NCLEX

NCLEX Diabetes

Diabetes mellitus refers to a group of diseases that affect how your body uses blood sugar (glucose). Glucose is vital to your health because it's an important source of energy for the cells that make up your muscles and tissues. It's also your brain's main source of fuel. If diabetes is detected, no matter what type, it means you have too much glucose in your blood, although the causes may differ. Too much glucose can lead to serious health problems. Chronic diabetes conditions include type 1 diabetes and type 2 diabetes. Potentially reversible diabetes conditions include prediabetes — when your blood sugar levels are higher than normal, but not high enough to be classified as diabetes — and gestational diabetes, which occurs during pregnancy but may resolve after the baby is delivered. To understand diabetes, first you must understand how glucose is normally processed in the body.

How Insulin Works

Insulin is a hormone that comes from a gland situated behind and below the stomach (pancreas).

• The pancreas secretes insulin into the bloodstream.
• The insulin circulates, enabling sugar to enter your cells.
• Insulin lowers the amount of sugar in your bloodstream.
• As your blood sugar level drops, so does the secretion of insulin from your pancreas.

The Role Of Glucose

Glucose — a sugar — is a source of energy for the cells that make up muscles and other tissues.

• Glucose comes from two major sources: food and your liver.
• Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.
• Your liver stores and makes glucose.
• When your glucose levels are low, such as when you haven't eaten in a while, the liver breaks down stored glycogen into glucose to keep your glucose level within a normal range

Signs and Symptoms

Some of the signs and symptoms of type 1 and type 2 diabetes are:

• Increased thirst
• Frequent urination
• Extreme hunger
• Unexplained weight loss
• Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there's not enough available insulin)
• Fatigue
• Irritability
• Blurred vision
• Slow-healing sores
• Frequent infections, such as gums or skin infections and vaginal infections

Causes

Causes of type 1 diabetes

The exact cause of type 1 diabetes is unknown. What is known is that your immune system — which normally fights harmful bacteria or viruses — attacks and destroys your insulin-producing cells in the pancreas. This leaves you with little or no insulin. Instead of being transported into your cells, sugar builds up in your bloodstream. Type 1 is thought to be caused by a combination of genetic susceptibility and environmental factors, though exactly what many of those factors are is still unclear.

Causes of Prediabetes and type 2 diabetes

In prediabetes — which can lead to type 2 diabetes — and in type 2 diabetes, your cells become resistant to the action of insulin, and your pancreas is unable to make enough insulin to overcome this resistance. Instead of moving into your cells where it's needed for energy, sugar builds up in your bloodstream. Exactly why this happens is uncertain, although it's believed that genetic and environmental factors play a role in the development of type 2 diabetes. Being overweight is strongly linked to the development of type 2 diabetes, but not everyone with type 2 is overweight.

Causes of gestational diabetes

During pregnancy, the placenta produces hormones to sustain your pregnancy. These hormones make your cells more resistant to insulin. Normally, your pancreas responds by producing enough extra insulin to overcome this resistance. But sometimes your pancreas can't keep up. When this happens, too little glucose gets into your cells and too much stays in your blood, resulting in gestational diabetes.

Risk Factors

Risk factors for type 1 diabetes

Although the exact cause of type 1 diabetes is unknown, factors that may signal an increased risk include:

• Family history - Your risk increases if a parent or sibling has type 1 diabetes.
• Environmental factors - Circumstances such as exposure to a viral illness likely play some role in type 1 diabetes.
• The presence of damaging immune system cells (auto-antibodies) - Sometimes family members of people with type 1 diabetes are tested for the presence of diabetes auto-antibodies. If you have these auto-antibodies, you have an increased risk of developing type 1 diabetes. But not everyone who has these auto-antibodies develops diabetes.
• Dietary factors - These include low vitamin D consumption, early exposure to cow's milk or cow's milk formula, and exposure to cereals before 4 months of age. None of these factors has been shown to directly cause type 1 diabetes.
• Geography - Certain countries, such as Finland and Sweden, have higher rates of type 1 diabetes.

Risk factors for Prediabetes and type 2 diabetes

Researchers don't fully understand why some people develop prediabetes and type 2 diabetes and others don't. It's clear that certain factors increase the risk, however, including:

• Weight - The more fatty tissue you have, the more resistant your cells become to insulin.
• Inactivity - The less active you are, the greater your risk. Physical activity helps you control your weight, uses up glucose as energy and makes your cells more sensitive to insulin.
• Family history - Your risk increases if a parent or sibling has type 2 diabetes.
• Race - Although it's unclear why, people of certain races — including blacks, Hispanics, American Indians and Asian-Americans — are at higher risk.
• Age - Your risk increases as you get older. This may be because you tend to exercise less, lose muscle mass and gain weight as you age. But type 2 diabetes is also increasing dramatically among children, adolescents and younger adults.
• Gestational diabetes - If you developed gestational diabetes when you were pregnant, your risk of developing prediabetes and type 2 diabetes later increases. If you gave birth to a baby weighing more than 9 pounds (4 kilograms), you're also at risk of type 2 diabetes.
• Polycystic ovary syndrome - For women, having polycystic ovary syndrome — a common condition characterized by irregular menstrual periods, excess hair growth and obesity — increases the risk of diabetes.
• High blood pressure - Having blood pressure over 140/90 millimeters of mercury (mm Hg) is linked to an increased risk of type 2 diabetes.
• Abnormal cholesterol and triglyceride levels - If you have low levels of high-density lipoprotein (HDL), or "good," cholesterol, your risk of type 2 diabetes is higher. Triglycerides are another type of fat carried in the blood. People with high levels of triglycerides have an increased risk of type 2 diabetes. Your doctor can let you know what your cholesterol and triglyceride levels are.

