Exam 1, Exam 2, Exam 3 final
Hypovolemic shock description
Loss of blood or volume from the vascular space. Low circulating volume Decreased circulating volume results in decreased preload
Idealism vs. realism
Loss of idealism is a major source of burnout and nurses leaving the profession Nursing classes - we nurture idealism Daily challenges of nursing forces us into realism
Hypoxemic definition
Low arterial blood o2 levels
Shock neuro s/s
Restless, anxiety, lethargy, confusion
Speech parkinsons s/s
Soft low pitched voice, dysarthria slurred speech, echolalia repetition of words, hypophonia soft voice
Beta blockers for Graves name? For?
-lol for supportive therapy ie diaphoresis, anxiety, tachycardia, palpitations but don't inhibit thyroid hormone
Corticosteroids names? Define? SE?
-one drugs. Antiinflammatory. SE: fluid/Na retention, hypertension, cushingoid state, gastric distress, adrenal suppression, psychosis, osteoporosis, susceptibility to infection
Goiter classes
0: none visible, 1:mass not visible but is palpated, 3:mass visible and easily palpated
Anaphylactic shock example
76 y.o. same-day -surgery client admitted to your unit a few minutes ago from PACU followi ng a left hip hemi-arthroplasty. His second dose of cefazolin IV was started 5 minutes ago. Client now c/o itching and SOB. He is extremely restless, anxious, and gasping. VS: T 100, P 130 irregular, R 40 dyspneic, stridor, wheezing BP 60 by Doppler only, skin warm, generalized edema.
7 tips of QRS in 6 second strip
7x10=70bpm
PaO2
80-100. Decreased: anaerobic metabolism
Healthy adult CD4 count? In HIV/AIDs?
800-1000, lower in HIV/AIDs
What is MAP when BP is 83/50
83+2(5) then divide answer by 3. Answer 61 which is normal 60-70
Glasgow scale score 8 means?
8= intubate, lower the worst
Calcium normal? Hypofunction of adrenal? Hyperfunction?
9-10.5 total or 4.5-5.6 ionized if older slightly decreased. Increased, decreased
BG normal? Early sepsis? Late? Septic shock
<110, 110-120, 120-150, >150
Serum lactate normal? Early sepsis? Late sepsis? Septic shock?
<2, normal/slightly increased, 2-4, >4
What K level for supplements
<4
Bradycardia
<60bpm
Massive hemothorax
>1.5 L of blood drained from pleural space upon chest tube insertion or >200cc/hour in 1st 4 hours
Tachycardia
>100 bpm
Sepsis w/ systemic inflammatory response syndrome criteria
>100.4 or <96.8 temp, >90HR, >20RR or PaCO2 <32, >12000 WBC. Sepsis present if >2 SIRS s/s present w/ infection + hypotension, u/o less, + fluid balance, decreased cap refill, hyperglycemia >120, unexplained changed LOC, or rising creatinine level
Sinus tachycardia s/s
>100bpm, fatigue, weakness, SOB, orthopnea, decreased O2 sat, decreased BP, restlessness, anxiety, decreased UO, angina pain, palpitations, T wave inversion, ST seg elevation
ST elevation: ST segment is what elevation? Associated w/?
>1mm elevation. Associated with MI
ESR that indicates chronic inflammation/infection
>20/mm
You want CD count to be what for immunocompromised
>200
Droplet precautions define? Ex?
>3 feet, private room, mask if w/in 3 ft of patient, transport w/ mask Ex: flu, mumps, pertussis, meningitis, flu type b, diphtheria, pharyngitis, pneumonia, rubella
Osteoarthritis : onset age? Gender affected? Risk factors/cause? Disease process? Disease pattern? Lab findings? Common drug therapy?
>60yr female. Aging, genetics, obesity, trauma, occupation. Degenerative. Can be unilateral weight bearing joints/hands/spine, nonsystemic. Elevated ESR. NSAIDs, acetaminophen, other analgesics
MAP WE WANT what
>65
ECG define? Captured by? ___ of cells?
A graphic representation, or picture, of cardiac electrical activity. Captured by conductive gel on adhesive pads. Positive or negative deflection from the isoelectric baseline Depolarization and repolarization of cells
Vaxes available for hepatitis
A+B
Rn dx from coagulation issues/varices
Activity Intolerance Decreased Cardiac Output Risk for Injury Pain
Rn dx from portal hypertension
Activity Intolerance Fluid Volume Excess Pain Altered Tissue Perfusion
Rn dx for cirrhosis
Activity intolerance Imbalanced nutrition Impaired skin integrity Fluid volume excess Risk for injury Body image disturbance Disturbed thought pattern Collaborative problem: hemorrhage
Assessment for Addison's
Activity level changes Lethargic, fatigue, muscle weakness, salt cravings, anorexia, n/v, diarrhea, ab pain, impotenence or amenorrhea Depressed Confused Psychotic Bronze pigment of skin, changes in distribution of hair, GI issue, weakness, hypoglycemia, postural hypotension, weight loss
Documentation should never be completed before it
Actually takes place
Acute on chronic s/s
Acute change in respiratory status in a chronic respiratory failure patient
Liver transplant complications
Acute graft rejection, infection which can lead to organ failure w/ encephalopathy
Assessment for high altitude ilnesses: acute? High altitude cerebral? Pulmonary?
Acute mountain: headache, anorexia, n/v, chilled, irritable, VS variable. High altitude cerebral edema: no ADLs, apathy, ataxia, changed LOC, confusion, seizures, stupor, coma, death. High altitude pulmonary edema: poor exercise tolerance, prolonged recovery time, fatigue, weakness, dry cough, cyanosis of lips/nails, tachycardia/tachypnea, crackles, pink sputum, alkalosis, hypoxemia, pnuemonia
Acute respiratory distress syndrome ARDS
Acute respiratory failure w/: hypoxemia even w/ 100% O2, decreased pulmonary compliance, dyspnea, non-cardiac associated bilateral pulmonary edema, dense pulmonary infiltrates on Xray aka ground glass appearance
Peripheral organs of immune system
Adenoids, tonsils, lymph nodes/vessels, spleen
What is most common method used to secure ET/NG tubes
Adhesive tape but it can irritate and tear skin, possible fungal infection.
Sinus bradycardia treatment
Adjust medication Treat the cause Anticholinergics- Atropine IV fluids/O2 Pacing
Sinus tachycardia treatment
Adjust medication Treat the cause Antipyretics Hydration
<15% EF
Advanced HF, severe activity and exercise intolerance
2 years you are
Advanced beginner
Level 4 trauma center
Advanced life support in rural/remote settings w/ no access to higher level trauma center
MG management
Affects symptoms w/out influencing the course of disease like anticholinesterases/cholinergics. Inducing remission via immunosuppressants, corticosteroids, plasmapheresis, thymectomy, don't allow in hot temps
First aid/prehospital care for heat stroke
After ensuring patent airway, effective breathing, circulation: rapid cooling is 1st. No food/liquid, ensure patent airway, remove from environment, remove clothing, pour/spray water, fan patient, ice packs, emerge in water
ACE inhibitors reduce
Afterload but dry hacking cough common
Contraindications for TIPS
Age over 65 Heart Failure Grade III or IV Hepatic Encephalopathy INR >5 Severe thrombocytopenia Moderate to severe Pulmonary HTN Uncontrolled infection
Escalating behaviors indicating violence
Agitation, inappropriate communication, hostility, physical violence
Hyperaldosteronism: aka? Increased? Causing? From?
Aka Conn's syndrome, Increased secretion of aldosterone from one or both adrenal glands resulting in mineralocorticoid excess causing Na retention w/ K/H excretion causing metabolic alkalosis+raised BP. From adrenal adenoma, high renin from kidney hypoxemia/thiazides
Amyotrophic lateral sclerosis aka? Define?
Aka Lou Gehrigs. Is progressive until entire body involved causing weakness, atrophy and then death.
Class 4 LHF from MI
Aka cardiogenic shock. Tachycardia, hypotension, BP <90, U/O <30, cold/clammy, poor pulse, agitation/confusion, pulmonary congestion, tachypnea, chest discomfort. Managed via drugs, intra-aortic balloon pump, percutaneous ventricular assist device, immediate reperfusion
Depolarization aka? Define?
Aka contraction.High potassium inside cell Exchange of potassium & sodium Action potential occurs
Type 4 hypersensitivity aka? Results in? Ex?
Aka delayed. Results in inflammation. Ex: Poson ivy, graft rejection, positive TB skin test, latex allergy, sarcoidosis
Neupogen aka? Function?
Aka filgrastim. Decreased incidence of infection in patients who are neutropenic from chemotherapy or other causes.
Repolarization aka? Define
Aka relaxation. Higher potassium in blood Exchange of potassium & sodium Resting potential occurs
Syndrome of inappropriate antiduretic hormone SIADH: aka? Definition?
Aka schwartz-barter. Hypersecretion of ADH resulting in inability to excrete appropriate amount of urine developing fluid retention/overload and dilutional hyponatremia
Fatty liver aka? Caused from? S/s?
Aka steatosis. Caused from alcohol, DM< obesity, elevated lipids. WEight loss, glucose control, lipid lowering agents are recommended
Viral load testing aka? Measures? Type?
Aka viral burden testing. Measures presence of HIV material in patient's blood. Type: quantitative RNA assay
Stage 4 severe Parkinson's
Akinesia, rigidity
AST vs ALT which is better for assessing liver
ALT more specific to liver
Hypothalamus
ANS controlling temp and cognition
Black widows cause? affect?
Abdominal pain, and neurotransmitters
Nerve 6
Abducens eye movement
Contractility
Ability of muscle to shorten and contract when stimulated
Excitability
Ability of non pacemaker cells to respond to impulse and depolarize
Conductivity
Ability to send an electrical stimulus from cell membrane to cell membrane and as result excitable cells depolarize aka P QRS
Conductivity
Ability to send electrical stimulus from cell to cell causing depolarization in succession from cell to cell causing P and QRS
Late signs of increased ICP
Abnormal posturing. Extension aka decerbrate rigidity or abnormal flexion aka decorticate rigidity
Dysrhythmia define
Abnormal rhythm of electrical stimulation
Ventilatory failure problem defined by PaCO2 level
Above 45 in patients w/ otherwise healthy lungs
Expected outcomes for HIV
Absence of chills and fever Absence of diarrhea Maintenance of WBC within patients normal range Absence of s/s of infection
Categories of HF
Acaute, chronic, left aka systolic or diastolic, right side, high output
ARDS 1st s/s? The rest of s/s?
Accessory muscles use are the first signs Dyspnea tachypnea, low blood O2 level Restlessness tachycardia sweating low blood pressure organ failure confusion Other S/S depend on the cause
Nerve 11
Accessory. Muscles of pharynx, larynx, sternocleidomastoid, trapezius
Sandostatin action? Indications? SE? Patient education? Contraindications?
Action: Blocks the production of hormone secreting tumors, reduces the loss of body fluids and minerals in severe diarrhea Indications: Vasoactive Intestinal Peptide (VIP)- secreting tumors of liver and GI tract, bleeding varicosities in esophagus Side Effects: loose/oily stools, dizziness, headache, increased liver pain, jaundice, unexplained weight gain, cold intolerance, bardycardia, DIB, irregular heartbeat Patient Education: Can increase pregnancy chance due to changes in hormones, inject precise dosage, alternate sites, refrigerate Contraindications: children, pregnancy. Use with caution in patient with Vit B12 deficiency
Furesomide action? SE? Patient education? If taking sucralfate?
Action: Loop diuretic that prevents the body from absorbing too much salt Indications: Edema, Hepatic Ascites, hypertension Side Effects: Ringing in the ears, confusion, jaundice, fever, chills, sore throat, dry mouth, blurred vision Patient Education: Avoid sudden, quick movements, no alcohol use, If taking Sucralfate, take 2 hours before or after Lasix
Vasopressin action? SE? Patient education? Contraindications?
Action: Man made form of "anti diuretic" hormone. Shifts sodium at the cell level Indication: Hyponatremia in patients with end stage liver disease, cirrhosis, and portal hypertension, severe ascites Side Effects: weakness, lightheaded, DIB, angioedemia, C/P, skin changes and discoloration, rapid weight gain Patient Education: No alcohol Contraindications: Use with caution in patients with kidney disease, asthma, HF, seizures, migraines
Hyperthyroidism s/s
Bulging eyes, finger clubbing, tremors, diarrhea, amenorrhea, heat intolerance, fine/straight hair, raised irritability, goiter, tachycardia, raised BP, dyspnea, weight loss, muscle wasting, localized edema
Acute coronary syndrome ACS
CAD- Coronary Artery Disease Results when the heart muscle no longer is able to receive needed perfusion Can be stable or unstable- pain is described as angina The loss of perfusion can result in the cardiac injury leading to ischemia and if no intervention cardiac muscle death. AKA MI
To assess leukocytes
CBC w/ differential that checks neutrophils, lymphocytes, etc. Normal WBC 4500-11000, Normal neutrophils 6300 or 40-70%, normal lymphocytes 4100 or 20-40%
AIDS immunologic manifestations
CD4/CD8 ration <2, CD4 <200, hypergammaglobulinemia, opportunistic infections, lymphadenopathy, fatigue
Thalamus
CNS
Corticosteroid SE
CNS changes like euphoria/insomnia/psychosis, CV changes like edema/hypertension, GI effects like irritation/ulcers/increased appetite/weight gain, hyperglycemia, muscle weakness, delayed wound healing, bone density loss, body fat redistribution
High output HF
CO remains normal/above normal unlike left/right HF and caused by increased metabolic needs or hyperkinetic conditions
Conditions that affect the flow of air in and out of the lungs that can lead to respiratory failure
COPD, cystic fibrosis, bronchitis
ARDS treatment
CPAP, BiPAP, mechnical ventilation, conservative fluid therapy w/ IV+diuretics, antibiotics if infection, corticosteroid solumedrol/prednisone
Calculating cerebral perfusion pressure CPP
CPP= MAP-ICP x MAP= SBP + 2 (DBP) then divide by 33
Asystole treatment? No?
CPR unless DNR, check another lead to ensure not fine VF(which requires defib) then epinephrine/atropine, oxygen, treat cause, follow advanced cardiac life support. Allow family presence. No shocks for asystole
Sodium affects
Cardiac activity/action potential
Patients who are severely hypothermic are at high risk for
Cardiac arrest so avoid external rewarming
Common threats to circulation
Cardiac arrest, myocardial dysfunction, hemorrhage
Digoxin
Cardiac glycoside for chronic HF w/ sinus rhythm and a fib. Increases contractility, reduces HR, inhibits sympathetic activity
Medulla brainstem
Cardiac slowing, respiratory center, Cranial nerves 9, 10, 11, 12
Obstructive shock specific cause/risk factors
Cardiac tamponade, arterial stenosis, PE, pulmonary hypertension, constrictive pericarditis, thoracic tumors, tension pneumothorax
Types of shock
Cardiogenic Obstructive Hypovolemic Distributive(includes septic, neurogenic, anaphylactic)
Emergent examples
Cardiopulmonary arrest Shock/hemorrhage Chest pain w/ diaphoresis Unstable VS Injury at T6 and above can lead to neurogenic shock Severe respiratory distress Myocardial infarction Major burns or trauma Uncontrolled bleeding Coma Status epilepticus Penetrating injury to the eye
Heart transplant procedure
Cardiopulmonary bypass, heart removed, posterior walls of left/right atria left intact, left atrium of donor is anastomosed to recipients atria and great vessels joined
If light pulse and awake
Cardioversion/defib
Foundation of ED rn
Assessment
Autonomic dysreflexia associated w/? Causes?
Associated w/ upper SCI. Causes severe hypertension, bradycardia, headache, nasal stuffiness, flushing, blurred vision from distended bladder/constipation.
Neural-induced/neurogenic distributive shock
Associated with cervical spine injuries Spinal cord injury, spinal anesthesia, epidural block, severe pain, decreased vasomotor center function Degenerative spine changes that interfere with blood flow to the spinal cord
Best practice for patient safety for those at risk for infection
Asssess fo s/s, monitor cultures/WBC, screen all visitors for infection, inspect skin/mucus membranes for redness/heat/pain/swelling/drainage, promote nutrition esp. protein, fluids for fever, education
First aid/prehospital care of snake bite
Assume poisonous if you don't know. Move to safe area first, encourage rest, remove jewelry/clothing, immobilize affected extremity, maintain extremity at level of heart, keep person warm, no alcohol, don't incise/suck wound/ice/tourniquet, elastic bandage to impede lymphatic flow but not super tight
Neuro findings of cirrhosis
Asterixis, paresthesias of feet, peripheral nerve degeneration, portal systemic encephalopathy, reversal of sleep wake pattern, sensory disturbances
Esophageal varices are often? Large scale?
Asymptomatic and sudden, 1st sign loss oc consciousness. Large scale blood loss
Premature ventricular complexes s/s? Treatment?
Asymptomatic of palpitations, chest discomfort, diminished/absent peripheral pulses w/ PVC. Treatment usually by eliminitating cause , O2 and amiodarone/Cordarone for ischemia/MI. K if hypokalemia, or beta blockers
Defibrillation define? Steps?
Asynchronous countershock. Clear, resume CPR after for 5 cycles/2 minutes then assess rhythm, if VF or pulseless VT continues 2nd shock, resume CPR
CD4 and HIV at first? Then?
At first normal and HIV load low then progressively CD4 cell counts fall and viral load rises
Stabilizing the tube
At mouth/nose, possible bite block if oral and after verify presence of bilateral/equal breath sounds and level of tube
TBI fluids
At risk for DI if pituitary injury
MI usually from
Atherosclerosis, or clot
A. Fibrillation caused by
Atrial fibrosis from old age, weight, white, alcohol, stroke, DM, mitral valve disease, heart diseases like hypertension, heart failrure, coronary artery disease
Premature atrial complexes? What wave? May not be visible due to?
Atrial tissue irritable and ectopic focus fires premature impulse. Premature P wave may not be visible from stress, fatigue, anxiety, inflammation, infection, caffeine/nicotine/alcohol/epinephrine/digitalis or myocardial ischemia, electrolyte issues, atrial stretch from heat failure
For tensilon test make sure
Atropine at bedside since antidote. Differentiated between myasthenic crisis which will see improvement like MG and cholinergic crisis where it will get worse/no change
Meds for intubation
Atropine, lidocaine, sedatives, paralytic agent succinylcholine/-nium meds
Parkinson's outcomes
Attains improved nutritional status Strives toward improved mobility Progresses toward self-care Maintains bowel function Achieves a method of communication Copes with effects of Parkinson's disease
Increased ICP evaluations
Attains optimal breathing pattern Demonstrates optimal cerebral tissue perfusion Attains desired fluid balance Has no signs or symptoms of infection Absence of complications
Shock requires immediate?
Attention to prevent organ dysfunction
When WBC low interventions
Avoid crowds, don't share toilet articles, bathe daily, clean tooth brush weakly, wash hangs before eating/drinking/touching pet/shaking hands/coming home, no raw foods, no liquids standing out >1hour, don't reuse dishes, don't change litter boxes, no reptiles, temp q day, report s/s of infection, take drugs, don't work in garden, wear condoms
S/s of inadequate organ perfusion r/t HF
Change in LOC, U/O <30ml/hr, cool/clammy, absent/decreased pulses, fatigue, recurrent chest pain
The indicator that patients may be in beginning of severe sepsis
Change in affect or behavior, can be less patient, restless, fidgety
Autoregulation
Changes diameter of vessel to maintain cerebral blood flow
ICP s/s
Changes in LOC 1st Pupillary changes Slow/slurred speech and delay in response N/v Cushing's triad Hypertension, bradycardia, posturing Restlessness, lethargy, and drowsiness Hypercapnia/hypoxemia Stupor---> Coma
Early assessment of increased ICP
Changes in Level of Consciousness (LOC) includes: Disorientation, restlessness, & confusion Pupillary changes in size, shape, and reaction to light as pressure is exerted on cranial nerve III Weakness Headache Projectile vomiting (not preceded by nausea)
Nonprogressive/compensatory stage for shock
Clinically apparent. Hormone/kidney response causing renin, ADH, aldosterone, epinephrine MAP decreases by 10-15 from baseline Decreased U/O, increased Na, b.vessel constriction, thirst anxiety, tachycardia, ^ RR, falling BP, cool/clammy, O2 decrease Tissue hypoxia in non-vital organs Acidosis and hyperkalemia Attempts at overcoming consequences of anaerobic metabolism and maintaining homeostasis
Hypovolemic shock labs/dx tests
Clotting studies Urinalysis ↑Specific gravity Pregnancy test (childbearing age women) X-ray, CT, ultrasound of suspected site of blood loss ECG Endoscopy Type and Screen for possible blood replacement High lactic acid, CDC/H&H/K, renal/liver function
Stage 4 of hepatic encephalopathy
Comatose:Unresponsive, leads to death in most patients Seizures, obtunded, muscle rigidity, + Babinski
Managing pain for HIV
Comfort measures w/ pressure relieving mattress/warm bath/massage/change positions, drugs, complementary therapies like guided imagery/distraction/relaxation/biofeedback
Rn management of cirrhosis
Comfort, activity, positioning, nutritional support, drugs like diuretics+laxatives+anti-infectives+vasopressin, parencentesis, surgery, psychosocial support
The surviving sepsis campaign
Committed to reducing mortality from severe sepsis and septic shock worldwide initiated in 2002 Enormous potential to save lives Could save 400,000 lives if we treat only half of the eligible patients with the Surviving Sepsis Campaign Bundles
Splenomegaly common in what type of cirrhosis
Common in nonalcoholic causes of cirrhosis
Chronic thyroiditis hasimotos disease affects who more? Define? Thyroid? S/s?
Common type of hypothyroidism affecting more women. Autoimmune disorder triggered by bacterial or viral infection. Thyroid destroyed by anitbodies leading to TH being low and TSH increased. S/s:dysphagia, painless enlargement of thyroid.
Cardiogenic shock risk factors
DM, cardiomyopathies
Chronic steroid therapy can result in
DM, infection, fluid/electrolyte imbalance, hypertension, osteroporosis, glaucoma
Autoantigens for: systemic lupus? RA? Scleroderma/systemic sclerosis? Mixed connective tissue disease? Sjogren syndrome?
DNA proteins. IgG possibly cartilage. DNA proteins. DNA proteins. Salivary gland cells, vaginal mucous cells, lacrimal gland cells
Most accurate way to document fluid retention
Daily weights, most reliable indicator of fluid gain/loss
Barotrauma
Damage to lungs by positive pressure
Volutrauma
Damage to the lung by excess volume delivered to one lung over the other
Complete spinal cord lesion injury define? Types?
Damage where all innervation below injury is damaged Paraplegia-paralysis of the lower body Tetraplegia (formerly quadriplegia)-paralysis of all four extremities
Passive vs. active immunity
Days/months and natural or transplacental or via artificial injection of antibodies aka immunoglobulin vs. lasts for years and from natural infection or via artificially w/ vaccines
Cirrhosis: death is caused by? Fatal w/o?
Death is caused by progressive liver failure, GI bleeding, sepsis, renal failure and hepatocellular carcinoma. Fatal without transplant
Posturing types and define each
Decorticating where arms, wrists, fingers flexed w/ internal rotation and plantar flexion of legs for spine. Decerebration via extension of arms/legs, pronation of arms, plantar flexion, opisthotonos body spasm for brainstem.
Cardiogenic shock description
Decrease in cardiac output and perfusion due to decrease in mechanical function of the myocardial muscle. Direct pump failure, fluid volume not affected
Aspirin MI
Decrease platelet aggregation and vasoconstriction
Nutrition therapy to reduce preload
Decrease sodium and water retention to decrease workload of heart Heart healthy diet (low fat/cholesterol, low sodium, high fiber) NAS/ sodium intake less than 2 grams daily Fluid restriction 1-2 liters daily Dietary collaboration 1 kg weight gain or loss = 1 liter of retained or lost fluid Same scale, clothes, time daily (before breakfast) Avoid salt substitutes containing K+ (drug interactions)
Changes of endocrine system r/t aging
Decreased ADH causing dehydration risk+dilute urine. Decreased estrogen decreasing bone density, dry skin. Decreased glucose tolerance causing increased weight +slow wound healing+yeast infection+polydipsia+polyuria. Decreased metabolism
Metabolic manifestations of hypothyroidism
Decreased BMR, decreased body temp, cold intolerance
Late neuro s/s of shock
Decreased CNS aka lethargy/coma, generalized muscle weakness, diminished/absent deep tendon reflexes, sluggish pupil response to light
Left sided HF manifestations r/t
Decreased CO Pulmonary Congestion Ineffective pump of left ventricle Usually caused by heart disease Pulmonary congestion due to blood back up Impaired activity and exercise tolerance
Cardiovascular key features of of shock
Decreased CO, increased HR, thready pulse, decreased BP, narrow pulse pressure, postural hypotension, low central venous pressure, flat neck/hand veins in dependent positions, slow cap refill, diminished peripheral pulses
Managing RHF from MI
Decreased CO, paradoxical pulse, clear lungs, JVD @ semi-fowlers. Sufficient fluids, monitor pulmonary artery wedge pressure keeping >15-20
Disability across room assessment
Decreased LOC or interaction with environment Irritable Doesn't recognize family members Inappropriate reactions to painful stimuli Flaccid/hyperactive muscle tone
S/s of hypercapnic respiratory failure
Decreased LOC, headache, lethargy, seizures
Patho of hypovolemic shock
Decreased MAP (decreases blood flow resulting in decreased tissue perfusion) Loss of oxygen-carrying capacity from the loss of circulating RBCs Lead to cellular anaerobic conditions Abnormal cellular metabolism
Kidney and urinary changes for hypovolemic shock
Decreased U/O for early, possibly progressing to none, possible kidney failure
Kidney s/s of shock
Decreased U/O, increased specific gravity, sugar/acetone in urine
Malnutrition on immunity
Decreased WBC+neutrophils
Radiation therapy on immunity
Decreased WBC, damage to 1st line barriers
Psychological manifestations of hyperthyroidism
Decreased attention span, restlessness, irritability, emotional lability, manic behavior
Coagulation deficits w/ cirrhosis
Decreased bile production prevents the absorption of Vitamin K. Vitamin K is needed for the production of clotting factors. This increases the risk of bleeding. Decreased production of prothrombin and fibrinogen. (think clotting cascade)
Growth hormone deficiency s/s?
Decreased bone density, pathological fractures, decreased muscle strength, increased serum cholesterol levels
Innate immune response changes of aging
Decreased hematopoietic cells, decreased phagocytic capacity, decreased cells, increased dendritic cells
Aging immune system
Decreased immune function causing increased infections. Increased production of autoantibodies causing increased autoimmune disorders. Decline in immune response causing increased cancer incidence
GI s/s of shock
Decreased motility, diminished/absent bowel sounds, n//v, constipation
Adrenocorticotropic hormone ACTH deficiency s/s?
Decreased serum cortisol, pale sallow complexion, malaise/lethargy, anorexia, postural hypotension, headache, hypoglycemia, hyponatremia, decreased axillary/pube hair
GONA complications of HIV
Decreased testosterone: reduced libido, fatigue, reduced fertility, decreased muscles, weight low. Decreased estrogen: reduced libido, premature menopause, decreased muscles
Adaptive immune response changes of aging
Decreased thymus size, decrease t cells, decreased b lymphocytes, decreased antibody response
TSH /throtropin deficiency s/s?
Decreased thyroid hormones, weight gain, cold intolerance, scalp alopecia, hirsutism, menstrual abnormalities, decreased libido, slowed cognition, lethargy
What indicates left ventricular failure
Decreased tissue perfusion from poor CO and pulmonary congestion from increased pressure in pulmonary vessels
S/s of pneumothorax
Decreased/absent breath sounds, respiratory distress, hypotension, JVD, tracheal deviation and if unrelieved mediastinal shift, CV collapse, death
HIV mouth wash does what
Decreases sores
Radioactive Iodine therapy function? Given how? Takes how long after therapy for symptom release?
Decreases vasculartity, inhibits release of thyroid hormones, given through straw to prevent teeth staining.. Takes 6-8 weeks after therapy for symptom relief due to stores
Asystole don't
Defib
If patient in VF or pulseless VT immediate priority is to? The earlier the?
Defibrillated after CPR and continue until defib time. The earlier the greater chance of survival
Glucocorticoids aka? Affects? Stimulated by?
Cortisol which affects metabolism, stress responses, emotions, immune function. Stimulated by corticotropin releasing hormone from hypothalamus that stimulates anterior pituitary ACTH which causes release.
Addison's drugs aka? Take w/? Cortex? Prednisone? Florine?
Cortisone, hydrocortisone/cortex, prednisone, fludrocortisone/Florinef. Take w/ meals. Cortex Report weight gain/round face/fluid retention since can be cushing's. Prednisone report d/n/v fever. Florine monitor BP wight gain/edema since possible hypertension
Pneumonia interventions? drugs?
Cough, deep breathing, bronchodilators, antibiotics Avelox, Levaquin, Zosyn, Vancomycin, Augmentin,
S/s pneumonia
Cough, fever, chills, tachycardia, tachypnea, dyspnea, pleural pain, malaise, respiratory distress, low breath sounds, productive cough
If mobilization not possible what other interventions for reducing risk for injection/injury
Coughing and deep-breathing exercises Chest PT Frequent position changes Position to facilitate breathing HOB up 30 degrees (depending on BP) Nutritional support (TF, TPN) NGT or PEG feedings (monitor protein and albumin levels Keep HOB ↑ to avoid aspiration
Pulmonary edema key features
Crackles, dypnea at rest, disorientation/confusion esp in elders as early s/s, tachycardia, hyper/hypotension, reduced U/O, pink frothy cough, premature ventricular contractions, dysrhythmia, anxiety, restlessness, lethargy
If after all interventions and still increased ICP
Craniotomy to remove tissue/hemaotomas
Atrioventricular node define? Rate?
Created slight delay in electrical impulses. Intrinsic rate 40-50bpm
Interventions w/ liver transplantation
Cyclosporine immunosuppressant. Vaccinations, prophylactic antibiotics
Immunosuppressive drugs
Cyclosporine/sandiummune/Neoral , mycophenolate mofetil/cellcept, azothriprine/imuran
Preventing or managing hepatic encephalopathy from cirrhosis due to ammonia/protein
Dietary limitations and drugs to reduce bacterial breakdown
Liver functions
Digestion, nutrition, metabolism
Bowel training
Digital stimulation of the anal sphincter Performed at regular intervals, after meals and when convenient Not appropriate if cord lesion involves the sacral segment or nerve roots Contraindicated if there is spasticity of the anal sphincter
Elective cardioversion: digoxin? If for a.flutter/fib? Make sure? Mode?do what before? Do what during?
Digoxin withheld 48 horus before, if for atrial flutter/fibrillation anticoagulants for 4-6 weeks before. Emergency equipment available, consent form, sedation. Synchronized mode. Turn o2 off away from patient, shout clear before. Maintain airway, o2, VS/LOC, drugs, monitor, assess for burns, support, document.
Assessment findings from portal hypertension
Dilated abdominal find vessels Enlarged spleen Bruits heard over the upper abdominal area due to esophageal and gastric varices
Types of cardiomyopathy
Dilated cardiomyopathy, nonobstructed, obstructed, restrictive
Distributive shock risk factors
Diminished immune response, reduced skin integrity, cancer, peripheral neuropathy, strokes, institutionalizations, malnutrition, anemia
Contact transmission
Direct via physical contact aka person to person or indirect from source to host via passive transmission from contaminated object
Beta blockers and MI
Decrease size infarct, dysrhythmias
Glasgow used for? Categories and points for each?
Describing LOC. Eye opening(4), motor response(6), verbal response(5)
Sinus dysrhythmia examples
Sinus tachycardia, sinus bradycardia, premature atrial complexes
Magnesium sulfate for
VT, VF and life threatening VT called torsades de pointed from antidysrhymics like amiodarone
Researcher
conduct research to increase knowledge thus improving patient care
Testing CSF
+ halo, + glucose
Sepsis= ?
2 or more SIRS criteria+known source of infection
Type 5 stimulated hypersensitivity aka? Ex?
Aka stimulated. Ex: Grave's, B-Cell gmamopathies
H/H used to IF HF resulting from
Anemia
GI manifestations of hypothyroidism
Anorexia, weight gain, constipation, abdominal distention
Thyroditis types?
Types: acute from bacteria, subacute/granulomatous from virus, or chronic aka hashmiotos
Dx for cirrhosis
US first, then biopsy, possible liver scan, xray, MRI, CT
Sepsis erythema, swelling, pain=?
Cellulitis
Communications
USE OF EFFECTIVE INTERPERSONAL AND THERAPEUTIC COMMUNICATIONS SKILLS BUILD RELATIONSHIPS IN ALL AGES
K
3.5-5. Increased: dehydration, acidosis
Sepsis dysuria, frequency=?
UTI
Hemothorax treatment
Chest tube
Asterixis
Coarse tremor characterized by rapid, nonrhythmic extensions/flexions in wrists and fingers
Collaborator
facilitate the functions of other health care team members as they provide care
Types of injuries
Deceleration and accleration
W/ HF focus on? Only cure is?
Focus symptom management Only "cure" is heart transplant
HIV endocrine issues
Gonadal dysfunction, body shape changes, adrenal insufficiency, DM, elevated triglycerides/cholesterol, change in libido
All old people are considered
Immunosupressed
Sepsis: HA+fever=?
Meningitis
Thyroid location
Neck
BNP <100
Normal/no HF
AV block treatment
O2, drugs, pacing, pacemakers
Skin shock s/s
Pale, clammy, cool
Glycoprotein inhibitors
Reduce platelet aggregation
Liver diseases often found during
Routine physical exam/lab test
Infarction
Tissue death that occurs over several hours
Scoring for reflexes
0-4, 2 normal
1 kg weight gain = how much water?
1 L fluid restriction
What labs can indicate hypovolemia
Elevated BUN, decreased proteins, increased hematocrit
Impairment of renal function resulting from inadequate perfusion causes
Elevated BUN/serum creatinine
Best possible score for intubated
11t
Hyper secretion of thyrotropin/TSH s/s
Elevated THS+T3/t4, weight loss, tachycardia, dysrhythmias, heat intolerance, increased GI motility, tremors
Acuity scales/triage 2 standardized systems that are most reliable
Emergency severity index ESI and canadian triage acuity scale CTAS
23-year old women with severe abdominal pain; positive home pregnancy test; BP 90/50 mm Hg.
Emergent
Big block method for regular rhythm define? If little blocks left over?
Count number of large blocks between R waves and divide it into 300, if little blocks left over count each as 0.2 and add to big blocks then divid into 300
Glasgow lowest score
3 which means unresponsive
Nursing assessment for shock
ABCs Focused assessment of tissue perfusion:VS, Peripheral pulses, LOC, Capillary refill, Skin (e.g., temperature, color, moisture), UO. Allergies
Determining HR on ECG
Count tips and x by 10
Bicarbonate normal? Hypofunction of adrenal? Hyperfunction?
23-30. Increased, decreased
CO norm? Early sepsis? Late sepsis? Septic shock?
3-5L, decreased, increased, greatly decreased
Lactic acid norm
3-7mg or 0.3-0.8 mmol. Increased: anaerobic metabolism with buildup of metabolites
Addison's disease aka? Primary cause? Secondary cause?
Aka adrenal insufficiency so not enough cortisol/aldosterone. Primary cause: idiopathic/autoimmune, TB, cancer, AIDs, hemorrhage, gram - sepsis, adrenalectomy, radiation, mitotane/toxins. Secondary: pituitary tumors/necrosis, hypophysectomy, radiation, sudden stop of long term glucocorticoid therapy
Hypersensitivity aka? Define? Types?
Aka allergy or increased/excess response to presence of antigen to which has been previously exposed. Types: 1 immediate, 2 cytotoxic, 3 immune complex mediated, 4 delayed, 5 stimulated
Cardiac resychronization therapy CRT for HF
Aka biventricular pacing. Permanent pacemaker or combo w/ cardioverter/defib
Type 2 hypersensitivity aka? Ex?
Aka cytotoxic. Ex: transfusion reaction, Autoimmune hemolytic anemia, goodpasture's syndrome, myasthenia gravis
Limbic lobe
Emotions, survival, learning/memory
Assess of multiple sclerosis
Fatigue Weakness aka ataxia Spasticity/hyperactive DTR, +babinski Visual impairment Incontinence Disorders of swallowing and speech
K normal? Hypofunction of adrenal? Hyperfunction?
3.5-5. Increased, decreased
RA age onset? Gender? Risk factors? Disease process? Disease pattern? Lab findings? Common drug therapy?
35-45 yr female. Autoimmune, genetic, emotional stress triggers, environment. Inflammator. Bilateral symmetric joints, systemic. Elevated rheumatoid factor, antinuclear antibody, ESR. NSAIDs, methotrexate, corticosteroids, BRMs, immunosuppressives.
Oxytocin from? Targets? Functions?
From posterior pituitary and targets uterus and mammary glands to stimulate contractions and ejection of milk
Nerve 9
Glossopharyngeal, pain and temp from ear, taste of 1/3rd of tongue, throat muscles, parotid glands
PEEP usually set to
5-15 cm H2O
MAP average
60-70 to maintain perfusion to organs
If anxiety from shock
Ativan
P wave
Atrial depolarization
ARDS often occurs after
Acute lung injury, sepsis, PE, shock, aspiration, inhalation injury, transfusion of plasma products like RBCs, platelets, plasma. Burns, DIC, shock, trauma, nervous system injury, pancreatitis, fat/amniotic fluid emboli, pulmonary infection, inhalation of toxic gases like smoke/O2, pulmonary aspiration esp. of gastric contents, drug ingestion/opioids/aspirin/heroin, hemolytic disorders, cardiopulmonary bypass, submersion of water w/ water aspiration
Endogenous secretion aka Cushing's disease conditions that increase cortisol secretion
Adrenal hyperplasia, pituitary adenoma increasing ACTH, malignancies/carcinomas, adrenal adenomas/carcinomas
Surgical interventions for cushing's
Adrenalectromy, transsphenoidal adenomectomy to remove tumor, hypophysectomy to remove pituitary, radiation of pituitary
HF-4
Adult smoking cessation advice/counseling
AST/ALT ratio >2 means
Alcoholic liver disease usually
PaCo2 alkalosis? Acidosis
Alkalosis -40- Acidosis 35 - 45
ACS all patients
All patients do not present the same; Some may have ST elevation (STEMI) or non-ST elevation (NSTEMI) or Unstable angina Risk
Monitoring for CSF leak after hypophysectomy? Treatment?
Halo w/ light yellow color at edge and clear plus positive for glucose. Persistent severe headaches. Tx: bedrest, spinal tap
Assessment for cirrhosis
Any exposure to chemicals, toxins, drugs, or alcohol (specifics such as amount, type) Sexual history, body fluid exposure, tattoos Abdominal assessment (palpation of liver) Skin, bruising, petechiae, fruity/musty breath odor Mental status/psychosoical assessment Cognitive issues, behavior changes, sleep pattern disturbances, labile emotions
Sinoatrial node
Conduction begins with this aka primary pacemaker. 60-100bpm
Glucose of Cushing's
BG are high b/c liver stimulated and insulin receptors are less sensitive
Purpose of med management in hyperthyroidism ? Priorities focus on?
Decreased effect ofthyroid hormone on cardiac function and reduce secretion. Priorities focus on monitoring, reducing stimulation, promoting comfort, teaching
For disability/neuro evaluate need for
CT scan, BG check, ABG, alcohol level
Imaging assessment for HF
CXR for left since cardiomegaly, radionuclide studies w/ thallium to indicate presence/cause of HF
The nurse is caring for a patient with a BP of 130/45 and an ICP of 25 mm HG. Calculate the MAP Calculate the CPP What do numbers indicate
Calculate the MAP=73 Calculate the CPP=48 Numbers indicate impaired blood flow to brain
Post ictal phase patient can
Can wake up violent
General assessment and tools for spinal injury
Detailed neurological exam Diagnostic x-rays (lateral cervical spine x-rays) CT scan MRI
AIDS wasting syndrome
Diarrhea, malabsorption, aneorexia, oral/esophageal lesions causing weight loss
GI manifestations of AIDS
Diarrhea, weight loss, n/v
Conventional HF therapy
Diuretics, vasodilators, inotropics
CD-4 <200 is?
