Block 2 FINAL EXAM ALL CARDS

Creatinine Normal Range

0.5-1.5 mg/dL **1.5 is the very high end of normal**

Primary defenses Against Infection

Anatomical features, limit pathogen entry ・Intact skin ・Mucous membranes ・Normal flora in GI tract ・Normal flora in urinary tract Mechanical Clearance ・Tears, coughing, vomiting, urination, defecation

Hemolytic Anemia

Anemia caused by the destruction of red blood cells

What is the mechanism of action for furosemide (Lasix)?

Blocks reabsorption of sodium, chloride, and water from the Loop of Henle and distal renal tubules in the kidney, resulting in diuresis and mobilization of excess fluid (edema) leading to decreased BP. ◆ K+, Mg+, and Ca++ may also be excreted

Hemothorax

Blood in the plural space

Neoplasia

Definition ❖ New growth which is uncontrolled, spreads, invasive ❖ > 200 known kinds

What is an infiltration?

Discharge or escape of non-vesicant solution or medication into the surrounding tissues as a result of cannula dislodgment which causes: ◆ Delay of fluid & drug absorption ◆ Limits veins available ◆ Predisposes patient to infection

What are some nursing diagnoses for COPD?

❖ Ineffective airway clearance ❖ Impaired gas exchange ❖ Imbalanced nutrition, less than body requirements Malnourished. The pt. cannot eat enough for the energy they need. ❖ Insomnia Can't lay down to sleep ❖ Risk for infection Due to collapsed cilia

Epinephrine

・Non-selective adrenergic agonist

Isovolumetric Contraction

- During early ventricular systole - Ventricles contract with NO volume change - All heart valves closed

Therapeautic PTT Range

1.5-2.5 times the control (90-175 seconds)

Therapeutic INR Range

2-3 or 2.5-3.5 (if patient has mechanical heart valve)

Isovolumetric Relaxation

- During early ventricular diastole - Ventricles RELAX with no volume change - All heart valves closed

Digoxin (Lanoxin) Mechanism of Action

**SLOWS HEART DOWN SO IT HAS TIME TO FILL WITH BLOOD AND INCREASE FORCE OF CONTRACTION** the 3 effects on heart muscle: 1. positive inotropic= increases myocardial contraction 2. negative chronotropic = decrease heart rate (allow for fill time) 3. negative dromotropic = decreased conduction of heart cells ∙ Boosts intracellular calcium and enhances movement of calcium into myocardial cells. This enables stronger heart contractions. ∙ Acts on the CNS to slow the heart rate ∙ Increases the refractory period when cells cannot conduct an impulse

Giving/Holding Meds Before Surgery

*Refer to handout* Drugs to GIVE ❖ Always clarify with MD 1st Typically safe to give: ❖ Anticonvulsants ❖ Antibiotics ❖ Antihypertensives Beta Blockers, CCBs ❖ Narcotics Drugs to HOLD ❖ 7 days before surgery: Plavix, herbs, aspirin ❖ 5 days before: Coumadin (Warfarin) ❖ 3 days before: NSAIDS ❖ 1 day before: Lovenox ❖ Day of surgery: Diuretics, oral hypglycemics, metformin, MAOIs

Myocardial Conducting Cells

*aka Autorhythmic Cells* For the conduction system of the heart. Initiate and propagate the action potential(the electrical impulse) that travels throughout the heart and triggers the contractions that propel the blood. Make up 1%of cells in atria and ventricles. One of 2 major types of cardiac muscle cells.

What is the reversal agent for Digoxin (Lanoxin)?

Digibind

K+ and H+ exchange during alkalosis

During alkalosis, H+ ions move out of the cell and into ECF ・K+ shifts into the cells ・Kidneys increase secretion of K+ and hypokalemia results

SLE: Nursing Intervention in Acute Care; Ambulatory Care

Acute Care Nursing Interventions ・Frequent monitoring ・Assess severity of symptoms and response to treatment ・Monitor weight and I&Os ・Promote rest ・Education and emotional support Ambulatory Care Nursing Interventions ・EDUCATION Disease process, meds, pain managment, stress management, heat therapy avoid sick people, avoidance of drying soaps, powders, or household chemicals, use sunscreen and sun avoidance, regular labs ・Pregnancy counseling as needed ・Community resources

What are the respiratory disorders of the lower airway?

Atelectasis, Pneumonia, TB, Valley Fever

What are the two parts of the CNS?

Brain & spinal cord

How do the kidneys contribute to BP regulation?

By controlling sodium excretion and extracellular fluid (ECF) volume. Sodium retention results in water retention, which causes an increase in ECF volume. This increases the venous return to the heart and stroke volume. Together these increase CO and BP.

Left Sided Systolic Heart Failure

Caused by: ・ Impaired contractile function (MI) ・ Increased afterload (HTN) ・ Cardiomyopathy ・ Mechanical abnormalities (i.e. valvular heart disease) ・ Hallmark is decreased ejection fraction (<45%) ・ Left ventricle loses ability to generate enough pressure to eject blood forward through the aorta

What are some examples of narcotic antitussives?

Codeine & Hydrocodone (low doses)

What are the two upper airway respiratory disorders?

Common cold & influenza

What do leukocytes do?

Defend the body against infection

Lymphadenopathy (LAD): Definiton

Definition A chronic, abnormal enlargement of the lymph nodes, usually associated with disease, neoplasia, AIDS

Buerger's Disease: Definition, At Risk, S/S

Definition A condition in which the blood vessels, especially those supplying the legs, are constricted whenever nicotine enters the bloodstream, the ultimate result being gangrene and amputation. At Risk Population Young male smokers S/S Pain and tenderness of hands and feet

Megaloblastic Anemia: Definition/classification, result from

Definition/Classification ❖ Group of disorders caused by impaired DNA synthesis ❖ Large RBCs that are easily destroyed ❖ Microcytic-normochromic RBCs are larger than normal, with a normal color Result From ❖ Cobalamin (vit B₁₂) deficiency anemia [AKA pernicious anemia] ❖ Folic acid deficiency anemia

Manifestations of Anemia

Many s/s will be related to tissue hypoxia b/c our RBCs are responsible for carrying oxygen. Most Common Finding ❖ Pallor Around mucous membranes, skin, conjunctiva. The result of decreased blood flow to the skin Second Most Common ❖ Glossitis Especially seen in B-12 deficiency CNS ❖ Debilitating fatigue ❖ Depression ❖ Impaired cognitive function GI/GU ❖ Anorexia ❖ Nausea ❖ Menstrual problems ❖ Loss of libido Immune System ❖ Impaired T-cell and macrophage function Vascular System ❖ Low skin temp Cardiorespiratory Sytem * These s/s usually not seen until Hgb drops to about 8 or so ❖ Exertional dyspnea ❖ Tachycardia, palpitations ❖ Cardiac enlargement, hypertrophy ❖ Increased pulse pressure, systolic ejection murmur ❖ Risk of life-threatening cardiac failure

Blood Pressure

Measure of the pressure exerted by blood against the walls of arteries.

Filtration

Movement of both water and small particles from an area of high pressure to an area of low pressure.

How long between sounds (per quadrant) is an absent bowel activity?

No bowel sound for a full 5 minutes

When should you apply heat therapy?

Only when you are sure it is absolutely safe.

Fluid Volume Excess

Overhydration Retention of water only Hypervolemia (ECF volume excess) Retention of water and electrolytes Results from: ∙ Excess intake of fluids (IV or PO) ∙ Abnormal retention of fluids ∙ Decreased renal function ∙ Interstitial-to-plasma fluid shift

Potentiate

Potentially cause

What are the 3 phases of the peri-op period and when does each of them occur?

Pre-Op Decision to have surgery ➪ pt transferred to OR Intra-Op Admission to surgical dept ➭ transfer to PACU Post-Op Admission to PACU ➯ Complete recovery from surgery

PCI (Percutaneous Coronary Intervention)

Prep ・NPO ・Consent ・Check allergies Shellfish, iodine ・Assess distal pulses ・Appropriate pt. education Post ・Check site Advise pt. if it is femoral that you will have to continually look under their gown at the groin area. Also, look at foot to see circulation has returned if it was a femoral entry. ・Maintain BR, avoid leg flexion Lay almost flat ・Encourage fluids, IV fluids To flush out the dye ・Think about food to feed them

What is Ethambutol? Side effects?

First line TB drug; retrobulbar neuritis, skin rash.

Parathyroid Glands

Four pea-sized glands found on back of thyroid gland. Produce and secrete parathyroid hormone(PTH), the major hormone involved in regulation of blood calcium levels.

Why is digoxin (Lanoxin) given?

Given to treat atrial fibrillation and atrial flutter, CHF, and paroxysmal atrial tachycardia.

How long between sounds (per quadrant) is a hypoactive bowel activity?

Greater than 20 seconds, but less than 5 minutes

When would you hold Calcium Channel Blockers?

HR < 60

In the restricted areas of the surgical suite, what is the attire required?

Head covers, masks, surgical attire.

Hormonal Stimulus

Hormone release caused by another hormone (a tropic hormone).

How is D5W different from other isotonic solutions?

It is isotonic in the bag, but becomes hypotonic once it is in the patient.

What are the actions of epinephrine?

Reacts at alpha- and beta-receptor sites in the sympathetic nervous system to cause bronchodilation, increased HR, increased RR, and increased BP.

What range is hypertension stage 1?

SBP of 130-139 or DBP of 80-89

What range is hypertension?

SBP of 140 or more DBP of 90 or more

Hypokalemia EKG Changes

ST depression T inversion U wave

Mechanoreceptors

Sensory receptors responsible for sensing distortion in body tissues.

First Dose Phenomenon

Severe and sudden drop in blood pressure after the administration of the first dose of an alpha-adrenergic blocker.

Hemoptysis

Small amount of blood mixed with sputum

Alpha-agonist

Specifically stimulating to the alpha-receptors within the SNS, causing body responses seen when the alpha-receptors are stimulated.

What drug therapy would you educate an allergic/anaphylactic pt on?

Sympathomimetic (Adrenergic Agents)/Decongestant Drugs ❖ Pseudoephedrine (Sudafed) Antihistamines ❖ Fexofenadine (Allegra) ❖ Diphenhydramine (Benadryl) Anti-inflammatory Medications ❖ Mast Cell Stabilizers Cromolyn (NasalCrom) ❖ Leukotriene Receptor Antagonists Montelukast (Singulair) ❖ Corticosteroids Prednisone, nasal spray ❖ Antipruritic Calamine lotion

Sympathetic Nervous System (SNS)

The component of the autonomic nervous system that responds to stressful situations by initiating the fight-or-flight response.

What does the parietal pleura line? What does the visceral pleura line?

The parietal pleura lines the chest wall. The visceral pleura lies the lungs.

Preload

The stretch on the ventricles prior to contraction. Initial stretching of cardiac myocytes prior to contraction. Another way of expressing EDV. Therefore, the greater the EDV is, the greater the preload is.

Facilitated Diffusion

The transport of substances through a cell membrane along a concentration gradient with the aid of carrier proteins.

Before you start the phlebotomy procedure on a patient how do you correctly identify the patient?

To the order and their specimen labels.

Raynaud's Disease

Vasospasms of vessels serving the fingers and toes that can lead to intermittent pain and cyanosis of the digits then rubor as blood flow returns.

Aortic Semilunar Valve; Prevents backflow of blood from the aorta.

What is the name of the valve located between the left ventricle and the aorta? What is it's function?

Define an infection.

When a pathogen invades the body and begins to multiply and produces disease. The immune and inflammatory response cannot control the pathogen.

The 5 Post-Op W's

Wind -- POD 1 Lungs, atelectasis, pneumonia, aspiration Water -- POD 3 Kidneys, UTI Walking -- POD 5 Veins, VTE Wound -- POD 7 Surgical site infection Wonder -- POD 7+ What did we do? Drug induced? Related to IV line or blood products?

What are some side effects of antihistamines?

∙ N/V/D ∙ Drowsiness/Fatigue ∙ Dizziness ∙ Thickened bronchial secretions ∙ Anticholinergic effects

Passive Transport

∙ Requires NO energy ∙ Movement of molecules from high to low concentration ∙ Moves with the concentration gradient ∙ Osmosis ∙ Diffusion ∙ Filtration

Goals for patients with DM

◆ Active patient participation in plan of care ◆ Fewer or no episodes of acute hyperglycemic emergencies or hypoglycemia ◆ Maintain normal blood glucose levels ◆ Prevent or minimize chronic complications ◆ Adjust lifestyle to accommodate diabetes regimen

Combination Insulin Therapy

◆ Can mix short- or rapid-acting insulin with intermediate-acting insulin in same syringe ◆ Clear before cloudy in syringe ◆ Provides mealtime and basal coverage in one injection ◆ Commercially premixed or self-mix

What are some signs and symptoms of infiltration?

◆ Swelling ◆ Pallor ◆ Coolness ◆ Pain at the IV site ◆ Slowed infusion rate

What are some reasons why a pt might have a tracheostomy?

❖ Long-term mechanical ventilation ❖ Bypass upper airway obstruction ❖ Esophageal tumors ❖ Facilitate removal of secretions ❖ Food aspiration ❖ Allergic reaction ❖ Trauma

When is preload going to be increased?

・ Hypervolemia ・ Regurgitation of the cardiac valves

Respiratory Acidosis

・Carbonic acid excess (CO2 retention) ・Can be acute or chronic

T-lymphocytes are responsible for __________. What are the two types and how do they work?

・Cell-mediated immunity T-Cytotoxic Attracted to bad antigens of foreign pathogens. Memory t-cells. Attack foreign antigens, recognize them and destroy them. Think of them as the body's surveillance. T-Helper Make different cytokines that help with phagocytosis. Help get the immune system to work together.

What are some nursing interventions when administering epinephrine?

・Check VS q 5 min ・Asses lung sounds ・Watch UO ・Monitor IV site (it is a vesicant-can destroy tissue) ・Client teaching (self-administration/parent-administration)

Metabolic Alkalosis Interventions

・Correct underlying problem ・Administer NaCl-rich fluids ・Replace potassium ・Dialysis in renal impaired patients

Clinical Manifestations of Metabolic Acidosis

・Deep, rapid respirations (Kussmaul respirations) ・CNS depression ・Decreased BP ・Dysrhythmias ・Warm, flushed skin ・N/V/D; abdominal pain

What do the kidneys do if the body has too much sodium? Too little?

・If the body has too little sodium, the kidneys hold it. ・If the body has too much sodium, the kidneys excrete it.

What are the side effects/adverse effects of bethanechol?

・PARASYMPATHETIC ACTIONS ・Pupillary constriction (miosis) ・Increased SLUD ・Decreased HR ・Decreased cardiac contractility ・Hypotension ・Cardiac arrest ・Bronchoconstriciton

Pitting Edema Grading Scale

1+ Barely detectable--0-1/4" pitting (mild) 2+ Disappears 10-15 seconds 3+ Lasts more than 1 minute 4+ Lasts 2-5 minutes

QT Interval

0.34-0.43 seconds Ventricles contract and relax. Beginning of the QRS complex to the end of the T wave.

What is a normal TSH level?

0.4-4 mIU/L (milli international units/L)

What are some hypotonic IV solutions?

0.45% NaCl (1/2 NS) [154 mOsm] 0.33% NaCl 2.5 % Dextrose in Water

Therapeutic Digoxin Range

0.5-2 ng/mL

What are some isotonic IV solutions?

0.9% NS (sodium chloride; normal saline) [308 mOsm] Lactated Ringers (LR) [275 mOsm] *** D5W*** [260 mOsm]

Therapeutic aPTT Range

1.5-2.5 times the control (30-87.5 seconds)

Leukocytosis

Abnormally high WBC count

What is the important neurotransmitter of the Parasympathetic (Cholinergic) Nervous System?

Acetylcholine (ACh)

What is an example of a mucolytic?

Acetylcysteine (Mucomyst) ∙ Delivered by inhalation (not OTC) ∙ Adverse effects: severe N/V, bronchospasm ∙ Hepatoprotective when given orally which is why it is the antidote to acetaminophen OD

Transmission of Pain

Action potential continues from the site of injury to the spinal cord, brainstem, thalamus, and cortex for processing.

Clinical Manifestations of Heart Failure

Acute Decompensated Heart Failure ・ Sudden worsening in symptoms ・ Increase in pulmonary venous pressure ・ Interstitial edema leads to tachypnea ・ Alveolar edema ・ Development of dependent edema or weight gain >3lb in 2 days Chronic ・ Progressive worsening that results in ventricular remodeling.

Acute conditions in patients with DM: Effects, patient teaching

Acute Illness, injury, or surgery ◆ Increases blood glucose levels ◆ Requires frequent monitoring of blood glucose ◆ May need increased insulin for DMT1 ◆ May necessitate insulin therapy in DMT2 Patient Teaching: Sick Day Protocol ◆ Maintain normal diet (if able) ◆ Drink a lot of (noncaloric) fluids ◆ Continue insulin or oral meds as prescribed ◆ Check glucose every 4 hours (minimum) ◆ Ketone testing every 3-4 hours if BS > 240 ◆ Choose meds wisely Watch out for hidden sugar

What does 1 tablespoon equal in mL?

15 mL

Platelets Normal Range

150,000-400,000/mm³

What are some differences between 1st generation & 2nd generation antihistamines?

1st Generation ∙ Likely to cause drowsiness ∙ Likely to cause anticholinergic symptoms ∙ Ex. diphenhydramine (Benadryl) 2nd Generation ∙ Little to no effect on sedation ∙ Fewer anticholinergic symptoms ∙ Ex. fexofenadine (Allegra), loratadine (Claritin), cetirizine (Zyrtec)

Numeric Sedation Scale

1—awake and alert; no action necessary 2—occasionally drowsy, but easy to arouse; no action necessary 3—frequently drowsy, drifts off to sleep during conversation; reduce dosage 4—somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone

Phosphorus Normal Range

2.5-4.5 mg/dL

What does 1 inch equal in cm?

2.54 cm (*conversion factor = 2.5 cm)

HCO₃ Normal Range

22-26 mEq/L

Which end of HCO3 is alkaline? Acidic?

26 is alkaline 22 is acidic

Serum Osmolality (normal range)

275-295 mOsm/kg

What is the normal blood osmolality?

275-295 mOsm/kg

What does one oz (AKA one fluid ounce) equal in tablespoons?

2T

Potassium Normal Range

3.5-5.0 mEq/L

What does one oz (AKA one fluid ounce) equal in mL?

30mL

What does 1 quart equal in ounces?

32oz

What does 1 pint equal in mL?

480 mL

Glycosylated Hemoglobin (HgbA₁C) Normal Range

< 6.5%

A patient is admitted to the hospital in hypertensive emergency (BP 244/142 mm Hg). Sodium nitroprusside is started to treat the elevated BP. Which management strategy(ies) would be most appropriate for this patient (select all that apply)? a. Measuring hourly urine output b. Decreasing the MAP by 50% within the first hour c. Continuous BP monitoring with an arterial line d. Maintaining bed rest and providing tranquilizers to lower the BP e. Assessing the patient for signs and symptoms of heart failure and changes in mental status

A, C, E

The auscultatory area in the left midclavicular line at the level of the fifth ICS is the best location to hear sounds from which heart valve? a. Aortic b. Mitral c. Tricuspid d. Pulmonic

B

While obtaining subjective assessment data from a patient with hypertension, the nurse recognizes that a modifiable risk factor for the development of hypertension is a. a low-calcium diet. b. excessive alcohol intake. c. a family history of hypertension. d. consumption of a high-protein diet.

B

Patients with a heart transplantation are at risk for which complications in the first year after transplantation (select all that apply)? a. Cancer b. Infection c. Rejection d. Vasculopathy e. Sudden cardiac death

B, C, E

Why do cancer cells increase with age?

B- and T-lymphocytes decrease as we age. Decreased immune response with increased age.

BMP

Basic Metabolic Panel

Why would you avoid performing phlebotomy at a site proximal to a running IV solution?

Because the IV fluids could contaminate and alter the results.

Benign Cells vs Malignant Cells

Benign ❖ Continuous or inappropriate cell division ❖ Small appearance ❖ Small nucleus ❖ Many differentiated functions ❖ Tight adherance ❖ No migration ❖ Follow a normal growth pattern (Expansion) Malignant ❖ Rapid or continuous cell division ❖ No specific morphology ❖ Large nucleus ❖ Loose adherance ❖ Migratory ❖ Growth is expansive & invasive

Pre-Op Medications

Benzodiazepines ◇ Help with anxiety and sedation ◇ midazolam (Versed), diazepam (Valium), lorazepam (Ativan) Anticholinergics ◇ Dry up secretions ◇ atropine, scoplamine H2 Antagonists ◇ Decrease gastric secretions, N/V ◇ famotidine (Pepcid), ranitidine (Zantac), cimetidine (Tagamet) Opioids ◇ Decrease pain ◇ morphing sulfate, hydromorphone (Dilaudid) Antiemetics ◇ Decrease N/V ◇ ondansetron (Zofran) Antibiotics ◇ Decrease risk of infection

Why are benzodiazepines used pre-operatively? H2 antagonists?

Benzos Sedative and amnesic properties H2 Antagonists To reduce gastric secretions

What drug interactions do decongestants have?

Beta Blockers May decrease the effect of a beta blocker MAOIs Increased risk of HTN and dysrhythmias Caffeine In large amount may lead to increased restlessness & palpitations

How do ACE inhibitors work for hypertension?

Block the ACE enzyme from converting angiotensin I to angiotensin II, thus mitigating that latter's ability to increase blood pressure. You would *NOT* give someone with hypotension an ACE inhibitor.

Myocardial Infarction

Blockage of coronary artery leading to heart muscle cell death. This is a "Heart Attack".

What is the MOA of spironolactone?

Blocks action of Aldosterone in distal renal tubules thereby increasing excretion of sodium and water and sparing K+

Name the 4 body fluids that can transmit HIV.

Blood, semen, vaginal secretions, perinatal.

What are the four ways of classifying surgical procedure? Briefly describe each.

Body System Cardiac, abdominal, etc. Urgency ❖ Elective Scheduled in advance at convenience of pt. and surgeon, no ill effect in delay. ❖ Urgent Will be done w/in 24-48 hours in order to alleviate symptoms, repair body part or restore function ❖ Emergent Done immediately to save a life or perform a function Risk ❖ Major Significant blood loss, vital organs, significant complications ❖ Minor Elective surgeries Purpose ❖ Diagnostic/Exploratory To confirm or rule out a diagnosis (biopsy, cardiac cath, etc) ❖ Ablative Removal of a diseased body part or tissue (cholecystectomy, gall bladder) ❖ Palliative Relieved discomfort or other disease symptoms (nerve root destruction for chronic pain) ❖ Preventative ❖ Transplantation ❖ Cosmetic Reconstructive, constructive ❖ Exploratory

All lymphocytes originate in the ___________________-. T-lymphocytes mature in the __________________. B-lymphocytes mature in the _____________________.

Bone marrow; Thymus; Bone marrow.

Is diabetes mellitus modifiable or non-modifiable?

Both. Type I is not. But you can modify what causes diabetes.

Is increased cholesterol modifiable or non-modifiable?

Both. You can modify what causes it but maybe some people just have it.

What are the three forms of calcium?

Bound: Calcium is bound to protein albumin Ionized(free): Carries out most of the Ca+ functions; the most physiologically important form. Complexed: With phosphate, citrate, carbonate

Name 3 late clinical manifestations of inadequate oxygenation

Bradycardia Extreme restlessness Dyspnea at rest

Glycogenolysis

Breakdown of stored glucose to increase the blood glucose levels.

If serum pH is too alkaline in metabolic alkalosis, lungs try to...

Breathing slower and less deeply

A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is a. ventricular dilation. b. ventricular hypertrophy. c. neurohormonal response. d. sympathetic nervous system activation.

C

A patient with a tricuspid valve disorder will have impaired blood flow between the... a. vena cava and right atrium b. left atrium and left ventricle c. right atrium and right ventricle d. right ventricle and pulmonary artery

C

When assessing the cardiovascular system of a 79-year-old patient, you may expect to find a. a narrowed pulse pressure. b. diminished carotid artery pulses. c. difficulty in isolating the apical pulse. d. an increased heart rate in response to stress.

C

You are caring for a patient with ADHF who is receiving IV dobutamine (Dobutrex). You know that this drug is ordered because it (select all that apply) a. increases SVR. b. produces diuresis. c. improves contractility. d. dilates renal blood vessels. e. works on the β1-receptors in the heart.

C, E

How is respiratory acidosis compensated?

Kidneys excrete hydrogen ions and reabsorb bicarbonate ions.

How does COPD lead to Cor Pulmonale?

COPD causes the right pulmonary artery to constrict so the right ventricle has to work harder to push fluid forward, but the fluid cannot go through so it goes back to the right atrium and then back into the body.

Ischemia EKG Characteristics

Can be an ST segment depress or an inverted T wave.

Late Effects of Radiation and Chemo

Can occur months-years after treatment stops Increased risk for secondary malignancies ❖ 8% of survivors ❖ Risk ⬆︎ for smokers ❖ Leukemia; multiple myeloma; non-hodgkin's lymphoma ❖ Cancer of the bladder, kidney, ureters ❖ Osteosarcoma of ribs, scapula, clavicle, humerus, sternum, ilium, and pelvis ❖ Alkylating agents and high-dose radiation are the most frequent cause Radiation ❖ Lymphedema (generally permanent) Chemotherapy ❖ Neurocognitive dysfunctions ("chemo brain") Mental cloudiness ❖ Arthralgia Pain in joints ❖ Cataracts ❖ Endocrine alterations ❖ Renal insufficiency ❖ Hepatitis ❖ Osteoporosis

Respiratory Alkalosis

Carbonic acid deficit

What are signs and symptoms of hypokalemia?

Cardiac Weak, irregular heart rate, orthostatic hypotension, palpitations EKG Flat or inverted T wave, U wave, ventricular arrhythmias, cardiac arrest Watch closely if patient is on digoxin Can potentiate action and cause toxicity Skeletal muscle weakness (especially in legs) Paresthesias, leg cramps, decreased reflexes Respiratory muscles may weaken Tachypnea (shallow) GI (smooth muscle) alterations Decreased bowel sounds, constipation, ilieus

Except for the Purkinje cells, autorhythmic cells are generally smaller than contractile cells and have few of the myofibrils and filaments needed for contraction. In contractile cells, there is a distinctly different electrical pattern. In this case, there is a rapid depolarization, followed by a plateau phase and then repolarization. This phenomenon accounts for the long refractory periods required for the cardiac muscle cells to pump blood effectively before they are capable of firing for a second time. These cardiac myocytes normally do not initiate their own electrical potential but rather wait for an impulse to reach them from a *conducting cell stimulus*. Contractile cells demonstrate a much more stable resting phase than conductive cells at approximately −80 mV for cells in the atria and −90 mV for cells in the ventricles. Despite this initial difference, the other components of their action potentials are virtually identical. In both cases, when stimulated by an action potential, voltage-gated channels rapidly open, beginning the positive-feedback mechanism of depolarization. Autorhythmic cells are specialized cells that transmit electrical impulses throughout the heart and *trigger contraction* by the myocardial contractile cells.

Cardiac Autorhythmic Cells vs Cardiac Contractile Cells

Autorhythmic Cells

Cardiac muscle cells are ____________________ because they are self-excitable. They repeatedly generate spontaneous action potentials that then trigger heart contractions. These cells act as a *pacemaker* to set the rhythm for the entire heart and form the conduction system. Part of the conduction system.

Atenolol (Tenormin): MOA, Therapeutic Effects/Uses, Side Effects/Adverse Reactions

Cardioselective beta₁ adrenergic blocker MOA Blocks NE from stimulating B₁ which leads to decreased HR and BP. *It might also block B₂ a little bit, leading to bronchoconstriction. Therapeutic Effects/Uses HTN, angina, HF, prevent MI (decrease mortality in pts with MI), dysrhythmia/arrhythmia, migraines, anxiety Side Effects/Adverse Reactions ・Inhibit Fight/Flight Response Fatigue, weakness, hypotension, bradycardia ・Bronchospasm (rare with atenolol) ・Caution diabetics May not feel symptoms of hypoglycemia ・Impotence

What are the Cations and Anions that make up ICF?

Cations ∙ Potassium ∙ Magnesium ∙ Calcium (found in fairly equal concentrations in ICF & ECF) Anions ∙ Phosphate ∙ Sulfate

What are the cations and anions that make up ECF?

Cations ∙ Sodium ∙ Calcium Anions ∙ Chloride ∙ Bicarbonate ∙ Sulfate

Folate: Causes, onset, manifestations, daily allowance, and food sources

Causes Dietary deficiency, medications, alcohol abuse, malnutrition Onset Insidious Manifestions ❖ Similar to cobalamin (B₁₂) deficiency, but no neurologic problems Daily Allowance 400 mcg/day Food Sources ❖ Replacement therapy usual dose is 1 mg per day by mouth ❖ Leafy greens, citrus fruits, dried beans and peas, enriched bread, pastas, flours, etc

Cancer SE: Pain - Causes & what do nurses do?

Causes ❖ Bone destruction ❖ Obstruction of an organ ❖ Compression of peripheral nerves ❖ Infiltration, dissection of tissue ❖ Inflammation, necrosis ❖ Psychological factors, such as fear or anxiety What do nurses do? ❖ Collaborate with HCP to develop pain management program ❖ DO NOT undermedicate the cancer pt who is in pain ❖ Thorough pain assessment ❖ Administer analgesics Involves a combo to be most effective ❖ VS May not be reliable indicators when pt is in chronic pain ❖ Monitor effectiveness of medications ❖ Non-pharmacologic techniques

Vitamin Deficient Anemia: Causes, s/s, treatment

Causes ❖ Low amounts of folate, vitamin B-12, Vitamin C S/S ❖ Same as iron deficient anemia Treatment ❖ Vitamin supplements ❖ Dietary changes

The Nervous System

Central Nervous System (CNS) + Peripheral Nervous System (PNS)

Cephalosporins

Class Anti-infective/cephalosporins Action ◇ Binds to the bacterial cell wall membrane, causing cell death. ◇Spectrum varies depending on drug generation. Third generation is more effective against more organisms. ◇ Work a lot like penicillin Allergies 5-10% of people allergic to penicillin are also allergic to cephalosporins Side Effects Rash, GI pain, anorexia, anaphylaxis, hypersensitivity Names ◇ cephalexin (Keflex) (1st generation) ◇ ceftriaxone (Rocephin) (3rd generation) ◇ cefepime ◇ cefazolin

Raltegravir (Isentress): Class, Action, Dose, Adverse Effects

Class Antiretroviral/Integrase Inhibitors/Integrase Strand Transfer Inhibitors (INSTIs) Action Inhibits the activity of HIV-1 integrase, which is required for viral replication. Blocking this prevents HIV-1 provirus formation and leads to a decrease in viral load and an increase in active CD4 cells. Route Oral Adverse Effects HA, dizziness, N/V/D, fever, rhabdomyolysis, suicidal thoughts

Enfuviritide (Fuzeon): Class, Actions, Dose, Adverse Effects

Class Antiretroviral/fusion inhibitor Action Prevents the entry of HIV-1 into cells by interfering with the fusion of the virus with cellular membranes Dose Sub-q, 2x/day Adverse Effects Pancreatitis, hypersensitivity reactions, HA, N/V/D, rash, anorexia, pneumonia, chills, injection-site reactions

Nevirapine (Viramune): Class, Action, Dose, Adverse Effects

Class Antiretroviral/nonnucleoside reverse transcriptase inhibitors (NNRTIs) Action Binds to HIV-1 reverse transcriptase and blocks replication of the HIV by changing the structure of the HIV enzyme. The chain is seen as corrupt and is terminated. Dose Oral, 2x/day Adverse Effects HA, N/V/D, rash, liver dysfunction, chills, fever

Zidovudine (Retrovir, AZT): Class, Action, Dose, Adverse Effects

Class Antiretroviral/nucleoside reverse transcriptase inhibitors (NRTIs) Action Inhibits the activity of HIV-1 reverse transcriptase, interfering with the order of transcription, which in turn terminates viral DNA replication. The first HIV med. Dose Oral or IV. May need to take up to 6x/day Adverse Effects Lactic acidosis, hypersensitivity reactions, hepatotoxicity, HA, insomnia, dizziness, N/D, fever, rash, bone marrow suppression

Ferrous Sulfate (Feosol): Class, daily dose, directions for use, s/e

Class Oral Iron supplement Daily Dose 150-200 mg (3-4 divided doses) Directions for Use ❖ Best absorbed in acidic environment ❖ EC or SR are counterproductive ❖ 1-2 hours before a meal Duodenal mucosa is most acidic ❖ Do not take with antacid, milk, or eggs Can interfere with absorption ❖ Liquid iron should be diluted and ingest through a straw Will stain teeth ❖ Iron therapy must be continued for 2-6 months after Hgb levels return to normal ❖ Increase dietary fiber while on med Side Effects ❖ Dark stool Harmless. Excess iron is excreted through GI tract ❖ Heartburn, constipation, diarrhea Constipation is more common than diarrhea

Methotrexate (Rheumatrex): Classification, action, side effects

Classification Antineoplastic; DMARD; immunosuppresant/antimetabolite, anti-rheumatic Action Interferes with folic acid metabolism. Result is inhibits DNA synthesis and cell reproduction in rapidly dividing cells. Side Effects Pulmonary fibrosis/toxicity, bone marrow suppression, hepatotoxicity Considerations ・Inexpensive and lower toxicity ・Can be used alone or in combination with other drugs ・Need frequent labs ・Report SOB, bruising, or sore throat

Thrombocytopenia: Acute Interventions

Closely monitor platelet count ❖ Thrombocytopenia < 150,000/mcL ❖ < 50,000 mcL: prolonged bleeding from trauma ❖ < 20,000/mcL: spontaneous, life-threatening hemorrhage can occur ❖ <10,000/mcL: platelet transfusion Medications can usually fix it before a transfusion is necessary Any bleeding needs evaluation and treatment ❖ Black/tarry stools, blood in any body excrement, bruising, bleeding from mouth ❖ Manage blood loss from excessive menstrual bleeding Pad counts. ≈ 50 mL will soak a sanitary napkin Watch for bleeding that can be difficult to detect ❖ Internal hemorrhage VS: hypotension, tachycardia, tachypnea, confusion, drowsiness, loss of consciousness ❖ Bleeding into the brain Sudden, severe HA Prevent or control hemorrhage ❖ Avoid IM injections ❖ If sub-Q injection unavoidable, use small-gauge needles and application of pressure or ice packs after ❖ Education - bleeding precautions ❖ May require platelet transfusion ❖ Meds as ordered Bleeding Precautions ❖ Prevent constipation ❖ Avoid crazy exercise ❖ Do not pluck body hairs ❖ Avoid mani-pedis ❖ do not blow nose, just dab ❖ Avoid tattoos & body piercings ❖ Soft toothbrush and gentle flossing ❖ Speak with HCP before any invasive procedure

If you patient has a productive cough, what are 4 assessments you should always perform on the expectorated sputum?

Color, viscosity, amount, presence of blood

QRS Complex

Component of the electrocardiogram that represents the depolarization of the ventricles and includes, as a component, the repolarization of the atria. Referred to as a unit. Hopefully contracting and pushing blood out (0.06-0.1 seconds).

QRS Complex

Component of the electrocardiogram that represents the depolarization of the ventricles and includes, as a component, the repolarization of the atria. Referred to as a unit. Indicates depolarization of ventricular fibers and repolarization of atrial fibers.

Joined to myocardium by thin layer of connective tissue. Lines the chambers where the blood circulates and covers the heart valves. Simple squamous epithelium called *endothelium*. Regulates the contraction of the muscle within the myocardium as well as growth patterns.

Composition and Function of Endocardium.

Made largely of cardiac muscles. Built upon a framework of *collagen fibers*, plus the blood vessel that supply the myocardium and the nerve fibers that regulate the heart. It's contraction is what pumps blood through the heart and into the major arteries.

Composition and Function of Myocardium.

Myocardial Contractile Cells

Conduct impulses and are responsible for contractions that pump blood through the body. Constitute 99% of cells in atria and ventricles. One of 2 major types of cardiac muscle cells.

Hyperparathyroidism - Nonsurgical Treatment

Conservative approach if asymptomatic or mild s/s Meds to help ⬇︎ Ca⁺⁺ levels ◇ Biphosphonates To inhibit osteoclastic bone resorption alendronic acid (Fosamax) ◇ Calcitonin To pull Ca⁺⁺ from blood into bone ◇ Calcimimetics To ⬇︎ PTH secretion and Ca⁺⁺ levels (Cincalcet -- approved only for parathyroid cancer or secondary hyperparthyroidsim in pt with CKD on dialysis) Increase fluids To remove kidney stones Diuretics Annual Exam ◇ PTH, Ca⁺⁺, and phos levels ◇ BUN & Creatinine (stones!) ◇ X-rays and DEXA scans

Depolarization; P Wave

Contraction of the atria follows _______________________, represented by the ___________ of the ECG.

When are hypotonic solutions contraindicated and why?

Contraindicated in acute brain injury b/c cerebrals cells absorb water rapidly leading to cellular edema.

Two hormones released during physical/emotional stress that are counterregulatory to insulin include:

Cortisol & epinephrine

A priority consideration in the management of the older adult with hypertension is to a. prevent primary hypertension from converting to secondary hypertension. b. recognize that the older adult is less likely to adhere to the drug therapy regimen than a younger adult. c. ensure that the patient receives larger initial doses of antihypertensive drugs because of impaired absorption. d. use careful technique in assessing the BP of the patient because of the possible presence of an auscultatory gap.

D

In teaching a patient with hypertension about controlling the illness, the nurse recognizes that a. all patients with elevated BP require medication. b. obese persons must achieve a normal weight to lower BP. c. it is not necessary to limit salt in the diet if taking a diuretic. d. lifestyle modifications are indicated for all persons with elevated BP.

D

Purkinje Fibers

Large diameter myocardial conductive fibers that conduct signals quickly. Spread the impulse to the myocardial contractile cells in the ventricles. Extend through the myocardium from the apex of the heart toward the atrioventricular septum and the base of the heart. Because of this the contraction also begins at the apex and moves towards the base allowing blood to be pumped out of the ventricles and into the aorta and pulmonary trunk.

Cluster of myocardial conducting cells in wall of right atria and in close proximity to the superior vena cava.

Location of SA Node

What are some causes of metabolic alkalosis?

Loss of acids, such as repeated vomiting; excessive intake of alkaline substances, such as antacids, gains of HCO3-, gastric suction, hypokalemia, use of potassium wasting diuretics, excessive corticosteroids, hyperaldosteronism.

What are some causes of metabolic acidosis?

Loss of bicarbonate ions through sever diarrhea or renal dysfunction; increased metabolic acids (diabetes mellitus), retained acids in blood, conditions that decrease bicarbonate, excessive intake of acids, ketoacidosis, lactic acid accumulation (shock), kidney disease

What is the most common cause of hypotension in the PACU?

Loss of fluids. Replace fluids.

Lipoproteins Produced in the Liver

Low-density lipoproteins (LDL) ・Enter circulation as tightly packed cholesterol, triglycerides, and lipids ・Carried by proteins that enter circulation; broken down for energy or stored for future as energy High-density lipoproteins (HDL) ・Enter circulation as loosely packed lipids ・Used for energy; pick up remnants of fats and cholesterol left in the periphery by LDL breakdown

What temperature is considered to be hypothermia?

Lower than 95°F or 35°C

What information do you need to include when labeling your primary IV tubing administration set?

Date, time, initials

Phenytoin: What nurses need to know & patient teaching

Decreases effectiveness of birth control pills ◆ Can have teratogenic effects ◆ Females needs to use additional non-hormonal methods of contraception ◆ Can cross into breast milk Can increase/decrease the absorption of many other meds ◆ Avoid OTC meds until discussed with HCP Can increase blood sugar ◆ Highly protein bound medicine ◆ Diabetics need to monitor BS closely Monitor CBC, platelet count, and liver/renal function tests Warm IV solutions to room temp Precipitates will dissolve Only mix with NS Patient Teaching ◆ Client ID card/bracelet ◆ May cause drowsiness ◆ Take med at same time each day May take with food. Avoid milk/antacids b/c they could disrupt absorption ◆ Need to maintain good dental hygiene ◆ Avoid alcohol

Oxygen

Decreases gas exchange.

Pancytopenia

Deficiency of all types of blood cells (WBC, RBC, and platelets)

Hypokalemia

Deficient level of potassium in the blood

Transient Ischemic Attack (TIA): Define, time frame, risk factors

Define ◆ "Chest pain of the brain" ◆ Warning sign Time Frame All symptoms have to be resolved w/in 24 hrs to be considered a TIA Risk Factors Diet, age, smoking, drinking, obesity, activity level, HTN, diabetes

Hyper proliferative Anemia: Define, Causes

Define ❖ Polycythemia ❖ A RBC disorder Causes ❖ Result from hypoxia, erythropoietin, secreting tumors, kidney disease, genetic defects

Hypertension

Defined as a persistent systolic BP (SBP) of 140 mm Hg or more, diastolic BP (DBP) of 90 mm Hg or more, or current use of antihypertensive medication.

Cancer

Definition A group of diseases characterized by uncontrolled growth and spread of abnormal cells Statistics ❖ 2nd leading cause of death in U.S. ❖ Mortality rates are declining ❖ Incidences of lung, colorectal, breast, & oral cancer have ⬇︎ largely due to preventative efforts ❖ Leukemia, liver, and skin cancers have ⬆︎

Aplastic Anemia: Definition & Causes

Definition A normocytic-normochromic type of anemia characterized by the failure of bone marrow to produce red blood cells Causes Drugs (chemo), toxins, infections, RA or immune diseases

EEG (electroencephalogram): Definition, implications

Definition An amplified recording of the waves of electrical activity that sweep across the brain's surface Implications ✷ Withhold stimulants or meds that could decrease electrical activity ✷ Seizure precautions

Hematopoiesis (hemopoiesis): Define, where it takes place, red vs yellow, bone marrow produces what?

