COMPLEX EXAM 2

BURNS

types of burns: - *Thermal burns:* > •Caused by flame, flash, scald, or contact with hot objects •*Most common type of burn injury* •Severity of injury depends on > •Temperature of burning agent > •Duration of contact time - *Chemical burns:* > •Result of contact with acids, alkalis, and organic compounds •Alkali burns are hard to manage because they cause protein hydrolysis and liquefaction > •Damage continues after alkali is neutralized •Chemical should be quickly removed from the skin •Clothing containing chemical should be removed •Tissue destruction may continue up to 72 hours after chemical injury - *Smoke inhalation injury:* > •From inhalation of hot air or noxious chemicals •Cause damage to respiratory tract •Major predictor of mortality in burn victims •Need to be treated quickly > 3 types: •Metabolic asphyxiation (Carbon monoxide poisoning) •Upper airway injury •Lower airway injury (manifests as ARDS) - *Electrical burns:* •Severity of injury can be difficult to assess, as most damage occurs beneath skin > •"Iceberg effect" •Electrical current may cause muscle spasms strong enough to fracture bones - *Cold thermal injury:* Frostbite CLASSIFICATION: Severity of injury is determined by: - Depth of burn: •Burns have been defined by degrees (first, second, third, and fourth) •ABA advocates categorizing burn according to depth of skin destruction: > •Partial-thickness burn > •Full-thickness burn - Extent of burn in percent of TBSA: Rule of 9s - Location of burn: > *Face, neck, chest → respiratory obstruction* > Hands, feet, joints, eyes → self-care > *Ears, nose, buttocks, perineum → infection* > Circumferential burns of extremities can cause circulation problems distal to burn > •*Patients may also develop compartment syndrome* - Patient risk factors •Superficial (first degree) burn: *blanching* on pressure, pain and mild swelling, *no vesicles or blisters* (although after 24 hrs skin may blister and peel) •Deep (second degree) burn: *Fluid-filled* vesicles that are red, shiny, wet (if vesicles have ruptured). Severe pain caused by nerve injury. Mild to moderate edema. •Third & Fourth degree burns: *Dry, waxy white, leathery, or hard skin*. Visible thrombosed vessels. *Insensitivity to pain because of nerve destruction.* Possible involvement of muscles, tendons, and bones •Superficial partial-thickness burn > •*Involves epidermis* with hyperemia, tactile and pain sensation intact. •Deep partial-thickness burn > •*Involves epidermis/dermis* varying depths, epithelial regeneration remains viable. •Full-thickness burn: •*Involves all skin elements, nerve endings, fat, muscle, bone (all destroyed)* •Coagulation necrosis present •Surgical intervention required for healing - Rule of 9 Chart

DKA

•An acute, life-threatening *complication of DM Type I*, that occurs when a profound insulin deficiency occurs •Results in cellular dehydration and volume depletion, acidosis, and protein catabolism •*Hyperglycemia, dehydration, ketosis, and acidosis ensues* •Develops quickly •Infection is often a precipitating factor •If left untreated patient becomes comatose from dehydration, electrolyte imbalances, and acidosis results CAUSES: *•Typically DM Type 1: undiagnosed/new onset; can occur in DM Type 2 in severe stress or infection* •Omission or inadequate insulin dosage •*Infections: pneumonia, sepsis, UTI, abscesses* •Stress •*Undiagnosed Diabetes Type 1* •Major/acute illness: MI, CVA, trauma, renal disease, pancreatitis •Other endocrine disorders: hyperthyroidism, Cushing's •High caloric parenteral or enteral feeding •Increased Insulin needs: pregnancy, puberty S/S: • Flushed dry skin •Dry mucous membranes, decreased skin turgor •Tachycardia •Dehydration •Hypotension, orthostatic hypotension •*Kussmaul's Respirations - body's attempt to reverse metabolic acidosis via exhalation of excess CO2 (rapid, deep breathing associated with dyspnea)* •*Acetone Breath (fruity)* •*Altered LOC* •*Visual Disturbances* •*Headache* •*Polyuria, Polydipsia, Polyphagia* •Nausea and Vomiting (electrolyte losses) •Anorexia, abdominal Pain, weight loss •Sunken eyes, soft eyeballs •Lethargy, coma •*ABG's - Metabolic Acidosis* •Glucose in urine -glucosuria •*Urine Ketones positive - ketonuria* •Serum Ketones or ketones in urine TREATMENT: •Treatment: First goal of therapy - establish IV access, begin fluid & electrolyte replacement *•IV infusion 0.45% or 0.9% NaCl at a rate of 1L/hr to raise BP and restore urine output to 30 - 60ml/hr* *•When serum glucose approaches 250 mg/dL, dextrose 5% - 10% is added to prevent hypoglycemia - severe drop in glucose = cerebral edema* •Too rapid administration of IV fluids; use of the incorrect types of IV fluids especially hypotonic solutions and correcting the blood glucose level too rapidly can lead to cerebral edema - monitor VS and I & O's, watch for fluid overload *•Regular Insulin gtt: 0.1mg/kg/hr, check hourly and titrate based upon BS levels* •Short-duration insulin only = *Regular insulin, ALWAYS place Regular insulin infusion on an IV infusion pump* •Insulin is infused continuously until subcutaneous administration resumes to prevent a rebound of the blood glucose level •*Always obtain K+ level before starting insulin (potassium may be elevated due to dehydration and acidosis)* •Insulin is responsible for cellular regulation of K+, promotes cellular influx of K+ from extracellular to intracellular •Monitor K+ closely as it will fall quickly within the 1st hour of tx COMPLICATIONS: •Hypovolemic shock •AKI •Coma •Need for intubation •AMI - Prevention Education: •Educate pt and family on self-management practices •Diet •Medication-insulin compliance •Frequency of self-checks •Routine A1C •"Sick time" management •*Check urine for ketones when blood glucose levels are elevated*

Upper GI

•Etiology •*Peptic ulcer disease* - acute or chronic erosion of GI mucosa from HCI acid & pepsin •Duodenal and gastric ulcers most common cause of peptic ulcer disease - Risk factors: •Smoking •*Helicobacter pylori bacteria* •Drugs: Nonsteroidal anti-inflammatory drugs *(NSAIDs), amino salicylic acid (ASA), steroids* •Alcohol •*Stress ulcer* - acute form PUD, accompanies severe illness, systemic trauma, neuro injury Types: - Ischemic—decreased blood flow •Hemorrhage •Trauma •Burns (Curling's ulcer) - Cushing's—decreased blood flow and hypersecretion of acid •Associated with head trauma or brain surgery - Prevention part of ICU "bundle" of care •*Antacids or H2-receptor blocker medications* •*Mallory-Weiss tear* - disruption mucosal lining= arterial hemorrhage from tear in gastroesophageal mucosa - Arterial hemorrhage •Longitudinal tear in gastroesophageal mucosa - Associated with: •*Forceful retching* •Long-term NSAIDs or aspirin use •Excessive alcohol intake •*Esophageal varices* - portal HTN increased (normal 2-6), *bleeds when at 12* varicosities develop, fragile, bleed easily •Potential for hypovolemic shock - S/S of hypovolemic • shock? - Portal hypertension •Veins become distended and varices develop •Varices develop when pressures exceed 10mmHg •Pressures at 12mmHg tend to bleed - Esophageal Varices •Complex enlarged veins at lower end of the esophagus, fragile tend to bleed easily - Gastric Varices •Upper portion of stomach •Tend to bleed easily ASSESSMENT: - *Blood loss* •Color, amount, and consistency of emesis and stool •Upper GI Bleed Bright red blood (ICU) •*Upper GI bleed Coffee ground blood* > Seen in vomitus = blood that has been in the stomach for some time and has come in contact with stomach acids •*Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding*, but can be seen when upper GI bleeding is massive (>1000 mL). •*Melena - Black, tarry stools = slow bleeding from an upper GI source* •The longer the passage of blood through the intestines, the darker the stool color because of hgb breakdown & release of iron •*Bowel sounds may be hyperactive* as active bleeding is passed quickly through the GI tract. •Symptoms of hypovolemia > *•Hypotension, tachycardia, dizziness* •Pain or discomfort - *First priority is to assess blood loss* •Vital signs •Level of consciousness •Urine output •S/S of hemodynamic instability •Determine need for fluid resuscitation/ administration of blood products •*Hyperactive bowel sounds* *•Soft, distended abdomen* DIAGNOSTICS: - *Endoscopy* •Procedure of choice •Diagnosis and treatment of upper GI bleeding - Barium studies •Ulcers/bleeding, tumors SURGICAL: •Types: •Gastric resection •Billroth I or II •Vagotomy •Pyloroplasty PRIORITY TREATMENT: - Hemodynamic stabilization: •Oxygen administration •Arterial pressure monitoring *(Pulmonary Artery Catheter)* •*Administration of fluids and/or blood products* •Hematocrit may not reflect actual blood loss - Gastric lavage •Upper GI bleeding •May be done prior to endoscopy to provide better visualization of gastric fundus > 1000 to 2000 mL of room temperature normal saline is instilled via nasogastric tube and is then gently removed by intermittent suction or gravity until the secretions are clear. PHARM; •Proton pump inhibitors •Antacids •H2-receptor blockers •Mucosal barrier enhancers •Antibiotics (Helicobacter pylori) > iThe first-line treatment for H. pylori infection consists of a *proton pump inhibitor (omeprazole, lansoprazole, esomeprazole, rabeprazole) and amoxicillin and clarithromycin (the t. wo antibiotics).* ENDOSCOPIC TREATMENT: - *Sclerotherapy:* •*Inject bleeding ulcer with a necrotizing agent* •Morrhuate sodium, ethanolamine, and tetradecyl sulfate •Traumatizes the endothelium causing necrosis and sclerosis of bleeding vessel - *Thermal methods:* •Involves use of heater probe, laser photocoagulation, and • electrocoagulation to tamponade the vessel - *Band ligation (varices)* reduce incidence of bleeding, used to • achieve hemostasis NURSING INTERVENTIONS: VARICES: •Avoid alcohol, ASA, NSAIDS •Screen for presence of varices with endoscopy •Avoid anything irritating to stomach •*Beta Blockers (dilate -takes pressure off of veins)* - Active bleeding: •Stabilize patient •Manage airway •Provide IV therapy (large bore IV's & blood products - Supportive measures for acute bleed: •*Fresh frozen plasma, packed RBC's, Vitamin K, Proton pump inhibitors, lactulose, antibiotics* - Drug therapy: *•Octreotide (Sandostatin) REDUCES PORTAL PRESSURE and Vasopressin drip (constrict vessels)* > Vasopressors: •Risk of fluid or electrolyte abnormalities •Continuous electrocardiogram (ECG) and blood pressure monitoring - Surgical therapy: •Band ligation or sclerotherapy •Trans jugular intrahepatic portosystemic shunt (TIPS): •Nonsurgical treatment for recurrent bleeding •Performed under fluoroscopy •Shunting procedures = Portacaval shunts > •Used after SECOND major bleeding episode > •TIPS procedure-connects portal vein to hepatic vein - *Esophagogastric (balloon) tamponade:* •*Sengstaken-Blakemore tube* •Gastric balloon 200-500mL •Attached to suction, empty stomach •Esophageal balloon, normal 20mmHg or up to 40mmHg •If esophageal balloon displaces upwards, the inflated balloon may occlude the airway! •*Cut esophageal balloon for respiratory distress!* •*Compresses bleeding vessels* •ICU continuous monitoring •*Verify position with chest x-ray* •Monitor for aspiration *•Semi-fowlers position*