Risk factors for gestational diabetes

Any pregnant woman can develop gestational diabetes, but some women are at greater risk than are others. Risk factors for gestational diabetes include:

• Age - Women older than age 25 are at increased risk.
• Family or personal history - Your risk increases if you have prediabetes — a precursor to type 2 diabetes — or if a close family member, such as a parent or sibling, has type 2 diabetes. You're also at greater risk if you had gestational diabetes during a previous pregnancy, if you delivered a very large baby or if you had an unexplained stillbirth.
• Weight - Being overweight before pregnancy increases your risk.
• Race - For reasons that aren't clear, women who are black, Hispanic, American Indian or Asian are more likely to develop gestational diabetes.

Complications

Long-term complications of diabetes develop gradually. The longer you have diabetes — and the less controlled your blood sugar — the higher the risk of complications. Eventually, diabetes complications may be disabling or even life-threatening. Possible complications include:

• Cardiovascular disease - Diabetes dramatically increases the risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke and narrowing of arteries (atherosclerosis). If you have diabetes, you are more likely to have heart disease or stroke.
• Nerve damage (neuropathy) - Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in your legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward. Left untreated, you could lose all sense of feeling in the affected limbs. Damage to the nerves related to digestion can cause problems with nausea, vomiting, diarrhea or constipation. For men, it may lead to erectile dysfunction.
• Kidney damage (nephropathy) - The kidneys contain millions of tiny blood vessel clusters (glomeruli) that filter waste from your blood. Diabetes can damage this delicate filtering system. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, which may require dialysis or a kidney transplant.
• Eye damage (retinopathy) - Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness. Diabetes also increases the risk of other serious vision conditions, such as cataracts and glaucoma.
• Foot damage - Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can develop serious infections, which often heal poorly. These infections may ultimately require toe, foot or leg amputation.
• Skin conditions - Diabetes may leave you more susceptible to skin problems, including bacterial and fungal infections.
• Hearing impairment - Hearing problems are more common in people with diabetes.
• Alzheimer's disease - Type 2 diabetes may increase the risk of Alzheimer's disease. The poorer your blood sugar control, the greater the risk appears to be. Although there are theories as to how these disorders might be connected, none has yet been proved.

Complications of gestational diabetes

Most women who have gestational diabetes deliver healthy babies. However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby. Complications in your baby can occur as a result of gestational diabetes, including:

• Excess growth - Extra glucose can cross the placenta, which triggers your baby's pancreas to make extra insulin. This can cause your baby to grow too large (macrosomia). Very large babies are more likely to require a C-section birth.
• Low blood sugar - Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Prompt feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal.
• Type 2 diabetes later in life - Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.
• Death - Untreated gestational diabetes can result in a baby's death either before or shortly after birth.

Complications in the mother can also occur as a result of gestational diabetes, including:

• Preeclampsia - This condition is characterized by high blood pressure, excess protein in the urine, and swelling in the legs and feet. Preeclampsia can lead to serious or even life-threatening complications for both mother and baby.
• Subsequent gestational diabetes - Once you've had gestational diabetes in one pregnancy, you're more likely to have it again with the next pregnancy. You're also more likely to develop diabetes — typically type 2 diabetes — as you get older.

Tests and Diagnosis

The ADA recommends that the following people be screened for diabetes:

• Anyone with a body mass index higher than 25, regardless of age, who has additional risk factors, such as high blood pressure, a sedentary lifestyle, a history of polycystic ovary syndrome, having delivered a baby who weighed more than 9 pounds, a history of diabetes in pregnancy, high cholesterol levels, a history of heart disease, and having a close relative with diabetes.
• Anyone older than age 45 is advised to receive an initial blood sugar screening, and then, if the results are normal, to be screened every three years thereafter.

Tests for type 1 and type 2 diabetes and prediabetes

• Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. It measures the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates that you have diabetes. An A1C between 5.7 and 6.4 percent indicates prediabetes. Below 5.7 is considered normal.

