N360 Exam 3

<Outline the classification of spinal cord injuries and associated clinical manifestations.> classification (3) mechanism of injury (6) level of injury: skeletal, neuro, quadriplegia vertebrae, paraplegia vertabrae degree of injury: complete vs incomplete cord involvement

1) mechanism of injury flexion flexion rotation- most unstable bc tears ligaments-> severe defecits hyperextension vertical compression extension-rotation lateral flexion 2) level of injury skeletal level: vertebral level w most damage neuro level: lowest segment of spinal cord w normal sensory/motor fx on both sides of body tetra/quadriplegia: c1-t1 l/t 4 extremity paralysis paraplegia below t2 3) degree of injury degree of spinal cord involvement may be complete or incomplete complete cord involvement: total loss of sensory/motor fx incomplete cord involvement: mixed loss of motor/sensation five major syndromes central cord anterior cord brown-sequard cauda equina conus medullaris

Two days after an acute MI, a pt complains of stabbing chest pain that increases w a deep breath. What is your first nursing action? A auscultate heart sounds B check pt temp C notify pt HCP D give prn aceta

A suspect pericarditis, listen for rub

<Describe the clinical manifestations, interprofessional care, and nursing management of the patient with PAD of the lower extremities.> dx (4) how to take ABI (4) how to take segmental BP drop greater than _mmHg suggest PAD

ABI PAD screening tool hand held doppler divide ankle SBPs by the higher of the left and rt brachial SBPs can be false if calcified or stiff arteries in older pts or diabetes segmental BP using doppler US and sphygmomanometer at thigh, below knee, and ankle while supine drop in segmental BP of greater than 30mmHG suggest PAD

A pt w T2 spinal cord transection 24 hrs ago, which actions would be included in the plan of care? a urinary cath care b NGTF c continuous cardiac monitoring d maintain a warm temp e admin h2 receptor blocekers

ACDE problems w too early ngtf

<Outline the classification of spinal cord injuries and associated clinical manifestations.> Motor sensory asia impairment scale... MS (2) integ peripheral vasc VTE d/t (4) thermoreg greater rx w _ _, decreased ability to..., poikilothermia is.. metabolism increased ntnl needs bc (3) nociceptive vs neuropathic pain

ASIA impairment scale determines neuro level and completeness of injury, helps us identify rehab goals MS atony (flaccid state) contractures (spastic state) skin breakdown VTE d/t hypercoaguability, venous stasis, venous endothelial injury, immoilization hard to dx bc cannot feel pain/tenderness thermoreg poikilothermia: cannot maintain temp bc interruption of SNS prevents peripheral temp sensations from reaching hypothalamus decreased ability to sweat/shiver below level of injury depends on level of injury, greater rx w cervical metabolic increased ntnl needs d/t increased metabolism and protein breakdown and stress nociceptive: MS, visceral (thorax, abd, pelvis) or other pain, dull, aching, starts/worsens w movement neuropathic: occurs from damage to spine or nerves; hot, burning, tingling, pins/needles, cold,shooting, extremely sensitive to pain

What nonpharmacological comfort measures should the nurse include in the plan of care for a client w severe varicose veins? A admin pain meds B applying elastic stockings C elevated the legs when lying or sitting D remind the client to do leg exercises E teach the pt about surgical options

BCD

A pt w a known abd aortic aneurysm reports dizziness and severe abd pain. The nurse assesses the pts BP at 82/40mmHg. What actions by the nurse are most important? A admin anaglesics B assess distal pulse q3-5min C have the pt sign surgical consent D Notify rapid response E take VS q3-5min

BDE

911 management: if pt w a suspected dysrhythmia becomes symptomatic, intitiate rapid response CM integ (3) CV (5) neuro (3) resp (2) initial interventions (6) ongoing (4)

CM integ CC skin pallor diaphoresis CV palpitations hypo or hyperTN decreased peripheral pulses chest pain, also can present in neck, sholder, back, arm, or jaw irregular rate neuro syncope weakness/fatigue decreased LOC resp dyspnea decreased O2 interventions initial initial ABCs admin 02 baseline VS obtain 12 lead EKG & continuously monitor ID dysrythymia baseline labs (CBC, electrolytes) ongoing monitor ABCs, VS, LOC, 02, EKG anticipated need for antidysrhythmic drugs & analgesics anticipate need for intubation anticipated need for ACLS

<Describe the clinical manifestations, interprofessional care, and nursing management of the patient with PAD of the lower extremities.> Management goals adequate tissue perf pain relief increase exercise tolerance intact skin increased knowledge of dz & tx CVD rx factor modifcation tobacco cessation exercise (2) ntn (2) lab control (3) drugs (2) tx claudicaiton s/s by (2) drugs (2): cilostazole: class, MOA (2), d/c w/in..., contra pentoxifylline: class, MOA, whcih is more effective foot care: avoid _ btw toes and _ to prevent maceration cover ulcers w _ dsngs protect heels (2) may prevent pain and increase perf to LE surgery for revascularization: optimal: postop care: VS checks how often, assess for (6), do not perform _, compare findings w (2) interventional radiology catheter based procedures (4)

