Med Surg Final

Atrial Flutter (sawtooth waves "flutter waves"

250-350 bpm, regular rhythm, no p wave Causes: MI, mitral valve disease, thyrotoxicosis, COPD, recent surgical procedures within the chest, pneumonectomy, digoxin toxicity Treatment: "control the rate",beta-blocker, calcium channel blockers, digoxin, antiarrhythmics- chemical cardioversion, cardioversion (last resort), TEE.

Normal Sinus Rhythm

60-10 bpm

Anti-Coagulant Therapy

Aspirin: decrases platelet aggregation Enoxaparin: no lab monitoring to determine therapeutic level, low molecular weight heparin. Stretokinase: "TPA", thrombolytic agent. Clopidogrel: decrases platelet aggregation Rivaroxaban: no lab monitoring Anticoagulants: warfarin, heparin, low molecular weight heparin, dabigatran, rivaroxaban, apixaban. Antiplatelet: aspirin, clopidogrel Thrombolytic: streptokinase, alteplase, tenecteplase, reteplase. Newer: Advantages; no labs, no dietary restrictions, Disadvantages; no antidote, no reversal agents

Peptic Ulcer Disease

Causes: H. pylori infection, smoking, excessive alcohol, NSIADs, aspirin, steroids, potassium burns, organ failure, ICU patients. Clinical manifestations: pain, burning epigastric pain (aggravated by fasting/improved food or antacids), abdominal pain (s/s perforation: stiff abdomen, rebound tenderness), N/V. Treatment: surgical, EGD, PPIs, protonix, Nexium Prilosec, (2 antibiotics and 1 PPI) avoid spicy foods, heavy meals at bedtime. Complications: long term side effects of meds: osteoporosis, spinal fractures, dementia. Perforamtion, peritonitis, sepsis, GI hemorrhage, vomiting blood, black tarry stools, low H&H, hypovolemic shock (decreased BP, increased HR, decreased LOC, hypotension, anxiety, pale), short bowel syndrome. Labs: endoscopy, H.pylori test, fecal occult blood test, CBC (WBC, H&H) electrolytes,

Diverticulitis

Causes: abdominal pain 3 or more days, gastrointestinal bleeding, decrease blood flow, weakness in the intestinal wall, bowel scarring, narrowing lumen, intestinal obstruction, decreased fiber, obesity, lack of physical activity, inflammation, bleeding. Clinical Manifestations: nausea, low grade fever, points of weakness in the intestine, abdominal pain, sigmoid colon tenderness, fever, increased flatus, anorexia, confusion, bloating, distension, diarrhea, mucous, blood, sepsis perforation, peritonitis tenderness. Assessment: fever, inflammation, low grade fever, tachycardia, serum potassium, NG suctioning, Left quadrant pain, mid abdomen, mental status. Labs: xray, ct scan, biopsy, CBC, no colonoscopy (due to increased risk for perforation. Treatment: antibiotics, bowel rest, NG tube, clear liquids, low fiber (during flair ups, low fiber when not "diverticulosis high fiber", IV fluids. NPO patient w/ IV fluids, antibiotics, NG tube Complications: risk of rupturing, perforation, abscess, fistula, bowel obstruction, bleeding peritonitis, sepsis, bleeding.

Hyperkalemia

Causes: acute/chronic renal failure, acidosis, crush injury or burns, diabetic ketoacidosis, lactic acidosis, medications, excessive intake, reduction in GFR, Addison's disease, adrenal cortex insufficiency, potassium sparing diuretics (spironolactone), NAIDs w/ renal failure, beta-blockers, digoxin/digitalis, foods high in K: bananas, oranges, tomatoes & high protein. Clinical Manifestations: muscle cramps, paresthesia to weakness, ECG changed, hypotension, ST depression, shortened OT interval, "peaked T wave", abnormal rhythms, widened QRS complex. Treatment: kayexalate, 50% dextrose, IV regular insulin, sodium bicarb 50, calcium gluconate, albuterol, loop diuretics Complications: cardiac dysrhythmias, arrest, death, nausea, diarrhea

