Medsurg Test 4

Urine specific gravity: 1.005-1.030

SIADH (Syndrome of inappropriate antidiuretic hormone): Hyperfunctioning of the posterior pituitary

glad where excess ADH is released, causing retention of fluid in the intravascular system.

Causes: trauma, stroke, drugs, tumors, stress

S/S: HEADACHE is first thing that client will complain about before having a seizure.

 Hyponatremia below 135

 Fluid volume overload
 Change in LOC and mental status
 Weight gain without edema
 Hypertension
 Tachycardia
 Anorexia, nausea, vomiting
 Low urinary output and concentrated urine

Interventions: Seizure precautions!

 Monitor vital signs and cardiac and neurological status

 Provide safety because client is prone to seizures
 Monitor for signs of increased intracranial pressure
 Implement seizure precautions
 Monitor intake and output and obtain daily weight
 Monitor fluid and electrolyte balance
 Monitor serum and urine osmolality
 Administer sodium plus diuretics (No IV or drinking+IV3% Saline+Eat salt)
 Restrict fluid intake as prescribed

DI (diabetes insipidus): Hyposecretion of ADH where the kidney tubules fail to reabsorb water.

S/S:

 Hypernatremia above 145

 Dilute urine (Low USG below 1.005)
 Polydipsia
 Dehydration (decreased skin turgor and dry mucous membranes)
 Inability to concentrate urine
 Fatigue
 Muscle pain and weakness
 HEADACHE
 Hypotension
 Tachycardia

Interventions:
  Monitor vital signs and clients neurological and cardiovascular status
 Provide a safe environment due to postural hypotension
 Monitor electrolyte levels and signs of dehydration
 Monitor intake and output, weight, serum osmolality, and diluted USG (below 1.005)
 Avoid foods or liquids that produce diuresis LOW SALT DIET
 Desmopressin

Hypopituitarism: Hyposecretion of one or more pituitary hormones caused by tumors, trauma,

encephalitis, autoimmunity or stroke.

Dwarfism due to lack of growth hormones.

S/S:

 Delayed development
 Delayed puberty
 Short stature
 Enlarged head
 Hunched back (scoliosis)
 Mild to moderate obesity
 Reduced cardiac output
 Fatigue, low BP

Interventions:

 Hormone replacement
 Encourage client to express feelings rt. Disturbed body image
 Provide emotional support to client and family

Hyperpituitarism: hypersecretion of growth hormone by the anterior pituitary glad in an adult primarily
caused by pituitary tumors.

S/S:

 Large hands and feet

 Thickening and protrusion of the jaw
 Arthritic changes and joint pain
 Visual disturbance
 Diaphoresis
 Oily, rough skin
 Organomegaly
 Hypertension, HF, atherosclerosis
 Dysphagia
 Deepening of the voice
 Hyperglycemia

Interventions:
  Pharmacological interventions to suppress GH or block action of GH.
 Prepare client for radiation of the pituitary gland.
 Provide medications for joint pain.
 Provide emotional support to the client and family.

Hypophysectomy: Removal of the pituitary tumor via craniotomy pr via sublabial transsphenoidal
approach (through the nose)

Complications include increased intracranial pressure, bleeding, meningitis, and hypopituitarism.

Postop interventions:

 Monitor vital signs, neurological status, and LOC.

 Elevate HOB
 Monitor for increased ICP.
 Avoid sneezing, coughing, and blowing the nose.
 Monitor for bleeding.
 Administer antibiotics, analgesics, and antipyretics as prescribed.
 Monitor for signs of DI and SIADH.

Adrenal gland disorders:

Addison’s disease: hyposecretion of adrenal cortex hormones (glucocorticoids, mineralocorticoids, and

androgen); autoimmune destruction is a common cause.

S/S:

 Lethargy, fatigue, and muscle weakness

 Gastrointestinal disturbances
 Weight loss
 Hypoglycemia, hyponatremia
 Hyperkalemia
 Postural hypotension
 Hyperpigmentation of the skin
 Alopecia

Interventions:

 Monitor BP, weight, and intake and output.

 Monitor WBC’s, blood glucose, and electrolyte levels.
 Administer glucocorticoids.
 Observe for Addisonian crisis caused by stress, infection, trauma, or surgery.

Client education: Cortisol injection for emergency

 Need for lifelong glucocorticoid replacement.

