*MS FINAL EXAM

A patient with hypotension and temperature elevation after doing yard work on a hot day is treated in the ED. After the nurse has completed discharge teaching, which statement by the patient indicates that the teaching has been effective?

"I should have sports drinks when exercising outside in hot weather." rationale: Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action.

When assessing a patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse notes multiple additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate?

"Is someone at home hurting you?" rationale: The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. The patient, not the nurse, is responsible for reporting the abuse. A social worker may be appropriate once further assessment is completed.

Spinal Penetration injury

"Open" or penetrating injuries to the spine and spinal cord, especially those caused by firearms, may present somewhat different challenges. Most gunshot wounds to the spine are stable, i.e., they do not carry as much risk of excessive and potentially dangerous motion of the injured parts of the spine. Depending upon the anatomy of the injury, the patient may need to be immobilized with a collar or brace for several weeks or months so that the parts of the spine that were fractured by the bullet may heal. In most cases, surgery to remove the bullet does not yield much benefit and may create additional risks, including infection, cerebrospinal fluid leak, and bleeding. However, occasional cases of gunshot wounds to the spine may require surgical decompression and/or fusion in an attempt to optimize patient outcome.

meds for flu- main med ... for prophylaxis for exposure for w/o vaccine

#1!!- get the vaccine (mild flu for 24 hrs, Guillian BS, not if allergic to eggs) Amantadine (Symmetrel)- prophylaxis for exposure rimantadine (Fumadine)-prohylaxis for exposure

Parkland Formula and Fluid replacement in the first 24 hours

(4mL of LR) x (body weight in kg) x (% of TBSA burned) = total fluid replacement for the 1st 24 hours. 1st 8hrs = 1/2 total volume 2nd 8hrs = 1/4 total volume 3rd 8hrs = 1/4 total volume

ANTITUBERCULOSIS AGENTS

(R.I.P.E) Rifampin (red urine, tears, and saliva) Isoniazid (may lead to hepatotoxicity) Pyrazinamide (may lead to hepatotoxicity) Ethambutol (decrease red/green color discrimination and visual acuity)

Dextran

(plasma expander) regulate BP to increase capillary blood flow to spinal cord to maintain adequate perfusion and prevent/treat hypotension

Medication

* A and B are preventable with vaccines * hep A - long term protection, inactivated whole-virus vaccine, pediatric and adult formulations, 95% immunity with one, recommended two Pain at injection site Post exposure - standard immune globulin IM into large muscle mass within 2 weeks hep A vaccine may be used in healthy people 40 years and younger risk of anaphylaxis in people with IgA deficiency * Hep B - three doses 90% protection in healthy adults, covers D also, recombinant vaccine older adults less likely to achieve immunity, immunocompromised may need larger doses, serologic testing for immunity is recommended on completion of series for high risk groups pain at injection site, fatigue, headache Post exposure - Hep B immune globulin given IM into large muscle mass within 24 hours, concurrent initiation of hep B vaccine series muscle pain stiffness * severe cases of acute hep b may be treated with antiretroviral drugs - (*vir, *ver) - relapse is common, monitor baseline and periodic renal and liver function tests, CBC with differential, blood chemistries and serum electrolytes Lactic acidosis is a risk, monitor for hyperventilation, lethargy and ABG values (met. acidosis) notify doctor if severe abdominal pain, n/v, or anorexia, jaundice * A and B combination is available - three doses, initial dose followed by doses no sooner than 4 weeks, and 6 months after * Acute viral hepatitis recover fully without pharmacologic treatment * Hep C - treated with interferon alpha to reduce risk of chronic hepatitis * peginterferon and ribavirin is treatment of choice for chronic hep C * interferon causes flulike syndrome can be treated with acetaminophen * depression is also side effect of interferon - watch for suicidal thoughts * ribarvirin may cause birth defects - two reliable forms of birth control * Alternate therapies - milk thistle (liver disease), licorice root (hepatitis), ginger (nausea), st johns wart (depression)

Acute renal failure vs. chronic renal failure

* Acute Onset is sudden Nephron involvement 50% Duration - 2-4 weeks, less than 3 months Prognosis - good for return of renal function with good care high mortality rate sometimes * Chronic Onset is gradual Nephron involvement 90-95% Duration is permanent Prognosis - fatal without replacement therapy (dialysis or transplant) ARF: Occurs over hours or days, pt. has hx of normal renal function, kidney size usually normal, anemia usually absent, no broad casts in urine sediment. usually reversible CRF: Gradual deterioration of renal function over time, pt. has hx of ^'d BUN & Creatinine, kidney size usually small, anemia usually present, broad casts present in urine sediment. usually irreversible Acute renal failure is most common in the acute care setting and chronic kidney disease, which may take years to develop, is more common in the community. Both types may interfere with urinary elimination and maintaining homeostasis of fluid volume, blood pressure, electrolytes, wastes, and acid-base balance. This can reduce general function, shorten life, and decrease quality of life. Kidney functions include excretion of waste, water and salt balance, acid-base balance, and hormone secretion. When kidney function declines gradually, as with chronic renal failure, 90% to 95% of the nephrons must be destroyed before renal failure is obvious. During this time of decreased renal function, the patient is at increased risk for acute renal failure because of the stress on remaining nephrons. When renal decline is sudden, the functioning nephrons are over-worked, and renal failure may develop with the loss of only 50% of functioning nephrons. Acute failure affects many systems, while chronic disease affects every system.

Liver failure causes

* Alcohol (Laennec's) * Viral hepatitis * Steatohepatitis (from fatty liver) * Drugs and toxins (Tylenol OD) * Biliary disease * Metabolic/genetic disorders * Cardiovascular disease

Risk factors of liver failure

* Alcohol intake * Drug use * Tattoos * Military or prison * Healthcare worker, firefighter or police officer

Esophageal varices treatment

* Esophageal tamponade-insert NGT or a balloon tamponade as prescribed, balloon tamponade is not used frequently-GI balloon is the anchor and the esophageal balloon is inserted in the esophagus and inflated to put pressure on the bleed * Medications-vasopressin or propranolol (inderal) or sandostatin * Administer blood transfusions or clotting factors * Sclerotherapy-injection of sclerosing agent into and around bleeding varices * Endoscopic variceal ligation-ligation of varices with an elastic rubber band * Shunting procedures to shunt blood away from bleeding varices

Diagnosis of end stage renal disease

* GFR < 15ml/min

Liver failure and vitamins

* Impaired metabolism of fat soluble vitamins ADEK * Vitamin supplements such as thiamine, folate, and multivitamin preparations are typically added to IV fluids because the liver cannot store vitamins

Assessment

* N/V * HA * Confusion * HTN * Restlessness * Agitation * Muscle cramps * Seizures

Interventions

* Slow or stop dialysis * Notify the physician * Reduce environmental stimuli * Prepare to admin IV hypertonic saline solution-volume expander (albumin or manitol) * Prepare for dialysis at a shorter period of time and reduced flow rates

Teaching for end stage renal disease

* To maintain current medication regime to take steps to reduce BP * Maintain blood glucose at appropiate levels * Teach S/S of infection control of diabetes and hypertension, education related to diet and exercise

Hep B

* acute, chronic, fulminate (rapidly progressive) or carrier * carrier is most often when the virus is acquired at birth * spread thru contact with infected blood and body fluids * high risk - injection drug users, multiple sex partners, men/men, exposed to blood products, healthcare workers * Hep B is a risk for primary liver cancer (infected perinatally) * liver cells are damaged by the immune response to the antigen * liver shows evidence of injury and scarring, regeneration and proliferation of inflammatory cells * prodromal - urticaria, rashes, arthalgias, serum sickness or glomerulonephritis * may be asymptomatic

Toxic Hepatitis

* alcohol, toxins, drugs directly damage liver cells * alcoholic hepatitis from chronic alcohol abuse * alcohol hepatitis causes necrosis of hepatocytes and inflammation of the liver parenchyma (functional tissue) * if alcohol is not avoided, progresses to cirrhosis * acetaminophen, benzene, carbon tetrachloride, halothane, chloroform, and poisonous mushrooms * degree of damage depends on age and extent of exposure * acetaminophen overdose is leading cause of acute liver failure

Autoimmune hepatitis

* chronic disorder - cell-mediated immune response against liver cells, causing persistent inflammation, necrosis with fibrosis and scarring * circulation of autoantibodies antinuclear antibody (ANA) are present * personal or family history of autoimmune disorders * leads to cirrhosis and liver failure

Assessment

* current manifestations: anorexia, nausea, vomiting, abdominal discomfort, changes in bowel, muscle or joint pain, fatigue, changes in color of skin or sclera, duration of symptoms, known exposure to hepatitis, high risk behaviors, privoius history of liver disorders, current meds * physical assessment - vitals, color or sclera and mucous membranes, skin color and condition, abdominal coutour and tenderness, color of stoor and urine * diagnostic tests - serum bilirubin, liver function tests, serologic antibody - antigen levels * Use standard precautions. For HAV and HEV use standard precautions and contact isolation if fecal incontinence is present * encourage prophylactic treatment of all members of household and intimate sexual contancts * fatigue and possible weakness are common in acute hepatitis - adequate rest periods and limitation of activities, may be unable to resume normal activity for 4 or more weeks * adequate nutrition is important for immune function and healing in patients with acute or chronic hepaititis high kilocalorie intake, smaller meals with snacks, avoid alcohol and diet drinks, nutritional suppliments * jaundice and rashes - prevent skin breakdown - body image * follow up

Hep A

* infectious hep, fecal oral route - comtaminated food, water, shellfish, direct contact * international travel is primary risk factor * close household or sexual contact * virus is in stool for up to 2 weeks before symptoms develop * once jaundice develops - risk dereases * abrupt onset, but benign and self limiting with few long term consequences - symptoms up to 2 mths

Hep C

* primary cause of chronic hepatitis, cirrhosis, and liver cancer * transmitted thru infected blood and body fluids * injection use primary risk factor * acute usually asymptomatic: if symptoms develop they are mild and non specific * recognized long after exposure when secondary effects develop (chronic hep/cirrhosis) * 15% resolve most progress to chronic active hepatitis

Diagnosis

* ↑ ALT * ↑ AST * ↑ ALP - even after ALT and AST have decreased * ↑ Serum Bilirubin - both conjugated and uncongugated - ↓ as inflammation and edema ↓ * viral antigens and their specific antibodies * liver biopsy

Troponin

***only effected with heart muscle damage the biomarker with high specificity to myocardial damage has two specific isomers called Troponin I and T Elevates within 3-4 hrs and remains elevated for up to 3weeks **MOST SENSITIVE and MOST HELPFUL when pt delays seeking care

*Dx for respiratory failure

*ABGs *Exhaled carbon dioxide (ETCO2) -evaluates alveolar ventilation -normal = 35-45 mmHg -elevated w/inadequate ventilation

Nicardipine

*Anti-Hypertensives Drug for Hypertensive Emergencies *Used when PO treatment is not feasible *Used to control hypertension and blood pressure elevation in acute ischemic stroke Reasonable alternative to sodium nitroprusside for treatment of hypertensive emergencies. *Calcium channel blocker Used to manage hypertension and hypertensive emergencies. Adverse - hypotension, reflex tachycardia, dizziness, headache

What are epinephrine's adverse effects?

*Causes hyperglycemia so monitor blood glucose levels with high doses and prolonged administration Cardiac arrhythmias Hypertension Palpitations Dizziness, anxiety, headache, tremor Myocardial infarction due to increased cardiac work Pulmonary edema

Factors that affect cardiac output:

*HR and certain arrthymias *blood volume (more or less to pump) *decreased contractability -MI, medication, muscle disease

Nursing Dx for SARS

*Impaired gas exchange -avoid resp depressant drugs (opioids...) *Risk for infection -negative flow room -mask on pt for transport -visitors should wear a mask

nutrition and fluids w/ventilation

*MV promotes Na and H2O retention *renal perfusion decreased= renin-angio....retain Na &H2O *Swan-Ganz catheter= monitor pulmonary pressure & CO *arterial line= ABGs & continuous arterial pressure monitor *Lytes, I&O, daily wt *enteral or parenteral nutrition w/MV

Considerations for antihypertensives and rate controllers

*Monitor pts, especially elderly, for hypotension and arrhythmias *Meds must be on infusion pump *Titrate meds thoughtfully and do not discontinue without titrating down slowly *Nitropursside turned off without titrating down can cause seizure activity *Beta blockers cause bronchospasms so use caution in pts with pulmonary disease *careful of nusing beta blockers with calcium channel blockers, this can cause complete heart block *watch for anaphylaxis *These meds can be admin peripherally, but central is most desired *Avoid extravasation

*Meds for pt on VENT (these meds inhibit breathing center & decrease anxiety while on a vent)

*Sedatives (benzodiazepines) *Analgesics (IV morphine or fentanyl) *POSSIBLE- neuromuscular blocking agent w/ sedation to induce paralysis) pg 1264

DX of SARS

*Serology (ELISA, immunofluorescence)- antibodies (antibodies may not be seen in acute stage) *Reverse transcriptase- resp & blood samples (early stages- only 33% positive) *x-ray (interstitial infiltrates, later=consolidation) *Pulse ox (hypoxemia in resp phase) *CBC- < lymphocytes, leukopenia, thrombocytopenia *CK, ALT, AST= > *Sputum specimen- to rule out other causes *Blood culture- ID bacteremia

Considerations of sedation and analgesia meds

*Use cautiously with elderly *Assure fluid volume is adequate with administering Precedex and Propofol because both cause bradycardia and hypotension *All meds except the Precedex will cause respirator depression *Propofol should not be given to an unintubated pt and if it is, someone with the ability to intubate needs to be present during administration of the meds *Propofol is not bolused with being given as a continuous infusion. Titrate the drip up until desired effect is reached *Daily sedation vacations help to clear the drug and allow for liberation form the ventilator sooner

pneumonomediastinum

*air in mediastinum *interferes w/function of heart, great vessels, trachea and esophagus....pneumopericardium *Dx- x-ray=widened mediastinal space

Considerations for vasoactive drips

*all are dose dependent *must be administered by pump *Elderly pts respoond different and need careful monitoring *pts should have an arterial line for blood pressure monitoring *fluid volume status is important with these meds, fill the tank *watch for lethal arrhythmias *all cause injury if infiltration occurs, adminster centrally if possible *correct acidosis to improve the effectiveness of the drip

*when to use mechanical vent

*apnea *acute ventilatory failure *hypoxemia unresponsive to O2 therapy *> work of breathing w/ progressive pt fatigue

What are dopamine's adverse effects

*causes significant tachycardia, especially in the presence of heart disease or hypovolemia -decreased renal perfusion at higher doses -arrhythmias -tachycardia -hypertension -tissue necrosis can occur if dopamine extravasates during infusion

**Pressure-control ventilation (PCV)

*controls pressure in airways *reduces risk of trauma (ex-after thoracic surgery) *time triggered, time cycled *pressure is limited *maintains preset airway pressure throughout inspiration *pt may need heavy sedation to prevent competing w/ vent

*Nursing Dx for ARDS

*decreased cardiac output (from positive pressure vent) -urine output hourly -LOC @ 4hrs *dysfunctional ventilatory weaning response -ck VS @ 15 min initially -keep intubation set readily available

*medications for respiratory failure

*depends on underlying cause *see table on pg 1235 for bronchodilators (sympathomimetics or anticholinergics) *Corticosteroids (inhale, IV)= < airway edema *antibiotics for infection

*ventilator cycle- define *can be limited (controlled) by 4 things

*duration of inspiration *volume, pressure, flow, time (ex- time-cycled ventilators deliver air at a set time interval)

*airway management with a tracheostomy

*for long term vent support *see pg 1265 table 37-6

*Barotrauma (volutrauma)

*from alveolar over distention *from >volume or pressures *alveoli rupture- air escapes...subcutaneous emphysema, pneumothorax or pneumomediastinum

**continuous positive airway pressure (CPAP)

*gives positive pressure for pt breathing spontaneously *use w/mask or endotrach *pressure controlled *maintains open airways & alveoli Used when weaning after brief periods of entubation (also T-piece)

**terminal weaning

*gradual withdrawal of MV when survival is not expected *analgesia and sedation for comfort

black widow S&S

*initial- tiny papule *some- intense pain- seems out of proportion *lactrodectism (severe ab pain, muscle rigidity & spams, HTN, N, V- similiar to peritonitis) *facial edema *ptosis *diaphoresis *weakness *increased salivation *priapism *resp difficulty *> resp secretions *fasciculations (twitching) *paresthesias (painful tingling or numbness) S&S usually resolve in a few days

*respiratory failure

*lungs unable to oxygenate the blood and remove carbon dioxide to meet needs *PO2 < 50-60 *PCO2 > 50 *w/COPD= acute drop in O2 levels & > in CO2 (these may function at very low O2 & high CO2 so you are looking for the acute change not just the level)

**Weaning

*must correct or stabilize underlying problem 1st *time required varies *Eval - VS, resp rate, dyspnea, ABGs, clinical status *short term vent- use T-piece or CPAP *long term vent- use SIMV or PSV then T-piece or CPAP

How to prevent acute respiratory failure

*no smoking *water safety *working smoke detectors *measure to prevent smoke inhalation in a fire *pneumococcal and flu vaccines esp over 65 *spinal cord injuries jor neuromuscular disease - deep breathing and coughing tehniques to maintain airway patency *narcotic addicts to stay clean *COPD taught to reduce risks of respiratory infection and symptoms to report to Dr.

*nosocomial pneumonia

*oral secretion and gastric contents can enter resp tree through open epiglottis *oral hygiene is vital *secretions are often thick and tenacious...possible atelectasis (collapse of part of all of a lung)

**possible complications of too much O2

*oxygen toxicity *pulmonary fibrosis

*extubation steps

*oxygenation *suctioning *deflate cuff *remove tube *admin humidified O2 *Observe for distress *inspiratory stridor= laryngeal edema (may need to intubate again) *sore throat/hoarse= common *oral intake reinitiated slowly

cardiovascular effects of ventilation

*positive pressure increases intrathoracic pressure...<venous return to heart...<ventricular filling *CO falls *PEEP =<CO...affects liver and kidney function

Lab work done to ensure proper nutrition and a positive nitrogen balance?

*prealbumin, total protein, albumin

**Tx

*prone positioning w/vent=< pressure on dependent areas *careful fluid replacement (too much= worse ARDS) *nutrition- enteral or TPN *treat infection IV antibiotics *Swan-Ganz line - monitor pressures *low molecular wt heparin to prevent -thrombophlebitis -PE -DIC Acute respiratory distress syndrome is usually treated with mechanical ventilation in the Intensive Care Unit. Ventilation is usually delivered through oro-tracheal intubation, or tracheostomy whenever prolonged ventilation (≥2 weeks) is deemed inevitable. The possibilities of non-invasive ventilation are limited to the very early period of the disease or, better, to prevention in individuals at risk for the development of the disease (atypical pneumonias, pulmonary contusion, major surgery patients). Treatment of the underlying cause is imperative, as it tends to maintain the ARDS picture. Appropriate antibiotic therapy must be administered as soon as microbiological culture results are available. Empirical therapy may be appropriate if local microbiological surveillance is efficient. More than 60% ARDS patients experience a (nosocomial) pulmonary infection either before or after the onset of lung injury. The origin of infection, when surgically treatable, must be operated on. When sepsis is diagnosed, appropriate local protocols should be enacted. Commonly used supportive therapy includes particular techniques of mechanical ventilation and pharmacological agents whose effectiveness with respect to the outcome has not yet been proven. It is now debated whether mechanical ventilation is to be considered mere supportive therapy or actual treatment, since it may substantially affect survival. Survivors of ARDS have an increased risk of lower quality of life, persistent cognitive impairment, depression and posttraumatic stress disorder.

**BiPAP

*provides inspiratory positive pressure *provides airway support w/expiration *at night *tight fitting mask *high or low PEEP *3 modes of ventilation 1. (S) spontaneous breathing 2. (T) timed mode 3. (S/T) switches to times if spontaneous falls below a certain rate

Be careful with Nitropursside in regards to

*renal impaired patients *monitor for cyanide toxicity *use very cautiously in pts with aortic stenosis as the use of this med can decrease coronary artery perfusion

*Independent lung ventilation

*separate ventilation for each lung *ex-for unilateral lung disease *requires double lumen endotracheal tube *requires 2 ventilators *pt may require heavy sedation

*High frequency ventilation

*sm. gas volumes at a rapid rate *for hemodynamic instability & intolerant of conventional MV *requires sedation & maybe pharm paralysis

**respiratory failure risk factors

*smoking *non working smoke detectors *pneumococcal vaccine- needed *flu shots-needed *ineffective breathing and coughing w/spinal cord injury or neuromuscular disease *narcotics addiction

GI effects of ventilation

*stress ulcers...painless GI hemorrhage *Histamine H2 receptor blockers or sucralfate to prevent stress ulcers *GI distention from air leaks (use GI tube) *meds may slow motility...constipation

*Negative-pressure ventilators

*subatmospheric pressure *draws the chest outward and air into lungs (mimics spontaneous breathing) *used for neuromuscular disorders (polio, ALS) *used for support during sleep

Uses of Ativan

*to treat anxeity and seizure activity *sedate in the critical care setting *off label - management of AWS (acute withdrawal syndrome) *can be used as an antiemetic adjunct

What is dobutamine's theraputic use?

*to treat cardiogenic shock (chemical balloon pump-reduces afterload, but increases rate and contractability) *Off Label Use is to administer for decompensated hemodynamics related to sepsis. -treatment of unstable CHF and shock

*Tx for respiratory failue

*treat underlying cause *ventilation *treat hypoxemia & hypercapnia *O2 to reverse hypoxemia- >89% saturation

S&S of pneumothorax

*unequal chest expansion *< breath sounds on affected side *hyperresonant percussion Tx- *rapid chest tube insertion

Adverse effects of dobutamine?

*use with caution with hypovolemia - the pt will develop profound hypotension. Stop infusion until fluid volume status is addressed -arrhythmias -tremor -headache -nausea and vomiting

*positive-pressure ventilators

*used for acute respiratory failure *push air into lungs instead of draw it in *uses endotracheal tube or tracheostomy or non invasive positive-pressure ventilation *noninvasive= nasal or face mask, nasal plugs, or oral mouthpiece *a trigger prompts vent to deliver a breath by a preset time interval

What are dopamine's therapeutic uses?

*used to enhance hemodynamic support -treatment of shock, raises blood pressure by stimulating the Beta 1 receptors of the heart -used in acute renal failur to increase renal blood flow -treatment of acute congestive heart failure

**Noninvasive ventilation (NIV)

*uses tight fitting facemask (no intubation) *for obstructive sleep apnea, neuromuscular disease, impending respiratory failure, pt who refuses intubation *limited by pt intolerance to discomfort of mask

*O2 administration principles

*usually 1-3 L for COPD *w/impaired diffusion - 40-60% *from 21%(room air) to 100% *high concentrations- short time to avoid O2 toxicity *CPAP for hypoventilation or when unable to correct hypoxemia -CPAP will increase lung volume, open alveoli

S&S of hypercapnia

*vasodilation....heart failure *dyspnea...resp depression *HA *papilledema (swelling of optic nerve) *tachycardia *HTN *drowsiness...coma *neuromuscular irritability *<LOC *resp acidosis *respiratory center depressed (< respirations) *O2 administration=further depress respiratory center =respiratory arrest

*airway management principles

*w/obstruction or positive pressure vent- endotracheal tube *tube is cuffed- prevent air going back to mouth or nose *excess cuff pressure= tissue ischemia, trachea necrosis *To avoid it- use high volume, low pressure (floppy) cuffs *low pressure cuffs may be left in for 3-4 wks

End stage renal disease treatment (ESRD)

- A very serious and life-threatening disease that minorities suffer much more frequently than do Whites. ESRD is treatable with dialysis however, dialysis is costly and can result in a poor quality of life for the patient. The preferred treatment of ESRD id kidney transplantation. Transplantation offers the patient "freedom" from dialysis to lead a more normal lifestyle and can successfully treat ESRD for many years

Inotropic Agents

- Dobutamine, Primacor directly stimulates adrenergic receptor sites on heart muscle and improve heart muscle cell contraction assess for chest pain, monitor BP q15 minutes

Vasoconstrictors

- Dopamine, Norepinephrine, Phenylephrine HCl assess for chest pain, monitor urine ouput hourly, assess BP q15 minutes, assess pt for HA

Cardiac Changes

- Initially HR increases and CO decreases may remain low until 18-36 hours after burn injury - CO increases w/fluid resuscitation

Agents Enhancing Myocardial Perfusion

- Sodium nitroprusside improves blood flow to myocardium by dilating coronary arteries effect is primary and rapid, but short protect container from light, assess BP q15 minutes can cause systemic vasodilation and increase shock if pt is volume depleted

Drug Therapy

- actions of drugs used for shock increase venous return, improve cardiac contractility or improve cardiac perfusion by dilating the coronary vessels -Vasoconstrictors -Inotropic Agents -Agents Enhancing Myocardial Perfusion

Curling's Ulcer

- acute gastroduodenal ulcer that occurs w/stress of severe injury, may develop w/in 24 hours after a severe burn injury

Electrical Injuries

- aka "grand masquerader" of burns b/c surface injuries may look small but are associated w/internal injuries than can be huge

Metaoblic Changes

- burns increase metabolism by increasing secretion of catecholamine, ADH, aldosterone and cortisol this causes patient's oxygen use and calorie needs to be high this state also increases core temperature

Dry heat injuries

- caused by open flame (house fires and explosions)

General Mgmt for ALL burns

- cover pt w/blanket, keep NPO, elevate the extremeties, administer tetanus

Resuscitation/Emergent Phase

- first phase of a burn, begins at onset and continues for about 48 hours Priority goals of mgmt during this phase: 1) secure the airway, 2) support cicrculation by fluid replacement; 3) keep pt comfortable w/analgesics; 4) prevent infection through careful wound care, 5) maintain body temp, 6) provide emotional support hypovolemia shock is a common cause of death during this phase urine output is usually decreased for the first 24 hours of this phase during this phase, IV route is used for opioids b/c if agtents are given IM or SubQ they remain in tissues spaces and do not relieve pain

Human Plasma

- given to restore osmotic pressure when H&H are WNL

Contact Burns

- hot metal, tar or grease contact skin often leading to full-thickness injury

Plasma protein fractures and synthetic plasma expanders

- increase plasma volume and are used as early tx for hypovolemic shock before cause has been established

Silver Sulfadiazine (Silvadene)

- interferes with DNA synthesis fo bacterial cell membranes may cause rash, pruritus, burning and leukopenia not consistently effective for burns covering 60% of body not effective against pseudomonas watch for signs of infection and allergic reaction

Gentamicin sulfate

- may have ototoxic and nephrotoxic effects

Disseminated intravascular coagulation

- microthrombi formation is widespread and using much of available platelets and clotting factors often missed because cardiac fxn is hyperdynamic CO is increased, more rapid HR and elevated systolic BP, extremities may feel warm and show no cyanosis, WBC may no longer be elevated Major Clinical Manifestations - lower O2 sat, rapid respiratory rate, decreased to absent urine output and a change in the pts cognition and affect

Chemical Burns

- occur as result of accidents in home or industry, or result of deliberate assault on a person Alkalis (Found in oven cleaners, fertilizers, drain cleaners and heavy industrial cleaners) - more severe burns Acids (Found in bathroom cleaners, rust removers, swimming pool chemicals, and industrial drain cleaners) - can limit depth of tissue damage Organic Compounds (chemical disinfectants and gasoline) - are fat soluble, once absorbed they produce toxic effects on kidneys and liver

Thermal Burns

- occur when clothesignite from heat or flames produced by electrical sparks

External Burn Injuries

- occur when electrical current jumps or arcs b/w two body surfaces; are usually severe and deep

True Electrical Injury

- occurs when direct contact is made w/an electrical source internal damage resultsand injuries can be devastating; damage starts on inside and goes out

Nonprogressive (Compensatory)

- occurs when map decreases 10-15 mm Hg from baseline kidney and hormonal adaptive mechanisms are activated trigger release of renin (cause widespread blood vessel constriction), ADH (increases water reabsorption - reduces urine output and blood vessel constriction in skin), aldosterone, epinephrine and norepinephrine tissue hypoxia occurs in nonvital organs (skin, GI tract) and in kidney - not great enough to cause permanent damage acidosis and hyperkalemia occur Manifestations: thirst sensation, anxiety, restlessness, tachycardia, increase RR, decreased urine output, falling systolic pressure, rising diastolic, narrowing pulse pressure, cool extremities and small decrease in O2 sats if patient is stable and adaptive mechanisms are supported, pt can remain in this stage for hours w/o having permanent damage

Radiation injuries

- occurs when people exposed to large doses of radioactive material

Progressive (Intermediate)

- occurs when there is a sustained drop in MAP of more than 20 mm Hg from baseline compensatory mechanisms can no longer effectively provide oxygen to vital organs Manifestations: severe thirst sensation, deeper anxiety, immediate confusion, rapid/weak pulse, low BP, pallor/cyanois, cool/moist skin, anuria and 5-20% decrease in O2 sats low pH, rising lactic acid and rising K+ pt's life can usually be saved if conditions causing shock are corrected w/in 1 hour or less from onset of this stage

Refractory (Irreversible)

- occurs when too much cell death and tissue damage result from too little oxygen reaching the tissues therapy is not effective in saving pt's life even if cause is corrected and MAP temporarily returns to normal Manifestations: rapid loss of consciousness, non-palpable pulse, cold mottled or dusky extremities, slow shallow respirations and unmeasurable oxygen sats

Risk Factors that Increase changes of death

- older than 60, burn greater than 40% TBSA and presence of inhalation injury (if has all 3, risk of death is very high)

Mafenide Acetate

- premedicate for pain before application, monitor blood gas and serume electrolyte level

initial (Early)

- present when patient's baseline MAP is decreased by less than 10 mm Hg adaptive (compensatory) mechanisms are so effective at returning MAP to normal levels that oxygenated blood flow to all vital organs is maintained increased anaerobic metabolism w/production of lactic acid increased sympathetic stimulation, mild vasoconstriction, increased heart rate (these allow CO and MAP to remain w/in normal range)

Severe Sepsis

- progression of sepsis w/an amplified inflammatory response all tissues are involved and all have some degree of hypoxia, though some organs are experiencing cell death and dysfunction at this time

chronic pancreatitis treatment

- relief of pain (morphine) - control pancreatic insufficiency with diet low in fat and high in carbs, pancreatic enzyme replacement, control "diabetes" - eliminate alcohol - surgery to remove gallbladder and portions of the pancreas

Moist Heat

- scald injuries, caused by contact w/hot liquids or steam

Multiple Organ Dysfunction Syndrome

- sequence of cell damage caused by massive release of toxic metabolites and enzymes metabolites trigger small clots to form --> clots block tissue oxygenation and damage more cells (this continuing the devasting cycle) occurs first in the liver, heart, brain and kidney most profound change is damage to heart muscle, cause of this damage is release of myocardial depressant factor from ischemic pancreas just being a patient in the acute care setting is a risk factor for hypovolemic shock it is important to determine AGE of patient because hypovolemic shock from trauma is more common in young adults and other types of shock are more common in older adults signs of shock are FIRST seen in Cardiovascular function - decreased MAP leading to adaptive responses changes in mental status and behavior may also be early signs if a patient is suspected of having hypovolemic shock, an RN NOT A LVN/UAP, should take assessment and obtain vital signs when vasoconstriction is present, diastolic pressure increases but systolic remain the same ANY O2 SAT VALUE BELOW 70% IS CONSIDERED A LIFE-THREATENING EMERGENCY AND MAY SIGNAL REFRACTORY STAGE OF SHOCK of the four vital organs (heart, brain, liver and kidney) only kidney can tolerate hypoxia and anoxia w/o permanent damage

Septic Shock

- stage of sepsis and SIRS when multiple organ failure is evidence and uncontrolled bleeding occurs even w/appropriate interventions, death rate is 60% blood cannot clot cardiac contractility is poor clinical manifestations resemble late stage of hypovolemic shock

Packed RBC's

- used for moderate blood loss

Whole blood

- used to replace large volumes of blood

Sepsis

- widespread infectioncouple with a more general inflammatory response, known as systemic inflammatory response syndrome (SIRS) that is triggered when infection escapes local control pt has mild hypotension, urine output lower than expected for fluid intake, and increase RR microemboli begin to form w/in capillaries causing some cell hypoxia and reducing organ fxn if caught and corrected during this phase, damage is reversible

Tobramycin

-Aminglycoside -Major drug for systemic disease.

