monitor EKG, administer large doses of levothyroxine, warm patient. Assist with intubation and mechanical ventilation. Intervention of myxedema coma: Place tracheostomy kit / endotracheal intubation set at bedside S/S of hypothyroidism: LOW AND SLOW - Low blood pressure - Low heart rate - lethargy - Low temperature (cold intolerance) - Low energy - Low/slow metabolism → weight gain (also edema eyes) - Low digestion (constipation) - Alopecia - ALOC - Low mood/depression - Low Libido Complication of treatment: - Myxedema coma (undermedication of levothyroxine) - Thyroid storm (overmedication of levothyroxine) **Monitor for overdose of thyroid medications, characterized by tachycardia, chest pain, restlessness, nervousness, and insomnia. Instruct the client to report episodes of chest pain or other signs of overdose immediately. 18. Diabetes mellitus. Clinical manifestation Acanthosis nigricans *** (A skin condition characterized by dark, velvety patches in body folds and creases) Fatigue, polyuria, and polydipsia, polyphagia. Hyperglycemia Weight loss (common in type 1 diabetes mellitus, rare in type 2 diabetes mellitus) Blurred vision Slow wound healing/ Signs of inadequate circulation to the feet Vaginal infections Weakness and paresthesia Signs of accelerated atherosclerosis (renal, cerebral, cardiac, peripheral) 19. Review and recognize the different neurologic body posturing: Decorticate, Decerebrate Decorticate: arms brought to the CORE of the patient Rational: The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The physician, the charge nurse, and other health care team members should be notified immediately of this change in status. Decerebrate posturing: external rotation and extension of the extremities. 20. Acute pancreatitis. Clinical manifestation Acute Pancreatitis: Pancreatic digestive enzymes are activated prematurely (before reaching the intestines), resulting in autodigestion, and fibrosis of the pancreas. RF: Alcohol abuse, bile tract disease, GI surgery, gallstones, trauma, medication toxicity. S/S: Severe LUQ or epigastric pain (radiating to the back or left shoulder), N/V, Cullen’s sign (blue/grey discoloration around the umbilicus), Turner’s sing (ecchymosis on flanks), ascites, jaundice, tetany. - Fever - Tachycardia - Low blood pressure - Abdominal pain (Left upper quadrant) , sudden onset and radiates to the back, left flank, or left shoulder. Described as intense, boring (feeling that it is going through the body), and continuous, and is worsened by lying in the supine position. Often the patient finds relief by assuming the fetal position (with the knees drawn up to the chest and the spine flexed) or by sitting upright and bending forward. - Pain aggravated by a fatty meal, alcohol, or lying in a recumbent position - nausea/vomiting - Cullen's sign: discoloration of the abdomen and periumbilical area. - Gray turner signs: sign is the bluish discoloration of the flanks. - Lab values: - Increased: - Amylase - Lipase - Triglycerides - Glucose - Decreased: - Calcium Question: A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? a. Nausea and vomiting b. Severe boring abdominal pain c. Jaundice and itching d. Elevated temperature The client who has acute pancreatitis reports severe boring abdominal pain that is often rated by clients as a 10+ on a 0-10 pain scale. Nausea, vomiting, and fever may also occur, but that is not the client’s priority for care. 21. Acute pancreatitis: Clinical manifestations Refer to the question above High amylase, lipase, triglycerides, glucose. Low Ca, Mg(magnesium), Platelets 22. Peritoneal dialysis. Complication. Nursing action - Infection (Peritonitis) monitor for signs of fever, cloudy outflow, rebound abdominal tenderness, abdominal pain, general malaise, nausea, and vomiting. - Cloudy or opaque outflow is an earliest sign of peritonitis. - Collect fluid and send to lab for culture and sensitivity - Antibiotics may be added to the dialysate. -nursing action - Avoid infections by maintaining meticulous sterile technique when connecting and disconnecting PD solution bags and when caring for the catheter insertion site. 23. Review: orchitis, Phimosis and Peyronie Disease. clinical manifestation Orchitis: An acute testicular inflammation resulting from trauma or infection such as STI. A history of mumps in men may cause orchitis (painful inflammation and swelling of the testes), which can lead to testicular atrophy and (uncommonly) sterility. Phimosis : Tightness that results in the inability to retract the foreskin. Swelling and pain at the head of the penis, causing difficulty