CVD rx factor modificaiton tobacco cessation regular exercise 30-45m/day 3xwk for 3mnths ideal body wt BMI <25 DASH diet glucose control if diabetes w Hb AIC monitoring BP control tx hyperlipidemia/hypertriglyceridemia statins fibric acid derivative (gemfibrozol [Lopid]) antiplatelets low dose ASA if no ASA, clopidogrel qd do no admin clopidogrel (plavix) w omeprazole (prilosec) [PPI] bc reduce effectivness of anticoagulant if high rx, combo w ASA and clopidogrel if distal peripheral bypass surgery warfarin (coumadin) not recommended for CVD prophylaxis in pts w PAD ACEIs reduce PAD s/s tx claudication s/s strucutred walking/exercise program drugs cilostazol phosphodieterase inhibitor inhibits platelet aggregation increases vasodilation d/c w/in 3 months d/t side effects contra in pts w HF pentoxifylline xanthine derivative improves flexibility of RBCs/WBCs and decreases fibrinogen concentration, platelet adhesiveness, blood viscosity not as affective as cilostazol foot care inspect, cleanse and lubricate avoid lubrication btw toes and soaking to prevent maceration cover ulcers w dry, sterile dressings protect heels analgesics and reverse trendelenburg may prevent control pain and increase perfusion to LE surgery for revascularization peripheral artery bypass w autogenous vein endarectomy (open artery and remove plaque) patch graft angioplasty post op q15 then hourly color, temp, cap refil, pulses, sensation, movement no ABIbc graft thrombosis compare findings w baseline and opposite limb SBAR: if pulses gone and temp cold, i suspect a clot, what do i recommend? interventional radiology catheter based procedures stents angioplasty balloons atherectomy (remove plaque) cryoplasty

You are caring for a 74-yr-old male patient who is recovering from left femoral-popliteal bypass graft surgery. When you respond to the patient's call bell, the patient reports severe pain in the operative leg. On assessment, you note that the dorsalis pedis and posterior tibial pulses are no longer palpable and the foot is cold to touch. • What are your next actions?

Suspected acute arterial occlusion, SBAR HCP & recommened 911 anticoagulation tx w unfractionated heparin (not LMWH) and 911 thrombectomy

3 c stop the IV for aPTT above baseline, this is what we want,

abd

What action does the nurse delegate to the UAP for DVT prevention? A apply compression stockings B assist w ambulation C encourage coughing and deep breathing D offer fluids frequently E teach leg exercises

abd

Which pts are at greatest rx for acute pericarditis? A 36yo woman w SLE B 42yo man recovering from coronary artery bypass graft surgery C 59yo woman recovering from a hysterectomy D an 80yo man w a bacterial infx of the resp tract E An 88yo man w stage 3 sacral ulcer

abd

Nurs planning care for pt w acute cervical SCI. According to best practice, which meds should we admin a BBs b abx c Vasopressors d H1 receptor antagonists e diuretics

bcde

A nurse cares for a client w lower motor neuro injury who experiencing a flaccid bowel elimination pattern. Which actions are best? a pour warm water over the perineum b high fiber diet c admin daily tap water enema d implement a consistent daily time for elimination e massage abd from lt to rt f perform manual disimpaction

bde

A pt has manifestations of autonomic dysrelfexia. Which are causes? a HTN b kinked cath tubing c resp wheezes and stridor d diarrhea e fecal impaction

be

The nurse caring for a client w Guillain barre syndrome has indentified the priority client problem of decreased mobility. Which actions by the nurse are best? a ask OT to help the client w ADLs b PT consult c info about support groups d refer pt to medical social worker or chaplain e work w dietitian to high-protein diet

be bill said no A cuz he crazy, he focusing on mobility

<Compare and contrast the clinical characteristics, interprofessional care and nursing management of patients with superficial vein thrombosis and VTE.> SVT CM (3) manage (4) dx do you always need anticoags or NSAIDS (2) DVT CM: what does unilateral leg look like, both legs, temp , dx(2) complications (4) posthrombotic syndrome (PTS) cause, patho, CM (4) phlegmasia cerulea dolens: what does the leg look like, caused by, complication

SVT CM palpable, firm, cordlike vein itchy, painful, reddened, warm mild temp or leukocytosis management dx w US (clot larger than 5cm) and rule out extension to DV if not small and not near aphenofemoral junction, maybe no neade anticoad and PO NSAIDs compression stockings warm compressess elevate limb above heart topical NSAIDs walking DVT CM unilateral leg edema, pain, tenderness, parethesia, warmth, erythema systemic temp >38C may be both legs edematous and cyanotic if inferior vena cava involved Dx w US and d-dimer complications PE chornic thromboembolic pulm HTN post-thrombotic syndrome from chronic inflam and venous HTN chronic venous HTN caused by vein wall and valve damage from acute inflam and thrombus reorganization, venous valve reflux, and persistent obstruction CM: lipodermatosclerosis (leathery brown skin, inverted bottle shape, lower leg scarring) , increase pigmentation, spider veins, venous ulcerations phlegmasia cerulea dolens swollen, blue, painful leg near-total occlusion of venous outflow sudden, massive sweling, cyaosis of extremitiy, deep pain if untreat can l/t amputation

<Outline the classification of spinal cord injuries and associated clinical manifestations.> Resp above C3 (4) at c4: (3) C5-t6: high cervical injury c3-c5 have resp insufficeincy d/t... if complete SCI above C5... paralysis of abd/intercostal muscles from C/Tinjuries can cause (4) cardiac affect if above _ d/t... (4) relative hypovolemia bc

above C3 - total loss of resp muscle fx, must be intubated or resp arrest, apnea, cannot cough C4: poor cough, diaphragmatic breathing, hypovent C5-T6: decreased resp reserve high cervical injury C3-c5 have resp insufficiency d/t loss of phrenic nerve innervation to diaphragm and decreased chest/abd muscle strength if complete SCI above C5, intubate 911 if incomplete SCI, variable resp fx cervical/thoracic injuries cause paralysis of abd/intercostal muscles: cannot cough effectively to remove secretions, ^rx of aspiraiton, atelectasis, and PNA above T6 l/t dysfx of SNS bradycardia, peripheral vasodilation, hypoTN (neurogenic shock), absence of vasomotor tone relative hypovolemia bc vasodilation-> reduce blood return-> reduced CO

