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What hormones does the thyroid gland produce
- three hormones:
- T3
- T4
- Calcitonin
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What is calcitonin
- A hormone that decreases serum calcium levels by taking calcium out of the blood and pushing it back into the bone
- Is also given as a drug to treat osteoporosis
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What do you need to make hormones?
Iodine... dietary iodine!!
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What does the thyroid hormone give us?
Energy!!
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Describe s/s of hyperthyroidism
- Common cause is Graves Disease
- Nervous, irritable
- Decreased attention span
- Sweaty/Hot
- GI is fast -
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Exophthalmos
- Bulging eyes
- caused by hyperthryoidism
- can be irreversible
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If you drew a serum thyroxine (T4) on a hyperthyroid pt, what would you see
Increased levels of T4
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for hyperthyroid, is you checked TSH what would you see?
- It would be low
- Thyroid Stimulating Hormone
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If a hyperthyroid pt needs a scan with iodine, what do you educate?
- Discontinue any meds containing iodine one week prior to thyroid scan
- Wait 6 weeks before resuming.
- Iodine is tough on kidneys
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What is a drug that contains high levels of iodine?
- Amiodarone
- may affect thyroid function
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What type of treatment is there for hyperthyroidism?
- Anti-thyroid meds
- Iodine compounds
- Beta Blockers
- Radioactive iodine therapy
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Name some anti-thyroid medications
- Methimazole - which is drug of choice
- Propylthiouracil
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What do anti-thyroid meds do?
- Stops thyroid from making thyroid hormone
- Sometimes used preoperatively to stun thyroid
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Name an iodine compound drugs used for hyperthyroidism
Potassium iodine
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What do iodine compounds to for hyperthyroidism
- *This is the drug iodine, not the dietary iodine
- This will decrease the size and vascularity of the gland.
- Give with milk or juice, and use a straw cause it will stain teeth
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Name a beta blocker and why is it used with hyperthyroidism
- Propanalol
- It doesn't fix the problem, but helps with the symptoms
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How does beta blockers help with symptoms?
- Decreases myocardial contractility, which would decrease cardiac output
- Therefore, HR and BP would decrease
- Can also decrease anxiety as it doesn't allow the release of epi or norepi. Leaves them cool and calm.
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What two pt would you NOT give a beta blocker to?
- Asthmatics or diabetics
- The beta blocker will block the feelings of hypoglycemia or an oncoming asthma attack
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Radioactive Iodine therapy for hyperthyroidism
- Before administering, rule out pregnancy!
- Only one dose
- Given PO
- Destroys thyroid cells so hyper turns to hypothyroidism
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What precautions should be taught for radioactive iodine therapy
- Stay away from babies for 1 week
- Don't kiss anyone for 1 week
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After a thyroidectomy, where should you check for bleeding?
at the insicion site and at the back of the neck (in case of pooling)
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How would they diagnose hypothryoidism? (Think lab values)
- T4 would be low
- TSH would be high
- *just the opposite of lab values for hyperthryoidism
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Drugs to treat hypothryoidism
- Levothyroxine
- Liothyronine
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What will you worry about when a pt starts meds for hypothyroidism
- An MI
- people with hypothyroidism tend to have palpitations.
- These meds will cause in increase in BP and HR
- need to be started at a low dose and increased slowly
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What does the parathyroid do?
- It secretes PTH (Parathyroid hormone) which makes you pull calcium from the bones and place it in the blood
- Therefore, it increases your serum calcium level
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If you don't have any parathormone in your body, what happens?
The serum calcium level will be low
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What happens with hyperparathyroidism?
Same s/s as hypercalcemia and hypophosphatemia
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S/S of hyperparathryoidism
- Means too much PTH
- Serum calcium is high and serum phosphorus is low
- THEY WILL BE SEDATED!!!!
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Treatment for hyperparathyroidism
- Partial parathyroidectomy - take 2 of the parathyroids
- PTH secretion decreases which means calcium goes down
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What would you monitor for after a partial parathyroidectomy?
