HPA II Exam 1

What do calcium channel blockers end in?

-dipine (expect Diltiazem)

What do beta blockers end in?

-olol

What do ACE-inhibitors end in?

-pril

What do angiotensin II receptor blockers end in?

-sartan

What do alpha-adrenergic blockers end in?

-zosin

What is the therapeutic serum level for lithium?

0.6-1.2 mEq/L

What is normal creatinine levels?

0.7-1.4 mg/dL

What are some cardinal feature of AKI?

1) 50% or greater increase in creatinine above baseline within 7 days or increase in serum creatinine by 0.3 mg/dL within 2 days 2) Decreased GFR 3) Azotemia (increases in BUN and creatinine) 4) Oliguira or anuria (urine output less than 0.5 mL/kg/hr)

Name some examples of situations in which respiratory acidosis occurs

1) Acute pulmonary edema 2) Aspiration of a foreign object 3) Atelectasis 4) Pneumothorax 5) Overdose of sedatives which causes hypoventilation 6) Sleep apnea 7) Administration of O2 to a patient with chronic hypercapnia (such as COPD patients) 8) Severe pneumonia 9) Acute respiratory distress syndrome 10) Diseases that impair respiratory muscles such as muscular dystrophy, multiple sclerosis, myasthenia gravis, and Guillain-Barre syndrome 11) CNS depression 12) Drowning 13) Bronchial spasms seen in asthma patients 14) Improper mechanical ventilation that results in hypercapnia due to a low ventilation rate (such as a patient who is intubated)

What are the clinical manifestations of fluid volume excess?

1) Acute weight gain greater than 5% 2) Edema 3) Crackles 4) Shortness of breath 5) Decreased BUN, decreased hematocrit 6) Distended neck veins 7) Tachypnea 8) Increased central venous pressure 9) Tachycardia, bounding pulse 10) Crackles, cough, dyspnea 11) Skin cool to touch with pallor

What are the clinical manifestations of fluid volume deficit?

1) Acute weight loss less than 5% 2) Decreased skin turgor 3) Dry mucous membranes 4) Oliguria or anuria 5) Increased hematocrit, increased BUN in proportion to creatinine 6) Hypothermia

What are risk factors for primary hypertension?

1) Advancing age 2) Race (African Americans are at a greater risk) 3) Drinking too much alcohol (more than two drinks per day for men and more than one drink per day for women) 4) Family history 5) Gender-related (men are at greater risk until 45 years, gender risk is equal between 45 to 64, and women have greater risks at 65 years of age and later) 6) Overweight/obesity 7) Poor diet habits (especially diets high in sodium, cholesterol) 8) Sedentary lifestyle 9) Use of tobacco products 10) Stress 11) Sleep apnea 12) Too much caffeine

Name some non-modifiable risk factors of hypertension

1) Age 2) Genetics 3) Gender

What should be collected during the health history during a perfusion assessment?

1) Ask about symptoms related to perfusion (any chest pain or discomfort, pain or discomfort in areas of the upper body, unexplained weight gain, edema, unusual fatigue, palpitations, dyspnea) 2) Assess for risk factors (how often do they work out, health concerns, family history) 3) Medication history 4) Diet, height and weight, blood glucose, eating habits 5) Elimination (is patient waking at night to urinate, fluid collecting in extremities while upright, asking about nay bloody urine or stool for patients taking anticoagulants) 6) Asking about any changes in activity intolerance 7) Sleep and rest (does the patient experience orthopnea, asking if patient snores loudly, awake with a headache, experience severe sleepiness during the day, wake up frequently during sleep) 8) Assess social support and self-perception for change 9) Ask about sexual dysfunction (are they experiencing erectile dysfunction, reproductive history) 10) Assessing stress as it is a risk factor for hypertension

What are interventions aimed towards promoting safety in a patient with bipolar disorder?

1) Assess patients directly for suicidal ideation and plans or thoughts of hurting others 2) Monitor patient's wheraeabouts and behaviors frequently 3) Set limits and inform patient that staff members will help them control behavior if patient cannot do so alone

What is the treatment for PTSD?

1) CBT with exposure therapy, adaptive disclosure, cognitive processing 2) SSRIs, second generation antipsychotics, and prozosin (anti-hypertensive used to treat insomnia associated with PTSD)

What are the adverse effects of valproic acid (Depakote)?

1) CNS depression 2) Liver toxicity 3) Thrombocytopenia 4) Nausea, vomiting

What are some nursing considerations regarding the use of calcium channel blockers?

1) Can cause bradycardia (so should check heart rate before giving) 2) Watch for hypotension 3) Do not discontinue suddenly 4) Report irregular heartbeat, dizziness, edema (can precipitate AV block) 5) Administer on an empty stomach or before meals 6) Avoid taking with grapefruit juice (can cause blood levels of calcium channel blockers to increase) 7) Monitor for edema (can cause peripheral edema)

What are some nursing intervention regarding ACE inhibitors?

1) Can cause dizziness and hypotension so watch for falls especially with elderly population 2) Monitor for hyperkalemia 3) Can cause altered renal function. Monitor for edema 4) Can cause cough 5) If angioedema, rash, or dysgeusia (distortion of taste) appears stop drug immediately 6) Can cause neutropenia (monitor blood levels and educate patients that if they have fever or sore throat to notify the provider) 7) Should avoid the use of ACE inhibitors with potassium sparing diuretics as it can cause hyperkalemia

What are some nursing considerations regarding the use of centrally acting alpha 2 agonists

1) Can cause dry mouth, drowsiness, sedation, and occasional headaches and fatigue 2) Anorexia, malaise, vomiting with mild disturbance of liver function (monitor LFTs) 3) Monitor blood pressure when stopping as it can cause rebound or withdrawal hypertension 4) Can cause impotence

What are some nursing considerations regarding the use of alpha adrenergic blockers?

1) Can cause occasional vomiting and diarrhea 2) Can cause urinary frequency 3) Patients can also experience drowsiness, headache, lack of energy, and weakness (falls risk) 4) Should watch for and put precautions in place for orthostatic hypotension

What are some complications or organ damage which can occur as a result of hypertension?

1) Chronic kidney disease 2) Heart disease (left ventricular hypertrophy, heart failure, angina, MI) 3) Peripheral arterial disease 4) Retinopathy 5) Stroke or transient ischemic attack (TIA)

What are some late signs of ischemia?

1) Confusion 2) Weak, thready pulse 3) Increased tachycardia 4) MAP less than 65 5) Abnormal heart rhythms 6) Pallor/cyanosis 7) Cool, clammy skin 8) Oliguria

What are nursing interventions that should be utilized with a patient with PTSD?

1) Continually assess the patient's potential for self-harm or suicide and take action accordingly 2) Helping patient develop a plan for going to a safe place when having destructive thoughts or impulses 3) Using grounding techniques when a patient is dissociating or experiencing a flashback. Involves reminding the patient that he or she is in the present, is an adult, and is safe 4) Validating what the patient is feeling and increasing contact with reality by diminishing dissociative experiences and focusing on experiences through the senses (for example; "do you feel your feet on the floor?") 5) Encourage the patient to move and stand during dissociative thoughts or flashbacks 6) Help patient get in touch with feelings using a log or journal and find distraction techniques that work for them 7) Define patient as a survivor not as a victim in order to promote empowerment 8) Connecting with local support groups and having patients establish a list of support people 9) Initially assign the same staff members and gradually increase the number and variety of staff members 10) Assess history of substance abuse 11) Encourage the patient to talk about experience 12) Encourage expression of anger, guilt, and rage and give patient positive feedback for expressing feelings and sharing experiences 13) Teaching deep breathing and relaxation techniques 14) Educate patient and staff and develop a set of PTSD resources 15) Develop self-awareness about issues and become comfortable asking patients about abuse and listening to accounts of trauma and dealing with own feelings from this

What are interventions that can be employed to help a patient with bipolar disorder meet psychological needs?

1) Decrease environmental stimuli in order to assist patients with relaxing 2) Providing a bed time routine 3) Providing finger foods or foods that patient can eat while moving around (foods should be as high in calories and protein as much as possible) 4) Having snacks available between meals 5) Monitor food and fluid intake and hours of sleep 6) Observe and supervise patients at meal times

Describe the process through which the RAAS system increases blood pressure

1) Decreased pressure in the kidney stimulates the secretion of renin by juxtaglomerular cells 2) The liver produces angiotensinogen in response, which reacts with renin to produce angiotensin 1 3) Angiotensin I is converted in the lungs by a converting enzyme to angiotensin II which acts as a powerful vasoconstrictor 4) Angiotensin II then becomes angiotensin III which causes the release of aldosterone from the adrenal cortex 5) Aldosterone causes increased sodium and water reabsorption which results in increased blood volume 6) ADH is also stimulated to be released which causes water retention and an increase in blood volume

What is the MOA of clonidine?

1) Decreases sympathetic nervous system activity which includes decreasing epinephrine, norepinephrine, and renin 2) Results in vasodilation which decreases blood pressure and heart rate

What are some complications that can occur with hemodialysis?

1) Disturbances of lipid metabolism (hypertriglyceridemia) which can cause CV complications 2) Anemia can be worsened due to blood loss during dialysis 3) Vomiting can occur due to rapid fluid shifts and hypotension and can also result in malnutrition 4) Poor calcium metabolism can result in renal osteodystrophy and bone pain and fractures 5) Calcification of major blood vessels 6) Phosphorus deposits in the skin which can cause itching 7) Episodes of shortness of breath as fluid accumulates between dialysis treatments 8) Painful muscle cramping late in dialysis as fluid and electrolytes rapidly leave the extracellular space 9) Esanguination (loss of blood) may occur if blood lines separate or dialysis needs become dislodged 10) Dysrhythmias from electrolyte and pH changes 11) Air embolism (rare) 12) Chest pain 13) Dialysis disequilibrium as a result of cerebral fluid shifts. Signs are headache, nausea and vomiting, decreased level of consciousness, and seizures. Is rare and more likely to occur in AKI or when BUN levels are very high 14) Bleeding/clotting at access site 15) Infection

What are signs of sodium excess?

1) Dry, sticky mucous membranes 2) Thirst 3) Rough dry tongue 4) Fever 5) Restlessness 6) Weakness 7) Disorientation

What is typical of the judgement and insight of someone with bipolar disorder?

