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Adult 1 NUR 3171 Final Exam Resource
I. Renal & Genitourinary Disorders
Urinary Tract Conditions
Cystitis (Urinary Tract Infection - UTI) Discharge Teaching: Encourage frequent urination to prevent stasis. Advise adequate fluid intake (e.g., 2-3 liters per day) unless contraindicated. Instruct on proper perineal hygiene (wipe front to back). Recommend avoiding irritants like bubble baths, harsh soaps, and douches. Explain the importance of completing the full course of antibiotics as prescribed. Educate on signs and symptoms of recurrence or complications (e.g., fever, flank pain, cloudy/foul-smelling urine). UTI Risk Factors: Female gender (shorter urethra). Sexual activity (introduces bacteria). Certain types of birth control (diaphragms, spermicides). Menopause (decreased estrogen reduces vaginal flora). Urinary tract abnormalities (e.g., kidney stones, vesicoureteral reflux). Catheterization (indwelling or intermittent). Immunosuppression. Diabetes mellitus (glucosuria can promote bacterial growth). Incomplete bladder emptying. Benign Prostatic Hyperplasia (BPH) Early Signs: Urinary frequency (especially at night - nocturia). Urgency. Hesitancy in starting urination. Intermittency (stopping and starting stream). Straining to urinate. A feeling of incomplete bladder emptying. Dribbling at the end of urination.
Acute & Chronic Renal Failure
Acute Kidney Injury (AKI) Hyperkalemia (Elevated Potassium): Causes: Decreased renal excretion of potassium is the primary cause. Other contributing factors include tissue breakdown, metabolic acidosis, and certain medications. Manifestations: Neuromuscular: Muscle weakness, fatigue, paresthesias (tingling/numbness), flaccid paralysis. Cardiovascular: Irregular pulse, bradycardia, hypotension, cardiac arrest. Gastrointestinal: Nausea, vomiting, diarrhea. ECG Changes: Peaked T waves, widened QRS complex, flattened P waves, prolonged PR interval, eventually sine wave pattern leading to cardiac arrest. Management: Immediate (Stabilize Membrane): Calcium gluconate or calcium chloride (IV) to protect the myocardium. Shift Potassium Intracellularly: Insulin with dextrose (IV), sodium bicarbonate (IV), albuterol (nebulized). Remove Potassium from Body: Diuretics (if renal function allows), sodium polystyrene sulfonate (Kayexalate) (PO or rectal), hemodialysis. Dietary restrictions (low potassium). Chronic Renal Failure (CRF) / Chronic Kidney Disease (CKD) Complications: Fluid Volume Overload: Edema, hypertension, heart failure, pulmonary edema. Electrolyte Imbalances: Hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia. Metabolic Acidosis: Impaired acid excretion. Anemia: Decreased erythropoietin production. Uremia: Accumulation of nitrogenous waste products (BUN, creatinine) leading to nausea, vomiting, anorexia, pruritus, uremic encephalopathy. Bone Disease (Renal Osteodystrophy): Due to altered vitamin D metabolism and phosphate/calcium imbalance. Cardiovascular Disease: Hypertension, heart failure, atherosclerosis. End-Stage Kidney Disease (ESKD) The final stage of CKD where kidneys can no longer maintain life. Requires renal replacement therapy (dialysis or transplantation).
Appendicitis & Peritonitis Indicators Appendicitis: Early Signs: Periumbilical pain that migrates to the right lower quadrant (RLQ), anorexia, nausea, vomiting. Classic Signs: RLQ pain (McBurney's point), localized tenderness, rebound tenderness, guarding, fever, elevated WBC count. Rovsing's sign: Palpation of the LLQ causes pain in the RLQ. Psoas sign: Pain on passive extension of the right hip. Obturator sign: Pain on internal rotation of the flexed right hip. Peritonitis: Inflammation of the peritoneum, often a complication of a ruptured appendix or other perforated viscus. Indicators: Severe, diffuse abdominal pain; rigid, board-like abdomen; marked tenderness and guarding; rebound tenderness; absent bowel sounds (ileus); fever; tachycardia; hypotension (septic shock).
Upper GI Disorders
Hiatal Hernia Protrusion of a portion of the stomach upward through the diaphragm into the chest cavity. Discharge Teaching: Advise small, frequent meals. Avoid lying down immediately after eating. Elevate the head of the bed. Avoid foods that trigger heartburn (fatty foods, caffeine, alcohol, chocolate, spicy foods). Maintain a healthy weight. Avoid tight clothing around the abdomen. Instruct on medications (e.g., antacids, H2 blockers, PPIs). Gastroesophageal Reflux Disease (GERD) Backward flow of stomach contents into the esophagus. Discharge Teaching: Similar to hiatal hernia management. Eat meals 2-3 hours before bedtime. Avoid trigger foods. Maintain upright position after meals. Elevate head of bed. Weight management. Smoking cessation. Medication adherence.