Dx of AIDS
Gynecomastia
Enlarged breasts
Anterior pituitary disorder hypo? Hyper?
GH hypo:dwarfism/cretinism, hyper:gigantism/acromegaly
Liver transplantation used for
Hep C, primary liver tumor, acute/chronic liver disease
Causes of left side ventricular HF
Hypertension, CAD, valvular disease
Tracheostomy considered for
If artificaial airway needed for longer than 10-14 days to reduce tracheal and vocal cord damage
Heart failure
Inability of heart to work effectively as pump
Immune system issues of cirrhosis
Increased infection, leukopenia
ST elevation it does what
It evolves over time
Chronic HF
Long term presence of the disease Focus on symptom management Cannot completely eradicate
Sepsis management bundle
Low dose steroids, insulin, mechanical ventilation
Remeron aka? Function?
Mertazipine. tetracyclic antidepressants
BNP 300-599
Mild HF
MAP is better indicator of
Perfusion to organs than systolic blood pressure
Systolic HF aka?
Pumping problem. "Relaxes but can't contract" Heart muscle has lost strength Ventricles can fill
Change in LOC is
The first indication that neuro status has declined
If patient is agitated, restless, has widely fluctuating inspiratory pressure reading, or has other signs of air hunger
The flow rate may be set too low. Increasing the flow should be tried before using chemical restraints.
Thyroid hormones
Triiodothyronine T3, thyroxine T4, calcitonin
44-year-old man with dislocated elbow.
Urgent
QRS
Ventricular depolarization
S/s of worsening encephalopathy
change in LOC/orientation, asterixis/liver flap, fetor hepaticus/liver breath
A high CVP indicates
hypervolemia or poor right ventricular contraction.
Parathyroid hormones
parathyroid hormone
Cardiomyopathy
Disease of the cardiac muscle Unknown Cause
Trauma impact on immunity
Disruption of barrier defenses, contamination from soil/water/objects
Surgery impact on immunity
Disruption of normal flora+barrier, reduced neutrophils
Class 2 and 3 LHF from MI interventions
Diuresis, nitroprusside/nitroglycerin, beta blockers, ACE/ARBs, inotropes like dobutamine
Drugs for hyperparathyroidism
Diuretic Lasix to promote Ca excretion, Calcimetics/oral phosphates, Cinacalet/Sensipar that decreases Ca. For patient who doesn't respond to Sensipar, IV phosphates given to prevent bone resorption/Ca absorption. Ca chelators mithramycin
Drug therapy for fluids for cirrhosis
Diuretic, quinolones like norflaxacin/noroxin for spontaneous bacterial pertionitis
Drugs for cirrhosis
Diuretics Aldactone, Lasix Laxatives Lactulose Anti-infectives Neomycin Vasopressin
Drug Interventions for HF that reduce preload raising SV
Diuretics and vasodilators like nitrates, morphine for anxiety
Med therapy for SIADH
Diuretics if Na WNL +HF present, Vasopressin antagonists to excrete water w/out Na loss like Tolyaptan/Samsca, Conivaptan/Vaprisol
Hypovolemic shock risk factors
Diuretics, diminished thirst reflex, immobility, aspirin, use of complimentary therapies, anticoagulants
To prevent bacterial contamination for ventilator
Do not allow moisture and water in ventilator tubing to enter humidifier
Nitroglycerin for MI
Do not give if patent is on sildenafil, tadalafil, vardenfil)- vasodilator- increase blood supply to coronary muscle
Ancillary staff who had hands on care w/ patient should
Document
Technology doesn't?
Does not change patient's rights to privacy of health information. Whether documentation is paper-based, electronic or in any other format, maintaining confidentiality of all information in a health record is essential, and relates to access, storage, retrieval and transmission of a client's information
With oxygenation failure applying 100% o2
Doesn't correct the problem
Sinoatrial node define? Rate?
Dominant pacemaker. intrinsic rate 60-100bpm
Nonabsorbable antibiotics: dont ? Names? Function? SE? Contraindications? Patient education?
Don't give w/ lactulose. Neomycin, metronidazole/flagyl, ridaximin/xifaxan. Kills normal flora diminishing protein breakdown thus decreasing ammonia. SE:dizziness, headache, loss of appetite, metallic taste, seizures, sudden vision changes, trouble speaking and neurologic changes Contraindications: Over the counter medications such as cough syrup that contain alcohol Patient Education: Take with food, may turn urine a dark color, no alcohol
Preparing body for viewing if trauma death, suspected homicide, or abuse
Don't remove IV/tubes or clean skin instead cover body w/ sheet while leaving face exposed and dimming lights
Meds for acromegaly
Dopamine agonists:bromocriptine mesylate (parlodel), Cabergoline (Dostinex) stimulate dopamine receptors and inhibit the release of GH and prolactin (PRL). Reduces the size of pituitary gland to normal or near normal size Octreotide (Sandostatin)- inhibits GH release
Babinski sign
Dorsiflexion of great toe and fanning of the other toes positive is abnormal
Testing motor function for SCI for cervical spine
Downward pressure when shrugging, resistance when pulling up arms, resistance when straightening flexed arms, grasp an object forming fist
Reality shock
- the stress, surprise, and disequilibrium experienced when shifting from a familiar culture into one whose values, rewards, and sanctions are different
Non glasgow motor scoring? Do what?
0 no movment 5 being normal against full resistance. Flex extend elbows, elevate arms, flex extend wrists and fingers and touch each finger to thumb
Normal creatinine? BUN?
0.5-1.2, 7-18. Elevated can indicate fluid deficiency and kidney issue. Determines kidney function
Acute rejection begins when? What happens? Dx? Doesn't?
1 week-3 months after. Either antibody mediated leading to vasculitis aka vessel necrosis or can be cellular causing lysis of organ cells. Dx: labs. Doesn't automatically mean they will lose organ
Rn dx of cirrhosis
1. Activity intolerance 2. Imbalanced nutrition 3. Impaired skin integrity 4. Fluid volume excess 5. Risk for injury 6. Body image disturbance 7. Disturbed thought pattern 8. Collaborative problem: hemorrhage
Protein goal for ARDS/respiratory failyure
1.5-2g/kg
1 kg of weight gain/loss equals how much retained/lost fluid
1kg=1L
Drugs for anaphylaxis
1st line synpathomimetics: epinephrine/adrenalin, isoproterenol/isuprel, ephedrine/vatronol. 2nd line antihistamines:diphenhydramine benadryl, corticosteroids: -one drugs. Support drugs:vasopressors norepinephrine/levophed, dopamine/inotropin
Epinephrine for? Aka?
1st line went for cardiac arrests aka adrenaline
Hospital care for heat stroke
1st priority monitor/support airway, breathing, circulation, o2, IV NS, catheter, no aspirin/antipyretic S, cooling blankets, ice packs, iced gastric/bladder lavage, continuous core temp monitoring, if shivering benzos like diazepam/valium chlorpromazine/thorazine
Prehospital care providers
1st to see patient before ED by ambulance ex. Emergency medical services EMS, emergency medical technicians EMTs for BLS like o2, wound care, splinting, spine immobilization, monitoring VS, paramedics for ALS that can include cardiac monitoring, advanced airway management, intubation, IV access, admin of drugs
CV changes for hypovolemic shock
1st: ^HR, difficult to palpate pulse progressing to absent, low BP
Noninvasive temporary pacing NTP: define? Used to? For? VS done on which side if NTP placed?
2 large external electrodes. To stimulate ventricular depolarization. For emergency bradycardia/asystole until invasive can be used or returns to normal. One over upper right chest, one over apex. VS on right side.
Patient identification for safety
2 unique identifiers before intervention and meds: DOB, identification #, telephone number, address, SS #
Communication must be
2 way process
Normal levels of CPAP ? If no pressure set?
5-15cm H2O. No positive pressure given thus being used as t-piece with alarms.
Fluid restrictions for SIADH interventions
500-1000mL/day, dilute tube feedings w/ saline, use saline to irrigate GI tubes, mix drugs w/ saline, measure I/O/weight, oral rinsing to keep moist mouth
For heart transplant if everything good when do you ambulate
6 hours after, bed sitting in chair
Cortisol normal from 6-9am? 4-6PM? Hypofunction of adrenal? Hyperfunction?
6-8AM 5-23mcg or 138-635 SI. 4-6PM 3-13mcg or 83-359 SI. Decreased, increased.
Normal rate? Bradycardia? Tachycardia?
60-100, <60 bradycardia, >100 tachycardia
Issues w/ cardiovascular for SCI if above
6th thoracic which can lead to bradycardia, hypotension, hypothermia, dysrhythmia
Comatose glasgow
7
PH
7.35-7.45 decreased: insufficient tissue oxygenation causing anaerobic metabolism and acidosis
Glucose normal? Hypofunction of adrenal? Hyperfunction?
70-115 but older adults can be increased. Normal to decreased, normal to increased.
Normal CPP range
70=100mmHg
ARDS dx
A low PaO2 < 60mmHg Progressive need for higher levels of Oxygen Patient does not respond to increased Oxygen Chest x-ray shows diffuse haziness or (ground glass) appearance of lungs Rule out cardiac pulmonary edema
What can increase variceal bleeding
A nominal pressure like heavy lifting, vigorous exercise, chest trauma, dry/hard food in esophagus
Avoiding
A person may recognize that a conflict exists and want to withdraw from it or suppress it, avoiding included trying to just ignore a conflict and avoiding others w/ whom you disagree
Acute respiratory failure cause is associated with
A physiological lung problem, a neuro problem, or musculoskeletal problems
Hepatorenal syndrome HRS s/s? Often occurs? Poor?
A sudden decrease in urinary flow, < 500ml/24 hours (oliguria). Elevated BUN and creatinine levels with abnormally decreased urine sodium excretion Increased urine osmolarity. Often occurs after clinical deterioration. Poor prognostic sign, often cause of death in these patients.
Examples of medical conditions that may cause respiratory failure
A. Asthma B. COPD: Emphysema, Chronic bronchitis C. Pneumonia • Aspiration pneumonia • Ventilator associated pneumonia • Community acquired pneumonia • Hospital/health-care associated pneumonia D. Tuberculosis E. Pulmonary Embolism
Diagnosis of ARF
A. History and physical exam B. Labs C. X-ray D. Pulmonary function tests
Treatment of respiratory failure/ARDS
A. Oxygen B. Positioning C. Fluids D. Medications E. Diet F. Exercise
TBI interventions
ABC, treat as if SCI until xray, assess for cushing's triad, neuro assessment/LOC/glasgow, prevent ICP, drugs fluids, nutrition , surgery
Initial assessment for SCI
ABCs, assess for hemorrage like hypotension/tachycardia/weak pulse, use glasgow to assess LOC, assess motor/sensory status
Dx of respiratory failure
ABGs look for hypoxemia+hypercarbia, CXR, urine+sputum cultures, pulmonary function test
ACE inhibitors/ARBs
ACE: -il drugs+vasotec, ARBs: -tan drugs. 1st choice. Suppress renin-angiotensin causing dilation and prevent aldosterone preventing Na and water retention
Automatic external defibrillation aka? Needs? Steps?
AEDs. Needs firm/dry surface. Stop CPR, clear, analyze pressed, shock for VF or pulseless VT, then CPR until instruction to stop
Lymphocytes in AIDs aka?
AIDS WBC <3500 aka leukopenic
Sepsis progression
ARDS (lungs usually first to fail) Fever/tachycardia Altered Mental Status Myocardial failure (hypotension) Death
Conditions that affect gas exchange in alveoli leading to respiratory failure
ARDS, pneumonia
Labs of cirrhosis
AST, ALT, LDH elevated but as liver detoriates AST/ALT can be normal, bilirubin usually elevated in blood and urine(urinobilogen), serum protein/albumin low in chronic, pt/inr prolonged, platelets low, anemia, WBC can be low, ammonia increased if chronic/advanced, possible hypnatremia if ascites, decreased hematocrit/hemoglobin
GI finding sof cirrhosis
Ab pain, anorexia, ascites, clay colored stool, diarrhea, varices, femoral hepaticus, gallstones, gastritis, GI bleeding, hemorrhoidal varices, hepatomegaly, hiatal hernia, hypersplenism, malnutrition, nausea, small nodular liver, vomiting
S/s of hepatitis
Ab pain, changes in skin/sclera aka icterus, arthralgia/joint pain or myalgia/muscle pain, diarrhea, constipation, changes in color or uurine/stool, fever, lethargy, malaise, n/v, pruritus/itching, RUQ liver tendernderness, jaundice, dark urine/clay stool
Urgent triage examples
Abdominal pain Non-cardiac chest pain Multiple fractures or lacerations w/o major hemorrhage Displaced/multiple fractures/dislocations Temps >101 Renal calculi Decrease level of consciousness Overdose that is conscious Chemical exposure to the eye New onset respiratory infection Acute psychosis Pneumonia w/o respiratory failure Complex/multiple soft
Fluid/electrolyte managagement interventions of cirrhosis
Accurate I/O, Daily weights, monitor trends Monitor S/S of fluid retention Monitor electrolytes Maintain sodium restricted diet
HF-3
Ace Inhibitors (ACE) or ARB for left ventricular systolic dysfunction (LVSD)
High altitude hospital care/treatment for AMS
Acetazolamide/Diamox/anhydrase to prevent/treat by inducing acidosis take 24 hours before and during trip, dexamethasone/decadron to treat to reduce edema to relieve sysmteoms.
Other increased ICP rn interventions
Achieving an Adequate Breathing Pattern Optimizing Cerebral Tissue Perfusion Maintaining Negative Fluid Balance (Strict I/O's) Preventing Infection Monitoring and Managing Potential Complications Detecting Early and Later Indications of Increased ICP
Ph acidosis? Alkalosis? Acidosis? Alkalosis?
Acidosis -7.40- Alkalosis 7.35 - 7.45 pH < 7.40 -Acidosis pH > 7.40 -Alkalosis
HCO3 acidosis? Alkalosis>
Acidosis 22 - 26 Alkalosis
Neomycin action? Indication? SE? Patient education? Contraindications?
Action: Aminoglycoside-stops the production of proteins that bacteria need to survive Indications: Hepatic encephalopathy Side Effects: hearing loss, ringing in ears, dizziness, tingling or numbness of skin, muscle twitching, seizures Patient Education: Patients need to follow low protein diet, obtain proteins from vegetables and dairy products, eat whole grain products Contraindications: Anticoagulants, vancomycin, keflex, PCN, lanoxin methotrexate
Quinolones action? SE? Patient education? Contraindications?
Action: Antimicrobial, antiviral properties Indications: Hepatitis C, Consistent elevated liver enzymes, Pre-transplantation prophalaxysis Side Effects: Bursitis, peripheral neuropathy, n/v/d, alterations in sensation Patient Education: Take on empty stomach, take with full glass of water, avoid alcohol Contraindications: Pregnancy, breast feeding
Propranol action? SE? Patient education? Contraindications?
Action: Inhibits renin secretion decreasing the tendency of ascites Indication: Portal hypertension, Liver dz, Ascites Side Effects: Black, tarry stools, blood in urine, blurred or loss of vision, body aches, crying, extreme fatigue, hair loss, anxiety Patient Education: No alcohol, do not skip doses or double up on doses, move slowly when standing Contraindications: Depression, asthma, Wolf-Parkinson White Syndrome (WPW)
Parathyroid hormone function on kidneys?
Activates vitamin D, increased reabsorption of Ca+Mg, increase phosphorus/bicarbonate/Na excretion all to increase serum Ca
Management of Addisons? Important to monitor?
Adrenocorticoid replacement : Hydrocortisone/Cortef Prednisone/Deltasone Cortisone/Cortisone Acetate Solu-medrol/methylprenisolone Important to monitor blood glucose levels
Interventions for hyperaldosteronism
Adrenolectomy of one or both glands, spironolactone to increase K, low Na diet, monitor BP, monitor labs, replace K if needed, I/O, meds
Interventions for HF that reduce preload raising SV
Aimed to decrease volume/pressure in left ventricle, increase ventricular muscle stretch+contraction. Good for HF w/ congestion w/ Na+H2o overload. Nutrition, drugs
Intrapulmonary causes of ventilatory failure
Airway disease:COPD/asthma, v/Q aka ventilation perfusion mismatch: PE, pneumothorax, acute respiratory distress syndrom ARDS, amyloidosis, PE, interstitial fibrosis
Triage nurse across room assessment
Airway, breathing, circulation, disability. Always scanning and look for clue that you need to be on alert.
Shock lung
Aka ARDS
Acute adrenal insufficiency aka? Define? Na and K? Severe?
Aka Addisonian crisis. Life threatening low cortisol and aldosterone due to stress from surgery/trauma/infection. Na falls and K raises, severe hypotension
Vasopressin aka? Function? Monitor? No more than?
Aka Pitressin. Parenteral ADH replacement. Monitor for water intoxication aka drowsiness/confusion/headache/anuria/weight gain >2lbs/24 hours. No more than 3L fluids/day
Gout aka? Patho? Types?
Aka gouty arthritis, systemic urate crystals deposit in joints/tissue causing inglammation. Types: primary from purine metabolism issue, secondary hyperuricemia aka uric acid in blood from crash diets, chemo,
Antibody mediate immunity aka? Types?
Aka humoral, antigen-antibody reaction. Types: adaptive from foreign organism either naturally artificially and can be active or natural. Passive is when you are given artifical antibodies from injection/mom
Acromegaly aka? Definition? Onset may be? Changes in?
Aka hyperpituitarism. Overproduction of Growth Hormone (GH) Onset may be gradual with slow progression. Changes in size of skeletal bones and soft tissues, skeletal thickness, hypertrophy of skin, organ enlargement, bone thinning, cartilage degerneration, hypertrophy of ligaments/vocal cords, peripheral neuropathy, hyperglycemia
Type 1 immediate hypersensitivity aka? Results in? Ex?
Aka immediate. Results in release of mediators especially histamine. Ex: hay fever/allergic rhinitis, classic allergy signs, allergic asthma, anaphylaxis, pollen, bee, peanuts, shellfish, drugs, inhaled/ingested/injected/contacted
Type 3 hypersensitivity aka? Results in? Ex?
Aka immune complex-mediated. Results in inflmmation. Ex: Serum sickness, vasculitis, systemic lupus, RA, scleroderma
Inflammation aka? Function?
Aka natural/innate immunity and provides immediate protection
Parkinson care
Allow tim, meds for pain/tingling, physical/occupational therapy, prevent complications of constipation/ulcers/contractures, schedule activities late in morning, alternate communication methods, monitor food intake, high protein/calorie foods
Hepatic encephalopathy aka? Define? S/s?
Also called Portal-systemic Encephalopathy (PSE) Cognitive Syndrome resulting from liver failure or cirrhosis Sleep and mood disturbances Change in mental status Speech problems Reversible with early intervention
After load
Also known as systemic vascular resistance (SVR) Amount of tension that the ventricle must overcome to open the aortic valve and eject blood into the systemic circulation Normal is 700-1500 dy/sec/cm
Reproductive manifestations of hyperthyroidism
Amenorrhea, decreased menstrual flow, increased libido
Antifungals for immunocompromised
Amphotericin B
Chemical-induced distributive shock
Anaphylaxis Wide spread reaction that occurs in response to contact with a substance to which the person has a severe allergy (antigen) Septic Shock Capillary leak syndrome
Hematologic findings of cirrhosis
Anemia, DIC, impaired coagulation, splenomegaly, thrombocytopenia
CV manifestations of addison's
Anemia, hypotension, hyponatremia, hyperkalemia, hypercalcemia
Bone marrow suppression from chemo SE
Anemia, thrombocytopenia, neutropenia increasing risk for infection/bleeding, hypoxia, fatigue
Coronary artery bypass drafting define
Aneruysm that causes ventricular tachydysrthmia respected via balloon in ventricles to eliminate irritable focus
Drugs for patients w/ systolic HF
Angiotensin-converting ACE inhibitor or angiotensin receptor blockers ARBs, high ceiling or K sparing duretics, human B type natriuretic peptides, nitrates, intropics beta andrenergic/phoshodiesterase/Ca sensiztizer/Digoxin/lanoxin, beta andrenergic blocker
What can stop digoxin absorption
Antacids
Drugs for GI issues from ventilation
Antacids, sulcralfate, histamine blockers, proton pump inhibitors
D if unresponsive anticipate
Anticipate cat scan
Preventing infection for HIV
Antiretroviral therapy, prophylaxis/active treatment of opportunistic infections, avoid infection, drugs
Low circulating volume hypovolemic shock s/s
Anxiety (hypoxia) Tachypnea Decrease in CO ↑Heart rate (compensatory) Decrease in stroke volume, PAWP, urinary output
Premature contraction rn dx
Anxiety, ineffective coping, impaired comfort
Early neuro s/s of shock
Anxiety, restlessness, increased thirst.
Endoscopic variceal ligation EVL banding
Application of small "O" bands around the base of the varices to decrease the supply
Testing motor function for SCI for S1
Apply resistance when plantar flexing feet
SBAR is? Define?
Approach to hand-off communication S = Situation B = Background A = Assessment R = Response
MS GI/GU s/s
Areflexic bladder or frequency/urgency/nocturia, constipation, incontinence, impotence
Fluid/electrolyte findings of cirrhosis
Ascites, decreased effective blood volume, dilutional hyponatremia or hyperatremia, hypocalcemia, hypokalemia, peripheral edema, water retention
Low exhaled volume/low pressure alarm sounds from leak in ventilator circuit preventing breath sounds from being delivered
Assess all connections and all ventilator tubings for disconnection
Preventing pulmonary edema
Assess for early signs Crackles in bases Dyspnea at rest, disorientation, confusion High Fowler's position
Artifact or ventricular tachycardia first thing to do
Assess or check leads
Nursing care for ET tube
Assess placement, cuff leak, breath sounds, chest wall movement, prevent pulling/tugging on tube to prevent slipping, check pilot ballon to ensure inflated, suctioning/coughing/speaking can cause dislodgement, neck flexion/head rotation/mouth secretions/tongue movements moves tube, possible soft wrist restraints and then sedation if other measures fail
Care of patient w/ mechanical ventilation
Assess respiratory status/VS/color/chest expansion/placement/pulse ox, ABGs, HOB raised, check venilator settings, check alarms, if PEEP observe peak airway pressure, check display for tidal volume, empty tubing if moisture, ensure humidity via air temp at body temp, cuff inflated, assculate lungs, check for suctioning q 2 hours, assess mouth for pressure ulcers, mouth care q 2 hrs, change tape as needed, trach care, check for GI distress, I/Os, turn q 2 hours, get out of bed as prescribed, rest,
The nurse is notified by the telemetry monitor technician about a patient's heart rate. Which method does the nurse use to confirm the technician's report?
Assess the heart rate directly by taking an apical pulse
If high pressure alarm sounds from obstruction in tubing b/c patient lying on the tubing or there is water or a kink in tubing
Assess the system, moving from artificial airway towards ventilator
Care of ET/Trach tube
Assess tube position q 2 hours, position ventilator tubing in a way that patient can move without pullin on tube. Mouth care q 8 hours
Ventricular tachycardia assessment
Assessment Palpitations Dizziness/ lightheadedness. Shortness of breath. Chest pain/ pressure. Near-fainting or fainting (syncope). Weak pulse or no pulse
Steps of delegation
Assessment+planning, communication, surveillance/supervision, evaluation+feedback
Victims of abuse
Assessment/documentation, communication, education
Respiratory MG
Assisted cough, keep ambulance bad and intubation equipment tat bedside, bipap
With ventilator what does nurse do
Assists in connecting patient to ventilator and monitoring settings
When to have liquids for ARDS/failure
At end of meal
Burn wound infection occurs through
Auto-contamination where patient's own flora overgrows or cross contamination from others
Myasthenia gravis
Autoimmune disease w/ remissions exacerbations. Progressive weakness that improves w/ rest, poor posture, ocular palsieas, ptosis, weak eye closure, diplopia, respiratory compromise, loss of GU/Gi control, fatifure, achiness, paresthesias, decreased smell/taste
Examples of commmon disorders and therapies leading to immunocompromise
Autoimmune disorders, Burns, Malnutrition, Cancer, Drugs, AIDS, Diabetes
Multiple sclerosis s/s
Autoimmune usually familial, tinnitus, lowered hearing, nystagmus, diplobia, blurred vision, dysarthria, dysphagia, onset 20s-40s, weakness that can progess to paralysis, muscle spasticity, ataxia, vertigo, urinary retention, spastic bladder, constipation
MAP
Average pressure in patient's arteries during one cardiac cycle. Influenced by total blood volume, CO, size of vascular bed
Education for hepatitis
Avoid all meds/OTCs, avoid all alcohol, rest frequently, eat small frequent meals w/ high carbs+moderate fat/protein, avoid sex until antibody testing -
Prevention of infection for neutropenic
Avoid crowds, don't share toilet items, bathe daily esp. armpits groin genitals anus, clean toothbrush, wash hands before eating after pet touching after shaking hands after getting home, avoid raw foods, don't drink liquids standing >1hr, don't reuse dishes, don't change litter box, take temp q day, report s/s of infection
Patient fam education for immunocompromised
Avoid large crowds, Bathe daily, Perianal care after each BM. Avoid fresh fruits and vegetables. Cooked meats only. No fresh flowers. Avoid Gardening
How to prevent those at risk for vasovagal attacks causing bradydysrhythmia
Avoid raising arms above head, pressure over carotid artery, pressure on eyes, bearing own/straining for BM, stimulating gag reflex
To prevent vagal stimulation
Avoid tracheal suctioning, enemas, rectal temp, BM straining, vomitting, gagging, tight collars, raising arms above head
Type 1 interventions
Avoidance therapy, decongestants, antihistamines, corticosteroids, alternative therapy, desensitization therapy aka allergy shots
Patient described as alert is? Can be alert but?
Awake and responsive. Can be alert but not oriented to person, place, or time
Skin findings of cirrhosis
Axillary/pube hair changes, caput medusae, eccymosis, increased skin pigmentation, jaundice, palmar erythema, pruritis, spider angiomas
Chronic rejection what happens? Occurs? Cure?
B.vessel muscle overgrows and occludes vessels and organ tissue replaced w/ fibrotic scar tissue reducing transplant organ function occurring continuously due to chronic ischemia. Occurs to some degree w/ all. No cure.
If DM and shock
BG can go up
Nitrates monitor
BP . Headache normal fixed w/ acetaminophen
3rd stage progressive
BP drops, MAP low, may say they will die, hypoxia, anxiety, tachycardia or possible bradycardia
For breathing both apneic patients and those w/ poor ventilators effort need
BVM ventilation until endotracheal intubation and mechanical ventilator used
Band aka? Mature is?
Baby neutrophil, mature is segment
Promoting mobility for MS
Baclofen/lioresal to lessen muscle spacisticy, paresthesia via antidepressants, amatadine/symmetrel for fatigue, antispasmodics, antieleptics. ROM, stretching
Antibiotics for immunocompromised
Bactrim, vancomycin
Dysrhythmia vs. arrhymias
Bad, pain, difficult, abnormal vs. no not without
patient is brought to the ED by a friends who report " he probably overdosed on downers". What type of airway management does the nurse expect this patient to receive? decreased level of consciousness deceased gag reflex Emesis to face and chest sonorous respirations pulse oxygen is 87%.
Based on clients ventilator effectiveness and physical abnormalities client requires airway management with an endotracheal tube. The use of the bag-valve-mask may be used for ventilation for support until endotracheal intubation is performed but does not serve as effective management for his client.
Artifact focus on
Baseline for p and t's, if nothing distinguishable artifact, see slide 34
Primary survey before engaging? Define?
Before engaging making sure safe w/ standard precautions/ PPE then the initial assessment: Airway/cervical spine, breathing, circulation, disability, exposure
Stage 4 of conflict
Behavior: this is a stage where conflict becomes visible
EF 40-50%
Below normal
Cause of hyperaldosteronism? Results in?
Benign adrenal adenoma, results in mineralocorticoids excess
Echocardiogram is
Best tool to dx HF(valve changes, pericardial effusion, chamber enlargement, ventricle hypertrophy, EF) and non invasive. Assesses EF, valvular changes, chamber enlargement, pericardial effusion, blood clots, cardiac wall motion.
Meds that help management HF+hypertension
Beta Blockers "lols" Angiotensin converting enzyme (ACE) inhibitors "prils" Angiotensin II receptor blockers (ARBs) "tan"
Drugs for preventing bleeding for cirrhosis
Beta blockers like propranolol/inderal, antibiotics , vasoactive vasopressins like terlipressin/somatostatin
Drugs for esophageal varices
Beta-blocking agents Propanolol/Inderal, Nadolol/Corgard
Stage 2 mild parkinsons
Bilateral limb involvement, maskike face, slow shuffling gate
Portal hypertension from liver dysfunction
Blood backs up and you get hemroids and umbilicus gets visible veins, you get splenomegaly, esophageal bleeding
Acute respiratory failure classified by? Further defined as?
Blood gas abnormalities. Further defined as ventilators, oxygenation, combination of both failures
Hemothorax
Blood loss into chest cavity
Expected outcomes for hyperaldosteronism
Blood pressure remains normal Fluid and electrolyte balance is maintained Decrease in aldosterone levels Client verbalizes understanding of condition Client verbalizes understanding of dietary recommendations
Hep C from? S/s? Recovery?
Blood to blood. S/s asymptomatic. Usually don't recover and chronic infection develops
Dx of cushings
Blood/salivary/urine Cortisol levels high, ACTH high if pituitary Cushings or very low if adrenal Cushing's or when chronic steroid use Dextramethasone suppression testing Incread BG, decreased lymphocytes, increased Na, decreased Ca+K MRI CT scan X- Ray
Types of trauma
Blunt or penetrating
MS visual issues
Blurred vision, diplopia aka double vision, decreased, scotomas aka peripheral vision change, nystagmus aka involvuntary REM
Neuro manifestations of hyperthyroidism
Blurred/double vision changes usually earlier s/s, eye fatigue, dry eyes, corneal ulcers/infections, increased tears, njected/red conjunctiva, photophobia, eyelid retraction/lag, globe lag, hyperactive DTR, tremors, insomnia
Trauma definition
Bodily injury
Congenital/primary immune deficiencies
Born w/ defect. Like selective immunoglobulin A deficiency which is treated by treating infections, or Bruton's agammaglobulinemia treated w/ antibody replacement
CV manifestations of hypothyroidism
Bradycardia, dysrhythmia, enlarged heart, decreased activity tolerance, hypotension
Atropine for
Bradydysrhythmia
Hypothalamus + pituitary location
Brain
Rapid deceleration/acceleration can cause
Brain damage through impact w/ hard skull aka coup-countercoup injury
Managing airway/breathing for SCI
Breath sounds/VS q 2-4 hours, if tetraplegic cough assist via placing hand on rib cage/ab and cough, incentive spirometer, monitor for pneumonia/PE/atelectasis
Ventilator rate
Breaths/min
CAD
Broad term including chronic stable angina and acute coronary syndromes like unstable angina, MI and affects arteries for myocardium causing ischemia and infarction
Asthma drugs
Bronchodilators, cholinergic Antagonist, long acting beta agonist Albuterol, atrovent, combivent, Advair, Singular, Prednisone
Examples of venomous arthropods
Brown recluse, black widow, scorpions, bees, wasps
Contusion
Bruising of brain aka coup if at site or contrecoup if injury at opposite
Clinical manifestations of cushing's
Buffalo hump on back, unusual behavior, facial features, fat/truncal obesity, ACTH/cortisol increase, loss of muscle mass on limbs, thin overextended skin, hypertension/hyperglycemia/hypernatremia/hyperpigmentation, urinary cortisol increased, menstrual irregularities, porosity of bones, weight gain, moon face, loss of bone density, purple striae, acne
Burnout: shares? If reality shock is not handled? S/s?
Burnout shares common characteristics with reality shock If reality shock is not handled in a healthy way - progress to full-fledge burnout Symptoms: depression, sadness, grief, and mourning
Bloodwork for dx of respiratory failure
CBC, chemistries(CMP, BMP)
Sepsis cv s/s
CO/BP low in early+septic shock. CO/HR/BP high in severe sepsis. With progression DIC causing hypoxia/ischemia.
Hypercapnic respiratory failure examples
COPD, asthma, neuromuscular disease, drug overdose, chest wall abnormalities
If no pulse and not awake
CPR
Ventricular tachycardia: rate? Rhythm? P wave? QRS?
Can be intermittent/nonsustained or sustained Rate- 100-200 bpm Rhythm- regular or irregular P wave- none or not associated with QRS QRS- wide, bizarre appearance
With fluid volume excess hematocrit Hct
Can be low from hemodilution
Fungal opportunistic infections
Candida causing candidiasis, stomatitis, esophagitis leading to altered taste, mouth pain, difficult swallowing, retrosternal pain, cottage cheese in mouth. Cryptococcosis meningitis causing fever, headache, blurred vision, n/v, nuchal rigidity/stiff neck, confusion, altered LOC, malaise, seizures. Histoplasmosis causing dyspnea, fever, cough, weight loss, enlarged lymph nodes
Tests verifying perfusion
Cap refill, MAP, skin color, temp
Complications of surgical interventions for MI
Cardiac Tamponade - fluid compresses the heart muscle reducing cardiac output Mediastinitis- infection of the mediastinum
Pons brainstem
Cardiac acceleration/vasoconstriction, controls RR and pattern, cranial nerves 5, 6, 7, 8
Immunocompromised
Care of patients with secondary immunodeficiency
Nursing roles
Caregiver, communicator, teacher/educator, counselor, leader, researcher, advocate, collaborator
Pheochromocytoma patho?
Catecholamine producing tumor in adrenal medulla which store/release epinephrine and norepinephrine. Excess of those mimic sympathetic division of ANS
Adrenal medulla hormones? Release stimulated by?
Catecholamines:epinephrine, norepinephrine. Release stimulated by activation of sympathetic nervous system from stress aka fight or flight
Central venous catheterCVP
Catheter inserted through subclavaian vein to superior vena cava to heart to right atrium. Measure central venous pressure. Lets you know of volume in right heart for HF. Trends up or down is most important
Atrioventricular node
Cause impulses to slow down before proceeding to ventricles aka PR allowing atria to contract and ventricles to fill
Cirrhosis caused by? Develops? Results in?
Caused by chronic reaction to hepatic inflammation or necrosis Develops slowly, results in end stage liver disease
In som VT causes? Assess? Treatment if stable?
Causes cardiac arrest. Assess ABC, LOC, O2 sat. If stable w/ sustained VT o2 and ECG then amiodarone, lidocaine, or mag sulfate
Drowning assessment fresh water
Causes surfactant to wash out which destabilizes alveoli to increase airway resistance
Education for pacemaker generator
Cell phones >6 inches away from generator, handset on ear opposite of generator, avoid electromagnetic fields like magnets/TV/radio transmitters/MRI. Carry ID card/bracelet. Don't apply pressure to generator, don't operate electrical appliances over/make sure grounded. If beeps move away and notify
Spinal cord injuries: incomplete spinal cord lesions
Central, anterior, posterior, brown-sequard. Cord damaged where some function/movement below level of injury
History assessment for Addison's
Changes in activity level:fatigue, muscle weakness, lethargy GI disturbances:nausea, vomiting, anorexia, diarrhea, abdominal pain Sexual disturbances in women:menstrual cycle changes r/t weight loss, men may experience impotence
Physical assessment of cushing's
Changes in fat distribution Muscle wasting and weakness Skin changes Hirsutism in women Male pattern baldness Edema Fluid and electrolyte imbalance GI issues like ulcer formation from raised HCl and decreased gastric mucus
reproductive manifestations of hypothyroidism in women? Men?
Changes in menses like amenorrhea or prolonged period/annovulation/decreased libido vs. men: decreased libido/impotence
Abdominal assessment of cirrhosis
Check for distended abdomen/umbilicus+veins/caput medusae+Problems w/ balance/posture+inguinal/umbilical hernias, right upper quad for heptamegaly by advanced RN, measure girth, take weight for most reliable indicator of fluid retention
MOI types
Chemical, lack of oxidation, smoke, electricity, heat, mechanical energy
Exposure to energy examples
Chemicals Lack of Oxidation Smoke Electricity Heat Mechanical Energy
Dx of hyperaldosteronism? K/renin? Na? Specific gravity?
Chemistry labs MRI, X-rays, CT scan Aldosterone levels, low K/renin, high Na, low specific gravity
Radiation induced immune deficiencies
Chemo more immmunosuppressive than radiation/radio therapy
Cancer treatments that can cause bone marrow suppression causing immunosuppression
Chemotherapy, biotherapy both lead to neutropenia/myelosuppression causing high risk for sepsis
Pneumothorax define
Chest injury that allows air to enter pleural space and results in lung collapse
MI pain
Chest, radiates to left arm, jaw/back/shoulder/ab pain, in morning, lasting 30 min>, n/v, diaphoresis, dyspnea, impending doom, palpitations, dizziness,
Protecting skin
Clean dry skin, mobility to decrease shearing forces, routine turning
Cardiac transplantation
Clients with ESRD, severe COPD, clotting disorders and infections are not candidates Immunosuppressive therapy usually begins in operating room
Stage 2 of conflict
Cognition/personalization: Conflict must be perceived by the parties to it whether or not conflict exists is a perception issue. If no one away of conflict then generally agreed that no conflict exists. Place where parties decide on what conflict is about.
Clinical reasoning focuses on
Collection of FACTUAL DATA Process information Understand problems/situation Plan & implement intervention Evaluate outcomes Reflect & learn from the process
Perceptions by new nurses
Colliding expectations - expected workplace to be more like nursing school High patient-to-nurse ratios were a particularly dominant source of stress The need for speed - felt there should be more time to transition to carrying full responsibility for patient care You want too much - complaints about heavy workload, with little time to do it and little time to spend with patients How dare you - feeling mistreated by nurse and physician colleagues and management Change is on the horizon - despite the complaints, still felt hopeful
To est. brain death
Coma of known cause, norma/near core body temp, normal BP, at least 1 neuro exam
Effects of liver cell failure
Coma, retro hepaticus aka bad breath, spider nevi, gynecomastia, jaundice, ascities, loss of sex hair, testicular atrophy, liver flap aka coarse hand tremor, bleeding tendency due to decreased prothrombin, anemia/iron deficiency, ankle edema
Stage 4
Comatose: unresponsiveness leading to death, unarousable, obtunded, no response to pain, no esterixis, + babinski, muscle rigidity, femoral hepaticus aka musty sweet breath, seizures
What should RNs document
Communication Quality Improvement/Assurance and Risk Management Continuity of Care Establishes Professional Accountability Legal Reasons All Aspects of the Nursing Process As a general rule, any information that is clinically significant should be documented. Plan of Care Admission, Transfer, Transport and Discharge Information Client Education
Level 2 trauma center
Community hospitals that may not be able to meet resource needs of patients w/ complex injury
3-4 years you are
Competent
Five conflict handling intentions
Competing, collaborating, avoiding, acommadating/cooperative, compromising, smoothing
Stage 5 complete parkinsons
Complete ADL dependence
HF core mreasures
Component of the Joint Commission initiative Accreditation process Standardized Evidenced based measures Importance of measuring the processes and outcomes Developed by panels of clinical experts and key stakeholders
Micropressor ventilators
Computer managed positive pressure ventilator. Computer allos ongoing monitoring of ventilation, alarms, patient condititions. Ventilators more responsive w/ severe lung disease who need prolonged weaning.
Western blot
Confirms HIV when ELISA is + and detects serum antibodies to 4 specific major HIV antigens
CNS manifestations of AIDS
Confusion, dementia, headache, fever, visual changes, memory loss, personality changes, pain, seizures
Nursing assessment of HIV client
Continuous assessment of opportunistic infections: Fungal infections- Pneumocystis Carinii Pneumonia, Oral or Vaginal Candidiasis, Mycobacterium Avium Complex- Herpes Simplex Virus Varicella-zoster virus Malignancies-Kaposi's Sarcoma skin lesions or oral lesions, Hodgkins lymphoma, Burkett's lymphoma
QRS complex define
Contraction/depolarization of bundle of his/Q and ventricles/RS
Hypothalamus considered the
Control center
Functions of thyroid hormones: controls? Promotes? Regulates? Affects? Increased? Increase? Decreased? What antagonist?