1) Easily angered and irritated and strike back at what they perceive as censorship 2) Impulsive and rarely think before acting or speaking 3) Insight is limited because they believe they are fine and have no problems and blame difficulties on others 4) Poor judgement

What are some clinical manifestations that you may see with CKD?

1) Elevated serum creatine levels 2) Anemia 3) Metabolic acidosis (kidneys are unable to remove H+ ions from blood) 4) Abnormalities in calcium and phosphorus 5) Fluid retention (edema, crackles, distended neck veins, shortness of breath, exercise intolerance, weight gain) 6) Hypertension

What are some nursing interventions for a patient with hypertension?

1) Encourage patient to consult a dietitian to help develop a plan for implementing nutrient intake or for weight loss 2) Restrict sodium and fat intake, increase intake of fruits and vegetables, and implement regular physical activity 3) Advise to limit alcohol and smoking 4) Provide written medication about expected effects and side effects of blood pressure meds. Patients should be informed that blood pressure meds that are suddenly stopped can cause rebound hypertension 5) Patients should be instructed to measure their blood pressure at home 6) Include older adult's family or caregivers in the educational program and consider monotherapy (treatment with a single agent) in order to simplify the medication administration and make it less expensive 7) Advise patients (especially older patients) that hypotension can occur with antihypertensive and positions should be changed slowly and supportive devices should be used when necessary 8) Life-style modifications should be started before medication 9) Stress reduction techniques 10) Advise patients to watch using too many salt substitutes as it can cause hyperkalemia

What populations are more at risk for PTSD?

1) Event exposure rather than personal characteristics is more indictive of risk: severity and duration of the trauma, proximity to event 2) Those who have lack of social support 3) History of psychiatric disorder 4) Lack of post-trauma conseling 5) Children (especially those with parental depression and abuse) and adolescents 6) Victims of rape have the highest rate of PTSD (about 70%)

What lab assessments and diagnostic tests are usually performed when a patient has hypertension?

1) Examination of retinas to see if there is any damage to the small vessels in the eyes 2) UA 3) Blood chemistry (especially looking at BUN, creatinine, glucose, and both HDL and LDL levels) 4) ECG 5) Echo (to assess for left ventricular hypertrophy) 6) Creatinine clearance, renin level, and 34 hour urine protein

Name some conditions that can result in respiratory alkalosis

1) Extreme anxiety which causes hyperventilation 2) Hypoxemia 3) Early phase of salicylate (aspirin) intoxication 4) Gram-negative bactermia (sepsis, fever increases metabolic needs causing increased breathing) 5) Inappropriate ventilator settings which results in hyperventilation 6) Asthma with hyperventilation 7) Pain 8) Chronic respiratory alkalosis can occur due to chronic hepatic insufficiency and cerebral tumors and are usually asymptomatic

What are nursing interventions aimed towards patients with bipolar disorder?

1) First priority is to provide safety of patient and others through monitoring of patient's behaviors 2) Want to set and maintain limits on behavior that are destructive or adversely affects others 3) Meet physiological needs by promoting rest and sleep and nutrition. Helps to provide finger food or food that can be eaten on the go 4) Decrease environmental stimuli whenever possible (respond to cues of increased agitation by removing stimuli and perhaps isolating the patient) 5) Reorient the patient to person, place and time 6) Provide consistent, structured environment. Let patient know what is expected of them and set goals. Take away privilege when these goals aren't met 7) Avoid getting involved in power struggles (better to talk one-on-one than with peers) 8) Redirect activity that is not appropriate 9) Monitor medication levels. Promote hydration with lithium and manage side effects through education 10) Provide proactive view of illness and educate family on signs to look for 11) Use short sentences and clarify the meaning of patient's communication 12) Make only promises you can realistically keep 13) Evaluate tolerance for group activities, interactions with others, or visitors, and limit those accordingly 14) Encourage appropriate expression of feelings 15) Avoid highly competitive activities (can exacerbate hostile feelings or reinforce low self-esteem)

What is the management for fluid volume overload?

1) Fluid and sodium restriction, diuretic agents, dialysis 2) Keep accurate I & O and daily weight 3) Patient and family education on rationale for fluid restrictions, assisting patient to cope with fluid restriction, providing or encouraging frequent oral hygiene

How is pharmacological therapy introduced for patients with hypertension?

1) For African American patients and all patients 60 years f age and older with stage I hypertension, the recommended initial meds include a calcium channel blocker or a thiazide diuretic 2) Patients with stage I hypertension and are less than 60 years and not African American are prescribed an ACE inhibitor or ARB 3) If blood pressure does not fall to less than 140/90 the dose is increased gradually and additional meds are included as necessary to achieve control

What are some lab tests to assess kidney function?

1) GFR (normal rate is 80 to 125 mL/min) 2) Urine Analysis (looks at sedimentation, electrolytes present in urine, osmolality, creatinine clearance which can be used as an estimate of GFR) 3) Blood tests (look at creatinine and BUN, electrolytes, ABGs)

What should be evaluated during the physical part of a perfusion assessment?

1) General appearance (are there signs of distress, patient's level of consciousness, is patient overweight) 2) Assessment of skin (look for any pain, pallor, check pulses, temperature of skin, edema, bruising, capillary refill, clubbing of fingers, brittle hair, ulcers, hair loss) 3) Blood pressure 4) Palpation of chest (look for apical impulse which indicates left ventricular enlargement, thrill which can be associated with heart disease or a murmur) 5) Ausculatate heart sounds

What should be obtained in the nursing assessment for a person with PTSD?

1) History (determine how close they are to the event) 2) General appearance and motor behavior (may appear hyperalert, uncomfortable with physical closeness, appear anxious or agitated and have difficulty sitting still or may pace and move around the room) 3) Assessment of mood and affect (may appear frightened, scared, agitated or hostile. When dissociating patient may speak in a different tone of voice or appear numb with a vacant stare) 4) Assessment of thought process ( Report of relieving the trauma through nightmares or flashbacks, intrusive, persistent thoughts which interfere with the ability to think about other things, self-destructive thoughts as well as intermittent suicidal ideation) 5) Assessment of intellectual processes (AAOX3 unless experiencing flashbacks, intrusive thoughts of self harm may impair ability to concentrate, may have memory gaps) 6) Assessment of judgment and insight (May be impaired, early on in treatment there maybe no association between trauma and symptoms, nurse should educate and describe on this association) 7) Assessment of self-concept (Have low self-esteem, may see themselves as helpless, hopeless, and worthless) 8) Assessment of roles and relationships (Difficulty with all types of relationships especially with authority figures, close relationships are difficult, often the patient has quit work or been fired and may be estranged from family members, have a lack of trust) 9) Physiologic assessment (Difficulty sleeping, anxiety, overeating or lack of appetite, use of alcohol or other drugs)

Which electrolyte imbalances would you expect to see with ESRD?

1) Hyperkalemia 2) Hypocalcemia 3) Hyperphosphatemia

What are some adverse effects of sodium polystyrene (kayexalate)?

1) Hypernatremia 2) Hypocalcemia 3) Hypokalemia 4) Hypomagnesemia 5) Sodium retention 6) Diarrhea 7) Fecal impaction 8) Intestinal necrosis (rare) 9) Intestinal obstruction (due to concentrations i association with aluminum hydroxide) 10) Nausea, vomiting

What are some conditions in which a hypertensive emergency can occur?

1) Hypertension in pregnancy (treated with emergent delivery) 2) Acute MI 3) Dissecting aortic aneurysm 4) Intracranial hemorrhage

What electrolyte imbalances might you see with metabolic alkalosis?

1) Hypocalcemia (will be the primary cause of manifestations with this imbalance) 2) Hypokalemia 3) Should also monitor urine chloride levels as it maybe a more accurate estimate of fluid volume and a sufficient amount of chloride is necessary in order to promote bicarb excretion

What are some of the clinical manifestations of metabolic alkalosis?

1) Hypocalcemia conditions (tingling of fingers and toes, dizziness, and hypertonic muscles) 2) Depressed respirations (as a compensatory mechanism) 3) Atrial tachycardia 4) Hypokalemia which may lead to ventricular disturbances (frequent PVCs, depressed T wave, and prominent U waves seen on ECG) 5) Decreased motility and paralytic ileus may be evident 6) Hypoxemia

What characteristics are seen with postrenal AKI?

1) Increased BUN and creatinine 2) Decreased urine output or sudden anuria 3) Urine sodium varies but is often decreased less than 20 mEq/L (decreased blood flow as a result of high pressures activates RAAS system and sodium is reabsorbed into blood) 4) Lowered GFR 5) Urine is more concentrated so urine osmolality is greater

Name some ways blood pressure can rise (think of systems which have an effect on blood pressure)

1) Increased sympathetic nervous activity 2) Increased activity of RAAS system 3) Increased renal reabsorption of sodim, chloride, and water 4) Decreased vasodilation of the arterioles 5) Resistance to insulin action 6) Activation of the innate and adaptive components of the immune response which may contribute to renal inflammation and dysfunction

How does the sympathetic nervous system work to increase blood pressure?

1) Increases heart rate (increases cardiac output) along with contractility (increases stroke volume) 2) Vasoconstriction of vessels (increases peripheral resistance)

Describe the four phases of AKI

1) Initiation period: Begins with the initial injury and ends when oliguria develops as a result of tissue damage 2) Oliguria period: Low urine output accompanied by an increase in serum concentration of substances such as urea, creatinine, uric acid, organic acids, and intracellular cations such as potassium and magnesium. Hyperkalemia and uremic symptoms present along with fluid volume overload 3) Diuresis period: May not see. Is marked by a gradual increase in urine output, which signals that glomerular filtration is starting to recover. Lab values stabilize and eventually decrease and uremic symptoms may still be present. A big risk during this phase is dehydration 4) Recovery period: Lab values return to normal. May see a clinically insignificant permanent decrease in GFR. This phase may take 3 to 12 months. Residual impairment of GFR may put them at risk for reoccurance

What are some nursing considerations with the administration of calcium gluconate?

1) Is administered IV 2) Monitor ECG, vital signs, and CNS 3) Should observe the infusion site closely to avoid extravasation

What are some clinical manifestations of respiratory alkalosis?

