Medical Surgical 3 Final Exam

Treatment of spinal cord injuries

-Just the basics-abc -stabilize them-only logroll -high doses of steroids-solumedrol -vasopressors -ppi -atropine for bradycardia -analgesics -antipasmodics

Labs for sepsis patient

-Lactic acid-over 4 -Check UA for bacturnia -Blood culture for bacteremia -Chest X-ray for pneumonia

Causes of ICP

-lesion -intracranial hemorrhage -hydrocephalus -cerebral edema -excess csf

Hemodialysis

-most rapid and effective dialysis -used for stable pts.

Post tpa care

-neuro checks -icu -bp below 185/110 -normal saline -o2 above 92%

Autonomic dysreflexia

-occurs with cord injuries above T-6 -exaggerated sympathetic response -potentially fatal -triggered by stimuli that would cause discomfort-like full bladder or bowel

How to avoid VAP

-oral care -re-positioning -ppis

Mannitol

-osmotic diuretic used to cause a increase in osmolarity to draw fluid from brain to plasma -works in 20 minutes -repeated use may cause cerebral edema

Treatment for ICP

-oxygenation -limit hyperventilation -diuretics -blood pressure control -temp control -sedation -reduce metabolic demands -drainage of excess csf -surgery to remove tumor or lesion

Manifestations of autonomic dysreflexia

-pounding headache -bradycardia -hypertension -warm,flushed skin above injury -profuse sweating above injury -pale, cool skin below injury

Treatment for post renal failure

-relief of obstruction -monitor fluid status

Nursing interventions for ICP

-space activities to avoid movement -position to maximize cpp -suction if needed less than 10 seconds per time -keep family at bay -avoid both hypertension and hypotension -keep map 60-100 mmHG -substain cpp of at least 60

Cardiac cath post op

-strict bedrest

Signs of a rupture cerebral anuresym

-sudden,explosive headache -neck pain -nausea and vomiting -stiff neck -photophobia -cranial nerve deficits -loss of consciousness -stroke syndrome

Risk factors for DKA

-surgery -trauma -illness -stress -omitted insulin -pregnancy -glucocorticoids

Treatment for pre-renal failure

-treat cause of hypo-perfusion -prevention

When does a DKA patient get off of being NPO

after the ketones are gone

What fluids do we use for DKA

-0.9% ns then 0.45% ns - when BG gets to 250- use 5% dextrose

Treatment for ARDS

-Intubation -PEEP -Sedation -Paralytic block -Positioning -Treat cause

Park and Baxter formula for fluid replacement in 1 st 24 hours

-4 ml of LR x wt in Kg x % of TBSA= total Amt of fluids needed -50% of fluid in 1st 8 hours -25% of fluid in 2nd and 3rd 8 hours

Diet for COPD

-6 small meals a day -Supplements

What causes ARDS-Direct or indirect lung injury

-Aspiration -Pneumonia -Trauma -Toxic inhalation -TB -Sepsis -Burns -Drug/alcohol overdose -CABG -Trauma

Lab findings in DKA

-BG over 300 -increased ketones -increased urine glucose -increased potassium -abnormal sodium and chloride -ph less than 7.3 -increased serum osmolarity

Where should the chest tube atrium be placed?

-Below the chest -Upright -Coiled tubing needs to be off the floor

What is considered a hemorrhage in a chest tube?

-Bright red drainage -Over 100 ml

Activase-TPA

-Can only be given within 6 hours of symptoms of a MI -Clot buster -Must watch for intracranial hemorrhage

TPN procedures

-Change tubing and bag every 24 hrs -Labs every morning -Monitor Bgs and check for signs of hyperglycemia

Signs of severe sepsis

-Chills -Alterations in LOC -Tachypnea -Unexplained metabolic acidosis -Decreased skin perfusion -Increased heart rate -40 point drop in systolic BP -Decreased urine output -Decreased platelets

Signs of ARDS

-Dyspnea -Pulmonary edema -Reduced lung compliance -Severe hypoxemia even with 100% O2

Test to declare brain death

-EEG -Cerebral perfusion flow

Pulse less electrical activity

-Exists when electrical activity other than VT/V-fib is observed but, the pulse is not palpable -Causes: hypovolemia, myocardial pump failure -Treatment: Poor prognosis unless treated rapidly, CPR, Atropine if rate is less than 60, Epi, and find the cause

What is pre-renal failure?