in retraction of the foreskin Is often associated with hygienic concerns (neglecting to replace the foreskin after cleaning, intercourse, or urination), or body piercing of the glans or foreskin Teach: • Proper hygiene is important. • Topical corticosteroids may be prescribed. • Circumcision may be recommended by the health care provider. Peyronie’s Disease: Fibrous scar tissue inside the penis that causes curved, painful erections.Is caused by repeated penile injury, typically during sex or physical activity. Penises vary in shape and size, and having a curved erection isn't necessarily a cause for concern. In Peyronie's disease, the bend is significant, and may occur along with pain or interfere with sexual function. Medications or surgery may be recommended if symptoms persist or worsen. 24. Esophageal varices. Complication. Clinical manifestation ● Complication: Hypovolemic shock due to hemorrhage from varices ● Clinical manifestation: ○ Tachycardia, hypotension ○ Jaundice ○ Dark tarry stools ○ Hematemesis/Melena ○ Ascites ○ Hepatomegaly and splenomegaly ○ Dilated abdominal veins ○ Signs of shock 25. Review Cranial Nerve Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in the face. Trigeminal neuralgia: the client experiences severe facial pain. Cranial nerve II, the optic nerve, provides central and peripheral vision. A client who has cranial nerve II impairment will not be able to see, so the nurse Or UAP should tell the client where different food items are on the meal tray. CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid movement. 1. A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) b. Impaired swallowing/ d. Inability to shrug shoulders/ e. Loss of gag reflex Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. 26. Review Which STD must be reported to the public health department? Chlamydia infection, gonorrhea, syphilis, chancroid, and HIV infection (through HIV Stage III—acquired immune deficiency syndrome [AIDS]) are notifiable to local health authorities in every state (CDC, 2020a). Other STIs such as genital herpes (GH) may or may not be reported, depending on local legal requirements. Positive results can be reported by clinicians and laboratories. Reports are kept strictly confidential. Question: A primary care clinic sees some clients with sexually transmitted infections. Which diseases would the nurse be required to report to the local authority? (Select all that apply.) a. Chlamydia b. Gonorrhea c. Syphilis d. Human immune deficiency virus e. Pelvic inflammatory disease f. Human papilloma virus ANS: A, B, C, D Chlamydia, gonorrhea, syphilis, human immune deficiency virus (HIV), and acquired immune deficiency syndrome (AIDS) are all reportable to local authorities in every state. Pelvic inflammatory disease and HPV do not need to be reported. 27. Colonoscopy. Positioning for procedure - Left lateral position with the knees drawn up 28. Review types of urinary incontinent. Recognize each one . - Stress incontinence. Urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy. - Urge incontinence. You have a sudden, intense urge to urinate followed by an involuntary loss of urine. You may need to urinate often, including throughout the night. Urge incontinence may be caused by a minor condition, such as infection, or a more severe condition such as a neurological disorder or diabetes. - Overflow incontinence. You experience frequent or constant dribbling of urine due to a bladder that doesn't empty completely. - Functional incontinence. A physical or mental impairment keeps you from making it to the toilet in time. For example, if you have severe arthritis, you may not be able to unbutton your pants quickly enough. - Mixed incontinence. You experience more than one type of urinary incontinence — most often this refers to a combination of stress incontinence and urge incontinence. 29. Paracentesis procedure. Pre procedure: 1. Informed consent 2. Obtain vital signs, including weight, and assist the client to void. 3. Position the patient in bed with the head of the bed elevated. 4. Assist the primary health care provider (PHCP), monitor vital signs, and provide comfort and support during the procedure. 5. Apply a dressing to the site of puncture. 6. Monitor vital signs, especially blood pressure and pulse, because these parameters provide information on rapid vasodilation postparacentesis; weigh the client postprocedure, and maintain the client on bed rest. 7. Measure the amount of fluid removed. 8. Label and send the fluid for laboratory analysis. 