1) Light-headedness as a result of cerebral vasoconstriction and decreased blood flow 2) Inability to concentrate 3) Numbness and tingling due to decreased calcium ionization 4) Tinnitus 5) Possible loss of consciousness 6) Tachycardia 7) Ventricular and atrial dysrhythmias 8) Hypokalemia (H+ is pulled out of cells to raise blood levels of acid in exchange for potassium) 9) Decreased calcium level due to inhibition of calcium ionization 10) Decreased phosphate levels as condition causes an increased uptake of phosphate by the cells

What is the pharmacological treatment for bipolar disorder?

1) Lithium 2) Antiepileptic drugs 3) Second generation anti-psychotic meds (used to treat disorder thinking that can be seen with delusions, hallucinations that can occur with the acute stage of mania or depression)

What are some common causes of chronic metabolic alklosis?

1) Long-term diuretic therapy with thiazides or furosemide in which potassium is lost causing hypokalemia 2) Villous adenoma (causes secretory diarrhea) 3) Anticoagulant increase (from massive blood transfusions) 4) Significant potassium depletion 5) Cystic fibrosis 6) Chronic ingestion of milk and calcium carbonate (more common in children)

What are some of the functions of the kidneys in maintaining homeostasis?

1) Maintain fluid balance 2) Maintain electrolyte balance 3) BP control (through RAAS system) 4) Erythropoiesis 5) Remove waste 6) Metabolize vitamin D (necessary for calcium absorption)

What are some lifestyle changes that should be implemented in order to reduce hypertension?

1) Maintaining normal body weight (should aim to have a BMI within the normal range of 18.5-24.9) 2) Adopting DASH eating plan (consuming diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat) 3) Reducing dietary sodium intake (Should reduce intake to less than 2400 mg daily, less than 1500 mg if better) 4) Engage in regular physical activity (should be more than 30 min/day for at least 5 days a week, should be aerobic exercise) 5) Moderation of alcohol consumption (2 or less drinks per day in men, 1 or less drinks per day in women) 6) Quit smoking

What are nursing interventions that can be utilized to promote acceptable behavior in someone with bipolar disorder (ways to prevent impulsive behavior)?

1) Monitor access to items such as money 2) Treat patients with dignity and respect despite inappropriate behavior and handle behavior in a matter of fact, nonjudgmental manner 3) Vigilant redirection to a more socially appropriate activity

What are nursing considerations regarding the use of lithium?

1) Monitor serum levels (therapeutic level should be between 0.6 to 1.2) 2) Should have an adequate intake of fluids and sodium (intaking at least 2L/day) 3) Monitor daily weight and intake-output 4) Assess for signs of toxicity (lethargy, slurred speech muscle weakness, N/V, ataxia, ECG changes) 5) Hold medication if therapeutic level is above 1.2 and immediately contact provider 6) Thyroid function tests should be taken every 6 months and at baseline (can increase TSH levels) 7) Dose should be decreased during periods of depression and should be considered being reduced in older patients 8) Contact provider if patient has diarrhea, fever, flu, or any other condition that can lead to dehydration

What are some important nursing interventions regarding diuretics?

1) Monitor signs of electrolyte imbalances (especially sodium and potassium) 2) Encourage intake of potassium rich foods with thiazides (potassium losing diuretics) 3) Watch for volume depletion (drowsiness, thirst, weakness, tachycardia, muscle weakness) and hypotension 4) Monitor for hyperkalemia with potassium-sparing diuretics (especially if given with ACE or ARB)

What are important nursing interventions that should be performed with a beta blocker?

1) Need to monitor heart rate before giving as it can decrease heart rate (should not give to patient who is bradycardic) 2) Need to monitor blood pressure as it can cause hypotension 3) Can cause mental depression 4) Avoid sudden discontinuation (can cause rebound hypertension) 5) Contraindicated in those with asthma 6) Should be used with caution in those with diabetes as it can mask signs of hypoglycemia 7) It can also cause erectile dysfunction in men

What are some patient education pieces regarding an AV fistula?

1) Needs about 2-3 months to mature 2) Encourage the patient to perform hand exercises to increase the size of the vessels 3) Should teach patient to feel thrill (turbulent blood) and hear bruit (whooshing sound) and have them feel for it everyday

What are some ways to assess for renal dysfunction?

1) Neurologic (may see asterixis, behavior changes, confusion, disorientation, inability to concentrate, seizures, tremors) 2) Integumentary (coarse, thinning hair, dry, flaky skin, ecchymosis, pruritus) 3) Cardiovascular (engorged neck veins, hyperkalemia, hypertension, pericardial friction rub, pericarditis, periorbital edema, pitting edema) 4) Pulmonary (crackles, depressed cough reflex, Kussmaul-type respirations, shortness of breath, tachypnea) 5) GI (anorexia, nausea, vomiting, constipation or diarrhea, metallic taste) 6) Hematologic (Anemia, thrombocytopenia)

What are some considerations regarding the use of tegeredol and depocoat to treat rapid cycling bipolar?

1) Not effective for those who aren't complainant with medication regiment as they require blood draws to monitor for therapeutic effectiveness

What are some clinical manifestations of hypertension?

1) Often there are no other symptoms besides high blood pressure 2) Retinal changes (such as papilledema) 3) Headache 4) Dizziness 5) Facial flushing 6) Visual disturbance 7) Epistaxis (nosebleed) 8) Fainting

What values on an ABG would you see if respiratory acidosis was occurring?

1) PaCO2 would be greater than 45 2) pH would be lower than 7.35 3) If compensation occurs would see higher levels of bicarb above 26

What are some nursing interventions that should be performed with peritoneal dialysis?

1) Pay attention to drainage (cloudy dialysate drainage fluid indicates infection) 2) Watch for diffuse abdominal pain and rebound tenderness 3) Look for signs of hypotension and shock 4) Look for leakage through catheter site. If leakage dialysis should be withheld for several days to promote healing and it is important to reduce factors such as undue abdominal muscle activity and straining during BMs 5) Using small volumes of dialysate gradually increase the volume 6) Use of antihypertensive agents to control hypertension and protect the heart 7) Pay attention to any redness, swelling, leakage at site 8) Teach patient about S/S of infection 9) Protect dialysis access 10) Carefully monitor fluid balance, accurate I & Os, and weights

What electrolyte levels are affected by respiratory alkalosis?

1) Potassium (can cause hypokalemia as potassium is pulled into cells in exchange for moving H+ into the blood as a way to compensate) 2) Calcium (can cause low calcium levels due to inhibition of calcium ionization) 3) Phosphate (can cause low phosphate levels due to phosphate being pulled into cells)

What are some causes of secondary hypertension?

1) Pregnancy 2) Cushing syndrome (increased cortisol production, which elevates blood pressure) 3) Chronic renal disease 4) Renal artery stenosis 5) Thyroid dysfunction 6) Diabetes 7) Pheochromocytoma (adrenal gland tumor) 8) Sleep apnea

What steps should be taken after obtaining an ABG sample?

1) Pressure should be applied for 5-10 minutes and the patient should be watched for evidence of bleeding 2) If the patient is on anticoagulants, pressure should be applied for longer 3) Supplemental O2 and respiratory settings should be recorded with the sample 4) The sample should be placed on ice and sent to the lab as soon as possible

What are some methods to prevent prerenal AKI?

1) Prevent/correct volume depletion 2) Maximize perfusion/treat hypotension promptly 3) Prevent/promptly treat sepsis

What are some methods to prevent intrarenal AKI?

1) Provide adequate hydration when administering nephrotoxic drugs and during skeletal muscle injuries 2) Promptly treat infections 3) Administer correct blood products in order to avoid transfusion reactions

Describe the categories of symptoms experienced in PTSD

1) Re-experiencing the trauma through dreams or recurrent and intrusive thoughts, avoidance, negative cognition or thoughts, being on guard 2) Hyperarousal: person shows persistent signs of increased arousal such as hypervigilance, irritability, angry outburst, or reactions to external cues 3) Avoidance of places or people 4) Emotional numbing (feels detached from others) 5) Negative cognitions and moods: persistent self-blame or blaming others along with pyschosocial issues such as depression, anxiety, substance use, disinterest in activities, shame, difficulty with cognition

What are the goals of treatment in hypertensive crisis?

1) Reduction of mean blood pressure by 20 to 25% within the first hour of treatment 2) A further reduction to a goal pressure of about 160/100 over a period of up to 6 hours and then a more gradual reduction in pressure over a few days

What is the nursing management for AKI?

1) Restriction of dietary protein when there is elevated BUN. Allowed protein should be of high biologic value (such as dairy products, eggs, meats) 2) Sodium restriction with hypertension and signs of fluid overload 3) Carbs given liberally to provide energy and reduce catabolism of protein 4) Careful measurement of I & Os (should see diuresis with effective treatment) 5) Patient should be weighed daily at the same time to watch for weight gain and fluid retention 6) Foods or fluids containing potassium, phosphorus, and magnesium should be restricted (avoid magnesium based antacids) 7) Following diuretic phase, patient should be placed on high protein, high calorie diet 8) Steps to reduce metabolic rate such as bed rest and treating any fevers 9) Prevention of skin breakdown by bathing with cool water, frequent turning, and keeping skin clean and well moisturized (uremia can cause uremic deposits in the skin) 10) Variety of antihypertensive agents to treat hypertension 11) Seizure precautions with patients with ESRD and IV diazepam or phenytoin to control seizures 12) Treatment of hyperkalemia with dialysis or sodium polystyrene sulfonate (Kayexalate)

What lab values are important to keep track of with lithium?

1) Serum blood levels (has narrow therapeutic range) 2) Sodium levels (hypernatremia can cause sub-therapeutic levels and hyponatremia or fluid depletion can cause toxicity) 3) Renal function (BUN, creatinine, GFR) 4) Thyroid hormones (can cause an increase in TSH)

What are nursing considerations regarding a patient suing valproic acid (Depakote)?

1) Serum levels need to be monitored periodically (should be between 50-125 mcg/mL) 2) Assess for liver toxicity and thrombocytopenia by monitor LFTs, platelets, ammonia, bleeding times 3) Assess for S/S of liver toxicity such as N/V, abdominal pain, yellowing of the skin or eyes, skin breakouts, ataxia, bruising, loss of appetite and provider should be alerted if these appear

What are some important nursing interventions that should be performed with patients who are on blood pressure meds?

