Section 3 Flashcards
(403 cards)
1
Q
How is the pancreas an exocrine gland?
A
It releases digestive enzymes
2
Q
How is the pancreas an endocrine gland?
A
Because it has beta cells in the Islets of Langerhans that produce and secrete insulin in response to rising blood sugars
3
Q
When do Beta cells in the Islets of Langerhans produce insulin?
A
in response to rising blood sugars
4
Q
The pancreas is both a ___ and a ___ gland
A
endocrine AND exocrine
5
Q
True or false: Normal insulin levels never go down to zero.
A
True - we always have some insulin basal level
6
Q
If your fasting blood sugar is between 100-126, you’re probably
A
pre-diabetic
7
Q
My LDL is > 100; my HDL is
A
abnormal cholesterol levels - at risk for diabetes
8
Q
3 ways that glucose gets into the bloodstream
A
- Intestines: absorption of simple sugars
- Liver: Glycogen is broken down into glucose through a process called glycogenolysis
- Protein catabolism (gluconeogenesis)
9
Q
In the liver, glycogen is broken down into glucose through a process called ____
A
glycogenolysis
10
Q
If blood sugars drop, patients can start breaking down their own protein (and even fat sometimes) to create glucose, a process called ____
A
neogenisis
11
Q
In the liver and muscles, glucose can be stored as
A
glycogen
12
Q
The kidneys have a renal threshold for blood sugar, which means
A
once blood sugar levels reach over 200, the kidneys will start dumping glucose into the urine
13
Q
Glucose is excreted in the urine if BS is >
A
200
14
Q
In tissues, glucose is used for
A
oxygenation
CO2 + H2O + E
15
Q
What does Insulin do? (5)
A
- Transports and metabolizes glucose for E
- Stimulates the storage of glucose in the liver –> glycogen (Glycogenesis)
- Enhances the storage of fat in adipose tissue
- Transports amino acids and glucose into the cells
- Inhibits the breakdown of stored glucose, protein, and fat
16
Q
If we go 8-12 hours without food, ___ starts
A
glycogenesis
17
Q
Even if a patient is fasting/not eating, the pancreas is still releasing ___-
A
a small amount of insulin
18
Q
During fasting, the pancreas releases insulin and glucagon (via glycogenolysis), creating what?
A
Constant level of BS
19
Q
About 5-10% of adults that are diabetic are
A
Type 1
usually comes on as a more acute onset than type 2, and is normally below the age of 30
20
Q
4 steps of the pathophysiology of type 1 diabetes
A
- Destruction of beta cell
- Glucose not stored as glycogen
- Glycogenolysis and gluconeogenesis occur unrestrained
- Fat breakdown occurs
all of this leads to HYPERGLYCEMIA
21
Q
Patients with type 1 diabetes must have ___
A
an exogenous source of insulin
22
Q
Etiology of Diabetes Type 2
A
Insulin resistance AND/OR Decreased production of Insulin
results in HYPERglycemia
23
Q
there’s enough insulin present in the type 2 diabetic to inhibit the breakdown of fat - which means it’s rare for them to
A
go into diabetic ketoacidosis
24
Q
99% of the time, diabetic ketoacidosis is found in
A
Type 1 diabetics
25
remember there’s a 3rd type of diabetes, which is ____
women that have gestational diabetes can later on convert to type 2 diabetes, so they need to be continually watched
26
For any blood sugar test to be reliable, it has to be done after ___
fasting (8-12 hours)
27
Normal vs. diabetic levels of Hemoglobin A1C
normal: 5-6.4
Diabetic: > 6.5 or 7
28
Random glucose level of 200 mg/dL or > on more than one occasion indicates
DM diagnosis
29
Fasting glucose level of ____ indicates diabetes
126 mg/dL or >
30
Normal fasting blood sugar
70-100
31
Pre-diabetic fasting blood sugar
100-125
32
Diabetic fasting blood sugar
126 or >
33
management of diabetes is a multi-stem approach, with the greatest emphasis on
patient education
34
Causes of hyperglycemia
too much food, too little insulin or diabetes medicine, illness or stress
35
Onset of hyperglycemia is ____
gradual - may lead to diabetic coma
36
ketoacidosis (HHMKS) OR very late signs of HYPERglycemia include
- severe HYPOtension due to polyuria
- have severe fluid volume deficit
- renal failure with oliguria
- coma and/or death
37
Hyperglycemia will ___ serum osmotic pressure
increase
38
Symptoms of HYPERglycemia
- Polyuria (frequent urination)
- Polydipsia (extreme thirst)
- Dry skin
- Blurred vision
- Drowsiness
- Decreased healing
- Hunger
39
hyperglycemia is usually a ___ onset
slow
40
When we talk about fractionals/sliding scale, it’s ___ insulin
REGULAR insulin
41
A 1 CC syringe is NOT for diabetics because
that is not a measurement of units
42
When giving insulin, always double-check order with whom?
Double check with HCP provider as well as another nurse
43
How often do Type 1 DM normally check blood sugar?
2-4x/DAY
44
How often do Type 2 DM normally check blood sugar?
2-3X/WEEK
and then one 2hr postprandial (after meal)
45
How often do Type 1/hospitalized DM normally check blood sugar?
4x day (before each meal, and at bedtime)
“Fractionals”
AC and bedtime
46
If BS is 150-199, give ___ insulin dose
2 units
47
If BS is 200-249, give ___ insulin dose
4 units
48
If BS is 250-299, give ___ insulin dose
6 units
49
If BS is 300-349, give ___ insulin dose
8 units
50
If BS is 350-399, give ___ insulin dose
10 units
51
If BS is >400, what should you do?