Biliary & Pancreatic Disorders
Cholecystitis Inflammation of the gallbladder, usually caused by gallstones obstructing the cystic duct. Diet: Low-fat diet is crucial to reduce gallbladder stimulation. Avoid fried foods, fatty meats, rich sauces, and full-fat dairy. Post-cholecystectomy Care Care after surgical removal of the gallbladder. Key Considerations: Pain management. Wound care. Monitoring for complications (e.g., bile leak, infection, atelectasis, DVT). Dietary adjustments: Initially a clear liquid diet, advancing as tolerated. Gradually reintroduce fats, but some individuals may need to limit them long-term. May experience temporary diarrhea. Cholelithiasis (Gallstones) Pain Characteristics: Sudden onset, severe, often described as a "gallbladder attack." Typically located in the right upper quadrant (RUQ) or epigastric area, may radiate to the right shoulder or back. Often occurs after a fatty meal. Lasts minutes to hours. Associated with nausea and vomiting.
Cancer Risk
Gastric Cancer Risk Factors: Helicobacter pylori infection. Diet high in salted, smoked, or pickled foods and low in fruits/vegetables. Pernicious anemia. Chronic atrophic gastritis. Family history of gastric cancer. Certain blood types (Type A). Smoking. Alcohol consumption.
HIV/AIDS
CD4+ T-cell Count Interpretation and Infection Risk: CD4+ T-cells: A type of white blood cell that plays a crucial role in the immune system. HIV primarily attacks these cells. Normal Range: Typically 500-1500 cells/mm³. Interpretation: The CD4 count is a key indicator of immune system function and the progression of HIV. High CD4 Count (e.g., >500 cells/mm³): Generally indicates a strong immune system with lower risk of opportunistic infections. Moderate CD4 Count (e.g., 200-500 cells/mm³): Immune system is weakening; risk of certain infections increases. Low CD4 Count (e.g., <200 cells/mm³): Indicates severe immune deficiency (AIDS diagnosis). High risk for opportunistic infections (e.g., Pneumocystis jirovecii pneumonia (PCP), candidiasis, toxoplasmosis). Infection Risk: The lower the CD4 count, the higher the risk of developing serious opportunistic infections that a healthy immune system would normally fight off. IV. Fluid, Electrolyte & Acid-Base Balance
Fluid Volume Excess (FVE)
Manifestations: Weight Gain: Sudden onset, significant gain over a short period (e.g., 1 kg ≈ 2.2 lbs). Edema: Peripheral edema (ankles, legs, sacrum), potentially generalized (anasarca). Cardiovascular: Increased blood pressure, bounding pulse, distended neck veins (JVD), elevated central venous pressure (CVP). Respiratory: Dyspnea, crackles in lungs (pulmonary edema), orthopnea, cough. Gastrointestinal: Ascites. Neurological: Headache, confusion, lethargy.
Hypercalcemia (Elevated Calcium)
Safety Nursing Actions: Fall Prevention: Calcium affects neuromuscular excitability. Patients are at risk for weakness and fractures. Ensure a safe environment, use assist devices, keep call light within reach. Hydration: Encourage increased fluid intake (e.g., 3-4 liters/day) to promote calcium excretion and prevent kidney stones. Saline infusions may be ordered. Dietary Modifications: Limit intake of calcium-rich foods and vitamin D. Monitoring: Monitor vital signs, intake and output, and neurological status. Assess for signs of constipation and kidney stones. Medications: Administer prescribed medications like calcitonin or bisphosphonates to lower calcium levels. Loop diuretics may be used to increase calcium excretion (monitor for dehydration and electrolyte imbalances).
Acidosis
Indicators and Arterial Blood Gas (ABG) Interpretation: Metabolic Acidosis: Causes: Diabetic ketoacidosis (DKA), lactic acidosis, renal failure, severe diarrhea, salicylate poisoning. Indicators: Kussmaul respirations (deep, rapid breathing) to blow off CO₂, headache, confusion, lethargy, nausea, vomiting, decreased cardiac output. ABG Interpretation: Low pH (<7.35), low bicarbonate ( < 22 mEq/L). PaCO₂ may be low due to compensatory hyperventilation. Respiratory Acidosis: Causes: Hypoventilation due to respiratory depression (opioids, sedatives), lung disease (COPD, pneumonia, ARDS), airway obstruction, chest trauma. Indicators: Shallow respirations, shortness of breath, headache, confusion, drowsiness, coma. ABG Interpretation: Low pH (<7.35), high PaCO₂ (>45 mmHg). HCO₃⁻ may be normal initially or elevated if chronic compensation occurs. ABG Interpretation Steps:
- Assess pH: Is it acidic (<7.35), alkaline (>7.45), or normal (7.35-7.45)?