1) Should assess adherence to the medication. Adherence can be increased by having patients actively participate in self-care (such as self-monitoring of blood pressure and diet) 2) Following up at each visit with the patient to see if they are progressing with the plan of care and developing modifications and alternatives to the plan when necessary 3) Providing support groups for weight control, smoking cessation, and stress reduction 4) Assisting the patient to develop and adhere to an appropriate exercise regimen 5) Education about blood pressure management and setting goal blood pressures 6) Providing written information about expected effects and side effects of meds 7) Need to inform patient that rebound hypertension can occur if antihypertensive therapy is suddenly stopped 8) Including older adult's family members in education program and watch for drug interactions (for example advise patients to avoid salt alternatives when taking meds such as ACE inhibitors, ARBs, and potassium sparing diuretics as it can cause hyperkalemia) 9) Understand that elderly on blood pressure meds are at an increased risk for falls 10) Important to perform regular follow up with a history and physical exam at each visit (data pertaining to problem, medication related problems, assessment of eyes, heart, nervous system, and kidneys)

What should be done in preparation if a patient is to undergo an ABG?

1) Should explain to the patient what the test is (measures adequacy of oxygenation, ventilation, and perfusion) and that it requires an arterial puncture and collection of a blood specimen (can obtain from an arterial line) 2) Should perform an Allen test in order to determine that there is adequate perfusion (is done by compressing the radial and ulnar arteries simultaneously causing the hands to blanch while making a fist, once the patient opens their hand blood flow should be restored within 6 seconds) 3) Any supplemental oxygen or respiratory settings should be recorded on the specimen information 4) Arterial specimen must be immediately placed on ice when obtained and taken to the lab

How is respiratory acidosis managed?

1) Should treat the underlying cause 2) Pulmonary hygiene measures to clear the respiratory tract of mucus and purulent drainage 3) Adequate hydration to keep mucus membranes moist and facilitate secretion removal 4) Supplemental oxygen as necessary (use caution in those that are chronically hypercapnic) 5) Fixing inappropriate mechanical ventilation (however this should be done slowly in order to avoid alklosis) 6) Maintaining a patent airway (such as suctioning) 7) Enhancing gas exchange (through pulmonary hygiene measures and placing patient in a semi-fowlers position)

Name some modifiable risk factors for hypertension

1) Smoking 2) Sedentary lifestyle 3) Obesity 4) Diabetes 5) Hypertension 6) Hyperlipidemia (diet)

What are some health promotion priorities with kidney disease?

1) Smoking cessation programs 2) Management and prevention of diabetes and hypertension (should be regularly checking A1C and test for albumin in the urine yearly) 3) Using NSAIDs and other medications that are hard on the kidneys with caution 4) Taking all antibiotics as prescribed for infections

What are some nursing interventions performed when a patient is receiving hemodialysis?

1) Some medications (such as antihypertensives) should be held until after dialysis in order to prevent dangerous hypotension 2) Restriction of fluid and dietary protein along with sodium, potassium, and phosorus (want to keep weight gain under 1.5 kg) 3) Feel for bruit and listen for thrill every day 4) Monitor platelet levels, INR times 5) Hold pressure after dialysis 6) Use sterile gloves and aseptic technique when changing dressing 7) Monitor for headache, seizures, nausea and vomiting after dialysis as these are signs of disequilibrium syndrome 8) Administer iron supplements and EPO SQ to increase RBCs 9) Dialysis access should be protected (do not take blood pressure on that arm!) 10) Carefully monitor fluid balance, signs and symptoms of uremia and electrolyte balance, regularly check lab data, and cardiac/respiratory status

What are some clinical manifestations associated with respiratory acidosis?

1) Sudden hypercapnia can cause increased pulse (tachycardia) and increased respiratory rate 2) Increased blood pressure 3) Mental cloudiness or confusion 4) Feeling of fullness in the head (due to cerebral vasodilation and increased cerebral blood flow) 5) Decrease in level of consciousness 6) Ventricular fibrillation (may be the first sign seen in anesthesized patients) 7) Hyperkalemia (in an attempt to move H+ into cells and reduce the level in the blood) 8) Hypoventilation (causes retainment of CO2) 9) Severe acidosis may lead to bradycardia

What are some early signs of ischemia?

1) Tachycardia 2) Tachypnea 3) Reduced blood pressure 4) Confusion 5) Decreased urine output

How does hypokalemia produce alkalosis?

1) The kidneys conserve potassium and therefore H+ excretion increases 2) Cellular potassium moves out of the cells into the ECF in an attempt to maintain near-normal serum levels (as potassium ions leave the cells, hydrogen ions must enter to maintain electroneutrality)

How does hypertension occur?

1) Through increases in cardiac output (such as an expansion in vascular volume) 2) Through increases in peripheral resistance (Examples are constrictions of the blood vessels, hardening of the vessels in artherosclerosis)

What are some methods to prevent postrenal AKI?

1) Treat BPH 2) Prevent/promptly treat renal calculi

What is the treatment of metabolic alkalosis?

1) Treat the underlying cause 2) Careful monitoring of I & Os (due to volume depletion from GI loss) 3) Restoring normal fluid volume by administering sodium chloride fluids (sufficient chloride must be available for the kidneys to absorb sodium with chloride and allow the excretion of bicarb) 4) Potassium replacement with KCl 5) Treatment with H2 receptor antagonists (such as cimetidine/Tagamet) in order to reduce the production of gastric hydrogen chloride 6) Carbonic anhydrase inhibitors in those who cannot tolerate rapid volume expansion (such as patients with heart failure) 7) Monitor ABGs and urine chloride levels

How is metabolic acidosis managed?

1) Treatment is aimed at correcting the metabolic imbalance 2) EKG and potassium levels should be monitored closely (hyperkalemia can occur initially and then hypokalemia) 3) Strict I & Os 4) Bicarb can be administered (use with caution in cardiac arrest as it can result in paradoxical intracellular acidosis) 5) In chronic metabolic acidosis, low serum calcium levels should be treated first before the chronic metabolic acidosis in order to avoid tetany resulting from an increase in pH and a decrease in ionized calcium. Hemodialysis or peritoneal dialysis is also considered 6) Should also utilize glasgow coma scale and monitor other electrolyte levels

What are some methods for therapeutic communication when speaking to a patient who has bipolar disorder?

1) Use short, simple sentences when speaking as patients have short attention spans 2) Give a brief explanation of each test a patient is undergoing and printed info to reinforce messages 3) Keep channels of communication open by asking the patient to speak more slowly 4) Ask patients to identify each person, place or thing being discussed to slow down speech 5) Talk to patients away from others so there is no competition for attention 6) Set limits regarding taking turns talking and listening

What are some common causes of metabolic alkalosis?

1) Vomiting or gastric suction with loss of hydrogen and chloride ions 2) Pyloric stenosis (frequent vomiting causes loss of gastric acid) 3) Situations which cause loss of potassium such as diuretic therapy (thiazides, furosemide) and ACTH secretion (hyperaldosteronism and Cushing syndrome) 4) Excessive alkali ingestion from antacids containing bicarb (such as baking soda) 5) Use of sodium bicarb during cardiac arrest

What are some expected patient outcomes regarding hypertension treatment?

1) Want to maintain blood pressure at less than 140/90 with lifestyle modifications, meds, or both 2) Have no symptoms of angina, palpitations, or vision changes 3) Stable BUN and serum creatine levels 4) Palpable peripheral pulses 5) Adherence to self-care program (adherence to meds, regular exercise, reduction in dietary intake of calories, sodium, fat, and cholesterol with an increase in fruits and vegetables, measurement of BP regularly and keeping follow-up appointments) 6) Want to have no complications (no changes in vision, no dyspnea or edema, maintain urine output, no headaches, dizziness, weakness, or falls) 7 Report knowledge of disease management sufficient to maintain adequate tissue perfusion

How is respiratory alkalosis managed?

1) Want to treat the underlying cause (for example if cause is anxiety want patient to breathe more slowly in order to allow CO2 to accumulate or treat with antianxiety agent) 2) Instructing patient on proper breathing techniques in order to slow down breathing 3) Monitoring electrolytes (can cause low potassium, phosphorus, and calcium) 4) Adjusting ventilator settings to slow down breathing

What is the management for CKD?

1) Want to treat the underlying cause (fully treat infections, keep diabetes or hypertension managed) 2) Want to keep BP below 130/80 3) Keep track of weight (should be measured at same time everyday) 4) Keep track of I & Os and watch for signs of oliguria and anuria 5) Smoking cessation, weight loss, exercise programs, and reduction in salt and alcohol intake

What are some nursing interventions regarding ARBs?

1) Watch for angioedema and allergic reactions 2) Can cause hyperkalemia so patient should avoid foods high in potassium 3) Should also pay attention to hypotension and put fall precuations in place

What values on an ABG would you expect to see with metabolic acidosis?

1) pH below 7.35 2) Bicarb below 22 (is the cardinal sign of metabolic acidosis) 3) PaCO2 is normal or low (depending on if respiratory system is compensating)

What values do you expect to see on an ABG with metabolic alkalosis?

1) pH greater than 7.45 2) Bicarb greater than 26 3) paCO2 less than 35 depending on if compensation is occurring or not

What will you see on an ABG in the case of respiratory alkalosis?

1) pH will be higher than 7.45 2) PaCO2 will be lower than 35 3) Bicarb may be lower than 22 if compensation is occurring

What is normal BUN levels?

10-20 mg/dL

What is considered an elevated BP?

120 to 129 systolic

What is now considered stage 1 hypertension?

130 or higher or 80 or higher diastolic pressure. Readings should be taken 1 to 4 weeks apart and should be taken at rest

What are the genetic theories behind bipolar disorder?

1st degree relatives with bipolar disorder increase the risk for bipolar

A nurse is developing a care plan for a patient with acute mania. Place the following behaviors according to the order in which they progress in a patient with acute mania: 1. Has delusions of grandeur 2. Uses relevant, calm speech patterns 3. Show high productivity and competitive attitude in work and leisure activities 4. Becomes easily irritated 5. Demonstrates poor judgement and impulse control

2., 3., 4., 5., 1.

What are the normal lab ranges for phosphorus?

2.5 to 4.5

What is the normal value for HCO3?

22-26 mmHg

What is the normal level for potassium?

3.5-5

What is the normal value for pCO2?

35-45 mmHg

What is the pH range of plasma that is compatible with life?