Call MD
52
Nursing interventions for HYPERglycemia
1. Check blood sugar
2. Fluids
3. Airway
4. Patient teaching
5. Diet
- CHO 50%, Protein 25%, Fat 25%, ↑ Fiber
* WEIGHT CONTROL*
6. Activity and exercise
7. Oral meds (Type 2 only)
8. Decrease stress
53
Diet for HYPERglycemia
CHO 50%, Protein 25%, Fat 25%, ↑ Fiber
54
Oral meds for Type 2 DM
1. For Insulin Resistance: Antihyperglycemic agents
(Glucophage, Precose, Glycet, Actos, Avandia)
2. For Decreased Insulin production: Hypoglycemic agents
(Diabinase, Glucotrol, Micronase, Prandin)
55
What medications address decreased insulin production in type 2 diabetics?
Hypoglycemic agents
| Diabinase, Glucotrol, Micronase, Prandin
56
What medications address insulin resistance in type 2 diabetics?
Antihyperglycemic agents
| Glucophage, Precose, Glycet, Actos, Avandia
57
Examples of Antihyperglycemic agents
Glucophage, Precose, Glycet, Actos, Avandia
58
Examples of Hypoglycemic agents
Diabinase, Glucotrol, Micronase, Prandin
59
Patient that have decreased insulin production will be treated with
oral hypoglycemics: glipizide (Glucotrol) or a Meglitinide (Prandin)
60
Sulfonylureas: Classification, prototype, action, ADE
Class: oral hypoglycemic
Prototype: glipizide (Glucotrol) -- Glyburide (Miconase, DiaBeta)
Action: Increases insulin production
ADE: Hypoglycemia -- can also commonly cause nausea, abd fullness
61
Meglitinide
Class: oral hypoglycemic
Prototype: Repaglinide (Prandin), Nateglinide (Starlix)
Action: Increases insulin production
ADE: Hypoglycemia
62
Thiazolidinediones
| AKA: Glitazones
```
Class: antihyperglycemics
Prototype: Pioglitazone (Actos)
Action: decreases Insulin resistance
ADE: increased incidence of angina, MI
BLACK BOX: CHF
```
63
Biguanide
```
Class: antihyperglycemics
Prototype: metformin (Glucophage)
Action: decrease Insulin resistance and hepatic glucose production
ADE: N, V, abd discomfort
Black box: lactic acidosis
```
64
Alpha-Glucosidase Inhibitors
Class: antihyperglycemics
Prototype: Miglitol (Glyset)
Action: Delays GI absorption of glucose
ADE: Common: Abd discomfort, D, flatulence
65
Note that antihyperglycemics are meant to utilize the insulin that is ALREADY there, which means
these drugs are NOT producing more insulin - this is why you do not see HYPOglycemia as an ADE
66
you ___ combine two different insulins in the same syringe
cannot
NEVER MIX! you can give separate injections, but not mixed in the same syringe
67
long-acting ulralente insulin is meant to
provide a relatively constant level of Insulin and act as a basal Insulin
68
70/30 Insulin:
70% NPH & 30% Regular
69
Rapid & short acting Insulin cover which meals?
immediately AFTER the injection
70
Intermediate acting Insulin is expected to cover
subsequent meals
i.e. if you give to patient before breakfast, it will not cover them for breakfast but for lunch
71
Only Regular Insulin is given
IV
72
Why MUST patients always rotate sites to administer insulin?
Because if always given in the same place can be damaging - you’ll destroy all the sub-q tissue in the area (lipoatrophy - losing the sub-q fat)
73
An intensive insulin regime is ___ injections/day, and meant to
3-4
trying to maintain blood sugar at about 100
74
Why is an intensive insulin regime contraindicated in elderly and patients with CV disease?
because hypoglycemia can cause tachycardia which can cause undue strain for the heart
75
Current thought is if normal blood sugar is 70-100, hypoglycemia should be anything less than
70
76
Causes of hypoglycemia
- too little food
- too much insulin or diabetes meds
- extra activity
77
Onset of hypoglycemia is ___, and may progress to ___
sudden
insulin shock
78
Symptoms of hypoglycemia
- Diaphoresis (sweating)
- Impaired vision
- Weakness/fatigue
- Dizziness
- Anxiety
- Headache
- Shaking
- Fast HR
- Hunger
- Irritable
79
Hypoglycemia: assessment
1. Blood sugar death
80
With BS
convulsions
81
Patients most at risk for hypoglycemia are
those who are on high-intensity regimes (4x day)
82
Hypoglycemia: Nursing Interventions
- Give sugar
- Glucagon IV
- Check VS
- Monitor BS
- On going assessment
- if Comatose - maintain airway
- Patient education
83
If patient is comatose, most important thing is to
maintain airway
84
if you can’t tell if the patient is hyper or hypo-glycemic, give them
sugar (either way, when it doubt) —> augment this with PROTEIN - half sandwich, glass of milk
85
if hypoglycemic, patient should start feeling better within ___ minutes of having sugar
5
86
Cold and clammy means
you need some candy
87
Hot and dry your sugar is
high
88
Food with 15 grams of carbohydrates:
```
3 to 4 chewable glucose tablets
1 tablespoon of jam
I tube of glucose gel
4 to 6 ounces of fruit juice
4 to 6 ounces of regular soft drink
3 packets of sugar or 1 tablespoon of sugar
1 tablespoon of honey
5 to 7 hard candies
```
89
Signs of MILD hypoglycemia
```
Hunger
Diaphoresis
Tremor
Anxiety or drowsiness
Weakness
```
90
Signs of MODERATE hypoglycemia
Headache
Behavior change
Blurred, impaired or double vision
Irritation or confusion, difficulty talking
91
Signs of SEVERE hypoglycemia
UNCONSCIOUS
Unresponsive – unable to take oral feeding
Seizure activity
92
Type 1 diabetics will do urine testing for ketones if their blood sugar is
over 200
93
Insulin Therapy is when
some patients can have a local reaction to the injection
(over 50% is because they wipe their skin with alcohol and inject it before the alcohol is dry)
sometimes patients do have a legitimate reaction and they are given an antihistamine beforehand
systemic reaction is extremely rare but possible
rotating spots is key
94
Remember that blood sugars will normalize BEFORE the acidosis is corrected, so fluids will
continue for another 18-24 hours
95
For diabetics: if you’re not feeling well, do you continue taking insulin?