- Assess PaCO ₂ : Is it high (>45 mmHg), low (<35 mmHg), or normal (35-45 mmHg)? This represents the respiratory component.
- Assess HCO ₃⁻ : Is it high (>26 mEq/L), low (<22 mEq/L), or normal (22-26 mEq/L)? This represents the metabolic component. HCO 3 −
Causes of Hypoglycemia (Low Blood Glucose): Too much insulin or oral hypoglycemic agents. Skipping or delaying meals. Insufficient food intake. Increased physical activity without adequate carbohydrate intake. Alcohol consumption (especially on an empty stomach).
Thyroid Disorders
Thyrotoxicosis (Hyperthyroidism) Priorities: Decrease Stimulation: Rest, quiet environment, reduce stimuli to prevent exacerbation of symptoms like tachycardia and anxiety. Manage Hyperthermia: Monitor temperature, provide cooling blankets, administer antipyretics as needed. High fever can indicate thyroid storm. Support Cardiovascular Function: Monitor heart rate and rhythm, blood pressure. Administer beta-blockers (e.g., propranolol) as prescribed to reduce heart rate and tremors. Nutritional Support: Provide adequate calories and protein to meet increased metabolic demands, but avoid stimulants like caffeine. Medication Management: Administer antithyroid medications (e.g., methimazole, propylthiouracil) as prescribed. Radioactive iodine therapy or thyroidectomy may be planned. Patient Education: Explain disease process, medication effects/side effects, importance of follow-up.
Pituitary Disorders
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Excessive secretion of ADH, leading to water reabsorption by the kidneys and dilution of serum sodium. Manifestations: Hyponatremia, decreased urine output, concentrated urine, edema (less common), neurological symptoms (headache, confusion, lethargy, seizures, coma) due to cerebral edema. Sodium Correction Safety: Goal: Gradual correction of hyponatremia to prevent osmotic demyelination syndrome (ODS), also known as central pontine myelinolysis. Rate of Correction: Typically aim for an increase of no more than 6-10 mEq/L in the first 24 hours, and avoid correcting too rapidly (e.g., >0.5-1 mEq/L per hour). Monitoring: Frequent monitoring of serum sodium levels is critical. Monitor neurological status closely. Interventions: Fluid restriction is the primary treatment. Diuretics (e.g., furosemide) may be used to promote water excretion. Hypertonic saline (e.g., 3% NaCl) is used cautiously for severe symptomatic hyponatremia, administered slowly with close monitoring.
VII. Oncology & Palliative Care
Cancer Prevention
Skin Cancer Education: Risk Factors: Excessive sun exposure (UV radiation), tanning beds, fair skin, history of sunburns, numerous moles, family history, weakened immune system. Prevention Strategies: Limit sun exposure, especially during peak hours (10 am - 4 pm). Use broad-spectrum sunscreen with SPF 30 or higher daily. Wear protective clothing (long sleeves, pants, wide-brimmed hats). Wear UV-blocking sunglasses. Avoid tanning beds and sunlamps. Perform regular self-examinations of the skin (monthly). Seek professional skin exams regularly, especially if high-risk. Early Detection: Teach the ABCDEs of melanoma: A symmetry: One half does not match the other. B order: Irregular, scalloped, or poorly defined borders. C olor: Varied colors within the same mole (shades of tan, brown, black, sometimes white, red, or blue). D iameter: Larger than 6 mm (about the size of a pencil eraser), although melanomas can be smaller. E volving: Any change in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting.
Hospice Philosophy & Palliative Symptom Management
Hospice Philosophy: Focuses on comfort, quality of life, and dignity for patients with a life-limiting illness, typically with a prognosis of 6 months or less if the disease runs its natural course. Emphasizes symptom management (pain, nausea, dyspnea, anxiety) and psychosocial/spiritual support for the patient and family. Care is provided in various settings (home, inpatient hospice units, skilled nursing facilities). Team approach involving physicians, nurses, social workers, chaplains, aides, volunteers.