HEPATIC FAILURE

•Hepatitis •Decreased perfusion •Cirrhosis •Fatty liver disease HEPATITIS: •Acute inflammation of liver cells •A: common; fecal contamination > •Vaccine available •B: blood-borne, sexual transmission > •Vaccine; begin in infancy •C: blood-borne •D: combined with hepatitis B •E: fecal-oral •G: blood-borne, sexual transmission S/S: •Many patients asymptomatic •*Flu like symptoms:* •Malaise, fatigue, myalgia, arthralgia •GI pain •Fever, chills •*Jaundice* •*Brown urine* •*Right upper quadrant pain* •Hepatomegaly •Lymphadenopathy •Splenomegaly •Pruritis •*Distaste for smoking cigarettes* •Weight-loss/anorexia •*Clay-colored stools* MANAGEMENT: *•No definitive treatment other than rest* •Nutritional support *•Prevention of spread of the virus*: universal precautions •Most people recover with no complications •Some develop chronic hepatitis > •Mostly Hep C but sometimes Hep B •Cirrhosis •Portal hypertension •Liver CA •Anemia, coagulation problems •Skin manifestations CIRRHOSIS: •Destruction of liver parenchyma and replacement by scar tissue - Types •Laënnec's (alcoholic; portal) •Biliary •Cardiac •Postnecrotic •*Liver enlarges due to increased fat accumulation* •Inflammation and necrosis of cells - Yellow, orange, fatty, and scarred liver •Liver shrinks •Flow of blood is obstructed •*Portal hypertension* COMPLICATIONS: - *Portal hypertension* > *•Varices* •Impaired metabolism •Impaired clotting •*Inability to detoxify drugs and toxins, including ammonia* •Impaired bile formation and flow - S/S: - Early: •*Anorexia, dyspepsia, flatulence, nausea, vomiting, and changes in bowel patterns* •Related to altered metabolism - Late •*Jaundice* •*Skin lesions* •Hematological •Endocrine •*Encephalopathy* •*Ascites* - DIAGNOSTICS: •*Elevated liver enzymes* •*Elevated bilirubin* •*Elevated ammonia* •Coagulation studies •Plasma proteins - *CT of abdomen:* •Each type of hepatitis has its own specific antigen that can be tested for •Correlate physical symptoms with lab results •Liver biopsies generally not needed •Bleeding risk - SUPPORTIVE THERAPY: •Fluids •Prevent injury and bleeding •Treat hypoglycemia - Nutrition: •Well-balanced diet that patient can tolerate ↑calorie↓ fat •Small, frequent meals •*Carbonated beverages to stimulate appetite (ginger ale)* •Hydration with electrolytes •*Vitamin supplements (esp. B complex & vitamin K for clotting) - AGRESSIVE THERAPY: •*Liver transplant* - Extracorporeal liver assist •Experimental •Bridge to transplant or healing - PATIENT TEACHING: •REST •*Avoid alcohol intake* •*Avoid drugs detoxified or metabolized in the liver* •*Notify possible contacts (esp. sex partners)* •Healthcare workers: handwashing, PPE •*Handwashing very important for Hep A due to fecal-oral route* •Practice safe sex •*Side effects of interferon (flu-like symptoms - fever, malaise, fatigue, depression* •*No blood donation* ENCEPHALOPATHY: •*Cerebral toxicity from elevated ammonia levels -hypokalemia triggers ammonia genesis in kidneys* *•Asterixis (flapping hand tremors)* •Impaired motor ability •Loss of consciousness (LOC) from confusion to coma (close neuro assessment) - MANAGEMENT: •Limit protein intake to 20 to 40g/day •*Neomycin and lactulose* > •Reduce bacterial breakdown of protein in bowel •Restrict toxic medications, those metabolized • by liver •*Lactulose for increased ammonia levels*

Neuro Assessment

•History of illness/injury - received in report from •*Baseline assessment "very important"* > •LOC - change in LOC most important indicator of neurologic decline > •Observation of behavior, appearance & ability to communicate •Mental status - with decline orientation to time lost first - Language & Comprehension: •Dysarthria - weakness or lack of coordination of muscles of speech (slurred) •Is content of speech is appropriate? •Aphasia •Expressive dysphasia? •Receptive dysphasia? •Short-term memory - give list of 3 small items to recall at a later time during assessment •Long-term memory - typically remains intact - Cranial Nerves - Measurement Tools: •Full Outline of Unresponsiveness (FOUR) > •Eye response, motor response, breathing pattern, brainstem reflexes •Glasgow Coma Scale > •Eye opening - amount of stimulation needed for client to open eyes > •Speech - coherent, appropriate content > •Motor response - assessed in each extremity, best motor response GLASGLOW: - Developed to assess: •Level of neurologic injury •Assessment of movement, speech, & eye opening •Avoids need to make arbitrary distinctions between consciousness and different levels of coma - Quick neurologic assessment for: •Indication of prognosis •Ability of client to maintain patent airway - *GCS 13-15: MILD INJURY* - *GCS 9-12: MODERATE INJURY* - *GCS 3-8: SEVERE INJURY (suggests coma with need for intubation)* - How much change matters? GCS •Extent of change witnessed to trigger action •Provides for early identification and intervention > •May need RRT or transfer to specialty unit for changes noted •General guidance is: > •Depends on where the patient is showing change from and the extent of change •Generally considered significant when change results in: *•Total score reduces by 2 points, or* *•Motor response reduces by a single point* MOTOR FUNCTION ASSESSMENT: •Movement - evaluated for symmetry •Strength - all extremities (out of a 5-point scale, 5 best response) •Muscle tone - relaxed client, passively move limbs at joints feeling for resistance or rigidity •Coordination - indication of cerebellar function (alternating rapid movements) •Involuntary movements - tics, or tremors •Sensation - light touch, pain/temperature, and position/vibration SENSORY FUNCTION: •Sharp •Dull •Hot •Cold •Position sense *NEUROVASCULAR ASSESSMENT: 5 P'S* 1. Pain 2. Pulse 3. Pallor 4. Paresthesia (can u feel this) 5. Paralysis (can u move this) VITALS CHANGES: - Changes due to CNS dysfunction may occur with: •Brain stem injury, decreased cerebral perfusion, or interruption of nerve pathways •*Hypotension*: in terminal stages of brain stem dysfunction & with spinal cord injury loss of sympathetic tone •*HR & rhythm:* abnormalities are common - neurologic decline, clot formation, inadequate CO, or symptom of neurologic dysfunction > •Example: ST-segment abnormalities following subarachnoid hemorrhage •*Temperature: careful monitoring* > •Hyperthermia causes increased cerebral metabolic demand can be caused by injury to brain stem, hypothalamus, or spinal cord - •Cushing response refers to triad of VS changes *seen late in the course of neurologic deterioration* > • *Cushings: Widening pulse pressure, bradycardia, and an irregular respiratory pattern* RESP ASSESSMENT: •Cheyne - Stokes, hyperventilation, apneustic breathing, cluster breathing, ataxic (Biot) respiration - •Early recognition of changes provides alert to increased intracranial pressure - Done every hour

Pheochromocytoma

•Rare condition caused by a *tumor in the adrenal medulla.* •Results in *excess production of Catecholamines (epinephrine, norepinephrine)* •The most *dangerous serious affect of this disorder is severe hypertension.* CAUSES: *•Direct trauma* •*Mechanical pressure to the tumor* •Stress •Drugs including antihypertensives, opioids, contrast media and tricyclic antidepressants •Attacks can last a few minutes to several hours S/S: - Classic triad of symptoms: •*Severe pounding headache* •*Tachycardia* •*Profuse sweating* •Also associated: • abdominal pain • chest pain DIAGNOSTIC: •Simplest test is for *urinary catecholamine metabolites and 24 hours urine creatinine clearance.* •Values are increased in 95% of patients TREATMENT: •Treatment: •*Removal of the tumor* •*Alpha- and Beta-adrenergic receptor blockers to control BP before surgery.* •Monitor for and tachycardias and arrythmias •Case finding is the most important role for nurse as they can go undiagnosed or misdiagnosed. •*Do not palpate abdomen of suspected cases.* •Monitor for DM, and increased glucose •Provide rest, nourishing food and emotional support during attack and or post op period.

2

•The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse? 1. Serum blood glucose level of 74 mg/dL. 2. Pulse oximeter reading of 90%. 3. Telemetry reading showing sinus bradycardia. 4. The client is lethargic and sleeps all the time.

Triage/ Primary Survery

•Triage: •"To sort" •Process of rapidly determining patient acuity •Represents a critical assessment skill •Triage system: •Categorizes patients so most critical are treated first •Emergency Severity Index (ESI) • Levels 1-5 - Stability of vital functions (ABCs) - ESI-1: Unstable - ESI-2: Threatened - ESI-3: Stable - ESI-4: Stable - ESI-5: Stable Patients assigned to ESI-3 must have normal vital signs. Patients with abnormal vital signs may be reassigned to ESI-2 •Trauma patients: •Primary survey and secondary survey •Nontrauma patients: •Primary survey and focused assessment Primary Survey: ABCDEFG - The primary survey focuses on airway, breathing, circulation (ABC), disability, exposure, facilitation of adjuncts and family, and other resuscitation aids. - If uncontrolled external hemorrhage is noted, the usual ABC assessment format may be reprioritized to <C>ABC. The <C> stands for catastrophic hemorrhage. - If present, it must be controlled first.6 Apply direct pressure with a sterile dressing followed by a pressure dressing to any obvious bleeding sites. - *A: Airway & Alertness:* > Interventions: Determine level of consciousness (LOC) by assessing the patient's response to verbal and/or painful stimuli. A simple mnemonic to remember is AVPU: A = alert, V = responsive to voice, P = responsive to pain, and U = unresponsive. > Rapid-sequence intubation is the preferred procedure for securing an unprotected airway in the ED. Keep C collar on until spine injury ruled out. Jaw thrust manuever - *B: Breathing:* > Interventions: BVM ventilation with 100% O2, needle decompression, intubation, and treatment of the underlying cause. - *C: Circulation:* > Check carotid pulrse. Interventions: Insert 2 large-bore (14- to 16-gauge) IV catheters. Start aggressive fluid resuscitation using normal saline or lactated Ringer's solution. OR packed RBCs; O negative blood > *Research is showing resuscitation with blood, not fluids likely the new standard* - *D: Disability:* > Interventions: Glascow Coma Scale GCS and check pupils - *E: Exposure & Environmental Control:* > Interventions: Remove clothes, vitals, use warming blankets, overhead warmers, and warmed IV fluids to limit heat loss, prevent hypothermia, and maintain privacy. > ▪Trauma Triad of death :(Hypothermia, Metabolic Acidosis, Coagulopathy) - *F: Facilitate adjuncts and Family:* - *G: Get resuscitation adjuncts:* > Labs, ABGs, UA, pregnancy test, EKG, NG tube, O2 Secondary Survey: •*History/Head to toe:* > •SAMPLE •Symptoms •Allergies •Medication history •Past health history •Last meal/oral intake •Events or environmental factors leading to illness or injury - HEAD: •Disconjugate gaze: •Check the eyes for extraocular movements. A disconjugate gaze is an indication of neurologic damage. •Battle's sign: or bruising directly behind the ear(s), may indicate a fracture of the base of the posterior portion of the skull. •Raccoon eyes:or periorbital ecchymosis, is usually an indication of a fracture of the base of the frontal portion of the skull. •Ears - blood and CSF > •Ruptured tympanic membrane: indicator of blast trauma > •Check the ears for blood and cerebrospinal fluid. Do not block clear drainage from the ear or nose. - Inspect the posterior: •Logroll patient (maintain C-spine, inspect the posterior surfaces •Requires 3-4+ people •Ecchymosis, abrasions, puncture wounds, cuts, obvious deformities •Palpate entire spine •Rectal exam: Rectal tone is an important neuro indicator - *Transport to CT*

