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662 COMPLEX II Exam
The term used to describe accumulation of nitrogenous wastes is: A.Anuria B.Azotemia C.Oliguria D.Uremic syndrome - correct answer B.Azotemia A treatment for postrenal etiology of AKI is: A.Diuretic administration B.Fluid administration C.Nephrectomy D.Ureteral stent placement - correct answer A.Ureteral stent placement Other treatments include bladder catheterization, ureteral stenting, or the placement of nephrostomy tubes (used if the nephrons aren't working). Which intervention is most important in assessing fluid balance in the patient with AKI? A.Daily weight B.Intake and output C.Serum creatinine D.Estimated GFR - correct answer A.Daily weight ** Critical thinking challenge question **
- How is Kayexalate given?
- What is the expected effect of administration? - correct answer - It is given orally 15 g 1- 4 times daily or rectally via enema 30-50 g every 6 hours.
- An expected effect after administration is constipation, rectal impaction in the elderly, hypokalemia, hypernatremia, nausea and vomiting Which assessment component is done last when assessing the abdomen? A.Auscultation B.Inspection C.Palpation D.Percussion - correct answer C.Palpation
The greatest risk of GI bleeding is: A.Anemia B.Hypovolemia C.Infection D.Increased cardiac output - correct answer B.Hypovolemia Portocaval shunt is done to prevent variceal bleeding. This surgery is associated with what negative outcome? A.Acute kidney injury B.Ascites C.Encephalopathy D.Gastric ulcer - correct answer C.Encephalopathy Hepatic encephalopathy is caused by an increase in: A.Ammonia B.Calcium C.Potassium D.Sodium - correct answer A.Ammonia The term for "flapping tremors" seen in hepatic encephalopathy is: A.Chvostek's sign B.Cullen's sign C.Asterixis D.Trousseau's sign - correct answer C. Asterixis Patients who are not able to meet their nutritional needs orally should be started on enteral nutrition within what time frame? A. 6-12 hours B. 12-24 hours C. 24-48 hours D. 5 days - correct answer C. 24-48 hours The nurse would suggest oral or enteral feedings for which patient?
The nurse admits a patient who hit his head on the concrete following a fall from a ladder. The nurse assesses bruising behind the left ear, bilateral periorbital bruising, and clear nasal drainage. What do these findings indicate? A.Subdural hematoma B.Basilar skull fracture C.Linear skull fracture D.Depressed skull fracture - correct answer B.Basilar skull fracture Paramedics arrive on the scene of a high school baseball game. The pitcher, after being struck in the left temple with a line drive, was knocked unconscious. Now the paramedics note the player to be sitting up on the mound and talking. What is the best interpretation of these assessment findings? A.Subdural hematoma B.Epidural hematoma C.Concussion D.Coup/Contrecoup injury - correct answer B.Epidural hematoma The patient is in asystole with a blood pH of 6.95 and has lost the IV access. Which drug does the nurse know can be administered via the ET tube first? A.Atropine B.Epinephrine C.Vasopressin D.Sodium bicarbonate - correct answer B.Epinephrine The nurse is caring for a patient being treated with therapeutic hypothermia post-CPR. Which order should the nurse question? A.Draw serum electrolytes stat B.Measure blood glucose every 2 hours C.Continuously monitor EEG and ECG D.Record tympanic temperature every hour - correct answer D.Record tympanic temperature every hour A 56-year-old female patient reports feeling fatigued with sudden nausea and lightheadedness. Which action should the nurse take immediately? A.Call the charge nurse B.Get the patient an antiemetic C.Call the attending physician
D.Notify the rapid response team - correct answer D.Notify the rapid response team Diabetic Ketoacidosis (DKA) - correct answer - Typically seen in patients who have type 1 diabetes
- The body attacks its own pancreas, which means NO insulin is being formed, which leads to NO sugar being produced to be burned, so fat is burned instead, leading to the release of ketones.