Pulmonary Embolism (PE)

Causes: amniotic fluid, post surgical trauma, DVT, obesity, smoking, chronic heart disease, immobility, pregnancy, Afib, fractures, hip/knee replacement, decreased physical activity. Clinical manifestations: sudden onset of chest pain, SOB, pleuritic chest pain, unilateral lower extremity edema, decrease/increase BP, increased RR, increased HR, diaphoretic, fear, anxious, EKG normal-check d-dimer, heart palpitations, anxiety, sweaty, fainting. Hypoxia, ineffective breathing pattern, decreased cardiac output, lactic acid levels, ABGs. Labs: d-dimer, ABG, ECG, BNP, troponin, Chest xray, EKG, Chest CT, V/Q scan, PT, INR, PTT, pulmonary angiography definitive diagnosis of PE. Treatment: heparin, warfarin, altepase, isotonic fluids, embolectomy, IVC filter, bleeding precautions, elevated head of the bed, administer IV fluids, disease process, medications, diet (vit K limitations) exercise, smoking cessation, follow up appointments, electric razor, fall precautions.

System Lupus Erythematosis (SLE)

Causes: chronic progressive inflammatory autoimmune response, kidney involvement, effects skin/tissue components, exacerbation of skin lesions, chronic inflammation. Clinical manifestations: skin involvement "butterfly rash", polyarthritis-inflammation of joints not as severe as RA. Osteonecrosis- from steroid use, muscle atrophy, fever & fatigue, renal involvement = nephritis, output; proteinurian hematuria, fluid retention, subjective: weakness, sensitivity to lights, pain in joints, objective: increased temp, rash, weight loss, pleural effusion, puemonia, raynauds, neurologic, chest pain, tachycardia, pericarditis Lab: decreased WBC, decreased platels, decreased RBC, decreased H&H, increased creatinine, pancytopenia, increased HR, increased RR, ataxia, ptosis, abdominal pain, skin biopsy, immunologic CBC, LE prep & ANA (antinuclear antibody "looks at autoimmune disorder") Treatment: topical drugs, plaquenil, Tylenol or NSAIDs, chronic steroid therapy, immunesuppression, plasmapheresis, remove antibodies, prednisone, s/s of infection, promote rest, avoid crowds, avoid being out of the sunlight. Complications: nephrtis, pleural effusion, pneumonia, tachycardia, pericarditis, serositis, pancytopenia, thrombocytopenia.

Heart Failure

Causes: coronary artery disease, hypertension producing LV hypertrophy, diabetes mellitus, hyperlipidemia, sedentary lifestyle, obesity, excessive alcohol use, smoking, high sodium dietary intake. Ejection Fraction: (EF) 55% to 70%). Right sided: fatigue, enlarged liver & spleen, ascites, peripheral venous pressure, anorexia, GI distress, swelling of hands/fingers, dependent edema, 2nd to chronic pulmonary problems, distended jugular veins. Left sided: can cause right sided, person can have either one or both. Weakness, cyanosis, SOB. Labs: dependent on history and physical assessment, Chest xray, echocardiogram, EKG/ECG, EF < 45% (normal 55-70%) , nuclear imaging, stress tests, CK, Troponin "last for 10 days", serum electrolytes, CBC, UA, Lipid profile, Liver function test, K+, creatinine, BUN, H&H, BNP, Pro-BNP. Treatment: ace inhibitors, ARBs, Beta-blockers, digoxin, diuretics, anticoagulants, Plavix, aspirin, coumadin, Biventricular pacemake/ICD, balloon, transplant, septal myectomy, surgical ventricular remodeling, VAD, TMP, heart transplantation.

