NRSE 3540 Exam Study Guides

Sepsis

1. Evaluate patients at risk for developing sepsis. Who is at risk?

a. Diabetics, cancer patients, immunocompromised, malnourished
(alcoholics), elderly, very young, those who have has an invasive
procedure
2. SIRS criteria (at least 2 of the following)
a. Abnormal WBC count >12,000 or <4,000
b. Normal WBC count with >10% bands
c. Heart rate >90 bpm
d. RR >20
e. Temperature >101 or <96.8
f. Also watch for decreased urine output and changes in mental
status 3. Stages of sepsis.
a. Early (SIRS)
i. Changes can be subtle
ii. Mild hypotension
iii. Decrease urine output
iv. Increased respiration rate and white blood cells
v. Inappropriate clotting (DIC)
vi. Hypodynamic (weak)
b. Severe
i. Improved BP and cardiac output
ii. Elevated heart rate
iii. Skin- pink and warm
iv. Mental status or behavioral changes
c. Septic shock (MODS)
i. Decreased blood pressure, cardiac output, and oxygen saturation
ii. Increased heart rate and respiration rate

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 iii. Decreased urine output iv.Temperature either too high or too low
v.Skin is cyanotic, pallor, clammy or mottled.
4. Assessment of patients with infection and sepsis.
a. Decreased BP, 02, urine, and CO
b. Increased HR and RR
c. Increased or decreased temperature
d. Inflammation
e. Inappropriate clotting
f. Erythema, pain, fever, skin changes
g. Elevated WBC or lactate levels
5. Patient education to prevent sepsis and infection.
a. Good wound care, know signs and symptoms of infection and sepsis,
good nutrition, exercise and rest.
6. Labs to assess for infection and sepsis.
a. Lactate, CBC (lactate), WBC, ABG, chest x-ray, urine output 8. Signs,
symptoms, assessment findings of patients with sepsis.
a. Increased or decreased temperature
b. Decreased urine, BP, CO and 02
c. Increased HR, RR
d. WBC >12,000 or <4,000
e. Mental changes
f. High lactate (>4).
g. Decreased perfusion to fingers and toes
h. Inappropriate clotting (DIC).
i. Hemodynamic (weak)
9. Sepsis guidelines for treatment.
a. First 3 hours:
i. Blood cultures, lactic acid level (hallmark for sepsis), administer
broad spectrum antibiotics, fluid challenge

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 b. Within 6 hours
i. Vasopressors given for hypotension resistant to fluid resuscitation
(maintain MAP greater than or equal to 60 mmHg), re-measure
lactate levels
10. Nursing interventions for sepsis and prioritization of interventions. When do you
call provider?
a. Administer oxygen, raise HOB, TCDB, call provider for further
orders 11. Discharge teaching for a patient at risk for sepsis.
a. Learn signs and symptoms of infection and sepsis, nutrition, exercise/rest,
wound care, good hygiene
11. Signs and symptoms of infection and sepsis.
a. Fever
b. Fatigue.
c. Inflammation
d. Erythema
e. Pain
f. Increased RR, HR, WBC and lactate levels
g. Decreased CO, BP, 02, and urine
h. Mental status changes

Respiratory

1. Identify assessment findings of the respiratory patient (ie, normal/abnormal lung

sounds, history).
a. Decreased oxygen, diminished or adventitious lung sounds, abnormal
heart rate and blood pressure, mental changes, history of smoking,
COPD, skin assessment
2. Know respiratory assessment methods/diagnostics.

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 a. Listen to heart and lung sounds, bronchoscopy, PFT, chest x-ray, CT
scan, 02 sat., skin assessment

3. Know patient prep, patient education, indications, nursing implications and

postprocedure care for the following:
a. Thoracentesis: needle aspiration of air or fluid from pleural space to
provide therapeutic relief or obtain specimen. Done at bedside. Local
anesthesia and pain medication. Sterile procedure. Need an additional
nurse. 1000 mL limit at one time to prevent re-expansion pulmonary
edema (swift change in pressure that draws fluid into the lung itself)
i. Pre
1. Explain procedure and obtain consent, gather supplies,
position patient upright supported on pillows or bedside table
ii. Intra
1. Make sure patient remain still, monitor vital signs, assist in
collecting specimen, measure amount of fluid removed and
record
iii. Post
1. Chest x-ray, pressure dressing, monitor VS and respiratory
status, auscultate lungs or reduced lung sounds, encourage
TCDB/IS, watch for mediastinal shift*
iv.Complications: bleeding, pneumothorax, infection
b. Bronchoscopy: used to look for airway obstruction and obtain samples for
biopsy or culture. Flexible can be done at bedside in an ICU and can be
inserted through endotracheal tube- moderate/conscious sedation. Rigid is
done in OR under general anesthesia
i. Pre
1. Informed consent, pre-procedural antibiotics (because
introducing foreign object), might get PT/INR, CBC. NPO 4-6
hours prior, remove dentures/prosthetics, may use topical

