Week 2 Day 1

Assessment of the Urinary System

 Pain caused by stone passing through Ureter.

 Kidney control BP and produce erythropoietin produces Vitamin D and regulates acid balance.
 Check creatinine, urea, BUN.
 Creatinine tells you specifically about kidney function and if you are in kidney failure
 NEPHRON is the functional unit of the kidney
o Glomerulus
o Bowman’s capsule
o Tubular System
 CHECK GFR for kidney function or someone who is sick
o Normal value 125ml
 Renal artery arises from the aorta
 Urine formation
o Antidiuretic Hormone (ADH)
 Important in water balance
 Regulated by pituitary gland
 Too much secretion causes Diabetes Insipidus with polyuria
o Aldosterone
 Reabsorption of sodium and water (regulates water and electrolytes and BP)
 Released from the adrenal cortex
o Erythropoietin
o BP regulation
 Renin is secreted
o Posterior-
 Ureters
o Join at the renal pelvis
 Bladder
o Capacity 600-1000mL
 Urethra
o Controls voiding and serve as a conduit for urine
o 1-2in in females
o 8-10in males
 Aging can cause:
o decreased renal blood flow
o altered hormonal levels
o loss of elasticity and muscle support
o prostate enlargement
 Diagnostic Studies
o Urinalysis- first morning void
o Creatinine clearance
 24hr urine specimen
 o Urodynamics
 Measures urinary tract function
o Cytoscopic- checking the bladder

Week 2 Day 2

Chronic Kidney Disease

 Irreversible loss of kidney function

 Kidney damage such as pathologic abnormalities and check GFR for 60ml or less for longer than
3 months
 Leading causes
o Diabetes
o Hypertension
 Check creatinine and gfr for kidney function
 Last stage of kidney failure
o End stage renal disease GFR will be 15

Stages of CKD

o Stage 1- GFR less than 90

 Diagnosis and treatment
o Stage 2- kidney damage GFR 60-89
 Estimation of progression
o Stage 3a- GFR 45-59
 Evaluate complication and treatment
o 3b- 30-44
o 15-29 prep for kidney transplant and dialysis
o Less than 15 or dialysis

Signs and symptoms

 Check BUN, Urea, creatinine GFR

 Check electrolytes like sodium, potassium
 Uremia
o White patches on hands when sodium isn’t excreted
 As CKD progresses patients will h0,6-1l.ave increased fluid retention
 Poor cardiac perfusion, poor renal function
 As GFR decreases, serum creatinine and bun increase
 BUN- 6-24
 Creatinine 0.6-1.2
 Calcium, phosphate, magnesium alterations
 Metabolic acidosis
 Anemia- hemodialysis
 Increased risk of infection, increased glucose levels
 Kussmaul respirations
  -prils protect kidneys (hold in AKI)

Dialysis

1. Peritoneal Dialysis
a. Obtained by a catheter through anterior abdominal wall
b. When uremia can no longer be treated
c. When they do not want a transplant or cant have one
d. Feeling of bladder is full and cannot pass urine
e. Always assess blood pressure before during and after and weight
f. Three phases
i. Inflow (fill)- prescribed about of solution over 10 minutes, after infusion close
the clamp
ii. Dwell (equilibration)- duration varies
iii. Drain- last 15-30 mins
g. Called an exchange
h. Client should be on high protein diet
2. Hemodialysis
 Obtaining vascular access is one of the most difficult problems
o Arteriovenous fistulas and grafts
o Temporary vascular access
 Two needles, one to pull blood from circulation into pump to dialyzer to another drain back
to the body
 If the patient is allergic to heparin, they can get alteplase instead
 Then flush with saline to return blood, remove needles, hold firm pressure.
 Before: check fluid status, vascular access and temperature and weight
 During check the vital signs every 30 mins
 Complication; hypotension, muscle cramps, hep C, electrolyte imbalance
a. More notes
b. Assess bp and electrolytes
c. Patients who cant tolerate- cardiac issues
d. Never use iv access for administering meds
e. On palpation- thrill
f. Auscultation- a bruit

Kidney Transplant

 Correct and heart issues or gallbladder issues

 Other organs need to function properly for renal perfusion
 Live donor need creatinine clearance, total protein
 Deceased donr