6.8 to 7.8

What is considered a normal plasma pH?

7.35-7.45

What is the normal range for anion gap

8-12 mEq/L

What is the normal lab range for calcium?

8.6 to 10.2

What is normal GFR?

80 to 125 mL/min

Describe the patho of CKD

A decrease in GFR causes a buildup of uric acid in the blood (azotemia). Azotemia can cause nausea, loss of appetite, and can eventually cause encephalopathy with asterixis (tremoring of hand). It can also cause hypertension, uremic frost seen on skin, increased vascular volume leading to edema and heart failure, bleeding issues (clots have trouble sticking together), anemia as a result of decrease in erythropoietin production, acidosis, hypocalcemia, and hyperparathyrodism in response to low calcium leading to muscle weakness.

Why is there a concern with administering O2 to a patient that has chronic hypercapnia (such as a COPD patient)?

A patient that has PaCO2 chronically greater than 50 mmHg does not use high CO2 levels as a respiratory stimulant and instead relies on O2 levels as the major drive for respiration. Administering oxygen may raise O2 levels in the blood to where that respiratory stimulant is lost and the patient develops "carbon dioxide narcosis"

What is hypomania classified by?

A period of abnormally and persistently elevated, expansive, or irritable mood lasting 4 days. It does not impair the ability to function

What is adaptive disclosure?

A specialized CBT approach developed by the military to offer an intense, specific, short-term therapy for active duty military personnel with PTSD. It incorporates exposure therapy as well as the empty chair technique in which the participant says whatever he or she needs to say to anyone dead or alive

What is considered hypertension?

A systolic blood pressure of 130 or higher or a diastolic blood pressure of 80 or higher based on the average of two or more accurate blood pressure measurements taken 1 to 4 weeks apart by a healthcare provider.

Which of the following best defines stroke volume? A) The amount of blood ejected with each heartbeat B) The amount of blood pumped by the ventricle in liters per minute C) Degree of stretch of the cardiac muscle fibers at the end of diastole D) Ability of the cardiac muscle to shorten in response to an electrical impulse

A) The amount of blood ejected with each heartbeat Rationale: Stroke volume is the amount of blood ejected with each heartbeat. Cardiac output is the amount of blood pumped by the ventricle in liters per minute. Preload is the degree of stretch of the cardiac muscle fibers at the end of diastole. Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse

A nurse is planning postprocedure care for a patient who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A) Check BUN and blood creatinine B) Administer meds the nurse withheld prior to dialysis C) Observe for findings of hypovolemia D) Assess the access site for bleeding E) Evaluate blood pressure on the arm with AV access

A), B), C), D)

A nurse is preparing to initiate hemodialysis for a patient who has acute kidney injury. Which of the following actions should the nurse take? (Select all that apply) A) Review the medications the patient currently takes B) Assess the AV fistula for a bruit C) Calculate the patient's hourly urine output D) Measure the patient's weight E) Check blood electrolytes F) Use the access site area for venipuncture

A), B), D), E)

What orientation is expected with someone in the mania phase of bipolar disorder?

AAOX2 (orientated to person and place but not to time)

How is hypertensive urgency treated?

With beta blockers, ACE inhibitors, or alpha2-agonists. The goal is to normalize blood pressure within 24-48 hours

How do diuretics work to reduce blood pressure? Name some examples of different types of diuretics

Works to reduce hypertension by removing water and sodium via the kidneys. Some examples are thiazide diuretics (ex. hydrcholorthiazide), loop diuretics (Furosemide), and potassium sparing diuretics (Spironolactone)

What is considered a positive screen for PTSD? What does a positive screening require?

Yes to any three questions on the PC-PTSD-5. This requires further investigation by a mental health professional and the person should be screened for suicidal ideation. Should also screen for ongoing traumatic events by asking directly (ask about nightmares or flashbacks, how this has disrupted their life) and provide information about local resources

What is an expected finding during the first week of peritoneal dialysis?

Abdominal pain

What are some changes that occur with aging that can lead to hypertension in the elderly?

Accumulation of atherosclerotic plaque, fragmentation of arterial elastin, increased collagen deposits, impaired vasodilation, and renal dysfunction that can occur with aging result in stiffing of major blood vessels, particularly the aorta. This causes the aorta and larger vessels to be less able to accommodate the volume of the blood pumped out and the energy that would have stretched the vessels instead elevates SBP and leads to an elevated systolic pressure (isolated systolic hypertension)

What is the MOA of alpha adrenergic blockers?

Acts directly in the vascular smooth muscle by blocking alpha adrenergic receptors causing vasodilation and decreasing BP. It also decreases levels of LDL cholesterol

What is the most common type of intrarenal failure?

Acute Tubular Necrosis (ATN). Results from damage of basement membrane to tubular epithelium which causes necrotic tissue to slough off and block tubules. Risk factors for this condition are prolonged pre-post renal failure, ischemia, increase in myoglobin, hypertension

What are contraindications for sodium polystyrene (kayexalate)?

Allergy, hypokalemia, obstructive bowel disease

What are some gerontologic considerations regarding kidney dysfunction?

Already have a risk for decreased blood flow to kidneys due to lack of perception of thirst and decrease in GFR and renal mass that comes with aging which puts them at increased risk for hypovolemia, dehydration, hyperkalemia, and hyponatremia.

What is the MOA of lithium?

Alters sodium transport in nerve and muscle cells by competing for sodium receptors. It also inhibits the release of norepinephrine and dopamine. It helps to stabilize bipolar disorder by reducing the degree and frequency of cycling or eliminating maniac episodes

What type of anacids are preferred for someone with CKD?

Aluminum hydroxide anacids as they lower phosphorus levels. Magnesium anacids are avoided as they can raise already high magnesium levels

What test should be performed doing an ABG? How is this performed?

An Allen test should be done before an ABG in order to determine that there is adequate ulnar blood flow when taking an arterial sample from the radial artery. The hand is elevated and the patient is asked to make a fist for 30 seconds while the nurse compresses the radial and ulnar arteries simultaneously, causing the hand to blanch. After the patient opens their fist, the nurse should release pressure from the radial and ulnar arteries and the hand should turn pink within 6 seconds indicating adequate perfusion.

What level is considered high anion gap acidosis?

An anion gap over 30. Indicates metabolic acidosis is present regardless of pH or HCO3 level

Which type of medications are used to treat rapid cycling bipolar disorder?

Antiepileptic drugs (especially tegretol and depakote)

When are second generation antipsychotics used with bipolar disorder? Name some examples of these medications.

Are used to control symptoms (hyperactivity) during maniac episodes during acute phase and used for mood stabilization long-term. They can benefit patients with or without psychotic symptoms and can be combined with a mood stabilizer. Examples are Olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal)

What are adverse effects for calcium gluconate?

Arrhythmia, bradycardia, cardiac arrest, hypotension, syncope, vasodilation, hypercalcemia, and tingling sensation with rapid IV administration

What does the diagnosis of a maniac episode require?

At least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem, sleeplessness, pressured speech, flight of ideas, reduced ability to filter extraneous stimuli, distractibility, increased activities with increased energy, and multiple, grandiose, high-risk activities involving poor judgement and severe consequences

A nurse is reviewing patient laboratory data. Which of the following findings is expected for a patient who has Stage 4 chronic kidney disease? A) Blood urea nitrogen (BUN) 15 mg/dL B) GFR 20 mL/min C) Blood creatinine 1.1 mg/dL D) Blood potassium 5.0 mEq/L

B)

A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN does of phenytoin? A) Decreased blood pressure, rapid pulse B) Headache, restless C) Pain and tingling at the access site D) Muscle cramps, chest heaviness

B) Headache, restlessness (Administer for any signs of disequilibrium syndrome)

The nurse teaches the patient with stage 1 hypertension about healthy diet modifications. Which diet choice indicates that the teaching has been effective? A) The patient restricts intake of chicken and fish. B) The patient has a glass of low-fat milk with each meal. C) The patient has two cups of coffee in the morning. D) The patient avoids eating nuts or nut butters.

B) The patient has a glass of low-fat milk with each meal Rationale: Including low fat milk is the best, appropriate dietary choice. Low fat proteins such as chicken and fish do not need to be restricted. Caffeine should be limited, therefore two cups of coffee is excessive. Nuts and nut butter should be limited but not eliminated from diets completely.

A nurse is planning care for a patient who has postrenal AKI due to metastatic cancer. The patient has a blood creatinine of 5 mg/dL. Which of the following interventions should the nurse include in the plan? (Select all that apply) A) Provide a high protein diet B) Assess the urine for blood C) Monitor for intermittent anuria D) Weight the patient once per week E) Provide NSAIDs for pain

B), C)

What are the psychodynamic theories behind bipolar disorder?

Believes that maniac episodes are a defense mechanism for depression

Which two types of blood pressure medications can cause bradycardia?

Beta blockers and calcium channel blockers

Which types of bipolar can lithium treat?

Bipolar I and Bipolar II is not helpful in treating rapid cycling bipolar

What is the MOA of beta blockers?

Blocks beta adrenergic receptors which block output of the sympathetic nervous system producing a slower heart rate and lower blood pressure. Causes a reduction in heart rate, force of contraction, and decreased rate of AV conduction

What is the MOA of calcium channel blockers?

Blocks calcium access to the heart which inhibits a calcium ion influx causing a decrease in cardiac work and energy consumption and increased delivery of oxygen to myocardium. Decreases contractility, conductivity of the heart, and demand of oxygen in the heart

What is the MOA of angiotensin II receptor blockers (ARBs)?

Blocks the effects of angiotensin II at the receptor which causes a reduction in peripheral resistance. Is used in patients who cannot tolerate ACE inhibitors and is not the first choice in meds

A nurse is caring for a patient who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? A) Administer an opioid B) Monitor for hypertension C) Assess level of consciousness D) Increase the dialysis exchange rate

C)

A nurse is planning care for a patient who has prerenal acute kidney injury (AKI) following abdominal aortic aneurysm repair. Urinary output is 60 mL in the past 2 hr, and blod pressure is 92/58 mm Hg. The nurse should expect which of the following interventions? A) Prepare the patient for a CT scan with contrast die B) Plan to administer nitroprusside C) Prepare to administer a fluid challenge D) Plan to position the patient in Trendelenburg

C)

A nurse is assessing a patient who has an AKI. Which of the following findings should the nurse expect? (Select all that apply) A) Reduced BUN B) Elevated cardiac enzymes C) Reduced urine output D) Elevated serum creatinine E) Elevated serum calcium

C), D)

To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply): A) Monitor the BP in the affect arm B) Irrigate the graft daily with low dose heparin C) Palpate the area of the graft to feel a normal thrill D) Listen with the stethoscope over the graft to detect a bruit E) Frequently monitor the pulses and neurovascular status distal to the graft

C), D), E)

What type of psychotherapy is most effective for patients with bipolar disorder?