Definition Blood cell production Occurs Where? Occurs within the bone marrow Red vs Yellow ❖ Red marrow is responsible for hematopoiesis ❖ Yellow is adipose Bone Marrow Produces: ❖ RBCs, WBCs, platelets ❖ All develop from the same non-differentiated immature cells in the bone marrow (stem cells)

Neurotransmitter: Definition, Function

Definition Chemicals that affect the transmission of impulses across the synaptic cleft Function They cause the neuron or body on the other end to change or illicit a response Excitatory ◆ Epinephrine, norepinephrine, glutamate ◆ Activate postsynaptic receptors that increase the likelihood that an action potential will be generated Inhibitory ◆ Serotonin, GABA, dopamine ◆ Activate postsynaptic receptors to decrease the likelihood that an action potential would be generated

Rheumatoid Arthritis (RA): What it is, what it targets, assessment/diagnostic findings, treatment goals

Definition Chronic, progressive autoimmune disease that causes inflammation, thickening and deformation of the joints. Joints are affected bilaterally and symmetrically. Characterized by periods of exacerbations and remissions. More pain after inactivity. Targets Connective tissue in the diarthrodial joints. Assessment/Diagnostics ・Positive Rheumatoid Factor (RF) Antibody 80% of people with RA ・Positive Antinuclear Antibody (ANA) titer 20%-30% of people with RA ・C-Reactive Protein (CRP) Increased = active inflammation ・Erythrocyte Sedimentation Rate (ESR) Increased = active inflammation ・Synovial Fluid Analyzed for MMP-3 enzyme, WBC count, and tissue biopsy ・X-rays To confirm disease activity and monitor treatment Treatment Goals ・Reduce inflammation ・Management of pain ・Maintain joint function ・Prevent/minimize joint deformity

Lumbar Puncture (LP): Definition, nursing implications

Definition Done to analyze CSF & pressure. Nursing Implications ✷ Pt are usually pretty sick ✷ Explain procedure ✷ Pt should go to the bathroom first ✷ Provide comfort to pt, help and label the vials ✷ Look out for CSF leakage or nerve damage (wiggle toes) ✷ Keep pt supine between 3-6 hours ✷ Lots of fluids to reduce HA & increase CSF production

Intracranial Pressure (ICP): Definition, normal ICP

Definition Hydrostatic force measured in the CSF Normal ICP ◆ Brain tissue + blood + CSF ◆ 5-15 mmHg ◆ Relatively constant volume

Hyperthyroidism: Definition, s/s, treatment, goals

Definition Hyperfunction. Too much thyroid hormone. Grave's Disease is the most common cause. Signs & Symptoms ✷ FAST!!! ✷ All VS are high: ⬆︎T, ⬆︎BP, ⬆︎RR, ⬆︎P ✷ Diarrhea, decreased weight, energizer bunny, insomnia ✷ Exophthalmos (bulging eyes) Treatment ✷ Cut it out Thyroidectomy. Spare the parathyroids though, or you will deal with Ca⁺⁺ issues ✷ Monitor the heart Give cardizem or inderal as ordered ✷ Suppress with drugs SSKI, Iodine, antithyroid drugs, beta-blockers ✷ Radioactive Iodine (RAI) ✷ Eye moisture, cool dark room Goals ✷ Experience relief of symptoms ✷ No serious complication r/t disease treatment ✷ Maintain nutritional balance ✷ Cooperate with therapeutic plan

Hypothyroidism: Definition, s/s, treatment, goals, patient teaching

Definition Hypofunction of the thyroid. Thyroid hormone is low. Early Symptoms: ✷ SLoooOOOoooW... so tired, so cold. ✷ Being more sensitive to cold, constipation, depression, fatigue or feeling slowed down, heavier menstrual periods, joint or muscle pain, paleness or dry skin, thin, brittle hair or fingernails, weakness, hair loss ✷ All VS are decreased: ↓T, ↓P, ↓RR, ↓BP Late Symptoms: Subnormal temp, bradycardia, weight gain, decrease LOC, thickened skin, cardiac complications *** The thyroid can be small or large (goiter) depending on the cause of the disorder. Treatment: ✷ Screen high risk populations ✷ Mostly outpatient therapy myxedema coma necessitates acute care ✷ Thyroid drug ✷ Warm environment Goals ✷ Experience relief of symptoms ✷ Maintain a euthyroid (normal) state as evidenced by normal T₃ & T₄ levels ✷ Maintain a positive self-image (myxedema) ✷ Comply with lifelong thyroid replacement therapy Patient Teaching ✷ S/S of both hypo- and hyperthyroidism ✷ Regular follow-up care ✷ Emphasize need for warm environment ✷ Measures to prevent skin breakdown ✷ Avoid sedatives or use lowest dose possible ✷ Measures to minimize constipation Stool softener, increased liquids, fiber, exercise. Avoid use of enemas

DVT (Deep Vein Thrombosis)

Definition Inflammatory response S/S Swelling, tenderness, redness Treatment Elevate extremity, Heparin

Systemic Lupus Erythematosus (SLE): What it is, how is it diagnosed?

Definition Multisystem inflammatory autoimmune disease. Immune bodies attack "self". Diagnosis **NEED 4*** Can be difficult to diagnose. SLE is diagnosed primarily on criteria relating to pt. hx, physical exam, and lab findings ・Positive Anti-Nuclear Antibody (ANA) ・ELISA for SLE-specific antibodies ・Malar (butterfly) rash ・Discoid lesion rash ・Photo sensitivity ・Oral ulcers ・Arthritis ・Pleuritis or pericarditis ・Renal disorder ・Neurologic disorder ・Hematologic disorder

Superior Vena Cava Syndrome

Definition Occlusion of superior vena cava leading to venous distention in upper extremities & head S/S Edema, venous distention in upper extremities, face & eyes, HA Treatment Radiotherapy, diuretics, steroids, anticoagulants, surgery

Oprelvekin (Neumega): Definition, MOA, administration, s/e

Definition Platelet enhancing drugs MOA ❖ Stimulates production of megakaryocytic & thrombopoeitin ❖ Enhances production of platelets in pts at risk for thrombocytopenia caused by chemo (specifically) Administration ❖ Sub-Q only ❖ Onset: 5-9 days ❖ Daily until therapeutic response > 50,000/mcL S/E ❖ Fluid retention As many as 60% of pts will have this. Watch out for pts at greater risk for HF & kidney failure

Thrombocytes: Definition, MOA, formation, lifespan

Definition Platelets MOA Initiate clotting process, plug openings in the capillary wall, and play a role in clot shrinkage and retraction Formation Stem cells transform into megakaryocytic which fragment into platelets Lifespan 8-10 days

Trigeminal Neuralgia (Tic Douloureux): Define, s/s, triggers, treatment

Definition Recurring episodes of intense stabbing pain in trigeminal nerve (V) area (near mouth or nose) S/S Grimacing, frequent blinking, tearing of the eye Triggers Touch, drinking, washing face Treatment ✷Pain relief ✷ Medication carbamazepine (Tegretol), oxcarbazepine (Trileptal) ✷ Treatment may require cutting nerve

Metastasis: Definition, main sites/migrations

Definition The spread of cancer beyond the main site Main Sites of Metastasis ❖ Breast cancer ➪ bone & lung cancer ❖ Lung cancer ➪ brain ❖ Colorectal cancer ➪ liver ❖ Prostate cancer ➪ bone, spine, and legs ❖ Brain tumors ➪ CNA

PAD (Peripheral Arterial Disease): Definition, S/S, Treatment

Definition Thrombus or embolus which obstructs arterial flow. Caused by plaque build up in the arteries. Progressive narrowing & degeneration of arteries of the neck, abdomen, and extremities. S/S The 4 P's, paralysis, mottled extremities, long cap refill, pain. If chronic skin will be thin and shiny Treatment Heparin, angioplasty, surgery, bypass grafts, catheterizations in lower extremity arteries Teaching Points Walk/rest/walk, avoid leg crossing, avoid exposure to cold, assess ulcer formation/gangrene, good skin care, no caffeine or tobacco, education on meds

Brain Tumors: Define, benign/malignant, s/s, diagnosis, treatment

Definition ◆ Abnormal growth of brain tissue and meninges Benign vs Malignant ◆ May be benign or malignant ◆ Benign tumors push things out of the way ◆ Malignant tumors eat through everything Primary Intracranial Tumors ◆ CNS tissue: Neurons, neuroglia ◆ Non-neural tissue: Meninges, pituitary tumor ◆ Metastatic S/S ◆ Depends on location ◆ General HA, projective vomiting, personality/mental changes, papilledema, visual disturbances, deficits of the motor and sensory, seizures Diagnosis CT, MRI, brain scan, EEG, angiography Treatment ◆ Surgery ◆ Radiation ◆ Chemotherapy

Cerebral Blood Flow (FYI): Definition, CPP

Definition ◆ Amount of blood in mL passing through 100 g of brain tissue in 1 minute ◆ 50 mL/min/100 g of brain tissue ◆ Autoregulation Cerebral Perfusion Pressure (CPP) ◆ CPP = MAP - ICP ◆ Normal CPP: 60-100 mm Hg

Neuron: Definition, Function

Definition ◆ Basic working unit of the brain ◆ Specialized cell designed to transmit information to other nerve cells, muscle, or gland cells Function ◆ Generate a nerve impulse ◆ Transmit an impulse to other portions of the cell ◆ Influence neurons, muscle cells, glandular cells through an electrical impulse

CVA (stroke, brain attack): Ischemic vs Hemorrhagic

Definition ◆ Inadequate blood flow to the brain ◆ Death of brain cells Ischemic ◆ 60% of strokes ◆ Occluded blood vessel in brain ◆ Thrombus /Thrombotic Clot in brain vessel (60% of strokes) ◆ Embolus/Embolic Clot forms and migrates to brain, lodges there and blocks blood flow (25%) Hemorrhagic (15% of strokes) ◆ Subarachnoid Vessel ruptures and bleeds onto brain surface ◆ Intracerebral Vessel ruptures with bleeding into brain tissue ◆ Associated with HTN ◆ N/V, at risk for IICP, aneuryism "Worst headache of my life" is what a pt might say.

IICP

Definition ◆ Increase in ICP ◆ Life threatening Possible causes ◆ Vascular insult Stroke ◆ Cerebral infections Meningitis, encephalitis ◆ Head injuries ◆ Mass lesions Brain tumors ◆ Toxic/metabolic encephalopathic conditions Liver failure, organ failure, makes brain swell

Meningitis: Definition, clinical manifestations, bacterial meningitis, diagnose

Definition ◆ Inflammation of the dura, arachnoid, & pia mater of the brain & spinal cord ◆ Can be bacterial, fungal, viral, protozoal ◆ Always assume it is bacterial until proven otherwise Clinical Manifestations ◆ FEVER ◆ HA ◆ NUCHAL RIGIDITY (neck pain) ◆ Photophobia ◆ Lethargy ◆ Disorientation ◆ Memory loss ◆ Positive Kernig's Sign ◆ Positive Brudzinki's Sign ◆ Rash Purpura purple rash is an emergency b/c it means it has spread into the bloodstream ◆ Seizures ◆ IICP Bacterial Meningitis ◆ Transmitted through direct contact, especially droplet ◆ Streptococcus pneumoniae ◆ Neisseria meningitis ◆ MEDICAL EMERGENCY If left untreated there is a 100% mortality rate Diagnose ◆ Lumbar puncture ◆ Bacterial ⇧ WBC, ⇧ Protein, ⬇︎ glucose ◆ Viral ⇧ Lymphocytes, ⇧ Protein, normal glucose

Cushing's Triad: Definition

Definition ◆ Late sign of IICP, medical emergency ◆ Systolic HTN with a widening pulse pressure + bradycardia with a full and bounding pulse + irregular respirations

Seizure Disorders: Definition, causes, assessment

Definition ◆ Transient, uncontrolled electrical discharge of neurons in the brain that interrupts normal function ◆ Symptoms of CNS disturbance (not a disease) ◆ Low threshold increases risk of seizure Causes ◆ Acidosis ◆ F&E imbalances ◆ Hypoglycemia ◆ Hypoxia ◆ Alcohol & barbiturate withdrawal ◆ Dehydration ◆ Water intoxication ◆ Extracranial Heart, lung, liver or kidney disease, SLE, DM, HTN, and septicemia Assessment ◆ Seizure history ◆ Occurrences before, during, and after the seizure Aura, loss of motor or bowel/bladder function, loss of consciousness, postictal (post seizure) state

Cerebral Angiogram: Definition, nursing implications

Definition ✷ Contrast injected into cerebral arteries via femoral catheter ✷ Series of digital computer pics taken ✷ Cerebral blood flow studied Nursing Implications ✷ Pt increase intake of fluids to remove contrast ✷ Lie flat for hours ✷ Monitor CMS

Thyroidectomy: Definition, pre-op care, patient teaching

Definition ✷ Excision of thyroid gland ✷ Usually almost sub-total thyroidectomy 80% to < 90%. Hopefully remaining thyroid will secret T₃ & T₄ Pre-op Care ✷ Administer meds to achieve euthyroidism ✷ Administer iodine to decrease vascularity Patient Teaching ✷ Comfort and safety measures Cut right across the neck. Support head, gentle ROM ✷ Routine post-op care ✷ Talking likely to be difficult post-op ✷ Monitor hormone balance periodically ✷ Reduce caloric intake (or they will gain weight) ✷ Adequate but not excessive iodine intake ✷ Regular exercise ✷ Avoid ⬆︎environmental temperatures ✷ s/s of hypothyroidism

Myelogram

Definition ✷ Injection of dye into the subarachnoid space and use of XRs of the spinal cord and vertebral column to identify lesions ✷ Spinal fluid is withdrawn and dye is injected

Parathyroidectomy: Defintion, post-op

Definition ✷ Partial or complete removal of glands (Remove 3¹/₂). Subtotal parathyroidectomy. ✷ Most commonly done endoscopically ✷ Leads to rapid reduction of Ca⁺⁺ levels Post-Op: What do nurses do? ✷ Observe for s/s of respiratory distress Emergency equipment at bedside ✷ Hypocalcemic crisis or laryngeal nerve damage can occur ✷ Routine post-op care ✷ Teach pt about s/s of hypocalcemia

Bell's Palsy

Definition ✷ Temporary paralysis of the seventh cranial nerve that causes paralysis only on the affected side of the face ✷ Usually follows infection ✷ Commonly associated with CVA diagnosis ✷ Unknown etiology ✷ 70% of time caused by herpes simplex virus Treatment ✷ No real treatment ✷ Recovery is usually full, ≈ 6 weeks What do nurses do? ✷ Mild analgesics ✷ Chew on unaffected side ✷ Dark glasses/artificial tears ✷ Support from family/friends ✷ Moist heat ✷ Gentle massage ✷ Electrical stimulation exercises ✷ Corticosteroids (prednisone) ✷ Acyclovir (Zovirax) ✷ Valacyclovir (Valtrex)

Hypo-proliferative Anemia: Define, Causes, Three Types

Definition ❖ A RBC disorder ❖ Low RBCs Causes ❖ Result of decreased production, increased RBC destruction, or blood loss Three Types ❖ Iron Deficient ❖ Vitamin Deficient ❖ Pernicious

General Anemia: Definiton, causes, labs & diagnostics, what do nurses do?

Definition ❖ A condition in which the blood is deficient in red blood cells, in hemoglobin, and/or in total volume ❖ Classified by cell size and color ❖ Manifestation of a pathologic process Causes ❖ Decreased RBC production d/t deficient nutrients, decreased erythropoietin, decreased iron availability ❖ Blood loss d/t chronic hemorrhage, bleeding duodenal ulcer, colorectal cancer, liver disease, acute trauma, ruptured aortic aneurysm, GI bleeding ❖ Increased RBC destruction d/t hemolysis (Sickle cell disease, medication, incompatible blood, trauma) Labs & Diagnostic Tests ❖ CBC ❖ Stool guaiac test ❖ Endoscopy ❖ Colonoscopy What do nurses do? For patients with fatigue: ❖ Alternate rest and activity ❖ Prioritize activities ・Accommodate energy levels. Arrange activities so you are decreasing competition for O₂ supply. For example, no activity before big meals. ・Maximize O₂ supply for vital functions ❖ Provide assistance to minimize risk for injury ❖ Evaluate nutritional needs ❖ Education ❖ Meds as ordered

Tumor Suppressor Genes: Definition, mutations

Definition ❖ A gene whose protein product inhibits cell division, thereby preventing the uncontrolled cell growth that contributes to cancer ❖ Function to regulate and suppress growth ❖ Prevent cells from going through the cell cycle Mutations Effect ❖ Make them inactive ❖ Result in loss of suppression of tumor growth ❖ Start proliferating rapidly ❖ Ex. BRCA-1, BRCA-2 genes

Myelosuppression: Define, pt at risk for, nadir

Definition ❖ Bone marrow suppression ❖ Most common s/e of chemo ❖ Can be life threatening Reduced amount of circulation number of: ❖ Erythrocytes Anemia leads pt feeling fatigued and tired ❖ Leukocytes (neutrophils) Leukopenia/neutropenia puts pt at risk for infection ❖ Platelets Thrombocytopenia puts pt at risk for bleeding Nadir ❖ Lowest point in which the erythrocytes, neutrophils, or platelets are depressed ❖ Pt is most at risk and feels their worst ❖ Typically around 10 days after chemo treatment ❖ Return to normal 3-4 weeks after nadir

Pernicious Anemia (PA): Definition, causes, reasons for lack of IF, onset, risk factors, symptoms, treatment

Definition ❖ Chronic, progressive macrocytic anemia ❖ Megaloblastic anemia Causes ❖ Deficiency of intrinsic factor which hinders ability to absorb vitamin B₁₂, so an oral supplement would not be absorbed ❖ Antibodies in stomach prevent the production of IF which is essential for B₁₂ absorption ❖ Caused by absence of IF (a protein secreted by the parietal cells) Reasons for Lack of IF ❖ Not enough secreted by stomach ❖ Atrophic gastric mucosa ❖ Autoimmune disease against parietal cells ❖ Autoimmunity against IF ❖ Absence of IF (most common) Onset ❖ Slow & insidious ❖ Can take months to years for s/s to develop ❖ ≈ age 30 Risk Factors ❖ Family history ❖ Hx of autoimmune disease ❖ Scandinavian or Northern European descent Symptoms ❖ Might occur before diagnosis ❖ Affects sensory & motor nerves, GI system, CV system ❖ Neuromuscular manifestions: weakness, paresthesia, ataxia, impaired thought process Treatment B-12 injections

Neutropenia: Definition, stages, causes, s/s, entry points of infection

Definition ❖ Decrease in number of neutrophils (first responder) ❖ Occurs when bone marrow doesn't produce enough neutrophils ❖ Puts patient at increased risk for infection & dying from sepsis Opportunistic & non-pathogenic organisms Stages ❖ 1,000 - 1,500 = mild ❖ 500-1,000 = moderate ❖ < 500 = severe Causes ❖ Infections, viral infections, & HIV ❖ Autoimmune disorders such as Lupus ❖ Certain meds, especially those in chemotherapy & some abx ❖ Radiation therapy ❖ Bone marrow diseases, such as leukemia or myelodysplastic syndromes S/S ❖ Normal s/s of inflammation/infection may not occur ❖ No ability to mount defenses ❖ Minor infections can rapidly lead to sepsis Entry points of infection ❖ Mucous membranes in mouth and throat ❖ Skin ❖ Perineal area ❖ Pulmonary system

Epoetin Alpha (Epogen, Procrit): Definition, admin, supplements, s/e, cautions

Definition ❖ Hematologic growth factor ❖ Erythropoiesis stimulating drug ❖ Effective in treating disorders caused by deficiency in RBC formation Renal failure, chemotherapy, surgery Administration ❖ Sub-Q 2-3 times/week until therapeutic response (2-3 weeks) ❖ Target Hgb 10-12g/dL Any higher and pt is at risk for thromboembolic events ❖ $200-$2800 depending on dose Iron/B₁₂/folic acid supplements? Yes Side Effects ❖ HTN May need to be on anti-hypertensives ❖ Edema Cautions ❖ Not for use in myeloid cancers Increases cancer growth for that type of cancer *Also darbepoetin alfa (Aranesp). Same, same, but longer duration of actions (administer 1x/week)

Iron Deficient Anemia: Definition, causes, S/S, most susceptible

Definition ❖ Most common nutritional disorder in the world ❖ Microcytic-hypochromic Causes ❖ Inadequate dietary intake, loss of blood including menstrual bleeding, bone marrow abnormalities, chemotherapy ❖ In men & post-menopausal women could be a GI bleed, or excess use of aspirins or NSAIDs S/S ❖ Pallor, fatigue, weakness, dyspnea, brittle nails, PICA, HA, low: Hgb, Hct, serum ferritin, serum iron Most Susceptible ❖ Women in reproductive years (b/c of menstruation)

Mitosis

Definition ❖ Normal cell proliferation ❖ Part of eukaryotic cell division during which the cell nucleus divides Body Tissues ❖ Contain undifferentiated cells Stem cells (cell proliferation begins in stem cells) ❖ Stem cells enter the cell cycle to differentiate into certain body tissues Will then function as body tissue until it degenerates and dies When? ❖ Activated only in the presence of cell degenerations/death Normally activated when there is cell death or some physiological need ❖ Activated if the body has a need for more cells

Erythrocytes: Definiton, composition, function, life span

Definition ❖ Red blood cells Composition ❖ Primarily composed of Hgb Hemoglobin = iron (heme) + protein (globin) ❖ Flexible within membranes Function ❖ Transport oxygen and carbon dioxide O₂ from lungs to body & CO₂ from body to lungs. Oxyhemoglobin = O₂ attached to iron on hgb ❖ Transport nutrients ❖ Help maintain acid-base balance b/c Hgb acts as a buffer Life Span 120 days *Lack of Hgb for any reason sets of a chain reaction and is anemia

Protooncogenes: Definition, mutations

Definition ❖ Regulate normal cellular process such as promoting growth ❖ Genetic locks that keep cells functioning normally Mutations Effect Mutations that can alter their expression can activate them to function as oncogenes (tumor inducing genes)

Cancer Development: Promotion

Definition ❖ Reversible proliferation of altered cells Takes months to years. Things can be done to reverse it. ❖ Abnormal cell can become a tumor after initiation of growth is enhanced. ❖ Activities of promotion are reversible Obesity, smoking, alcohol, dietary fat

Chronic Venous Insufficiency (CVI): Definition, S/S, Interventions

Definition ・Inadequate venous return over a long period due to varicose veins or valvular incompetence ・Prolonged venous HTN which stretches the veins and damages the valves. The resultant edema & venous stasis causes venous leg ulcers, swelling, cellulitis. S/S Hyperpigmented lower extremities, edema, cell death, necrotic tissues Nursing Interventions ・Elevation of legs. Sleep with foot of the bed elevated. ・Nutritional status evaluation ・Encourage walking, no prolonged sitting or standing. Avoid pressure to popliteal area. ・Good skin care ・Graduated compression stockings

Multiple Myeloma: Definiton, manifestations, treatment

Definiton ❖ Abnormal antibodies produced by B cells ❖ Malignant tumor of bone marrow Manifestations ❖ Bone lesions, pain, pathologic fractures, hypercalcemia Treatments Plasmaphatesis, chemo

Carcinogens: Defintion, examples, viral carcinogens & resulting cancers

Defintion Substances that may cause cancer when exposed to living tissue Examples Chemicals (tobacco, alcohol), radiation, UV radiation, viruses (HPV) Viral Carcinogens ❖ Epstein-Barr Virus (EBV) ➠ Burkitt's Lymphoma ❖ HIV ➭ Kaposi Sarcoma ❖ Hepatitis B virus ➛ Hepatocellular Carcinoma ❖ Human Papilloma Virus ➨ Squamous Cell Carcinomas

Filgrastim (Neupogen): Definition, MOA, dose, s/e

Defintion ❖ Granulocyte colony stimulating factor ❖ Leukopoietic growth factors MOA ❖ Goal is to produce a rapid ⇧ in number of neutrophils ❖ Shortens time patient is susceptible to life-threatening infections ❖ Immunosuppressed pts/chemo pts Helps keep dosing regimens on schedule Dose ❖ Dose based on ANC Target > 1,000/mcL ❖ Sub-Q or IV SE ❖ Bone pain * Also pegfilgrastim (Neulasta)

Polycythemia Vera

Defintion ❖ RBC disorder ❖ Too many erythrocytes ❖ Blood becomes too thick to flow easily through blood vessels ❖ Increased total blood volume, and severe congestions of tissues and organs ❖ Consider neoplastic and cancerous, those RBCs cannot be donated ❖ Dehydration must be checked for before making a diagnosis

Fluid Volume Deficit

Dehydration ∙ Loss of water only ∙ Increase in concentration of molecules dissolved in water Hypovolemia (ECF volume deficit) ∙ Loss of water and electrolytes Results from: ∙ Abnormal loss of body fluids ∙ Inadequate intake ∙ Plasma-to-interstitial fluid shift (3rd spacing)

During the early phase of ventricular diastole, as the ventricular muscle relaxes, pressure on the remaining blood within the ventricle begins to fall. When pressure within the ventricles drops below pressure in both the pulmonary trunk and aorta, blood flows back toward the heart, producing the *dicrotic notch* (small dip) seen in blood pressure tracings. The semilunar valves close to prevent backflow into the heart. Since the AV valves remain closed at this point, there is no change in the volume of blood in the ventricle, so the early phase of ventricular diastole is called the *isovolumetric ventricular relaxation* phase. In the second phase of ventricular diastole, called *late ventricular diastole*, as the ventricular muscle relaxes, pressure on the blood within the ventricles drops even further. Eventually, it drops below the pressure in the atria. When this occurs, blood flows from the atria into the ventricles, pushing open the tricuspid and mitral valves. As pressure drops within the ventricles, blood flows from the major veins into the relaxed atria and from there into the ventricles. Both chambers are in diastole, the atrioventricular valves are open, and the semilunar valves remain closed. The cardiac cycle is complete.

Describe Ventricular Diastole

Initially, as the muscles in the ventricle contract, the pressure of the blood within the chamber rises, but it is not yet high enough to open the semilunar (pulmonary and aortic) valves and be ejected from the heart. However, blood pressure quickly rises above that of the atria that are now relaxed and in diastole. This increase in pressure causes blood to flow back toward the atria, closing the tricuspid and mitral valves. Since blood is not being ejected from the ventricles at this early stage, the volume of blood within the chamber remains constant. Consequently, this initial phase of ventricular systole is known as *isovolumetric contraction*. In the second phase of ventricular systole, the *ventricular ejection phase*, the contraction of the ventricular muscle has raised the pressure within the ventricle to the point that it is greater than the pressures in the pulmonary trunk and the aorta. Blood is pumped from the heart, pushing open the pulmonary and aortic semilunar valves. *END OF PHASE* Pressure generated by the left ventricle will be appreciably greater than the pressure generated by the right ventricle, since the existing pressure in the aorta will be so much higher. Nevertheless, both ventricles pump the same amount of blood. This quantity is referred to as *stroke volume*. Stroke volume will normally be in the range of 70-80 mL. Since ventricular systole began with an EDV of approximately 130 mL of blood, this means that there is still 50-60 mL of blood remaining in the ventricle following contraction. This volume of blood is known as the end systolic volume (ESV).

Describe Ventricular Systole

Cluster Breathing: Description

Description Clusters of breaths follow each other with irregular pauses in between Location of lesion in a coma pt Medulla or lower pons

Cheyne-Stokes Respiration: Description

Description Cycles of hyperventilation and apnea Location of lesion in a coma pt Bilateral hemispheric disease or metabolic brain dysfunction

Apneustic Breathing: Description

Description Prolonged inspiratory phase or pauses alternating with expiratory pauses Location of lesion in a coma pt Mid or lower pons

Central Neurogenic Hyperventilation: Description

Description Sustained, regular & rapid deep breathing Location of lesion in a coma pt Brainstem between lower midbrain and upper pons

Ataxic (Biot's) Breathing: Description

Description ✷ Completely irregular with some breaths deep and some shallow ✷ Random, irregular pauses ✷ Slow rate. Location of lesion in a coma pt Reticular formation of the medulla

Normal Sinus Rhythm

Description: 60-100 BPM. Each complex complete and all intervals WNL Next step: Monitor patient's condition

Emergency Stroke Management

Determine onset of symptoms Ask when the symptoms started. It can help determine the course of treatment Obtain CT scan immediately! ◆ An ischemic CT scan will look normal ◆ A hemorrhagic would see white ◆ Do no contrast first (b/c it must be done quickly), and then with contrast ◆ Can't have an MRI until pt has a metal screening Ensure patent airway ◆ Perform pulse oximetry ◆ Maintain adequate oxygenation > 95% with supplemental O₂ if necessary ◆ Suction PRN ◆ Position HOB 30° ◆ Keep client NPO until swallow reflex has been evaluated ◆ Remove dentures Assessment ◆ Monitor LOC & VS ◆ Call stroke code or stroke team ◆ NIHSS assessment Establish IV access with NS ◆ Maintain BP Maintain cerebral perfusion (MAP) ◆ IVFs Fluids and electrolytes. Isotonic fluids are good b/c they do not cause fluid shifts and keeps it in the vasculature. Hypo and hyper are bad. Perform baseline lab tests ◆ COAGs, CMP, CBC, type & cross, troponin, CK-MB, lipid panel, EBG, lactic acid ◆ Blood glucose Treat if high/low IICP Interventions ◆ Position head midline ◆ HOB 30° ◆ Institute seizure precautions Quiet, safe environment Prepare for treatment

What are some nursing interventions for patients with RA?

Diagnoses ・Chronic/Acute Pain ・Self-care deficit ・Distrubed body image Assessment Physical, labs, psychosocial needs, functional status, environment concerns, s/s of depression

What patients might benefit from receiving hypotonic IV fluids?

Dialysis patient on diuretic therapy.

Long Acting Nitrates: Differences, Types, Interventions, Teaching

Differences ・Slower onset ・Taken before CP causing situations ・NOT for acute attacks Types ・Isosorbide dinitrate (Isordil) 2x/day ・Isosorbide mononitrate (ISMO, Imdur) 1x/day ・Nitroglycerin Transdermal Patch NTG paste Interventions ・Do not use fingers for ointment ・Transdermal patch placed anywhere above the liver ・On 12 hours/Off 12 hours Teaching ・Self administration of transdermal patch ・Orthostatic hypotension

What are the pharmacodynamics/MOA of bethanechol?

Direct stimulation of the cholinergic (muscarinic) receptor promoting contraction of the bladder and relaxation of the bladder sphincters.

Mucolytics

Directly loosen thick, viscous bronchial secretions by breaking down the chemical structure of mucus molecules.

What does DMARD stand for?

Disease Modifying Anti-Rheumatic Drugs

What are some non-pharmacological pain relief measures that are collaborative interventions and are also cognitive/behavioral measures?

Distraction ∙ Drawing the patient's focus away from the pain and focusing on something else ∙ Mild to moderate pain Guided Imagery ∙ Uses auditory and imaginary processes to affect emotions and help calm and relax. ∙ Relaxation CDs Relaxation Techniques ∙ Not chest breathing ∙ Primary diaphragm breathing ∙ Slow, steady, and deep. Abdomen moves in and out. Hypnosis Humor Therapeutic Touch ∙ Laying on of hands ∙ No physical contact ∙ Direct energy fields Music Therapy

Sympathomimetic

Drug that mimics the sympathetic nervous system (SNS) with the signs and symptoms seen when the SNS is stimulated.

Adjuvant Analgesics Drugs

Drugs that are marketed for indications other than pain, but found to be useful for pain as an off-label use. ∙ Corticosteroids ∙ Anti-psychotics ∙ Antiseizure medications ∙ And others...

K+ and H+ exchange during acidosis

During acidosis, H+ ions move into and accumulate in ICF ・To balance the cations, K+ ions shift out of cells to ECF ・Decreased cellular K+ causes kidneys to retain K+ and hyperkalemia results

S/S of IICP

Early S/S ◆ Altered LOC ◆ Unilateral pupillary dilation Side the pupil is dilated (not constricting) is the side of swelling. This is compressed CN III. Late S/S ◆ Pupils dilated and fixed Ominous sign, very late

Primary Hypertension

Elevated BP without an identified cause (90% to 95% of all cases). Although the exact cause of primary hypertension is unknown, there are several contributing factors. These include changes in endothelial function related to either vasoconstricting or vasodilating agents, increased SNS activity, overproduction of sodium-retaining hormones, increased sodium intake, greater-than-ideal body weight, diabetes, tobacco use, and excessive alcohol intake.

What do positive CK-MB, troponin levels indicate?

Elevation of levels, along with either ischemic symptoms (chest pain) or EKG changes are consistent with MI.

Foot Complications of Diabetes: Etiology, patient teaching

Etiology ✷ Result from combination of micro and macrovascular problems ✷ Sensory neuropathy ➠ loss of protective sensation ➠ unawareness of injury ✷ PAD ⇓ blood flow, ⇓ wound healing, ⇑ risk for infection Patient teaching ✷ Proper footwear, avoidance of foot injury, skin & nail care, daily inspection of feet, prompt treatment of small problems ✷ Monofilament screening

How often should a PIV site be assessed?

Every 4 hours (Mayo Clinic Handout)

How often should IV tubing be changed?

Every 96 hours.

The more forceful the contraction is, the greater the SV and smaller the ESV are. Less forceful contractions result in smaller SVs and larger ESVs.

Explain the relationship between contractility, ESV, and SV.

Any sympathetic stimulation to the venous system will increase venous return to the heart, which contributes to ventricular filling, and EDV and preload. While much of the ventricular filling occurs while both atria and ventricles are in diastole, the contraction of the atria, the atrial kick, plays a crucial role by providing the last 20-30 percent of ventricular filling. And therefore increase SV.

Explain the relationship between venous return, end diastolic volume, preload, and stroke volume.

Allows the action potential to move from the interatrial septum to the interventricular septum, connecting the AV node to the Bundle Branches.

Explain the significance of the fact that the AV bundle is the only electrical connection between the atria and the ventricles.

What is Pyrazinamide (PZA)? Side effects?

First line TB drug; hepatotoxic, GI symptoms, polyarthralgias, skin rash, hyperuricemia.

Types of Seizures

Focal (Partial) ◆ Takes place in one half of the brain ◆ Pt maintains some LOC ◆ Can become generalized ➠ they have an aura (strange sensations to give a sign it is coming) Generalized ◆ A seizure that involves the entire brain ◆ Loss of consciousness

Thrombosis

Formation of fibrin along the wall of the vein

Prevents the backflow of blood between the right atrium into the right ventricle. It typically consists of three flaps, or leaflets, made of endocardium reinforced with additional connective tissue. The flaps are connected by chordae tendineae to the papillary muscles, which control the opening and closing of the valves.

Function & Structure of Right Atrioventricular Valve(Tricuspid)

What are the 4 types of anesthesia? Give a brief description of each.

General ❖ A single or combo agent (Inhaled, IV). ❖ CNS depressed resulting in analgesia, amnesia, unconsciousness, loss of muscle tone & reflexes, loss of somatic, autonomic, and endocrine responses. ❖ 3 phases: Induction, maintenance, emergence. Regional ❖ Briefly disrupts sensory nerve impulse transmission from specific body area or region. ❖ May affect motor function ❖ Pt. remains conscious and able to follow instructions ❖ Gag and cough reflexes remain intact ❖ Sedatives, opioid analgesics, or hypnotics often used as adjuncts. ❖ Types: Nerve blocks, spinal, epidural Local ❖ Mucous membranes, skin, burns ❖ Types: Injectable, topical, opthalmic, nebulized Monitored Anesthesia Care (MAC) ❖ AKA conscious sedation ❖ IV delivery of sedative, hypnotic, and opioid drugs ❖ Reduces LOC but allows pt to maintain patent airway and respond to commands ❖ MAC nursing assessment: Airway, O₂ sats, LOC, ECG, VS q 15-30 min

Cancer: Laboratory/Diagnostic Procedures

Genetic Testing ❖ Does not diagnose presence of cancer ❖ IDs people at high risk before any symptoms appear ❖ Expensive Oncofetal Antigens ❖ AKA: Tumor Markers ❖ Found on tumor cell surfaces, inside tumor cells, and fetal cells ❖ Appearance of fetal antigens is not well understood ❖ May result as cell regains its embryonic capability to differentiate into many cell types CBC with Differential ❖ WBC Either up or down. Part of the body's defense mechanisms. Will change in response to cancer invasion ❖ Platelets Either increased or decreased. Decreased count can suggest leukemia. CMP Includes LFTs Liver Function Studies Imaging ❖ CT ❖ MRI ❖ Ultrasound ❖ X-ray ❖ Bone scan ❖ Mammogram ❖ Positron emission tomography (PET) Endoscopic Examinations Colonoscopy Cytology Studies Pap test, bronchial washings Tissue Biopsy Bone marrow Biopsy ❖ Removal of a tissue sample for pathologic analysis ❖ Various methods Radiologic techniques in conjunction ❖ Only definitive means to dx malignancy Bone Marrow Biopsy ❖ Analysis of bone marrow ❖ Evaluates hematopoiesis (how blood cells originate and blast off) ❖ Sites Posterior iliac crest, anterior iliac crest, sternum ❖ Nursing Responsibilities

Iron Deficient Anemia: Treatment (goal, diagnostic studies, dietary teaching, iron replacement, side effects)

Goal ❖ In order to treat you must first identify the cause ❖ Treat underlying disease causing reduced intake and absorption of iron Diagnostic Studies Labs, CBC, iron, TIBC, bilirubin, stool for occult blood, endoscopy, colonoscopy Dietary Teaching ❖ Foods high in iron ❖ How to maximize absorption Replacement of Iron ❖ Available IV, IM, or PO ❖ Women need 10 mg more a day of iron than men do (18mg for women vs 8 mg for men) Oral Supplements ❖ Best on an empty stomach ❖ Can cause severe gastric upset ❖ Vitamin C enhances absorption ❖ Follow up is necessary as iron deficient anemia can recur ❖ Take for 6-12 months to re-establish iron stores PO Side Effects ❖ Nausea, constipation, dark stool, epigastric pain

What temperature is hyperthermia?

Greater than 100°F or 37.8°C

What are the nursing implications for Heparin (monitor, interactions, antidote, administration)?

HIT (Heparin Induced Thrombocytopenia) Happens ≈ 10 days into drug therapy. An autoimmune reaction that occurs in 30% of patients. Monitor platelet counts. Monitor for Bleeding ・VS: ⇧HR, ⬇︎BP ・Mouth, urine, stool ・Decreased LOC Drug-Drug Interactions Potentiated effects of oral anticoagulants & NSAIDs (aspirin, Ibuprofen) Antidote Protamine Sulfate Administration SubQ ・Ensure that SC doses are given SC, not IM ・SC doses should be given in areas of deep subcutaneous fat, and sites rotated. ・Do not give SC doses w/in 2 inches of: The umbilicus, abdominal incisions, or open wounds, scars, drainage tubes, stomas ・Do not aspirate SC injections or massage injection site IV ・Intravenous doses are double checked with another nurse (Safety, high alert med, need four eyes on it) ・IV doses may be given by bolus (quickly) or IV infusions (slowly) or both ways would be called a loading dose. ・Must use an infusion pump

Atorvastatin (Lipitor): MOA, Effect/Uses, Contraindications, Side/Adverse Effects

HMG-CoA Reductase Inhibitors (Statins) Pharmacodyanmaics/MOA Inhibit HMG-CoA reductase Therapeutic Effect/Uses ・Decrease cholesterol levels LDL, VLDL/Triglycerides ・Increase HDL ・Reduce risk of MI & CVA Contraindications ・Active liver disease ・Pregnancy: Category X Will harm or kill fetus Side/Adverse Effects ・HA ・GI disturbances Give with food ・Hepatotoxicity Monitor liver function with blood tests. ALT & AST. Can cause liver failure. ・Muscle breakdown Rhabdomyolysis (can cause renal failure!). Monitor for myalgia. Urine could look like deep red wine. Muscle tissue ends up in the urine. Increased risk of rhabdo with GF juice

What should you do to hear a COPD patient's heart?

Have them lie on their left side and lean forward. q

What is the rationale behind placing a patient on their left side in Trendelenburg position if they experience an air embolism?

Head is lower than the feet and keeps air in the right atrium to prevent pulmonary embolism.

HIV: Prevention & Early Assessment

Health Promotion ・Emphasis on risk reductions ・Education Sexual activity, drug use, work risks ・Detect HIV infection early Antibody testing with counseling ・FYI Prevention PrEP: Pre-Exposure Prophylaxis Certain at-risk groups are on the meds to prevent transmission

What is a healthy adult sodium intake? What should people with HTN, DM, or CKD restrict sodium too?

Healthy adult: 2300 mg/day Sodium restriction: 1500 mg/day More salt ⟹ more water retained ⟹ higher BP

Erythrocytosis

High numbers of erythrocytes. Hgb & Hct elevate with increased production of RBCs.

The nursing process of the assessment of pain would include:

History (PQRST) ∙ Precipitating factors ∙ Aggravation/alleviation factors ∙ Localization of pain ∙ Character and quality of pain ∙ Duration ∙ Management strategies: ETOH Hx, medication Hx Physical Assessment/Clinical Manifestations

When would you hold nystatin (Mycostatin)?

Hold for mucosal irritation (inspect oral mucous membranes before and frequently throughout therapy)

Antidiuretic Hormone(ADH)

Hormone of posterior pituitary. Chemical class: Peptide *Stimulates water reabsorption by kidneys*.