Week 3 Day 1

Assessment of Visual and Auditory Systems

 Head injuries- always check the pupil size and crania nerve damage (ears)
  Memorize cranial nerves and what they are associated with
o Vision- 2,3,4,6
o Ears- 8
 External structures include the eyebrows, eyelids, eyelashes, lacrimal system, conjunctiva, and
sclera. The cornea and extraocular muscles play an important role in vision.
 Internal structures include the iris, lens, ciliary body, choroid, and retina
 Optic nerve can be damaged if eye damage is sustained
 Refractive errors
o Myopia- nearsightedness
o Hyperopia- farsightedness
o Astigmatism- uneven curvature of cornea
o Presbyopia- loss of accommodation resulting in inability to focus on near objects
 Pupil- cranial nerves 5 and 3
 Retina- composed of
o Rods- vision in dim light
o Cones- receptive to color in bright light
 Normal ocular pressure 10-21
o Greater than 21= Glaucoma
 Ishihara color test- test to distinguish a pattern of color
 Stereopsis- judging the distance
 Diagnostic studies
o Refractometry
o Ultrasound
o Fluorescein angiography
o Amsler grid test- detect macular degeneration where central vision is lost
 3 bones inside ear (middle ear)
o Malleus
o Incus
o Stapes
 Vertigo- stimulated by movement of the head and feels like persons or objects around the
person are moving
 Dizziness- sensation of being off-balance
 Nystagmus- abnormal eye movement, twitching, or blurring of vision with head or eye
movement
 Confrontation Test- patient covers one eye and focuses on examiners face and counts the
number of finger the examiner brings in to the field of vison
 Glaucoma- peripheral vision loss
 Corneal light reflex- assess extraocular nerves
 Tuning fork- differentiating between conductive and sensorineural loss. (Rinne or Weber)

Chapter 21 Visual Problems

 Aphakia- absence of lens through birth or surgery

 Always address patient and not the caregiver with a patient with visual problems
 Inflammation and infection
o Chalazion- chronic inflammation of lid
o Stye- infection of sebaceous glands in the lid margin
 Blepharitis- bilateral inflammation of the lid margins
 Bacterial and Viral Keratitis
o Inflammation of cornea or infection- when both conjunctiva and cornea are involved
 Corneal ulcer- feel as though there is a foreign body in the eye
 Strabismus occurs when the eyes are unable to focus on an object, simultaneously causing the
complaint of double vision.
o May deviate in (esotropia), out (exotropia), up (hypertropia), or down (hypotropia)
o May be a result of thyroid disease, neuromuscular, retinal detachment, or cerebral
lesions
 Retinopathy- microvascular damage to the retina causing blurred and progressive vision loss
o Diabetic
o Hypertensive
 Signs and symptoms of retinal detachment
o Light flashes (photopsia)
o Floaters
o Painless loss of vison
 Age-Related Macular Degeneration- distorted central vision
o Risk factors- white ethnicity, family history, chronic inflammation conditions, smoking,
and hypertension, light colored eyes, females are effected more, prolonged sun
exposure
o Clinical manifestations- blurred and darkened vision, scotomas (blind spots),
metamorphopsia
o CENTRAL vision loss
o Early signs
 Cataracts
o Cloudy vision- opacity within the lens
o Risk factors
 Age
 Blunt trauma
 Congenital factors
 Radiation and UV light exposure
 Corticosteroid use
 Ocular inflammation
 Patient with diabetes mellitus tend to develop at a younger age
o Clinical manifestations
 Decrease in vision
 Abnormal color perceptipn
 Glaring of vision
o Diagnostic studies
o No non-surgical cure
 o Mydriatic eyedrops dilate pupils
o Phacoemulsification- dissolve clouded lens then suction out
o Patients can increase intraocular pressure after surgery
 Glaucoma- increased IOP, peripheral visual field loss, optic nerve atrophy
o Primary open-angle glaucoma
 Most common type- peripheral vision loss
 Drainage channels become clogged causing a reduction in outflow of aqueous
humor
 Can result in damage to the optic nerve
 22-32
 Treat with drugs, argon laser trabeculoplasty, trabeculectomy
o Acute angle-closured- closed angle
 Sudden onset, excruciating pain, nausea and vomiting, and colored halos around
light, blurred vision, red eyes
 IOP > 50
 Treat with miotics (for constriction), oral/iv hyperosmotic, laser peripheral
iridotomy, or surgical iridectomy
o Nursing Assessment
 Do not do anything that increase IOP
o PRACTICE QUESTIONS FOCUSING ON IOP
 Teaching
 Restrictions
 What they can and cannot do
 Assessment
 Medications
 Interventions
 Hearing Loss and Deafness
o Conductive- outer and middle ear and impairs the sound being conducted
o Sensorineural- impairment of the inner ear of CN 8
 Ototoxic drugs- Aspirin, NSAIDs, antibiotics, loop diuretics, chemo drugs
o Mixed hearing loss
o Sudden hearing loss
o 0-15 normal hearing
o Tinnitus- may be the first symptom of hearing loss
 Causes ringing in ears
 Caused by inner ear nerve damage
o Otosclerosis- most common cause of bilateral hearing loss in young adults
 Tympanum is reddish blush instead of grey
 Poor air conduction
o Presbycusis- hearing loss associated with aging
o Meniere’s Disease- tinnitus, fluctuating sensoneural, naseaua vomiting, pallor, and
sweating. Improper fluid drainage in the ear due to blockages.