CBT. Therapy should be given during mildly depressive or normal portion of bipolar cycle. It is not useful during acute manic stages because the person's attention span is brief

What are signs of lithium toxicity?

CNS problems (ataxia, slurred speech), nausea, vomiting, ECG changes, CV collapse, severe hyponatremia

Which medication is used as a cardioprotective measure to prevent complications that can occur from hyperkalemia with kidney disease?

Calcium gluconate

What are grounding techniques?

Can be used when a patient with PTSD is experiencing a flashback or dissociating involves reminding the patient that they are safe, are an adult, and are in the present.

What is dialysis disequilibrium syndrome?

Can develop during or after hemodialysis. The syndrome is caused by a rapid change in fluid volume and BUN levels following dialysis. The change in urea levels can cause cerebral edema and increased intracranial pressure. Manifestations include nausea, vomiting, restlessness, seizures, and coma

Why should beta blockers be used with caution in diabetics?

Can mask signs of hypoglycemia

What does central perfusion refer to?

Cardiac output or the amount of blood that is pumped by the heart every minute and which propels blood from the heart to organs and tissues

What type of drug is clonidine (Catapres)?

Centrally acting alpha 2 agonist

What are some signs of protein deficit?

Chronic weight loss, emotional depression, pallor, fatigue, soft flabby muscles

What are some signs of hypocalcemia? What ABG condition might you see this with?

Chvostek sign (twitching of muscles in the face) and trousseau sign when blood pressure cuff is inflated which causes carpal spasm. It can also present with seizures, stridor, carpopedal spasm, hyperactive reflexes, tetany, tingling of finger and around mouth, mental changes such as depression, confusion, delirium, prolonged QT interval, dyspnea, and laryngospasm. It can also present with hyperactive bowel sounds. It is seen in respiratory alkalosis as more calcium is bound to albumin and not ionized

Why does metabolic acidosis occur?

Common clinical disturbance characterized by a low pH (increased H+ concentration) or a loss of bicarb. It is divided into two forms which are classified according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis.

A nurse is teaching a patient who has chronic kidney disease and is to being hemodialysis. Which of the following information should the nurse include in the teaching? A) Hemodialysis restores kidney function B) Hemodialysis replaces hormonal function of the kidney C) Hemodialysis allows an unrestricted diet D) Hemodialysis returns a balance to blood electrolytes

D)

Describe what occurs during the oliguria phase of AKI

Decreased urine output is accompanied by an increase in serum concentration of substances such as urea, creatinine, potassium, magnesium, uric acids, and organic acids. Will also see uremic symptoms along with fluid volume overload

What are signs of hypercalcemia?

Deep bone pain, flank pain, muscle weakness, depressed deep tendon reflexes, constipation, nausea and vomiting, confusion, impaired memory, polyuria, polydipsia, ECG changes.

What is the biggest risk during the diuresis phase of AKI?

Dehydration as fluid volume overload is corrected with an increase in urine output

What are some signs of a bicarb excess?

Depressed respirations, muscle hypertonicity, dizziness, tingling of fingers and toes

What is the primary cause of CKD?

Diabetes followed by hypertension

How is hypokalemia managed?

Diet increase in potassium, oral or parenteral potassium replacement therapy

What is the DASH diet?

Dietary Approaches to Stop Hypertension. Diet which is aimed at lowering hypertension through consuming a diet that is rich in fruits, vegetables, grains, and low-fat dairy products. Should also limit meat servings to less than 2 servings a day and implement a low sodium diet (less than 1500 mg of sodium in a day). Alcohol should be limited to less than 2 servings of alcohol in a day

How is hyperkalemia treated?

Dietary restriction of potassium, diuretics which are potassium depleting, IV glucose, insulin and sodium bicarb, cation-exchange resin, calcium gluconate, dialysis

What is PTSD?

Disturbing pattern of behavior demonstrated by someone who has experienced, witnessed or been confronted with a traumatic event such as a natural disaster, combat, or assault. The event posed actual or threatened death or serious injury which was responded to with intense fear, helplessness, or terror

If a patient has respiratory acidosis due to inappropriate mechanical ventilation how is this managed?

Elevated PaCO2 must be decreased slowly in order to avoid causing rapid excretion of CO2 to the point where the kidneys are unable to excrete bicarb fast enough and alkalosis and seizures could occur

What are the biological theories behind bipolar disorder?

Epinephrine is believed to be increased and acetylcholine is also believed to be implicated

What is the most effective treatment for PTSD?

Exposure therapy. Is a treatment approach designed to combat the avoidance behavior that occurs with PTSD, help the patient face troubling thoughts and feelings, and regain a sense of control. The patient confronts the feared emotions, situations, and thoughts associated with trauma while employing various relaxation techniques to help the patient tolerate and manage the anxiety response. This therapy can be based in reality

What is the onset and clinical course of bipolar disorder?

First manic episode generally occurs in a person's teens, 20s, or 30s. Manic episodes typically begin with rapid escalation of symptoms over a few days, and they last from a few weeks to several months. They tend to be briefer and end more suddenly than depressive episodes.

What is the management for fluid volume deficit?

Fluid challenge, fluid replacement orally or parenterally

How is sodium excess treated?

Fluids, diuretic agents, dietary restriction on sodium

A 55 year old male chronic smoke with emphysema and chronic bronchitis. ABG is 7.36 pH, PaO2 60, PaCO2 70, and HCO3 38. What is the acid base imbalance?

Fully compensated respiratory acidosis

62 year old female with pneumonia for one week. ABG is 7.44 pH, PaO2 90, PaCO2 20, and HCO3 13. What is the acid base imbalance?

Fully compensated respiratory alkalosis

How is postrenal AKI managed?

Goal is to alleviate obstruction. This may require an indwelling urinary catheter (transurethral, suprapubic) or stent placement

How is intrarenal AKI managed?

Goal is to conserve kidney function and prevent and manage complications. Treatment may include prescribing corticosteroids, managing hypertension, and controlling proteinuria. Dietary protein is restricted when renal insufficency and elevated BUN develop and sodium is restricted when the patient has hypertension, edema, and heart failure.

How is prerenal AKI managed?

Goal is to improve renal perfusion with appropriate volume replacement. This can be obtained through IV fluids, transfusions of blood products, vasoactive medications, and hemodynamic monitoring to guide treatment

What is the normal value for pO2?

Greater than 80 mmHg

What is typical of the self-concept of someone with mania?

Have exaggerated self-esteem and believe they can accomplish anything

What are signs of a bicarb deficit?

Headache, confusion, drowsiness, increased respiratory rate and depth, nausea and vomiting, warm flushed skin

What is cardiac output a measure of?

Heart rate (heart beat/min) X stroke volume (volume/beat). It measures the amount of blood pumped by the heart in one minute

What is the most life-threatening electrolyte imbalance seen in AKI?

Hyperkalemia

What type of electrolyte imbalance can occur with respiratory acidosis and why?

Hyperkalemia can occur as potassium move out of the cells in order to try and bring H+ into the cells and lower acidity of the blood

What is primary or essential hypertension?

Hypertension that has no identifiable cause. About 95% of those with hypertension have primary hypertension

What is often noted in an assessment of the general appearance of someone with bipolar disorder?

In the mania phase patients will often be in perpetual motion due to pyschomotor agitation. The patient may also wear clothes that reflect elevated mood (brightly colored, flamboyant, attention-getting, or sexually suggestive). Move, think, and talk fast, Show pressured speech (evidenced by unrelentingly rapid and often loud speech without pauses). They interrupt and cannot listen to others.

How is sodium deficit treated?

Increase in sodium in diet, normal saline or hypertonic saline solutions

What are adolescents with PTSD also at risk for?

Increased risk for substance abuse, suicide, poor social support, academic problems and poor health. It can also disrupt the biologic maturation process contributing to long-term emotional and behavioral problems

What are some signs of severe respiratory acidosis?

Increasing intracranial pressure due to vasodilation can cause papilledema and dilated conjunctival blood vessels. Hyperkalemia can also result as potassium moves out of the cells into blood in order to reduce the levels of H+

What does a higher H+ concentration indicate?

Indicates increased acidity

What does a lower H+ concentration indicate?

Indicates more alkalinity and an increased pH

What is systolic pressure?

Indicates the amount of pressure your blood is exerting against your artery walls when the heart beats

What is diastolic pressure?

Indicates the amount of pressure your blood is exerting against your artery walls while the heart is at rest

What is the biggest risk with a percutaneous venous catheter?

Infection

What is the biggest risk with peritoneal dialysis?

Infection

How do ACE-inhibitors work?

Inhibit the conversion of angiotensin I to angiotensin II which causes a decrease in peripherial vascular resistance

What electrolyte imbalances may occur with metabolic acidosis?

Initially hyperkalemia may occur as potassium moves into the blood in order to compensate for the acidity of the blood. Hypokalemia may occur as metabolic acidosis is corrected when potassium moves back into the cells. Potassium should not be replaced in metabolic acidosis as the body can maintain potassium homeostasis itself!

Describe what occurs during the initiation phase of AKI

Injury occurs. Phase ends when oliguria begins

What is bipolar disorder?

Involves extreme mood swings from episodes of mania to episodes of depression. During manic phases, patients are euphoric, grandiose, energetic, and sleepless. They have poor judgment and rapid thoughts, actions, and speech. During depression they experience the same issues as a person with regular depression and are sad, have a lack of energy, interest, and impaired concentration, along with thoughts of suicide. Each mood may last for weeks or months before the pattern begins to descend or ascend once again. It is often comorbid with other conditions such as anxiety, ADHD, substance use disorders and has high rates of suicide.

How is an arteriovenous fistula or graft made for dialysis?

