Exam 2 -DI, SIADH, Cushings, Addisons, DIC

What are the potential causes of DI, SIADH, Cushings, Addisons, & DIC

*DI:* -*Central DI*: surgery, tumor, illness (meningitis), inflammation, sarcoidosis, head injury -*Nephrogenic DI*: inherited (genetic) disorder, CKD, lithium, demeclocycline -*gestational DI*: pregnancy *SIADH:* -MAOI, NSAID, SSRI, vasopressin, respiratory problems, emphysema, TB, pneumonia, asthma, cancer, malignancies, tumors, HF, CNS disorders, brain injury (esp hypothalamus) stroke, infection (meningitis), trauma, burns, hemorrhage, psychosis, emergency & ICU situations, surgery, mental health crisis, HIV/AIDS, Guillian Barre, hereditary *Cushings:* -*Cushings disease*: pituitary tumor -*Iatrogenic Cushings*: from long term steroids with respiratory problems, autoimmune, infection -*Ectopic Cushings*: lung cancer *Addinsons:* -*Primary*: autoimmune & infection -*Secondary*: Iatrogenic from long term steroids or abrupt withdrawal with respiratory problems, autoimmune, infection, allergic reaction -*Addisonian crisis*: stress (MVA, surgery, final exam, job presentation, weddings) trauma, infection *DIC:* -*Acute:* cancer, sepsis esp. gram + or - infections, surgery/trauma, burns, MVA, frostbite, poisonous snake bites, childbirth, preeclampsia, placental abruption, blood transfusion reaction, pancreatitis, liver disease, artificial devices (articial heart valves), SIRS -*Chronic:* cancer, tumor, MI, inflammatory/autoimmune processes, rheumatoid arthritis, ulcertive colitis, crohns disease, sarcoidosis, lupus

What are potential symptoms of SIADH? *Each person may experience symptoms differently; slow changes in Na+ & fluid which may be tolerated by pt

*If more severe, symptoms include: r/t decreased Na+* -extreme thirst (starts 290-295 serum osmo) -irritability & restlessness -cramps & tremors -depressed mood or memory impairment -personality changes like combativeness, confusion, & hallucinations -seizures -shock, stupor, or coma -decreased urine output -dark yellow/orange urine -high specific gravity (>1.030) -low serum osmolality (<270) -increased HR -increased BP (w FVE)

What are the interventions for pt with DI?

*Nursing care:* -monitor I&O -record daily weights -baseline electrolytes esp Na+ -monitor perfusion status/BP/HR -neuro checks, cognition, lethargy -baseline testing of pituitary & kidneys to rule out structural defects, injury, inflammation with CT/MRI -assess for N/V -assess for weakness & fatigue -monitor for seizures -assess mental health hx -assess med hx like lithium or demeclocylcine *Meds/tests/other:* -surgery ex: remove brain tumor -desmopressin PO or IV; not for nephrogenic -hydrochlorothiazide for nephrogenic -stop lithium or demeclocycline -fluid replacement for large fluid losses

What meds may be prescribed prn for Addisons disease?

*Oral corticosteroids:* -fludrocortisone -hydrocortisone (cortef) -prednisone -cortisone acetate *may need prophylactically for stressful sitations like root canal, surgery, weddings, exams, job presentations

What labs & diangostic tests are used for pt with suspected DIC?

-*NO one test; look at several labs w assessment findings* -PT increased (normal 11-15) -INR increased (normal <1.1) -PTT increased (normal 25-37) -platelets decreased (normal 150-400) -blood clotting factors 1,2,5,8,8a,9,10,11,12 -fibrinogen, factor one decreased (normal 150-400) -hgb/hct decreased (normal 12-18; 37-52) -fibrin degredation/FDP/D-dimer positive -scoring rubric with aggregation of symptoms -venous & arterial dopplers

What other meds may be prescribed for DIC

-*heparin* -*dalteparen (fragmin)* -*rivaroxaban (xarelto)* -*dabigatran (pradaxa)* -*bivalirudin (angiomax)* not 1st choice -*streptokinase (tPA)* not 1st choice -*recombinant human soluble thrombomodulin*

What are assessment findings the nurse should monitor for a pt with DIC r/t increased risk of bleeding?

-Acral cyanosis (bluish discoloration of hands/feet from poor perfusion) -Petechiae (small round dots that are actually bruises) -Hematuria (blood in urine; send UA if not noticable but suspect DIC) -Petechiae of buccal mucosa (small dots in the mouth) -Purpura fulminans (sudden or severe bruising)

Match the following assessment findings of DIC to their correct term: ____bluish discoloration of hands/feet from poor perfusion ____small round dots that are actually bruises ____blood in urine; send UA if not noticeable but suspect DIC ____small round dots/bruises in the mouth ____sudden or severe bruising

-Acral cyanosis=bluish discoloration of hands/feet from poor perfusion -Petechiae=small round dots that are actually bruises -Hematuria=blood in urine; send UA if not noticeable but suspect DIC -Petechiae of buccal mucosa= small dots in the mouth -Purpura fulminans= sudden or severe bruising

What are the "big time" anticoagulants that will not be commonly prescribed on the medsurg floor? What are the reversal agents? *r/t DIC

-Angiomax (has no reversal agent; need hemodialysis) -Streptokinase (reverse w aminocaporic acid in emergencies only) -tPA (reverse w aminocaporic acid in emergencies only)

What should the nurse assess for in a pt with DIC?

-BP: hypotension -HR: tachycardia -lung sounds: pleural friction rub, ARDS, PE -SaO2: dropping -GI: abd bruising, bloody emesis, bloody stools -GU: hematuria, oliguria (most common site of clots) -skin: petechiae, acral cyanosis (hands & feet), wound bleeding, bullae/purpura, bruising

What is the patho for DIC?

-Body clots abnormally & form clots in the small vessels of the body ex: periphery, kidneys -once clot forms, stops blood flow & causes problems like tissue necrosis -there is unregulated activation of coag cascade -clotting factors used up -fibrin continues its process unregulated & causes fibrin degradation products (FDP) -FDP interfere with platelets -platelets are used up in clots, causing thrombocytopenia -feedback to make more clotting factors not working -lack of clotting factor replacement causes bleeding -pt at risk for both clotting & bleeding

Demeclocycline is given for a pt with ____ while Desmopressin is given for ____.

-Demeclocycline is for SIADH (150-300mg several times/day up to 600-1200mg/day) -Desmopressin is for DI (nasal spray 10 mcg/spray or tablet 0.1mg or 100mcg)

What is the worst case scenario for pt with SIADH?

-FVE w hyponatremia -confusion -changes in LOC -changes in heart rhythm (r/t fluid & electrolyte imbalance) -seizures -coma

Hypercorticoid is also known as_____ & ____ while Hypocorticoid is known as ____, ____, & ______

-Hypercorticoid: Cushings syndrome & hyperaldosteronism -Hypocorticoid: Adrenal insufficiency, Addison's, & Addisonian Crisis

What should the nurse assess for a pt with DI?

-I&O (3-20 L/day) -thirst (increased) -urine color (pale/clear) -urine osmolality (dilute <200-300) -serum osmolality (elevated >300) -specific gravity (dilute <1.003) -HR (increased to compensate >100) -BP (decreased) -Hx or trauma, infection, head injury, chronic disease, kidney disease

What should the nurse assess for in a pt with SIADH?

-I&O (I>O) -increased thirst -urine color (concentrated dark yellow/orange) -specific gracity (high bc concentrated) -serum osmolality (low/diluted) -increased HR -BP (can be increased with FVE) -daily weight

What are causes of SIADH?

-MAOI use -NSAID use -SSRI use -psychosis -mental health crises -vasopressin use -emphysema -tuberculosis -pneumonia -asthma -cancer -malignancy -tumors -stroke -heart failure -infection -HIV/AIDS -Guillan Barre -trauma -surgery -brain injury (esp hypothalamus) -emergency & ICU situations -burns -hemorrhage -hereditary

What is the normal dosing for desmopressin, the medication given for diabetes insipidus? (think about different routes)

-Nasal spary: 10 mcg/spray -Tablet: 0.1mg or 100 mcg

What are the proper routes & doses for DDAVP/desmopressin/vasopressin for DI?

-PO: 0.1-0.2 mg or 100 mcg -IV: 4 mcg -intranasal: 10 mcg/spray -sublingual: 25 mcg *start at a low dose and titrae; for 24-36 mos

What is primary disease vs secondary disase in alterations in endocrine function?

-Primary: dysfunction in the gland itself -Secondary: disease due to dysfunction in glands' stimulating hormone production or regulation (ex: if problems w pituitary, then problems elsewhere bc signaling mechanism)

In SIADH what does the urine look like? What about DI?

-SIADH= urine is dark, amber color bc fluid is retained & there's scant urine -DI= urine is clear, pale color bc lots of fluid being excreted, diluting the urine

What are potential causes of ACUTE DIC?

-cancer -*sepsis!* (bacterial, fungal, or protazoal; esp gram +/-) -surgery -trauma -burns -MVA -frostbite -posionous snake bites -childbirth -preeclampsia -placental abruption -blood traunsfusion reaction (wrong blood products) -pancreatitis -liver disease -artificial devices (artificial heart valves) -systemic inflammatory response syndrome (SIRS)

What are potential causes of chronic DIC?

-cancer -tumor -MI -autoimmune/inflammatory process -rheumatoid arthritis -ulcertive colitis -chrons disease -sarcoidosis -lupus

What are some indications for the use of desmopressin? *also known as vasopressin or DDAVP; Doses are PO 0.1-0.2 mg, IV 4 mcg, intranasal 10 mcg, sublingual 25 mcg

-central DI -after surgery -after brain/head surgery -control bedwetting for children (use nasal spray)

What is cortisol's (glucocorticoids) effects on the body?

-collagen production -protein catabolism -metabolism of fats, carbs, & proteins -anti insulin effect (hyperglycemia) -inhibitory effect on T-cells (impaired immunity) -enhanced catecholamine activity -works on CV system like BP

The adrenal cortex secretes cortisol, aldosterone, (& adrogens). What are their actions?

-cortisol: controls BP, response to stress, BG, & metabolism -Aldosterone: controls BP, Na+, & K+

What is the extreme version of DI? *rapid & large water loss

-extreme dehydration -confusion -changes in LOC -changes in heart rhythm -seizures -coma

What are the most common s/s & assessments of DI? *must know

-extreme thirst (polydispsia) -excretion of an excessive amount of diluted urine (polyuria; 3-20L/day) -getting up at night to urinate (nocturia) -bed wetting in children -dry skin -dizziness -nausea -fatigue -weakness -muscle weakness (from losing electrolytes) -pale/clear urine -low urine osmolality (<200-300) -high serum osmolality (>300) -low specific gravity ( <1.003) -increased HR (>100) -decreased BP

A 78 year old pt fell on the stairs this morning with a glass of water in her hand. Pt has hx afib & taking coumadin. A SSRI was prescribed 2 mos ago for complaints of depression following the suicide of her son. She had been eating a cariac diet with 2g of sodium intake daily. On physical exam she had several bruises on her head was disoriented, & had pain in her head. What are red flags for SIADH?