HHS

•What is HHS? Hyperosmolar Hyperglycemic State • An acute, life threatening metabolic *complication of DM type 2, characterized by a severe elevation of blood glucose > 600,hyperglycemic, hyperosmolar state, which leads to electrolyte and fluid losses (extreme dehydration)* •*Altered level of consciousness often seen as confusion or disorientation* •Develops insidiously, gradually, often seen in setting of physiologic stress, in those who are older and may have cardiac and/or renal compromise •*Infection is often a precipitating factor, or non-compliance with medications and diet* CAUSES: • *Alcohol & drug abuse* •*Pancreatitis* •GI hemorrhage or intracranial hemorrhage •Infections (UTI, PNA) •Poor fluid intake •Decreased thirst mechanism or decreased access to fluids •Occurs mostly in elderly with concurrent renal insufficiency, dialysis •CHF, MI, PE, Stroke, chronic lung disease •Drugs that impair glucose tolerance (steroids) or increase fluid loss (diuretics) •Medications - antiepileptics, antihypertensives, thiazides, antipsychotics, BB, CCB, corticosteroids, diuretics and chemotherapy drugs S/S: • Flushed dry skin •Dry mucous membranes •Decrease skin turgor •*Tachycardia* •*Hypotension* •*Dehydration* •*Electrolyte losses* •*Shallow Respirations* Altered CNS function with neurological symptoms: *LOC, *Babinski sign, absent deep tendon reflexes* *•Ketones are negative or minimal in both blood and urine* TREATMENT: • Similar for DKA •IV infusion 0.45% or 0.9% NaCl at a rate of 1L/hr to raise BP and restore urine output to 30 - 60ml/hr •When serum glucose approaches 250 mg/dL, dextrose 5% - 10% is added to prevent hypoglycemia - severe drop in glucose = cerebral edema •Too rapid administration of IV fluids; use of the incorrect types of IV fluids especially hypotonic solutions and correcting the blood glucose level too rapidly can lead to cerebral edema •Monitor VS and I & O, watch for fluid overload •*Short-duration insulin only = Regular insulin*

diabetes insipidus (DI)

*•A deficienc LOW AMOUNT y of antidiuretic hormone (ADH or vasopressin)* •Primary function of ADH is to retain H2O in the body & constrict blood vessels •Results in inability of the kidney to conserve water appropriately (fluid loss) - Characterized by: •*Excessive thirst* *•Excretion of large amounts of dilute urine (polyuria)* - *A stroke, head trauma, or surgery, radiation, CNS infections, or failure of renal tubules to reabsorb water* S/S: •Urine chemistry (dilute): *decreased urine specificity,* decreased urine osmolality, urine sodium normal •*Low urinary specific gravity (normal is 1.010 to 1.020)* •Serum Chemistry (concentrated): *hypernatremia*, increased serum osmolality •*Polyuria, polydipsia*: increased urine output of large amounts of dilute urine, clients may crave ice •*Dehydration (dry mucous membranes, poor skin turgor)* •*Weight loss* •Muscle weakness, fatigue, pain, headache •Inability to concentrate •Tachycardia *•Postural hypotension* that may progress to vascular collapse without rehydration •Hypovolemic Shock •Heme concentration •Normal blood glucose levels DIAGNOSTIC: •*Fluid deprivation test: daily weight, I & O, VS, urine osmolality* •MRI of hypothalamus and pituitary24 hour urine - Blood Work: (expected results) •Low Urine Osmolality <200 •Urine Specific gravity 1.005 •High Serum Osmolality >295 •Hypernatremia (serum) >145 •Elevated BUN •CT scan •Identification of Central DI requires water deprivation test TREATMENT: Treat underlying cause •Volume/fluid replacement •Hormone replacement: *DDAVP (desmopressin) synthetic vasopressin (lifetime replacement therapy)* •*Thiazide diuretics - if nephrogenic in origin* INTERVENTIONS: •*Weigh client daily* •Monitor strict I & O •*Monitor urine specific gravity (with treatment falls within normal range 1.010 - 1.025)* •Monitor VS and neurological and cardiovascular status •Monitor and maintain fluid and electrolyte balances •Maintain client intake of adequate fluids; IV hypotonic saline may be prescribed to replace urinary losses •*Admin DDAVP (Desmopressin Acetate for Diabetes Insipidus)* •Nursing Interventions cont.: •Desmopressin Acetate used to replace ADH if severe deficiency or chronic DI. •Take medications as prescribed (sc inj., IV, intranasal, or PO •*Must monitor for S/S of overtreatment = water intoxication* •*Assess response to DDAVP (wt. gain, headache, depression, restlessness, and hyponatremia)* •Get parameters for notifying MD - in hospital and at home •*Educate patient to drink to thirst and avoid excessive drinking* •Avoid diuretic action foods and drinks •Provide safe environment •Pt. should wear Medic Alert Bracelet

SIADH

*•Excessive release of ADH* *•Results in the kidneys inability to excrete appropriate amount of urine* •Results in increased intravascular volume (fluid retention) *•Water intoxication* •*Dilutional hyponatremia* •Decreased serum osmolality •Condition in which the posterior pituitary gland is hyper-functioning •Producing and releasing an excess of ADH that is not in response to the body's need for it •More common than diabetes insipidus CAUSES: •*Neoplastic Tumors* •*Head Injury* •Meningitis •Small cell Lung CA (major cause) •Hodgkin's Disease •Sarcoma •CA of prostate, pancreas, or duodenum •Lupus •Guillian-Barre •Several meds including: ACE inhibitors, Nicotine, Barbituates, NSAIDS •Trauma •Stroke •Stress S/S: •Urine chemistry (concentrated): *increased urine specific gravity*, increased urine osmolality •*Low urinary output* and concentrated urine •Serum Chemistry: *hyponatremia*, decreased serum osmolality *•Headache, irritable, lethargic* •*Changes is LOC and/or mental status = decreased neuro function* •May cause cerebral edema, *at risk for seizures* •Weakness •*Anorexia, nausea and vomiting* •Tachycardia •*Hypertension* •*Weight gain*, may be with or without edema •Signs of fluid volume overload DIAGNOSED: *•Blood (Na+ serum level <136mmol/l) & urine test* •Blood Work and vital signs: (expected results) •High urine osmolality > 100 •Increased urine specific gravity •Low serum osmolality <280 •Hyponatremia <135 •Decreased BUN TREATMENT: Treat underlying cause •Monitor fluid balance •*Use of loop diuretics (furosemide/Lasix)* *•Administer hypertonic sodium solutions* •*Vasopressin receptor agonist: Conivaptan* INTERVENTIONS: - Mild symptoms with serum Na+ > 125mEq/L- treatment may only be to *restrict oral fluids to 800-1000 mL/ day (or as prescribed)* •GI symptoms to include vomiting & abdominal cramping •Na+ 130- 140 mEq/L symptoms may include Impaired taste, anorexia, dyspnea with exertion, fatigue, dulled sensorium - Severe hyponatremia <120mEq/L especially with neurologic manifestations: confusion, lethargy, muscle twitching, convulsions •*IV hypertonic saline solution (3-5%) may be administered slowly and a loop diuretic may be used to promote diuresis (only if serum Na+ is at least 125mEq/L)* •*Fluid restriction may be reduced to 500mL/day* •*Monitor I & O, weight pt daily* •*Monitor for increased BP*, tachycardia, hypothermia •*Monitor mental status & changes in neuro status* •Seizure precautions, monitor for S/S of increased intracranial pressure •*Elevate the HOB a maximum of 10 degrees to promote venous return and decrease baroreceptor-induced ADH release* •Provide a safe environment, place on fall precautions

Seizures

- Abnormal electrical discharge in the brain: •Partial •Simple partial •Complex partial •Generalized seizures •May be caused by sudden withdrawal of anticonvulsant medications. •Other causes: ETOH withdrawal, sedatives, electrolyte imbalances, head trauma, brain tumor, and infection. - Status Epilepticus •A life-threatening condition characterized by: •Seizures in close proximity to each other •Seizures without full recovery of consciousness between them •Lasting longer than 30 minutes •Two or more without full recovery •May result in brain damage or death. •Occurs most commonly with tonic-clonic type seizures MANAGEMENT: •Seizure precautions •Maintain airway and ventilation •Monitor SpO2 •Neurological assessment •Characteristics of seizure activity •Cardiac monitoring •Hypoglycemic management •Safety precautions MEDS: - Benzodiazepines: •*Diazepam* rectal (gel) suppository used outside of acute care for an emergency •Diazepam IVP or IM 2 - 10 mg every 3-4 hours PRN •*Lorazepam IVP (med of choice acute care settings)* - Anticonvulsants: •*Dilantin/phenytoin, administer slowly, no faster than 50mg/min.* •Do not mix with glucose, administer with NS 0.9% & monitor for bradycardia and/or heart block •Cerebyx IV infusion •Phenobarbital, depresses CNS, occasional use as sedative.

Cranial Nerves

- CN 1 - Smell (Olfactory) - *CN 2 II (Optic) & 3 III (Oculomotor)* •Shine light into one eye & observe the pupil of the other eye - should constrict/dilate similarly •Certain medications can affect pupil size/reactivity •*Narcotics = constriction* •Neuromuscular blocking agents do not affect pupillary response •Pupil changes often seen late in course of neurologic decline as increased ICP leads to compression or stretching of CN III - CN 3 III (Oculomotor) , 4 IV (Trochlear), & 6 (Abudcens) IV - Client asked to follow moving object with use of eyes only - 6 positions •Normal response: both eyes moving in same direction, at same speed, in constant alignment •*Abnormal response: nystagmus (jerking/rhythmic movement of one or both eyes)* •extraocular palsy (inhibited eye movement in certain direction in one or both eyes) •*Dysconjugate gaze: abnormal as eyes are not aligned* - *Unconscious client - oculocephalic reflex (doll's eyes) NOT assessed with suspected C-spine injury* •Eyelids held open, clients head quickly rotated to side •If eyes deviate in opposite direction from which head is turned, pons is intact •If eyes do not move or movement is asymmetric, indicative of pontine dysfunction - *Also used to determine brain stem function (cold calorics test)* •Bolus of cold water (iced water) instilled into ear canal •Intact brain stem function = conjugate deviation of eyes toward the irrigated ear occurs •Interrupted brain stem function = no response or dysconjugate eye movement - CN 5 V (Trigeminal) & CN 7 VII (Facial) •Corneal reflex evaluates both CN V & CN VII •Does the client blink with rapid movement of object toward the face/eye, or a drop of sterile saline in the eye •*Movement - smile, puff out cheeks with air, raise eyebrows* •Sensation - facial sensation forehead, cheek and mandible •Clients with CN VII dysfunction are unable to close the eyelid on affected side •Lubricating ointment/drops or taping eyelids closed - CN 9 IX (Glossopharyngeal) & CN 10 X (Vagus) •*Ability to swallow & gag reflex* •Ask client to open mouth and stick out tongue •Observe soft palate for B/L elevation, if does not elevate symmetrically, lightly touch back of throat with tongue blade and observe response (test both sides) •Unconscious client stimulate back of the throat with suction catheter or tongue blade to elicit gag response •Forward thrust of tongue indicates intact gag reflex •Cough reflex controlled by CN IX & X •Spontaneous cough or cough in response to suctioning - CN 11 (Accessory) - CN 12 (Hypoglossal)