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 anesthetics (careful with benzocaine-methemoglobemia)
typically lidocaine to numb back of throat to prevent gagging.
ii. Intra
1. Position upright or supine, assist in collecting specimen, IV,
vitals,
02, respiratory status
iii. Post
1. Monitor VS and resp. status and cardiac status, monitor until
sedation wears off and gag reflex returns, VS x 15 min q 2
hours, LOC, complications- sore throat (gargle salt water,
lozenges) ABCgag reflex= airway.
iv. Complications: bleeding, infection, laryngospasms (voice box-
hoarseness), pneumothorax (puncture), aspiration
c. Lung biopsy: to diagnose inflammation, infection, cancer or lung disease.
Transbronchial biopsy (TBB), transbronchial needle aspiration (TBNA),
transthoracic needle aspiration (usually done in radiology using CT scan
to monitor), open lung biopsy- fluid or tissue specimen to send to labs----
trans means through or across
i. Pre
1. Explain procedure, informed consent, administer
preprocedural meds, NPO
2. Transthoracic: local anesthesia, pain meds, informed
consent
3. Transbronchial: same as bronchoscopy- NPO, informed
consent, any pre-op meds or labs
4. Open: general anesthesia, informed consent, NPO, pre-op
labs and med
ii. Intra

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 1. Percutaneous biopsy usually done in radiology (guided with
CT scan), transbronchial is probably the only one we will
assist with- usually patient comes back with chest tube
iii. Post
1. Obtain chest x-ray, CT scan to assess for pneumothorax,
monitor vitals, monitor respiratory status.
d. Pulmonary Function Test: assess lung function and breathing problems,
aides in diagnosing lung disease and guides management of existing lung
disease. Measures lung volume and capacities, flow rates, diffusion
capacity, gas exchange, resistance, ventilation- usually outpatient
i. Pre
1. No smoking 6-8 hours prior, no bronchodilators 4-6 hours
prior, explain procedure thoroughly to reduce anxiety
ii. Intra
1. Done at bedside or respiratory lab by
RT iii. Post
1. Assess for increased dyspnea and bronchospasms,
document any drugs given during procedure- monitor
respiratory status.

4. Know symptoms, assessment findings, diagnostics, treatment, nursing care,

patient education, medications, complications and safety considerations for the
following:
a. Pneumothorax (different types): air in pleural space. Assessment findings-
asymmetrical chest wall expansion, diminished lung sounds on side of
pneumothorax, increased respiration rate and decreased heart rate
i. Open: pleural space exposed to outside air
ii. Closed: spontaneous (lung disease), caused by pulmonary blebs
that rupture and the air inside the lungs build up in the pleural
space.

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 iii. Tension: air gets trapped in the pleural space due to a one-way
valve- life threatening, pushes on the other lung (causes
compression and atelectasis) and the heart- can cause tracheal
deviation to unaffected side (could cut off air way and will have
significant loss of cardiac output, blood pressure and eventually
pulse). Findings- tachypnea, tachycardia, JVD
b. Hemothorax: blood in pleural space- same assessment findings as
pneumothorax except blood in pleural space
c. Pleural effusion: fluid in the pleural space
d. Flail chest: inadequate and unequal lung and chest expansion due to
injury (rib fractures) paradoxical chest wall movement (moving opposite
the way it should)
e. Pulmonary contusion: hemorrhage and edema in and between alveoli 
decreased gas exchange  leads to hypoxemia and dyspnea overtime or
be immediate. May find SOB, crackles, tachycardia, anxiety, chest pain.
5. Purpose of CPAP, BiPAP, and PEEP. Which patients are these devices used
for?
a. PEEP: positive end-expiratory pressure. Open alveoli, increased surface
area, and improves gas exchange, provided through BiPAP, CPAP or
mechanical ventilation
b. CPAP: continuous positive airway pressure- delivers set pressure
throughout inspiration and expiration
c. BiPAP: cycles different pressures at inspiration and expiration—can turn
down amount of 02 patient requires.
6. Know how to interrupt ABGs.
a. CO2: 45-34
b. HCO3: 22-28
c. pH: 7.35-7.45

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 7. Chest Tubes: chest tubes are a tube placed in the pleural space of the lung that
allows for removal of air, blood or fluids and restore natural intrapleural pressure
for lung reexpansion- mainly used for hemothorax.
a. Prep for chest tube insertion: informed consent, education on
expectations, supine or semi-fowlers, prepare the system, pre-procedural
meds- can be done at bedside with sterile procedure
b. Indications for chest tube: pneumothorax
c. Assessment of a patient with a chest tube: chest tube insertion site, tube
itself and patient- interventions: encourage TCDB, use splinting for
comfort, keep sterile gauze at bedside, tape connection, do not strip
tubing, keep clamps at bedside, call provider if sudden increase or
decreased in drainage, tracheal deviation, dislodgement of chest tube, or
sudden change in respiration status (02 drop)
d. Troubleshooting a chest tube
e. Proper function of chambers of chest drainage system
i. Fluid/drainage chamber: monitor characteristics of drainage, monitor
amount of drainage- hourly for first 24 hours then at least every 8
hours, notify provider if drainage >70 mL/hour. If drainage color
changes- notify provider of significant changes. ii. Water seal chamber:
gentle bubbling is expected, excessive bubbling indicated air leak, no
bubbling means pneumothorax has resolved, or tube is clogged,
tidaling of narrow column, monitor water level and add sterile water as
needed iii. Suction chamber
1. Wet suction: water level prescribed by provider (20cm),
connects to wall suction, increase suction until gentle
bubbling is seen
2. Dry suction: provider prescription suction level of dial-
amount of suction is determined by manufacturer
f. Complications of chest tubes: dislodgement, clogged
g. Nursing management/monitoring of chest tubes