Special note on Beta blockers

-Beta blockers block beta cells, sites for epi and norepi (catecholamines) -so we decreased the contractability of the heart and that means CO is DECREASED -due to that, workload is decreased -it is good we reduced the workload of the heart, but we must be careful not to decrease the pts cardiac output too much (HR and BP)!

Diagnositic lab work

-CPK-MB -troponin -myoglobin

Wrist drop

-Condition in which a person cannot extend the hand at the wrist. - Due to paralysis or weakness of the posterior forearm muscles which can extend the hand at the wrist.

S/S of dig toxicity

-EARLY - anorexia, nausea, vomiting -LATE - arrhythmias and vision changes (halos, things look yellow)

Penicillins S/E and pt teaching

-GI upset: diarrhea as side effect vs. C. diff -MANY DRUG INTERACTIONS -Allergies: -5 to 8% more likely to be allergic to cephalosporans if allergic to penicillins -IV vs. PO (Make 100% sure arent allergic because if given IV it goes all over body) -Patient teaching- rash

What are the goals of fibrinolytics:

-Goal: dissolve the clot that is blocking blood flow to the heart muscles => decreases the size of the infarction -Medications: Streptokinase, Alteplase, Teneteplase (a 1 time push), Reteplase

Dx avian flu

-H5 polymerase chain reaction test @ WHO lab -blood antibody tests (not accurate for 14 days)

A-line

-Measures BP continuously on a monitor -NEVER put medicine in an A-line -placed in radial artery -allens test - a check for alternative circulation (you want it +) Apply pressure to client's ulnar and radial arteries at the same time, ask pt to open and close hand, hand shouldn't blanch, release the pressure from the ulnar artery while continuing to compress the radial artery and assess the color in the extremity distal to the pressure point - pinkness should return within 6 seconds (indicating the ulnar artery is sufficient to provide hand with adequate circulation if radial artery is occluded with A-line). This is considered a + Allen's test. -You do have to be careful with an A-line because if you do not have the connections secure on your pressure tubing or if you do not have the stopcocks in the proper positions your client could bleed out. -check distal circulation while in place the 5 Ps: pulselessness, pallor, pain, paresthesia, paralysis

what drugs are used for chest pain in the ER?

-O2 -Asprin, chewable, to prevent platelet aggrigation -Nitroglycerin -morphine

Pacemaker Facts

-SA node is the hearts natural pacemaker, it sends out impulses that make the heart contract -if the natural pacemaker malfunctions cardiac output decreases -pacemakers are used to increase the heart rate wit symptomatic bradycardia -pacemakers depolarize the heart muscle and a contraction will occure (electricity going through the muscle) -repoloarization (rest) (ventricles are resting and are filling up with blood)

Cardiac Rehab consists of?

-STOP smoking -Diet change - low fat, low salt, low cholesterol -stepped-care plan (increase activity gradually) -no isometric exercises, increases workload of heart -no valsalva -no straining; no suppository. put pt on Docusate (colace) -resume sex when pt can walk around the block or up stairs with no pain and breathlessness -safest time of day for sex is the morning -best exercise is walking -teach pt S/S of heart failure: weight gain, ankle edema, shortness of breath, confusion

Digitalis

-Used with atrail fibrillatioon and HF -makes contractions stronger -decreases HR when the heart rate is slowed this gives the ventricles more time to fill with blood -cardiac output will increase -kidney perfusion will increase (diuresis is good, HF pt cannot handle the fluid)

Nitroglycerin IV

-Vasodialtion, decrease afterload -deceased afterload = increased CO because of the heart is pumping against less pressure and more blood can be moved forward

Acute Coronary Syndrome complications

-Vfib arrhythmia, can cause sudden death -if pt remains in Vfib after the first shock, give epinephrine -When Vfib is resistant to treatment (and for fast arrhythmias) give Amiodarone (Cordarone), an anti-arrhythmic -To prevent a second Vfib give Amiodarone and Lidocaine (numb)

pulmonary artery catheter (Swan Ganz cath)

-a type of central line that measures pressures inside the heart -helps determine the cause of decreased cardiac output -killer complications: air embolus, pulmonary infarction

*define ARDS

-acute lung injury from unregulated systemic inflammatory response to acute injury or inflammation -noncardiac pulmonary edema and progressive refractory hypoxemia (low O2 w/O2 admin) -mortality 40% -not a primary process- follows another problem -those w/acute from trauma etc- good prognosis -those w/chronic- poor prognosis

Ace inhibitors

-angiostensin converting enzyme inhibitor -Blocks conversion of angiotensin I to angiotensin II -promote vasodialtion and diuresis, decreases the secretions of aldosterone (so the kidneys will get rid of sodium and water and retain potassium) *Enalapril *Fosinopril *Captopril

ABRs

-angiotension II receptor blockers -blocks effects of angiotensin II (a potent vasoconstrictor) at the receptor site (used as an alternative to ACE inhibitors) ACE inhibitors block the conversion of AI to ALL but All can also be formed by other enzymes that re not blocked by ACE inhibitors -They decrease blood pressure, increase CO *Valsartan (Diovan) *Losartan (Cozzar) Irbesartan (Avapro)

TX of DVT

-anticoagulants -limit foods with potassium (green leafy vegs) -surgery -bed rest-don't want to dislodge it and cause a pulmonary embolism -elevate to increase blood return and decrease blood pooling -TED hose to increase venous return, decrease pooling, used with SCD's many times -warm, moist heat, reduce inflammation. never cold on a vein=excessive vasoconstriction. never hot on a vein = excessive vasodilation -PREVENTION is the key Ambulate and Hydrate this pt Also for prevention put on SCDs and get the client to do isometric exercises

Cardiac catheterization pre-op

-ask if allergic to iodine, shellfish (Iodine based dye will be used during procedure) -check kidney function since you excrete the dye through the kidneys -hot shot - warm flushing normal -palpations - normal

Buerger's Disease TX

-avoid cause -stop smoking -avoid cold -hydration -bypass surgery -wear shoes that fit well; avoid any trauma to feet -gangrene => amputation

Client education/teaching

-avoid isometic exercise (exercise that make your muscles squeeze/tense up), this will increase the workload. -avoid overeating -rest frequently -avoid excess caffeine or any drugs that increase HR -wait 2hrs after eating to exercise -dress warmly in cold weather (any temperature extreme can precipitate an attack) -take nitroglycerin prophylactically -smoking cessation -lose weight DO EVERYTHING YOU CAN TO DECREASE HEART WORKLOAD

Beta Adrenergic Blockers

-block adverse effects from sympathetic nervous stimulation -block the receptor sites for epi and norepi...so they will decrease afterload and contractility...as a result they will decrease the BP and HR. *Propranolol *Metoprolol *Atenolol *Carvedilol

CABG

-can be scheduled or emergency procedure -used with multiple vessel disease -left main artery occlusion which supplies the entire left ventricle

Furosemide (Lasix)

-causes diuresis and vasodilation which traps more blood out in the arms and legs and reduces preload and afterload -40mg IV push over 1-2 min to prevent hypotension and ototoxicity

Nitroglycerin (Nitrostat): Sublingual FACTS

-causes venous and arterial dialation -results in decreased preload and afterload -causes dilation of cornary arteries which will increas blood flow to the actual heart muscle (myocardium) -take 1 every 5 min x 3 doses (call Dr if pain is not relieved) -Do Not Swallow -Keep in dark, glass bottle; dry, cool -may or may not burn or fizz -will cause headache, if NO HEADACHE CALL DR. -renew prescription every 3-5 mos. -renew spray every 2yrs. -will cause BP to decrease - you are manipulating the BP so DO NOT LEAVE THE PT. NEVER LEAVE AN UNSTABLE PT!!

client education/teaching:

-ck pulse daily -ID card -avoid electromagnetic fields (cell phones, large motors, arc welding, electrical substations) -avoid MRI's (will change the settings or turn it off) -they will set off alarms in airports -avoid contact sports

Milrinone

-continuous infusion -vasodilates veins and arteries

Patho of chronic stable angina:

-decrease blood flow to myocardium =>ischemia=> temporary pain/pressure in chest -usually caused by cornary heart disease -Low O2 brings the pain on, usually due to exertion -Rest and/or nitroglycerin sublingual relieves pain

S/S of cardiac tamponade

-decreased Cardiac output -CVP will increase and BP will be dropping (this is key, heart being squeezed like squeezing a baloon) -heart sounds will be muffled or distant -neck veins distended -pressures on all 4 chambers the same -shock -paraxocical pulse - this is when the BP is greater than 10 mm Hg higher on the expiration than on inspiration -narrowed pulse pressure (from the baseline) pulse pressure is the difference between the systolic and the dystolic ex. 120/80 = 40m pulse pressure; 90/60 = 30 pulse pressure = it is dropping

Patho of Acute Coronary Syndrome

-decreased blood flow to mycardium => ischemia and neccrosis -pt does NOT have to be doing anything to trigger (occurs a lot during REM sleep) -Nitroglycerin will NOT relieve the pain

causes of hypoxemia

-decreased oxygen content (PaO2) of inspired gas (high altitude=low atmospheric pressure) -hypoventilation of alveoli causes elevated PaCO2 -diffusion abnormalities through the alveolocapillary membrane (thickness/fibrosis=tissue edema, decreased surface area d/t alveolar destruction= emphysema) -V/Q abnormalities (most common cause) -Right to left shunting in pulmonary capillary bed (causes hypoxemia in ARDS and RDS) -poor perfusion d/t emboli can cause a high v/q (area is ventilated but no perfused=alveolar dead space) "Impaired diffusion across alveolar-capillary membrane and a ventilation-perfusion mismatch can cause a drop in arterial oxygen Indicates failure of oxygenation"

Nursing considerations with Digitalis

-diuresis is a good thing -we always want diuresis with HF pts, they cannot handle the fluid -Digitalizing dose-loading dose -normal Dig level is 0.5 to 2 ng/ml -You know Dig is working when cardiac output increases (LOC increases, skin warm and dry, not SOB, no chest pain) -before administering take apical pulse (don't give if below 60) -monitor electrolytes all electrolytes must remain normal, but k+ is the one that causes the most trouble *Hypokalemia+Dig=toxicity

avian flu prevention

-early recognition and quarantine -wide distribution of oseltamivir (Tamiflu) and zanamivir (Relenza) -strict isolation -stop all public gatherings (school, shop, church, work) for 2 weeks -No travel to the area

S/S of DVT

-edema -tenderness -warmth testing for a positive Holman's sign is out of favor (but they still do it in Post Part.) because it can cause the clot to break lose there will not be an O2 answer with DVT, it is a vein problem!

MISC HF info

-elevate head of bed, 10" blocks under the head of the bed -weigh daily (report gain of 2-3lbs) -report SS of recurring failure

Raynaud's Disease S/S and TX

-female -happens iin fingers (bilaterally, usually tips) -turns white, blue, red (vasoconstriction) -gets cold, upset, smoking -painful, can cause ulceration TX - avoid the cause

Ace inhibitor uses/nursing observations

-for hypertension and HF -if the drug ends in -pril it is most likely and ACE inhibitor -watch for hyperkalemia, orthostatic syncope, hypotension, and renal dysfunctio-Angioedema-laryngeal swelling, can be fatal -dry, nonproductive cough-reversable when stopped -use fall precautions

arterial disorder patho

-if you have atheroscloerosis in one place you have it everywhere -it is a medical emergency if you have and acute arterial occlusion (numb, pain, cold, no pulse) -more symptomatic in lower extremities -INTERMITTENT CLAUDICATION - HALLMARK SIGN -arterial blood isn't getting to the tissue => coldness, numbness, decreased peripheral pulses, atrophy, bruit, skin/nail changes, and ulcerations -rest pain means severe obstruction

PCI

-includes all interventions such as PTCA (angioplasty) and stents -major complication of angioplasty is a MI, don't forget client may bleed from heart cath site -If any problems occur, go to surgery. *Chest pain after procedure = call dr. ASAP = reoccluding! -antiplatelet meds: aspirin, clopidogrel (Plavix), Abxiximab and Eptifibaride (given to high risk clients who have been stented to keep artery open those waiting to go to cath lab)

Myoglobin

-increases within 1hr and peaks in 12hrs -Neg results are GOOD

Buerger's Disease S/S

-inflammation of arteries and veins -men -heavy smoking, cold, emotions causes vasoconstriction of vessels -lower extremeties/sometimes fingers

Nesiritide

-infusion; short term therapy; not to be given more than 48hrs --vasodilates veins and arteries and has a diuretic effect

Shock is:

-is widespread abnormal cellular metabolism that occurs when the human need for oxygenation and tissue perfusion is not met to the level needed to maintain cell function -all body organs are affected and either work harder to compensate or fail to function

S/S of permanent pacemaker malfunction

-its possible that no mechanical even or contraction follows the stimuli, this is called loss of capture -loss of capture is caused by the pacemaker not being programmed correctly, electrodes becoming dislodged, or battery depleted -any sign of decreased CO or decreased rate

Cardiac catheterization post-procedure

-monitor VS -watch puncture site (for bleeding and hemotoma) -assess extremity distal to puncture site (the 5 Ps) -bed rest, flat, leg straight x 4-6hrs -report pain ASAP -major complication post cath is HEMORRHAGE

Post-permanent procedure care:

-monitor the incision -most common complication in the early hours is electrode displacement, needs time to embed in the tissue -immobilize arm -PROM to prevent frozen shoulder -keep the pt from raising their arm too high

Signs and symptoms of Acute Coronary Syndrome

-pain -cold/clammy/BP drops -cardiac output decreases -WBC increase (due to inflammation) -Temp increases (due to inflammation) -ECG changes: stemi - ST elevation, indicates MI, nstemi - less dangerous -vomiting - vegus nerve is stimulated, HR decreases, BP decreases

avian flu care of the patient

-prevent spread -supportive -PPE -fit tested respirator -airborne and contact precautions -negative air pressure room -O2 for hypoxia -respiratory treatments -MV if needed -antibiotics for secondary pneumonia -fluid if pt has severe D -I&O for fluids if needed -estimate hydration status from I&O & pulse rate

How to DX HF

-pulmonary artery catheter (Swan Ganz cath) -A-line -BNP: B-type natriuretic peptide -CXR -echocardiogram -NY Heart association functional classification of persons with HF classes 1-4 with 4 being the worst

BNP: B-type natriuretic peptide

-secreted by ventricular tissues in the heart when ventricular volumes and pressures in the heart are increased -sensitive indicator -can be + for HF when the CXR doesn't indicate a problem -if the client is on Natrecor, turn it off 2hrs prior to drawing a BNP

Chronic pancreatitis labs

-serum amylase and lipase levels may be slightly elevated (or normal!) -in the later stages atrophy of the pancreatic parenchyma can result in normal serum enzyme levels -LOW concentrations of serum TRYPSIN are relatively specific for advanced chronic pancreatitis -high serum calcium and triglyceride levels **-BENTIROMIDE test - PABA (para-aminobenzoic acid) is not excreted in the urine * The best test for chronic pancreatitis!

SS of pulmonary edema

-severe hypoxia -usually occurs at night -sudden onset -breathlessness -restless/anxious (think hypoxia) -productive cough (pink frothy sputum)

avian influenza info

-there have been past epidemics -bird virus's don't usually transfer to people -when humans get it- they usually don't pass it to other humans -if they do - we don't have immunity- pandemic -expect high mortality rates -suspect - oral fecal route -NOT from eating infected birds -no vaccine available

Temporary pacemakers

-used in emergency situations -used after heart surgery -used for acute MI -used until the client is stable enough for a permanent pacemaker to be inserted -can be classified as invasive or noninvasive

Permanent Pacemaker Facts

-used when heart condition is chronic -electrodes are anchored to the endocardium and attached to a battery source implanted into a subcutaneous pocket -a demand pacemaker kicks in only when the client needs it to -fixed rate fires a fixed rate constantly it's okay for the rate to increase but never decrease always worry if the rate drops below a set rate

The nurse's young neighbor who smokes is going on an oversea flight. The neighbor knows he is at risk for PE and DVT and asks the nurse for advIce. What does the nurse suggest? a. Exercise regularly and wa1k around before boarding the flight. b. Get a prescription for Heparin therapy and take it before the flight · c. Drink water;get up hourly for at least 5minutes duing the flight. d. Elevate the legs as much as possible during and after the flight

...

Labs:

no single lab finding confirms or rules out shock, they may support the diagnosis partial pressure of arterial oxygen (PaO2) decreases partial pressure of arterial CO2 (PaCO2) increases pH decreases hematocrit and hemoglobin levels decrease if shock is caused by hemorrhage if shock is caused by dehydration or fluid shift, hematocrit and hemoglobin levels are elevated

Liver transplant complications

o Acute, chronic graft rejection o Infection o Hemorrhage o Hepatic artery thrombosis o Fluid and electrolyte imbalances o Pulmonary atelectasis o Acute renal failure o Psychological maladjustment

Portal Hypertension

o An abnormally high BP within the portal vein system; most commonly caused by cirrhosis but can be caused by anything that impedes blood flow through the portal venous system or through the vena cava, such as fibrosis or inflammation of the liver tissue secondary to cirrhosis, hepatitis, or infection, hepatic vein thrombus, tumor, or right heart failure 3 Types: -prehepatic (obstruction/constriction of portal vein or tributaries) -intrahepatic (cirrhosis- most common cause of portal hypertension) -posthepatic (hepatic vein thrombosis, inferior vena cava obstruction, or right heart failure causing back-up)

Renal Calculi (kidney stone)

o Calculi are stones that can form anywhere in the urinary tract; however the most frequent site is the kidneys o These form in the renal parenchyma o Stones are 75% calcium kidney stones, bedrest immobility, poor fluid intake, severe cramping& pain just below ribs, nausea, vomiting, fever, chills, blood in urine, person needs 2000-3000ml of fluid/day - urinary system disorders

Medications for acute pancreatitis

o Demerol for pain o Antiemetics o H2 blocker, Tagament or Zantac o Antispasmotics such as Bentyl o Electrolyte replacement o Insulin o Antibiotics as ordered for infection o Some patient may need long term with pancreatic enzyme replacemnt lipan, creatine

Cause of renal calculi

o Diet high in calcium, vit D, purines, alkali o Urinary statis, dehydration, immobilization, UTIs, diuretics, hyperparathyroidism, elevated uric acid levels such as in Gout

Medications for portal hypertension

o Diuretics and fluid restrictions are treatment of choice o Propranolol used to decrease portal venous pressure Meds -Spiranolactone and Eplerenone are nice, as they directly block Aldosterone Receptors. Aggressive Diuretic treatment in this disease can cause Hepatorenal Syndrome and Hepatic Encephalopathy, eg Death.

Intervention/Teaching renal calculi

o Encourage fluid intake of up to 3000mL/day o Provide warm baths and heat to the flank area, but DO NOT massage o Opioid anagelsics for the 1st 36 hrs o Promote ambulation to encourage passage of stone o Instruct client in diet restrictions: 1. Speical diet such as alkaline-ash 2. Or acid ash diet

Education for pancreatitis

o NPO until acute phase is over and then small meals with NO ALCOHOL. o Teach about enzyme replacement for malnutrition

A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, the nurse should _____________

obtain a Glasgow Coma Scale score. rationale: The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.

unilateral neglect (neglect syndrome)

occurs most commonly in clients who have had a right cerebral stroke; client experiences an inability to recognize his or her physical impairment

Cardiogenic Shock -

occurs when actual heart muscle is unhealthy and pumping is directly impaired MI is most common cause of direct pump failure any type of pump failure decreases cardiac output and MAP Risk Factors: diabetes, prescence of cardiomyopathies

Distributive Shock -

occurs when blood volume is not lost from body but is distributed to interstitial tissues where it cannot circulate and deliver oxygen can be caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, and increased blood vessel permeability these can decrease MAP and may be started by nerve changes or presence of chemicals neural induced - is a loss of MAP that occurs when sympathetic nerve impulses controlling blood vessel smooth muscle are decreased and smooth muscle of blood vessels relax causing vasodilation chemical induced - origin usually anaphylaxis, sepsis or capillary leak syndrome Risk Factors: diminished immune response, reduced skin integrity, cancer, peripheral neuropathy, strokes, institutionalized, malnutrition, anemia

Open head injury

occurs when there is a skull fracture or when the skull is pierced by a penetrating object; the integrity of the brain and the dura is violated, and exposure to outside contaminants occurs.

Hypovolemic Shock -

occurs when too little circulating blood volume causes a MAP decrease resulting in the body's total need for oxygen not being met common problems leading to hypovolemic shock are hemorrhage and dehydration Risk Factors: diuretics, diminished thirst reflex, immobility, aspirin products, Ginkgo biloba, anticoagulant therapy

cranial nerve 3; how to assess

oculomotor; motor, checks pupillary constriction, upper eyelid elevation, and most eye movement

Lactate

of 0.7 mmol/L implies that tissue perfusion is adequate.

cranial nerve 1; how to assess

olfactory: sensory, smell; have the client close his or her eyes and occlude one nostril with finger; ask the client to identify nonirritating odors such as coffee, tea, cloves, soap, chewing gum, peppermint; repeat the test on the other nostril

cranial nerve 2; how to assess

optic: sensory, vision; check visual acuity with a snellen chart or newspaper, or ask the client to count how many fingers the examiner is holding up; check visual fields by confrontation; have the client sit directly in front of examiner and stare at examiner's nose; examiners lowly moves his or her finger from the periphery toward the center until the client says it can be seen; check color vision by asking the client to name the colors of several nearby objects

Mass casulaty event

overwhelming local medical capabillities and requires collaboration of multiple agencies

Treatments/Interventions

oxygen is useful whenever shock is present IV therapy for fluid resuscitation in mainstay of mgmt of hypovolemic shock crystalloids and colloids are used for volume replacement during hypovolemia crystalloids: contain nonprotein substances (minerals, salts, sugars) given to help maintain adequate fluid and electrolyte balance include Normal Saline and Ringer's Lactate (DO NOT INFUSE THIS SOLUTION W/BLOOD PRODUCTS B/C CALCIUM INDUCES CLOTTING OF THE INFUSING BLOOD) colloids: contain large molecules (usually proteins or starches) help restore osmotic pressure and fluid volume blood and blood products are often used for this purpose when shock is caused by blood loss

FiO2 -

oxygen level delivered to the patient Prescribed amount is determined by ABGs and pt's condition

Hypoventilation ABG

pH <7.35-7.45 pCO2 >35-45 PaO2 Low Resp. Acidosis

Hyperventilation ABG

pH >7.35-7.45 pCO2 <35-45 PaO2 High Resp. Alkalosis

S/S of hypoxemia

pO2 <80 CNS sx: confusion, restlessness, anxiety, perspiration Cardiac: early > of HR; if hypoxic state continues pulse may < Resp: increased rate, use of accessory muscles, flared nostrils, cyanosis "PO2 is significantly reduce Metabolic acidosis occurs in tissue hypoxia Dyspnea, neurological symptoms (restlessness, apprehension, impaired judgment and motor impairment), tachycardia, HTN As it continues - dysrhythmias, hypotension and decreased cardiac output"

Hypoxemia ABG

pO2 <80-100 O2 Sat. <95-100%

Invasive temporary pacemaker

pacing wires are placed into a heart muscle (transvenous pacing) -wires are connected to a power source outside the body -epicardial pacing is when the wires are attached to the epicardium during surgery

why would a Dr want the client NPO and have a NG tube for suction?

paralitic ilius stress = less blood volume hyperkalemia = muscle weakness

paraplegia

paralysis of both legs and the lower part of the body

tetraplegia

paralysis of the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord. This disorder is usually caused by spinal cord injury, especially in the area of the fifth to the seventh vertebrae

treatment for cardiac tamponade

pericardiocentesis to remove fluid from around the heart surgery

3 risks for hypthermia

phenothiazines barbituates hypothyroidism

Superficial:

pink to red, mild edema, painful, no blisters or eschar, 3-5 days for healing time, no grafts required EX: sunburn, flash burns epidermis is only part of skin that is damaged

halo traction

pins or screws are inserted into the client's skull, and a circular fixation device and halo jacket or cast is applied

Hepatic cell damage in cirrhosis may lead to:

portal hypertension, ascites, bleeding esophageal varices, coagulation defects, jaundice, portal-systemic encephalopathy (PSE) with hepatic coma, hepatorenal syndrome, spontaneous bacterial peritonitis

PEEP -

positive end-expiratory pressure - positive pressure exterted during expiratory phase of ventilation Is used to treat persistent hypoxemia that does not approve with acceptable oxygen delivery level Opften added when partial pressure of PaO2 remains low w/ FiO2 of 50-70% or greater

**synchronized intermittent mandatory ventilation (SIMV)

positive pressure *allows spontaneous breathing between vent breaths *controlled breaths at set rate, volume and/or pressure *coordinated w/inspiration *exercises respiratory muscles between assistance *used during weaning after longer ventalation periods

**Positive end-expiratory pressure (PEEP)

positive pressure *requires intubation *can be applied to all other ventilator modes *positive pressure during exhalation and between breaths *keeps alveoli open *improved perfusion and diffusion *reduces hypoxema *allows lower % of inspired O2 *good for ARDS

**pressure support ventilation (PSV)

positive pressure *vent support w/inspiration *flow limited *decreased work of breathing *used w/SIMV when resp drive is depressed maintains positive pressure throughout the respiratory cycle used for weaning after long times on vent.

