Medical-Surgical

Nursing

Enrichment Class
Merceditas L. de Belen-Cristobal,
USRN, MD

Endocrine Disorders

 Pituitary gland
anterior pituitary
growth hormone : gigantism and

acromegaly vs. dwarfism

ACTH : secondary Cushings vs Addisons
disease
TSH : hyper vs. hypothyroidism
FSH and LH : precocious puberty vs. no
secondary sexual characteristics

 Posterior pituitary
ADH : SIADH vs. Diabetes insipidus

management of Diabetes insipidus

vasopressin replacement
(desmopressin)
Clofibrate
low ____ diet?

Hyperpituitarism
caused by pituitary adenoma
Usually excessive GH
managed by surgery (hypophysectomy),
radiation therapy and pharmacotherapy
Gigantism/ Acromegaly
Enlargement of existing bones/ internal
organs
(heart, liver, spleen)

Hands, feet, face and skull enlarge from GH.

Slanting of forehead, protrusion of jaw and
widening of teeth also present.
- Soft tissue changes increases the size of every
body organ (heart and liver)
- Increased glucose (GH- insulin antagonist) ,
hypertension, oily skin, weight gain, menstrual
irregularities, bone thinning, degeneration of
joint cartilage
Interventions:
Counseling re changed body image
Visual disturbances
Octreotide Somatostatin - GH analogue that
suppresses GH production
bromocriptine (Parlodel) dopamine agonists
-inhibit GH synthesis
Tumor removal by cranial or transsphenoidal
hypophysectomy
or pituitary radiation therapy

Gigantism

Acromegaly

Gigantism-acromegaly

Hypopituitarism
deficient secretion of anterior pituitary hormones-

marked by dwarfism, metabolic dysfunction, sexual

immaturity and growth retardation
Cause: tumors, congenital defects, head injury ,
radiation therapy to the head and neck area
Simmonds Disease panhypopituitarism
Sheehans syndrome postpartum pituitary necrosis
- Gland must be 75% dysfunctional
- Pituitary gland undersecretes hormones then all
target organs affected
- ACTH- Addisons, sex hormones- sexual
development, GH- stunted growth, ADH- DI, TSHhypothyroidism
Interventions:
Treat and replace hormones as necessary
(cortisol, thyroxine, estrogen, androgens)

 Thyroid gland
triiodothyronine (T3) and thyroxine
(T4)
metabolism and growth
hyperthyroidism vs. hypothyroidism
diagnostic tests: screening test ____?
T3 and T4 levels
Fine needle biopsy

Hyperthyroidism (Graves Disease)

Hypermetabolism-

Increased SNS activity

Signs
restlessness,
nervousness,
irritability and
agitation
fine tremors
tachycardia
hypertension
increased appetite
with weight loss
diaphoresis

Diarrhea
heat intolerance
amenorrhea
exopthalmos
Thyroid stormthyrotoxicosistachycardia, HTN and
heat intolerance
becomes life-threatening.
Maybe due to lack of
meds, induced by stress
Diagnostics: T4, T3,
RAIU, TSH

Nursing management
Rest
diet : high calorie and high protein
Cool environment and cold fluids
promote safety
protect the eyes
replace fluid and electrolyte losses
pharmacotherapy
beta blockers
propanolol (inderal)

 Iodides : lugols solution (SSKI) -reduce size

and vascularity of the gland
Thioamides- inhibits thyroid hormone
synthesis
propylthiouracil (PTU)- agranulocytosis
methimazole (Tapazole)
Ca-channel blockers- anti-hypertensives

Radiation therapy- RAI131

thyroidectomy : total vs. subtotal

Hyperthyroidism
Monitor CV status- hypertension, cardiac
arrythmias and temperature

Thyroidectomy
- check for respiratory distressTracheostomy set
- watch for hemorrhage into the neck- tight
dressing with no blood.
- Monitor for signs of hypocalcemia (calcium
gluconate)
- Monitor for laryngeal nerve damage

Radioactive Iodine
Feeling of fullness131
in neck
Metallic taste
Stop all anti-thyroid medications one week
before treatment
Given on empty stomach
Radioactive precaution on body secretions
for 3 days
Avoid contact with children for 1 week
Sleep alone for 1 week
Not to resume anti-thyroid medications for 6
weeks