 Corticosteroid replacement needs to be increased during times of stress.
 Avoid strenuous exercise and stressful situations.
 Avoid over the counter medications.
  Avoid people with infections.
 Diet high in protein and carbohydrates, and sodium. Vitamin D and calcium to prevent
osteoporosis induced by corticosteroids.
 Don’t abruptly stop taking steroids (crisis)

Cushing’s disease and Cushing’s syndrome: hypersecretion of cortisol. Suppression of immune response

Causes: tumors in the lungs, pancreas, or GI tract, overuse of corticosteroids. High likelihood for
infection

S/S:

 Moon face, buffalo hump

 Obesity
 Hyperglycemia, hypernatremia
 Osteoporosis, prone to fractures due to increased cortisol
 Hypertension
 Fragile skin that easily bruises, stretch marks on abdomen and upper thighs.
 Generalized muscle wasting and weakness.

Interventions:

 Monitor BP.
 Monitor intake and output, weight.
 Monitor lab values, WBC, blood cell count, serum glucose, sodium, potassium, and calcium.
 Clients require lifelong glucocorticoid replacement following adrenalectomy.
 Prepare client for adrenalectomy if condition cannot be controlled.

7 S’s Steroid precautions:

S-swollen (water gain=weight gain) Report 1 lb in one day, 2-3lbs in 3 days

S-Sepsis (infections and illnesses) Low WBC Fever is PRIORITY

S-Sugar increased Hyperglycemia

S-Skinny Muscle and bones “Osteoporosis”

S-Sight (Cataract risk) refer to Optometrist.

Thyroid gland disorders:

S/S:

Hypothyroidism Hyperthyroidism
Lethargy, fatigue Irritability, agitation, mood swings
Weakness, muscle aches, paresthesia Nervousness and fine tremors of the hands
Intolerance to cold Heat intolerance
Dry skin and hair and loss of body hair (alopecia) Smooth, soft skin and hair
bradycardia Palpitations, cardiac dysrhythmias: tachy, AFIB
Constipation Diarrhea
 Generalized puffiness and edema around the Protruding eyeballs (exophthalmos)
eyes and face
Loss of memory diaphoresis
Cardiac enlargement, HF Hypertension
amenorrhea Goiter
Weight gain Weight loss
Hypothyroidism: decreased T3 and T4 hormones, increased TSH

Interventions:

 Monitor vital signs: Heart rate and rhythm.

 Administer levothyroxine, this is a life long treatment, no cure. Take in the morning, 1 hour
before eating on an empty stomach, no double doses, if missed, take ASAP, Never abruptly stop
taking meds, pregnancy safe
 Low-calorie, low-cholesterol, and low-fat saturated diet, daily exercise program-walking
 Monitor for constipation
 Avoid sedatives and opioid analgesics
 Monitor for symptoms of hyperthyroidism

Myxedema coma: Rare but emergent situation with persistent low thyroid production.

S/S:

 Bradycardia
 Hypotension
 Hypothermia
 Hypoglycemia
 Hyponatremia
 Respiratory failure
 Generalized edema
 Coma

Interventions:

 Maintain a patent airway, tracheostomy kit at bedside

 Institute aspiration precautions
 IV levothyroxine
 Monitor temperature, BP, change in mental status, electrolyte and glucose levels
 No use of electric blanket

Hyperthyroidism: Decreased T3 and T4, elevated TSH

Interventions:

 Provide adequate rest

 High-calorie, high protein diet with frequent small meals (4000-5000 per day)
 No fiber, caffeine, or spicy food
 Administer Beta blockers, SSKI, PTU-safe for baby, Methimazole-not baby safe
  Radioactive iodine

Thyroid storm: Life threatening, emergency situation with uncontrollable hyperthyroidism.

S/S:

 Elevated temperature
 Tachycardia
 Systolic hypertension
 Nausea, vomiting, diarrhea
 Delirium and coma

Interventions:

 Maintain a patent airway.

 Monitor vital signs.
 Monitor for cardiac dysrhythmias.
 Use a cooling blanket to decrease temperature.
 Administer thyroid medication.

RAIU-Radioactive Iodine uptake- up to 7 days they remain radioactive. Stays in the blood for up to
72hrs.

Before After AVOID everything

Negative pregnancy test No pregnant people
Remove neck jewelry and dentures No crowds
5-7 days before hold antithyroid medication Don’t use the same restroom as others (flushx3)
AWAKE-no anesthesia or conscious sedation Don’t share food utensils
NPO: 2-4 hours before+1-2 hours after Don’t do laundry with others
Parathyroid Gland disorders:

Hypoparathyroidism: hyposecretion of parathyroid hormone by the parathyroid gland.

S/S: hypocalcemia and hyperphosphatemia

 Numbness and tingling around the mouth

 Positive Trousseu’s sign and Chvostek’s sign
 Hypotension

Interventions:

 Initiate seizure precautions

 Administer calcium supplements
 Vitamin D to help absorb calcium

Hyperparathyroidism: Hypersecretion of PTH by the parathyroid gland

S/S: hypercalcemia and hypophosphatemia

 Renal stones
 Constipation
  Fatigue and muscle weakness

Interventions:

 Monitor for cardiac dysrhythmia.