YES! continue to` take your insulin as prescribed
96
Sick Day Rules for Type 1 and 2 Diabetes
- Take Insulin/oral meds as usual
- Test BS q 3-4 hrs
- Type 1 BS > 200 – test for ketones
- Report BS > 300
- Small, freq meals
- V or D: ½ c cola, juice, or broth q ½ hr, Report N/V/D to MD
97
Medical management for DKA
- Insulin
- Hydration (NS or 0.45 NS)
- Electrolyte loss – K
- Acidosis
98
Diabetic Ketoacidosis is the result of
absence of insulin - occurs in Type 1 patients
99
Diabetic Ketoacidosis presents as:
- Hyperglycemia (BS of 300-800)
- FVD - polydipsia, polyuria, electrolyte loss especially K
- acidosis - pH will be less than 7.2
- Resp: rapid, deep (Kussmauls)
- Ketones
100
When treating patient with DKA, remember that fluids will
always have potassium in them (because of hypokalemia)
101
When treating patient with DKA, remember that insulin will probably be given via
IV drip
102
3 main things that increase osmotic pressure (water will follow):
glucose
sodium
albumin
103
Serious illness that can develop in Type 2 diabetes patients if their blood sugar goes uncontrolled
Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
104
Warning Signs of HHNS
- Blood sugar level over 600 mg/dl
- Dry mouth
- Extreme thirst
- Warm, dry skin that does not sweat
- High fever - over 101
- Sleepiness or confusion
- Loss of vision
- Hallucinations
- Weakness on one side of the body
105
Clinical Picture of HHNS
Hyperglycemia
FVD
Tachycardia
Alteration in Sensorium
106
Your patient is a Type 2 DM. BS is > 1,000, he has polyuria, RR and pH are WNL, and there are no ketones. What may be the problem?
HHNS
107
How do you prevent HHNS?
"Sick Day Rules"
108
mortality rate from HHNS is about
50%
109
Cause of HHNK
Lack of enough Insulin, but enough to prevent the breakdown of fats
110
Microvascular complications of DM include
Retinopathy
| Nephropathy
111
diabetic retinopathy is the ____ cause of blindness in the diabetic patient
leading
112
Macrovascular complications of DM include
CAD
CVD
PVD
113
higher risk for gangrene and amputations
| diabetic patients who are also at risk for cardiovascular disease are put on:
the AHA regime: 1 aspirin/day, beta blockers, Statin to lower cholesterol, ACE inhibitor (preferred) or calcium channel blocker
114
Due to peripheral (sensorimotor) neuropathies, diabetic patients might not feel
pain or infection - these patients should have their shoes on, be very careful with bathwater
115
Common Urinary neuropathy in diabetics is
retention which can lead to UTI - diabetics are prone to repeated kidney or bladder infections
116
Common GI neuropathy in diabetics is
a delay in gastric emptying (bloating, n/v) - can also cause swings in blood sugar - diabetic constipation
117
Common cardiovascular neuropathy in diabetics is
fixed tachycardia
118
Patients with diabetes insipidus can urinate
4-16L of urine/day
119
DIABETES
INSIPIDUS is
a pituitary disorder that causes deficiency of ADH (anti diuretic hormone) - loss of water
--> leads to polyuria and polydipsia
120
Treatment for diabetes insipidus
Replace fluids
Monitor ins and outs
Diet: Hi Na and hi K
Aqueous vasopressin (Pitressin) or Desmorpressin (Stimate)
121
Patients with diabetes insipidus should have a diet that is
Hi Na and hi K
122
Cluster of risk factors for Metabolic Syndrome or
Syndrome X
High Triglycerides: > 150
Low HDL: 130/85
Insulin-resistance: BS 110-125
Waist: Females: > 35 inches, Males: > 40 inches
123
Cancer cells are described as
“malignant neoplasms”
124
What do we call it when cancer cells infiltrate lymph and blood vessels which carry the mutant cells to other parts of the body
metastasis
125
How does cancer begin?
when a cell is transformed by a genetic mutation of the cellular DNA--> forms a clone --> begins to proliferate abnormally (a loss of apoptosis, or programmed cell death)
126
Eight ways of primary prevention for cancer patients
1. Eat 5-9 fruits/vegetables a day
2. Increase fiber intake
3. Reduce fat intake
4. Stop smoking
5. Moderate Alcohol Intake
6. Avoid exposure to the sun
7. Be physically Active
8. Weight control
127
How often should women have mammograms?
every 2 years
128
How often should women 20 -39 years old have a clinical breast exam
every 3 years
129
How often should women over 40 years old have a clinical breast exam
yearly
130
If patient is 50 years old or older, how often should they be screened for Colon and Rectal cancer?
Yearly fecal occult blood test and one of the following:
- Sigmoidoscopy every 5 years
OR
- Colonoscopy every 10 years
131
Frequency required for prostate cancer detection
Yearly digital rectal exam
| As needed a PSA
132
Screening processes for cervical cancer
Yearly GYN exam
PAP test yearly at age 21
After 3 or more negative PAPs, every 3 years
133
Generalized Cancer Symptoms
```
Unexplained weight loss
- usually of 10 lbs. or > w/o dieting
Unexplained fever
Fatigue
Pain
Skin clues
```
134
ACS 7 common cancer symptoms
1. Change in bowel or bladder function
2. Sores that do not heal
3. Unusual bleeding or discharge
4. Thickening or a lump
5. Indigestion or difficulty swallowing
6. Recent change in a wart or mole
7. A nagging cough or hoarseness
135
Complete eradication would mean
cure
136
Prolonged survival and containment of the cancer would mean
control
137
Relief of symptoms would mean
palliative
138
Cancer Tx options should be based on
a realistic and achievable goal
139
Staging determines
the size of the tumor and metastasis
T - primary tumor
N - lymph node involvement
M- metastasis is present
140
Grading of cancer is a classification that
predicts the prognosis
141
Grading I
caught early w/ excellent prognosis
142
II- IV Grading
aggressive and less responsive to tx
143
Stage 1 cancer
small, no mets
144
Stage 2 cancer
Large w/o lymph spread
145
Stage 3 cancer
Larger cancer w lymph node involvement
146
Stage 4 cancer
Mets to other organs
147
Patients who have chemotherapy and/or radiation prior to surgery are at greater risk for complications post-op, such as
- infection, wound healing
- pulmonary or renal
- DVT
148
In the context of cancer surgery, you, as the nurse, explain, clarify, or reinforce info, but do not
give results
149
Pancytopenia
decrease in WBC, RBC, AND platelets
150
For a patient getting abdominal radiation, what medication should you give and when?