acute pancreatitis

- Etiology •*Alcoholism* •*Biliary tract disease, obstruction gall stones* •Medications •Trauma •Idiopathic •Abdominal surgery •Hyperlipidemia - Inflammation of pancreas: •Mild to severe •Mild pancreatitis - swollen pancreas, causes mild pain •*Severe pancreatitis spilling of enzymes into surrounding tissue causes autodigestion, severe pain, and sepsis* •Severe can lead to necrosis and hemorrhage •Severe has high mortality rate •Impaired exocrine and endocrine function S/S: •*Severe pain in left upper quadrant or mid-epigastric* • Boring pain that may radiate to back - lumbar area • Sudden onset of pain, deep piercing, steady pain that is not relieved by vomiting •*Nausea & vomiting, decreased or absent bowel sounds* •*Abdominal distension, rigid abdomen, no rebound tenderness* •*Ascites and jaundice* •*Low grade fever, flushing* •Leukocytosis •*Hypotension, tachycardia (think shock)* •Hypovolemic or hemorrhagic HR↑ BP↓ *Administer Plasma or plasma volume expanders (Dextran or albumin* HEMORRHAIC PANCREATITIS S/S: •*Grey Turner's sign - bluish discoloration of flanks* = hemorrhagic pancreatitis - Retroperitoneal hemorrhage: *•Turner's sign (flank)* •*Cullen's sign - bluish discoloration and ecchymosis of periumbilical area (around umbilicus)* COMPLICATIONS: - *Pseudocyst:* •*Fluid, enzyme, debris and exudates surrounded by wall* •Abdominal pain, palpable mass, nausea/vomiting, anorexia •Resolves spontaneously or may perforate and cause peritonitis - *Pancreatic Abscess:* •*Infected pseudocyst, may rupture or perforate* •Upper abdominal pain, mass, high fever, leukocytosis •*Will require prompt surgical drainage* - *Systemic complications:* •Renal failure •*Hypotension* •Thrombi, PE, DIC •*Hypocalcemia: Tetany •Chvosteks (cheek stroke) spasm of lip and cheek* *•Trousseaus (BP cuff twitching fingers)* - *PULMONARY:* •Dyspnea •Left diaphragm lifted •*Atelectasis, left lower lobe* •*PNA* •Left pleural effusion •*Crackles in lungs (irritation)* •Acute respiratory distress syndrome •*Phospholipase A released which kills Type II alveolar cells, leads to decreased surfactant = ARDS* LABS: - *Elevated:* •*Serum amylase peaks in 4-24 hrs. returns to normal in 4 days* •*Serum lipase stays elevated longer than amylase* •WBCs •Glucose •Liver function tests •Bilirubin •Triglycerides - *Decreased:* •*Calcium -Trousseau's sign inflation of BP cuff occludes brachial artery, absence of blood flow + hypocalcemia and subsequent neuromuscular irritability induces spasm of the muscle of hand and forearm* > •*Prolonged QT, seizures* •Albumin •Protein •Potassium DIAGNOSTICS: •*Computed tomography (CT) of abdomen* > *•Contrast enhanced (CECT)* •Magnetic resonance imaging (MRI) •Abdominal Ultrasound •X-rays of abdomen and chest •Upper gastrointestinal (UGI) •IV cholangiogram •Endoscopic retrograde cholangiopancreatography (ERCP) •Angiography TREATMENT-FLUIDS: - *Volume/Fluid replacement:* •*Lactated Ringer's (LR)* •*Colloids* •*Fresh frozen plasma (FFP)* •Packed red blood cells (RBCs) (hemorrhagic type) - Monitor volume status: •Pulmonary Artery (PA) catheter •Intake and output •Daily weights •*Vasopressors may be indicated - *Surgical decompression of abdominal compartment syndrome (ACS)* REST: - Decrease pancreatic secretions •*NPO* controversial but still the standard •Mild cases oral intake is safe and may even accelerate healing •*Gastric suctioning via NG tube* - Issues related to early enteral versus parenteral nutrition: •Enteral feeding below duodenum •*Once able, small frequent meals, no alcohol* •Supplemental fat-soluble vitamins - *H2 blockers or PPI's to decrease gastric secretions* - *Ranson's criteria is one way to predict* mortality. MANAGEMENT: •Opiates, antispasmodic agents •PCA if able to use •*Morphine may be acceptable as long as pancreatitis is not caused by gallbladder disease* •NG tube may help relieve pain •Position patient for comfort, frequent position changes •*Knees drawn to abdomen* *•Side-lying with HOAB elevated 45 degrees* - Patient Teaching: •*↓ Fat ↑ Carb diet* •S/S of infection •*May develop diabetes* •*Chronic pancreatitis give pancreatic enzymes with each meal/snack*

ICP

- Intracranial pressure (ICP) is the hydrostatic force measured in the brain CSF compartment. - Under normal conditions in which intracranial volume stays relatively constant, the balance among the 3 components (brain tissue, blood, CSF) maintains ICP. - *Normal ICP ranges from 5 to 15 mm Hg.* - A sustained pressure greater than 20 mm Hg is considered abnormal and must be treated - Increased Brain Volume •*Common cause: cerebral edema* > •Cytotoxic >> •Intracellular swelling of neurons; fluid shift extracellular to intracellular >> •Hypoxia/hypo-osmolality > •Vasogenic (most common) >> •Increased capillary permeability >> •Tumors/meningitis - Increased Blood Volume •Loss of autoregulation > •Autoregulation only effective if MAP 70 to 150 mm Hg •Decreased oxygenation •Hypercapnia •Increased metabolic demands •Obstruction of venous outflow - Increased Cerebrospinal Fluid > •Hydrocephalus •Blockage of normal flow •Obstruction of normal reabsorption •Excess production of CSF fluid •Treat with ventriculostomy or shunt COMPLICATIONS: - Inadequate cerebral perfusion •CO2, O2, Hydrogen ion concentration affect cerebral blood vessel tone - *Stages of increased ICP:* •Stage 1: Total compensation •Stage 2: Decreased compensation > •Risk for increased ICP •Stage 3: Failing compensation; clinical manifestations of increased ICP (Cushing's Triad) •Stage 4: Herniation imminent = death - Cerebral herniation: •Tentorial herniation •Uncal herniation •Cingulate herniation CLINICAL MANIFESTATIONS: - Can take may forms depending on the cause, location, and rate of increase in ICP. •Change in LOC most sensitive & reliable indicator of pt's neurological status. > •Restlessness, irritability, and confusion. > •Changes in vital signs. > •GCS < 8 (need to intubate) > *Cushing's triad (systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, irregular respirations - Cheynes Stokes)* - With continued increase in ICP •Speech, voluntary movements, sensations and extraocular movements will slow •*T wave elevation on EKG as ICP increases* •Ocular signs, compression CN III/Oculomotor = dilation of the pupil on the same side (ipsilateral) as the mass lesion. Sluggish response to light, inability to move eye upward or to adduct, and ptosis of eyelid. Assess corneal reflex. *Headache* •*Vomiting (not preceded by nausea) projectile* as pressure increases near medulla •Pt. may only speak when stimulated, have no voluntary movements, and respond only to painful stimuli •Cardiac arrhythmias range from SVT to severe bradycardia. •Coma, reaction to painful stimuli reflexive or absent •Herniation of brain imminent = loss of EOM, pupils dilating/unreactive and turning outward. DIAGNOSTICS: - Blood/Urine •ABGs •CBC •Coagulation profile •Electrolytes •Serum osmolality •Urinalysis and osmolality •*NO LUMBAR PUNCTURE* - Radiographic/Other •Computed tomography *(CT)* of the head •Magnetic resonance imaging *(MRI)* •Cerebral blood flow with transcranial Doppler (Infrascanner) •Evoked potentials •EEG •Cerebral Angiography ICP MONITORING: •Normal ICP 5 - 15 mm Hg •Elevated if > 20 mm Hg = must treat - Cerebral Perfusion Pressure (CPP) •*CPP = MAP - ICP* •*Normal is 60 - 100 mm Hg* •< 50 mm Hg is associated with ischemia and neuronal death - Indications: •GCS score 3 to 8 (need to intubate) - Purpose: •Assess response to therapy •Augment neurological assessment - *Transducer system:* •Fluid-filled (most used) > •Normal saline with no preservatives > •No pressurized flush system •Microchip •*Fiberoptic catheter:* The sensor tip is placed within the ventricle or the brain tissue and gives a direct measurement of brain pressure. - Monitor I's & O's - Monitor fluid intake, serum Na & glucose - *The gold standard for monitoring ICP is the ventriculostomy*, in which a specialized catheter is inserted into the lateral ventricle and coupled to an external transducer. It is important to ensure that the transducer is level with the foramen of Monro (interventricular foramen). *A reference point for this foramen is the tragus of the ear.* > can drain CSF > complications: infection •Waveform should be recorded > •Normal, elevated, and plateau waves Inaccurate readings can be caused by: •CSF leaks •Obstruction in catheter/kinks in tubing •Differences in height of bolt/transducer •Incorrect height of drainage system •Bubbles/air in tubing MANAGEMENT: - POSITIONING: •*HOB elevation 30 degrees (30 - 45)* •Neutral head/neck position avoid extreme neck flexion •Turn side to side, slowly > •Watch for return to baseline CPP •Intubation/mechanical ventilation •Positive end-expiratory pressure (PEEP) - use with caution - Suctioning: •Only when necessary & preoxygenate •Limit suction to 10 seconds •*Avoid coughing, straining, Valsalva Maneuvers* •*Avoid hip flexion* •Continuous ICP Monitoring •Quite, nonstimulating environment, avoid noxious stimuli •Maintain PaO2 > 100% •Maintain normal body temperature •*Avoid overhydration* •*Avoid clustering of treatments* •Avoid hyperventilation •Minimize abdominal distention •Monitor ABG's •Monitor electrolytes daily •*Monitor for DI or SIADH* - Blood Pressure: •Goal: MAP 70-90 mm Hg •*CPP: at least 70 mm Hg* •*CPP that is low = brain hypoxia* •<50 mm Hg associated with ischemia & neuronal death •MAP - ICP = CPP •Avoid hypertension > •Increases cerebral blood volume >> •*Nicardipine IV infusion as a treatment* •Avoid hypotension > •Ischemia > •Vasopressors - Metabolic Demands •Temperature control (antipyretic) > •Induced hypothermia >> •Goal: 34o - 35o C - Sedation: •Benzodiazepines •Propofol •Precedex •Analgesia •Seizure prophylaxis •Neuromuscular blockade - Diuretics: •Osmotic diuretics > •Reduce brain tissue volume >> •*Mannitol* >> *•Hypertonic saline* •Loop diuretics > •Reduce brain tissue volume > •Decrease CSF formation - Fluid Administration: •*Hypertonic saline solutions decrease brain fluid/water and ICP while temporarily increasing systolic blood pressure and cardiac output* •Strict intake/output •Goal: serum osmolality less than 320 mOsm/L. •Colloids or blood products used to restore volume DRUG THERAPY: •*Mannitol (Osmitrol 25%) osmotic diuretic IV. (have pharmacy verify dose)* •*Hypertonic saline solution* - massive movement of water out of edematous brain cells into blood vessels. > *•Monitor BP and Na+ levels closely* •Corticosteroids (dexamethasone), may cause hyperglycemia, increased incidence of infection and GI bleeding. > •Check BS every 6 hours. •Antacid, histamine (H2) receptor blocker (cimetidine, ranitidine), or proton pump inhibitor (propazole) •Fever, agitation, shivering, pain, and seizures can increase ICP = treat PRN - POSTURING: - Decrease in motor function: •Hemiparesis/hemiplegia •*Decerebrate posturing (extensor)* > *•Indicates more serious damage*, dysfunction in brainstem > •Mid-brain, pons injury •*Decorticate posturing (flexor)* > •Damage in cerebral hemispheres, thalamus NUTRITIONAL THERAPY: •Hypermetabolic & hypercatabolic state increases need for glucose •Enteral or parenteral nutrition •*Early feeding within 3 days of injury* •Goal is to keep patient normovolemic •*IV 0.9% NaCl preferred over D5W or 0.45% NaCl*