Rheumatoid Arthritis (connective tissue disease & destructive to joints)

Causes: decreased RBC, WBC, platelets, pregnancy, NSAIDs- GI upset, GI bleeding, autoimmune disorders Clinical manifestations: fatigue, low grade fever, anorexia, joint pain, weakness, paresthesia, weight loss, joint stiffnes, swelling, pain, morning stiffness, joints progressively inflamed, joint deformity, accumulation of fluid in joints. Labs: decreased RBC, WBC, due to enlarged spleen, erhthrocyte sedimentation rate (sed rate), antinuclear antibody titer, xray, CT scan, bone scan Treatment: methotrexate -chemo med, glucocorticoids, hydroxychloroguine, NSAIDs, prednisone, immune suppressive, avoid crowds, GI black tarry stools, reduce inflammation, adequate rest, ice/heat applications. Complications: weight loss, fever, fatigue, hyperglycemia, increased risk for infection, increased risk for osteoporosis, moon face, pulmonary complications, vasculitis, inflammation of small blood vessels, paresthesia, peripheral neuropathy, cardiac complication.

Hypernatremia

Causes: diabetes insipidus, hyperglycemia, neoplasms, hypercalcemia, hyperkalemia, lithium, amphotericin B, hyperventilation, burn injuries, febrile, exercise. Clinical manifestations: disorientation, hallucinations, agitation, restlessness, confusion, seizures, lethargy, tachycardia, dry mucous membranes, skin flushed, thirst. Treatment: fluid replacement 1/2NS or D5W, underlying cause, Complications: restlessness, weakness, disorientation, delusions, hallucinations, seizures, stupor, coma, death, orthostatic hypotension, tachycardia.

Cariomyopathy

Causes: diabetes, HTN, high cholesterol, high fat diet, family history, obesity, sedentary lifestyle. Clinical Manifestations: chest pain, dizziness, sweating, indigestion, n/v, palpitations, SOB, edema, pulmonary congestion, JVD. Labs: BNP increased levels "overstretched ventricular tissue" Diagnosis: chest xray, Echo, ECG, right heart cath, MRI, BNP Treatments: betablockers, digoxin, diuretics, antiarrhythmics, ace inhibitors, oxygen, pacemaker Complications: heart failure, angina, dysrhythmias, thrombosis

Metabolic Alkalosis

Causes: excess use of bicarb-antacids, lactate administration, vomiting (acid out, base in) NG suctioning, hypokalemia, hypochloremia, diuretics, increased aldosterone Clinical manifestations: hyperventilate, muscle fatigue, cramps, hypokalemia, tetany (decreased calcium), dizziness, lethargy, convulsions, coma. Treatment: discontinue NG tube suctioning, stop diuretics, antiemetics, administer fluids, potassium replacements

Pancreatitis

Causes: fat necrosis, hypoalbumin, hypocalium, malnutrition, bile duct abnormalities, surgery, parasites, idiopathic, congenital abnormalities, nicotine. Clinical manifestations: epigastric pain that radiates to the back and sholders, gas, bloating, indigestion, fever, tachycardia, hypotension, nausea, vomiting, anorexia. Cullens sign (periumbilical bruising), greys tumer's sign (flank pain), abdominal tenderness Labs: amylase: 0-130, lipase: 0-160, glucose check: 70-110. CT scan, MRI, H&H, BUN, creatinine, albumin, pre albumin, CBC, WBC. Treatment: NPO, IV hydration (isotonic, high rate), pain medications, cholecystectomy if gallstones causing, endoscopy procedures, enteral nutrition. s/s: hypo/hyper glycemia. PPI, opioids for pain, spasmotic anticholingercis (decreased motility and pancreatic enzymes) NG tube, antibiotics. Complications: dead pancreatitis (necrotizing), pancreatic cancer, kidney failure, pancreatic hemorrhage, pancreasic pseudocyst, infection, breathing problems, diabetes, malnutrition.