Low sodium diet decreases

preload

escharotomy relieves what

pressure and restores circulation, cut through the eschar

fasciotomy relives what

pressure and restores the circulation, deeper cut into the tissue, cut goes through eschar and fascia

Dialysis

process of separating nitrogenous waste materials from the bloodstream when the kidneys no longer function

Chronic pancreatitis -

progressive and destructive with remissions and exacerbations -inflammation and fibrosis of the tissue contribute to pancreatic insufficiency and diminished function of organ Major causes: -usually develops after repeated episodes of alcohol induced acute pancreatitis -alcohol consumption in Western societies=70-80% -associated with chronic obstruction of CBD -malnutrition worldwide

Alveolar collapse phase of ARDS

protein rich fluid in alveoli inactivates surfactant and cells that produce it. This decreases compliance, atelectasis and fluid filled alveoli interfere with gas exchange. PaO2 falls, PaCO2 also fall as tachypnea causes more CO2 to b expired

*when to remove vent support (extubation)

pt able to maintain effective respirations

IF ANY OF THE FOLLOW OCCURS, Apply O2 and Call RRT

pt becomes progressively hoarse; develops a brassy cough; drool or have difficulty swallowing; produce sounds on exhalation that include audible wheezes, crowing and stridor if wheezing sounds disappears, thing indicates impending airawy obstruction and demands immediate intubation Carbon Dioxide Poisoning - oen of leading causes of death from a fire inhalation injury is a risk from CO poisoning noninvasive BP readings are inaccurate in patients w/large burns involving the upper extremities at first cardiac S/S will be: tachycardia, decreased BP, decreased peripheral pulses, slow or absent cap. refill

systemic S&S of flu

rapid onset profound malaise (maybe w/in minutes) chills fever (may last a week) muscle aches HA

rare systemic brown recluse S&S

rash, fever, chills, N, V, malaise, joint pain massive hemolytic reactions, renal failurre, cardiovascular collapse, death

left atrium

receives oxygen-rich blood from the lungs through the four pulmonary veins

Therapeutic use of Fentanyl is

relieve pain or as an adjunct to general anesthesia if Fentanyl is not effective in relieving pain, consider using morphine instead

Decompressive laminectomy

removal of bone fragments, penetrating objects, or hematomas that are compressing the spinal cord. Removal of one or more Laminae- allows for cord expansion from edema to prevent neurologic deterioration.

what do you do with a burn pts clothing?

remove non-adherent clothing (can constrict blood flow) and cover with a clean dry cloth

brown recluse severe complications

renal failue leukopenia seizures hemolytic anemia thrombocytopenia coma death

RSV children infants adults elderly

respiratory syncytial virus primary cause -resp illness in young children majority of lower resp in infants mild- common cold immunosuppressed= severe pneumonitis

Intrahepatic obstructive jaundice

results from edema, fibrosis, or scarring of the hepatic bile channels and bile ducts, which interferes with normal bile and bilirubin excretion

RSV S&S for adults

rhinorrhea sore throat cough HA malaise low temp

Complications of flu

secondary bacterial infections -sinusitis -otitis media -tracheobronchitis (may last 3 weeks) -pneumonia -primary influenza viral pneumonia (uncommon) ---maybe fatal, dev w/in 48 hrs (hypoxia, death in days) -secondary bacterial pneumonia ---relapse of flu w/productive cough, x-ray-pneumonia -exacebation of COPD, chronic bronchitis, asthma -Reye's syndrome, w/in 2-3 wks, 30% mortality ---hepatic failure, encephalopathy -myositis (inflammation of skeletal muscles) -myocarditis -CNS disorders (encephalitis, Guillain-Barre S)

Peak and trough

serum samples collected to determine the level of an antibiotic or other pharmaceutic agent in the blood. Peak specimens, which represent the highest level, are generally collected ½ hour after the dose is given intravenously or 1 hour after it is given intramuscularly. Trough specimens, representing the lowest level, are generally collected approximately ½ hour before the next dose

*SARS define primary population

severe acute respiratory syndrome lower resp illness - unknown etiology 25-70 yrs

cardiogenic shock

shock caused by cardiac arrest

ARDS predesposing factors

shock, inhalation injuries, infections, drug overdose, trauma, DIC, pancreatitis, uremia, amniotic fluid and air emboli, multiple transfusions, open heart surgery w/cardiopulmonary bypass, TRALI

what are signs of airway injury?

singed nasal and face hair black secretions blisters on mucous membranes

Canned and processed foods contain a lot of

sodium

cranial nerve 11; how to assess

spinal accessory: motor; checks uvula and soft palate movement, sternocleidomastoid and trapezius muscles; checks upper portion of the trapezius muscle, which governs shoulder movement and neck rotation; palpate and inspect the sternocleidomastoid muscle as the client pushes the chis against the examiner's hand; palpate and inspect the trapezius muscle as the client shrugs his or her shoulders against the examiner's resistance

reporting of SARS

state and local health departments

Methylprednisolone

steroidal anti-inflammatory / glucocorticoid (replacement tx in adrenal insufficiency; used systemically & locally in CHRONIC disorders such as: ANAHII2: allergic, neoplastic, autoimmune, hematologic, inflammatory, immunosuppressant; unlabeled: acute spinal cord injury, hypercalcemia adj, n&v r/t chemo adj)

Prevention of PE

stop smoking, reduce weight, become more active, drink plenty of water if you are traveling long distances, get out of sitting position for at least 5 minutes every hour, early ambulation after surgery, avoid constricting clothing, prevent pressure under popliteal space, change positions every 2 hours, refrain from massaging or compressing leg muscle, do not cross legs, avoid valsalva maneuver

spinal shock (neurogenic shock)

sudden depression of reflex activity in the spinal cord below the level of injury (areflexia) that occurs within the first hour of injury and lasts for days to months; muscles become completely paralyzed and flaccid, and reflexes are absent

broad spectrum antibiotics are avoided to prevent

super infections or secondary infections they may be used until wound cultures have been returned

**Tx of SARS

supportive O2 maybe MV

Nursing care

supportive teach self care ID complication (pneumonia, sinusitis) teach prevention of spread

tarantual tx

supportive management analgesics immobilize and elevate extremity prophylaxis tetanus remove hairs ASAP (duct tape) thoroughly irrigate skin antihistamines topical or systemic steroids for intense pruritus & irritation

papilledema

swelling and inflammation of the optic nerve at the point of entrance into the eye through the optic disk

SVR

systemic vascular resistance: resistance to ejection from the left side of the heart/usually 800-1200

Stoke Volume

the AMOUNT of blood pumped out of the ventricles with each beat.

Preload

the amount of blood VOLUME to the heart

Right sided HF

the blood is not moving forard into the lungs...If it does not move forward then it goes backwards into the venous system S/S: enlarged organs edema weight gain distended neck veins ascites *systolic heart failure *diastolic heart failure

Left sided HF

the blood is not moving forward into the aorta and out to the body... IF it does not move forward then it goes backwards into the lungs S/S: pulmonary congestion dyspnea cough blood tinged frothy sputum restlessness tachycardia S-3 Orthopnea nocturnal dyspnea

Cardiac output changes accordingly to?

the body's needs

circumferential burn?

the burn goes all the way around check circulation

Hyperflexion injury

the head goes forward from back; damages to the front part of the spinal cord. When the neck area is damaged usually the whole body is paralyzed. C5-6 area injured commonly Example is hitting a tree when driving

apraxia

the inability to carry out a purposeful activity

agnosia

the inability to use an object correctly

vital capacity

the maximum amount of air that can be exhaled after a maximum inhalation (usually tested with a spirometer)

Heart rate

the number of times per minute the heart contracts

extravasation

the process of exuding or passing out of a vessel into surrounding tissues

polycythmemia

the proportion of blood volume that is occupied by red blood cells increases. Blood volume proportions can be measured as hematocrit level. It can be due to an increase in the number of red blood cells[1] ("absolute polycythemia") or to a decrease in the volume of plasma ("relative polycythemia")

systemic vascular resistance

the resistance the left ventricle must overcome to pump blood through the systematic circulation; primarily influenced by the radius of small arteries and arterioles.

Risk of death with burns increases in?

the very old - less subQ, so it is deeper burns the very young - small body surface area

stroke volume

the volume of blood pumped out by a ventricle with each heartbeat

ARDS risk factors

there is a genetic risk

Intramedullary tumors

these are all caused by parenchymal cell tumors of the spinal cord ; these account for only 5% of spinal cord tumors ; astrocytoma, ependymoma ; pure spinal cord syndromes seen here ; dissociated sensory loss ; rapidly progressive symptoms include paralysis and sensory loss

Ace inhibitor/ARBs and/or a Beta Blocker in HF

these drugs will decrease the workload in the heart, prevent vasoconstriction (decreasing afterload) which will increase cardiac output, keeping the blood moving forward out of the heart

Arrhythmias are no big deal UNTIL -

they affect your cardiac output 1. Vfib 2. Asystole 3.

what happens to cells of a burn pt?

they rupture

autonomic dysreflexia

this is an emergency situation resulting in a hypertensive crises (elevated systolic pressures of 260-300mm Hg), bradycardia, severe headache and possibly stroke or seizure activity. Happens to client with injury above 6th thoracic vertebra (paralyzed) and is caused by noxious stimuli - full bladder, fecal impaction, wrinkle in clothing, cramps, ingrown toenail, etc. Drug of choice is nitroprusside sodium (Nipride) or Nifedipine (procardia)

Autonomic Dysreflexia

this is an emergency situation resulting in a hypertensive crises (elevated systolic pressures of 260-300mm Hg), bradycardia, severe headache and possibly stroke or seizure activity. Happens to client with injury above 6th thoracic vertebra (paralyzed) and is caused by noxious stimuli - full bladder, fecal impaction, wrinkle in clothing, cramps, ingrown toenail, etc. Drug of choice is nitroprusside sodium (Nipride) or Nifedipine (procardia) *Commonly seen in patients with upper spinal cord injury (Usually above T6) Severe hypertension Bradycardia Severe headache Nasal stuffiness Blurred Vision Flushing of face and chest (above lesion) Piloerection Apprehension

myocardium

this is the middle layer and actual contracting muscle of the heart

systole

to contract; period in the cardiac cycle when the heart is in contraction and blood is ejected through the aorta and pulmonary artery

diastole

to expand; period during the cardiac cycle when blood enters the relaxed ventricles from the atria

Why are carbonate/magnesium carbonate (mylanta), pantoprazole (protonix), or famotidine (pepcid) ordered for burn pts?

to prevent stress ulcers curlings ulcers

brown recluse hospital care infection-

topical antiseptic & sterile dressing antibiotics dapsone therapy (50 mg x2 daily) possible debridement and skin graft prophylactic tetanus

euvolemia

total body water increases but sodium content remains the same causing a shifting of sodium INTRAcellularly.

ANTIVIRAL AGENTS

treat viral infections, including oral and genital herpes, influenze and HIV

cranial nerve 5; how to assess

trigeminal: sensory and motor; checks sensation to the cornea, nasal, and oral mucosa, facial skin, and mastication; ask the client to close jaws tightly ant then try to separate the clenched jaw; test the corneal reflex by lightly touching the client's cornea with a cotton wisp; check sensory function by asking the client to close the eyes, then lightly touch the forehead, cheeks, and chin noting if the touch can be felt equally on both sides

cranial nerve 4; how to assess

trochlear; motor, checks downward and inward eye movements

Esophageal varicies

twisted, torturous, dilated veins. Portal vein to the liver has decreased circulatin resulting in increased hypertension. Caution for hemorrhaging, S/S: hematemesis, melena, Monitor for hypovolemic shock a. Esophageal varices - occur when fragile, thin-walled esophageal veins become distended from increased pressure - potential to bleed depends on size i. Bleeding esophageal varices is a life-threatening medical emergency. There can be severe blood loss, resulting in shock from hypovolemia. Bleeding may be either hematemesis or melena - can occur with no precipitating factors or with activity that increases abdominal pressure (heavy lifting, vigorous physical exercise, etc)

BROWN RECLUSE SPIDER S&S

ulcerative lesions necrotic wound local aching and pruritus- maybe in min-hrs bleb or vesicle surrounded w/edema & redness center becomes bluish purple 1-3 days- dark, necrotic eschar "Red, white and blue" sign eschar sloughs=open wound or ulcer lasts wks to months

A patient who has experienced blunt abdominal trauma during a car accident is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of ______________

ultrasonography. rationale: For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding.

flu S&S = 3 syndromes

uncomplicated nasopharyngeal inflammation viral upper resp infection followed by 1. bacterial infection OR 2. viral pneumonia

Positioning for pulmonary edema

upright with legs down this improves cardiac output promotes pooling in lower extremities

Digoxin (Lanoxin)

used to get the blood moving in a forward direction

with electrical burns why may the pt be placed on a supine board with a c-collar?

usually occur in HIGH places muscle contractions can cause fractures force of electricity can actually throw the victim forcefully

When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of ______________

vaccine. rationale: Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox.

cranial nerve 10; how to assess

vagus: sensory and motor; checks swallowing and phonation, sensation to the exterior ear's posterior wall, and sensation behind the ear; checks sensation to the thoracic and abdominal viscera

barotrauma

ventilations that are too forceful can result in this kind of trauma from the pressure. volutrauma. Caused by too much pressure or volume. alveolar is over distented.

diastolic HF

ventricles can't relax and fill

what arrhythmia is the electrical burn pt at high risk for?

vfib

occipital lobe

visual area

Tidal volume -

volume of air the patient receives with each breath Amount is usually 7-10 mL/kg of body weight

**S&S of ARDS- initial

w/in 24-48 hrs of insult dyspnea tachypnea anxiety ...People usually present with shortness of breath, tachypnea leading to hypoxia and providing less oxygen to the brain, occasionally causing confusion... progressive resp distress > resp rate intercostal retractions use of accessory muscles of resp cyanosis crackles rhonchi mental status chg (agitation, confusion, lethargy)

quadriparesis

weakness or partial paralysis in all 4 limbs

BURNS (P 519)

when a burn injury occurs, skin can regrow as long as parts of dermis are present evaporation through burn-injured skin occurs 4x as rapidly as from intact skin Fluid and cell damage cause profound imbalances of fluid, electrolytes (hyperkalemia and hyponatremia) and acid-base imbalance (metabolic acidosis) aldosterone secretion increases leading to increase sodium reabsorption by kidneys however, the sodium quickly passesinto the interstitial spaces of burned area w/fluid shift, therefore most of the sodium is trapped and a sodium deficiency occurs in the blood hemoconcentration (elevated blood osmolarity, H&H) develops from vascular dehydration - causes increased blood viscosity reducing flow through small vessels and increasing tissue hypoxia more airway injury is caused by chemicals and toxic gases produced during combustion rather than heat

Prevention of pulmonary edema

when possible prevent check lung sounds avoid fluid volume excess

when given -MYCIN drugs, we worry about?

when the client's BUN or creatinine increases OR if the pt complains of hearing loss Mycin drugs can cause irreversible hearing loss (ototoxicity) and nephrotoxicity (kidney)

the NG tube can be removed when?

you hear bowel sounds

Assessment of chronic renal disease

• BUN and creatinine rise, urine specific gravity is fixed at 1.010 • Uremia • Uremic syndrome (uremic frost) • Metastatic calcifications- From increased calcium in your blood-calcium binds with phosphorous and causes spurs—occurs in many parts of the body—when exceeds 70 the crystals dislodge in the kidneys, hearts, lungs, major blood vessels, eyes, brain, and joints • Renal osteodystrophy- Induced low calcium levels and high phosphorous levels-bone mineral loss causes bone pain, spinal sclerosis, fractures, bone density loss, osteomalacia, and tooth calcium loss • Cardiac changes: • Hypertension- because of retention of fluids- Pericarditis happens because of build-up of uremic toxins or infection • Hyperlipidemia- statins are nephrotoxic • Heart failure • Pericarditis • Hematologic changes • GI changes- Uremia affects the entire GI system-normal flora of the mouth changes with uremia, ammonia builds up causing halitosis and stomatitis—anorexia N/V and hiccups are common with a patient with uremia--ulcers can cause erosion of blood vessels which can lead to hemorrhagic shock from severe GI bleed • Anemia is common problem for CKD -causes are decreased erythropoietin level that decreases RBC production and survival • Uremia affects the entire GI system-normal flora of the mouth changes with uremia, ammonia builds up causing halitosis and stomatitis—anorexia N/V and hiccups are common with a patient with uremia • Neurologic-r/t electrolytes • Cardiovascular • Respiratory • Hematologic • Gastrointestinal • Skeletal • Urinary • Skin

Chronic Renal Failure Causes

• May follow ARF • DM and other metabolic disorders • HTN • Chronic urinary obstruction • Recurrent infections • Renal artery occlusion • Autoimmune disorders (systemic lupus erythematosus)

Teaching Acute Renal Failure

• Monitor urine output (frequency, volume, color, characteristics, discomfort or distress is not normal) • Kidneys need 1-2 quarts of fluid/day to flush out waste • Reduce intake of soft drinks • Frequent follow-up blood tests (Creatinine) and urinalysis • Teach drugs, diagnostic tests, and therapeutic procedures that can be nephrotoxic • Diet-low to moderate protein and high carbohydrates • Restrict potassium and sodium intake as indicated Encourage patients with renal failure to follow fluid and dietary restrictions regarding sodium, potassium, and protein. The patient with ARF may move from the oliguric phase to the diuretic phase, in which hypovolemia and electrolyte losses are the main problems.

Stages of Chronic kidney disease

• Reduced renal reserve (can stay on this for the rest of your life) • Renal insufficiency • End-stage renal disease

Hepatocellular dysfunction

• Yellowish discoloration of the skin and eyes • Abdominal pain • Distension of the abdomen • Severe itching of skin • Dark or tea colored urine • Pale stools • Intermittent blood in the stools • Extreme fatigue • Nausea • Loss of appetite After the liver has been exposed to causative agents (e.g., a virus), it becomes enlarged and congested with inflammatory cells, lymphocytes, and fluid, resulting in right upper quadrant pain and discomfort. As the disease progresses, the liver's normal lobular pattern becomes distorted as a result of widespread inflammation, necrosis, and hepatocellular regeneration. This distortion increases pressure within the portal circulation, interfering with the blood flow into the hepatic lobules. Edema of the liver's bile channels results in obstructive jaundice (yellowing of the skin).

ANTIVIRAL AGENTS

•Acyclovir •Ganciclovir

Aminoglycosides

•Amikacin •Gentamycin •Tobramycin Check Peak and Trough for this family of antibiotics! High trough levels, toxicity can occure. Nephrotoxicity and ototoxicity are primary problems. Report serum levels that are not normal.

ANTIHYPERTENSIVES

•Atenolol •Captopril •Diltiazem •Enalapril •Lisinopril •Methyldopa •Nifedipine •Propranolol •Verapamil

MISCELLANEOUS dialyzable drugs

•Aztreonam •Cimetidine •Vitamins

CEPHALOSPORIN Meds

•Cefaclor •Cefazolin •Cefoxitin •Ceftizoxime •Ceftriaxone •Cefuroxime

NARCOTICS -

•Codeine •Morphine

ANTICONVULSANTS

•Ethosuximide •Gabapentin •Phenobarbital

VASOACTIVE DRUGS ANTIDYSRHYTHMICS -

•Flecainide •Lidocaine •Procainamide •Quinidine

VASODILATORS -

•Hydralazine ●Nitroglycerin •Nitroprusside

SEDATIVES -

•Midazolam •Phenobarbital •Propofol

Hypotonic Solutions

0.45% Saline.

Isotonic Solutions

0.9 % Saline (NS), 5% Dextrose in 0.225% Saline, Ringers Solution, Lactated Ringers (Hartmann's) solution.

suctioning procedure

1 .When to suction - when patient needs it! Some Docs write specific orders, such as q 1-2 hours - this can cause unnecessary trauma to the trachea. Should be suctioned when it is needed. 2. Essential principle - when suction vacuum pressure is on - oxygen is being sucked out of lungs - never apply suction pressure while threading in - only on retrieval. 3. Things to monitor closely during suctioning - SpO2, HR, cardiac rhythm Preoxygenate Suction limit - 10 sec Reoxygenate Suction again as needed STEPS 1. Gather equipment 2. Set suction vacuum pressure between 100 and 120 3. Aseptically assemble equipment 4. Test suction 5. Check VS 6. Hyperinflate/ hyperoxygenate 7. Insert catheter until resistance is met, pull back and intermittently suction 8. Hyperinflate/ hyperoxygenate and reassess 9. Chart

Hepatic encephalopathy treatment

1) withdraw or treat factors causing. 2) reduce ammonia levels thru diet restriction (low protein) 3) zinc supplements 4) lactulose to make intestinal environment acidic to draw ammonia out of blood 5) Neomycin to kill bacteria instead of lactulose. Reduces ammonia released.

frequency of local outbreaks frequency of global outbreaks (pandemic)

1-3 years 10-15 year

Why would UO decrease immediately following a burn?

1. Fluid is escaping from the vascular space into the tissue so the kidneys are not being perfused. 2. Because rhabdomyolysis has occurred which can lead to "clogged kidneys".

Treatment for chronic stable angina: MEDS:

1. Nitroglycerin (Nitrostat): Sublingual 2. Beta Blockers (lol) 3. Calcium Channel Blockers 4. Acetylsalicylic Acid (ASA/aspirin)

What things are you assessing when performing a circulatory check?

1. Pulse 2. Skin color 3. Temperature 4. Cap refill

The 5 Ps

1. Pulselessness 2. Pallor 3. Pain 4. Paresthesia 5. Paralysis looking at circulation

In regards to the GI system what are 2 main concerns post burn and why?

1. Stress ulcers (curling's ulcer) 2. Paralytic Illeus (r/t decrease blood flow to gut 2 to decreased fluid in vascular space)

mean arterial pressure

1. The average pressure within the arteries 2. Diastolic BP + 1/3 of pulse pressure 3. Best indication of end organ perfusion

Chemical and electrical burn To Knows:

1. chemical burns, first remove client from chemical and flush 15-20 min. 2. electrical burn, has two wounds, enterance (small) and exit (large)

Complications with burn pts

1. circulatory system 2. renal system 3. electrolyte imbalance 4. GI system 5. Integumentary system

3 TX for pts with burns over 20% of their body

1. fluid replacement 2. emergency management 3. medication management

Pain Mgmt for burns:

1. give the smallest amount of narcotics to relieve pain 2. IV is preferred, it is faster and profusion is needed for IM 3. count respirations with narcotics!

Albumin (a colloid)

1. holds onto fluids in the vascular space 2. vascular volume increases 3. kidney perfusion increases 4.BP raises 5. Cardiac output increases 6.this helps correct fluid volume deficit by putting more fluid in the vascular space 7. Vascular volume increases sooo... 8. workload of heart increases

**complications of ventilation

1. improper placement= over inflation of 1 lung and atelectasis of the other W/NONINVASIVE VENT 1. gastric dilation 2. aspiration 3. facial skin necrosis 4. drying of the eyes and mucous membranes 5. stress 6. claustrophobia

Fluid Replacement Facts:

1. one of the most important aspects 2. fluid therapy (for the first 24hrs) is based on the time the injury OCCURED, not when treatment was started. So time of the injury is important. ~a common rule, calculate what is needed for the first 24hrs and give half of that volume during the first 8hrs~ 3. You need to know the clients weight in kg and total body surface area (TBSA) to calculate fluid replacement 4. for restless pt, look for inadequate fluid replacement, pain, hypoxia

what can a nurse do for a burn pt?

1. place in protective isolation 2. use Sutilanis (travase) or collagenase (santyl): enzymatic drugs that eat dead tissue (no face, no preggo, not over large nerves, not if it is opened to a body cavity) 3. hydrotherapy used to debried (less popular, cross contamination) painful, medicate first

if the use of Albumin stresses the heart too much what occurs?

1. pt thrown into fluid volume overload 2. cardiac output decreases 3. lung sounds become wet

Grafting To Knows: (7)

1. remove the burned dead tissue until healthy tissue is seen 2. good skin is taken from healthy doner site and placed over burned area 3. now doner site is an open wound, so transparent dressing is applied till bleeding stops 4. then donor site is left open to air 5. if client is well nourished, they can reharvest from same doner site every 12-14 days 6. if becomes blue or purple it means there is poor circulation 7. you may be asked to roll sterile Q-tips over the graft with steady gentle pressure from the center to the edges to smooth it

Common drugs used for burn pts: (4)

1. silver sulfadiazine (silvadene) - soothing, apply directly, if rubs off apply more, can lower the WBC, can cause rash 2. Mafenide Acetate (sulfamylon) - can cause acid base problems, stings, if it rubs off apply more 3. silver nitrate - keep these dressings wet; can cause electrolyte problems 4. povidone-iodine (betadine) - stings, allergies, acid-base problems.

circulatory check:

1. skin color 2. pulse 3. capillary refill 4. skin tint

classification of burns

1. superficial burns (first-degree): confined to epidermis 2. partial thickness burns (second-degree): injury to dermis 3. full-thickness burns (third-degree): extend to subQ or even muscle tissue (fourth-degree)

Immunizations for burn pts

1. tetanus toxoid (active immunity) - body has to work, takes 2-4 weeks 2. Immuno globulin (immediate protection - passive immunity) body did not work

Acites treatment

1. treatment tailored based on severity 2. mild ascites -15% of ascites cases -sodium restriction to 3 to 5 g/day may be sufficient if able to excrete this sodium load 3. higher grade ascites -sodium restriction to 2 g/day is recommended -initiate diuretics 4. diuretics -spironolactone (aldactone) is effective in minimal fluid overload -furosemide (lasix) gives additive therapy -intiate with combination therapy * Limit sodium intake, use diuretics (aldactone and lasix) * TIPS procedure (transjugular intrahepatic portosystemic shunt) o Nonsurgical procedure uses normal vascular anatomy of the liver to create a shunt with the use of a metallic stent o Shunt is between the portal and systemic venous system in the liver and is aimed at relieving portal htn Paracentesis

**ventilator settings- 1. rate 2. tidal volume 3. % of oxygen

1. usually 12-15 bpm OR use PCO2 35-45 2. controls amt of gas delivered- 500-750 mL. Higher volumes can cause lung tissue trauma 3. % of O2 set to maintain O2 w/in acceptable range. Uses lowest level possible - usually to maintain >90%

TARANTULAS defense mechanism

1. venom 2. launch 1,000's barbed hairs= severe inflammatory reaction

Contractures:

1. wrap fingers seperately 2. use splints to prevent contractures 3. hyperextend neck, no pillows

INR normal lab values

1.3-2.0

Hypertonic Solutions

10% Dextrose in Water, 3% Saline, 5% Dextrose in 0.45% Saline, 5% Dextrose in 0.9% Saline.

half life of Ativan

10-20 hours

Dosing of Propofol

10mg/ml (100mL bottles) lipid based 5-50mcg/kg/min MUST be given alone without any other infusions in the port it is being administered in change tubes q12hrs to prevent infection DO NOT BOLUS

mortality rate for SARS

11% 20% require MV

PT normal lab values

11-12.5 seconds

CPK-MB

12 lead EKG cardiac specific isoenzyme this is increased with damage to cardiac cells elevates in 3-12hrs and peaks in 24hrs

incubation for flu

18-72 hrs

Special considerations for electrical burns

2 wounds: entrance and exit Heart monitor for the 1st 24 hours, high risk for VF May first be placed on spine board w/c-collar b/e often happen in "high" places Amputations are common r/t problems w/circulation Other complications: cataracts, gait problems and neruo deficits.

Morphine (morphine sulfate)

2mg IV push for vasodilation to decrease preload and afterload

UO under what per hour would cause concern?

30 mL/hr

aPTT normal lab values

30-40 seconds

Exhaled CO2 (ETCO2)

35-45 >when ventilation is inadequate <when pulmonary perfusion is impaired

Bumetanide

40x stronger than lasix -can be given IV push or as continuous IV to provid rapid fluid decrease -1-2mg IV push given over 1-2 min

Isotonic but physiologically Hypotonic

5% Dextrose in Water.

Normal dose of Nitroglycerine

50mg in 250 ml D5W dose 10-200 mcg/min start slowly and titrate up. If drip is at 200 mcg/min, and the patient is still hypertensive or experiencing angina, another agent needs to be considered

How soon after onset of myocardial pain should these drugs be administered?

6-8hrs (sooner the better) TIME IS BRAIN

What is the use and dosage of the ASA?

81-325mg depending on Dr. recomendations for clotting

Moderate Hypothermia

82.4-89.6F (28-32C)

mild Hypothermia

89.6-95F (32-35C)

A nurse caring for a client on a mechanical vent who is also receiving PEEP as part of the treatment. The nurse recognizes the purpose of PEEP is for A. expand collapsed alevoli B. decrease alveolar volume C. decrease bronchospasms D. prevent spontanesous breathing

A

ERCP

A diagnostic test that views the pancreas, gallbladder & ducts (endoscopic retrograde cholangiopancreatogram)

Nitroglycerine

A drug that helps to dilate the coronary vessels that supply the heart muscle with blood *Nitrate *vasodilator

brain death

A neurological definition of death. A person is brain dead when all electrical activity of the brain has ceased for a specified period of time. A flat EEG recording is one criterion of brain death.

