Polyuria (increased urination) is an early sign of hyperglycemia. Other signs can include polydipsia, dry mouth, increased appetite, fatigue, nausea, hot flushed skin, rapid deep breathing, abdominal cramps, acetone breath, headache, drowsiness, depressed reflexes, oliguria or anuria, stupor, and coma.
If the client has sustained a craniocerebral injury or is recovering from a craniotomy, careful observation of any drainage from the eyes, ears, nose, or traumatic area is critical. Cerebrospinal fluid is colorless and generally nonpurulent, and its presence indicates a serious breach of cranial integrity. Any suspicious drainage should be reported immediately.
With acute renal failure, the client is often oliguric or anuric, although the client may have nonoliguric renal failure. The BUN and serum creatinine levels also rise, indicating defective kidney function. Normal serum BUN levels are usually 5 to 20 mg/dL. Normal creatinine levels range from 0.6 to 1.3 mg/dL.
Of all the electrolyte imbalances that accompany renal failure, hyperkalemia is the most dangerous because it can lead to cardiac dysrhythmias and death. If the potassium level rises too high, sodium polystyrene sulfonate (Kayexalate) may be administered to cause excretion of potassium through the gastrointestinal tract.
Hypertension is the most common cardiovascular finding in the client with chronic renal failure. It is caused by several mechanisms, including volume overload, renin-angiotensin system stimulation, vasoconstriction from sympathetic stimulation, and the absence of prostaglandins. Hypertension may also be the cause of the renal failure. It is an important item to assess because hypertension can lead to heart failure in the chronic renal failure client, because of increased cardiac workload in conjunction with fluid overload. The client may experience tachycardia or bradycardia or may have a normal pulse rate; these cardiovascular manifestations will depend on a variety of physiological events such as fluid overload, fluid deficit, or normal fluid volume.
Aldactone antagonizes the effect of aldosterone and decreases circulating volume by inhibiting tubular reabsorption of sodium and water. Thus, it produces a decrease in blood pressure. It increases the excretion of sodium and water and increases potassium retention. It has no effect on body metabolism.
Hyperpyrexia up to 107° F may be present in neuroleptic malignant syndrome. Symptoms develop suddenly and may include respiratory distress and muscle rigidity. As the condition progresses, there is evidence of tachycardia, hypertension, increasing respiratory distress, confusion, and delirium. The presence and severity of symptoms is compounded when two or more antipsychotics are taken concurrently.
Cancer treatments may cause distortion of taste. Frequent oral hygiene aids in preserving taste function. Keeping a client NPO increases nutritional risks. Antiemetics are used when nausea and vomiting are a problem. TPN is used when oral intake is not possible.
Redness, warmth, and purulent drainage are signs of an infection, not an allergic reaction. Infiltration causes the surrounding tissue to become cool and pale.
Chronic use of alcohol is the most frequent cause of chronic calcifying pancreatitis. Abstinence from alcohol is important to prevent the client from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Pain will not be relieved with food or antacids. Chemical exposure is associated with cancer of the pancreas.
Glucocorticoids have three primary uses: replacement therapy for adrenal insufficiency, immunosuppressive therapy, and antiinflammatory therapy. Exogenous glucocorticoids cause the same effects on cellular activity as the naturally produced glucocorticoids; however, exogenous glucocorticoids may produce undesired effects. The glucocorticoids stimulate appetite and increase caloric intake. They also increase the availability of glucose for energy. These combined effects cause the blood glucose levels to rise, making the client prone to hyperglycemia.
The dexamethasone suppression test is performed to evaluate the function of the adrenal cortex. The procedure for this test is to administer 1 mg of dexamethasone at 11:00 p.m. to suppress ACTH formation and then to obtain 8:00 a.m. serum cortisol levels on the following day.
The presence of pulsation between the umbilicus and the pubis could indicate abdominal aortic aneurysm and should be reported to the physician. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute. Bruits are not normally present.
The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux are all indicators of right-sided heart function. Breath sounds are an accurate indicator of left-sided heart function.
Clients frequently at risk for pulmonary embolism include those who are immobilized, especially postoperative clients. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, and advancing age.
The potassium level is usually low and the blood urea nitrogen is usually high in clients with anorexia nervosa. These clients lose at least 15% of their original body weight in a short period of time. They are very knowledgeable about nutrition and the caloric value of food.
Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved from these measures should be reported to the physician, because it may be caused by impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in.
A key feature of fat embolism is a significant degree of hypoxemia with a Pao2 often less than 60 mm Hg. Other features that distinguish fat embolism from pulmonary embolism are an elevated temperature and the presence of fat in the blood with fat embolus.
Mannitol (Osmitrol) is an osmotic diuretic that can be administered parenterally to treat cerebral edema. Lowering of intracranial pressure occurs within 15 minutes of administration, and diuresis occurs within 1 to 3 hours. Expected effects of the medication include rapid diuresis and fluid loss. For the client with cerebral edema (as in closed head injury), effectiveness is measured by assessing neurological status and intracranial pressure readings.
Captopril is an angiotensin-converting enzyme (ACE) inhibitor, which may be used for clients who do not respond to the first-line antihypertensive agents. ACE inhibitors are used cautiously in clients with renal impairment. Before beginning treatment, baseline assessment of blood pressure, complete white cell count, and urine protein is performed. Clients with renal insufficiency may develop nephrotic syndrome, so the client may be monitored for proteinuria on a monthly basis for 9 months, and periodically afterward.