 Monitor intake and output for renal stones.
 Move client slowly and carefully.
 Encourage fluid intake.
 Prepare for parathyroidectomy if needed.

PCC (Pheochromocytoma): Catecholamine producing tumor found in the adrenal medulla. Excessive
amounts of epinephrine and norepinephrine are secreted.

Diagnostic test is a24 hour urine collection.

Surgical removal of adrenal gland is the primary treatment.

Complications: Hypertensive crisis, heart failure, dysrhythmia, MI, increased platelet aggregation, and
stroke. Death can occur.

S/S:

 Hypertension
 Severe headache
 Palpitations
 Pain in the chest and abdomen
 Hyperglycemia
 Diaphoresis

Interventions:

 Monitor vital signs especially BP and HR

 Don’t smoke, avoid caffeine, change positions slowly
 A-adrenergic blockers, Beta blockers
 Diet high in calories, vitamins, and minerals
 Prepare client for adrenalectomy
 DON’T palpate abdomen to avoid hypertensive crisis!

Diabetes Mellitus: Chronic disorder of impaired carbohydrate, protein, and lipid metabolism caused by
deficiency of insulin.

Type 1: Absolute deficiency of insulin. Primary beta cell destruction.

Type 2: Lack of insulin or resistance to the action of insulin.

Metformin: kidney and liver damage. Weight gain.

Glipizide and glyburide: Heart problems, weight gain. Avoid alcohol: SULFA drugs.

Retinopathy-reduce risk for falls.

 Hypoglycemia S/S Hyperglycemia S/S
Mild: Nervousness, irritability, sweating, Polyuria, polydipsia, polyphagia: type 1
tachycardia, tremors, hunger
Moderate: Confusion, double vision, drowsiness, Weight loss: common with type 1
headache, impaired coordination, inability to
concentrate, light-headedness, slurred speech,
numbness of lips and tongue
Severe: Difficulty arousing, disoriented behavior, Blurred vision
loss of consciousness, seizure
Slow wound healing
Weakness and paresthesia
Inadequate circulation to the feet
Hypoglycemia: blood glucose falls below 70mg/dL

Priority interventions: Assess blood glucose levels if available.

 Give 15g of carbohydrates such as ½ cup of fruit juice or 15g of glucose gel.
 Recheck glucose levels Q15minutes. If still below 70mg/dL give another 15g of simple
carbohydrate.
 If still below after 15 minutes give another 15g of simple carbohydrate.
 If after another 15 minutes still below 70mg/dL give IV 50% dextrose
 After levels have been recovered give a complex carbohydrate snack and protein.

DKA: Glucose level above 300 HHS: Glucose level above 800
S/S: Kussmaul’s respirations, fruity breath, S/S: altered CNS function with neurological
nausea, abdominal pain, dehydration and symptoms.
electrolyte loss, polyuria, polydipsia, weight loss, Dehydration/electrolyte loss
dry skin, sunken eyes, soft eyeballs, lethargy,
coma
Interventions: IV fluids 0.9% normal saline Interventions : IV fluids 0.9% normal saline
Regular insulin IV Regular insulin IV
Cardiac monitoring due to potassium levels.
Administer potassium IV in a dilated solution
Monitor client for ICP

Hypothermia: below 95 degrees-core temperatures. Rectal temp check. Vasoconstriction.

S/S: wheezing, crackles, weak pulses.

Interventions: Attach client to cardiac monitor

Anticipate defibrillation due to V fib.

2 large IV’s

Airway: mechanical ventilation

Circulation: Cardiac monitor, defib

Then start warming process.

Remove wet clothes, put on dry clothes.

Warm core of the body first, warm IV fluids, cover with blankets: head and trunk.

Frostbite: Tissues in the body freeze. Ice in the veins: ice crystals. Venostasis. Vasoconstriction, blue skin,
waxy yellow.

Deep frostbite: white skin resulting in amputation.

Interventions:

 Warm water soak in a whirlpool for 30 minutes.

 Elevate extremity.
 Provide analgesic pain medication,
 No pressure to the sight, no massaging or rubbing.
 No occlusive dressing on the wounds. Want them open to air with a loose sterile dressing.

Hyperthermia: body’s temp higher than normal. Body cant get rid of enough heat. Get out of the
element and elevate the legs to promote core temperature increase. Remove clothing, ice to axilla,
groin, and neck area to cool down core temperature.