Anti-emetic, right beforehand
151
For a patient getting upper body radiation, you should expect to see
dry mouth
152
Internal Radiation: brachytherapy is when
implantation is by catheters into body cavities
153
When is Internal Radiation: brachytherapy frequently used?
to tx gyn ca
154
How long is the radiation in place for brachytherapy?
24-72 hrs
155
To prevent dislodgement of radiation put in place by brachytherapy, what should you do?
- complete bed rest
- log roll the pt
- foley catheter
- low residue diet and antidiarrheal meds (Lomotil) - don't want them using the bedpan
156
Nursing Interventions for Internal Radiation
- Private room
- Post notice of radiation
- Staff wear dosimeter badges, minimize time at the bedside
- Radiation falls out - DO NOT TOUCH
- Instruct pt to call if it dislodges and do not touch it
- NO pregnant staff caring for pt
- NO children or preg visitors
- Visiting: 30 mins and keeping a 6ft distance
157
If a patient is on internal radiation for gyn cancer and the radiation falls out, what should you do?
neither you nor the patient should touch it
pick it up using the forceps in the room and put it into the lead canister
158
Interstitial compartments (breast or prostate) can have radiation how?
- temp or permanent
- consists of needles, seeds, or beads
- less likely to be dislodged
159
Some chemo agents are cell cycle-specific drugs that
destroy cells actively reproducing
160
What phase of the cell cycle does most chemotherapy work at?
S phase – DNA synthesis
161
G 0 cell phase
resting or dormant
162
G 1 cell phase
RNA and protein synthesis
163
G 2 cell phase
pre-mitotic phases, DNA synthesis is complete, mitotic spindles form
164
M cell phase
Mitosis, cell division occurs
165
3 most common side effects from chemo
alopecia, stomatitis, and bone marrow suppression
166
Dose limiting chemo side effects
- hepatotoxicity, pneumonitis
- hemorrhagic cystitis
- tubular necrosis
- Cardiotoxicity, pericarditis
167
Cumulative chemo side effects
neurotoxicity - numbness, tingling, “chemo brain”
168
Chemotherapy agents that are Cell Cycle Specific to S phase are
Antimetabolites:
- Fluorouricil (5FU)
- Methotrexate
169
Chemotherapy agents that are Cell Cycle Specific to M (mitosis) are
Antimicrotuble Agents
- “Taxanes”
- Paclitaxel
- Docetaxel
170
2 types of Cell Cycle Nonspecific chemotherapy medications
1. Alkylating agents:
Cyclophosphamide
2. Antitumor antibiotics:
Doxorubicin
171
Hormonal chemotherapy agent
Tamoxafin (causes heat flashes - like Samantha in sex in the city)
172
Pregnant nurses should ___ handle chemotherapy agents
NOT
173
Administration of Chemotherapy protocol
- Surgical gloves - usually double glove
- Wear a plastic lined gown
- Do Not eat or drink while administering chemo
- Chemotherapy spills - block off the area and call Environmental Services
- Dispose of all items used for chemo as per facility policy
174
Patients getting Prolonged or frequent chemo will often have ____ installed
Central line: R atrial cath, PICC
| Venous access device
175
Allogenic bone marrow transplant means it's from
a selected donor
176
Before getting allogenic bone marrow transplant, the patient undergos
ablative chemo and possibly total body radiation
177
"engraftment" with regards to bone marrow transplants indicates
Bone marrow from the donor is infused by IV in to the recipient
178
It takes about ___ wks for the bone marrow to begin producing RBCs, WBCs, and platelets
2-4
179
graft-versus-host disease (GVHD)
when the donor T-lymphocytes recognize the recipient as “foreign” and attack the recipient
180
to prevent graft-versus-host disease (GVHD), what do we do?
give immunosuppressant drugs and steroids
- the 1st 100 days are critical
181
Autologous bone marrow transplant means it's from
the patient themselves
182
What happens in autologus bone marrow transplants?
- pts marrow is harvested, preserved, and tx w/ chemo
- after his marrow has been harvested pt is tx w/ chemo and possibly total body radiation
- his own marrow is then re-infused and must undergo “engraftment”
183
Stem cell transplantation is done with ___ stem cells
Hematopoietic – undifferentiated cells
| not to be confused with embryonic stem cells
184
Nursing care for bone marrow transplant patients requires what type of isolation?
REVERSE isolation (protecting the patient):
- private room, laminar air-flow, sterile linen, sterile hygiene equip
- shoe covers, mask, cap, and sterile gown, sterile gloves
- remove gown AFTER leaving the room
185
Nursing assessment relating to infection will involve:
```
Impaired skin and mucous membranes
Chemo, radiation- suppress the bone marrow
Poor nutrition
Urinary and IV catheters
Invasive procedures
Age
Co-morbidities
Prolonged hospitalizations
```
186
nursing diagnosis and goal for cancer-related infection
high risk for infection r/t ... any of the above
goal: pt will remain free of infection
187
Nursing interventions for cancer-related skin problems
- handle gently
- loose clothing
- moisture and vapor-permeable dressings
- hydrocolloids promote healing
- topical antibiotics
188
Nursing interventions for cancer-related stomatitis
- good oral hygiene
- avoid food too hot, cold or spicy
- lubricate lips
- Rinse of pediatric Benadryl elixir, Maalox, and viscous Lidocaine in a 1:1:1 solution - swish and spit about 1 hr a.c.