Control metabolism, promote pituitary secretion of GH+gonadotropins, regulate protein/carb/fat, affects HR, increased RBC production, increase bone formation and decrease bone resorption of calcium. Insulin antagonist
Reducing metabolic demands for increased ICP
Controlling body temp via treating fevers and not allowing shivering
Mineralocorticoids controls? Aka and what it does? Stimulated via? Hypo?
Controls Na and K. Aldosterone maintains extracellular fluid volume promoting Na+H2O reabsorption and K excretion. Stimulated via renin-angiotensin release, raised K, ACTH. Hypo: hyperkalemia, hyponatremia, hypovolemia, acidosis
Skin manifestations of hypothyroidism
Cool pale or yellowish dry coarse scaly skin, thick/brittle nails, dry/coarse/brittle hair, decreased hair growth w/ loss of eyebrow hair, poor wound healing
Skin changes for hypovolemic shock
Cool, moist, pallor/cyanosis, mottled/gray or blue if light/darker if dark, slow cap refill
Integumentary s/s of shock
Cool/cold, pale/mottled/cyanotic, moist/clammy, mouth dry/pastelike
Cerebellum
Coordination/movement, equilibrium, overshooting target, predict distance/speed
Preop care for Cushings
Correct electrolyte/glucose imbalances. Cardiac monitoring. Decrease fall risk, high calorie/protein diet. Glucocorticoid preps given.
Hyperfunction of adrenal glands: Cortex? Medulla?
Cortex:Cushing's Disease Excess cortisol (glucocorticoid), hyperaldosteronism excess mincerlocorticoid, or excess androgens. Medulla: pheochromocytoma/tumor causes excess catecholamines epinephrine/norepinephrine
Hyperfunction of adrenal gland: Cortex? Medulla?
Cortex:Cushing's syndrome aka excess cortisol. Conn's syndrome aka excess aldosterone. Adrenal virilizing syndrome aka excess androgens. Medulla:Pheochromocytoma aka tumor.
AIDS respirator manifestations
Cough SOB
ARB example
Cozaar, diovan
Scorpion s/s
Cranial nerve and/or skeletal muscle involvement, pain, possible fever, hypertension, GI issues, tachycardia, cardiac dysfunction, pulmonary edema, paresthesia
Common disorders associated with arthritis
Crohn's, ulcerative colitis, TB, hemophilia, whipple's, intestinal bypass, hyperparathyroidism, hyperthyroidism, DM, sickle cell crisis, psoriasis, infection
Interleukin 1 IL-1
Cytokines that induces fever, stimulates prostaglandin, increases growth of CD4 T cells
Viral opportunistic infections
Cytomegalovirus in eye, respiratory/GI tract/CNS. Herpes simplex virus HSV in perirectal/oral/genital area. Varicella /shingles
Vasopressin aka ADH deficiency aka? S/s?
DI: increased UO, low specific gravity <1.005, hypovolemia, hypotension, dehydration, increased plasma osmolarity, increased thirst, output doesn't decrease when fluid intake decreased
Renal disease on immunity
Decreased neutrophils+immunoglobulin
Hepatic disease impact on immunity
Decreased neutrophils+phagocyt+immunoglobulin
Priority problems for hypothyroidism
Decreased oxygenation, hypotension, altered cognitive functioning, potential for myxedema coma which can cause respiratory failure
Hypoesthesia vs. hyperesthesia
Decreased sensation vs. increased sensation
Pulmonary diseases on immunity
Decreased ueutrophils
Advanced beginner characteristics
Demonstrates marginally acceptable performance, gaining experience w/ real situations to note meaningful patterns and attributes or have them pointed out by preceptor, can formulate guidelines for actions in terms of patterns and attributes, difficulty identifying important aspects, treat all attributes as equally important, can note recurrent meaningful situational comments but not prioritize between them
Depth markings? Tube cuff?
Depth markings show how far the tube has been inserted, (how many cm at teeth or lips) Tube cuff is inflated-minimal air can pass around cuff to the vocal cords, nose or mouth.
First aid/prehospital care for high altitude illnesses
Descend to lower altitude, if mild rest/acclimate, o2 admin
High altitude hospital care/treatment for HACE/HAPE
Descent, o2, dexamehasone/decadron for HACE. Phosphodiesterase/tdalafil/cialis. HAPE: sildenafil/viagra to prevent HAPE since vasodilation, o2, bedrest warmth, calcium channel blocker nifedipine/Procardia to decrease vascular resistance if.
Labs for HF primary goal
Determine and treat underlying cause
Chronic respiratory failure s/s
Develops over days or longer Slight changes in ABG's
Acute respiratory failure s/s
Develops rapidly, life threatening Change in ABG and acid/base balance
Dexamethasone suppression testing
Dexamethasone given and 24 hour urine collection follows if urinary corticosteroid excretion and cortisol levels suppresses Cushing's disease not present
S/s of cardiogenic shock
Diaphoresis Pale, cool skin Rapid respirations Rapid weak thready pulse Low BP (systolic < 90 mm Hg for 30 minutes) Confusion or loss of ability to concentrate Unresponsiveness
ARDS interventions
Drugs, fluids, nutrition, case management
Assessment of parkinson's
Dysarthria Tremor, rigidity, bradykinesia, & postural instability Excessive and uncontrolled sweating Paroxysmal flushing Orthostatic hypotension Gastric and urinary retention, constipation Sexual dysfunction Depression, dementia Sleep disturbances, hallucinations Personality changes Psychosis, dementia, & acute confusion
Obstructive shock s/s
Dyspnea Tachycardia Cyanosis Pleuritic pain Hemoptysis, Pulsus paradoxus >10 mm Hg decrease in systolic BP on inspiration Distant muffled heart sounds pericardial tamponade
The hallmark s/s for respiratory failure
Dyspnea aka difficulty breathing
Orthopnea
Dyspnea in recumbent/lying flat position. Check pillows when sleeping, paroxysmal nocturanal dyspnea
Respiratory failure s/s
Dyspnea, dyspnea on exertion/lying down, orthopnea aka easier to breath upright, RR or pattern change, change in lung sounds, hypoxemia s/s(pallor, cyanosis, increased HR, restlessness, confusion), hypercarbia, decreased O2 sat
Pulmonary findings of cirrhosis
Dyspnea, hydrothorax, hyperventilation, hypoxemia, orthopnea
To assess inflammation
ESR, c-reactive protein aka CRP
BP for shock
Elevate feed, keep head flat/elevated 30 degrees all to increase perfusion to brain
Pulmonary artery pressure PAP and pulmonary wedge pressure PAWP are
Elevated in left HF b/c volume and pressure is increased in left ventricle
Common risk factors for CAD
Elevated lips, tobacco, limited physical activity, hypertension, DM, obesity, excess alcohol, stress
Liver cancer dx
Elevated serum alpha-fetoprotein AFP, increased phosphatase, xray, CT, US, biopsy
Classifications of triage
Emergent, urgent, non urgent
If high pressure alarm sounds from patient anxious or fights ventilator
Emotional support, increase flow rate, explain procedures, sedate/paralyze as ordered
Psychosocial interventions for acromegaly
Encourage to express concerns about altered appearance, help indentify strengths, reassure that treatment may reverse some problems
Patho of endocrine system: endocrine glands? Hormones? There is no? Uses what to transport hormones to target tissues?
Endocrine glands secrete hormones Hormones exert their effects on specific tissues or target tissues There is no direct connection between the target tissues and the endocrine gland (Ductless glands). Uses the circulatory system to transport the hormones to the target tissues.
Parathyroid hormone function on GI
Enhances absorption of Ca and phosphorus from gut via activated vitamin D to increase serum Ca
Splenomegaly define? What does this cause?
Enlargement of the spleen as a result of the inability of the veins that drain the spleen to empty into a congested portal system from portal HTN. The enlarged spleen takes up and holds/destroys formed elements of the blood causing thrombocytopenia and anemia increasing bleeding risk.
6 second strip how many blocks?
Enough info to define rhythm, all test questions. 30 blocks
Hemorrhage after TBI
Epidural, subdural, intercerebral
Paracentesis interventions
Explain procedure, obtain VS/weight, void before procedure to prevent bladder injury, HOB elevated, measure/record drainage, decribe fluid, send fluid to lab for analysis, after removal apply dressing, maintain bedrest per protocol, weight after
Preop for hypophysectomy
Explained that body changes, organ enlargement, visual changes not reversibl, nasal packing present for 2-3 days after so will be necessary to breath via mouth, not to brush teeth/cough/sneeze/blow nose/bend forward after surgery since can increase ICP delaying healing or causing bleeding for up to 2 months
Cirrhosis definition
Extensive, irreversible scarring of liver
Acceleration vs. deceleration injury
External force contacting head putting head in motion vs. moving head suddenly stopped
Invasive temporary pacemaker define? Safety?
External generator and leads that are inserted. Safety: when not attached to generator insulate wire ends, all electrical equipment grounded, wear rubber gloves when touching wire to prevent static electricity
Causes of ventilatory failure
Extrapulmonary involving nonpulmonary tissues or intrapulmonary aka disorder of respiratory tract
Hemoglobin
F:12-16, M:14-18. Increased: fluid shift, dehydration. Decreased:hemorrhage
Hematocrit
Female 37-47%, M: 42-52%. Increased: fluid shift, dehydration. Decreased: hemorrhage
Acute hemolytic reaction s/s?
Fever, heat sensation, lumbar pain, chills, hypotension, bleeding, increased HR, chest pain, hemoglobinuria, hyperbilirubinemia
Manifestations of acute HIV infection
Fever, night sweats, chills, headache, muscle aches, rash, sore throat
Early s/s of sepsis
Fever, u/o less than intake, lightheadedness
Diastolic HF aka?
Filling problem. "Contracts but can't relax" Inadequate relaxation or "stiffening" LV cannot relax adequately during diastole
Most important question to ask for shock
Fluid i/o during past 24 hours. U/O reduced during first stages when fluid intake normal
Diuresis at risk
Fluid in peripheral tissue is mobilized and excreted and patient describes awakening at night to urinate
Acute and rehab phases: spinal shock intervention
Foley catheter insertion, NG tube insertion
Neutropenic precautions
For AIDS only:No fresh flowers in room, no fresh food, no one in the room that is sick.
CXR of HF?
For LHF, cardiomegaly, hypertrophy, vascular engorgement, pleural effusions
Beta adrenergic agonists/inotrope
For acute HF. aka dobutamine/dobutrex for short term acute HF. Improves contractility
Digoxin/lanoxin for? Do what?
For atrial fibrillation. Apical pulse taken
Azothioprine/imuran
For autoimmune hepatitis+RA by disrupting DNA/RNA synthesis resulting in decreased B+T cells
Calcitonin from? Function? Opposite of? Low Ca? Elevated Ca?
From thyroid and lower Ca and phosphorus by reducing bone resorption/breakdown. Opposite of parathyroid hormone. Low Ca suppress, elevated increase secretion
Stimulation of sympathetic nervous system w/ HF
From tissue hypoxia. 1st mechanism. Causes increase in HR/BP from vasoconstriction, resulting in immediate increase in CO/SV but then eventually goes dow causing pulmonary edema
Hypovolemic shock from hemorrhage cause or risk factor
From trauma, GI ulcer, surgery, inadequate clotting from hemophilia, liver disease, malnutrition, bone marrow suppression, cancer, anticoagulants
Hypovolemic shock from dehydration case/risk factors
From vomiting, diarrhea, heavy diaphoresis, diuretic therapy, NG suction, DI, hyperglycemia
Late signs of advanced cirrhosis aka end stage liver failure
GI bleeding, jaundice, ascites, spontaneous bruising
Antiviral for immunocompromised
Ganciclovir
5 foods to boost liver function
Garlic, lemons, broccoli, turmeric, organic protein
Nurse thyself
Get organized Breaks Avoid OVER TIME trap REST & RELAXATION Personal habits diet exercise BALANCE Enjoy your patients - Customer Service Keep a sense of humor - Laugh at yourself
TPA
Gets rid of all clots. So you cannot give anything else until it wears off
For epipen have patient
Give return demo
Prevent escalating violence
Give time, give attention, if someone has threat body language notify security ahead that they might get called, be calm, listen, be respectful, specify specific limits like 1013/1014, offer food/tv, admin meds if needed like ativan haldol g med
If tachycardic CO will
Go down since you don't have volume since no volume to fill
Hepatic encephalopathy goal? treatment?
Goal is to reduce ammonia load. Nonabsorbable disaccharides (carbohydrate):Lactulose- Also can be given as an enema. Nonabsorbable antibiotics : Neomycin (GI upset), Rifaximin (better tolerated) , Flagyl
Other manifestations of hyperthyroidism
Goiter+bruits over goiter, wide eyed/startled appearance aka exophthalmos, decreased WBC, enlarged spleen
BNP is used to
Golden standard. Dx HF part of body's response to decreased CO from ventricles having ^ pressure. amino acid secreted by the body as a natural response to help correct the sequela of a HF exacerbation. BNP causes the blood vessels to dilate resulting in increased cardiac output. Measures severity of HF
Sepsis patho
Gram positive/negative bacteremia Can also be virus or fungal Inflammatory response activated Release of macrophages and lymphocytes produce fever leukocytosis, hypotension, vasodilatation and myocardial depression
Electrocardiogram
Graphic representation of cardiac electrical activity
Best practice for immunocompromised
Hand Washing/Hand Rub for all patients/caregivers, No visitors with s/s of respiratory infections, Environmental interventions such as keeping windows closed+negative pressure rooms+HEPA filters. Contact Precautions for patients known to be colonized/infected w/ resistant organisms, Avoid fresh/dried flowers/plants, Avoid contact w/ animal feces, saliva, urine or litter boxes. Wear masks when moving/transporting to different areas in the hospital. Avoid uncooked meats, seafood, and eggs. Wash fruits and vegetables
joint commission guidelines to prevent infection
Hand cleaning Prevent infection of the blood from central lines Prevent infection after surgery Prevent infections of the urinary tract that are caused by catheters
Best ways to prevent infection
Hand hygiene >15 seconds, PPE, adequate staffing, disinfection/sterilization, patient placement/transport
Standard precautions define?
Hand hygiene, PPE:gloves for fluids/nonintact skin, gown, mask/eye/shield when splash possible like suction,
Prevention of injury for thrombocytopenia
Handle gently, avoid IM, use small needle, firm pressure q 10 min or no longer bleeds, ice areas of trauma, test urine/stool for blood, observe IV q 4 hours for bleeding, avoid enema/suppository, measure ab girth daily, electric shaver, soft toothbrush, don't blow nose, keep walkways clear
Preventing infection for Cushing's
Handwashing, anyone w/ upper respiratory tract infection must wear ask, continuous assessment, WBC check, inspect mouth/lungs/urine, skin care, pulmonary hygeine
Measures for prevent hep A
Handwashing, avoid contaminated food/water, immunoglobulin w/in 14 days if exposed to virus, HAV vax before traveling to Mexico/Caribbean, vax if living/working in enclosed areas
Tests for glucose
HcA1c glycosylated hemoglobin reveals average blood glucose over 2-3 months
Secondary survey
Head-to-Toe assessment Reassess all interventions
Sodium potassium pump responsible for
Heart contractions
Surgical management of HF
Heart transplantation, VADs/ventricular assistive device
What doesn't tolerate hypoxia and only a few minutes w/out O2 resulting in damage and cell death
Heart, brain, liver, pancreas
Skin manifestations of hyperthyroidism
Heat intolerance, Diaphroesis, fine/soft body hair, smooth/warm/moist skin, thinning of scalp hair
Sex hormone binding globulin function? So liver dysfunction can mean?
Helps body macrophage sex hormones. So liver dysfunction can mean too many sex hormones leading to gynecomastia and spider angiomas(classic sign)
Assessment findings from coagulation issues
Hematemesis Melena (black tarry stools) Can be spontaneous with no precipitating factors Decreased H&H, Increased ammonia level Confusion Ascites
Esophageal varices bleeding s/s can either be
Hematemesis aka vomiting blood or melena black tarry stools
SE of chemo
Hemorrhagic cystitis, cardiac muscle damage, loss of bone density, anemia, neutropenia aka decreased WBC, thrombocytopenia, n/v, hairloss/alopecia, mucositis, anxiety, sleep issues, change in cognition, bone marrow suppression, peripheral neuropathy
Most common cause of cirrhosis
Hep. C, alcoholism, biliary obstruction
Pulmonary embolus drugs
Heparin, fibrinolytics, lovenox
Immune system infection risk factors
Hepatic disease, malnutrition, pulmonary disease, radiation, renal disease, splenectomy, surgery, trauma
Felty's syndrome from RA
Hepatosplenomegaly and leukopenia occur
Hypercarbia
High arterial blood levels of CO2
Parkinsons diet
High calorie, soft dieat, thickened fluids, small frequent meals
Usual diet for cirrhosis if no encephalopathy
High carbs, moderate fat, high protein
What diuretics are most effective for treating fluid volume overload
High ceiling/loops like furosemide/lasix, torsemide/demadex, bumetanide/bumex
Factors that can lead to hepatic encephalopathy w/ cirrhosis
High protein diet, infections, hypovolemia, hypokalemia, constipation, GI bleeding, drugs like sedatives/diuretics
AF interventions
High risk for PE, antidysrhythmics, beta blockers, anticoagulants. Cardioversion, ablation, or pacing
Diffuse axon also injury
High speed acceleration/deceleration
Most common environmental factors causing heat related illness like heat exhaustion/heat stroke
High temp and high humidity
Preload higher blood volume? Lower blood volume?
Higher blood volume-higher CVP Lower blood volume-lower CVP
Sepsis community based care
Home care management Teaching for self-management Good handwashing Good hygiene Balance diet Rest and exercise Skin care Mouth care How to take temperature
Community based care for cardiomyopathy
Home care management Teaching for self-management Health care resources
Reality shock phases
Honeymoon, shock/rejection, recovery, resolution
Expected outcomes for hyperthyroidism
Hormone level return to normal Improved nutritional status Verbalizes understanding of lifelong treatment Effective coping measures
Expected outcomes for SIADH
Hormone level return to normal range Lab values return to normal (sodium, potassium, urine osmolality, urine specific gravity)
Laundry for HIV
Hot water, bleach, keep soiled clothes in plastic bag
Metabolic processes that can affect disability/neuro
Hypoglycemia, hypoxia, neuro injury, drugs
Physical assessment of hyperaldosteronism
Hypokalemia Hypertension Headache Fatigue Nocturia, stamina loss Muscle weakness Dehydration Polydipsia Polyuria Numbness and tingling Fluid and electrolyte imbalance
Sepsis= 2 or more SIRS criteria+known source of infection and one or more of the following clinical manifestations may also be present
Hypotension ↓U/O Positive fluid balance Decreased capillary refill BG > 120 (without DM) Unexplained change in mental status Rising serum creatinine (without kidney problems
Cardiac problems from ventilation
Hypotension if dehydrated or need high PIP: avpod valsalva maneuver fluid retention so monitor fluid I/O, weight, hydration, signs of hypovolemia
Neural-induced neurogenic distributive shock s/s? Greatest risk when?
Hypotension, bradycardia. Greatest risk in 1st 14 hours after injury
Indicators of hypovolemic shock
Hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool/clammy ski/, confusion
Hypofunction of thyroid: disorders?
Hypothyroidism: autoimmune thyroiditis aka hashimoto's disease, myxedema coma
Pulmonary manifestations of hypothyroidism
Hypoventilation, pleasurable effusion, dyspnea
A low CVP indicates
Hypovolemia
Warfarin education
INR, no high K, avoid herbs like ginger
If patient develops respiratory distress during mechanical ventilation
Imeediately remove ventilator and provide ventilation with bag valve mask to allow quick determination of whether problem is w/ ventilator or patient
Unstable dysrhythmia treatment
Immediate defibrillation, follow advanced cardiac life support, treat cause
Ventricular fibrillation treatment
Immediate defibrillation, then CPR, airway, epinephrine/vasopressin/amiodarone/lidocain/mag sulfate, oxygen, then defib, after stable treat cause
Spinal shock syndrome immediately? Complete? Not?
Immediately after injury, complete temporary loss of motor/sensory/reflex/autonomic function for <48 hours but function if cervical/high thoracic injuries comes back once resolved. Not abnormal for all this to be absent immediately after
If you suspect anaphylaxis
Immediately call rapid response tesam
Preventing further SCI after SCI
Immobilize fracture via fixation/traction/surgery, assess LOC/VS/pulse ox/pain
Multiple sclerosis define? Types?
Immune-mediated, progressive demyelinating disease of the CNS has remission and exacerbation. 4 types: releasing/remitting, primary, secondary, progressive/relapsing
RN dx priority
Impaired gas exchange, ineffective breathing pattern, risk for decrease CO
Parkinson's rn dx
Impaired verbal communication related to decreased speech volume, slowness of speech, inability to move facial muscles Impaired physical mobility related to muscle rigidity and motor weakness Imbalanced nutrition, less than body requirements, related to tremor, slowness in eating, difficulty in chewing and swallowing
Stages 2 of hepatic encephalopathy
Impending:Continuing mental changes, mental confusion Asterixis-hand flapping Disorientation to time, place, person
Stage 2 portal systemic hepatic encephalopathy
Impending:Mental confusion, disorientation to time/place/person, asterixis aka hand flapping
Anaphylaxis interventions
Important to get history of all allergens and discontinue Keep a list of all allergens, tell all healthcare providers Immediately assess respiratory status and airway Epinephrine and diphenhydramine (IV) Treat anxiety as patient will be anxious Teach automatic epinephrine injector Return demonstration/Epi-Pen Manifestations of allergic reaction and when to call health care provider D/C IV medications, keep fluids, change tubing
Purpose of mechanical ventilation
Improve gas exchange, decrease work needed for effective breathing until lungs adequate or acute episode has passed
Multiple sclerosis outcomes
Improves physical mobility Reports no injury Attains or maintains control of bladder and bowel patterns Participates in strategies to improve speech and swallowing Compensates for altered thought processes Demonstrates effective coping strategies Adheres to plan for home maintenance management
Reduced immunity and blood producing functions of cancer
Increased risk for infection, anemia, thrombocytopenia putting them at risk for bleeding
HIV malignancies
Increased risk for kaposi's sarcoma, lymphoma, cervical cancer, lung cancer, GI cancers, anal cancer
Immune manifestations of Cushing's
Increased risk of infection, decreased immune function, decreased WBCs+antibodies, decreased inflammator response, decreased cytokines+histamine+prostaglandins, manifestations of infection/inflammation may be masked
<35% EF
Increased risk of sudden cardiac death and life threatening arrhythmia
Causes of the high pressure alarm sound
Increased secretions or mucus plug in airway, coughs/gags/bites tube, anxious/fights ventilator, airway size decreases r/t wheeze/bronchospasm, pneumothorax, artificial airway displaced/tube in r. Mainstem bronchus, obstruction in tubing from lying on tube/water or kick in tube, increased PIP from sigh, decrease compliance from gradual trend up in PIP
Teaching for early s/s of shock
Increased thirst, decreased u/o, lightheadness, sense of apprehension
Cardiac transplant complications
Infection is primary complication Other Acute rejection (1st year) Malignancy (lymphoma) Coronary artery vasculopathy cause of death after first year
Acute spontaneous bacterial peritonitis SBP define? Identified how?
Infection of ascetic fluid resulting from bacteria. Identifies when positive ascetic fluid bacterial culture.
Complication for transphenoidal surgery for Acromegaly
Infection, bleeding, increased ICP, transient diabetes insipidus, increased chance of CSF leak/nose bleed(look for halo)
Systemic sclerosis s/s
Inflamed, fibrotic, sclerotic, edamtous, renal failure, myocardial fibrosis, raynaud's, pulmonary hypertension, esophagitis, ulcers, joint inflammation, myositis, fever, fatigue, anorexia, vasculitis, calcinosis, esophageal dysmotility, sclerodactyly of digits, telangiectasis aka spider hemangiomasm hand/arm symmetric pitting edema
Liver disease
Inflammation leads to the destruction of hepatocytes (liver cells).
Hepatitis definition? From what cuases? Results in?
Inflammation of liver. Viral most common but can also be from chemicals, drugs, herbs causing edema in liver's bile channels resulting in jaundice
3 decisions of immunity that make immunocompetence
Inflammation, antibody mediated immunity, cell mediated immunity
Hypersecretion of prolactin secreting tumors/adenoma causes what? Resulting in?
Inhibits gonadotropins and sex hormones resulting in galactorrhea/breast milk production, amenorrhea, infertility, hypogonadism aka loss of secondary sex characteristics, increased body fat
Antiretroviral therapy function? Multiple?
Inhibits viral replication. Multiple drugs used together aka highly active antiretroviral therapy HAART
Trauma define
Injury to living tissue.
Doutamine teaching
Instruct client or caregiver to report: Signs of worsening HF (shortness of breath, orthopnea, decreased exercise tolerance), Abdominal pain Nausea or vomiting Explain to patient the rationale for instituting this medication and the need for frequent monitoring. Chest pain Instruct client to notify nurse immediately of pain or discomfort at the site of administration.
Acute respiratory failure causes what
Insufficient oxygenation of the blood may lead to hypoxemia Hypoxia is inadequate oxygen to tissues
Cerebrum
Intelligence, creativity, memory. Right controls left, left controls right
MS cerebellar issues
Intention tremor during activity, dysmetria aka inability to direct/limit movement, dysdiadochokinesia aka inability to stop motor impulse, clumsiness
Stage 3 of conflict
Intentions: are decisions to act in given way intentions intervene betwee people's perception/emotions and their overt behavior
Drugs for Cushing's interferes w/? Names?
Interferes w/ ACTH or adrenals. Amino/elipten, metyrapone/metopirone affect cortisol, cyproheptadine/periactin for lowering ACTH
Multiple sclerosis disease modifying therapy
Interferon beta-1a Interferon beta-1b Glatiramer acetate Methylprednisolone Baclofen Imuran
Pheochromocytoma s/s
Intermittent hypertension w/ severe headaches, palpitations, diaphoresis, apprehension, impending doom, chest/ab pain w/ n/v, increased defecation
ICP monitoring devices
Intraventricular catheter, subarachnoid bolt/screw, subdural/epidural catheter or sensor, fiberoptic transducer tipped catheter
With ARDS usually patients require
Intubation
ARDS often needs
Intubation and conventional mechanical ventilation w/ positive end-expiratory pressure PEEP or continuous positive airway pressure CPAP
Radio frequency catheter ablation define?
Invasive to destroy irritable focus causing supraventricular or ventricular tachydysrthmia.
Lugol's solution: what containing? Definition? Admin when? Check for? Can be given w/? Used when?
Iodine containing, Saturated solution of potassium iodine. Admin 1 hr after thionamide, check for fever/rash/mouth sores/sore throat/gi distress since manifestation of iodism Can be given with orange juice or milk due to bitter metallic taste Used prior to thyroidectomy
Breathing across room assessment
Irregular breathing patterns-tachypnea, bradypnea, apnea Cyanosis or dusky skin tone Tripod position Retractions Use of accessory muscles Flaring of nares
CPP <50mmHg=
Irreversible neurological damage
Cirrhosis define? Develops how?
Irreversible scarring of liver usually from chronic reaction to necrosis. Develops slowly and has progressive prolonged course resulting in end stage liver disease and without transplant fatal
S/s of hypoxic respiratory failure
Irritability, restlessness, confusion & tachycardia
Airway assessment
Is airway patent? Clear of secretions/debrit C-spine immobilization C3, C4, C5 innervates the diaphragm Jaw-thrust, if needed to establish airway Intubation/O2 Masks
Too rapid correction of NA replacement
Is bad and can cause brain damage, pulmonary edema, or death/HF, must do it gradually
Jaw thrust chin lift for ?
Is suspected spine issue and need to see if patent airway
Hypertonic/isotopic IV fluids and ICP
Keeps CPP 60-70, SBP >90 and to maintain colloid osmotic pressure
Baclofen aka? Function
Kemstro. Helps muscle spasms
Black widow spider s/s
Latrodectism/neutransmitter release, ab pain, muscle rigidity, spasm, hypertension, n/v, facial edema, ptosis, diaphoresis, weakness, salivation, respiratory difficulty, fasciculations/twitching, parethesia
For continuous ECG leads are where and why
Leads on trunk to reduce motion artifact
Causes of right HF
Left HF, right ventricular MI, pulmonary hypertension
Diastolic HF
Left ventricle cannot relax during diastole preventing from filling to ensure CO causing less compliance
Pulmonary edema patho
Left ventricle fails and pressure rises causing fluid to leak across pulmonary capillaries into lungs
Important content for good documentation
Legible, complete, accurate, reflects nursing process
Who should document
Legislation and Standards of Practice of the profession require nurses to document the care they provide demonstrating accountability for their actions and decisions. First hand knowledge means the professional who is doing the recording is the same individual who provided the care. Students it is important that the RN record the care s/he provided in all relevant documents.
High alititude illness/disease/sickness
Less o2 available, hypoxia , increased RR leading to hypocapnia+resp. Alkalosis, REM impaired, excess HCO2 to increase RR/HR/BP/CO, erythropoietin leading to polycythemia
Teaching for hypothyroidism
Lifelong drugs, wear bracelet, periodic blood tests, no OTC drugs, adequate fiber diet but no supplement, take drug on empty stomach, if pt. Has more sleep and is consitpated dose may need to be increased or if difficulty sleeping and more bowel movements dose may need to decrease
Endoscopic therapies for esophageal varices
Ligation/banding w/ O bands on base of varices to decrease blood supply or sclerotherapy via injection
Neutropenic patient w/ infection
Limited manifestations, but consider any temp elevation in neutropenic as sign of infection
EF of 30% what meds to order
Linopril/zestril, digoxin/lanoxin, furosemide/lasix. Have to have diuretic, ACE, and ARB together
Jaundice: patho? Can cause?
Liver cells can not excrete bilirubin Fibrosis or scarring of the hepatic bile channels and ducts interferes with normal bile and bilirubin excretion Elevated serum bilirubin levels Can cause itching/pruritus
Labs for cirrhosis
Liver enzymes, total serum protein, albumin, PT/INR, platelet count, CBC, ammonia level, sodium, fecal occult blood, kidney function
Compensated vs. decompensated cirrhosis
Liver scarred but can perform essential functions w/out major symptoms vs. obvious manifestations
Infection path to sepsis
Local infection, then systemic infection/early sepsis, systemic inflammatory response syndrome, organ failure/severe, MODS/septic shock, then death
Remote vs. recall vs. immediate memory
Long term vs. recent vs. new
Splectomy on immunity
Loss of bacteria recognition
Nutrition therapy for fluids from cirrhosis
Low sodium diet aka 1-2g Na restriction. Read labels, table salt completely excluded, alternative flavoring via lemons etc. If late stage vitamin supplements like thiamine if alcoholic, folate etc.
Metabolism shock s/s
Low temp, thirst, acidosis, low urine output
iN ARDS the pulmonary capillary wedge pressure is
Low to normal vs. in cardiac induced pulmonary edema PCWP is >18
Kidney/urinary s/s of sepsis
Low u/o compared to intake. Kidney function decreases and creatinine increases
Labs of HIV
Low white blood cells counts CD4+ count CBC PPD Vital Signs Cough Nutritional Status GI Status
With PEEP it's important to
Lower FiO2 delivered whenever possible b/c prolonged use of high FiO2 can damage lungs from toxic effects of O2
Lasix and ICP
Lowers CSF production
Hyperventilation and increased ICP
Lowers PaCO2 causing vasoconstriction
Barbiturate coma and ICP
Lowers by lowering metabolic process/o2 consumption/CO2 production
Indications for mechnical ventilation
Maintain a patent airway, support and maintain gas exchange Reduce the work of breathing and reduce cardiac workload in heart failure Control the level of CO2 elimination & provide adequate ventilation and oxygen Serves as prophylaxis for patients at high risk of respiratory failure or an inability to breathe adequately
Until parameters other than a skin test come back negative for TB in patient w/ aids who also has TB s/s
Maintain airborne precautions
Planning for HIV
Maintain and Support Immune Function with Antiretrovirals Prophylactic and treatment of opportunistic infections
Interventions for Addisons
Maintain fluid balance to prevent dehydration via weight daily+I/O Monitor glucose levels Monitor electrolytes Hormone Replacement Therapy w/ cortisol/aldosterone or hydrocortisone for glucocorticoids or cortisol via prednisone
Purpose of intubation
Maintain patent airway, provide means to remove secretions, provide ventilation/oxygen
Goal in hypovolemic shock
Maintain tissue oxygenation, increase vascular volume to normal range, support compensatory mechanisms Lie flat with lower ext. elevated 12 inches (modified Trendelenburg) to facilitate venous return to central circulation
Management of transplant rejection: maintenance therapy
Maintenance therapy w/ continuous immunosuppression like cyclosporine+corticosteroids like prednisone
E exposure make sure
Make sure no issues and prepare for secondary survey
E of ABCDE if cold?
Makes them cold so make sure they are warmed back up via internal fluid warmers or external
Conditions predisposing to sepsis and septic shock
Malnutrition, immunosupression, large open wounds, mucus membrane fissures, GI ischemia, invasive procedures, malignancy, >80 y/o, infection, chemo, alcoholism, DM, chronic kidney disease, transplant, hepatitis, HIV/AIDs
For patient who has undergone liver transplantation monitor for
Manifestations of rejection like tachycardia, fever, RUQ/flank pain, decreased bile pigment, increased jaundice, elevated bilirubin/ALT/AST/phosphatase/PT/INR
TBI drugs
Mannitol diuretic for cerebral edema which lowers ICP, fever drug
Treatment of increased ICP
Mannitol, lasix, hypertonic/isotonic IV, steroids, anticonvulsants, hyperventilation, sedatives, barbiturate coma, coagulation, hypertensive therapy, hypotensive therapy
Altered GI structure and function of cancer
Many have anorexia, cachexia aka body wasting/malnutrition develops, diet high in protein and carbs for weight
To detect changes in tube position
Mark where the tube touches patient's teeth or nose
Monitoring for Graves
Measure apical, BP, temp q 4 hours. Repot any palpitations, dyspnea, vertigo, chest pain. Increase in temp can indicate thyroid storm
Sepsis resuscitation bundle
Measure lactate, blood cultures before antibiotics, broad spectrum, if hypotension or high lactate IV then vasopressor, if hypotension persists monitor CVP
Afterload measured w/? Lower the SVR the? Higher the SVR the?
Measured with a pulmonary artery catheter Lower the SVR the higher the CO Higher the SVR the lower the CO
HIV antibody tests measures?
Measures response to virus aka ELISA/western blot for antibodies
Interventions of hepatitis: what are the goals
Measures to rest liver, promote regeneration, prevent complications
History assessment for hypothyroidsm
Medication history- lithium, sodium or potassium perchlorate (blocks iodine uptake), amiodarone (damaging effects to thyroid) Fatigue, weakness Slowed mentation
Parasympathetic nerves
Medulla Vagus (10th cranial) Releases Acetylcholine Decreased heart rate Decreased contractility Heart can rest and conserve
Megace aka? Function?
Megesterol, Treatment of anorexia, weight loss, and cachexia associated with AIDS
TBI key features
Memory loss, headache, dizziness, seizure, loss of consciousness, sleepiness, restlessness, confusion, bruising, personality changes, diplopia, gait changes, pupil changes, bradycardia, papilledema, high BP, hypotension/tacycardia if hypovolemic shock, nuchal rigidty if CSF leak
Sepsis respiratory s/s
Metabolic acidosis, RR increases, ARDs can occur
S/s of coral snake
Mild pain, no swelling, difficult to find marks, n/v, headache, pallor, ab pain, paresthesias, numbness, altered LOC, flaccid paralysis, difficulty talking/swallowing/breathing
Eye/vision problems for grave's interventions
Mild s/s:elevate HOb at night+artificial tears. If photophobia dark glasses/eye patch. If cannot close eyelids tape lids at night. Possible short term steroid therapy for swelling like prenisone or diuretics for edema in eye
Adrenal cortex hormones
Mineralocorticoids aka aldosterone salt, androgens sex, glucocorticoids aka cortisol sugar.
Balloon tamponade for varices: definition? Placed how? Usually?
Minnesota/sengstaken-blakemore tube to control bleeding, but can cause aspiration/asphyxia/perforation. Tube placed through nose to stomach and balloon inflated to apply pressure to bleeding spot. Usually intubated w/ mechanical ventilation if they cannot do second endoscopy or TIPS
BNP 600-899
Moderate HF
Nutrition therapy for hepatic encephalopathy from cirrhosis
Moderate amount of protein, fat foods, simple carbs
When giving netrecor
Monitor BP and pulse because can lower BP. Can be asymptomatic. Give on separate IV line
Psychosocial assessment of cushing's
Mood changes Laughing or crying Irritability Confusion Depression Sleep disturbances
Urine tests for hormones accuracy? Procedure?
More accurate. Start by emptying bladder first and don't save. At end empty bladder and save. Make sure if needed preservative added first.
Shift to left define? Shows?
More baby band neutrophils than segment. Shows infection
As you get older you build up
More coronary arteries so MI they have more collateral to not loose o2 like younger people.
Ventricular dysrhythmias
More life threatening. Premature ventricular complexes, ventricular tachycardia, ventricular fibrillation, ventricular asystole
MI treatment
Morphine Oxygen Nitrates Aspirin Rest Angioplasty repair
Morphine MI
Morphine - Control patient pain and anxiety- decrease demand on heart
Management of acute MI
Morphine, O2, nitroglycerin, aspirin aka MONA. Transfer to facilities designated to intervene for MI
MI remember MONA
Morphine, oxygen, nitrates, aspirin
Dilated cardiomyopathy
Most common fibrosis of myocardium
End stage of sepsis and SIRS
Multiple organ failure evident uncontrolled bleeding occurs Death rate for patients in this stage exceeds 60% Manifestations resemble late stage of hypovolemic shock
Musculoskeletal manifestations of hypothyroidism
Muscle aches/pains, delayed contraction and relaxation of muscles
Musculoskeletal manifestations of Cushing's
Muscle atrophy most apparent in extremities, osteoporosis aka bone density loss which leads to fractures+decreased height+aseptic necrosis of femur+slow/poor healing of bone fractures
Long term complications for SCI
Muscle wasting, contractures, skin issues, heterotopic ossification causing decreased ROM and swelling/redness/warmth
Sudden stop in steroid therapy causes
Muscle weakness, Hypoglycemia, Fever, Malaise, N/v, Hypotension, dizziness
Conditions that affect nerves and muscles that control breathing and lead to respiratory failure
Muscular dystrophy, ALS, spinal cord injury
Pneumothorax treatment
Needle decompression, chest tube
Radial cardiac catheterization
Needs positive allens test, femoral is more restrictive
For lungs you want what pressure
Negative for the lungs to be expanded
Hyperthyroidism s/s?
Negative nitogen balance, hyperglycemia, decreased body fat, increased appetite
Hypotensive therapy and increased ICP
Neosynephrine, levophed, vasopressin
Lasix has what negative effect
Neprhotoxic
Human B type natriuretic peptide
Nesiritide/natrecor for acute HF. Causes nitruresis aka loss of Na in kidneys as well as vasodilation lowering pulmonary capillary wedge pressure PCWP and improves glomerular filtration.
Distributive shock cause/risk factors
Neural induced causing systemic vasodilation: pain, anesthesia, stress, SCI, head trauma. Chemical induced: anaphylaxis, sepsis, capillary leak from burns/trauma/liver issue/hypoproteinemia
2 types of distributive shock
Neural-induced distributive shock Chemical-induced distributive shock
Disability assessment
Neuro: AVPU: alert, responsive to voice, responsive to pain, unresponsive Level of consciousness? Glasgow Coma Scale (score 3-15) Eye opening Verbal response Motor response
Extrapulmonary causes of ventilatory failure
Neuromuscular disorders:MG, Guillain-barre, poliomyelitis. SCI, CNS dysfunction from stroke/^ ICP, meningitis, chemical depression, kyphoscoliosis, obesity, sleep apnea, external obstruction/constriction
Segs vs. bands
Neutrophils that are mature and capable of phagocytosis are segmented the higher the better protection from infection, neutrophils that are less mature are called bands
Hypertensive therapy and increased ICP
Nipride, nicardipine, labetalol, metoprolol
Bigeminy vs. trigeminy vs. quadrigeminy
Normal then premature vs. 2 normal then premature vs. 3 normal followed by premature
R. Atrial pressure in left HF
Normal/elevated and elevated in right HF
CSF lumbar puncture
Not for increased ICP
Heat exhaustion not? Define? S/s?