If the A1C test results aren't consistent, the test isn't available, or if you have certain conditions that can make the A1C test inaccurate — such as if you're pregnant or have an uncommon form of hemoglobin (known as a hemoglobin variant) — your doctor may use the following tests to diagnose diabetes:

• Random blood sugar test - A blood sample will be taken at a random time. Regardless of when you last ate, a random blood sugar level of 200 milligrams per deciliter (mg/dL) or higher suggests diabetes.
• Fasting blood sugar test - A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.
• Oral glucose tolerance test - For this test, you fast overnight, and the fasting blood sugar level is measured. Then you drink a sugary liquid, and blood sugar levels are tested periodically for the next two hours. A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A reading of more than 200 mg/dL (11.1 mmol/L) after two hours indicates diabetes. A reading between 140 and 199 mg/dL (7.8 mmol/L and 11.0 mmol/L) indicates prediabetes.

If type 1 diabetes is suspected, your urine will be tested to look for the presence of a byproduct produced when muscle and fat tissue are used for energy when the body doesn't have enough insulin to use the available glucose (ketones). Your doctor will also likely run a test to see if you have the destructive immune system cells associated with type 1 diabetes called auto-antibodies.

Tests for gestational diabetes

Your doctor may use the following screening tests:

• Initial glucose challenge test - You'll begin the glucose challenge test by drinking a syrupy glucose solution. One hour later, you'll have a blood test to measure your blood sugar level. A blood sugar level below 140 mg/dL (7.2 to 7.8 mmol/L) is usually considered normal on a glucose challenge test, although this may vary at specific clinics or labs. If your blood sugar level is higher than normal, it only means you have a higher risk of gestational diabetes. Your doctor will order a follow-up test to determine if you have gestational diabetes.
• Follow-up glucose tolerance testing - For the follow-up test, you'll be asked to fast overnight and then have your fasting blood sugar level measured. Then you'll drink another sweet solution — this one containing a higher concentration of glucose — and your blood sugar level will be checked every hour for a period of three hours. If at least two of the blood sugar readings are higher than the normal values established for each of the three hours of the test, you'll be diagnosed with gestational diabetes.

Treatments

Depending on what type of diabetes you have, blood sugar monitoring, insulin and oral medications may play a role in your treatment. Eating a healthy diet, maintaining a healthy weight and participating in regular activity also are important factors in managing diabetes.

Treatments for all types of diabetes

An important part of managing diabetes — as well as your overall health — is maintaining a healthy weight through a healthy diet and exercise plan:

• Healthy eating - Contrary to popular perception, there's no specific diabetes diet. You'll need to center your diet on more fruits, vegetables and whole grains — foods that are high in nutrition and fiber and low in fat and calories — and cut down on animal products, refined carbohydrates and sweets. In fact, it's the best eating plan for the entire family. Sugary foods are OK once in a while, as long as they're counted as part of your meal plan. Yet understanding what and how much to eat can be a challenge. A registered dietitian can help you create a meal plan that fits your health goals, food preferences and lifestyle. This will likely include carbohydrate counting, especially if you have type 1 diabetes.
• Physical activity - Everyone needs regular aerobic exercise, and people who have diabetes are no exception. Exercise lowers your blood sugar level by moving sugar into your cells, where it's used for energy. Exercise also increases your sensitivity to insulin, which means your body needs less insulin to transport sugar to your cells. Get your doctor's OK to exercise. Then choose activities you enjoy, such as walking, swimming or biking. What's most important is making physical activity part of your daily routine. Aim for at least 30 minutes or more of aerobic exercise most days of the week. If you haven't been active for a while, start slowly and build up gradually.

Treatments for type 1 and type 2 diabetes

Treatment for type 1 diabetes involves insulin injections or the use of an insulin pump, frequent blood sugar checks, and carbohydrate counting. Treatment of type 2 diabetes primarily involves monitoring of your blood sugar, along with diabetes medications, insulin or both.

• Monitoring your blood sugar
• Insulin
• Oral or other medications - Metformin (Glucophage, Glumetza, others) is generally the first medication prescribed for type 2 diabetes.
• Transplantation - In some people who have type 1 diabetes, a pancreas transplant may be an option. Islet transplants are being studied as well. With a successful pancreas transplant, you would no longer need insulin therapy. But transplants aren't always successful — and these procedures pose serious risks. You need a lifetime of immune-suppressing drugs to prevent organ rejection. These drugs can have serious side effects, including a high risk of infection, organ injury and cancer. Because the side effects can be more dangerous than the diabetes, transplants are usually reserved for people whose diabetes can't be controlled or those who also need a kidney transplant.
• Bariatric surgery - Although it is not specifically considered a treatment for type 2 diabetes, people with type 2 diabetes who also have a body mass index higher than 35 may benefit from this type of surgery. People who've undergone gastric bypass have seen significant improvements in their blood sugar levels. However, this procedure's long-term risks and benefits for type 2 diabetes aren't yet known.

 

NCLEX Hypertension

High blood pressure is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. Blood pressure is determined both by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure. You can have high blood pressure (hypertension) for years without any symptoms. Even without symptoms, damage to blood vessels and your heart continues and can be detected. Uncontrolled high blood pressure increases your risk of serious health problems, including heart attack and stroke. High blood pressure generally develops over many years, and it affects nearly everyone eventually. Fortunately, high blood pressure can be easily detected. And once you know you have high blood pressure, you can work with your doctor to control it.