-Happens above the kidney - Hypovolemia, -Low bp, -Hemmorage/Trauma-That causes BP to go down

Diet for Chron's

-High protein -Low fat -Lactose free -High calorie -Low residue -Low roughage -Small feedings with vitamin supplements -TPN if acute

SIRS-(Systemic Immune Response Syndrome)- for sepsis

-Hyperthermia -Hypothermia -Tachycardia -Tachypnea -PaCO2 of 32 or more -Leukopneia -Altered mental status -Leukocytosis -Hyperglycemia

Atropine

-Increases heart rate and induces parasympathetic response-fight or flight response -Treats: bradycardia -Side effect: dry mouth, blurred vision

A patient has to meet what criteria to be considered septic?

-Infection -2 or more systemic inflammatory response symptoms -Acute organ dysfunction -Lactic acid of 4 or more

Cardiac cath-pre op

-Informed consent -NPO 6 hours prior -BUN/Creatinine

Abdominal Aortic Aneursym

-Initially asymptomatic -Related to atherosclerosis -Constant gnawing feeling in abdomen, flank and back pain -Elevated BP -Loss of pulses -Pulsating abdominal mass-Do not palpate, may rupture -Bruit-blowing sound over aneurysm -Surgery for aneurysm over 7cm

Symptoms of stoma food blockage

-No output for 4-6 hours -Cramping -Swelling of the stoma

What does a MI cause ?

-Part or all the blood supply to the heart muscle is reduced or stopped -Causes tissue death, time is muscle

Risk factors for sepsis

-Poor immune system -Recent surgery -Mechanical ventilation -Invasive procedures -Central lines

SIMV-Synchronized intermittent mandatory ventilation

-Preset rate and tidal volume -Client initiates breath and tidal volume will depend on client's effort -Ventilator initiated breaths are synchronized to reduce competition -Used as a regular mode or for weaning -Can increase work of breathing causing respiratory muscle fatigue

Nurse's role in sepsis

-Prevent infection -Early recognition of signs in patients -Early initiation of therapies

AC-assisted control settings

-Pt triggers vent -Vent delivers specific volume -Rate can also be set on vent

V-fib

-Rate - 300+, disorganized -P Wave - Not seen -This patient needs to be defibrillated!! QUICKLY -Drugs usually given are MEAL-epinephrine, amiodarone, lidocaine or magnesium

Sinus Brady

-Rate - < 60 beats per minute -P Wave - Visible before each QRS complex -Occurs in patients on beta blockers, calcium channel blockers, and digoxin -Treat only if symptomatic -Symptomatic bradycardia is treated with atropine, dopamine, O2, and pacing

Sinus Tachy

-Rate - >100 beats per minute -P Wave - Visible before each QRS complex -Treat only if symptomatic -Seen during exercise or when the patient is in some type of distress -Once the distress is relieved the sinus tachycardia usually resolves -Treat underlying causes: Hypovolemia/Fever/Pain -Treat with beta blockers or verapamil

V-tach

-Rate - Variable - usually greater than 150 beats per minute -P Wave - Not seen -Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest -Defibrillate this rhythm if the patient is unconscious and without a pulse -Drugs usually given are MEAL-epinephrine, amiodarone, lidocaine, or magnesium

Diet for Cirrhosis

-Restrict sodium intake -Low protein -Vitamin supplements based on labs

What is septic shock?