Not medical emergency. Syndrome resulting primarily from dehydration. S/s life flu w/ headache, weakness, n/v, orthostatic hypotension, tachycardia, confusion
Mr. Stella's has history of alcoholism and admitted w/ cirrhosis has average 24 hour UO of 1000mL and today had 486 mL UO in last 24 hours. Elevated BUN+creatinine and urine Na of 6, not orietented to place or time. WHat are priorities
Notifying primary care provider, preventing infection, monitoring for fever/chills/abpain which indicate infection and continued mental status monitoring. Indicates heptaorenal syndrome
First 2 years you are
Novice
Benner's novice to expert
Novice Advanced beginner Competent Proficient Expert
Documentation
Nursing documentation must provide an accurate and honest account of what and when events occurred, as well as identify who provided the care
Shock/rejection phase
Nursing is not what you expected Loss of balance between idealism and realism Ready to quit Anger, frustration, disappointment, negativism Excessive fatigue
Interventions that reduce preload
Nutrition therapy to decrease volume and pressure in left ventricle increasing muscle stretch and contraction. appropriate for HF accompanied by congestion with total body sodium and water overload.
Nursing implications for ascites? Low grade fever could be?
Nutrition therapy, low sodium diet Drug therapy-Lasix, Aldactone Paracentesis- Monitor vital signs Respiratory Support Monitor VS- Low grade fever could be a sign of peritonitis
Respiatory failure treatment: always consider
O2
respiratory changes for hypovolemic shock
O2 90-95% for nonpreogressive and 75-80% progressive stage >70% refractory stage. RR increases, once lactic acidosis pressure depth increases
Hospital care for drowning
O2 admin, intubation, cpr, defib, gastric decompression via NG tube to prevent aspiration,
FiO2 fraction inspired o2
O2 level delivered to patient(21-100%)
Substances that can pass blood brain barrier
O2, glucose, CO2, alcohol, anesthetics, water
Best motor response
Obeys 6, localizes 5, withdraws/flexion 4, abnormal flexion posturing 3, extension posturing 2, none 1
Pneumonia patho
Obstruction of bronchioles leading to low gas exchange and high exudate
The nurse is caring for a patient with a spinal cord injury. The patient is complaining of a headache rated 10/10. On assessment the nurse notices a BP=155/78, HR=52 and abdominal distention. The patient's sitter reports that the patient has not had a BM for 2 weeks.
Obtain an order for NG tube placement
Hep D from?
Occurs only w/ hep B. Blood to blood and sex
DIC
One of the most common complication of sepsis. Patient bleeds out. Too much clotting leads to too much bleeding. Clotting factors depleted so much bleeding
You may benefit from VAD if
One or both ventricles don't work well b/c of HF
Siadh vs. DI
Opposite high fluid and low UO w/ fluid volume excess/edema/high BP vs. low fluid high UO and fluid volume deficit+low BP
Expected outcomes for hypothyroidism
Optimal tissue perfusion and cardiac functioning BP and HR are within normal limits Verbalizes understanding of lifelong therapy Clear communication
Heat stroke complications
Organ dysfunction, renal impairment, electrolyte imbalance, coagulopathy, pulmonary edema, cerebral edema
Verbal response
Oriented 5, confused/disoriented 4, inappropriate words 3, incomprehensible sounds 2, none 1
Autonomic parkinsons s/s
Orthostatic hypotension, perspiration, seborrhea, flushing, blepharospasm eyelid spasm
Systemic s/s of RA
Osteoporosis, severe fatigue, anemia, weight loss, nodules, peripheral neuropathy, vasculitis, pericarditis, fibrotic lung, sjogren's syndrome aka dry eyes/mouth/vag, renal disease, felty's syndrome
Stage 5
Outcomes: conflict is constructive when it improves the quality of decisions and dysfunctional when uncontrolled opposition breeds discontent
Classic heat stroke
Over period of time as result of chronic exposure to hot humid environment
Anaphylaxis treatment
Oxygen Antihistamine such as diphenhydramine (Benadryl) Epinephrine Corticosteroids to reduce allergic response H2 blocker Medical alert bracelet Prevent cardiac/respiratory arrest due to anoxia Adequate airway/O2 if needed Monitor VS and levels of activity as indicators of oxygen saturation IV access Latex free
Med therapy for HF
Oxygen as necessary to keep O2 saturation at prescribed levels Diuretics (loop, thiazide, potassium sparing) ACE inhibitors (captopril, lisinopril, prinivil, zestril, accupril) ARB-(Diovan, Cozaar) Beta-Blockers (coreg, lopressor) Vasodilators (hydralazine, morphine) Human B-type natriuretic peptides
ACS/MI assessment
Pain onset, location, and duration Pain intensity, precipitating factors, relieving factors Patient History Vital Signs
Assessment findings of cirrhosis
Pain, fever, GI symptoms, fatigue
Compartment syndrome s/s
Pain, paresthesias, pallor, no pulse, weakness
Brown recluse bite s/s
Painless/stinging, pruritus, vesicle surrounded by edema, erythema, bluish purple, necrosis, eschar, red/white/blue, ulcer, possibly systemic w/ rash, fever, chills, n/v, malaise, joint pain, renal failure, pulmonary edema, hemolytic anemia, thrombocytopenia, DIC, death
Circulatory across room assessment
Pale or mottled skin tone Flushed Diaphoresis Obvious and uncontrolled bleeding
Hypoxemia s/s
Pallor, cyanosis, increased HR, restlessness, confusion
In resuscitation situation BP can quickly be estimated before cuff by
Palpating for presence of peripheral/central pulses. If radial present BP at least 80, if femoral present at least 70, if carotid present at least 60
Care w/ SVT: assessment
Palpitations Chest pain Weakness Fatigue Shortness of breath Nervousness Anxiety Hypotension syncope
Sustained s/s of sinus dysrhythmia
Palpitations, chest discomfort from myocardia ischemia, restlessness, anxiety, pale/cool skin, syncope from hypotension, SOB, weakness
Tachydysrthmia additional s/s
Palpitations, chest discomfort/pressure/pain, pale/cool skin, syncope from hypotension, heart failure causing dyspnea, crackles JVD, weakness. >100bpm
CV manifestations of hyperthyroidism
Palpitations, chest pain, increased BP, widened pulse pressure, tachycardia, dysrhythmia
Spinal cord injury s/s
Paralysis below level of injury. above C4 paralysis of respiratory muscles and quadriplegia(all 4).
Tetraplegia/quadriparesis vs. paraplegics/paraparesis
Paralysis in all fours, weakness frin cervial/upper thoracic vs. paralysis/weakness in lower extremities like in lower thoraci/lumbar injury
GI/GU if SCI
Paralytic ileus, lowered peristalsis, distention, areflexis/neurogenic bladder aka no bladder contraction causing urinate retention
Left sided HF s/s
Paroxysmal nocturnal dyspnea, elevated pulmonary capillary wedge pressure, pulmonary congestion(dry cough at night, crackles, wheezes, blood-tinged sputum, tachypnea), restless, confusion, orthopnea, tachycardia, exertional dyspnea, fatigue, cyanosis, gallup, pulmonary edema, pleural effusion, displaced apical pulse
Surgical treatment for hyperparathyroidism? Post op?
Partial para thyroidectomy to remove glands affected by tumor leaving the remaining glands intact. Total parathyroidectomy where all 4 glands are removed. Ca decreased preop. Postop Ca checked, also assessed for tingling/twitching/+ Trousseaus?/+Chvostek's which can indicate tetany
Transition to practive model from base to tip
Pass NCLEX, workforce orientation, transition modules including patient centered care/communication and teamwork/evidence based practice/quality improvement, informatics, orgoing institutional support, license renewal
Deep tendon reflexes
Patellar, brachioradialis, achilles, biceps, triceps, achilles tendon
Emergency care for thyroid storm/crisis
Patent airway, antithroids -azole/PTU, sodium iodide admin, propranolol given, glucocorticoids hydrocortisone/prednisone/dexamethasone , monitor for dysrhythmia/VS, cooling blanket/comfort, antipyretics, NS IV
Emergency care for myxedema coma
Patent airway, replace fluids w/ IV, levothyroxine IV, glucose IV, corticosteroids, check temp, monitor BP, cover w/ warm blankets, monitor for changes in mental status, turn q 2 hrs, aspiration precautions
Hypovolemic shock interventions at beginning
Patent airway, start/maintain IV, admin O2, elevate feet, head flat/elevated <30 degrees, examine for bleeding, if bleeding direct pressure, admin drugs, increase IV fluids, don't leave patient
Pathogenic vs opportunistic infection
Pathogenic infection caused via virulent organisms vs. infection caused by organisms present as part of normal environment
Patient safety examples
Patient Identification Fall Prevention Skin Integrity Medication Error Prevention Infection Prevention
Synchronous intermittent mandatory ventilation weaning method
Patient breaths between preset breaths/min, machine set to 12 breaths/min, RR of patient will be combo of patient and ventilator breaths, as weaning ensues gradual decrease in SIMV rate usually 1-2 breaths/min
Expected outcomes for ADH deficiency
Patient experiences normal fluid volume Absence of thirst, normal lab values, and stable weight Verbalizes understanding of Diabetes Insipidus and medication regime
T-piece technique weaning method
Patient teacher off ventilator for short periods 5-10 min to breath spontaneously, ventilator replaced w/ t-piece or CPAP, prescribed FiO2 may be higher on T-piece than on ventilator, weaning progressives, nighttime weaning not attempted until spontaneous breaths most of the day
More recently further specified as the quality and safety education for nursing (QSEN), competencies
Patient-centered care Teamwork and collaboration Quality improvement Safety Evidence-based practice (EBP) Informatics
Confidentialtiy: patients have? Healthcare professionals should? HIPAA?
Patients have a right to protection of their privacy with respect to the access, storage, retrieval and transmittal of their records . Healthcare professionals should view security of Patient's documentation as a serious issue. Health insurance portability and accountability act (HIPAA) is maintained at all times - no exceptions.
Combined ventilatory and oxygenation failure caused by
Patients w/ abnormal lungs like chronic bronchitis, emphysema, asthma attach. Cardiac failure w/ respiratory failure
ICP monitoring
Patients who have intracranial pressure need to be monitored closely to determine if cerebral perfusion is adequate Catheter is inserted
High pressure alarm sounds when
Peak inspiratory pressure reaches alarm limit(10-20 above patient's baseline PIP)
Surgical intervention for MI
Percutaneous Coronary stents to open Intervention Atherectomy Coronary Bypass Graft Surgery
Other manifestations of hypothyroidism
Periorbital edema, facial puffiness, nonpitting edema of hands/feet hoarseness, goiter, thick tongue, increased sensitivity to opioids, weakness/fatigue, decreased UO, anemia, easy bruising, iron deficiency, folate deficiency, vitamin B 12 deficiency
Neuro issues from HIV
Peripheral neuropathies, myopathies, reduced sensory, pain, gait changes leg weakness, ataxia, muscle pain
Surgical management of dysrhythmias
Permanent pacemaker, coronary artery bypass grafting, implantable cardioverter/defibrillator
Surgical management for life threatening dysrhythmia
Permanent pacing, coronary artery bypass grafting, aneurysmectomy, implantable vardioverter/defibrillator, open chest cardiac massage
PEEP used when
Persistent hypoxemia that doesn't improve w/ acceptable o2 delivery level. Or added when PaO2remains low w/ FiO2 50-70%
Autoimmunity define? Example? Cure?
Person develops inappropriate immune response against healthy normal cells. Ex: systemic lupus, polyarteritis, rheumatoid arthritis, rheumatic fever, type 1 DM. No cure just anti-inflammatory and immunosuppressive drugs
Cushing's syndrome s/s
Personality changes, mooon face, increased infection risk, males: gynecomastia, females:amenorrhea/hirsutism, fat deposits on face/back of shoulders, osteoporosis, hyperglycemia, CNS irritability, NA/fluid retention causing edema, thin extremities, GI distress from high acid, thin skin, purple striae, easy bruises/petechiae, poor wound healing
Adrenal medulla disorder
Pheochromocytoma
Ventilatory failure results from
Physical problem of lungs/chest, defect in respiatory control center in brain, poor function of respiatory muscles esp. diaphragm
Discharge determined by
Physician
Vagal maneuver done by
Physician
When a client dies
Physician is responsible for family notification Evaluate if it is safe/appropriate for a family member to be present during resuscitation Prepare body for viewing
ACCLIMATIZATION
Physiologic changes that help body adapt to less o2
2 families of poisonous snakes
Pit viper like rattlesnakes, copperheads, cottonmouths and coral snakes
Pit viper characteristics
Pit, triangular head, 2 fangs, 3 sets of replacement fangs
Cutaneous/superficial reflexes
Plantar flexion of all toes
Guillain-barre interventions
Plasmapheresis aka plasma exchange, immunoglobulin, ABC, mobility/immobility, manage pain, promote communication, psychosocial support, keep intubation stuff at bedside, skin care, PE prevention
Antineoplastics for immunocompromised
Platinum/cisplatin, methotrexate
Complications of HF
Pleural effusion Atrial fibrillation High risk fatal dysrhythmias (EF < 35% Renal insufficiency or failure Pulmonary edema
Protozoan opportunistic infections
Pneumocystis PCP causing dyspnea, tachypnea, dry cough, fever, fatigue, weight loss, crackles. Toxoplasmosis encephalitis from cats/undercooked meats causing changed LOC, headaches, fever, speech/gait/vision issues, seizures, lethargy, confusion. Cryptosporidiosis causing diarrhea
Pneumonia organisms
Pneumocystitis carinii pneumonia/PCP, mycobacterium MAC
Sepsis productive cough/yellow sputum+fever=?
Pneumonia
Artifact can be caused by
Poor electrical contact, loose electrode, patient movement or broken wire so always assess first to make sure it's artifact and not an actual lethal rhythm
Nutrition therapy for Cushing's
Possible fluid/Na restrictions like no salt added or 3-4g/day, teach to check labels and daily record for Na
Sinus bradycardia s/s
Possibly asymptomatic, syncope, dizziness/weakness, confusion, hypotension, diaphoresis, SOB, chest pain
Honeymoon phase
Post graduation Excited about being a nurse Idealistic Enthusiastic "Big things poppin'"
ADH deficiency patho
Posterior pituitary doesn't produce enough vasopressin aka ADH and causes diabetes insipidus
Cirrhosis types
Postnecrotic from hepatitis/drugs/toxins, laennec's/alcoholic, biliary aka cholestatic from chronic biliary obstruction/autoimmune disease
Stage 3 moderate Parkinson's
Postural instability, increased gait disturbance
Nursing priority for HIV client
Potential for Infection Inadequate oxygenation Pain Inadequate nutrition Impaired Skin Integrity Confusion
Stage 1 of conflict
Potential opposition/incompatibility: presence on conditions that create opportunities for conflict to develop
Determinants of contractility include
Preload and afterload Ventricular musculature Neural control Physiological depressants Drug therapy Electrolytes
Atrial dysrhythmia examples
Premature atrial complexes, supraventricular tachycardia,
Atrial dysrhythmias include? What wave affected
Premature atrial complexes, supraventricular tachycardia, atrial fibrillation. Altered P wave shape
If premature p wave
Premature atrial contraction
What are common heart rhythms w/ HF
Premature atrial contractions, premature ventricular contractions, atrial fibrillation
Apical and radial pulse irregularity can occur w/
Premature beats, AF, heart blocks
Ventricular dysrhymias
Premature ventricular complexes, ventricular tachycardia, ventricular fibrillation, ventricular asystole
Wide QRS and no T wave means? Won't?
Premature ventricular won't feel it on pulse but will see it on EKG
Immunosuppressants
Prenisone, cyclosporine
If glasgow <8 or risk for airway compromise
Prepare for intubation and mechanical ventilation
Inspiration is cycled in what major ways
Pressure cycled, time cycled, volume cycled
Peak airway inspiratory pressure PIP
Pressure used by ventilator to deliver set tidal volume at given lung compliance. Highest pressure reached during inspiration. Trends reflect changes in resistance of lungs and resistance in ventilator. Upper pressure limit set to prevent barotrauma which can sound alarm and prevent volume
HOB >30 degrees when supine to
Prevent aspiration and ventilator associated pneumonia
ACI inhibitors for Mi
Prevent development of HF
Physical assessment for endocrine: examine for?
Prominent forehead/jaw Round/puffy face Dull/flat expression Exophthalmos, Vitiligo, Striae, Hirsutism
Four broad aims of nursing practice identified in the definition of nursing:
Promote heath, prevent illness, restore health, to facilitate coping w/ disability/death
Turning and positioning does
Promotes comfort, prevents skin breakdown, improves gas exchange, prevents pneumonia and atelectasis
Lactulose/lactitol function? SE?
Promotes excretion of ammonia in stool, cleanses bowels, increases osmotic pressure to draw fluid into colon preventing ammonia absorption thus decreasing confusion/encephalopathy. SE: intestinal bloating/cramps, hypokalemia, dehydration, skin breakdown from stools, burping, n/v
Multiple sclerosis interventions
Promoting Physical Mobility Minimizing Spasticity and Contractures Activity and Rest Minimizing Effects of Immobility Preventing Injury Enhancing Bladder and Bowel Control Enhancing Communication and Managing Swallowing Difficulties Cognition and Emotional Responses Teaching Patients Self-Care
Bilateral equa breath sounds to ensure
Proper ET tube placement
Beta adreneric blockers examples? For?
Propranolol/inderal for supraventricular and ventricular premature beats and tachydysrthmias
Androgen therapy avoided in men w/
Prostate cancer
Structures important to HIV
Protease and reverse transcriptase. CD4 t lymphocyte receptors
Priority nursing interventions for patient w/ neutropenia
Protecting from infection, teaching how to reduce infection, total patient assessment including IV sites q 8 hours
Very cold water and drowning
Protective effect by reducing metabolic rate and diving reflex to asphyxia causing bradycardia, vasoconstriction to reduce o2 use and enhance blood flow
Bi-level positive airway pressure BiPAP
Provides positive pressure ventilation
Interventions for acromegaly
Psychosocial, meds, radiation for removal of hypophysis/pituitary gland, surgery via hypophysectomy
Interventions for LHF r/t MI
Pulmonary complications.
Obstructive shock caused by
Pulmonary embolism large blood clot blocks the pulmonary artery. Immobility Blunt chest trauma Tension pneumothorax History of clotting Cardiovascular disease Hypertension CAD-arterial plaque Large tumor Pericarditis
Obstructive shock risk factors
Pulmonary hypertension, cancer
Right sided HF in absence of left sided HF usually from
Pulmonary issues like COPD or pulmonary hypertension, ARDS
Education for pacemakers
Pulse 1 full minute same time each day and record in diary, take pulse if you feel pacemaker failure, inform other docs of pacemaker, don't lean over electric/gas motors, anti theft devices in stores can cause malfunction, inform airport before metal detector, stay away from welding equipment, safe to operate microwave oven unless old/defective. Notify if SOB, dizziness, fainting, chest pain, weight gain, prolonged hiccuping.
If apical pulse differs from radial
Pulse deficit suggests the heart not pumping adequately to perfume body
2nd stage of shock nonprogressive
Pulse ox on forehead/ear, cool/clammy skin
Dysrhytmia affects? Can be?
Pumps oxygenation of blood in body, perfusion/oxygenation, impairs organs+electrolytes. Can be life threatening
PERRLA
Pupils equal, round, react to light, accommodate to assess cranial nerve 3
Nutrition for varices
Puréed or soft diet, low protein high fiber
Pressure cycled ventilators
Push air into lungs until preset airway pressure reached. Tidal volumes+inspiratory time vary. Used for short time like post op or respiratory therapy. AKA Bi-Pap but can also expiratory pressure similar to PEEP
Volume cycled ventilators
Push air into lungs until preset volume delivered, constant tidal volume delivered regardless of pressure needed to deliver tidal volume. Set pressure limit prevents excessive pressure from being exerted on lungs. Advantage: constant tidal volume delivered regardless of changes in lung/chest wall compliance or in airway resistance
Time-cycled ventilators
Push air into the lungs until a preset time has elapsed. Tidal volume and pressure depends on needs of patient and type of ventilator
Sepsis flank pain+fever=?
Pyelonephritis
Thionamides: aka? Function? Response? PTU? Meth can cause? Both?
Pylthiouracil PTU and methimazole/Tapazole. Blocks thyroid hormone production by preventing iodine binging. Response delayed b/c patient may have amounts stored to continue to release. PTU can cause liver issues like jaundice/dark urine/clay stool, meth can caus ebirth defects. Both avoid crowds/ill b/c increased infection risk, check weight gain+slow HR+cold intolerance which can indicate hypothyroidism.
Premature ventricular complexes
QRS has repetitive rhythm but can be different shapes. Frequency increases w/ age. Can be from MI, heart failure, COPD, anemia, hypokalemia, hypomagnesemia, stress, nicotine, caffeine, alcohol, infection, surgery
Documentation: quality documentation is? It reflects?
Quality documentation is an integral part of professional RN practice. It reflects the application of nursing knowledge, skills and judgment, the clients' perspective and interdisciplinary communications.
First aid emergency care for bee/wasp
Quick removal of stinger, ice, ABC, determine if allergic and has EPI kit, then antihistamine
Nutrition therapy for cirrhosis
R/t vitamin and mineral deficiency 4-7 small meals/day, low sodium 12g/day, low ammonia Protein restriction 1.2-1.5g/kg is for patients with episodic hepatic encephalopathy who do not respond to standard treatment. Veg protein better, consider TPN/enteral
Assessment/planning of delegation is
RNs responsibility
For freezing gait and postural instability w/ parkinsons
ROM, stretching, remind to avoid concentration on feet when walkin, encourage participation in ADLs
Lowered CPP =?
Raised ICP+poor autoregulation
Increase in blood volume or CO
Raises MAP. Increase in vascular bed=lower MAP or small bed=higher MAP
Implantable cardioverter/defibrillator ICD for? Activated/deactivated via?
Random episodes of sustained ventricular tachycardia or ventricular fibrillation not caused by MI. Activated/deactivated via magnet
Respiratory shock s/s
Rapid breathing, shallow respiration
Hospital care for frostbite
Rapid rewarming via water bath, hot towels, IV opiates/rehydration, no dry heat/massage, elevate, splints, assess q hr for compartment syndrome, tetanus prophylaxis, loose sterile dressing, no compression, antibiotics, antiprostaglandin ibuprofen, possible debridement/amputation
Myexedma coma define? Decreased metabolism causes?
Rare serous complication of untreated/poorly treated hypothyroidism. Decreased metabolism causes heart muscle to become flabby resulting in low CO+decreased perfusion resulting in organ failure
Restrictive cardiomyopathy
Rare, characterized by stiff ventricles that prevent filling
Nonurgent examples
Rash, chronic headache, sprains/strains, colds, head injury but alert no vomitting and no altered LOC, simple fractures
Ventricular fibrillation rate? Rhythm? P wave? QRS?
Rate- indeterminate Rhythm- chaotic P wave- none QRS- none
Recovery phase
Realize there is more than one perspective within the nursing profession Begins to "see a light and the end of the tunnel" A renewed enthusiasm for nursing
For premature contractions
Really random usually so probably no long term effects
Physical assessment for SIADH
Recent head trauma Past and current medication use Weight gain GI disturbances - nausea, vomiting, poor appetite, Hyponatremia Serum level < 115 can cause changes in mental status
First aid/prehospital care for for frostbite
Recognize early for white/waxy appearance, seek shelter, body heat to warm via hands over area
Teach patient and caregiver to do what for which s/s that can indicate worsening/recurrent heart failure
Report imeediately s/s: rapid weight gain >3lb in a week, decrease in exercise tolerance, cold symptoms >3-5days, wakening to urinate at night, dyspnea/angina at rest or worsening, increased swelling in feet/ankles/hands
Rigidity define
Resistance to passive movement. Cogwheel rhythmic interruption of muscle, plastic mildly restrictive, lead pipe total resistance
Testing motor function for SCI for lumbar spine
Resistance when lifting legs, resistance when dorsiflexing feet
Patient w/ cervical SCI at risk for
Respiratory compromise b/c C3-5 innervation the diaphram
Ascites excess fluid volume can cause
Respiratory issues
Hypovolemic shock : resposne to
Response to acute volume loss depends on Extent of injury or insult Age General state of health
During acute hepatitis interventions
Rest periods, diet high in carbs/calories w/ moderate fat/protein, small/frequent meals, drugs used sparingly, if B or C antivirals given
Decreasing fatigue and weakness for HF
Rest, ambulate according to activity tolerance and increase
Dx of RA
Rheumatoid factor +, ANA +, elevated ESR
Paroxysmal supraventricular tachycardia
Rhythm intermittent from premature atrial complex
D-diner and c protein for sepsis
Rise
Preventing injury for hyperparathyroidism
Risk for fractures teach to handle carefully, use lift sheet to reposition, help w/ ambulation
Severe sepsis
S
ARDS intervention:assessment
S/E of PEEP=pneumothorax so assess lung sounds, suction, repositioning, prone
Cardiac conduction pathway
SA node fires, spreads through atria causing depolarization/P wave, AV node fires, spreads down AV bundle of his causing PR delay, purkinje fibers distribute through ventricles causing depolarization QRS
Cardiac conduction from
SA node, AV once, ventricular muscle cells
MAP formula
SBP+2(DBP)/3
Bromocriptine/parlodel SE? Give how? Notify if?
SE: orthostatic hypotension, GI irritation, nausea, heachaed, cramps, constipation/ Give w/ meal, treatment start low and gradually increased. Notify if chest pain, dizziness, watery nasal discharge because might be dysrhythmia, coronary artery spasm, or CSF leak
Pulmonary manifestations of hyperthyroidism
SOB w/ or w/out exertion, dyspnea, rapid/shallow respirations, decreased vital capacity
First aid/emergency care for drowning
Safe rescue first, spine stabilization if spine trauma risk, airway clearance, ventilators support, if hypothermia concern handle gently to prevent ventricular fib, ab/chest thrusts if airway obstruction
Restoring fluid volume balance for Cushing's
Safety, drugs, nutrition, monitoring, radiation, surgery
Obstructed cardiomyopathy
Same as nonobstructed except left ventricle outflow is obstructed
Beta blocker/digoxin therapy education
Same time of day to take, no antacids/cathartics/laxatives w/ dig, take pulse before and notify if change +fatigue/weakness/confusion/loss of apetite aka toxicity s/s for dig, report for lab tests
Antiretroviral for immunocompromised
Saquinavir, delavirdine
A client is brought to the ED by the family because he has verbally threatened others and attempted to stab the neighbor's dog. What does the nurse do in order to ensure the safety of the patient and others?
Search belongings and secure personal effects, remove dangerous equipment from room like sharps container or portable instrument, instruct nursing students to avoid wearing stethoscope around necks
If rebleeding occurs for esophageal varices
Second endoscopic procedure, balloon tamponade via minnesota/sengstaken-blakemore tube if they cannot do endoscopy or TIPS, esophageal stents, shunts
ARDS also can need
Sedation and paralysis for adequate ventilation and to reduce tissue needs
Left shift
Seg neutrophils are no longer the most numerous type of circulating neutrophil and instead bands are more numerous
MAOI-B example? Avoid?
Selegiline/Deprenyl. Avoid foods/drinks w/ tryamine in cheeses/smoked or aged or cured meats and sausage and wine /beer which can cause hypertension
Innate/natural/nonspecific immunity aka? Define? Types?
Self vs. nonself. 1st line defense like barriers/skin+biochemical barriers+mechanical barriers. 2nd line defense aka inflammation: inflammatory response to acuteacellular injury causing vasdilation aka redness/heat, increased permeability causing edema, cellular infiltration causing pus, thrombosis, pain, phagocytosis/cleanup, interferons, complement
Parietal lobe
Sensation, spatial, singing/instruments, processing visual experiences, perception of body parts/position
Severe sepsis
Sepsis and acute organ dysfunction Progression of sepsis with greater inflammatory response All tissues involved and hypoxic Microthrombi formation DIC Disseminated intravascular coagulation Often missed Looks better Rapid progression to Septic Shock
ARDS common causes
Shock, trauma, sepsis , pancreatitis, CABG, pulmonary infections , inhalation of toxic gases, pulmonary aspiration, multiple blood transfusions, near- drowning , burns
Treatment of esophageal varices
Short term esophagogastric ballooon tamponade, endoscopic variceal ligation, endoscopic sclerotherapy
Community acquired pneumonia
Shouldn't have been hospitalized w/in 14 days prior to s/s or has been hospitalized less than 4 days prior to onset of s/s
Bladder training education
Signs and symptoms of Urinary Tract Infection Adequate fluid intake Frequent bladder emptying Personal hygiene and cleanliness Skin creams and barrier ointments
Thyroid scan function? Procedure? IF hypersecretion? Ask?
Size, position, functioning of thyroid. Radioactive iodine given by mouth and up take by thyroid measured, if hypersecretion it's increased if normal it's 5-35%. Ask if procedures done w/ iodine die like renography before or drugs w/ iodine.
Preventing injury for Cushing's
Skin assessment/protection, turn q 2 hours, pad prominences, avoid activities w/ skin trauma, reduce tissue injury via soft toothbrush/electric razor, keep skin clean/dry, use lift sheet, call for help when ambulating, walkers/canes, gait belt, high calorie/calcium/vit D diet, no caffeine/alcohol, antacids, H2 receptors like tagamet or ranitidine/zantac, pepcid. No smoking/NSAIDS
Dx of acromegaly
Skull xray, CT scan, MRI
If ET tube moves it can
Slip into right mainstem bronchus
Neuro manifestations of hypothyroidism
Slowing of intellectual functions aka slowness/slurring of speech+impaired memory+inattentiveness, lethargy/somnolence, confusion, hearing loss, paresthesia, decreased tendon reflexes
Hypothermia complications
Slows drug metabolism, causes vasoconstriction that makes venous/arterial access more difficult, causes coagulopathies that increases bleeding risk
Airborne
Small particles enter host, suspended in air for long time. Ex: tuberculosis, varciella. Requires special ventilation systems, N95
Kaposi's sarcoma
Small purplish brown raised lesions not painful/itchy anywhere on body including membranes, lymph nodes, mouth/throat, lungs
Critical access hospitals
Small rural ED facility
Preventing CAD
Smoke, less fats/cholesterol/sodium, cholesterol checks, physical activity, manage DM, BP checks, prevent obesity
Mucositis define? Interferes w/? Interventions?
Sores in mucous membranes often developing in GI tract and mouth aka stomatitis from chemo/radiation. Interferes w/ eating, avoid alcohol mouthwashes, use good oral hygiene w/ soft brush, magic mouthwash
Temporal lobe
Sound, complicated memory, wernicke's area for processing words into thought
For pacemaker
Spike
Peripheral nervous system
Spinal nerves, cranial nerves, ANS
Eye opening
Spontaneous 4, to loud voice 3, to pain 2, none 1
Non rebreather best for? Bag valve mask best for? Endotracheal tube?
Spontaneous breathing. Ventilation assistance during resuscitation. Impaired consciousness and mechanical ventilation
Pneumonia dx
Sputum culture, CXR, ABGs
Ventricular tachycardia treatment if stable? If unstable?
Stable- Elective cardioversion Oral antiarrhythmics- Sotalol, Amiodarone Treat the cause Unstable VT w/out pulse: treat as VF
If not breathing do what
Start CPR then reassess and if still not breathing mechanical bag or if that doesn't work mechanical breathing
Performing glasgow start with?
Start with least noxious/pressure than advance. Normal voice then loud then shaking, then pain via supraorbital/trapezius/mandibular/sternal pressure
Surgical management of parkinsons
Stereotactic pallidotomy, thalamotomy via scar tissue to area to stop tremors. Deep brain stimulation where electrode connected to pacemaker.
Medical/surgical interventions that can impair normal immune response
Steroid therapy, chemo, antirejection drugs, catheters, trach tubes, synthetic implants, surgery, trauma, radiation therapy, burns, skin breakdown, adrenal insufficiency,infants
Testing for pituitary hypofunction
Stimulation testing via insulin injection and positive if GH+ACTH doesn't increase
Stimulation tests for hormones define? Ex?
Stimulation: stimulus provided to see if able to produce hormones normally and failure of hormone level to rise indicates hypofunction. Ex: insulin should result in GH and ACTH to rise but if it doesn't hypofunction
For anaphylactic shock priorities
Stop drug, Epi first via IM or SQ never IV for anaphylaxis if code situation IV, Benadryl/solumedrol, pepcid h2 blocker
Heat exhaustion interventions
Stop physical activity, cool place, cold packs, cool water, fanning, spraying water, remove clothing, oral rehydration, monitor VS, NS IV
Stage 3
Stuporous: mental confusion, stuporous/drowsy but arousable, abnormal ECG, muscle twitching, hyperreflexia, asterixis
Stage 3 of hepatic encephalopathy
Stuporous:Marked mental confusion Muscle twitching, hyperreflexia, Stuporous, drowsy but arousable
Patho of hepatic encephalopathy
Substances absorbed by intestines not broken down leading to elevated serum ammonia and GABA
Psychosocial assessment of cirrhosis
Subtle/obvious personality, cognitive, behavior changes possible, sleep pattern disturbances possible to emotional lability aka fluctuations in emotions
If high pressure alarm sounds from increased secretions or mucus plug in airway
Suction
Maintaining patent airway for trach/ET tube
Suctioning when these are present: secretions, increased peak airway/inspiratory pressure PIP, rhonchi/wheezes, decreased breath sounds. Also proper care of ET/trach tube
Acute HF
Sudden HF s/s
Exwertional heat stroke
Sudden onset from physical activity in hot condition
BNP 101-299
Suggest HF present
Blunt force more is? Penetrating is?
Superficial things like skin integrity vs. penetrating is more underlying structures
4th refractory/irreversible shock
Support patient , ventilator, pressors, epinephrine to keep HR up
Sudden cessation of long term glucocorticoid therapy leading to Addison's function? Must be?
Suppresses glucocorticoid production through negative feedback causing adrenal atrophy. Must be withdrawn gradually to allow pituitary production of ACTH and activation of adrenal to make cortisol
AV blocks define? 1st degree? 2nd degree? 3rd degree?
Supraventricular impulses delayed/blocked. 1st degree: sinuses impulse enventually reaches ventricle vs. 2nd some sinus impulses reach but others don't vs. complete and no impulses to ventricles. P wave there but QRS delayed/blocked
Pheochromocytoma interventions
Surgery, don't smoke drink caffeine, change position slowly, don't palpate abdomen, hydration, calm/restful environment, limit activity
Inteventions for liver cancer
Surgical resection and liver transplantation, radiation, hepatic artery embolization, ablation, chemo
Main trigger leading to hypovolemic shock
Sustained decrease in MAP of 5-10 below baseline resulting from decreased circulating blood volume, compensatory mechisms go into place and if MAP still decreased anaerobic increases lactic acid cause electrolyte/acid-base issues leading to MODS
Immunocompromised patient you may need to do what for IV
Switch sites more. Use ports under skin
Novice preceptor implications
Teach rule to guide action that can be recognized without situational experience, must be backed up by competent nurse
SIRS/systemic inflammatory response syndrome criteria
Temperature > 100.4 ° or < 96.8 ° F HR > 90 RR > 20 or PCO2 < 32 Abnormal WBC
Cushing's triad seen in?
Terminal stages of acute head injury and indicates imminent herniation and occlusion of cerebral blood flow
Testes hormones
Testosterone
Drug therapy for infection prevention
Tetanus toxoid given IM when admitted or tetanus immune globulin when history of tetanus immunization not known. Antibiotics
Systems that must be in place for perfusion
The "pump" (the heart) The pipes (the blood vessels) The fluid (the blood)
Ventricular tachycardia the arches?
The arches have a pattern
Reaching the best outcome w/ reality shock
The best outcome of reality shock is bicultural adaptation Blending of the value systems of school and work
Etiology of shock
The different types of shock can be traced back to one of the three components of the heart. The "pump" (the heart) The pipes (the blood vessels) The fluid (the blood)
Functions of endocrine system
The endocrine system controls overall body function and regulation, including: metabolism, temperature, fluid+electrolyte balance, growth, reproduction, elimination
The provider comes to examine Mr. Stellas and performs a paracentesis. The nurse is talking with family members who state that they are worried that Mr. Stellas is "not going to make it through this hospitalization." What types of nursing responses are appropriate?
The nurse should engage in active listening, therapeutic use of silence, exploration, and making clarifying statements. Rationale: The nurse should allow family members to express their feelings and provide a nonjudgmental acceptance of their concerns. Utilizing appropriate therapeutic communication techniques provides family members with a safe environment in which to express concerns and feelings
Ventilator tidal volume
The volume of air the patient receives with each breath (7-10 ml/kg)
Modes of ventilation
The way patient receives breaths from ventilator: assist control/AC, synchronized intermittent mandatory ventilation SIMV, bilevel positive airway pressure, other modes
Conditions causing increased cortisol secretion: exogenous admin aka Cushing's syndrome
Therapeutic use of ACTH or glucocorticoids most commonly for treatment of: asthma, autoimmune disorders, organ transplant, chemo, allergies, fibrosis
Low exhaled volume/ low pressure alarm sounds when
There is a disconnect or leak in ventilator circuit or a leak in the patient's aritifical airway cuff
Multiple sclerosis system management can cause?
These medications can cause depression and thoughts of suicide, photosensitivity, dizziness, constipation and change in blood count, and liver profile.
Shivering can indicate
They are being cooled too quickly
Left ventricular assist device
They have bags from tubes. Patients will be on blood thinners for whole life, they have to carry batteries. Last about 4 hours, cannot let them die. Make sure fam support. Ensure complicance, keep site clean
S/s of acromegaly
Thickened lips, scalp skin folding, voice deepening, fingertip tufting, kyphosis, backache, excess sweat Coarse facial features Increasing head size Lower jaw protrusion Enlarged hands and feet Joint pain, body pains due to growth Barrel Shaped Chest/breathing issues Hyperglycemia Sleep apnea Enlarged heart, lungs, and liver Broad rounded nose
Skin manifestations of Cushing's
Thinning skin or paper-like appearance especially on back of hands, striae, increased pigmentation w/ ACTH
Preventing acute adrenal insufficiency those most at risk? Low ACTH causes?
Those most at risk: Cushings from glucocorticoid therapy. Low ACTh causes adrenal atrophy and patient completely depends on drug and if drug stopped not enough glucocorticoids causing this which is life threatening
Drugs that improve SV for HF
Those that reduce afterloa, reduce preload, and improve cardiac muscle contractility
A. Fib can lead to
Thrombus formation leading to stroke or embolic events or PE or venous thromboembolism VTEfrom blood pooling
Central organs of immune system
Thymus, peyer's patches aka s. Intestine mucosa, bone marrow
Levothyroxine/synthroid definition? Started how?
Thyroid replacement. Started in low dose and gradually increased since can cause severe hypertension
Morning care develops SOB, fatigue, tachycardia what is interpretation? Interventions
Tired from activity, reduce morning care, cluster interventions, if doesn't resolve RRT/notify dr. If they do better you respiratory, physical therapy, nutritionist
Frostbite vs. frostnip
Tissue freezes and can be superficial, partial, full thickness vs. superficial injury that can cause pain, numbness, pallor but relieved by warmth w/ no tissue damage
Injury
Tissue injured but not necrotic
Ischemia
Tissue that is oxygen deprived
Mean arterial pressure function? Target number?
To maintain blood flow through coronary arteries >60, to maintain perfusion of organs 60-70
Vagal maneuver to treat? Includes? Can cause?