- Faster onset CAUSES? Sepsis Stress (surgeries) Skipping insulin S/S Dry and HIGH sugar (250-500 mg/dl) Ketones & Kussmaul respirations are present (deep rapid breathing that smells fruity) Abdominal pain Acidosis (metabolic) --> pH 7.35 or less Lethargy, weight loss, nausea and vomiting TREATMENT
- FIRST PRIORITY Provide IV fluids (0.9% NS)
- Provide IV insulin (REGULAR)
- Hourly blood sugar checks
- When the ketones withdrawal or the patients glucose levels drop at 200-250 mg/dl, provide them SQ insulin --> give subcutaneous insulin first before stopping the IV
Add D5W with the insulin to prevent the low sugar crash Add potassium during IV insulin not after (insulin puts sugar and potassium into the cell) ** HIGH potassium will show peaked T waves & ST elevation (Have patient on a monitor) Hyperosmolar Hyperglycemic State (HHS) - correct answer - Typically seen in Type 2 diabetics
- Fewer amount of insulin is being produced, so some sugar is going into the cell which leaves the blood thick and concentrated causing dehydration.
- Slower onset; harder to fix CAUSES? Illness Infection
(THE HIGHS)
Potassium & Pigmentation (hyperkalemia & hyperpigmentation/bronzed skin) ** Hyperkalemia can lead to muscle spasms --> Peaked T waves and ST elevation TREATMENT
- Add steroids IV (NEVER stop taking steroids abruptly) ** Tell patients to inform their provider when there is an increase of stress in their life
- diet high in protein, fats and sodium
- hormone replacement therapy is life long MEDICATIONS WON'T CURE YOU!!! Hypercortisolism (Cushing's Disease) - correct answer - Occurs when there is excessive secretion of cortisol in the adrenal cortex, anterior pituitary, and hypothalamus.
- The immune system is slowed down (slow wound healing)
- causes from an exogenous cause --> long term cortisol therapy treatment
- Can come from an endogenous cause --> small cell lung cancer S/S (EVERYTHING WILL BE HIGH) High blood pressure, HYPERglycemia, HYPERnatremia, weight gain, trunkal obesity, moon face, buffalo hump, hirsutism, purple striae on the face and abdomen, rosey cheeks, slow wound heeling, big risk of fractures from brittle bones & osteoporosis, hyperpigmentation (THE LOWS) Low potassium CAUSES Stress (surgeries) Sepsis Strenuous activity TREATMENT Cut out the tumor Slowly decrease the steroids ** Monitor weights Hyperthyroidism (Graves disease) - correct answer - Excessive thyroid secretion from the thyroid gland.
- High T3 and T4, low TSH levels WHAT CAUSES HYPERthyroidism?
- Graves disease is an autoimmune disorder often caused by inflammation of the thyroid hormone (> 100 HR)
- Too much levothyroxine
- Too much iodine S/S High and fast energy, fever (high temperature), high BP, high HR, heart palpitations (a. fib), weight loss, hot and sweaty skin, high GI (diarrhea) Grape eyes "exopthalamos" Goiter "Gulf balls in the throat" WHAT IS PRIORITY? Monitor for thyroid storm DIET High protein, high calories, frequent meals and snacks (6-8 a day), Low fiber, no caffeine, no spicy food TREATMENT
- Methimazole (NOT baby safe)
- Propylthiouracil (report fever and sore throat)
- Potassium Iodine (shrinks the thyroid before the removal, stains the teeth --> drink with a straw)
- Beta Blockers (to slow down the heart rate) "-lol" Hypothyroidism - correct answer - Reduced or absence of secretion from the thyroid gland and results in whole body decreased metabolism from inadequate cellular regulation.
- Low T3 and T4, high TSH levels WHAT CAUSES HYPOthyroidism?
- Iodine deficiency
- Major cause is hoshimotos (autoimmune disease) < 60 HR
- Antithyroid treatment (thyroidectomy) or pituitary tumor S/S Low and slow energy, super depressed, weight gain, lethargic, weakness, low metabolism (water gain --> edema in the legs and eyes), low GI (constipation), alopecia (low hair), low mental status (forgetfulness), slow dry skin turgor WHAT IS PRIORITY? Monitor for Myxedema DIET
- Low calories, low saturated fats, low cholesterol
- FREQUENT rest periods
- Patient is at risk for respiratory failure
- Most people diagnosed are the elderly WHAT ARE RISK FACTORS?