-fell on the stairs (trauma risk factor) -holding a glass of water (r/t increased thirst) -use of SSRI & depression (risk factor) -2g of sodium (already have risk of hyponatremia w SIADH & sodium restriction increases risk) -bruises on head & disoriented (head/brain injury risk factor)

What are some blood transfusion adverse effects that would alert the nurse to stop the transfusion? *r/t DIC

-fever -chills -itching/urticaria -rash -hypotension -SOB -anaphylaxis *the nurse should stay with the pt for 1st 15 minutes to watch for these reactions; the transfusion should run for max 4 hours

What does the adrenal cortex secrete? *adrenal glands sit ontop of the kidneys & cortex means inside; r/t Cushings &Addisons

-glucocorticoids (cortisol) -mineralcorticoids (aldosterone) -androgens

What are the normal ranges for the following lab tests: -hgb -hct -rbc -wbc -platelet -sodium -potassium -calcium -magnesium -bun -creat -urine specific gravity -urine osmolality -serum osmolality -fibrinogen/factor 1 -fibrinogen activity level -fibrinogen antigen level -thrombin time -PT -INR -PTT -firbin degredation products

-hgb : 12-18 -hct : 37-52% -rbc: 4.2-6.1 -wbc: 5,000-10,000 -platelets: 150,000-400,000 -sodium: 135-145 -potassium: 3.5-5 -calcium: 9-10.5 -magnesium: 1.2-2 -BUN : 10-20 -Creatinine: 0.5-1.2 -Urine Specific Gravity 1.003-1.030 -urine Osmolality: 300-900 -Serum Osmolality 270-300 -fibrinogen: 60-100 -fibrinogen activity level: 150-400 -fibrinogen antigen level: 149-353 -Fibrin Degradation Products: <10 -thrombin time: 12-14 secs -PT: 11-14.5 -INR: 0.8-1.1 -PTT: 24-36

What labs & test help to diagnose SIADH?

-high urine osmolality >900 -low serum osmolality <270 -low Na+ <135 -high urine specific gravity >1.030 -CT/MRI to rule out pituitary traume/injury/tumor -ADH level draw (not common)

What is the worst case scenario for DIC?

-hypovolemic shock -hemmorhagic shock -organ failure -death

What may cause Addison's crisis?

-infection -stress -trauma *teach pt to take prn cortisol medication ex: MVA, surgery, final exam, wedding, job presentation

What can cause nephrogenic DI, the damage to the end site of ADH where structures in the kidneys that cause water to be excreted or reabsorbed? This makes kidneys unable to properly respond to ADh

-inherited (genetic) disorder -CKD -lithium -demeclocycline

What discharge teaching should be included for a pt with SIADH? *must know

-med dosing & need to be on demeclocylien for many months -monitor daily weight for fluid retention -monitor urine color changing ex: clear (too much out), yellow (good), orange (too much retained/dehydrated) -monitor for dizziness, fatigue, confusion, & other symptoms of hyponatremia -monitor pts closely with respiratory disease (CTB, emphasema, & asthma), mental health treatments, injury/ trauma, emergency medicine & ICU -follow up for med titration & Na+ lab redraws

What discharge teaching should be included for a pt with DI? *must know

-med dosing & need to be on desmopressin/DDVAP for 24 to 36 mos -monitor daily weight & report weight loss/gain ex: 2lbs in 24 hrs -monitor urine color changing ex: clear (too much out), yellow (good), orange (too much retained/dehydrated) -monitor for dizziness, fatigue, & confusion -monitor for kidney disease & chronic inflammation diseases ex: sarcardosis -frequent checks of Na+ & tighter control of I&O -monitor pts closely with injuries/trauma/structural defects ex:brain tumor or surgery -follow up lab redraws

What are interventions for SIADH?

-monitor I&O -record daily weights -baseline electrolytes -monitor perfusion (BP/HR/VS) -monitor cognition (neuro checks, assess for changes) -baseline testing of pituitary & kidneys to rule out structural defects, injury, or obvious inflammation, brain bleed, tumor assess for N/V, weakness, fatigues, & seizures -assess mental health & meds like MAIOs & SSRI (can cause) -surgery if caused by tumor of pituitarym hypothalamus, or head -fluid restriction (1000ml/24hrs or NPO) -hypertonic IV given slowly -PO salt tablets -demeclocyline, VRA/vaptans, or lasix if ordered

What interventions are there for pts with DIC?

-monitor underlying cause: sepsis, cancer, etc -monitor VS for shock, tachypnea Clotting: -monitor SaO2; orientation; heart rhythm; I&O; abd pain; peripheral skin, tissue, circulation, & pulses -give antithrobin treatments ex: IV heparin or subQ LMWH (dalteparen/fragmin) -give PO anticoagulants/antifibrinolytics (aminocaproic acid/amicar Bleeding: -monitor sites IV, catheter, foley, surgical site, mucosa, urine, stool, skin -give platelets -give IV blood products like PRBC or FFP (contain coag factors) -give specific IV clotting factors -monitor lab redraws for improvement of decline

What should the dr order for a pt bleeding with DIC? (put in most likely order)

-platelets -PRBC -FFP -specific clotting factors

What pts are on long term steroids, putting them at risk for cushings or addisons?

-respiratory problems -autoimmune -infections

What can cause central DI, from damage to the pituitary gland or hypothalamus where they body is not producing vasopressin?

-surgery -tumor -illness like meningitis -inflammation like sarcoidosis -head injry

What labs & tests are used to diagnose DI?

-urine osmolality low <200 -serum osmolality low or normal; high in nephrogenic DI -sodium high or normal >145 -glucose normal -urinalysis -urine specific gravity very dilute <1.003 -CT/MRI to rule out trauma, injury, tumor w central DI -ultrasound & kidney labs to rule out structural damage or inflammation w nephrogenic DI -water deprivation test to stop drinking fluids & check ADH stimulation

List the expected outcomes with treatment of DI or SIADH? *shows that treatment is helping

-urine osmolality normal (300-900) -serum osmolality normal (270-300) -sdoium normal (135-145) -specific gravity normal (1.003-1.030) -CT/MRI negative -stable I&O -meds delivered and taken as ordered -stable pt weight -stable post op -In DI: free from s/s FVD (confusion, dry skin, tachy, etc) -In SIADH: free from s/s of FVE (VS, orientation, etc)

The healthcare provider prescribes heparin 2500 units subcutaneous daily. The drug is available in 10,000 units per mL. How may milliliters will the nurse give? __________________________

0.25 mL

A pound of fluid is about ____mls and 2.2 pounds is about ______mls

1 lb= 500ml; 2.2 lbs=1000ml

Match the following Na+ levels for the interventions for DI 1) oral replacement 2) hypotonic IV ex: D5W 3) Critical emergency, ICU! Give colloids

1) 145-149 2) 150-169 3) >170 *calculate pts weight for % fluid lost; titrate & recheck Na+ levels q 1-2 hrs & prn; Na+ should reduce no more than 0.5 meq/L every hour

What is the normal range for: 1) fibriniogen (protein/coag factor) 2) fibrinogen activity level (how well fibrinogen/clotting is working) 3) fibrinogen antigen level (fibrinogen amount in blood)

1) 60-100 2) 150-400 3) 149-353

What's wrong with the following orders? How should they be modified for pt with SIADH? 1) fluid restriction of 2550 ml/day all sources 2) IVF 0.45%NS at 30ml/hr 3) continue sertraline, coumadin, & beta blocker 4) pt up to bathroom ad lib 5) notify provider if urine output <30ml/hr or >1000ml/hr 6) neuro checks q 6-8 hrs 7) recheck sodium 3 hrs after initiating IV therapy 8) IVF 20%saline at 250 ml/hr 9) restraints for confusion prn

1)that's normal intake of 2,000-3,000 so change to 1500 ml/day 2) need hypertonic IV so change to 3%NS at 50ml/hr 3) switch dose of setraline, d/c coumadin, BP parameters for BB 4) change to up with assist, bed rest, or foley 5) change to <30ml/hr or >100ml/hr (don't want to over diurese) 6) change to neuro check 2-4 hrs & prn 7) recheck Na+ q 1-2 hrs 8) change to 3%, D5 .9, D5 1/2, 2% at 50ml/hr 9) no restraints, move pt closer to nurses station

Match the following types of Cushings to their definitions: 1. high glucocortiticoid (ex: cortisol) 2. high cortisol from any cause 3. high cortisol from a pituitary cause or tumor 4. man made cause of cushings from prescribed steroids (most common) 5. lung cancer releases ACTH like hormone (precursor of cortisol) that causes cushings

1. Cushings 2. Cushings Syndrome 3. Cushings Disease 4. Iatrogenic Cushings 5. Ectopic Cushings

Lab tests for DI specifically look @ fluid parts of blood & urine 1. what is the most common electrolyte affected? 2. what happens to urine osmolality? 3. what happens to serum osmolality? 4. what happens to Na+? 5. what happens to glucose? 6. what happens to urine specific gravity?

1. Na+ high or normal 2. urine osmolality super low <200 bc losing a lot of fluid 3. serum osmolality high or normal 4. Na+ increased >145 or normal 5. glucose is not involved, so it will be normal 6. urine specific gravity low/dilute <1.003

Match the following intake and output with the following questions: a) I=4000, O=1800; b) I=2200, O=4000; c) I=2500, O=2500 1. probable 2 lb weight gain 2. probable 2 lb weight loss 3. I&O for pt with DI 4. I&O for DI treatment with DDVAP 5. I&O in DI pt with desmopressin dose needing to be increased 6. I&O in pt with active SIADH 7. I&O in SIADH with successful demclocycline 8. demeclocycline treatment needing to be increased in SIADH 9. I&O has the most risk for hyponatremia 10. I&O has the likely serum osmolality of 225 11. I&O has the likely serum osmolality of 400

1. a) SIADH bc intake increased 2. b) DI bc output increased 3. b) DI bc output increased 4. c) bc therapuetic effect; euvolemia 5. b) DI bc ouput still high 6. a) SIADH bc retaining fluid/scant urine 7. c) bc therapuetic effect; euvolemia 8. a) SIADH bc retaining fluid 9. a) SIADH bc high intake & low output diluting blood 10. a) SIADH bc high intake diluting blood 11. b) DI bc high output concentrating blood

Match the correct sign or symptoms to either cushings or addisons disease a) Addisons b) Cushings 1. Fatigue, low BP 2. Weight loss 3. Darkened or bronzed skin 4. Puffy or rounded face 5. High BP 6. Weight gain, especially around the middle (central obesity)

1. a) addisons 2. a) addisons 3. a) addisons 4. b) cushings 5. b) cushings 6. b) cushings

What type of DI can the: 1. body not producing vasopressin bc of damage to pituitary or hypothalamus 2. kidneys not utilizing vasopressin 3. occurs only during pregnancy & when an enzyme made by the placenta destroys ADH

1. central DI 2. nephrogenic DI 3. gestational DI

What are the 3 different types of DI?

1. central DI (damage to pituitary or hypothalamus where body is not producing vasopressin) 2. nephrogenic DI (kidneys not utilizing vasopressin) 3. gestational DI (during pregnancy when enzyme made by the placenta destroys ADH)

Match the following anticoagulants meds for DIC with its reversal agent/antidote: 1. warfarin (Coumadin) [PO] 2. heparin [IV] 3. dalteprin (Fragmin) [subq] 4. rivaroxaban (Xarelto) 5. dabigatran (Pradaxa) 6. angiomax 7. streptokinase 8. tPA agents Either: a) idarucizumab (praxbin) b) protamine sulfate [IV] c) andexxa d) vitamin k [IV, IM, Subq, PO] e) no antidote: hemodialysis f) aminocaprioc acid in emergencies only

1. d) vitamin k; *warfarin not used in DIC* 2. b) protamine sulfate 3. b) protamine sulfate 4. c) andexxa 5. a) idarucizumab (praxbin) 6. e) no antidote: hemodialysis 7. f) aminocaprioc acid in emergencies only 8. f) aminocaprioc acid in emergencies only

Match the meds given with the proper condition, or choose "not correct dose, meds or intervention for any condition" a) Addison's b) Cushing's c) SIADH d) Diabetes Insipidus e) not correct dose, medication, or intervention for any condition 1) ___ fludrocortisone acetate 100 mg daily 2) ___ demeclocycline, dose titrated to achieve effect 3) ___ implanted synthetic or robotic pituitary to replace malfunctioning gland 4) ___ reduce or discontinue corticosteroids 5) ___ desmopressin/DDAVP 10-40 mcg, possibly in divided doses 6) ___ possible surgery to remove overactive adrenal gland 7) ___ fludrocortisone acetate 0.1 mg daily 8) ___ desmopressin/DDAVP 100-400 mg, possibly in divided doses

1. e) not correct dose, medication, or intervention for any condition 2. c) SIADH 3. e) not correct dose, medication, or intervention for any condition 4. b) Cushing's 5. d) Diabetes Insipidus 6. b) Cushing's 7. a) Addison's 8. e) not correct dose, medication, or intervention for any condition

Answer the following questions 1. another name for ADH? 2. glands involved in ADH production & secretion? 3. when is ADH released? 4. effects on concentration of blood, blood volume, BP, osmolality? 5. the body reaction to dehydration/hemorrhage?