To treat supraventricular tachydysrthmia and includes carotid sinus massage can cause rebound tachycardia or severe bradycardia
Drugs for SIADH
Tolvaptan/samsca or conivaptan/vaprisol promoting water excretion w/out Na loss and should only be administered in hospital to monitor Na, diuretics if Na normal and no HF, hypertonic saline if Na low
Hospital care for brown recluse
Topical antiseptic, sterile dressing, antibiotics, possible debridement/skin graft, tetanus prophylaxis, hydration, is systemic blood transfusion
Hypovolemic shock
Total body fluid decreased decreasing MAP. From hemorrhage like surgery, trauma or from fluid loss like d/v, burns, dehydration. Both lead to low venous return/CO which leads to poor perfusion causing shock
Surgical management of hyperthyroidism
Total thyroidectomy to remove all and daily hormone treatment required to replace function. Partial thyroidectomy where may return to normal functioning
Normal serum Ca? Normal serum phosphate? If older?
Total: 9-10.5 mg/dl. 3-4.5 mg/dL but if older can be lower
Other hyperthyroidism types
Toxic multinodular goiter that is more mild an no exopthalmos/edema. Exogenous hyperthyroidism from excess thyroid replacement hormones
For ARDS/ respiratory failure transition to what diet upon removal from mechanical ventilation
Transition to a high-calorie and high protein diet upon removal from Mechanical Ventilation and improved respiratory/mental status
If med management fails to control ascites
Transjugular intrahepatic portal shunt TIPS used to control ascites and reduce variceal bleeding
Pain and temp
Transmitted by same nerves so if one intact the other can be assumed to be intact
Surgical management of acromegaly? Procedure?
Transsphenoidal Hypophysectomy - removal of the pituitary gland Entry through the sphenoid sinus in nose muscle Grady then taken from thigh and used to support and prevent CSF leak. Nasal packing then inserted Minimally invasive approach
Brain tissue expansion/pressure examples
Trauma to head, tumors, abscesses aneurysms, edema
Premature contraction treatment
Treat the cause Beta blockers Antiarrhythmics Teach education : Manage stress Avoid caffeine/ alcohol/ tobacco
Cardiogenic shock treatment
Treat underlying problem (MI, HF etc.) Fluid resuscitation is limited due to concern with fluid overload. Vasopressors are begun earlier than in other shock states Norepinephrine Vasopressin
Pre thyroidectomy treated with? What's controlled? Diet? Educate?
Treated with iodine therapy+antithyroids to decrease the thyroid size and vascularity. Hypertension, dysrhythmias, tachycardia must be controlled. Possible high protein+carb diet. Educate on supporting neck when coughing to reduce strain on suture, hoarseness may be present after
Mechanism of injury determines
Treatment and care
Surviving sepsis bundles treatment protocols
Treatment for first 3-6 hours 30ml/kg Respiratory support/ventilation Identify/remove source Central Venous Access IV fluids/vasopressors Lactic acid levels (3-23 mg/dl) you want it to drop after 3 hours Broad spectrum antibiotics
Nerve 5
Trigeminal sensation of face, scalp, mouth, nose
Nerve 4
Trochlear eye movement
Labs for MI
Troponin and creatinine kinase, myoglobin.
If abdomen distended
Tube in stomach and must be decompressed via NG tube
Hyperparathyroidism caused by
Tumor or renal disease. Loss of calcium from the bones to the serum Hypercalcemia Hypophosphatemia, vitamin D deficiency, kidney disease, carcinoma, neck trauma/radiation
Imaging for cirrhosis
Ultrasound is often the first assessment. Detects ascites, hepato-megally, spleenomegally, bile duct obstruction. An x-ray, CT scan or MRI may also be ordered.
High output HF is
Uncommon. Cardiac output remains normal or above normal Caused by increased metabolic needs Anemia Septicemia High fever Hyperthyroidism Hyperkinetic-unusually increased movement in muscle (spasms
Stage 1 initial Parkinson's
Unilateral limb involvement, minimal weakness, hand/arm trembling
Positive vs. negative deflections vs. isoelectric baseline
Up lines vs. down lines representing depolarization/repolarization. Line in middle when no current flow after depolarization/repolarization is isoelectric baseline
S/s of diabetes insipidus
Up to 20L urine/day, polyuria, dry skin/mucuouslow specific gravity 1.010-1.030, low osmolarity, hypovolemia, high thirst, tachycardia low BP, elevated NA, K decreased
Eyes of graves: eyelid retraction/lag vs. globe/eyeball lag? Ask patient to?
Upper eyelid fails to descend when patient gazes downward vs. upper eyelid pulls back faster than the eyeball when patient gazes up. Ask pt. To look down then up
10-year-old girl with vomiting, diarrhea, and abdominal pain onset 4 hours after eating fish.
Urgent
56-year old man with severe unilateral back pan and previous history of kidney stones.
Urgent
Proficient preceptor implications
Use complex case studies for learning, good preceptor for competent nurse
For skin irritation and pruritus associated w/ jaundice from cirrhosis
Use cool rather than warm water on skin, don't use excessive soap, Use lotion to soothe skin, assess for open skin areas from scratching
If TBI personality/behavior problems
Use structured consisten environment
High levels of androgens usually in? S/s?
Usually in cushing's causes acne, hirsutism aka increased hair, and clitoral hypertrophy, decreases estrogen and progesterone, oligomenorrhea aka scant/infrequent menses can occur
For patients w/ diastolic HF drug therapy
Usually not effective
Interventions for hyperthyroidism/graves
VS, monitor weight, rest periods, calm environment, comfort measures, cool temps/water, high calor/protein diet, small frequent feedings if hypermotility present
Hospital care for black widow
VS, opioids, muscle relaxant diazepam/valium, tetanus prophylaxis, possible antihypertensives, antivenom
Spider angioma define? AKA?
Vascular lesion w/ red center+radiating branches on nose, cheeks, upper thorax, shoulders in cirrhosis. AKA telangiectases
Catecholamine norepinephrine effects on Blood vessels? GI? Bladder? Skin? Liver? Pancreas? Eyes?
Vasoconstriction. Increased sphincter tone, sphincter contractions. Increased sweating. Increased gluconeogenesis and glycogenolysis. Decreased glucagon and insulin release. Dilation of pupils
Vasopressors do what
Vasoconstricts
Drugs that reduce afterload to improve SV for HF
Vasodilator: ACE inhibitor, ARBs, human B-type natriuretic peptide
Posterior pituitary hormones
Vasopressin aka ADH, oxytocin
Blood through heart
Vena cava, right atrium, tricuspid right ventricle, pulmonic valve, pulmonic arter, pulmonic vein, left atrium. Mitral valve, left ventricle, aortic valve, aorta
Nitrates
Venous vasodilator for persistent dyspnea. Benefits by returning venous vasculature capacity, decreases volume of blood return to heart, improves left ventricle function
If cause of ventilator alarm cannot be determined
Ventilate manually w/ resuscitation bad until problem corect by another healthcare pro
T
Ventricular repolarization
Sudden death very important to say?
Very important to say patient died, no passed away/expired, say they died
Dig toxicity s/s
Very irregular heart rate Vomiting Dizziness Vision changes (blurred vision or yellow, green or white halo) Confusion
Nerve 8
Vestibulocochlear hearing, equilibrium
Subacute/granulomatous thyroiditis caused how? S/s?
Viral after cold or upper respiratory infection. S/s: fever, chills, dysphagia, muscle/joint pain that can radiate to ears/jaw, hard enlarged thyroid
Esophagogastroduodenoscopy
Visualize upper GI to detect varices
What is most common ventilator
Volume cycled ventilator, Phsyician prescribes rsettings
Gonadotropin LH+FSH deficiency for women? Men?Both?
W: amenorrhea, anovulation, low estrogen, breast atrophy, loss of bone density, decreased pubic/axillary hair, decreased libido, dyspareunia/painful intercourse. M: decreased facial hair, decreased ejaculate volume, reduced muscle mass, loss of bone density, decreased body hair, decreased libido, impotence. Both: secondary sex characteristics
Minor head injury education
Wake q 3-4 hours for first 2 days if sleeping, expect headache/n/dizziness for @ least 24 hours, tylenol for headache, no sedatives/alcohol/sleeping for at least 24 hours, no strenuous activity for at least 48 hours, no nose blowing/ear cleaning for 48 hours. Take back to ED for: blurred vision, drainage from ear/nose, weakness, slurred speech, progressive sleepiness, vomiting, worsening headache, unequal pupil size
Systolic HF/systolic ventricular dysfunction
When heart cannot contract enough during systole to eject enough blood into circulation leading to decreased perfusion and blood to accumulate in pulmonary vessels leading to congestion. CO decreased
Suppression tests for hormones define? Ex?
When hormone levels high. Failure of suppression of hormone production indicates hyperfunction. Ex: glucose should suppress GH
ET tube cuff
When inflated cannot talk
Hand hygiene when?
When soiled, before direct contact, before sterile gloves, after intact skin contact/body fluids, after removing gloves, after contact w/ inanimate objects in contact w/ patient
Liver trauma? Observe for?
When upper abdominal or lower chest trauma sustained. Observe for hypovolemic shock, RUQ pain, distention/rigidity, guarding
Disposition define? Depends on?
Where client goes next like discharge home, observation, inpatient, transfer, rehab etc. Depends on extent of injury and situation
Sepsis define
Widespread infection that triggers a whole body inflammatory response Infection enters bloodstream If not treated, cell death will occur and patient will die
Loop /high ceiling diuretics continue to
Work even after excess fluid is removed and as result some can become dehydrated so assess for s/s like confusion, decreased U/O, dizziness
ET tube placement verified via
Xray and checking end tidal CO2 levels are most accurate. Assessing for breath sounds, symmetric chest rise until verified and air emerging from tube
Productive cough of pneumonia
Yellow, bloodstreaked, rusty sputum= infection
Does caregiver have appropriate knowledge, skills, abilities to accept delegation? Are there organizational policies/procedures in place for task, is RN supervision available?
Yes delegate, no don't delegate
Delegation: has there been asssessment of the patient's needs by RN?
Yes go on, no: assess needs and procee to consideration of delegation
Is task w/in delegating RN SOP? Are statues/regulations in place supporting delegation? Does organization permit delegation? Is delegating RN competent to delegate? Is task w/in rang of function? Frequently refunds? Is perfomed according to steps? Involves little/no modification ? May be performed w/ predictable outcomes?doesn't inherently involve ongoing assessment/decision making? Does not endanger healthcare?
Yes keep going, no: don't delegate
Clinical reasoning
ability to reason as a clinical situation changes, taking into account the context and concerns of the patient and family
ACS- MI occurs when the tissue of heart is
abruptly or severely deprived of oxygen
All members of healthcare team require
accurate information about clients to ensure the development of an organized comprehensive care plan.
ARBS-ACE inhibitors
act by preventing the formation of angiotensin II rather than by blocking the binding of angiotensin II to on blood vessels. Angiotensin II is a very potent chemical that causes muscles surrounding blood vessels to contract, thereby narrowing blood vessels-increasing BP Block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on blood vessels Blocks the binding of angiotensin II receptors on blood vessels Blood vessels enlarge (dilate) and blood pressure is reduced Reduced blood pressure makes it easier for the heart to pump blood and can improve heart failure. Persistent cough, elevated K+
Systemic sclerosis aka? Define? S/s?
aka scleroderma chronic inflammatory autoimmune connective tissue disease. Hardening of skin
Hepatic encephalopathy late signs? It may be?
altered LOC, impaired thinking and neuromuscular problems It may be acute and reversible it treated early
Methimazole/Tapazole aka? Avoid? Monitor?
antithyroid medication Avoid in pregnant women Avoid large crowds (decrease in WBC's) Monitor heart rate, weight gain, and cold intolerance (signs of hypothyroidism)
Good test to evaluate whether documentation is satisfactory
ask the following question: "If another RN had to step in and take over this assignment, does the record provide sufficient information for the seamless delivery of safe, competent and ethical care?"
As cirrhosis develops the tissue? These do what?
becomes nodular. These nodules block bile ducts and normal blood flow thru the liver
The risk of inaccurate/incomplete documentation is
care that is fragmented, tasks that are repeated and therapies which could be delayed or omitted
Cardiac catheterization
catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. Through the catheter, your doctor can do diagnostic tests and treatments on your heart. Gets xray to see blood flow/blocks aka coronary angiography
AIDS dementia complex causes?
causes cognitive , motor, behavioral impairment rangng from barely noticeable to severe dementia
Chronic HF results in
changes to the ventricular size, shape, and dimension. This process is called ventricular remodeling.
S/s of tension pneumothorax
decreased or absent breath sounds on affected side respiratory distress hypotension JVD Uneven chest movements Tracheal deviation (late)
Treatment for respiratory failure
depends on whether the condition is acute (short-term) or chronic (ongoing) and its severity. O2 and treating underlying cause
Implantable cardioverter defibrillator ICD
device that's placed in the chest or abdomen. Doctors use the device to help treat irregular heartbeats called arrhythmias An ICD uses electrical pulses or shocks to help control life-threatening arrhythmias, especially those that can cause sudden cardiac arrest (SCA).
The result of acute respiratory failure: either? PaO2? PaCO2? Ph? These can?
either a low oxygen level and/or a high carbon dioxide level in the blood. PaO2/ partial pressure of arterial oxygen <60mmHg PaCO2/ partial pressure arterial carbon dioxide >45mmHg Acidosis pH <7.35 These can occur at the same time.
VAD can help which stages of HF
end stage, earlier stage
To meet aims the nurse uses
four blended competencies; Cognitive, Technical, Interpersonal, and Ethical/legal.
When ventricular remodeling occurs from chronic HD
heart tries to compensate for the fall in stroke volume by dilating the ventricular chamber to increase intraventricular volume. The increase in volume does initially increase cardiac output, but at the cost of increasing ventricular filling pressures and wall stress, which leads to further remodeling and worsening heart failure. (Hypertrophy)
Hypofunction of adrenal gland s/s? Aka? From? If acute?
hyperkalemia, hyponatremia, hypovolemia, acidosis. Addison's disease aka insufficient cortisol or aldosterone. From inadequate ACTH, hypothalamus/pituitary issues, or adrena issue. If acute adrenal crisis and life threatening
CV manifestations of DI
hypotension, decreased pulse pressure, tachycardia, weak peripheral pulses, hemoconcentration aka increased hemoglobin/hematocrit/BUN
PEEP positive end expiratory pressure
is positive pressure exerted during expiration. PEEP improves oxygenation by preventing alveoli from collapsing. This promotes gas exchange and prevents atelectasis. It is used to treat hypoxemia. (5-15 cm H2O
One of main goals of treating respiratory failure
is to get oxygen to your lungs and other organs and remove carbon dioxide from your body
Anabolic effects of insulin: liver? muscle? Fat?
liver: promotes glycogen synthesis/storage, inhibits glycogenolysis/gluconeogenesis/ketogenesis, increases triglycerides. Muscle: promotes protein and glycogenesis. Fat: increases fat synthesis, promotes triglyceride storage, decreases lipolysis
When stridor, dypsnea, or other s/s of obstruction appear after thyroid surgery
notify rapid response
ACS unstable angina
occurs with increase physical activity or exertion, resolved with rest
PH compensated? Uncompensated?
pH 7.35-7.45-Compensated pH < 7.35 -Uncompensated pH > 7.45 -Uncompensated
Hypovolemic shock ABGs
pH ↓decrease tissue oxygenation→ acidosis pO2 ↓ anaerobic metabolism pCO2 ↑
Earliest manifestation of shock
raised HR, use changes in pulse as main indicator of shock and progression. Change in mental status/behavior can also be early s/s
Corticosteroids for ARDS: name? Function? Effectiveness?
solumedrol/prednisone Reduce inflammation, Stabilize capillary membranes, Decrease WBC movement Effectiveness has not been proven
The guidelines of documentation will
support RN's to contribute to the development of agency policy and promote evidence-informed practice, which enables RNs to meet the Standards of Practice for Registered Nurses every day in client care
Clear, complete and accurate documentation in a health record ensures
that all those involved in a client's care, including the client, have access to information upon which to plan and evaluate their interventions.
Perfusion defined
the act of pouring over or through, especially the passage of a fluid through the vessels of a specific organ.
If supplemental o2 doesn't maintain adequate o2
then consider mechanical ventilation, either invasive or non-invasive. Consider positive pressure ventilation CPAP or BiPaP ventilation
Liver biopsy
to obtain a tissue sample to assess pathology. Increased risk due to bleeding risk.
When blood vessels dilate
total blood volume remains the same Blood pressure decreases Blood flow slower
How to eat for ARDS/failure
•Eat while sitting upright •Use pursed-lip breathing •Liquids may be easier to consume. •Limit empty calorie foods •Accept meal prep help, MOW, freeze extra portions, rest before eating
Treatment of hypovolemic shock
Keep patient warm to avoid hypothermia Apply direct pressure to sites of obvious bleeding Start one or two large-bore intravenous access for fluid and blood replacement Always start IV fluids before administering medications (vasoconstrictors) dopamine (Epinephrine) norepinephrine (Levophed) Immobilize any obvious fractures Get a good history
Adrenal glands location
Kidneys
Normal creatinine
Know
A. Fib
Know difference between that and artifact
Preventing dysrhytmia for those at risk for potassium imbalance
Know s/s of decreased K like weakness/cardiac irregularity, eat K like tomatoes/beans/prunes/avocados/bananas/strawberries/lettuce, take K supplements
Airborne precautions define? Equipment? Ex?
Known/suspected from infection suspended in air for prolonged periods. Negative airflow used, private room, n95, transport wearing mask. Ex:tuberculosis, measles/rubeola, varicella
Neuro for TBI
LOC most important and early sign is behavior change, PERLLA, cranial nerves, glasgow, motor, posture, ears/nose for CSF leaks, nuchal rigidity aka stiff neck, hyperventilate if suctioning
Psychosocial parkinsons s/s
Labile, depressed, paranoid, upset easily, mood swings, cognitive impairment, dementia, delayed reaction, sleep issues
Labs for ARDS/respiratory failure
Laboratory indices: Sodium levels 135-145 Hypernatremia may indicate fluid deficiency; hyponatremia may indicate fluid overload. BUN/creatinine ratio: Elevated BUN may indicate fluid deficiency
Dx of Graves
Labs T3, T4 are increased, TRH stimulation test w/ no response, TSH low EKG -assess cardiac status Ultrasound, thyroid scan (size, position, and functioning of the thyroid gland)
Best for assessing for bleeding**
Labs for liver clotting factors:PT, PTT, INR
Drug therapy for hepatic encephalopathy from cirrhosis
Lactulose, lactitol, nonabsorbably antibotics, thiamine supplement+benzos if alcohol withdraw
Types of cirrhosis
Laennec's alcohol induced, Postnecrotic viral hepatitis/drugs, Biliary chronic biliary obstruction and infection
Decerebrate/decorticate posturing as well as pinpoint/dilated and nonreactive pupils is
Late mental deterioration sign so notify immediately
Cushing's triad
Late sign of increased ICP: severe hypertension, widened pulse pressure, bradycardia
HF -2
Left ventricular function assessment (LVF < 40%)
Lemon glycerin swabs
Lemon swabs as well as mouthwashes/swabs with alcohol base to them are contraindicated in care of compromised patients. They serve to dry out the mucosal membranes. In many patients, they contribute to mucositis. Swabs in ice water can be as refreshing as lemon based ones. Cancer patients typically rinse with NS (ocasionally with Baking Soda if needed to buffer it).
Patients who are less than alert are
Lethargic aka drowsy/sleepy but easily awakened, stuporous if aroused only via vigorous/painful stimuli, or comatose if cannot be aroused/unconscious
Rapid neuro assessment
Level of consciousness, orientation movement of arms/legs, pupil size/reaction to light
How to measure ab girth
Lie flat while RN pulls tape around largest diameter usually over umbilicus of abdomen. Girth measured at end of exhalation, mark the skin to ensure same placement on subsequent readings
Ventricular fibrillation assessment
Life threatening Immediate loss of consciousness Pulseless Seizures Apneic No BP or heart sounds Pupils fixed and dilated Skin cold and mottled Death will result without immediate intervention
Hypercalcemic crisis is what? Ca level? Interventions?
Life threatening Calcium level > 15mg/dl (level greater than 12 can lead to psychosis, coma and death) Calcitonin, IVF, Phospate therapy, Observe for signs of hypocalcemia
Insufficient adrenocortical steroids causes
Loss of aldosterone and cortisol decreasing gluconeogenesis, hypoglycemia, reduced urea nitrogen excretion causing anorexia/weight loss
Distributive shock cause
Loss of sympathetic tone Loss of vascular tone Pooling of blood in venous and capillary beds Capillary leak
Clinical manifestations of HIV
Low CD4+ count, Opportunistic Infections, Lymphadenopathy, Fatigue, Dry Skin, Poor Wound Healing, Skin lesions, Night Sweats, Cough, SOB, Diarrhea, Weight Loss, N/V, Diarrhea, Change in Mental Status, Fungal/bacterial/viral infections, Cancer
Diagnosis ARDS
Low PaO2 via ABG, sputum culture via bronchoscopy/transtracheal aspiration, chest xray for whited out ground glass appearance of lung, ECG ruling out cardiac issues, hemodynamic monitoring w/ pulmonary artery catheter.
Causes of oxygenation failure
Low atmospheric o2:altitudes, closed spaces, smoke inhalation, carbon monoxide poisoning, pneumonia congestive HF w/ PE, PE, ARDS, interstitial pneumonitis-fibrosis, abnormal hemoglobin, hypovolemic shock, hypoventilation, nitroprusside therapy:thyocyanate toxicity, methemoglobinemia
Examples of positive/negative feedback control via hypothalamus
Low cortisol from adrenal cortex stimulates secretion of corticotropic releasing hormone from hypothalamus which stimulates anterior pituitary to secrete ACTH that then triggers release of cortisol from adrenal cortex and rising cortisol inhibits CRH release from hypothalamus
Dx of Addisons: cortisol? BG? Na? K? BUN? ACTH? Other labs?
Low cortisol levels Low fasting blood glucose Low sodium Increased potassium Increased BUN Adenocorticotropic hormone (ACTH) stimulation test most definitive via ACTH given and in primary cortisol absent/decreased or secondary it's increased Imaging MRI, CT scan pituitary gland or adrenal gland hypertropy
Spontaneous bacterial peritonitis s/s
Low fever, loss of appetite, ab pain, change in mental staus
Lactic acid=
Low o2
Clinical manifestations of severe sepsis
Low o2, high RR, decreased/absent u/o, change in LOC.
Steroids and ICP
Lowers inflammation
Sedatives and increased ICP
Lowers metabolic rate of brain
Anticonvulsant and ICP
Lowers seizure risk
Major parts of immune system
Lymph nodes, thymus, spleen, bone marrow
Poor CD4 t cell function as result of HIV leads to
Lymphocytopenia, increased incomplete and nonfunctional antibodies, abnormal macrophages leading to bacterial, final, viral infections, opportunistic infections
Creatinine normal? Early sepsis? Late? Septic shock
M:0.6-1.2, W:0.5-1.1, normal to increased
HF self-management health teaching
MAWDS: medications like regime and no NSAIDs, activity like limits/carry convo during exercise, weight each day at same time on same scale, diet limiting Na 2-3g/day+limiting fluids to 2L, symptoms to notify
Esophageal varices are? Caused by? Blood loss can lead to?
MED EMERGENCY. Portal HTN causes blood to back up from the liver into the esophageal veins. Fragile, thin-walled esophageal veins become distended from increased pressure, they can rupture.Blood loss can lead to shock from hypovolemia
If MAP decreases too much with hypovolemic shock
MODS occurs
If chest pain from MI+cardiogenic shock and EKG pain meds to use
MONA, 12 lead, thrombolytics, surgery
When cardiac output is insufficient to meet body's demands, these temporary mechanisms operate to increase cardiac output
Major types Sympathetic nervous system stimulation release of norepinephrine and epinephrine Renin-angiotensin-aldosterone system activation ADH secreted by posterior pituitary - total body fluid increased Chemical responses (BNP) Myocardial hypertrophy Blood is shunted from skin and less vital organs Anaerobic metabolism
HAART make sure?
Make sure not missed, delayed, admined in lower than prescribed doses to maintain effectiveness of drugs.
What is high priority for ET tube
Making sure not dislodged then Protect skin
Distributive shock
Maldistribution of adequate circulating blood volume
SIADH caused by?
Malignancies like cancers, pulmonary disorders like pneumonia/abscess/TB/pneumothorax/chronic lung disease/positive press. Ventilation, CNS issues like trauma/infection/tumor/stroke/lupus, drugs like ADH, chlopropramide, opioids, antidepressants
Immmunocompetent definition
Max protection against infection
Therapeutic paracentesis may? Up to? Risk of? This can lead to? Use what to replace volume?
May also provide diagnostic information Up to 5 Liters of ascitic fluid can be removed at one time (careful monitoring required) Risk of hypovolemia, circulatory dysfunction and renal impairment. This can lead to HRS. Use albumin to replace volume.
Mechanical ventilation can be what or what? Insertion of?
May be Invasive or non-invasive Insertion of an artificial airway endotracheal (ET) tube or tracheostomy; Oral (preferred) or nasal site for ET tube
Violent clients
May be under the influence of drugs/alcohol Preexisting psychiatric disorders Ineffective communication
EF <40%
May confirm dx of HF, ventricular failure
Person w/ TB and CD4 <200
May not have positive TB skin test because inability to mount immune response aka anergy so confirmed via gamma assay blood test
Treatment for SVT
May stop on its own Vagal Maneuver by qualified personnel If hypotensive or unstable, immediate cardioversion with sedation Antiarrhythmics- Adenosine Cardiac catheter ablation Treat cause
If CPR becomes necessary for breathing
Mechanical ventilator disconnected and manually ventilated via BVM
Positive pressure ventilators are classified by
Mechanism that ends inspiration and starts expiration
Health promo/maintenance for anaphylaxis
Medical ID bracelet, epipen, ask about drug allergies
Management of valve disease
Medical Management Balloon Valvuloplasty Transcatheter aortic valve replacement Valve Replacement using synthetic and tissue valves Keep BP down
History assessment of cushing's
Medical history Medication history (use of glucocorticoids) Weight gain, increased appetite Menstrual history (oligomennorrhea)
Medical treatment of parkinsons
Medication Review Anti-Parkinsonian Meds: Levodopa, Carbidopa Anticholinergic Therapy: Cogentin, Akineton, Artane Dopamine Agonists: Requip, Parlodel, Mirapex Monoamine Oxidase Inhibitors: Eldepryl, Azilect Catechol-O-methyltransferase Inhibitors: Comtan Antidepressants Antihistamines
Key points of HF med management
Medication adherence is an essential part of management of heart failure. Medications should be reviewed with the patient on every doctor's visit or hospitalization Review drug-to-drug, food-to-drug reactions, and allergies Check Pulse and BP before medications administered and monitor closely during therapy Best practice: apical pulse for one full minute
SCI drugs
Methylprednisolone for inflammation, baclofen/lioresal pumped in CSF for muscle relaxation
Immunocompromised Client Secondary to Cancer Rn assessment: monitor? Monitor? Inspect? Inspect? Monitor?
Monitor CBC results, cultures (urine, blood, sputum, central line, wounds) Monitor VS q4h Inspect mouth q8h Inspect skin, mucous membranes, peri-rectal area for fissures, abscesses Monitor IV sites for infection
Carotid sinus massage monitor? Complications? What's needed?
Monitor ECG/VS/LOC, complications include bradydysrhythmia, asystole, VF, cerebral damage. Defibrillator and resuscitation equipment needed at bed
ADH deficiency interventions
Monitor I&O Daily weight Monitor labs (urine specific gravity) Patient Education (I&O, lifelong therapy, medication teaching) Administration of desmopressin acetate (DDAVP) a synthetic form of ADH given orally, intranasally, SQ, or IV.
Neuro interventions for cirrhosis
Monitor LOC, orientation, mental status Memory status Monitor for behavioral changes Ask about sleep pattern disturbances, personality changes Monitor/assess ammonia, liver function tests
Interventions for hypothyroidism
Monitor VS Medication therapy (synthroid) Patient Education
Interventions for immunocompromised
Monitor VS Monitor WBC, neutrophils, Patient-Family Education
After extubation
Monitor VS q 5 min and assess ventilatory pattern for respiratory distress/obstruction. Sore/hoarse throat common. Semi-fowlers Deep breaths q 30 min, incentive spirometer q 2hours, limit speaking to help gas exchange, decrease laryngeal edema, reduce vocal coward irritation
Key points med management of HF: monitor? Low K can cause? Know the cumulative? Inquire about?
Monitor applicable lab especially electrolytes Low potassium levels can cause arrhythmias especially in HF patients. Know the cumulative effects of taking medications that may have similar actions Inquire about non-prescription medications
Bleeding precautions for cirrhosis
Monitor for S/S of bleeding:stool, urine, bruising Monitor coagulation studies (PT, INR, Platelet count, PTT) Avoid injections (IV, IM or SQ), keep nails trimmed/smooth Monitor orthostatic vital signs, Use soft toothbrush, use electric razor
Post surgical for cushing's: monitor? If adrenal removed? If unilateral adrenalectomy?
Monitor for adrenal insufficiency, shock(hypotension, rapid/weak pulse, low UO), life long glucocorticoid and mineralocorticoid replacement if adrenal removed, if unilateral adrenalectomy hormone replacement until other gland increases, slowly taper corticosteroid therapy
Neurogenic shock SCI
Monitor for bradycardia/warm skin/hypotension and notify if occurs+give fluids, hydration via IV
Preventing hypotension for hypothyroidism
Monitor for changes like shock, prevent complications. Lifelong thyroid hormone replacement like levothyroxine/synthroid
Post thyroidectomy interventions
Monitor for complications most important. Use pillows/sandbags to support head and neck, semi fowlers, avoid neck extension, humidify air, cough/deep breath, suction, Monitor for hemorrhage Monitor for respiratory distress, keep equipment at bed side w/ o2+suctioning
Ascites interventions: monitor? Kee? Provide? Elevate? Encourage?
Monitor for dyspnea, O2 saturation Keep HOB elevated 30 degrees or more Provide oxygen if needed Elevate feet to decrease pedal edema Encourage OOB to chair
Providing safe environment for SIADH
Monitor for fluid overload/pulmonary edema like bounding pulse, neck veins distended, crackles, edema, reduced UP. If Na <120 neuro changes so seizure risk, reduce environment noise/lighting
Interventions for cushing's
Monitor for infection, protect from accidents/falls, assess nutrition, monitor/treat hyperglycemia, assess BP/heart rhythm
Rn care for diabetes insipidus
Monitor pulse, replace fluids, check neuro/VS/mucous membranes, drugs if not severe oral chlorpropamide/Diabinese or if severe Desmopressive DDAVP, weigh patient
Improving oxygenation for hypothyroidism
Monitor respiratory, possible ventilatory support or o2, don't/reduce sedation
Rn interventions for SIADH
Monitor response to treatment Fluid restriction (500- 1,000mL/day) despite patient being thirsty Slowly replace lost sodium Monitor I & O Observe for S/S hyponatremia and fluid volume excess Assess for other problems that may cause fluid retention Weigh daily (report > 2lbs/day) VS, LOC Safe Environment Monitor mental status frequently; initiate seizure precautions
HF management
Monitor vital signs closely Elevated heart rate may be first sign of HF (compensatory) Semi-fowler's position to degrease preload (volume return to the heart) Organize activities to provide adequate rest for patients who are decompensated Appropriate delegation of duties
The rn priorities in care for patient during mechnical ventilation
Monitoring and evaluating patient responses, managing the ventilator system safely, and preventing complications
Surveillance/supervision is
Monitoring performance of task/function and assures compliance w/ standard of practice+policies+procedures. Frequency/level of monitoring vary w/ needs of patient and experience of LPN/NAP
Monitoring fluid status for ARDS/ respiratory failure
Monitory daily, overload may result in pulmonary edema
Ascites: most? Define? Can cause? Triggers? Leads to? Increases? Causing?
Most common complication from portal hypertension Collection of free fluid within the peritoneal cavity (abdominal distention) causing third spacing where fluid shifts to abodmen Can cause renal vasoconstricton Triggers the renin-angiotensin system Leads to sodium and water retention Increases hydrostatic pressure and vascular volume Causing more ascites.
Prevalence of graves
Most often women between 20-40
Frontal lobe or cerebral cortex
Motor cortex for voluntary/eye movement, broca's speech formation, memory, behavior/judgement, reasoning/abstraction
Fall prevention for safety
Move slowly, siderails up/locked, call light within reach, fall risk communicated, bed lowest, if older assess mental status for delirium and think of sitter to reorient
Addison's neuromuscular and skin manifestations
Muscle weakness, fatigue, joint/muscle pain, vitiligo or hyperpigmentation
Skeletal muscle changes for hypovolemic shock
Muscle weakness, pain, deep tendon reflexes decreased/absent
Musculoskeletal manifestations of hyperthyroidism
Muscle weakness/wasting
Pleuritic pain
Muscular achy chest pain
MG issues with chholinesterase inhibitors/anticholinesterase
Myasthenic crisis via increased pulse/RR/BP, incontinence fixed via drugs gradually . Cholinergic crisis n/v/d/cramps/blurred vision/twitching fixed via atropine
Bacterial opportunistic infections
Mycobacterium causing fever, debility, weight loss, mailuse, swollen lymph glands. TB causing cough, dyspnea, chest pain, fever, weight loss.
Asystole caused from
Myocardial hypoxia, advanced heart failure, hyperkalemia, acidosis
Cardiogenic shock: most common cause? Impaired? Any type?
Myocardial infarction most common cause Impaired pumping of heart muscle Any type of pump failure with decreased CO. Cardiac arrest, ventricular dysrhythmia, cardiac amyloidosis, cardiomyopathies myocardial degeneration
Other interventions for bleeding w/ cirrhosis
NG tube inserted to detect bleeding, packed RBC, fresh plasma, dextran, albumin, plateleyts, monitor VS/PT/PTT/platelets/INR
Secondary survey includes
NGT insertion for decompression to prevent vomiting/aspiration Foley insertion Labs Diagnostic studies Pain Medical history
Transplant rejection definition? Types?
NK+t cells destroy cells from animals/people. Types: hyperacute, acute, chronic rejection
Resolution phase
NURSES Begin to make conscious decisions about their future in nursing Adapt to current job or leave for another position May quit nursing altogether Go back to school
Treatment of cirrhosis for excess fluid volume
Na restriction 2g/24 hours, spironolactone/lasix diuretics, paracentesis
Reducing stimulation for Grave's
Noisy/stressful environment can increase hyperthyroidism+cardiac issues. Encourage rest, keep environment quiet by closing door to room, limit visitors, postponing/eliminating nonessential care
Asystole rate? Rhythm? P wave? QRS?
None for all possible p waves but usually not
When breathing ineffective interventions
Nonrebreather mask Bag-Valve-Mask ventilation Prepare for intubation Prepare for needle thoracentesis Prepare for chest tube placement
Hypokalemia s/s
Nonspecific neuro and muscular symptoms like generalized weakness, depressed reflexes, irregular HR. Can be fixed w/ K sparing diuretic like spironolactone/aldactone
Temporary pacing define? For? Modes? Types?
Nonsurgical w/ timed stimulus when impulse or conduction is defective. For symptomatic bradydysrhythmia, heart block or asystole. Modes: synchronous/demand and asynchronous/fixed. Types: noninvasive/external or invasive
6 -year-old with a temperature of 101 F and flu-like symptoms
Nonurgent
65-year-old woman with redness and swelling on forearm associated with bee sting.
Nonurgent
When can mechanical ventilation be discontinued
Normal O2, normal ventilation, respiratory muscle strength are achieved
Respiratory failure interventions
O2 for acute hypoxemia to keep PaO2 >60 while treating cause. If O2 doesn't maintain PaO2 mechanical ventilation. Upright position, relaxation/diversion/guided imagery ti decrease anxiety, energy conserving measures like minimal self care/no unnecessary procedures. Systemic or MDI drugs , deep breathing
For patient w/ hepatopulmonary syndrome monitor
O2 sat w/ pulse ox, if needed o2 therapy to ease breathing, elevate HOB >30 degrees, feet elevated to decrease dependent ankle edema all to relieve dyspnea
Nonsurgical interventions for shock
O2 therapy, IV crystalloid NS/LR colloids like blood/plasma/expanders, vasoconstrictors dopamine/inotropin+norepinephrine/levophed, intropics like dobutamine/dobutrex, milrinone/primacor, drugs for coronary perfusion like nitroprusside/nitropress, monitoring VS(pulse, BP, pulse press, central venous press, RR, skin color, o2, LOC, U/O)
Hospital care of snake bite
O2, 2 large bore IV w/ NS or RL, continuous monitoring, opioids, tetanus prophylaxis, wound care, labs, ECG, history, measure circumference of bitten extemity q 15-30 min, antivenom CroFab if pit viper w/in 6 hours or Micrurus/Wyeth for Coral snake. Keep epinephrine, antihistamines, steroids at bed side for anaphylactic response to antivenom
Hospital care for bees/wasp
O2, continuous monitoring, IV w/ NS, epinephrine IM, albuterol for bronchospasm, antihistamines, corticosteroids
Sepsis interventions
O2, drugs, IV antibiotics, corticosteroids for adrenal support, insulin, heparin, synthetic activated protein C drotrecogin/xigris to prevent clots, blood replacement if hemorrhage
Other physical assessment of cirrhosis
Observe vomit/stool for blood via frank blood or + fecal occult blood test, assess breath for retro hepaticus aka fruity/musty odor, amenorrhea, continuous mental function
Increased blood flow/pressure examples
Obstruction of venous outflow, acidosis from high arterial PaCO2, increased right atrial pressure, Duran sinus thrombosis
Obstructive shock description
Obstructive shock is a ↓ in blood flow Caused by a physical obstruction in the heart or neighboring blood vessels Tissues begin to die because they don't receive essential oxygen and nutrients
Special notes on diuretics
Obtain baseline BP and P Potassium deficiency ACE inhibitors or ARBs + diuretics may not experience hypokalemia Monitor kidney function Creatinine > 1.8 mg/dl Notify healthcare provider Hypovolemia Furosemide- hearing loss Be aware of cumulative effect if taking diuretics and antihypertensive medications
Clinical criteria 2 anaphylaxis
Onset minutes-hours of 2 or more of these s/s after exposed to allergen: skin/mucous membrane problems involving swollen lips, tongue, soft palace, uvula, hives, pruritis, flushing. Respiratory distress r/t dyspnea, bronchospasms, wheezes, stridor, hypoxia, cyanosis. Hypotension r/t loss of consciousness, incontinence, hypotonia, absent DTR. Gi issues like n/v, cramping, ab pain
Clinical criteria 3 anaphylaxis
Onset minutes-hours of hypotension w/ systolic BP <90 or 30% lower than baseline pressure
Clinical criteria 1 anaphylaxis
Onset minutes-hours of skin/mucous membrane problems involving swollen lips, tongue, soft palate, uvula, hives, pruritis, flushing, respiratory distress causing dyspnea, bronchospasm, wheezes, stridor, hypoxia, cyanosis. Hypotension causing loss of consciousness, incontinence, hypotonia, absent DTR
Immunocompromise secondary to cancer
Open Wounds Active Infection Mucositis
Cranial nerve 2
Optic, vision
Therapy induced immune deficiencies
Organ transplant, treatment of autoimmune disorder, complication of chemo, cytotoxic drugs for cancer/autoimmune disorder, corticosteroids for autoimmune diseases/neoplasms/endocrine issues for inflammation and immunosuppression, cyclosporine for RA, disease modifiers for RA/psoriasis like alefacept/infliximab/remicade
Basics of triage
Organized system of sorting Prioritization based upon severity (including MOI) Highest acuity receives quickest evaluation and treatment
Supporting cognition for hypothyroidism
Orient to person, place, time, explain all procedures slowly, provide safe environment, encourage fam to accept mood changes and mental slowness and remind them that problem should improve
Fraction of nspired o2 FiO2
Oxygen level delivered to patient, based on ABG and condition, range is 21-100% o2
Managing pulmonary edema
Oxygen therapy Nitroglycerin Rapid-acting diuretics IV morphine sulfate Continual assessment
Interventions for sepsis/SIRS
Oxygen therapy Poor perfusion and oxygenation More likely mechanical ventilation Drug therapy Enhance CO and restore vascular volume Antibiotics (gram negative) Adrenal insufficiency (hydrocortisone) Hyperglycemia Clotting problems (heparin) Blood replacement therapy
What is appropriate for any patient who has acute hypoxemia(respiratory failure)? It's to keep PaO2 at what level?