When may isotonic saline be used?

A patient has experienced both fluid and sodium losses or as vascular fluid replacement in hypovolemic shock.

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the hospital. Which of these patients will the nurse need to assess first?

A patient with a red tag rationale: The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die.

The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment?

A patient with a sucking chest wound rationale: Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid intervention but do not have airway or breathing problems.

Mitral valve

A valve in the heart that guards the opening between the left atrium and the left ventricle; prevents the blood in the ventricle from returning to the atrium. Alternative name is bicuspid valve.

common drugs used in renal failure

A. Cardiac glycosides a. Digoxin - used when heart failure induces renal failure or makes it worse - improves ventricular contraction, increasing stroke volume and CO i. Take pulse before taking drug (don't take if less than 60) ii. Notify prescriber if you have vision or behavior changes iii. Notify physician if you have chest pain or palpitations iv. Do not take antacids within 2 hrs of taking digoxin B. Vitamins and minerals a. Folic acid and ferrous sulfate - when the pt is receiving dialysis, many essential vitamins and minerals are removed from the blood. Replacement is needed to prevent severe deficiencies i. Take drugs after dialysis ii. Take iron supplements (ferrous sulfate) with meals iii. Take stool softeners daily while taking iron supplements iv. Iron supplements may change color of stool C. Synthetic erythropoietin a. Epoetin alfa and Darbepoetin alfa - drug prevents anemia by stimulating red blood cell growth and maturation in the bone marrow i. Report any of these to prescriber: chest pain, difficulty breathing, high BP, rapid weight gain, seizures, skin rash or hives, swelling of feet or ankles ii. Pts must have hemoglobin levels monitored weekly D. Phosphate binders a. Aluminum hydroxide gel and Aluminim carbonate gel - high blood phosphate levels cause hypocalemia and osteodystrophy. Drugs lower serum phosphate levels by binding phosphorus present in food i. Take drugs with meals ii. Pts taking dig - separate drugs by at least 2 hours iii. Take stool softeners while taking these drugs iv. Report muscle weakness, slow or irregular pulse, or confusion to prescriber

acute respiratory failure prevention

ABG values Hypoxemia Hypoventilation - respiratory alkalosis Hyperventilation - respiratory acidosis O2 toxicity

**respiratory failure Dx tests

ABGs chest x-ray pulmonary artery pressure wedge pressure readings cardiac output

*Dx of ARDS

ABGs - initial= hypoxemia PO2 < 60 & resp alk (tachyp) x-ray after 24 hrs=diffuse infiltrates...white out CT-consolidation, atelectasis pulmonary function tests= less compliance pulmonary artery pressure monitoring=Normal (cardiogenic pulmonary edema would not be normal) ARDS mostly occurs about 72 hours after the trigger, such as an injury (trauma, burns, aspiration, massive blood transfusion, drug/alcohol abuse) or an acute illness (infectious pneumonia, sepsis, acute pancreatitis).

Diagnosis guidelines

ABGs - initially show hypoxemia with PO2 of less than 60 mmHg and respiratory alkalosis due to tachypnea Chest X-ray - changes may not be evident for as long as 24 hours after onset; difuse infilatrates seen initially progressing to "white out" pattern CT scan - provides better illustration of consolidation and atelectasis than X-ray Pulmonary function test - shows decreased lung compliance w/reduced vital capacity, minute volume and functional vital capacity Pulmonary Artery pressure monitoring - shows normal pressue in ARDS helping distinguish from cardiogenic pulmonary edema A large difference between predicted and actual alveolar oxygen tension indicated shunting ECG rules out cardiac problems

**assist-control mode ventilation

ACMV positive pressure *for at risk respiratory arrest (head injury, drugs) *frequently used when initiating ventilation *assists breaths w/inspiratory effort *if rate falls, controlled breaths delivered *at specific tidal volume or pressure & rate

Liver Failure

ACUTE: usually viral hepatitis (including Hep A), fulminant, more likely in children CHRONIC: more likely in adults STAGE 1: Helatic Encephalopathy sleep impaired, tremors, very depressed, constructional apraxia (ask them to draw an object and they cannot do it). STAGE 2: argumentative, combative, short term memory loss, ataxia (difficulty walking), dysarthria (difficulty speaking), asterixis (flapping tremor of hand) STAGE 3: very confused, very angry, very combatative, lots muscular rigidity, hypo or hyper reflexia STAGE 4: Coma, decerebrate prosture (everything extended), flaccid paralysis (once it hits brain stem they become a vegetable). Fector hepaticus (rotting cabbage smell to breath, smell of death on breath, body is breaking down and the smell is obvious).

What are vasopressin's clinical uses?

ADH, Pitressin *Use as a second line vasopressor (use to augment Levophed) -central but not nephrogenic DI -control of variceal or diverticular colonic bleeding through its vasoconstrictive properties

Vasopressin's mechanism of action

ADH, Pitressin Activates V1 receptors, which are found in vascular smooth muscle and mediate vasoconstriction. Also stimulates V2 receptors in the collecting tubules of nephrons to increase water reabsorption. This results in more concentrated urine. ADH; Aids Hydration to the body

What are the adverse effects of vasopressin?

ADH, Pitressin decrease coronary circulation nausea and abdominal cramps water intoxication headache

Off label use of vasopressin?

ADH, Pitressin infusion cardiac arrest

Vasopressin

ADH, pitressin vasocontrictor used in hypotensive emergencies, gi bleeding, pulseless cardiac arrest. Use 1 time. *used in ER, ICU

DIALYZABLE drugs

AMINOGLYCOSIDES ANTIVIRAL AGENTS PENICILLINS ANTICONVULSANTS CEPHALOSPORINS ANTITUBERCULOSIS AGENTS

**Diagnose guidelines

ARDS is characterized by: -Acute onset -Bilateral infiltrates on chest radiograph sparing costophrenic angles (means where diaphram meets ribs) -Pulmonary artery wedge pressure < 18 mmHg (obtained by pulmonary artery catheterization), if this information is available; if unavailable, then lack of clinical evidence of left atrial hypertension if PaO2:FiO2 < 300 mmHg (40 kPa) acute lung injury (ALI) is considered to be present if PaO2:FiO2 < 200 mmHg (26.7 kPa) acute respiratory distress syndrome (ARDS) is considered to be present The PaO2:FiO2 ratios above refer to the gradient between the inspired oxygen level and the oxygen that is present in the blood. The lower the ratio, the less inspired oxygen is getting into the blood, and so the worse the patient's condition — so ARDS represents a more severe progression of disease from ALI by these diagnostic criteria. To summarize and simplify, ARDS is an acute (rapid onset) syndrome (collection of symptoms) that affects the lungs widely and results in a severe oxygenation defect, but is not due to heart failure.

**Clinical features:

ARDS usually occurs within 4-5 days of the initial at-risk diagnosis in majority of patients. In more than 50% of patients, ARDS develops in the first 24 hours. Earliest clinical sign is tachypnea followed by dyspnea.

meds for pain, fever, malaise meds to decrease cough

ASA, NSAIDs, Tylenol antitussives, mucolytics

Dose of Amiodarone

Administer a loading dose and then begin the drip. Use a 22 micron filter during administration

Esmolol

Adrenergic Antagonist beta1-Antagonist Class II Beta Blocker Ultra-short acting. RBCs rapidly metabolize ester bond in drug, resulting in half-life of about 10 minutes. Given IV, and steady state concentrations are achieved quickly. Used in critically ill patients to control supraventricular arrhythmias, arrhythmias associated with thyrotoxicosis, perioperative hypertension, and myocardial ischemia.

Epinepherine

Adrenergic agonist, emergency asthma, prolongs action of local anesthetics by vasoconstriction, tx of open angle glaucoma, emergency cases of cardiac arrest, anaphylactic shock or hypersensitivity

Nursing considerations with diuretics

Aldactone may be given to decrease aldosterone levels Give diuretics in the morning

why does the body secrete ADH and aldosterone with burn victims?

Aldersterone retains water and Na Anti-diuretic hormone retains water this is done to increase blood volume

What receptor does Dopamine act on?

Alpha 1, Beta 1 and 2 Also stimulates its own dopamine (D1 and D2) receptors Dopamine receptors stimulated at low doses Beta receptors at moderate doses Alpha 1 receptors at higher doses Does NOT cross blood brain barrier

Amikacin

Aminoglycoside Most often used for treating severe, hospital-acquired infections with multidrug resistant Gram negative

What is the first anti-arrhythmic of choice?

Amiodarone (Cordarone) -hypotension is a SE, and can lead to more arrhythmias

PENICILLINS

Amoxicillin •Ampicillin •Cloxacillin •Dicloxacillin •Mezlocillin •Penicillin G •Ticarcillin

Gentamycin

An antibiotic. Levels are usually drawn before and after a dose is given, ( peak and trough)

penicillins are a what

Antibiotic: -Bacteriocidal -Beta lactams -MOA: inhibits bacterial cell wall synthesis -Change in osmotic pressure -Cell lysis -Death

Anticoagulation treatment and associated labs for PE

Anticoagulants Heparin initiated at bolus of 5000-10000 units followed by continuous infusion at rate of 1000-1500 units per hour aPTT or PTT are frequently monitored normal range is 20-40 seconds therpeutic range is 1.5-2.5 times normal control range rebolus every time infusion in increased, do not use with salicylates antidote - protamine sulfate monitor platelets daily for thrombocytopenia Warfarin - takes 5 to 7 days to become fully effective Monitor INR Therapeutic range is 2.5-3,0 (for recurrent PE is 3.0-4.5) Vitamin K is antidote Normal range of PT is 11-12.5 seconds Therapeautic range is 1.5-2 times normal control range

Treatment of PE

Anticoagulants Heparin intiated at bolus of 5000-10000 units followed by continuous infusion at rate of 1000-1500 units per hour aPTT or APP are frequently monitored Warfarin - takes 5 to 7 days to become fully effective Thrombolytic therapy for large emboli When anticoagulant therapy fails to prevent recurrent emboli, umbrella-like filter may be inserted into inferior vena cava to trap large emboli

Gabapentin

Anticonvulsant: structural analog of GABA that facilitates its inhibitory actions in the CNS; used for partial seizures, for neuropathic pain, and in bipolar disorder. Tox: sedation, movement disorders.

Ethosuximide

Anticonvulsant: used in absence seizures; may block T−type Ca2+ channels in thalamic neurons. Tox: GI distress but safe in pregnancy

Antivenom Vipers -

Antivenin - horse, assoc with adverse drug event. Serum sickness. Skin test first! Crotalidae Polyvalent Immune Fat (Crofab) - sheep, binds, nuetralizes, redistributes, do not need skin testing but do not use if allergic to papya *give ASAP (w/n 6hrs) *initial 4-6 over 60min (slow 1st 10min - watch for allergies) *symptoms controlled - 2 vials @ 6hrs for 18hrs

when is it considered acute respiratory failure

Arterial oxygen level (PO2) less than 50-60 and PCO2 greater than 50 In patients w/advanced COPD is indicated by acute drop in blood O2 levels along with increased carbon dioxide levels IGGY BOOK - PaO2 less than 6-, SaO2 less than 90%, or PaCO2 more than 50 occuring with academia (pH <7.35)

A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which action is best for the nurse to take initially?

Ask the family members about whether they would prefer to remain in the patient room or wait outside the room. rationale: Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences.

Gastrointestinal and Genitourinary assessment

Assess abdomen for indications of hemorrhage, distention, or paralytic ileus. Assess for reflex or hypotonic bowel. Assess for areflexic bladder, which later leads to urinary retention. Assess for neurogenic bladder.Assess abdomen for indications of hemorrhage, distention, or paralytic ileus.

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 diazepam (Valium) tablets. Which action will the nurse plan to take first?

Assist with intubation of the patient. rationale: In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

Help for Ineffective Airway Clearance

Assisted coughing, quad cough, cough assist Use of incentive Spirometer

Do/watch for with Norepinephine

Assure adequate fluid resuscitation Maintain adequate pH Monitor blood pressure continuously Administer via central line to prevent extravasation

A patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to take during the observation period?

Auscultate breath sounds. rationale: Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse, but it is not as pertinent to the patient's admission diagnosis.

Pt. teaching for esophageal varices

Avoid straining and coughing. * HOB elevated * Nothing by mouth * Avoid activities that will initiate vasovagal responses * Teach bleeding precaution

Prevention of difficulties associated with the ventilated patient

Avoid valsalva maneuver Monitor fluid intake and output, weight, hydration and signs of hypovolemia Antacids, Histamine blockers or PPIs are often prescribed to prevent GI problems Balanced nutrition To prevent pneumonia - oral care every 2 hours, chest physiotherapy, postural drainage and turning and repositioning Perform exercises

versed

BEnzodiazepine an injectable form of benzodiazepine (trade name Versed) useful for sedation and for reducing pain during uncomfortable medical procedures

What do hypertonic solutions require moitoring of?

BP, lung sounds, and serum sodium levels and should be used with caution because of the risk of intravascular fluid volume excess.

check pts given MYCIN drugs what? (labs)

BUN and CREATININE if they are increaseing, assume they are nephrotoxic

Weaning pt off ventilator- what, when, how etc

Begins only after underlying processing has been corrected or stabilized Monitor vital signs, respiratory rate, extent of dyspnea, blood gases and clinical status to decide when Afterwards - sit in semi-fowolers, take deep breaths ever half-hour, use an incentive spirometer every 2 hours and limit speaking right after intubation

treatment of acute respiratory failure

Beta-adrenergic (sympathomimetic) and anticholinergics may promote bronchodilation Corticosteroids may reduce airway edema Benzos or Versed may be given for sedation while on vent When respiratory failure is caused by hypoventilation, CPAP may be used Oxygen therapy to keep PaO2 above 60

**treatment of acute respiratory failure

Beta-adrenergic (sympathomimetic) and anticholinergics may promote bronchodilation (inhaled/maybe nubulizer if on vent, theophylline derivates my be given IV) Corticosteroids may reduce airway edema (inhale or IV) Benzos (Valium or Ativan) or Versed may be given for sedation while on vent (and to inhibit the drive to breath) IV morphine to inhibit drive to breath neuromuscular blocking agent combined with sedation to induce paralysis and supress the ability to breath Antibiotic for underlying infection When respiratory failure is caused by hypoventilation, CPAP may be used Oxygen therapy to keep PaO2 above 60

Major complication of fibrinolytics?

Bleeding! Obtain a bleeding history During and after administration we take bleeding precautions Draw blood when starting IVs, decrease the number of injection (puncture) sites watch for bleeding gums, hematuria and black stools, use an electric razor, use soft toothbrush, no IMs

Portal hypertension can result in

Blood flow backs into the spleen causing splenomegaly ascites, esophageal varices, prominent abdominal veins, and hemorrhoids Pts with portal hypertension may also have portal hypertensive gastropathy - slow gastric mucosal bleeding - may result in chronic blood loss, occult-positive stools, and anemia

cardiac tamponade patho

Blood, flluid, or exudates have leaked into the pericardial sac this can happen if the client has had a motor vehicle collision, right ventricular biopsy, pericarditis, or hemorrhage post CABG (open heart surgery)

Cirrhosis

Body Effects of ETOH Alcohol abuse is the leading cause. End-stage of alcoholic liver disease and results from long-term chronic alcohol abuse. Widespread destruction of liver cells, which are replaced by scar tissue. o Compensated cirrhosis: liver is scarred but can still perform essential functions without causing major symptoms o Decompensated cirrhosis: liver function is impaired with obvious manifestations of liver failure

Types of arterial disorders

Buerger's Disease Raynaud's Disease

Hospital treatment for SEVERE Hypothermia

CAVR - continuous arteriovenous rewarming, or cardiopulmonary bypass, or hemodialysis Cardiopulmonary Bypass - fastest, but may get ARDS, acute renal failure or pneumonia

Lidocaine toxicity causes

CNS changes

Early Sepsis:

CO (decreased); Stroke Volume (decreased); Serum Lactate (norma/slightly increased); Blood Glucose (110-120), O2 (<95)

Septic Shock:

CO (greatly decreased); Stroke Volume (greatly decreased); Serum Lactate (>4); Blood Glucose (>150), O2 (<80%)

Late Sepsis:

CO (increased); Stroke Volume (increased); Serum Lactate (2-4); Blood Glucose (120-150), O2 (<85%)

a burn pts respirations are shallow, they are retaining what? therefore which acid-base imbalance will they have?

CO2 respiratory acidosis more people die from upper body burns than lower

cardiac output

CO=stroke volume x heart rate during exercise CO ↑ initially=>result of ↑ HR HR too high=>diastolic filling incomplete=>CO ↓ *early stages of exercise CO maintained by stroke vol; during late stages CO maintained by HR

cranial nerves

CRANIAL NERVES: I-Optic, II-Olfactory, III-Oculomotor, IV-Trochlear, V-Trigeminal, VI-Abducens, VII-Facial, VIII-Acoustic (Vestibulocochlear), IX-Glossophrayngeal, X-Vagus, XI-Spinal Accessory, XII-Hypoglossal Oh, Oh, Oh To Touch And Feel A Girl's Vagina, Ahhhh, Heaven

In a client who is recieving fluids rapidly, what is a measurement you could take hourly (hint HEART) to ensure you're not overloading the client?

CVP look at rt. atrial pressure, if the number is high and too fast then you are filling up the atrium = right sided heart failure

What would you do if the urine was brown or red?

Call the doctor, hematuria!

Most common airway injury r/t burns?

Carbon monoxide poisoning

What are some meds that would be ordered to prevent a stress ulcer?

Carbonate/Magnesium Carbonate (Mylanta) Pantoprazle (protonix) Famotidine (pepcid)

Hospital care for lightening

Cardiac monitoring, 12 lead EKG, ABCs Check Creatine Kinase - shows skeletal muscle damage due to rhabdomolysis which can occur and lead to renal failure

what are the physiological responses to epinephrine?

Cardiovascular - increased heart rate and contractility as well as vasoconstriction of arterioles in the skin, viscera, and mucous membranes Respiratory - bronchodilation through activation of Beta2 receptors Metabolic - increased glycogenolysis, release of glucagon, and a decreased release of insulin result in hyperglycemia. Epinephrine also increases the concentration of free fatty acids in the blood

Cardiovascular assessment

Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system especially if the injury is above the 6th thoracic vertebra. Bradycardia, hypotension that may result in cardiac dysrhythmias Systolic BP below 90 requires treatment because lack of perfusion to the spinal cord could worsen the patient's condition. Hypothermia

What must solutions containing greater than 10% dextrose be administered by?

Central line so there is adequate dilutions to prevent shrinkage of RBCs.

What should hypotonic solutions be monitored for when administering?

Cerebral edema.

Signs of airway injury

Cinged nasal hairs, coughing up black stuff, blisters on the oral mucosa, soot on face

Establishing a Bowel Retraining

Consistent time for bowel elimination High fluid intake High-fiber diet Rectal stimulation (with or without suppositories) Stool softener medications, as needed

Hypothermia

Core body temp below 95F (35C) A cold heart is a irritable heart - Afib/Vfib, careful joilting when moving pt. Early manifestation - tachycardia and increased heart rate

CAD

Coronary Artery Disease

A client who has TB is being treated with combination drug therapy. The nurse should explain to the client theat combination drug therapy is essential for A. minimize the required dose of each of the meds B. reduce the unpleasant side effects of the meds C. shorten the lenght of time the treatment regimen will be needed D. decrease the development of resistant strains of the TB organism

D

Bed rest prescribed for a client during the acute phase of respiratory failure. What is the rationale for the nursing plan of care to recommend bed rest and other limited activity for this client? A. To prevent further alveolar collapse B. To promote clearance of secretions C. to decrease basal metabolic rate D. to reduce the cellular demand for oxygen

D

What do Beta Blockers do to Cornary arteries?

DILATE get more O2 to the muscle!

*Anterior cord syndrome

Damage to the anterior portion of both gray and white matter of the spinal cord Usually a result of decreased blood supply Motor function and pain and temperature lost below the level of the injury Sensations of touch, position, and vibration remain intact

*Posterior cord lesion

Damage to the posterior gray and white matter of the spinal cord Motor function remains intact Patient experiences loss of vibratory sense, touch, and position sensation

Posterior cord lesion

Damage to the posterior gray and white matter of the spinal cord Motor function remains intact Patient experiences loss of vibratory sense, touch, and position sensation, paralyzed: deltoid, triceps, wrist & finger extensors, Trauma, posterior tumors, B12/iron deficiency Wrist drop

What do Beta Blockers do to BP, Pulse, and myocardial contractability?

Decrease it *always check BP and HR first! we can overshoot it

DVT patho

Deep venous Thrombosis -blood stasis, vessel injury, blood coagulation -blood can get to the tissue, it just cannot get away

Why is Dextrose 5% in water isotonic but physiologically hypotonic?

Dextrose is quickly metabolized and the net result is the administration of free water (hypotonic) with proportional equal expansion of the ECF and ICF.

HF Treatment

Digitalis (Lanoxin) Diuretics ACE inhibitor/ARBs and/or a Beta Blocker Low Na+ Diet

**Predisposing factors of ARDS:

Direct injury to alveolar epithelium Aspiration of gastric contents Diffuse pulmonary infection Toxic inhalation Near drowning etc Indirect lung injury via hematogenous delivery of inflammatory mediators Severe sepsis Trauma (non-thoracic) Hypertransfusion Pancreatitis Falciparum malaria Cardiopulmonary bypass, etc.

*Prone position

Distribution of lung infiltrates in acute respiratory distress syndrome is non-uniform. Repositioning into the prone position (face down) might improve oxygenation by relieving atelectasis and improving perfusion and overcoming the hypoxemia.

Axial loading injury

Diving accidents, falls on the buttocks, or a jump in which a person lands on the feet can cause many of the injuries. Vertical compression. Pieces of bone enter the spinal canal and damage the cord.

Penicillins uses are what

Drug of choice for GM + organisms (natural penicillins) Strep, staph (resp. tract, otitis media, skin) -GM - (extended spectrum agents) UTI's

Types of Burns

Dry heat injuries Chemical Burns Contact Burns Moist Heat Electrical Injuries Thermal Burns

ARDS drug therapy

Dysnea, tachypnea and anxiety are early manifestations Progressive respiratory distress develops w/increasing respiratory rate, intercostal retraction and use of accessory mucles of respiration Cyanosis develops that may not improve w/oxygen administration Breath sounds are initially clear but crackles (rales) and rhonchi develop later As respiratory failure progresses, mental status changes such as agitation, confusion and lethargy occur IGGY - hyperpnea, grunting respiration, cyanosis, pallor, retraction No abnormal lung sounds are present on ausculation because the edema of ARDS occurs first in the intersititial spaces and not in the airways

ARDS signs

Dysnea, tachypnea and anxiety are early manifestations Progressive respiratory distress develops w/increasing respiratory rate, intercostal retraction and use of accessory mucles of respiration Cyanosis develops that may not improve w/oxygen administration Breath sounds are initially clear but crackles (rales) and rhonchi develop later As respiratory failure progresses, mental status changes such as agitation, confusion and lethargy occur IGGY - hyperpnea, grunting respiration, cyanosis, pallor, retraction No abnormal lung sounds are present on ausculation because the edema of ARDS occurs first in the intersititial spaces and not in the airways

Manifestations of Hypoxemia (ventilation perfusion mismatch or impaired gas diffusion)

Dyspnea (early sign of CO2) Cyanosis - not profused Restlessness, apprehension - brain not profused Confusion, impaired judgment - brain not profused tachycardia, dysrhythmias - heart trying to profuse body hypertension - heart trying to profuse body metabolic acidosis correct with 28% O2

Multi-casulity

EMERGENCY managed by hospital with local rescources

Surgical Management

Emergency surgery necessary for spinal cord decompression, remove bone fragments, hematomas or penetrating objects Decompressive laminectomy Spinal fusion Harrington rods to stabilize thoracic spinal injuries

Bee stings

Epi, then corticosteroids and antihistamines to decrease immune response Bronchospasm treated with Albuterol (bronchodilator) meds may need to re-administered for hours or days because the toxins may outlast the effects of treatment.

Glasgow Coma Scale

Establishes base line data in each of the following areas: eye opening, motor response, and verbal response • Score of 15 = normal response (highest) • Score of 3 = deep coma • Coma is defined as a score of 7 or less. With a score of 3-4, there is an 85% chance of dying or remaining in a vegetative state. A score above 11 is associated with an 85% chance of moderate disability or good recovery. if patient is intubated or cannot talk, best score you'll get is 11(15 is not their norm)-when you chart 11 add t beside (11t) to indicate inability to talk *KNOW THIS*

Isotonic:

Expands only the ECF. No net loss or gain from the ICF.

Any substance can cause an embolism, but septic clots are the most common cause. (T/F)

F

The most common site of origin for a PE is clots in the right side of the heart (T/F)

F

02 Toxicity ABG

FiO 2 greater than 0.50 for more than 72 hours may cause oxygen toxicity. pO2(a) reference range (adult): 83-108 mmHg (11.1-14.4 kPa)arterial oxygen tension FO2Hb(a) reference range (adult): 94-98% (0.94-0.98)oxyhemoglobin sO2(a) normal range (adult): 95-99% (0.95-0.99) arterial oxygen saturation

*Phase 3 ARDS

Fibrotic or Chronic Phase Occurs approximately 2 to 3 weeks after the initial lung injury. By this time the lung is completely molded by sparsely collagenous and fibrous tissues. There is diffuse scarring and fibrosis resulting in decreased lung compliance. The surface area for gas exchange is significantly reduced because the interstitium is fibrotic and therefore hypoxemia continues. Pulmonary hypertension results from pulmonary vascular destruction and fibrosis.

Spinal cord injury initial assessment

First priority is assessment of the patient's airway, breathing pattern, and circulation status Assessment for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around fracture sites Assessment of level of consciousness using Glasgow Coma Scale Establishment of level of injury: tetraplegia, quadriplegia, quadriparesis, paraplegia, and paraparesis

spinal cord injury assessment

First priority is assessment of the patient's airway, breathing pattern, and circulation status Assessment for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around fracture sites Assessment of level of consciousness using Glasgow Coma Scale Establishment of level of injury: tetraplegia, quadriplegia, quadriparesis, paraplegia, and paraparesis

Immobilization for Cervical Injuries

Fixed skeletal traction to realign the vertebrae, facilitate bone healing, and prevent further injury Halo fixation and cervical tongs Pin site care and monitoring of traction ropes

quad cough

For clients without abdominal muscle control, such as those with spinal cord injuries. The client breathes out with the maximal expiratory effort, the client or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough

ARBs uses/nursing considerations

For hypertension and HF -if the drug ends in -sartan it is most lieky and ARB -watch for hyperkalemia, hypotension, and renal dysfunction

Afterload

Force against which the heart pumps when ejecting blood (is the pressure or resistance against flow)

*prognosis for respiratory failure

From drug overdose- probably quick resolution From lung disease-prolonged, less favorable

Medications

Furosemide (Lasix) Bumetanide Nitroglycerin IV Digoxin (Lanoxin) Morphine (morphine sulfate) Nesiritide Milrinone Dobutamine

Examples of Diuretics used with HF pts

Furosemide (lasix), Hydrochlorothiazide, Bumetanide (Bumex), Hydrochlorothiazide/Triamterene (Dyazide)

A patient arrives in the emergency department (ED) a few hours after taking "20 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?

Give N-acetylcysteine (Mucomyst). rationale: N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning.

What are the therapeutic uses of epinephrine?

Given for bronchospasm secondary to acute asthma or anaphylactic shock Used in anaphylaxis and cardiac arrest to increase cardicac electrical activity Used in conjunction with local anesthetics to prolong the duration of anesthesia Used to achieve hemostasis *Used for profound, refractory hypotension

FLUID RETENTION THINK???

HEART FAILURE

Heart Failure (HF) causes

HF is a complication that can result from problems such as cardiomyopathy, valvular heart disease, endocarditis, acute MI and hypertension

where do most burn accidents take place at?

HOME

Rule of nines

Head 9 Each arm 9 Each leg 18 Front of trunk 18 Back of trunk 18 Genital 1

Rule of 9

Head = 9% Chest (front) = 9% Abdomen (front) = 9% Upper/mid/low back and buttocks = 18% Each arm = 9% (front = 4.5%, back = 4.5%) Groin = 1% Each leg = 18% total (front = 9%, back = 9%)

Teaching chronic renal failure

Health-promotion activities to prevent or delay the onset of chronic kidney disease focus on controlling the diseases that lead to its development, such as diabetes mellitus and hypertension.

Cardiac Output =

Heart Rate x Stroke Volume

Anticoagulant drugs

Heparin Fibrinolytics Warfarin clopidogrel (plavix) aspirin enoxaparin (lovenox) dipyridamole (persantine) Theses drugs either preven aggregation or prevent the clot from getting bigger

COMMUNITY BASED RESOURCES

Home care management Health teaching Health care resources

ventilator settings

How do we deliver the breath? Mode= amount of work the ventilator does and the amount of work the patient does. - Volume (6-10 ml/kg) -pressure to push breath in (PIP <35) How big a breath does the vent give or patient take? -Tidal Volume of each inspiration How many breaths per minute? Rate: 12-20 TV*R= Minute Volume PIP: peak inspiratory pressure Normal <35, if 40< it mean the lungs are not compliate, they are stiff and it takes lot of force to push the breath into the lungs. FiO2 100% Tidal Volume 6-8 mL/kg Rate 16-18* Asthma rate 6-8 Acidosis rate 20-24

Which electrolyte imbalance occurs w/burns and why?