1. vasopressin or AVP 2. hypothalamus makes ADH; pituitary stores until used 3. body is dehydrated to anti-diurese or hold onto water 4. decreasing concentration, increasing blood volume & BP, decreasing serum osmolality, and increase urine osmolality 5. release ADH to conserve fluids

What is the normal thrombin time? What if it's increased/decreased?

11-14 seconds which if increased=takes longer to clot=bleeding; decreased=clot quickly=clotting *heparin, fibrin degradation products (FDPs), an deficiency of fibrinogen increase it

The patient's heparin is infusing at 11 mL/hr. The bag of fluid is mixed 25,000 units of heparin in 250 mL D5W. What hourly dose is the patient receiving? __________________________

1100 units/hr

The patient's heparin is infusing at 28 mL/hr. The bag of fluid is mixed 20,000 units of heparin in 500 mL D5W. What hourly dose is the patient receiving? _________________________

1120 units/hr

What is the normal dosing for demeclocycling, the medication given for SIADH? What is the max dose?

150-300 mg several times a day *titrate to effect up to 600-1200 mg/day; monitor I&O, serum osmolality, urine osmolality,etc ex: give 150 mg at 0800 and by 1200 still no urine so call dr who will increase to 300 mg so watch, monitor, chart, and contact dr

What amount of urine output a day is considered polyuria, a symptom of DI?

3L/day in adults; 2L/day in children *high urine output; up to 3-20L out a day with DI

The healthcare provider prescribes heparin 900 units/hr. The label on the IV bag reads Heparin 10,000 units in 500 mL D5W. How many mL/hr will deliver the correct dose? ___________

45 mL/hr

What is the normal range for fibrinogen, a lab tested after PT/PTT is elevated?

60-100 *high fibrinogen= high clotting=thrombus formation; low fibrinogen= low clotting=bleeding

The nurse is starting a heparin infusion on a patient with DIC. The patient is 160 pounds. Initial rate = 10 units/kg/hr, or 1000 units. The heparin is supplied as 25000 units in 250 mL, or 100 units per mL. Therefore 1000 units is 10 mL/hr on the pump. Using the following protocol, what should the nurse do for an APTT of 86 seconds at 1300? *heparin protocol chart states at aPTT 86-100 bolus dose is 0, stop heparin infusion (mins) at 30 min, rate change (u/hr) at decrease 100, and next aPTT at 6 hrs after dose change A) Hold infusion for 30 minutes, decrease to 9 mL/hr, redraw APTT at 1930 B) Decrease heparin infusion to 900 mL/hr on the pump and redraw APTT at 1930 C) Decrease heparin infusion to 9 mL/hr on the pump and redraw APTT at 1930 D) Hold infusion for 30 minutes, decrease to 900 mL/hr, redraw APTT at 1930 Hold infusion for 30 minutes, decrease to 900 units/hr, redraw APTT at 1900

A) Hold infusion for 30 minutes, decrease to 9 mL/hr, redraw APTT at 1930 *Hold for 30 minutes. Restart at 100 units/hr less, so from 10 to 9 mL/hr on the pump using the concentration above. Recheck 6 hours AFTER restarting

A client has been diagnosed with SIADH. Which of the following should the nurse know to question in the client's plan of care?Select all that apply. A) Monitor serum calcium level B) Monitor weight C) Look for urine specific gravity < 1.003 D) Provide IV fluids of 0.9% normal saline at 100-200 mL/ hour for adequate hydration E) Monitor for possible mental status changes

A) Monitor serum calcium level C) Look for urine specific gravity < 1.003 D) Provide IV fluids of 0.9% normal saline at 100-200 mL/ hour for *Question monitoring Ca+ bc this is not a focus electrolyte in SIADH. The focus electrolyte is Na+ & its balance. Also question looking for a low, dilute specific gravity bc should be looking for an increase in urine specific gravity. Fluid in SIADH is retained and not readily excreted, making the urine more concentrated. DI, with a large volume of output, would have a more dilute specific gravity, less than the normal 1.003 to 1.030 range. Question providing IV fluids of NS bc pt with SIADH is over hydrated so need hypertonic IV. Fluid restriction is the key here to not overload the patient further.

What can the nurse expect to do with suspected PE? (select all that apply) A) call rapid response B) assess toe fungus status C) give oxygen to increase oxygenation D) give anticoagulants

A) call rapid response C) give oxygen to increase oxygenation D) give anticoagulants *give massive anticoagulation , not going to mess around with fragmin or coumadin; they're going to get the biggies

The nurse is reviewing lab values for a patient admitted to the ICU post brain trauma with SIADH. The nurse would likely expect that the lab values would show: A) decreased serum sodium, elevated urine osmolality & decreased serum osmolality B) elevated serum sodium, elevated urine osmolality & increased serum osmolality. C) decreased serum sodium, elevated urine osmolality & increased serum osmolality. D) elevated serum sodium, elevated urine osmolality & decreased serum osmolality

A) decreased serum sodium, elevated urine osmolality & decreased serum osmolality

What meds should be ordered at discharge either scheduled or PRN for the pt with Addison's disease? (select all that apply) A) dexamethasone B) amiodarone C) fludrocortisone D) hydrocortisone E) iodine F) calcium

A) dexamethasone C) fludrocortisone D) hydrocortisone *remember "sone" is a type of steroid which help mimic fluctuation of cortisol levels. It should be prescribed prn for stressful situations like weddings, surgery, and when ill

What are likely treatments for DIC? (select all that apply) A) platelets B) fresh frozen plasma C) streptokinase D) heparin E) PRBC

A) platelets B) fresh frozen plasma C) streptokinase D) heparin E) PRBC *could have bleeding or clotting

What do vaptans do such such as tolvaptan in SIADH? A) promote water loss without moving sodium b) promote ADH loss without sodium loss C) promote sodium loss without losing water D) promote demylination

A) promote water loss without moving sodium *SIADH is when body retains water causing hyponatremia, so want to remove water without removing more sodium

What conditions can cause SIADH? (select all that apply) A) pulmonary issues (emphysema, asthma) b) neurotic bladder C) trauma, cancer, tumor, or HIV D) none of the above

A) pulmonary issues (emphysema, asthma, TB, pneumonia) C) trauma, cancer, malignancies, tumor, or HIV/AIDS *also MAOI, NSAID, SSRI use; psychosis, mental health crises, Emergency & ICU situations, burns, hemorrhage, stroke, infection, Guillian Barre, hereditary

What will you not do with platelet administration? (select all apply) A) reuse tubing to save money B) assume info is correct and not double check pt armband C) run slow over 6 hrs to avoid pulmonary edema D) use 26 gauge IV site

A) reuse tubing to save money B) assume info is correct and not double check pt armband C) run slow over 6 hrs to avoid pulmonary edema D) use 26 gauge IV site *blood products are limited to 4 hrs; 26 is too small so maybe use 14-16 gauge

Which of the following are assessed and monitored with DI? (select all that apply) A) signs of hypotension b) signs of hypertension C) increased thirst D) decreased thirst

A) signs of hypotension C) increased thirst *hypotension bc losing a lot of fluid; increased thirst is apart of DI and SIADH

Which of the following occurs with DIC? (select all that apply) A) small clots that use up fibrinogen B) organ damage from small clots C) eventual bleeding D) risk for hypovolemia

A) small clots that use up fibrinogen (factor 1) B) organ damage from small clots C) eventual bleeding D) risk for hypovolemia *could have clots or bleeding

What are the expected nursing interventions for SIADH and DI? (select all that apply) A) strict I&O B) daily weight C) monitor sodium frequently D) monitor adrenal levels frequently

A) strict I&O B) daily weight C) monitor sodium frequently

After having a craniotomy, the pt is receiving desmopressin (DDAVP) intranasally for surgically induced DI. Which manifestation or behavior indicates to the nurse that the med is having a therapeutic effect? A) urine output is 50 ml/hr B) urine output is 150 ml/hr C) urine specific gravity is 1.303 D)urine specific gravity is 1.003

A) urine output is 50 ml/hr *urine putput of 150 ml/hr is too rapid. Daily range minimally is 30ml/hr. 50 ml/hr is still on the lower side. Even more normal urine output should range about 80-100 mL/hr, or 400 mL every 4 hours (that's about bladder capacity) to provide the 2000-2500 mL of expected urine output each day.

What's the antidote for warfarin (Coumadin ) A) vitamin K B) protamine sulfate C) vitamin D D) pyretasigmine sulfate

A) vitamin K *CTN in DIC

The laboratory calls to report a drop in the platelet count to 90,000/mm3 for a patient with DIC receiving heparin. Which action by the nurse is the most appropriate? A. Notify the healthcare provider to discuss the reduction or withdrawal of heparin. B. Call the healthcare provider to discuss increasing the heparin dose to achieve a therapeutic level. C. Obtain vitamin K and prepare to administer it by IM injection. D. Observe the patient and monitor the aPTT as indicated.

A. Notify the healthcare provider to discuss the reduction or withdrawal of heparin. *Heparin-induced thrombocytopenia (HIT) is a potential immune-mediated adverse effect of heparin infusions that can prove fatal. HIT is suspected when the platelet counts fall significantly. A platelet count below 100,000 would warrant discontinuation of the heparin.

What disorer is characterized by low glucocorticoids including aldosterone? What are the different causes?

Addison's -Primary causes: autoimmune & infection (most common) -Seconday caues: Iatrogenic (man made from long term steroids, can't produced on steroids when stressed or abrupt withdrawal)

What are s/s & nursing assessment of addisons disease & addisons crisis? *must know!

Addison's: -nausea -weight loss, anorexia -low aldosteorone -low Na+ -high K+ -low BG -weakness -postural hypotension -abdominal pain/GI disturbances -bronzed skin -change in distribution of body hair Addison's crisis (from stress, trauma, infection): -profound fatigue -dehydration -low Na+ -High K+ -cardiac collapse -severe low BP/vascular collapse -abdominal pain -acute renal failure/renal shut down -fatal if untreated

What is the extreme version of Addisons?

Addisonian crisis (severe hypoadrenal) which is a life threatening situations that results in low BP, low BG, high K+ aka shock *treat with IV injections of hydrocortisone, saline solution, sugar (dextrose), & correct high K+

What is severe hypoadrenal life threatening situation that results in low BP, low BG, & high K+ (shock)? What is the treatment?

Addisonian crisis; treat with IV injection of: -hydrocortisone -saline solution -sugar (dextrose) -correct high K+

What can cause s/s of hypo secretion of aldosterone, cortisol, & androgens & out of ocntrol side effects each way, high or low?

Adrenalectomy (lose adrenal glands) from trauma, infection, MVA, etc

The nurse knows that which of the following patients are likely to develop SIADH? (select all that apply) A) 45 year old prisoner admitted as chest pain rule out MI B) 75 year old pt with rheumatoid arthritis taking methotrexate and motrin C) ICU patient admitted with acute pneumonia. History of COPD now with ARDS. Blood cultures positive for gram positive rods. D) 21 year old college student who is being admitted for acute delusions and hallucinations. She has a history of living with mental illness and is taking Nardil and Zoloft. E) 28 year old motorcycle traffic incident patient who hit his head and has developed a cerebral bleed. May have to have a crainiotomy.