Hypothyroidism (Myxedema)
Slowed physical and mental reactions
expressionless face
anorexia and obesity
bradycardia
hyperlipidemia and atherosclerosis
cold intolerance
constipation

Myxedema

Nursing management

Monitor daily weights

diet : low calorie high fiber
pharmacotherapy
thyroglobulin (proloid)
levothyroxine (synthroid)
dessicated thyroid extract
liothyronine (Cytomel)

Treatment for Hypothyrodism

Levothyroxine sodium (Synthroid) (T4)
Liothyronine (Cytomel) (T3)
Iodized salt (WHO recommendation that salt be
iodized to a concentration of 1 part in 100,000)
If the mean iodine intake is less than
40g/day, the thyroid gland hypertrophies.
Should stop all pharmacologic goitrogens
(sulfonamides, salicylates, lithium) &
vegetables (cabbage, soybeans, peanuts,
peaches, peas, strawberries, spinach, radishes)

Cushings Disease and

Syndrome
Hypersecretion of adrenal hormones due to ACTH
-

excess by pituitary gland or extrapituitary tumors

Syndrome is due to the disease or administration of
steroids
Causes: Adrenal gland neoplasms and other tumors
Steroids antagonize insulin- glucose
Fat metabolism affected- adipose tissue accumulates in
the abdomen, neck and behind the shoulders
(supraclavicular)- Buffalo hump
Accelerated CHON metabolism leads to muscle wasting
CHON loss- osteoporosis, edema, thinning of skin, moon
face, changes in skin pigmentation
salt, sugar, sick, sad (mood elevation)

CUSHINGS DISEASE

Cushings Disease and

Syndrome
Interventions:

Interventions:
- Monitor VS and labs
- Antihypertensive drugs
- Adjust insulin for diabetics
- Protect from infection
- Emotional support
- Low calorie diet, high CHON
- Monitor I&O
- Pituitary tumors- remove by hypophysectomy
- Adrenal cortex tumors- removed
- Radiation

Addisons Disease
Signs
fatigue, muscle weakness
anorexia, nausea and vomiting with weight
loss
hypoglycemia
hypotension, weak pulse
Salt, sugar and sad
management
Hormone replacement therapy

Pheocromocytoma

Adrenal medulla which secretes

catecholamines
hypersecretion
signs

hypertension
headache
hyperhidrosis
hypermetabolism
hyperglycemia

Diabetes Mellitus

Chronic systemic metabolic disease

diagnostic test
fasting blood sugar (FBS)
glycosylated hemoglobin (HbA1c)

direct cause
lack of insulin or resistance of receptors

 Signs
hyperglycemia > glycosuria
polyuria, polydipsia and polyphagia
Fats utilized- ketones > metabolic acidosis
Ketoacidosis > Lungs compensate
Kussmauls respirations (increased rate
and depth)
Acetone (fruity odored breath)
Macroangiopathy- CAD
Microangiopathy- retinopathy
neuropathy

 Predisposing factors
heredity, obesity, stress, autoimmune, and
pregnancy

types
type I
juvenile onset with absolute insulin deficiency
prone to diabetic ketoacidosis (DKA)
management includes diet, activity and always
insulin therapy

 Type II
maturity onset with resistance rather
than deficiency in insulin
obesity is common
ketosis resistant but prone to HHNKC
(Hyperglycemic, hyperosmolar NonKetotic coma)
management is diet, activity and oral
hypoglycemic agents

Nursing management

Diet
low calorie, high fiber diet
20% CHON 30% fats 50% CHO

activity

regular exercise pattern

maintenance of ideal body weight

 Pharmacotherapy
Oral Hypoglycemic agents
sulfonylureas : gliclizide (diamicron),

glibenclamide (Diabinase), glipizide (Solosa)

biguanides : metformin (Glucophage)
acarbose (glucobay, Avandia)

Insulin therapy
rapid acting Humulin - R
intermediate acting- Lente Humulin - N
long acting Ultralente

Diabetic Ketoacidosis

Signs

DM signs
warm flushed dry skin
tachycardia
nausea and vomiting and abdominal
pain
kussmauls breathing
fruity odor of breath