WEEK 3 DAY 2
Assessment of Nervous System

 CNS
 PNS (ANS)
 Review lumbar puncture for finals

REVIEW ON Renal

Peritoneal

 Teaching
 Expectations
 What info
 How you would administer
 Complications
 Continuous ambulatory peritoneal dialysis
 High proteins

Cystoscopy

 Before during and after procedure

 Complications
 Symptoms after procedure

UTI

 Risk factors, signs and symptoms, discharge teachings, medications, interventions

 2 questions (SYMPTOMS FOR OLDER ADULTS

AKI

1. Lab changes, symptoms, oliguria, polyuria, normal gfr, normal urinary output, is it reversible

Kidney biopsy

1. Think about bleeding and checking labs. PT and INR

End Stage renal disease

1. Signs and symptoms, assessment, long turn interventions

Hemodialysis

1. Who cant and can do it, steps, lab values, complications, assessment after
2. Dialysis Disequilibrium Syndrome- happens after hemodialysis (a complication) caused by a rapid
decrease in fluid volume and decrease in BUN levels, sudden fluid volume deficit, change in urea
levels, patient will get cerebral edema and increased ICP.
1. Symptoms: severe headache, nausea and vomiting, restlessness, seizure, and coma
2. Keep medication- Phenytoin if patient experiences seizures- Dialysis Disequilibrium Syndrom
3. Know av graft and av fistula
CKD

1. Know S/S risk factors labs

Kidney Stones

Intravenous pyelogram- to see kidneys urethra and bladder. Patient should have hydration after
procedure

ONE ABG value to know about kidney disease

Cystitis- inflammation of bladder and how to prevent

Nephrotic syndrome- kidney condition where patients should be on low sodium diet due to HTN and
edema and have a high protein diet.

LOW PROTEIN IN EVERYTHING ELSE except peritoneal and nephrotic syndrome

EYES AND EARS REVIEW

1. Cataract surgery (4-5 questions focusing on IOP)

a. Laser
b. Advanced cataract
c. Discharge teaching
d. Concepts, advise patient about IOP
2. Glaucoma
a. Central and Peripheral Vision loss
i. Cannot gain vision back
ii. Start screening early
b. What teaching for those at risk
3. Meiniers disease (EARS)
a. Review case study
b. Symptoms and safety measures
4. Know signs and symptoms of cataract and glaucoma and when to repot to provider
5.

ENDOCRINE SYSTEM REVIEW

1. Addison’s Disease
a. Hormones are not produced so you ADD the hormones
b. Weight loss, muscle weakness, fatigue, low BP, darkening of the skin,
c. S/s
2. Thyroidectomy
a. Expect parathyroid removal as well which is rich in calcium
b. Check for chovsteks and troussaus
c. Closer to larynx check for laryngeal nerve damage (hoarsness, stridor)
3. Cushing Syndrome
a. Know S/S- moon face buffalo hump, purple stria in abdomen
4. Levothyroxine (Synthroid)
 a. What time you take
b. Teachings
c. Side effects, adverse effects
5. Insulin
a. Know table with onset, peak, duration, and types
6. Diabetes Mellitus
a. Know difference between the types
b. Complicaitons
c. How to identify symptoms of complications
7. Diabetes Insipidus
a. Polyuria
b. Comes from pituitary gland
c. Check urine specific gravity
8. Metformin
a. Side effects
b. Teachings
c. Action
d. Take with a meal- may cause hypoglycia
9. Hypo/Hyperthyroidism (assessment and interventions SATA)
a. Hypo= LOW(weight gain mood swing, constipated)
b. Know signs and symptoms
c. Hyper= HIGH ( increase in T3 and T4 low TSH), increased in appetite hr, diarrhea
d. Hyper-increased calcium and phosphate so bone density decreases at more risk for
fractures
e. Check lab values
f. Parathyroidism
g. Nutrition bn
h. Teachings
10. Thyroidtoxicosis
a. Thyroid storm
b. Huge release
c. Signs and symptoms
d. Adverse effects of hyperthyroidism (extreme tachycardia
11. Know complications of diabetes
12. Know lab values to check for thyroid
a. Check TSH FIRST- will tell if patient has graves disease, hyperthyroidism
13. Know dietary plans for
a. Cushings- limit sodium intake
b. Addisons- limit sodium intake
14. Glipizide
a. Actions
b. Side effects
c. Adverse effects
15. Addisonian Crisis
 a. Patient has no hormones
b. Always at risk for weight loss, muscle weakness, fatigue low BP
c. Always give IV
d. Key assessment- always check the patients weight.
16. NPH Insulin- Long acting insulin