B) 75 year old pt with rheumatoid arthritis taking methotrexate and motrin C) ICU patient admitted with acute pneumonia. History of COPD now with ARDS. Blood cultures positive for gram positive rods. D) 21 year old college student who is being admitted for acute delusions and hallucinations. She has a history of living with mental illness and is taking Nardil and Zoloft. E) 28 year old motorcycle traffic incident patient who hit his head and has developed a cerebral bleed. May have to have a crainiotomy. -A) MI is risk for chronic DIC. -B) The chronic inflammatory disease coupled with the NSAID use can cause SIADH. Remember that kidney function also declines with age, so that doesn't help in SIADH! -C) Pneumonia, respiratory hx, respiratory complication (ARDS) and positive blood cultures (point to sepsis, another SIADH indicator. 30-50% of septic patients will develop SIADH! ). -D) This mental health crisis along with the MAOI (Nardil) and SSRI (Zoloft) put this patient at risk for SIADH. Age doesn't matter here with SIADH! It's all metabolic! -E) The trauma of the incident is one reason, and also the hemmorhage itself can enhance ADH release. The brain bleed has potential to also cause injury to the hypothalamus and/or pituitary just by happening in that enclosed space. If your patient goes to surgery, that's another reason that SIADH can occur!

The nurse knows that which of the following extreme conditions can occur if DIC is not recognized and controlled? Select all that apply. A) Septic shock B) Hemorrhagic shock C) Hypovolemic shock D) Organ failure E) Death

B) Hemorrhagic shock C) Hypovolemic shock D) Organ failure E) Death *Prognosis for those with DIC, regardless of cause, is often not good. Between 20-50% of DIC patients will die. DIC that is associated with sepsis has a significantly higher rate of death than DIC associated with trauma or injury. The bleeding that occurs with DIC can cause blood loss to be so severe that there can be hemorrhagic shock (a specific type of hypovolemic shock). Both are terrible. Treatment for hemmorrhagic shock may include crystalloids for volume, colloids/plasma expanders for volume, surgery to stop bleeding, PRBCs, or other blood products such as platelets. The pt in hemorrhagic shock can have chest pain from lack of O2-carrying capacity. Broadly speaking, someone who is bleeding could be losing volume, and losing more than 20% of your circulating volume could cause hypovolemic shock. Circulating BV in adults is about 5000 mLs. So a loss of 1000 mLs is 20%...a pint is 473 mLs.... so 2 pints is all you have to lose! In hypovolemic shock, CO drops, HR rises, BP drops. Treatment for hypovolemic shock includes isotonic crystalloids, and also colloids. The benefit of the volume-expanding colloids here is that you may need less fluid to get the same positive effect, which is great for fluid-y patients such as CHF, etc. Remember that if there is micro-clotting as part of DIC, those clots can be anywhere, and can block blood flow to organs.The kidneys are the number one affected organ in DIC which is not good, as they manage excretion! If blood isn't effectively reaching vital organs like your kidneys, liver, or lungs, any organ can 'infarct' just like a 'myocardial infarction'... you can have a pulmonary infarction, liver infarction, or kidney infarction. Infarction means tissue death or necrosis.A clot to the brain can mean a stroke as an outcome of DIC. Yup. Death occurs frequently when associated with sepsis.

A client living with cancer has an ADH- hormone secreting lung tumor. Which of the following provider orders and plan would the nurse expect? Select all that apply. A) Hypotonic saline intravenous solution B) Hypertonic saline intravenous solution C) Accurate intake and output D) Fluid restriction E) Urinalysis for osmolarity F) Serum sodium level testing

B) Hypertonic saline intravenous solution C) Accurate intake and output D) Fluid restriction E) Urinalysis for osmolarity F) Serum sodium level testing -B) use less fluid with more Na+ particles to replace the sodium that is being diluted from the extra ADH. The patient does not need extra fluid so a more concentrated formulation is chosen. -C) I&O is one way to calculate fluid lost or gained with this fluid-impacting hormone that is being released. -D) You would expect a fluid restriction as the client is already overloaded from the extra ADH being secreted and retaining more water. -E) The nurse and team should stay on top of how diluted the urine is, especially to then see it respond back to normal with treatment. A serum sodium would be good to also check. Specific gravity can also be assessed. -F)If the tumor is giving off more ADH, more water is retained, and is diluting the sodium that is there. You would want to assess sodium status to see what potential replacement is needed.

What is included in general discharge teaching in DIC? (select all that apply) A) call dr with increased thirst B) call dr with any bruising C) call dr with increased urination D) call dr with any blood tinged urine

B) call dr with any bruising D) call dr with any blood tinged urine *refer to last slide; SIADH & DI cause increased thirst; increased urination is DI

The nurse cares for a pt admitted 2 days ago with a diagnosis of closed head injury. If the pt develops diabetes insipidus, the nurse will observe which symptoms (select all that apply) A) glucosuria B) cracked lips C) weight gain of 5 lbs D)BP 160/100, pulse 56 E) urinary output of 4L/day F) urine specific gravity of 1.004

B) cracked lips E) urinary output of 4L/day F) urine specific gravity of 1.004 *glucosuria occurs with DM; cracked lips occurs bc dehydration by excessive water loss; weight loss occurs which is opposite of SIADH where pt gains weight; hypertension and bradycardia are late signs of increased ICP or brain damage; high urine output from excessive fluid loss; low urine specific gravity from urine not concentrated in the kidney from high fluid loss diluting the urine (normal specgrav is 1.003-1.030)

The nurse should notify the physician for which incorrect order for a pt with SIADH? A) demecocycline 200 mg 3-4x/day B) desmopressin 200 mg/day C) demecocycline 150 mg 3x/day D) correct answer not shown

B) desmopressin 200 mg/day *desmopressin is given for DI which means that it is an incorrect order; demecocyline is given, but option A) is a better dose to give bc it equals around 600-800 mg for the day and its titrated to effect with dose of 150-300mg several times a day up to 600-1200mg/day

What can the nurse expect on the med list for the pt with SIADH? (select all that apply) A) desmopressin B) hypertonic IV C) demeclocycline D) hypotonic IV

B) hypertonic IV C) demeclocycline *don't jump right to 2-3%NS, use other options like D5NS, D5 0.45%NS, D5LR, D10W?

The pt diagnosed with Addison's disease comes to the health clinic. When assessing the pts skin, the nurse expects to make which observation? A) skin that is pale and dry B) skin that is darker and more pigmented C) skin that is puffy and scaly D) skin that is ruddy and oily

B) skin that is darker and more pigmented

The pt is diagnosed with Cushing's syndrome. Which assessment finding does the nurse recognize as a pertinent to this diagnosis? A) low BP and weight loss B) thin extremities with easy bruising C) decreased urinary output and decreased serum potassium D) tachycardia with reports of night sweats

B) thin extremities with easy bruising *BP will increase & pt gains weight; no correlation with urinary output, but there is low K+ & high Na+; there is no correlation with cushing's syndrome & tachycardia with night sweats

The nurse knows to question which which of the following discharge orders for hypo cortisol isn't/addisons disease? (Select all that apply) A) fatigue B) watch urine color so it doesn't get dark C) call provider with weight loss, lightheadedness, headache, or fatigue D) pt will take their medication as ordered and will report any side effects to their provider before deciding to discontinue any meds E) pt should notify all of their providers regarding their disease especially prior to undergoing procedures F) dipstick their urine for cortisol

B) watch urine color so it doesn't get dark F) dipstick their urine for cortisol *make sure they are notifying the provider with extreme fatigue, a symptoms of this condition. Think about giving your pt their own pee chart & teach them all of the urine colors. We want the pt to be set up with lab draws to check serum/plasma cortisol levels instead.

The nurse is ready to begin a heparin infusion for a patient with DIC with an evolving stroke. The baseline aPTT is 40 seconds. Which aPTT value indicates that a therapeutic dose has been achieved? A. 50 B. 70 C. 90 D. 110

B. 70 *The therapeutic level of heparin is achieved when the aPTT reaches 1.5 to 2 times normal. Thus, a range of 60 to 80 seconds would be appropriate for this patient.

A patient with DIC is receiving an IV heparin infusion asks the nurse how this medication works. What is the nurse's best response? A. Heparin prevents the activation of vitamin K and thus blocks synthesis of some clotting factors. B. Heparin suppresses coagulation by helping antithrombin perform its natural functions. C. Heparin works by converting plasminogen to plasmin, which in turn dissolves the clot matrix. D. Heparin inhibits the enzyme responsible for platelet activation and aggregation within vessels.

B. Heparin suppresses coagulation by helping antithrombin perform its natural functions. *Heparin is an anticoagulant that works by helping antithrombin inactivate thrombin and factor Xa, reducing the production of fibrin and thus decreasing the formation of clots.

A 38 yr old pt with coronavirus infection has suspected DIC. What is the nurse concerned is happening if the pts labs come back as: RBC 3.0 (4.2-6.1) Hgb 9.7 (12-18) Hct 31 (37-52) platelet 110 (150-400) PT 16 (11-14.5) INR 3.2 (0.8-1.1) PTT 42 (24-36) fibrinogen 450 (150-400)

Bleeding *fibrinogen should be decreased bc low fibrinogen=low clotting=bleeding; so call the dr to redraw

If pt with DIC has low fibrinogen level, what would the nurse expect the pt will look like? *normal range 60-100

Bleeding at places like mucosa & nosebleed (ear & eyes not common), IV site, NG tube, foley catheter, hematuria (orange urine), bloody stools (bright red or black tarry)

What is the pt with DIC at risk for?

Both clotting & bleeding

Does the nurse suspect that a pt hyponatremic or hypernatremic if they are showing signs of confusion?

Both! so SIADH=hyponatremia=confusion & DI=hypernatremia=confusion

What response to the UAP most shows that the nurse needs the most education regarding delegation for the pt with diabetes insipidus? A) "empty his foley" B) "empty his foley and chart the results' C) "he is up as tolerated to the bathroom and is voiding in the toilet" D) "ambulate the pt with a standby assist in the hallways"

C) "he is up as tolerated to the bathroom and is voiding in the toilet" *pt should be monitored with strict I&O and should be monitored/assisted with toileting to avoid falls r/t dehydration

Which of the following rhythms does the nurse most anticipate in acute DIC? Select all that apply. A) NSR B) Sinus Bradycardia C) ST elevation D) Sinus tachycardia E) Afib

C) ST elevation D) Sinus tachycardia *significant ST segment elevation is a sign of a MI. Infarctions can be caused by the thrombi, or the clots of DIC. Yes, sinus tachycardia, which can occur with hypovolemia related to bleeding in DIC, hemmorrhagic shock r/t bleeding in DIC, and possibly with decreased gas exchange and/or pain related to thrombi in DIC.

Diabetes Insipidus is a possible complication after pituitary surgery. The nurse should assess for which symptom of diabetes insipidus? A) urine specific gravity greater than 1.500 B) urine output 1000-1250 ml/day C) urine specific gravity less than 1.005 D) urine output between 750-1000 ml/day

C) urine specific gravity less than 1.005

A patient with DIC presents to the ED with symptoms of stroke. After a diagnostic workup, the HC provider prescribes a 15mg IV bolus of alteplase (tPA), followed by 50 mg infused over 30 minutes. In monitoring this patient, which finding by the nurse most likely indicates an adverse reaction to this drug? A. Urticaria, itching, and flushing B. Blood pressure of 90/50 C. Decreasing LOC D. Potassium level of 5.5

C. Decreasing LOC *The greatest risk with this drug is bleeding, with intracranial bleeding being the greatest concern. A decreasing level of consciousness indicates intracranial bleeding. Alteplase does not cause an allergic reaction or hypotension. Thrombolytic agents, such as alteplase, do not typically cause an elevated potassium level.

The nurse is monitoring a patient with DIC receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding most likely relates to an adverse effect of heparin? A. Heart rate of 60 beats/min B. Blood pressure of 160/88 mm Hg C. Discolored urine D. Inspiratory wheezing

C. Discolored urine *The primary and most serious adverse effect of heparin is bleeding. Bleeding can occur from any site and may be manifested in various ways, including reduced blood pressure, increased heart rate, bruises, petechiae, hematomas, red or black stools, cloudy or discolored urine, pelvic pain, headache, and lumbar pain.

The nurse knows that which statement is accurate for LMWH like enoxaparin [Lovenox] for DIC? A. It equally reduces the activity of thrombin and factor Xa. B. It has selective inhibition of factor Xa and no effect on thrombin. C. It reduces the activity of factor Xa more than the activity of thrombin. D. It has a lower bioavailability and shorter half-life than unfractionated heparin.