A nurse assesses a client who experiences a spinal cord injury at the T5 lever 12hrs ago. Which manifestations should the nurse correlate w neurogenic shock? a HR of 34bpm b BP 185/65 c UO <30ml/hr d decreased LOC e increase O2 sat

acd

<Prioritize the key aspects of nursing management of the patient receiving anticoagulant therapy.> active VTE tx (3) anticoags initial warfarin therapetutic INR for at least _ thrombolytic (2) surgery (3) goals (2) decreased edema by pt teaching (5) no bleeding: assess for (8), avoid (2), admin _ , use _

active VTE anticoags initial anticoag tx w heparin or Factor Xa therapeutic INR btw 2.3-3.5 for at least 3 months if warfarin thrombolytic tPA catheter w med systemic anticoag needed throughout tx surgery if not elegibile for catheter tPA venous thrombectomy vena cava interuption (sieve) goals pain relief decreased edema early ambulation unless active pt teaching report black/bloody stools, bleeding gums, bloody urine, excessive brusing, nosebleeds no skin ulceration no bleeding assess for hypoTN, tachycardia, hematuria, mela, hemateemsis, petechia, brusing assess mental status for cerebral bleeding avoid IM and venipunctures use paper tape stool softeners no PR

<Differentiate the pathophysiology, clinical manifestations, interprofessional care, and nursing management of patients with different types of aortic aneurysms.> Define rx (6) CVD rx (5) etio and patho majority occur as ___ (location) usually (4) classification true, define fusiform (2) saccular (2) false, define, can be caused by (2) CM TAAs when present, describe pain ascending aorta and aortic arch aneurysms can cause (3) if pressure on superior vena cava (2) AAAs pulsatile mass ... bruits compresion of nearby strucutres/nerves can cause (5)

aneurysm is a permanent, localazied outpuching or dilation of vessel wall rx men white incidence increases w age CV high cholesterol PAD, CAD HTN stroke hx obesity family hx tobacco use* marfans syndrome etio and patho majority occur in abd aorta (AAAs) below renal areries usually caused by degenerative, congential, mechanical trauma, or infections classifications true aneurysm wall of artery forms aneurysm w at least 1 vessel layer still intact fusiform aneurysm circumferential uniform shape saccular aneursym pouchlike narrow neck false/pseudoaneurysm disruption of all arterial wall layers w bleeding contained by surrounding anatomic structures can be caused by peripheral artery bypass graft surgery @site of anastamosis or arterial leakage of cannulae CM thoracic aortic aneurysms TAAs often asymtpomatic when present, deep, diffuse chest pain raidaition to scapulae ascending aorta & aortic arch aneuysms can cuase anginga from decreased BF to coronaries transient ischemic attacks (TiAs) from decreased BF to carotid coughing, SOB, hoardness or dysphagia from pressure on laryngeal nerve if pressure on superior vena cava JVD and facial edema AAAs usually asymptomatic pulsatile mass in periumbiclical area lt to midline bruits compression of nearby structures/nerves pain of abd or back epigastric pain altered bowel fx intermittent claudication blue toe syndrome

A pt recovering from prosthetic valve surgery asks why they need to take anticoagulants the rest of their life.. A The prosthetic valve places you at greater rx for MI B Blood clots form more easily in artificial replacement valves C The vein taken from your leg reduces circulation in the leg D the surgery left a lot of small clots in your heart and lungs

b

After mitral valve replacement surgery, which statement indicates a need for additional teaching A I'll be able to carry heavy loads after 6 months of rest B i will have my teeth cleaned by dentist in 2 weeks C I must avoid eating foods high in vit K, like spinach D i must use an electric razor instead of a straight razor

b avoid dentist for 6 months

Pt w a halo fixator. Which interventions should the nurse include in plan of care? a tape a halo wrench to the vest b assess the pin sites for infx c loosen pins while sleeping d decrease the fluid intake e assess the chest abd back for skin brkdwn

a to take em off if CPR be

<Describe the pathophysiology, clinical manifestations, interprofessional care, and nursing management of the patient with aortic dissection.> Aortic dissection classification based on location and duration of onset Type A affects (2), (acute/conservative) Type B affects _, (acute/conservative) acute: subacute chronic etio/patho nontraumatic dissection caused by _ and worsened by _ biggest rx, gender rx, other is (6) CM type A: pain (2) type B: pain in (3) pain characteristics (3) dissection pain is more if aortic arch involved, (4) pulse and BP may differ btw _ complications (2) and tamponade tamponade; beck triad w pulse pressures (2) manage activity _ analgesics drugs (4) surgical repair (2) preop HOB quiet environment, analgesia, and sedatives to keep... when titrating IV antiHTN continous monitoring (2) VS q_ assess (3) pt teaching antiHTN drugs qd for life (3) _

classifed based on location and duration of onset Type a dissection affects ascedning aorta and arch, 911 type B begins in descending aorta potential conservative management acute first 14 days subacute 14-90 days chronic greater than 90 days etio and patho nontraumatic aoritc dissection caused by weakned elastic fibers of artery chronic HTN hastens process each pulsation increases pressure and worsens dissection rx men women who get dissection are older, have HF, coma, or altered mental HTN* age, aortix dz, athererscleoris, tobacco, drug use, congenital dz, pregnancy, family hx CM acute type A aortic dissection 80% severe anterior chest or back pain type B aortic dissection more likely to report pain in back, abd or legs pain is sharp, tearing, stabbing, ripping disection pain vs MI Mi pain is more gradual in onset and increasing in intesitiy if aortic arch involed neuro deficitys altered LOC weak carotid/temporal pulses dizziness or syncope pulse and BP may differ btw arms complications cardiac tamponade blood leaks into pericardial sac s/s becks triad:hypoTN, muffled heart sounds, JVD narrowed pulse pressure & pulsus paradoxus aortic rupture spinal, renal, abd ischemia manage BR opioid analgesics drug tx IV BBs IV CCBs blood transfusion ACEIs surgical endovascular aortic dissection repair open surgical repair preop semifowlers quiet room to keep HR and SBP as low as possible admin analgesics and sedatives as ordered manage pain & anxiety titrate IV antiHTN continuous ECG and art BP VS q3min until target HR and BP reached assess changes in pulse and s/s of increasing pain, restlessness, anxiety post op care similar to after OAR pt teaching antiHTN drugs qd for rest of life BB to control HR, BP, decrease contractility ACEI if cannot tolerate BBs side effects: dizziness, fatigue, ED f/up MRI/CT essential to prevent redissection