The catecholamines, epinephrine and NE, secreted by the adrenal medulla form one component of the extended fight-or- flight mechanism. The other component is sympathetic stimulation. Epinephrine and NE have similar effects: binding to the beta-1 receptors, and opening sodium and calcium ion chemical- or ligand-gated channels. The rate of depolarization is increased by this additional influx of positively charged ions, so the threshold is reached more quickly and the period of repolarization is shortened. However, massive releases of these hormones coupled with sympathetic stimulation may actually lead to arrhythmias. There is no parasympathetic stimulation to the adrenal medulla.

How do epinephrine and norepinephrine affect heart rate?

Decreases heart rate. It is parasympathetic and vagus nerve activation(cardioinhibitory center) that releases acetylcholine onto your SA node. This action decreases pacemaker rate by increasing potassium and decreasing calcium and sodium movement. As the pacemaker slows, so does your heart rate

How does acetylcholine affect heart rate?

PR Interval

How long it takes for electricity to go from the SA (atria) Node to the AV Node. 0.12-0.2 seconds Contraction occurs (we hope) Measure from beginning of the P wave to the end of the PR segment (beginning of QRS complex).

IICP Drug Therapy

Hypertonic Solution ◆ 3% NS Helps to pull out extra fluid & put in vasculature so cells will shrink Osmotic Diuretics ◆ Pulls excess fluids out and decreases ICP ◆ Mannitol (Osmitrol) Pulls it in ◆ ➠ Furosemide Pees it out Coritcosteroids ◆ Anti-inflammatory, also tightens up vessels and fenestrations in the brain ◆ dexamethasone (Decadron) Barbiturates ◆ Induced coma to keep brain calm ◆ pentobarbital (Nembutal) Anticonvulsants ◆ High risk for seizure ◆ phenytoin (Dilantin)

Hemorrhagic Stroke: Treatment

IICP Interventions Diuretics NO anticoagulants Would not want pt to bleed any more if they are already bleeding in the brain HTN Management ◆ Not too high/too low b/c we need brain perfused based on their MAP ◆ MAP Seizure Prevention Prophylactic (phenytoin) Surgical Intervention

Why is it important to manage pain postoperatively?

If pain in not controlled the pt. may not be able to participate in all of the activities they need to do in order to get better and prevent complications.

What are the 5 types of Antibodies/immunoglobulins? Which is the most abundant?

IgG (76%) Principle in human serum. Moves across placenta giving the infant the mother's immunity. Secondary immune response. IgA (15%) Found in breast milk, respiratory and GI mucous, saliva, tears. IgM (8%) Controls ABO blood groups, primary immune response IgD (1%) Present on surface of B-lymphocytes and serves as antigen receptors IgE (0.002%) Attaches to mast cells in respiratory and GI tract. Major role in allergic reactions and parasitic infections.

Cancer: Immune System Role (response, surveillance, cells)

Immune Response ❖ Immune response is reject or destroy cancer cells May be inadequate as cancer cells arise from normal human cells Immunologic Surveillance ❖ Some cancer cells have changes on their surface antigens Tumor-Associated Antigens (TAAs) ❖ Immunologic Surveillance is response to TAAs ❖ Lymphocytes continually check cell surface antigens to detect and destroy abnormal cells ❖ Involves cytotoxic T cells, natural killer cells, macrophages, and B cells Cytotoxic T-Cells ❖ Recognize TAAs ❖ Kill tumor cells directly ❖ Produce cytokines Natural Killer Cells & Activated Macrophages ❖ Lyse tumor cells B Cells ❖ Summoned in by T-cells ❖ Produce antibodies that bind to tumor cells

Innate Immunity

Immunity that is present before exposure and effective from birth. Responds to a broad range of pathogens.

Acquired Immunity

Immunity that is present only after exposure and is highly specific.

Thrombocythemia (thrombocytosis)

Increase in platelets. increased risk for clots (thrombosis)

Interactions between a patient's current medications and anesthesia can either _______ or __________ the desired effects of anesthetics.

Increase or decrease.

Hypercoagulability

Increased ability of the blood to coagulate

When a patient has fluid volume deficit, what is their pulse like? BP?

Increased pulse; decreased BP

How is metabolic acidosis compensated?

Increased respiratory rate

What does epinephrine do when it stimulates Beta₁?

Increases HR (tachycardia), myocardial contraction, and BP

Why is asking a patient to pump their fist after a tourniquet application not best practice?

Increases K+ levels and ionized Ca+ levels leading to inaccurate results.

What does epinephrine do when it stimulates Alpha₁?

Increases force of heart contraction and BP

What does glucagon do and how?

Increases the release of glycogen from the liver to raise blood sugar.

Parenteral Iron: Indications, injection method, high risk

Indications ❖ Malabsorption ❖ Oral iron intolerance ❖ Need for beyond normal iron limits ❖ Poor patient compliance Injection Method ❖ Z-track To prevent stain in skin * High risk for allergic/anaphylactic reactions* Do test dose before first dose & be cautious

What is the action of cholinergic agonists?

Induce rest & digest.

What are the drug-lab-food interactions of Nifedipine (Procardia)? Nursing interventions?

Interactions ・Increased hypotension with other anti-hypertensives ・Increased bradycardia with beta-blockers or digoxin ・Increased medication effects with grapefruit juice Effects the enzymes in the liver Interventions ・VS ・Do not crush SR tablets ・No grapefruit juice

Atrial Fibrillation (atrial flutter)

Irregularly irregular. The atria are being stimulated at a very fast rate. This results in a quivering of the atrial heart muscle. The ECG shows several small P waves before each QRS complex.

If a patient's lab values are normal, what kind of fluids do you give them?

Isotonic solutions.

Why is the median antebrachial vein a poor choice for veinipuncture?

It can be painful because it is close to the nerves.

How is addiction a barrier to effective pain management and how can it be overcome?

It is a complex, neurobiological condition characterized by a drive to take substances for other than the prescribed, therapeutic value. Impaired control over drug use. Compulsive drug use. Continued despite the harm it causes. Craving.

How is tolerance a barrier to effective pain management? How can this obstacle be managed?

It is a state of adaptation in which exposure to a drug induces changes in it's effect over time. The client will require increased opioid doses to maintain the same degree of pain control. To counteract this, assess for disease progression and presence of infection. Consider rotating to a different opioid.

When sodium levels are low, what does the adrenal cortex do?

It secretes aldosterone which stimulates renal tubules to conserve water and sodium, thus helping to normalize ECF Na+ levels.

Treatment of Active TB

Aggressive treatment using 4 drugs (RIPE) ∙ Initial phase = all 4 drugs daily x weeks ∙ Continuation: INH & RIF daily x 126 doses (18 weeks) or twice-weekly INH and RIF doses for 36 doses (18 weeks)

What are some causes of respiratory acidosis?

Airway obstruction, depression of the respiratory center, emphysema, pulmonary edema, sedative overdose, COPD, mechanical hypoventilation, atelactasis, severe pneumonia.

Types of Chemo Agents

Alkylating agents cyclophosphamide (Cytoxan) Antimetabolite Agents ❖ Reduce needed elements that cancer cells need to grow ❖ methotrexate (Rheumatrex) Antitumor Antibiotic ❖ Can kill cancer cells much more cytotoxic than traditional abx ❖ doxorubicin (Adriamycin) Alkaloids vincristine (Oncovin)

Labetalol (Trandate, Normodyne)

Alpha₁ & non-selective Beta Blocker Ends in -alol b/c it also blocks alpha₁ Uses HTN Caution ・May cause BRONCHOSPASM ・Orthostatic hypotension It causes vasoconstriction really quickly

Right Sided Heart Failure

Also known as Cor Pulmonale

Name two protozoal infections and their associated medication treatments.

Amebic Dysentery Metronidazole (Flagyl) Malaria Chloroquine (Aralen)

Isolated Systolic Hypertension (ISH)

An average SBP of 140 mm Hg or more, coupled with an average DBP of less than 90 mm Hg. SBP increases with aging. DBP rises until approximately age 55 and then declines.

Action Potential and Contraction of Contractile Fibers

An impulse in a ventricular contractile fiber is characterized by rapid *depolarization*, *plateau*, and *repolarization*. Cardiac muscle cells undergo twitch-type contractions with long refractory periods followed by brief relaxation periods. *The relaxation is essential so the heart can fill with blood for the next cycle.* The refractory period is very long to prevent the possibility of tetany, a condition in which muscle remains involuntarily contracted. In the heart, tetany is not compatible with life, since it would prevent the heart from pumping blood.

Agonists MOA

An opioid analgesic that binds to an opioid pain receptor in brain causing analgesia (reduction of pain sensation) Examples: ∙ morphine ∙ Pain ∙ meperidine (Demerol) ∙ fentanyl ∙ codeine ∙ hydrocodone (+ acetaminophen = Vicodin/Norco) ∙ hydromorphone (Dilaudid) ∙ methadone ∙ oxycodone (+ acetaminophen = Percocet)

Cancer tumors can by classified by...

Anatomic Site Tumor identified by tissue of origin and tumor behavior (i.e. bone = osteosarcoma, malignant vs benign) Histology ❖ Classifies cellular aspects of the cancer ❖ Grades I through IV Grade I is better, grade IV means cells are undifferentiated, more immature, and unruly ❖ Based on cell appearance and activity Compares cancer cell with normal tissue from which it arose Extent of Disease/Staging ❖ Classifies clinical aspects of the cancer ❖ Determines exact location and degree of metastasis (if any) ❖ Clinical staging, TNM classification system Clinical Staging 0: Cancer in situ (neoplasm, but localized & not showing tendency to invade) 1: Tumor limited to tissue of origin; localized tumor growth 2: Limited local spread 3: Extensive local and regional spread 4: Metastasis

TNM Classification System

Anatomic extent of the disease is based on three parameters: ❖ Tumor size & invasiveness (T) ❖ Spread to lymph nodes (N) ❖ Metastasis (M) Primary Tumor (T) T₀: No evidence of primary tumor Tis: Carcinoma in situ T ı-₄: Ascending degrees of increase in tumor size and involvement Regional Lymph Nodes (N) N₀: No evidence of disease in lymph nodes Nı-₄: Ascending degrees of nodal involvement Nx: Regional lymph nodes unable to be assessed clinically Distant Metastases (M) M₀: No evidence of distant metastases Mı-₄: Ascending degrees of metastatic involvement, including distant nodes Mx: Cannot be determined

ACE Inhibitors

Angiotensin Converting Enzyme Inhibitors block the conversion of angiotensin I to angiotensin II. Avoiding Angiotensin II may avoid increased blood pressure and vasoconstriction. They usually have the suffix "PRIL"

Thyrotropin/Thyroid Stimulating Hormone(TSH)

Anterior pituitary hormone that triggers secretion of thyroid hormones by the thyroid gland.

What is the therapeutic classification of warfarin (Coumadin)? Pharmacologic?

Anticoagulant; Coumarins

What is the therapeutic classification of nystatin (Mycostatin)?

Antifungal

Calcium Channel Blockers: Names, MOA, & Results

Are Very Nice Drugs Amlodapine Verapamil Nifedipine Diltiazem Calcium channels found in the myocardium and arterial smooth muscle. Ca++ increases contractility, peripheral resistance, and BP. These drugs block these effects. MOA Causes smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction. Results Causes decreased peripheral smooth muscle tone & decreased systemic vascular resistance leading to decreased contractility, decreased conductivity of the heart, decreased demand for oxygen, and decreased blood pressure.

What are the ABCDEs of pain management?

Assess Assess for pain and ask about pain Believe Believe the patient's account of pain description Choose Choose the most appropriate pain control options Deliver Deliver possible therapeutic interventions in a timely, logical, and coordinated manner Empower Empower and enable patient to have pain control

Post-Op Fever: Assessment, Interventions

Assessment Teach pt to take temp at home at same time everyday Interventions ❖ Measure temp q4h for first 48 hrs post-op ❖ Encourage airway clearance ❖ CXR ad cultures if infection spread ❖ Asepsis w/wound and IV sites ❖ Antipyretics and body-cooling as indicated0

Allergic Reaction/Anaphylaxis: Assessment & Diagnostic Tests

Assessment ❖ History & Physical So imortant! Family hx of allergies, hx of allergen exposure, reaction... Diagnostic Tests ❖ CBC with differential Eosinophil count & basophils both ⬆︎ with reaction ❖ Serum IgE ❖ Skin Testing

Atrial Systole

Atria Status: *Contracted* Ventricles Status: *Relaxed* AV Valves: *Open* Semilunar Valves: *Closed* Pressure L. Atrium: *High* Pressure L. Ventricle: Pressure Aorta:

Ventricle Diastole

Atria Status: *Relaxed* Ventricles Status: *Relaxed* AV Valves: *Closed* during the isovolumetric ventricular relaxation phase. *Open* during the late ventricular diastole phase. Semilunar Valves: Closed Pressure L. Atrium: Opposite of below. Pressure L. Ventricle: *Higher* than atria in isovolumetric ventricular relaxation phase. *Lower* than atria in late ventricular diastole phase. Pressure Aorta: *Lower* than ventricles at very start but quickly becomes higher as ventricles continue to relax and the semilunar valves close.

Immune Thrombocytopenic Purpura (ITP)

Autoimmune platelet destruction is a common cause of thrombocytopenia and should be supsected in patients with echymoses, petechiae, mucosal bleeding, and no other obvious causes of thrombocytopenia (ex- medications, bone marrow failure) .

Mean Arterial Pressure (MAP)

MAP = (SBP + 2DBP) ÷ 3 Need > 60 mmHg under most conditions When treating hypertensive emergencies, the mean arterial pressure (MAP) is often used instead of BP readings to guide and evaluate drug therapy. The initial goal is to decrease MAP by no more than 20% to 25%, or to decrease MAP to 110 to 115 mm Hg. If the patient is clinically stable, drugs can be titrated to gradually lower BP over the next 24 hours. Lowering the BP too quickly or too much may decrease cerebral, coronary, or renal perfusion. This could cause a stroke, MI, or renal failure. *** Anytime you see a BP listed on the NCLEX calculate the MAP

NSAIDs

MOA ∙ Inhibits prostaglandin synthesis. ∙ COX-1 & COX-2 enzymes produce prostaglandins. ∙ Prostaglandins promote inflammation, pain, and fever Non-Selective NSAIDS: block COX-1 & COX-2 enzymes ∙ Indomethacin (Indocin) ∙ Ibuprofen (Motrin, Advil) ∙ Ketorolac (Toradol) ∙ Naproxen (Aleve) *** These should only be used for a short period of time. Otherwise, use a selective one. Selective NSAIDS: block only COX-2 enzymes ∙ Produces effect without the adverse effects associated with COX-1 inhibition (GI upset/ulceration, renal impairment, bleeding tendencies) ∙ Celecoxib (Celebrex) ∙ Concern: increased risk of CV effects (MI, CVA, heart failure)

Anemia: The Three Classifications

Macrocytic/Normochromic Large cells, WNL Hgb Microcytic Hypochromic Small cells, deficient in Hgb Normocytic-Normochromic Normal size & Hgb

What circumstances warrant an 18 gauge IV?

Major trauma or surgery, blood administration

Brain Injury: Manifestations, Treatment

Manifestations ◆ Widening pulse pressure ◆ Bradycardia ◆ Irregular breathing &/or bradypnea ◆ Hyper- or hypothermia ◆ Changes in LOC ◆ Pupillary constriction Treatment ◆ Oxygenation/ventilation ◆ Support circulation ◆ Prevent/reduce IICP Treat hypoxia, hypercapnia, proper positioning, prevent seizures, maintain normal temp ◆ Prevent/reduce cerebral edema ◆ ICP monitoring ◆ Treatment of hydrocephalus

Angle of Louis (sternal angle)

Manubriosternal angle, the articulation of the manubrium and body of the sternum, continuous with the second intercostal space.

Anemia Caused by Blood Loss: May be, what to do

May be: ❖ Acute Sudden hemorrhage ❖ Chronic Sources similar to those of iron-deficiency anemia Regardless of Cause: ❖ ID source and stop the bleeding first ❖ IVF to replace volume ❖ PRBC transfusions ❖ Supplements as needed (iron, B₁₂, Folate)

U Wave

May follow T wave Repolarization of Purkinje fibers Sign of hypokalemia

Other than SBP/DBP what else do we look at with blood pressure?

Mean Arterial Pressure (MAP)

Cerebral Blood Circulation & Stroke

Measurement of blood flow to localize where cognitive operations occur in the brain

DKA & HHNKS: What do nurses do?

Monitor ◆ IV fluids ◆ Insulin therapy ◆ Electrolytes (especially K⁺) Assess ◆ Renal status ◆ Cardiopulmonary status ◆ LOC Patient Teaching for Prevention ◆ Ketone testing ◆ Sick day protocol

Thyroidectomy: Post-op Care

Monitor for complications ✷ Hypocalcemia The parathyroid glands are in the thyroid and without them/or fewer of them they may not produce calcium. Watch for numbness & tingling around the lips ✷ Hemorrhage The thyroid gland is highly vascular ✷ Laryngeal nerve damage Vocal cord damage, trach damage ✷ Thyrotoxic crisis ✷ Maintain patent airway/monitor for airway obstruction Emergency equipment at bedside (suction, O₂, trach tray) ✷ Monitor for laryngeal stridor Be concerned! Airway obstruction ✷ IV calcium readily available ✷ Assess for signs of hemorrhage or tracheal compression Difficulty breathing, feeling of fullness at neck, check dressing, too much swallowing??? They could be swallowing blood. Q2 hours during first 24 hours. ✷ Semi-Fowler's position; support head with pillows ✷ Avoid neck flexion and tension on suture line ✷ Monitor VS & Ca⁺⁺ levels

Neutropenia: What do nurses do?

Monitor for s/s of infection at entry points ❖ Sore throat, dysphagia, ulcerative lesions in the mucosa, diarrhea, rectal lesions, vaginal itching/discharge, SOB, non-productive cough ❖ Report minor complaints ➭ sepsis Safety Alert: Low grade fever ❖ Very important ❖ May indicate infection ➭ sepsis ❖ Neutropenic fever ≥ 100.4 ℉ (38℃) ❖ Blood cultures STAT & antibiotics w/in 1 hour ❖ Education-neutropenic precautions ❖ Meds as ordered Neutropenic Precautions ❖ HAND WASHING ❖ Reverse isolation ❖ Screen visitors for infection Educate about hand washing. PPE may be necessary ❖ Avoid crowds ❖ Bathe/shower daily ❖ Brush teeth w/soft toothbrush 4x/day ❖ No gardening No fresh flowers. No fresh fruit or veg in room. ❖ No pet poop duty ❖ Diet low in bacteria

What are some signs/symptoms of hypocalcemia?

Most Common: Nerve transmission, muscle and heart function changes Neuro Anxiety, confusion, irritability, seizures CV V-fib, heart block, EKG changes Neuromuscular Paresthesia (toes, fingers, face), twitching, muscle cramps, laryngo- and bronchospasm, tetany, positive, Trousseau's and Chvostek's sign GI Diarrhea

What circumstances warrant a 14-16 gauge IV?

Multiple trauma, heart surgery, transplantation

How do you convert Celsius to Fahrenheit?

Multiply the temperature by 1.8 and add 32. (C × 1.8) + 32 = F°

What are the receptors of the Parasympathetic (Cholinergic) Nervous System?

Muscarinic Nicotinic

Myxedema; Myxedema Coma

Myxedema Patients with severe, long-standing hypothyroidism may display myxedema, which alters the physical appearance of the skin and subcutaneous tissues with puffiness, facial and periorbital edema, and a masklike affect. Myxedema Coma The mental sluggishness, drowsiness, and lethargy of hypothyroidism may progress gradually or suddenly to a notable impairment of consciousness or coma. This situation, termed myxedema coma, is a medical emergency. Myxedema coma can be precipitated by infection, drugs (especially opioids, tranquilizers, and barbiturates), exposure to cold, and trauma. It is characterized by subnormal temperature, hypotension, and hypoventilation. Cardiovascular collapse can result from hypoventilation, hyponatremia, hypoglycemia, and lactic acidosis. For the patient to survive myxedema coma, vital functions must be supported and IV thyroid hormone replacement administered.

What are the side effects/adverse reactions of systemic glucocorticoids (prednisone, methylprednisolone)?

N/V/D Increased blood sugar Increased appetite Mood changes Ecchymosis HTN Osteoporosis Muscle wasting Infection Abnormal fat deposits Sodium/water retention Euphoria/psychosis Thinned skin with purpura Increased IOP Peptic ulcers Tachycardia Thrombophlebitis Embolism

What are the intermediate acting insulins? What is the onset, peak, and duration of intermediate acting insulin?

NPH (Humulin N, Novolin N) Onset: 1.5-4 hours Peak: 4-12 hours Duration: 12-18 hours Give them food about an hour or two after administration.

Physical Patient Prep: Why NPO? Why bowel prep? Skin prep? Pre-op meds?

NPO Status ◇ Prevents aspiration ◇ 6-8 hours prior. Last clear fluids 2 hours prior ◇ PO Meds? It depends Skin Prep ◇ Make sure area is clean to prevent microbes ◇ Clorhexadine ◇ Most use clipper for hair nowadays. Maybe an electric razor Bowel Prep ◇ GI surgery. Not everyone needs it. Usually GI or GU ◇ Done when there is an increased risk for contamination ◇ Enema, laxatives, stool softener Pre-Op Meds ◇ Antibiotics, benzos, antiplatelets, opioids, antiemetics ◇ Scheduled vs "on-call"

Name some medications used to treat SLE and the reasons for each

NSAIDs Joint pain and swelling Antimalarial Meds Fatigue, skin and joint problems Corticosteroids Severe exacerbations (topical for rashes) Immunosuppressive Medications Reduce the need for corticosteroids Anticoagulants Treatment of blood clots Anticonvulsants Treatment of seizures, phenytoin (Dilantin)

What is the reversal agent for opiods?

Naloxone

Cranial Nerve VI: Name, S/M/B, Function, Test

Name Abducens Motor Function To the lateral rectus of the eye. One eye movement. How to Test ◆ III, IV, & VI are always tested together ◆ Examine each eye independently and together ◆ Follow pen light

Cranial Nerve VIII: Name, S/M/B, Function, Test

Name Acoustic Sensory Function ◆ Hearing Innervates Wernicke's Area to say we are hearing something and Wernicke's will tell us what we are hearing ◆ Also taste with the posterior tongue How to Test Cover one ear, rub fingers together, close eyes while standing to check equilibrium. Tuning fork, audiometer

Cranial Nerve VII: Name, S/M/B, Function, Test

Name Facial Both Function ◆ Motor: Facial muscles of expression ◆ Sensory: Taste from anterior 2/3 of tongue How to Test Have pt smile, puff out cheeks, taste something

Cranial Nerve IX: Name, S/M/B, Function, Test

Name Glossopharyngeal Both Function ◆ Receives general somatic sensory fibers from the tonsils, the pharynx, the middle ear and the posterior 1/3 of the tongue. ◆ Receives special visceral sensory fibers (taste) from the posterior 1/3 of the tongue ◆ Motor innervation to the stylopharyngeus muscle, visceral motor innervation to the parotid gland How to Test Check the gag reflex, say "Ah"

Cranial Nerve XII: Name, S/M/B, Function, Test

Name Hypoglossal Motor Function Tongue movement How to Test Stick tongue out, move side to side

Cranial Nerve III: Name, S/M/B, Function, Test

Name Oculomotor Motor Function Pupil dilation How to Test ◆ Examine each eye independently & together ◆ Check constriction of pupils ◆ III, IV, & VI are always tested together ◆ Flashlight, pupils size chart, mm ruler

Cranial Nerve II: Name, S/M/B, Function, Test

Name Optic Sensory Function Sight. Sends info to occipital lobe. How to Test Snellin chart. Test each eye separately & together. IT is okay to wear glasses. Opthalmic scope.

Cranial Nerve XI: Name, S/M/B, Function, Test

Name Spinal Accessory Motor Function Head turning & shoulder shrugging How to Test Shrug shoulders, turn head side to side against resistancee

Cranial Nerve V: Name, S/M/B, Function, Test

Name Trigeminal Both Function ◆ Senses stuff on the face and in the eyes ◆ Motor of mastication How to Test ◆ Cotton or sharp object on face ◆ Cotton wisp in eye ◆ Clench jaw

Cranial Nerve IV: Name, S/M/B, Function, Test

Name Trochlear Motor Function To one eye movement muscle, the superior oblique muscle How to Test ◆Examine each eye independently & together ◆ Ask pt to follow pen light ◆ III, IV, & VI are always tested together

Cranial Nerve X: Name, S/M/B, Function, Test

Name Vagus Both Function ◆ HR regulations ◆ Respiratory drive ◆ Swallowing, talking, coughing ◆ Chemoreceptors & baroreceptors of aortic arch ◆ Taste from epiglottic region ◆ Palate elevation How to Test Check the gag reflex, say "Ah"

What can we give someone who has taken too much morphine/opioids?

Narcan

What is the most common post-op complication? Which individuals are most at risk of this?

Nausea and vomiting; Females, hx of motion sickness, obesity, abdominal or GI surgery

Why is it important to think of our patients in terms of albumin and calcium?

Nearly half of Ca is bound to protein albumin, serum protein abnormalities. So if the patient is low in albumin, they may be low in calcium. So, we need to draw an ionized level of Ca level to see what level our calcium is truly that is performing those functions.

What information do you need to include when labeling your IV insertion site?

Needle gauge, date, time, initials

Neural Stimulus

Nerve fibers stimulate hormone release.

How can we best assess for cellular swelling when giving hypotonic IV fluids?

Neuro assessment. The fluids will be moving towards the cells.

Pre-Op Physical Assessment Considerations

Neurologic Cognitive function - Many contributing factors, confusion in elderly, sedations, slow metabolism, dehydration, hypothermia Integumentary Hx of pressure ulcers? Any area that was previously a wound & healed is only ever 80% as strong Musculoskeletal Report problems affecting neck or lumbar spine to ACP b/c anesthesia must maintain a patent airway and we need to know how to position them Respiratory Reproductive F&E Status Because we make patients NPO

What are some signs/symptoms of hypernatremia?

Neuromuscular Twitching, hyperreflexia, ataxia, tremors Early Signs Restlessness/agitation, thirst, anorexia, n/v Later Signs Weakness, lethargy, confusion, stupor, seizures, coma➡️death Low Grade Fever Flushed Skin Intense Thirst If sodium gain: Hypervolemia, increased BP, bounding pulse, dyspnea If water loss: Hypovolemia, dry mucous membranes, oliguria, orthostatic hypotension

List 3 possible causes of a hematoma related to IV therapy

Nicking the vein, inadequate pressure, applying the tourniquet too tightly, not pulling the tourniquet

Would you give hydrochlorothiazide to someone who can't breathe?

No, because it is not going to work as fast.

Is socioeconomic status modifiable or non-modifiable?

Non-modifiable.

Propanolol (Inderal): Uses & Cautions

Non-selective β₁ & β₂ antagonists Uses HTN, angina, cardiac dysrhthmia/arrhythmia Caution May cause BRONCHOSPASM, b/c of β₂ blocking effect

What are the four classifications of pain meds?

Nonopioids, Opioids, Adjuvants, Muscle Relaxants

If your pt. has a normal BP what treatment/follow-up should they have? Elevated BP?

Normal BP Encourage healthy lifestyle to maintain normal BP, re-evaluate yearly Elevated BP Recommend healthy lifestyle changes, re-evaluate in 3-6 mos

Vesicular Breath Sounds

Normal breath sounds. Soft, low-pitched, gentle.

First Spacing

Normal distribution between ECF and ICF

Coronary Artery Disease (CAD) & Angina: Nursing Diagnoses

Nursing Diagnoses ・Ineffective therapeutic regimen management (prevention) ・Ineffective Tissue Perfusion (cardiac) ・Acute pain ・Anxiety ・Activity intolerance

Decreasing symptoms/promoting well-being in a patient with DM: Nutritional therapy, exercise, drug therapy, self-monitoring

Nutritional Therapy ◇ Paramount for pts with diabetes ◇ Goal: Maintain optimum body weigh & control blood glucose levels ◇ Food intake should equal available insulin & metabolic needs ◇ Register dietician/CDE Exercise ◇ Obtain medical clearance first ◇ Monitor blood glucose Glucose lowering effect up to 48 hours after exercise ◇ Monitor blood glucose before, during, and after exercise ◇ Do not exercise if blood glucose level > 300 mg/dL and if ketones are present in urine. Glucose is not getting into the cells, if you exercise in this state, the cells are going to starve even more ◇ Exercise 1 hour after a meal ◇ Snack during exercise to prevent hypoglycemia ◇ Minimum amount of 150 minutes/week aerobic exercise ◇ Resistance training 3x/wk Benefits: ◆ ⇩Insulin resistance & blood glucose ◆ Weight loss ◆ ↓triglycerides and LDL, ⬆︎HDL ◆ Improve BP & circulation Drug Therapy ◇ 3 major types of glucose lowering agents (GLAs) Insulin, oral agents (OAs), noninsulin injectable agents Self-monitoring blood glucose (SMBG) ◆ Enables decisions regarding diet, exercise, and meds ◆ Accurate record of glucose fluctuations ◆ Helps identify hypo- and hyperglycemia ◆ A must for insulin users ◆ Frequency of testing varies ◆ Alternate site testing Do not recommend alternate sites when pregnant, symptoms of hypo- or hyperglycemia, if they've been fluctuating Continuous Glucose Monitoring (CGM) ◆ Sensor inserted subcutaneously under skin ◆ Displays glucose values with updating every 1 to 5 minutes ◆ Helps identify tracks and patterns ◆ Alerts to hypo- or hyperglycemia

Nursing Interventions: Antiplatelets

Observe for signs of bleeding Education ・Do not mix with alcohol or other anticoagulants w/o MD consultation ・Notify all MDs about use ・D/C one week before surgery ・GI distress Take with food/fluids, notify immediately ・Report side effects Bleeding, tinnitus, HA, dizziness, GI symptoms, visual changes, seizures

Hypertensive Crisis

Occurs at SBP > 180mm Hg and/or DBP > 110mm Hg. Hypertensive Urgency develops over hours to days and does not have clinical evidence of target organ disease. It may not require hospitalization to correct. Hypertensive Emergencies have target organ diseases and most often require hospitalization for prompt, controlled reduction of BP.

Managing Pain in Older Adults

Older patients are at greater risk for under treatment due to: ∙ Cognitive impairments ∙ Higher risk of GI bleeding form NSAIDS ∙ Risk of drug interactions *Older people are also at risk of over-treatment due to higher peak effect and longer duration

How are the boxes in an ECG broken down by seconds?

One small box = 0.04s 5 small boxes = 0.2s (equal one large box) 5 large boxes = 1s

What is the onset, peak, and duration of IV furosemide?

Onset: 5 min (Great for emergencies) Peak: 20-30 min Duration: 2 h *Push slowly for IV due to risk of ototoxicity

What is the onset, peak, and duration of PO furosemide?

Onset: < 60 min Peak: 1-4 h Duration: 6-8 h

Routes of Administration for Opioids

Oral Nasal Transdermal Rectal Subcuteneous IM IV PCA (patient controlled analgesic) Intraspinal

What fluids should a patient suffering from Hypernatremia with Hypovolemia (water loss) receive?

Oral or IV D5W

Opioid-Nonopioid Combination Drugs

Other drugs added to the opioid to assist in relieving pain ∙ NSAIDS ∙ Acetaminophen ∙ ASA ∙ Antidepressants ∙ Anticonvulsants ∙ Corticosteroids Positive effects = smaller dose of opioid = less side effects

Calcium Regulation

Our bones stores approximately 99% of Ca+. ・The small intestines absorb Ca+ but we need vitamin D for this to take place. ・Vitamin D promotes absorption through the intestines and then Ca+ reabsorption from bone thereby increasing Calcium levels.

Where do you hear bronchial breath sounds?

Over the TRACHEA and LAYRNX Duration: Inspiration is < Expiration High pitched, hollow and loud sound.

Where do you hear bronchovesicular breath sounds?

Over the main bronchi anteriorly, between the scapula posteriorly. I = E Medium pitch and intensity, blowing sound.

Where do you hear the vesicular breath sounds?

Over the remaining lung field (apex and periphery) I > E Soft, low pitched, breezy sound

What is a normal interval value for a PR? QRS? QT?

PR interval: 0.12-0.2 seconds QRS interval: 0.06-0.1 seconds QT interval: 0.34-0.43 seconds

What 2 hormones work together to regulate calcium balance?

PTH & calcitonin

Breakthrough Pain

Pain that occurs between doses of pain medication. Give them a small amount of something that will work quick for a shorter amount of time until their next true dosage. Treat with something short acting (usually an IV route).

Besides the kidneys and Vitamin D, how else are serum calcium levels regulated?

Parathyroid Hormone (PULLS) Excreted by cells of parathyroid gland when there is a decrease in Ca+ levels. Helps Ca+ levels by drawing Ca+ from the bones and promotes transfer of Ca+ and phosphorus into plasma = increase in serum Ca+ levels. Calcitonin (KEEPS) When Ca+ levels are elevated, the thyroid gland excretes calcitonin. The calcitonin then tells the bones to reabsorb Ca+ or, it could also tell the kidneys to start excreting additional Ca+. Phosphorus & pH -- BOTH HAVE INVERSE RELATIONSHIP WITH Ca++

Hematocrit (Hct) Normal Range

Percentage of erythrocytes in a volume of blood. Hgb × 3 Male 42%-54% [0.42-0.54] Female 36%-48% [0.36-0.48]

What is the antidote that can be used if a patient experiences extravasation from an IV adrenergic agonist?

Phentolamine Mesylate

Stroke Nursing Interventions: Post-acute & Chronic

Post-Acute Phase ◆ Q 2 hour positioning ◆ Skin, mouth, eye care ◆ AROM/PROM ◆ SCDs ◆ Gag reflex ◆ Feeding Avoid thin liquids, place in high Fowler's Chronic Phase ◆ Neglect syndrome ◆ Hemianopsia Homonymous Hemianopsia, loss of vision in half visual field ◆ PT/OT/ST ◆ Fluids/fiber ◆ Bowel care ◆ Express feelings ◆ Independence ◆ Assistive devices

Epinephrine

Primary and most potent catecholamine hormone secreted by the adrenal medulla in response to short- term stress; also called adrenaline.

Atherosclerosis: Process, S/S, Treatment Goals

Process 1. Injury to artery endothelial cells HTN, DM, increased lipids, infection ➨ Inflammation 2. Macrophages rush to injured area, release enzymes & O₂ radicals, oxidized LDL 3. Macrophages eat oxidized LDL -- Foam cell 4. Fatty streaks develop over time 5. Fibrous plaque w/platelet adhesion S/S Inadequate tissue perfusion, chest pain associate with stress or exercise Treatment Goals Lower LDL cholesterol, control BP, blood sugar

Decannulation

Process of removing tracheostomy tube

Nociception

Processing of pain signals in the brain that gives rise to the feeling of pain.

What does epinephrine do when it stimulates Beta₂?

Promotes bronchodilation

What does antidiuretic hormone (ADH) do?

Promotes retention of water by kidneys, secreted by the pituitary. This makes the body hold onto water, then the kidneys tell the body to produce more RBC's which will increase blood volume and it was also tell the body to increases sodium and water which will also increase blood volume.

What are some side effects of RIF?

RIF is a first line TB drug. Side effects include: Cutaneous reactions, GI disturbance, hepatotoxicity, orange discoloration of body fluids (sputum, urine, sweat, tears)

Beta-Adrenergic Receptors

Receptors located on postsynaptic cells that are stimulated by specific autonomic nerve fibers. Beta1-adrenergic receptors are located primarily in the heart, whereas beta2-adrenergic receptors are located in the smooth muscle fibers of the bronchioles, arterioles, and visceral organs.

Perception of Pain

Recognition and interpretation of pain in the somatosensory cortex and limbic system.

Myocardial Ischemia and Infarction

Reduced blood flow through coronary arteries may cause *ischemia*. Ischemia is often manifested through *angina pectoris*(chest pain due to coronary disease). A complete obstruction of flow in a coronary artery may cause *myocardial infarction*(heart attack). This causes tissue distal to the obstruction to die and be replaced by scar tissue. While it was long thought that cardiac muscle lacked stem cells, recent studies suggest stem cells in the blood can migrate to the heart and differentiate into myocardial cells.

Paroxysmal Nocturnal Dyspnea

Refers to attacks of severe shortness of breath and coughing that generally occur at night. It usually awakens the person from sleep, and may be quite frightening. ・ S/S of left sided heart failure

What are the short acting insulins? What is the onset, peak, and duration??

Regular insulin (Humulin R, Novolin R) Onset: 30 min-1 hour Peak: 2-5 hours Duration: 5-8 hours Give food right when administering insulin (injected 30-45 min before a meal)

Seizures: What do nurses do?

Remain with client Provide privacy Maintain patent airway ◆ Evaluate respiratory status ◆ Do NOT force anything into mouth ◆ Administer O₂ ◆ Suction equipment at bedside ◆ Turn on side ◆ Loosen constrictive clothing Protect from injury ◆ Standing ➠ place on floor and protect head/body ◆ Padded rails ◆ Do not restrain Record ◆ Start & end time ◆ Details of event What they smell, see, or feel. What side of the body did they feel this, unilateral/bilateral, muscle tone, loss of consciousness, loss of bowel/bladder function ◆ ID precipitating factors Flashing lights, certain meds, sleep deprivation, hyperventilation IV Access ◆ Administer meds Much easier to put an IV in before a seizure. Make sure site is protected so it doesn't fall out Postical ◆ Evaluate respirations, initiate suction/ventilation if necessary ◆ Monitor LOC ◆ Maintain a calm environment ◆ Monitor for incontinence ◆ Privacy ◆ Re-orient Long Term ◆ Avoid precipitating factors ◆ Meds and blood testing as directed ◆ Education/counseling

P Wave

Represents depolarization of the atria. (Becoming more positive).

T Wave

Represents the repolarization of ventricles. Ventricles are resting and being filled.

Dystolic Blood Pressure (DBP)

Residual pressure in the arterial system during ventricular relaxaton, or filling.

Thrombotic Thrombocytopenic Purpura (TTP)

Results from impaired funciton of ADAMTS13, a von-willebrand factor cleaving protease. Thus, large vWF multimers build and cause a prothrombotic state resulting in microvascular thrombosis. Thrombocytopenia and hemoltic anemia with shcistocyte formation occur as erythrocytes are sheared by platelet rich thrombi.

Microvascular Angiopathy

Retinopathy Annual eye exam Nephropathy ✷ Annual screening ✷ Drugs to delay progression ACEI; ARBs ✷ Control of HTN Neuropathy ✷ Drug therapy Topical creams, antidepressants, antiseizure meds ✷ Foot care Other ✷ Frequent oral care ✷ Maintain blood glucose levels at or as near normal as possible

Pernicious Anermia: Treatment

Reversible? ❖ Can be reversed with ongoing treatment ❖ Long standing neuromuscular complications may not be reversible Without Treatment? Patient will die within 1-3 years Cyanocobalamin ❖ Purified form of B₁₂ ❖ Parenteral IM or Sub-Q. 1,000 mg daily for two weeks, then monthly for life ❖ Intranasal Maintenance therapy after B₁₂ returns to normal

RIPE

Rifampin (Rifadin) Isoniazid (INH) Pyrazinamide (PZA) Ethambutol (Myambutol)

OR Nurse's Role: Room prep, before surgery

Room Prep ◇ Ensure all necessary supplies are available ◇ Electrical & mechanical equipment checked for proper function ◇ Ensure aseptic technique practiced when placing instruments/supplies Sponges, sharps, and instruments counts. Monitor sterility. Count all instruments (scrub tech & circulating RN) Before Surgery ◇ Chart review H&P, consents, labs ◇ Reassessment ◇ Last-minute questions ◇ Verify SCIP measures done ◇ Transport pt to OR ◇ Patient positioning Crucial part of every procedure. Usually follows administration of anesthesia. Focus on safety/injury prevention ◇ Preparing the surgical site Scrub or clean with antimicrobial agents, hair may be removed with clippers, after prepped, sterile team members drape area ◇ Assisting ACP Understand MOA & pharmacologic effects of anesthetic agents, know location of emergency equipment and drugs in the OR, place monitoring devices on pt, server as communication link between ACP & other departments, both take pt to PACU after procedure

What range is hypertension stage 2?

SBP of 140 or more or DBP of 90 or more

What is the range for elevated BP?

SBP: 120-129 and DBP: Less than 80

What range is hypertensive crisis?

SBP: Higher than 180 and/or DBP Higher than 120

AV Node(Atrioventricular Node)

Second clump of myocardial cells located in the inferior portion of the right atrium within the atrioventricular septum; receives the impulse from the SA node, pauses, and then transmits it into specialized conducting cells within the interventricular septum.

Norepinephrine

Secondary catecholamine hormone secreted by the adrenal medulla in response to short-term stress; also called noradrenaline.

Humoral Stimulus

Secretion of hormones in direct response to changing blood levels of ions and nutrients.

Types of Aphasia

Sensory Aphasia ◆ Receptive aphasia ◆ Loss of comprehension ◆ Wernicke's Area affected Motor Aphasia ◆ Expressive aphasia ◆ Inability to produce language, difficulty speaking, writing ◆ Broca's Area affected Mixed Aphasia ◆ Global aphasia ◆ Total inability to communicate

Type I IgE Mediated Allergy/Anaphylaxis

Severe type I hypersensitivity reaction in which IgE antibodies attached to mast cells, previously sensitized to an antigen, are reactivated. Examples Allergic Rhinitis - Seasonal allergies Asthma Atopic dermatitis - Eczema Urticaria - Hives Angioedema - ACE inhibitors cause it Anaphylaxis

What are the side effects & adverse reactions of decongestants?