- use of topical anesthetics, antifungal, or antibiotics prn
189
For cancer patient in mild pain, give
Tylenol, NSAIDs - Motrin
190
For cancer patient in moderate pain, give
Codeine, Demerol
191
For cancer patient in severe pain, give
Morphine, Fentanyl
192
How can Epogen be used for cancer patients?
As a fatigue-related intervention
used to treat anemia (a lack of red blood cells in the body)
193
For cancer patients with fatigue, assess their
O2 level, Hgb/Hct
194
Ulcers are a result of damage due to:
- increase contact with HCL acid
- increase contact with Pepsin
- decrease mucosal resistance
(All or some of the above)
OR
- Helicobacter pylori (H Pylori)
195
How does gastritis lead to ulcers?
tissue irritation (gastritis) leads to erosions, which can lead to ulcers, which can lead to perforations
196
Main causes of ulcers
Stress
Smoking
Medications (ASA, NSAID, steroids)
H. Pylori
197
Nursing Assessment for ulcers may include what things?
```
Pain
GI history
N/V
Night pains
Hematemesis
Melena
Hyperperistalsis
```
198
Post Procedure Nursing Care for gastrocopy
ABC
NPO until gag reflex returns
Assess for Signs and symptoms of perforation
199
Nursing interventions for patients with ulcers
```
Assess for bleeding
Check WBC, BUN
Assess for perforation and obstruction
Diet
Rest
Stress reduction
No ASA, no NSAIDS
Meds
```
200
Medications to give ulcer patients
Antacids:
MOM, Mylanta, Maalox
Cytroprotective:
Sucralfate (Carafate)
Antispasmodic:
Banthine
Histamine 2 Antagonists:
Cimetidine(Tagamet), Zantac
Proton Pump Inhibitors:
Omeprazole (Prilosec), Prevacid, Nexium, Protonix
H. Pylori agents:
Prevacid, Amoxicillin, Biaxin
201
MOM, Mylanta, Maalox are
Antacids
202
Sucralfate (Carafate) is a
Cytroprotective
203
Antispasmodic for ulcer patients
Banthine
204
Histamine 2 Antagonists for ulcer patients
Cimetidine (Tagamet), Zantac
205
Proton Pump Inhibitors
Omeprazole (Prilosec), Prevacid, Nexium, Protonix
206
H. Pylori agents:
Prevacid, Amoxicillin, Biaxin
207
What happens in a Bilroth 1
Gastroduodenostomy?
The top half of the stomach is surgically connected to the duodenum (after the middle portion of the stomach is removed)
this is surgical tx for ulcers
208
What happens in a Bilroth II gastrojejunosotmy?
The middle portion of the stomach is removed
The top half is connected to the small bowel
The top end of the duodenum is sewn up
209
What happens in a Gastrectomy (total)
?
All of the stomach is removed, but the bile duct and the pancreatic duct are allowed to continue to drain into the duodenum
210
What goes into the blue cord section of the Salem sump?
NOTHING but air
211
Remember that early symptoms for colon cancer are often
absent or vague
212
Later symptoms of colon cancer include
```
Melena
Pain
Change in bowel habits
Anemia
Anorexia, weight loss
```
213
For colon cancer detection, 1-2 days pre test or surgery patients should be
put on a Low residue diet
214
For colon cancer detection, on the day prior to surgery patients should be
- Clear fluids
- Regime of: laxatives and cleansing enemas or oral electrolyte lavage (Golytely)
- NPO 8 hrs prior to test/surgery
215
Pre-operative Care goal for colon cancer surgery is to
clean the bowel
216
Potential complications from Colostomy
- paralytic ileus
- bowel obstruction
- peritonitis
- wound infection
- atelectasis, pneumonia
- pain
217
Patients with a Colostomy can maintain a
normal diet
218
Patients with Ileostomy needs to modify to a ___ diet
low-residue
limits high-fiber foods, such as whole-grain breads and cereals, nuts, seeds, raw or dried fruits, and vegetables
219
Patients with ileostomy won't have constipation, but food blockage can occur, so they should
chew thoroughly
| avoid nuts, corn
220
Contents coming from the ileostomy will be
liquid (rarely semi-liquid)
221
Contents coming from the Ascending colon colostomy will be
liquid
222
Contents coming from the Transverse colon colostomy will be
semi-liquid
223
Contents coming from the Descending colon colostomy will be
semi-solid
224
Contents coming from the Sigmoid colon colostomy will be
solid
225
Patients with ileostomy should ___ their fluid intake
increase
226
Patients with colostomy should ___ their fluid intake
maintain
227
How often do ileostomies need to be irrigated?
never
228
Which types of colostomies need to be irrigated?