Hypoglycemia
Signs

restlessness
hunger pangs, weakness, tremors, pallor
diaphoresis, cold clammy skin
headache and dizziness, syncope
blurred vision, slurred speech and
altered LOC
management
simple sugars p.o.
D50% IV; glucagon SQ, IM

Management of Hypoglycemia:
Conscious Client:
10 15 g of fast acting simple
sugar
3 4 glucose tablet
4 6 oz fruit juice or regular soda
6 10 life saver or hard candies
2 3 tsp. sugar or honey

Management of Hypoglycemia:
Unconscious Client:(if not in the hospital)
1. Glucagon S.C. 1 mg or IM (increases
blood sugar level within 5 mins.)
2. Snacks: CHON & starch ( milk, cheese &
crackers)
Note: if powder : takes 20 mins to awaken
Unconscious Client (In the hospital)
1. D 50 Water per IV

Sample Questions
The nurse teaching a type 2 diabetic client how to manage
the disease while on a prescribed diet and taking an oral
antidiabetic agent would recognize that the client has an
accurate understanding of diabetes management when the
client states
a.I must exercise at least 1 hour daily to help bring down
my sugar.
b.Im really happy I can take insulin pills; its much easier
than an injection.
c.I must decrease my total daily fat intake to less than
45% of my total calories.
d.I can use oral medications for my diabetes as long as
my pancreas can still produce insulin.

The nurse educating a client about an upcoming

oral glucose tolerance test would include
information relevant to
a.eating at least 500 g of carbohydrate for 3 days
before the test.
b.the first blood sample being drawn 1 hour after
drinking a glucose-containing beverage.
c.not eating or drinking anything else during the
test.
d.exercising during the test to relieve boredom.

Smil
e!

Musculoskeletal Disorders

 Common interventions
Range of Motion Exercises (ROM)
passive / active - assistive/resistive
isotonic vs. isometric
assistive devices for ambulation
cane
walker
crutches and crutch gaits

 Care of clients with casts

care of clients with tractions
skin tractions : Bucks
Cervical
Pelvic
skeletal tractions : Crutchfield
balanced suspension tractions

Bucks traction

Cervical traction

Pelvic traction

Crutchfield tong

Trauma

strain vs. sprain

dislocation
fracture
types
complete vs. incomplete
transverse, oblique, spiral
greenstick
comminuted

Types of Fractures

 Impacted
closed/simple vs. open/compound
stress, pathologic, or traumatic
signs
pain aggravated by motion, tenderness
loss of motion
edema
crepitus
ecchymosis

 Shortening of the limb

obvious deformity
X-ray reveals fracture

management

traction
reduction
casting
neurovascular checks

Types of Internal Fixation Devices

CASTING MATERIALS
Plaster Type
Synthetic Type
- Can be used for
- lightweight, dry
severely displaced
quickly and are
fractures
moisture resistant
- Easily molded and
- Increased chance of
inexpensive
- Slow drying, heavy and skin maceration, if
not dried properly
easily weakened by
moisture
- Expensive

CASTS

Nursing Care for Clients

with a Cast:
Keep the cast and
extremity elevated
Allow a wet cast to dry
within 24-48hrs
Handle a wet cast with the
palms of the hands
Monitor the extremity for
circulatory impairment
Notify the physician for any
circulatory compromise
Inspect cast edges and
underlying skin for
irritation

Monitor for any

signs of infection
(hot spots)
Monitor for any
drainage on the cast
Instruct not to insert
anything in the cast
Instruct to keep the
cast clean and dry
Instruct to do
isometric exercises

TRACTION
- Ensure that the

weights are
hanging freely
- Maintain
continuous traction
- There should be a
countertraction

Sample Question
A client was placed in traction to align a
fractured bone in a lower extremity. The
nurse observes the traction weights
touching the floor. The nurse should:

a.
b.
c.
d.

raise the foot of the bed

notify the MD
lengthen the traction rope
move the client up toward the head of the
bed

CRUTCH
WALKING
Used to aid the client in ambulation

Accurate measurement is important to avoid

damage to the brachial plexus

The distance between the axillae and the arm
pieces on the crutches should be two
fingerbreadths in the axilla space
The elbows should be slightly flexed, 20-30
when the client is walking
Instruct never to rest the axilla on the axillary
bars
Instruct to stop ambulation if numbness or
tingling in the hands or arms occur