- Calcium will be low, so monitor for tight, ridged muscles.
- Could lead to tentany
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What is equal to hypoparathyroidism?
Hypocalcemia & hyperphosphatemia
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S/S of hypoparathyroidism
- Not enough PTH
- Serum calcium is low and phosphorus is high
- Their NOT SEDATED
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Treatment for hypoparathyroidism
- Give IV calcium
- Can give a phosphorus binding drug which would make phosphorus go down and bring calcium up
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Explain adrenal glands
- Need adrenals to handle stress
- Two parts: adrenal medulla and adrenal cortex
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What does the adrenal medulla do?
secretes epi and norepi
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What problem can occur with adrenal medulla?
- Pheochromocytoma which is a benign tumor that secretes epi and norepi in boluses
- Tend to be familial, so screen the family
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S/S of Pheochromocytoma
- *You have a surge of epi/norepi
- Increased BP/HR
- Palpitations
- Flushing and diaphoretic
- HA!!
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How do they diagnose pheochromocytoma
- catecholamine levels (catecholamine is epi and norepi)
- 24 hr urine test
- *both are looking at epi and norepi levels. Educate pt not to do anything that will increase levels (no stress)
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What tests the catecholamine levels?
- VMA (vanillylmandelic acid) test
- Metanephrine (MN) test
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Education prior to the VMA and/or MA test
- Avoid foods that can alter test:
- Anything with vanilla in it
- caffeine
- Vit B
- fruit juices and bananas
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What is secreted from adrenal cortex?
- STEROIDS:
- Glucocorticoids, mineralcorticoids, and sex hormones
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What are the 4 actions of glucocorticoids?
- Change your mood (can be excessively happy or depressed)
- Alters defense mechanisms (immunosuppressed = high risk for infection)
- Breakdown of fats and proteins (think cushings)
- Inhibits insulin = can become hyperglycemic
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What mineralcorticoid is secreted from adrenal cortex?
- Aldosterone!!
- Makes you retain water and sodium
- Makes you lose potassium
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What sex hormones are released by adrenal cortex?
testosterone, estrogen, and progestrone
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what happens with too many sex hormones?
- hirsutism
- Acne
- irregular menstrual cycle
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what happens with not enough sex hormones
- Decreases axillary/pubic hair
- Decreased libido
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Adrenocorticotropin hormones
- ACTH
- made in the pituitary and they stimulate cortisol to be made
- Cortisol is a hormone secreted by the adrenal cortex
- Just think STEROIDS!
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What happens with increased ACTH levels
Increased Cortisol levels
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What is another word for too many steroids?
Hypercortisolism
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Adrenal cortex Problems:
- Not enough steroids
- shock
- Hyperkalemia
- Hypoglycemia
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What disease involves not enough steroids? (Adrenocortical insufficiency)
- Addison's disease
- recall if we don't have enough aldostrone, we lose sodium and water and retain potassium.
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S/s of Addison's disease
- Extreme fatigue
- N/V and diarrhea
- Weight loss
- hypotension (decreased BP)
- Confusion
- Decrease sodium, increased potassium, and hypoglycemia (your not eating!)
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What are s/s of the skin pertaining to addisons disease?
- Hyperpigmentation - bronzing color of skin and mucous membranes
- Vitiligo - white patchy area of depigmentation
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How do we treat Addison's
- Combat shock
- increase sodium in diet (processed fruit juice, broth has lots of sodium)
- I&O and daily weights
- Their BP will be low as they are in fluid volume deficit
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Medication for Addisons
- Prednisolone
- Fludrocortisone
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How will prednisolone be given?