Sinus Tachycardia (greater than 100bpm "100-150")

Causes: fever, anemia, hypotension, pulmonary embolism, myocardial infarction, ilicit drugs, caffeine, shock, infection, heart failure, Low BP or CO. Clinical manifestations: dizziness, lightheadedness, fainting, SOB, sweating, anxiety, hypotension, palpitations, weakness, chest pain. Treatment: administering blood, IV fluids, beta blockers, calcium channel blockers, treat underlying cause

ECV Deficit (hypovolemia)

Causes: gastrointestinal loss, vomiting, diarrhea, NG suction. Increased perspiration, hemorrhage, burns, diabetes insipidus, diabetic ketoacidosis, adrenal insufficiency, nausea, anorexia, oral injury, neck or neck trauma, cerebrovascular accident (stroke), third spacing Labs: increased sodium, decreased potassium, decreased hemoglobin, decreased hematocrit, increased serum osmolality, increased urine osmolality, aldosterone, ADH, increased BUN, increased creatinine, increased urine specific gravity Clinical Manifestations: weight loss, loss of skin turgor, concentrated urine output, oliguria (low urine output), thirst, dry mucous membranes, weak, rapid pulse peripheral pulses, flattened neck veins, hypotension, anxiety, restlessness, cool clammy pale skin. Treatment: intake of oral fluids preferred method when not severe. IV isotonic fluids (NS & LR) Once hypotension has been corrected, electrolytes, can change to: D5 0.45NS, 0.45NS Assessment: urine output, vital signs, neurological & pulmonary status. (prevent development of fluid volume overload). Improvement: decrease restlessness. Fluid over load symptoms: increased RR, cough, crackles, decreased O2 sat. Complications: hypovolemic shock (hypotension, tachycardia, hypoperfusion, cool, clammy skin, oliguria to anuria (lack of urine output, decreased levels of consciousness, tachypnea.

Respiratory Alkalosis

Causes: hyperventilation, fever, sepsis, anxiety, PE, pregnancy, pain, ASA intoxication. Clinical manifestation: anxious, dizziness, hyperventilation, palpitation, sweating, dry mouth, blurred vision, tetany and/or spasms, confusion and decreased concentration lack of CO2. Labs: hypokalemia, CBC, EKG Treatment: stop caffeine to reduce anxiety, reduce stress causing anxiety, Tylenol for fever, benzo's, paper bag, cup hands, non-rebreather, change ventilator settings if too high, monitor VS, telemetry, labs, ABGs.

Bradycardia (less than 60 bpm)

Causes: hypoxia, hypothermia, surgery, vagal stimulation, athletes. Clinical Manifestations: syncope, dizziness, confusion, decreased BP, chest pain, hypotension, SOB, diaphoresis, electrolyte imbalance, ischemia, lightheadedness, fainting, sweating, anxiety Treatment: atropine, oxygen, pacing, obtain ECG 12 lead, LOC, pulses , BP

Hypervolemia (fluid volume excess)

Causes: increased water and sodium retention. Cirrhosis, heart failure, stress conditions, ingestion of excessive sodium containing fluids. Labs: low hematocrit, BUN, osmolality, albumin, sodium Clinical manifestations: weight gain, ascites, edema, increased urinary output, hypertension, tachycardia, elevated BP, development of S3, jugular vein distention, decreased tissue perfusion, Pulmonary symptoms: cough, tachypnea, wheezing, crackles, orthopnea, decreased O2 sat. Treatment: prevent/correct underlying cause. Limit daily intake of fluid and sodium, monitor daily weights. Diuretics, dialysis. Complications: Pulmonary edema. Hypoxia Interventions: oxygen therapy, diuretics, morphine, vasodilators

Hyperchloremia

Causes: loss of bicarbonate, metabolic acidosis, hypernatremia.... Clinical manifestations: deep rapid respirations, lethargy, tachypnea, decreased cognitive ability, hypertension Treatment: 0.45% NS, correct underlying cause Complications: dysrhythmias, decreased cardiac output, coma

Hypoparathyroidism (hypocalcemia, hypomag)

Causes: not enough calcium clinical manifestations: numbness & tingling (mouth, hands, feet), muscle cramps, spasms, chvoskets sign, troussea sign, airway compromise, QT interval prolongation. labs: decreased calcium, magnesium, PTH (parathyroid hormone) & increased phosphorus. treatment: cardiac monitoring, IV calcium (calcium gluconate), oral calcium & vitamin D, life long therapy potential-treat underlying cause, calcium rich diet.