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 i. Water seal: no suction
ii. Wet suction: amount of suction is controlled by height of water in
suction control chamber
iii. Dry: amount controlled by dial
8. Diagnostics imaging
a. Chest x-ray: PA and lateral
b. CT scan: may require IV contrast (check allergies to IV dye, shellfish,
iodine), nephrotoxic- watch I&O, kidney function (BUN, GRF, Cr), if
diabetic and takes metformin stop 24 hours before and do not start back
until kidney function is good (could cause lactic acidosis)

Reversal agent for benzo: flumazenil and romazicon

Wet and dry suction do the exact same thing- dry suction has a dial, wet suction
has water that controls suction

Informed consent: type of procedure, person doing it, understanding procedure,

signature of patient and nurse, risk, benefits, alternative Tape on 3 side if tube
comes out with sterile gauze Chest tube dressing should be changes daily.

Cardiac

1. Review basic cardiac assessment, cardiac cycle and anatomy. Know

terminology.
2. Mechanical properties of the heart and how that influences heart function.
3. How is blood pressure regulated?
4. Identify patients at risk for CV problems. Modifiable vs non modifiable risk
factors.
a. Modifiable: smoking, diet, alcohol usage, weight, lack of exercise, HTN or
diabetes (maybe), stress, anxiety, drug history, occupation, socioeconomic
status

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 b. Non-modifiable: genetics, family heath history (more important than the
others), ethnicity, male gender, age- African Americans, Asian Americans,
Hispanics are at higher risk
5. Cardiovascular Assessment – physical assessment, psychological assessment
and labs.
a. EKG, stress test, monitor BP and HR, MRI of heart, ECHO, respiratory
and cardiac assessment, skin, extremities, VS, pulse, ask about risks,
economic status.
b. Symptoms- skin (rubor-arterial insufficiency), extremities, VS, pulses,
chest and heart, psychosocial assessment, syncope (low BP/HR or
electrical problemspassing out), palpitations.
c. Labs- lipids (total cholesterol < 200, triglyceride <150, HDL > 45, LDL
<130), troponin (helps identify heart attack
6. Understand sequence of events during the cardiac cycle.
7. Analyze basic EKG rhythm strip to identify normal sinus rhythm, sinus
bradycardia, and sinus tachycardia.
a. Normal sinus rhythm: impulse initiated by the sinus node, regular rhythm,
rate 60100 bpm, normal P wave in lead 2, P wave before each QRS,
normal PR, QRS, and QT
b. Sinus bradycardia: <60 bpm. Causes: vagal, ischemia, drugs, disease of
nodes, ICP, hypoxemia, athletes.
c. Sinus tachycardia: >100-150 bpm. Causes: hyperthyroidism, hypovolemia
(dehydration), heart failure, anemia, fever, anxiety, fear, pain,
meds/substances- assess for low cardiac output
8. Determine heart rate on rhythm strip.
9. Know normal values for each part of EKG waveform (ie. P wave, QRS, PR
interval, QT interval, etc.)
a. PR: .12-.20
b. QRS: <.10
c. QT: <.44

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 10. Patients at risk for DVT/PE
a. Virchow’s triad (stasis of blood flow—bed rest/AFIB, endothelial injury
(surgical patients), hypercoagulability (dehydration/pregnancy)),
orthopedic surgery, oral contraceptives (especially combined with
smoking)
11. Diagnostics for DVT/PE.
a. Venous duplex ultrasound, d-dimer, MRI
12. Pharmacological interventions for DVT & PE
a. Administration: LMWH- enoxaparin, IV heparin (continue until INR
therapeutic), warfarin
b. Contraindications (warfarin): foods high in vitamin K, alcohol, drug
interactions,
INR monitoring, reversal- hold dose or administer vitamin K
c. Adverse effects
d. Nursing implications
13. Other interventions for DVT/PE
a. Elevated extremity (reduces swelling), warm compression (for comfort),
compression socks on ted hose (helps with swelling), -- DO NOT
MASSAGE OR USE SCD
14. Patient education about treatment and prevention of DVT/PE.
15. Joint commission guidelines for DVT/PE.
16. Standard interventions monitored in inpatient setting and on discharge for
DVT/PE.

Endocrine

1. Review A/P (and patho) of the endocrine system, specifically the glands we
talked about in class. Know the effects of the different hormones of the
endocrine system and from which gland they are secreted.
2. Know how different negative feedback loops work.
3. Dietary recommendations for the different endocrine disorders.