Sample Question
A child with a fractured leg is to have no

weight bearing on the affected leg. When

measuring the child for crutches, the nurse
knows that:
a. The elbows should be in extension when
the crutches are held at the crossbar
b. There should be a snug fit under the
axillae when walking to provide support
c. There should be a slight stoop of the
shoulders when the crutches are used
d. The crutches should be 2 inches below
the axillae when the crutch tips are 6
inches to the side of the feet

HIP FRACTURES
Common among elderly women
Total or partial hip replacement
Traction can be used pre-operatively
Post-op care:
- maintain leg and hip in proper
alignment
- maintain legs in abduction
- avoid bending
- use trochanter roll to prevent external
rotation
- make sure hip flexion does not exceed
90 degrees

SAMPLE QUESTION
When planning the discharge

teaching for a client who has a total

hip replacement, the nurse should
include encouraging the client to
avoid:

a. climbing stairs c. sitting in a low chair

b. stretching exercises d. keeping legs
apart

 Compartment Syndrome
signs

pain, pallor, pulselessness,

paresthesia and paralysis

management
extremity elevated by the level by
the heart
remove tight dressings or casts

Rheumatoid Arthritis
Autoimmune and hereditary
Bilateral, symmetrical, inflammatory,
systemic
progression through stages

synovitis - pannus formation (scar tissue) fibrous ankylosis - bony ankylosis

signs
fatigue, anorexia, malaise, weight loss, slight
temperature elevation

 Painful, warm, swollen joints with limited

motion, stiff in the morning and after
periods of inactivity
crippling deformity/ swan-neck or
buotonierres deformity
muscle weakness
history of remissions and exacerbations
severe anemia

Rheumatoid Arthritis

Management

Bed rest during acute pain

passive ROM exercises
splint painful joints
heat and cold applications
well-balanced diet
physical therapy

 Surgery
osteotomy, synovectomy or arthroplasty

pharmacotherapy
Aspirin
NSAIDS
indomethacin (Indocin)
phenylbutazone (Butazolidin)
Ibuprofen (Motrin)

 Gold compounds (chrysotherapy)- arrest

progression of the disease
sodium thiomalate (Myochrisine)
aurothioglucose (Solganal)
auranofin (Ridaura)
Corticosteroids
intra-articular injections

Osteoarthritis

Degeneration of articular cartilage

involves weight bearing joints
signs
joint pain aggravated by use; relieved by
rest
stiffening of the joints
Heberdens and Bouchards nodes
decreased ROM and crepitus

 Management

relieve strain and further trauma to joints

cane or walker if indicated
proper body mechanics
avoid excessive weight bearing and standing
physical therapy
relief of pain (NSAIDS)
joint replacement as needed

Osteoarthritis

MUSCULOSKELETAL
PROBLEMS
DIFFERENCE BETWEEN RA & OA
RA
Pain
periods of inactivty
Joint
ankylosis
Symptoms systemic
ESR
increased
Weight
underweight
Age
young

OA
after movement
motion limitation
local
normal
overweight
4th decade

Gout
Disorder of purine metabolism
uric acid crystals in the joint: _______
signs
joint pain, redness, heat, swelling
unilateral with ears, ankle and great toe most
commonly affected
headache, malaise, anorexia
elevated BUA levels

 Management

rest
dietary modification and increase fluids
pharmacotherapy
acute attack - Colchicine and NSAIDS
prevention
uricosuric drugs: excretes uric acid
Probenecid(Benemid)
Allopurinol(Zyloprim) inhibits uric acid formation

Gouty Arthritis

Osteomyelitis
Infection of the bone (S. Aureus)
signs
malaise, fever
pain and tenderness of bone, redness and
swelling of the bone and tissue over the bone
difficulty in weight bearing
drainage from wound site
necrosis of the bone (sequestrum)
Treatment:
2 months of IV ATB; 2 months of oral ATB

Herniated Nucleus Pulposus (HNP)

Compression of the spinal nerve roots
L4 and L5 most commonly affected
caused by heavy lifting, degeneration
and congenital predisposition
signs

cervical disc
shoulder pain radiating to hand
weakness, paresthesia and sensory disturbance