9. Document the event, client’s response, and appearance and amount of fluid removed. Postprocedure a. Monitor vital signs, BP, HR b. Measure fluid collected, describe, and record. c. Label fluid samples and send to the laboratory for analysis. d. Apply a dry sterile dressing to the insertion site; monitor the site for bleeding. e. Measure abdominal girth and weight. f. Monitor for hypovolemia, electrolyte loss, mental status changes, or encephalopathy. g. Monitor for hematuria caused by bladder trauma. h. Instruct the client to notify the PHCP if the urine becomes bloody, pink, or red. The rapid removal of fluid from the abdominal cavity during paracentesis leads to decreased abdominal pressure, which can cause vasodilation and resultant shock; therefore, heart rate and blood pressure must be monitored closely. Complication: Hypovolemia, bladder perforation, peritonitis. Hypovolemia: albumin levels can drop dangerously low because the peritoneal fluid removed contains a large amount of protein. The removal of this protein-rich fluid can cause shifting of intravascular volume, resulting in hypovolemia. Bladder perforation: Rare but possible complication. Manifestations include hematuria, low or no urine output, suprapubic pain or distention, symptoms of cystitis and fever. Peritonitis: can occur as a result of injury to the intestines during needle insertion. Manifestations include sharp, constant abdominal pain , fever, nausea, vomiting, and diminished or absent bowel sounds. Nursing assessment: Blood pressure & vital signs ● Preprocedure: labs (serum albumin, protein, glucose, amylase, BUN, and creatinine). ● Postprocedure: Intake and output every 4 hr 30. Graves’ disease. Diet recommendation - really fast due to high metabolism 31. Bacterial vaginosis. Clinical manifestations Client complains of “Fishy Odor” to vaginal secretions and increased odor after intercourse. Microscopic examination of the vaginal secretions identifies the infection (presence of clue cells) - Increased grey/white colored vaginal discharge This results in a rise in PH from the usual 4.5 to as high as 7.0 Mngmt: Treatment: Oral Metronidazole (Flagyl) or intravaginal gel Clindamycin cream (Cleocin) 32. Duodenal ulcers. Diagnostic test: - Main cause of duodenal ulcers: H. Pylori infection - H. Pylori diagnostic test: - Esophagogastroduodenoscopy (EGD) - Urea breath test 33. 24-hour urine collection for creatinine clearance test. Nursing education Do not change the diet - A 24 hr collection of all urine - Discard the first urine sample and document time. - Put urine on ice to keep cold and check with the laboratory regarding adding a preservative to the specimen during collection. - At the end of the prescribed time, instruct the client to empty the bladder and add that urine to the collection container. - Not needed: High protein and calorie diet Because they process food - Mid-stream sample - Sterile container - Perineal area cleaned with bacteriostatic solution Question: The nurse will teach a patient who is scheduled to complete a 24-hour urine collection for 17-ketosteroids to a. insert and maintain a retention catheter. b. keep the specimen refrigerated or on ice. c. drink at least 3 L of fluid during the 24 hours. d. void and save that specimen to start the collection. ANS: B The specimen must be kept on ice or refrigerated until the collection is finished. Voided or catheterized specimens are acceptable for the test. The initial voided specimen is discarded. There is no fluid intake requirement for the 24-hour collection. 34. Diabetes insipidus. Clinical manifestation. (caused by low ADH) - High urine output - Decrease of urine specific gravity. - Diluted urine - Dry inside (High and dry labs) - Hypernatremia - Hyperosmolality - Polydipsia - Polyuria - polyphagia - Decreased BP - Dry mucosa and poor skin turgor 35. Addison Disease. Pathophysiology. Abnormal Labs - Hyponatremia - Hypoglycemia - Hyperkalemia. Potassium retention also promotes reabsorption of hydrogen ions, which can lead to acidosis. - Hypercalcemia, Decreased glomerular filtration leads to excessive blood urea nitrogen (BUN) levels. Labs: High: K, CA, Bun (10-20) Low: Cortisol, Na, Glucose, 36. Acute glomerulonephritis. Clinical manifestations of Periorbital and facial edema that is more prominent in the morning, Assess for fluid overload, auscultate lungs locking for pulmonary edema ▪ Anorexia ▪ Decreased urinary output ▪ Cloudy, smoky, brown-colored urine (hematuria) ▪ Pallor, irritability, lethargy ▪ In an older child: Headaches, abdominal or flank pain, dysuria ▪ Hypertension ▪ Proteinuria that produces a persistent and excessive foam in the