-Severe sepsis + severe hypotension -Hypotension will not improve with fluids

Albuterol

-Short acting bronchodialator -Treats asthma,bronchospasm,wheezes,and COPD -Causes palpitations and tachycardia

Stoma education

-Small amount of bleeding is normal -Mild edema is normal -Skin should be clean and dry -Stoma pouch should fit snugly -Drink plenty of fluids -Avoid odor causing and fast foods -Avoid food that could cause obstruction like those contains seeds or nuts

Self measures to relieve food blockages

-Take warm bath or shower -Assume a knee chest position -Drink warm fluids or grape juice -Massage peristomal area -Remove pouch if swollen and replace with new one

Dobutamine

-Treats: CHF -Increases BP and contractility -IV only

Nitroglycerin

-Treats: Chest pain, HTN, CHF -Relaxes smooth muscle layer of the blood vessels which allows for dilation of the vessel and more blood flow -Decreases preload, afterload, and myocardial O2 consumption -Side effects: Headache, hypotension

Beta Blockers

-Treats: HTN, MI, angina, tachydysrhymias, heart failure -Decreases the excitability of the heart, decreases cardiac workload, and O2 consumption, and provide stabilization of dysrhythmias. - Decreases activity of the sympathetic nervous system on certain tissues (Beta 1 primary cardiac & renal, Beta 2 found in lungs, GI, liver, skeletal) -Decreases contractility, preload, and afterload Example: Metoprolol, Atenolol, Propranolol, Labetalol Side effect: Inderal can cause bronchial constriction, fatigue, weakness,

Coumadin

-Treats: Used to prevent the formation and extension of a thrombus, Slow acting -Used for a-fib/flutter, clots

Heparin

-Treats: Used to prevent the formation and extension of a thrombus,Quick acting -Used for surgery patients, clots

What is intra-renal failure?

-kidney related damage or trauma -ct contrast or some antibiodics

Liver biopsy procedures

-Withhold anticoagulants for a week prior to test -NPO 4-6 hours prior -Get ptt and plt count prior -Pt will hold breath as needle is inserted -Administer vitamin k if needed -Apply pressure after needle removal -Pt will lay on right side for 1-2 hours after procedure -NPO for two hours after -No coughing,lifting,straining for 1-2 weeks

What is post renal failure?

-after kidney/obstruction -stones -bph

Manifestations of ICP

-aloc -mental status change -posturing -hemiparesis -hemiaplegia -pupillary dysfunction -increase in map/systolic pressure/pulse pressure -increase in temp -decreased pulse -altered respirations -headache -nausea with projectile vomiting -papilledema

Manifestations of subarachnoid hemorrhage

-bad headache -vasospasm

Diuretic phase of atn

-beginning of the return of tubular function -begins when output is 400 in 24 hrs -patient is unable to concentrate urine and may put out lots of urine -electrolyte monitoring is critical

What causes high vent alarms

-bitting -coughing -suctioning

Management of SAH

-bp control -prevention of vasospasm -angioplasty -craniotomy

Treatment for cerebral anursym

-craniotomy with clip placement -placement of detachable coils -stent placement -balloon remodeling

Manifestations of left sided heart failure

-decreased perfusion -decreased pulses -crackles -dyspnea

What causes a low vent alarm

-deflated cuff -disconnection

CRRT

-dialysis used for critical care pts. -avoids major shifts in fluids

Treatment for right sided heart failure

-digoxin

Treatment for left sided heart failure

-diuretics

Signs of DKA

-flushed dry warm skin -increased thirst -fruity breath -decreased BP -increased pulse -kussmauls respirations -confusion -increased fluid intake -nausea/vomiting/ab pain -moderate fluid loss -decreasing LOC -weakness -weight loss -blurred vision -cerebral edema -coma

Manifestations of spinal shock

-hypotension -bradycardia -urinary retention -hypothermia -paralytic ileus -respiratory insufficiency