 Lumbosacral
back pain radiating across buttocks and
down the leg (sciatic nerve)
weakness
numbness and tingling sensation
muscle spasms I the lumbar region

Management

Bed rest on firm mattress with bed

board
traction
local application of heat
lumbosacral corset (back brace)
prevent complications of immobility

SPINAL CORD INJURY

-Injury to the spinal cord which ranges in
severity from mild flexion-extension
whiplash injuries to complete
transection of the cord w/ quadriplegia

- Trauma- most common cause

May be due to automobile or
motorcycle accidents, gunshot or knife
wounds, falls, or sporting mishaps

Classification of spinal cord

injury
According to the level of injury
1. QUADRIPLEGIA
- Paralysis (complete or incomplete) involves all
four extremities
Injury to the cervical spine and cord

2. PARAPLEGIA
- Paralysis of the lower extremities
- Injuries to the thoracic or lumbar spine

*QUADRIPARESIS and PARAPARESIS are used to

denote weakness rather than total paralysis

Assessment of SCI
Depends on the level of the cord injury
The level of SCI is the lowest spinal cord

segment with intact sensory and motor

function
Motor and sensory changes below the injury
Loss of reflexes below the level of injury
Loss of bowel and bladder control
Presence of sweat, which does not occur on
paralyzed areas

Spinal Shock
-

post-traumatic areflexia
Complete loss of skeletal muscle function,
bowel and bladder tone, sexual function,
and autonomic reflexes
Damage to motor neurons and vasomotor
center > Loss of venous return and
hypotension
May last for 7 days to 3 months
Indications that Spinal shock is resolving:
return of reflexes, devt of hyperreflexia
rather than flaccidity, return of reflex
emptying of the bladder, babinski reflex

Sample Question
A patient who has a SCI is in spinal shock,. On
assessment, the nurse would expect the
patient to describe which of the following
findings in the LE?
a. loss of sensation
b. complaints of tingling
c. excessive diaphoresis
d. constant tremors

Sample Question
A nurse is evaluating the neurological

signs of a male client in spinal shock

after SCI. Which of the following
observations by the nurse indicates that
spinal shock still persists?
a. presence of bulbospongiosis reflex
b. absence of Babinski reflex
c. hyperreflexia
d. reflex emptying of bladder

Autonomic dysreflexia
-

In clients w/ injury above T7 and can occur

for up to 6 years after injury
- Exaggerated response to a noxious stimuli
(bladder & bowel distention; pressure
ulcers, spasms, pain, pressure on the penis,
uterine contractions)
- Increased BP (200-300mmHg systolic),
bradycardia, profuse sweating, nasal
congestion, cold clammy skin
Management:
- HOB elevated semi-fowlers position
- Notify MD
- Vasodilators

Sample Question
A hospitalized patient who has a spinal
cord injury reports an acute, pounding
headache. Which of the following
actions should the nurse take first?
a. suction the patient
b. raise the HOB
c. institute seizure precautions
d. administer analgesics as ordered

Emergency Management
Jaw thrust
Log-rolling
Client is in supine position on a firm

surface. Head is supported in alignment w/

the body and is immobilized by placing
sandbags on either side of it or taping it to
the board. Cervical collar is applied.
Clothing is cut off
Always suspect SCI until injury is ruled out
Prevent head flexion, extension or rotation

Medical Management
Immediate care in the hospital

suction
mechanically assisted respiration
careful monitoring of hemodynamic
parameters
Hypotension initially treated w/ IVF

neurologic examination
assess motor function

Pharmacologic management
Vasoactive agents
- To support blood pressure immediately
after injury

Methylprednisolone

- In high doses started w/ in 8 hours of

injury can result into improved motor and
sensory function

Anti-infectives, anticoagulants,
laxatives, and antispasmodics

Surgical management
Decompressive laminectomy
- For complete SCI
- Lamina of the vertebrae are removed to
minimize the pressure on SC; allows for
cord expansion from edema

Surgical fusion (spinal fusion and rod

insertion)