<Differentiate the pathophysiology, clinical manifestations, interprofessional care, and nursing management of patients with different types of aortic aneurysms.> Complications grey turner sign rupture is most serious increase w _ use if rupture in periotoneal... if rupture in thoracic or abd.. tx w simultaneous (2) dx (6) manage by preventing rupture small, asymptomatic AAAs rx modifification (4) controlle dby drugs (3) if larger than 5.5cm-> surgery preop interventions (5) open aneurysm repair (OAR) vs endovascualr repair (EVAR) EVAR eligibility postop ICU duration ICU interventions (6) assessments cardiac (5) infx (3) vte gi (6) ng TUBE (2) check graft patency (2) neuro (2) peripheral perf (2) renal perf (5) ambulatory (2) postop complications EVAR better bc (2) endoleak aneurysms post graft prevnetions intrabd hypertn (IAH) l/t abd compartment syndrome (2)

complications rupture is most serious increased rx w tobacco use if rupture in pertioneal, bleeding maybe controlled by surrounding structure if rupture in thoracic or abd, massive hemorrhage can occur hypovolemic shock hypoTN tachycardia pale, clammy skin decrease UO altered LOC abd tenderness simultaenous resuscitation and 911 surgery grey turner sign back or flank ecchymosis dx CXR and abdXR may show calclification of aorta EKG rule out MI since angina can occur echo angio CT MRI small, asymptomatic AAAs rx factor modification tobacco cessation decrease BP optimize lipids exercise controlled by drugs maybe statin or ACEi or antidiabetics if indicated preop nursing interventions bowel prep chlorhex bath NPO prophylactic abx if CVD, admin BB assess for cardiac continuous ECG and pulse ox FE monitor w ABGs 02 admin IV antidysrhythmics & antiHTN ischemia, dysrhythmias, infx prostehtic vascular graft infx assess temp, WBC, and surgical site incistion dsngs CDI VTE GI postop ileus bc anesthesia and handling of bowel function expected to fully return by day 4 postop may be swollen or brusied intermittne persitalsis assess bowel sounds q4hrs bowel infarction may occur NG tube record amt and character of NG output low, intermittent sxn to decmpress stomach, prevent aspiration and decrease pressure on suture lines check graft patency adequate BP needed, prolonged hypoTB l.t graft thrombosis** give IVF and blood prn to maintain BF neuro may need LP to drain excess CSF full neuro assess periperhal perfusion LE pulses may be absent transiently bc vasospasms and hypothermia assess for graft occlusion by a decrease pulse, cool/pale/mottled/painful extremitiy renal perfusion CVP, PA pressure and UO hourly daily BUN and CR CVP (hydration status) IOs daily wts ambulatory avoid lifting for 6wks postop urologist referral if ED EVAR elgibiltiy iliofemoral vessels for safe graft insertioni and large enough vessels to support graft, angiography afterwards complications EVAR is less invasive than OAR and shorter hospitalization, fewer complications endoleak seepage of blood into old aneruysm aneurysm below or above graft prevent w periodic imaging intraabd hyperTN (IAH) w abd compartment syndrome persistent IAH reduces blood flow to viscera impaired organ perfusion from IAH->multisystem organ failure function expected to fully return by day 4 postop

<Describe the clinical manifestations, interprofessional care, and nursing management of the patient with PAD of the lower extremities.> Complications _ progression and prolonged ischemia l/t (2) minor foot trauma -> (3) arterial (ischemic) ulcers usually over _ _ (3) most serious (2) amputation if (2) Care of the leg w CLI (chronic leg ischemia) (3)

complications slow progression prolonged ischemia l/t atrophy of skin and muscles minor foot trauma-> delayed healing, infx, necrosis arterial (ischemic) ulcers usually over bony prominences (toes, feet, lower legs) most serious gangrene may be prevented by collateral circ nonhealing arterial ulcers amputation if inadequate BF or severe infx care of the leg w CLI optimal is revascularization w bypass surgery using an autogenous vein alternative; percutatneous transluminal angioplasty prostanoids if not surgical candidates

A pt w SCi who is quadriplegic w a severe HA. BP of 210/108. Suspects AD, what is the first nursing action? a admin a nitrate antiHTN b assess pt for bladder distension c place pt in high fowlers d obtain client in HR

d bc decrease BP, admin before antiHTN med bc could change BP too much and go hypoTN

<Relate the pathophysiology and clinical manifestations to the interprofessional care, drug therapy, and interventional/surgical therapies of patients with varicose veins, chronic venous insufficiency, and venous leg ulcers> Varicose veins define types (5) define path of primary (3) dx gold standard tx (3) drugs surgery if recurrent (2) manage (3) Chronic Venous Insufficiency (CVI) & venous leg ulcers etio (2) patho (3) CM CVI (3) CM ulcers (4) manage compression stockings/bandages replaced q_ assess for _ via_ pt teaching (4) ntn (4) assess infx and admin or tx w (3)