Side Effects ∙ Jittery ∙ Nervous ∙ Restlessness Adverse Reactions ∙ HTN ∙ Hyperglycemia EXTREME CAUTION IN PATIENTS WITH: ∙ HTN ∙ Hyperthyroidism ∙ Cardiac disease ∙ DM

What are some side effects/adverse reaction of Captopril?

Side Effects: ・Metallic taste in mouth ・HA ・Dizziness ・Rash ・ACE Cough (dry cough, like that annoying dry tickle in the back of your throat) Adverse Reactions: ・Hypotension Orthostatic - First Dose Phenomenon ・Hyperkalemia Does not allow aldosterone to do it's thing ・Angioedema Life threatening ・Neutropenia Low white blood cell count

Brudzinski's Sign

Sign of meningitis; positive when a patient's legs lift involuntarily when lifting a patient's head

Pre-Op Report to OR Staff

Situation Pt name, age, surgical procedure, surgeon, surgical site, etc Background Significant pt history, allergies, medications Assessment Baseline vital signs, findings relative to the surgical procedure, coping strategies Recommendation Preoperative care still needed, positioning concerns, etc

Beta-agonist

Specifically stimulating to the beta-receptors within the sympathetic nervous system, causing body responses seen when the beta-receptors are stimulated.

Wernicke's Area Function

Speech interpretation

Colloids

Substances such as large protein molecules that do not readily dissolve into true solutions

How do you convert Fahrenheit to Celsius?

Subtract 32 from temperature, and divide by 1.8. (F-32)/1.8 = C°

What does SCIP stand for? What are the initiatives geared towards?

Surgical Care Improvement Project; Improving surgical care by significantly reducing surgical complications

Autonomic Nervous System (ANS)

Sympathetic Nervous System (adrenergic) + Parasympathetic Nervous System (cholinergic) The involuntary "automatic" nervous system.

What are some physiological (involuntary) pain responses?

Sympathetic Responses (Acute Pain) ∙ Elevated SBP, HR, RR ∙ Dilated pupils Parasympathetic (Deep/Prolonged Pain) ∙ Lowered SBP, HR ∙ Withdrawal ∙ Constricted pupils Behavioral ∙ Moaning ∙ Facial grimacing ∙ Crying ∙ Agitation ∙ Guarding the painful area Pyschological ∙ Anxiety ∙ Depression ∙ Anger ∙ Fear ∙ Hopelessness ∙ Exhaustion ∙ Irritability

How do you take orthostatic vitals?

Take vitals while pt is supine, sitting, and standing; waiting 2 minutes in between BEFORE moving from one position to the next.

Hyperkalemia EKG Changes

Tall T wave Flat P wave Wide QRS Prolonged PR

Bradycardia

The ECG wave is normal, but the heart rate is usually less than 60 bpm. This occurs when the SA node does not initiate the wave of stimulation often enough.

Tertiary Defenses Against Infection

The Immune Response ・Specific Look for antigens. Slower than the inflammatory response.

End Diastolic Volume(EDV or Preload)

The amount of blood in the ventricles at the end of atrial systole just prior to ventricular contraction. At the *end of atrial systole* and *just prior to atrial contraction*, the *ventricles contain* approximately *130 mL* of blood in a resting adult in standing position.

Cardiac Output

The amount of blood pumped by each ventricle in one minute.

Filling Time

The duration of ventricular diastole during which filling(of the ventricles) occurs. The more rapidly the heart contracts, the shorter the filling time becomes, & the lower the EDV and preload are. This effect can be partially overcome by increasing contractility, and raising SV, but over time, the heart is unable to compensate for decreased filling time, and preload also decreases.

Venous Return

The flow of blood back to the heart.

Systemic Vascular Resistance (SVR)

The force opposing the movement of blood within the blood vessels. The radius of the small arteries and arterioles is the principal factor determining SVR.

Contractility

The force or strength of the contraction itself.

Afterload

The force the ventricles must generate in order to pump blood against the resistance in the vessels. Any condition that increases resistance requires a greater afterload to force open the semilunar valves and pump the blood. Damage to the valves, such as stenosis, which makes them harder to open will also increase afterload. Any decrease in resistance decreases the afterload.

Cardiac Cycle

The heartbeat. The period of time between the start of one heartbeat to the beginning of the next. The period of time that begins with contraction of the atria and ends with ventricular relaxation.

SA Node(Sinoatrial Node)

The highest inherent rate of depolarization and is known as the *pacemaker* of the heart. Initiates the *sinus rhythm*, or normal electrical pattern followed by contraction of the heart. *Begins heart activity that spreads to both atria through specialized internodal pathways*. Excitation spreads to AV node via these pathways.

Aldosterone

The major mineralocorticoid. Important in the regulation of the concentration of sodium and potassium ions in urine, sweat, and saliva. Released in response to *elevated blood K+, low blood Na+, low blood pressure, or low blood volume*. In response it increases the excretion of K+ and the *retention of Na+*(which *increases water aborption*), which in turn increases blood volume and blood pressure. Its secretion is prompted when CRH from the hypothalamus triggers ACTH release from the anterior pituitary.

Parathyroid Gland and Blood Calcium Homeostasis

The parathyroid glands produce and secrete PTH, a peptide hormone, in response to low blood calcium levels. PTH secretion causes the release of *calcium* from the bones by *stimulating osteoclasts*, which secrete enzymes to degrade bone and release calcium into the intersitial fluid. PTH also inhibits osteoblasts, the cells involved in bone deposition, thereby sparing blood calcium. PTH causes increased reabsorption of calcium(and magnesium) in the kidney tubules from urine filtrate. In addition, PTH initiates the production of the steroid hormone *calcitriol*, which is the active form of vitamin D3, in the kidneys. Calcitriol then stimulates increases absorption of dietary calcium by the intestines which increases blood Ca2+ levels. A negative feedback loop regulates the levels of PTH, with rising blood calcium levels inhibiting further release of PTH.

Oncotic Pressure

The pressure of water to move, typically into the capillary, as the result of the presence of plasma proteins. *The pulling power of albumin to reabsorb water*

Longer Explanation of Blood Flow

The right ventricle pumps deoxygenated blood into the pulmonary trunk, which leads toward the lungs and bifurcates into the left and right pulmonary arteries. These vessels in turn branch many times before reaching the pulmonary capillaries, where gas exchange occurs: Carbon dioxide exits the blood and oxygen enters. The pulmonary trunk arteries and their branches are the only arteries in the post-natal body that carry relatively deoxygenated blood. Highly oxygenated blood returning from the pulmonary capillaries in the lungs passes through a series of vessels that join together to form the pulmonary veins—the only post-natal veins in the body that carry highly oxygenated blood. The pulmonary veins conduct blood into the left atrium, which pumps the blood into the left ventricle, which in turn pumps oxygenated blood into the aorta and on to the many branches of the systemic circuit. Eventually, these vessels will lead to the systemic capillaries, where exchange with the tissue fluid and cells of the body occurs. In this case, oxygen and nutrients exit the systemic capillaries to be used by the cells in their metabolic processes, and carbon dioxide and waste products will enter the blood. The blood exiting the systemic capillaries is lower in oxygen concentration than when it entered. The capillaries will ultimately unite to form venules, joining to form ever-larger veins, eventually flowing into the two major systemic veins, the superior vena cava and the inferior vena cava, which return blood to the right atrium. The blood in the superior and inferior venae cavae flows into the right atrium, which pumps blood into the right ventricle. This process of blood circulation continues as long as the individual remains alive.

This pause is critical to heart function, as it allows the atrial cardiomyocytes to complete their contraction that pumps blood into the ventricles before the impulse is transmitted to the cells of the ventricle itself.

The septum, where the AV Node is located, prevents the impulse from spreading directly to the ventricles without passing through the AV Node. There is a critical pause before the AV node depolarizes and transmits the impulse to the AV Bundle. *Explain the significance of the delay in impulse conduction at the AV node.*

What parts of the primary IV tubing administration set must be kept sterile?

The spike and the catheter adapter.

Non-Hodgkin's Lymphoma

The term used to describe all lymphomas other than Hodgkin's lymphoma

Losartan (Cozaar)

Therapeutic Effect/Use HTN, HF, Type II Diabetic Nephropathy ✤ No cough ✤ Much less risk of angioedema ✤ ACE first b/c it is stronger

Nifedipine (Procardia): Therapeutic Effects, Side/Adverse Effects

Therapeutic Effects/Uses HTN, angina, *dysrhythmias/arrhythmia* Side/Adverse Effects ・R/T Vasodilation Dizziness, HA, peripheral edema, facial flushing ・Constipation Smooth muscle is relaxed ・HF May decrease the contractility of the heart too much ・Dysrhythmia/Arrhythmia Could lead to sinus bradycardia

Why is using a 25+ gauge needle for phlebotomy not best practice?

There is a much higher risk of hemolysis (rupture of RBCs), leading to inaccurate test results.

Ventricular Fibrillation

There is no organized wave of stimulation spreading through the heart muscle. As a result, individual heart cells contract independently leading to a quivering of the heart muscle. Since there is no coordinated contraction of the ventricles, blood is not effectively ejected from the heart. *If V-fib continues, cardiac arrest follows*.

Indications of atropine

To decrease secretions before surgery, treatment of parkinsonism, restoration of cardiac rate and arterial pressure following vagal stimulation, relief of bradycardia and syncope due to hyperactive carotid sinus reflex, relief of pylorospasm, relaxation of the spasm of biliary and ureteral colic and bronchspasm, control of crying and laughing episodes associated with brain lesions, relaxation of uterine hypertonicity, management of peptic ulcer, control of rhinorrhea associated with hay fever, antidote for cholinergic overdose and poisoning from various mushrooms.

What are some non-pharmacological pain relief measures that are collaborative interventions and cutaneous stimulating?

Transcutaneous Electrical Nerve Stimulator (TENS) ∙ Worn externally ∙ Intermittently or long term Acupuncture ∙ Fine needles to specific sites ∙ Stimulates endogenous analgesia system ∙ Most credible Acupressure ∙ Fingertips ∙ Firm/gentle pressure over pressure points ∙ Release of endorphins Massage ∙ Decreases pain by providing stimulation and relaxing the muscles ∙ May improve sleep ∙ Relaxing both mentally and physically ∙ Obtain verbal permission ∙ Increases workload of kidneys and liver Heat/Cold Application (PDF RESOURCE ON CANVAS) COLD APPLICATION ∙ Causes vasoconstriction ∙ Prevents swelling & bleeding ∙ Do not apply to open wounds or areas with poor circulation ∙ Do not use in areas being treated with radiation ∙ If unable to apply directly to the site, try applying above or on the opposite side of the body HEAT APPLICATION ∙ Promotes circulation which speeds healing ∙ Do not use in area that is bleeding ∙ Do not use in area being treated with radiation therapy ∙ Do not use in area with decreased sensation ∙ Do not use in area injured in past 24 hours ∙ DO NOT USE WITH MENTHOL CONTAINING PRODUCTS AS THIS MAY CAUSE BURNS (Vicks, Ben-Gay, Icy Hot) HEAT & COLD APPLICATION STRATEGIES ∙ Avoid direct contact with device ∙ Apply intermittently to avoid tissue injury ∙ Check skin frequently ∙ DC treatment immediately if redness, blistering, cyanosis, or blanching occurs. ∙ Be extra cautious when adding moisture to treatment Contralateral Stimulation ∙ Stimulation of area on opposite side of the body ∙ Especially useful when affected are is not accessible (casted areas, phantom limb)

Hypoglycemia: Treatment, Rule of 15

Treatment ◆ If pt displaying s/s check blood glucose If less than 70 mg/dL, begin treatment. If > 70 mg/dL investigate further for cause of s/s ◆ If monitoring equipment not available, assume treatment ◆ Give glucagon or have pt eat glucose tablets or gel, corn syrup, honey, fruit juice, or non-diet soft drink OR ◆ Have the patient eat a small snack such as crackers or half a sandwich Rule of 15 𝟏. Consume 15 g of simple carb 4-6 oz of juice, regular soft drink 𝟐. Recheck glucose level in 15 minutes Repeat #1 if still less than 70 mg/dL ◆ Avoid foods with fat ◆ Avoid over-treatment ◆ Give complex CHO after recovery In acute care settings w/NPO or not alert pt 50% dextrose, 20-50 mL, IV push Patient not alert enough to swallow Glucagon, 1 mg, IM or sub-Q Teach pt to carry glucose at all times How to administer glucagon Explore reason why it occurred

Troponin Normal Range

Troponin I < 0.5 ng/mL (<0.5 mcg/L) and Troponin T < 0.1 ng/mL (<0.1 mcg/L)

How often should peripheral saline locks be flushed? Flushed with?

Twice a day or after each use, whichever is more frequent; Normal saline.

Cancer Surgery: Used for, s/e, nursing care

Used For ❖ Prevention Eliminate or reduce risk of at-risk patients (ex. BRCA-1 remove breasts & ovaries) ❖ Diagnosis ❖ Cure ❖ Control Can also be done by de-bulking. Reducing tumor mass. ❖ Support palliation ❖ Determining efficacy of therapy Can be done to see if treatment is working Side Effects ❖ Loss of body part or it's function ❖ Reduced function ❖ Major scarring ❖ Disfigurement ❖ Anxiety ❖ Body image disturbances Reconstruction Nursing Care ❖ Physical care needs similar to that of other surgeries ❖ Consider client's ability to cope Uncertainty, change in body image, role disturbance

Post-Op Vitals Protocol: Frequency, when to call MD, what to focus on

VS ◇ Q15min x 4 (1st hour) ◇ Q30min x 2 (2nd hour) ◇ Q1hr x 4 (4 more hours) ◇ Then per facility P&P * Monitor surgical site with vitals. Remove only per orders. Reinforce if necessary. Mark the shadowing! Call the surgeon if... Excessive bleeding, fluid loss, type of drainage Renal/Urinary Focus on retention/distention. We want them to pee within 6 hours (no more than 8) GI ◇ N/V common; who is at risk? ◇ Decreased peristalsis d/t anesthesia, pain meds, immobility, manipulation of GI Pyschosocial How is pt responding, handling it? Pain Pain peaks post-op day 2 b/c anesthesia and adjunct meds are out of the system

What are the priorities for the RN when the patient is admitted to the PACU?

VS, in-depth assessment, initiate post-op orders, appropriate nursing care, prevent complications.

S1: Valves, Sound, Represent

Valves The sound created by the closing of the atrioventricular valves (triscuspid & mitral) and the opening of the aortic and pulmonic valves during ventricular contraction. Sound A "lub". Represent Systole. Blood pumping out.

Why do we monitor K+ in heart failure patients?

We are concerned about potassium because of the digoxin. Potassium levels can cause death so we need to watching their levels.

Blood flows into the left atrium from the four pulmonary veins. This blood is *high* in O2 and *low* in CO2. Drains the lungs.

What 4 vessels empty into the left atrium?

Allergy Skin Testing

What It Is Antigen liquid shots are given to a patient to see if there's a reaction Nursing Interventions ❖ D/C corticosteroids and antihistamines 5 days prior b/c corticosteroids ⬇︎ the immune response & antihistamines would prevent a reaction ❖ Consent ❖ Administer allergens to skin surface ❖ Risk of anaphylaxis Post procedure Interventions ❖ Have pt. remain in office for 30 minutes ❖ Resuscitation equipment available ❖ Inspection of sites, measure and document ❖ Identify allergen and educate about lifestyle modifications to avoid exposure ❖ Desensitization programs & immunotherapy

Cholestyramine (Questran): What are they? How do they work? Treatment?

What They Are & How They Work ・Bile Acid Sequestrant ・Bile acids contain high levels of cholesterol ・Bile acid sequestrants bind with bile acids in the intestine and are excreted in feces Treatment ・Used to be first line drug, may now be used in combo with statins ・Powder mixed with liquid up to 6x/day ・Decreases total cholesterol

SA Node, AVNode, AV Bundle, AV Bundle Branches, and the Purkinje Cells.

What are the 5 groups of autorhythmic cardiac cells?

Diabetic Ketoacidosis: What it is, S/S, Treatment

What is DKA? ◆ Complication of DMT1 ◆ When the body produces excess blood acids (ketones) S/S ◆ Kussmal respirations The pt is in metabolic acidosis and the body is trying to blow off CO₂ ◆ Thirsty, dehydration ◆ Sweet breath ◆ Tachycardia ◆ Hypotension ◆ Acidosis ◆ High blood sugar (> 240 mg/dl) ◆ Hyperkalemia ◆ Polyuria Treatment ◆ Administration of insulin Need an insulin drip to bring it down 36-54 mg/dL every hour ◆ Replacement of fluids NS, ¹/₂ NS to start, when BS hits 250 add dextrose to prevent hypoglycemia ◆ Replenishment of electolytes (if low) Especially K⁺. Potassium is high but with treatment it could get low ◆ Bicarbonate To treat acidosis

Atrial Contraction; The remaining 20-30 percent of filling.

What is known as the "atrial kick"? What percentage of blood gets pumped in during this?

Atrial Systole. Fluids, whether gases or liquids, are materials that flow according to pressure gradients—that is, they move from regions that are higher in pressure to regions that are lower in pressure. Accordingly, *when the heart chambers are relaxed (diastole), blood will flow into the atria from the veins*, which are higher in pressure. *As blood flows into the atria, the pressure will rise*, so the *blood will initially move passively from the atria into the ventricles*. When the *action potential triggers* the muscles in the atria to contract (*atrial systole*), *the pressure within the atria rises further, pumping blood into the ventricles*. This is called an *"atrial kick"*. *Atrial systole ends prior to ventricular systole, as the atrial muscle returns to diastole(Phase 2)*.

What is phase 1 of the cardiac cycle? Describe it.

Stable A-fib: What is stable A-fib? What medications would control rate and rhythm? What medications would prevent thrombi/emboli?

What is stable A-fib? Controlled HR of less than 100 BPM (resting). Patient will be hypotensive and dizzy. What medications would control rate & rhythm? Digoxin, beta blockers, CCB What medications would prevent thrombi/emboli? Warfarin, heparin. Educate on importance of these meds

Pulmonary Semilunar Valve; Prevents backflow of blood into the right ventricle. Blood trying to flow back fills the pocket-like flaps of the valve causing it to close.

What is the name of the valve located between the right ventricle and pulmonary trunk? What is it's function?

Cancer Radiation: What it does, beam, procedure, external vs internal, s/e

What it does ❖ Destroys cancer cells with minimal exposure of normal cells ❖ Most effective for localized cancer Beam radiation ❖ Low energy & high energy Procedure ❖ Divided doses Into daily fractions ❖ Simulation Determines orientation, size of radiation beams, location ❖ Site will be marked ❖ Same position each time Immobilization devices External Radiation/Teletherapy ❖ Most common radiation treatment ❖ Pt exposed to radiation from a megavolt machine ❖ Gamma knife technology - Cobalt ❖ Cyclotron - Neutrons or protons ❖ Linear accelerator - ionizing radiation Internal Radiation/Brachytherapy ❖ Implantation or insertion or radioactive materials into, or close to tumor ❖ Radiation source is within the client Minimal exposure to healthy tissue ❖ Emits radiation for a period of time ❖ Commonly used in combination with external radiation S/E ❖ Vary according to site ❖ Bone marrow cells ❖ Skin Local skin changes and hair loss the will likely be permanent depending on the total absorbed dose. Inflammatory responses that cause tissue fibrosis and scarring. Can be acute or chronic. Erathema ➛ dry desquamation ➛ wet desquamation ❖ Mucous membranes Altered taste sensations ❖ Hair follicles ❖ Reproductive tissues Infertility ❖ Fatigue related to increased energy demands

Cancer Chemotherapy

What it does ❖ Mainstay for most solid tumors (invasive) and hematologic cancers ❖ Treating cancer with chemical agents ❖ Can offer cure, control, or palliative care Chemo in beginning cancer ❖ Cells are rapidly dividing (in cell cycle) ❖ Chemo targets dividing cells Cell cycle phase non-specific, cell cycle phase specific ❖ Given in combination Prevent resistance. Its may experience increased toxicities Methods of Administration ❖ Systemic Oral, IM, IV (most common) ❖ Regional (less toxic systemic SE) Intracavitary (intraperitoneal) Intrathecal/intraventricular (infusing into CSF of CNS) Intravesical (bladder) Intraarterial Side Effects ❖ Chemo agents cannot distinguish between normal cells and cancer cells ❖ S/E are the result of the destruction of normal cells ❖ Integumentary Skin, hair (alopecia), nails ❖ Intestinal issues N/V. mucositis in the entire GI tract ❖ Bone marrow Low H&H, low WBC, etc ❖ Spermatocytes (sterility)

Chronic Stable Angina: Definition, D/T, Defining Characteristics, & Diagnostic Studies

What it is Chest pain (pressure, ache, heavy, suffocating sensations) D/T CAD Characteristics ・Intermittent: 5-10 min ・Predictable Some pattern of onset, duration, and intensity. Provoked by exertion and relieved by rest/meds. ・Controlled with medications Diagnostic Studies for CAD/Angina ・ECG ・Cardiac enzyme and troponin levels ・Exercise stress test ・Cardiac catheterization ・Percutaneous Coronary Intervention (PCI) Percutaneous Transluminal Coronary Angioplasty (PTCA)

Exercise Stress Test: Is, Does, Types,

What it is Study of the heart during activity What it does Detects and evaluates CAD. Under stress parts of the heart may be ischemic and not getting enough blood flow. Treadmill Stress Test ・Noninvasive ・ECG & BP Pharmacological Stress Test ・Vasodilators injected: dipyridamole, adenosine, dobutamine Radionuclide Injection

Levothyroxine (Synthroid, Levoxyl)

What it is Synthetic thyroid hormone Very predictable. Works much in the same way as the thyroid. Dosing ✷ Start with low dose then closely monitor the patient ✷ Increase does in 4- to 6-week intervals as needed ✷ Watch out: Dose is in mcg but it is often supplied in mg ✷ Medication is effective with a goo pul Monitor For: ✷ CV side effects, weight loss, nervousness, tremors, insomnia Patient Teaching ✷ Take in AM, with full glass of water, on an empty stomach ✷ Take at the same time every day ✷ Don't switch brands without physician approval ✷ Side effects ✷ Report any unusual s/s, CP, or palpitations ✷ Check before taking OTC meds ✷ May increase effects of Warfarin ✷ Therapeutic effects may take several months to occur ✷ Therapy needs to be lifelong

Echocardiography (Echo): Is, Does, & Interventions

What it is Ultrasounds of the heart What it does Evaluates structural and functional changes of the heart Nursing Interventions Educate pt. to lie still, left side and breathe normally (may need to hold breath occasionally)

Biguanides: What it is, name, MOA, precautions, contraindications, side effects

What it is ◆ Oral antidiabetic ◆ Used in prevention of DMT2 Name ◆ Metformin (Glucophage) MOA ◆ Reduces hepatic glucose production ◆ Enhances insulin sensitivity ◆ Improves glucose transport into cells Precautions ◆ Withhold if contrast medium is used For at least a day or two before and 48 hours after. ◆ Monitor serum creatinine To make sure there is no damage to the kidneys (don't look at urine b/c you need a 24-hour urine sample whereas a serum creatinine takes a couple of hours) ◆ Give with meals to reduce GI effects Contraindications ◆ Renal, liver, cardiac disease ◆ Excessive alcohol intake It is excreted by the kidneys and if it isn't excreted it could become concentrated and lead to lactic acidosis. Also, trying to control liver production. It is believed that metformin could cause damage to the cardiac tissue. Side Effects/Adverse Effects ◆ Primarily affects GI tract: abdominal bloating, nausea, cramping, diarrhea, feeling of fullness. ◆ May also cause metallic taste, reduced vitamin B12 levels ◆ LACTIC ACIDOSIS is rare but lethal if it occurs ◆ Does not cause hypoglycemia. All it does is make the liver stop putting out more glucose. So, you don't have to worry about blood glucose with just this med.

Hypoglycemia: What it is, causes, s/s

What it is ◆ Too much insulin in proportion to glucose in the blood ◆ Blood glucose level less than 70mg/dL ◆ Neuroendocrine hormones released ◆ Autonomic nervous system activated Causes ◆ Too much insulin or oral hypoglycemic agents ◆ Too little food ◆ Delaying time of eating ◆ Too much exercise S/S T... tremors/tachycardia I... irritability R... restlessness E... excessive hunger D... diaphoresis/depression ◆ Shakiness ◆ Nervousness ◆ Anxiety ◆ Pallor

What is DMT1? Treatment?

What it is ◆ Total absence of insulin ◆ Autoimmune destruction of β-cells Due to a genetic predisposition and/or viral exposure ◆ Idiopathic diabetes ◆ Latent autoimmune diabetes in adults (LADA) 2%-12% Treatment ◇ Insulin They MUST HAVE insulin ◇ Lifestyle modifications

Radioactive Iodine Therapy (RAI): What it is, when it's given, patient teaching

What it is ✷ I-131 When it's given ✷ Option when drugs don't work ✷ Usually given on an outpatient basis Patient Teaching ✷ Drink normal amount of fluids ✷ Radiation precautions Use private toilet for three days, flush two times every time you pee, wash utensils separately, no intimate contact for three days, sleep in separate room ✷ Oral care for thyroiditis/paroditis ✷ Symptoms of hypothyroidism Works so well the pt winds up with hypothyroidism & take levothyroxine for the rest of their lives Review Purple Handout

Diabetic Angiopathy: What it

What it is ✷ Macrovascular angiopathy ✷ LT complication of DM ✷ Inappropriate elevation of blood glucose levels and accelerated atherosclerosis ✷ CVD/PVD/atherosclerosis ✷ Leading cause of Type 1 Diabetes related deaths Prevention ✷ Decrease risk factors Obesity, smoking, HTN, high fat intake, sedentary lifestyle ✷ Screen for and treat hyperlipidemia ✷ Weight loss if indicated ✷ Maintain blood glucose levels at or as near normal as possible If BS is greater than 200 mg/dL it has the consistency of ketchup

The Heart Conduction System

What starts the systolic and diastolic processes?

Metaglinides: What they are, MOA, examples, administration, side effects

What they are Oral antidiabetics MOA Increases insulin production from pancreas Examples ◆ repaglinide (Prandin) ◆ nateglinide (Starlix) Administration ◆ Rapid Onset: HIGH RISK FOR HYPOGLYCEMIA ◆ Risk is reduced if taken properly ◆ Taken 30 minutes to just before each meal. ◆ Should not be taken if meal has been skipped. Side Effects ◆ Headache ◆ Hypoglycemic effects (too much of them) ◆ Dizziness ◆ Weight gain (b/c you have to eat every time you take it) ◆ Joint pain ◆ Upper respiratory infection or flulike symptoms

Thiazolidinediones (glitazones): What they are, MOA, Examples, side effects

What they are Oral antidiabetics MOA ◆ Decrease insulin resistance ("insulin sensitizing drugs") ◆ Increase glucose uptake and use in skeletal muscle ◆ Inhibit glucose and triglyceride production in the liver Examples ◆ pioglitazone (Actos) ◆ rosiglitazone (Avandia) Side Effects/Adverse Effects ◆ Moderate weight gain, edema, mild anemia ◆ Hepatic toxicity--monitor ALT levels

Sulfonylureas: What they are, examples, MOA, side effects, interactions

What they are Oral hypoglycemics Examples ◆ glipizide (Glucotrol) ◆ glyburide (Diabeta) ◆ glimepriride (Amaryl) MOA Increases insulin production/secretion from the pancreas Side Effects ◆ Hypoglycemia Due to increased productions of insulin Interactions ◆ Adrenergics, corticosteroids, thiazides, others may reduce hypoglycemic effects. ◆ Allergic cross-sensitivity may occur with loop diuretics and sulfonamide antibiotics ◆ May interact with alcohol, causing Disulfiram type reaction

SGLT-2 Inhibitors: What they are, examples, MOA, precautions

What they are ◆ Oral antidiabetic ◆Sodium-glucose cotransporter-2 (SGLT-2) Examples ◆ canagliflozin (Inkovana) ◆ dapagliflozin (Farxiga) ◆ empaglifozin (Jardiance) MOA ◆ Allows for absorption of glucose in the kidneys ◆ Increase urinary glucose secretions ◆ Lead to mild osmotic diuresis Precautions Must be used cautiously in renal impairment

Anti-epileptic Drugs (AEDs): What they do, principle drug therapy, acute seizure drugs, prophylactic drugs

What they do ◆ Therapy aimed at preventing seizures ◆ Used to depress abnormal neuronal discharges & prevent the spread of seizures to adjacent neurons Prevent seizures, not eliminating the cause ◆ Drugs generally act by stabilizing nerve cell membranes & preventing abnormal electric impulses from the seizure focus to other cortical areas ◆ Classified as CNS depressants Principle Drug Therapy ◆ Single drug based on client age, weight, type, frequency, and cause ◆ Increase dose to achieve therapeutic range or until toxic side effects ◆ May need combination regimen Acute Seizure Intervention Benzodiazepines ◆ "PAM" diazepam (Valium), lorazepam (Ativan) ◆ Depress the CNS and enhance GABA (inhibitory like your Mom in your brain) ◆ To stop quickly must be administered IV Prophylactic Seizure Intervention Hydantoins ◆ "toin" phenytoin (Dilantin)

Blood flows into the right atrium from the superior and inferior cavae and the coronary sinus. This blood is *low* in O2 and *high* in CO2. Drains the upper and lower body regions and coronary veins.

What three vessels empty into the right atrium?

Prolapsed Valve

When one cusp of a valve is forced backward by the force of the blood. May occur if chordae tendineae are damaged or broken. This disrupts the one-way flow and results in regurgitation, when the blood flows backward from its normal path. This disruption produces a *heart murmur*.

When can lower extremity sites be used for IV insertion?

When upper extremity sites have been exhausted. *An order must be obtained for use of lower extremity sites in adults (Mayo Clinic Handout)

The right side.

Which side of the heart acts as the pulmonary pump?

The left side.

Which side of the heart acts as the systemic pump?

The left ventricle endures the highest pressure, because it must pump blood to everywhere else in the body, from the brain all the way to the hands and feet. . The myocardium in the left ventricle is significantly thicker than that of the right ventricle. Both ventricles pump the same amount of blood, but the left ventricle must generate a much greater pressure to overcome greater resistance in the systemic circuit

Which side of the heart pumps blood at a higher pressure and why?

It initiates the sinus rhythm.

Why is the SA Node known as the pacemaker of the heart?

To prevent the possibility of tetany in myocardial cells. Also, so the heart can fill(According to ppt. slides).

Why is the refractory period of a cardiac muscle fiber longer than the contraction itself?

Oral Antidiabetics

Work on three defects of type 2 diabetes: ✷ Insulin resistance ✷ Decreased insulin production ✷ Increased hepatic glucose production Not for Type 1 Diabetes ✷ Require some circulating endogenous insulin to be effective ✷ Can be used in combination ✷ May not be effective unless the patient also makes behavioral or lifestyle changes ✷ Usually given 30 minutes before meals Except Metformin which is given with meals

Tropic Hormones

_____________ stimulate other endocrine glands to secrete hormones.

What are some examples of expectorants?

guaifenesin (Mucinex & Robitussin)

Milli

m 1/1,000th or 0.001

Micro

mc 1/1,000,000th or 0.000001

What are some examples of nasal decongestants?

oxymetazoline (Afrin 12hour); phenylephrine (Afrin)

Acid Base Mnemonic (ROME)

• Acid-Base Mnemonic to interpret blood gas values. R: Respiratory O: Opposite: pH ↑ PCO₂ ↓ Alkalosis pH ↓ PCO₂ ↑ Acidosis M: Metabolic E: Equal: pH ↑ HCO₃⁻ ↑ Alkalosis pH ↓ HCO₃⁻ ↓ Acidosis

What surgical risk does diabetes pose for a patient?

⇪ Risk for: ❖ Hyper- or hypglycemia ❖ Acidosis ❖ Post-op cardiovascular complications ❖ Infection ❖ Slow wound healing

Chronic Pain

∙ 6 months or more ∙ Interferes with ADLs ∙ Can be progressive or without tissue injury.

Surfactant

∙ A lipoprotein that lowers the surface tension within alveoli to allow them to inflate during breathing. ∙ Produced by type II alveolar cells

Hypertonic Solution

∙ A solution in which the concentration of solutes is greater than that of the cell that resides in the solution. ∙ Higher ( ) than blood

Hypotonic Solution

∙ A solution in which the concentration of solutes is less than that of the cell that resides in the solution. ∙ Lower ( ) than blood.

Isotonic Solution

∙ A solution whose solute concentration is equal to the solute concentration inside a cell. ∙ Same ( ) as blood

Intravascular Fluid

∙ A type of ECF ∙ Fluid in the blood (plasma)

Transcellular Fluid

∙ A type of ECF ∙ Specialized fluids

Interstitial Fluid

∙ A type of extracellular fluid ∙ Fluid in the space between cells

What are some non-opioid pain meds?

∙ Acetaminophen ∙ Non-steroidal Anti-inflammatory Drugs (NSAIDS) ∙ Salicylates (ASA)

What are the mechanisms of action for ACE Inhibitors?

∙ Affects the RAAS ∙ Inhibit angiotensin-converting enzyme, which is responsible for converting angiotensin I (through the action of renin) to angiotensin II. ∙ Angiotensin II is a potent vasoconstrictor and causes aldosterone secretion from adrenals. ∙ ACE inhibitors lead to a decrease in aldosterone production (sodium and fluid loss & a small increase in K+ levels. ∙ As Angiotensin II is reduced, arterioles dilate and peripheral vascular resistance is reduced ∙ Also prevent the breakdown of the vasodilating substance, bradykinin (therefore you can get vasodilation) ∙ Result: decreased systemic vascular resistance (afterload), vasodilation, and therefore decreased blood pressure.

What are some opioid pain meds?

∙ Agonists ∙ Agonist-Antagonists (Partial agonists) ∙ Antagonists ∙ Opioid-Nonopioid Combination Drugs

What are the contraindications of NSAIDS & ASA?

∙ At risk for bleeding (peptic ulcer disease, anticoagulant therapy) ∙ Conditions or other drug therapy that places client at risk for renal impairment b/c we need the patient to filter it out. ∙ Pregnancy, especially last trimester due to risk of maternal bleeding and possible miscarriage. ∙ Allergy/hypersensitivity (either drug) ∙ ASA products (and all agents containing ASA) contraindicated with children who may have viral infection due to association with Reye's Syndrome.

Tonicity

∙ Comparing two solutions ∙ Term to describe the effect of particles in concentration on osmolality. ∙ Basically another term for osmolality/total concentration of solutes. ∙ In medicine, we are comparing tonicity of different IV fluids to blood. A solutions solute concentration compared to another. ∙ If IV fluids and blood concentration can effect water movement between the plasma and inside of the RBCs.

Chemoreceptors

∙ Control respiration ∙ Located in the medulla of the brain stem, the carotid arteries, and the aorta ∙ Detect changes in the blood pH, O2, and CO2 levels and send message back to the central respiratory center in the brainstem. ∙ In response, the respiratory center increases or decreases ventilation to maintain normal levels of pH, O2 (PO2), and CO2 (PCO2)

Renin-Angiotensin System

∙ Created by kidneys in response to decreased blood flow ∙ Balances Na+ and water ∙ Renin stimulates the conversion of angiotensinogen to Angiotensin 1 converted to Angiotensin 2 ∙ Causes blood vessel constriction to stimulate aldosterone. ∙ blood volume/blood pressure Blood flow to glomerulus decreases, specialized cells secrete RENIN ➞ Renin (through complex steps*all you need to know) ➞ leads to the production of Angiotensin II, a powerful vasoconstrictor ➞ Angiotensin II causes peripheral vasoconstriction & stimulates Aldosterone, both increase BP

What are some factors that affect the pain experience?

∙ Emotions ∙ Anxiety and other stressors ∙ Past pain experience ∙ Culture ∙ Gender ∙ Developmental ∙ Environment and support people

Active Transport

∙ Energy-requiring process that moves material across a cell membrane against a concentration difference. ∙ Solutes move across a cell membrane from an area of low concentration to an area of high concentration. ∙ Requires energy - ATP Think sodium-potassium pump.

What are the side effects and interactions of NSAIDS & Salicylates?

∙ Epigastric distress to GI bleeding, tinnitus, platelet dysfunction Drug Interactions: ∙ ETOH (additive affect) ∙ Anticoagulants (increased bleeding) ∙ Diuretics (reduced diuretic effects)

Define ECF; What is the % of TBW?

∙ Extracellular Fluid ∙ Fluid outside the cells of the body ∙ Carries water, electrolytes, nutrients, and oxygen to cells ∙ Removes waste products of cell metabolism ∙ 20% of TBW (1/3 of total body fluid)

When it comes to dehydration, what are we gonna do as nurses?

∙ First, identify high risk patients (older adults, children, conditions with fluid loss) ∙ Correct underlying cause ∙ Encourage adequate fluid intake ∙ May need IVFs ∙ Monitor VS, skin, neurological status ∙ Daily weights (low weight if dehydrated) ∙ Accurate I&O ∙ Oral hydration ∙ IV hydration ∙ Monitor labs ∙ Skin and oral care ∙ Provide safe environment (fall risk, side rails) ∙ Foley (if meets criteria, if we need accurate I&Os) Remember when your patient is dehydrated, they are hypertonic.

Third Spacing

∙ Fluid is trapped and unavailable for functional use ∙ Can cause a relative hypovolemia/dehydration Ascites, burns, pericardial effusion (fluids around the heart), pleural effusion (fluid around the lungs).

What are some NSAIDS & ASA considerations?

∙ Give meds with food to avoid GI upset ∙ Immediately report signs of GI bleeding ∙ Stop ASA 5-7 days prior to surgery (if OK'd by HCP) ∙ Do not crush enteric coated tablets ∙ Minimize ETOH intake Monitor for S/Sx of liver toxicity: ∙ N/V ∙ Lethargy, fatigue ∙ Itching ∙ RUQ pain

When would you hold furosemide (Lasix)?

∙ Hold for SBP < 90 ∙ Hold if K⁺is low (<3.5 mEq/L) ∙ Hold if patient is dehydrated

Aldosterone

∙ Hormone made by kidneys ∙ Works to increase sodium and water reabsorption ∙ Produced as a result of Renin-Angiotensin system ∙ BP and flood balance Angiotensin II stimulates adrenal gland to release aldosterone ➞ Aldosterone causes kidneys to RETAIN Na+ and H2O ➞ Na+ AND H2O retention ➞ increased blood volume and Na+ levels

What do nurses do in patients with acid-base imbalances?

∙ Hydration status ∙ Lung sounds ∙ Level of consciousness ∙ Daily weights ∙ VS ∙ Intake and output ∙ Skin moisture/turgor ∙ Tongue/mouth ∙ GI system ∙ Heart sounds: S3/fluid overload ∙ Laboratory studies ∙ Dysrhythmias (block 2/4)

What is potassium contraindicated in?

∙ Hyperkalemia ∙ Severe renal impairment ∙ Untreated Addison's disease ∙ Some products may contain tartazine (yellow dye #5) or alcohol; avoid using in patients with an intolerance ∙ Hyperkalemic familial periodic paralysis

What are some contraindications for nitroglycerin?

∙ Hypersensitivity ∙ Increased intracranial pressure ∙ Severe anemia ∙ Pericardial tamponade ∙ Constrictive pericarditis ∙ Uncorrected hypovolemia ∙ Alcohol intolerance (large IV doses only)

What is furosemide (Lasix) contraindicated in?

∙ Hypersensitivity ∙ Some liquid products may contain alcohol, avoid patients with alcohol intolerance ∙ Hepatic coma or anuria ∙ Cross sensitivity with thiazides and sulfonamides may occur.

What is nystatin (Mycostatin) contraindicated in?

∙ Hypersensitivity ∙ Some products may contain alcohol-- avoid patients who may be hypersensitive or intolerant ∙ Use cautiously in denture wearers (dentures require soaking in nystatin suspension)

What is digoxin (Lanoxin) contraindicated in?

∙ Hypersensitivity ∙ Uncontrolled ventricular arrhythmias ∙ AV block ∙ Idiopathic hypertrophic subaortic stenosis ∙ Constrictive pericarditis ∙ Known alcohol intolerance (elixir only)

What lab results would you have with a dehydrated patient?

∙ Increased BUN ∙ Elevated HCT ∙ Elevated serum osmolality ∙ Increased urine specific gravity ∙ Elevated sodium *Remember patient is hypertonic*

What is the overall effect of Digoxin (Lanoxin)?

∙ Increased myocardial contractility ∙ Reduced HR ∙ Increased SV ∙ Reduced heart size during diastole ∙ Decrease in venous BP ∙ Increased coronary circulation ∙ Promotion of diuresis as the result of improved circulation

Pneumonia

∙ Infection of the lung tissue ∙ Enters the lungs by aspiration, inhalation, spread of other infection.

Aspirin: MOA

∙ Inhibits prostaglandin synthesis and release. ∙ Inhibits platelet aggregation (for a longer period than NSAIDs) ∙ Used to enhance blood flow during an MI and to prevent MI ∙ Competes with many other protein-bound drugs.

Neuropathic Pain

∙ Injury to one or more nerves resulting in repeated transmission of pain signals even in the absence of painful stimuli. ∙ Often the cause of chronic pain ∙ May result from nerve damage caused by DM, CVA, tumor, or chemotherapy.

Extracellular Fluid Components

∙ Interstitial Fluid: 2/3 of ECF ∙ Intravascular Fluid (plasma): 1/3 of ECF ∙ Transcellular Fluid (spinal fluid, digestive, eyes): 1 L of ECF

Assessment with Administration of Opioids

∙ LOC ∙ BP/pulse/respirations If RR<10, assess level of sedation ***If less than 12 notify HCP (MedSurge Text) Physical stimulation ∙ Initial drowsiness will diminish with continued use ∙ Do not discontinue abruptly

What lab results would we expect to see with a patient who has fluid volume excess?