urine ▪ Azotemia ▪ Increased blood urea nitrogen and creatinine levels ▪ Increased anti–streptolysin O titer (used to diagnose disorders caused by streptococcal infections) 37. Cauda equina syndrome. Common cause of syndrome - Spinal infections or inflammation - Narrowing of the spinal cord - Lumbar spinal stenosis - Violent injuries to the lower back (gunshots, falls, auto accidents) - Birth abnormalities - Spinal arteriovenous malformations (AVMs) - Spinal hemorrhages (subarachnoid, subdural, epidural) - Postoperative lumbar spine surgery complications - Spinal anesthesia - Herniated disc in the lumbar region (most common) - Areflexia of the bowel, bladder, and lower reflexes. The size of the disc herniation that results in cauda equina is often much larger than normal; however, if the spinal canal is smaller due to conditions such as arthritis, a smaller disc herniation can produce CES. Neurosurgical emergency, loss of sensation, saddle area and movement. 38. Hemorrhagic stroke. Nursing education to prevent compilation - Avoid things that increase ICP: - Coughing - Straining - Constipation - Changing position in the bed - Valsalva maneuver ( popping of the ears) 39. Type 1 diabetes mellitus (DM). Nursing education if patient requires to go surgery - Stress to the body (surgery, sepsis, etc) will increase blood glucose lvl: - Patient must increase insulin during sepsis/surgery Question: A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The clients blood glucose level is 160 mg/dL. Which action should the nurse take? R: Document the finding in the clients chart. Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. 40. Renal calculi. Nursing diagnosis - Acute pain related to impaired elimination - Acute pain related to stone movement - Fever/chills PAIN MANAGEMENT STRAIN URINE TO CATCH STONE!!!!!!!!!!!!!!! Question: A nurse assesses a client who presents with renal calculi. Which question would the nurse ask? a. “Do any of your family members have this problem?” There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. 41. Kidney transplant rejection. Clinical manifestation - Temperature higher than 100° F (37.8° C) LOWER BACK PAIN - Swelling/edema/ patient weight gain in 24 hours - Reduced urine output - Rapid weight gain - Pain over graft site - Flu-like symptoms - Hypertension - Elevated BUN & Creatinine lvls - Elevated WBC count - Rejection indicated by ultrasound or biopsy Hyperacute rejection: Occurs within 48 hours after the transplant. Pain at transplant site with S&S of hypertension and fever. Intervention: Removal of rejected kidney Acute rejection: Occurs within 1 week postoperatively, but can occur any time posttransplantation. Intervention: Potentially reversible with increased immunosuppressive therapy. Chronic rejection:Occurs slowly months to years after transplant. Gradual increase in BUN and serum creatinine levels Fluid retention Changes in serum electrolyte levels Fatigue Interventions: Immunosuppressive medications and dialysis if necessary. 42. Review each region of the brain Function Simple nursing video !! 43. Hiatal Hernia. Clinical manifestation. Treatment - Hiatal hernia is related to the development of GERD (s/s of GERD) - Heartburn - Regurgitation - Chest/abdominal pain - Dysphagia Treatment: - Elevate HOB - Medications: H2 blockers/ Proton pump inhibitors/ Antacids - Fundoplication 44. Colostomy. Normal versus abnormal finding., Nursing action - A healthy stoma should be reddish pink and moist and protrude about inch (2 cm) from the abdominal wall - Abnormal finding: - Dark blue/purple discoloration → ischemia Question: The nurse is teaching a client who had a descending colostomy 2 days ago about the ostomy stoma. Which changes in the stoma would the nurse teach the client to report to the primary health care provider? (Select all that apply.) a. Stool consistency is similar to paste. b. Stoma becomes dark and dull. c. Skin around the stoma becomes excoriated. d. Skin around the stoma becomes protruded. e. Stoma becomes retracted into the abdomen. A colostomy placed in the descending colon would be expect to have a paste-like stool consistency. However, if the stoma becomes retracted or discolored, the client should report those changes to the primary health care provider. Skin around the stoma that becomes protruded would suggest the formation of a peristomal hernia, and skin excoriation needs appropriate management. 45. Myasthenia gravis. Diagnosis test Autoimmune disorder that causes severe muscle weakness – After injection of edrophonium: marked improvement in muscle tone that lasts 4 to 5 minutes.