- The removal of the thyroid
- Abruptly stopping thyroid replacing hormones S/S Decreased HR, super low temperature (sometimes in the 80's), low BP, low RR (hypoventilation); CO2 is being retained, muscle weakness, delirium, seizures, somnolence (drowsiness),
- Patients may develop upper airway edema or pleural effusions Diabetes Insipidus (DI) - correct answer - Primary cause is from trauma injury to the posterior pituitary or hypothalamus as a result form head injury or trauma.
- Results from an ADH deficiency, leading to excessive urination.
- If the patient is unable to replace water loss by the response of excessive thirst, then hypovolemia may occur. CAUSES? Damage to the brain (trauma, surgery, brain injury) S/S Polyphagia, polydipsia (excessive thirst), polyuria, pale and diluted urine, dehydrated (HIGH urine output), low specific gravity, HIGH blood serum osmolality, HYPERnatremia, low BP, dry mucosa & skin, low BP TREATMENT
- Desmopressin (vasopressin) decreases urine output and increases blood pressure (SIDE EFFECT: Headaches)
Desmopressin can also decrease sodium, causing headaches which can be deadly INTERVENTIONS
- Monitoring for s/s of hypovolemia is priority
- Vital signs and urine output should be recorded hourly
- Correction of hypernatremia and free water losses are done by using hypotonic solutions with dextrose in water
- Monitor for fluid overload Syndrome of Inappropriate Antidiuretic Hormone (SIADH) - correct answer - A common cause of SIADH is from malignant diseases (such as small cell carcinoma of the lung, pancreatic and duodenal carcinomas, etc,.)
- Non-malignant pulmonary problems such as TB, pneumonia, lung abscess and COPD can also lead to SIADH
- Excessive production of the ADH causes the Urination to stop
CAUSES?
Small cell lung cancer Severe brain trauma Sepsis or viral pneumonia S/S High urine specific gravity, thick and concentrated urine, hyponatremia, water retention, hypo- osmolality of the serum , headache, confusion (should be reported immediately) , and seizures, High BP, High HR INTERVENTIONS
- Monitor I & O (taking daily weights)
- Set up seizure precautions because of the low sodium
- STOP giving fluids, but add salt to prevent seizures
- Diuretics can be given TREATMENT
- Water restriction
- Loop diuretics What are some medications that can affect glucose levels? - correct answer Beta blockers Glucocorticosteroids Thiazide Phenytoin When should SubQ insulin start after IV insulin is used? - correct answer DKA Whenever a patients blood glucose levels reach 250 mg/dl or whenever the ketones resolve
This means that the patient is no longer burning fat for fuel and it is now burning glucose. ** ADD dextrose (D5W) to the insulin to prevent the low sugar crash of hypoglycemia ** GIVE SUBQ injections before discontinuing the IV therapy Why do you not stop IV insulin abruptly? - correct answer It can lead to rebound hyperglycemia Commonalities/differences between DKA and HHS - correct answer COMMONALITIES