STROKE

- Related to location of stroke •Neural tissue destruction = neurologic dysfunction •Can affect many body functions > •Related to artery involved and area/half of brain it supplies *•Time of the onset of symptoms /length of period of ischemia is important* *•BE FAST (balance, eyes, face, arms, speech, TIME)* STOKE MANIFESTATIONS R/T ARTERY INVOLVEMENT: - *Anterior cerebral artery:* •Motor and/or sensory deficit (contralateral), suckin or rooting reflex, rigidity, gait problems, loss of proprioception and fine touch. - *Middle cerebral artery:* •Dominant side - Aphasia, motor and sensory deficit, hemianopsis. •Nondominant side - neglect, motor and sensory deficit, hemianopsia - *Posterior cerebral artery:* - Hemianopsia, visual hallucination, spontaneous pain, motor deficit - *Vertebral artery* - Cranial nerve deficits, diplopia, dizziness, nausea, vomiting, dysarthria, dysphagia, and or/coma CLINICAL MANIFESTATIONS: - COMMUNICATION: •*Dysphasia refers to impaired ability to communicate* > •Used interchangeably with aphasia - Nonfluent •Minimal speech activity with slow speech - Fluent •Speech is present but contains little meaningful communication - Many patients experience dysarthria •Disturbance in muscular control of speech - Impairments may involve •Pronunciation •Articulation •Phonation - *Aphasia occurs when stroke damages dominant hemisphere of brain and affects language* •Receptive - loss of comprehension •Expressive - loss of production of language •Global - total inability to communicate - MOTOR: - May include impairment of: •Mobility •Respiratory function •Swallowing and speech •Gag reflex •Self-care abilities - Initial period of flaccidity •Can last from days to weeks, related to nerve damage •Spasticity of muscles follows flaccid stage. - Characteristic motor deficits •*Loss of skilled voluntary movement* > *Akinesia* •Impairment of integration of movements •Alterations in muscle tone •Alterations in reflexes •Changes from hyporeflexia to hyperreflexia - AFFECT: •*May have difficulty controlling emotions.* - Emotional responses may be exaggerated or unpredictable •Magnified by: •Depression •Changes in body image •Loss of function - •Spatial-Perceptual Alterations - *Stroke (right side) of brain is more likely to cause problems in spatial-perceptual orientation* •Incorrect perception of self and illness •Unilateral neglect of affected side •Homonymous hemianopsia •Agnosia •Apraxia - ELIMINATION: •Most problems with urinary and bowel elimination occur initially and may be temporary •When a stroke affects one hemisphere of brain, prognosis for normal bladder function is excellent DIAGNOSTIC STUDIES: •*MRI or non-contrast CT scan* •Indicate size and location of lesion •*Differentiate between ischemic and hemorrhagic stroke* *NIH STROKE SCALE* ACUTE STROKE: •Ischemia to part of the brain. •Hemorrhage into brain that results in death of brain cells. - Also known as: •Brain attack/Cerebrovascular accident •Fifth most common cause of death in US. •Leading cause of serious, long-term disability (approx. 800,000 per year). - Ischemic Stroke: Inadequate blood flow from partial or complete occlusion of an artery MANAGEMENT: - Hemorrhagic Stroke •Goal: MAP < 130 mm Hg •Glycemic management - Diagnostic exams: •CT evaluation •Laboratory tests - Medications: *•IV antihypertensives* •Manage ICP > *•Osmotic diuretics* - •Ischemic Stroke •Goal: BP < 220 mm Hg; diastolic < 120 mm Hg •Glycemic management •Diagnostic exams •CT evaluation •Laboratory tests •Medications •r*T-PA*

AUTONOMINC DYSREFLEXIA

- Return of reflexes after resolution of spinal shock - clients with injury T6 or higher are at risk of developing AD •Massive, uncompensated cardiovascular reaction mediated by the SNS •Stimulation of sensory receptors below level of SCI •Intact SNS below level of injury responds to stimulation with reflex arteriolar vasoconstriction that increases BP •PNS unable to directly counteract responses via injured spinal cord > •*Intense sympathetic response to stimuli such as:* >> *•Kinked urinary catheter - distended bladder* >> *•Fecal impaction - distended rectum* •Severe hypertension, throbbing headache, diaphoresis above level of injury, and bradycardia (30 - 40 bpm) •Piloerection, flushing of skin above level of injury, blurred vision or spots in visual fields, nasal congestion •Assess and remove the cause! •*If symptoms persist once cause is removed consider rapid-onset & short-duration agent (nitroglycerine, nitroprusside, or hydralazine)* - Medical Emergency: •Can result in stroke, seizures, or other complications. •*Occurs with injury at T6 or above, after spinal shock has resolved.* •Characterized by exaggerated response of the SNS - *Triggered by a variety of stimuli:* •*Bladder* - kinked indwelling catheter, infection, calculi, cystoscopy •*Bowel* - fecal impaction, rectal examination, insertion of suppository •*Skin* - tight clothing, irritation from bed linens, temperature extremes - Common S/S •*Sudden, sever, pounding H/A* •*Elevated, uncontrolled BP8 •*Bradycardia* •*Nasal congestion* •*Blurred vision* •Profuse diaphoresis above the level of injury •*Flushing above the level of injury* •*Pallor, chills, and pilomotor erection below the level of injury* •Anxiety - Treatment •Elevate the head of the bed = *high-fowlers* •Find and remove the cause of stimulation •Remain calm & supportive, avoid increasing symptoms •If symptoms persist, give vasodilator's to decrease BP •Teach patient to recognize and report symptoms

A

1. A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that a. itching is a common problem with jaundice in this phase. b. the patient is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase.

A

1. After a hypophysectomy for acromegaly, immediate postoperative nursing care should focus on a. frequent monitoring of serum and urine osmolarity. b. parenteral administration of a GH-receptor antagonist. c. keeping the patient in a recumbent position at all times. d. patient teaching about the need for lifelong hormone therapy.

a

1. An older man arrives in triage disoriented and dyspneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to a. assess his vital signs. b. obtain a brief medical history from his wife. c. start supplemental O2 and have the provider see him. d. determine the kind of insurance he has before treating him.

A

1. During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8

A

1. The most appropriate therapy for a patient with acute diarrhea caused by a viral infection is to a. increase fluid intake. b. administer an antibiotic. c. administer an antimotility drug. d. quarantine the patient to prevent spread of the virus

B

1. Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter. b. altering the endothelial lining of cerebral capillaries. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component.

B

1. Which patient has the highest risk for a having a stroke? a. An obese 45-yr-old Native American. b. A 65-yr-old black man with hypertension c. A 35-yr-old Asian American woman who smokes. d. A 32-yr-old white woman taking oral contraceptives.

C

10. A patient is recovering from second- and third-degree burns over 30% of his body, and the burn care team is planning for discharge. The first action the nurse should take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. teach the patient and the caregiver proper wound care to be performed at home. c. review the patient's current health care status and readiness for discharge to home. d. give the patient written information and websites for information for burn survivors.

B

10. Several patients come to the urgent care center with nausea, vomiting, and diarrhea that began 2 hours ago while attending a large family reunion potluck dinner. You ask the patients specifically about foods they ingested containing a. beef. b. meat and milk. c. poultry and eggs. d. home-preserved vegetables

A

10. The nurse determines that the goals of dietary teaching have been met when the patient with celiac disease selects from the menu a. scrambled eggs and sausage. b. buckwheat pancakes with syrup. c. oatmeal, skim milk, and orange juice. d. yogurt, strawberries, and rye toast with butter.

D

11. What should a patient be taught after a hemorrhoidectomy? a. Take mineral oil before bedtime. b. Eat a low-fiber diet to rest the colon. c. Use oil-retention enemas to empty the colon. d. Take prescribed pain medications before a bowel movement.

ALL

2. A 35-yr-old female patient is admitted to the emergency department with acute abdominal pain. Which medical diagnoses should you consider as possible causes of her pain? (select all that apply) a. Gastroenteritis b. Ectopic pregnancy c. Gastrointestinal bleeding d. Irritable bowel syndrome e. Inflammatory bowel diseas

b

2. A patient has a core temperature of 90°F (32.2°C). The most appropriate rewarming technique would be a. passive rewarming with warm blankets. b. active internal rewarming using warmed IV fluids. c. passive rewarming using air-filled warming blankets. d. active external rewarming by submersing in a warm bath.

B

2. A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction

C

2. A patient with a head injury develops SIADH. Manifestations the nurse would expect to find include a. hypernatremia and edema. b. muscle spasticity and hypertension. c. low urine output and hyponatremia. d. weight gain and decreased glomerular filtration rate.

B

3. A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position

A E

3. Assessment findings suggestive of peritonitis include (select all that apply) a. rebound tenderness. b. a soft, distended abdomen. c. dull, intermittent abdominal pain. d. shallow respirations with bradypnea. e. observing that the patient is lying still.

D

3. Information provided by the patient that would help distinguish a hemorrhagic stroke from a thrombotic stroke includes a. sensory changes. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

C

3. The nurse teaching young adults about behaviors that put them at risk for oral cancer includes a. discouraging use of chewing gum. b. avoiding use of perfumed lip gloss. c. avoiding use of smokeless tobacco. d. discouraging drinking of carbonated beverages.

C

4. A patient is having word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

D

4. After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops a. muscle weakness and weight loss. b. hyperthermia and severe tachycardia. c. hypertension and difficulty swallowing. d. laryngospasms and tingling in the hands and feet.

A

4. Which statement by the patient with type 2 diabetes is accurate? a. "I will limit my alcohol intake to 1 drink each day." b. "I am not allowed to eat any sweets because of my diabetes." c. "I cannot exercise because I take a blood glucose-lowering medication." d. "The amount of fat in my diet is not important. Only carbohydrates raise my blood sugar."

A D E

5. You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital? (select all that apply) a. Insulin administration b. Elimination of sugar from diet c. Need to reduce physical activity d. Use of a portable blood glucose monitor e. Hypoglycemia prevention, symptoms, and treatment

C

6. An important preoperative nursing intervention before an adrenalectomy for hyperaldosteronism is to a. monitor blood glucose levels. b. restrict fluid and sodium intake. c. administer potassium-sparing diuretics. d. advise the patient to make postural changes slowly.

B

7. A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day.

D

9. A nursing intervention that is most appropriate to decrease postoperative edema and pain after an inguinal herniorrhaphy is to a. apply a truss to the hernia site. b. allow the patient to stand to void. c. support the incision during coughing. d. apply a scrotal support with an ice bag

B

9. A nursing measure that can reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. maintaining strict bed rest with the head of the bed slightly elevated. d. keeping the room dark and quiet to minimize environmental stimulation.

A

9. A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments. b. repositioning the patient every 2 hours. c. performing active ROM at least every 4 hours. d. massaging the new tissue with water-based moisturizers.

A C E

9. Common psychosocial problems a patient may have post stroke include (select all that apply) a. depression. b. disassociation. c. sleep problems. d. intellectualization e. denial of severity of stroke.