dilated superficial veins types primary d/t weak venous walls valve rings enlarge, leaflets cannot fit together and are incompetent-> regurg especially when stadning secondary direct injury, previous VTE, vein distension congenital reticular telangiectasis spider veins etio/patho dilated in response to retrograde (backward BF) and increased venous pressure rest w leg elevation leg strengthening exercises, walking compression stockings drugs venoactive drugs from plants are antioxidants that stimulate release of chemicals w/in veins to strengthen circ, reduce inflam and edema surgery sclerotherapy sclerosing substance that destroys injected veins after, compression stocking or bandage is worn transcutaneous laser therapy if sclerotherapy contra or ineffective needed if recurrent superficial venous thrombosis management prevention avoid sitting or standing longer periods elevate legs 15 degrees to limit edema after vein ligation surgery periodic position of legs above heart etio/patho primary varicose veins and PTS can progress to CVI amulatory venous HTN causes serous fluid and RBCs to leak into tissue-> edema and chornic inflam enzymes in tissue break down RBCs-> hemosiderin release-> brownish skin discoloration fibrous tissue replace subq tissue around ankle-> thick, hard, contracted skin CM leathery, brown lower leg from hemosiderin edema eczema w itching and scratching venous ulcers caused by CVI classically above medial malleolus painful, worse in dependent position infx rx management compression for venous ulcer healing stockings or bandages wear daily and replace q4-6months assess arterial status to ensure PAD not present (ABI) pt teaching avoid sit/stand long periods and frequently elevate above heart daily walking once ulcer heals leg & foot care moist dressings ntn high protein, vit A and vit C and zinc assess infx pentoxifylline or Daflon w compression tx to improve healing skin graft if no response w/in 4-6 weeks Subtopic 10

<Differentiate the pathophysiology, clinical manifestations, and nursing and interprofessional management of the patient with thromboangiitis obliterans (Buerger's disease) and Raynaud's phenomenon. Raynauds phenomenon define rx (5) patho dx based on persistent s/s for _ and routine f/u for _ s/s vasospasm induced color (3) changes of (4) s/s of vasocontrictive phase (3) s/s of hyperemic phase duration integ (4) pt teaching (4) tx first line, MOA second line, whcih can be taken concurently 911 interventions if digital ulcerations or critical ischemia (4) (2) meds may lessen severity _ only in severe refractory cases where digit survival is compromised

episodic vasospasic d/o of small arteries, usually fingers & toes rx women 15-40yo vibrating machinery work in cold environments exposure to heavy metals high homocysteine patho d/t abnml vasc/neuronal mechanisms that cause vasodilation may occur in isolation (primary raynauds) or w an underlying dz (thyroid, lupus) (secondary raynauds) dx based on persistent s/s for at least 2 years routine follow-up to monitor for development of connective tissue or autoimmune dzs s/s vasospasm-induced color changes of fingers, toes, ears, nose (white, blue, red) vasoconstrictive phase decreased perfusion-> pallor coldness, numbess in digits appear cyanotic (bluish purple) hyperemic phase changes followed by rubor when BF restored usually lasts a minute, but can last several hours can be triggered by exposure to cold, emotional upset, tobacco use, caffeine integ skin thickened brittle nails punctate (small hole) lessions and fingertips superficial gangrenous ulcers pt teaching focus on preventing episodes avoid temp extremes, wear warm clothes avoid tobacco, caffeine, and other substances w vasocontrictive effects stress management immersion in warm water decreases vasospasm tx sustained-release CCBs first line nifedipine(procardia) relax smooth muscles of arterioles by blocking influx of Ca into cells-> reduces frequency and severity of vasospastic attacks if s/s persists after CCBs, try other vasodilators phosphodiesterase-5 inhbitors [sildeanfil] top NTG ointment CCBs can be taken w NtG ointment, but not w sildeanifil bc hypoTN 911 interventions if difital ulcerations or critical ischemia prostaclyclin infusion abx analgesics surgical debridement of necrotic tissue botulinum toxin A and statins may lessen severity sympathectomy only in sever cases refractory to medical treatment where digit survival is threatened

A pt being discharged on warfarin d/c instructions A dietary counseling B driving instructions C follow-up laboratory monitoring D possible drug interactions E reason to take meds

everything but b

ALS s/s can occur as a urinary incontinence b difficult speech c Vasopressors d limb weakness e muscle wasting

everything?

<Describe the clinical manifestations, interprofessional care, and nursing management of the patient with PAD of the lower extremities.> Affect affect (6- iliac, femoral, politeal, tibial, peroneal arteries); _ _ most common in non diabetic pts, diabetics pts develop PAD _ classification of arterial d/os: (3) atherosclerotic d/o can occur in (5- coronary, cerebral, peripheral, mesenteric, renal artery dz) CM severity depends on (3) classic s/s : _ define caused by resolved by occurs in butt/thighs-> PAD of _ occurs in calf-> PAD of (2) 1/3 of pts w classic s/s, others asymptomatic or atypical atypical s/s in atypical locations (6) s/s (6) locations paresthesia in toes/feet from _ _ true peripheral neuropathy occurs in pts w (2) describe neuropathic pain (2) pt may not notice LE injury d/t... appearance skin (3) nails hair pulses _ pallor/blanching _ _ d/t reactive hyperemia (redness of foot) _ _ as PAD progresses, usually in fingers or toes and worsen w elevation occurs when... more often at night bc... (2) relieved by critical limb ischemia chronic rest pain lasting _, (2) rx (3)

femoral & popliteal, below the knee, atherosclerotic, nonatherosclerotic, aneurysmal site, blockage % and collateral circulation classic s/s: intermittent claudication ischemic muscle pain caused by exercise d/t buildup of lactice acid from anaerobic meta resolves w/in 10 minutes of rest claudication in butt/thighs-> PAD of iliac claudication in calf-> PAD of popliteal or femoral parethesia in toes/feet from nerve ischemia true peripheral neuropathy in pts w diabetes & long term ischemia neuropathy causes severe shooting or burning pain in extremity pt may not notice lower extremitiy injury d/t loss of sensation appearance skin shiny, thin, taut thick nails lower legs lose hair pulses decreased or absent elevation pallor/blanching dependent rubor d/t reactive hyperemia (redness of foot) rest pain as PAD progressess usually in fingers or toes, worse w elevation occurs when BF insufficient to meet meta requirements of distal tissues more often at night bc CO drops during sleep and limbs at level of heart relieved by dangling critical limb ischmia (CLI) chronic ischemic rest pain lasting >2wks, nonhealing arterial leg ulcers, gangrene of leg rx: diabetes, HF, stroke hx