∙ Low hematocrit, K+, and BUN ∙ BNP: Increased (the only lab that will increase) ∙ Decreased urine specific gravity ∙ Decreased serum osmolality ∙ Decreased serum sodium (if overhydration) Your patient will be hypotonic.

What do nurses do with a patient who has fluid volume excess?

∙ Monitor I&O hourly (Foley if needed) ∙ Monitor daily weight (1 kg wt gain = 1 L fluid gain) ∙ Observe for s/s of fluid overload ∙ Use IV pumps to control the rate of infusion ∙ Elevate HOB to facilitate breathing ∙ Monitor ABGs ∙ Assess breath sounds regularly to check for pulmonary edema ∙ Emotional support ∙ Maintain IV access ∙ Restrict fluids prn Goal: Remove fluids without messing up electrolytes or osmolarity Treatment: ∙ Fluid and sodium restriction ∙ Diuretics (IV or PO) ∙ Dialysis ∙ Find cause/treat ∙ Remove fluid ∙ Cardiac monitor ∙ Assess skin/edema

Nursing Implications for Digoxin

∙ Monitor apical pulse for 1 full minute before administering. ∙ Monitor potassium levels. ∙ Monitor therapeutic levels: 0.5-2 ng/mL. ∙ Monitor I & O's, daily weights (fluid retention) ∙ Monitor peripheral edema ∙ Monitor for adventitious lung sounds ∙ Assess for toxicity

Osmosis

∙ Movement of water from an area of low solute concentration to an area of higher solute concentration. ∙ Water moves across the membrane to dilute higher concentration of solutes. ∙ Concentration gradients. ∙ Semipermeable membranes let certain things through. Semipermeable membranes let water pass through but not solutes.

What are some signs of Digoxin toxicity?

∙ N/V/D ∙ Fatigue ∙ Headache ∙ Yellow/green or halo vision ∙ Arrhythmias, including bradycardia ∙ Irritability/insomnia *** If you see these signs you want to request a STAT DIG LEVEL ***

Toxicity/Management of Opioid Overdose

∙ Naloxone (Narcan) Reverses the opioid effects. Binds to and occupies the receptor. Awareness of impact of therapy. ∙ Signs/symptoms of withdrawal Anxiety/irritability, chills/hot flashes, joint pain, diaphoresis, n/v, diarrhea, abdominal cramps.

Opioid Analgesics

∙ Natural & synthetic compounds that bind to opiate receptors and activate the endogenous analgesia system ∙ Mu receptors are the most effective in relieving pain ∙ Most share the same side effects (SEs): N/V, constipation, drowsiness ∙ Large doses may cause respiratory depression & ↓BP ∙ Other SEs: urinary retention, dry mouth, sweating ∙ ALWAYS ASSESS LEVEL OF ALERTNESS & RESPIRATORY STATUS BEFORE GIVING MED Central nervous system ∙ CNS depression Sedation........leads to........... Respiratory depression - Strongly related to the degree of sedation - More common in those with preexisting condition Reversal First: Try to stimulate the patient Second: Ventilatory assistance Third: Naloxone (Narcan) Interactions ∙ Potential drug interactions with MAOIs which could lead to respiratory depression/seizures/hypotension ∙ Co-administration ∙ Any CNS depressant ∙ ETOH ∙ Antihistamines ∙ Benzodiazepines Cautions & Contraindications ∙ Allergy ∙ Severe asthma ∙ Severe head injury ∙ Sleep apnea ∙ Paralytic ileus (bowel paralysis) ∙ Pregnancy Adverse Effects Unwanted effects usually on other parts of the body other than the CNS. - Psychologic dependence - Physical dependence - Opioid tolerance - Cardiovascular - Gastrointestinal (constipation) - Genitourinary (can cause urinary retentions) - Integumentary - Respiratory

How do you manage pain in patients with substance abuse or addiction?

∙ Obtain a substance abuse history, including ETOH ∙ Be nonjudgemental ∙ Addictive behaviors may include: repeated requests for medications, refusal to try oral meds, continued high doses well after surgery date.

When would you assess pain?

∙ On admission ∙ With each check of VS ∙ When the client complains of pain ∙ Prior to and after a pain management intervention ∙ Before & after a procedure

Partial Agonists

∙ Opioid analgesics ∙ AKA agonist-antagonist or a mixed agonist ∙ Binds to pain receptor but causes a weaker neurologic response than an agonist ∙ Stimulate some receptors but block others ∙ Not as strong as the "agonists" ∙ Appropriate for acute moderate to severe pain ∙ Must be administered parentally ∙ Not 1st line drugs ∙ Do not give with the "agonists" as they may block the mu receptor site and reduce/reverse analgesia Examples: ∙ Stadol, Nubain, Talwin

What dietary teaching does a nurse conduct regarding electrolytes?

∙ Oral electrolyte supplements ∙ Limiting or facilitating oral fluid intake ∙ Parenteral replacement of fluids and/or electrolytes ∙ Prevention

Onset of Action & Pain Management

∙ Oral vs IV ∙ Immediate Release vs Extended (sustained) Release ∙ Treatment of Breakthrough Pain ∙ Reassessment (Evaluation) Timing

Documentation of Pain

∙ Pain level ∙ Pain description ∙ Interventions- Pharmacologic/Non-pharmacologic ∙ Reassessment/Patient response to interventions ∙ Planned interventions to improve pain relief if needed

What are the core principles of pain assessment?

∙ Patients have the right to appropriate assessment and management of pain ∙ Objective signs of pain are not specific for pain ∙ Different patients experience different levels of pain in response to comparable stimuli? ∙ Pain is always subjective. ∙ Patients with chronic pain may be more sensitive to pain and other stimuli ∙ Unrelieved pain has adverse physical and psychological consequences ∙ Assessment approaches must be appropriate for the patient population.

What are some misconceptions that interfere with pain management?

∙ Patients may fear increased pain is a sign of impending death instead of an acute situation. ∙ Family members fear meds will make the patient comatose ∙ Nurses doubt pain report because: there is no obvious cause, most patients don't have pain from that particular procedure, they are concerned about addiction and drug-seeking behaviors.

Osmotic Pressure

∙ Pressure that must be applied to prevent osmotic movement across a selectively permeable membrane ∙ Power of solution to draw water ∙ Pressure needed to stop fluid movement across a membrane created by concentration gradients.

Nonopioid Analgesics

∙ Relieve mild to moderate pain ∙ Many also reduce fever & inflammation ∙ Many are available OTC ∙ Often compounded with opioids to reduce the amount of opioid that is needed. ∙ No physical dependence is associated with these

What are some implementation considerations for nystatin (Mycostatin)?

∙ Shake well before administration per Davis' Drug Guide ∙ No POs are to be given after this medication, give this medication last ∙ Patient is to hold suspension in mouth and swish throughout mouth for at least two minutes. It continues to kill the fungal infection the longer it is in the mouth. ∙ No food or drink for at least 30 minutes after dosage.

Antidiuretic Hormone (ADH)

∙ Stimulated by increase ( ) of electrolytes or decreased BP ∙ Produced by hypothalamus, released from pituitary gland into blood to act on kidneys. ∙ Stimulates constriction of blood vessels and water conservation by increasing water reabsorption. Low blood volume(high serum osmolality) ➞ pituitary gland secreted ADH ➞ ADH causes kidneys to retain water ➞Water retention increases & boost s blood volume ➞ (serum osmolality decreases) High blood volume (low serum osmolality) ➞ inhibits release of ADH ➞ No ADH = less water reabsorbed by kidneys = kidneys excrete more urine ➞ water excretion decreases blood volumes ➞ high serum osmolality

ATP (adenosine triphosphate)

∙ Supples energy for solute movement in and out of cell. ∙ Moves Na+ out of the cell, forces K+ back into the cell.

Lung Compliance

∙ The ease of lung inflation ∙ Reduced by increased lung water (edema), loss of surfactant, or conditions that cause elastin fibers in teh lungs to be replaced with scar tissue (collagen).

Osmolarity

∙ The number of particles in a solution by volume (mOsm/L) ∙ Osmotic pressure ∙ Amount of pressure required to stop osmotic flow of water ∙ Pressure needed to stop fluid movement across a cell membrane created by concentration gradients. When molecules can't move across a membrane, fluid will move to equilibrate concentrations.

The Timeline of HIV

≈ 1969 Arrived in U.S. ≈ 1979 U.S. men seemed to have opportunistic diseases 1981 AIDS 1983 Virus management figured out Name HIV ➨ Acquired Immunodeficiency Syndrome (AIDS) ➨ HIV Disease *It is called HIV disease today because it is a chronic disease

Hypocalcemia: What do nurse's do?

▪ID high-risk patients ***Closely monitor post parathyroid or thyroid surgery patients*** ▪ Assess/monitor serum Ca++ ▪ Monitor VS - Hypotension, bradycardia, tachypnea ▪ Cardiac monitoring ▪ Assess ability to perform ADLs ▪ Assess for Chvostek's and Trousseau's signs ▪Seizure precautions, safe environment - Trach tray at BS in the event of laryngospasm ▪ Maintain IV line ▪ Administer PO supplements as ordered: - Ca++ supplements: calcium carbonate (TUMS) - Vitamin D supplements: calcitriol (Calcijex, Rocaltrol) ▪ Administer IV Ca++ carefully - Calcium gluconate when severe

Nursing Responsibilities: Telemetry 5 Lead

▪️ Electrode change Per facility policy (q24hr & PRN) ▪️ Clean skin with soap and water, ETOH if necessary ▪️ Electrodes Do not get wet. Attach lead wire then press electrode pad firmly to site.

What is measured on a "TELE" strip?

▪️ PR interval ▪️ QRS interval ▪️ QT interval

EKG/ECG

▪️Can be done resting, ambulatory, during exercise ▪️ Gives a view of one point in time. Shows how heart is doing right then electrically ▪️ Show conductive abnormalities, cardiac dysrhythmias, hypertrophic, pericarditis, MI (site & extent), pacemaker performance, and effectiveness of drug therapy.

Meninges

◆ 3 layers of protective membranes that surround the brain, spinal cord ◆ Dura, arachnoid space, and pia matter

Foramen Magnum

◆ A large opening at the base of the skull through which the brain connects to the spinal cord ◆ Increased ICP Pushes down and out through this and applies pressure to brainstem and spinal cord

IICP: What do nurses do?

◆ Assess LOC ◆ HOB 30° angle Prevent flexion of neck and hips. To relieve pressure via gravity, not too high b/c then the venous drainage is cut off at the hip leading to increased intrathoracic pressure ◆ Monitor respiratory status and prevent hypoxia PaO₂ = 100 mmHg PaCo₂ = 30-35 mmHg This is lower b/c someone on a ventilator. B/C CO₂ can actually cause vasodilation of some arteries. ◆ SBP: 100-160 mmHg High enough to get blood perfusion ◆ Maintain body temperature Prevent shivering which causes bearing down and ⇧ BP ◆ Decrease environment stimuli ◆ Seizure precautions ◆ Monitor electrolytes levels, acid/base balance, and I&Os ◆ Meet nutritional needs Feeding them the sooner, the better. Helps recovery ◆ Avoid straining Coughing, sneezing, valsalva

What do nurses do for patients taking spironlactone?

◆ Assess fluid volume status (Daily weights, I&Os, skin turgor, lung sounds) ◆ Monitor for s/s of hyperkalemia

What should nurses do with a patient suffering from hypernatremia?

◆ Assess: VS, neuro status, I/O and daily weights, edema, lab values (Na+, chloride, osmolarity) ◆ Meds: Are they taking Alka Seltzer??? ◆ Observe high risk patients closely to prevent ◆ Involve patient and family: Set fluid intake goals, provide fluids w/in easy reach, all them to record ◆ Maintain IV patency ◆ Frequent oral hygiene ◆ Safe environment ◆ Educate patient

When should you conduct self monitoring of blood glucose (SMBG)?

◆ Before meals ◆ Two hours after meals ◆ When hypoglycemia is suspected ◆ During illness ◆ Before, during, and after exercise

Blood-Brain Barrier

◆ Blood vessels (capillaries) that selectively let certain substances enter the brain tissue and keep other substances out ◆ Allows blood & nutrients, prevents toxins ◆ Downside is it also prevents some meds ◆ Water soluble compounds excluded (antibiotics) ◆ Lipid soluble cross easily (alcohol, nicotine) ◆ Can be altered by trauma, cerebral edema, and cerebral hypoxia

Diamox (Acetazolamide)

◆ Carbonic Anhydrase Inhibitor ◆ A super powerful diuretic because of where it works in the nephron.

How is chloride regulated in the body?

◆ Chloride follow sodium. So, wherever sodium goes, chloride follows. ◆ It is absorbed in the colon

Cerebrospinal Fluid (CSF)

◆ Circulates throughout the brain and spinal cord ◆ 150 mL ◆ Formed by choroid plexus in ventricles, circulates in subarachnoid space ◆ Absorbed by arachnoid villi ◆ Functions as cushion for brain and spine ◆ Composition similar to plasma

Basal Ganglia Function

◆ Controls/facilitates learned & autonomic movements ◆ Blinking, swinging arms, swallowing ◆ Affected in Parkinson's Disease

Cerebellum Function

◆ Coordinates voluntary movement ◆ Coordinates posture, equilibrium, and muscle tone

How should nurses treat a patient with Hypernatremia from decreased Na+ secretion (Na+ gain)?

◆ Dilute sodium concentration with IVF D5@ ◆ Administer diuretics to promote sodium excretion (furosemide)

Insulin Storage

◆ Do not heat/freeze ◆ In-use vial may be left at room temperature for up to 4 weeks ◆ Extra insulin should be refrigerated ◆ Avoid exposure to direct sunlight, extreme heat or cold ◆ Store prefilled syringes upright for 1 week if two insulin types in there; 30 days for one insulin type.

Limbic System Function

◆ Emotion ◆ Aggression ◆ Feeding behavior ◆ Sexual response

Circle of Willis Function

◆ Equalizes blood pressure within the brain ◆ Equalizes distribution of blood flow ◆ Allows blood to keep flowing even if there is a blockage in one area

Glasgow Coma Scale

◆ Eyes, verbal, motor ◆ Max- 15 pts ◆ Below 8 = coma

What are some diagnostic studies that could be performed to diagnose DM?

◆ Fasting plasma glucose level Must fast for at least 8 hours. Impaired fasting glucose puts pts at risk for diabetes & cardiovascular disease ◆ Oral Glucose Tolerance Test (OGTT) Drink something full of sugar and then check how the body reacts to it. ◆ Hemoglobin A1c 90-120 days of the average amount of sugar carried in your body. ◆ Random plasma glucose level Generally used if symptoms are serious and fasting test is not possible. WNL = Result of less than 200mg/dL.

What would normal lab results be when checking for DM?

◆ Fasting: 70-100 mg/dL ◆ 2 hour OGTT: less than 140 mg/dL ◆ Hgb A1c: Below 5.7%

What lab results would we expect to find in a patient diagnosed with DM?

◆ Fasting: > 126mg/dL ◆ 2-hour OGTT: ≥ 200mg/dL ◆ Hgb A1c: ≥ 6.5% ◆ Confirmed with repeated testing

Decorticate Posturing

◆ Flexion posturing ◆ Problems with cervical spine tract or cerebral hemisphere

What should nurses do with a patient who is hypervolemic hyponatremic?

◆ Fluid restriction: Safer than Na+ administration ◆ Osmotic diuretics: water out, not sodium ◆ Severe: hypertonic solution (3% NaCl) (can be paired with osmotic diuretics)

Phenytoin (Dilantin): Class, effects/uses, MOA, Onset, s/e, adverse reactions

◆ Follow up med Class ◆ Hydantoin ◆ Ends in "TOIN" Therapeutic Effects/Uses ◆ Prevent partial & generalized tonic-clonic seizures ◆ Therapeutic level: 10-20 mcg/ML Pharmacodynamics/MOA ◆ Drug binds to sodium channels, suppressing sodium influx, prolonging the channel inactivation, thus preventing the neuron from firing (prevents repetitive neuronal firing) Onset ◆ PO: 0.5-2 hours ◆ IV: within minutes to 1 hour Side Effects HA, nausea, hypotension (dizziness, diplopia-- perception of single object as 2 images), discolored urine Adverse Reactions ◆ Gingival hyperplasia Too much growth on gums ◆ Bone marrow suppression Thrombocytopenia, leukopenia ◆ Steven-Johnson Syndrome Very rare. Loss of a whole epidermal layer of skin

Causes of Hypovolemia

◆ Hemorrhage ◆ GI loss ◆ Burns ◆ 3rd space fluid shift ◆ Others

Hypovolemic Hyponatremia

◆ Loss of Na+ and H2O ◆ Happens with: Diuretics, diabetic glycosuria, vomiting, diarrhea, excessive diaphoresis, burns, fever, aldosteron deficiency ◆ Poor skin turgor, dry cracked mucous membranes, weak, rapid pulse, low BP or orthostatic hypotension

Hypovolemia

◆ Low blood volume ◆ Loss of both fluids and electrolytes ◆ Fluid loss is primarily ECF ◆ Causes: hemorrhage, GI loss, burns, 3rd space fluid shift, others

What should we as nurses do for patients with fluid volume deficit?

◆ Monitor symptoms ◆ Daily weights ◆ Accurate I&Os ◆ Oral rehydration ◆ Maintain IV access ◆ IVF replacement as order: Isotonic then hypotonic. Get pressure up with ISO and then hydrate the cell with HYPO. ◆ Watch for s/sx of cerebral edema when replacing fluids ◆ Monitor serum Na+, urine osmolality, and specific gravity ◆Provide safe environment Dizzy, low BP, seizure precautions, etc. ◆Skin and oral care ◆ Documentation

Nursing Interventions for Neurological Infections

◆ Neurological assessment ◆ VS ◆ Assess for IICP ◆ HOB elevated slightly at 30° For venous drainage ◆ Administer analgesics, antivirals, antibiotics ◆ Initiate seizure precautions ◆ Monitor for seizure activity ◆ Isolation precautions PRN ◆ Quiet environment (photophobic)

DMT2: What it is, Treatment

◆ Pancreas continues to produce insulin but... Insufficient amount and/or poorly utilized by cells. The cells have become desensitized. ◆ Multiple factors Obesity is the greatest risk factor. Genetic component increases insulin resistance and obesity. ◆ Gradual onset May go undiscovered for years. Often discovered by chance. Treatment ◆ Adjust the body's need for insulin: ◇ Regulate diet ◇ Exercise (to better utilize glucose) ◇ Weight loss (to reduce insulin resistance) ◇ Stimulate beta cells to produce more insulin with oral drug therapy Lastly... ◆ Insulin when the above no longer provide glycemic control

Midbrain Function

◆ Part of the brain stem ◆ Motor, coordination, nerve pathway of cerebral hemispheres

Medulla Function

◆ Part of the brain stem ◆ Relay stations ◆ HR, RR, BP ◆ Sneezing, swallowing, vomiting, coughing ◆ The pons and the medulla both contain activities related to respiratory control

Pons Function

◆ Part of the brain stem ◆ Bridge motor & sensory paths ◆ Respiratory center ◆ The pons and the medulla both contain activities related to respiratory control

What are the clinical manifestations of DMT1?

◆ Polyuria ◆ Polydipsia (excessive thirst) ◆ Polyphagia (excessive hunger) ◆ Weigh loss (catabolism) ◆ Fatigue ◆ Increase frequency of infections (Pruritus) ◆ Rapid onset ◆ Blood sugar > 200 (random or 2 hours postprandial) ◆ Fasting Blood sugar > 126 on 2 separate tests

What areas (in terms of patient condition/diagnosis) should be avoided when starting an IV?

◆ Poor vascular return ◆ Phlebitis/infiltration ◆ An arm with a: graft/shunt, CVA, masectomy, amputation, orthopedic/plastic surgery

Spironolactone (Aldactone)

◆ Potassium sparing diuretic ◆ Treats HTN (in combo); reduce edema with kidney or liver disease; slow progression of HF ◆ Promotes Na+ and water excretion adn K+ retention in distal renal tubules ◆ Blocks action of aldosterone b/c aldosterone causes us to retain Na+ and water and excrete potassium

What are fluid volume excess s/sx?

◆ Rapid, bounding pulse ◆ Increased BP With progression: falling BP & CO ◆ Development of S3 ◆ Distended veins ◆ Edema Tissues, lungs ◆ Labs: Hemodilution ∙ BNP: Increased ∙ Hematocrit: decreased due to dilultion ∙ Sodium: decreased in presence of water retention ∙ Urine Specific Gravity: decreased when kidneys are removing excess fluid Also: ∙ Faster, shallow respirations (tachypnea) ∙ SOB ∙ Chest xray: vascular congestion/pulmonary congestion ∙ Pale, cool skin ∙ Lungs (crackles) ∙ Increased urine volume ∙ Increased CVP (central veinous pressure) Could turn into cardiogenic shock Remember patient is HYPOtonic

Stroke Prevention: What do nurses do?

◆ Reduce salt/sodium intake ◆ Maintain a normal body weight ◆ Maintain a normal BP ◆ Increase level of physical activity ◆ Avoid cigarette smoking or tobacco products ◆ Limit consumption of alcohol to moderate levels ◆ Follow a diet that is low in saturated fat, total fat and dietary cholesterol and high in fruits and vegetables ◆ Meds: Aspirin, Clopidogrel, statins, Warfarin (Afib)

Hypothalamus Function

◆ Regulates endocrine and autonomic functions ◆ Contains the satiety center that regulates appetite. ◆ Subject to input from the limbic system, it also regulates body temperature, water balance, circadian rhythm, and expression of emotion.

Thalamus Function

◆ Relay station for sensory and motor impulses to cortex and cerebrum ◆ Pain gate

MERCI Retriever

◆ Removes blood clots in patients experiencing ischemic strokes ◆ Can pull a clot out to try to save an area that is not completely dead

Hypervolemia

◆ Retention of both fluid and electrolytes (primarily Na+) ◆ Isotonic ◆ Fluid gain is primarily ECF ◆ Causes: Renal failure, heart failure, too much isotonic IVF, others

Overhydration (water intoxication)

◆ Retention of water only ◆ Hypotonic ◆ Fluid from ECF pulled into ICF ◆ Causes: Overzealous water intake, SIADH, too much hypotonic IVF, others

Sliding Scale Therapy

◆ Short-acting or rapid(regular) insulin doses according to blood glucose test results ◆ Typically used in hospitalized diabetic patients or those on TPN or enteral tube feedings ◆ Subcutaneous insulin is ordered in an amount that increases as the blood glucose increases ◆ Disadvantage: delays insulin administration until hyperglycemia occurs; results in large swings of glucose control.

Human Amylin

◆ Subcutaneous anti-diabetic ◆ Slows gastric emptying preventing spikes in blood glucose

DDP-4 Inhibitors

◆ Subcutaneous antidiabetic ◆ Dipeptidyl peptidase-4 (DDP-4) is the enzyme that breaks down incretins.

Incretin Mimetic/GLP-1 Agonists

◆ Subcutaneous antidiabetic ◆ Incretins are hormones ◆ Glucagon Like Peptide 1 (GLP-1) is an incretin--slows gastric emptying, improves insulin secretion, suppress glucagon production, slows glucose absorption.

What are some signs and symptoms of thrombophlebitis?

◆ Tender to touch ◆ Redness ◆ Warmth ◆ Cord-like veins

Glycemic Index (GI)

◆ Term used to describe rise in blood glucose levels after carbohydrate-containing food is consumed. ◆ High GI foods increase glucose levels faster ◆ Pure Glucose GI = 100 ◆ Low GI = 55 or less (less peaks or valleys in blood glucose when eaten) ◆ Moderate GI = 56-69 ◆ High GI = 70 or more (breaks down into glucose so quickly there is a huge spike in blood glucose when eaten) ◆ Eat more low GI foods vs high

Hypervolemic Hyponatremia

◆ Too much fluid, not enough sodium ◆ Happens with: HF, hepatic cirrhosis, renal failure, overhydration ◆ Edema, HTN, weight gain, rapid, bounding pulse r/t hypervolemia

Hemoglobin A1c Test

◆ Used to diagnose and monitor response to therapy ◆ Reflects glucose levels over past 2-3 months (average) ◆ Goal for diabetics: 6.5%-7% ◆ Conversion (FYI): 28.7 × A1c% - 46.7

What should nurses do with a hyponatremic patient?

◆ VS ◆ Neuro status ◆ I&Os ◆ Daily weights ◆ Turgor ◆ Labs (Na+, chloride because of their relationship, & osmolarity) ◆ Fluid restriction ◆ Maintain patent IV line ◆ Cautious rehydration/replacement 10mEq/L in 24 hours ◆ Dietary intake ◆ Keep patients safe

Broca's Area Function

◆ Word formation ◆ 90% of us it is in the left frontal lobe (if we are right handed) ◆ Expressive speech center

What are some rapid acting insulins? What is their onset, peak, and duration?

◆ lispro (Humalog) ◆ aspart (Novolog) ◆ glulisine (Apdira) Onset: 10-30 min Peak: 30 min - 3 hours Duration: 3-5 hours MAKE SURE TO HAVE FOOD READY FOR THEM IMMEDIATELY WHEN ADMINISTERING INSULIN (injected w/in 15 min of mealtime)

Osmotic Diuretics

◆ mannitol (Osmitrol) ◆ Increase osmotic pressure of glomerular filtrate ◆ Inhibit water and electrolyte reabsorption ◆ Used for: Decreases in ICP, oliguria, prevention of RF *FYI for now*

JP Drains

◇ Additional fluid builds up d/t inflammation ◇ Used to remove the fluid ◇ Must remove air before replacing the cap ◇ Pin to pts gown to avoid tugging

Intra-Op Gerontologic Considerations

◇ Anesthetic drugs should be carefully titrated ◇ Assess for poor communication ◇ Risk from tape, electrodes, and warming/cooling blankets due to impaired skin integrity ◇ Osteoporosis & osteoarthritis so think of positioning! ◇ Perioperative hypothermia

Insulin

◇ Human insulin No more pork or beef. Made from bacteria or yeast using DNA technology ◇ Subcutaneous Regular (and some rapid acting) insulin can also be given IV. It cannot be given orally b/c it would be destroyed in the digestive tract ◇ Standardized units Use an insulin syringe

Dietary Recommendations for patients with DM

◇ Increase complex carbohydrates ◇ Minimize simple sugars ◇ Adequate protein intake ◇ Decrease cholesterol ◇ Decrease fat intake ◇ Alcohol only in moderation Detrimental effects on the liver. Must be cognizant of their drinking.

Varicose Veins

✤ Abnormally swollen, twisted veins with defective valves; most often seen in the legs. ✤ Pooled blood in the veins

Graves Disease

✷ Autoimmune disease ✷ Hyperthyroidism ✷ Antibody: Thyroid stimulating hemoglobin ✷ TSH attaches to thyroid cells and stimulations production of thyroid hormone Symptoms Intolerance to heat, heart palpitations, sensitivity to light, weight loss, appetite increase, easily agitated, protruding eyes.

Spinal Nerve

✷ Combined motor & sensory nerve Combining ascending and descending nerves ✷ Innervates different parts of the body

Thyroid Stimulating Hormone (TSH or Thyrotropin)

✷ Hormone of anterior pituitary ✷ Normal level is 0.4-4 mIU/L ✷ Chemical Class: Glycoprotein ✷ Stimulates thyroid hormone release

Goiter

✷ Iodine deficiency that causes thyroid to enlarge as it tries to produce thyroxine ✷ Can be hypo- or hyper- or any thyroidism

What are some causes of hyperfunction in the endocrine system?

✷ Neoplasia, hyperplasia ✷ Autoimmune disorders ✷ Exogenous hormones (prednisone) ✷ Altered target tissue responses

Iodine

✷ Potassium Iodine (SSKI) & Lugol's Solution ✷ Inhibits synthesis of T₃ & T₄ and block their release into circulation ✷ Decreases vascularity (bleeding) of thyroid gland ✷ Maximal effect within 1 to 2 weeks ✷ Used before surgery to treat crisis (thyroid storm) ✷ Mix with water or juice; have pt sip through straw (it will stain their teeth)

Antithyroid Drugs (Thioamides)

✷ Prophylthiouracil (PTU) & methimazole ✷ Inhibits synthesis of thyroid hormone ✷ Improvement in 1 to 2 weeks and good results in 4 to 8 weeks ✷ Cardiovascular adverse effects Might not be good for an older patient ✷ Therapy for 6 to 15 months To allow for spontaneous remission

How do β-adrenergic blockers help with hyperthyroidism?

✷ Symptomatic relief Will not treat it, but will help the pt to feel better ✷ Blocks effects of sympathetic nervous stimulation ✷ Propranolol Usually administered along with antithyroid agents ✷ Atenolol Preferred for pts with a history of asthma or heart disease

What is the difference between primary and secondary hyperthyroidism?

✷ T₃ & T₄ are high no matter what Primary (thyroid gland) TSH is ⬇︎ T₃ & T₄ are ⬆︎ This is b/c negative feedback is working. The hypothalamus is aware there is plenty of thyroid hormone so it isn't asking for any Secondary (pituitary gland) TSH is ⬆︎ T₃ & T₄ are ⬆︎ This is b/c the pituitary gland is asking for more TH to continue to be produced

What is the difference between primary and secondary hypothyroidism?

✷ T₃ & T₄ are low no matter what Primary (thyroid gland) TSH is ⬆︎ T₃ & T₄ are ⬇︎ Secondary (pituitary gland) TSH is ⬇︎ T₃ & T₄ are ⬇︎ In secondary, the pituitary gland isn't asking for any

What are the 3 hormones produced and secreted by the thyroid gland?

✷ T₃ (Triiodothyronine) More potent but less abundant than T₄ ✷ T₄ (Thyroxine) More abundant but not as potent as T₃ ✷ Calcitonin

Hypoparathyroidism: Characterized by, s/s, treatment, what do nurses do?

✷ Uncommon ✷ Usually occurs inadvertently when parathyroid glands are accidentally removed during surgery Characterized by ⬇︎ PTH, ⬇︎ Ca⁺⁺, ⬆︎PO₄ ⬇︎❤︎ function S/S Clinical manifestations are due to hypocalcemia Treatment Give a drug (calcium) What do nurses do? ◆ Administer IV Ca⁺⁺ for emergency tx of tetany ・Calcium gluconate ・Calcium chloride ・Calcium gluceptate ◆ Rebreathing may partially alleviate acute neuromuscular symptoms of hypocalcemia ◆ Teach patient about lifetime management with PO Ca⁺⁺ supplements and Vitamin D

Composition of Whole Blood? How much blood is in the average adult?

❖ 55% plasma, 45% formed elements ❖ About 5-6 quarts of blood are in the average adult weighing between 150-180 pounds

Mast Cell

❖ A cell that produces histamine and other molecules that trigger inflammation in response to infection and in allergic reactions. ❖ Most important activator of the inflammatory response? ❖ Degranulation Release powerful inflammatory modulators (histamine, leukotriene, prostaglandin...) ❖ These modulators... ∙ Vasodilate ∙ Increase vessel permeability ∙ Constrict bronchial smooth muscle

Ribonucleic Acid (RNA) Virus

❖ A molecule that plays a major role in the pathway from DNA to proteins. When RNA viruses invade the human organism, they inject their RNA into the cytoplasm of the host cell. Once they are inside the cytoplasm, RNA can be used to synthesize proteins, and, eventually, to form replica viruses. ❖ A retrovirus

Asthma Pathophysiology

❖ A restrictive lung disease. Inflammation causing airway narrowing & hyper-responsiveness. ❖ A trigger stimulates mast cells to release chemical mediators leading to bronchoconstriction, bronchial edema, and increased bronchial secretions.

Pseudoephedrine (Sudafed)

❖ A systemic decongestant ❖ Alpha-1 adrenergic agonist ❖ Speeds up the heart, opens up the airways, vasocontricts

Nursing Diagnoses for DVT

❖ Acute pain ❖ Ineffective health maintenance ❖ Risk for impaired skin integrity ❖ Potential complication: bleeding Because they will be on an anticoagulant ❖ Potential complication: PE

Beclomethasone (Beconase)

❖ Anti-inflammatory Glucocorticoid (inh) ❖ Inhaled steroid ❖ Decreases inflammation ❖ Therapeutic Effect/Uses ∙ Maintenance prophylactic for asthma ∙ Almost no side effects ❖ Pharmacodynamics/MOA ∙ Prevents release of and synthesis of inflammation mediators (Leukotrienes, prostaglandins, histamine) ∙ Decrease migration of inflammatory cells into the lungs (acts locally) ∙ Decreases edema of airways ❖ Side Effects Throat irritation, hoarseness, dry mouth, coughing ❖ Adverse Reactions Candida albicans infection, possible systemic effects of steroids ❖ Nursing Interventions ∙ When to administer? (1) albuterol (2) ipatropium (3) beclomethasone ∙ NO spacer ∙ Monitor for thrush

Montelukast (Singulair)

❖ Anti-inflammatory leukotriene receptor antagonist ❖ Prevention of chronic/maintenance treatment of asthma ❖ MOA/Pharmacodynamics: ∙ Inhibit release of leukotrienes ∙ Binds with leukotriene receptors to inhibit smooth muscle contractions and bronchoconstriction ❖ Side Effects ∙ Minimal. HA, dizziness, nausea, generalized pain, fever ❖ Nursing Interventions ∙ Monitor VS ∙ Provide adequate hydration ∙ Administer after meals to prevent GI upset ∙ Do not discontinue other asthma medications w/o consulting with MD ∙ NOT for acute asthma attacks

Ipratropium

❖ Anticholinergic bronchodilator Will find receptor sites in PSNS and will not allow acetylcholine on the sites leading to bronchodilation. Without systemic anticholinergic effects. ❖ Prophylactic medication. Take daily. ❖ Maintenance therapy for obstructive disorders Will relieve and prevent bronchospasm. Adjunctive management of bronchospasm in asthma. Off label. ❖ Not for acute attacks. Rinse mouth after use

If a tracheostomy tube dislodges and it cannot be replaced, what does the nurse do?

❖ Assess level of respiratory distress ❖ Minor dyspnea may be alleviate with semi-fowlers position ❖ Severe distress ➜ respiratory arrest ❖ Cover stoma with sterile dressing and ventilate with bag mask until help arrives

What are the nursing interventions for albuterol?

❖ Assess lungs sounds, RR, and O₂ levels ❖ Nebulizer & inhaler administration ❖ Teaching ・Self administration of inhaler and correct use ・Contact MD if SOB not relieved by medication ・Use Albuterol 1st if using many inhaled drugs (It is a rescue inhaler!) ・1 minute between doses. Rinse mouth after dose.

What surgical complications are patients at increased risk for due to... cardiovascular, respiratory, kidney diseases, liver diseases, endocrine diseases, immune diseases, F&E, GI/GU, surgical site, neuropsychologic

❖ Cardiovascular Diseases Dysrhythmias, hemorrhage, HTN, hypotension, VTE, superficial thrombophlebitis ❖ Respiratory Diseases Airway obstruction, atelectasis, bronchospasm, hypoventilation, hypoxemia, pneumonia, pulmonary edema, PE ❖ Kidney Diseases ❖ Liver Diseases ❖ Endocrine Diseases ❖ Immune Diseases Infection ❖ F&E Acid-base disorders, electrolyte imbalances, fluid deficit, fluid overload ❖ GI Delayed gastric emptying, distention and flatulence, hiccups, N/V, postoperative ileus ❖ GU Infection, retention ❖ Surgical Site Dehiscence, hematoma, infection ❖ Neuropsychologic Delirium, fever, hypothermia, pain, postoperative cognitive dysfunction

Cancer Development: Progression

❖ Cells proliferate ❖ Ignore growth regulating signals ❖ Tumor Angiogenesis Factor (TAF) Developing it's own blood supply through this ❖ Metastasis Cancer cells move from the primary location to other areas

Cancer SE: Integumentary - What do nurses do?

❖ Chemotherapy induced skin changes Hyperpigmentation, telangiectasia, photosensitivity, acneiform eruptions, acral erythema ❖ AVOID SUN ❖ Symptomatic management as needed

Pre-Op Labs/Testing

❖ Chest x-ray ❖ ECG ❖ Blood work ◇ Complete blood count ◇ CMP ◇ Coags (PT/INR, aPTT) ◇ Type & Cross ❖ Urinalysis ◇ Pregnancy test Any female of childbearing age ❖ Patient on antiplatelets (COAG & CBC) ❖ Pt on diuretics (K+ & BMP) ❖ Pt on meds for dysrhythmias (EKG) ❖ Diabetic pt (blood glucose) Remember to report abnormals BEFORE the surgery!

PE

❖ Clot in the pulmonary vasculature/pulmonary artery ❖ Thrombus which comes from venous circulation or R. side of heart and lodges in the pulmonary arteries. May also be amniotic fluid (air, fat, bone marrow). ❖ S/S Restlessness Anxiety Tachycardia Tachypnea Also, low grade fever & blood tinged sputum ❖ Nursing Diagnoses ∙ Impaired gas exchange Adequate ventilation, but poor perfusion ∙ Anxiety

Goals of Cancer Treatment

❖ Cure ❖ Control ❖ Palliation

What patient eduction would you give regarding systemic glucocorticoids (prednisone, methylprednisolone)?

❖ Daily dosing in the a.m. Because it mimics the release of cortisol in the body which is released in the morning ❖ PO: Administer with meals ❖ Do not stop taking abruptly As they taper the adrenals, by tapering it off they will wake up a little bit each day. If you stop suddenly you could go into cardiac arrest. ❖ Inform all doctors ❖ MedicAlert card/bracelet

Leukopenia

❖ Decrease in number of circulating WBCs ❖ < 5,000 mm³

Cancer Therapy: Hormonal Manipulation

❖ Decreasing the amount of the specific hormone that feeds a hormone sensitive tumor ❖ Slows the growth rate of certain hormone dependent tumors ❖ Block different substances essential for tumor growth

DVT

❖ Deep Vein Thrombosis ❖ Can by asymptomatic ❖ DVT prevention ∙ Early ambulation ∙ apply graduated compression stockings as prescribed ∙ Apply intermittent pneumatic compression devices (SCDs) as prescribed ∙ AROM/PROM (active/passive) ∙ No crossing legs ∙ Proper leg positioning with pillows ∙ Encourage 3L/day PO/IV Because we don't want the blood to be thick or dehydrated ∙ Monitor IV lines ∙ Prophylactic anticoagulants: LMWH ∙ Encourage lifestyle changes

Carcinogenesis

❖ Development of cancer Begins with: I. Oncogenes When healthy: Cells initiate cell division When unhealthy: Rapid proliferation of cells ⬇︎ II. Failure of tumor suppressors Proteins that stop multiplication of cells. Expressed in stressed cells to reduce cell division. Mutation ➠ no suppression (i.e. no brakes!) ⬇︎ III. Clonal Expansion Why? All gas, no brake ⬇︎ IV. Tumor Cells become mutated (no time for repair)

Nursing Responsibilities: Thoracentesis

❖ Done bedside, sitting upright, elbows over bed table and feet supported on floor ❖ Emotional support, VS, s/s of resp. distress. ❖ Continue to monitor after procedure ❖ Watch puncture site, watch for crepitus, pulmonary edema, encourage coughing and deep breathing ❖ Observe for signs of hypoxia and pneumothorax

Paradoxical Respiration

❖ Early s/s of respiratory distress. How a nurse can tell a COPD pt. is going downhill. ❖ Diaphragm goes in on inspiration. ❖ Will happen 1-2 hours before a change in the ABGs. ❖ Respiratory failure ❖ Have an SBAR with the HCP ASAP

Long-term Management COPD: What do nurses do?

❖ Education ・Vaccines ・Long term control: medication ・Oxygen ・ Activity tolerance: Balance activity & rest! ・Self-care Vaccines, take meds, stop smoking ・Smoking cessation

COPD: ACT (Airway Clearance Techniques)

❖ Effective coughing: Huff coughing Pushes the sputum up through the airways ❖ Chest Physiotherapy (CPT) ❖ Postural Drainage Positioning techniques that drain secretions by using gravity. ・Administer bronchodilators and hydration prior ・Position held for 5 minutes ・Percussion and vibration therapy Vibration is only done when the client is about to breathe out.

Cancer: Gene Therapy

❖ Experimental Genetic material is introduced into cells to: ❖ Fight disease ❖ Replace missing genes to prevent the development of bone disease ❖ Rendering the tumor cells more susceptible to damage by other treatments ❖ Example: Inserting viral enzyme gene into brain tumor cells makes them more susceptible to being killed by antiviral agents

Crackles (rales)

❖ Fluid in the alveoli or alveoli popping open ❖ Heard on inspiration and may clear with cough ❖ May be high-pitched, popping sounds, or low-pitched, bubbling sounds ❖ Described as rubbing strands of hair together with fingertips

Radiation Therapy: Skin Care Education

❖ Gently cleanse skin Mild soaps, tepid water, soft cloth, pat dry ❖ Avoid potential irritants Apply non-medicated, non-perfumed, moisturizing lotion/cream. Avoid swimming in saltwater or chlorinated pools during treatment ❖ Observe area daily for infection, redness, irritation ❖ Expose area to air as often as possible ❖ Avoid tight fitting clothing over treatment areas ❖ Avoid harsh fabrics, lightweight cotton fabrics are best ❖ Avoid direct exposure to sun for at least one year after completing treatment ❖ Avoid sources of excessive heat or cold to treatment area

Characteristics of Abnormal Cells

❖ Grow in wrong place at wrong time ❖ Cells lack contact inhibition ❖ Cells return to previous undifferentiated state ❖ New proteins characteristic of embryonic stage emerge on cell membrane ❖ Have undergone a change in cell growth or cell function (Neoplasia) Any new or continued cell growth not needed for normal development ❖ Two types: Benign cells or malignant cells

Pre-Op Stage: Nurse's Role

❖ Have knowledge of the nature of the disorder requiring surgery (what & why) ❖ Identify the individual patient's response to the stress of the surgery ❖ Have knowledge of the results of the pre-operative diagnostic tests ❖ Identify potential risks & complications associated with surgery ❖ Ensure all documentation, pre-op procedures, and orders are complete ❖ Report abnormal lab results!!!!