SPINAL CORD INJURY

CAUSES: •Motor vehicle crashes (MVCs) •Falls •Gunshot wound to spine •Sports injuries •Diving accidents •Medications that affect ANS SPINAL SHOCK: •Complete loss below level of injury - Absence of all voluntary & reflex neurologic activity below level of injury •Motor •Sensory •Reflex activity •Transient condition NEUROGENIC SHOCK: •Disruption of autonomic pathways •*Temporary disruption of autonomic pathways below level of injury* •Hemodynamic condition that can occur within *30 minutes of a spinal cord injury & last up to six weeks* •*Usually associated with cervical or high thoracic injuries (maintain cervical collar)* •Can also occur with certain medications (opioids, benzodiazepines). - Characterized by: •Hypotension - massive vasodilation •Bradycardia - unopposed parasympathetic stimulation •Hypothermia - inability to regulate body temperature •Massive vasodilation due to loss of SNS vasoconstrictor tone = pooling of blood in blood vessels, tissue hypoperfusion, & impaired cellular metabolism NEUROGENIC SHOCK: ASSESSMENT: •Warm/dry extremities *initially* •In time skin may be cool or warm (ambient temperature) •As heat disappears, at risk for hypothermia •Change in patient's vital signs = *hypotension* *•Bradycardia*- due to vasodilation and because the parasympathetic nervous system is unopposed •*Distended abdomen* •Signs of DVT due to pooling of blood - DIAGNOSTIC STUDIES: •Physical examination, CT, MRI, lab diagnostics - COMPLICATIONS: •*Hypotension (provide IV fluid NS 0.9%)* •Bradycardia •Respiratory Arrest •Death - *TREATMENT:* •Atropine (bradycardia) •Fluids (support BP/MAP) •Vasopressors (dopamine, epinephrine or norepinephrine/levophed may be needed SCI LESIONS: - Complete: > Paraplegia > Tetraplegia - Incomplete: •Anterior cord syndrome •Central cord syndrome •Brown-Séquard syndrome SCI ASSESSMENT: - Impact on Breathing: Cervical Injuries: •*C1 to C3: ventilator dependent* •C4 to C5: may or may not need ventilator •Below C5: have intact diaphragmatic breathing - Level: Above C3 •*Diaphragm does not work at all* •Cannot sneeze or cough •Mechanical ventilation maintains breathing for pt. • - Level: C4 - C5 •Partial function of diaphragm •Intercostal & abdominal muscles do not work at all •Cannot cough or sneeze well •Some may need mechanical ventilator (C4), or may need ventilator at certain times of the day (sleep or rest times) • - Level C 6 - C8) •*Diaphragm works well* •*Intercostal and abdominal muscles do not work at all* •Level T1 - T5 •Diaphragm works well •Intercostal muscles work but not well •*Abdominal muscles do not work* •Ability to cough & sneeze is present but weak • •Level T6 - T12 •Diaphragm and intercostal muscles work well •Abdominal muscle work but are weak •*Ability to cough & sneeze is present but remains weaker than before the injury* • •Level L1 - L5, S1 - S4 •*All breathing muscles work well* •*Ability to cough & sneeze is normal* MANAGEMENT: - Spinal cord stabilization •Halo vest to immobilize cervical spine •Surgical intervention (plates, rods, bone grafts) - Medications •Glucocorticoids - high dose •Vasopressors/fluids •Proton pump inhibitors •IV fluids SECONDARY INJURY: - The fall in spinal cord blood flow (SCBF) associated with the primary injury leads to ischemia of the cord that triggers a biochemical cascade promoting a secondary injury and eventual infarction of the spinal cord and permanent loss of function. SENSORY DERMATOMES: ØDermatome is the area of skin innervated by the sensory fibers of a single dorsal root of a spinal nerve. ØTransmit sensory details from a particular area of skin back to the brain. ØCan be helpful in evaluating and diagnosing conditions affecting the spine or nerve roots.

Answer: d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of a.Blood loss from injured tissue. b.Third spacing of fluid into fluid-filled vesicles. c.Evaporation of fluid from denuded body surfaces. d.Capillary permeability with fluid shift to the interstitium.

HYPO AND HYPER THYROID

HYPOTHYROID: •T4 is low •*TSH is elevated* •Administer thyroid replacement: *levothyroxine sodium/Synthroid (most commonly prescribed) daily on an empty stomach, one hour prior to eating breakfast = provide patient education* •Provide education on importance of taking medication on a regular basis and *not to stop taking this medication without consulting prescribing physician* •Monitor for *overdose/over medication (tachycardia, chest pain, restlessness, nervousness, and insomnia)* •Teach patient to report theses symptoms to PCP immediately •Regularly monitor TSH levels to determine effectiveness and maintain therapeutic dosage, provide patient education as to these requirements as well HYPERTHYROID: •T3 and T4 usually elevated •*TSH is low* •Provide adequate rest in the form of a *quiet and cool environment* •Administer *antithyroid medications as prescribed: methimazole or propylthiouracil (block thyroid synthesis)* •Patient experiencing *exophthalmos, low salt diet, administer artificial tears, use of dark glasses, tape eyelids closed when sleeping*

A

Hepatic encephalopathy is caused by an increase in: A.Ammonia B.Calcium C.Potassium D.Sodium

burns continued

PRE HOSPITAL CARE: - Electrical injuries: •Remove patient from contact with source - Chemical injuries: •Brush solid particles off skin •Use water lavage - Small thermal burns •*Cover with clean, cool, tap water—dampened towel* - Large thermal burns •*Circulation, airway, breathing* *•Cool burns for no more than 10 minutes* •Do not immerse in cool water or pack with ice •Remove burned clothing •Wrap in clean, dry sheet or blanket - Inhalation injury •*Watch for signs of respiratory distress* •Treat quickly and efficiently •100% humidified oxygen if CO poisoning is suspected PHASES OF BURN MANAGEMENT: •Emergent (resuscitative) •Acute (wound healing) •Rehabilitative (restorative) EMERGENT PHASE: - Emergent (resuscitative) phase is time required to resolve immediate problems resulting from injury •Up to 72 hours •Primary concerns > •*Hypovolemic shock* > •Edema • Burn shock, a type of hypovolemic shock, rapidly ensues and, if not corrected, can result in death. -Normal insensible loss: 30 to 50 mL/hr -Severely burned patient: 200 to 400 mL/hr •↓ Blood pressure •↑ Pulse - CLINICAL MANIFESTATIONS: •*Shock from hypovolemia* •Blisters •Paralytic ileus •*Shivering* •*Altered mental status* - COMPLICATIONS: •Dysrhythmias and hypovolemic shock •Impaired circulation to extremities, VTE •Tissue ischemia •Paresthesias •Necrosis •Pneumonia •Pulmonary edema •↓ Blood flow to kidneys causes renal ischemia •Acute tubular necrosis (ATN) - INTERVENTIONS: •Airway management •*Early endotracheal intubation* •Escharotomies of the chest wall •Fiberoptic bronchoscopy •Humidified air and 100% oxygen •Fluid therapy: •*Two large-bore IV lines for >15% TBSA* •Type of fluid replacement based on size/depth of burn, age, and individual considerations *•Parkland (Baxter) formula for fluid replacement* *Colloidal solutions (e.g., albumin) may be given.* However, administration is recommended after the first 12 to 24 hours post burn, when capillary permeability returns to normal or near normal. •Wound care: •Cleansing > •Can be done on a shower cart, in a shower, or on a bed, once daily; dressing change morning and night •Debridement > •May need to be done in the OR > •Loose necrotic skin is removed •Infection is most serious threat to further tissue injury > *•Source of infection is patient's own flora* •Preventing cross-contamination is a priority •Ears should be kept free of pressure > •No use of pillows - DRUG THERAPY: •Analgesics and sedatives •Morphine •Hydromorphone (Dilaudid) •Haloperidol (Haldol) •Lorazepam (Ativan) •Midazolam •*Tetanus immunization* > •Given routinely to all burn patients •Antimicrobial agents: - Topical agents •*Silver sulfadiazine* •Mafenide acetate •Systemic agents are not usually used in controlling burn flora •Initiated when diagnosis of invasive burn wound sepsis is made •VTE prophylaxis: •*Low-molecular-weight heparin or low-dose unfractionated heparin is started* •Those with high bleeding risk, VTE prophylaxis with sequential compression devices, or compression stockings recommended ACUTE PHASE: •Begins with mobilization of extracellular fluid and subsequent diuresis •Concludes when: •Partial thickness wounds are healed and/or •Full thickness burns are covered by skin grafts - CLINICAL MANIFESTATIONS: •*Partial-thickness wounds form eschar* > •Once eschar is removed, reepithelialization begins •*Full-thickness wounds require debridement* - COMPLICATIONS: •Musculoskeletal system •Decreased ROM •Contractures •Gastrointestinal system •Paralytic ileus •Diarrhea •Constipation •Curling's ulcer: •generalized stress response due to decreased blood flow to the GI tract. •Endocrine system •↑ Blood glucose levels •↑ Insulin production •Hyperglycemia - INTERVENTIONS: •Wound care •*Enzymatic debridement* •Speeds up removal of dead tissue from healthy wound bed •Cleanse with soap and water •Cover with antimicrobial creams •*Excision and grafting* •Eschar is removed down to subcutaneous tissue or fascia •Graft is placed on clean, viable tissue •Wound is covered with autograft •Donor skin is taken with a dermatome •Choice of dressings varies •Cultured epithelial autographs (CEAs) •Grown from biopsies obtained from the patient's own skin •Used in patients with a large body surface burn area or those with limited skin for harvesting REHAB PHASE: •The rehabilitation phase begins when •Wounds have healed •Patient is engaging in some level of self-care *•In approximately 4 to 6 weeks, area becomes raised and hyperemic* •*Mature healing is reached about 12 months* •Skin never completely regains its original color - COMPLICATIONS: •*Skin and joint contractures* •Most common complications during rehab phase. •Positioning, splinting, and exercise should be used to minimize contracture. - INTERVENTIONS: •Encourage both patient and caregiver to participate in care •Skills for dressing changes •Wound care • *Use water-based creams* •Reconstructive surgery is frequently required after a major burns EXERCISE

stroke cont

TIA •History of TIA is associated with an increased risk of stroke •TIA is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of brain •Symptoms typically last < 1 hour •There is no way to predict outcome - Surgical interventions for patient with TIAs from carotid disease include: •Carotid endarterectomy •Transluminal angioplasty •Stenting - Postoperative care is important: •Neurovascular assessment •BP management •Assess for complications •Stent occlusion •Retroperitoneal hemorrhage •Minimize complications at insertion/access site *ISCHEMIC STROKE:* - THROMOBOLYTIC - EMBOLIC - THOMBOLYTIC: •Occurs from injury to a blood vessel wall and formation of a *blood clot* •Results in narrowing of blood vessel - *Most common cause of stroke (60%)* •*Often associated with HTN and DM* •*Many times they are preceded by TIA* - EMBOLIC: •Occurs when an *embolus lodges in and occludes a cerebral artery* •Results in infarction and edema of area supplied by involved vessel •2nd most common cause of stroke - •Sudden onset with severe clinical manifestations •Warning signs are less common •Patient usually remains conscious •Prognosis is related to amount of brain tissue deprived of blood supply •Commonly recur CARE FOR ISCHEMIC: •*Time of onset of symptoms is critical information, as well as, duration, nature, and any changes* - Begins with managing: •Airway •Breathing (respiratory assessment) •Circulation (cardiac assessment) •*STAT CT* •Monitor vital signs if systolic BP ≥ 185 mmHg or diastolic BP ≥110 mmHg *anticipate IV antihypertensive medication* •*Administer tPA* •Assess ability to swallow DRUG THERAPY: ISCHEMIC: •*Recombinant tissue plasminogen activator (tPA):* •Used to re-establish blood flow through a blocked artery to prevent cell death •*Must be administered within 3 to 4 ½ hours of onset of clinical signs of ischemic stroke* •Patients are carefully screened for contraindications. •Once stable, to prevent further clot formation, patients with thrombotic and embolic strokes are often treated with anticoagulants and platelet inhibitors •*Platelet inhibitors: ASA, ticlopidine, clopidogel, dipyridamole.* •*Pt's with afib, oral anticoagulants = warfarin/Coumadin* •And direct Xa inhibitors: rivaroxaban/Xarelto, dabigatran/Pradaxa, and apixaban/Eliquis. •May be placed on a statin. -*Control of BP: Atenolol (SBP < 185mm Hg is critical during treat and for 24 hours after treatment). Give before tPA administration.* *HEMORRHAGIC STROKE:* - SUBACRACHNOID HEMORRHAGE (SAH) - INTRACEREBRAL ANEURYSM/HEMORRHAGE SUBACRACHNOID HEMORRHAGE (SAH): •Intracranial bleeding into cerebrospinal fluid-filled space between arachnoid and pia mater •*Commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse* INTRACEREBRAL ANEURYSM/HEMORRHAGE *•Majority are in Circle of Willis* •Incidence ↑ with age; higher in women •*Silent killer* •Loss of consciousness may or may not occur •High mortality rate •Survivors often suffer significant complications and deficits •*Hypertension - common cause* •Hemorrhage occurs during activity •Extent of symptoms depends on amount, location, and duration of bleeding. •Bleeding within brain caused by rupture of a vessel •Sudden onset of symptoms - MANIFESTATIONS: •Neurologic deficits *•Severe headache* •Nausea and/or vomiting •Decreased levels of consciousness •*Hypertension (most common cause)* •Seizure - acute onset seizures typically occur within 24 hours of the stroke. > •More likely to have a seizure with a severe stroke: a stroke caused by bleeding in the brain (hemorrhagic stroke) or a stroke in the cerebral cortex. DRUG THERAPY: HEMORRHAGIC - Drug Therapy Hemorrhagic Stroke •*Anticoagulants and platelet inhibitors are contraindicated!!!* •Management of hypertension is main focus •Oral and IV agents are used to maintain BP within a normal to high-normal range •Seizure prophylaxis is situation-specific •*Vasospasms can be treated with calcium channel blocker nimodipine (Nimotop)* - SURGICAL THERAPY: •Resection •Clipping of an aneurysm •Coiling, reduce blood pulsations within aneurysm, eventual thrombus formation followed by sealing off from parent vessel. •Evacuation of hematomas •Surgical interventions: immediate evacuation of aneurysm-induced hematoma or cerebellar hematoma > 3cm. •AVM treatment, surgical resection and/or radio surgery (gamma knife). •Procedure is chosen based on cause of stroke.