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 4. Know symptoms, assessment findings, treatment, nursing care, patient
education, medications, lab values (what will be ordered and do you expect
values to be low, high or normal) and safety considerations for the following: •
Hypopituitarism
• Causes: tumors, malnutrition, shock, head trauma, surgery,
radiation.
• Assessment:
• GH: children are shorter, adults have decreased bone density
• Gonadotropins (FSH and LH): changes in sexual characteristics
and function, infertility
• ACTH (low cortisol): pale, lethargic, anorexia, hypoglycemic,
hyponatremia
• TSH (low thyroid hormone): weight gain, cold intolerance, slow
cognition.
• Med Tx: hormone replacement. Hydrocortisone (adrenal),
prednisone (adrenal), Synthroid (thyroid), testosterone and
estrogen (gonads), somatropin (GH).
• If it’s a tumor, hypophysectomy is done and same nursing
implications.
Treat underlying cause.
• Hyperpituitarism- acromegaly, Cushing’s
• Acromegaly: relates to GH. Adult that has too much secretion of
GH. Can be caused by aging but usually caused by adenoma.
• Assessment: enlarged body parts and atrophy of tissues
(lengthening of hands and feet, lips, nose, mouth, skull, coarse
facial features), headache, ICP, vision changes, voice changes,
sleep apnea, organ enlargement. Slow progression and changes
are permanent.

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 • Dx: GH suppression test --administer glucose, measure BG and
GH at baseline 10, 60, 120 min. GH will not decline, NPO 6-8
hours, skull x-ray, CT/MRI.
• Med Tx: dopamine agonists, somatostatin analog, GH receptor
blockers,
• Surgery Tx: hypophysectomy
• NI: client education, surgical care
• Complications: HTN, diabetes, heart problems
• Hyperthyroidism- grave’s, thyroid storm
• Causes: Grave’s disease- most common form of hypothyroidism
(autoimmune d/o, hypersecretion of thyroid hormone), toxic
modular goiter (multiple nodules on thyroid; hypersecretion of TH);
exogenous hyperthyroidism (caused by excessive use of thyroid
replacement).
• Assessment finding: hypermetabolic state, hyperactivity, mood
swings, heat intolerance, weight loss, increased appetite, insomnia,
diarrhea, menstrual irregularities, infertility, increased libido,
exercise intolerance, fatigue, muscle weakness, glucose
intolerance, hyperglycemia, goiter, tachycardia, HTN,
exophthalmos, pretibial myxedema (Grave’s only), (develops
mucinous edema).
• Labs: TSH (low), total and free T3 and T4 (high), thyroid-stimulating
immunoglobulin- Grave’s, thyrotropin receptor antibiotics- Grave’s,
imaging, thyroid scan- radioactive iodine uptake (drink), thyroid
ultrasound, EKG
• Treatment meds: thioamides (methimazole and propylthiouracil),
BB, iodine agents (lugol’s)
• Procedure/surgery: radioactive iodine- shrinks thyroid gland and
decreases the secretion of thyroid hormone

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 • Precaution: patient cannot be pregnant, one time dose, pick a room
to stay in for 48-72 hours, do not go around pregnant women or
children for 1 week, use disposable utensils, flush multiple times,
men must sit when peeing.
• Pre: informed consent, general anesthesia, NPO, abx, labs.
Bleeding and infection precautions.
• Post: risk-internal bleeding could obstruct airway, stridor will be
heard (airway obstruction), Rapid response team, blood run to back
of neck, laryngeal nerve damage (hoarseness), hypocalcemia
(Chvostek’s, Trouss)/tingling around mouth, fingers and toes.
• Nursing implications (inpatient acutely ill): administer medications,
promote comfort, decrease stimuli, nutritional support, monitor
ECG, monitor mental health, temperature, do not aggressively
palpate gland
• Nutrition: high calorie, high protein diet.
• Complications: thyroid storm (by aggressively palpating the thyroid
gland or by manipulating the thyroid gland in thyroidectomy, when
person is under a significant amount of stress that has
hyperthyroidism). – can be life threatening- give meds (BB),
decrease stimuli, IV fluids, 02, iodide agents (Lugol’s solution)
• Hypothyroidism- myxedema coma
• Causes: female, lack of iodine (can develop a Goiter- thyroid gland
enlarges to uptake more iodine), thyroidectomy, radioactive iodine
(too much can destroy tissues of thyroid).
• Assessment: hypometabolic state, cold intolerance, fatigue,
constipation, bradycardia, hypotension, slow cognition, abnormal
menstruation/decrease libido.
• Diagnostics: labs T3 and T4 (low), TSH (high), imaging- radioactive
iodine scan, EKG.