HAART (ART)

❖ Highly Active Anti-Retroviral Therapy ❖ On a combo of at least 3 meds Viral Entry Blockers ❖ Fusion Inhibitors ❖ CCR5 Coreceptor Antagonists Enzyme Inhibitors ❖ Nucleoside Reverse Transcriptase Inhibitors (NRTI) ❖ Nucleoside Reverses Transcriptase Inhibitors (NNRTI) ❖ Protease Inhibitors (PI) ❖ Integrase Inhibitors 3 Drug Combo ❖ PI + 2 nRTI ❖ NNRTI + 2 NRTI *Consistency is key

What nursing interventions should be initiated if a tracheostomy tube accidentally becomes dislodged?

❖ Immediately replace tube (perfect world) ❖ Spread opening with retention sutures grasped or hemostat ❖ Obturator inserted in replacement tube ❖ Lubricated with saline poured over tip ❖ Inserted at 45 degrees to the neck ❖ If insertion is successful, obturator removed immediately for air flow through the tube

Cancer: Biologic Therapy

❖ Immunotherapy ❖ Stimulate the immune system to recognize cancer cells and take action to eliminate or destroy them ❖ AKA immunomodulator agents ❖ Interleukins Promote response of cytotoxic t-cells ❖ Interferons Promote t-cells working and destroying the cancer

What are some possible nursing diagnoses for asthama?

❖ Impaired gas exchange ❖ Ineffective airway clearance B/C they pt. is having trouble clearing whatever is in the bronchioles. Give lots of fluids IV. ❖ Anxiety ❖ Deficient Knowledge

Genetic Disease-Related Consequences of Cancer & Treatment

❖ Impaired immune and hematopoietic function ❖ Altered GI structure and function ❖ Motor & sensory deficits ❖ Decreased respiratory function *Keep these in mind when discussing different treatment options

When obtaining pre-op health history, what information is included in the baseline data?

❖ Knowledge & understanding of surgery ❖ VS ❖ Height/weight An obese pt is at increased risk for dehiscience, evisceration, slow to recover from the anesthesia and increased risk for CV, resp, and GI complications. ❖ Nutritional status Any alteration in nutrition delays wound healing and increases risk for infection. Malnourished pt is at risk for F&E imbalances, and skin breakdown. Provide high calorie snacks, dietary consult pre- & post-op. Extra padding during surgery. Also... ❖ Allergies Latex allergy? ❖ Medical history ❖ Current meds ❖ Cultural and spiritual factors ❖ Use of alcohol & drugs Alcohol requires larger doses of anesthesia and post-op anesthetics. Illicit drugs may interact with anesthetics. Nicotine increases the risk for post-op complications * Check any documented info before interview to avoid repetition

Informed Consent

❖ Legal document and ethical imperative ❖ Who is unable to sign? Minors, unconscious, mentally incompetent, vegetative state, heavily medicated. Have a family member, PoA, or follow chain of surrogacy for signature. ❖ What if a patient can't read/write? Surgeon must inform them. We read it to them. ❖ May obtain phone consent in emergency situations 2 nurses must sign as witnesses. If phone consent cannot be achieved, 2 physicians can sign consent in an emergency ❖ Nurse's Role? Are they qualified for informed consent? Make sure they understand. Surgeon must educate them FIRST!!! We can answer question and clarify.

What are some advantages to having a tracheostomy verse an endotracheal tube?

❖ Less risk of long-term damage to airway ❖ Increased comfort ❖ Permit oral intake and speech ❖ Increased mobility b/c tube is more secure

HIV Disease & HAART Regimen Metabolic Complications

❖ Lipodystrophy Fat redistributed ❖ Endocrine Increase in blood sugar ➠ Diabetes. May need insulin or antidiabetic meds ❖ Bone disease/fractures Five fold increase ❖ Cardiovascular disease High risk for atherosclerosis/hyperlipidemia. Increased triglycerides, high LDL, low HDL. May need to be on a statin. ❖ Interventions Assess risk and treat per guidelines. Change in HAART regimen if possible.

Rhonchi

❖ Low-pitched, continuous gurgling sounds caused by secretions in the large airways. ❖ Heard on inspiration and expiration, but predominantly expiration. ❖ Clear with coughing

Cancer SE: N/V - What do nurses do?

❖ May need combination therapy ❖ Prophylactic administration of antiemetics Such as: ❖ Serotonin antagonists: ondanestron (Zofran) IV, oral, transdermal patch. Very few adverse effects, HA ❖ Corticosteroids: dexamethasone (Decadron) & methyprednisolone (Solu-medrol) Short term, IV, PO ❖ Eat/drink when not nauseated, pre-medicate ❖ Non-pharmacologic Music, muscle relaxation, acupressure

Chemotherapy: Preparation/handling

❖ May pose an occupational hazard ❖ Drugs may be absorbed through skin and inhalation ❖ Only properly trained personnel ❖ Proper labeling ❖ Chemotherapy (or double) gloves and other PPE ❖ Double bag chemo waste ❖ Be cautious with body fluids for 48 hours after pt receives chemo ❖ Hand washing ❖ Many routes for chemo administration ❖ IV is most common (CVAD). PIV is very rare. ❖ Risk of extravasation injury

Mast Cell

❖ Mediator of Injury ❖ Most important activator of inflammatory response/ ❖ Degranulation Release powerful inflammatory modulators. Histamine, leukotriene, prostaglanding... These modulators... ❖ Vasodilate ➜ hypotension ❖ Increase vessel permeability ❖ Constrict bronchial smooth muscle ❖ Increase secretion of mucous ❖ Itching

Immunologic Escape

❖ Method by which cancer cells evade immune system ❖ Suppression of factors that stimulate T cells ❖ Weak surface antigens allow cancer cells to "sneak through" surveillance

Nursing Responsibilities: Bronchoscopy

❖ NPO for 6-12 hours ❖ Administer sedative ❖ Post procedure keep NPO until gag reflex returns ❖ Blood tinged mucous is normal (Frank red is not) ❖ Biopsy: Watch for hemorrhage and pneumothorax ❖ If you see bronchospasm report it immediately!

Nursing Responsibilities: MRI of Chest

❖ No iodine dye ❖ No radiation used ❖ Metal screening ❖ Claustrophobia

Long Term Management of Asthma

❖ Obtain health and medication history ❖ Pneumococcal & flu vaccines ❖ Watch out for allergies to aspirin ❖ Beta Blockers can stimulate B₂ causing bronchoconstriction ❖ Teaching self care Know your triggers, stress management, etc. ❖ Prevention of exacerbations Avoid triggers. Peak flow meter & action plan. Proper medication administration.

Tracheostomy Precautions

❖ Obturator and tube of equal and also smaller size kept at bedside for emergency insertion ❖ Tapes/ties not changed for at least 24 hours after insertion ❖ First tube changed by physician no sooner that 7 days after trach

What oral manifestation associated with HIV infection presents as a white mucosal plaque that does not rub off, and most often involves the lateral border of the tongue?

❖ Oral Hairy Leukoplakia (OHL) ❖ This is a sign of severe immunosuppression in HIV-infected patients. ❖ No treatment

Characteristics of Normal Cells

❖ Perform in a predictive manner ❖ Work together to function at optimal levels ❖ Undergo mitosis as needed ❖ Undergo apoptosis (cell death) ❖ Contain a small nucleus ❖ Show specific morphology ❖ Perform special functions ❖ Adhere together

Theophylline

❖ Pharmacologic class: Xanthine ❖ Therapeutic class: Bronchodilator ❖ Used infrequently ・Unresponsive to asthma ・Narrow safety margin ・Many interactions ❖ Therapeutic range: 10-20 mcg/mL ❖ Oral or IV route

Peak Flow Meter (PFM)

❖ Portable instrument used to measure air flow early in forced exhalation; helps monitor asthma and adjust medication accordingly ❖ Green 80%-100% ❖ Yellow 50%-79%

Where does the pt go in the immediate post-op period? What is the primary goal there? What scoring system is often used to determine when a pt. can be discharged from there?

❖ Post-Anesthesia Care Unit (PACU) ❖ To monitor for complications of anesthesia and/or the surgery itself ❖ Priorities: ABCs, pain, VS/temp, monitor for bleeding ❖ The 'Modified' Aldrete Scale Respiration, O₂ sat, consciousness, circulation, activity

Systemic Glucocorticoids

❖ Prednisone (Rayos) PO ❖ Methylprednisolone (Medrol) IV (succinate) or PO ❖ Action of Both ∙ Suppresses inflammation and normal immune response ∙ Can be used for autoimmune diseases ∙ Immunosuppressive

PE Long Term Management: What do nurses do?

❖ Prevention Incentive spirometer will keep alveoli open ❖ TCDB/IS Turn, cough, deep breath/Incentive Spirometer ❖ S/S of complications Keep a look out for R. sided heart failure ❖ Self-care Anticoagulation therapy for 6 mos to 1 year. Oxygen therapy.

Brachytherapy: What do nurses do?

❖ Private room ❖ "Caution: Radioactive Material" sign ❖ Dosimeter film badge Tracks radiation exposure ❖ Restricitons Cluster care, shields, no pregnant nurses/children under 16, limit visitation to 30 min/day, 6 ft from source ❖ Never touch implant with bare hands ❖ Dressings/bed linens ❖ Pts with permanent implants can be discharged with normal precautions

What is the goal of anesthesia?

❖ Produce the desired effects with minimal disturbances in physiologic function ❖ Induced states of partial or total loss of sensation, with or w/o consciousness used to: Block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and achieve a controlled level of consciousness

What are some s/s of asthma?

❖ RAT (Restlessness, anxiety, tachypnea) ❖ Retractions (Ribs concaving in during breathing) ❖ Cough ❖ Increased mucus ❖ SOB ❖ Expiratory wheeze ❖ CO₂ retention (respiratory acidosis) ❖ Prolonged expiration (because the body is trying to get rid of CO₂)

Cancer SE: Alopecia - What do nurses do?

❖ Reassurance: Hair loss is usually temporary ❖ Re-growth usually begins about 1 month after completion of surgery ❖ New hair may differ in color, texture, thickness ❖ Assist in selecting head cover that suits them Caps, scarves, wigs, turbans

What can put a pt. at risk for pos-op complications?

❖ Receiving general anesthesia ❖ An older client ❖ Respiratory cardiac disease ❖ Obesity ❖ Diabetes ❖ Undergoing thoracic, airway, or abdominal surgery

COPD Pathophysiology

❖ Repeated, ongoing tissue injury & repair ・Inflammation & formation of scar tissue (remodeling) = airway narrowing ・Increase in mucous production ・Cilia & macrophage malfunction They are deflated sad. Also leads to lower immunity. ❖ S/S Presence of cough & sputum production ❖ Over-distended alveoli/bronchioles ・Big & floppy ・Alveoli destroyed & capillary bed reduced ❖ S/S ・Lack of recoil (100 mph vs 600 mph) ・Hyperinflation ・Barrel chest B/C the lung tissue has been expanded so much and cannot snap back the way it used to.

What are some roles of the circulating RN during surgery?

❖ Serves as pt. advocate throughout the surgical experience ❖ Maintains pt. privacy, safety, dignity, and confidentiality ❖ Remains unsterile ❖ Keeps an eye on any breaks in sterility ❖ Anticipates the pts needs and surgical teams needs ❖ Documents care, events, findngs, and counts

What are some contraindications of ipatropium?

❖ Side Effects/Adverse Reactions Minimal d/t low systemic absorption ❖ Drug-Lab-Food Interactions Minimal. Increases with other anticholinergics.

Cancer: Targeted Therapy

❖ Specially engineered to attack cancer antigens ❖ Monoclonal antibodies attach to surface antigens ❖ Rituximab (Rituxan) ❖ Trastuzuman (Herceptin) ❖ Less damage to normal cells

Acute Management of COPD: What do nurse do?

❖ Stay calm ❖ Assess respiratory system ❖ Yes/No questions ❖ Tripod position ❖ PLB (1:3) breathing ❖ Small, frequent meals to increase caloric intake Interprofessional Care: ・IVF (as long as they can have it) ・Administer meds Quick relief, oxygen, ACT (Airway Clearance Techniques) * You don't want to give your COPD pt. too much oxygen b/c their body could think that they've had enough and they the pt. would stop breathing.

PE Acute Management: What do nurses do?

❖ Stay calm and stay with patient ❖ Sit them up ❖ Assess VS, respiratory assessment. Breath sounds will be normal until the alveoli collapse and then the sounds will be diminished. ❖ Oxygen Depends on the patient ❖ IV access: IVF ❖ Anxiety treatment Morphine is good for anxiety & will pull blood down into the extremities ❖ Anticoagulation meds ❖ Interprofessional care

Anaphylaxis: Priority Nursing Actions!

❖ Stop the offending agent or antibiotic causing it!!! ❖ Call RRT or Code ❖ Epinephrine Reverses the symptoms (↑ HR, ↑BP, bronchodilation) ❖ Assess respiratory status Maintain patent airway, elevate HOB, administer O₂ as necessary ❖ Establish IV access ❖ Nubulized Albuterol ❖ Diphenhydramine (Benadryl) ❖ Corticosteroids ❖ Document

What will the nurse include in pre-op teaching?

❖ Surgical event and sensations ◇ What they will see, hear, smell, feel during surgery. ◇ General flow: pre-op holding ➯ OR ➯ PACU (they will wake up in a different place) ◇ Additional details Multiple incisions? Tubes or drains post-op? Special equipment? ❖ Special equipment/surgery specific info ❖ Post-op complication prevention ◇ TCDB/IS; splinting; SCDs/leg exercises ◇ If you teach them nothing else... deep breathing! Slow, steady deep breaths.

Nursing Interventions: CT of Chest

❖ Test renal function b/c of IV dye ❖ Patient must be well hydrated to urinate the dye out ❖ Shellfish or iodine allergies? ❖ Warn pt. that when dye is injected they will feel a warm sensation, and they must lie very still on a hard surface. The warmth can extend to the groin and they may feel like they've wet themselves. ❖ Get correct weight for pt. since machines have a weight limit.

What are some potential complications of general anesthesia?

❖ Unrecognized hypoventilation ❖ Complications of specific anesthetic agents Inhaled agents irritating to respiratory tract ❖ Complications of intubation ❖ Overdose ❖ Malignant hyperthermia

Why would a patient have a D-Dimer lab test performed?

❖ Used to rule out active blood clot formation ❖ Negative outcome = Ruled out blood clot formation in the body

Venous Thromboembolism (VTE)

❖ VTE = DVT + PE ❖ S/S of acute VTE Mild to moderate calf pain and tenderness, unilateral edema, warmth, and tenderness of affected extremity, elevated temp, erythema, edema.

Bone Marrow Biopsy: Nursing Responsibilities

❖ Very painful procedure ❖ Local anesthesia, possibly conscious sedation ❖ Pre-medicate with pain or anti-anxiety meds ❖ Positioning ❖ Monitor patience tolerance & VS ❖ Immediately after cover area with sterile occlusive dressing ❖ Prevent leakage ❖ Have pt lie on area to apply pressure for 30-60 minutes post procedure

Important Tracheostomy Things to Remember

❖ You can be on room air with a trach ❖ If O₂ is over 1 L it needs to be humidified ❖ Trach suction setting is put to 'continuous' @ 100-120 mmHg and then used intermittently ❖ The T-piece trach is at greater risk for falling out ❖ When tube is inserted, the thumb is up, no suction ❖ When hyper-oxygenating a pt the O₂ should be up all the way to 15 ❖ Offer oral care!

Hyponatremia

・ <135 mEq/L ・S/Sx are not apparent until the sodium level is less than 120 mEq/L ・Body fluids are diluted and cells swell from decreased extracellular osmolality ・Severe symptoms (110 mEq/L or less) include seizures, coma, and permanent neurologic damage.

Ventricular Thrombus

・ A ventricle that is not able to pump out all of the blood due to a blood clot. ・ A clot forming in the ventricle

Heart Failure: What Medications May Be Used?

・ ACE Inhibitors & Angiotensin Receptor Blockers Inhibition of RAAS ・ Beta Blockers Decrease heart rate Allow more filling time ・ Vasodilators Decreases blood pressure ・ Diuretics Removes excess fluid ・ Cardiac Glycosides Decreases heart rate Increases contraction

What medications may be used for hypertension?

・ ACE Inhibitors and Angiotensin Receptor Blockers Inhibition of the RAAS ・ Beta Blockers Decrease heart rate Allow more filling time ・ Vasodilators Decreases blood pressure ・ Diuretics Removes excess fluid ・ Calcium Channel-Blockers Reduce afterload Vasodilation

Orthopnea

・ Ability to breathe only in an upright position. ・ S/S of left sided heart failure

Ascites

・ Abnormal accumulation of fluid in the abdomen. ・ Leads to swelling in the abdomen. ・ S/S of right sided heart failure.

Potassium Regulation & the Kidneys

・ Absorbed in intestines and excreted from kidneys ・ Kidneys eliminate about 90% of potassium ・ Kidneys have no effective mechanism to combat loss of K+, may excrete K+ even when levels are low ・If kidney function is significantly impaired, retained potassium can lead to toxic levels.

Aspirin: MOA, Use, & Considerations

・ Acetylsalicyclic Acid, ASA ・Antiplatelet MOA ・Blockage of COX-1 Prevents platelets from forming a clot ・Prevents ADP from binding with platelet receptors Prevents fibrinogen binding to platelet receptors Use ・Mainly used for prophylaxis ・Prevent MI or PAD/CVA ・Prevent repeat MI or PAD/CVA ・Prevent arterial clot formation Considerations ・Platelet aggregation inhibition caused by ASA is irreversible (cannot be on a week before surgery) ・DC for one week prior to elective surgery ・Available in enteric coated form ECASA dissolves in small intestine and not the stomach. If not EC it could burn a hole in the stomach and cause bleeding.

What are the mechanisms of action of furosemide?

・ Acts along the ascending limb of the loop of Henle ・ Increases secretion of chloride, sodium, and water ・ Blocks chloride, sodium, and water reabsorption

Contraindications of Potassium

・ Allergy to a specific product ・ Hyperkalemia ・ Severe renal disease

Health Promotion

・ Annual flu vaccine ・ Initial Pneumonia vaccine and revaccinate in 5 years ・ Risk factor reduction BP control Smoking cessation Weight reduction

Dysrhythmias

・ Any deviation from the normal rhythm of the heart ・ Atrial fibrillation is a specific dysrhythmia that goes with heart failure

Nursing Implications for Heart Failure Drug Interactions

・ Assess fluid status Monitor weight, I&O's, lung sounds, skin turgor, mucous membranes, edema ・ Monitor BP before and during administration ・ Monitor electrolytes (baseline and ongoing) ・ Monitor kidney function (BUN, Creatinine) ・ Give in the AM

When would you hold Digoxin (Lanoxin)?

・ Check apical pulse for one full minute; Hold if < 60BPM or EKG changes ・ Hold if K⁺ is low (<3.5mEq/L) ・ Hold if Digoxin level is > 2 ng/mL

Nursing Management of Heart Failure

・ Decrease intravascular volume Give patient a diuretic. This will get the fluid to flow into the kidneys and help the kidneys to get rid of excess fluids (as long as kidneys have function) ・ Decrease venous return Helps to decrease workload on heart so there is not as much fluid going into it. (If needed) ・ Decrease afterload Vasodilate or lower BP ・ Increase gas exchange Help get fluid out of the lungs. Maybe a diuretic could help. Diuretics help pull fluids from where they aren't supposed to be back into the kidneys so the kidneys can pump it out. ・ Reduce anxiety

What are some drug interactions of Hydrochlorothiazide (HCTZ)?

・ Decreases effectiveness of anticoagulants and antibiotics ・ digoxin (Lanoxin) = hypokalemia

Teaching Points for Heart Failure Drug Interactions

・ Do not double dose if missed ・ Change positions slowly ・ Diabetic patients- monitor BS, may increase levels ・ Teach S/Sx of hypokalemia ・ Safety precautions Frequent urination, dizziness

What are common contraindications of furosemide?

・ Drug allergy ・ Allergy to sulfonamide antibiotics ・ Severe electrolyte loss

Heart Failure: Diagnostic Studies

・ Echocardiography ・ Electrocardiogram (ECG) ・ CXR ・ Heart Catheterization ・ Elevated Brain Natriuretic Peptide (BNP) - Draw blood and look for this BNP

Exertional Dyspnea

・ Effort at breathing when physically active ・ S/S of left sided heart failure

Hepatomegaly

・ Enlargement of the liver due to excess fluid backup

Dietary Therapy

・ Examine labels to determine sodium content ・ Some laxatives, antacids, and cough meds contain sodium ・ Avoid adding salt to foods when cooking ・ Weigh yourself at the same time each day in AM, same scale, similar clothes ・ Eat smaller, more frequent meals. (eating when you can't breathe is hard, eating smaller meals makes it easier. It helps you make better decisions too)

What are some side effects and adverse reactions of flurosemide?

・ Fluid volume deficit We never want to over correct to where it becomes a problem. We don't want to go from having too much to not having enough. ・ Hypokalemia When we think potassium, we think heart. ・ Hyponatremia ・ Hypomagnesemia ・ Hypochloremia ・ Metabolic alkalosis Part of what keeps our ph normal is hydrogen ions and this has to do with the swap of potassium and hydrogen ions (More for Block 2) ・ Hypotension Overcorrected fluid intake ・ Increased BUN Blood, urine, nitrogen. It would not be therapeutic if these went up because we wouldn't expect the increased BUN b/c they are promoting the excretion of sodium, water, and chloride and what you're peeing out is diluted and you could wind up losing so much water that the concentration of urea in your blood looks like you have too much. ・ Orthostatic Hypotension This is a potent diuresis and when you lose a lot of fluid you are prone to get that with orthostatic hypotension

What are some side/adverse effects of potassium?

・ GI distress N/V/D, GI ulcerations/bleeding, esophagitis ・ Hyperkalemia (K > 5 mEq/L) ・ Pain/phlebitis at injection site

Diastolic Heart Failure

・ Inability of ventricle to relax and fill during diastole ・ Decreased filling of ventricles results in decreased SV and CO ・ Most common reason - HTN

Activity Program

・ Increase activity gradually, as long as it does not cause dyspnea ・ Consider cardiac rehab program ・ Avoid extremes of heat and cold ・ Plan rest periods after exertion (ex. ADLs or exercise) ・ Shorten working hours ・ Avoid emotional upsets

Pulmonary Congestion

・ Left side fails, blood backs up in lungs ・ Cough ・ Crackles ・ Wheezes ・ Blood-tinged sputum (Unless you have TB it is cardiac, not respiratory) ・ Tachypnea

Renal Failure

・ Loss of kidney function resulting in its inability to remove waste products from the body and maintain electrolyte balance. ・ Kidney failure

Treatment Goals of Heart Failure

・ Maximize CO ・ Reduce symptoms ・ Improve ventricular function ・ Improve quality of life ・ Preserve organ function ・ Improve mortality and morbidity risks *This is how you think through your nursing process without an assessment. Your assessment is your expected findings*

Potassium (K⁺)

・ Most abundant cation in the ICF (150mEq/L) ・ ECF plasma levels (3.5-5.0mEq/L) are critical for normal body function Essential for: ・ Transmitting nerve impulses ・ Muscle contraction ・ Regulation of acid/base balance

Regulation of Low Blood Pressure

・ Nervous/Cardiovascular/Renal/Endocrine Systems ・ Short Term Mechanisms Sympathetic Nervous System & vascular responses ・ Long Term Mechanisms Renal and hormonal processes

What are the drug interactions of furosemide?

・ Oral antihyperglycemics Decreases effectiveness of antidiabetic drugs because it prevents high blood sugar. ・ Anticoagulants Decreases effectiveness of anticoagulants ・ digoxin (Lanoxin) Increases potential for DIG toxicity due to hyperkalemia

Compensatory Mechanisms of Heart Failure

・ Our body tries to "help" ・ SNS activation: 1st, not effective, ultimately harmful ・ Neurohormonal Response Kidney: Renin Brain: ADH ・ Dilation of heart tissues Helps for a little bit but eventually it hurts b/c it makes the heart weaker ・ Hypertrophy

Ejection Fraction

・ Percentage of end-diastolic blood volume that is ejected during systole ・ Normal is 55-70% ・ Heart failure if < 40%

Complications of Heart Failure

・ Pleural effusion ・ Dysrhythmias ・ Hepatomegaly ・ Renal Failure ・ Ventricular Thrombus

Factors affecting SV are:

・ Preload How much blood is in the ventricle right before systole. (volume of blood in the ventricles at the end of diastole and before the next contraction) ・ Contractility The ability for the muscle to contract. Increasing raises the SV by increasing vascular emptying ・ Afterload The peripheral resistance against which the left ventricle must pump. Resistance left ventricle must overcome to circulate blood. ・ Increasing preload and/or afterload increases the workload of the myocardium, resulting in increased O₂ demand

What is the overall effect of furosemide?

・ Produce potent diuresis and subsequent loss of fluid ・ Increased urine output ・ Results in decreased fluid volume ・ Decreased return of blood to heart ・ Decreased filling pressures

Heart Failure is...

・ Progressive condition generally speaking ・ Over time... Increased workload on the heart muscle causes decreased function leading to: Decreased elasticity of ventricles Decreased filling capacity Decreased force of contractions Decreased cardia output Leading to decreased perfusion and oxygenation to organs and tissues. Also leading to... ・ Decreased CO causes a "backup" in the blood flow ・ Right sided heart failure means the right side cannot pump enough blood to the lungs and the blood will back up into the body. ・ Left sided heart failure means the left side cannot get the blood out into the body and it is going to back up into the lungs (shortness of breath, crackles in lungs, activity intolerance, issues with organs and perfusion)

Causes of Hyperkalemia (↑K⁺) include:

・ Renal failure ・ ACE inhibitors ・ Potassium supplements ・ Potassium-sparing diuretics ・ Trauma/burns ・ (FYI) Metabolic acidosis

Is fatigue a s/s or which sided heart failure?

・ S/S of left sided heart failure?

Dependent Edema

・ Swelling in the part of the body closest to the ground, caused by collection of fluid in the tissues; a possible sign of congestive heart failure. ・ S/S of right sided heart failure

What is blood pressure affected by?

・ Systemic Vascular Resistance (SVR) Force opposing the movement of blood ・ CO (without adequate CO the organs do not get enough perfusion and will in turn tell the body they need more blood and the body will produce more blood, leading to higher blood pressure)

General Guidelines of Drug Therapy for HF

・ Take as prescribed ・ Know the S/Sx of orthostatic hypotension and how to avoid it ・ Know the S/Sx of internal bleeding if taking anticoagulants (Your body may not be clotting like it should when taking anticoagulants and there is potential for internal bleeding) ・ If taking Coumadin (warfarin), have INR (tells you how much time the body takes to clot) checked regularly. If INR is too high, you would not continue giving Coumadin.

Parasympathetic Nervous System

・ The division of the autonomic nervous system that calms the body, conserving its energy. ・ Rest and digest ・ A set of nerves that helps the body return to a normal resting state

Anorexia

・ The loss of appetite for food, especially when caused by disease. ・ This is a symptom. Anorexia nervosa is a disease process. ・ S/S of right sided heart failure.

First Spacing of Fluid

・ The normal distribution of fluid in the ICF and ECF compartments. ・ Where the fluid is supposed to be.

Functions of Potassium

・ Transmission and conduction of nerve impulses ・ Muscle contractions ・ Maintenance of cardiac rhythms/maintains cell's electrical neutrality and osmolality ・ Cellular growth ・ Acid-base balance

Therapeutic Uses of Potassium

・ Treating hypokalemia (K<3.5 mEq/L) ・ For clients on diuretics ・ Post-op cardiac patients (helps to manage dysrhythmias) ・ Try dietary measures first

Ongoing Monitoring

・ Understand the symptoms ・ Report any changes or worsening of symptoms to HCP ・ Report weight gain of: 3 lbs in 2 days or 3-5 lbs in a 1 week

Sinus Tachycardia (Intervals, EKG, why is it an issue? What could cause it? Medications?)

・100-160 bpm ・Each complex is complete. Note: P waves may be buried in the previous T wave. All intervals except the rate are WNL Why is ST an issue? Decreased filling time (preload) ⟹ Decreased SV ⟹ Decreased CO What could cause ST? ・Identify and treat underlying cause. ・Usually caused by SNS stimulation. ・Fear, anxiety, exercise, pain, fever, bleeding, dehydration, HF, hyperthyroid Medications ・Beta Blockers, CCB, ablation

HIV Facts

・70% of HIV cases are not under control ・% of people with HIV virus under control increases with age ・When used correctly, antiretroviral medications can keep HIV controlled. Reduce sexual transmission by 96%

Calcium

・8.5-10.5 mg/dL ・Most abundant electrolyte in the body ・Total serum calcium level looks at the total amount of calcium in the blood. Includes both ionized and protein bound calcium. This includes all three forms.

Hyperchloremia

・>105 mEq/L ・Rarely produces symptoms on its own but are present due to metabolic acidosis, hypernatremia, or hyperkalemia. Signs & Symptoms: ・Tachypnea ・Lethargy ・Thirst/dehydration ・Weakness ・Hypotension ・LOC ・Arrhythmia, decreased CO ・Coma

What is an autoimmune disease/disorder?

・A group of disorders caused by the breakdown of the ability of the immune system to differentiate between self and non-self antigens ・Destroys host tissues ・Can affect almost any cell or tissue in the body

What are the MOA, uses, and assessment considerations for enoxaparin (Lovenox)?

・A low molecular weight heparin (LMWH) MOA ・Works similar to the way heparin works (not as easily manipulated though) ・More predictable anticoagulant response ・Used to "bridge" to warfarin (Coumadin) ・Inhibit thrombus and clot formation by blocking Xa Uses ・Prevention of DVT/VTE Surgery/immobility ・Prevention of ischemic complications USA (Unstable Angina) = much bigger dose, MI Assess for bleeding ・PTT/aPTT not necessary ・H&H Discontinue if platelets < 100,000

Superinfection

・A secondary infection that results from the destruction of normal microflora and often follows the use of broad-spectrum antibiotics. ・A second infection that has occurred on top of an earlier infection, especially following treatment with antibiotics.

Hydralazine

・A vasodilator ・Directly relax arteriolar and/or venous smooth muscle Result: Decreased systemic vascular response, decreased afterload, and peripheral vasodilation Adverse Effects: ・Dizziness ・Headaches ・Anxiety ・Tachycardia ・N/V/D ・Anemia ・Dyspnea ・Edema ・Nasal congestion

Respiratory Mechanisms

・Act within minutes to compensate for acidosis or alkalosis ・Respiratory center in medulla controls breathing

What are the functions of magnesium?

・Activates enzymes that break down carbohydrates and proteins ・Helps maintain calcium and potassium balances ・Necessary for sodium-potassium pump ・Involved in electrical activity in nerves and muscles ・Helps maintain heart rhythm ・Acts synergistically with calcium in hundreds of reactions in the body ・Is required for calcium and B12 absorption ・Has a sedative effect on the neuromuscular junction, which causes smooth muscle relaxation.

What are some drug interactions of Beta Blockers?

・Antacids delay absorption ・NSAIDS decrease hypotensive effects ・Diuretics Increases hypotensive effects

What is atropine? What are it's therapeutic effects/uses?

・Anticholinergic ・Treats bradycardia/PEA/Asystole by increasing the HR ・Pupil dilation (mydriatic) ・Decreases respiratory secretions. Used prior to anesthesia/surgery and in hospice.

What are some nursing interventions for hypercalcemia?

・Assess/monitor serum Ca++ & other electrolytes ・Neuro, CV assessments ・Low Ca++ diet ・Maintain IV access (hydrate with isotonic saline solutions) ・Promote excretion of Ca++ Encourage 3-4L fluid intake/day, monitor I/O, loop diuretics, Calcitonin (synthetic) IM/SQ ・Strain urine for calculi ・Mobilize patient to prevent bone loss of Ca++

What are some food sources that are high in potassium?

・Bananas, oranges ・Chocolate ・Dried fruits, nuts, and seeds ・Beans, potatoes, mushrooms, broccolis, tomatoes, and celery ・Meats ・Salt substitutes Contain high potassium. We need to make sure to educate patients with a high potassium level not to use salt substitutes at that time due to the risk of toxicity.

What are the nursing implications for enoxaparin (Lovenox)?

・Be sure to inject the air bubble to help with absorption (keep the air bubble in the syringe and it should be injected last... so pay attention to positioning of your syringe) ・Be sure plunger pushes all the way in to avoid injury ・Rotate injection sites

Active DVT: What do nurses do?

・Bed rest We don't want it to break off and travel ・Palpate site gently for warmth/edema Do not massage extremity. May break off and travel. ・Measure/record leg circumferences ・Monitor for SOB/chest pain ・Elevate affected extremity Avoid pillow under knee ・Intermittent warm compresses ・Administer diuretics, analgesics, and anticoagulants as prescribed. ・ Prepare for Vena Cava filter

Home BP Monitoring: Educaton

・Bring monitor to office for verification ・Teach BP steps ・New HTN Dx or medication adjustments: LOG First thing in AM and last thing before bed (for 1 week or until normoretensive) ・Stable HTN clients AM or PM for 1 week every 3 months ・While taking BP No talking, don't cross legs, no smoking, no drinking, no caffeine, cuff size & placement, same time every day.

Regulatory Mechanisms for Acid-Base Balance

・Buffer System Immediate ・Respiratory Mechanisms Minutes to hours ・Renal Mechanisms Hours to days

Describe the parameters needed to be diagnosed with the final stage of the HIV disease, AIDS.

・CD4 counts of less than 200 ・Severe immunosuppression ・The presence of some opportunistic diseases and cancer

Nursing Implications/Education of HTN Drugs

・Conduct a thorough head-to-toe assessment before beginning therapy ・Assess for contraindications to specific antihypertensives ・Assess for conditions that require cautious use of these drugs ・Monitor BP during therapy; instruct client to keep a journal of regular BP checks AM & PM for 1 week or until normotensive with new meds and med adjustments. AM & PM for a week q3months. ・Educate pt about the importance of not missing a dose and taking meds exactly as prescribed ・Clients should never double up on doses if a dose is missed; check with HCP on what to do about a missed dose ・Drugs should not be stopped abruptly b/c this may cause a rebound hypertensive crisis and perhaps lead to stroke ・Oral forms should be given with meals so that absorption is more gradual and effective ・Medication is only part of therapy. Encourage lifestyle modifications. ・Change positions slowly to avoid syncope from orthostatic hypotension ・Men taking these drugs may not be aware that impotence is an expected effect. This may influence compliance. ・Hot tubs, shower, or baths; hot weather; prolonged sitting or standing; physical exercise; and alcohol ingestion may aggravate low BP, leading to fainting and injury. Client should sit or lie down until symptoms subside. ・Monitor for adverse effects such as: dizziness, orthostatic hypotension, fatigue, and toxic effects ・Clients should report unusual SOB, difficulty breathing, swelling of the feet, ankles, face, or around the eyes; weigh gain or loss, chest pain, palpitations, or excessive fatigue ・Clients should contact HCP immediately if they are experiencing serious adverse effects, or they believe that their medication should be changed. ・Monitor for therapeutic effects: BP should be maintained per HCP directions, once antihypertensive therapy is started, clients should return for follow-up adjustments of meds in monthly intervals until BP is reached. Then 3-6 month follow-ups.

Magnesium and the Kidneys

・Conserve magnesium in times of need ・Excretes when there is excessive amounts

What are some calcium food sources?

・Dairy (milk, cheese, yogurt, ice cream) ・Dark leafy greens(broccolli, spinach, collard greens) ・Salmon

Hypermagnesemia and S/Sx

・Decreased muscle and nerve activity ・Hypotension, bradycardia, and respiratory paralysis ・Hypoactive deep tendon reflexes ・Facial paresthesia ・N/V ・Drowsy and lethargic---altered LOC (coma) ・Weak pulse--heart blocks ・Vasodilation = hypotension

What do cholinergics that stimulate muscarinic receptors do?

・Decreases HR ・Bronchoconstriction ・Increased bronchial secretions ・Vasodilation (decrease BP) ・Miosis (pupil constriction) ・Increase GI motility ・Increase GI secretions ・Increase bladder contractions ・Relaxation of bladder sphincter ・Stimulates urination ・Increased salivation ・Increased perspiration ・Increased tears ・SLUD (salivation, lacrimation, urination, defecation)

What do anticholinergics do for the eye?

・Dilate the pupil ・Cycloplegia ・Paralyzes accommodation

What is Bethanechol? What are it's therapeutic effects/uses?

・Direct acting cholinergic agonist Treatment of urinary retention ・Non-obstructive post-op and postpartum urinary retention ・Neurogenic atony of the bladder with retention

What are some nursing interventions for Atorvastatin (Lipitor)?

・Do not take if pregnant ・Monitor lipid panel ・Monitor LFTs ・Monitor urine and for muscle tenderness (rhabdo) ・Monitor for GI upset ・Administer with food ・Administer after dinner Rest and digest. The liver is most active at night. ・Teaching Continue with lifestyle modifications, no Gf juice, report any muscle tenderness/weakness immediately

What are some clinical manifestation of HIV?

・Dyspnea ・Cough ・Lymphadenopathy ・Fever ・Weight Loss ・GI symptoms ・Neuro symptoms ・Rash ・Night sweats ・Flu-like symptoms

Angiotensin II Receptor Blockers (ARBs)

・End in -sartan (-sartan = satan and therefore angiotensin) ・Blocks angiotensin II in arteriolar smooth muscle and in adrenal gland ・Prevent release of aldosterone ・Dilates arterioles and increases sodium excretion by kidneys ・Few side effects except s/s of low blood pressure First dose phenomenon ・Ex. losartan (Cozaar), valsartan (Diovan)

ELISA

・Enzyme-Linked Immunosorbent Assay ・Test to detect presence of circulating anti-HIV antibodies & 1 viral protein ・Negative: Could mean no HIV, or the pt. is in a window period. ・Positive: Another ELISA positive ➞ Western Blot

What is the function of chloride?

・Follows sodium and potassium ・Essential for production of HCL for gastric secretions ・Acid-base balance (chloride vs bicarbonate)

What are the functions of calcium?

・Formation of teeth and bone ・Facilitates blood clotting ・Promotes transmission of nerve impulses ・Myocardial contractions ・Muscle contractions ・Hormone release

Warfarin (Coumadin)

・Given orally ・Monitored by prothrombin time (PT) and INR (PT-INR) ・May be started while the patient is still on heparin until PT-INR levels indicate adequate anticoagulaton. ・Full therapeutic effect takes several days ・Monitor PT-INR regularly--keep follow-up appointments ・Vitamin K (phytonadione) can be given if toxicity occurs ・Must watch their diet, no drastic changes to a diet either already high or already low in leafy greens. Must speak with physician first.

What do nurses do for clients with CAD?

・Health promotion ・Flu/Pneumonia vaccines Infections are inflammatory and lead to a potential heart attack ・Medication BP, cholesterol lowering drugs, antiplatelet therapy

Clinical Manifestations of Metabolic Alkalosis

・Hypoventilation ・Dysrhythmias, tachycardia ・Neuromuscular excitability ・N/T ・Confusion ・N/V, anorexia ・Seizures

What do nurses do with a patient suffering from hypokalemia?

・ID high risk patients (diuretics, anorexia, NG suctioning, dialysis) ・Assess/monitor serum K+ level ・Assess for skeletal muscle weakness (cramps?) ・Assess for cardiovascular changes ・Assess respiratory system ・Assess bowel sounds ・Monitor I&O ・Safe environment ・Implement HCP orders

Respiratory Alkalosis Interventions

・If caused by anxiety, encourage the patient to relax & breathe slowly ・For other causes, identify and treat the underlying disorder ・Decrease settings if patient on ventilator

If sodium is low, what does ADH do? If it is high?

・If sodium is low, Na+ thirst and ADH secretion are suppressed, kidneys excrete more water. ・If sodium is high, NA+ causes a person to feel thirsty and release ADH, which reabsorbs water.

What are some general patient education points regarding anticoagulants?

・Importance of regular lab testing ・Signs of abnormal bleeding ・Measures to prevent bruising, bleeding, or tissue injury ・Wearing a medical alert bracelet ・Avoiding drastic changes in foods high in Vitamin K (tomatoes, dark leafy greens) ・Consulting physician before taking other meds or OTC products, including herbals

Effects of Blocking the PSNS

・Increase in HR ・Decrease in GI activity/secretions ・Decreased respiratory secretions ・Decrease in urinary bladder tone and function ・Pupil dilation (Mydriasis) ・Cycloplegia (Accommodating) ・Decreased sweating

What do adrenergics that stimulate Beta₁ receptors do?

・Increased HR ・Increased myocardial contraction ・Increased renin secretion (increased BP)

What do adrenergics that stimulate Alpha₁ receptors do?

・Increases force of heart contraction ・Vasoconstriction (Increased BP) ・Mydriasis (pupil dilation) ・Decreased salivation ・Bladder relaxation ・Urinary sphincter contraction

What are some nursing diagnoses for HTN? Client goals? Education of lifestyle modifications?

・Ineffective health maintenance ・Deficient knowledge ・Anxiety ・Sexual dysfunction ・Ineffective therapeutic regimen management ・Noncompliance ・Disturbed body image ・ Ineffective tissue perfusion Client goals: Understanding of HTN, understanding of treatment, participation in self-care program, Absence of complications Education on lifestyle modifications: BP measurement/monitoring, weight reduction/nutritional therapy (DASH and alcohol consumption), physical activity, stress reduction

What are some food sources of phosphate?