- Insertion of metal plates and screws

and/or use of bone grafts

GENITOURINARY
DISORDERS

FUNCTIONS OF THE KIDNEY

Uri
Urine
ne fo
forrma
matitioonn
-- glo
glomerula
merularr fifi ltra
ltratitioonn
-- tubula
tubularr rreabso
eabsorpti
rption
on
-- tubula
tubularr secr
secretio
etionn
Excr
Excreti
etion
on ooff wa
waste
ste pr
prooducts
ducts
-- ur
urea
ea (m
(maajo
jor)
r)
-- crea
creatinine,
tinine, pho
phospha
sphates,
tes,
-- sulfates,
sulfates, uri
uricc aci
acidd
Regula
Regulatitioonn ooff el
electr
ectrooly
lytes
tes
-- so
sodium
dium
-- pota
potassium
ssium
Regula
Regulatitioonn ooff acid
acid ba
base
se bal
balaance
nce
-- pho
phospho
sphoric,
ric, sulfuric
sulfuric aacid
cid

-- buff
buffers:
ers: phospha
phosphate
te io
ions,
ns, aamm
mmoni
oniaa

FUNCTIONS OF THE KIDNEY

Control of water balance

- ADH (vasopressin)

Control of blood pressure

- renin-angiotensin system

Regulation of RBC production

- erythropoeitin

 Diagnostic tests
laboratory tests
routine urinalysis
creatinine clearance
blood studies : BUN (8-25mg/dL), Serum
Creatinine (0.6-1.3mg/dL), creatinine
clearance (85-135ml/min), serum
electrolytes
cystoscopy
abdominal X-ray (KUB)

SAMPLE
QUESTION
a patient is
After a cystoscopy,

alarmed with the presence of pinktinged urine. The nurse would:

a. administer atropine suppository as
ordered
b. tell the patient this is common and
continue to observe
c. notify the physician immediately
d. decrease fluid intake

RENAL FAILURE
Types
acute - sudden loss of renal function ;
reversible
chronic - gradual progressive and irreversible
loss of renal function

causes
pre-renal
renal
post-renal

Stages of ARF
oliguric phase
diuretic phase
recovery phase
Stages of CRF
renal impairment or diminished renal
reserve
renal insufficiency
End Stage Renal Disease ESRD

3 PHASES of ACUTE RENAL

FAILURE
Oliguria/anuric phase- 8-15 days- output

<400ml/day. Toxins accumulate- metabolic

acidosis- Increased BUN, Crea, K
- decreased ph, bicarb, Na and Ca; azotemia
(elevated serum levels of urea, creatinine
and uric acid)
Early Diuretic phase- extends from the
time daily output > 400ml/day- BUN stops
increasing, UO > 3-5L/day, hyponatremia,
hypokalemia, change in LOC
Recovery phase- extends from 1st day BUN
falls to the day it returns to normal

ARF INTERVENTIONS
- Dialysis, monitor f&E, acids and bases
-

observe for fluid overload

moderate protein restriction, high in calories,
CHO, low K
Monitor cardiac status, I&O, weigh daily
Monitor creatinine and BUN
Fluid restriction
Diuretic therapy to treat oliguric phase
Sodium polystyrene sulfonate (Kayexalate)hyperkalemia- to exchange Na for K ions in
GIT
Monitor for patients response to medications
Monitor for infection and anemia

CHRONIC
Manifestations: RENAL FAILURE
Azotemia, metabolic acidosis
Altered LOC due to accumulation of wastes
Irregular heart rate
Yellow bronze skin due to altered metabolic
process
Dry, scaly skin and severe itching due to
uremic frost
Proteinuria, glycosuria
Diminished erythropoetin secretion- anemia
Renal phosphate excretion and Vit D
synthesis are diminished; K secretion
increases

CRF
INTERVENTIONS
Dialysis, monitor I&O, F&E, manage symptoms

Kidney transplant
Low CHON diet- limit accumulation of end
products of CHON metabolism
Fluid restrictions
Monitor for fluid overload
Antihypertensives, diuretics
Epogen- stimulate bone marrow to produce
RBCs
Antipruritics; good skin care
Dialysis for hyperkalemia and fluid imbalances
Assess for infection, cardiac arrhythmias