Signs and Symptoms

A few people with high blood pressure may have headaches, shortness of breath or nosebleeds, but these signs and symptoms aren't specific and usually don't occur until high blood pressure has reached a severe or life-threatening stage.

Causes

Primary (Essential) Hypertension

For most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure, called primary (essential) hypertension, tends to develop gradually over many years.

Secondary Hypertension

Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including:

• Obstructive sleep apnea
• Kidney problems
• Adrenal gland tumors
• Thyroid problems
• Certain defects in blood vessels you're born with (congenital)
• Certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs
• Illegal drugs, such as cocaine and amphetamines
• Alcohol abuse or chronic alcohol use

Risk Factors

High blood pressure has many risk factors, including:

• Age - The risk of high blood pressure increases as you age. Through early middle age, or about age 45, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
• Race - High blood pressure is particularly common among blacks, often developing at an earlier age than it does in whites. Serious complications, such as stroke, heart attack and kidney failure, also are more common in blacks.
• Family history - High blood pressure tends to run in families.
• Being overweight or obese - The more you weigh the more blood you need to supply oxygen and nutrients to your tissues. As the volume of blood circulated through your blood vessels increases, so does the pressure on your artery walls.
• Not being physically active - People who are inactive tend to have higher heart rates. The higher your heart rate, the harder your heart must work with each contraction and the stronger the force on your arteries. Lack of physical activity also increases the risk of being overweight.
• Using tobacco - Not only does smoking or chewing tobacco immediately raise your blood pressure temporarily, but the chemicals in tobacco can damage the lining of your artery walls. This can cause your arteries to narrow, increasing your blood pressure. Secondhand smoke also can increase your blood pressure.
• Too much salt (sodium) in your diet - Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
• Too little potassium in your diet - Potassium helps balance the amount of sodium in your cells. If you don't get enough potassium in your diet or retain enough potassium, you may accumulate too much sodium in your blood.
• Too little vitamin D in your diet - It's uncertain if having too little vitamin D in your diet can lead to high blood pressure. Vitamin D may affect an enzyme produced by your kidneys that affects your blood pressure.
• Drinking too much alcohol - Over time, heavy drinking can damage your heart. Having more than two drinks a day for men and more than one drink a day for women may affect your blood pressure. If you drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
• Stress - High levels of stress can lead to a temporary increase in blood pressure. If you try to relax by eating more, using tobacco or drinking alcohol, you may only increase problems with high blood pressure.
• Certain chronic conditions - Certain chronic conditions also may increase your risk of high blood pressure, such as kidney disease, diabetes and sleep apnea.

Complications

• Heart attack or stroke - High blood pressure can cause hardening and thickening of the arteries (atherosclerosis), which can lead to a heart attack, stroke or other complications.
• Aneurysm - Increased blood pressure can cause your blood vessels to weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
• Heart failure - To pump blood against the higher pressure in your vessels, your heart muscle thickens. Eventually, the thickened muscle may have a hard time pumping enough blood to meet your body's needs, which can lead to heart failure.
• Weakened and narrowed blood vessels in your kidneys - This can prevent these organs from functioning normally.
• Thickened, narrowed or torn blood vessels in the eyes - This can result in vision loss.
• Metabolic syndrome - This syndrome is a cluster of disorders of your body's metabolism, including increased waist circumference; high triglycerides; low high-density lipoprotein (HDL) cholesterol, the "good" cholesterol; high blood pressure; and high insulin levels. These conditions make you more likely to develop diabetes, heart disease and stroke.
• Trouble with memory or understanding - Uncontrolled high blood pressure may also affect your ability to think, remember and learn. Trouble with memory or understanding concepts is more common in people with high blood pressure.

Treatments

• Lifestyle changes
• Antihypertensives
• Diuretics
• Beta-blockers

 

NCLEX Pulmonary Edema

Pulmonary edema is a condition caused by excess fluid in the lungs.  This fluid collects in the numerous air sacs in the lungs, making it difficult to breathe.  In most cases, heart problems cause pulmonary edema.  But fluid can accumulate for other reasons, including pneumonia, exposure to certain toxins and medications, trauma to the chest wall, and exercising or living at high elevations. Pulmonary edema that develops suddenly (acute pulmonary edema) is a medical emergency requiring immediate care.  Although pulmonary edema can sometimes prove fatal, the outlook improves when you receive prompt treatment for pulmonary edema along with treatment for the underlying problem.  Treatment for pulmonary edema varies depending on the cause but generally includes supplemental oxygen and medications.