Oxygen therapy is appropriate for any patient who has acute hypoxemia. To keep PaO2 level about 60mmHg
Conditions that affects the flow of blood into the lungs leading to respiratory failure
PE causing lung damage
Labs for shock
PH low, PaO2 decreases, PaCO2 increases. Hematocrit/hemoglobin decrease if due to hemorrhage, if dehydration H/H raised
Caregiver
PROVISION OF CARE MEETING PHYSICAL, EMOTIONAL, INTELLECTUAL, SOCIOCULTURAL, AND SPIRITUAL NEEDS
Pressure support ventilation weaning
PSV allows respiratory effort to be augmented by predetermined pressure assist from ventilator, as weaning starts amount of pressure applied to inspiration gradually decreased. Another method is to maintain pressure but gradually decreasing preset breaths/min
Adenosine used for?
PSVT, WPW. Causes asystole then bradycardia and hypotension
Hypoxic respiratory failure: PaO2? SaO2? Usually? Most? Involves?
Pa O2 < 60 mmHg, SaO2 < 90 Usually a normal or low Pa CO2. Most common form of respiratory failure Involves fluid filling or collapse of alveoli
Hypercapnic respiratory failure: PaCO2? PH? PH depends on? What's common?
PaCO2 >45mm HG Acidosis- pH < 7.30, pH depends on the level of bicarbonate, which is dependent on the duration of the hypercapnia ( think Renal) Hypoxemia is common w/o supplemental O2
Critical values of acute respiratory failure: PaO2? SaO2? PaCO2? PH?
PaO2 <60, SaO2 ,<90, PaCO2 >50 occurring w/ academia pH <7.30,
Automaticity
Pacing function from SA node. If myocardial ischemia, electrolyte imbalance, hypoxia, drugs, infarction any cell can produce impulses causing dysrhythmias
Automaticity
Pacing function, the ability of cardiac cells to generate an electrical impulse spontaneously and repetitively
Premature contractions assessment
Palpitations/skipping of heartbeat Difficulty catching their breath Faintness Dizziness Loss of consciousness
Ejection fraction EF
Percentage of blood ejected from the heart during systole Normal adult range 50%-70%
Diabetes insipidus patho? Primary? Secondary? Can also be from?
Pituitary gland doesn't make enough ADH so kidneys make a lot of urine/polyuria and dehydration, increasing plasma osmlatrity, increasing thirst from nephrotic aka inherited, primary aka defect of hypothalamus/pituitary, or secondary aka head injury, pituitary tumor, infection, hypophysectomy, or craniotomy. Can also be from drugs like lithium
Circulatory treatment
Place 2 large-bore 16 gauge IV catheters (IV, IO, or CVL) in antecubital of elbow Crystalloid fluids Normal Saline or Ringer's lactate Warmed blood IV fluids to prevent hypothermia Rapid infusers Blood products (O negative) CPR Hemorrage control Manual pressure if external hemorrhage or tourniquet
Examples of hypoxic respiratory failure
Pneumonia, pulmonary edema(cardiac or non-cardiac), pulmonary hemorrhage
ADH deficiency assessment: s/s? Na? BP? HR? Specific gravity? Urine osmolarity?
Polydipsia Polyuria (4 to 30 L per day) Dehydration Hypernatremia Hypotension Tachycardia Specific gravity decreased < 1.005 Urine osmolarity decreased < 300 mOsm/kg
Other connective tissue diseases
Polymyositits/dermatomyositis, systemic necrotizing vasculitis, polymalgia rheumatica/temporal arthritis, ankylosis spondylitis, reiter's, ma fan, lyme disease, psoriatic arthrisis, fibromyalgia syndrom
Complications of cirrhosis
Portal Hypertension, Ascites, Jaundice, Nutritional deficiencies, Coagulation deficits, Bleeding esophageal varices, Hepatic encephalopathy, Hepatorenal syndrome, Biliary obstruction
Mr. Stellas is a 54-year-old man with a known history of alcoholism. He has been admitted numerous times to the hospital. Today he is again admitted with complications of cirrhosis. What assessment findings should the nurse anticipate?
Portal hypertension, splenomegaly, esophageal varices, hematemesis, melena, jaundice
Treatment goals for ARDS/respiratory failure: positioning? Provide? Conserve? Use what to promote gas exchange?
Position the patient in an upright position Provide relaxation techniques, diversion and guided imagery to assist with dyspnea Conserve the patient's energy, minimal self care and cluster activity, allow for rest Bronchodilators to promote gas exchange
Continuous positive airway pressure CPAP
Positive airway pressure throughout the entire respiratory cycle for spontaneously breathing patients. Keep alveoli open during inspiration and expiration improving gas exchange and o2
Mechnical ventilation
Positive end-expiratory pressure (PEEP) is positive pressure exerted during the expiratory phase of ventilation. Improves oxygenation by enhancing gas exchange and preventing atelectasis and alveoli from collapsing Used to treat persistent hypoxemia that does not improve with acceptable oxygen delivery. Which results in an increase in arterial blood oxygen
ET tube/tracheostomy used for
Positive pressure and during inspiration pressure generated that pushes air into lungs and expands chest
Positive end expiratory pressure PEEP
Positive pressure exerted during expiration. Enhances gas exchange and prevents atelectasis via preventing alveoli from collapsing b/c lungs kept partially inflated so gas exchange promoted throughout cycle.
Most problems are caused by which ventilator
Positive pressure from ventilator
Care/use of rip injector
Practice assembly, keep at all times, inject in top thigh, can inject through pants, use when any s/s of anaphylaxis and call 911, go to hospital 4-6hrs after injection, have at least 2 drug filled devices, protect from light, room temp,
Expert characteristics
Practices holistic rather than fractionated, grasp situation intuitively and correctly identifies solutions w/out wasting time, extraordinary management of clinical problems, considered an expert by others, has intuitive grasp of situation and zeros in on accurate region of problem
Strategies to decrease reality shock
Preceptor program-structured Mentor - an experienced nurse that is not evaluating your job performance Support groups - not complaining - positive and uplifting
Steps to securing oral/nasal ET tube
Prepare skin via shaving, protect skin via benzoin, then apply duroderm, tape tube to upper lip or nose
Interventions for cirrhosis: potential for hemorrhage? These all function to do what?
Prevent bleeding in patients with varices IV Sandostain or Vasopressin is used for acute hemorrhage Constricts blood vessels to stop bleeding Nonselective beta blocker Propranolol (inderal), nadolol (corgard) Decrease heart rate, decrease hepatic venous pressure, reducing the chance of bleeding
Preventing hypovolemic shock
Prevent dehydration, prevent trauma/hemorrhage via safety. Secondary prevention via assessing by assessing for occult bleeding via comparing baseline to current pulse, U/O, VS, LOC, anxiety, thirst, impending doom. Aspiring, NSAIDs, diuretics can lead to it
Safety intervention for violent
Prevent escalating, de-escalation, mitigating violence
Functions of glucocorticoids
Prevent hypoglycemia by increasing gluconeogenesis in liver, maintains cardiac muscle, increase lipolysis, increases protein catabolism, degrades collagen, increase mature neutrophils, anti-inflammatory, maintain behavior/cognitive function
Patient safety interventions for Cushing's
Preventing/monitoring fluid overload via bounding pulse/vein distention/crackles/edema/low UO. Skin breakdown risk so pressure reducing mattress, assess pressure areas, O2 mask/cannula, change positions q 2 hours
With diastolic HF prevents? Blood? EF?
Prevents ventricles from filling with sufficient blood to ensure adequate cardiac output, causes ventricles to be less compliant causing more pressure needed to move same amount of blood Blood backs up (pulmonary) Normal EF (>40%)
TBI types
Primary: open aka fractured/penetrating and closed aka blunt trauma which includes contusion/concussion. Secondary occurs after initially injury and worsen outcome
Hypothyroidism primary caused by? Secondary?
Primary:Secondary to surgery or radiation of thyroid for hyperthyroidism/cancer Autoimmune (Hashimoto's) Congenital Cancer Iodide/tyrosine deficiency, lithium, excess exposure to iodine. Secondary to pituitary/hypothalamic tumors/trauma causing inadequate TSH
During hospitalization, Mr. Stellas has had an average 24-hour urinary output of 1000 mL. Today, the nurse notes that he has had 486 mL of urinary output in the last 24 hours. Laboratory results indicate elevation in BUN and creatinine levels, and a urine sodium level of 6 mEq/L. He is oriented occasionally to person; he is not oriented to place or time. What priorities of care should the nurse identify?
Priorities of care should include notifying the primary care provider; preventing infection (e.g., due to spontaneous bacterial peritonitis); monitoring for fever, chills, and abdominal pain (signs of infection); and continued monitoring of mental status. Rationale: A sudden decrease in urinary flow, elevated BUN and creatinine levels, abnormally decreased urine sodium level, and worsening encephalopathy are indicators of hepatorenal syndrome (HRS). The nurse should prioritize care by notifying the primary care provider, preventing infection; these patients are prone to develop acute spontaneous bacterial peritonitis and are also susceptible to other types of infection, thought to be the result of low concentration of proteins.
Health promotion/maintenance of ARDS
Priority: early recognition of those at high risk, closely assess tube feedings/impaired swallowing+gag reflexes. Infection control guidelines like hand washing, invasive catheter/wound care, contact precauses
Contact precautions equipment? Ex?
Private room, gloves, wash hands before leaving, wear gown, dedicate items to patient. Ex: Multidrug resistant organisms like MRSA, VRE, pediculosis/lice, scabies, respiratory synctial virus/RSV, c.diff, ebola
Hospitalized care of immunocompromised
Private room, handwashing, clean room 1x/day, dedicated items in their room and don't share equipment w/ other pts., limit people working w/ pt., inspect mouth q 8 hours, inspect skin/mucus membranes q 8hrs, inspect IV sites q 4 hrs, wound care daily, cough/deep breath, limit visitors to healthy adults, strict aseptic, avoid indwelling caths, no fresh flowers, no raw foods
Care of patient w/ myelosuppression and neutropenia
Private room, handwashing, no supplies from common areas keep a set of patient equipment in their room, limit personnel, inspect mouth q 8hrs, inspect skin/membranes q 8hrs, assess IV q 4 hrs, change dressings, coughing/deep breathing, limit visitors to healthy adults, avoid indwelling caths, avoid raw foods
Ventilators failure
Problem in o2 intake/ventilation and blood delivery/perfusion that causes ventilation perfusion mismatch where perfusion normal but ventilation inadequate. Chest perssure doesn't change enough for air movment and as result too little o2 reaches alveoli and CO2 retained.
Stage 1 portal systemic hepatic encephalopathy
Prodromal: subtle s/s, personality/behavior changes, emotional lability aka euphoria/depression, impaired thinking, inability to concentrate, fatigue/drowsiness, slurred/slowed speech, sleep pattern disturbances
Stage 1 of hepatic encephalopathy
Prodromal:Subtle personality, behavioral and emotional changes
Adrenal crisis in Addison's
Profound fatigue, dehydration, vascular collapse, low BP, renal shut down, low Na, high K
Patho of cirrhosis
Progression of liver disease results in widespread irreversible scarring (fibrous bands of connective tissue). Excessive fibrous tissue causes compression leading to impairments in blood and lymph flow.
Guillain-barre syndrome define? Starts in?
Progressive demyelinating polyneuropathy causing moron weakness and sensory abnormalities. Starts in legs and spreads up aka ascending paralysis snf then recovers from top to bottom
Albumin function? If you have liver dysfunction?
Protein in interstitial space to form oncotic pressure. If you have liver dysfunction water cannot go in interstitial space leading to ascites/pitting edema+you will have high albumin at first then low
Hepatocyte function
Protein synthesis & storage Transformation of carbohydrates Synthesis of cholesterol+bile salts & phospholipids Detoxification, modification, and excretion of substances Initiates formation and secretion of bile.
Urine analysis of HF
Proteinuria and high specific grav, microalbuminuria is early indicator of decreased compliance before BNP rises and s/s
Helping fam w/ sudden death
Provide a private place Talk with the family with everyone together Reassure that all possible efforts were taken Keep comments factual Use concrete words such as "died" or "death": Avoid confusing words such as "expired" or "passed away" Encourage and allow time for family to support each other Encourage viewing of the body Spend time with the family Allow the family to talk about their loved one Avoid unnecessary information (drunk, high, etc.)
Supporting self esteem for HIV
Provide acceptance, allow for privacy but dont avoid/isolate, encourage self care/independence, guided imagery
VAD can help support your heart how
During or after surgery, until your heart recovers. While you're waiting for a heart transplant. If you're not eligible for a heart transplant. (A VAD can be a long-term solution to help your heart work better.)
S/s of respiratory failure
Dyspnea/Dyspnea on exertion, Orthopnea, Change in RR/pattern, Change in lungs sounds, Pallor, confusion, cyanosis, increase HR, restlessness , anxiety, lethargy, bradycardia (which can occur early or late), Hypercarbia-high arterial blood levels of carbon dioxide.
CV findings of cirrhosis
Dysrhythmia, collateral circulation, fatigue, hyperkinetic circulation, peripheral edema, portal hypertension, spider angiomas
RN following progress of client being treated for hypothyroidism which finding indicates thyroid replacement has been inadequate? Which findings indicates too much has been given
ECG changes, low temp, bradycardia. body is in a hypo-metabolic state. Tachycardia, nervousness, and dry mouth are all signs of hyperthyroidism and would indicate the client has received an excessive dose of thyroid hormone.
Advanced life support ACLS steps
ECG, CPR, airway inserted, manual bag w/ mask w/ o2, head tilt or chin lift, 2 large IV lines, suction setup, check pulses/BP/pupils, intubation, emergency drugs, possible external pacing, chest compressions until pulses or stopped by dr., if return of circulation for VF/VT pulses/asystole therapeutic hypothermia to protect brain
ACS/MI dx
EKG - ST depression, T wave inversion, ST Elevation Troponin levels- serial every 8 hours Chest X-ray (rule out aortic dissection Cardiac Catherization
Graph of EKG each wave has?
Each wave has a definition and based on numbers/measurement
Hypovolemic shock prevention/screening
Early ID and tx of the cause of fluid volume loss Early control of bleeding Monitoring of fluid volume status and early replacement of fluids
Reducing risk for infection and injury
Early and frequent patient mobilization to improve circulation and help prevent pneumonia
Premature contractions/complexes define
Early rhythm complexes when cells/cell groups other than SA node fire impulse before SA node aka ectopic focus
Managing fluids for cirrhosis interventions
Early stages aimed at preventing acculumulation via nutrition, drugs, paracentesis, respiratory support
Sepsis skin s/s
Early/septic shock pallor/cyanosis/mottling, severe sepsis skin warm/no cyanosis. If DIC petechia, ecchymoses. Blood can ooze from sites
S/s of airway obstruction
Early: dyspnea, coughin, inability to clear secretions. Late:stridor. Requires prompt attention and epinephrine give
Manifestations of SIADH: early?
Early: loss of appetite, n/v. Weight gain, hyponatremia, fluid shifts, lethargy, headaches, hostility, disorientation, change in LOC, seizures, coma, decreased DTR's, bounding pulse, hypothermia, elevated urine Na/specific gravity
Whats best for diagnosis HF
Echocardiogram which can detect valve changes, pericardial effusion, chamber enlargement, ventricular hypertrophy
Clinical observations for ARDS/failure
Edema, skin turgor, mucus membranes, I/Os, monitor for weight changes
Forensic nurse examiners RN-FNEs
Educated to obtain history, collect forensic evidence, offer counseling/follow up for rape/abuse
Responding to feelings of isolation
Education about modes of infection
Jane is seasoned nurse w/ 30 years experiences and is on 15 bed unit and she is just rehabilitating from knee surgery, how would you respond to the situation when other nurses complain unnecessarily that Jane's assignment has all of the patients in the front hall and with patient acuity scores of 1
Effective communication
Drop in creatinine is good indicator of
Effective treatment of therapy
Risk factors for sepsis
Elderly persons and children Postoperative patients 10 times more likely to die from sepsis than from MI or CVA Chronic illnesses DM CVD Immunosuppressive disease HIV/AIDS Use of long term immunosuppressive therapy Chemotherapy Poor nutrition Debilitation
Considerations for older adults and ventilation
Elders especially smokers/COPD at risk for dependence and failure to wean.
Preventing injury/bleeding
Electric shaver, soft brush, no aspirin, no contact spots, ice trauma sit, avoid hard foods, eat warm/cool/cold foods, check skin/mouth family, no anal sex, stool softener, no enemas/suppositories, don't bend at waste, loose clothes/shoes, no blowing nose or don't block both passages, no music instruments
Pacemakers
Electrical Stimulus to the heart muscle to depolarize cells to start muscle contraction Pacemakers can be temporary or permanent -Temporary: Used in patients with symptomatic bradycardia Transcutaneous- apply the electrodes to the chest wall Transvenous - external battery operated pulse generator flows with lead wire to stimulate the heart
Labs for HF
Electrolytes* + cardiac enzymes Creatinine* good indicator for renal perfusion magnesium CBC- hemoglobin and hematocrit B-type natriuretic peptide (BNP)* Urinalysis ABGs Coagulation studies Renal and hepatic function tests Thyroid function
Labs for HF
Electrolytes, possible raised BUN/creatinine, H&H to see if anemia, BNP/natriuretic peptide to dx HF w/ acute dyspnea, proteinuria, high specific gravity, microalbuminuria, ABG
Labs of hepatitis
Elevated ALT/AST, elevated phosphatase, bilirubin elevated, liver biopsy
ACS risk factors
Elevated Cholesterol Smoking HTN, DM, Obesity Increasing age, Family history, Premenopausal women, Race
35-year-old man with chest pain and diaphoresis
Emergent
85-year-old man with new onset of confusion; BP elevated compared to his usual reading.
Emergent
Psychosocial for cushing's
Emotionional instability, don't feel like themselves, mood swings, irritability, confusion, depression, crying/laughing inappropriately, sleep difficulties, fatigue
If high pressure alarm sound from increased PIP associated w/ deliverance of a sigh
Empty water from ventilator tubing, remove any kinks, coordinate w/ respiratory therapist or physician to adjust the pressure alarm
Conditions causing increased cortisol secretion
Endogenous secretion aka cushing's disease or exogenous admin aka cushing's syndrome
Endoscopic retrograde cholanggiopancreatogaphy ERCP
Endoscope to inject contrast to view biliary tract for stone removal, biopsy, stent placement
ERCP
Endoscopic retrograde cholangiopancreatography use a scope to inject contrast material to view the biliary tract.
Increased ICP rn interventions: maintaining patent airway
Endotracheal Intubation & mechanical ventilation if indicated Careful mouth care and suctioning as needed HOB 30-45°
What is most common type of airway for short term basis
Endotracheal tube and passes through mouth/nose and into trachea and rests 2cm above carina before bronchi
Penetrating trauma define? Skin integrity? Surrounding tissue?
Energy to body tissue from a moving or sharp object Skin integrity is interrupted Surrounding tissue deformation results
All patients w/ cirrhosis should be screened for
Esophageal varices by endoscopy to detect early before bleeding
Effects of portal hypertension w/ liver damage
Esophageal varices causing hematemesis, gastropathy, and melena. Splenomegaly, dilated abdominal veins aka caput medusae, ascites, rectal varices aka hemorrhoids
EGD
Esophagogastroduodenoscopy to directly visualize the upper GI tract
Maintaining social contact for HIV
Establish therapeutic relationship, don't isolate, spend time with them
Ovary hormones
Estrogen, progesterone
Sedatives for intubation
Etomidate, ketamine, propofol, midazolam, fentanyl, morphine
Health promotion and maintenance for sepsis
Evaluate all patients for risk factors (older adults) Aseptic technique Remove indwelling urinary catheters ASAP Remove and IV access lines ASAP Early detection of sepsis Hallmark of sepsis is rising lactate level normal or low WBC Teach patient and family manifestations of infection When to contact health care provider Take ALL antibiotics as prescribed
Low exhaled volume/low pressure alarm sounds from a cuff leak occurring in the ET or tracheostomy tube
Evaluate for cuff leak, Cuff leak suspected when patient can talk/airway escapes from mouth or when pilot balloon on artificial airway is flat
Low exhaled volume/low pressure alarm sounds from the patient stopping spontaneous breathing in the SIMV or CPAP mode or on pressure support ventilation
Evaluate patient's tolerance of the mode
If high pressure alarm sounds from decreased compliance of lung, a trend of gradually increased PIP
Evaluate reasons for decreased compliance, increased PIP occurs in ARDS, pneumonia, worsening of pulmonary disease
Evaluation and feedback
Evaluation is often the forgotten step in delegation
Although causes and initial manifestations associated w/ different types of shock vary
Eventually the effects of hypotension and anaerobic cellular metabolism result in key features of shock
Mouth care for mucositis
Examine mouth q 4 hours, if present notify, soft brush q 8 hrs/before meals, rinse mouth q 12 hrs, avoid alcohol mouthwash, rinse mouth 4x/day, drink 2L+ water, antimicrobial drugs, topical analgesics, swish and spit water, water based moisturizer, artificial saliza, no tobacco, no spicy/salty/acidic/dry/rough/hard food, cool liquids
Cushing's patho
Excess glucocorticoids causes slow turnover of fats causing total body fat increases, increases in tissue breakdown leading to increased urine N resulting in decreased muscle mass/strength+thin skin+fragile capillaries all leading to bone density loss
Hyperparathyroidism patho
Excess secretion of parathyroid hormone Increased serum calcium aka hypercalcemia and decreased serum phosphorus levels aka hypophosphatemia causing bone resorption/loss of Ca+reduced bone density
ADH excess? Causes what?
Excess secretion of vasopressin (ADH) Causes Syndrome of Inappropriate Antidiuretic Hormone
Cushing's : a group of abnormalities that result from?
Excessive levels of hormones produced by the outer layer of the adrenal glands Taking steroid hormones Excess production of adrenocorticotrophic (ACTH) may result from a pituitary gland tumor or a tumor associated with other organs Widespread symptoms
Functions of liver
Excretory, synthesis, storage, metabolism, detoxification. Clothing factors, sex hormone binding globulin aka SHBG, albumin
MODS multiple organ dysfunction syndrome
Exhaustion of metabolic reserves leads to failure and acidosis Oxygen supply/demand imbalance leads to acidosis Impaired myocardial function leads to decreased cardiac function and tissue hypoxia Microvascular thrombi leads to DIC and insufficient blood supply to multiple organs/systems
Common assessment findings for immunocompromised
Recurrent infections, diarrhea, fatigue, anemia
Preparing for intubation
Explain procedure, if emergency bring code/crash cart/airway equipment box/suction to bedside, maintain patent airway via positioning+oral/nasopharyngeal airway until intubated, monitor VS, s/s of hypoxia/hypoxemia, dysrhythmia, aspiration
Malnutrition is
Extreme issue fro patients and main reason for failure to wear from ventilator
Rn performing admission assessment on client dx w/ diabetes insipidus which findings does rn anticipate during assessment
Extreme polyuria, low specific gravity, excess thirst
Glasgow coma scale for head injury
Eye opening up to 4 points, verbal response up to 5 points, best motor response up to 6
Nerve 7
Facial pain, temp from ear, deep sensation of face, taste
Lupus erythematosus define
Facial rash systemic if chronic progressive autoimmune
Most heart failure begins w/
Failure of left ventricle and progresses to both ventricles
Fulminant hepatitis define? Results in?
Failure of liver cells to regenerate results in acute hepatitis
Major contributing factor for pression to septic shock
Failure to recognize/intervene
Coral snake characteristics
Red on yellow can kill a fellow
Systemic lupus s/s
Red rash, lesions, nephritis, pericarditis, raynaud's phenomenon, pleural effusion, CNS lupus, ab pain, joint inflammation, myositis, fever, fatigue, anorexia, vasculitis, muscle atrophy, pneumonia
Nutrition Interventions for HF that reduce preload raising SV
Reduce Na and water retention. Restricted Na to 2-3 g/day, possible fluid restriction to 2 L/day, weight daily
Goals for cushing's
Reduce cortisol levels, remove tumors, restoration of normal/acceptable body appearance
Diuretics
Reduce fluid volume. Vasodilators reduce preload and/or afterload, inotropics increase contractility
Promoting comfort for Graves
Reduce room temp, make sure fresh pitcher of ice water, change bed linen when wet from diaphoresis,suggest cool shower/bath, artificial tears for eyes, taping eyelids closed for sleep
Renin-angiotensin system activation w/ HF
Reduced blood flow to kidneys activates. Vasoconstriction and aldosterone causes sodium and wate rentention causing peripheral edema
Pancreas complications of HIV
Reduced exocrine function: fatty food intolerance, cholelithiasis, pancreatitis. Reduced endocrine function: DM, hyperlipidemia
CD4 in HIV is? Leading to?
Reduced leading to lymphocytopenia, increased production of incomplete antibodies, abnormal macrophages
Compensatory mechanism to improve increased ICP
Reduction of CSF volume by contraction of ventricles Reduction of blood volume in the cranium Hypoventilation PCO2 causing vasodilation Cushing's reflex Displacement of brain matter (herniation)
Expected outcomes for cushing's
Reduction of cortisol levels Removal of tumors Restoration of normal body appearance Maintain fluid and electrolyte balance
Warning signs of primary immune deficiency
Fam history of immune deficiency, drugs that cause it, RA Frequent/unusual infections or unusual complication. 8+ infections w/in 1 yr, 2+ sinus infections w/in 1 yr, 2+ months on antibiotics w/ little/no effect, 2+ pneumonias w/in 1 yr, failures of infant to gain weight/grow, recurrent deep skin/organ abscesses, persistent thrush after 1 y/o, need for IV antibiotics for infection, 2+ deep seated infections
Assessment for hyperpituitarism
Fam history, hat/glove/ring/shoe size change, fatigue lethargy, backache, arthralgias/joint pain, headaches, vision changes. Initially lip/nose size increase
S/s of pit viper envenomation
Fang marks, swelling, a lot of pain n/v, parathesia, hypotension, ecchymosis, necrosis, hypovolemic shock, pulmonary edema, renal failure, DIC, minty/metallic taste, tingling/paresthesia of scalp/face/lips, fasciculations/twitching, seizures
Amyotrophic lateral sclerosis s/s
Fasciculations/face twitching, dysarthria/slurred speech, dysphagia,, fatigue, muscle atrophy/weakness
Oral vs. nasal route
Fast/easy for emergency vs. facial/oral traumas/surgeries when oral not possible but not for blood clotting issue
General appearance of Cushing's
Fat redistribution: moon face, buffalo hump, truncal obesity. weight gain, ace, fine coating of hair over face/body, male pattern balding in women
Symptoms r/t decreased CO
Fatigue Weakness/Activity intolerance Oliguria during day (nocturia during night) Angina Confusion, restlessness Dizziness Tachycardia, palpitations Pallor Weak peripheral pulses Cool extremities
Early manifestations of cirrhosis
Fatigue, change in weight, GI s/s like anorexia/vomiting/ab pain/liver tenderness
Right sided HF aka for pulmonale
Fatigue, high peripheral venous pressure, ascites, enlarged liver/spleen, may be secondary to chronic pulmonary problems, distended jugular veins, anorexia/GI distress, weight gain, dependent edema
Left sided heart failure key features of decreased CO
Fatigue, weakness, oliguria during day, nocturia at night, angina, confusion/restless, dizziness, tachycardia, palpitations, pallor, weak pulses, cool extremities
Stages of liver damage
Fatty aka fat deposits, fibrosis aka scar tissue, cirrhosis aka cell damage
For cerebellar function test
Fine coordination test via running heel of foot down shin, hands palm up then palm down on each thigh, arms out at the side and fingers to nose, gait and equilibrium
ACE
First choice treatment for HF Lowers BP and reduce progression of heart damage from HF Inhibit angiotensin-converting enzyme (ACE) from activating the hormone angiotensin. Angiotensin signals the body to constrict blood vessels-raising BP Decrease the resistance to blood flow in vessels Dilates arteries Common side effect- dry cough, altered taste
Ventricular fib first thing to do?
First thing to do assess, immediate defib/cpr if leads correct
Assessment of anaphylaxis
First uneasiness, apprehension, weakness, impending doom, anxious, frightened. Then itching, urticaria/hives, erythema, angioedema of eyes/lips/tongue. Then histamine causing bronchoconstriction, excess mucus causing confession/wheezing/crackles/stridor, hypotension, hypoxemia
Bladder training
Reflex bladder treated with medications, neuromodulation, bladder surgery, or indwelling catheter. Infection control, utilizing proper techniques to prevent UTI Nonreflex bladder requires the uses of condom catheters for men and pads/waterproof undergarments for women. Skin breakdown and external infections are a major concern
Level 1 trauma center
Regional capable of total care for every aspect of injury
HF management: exercise? Drugs? Vax? Monitor? Focus on?
Regular exercise (unless decompensated) Smoking cessation No drugs Influenza and pneumonia vaccines Monitor daily weights (plan of action if weight increases by 2-3 lbs.) Focus on control of risk factors for other underlying/aggravating diseases (such as DM, ischemic heart disease)
Points oc transition to practice model
Regulation(providing new graduates w/ info on SOP, Nurse practice act, maintaining license), practice(provides link that will provide new graduates w/ planned practice experiences w/ qualified nurses to mentor), education(experts in curriculum design)
To increase ability with ADLs for ards/respiratory failure
Reinforce O2
Nutrition/exercise for respiratory failure/ARDS
Frequent small meals and medical food supplements •supplementations for 7 -12 days. Medical food supplements for outpatients: low BMI, weight loss patients at nutritional risk benefit especially when combined with exercise. •Osteoporosis:Calcium & vitamin D, avoid tobacco/ETOH intake •Vitamins:diet w/ adequate intake (AI) vitamins A/C/E. . No studies to show needs >RDA, •Omega-3 Fatty Acids •Milk and Mucus: •Limit empty calorie foods •Accept meal prep help, MOW, freeze extra portions, rest before eating Tube Feeding Consider Takes the pressure off of the child to Eat more than they would like. Night time feedings Daytime boluses Formula
Coagulation intracranial hemorrhage from anticoagulation increased ICP
Fresh frozen plasma, vitamin K, platelets
Cardiogenic shock
From MI, arrhythmia, valvular heart disease, HF leading to low venous return/CO leading to poor o2 perfusion causing shock
Hepatitis B from? S/s? Recovery?
From Sex, needles, blood, hemodialysis, maternal-fetal route, person-to-person contact by open cut/sores, if immunnosuppressed. S/s: anorexia, n/v, fever, fatigue, RUQ pain, dark urine, light stool, joint pain jaundice, no symptoms. Can recover
Adrenocorticotropic hormone ACTH from? Targets? Stimulates?
From anterior pituitary and targets adrenal cortex. Stimulates corticosteroids and adrenocortical growth
Growth hormone from? Targets? Function?
From anterior pituitary and targets bone/soft tissue to promote growth via lipolysis, protein anabolism, and insulin antagonism
Leuteinizing hormone from? Targets?function?
From anterior pituitary and targets ovaries and testes to stimulate ovulation/progesterones and testosterone secretion
Follicle stimulating hormone from? Targets? Function?
From anterior pituitary and targets ovary/testes to stimulate estrogen+follicle maturation or spermatogenesis
Acute thyroiditis from? Causes what?
From bacteria causes pain, neck tenderness, malaise, fever, dysphagia and fixed w/ antibiotics
Hepatopulmonary syndrome from? Aka? Monitor?
From cirrhosis aka breathing issues from ascites pressure. Listen for crackles
Chronic hepatitis from? Usually leading to?
From hep B or C usually leading to cirrhosis and liver cancer
Hyperpituitarism from? Leading to?
From hypothalamus hyper functioning, tumors, tissue hyperplasia, adenoma/benign tumor leading to endocrine symptoms, visual changes, headache, increased ICP
Brain herniation
From increased ICP tissue shifts and herniated down causing pressure on nerves causing eye/LOC/cheyen stokes issues
Right sided/ventricular failure
From left HF, right ventricular MI, or pulmonary hypertension. Right ventricle cannot empty and increased volume/pressure develop in venous system causing edema
Distributive shock
From neural induced, spinal injury, chemical induced, anaphylactic, sepsis. All lead to peripheral dilation lowering venous return/CO/MAP leading to poor perfusion causing shock. Fluid shifted from central vascular space, body fluid volume normal/increased
Obstructive shock
From pericarditis, cardiac tamponade, extended immobility leading to low venous return/CO causing poor o2 perfusion leading to shock. Cardiac function decreased from noncardiac factor, central volume decreased but total fluid no affected
Adenocorticotropic hormone ACTH from what? Affects what? Hyper?
From pituitary and affects adrenal cortex. Hyper: excess glucocorticoids, mineralcorticoids, androgens leading to Cushing's disease
Portal hypertension gastrophy
From portal hypertension, slow gastric mucosal bleeding occurs resulting in chronic slow blood loss, occult positive stools, anemia
Preventing myxedema coma r/t hypothyroidism
From stress like illness, surgery, chemo, discontinuing thyroid replacement+sedatives/opioids. Coma, respiratory failure, hypotension, hyponatremia, hypothermia, hypoglycemia, shock, organ damage/failure can all occur due to this. Monitor for and report change in LOC
Androgen/steroid/testosterone therapy SE:
Gynecomastia, acne, baldness, prostate enlargement
Restoring skin integrity for HIV
HAART/radiation/chemo for kaposi's sarcoma, analgesics/comfort, clean/dressed, skin care
Cardiomyopathy leads to
HF so treat as HF. Usually gets LVAD or transplant. Treated via treating symptoms.
dx of AIDS requires? Once AIDs diagnosis?
HIV + and have either CD4 count <200 or an opportunistic infection or 2 or more episodes of pneumonia in 1 year. Once AIDS diagnosis even if CD4 goes up or infection treated they will still have AIDS
How to prevent ventilator associated pneumonia
HOB at least 30-45 degrees(reduce reflux/aspiration) Assess need for suctioning(oral, nasal, tracheal)Q2 Oral Care Q2-4 hours (reduce dental plaque and infection) Stress Ulcer prophylaxis (Protonix, Pepcid) Hand Hygiene/ gloves when providing care Turn/position Q2 hours ("GOOD LUNG DOWN") Assess readiness to wean off ventilator daily with spontaneous breathing trials (SBT) Daily Spontaneous Awakening Trials (SAT)
CO=?
HR x SV(preload, afterload, contractility)
CO equation
HR x SV(volume of blood ejected w/ contraction 60-70)
Activity intolerance s/s
HR/BP change >20, fatigue, chest pain,dyspnea
Normal sinus them
HR:60-100, P, QRS, present
Left sided heart failure key features of pulmonary congestion
Hacking cough worse at night, dyspnea, breathless, crackles/wheezes, frothy/pink sputum, tachypnea, heart Gallup/extra sound
Complications of thyroidectomy
Hemorrhage, respiratory distress from tracheal compression/nerve damage/tetany, parathyroid injury causing hypocalcemia/tetany, nerve damage, thyroid storm
Common joint deformities in RA
Herberden's and Bouchard' nodes affecting fingers
Expected outcomes of acromegaly
Hormone levels return to normal or near normal Reduce or eliminate headache and visual disturbances Reverse body changes if possible
Interventions for pituitary hypofunction? If gonadotropins steroids/testosterone given via IM? For women what's given?
Hormone replacement. If gonadotropins steroids/testosterone given via IM w/ high dose first and continued until virilization aka presence of male secondary sex characteristics is achieved. For women estrogen/progesterone given
Skin and skeletal muscles can tolerate low O2 for how long without dying/damaged
Hours
Flow rate is
How fast each breath delivered and usually set to 40 L/min
Mechanism of injury define
How patient's traumatic event occurred
Risk factors for cardiogenic shock
Hx CAD PVD DM Hypertension High cholesterol and triglycerides Tobacco and alcohol use Hx heart attack or CAD Obesity
Increased CSF examples
Hydrocephalus, pseudotumor cerebri
Thiazide diuretics
Hydrochlorothiazide or metolazone/zaroxolyn. Longer acting. Dehydration not common like loops
Lupus inteventions
Hydroxychloroquine/palquenil, chronic steroid therapy, immmunosuppressant methotrexate, protect skin from sun, no perfume, lotion, no drying agents like alcohol
MS sensory issues
Hypalgesia aka diminished pain sensitivity, paresthesia, facial pain, decreased temp. Sensation, numbness, tingling, burning
If no perfusion and DM
Hyper or hypglycemia possible with HF. If RHF anorexia which can affect meds and diet
Calcium: hyper? Hypo?
Hyper- blocks conduction pathways Hypo- decreased myocardial contraction
Magnesium: hyper? Hypo?
Hyper- causes delayed impulse conduction Hypo- irregular ventricular contraction
Potassium: hyper? Hypo?
Hyper- decreased cardiac conduction, life threatening rhythm Hypo- myocardial hyper excitability, ECG changes
Cushing's aka? From? Affects?
Hypercortisolism. From problem w/ adrenal cortex, problem w/ anterior pituitary, or problem w/ hypothalamus, or glucocorticoid therapy. Affects metabolism and all body systems
1st degree vs. 2nd degree vs. 3rd degree vs. 4th degree frostbite
Hyperemia and edema vs. blisters w/ partial thickness necrosis vs. dark blisters no blanching, full thickness necrosis w/ debridement vs. no blisters/edema, bloodless, necrosis to muscle/bone, gangrene w/ amputation
Primary mechanisms that can result in SCI
Hyperflexion, hyperextension, axial loading/vertical compression, excess rotation
Insufficiency of adrenocortical steroids aka Addison's can result in
Hyperkalemia - excretion is decreased Poor glucose regulation - hypoglycemia Fluid and electrolyte imbalance, increased sodium and water excretion causing hyponatremia and hypovolemia Decrease in body, axillary, and pubic hair, particularly in women
Monitoring kidneys for K
Hyperkalemia if kidneys not functioning well, review creatinine and if >1.8 notify before admin of K
CV manifestations of Cushing's
Hypertension, increased risk for thombolic events, frequent dependent edema, capillary fragility leading to bruising+petechiae, hypervolemia
SE of women gonadotropin hormone replacement? What's given to induce ovulation?
Hypertension, thrombosis increased esp. if they smoke. Clomid given to induce ovulation
Acute and rehab phases: autonomic dysreflexia assessment
Hypertensive emergency S/S include pounding HA, diaphoresis, nasal congestion, piloerection, bradycardia, and HTN
Grave's aka? Definition? Leads to? Occurs w/?
Hyperthyroid aka toxic diffuse goiter. Autoimmune disorder leading to goiter, exopthlamos aka abnormal eye protrusion, pretibial myxedema aka dry/waxy swelling of lower legs. Occurs w/ DM, vitiligo, arthritis
Hyperfunction of thyroid: disorders
Hyperthyroidism aka thyrotoxicosis/grave's disease, thyroid storm, goiter
Drowning assessment salt water
Hypertonic fluid draws protein fluid into alveoli causing pulmonary edema
Nonobstructed cardiomyopathy
Hypertrophy of all walls and septum
Posterior pituitary disorders hypo? Hyper?
Hypo: diabetes insipidus. Hyper: syndrome of inappropriate antidiuretic hormone SIAH, oxytocin
Growth hormone disorders: hypo? Hyper?
Hypo: dwarfism, cretinism. Hyper: gigantism, acromegaly
Adrenal cortex disorders hypo? Hyper?
Hypo:Addison's aka insufficient cortisol, hyper:Cushing's excess cortisol, Conn's excess aldosterone, Adrenal virilizing syndrome aka excess androgens
Parathyroid disorders hypo? Hyper?
Hypo:hypocalcemia, elevated phosphate. Hyper: hypercalcemia, hypercalcemia crisis
Thyroid gland disorders hypo? Hyper?