Palliative Symptom Management: Goal: To prevent and relieve suffering and support the best possible quality of life for patients and families facing life-threatening illness, regardless of prognosis. Key Symptoms Addressed: Pain: Pharmacological (opioids, NSAIDs, adjuvants), non-pharmacological (positioning, relaxation, distraction). Dyspnea (Shortness of Breath): Opioids (low dose), benzodiazepines, oxygen, fan blowing on face, positioning, energy conservation. Nausea/Vomiting: Antiemetics, dietary adjustments, avoiding strong odors. Anxiety/Agitation: Anxiolytics, environmental modifications, therapeutic communication. Constipation/Diarrhea: Stool softeners, laxatives, antidiarrheals, dietary changes. Fatigue: Energy conservation, activity pacing, addressing underlying causes. Loss of Appetite: Small, frequent meals; nutritional supplements; addressing underlying causes of nausea/discomfort. VIII. Nutrition
Fat-Soluble Vitamins
Properties: Vitamins A, D, E, and K. Absorbed in the small intestine along with dietary fats. Can be stored in the body, primarily in the liver and adipose tissue. Toxicity can occur due to excessive intake and storage. Vitamin A: Vision, immune function, cell growth, skin health. Sources: Liver, fish oils, dairy products, orange/yellow fruits and vegetables (beta-carotene). Vitamin D: Calcium and phosphorus absorption, bone health, immune function. Sources: Sunlight exposure, fatty fish, fortified dairy products. Vitamin E: Antioxidant, protects cell membranes. Sources: Vegetable oils, nuts, seeds, green leafy vegetables. Vitamin K: Blood clotting, bone metabolism. Sources: Green leafy vegetables, vegetable oils.
Medication Review: Purpose: To identify medications that may interact with anesthesia, affect hemostasis, or require adjustment/discontinuation before surgery. Key Classes to Review: Anticoagulants/Antiplatelets: (e.g., warfarin, aspirin, clopidogrel) - Risk of bleeding. Often stopped several days prior. Antihypertensives: (e.g., beta-blockers, calcium channel blockers) - May need to be continued to manage blood pressure during and after surgery. Diuretics: May affect fluid and electrolyte balance. Insulin/Oral Hypoglycemics: Blood glucose control is critical perioperatively. Herbal Supplements: Many can affect coagulation or interact with anesthesia (e.g., Ginkgo, Ginseng, Garlic). Corticosteroids: May need to be continued or tapered to prevent adrenal insufficiency. X. Chronic Illness Management Definition and Characteristics of Chronic Conditions: Definition: A long-lasting condition that generally cannot be cured completely but can be managed effectively. It often requires ongoing medical attention and significantly impacts daily life. Characteristics: Persist over time: Lasting months, years, or a lifetime. Slow onset: Often develop gradually. Non-communicable: Typically not passed from person to person (though some have genetic components). Progressive: May worsen over time if not managed. Require ongoing management: Involve lifestyle changes, medication, regular monitoring. Impact on quality of life: Can affect physical, emotional, social, and economic well- being. Associated with risk factors: Often linked to lifestyle choices (diet, exercise, smoking) or genetic predisposition. Examples: Diabetes, heart disease, COPD, arthritis, cancer, chronic kidney disease, HIV/AIDS.
XI. Delegation & Prioritization
RN Delegation to Unlicensed Assistive Personnel (UAP)
Key Principles: The RN is always accountable for the outcomes of delegated tasks. Delegation must consider client stability, task complexity, predictability of outcome, and state Nurse Practice Act/facility policy. UAPs can perform tasks that are routine, non-invasive, have predictable outcomes, and do not require nursing judgment. Appropriate UAP Tasks: Activities of Daily Living (ADLs): Bathing, toileting, feeding (unless swallowing precautions), linen changes, repositioning. Basic Measurements & Monitoring: Vital signs (stable patients), daily weights, intake/output recording, observing and reporting changes (not interpreting). Mobility & Safety: Ambulating stable clients, assisting with transfers, fall prevention. Basic Comfort & Hygiene: Perineal care, oral care, emptying urinary drainage bags. Tasks NOT Appropriate for UAP Delegation: Patient assessment, evaluation of responses, client education, medication administration (generally), sterile procedures.
RN Delegation to LPN and Client Assignments
Key Principles: LPNs can perform tasks within established care plans, requiring technical skill but limited judgment, for stable or predictable patients. The RN develops and modifies the plan of care and performs initial assessments. Appropriate LPN Tasks: Monitoring & Data Collection: Collecting focused data (e.g., pain score, wound appearance), monitoring vital signs (stable clients), reporting findings to RN. Medication Administration: Oral, topical, subcutaneous, intramuscular; IV medications per facility policy (often excluding IV push). Treatments & Procedures: Wound care, ostomy care, urinary catheter insertion/removal (if trained), NG tube care/feedings. Reinforcement of Teaching: Reinforcing education previously provided by the RN. Tasks NOT Appropriate for LPN Delegation: Initial admission assessments, care plan development/revision, comprehensive patient education, triage, blood product verification/initiation (in most settings).