<Describe the nursing management of the patient with a spinal cord injury.> fluid/ntn during firs 48-72hrs... start ntn w/in... what kind of diet swallow eval when ..., if fails... _ is common bc boredom/depression/discomfort how many servings of dairy, meat, veggies/fruits, bread/cereal, g of fiber, l of fluid bladder/bowel urine retention immediately post injury d/t... no sensation of fullness l/t... CIC q_ and keep residuals _ minimize _ and create a plan for continence admin _ to suppress contratciton or _ to relax sphincter bowel regimen (4) _ _ if injury below t12 when to evacuate temp control (2) stress ulcers check (3) and admin (2)

fluid/ntn during first 48-72hrs, GI tract may stop fx (paralytic ileus) if this occurs, insert NG tube start ntn w/in 72hrs high protein, high calorie diet bc severe catabolism swallow evaluation once bowels sounds present/flatus is passed, if fails, start g/jtube anorexia common d/t depression, boredom or discomfort 4 meals, 2servings dairy, 2+meant, 4+veggies/fruits, 4+bread/cereal, 20-30g fiber, 2-3L fluid bladder and bowel urine retention 911 post injury d/t neurogenic bladder, no sensation of fullness-> renal reflux or rupture -> may admin foley CIC (clean intermittent catheterization) q4-6hr to prevent bacteral growth from urinary stasis keep residuals under 500 mL to prevent distension stones, anticholinergics and alpha adrenergics bowel regimen suppos or small volume enema qd at a regular time w gentle digital stimulation or manual evacuation move to bedside commode ASAP valsalva,fluid/ntn during first 48-72hrs, GI tract may stop fx (paralytic ileus) if this occurs, insert NG tube start ntn w/in 72hrs high protein, high calorie diet bc severe catabolism swallow evaluation once bowels sounds present/flatus is passed, if fails, start g/jtube anorexia common d/t depression, boredom or discomfort 4 meals, 2servings dairy, 2+meant, 4+veggies/fruits, 4+bread/cereal, 20-30g fiber, 2-3L fluid bladder and bowel urine retention 911 post injury d/t neurogenic bladder, no sensation of fullness-> renal reflux or rupture -> may admin foley CIC (clean intermittent catheterization) q4-6hr to prevent bacteral growth from urinary stasis keep residuals under 500 mL to prevent distension bowel regimen suppos or small volume enema qd at a regular time w gentle digital stimulation or manual evacuation move to bedside commode ASAP

<Describe the nursing management of the patient with a spinal cord injury.> Goals (4) immobilization (3) halo vest care (5) benefits: contra (4)

goals optimal neuro fx minimal mobility complications learn self care return home at an optimal level of fx immobilization logroll infx at pins clean BID w chlorohexidine traction HCP may start w 10lbs and go up w 5lbs monitor w xray and neuro/pain assess halo vest pt can move while cervical bones fuse contra: instead of severe deformity, ligament instability, morbidly obese, or noncompliant apply abx ointment as ordered for skin care, have pt rest head on pillow, loosen 1 side of the best and clean mark buckling to ensure consistency sheepskin pad under vest cotton tshirt under if itching

<Describe the nursing management of the patient with a spinal cord injury.> Relflexes (3) pain MS noiceptive worse w (2) admin (2) visceral nocicpetive (4) neuropathic pain (3) sex 2 kinds of erections meds first line if t6-l5: vacuum sxn... constriction band how it affects fertility grief

pain management MS nocicpetive pain worse w movement or plpation admin antiinflam or opioids visceral nociceptive pain dull, tender, cramping in thorax/abd/pelvis can be from bladder or bowel, assess for distension neuorpathic pain initially at level of SCI w/in affected dermatome and up to 3levels below admin pregabalin (lyrica) can occur for years after SCI sex 2 erections psychogenic sex thoughts through t10-L2, low level incomplete injuries are more likely to have these erections reflex direct contact w stimulation if s2-s4 pathways damaged phosphodiesterase inhibitors sildenafil (viagra) first lineif t6-l5 penile injection vacuum suction use negative pressure to encourage blood blow constriction band at base of penis affects male fertility, poor sperm and ejac dysfx grief adjustment> acceptance

Neuro damage by SCI occurs in 2 phases: primary: _ _ of the cord by _ _ _ such as _ or _ -> _ _ _ secondary is ongoing and progressive occurs from (4) results in (3) seconds after primary injury, mechanical disruption l/t ... BBB disruption-> hypoxia of spinal cordd increases release of (2) and causes _ l/t _ (programmed cell death) for weeks -> _ _ describe a glial scar and its affects

initial disruption, direct physical trauma, blunt, penetration, spinal cord compression primary initial disruption of the spinal cord direct physical trauma d/t blunt or penetration spinal cord compression secondary fromo ischemia, hypoxia, hemorrhage and edema ongoing, progressive result in cell death, BBB disruption and demyelination seconds after primary injury, mechanical disruption l/t small hemorrhage in white/gray matter-> axon damage, cell membrane disruption BBB disruption-> influx of inflam CK-> ^ spinal cord edema; very harmful bc limited space l/t ^ spinal cord compression-> ischemic damage hypoxia of spinal cord ^lactate and vasoactive substances (NE, serotonin, dopamine)-> vasospasms -> necrosis bc spinal cord cannot adapt to vasospasm apoptosis (programmed cell death) for weeks-> postinjury dyemlination inflam response at initial site of injury clears initial cellular debris -> central non-neural core of connective tissue -> glial scar-> creates a physical barrier, restricts cells in spinal crod from regeneration-> irreversible nerve damage and perm neuro defecit

<Describe the nursing management of the patient with a spinal cord injury.> Drug tx of SCI tx of methylprednisolone _ w/in 72hrs, except if compromised kidney fx admin _, and continue for... vasopressors, (phynelphrine/dopamine)

methylprednisolone is mixed, maybe 24hr high dose w/in 8hrs of acute SCI LMWH (enoxaparin) w/in 72hrs if kidney fx, admin heparin bc LMWH excretion primarily renal, 3 months post injury vasopressors: good MAP maintains spinal perfusion ocmplicaitons: Vtachy, afib, meta acid, troponin elevation phenylephrine less complciations than dopamine in SCI