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 • Med Tx: hormone replacement- levothyroxine given at same time
every day on empty stomach, regularly check labs,
• Nursing implications (inpatient): monitor for hypotension and
bradycardia. Med education: nutrition support (low calorie, high
fiber, adequate fluids, promote comfort (keep warm), assess mental
status (may be depressed), assess for chest pain (myxedema
coma)
• Complications: myxedema coma- hypotension, hypothermia,
bradycardia, hypoglycemia, respiratory failure, coma, puffy around
the eyes
• Thyroiditis: inflammation of the thyroid gland.
• Acute: bacterial, pain, neck tenderness, malaise, fever, dysphagia
• Subacute: viral, fever, chills, dysphagia, muscle/joint pain, thyroid
hard to palpation
• Chronic: (Hashimoto’s): common, occurs in women more than men;
autoimmune response, low T3 and T4, high TSH, dysphagia,
painless enlargement of thyroid; end up being put on levothyroxine.
• Thyroid Cancer
• Papillary: most common; slow growing, younger women, good
prognosis if confined to thyroid
• Follicular: older patient, spread to bone and lung, dyspnea and
dysphagia.
• Medullary: most common; in patient >50, secretes ACTH,
prostaglandins, calcitonin and serotonin
• Anaplastic: rapid growing, aggressive with Mets, stridor,
hoarseness, dysphagia, single painless lump. Tx: ablative radiation
and chemo (if not responsive)
• **elevated serum thyroglobulin (Tg) is hallmark to thyroid cancer •
Hyperparathyroidism: increased PTH, hypercalcemia and
hypophosphatemia. Increased PTH=increased bone resorption

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 (bone loss of calcium), decreased bone density and increased
deposition of Ca in soft tissues.
• Causes: unknown, hyperplasia, benign tumor most common
• Assessment: GI upset, fractures, kidney stones
• Diagnostics: Ca, P, Mg (same as Ca), PTH. Imaging: ultrasound,
CT scan. • Surgery: parathyroidectomy
• Hypoparathyroidism: lack of PTH or decreased PTH effectiveness,
hypocalcemia.
• Causes: iatrogenic- caused by removal of all tissue during surgery
or idiopathic. Hypomagnesemia; malabsorption syndromes. CKD,
malnutrition, low Mg suppresses PTH.
• Assessment: tingling around mouth, hands and feet, seizures,
irritability, Chvok, Trouss (+)
• Diagnostics: decreased Ca, Mg and vit. D, increased P.
• Imaging: CT scan, EKG
• Tx: correct decrease in Ca, vit. D, and magnesium. May give IV Ca
and Mg sulfate.
• Nursing implications: teach about drug therapy and lifelong therapy
(Tx), diet teaching, high calcium, low P (avoid milk, cheese and
yogurt)
5. Education for the patient receiving radioactive iodine therapy.
• Patient cannot be pregnant, one time dose, 48-72 hours in one room
alone, do not be around pregnant women/children for 1-week, disposable
utensils, flush multiple times, men must sit.
6. Know procedure, nursing interventions (pre- and post-surgical), patient
education, and potential complications (signs/symptoms and nursing
interventions of complications) for the following:
• Hypophysectomy
• Pre: informed consent, general anesthesia, pre abx, NPO, no blood
thinners, PT/IRN check, CBC

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 • Post: assess for complications, ABCs, mental status, meningitis risk
(neck stiffness- nuchal rigidity, unable to flex head forward, fever,
chills, fatigue, headache*), bleeding (ICP), risk for CSF leak (watery
discharge from nose), patient will come back with mustache
dressing (yellow outline if CSF leak) (or can test for glucose),
sometimes patient will have decrease in ADH which cause diabetes
insipidus (copious amounts of clear urine), I&O, do not want patient
to do anything to increase ICP (coughing, blowing nose, bending
forward, keep HOB elevated, do not brush teeth for 2 weeks- can
swish and swallow), patient can lose smell but usually comes back
in a few months.
• Thyroidectomy
• Pre: informed consent, general anesthesia, NPO, abx, labs.
Bleeding and infection precautions
• Post: risk- internal bleeding could obstruct airway, stridor will be
heard (airway obstruction), Rapid response team, blood runs to
back of the neck, laryngeal nerve damage (hoarseness),
hypocalcemia (Cvoks, Trouss
+)/tingling around hands, mouth and toes
• Parathyroidectomy: if hyperplasia- 3.5 glands removed- if 4 glands
removed, will implant portion of gland in forearm where it will
product PTH and maintains Ca.
if all 4 removed, will need lifelong vit. D and Ca replacement.
• Nursing implications: prevention injury- bone density loss, monitor
cardiac function, monitor paresthesia, monitor Ca
• Pre: stabilize Ca – care same as thyroidectomy
• Post: monitor Ca