Hyperkalemia b/e cells rupture when a burn occurs and K is released into the blood.

10% Dextrose in Water

Hypertonic

3.0% Saline

Hypertonic

5% Dextrose in 0.45% Saline

Hypertonic

5% Dextrose in 0.9% Saline

Hypertonic

0.45% Saline

Hypotonic

What are hypertonic solutions useful in treatment for?

Hypovolemia and hyponatremia.

Type of Shock (more than one can be present at a time) :

Hypovolemic Shock Cardiogenic Shock Distributive Shock Obstructive Shock

manifestations of acute respiratory failure

Hypoxemia Dyspnea, neurological symptoms (restlessness, apprehension, impaired judgment and motor impairment), tachycardia, HTN As it continues - dysrhythmias, hypotension and decreased cardiac output Hypercapnia Increased CO2 levels can depress CNS function and cause vasodilatation Dyspnea and HA are early signs Peripheral and conjunctival vasodilation, papilledema, neuromuscular irritability and decreased LOC As it worsens, respiratory center may be depressed reducing dyspnea and slowing respirations Administering oxygen may further decrease the drive to breathe leading to respiratory arrest

Why are IV pain meds prefered over IM with burn patients?

IM needs good muscle to work and IV works quicker.

*some causes of respiratory failure

IMPAIRED VENTILATION *airway obstruction *resp disease -Asthma, COPD *neurologic causes -spinal cord injury, Guillain-Barre Syndrome, polio *chest wall injury -pneumothorax, flail chest IMPAIRED DIFFUSION *alveolar disorders -pneumonia, COPD *pulmonary edema -heart failure, ARDS, near-drowning *ventilation-perfusion mismatch -pulmonary embolism

Whats the number 1 complication w/a perineal burn?

INFECTION

How is Dopamine administered?

IV

Patho of decreased CO:

If CO is decreased you will not perfuse properly -Brain: LOC decreases -Heart: client complains of chest pain -Lungs: short of breath -Skin: cold and clammy -Kidneys: UO goes down -Peripheral pulses: weak

Spinal Shock/Spinal Shock Syndrome

Immediately after injury--flaccid paralysis, loss of reflex below injury level, bradycardia, paralytic ileus, hypotension, lasts a few days to several months *This condition occurs immediately as a concussion response to the injury. The patient has: Flaccid paralysis Loss of reflex activity below the level of the lesion Usually resolves within 24-48 hours but may continue for weeks Muscle spasticity begins in patients with cervical or high thoracic injuries

Manifestations of hypoxic respiratory failure (hypoventilation-hypercapnia)

Increased CO2 levels depress CNS function and cause vasodilation Dyspnea (early sign of CO2) headache - vasodilation (early sign of CO2) papilledema - fluid shunted to brain tachycardia, hypertension - heart trying to profuse body drowsiness, coma - Ca increase = sedation systemic vasodilation, heart failure respiratory acidosis = not breathing out CO2 may need 40-60% O2 (only for short period due to O2 toxicity = impaired synthesis of surfactant = reduces lung compliance (ease of inflation)

what are physiological effects of dobutamine?

Increased heart rate (B1) increased contractability (B2) THIS COMBINATION ALLOWS THE HEART TO PUMP FORCEFULLY WHILE NOT HAVING TO OVERCOME THE INCREASED PERIPHERAL VASCULAR RESISTANCE WITH OTHER PRESSORS

Azotemia

Increased nitrogenous waste (urea) and frequently creatinine levels in the blood

**ARDS is characterized by:

Increased permeability of alveolar capillary membrane. Diffuse alveolar damage. Accumulation of proteinaceous pulmonary edema.

S/S of SARS

Incubation period is usually 2-7 days, but can be as long as 10 Fever higher than 100.4 (38 C) is typically initial May be accompanied by chills, HA, malaise and muscle aches After 1-2 days respiratory manifestation develops Nonproductive cough, SOB, dyspnea, possible hypoxemia These may worsen and advanced to respiratory distress during second week Mild cold symptoms such as runny nose, sore throat, and water eyes may also be present Hypoxia with cyanosis low oxygen sats and a feeling of breathlessness indicate more severe illness

Compensatory Responses to Burns

Inflammatory Response - helps trigger healing in body but can also cause massive fluid shift, edema and hypovolemia Sympathetic Nervous System - changes are most evidence in cardio, respiratory and GI systems

Hypertonic:

Initially raises the osmolality of ECF and expands it.

During the primary survey of a patient with multiple traumatic injuries, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen. Which of these actions will the nurse take next?

Initiate isotonic fluid infusion through two large-bore IV lines. rationale: The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

*Phase 1 ARDS

Injury or Exudative Phase Occurs approximately 1 to 7 days (usually 24 to 48 hours) after the direct lung injury or host insult. The primary pathophysiological changes that characterize this phase are interstitial and alveolar edema (noncardiogenic pulmonary edema) and atelectasis. Severe V/Q mismatch and shunting of pulmonary capillary blood result in hypoxemia unresponsive to increasing concentrations of O2 termed refractory hypoxemia. Hypoxemia and the stimulation of juxtacapillary receptors in the stiff lung parenchyma (J reflex) initially cause an increase in respiratory rate, decrease in tidal volume, respiratory alkalosis and an increase in cardiac output.

Hyperextension injury

Injury that occurs during a car accident as a person's head snaps backward and then forward. This can cause muscle strain or a muscle tear, as well as damage to the nerves. Also known as acceleration-deceleration injury or whiplash. Treatment: Rest, analgesic drugs, nonsteroidal anti-inflammatory drugs. C4-5 are injuried commonly

Inspiration vs. expiration

Inspiration •Active process •Muscle contraction and increased volume in thoracic cavity •Adhesive membranes pull •Negative pressure (vacuum) in lungs - SUCKING air into alveoli Expiration •Passive process (usually) •Muscle relaxation and decreased volume in thoracic cavity •Air is pushed out through muscle recoil

Interventions for impaired urinary elimination

Interventions include: A bladder retraining program Flaccid bladder—Valsalva maneuver or tightening of abdominal muscles Encouraging consumption of 2000 to 2500 mL of fluid daily to prevent urinary tract infection Long-term renal complications because of infections Signs and symptoms of urinary tract infection not perceived by the patient Patient only knows if they have infection by foul smelling urine or fever

Interventions for impaired mobility

Interventions include: In patients with spinal cord injury, monitor for risk of pressure ulcers, contractures, and deep vein thrombosis or pulmonary emboli. Proper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings. Prevent orthostatic hypotension. Promote self-care.

ABSOLUTE contraindictions to fibrinolytics:

Intracranial neoplasm intracranial bleed suspected aortic dissection internal bleeding (of any kind)

Impaired Adjustment interventions

Invite patients to ask questions about significant life changes; reply openly and honestly. Encourage patients to discuss their perceptions of their situation and coping strategies that can be used. Begin a patient education program to clarify misconceptions.

Nitropursside

Is a direct acting nonseletive peripheral vasodilator, causes relaxation of arterial and venous vascular smooth muscle *Is used to manage acute hypertensive crisis, compensated heart failure and to control bleeding during surgery.

Which Antitburculosis agents are dialyzable?

Isoniazid (may lead to hepatotoxicity) Ethambutol (decrease red/green color discrimination and visual acuity)

0.9% Saline

Isotonic

5% Dextrose in 0.225% Saline

Isotonic

Lactated Ringers

Isotonic

Ringers Solution

Isotonic

5% Dextrose in Water

Isotonic, but physiologically hypotonic.

Rotational brain injury

It happens because the head rotates around its point of articulation, which is the neck. This causes the brain to rotate within the skull tearing the veins. This causes bleeding which results in a subdural haematoma. It is also an injury which is effectively untreatable.

What happens to UO 48 hrs after a burn and why?

It will increase (if the kidneys are still working) because the patient is beginning to diurese b/e the fluid is going back into the vascular space. Worry about FVE.

Salt substitutes can contain excessive

K+ watch for this!

what is released when cells rupture?

K+ (potassium)

Renal calculi diagnosis

KUB (Kidney, Ureter, Bladder) U/A, urine C&S ultrasound IVP CT scan labs - Calcium, uric acid, renal fxn o Can be located through radiography of kidneys, ureter, and bladder o IV pyelography, CT scan and renal US o Stone anylsis will be done after the passage to determine type of stone and determining txt

Portal systemic encephalopathy (PSE)*

Known as hepatic coma in later stages early signs: sleep disturbance, mood changes, mental status change, speech problems later signs: altered LOC, impaired thinking, neuromuscular problems. PSE is most likely a result of toxins released during shunting of portal venous blood into central circulation. Ammonia * Affects function of the brain * Portal venous blood is shunted into the central circulation so that the liver is bypassed àtoxic substances absorbed by intestine are not broken down or detoxified and may lead to metabolic abnormalities (elevated serum ammonia and gamma-aminobutyric acid (GABA) * Factors that may lead to PSE: high-protein diet - infections - hypovolemia - hypokalemia - constipation - GI bleeding - drugs (hypnotics, opioids, sedatives, analgesics, diuretics)

types of HF

Left sided - left lungs Right sided - right feet

*Central cord syndrome

Lesions of the central portion of the spinal cord. Loss of motor function is more pronounced in the upper extremities than in the lower extremities. Varying degrees and patterns of sensation remain intact.

Norepinephrine's Actions

Levophed Actions - vasoconstriction(alpha1), increases both systolic and diastolic pressures. Unlike epinephrine, does not cause vasodilation with small doses, is not an effective "hormone"(no hyperglycemia/lipolysis).

Recepters Norepinephrine stimulates are?

Levophed Alpha 1 & 2, Beta 1 stronger affinity to Alpha

Norepinephrine's adverse effects?

Levophed Tissue hypoxia secondary to potent vasoconstriction Decreased profusion to the kidneys Tissue necrosis due to extravasation during IV administration Arrhythmias

Normal dose of Norepinephrine

Levophed Titrate to desired effect (MAP greater than 65) Mix 2mg in 250mL NS or D5W

What is norepinephrine's therapeutic use?

Levophed a last-line agent in the treatment of shock -Used to treat shock, cardiac arrest and anaphylaxis -Used to treat shock because it increases vascular resistance and therefore BP, but also decreases kidney blood flow(dopamine is better. Note: If pre-treated with atropine, effect is tachycardia due to blocked transmission of vagal effects from atropine.

Norepinephrine

Levophed • Adrenergic agonist (alpha/beta agonist) • Mixed alpha/beta (B1>>B2; A1=A2) • Used as a vasopressor for treatment of shock (induces vasoconstriction via A1 and increases CO via B1); also used to reduce diffusion of local anesthetics from injection site • Administered via IV (only) quick acting -a neurotransmitter that activates the sympathetic response to stress, increasing heart rate, rate of respiration, and blood pressure in support of rapid action. -A hormone secreted by the adrenal gland. It increases blood pressure and rate and the depth of breathing, raises the level of blood sugar, and decreases the activity of the intestines. It is also the main neurotransmitter of sympathetic nerve endings supplying the major organs and skin.

Ativan

Lorazepam Benzodiazepine

Anterior cord syndrome

Loss of motor function, as well as loss of the sensations of pain and temperature below the level of injury. However, below the level of injury, position sense and sensations of pressure and vibrations remain intact. Anterior cord syndrome is commonly caused by flexion injuries or acute herniation of an intervertebral disk.

OTHER Spinal cord injury assessments

Lower motor neuron assessment Upper motor neuron assessment Skin assessment Heterotrophic ossification assessment Psychosocial assessment Laboratory assessment Imaging assessment

When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first?

Lung sounds rationale: The priority assessment data are how well the patient is oxygenating, so lung sounds should be assessed first. The other data also will be collected rapidly but are not as essential as the lung sounds.

Acute coronary syndrome

MI, unstable angina

ARDS treatment

Mainstay of ARDS management is endotracheal intubation and mechanical ventilation FIO2 is set at lowest possible level to maintain PO2 higher than 60 and oxygen sat above 90% Is often necessary to add PEEP (will decrease cardiac output and increase risk of barotraumas); Assit control or SIMV may be used with PEEP or CPAP Prone position along with mechanical ventilation reduces pressure of surrounding tissue on dependent regions and improves oxygenation Careful fluid replacement, attention to nutrition, treatment of any infection Swan-Ganz line will monitor pulmonary artery pressures and cardiac output Heparain may be ordered to provent thrombophlebitis and possible pulmonary embolus or DIC Monitor vital signs at least hourly Give nutrition via parental or enteral route, malnutrition is a big problem

Care of a patient on a ventilator

Maintain head of bead at 30 degree angle Provide suctioning every 2 hours Mouth care every 2 hours Provide tracheostomy care every 8 hours Turn patient every 2 hours Assess VS and breath sounds every 30-60 minutes at first Assess area around ET tube every 4 hours Should remove condensation in the ventilator tubing by draining water into drainage collection receptacles, empty every shift

spinal cord injury interventions

Maintaining airway patent: (Neuro slides) Q&A Pt sustains C7 spinal cord injury. which of the following is most important nursing intervention during acute stage of care? a. Monitor VS b. Maintain patent airway c. maintain proper body alignment d. turn Q2hr

treatment of pulmonary edema

Mediations Positioning Prevention

Drug Therapy

Methylprednisolone Dextran Atropine sulfate Dopamine hydrochloride Tizanidine Intrathecal baclofen

Normal dose of dobutamine

Mix 500mg in 250 ml D5W and start infusion at 1-2 mcg/kg/min and titrate up slowly and carefully

Normal dose of Nicardipine

Mix 50mg in 250 ml D5W and administer 0.3-10 mcg/kg/min

In regards to diet, what changes does the burn patient need to make?

More calories, more protein and more vitamin c

MONA

Morphine Oxygen Nitroglycerin Aspirin initial medical treatment options for a patient with Acute Coronary Syndrome but use in the order of OANM

**ARDS risk factors

Most people who develop ARDS are already hospitalized for another condition, and many are critically ill. You're especially at risk if you have a widespread infection in your bloodstream (sepsis). Clinical Conditions Associated with Development of Acute Respiratory Distress Syndrome Direct lung injury Pneumonia Aspiration of gastric contents Inhalation injury Near drowning Pulmonary contusion Fat embolism Reperfusion pulmonary edema post lung transplantation or pulmonary embolectomy Indirect lung injury Sepsis Severe trauma Acute pancreatitis Cardiopulmonary bypass Massive transfusions Drug overdose People who have a history of chronic alcoholism are at higher risk of developing ARDS. They're also more likely to die of ARDS.

The increase in WHAT strengthens cardiac, peripheral, and kidney function by enhancing cardiac output, decreasing preload, improving blood flow to the periphery and kidneys, decreasing edema, and promoting fluid excretion. As a result, fluid retention in the lung and extremities is decreased.

Myocardial contractility

Testing strategy for DVT:

NEVER DELAY TREATMENT

A blanket is used to stop the flames, does the burning process stop?

NO. cool water soak can be used do not use ice, vasoconstriction will occur

*Meds for SARS

NONE if diagnosis unclear- antibiotic and/or antiviral

Phenylephrine

Neosynepherine Adrenergic Agonist - Direct alpha1-Agonist Vasconstrictor. Given orally or topically. Induces reflex bradycardia when given IV. Used as nasal decongestant, mydriatic, or to increase blood pressure and terminate episodes of supraventricular tachycardia or paroxysmal atrial tachycardia (PAT). *Used for profound hypotension

Use caution with phenylephrine under what circumstances

Neosynepherine Elderly CAD Hypovolemia Give centrally to avoid extravasation

Do NOT use phenylephrine in pts with

Neosynepherine cardiogenic shock or elevated SVR

Calcium Channel Blocker examples

Nifedipine, Verapamil, Amlodipine, Ditiazem

*Meds for ARDS

No difinitive drug therapy surfactant low dose corticosteroids Low molecular weight heparin my be ordered to prevent thrombophlebitis and possibly pulmonary embolus or DIC, a possible complication of ARDS

SARS treatment

No medications have been shown to be consistently effective in treating SARS Antibiotic and/or retroviral therapy targeted at community acquired forms of pneumonia may be given if diagnosis is unclear Treatment is supportive - oxygen given to treat hypoxemia, may require intubation and mech. vent. Standard antibiotic agents and antirival drugs cannot kill the virus or prevent its replication; so interventions are supportive to allow the patients immune system to fight the infection Oxygen is given when hypoxia or breathlessness is present Respiratory treatment to dilate bronchioles and move secretions Antibiotics are used to treat bacterial pneumonia that may occur with SARS

Nstemi

Non-elevated ST segment myocardial infarction, these clients are usually less worrisome.

Which is the best to choose to determine if a burn patient's fluid volume is adequate, weight or UO?

Normally weight is adequate but for burn patients UO is the best.

Problems associated with mechanical ventilation

Nosocomial pneumonia - oral hygiene!!! Barotrauma - can cause subcutaneous emphysema, pneumothorax and pneumomediastinum PEEP can cause decrease in Cardiac output Stress ulcers may develop causing GI hemorrhage

treatment of hypoxemia

O2 therapy, mechanical ventilation, CPAP, body positioning, nitric oxide, blood transfusion

During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?

Observe the patient's respiratory effort. rationale: Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions also are part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.

Fentanyl

Opioid; more potent and shorter duration than morphine, parenteral; has minimal cardiac suppression; smoother induction with less generalized anesthesia; Rapid IV admin can cause truncal muscle rigidity; transdermal patch too for chronic pain *analgesic opiate

Impedance

Opposition to the current flow, tissue that resist flow; adipose, bone, tendons, fascia

**DX guidelines

Originally most definitions of ARDS required three general criteria: Severe hypoxemia Reduced pulmonary compliance and Diffuse pulmonary infiltrates on chest X-RAY Recently American - European consensus conference proposed a new definition of ARDS, which is new uniformly accepted. Acute lung Injury (ALI) TIMING: Acute Onset OXYGENATION: PaO2 / FiO2 < 300 mm Hg (regardless of PEEP) XRAY CHEST: Bilateral Infiltrate Pulmonary artery Occlusion pressure< 18 mm Hg or No evidence of left Atrial Hypertension ARDS TIMING: Acute Onset OXYGENATION: PaO2 / FiO2 < 200 mm Hg (regardless of PEEP) XRAY CHEST: Bilateral Infiltrate Pulmonary artery Occlusion pressure: < 18 mm Hg or No evidence of left Atrial Hypertension

Medical interventions for acute coronary syndrome (MI or angina)

PCI (percutaneous Coronary Intervention) CABG (coronary artery bypass graft Pacemaker

How to prevent acute respiratory failure

PEEP prevents a decrease in lung compliance and surface activity of lung extracts indicating a prevention of loss of alveolar surfactant function during lung over inflation. Others suggest PEEP prevents alveolar collapse and thus keeps the end-expiratory volume of alveoli at a higher level, thereby preventing excess loss of surfactant in the small airways by a squeeze out mechanism during expiration nosocomial precautions sepsis precautions

Paroxysmal nocturnal dyspnea

PND - Sudden attacks of SOB that usually occur during sleep. Person wakes gasping forbreath and sits up to relieve symptoms; associated with left ventricular heart failure.

*pathophysiology of respiratory failure

PO2 reduced w/ PCO2 remaining normal...Drop in arterial O2 levels... Metabolic acidosis from tissue hypoxia...increased work of breathing... resp muscle fatigue... hypoventilation.. resp acidosis

Liver transplant pt care

PRE-TRANSPLANT - attempt to resolve malnutrition, increase energy needs POST-TRANSPLANT - energy and protein needs elevated to allow for healing

Proton Pump Inhibitors

Pantoprazole (Protonix) Esomeprazole (Nexium)

Common Burn Fluid Resuscitation:

Parkland (Baxter) - Crystalloid only (lactated Ringers) 4 mL/kg/%TSBA burn Modified Parkland - Crystalloid (Lactated Ringers) 4 mL/kg/%TBSA burn + 15 mL/m(squared) of TBSA Modified Brooke - Protenate or 5% albumin in 0.9% Saline; Lactated Ringers w/o dextrose 0.5-1.5 mL/kg/% TBSA burn All common formulas recommend that half of the calculated fluid volume for 24 hours be given in the first 8 hours after injury Fluid replacement formulas are calculated from time of injury NOT time of arrival at hospital

Respiratory Assessment

Patients with cervical SCI are at risk for respiratory problems resulting from immobility or from an interruption of spinal innervations to the respiratory muscles. Continued respiratory assessment including vital capacity and minute volume. Patients with injuries at or above the 6th thoracic vertebra are especially at risk for respiratory complications.

A patient arrives in the emergency department after exposure to radioactive dust. Which action should the nurse take first?

Place the patient in a shower. rationale: The initial action should be to protect staff members and decrease the patient's exposure to the radioactive agent by decontamination. The other actions can be done after the decontamination is completed.

Patho of a burn patient

Plasma seeps into tissue b/e of capillary permeability (1st 24 hours), increased HR b/e of fluid volume deficit, decreased CO, decreased kidney perfusion and UO. ADH and Aldosterone are secreted to conserve fluid and epinephrine is released to counteract the vasodilation that occurs immediately after a burn.

What are norepinephrine physiological effects?

Powerful vasoconstriction of skeletal muscle and renal vasculature, increased myocardial contractility. Reflex bradycardia via a rise in vagal activity.

frostnip

Pre-frost bite Reversible skin injury Transient skin blanching, numbness and tingling

What is some lab work you could check to ensure proper nutrition and a positive nitrogen balance is present in your patient? Which is the most sensitive? What does a negative nitrogen balance mean?

Prealbumin (most sensitive), total protein and albumin. Negative nitrogen balance means starvation!

blood flow through the heart

Preload Rt atrium receives blood from Superior Vena Cava, Inferior Vena Cava, this is deoxygenated blood Tricuspid valve to Rt ventricle Pulmonary semilunar valve Pulmonary trunk Pulmonary artery, this artery carries deoxygenated blood. Lung where it is oxygenated Pulmonary veins which are carrying oxygenated blood Afterload Left atrium Bicuspid (mitral) valve Left ventricle - the big bad pump Aortic semilunar valve Aorta and finally the oxygenated blood is delivered throughout the body thorough the arterial system where it eventually ties back into the venous system

Types of acute renal failure

Prerenal Azotemia Intrarenal (intrinsic) Postrenal azotemia

what receptors does dobutamine act on

Primarily Beta 1, but does act on Beta 2 some

SPINAL CORD TUMORS

Primary spinal cord tumors Intramedullary tumors Extramedullary tumors

Propofol

Produces both rapid anesthesia and recovery, has antiemetic activity and commonly used for outpatient surgery, may cause marked hypotension *general anesthetic

Beta Blocker examples

Propranolol, metoprolol, Atenolol, Carvedilol -lol

What are the indications and considerations for 5% Dextrose in 0.225% Saline?

Provides Na+, Cl- and free water. Used to replace hypotonic losses and treat hypernatremia, provides 170 calories/L.

What are the indications and considerations for 0.45% Saline?

Provides free water in addition to Na+ and Cl-. Used to replace hypotonic fluid losses. Used as maintenance solution. Provides no calories.

What are the indications and considerations for 5% Dextrose in Water?

Provides free water necessary for renal excretion of solutes, used to replace water losses and treat hypernatremia, provides 170 calories/L. No electrolytes.

What are the indications and considerations for 10% Dextrose in Water?

Provides free water only, no electrolytes, Provides 340 calories/L.

Hypotonic:

Provides more water than electrolytes, diluting the ECF.

Administration of Esmolol

Quick acting so careful dosing is a must Can use loading dose or not depending on hemodynamics

H2 Antagonist

Ranitidine (zantac) Famotidine (Pepcid) Nizatidine (Axid)

rhabdomylosis

Rapid breakdown of skeletal muscle tissue due to mechanical, physical or chemical traumatic injury Large release of CPK- creatine phosphokinase enzymes and other cell by-products in the blood system Can lead to acute renal failure due to by-products of muscle breakdown typical treatment is a lot of IV fluid so this will lower their K+ level

After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care?

Rapidly infuse cold normal saline. rationale: When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Since hypothermia will decrease brain activity, neurologic assessment every 30 minutes is not needed. Sedative medications are administered during therapeutic hypothermia.

A client is admitted to the hospital with acute exacerbation of COPD following an upper respiratory infection. His daughter found him at home, confused and in respiratory distress, a day after he developed a cold. He was placed on 4 L of Oxygen via nasal cannula, but oxygen saturation remains at 89%. Blood gases reveal ph 7.33, pCO2 58, PO2 84, HCO3 33. Based on this assessment the nurse determines that the client has developed which acid base imbalance? Choose one answer. 1) Respiratory acidosis 2) Respiratory alkalosis 3) Metabolic acidosis 4) Metabolic alkalosis

Rationale 1. Correct: Respiratory failure, COPD, muscular weakness can lead to respiratory acidosis. Signs and symptoms: hypoventilation, sensorium changes, somnolence, semicomatose to comatose state. Ph < 7.35, pCO2 > 45, HCO3 > 27. 2. Incorrect: Not alkalosis 3. Incorrect: Not metabolic related acid-base imbalance 4. Incorrect: Not metabolic

A nurse is caring for a client who has crackles on lung auscultation and is short of breath. To promote rapid diuresis in a client in acute pulmonary edema, the nurse should implement which of these orders first? Choose one answer. 1) Furosemide (Lasix®) 40 mg IVP 2) Morphine sulfate 2 mg IVP 3) Potassium chloride 20 meq PO 4) Captopril® (capoten) 25 mg PO

Rationale 1. Correct: Yes, there is a good bit of fluid overload here-let's get the lasix started first! 2. Incorrect: No, must address the fluid overload first 3. Incorrect: Well, the K is to go with the Lasix, so give the Lasix first then determine need for K. 4. Incorrect: Give the Lasix first then determine need for ACE inhibitor

A client with deep vein thrombosis has been treated with intravenous heparin for one week. The primary healthcare provider plans to change the medication to warfarin sodium (Coumadin). The nurse understands which approach would be appropriate? Choose one answer. 1) Begin the Coumadin and stop the heparin simultaneously. 2) Stop the heparin 24 hours, then begin the Coumadin. 3) Begin the Coumadin before stopping the heparin. 4) Stop the heparin, wait for the coagulation studies to reach the control value, and begin the Coumadin.

Rationale 3. Correct: Coumadin is initiated while the client remains on heparin. This is done so the client remains adequately anticoagulated during the transition from IV heparin to Coumadin. 1. Incorrect: Coumadin's onset of action is 36 hours to 3 days. If heparin were stopped and Coumadin initiated there would be a lag of time wherein the client would be at increased risk for clotting. 2. Incorrect: Coumadin's onset of action is 36 hours to 3 days, which would be lag time with increased risk for clotting. 4. Incorrect: Client would not be adequately antiocoagulated and at increased risk for clotting.

76) How would the nurse determine the best size oropharyngeal airway for a client? Choose one answer. 1) Be the same size as the little finger of the victim. 2) Reach from the tip of the lips to the epiglottis. 3) Be the length from the earlobe to the xiphoid process. 4) Reach from the earlobe to the corner of the mouth.

Rationale 4. Correct: An airway of proper size will extend from the corner of the client's mouth to the tip of the earlobe on the same side of the client's face. 1. Incorrect: The size of the client's little finger does not determine the size of the oral airway that should be used. 2. Incorrect: The epiglottis is an internal body part thus making it impossible to correctly measure to it. 3. Incorrect: Measuring from the client's earlobe to the client's xiphoid process would make the oral airway too long.

cervical tongs

Realigns fractures of cervical vertebrae and relieves pressure on cervical nerve Never lift the weights No pillow under head during feedings

The following actions are part of the routine emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

Remove the patient's rings. rationale: The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jewelry.

In a burn pt. with no urine output or less than 30mL/hr what do you worry about?

Renal Failure

*Phase 2 ARDS

Reparative or Proliferative Phase Begins 1 to 2 weeks after the initial lung injury. During this phase there is an influx of neutrophils, monocytes, lymphocytes and fibroblast proliferation as part of the inflammatory response. The proliferative phase is complete when the diseased lung becomes characterized by dense, fibrous tissue. Increased pulmonary vascular resistance and pulmonary hypertension may occur in this stage because fibroblasts and inflammatory cells destroy the pulmonary vasculature. Lung compliance continues to decrease as a result of interstitial fibrosis and hypoxemia. Hypoxemia worsens because of the thickened alveolar membrane causing diffusion limitation and shunting. If the reparative phase persists widespread fibrosis results, if it is arrested the lesions resolve.