・Meat ・Fish ・Poultry ・Dairy Products ・Legumes ・Whole Grains

What nursing precautions would you take with bethanechol?

・Monitor VS ・Monitor I&Os ・Monitor for side effects: Auscultate bowel sounds & breathsounds, monitor for bradycardia and hypotension

Nursing Interventions: Sublingual Nitroglycerine (Nitro-Dur, Nitrostat)

・Monitor VS Q5 min ・Sit down ・How to self administer ・Feels bubbly, fizzy, burning under tongue ・Store away from light, heat, moisture, do not change containers

What are the nursing implications of warfarin (Coumadin)?

・Monitor the patient closely for bleeding Bleeding gums, tarry stools, bruises ・Monitor H/H (hemoglobin/hematocrit to watch for internal bleeding), platelet count (look out for thrombocytopenia), PT/INR ・Therapeutic INR is 2.0-3.0 (2.5-4.5 in patients with mechanical heart valves). Consider this level if patient is having invasive testing. ・Assess urine, stool, and emesis (will look like used coffee grounds) for blood

Potassium

・Most common cation in intracellular fluid ・ Important role in neuromuscular and cardiac funciton ・ Must be ingested daily b/c body can not conserve it ・ 98% in intracellular fluid, 2% in extracellular. ・When we draw a potassium level it is drawn from extracellular fluid. ・THINK CARDIAC

What are the side effects/adverse effects of epinephrine?

・Nervousness ・Tremors ・Agitation ・Tachycardia/Palpitations ・HTN Also: ・Fear/anxiety ・Restlessness ・Headache ・Nausea ・Decreased renal formation ・Pallor ・Local burning & stinging ・Rebound congestion with inhalation Can't see, spit, pee, or shit!

What s/s could meant that HIV Disease is progressing in a pt. or that they could be experiencing side effects?

・New cough ・SOB or DOE ・Increase in fatigue or malaise Change in LOC ・Depression/anxiety ・Headache or stiff neck ・Fever/rash ・Night sweats ・Visual changes ・N/V/D Blood, dehydration ・Sudden weight loss ・Skin lesions Oral lesions, yellow discoloration of the skin ・Pain Flank, chest, vaginal

What are the nursing implications for CCB?

・Obtain baseline BP, APICAL pulse rate and rhythm ・Hold if SBP < 90 or P < 60 BPM ・Assist with ambulation at the start of therapy as dizziness may occur ・Fluid and sodium may need to be restricted to minimize edema ・Monitor LFTs as indicated

What are the nursing implications for Beta Blockers?

・Obtain baseline BP, pulse rate & rhythm *** Hold dose if SBP < 90 or APICAL pulse < 60 ・Don't crush SR tablets (Then they will release too much at one time and won't be sustained which could lead to too low a HR or too law a BP) ・Dose is adjusted to patient's BP and tolerance ・Teach patient about orthostatic hypotension (b/c they are a fall risk) ・Monitor LFTs as indicated (b/c it could cause liver injury)

Examples of Alpha-Specific Adrenergic Agonists

・Phenylephrine ・Midodrine ・Clonidine (Alpha2-specific)

Hyperphosphatemia and S/Sx

・Phosphorus and calcium have an inverse relationship ・If one is high, the other is low ・S/Sx are usually the same s/sx caused by the effects of hypocalcemia.

IV K+ Replacement

・Rate max 10 mEq/hr ・Should not exceed 40 mEq/L ・Never give IV push -- Can cause cardiac arrest ・Monitor EKG ・Watch for signs of infiltration

Buffers

・React immediately ・Primary regulators of acid-base balance ・Present in blood and tissues ・Take up extra H+ ions or release H+ ・Act chemically to neutralize acids or change strong acids to weak acids ***Can't work without proper functioning of respiratory and renal systems***

What are the pharmacodynamics of Beta Blockers?

・Reduce CO → decreased vascular resistance → decreased BP ・ Reduce BP by reducing HR and contractility through β₁ blockade

Rapid HIV-Antibody Testing

・Screen for antibodies in blood and saliva ・Takes 20 minutes to receive results ・Negative or positive **Note: if it is negative the pt. may be in a window period so a further assessment may be necessary if the pt. has some risk factors (sexually active, drug use, etc)

How do viruses replicate?

・Simple parasites that take over the metabolic machinery of a host cell and use that for replication. ・During attachment and penetration, the virus attaches itself to a host cell and injects its genetic material into it. During uncoating, replication, and assembly, the viral DNA or RNA incorporates itself into the host cell's genetic material and induces it to replicate the viral genome.

What are some food sources that are high in sodium?

・Table salt ・Cheese ・Canned foods ・Butter ・Ketchup/Mustard ・Lunch Meat ・Fish, shellfish, poultry ・Soy Sauce ・Pickled Foods ・Snack Foods ***We don't tell them to just avoid sodium products we need to identify specifically which ones. We won't tell the patient to limit sodium necessarily but to identify foods that are high in sodium.

Monocytes

・The clean-up crew ・Better at cleaning but take longer to get there Roughly 3-7 days. ・High monocytes means the infection has been there for a while.

What are some indications for epinephrine (Adrenalin, Adrenaclick)?

・Treatment of allergic reaction, anaphylaxis, cardiac arrest ・ Treatment of shock when increased BP and heart contractility are essential ・ To prolong the effects of regional anesthetic ・Primary treatment for bronchospasm ・To produce a local vasoconstriction that prolongs the effects of local anesthetics Also used in: ・Ophthalmic & Dental agents vIncrease local anesthetic effects

What are the mechanisms of action of nitrates?

・Vasodilation of coronary arteries Decreases afterload ・Vasodilation of venous vessels Decrease preload ・Reduces myocardial O₂ consumption

If a client has Stage 2 HTN, what is the treatment and follow-up?

・≥ 140/90 ◆ Recommend healthy lifestyle changes, initiate pharmacologic therapy (2 agents, but might start with 1) and re-evaluate monthly until target BP met

Intermittent Claudication (IC)

"Chest pain" in the leg muscles that occurs during exercise - relieved by rest - associated with peripheral vascular disease.

Diffusion

"Go with the flow" ∙ Movement of solutes from an area of high concentration to an area of lower concentration. ∙ Must be concentrated gradient for diffusion to occur. ∙ Diffusion is affect by: temp, concentration, size of molecules, and surface area of membrane. ∙ Electrical gradient: If + ion moves into the cell - ions will follow.

Super Bug

A bacteria that can't be killed even if using multiple antibiotics.

Sodium-Potassium Pump

A carrier protein that uses ATP to actively transport sodium ions out of a cell and potassium ions into the cell.

Hematoma

A collection of blood into the tissue

A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage? a. AV node b. Left ventricle c. Coronary sinus d. Right ventricle e. Pulmonic valve

A, B, D

When Hgb and Hct are low, it could mean...

Anemia, increased breakdown of RBCs, blood loss, hemodilution (i.e. rapid fluid replacement after dehydration)

What is pH > 7.45

Alkalosis

HIV: Assess/Monitoring HIV disease progression and immune function

CD4+ T-cell counts Normal CD4+ count: 800=1200/mcL Problems: < 500 AIDS: < 200 (The body can no longer keep up with the destruction) Viral Load: HIV RNA ・Reported as real numbers ・"Undetectable" ・Tests performed every 3-6 months

What are some side effects of warfarin (Coumadin)?

Bleeding, bruising.

Fibrinolysis

Breakdown of a clot

What does albuterol do?

Bronchodilator. Stimulation of B₂ adrenergic receptors in the lungs (SABA). It relaxes the smooth muscle and dilates the bronchi and bronchioles. Beta₂ → to lungs

Reticulocytes

Immature red blood cells, in the bone marrow

Who is more at risk of fluid and electrolyte imbalances?

Infants and the elderly.

Myocarditis

Inflammation of myocardium.

CABG (Coronary Artery Bypass Graft)

Creation of a new blood supply to an area of the heart with a clotted/blocked artery.

Neutrophils

Definition ・Most abundant white blood cell Roughly 2,200-6,000/mcL ・Phagocytic and tend to self-destruct as they destroy foreign invaders, limiting their life span to a few days ・Get to the site quickly. Within 6-12 hours they are working. Two Types Segments The bazookas. Mature neutrophils. Bands The babies. Immature neutrophils; multiply quickly during acute infection Lifespan 2-14 days Never Let Mother Eat Bacon

Erythropoiesis: Definition, how it is regulated, controlled, how it works, what the signal is

Definition ・Process of RBC production ・Reticulocyte formation = Hemolysis Regulated by: Regulated by cellular oxygen requirements and vernal metabolic activity Controlled by The hormone erythropoietin How It Works Erythropoietin stimulates the bone marrow to produce RBCs Signal for increased secretion of erythropoietin is: Hypoxemia (reduction in O₂ reaching kidneys) Influenced by nutrient availability ・Iron: Needed for hemoglobin synthesis ・B12 & Folate: Needed for DNA synthesis in RBCs

Secondary Hypertension

Elevated BP with a specific cause that often can be identified and corrected. Clinical findings that suggest secondary hypertension relate to the underlying cause. For example, an abdominal bruit heard over the renal arteries may indicate renal disease. Treatment of secondary hypertension is aimed at removing or treating the underlying cause. Secondary hypertension is a contributing factor to hypertensive crisis.

Polyphagia & how it relates to diabetes

Excess hunger caused by cellular starvation from lack of glucose and use of fat & protein for energy.

Polydypsia and how it relates to diabetes

Excessive thirst caused by fluid loss of polyuria.

Pleural Effusion

Fluid in the pleural space related to inflammation or third spacing

Third-Spacing of Fluid

Fluid shifts out of the blood into a body cavity or tissue and can no longer reenter vascular compartment

What should we closely watch for when our patient is receiving hypertonic IV fluids?

Fluid volume excess. This fluid is rich with solutes and the cells will shrink.

Fluid Intake (gain)

Fluids are added to the body in the following ways: ∙ Metabolism ∙ Beverage/drinking fluids ∙ Food/eating foods Fluid intake regulated by thirst ∙ Change in plasma osmolality ∙ Hypothalamus

What food sources are high in chloride?

Food sources that are also high in sodium.

What are some side effects of nystatin (Mycostatin)?

N/V/D, stomach pain (large doses)

Cranial Nerve I: Name, S/M/B, Function, Test

Name Olfactory Sensory Function Smell How to Test Check each nostril separately. Close their eyes. Ask them about each smell.

Modulation of Pain

Neurons descend to the spinal cord and activate the endogenous analgesia and gate control mechanisms.

Transduction of Pain

Nociceptors become activated by the perception of mechanical, thermal, and chemical stimuli.

Structures of the Upper Respiratory Tract

Nose, mouth, pharynx, epiglottis, larynx, and trachea

What is the function of the cardiovascular system?

Provides blood supply to itself first and then the rest of the body, then to take the old blood and get rid of it as necessary.

What are some s/s of hyposxemia?

RAT ↑ Restlessness Tachycardia Tachypnea

McGill-Melzack Pain Questionnaire

Rating of pain intensity questionnaire

Dyspnea

Shortness of breath or difficulty breathing.

Heart Blood Flow Order

Superior and Inferior Vena Cava ➟ Right Atrium ➟ Tricuspid Valve ➟ Right Ventricle ➟Pulmonic Valve ➟ Pulmonary Artery ➟ Lungs ➟ Pulmonary Vein ➟ Left Atrium ➟ Mitral Valve ➟ Left Ventricle ➟ Aortic Valve ➟ Aorta ➟ Body

Type I Alveolar Cells

The gas exchange cells

What is Hemoglobin (Hgb)?

The portion of RBC's that carry iron and oxygen.

Helpful Hints to Remember Hypercalcemia

Too much CALciuM = Too calm Groans (constipation) Moans (fatigue, lethargy) Bones (bone pain) Stones (kidney stones) Psychiatric Undertones (depression, confusion)

Hyperosmolar Hyperglycemic Non-Ketotic State (HHNKS)

What is HHNKS? ◆ Complication of DMT2 ◆ Very high blood glucose levels Treatment ◆ Fluid replacement First priority. Hyperglycemic blood is hypertonic and patient will be hypovolemic ◆ IV Insulin ◆ Monitor serum potassium and replace as needed ◆ Correct underlying precipitating cause

SV = EDV - ESV(Stroke Volume = End Diastolic Volume - End Systolic Volume)

What is the mathematical equation to find stroke volume?

What are some s/s of COPD?

*Note, the patient may be thin in appearance but if they are taking steroids, they will have gained weight.

Centi

c 1/100th or 0.01

Nociceptive Pain

∙ Pain from a normal process that results in noxious stimuli being perceived as painful ∙ Most common type ∙ Results from trauma, injury, or inflammation

Calcium Channel Blockers

∙ Reduce afterload ∙ Vasodilation ∙ Med for hypertension

Parietal Lobe Function

◆ Integrates somatic and sensory input ◆ Interprets spatial information ◆ Also responsible for reading and math

Temporal Lobe Function

◆ Integrates somatic, visual, and auditory data ◆ Memories of taste, smell, sound, deja vu ◆ Integrates past experiences ◆ Home to Wernicke's Area

Status Epilepticus

◆ Life threatening, emergent situation ◆ Non-stop seizure activity ◆ Respiratory failure

How is hydrochlorothiazide different from furosemide?

◆ No ototoxicity ◆ Less diuresis (Assess BP, weight, lung sounds instead) ◆ Less loss of electrolytes ◆ Can cause hypercalcemia (Bones, groans, moans, and stones) ◆ Can cause hyperglycemia ◆ Furosemide is used for more severe HTN

What are the clinical manifestations of DMT2?

◆ Nonspecific symptoms ◆ May have classic symptoms of T1 ◆ Fatigue ◆ Recurrent infections ◆ Prolonged wound healing ◆ Visual changes

Alpha-Glucosidase Inhibitors

◆ Oral antidiabetic ◆ Breaks down glucose so it can be absorbed.

Basal-Bolus Regimen: What it is

◇ Most closely mimics endogenous insulin production ◇ Rapid- or short-acting insulin before meals (bolus) ◇ Intermediate- or long-acting background insulin once or twice a day (basal)

Facts about the Thyroid

✷ The thyroid makes calcitonin ✷ Calcitonin deposits Ca⁺⁺ to the bone (Cal-ci-"bone-in") ✷ Iodine is need to make thyroid hormone ✷ An overactive thyroid gland uses/uptakes a lot of iodine

Hypokalemia

・ < 3.5 mEq/L ・ Can be life threatening ・Cardiac dysrhythmias are most dangerous with this balance ・ The consequences of a patient having hypokalemia are often worsened by alkalosis, or on digoxin therapy, or they also have hypocalcemia.

Nursing Interventions for Heart Failure Drug Interactions

・ Assess fluid status Monitor weight, I&O's, lung sounds, skin turgor, mucous membranes, edema ・ Monitor BP before and during administration ・ Monitor electrolytes (baseline and ongoing) ・ Monitor kidney function (BUN, Creatinine) ・ Give in the AM

Stimulation of the RAAS System

・ Automatic response ・ Activated by decreased perfusion and/or oxygenation of kidneys ・ Involves multi-organ response ・ Leads to fluid retention and vasoconstriction ・ Ultimately harmful in patients with heart failure ・ Further increases workload on the heart

Patient Teaching

・ Dietary therapy ・ Activity program ・ Ongoing monitoring ・ Health promotion ・ Rest ・ Drug therapy

Examples of Alpha- and Beta-Adrenergic Agonists

・ Epinephrine ・Norepinephrine ・Dopamine ・Dobutamine ・Ephedrine ・Metaraminol

Tachycardia

・ Fast heart rate ・ S/S of left sided heart failure

Nitrates

・ Vasodilate and open up the blood vessels and decrease afterload

Causes of Hypokalemia

・ Vomiting ・ Laxative misuse/diarrhea ・ Loop and thiazide diuretics ・ Malabsorption ・ Corticosteroids

If a client has Stage 1 HTN, what is the treatment and follow-up?

・130-139/80-89 ASCVD risk less than 10% Recommend healthy lifestyle changes, re-evaluate in 3-6 mos ASCVD risk greater than 10% (high risk) or if client has history of CVD, DM, or CKD Recommend healthy lifestyle changes, initiate pharmacologic treatment and re-evaluate monthly until target BP met

What is hypochloremia and what are the s/sx?

・<95 mEq/L ・Could be due to acid base imbalances: Hyponatremia Hypokalemia Metabolic alkalosis ・Respirations slow and shallow (compensation) ・Nerves excited = tetany, hyperactive deep tendon refluxes ・Muscle cramps, twitching, weakness, irritability ・***life threatening*** arrhythmias, seizures, coma, respiratory arrest

Pulmonary Edema

・Acute heart failure in which there is severe fluid congestion in the alveoli of the lungs; life threatening. ・Most common cause is left-sided heart failure secondary to CAD.

What is the therapeutic class and effect of doxazosin?

・Antihypertensive ・Decreases BP ・Benign Prostatic Hypertrophy (BPH)

What are the side effects/adverse reactions of Beta Blockers?

・Bradycardia and other dysrhythmias ・Fainting ・Fluid retention ・Peripheral edema ・Rare: liver injury ・ Respiratory problems- more common with non-selective medications ・Can cause or worsen HF- use with caution ・***Discontinuing suddenly may trigger angina, HTN, and acute MI***

What do adrenergics that stimulate Beta₂ receptors do?

・Bronchial dilation ・GI relaxation ・Uterine relaxation ・Increased blood sugar ・Increased blood flow to muscles

What are the nursing precautions of atropine?

・Monitor VS ・Monitor I&Os ・Auscultate bowel sounds ・Provide mouth care ・Client education (avoid hot environments)

Full Compensation

・pH normal ・CO2 & HCO3- BOTH abnormal

What is an example of an intranasal glucocorticoid?

fluticasone (Flovent/Flonase)

Kernig's Sign

A diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down

Sickle Cell Anemia

A genetic disorder that causes abnormal hemoglobin, resulting in some red blood cells assuming an abnormal sickle shape

What is a pH < 7.35?

Acidosis

Fenestrated Tracheostomy

Allows for air to flow over vocal cords - allows patient to be able to talk

Atrial Flutter

Also called atrial fibrillation. The atria are being stimulated at a very fast rate. This results in a quivering of the atrial heart muscle. The ECG shows several small P waves before each QRS complex.

Ventricle Systole

Atria Status: *Relaxed* Ventricles Status: *Contracted* AV Valves: *Closed* Semilunar Valves: *Closed at first until enough pressure rises to open them during the ventricular ejection phase* Pressure L. Atrium: *Low* Pressure L. Ventricle: *Greater than pressure in the right ventricle*. Pressure Aorta: *Higher at first, then the pressure in the l. ventricle has to be be higher so the blood can eject up*.

What is the antidote for bethanechol?

Atropine... an anticholinergic.

Leukemia

Blood condition of white cells; malignant (cancerous) condition.

Urine Specific Gravity Normal Range

1.003-1.030 mg/dL

Magnesium Normal Range

1.5-2.5 mEq/L

PT Normal Range

10-13 seconds

What is the therapeutic range of acetaminophen?

10-20

BUN Normal Range

10-20 mg/dL

What is the normal range for systolic blood pressure (SBP)?

100-119 mmHg

Sodium Normal Range

135-145 mEq/L

Hgb Male Normal Range

14-18 g/dL

Where do you hear the aortic valve? Which sound is louder?

2nd intercostal space at right sternal margin; S2 > S1

How is metabolic alkalosis compensated?

Decreased respiratory rate

What are the clinical manifestations of SLE in each body system?

Dermatologic Butterfly rash, rashes, lesions Musculoskeletal Arthritis Cardiopulmonary Pleurisy, dysrhythmias Renal Lupus nephritis Hematologic Attack blood cells ⇒ anemia, risk of infections, bleeding Neurological Seizures, cognitive dysfunction, psychosis GI Abdominal pain, dysphagia, N/V/D Reproductive Menstrual abnormalities

What is the mechanism of action of potassium (KCL)

Electrolyte replacement for acid-base balance, nerve conduction, and muscle contraction. Treatment and prevention of potassium depletion.

BNP

Elevated Brain Natriuretic Peptide

Name some opportunistic infections and opportunistic cancers associated with AIDS

Fungal ・Candidiasis of bronchi, trachea, lungs, or esophagus ・Pneumocystis Pneumonia (PCP) Viral ・Cytomegalovirus (CMV) ・Herpes Simplex w/chronic ulcers Protozoal ・Toxoplasmosis of the brain ・Chronic intestinal cryptosporidiosis Bacterial ・Mycobacterium TB ・Recurrent Pneumonia Cancer ・Invasive cervical cancer ・Kaposi Sarcoma (KS) ・Burkitt's Lymphoma ・Immunoblasti Lymphoma ・Primary Lymphoma of the brain ・HIV Associated Wasting Syndrome

What are some side effects of potassium (KCL)?

GI upset, confusion, restlessness, ARRHYTHMIAS.

When would you hold nitroglycerin?

Hold for SBP < 90

When should you hold potassium (KCL)?

Hold if K⁺ is elevated (normal is 3.5-5 mEq/L)

What are some causes of respiratory alkalosis?

Hyperventilation, severe anxiety, hysteria, high altitude, early aspirin overdose, hypoxemia from acute pulmonary disorders, fever or sepsis, brain lesion or injury, excessive mechanical ventilation, PE

Chvostek's Sign

Hypocalcemia (facial muscle spasm upon tapping)

Drug Interactions of Digoxin

Hypokalemia and Hypokalemia causing drugs: ∙ Increase digoxin effect = increase risk of toxicity ∙ Digoxin and K+ use the same receptors Beta Blockers and Calcium Channel Blockers ∙ Taken with digoxin may cause an excessively slow heart rate St. John's Wart ∙ May speed up digoxin metabolism = increase risk of toxicity

The patient with low PTH, low calcium, and increased phosphate most likely has...

Hypoparthyroidism

What patients might benefit from receiving isotonic IV fluids?

Hypotensive or hypovolemic patients. ***Use with caution as clients will be at risk of fluid volume excess***

The ______________ stimulates the _________________ to secrete ________ which in turn stimulates the thyroid gland to release __________.

Hypothalamus; anterior pituitary; TSH; T₃ & T₄

If a patient is dehydrated, what types of fluids do you give them?

Hypotonic solutions.

What patients might benefit from receiving hypertonic IV fluids?

Hypovolemia or hyponatremia

What is the purpose of the pre-op interview?

ID risk factors and plan care to ensure pt safety

What are some other "causes" of DM?

ILLNESS ◆ Cushing Syndrome ◆ Hyperthyroidism ◆ Recurrent pancreatitis ◆ Cystic Fibrosis ◆ Hemochromatosis ◆ Parenteral nutrition use MEDICATIONS ◆ Corticosteroids (prednisone) ◆ Thiazides ◆ Phenytoin (Dilantin) ◆ Atypical antipsychotics

What fluids should a hypovolemic hyponatremic patient receive?

IV sodium chloride: 0.9% NaCl, 3% NaCl

Somogyi Effect

If a client fails to eat her bedtime snack she might experience the Somogyi effect. tThis abrupt drop in the client's blood glucose level during the night is followed by a false elevation.

What do platelets do?

Important in promoting coagulation

Who is COPD different from asthma at a bronchial level?

In COPD there is an increased number of mucous glands.

Endocarditis

Inflammation of the endocardium.

Thrombophlebitis

Inflammation of vein with clot formation and danger of embolism.

Secondary Defenses Against Infection

Inflammatory Response The external barriers have been breached and pathogens have entered. They release harmful wastes and secretions causing damage to cells and tissue. Chemicals released trigger the secondary defenses. ・Phagocytosis ・Compliment cascade ・Inflammation ・Fever ・Nonspecific

Flow of CSF

Lateral ventricles ➠ 3rd ➠ 4th ➠ arachnoid space ➠ out arachnoid villi into blood stream.

Which color vacutainer tube top is needed for CBC with diff?

Lavender

Clinical Manifestations of Left vs Right Sided Stroke

Left Side Stroke ◆ Right side hemiplegia ◆ Impaired right/left discrimination ◆ Impaired speech aphasias ◆ Aware of deficits ◆ Cautious/slow performance ◆ Anxiety ◆ Depression ◆ Impaired language/math comprehension Right Side Stroke ◆ Left side hemiplegia ◆ Left side neglect ◆ Spatial perceptual deficits ◆ Deny/minimize problems ◆ Rapid performance/short attention spans ◆ Impulsive ◆ Impaired judgement ◆ Impaired time concepts

Where do you hear Erb's Point? Which sound is louder?

Left sternal border, 3rd intercostal space; S1 = S2

INR Normal Range

Less than 1

How long between sounds (per quadrant) is a hyperactive bowel activity?

Less than 5 seconds

Which color vacutainer tube top is needed for a PT/INR/PTT?

Light blue

Atrial Systole, Atrial Diastole, Ventricular Systole, Ventricular Diastole.

List the four phases of the cardiac cycle in order.

Local vs Systemic Anaphylaxis

Local ❖ Itching, tearing, burning of eyes ❖ Nose stuffiness ❖ Cutaneous response Wheal-and-flare- reaction Systemic Anaphylaxis

In atrial septum, transmits signal to bundle of His. Located in the inferior portion of the right atrium within the atrioventricular septum.

Location of AV Node.

What is the pharmacologic classification of furosemide (Lasix)?

Loop diuretic

Diuretics

Loop: ・furosemide (Lasix) ・bumetanide (Bumex). Thiazide: ・hydrochlorothiazide ・metolazone (Zaroxolyn) Potassium-Sparing: ・spironolactone (Aldactone) ・eplerenone (Inspra) Mechanisms of Action: ・Decreases fluid volume ・Decrease preload ・Decrease pulmonary venous pressure ・Relieve symptoms of heart failure (e.g. edema)

What is the relationship between calcitonin and the parathyroid glands?

Calcitonin, which is released from the thyroid gland, decreases blood calcium levels when they become too high. The parathyroid gland is what increases blood calcium levels by releasing the parathyroid hormone(PTH).

Electrocardiogram(ECG or EKG)

Records the electrical changes in the myocardium.

What is the action of doxazosin?

Selective Alpha₁ adrenergic antagonist drug that blocks NE from stimulating the alpha₁ receptors leading to decreased BP.

What are the side effects of albuterol? Adverse reactions?

Side Effects ・Nervousness ・Restlessness ・Tremor ・Dizziness Adverse Reactions ・Chest pain ・Tachycardia/palpitations ・Cardiac dysrhythmias

What particles have pull power?

Sodium, sugar, protein (albumin)

Crystalloids

Solutes that dissolve readily into true solutions

Peripheral Nervous System (PNS)

Somatic Nervous System + Autonomic Nervous System (ANS)

Virchow's Triad

Stasis, hypercoagulability, endothelial damage

Ventricles of the Brain

Canals in the brain that contain CSF

Muscle Relaxants

Centrally acting. They work on all muscles. Not just one. MOA not fully known. Examples ∙ cyclobenzaprine (Flexeril) ∙ carisoprodol (Soma) *more likely to be habit forming ∙ methocarbamol (Robaxin) Side Effects ∙ Drowsiness ∙ Dizziness ∙ Lightheadedness ∙ HA ∙ GI upset ∙ Possible Anticholinergic effects Adverse Effects ∙ Angioedema ∙ MI ∙ Seizures ∙ Ileus (possible inhibition of rest and digest which could lead to an ileus that could rupture the bowel) ***If on a muscle relaxant or opioid take a stool softener, drink more water, increase fiber.

What is the heart rate regulated by?

The Autonomic Nervous System *Understand this concept. Go back and look at it*

Ventricular Tachycardia

The ECG shows multiple QRS complexes without visible P or T waves. This rhythm indicates damage to the ventricles.

Systole

Chamber contraction. The period of contraction that the heart undergoes while it pumps blood into circulation. Contraction of the myocardium resulting in the ejection of blood from the ventricles.

Diastole

Chamber relaxation. The period of relaxation that occurs as the chambers fill with blood. Relaxation of the myocardium allowing for filling of the ventricles.

The 7 Warning Signs of Cancer

Changes in bowel/bladder A sore that does not heal Unusual bleeding or discharge Thickening or lump in tissue Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough/hoarseness

Name two meds approved for intermittent claudication and how do they work?

Cilostazol (pletal) ・Platelet aggregation inhibitor. ・Inhibits enzyme CAMP PDE III ➨ vasodilation and inhibition of platelet aggregation. ・Reduces symptoms of IC with improved walking distances Pentoxifylline (Trental) ・Blood viscosity reducing agent ・Therapeutic management of symptomatic PVD & IC ・Inhibits platelet aggregation & fibrinogen ・Reduces blood viscosity ・Increases RBC flexibility

Fosamprenavir (Lexiva): Class, Action, Dose, Adverse Effects

Class Antiretroviral/protease inhibitor Action Inhibits protease activity, leading to the formation of immature, noninfectious virus particles Dose Oral Adverse Effects HA, mood changes, N/D, fatigue, rash, Stevens-Johnson syndrom, redistribution of body fat (buffalo hump, thin arms and legs).

Maraviroc (Selzentry): Class, Action, Dose, Adverse Effects

Class Antretroviral/CCR5 Coreceptor Agonist Action Blocks a specific receptor (CCR5) on CD4 and T-cell surfaces that prevents CCR5-tropic HIV-1 from entering the cell and multiplying Dose Oral, 2x/day Adverse Effects Dizziness, paresthesias, N/V/D, cough, upper respiratory infection, fever, musculoskeletal symptoms, hapatotoxicity

Biologic Response Modifiers (BRMs): Class, action, when used, names, common side effect, teaching

Class DMARD/TNF blocker Action Binds to TNF, making it inactive. TNF is a mediator of the anti-inflammatory response When Used Use when pts have failed other DMARDs The Inhibitors etanercept (Enbrel) infliximab (Remicade) adalimumab (Humira) Other BRMs anakinra (Kineret) abatacept (Orencia) tocilizumab (Actemra) rithximab (Rituxan) Side Effects TB, bone marrow suppression, infections Teaching ・Watch for s/s of infection ・Importance of labs monitoring (CBC with diff and ANA) ・Action and s/e of drug prescribed ・Balance of activity and rest ・Joint protection ・Non-pharm relief of pain

How do the kidneys regulate phosphate?

The kidneys are the primary regulator of phosphate.

Atheromatous Plaque (Atheroma)

The lumen has gotten so small, enough O₂ has gotten cut off and chest pain is experienced.

How do the lungs remove CO2 if PH is too acidic?

The lungs increase the rate of breathing

Nitroglycerin (Nitro-Dur, Nitrostat): Effect/Uses, Admin, SE, Contraindications

Therapeutic Effects/Uses ・Control of angina pectoris ・Acute MI ・Management of HF Long acting nitrates Administration ・Can be given multiple routes ・Use gloves when applying the paste or ointment Side Effects/Adverse Effects ・Side effects due to vasodilation Hypotension, dizziness, reflex tachycardia, flush, HA ・Life threatening Hypotension and CV collapse when given with ED meds (Viagra, Cialis, & Levitra) Contraindications Severe anemia H&H low, they need RBC. Chest pain due to low H&H. Already not enough blood volume, nitrates could make it worse.

How are calcium and phosphorus related?

They have an inverse relationship. When calcium is high, phosphorus is low and vice versa. Phosphorus inhibits Ca+ absorption in the intestines.

Why would you decrease fluids when a patient has heart failure?

They need to be on a fluid restriction because we have to track intake and output. They need to be on a fluid restriction to do this.

How is physical dependence a barrier to effective pain management? How can this obstacle be overcome?

This is the adaptation manifested by withdrawal symptoms resulting when dependent use of opioids ceases abruptly. A tapering schedule should be used. Early signs include anxiety, diaphoresis, anorexia, shaking/chills/tremors. Late response: excitation, diarrhea, fever, N/V, HTN, tachycardia, insomnia. It is a barrier b/c people fear this means they are addicted. But, it does not.

Absolute Neutrophil Count (ANC)

Total number of WBC's x percentage of neutrophils (segments & bands)

Sinus Bradycardia

The ECG wave is normal, but the heart rate is usually less than 60 bpm. This occurs when the SA node does not initiate the wave of stimulation often enough. What does the nurse do? ・Assess client If not symptomatic ... monitor If symptomatic... need treatment ・Clinical Manifestations Moving slow, dizziness, fatigue, decreased BP, decreased CO, hypotension, SOB, decreased LOC, chest pain ・Notify MD ・Treatment of choice - Oxygen and atropine to get HR above 60 BPM - IV fluids - Be ready to apply trancutaneous pacemaker - May need permanent pacemaker ・Attempt to determine cause ・Medications that could cause SB? Beta Blockers, CCB, Digoxin ・What else could cause SB? Constipation. Encourage stool softeners, water, and fiber.

The 4 Types of Hypersensitivity Reactions

Type I ❖ IgE-mediated allergic reactions ❖ Allergic/anaphylactic reactions Type II (Block 4) ❖ IgG or IgM antibodies ❖ Cytotoxic & Cytolytic Reactions ❖ Tissue specific reactions ❖ ABO blood types Type III ❖ IgG or IgM antibodies + antigen ❖ Immune-complex-mediated reactions ❖ Autoimmune Type IV ❖ Cell-mediated reactions/delayed hypersensitivity. Sensitized T cells ❖ Contact dermatitis

Visual Analog Scale (VAS)

Typically used to measure strength, magnitude, or intensity of individuals' subjective feelings, sensations, or attitudes about symptoms or situations.

Extravasation

Unintended discharge or leakage of a vesicant solution or medication into surrounding tissue as a result of cannula dislodgment or inflitration.

What is the most effective intervention for post-op pain managmenet?

Using a variety of different analgesics.

S2: Valves, Sound, Represent

Valves The sound of the closing of the semilunar (aortic & pulmonic) and the opening of the atrioventricular (tricuspid & mitral) valves during ventricular diastole. Sound Described as a "dub". Represent Heart at rest

Stroke Volume

The amount of blood pumped by each ventricle.

End Systolic Volume(ESV)

The amount of blood remaining in each ventricle following systole. Stroke volume(amount of blood pumped) will normally be in the range of 70-80 mL. Since ventricular systole begins with an EDV of approximately 130 mL of blood, this means that there is still *50-60 mL* of blood remaining in the ventricle following contraction. This is called ______________________.

What is the "window period" of HIV?

The amount of time between when the pt. is infected and the body has made enough antibodies to be detected by the screening tests available to them at that point. Basically, a person can be infected with HIV but their body has not produced enough antibodies yet against it, so it is still undetectable by tests. Can last around 2 months

Why are cholinergic agonists prone to many undesirable systemic effects?

The are not limited to a specific site.

What are two key measures for weight reduction when it come to HTN lifestyle modifications?

Waist Measurement < 35 inches for women < 40 inches for men BMI: < 25 > 25 = overweight > 30 = obesity

When do we treat a fever?

We treat if the temperature rises above 101.5℉ because we want the immune system to fight it. Some infection control doctors will even wait till the temperature hits 102.5℉.

Ketone Testing

What are ketones? ◆ Ketones are a byproduct of fat breakdown ◆ Ketones are a warning sign to get insulin so body can metabolize glucose instead of fat When is testing done? ◆ When BS levels are elevated (> 240 mg/dl) ◆ During acute illness, infection, or injury ◆ When exercising if blood glucose is elevated ◆ If s/s of DKA N/V; abdominal pain

The components of the cardiac conduction system include the SA node, the AV node, the AV bundle, the AV bundle branches, and the Purkinje cells.

What are the components of the cardiac conduction system?

Isovolumetric Contraction & Ventricular Ejection Phase

What are the two phases of ventricular systole?

Filling Time & Contractility

What are the two primary factors that influence EDV?

Contractility & Afterload.

What are the two primary factors that influence ESV?

- In the brain: Medulla oblongata, hypothalamus, and cerebrum. - In the vessels: Baroreceptors(sensory neurons in blood vessel walls) that pick up info about blood pressure and send it to the medulla. - Body temperature changes - Electrolyte imbalances (K+, Ca2+, Na+)

What can alter the heart rate?

- In the brain: Medulla oblongata, hypothalamus, and cerebrum. - In the vessels: Baroreceptors(sensory neurons in blood vessel walls) that pick up info about blood pressure and send it to the medulla. - Body temperature changes - Electrolyte imbalances(K+, Ca2+, Na+)

What can alter the heart rate?

Mineralcorticoids(e.g. *aldosterone*); regulate mineral balance.

What hormones are released from the zona glomerulosa of the adrenal cortex and what are their functions?

Slow influx of Na+ ions.

The cardiac pacemaker potential is caused by _____________________. (This is in conducting/autorhythmic cells)

Bundle of His(Atrioventricular[AV] Bundle)

The connection between the atria and ventricles. Divides into two AV bundle branches and purkinje fibers.

Deci

d 1/10th or 0.1

Vasculitis

inflammation of blood vessels

Thalassemia

inherited defect in ability to produce hemoglobin, leading to hypochromia

Kilo

k 1,000

Other barriers to effective pain management?

∙ Fear of addiction or tolerance ∙ Concern about side effects ∙ Fear of injections ∙ Desire to a be a "good" patient ∙ Forgetting to take meds

Hydrostatic Pressure

∙ Force within a fluid compartment ∙ Pressure created by the pull of gravity, pressure can also be created by the pull of gravity, pressure can also be created by blood against the surface of out vessels, BLOOD PRESSURE-created by heart pumping.

Define ICF; What is the % of TBW?

∙ Intracellular Fluid ∙ Fluid within the cells of the body ∙ Essential for cell function and metabolism ∙ 40% of TBW (2/3 of total body fluid)

When should you hold warfarin (Coumadin)?

∙ S/Sx of bleeding ∙ Hold for platelets < 150,000mcL ∙ Hold & verify with MD prior to giving dose if INR > 3

Fluid Output (loss)

∙ Sensible vs Insensible Fluids are lost from the body in the following ways: ∙ Urine: 1200-1500 mL/day ∙ Skin: 650-900 mL/day ∙ Lungs: 300-400 mL/day ∙ Feces: 100-200 mL/day

What are some s/sx of dehydration?

∙ Thirst: First S/S ∙ Dizziness/weakness ∙ Mental status changes ∙ Restlessness ∙ Dry skin/mucous membranes ∙ Poor skin turgor ∙ Decreased urine output ∙ Fatigue ∙ Fever ∙ Seizures ∙ Hypotension ∙ Tachycardia ∙ Weight loss

What is warfarin contraindicated in?

∙ Uncontrolled bleeding ∙ Open wounds ∙ Active ulcer disease ∙ Recent brain, eye, or spinal cord injury or surgery ∙ Severe liver or kidney disease ∙ Uncontrolled hypertension ∙ OB: Crosses placenta and may cause fatal hemorrhage in fetus.

Pain

∙ Unpleasant sensory & emotional experience associate with actual/potential tissue damage. ∙ Pain is whatever the experiencing person says it is and exists whenever he/she says it does. ∙ Self report is the most reliable indicator.

What are some adverse reactions of antihistamines?

∙ Wheezing Hematologic reactions: ∙ Hemolytic anemia ∙ Thrombocytopenia ∙ Agranulocytosis *Use cautiously in asthmatic patients

What are some non-narcotic antitussives?

∙ dextromethorphan (in Robitussin DM) Chemically similar to opioids but less potential for abuse. ***Contraindicated in patients with COPD & asthma ∙ benzonatate (Tessalon Pearls) Desensitizes stretch receptors in lungs, do not chew

Decerebrate Posturing

◆ Extension posturing ◆ Problems within midbrain or pons

What is the MOA of thiazide diuretics?

◆ Promotes Na+, K+, and water excretion in distal renal tubules ◆ May also cause vasodilation of arterioles

Spinal Cord Function

◆ Second part of central nervous system ◆ Descending sends motor response down to muscles ◆ Ascending tracts carry sensory info to brain

Carbohydrate Counting for Diabetics

◆ Serving size is 15g of CHO ◆ Typically 45-60g per meal ◆ Insulin dose based on number of CHOs consumed ◆ Patient teaching is essential

What are some signs and symptoms of extravasation?

◆ Swelling, blanching, bleb formation ◆ Stretched firm and/or cool skin ◆ Can progress to form blisters with subsequent sloughing of tissues (necrosis)

Thiazide Diuretics

◆ hydrochlorothiazide (HCTZ, Microzide) ◆ Usually first line diuretic given for HTN. ◆ Edema from heart, liver, &/or renal failure ◆ Promotes Na+, K+, and water excretion in distal renal tubules ◆ May also cause vasodilation of arterioles ◆ Onset (PO) = 2 hours

Acetaminophen (Tylenol)

∙ Analgesic and antipyretic effects ∙ Inhibits prostaglandin synthesis ∙ Little to no anti-inflammatory effects ∙ Fewer side effects than NSAIDs ∙ Available OTC and in combination products with opioids ∙ NO MORE THAN 3G/DAY Contraindicated in Allergy, liver disease Interactions ETOH & other drugs metabolized in the liver can cause an interaction. Precautions ∙ Inadvertent excessive doses may occur when different combination drug products are taken together ∙ Be aware of the acetaminophen content of all the medications taken by the patient (OTC & prescription) ∙ Recommended antidote: acetylcysteine regimen (Mucomyst)

Intranasal Glucocorticoids

∙ Anti-inflammatory properties, decrease symptoms of allergic rhinitis ∙ Use 1-3 weeks for peak effectiveness ∙ May experience burning or epistaxis due to dryness with continued use ∙ May be used in combination with an H1 blocker ∙ Low risk of system side effects when delivered intranasally ∙ Ex. fluticasone (Flovent/Flonase)

Nursing Implications for Analgesics

∙ Before beginning therapy, perform a thorough history regarding allergies and use of other medications, including alcohol, health history, and medical history ∙ Obtain baseline vital signs and I&O ∙ Use of a pain scale ∙ Assess for potential contraindications and drug interactions ∙ Administration of other previous analgesics ∙ Response? ∙ Check chart, orders, notes, MAR, and allergies prior to administering ∙ Assess and reassess at regular intervals

Antagonists

∙ Binds to pain receptor but does not reduce pain signals ∙ Reverses the effects of agonists & partial agonists ∙ A chemical that acts to reduce the physiological activity of another chemical substance ∙ It opposes the action of an opioid ∙ Naloxone HCL (Narcan) ∙ Opioid reversal agent ∙ Always have available when giving opioid agonists

What is the mechanism of action of Digoxin (Lanoxin)

∙ Boosts intracellular calcium and enhances movement of calcium into myocardial cells. This enables stronger heart contractions. ∙ Acts on the CNS to slow the heart rate ∙ Increases the refractory period when cells cannot conduct an impulse

Structures of the Lower Respiratory Tract

∙ Bronchi, bronchioles, alveolar ducts, alveoli ∙ Surfactant ∙ Blood supply

Intractable Pain

∙ Chronic & highly resistant to relief ∙ Requires multiple methods of relief

Atelectasis

∙ Collapsed lung; incomplete expansion of alveoli ∙ Inadequate amount of surfactant present ∙ Lower respiratory disorder

What are the different types of pneumonia?