Diabetes

1. Pathophysiology of DM (both types).

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 2. Risk factors for diabetes mellitus.
African American, Native American, Hispanic, men more than women
3. Differentiate between Type 1 and Type 2 diabetes.
 Type 1: autoimmune beta-cell destruction, insulin deficient, idiopathic, age
of diagnosis <30, symptoms- polyuria, polyphagia (increase UO, thirst,
hunger), weight loss; insulin dependent, genetic component, can be
triggered by viral infection. Tx: insulin
 Type 2: dysfunctional pancreatic cells, progressive disorder, insulin
resistant, adult onset- peaks in 50s, genetic component, metabolic
syndrome. Symptoms:
often none, can have thirst, fatigue, blurred vision, vascular or neural
complications.
4. Metabolic syndrome.
 Increase risk for DM2 and cardiovascular disease. Also called syndrome
X, diagnosis with 3 of the following—HTN, hyperlipidemia, elevated fasting
BG, larger waist size.
5. Diabetic foot care teaching.
6. Lab values for pre-diabetes and diagnosis of diabetes.
 Pre-diabetic: fasting BG 100-126, 2-hour BG tolerance 140-199, A1C=5.5-
6%, significantly increases 3–5-year risk of developing DM2
 Diagnosis of DM: 2 findings on separate days of at least one of the
following: casual BG >200, fasting >126, glucose tolerance 2-hour test
>200, A1C. >6.5%
Labs: urine ketones, albuminuria, serum Cr, glucosuria
7. Onset, peak, and duration of short, intermediate and long-acting insulins. 
Short: onset: 30-60 min., peak 1-5 hours, duration is 6-10 hours
Intermediate: onset 1-2 hours, peak 6-14 hours, duration 16-24 hours
 Long: onset 70 min., peak none (risk for hypoglycemia), duration 24
hours  Rapid: onset 15-30 min, peak 30min, 2.5 hours, duration 3-6
hours.

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 8. Insulin administration: proper procedure and patient education.
 Rotation of sites, absorption rates, 90 degrees, lag time, dawn and
somogyi phenomena
9. Blood glucose monitoring: when to perform, proper procedure, and patient
education.
10. Be familiar with oral diabetic medications, adverse reactions/side effects and
nursing implications.
11. Determine appropriate blood sugar levels and treatment for the sick and/or
hospitalized patient.
 Sick day: monitor BG more often, take meds and insulin as prescribed,
stay hydrated, eat regularly, if unable to eat consume liquids with carbs,
rest, know when to call provider (persistent n/v, not able to eat—DM1:
ketones in urine, call provider if high BG after meals) BG is higher when
sick
 Hospitalized: hyperglycemia in hospitalized patient- higher infection rate,
longer hospital stays, ICU potential, greater mortality. Glycemic control=
140-180 for critically ill and during surgery, monitor for hypoglycemia,
administer carb replacement if patient is awake, administer 50% dextrose
IV or glucagon SQ or IM if unable to swallow, if NPO may administer long
acting (basal) insulin, maintain premeal BG <140 for non-critically ill and
maintain random BG <180
12. Complications of diabetes mellitus, how to assess for complications, and what
teaching is important regarding complications.
 Chronic: HTN, MI, stroke, PVD, CVD (macro)- diabetic
retinopathy/neuropathy/nephropathy (micro)
 Acute: DKA- typically DM1, rapid onset, infection most common cause,
hyperglycemia  diuresis  dehydration  electrolyte loss. Polyuria,
polydipsia, polyphagia, vomiting, abdominal pain, weakness, confusion,
shock and coma. Kussmaul respirations (fast breathing), metabolic
acidosis

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  Interventions: vitals, fluids, BG control, F&E monitoring (worry
about K when on insulin drip, insulin pushes K from vascular space
into the cell causing hypokalemia- then may need to add KCl to IV)
13. Symptoms of hypoglycemia and hyperglycemia (DKA and HHS) and the
treatment and nursing implications involved in each.
 HHS: differs. From DKA in no ketones and much higher BG, occurs most
often in older adults with DM2. Caused by infection or other stressor,
gradual onset over several days. Hyperglycemia  diuresis  dehydration
 electrolyte loss, confusion, coma, seizure, paralysis.
 Interventions: BG monitoring and control, fluids, mental status
assessment, F&E monitoring
 Hyper: DKA and HHS
 Hypo: mild shakiness, mental confusion, agitation, sweating, palpitations,
headache, lack of coordination, blurred vision, seizure, coma.
Tx: if <60 10-15 g of cabrs, if <40 15-30 g of rapidly absorbed carbs, if
<20, 50% dextrose IV or glucagon SQ or IM
 Prevention of causes: insulin excess, deficient intake, exercise,
alcohol
14. Dietary and exercise information included in diabetic teaching.
 Type 1: more likely to develop hyperglycemia in exercise- check if ketones
are present in urine if they are, no exercise
 Type 2: more likely to develop hyperglycemia in exercise- take snack if BG
stops.