Descending
| Sigmoid
229
Sigmoid colostomies are the only ones that can get
constipation
increase fiber, bulk, and fluid
230
Restrictions for colostomies and ileostomies
No rough contact sports
| No heavy lifting
231
Patients with an ileostomy should never take/eat
laxatives, enteric coated pills, time release pills - cannot be digested
NO fresh fruit, raw veg. or nuts
- notify MD if vomiting or diarrhea
232
Patients with an ileostomy should be mindful of what in hot weather?
increasing their fluid intake
233
Cerebrum or Cerebral Cortex Frontal Lobe controls
Behavior and Motor
- L Motor Cortex controls R body
- R Motor Cortex controls L body
234
Parietal Lobe controls
Sensory and Spatial
235
Temporal Lobe controls
auditory
236
Occipital Lobe controls
visual
237
Basal Ganglia controls
fine motor control
238
Brain Stem is the body's
cardiac, respiratory, and vasomotor center
239
Cerebellum controls
gait
240
Spinal nerves
- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 1 coccygeal
241
CNS =
brain, supporting structures, and spinal cord
242
Peripheral NS =
12 Cranial N + Peripheral N
243
Autonomic NS function, components
regulates involuntary vital function
SNS:
↑HR, ↑BP, vasoconstricts
PSNS:
↓HR, ↑ intestine peristalsis, ↑ glandular activity, relaxes sphincters
244
lumbar puncture
(also called a spinal tap) is a procedure to collect and look at the fluid (cerebrospinal fluid, or CSF) surrounding the brain and spinal cord
a needle is inserted into the spinal canal low in the back (lumbar area)
245
Normal, abnormal CSF pressure readings from lumbar puncture
Normal: 1-15cm
Over 15 is abnormal/high pressure
246
Minor complications from lumbar puncture include:
Headache, voiding problems, backache
247
Major complications from lumbar puncture include:
Herniation of the cerebral contents
Infection
hematoma
248
paresis
motor weakness
249
plegia
paralysis
250
hemiparesis/ hemiplegia
weakness/paralysis of one side of the body
251
paraparesis /paraplegia
weakness/paralysis of both legs and the lower part of the trunk
252
Examples of neurological dysfunction from structural causes
- Head injury
- intracranial hemorrhage
- encephalitis
- brain abscess
- stroke
253
Examples of neurological dysfunction from metabolic causes
```
Sepsis
hypovolemia
MI
respiratory arrest
hypoglycemia
electrolyte imbalance
drug and/or alcohol abuse
diabetic ketoacidosis
hepatic encephalopathy
```
254
Intracranial Pressure (IP) is a refection of what 3 relatively fixed volumes:?
the brain, CSF, and blood
255
Munro-Kellie hypothesis, or the “closed box” theory:
States that any increase in ICP within an intact skull results in a compression or decrease in one of the other compartments
256
any condition which causes excessive:
- Brain volume
- Blood volume
- CSF volume
can also increase
ICP
257
Hypercapnia means the paCO2 is
> 45
258
Hypoxemia means paO2 is
259
Factors Contributing to ICP
Hypercapnia - paCO2 > 45
| Hypoxemia - paO2
260
Lethargic
oriented x 3, sleeps often, speech and thought slow
261
Confused
disoriented X 1-3
262
Obtunded
sleeps a lot, rousable, awake only w/ constant stimuli, follows simple commands
263
Stuporous
wakens to painful stimuli
264
Comatose
does NOT respond to environmental stimuli
265
Early Picture of ⇧ICP
1. Change in LOC or behavior
2. Pupils
3. Motor function
4. Constant headache
5. VS
6. Visual disturbances
266
Most important early sign of increased ICP is
Change in LOC or behavior
267
Late Picture of ICP - signs in assessment
1. LOC - continues to deteriorate
2. Loss of brain stem reflexes
3. Motor response
4. VS
5. Projectile vomiting
268
What medications are used to decrease Cerebral Edema?
```
osmotic diuretics (Mannitol),
steroids (Methylprednisolone)
```
269
Norcuron is a ____ medication for patients with ICP
paralyzing
270
Unconsciousness
unresponsive, unaware of environmental stimuli
271
Coma
unconsciousness for days, months, years
272
Persistent vegetative state
wakeful but no conscious or cognitive mental function
273
Causes of unconsciousness and coma (3)
1. Neurological
2. Toxic
3. Metabolic
274
Cheyne-Stokes respirations in an unconscious patient indicate
Brain lesion
275
Hyperventilation in an unconscious patient indicate
Brain or metabolic issue
276
Dilating pupils in an unconscious patient indicate
ICP or brain injury
277
Corneal reflex assessment in unconscious patient
Blink is normal
Unilateral - local
Absent - deep coma
278
Asymmetrical facial symmetry in unconscious patient indicates
Paralysis
279
Drooling in unconscious patient indicates
coma
280
Stiff neck in unconscious patient indicates
Subarachnoid heme
| Meningitis
281
If an unconscious patient is stiff with bent arms, clenched fists, and legs held out straight and internally rotated. The arms are bent in toward the body (adducted) and the wrists and fingers are bent and held on the chest - this is called and indicates what?
Decorticate
Indicates problems with : Cerebral hemisphere
Midbrain issue
282
If an unconscious patient is stiff with feet plantar flexed, arms adducted and extended, hand pronated and flexed like "e" shape, this is called and indicates what?
Decerebrate
Lower brain stem problem
283
If an unconscious patient is flaccid...
This is a *Neuro or Metabolic problem
284
Contralateral neuro sign for Babinski reflex
dorsiflexion of toes, esp. great toe
Normal is toes curl down
285
1 point on all sections of the Glasgow Coma Scale means
no response
286
Main risk factors for CVD
- CARDIOVASCULAR DISEASE
- HTN
- DM
- SMOKING
- FAMILY HX of CVA
- SEDENTARY LIFESTYLE
287
TRANSIENT ISCHEMIC ATTACK – TIA
Temporary episode of neurological dysfunction manifested by a sudden loss of motor, sensory, or visual function
288
How do you assess a TIA patient?
- Auscultate Carotid arteries
| - Carotid Doppler Study, Carotid angiogram
289
If a TIA patient is not a candidate for surgery, what can you do to manage?
anticoagulation treatment
290
2 surgical management for TIA patient
1. Carotid angioplasty w/ or w/o stent placement
| 2. Carotid Endarterectomy (CEA)
291
How to use the F.A.S.T. test for learning to recognize and respond to symptoms of stroke
F = FACE Ask the person to smile. Does one side of the face droop?
A = ARMS Ask the person to raise both arms. Does one arm drift downward?
S = SPEECH Ask the person to repeat a simple phrase. Does the speech sound slurred or strange?