- Twice a day
- 2/3 in morning and 1/3 in evening
- this is similar to how body naturally secretes hormones
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What is Fludrocortisone
Aldosterone as a drug
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What happens in Addison's crisis
- Acute onset of severe hypotension and vascular collapse
- Can occur with infections, emotional stress, physical exertion or stopping steroids abruptly
- 100x worse than Addisons
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What is Cushings
Too many steroids
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S/S of too much glucocorticoids
- Growth arrest (breaks down fat/protein)
- Thin extremities
- Increase risk for infection
- Hyperglycemia
- Mood changes (psychosis to depression)
- Moon faced (fat redistribution)
- Buffalo hump (fat redistribution)
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Treatment for Cushings
- Adrenalectomy (either unilateral or bilateral)
- If both are removed, will need lifetime replacement hormones
- *These pt need a quiet environment as they can't handle stress
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Diet pretreatment for cushings?
- *Remember, too much hormones/steroids!
- Increase potassium, decrease sodium (aldostrone)
- Increase protein
- Increase Calcium (steroids decrease Ca by excreting it through GI Tract)
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Describe Diabetes type 1
- Usually diagnosed in childhood
- They have little or no insulin
- First sign may be DKA
- Appears abruptly, despite years of beta cell destruction
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What causes diabetes type 1?
- Auto immune response
- or
- Idiopathic (cause unknown)
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What are the classic 3 P's?
- Polyuria
- Polydipsia
- Polyphagia
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Explain pathophysiology for DKA
- Normally, you have insulin to carry glucose out of blood and into cell
- Since DM type 1 have no insulin, glucose builds up in blood
- Blood becomes hypertonic and pulls fluid into vascular space
- Kidneys filter excess glucose and gluids
- Cells are starving so they start breaking down protein and fat for energy
- This results in ketones, which is an acid
- Eventually, development of metabolic acidosis
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What respirations will be seen in DKA pt
- Kussmaul respirations which is a deep and labored breathing pattern
- they are trying to blow off CO2
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Treatment?
- Must have insulin
- Oral hypoglycemic agents wont work for this pt
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Explain type 2 DM
- These clients have insulin, just not enough insulin or the insulin they have is no good
- Can't make enough insulin for the glucose load the client is taking in
- Usually found by accident
- *Usually don't see DKA with type 2 as they don't usually break down fat
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What should type 2 diabetics me assessed for?
Metabolic syndrome or Syndrome X
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What is Metabolic Syndrome?
- must have 3 or more of these:
- Large waist circumference
- Triglycerides greater than 150
- High HDL
- Blood pressure above 130/85
- FBS greater than 100
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Treatment of Type 2 diabetics
- Will start with diet and exercise
- Some pt's may need to include insulin
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Explain gestational diabetes
- Resembles Type 2
- Mom needs 2-3x more insulin than normal
- If mom is at high risk, will be screened at first visit.
- ALL moms screened at 24 - 28 weeks gestation
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What complications can baby have with gestational diabetes?
- Increased birth weight
- Hypoglycemia
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What happens with extreme blood sugar?
Why?
- Vascular damage
- Sugar destroys vessels just like fat.
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What type of diet is recommended for both types of diabetes
- Majority of calories should come from COMPLEX carbs, then fats, then protein.
- Carbs: 45%
- Fats: 30-40%
- Protein: 15-20%
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What should be taught to the pt about exercise
- Wait until blood sugar normalizes to begin exercises
- Eat before to prevent hypoglycemia
- Exercise with BS is highest
- Exercise same time and amount daily
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How do oral anti-diabetics and non-insulin injectable medications work?
- They improve how the body produces insulin, and how the body uses insulin and glucose
- ONLY prescribed for type 2 diabetes when diet and exercise doesn't work.
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Most widely used oral anti-diabetic medication
- Metformin
- It's the first choice for most clients.
- Reduces glucose and enhances how glucose enters cells.
- Does NOT stimulate the release of more insulin, so wont see hypoglycemia with this drug.
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If metformin isn't controlling BS levels, what might be ordered
- Lantus
- It is a Long acting anti-diabetic medication
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You have a client on metformin. They are going to undergo a radiologic procedure that involves contrast dye. What should you educate?
- With any surgery or radiologic procedure that involves contrast dye, temporarily discontinue metformin.