- They are considered an endocrine medical emergency
- Patient will present with classic polyuria, polydipsia, and polyphagia
- Patient will have severe dehydration DIFFERENCES
**IF CORRECTED, pre-renal can be reversed.
- AKI - Pre-renal - correct answer - Caused by conditions that interfere with renal perfusion (PREfusion); diminished blood flow; hypo-perfusion of the kidney
- Most causes are from volume depletion (blood loss or fluid loss), decreased cardiac output, and vasodilation leads to a decrease in GFR (decrease in MAP)
- If pre renal is prolonged, it can lead to necrosis CAUSES
- Intravascular volume depletion (surgery, trauma, hemorrhage)
- Vasodilation (sepsis, anaphylaxis, anesthesia, meds: antihypertensives)
- Decreased cardiac output (MI, cardiogenic shock, PE, heart failure, dysrhythmias)
- Pharmacological agents (prolonged used of NSAIDS, antibiotics ending in - cin, ACE inhibitors, norepinepherine)
- AKI - Intra-renal - correct answer - Caused by conditions directly acting upon the renal tissues (glomerulus or renal tubules)
- Direct damage INside the renal for INtra renal AKI
- Most common condition is Acute Tubular Necrosis (ATN) ** Typically caused by infections (glomerulonephritis) or autoimmune diseases (lupus), nephrotoxic agents (NSAIDs or antibiotics), ischemia, rhabdomyolysis, or contrast induced CAUSES
- Glomerular, vascular, or hematological problems (HTN of pregnancy, glomerulonephritis, lupus, rhabdomyolysis)
- Tubular problem (Ischemia, hypotension from any cause)
- AKI - Post renal - correct answer - Results in the obstruction of the flow of urine
- PAST renal for POST renal injury
- There is a renal blockage after the kidneys that blocks the outflow of urine causing pressure, pain, and strain on the renal. ** Examples of blockage: Benign prostatic hyperplasia (BPH --> big prostate that holds back urine), Kidney stones, tumor CAUSES
- Blood clots
- Renal stones or crystals
- Post operative edema
- BPH
- Foley catheter obstruction
- Ligation of utterer during surgery TREATMENTS Bladder catheterization, ureteral stenting, or the placement of nephrostomy tubes (used if the nephrons aren't working). Glomerular Filtration Rate (GFR) - correct answer - Normal range is 80-125 ml/min
- The result of pressure gradient
- Reabsorption
- Secretion
- MAP influences GFR
- As MAP decreases, so does GFR
- MAP needs to be 60 or greater 4 phases of AKI - correct answer 1. Onset of Injury --> (Several hrs to 2 days)
- Time of the event to signs of decreased renal perfusion
- S/S reflect chemical imbalances
- MAY be reversible at this time
- Oliguric Phase --> Hyperkalemia and infection usually occur (the maintenance phase)
- Low urine output
- Less than 400 ml in 24 hours
- Very sticky & thick urine (HIGH specific gravity)
- Renal replacement therapy is required
- KEY FINDINGS: Anorexia, nausea & vomiting
- Diuresis Phase
- Dramatically high urine output (3-6L a day)
- They kidneys are trying to flush out the problem (LOW specific gravity)
- Recovery Phase
- It can take up to one year to recover
- Dialysis may prevent the diuretic phase of AKI Different Insulins - correct answer Rapid Acting (EX: Lispro/Humalog, aspart/Novolog, glulisine/apirda)
- Peak: 30-90 minutes
- Onset: 15 minutes
Peritoneal Dialysis
- Removal of solutes and fluids by diffusion through the patients semi-permeable membrane (peritoneum)
- Not commonly used in renal replacement therapy
- Peritonitis is the most common complication, so aseptic technique should be used when handling the catheter and connections
- Can be done at home CRRT
- Continuous extracorporeal blood purification system managed at the patients bed side
- Similar to hemodialysis, but it removes the solutes more slowly
- Heparin is used frequently in CRRT to inhibit coagulation and extend the life of the hemofilter
- Can be done at bedside Practice Questions regarding Dialysis and CRRT - correct answer 1. What would you do if a patient cannot tolerate hemodialysis? ** Switch them over to CRRT
- What are important interventions to know about fistulas?
- ALWAYS auscultate for a bruit or thrill every 8 hours
- NEVER take blood pressure on the arm with the fistula
- DO NOT give medications through the fistula ** The physician is notified immediately if no bruit is auscultated, no thrill is palpated, or the distal pulse is absent.
- What is the first intervention to take whenever a patient has complications on dialysis? ** STOP the treatment immediately!!