T = TIME If you observe any of these signs, it’s time to call 9-1-1
292
Ischemic CVA happens when there is a
Embolic or thrombotic occlusion
293
Risk factors for Ischemic CVA
**atrial fibrillation
arteriosclerosis
disease of heart valves
294
Hemorrhagic CVA involves
Rupture of cerebral vessel
295
Risk factors for Hemorrhagic CVA
```
**Uncontrolled HTN
arteriovenous malformation
intracranial aneurysms
Meds
Trauma
```
296
Left Hemisphere CVA clinical signs
```
Right paralysis or paresis
Right visual field deficit
Aphasia (R handed people)
Altered intellectual ability
Slow, cautious behavior
```
297
clinical signs of Right hemisphere CVA
```
Left paralysis or paresis
Left visual field deficit
Spatial-perceptual deficits, very distractible
Impulsive behavior and poor judgment
Lack of awareness of deficits
```
298
Medical management for Ischemic Stroke involves
Thrombolytic Therapy
| Anticoagulants
299
Medical management for Hemorrhagic Stroke involves
Manage ICP
| Surgery
300
Rehabilitation for stroke begins
as soon as stroke is diagnosed
301
Stroke care/rehab is
individualized
302
Priority nursing interventions for stroke patients include
1. Improve mobility and prevent joint deformities
2. Enhance self-care
3. Managing sensory-perceptual problems
4. Dysphagia
5. Bowel, bladder control
6. Improve thought process
7. Improve communication
8. Maintain skin integrity
9. Improve family coping
303
How do you prevent Cerebral hypoxia in a stroke patient?
- oxygenation
| - make sure H and H WNL
304
How do you prevent decreased cerebral blood flow in a stroke patient?
- make sure BP and CO WNL
| - adequate hydration
305
How do you prevent Extension of the area of injury in a stroke patient?
- avoid hypo or hypertension
306
Craniotomy
removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been performed
307
Preoperative Craniotomy care includes
- Baseline neurological assessment
- Prepare client and family for postop appearance
- Preoperative Teaching
- Allow pt and family to ask questions, verbalize fears, concerns
- Antiseptic shampoo
- Anticonvulsant medication
- Reduce cerebral edema
- Prevent infection -
- Sedation preoperatively
308
Consent for Craniotomy surgery must also include consent for
shaving hair
309
Craniotomy: Post-operative complications to assess for and avoid
- ICP
- Bleeding
- Fluid and electrolyte imbalances
- Infection
- Seizures
310
CRAINIOTOMY Post-operative care for unconscious patient
```
Monitor for ICP
Temp
Seizure precautions
Proper positioning
Routine postoperative care
Check dressing
Analgesia
Steroid therapy
Avoid fluid overload
Avoid restraints
Suction carefully
```
311
Baseline vital signs are important to get pre-op because
they're constantly referenced in the OR
312
Patients that are taking ASA may have ___ in surgery
bleeding problems
313
Ideally, ASAs and Coumadin should be stopped ___ prior to surgery
1 week
314
Patients that take MAO Inhibitors are at risk for ____ during surgery
hypotension
315
Ideally, we would stop MAO inhibitors ___ pre-op
1-2 weeks
316
Bare minimum pre-op testing for healthy person includes
CBC and urine analysis
317
Immediate Pre-op Nursing Interventions
```
V/S
Cap and gown
Dentures
Nail polish
Jewelry and valuables
Void
Name band in place
Chart ready
Preoperative medications given
```
318
Anticholinergic pre-op medications
Atropine, Robinul
319
Opiates pre-op medications
Morphine, Demerol
320
Tranquilizers or Anoxiolytics pre-op medications
Versed, Valium
321
Most Common Post-Op Complications
```
Atelectasis
Pulmonary Embolus
Pneumonia
Paralytic Ileus
Deep Vein Thrombosis (DVT)
Shock
Urinary Retention
Dehiscence-Evisceration
```
322
Patients that are allergic to ___ cannot take Propofol
soybeans
323
Skin prep is normally done ___ the OR
in
324
Studies have shown that patients only remember ___ percent of things they're told pre-operatively
10%
325
For a patient getting abdominal or thoracic surgery, you teach them how to splint the wound, which means
putting a pillow or blanket, holding pressure against it so it doesn't hurt as much
326
Less than ___ percent of patients who are in pain take pain medications and become addicted
1%
327
Key thing for incentive spirometer to teach patients
form a tight seal around the mouthpiece and breathe IN
328
The ideal thing with patients with dentures is to have the patient remove them and give them to
a family member or other designated person
if no one can do it, call security
329
Does a patient have to be completely free of nail polish before surgery?
No - just 1 finger to do the O2 sat
330
Rule of thumb is that patient should void within ___ hours post- surgery
8
331
Atelectasis can lead to ____, one of the biggest post-op complications there is
pneumonia
332
Paralytic Ileus
bowel can be put to rest - absence of peristalsis post-surgery
333
Make sure patients are putting out at least ____ mL of urine/hour post-op
30mL
334
Dehiscence-Evisceration is a post-op complication that can happen in the
abdomen - when sutures come apart
Evisceration is when the bowel comes out from between the sutures
335
How do intraventricular monitors for patients with ICP work?
attaches to ventricles in the skull to get a direct measurement of pressure
allows us to measure increased ICP AND drain off some of the cerebral spinal fluid
STRICT ASEPTIC technique needed with intraventricular monitors - FOR GOING IN, DRESSING CHANGE, AND MONITORING
336
when giving osmotic diuretic, make sure there's
a foley cath in place
337
2 ways to reduce CSF in ICP patients
1. draining (via intraventricular)
2. hyperventilating the patient - if they can lower patient’s PaCO2 to 30-34, it can cause vasoconstriction in the cerebral area and decrease pressure temporarily - somewhat controversial
338
anytime a patient has a fever, it increases
cerebral metabolism
339
if an ICP patient is shivering, what do you do?