Interventions:

 Maintain a patent airway.

 Initiate seizure precautions
 Monitor I&O and monitor skin and mucous membranes for signs of dehydration.
 Monitor lung sounds, dysrhythmia, check peripheral pulses for systemic blood flow.
 Induce normothermia with IV fluids, cool baths, fans, or a hypothermia blanket.
 Prevent shivering which will increase ICP and O2 consumption.
 Administer acetaminophen for fever.

Rhabdomyolysis: Breakdown of skeletal muscle due to direct or indirect muscle injury.

 S/S: Muscle pain in the shoulders, thighs, or lower back

 Muscle weakness or trouble moving arms and legs.
 Dark red or brown urine or decreased urination: myoglobinuria
 Some cases may show no muscle-related symptoms.

Interventions:

Hemodialysis: Cleansing of the patients blood due to loss of kidney function. Cleanses the blood of
accumulated waste products, removes byproducts of protein metabolism such as urea, creatinine and uric
acid from the blood, removes excess body fluids, maintains or restores the buffer system of the body, and
maintains or restores electrolyte levels in the body.
Interventions: Monitor for infection, bleeding and “feel a thrill” with a stethoscope
 Monitor the clients’ vital signs before, during and after dialysis.
 Weigh the client before and after dialysis to determine fluid loss.
 Withhold antihypertensives and other meds that can affect the BP until after dialysis treatment.
 Also withhold meds that could be removed by dialysis: water soluble vitamins, digoxin, and
antibiotics.
Internal fistula: Takes 4-6 weeks to mature. Educate client to use “ball squeezing” to help mature the
fistula.
No restrictive clothing, don’t lift more than 5lbs, no sleeping on the arm, no BP in arm and no creams or
lotions.
Pitting edema is a normal finding.

Peritoneal dialysis: Accessed by insertion of a PD catheter through the abdomen.

Interventions prior to: STERILE TECHNIQUE IS USED.
Obtain weight
Monitor vital signs.
Monitor glucose and electrolyte levels.
During: Greatest risk is infection that can lead to peritonitis
Key things to report are tachycardia, fever and cloudy drainage.
DEADLY PRIORITY:
CRACKLES IN THE LUNGS
RAPID RESPIRATIONS
DYSPNEA
PRIORITY INTERVENTION: FIRST ACTION IS THE RAISE THE HEAD OF THE BED.
Monitor for respiratory distress, pain or discomfort.
Monitor for signs of pulmonary edema.

Pyelonephritis: Inflammation of the kidney secondary to an invasion of bacteria. (UTI)

S/S:
 Fever, chills
 Flank pain on affected side
 Costovertebral angle tenderness
 Headache
 Dysuria
 Increased WBC in the urine
Interventions:
Monitor vital signs especially temperature
Encourage fluid intake up to 3000ml/day to prevent dehydration and reduce fever
Monitor intake and output
Monitor weight
High-calorie, low-protein diet
Provide warm, moist compress to the flank area to alleviate pain
Administer Analgesics, antipyretics, antibiotics

Glomerulonephritis: Inflammatory injury in the glomerulus, mostly caused by strep throat.

S/S:
 Periorbital edema, facial edema most prominent in the morning
 Anorexia
 Decreased urine output
 Cloudy, smoky, brown colored urine (hematuria)
 Lethargy
 Hypertension
 Increased BUN and Creatinine

Interventions:
 Monitor vital signs, daily weight, intake and output, characteristics of urine.
 Daily weight at the same time each day
 Sodium restrictions
 Administer diuretics for extreme edema, and Antibiotics.
 Initiate seizure precautions
Benign Prostatic Hypertrophy: slow enlargement of the prostate gland with hypertrophy and hyperplasia
of normal tissue
S/S:
 Diminished size and force of urinary stream
 Urinary urgency and frequency
 Nocturia
 Hesitancy to continue a urinary stream.
 Urinary retention and bladder distention
Interventions:
 Encourage fluid intake up to 2000ml/day-3000ml/day.
 Prepare for urinary catherization to drain the bladder and prevent distention.
 Avoid anticholinergics, antihistamines, decongestants, and antidepressants.
 Instruct client to avoid caffeine and artificial sweeteners and limit spicy or acidic foods.
 Instruct client to follow a voiding schedule.
 Prepare client for surgery if needed.
Postoperative interventions:
 Monitor intake and output for hemorrhage or clots
 Monitor for arterial bleeding as evidenced by bright red urine with clots.
 Monitor for venous bleeding as evidenced by burgundy-colored urine.
 Monitor hemoglobin and hematocrit levels
 Expect red to light pink urine for 24 hours turning to amber in 3 days.