TYPES OF DIALYSIS

Hemodialysis- removes wastes and fluids

rapidly than PD
removes toxic wastes and impurities
from the blood. Blood removed from
surgically created access site- filtration
unit- osmosis, diffusion and filtration
Nursing Responsibilities:
monitor venous access site for bleeding
Dont use arm for BP, IVT or
venipuncture
Auscultate for bruits and palpate for
thrills
Weigh before and after the procedure
Monitor for shock and hypovolemia

HEMODIALYSIS

TYPES
Peritoneal

OF
DIALYSIS
- removes
toxins from the

blood- uses peritoneal membrane as a

semi-permeable dialyzing membrane.
- Infusion time
- Dwelling time- solution is drained taking
toxins and wastes with it
- Drainage time

- NR: Weigh daily, change dressing daily,

calculate fluid balance after each session.

Record all imbalances, either + or - .
Maintain sterile technique, warm dialysate,
turn patient; Monitor for peritonitis

PERITONEAL DIALYSIS

When
teaching
a client who has just started
SAMPLE
QUESTION
peritoneal dialysis about the procedure,
the nurse should tell the client that if the
drainage of dialysate from the peritoneal
cavity ceases before the required amount
has been drained out, the client should:
a. drink 8oz of water
b. turn from side to side
c. deep breathe and cough
d. periodically rotate the catheter

SAMPLE QUESTION
A client with ARF moves into the

diuretic phase after 1 week of therapy.

During this phase the client must be
assessed for signs of developing:
a. renal failure
b. hypovolemia
c. hyperkalemia
d. metabolic acidosis

SAMPLE QUESTION
In caring for a client with

hypovolemic shock related to trauma,

the nurse recognizes that he is at risk
for pre-renal failure related to:
a. decreased perfusion to kidneys
b. direct trauma to the kidneys
c. obstruction to urine flow
d. vasodilation of renal arterioles

URINARY TRACT
INFECTION
Signs
frequency, urgency, dysuria
hypogastric pain
malaise
fever, chills
nausea and vomiting
low back pain
urinalysis findings

MANAGEMENT
C and S before antibiotic therapy
increase fluid intake
acidify the urine
perineal hygiene
regular bladder emptying
hot sitz bath

SAMPLE QUESTION
To help prevent recurring UTI, the nurse
should plan to instruct a female client
to:
a. increase the daily intake of fruits
b. douche frequently with alkaline
agents
c. urinate ASAP after intercourse
d. cleanse from the back to the front

UROLITHIASIS/ NEPHROLITHIASIS
- formation of stones in the urinary tract

2ndary to precipitates caused by Ca, stasis,

altered purine metabolism
Risk factors :
- diet high in calcium and protein
- Urinary stasis
- Dehydration- increases urine concentration
- Obstructive disorders
- Metabolic disorders uric acid accumulation
- Osteoporosis
- Prolonged immobility

URINARY CALCULI
(UROLITHIASIS)
Types of stones
Ca Oxalates, Phosphates
Uric acid

Signs
colicky pain
nausea and vomiting
dysuria and hematuria

MANAGEMENT

Fluids
strain urine
encourage ambulation
pain control
- Acid ash diet for Ca/phosphate stones
- Alkaline ash- cystine and uric acid stones
- Low purine diet for uric acid stones
surgery
Urolithotomy/ nephrolithotomy
(nephrostomy tube)
extracorporeal shockwave lithotripsy

SAMPLE QUESTION
A patient passes a urinary stone and lab

analysis of the stone indicates that it is

composed of calcium oxalate. On the basis of
this analysis, which of the following would the
nurse include in the dietary instructions?
a. increase intake of meat, fish, plums and
cranberries
b. increase citrus fruits and juices
c. Eat more green leafy vegetables such as
spinach and bran
d. increase intake of dairy products

BENIGN PROSTATIC
HYPERPLASIA
Signs
nocturia, frequency, hesitancy
decrease in the caliber of the urine
stream
residual urine
hematuria
recurrent UTI

 Interventions:
- Administer Finasteride (Proscar)- reduce size

of prostate
- Terazosin- Hytrin- relax the muscles and
promote urination
- Urinary antiseptics and antibiotics to prevent
infection from stasis if urine

- Surgical Removal of Prostate

- TURP- resectoscope or laser inserted thru

urethra
- Suprapubic- incision in abdomen and bladder
- Retropubic- abdominal incision
- Perineal- perineal incision- highest risk for
incontinence, impotence and wound
contamination