Signs and Symptoms

Sudden (acute) Pulmonary Edema Symptoms

• Extreme SOB of difficulty breathing (dyspnea) that worsens when lying down
• A feeling of suffocating or drowning
• Wheezing or gasping for breath
• Anxiety, restlessness or a sense of apprehension
• Blood tinged frothy sputum
• Chest pain and palpitations

Long-term (chronic) Pulmonary Edema Symptoms

• Having more SOB than normal when physically active
• Difficulty breathing with exertion
• Difficulty breathing when lying flat
• Wheezing
• Awakening at night with a breathless feeling relieved by sitting up
• Rapid weight gain when pulmonary edema develops
• Swelling in your lower extremities
• Fatigue

High Altitude Pulmonary Edema Symptoms

• Shortness of breath after exertion, which progresses to SOB at rest
• Cough, fever, and chest discomfort
• Difficulty walking uphill
• Blood tinged sputum, palpitations
• Headaches

Causes

Cardiogenic Pulmonary Edema

Cardiogenic pulmonary edema is a type of pulmonary edema caused by increased pressures in the heart.  This condition usually occurs when the diseased or overworked left ventricle isn't able to pump out enough of the blood it receives from your lungs (CHF).  As a result, pressure increases inside the left atrium and then in the veins and capillaries in your lungs, causing fluid to be pushed through the capillary walls into the air sacs.  Medical conditions that can cause the left ventricle to become weak and fail includes

• Coronary artery disease
• Cardiomyopathy
• Heart valve problems
• Hypertension

Noncardiogenic Pulmonary Edema

Pulmonary edema that isn't caused by increased pressures in your heart is called noncardiogenic pulmonary edema.  In this condition, fluid may leak from the capillaries in your lung's air sacs because the capillaries themselves become ore permeable or leaky, even without the buildup of back pressure from your heart.  Some factors that can cause noncardiogenic pulmonary edema includes:

• ARDS
• High altitudes
• Nervous system conditions
• Adverse drug reactions
• Pulmonary embolism
• Viral infections
• Lung injury
• Exposure to certain toxins
• Smoke inhalation
• Near drowning

Complications

• Lower extremity and abdominal swelling
• Pleural effusion
• Congestion and swelling of the Liver

Treatment

• Preload reducers such as Lasix, Nitroglycerin, Procardia
• Morphine for pain
• Afterload reducers such as MS Contin
• Blood pressure meds

 

NCLEX Cardiogenic Shock 

Cardiogenic Shock Overview

Cardiogenic shock is a life threatening medical condition resulting from an inadequate circulation of blood due to primary failure of the ventricles of the heart to function effectively.  Cardiogenic shock is a type of circulatory shock, where there is insufficient perfusion of tissue to meet the demands for oxygen and nutrients.  Cardiogenic shock is a largely irreversible condition and as such is more often fatal than not.  The condition involves increasingly more pervasive cell death from oxygen starvation (hypoxia) and nutrient starvation (low blood sugar).  Because of this, it may lead to cardiac arrest, which is an abrupt stopping of cardiac pump function. Cardiogenic shock is defined by sustained low blood pressure with tissue hypoperfusion despite left ventricular filling pressure.  Signs of tissue hypoperfusion include low urine production (<30 mL/hr), cool extremities, and altered level of consciousness.

Signs and Symptoms

• Anxiety, restlessness, altered mental state due to decreased blood flow to the brain and subsequent hypoxia
• Low blood pressure due to decrease in cardiac output
• A rapid, weak, thready pulse due to decreased circulation combined with tachycardia
• Cool, clammy, and mottled skin due to vasoconstriction and subsequent hypoperfusion of the skin
• Distended jugular veins due to increased jugular venous pressure
• Oliguria due to inadequate blood flow to the kidneys if the condition persists
• Rapid and deeper respirations due to sympathetic nervous system stimulation and acidosis
• Fatigue due to hyperventilation and hypoxia
• Absent pulse in fast and abnormal heart rhythms
• Pulmonary edema, involving fluid back up in the lungs due to insufficient pumping of the heart

Causes

Cardiogenic shock is caused by the failure of the heart to pump effectively.  It can be due to any of the following

• Myocardial infarction
• Abnormal heart rhythms
• Cardiomyopathy, Cardiac valve problems
• Aortic valve stenosis, aortic dissection
• Cardiac tamponade
• Constrictive pericarditis
• Systolic anterior motion
• Hypertrophic cardiomyopathy
• Sudden decompressurization (aircraft)

Risk Factors

• Old age
• History of heart failure or heart attack
• Coronary artery disease
• Diabetes and/or HTN

Diagnosis

Electrocardiogram - helps establishing the exact diagnosis and guides treatment, it may reveal:

• Abnormal heart rhythm
• Myocardial infarction
• Signs of cardiomyopathy

Ultrasound - may show poor ventricular function, rupture of the interventricular septum, an obstructed outflow tract or cardiomyopathy. Swan-Ganz Catheter - or PA catheter may assist in the diagnosis by providing information on the hemodynamics. Biopsy - when cardiomyopathy is suspected as the cause of cardiogenic shock, a biopsy of heart muscle may be needed to make a definite diagnosis.

Treatment

• Aspirin
• Thrombolytics
• Blood thinners
• Inotropic agents
• Angioplasty and stenting
• Balloon pump
• Coronary artery bypass surgery
• Ventricular assist devices
• Heart transplant

 

NCLEX Bacterial Meningitis

In this featured article, we will focus primarily on Bacterial Meningitis.  Although there are other forms forms of meningitis, bacterial meningitis poses the biggest threat.  