Renal

1. Review A/P and functions of the renal system.

2. Assessment of a patient with confirmed or potential renal/urinary dysfunction.
• Voiding patterns
• Personal hygiene
• Urine characteristics

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Updated 1/2020
 • Burning/pain while urinating
• Signs and symptoms of infection
• Pain
• Older adults, confusion, incontinence • Some have no symptoms.
3. Review diagnostic tests/procedures for the renal patient. Know procedure,
nursing interventions (pre- and post-surgical), patient education, and potential
complications
(signs/symptoms and nursing interventions of complications) for the following;
• UA: looks at color, odor, turbidity. Tests for leukoesterase (enzyme
for WBC) and nitrites in urine which are indicative of UTI (suggests
E. Coli as cause)
• Ultrasound
• CT/MRI
• Cystoscopy & cystourethroscopy: SCOPE for diagnosis or
treatment of bladder wall abnormalities or occlusions of ureter or
urethra. Used for complicated or recurrent UTI. May also be used
for removal of tumors, plant radium seed, filate urethra and ureters,
place stents or resect prostate
• Pre: informed consent, local anesthesia (not NPO) or general
anesthesia (NPO), bowel prep (enema)
• Intra: lithotomy position (same position to put catheter in)
• Post: ABC’s, vitals, mental status, bleeding and infection (pink urine
is not uncommon-bright red urine is uncommon), monitor urine
output (bladder scan), encourage fluids.
• Interventions: relief of pain and discomfort, encourage fluids,
educate on prevention and treatment, personal hygiene, meds
(prescribed abx, analgesics, antispasmodics), application of heat to
perineum for pain (sitz bath), avoid UTI irritants such as coffee, tea,
citrus, spices, soda, alcohol; frequently void
• Meds?

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 • Xray – KUB: patient must be metal free, this is of kidney, urethra
and bladder
• IV pyelogram (excretory urography): IV contrast dye, bowel prep,
NPO
• Renal scan (nuclear medicine scan): evaluate for renal function,
structure and perfusion, can replace CT in patients with allergies, IV
access needed, furosemide and captopril, tell patient to drink lots of
fluids post-op to help with eliminating isotope from system (6-24
hours)
• Composite urine collection/creatinine clearance (GFR): similar to 24
hours urine collection- all rules apply such as waste the first void,
do not miss any urine, no contaminated urine, 24 hours. GFR is the
same thing as creatinine clearance. If kidney function is declining,
the GFR (creatinine clearance) is low too—whereas serum
creatinine would be elevated
• Kidney biopsy: this provides accurate diagnosis. Either excision
needle aspiration. Most performed percutaneously using ultrasound
or CT.
• Pre: informed consent, local anesthesia (No NPO), pain meds (for
needle); for open biopsy- NPO, increased risk of bleeding (keep
blood pressure under control, monitor PT/INR, be aware of any
anticoagulants being used)
• Intra: prone position
• Post: ABC, vitals, mental status, infection (UTI and surgical site),
bleeding (esp. in urine), severe back pain usually indicated
bleeding, supine, bed rest for 2-6 hours after surgery, within 24
hours can go back to normal ADL with exception of no heavy lifting
(anything over 5 lbs.) for two weeks.
• Lithotripsy: (ESWL- extracorporeal shock wave lithotripsy). Sound,
laser. Or shock wave energy to break up stone, conscious

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Updated 1/2020
 sedation, local anesthetic cream, must lay flat, continuous ECG
monitoring (shock was delivered on R wave, otherwise could cause
dangerous arrythmia)
• Ureterolithotomy & nephrolithotomy (percutaneous- through the
skin): after procedure patient may have urinary catheter put in
place. With percutaneous procedures, may have nephrostomy tube
to prevent stones from passing through urinary tract. Post op-
monitor for bleeding at sites, pneumothorax (esp. with
percutaneous) and infection. 24-48 hours post op blood is normal in
tubes, sterile dressing changes and irrigated if ordered.
4. Care and nursing interventions for a nephrostomy tube.
• External and internal diversions. Most are just external with
drainage tube
• Pre: moderate sedation, PT/IRN, PTT, HTN controlled, informed
consent
• Intra: prone position
• Post: assess drainage every hour for 24 hours, if drainage is just
external the min. is 30 mL/hr. monitor tube side for bleeding and
infection. If patient reports back pain the tube may be clogged.
5. Know symptoms, assessment findings, diagnostics, treatment, nursing care,
patient education, medications, lab values (what will be ordered and do you
expect values to be low, high or normal) and safety considerations for the
following:
• Urinary tract infections—most common cause is E. coli more
common in womencan be complicated or uncomplicated
• Risk factors: obstruction, stones, reflux, concentrated urine,
moisture, gender, age, diabetes, sexual activity, indwelling urinary
catheter
• Assessment: voiding patterns, personal hygiene, urine
characteristics, burning/pain with urinating, some may have no

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Updated 1/2020
 symptoms, s/sx of infection, pain, older adults- confusion and
incontinence
• Diagnostics urinalysis
• Endoscopic procedures: cystoscopy and cystourethroscopy
• Interventions: relief of pain and discomfort, encourage fluids,
educate on preventative measures and treatment, personal
hygiene, meds, application of heat to perineum for pain (sitz bath),
avoid urinary tract irritants such as coffee, tea, spices, citrus, soda
and alcohol; frequently urinate
• Medications: antibiotics
• Sulfonamides: allergies to sulfa, increases sun sensitivity
• Fluoroquinolone: only used when complicated UTI has not been
treated successfully with other meds. Do not take with antacids,
cardiac dysrhythmias, sun sensitivity, tendonitis, and tendon
rupture
• Penicillin’s: allergies to PCN and diarrhea
• Cephalosporins: allergies to PCN or cephalosporins, diarrhea
• Nitrofurantoin:
• Fosfomycin: do not take with drugs that increase GI motility
• Phenazopyridine (bladder analgesics): turns urine orange/red
• Renal calculi (urolithiasis, nephrolithiasis, ureterolithiasis)
• Risk factors: may be unknown, metabolic defects (90% of patients),
urine pH too high or too low, urinary stasis or retention,
dehydration, male gender, white, older, obsess, DM, gout,
hyperparathyroidism, urinary tract obstruction, or IBD (Crohn’s and
ulcerative colitis)
• Assessment: PAIN! (flank pain, pain worse when stones move
through ureters), n/v, pale, diaphoretics, bladder distention, urine
output (frequency or oliguria/anuria), urine characteristics, VS
(tachycardia, tachypnea, high BP—if in shock BP will be low)