*Brown-Séquard syndrome

Results from penetrating injuries that cause hemisection of the spinal cord, or injuries that affect half of the spinal cord. Motor function, proprioception, vibration, deep touch sensations are lost on the same side (ipsilateral) of the body as the lesion. Opposite side (contralateral) of the body sensations of pain, temperature, light touch are affected due to spinal nerve tract crossing.

Hospital care for frostbite

Rewarming bath 104-108 IV opiates and IV rehydration never apply dry heat or rub!! elevate areas for edema tetanus do not compress topical and systemic antibiotics

Preferred resuscitation fluid is

Ringer's lactate and 0.9% NS Isotonic (crystalloid) - stay where I put you

Harrington rods

Rods put up and down lamina- belted at each; Help support fusion of vertebrae

RSV S&S for infants

S&S of upper resp infection- BUT USUALLY- pneumonia bronchiolitis tracheobronchiolitis

Stemi

ST- segment elevation myocardial infarction, indicates the client is having a heart attack and the goal is to get them to the cath lab for PCI n less than 90 min. WORRY ABOUT THIS CLIENT

What are the indications and considerations for 5% dextrose in 0.45% Saline?

Same as 0.45% NaCl except provides 170 calories.

What are the indications and considerations for 5% dextrose in 0.9% Saline?

Same as 0.9% NaCl except provides 170 calories/L.

*Statistical Facts of ARDS and sepsis:

Sepsis especially gram negative with shock is the most common and frequent risk factor. Frequency of ARDS with sepsis is 18-38%. 18-25% of patients with gram negative sepsis develop ARDS. Bacteremia with sustained hypotension is the harbinger for development of ARDS. 30% of patients with septic shock develop ARDS while only 14% of patients with sepsis without shock develop ARDS. When DIC is present, 38% patients developed ARDS, while only 17% developed ARDS when DIC was not present.

What are some drugs used w/burns

Silver Sufadiazine (Silvadene): soothing, apply directly, apply more if rubbed off, can lower WBC, can cause a rash. Mafenide Acetate (Sulfamylon): can cause acid-base problems, stings, if it rubs off apply more Silver nitrate: keep these dressings wet; can cause electrolyte problems Povidone-Iodine (Betadine): stings, stains, allergies, acid-base problems

What are the indications and considerations for Lactated Ringers Solution?

Similar in composition to normal plasma except does not contain Mg2+. Used to treat losses from burns and lower GI. May be used to treat mild metabolic acidosis but should not be used to treat lactic acidosis. Does not provide free water or calories.

What are the indications and considerations for Ringers Solution?

Similar in composition to plasma except that it has excess Cl-, no Mg2+ and no HCO3-. Does not provide free water or calories. Used to expand the intravascular volume and replace ECF losses.

S/S of PE

Small emboli may be asymptomatic Develop abruptly Most common are dyspnea and pleuritic chest pain Anxiety, sense of impending doom and cough are also common Diaphoresis and hemoptysis may develop Massive pulmonary embolus can cause syncope and cyanosis Tachycardia and tachypnea are noted Crackles may be heard and S3 and S4 may be noted Low grade fever may develop Characteristics of fat emboli - sudden onset of dyspnea, tachypnea, tachycardia, confusion, delirium, decreased LOC, petechiae on chest and arms **if patient has distended neck veins, syncope, cyanosis and hypotension, notify RRT

analogue

Something that is similar in some way to something else

Tizanidine

Spasmolytic α2 agonist; centrally acting Short duration of action ↑ presynaptic inhibition of motor neurons - inhibits cerulospinal pathways, polysynaptic reflexes and monsynaptic reflexes - ↓ muscle tone and frequence of muscle spasms - no withdrawal problem like w/ baclofen Side Effects: dry mouth, sedation, asthenia,dizziness, hypotension, bradycardia, visual hallucinations/delusions to receptors in brain

spinal shock

Spinal Shock is common in acute spinal cord injuries. SIGNS / SYMPTOMS Hypotension Flaccid paralysis on one side Absent bowel sounds Decreased urine output Palpation of a distended bladder Lack of respiratory effort associated with high cervical injury

In preventing contractures what precautions should the nurse take?

Splint in normal looking positions (for example neck extended vs. chin to chest). If burns are to hands wrap separately.

SARS prevention

Standard, airborne and contact precautions ***HANDWASHING*** CDC recommends hand hygiene, gown, gloves, eye protection and N95 respiratory For patients treated at home, remain home for 10 days after fever is gone and until respiratory symptoms are absent Routine cleaning with soap and hot water are adequate to disinfect objects If patient is out of isolation, they must wear a mask - if they can't wear a mask for some reason, everyone else should

Renal calculi treatment

Start an IV Pain management thru IV Hydration Limit purines (liver, venison, pork) Limit oxalate (dark leafy veggies, chocolate, tea) * Non surgical mgmt 1. Drug therapy 2. Toradol- (NSAID)- in the acute phase may be quite effective, but increases the risk of bleeding, so the lithotripsy needs to be delayed 3. Spasmotic (Ditropan, Pro-banthine)-pain meds 4. Relaxation techniques, healing touch, breathing techniques 5. Avoiding overhydration and under hydration in the acute phase to make the stone easily passable 6. Lithotripsy- (shock wave)- sound laser to break the stone into fragments * Surgical mgmt (MIS) 1. Stenting- small tube placed in the ureter, dialtes for passway of stone 2. Inscision to remove stone, 3. Ultrasonic waves 4. Chemical irrigation

Risk Factors of PE

Statis of blood flow, vessel wall damage, altered blood coagulation, prolonged immobility, trauma, surgery, MI and heart failure, obestity, advanced age, women using oral contraceptives or estrogen therapy, pregnant women and childbirth, central venous catheters, lung/prostate cancer

Parkland Formula

Step 1: calculate only the 2nd and 3rd degree burn areas. Step 2: First 24 hours give 4mL/kg times the amount of burned BSA as follows; 50% over the first 8 hours. 25% over the second 8 hours, 25% over the third 8 hour period.

Using the above five-step approach we can interpret ABGs easily in a systemic and logical way without confusion.

Steps to interpreting ABGs Follow this five-step approach to interpreting your patient's ABGs. 1. Is the patient hypoxic? Look at the Pao2 and Sao2. 2. What is acid-base balance? Check the pH. 3. How is pulmonary ventilation? Look at the Paco2. 4. What is the metabolic status? Review the HCO3-. 5. Is there any compensation or other abnormalities? What is the primary cause of acid-base imbalance and which derangement is the result of secondary (compensatory) change? Examine serum lactate and electrolyte results; match Paco2 and HCO3- parameters with the pH.

Which receptors does epinephrine work on?

Stimulates Alpha 1,2 and Beta 1,2 receptors. Low doses = Beta receptors High doses = Alpha receptors

second degree frostbite

Superficial Full-thickness skin freezing, formation of edema Formation of clear blisters Black, hard eschars over several days Complains of numbness, aching, and throbbing Prognosis is good

Classifications of burns

Superficial thickness: only to the epidermis Partial: entire epidermis and varying depths of the dermis Full-thickness: entire dermis and sometimes fat

Classification of Burn Depth

Superficial: -Superficial Partial -Deep Partial- Full Thickness:

What are some Tx for burn patient w/eschar?

Sutilanis (Travase) or Collagenase (santyl): enzaymatic drugs (eat dead tissue). Don't use on face, over large nerves, if area is opened to a body cavity or if pt is preggo.

Additional risk factors for PE and DVT include smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostrate), Trousseau's syndrome, and trauma.(T/F)

T

Amnionic fluid embolus has a high mortality rate and occurs as a rare complication of childbirth, abortion, or ammocentes. (T/F)

T

In PE, platelets collect on the embolus, triggering the release of substances that cause blood vessel constriction. (T/F)

T

With PE, some patients could have more vague symptoms resembling the flu such as nausea, vomiting, and general malaise.(T/F)

T

Troponin Isomers normal amounts:

T<0.20 I<0.03

An 18-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate administration of ______________

TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap). rationale: For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.

Tetanus Toxoid vs. Tetanus Immune Globulin

Tetanus Toxoid: Active Immunity (takes 2-4 weeks to develop their own immunity) Tetanus Immune Globulin: Passive Immunity (think immediate protection)

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F, which assessment indicates that the nurse should discontinue the rewarming?

The core temperature is 94° F (34.4° C). rationale: A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient.

Dopamine

The metabolic precursor to norepinephrine Adrenergic Agonist

Kidney transplant

The removal of a kidney from a living donor or cadaver and implantation into the patient. It's performed due to acute or chronic end stage renal failure.

areflexic bladder

The sacral reflex is disrupted; cauda equina lesion; the bladder does not recieve PNS activity; urinary retention occurs and then dribbling incontinence bladder fills without emptying feels bladder fill. no control of urination. overflow incontinence.

**DX ARDS

There are no characteristic abnormalities in ARDS, except related to a specific underlying condition e.g. leucocytosis in sepsis, raised serum amylase in pancreatitis, etc. Chest X-Ray: Initially may be normal but soon diffuse bilateral interstitial or alveolar infiltrates develop. CT scan (Chest): Heterogeneous pattern with a predominance of infiltrates in the dependent regions of lungs.

Superficial Partial

Thickness: pink to red, blanch when pressure is applied, mild to moderate edema, painful, blisters, no eschar, 2 week healing time, no grafts required EX: scalds, flames, brief contact w/hot objects involves entire epidermis and varying depths of dermis

Deep Partial

Thickness: red to whtie, moderate edema, painful, blisters are rare, eschare is soft and dry, 2-6 week healing time, grafts can be used if healing is prolonged EX: scalds, flames, prolonged contact w/hot objects, tar, grease, chemicals

Ganciclovir

This guanosine analog causes significant myelosupression and is used to tx acyclovir resistant CMV, HSV-6/7

left ventricle

This is the largest & most muscular chamber; it receives oxygenated blood from the lungs via the left atrium & pumps blood into the systemic circulation via the aorta

right ventricle

This receives blood from the right atrium and pumps it to the lungs via the pulmonary artery

setting ventilator parameters

Tidal volume - 10-15 ml/kg (standard is 12 ml/kg), Respiratory rate - initially 10-16/ minute, FiO2 - 0.21-1.0 depending on disease process (100% causes oxygen toxicity and atelectasis in less than 24 hours, 40% is safe indefinately, PEEP can be added to stay below 40%, goal is to achieve PaO2 >60) , IE ratio 1:2 is a good starting point obstructive diseases requires longer expirations and restrictive disease requires longer inspirations

**setting ventilator parameters

Tidal volume - 10-15 ml/kg (standard is 12 ml/kg), Respiratory rate - initially 10-16/ minute, FiO2 - 0.21-1.0 depending on disease process (100% causes oxygen toxicity and atelectasis in less than 24 hours, 40% is safe indefinately, PEEP can be added to stay below 40%, goal is to achieve PaO2 >60) , IE ratio 1:2 is a good starting point obstructive diseases requires longer expirations and restrictive disease requires longer inspirations TXBK -Rate (f) Number of ventilator-delivered breaths per minute: usually 12-15 in adults using ACMV, may be lower in SIMV -Tidal volume (Vt) Amount of gas delivered with each ventilator breath: usually 8-10mL/kg of body weight -02 (FIO2) Percentage of xoygen delivered with ventilator breaths: can be set between 21% (room air) and 100% -I:E ratio Duration of inspiration to expiration: usually 1:2 to 1:1.5 -Flow rate Speed at which air is delivered -Sensitivity Effort required by patient to initiate an ventilator-assisted breath -Pressure limit Maximal pressure within airways that will terminate a ventilator breath

Action of Diuretics on HF

To decrease preload decrease volume = decrease preload

IV pyelography

To view Kidneys, calices, ureters, pelivices, urinary bladder. To assess teh adequacy of uptake and rate of excretion of contrast. Pretest:bowel prep, NPO Intratest: may have Nausea Post test: adequate hydration, dye is nephrotoxic.

Complete spinal lesion

Total loss of sensation and voluntary muscle control below the lesion, can result in paraplegia or tetraplegia.

theraputic use of Esmolol

Treat tachy arrhythmias such as SVT or sinus tachycardia For post op hypertension

Assessment of pt on ventilator

Tube placement, minimal cuff leak, breath sounds and chest wall movement Check pilot balloon to ensure that cuff is inflated VS at least every 4 hours Check settings every 8 hours tube placement every 2 hours potassium, calcium, magnesium and phosphate levels

Atropine sulfate

Tx of bradycardia S/E: Headache, dry mouth, urinary retention Check for hx of glaucoma, asthma, HTN

Why would your burn patient have an order for an NG tube w/suction?

Tx/prevention of paralytic illeus

NCLEX ? Which of the following would you choose to determine if a client's fluid volume is adequate? Their weight or their urine output?

Urine output 99.9% of the time this is weight, but for burns it is UO because they are getting fluid rapidly

1st sign of cardiac output decrease may be?

Urine output less than 30mL/hr

Nitroglycerine uses

Used for acute angina, hypertensive crisis and pulmonary edema *Drug of choice for cocaine induced MI or chest pain

Versed theraputic uses

Used in the ICU for sedation, treatment of anxiety and procedural sedation Shorter acting and onset of action is faster than Ativan

What are the indications and considerations for 0.9% Saline?

Used to expand intravascular volume and replace extracellular fluid losses. Only solution that may be administered with blood products. Contains Na+, and Cl- in excess plasma levels. Does not provide free water, calories, or other electrolytes. May cause intravascular overload or hyperchloremic acidosis.

Intrathecal baclofen

Used to treat muscle spasticity For pts with severe intractable spasticity Delivery: subarachnoid space at spinal cord level, catheter implanted with pump in abdomen Uses: those who haven't responded to other txs May not improve for those with severe spasticity, those who don't have adequate voluntary motor function, if not enough residual motor ability Adverse effects: pump/catheter malfunction, overdose = respiratory and cardiac depression, coma, withdrawal sx, tolerance Pharmacokinetics: can't be completely metabolized, terminated by redistribution, excreted in bile unchanged

What are the indications and considerations for 3.0% Saline?

Used to treat symptomatic hyponatremia, must be administered slowly with extreme caution because it may cause dangerous intravascular fluid overload and pulmonary edema.

paralytic ileus

Usually temporary paralysis of intestinal wall that may occur after abdominal surgery or peritoneal injury and that causes cessation of peristalsis; leads to abdominal distention and symptoms of obstruction.

black widow hospital care

VS - esp bp and resp supportive therapy opioid pain muscle relaxants calcium gluconate tetanus observe- seizures (rapid >BP) anti HTN antivenin (rare use- anaphylaxis, serum sick)

Bark scorpion

VS and monitor ICE packs for pain tetnus atropine for salvation cooling blanket

Preload

Volume of blood that fills the heart and stretches the heart muscle fibers during its resting phase (volume of blood in ventricles at end of diastole, just prior to contraction)

What does the term "epinephrine reversal" refer to?

Wen it is administered alone, it will cause an increase in systemic systolic blood pressure because of its Alpha activity. When given in conjunction with an Alpha blocker such as phenoxybenzamine, it will cause a decrease in systolic blood pressure because of its Beta 2 activity.

Disequilibrium syndrome

What is it?-A rapid change in the composition of the extracellular fluid that occurs during hemodialysis. Solutes are removed from the blood faster than the cerevrospinal fluid and brain, fluid is pulled in to the brain causing cerebral edema. Occurs more frequently in new clients, at the start of treatment

myofibril sarcomere

Within the "I band" Z disc - middle of the I band "Sarcomere" Region b/t two succesive "Z discs" Smallest contractile(functional) unit of muscle

Is it important to know if the burn victim was burnt in an open or closed space?

YES, more airway injury will occur in a closed space

Beta Adrenergic Blockers uses/nursing considerations

_angina, chest pain, Hypertension, ventricular dysrhythmias, thyroid storm --If the drug ends in -lol it is most liekly a beta blocker -don't give to asthmatics (some BB also constrict the smooth muscle of the bronchioles) -don't give to diabetics (block the sympathetic responses seen in hypoglycemia)

Dopamine hydrochloride

a adrenergic drug used to treat hypotension does not decrease renal function

Prior to the surgery for a liver transplant

a base line study is performed to evaluate the liver parenchyma to identify the presence of hepatic lesions, determine the patency and size of the portal vein, hepatic veins, and IVC and assess the biliary system for dilatation

vesicant

a chemical agent that causes blistering

Hyperesthesia

a condition of abnormal and excessive sensitivity to touch, pain, or other sensory stimuli

Dobutamine

a dopamine analogue Adrenergic agonist

mydriatic

a drug that causes the pupil of the eye to dilate

serum sickness

a hypersensitivity reaction that may occur 2 or 3 weeks after administration of an antiserum; symptoms include fever, enlargement of the spleen (splenomegaly), swollen lymph nodes, joint pain, and skin rash.

CEPHALOSPORINS

a large group of antibiotics, similar to penicillin, that are effective against a wide range of bacteria

Bleeding esophageal varices is

a life-threatening medical emergency. There can be severe blood loss, resulting in shock from hypovolemia. Bleeding may be either hematemesis or melena - can occur with no precipitating factors or with activity that increases abdominal pressure (heavy lifting, vigorous physical exercise, etc)

End stage renal disease

a severe stage of chronic renal failure that requires life-sustaining treatment with either dialysis or a kidney transplant. BUN may be as high as 150 to 250 mg/dL. * Over time the patients progress to severe CKD and ESKD. (chronic, end stage kidney disease) * Excessive amounts of urea and creatinine build up in the blood, and the kidneys cannot maintain homeostasis. * Severe fluid, electrolytes, and acid base imbalances occur Patients with ESRD are at risk for fluid volume overload and this would be the priority diagnosis. Fluid volume overload could lead to other serious conditions like Congestive Heart Failure (CHF),respiratory distress, and other disorders.

paraparesis

a slight paralysis or weakness of both legs

syncope

a sudden, and generally temporary, loss of consciousness and postural tone, due to inadequate flow of oxygenated blood to the brain (fainting)

Spinal fusion

a technique to immobilize part of the spine by joining together (fusing) two or more vertebrae

Hepatorenal syndrome*

a unique form of prerenal failure associated with advanced cirrhosis or acute liver failure. The kidneys are structurally normal but fail due to splanchnic vasodilation and profound renal vasoconstriction. Mortality >90% * Indicates poor prognosis - often the cause of death * Manifested by: a sudden decrease in urinary flow - elevated blood urea nitrogen and creatinine levels with abnormally decreased urine sodium excretion - increased urine osmolarity

Intrarenal (intrinsic)

a. Actual physical, chemical, hypoxic, or immunologic tissue damage to the kidney, such as: i. Acute interstitial nephritis ii. Exposure to nephrotoxins iii. Acute glomerular nephritis iv. Vasculitis v. Acute tubular necrosis vi. Renal artery or vein stenosis vii. Renal artery or vein thrombosis viii. Formation of crystals or precipitates in the nephron tubules

Operative procedure of Kidney transplant

a. All arterial and venous vessels and a long piece of ureter are preserved b. Technique for removal from living donors is delicate and lasts 3-4 hrs - flank incision used and care taken to avoid scarring - donors have more pain after surgery than do recipients c. Transplantation surgery usually takes 4-5 hrs - transplanted kidney is usually placed in the right or left anterior iliac fossa instead of normal anatomic position - this allows for easier connection of the ureter and the renal artery and vein - also allows for kidney assessment and palpation - recipients kidneys are not usually removed unless chronic infection is present

Prerenal Azotemia

a. Any condition decreasing blood flow to the kidneys and leading to ischemia in the nephrons, such as: i. Shock ii. Heart failure iii. Pulmonary embolism iv. Anaphylaxis v. Sepsis vi. Pericardial tamponade

Enzyme replacement for chronic pancreatitis

a. Contain amylase, lipase, and protease b. Dosage depends on severity of malabsorption - record number and consistency of stools per day to monitor the effectiveness of enzyme therapy - stools should become less frequent and less fatty c. Pt and family education: a. Take pancreatic enzymes before or with meals and snacks with a glass of water b. Administer enzymes after antacid or H2 blockers (decreased pH inactivates drug) c. Tell pt to swallow the tablets without chewing to minimize oral irritation d. Mix the powder form in applesauce or fruit juice at pts request e. Do not mix enzyme preparations in protein-containing foods f. Have the pt wipe his or her lips after taking enzymes to avoid skin irritation g. Do not crush enteric-coated preparations h. Follow up on all scheduled lab testing (pancrelipase can cause an increase in uric acid levels)

Complications of HD

a. Dialysis disequilibrium syndrome may develop during HD or after HD has been completed - the cause is thought to be due to the rapid decrease in fluid volume and BUN levels during HD - changes in urea nitrogen levels can cause cerebral edema and increased ICP - neurologic symptoms can result (headache, nausea, vomiting, restlessness, decreased LOC, seizures, coma, death) - assess for and document these symptoms because early recognition of the syndrome and tx with anticonvulsants and barbiturates may prevent a life-threatening situation b. Infectious disease transmitted by blood transfusion are a serious complication of long-term HD - most serious infections: hepatitis and HIV c. Hepatitis infection (B&C) in pts with CKD has decreased because the use of erythropoietin has reduced the need for blood transfusions to maintain RBC counts d. HIV

Pre-op care Kidney transplant care

a. Immunologic studies needed because the major barrier to transplant success after a suitable donor kidney is available is the body's ability to reject "foreign" tissue - in depth tissue typing must be done on all candidates - these studies include simple blood typing and human leukocyte antigen (HLA) studies b. HLA - the more similar the antigens of the donor are to those of the recipient, the more likely the transplant will be successful and rejection will be avoided c. Nursing actions: teach pt about procedure and care after surgery, in-depth assessment, coordination of diagnostic tests, and development of treatment plans d. Pt usually requires dialysis within 24 hrs of the surgery - recipient often receives a blood transfusion before surgery - usually blood from donor kidney is transfused into the recipient which increases graft survival of organs from living related donors

Lab test for acute pancreatitis

a. Increased serum amylase b. Elevated serum lipase c. Elevated serum trypsin d. Elevated serum elastase e. Elevated serum glucose f. Decreased serum calcium and magnesium g. Elevated bilirubin h. Elevated alanine aminotransferase i. Elevated leukocyte count j. Hyperglycemia Labs: ↑ serum & urine amylase and lipase, ↑ bilirubin, ALT, and alkaline phosphatase levels, ↑ WBC, ESR, and serum glucose, ↓ calcium and magnesium levels

lab profile for renal failure

a. Increased serum creatinine b. Increased BUN c. Normal, increased or decreased serum sodium d. Increased potassium e. Increased phosphorus f. Decreased calcium g. Increased magnesium h. Decreased bicarbonate i. Decreased (in metabolic acidosis) or normal pH j. Decreased hemoglobin and hematocrit

c. Post-op care kidney transplant

a. Large-bore indwelling foley for accurate measurements of urine output and decompression of the bladder - decompression prevents stretch on sutures and ureter attachment sites on the bladder b. Assess urine output at least hourly during first 48 hrs - abrupt decrease may indicate complications such as rejection, acute tubular necrosis (ATN), thrombosis, or obstruction c. Examine urine color - urine is pink or blood-tinged right after surgery and gradually returns to normal over several days to several weeks d. Obtain daily urine specimens for urinalysis, glucose measurement, the presence of acetone, specific gravity measurement, and culture e. Continuous bladder irrigation may be prescribed to decrease blood clot formation - perform routine catheter care to reduce catheter contamination - catheter removed as soon as possible to avoid infection (usually 3-7 days post-op) f. Oliguria may occur as a result of ischemia and ATN, rejection, or other complications - to increase output physician may prescribe diuretics and osmotic agents, such as mannitol g. Monitor fluid status because fluid overload can cause hypertension, heart failure, and pulmonary edema - take daily weight, measure BP q2-4 hrs, and measure I&O h. Pt may have diuresis (especially with kidney from living related donor) - monitor I&O and observe for serum electrolyte imbalances such as low potassium and sodium levels - may cause hypotension which reduces blood flow and oxygen to the new kidney causing a threat to graft survival

Postrenal azotemia

a. Obstruction of the urine collecting system anywhere from the calyces to the urethral meatus (obstruction of the ureter must be bilateral to cause postrenal failure unless only one kidney is functional), such as: i. Ureter, bladder, or urethral cancer ii. Kidney, ureter, or bladder stones iii. Bladder atony iv. Prostatic hyperplasia or cancer v. Urethral stricture vi. Cervical cancer

Peritoneal dialysis

a. Occurs through diffusion and osmosis across the semipermeable peritoneal membrane and capillaries b. Peritoneal cavity is rich in capillaries and is ready to access the blood supply - fluid and waste products dialyzed from the pt move through the blood vessel walls, the interstitial tissues, and the peritoneal membrane and are removed when the dialyzing fluid is drained from the body c. Efficiency of PD is affected by many factors, such as decreased peritoneal membrane permeability caused by infection or scarring and reduced capillary blood flow resulting from blood vessel constriction, vascular disease, or decreased perfusion of the peritoneum d. Unlike HD, water removal depends on the concentration of the dialysate - increasing glucose concentration of the dialysate makes the solution more hypertonic - the more hypertonic the solution, the greater is the osmotic pressure for water filtration and fluid removal from the pt during an exchange - dialysate concentration is prescribed on the basis of the pts fluid status e. Advantages: easy to learn; can be done at home; ambulatory - no machine needed; when machines are used, they are small; less stressful on the body; hemodynamic tolerance; continuous process; better blood pressure control; less dietary and fluid restrictions; greater freedom in scheduling and traveling f. Disadvantages: time-consuming exchanges; protein wasting; extensive glucose load à hyperlipidemia; sterile technique required; presence of permanent catheter; weight gain; peritonitis risk; cannot be done if pt has had many abdominal surgeries; chronic back pain or development of hernia

Phases of acute renal failure

a. Onset phase b. Oliguric phase c. Diuretic phase (high-output phase) d. Recovery phase (convalescent phase)

Hemodialysis

a. Passive transfer of toxins by diffusion b. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration c. When HD is started, blood and dialysate flow in opposite directions across an enclosed semipermeable membrane. The dialysate contains a balanced mix of electrolytes and water that closely resembles human plasma. On the other side of the membrane is the pts blood which contains nitrogenous waste products, excess water, and excess electrolytes. During HD, the waste products move from the blood into the dialysate because of the difference in their concentrations (diffusion). Excess water is also removed from the blood by osmosis. Electrolytes can move in either direction, as needed. K and Na generally move out of plasma into the dialysate and bicarbonate and calcium move from dialysate into the plasma. d. HD system includes a dialyzer, dialysate, vascular access routes, and HD machine e. Dialysate is made from clear water and chemicals and is free of any waste products or drugs - bacteria are too large to pass through the membrane so dialysate does not need to be sterile - dialysate composition may be altered according to the pts needs for treatment of electrolyte imbalances - dialysate is warmed to 100 F to increase rate of diffusion and to prevent hypothermia f. HD machine has alarm system to monitor for potential problems, including changes in dialysate temp, air in tubing, a blood leak in the dialysate compartment, changes in the pressure in either compartment, and changes in composition of the blood or dialysate g. Number and length of tx depend on the amount of wastes and fluid to be removed, the clearance capacity of the dialyzer, and the blood flow rate to and from the machine

Complications of PD

a. Peritonitis is the major complication of PD - most common cause is connection site contamination - to prevent peritonitis, use meticulous sterile technique when caring for the PD catheter and when hooking up or clamping off dialysate bags i. Manifestations: cloudy dialysate outflow (effluent), fever, abdominal tenderness, abdominal pain, general malaise, nausea, and vomiting ii. Cloudy or opaque effluent is the earliest sign of peritonitis - examine all effluent for color and clarity to detect peritonitis early iii. When peritonitis is suspected, send a specimen of the dialysate outflow for C&S study, Gram stain, and cell count to identify the infecting organism c. Pain during the inflow of dialysate is common when pts are first started on PD therapy - usually no longer occurs after a week or two of PD - cold dialysate increases discomfort - warm dialysate bags before instillation by using a heating pad to wrap the bag or by using a warming chamber of the automated cycling machine - microwave ovens are NOT recommended for the warming of dialysate d. Exit site and tunnel infections are serious complications - exit site from a PD catheter should be clean, dry, and without pain or inflammation - exit site infections are difficult to treat and can become chronic - can lead to peritonitis, catheter failure, and hospitalization - dialysate leakage and pulling or twisting of the catheter increase the risk for ESIs - Gram stain and culture should be performed when exit sites have purulent drainage a. Occur in the path of the catheter from the skin to the cuff - manifestations include redness, tenderness, and pain - treated with antimicrobials - deep cuff infections may require catheter removal e. Poor dialysate flow is usually r/t constipation - use bowel prep before placing the PD catheter to prevent constipation - an enema may help prevent flow problems a. Teach pt to eat high fiber diet and use stool softeners to prevent constipation b. Other causes of flow difficulty include kinked or clamped connection tubing, the pts position, fibrin clot formation, and catheter displacement c. Ensure drainage bag is lower than the pts abdomen to enhance gravity drainage d. Ensure that clamps are open e. If still inadequate, reposition the pt to stimulate inflow or outflow f. Turning the pt to the other side or ensuring that he or she is in good body alignment may help - have pt in a supine low-Fowler's position reduces abdominal pressure g. Fibrin clot formation may occur after PD catheter placement or with peritonitis - milking the tubing may dislodge the fibrin clot and improve flow f. Dialysate leakage is seen as clear fluid coming from the catheter exit site - small volumes of dialysate used first - may take pt 1-2 weeks to tolerate a full 2-L exchange without leakage around catheter site - leakage occurs more often in obese or diabetic pts, older adults, and those in long-term steroid therapy g. Other complications include bleeding, which is expected when the catheter is first placed, and bowel perforation, which is serious a. Observe for and document any change in the color of the outflow - Brown-colored effluent occurs with a bowel perforation - If outflow is same color as urine and has the same glucose level, a bladder perforations is possible - Cloudy or opaque effluent indicates infection