- What is the best site to use for a percutaneous catheter? and why? ** The left internal jugular vein; because it is easier to access and provides less complications. (A central line could be used as well) -----> Femoral sites are discouraged because it increases the risk of infection Glasgow Coma Scale - correct answer - The Glasgow coma scale is used to assess cognition and consciousness
- A score less than 8 is consistent with a coma
- The GCS scores 3-15 (3 being the lowest and 15 being the highest)
- Eye opening (4)
- Verbal response (6)
- Motor Response (5) **Less than 8 means to INTUBATE!! What is the NIH stroke scale used for? What are the levels of stroke? - correct answer - The NIH stroke scale is used to determine the severity at which an individual has a stroke. LEVELS
- Score of 0 = NO stroke symptoms
- Score of 1-4 = Mild stroke symptoms
- Score of 5-15 = Moderate stroke symptoms
- Score of 16-20 = Moderate to severe stroke symptoms
- Score of 21-42 = Severe stroke symptoms Neurological Assessment: language and comprehension - correct answer Expressive Dysphasia
- Deficit in language production
- Frontal lobe deficit (Broca's area)
- Can't find the words Receptive Dysphasia
- Wernicke's area in temporal lobe
- Deficit in language comprehension
- Inability to follow commands
- "Word salad" Increased ICP - correct answer - High pressure inside the head, which puts pressure inside the brain (squashing the brain stem)
- Increased ICP can be caused by head trauma (increased bleeding or inflammation), meningitis, tumor or stroke
- It compresses the blood vessels that send oxygen to the brain, disrupting the respiratory system and LOC
- Regular ICP is 0-15 (↑ ICP is 20 mmHg or greater)
- FIRST SIGN of ICP is altered LOC: irritability, restlessness S/S Flat affect, drowsiness, sleepiness, constant headache, sudden vomiting WITHOUT nausea, irregular breathing (cheyne-stoke --> fast and slow breathing), stiff neck, pupils will be fixed and dilated + unequal, babinskis reflex will fan out when stimulated, seizure and coma, abnormal posturing (decorticate & decerebrate --> far worse) DIAGNOSTICS
Assessment
- Complete a neurological assessment (GCS)
- Take vital signs
Cushings triad: LATE sign of ICP; S/S of cushings triad Widening pulse pressure (the blood pressure numbers are getting further apart), HIGH BP, Low HR, Low RR ** EX of widening pulse pressure: The systolic number is getting higher and the diastolic number is getting lower Immobilize head (log roll the patient in one unit) CO2 that is low (carbon dioxide vasodilates the brain) Putting the patient on a ventilator will force CO2 out Positioning (Semi fowlers promotes drainage) Suctioning (10 seconds or less and limit suctioning as much as possible) Before suctioning use 100% oxygen PATIENT SHOULD NOT cough, hold their breath, bear down Traumatic Brain Injury (TBI) - correct answer - Primary brain injury is the direct injury that occurs in the brain from impact
- Secondary brain injury occurs as a consequence of the initial trauma and is characterized by an inflammatory response. TBI MONITORING
- Neurological assessment
- Glasgow Coma Scale
- Airway assessment
- ICP monitoring
- Hemodynamic monitoring
- Interventions to control elevated ICP
- Evaluation of diagnostic tests Seizures - correct answer - Seizures are uncontrolled electrical discharges in the brain
Neurons are firing when they are not supposed to COMMON CAUSES
- Anything that can cause swelling or hypoxia in the brain
EX: Meningitis, mass (brain tumor), withdrawal (drugs and alcohol)
- Generalized: All over the brain
- Partial: Only one part of the brain TREATMENT
- Benzos are going to be used to stop the seizure activity
- Anticonvulsants (Dilantin, Cerebryx)
- Phenobarbital What classifies as Status Epileptics?
- Occurs when one single seizure lasts 30 minutes or longer
- When two seizures have occurred back to back without full recovery of consciousness between the seizures Spinal Cord Injuries - correct answer - Caused from trauma to the spinal cord C3,C4,C5 KEEP THE DIAPHRAGM ALIVE!!!
- Main priorities is airway and ventilation
- Paralysis of diaphragm and intercostal muscles can result in ineffective breathing ASSESSMENT
- DVT prophylaxis
- Skin care (assessment done every 4 hours)
- Gastric decompression
- Elimination
- Continuous monitoring of SpO
- When would a patient require ventilation? When there is an injury at C1 and 2
- What is autonomic dysreflexia?
- It occurs in high spinal cord injuries above the T6 areas (ANY)
- Medical Emergency!!
- Very deadly because it results in extremely high BP (300 systolic) WHAT CAUSES autonomic dysreflexia?
- Tight bladder (full or distended)
- Tight bowels (constipation)
- Tight clothing (tight gowns) What actions to take? Palpate the bladder to see if there is distension