3

The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations .2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.

3

The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the UAP tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level. 2. Have the client drink eight (8) ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one (1) ampule 50% dextrose intravenously.

1 2 3 4

The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that apply. 1. Notify the HCP if a three (3)-pound weight loss occurs in two (2) days. 2. Discuss ways to cope with the emotional lability. 3. Notify the HCP if taking over-the-counter medication 4. Carry a medical identification card or bracelet. 5. Teach how to take thyroid medications correctly.

C

The term for "flapping hand tremors" seen in hepatic encephalopathy is: A.Chvostek's sign B.Cullen's sign C.Asterixis D.Trousseau's sign

3

Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism? 1. Thyroid hormones. 2. Oxygen. 3. Sedatives. 4. Laxatives.

Brain Death

- Ethical/Legal Points for Consideration: •Irreversible loss of all brain functions, including those of the brainstem. *•Criteria for brain death include coma or unresponsiveness, absence of brainstem reflexes, and apnea (see Chapter 9 Palliative & End of Life Care).* •A circumstance that influences the manner in which a state of death is determined is the customary practice or best practice for the specific situation. •In a situation in which the professional responsible for determining a state of death is in remote contact with the patient, but the monitoring devices available provide virtual contact with the patient, a remote diagnosis of death may be legally acceptable. •Brain death criteria do not address patients in a permanent vegetative state, since the brainstem activity in these patients is adequate to maintain heart and lung function. •*CPR is inappropriate when survival is not expected or if the patient is expected to survive without the ability to communicate.* •Quantitative futility implies that survival is not expected after CPR under given circumstances. •In the absence of mitigating factors, prolonged resuscitative efforts are unlikely to be successful and can be discontinued if there is no return of spontaneous circulation at any time during 30 minutes of cumulative advanced life support.

B

1. M.J. calls the clinic and tells the nurse that her 85-yr-old mother has been nauseated all day and has vomited twice. Before the nurse hangs up and calls the HCP, she should tell M.J. to a. administer antiemetic drugs and assess her mother's skin turgor. b. give her mother sips of water and elevate the head of her bed to prevent aspiration. c. offer her mother large quantities of Gatorade to decrease the risk for sodium depletion. d. give her mother a high-protein liquid supplement to drink to maintain her nutritional needs.

B

1. Polydipsia and polyuria related to diabetes are primarily due to a. the release of ketones from cells during fat metabolism. b. fluid shifts resulting from the osmotic effect of hyperglycemia. c. damage to the kidneys from exposure to high levels of glucose. d. changes in RBCs resulting from attachment of excess glucose to hemoglobin.

C

1. Which prevention strategy would the nurse include when teaching about home fire safety? a. Set hot water temperature at 140°F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Do not allow older adults to cook unattended

B

2. A patient with acute hepatitis B is being discharged. The discharge teaching plan should include instructions to a. avoid alcohol for the first 3 weeks. b. use a condom during sexual intercourse. c. have family members get an injection of immunoglobulin. d. follow a low-protein, moderate-carbohydrate, moderate-fat diet.

D

2. A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance among brain tissue, blood, and cerebrospinal fluid.

D

2. The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. O2 content of the blood. b. amount of cardiac output. c. level of CO2 in the blood. d. degree of collateral circulation.

A

2. The injury that is least likely to result in a full-thickness burn is a. sunburn. b. scald injury. c. chemical burn. d. electrical injury.

D

2. The nurse explains to the patient with Vincent's infection that treatment will include a. tetanus vaccinations. b. viscous lidocaine rinses. c. amphotericin B suspension. d. topical application of antibiotics.

D

2. Which statement would be correct for a patient with type 2 diabetes who was admitted to the hospital with pneumonia? a. The patient must receive insulin therapy to prevent ketoacidosis. b. The patient has islet cell antibodies that have destroyed the pancreas's ability to make insulin. c. The patient has minimal or absent endogenous insulin secretion and requires daily insulin injections. d. The patient may have enough endogenous insulin to prevent ketosis but is at risk for hyperosmolar hyperglycemia syndrome.

B

3. A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include a. having genetic testing done. b. recommending a heart-healthy diet. c. the necessity to reduce weight rapidly. d. avoiding alcohol until liver enzymes return to normal.

C

3. A patient with spinal cord injury has severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. Compression b. Hyperextension c. Flexion-rotation d. Extension-rotation

A

3. Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? a. A1C 9% b. BP 126/80 mmHg c. FBG 130 mg/dL (7.2 mmol/L) d. LDL cholesterol 100 mg/dL (2.6 mmol/L)

B

3. The health care provider prescribes levothyroxine for a patient with hypothyroidism. After teaching about this drug, the nurse determines that further instruction is needed when the patient says a. "I can expect the medication dose may need to be adjusted." b. "I only need to take this drug until my symptoms are improved." c. "I can expect to return to normal function with the use of this drug." d. "I will report any chest pain or difficulty breathing to the doctor right away."

a d e

3. What are effective interventions to decrease absorption or increase elimination of an ingested poison? (select all that apply) a. Hemodialysis b. Eye irrigation c. Hyperbaric O2 d. Gastric lavage e. Activated charcoal

A D E

3. When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters. b. exposed fascia. c. exposed muscles. d. intact nerve endings. e. red, shiny, wet appearance.

D

4. A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the breath sounds are greatly decreased. Which action is the most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again. b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the provider.

C

4. A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the health care provider. b. check the patient's temperature. c. measure the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

c

4. An older woman arrives in the ED reporting severe pain in her right shoulder. The nurse notes her clothes are soiled with urine and feces. She tells the nurse that she lives with her son and that she "fell." She is tearful and asks you if she can be admitted. What possibility should the nurse consider? a. Dementia b. Possible cancer c. Family violence d. Orthostatic hypotension

C

4. In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease a. often results in toxic megacolon. b. causes fewer nutritional deficiencies than ulcerative colitis. c. often recurs after surgery, while ulcerative colitis is curable with a colectomy. d. is manifested by rectal bleeding and anemia more often than is ulcerative colitis.

C

4. The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

B

4. The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid

A

4. Which instructions would the nurse include in a teaching plan for a patient with mild gastroesophageal reflux disease (GERD)? a. "The best time to take an as-needed antacid is 1 to 3 hours after meals." b. "A glass of warm milk at bedtime will decrease your discomfort at night." c. "Do not chew gum; the excess saliva will cause you to secrete more acid." d. "Limit your intake of foods high in protein because they take longer to digest."

b

5. A chemical explosion occurs at a nearby industrial site. First responders report that victims are being decontaminated at the scene and about 125 workers will need medical evaluation and care. The first action of the nurse receiving this report should be to a. issue a code blue alert. b. activate the hospital's emergency response plan. c. notify the Federal Emergency Management Agency (FEMA). d. arrange for the American Red Cross to provide aid to victims.

C

5. A patient who has undergone an esophagectomy for esophageal cancer develops increasing pain, fever, and dyspnea when a full-liquid diet is started postoperatively. The nurse recognizes that these symptoms are most indicative of a. an intolerance to the feedings. b. extension of the tumor into the aorta. c. leakage of fluids into the mediastinum. d. esophageal perforation with fistula formation into the lung.

A

5. During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glasgow Coma Scale. d. cerebrospinal fluid leakage from the ears or nose.

C

5. Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include a. adherence of albumin to vascular walls. b. movement of potassium into the vascular space. c. movement of sodium and water into the interstitial space. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

B E

5. Important nursing intervention(s) when caring for a patient with Cushing syndrome include (select all that apply) a. restricting protein intake. b. monitoring blood glucose levels. c. observing for signs of hypotension. d. administering medication in equal doses. e. protecting patient from exposure to infection.

A

5. In planning care for a patient with metastatic liver cancer, the nurse should include interventions that a. focus primarily on symptomatic and comfort measures. b. reassure the patient that chemotherapy offers a good prognosis. c. promote the patient's confidence that surgical excision of the tumor will be successful. d. provide information needed for the patient to make decisions about liver transplantation.

C

5. The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

A

5. The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply) a. persistent abdominal pain. b. marked abdominal distention. c. diarrhea that is loose or liquid. d. colicky, severe, intermittent pain. e. profuse vomiting that relieves abdominal pain.

C

6. A patient having TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

A

6. A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual changes, weakness of right upper and lower extremities, and personality changes. The nurse determines that the tumor is most likely located in the a. frontal lobe. b. parietal lobe. c. occipital lobe. d. temporal lobe

C

6. A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that a. chemotherapy will begin after the patient recovers from the surgery. b. both chemotherapy and radiation can be used as palliative treatments. c. follow-up colonoscopies will be needed to ensure that the cancer does not recur. d. a wound, ostomy, and continence nurse will visit the patient to identify the site for the ostomy.

A B E

6. Nursing management of the patient with acute pancreatitis includes (select all that apply) a. administering pain medication. b. checking for signs of hypocalcemia. c. providing a diet low in carbohydrates. d. giving insulin based on a sliding scale. e. monitoring for infection, particularly respiratory tract infection.

C

6. The pernicious anemia that may accompany gastritis is due to a. chronic autoimmune destruction of cobalamin stores in the body. b. progressive gastric atrophy from chronic breakage in the mucosal barrier and blood loss. c. a lack of intrinsic factor normally produced by acid-secreting cells of the gastric mucosa. d. hyperchlorhydria from an increase in acid-secreting parietal cells and degradation of RBCs.

A

6. To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, high-carbohydrate diet. b. increase normal caloric intake by about four times. c. eat at least 1500 calories/day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balance.

D

6. What is the priority action for the nurse to take if the patient with type 2 diabetes reports blurred vision and irritability? a. Call the provider. b. Give insulin as ordered. c. Assess for other neurologic symptoms. d. Check the patient's blood glucose level.

C

7. A patient with diabetes has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetes-related ketoacidosis rather than hyperosmolar hyperglycemia syndrome based on the finding of a. polyuria. b. severe dehydration. c. rapid, deep respirations. d. decreased serum potassium.

C

7. A patient with pancreatic cancer is admitted to the hospital for evaluation of treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves a. creating a bypass around the obstruction caused by the tumor by joining the gallbladder to the jejunum. b. resection of the entire pancreas and the distal part of the stomach, with anastomosis of the common bile duct and the stomach into the duodenum. c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum. d. removal of the pancreas, the duodenum, and the spleen, and attachment of the stomach to the jejunum, which requires oral supplementation of pancreatic digestive enzymes and insulin replacement therapy.