Patho for chronic pancreatitis'

a. Progressive, destructive disease of the pancreas that has "flare-ups" - inflammation and fibrosis of the tissue contribute to pancreatic insufficiency and diminished function of the organ - usually develops after repeated episodes of alcohol-induced acute pancreatitis - may also be associated with chronic obstruction of the common bile duct b. Alcoholism is the primary risk factor for chronic calcifying pancreatitis (CCP) - in early stages, pancreatic secretions precipitate as insoluble proteins that plug the pancreatic ducts and flow of pancreatic juices à as the protein plugs become more widespread, the cellular lining of the ducts changes and ulcerates àinflammatory process causes fibrosis of the pancreatic tissue à intraductal calcification and marked pancreatic tissue destruction develop in the late stages à organ becomes hard and firm as a result of cell atrophy and pancreatic insufficiency c. Chronic obstructive pancreatitis develops from inflammation, spasm, and obstruction of the sphincter of Oddi, often from cholelithiasis (gall stones) à inflammatory and sclerotic lesions occur in the head of the pancreas and around the ducts, causing an obstruction and backflow of pancreatic secretions d. Pancreatic insufficiency in chronic pancreatitis causes loss of exocrine function - most pts with chronic pancreatitis have decreased pancreatic secretions and bicarbonate - pancreatic enzyme secretion must be greatly reduced to produce steatorrhea resulting from severe malabsorption of fats (characteristic stools are pale, bulky, and frothy and have an offensive odor) - the action of colonic bacteria on unabsorbed lipids and proteins is responsible for the extremely foul odor e. Fat malabsorption contributes to weight loss and muscle wasting and leads to general debilitation - results in "starvation" edema of the feet, legs, and hands caused by decreased levels of circulating albumin f. Loss of pancreatic endocrine function is responsible for the development of diabetes mellitus in pts with chronic pancreatic insufficiency g. May have pulmonary complications, such as pleuritic pain, pleural effusions, and pulmonary infiltrates - pancreatic ascites may decrease diaphragmatic excursion and lung expansion, resulting in impaired ventilation - ARDS may develop in ill pt

Complications to kidney transplant

a. Rejection - most common and serious - leading cause of graft loss - antibodies and cytotoxic T-cells treat new kidney as foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis - 3 types: hyperacute, acute, and chronic (table 71-13) b. Acute tubular necrosis (ATN) - can occur as a result of hypoxic damage when transplantation is delayed after kidneys have been harvested - pts need dialysis until adequate urine output returns and the BUN and creatinine levels normalize c. Thrombosis - may occur during first 2-3 days after transplant - sudden decrease in urine output may signal impaired perfusion resulting from thrombosis - emergency surgery required to prevent ischemic damage or graft loss d. Renal artery stenosis may result from hypertension - bruit over artery anastomosis site and decreased renal function - involved artery may be repaired surgically or by balloon angioplasty in the radiology department

Nursing care following PD

a. Routinely started and monitored by the nurse b. Before tx, assess baseline VS, including BP, apical and radial pulse rates, temperature, quality of respirations, and breath sounds c. Weigh pt (always on same scale!) before the proc and at least every 24 hrs while receiving tx - weight should be checked after a drain and before the next fill to monitor the pts "dry weight" d. Baseline lab tests (electrolytes, glucose, etc) obtained before starting PD and repeated at least daily during PD tx e. Take and record VS q15-30 min during PD f. Assess for signs of resp distress, pain, or discomfort g. Check dressing around catheter exit site q30 min for wetness during the proc h. Assess blood glucose levels in pts who absorb glucose i. Observe the outflow pattern (outflow should be a continuous stream after the clamp is completely open) - measure and record total amount of outflow after each exchange - maintain accurate inflow and outflow records when hourly PD exchanges are performed j. When outflow is less than inflow, the difference is retained by the pt during dialysis and is counted as intake k. Chart 71-10 Caring for the Patient with a Peritoneal Dialysis Catheter i. Mask yourself and your pt. Wash your hands ii. Put on sterile gloves. Remove the old dressing. Remove the contaminated gloves iii. Assess the area for signs of infection, such as swelling, redness, or discharge around the catheter site iv. Use aseptic technique: a. Open the sterile field on a flat surface, and place two pre-cut 4x4—inch gauze pads on the field b. Place three cotton swabs soaked in povidone-iodine on the field. Put on sterile gloves v. Use cotton swabs to clean around the catheter site. Use a circular motion starting from the insertion site and moving away toward the abdomen. Repeat with all three swabs vi. Apply precut gauze pads over the catheter site. Tape only the edges of the gauze pads

Labs of acute liver disease

a. Tests done for acute liver disease a. Serum AST - elevated b. Serum ALT - elevated c. Serum total protein - elevated Other tests a. Elevated LDH b. Elevated serum alkaline phosphatase - in obstructive jaundice, hepatic metastasis c. Elevated serum total bilirubin d. Elevated serum direct conjungated bilirubin e. Decreased serum albumin in severe liver disease f. Elevated serum globulin - immune response to liver disease g. Elevated serum ammonia - advanced liver disease or PSE h. Prolonged PT or INR - hepatic cell damage and decreased synthesis of prothrombin LABS: Hyperglycemia because glucose is stored in liver..releases into blood. Plus same as cirrhosis: moderately increased AST/ALT, increased bleeding times, slightly increased ALK PHOS, DECREASED albumin, DECREASED WBC. If ammonia is present they are on the verge of LV failure. Prior to a liver biospy its important to be aware of the lab result for prothrombin time

Nursing care following HD

a. Vasoactive drugs can cause hypotension and may be held until after tx b. Closely monitor pt immediately and for several hrs after dialysis for any side effects from the tx - common problems include hypotension, headache, nausea, malaise, vomiting, dizziness, and muscle cramps c. Obtain VS and weight for comparison with pre-dialysis measurements - BP and weight are expected to be reduced as a result of fluid removal - hypotension may require rehydration with IV fluids - pts temp may be elevated because the dialysis machine warms the blood slightly - if fever is present pt may have sepsis and blood sample is needed for C&S d. Risk for excessive bleeding due to the heparin that is required - all invasive procedures must be avoided for 4-6 hrs after dialysis e. Chart 71-9 i. Weigh the pt before and after dialysis ii. Know the pts dry weight iii. Discuss with the physician whether any of the pts drugs should be withheld until after dialysis iv. Be aware of events that occurred during the dialysis tx v. Measure BP, pulse, resp, and temp vi. Assess for symptoms of orthostatic hypotension vii. Asses the vascular access site viii. Observe for bleeding ix. Assess the pts level of consciousness x. Assess for headache, nausea, and vomiting

cranial nerve 6; how to assess

abducens; checks lateral eye movements

Edema

abnormal accumulation of fluid in interstitial spaces of tissues

COTTON KILLS

absorbs moisture and stays wet, use goretex or polyester fleece

DIAMOX

acetazolamide tx of glaucoma, high altitude sickness...dont take if allergic to sulfa drugs Carbonic anhydrase inhibitor Idiopathic intracranial hypertension DIURETIC Inhibits CA → ↓secretion of fluids driven by H+/HCO3- secretion → ↓production of CSF Take 24hr before acent and for days after

cranial nerve 8; how to assess

acoustic: sensory the ability to hear tests the cochlear portion; the sense of equilibrium tests the vestibular portion; check the client's ability to hear a watch ticking or a whisper; observe the client's balance, and observe for swaying when walking or standing

Labs: Drugs:

activated C protein - decreased plasma d-dimer levels rise IL-6 levels rise IL-10 levels remain normal or decrease SEE PAGE 843 for Bundles for Resuscitation and Mgmt of Service Sepsis Synthetic activated protein C has been shown to reduce inflammatory responses during sepsis preventing small clott formation Xigris is only currently approved drug w/this activity given as a continuous infusion over 4 days to pts that are at high risk for death has serious complications, disrupts clotting activity so not given to pts w/other bleeding problems

*ARDS

acute respiratory distress syndrome

treatment for severe brown recluse

aggressive hydration blood transfusions systemic steroids supportive therapies

flu- method of infection 3 major strains strain resp for most infectious and severe less extensive and severe strain mild strain - usually unnoticed

airborne droplet & direct contact influenza A virus, B, C A (birds, pigs, whales, us- pandemics) B (us- local outbreaks, not pandemics) C (us, pigs, dogs)

epinephrine reversal

all alpha 1 adrenergic blockers reverse the alpha-agonist effects of epinephrine, this leads to blockage of alpha1 vasoconstriction, but beta2 vasodilation is not blocked. this leads to a systemic BP decrease in response to epinephrine given in the presence of phenoxybenzamine (or other alpha blocker). can be a fatal effect.

Antacids:

aluminum hydroxide gel (amphogel) magnesium hydroxide (milk of magnesium)

Meds to decrease duration and severity

amantadine rimantadine zanamivir- inhalation (can cause bronchospasm not for asthmatics) oseltamivir ribavirin--inhalation

Total lung capacity -

amount of air in the lungs at the end of maximum inhalation Increased indicated air trapping associated w/obstructive pulmonary disease Decreased indicated restrictive disease

Residual volume -

amount of air remaining in the lungs at the end of a full forced inhalation Is increased in obstructive pulmonary disease such as emphysema

what is commonly done in electrical burn pts?

amputations due to the circulatory system being destroyed

Tissue perfusion is dependent on

an adequate cardiac output

echocardiogram

an image of the heart produced by ultrasonography

An unstable chronic angina =

an impending MI

Arterial disorders of th lower extremities are usually treated with

angioplasty or endarterectomy to enhance perfusion

Acyclovir

anti-viral med to treat shingles (and herpes)

Amiodarone

antiarrhythmic Agent Class III (*life-threatening ventricular arrhythmias, *treat rapid atrial arrhythmias causing hemodynamic instability, unresponsive to less toxic agents; unlabled: supraventricular tachyarrhythmias; used in ACLS after CPR & de-fib have failed)

Follow up therapy to fibrinolytics

antiplatelets are an important component ASA, Plavix, Abciximab (a continuous infusion to inhibit platelet aggregation)

what causes the pulse to increase in burns?

anytime you are in a fluid volume deficit, the pulse will go up. the heart is trying to pump what little fluid you have (thready pulse)

An unresponsive 78-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 106.2° F (41.2° C), blood pressure (BP) 86/52, and pulse 102. The nurse initially will plan to _____________

apply wet sheets and a fan to the patient. rationale: The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.

Extramedullary tumors

are medical emergencies and need to be addressed immediately b/c they compress the spinal cord.

Primary spinal cord tumors

arise from the epidural vessels, spinal meninges, or glial cells of the cord. surgery to remove as much of the tumor as possible.

A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first action should be to ______________

assess the patient's current vital signs. rationale: The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with the data needed to determine this. The health care provider will not order a medication before assessing the patient.

When preparing to rewarm a patient with hypothermia, the nurse will plan to _____________

attach a cardiac monitor. rationale: Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation.

temporal lobe

auditory center; weniche's area for sensory and speech

why should drugs be altered with burn pts?

bacteria will build resistance or tolerance

Phenobarbital

barbiturate used as a sedative and as an anticonvulsant

Hypovolemic Shock

basic problem is loss of blood from vascular space resulting in cecreased MAP and loss of oxygen-carrying capacityk main trigger is a sustained decreased in MAP that reesults from decreased circulating volume moving oxygenated blood into selected areas while bypassing others causes manifestations of shock will result in acid-base imbalances, electrolyte imbalances and increased metabolites; if these are not corrected quickly, can result in cell damage in vital organs, multple organ dysfunction syndrome occurs and full recovery is no longer possible

For patients with thoracic injuries—

bedrest and possible immobilization with a fiberglass or plastic body cast

Acute Phase of Burn Injury

begins 36-48 hours after injury and lasts unti wound closure is complete burn wound sepsis is a serious complications and infection in leading cause of death during actue phase of recovery restoring skin starts with removal of eschare and cellular debris from burn wound (debridement) can be debrided mechanically using hydrotherapy - nurses, UAP and physical therapists can perform this most of the time small blisters are left alone b/c they provide a skin barier and promote wound healing topical enzyme agents such as collagenase (Santyl) are used for rapid wound debridement polysporin powder is often used w/this to prevent infection pigskin is most common type of heterograft used b/c compatible w/human skin surgical excision is the most common tx for full-thickness and deep partial-thickness wounds burn wound condition promote growth of Clostridium tetani and all burn patients are at risk for this, so tentaus vaccine is often given to all patients when admitted to hospital if having to give a burn patient antibiotics, they normally require larger doses ALL plants and flowers are prohibited in burn patients room because of risk for pseudomonas; some also prohibit raw foods

Severe Hypothermia

below 82.4 or 28C

PREVENTION is

best mgmt strategy

Full Thickness:

black, brown, yellow, white, red, severe edema, can be painful, no blisters, eschare is hard and inelastic, healing time is weeks to months, grafts are required EX: flames, electricity, grease, tar, chemicals

hemianopsia

blindness in half the visual field

homonymous hemianopsia

blindness in the same visual field of both eyes

Aldosterone receptors

blockade (promote excretion of Na and H2O)

If the Left ventricle does not pump, what occurs?

blood backing up into the lungs

AE for dapsone

blood dyscrasias if pt has G6PD deficiency screen for it agranulocytosis aplastic anemia

where else is this virus found in the body

blood, urine, feces

altitude illness

body senses less O2 RR increases to compensate hypocapnea occurs (blow off too much CO2 - hyperventilate - respiratory alkalosis) this limits further RR increases sleep disturbance, apnea, lack REM 24-48hrs kidney excretes less bicarbonate and pH returns to normal RR again rises, pulmonary artery pressure rises, cerebral blood flow increases Hypoxia also increases RBC production which can cause polycythmemia

PRIMARY BRAIN INJURY

brain injured at time of accident= contusion, laceration, hemorrage, hematoma

frontal lobe

broca's are for speech; prefontal lobe: controls morals, emotions, and judgments

craniotomy

burr holes are drilled into the skull for the surgical excision of a portion of the skull (perhaps for blood drainage or biopsy). The holes will be replaced/repaired.

In the event of a new SARS outbreak, what is the nurses primary role? A. Immediately report new cases of SARS to the Center for Disease control? B. Administer O2, standard antibiotics, and use pportive therapies to pts C. Prevent the spread of infection to other employees and pts D. Initiate and strictly enforce contract isolation procedures

c

These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed?

c) A 22-year-old with multiple fractures of the face and jaw a) A 72-year-old with palpitations and chest pain b) A 45-year-old complaining of 6/10 abdominal pain d) A 30-year-old with a misaligned right leg with intact pulses rationale: The highest priority is to assess the 22-year-old patient for airway obstruction, which is the most life-threatening injury. The 72-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 45-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 30-year-old appears to have a possible fracture of the right leg and should be seen soon, but this patient has the least life-threatening injury.

if urine in burn victim is brown or red, do what?

call Dr. this is normal, BUT... myglobin is in bloodstream, flushed thru kidneys, CAN CAUSE renal failure Dr. may want to give Mannitol

Noninvasive temporary pacing-

called transcutaneous pacing tow large electrode pads are applied to client and turned to the pacing mode -this is an emergency procedure -this hurts and the client will need analgesics

Dosing Versed

can be given in bolused doses or as a continuous infusion

Halo fixation

can lead a halfway normal life: take care of pins, do mess with bars, make sure they carry wrench with them, monitor neuro stuff (make sure maintaining or doing better), skin integrity is a huge issue

Most common airway injury?

carbon monoxide poisining normally O2 binds with hemoglobin. Carbon monoxide is faster and beats O2 to the hemoglobin and binds. O2 is unable to bind and the client becomes hypoxic

creatine kinase

cardiac specific isoenzyme; found mainly in cardiac cells & only rises when there has been damage to these cells; level starts to increase within a few hours (3-12) and peaks 12-24h of an MI; return to normal within 2-3d (this is why they keep them on CPU for 3d)

Careful of what with Propofol

careful in pts with GI disorders monitor lipase and triglycerides assure euvolemia prior to administration

Complications of of electrical wounds are?

cataracts, gait problems, neurological deficits

Jaundice

caused by one of two mechanisms: hepatocellular disease or intrahepatic obstruction

Obstructive Shock -

caused by problems that impair the ability of the noraml heart muscle to pump effectively heart itself remains normal but conditions outside heart prevent adequate filling or contraction of the heart most common causes are pericarditis and cardiac tamponade Risk Factors: pulmonary HTN, cancer

autonomic dysreflexia (hyperreflexia)

caused by visceral distention from a distended bladder or impacted rectum; NUEROLOGICAL EMERGENCY; must be treated immediately to prevent a hypertensive stroke; occurs after the period of spinal shock is complete and occurs with lesions above T6

IICP

caused by: trauma, hemorrhage, growths or tumors, hydrocephalus, edema, or inflammation; can impede circulation to the brain and absorption of CSF & affect the functioning of nerve cells and lead to brainstem compression and death

*Initiation phase of ARDS

cellular level damage to alveolus due to toxin

right atrium

chamber on the right side of the heart that receives oxygen depleted blood returning to the heart from the superior vena cava, the inferior vena cava and the coronary sinus.

flaccid posturing

client displays no motor response in any extremity

decorticate posturing

client flexes one or both arms on the chest and may extend the legs stiffly; indicates a nonfunctioning cortex

decerebrate posturing

client stiffly extends one or both arms and possibly the legs; indicate a brainstem lesion

acute renal failure

clinical syndrome characterized by a rapid decline in renal function with progressive azotemia and increasing levels of serum creatinine. hrs or days Acute renal failure (ARF) is a rapid decrease in renal function, leading to the collection of metabolic wastes in the body, and is described by three causes. Patients with acute failure usually do not have the anemia associated with chronic failure unless there is hemorrhagic blood loss or high blood urea levels.

Hepatic encephalopathy complications

clinical: complication of liver failure, disturbance in consciousness, seizures, asterixis, rigidity and hyperreflexia

Hypoesthesia

condition of having a dulled sensitivity to touch

transmission of RSV ... incubation

contaminated hands or objects course droplets- cough, sneeze incubation = 4-6 days

what is the first thing you do for electrical burn?

continuous heart monitor for 24hr due to possible Vfib

*common modes of ventilation

continuous positive airway pressure bi-valve airway pressure support assist-control mode ventilation synchronized intermittent mandatory ventilation positive end-expiratory pressure (PEEP) pressure support ventilation pressure-control ventilation

CPAP -

continuous positive airway pressure - applied positive airway pressure throughout the entire respiratory cycle for spontaneously breathing patients Most common use is during weaning process

**CPAP -

continuous positive airway pressure - applied positive airway pressure throughout the entire respiratory cycle for spontaneously breathing patients Most common use is during weaning process, also used for with respiratory failure is caused by hypoventilation or usual O2 delivery systems are not working Tight fitting increases lung volume, opening previously closed alveoli, improving ventilation of under ventilated alveoli, and improving ventilation=perfusion relationships

BLACK WIDOW environment

cool and damp

*SARS Forms of contact for infection

coronavirus spread by contact w/ resp secretions direct contact w/ infected person/object exposure of eyes or mucous m. to resp secretions contaminated H2O or sewage (maybe fecal oral)

S&S of flu

coryza (Symptoms of a cold) fever cough HA malaise

S&S avian flu

cough fever sore throat... SOB pneumonia D, V, ab pain bleeding from nose and gums ask about recent travel

resp S&S of flu

cough- initially dry sore throat substernal burning coryza acute S&S lessen in 2-3 days cough may be severe and productive (days-wks)

Atropine

counters the rest and digest dilate pupils, increase heart rate, decrease salvation and secretions given for bark scorpian sting if oversalvating, also given to treat bradycardia if HR drops below 50-60 (spinal cord injury)

Indicators for suctioning

crackles rhonchi frequent coughing setting off the high-pressure alarm increasing restlessness anxiety

Brown-Séquard syndrome

damage to one half of the spinal cord characterized by spastic paralysis on the body's injured side, loss of postural sense (proprioception), and loss of the senses of pain and heat on the other side of the body.

*Onest of Pulmonary Edema phase of ARDS

damaged walls allow plasma and proteins, etc to enter the interstitial space. Edema increases, pressure rises, fluid leaks into alveoli.

Eschar:

dead tissue must be removed so new tissue can reginerate likes to grow bacteria

What do Calcium Channel Blockers do to the BP?

decrease it

Heterotrophic ossification

deposition of calcium in ms typically after injury and nerve damage 10-53% of all pts are affected occurs typically below neuro level hips, knees, elbows first appears 1-6 mos after injury

Erythproiesis

describes the process of RBC formation or production. The organ responsible for "turning on the faucet" of RBC production is the kidney * A RBC production that must be properly balanced with RBC destruction

Hepatocellular jaundice -

develops because the liver cells cannot effectively excrete bilirubin - results in excessive circulating bilirubin levels

Careful for what with Precedix

dexmedetomidine Use carefully in the presence of hypotension

Use of Precedix

dexmedetomidine used for ICU sedation and for the treatment of AWS (acute withdrawal syndrome) OFF LABEL to use longer than 24hrs

Precedex

dexmedetomidine; sedative that does not cause respiratory distress; mechanism of action is agonism of alpha-2 adrenergic receptors in certain parts of the brain. *Alpha adrenergic agonist/sedative

What do Calcium Channel Blockers do to the cornary arteries?

dialate (more 02 to the muscle)

*Name 3 benzodiazipines

diazepam (Valium) lorazepam (Ativan) midazolam (Versed)

dyspnea

difficult or labored respiration

*acute pancreatitis treatment

during nausea and vomiting-intravenous hydration, avoid fluids and food; after nausea/ vomiting cease- liquid diet of small, low-fat meals, tube feeding in severe case o NPO with NG tube if ileus or protracted vomitting o IV hydration to prevent hypotension and shock o TPN if needed for prlonged episodes. (Reversible catabolic state) o Possible peritonal lavage to remove exudates from abdominal cavity o ERCP if needed o Removal of galbladder after pancreatitis is resolved

*S&S of hypoxemia

dyspnea neuro (restless, apprehension, impaired judgment, motor impairment) confusion tachycardia HTN (body wants more O2) metabolic acidosis dysrhythmias cyanosis <cardiac output

DOE

dyspnea on exertion

CXR

enlarged heart, pulmonary infiltrates

Bronchiovesicular-

even exp and insp, blowing sounds medium pitch and intensity.

Ascites causes

excess fluid in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity) Causes * Ascites is the collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension * Collection of plasma proteins in the peritoneal fluid reduces the amount of circulating plasma protein in the blood, when this decrease is combined with livers inability to produce albumin, serum colloid osmotic pressure is decreased in circulatory system-result is fluid shift from the vascular system to the abdomen

cranial nerve 7; how to assess

facial: sensory and motor; test taste perception on the anterior two thirds of the tongue; have the client show the teeth; attempt to close the client's eyes against resistance, and ask the client to puff out the cheeks; place sugar, salt, or vinegar on the front of the tongue, and gave the client identify these substances by their taste

hypotonic bowel

few bowel sounds

End Stage phase of ARDS

fibrin and cell debris from necrotic cell combine to form hyaline membranes, which line the interior of the alveoli and further reduce alveolar compliance and gas exchange. PaCO2 levels rise which PaO2 levels continue to fall. Respiratory acidoses Resp failure will occur without help Almost 50% will die

fires and burns are

fifth most common cause of unintentional injury deaths and 3rd leading cause of fatal home injuries

Cirrhosis treatment

first: high-protein, high-carb diet with vitamin B then: restrictions on fiber, protein, fat, and sodium; high calorie diet with small frequent feedings and fluid restriction; no alcohol abd girth and daily weights bleeding precautions skin integrity measures (no harsh soaps) balloon tamponade - sengstaken-blakemore tube shunts, esophageal banding to band varices, surgical bypass, vasopressin/propranolol IV to temporarily lower portal pressure via splenic artery endoscopic sclerotherapy: injection of sclerosing agent into esophagus causes varices to become fibrotic treatment for hepatic encephalopathy: lactulose, neomycin Meds -Spiranolactone and Eplerenone are nice, as they directly block Aldosterone Receptors. Aggressive Diuretic treatment in this disease can cause Hepatorenal Syndrome and Hepatic Encephalopathy, eg Death.

brudzinski's sign

flexion of the head causes flexion of both thighs at the hips and knee flexion; indicates meningeal irritation

kernig's sign

flexion of the thigh and knee to right angles; when they are extended, spasm of hamstring and pain occur; indicates meningeal irritation

48hrs after the accident, the pt begins to diurese. Why does this occur? what do we have to worry about? what happens to urine outflow?

fluid is going into vascular space fluid volume overload increase

Orthopnea

form of dyspnea in which the person can breathe comfortably only when standing or sitting erect

third degree frostbite

formation of small blisters that contain dark fluid and an affected body part that is cool, numb, blue, or red. Area does not blanch. Full thickness and subcut. tissue necrosis requires debridement.

parenchyma

functional tissue of an organ

when starting GI feedings, you measure what to ensure supplement is moving through GI tract?

gastric residual

what does a nurse do for a hypoxic pt?

give 100% O2

cranial nerve 9: how to assess

glossopharyngeal: sensory and motor; checks swallowing ability; checks sensation to the pharyngeal soft palate and tonsillar mucosa, taste perception on the posterior third of the tongue, and salivation

Piloerection

goosebumps

cranial nerve 9 & 10 assessed together

have the client identify a taste at the back of the tongue; inspect the soft palate and observe for symmetrical elevation when the client says "aah"; touch the posterior pharyngeal wall with a tongue depressor to elicit a gag reflex

systolic HF

heart can't contract ad eject

Pulmonary Edema patho

heart isn't pumping strong so cardiac output goes down, and fluid backs up into the lungs

diving reflex

heart rate declines after diving into water and blood is shunted from the less essential tissues to the more essential tissues such as the heart and brain

Liver Transplant

hep c most common cause requiring-- -HA thrombosis most serious complication o Patients with end stage liver disease or acute liver failure who has not responded to conventional medical or surgical inteventions is a candidate for transplantation. o Liver transplantation must occur within 8 hours of harvesting the organ

presence of ARDS in pt w/septic shock has a

high mortality rate

**Infection control principles

highly contagious standard precautions contact precautions airborne precautions CDC-gown, gloves, hand hygiene, eye, N95 resp AT HOME- stay home 10 days after fever breaks & S&S resolving hand hygiene mask w/ close contact No sharing of utensils, bedding etc

influenza

highly contagious viral respiratory illness

a blanket helps?

hold in body heat (pt is hypothermic), and keep out germs

how often will a foley cath need to be monitored on burn pt?

hourly it is possible that when it is insterted there will be no urine return, kidneys may be conserving fluid or may not be perfused adequately.