C. It reduces the activity of factor Xa more than the activity of thrombin. *Enoxaparin acts primarily on factor Xa and also, but to a lesser degree, on thrombin. Unfractionated heparin equally reduces the action of thrombin and factor Xa. Fondaparinux [Arixtra] causes selective inhibition of factor Xa. Low-molecular-weight (LMW) heparins, such as enoxaparin, have greater bioavailability and a longer half-life than unfractionated heparin.

What increases a pts risk for DI?

Central: -surgery -tumor -illness like meningitis -inflammation like sarcoidosis -head injury Nephrogenic: -inherited (genetic) disorder -CKD -lithium -demeclocycline Gestational: -pregnancy

What assessment findings indicate a thombi? (can also use venouos & arterial dopplers to assess)

Clot: -red -warm -swollen -painful Distal to clot: -cyanotic -decreased pulses

What are the potential s/s of DIC? *must know!

Clotting: -clots in peripheral, organs, & vessels that supply organs (heart, lung, brain, liver, kidneys) -petechiae -purpura -PE -stroke -MI -kidney infarction -liver infarction Bleeding: -blood in urine, stool, IV sites, chest tubr, surgical site, foley -bleeding from mucosa like nose, gums, etc -internal bleeding/unseen which can cause hypovolemic/hemmorhagic shock

What is the best definition of disseminated intravascular coagulation?

Concerns both clotting & bleeding

What is more likely to occur, Cushing's (hypercortisolism) or Addison's (hypocortisolism)

Cushing's

What s/s & nursing assessments indicate cushings syndrome & cushings disease? *must know!

Cushing's Syndrome: -CNS irritability -personality changes -psychiatric issues -increased susceptibility to infection -HTN -high BG -high Na+ -low K+ -moon face -acne -fat deposits on face & back of sounders (buffalo hump) -central obesity -purple striae on abd -GI distress/ high acid -thin extremities -thin skin -Na+ & fluid retention (edema) -poor wound healing -easy bruising -petechiae -osteoporisis -males: gynecomasia (breast development) -females: amenorrhea (no period), hirsutism (overgrowth unwanted hair ) Cushing's Disease ONLY: -masculinization in females

What endocrine syndrome may be caused by a tumor, use of corticosteroids, or high stress on the body?

Cushing's syndrome *use of corticosteroids most commonly causes so see increased likelyhood for pts with allergies, asthma, COPD, lupus, & autoimmune disease bc taking steroids

What is the antidote/reversal agent for Heparin? A) Vitamin K B) streptokinase C) magnesium sulfate D) protamine sulfate

D) protamine sulfate

The nurse is caring for a patient who takes warfarin [Coumadin]. The patient has an INR of 1.2. Which action by the nurse is most appropriate? A. Administer IV push protamine sulfate. B. Continue with the current prescription. C. Prepare to administer vitamin K. D. Call the healthcare provider to increase the dose.

D. Call the healthcare provider to increase the dose. *An INR in the range of 2 to 3 is considered the level for warfarin therapy. For a level of 1.2, the nurse should contact the healthcare provider to discuss an order for an increased dose. warfarin is CTN in DIC

What are the different names for Disseminated, Intravascular, & Coagultion (DIC)

D=widespread I=across many vessels C= clotting

What is an tetracycline ATB derivative which induces DI by acting on the collectin tubule to diminish responsiveness for ADH?

Demeclocycline *used for SIADH; the role is limited in emergency care bc of its slow onset of action; start low dose & titrate at 150-300 3-4 times a day for 7-14 days (max 600-800 a day)

What is a disease in which there is a decrease response or decreased release of ADH (vasopressin)?

Diabetes insipidus *is an uncommon disease; opposite of SIADH

How often should the nurse recheck sodium levels when administering IV fluids for DI or SIADH? What sodium level should it decrease by each time?

Every 1-2 hours; decrease by NO more than 0.5 meq/L *ex: pt at 150, recheck in 1 hour & make sure no less than 145.5; in DI pt has hypernatremia so receiving hypotonic IV; in SIADH pt hyponatremia so receiving hypertonic IV

T or F abrupt withdrawl of corticosteroids can cause Iatrogenic Cushings?

False! It is Iatrogenic Addisons (secondary cause)

T or F: the nurse should monitor BG for pt with DI

False! Not r/t glucose metabolism/DM

T or F: pt with DIC has PE and should be prescirbed fragmin (LMWH)?

False! Should give tPA

What is a lab test is a protein and a coagulation factor often tested after PT/PTT is elevated for pt with suspected DIC?

Fibrinogen *also called Factor 1 or Plasma Fibrinogen; normal range 60-100; fibrinogen activity level is is 150-400

What are interventions for addisons?

Give cortisol: -*PO corticosteroid* ex: fludrocortisone to replace aldosterone; -*PO corticosteroids* ex: hydrocortisone (cortef), prednisone, or cortisone acetate to replace cortisol -*cortisosteroid injections* if pt ill with vomiting -*Androgen replacement therapy* to treat women with androgen deficiency ex: dehydroepiandrosterone -*Na+ replacement* esp with heavy exercise, GI upset, diarrhea -*Increased Na+ needs with stress* with operations, infection, minor illness, etc -*IV injections* like hydrocrtisone, saline soluion, sugar/dextrose, & correction of high K+ for Addisonian crisis

What are metabolic conditions which have some alterations in endocrine function?

Hyper/hypo cortisolism like cushing's & addisons *more common to have cushing's

What occurs with endocrine disorders? What is the treatment?

Hypo or hypersecretion of an endocrine organ. Treatment is aimed to block (if hyper) or replace (if hypo) hormones

The nurse is taking care of a patient with DIC. The provider's order reads, "infuse 2 units of fresh frozen plasma (FFP) each over 4 hours". Put the following nursing actions in the correct order: I)____Check patient's allergies, check for 20 gauge or larger patent IV site, teach patient about transfusion II)____Receive FFP from blood bank and check product including amount of fluid and expiration date, check against orders III)_____Check vital signs 15 minutes after infusion started and assess for any signs of a reaction: chart vitals IV)____Recheck patient's armband and identifiers and blood product with another RN at bedside just prior to hanging FFP; chart current vital signs and ensure recent baseline assessment including lung sounds has been completed and charted V) ____Check order & patient labs including all coagulation labs VI) ____At completion of infusion, keep unit bag and tubing at bedside, reassess lung sounds and vital signs, start second unit when able and as patient tolerates VII)____Spike FFP and prime tubing: set pump to divide volume over no more than 4 hours: connect to patient and start infusion

I) __2__Complete teaching and ensure pt is ready to receive infusion. IV's smaller than a 20g (22 or 24) are harder to run blood products on: consider a 18g or 20 g minimum. Teaching and making sure patient is ready to receive the blood transfusion should happen long before you get the blood product on the unit. Asking about previous transfusions here is smart! Jehovah Witnesses do not receive PRBCs as it is against their religion. However, they might agree to platelets, clotting factors, or albumin. Jehovah Witnesses are found in every country. Many African nations have a much higher rate of JW in their population than the US. II) __3__Do not receive the blood product until you are ready for it and have checked out your IV site and patient orders and info! Most blood products need to be hung within an hour of dispensation. You will have varying institutional policies to follow regarding these timeframes - look them up! III)__6__Do not go to lunch or delegate these vitals! Stay present and ideally stay at bedside to reassess your patient. IV) __4__Recheck product and info at bedside! You need to chart vital signs and lung sounds to monitor for any signs of fluid volume overload during and post transfusion. V) __1__First make sure of order and patient before going to patient. Check baseline labs to ensure you know what you're dealing with. In this case, the nurse might question the 'over 4 hours' timeframe. This is common with PRBCs but might be too slow for plasma or platelets that will have less volume (typically run over 30-60 minutes). A patient also in CHF or otherwise fluid overloaded would be a good reason to run it more slowly. VI) __7__ Keep tubing and bag at bedside in case of a delayed reaction: blood bank will want the info. Do not start second unit until you have reassessed your patient and are sure they can tolerate both the additional blood product and the additional fluid. VII)__5__If you are priming tubing with fluid, you will always use 0.9% saline/isotonic solution. Start your patient's infusion!

If pt is prescribed heparin for DIC and the nurse notes bleeding, what is likely the route heparin is being given?

IV *half life of 15 mins

What is used for diagnosis of nephrogenic DI?

Look at kidneys by doing an ultrasound for structural damage & inflammation

What does the fibrinogen level look like as DIC increases?

Lower plasma fibrinogen levels (increased risk of bleeding) *but high fibrinogen shows less secondary fibrinolysis (cleanup crew to dissolve clots, not working) which explains organ failure

If Desmopressin is working for DI, what is the color of the urine expected to change to?

More yellow instead of pale bc urine will be more concentrated from less fluid excreted *urine specific gravity will increase & serum osmolality will decrease

What is used for diagnosis of central DI with pituitary & hypothalamus area ?

Must rule out injury, trauma, infection, inflammation by doing a CT or MRI

What are fibrin degradation products (FDPs)? What happens if they're low/high

Normal process for a clot to dissolve; stuff left after a clot dissolves; the normal "clean up crew" -low=not dissolving clots normally (not cleaning up=clots) -normal <10 -high (D-dimer)=rise after thrombotic event; too many clots; increase thrombin time (dissolve too many clots= risk for bleeding)

What is the dose for demecloclycline for SIADH?

PO: 150-300 mg 3-4x/day up to 600-1200 a day for 7-14 days

What are the expected outcomes for pt with DIC? *must know

Patient will have/be: -stable VS -continued central & tissue perfusion -stable urinary function & excretion -stable I&O -receive blood products accurately as ordered (<4 hrs) -labs trended & followed -anticoagulation therapy as ordered -free from s/s of bleeding; monitor sites; teach pt look at stool & urine, careful brush teeth & shave -stable tissue integrity; monitor bleeding, purpura, petechiae -free from injury -discharged on anticoag regimen; monitor closely for bleeding -able to verbalize s/s of both bleeding & clots; report SOB, changes in cognition, DIB,etc)

What is considered the "master gland" in the body? Why? *r/t Cushings & Addisons

Pituitary *sends out hormones to target organs, telling them to start secreting the target organ's hormone

What glands are damaged in central DI?

Pituitary gland or hypothalamus

What gland sends out hormones to target organs, telling them to start secreting target organ's hormone? It is considered the "master gland" *r/t Cushings & Addisons

Pitutary

What term describes a disease of the gland itself like thyroid? What is the term when a disease is occurring in the gland above it like the pituitary?

Primary disease=gland itself vs Secondary disease=above the gland *ex: a head injury would affect the pituitary but an arrow through the neck would affect the thyroid

What are potential causes of Addisons?

Primary: -autoimmune -infection Secondary: -Iatrogenic (man made from long term use of steroids, where can't produce own steroids when stressed or with abrupt withdrawal)

What endocrine syndrome may be caused by brain injury (esp hypothalamus), heart failure, infection, stroke, or surgery?

SIADH *increased production of ADH/vasopressin

What is more likely to cause hyponatremia: DI or SIADH?

SIADH (DI will more than likely cause hypernatremia) *r/t water retention diluting blood

What are the different types of fluid replacement based on Na+ levels for DI vs SIADH?