Addison's Disease

Causes: not enough cortisol, not enough aldosterone. Sickness, Addison's crisis, life threatening, stressful events, surgery, trauma, infection; Cortisol: decrease glucose production by liver hypoglycemia. Slower inflammatory response developed protein and fat metabolism decreased appetite/weight. Aldosterone: shift water/sodium excretion/retention. Poor maintenance of BP (up & down), dysregulation of H2O and Na, hyponatremia/hypovolemia, Hyperkalemia (increased BP, HR, RR). Clinical Manifestations: weight loss, postural hypotension, hyperpigmentation (bronze pigmentation); decreased BP, increased HR, increased, GI distress, decreased Na, decreased glucose, fatigue, N/V, mental instability (provide emotional support), dehydration, vascular collapse. Labs: BMP: decreased Na, Increased K, decreased glucose, increased BUN. Cortisol released in AM, draw labs in AM. CT scan (size & tumors), MRI. "peaked T waves" Treatment: IV fluids (bolus), potential surgery, steroids (cortisol) long term, patient to wear ID bracelet, glucose, hydrocortisone, dexamethasone, cortisol injections, kayexalate to decrease potassium levels, take meds in the AM, fall risk precautions, s/s: of increased cortisol, low K+ diet, glucose monitoring, protect from infection. If low low BP: vasopressors (dopamine) volume expander (albumin) to raise BP. Complication: immune suppression, surgery, hyponatremia, hypovolemia, hyperkalemia, low low BP.

Peripheral Artery Disease

Causes: obstruction of blood flow through the large peripheral arteries cause a partial or total arterial occlusion. Increased risk if family history, depends on lower extremitis of blood, nutrients, oxygen, prolonged results in necrotic tissue, gangrene. Intermittent claudication: by muscle pain-ache cramping, numbness, sense of fatigue occurs with exercise, relived by short periods of rest. Assessment/diagnosis: ankle brachial index, treadmill test, radiography, plethysmography, "we want a higher ankle". Treatment: providing relief of symptoms, weight reduction, smoking cessation, exercise, low-fat diet, antihypertensives, platelet inhibitors, statins, ace inhibitors, educate patient on meds, lifestyle compliance, positioning, foot inspection, warning signs to seek emergency help. (look at bottoms of feet).

Deep Vein Thrombosis (DVT)

Causes: pregnancy, hormone therapy, PE, advanced age, active cancer, history of DVT, various veins, surgery, bedrest, trauma, diabetes, hospital stay, obesity, post-partum period, chemotherapy. Clinical manifestations: pain, tenderness, decreased mobility, sores on skin, redness, normal cap refill, decreased pulse, CALL MD if SOB or chest pain develops!! Increased tendency of blood to clot hypercoagulability. Labs: D-dimer, venous ultrasound, CT or MRI/ venography, contract venography, PTT, PT, INR, compression ultrasound. Treatment: heparin, warfarin, blood thinners, surgical management (rare), thromboectomy, balloon angioplasty, stent placement, SCD, TED hose, adequate fluid intake, early ambulation, exercise, avoid constrictive clothing, long peroids of sitting/laying. s/s of bruising, bloody stools petechia. Complications: PE, SOB, decreased O2 sat, tachycardia, hypotension, sweating, chest pain, hemoptyosis (bloody sputum).

Metabolic Acidosis

Causes: renal failure, DKA, diarrhea, intestinal fistula, anaerobic metabolism, starvation, ASA intoxication (salicylate) Clinical manifestations: kussmauls breathing, hyperventilate, lethargy, confusion, CNS depression, headache Labs: ABGs, VS, blood glucose, BMP, K+ increase, EKG tall peaked T wave, lactic acid, anion gap Treatment: Na bicarb, IV fluids, rapid acting insulin, antidiarrheals, dialysis, ventilate if needed, antibiotics.