DON'T let them shiver
give Tylenol to reduce fever
move more slowly
give something like thorazine to stop shivering
340
to improve cerebral tissue perfusion in ICF patients, keep the head
MIDLINE
no rotation
341
For patients with ICP, keep head ___ to improve venous return
lifted to 30 degrees
342
What measures should you never take with ICP patients
NO: valsalva, stool softeneres, emotional stress
343
Most lethal complication for ICP patients is
brain herniation
344
unconscious usually means between
minutes to hours
any longer and this is deemed "coma"
345
Corneal reflex test for unconscious patients is
touching cornea with wet cotton ball
346
What patients can you NOT use glasglow coma scale on
- patients who are intubated/respirator
- just came out of surgery and eyes sealed shut
- certain medications
347
by definition, the unconscious patient has lost ___ of their protective reflexes
all
348
if the head of the bed is down/bed is flat, unconscious patients should be lying ____
laterally (on their side)
if supine, head should be raised to 30 degree to prevent aspiration
349
just because a patient is having loose stools doesn't mean
they don't have a fecal impaction
350
Big risk factor for CVD is
cardiac arrhythmias, especially atrial fibrillation***
351
If it's a TIA, the patient's condition should improve between ___ hours. But don't want to bring them in!
3-6
352
What always needs to be done before a CEA or carotid angioplasty?
Neuro assessment
353
What happens in a Carotid Endarterectomy (CEA)?
make an incision over the artery and remove those plaques
354
Anticoagulation treatment for TIA patients can include
warfarin, coumadin
355
____ of strokes are ischemic. What is the main cause?
80-90%
atrial fibrillation
356
Patients with ischemic stroke often complain of
weakness/numbness on one side of the body
357
____ of strokes are Hemorrhagic. What is the main cause?
10-20%
uncontrolled HTN
358
Chief complaint for patients with Hemorrhagic stroke is
headache
359
Hemianopsia
loss of one half of visual field
360
diplopia
seeing double
361
Hemiparesis
one side weakness
362
Hemiplegia
one sided paralysis
363
Ataxia
unsteady gait
364
Dysarthria
the difficulty of forming words NOT because there’s something wrong with speech center but with the muscles involved in speech
365
What is the difference between receptive, expressive, and global aphasia?
receptive aphasia- cannot decipher what people are saying TO you
expressive aphasia - when you cannot understand what you’re saying
global aphasia: both receptive and expressive
366
emotional lability:
patient may be appearing content and then randomly dissolve into tears (huge swings of emotion)
367
With a CVA, what do you always do first?
CT scan
1. verify that its a stroke
2. tell whether it’s ischemic or hemorrhagic
368
if CVA patient is not a candidate for thrombolytic therapy, they may be given
heparin (anticoagulant)
369
hemorrhagic stroke is managed in a similar way like a patient who has
ICP
370
Patients with dysphagia should sit at
90 degrees (upright)
371
How long are anticonvulsants like Dilantin continued post-op for craniotomy patients?
1 year
372
if stoma is a dusky, dark blue you need to
contact HCP immediately (should be pink)
373
stomas begin to function about ___ days postoperatively
3-6
374
Why would we give antibiotics for a colonoscopy?
can’t make the bowel sterile but can reduce the number of flora
375
Dura
Superior level (tough and inflexible)
Subdural
Epidural
376
Arachnoid
Thin and fibrous
Below the arachnoid is the CSF
377
Pia mater
Innermost layer
Follows contours of the brain and blood vessels to the brain
Nutrients to brain
378
CSF is
Clear colorless fluid
Produced by ventricles
Circles around brain and spinal cord
379
Cerebral circulation rate
750 mL/min of blood to the brain
Blood supply to the brain is up against gravity
380
Circle of Willis
Frequent site for aneurysms leading to stroke/CVA
381
Spinal cord and medulla connect brain to
Periphery
382
Spinal anesthesia is put into the
Subarachnoid space
383
How will cancer vs MI look in cat scan?
Infarction: less light
Cancer: will light up more
384
PET scan is looking at
Organ function, brain metabolism
Glucose and oxygen
385
Cerebral angiogram is looking at
Bleeding, narrowing
386
After cerebral angiogram, how long should you put pressure on the groin?
20 minutes
387
EEG is looking at
Electrical activity in the brain
Through electrodes in the head
388
What 4 things are we looking for in CSF sent to the lab after lumbar puncture?
1. Glucose
2. Protein
3. Bacteria
4. Cell count
389
How do you position a patient for lumbar puncture?
Fetal position at the edge of the bed
Hand behind neck
Hand beneath knees
390
How long should you lay the needle flat after sampling from lumbar puncture?
New needle: 2 hrs
| Older needle: 6 hours
391
How do you treat spinal headache?
Analgesics
Bed rest
Hydration
Caffeine/chocolate
392
What is the sign of a spinal headache?
When they stand up, head hurts
Relieved when lying down
393
DKA
Serum glucose: 300-800
Only Type I
Arterial pH: acidic
Ketones: positive
Onset: quick
Breakdown of fats
Kussmaul's respirations
394
HHNK
Only Type II
Glucose: often over 1000
Negative for ketones
Slow onset
Regular and shallow breathing
50% mortality
395
Black box warning for Biguanide
Lactic acidosis
396
For mixing insulin always remember
Clear to cloudy
397
Random glucose level of 200 mg/dL or higher on more than 1 occasion indicates
Diabetes
398
Safety points for giving insulin to hospitalized patients
- check BS before each meal (AC) and at bedtime
- units must be written out
- give insulin in insulin-specific syringe
- double check order with another nurse
399
Patients with hyperglycemia should not be given
Dextrose
400
Antihyperglycemic agents won't see ____ as an ADE
Hypoglycemia
401
What do oral hypoglycemics do?
Increase insulin production
402
ADE of oral hypoglycemics
Hypoglycemia
403
Black box warning for glitazones (antihyperglycemic)
CHF
Increased risk of angina mI