SIADH: -Na+ of <125: rapid response; critical emergency! transger to ICU; high morbidity! -Na+ of 125-135: hypertonic IV like 3% saline DI: -Na+ of 145-149: oral replacement; no IV -Na+ of 150-169: hypotonic IV like D5W -Na+ of >170: colloids; critical emergency! transfer to ICU *IV not too fast! titrate w frequent sodium checks q 1-2 hrs; no more than 0.5 mEq/L change every hour

Indicate if the following is increased or decreased if the pt has SIADH vs DI 1. urine output 2. serum sodium 3. urine osmolality 4. serum osmolality 5. BP

SIADH: 1. urine output decreased 2. serum sodium decreased; confusion, delirium, coma 3. urine osmolality increased 4. serum osmolality decreased 5. BP normal, no dehydration DI: 1. urine output increased 2. serum sodium increased; seizures, coma 3. urine osmolality decreased 4. serum osmolality increased 5. BP decreased, dehydration

Match the following to either a) SIADH or b) DI 1. urine output <200 ml in 2hrs 2. confusion, delirium, coma with hyponatremia 3. urine output increased >250 ml in 2hrs 4. serum Na+ decreased <135 5. urine osmolality increased >900 6. serum osmolality decreased <270 7. seizures, coma 8. serum Na+ increased >135 9. urine osmolality decreased <300 10. normotension; BP 90/60-120/80 11. serum osmolality increased >300 12. hypotension <90/60 13. dehydration 14. no dehydration

SIADH: 1. urine output decreased <200 ml in 2hrs 2. confusion, delirium, coma with hyponatremia 4. serum Na+ decreased <135 5. urine osmolality increased >900 6. serum osmolality decreased <270 10. normotension; BP 90/60-120/80 14. no dehydration DI: 3. urine output increased >250 ml in 2hrs 7. seizures, coma 8. serum Na+ increased >135 9. urine osmolality decreased <300 11. serum osmolality increased >300 12. hypotension <90/60 13. dehydration

What term is to "turn on production & secretion of hormones in the receptor gland"? *r/t Cushings & Addisons

Stimulating *individual hormones may contain this word

What are interventions for cushings?

Take away cortisol: -restrict corticosteroid use esp with asthma, arthritis, autoimmune disease -give blocking meds b4 surgery or to control cortisol when surgery/radiation don't work -block or stop cortisol with radiation therapy & Gamma knife surgery -surgical removal of tumor (if causing) -adrenalectomy (full gland removal) -need some cortisol replacement to provide body balance after blocking

T or F: Central obesity but thin arms/legs is an assessment finding of Cushing's disease

True

T or F: DIC is not really its own disease, but a complication of other processes gone wrong

True

T or F: If pt with DIC is suspecting of clotting heparin should be started

True

What meds may be given for SIADH that spare elevtrolytes (aquaresis) where they excrete water without electrolytes than regular diuretics?

Vasopressin receptor agonist (VRA) like vaptans (PO or IV) *works to block ADH; sometimes used for correction of hypervolemic hyponatremia by increasing urine volume/excretion

Match the expected treatment with the correct condition of 1. SIADH or 2. Diabetes Insipidus. ____ IV fluid 0.9% normal saline ____ Oral fluid restriction ____ Oral fluid replacement ____ IV fluid 3% saline ____ Desmopressin ____ Demeclocycline ____ DDVAP

__2__ IV fluid 0.9% normal saline __1__ Oral fluid restriction __2__ Oral fluid replacement __1__ IV fluid 3% saline __2__ Desmopressin __1__ Demeclocycline __2__ DDVAP

The nurse knows that the pt with DIC is at increased risk for bleeding if the fibrinogen level is what? a) 35 b) 60 c) 95 d) 125

a) 35 *normal range is 60-100; low fibrinogen=low clotting

What hormone is in charge of keeping fluid in the body to maintain homeostasis? If there's too much of this hormone, there's fluid retention? (select all that apply) a) ADH b) AVP c) vasopressin d) diuretic hormone e) antidiuretic hormone

a) ADH b) AVP c) vasopressin e) antidiuretic hormone *these are all different names for the same hormone; too much causes SIADH; it is made in hypothalamus

Which of the following does cortisol control? a) BP b) Na+ c) response to stress d) BG d) Na+ & K+ e) metabolism

a) BP c) response to stress d) BG e) metabolism *aldosterone also controls BP, then Na+ & K+

What should the nurse assess for in a pt with suspected DI? (select all that apply) a) BP b) BG c) thirst d) platelets e) color of urine f) I&O

a) BP (decreased) c) thirst (increased) e) color of urine (clear) f) I&O (I<O) *monitor BG in DM; monitor platelets in DIC; other assessments include HR (high), urine osmolality (low), serum osmolality (high), specific gravity (low), & hx of trauma, infection, head injury, chronic disease, kidney disease, etc

A patient states that she has been experiencing a high level of stress lately. Which hormone level is most likely increased due to stress? a) Cortisol b) Calcitonin c) Oxytocin d) Prolactin

a) Cortisol *Glucocorticoids, such as cortisol, are released during the stress response. Calcitonin is regulated through the thyroid and not readily influenced by stress. Oxytocin and prolactin are released during pregnancy and breastfeeding, not when stressed.

Which of the following assessments should the nurse do for a pt with DI? (select all that apply) a) HR & BP b) thirst c) hx of head injury or trauma d) stress level e) urine output, urine specific gravity, urine osmolality, urine color f) baseline electrolytes

a) HR & BP b) thirst c) hx of head injury or trauma e) urine output, urine specific gravity, urine osmolality, urine color f) baseline electrolytes *assess I&O, dialy weights, neuro checks, HR, BP, color of urine, labs, pt thirst; also assess for route causes like head injury, surgery, chronic disease, CKD, infection, meningitis

A patient is receiving continuous heparin infusion for venous thromboembolism treatment. Which laboratory results should the nurse monitor? (Select all that apply.) a) Platelets b) Vitamin K c) Prothrombin time (PT) d) International normalized ratio (INR) e) Activated partial thromboplastin time (aPTT)

a) Platelets e) Activated partial thromboplastin time (aPTT) *To reduce the risk of heparin-induced thrombocytopenia (HIT), platelet counts should be monitored. Heparin therapy is monitored by measuring the laboratory test activated aPTT. Warfarin therapy is monitored by measuring PT and results are expressed as an INR. Vitamin K is not monitored for a heparin infusion.

Which interventions are most important for preventing bleeding in patients with bleeding disorders? a) Using a soft-bristle toothbrush b) Avoiding over-the-counter medications that contain aspirin c) Using a blade razor d) Removing obstacles that may result in a fall e) Giving medication by intramuscular injection

a) Using a soft-bristle toothbrush b) Avoiding over-the-counter medications that contain aspirin d) Removing obstacles that may result in a fall *Use of a soft-bristle toothbrush decreases the trauma to the gums with oral care. Avoid the use of aspirin because of its antiplatelet effect. Decrease the fall risk to prevent bleeding from trauma. Do not use a blade razor because of the risk for nicks when shaving. Intramuscular injections are avoided in bleeding precautions due to the risk of bleeding into muscle from the trauma of the injection.

A patient is being discharged from the hospital on warfarin (coumadin). Which instructions should the nurse include in the patient's discharge teaching plan? (Select all that apply.) a) Wear a medical alert bracelet. b) Check all urine and stool for discoloration. c) Do not start any new medication without first talking to your healthcare provider. d) Enteric-coated aspirin and any aspirin products can be used unless they cause a gastrointestinal ulcer. e) No laboratory or home monitoring of INR is required after the first 6 months.

a) Wear a medical alert bracelet b) Check all urine and stool for discoloration. c) Do not start any new medication without first talking to your healthcare provider. *Advise the patient to wear some form of identification to alert emergency personnel to warfarin use. Bleeding is a major complication of warfarin therapy. Inform patients about the signs of bleeding, which include discolored urine or stools. Inform patients that warfarin is subject to a large number of potentially dangerous drug interactions. Instruct them to avoid all prescription and nonprescription drugs that have not been specifically approved by the prescriber. Aspirin and aspirin products should be avoided because aspirin can increase the effects of warfarin to promote bleeding and on the gastrointestinal tract to cause ulcers, thereby initiating bleeding. The INR should be determined frequently: daily during the first 5 days, twice a week for the next 1 to 2 weeks, once a week for the next 1 to 2 months, and every 2 to 4 weeks thereafter. warfarin is CTN in DIC

Which of the following increase a pts risk of developing SIADH? a) cancers, malignancies, tumors b) high stress on the body c) use of MAOI d) respiratory problems, emphysema, TB, pneumonia, asthma e) use of corticosteroids f) brain injury

a) cancers, malignancies, tumors c) use of MAOI d) respiratory problems, emphysema, TB, pneumonia, asthma f) brain injury *high stress & use of corticosteroids is cushings. Other causes of SIADH include: stroke, hemorrhage, trauma, surgery, burns, infections, HIV/AIDS, Guillain Barre, vasopressin use, NSAID use, SSRI use, psychosis, mental health crisis, emergency/ICU situations, & hereditary

The nurse is taking care of a patient with platelets of 110,000 who is actively bleeding. The nurse knows that which of the following are appropriate actions for a patient who is bleeding? (select all that apply) a) hold pressure to site b) administer fresh frozen plasma (FFP) c) subq fragmin d) insert IV catheter to get access e) external female catheter

a) hold pressure to site b) administer fresh frozen plasma e) external female catheter Yes! Holding pressure is an appropriate intervention. Reinforcing the bleeding site with more gauze, etc., on top of saturated pads will enable the bottom layer to help clot and slow. Yes!Administering fresh frozen plasma (FFP) is a good way to replace lost blood products in DIC. It will come frozen, requires all of the same blood product double checks, and is usually administered with a blood product filter. It is usually infused over 30 minutes and can be given more rapidly in acute situations. Remember to monitor for both blood product side effects such as an allergic response and also fluid overload side effects such as crackles in the lungs that could increase rapidly (pulmonary edema). Yes! These are external female catheters - a great alternative to an indwelling catheter! Placing an indwelling traditional foley catheter may injure the ureter/bladder mucosa in a patient with DIC and cause further bleeding!

What occurs in Addisonian crisis? (select all that apply) a) low Na b) low K+ c) low BP d) low BG

a) low Na c) low BP (vascular collapse) d) low BG *low K+ is cushings; addison's crisis has high K+, cardiac collapse, renal shut down/acute renal failure, profound fatigue, dehdyration, abd pain, fatal

What would the nurse anticipate would be ordered for a pt with DI, that has an Na+ of 148 and denies N/V, & they're conscious a) oral replacement b) hypotonic IV c) hypertonic IV d) collois

a) oral replacement *Na+ 145-149 is oral replacement; Na+ 150-169 hypotonic IV; Na+ >170 colloids in ICU

Which of the following are potential causes of acute DIC? (select all that apply) a) pancreatitis b) MI c) kidney disease d) cancer e) blood transfusion

a) pancreatitis c) kidney disease d) cancer e) blood transfusion *MI is chronic DIC; other risks include liver disease, sepsis, surgery, trauma, MVA, burns, frostbite,

Which of the following are potential causes of chronic DIC? (select all that apply) a) rheumatoid arthritis b) sarcoidosis c) sepsis d) cancer e) crohns disease f) MI

a) rheumatoid arthritis b) sarcoidosis d) cancer e) crohns disease f) MI *sepsis is acute DIC; other risks include tumors, ulcertive colitis, & autoimmune/inflammatory processes

Which of the following medications for DIC should the nurse question? a) warfarin (coumadin) b) rivaroxaban (xarelto) c) dabigatran (pradaxa) e) heparin (unfractionated) e) dalteparen (fragmin)

a) warfarin (coumadin) *CTN with DIC! Can make bleeding worse

What are signs of addison's? (select all that apply) a) weight loss b) central obesity c) low Na+ & K+ d) easy bruising e) poor wound healing

a) weight loss *central obesity, easy bruising, & poor wound healing are s/s of cuhsings; Addison's causes anorexia, weight loss, nausea, abd pain, low aldosterone, low Na+ but high K+, low glucose, bronzed skin, addison's crisis

A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for adrenal insufficiency (Addison's)? (Select all that apply.) a. A 22-year-old female with metastatic cancer b. A 43-year-old male with tuberculosis c. A 51-year-old female with asthma d. A 65-year-old male with gram-negative sepsis e. A 70-year-old female with hypertension

a. A 22-year-old female with metastatic cancer b. A 43-year-old male with tuberculosis d. A 65-year-old male with gram-negative sepsis infection *Metastatic cancer, TB, and gram-negative sepsis are primary causes of adrenal insufficiency. Gram - sepsis is also a risk for DIC. Active TB & asthma are risks for SIADH. Hypertension is a key manifestation of Cushings disease. Watch out for addisonian crisis which is caused by stress, trauma, or infection

A client with DIC has been diagnosed with a very large PE and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

a. Alteplase (Activase) aka tPA *tPA is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

A client with DIC appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

a. Assess for other manifestations of hypoxia. *Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

Which of the following tests are used in diagnosis of DI? (select all that apply) a. CT/MRI b. serum osmolality c. ultrasound d. kidney labs e. urine osmolality f. sodium

a. CT/MRI (rule out trauma/injury/tumor w central DI) b. serum osmolality (low; but high w nephrogenic DI) c. ultrasound & d) kidney labs (rule out structural damage or inflammation w nephrogenic DI) e. urine osmolality (low) f. sodium (high) *also test glucose (normal), urinalysis & urine specific gravity (low), water deprivation test (less common); will

A nurse cares for clients with hormone disorders. Which are common key features of hormones? (Select all that apply.) a. Hormones may travel long distances to get to their target tissues. b. Continued hormone activity requires continued production and secretion. c. Control of hormone activity is caused by negative feedback mechanisms. d. Most hormones are stored in the target tissues for use later. e. Most hormones cause target tissues to change activities by changing gene activity.

a. Hormones may travel long distances to get to their target tissues. b. Continued hormone activity requires continued production and secretion. c. Control of hormone activity is caused by negative feedback mechanisms. *Hormones are secreted by endocrine glands and travel through the body to reach their target tissues. Hormone activity can increase or decrease according to the bodys needs, and continued hormone activity requires continued production and secretion. Control is maintained via negative feedback. Hormones are not stored for later use, and they do not alter genetic activity.