Hyponatremia

Causes: see below Clinical manifestations: headache, lethargy, confusion, convulsions, nausea/vomiting, coma Treatment: fluid restriction, "if neuro": 3% NS, oral sodium supplements, loop diuretics. Complications: neurological symptoms, lethargy, confusion, weakness, fatigue, muscle cramps, postural hypotension, seizures, coma, death.

Hypoglycemia (decreased sugar, increased insulin)

Causes: sickness, too much insulin What to do: sports drinks, fruit drinks, fluids that replace electrolytes, if unable to eat & replaced 4 to 5 meals w/ liquids: call MD. Check glucose every 3 to 4 hours & urine for ketones, Don't be alone and get rest; do not skip meds unless MD orders. Seek treatment at ED if: decreased LOC, sick for > 2 days, temp > 102 & doesn't respond to meds or > 12 hours. Increased RR, can't tolerate any fluids, glucose > 240. (might be going into DKA). Labs: glucose check Clinical manifestations: anxiety, hunger, sweaty, shaking, dizziness, slurred speech, weakness, difficulty thinking, seizure, coma, altered mental status, vision problems, fatigue. Treatment: PO sugar substance, IM glucagon, IV glucose (25-50% dextrose)

Hypochloremia

Causes: vomiting, burns, chronic respiratory acidosis, NG suction, metabolic alkalosis, Addison's. IV fluids low in chloride (D5W), high in bicarbonate, hyponatremia. Clinical manifestations: irritability, hypotension, tetany, shallow respirations, hyperexcitability of muscles and nerves Treatment: 0.45% or 0.9% NS, correct underlying cause Complications: develops as a result of hypokalemia, dysrhythmias, seizuures, coma.

Cirrhosis

Chronic and progressive risk factor: chronic infection with hepatitis A,B,&C. Chronic Alcoholism, biliary disease accumulation of fat in the liver, autoimmune disease. complications: 3rd spacing, ascities, portal hypertension, varies of the esophagus, enlarger spleen, irrevisiable scarring. clinical manifestations: loss of appetite, fatigue, weakness, weight loss, ascites, hepatomegaly, jaudice, abdominal pain, diarrehea, portal hypertension, splenomegaly, glucose intolerance, testicular atrophy, gynecomastia, spider hemangiomes, palmer erthema, encephlopathy, floppy hands. Labs/diagnostics: increased ammonia, AST, ALT, PT, Bilirubin. Decrease albumin and H&H. interventions: improving health habits, refraining from risky behavior, daily lactose to decrease ammonia, control BP

Myocardial Infarction

Clinical Manifestations: pain; sudden onset, substernal, crushing, tightness, severe, unrelieved by nitro, (radiate to back, neck, jaw, shoulder, arm). Dyspnea, syncope (decrease BP), n/v, extreme weakness, diaphoresis, denial is common, increased HR. Assessment: ST elevation Acute injury, ST depression- ischemia Treatment: O2 & IV meds, Monitor dietary restrictions, decrease Na, cholesterol, caffeine, PCI, surgery, pacemaker. Aspirin, beta-blockers, calcium channel blockers, statins, diet & exercise, healthy body weight Labs: CK/ troponin, ECG- presence of ST elevation, ECG, coronary angiography, left sided cardiac catheterization with purpose of inspecting the coronary arteries for blockage. Aspirin- nitroglycerin (max 3 doses, 5 min apart; don't give to patient on vasodilator)-morphine (if nitro doesn't work) - beta blocker, CCB, statins

Crohn's Disease

Clinical manifestations: anemia, involved through all layers of the bowel, mouth to anus skipping around. May lead to fistulas, abscess, peritonitis, strictures, adhesions. Nutritional deficits: inability to absorb nutrients, electrolyte imbalance, Lower Right Quadrant, abdominal pain, worse in right side. Stools typically soft but do not contain blood, diarrhea less severe. Abdominal cramps, anemia, K+, Na+. Labs: creative reaction protein, sed rate (ESR), CBC, electrolyte/fluids, albumin, protein, vitamin B12, iron. Colonscopy Treatment: end in mab, causes immunosuppression, teach first signs of illness and avoid crowds, TB test, surgery does cure, section of bowel removed only allows it to move to another location. Complications: strictures, fistulas, arthritis, inflammation, skin lesions, fever, anorexia, malaise, edema, malnutrition, sepsis, skin irritation, dehydration, anemia, narcotic bowel syndrome.