- They can resume after 48 hours after the procedure if kidney function has returned and creatinine is normal.
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With rapid acting insulin:
Onset
Peak
Duration
Example
- Onset: 15 mins
- Peak: 1-3 hr
- Duration: 3-5 hr
- Novolog
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Regular insulin:
Onset
Peak
Duration
- Onset: 30 mins
- Peak: 2-4 hrs
- Duration: 6-8 hr
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NPH insulin:
Onset
Peak
Duration
- Onset: 1.5 hr
- Peak: 4-12 hr
- Duration: 16-24 hr
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Long Acting Insulin
Onset
Peak
Duration
Example
- Onset: 2-4 hours
- Peak: NO PEAK
- Duration: 24 hours
- Example: Lantus
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Compare Reg insulin to NPH
- Reg insulin is clear
- NPH is cloudy as it has lots of particles to make it time released
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Can you draw up reg insulin with NPH?
- Yes!
- Just draw up the clear on first.
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Can you mix a long acting insulin?
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Most common method of daily dosing insulin
- Basal /Bolus method
- combination of long acting and rapid acting insulin
- Long acting is given once a day
- Rapid acting is given throughout day, before meals in divided doses
- *Snacks are not required, but clients still must eat with rapid-acting insulin. So have food available.
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What should be tested every 3-6 months on diabetics
- HbA1c or Glycosylated Hemoglobin
- Gives average of blood sugar over past 3-4 months
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What is the goal level for HbA1c?
- greater than or equal to 6.5% is diagnostic for diabetes
- for people with diabetes, the ideal goal is less than or equal to 7%
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What is the standard insulin that can be given in IV fluids as an infusion
Regular Insulin
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What insulin can be given via subQ insulin infusion pump
- Rapid-acting insulin
- these are small computerized devices warn by client that provides both continuous (basal) dosing and on-demand (bolus) dosing
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What should you give a pt who is hypoglycemic?
- First do a simple carb
- Snacks should be 15 grams of carbs
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Why would you not want to give a hypoglycemic pt something with alot of fat
Glucose absorption is delayed in foods with lots of fat
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Whats the rule to remember when treating hypoglycemia
- 15-15-15
- give 15 grams of carbs
- Wait 15 mins
- Give 15 more grams of a complex carb
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To prevent hypoglycemia, what should you teach your pt
- Have to eat
- Take insulin regularly
- Know s/s of hypoglycemia
- Check BS regularly
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What two major complications can occur with diabetes/
- DKA
- HHNK(HHS)
- Vascular problems
- Neuropathy
- Increased risk for infection!
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How do you treat DKA
- Find the cause (illness, infection, skipped insulin?)
- Hourly BS and Potassium levels
- IN insulin
- ECG
- Hourly output
- ABG's - worried about metabolic acidosis
- IVF
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Why are you worried about hourly potassium levels with DKA
- You'll give insulin
- Insulin decreases blood sugar and potassium by driving them out of the vascular space and into the cell.
- Therefore, potassium will decrease
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What is HHNK or HHS
- Hyperosmolar Hyperglycemic Nonketosis
- and
- Hyperglycemic Hyperosmolar State
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Explain HHNK
- Looks just like DKA, but no acidosis
- BS is greater than 600
- The body is making just enough insulin so they aren't breaking down body fat.
- Therefore, no ketones, no acidosis, no Kussmaul respirations
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What vascular problems can develop?
Poor circulation can develop everywhere from vessel damage (similar to atherosclerosis)
- Diabetic retinopathy
- Nephropathy
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What about Neuropathy?
- Sexual problems: impotence/decreased sensation
- Foot/leg probs
- Neurogenic bladder
- Gastroparesis
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What is neurogenic bladder
- Bladder that does not empty properly
- Bladder may empty spontaneously (incontinence) or it may not empty at all (retention)
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What is gastroparesis?
Stomach emptying is delayed so there is an increased risk for aspiration
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