Treatment for DKA

-insulin -tons of fluids -electrolytes -respiratory support -correct acidosis -prevent complications

Manifestations of right sided heart failure

-jugular vein distension -edema

Genitals percentage in burns

1%

Treatment for sepsis

1. Fluids 2. Find the cause 3.Broad spectrum antibiotics 4. Steroids 5. Vasopressors 6. Nutrition 7. Emotional support 8. Prevention of secondary effects 9. Good basic care 10. Education

Post procedure care for thoracentesis

1. Monitor vitals 2. Apply dressing and have pt lie on unaffected side for 1 hr 3. Label specimen and send to lab 4. Perform frequent assessments 5. Obtain chest x-ray 6. Normal activities can be resumes within 1 hr if no complications occur

7 things to do for thoracentesis preparation

1. Verify signed informed consent form 2. Verify pt has knowledge of the procedure and encourage them to ask any needed questions 3. No fasting or sedation is required/Only local-gaga and cough reflex must be present 4. Administer cough suppressant if needed to avoid coughing during procedure 5. Obtain thoracentesis tray,lidocaine,etc. 6. Position pt. upright and leaning over bedside table 7.Tell pt they will pressure but, no pain

Arm percentage in burns

4.5%

Head percentage in burns

4.5%

In order to treat sepsis effectively it has to be caught within what?

6 hrs

Normal CPP values

70-95

Abdomen percentage in burns

9%

Back percentage in burns

9%

Buttocks percentage in burns

9%

Chest percentage in burns

9%

Leg percentage in burns

9%

Sepsis

A body's immune response to infection

Escharotomy

Surgical incision made along extremity or trunk of a burn victim to allow for tissue expansion

What determines the severity of sepsis?

Amt of organ damage

What triggers sepsis

Any type of infection

Why should you never milk a chest tube

Because it can cause a pneumothorax

What does the 1st chamber of a chest tube system do?

Collect fluids draining from the patient

Progressive stage of shock

Compensatory mechanisms begin to fail

What does the 3rd chamber of a chest tube system do?

Contains suction control system

What does the 2nd chamber of a chest tube system do?

Contains water seal that prevents air from reentering patient's pleural space

What do you do if a client pulls a chest tube out?

Cover the hole with petroleum gauze and tape on 3 sides

Refractory stage of shock

Irreversible shock and total body failure

How do we know if someone is having a MI?

Look for St elevation, if seen order ekg, if still seen call Cath Lab STAT

Compensatory stage of shock

Measures occur to increase cardiac output to restore tissue perfusion

Should you see bubbling in the water seal chamber?

No it indicates a water leak

Initial stage of shock

No visible changes,only changes on a cellular level

Respiratory acidosis ranges

PH 7.35 or lower/CO2 45 or above

Metabolic acidosis ranges

PH 7.35 or lower/HCO3 22 or under

Respiratory alkalosis ranges

PH 7.45 or above/CO2 35 or below

Metabolic alkalosis

PH 7.45 or above/HCO3 above 26

What do you do if the atrium falls over?

Pick it up and replace with a new one

What does a low vent alarm indicate?

Pt is not getting enough oxygen

What does a high vent alarm indicate?

Resistance between patient and ventilator

MODS-Multiple organ dysfunction syndrome

Severe septic shock + organ failure

Untreated sepsis turns into what?

Shock

Spinal shock

Temporary loss of reflex function below the level of injury

What happens during sepsis?

The body's normal reaction goes into overdrive, leading to widespread inflammation and blood clotting in tiny vessels leading to the depletion of activated protein C-( body's natural clot busting enzyme)

Should you see bubbling in the suction control chamber?

Yes because that is how you know the suction is working

Cushing's traid

late signs of icp -severe hypertension -widened pulse pressure -bradycardia

CPP formula

map-icp=cpp

When can TPA be given for a stroke?

within 3 hours of beginning of a stroke