Intermittent claudication is a classic symptom of peripheral vascular disease, also known by other names, including peripheral arterial disease and chronic arterial insufficiency. Intermittent claudication is described as a cramp-like pain that occurs with exercise and is relieved by rest. Intermittent claudication is caused by ischemia and is reproducible; that is, a predictable amount of exercise causes the pain each time.
Daunorubicin is an antineoplastic medication. The major gastrointestinal (GI) side effects include nausea, vomiting, stomatitis, and esophagitis. Cardiovascular side effects include congestive heart failure and dysrhythmias. Other frequently occurring side effects are alopecia and bone marrow depression.
Enoxaparin is an anticoagulant. A common side effect of anticoagulant therapy is bleeding. Because of this, the nurse questions the client about symptoms that could indicate bleeding, such as bleeding gums, bruising, hematuria, or dark tarry stools.
The client who has been prescribed sulfasalazine (Azulfidine) should be checked for history of allergy to either sulfonamides or salicylates because the chemical composition of sulfasalazine and these medications are similar.
The nurse avoids using lemon-glycerin swabs for the client with impaired oral mucous membranes because they dry the membranes further and could cause pain. Items that are helpful include a soft toothbrush to prevent trauma, lip moistener to prevent lip cracking, and soothing cleansing rinses, such as nonalcoholic mouthwash or a saline and hydrogen peroxide mixture.
Potassium chloride may be administered by the intravenous route when the client has moderate to severe hypokalemia. It is always diluted in intravenous solution; administration by IV push could cause death by cardiac arrest. It is not administered intramuscularly or subcutaneously. Intravenous potassium should be administered through an infusion pump. A cardiac monitor should also be in use when administering intravenous potassium.
The nurse waits 3 to 5 minutes between administration of the two separate ophthalmic medications. This allows for adequate ocular absorption of the medication and prevents the second medication from flushing out the first.
Acetazolamide (Diamox) is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase. Administration of sodium bicarbonate would aggravate the already existing condition and is contraindicated. Furosemide and spironolactone are loop and potassium-sparing diuretics, respectively. These are of no value when there is a need to excrete bicarbonate.
The primary treatment for any acid-base imbalance is treatment of the underlying disorder that caused the problem. In this case, the underlying cause of the metabolic acidosis is anaerobic metabolism caused by lack of ability by the body to use circulating glucose. Administration of insulin corrects this problem.
Metoclopramide (Reglan) is an antiemetic. The nurse would monitor to see whether the client has experienced a decrease or absence of vomiting to determine the effectiveness of therapy.
The therapeutic level for lithium for the treatment of acute mania is 0.8 to 1.6 mEq/L. A level of 2.0 mEq/L indicates toxicity and requires that the medication be withheld and the blood work repeated. The physician also needs to be notified.
Peau d’orange or the orange peel appearance of the skin over the breast is associated with late breast cancer. Therefore, the nurse would arrange for the client to come to the clinic at the earliest time possible.
BSE should still be done even after menopause. No one is “too old” to get breast cancer.
Hypokalemia is a common characteristic of Cushing’s syndrome, and the client is instructed to consume foods high in potassium. Clients also experience activity intolerance, osteoporosis, and frequent bruising. Excess fluid volume results from water and sodium retention. Hyperglycemia is caused by an increased cortisol secretion.
The nurse is hearing a pleural friction rub, which is characterized by sounds that are described as creaking, groaning, or grating in quality. The sounds are localized over an area of inflammation of the pleura and may be heard in both the inspiratory and expiratory phases of the respiratory cycle. Crackles have the sound that is heard when a few strands of hair are rubbed together near the ear and indicate fluid in the alveoli. Wheezes are musical noises heard on inspiration, expiration, or both. They are the result of narrowed air passages. Rhonchi are usually heard on expiration when there is excessive production of mucus, which accumulates in the air passages.
The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. In order for kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The pulse rate affects the cardiac output, but it can be altered by factors unrelated to kidney function. Bladder distention reflects a problem or obstruction that is most often distal to the kidneys.
If a TPN solution bag stops running or becomes empty, the nurse should hang an infusion of 10% dextrose in water until another TPN solution arrives or the problem is fixed. This minimizes the chance of the client developing hypoglycemia, because the body produces more insulin in the presence of the high TPN glucose load.
Acetaminophen (Tylenol) is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents should be investigated whenever a client presents with symptoms compatible with liver disease (such as ascites and jaundice).
The client is taught to avoid activities that raise intraocular pressure and could cause complications in the postoperative period. The client is also taught to avoid activities that cause rapid eye movements that are irritating in the presence of postoperative inflammation. For these reasons, the client is taught to avoid bending over, lifting heavy objects, straining, sneezing, making sudden movements, or reading. Watching television is permissible because the eye does not need to move rapidly with this activity, and it does not increase the intraocular pressure.
Pain or discomfort from a problem that originates in the kidney is felt at the costovertebral angle on the affected side. Ureteral pain is felt in the ipsilateral labium in the female client or the ipsilateral scrotum in the male client. Bladder infection is often accompanied by suprapubic pain and pain or burning at the urinary meatus when voiding.
Although the incidence of cataracts increases with age, the older client with diabetes mellitus is at greater risk for developing cataracts. The most frequent complaint is blurred vision that is not accompanied by pain. The client may also experience difficulty with reading, night driving, and glare.
The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack-years, which is the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the information has no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking cessation plan with the client.
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