Bacterial Meningitis Overview

Meningitis is an infection of the membranes (meninges) surrounding the brain and spinal cord. Meningitis can be caused by a bacterial, fungal or viral infection. Meningitis can be acute, with a quick onset of symptoms, it can be chronic, lasting a month or more, or it can be mild or aseptic. Anyone experiencing symptoms of meningitis should see a doctor immediately. Acute bacterial meningitis is the most common form of meningitis. Approximately 80 percent of all cases are acute bacterial meningitis. Bacterial meningitis can be life threatening. The infection can cause the tissues around the brain to swell. This in turn interferes with blood flow and can result in paralysis or even stroke.

Signs and Symptoms

• Sudden high fever
• Stiff neck
• Severe headache that seems different than normal
• Nausea and vomiting
• Confusion, Seizures
• Sleepiness or difficulty waking up
• Sensitivity to light
• No appetite or thirst
• Skin rash

Causes

• Streptococcus pneumoniae (pneumococcus)
• Neisseria meningitidis
• Haemophilus influenza
• Listeria monocytogenes

Risk Factors

• Skipping Vaccinations
• Age - more common when <20 y/o
• Living in a community setting - college life
• Pregnancy
• Compromised immune system - AIDS

Complications

• Hearing loss
• Memory difficulty
• Learning disabilities
• Brain damage
• Gait problems
• Seizures
• Kidney failure
• Shock and death

Diagnosis

• Positive Blood cultures
• CT scan or MRI, X-rays
• Lumbar puncture

Treatment

Acute bacterial meningitis must be treated with antibiotics and more recently corticosteroids.  The antibiotics or combination of antibiotics depends on the type of bacteria causing the infection.  

NCLEX Cerebrospinal Fluid

As a part of our continued review of the human body, we decided to take an in-depth look at Cerebrospinal fluid.  Within this article, we will cover in great detail the structure and make-up of cerebrospinal fluid.

Cerebrospinal Fluid (CSF) Overview

Cerebrospinal fluid (CSF) is a clear, colorless body fluid found in the brain and spine. It is produced in the choroid plexuses of the ventricles of the brain. It acts as a cushion or buffer for the brain's cortex, providing basic mechanical and immunological protection to the brain inside the skull. The CSF also serves a vital function in cerebral autoregulation of cerebral blood flow. The CSF occupies the subarachnoid space (between the arachnoid mater and the pia mater) and the ventricular system around and inside the brain and spinal cord. It constitutes the content of the ventricles, cisterns, and sulci of the brain, as well as the central canal of the spinal cord.

Production of CSF

• The brain produces roughly 500 mL of cerebrospinal fluid per day. This fluid is constantly reabsorbed, so that only 100-160 mL is present at any one time.

• Ependymal cells of the choroid plexus produce more than two thirds of CSF. The choroid plexus is a venous plexus contained within the four ventricles of the brain, hollow structures inside the brain filled with CSF. The remainder of the CSF is produced by the surfaces of the ventricles and by the lining surrounding the subarachnoid space.

• Ependymal cells actively secrete sodium into the lateral ventricles. This creates osmotic pressure and draws water into the CSF space. Chloride, with a negative charge, moves with the positively charged sodium and a neutral charge is maintained. As a result, CSF contains a higher concentration of sodium and chloride than blood plasma, but less potassium, calcium and glucose and protein

Circulation of CSF

CSF circulates within the ventricular system of the brain. The ventricles are a series of cavities filled with CSF, inside the brain. The majority of CSF is produced from within the two lateral ventricles. From here, the CSF passes through the interventricular foramina to the third ventricle, then the cerebral aqueduct to the fourth ventricle. The fourth ventricle is an outpouching on the posterior part of the brainstem. From the fourth ventricle, the fluid passes through three openings to enter the subarachnoid space – these are the median aperture, and the lateral apertures. The subarachnoid space covers the brain and spinal cord.  There is connection from the subarachnoid space to the bony labyrinth of the inner ear making the cerebrospinal fluid continuous with the perilymph.

Reabsorption of CSF

It had been thought that CSF returns to the vascular system by entering the dural venous sinuses via the arachnoid granulations (or villi). However, some have suggested that CSF flow along the cranial nerves and spinal nerve roots allow it into the lymphatic channels; this flow may play a substantial role in CSF reabsorbtion, in particular in the neonate, in which arachnoid granulations are sparsely distributed. The flow of CSF to the nasal submucosal lymphatic channels through the cribriform plate seems to be especially important. 

CSF Contents

• The CSF is created from blood plasma and is largely similar to it, except that CSF is nearly protein-free compared with plasma and has some modified electrolyte levels. CSF contains approximately 0.3% plasma proteins, or approximately 15 to 40 mg/dL, depending on sampling site, and it is produced at a rate of 500 ml/day. Since the subarachnoid space around the brain and spinal cord can contain only 135 to 150 ml, large amounts are drained primarily into the blood through arachnoid granulations in the superior sagittal sinus. Thus the CSF turns over about 3.7 times a day. This continuous flow into the venous system dilutes the concentration of larger, lipid-insoluble molecules penetrating the brain and CSF.