<Outline the classification of spinal cord injuries and associated clinical manifestations.> urinary neurogenic bladder is... early stage late stage if above t_ lack of coordination btw _ and _... decreased Gi activity (2) delayed _ excessive _ l/t _ _ _ intrabd bleeding hard to dx bc no pain, assess for (2) paralytic ileus if injury above _ neurogenic bowel hyperreflexic: SCI above _ _ (3) areflexic: sci below_, (3) l/t (3)

neurogenic bladder: bladder dysfx r/t abnml bladder innervation 1) have no relfex detrusor contractions at early stages (flaccid, hypotonic) 2) hyperactive reflex detrusor contractions at late stages (spastic) SCI above t12 3) lack of coordination btw detrusor contraction and urethral relaxation (dyssynergia) -> reflux of urine into kidneys decrease GI activity-> distension and paralytic ileus (above t5) delayed emptying excessive Hcl-> stress ulcers dysphagia intrabd bleeding may be hard to dx bc no pain/tenderness, so assess for hypoTN or decreases in HnH neurogenic bowel: loss of voluntary control hyperreflexic: SCI above conus medullaris, increased rectal/sigmoid compliance, ^spinctal tone and inability to sense full rectum-> retention & constipation areflexic: SCI below conus medullaris, slow movement bc peristalsis impaired, damaged defecation relfex and releaxed anal tone l/t constipation, ^rx for incontinence, impaction, megacolon

When assessing a pt w infective endocarditis, what assessment should you expect? A wt gain B night sweats C cardiac murmur D abd bloating E oslers nodes

night sweats, cardiac murmur, and oslers nodes

<Differentiate the pathophysiology, clinical manifestations, and nursing and interprofessional management of the patient with thromboangiitis obliterans (Buerger's disease) and Raynaud's phenomenon.> Buerger's dz define (3) d/o of small/medium veins/arteries (very rarely are large vessels involved) rx (2) patho acute phase (2) chronic (2) l/t tissue ischemia s/s often confused w PAD (5) over time, (20 may develop) management cessation of (2) contra avoid if infected ulcers, _ exercise analgesia IV iloprost class and MOA (3) surgery (4)

nonatherosclerotic, segmental, recurrent inflam d/o of small/medium veins/arteries rx men <45yo hx tobacco/marijuana use patho acute phase inflam thrombus blockage over time, thrombus becomes organized and inflam in vessel subsides chronic thrombosis and fibrosis l/t tissue ischemia s/s often confused w PAD may have intermittent claudicaiton color/temp changes of limbs parethesia superficial vein thrombosis over time, rest pain and ischemic ulcerations develop cold sensitivity manage complete cessation of tobacco and marijuana in any form nicotine replacement product use is contra avoid cold temp exposure supervised walking program abx for infected ulcers analgesics to manage ischmic pain IV iloprost (ventavis) prostaglandin that promotes vasodilation manages rest pain promote ulcer healing decrease need from amputaiton surgery painful ulcers may require foot/toe amputations lumbar sympatecteomy (transection of SNS) spinal cord stimulator implant stem cell tx promot ulcer healing, angiogensis, nerve cell regen improve distal BF, reduce pain, decrease amputation rate, but neither alters inflam process

Approach to Assessing Heart Rhythm P wave (5) PR interval (2) QRS (2) ST QT T

p wave upright or inverted is there one for ea QRS is afib or a flutter present atrial reguarity atrial rate PR interval is there prolonged duration is duration consistent QRS complex ventricular rhythm/rate is there prolonged duration ST segment is it flat, elevated or depressed QT interval measure duration T wave upright or inverted

Interprofessional Management of SCI prehospital (3) acute hx (3) MAP, Sa02 asia tool: neuro/sensory exam: internal trauma indicated by rapid (2) check urine for _ nonoperative stabilization (2) early surgery w/in _: (2) rehab PT/OT (2) speech therapy (2) (2) management (2) training prevent (2)

prehospital A airway, B adequate ventilation, C circulation immobilize spine to prevent secondary injury w rigid cervical collar and supportive backboard systemic/neurogenic shock tx w IVF and vasopressors to maintain SBP>90mmHg acute hx, emphasize how injury occurred, review ERS and ED assessments MAP >85 and Sa02 >92% ASIA tool: muscle groups tested w/against gravity, alone/against resistance on both sides of the body; record strength, symmetry and spontaneous movement neuro: LOC, concussion, ICP; sensory exam w pinprick internal trauma indicated by rapid hypoTN and ^HR hematuria nonoperative stabilization traction, realignment early surgery w/in 24hrs decompress spinal cord fixation: atttach metal screws/plates to spine rehab PT,OT: ROM, ADLs speech therapy (swallow, cognition) pain/spascitiy management bladder/bowel training prevent autonomic dysrelfection prevent pressure injury