Flow -

how fast each breath is delivered and is usually set at 40 L/min

Dx of flu

hx clinical findings knowledge of outbreak x-ray to rule out pneumonia <WBC for viral >WBC for bacterial

Tx for adults with progression to lower resp inf

hydration mobilize resp secretions intubation/MV w/hypoxia FOR ELDERLY & IMMUNOCOMPROMISED- aerosolized ribavirin (Virazole, antiviral drug)

cranial nerve 12; how to assess

hypoglossal: motor; checks tongue movements involved in swallowing and speech; observe the tongue for asymmetry, atrophy, deviation to one side, and fasciculations; ask the client to push the tongue against a tongue depressor, and then have the client move the tongue rapidly in and out and from side to side

Assess for neurogenic shock. Neurogenic shock is a type of

hypovolemic shock with: Severe bradycardia Decreased or absent bowel sounds Warm, dry skin Hypothermia Severe hypotension

*refractory hypoxemia

hypoxemia that does not improve w/O2 admin HALLMARK OF ARDS

Onset phase

i. Description a. Begins with the precipitating event and continues until oliguria develops. b. Lasts hours to days ii. Characteristics a. The gradual accumulation of nitrogenous wastes, such as serum creatinine and BUN, may be noted

Diuretic phase

i. Description a. Often has a sudden onset within 2-6 wk after oliguric stage b. Urine flow increases rapidly over a period of several days c. The diuresis can result in an output of up to 10 L/day of dilute urine ii. Characteristics a. Electrolyte losses typically precede clearance of nitrogenous wastes b. Later in the diuretic phase, the BUN level starts to fall and continues to fall until the level reaches normal limits or reaches a plateau c. Normal renal tubular function is re-established during this phase

Oliguric phase

i. Description a. Characterized by a urine output of 100-400 mL/24 hr that does not respond to fluid challenges or diuretics b. Lasts 1-3 weeks ii. Characteristics a. Lab data include increasing serum creatinine and BUN, hyperkalemia, bicarbonate deficit (metabolic acidosis), hyperphosphatemia, hypocalcemia, and hypermagnesemia b. Sodium retention occurs, but this is masked by the dilutional effects of water retention c. Urinary indices are typically low and fixed; regulation of water balance by the kidneys is impaired, so urine specific gravity and urine osmolarity do not vary as plasma osmolarity changes

Recovery phase

i. Description a. In this phase, the pt begins to return to normal levels of activity b. Complete recovery may take up to 12 months ii. Characteristics a. The pt functions at a lower energy level and has less stamina than before the illness b. Residual renal insufficiency may be noted through regular monitoring of renal function c. Renal function may never return to pre-illness levels, but renal function sufficient for a long and healthy life is likely

black widow first aid

ice pack monitor for systemic toxicity if systemic - ABC's & hospital

Reflex bradycardia

if a drug increases blood pressure by constricting the blood vessels, the body will attempt to compensate for the increased pressure by slowing the heart rate and decreasing cardiac output.

why does the cardiac output decrease in burns?

if there is fluid volume deficit, there is less volume to pump

For patients with lumbar and sacral injuries—

immobilization of the spine with a brace or corset worn when the patient is out of bed; custom-fit thoracic lumbar sacral orthoses preferred

flu prevention

immunizations w/polyvalent- 85% effective annual for 6 mo-18 yrs, want it, at-risk pts live attenuated vaccine- internasal for <50 & healthy

Central cord syndrome

incomplete loss of center of body They can walk around but can't hold up their body. characteristic are: motor deficit in the upper extremities compared to the lower extremities. Sensory loss varies but is more pronounced in the upper extremities. bowel bladder function is variable or may be completely perserved CAUSED BY: injury or edema of the central cord, usually of the cervical area. May be caused by hyperextension injuries.

if a client has no bowl sounds, what will occur to girth area?

increase

Since arterial blood is having problems getting to the tissue, if you elevated the extremity the pain would increase or decrease?

increase - made worse, harder for blood to reach

What complaints/labs cause a nurse to worry when her patient is on Mycin drugs

increased BUN or creatinine and complaints of hearing loss (nephrotoxicity and ototoxicity).

in a burn, why does plasma seep into the tissue?

increased capillary permeability (leak due to damage) this occurs mostly in the first 24hrs (fluid deficit or shock)

*Pathophysiologic hallmark of ARDS is

increased vascular permeability to proteins. Even mild increase in pulmonary capillary pressure (because of increased intravascular fluid or myocardial depression) causes increased interstitial and pulmonary edema. Alveolar damage occurs also because of: Quantitative reduction of surfactant synthesis due to injury to type-II pneumocytes Qualitative abnormality in size, composition and metabolism of the remaining surfactant pool causing alveolar collapse. There is increased pulmonary airway resistance due to: Bronchial wall edema Cytokine-mediated bronchospasm

So what happens to the number of K+ in the serum of a pt?

increases causes hyperkalemia

Dobutamine

increases cardiac output

Hallmark of sepsis is

increasing serum lactate level, normal or low total WBC count, decreasing segmented neutrophil level w/a rising band neutrophil level (left shift) sepsis develops quicker among older, debilitated pts who are immunosuppressed Normal Parameters: CO (3-5L Min); Stroke Volume (60-80 mL); Serum Lactate (<2 mmol/L); Blood Glucose (<110), O2 (95-100%)

**S&S of SARS (less severe in children)

incubation 2-7 days- up to 10 fever 100.4 (38) or more chills HA malaise muscle aches AFTER 1-2 DAYS-resp S&S initially a nonproductive cough SOB dyspnea possible hypoxemia MAY PROGRESS TO- ARDS multiple organ dysfunction resp distress (during 2nd week)

babinski's reflex

indicates a disruption of the pyramidal tract; dorsiflexion of the ankle and great toe with fanning of the other toes

Peak Airway Pressure (PIP) -

indicates pressure needed by ventilator to deliver a set tidal volume at given lung compliance Monitors the highest pressure reached during inspiration An increased reading means increased airway resitance in pt or ventilator tubing, increased amt of secretion, pulmonary edema or decreased pulmonary compliance There will be a limit set, when limit is reached, high-pressure alarm sounds and remaining volume is not given (this is done to prevent barotraumas)

flu nursing Dx

ineffective breathing pattern ineffective airway clearance disturbed sleep pattern risk for infection

#1 complication of perineal burn?

infection

a tracheotomy increases risk for

infection in burn patients even more than in normal non-burned patients

patho

infects cells is resp tract...surface necrosis...sloughing of pneumoncytes in alveolar spaces...hyaline (fibrin) film forms (alveolar damage)... interferes w/gas exchange...also has inflammation of interstitial pulmonary tissues w/ lymphocytes and monocytes

patho for flu

infects resp epithelium...replicates & releases...infects neighboring cells..inflammation...necrosis...shedding of serous and ciliated resp cells...extracellular fluid escapes...rhinorrhea... serous cells replace faster than ciliated= continued cough & coryza

*patho

inflammatory cell responses and biochemical mediators damage the alveolar-capillary membrane...may dev w/in 90 minutes...plasma and blood escape into interstitial membrane...fluid enters alveoli...inactivates surfactant...increased surface tension...alveolar collapse w/atelectasis...lungs are noncompliant...gas exchange impaired...hyaline membranes form...fibrotic changes...intra-alveolar septa thicken...less gas exchange...hypoxemia is resistant to improvement w/O2 admin...PCO2 rises...tissue hypoxia....metabolic adicosis...resp acidosis also...sepsis...multiple organ dysfunction (kidneys, liver, GI, CNS, cardio)...death

fluDx

influenza tests (nasal swabs) For suspect of bacterial infection- WBC throat and sputum cultures x-ray

Stages of Shock

initial (Early) Nonprogressive (Compensatory) Progressive (Intermediate) Refractory (Irreversible)

cranial nerve 3,4 &6 overlap and need to be tested together

inspect the eyelids for ptosis (drooping); inspect for ocular movements and note any eye deviation; test accommodation and direct and consensual light reflexes

neurogenic bladder

interference with the normal mechanisms of urine elimination in which the client does not perceive bladder fullness and is unable to control the urinary sphincters; the result of impaired neurologic function

brown recluse first aid

intermittent ice 1st 4 days No heat- increases enzyme activity elevate extremity rest

parietal lobe

interprets pain, touch, temperature, and pressure

what may a physician do prophylactically with a burn patient?

intubate the airway may swell and close off, this will get worse over the first 24hrs. if this occurs a trach will be needed. HINT: least invasive first!!

In patients with more than 35% TBSAthe use of urine output and VS as a guide to resuscitation may not be adequate, soooo

invasive monitoring may be necessary

SEPSIS AND SEPTIC SHOCK

is a complex type of distributive shock that usually begins as bacteral or fungal infection and progresses to a dangerous condition over a period of days

Afterload

is the PRESSURE in the aorta and peripheral arteries that the left ventricle has to pump against to get the blood out. *that pressure is referred to as resistance (afterload) *the resistance the left ventricle has to overcome to get the blood out. left ventricle is thicker and more muscular you want lose pipes!

Closed head injury

is the result of blunt trauma; the integrity of the skull is not violated.

why is epinephrine secreted in burn victims?

it causes vasoconstriction, the body shunts blood to vital organs, BP increases

Why position the pt in a head up position?

it decreases the workload on the heart and increases cardiac output

with electrical burns, myoglobin and hemoglobin can build up and cause what?

kidney damage

why does urine output decrease in burns?

kidneys either try to hold onto fluid or they are not being perfused (it only takes 20 min to cause kidney necrosis)

TEST HINT: Pain never?

killed anyone!

Inspiratory strider within the first 24hrs of extubation indicates?

larlyngeal edema (may need reintubated) sore throat and hoarse voice are common

What can be a problem for pts with hypercapnia if given O2 levels that bring tissue perfusion over 60?

lead to hypoventilation Ca depresses, more O2 causes less breathing, combination = less ventilation 28% may be enough for COPD (ventilation) while 40% to 60% may be needed when diffusion is an issue

flash over phenomenon

lightening electrical current flows over the body rather than through the body, red feather like pattern across the skin (Lichtenberg figures) Can cause *ASYSTOLE - apnea due to Vfib

tricuspid valve

located between the right atrium and the right ventricle. closes when the right ventricle contracts, allowing blood flow into the lungs and prevent backflow into the right atrium

bronchial-

longest expiration, shortest inspiration, high pitched and hollow sound.

Vesicular-

longest inspiration, shortest expiration, sounds are soft breezy and low pitch. If lobes sound like bronchial you may have liquid or solid in them.

RSV S&S for elderly

lower resp infection fever pneumonia

MAP

mean arterial pressure

myocardial contractility

measure of stretch of the cardiac muscle fiber. it can also affect stroke volume and cardiac output. poor contraction decreases the amount of blood ejected by the ventricles during each contraction

Nursing concerns with hypothermia

metabolism is unpredictable once body warms, medications may become more active w/h IV meds till body is over 30C (86F) CPR if needed defib may be ineffective till body is over 30C

why would you remove a burn pts jewelry?

metal gets hot swelling will occur

Glasgow coma scale

method of assessing a client's neurological condition; score below 8 indicates that coma is present; client's ability to open his or her eyes is the most important indicator

Normal dose of Nitropursside

mix 50mg in 250mL D5W and start infusion at 0.3 mcg/kg/min and increase slowly to a max dose of 10mcg/kg/min *Titrate off slowly to prevent seizure activity

will a client need more or less calories?

more max nutrition, vit C, protein

cardiac index

more precise measure and takes into consideration tissue perfusion and the client's body surface area(BSA). Divide the CO by the BSA. Normal is 2.5-4.0L/min/m2

4 stages of Portal-systemc encephalopathy

* Stage 1: Prodromal - subtle manifestations that may not be recognized immediately - personality changes - behavior changes (agitation, belligerence) - emotional lability (euphoria, depression) - impaired thinking - inability to concentrate - fatigue, drowsiness - slurred speech - sleep pattern disturbances * Stage 2: Impending - continuing mental changes - mental confusion - disorientation to time, place, or person - asterixis (hand flapping) * Stage 3: Stuporous - progressive deterioration - marked mental confusion - stuporous, drowsy but arousable - abnormal electroencephalogram tracing - muscle twitching - hyperreflexia - asterixis * Stage 4: Comatose - unresponsiveness, leading to death in most pts progressing to this stage - unarousable, obtunded - response to painful stimulus - no asterixis - positive Babinski's sign - muscle rigidity - fetor hepaticus (characteristic liver breath—musty, sweet, odor) - seizures

Acute pancreatitis assessment

**Abdominal pain- sudden onset, mid-epigastric area or L upper abdomen radiating to the back, left flank, or shoulder Abdominal tenderness, rigidity, and guarding from peritonitis Jaundice, N/V Cullen's sign (gray-blue discoloration of abdomen and peri-umbilical area) and Turner's sign (gray-blue discoloration of flanks) indicate pancreas hemorrhaging o Often pt reports severe and constant abdominal pain - once pain is controlled, interview him or her to take a history - does abdominal pain occur when drinking alcohol or eating a high-fat meal? - alcohol usage: amount of alcohol consumed during what period of time? - question about a family or personal history of alcoholism, pancreatitis, or biliary tract disease - ask about peptic ulcer disease, renal failure, vascular disorders, hyperparathyroidism, and hyperlipidemia a. Diagnosis made on the basis of the clinical presentation combined with the results of diagnostic studies - both lab and imaging assessments b. Pt usually presents with severe abdominal pain in the mid-epigastric area or left upper quadrant - assess intensity and quality - pt often states pain had a sudden onset and radiates to the back, left flank, or left shoulder - pain described as intense, boring, and continuous and is worsened by lying in supine position - often finds relief by assuming the fetal position or by sitting upright and leaning forward c. Pt may report weight loss resulting from N&V d. When performing abdominal assessment, inspect for: generalized jaundice; gray-blue discoloration of the abdomen and periumbilical area (Cullen's sign); gray-blue discoloration of the flanks (Turner's sign), cuased by pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity e. Listen for bowel sounds (absent or decreased BS usually indicate paralytic ileus); pancreatic ascites creates a dull sound on percussion f. Monitor VS for elevated temp, tachycardia, and decreased BP g. Respiratory problems such as left lung pleural effusions, atelectasis, and pneumonia are common - auscultate lungs for adventitious sounds or diminished breath sounds, and observe for dyspnea or orthopnea h. Significant changes in VS may indicate the life-threatening complication of shock. Hypotension and tachycardia may result from pancreatic hemorrhage, excessive fluid volume shifting, or the toxic effects of abdominal sepsis from enzyme damage. Observe the pt for changes in behavior and LOC that may be r/t alcohol withdrawal, hypoxia, or impending sepsis with shock i. Excessive alcohol intake, particularly in men, is the most frequent cause of acute pancreatitis

hepatorenal syndrome

*Often assoc w/ fulminant hepatitis or alcoholic cirrhosis *Precipitating problems: GI bleeding or hypotension from a failing liver *Patho: hypotension-> decreased glomerular filtration-> tubular necrosis-> vasoconstriction of the renal circulation Functional kidney failure caused by advanced liver disease, particularly cirrhosis with portal hypertension. Renal failure is caused by a sudden decrease in blood flow to the kidneys, usually as a result of massive gastrointestinal hemorrhage or liver failure. Its chief clinical manifestation is oliguria (sm amt of urine production)

Esophageal varices

- dilated veins - in submucosa of esophagus - caused by portal hypertension - often associated w/liver cirrosis - at high risk for rupture if ---- portal circulation pressure rises

High Altitude Pulmonary Edema

-*dry cough, mild SOB, slight crackles in lungs, tachypnea, cynosis Treatment: oxygen, descent, portable hyperbaric bag, acetazolamide LATE - pink frothy sputum resperatory alkalosis, hypoxemia, pneumonia, elevated temp PRIORITY DECEND

Hepatic encephalopathy

-blood bypasses liver so ↑ ammonia levels (due to lack of filtering by liver) in blood which perfuse the brain causing reversible CNS alterations -central nervous system dysfunction resulting from liver disease; frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma

first degree frostbite

only epidermis damaged - skin shows hyperemia (increased blood flow) and edema (red and swollen)

Antivenom Bark scorpion -

Centruroides Exilicauda Antivenom only in Arizona, controversal, comes from goats, risk for serum sickness which is treated with antihistimines and corticosteriods

High altitude cerebral edema

HACE - Most common cause of death with altitude neurologic deterioration of acute mountain sickness or high altitude pulmonary edema Altered mental status, ataxia (muscle coordination, KEY SIGN), stupor, coma TX - O2 (intubate if severe altered mental status) Immediate descent or hyperbaric Dexamethasone Admit pts who remain ataxic or confused after descent PRIORITY DECEND

Atropine

Muscarinic antagonist drug; Used to block DUMBBELSS; Toxicity: hot as a hare, dry as a bone, red as a beet, blind as a bat, mad as a hatter The symptoms of an anticholinergic toxidrome include blurred vision, coma, decreased bowel sounds, delirium, dry skin, fever, flushing, hallucinations, ileus, memory loss, mydriasis (dilated pupils), myoclonus, psychosis, seizures, and urinary retention. Complications include hypertension, hyperthermia, and tachycardia. Substances that may cause this toxidrome include the four "anti"s of antihistamines, antipsychotics, antidepressants, and antiparkinsonian drugs[3] as well as atropine, benztropine, datura, and scopolamine.

fourth degree frostbite

No blisters or edema. The part is numb, cold and bloodless. Full thickness necrosis extends into the muscle and bone. Gangrene develops, which may require amputation.

Acute mountain sickness

No relationship of susceptibility to AMS & physical fitness. Inherent factors determine individual susceptibility to AMS. hangover HALLMARK: Fluid retention, peripheral edema, esp. face. Tx: *Descent & Oxygen, DIAMOX note: diamox can also be given in advance for prevention. Hypoxemia + alkalosis. Sx: headache, fatigue, nausea, dizziness, palpitations, insomnia PRIORITY DECEND

cirrhosis complications

Portal hypertension - persistent increase in pressure within the portal vein - major complication of cirrhosis - results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein branches(which can lead to leakage) Ascites - the collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension Bleeding esophageal varices (Life threatening emergency) - occur when fragile, thin-walled esophageal veins become distended from increased pressure - potential to bleed depends on size Production of bile is decreased - this prevents absorption of fat-soluble vitamins (vitamin K) - decreased clotting factors - pt susceptible to bleeding and easy bruising - Coagulation defects (malabsorption of vitamin K, necessary for coagulation) Splenomegaly - destroys platelets (causing thrombocytopenia) - increased risk for bleeding - thrombocytopenia may be first sign that pt has liver dysfunction Jaundice Portal systemic encephalopathy (PSE)* Hepatorenal syndrome* Spontaneous bacterial peritonitis (SBP)* Cirrhosis develops over months to years, has nonspecific signs like anorexia, weight loss, fatigue, jaundice, estrogenic effects (spider angiomas & gynecomastia). Complications include portal HTN caused by impaired blood flow through liver due to fibrosis (can manifest as esophageal & rectal varices which can rupture & cause fatal GI bleed), ascites, progressive liver failure, hepatic encephalopathy, hepatocellular carcinoma

1st Aid for lightening

Spinal immobilization and the ABCs skin burn is NOT the priority, look them once the pt is stable

Cirrhosis S/S

Symptoms: N/V anorexia weight loss abdominal pain jaundice edema anemia blood coagulation abnormalities Early: fatigue, significant change in weight, GI symptoms, adominal pain and liver tenderness, pruritis (from dry skin) Later: GI bleeding, jaundice, ascites, spontaneous bruising, purpura, spider angiomas, peripheral and sacral edema, nail clubbing, fixed flexion of fingers

Treatment of liver failure

TX: Liver transplant Nutrition therapy for patients with advanced liver disease o Pt with abdominal ascites - low-sodium diet - may not taste good so suggest pt use lemon, vinegar, parsley, oregano, and pepper o Vitamin supplements such as thiamine, folate, and multivitamin preparations are typically added to IV fluids because the liver cannot store vitamins

Labs of chronic liver disease

Tests done for chronic liver disease a. Serum total protein - decreased Other tests a. Elevated LDH b. Elevated serum alkaline phosphatase - in obstructive jaundice, hepatic metastasis c. Elevated serum total bilirubin d. Elevated serum direct conjungated bilirubin e. Decreased serum albumin in severe liver disease f. Elevated serum globulin - immune response to liver disease g. Elevated serum ammonia - advanced liver disease or PSE h. Prolonged PT or INR - hepatic cell damage and decreased synthesis of prothrombin LABS: Hyperglycemia because glucose is stored in liver..releases into blood. Plus same as cirrhosis: moderately increased AST/ALT, increased bleeding times, slightly increased ALK PHOS, DECREASED albumin, DECREASED WBC. If ammonia is present they are on the verge of LV failure. Prior to a liver biospy its important to be aware of the lab result for prothrombin time

S/S of Liver failure

ascites, jaundice, hepatomegaly, portal hypertension, bleeding and bruising (from decreased fibrinogen), confusion and cognition problems, nausea, weakness, cholestasis (decreased bile flow) or gallstones, acidosis (can't perform urea cycle), and immune system depression (decreased immunoglobins).

Spontaneous bacterial peritonitis (SBP)*

infection within the abdomen and the ascites. SBP is a life- threatening complication. ascitic fluid is obtained by paracentesis for cell counts & culture. Some patients with SBP have no symptoms, while others have fever, chills, abdominal pain and tenderness, diarrhea, and worsening ascites. May be the result of very low protein concentrations. Proteins help with bacteria. * Bacteria from bowel (usually) reach the ascitic fluid after migrating through the bowel wall and transversing the lymphatics * Clinical manifestations: fever, chills, and abdominal pain and tenderness * Diagnosis made when a sample of ascitic fluid is obtained by paracentesis for cell counts and culture - ascitic fluid leukocyte count more than 250 polymorhonuclear (PMN) leukocytes can be the basis for treatment

Dexamethasone -

is a potent synthetic member of the glucocorticoid class of steroid drugs. It acts as an anti-inflammatory and immunosuppressant (corticosteriod) dehydrates the CNS

Intervention activities for patient with cirrhosis

o Fluid/electrolyte management: regulation and prevention of complications from altered fluid and/or electrolyte levels * Obtain lab specimens for monitoring of altered fluid and electrolyte levels(hematocrit, BUN, protein, sodium, and potassium levels) * Keep an accurate record of I&O * Weigh pt daily, and monitor trends * Monitor for signs and symptoms of fluid retention * Monitor vital signs, as appropriate * Administer prescribed supplemental electrolytes, as appropriate o Bleeding precautions: reduction of stimuli that may induce bleeding or hemorrhage in at-risk pts * Monitor the pt closely for hemorrhage * Monitor for signs and symptoms of persistent bleeding (check all secretions for frank or occult blood) * Monitor coagulation studies (PT, PTT, fibrinogen, fibrin degredation/split products, and platelet counts) * Monitor orthostatic vital signs, including BP * Use electric razor * Use soft toothbrush or toothettes for oral care * Avoid injections (IV, IM, or subQ) * Protect pt from trauma, which may cause bleeding o Neurologic monitoring: collection and analysis of pt data to prevent or minimize neurologic complications * Monitor level of consciousness * Monitor level of orientation * Monitor recent memory, attention span, past memory, mood, affect, and behaviors * Monitor vital signs: temperature, blood pressure, pulse, and respirations * Know nutrition needs for patients with PSE. o Diets should be moderate in protein when the serum ammonia level is high and signs of PSE are present

Assessment of Portal Hypertension

o Includes all findings with cirrhosis - Early: fatigue, significant change in weight, GI symptoms, adominal pain and liver tenderness, pruritis (from dry skin) Later: GI bleeding, jaundice, ascites, spontaneous bruising, purpura, spider angiomas, peripheral and sacral edema, nail clubbing, fixed flexion of fingers o Most common clinical manifestations is vomiting of blood secondary to rupture of esophageal varices; clients with oozing varices may present with anemia and melanotic stools (esophagus veins draining into hepatic portal vein cause pooling of blood in veins creating distention and bulges in esophageal wall) o Splenomegaly o Hemorrhoids cause irritation or bright red rectal blood o Other conditions that can develop as a result of portal hypertension-varices, ascites (increased venous pressure forces plasma into ab cavity), hepatic encephalopathy leading to coma, and hepatorenal syndrome

Drugs used for PSE

o Lactulose (lactitol) - promote the excretion of ammonia in the stool - viscous, sticky, sweet-tasting liquid that is given either orally or by NG tube - obtains a laxative effect - cleansing the bowels rids the intestinal tract of the toxins that contribute to encephalopathy - increases osmotic pressure to draw fluid into the colon and prevents absorption of ammonia in the colon - desired effect is to produce 2-3 soft stools per day and a decrease in pt confusion caused by PSE * Pt may report intestinal bloating and cramping - hypokalemia and dehydration may result from excessive stools - help pt with skin care!! o Nonabsorbable antibiotics - given if lactulose doesn't help or the pt cannot tolerate it - should not be given with lactulose! * Neomycin sulfate - may be given to act as an intestinal antiseptic - destroys the normal flora in the bowel, diminishing protein breakdown and decreasing the rate of ammonia production - maintenance doses given orally, may also be given as retention enema - long term use has the potential for kidney toxicity (reason it is not commonly used) - not used for pts with existing kidney disease * Metronidazole - similar to neomycin - less potential for renal toxicity - should be used for short period - not commonly used * Rifaximin - most effective and safest for long-term use - not yet FDA approved for PSE

Acute pancreatitis

o Obstruction of pancreatic enzymes resulting in inflammation o Can be mild severe or fulminant o Associated with alchoholism, obstruction biliary disease, PUD, and medications such as diuretics, estrogens, steroids, salicyclates, or hyperlipidemia o Alcholol abuse and galbladder disease are 80% of the disease Autodigestion of pancreas by pancreatic enzymes, epigastric abdominal pain radiating to back, elevated amylase and lipase (higher specificity), can lead to DIC, ARDS (pancreas enzymes digest lung tissue), hypocalcemia (Ca++ collects into pancreating calcium soap deposits)

Cirrhosis Assessment

o Obvious yellowing of skin and sclera; dry skin; rashes; purpuric lesions, such as petechiae or ecchymosis; warm and bright red palms of the hands; vascular lesions with a red center and radiating branches known as "spider angiomas" on the nose, cheeks, upper thorax, and shoulders; peripheral dependent edema of the extremities and sacrum; clubbing of nails; fixed flexion of fingers d. Usually massive ascites is detected - distended abdomen with bulging flanks - ascites can cause other problems like orthopnea and dyspnea from increased abdominal distention e. Minimal ascites is harder to detect - percussion test for shifting dullness and the presence of a fluid wave may be performed f. Palpate right upper quadrant for hepatomegaly below the costal (rib cage) border - may also be assessed by percussing for dullness over the enlarged liver g. Measure abdominal girth to evaluate progression of ascites - pt lies flat while nurse pulls a tape measure around the largest diameter (usually umbilicus) of the abdomen - measured at the end of exhalation - mark abdominal skin and flanks to ensure the same tape measure placement h. Daily weights is the most reliable indicator of fluid retention i. Look for blood in vomitus and stool j. Assess for fetor hepaticus k. Amenorrhea may occur in women - men may exhibit testicular atrophy, gynecomastia, and impotence as a result of inactive hormones l. Subtle changes in mental status and personality often progress to coma - late complication of PSE m. Ultrasound is often the first assessment for a person with suspected liver disease to detect ascites, hepatomegaly, and splenomegaly

Liver Transplant assessment

o Patients with advanaced cardiovascular disease, severe respiratory disease, alcoholism or substance abuse, metastatic tumors, and inability to follow instruction. o Rejection- tachycardia, fever, right upper quadrant or flank pain, decreased bile pigment and volume, increasing jaundice 1. Labs: increased bilirubing rising AST and ALT, elevated alkaline phosphatase levels, increased PT/INR 2. Medications: treated with immunosupprusants and cyclosporine A is the most common 3. Opportunistic infections usually happen first in the mouth, (cytomeglovirus, mycobacterial ). Later infections are TB and herpes, if once acquired it may be reactivated 4. Monitoring for a change in neurological status can indicate hepatic encephalophy from a non-functioning liver 5. Report signs of clotting problems (bloody oozing from a catheter, petechiae, ecchymosis) to the surgeon immediately because of they may indicate impaired function of the transplanted liver

Procedure for Paracentesis and possible complications

o Procedure performed at bedside - physician inserts a trocar catheter into the abdomen to remove and drain ascitic fluid from the peritoneal cavity - done using ultrasound - commonly used as diagnostic tool o Nurse implications: explain procedure; answer questions; obtain vital signs, including weight; ask the pt to void before the procedure to prevent injury to the bladder!; position the pt in bed with the head of the bed elevated; monitor vital signs per protocol or physician's request; describe the collected fluid; label and send the fluid for lab analysis; document in the pt record that specimens were sent; after the physician removes the catheter, apply a dressing to the site; assess for leakage; maintain bedrest per protocol; weigh the pt after the procedure; document weight in pt chart before and after the procedure o High-volume paracentesis may be used for temporary relief of abdominal pressure - physician may remove as much as 4 liters of ascitic fluid - hypovolemia may occur with rapid or excessive fluid removal because these pts have adjusted to the excessive fluid volume in the abdomen * Rapid, drastic removal of ascitic fluid leads to decreased abdominal pressure, which may contribute to vasodilation and shock * Observe for impending signs of shock from fluid shifts during and immediately after the procedure o Serial paracentesis procedures may be needed for continued ascites - pts at risk for protein depletion, hypovolemia, and electrolyte imbalances

Liver patient transplant discharge teaching

o The importance to stress the need to follow medication regimens for the rest of the persons life. o Possible changes in body image and psychological responses.

tarantula S&S

pain at site swelling redness numbness lymphangitis systemic (not in US)

Murphy's sign - Cullen's sign - Turner's sign - McBurney's Point -

pain with palpation of gall bladder area seen with cholecystitis ecchymosis in umbilical area, seen with pancreatitis flank grayish blue (turn around to see your flanks) pancreatitis pain in RLQ indicative of appendicitis, watch for peritonitis

FIRST AID External warming

passive - warm clothes or blankets Active - heating blankets, warm packs, convective heaters No one is dead, till warm and dead

Eye care

specks - flush with water cut, puncture, objects - do not wash out eye, do not remove objects chemical burns - flush with any drinkable fluids, at least 15 min./all the way to hospital, flush OVER a contact lense blow to eye - cold compress

Hospital Care for Hypothermia

water bath 104-108F (40-42C) IV opiates for pain consider w/h IV drugs till temp is over 30C - also defib may not work till this temp is reached If SEVERE - active warming is contradicted watch for compartment syndrome