Hypo:hypothyroidism, autoimmune thyroiditis/hashimotos, myxedema coma. Hyper: hyperthyroidism, Grave's/thyrotoxicosis, goiter, thyroid storm
Hypo-parathyroid disorder define? From? Fixed how? diet?
Hypocalcemia, elevated phosphate. From surgery that removed parathyroid, autoimmune, or hypomagnesemia, radiation. Fixed via IV calciium, calcitriol, mag sulfate replacement. Test to eat high Ca lo phosphorus foods no milk/yogurt/cheeses
Nerve 12
Hypoglossal muscle of tongue
Combined ventilatory and oxygenation failure
Hypoventilation. Impaired gas exchange at alveoli resulting in poor diffusion of o2 into blood and CO2 retention and may/may not include poor lung perfusion. When lung perfusion not adequate V/Q mismatch and both ventilation and perfusion inadequate
Unstable dysrhythmias H and T's?
Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/ hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma
ARDS indicated by
Hypoxemia that persist (despite 100% oxygen) Decreased pulmonary compliance (elasticity) Dyspnea Non-cardiac related bilateral pulmonary edema Chronic pulmonary fibrosis which can lead to a systemic inflammatory response syndrome (SIRS)
Mechanical ventilation most used for
Hypoxemia, or progressive alveolar hypoventilation w/ respiratory acidosis, surgery, those who expend too much energy w/ breathing, those who have general anesthesia/heavy sedation
Whatever the underlying problem patient in ARF is always
Hypoxemic aka has low arterial blood oxygen levels
Types of respiratory failure
Hypoxic respiratory failure, hypercapnic respiratory failure,
Teacher/educator
INDIVIDUALED TEACHING PLANS TO MEET LEARNING NEEDS OF PATIENTS AND THEIR FAMILIES THROUGH COMMUNICATION
ER care of patient w/ acute adrenal insufficiency
IV NS/dextrose, Hormone replacements H2 blocker for ulcer prevention. Hyperkalemia:Insulin w/ dextrose/NS, Kayexalate for K binding/excreting resin, loop/thiazide diuretics, K restriction, I/O, monitor ECG for slow HR/block/fibrillation. Hypoglycemia: IV glucose, glucagon, monitor BG
Acute spontaneous bacterial peritonitis treatment
IV antibiotics-Quinolones: Norfloxacin, Bactrim if patient has an allergy.
Interventions for hyperparathyroidism
IV fluids, drugs, monitor Ca levels, EKG/cardiac monitor, I/O, prevent injury from bone density loss, encourage low Ca/Vitamin D diet, strain urine, furosemide/lasix+IV saline for Ca excretion, prevent injury
Class 1 LHF from MI interventions
IV nitrates and diuretics, monitor u/o+VS hourly, monitor K
Precautionary measures if an agent must be used despite history of allergic reaction
IV solution, intubation equipment/trach set at bedside, premeditated w/ diphenhydramine aka benadryl or corticosteroid and started slowly
Sores in mouth for HIV interventions
Ice and cold stuff to decrease pain
First aid/prehospital care for black widow
Ice first, monitory for systemic toxicity and if systemic ABC then ED
First aid/prehospital care for brown recluse
Ice, no heat, elevation, wound care, rest
Health promotion for hypovolemic shock
Identify patients at risk Elderly Debilitating illness (avoid overload) Immunocompromised Surgical or accidental trauma patients Cultural and religious attributes (blood products Length of time of hypo-perfusion can impact outcome despite appropriate intervention
If adrenal issue due to pituitary increased ACTH? If from adrenal tumor?
If Adrenal issue due to pituitary increased ACTH removal of pituitary adenoma or hypophysectomy via transphenoidal or transfrontal rout. If from adrenal tumor a partial or complete adrenalectomy.
Neuro manifestations of hypopituitarism if from tumor?
If from tumor changes in vision first, temporal headaches, diplopia/double vision, ocular muscle paralysis limiting eye movement
How to prevent dysrhythmia for ischemic heart disease? If not relieved or gets worse?
If having angina attack treat w/ rest and nitroglycerin, if not relieved/gets worse/sweating/n/weakness/palpitations seek medical help
Stress test
If no chest pain, walks on treadmill to see how well squeeze of heart is for HF
Hypopituitarism if one hormone affected know as? If all hormones? Caused by?
If one hormone affected known as selective, if all hormones decreased called panhypopituitarism. Caused by tumors, malnutrition, rapid loss of body fat, shock, severe hypotension, head trauma, infection, radiation, surgery, AIDs, postpartum hemorrhage
Hypocalcemia/tetany after thyroid surgery: if what happened? Monitor for?
If parathyroid removed/damaged. Monitor for tingling around mouth/toes/fingers, assessor muscle twitching if Ca definiciency
Compensatory stage of shock
If perfusion deficit corrected during or before nonprogressive/compensatory, patient recovers with no residual sequelae If deficit not corrected, patient enters progressive stage
Teach that minor head injury that what can occur
If they have concussion post concussion syndrom can happen. S/S: personality changes, irritability , headaches, dizziness, restlessness, nervousness, insomnia, memory loss, de[presson
Expected outcomes of hyperparathyroidism
If total surgical removal of parathyroid glands, pt verbalizes requirement for lifelong therapy. Hormone levels return to normal Remains free of injury
To assesss humoral immunity
Immunoglobulin Ig levels: IgA, IgG should be 75%, IgM 15%. Presence of circulating B cells
Disease modifying antirheymatics + biological response modifiers
Immunosuppressant decreasing WBCs+platelets avoid large crowds/ill, avoid alcohol,
How ascites develops
Impaired albumin production Serum osmotic pressure decreases, reducing the return of fluid to the blood from the tissues Fluid shifts from the vascular system into the abdomen, a form of "third spacing".
HF impaired? Heart unable to? Characteristic
Impaired cardiac pumping/filling Heart unable to produce adequate cardiac output (CO) to meet metabolic needs Chronic and progressive
Left sided HF assessment
Impaired perfusion, anaerobic metabolism, unusual fatigue. Ask about ADLs, chest discomfort/palpitations/slipped beats, nonproductive cough usually at night, later possible pink frothy sputum if pulmonary edema, dyspnea, exertions dyspnea, orthopnea
Whats characteristic from left ventricular failure
Impaired tissue perfusion, pulmonary congestion, edema, decreased CO
Multiple sclerosis rn dx
Impaired verbal communication and risk for aspiration related to cranial nerve involvement Impaired physical mobility related to weakness, muscle paresis, spasticity Risk for injury related to sensory and visual impairment Impaired urinary and bowel elimination (urgency, frequency, incontinence, constipation) related to nervous system dysfunction Disturbed thought processes (loss of memory, dementia, euphoria) related to cerebral dysfunction
CPAP for HF
Improves sleep apnea which is directly correlated w/ CAD as result of diminished o2 to heart
Parkinson's interventions
Improving Mobility Enhancing Self-Care Activities Improving Bowel Elimination Improving Nutrition Enhancing Swallowing Encouraging the Use of Assistive Devices Improving Communication Promoting Home and Community-Based Care Teaching Patients Self-Care
Priority problems of HF
Improving gas exchange, improving CO, decreasing fatigue/weakness, preventing/managing pulmonary edema
In ventilatory failure what leads to hypoxemia
Inadequate o2 intake or CO2 retention
Hypoxia
Inadequate o2 to tissues
Shock is? Insufficient?
Inadequate tissue perfusion+o2 to maintain function Insufficient oxygen delivery, uptake and utilization to meet the metabolic demands of cells and organs.
Hydrocephalus
Increase in CSF from TBI
Maximal effects of sex steroid replacement w/ androgen/testosterone replacement
Increase in penis size, libido, muscle mass, bone size, bone strength, hair growth, voice deepens, improved self esteem/body image
Cushing's response/reflex triad
Increase in the systolic blood pressure with a widening of the pulse pressure (Hypertension) Cardiac slowing (Bradycardia) Change in respiratory pattern (Bradypnea)
Metabolic manifestations of hyperthyroidism
Increased BMR, heat intolerance, low fever, fatigue
Catecholamine epinephrine effects on heart? Blood vessels? GI? Kidneys? Bronchioles? Bladder? Fat? Pancreas?
Increased HR. Vasodilation. Decreased motility. Increased renin release. Relaxation/dilation. Relaxation. Increased lipolysis. Increased glucagon and insulin released.
Respiratory key features of shock
Increased RR, shallow depth, increased PaCO2, decreased PaO2, cyanosis esp. around lips/nails
Kidney/urinary + skin manifestations of DI
Increased U/O: low specific gravity/dilute urine, hypo-osmolar, poor turbot, dry mucous membranes
Increased PIP means
Increased airway resistance in patient or ventilator tubing aka bronchospasm or pinched tubing, increased secretions, pulmonary edema, decreased pulmonary compliance(lungs stiffer to inflate)
Endocrine findings of cirrhosis
Increased aldosterone/ADH/estrogen/glucocorticoids, gynecomastia
What labs indicate cirrhosis from biliary obstruction
Increased alkaline phosphatase and gamma-glutamyl GGT decreased fecal urinobilinogen, light/clay colored stool, high AMA and ANA titers and elevated immunoglobulin
ARDS: increased? Diffuse? Poorly?
Increased alveolar capillary membrane permeability Diffuse alveolar inflammation and damage is a defining feature of ARDS, appearing as dense bilateral pulmonary infiltrates on chest radiography which significantly reduce lung compliance. Poorly inflated alveoli receive blood but cannot exchange gases therefore a (V/Q) mismatch and hypoxemia results.
Which manifestations are most often seen in general hyperthyroidism
Increased appetite, eyelid retraction, insomnia, palpitations, tremors
Adrenal cortex complications of HIV
Increased cortisol: fat redistribution, decreased muscle. Decreased cortisol: adrenal insufficiency, hypoglycemia, hyperkalemia, hypotension, fatigue, weight loss
In infection WBC differential count usually shows
Increased number of immature nutriophils aka shift to the left
Portal hypertension from cirrhosis define? This leads to? Blood seeks? The hepatocytes have? Leads to?
Increased resistance to or obstruction of the flow of blood thru the portal vein and its branches. This leads to an increase pressure within the portal vein. Blood seeks an alternative path around the increased pressure. The hepatocytes have less access to blood impairing their ability to perform. Leads to esophageal, gastric, and hemorrhoidal varices
Neuro manifestations of DI
Increased thirst, irritability, decreased cognition, hyperthermia, lethargy-coma, ataxia all b/c of dehydration
Renal findings of cirrhosis
Increased urine bilirubin, hepatorenal syndrome
Right sided HF r/t
Increased volume and pressure develops in the venous return Ineffective pump of right ventricle Cannot empty completely Usually caused by lung disease or left HF Weight gain and edema due to systemic blood flow back up Impaired activity and exercise tolerance
S/s of ARDS
Increased work of breathing/hyperpnea, noisy respiration, cyanosis, pallor, intercostal/substernal retractions, sweating, respiratory effort, altered LOC, hypotension, tachycardia, dysrhythmia
Erythropoietin vs. thrombopoietin
Increases RBCs vs. platelets
Megace does what
Increases appetite
Parathyroid hormone function on bone
Increases release of Ca+phosphorus from bone into extracellular fluid aka bone resorption, decreased bone formation, increased bone breakdown all to increase serum Ca
Histamine activity? Symptoms produced?
Increases vascular permeability, constricts smooth muscle, increases gastric acid secretion. Edema of airway, bronchial constriction, urticaria, angioedema, pruritus, n/v/d, shock
Hallmark of sepsis is
Increasing serum lactate, normal/low WBC, decreasing segmented nutrophil w/ rising band nutrophil aka left shift
Dyspnea assessment guide
Indicate amount of SOB you are having by marking the line. Left side of line is no SOB and right side is SOB as bad as can be
Droplet
Indirect transmission w/ infected secretions. Stay at least 3 ft away. Ex: flu
Rn dx for increased ICP
Ineffective airway clearance related to diminished protective reflexes (cough, gag) Ineffective cerebral tissue perfusion related to the effects of increased ICP Risk for infection related to ICP monitoring system (fiberoptic or intraventricular catheter)
Rn dx for shock
Ineffective tissue perfusion; renal, cerebral, cardiopulmonary, gastrointestinal, hepatic, and peripheral related to decreased perfusion to vital organs as evidenced by low heart rate/decreased blood pressure/cool clammy skin etc. Fear and anxiety related to potential for death as evidenced by restlessness Potential complication for organ ischemia/dysfunction related to decreased perfusion as evidenced by abnormal vital signs
Initial assessment is?
Initial assessment for who to see first, not secondary stuff
Basic stages of shock: common to all types of shock
Initial stage (early shock) Non-progressive (compensatory) stage Progressive (intermediate) stage -life threatening emergency Refractory (irreversible) stage MODS/multi organ dysfunction syndrome
Drug therapy for hyperthyroidism/graves
Initial treatment. Iodine, lugol's solution, thionamides like PTU/uracil+methimazole/tapazole, lithium, bea blockers -lol, radioactive iodine therapy
ARDS patho
Injury causes lung fluid increases w/ more protein. Surfactant reduced causing unstable alveoli, edema forms, then hypoxemia and ventilation-perfusion V/Q mismatch result
Secondary mechanisms that can result in SCI
Injury that worsens primary injury: hemorrage, ischemia/lack of blood flow, hypovolemia, neurogenic shock
Trauma definition? Mechanisms? Multi? What results
Injury to living tissue Mechanism of injury (MOI) : Intentional, Unintentional Multisystem affect Injury results
Blunt trauma define? Extent of injury? Transfer energy?
Injury without interruption of skin integrity from impact forces like MVA, fall, blast effect from bomb, acceleration-deceleration forces Extent of the injury may be masked Transfer energy causing tissue deformation trauma to bones, vessels, tissue
Drugs that enhance contractility Interventions for HF raising SV
Inotropics , vasodilators, beta blockers. If chronic low dose beta blockers. Digoxin for symptoms decreasing dyspnea
If high presssure alarm sounds from coughing/gagging/biting ET tube
Insert oral airway to prevent biting
If you cannot get vein via IV or catheter
Intraosseous access
Terlipressin and somatostatin can cause? So observe?
Ischemic complications and dysrhythmia so observe heart rhythm, apical pulse, BP, assess for stroke
Ventricular tachycardia caused by
Ischemic heart disease, MI, cardiomyopathy, hypokalemia, hypomagnesemia, valvular disease, heart failure, drugs, hypotension, ventricular aneurysm, common the initial rhythm before ventricular fibrillation/arrest
Pancreas hormones patho?
Islets have alpha cells for glucagon to raise glucose and beta cells for insulin to lower glucose and delta cells for somatostatin to inhibit glucagon/insulin
If no p
Issue with ventricle
Issues w/ brainstem, thalamus, cortex result in? Cerebellar issues?
Issues w/ opposite side of body. Same sside
Dysrhymias are abnormal rhymes of heart's electrical system how does this affect heart function
It cannot effectively pump oxygenated blood throughout the body
If a person has a positive test result for HIV antibodies
It doesn't mean they ave AIDS only that they are infected w/ virus
Late assessment findings of cirrhosis
Jaundice- (skin and sclera), edema Deterioration of mental function /memory Ascites, hepatosplenomegaly,esophageal varices, Spider angiomas on nose, cheeks, shoulders, veins on abs, palmar arethyma Gynecomastia, hirsutism, peripheral neuropathy Bleeding tendencies and hemorrhage, varices/hemorrhoids, anemia, thrombocytopenia Weakness/wasting R/T anemia & malnutrition RUQ firm, nontender
Late manifestations of RA
Joint deformities, moderate/sever pain, morning stiffness and systemic s/s
Early manifestations of RA
Joint inflmmation, systemic: low fever, fatigue, weakness, anorexia, paresthesias
Acute gout s/s
Joint inglammation, pain, swollen, usually pain in great toe aka podagra, ESR increased, serum uric acid >6.5, urinary uric acid >750
If taking lasix at home they are probably taking what else
K supplement
To prevent VAP/ventilator acquired pneumonia
Keep HOB >30 degrees
Patient fluid restriction teaching should include
Keep a fluid log to record their daily fluid intake Patient to weigh daily. A rapid change in weight can be the result of fluid gain or loss Be aware of how much fluid is in each cup or glass regularly used To determine this, fill each with water. Then, pour the water into a measuring cup To reduce thirst and to decrease dry mouth: Maintain a diet low in sodium Chew on ice cubes/chips. Remember, this fluid needs to be counted in daily fluid intake Suck on sugar-free hard candy Chew gum
Diastole vs. systole
Relaxation/filling vs. contraction and emptying
Extubation
Removal of ET tube. Explain procedure, O2/emergency intubation equipment at bedside. Hyperoxygenate and suction tube/mouth then deflate cuff and remove tube at peak inspiration. Instruct to cough, O2 via facemask/nasal cannula
Obstructive shock treatment
Removal of obstruction CT or needle decompression to remove trapped air pneumothorax Needle pericardiocentesis remove blood pericardial sac Surgical embolectomy Surgical repair aneurysm Anticoagulant therapy (PE)
Exposure interventions
Remove all clothing via scissors if rapid access/possible further injury/fabrics melt into skin. Consider forensics using paper bag for clothing/gloves. Warm client
Acute and rehab phases: autonomic dysreflexia interventions
Remove triggering stimulus Place pt in high fowlers position to ↓BP Identify and Treat the Cause Urinary catheter insertion Fecal decompaction Administration of ganglionic blocking agent (hydralazine) IV Patient education Skin assessment for irritants (wrinkle sheets, food crumbs...)
Preventing hypothermia
Remove wet clothing/sheets Cover client Infuse warm (Invasive) solutions/blood products Increase room temperature Warm/Warming blankets Heat lamps
Minimizing confusion for HIV
Reorient to person/time/place, simple directions, simple language, bring familiar items from home, calendars/clocks, safety, assess for increased ICP and change in LOC
Dx of MG
Repetitive nerve stimulation, electrolyography, tensilon testing
51 y/o in hospital w/ recurrent HF. 237lb, IV in left arm, on O2 2L via nasal cannula. Sitting on side of bed, SOB, returned from bathroom, sweating, nasal cannula on bedside table, what should you do first
Replace nasal cannula ABCDE
Patients w/ HF may experience increased
Thirst and drink excess fluid from sodium retention
CNS changes for hypovolemic shock
Thirst, initial/nonprogressive restless/agitated/anxious/impending doom, progresses to confusion/lethargy then somnolence/loss of consciousness
Control of metabolism via thyroid gland occurs through? Controlled by? What's needed for t4/t3?
Thyroxine T4 and triiodothyronine T3 which increase metabolism/BMR Controlled by hypothalamus thrytropin releasing hormone which trigggers anterior pituary TSH which stimulates T3/T4. Protein and iodine needed for t4/t3.
Emergent triage time to RN/MD? Reassess when? Condition exists that?
Time to RN/MD is immediate, reassess continually. Condition exists that Potawatomi immediate threat to life or limb
Urgent triage time to intervention? Reassess? Define?
Time to intervention 1-2 hours, reassess q 30 minutes or less. Immediate threat to life doesn't exist
Urgent Define? Reassess how often? Examples?
Time to intervention 1-2 hours, reassess q. 30 minutes or more. Suicide or mental issues
Nonurgent triage time to intervention? Reassess?
Time to intervention is several hours, reassess q 1-2 hours
When should RNs document
Timely Chronologically Frequently Late, Delayed or Lost entries
Hypocalcemic crisis s/s
Tingling and twitching of facial muscles and extremities Tetany - muscle spasms as a result of calcium deficiency
Hypoparathyroidism s/s
Tingling, numbness, muscle tentany, severe cramps, spasms, seizures, irritability, psychosis, inappropriate muscle contractions(which can indicate tentative), + Chnosteks/Trousseaus indicate tetany
MS cranial nerves s/s
Tinnitus, vertigo, hearing loss, facial weakness, dysphagia, dysarthria aka slurred speech, dysphagia
Refractory/irreversible stage of shock
Too little oxygen reaches tissues Cell death and tissue damage result causing MOD Body cannot respond effectively to interventions Rapid loss of consciousness Non-palpable pulse Cold, dusky extremities Slow, shallow respirations Immeasurable oxygen saturation
Overal goals of management of shock
Treatment of cause if known Restoration of oxygen delivery to the tissues Reduce oxygen consumption
Mannitol and increased ICP
Treatment of choice, osmotic diuretic, keeps serum osmolarity higher which dehydrated brain. High is dry, low is overload
Thyroid storm/crisis: triggered by? Event that occurs w/? Report? UAP? If temp increased?
Triggered by stressors like trauma, infection, ketoacidosis, pregnancy, iodine. Life threatening event that occurs w/ uncontrolled hyperthyroidism and characterized by high fever and hypertension, tachycardia, ab pain, n/vm diarrhea, anxiousness, tremors, restless, confused, seizures, coma, death. Report any temp increase even of 1 degree F. UAP reports temp as soon as obtained. If temp increased immediately assess cardiac
Tests for HF/MI and could progress to cardiogenic shock
Troponin, EKG, electrolytes, d-diner to test blood clots in lungs, xray.
Heat stroke true? Types? S/s?
True emergency. Types: exertional, classic. Temp >104, hot/dry skin, mental status changes, hypotension, tachycardia, tachypnea, electrolyte imbalances, decreased renal function aka oliguria, coagulopathy abnormal clotting, pulmonary edema aka crackles
If breath sounds and chest wall movement are absent on left side
Tube may be in right mainstem bronchus so reposition tube
Anaphylaxis define? S/S?
Type 1 hypersensitivity that stimulates histamine release. All blood vessels dilated, decreased CO, bronchoconstiction, edema of airway, angioedema, bronchial constriction, urticaria, pruritus, n/v/d, shock within seconds to minutes after allergen exposure
Chronic gout s/s
Urate kidney stone formation, skin tophi aka Na urate crystals on skin, changes in UO
Safety precautions for radioactive iodine therapy: do what? If urine spills? Use what if urinary incontinence? If women incontinence? on 2-3rd day after? Wear? Wash? Avoid? Don't?
Use toilet not used by others for 2 weeks after, sit to urinate, flush 3 times after, if urine pills use paper towel to clean up, bag in sealable bag and take to hospital radiation therapy department, use condom cath if urinary incontinence, use facial tissue layers to cath urine if women incontence, use laxative on 2nd-3rd day after, wear only machine washable clothing and wash separately, wash on empty after using washing machine, avoid close contact w/ pregnant/infants/young, don't share toothbrush/paste,disposable plates/utensils
Drugs and failing liver used? Especially?
Used sparingly since difficult to metabolize. Especially opioids, sedatives, barbiturates, fat soluble vitamins/minerals, excessive iron supplements, niacin, NSAIDs, all OTC drugs and should be restricted
Common causes and risk factors for heart failure
Usually Hypertension, MI, CAD, cardiomyopathy, drugs, valvular disease/stenosis, congenital defects, cardiac infection, dysrhythmia, DM, smoking, fam history, obesity, lung disease, sleep apnea, hyperkinetic conditions(hyperthyroidism), long term NSAIDs/thiazolidinediones for diabetics
High levels of corticosteroids usually in? S/s?
Usually in cushing's Kill WBCs and shrink organs like spleen and lymph nodes
Initial stage of shock
Usually not clinically apparent Metabolism changes from aerobic to anaerobic Lactic acid accumulates and must be removed by blood and broken down by liver
Those w/ minor or moderate TBI
Usually recover at home after discharge
Scorpion interventions
VS first, possible intubation, o2, IV, ice, analgesics/sedatives w/ caution, acetaminophen/tylenol, cooling blanket, tetanus prophylaxis, wound care
Care for dysrhythmias
VS q 4 hours, monitor, evaluate response, notify if chest pain, assess pain/perheral circulation, antidysrhythmic therapy via drugs, cardioversion or defib. Monitor labs and activity tolerance, rest periods, observe respiratory difficulty, promote stress reduction, spiritual support
Home care assessment for HF
VS, poor tissue perfusio(fatigue, angina, activity intolerance, LOC change, pallor/cyanosis, cool extremities), congestion, functional ability, nutrition, home environment, adherence/understanding
Lidocaine for?
VT, VF treatment, ventricular premature beats
Digoxin toxicity
Vague nonspecific including anorexia, fatigue, blurred vision, changes in LOC, dysrhythmia. Early signs of toxicity: bradycardia and loss of P wave. Monitor apical and rhythm. Hypokalemia potentiates toxicity
Nerve 10
Vagus pain and temp from ear, sensation of pharynx/larynx/thoracic/abs, muscles of soft palate/larynx/pharynx, secretory BG lands, cardiac/smooth muscle innervation
Managing urinary/bowel elimination for SCI
Valsalva manuever or tightening abs or catheter for UI. Stool softeners, fluid intake, high fiver diet, consistent time for elimination
Manifestations for addison's if primary ACTH and MSH elevated? If primary autoimmune?
Varies depending. If primary ACTH and MSH elevated increasing pigmentation. If primary autoimmune decreased pigmentation patches and low body hair.
S/s of hemothorax
Varies, respiratory distress, decreased breath sounds
Improving gas exchange HF
Ventilation assistant,monitor RR/rhythm/quality q 1-4 hours, ascultate breath sounds, Supplemental o2 to maintain sat >90%. If dyspea high fowlers w/ pillows under arm, repositioning/coughing/deep breathing q 2 hours to improve oxygenation/prevent atelectasis
Infections from ventilator
Ventilator associated pneumonia from aspiration. Prevented via handwashing and care of tube, oral care, pulmonary hygiene/chest physiotherapy, postural drainage, and turning/position
Blood gas problems from ventilation can be corrected by
Ventilator changes and adjustment of fluid and electrolyte imbalance
Disadvantage of assist control/AC ventilation
Ventilator continues to deliver preset tidal volume even if breathing rate increases which can cause hyperventilation and respiratory alkalosis. If that happens from pain, anxiety, acid/base imbalance correct cause
Surgical management for HF
Ventricular assist deviceventriculectomy, cardioplasty, acorn cardiac support device, myosplint
When cardiac arrest occurs underlying rhythm usually? Then whats initiated?
Ventricular tachycardia VT, ventricular fibrillation VF, or asystole no pulse and unconscious and then CPR must be initiated
CPR for
Ventricular tachycardia, ventricular fibrillation, asystole
Tidal volume Vt is
Volume of air patient receives w/ each breath, as measured on inspiration or expertion. Average prescribed range: 7-10mg/kg
Cardiac output
Volume of blood ejected by the heart each minute Normal adult range 4.8 liters
No one is dead unless
Warm and dead
O2 delivered is
Warmed to body temp, 98.6 and humidified 100% to prevent mucosal damage
Health care associated pneumonia
Was hospitalized >2 of last 90 days, resided in long term care facility in last 90 days, received outpatient infusion or wound care in last 30 days, attended clinic or hemodialysis in last 30 days, has fam member w/ MDRP
Hep E from? Recovery?
Waterborne in India/Asia/Africa/Middle East/Mexico/Central+South America. Fecal contamination. Can recover
Ventilator mode
Way in which the patient receives breaths from the ventilator Assist Control(AC): breathing for the patient Synchronized intermittent mandatory ventilation (SIMV): mandatory breaths are patient-triggered
Muscle deconditioning from ventilator
Weakness from immobility. Get out of bed, ambulate, help w/ exercises
CPAP used commonly for
Weaning. No ventilator breaths delivered, just delivers o2 and provides monitoring and alarm system.
Diuretic interventions
Weigh daily, i/o, measure ab girth, document edema, assess electrolytes since loops like furosemide/lasix can cause hypokalemia or spironolactone conserves it
UAP can
Weigh patient and get I/Os
HF=1 discharge instructions
Weigh yourself daily Take your medication as prescribed Follow your diet and fluid restrictions Follow your activity program Know when to get help (symptoms worsening) Keep your follow up appointments Strongly advised to take influenza and pneumonia vaccines
S/s for Graves
Weight loss Increased appetite Diarrhea Sweating Dyspnea Exophthalamus Thinning hair Vision changes, Irritability Insomnia Fatigue Amenorrhea Increased libido Chest palpitations Hypertension Tachycardia Dysrhythmias
GI manifestations of hyperthyroidism
Weight loss, increased appetite, increased stools, hypoproteinemia
Guillain-barre s/s
Wekness, paralysis, DTR decreased/absent, RR compromise, loss of GUI/GI, ataxia, paresthesia, pain, dysphagia, diplopia, dysrhythmias, tachycardia
Competing
When 1 person seeks to satisfy own interests regardless of the impact on the other parties to the conflict he is competing
Synchronous/demand temporary pacing: how it works
When HR above rate on generator it doesn't fire, when HR less than setting provides impulses
Goal for intervention's for Cushing's
When caused by adrenal or pituitary issue cure possible, when caused by drug therapy for other health problem focus is to prevent complications
Shock: whole? Any problem? More than one?
Whole-body" response "syndrome" Any problem impairing oxygen delivery to tissues and organs can start shock, lead to life-threatening emergency More than one shock state can exist at a time
Masklike face
Wide open fixed staring eyes
Cirrhosis patho? Inflammation? Early on?
Widespread scarred/fibrotic tissue that changes normal makeup. Inflammation from toxins/disease causes degeneration as it develops tissue becomes nodular blocking ducts/blood. Early on enlarged/firm/hard but shrinks
If a person has unprotected sex w/ HIV + person one night and comes in for testing week later the ELISA
Will be - even though the patient may have active HIV since the body hasn't had enough time to form antibodies
Accommodating/cooperating
Willingness of one partying to a conflict top lace the opponent's interest above his/her own
Housekeeping for HIV
Wipe up body fluids w/ soap/water and disinfect w/ bleach wearing gloves
With rhythms you can have?
You can have a mix of more than one
Once doctor tells fam death you can
You can reiterate what doc has said
History for hypovolemic shock
Younger most common, trauma, procedures, GI ulcers, hemophilia, liver disorders, prolonged n/v/d, aspiring, NSAIDs, diuretics
Intervention to increase intake for nutrition for HIV
Zofran 30 min prior to meals, if mouth sores magic mouth wash with lidocaine
Assist control ventilation
Resting mode. Takes over work of breathing. TIdal volume/ventilatory rate preset. If no spontaneous breaths ventilatory pattern established by ventilator. Programmed to respond to inspiratory effort if breathing which then ventilator delivers preset tidal volume while allowing patient to control breathing rate
Beta adrenergic blockers
Reverses catecholamines. Started slowly in chronic HF. Carvedilol/coreg, metoprolol/lopressor. AAssess for bradycardia/hypotension. Weight daily
Hypovolemic shock interventions focus on
Reversing shock, restoring fluid volume, preventing complications
Sinus arrhythmia difference from normal sinus rhythm
Same as normal sinus rhythm except HR increases during inspiration and decreases during exhalation causing PP/RR intervals to vary is normal and can be from digitalis or morphine
Ventricular fib can look like
Seizure
Standard for sepsis treatment
Sepsis rescucitation bundle
Distributive shock septic shock
Septic Shock = Presence of sepsis with hypotension despite fluid resuscitation Presence of tissue perfusion abnormalities Stage of sepsis/SIRS when MOD evident and uncontrolled bleeding. Severe hypovolemic shock and hypodynamic cardiac function present.
Hyperkinetic conditions causing high output HF
Septicemia, high fever, anemia, hyperthyroidism
Close sepsis
Serious emergency. Common in the US > 750,000 cases annually > 200,000 deaths Management improved but Increased drug resistant organism Early discharges "quicker and sicker"
Dx of hyperparathyroidism
Serum PTH levels X rays (kidney stones, calcium deposits, and bone lesions)
Dx for SIADH
Serum sodium, potassium, chloride, and bicarbonate Plasma osmolality Serum creatinine Blood urea nitrogen Blood glucose Urine osmolality Serum uric acid Serum cortisol Thyroid-stimulating hormone CT scan, MRI
Managing ventilator system
Settings prescribed and checked. Check water and temp. Remove condensation in tubing by draining into receptacles and empty. Assess/care for et/trach tube to maintain patency
BNP >900
Severe HF
Pulmonary edema causes by
Severe HF w/ fluid overload, acute MI, valve disease, dysrhytmia
Sepsis can progress to?
Severe sepsis occurs when a patient with documented sepsis goes on to develop acute organ dysfunction and tissue hypoxemia Most commonly affected organs are the kidney, lungs, heart and blood vessels
HIV transmission
Sexual w/ mucous membrane to infected sectretions, parenteral w/ needles/equipment w/ blood, perinatal from placenta or maternal blood/fluids/milk
Waste disposal for HIV
Sharps in puncture proof container like coffee can, standard precations, bleach,
Hypothermia first aid/prehospital care
Shelter, remove wet clothing, passive rewarming via warm clothing/blankets, active rewarming via heating blankets, warm packs, heaters. Warm high carb liquids w/ no caffeine/alcohol
Advanced beginner preceptor implications
Shift from teaching rules to guidelines, help to recognize patterns and their meanings, assist in prioritizing, must be backed up by competent nurse
ECG and HF
Shows hypertrophy dysrhythmias, MI, not helpful determining extent/presence of HF
Surgical treatment for cirrhosis? Who is surgical risk?
Shunt- Diverts fluid away from the liver. Correction of:electrolyte imbalances, abnormal coagulation (FFP, vitamin K, and PRBCs) Patients with ascites are poor surgical risks.
Levodopa-carbidopa aka? Function? SE? Take when
Sinemet. Less expensive and better for motor function. SE: long term use leads to dyskinesia. Take before meals
For MS w/ cognitive impairment
Single date calendar, written lists, recorded messages, organized environment, frequently used items in familiar places
Sinus dysrhythmias include
Sinus tachycardia or bradycardia
Pulmonary cather/Swans catheter
Sits in pulmonary artery for pressure. Enters through jugular vein into right atrium
Compromising
Situation in which each party to conflict is willing to give up something
Collaborating
Situation in which the parties to a conflict each desire to satisfy fully the concerns of all the parties. In collaborating the intention to the parties are to solve the problem by clarifying differences rather than by accommodating various points of view
Smoothing
Situation where an effort to compliment the other part and focus on agreement. original conflict rarely resolved
ED handoff to inpatient info to give
Situation, brief history, assessment/diagnostic findings, transmission precautions needed,interventions, response to interventions AKA SBAR
Calcium channel blockers function? Examples? For?
Slow HR. Verapamil/calan and diltiazem/cardizem for supraventricular tachycardia, atrial flutter, atrial fibrillation
Parkinson's disease define? Can be?
Slowly progressing neurologic movement disorder that eventually leads to disability characterized by tremor, rigidity, bradykinesia/akinesia slow or no movment, postural instability due to dopamine loss and reduced sympathetic nervous system. Can be primary idiopathic or secondary from tumors/drugs
ACEI and ARDs are started
Slowly, 1st dose can rapidly drop BP. Those at risk: BP already <100, >75y/o, Na <135, or are volume depleted. Monitor bP and immediately notify if BP < 90, if BP <90 lay flat to increase cerebral perfusion
Romberg sign
Stand w/ arms at sides and eye open w/ no swaying then w/ eyes close and sways proprioceptive issue if swaying for both eyes closed+open cerebellar
Staff safety examples
Standard Precautions PPE Negative pressure rooms for tuberculosis etc. Domestic violence Follow security plan for violent clients look for escape/de-escalation
Direct home care for HIV
Standard precautions, good handwashing, don't share razors/toothbrushes
Prevniting hepatitis in healthcare
Standard precautions, needless systems, hep B vax, immunoglobulin w/in 14 days, adequate sanitation/hygiene, wash hands, drink treated water, don't share bed linen/towels/utensils/glasses, don't share needles/razors/nail clippers/toothbrush/waterpiks, condoms, bandages over cuts/sores
Treatment goals for ARDS/respiratory failure: use what to reduce inflammation? Maintain? Provide adequate? Provide what as necessary?
Steroids to reduce inflammation Maintain an appropriate fluid balance, considering underlying conditions, conservative fluid management has been linked to improved outcomes in ARDS. Provide adequate nutrition: consider enteral or parenteral nutrition. Provide hemodynamic support as necessary.
One of the most important aspects of ongoing care for patient w/ cirrhosis is to
Stress avoiding alcohol/illicit drugs to prevent further fibrosis, allow it to heal, prevent GI irritation, reduce bleeding
GI and nutrition issue from ventilation
Stress ulcers decreasing nutrition and increasing risk for infection Fixed via drugs. Paralytic ileum requiring PTN Malnutrition causing weakness
Preload
Stretching of the muscle fibers in the ventricle Called central venous pressure Measured in the right atria Normal CVP 0-8mm Hg The larger the volume the greater the stretch Affected by venous return
Airway across room assessment
Stridor or wheezing Grunting Sniffing position Can't speak Drooling/can't control secretions
Conditions that affect areas of the brain that control breathing that can lead to respiratory failure
Stroke, drug/alcohol OD
Distributive shock anaphylactic shock
Swelling of the lips and tongue, angioedema Wheezing, stridor Flushing, pruritus, urticaria Respiratory distress and circulatory failure Anxiety, confusion, dizziness Sense of impending doom Chest pain Incontinence
Bees/wasps s/s
Swelling, systemic effects like edema, n/v, diarrhea, renal failure, liver injury, dysrhythmias. If allergic urticaria/hives, pruritus/itching, swelling of lips/tongue. Anaphylaxis shown via respiratory distress bronchospasm, laryngeal edema, hypotension, altered LOC
Amatadine aka? Function
Symmetrel antiviral for parkinsons
Sinus tachycardia
Sympathetic stimulation or vagal/parasympathetic inhibition causing increased SA node discharge >100bpm from activity, anxiety, pain, stress, fear, fever, anemia, hypoxemia, hyperthyroidism, pulmonary embolism, epinephrine, atropine, caffeine, alcohol, nicotine, aminphylline, thyroid meds, hypovolemic shock, MI, infection, heart failure
Compensatory mechanisms for HF
Sympathetic system stimulation, renin-angiotensin system activation, other chemical responses, myocardia hypertrophy
Cardiomyopathy assessment
Symptoms are dependent on the structural and functional abnormalities of the heart muscle These patients tend to have right or left side heart failure
Early assessment findings for cirrhosis
Symptoms are vague and nonspecific. Fatigue, anorexia, abdominal pain edema of ankles, epistaxis, bleeding gums, itching and significant weight change. .
Bowel training education
Symptoms of impaction Diet with sufficient fluid intake and fiber
Physical assessment for Addison's
Symptoms r/t hypoglycemia:sweating, tachycardia, tremors Dehydration Hyperpigmentation r/t increased melanocyte stimulating hormone (MSH)
Cardioversion define? For?
Synchronized countershock for emergency unstable ventricular or supraventricular tachydysrthmias or elective for stable tachydysrthmia and resistant to meds
Health promotion for cold
Synthetic clothing since stays dry, no cotton. Layer clothing, inner layer of polyester fleece, outer wind/waterproof layer , hat, facemask, sunscreen, glasses
Right sided HF assessment
Systemic congestion, fluid retained, pressure builds, edema in lower legs progressing up, ask about weight gain, nausea, anorexia from liver resulting in fluid retention, advanced HF ascites and increased ab girth, diuresis at risk
Right sided heart failure key features
Systemic congestion: jugular vein distention, enlarged liver/spleen, anorexia/nausea, dependent edema of legs/sacrum, distended abdomen, swollen hands/fingers, polyuria at night, weight gain, increased BP from excess volume or decreased BP from failure, increased ab girth, ascites
Systemic sclerosis interventions
Systemic steroids, immunosuppressants, skin protection, warmth, no stress/drugs, HOB elevated, small/frequent meals, semisoft foods, no caffeine/pepper
Whats characteristics from right ventricular failure
Systemic venous congestion, peripheral edema
Sympathetic nerves
T1-4 Releases Noradrenaline Cardiopulmonary splanchnic nerve Increase heart rate Increase contractility Cell can meet oxygen demand
Treatment for portal hypertension
TIPS transjugular intrahepatic portosystemic shunt
Synchronized intermittent mandatory venilation SIMV
TIdal volume and ventilatory rate preset. if patient doesn't breath ventilatory pattern established by ventilator, allows spontaneous breathing at patient's own rate and tidal volume between ventilator breaths. Ventilatory and weaning mode.