<Prioritize the key aspects of nursing management of the patient receiving anticoagulant therapy.> Prevention movement (4) is anticoag recommedned if low rx w minor surgery compression devices (2) dx blood test (5) imaging (2) drug class (3) VKA ex INR how often, normal, therapeutic level when to admin onset, peak, overlap of parenteral coag antidote diet interactions (2) indirect thrombin inhibitors enoxaparin (LMWH) lab tests needed (2) admin caution antidote UH lab tests needed (3) normal & therapeutic aPTT comlications (2) antidote factor Xa inhibitors ex (2) lab tests needed (2) complicaiton contra antidote

prevent early ambulation turn q2hr flex and extend feet, knees, hips if can, chair for meals and walk 4-6 qd anticoag not recmmened if acutely ill w low rx of VTE (minor surgery) compression stockings: no wrinkles to avoid impeding venous return, contra if already have VTE intermittent compression devices: contra if active VTE dx leukocytosis anemia, ^hct or RBC ^d dimer psotive venous compression on duplex YS positive venogram vit K antagoinsts (VKAs) warfarin admin same time ea day antidote: Vit K; admin w prothrombin concentrate and FFP onset: 48-72hrs peak: a few days overlap of parenteral anticoag required 5 days INR qd reports PT normal 0.75-1.25 therapeutic 2.5-3.5 consistent vit K intake drug interactions NSAIDs black cohosh, chamomile, feverfew, garlic, ginger, ginko bilobab, ginseng, soy, saw palmetto, fish oil, Bactrim thrombin inhibitors indirect enoxaparin (LMWH) CBC regularly no regu anticoag monitoring needed do not expel air bubble form syringe reduce dose if renal impaired antidote: protamine unfractionated heparin (UH) measure aPTT, CBC, ACT regularly aPTT normal 30-40s aPTT therapeutic: 46-70s complications of heparin HIT: immune reactions w sudden reduction in platelet count osteoporosis antidote: protamine factor Xa inhibitors (apixaban[eliquis] or rivaroxaban [xarelto]) CBC and Cr regularly no reg anticoag monitoring needed may cause thrombocytopenia antidote: andexenate alfa (andexxa) contra: renal dz

<Distinguish the clinical characteristics and ECG patterns of normal sinus rhythm, common dysrhythmias, and pacemaker rhythms.> Describe waveforms that represent repolarization/depolarization repolarization: (contract/fill) (systole/diastole), describe movement of ions, main ion & charge, which wave determines ventricular repolarization, which wave depolarization: (contract/fill) (systole/diastole)

repolarization heart fills during diastole K is in, inside of cell is negative slower movement of ions across the semipermeable membrane of heart cell restores cell to polarized state ventricular repolarization: T wave atrial repolarization: unk, occurs during QRS heart contracts sodium moves in rapidly, making inside positive ventricular depolarization: QRS atrial depolarization: P wave

<Describe the nursing management of the patient with a spinal cord injury.> Resp dysfx first 48hrs, bc of spinal cord edema... injury at C4... clear secretions w (3) assess (6) CV instability bradycardia bc... and can cause..., if symptmatic brady, admin _ loss of SNS tone in peripheral vessels (4) _ orthostatic hypoTN likely at _ and can cause _

resp dysfx first 48hrs, spinal cord edema may cause resp distress injury at C4 can affect phrenic nerve (diaphragm) and stop breathing assess breath soiunds and patterns abgs Vt vital capacity skin color sputum clear secretions w sxn, chest physio, augmented coughing CV instability HR slowed bc unopposed vagal response, any vagal response like turning/sxn can cause cardiac arrest loss of SNS tone in peripheral vessels-> chronic hypoTN w orthostatic, sluggish BF l/t VTE-> use compression stockings and abd binder to promote venous return dysrhtmias if symptomatic bradycardia, admin anticholinergic like atropine orthostatic hypotn likely at t6, can lose consciousness

Draw the patho: Cascade of metabolic and cellular events that leads to spinal cord ischemia and hypoxia of secondary injury

see pic

<Describe the clinical manifestations and interprofessional and nursing management of neurogenic and spinal shock.> Spinal shock can occur shortly after characterized by (2) relfeces and (2) below level of injury, often masks _ _ _ neruogenic shock occurs in.. caused by ... l/t (3) CM then (5) CM

spinal shock cann occur shortly after acute SCI DTR and spincter reflexes, loss of sensation, flaccid paralysis below level of injury often masks postinjury neuro fx neurogenic/vasogenic shock occur in cervical or high thoracic (T6 or higher) occurs from unopposed PSNS response d/t loss of SNS innervation l/t peripheral vasodilation, venous pooling, decreased CO -> significant hypoTN (<90mmHg) bradycardia, temp dysreg-> poor perf and oxy to cord and worsen ischemia

<Describe the nursing management of the patient with a spinal cord injury.> autonomic dysreflexia if injury at _ or higher define patho: (3) common cause, also by manifestations CV (3) integ (2) neuro (4) interventions (3)

t6 or higher 911 massive, uncompensated CV reaction by SNS stimulation of sensory receptors below SCI, reflex arteriolar vasoconstriction ^BP PSNS cannot counteract responses via injured spinal cord barorepcetors in carotid/aorta sense HTN and stimulate PSNS-> decrease in HR, vessels cannot dilate bc spinal injury common cause: distended bladder/rectum, also by skin stimulation or pain manifestations HTN, bradycardia, piloerection, marked diaphoresis above level of injury, flushing of skin blurry vision, nasal congestion, anxiety, HA SBPcan be 20-40mmHg above baseline interventions raise HOB 45 degrees to lower BP determine cause, maybe 911 catheterization to relieve distension if 911 stool evac, apply anestethic ointment, rectal exam, may admin antiHTN rapid (NTG, hydralazine)

<Evaluate the risk factors predisposing patients to the development of superficial vein thrombosis and venous thromboembolism (VTE)> SVT is usually in (2) and indicate DVT most often occurs (2) describe virchows triad venous stasis dysfx valve (2) inactive (3) endothelial damage (4) patho hypercoaguability (5)

thrombus w vein inflam, most common d/o superficial vein thrombosis usually in greater or lesser saphenous vein nearly 25% w superficial thrombosis have a DVT or PE at time of dx DVT most often in iliac and/or femoral veins VTE represents spectrum from DVT to PE virchows triad venous stasis dysfx valves chronic HF afib inactive obese pregnant immobile damage to endothelium direct or indirect trauma IV drug abse surgery fractures caustic/hypertonic IV drugs stimulates platelet activation and coagulation cascade-> thrombus development hypercoaguability of blood rx smoking CA anemia sepsis contraceptive PO local platelet aggregation and fibrin trap blood cells->thrombus, often in valve cusps