• Healthy cerebrospinal fluid is free of red blood cells, and at most contains only a few white blood cells. Any cell count higher than that constitutes pleocytosis, an excess of cells.

Development of CSF

• Around the third week of development, the embryo is a three-layered disc, covered on the dorsal surface by a layer of endoderm. In the middle of this surface is a linear structure called the notochord. As the endoderm proliferates, the notochord is dragged into the middle of the developing embryo and becomes the neural canal.

• As the brain develops, by the fourth week of embryological development three swellings have formed within the embryo around the canal, near where the head will develop. These swellings represent different components of the central nervous system: the prosencephalon, mesencephalon and rhombencephalon.

• The developing forebrain surrounds the neural cord. As the forebrain develops, the neural cord within it becomes a ventricle, ultimately forming the lateral ventricles. Along the inner surface of both ventricles, the ventricular wall remains thin, and a choroid plexus develops, releasing CSF. The CSF quickly fills the neural canal.

Function of CSF

• Buoyancy: The actual mass of the human brain is about 1400 grams; however, the net weight of the brain suspended in the CSF is equivalent to a mass of 25 grams. The brain therefore exists in neutral buoyancy, which allows the brain to maintain its density without being impaired by its own weight, which would cut off blood supply and kill neurons in the lower sections without CSF.

• Protection: CSF protects the brain tissue from injury when jolted or hit. In certain situations such as motor vehicle crashes or sports injuries, the CSF cannot protect the brain from forced contact with the skull case, causing hemorrhaging, brain damage, and sometimes death.

• Chemical stability: CSF flows throughout the inner ventricular system in the brain and is absorbed back into the bloodstream, rinsing the metabolic waste from the central nervous system through the blood–brain barrier. This allows for homeostatic regulation of the distribution of neuroendocrine factors, to which slight changes can cause problems or damage to the nervous system. For example, high glycine concentration disrupts temperature and blood pressure control, and high CSF pH causes dizziness and syncope.  To use Davson's term, the CSF has a "sink action" by which the various substances formed in the nervous tissue during its metabolic activity diffuse rapidly into the CSF and are thus removed into the bloodstream as CSF is absorbed.^[

• Prevention of brain ischemia: The prevention of brain ischemia is made by decreasing the amount of CSF in the limited space inside the skull. This decreases total intracranial pressure and facilitates blood perfusion.

• Clearing waste: CSF has been shown to be critical in the brain's glymphatic system, which plays an important role in flushing metabolic toxins or waste from the brain's tissues' cellular interstitial fluid (ISF).  CSF flushing of wastes from brain tissue is further increased during sleep, which results from the opening of extracellular channels controlled through the contraction of glial cells, which allows for the rapid influx of CSF into the brain.  These findings indicate that CSF may play a large role during sleep in clearing metabolic waste, like beta amyloid, that are produced by the activity in the awake brain. 

 

NCLEX Chronic Renal Failure

Chronic Renal Failure Overview

Chronic renal failure, also known as, chronic renal disease, is a progressive loss in kidney function over a period of months or years.  The symptoms of worsening kidney function are not specific, and might include feeling generally unwell and experiencing a reduced appetite.  Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic renal disease.  This disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia, pericarditis or renal osteodystrophy. Chronic kidney disease is identified by a blood test for creatinine, which is a breakdown product of muscle metabolism.  Higher levels of creatinine indicate a lower GFR and as a result a decreased capability of the kidneys to excrete waste products.  Creatinine levels may be normal in the early stages of chronic renal disease, and the condition is discovered if urinalysis shows the kidney is allowing the loss of protein or red blood cells into the urine.  To fully investigate the underlying cause of kidney damage, various forms of medical imaging, blood tests, and sometimes a kidney biopsy are employed to find out if a reversible cause for the kidney malfunction is present.

Signs and Symptoms

Signs and symptoms of kidney disease are often nonspecific, meaning they can also be caused by other illnesses.  Because your kidneys are highly adaptable and able to compensate for lost function, signs and symptoms may not appear until irreversible damage has occurred.

• Nausea and vomiting
• Loss of appetite
• Fatigue and weakness
• Sleep problems
• Changes in urine output
• Muscle twitches and cramps
• Swelling of feet and ankles
• Chest pain, shortness of breath
• HTN that's difficult to control

Causes

• Type 1 or Type 2 Diabetes
• High blood pressure
• Glomerulonephritis
• Interstitial nephritis
• Polycystic kidney disease
• Prolonged obstruction of the urinary tract
• Vesicoureteral reflux
• Pyelonephritis

Risk Factors

• Diabetes, HTN
• Smoking
• Heart disease
• Obesity
• High cholesterol
• African Americans
• Family history of kidney disease
• Age 65 or older

Complications

• Fluid retention - pulmonary edema
• Hyperkalemia
• Cardiac disease
• Osteoporosis
• Decreased sex drive or impotence
• Anemia
• Decreased immune response
• Pericarditis

Treatments

Depending on the underlying cause, some types of kidney disease can be treated.  Often, though, chronic kidney disease has no cure.  In general, treatment consists of measures to help control signs and symptoms, reduce complications, and slow the progression of the disease.