Thombolytic therapy for MI
TPA, retaplase
Anterior pituitary hormones
TSH aka thyrotropin, adrenocorticotropic ACTH, lerutinizing hormone, follicle stimulating, prolactin, growth hormone, melanocytes stimulating
Desmopressin DDAVP: forms? Function? Dont? Do what? Notify if?
Tabs, nasal spray, parenteral. ADH replacement. Don't drink >3L fluids/day. Weigh daily. Notify if >2lbs/day gained or persistent headache/confusion since can indicate water toxicity
1st stage of shock early
Tachycardia, fever, tachypnea, CO2 retention
Cardiovascular shock s/s
Tachycardia, thready pulse, low CO/BP
Distributive shock/septic shock s/s
Tachypnea/hyperventilation Temperature dysregulation ↓ urine output Altered neurologic status GI dysfunction Respiratory failure is common
Education for cortisol replacement therapy
Take in divided doses in morning and 2nd at 4-6PM, take w/ meals, weight daily, increase dosage as directed for stress, never skip dose, wear alert bracelet, know how to give IM hydrocortisone
How to prevent premature beats and ectopic rhythms
Take meds, stop smoking/caffeine/alcohol, manage stress, don't get too tired
When counting regular rhythm aka small box method
Take number of small 0.2 boxes between 1 R wave and another R wave and divide by 1500.
RN is caring for client being discharged after thyroidectomy, what discharge instructions should be appropriate
Take thyroid replacement meds as ordered, watch for body changes like lethargy/restlessness/sensitivity to cold/dryer skin and report to Dr.
Rn management for mechanically ventilated
emergency equipment available Have a patent IV access/IV fluids, IV flush and medications available if needed Notify and/or partner with Respiratory therapist Educate patient/family regarding immediate post intubation process (CXR, ABG, IV drips, restraints, communication, etc.) Ensure patient safety and comfort and a method of communication Monitor cardiac/respiratory function Monitor vent alarms/response to therapy Assess mouth around ETT for pressure ulcers Insert/maintain indwelling urinary catheter, nasal/oral gastric tube Prevent complications of immobility, i.e. DVT
RN's provide a wide range of client education on a daily basis. Accurate documentation of this education is essential to
enable communication and continuity of what has been taught. Lack of documentation about client education diminishes this important aspect of care.
Clinical competency
encompasses the ability to observe and gather information, recognize deviations from expected patterns, prioritize data, make sense of data, maintain a professional response demeanor, provide clear communication, execute effective interventions, perform nursing skills correctly, evaluate nursing interventions, and self reflect for performance improvement within a culture of safety
Vasopressin antagonists function? Names? Only?
excrete water without sodium loss Tolvaptan (Samsca), Conivaptan IV (Vaprisol) used in hospitalized patients. Only given in the hospital setting allowing close monitoring for the development of hypernatremia.
5 important characteristics for good documentation
factual, accurate, complete, current (timely), organized, compliant with standards These core principles of nursing documentation apply to every type of documentation in every practice setting.
Acute spontaneous bacterial peritonitis SBP s/s
fever, chills, abdominal pain and tenderness, anorexia, change in mental status
COPD drugs
includes meds for asthma) and corticosteroids, mucolytic, positioning Symbicort, Spiriva, flovent
Beta blockers
lols" Widely prescribed classes of drugs to treat Hypertension (high blood pressure) Heart failure Long-term use of beta-blockers helps manage chronic heart failure Action Beta-blockers work by blocking the effects of epinephrine (adrenaline) and slowing the heart's rate Decreasing the heart's demand for oxygen Decreases force of contractions Worsen asthma, impotence, hallucinations (elderly)
COPD patients may have
lower levels that are acceptable PaO2 of <60 mmHg or a SaO2 of <90% or a PaCO2 of >50 mmHg as their normal.
Ventricular assist device VAD is
mechanical pump that's used to support heart function and blood flow in people who have weakened hearts. The device takes blood from a lower chamber of the heart and helps pump it to the body and vital organs, just as a healthy heart would.
Hepatitis A s/s? Route? Rocovery?
mild, flu like. Fecal oral route from people or consuming contaminated food/water like shellfish. Can recover
Patient after hypophysectomy
monitor neuro q 1 hour 1st 24 hrs, monitor IO since DI possible, deep breathing, don't cough/blow nose/sneeze, don't brush teeth instead floss/mouth rinse, avoid bending at waist, monitor nasal drip for halo since CSF, monitor bowels to prevent straining, teach self admin of hormones+vasopressin
Normal pH? PaCO2? HCO3?
pH: 7.35 - 7.45 7.40 PaCO2: 35 - 45 40 HCO3: 22 - 26
Advocate
protection of human or legal rights; patients have the right to make informed decisions about their own care
COUNsELOR
provide appropriate information to help patients and their families facilitate problem-solving and decision-making
CD4/CD8 ratio? CD4 count of AIDS?
ratio <2, count <200/mm3
ABGs of HF
reveal hypoxemia oxygen does not diffuse easily through fluid filled alveoli. Respiratory alkalosis - hyperventilation, resp acidosis- CO2 retention, met acidosis - accumulation of lactic acid
Patients who are not considered candidates for transplantation
severe CV instability w/ cardiac disease, severe respiratory disease, metastic tumors, inability to follow instructions
Autonomic dysreflexia interventions
sitting position first, notify, loosen clothes, check catheter for kinks, catheter if not already, check for fecal impaction, check roll temp to make sure not cold, measure BP q 10-15 minutes, nitrates/hydralazine
Prednisone aka? Function? SE?
anti-inflammatories (steroidal) (intermediate acting) immune modifiers. Suppresses adrenal function at chronic doses of 5 mg/day. Replaces endogenous cortisol in deficiency states.acne, ↓ wound healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression, hyperglycemia, cushingoid appearance, increased infection, muscle wasting, osteoporosis, hypertension, depression, euphoria, edema
Methyl prednisolone aka? Function?
anti-inflammatories (steroidal) immunosuppressants, corticosteroids Replacement therapy in adrenal insufficiency., SE just like prenisone
Propylthiuracil PTU aka? Do what? May affect? SE?
antithyroid drug Avoid large crowds (decrease WBC's) May affect liver functioning Slow heart rate, weight gain, and cold intolerance
Decompensated cirrhosis
the development of ascites, jaundice, hepatic encephalopathy or variceal bleeding (metabolic abnormalities occur
In physiology perfusion is
the process of a body delivering blood to a capillary bed
Magic mouthwash: used when? Compounded how? The most common ingredients are?
used 30 min prior to eating to prevent or treat oral mucositis. compounded by a pharmacy and most often contains anticholinergic agents such as diphenhydramine (Benadryl); an anesthetic, such as viscous lidocaine; and an antacid or mucosal coating agent, such as magnesium or aluminum hydroxide, kaolin, or sucralfate. may also contain an antibiotic and/or an antifungal medication such as nystatin, and a corticosteroid. The most common ingredients are diphenhydramine, viscous lidocaine, antacid, nystatin, and corticosteroids
Echocardiography aka echo is
uses sound waves to create moving pictures of your heart. The pictures show the size and shape of your heart. They also show how well your heart's chambers and valves are working. Echo also can pinpoint areas of heart muscle that aren't contracting well because of poor blood flow or injury from a previous heart attack. A type of echo called Doppler ultrasound shows how well blood flows through your heart's chambers and valves. Echo can detect possible blood clots inside the heart, fluid buildup in the pericardium (the sac around the heart), and problems with the aorta. The aorta is the main artery that carries oxygen-rich blood from your heart to your body.
Short term esophagogastric balloons tamponade
using a Minnesota or Blakemore tube. Difficult process for patient.
Endoscopic sclerotherapy
varices are injected with a sclerosing agent. Many complications, EVL is preferred
Acute respiratory failure can occur as a result of
ventilatory (air movement) or oxygenation (gas exchange) failure or a combination of both
The pressure in right atrium is indicator of
circulating blood volume and right ventricle pumping strength. Normal CVP readings are between 2-8 mm Hg.
Clinical competency focuses on
clinical nursing skills: Technical skills Patient care Cultural competency communication
Gout interventions
colchicine+NSAID for acute if chronic allopurinol, low purine diet, no ogran meats+fish+shellfish
Electrolyte imbalance can occur from
complications of HF or as SE of drug therapy, esp diuretic.
S/s of pulmonary edema
crackles/dyspnea/disorientation/confusion. Acute: anxious, tachycardia. Late sides: moist productive frothy blood tinged sputum+cold/clammy/cyanotic
If 17 small boxes between 2 R waves
1500/17=88.23 or 88 bpm
Phases of case management of ARDS
1: early dyspnea/tachypnea via supporting/O2, 2: patchy infiltrates increasing pulmonary edema and supported via mechanical ventilation/preventing complications, 3: hypoxemia and supported via O2, preventing complications, supporting lungs, 4: irreversible pulmonary fibrosis and supported via preventing sepsis, pneumonia, multiple organ dysfunction syndrome, weaning from ventilator
Goals for management of ARDS phase 1? 2? 3? 4?
1: give o2, support. 2: prevent complications from PE/ventilation. 3: support lungs, give O2, prevent complications r/t hypoxemia. 4: irreversible lung damage, prevent sepsis, organ failure, wean from ventilator, long term care/rehab
Classification/staging of HF
1: high risk, cardiac structural abnormalities. 2/3: current/prior s/s of HF. 4:end stage HF
Stages of conflicts
1: potentional opposition/incompatibility, 2: cognition and personalization, 3:intentions, 4:behavior, 5:outcomes
Stages of hepatic encephalopathy
1: prodromal, 2:impending, 3: stuporous, 4:comatose
Hypothermia hospital care for? Do what?
For moderate/severe. Handle gently, supine position, ABC, drugs w/ caution and/or spaced longer, drugs can accumulate w/out effect and once warmed can lead to toxicity, withhold IV drugs until core >86, CPR if w/out spontaneous circulation, defib can be ineffective until >86, active external and core warming, trunk warmed before extremities, warm IV fluids/O2, heated peritoneal/pleural/gastric/bladder lavage. Cardiac bypass, hemodialysis, venous rewarming via catheter
Thyroxine/T4 and TSH
For older than 65, a.fib, or evidence of thyroid disease since HF can be caused by or aggravated
Dopamine agonists function? Example? SE?
For parkinsons. Lowers dyskinesia. Ex: ropinirole/requip. SE: postural hypotension, hallucinations, sleepiness.
Cyclosporine/sandimmune/neoral
For psoriasis, RA, MS, MG, scleroderma, lupus, organ transplant rejection. Blocks helper t cells
Iodine preparations used for? Can result in?
For short term therapy before surgery to decrease thyroid blood flow reducing thyroid hormone for 2 weeks. Can result in hypothyroidism
If high pressure alarm sounds from airway size decreased r/t wheezing/bronchospasm
Ascultate breath sounds
If high pressure alarm sounds from pneumothorax
Ascultate breath sounds, Alert doc or rapid response about bronchospasm or decreased breath sounds or unequal chest excursion
Neurogenic shock example
30 year old client comes to ER after a diving injury. He and some of his friends were swinging from a rope into a creek below when his head struck the bottom of the creek resulting in a cervical fracture and paralysis from his neck down. He is alert and oriented vital signs T -99.6 BP 110/68, MAP 82 , HR-72, Resp-22. He is placed on a ventilator due to suspected cervical injury. His neck is immobilized in a cervical collar. 30 minutes later you enter his room because the ventilator alarms are going off. VS: 99.8, 60 and bounding, BP 82/62, MAP 68, R 28 bucking the ventilator. Capillary refill >2, client is anxious, extremely restless.
PaCO2
35-45. Increased: anaerobic metabolism
Adaptive immunity aka? Define?
3rd line defense. Passive vs. active immunity. Cellular T cell mediated or humoral B cell mediated
Nonsurgical management for burn wound infection
Asepsis, safe environment, monitoring for early infection, drugs, isolation, environmental infection, no plants, no raw foods
Remember with SBAR
Ask clarifying questions
Med management for MI
Aspirin, glycoproteins inhibitors, beta blockers, ACE inhibitors, thrombolytic therapy
Leader
Assertive, self-confident practice, effecting change and teamwork
For test remember to
Assess
Assessing level of spinal injury
Assess ABC's Respiratory dysfunction is related to level of injury Pons in the Brainstem is the respiratory center Abdominals and intercostal muscles (T1-T11) Diaphragm (C4) ARF leading cause of death in high cervical cord injury CV dysfunction common in acute spinal cord injuries Cont. ECG monitoring for bradycardia, asystole, & other arrhythmias
Emergency care of anaphylaxis
Assess ABC, call RRT, intubation/tracheotomy equipment at bed, O2, discontinue IV by changing tubing w/ NS, start IV if no IV w/ NS, prepare epinephrine, HOB elevated 10 degrees if hypotension if normal BP 45 for ventilation, raise feet/legs, stay w/ patient, reassure
Monitoring patient response to ventilator
Assess VS, breath sounds, pulse ox, ABGs, breathing pattern, et/trach site
Because other dysrhythmias besides PVCs can cause widened QRS
Assess carotid, brachial, or federal arteries against monitor or auscultation apical pulse. PVCs can indicate ventricular tachycardia or fibrillation
BUN normal? Hypofunction of adrena? Hyperfunction?
10-20 but in older can be higher. Increased, normal.
Ventricular muscle cells rate
10-20bpm
Sinus tachycardia vs. supraventricular tacycardia
100-149 vs. 150-250bpm
Normal sodium? Hypernatremia can indicate? Hyponatremia can indicate?
135-145, fluid deficiency, fluid overload
Na normal? Hypofunction of adrenal? Hyperfunction?
136-145. Decreased, increased
Normal glasgow
15
If 10 small boxes between 2 R waves
1500/10 = 150 bpm
12 lead ekg how many leads
10 stickers on but actually captures 12 views
THe fraction of inspired O2 aka FiO2 is usually prescribed at what than the level used while ET tube in place
10% higher
Normal ICP range
10-15mmHg
If high pressure alarm sounds from artificial airway being displaced/ ET tube slipped into right mainstem bronchus
Assess chest for unequal breath sounds and chest excursion. Obtain CXR as ordered after proper position verified, tape securely in place
Preventing or managing pulmonary edema w/ HF
Assess for early s/s: Document crackle location, if not hypotensive sitting high fowlers w/ legs down. Priority admin O2 via facemask or nonrebreather. Pulse ox >90. If not better notify respiratory therapy for BiPAP/CPAP. If BP >100 nitroglycerin q 5 minutes 3x. Lasix/bumex, if BP good morphine, if severe ultrafiltration
Physical assessment of hyperparathyroidism
Assess for recent bone fractures Weightless, psychological distress, waxy pallor of skin, bone deformities, GI issues like anorexia/n/v/pain/constipation, peptic ulcers, fatigue, lethargy, psychosis, entail confusion, coma Arthritis Recent radiation treatment to the head or neck Renal stones Confusion
Assessment: targeted history dx of respiratory failure
Assess for underlying conditions that lead to respiratory failure. Focused respiratory assessment
Transjugular intrahepatic portal systemic shunt TIPS: for those? Procedure? Usually discharged when? Requires?
For those who don't respond to other treatment for hemorrhage or long term ascites. Sheath through jugular and needle guided through liver into portal vein and balloon enlarges and stent keeps it open. Usually discharged in 1-2days and requires 1 yr follow up US
Rescue therapy for transplant rejection used for? What is used?
For treating acute rejection. Globulin or muromonab
Psychosocial assessment of Graves
Assess mood swings Irritability Decreased attention span Manic behavior
Increased ICP inteventions
No extreme neck/hip flexion, no suctioning, avoid low o2, don't cluster activities, quiet environment, low lights, no high temp/fever
AIDs dietary limits
No fresh/raw or rare
Compensated cirrhosis
No obvious symptoms, may be unaware of disease, stable
V. Fib no? Can be from?
No recognizable deflections, no CO or pulse. Can be from CAD, MI, hypokalemia, hypomagnesemia, hemorrhage, antidysrhythmics, SVT, shock, surgery, trauma
Assessment for acromegaly
Assess patient's age, gender, and family history Changes in hat size, glove, ring, or shoe size Presence of fatigue Headache Joint pain Increase in lip, nose, hands, feet, Prominent brow ridge Visual disturbances
Snakebit prevention
No venomous snakes as pets, protective attire, walking sticks/poles, inspect areas before placing hands/feet in them, don't harass snakes, don't transport snake w/ victim unless in sealed container
Normal ratio of CD4 to CD8? In HIV/AIDS?
2:1, in HIV and AIDS because of low CD4 ratio is low and associated with increased manifestation of disease
Sepsis can usually be? Avoid? Secondary prevention? Patient?
Can usually be prevented Avoid trauma and hemorrhage Proper safety equipment Seat belts Awareness of hazards in home/workplace Secondary prevention Assess for early manifestations Patient teaching
Hypothermia s/s for mild, moderate, severe
Core <95, Mild: shivering, dysarthria/slurred speech, decreased coordination, impaired cognition, diuresis. Moderate: weakness, acute confusion, apathy, incoherence, stupor, decreased clotting/thrombocytopenia. Severe: bradycardia, hypotension, decreased RR, dysrhythmia, decreased neuro reflexes, acid/base imbalance
Drug and fluid therapy for ARDS
Corticosteroids to reduce inflammation, antibiotic is infection, conservative fluid therapy w/ diuretics
Hypothalamus hormones
Corticotropin releasing, thyrotropin-releasing, gonadotropin releasing, growth hormone releasing, growth hormone inhibiting, prolactin inhibiting, melanocytes inhibiting
ECG paper
30 boxes in 6 second strip, big box=0.2 seconds and little box = 0.04seconds
Ensure each intubation attempt lasts no longer than
30 seconds, preferably <15 seconds then. After give O2 and suction if needed
Deceleration vs. acceleration
Flying off motor cycle and due to gravity being slowed down across gravel slowly vs. acceleration ejected off motor cycle and hitting a tree ie they are going fast and stopped abruptly and organs keep going and hit the inner body
Competent preceptor implications
Focus on improving decision-making skills and ways to improve coordination of multiple/complicated care needs of patient assignments, food preceptor for novice nurse
Pronator drift
For cerebral/brainstem motor issue if patient closes eyes and hold arms up w/ palms up for 15-30 seconds the arm on weak side will fall/drift with palm pronating turning inward
Level 3 trauma center
For communities w/out level 1-2 centers, primary focus is stabilization and transfer
Ventricular assist devices
For end stage. Mechanical pump implanted for short term awaiting heart transplant or long term
Assessment of sensory function for? Includes?
For guillain barre syndrome. Includes pain, superficial/deep sensation, light touch, proprioception
Barbiturate coma define? Complications?
For increased ICP using pentobarbital/nembutal or thiorpentone. Has mechanical ventilation. Complications: decreased GI motility, dysrhythmia, hypokalemia, hypotension
Parkinson's s/s
Onset gradual, after 50 y/o, mask like blank expression, stooped posture, pill rolling tremors in hands/arms/diaphragm/tongue/lips/jaw, shuffling gait, rare in black people, muscle rigidity, depression, mental deterioration, bradykinesia aka loss of normal arm swing/lowered eye blinking/loss of slawllowing/difficulty initiating movement
Immune history assessment
Allergies, meds that have immmune SE like antibiotics/anti-inflammatory/immunosuppressive agents/antimetabolites/ antineoplastics/thyroid suppressive therapy. Fam history, infection history, immunizations, autoimmune disorders, cancer
Common rn dx for immunocompromised
Altered Nutrition:Nutrition meets metabolic needs Altered Protection:Resolution of signs of altered protection Impaired Skin Integrity:Signs of impaired skin integrity resolving Activity Intolerance:Resolution of signs of activity tolerance Knowledge Deficit: Client demonstrates or verbalizes understanding Risk for infection:Absence of infection or risk for infection decreased
Use of halo
Alters balance, loose clothing, bathe in bathtub, wash under vest, support head w/ pillow when sleeping, stay active, don't drive, straws for drinking, cut food in small pieces, wrap pins w/ cloth if cold temp, pin care, observe pins daily, increase fluids/fibers
Target cell concept-interlocking puzzle
Although many different hormones circulate throughout the bloodstream, each one affects only the cells that are genetically programmed to receive and respond to its message.
Safety is
Always first
Nonurgents are
Ankle sprain and cold or broken toe or flu like
Addison's GI manifestations
Anorexia, n/v, ab pain, bowel changes either constipation or diarrhea, weight loss, salt craving
Managing fever
Anti-infectives, antipyretics like acetaminophen/tylenol, increase fluid intake, external cooling w/ hypothermia blankets/ice, sponging w/ tepid water, cool compress, no fans
Common agents that cuase anaphylaxis
Antibiotics, ACTH, insulin, opioids, local anesthetics, ACE inhibitors, chemo, radiocontrast, foods, pollen, mold, latex, bee, wasp, fire ants, hornets
Benzotropine type? Aka? SE?
Anticholinergic aka congentin. SE: confusion, urinary retention, constipation, dry mouth, blurred vision
Minimizing diarrhea for HIV
Antidiarrheals, less fat/spicy/sweet foods, no alcohol/caffeine
Meds for hyperaldosteronism
Antihypertensive medications Potassium sparing diuretics: Aldactone, Spirono Eplerenone (Inspra) blocks action of adolsterone
Circulation assessment
Any obvious bleeding. Use direct/firm/manual pressure, tourniquet last resort or w/ traumatic amputation. Assess peripheral/central pulses, HR, BP, perfusion
Shock caused by
Any problem that impairs o2 delivery to tissues and organs leading to life threatening emergency, usually from cardiovascular problems and changes
Valvular heart disease
Aortic Valve Stenosis/ Regurgitation Mitral Valve Stenosis/Regurgitation Endocarditis
Psychological manifestations of hypothyroidism
Apathy, depression, paranoia, withdrawal
Breathing
Are ventilatory efforts effective? Spontaneous breathing/chest expansion Respiratory rate and/or effort Auscultate breath sounds Chest wall integrity Lung compliance via ventilating w/ BVM Signs and symptoms of pneumothorax or hemothorax Intubation masks or chest decompression via needles/chest tube if pneumothorax
Acute& rehab phases spinal shock assessment
Areflexia below the level of injury Spinal cord segment below is without sensation, paralyzed, flaccid, & reflexes are depressed Reflexes initiating bladder & bowel function are affected leading to bowel distention & paralytic ileus
After heart transplant
Arrthymias are possible. The younger the donor heart the better the outcome
Common meds for immunocompromised and function of each
Bactrim- To prevent pneumocystis carinii pneumonia Antifungal drugs to prevent oral candidiasis Antibacterial prophylaxis (levaquin) Antiviral drugs-Acyclovir to prevent Hep B, CMV, Herpes
Bands normal %+ /mm3? Lymphocytes % + /MM3
Bands 5% or 500/mm3. Lymphocytes 28% or 2800 /mm3
Cause of tension pneumothorax
Barotrauma from BVM or ventilation, blunt/penetrating chest trauma, progression of simple pneumothorax
Lung problems from ventilation
Barotrauma: pneumothorax, emphysema, pneumomediastinum from airflow limitation, blebs/bullae, PEEP, hyperinflation, or high pressure to ventilate like ARDS Volutrauma Acid base imbalance
Hyperacute rejection begins when? What happens? Those at risk? Treatment?
Beginning immediately. Antibody mediated triggering blood clotting leading to necrosis, inflammation. At risk: received donated organs of ABO different from their own, have received multiple transfusions before, have history of multiple pregnancies, or have received previous transplant. Tx: removal of organ
Competent characteristics
Begins to see his/her actions in terms of long term goals or overall plan, begins to distinguish between relevant and irrelevant attributes, feels the ability to cope/manage unforeseen events, lacks the speed and flexibility of a proficient nurse, begins to unsterstand actions in terms of long range goals
Progressive stage of shock
Begins when compensatory mechanisms fails Aggressive interventions to prevent multiple organ dysfunction syndrome
Biliary obstruction
Bile production decreased preventing absorption of fat soluble vitamins like K which causes insufficient clotting factors causing bleeding/bruising risk
Infection risk from chemo managed w/
Biological response modifiers, growth factors to stimulate immunity or if already sick drugs for that organism
After assessing patient you document, JVD, edema, swollen hands, distended abs, bibasilar crackes, productive cough that is pink what is interpretation
Biventricular failure
Artificact
Bizarre irregular deflections in baseline of ECG, NOT a. Fib
Patho of portal hypertension
Blockage of blood through portal vein seeks collateral/alternative venous channels and backs up into spleen causing splenomegaly, dilated veins, ascites, esophageal varices, prominent ab veins aka caput medusae, and hemorrhoids, portal hypertensive gastrophy
When blood vessels constrict and total blood volume remains the same
Blood pressure increases Blood flow faster
Physical assessment for hypothyroidism
Bradycardia, goiter Hypotension Hair loss Constipation Weight gain Facial edema aka myxedema+nonpitting edema everywhere Decreased T3 and T4 levels
Motor parkinsons s/s
Bradykinesia slow movement, rigidity, akinesia, tremors, pill rolling, maskline face, difficulty chewing/swallowing, uncontrolled drooling, fatigue, reduced arm swinging, microphagia aka change in writing
ICP increased by
Brain tissue expansion/pressure, increased CSF, increased blood flow/pressure
C3/c4/c5 can cause? Urgency?
Breathing issues and emergent
Priority issues w/ SCI
Breathing, neurogenic shock, further SCI, impaired mobility, bladder/bowel, impaired adjustment
Rate of ventilator
Breaths/min number of breaths delivered by ventilator. Rate usually 10-14 breaths/min
Treatment for atrial dysrhythmia
Calcium channel blockers Antiarrhythmics Digitalis glycoside Beta blockers Anticoagulants Cardioversion Ablation Patient education: Monitor HR s/s Stroke Decrease stress
Initial stage of shock: do what? Baseline MAP? HR/RR? Adaptive?
Call for help/RRT, Baseline MAP decreased by 5-10 mm Hg, Cardiac response Heart and respiratory rate increased from baseline Adaptive responses of vascular constriction, increased heart rate. HR/RR increasing from baseline may be only s/s
When stridor or other manifestations of obstruction after extubation
Call rapid response team before airway become completely obstructed
Proficient characteristics
Can discern situations as wholes rather than single pieces, uses past experiences rather than rules to guide practice, can recognize when the expected normal picture is absent, considers fewer p[topms and hones in on accurate elements of problems, perceives situations as whole rather than in aspects
Systolic HF: can not? Reduced? Blood? Hallmark finding?
Can not contract forcefully enough during systole to eject adequate amounts of blood into circulation Reduced left ventricular ejection Blood backs up (pulmonary) Hallmark finding: Ejection fraction below 40%
Hypovolemic shock etiology
Can occur with 20% (~ 1 liter) of volume loss. Hemorrhage (external):trauma, Surgery. Hemorrhage (internal):Blunt trauma, GI ulcers/Liver disease, Overuse of NSAIDS/ASA, Poor control of surgical bleeding. Dehydration, decreased fluid intake, increased fluid loss, DI, conditions reducing clotting
MI assessment
Chest pain unrelieved with rest Diaphoresis Mottled skin Nausea Anxiety Shortness of breath Palpitations Elevated Troponin
Oxygenation failure
Chest pressure normal but doesn't oxygenate blood sufficiently. V/Q mismatch in which air movement and O2 intake/ventilation normal but lung blood flow/perfusion is decreased.
Conditions causing respiratory failure
Condition that affects the flow of blood into the lungs, affect the nerves and muscles that control breathing, that affect the areas of the brain that control breathing, that affect the flow of air in and out of th lungs, that affect gas exchange in alveoli
CPR steps
Confirm unresponsiveness, call 911/response team then CPR: chest compression 100 per minute, patent airway, ventilate/breathing w/ mouth to mask 10-12 breaths/min
Left sided HF aka? Types of left HF?
Congestive heart failure. 2 types: systolic HF and diastolic HF
Rheumatoid arthritis define?
Connective tissue disease destructive to bilateral joints and chronic progressive systemic autoimmune disease leading to bony ankylosis, calcification, bone density loss, secondary osteoporosis
Preparing body for viewing
Consider Forensic/coroner requirements, cultural requirements
After o2 replaced and rested no SOB but o2 sat is 96% do what next
Continue assessment as 96% is considered acceptable
Interventions for cardiomyopathy
Drug therapy to help increase cardiac output Antidsyrhythmic medications Implantable cardiac defibrillators
Enhancing nutrition for HIV
Drugs like ketoconazole/fluconazole/amphotericin, mouth care, ice chips, no unpleasant odors, antiemetics, monitor weight+I/O, high calorie/protein low fat, small frequent meals, supplements, TPN
Enhancing oxygenation for HIV
Drugs like trimethoprim/sulf/bactrim/pentamidine for PCP bronchodilators/steroids, respiratory support w/ O2/suctioning/chest physical therapy, maintenance, comfort, rest
ICD education
Drugs still, sit/lie down if shock and notify, if someone else touching shock not harmful, avoid electromagnetic fields/electric generators/radio or TV transmitters /metal detectors/welding equipment/motors which can inhibit tachydysrthmia detection or cause shocks, cell phones >6 in away from generator and held opposite ear of ICD, wear ID card/bracelet, no swimming/driving/dangerous equipment
Improving CO w/ HF nonsurgical
Drugs, CPAP, cardiac resychronization therapy CRT, investigative gene therapy
Nursing implications for esophageal varices
Drugs, Monitor- PT, PTT, fibrinogen, platelet count, INR, and ammonia levels, monitor black tarry stools
Environmental factors that increase infection
Drugs, chemicals, vitamin definiciences, malnutrition esp. protein malnutrition, DM, older adults
Preventing/managing hemorrhage interventions
Drugs, endoscopic therapies, rescue therapies like 2nd endoscope/ballon/stents/shunts, TIPS
Nonsurgical management for dysrhythmias
Drugs, vagal maneuver, pacing, CPR, ACLS, cardioversion, defibrillation, catheter ablation
Managing inflammation/pain from RA
Drugs: immunosuppressive DMARDs like methotrexate, lefluomide/arava, hydroxychloroquine/plaquenil, NSAIDs, BRMs, glucorticoid prednisone, rest, positioning, ice/heat, hot shower, alternative therapies for pain, assistive devices, managing fatigue, promoting rest
ACE SE
Dry cough, hyperkalemia, orthostatic hypotension, confusion, reduced U/O
Skin changes for HIV
Dry, itchy, irritated, rashes, folliculitis, eczema, psoriasis, peteciae, bleeding gums, poor wound healing, lesions, night sweats
Acute spontaneous bacterial peritonitis
Due to low concentrations of plasma proteins causing fever, chills, ab pain, tenderness
Common quinolones
Floxin Levofloxacin Ciproflaxacin Moxifloxacin (Avelox) Gatifloxican (Tequin)
Expected outcomes of Addisons
Fluid and electrolyte balance is maintained Nutritional Status is maintained Verbalizes understanding of Adrenal Insufficiency Hormone levels return to normal or near normal
Priority problem for Cushing's
Fluid overload, risk for injury r/t thin skin/poor healing/bone loss, potential for infection, potential for acute adrenal insufficiency
Most important s/s of AIDS
Night sweats, diarrhea, weight loss, n/v, opportunistic infections like pneumocystis jiroveci aka carinini pneumonia, cytomegalovirus CMG, shingles/varicella. Malignancies like kaposi's sarcoma, invasive cervical carcinoma
Ventricular fibrillation
No CO, no pulse. Defibrillate then CPR, o2, drugs like epinephrine
Ventricular asystole
No CO, no pulse. Manage airway, O2, epinephrine, atropine, CPR after notifying, check leads. NO SHOCK
Assessment for asystole
No CO, no pulse/BP/RR full cardiac arrest
Heat related illness prevention
No alcohol/caffeine, sunscreen, breaks, light weight light colored loose clothing, cool baths/showers, indoors, ask neighbor/friend to check at least q 2x a day during heat wave
C of ABC make sure
No bleeding, pulse and color
Novice characteristic
No experience, inability to use discretionary judgement, use of context free rules for actions, no rule about which tasks are most relevant in a real world situation or when an exception to the rule is necessary, has no profession experience
Deceleration define? The more distance involved? Example?
Occurs as energy that is dispensed from the moving object. The overall result is deceleration over distance. The more distance involved, the better the outcome. Ex.- A body slides across pavement through friction
Septic shock/chemical induced distributive shock
Occurs secondary to infection Develops from volume loss in the core circulation and poor circulatory support Life threatening blood pressure drop Reduced U/O Body temperature changes Skin is warm Late signs of inadequate tissue oxygenation
Acceleration define? Example?
Occurs when the body is abruptly set in motion for a position of rest. Ex.- A body coming to a sudden stop but the internal organ continue to move forward
Hepatic encephalopathy Occcurs when?
Occurs when the liver fails to breakdown toxins properly and the toxins buildup in the bloodstream aka elevated ammonia levels. These toxins can cause damage to organs and nerves.
Nerve 3
Oculomotor eye movement and pupil constriction
Expert preceptor implications
Often not possible to recapture mental processes, encourage exemplars and descriptions of excellent practice, good preceptor for competent nurse
Cranial nerve 1
Olfactory, smell
Pulmonary artery
Only artery w/ deoxygenated and goes to lungs for oxygenation and goes back in pulmonary vein to left vatrium throu mitral valve to aorta
Paroxysmal nocturnal dyspnea
Sudden awakening with a feeling of breathlessness 2-5 hours after falling asleep. Sitting upright, dangling the feet, walking usually relieves the condition
Testing for hyperpituitarism
Suppression testing of negative feedback control mechanism. High BG suppress GH. If GH levels don't fall below 5 it's positive/abnormal
Progressive stage of shock: MAP? Organs? Life? Conditions causing?
Sustained decrease in MAP of >20 mm Hg from baseline Vital organs develop hypoxia, ischemia Life-threatening emergency, impending doom Conditions causing shock must be corrected within 1 hour of progressive stage onset Rapid weak pulse, low BP, pallor/cyanosis, cool moist skin, anuria, decreased O2 w/ rising lactic acid/K
Sinus bradycardia
Excess vagal/parasympathetic stimulated causing decreased SA node <60bpm from sinus massage, vomiting, suctioning, valsalva manuever aka bearing down for BM/gagging, hypoxia, MI, beta adrenergic blockers or calcium channel blockers or digitalis, athletes
Dysrhythmia issues
Alteration in perfusion, abnormal rhythm and can lead to organ failure, electrolyte imbalances, morbidity
Drowning better in what temp? Since? Do what first?
Better in cold water since slows metabolism and HR. Get them warm first.
Fresh vs. salt water drowning which is better and why
Better to be in salt water since cells shrink/dehydrate which is better then them bursting in fresh
Assessment of atrial dysrhythmia
Dizziness Weakness/ fatigue Shortness of breath Chest discomfort/ pain Hypotension Asymptomatic
Initial assessment for sinus dysrhythmia
Dizziness, weakness, confusion, hypoxia diaphoresis, SOB, chest pain
T wave
Ventricular repolarization
A. Fib s/s
Fatigue, weakness, SOB, dizziness, anxiety, syncope, palpitations, chest discomfort/pain, hypotension, possibly asymptomatic, thrombi formation
4 steps to interpretation
Whats rate, is it regular, is ther 1 p wave per QRS, does QRS appear normal
If after using valve bag mask and absent sound in certain area
Xray, tube
Is it regular
Yes is R to R interval regular or <3 small not big blocks between and same shape for ventricles, P to P w/ same shapes/regular timing <3 small blocks for atrium or no irregular
Does QRS appear normal
Yes- duration consistent/similar normal conduction through AV nodes. No-ventricular in origin.
Is ther 1 p wave per qrs
Yes- sinus rhythm, no-pacemaker not sinus node
Diabetic urinated on floor do what first? Then
Is scene safe FIRST then A via jaw thrust due to fall, B via chest rise/fall sounds if weak assist w/ breathing via o2 or mask, then reassess after intervention,
Prevent escalating for violence and psych issue
Keep in area to minimize chaos like if psych issue take them out of waiting room/get away from others
Renal calculi define? Urgency?
Kidney stones are urgent due to pain level being high
Emergent define? Examples ?
Life threatening and needs to be addressed right then. All team needed. Ex: codes like strokes, heart attack
P wave means? Formed as?
Means atrium working and depolarized(contracted/positive charge). Formed as impulses originate in SA node/pacemaker passes through atrium.
Graph paper measures? How many boxes for 3 seconds? 1 box=?
Measures voltage against time. 15 boxes= 3 seconds. 1 box=.20 seconds
Degree of trauma affected by? Types?
Mechanism of injury(MOI): intentional, unintentional
If you fix something for ABCDE etc then! You cannot?
Then reassess. You cannot move on until you address A or whatever the issue is
Q wave isn't always? Still called? In MI? In normal person?
There and visible. Still called QRS though if you cannot say. Still can be present in Q wave MI. Normal person usually don't see Q
Premature atrial complexes s/s and treatment
Usually no s/s except palpitation. No intervention except for causes like heart failure, stress management, avoiding substances like caffeine/alcohol
Tachydysrthmia/bradydysrhythmia s/s
chest discomfort/pain that can radiate to jaw/back/arm, anxiety, restless, confusion, dizziness, syncope, changes in pulse, pulse deficit, SOB/dyspnea, tachypnea, crackles, orthopnea, extra heart sounds, JVD, weakness, pale/cool skin, n/v, decreased UO, delayed cap refil, hypotension
Bradydysrhythmia additional s/s
If BP normal possibly no s/s, if BP no adequate myocardial ischemia, infarction, dysrhytmia, hypotension, heart failure
Sinus dysrhythmia can be
Bradycardia or tachycardia
Big block example: 4 blocks between Rs?
4 blocks between R's = 300/4=75bpm
Lead placement? Right leg? Right arm? Left leg? Left arm? Can be placed by?
4 leads on limbs, 6 leads on chest. Right leg is ground, right arm negative, left leg positive, left arm is positive or negative. Can be placed by UAP but placement verified via RN
Very old and very young
Are more at risk for decompensation so can be urgent or emergent usually
Extrinsic factors of heart contraction
Autonomic nervous system: parasympathetic vs. sympathetic fight or fight
Atrial fibrillation treatment
Calcium channel blockers like diltiazem/cardizem, amiodarone/cordarone, drondarone/multaq, cardioversion. Beta blockers like metoprolol/Toprol, esmolol/brevibloc. Digoxin/lanoxin if heart failure. Anticoagulants like heparin, enoxaparin/lovenox, warfarin/coumadin or antiplatelets like aspirin or clopidogrel/plavix. Cardioversion, catheter ablation, pacers, maze procedure w/ bypass
If rate to slow vs. high
If slow might be AV issue since slower if high maybe SA issue
Supraventricular tachycardia s/s
If sustained palpitations, chest pain, weakness, fatigue, SOB, nervousness, anxiety, hypotension, syncope and if BP not sustained angina, heart failure, cardiogenic shock. If nonsustained possibly asymptomatic
Rn dx. For atrial dysrhythmia
Impaired gas exchange Decreased cardiac output Ineffective tissue perfusion
If quality of breathing not good what's anticipated
Non rebreather and if still bad use valve bag mask and anticipate intubation
Supraventricular tachycardia rate? Rhythm? P wave? QRS?
Rate - 150-250 bpm Rhythm - Regular P wave- buried in T wave QRS: narrow but can be wide
Atrial flutter rate: atrial? Ventricular? Rhythm? P wave? QRS?
Rate - Atrial - 250-350 bpm Ventricular - variable Rhythm - Atrial-regular, Ventricular-variable P wave - saw-tooth pattern QRS - Narrow
Atrial fibrillation rate? Rhythm? P wave? QRS?
Rate - Atrial - > 350 bpm Ventricular - Variable Rhythm - Irregular P wave Chaotic not clear QRS Normal
Normal sinus rhythm rate? Thythm? P wave? QRS?
Rate 60-100bpm, rhythm regular, p wave 1 per QRS that is consistent, QRS narrow<0.10 sec and constant
Low BG s/scan seem like
Stroke
If alcoholic assume
They have a brain injury
Nonurgent define? Reassess how often?
Time to intervention several hours. Reassess q 1-2 hours to make sure no change in status
Counting irregular rhythms aka 6 second strip method
Tip of R aka QRS numbers(aka just count the number of tips of QRS) in 6 second strip and multiply by 10