A nurse assesses a client with Cushings disease. Which assessment findings should the nurse correlate with this disorder? (Select all that apply.) a. Moon face b. Weight loss c. Hypotension d. Petechiae e. Muscle atrophy

a. Moon face d. Petechiae e. Muscle atrophy *Clinical manifestations of Cushings disease include moon face, weight gain, hypertension, petechiae, and muscle atrophy. Weight loss & hypotension are Addison's

An emergency nurse cares for a client who is experiencing an acute adrenal crisis (addisonian crisis). Which action should the nurse take first? a. Obtain intravenous access. b. Administer hydrocortisone. c. Assess blood glucose. d. Administer insulin and dextrose.

a. Obtain intravenous access. *All actions are appropriate for the client with adrenal crisis. However, therapy is given intravenously, so the priority is to establish IV access. Hydrocortisone is the drug of choice. Will also give IV saline solution, sugar dextrose, & correct high K+. BG is monitored hourly and treatment is provided as needed. Insulin and dextrose are used to treat any hyperkalemia.

A client with hyperaldosteronism is being treated with spironolactone (Aldactone) before surgery. Which precautions does the nurse teach this client? a. Read the label before using salt substitutes. b. Do not add salt to your food when you eat. c. Avoid exposure to sunlight. d. Take Tylenol instead of aspirin for pain.

a. Read the label before using salt substitutes. *Spironolactone is a potassium-sparing diuretic used to control potassium levels. Its use can lead to hyperkalemia. Although the goal is to increase the clients potassium, unknowingly adding potassium can cause complications. Some salt substitutes are composed of potassium chloride and should be avoided by clients on spironolactone therapy. Depending on the client, he or she may benefit from a low-sodium diet before surgery, but this may not be necessary. Avoiding sunlight and Tylenol is not necessary.

What lab is monitored for the effectiveness of heparin? How often should it be repeated? *r/t DIC

aPTT every 6 hrs

Which of the following are examples of IV fluids that may be ordered for a pt with SIADH? (select all that apply) a) D5W b) D5 .45NS c) D5NS d) 0.9% NS e) D5 .25NS f) 3% NS

b) D5 .45NS c) D5NS g) 3% NS *if pt is ordered to have IV solutions, the pt should receive hypertonic solutions bc pt already is not excreting fluid and is hyponatremic so want to replace sodium; D10W and D5LR are also hypertonic IVs

The nurse assesses the following lab report: WBC: 11 (5-10) RBC: 3.6 (3.50 - 5.55) HGB: 10 (12-18) HCT: 38 (37-52) MCV: 85 (80 - 100) MCH: 28 (27.0 - 33.0) PLATELET: 135 (150 - 400) PT: 22 (11.6-15.2) INR: 3.2 (<1.1) Which of the following orders can the nurse most expect? a) Coumadin 5 mg, consult hematology for tPA administration dosing, oxygen at 2 L per NC. b) Give 2 units fresh frozen plasma and recheck CBC in 8 hours, cancel knee surgery. c) Give 2 units platelets and recheck CBC tomorrow at 6 pm, oxygen at 2 L per NC. d) Heparin infusion tonight, change to Fragmin SQ prior to discharge, hold all blood draws.

b) Give 2 units fresh frozen plasma and recheck CBC in 8 hours, cancel knee surgery. *expected intervention and the lab recheck is appropriate. The nurse may be the gatekeeper to help stop risky procedures when signs of bleeding are noted. Be an advocate!

What shows that the pt with DI needs more teaching? (select all that apply) A) I don't have enough hormone to hold water in my body b) I have too much hormone to hold water in my body C) I don't have enough hormone for sugar metabolism D) I have too much hormone for sugar metabolism

b) I have too much hormone to hold water in my body C) I don't have enough hormone for sugar metabolism D) I have too much hormone for sugar metabolism *I don't have enough hormone is correct as there is excess fluid loss

The nurse knows that which of the following patient clusters has the most/highest risk of disseminated intravascular coagulation (DIC)? a) Preeclampsia, surgery, sepsis, hypothyroidism b) ICU patient with sepsis, cancer pt, burn patient, valve replacement patient c) Chron's disease patient, 85 year old with flareup of osteoarthritis, domestic violence patient with bruised arm d) Measles, snake bite, motor vehicle accident

b) ICU patient with sepsis, cancer pt, burn patient, valve replacement patient *while others are risks, sepsis & cancer are most common causes

What is a disease where there is an increase production/secretion of ADH/vasopressin a) DI b) SIADH c) cushings d) addisons

b) SIADH *ADH keeps fluid in the body to maintain homeostasis; too much causes fluid retention

Which syndromes occur most frequently? (Select all that apply) a) diabetes insipidus b) SIADH c) Cushing's syndrome d) Addison's disase e) none of the choices are correct

b) SIADH c) Cushing's syndrome

The pt with DI is on desmopressin, which of the following indicates that the med needs to be increased? a) nurse checks urine color at 1200, which is a dark yellow color b) UAP informs the nurse that she had to empty the pts foley 3x this morning c) lab results came back and pts urine specific gravity has increased from 1.005 to 1.020 d) UAP charts that the pts input is 2,500 and output as 1,800

b) UAP informs the nurse that she had to empty the pts foley 3x this morning *if the med is working the urine will change from clear to more concentrated yellow color, urine specific gravity should increase as there is less fluid being excreted, & ouput should decrease

What is the best definition of ADH in SIADH A) a surplus of ADH excretion b) a surplus of ADH secretion C) a deficit of ADH secretion D) a deficit of ADH excretion

b) a surplus of ADH secretion *excretion is the removal of a materials, while secretion is the production & release of materials

A patient with DIC diagnosed with a PE is receiving a continuous heparin infusion at 1000 units/hr. Of which findings should the nurse immediately notify the healthcare provider? (Select all that apply.) a) aPTT of 65 seconds b) aPTT of 40 seconds c) Nosebleeds d) aPTT of 100 seconds e) Platelet count of 300,000

b) aPTT of 40 seconds c) Nosebleeds d) aPTT of 100 seconds *Measurement of the aPTT is essential to determine whether the heparin infusion is having the desired effect. If the normal value of the aPTT is 40 seconds, the goal is to achieve a therapeutic range of a factor of 1.5 to 2 (60 to 80 seconds). Because 40 seconds is too short (increases the risk for clotting) and 100 seconds is too long (increases the risk for bleeding), the physician requires notification for adjustment of the infusion rate. Evidence of bleeding, such as nosebleeds, hematuria, and red or tarry stools, warrant a call to the physician. An aPTT of 65 seconds indicates that a therapeutic effect has been achieved, and a platelet count of 300,000/mcL is within normal limits, indicating no evidence of thrombocytopenia.

What are signs of Addison's crisis? (select all that apply) a) severe HTN b) cardiac collapse c) abdominal pain d) acute renal failure e) easy bruising

b) cardiac collapse c) abdominal pain d) acute renal failure (low Na+ , high K+) *sever hypotension; caused by stress, trauma, or infection ex: MVA, surgery, final exa,

What are potential symptoms of SIADH? (select all that apply) a) decreased thirst b) cramps & tremors c) shock d) restlessness e) hyperactive neuromuscular effects

b) cramps & tremors c) shock d) restlessness *extreme thirst, irritability, depressed mood, memory impairment, combativeness, confusion, hallucinations, seizures, stupor, coma, personality changes, or pt may not have symptoms & tolerate

If serum osmolality increases, what does urine osmolality do? a) increase b) decrease c) remain the same

b) decrease *if serum osmolality increases, then the body is excreting a lot more fluid making the urine more dilute and vice versa

What is the most concerning assessment for pt with DIC? a) decreased pedal pulses b) flank pain c) reflux d) crackle lung sounds e) loose stools

b) flank pain *flank pain from kidneys r/t microvessel clots; won't have crackles bc not r/t fluid; won't have loose stools, they will be bloody stools

Which of the following are signs of cushings syndrome? (select all that apply) a) high K+ b) high Na+ c) acne d) HTN e) high glucose e) bronzed skin

b) high Na+ c) acne d) HTN e) high glucose *high K+ & bronzed skin are addisons; cushings is low K, central obesity, moon face, buffalo hump, poor wound healing, easy bruising, purple striae on abd, psychiatric issues

Which of the following increase a pts risk of nephrogenic DI? (select all that apply) a) surgery b) lithium use c) head injury d) demeclocycline use e) pregnancy f) CKD g) genetics

b) lithium use d) demclocycline use f) CKD g) genetics -central DI is occurs with surgery, tumor, illness like meningitis, inflammation like sarcoidosis, head injury -gestational DI is occurs in pregnancy

Which of the following are symptoms of DI? (select all that apply) a) decreased thirst b) polydispia c) nausea d) dizziness & fatigue e) oliguria f) diaphoresis

b) polydispia c) nausea d) dizziness & fatigue *increased thirst (polydipsia), increased urine output (polyuria), getting up at night to urinate (nocturia), bed wetting in children, dry skin, dizziness, fatigue, weakness, msucle weakness, nausea

What assessment findings indicate that interventions for DI are working? (select all that apply) a) urine osmolality 200 b) serum osmolality 280 c) sodium level of 145 d) urine specific gravity 1.050 e) CT/MRI negative

b) serum osmolality 280 c) sodium level of 145 e) CT/MRI negative *urine osmolality 300-900, serum osmolality 270-300, Na+ 135-145, specgrav 1.003-1.030, CT/MRI negative, stable postop pt, stabile I&O, meds taken as ordered, stable weight, free from dehydration (no confusion, dry skin, tachy, etc)

The nurse walks into the pts room, who is at 20 units of heparin for DIC. The nurse notes hematuria & bruises that weren't there before. What is the nurse's priority action? a) call the dr b) stop the heparin c) increase the heparin d) continue to monitor bc that is an expected finding

b) stop the heparin *half life is 15 mins, so want to stop the heparin so pt doesn't keep bleeding while waiting for the dr to get the call to change the order

A nurse cares for a client who is prescribed a drug that blocks a hormones receptor site. Which therapeutic effect should the nurse expect? a. Greater hormone metabolism b. Decreased hormone activity c. Increased hormone activity d. Unchanged hormone response

b. Decreased hormone activity *Hormones cause activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the activity of the cell. When receptor sites are occupied by other substances that block hormone binding, the cells response is the same as when the level of the hormone is decreased.