• Antihypertensives
• Medications to lower cholesterol levels
• Treat anemia
• Diuretics to relieve the swelling
• Vitamin D supplements
• Low protein diet to minimize waste products in your blood
• Hemodialysis or Peritoneal dialysis

 

 

NCLEX Placenta Abruption

Placenta Abruption Overview

Placental abruption is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother prior to delivery.  It is the most common pathological cause of later pregnancy bleeding.  In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth.  Placental abruption is a significant contributor to maternal mortality worldwide; early and skilled medical intervention is needed to ensure a good outcome, and this is not available in many parts of the world.  Treatment depends on how serious the abruption is and how far along the woman is in her pregnancy. Placental abruption has effects on both the mother and fetus.  The effects on the mother depend primarily on the severity of the abruption, while the effects on the fetus depend on both its severity and the gestational age at which it occurs.  The heart rate of the fetus can be associated with the severity.

Signs and Symptoms

In the early stages of placental abruption, there may be no symptoms.  When symptoms develop, they tend to develop suddenly.  Common symptoms include sudden onset abdominal pain, contractions that seem continuous and do not stop, pain in the abdomen and back, vaginal bleeding, enlarged uterus disproportionate to the gestational age of the fetus, decreased fetal movement, and decreased fetal heart rate. A placental abruption caused by arterial bleeding at the center of the placenta leads to sudden development of severe symptoms and life threatening conditions including fetal heart rate abnormalities, severe maternal hemorrhage, and DIC.  Those abruptions caused by venous bleeding at the periphery of the placenta develop more slowly and cause small amounts of bleeding, intrauterine growth restriction, and oligohydraminos.

Classic symptoms of placental abruption include

• Vaginal bleeding
• Abdominal pain
• Back pain
• Uterine tenderness
• Rapid uterine contractions

Causes

The specific cause of placental abruption is often unknown.  Possible causes include trauma or injury to the abdomen from an auto accident or fall.

Risk Factors

• Pre-eclampsia
• Chronic hypertension
• Short umbilical cord
• Prolonged rupture of membranes
• Thrombophilia
• Multiparity
• Multiple pregnancy
• Maternal age: < 20 or > 35 are at greatest risk

Complications

For the mother, placental abruption can lead to

• Shock due to blood loss
• Blood clotting problems (DIC)
• The need for blood transfusions
• Failure of the kidneys or other organs

For the baby, placental abruption can lead to

• Deprivation of oxygen and nutrients
• Premature birth
• Stillbirth

Treatments

Treatment depends on the amount of blood loss and the status of the fetus.  If the fetus is less than 36 weeks and neither mother or fetus is in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first. Immediate delivery of the fetus may be indicated if the fetus is mature of if the fetus or mother is in distress.  Blood volume replacement to maintain blood pressure and plasma replacement to maintain fibrinogen levels may be needed.  Vaginal birth is usually preferred over caesarean section unless there is fetal distress.  C-section is contraindicated in cases of DIC.  Excessive bleeding from uterus may necessitate hysterectomy.  The mother may be given Rhogam if she is Rh negative.  

NCLEX Placenta Previa

Placenta Previa Pathophysiology

Placenta previa is obstetric complication in which the placenta is inserted partially or wholly in the lower uterine segment.  It is a leading cause of antepartum hemorrhage.  In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment.  In a normal pregnancy the placenta does not overlie.  If the placenta does overlie the lower segment, as is the case with placenta previa, it may shear off and a small section may bleed.

Signs and Symptoms

Women with placenta previa often present with painless, bright red vaginal bleeding.  This common occurs around 32 weeks of gestation, but can be as early as late mid trimester.  This bleeding often starts mildly and may increase as the area of placental separation increases.  Previa should be suspected if there is bleeding after 24 weeks of gestation.

Causes

Exact cause of placenta previa is unknown.  It is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection.  These factors may reduce differential growth of lower segment, resulting in less upward shift in placental position as pregnancy advances.

Risk Factors

• Maternal age >40
• Illicit drugs and alcohol
• Previous C-section
• Parity > 5
• Prior abortion
• Smoking
• Congenital anomalies
• Male fetus
• Pregnancy induced hypertension

Diagnosis

History may reveal antepartum hemorrhage.  Abdominal exam usually finds the uterus non-tender, soft and relaxed.  Leopold's Maneuvers may find the fetus in an oblique or breech position or lying transverse as a result of the abnormal position of the placenta.  Malpresentation is found in about 35% cases.  Vaginal examination is avoided in known cases of placenta previa.

Management

Treatment for placenta previa depends on various factors.  For little or no bleeding, bed rest at home is recommended.  For heavy bleeding, bed rest in a hospital is recommended, as well as, a blood transfusion and medications to prevent premature labor.

Complications

Maternal

• Antepartum hemorrhage
• Malpresentation
• Abnormal placentation
• Postpartum hemorrhage

Fetal

• Premature delivery
• Death