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Updated 1/2020
 • Diagnostics: UA, KUB, CT/MRI, ultrasound, cystoscopy (used to
diagnose or retrieve stone)
• Interventions: pain management (IV morphine, ketorolac- NSAID,
spasmolytics- oxybutynin), prevent/treat infection (broad then
narrow), high fluid intake, accurate I&O, ambulation, nutritional
therapy, strain urine, stone expulsion (thiazide diuretics and
allopurinol with high fluid intake)
• Nutritional therapy
• Ca: liberal fluid intake, may benefit from low Ca but cannot
recommend with confidence due to lack of evidence, meds may be
used- limit animal protein
• Uric acid: low purine diet (shellfish, anchovies, asparagus,
mushrooms, red wine, organ meats): allopurinol
• Cystine: low protein diet, liberal fluid intake
• Oxalate: limit foods that increase urinary excretion of oxalate
(spinach, strawberries, rhubarbs, chocolate, tea, peanuts)
• Struvite: limit high phosphate foods (diary, organ meats, whole
grain)
• Therapeutic procedures: ESWL, stents, ureteroscopy,
uretherolithotomy, nephrolithotomy, open surgery
• Polycystic Kidney Disease: dominant starts getting worse around
age 30 and recessive is as a kid- usually do not survive
• Risk: Caucasian
• Assessment: family history, pain is first symptom, abdominal
distention (constipation), flank pain (kidney enlargement), sharp
pain (cyst rupture or stone), cyst rupture (blood in urine), nocturia,
headache (with or without neurological changes- needs attention
because could be aneurysm), psychosocial assessment
• Diagnostics: UA, BUN, Cr, GFR, ultrasound, CT/MRI

25
Updated 1/2020
 • Interventions: pain management (No ASA or NSAIDS), antibiotics
(watch serum Cr- nephrotoxic), dry heat to flank/abdominal, guided
imagery, relaxation, need aspiration, prevent constipation, control
blood pressure (ACE and ARB)
• Hydronephrosis: urine collects in renal pelvis, kidney enlarges
• Assessment: history of UT problems, urine patterns and
characteristics, signs and symptoms of infection, flank-symmetry,
tenderness, swelling; bladder (palpate, percuss, bladder scan),
STD (urethral stricture)
• Diagnostics: UA, Cr, BUN, GFR, serum electrolytes, ultrasound, CT
• Interventions: cystoscopy with stent placement, nephrostomy tube •
Hydroureter^^^ same
• Pyelonephritis: severe upper UTI (kidney and renal pelvis) usually
caused by E.
Coli
• Acute is usually due to active bacterial infection and chronic is due
to tract defects such as reflux- chronic causes repeated infections
• Risk factors: women, men >65 with prostitis, urinary stasis,
NSAIDs, chronic stones, pregnancy, urine reflux, urinary catheters
• Assessment
• History: DM, stones, UTI, anatomical defects, immunosuppression
• Physical: s/sx of infection, flank pain, tachycardia, tachypnea, n/v,
UTI symptoms, chronic pyelonephritis has severe presentation
• Diagnostics: UA, C&S, blood culture, serum Cr (normal 0.5-1.2),
serum BUN (10-20), C-reactive protein and ESR, x-ray (KUB), IV
pyelogram, renal scan
• Interventions: pain management (opioid and acetaminophens),
medications (antibiotics- broad then narrow), 2L/day fluids,
adequate caloric intake, pyelolithotomy (stone removal from
kidney), nephrectomy

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Updated 1/2020
 (kidney removal-last resort), urethroplasty (ureter repair or revision)
• Complications: ESRD, septic shock, HTN due to water and sodium
retention
• Glomerulonephritis- acute and chronic
• Acute: post infectious glomerulonephritis (rapidly progressive-
1. diarrhea is common.

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https://docmerit.com/bundle/show/nrse-3540-adult-care-
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https://docmerit.com/bundle/show/nrse-3540-adult-care-
study-material

FIND FULL DOCUMENT AT:

https://docmerit.com/bundle/show/nrse-3540-adult-care-
study-material
https://docmerit.com/bundle/show/nrse-3540-adult-care-
study-material
https://docmerit.com/bundle/show/nrse-3540-adult-care-
study-material

27
Updated 1/2020