B

7. For a patient who is suspected of having a stroke, the most important piece of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

A

7. The nurse determines a patient undergoing ileostomy surgery understands the procedure when the patient states a. "I should only have to change the pouch every 4 to 7 days." b. "The drainage in the pouch will look like my normal stools." c. "I may not need to wear a drainage pouch if I irrigate it daily." d. "Limiting my fluid intake should decrease the amount of output."

D

7. The nurse is teaching the patient and family that peptic ulcers are a. caused by a stressful lifestyle and other acid-producing factors, such as H. pylori. b. inherited within families and reinforced by bacterial spread of Staphylococcus aureus in childhood. c. promoted by factors that cause oversecretion of acid, such as excess dietary fats, smoking, and alcohol use. d. promoted by a combination of factors that cause erosion of the gastric mucosa, including certain drugs and H. pylori.

A

7. To control the side effects of corticosteroid therapy, the nurse teaches the patient who is taking corticosteroids to a. increase calcium intake to 1500 mg/day. b. perform glucose monitoring for hypoglycemia. c. obtain immunizations due to high risk for infections. d. avoid abrupt position changes because of orthostatic hypotension

D

8. An optimal teaching plan for an outpatient with stomach cancer receiving radiation therapy should include information about a. cancer support groups, alopecia, and stomatitis. b. nutrition supplements, ostomy care, and support groups. c. prosthetic devices, wound and skin care, and grief counseling. d. wound and skin care, nutrition, drugs, and community resources.

B

8. Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. helping the patient to stand to void. c. keeping a urinal in place at all times. d. catheterizing the patient every 4 hours.

B

8. In contrast to diverticulitis, the patient with diverticulosis a. has rectal bleeding. b. often has no symptoms. c. usually develops peritonitis. d. has localized cramping pain.

A C D

8. Pain management for the burn patient is most effective when (select all that apply) a. a pain rating tool is used to monitor the patient's level of pain. b. painful dressing changes are delayed until the patient's pain is completely relieved. c. the patient is informed about and has some control over the management of the pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

B C D

8. The nurse caring for a patient with suspected acute cholecystitis would anticipate (select all that apply) a. ordering a low-sodium diet. b. administration of IV fluids. c. monitoring of liver function tests. d. administration of antiemetics for patients with nausea. e. insertion of an indwelling catheter to monitor urinary output.

C

8. The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. An older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0- to 10 scale d. Patient 2 days postoperative after a craniotomy for a brain tumor who has had continued vomiting

A C E

8. Which are appropriate therapies for patients with diabetes? (select all that apply) a. Use of statins to reduce CVD risk b. Use of diuretics to treat nephropathy c. Use of ACE inhibitors to treat nephropathy d. Use of serotonin agonists to decrease appetite e. Use of laser photocoagulation to treat retinopathy

B

9. Teaching in relation to home management after a laparoscopic cholecystectomy should include a. keeping the bandages on the puncture sites for 48 hours. b. reporting any bile-colored drainage or pus from any incision. c. using over-the-counter antiemetics if nausea and vomiting occur. d. emptying and measuring the contents of the bile bag from the T tube every day.

C D

9. The teaching plan for the patient being discharged after an acute episode of upper GI bleeding includes information about the importance of (select all that apply) a. limiting alcohol intake to 1 serving per day. b. only taking aspirin with milk or bread products. c. avoiding taking aspirin and drugs containing aspirin. d. only taking drugs prescribed by the health care provider. e. taking all drugs 1 hour before mealtime to prevent further bleeding

Answer: c Rationale: Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient's own unburned skin.

A patient is to undergo skin grafting with the use of cultured epithelial autografts for full-thickness burns. The nurse explains to the patient that this treatment involves a.Shaving a split-thickness layer of the patient's skin to cover the burn wound. b.Using epidermal growth factor to cultivate cadaver skin for temporary wound coverage. c.Growing small specimens of the patient's skin into sheets to use as permanent skin coverage. d.Exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage.

Answer: d Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? a."Blood loss from burned tissue is the most likely cause of hypovolemia." b."Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." c."The usual cause of hypovolemia is vaporation of fluid from denuded body surfaces." d."Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

Traumatic Brain Injury Classifications

Primary - *Direct injury to brain from impact* •Coup injury (primary impact) •Contrecoup injury (second impact) - Types •Concussion •Contusion •Penetrating injuries •Diffuse axonal injuries •Hematomas - Complications •Intracranial bleeding Primary injury occurs at the initial time of an injury (e.g., impact of car accident, blunt-force trauma). It results in displacement, bruising, or damage to any of the components (brain tissue, blood, CSF). Secondary - Consequence of initial trauma •Inflammatory response •Release of cytokines > •Vasogenic edema Secondary injury is the resulting hypoxia, ischemia, hypotension, edema, or increased ICP that follows the primary injury. MANAGEMENT: - Nursing •Neurological assessment •> Glasgow Coma Scale •Airway assessment •ICP monitoring •Hemodynamic monitoring •Interventions to control elevated ICP •Evaluation of diagnostic tests •Support of client & family - Medical/Surgical •Same as increased intracranial pressure •Several surgical procedures > •Craniotomy >> •Bone fragments >> •Evacuation hematoma >> •Foreign body removal

Answer: d Rationale: Adequacy of fluid replacement is assessed by urine output and cardiac parameters. Urine output should be 0.5 to 1 mL/kg/hr. Mean arterial pressure should be >65 mm Hg, systolic BP >90 mm Hg, and heart rate <120 beats/min. A blood pressure of 86/72 indicates inadequate fluid replacement. However, the MAP is calculated at 77 mm Hg.

When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse? a.Serum K+ of 4.5 mEq/L b.Urine output of 35 mL/hr c.Decreased bowel sounds d.Blood pressure of 86/72 mm Hg

Distaster Management

•Disaster: •Any extraordinary event that requires a rapid and skilled response and can be managed by a community's existing resources •Mass casualty incident (MCI): •Manmade or natural event or disaster that overwhelms community's ability to respond with existing resources •When an emergency or MCI occurs, first responders (e.g., police, emergency medical personnel) are dispatched •Triage of casualties differs from usual ED triage and is conducted in <15 seconds MCI triage: - *BLACK:* •*Expectant* •dead or actively dying •Adult: • Apenic with airway repositioning •Pediatric: •No palpable pulse •Apenic with repositioning AND 5 rescue breaths Palliative Care and pain meausrements when applicalbel - *RED:* • *Critical*: Requires treatment within 1 hour; compromises to ABC - *YELLOW:* •*Delayed* •Adult: •Respirations, circulation and mental status intact •May still have potentially life threatening injuries but status not expected to deteriorate in the next few hours •Pediatric: AVPU appropriate, Resp and pulse intact - *GREEN:* •*Minor Injuries* •"walking wounded" •May be able to assist in own care, unlikely to deteriorate for days - *Worried Well:* •People not involved or at risk who are anxious and will present for evaluation and treatment •Quick tool to sort yellow vs. Green •3, 2, "I can do" •A&O x3 •Cap refill < 2 •Can follow commands BIOTERRORISM: •Anthrax, plague, and tularemia > •Treated with antibiotics assuming sufficient supplies and nonresistant organisms •Smallpox can be prevented or ameliorated by vaccination even when given after exposure •Botulism is treated with antitoxin

MYXEDEMA COMA

•What is Myxedema Coma? •High mortality rate!! •*Rare, life threatening condition seen in untreated or uncontrolled hypothyroidism (persistently low thyroid production)* •*To survive, vital functions must be supported and IV thyroid hormone replacement given* •Decrease in metabolic rate of all body systems DIAGNOSTICS: •Labs •T3 <0.2 (Low T3) •T4 <5 (Low T4) *TSH >25 (elevated TSH levels when defect is in thyroid gland & low when in the pituitary or hypothalamus* •Thyroid ultrasound CAUSES: •*Not precipitated by an event highly unlikely* •*Infection being the most frequent cause* •Stressors •Drugs, especially opioids, tranquilizers, and barbiturates •Exposure to cold •Trauma •Autoimmune in origin S/S: •*Hypothermic & cold intolerance* •*Change in LOC*, fatigue, depression to unconscious, coma •*Hypotension* •*Hypoventilation* - Respiratory depression and or failure •CV collapse may result from hypoventilation, hyponatremia, hypoglycemia, & lactic acidosis •Mental sluggishness, somnolence •Drowsiness, lethargy •Decreased initiative •Severely decreased metabolism •Decreased cardiac contractility, resulting in decreased cardiac output •Low exercise tolerance •Shortness of breath on exertion •*CV collapse: bradycardia, hypotension* •Hyponatremia •Hypoglycemia •Weakness •*Decreased appetite* *•Stiff joints* •Pernicious Anemia and jaundice •*Periorbital edema/Generalized edema* •Prominent tongue •*Dull, puffy skin* •*Coarse, sparse hair* TREATMENT: •Identify and treat underlying cause •*To survive vital functions must be supported and IV thyroid hormone replacement given •*Thyroid replacement: levothyroxine sodium (Synthroid)* > •First dosages are low for those with compromised cardiac status > •Requires careful monitoring in starting and adjusting dosage due to increased myocardial O2 demand = angina, dysrhythmias •Correct fluid and electrolyte imbalances •Correct Hypoglycemia •Support hemodynamics •Provide ventilatory assistance of needed •Avoid narcotics COMPLICATIONS: •*Coma* can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, or the use of sedatives and opioid analgesics •*Cardiovascular collapse*

THYROID STORM

•What is Thyrotoxicosis or Thyrotoxic Crisis / Thyroid Storm? • •Acute, severe, and rare life-threatening condition occurs when *excessive amounts of thyroid hormones are released into circulation (untreated or uncontrolled hyperthyroidism)* •* *Low level of TSH in blood is due to pituitary gland sensing that there is "enough" thyroid hormone in circulation* •* Requires aggressive treatment in the ICU > •Medications to block thyroid hormone production & the sympathetic nervous system •Causes an increase in the metabolic rate of all body systems DIAGNOSTICS: •Labs •T3 >0.52 (elevated T3) •T4 >12 (elevated T4) •*TSH < 0.01 (Low TSH levels)* •Thyroid ultrasound CAUSES: •Usually precipitated by underlying illness, general anesthesia, surgery, or infection •Infection, surgery, trauma in a patient with hyperthyroidism Metastatic thyroid CA •Trauma •*Surgery - removal of thyroid gland (thyroidectomy)* •Can also be caused by manipulation of the thyroid gland during sx. - release of thyroid hormone into the bloodstream S/S: •Exaggerated S/S of hyperthyroidism •*Hyperpyrexia-controlled increase of the overall body temperature* •*Hyperthermia* - failure of the body's thermo-regulatory apparatus; heat produced overruns the body's heat-loss capacity - causing sharp spike in body temperature •*Tachycardia severe - while asleep, AFib with RVR (rapid ventricular response)* *Alt LOC*- irritability, hyperactive, nervousness, agitation, restlessness, anxiety, confusion and delirium Increased cardiac workload, decreased cardiac output •Heart failure •Shock •Increase O2 demand due to hypermetabolic state •*Ineffective breathing pattern, increase RR* •N/V/D & abdominal pain •Seizures as condition progresses •*Fine tremors of tongue or eyelids* •Muscle weakness •*Exophthalmos* •May cause normochromic anemia and leukocytosis TREATMENT: •Identify and treat underlying cause •Antagonize peripheral effects of thyroid hormone: *Propranolol* •Inhibit hormone biosynthesis: *Propylthiouracil, Methimazole* •Block Thyroid Hormone Release: *Saturated Solution Potassium Iodine(SSKI), Iopanoic Acid- takes effect 3-6 days* •Give prescribed drugs and monitor effects: *B-Adrenergic blockers, antithyroid agents, iodine compounds, and glucocorticoids* •Correct fluid and electrolytes imbalances •Begin fluid replacement with *isotonic saline infusions containing dextrose* •Support with high calorie high protein diet •Antithyroid medications, beta blockers, glucocorticoids, and iodides may be administered to the client before thyroid surgery to prevent occurrence