∙ Community Acquired Pneumonia (CAP) ∙ Medical Care-Associated Pneumonia (MCAP) ∙ Aspiration Pneumonia (can be either CAP or MCAP) ∙ Opportunistic Pneumonia

Osmolality

∙ Concentration of solutes in body fluid ∙ The measure of particles in a solution: shape, size, and charge of particles do not impact osmolality ∙ Number of particles in a solution by mass (mOsm/kg)

Origin of Pain

∙ Cutaneous (superficial) ∙ Visceral ∙ Deep somatic ∙ Radiating ∙ Referred ∙ Phantom ∙ Psychogenic

What are some home care teachings to provide a client with DM?

◆ ⇧ blood glucose level secondary to counter-regulatory hormones ◆ Frequent monitoring of blood glucose (q4h) ◆ Ketone testing if glucose levels exceeds 240 mg/dL (q3-q4h) ◆ Report glucose levels exceeding 300mg/dL for two tests &/or moderate to high ketone levels **You have too much glucose & not enough insulin which could lead to a hyperglycemic emergency*** ◆ May need to increase insulin for DMT1. ◆ DMT2 may necessitate insulin therapy. ◆ Maintain normal diet if possible. Supplement with CHO containing fluids if not possible ◆ Frequent oral care (prevent infection) ◆ Foot care (prevent diabetic ulcers) ◆ Travel needs (meds, food, activity, supplies)

Venous Stasis Ulcers

✤ Most commonly found in lower extremities, appear as an erosion of the skin ✤ Poorly healing ulcers that result from inadequate venous flow

Nursing Interventions: Captopril

✤ VS (BP) ✤ Monitor WBC (neutropenia) & electrolytes (⇧K+ & ⬇︎Na+) Teaching ✤ Not for use when pregnant Can cause fetal injury or death ✤ Dizziness may be present during 1st week

Thyroid Storm (Thyrotoxic Crisis)

✷ A relatively rare, life-threatening condition caused by exaggerated hyperthyroidism ✷ Death within 48 hours if not treated

Hyperthyroidism -- Acute Thyrotoxicosis: What do nurses do?

✷ Administer meds to block thyroid hormone production and SNS ✷ Monitor for dysrhythmias ✷ Ensure adequate oxygenation ✷ F&E replacement ✷ Ensure adequate rest Can be really difficult to do. Dim lights, reduce noise, room at the end of the hall, cool room, cluster care

Hyperthyroidism -- Exophthalmos: What do nurses do?

✷ Artificial tears ✷ Salt restriction Help with edema ✷ Elevate HOB ✷ Dark glasses Photophobia and a protective barrier ✷ Tape eyelids closed if needed for sleep ✷ ROM of intraocular muscles ✷ May need steroid and/or diuretic therapy

What are some causes of hypofunction in then endocrine system?

✷ Autoimmune destruction ✷ Neoplasm (cancer) ✷ Infection ✷ Ischemic damage, profound hypotension ✷ Altered hormone synthesis

Insulin Pumps

✷ Continuous subcutaneous infusion Usually it is rapid acting. One stick every two days. ✷ Battery-operated device ✷ Connected to catheter inserted into subcutaneous tissue ✷ Program basal and bolus doses that can vary throughout the day ✷ Potential for tight glucose control

Insulin: What do nurses do?

✷ Ensure correct type of insulin, timing of dose, correct dosage, route, etc ✷ Higher alert- 2 nurses check Only sign off on what you ACTUALLY witness. Be the nurse who actually checks ✷ Check blood sugar BEFORE giving insulin ✷ Assess ability to consume food If NPO could affect the insulin ✷ Ensure correct storage of insulin vials ✷ Patient teaching

Pneumocystis Jiroveci

❖ A pneumonia not seen in healthy people ❖ Can be treated with antibiotics ❖ Seen in HIV/AIDS patients

Lymphocytosis

❖ Abnormal increase in lymphocytes ❖ Common with chemo patients ❖ Problem with B cells, viral infection

Pneumothorax (PTX)

❖ Air in the pleural space ❖ Complete or partial lung collapse ❖ S/S: SOB, chest pain, unequal lung expansion ❖ Diagnose: CXR ❖ Treatment: Chest tube

Problem Meds for Surgery

❖ Anticoagulants Increase risk for bleeding ❖ Diuretics ❖ Tranquilizers ❖ Adrenal steroids ❖ Antibiotics in Mycin group ❖ Herbs/supplements Increase risk for bleeding

Cancer SE: Fatigue - What do nurses do?

❖ Assess for reversible causes of fatigue Anemia ❖ Encourage conservation strategies Rest before activity, get assistance with activity, remain active during periods when feeling better ❖ Maintain nutritional and hydration status

Who would take albuterol?

❖ Asthmatics, COPD, flu, pneumonia, respiratory infection ❖ Treatment of bronchospasm.

HIV: Goals of Treatment

❖ CD4 > 900 and reduction in viral load Starting therapy ASAP is much more effective in keeping CD4 levels high ❖ Take the meds

Wheezes

❖ High-pitched, continuous musical sounds, usually heard on expiration. ❖ Caused by narrowing of airways

Why might a pt with a tracheostomy tube need oro/naso-tracheal suctioning?

❖ If pt does not have trach, but has lower airway secretions that need removal ❖ When pt is unable to cough effectively to clear the airway

Stridor

❖ Piercing, high-pitched sound that is heard without a stethoscope ❖ Primarily during inspiration ❖ Infants experiencing respiratory distress or if someone has an obstructed airway.

What are retention sutures and what purpose do they serve?

❖ Placed in tracheal cartilage during tracheostomy ❖ Free ends taped to skin & left accessible in case tube is dislodged ❖ This way the trachea will not close up. The sutures can be pulled to keep the trachea open

What does a CBC measure?

❖ RBC ❖ Hgb ❖ Hct ❖ MCV Measures RBC size. If ⬆︎ considered microcytic. If ⬇︎ considered microcytic ❖ MCH ❖ MCHC Mean Corpuscular Hemoglobin ❖ WBC ❖ Platelets ❖ Others

Acute Asthma: What do nurses do?

❖ Stay calm ❖ Sit them up as high as they need to be so the lungs can expand. ❖ PLB (1:3) "We are going to smell some roses and then blow out 100 candles." ❖ Assess respiratory system ❖ Yes/No questions No long winded answers ❖ IVF Isotonic. 5,000-4,000 mL/day ❖ Small, frequent meals ❖ Interprofessional care Oxygen, administer meds, quick relief, long term control

Stimulation of the RAAS System

・ Automatic response ・ Activated by decreased perfusion and/or oxygenation of kidneys ・ Involves multi-organ response ・ Leads to fluid retention and vasoconstriction ・ Ultimately harmful in patients with heart failure ・ Further increases workload on the heart *** CONCEPT MAP ***

Cyanosis

・ Bluish discoloration of skin ・ S/S of left sided heart failure

Nursing Implications of Potassium

・ Take with meals or a full glass of water ・ Do not let tablet dissolve in the mouth or oral ulceration may result ・ Monitor serum K⁺ levels ・ Hold if K⁺ is elevated ・ Use an IV pump ・ Monitor I&O ・ May be placed on a heart monitor

Secondary Spacing of Fluid

・ Where the fluid is not supposed to be.

Magnesium

・1.5-2.5 mEq/L ・The second most abundant cation in the body located in the ICF ・50%-60% of Mg is stored in bone, 1% in blood, rest inside cell. ・Mg++ and K+ levels rise and fall together ・Must replace Mg++ before K+ (or at least at the same time)

Phosphate

・2.5-4.5 mg/dL ・Exists in ECF as phosphorus ・Major anion in the ICF (bound with oxygen = phosphate) ・Phosphate is the primary anion in the ICF and the 2nd most abundant mineral in the body after calcium ・Most phosphate is in the bones and teeth as calcium phosphate ・The remaining phosphate is metabolically active and essential to the function of muscle, RBCs, and the nervous system.

Chloride

・95-105 mEq/L ・Most abundant anion in the extracellular fluid

Hypophosphatemia & S/Sx

・< 2.5 mg/dL ・Mild to moderate levels do not usually cause symptoms ・Affect musculoskeletal, CNS, cardiac, and hematological system ・Phosphorus is required to make high energy ATP, many of the signs and symptoms relate to low energy stores ・Hypotension, irritability, confusion, low CO

What are some signs and symptoms of hyperkalemia?

・> 5 mEq/L ・Muscle cramps, weakness, flaccid paralysis ・Drowsiness ・EKG changes Tented T wave, flattened p wave, widened QRS, heart block, ventricular arrhythmias, asystole ・Abdominal cramping, diarrhea ・Oliguria

What are the side effects/adverse effects of atropine?

・ADRENERGIC ACTIONS! ・Dry mouth ・Constipation ・Urinary retention ・Increased HR (tachycardia) ・Pupillary dilation/blurred vision/photophobia ・CNS excitement (delirium) Also: ・Palpitations ・Bradycardia ・Altered taste perception ・Decreased sweating

What do anticholinergics do?

・Act by competing with acetylcholine for the muscarinic acetylcholine receptor sites. ・Block the effects of acetylcholine ・Decrease parasympathetic activities to allow the sympathetic system to become more dominant ・Induce the fight or flight response

What are some clinical manifestations of respiratory acidosis?

・CNS depression ・Low BP ・Warm, flushed skin ・Headache ・Hypoventilation with hypoxia ・Dysrhythmias

What are some treatments for severe hyperkalemia?

・Calcium gluconate IV (for EKG changes) ・IV insulin & glucose ・Sodium bicarbonate IV (if acidotic) ・Dialysis

Cholinergic Agonists

・Chemicals that act at the same time as the neurotransmitter acetylcholine (ACh). ・Parasympathetic(PSNS) agonists, parasympathomimetics

What are the functions of phosphate?

・Combines with calcium to form mineral salts of teeth and bones ・Essential function of muscle, red blood cells, and nervous system ・Component of ATP ・Acid-Base balance ・Helps with deregulation of Ca+ levels

Cardiac Catheterization/PCI

・Examines blood flow in the coronary arteries to heart muscle and heart function ・Catheter inserted into the appropriate coronary artery ・Blockage located → catheter passed through blockage → balloon inflated → stent placed ・Can enter through femoral or radial artery

What are some food sources of magnesium?

・Green leafy vegetables ・Chocolate ・Dried beans ・Nuts ・Seafood ・Legumes ・Whole grains

Describe two ways a bacteria can cause disease within a human body.

・Grow inside a cell ・Secrete toxins

Describe how HIV replicates

・HIV reverse replicates. When HIV infects a cell, it first attaches to and fuses with the host cell. Then the viral RNA is converted into DNA and the virus uses the host cell's machinery to replicate itself during a process called reverse transcription. ・Target CD4 cells by destroying Helper T-cells and infecting CD4 cells. So when they replicate, the HIV replicates also.

HIV: Nursing Assessment

・HIV risk factors ・HIV test result, date of HIV infections, CD4 count, viral load ・Client's knowledge base Etiology, s/s, mode of transmission, disease progression, treatment regimen ・Adherence to medication regimen If pt misses even a few doses it will render the meds useless ・Immunizations

Diastolic Failure

・Heart Failure with Preserved Ejection Fraction (HFpEF) ・Hypertension is the most important cause

Systolic Failure

・Heart Failure with Reduced Ejection Fraction (HFrEF) ・Results from the inability of the heart to pump blood effectively ・Hallmark is reduced EF (Normal is 55% to 60%)

B-lymphocytes are responsible for ___________. Once activated what do they become?

・Humoral immunity Once activated they become memory cells or plasma cells. Plasma Cells Antibody factories. Start releasing tons of antibodies against foreign invader antibodies (immunoglobulins)

What are the uses for ACE Inhibitors?

・Hypertension ・Heart failure (either alone or in combination with diuretics or other drugs) ・To slow progress of left ventricular hypertrophy after an MI (cardioprotective) ・Renal protective effects in patients with diabetes

What are some clinical manifestations of respiratory alkalosis?

・Hyperventilation ・Dysrhythmias, tachycardia ・Lightheadedness, lethargy, confusion ・N/V ・N/T extremities ・Seizures

What are the pharmacodynamics/MOA of atropine?

・Inhibition of ACh by occupying the receptor sites ・Increased HR by blocking vagus stimulation ・Promote dilation of the pupils by blocking the iris sphincter muscle

Renal Mechanisms of Acid-Base Balance

・Last line of defense ・Regulate concentration of plasma HCO3- ・If serum pH is too acidic, kidneys conserve bicarb (and excrete h+) ・If serum pH is to alkaline, kidneys dump bicarb (and increase absorption of H+)

What are the adverse effects of doxazosin? Nursing precautions?

・Orthostatic hypotension ・Dizziness ・Lightheadedness ・Reflex tachycardia Also: headache, fatigue, vertigo, edema, nausea, dyspepsia, diarrhea, sexual dysfunction Get up slowly, change positions slowly, fall precautions.

Anticoagulants: How They Work and Uses

・Prevent formation of clots by inhibiting clotting factors ・Prophylactic only Have no direct effect on a blood clot already formed ・Decrease blood coagulability Prevent thrombosis Uses ・DVT prophylaxis and treatment postoperatively ・PE treatment ・CVA treatment ・Heart A-fib, unstable angina, MI, indwelling devices such as mechanical heart valves ・Coagulopathies FYI: disseminated intravascular coagulation

HIV/AIDS: Interprofessional Care

・Preventing HIV transmission ・Monitoring HIV disease progression and immune function ・Assessment Preventing/detecting/treating opportunistic diseases ・HAART (ART) Regimen ・Preventing/managing treatment complications

What are some signs and symptoms of hyponatremia?

・Primarily: Neurological ・Vary from patient to patient ・Depends on rapidity of development ・Headache, irritability, disorientation, lethargy, confusion. ・If sodium falls to 110 mEq/L, further deterioration: Stupor, delirium, ataxia, seizures, coma, even death.

Sodium Bicarbonate

・Quickly neutralized acids in blood and body fluid ・PO & IV ・Careful assessment during administration Watch for overcorrection (→alkalosis) Can cause hypernatremia & hypokalemia

What are the functions of sodium?

・Regulation of fluid volume (serum Na+ tells you about water balance) ・Maintaining electrolyte balance ・Generation/transmission of nerve impulses ・Muscle contractility ・Acid-base balance (by combining with chloride or bicarbonate) ・Main contributor to osmolality in blood

Lymphocytes

・The second highest percentage of WBCs Two Types B lymphocytes Form in the bone marrow and release antibodies that fight bacterial infections T lymphocytes Form in the thymus and other lymphatic tissue and attack cancer cells, viruses, and foreign substances.

Hydrochlorothiazide (HCTZ) (our prototype)

・Thiazide diuretic given for HTN and edema ・ Acts on renal tubule to decrease reabsorption of Na⁺ ・ Blood volume and blood pressure falls ・ Watch for hypokalemia

Scopolamine

・Transderm Scop ・PSNS antagonist (blocks PSNS) ・Muscarinic antagonist ・Used for motion sickness

Metabolic Acidosis Interventions

・Treat the underlying cause ・Sodium Bicarbonate ・Evaluate and correct electrolyte imbalances ・IVFs ・Insulin for DKA

No Compensation

・pH abnormal ・EITHER CO2 or HCO3- abnormal

Left Sided Heart Failure

(Left sided heart failure does not have another name)

Metabolic Acidosis

(base bicarbonate deficit) occurs when an acid other than carbonic acid accumulates in the body or when bicarbonate is lost from body fluids.

Ischemic Stroke Drug Therapy

**Not for Hemorrhagic Stroke** Anticoagulants ◆ Long term ◆ Warfarin (Coumadin) ◆ Heparin Sodium Platelet Inhibitors ◆ Within 24-48 hours ◆ Aspirin ◆ Clopiodogrel (Plavix) Alteplase (Block 4) Breaks down a clot

What is the osmolality of a hypotonic solution?

<250 mOsm/kg

SaO₂ Normal Range

95%-100%

Chloride Normal Range

95-105 mEq/L

What does 1 quart equal in mL?

960mL

Central Pontine Myelinolysis (CPM)

FYI ◆ What happens if Na+ is brought up too quickly

WILDA pain scale

Words that describe pain Intensity of pain Location of pain Duration of pain Aggravating or alleviating factors

Acute Pain

∙ Rapid onset & short duration ∙ Associated with injury/surgery ∙ Disappears as tissues heal

What is the therapeutic classification of nitroglycerin? Pharmacologic?

Antianginal; Vasodilator, Nitrates

What is the therapeutic classification of digoxin (Lanoxin)? Pharmacologic?

Antiarrhythmics, inotropics; Digitalis glycosides, cardiac glycosides

T/F: All fungi are pathogenic

False

What are some side effects of furosemide (Lasix)?

Frequent urination, dizziness, blurred vision, headache, vertigo.

What is Isoniazid (INH)? Side effects?

Isoniazid is an antibiotic used a first line agent for the prevention and treatment of both waiting and active tuberculosis. Side effects include hepatitis & peripheral neurotoxicity. Supplement with vitamin B6 to prevent peripheral neuropathy.

How can you diagnose COPD?

PFT, FEV, CXR, O₂ sat, ABG, sputum samples/cultures

Pleurisy

Painful inflammation of the pleura

Cycoplegia

Paralysis of the ciliary body (accommodation)

What are some ethical issues in pain management?

Fear of Hastening Death ∙ The principle of double effect Requests for Assisted Suicide ∙ ANA does not support ∙ Death with Dignity laws CA, CO, DC, OR, VT, WA, MT Clinical use of placebos is considered unethical.

Triglycerides Normal Range

< 150 mg/dL

Cholesterol Normal Range

< 200 mg/dL

Arterial Occlusion

4 P's Pain, pulselessness, pallor, paresthesia

RBCs Normal Range

4-6 million/mm³

What is the mechanism of action of nystatin (Mycostatin)?

Inhibits fungal wall synthesis leading to cell leakage and death.

Process of Cancer Development

Initiation, promotion, progression

What information do you need to include when labeling your bag of IV fluids?

Patient name, date, time, initials

What is Rifampin contraindicated in?

Patients with HIV; substitute Rifabutin (Mycobutin).

Systolic Blood Pressure (SBP)

Peak pressure exerted when heart contracts

What circumstances warrant a 22 gauge IV?

Pediatric, small veins

RAAS System ***VERY IMPORTANT***

Renin-Angiotensin-Aldosterone System

P Wave

Represents depolarization of the atria and the firing of the SA node. Na+ and K+ moving in and out of cells.

Rhythm of the Conduction System

SA node(Pacemaker) fires spontaneously 60-100 times per minute. AV node fires at 40-60 times per minute. If both nodes are suppressed fibers in ventricles by themselves they will fire only 20-40 times per minute.

What range is prehypertension?

SBP of 120-139 DBP of 80-89

What is Hematocrit (Hct)?

The percentage of whole blood that is erythrocytes (RBCs)

When is afterload increased?

・ Hypertension ・ Vasoconstriction

Elevated Pulmonary Capillary Wedge Pressure

・ S/S of left sided heart failure

What is the important neurotransmitter of the Sympathetic (Adrenergic) Nervous System?

Norepinephrine (NE)

Intake/Output Formula

0.5mL/kg/hr

HIV Pathophysiology

1. After HIV binds to the CD4+ T helper cell, it gains entry and is transcribed into single-strand DNA with assistance of REVERSE TRANSCRIPTASE (enzyme made by retroviruses) 2) Single-strand DNA replicates and makes double-strand DNA 3) HIV DS-DNA enters cell nucleus and splices itself into the genome with the assistance of INTEGRASE, and becomes a permanent part of the genetic structure causing two effects: all daughter cells become HIV infected AND viral DNA in cell directs cell to create more HIV (long strands of HIV RNA are created) 4) With the help of PROTEASE, long strands of HIV RNA are "cut to size," which allows RNA to leave the cell in a budding process (this process eventually leads to cellular destruction)

Frontal Lobe Function

◆ Higher cognitive function Judgement, reasoning ◆ Memory retention ◆ Voluntary eye movements ◆ Voluntary motor movement ◆ Motor functions involved in speech production (Broca's area)

What lab results would we expect to find in someone who is pre-diabetic?

◆ Impaired Fasting Glucose (IFG): 100-125 mg/dL ◆ 2-hour OGTT: 140-199 mg/dL At risk for DMT2 ◆ Hgb A1c: 5.7% - 6.4%

Causes of Dehydration

◆ Inadequate fluid intake ◆ Severe or prolonged isotonic fluid loss ◆ Watery diarrhea ◆ DI ◆ Others

Encephalitis (FYI)

◆ Inflammation of the brain ◆ HSV is the most common cause in the U.S.

How does insulin interact with potassium?

◆ Insulin stimulates the NA⁺K⁺ channel ◆ Drives potassium into the cell ◆ May cause hypokalemia ◆ Treatment for hyperkalemia

What is the order of blood draw?

1. Sterile blood culture tubes or vials 2. Blue stopper (sodium citrate) tubes 3. Serum tubes (red/black, red/yellow top) 4. Green stopper (lithium heparin, plasma) tubes 5. Lavender stopper (EDTA) tubes 6. Gray-top (glycolytic inhibitor) tubes ***Will not be tested on-- Check facility policy***

Dehydration

◆ Loss of water ◆ Hypertonic ◆ Fluid loss in both ECF and ICF ◆ Causes: inadequate fluid intake, severe or prolonged isotonic fluid loss, watery diarrhea, DI, others

What venous site is the most common site used to obtain blood?

Median cubital

When suctioning an adult patient the suctioning level should be set at ____________ mmHg. _________ seconds is the max length of suctioning that should be applied per suctioning pass.

100-120 mmHg; 10 seconds

Hgb Female Normal Range

12-16 g/dL

If an IV catheter has a green hub, what gauge is it?

18

How long must you wait before retying a tourniquet?

2 minutes

Which BP-regulating mechanism(s) can result in the development of hypertension if defective (select all that apply)? a. Release of norepinephrine b. Secretion of prostaglandins c. Stimulation of the sympathetic nervous system d. Stimulation of the parasympathetic nervous system e. Activation of the renin-angiotensin-aldosterone system

A, C, E

Where do you hear the mitral valve? Which sound is louder?

Mid-Clavicular Line, 5th intercostal space (PMI); S1 > S2

What circumstances warrant a 20 gauge IV?

Minor trauma or surgery, blood administration

Signs and Symptoms of Hypertension

・ When severe a patient may experience: fatigue, dizziness, palpitations, angina, dyspnea. ・ Generally asymptomatic if not severe.

Hyperlipidemia (HLD): Causes and Treatment Guidelines

Causes ・Excessive dietary intake of fats ・Genetic alterations in fat metabolism leading to a variety of elevated fats in the blood Treatment Guidelines ・Lipid lowering agents are used as an adjunct to diet therapy All reasonable non-drug means of controlling cholesterol levels should be tried for up to 6 mos and found to fail before drug therapy is considered ・Drug choice based on specific lipid profile of client

Hyperparthyroidism: Characterized by, goals, treatment

Characterized by ⬆︎ PTH ⬆︎ Ca⁺⁺ ⬇︎ PO₄ ⬆︎ ♡ function (⬆︎ contractility) Goals ✷ Relief of symptoms ✷ Prevent complications caused by ⬆︎PTH (hypercalcemia, hypophosphatemia) Treatment ✷ Parathyroidectomy ✷ Nonsurgical treatment

If an IV catheter has a pink hub, what gauge is it?

20

What is the smallest gauge catheter that can be used to administer blood?

20

The intrapleural space if filled with _____________ mL of fluid.

20-25 mL. Drained by the lymphatic system.

aPTT (activated partial thromboplastin time) Normal Range

20-35 seconds

If an IV catheter has a blue hub, what gauge is it?

22

How long is IV fluid good for once it is spiked?

24 hours

What does one cup equal in mL?

240 mL

What is the osmolality of an isotonic solution?

250-375 mOsm/kg

What are some hypertonic solutions?

3% NS [1026 mOsm] *D5 0.45% NaCl [406 mOsm] D5 0.9% NaCl [560 mOsm] D5LR [575 mOsm] D10W [556 mOsm] Colloids: Albumin Plasma protein fraction Dextran Hetastarch

A hormone is a _____________ that is __________________________ and has a ____________.

Chemical substance; produced in the body; target

Hypernatremia

・>145 mEq/L ・Severe: can lead to seizures, coma, permanent neurological damage ・Fluids have moved from ICF into ECF ・Cells are shrinking

Post-Op Assessment Priorities

ABCs ◇ Airway Patency/artificial airway? ◇ Breathing O₂ sats. RR & rhythm, cyanosis? Cap refill? Stridor? ◇ Circulation Cap refill, BP, pulse, VS, distal pulses, cms checks, edema, skin color, EKG Plus ◇ Monitor for bleeding Estimated blood loss (EBL), surgical site & underneath, drains ◇ Pain Incisional, other? Gas could cause shoulder pain ◇ VS/Temp ◇ Neurologic LOC/orientation, sensory/motor (especially with orthopedic surgery or regional anesthesia), remember hearing is the first sense to return! ◇ GU I&Os ◇ GI Bowel sounds are okay not to hear

Exetimibe (Zetia)

Cholesterol Absorption Inhibitor MOA ・Inhibits absorption of cholesterol in small intestine ・Decrease dietary cholesterol to liver ・decrease in total cholesterol Adjunctive Treatment Used in combo with statins

Basophils

・A circulating leukocyte that produces histamine. ・Mast cells

Western Blot

・A final test to confirm HIV status ・Detects the presence of circulating antibodies against HIV and Viral Proteins

Glucocorticoids & Inflammation

ADRENAL GLAND ❖ Cortex Produces corticosteroids (glucocorticoids, mineralocorticoids, and androgens) ❖ Glucocorticoids ∙ Coristol: most abundant and potent glucocorticoid Cortisol has powerful anti-inflammatory and immunosuppressive properties ❖ Glucocorticoids/Corticosteroids "SONE" or "LONE"

Which end of PaCO2 is alkaline? Acidic?

35 is alkaline 45 is acidic

PaCO₂ Normal Range

35-45 mmHg

What is the normal range for temperature?

36°-38°C (96.8°-100.4°F)

What does 1 tablespoon equal in teaspoons?

3t

A patient with newly discovered high BP has an average reading of 158/98 mm Hg after 3 months of exercise and diet modifications. Which management strategy will be a priority for this patient? a. Medication will be required because the BP is still not at goal. b. BP monitoring should continue for another 3 months to confirm a diagnosis of hypertension. c. Lifestyle changes are less important, since they were not effective, and medications will be started. d. More vigorous changes in the patient's lifestyle are needed for a longer time before starting medications.

A

The nurse recognizes that primary manifestations of systolic failure include a. ↓ EF and ↑ PAWP. b. ↓ PAWP and ↑ EF. c. ↓ pulmonary hypertension associated with normal EF. d. ↓ afterload and ↓ left ventricular end-diastolic pressure.

A

Stenosis

A condition in which the heart valves become rigid and may calcify over time. The loss of flexibility of the valve interferes with normal function and may cause the heart to work harder to propel blood through the valve, which eventually weakens the heart.

Partial Compensation

ALL values are abnormal

What is a culture and sensitivity and why is it performed?

A culture is a test to identify the germs that cause have caused the infection. A sensitivity test checks to see what kind of medicine will work best to treat the illness or infection.

Lasix

A diuretic that helps get rid of the excess volume.

Adrenergic Agonist

A drug that stimulates the adrenergic receptors of the sympathetic nervous system, either directly (by reacting with receptor sites) or indirectly (by increasing norepinephrine levels)

Myeloproliferative Disorder

A group of slow-growing blood cancers, including chronic myelogenous leukemia, characterized by large numbers of abnormal RBCs, WBCs, or platelets growing and spreading in the bone marrow and the peripheral blood.

What is hypercalcemia and what are the s/sx?

A metabolic emergency that occurs when Ca+ levels rise above 10.5 mg/dl. ・Fatigue ・Confusion, altered mental status, depression, personality changes, lethargy to come ・Muscle weakness, hyporflexia, loss of muscle tone ・Bradycardia, cardiac arrest ・Intestinal(may be first indications noted by patient) Anorexia, n/v, decreased bowel sounds, constipation ・Renal Kidneys work overtime-may lead to renal failure

What is the fastest rate of absorption for insulin?

Abdomen is fastest, followed by arm, thigh, and buttock.

Trousseau's Sign

A sign of hypocalcemia . Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.

Fluid Spacing

A term used to describe the distribution of body water

Hodgkin's Disease

A type of cancer that affects the lymph tissue

Negative Feedback

A type of regulation that responds to a change in conditions by initiating responses that will counteract the change. Maintains a steady state. ✷ Regulates the hormones ✷ Relies on blood level of a hormone ✷ Most common regulator in the endocrine system ✷ Works much like a thermostat. The hypothalamus is the thermostat of the body, constantly monitoring.

Kaposi Sarcoma (KS)

A type of skin cancer often seen in patients with AIDS; consists of brownish-purple papules that begin in skin and spread to internal organs

Bacille Calmette-Guerin (BCG)

A vaccine against tuberculosis that is prepared from a strain of the attenuated (weakened) live bovine tuberculosis bacillus ∙ Can result in positive PPD reaction

A patient with chronic HF and atrial fibrillation is treated with a digitalis glycoside and a loop diuretic. To prevent possible complications of this combination of drugs, what does the nurse need to do (select all that apply)? a. Monitor serum potassium levels. b. Teach the patient how to take a pulse rate. c. Keep an accurate measure of intake and output. d. Teach the patient about dietary restriction of potassium. e. Withhold digitalis and notify health care provider if pulse is irregular.

A, B

Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Assisting the patient to ambulate to the bathroom to void d. Informing the patient that he will be sleepy from the general anesthesia e. Instructing the patient about the risks of the radioactive isotope injection

A, B

What does 1 teaspoon equal in mL?

5 mL

WBCs Normal Range

5,000-10,000/mm³

How long between sounds (per quadrant) is a active bowel activity?

5-20 seconds

For a diabetic patient, the goal of a glycosylated hemoglobin (A1c) is between:

6.5%-7%

PTT (partial thromboplastin time) Normal Range

60-70 seconds

What is the normal range for diastolic blood pressure (DBP)?

60-80 mmHg

pH Normal Range

7.35-7.45

Glucose Normal Range

70-100 mg/dL *according to lab value reference table

Calcium Normal Range

8.5-10.5 mg/dL

PaO₂ Normal Range

80-100 mmHg

What is a normal CD4+ count? Lifespan? Lifespan of an HIV infected CD4+ cell?

800-1200 cells per microliter; 100 days; 2 days

Hypomagnesemia and S/Sx

< 1.5 mEq/L ・Hyperactive deep tendon reflexes ・Weakness ・Muscle cramping ・Restless legs ・Rapid heartbeat ・Tremor ・Vertigo ・Anxiety, agitation, depress At it's worst it can lead to: ・Respiratory muscle paralysis ・Complete heart block ・Altered mental status ・Coma

What is the target BP for a pt. with HTN?

< 130/< 80

If a client has hypertensive crisis, what is the treatment?

> 180/> 120 Client needs intervention now

What is the osmolality of a hypertonic solution?

> 375 mOsm/kg

Autorhythmicity

Ability of cardiac muscle to initiate its own electrical impulse that triggers the mechanical contraction that pumps blood at a fixed pace without nervous or endocrine control.

Pleural Effusion

Abnormal accumulation of fluid in the pleural space

Cancer Development: Initiation (define, inherited vs acquired)

Definition Abnormal cell is transformed by genetic mutation of DNA Can be: ❖ Inherited Passed from previous generation. 5% of cases ❖ Acquired Carcinogens. Something triggered the cancer to form

What should you be monitoring in a patient taking furosemide (Lasix)?

Monitor I&O, daily weight, peripheral edema, adventitious lung sounds, turgor, labs (K⁺, BUN, Creatinine)

What do adrenergics that stimulate Alpha₂ receptors do?

Decrease GI motility and tone

Thrombocytopenia: Definition, causes, parameters, results in, symptoms, major complications

Definition ❖ Deficient number of platelets ❖ Congenital or acquired (most common) Causes ❖ Primarily an acquired disorder Commonly from ingestion of certain herbs/drugs ❖ Decreased platelet production ❖ Increased destruction ❖ Sequestration ❖ Blood loss ❖ Chemotherapy & HIT Heparin aka White Clot Syndrome ❖ Loveknox (enoxaprin) Parameters < 150,000/mcL = thrombocytopenia < 10,000/mcL ➠ Severe bleeding Results in ❖ Abnormal hemostasis ❖ Prolonged or spontaneous bleeding Symptoms ❖ Sudden onset of petechiae Microhemorrhages (may be only symptom) ❖ Purpura Bruise from numerous petechiae ❖ Ecchymoses Larger lesions from hemorrhage ❖ Mucosal cutaneous bleeding, bleeding gums, nose bleeds ❖ Malaise ❖ Fatigue ❖ General weakness Major Complications -- Hemorrhage ❖ Insidious or acute Might first be discovered when anemia if found ❖ Internal or external Internal ➛ weakness, fainting, dizziness, tachycardia, abdominal pain, hypotension

Three Layers of the Heart

Epicardium, myocardium, endocardium

What are the 3 major abdominal regions?

Epigastric (Upper) Umbilical (Middle) Hypogastric or Suprapubic (Lower)

The Stress Response

Eustress is helpful stress. Distress is harmful. Body's homeostatic mechanisms attempt to counteract stress. Prolonged stressful conditions can result in stress response or *general adaptation syndrome(GAS)*. Three stages: Initial fight-or-flight, slower resistance reaction eventually exhaustion.

If a patient has brain swelling, what type of fluid do you give them?

Hypertonic solutions.

When the sodium gates open and sodium diffused into the cardiac muscle fiber.

In a cardiac myocyte, depolarization of the cell membrane occurs...

Cancer SE: GI effects - What do nurses do?

In general ❖ Monitor I&Os ❖ Assess for s/s of dehydration & malnutrition Stomatitis/mucositis/esophagitis ❖ Frequent mouth assessment and oral hygiene ❖ Artificial saliva ❖ Oral rinses (saline) or as prescribed ❖ Pain relief compounds Swish and spit mixtures, non alcohol based mouthwashes ❖ Avoid irritating foods ❖ Pre-medicate before eating ❖ Nutritional supplements ❖ Avoid tobacco/alcohol Diarrhea ❖ Antidiarrheal, anti motility and antispasmodic meds ❖ Nonirritating, low-fiber, high-calorie, high-protein diet ❖ Enc 3+ L fluid/day Anorexia ❖ Monitor carefully to avoid weight loss Weigh twice weekly ❖ Small, high-calorie, high-protein diet Encourage nutritional supplements ❖ Enteral/parenteral nutrition ❖ dronabinol (Marinol) Synthetic marijuana

Troponin Levels: Increase, Peak, Lasts, Drawn, Angina?

Increase 2-6 hours Peak 10-24 hours Lasts 10-14 days Drawn Q6 hour x3 Q8 hour x3 Negative in angina

CK Levels: Increase, Peak, Lasts, Drawn, Angina?

Increase 4-6 hours Peak 18-24 hours Lasts 2 days Drawn Q6 hour x3 Q8 hour x3 Negative in angina

If you were stranded in a desert without any water the amount of ADH secreted would...

Increase (ANTI-diuretic hormone, no diuresing)

How is respiratory alkalosis compensated?

Kidneys conserve hydrogen ions and excrete bicarbonate ions.

ABGs (arterial blood gases)

Laboratory test for levels of oxygen and carbon dioxide present in blood. Monitor in heart failure patients.

Eosinophils (granulocyte)

Large brick-red cytoplasmic granules Found in response to allergies and parasitic worms

Where do you hear the pulmonic valve? Which sound is louder?

Left sternal border, 2nd intercostal space; S2 > S1

Where do you hear the tricuspid valve? Which sound is louder?

Left sternal border, 4th intercostal space; S1 > S2

How can you treat COPD?

Low flow O₂, SVN, medication, activity management, nutrition, hydration, health maintenance More advanced: bronchoscopy

Mean Arterial Pressure (MAP)

MAP = (SBP + 2DBP) ÷ 3 When treating hypertensive emergencies, the mean arterial pressure (MAP) is often used instead of BP readings to guide and evaluate drug therapy. The initial goal is to decrease MAP by no more than 20% to 25%, or to decrease MAP to 110 to 115 mm Hg. If the patient is clinically stable, drugs can be titrated to gradually lower BP over the next 24 hours. Lowering the BP too quickly or too much may decrease cerebral, coronary, or renal perfusion. This could cause a stroke, MI, or renal failure.

Loop Diuretic furosemide (Lasix) (our prototype)

MOA: blocks Na + Cl-/water reabsorption in LOH

Heparin: MOA, Lab Values, & Teaching

Pharmacodynamics/MOA 1. Heparin binds with antithrombin III 2. Inactivates thrombin 3. Inhibits conversion of fibrinogen & decreases fibrin 4. Clot prevented Lab Values ・H&H If their H&H is low, the pt. is already depleted of that and they could be bleeding internally ・PTT Normal is 60-70 seconds. Therapeutic is 90-175 seconds. The bigger the number, the thinner the blood. ・aPTT Normal is 20-35 seconds. Therapeutics is 30-87.5 seconds Teaching ・Medical ID bracelet ・Notify all MD or DDS ・Prevent bleeding ・External hemorrhage

What is the mechanism of action of warfarin (Coumadin)?

Prevents thromboembolic events by inhibiting the livers ability to make vitamin K dependent clotting factors.

Occipital Lobe Function

Processing of sight

T Wave

Represents the repolarization of ventricles.

What is the difference between the sterile team and the clean team in the OR?

Sterile ❖ Scrubs in before surgery, does sterile gowns and gloves ❖ Surgeon, surgical assistant, scrub tech/nurse Clean ❖ Abides by clean technique, medical asepsis ❖ Anesthesia Care Provider (ACP), circulating RN, others

How do decongestants work?

Stimulate alpha-adrenergic receptors causing vasoconstriction of the capillaries.

Prevents the backflow of blood between the left atrium and the left ventricle. Consists of two cusps, known as the anterior medial cusp and the posterior medial cusp. The two cusps of the mitral valve are attached by chordae tendineae to two papillary muscles that project from the wall of the ventricle.

Structure and Function of Left Atrioventricular Valve(Mitral Valve/Bicupsid).

Systemic Circuit

Transports *oxygenated* blood to virtually all of the tissues of the body and returns relatively deoxygenated blood and carbon dioxide to the heart to be sent back to the pulmonary circulation. From heart to body to heart.

Pulmonary Circuit

Transports blood to and from the lungs, where it picks up oxygen and delivers carbon dioxide for exhalation. From heart to lungs to heart.

Respiratory Acidosis Interventions

Treat underlying cause and improve lung function ・Bronchodilators ・Supplemental oxygen ・CPT ・ABX ・Maintaining hydration ・Mechanical ventilation

Define empiric therapy/treatment

Treatment by which experience has already proved to be beneficial. A certain antibiotic proved to work in the past may be prescribed.

Cardiac Muscle Tissue

What makes up the myocardium. - Striated - Branched, mono-nucleated - Intercalated disks are anchoring structures(include *gap junctions* and *desmosomes*) - Action potential travels through connected cells forming a functional *synctium*(unit).

Frank-Starling Mechanism(Starling's Law of the Heart)

Within physiological limits, the force of heart contraction is directly proportional to the initial length of the muscle fiber. This means that the greater the stretch of the ventricular muscle(within limits), the more powerful the contraction is, which in turn increases SV. Therefore, by increasing preload, you increase the second variable, contractility.

Hormones

__________________ are chemical messengers that are produced in one body region but affect a different body region.

What are the long acting insulins? What is the onset, peak, and duration of long acting insulin?

glargine (Lantus) detemir (Levemir) Onset: 0.8-4 hrs Peak: No pronounced peak Duration: 24+ hours Food is not a concern when administering. But, check blood sugar before administration.

Second Spacing

∙ Abnormal accumulation of interstitial fluid ∙ Fluid overload

What is part of the somatic nervous system?

◆ Voluntary ◆ Spinal and cranial nerves

Clopidogrel (Plavix): Uses, Considerations, Labs, Adverse Effects

・Platelet aggregation inhibitor ・Antiplatelet drug Uses ・Acute coronary syndrome (ACS) ・Hx: MI, ischemic stroke, PAD Considerations Given PO with or without aspirin Give with food! Labs to watch AST, ALT, CBC, Hct/Hgb, PT Adverse Effects: - Prolonged bleeding time; bleeding; bruising - Diarrhea Monitor for signs of bleeding Monitor for rash as can cause Stevens Johnson syndrome

What are some other ways we can lose sodium?

・Sweat ・Feces