Involves joining an artery to a vein either side to side or end to end. The arterial segment is used for arterial flow to the dialyzer and the venous segment for reinfusion of dialyzed blood. It needs about 2-3 months in order to mature and be able to be used

What are the clinical manifestations of mania with bipolar diorder?

Is a distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased activity lasting at least 1 week for every day that week. It is classified by: 1) Inflated self-esteem 2) Pressured speech (talking faster than usual) 3) Delusions of grandeur 4) Psychomotor agitation 5) Decreased sleep 6) Risk-taking 7) Cheerful, irritable 8) Psychotic features (can have psychosis in the form of delusions or hallucinations) 10) Patients are also often resistant to taking meds when maniac 11) The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning

What is hypertensive urgency?

Is a situation in which blood pressure is very elevated but there is no evidence of impending or progressive target organ damage. It is associated with severe headaches, nosebleeds, or anxiety (symptomatic hypertensive episode)

What is a hypertensive emergency?

Is a situation in which blood pressures are extremely elevated (greater than 180/120) and must be lowered quickly. It is acute, and life-threatening.

How does respiratory alkalosis occur?

Is always caused by hyperventilation which causes excessive blowing off of CO2 and lowering of carbonic acid levels in the blood.

What type of ABG condition is rhabdomyolysis? What are some symptoms that this condition presents with?

Is an example of high anion gap acidosis in which muscle breakdown causes the release of myoglobin into the blood which can cause severe kidney damage. Symptoms include muscle weakness, nausea, vomiting, abdominal pain, severe muscle aches and pain, fever, rapid heart rate. It is treated with fluid replacement

How is DKA treated? What type of ABG condition is this?

Is an example of high anion gap acidosis. It is treated with large volumes of normal saline and an insulin drip

What causes prerenal injury?

Is caused by hypoperfusion of the kidney. Examples of this are volume depletion (as a result of burns, hemorrhage, clots, GI losses), hypotension (sepsis, shock), and renal artery stenosis.

How is stroke volume calculated? What is this value dependent on?

Is end diastolic volume (EDV)- End systolic volume (ESV). It is dependent on contractility (more forceful the contraction, stronger the contractility), preload (degree of stretch of cardiac myocytes at end of cardiac filling, is measured by EDV, more blood=increased stretch and preload), and afterload (resistance that ventricles must overcome to eject blood, hypertension causes higher vascular pressure and a reduced amount of ejected blood)

Describe what occurs during the diuresis phase of AKI

Is not always seen. GFR starts to gradually increase and fluid volume overload begins to correct with an increase in urine output. Risk for dehydration during this phase

When is pyschotherapy not effective in bipolar disorder?

Is not effective when client is experiencing mania

How is blood pressure measured?

Is the product of cardiac output X peripheral resistance

When is a percutaenous venous catheter used for dialysis?

Is used for temporary access during hemodialysis and for emergent needs. Should not be used as an IV and is solely used for dialysis purposes.

What are mixed acid-base disorders?

Is when the patient experiences two or more independent acid-base disorders. They have a normal pH but changes are occurring in both PaCO2 and HCO3.

What are some of the clinical manifestations of pre-renal injury?

It causes hypoperfusion. BUN is elevated out of proportion to creatinine, creatinine is also elevated, oliguria is present, urine sodium is decreased due to reabsorption of sodium (below 20), urine is more concentrated (urine osmolality greater than 500, and increased urine specific gravity). May also see a few hyaline casts

What is an added advantage of alpha adrenergic blockers in addition to lowering BP?

It decreases LDL cholesterol

What is metabolic alkalosis caused by?

It is produced through a gain of bicarb or a loss of H+

What is the first step of treatment aimed at treating hypertension?

Lifestyle modifications

How is chronic metabolic acidosis managed? (what should be treated first)

Low calcium levels should be corrected before acidosis in order to avoid tetany as pH goes up. Hemodialysis or peritoneal dialysis may also be utilized

What clinical manifestations are seen with intrarenal AKI?

Lowered GFR, oliguria, increased levels of BUN and creatinine, hyperkalemia, metabolic acidosis, brown granular casts seen in urine, low normal urine specific gravity, damaged cells in nephron can't reabsorb sodium so urine sodium rises above 40 mEq/L

What are some complications that can occur as a result of uncontrolled hypertension?

MI, heart failure, stroke, chronic kidney disease, and death

What is typical of the mood and affect with someone with bipolar disorder?

Mania is seen with reflected periods of euphoria, exuberant activity, grandiosity, and false sense of well-being. Project an all-knowing and all-powerful image. They can be angry, verbally aggressive tone, sarcastic and irritable (especially when setting limits). Mood is labile and they often alternate between periods of loud laughter and episodes of tears.

Describe what occurs during the recovery phase of AKI?

Marked improvement in renal function which may take 3-12 months. Residual impairment of GFR may put them at future risk for reoccurance of AKI

What are some signs of hypokalemia? What ABG condition might you see this with?

May see fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria, paresthesias, leg cramps, abdominal distention, paralytic ileus and flattened T waves and prominent U waves on an ECG. It is seen with respiratory alkalosis, as potassium moves into the cells in order to move H+ into the blood in order to compensate

What are signs of hypophosphatemia? What condition may you see this in?

May see in alklalosis as when the pH rises it causes phosphorus to move into the cells. It presents with muscle weakness, muscle pain, acute rhabomyolysis, insulin resistance (possible hyperglycemia), and bruising and bleeding from platelet dysfunction

What type of acid base imbalance is ketoacidosis?

Metabolic acidosis (high anion gap acidosis)

What type of acid base imbalance is lactic acidosis?

Metabolic acidosis (high anion gap acidosis)

What type of acid base imbalance is associated with diarrhea?

Metabolic acidosis (normal anion gap acidosis)

What type of acid base imbalance is associated with hypokalemia?

Metabolic alkalosis

What type of acid base imbalance is associated with vomiting?

Metabolic alkalosis

What is the MOA of calcium gluconate?

Moderates nerve and muscle performance via action potential threshold regulation. Are used as a cardioprotective measure to prevent complication from hyperkalemia

How long does it take for lithium to cause mood changes in patient's with bipolar disorder?

Mood changes may not be apparent for 7 to 21 days

What type of symptoms will you see with hyperkalemia?

Muscle weakness, dysrhythmias, paresthesia, diarrhea, colic, nausea, irritability and anxiety

What is the equation for anion gap?

Na+ - (Cl- + HCO3-)

What are signs of sodium deficit?

Nausea, malaise, lethargy, headache, abdominal cramps, apprehension, seizures

When do symptoms begin to be experienced with PTSD?

Occurs 3 or more months after the trauma and is typically chronic in nature (symptoms can fluctuate in intensity and severity becoming worse during stressful periods)

Why does respiratory acidosis occur?

Occurs due to the inadequate excretion of CO2 from the lungs which causes retention of CO2 and in turn the rise of the carbonic acid level in the blood. It is due to hypoventilation and is usually accompanied by a low PaO2 also

What is End-Stage Kidney Disease (ESRD)?

Occurs when a patient has sustained enough kidney damage to require renal replacement therapy on a permanent basis and have entered the final stage of CKD. The end products of protein metabolism accumulate in the blood and uremia develops and adversely affects every system in the body

What is secondary hypertension?

Occurs when there is a cause that can be identified for hypertension (occurs in about 5% of cases). Causes can be chronic kidney disease, renal artery stenosis, hyperaldosteronism, pheochromocytoma, and sleep apnea

How do patients with mania react towards self-care needs?

Often go days without sleep or food and do not realize they are hungry or tired. They are at risk for physical exhaustion and often ignore personal hygiene. This can lead to death as they are unaware of their health needs.

What is typical of the thought process of someone with bipolar disorder?

Often orientated to person and place but rarely to time. Intellectual functioning is difficult to assess and patient may claim to possess many abilities but do not. Ability to concentrate or pay attention is grossly impaired. If patient is psychotic they may be experiencing hallucinations

What is bipolar II?

One or more major depressive episodes and at least one hypomanic episode. Does not have mania but does experience hypomania for at least four days

What is bipolar I?

One or more maniac or mixed + major depressive episode (classic highs and lows)

What is the onset of action and the method of excretion for sodium polystyrene (kayealate)?

Onset of action is 2-24 hours and the excretion is completely through the feces

What is the primary screening tool for PTSD?

PC-PTSD-5

22 year old male, upset that he broke up with his girlfriend, was found confused next to a bottle of pills. ABG is 7.53 pH, PaO2 85, PaCO2 15, and HCO3 14. What is the acid base imbalance?

Partially compensated respiratory alkalosis

What will you see on an ECG with hyperkalemia?

Peaked T waves, ST segment depression, and a shortened QT interval

What is the medical treatment for bipolar disorder?

Pharmacological agents along with pyschotherapy (pyschotherapy is only effective when patient is not maniac)

What electrolyte should be paid attention to while a patient is on an ACE-inhibitor?

Potassium (can cause hyperkalemia)

Which electrolyte level should be paid attention to in ARBs?

Potassium (can cause hyperkalemia, even more so than ACE inhibitors)

What causes intrarenal AKI?

Prolonged renal ischemia which causes damage to the kidney tissue causing impaired function of the nephron. Possible causes are acute tubular necrosis (ATN), ischemia, nephrotoxic exposure, infection, acute glomerulonephritis, and rhabdomyolysis.

What are the sites of choice for an ABG?

Radial, brachial, or femoral arteries

What is bipolar mixed?

Rapid cycling between periods of mania, normal mood, depression, normal mood, mania and so forth. Experiences greater than four moods in a year and is the most difficult to treat (not treated with lithium!).

How does someone with mania typically confront relationships and responsiblities?

Rarely fulfill responsibilities and are unable to function doing normal tasks of life. They do not understand boundaries and often invade the intimate space and personal business of others. Usual mood is elation but emotions can fluctuate readily between hostility and mania (especially when someone stands in their way).

What does the anion gap measure?

Refers to the difference between the sum of all measured positively charged electrolytes (cations) and the sum of all negatively charged electrolytes (anions). The sum of measured cations is typically greater than the sum of measured anions creating a gap. This gap reflects normally unmeasured anions (phosphates, sulfates, and proteins) in plasma which can increase the gap through replacement of bicarbonate. A higher anion gap suggests excessive accumulation of unmeasured anions and indicates high anion acidosis as the metabolic acidosis type (results from excessive accumulation of a fixed acid which occurs in ketoacidosis, lactic acidosis, late phase of salicylate poisoning, uremia, etc)

How do the kidneys regulate pH?