Ulcerative colitis

Clinical manifestations: beings in rectum & proceeds in a continues toward cecum. Two layers of intestines submucosa & mucosa, diarrhea, common > 20 stool per day, blood mucus, pus common, abdominal pain, Lower Left Quadrant, tenderness worse in left side, bowel urgency, tenesmus: spasm of the anal sphincter & persistent desire to empty bowel. Scar tissue common, Fluid imbalance, anemia, electrolyte imbalance. Complications: perforation; board like abdomen/rebound tenderness Treatment: colectomy, surgical, colostomy, proctocolectomy, encourage smaller frequent meals, decrease gastric motility, periods of rest, interprofessional team referral, pain management, skin care

Supraventricular tachycardia (SVT) "150-250 bmp" any rate over 150

Clinical manifestations: chest pain, palpitations, fatigue, dizziness, anxiety, SOB, hypertension, syncope. Treatment: slow down HR, vagal stim, adenosine, cardioversion, ablation

Breast Cancer

Clinical manifestations: new mass, lump, typically hard, irregular painless, chinges within the breast, swelling, peeling, flaking, pitting, dimpling or redness, changes within the nipple, inversion, thickening, drainage. Labs: mammogram, MRI, biopsy, ultrasonography. assessment: lymphedema (can't do BP, IV, needle sticks), skin changes, wound monitoring, monitor labs (bleeding), vital signs, I&O, daily weight, cough and deep breath, medications, wound care, nutrition, support (reach for recovery) mastectomy.

Chronic Renal Failure cont.

Decreased BUN/Creatinine Decreased GFR decreased RBC, HCT, HGB increased urine protein. hyperhalemia hypermag, hyperphos, hypocalcemia

Diabetic Ketoacidosis

Diagnosis: glucose > 230, pH: 7.30, keonuria, positive anion gap ( anion gap: 12+/- 4) Clinical manifestations: polyuria, polydipsia, dehydration, tachycardia, kussmal's respiration, ketone breath, N/V, deep rapid breathing, abdominal pain, mental status changes. Treatment: isotonic IV fluids, D51/2NS, insulin administration (regular insulin IV piggy bag), electrolyte imbalance correct.

COPD

Emphysema: alveoli collapse unable to get oxygen, excessive mucous pink puffer. Bronchitis: bronchials, constrict, excessive mucous, blue bloater. Causes: smoking, genetics, occupational exposure, age > 40, obesity, environmental dust/chemicals. Clinical Manifestations: respiratory distress, anxiety, SOB, tripod breathing, confusion, labored breathing, wheezing, chronic cough, dyspnea, barrol chest, rib cage, easily fatigued, increased respiratory infection, use of accessory breating muscles, thin appearance, edema, fatigue, pursed lip breathing, digital clubbing, decreased O2, increased RR. Labs: chest xray, ABGs, pulse ox, pulmonary function testing, oxygen (limiting amounts). Treatment: O2 application, Bipap, albuterol, steroids, pneumonia (antibiotics, budesonide, small frequent meals Education: smoking cessation, loss of weight, change environment, incentive spirometer, breathing techniques, deep breathing, pursed lip breathing, diaphragmatic sleep on pillows. Complications: decreased O2, change in consciousness, color change, decreased HR, decreased RR, fatigue, difficulty breathing, transfer of O2 to body, decreased perfusion, call MD if getting sick.

hyponatremia continued

Hypovolemic Hyponatremia: Decrease in body sodium and water in ECF; causes: renal insufficiencies, diuretics, diarrhea, vomiting, hyperglycemia, perspiration; clinical manifestations: weight loss, orthostatic hypotension, tachycardia, abdominal cramping, polydipsia. Euvolemic Hyponatremia: increase in body water, no edema or hypovolemia; causes: SIADH, endocrine disorders, hypothyroidism, adrenal insufficiency, polydipsia, antipsychotic drugs, anticholinergic effect causing dry mouth, increased thirst. Hypervolemic Hyponatremia: increase in ECF, increase in body sodium/water. Causes: heart failure, cirrhosis, nephrotic syndrome. Pg. 117