A nurse assesses a client diagnosed with adrenal hypofunction (Addison's). Which client statement should the nurse correlate with this diagnosis? a. I cannot seem to drink enough water. b. I have a terrible craving for potato chips. c. I no longer have an appetite for anything. d. I get hungry even after eating a meal.

b. I have a terrible craving for potato chips. *The nurse correlates a clients salt craving with adrenal hypofunction. Excessive thirst is related to diabetes insipidus or SIADH. Clients who have hypothyroidism often have a decrease in appetite. Excessive hunger is associated with DM.

A client with DIC is on intravenous heparin to treat a pulmonary embolism. The clients most recent PTT was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin).

b. Increase the heparin rate. *For clients on heparin, a PTT of 1.5 to 2 times the normal value (so 60-80) is needed to demonstrate the heparin is working. A normal PTT is 30 to 40 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chefs salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips

b. Large chefs salad and muffin *Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medications mechanism of action. warfarin is CTN in DIC

A nurse teaches a client with Cushings disease. Which dietary requirements should the nurse include in this clients teaching? (Select all that apply.) a. Low calcium b. Low carbohydrate c. Low protein d. Low calories e. Low sodium

b. Low carbohydrate d. Low calories e. Low sodium *The client with Cushings disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of carbohydrates and total calories to prevent or reduce the degree of hyperglycemia. Sodium retention causes water retention and hypertension. Clients are encouraged to restrict their sodium intake moderately. Clients often have bone density loss and need more calcium. Increased protein intake will help decrease muscle loss.

A nurse answers a call light and finds a client with DIC that is anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

b. Notify the Rapid Response Team. *This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergies and no significant health history. Which action should the nurse include in this clients plan of care? a. Initiate Airborne Precautions. b. Offer fluids every hour or two. c. Place an indwelling urinary catheter. d. Palpate the clients thyroid gland.

b. Offer fluids every hour or two. *A normal age-related endocrine change is decreased antidiuretic hormone (ADH) production. This results in a more diluted urine output, which can lead to dehydration. If no contraindications are known, the nurse should offer (or delegate) the client something to drink at least every 2 hours. A client with simple pneumonia would not require Airborne Precautions. Indwelling urinary catheterization is not necessary for this client and would increase the clients risk for infection. The nurse should plan a toileting schedule and assist the client to the bathroom if needed. Palpating the clients thyroid gland is a part of a comprehensive examination but is not specifically related to this client.

A student nurse is preparing to administer LMWH like dalteparin (fragmin) to a client with DIC. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the clients platelet count b. Offer the client a cup of water with the capsule c. Teach client to report signs of bleeding d. Swab the injection site with alcohol

b. Offer the client a cup of water with the capsule *Fragmin is given subcutaneously. The other actions are appropriate.

A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The clients symptoms have now resolved and the client asks, When can I stop taking these medications? How should the nurse respond? a. It is possible for the inflammation to recur if you stop the medication. b. Once you start corticosteroids, you have to be weaned off them. c. You must decrease the dose slowly so your hormones will work again. d. The drug suppresses your immune system, which must be built back up.

b. Once you start corticosteroids, you have to be weaned off them. *One of the most common causes of adrenal insufficiency aka Addison's disease is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of adrenocorticotropic hormone and adrenal production of cortisol. Decreasing hormone therapy slowly ensures self-production of hormone, not hormone effectiveness. Building the clients immune system and rebound inflammation are not concerns related to stopping high-dose corticosteroids.

A nurse is caring for four clients with DIC on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 b. Platelet count: 82,000 c. Red blood cell count: 4.8 d. White blood cell count: 8.7

b. Platelet count: 82,000 *This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

A nurse cares for a client who possibly has SIADH. The clients serum sodium level is 114. Which action should the nurse take first? a. Consult with the dietitian about increased dietary sodium. b. Restrict the clients fluid intake to 600 mL/day. c. Handle the client gently by using turn sheets for re-positioning. d. Instruct unlicensed assistive personnel to measure intake and output.

b. Restrict the clients fluid intake to 600 mL/day *With SIADH, clients often have dilutional hyponatremia. The client needs a fluid restriction, sometimes to as little as 500 to 600 mL/24 hr. Adding sodium to the clients diet will not help if he or she is retaining fluid and diluting the sodium. The client is not at increased risk for fracture, so gentle handling is not an issue. The client should be on I&O; however, this will monitor only the clients intake, so it is not the best answer. Reducing intake will help increase the clients sodium.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery

b. Strict vegetarian *Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related. warfarin CTN in DIC

A nurse cares for a client who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.) a. Urine output is increased. b. Urine output is decreased. c. Specific gravity is increased. d. Specific gravity is decreased. e. Urine osmolality is increased. f. Urine osmolality is decreased.

b. Urine output is decreased. c. Specific gravity is increased. e. Urine osmolality is increased. *Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolality, as evidenced by a low specific gravity. Effective treatment results in decreased urine output that is more concentrated, as evidenced by an increased specific gravity.

The nurse knows that the patient needs more education about DIC if they hear which of the following patient statements? Select all that apply. a) "I should tell somebody if I get new bruises" b) " I should wear these thick foam stockings to protect my legs from any injury" c) " If I start bleeding, I should just let it go to flush the wound really well" d) "I shouldn't worry if I get out of breath, I'm just out of shape." e) " I should use an electric razor for a while versus my cool Dollar Shave Club razor"

c) " If I start bleeding, I should just let it go to flush the wound really well" d) "I shouldn't worry if I get out of breath, I'm just out of shape." *Yes, this is an incorrect statement! We don't want people to bleed! Holding pressure would be a better teaching point. Yes, this needs to be fixed! With either clotting or bleeding, we go want to know about any shortness of breath.

Which instruction about clopidogrel [Plavix] should the nurse include in the discharge teaching for a patient with DIC? a) "Constipation is a common side effect of clopidogrel, so take a stool softener daily." b) "If you see blood in your urine or black stools, stop the clopidogrel immediately." c) "Check with your healthcare provider before taking any over-the-counter medications for gastric acidity." d) "Keep the amount of food containing vitamin K, such as mayonnaise, canola and soybean oil, and green, leafy vegetables, consistent in your diet."

c) "Check with your healthcare provider before taking any over-the-counter medications for gastric acidity." *PPIs, such as omeprazole [Prilosec], and CYP2C1 inhibitors, such as cimetidine [Tagamet], can be purchased OTC to treat heartburn. However, patients taking clopidogrel should consult their HC provider before using them. PPIs and CYP2C1 inhibitors can reduce the antiplatelet effects of clopidogrel. Diarrhea (5% incidence), not constipation, is a side effect of clopidogrel. Patients should immediately contact their healthcare provider if signs of bleeding occur, such as bloody urine, stool, or emesis. The drug should not be stopped until the prescriber advises it, because this could lead to coronary stent restenosis. Consistency of vitamin K intake is indicated while taking warfarin [Coumadin].

What is most likely to have a urine osmolality of 100? a) cushings b) addisons c) DI d) SIADH

c) DI *normal is 300-900, so more fluid excreted diluting urine. Serum osmolality would be increased

What might cause sodium to be 124, urine osmolality 1850, & serum osmolaliry 268? a) cushings b) diabetes insipidus c) SIADH d) addisons

c) SIADH *SIADH the body is holding onto water makeing sodium and serum osmolality decrease/dilute & urine more concentrated since less water being excreted; normal Na+ 135-145, urine osmolality 300-900, serum osmolality 270-300

The UAP informs the nurse that she has emptied the foley 3x for the pt on desmopressin for DI. What is the priority action for the nurse? a) give the next dose b) stop giving the medication c) call the dr d) increase the dose

c) call the dr *the nurse should go check herself & assess the pt, then call the dr to change the dose since the medication is not working and needs to be increased bc urine output should decrease if med is working

Which assessment findings alert the nurse for DIC? (select all that apply) a) central obesity b) increased urine output c) hematuria d) oliguria e) abdominal bruising f) bradycardia

c) hematuria d) oliguria e) abdominal bruising *central obesity is cushings; increase UO is DI; other s/s include tachycardia, hypotension, pleural friction rub, ARDS, PE, bloode emesis, bloody stools, petechiae, acral cyanosis, wound bleeding, bullae/purpura, bruising

Which pt is most at risk for developing acute DIC? a) pt receiving a blood transfusion after a MVA b) pt who just had a MI c) pt who was brought in for surgery & is now septic d) pt who was diagnosed with cancer

c) pt who was brought in for surgery & is now septic *MI is risk for chronic DIC; blood transfusion and cancer are risks, but sepsis is most common with 30-50% of septic pts developing it. (cancer is also common but highest risk is sepsis & other risk factor of surgery)

A client with DIC has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best? a. Breathing so rapidly interferes with oxygenation. b. Maybe the client has respiratory distress syndrome. c. The blood clot interferes with perfusion in the lungs. d. The client needs immediate intubation and mechanical ventilation.

c. The blood clot interferes with perfusion in the lungs. *A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

A nurse plans care for a client with Cushings disease. Which action should the nurse include in this clients plan of care to prevent injury? a. Pad the siderails of the clients bed. b. Assist the client to change positions slowly. c. Use a lift sheet to change the clients position. d. Keep suctioning equipment at the clients bedside.

c. Use a lift sheet to change the clients position. *Cushings syndrome or disease greatly increases the serum levels of cortisol, which contributes to excessive bone demineralization and increases the risk for pathologic bone fracture & osteoporosis. Padding the siderails and assisting the client to change position may be effective, but these measures will not protect him or her as much as using a lift sheet. The client should not require suctioning.

The nurse knows that the pt with DIC is at increased risk for clotting if the fibrinogen level is what? a) 35 b) 60 c) 95 d) 125

d) 125 *normal range is 60-100; high fibrinogen=high clotting

Which of the following is true of disseminated intravascular coagulation? Select all that apply. a) It is contagious b) It occurs more frequently in younger people c) It is inherited d) It can result in both blood clots and bleeding e) It can occur in pregnancy

d) It can result in both blood clots and bleeding e) It can occur in pregnancy *Remember that in DIC, first the abnormal clotting cascade clots, then uses up the clotting factors/platelets, does not signal the body to make more, and then results in bleeding. Yes, specific conditions might be preeclampsia or placental abruption.

What is most likely to have a urine osmolality of 1,000? a) cushings b) addisons c) DI d) SIADH

d) SIADH *normal is 300-900, so less fluid excreted making urine more concentrated. Serum osmolality would be low

What thrombin inhibitor is used with cardiac procedures to prevent HIT, use w aspirin, use after MI, use in DIC when device in place like aortic balloon pump or VAD a) heparin b) warfarin (coumadin ) c) dabigatran (pradaxa) d) bivalirudin (angiomax)

d) bivalirudin (angiomax) *IV med given in hospital; not 1st choice for DIC

What is the best definition of primary endocrine disease a) disease in the stimulating hormone production b) disease in the stimulating hormone regulation c) disease in the hormonal pathway d) disease in the the gland itself

d) disease in the the gland itself *can have a seconday disease occuring further down the pathway

What is the best explanation to the pt with fibrinogen of 375 (normal 60-100) a) need to give platelts b) give protamine sulfate c) insert central line d) give tPA e) not a value for this lab

d) give tPA *high fibrinogen means high clotting; platelets & protamine sulfate (heparin antidote) make clot more

What anticoagulant is subQ that may be given instead of IV heparin for DIC, that has a longer half life so aPTT, PT/INR labs should be redrawn throughout the shift? What is the reversal agent? *r/t DIC

dalteprin (Fragmin) & reversal agent is also protamine sulfate

What term describes the breakdown of fibrin (factor 1a) by enzymes in blood clots?

fibrinolysis

What is the most freuquent site of clots in DIC?

kidneys! watch for oliguria & hematuria

What anticoagulant is more selective & makes blood slippery? What is the antidote? *r/t DIC

rivaroxaban (xarelto) & reversal agent is andexxa

What does thirst mechanism start for a pt with SIADH?

serum osmolality of 290-295 (normal 275-295) *thirst also occurs in DI