BPH
CBI (continous bladder irrigation) after surgery
to promote hemostasis and limit clots that
block the catheter
Installation of sterile isotonic solution into the
bladder using 3 lumen catheter- used to
prevent occlusion of catheter by clots or to
administer direct antibiotic treatment to the
bladder
Nursing Care:
Set rate of infusion per MD order; usually to
keep drainage reddish pink
Maintain infusion continuously, observing
color, clarity and amount of drainage
Bladder spasms typical after TURP, notify
patient

SAMPLE QUESTION
In the early post-operative period after
TURP, the most common complication
the nurse should observe would be:
a. sepsis
b. hemorrhage
c. leakage around the catheter
d. urinary retention with overflow

SAMPLE QUESTION
The nurse assesses a client with BPH
for which of the following clinical
manifestations?
a. testicular edema
b. nocturia
c. pain at the base of the penis
d. constipation

PROSTATE CANCER
slow malignant change in the prostate
gland that spreads by direct invasion of
surrounding tissue and can metastasize
to bony pelvis and spine
Elevated serum acid phosphatase and
serum PSA (prostate specific antigen)
and carcinoembryonic antigen (CEA)
Biopsy- reveals malignancy , MRI, CT

PROSTATE CANCER

Interventions:
Radical prostatectomy- perineal or retropubic
approach- remove the seminal vesicles and
portion of bladder neck

Radiation alone or along with surgery- pre or

post-op- reduce lesion, reduce metastasis

Diethylstilbestrol (Estrogen)- reduce the size of

an inoperable lesion or can be used post-op to
limit metastasis

PROSTATE
CANCER
Nursing Management
Same care as with BPH
Explain to pt that development of secondary
female characteristics is due to estrogen
Monitor for development of metastasis
Provide care for patients receiving radiation
Provide emotional support to patient and
family
*** advise men over age 40 to have digital
rectal exam annually for early detection of
prostate CA

GLOMERULONEPHRITIS
Acute vs. chronic
acute : post streptococcal infection
chronic :gradual and progressive destruction
of glomeruli (interstitial or tubular)
signs
headache, weakness, fatigue
edema and hypertension
nocturia

MANAGEMENT
Bed rest
relief of edema
diet
fluid restrictions

 . Poststreptococcal glomerulonephritis occurs as a result of:

a. antigens directly attacking the nephrons
b. deposit of antigen-antibody / complement complexes
along the glomerular membrane
c. exotoxins released from streptococcal organisms
d. an anaphylactic reaction to penicillin

Acute glomerulonephritis may follow an immunologic

reaction such as:
a. streptococcal infections
c. fungal infections
b. rheumatoid arthritis d. viral infections

The edema that occurs in nephrotic syndrome is caused by:

a. increased hydrostatic pressure in the arteries due to
sodium excess
b. increased colloidal pressure due to increased serum
albumin
c. decreased colloidal osmotic pressure due to loss of
serum albumin
d. decreased aldosterone secretion due to adrenal disease

FLUID AND ELECTROLYTES

Body fluids
ICF 70% ECF 30%
IVC 25% and IC 5%

internal regulation of body water and

electrolytes
sodium
potassium
hydrogen ion
calcium

DEHYDRATION
Signs
thirst
weight loss
elevated temperature
warm flushed dry skin and dry mucosa
soft sunken eyeballs
tachycardia with low BP
altered LOC

WATER INTOXICATION
Changes in mental status
sudden weight gain
peripheral edema
low serum sodium (dilutional
hyponatremia)

ELECTROLYTE
IMBALANCE
Hyponatremia vs. hypernatremia
hypokalemia vs. hyperkalemia
hypocalcemia vs. hypercalcemia
hypomagnesemia vs.
hypermagnesemia

ACID-BASE BALANCE
pH of the blood
buffer systems
chemical regulation
respiratory regulation
renal regulation

diagnostic : ABG analysis

HCO3 : H2CO3 20:1

pH
pCO2
HCO3

7.48
37
30

pH
pCO2
HCO3

7.5
30
24

pH
pCO2
HCO3

7.28
50
23

pH
pCO2
HCO

7.37
36
25