Week 4 Day 2

Head injury

 Most common cause include falls and MVA

 Firearm, assaults, war

TBI

1. Twice as common in males

2. Death occurs at 3 points

Types of Head injuries

a. Scalp Laceration-blood loss and infection, external, scalp is highly vascular

b. Skull fracture- lineal, depress, simple, comminuted, compound, hematoma, infections
i. Look around eyes for raccoon eyes- Periorbital eccymosis
ii. Look behind ear for or nose for CSF leakage
c. GCS
d. Diffuse injury
i. Concussion- brief disruption in LOC
ii. Retrograde amnesia
iii. Headache
iv. Short duration
v. Postconcussion syndrome- persistent headache, lethargy, short term memory
changes, changes in intellectual abilitis
e. Diffuse Axonal injury
i. Decreased LOC, Increased ICP, decortication or decerebration
f. Focal Injury
g. Contusion- bruising of brain tissue
h. Coup-contrecoup

Cushing triad- decreased hr bp

Don’t do anything to increase ICP

Side lying with 30 degrees or less to decrease ICP

Posturinf

Where does hematomas happen

Nursing assessment: LOC, ICP symptoms, then condition, abg, urinary output, vital signs, mixed venous
oxygen saturation
Interventions- follow up with assessment interventions, check complications and mangae

CT is best, then evacuation procedures, ventriculostomy

Mannitol-

REVIEW CASE STUDIES

Abnormal Respiratory Patterns of Coma Chart- ICP ppt

Normal ICP level- 5-15

Normal CPP- 60-100

Early signs of ICP- deterioration of LOC

Late signs- Cushing’s striad

Optimize ICP and CPP- no ng tube, no sneezing, no straining, no suctioning, less than 30 degrees.
Medication

Don’t do lumbar puncture

Review ICP PowerPoint

HEADACHE ppt REVIEW

Seizures ppt

WEEK 5 DAY 1

Alzheimer’s Disease

1. Dementia
a. Vascular dementia

Inflammatory Brain Disorders

1. Meningitis will be on final

2. Assess fever, prevent dehydration caused by nausea and vomiting and high temperature
3. Start antibiotics based on patient blood culture
4. Perform blood culture after antibiotic to measure effectiveness
5. Viral Meningitis- spread through direct contact of respiratory secretions
a. Common cause- HIV, HSV, Enterovirus, Arbovirus
b. Presents as headache fever photophobia stiff neck
c. Kernig’s and Brudzinski’s
d. Diagnosis testing of CSF
e. Teat with antibiotics after obtaining diagnostic sample but before receiving test results
6. Encephalitis
a. Acute inflammation of brain
i. Sometime fatal, serious
ii. Tick and mosquitoes can transmit
 iii. Signs appear in 2 to 3 days
iv. Any CNS abnormality can occur
7. Myasthenia Gravis

Week 5 Day 2

Hepatitis

1. Inflammation of the liver

a. Viral or metabolic
2. Types
a. HAV- mild to acute liver failure, RNA virus transmitted via fecal oral route, contaminated
food or drinking water. Will see Anti-HAV IgM when infected. Will see Anti-HAV IgG
when recovering.
b. HBV- Acute or chronic. DNA virus transmitted- perinatally, percutaneously, and small
cuts exposed to infectious blood, blood products, or other body fluids. At risk: Patients
undergoing hemodialysis, men who have sex with men, household chronically infected,
transplant recipients.
c. HCV- acute is asymptomatic, chronic causes liver damage. RNA virus is transmitted
percutaneously through IV drug use, high-risk sexual behaviors, dialysis, blood
transfusions before 1992, perinatal exposure.
d. HDV (delta virus)- defective single stranded RNA, cannot survive on it own. Needs HBV
to replicate. Transmitted percutaneously. NO vaccine.
e. HEV- SAME AS HAV
3. Pathophysiology
a. Acute infection- large numbers of hepatocytes are destroyed, liver cells can regenerate
in normal form after resolution of infection
b. Chronic infection- can cause fibrosis and progress to cirrhosis
c. Systemic manifestations- REFER TO SLIDE
d. Clinical Manifestations
e. Signs and symptoms of jaundice
4. Complications
a. Too much iron
b. Ascites- accumulation of excess fluid in peritoneal cavity- Third spacing causing fluid
volume deficit
5. Diagnostic Studies- review grafts in ppt.
a. Liver function testst
b. Genotype testing
c. Physical assessment findings
d. If patient is at risk for bleeding, transjugular biopsy should be performed
e. Normal AST and ALT values- values will be abnormal
f. Check antibodies
6. Interprofessional care
a. Adequate nutrition, well balanced diet, rest, contact tracing
b. Chronicn HBV- prevent cirrhosis, portal hypertension, liver failure, cancer, GI bleeding.
7. Drug therapy- review slidxe
 a. Interferon (HBV)-

Cirrhosis of Liver

1. Common causes- chronic hep C, and alcohol induced liver disease