Regulate the bicarb level in the extracellular fluid by regenerating bicarbonate ions as well as reabsorbing them from the renal tubular cells. They also can increase excretion of hydrogen ions and conserve biocarbonate ions to help restore balance

What is the MOA of sodium polystyrene (kayexalate)?

Removes potassium by exchanging sodium ions for potassium in the intestine (especially the large intestine)

What are the contraindications of lithium?

Renal and cardiac disease, sodium-depletion dehydration, diuretic use, pregnancy and lactation

What type of acid base imbalance is a sedative overdose?

Respiratory acidosis

What type of acid base imbalance is associated with acute pulmonary edema?

Respiratory acidosis

What type of acid base imbalance is associated with hypoxemia?

Respiratory acidosis

What type of acid base imbalance is pneumonia?

Respiratory acidosis

Which type of condition is associated with a condition that leads to hypoventilation (bradypnea)?

Respiratory acidosis

What causes high anion gap acidosis? Name some conditions.

Results from an excessive accumulation of fixed acid (anion gap is greater than 30). This is seen in ketoacidosis, intake of a high fat diet, renal failure/rhabdomyolysis, severe lung problems, lactic acidosis, the late phase of salicylate poisoning, uremia, methanol or ethylene glycol toxicity, and ketoacidosis with starvation. Hydrogen is also buffered by HCO3- causing the bicarb concentration to fall.

What causes normal anion gap acidosis? Name some examples of conditions in which this is seen.

Results from the direct loss of bicarbonate. This can occur in diarrhea, lower intestinal fistulas, ureterostomies, and the use of diuretics, early renal insufficiency, excessive administration of chloride, and the administration of parenteral nutrition without bicarb or bicarb producing solutions (e.g., lactate).

What is a risk with calcium and phosphorus binders?

Risk of hypercalcemia

When should calcium and phosphorus binders be taken?

Should be taken with meals

What is important to check before administering a beta blocker?

Should check heart rate in addition to blood pressure as beta blockers cause heart rate to decrease

What are some nursing considerations regarding the administration of sodium polystyrene (kayexalate)?

Should closely monitor serum electrolytes (specifically magnesium, potassium, calcium, and sodium)

Which medication can be used to reduce potassium levels?

Sodium polystyrene (kayexalate)

What should also be assessed for when performing a nursing assessment on a patient with PTSD?

Suicidal ideation

What about PTSD distinguishes it from acute stress disorder?

Symptoms occur three months or more after the trauma, while with acute stress disorder it occurs about 2 days to 4 weeks after the event

What is considered stage 2 hypertension?

Systolic at or above 140 or diastolic at or above 90

If angioedema appears with an ACE inhibitor what should be done?

The drug should be stopped immediately as the patient is having a life-threatening allergic reaction

What are the buffer systems which maintain plasma pH? How do they work?

The kidneys and lungs are the major buffer systems within the body. Buffer systems prevent major changes by removing or releasing H+. There are normally 20 parts of bicarb to 1 part carbonic acid in plasma.

In respiratory acidosis which system compensates? How does it do this?

The kidneys compensate by excreting more H+ and retaining more bicarb ions. This will cause the bicarb level to become higher when the kidneys are compensating (above 26)

In respiratory alkalosis which system compensates? How does it do this?

The kidneys compensate by excreting more bicarb and retaining H+. This will cause the bicarb level to become lower when the kidneys are compensating (below 22)

Which type of compensation is faster: kidneys or lungs?

The lungs are faster while the kidneys usually take a matter of hours or days to correct a pH imbalance

In metabolic acidosis which system compensates? How does it do this?

The lungs compensate by blowing off more CO2 (increasing respiratory rate), in order to decrease carbonic acid presence and the kidneys excrete bicarb and retain H+. When the lungs are compensating in metabolic acidosis you will see a lower paCO2 level (below 35).

In metabolic alkalosis which system compensates? How does it does this?

The lungs compensate by retaining CO2 (through decreasing the respiratory rate) and the kidneys compensate through increasing the retention of bicarb which increases the plasma level of carbonic acid. This causes paCO2 to rise (when the lungs are compensating in this condition you will see a paCO2 above 45).

Which type of diuretic causes potassium loss and has the potential for hypokalemia?

Thiazide diuretics

Who is more susceptible to bipolar disorder?

Those that are creative and are of higher socioeconomic background

What type of patients undergo renal replacement therapy?

Those who need acute or urgent dialysis is indicated when there is increasing level of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, or advanced uremia

How is acid-base balance measured?

Through an arterial blood gas (ABG)

When pH is acidotic how can the kidneys compensate to help restore pH balance?

Through excretion of hydrogen ions and retainment of bicarb

How do the lungs compensate when pH is altered?

Through retaining or blowing off of CO2. The lungs control the carbonic acid content of the ECF. When CO2 is increased, it increases the content of carbonic acid in plasma (CO2 dissolved in water becomes carbonic acid). In the reverse situation, when more CO2 is released through exhaling, the carbonic acid concentration decreases (thus increasing pH).

When pH is alkalotic how can the kidneys work to help restore pH balance?

Through retainment of hydrogen ions and loss of bicarb ions

How is the hypocalcemia and hyperphosphatemia in ESRD treated?

Through the use of calcium and phosphorus binders such as calcium carbonate (Os-Cal) and calcium acetate (Phos-Lo).

What is the purpose of renal replacement therapy?

To rid the body of excess fluid and electrolytes, achieve acid base balance, and eliminate waste products. Can be done acutely or done in outpatient. Types of renal replacement are intermittent hemodialysis, peritoneal dialysis, and continuous renal replacement therapy (CRRT)

What is the main treatment for a patient with respiratory acidosis?

Treating the underlying cause (ex. using bronchodilators to treat bronchial spasms in asthmatics, using thrombolytics to remove pulmonary emboli)

What is the depression phase of bipolar disorder classified by?

Typical symptoms of depression: 1) Sad mood 2) Hypersomnia or insomnia 3) Lack of energy 4) Impaired concentration and decision making 5) Feelings of worthlessness, hopelessness, despair 6) Thoughts of death or suicide

What is chronic kidney disease?

Umbrella term that describes kidney damage or a decrease in the GFR lasting for 3 or more months. Untreated CKD can result in end-stage kidney disease which results in retention of uremic waste products and the need for renal replacement therapies, dialysis, or kidney transplant. Some examples of this are chronic glomerulonephritis, pyelonephritis, nephrotic syndrome

23 year old female with seizures lasting longer than 90 minutes. ABG is 7.24 pH, PaO2 120, PaCO2 36, and HCO3 is 14. What is the acid base imbalance?

Uncompensated metabolic acidosis

40 year old male admitted as a pedestrian versus motor vehicle with bilateral pneumothoraces. ABG is pH 7.10, PaO2 50, PaCO2 50, and HCO3 22. What is the acid base imbalance?

Uncompensated respiratory acidosis

A 25 year old male is admitted to the ER with a heroin overdose. ABG is 7.10 pH, PaCO2 80, and HCO3 24. What is the acid base imbalance?

Uncompensated respiratory acidosis

What is the MOA of valproic acid (Depakote)?

Unknown, may raise brain's threshold for dealing with stimulation by reducing abnormal activity in the brain and increasing GABA activity at inhibitory receptors. Is used to treat rapid cycling bipolar

Why should patients with chronic kidney failure follow a low protein diet?

Urea is a waste product of protein and increased protein can result in increased protein breakdown causing uremia

What is cognitive processing therapy?

Used successfully with rape survivors with PTSD as well as combat veterans. The therapy involves structured sessions that focus on examining beliefs that are erroneous or interfere with daily life.

Which type of bipolar disorder is valproic acid (Depakote) used to treat?

Used to treat rapid cycling bipolar

What is peritoneal dialysis?

Uses the peritoneal membrane that covers the abdominal organs as a semipermeable membrane. Sterile dextrose dialysate fluid is introduced into the peritoneal cavity through an abdominal cavity at established intervals in order to remove toxins.

What causes postrenal AKI?

Usually results from obstruction distal to the kidney by conditions such as renal calculi, strictures, blood clots, BPH, malignancies, and pregnancy. Pressure rises in the kidney tubules, and eventually GFR decreases

What are the clinical manifestations of metabolic acidosis?

Varies with the severity of the condition but can include headache, confusion, drowsiness, increased respiratory rate and depth (Kussmaul respirations as a compensatory mechanism), nausea, and vomiting. Peripheral vasodilation and decreased cardiac output can occur when the pH drops to less than 7. Can also see decreased blood pressure, cold and clammy skin, dysrhythmias, and shock. Hyperkalemia may occur (as potassium shifts out of the cells) and then once metabolic acidosis hypokalemia can occur as potassium shifts back into the cells. Chronic metabolic acidosis is usually associated with chronic renal failure (maybe treated with dialysis)

What may be the first sign of respiratory acidosis if a patient is anesthetized?

Ventricular fibrillation

What are some contraindications for calcium gluconate?

Ventricular fibrillation, hypercalcemia

What are some of the clinical manifestations of ESRD?

Virtually every body system is affected in ESKD so a number of signs and symptoms are exhibited. Peripheral neuropathy is present in some patients along with restless leg syndrome and burning feet as an early stage of uremic peripheral neuropathy. Other symptoms are asterixis, weakness and fatigue, seizures, ecchymosis, hyperkalemia, fluid volume overload, hypertension, pitting edema, crackles, shortness of breath, ammonia odor to breath, bleeding from GI tract, metallic taste, anemia, thrombocytopenia, bone fractures, bone pain, foot drop, and muscle cramps.

How is a hypertensive crisis treated?

Want to reduce the blood pressure by 20 to 25% within the first hour of treatment, a further reduction to a goal pressure of about 160/100 in a period of up to 6 hours, and then a more gradual reduction over a few days. Is treated with IV vasodilators that have an immediate effect such as nitroglycerin, sodium nitroprusside (Nitropress). It is also important to assess fluid volume status as volume depletion can occur secondary to the meds and sodium excretion (should give volume replacement with normal saline)

What is the most accurate indicator of fluid loss or gain?

Weight. A 1kg weight gain is equal to 1000 mL of retained fluid