Radiation

can be delivered by many different routes, brady therapy, external, injected, radiosurgery, destroys the DNA structure to induce cell death, goal is to decrease size of tumor, but minimize injury to normal cells, doesn't differentiate between cancer & good cells, fatigue will have for months after treatment. 1) group needed activites/limit times in patient rooms, 2) skin irritated- unscented lotion, gentle w/skin, wash skin w/soap and water, double glove with all body fluids, avoid it if pregnant & children (know who could take care of them), small meals, private rooms, wear radioactive protective clothing, etc.

Benign Prostatic Hyperplasia (BPH)

causes: age, family history clinical manifestations: difficutly starting flow, straining, weak stream, interuptions, urgency, frequency, feeling of not complete emptying, uretheral obstruction, bladder obstruction, increased kidney pressure, AKI, infection, bladder stones, urinary hesitency, dribbling, nocturia, urinary retention. labs: digital rectal exam, PSA, urinalysis to rule out UTI, bladder scan, post void residual treatments: meds, avodart, finasteride (not handle if pregnant), terazosin, tamsulosin, assess postural hypotension, transurethral resection prostate (TURP), Irrigation, watch for clotting, palpate bladder for distention. complications: acute urinary retention, urinary tract infection, infection, hydronephrosis, pylenophritis, AKI, catheter occlusion, hypovolemic shock

Multiple Sclerosis

causes: autoimmune disorder (disease), women>men, 20-50 yo, family history, viral infection, impaired sensation, movement & thinking. clinical manifestations: numbness or weakness in one or more limbs, partial or complete, vision loss, aften w/pain during eye movement, double or blurred vision, tingling or pain, electric shock sensations that occur w/head movements, tremor, lack of coordination or unsteady gate, fatigue, dizziness. labs: test for Vit B12 & E deficience, lyme titer, antinurtrophilic antibodies, HIV/AIDs, ESR erythromycin sedimentation rate, inflammation, lumbar puncture, MRI. treatment: No cure, s/s of exacerbation, take meds, immunodiluator, immunodilator synthetic protein, immunosuppresents, anticholinergic, muscle relaxants, antispasmodic, anticonvulsants, stool softeners, corticosteroids. Assessment: impaired physical mobility, self-deficit, impaired coping, depression, neromuscular function. complications: mental changes, decreased concentration, attention deficit, memory loss, limb weakness, loss of coordination & balance, loss of sensation, speech impediment, tremors or dizziness, depression, unstable mood, visual disturbances, blurred vision, fatigue, numbness, tingling, princkling, bladder and bowel dysfunction, seizures, muscle stiffnes or spasms, paralysis of the in legs.

Hyperthyroidism (increased T3&4, decreased TSH)

causes: autoimmune disorder, increased metabolism, tumor in thyroid/pituitary, person feels like on treadmill. Clinical manifestation: increased HR, thyroid bruit, increased blood flow, heat intolerance, excessive sweating, diarrhea, increased mobility, increased appetite, weight loss, fatigue, nervousness, insomnia, hair loss, exophthalmos (bulging eyeballs "doesn't always go away permanent") labs: increased T3&T4, decreased TSH<0.4, thyroid scans, radioactive iodine, electrolytes treatment: eat everything they want, s/s hypothyroidism, take meds same time everyday, radioactive iodine therapy, PTU, tapazole, beta-blockers, quiet calm environments complications: Thyroid storm: cardiac/temp priority, dysrhthmias, hypertension, tachycardia, hypothermia (temp>102), seizures, death.

Pyelonephritis

causes: bacterial infection, pre-existing UTIs, vesicoureteral reflux-retrograde urine flow, obstructions (BPH, strictures, urinary stone) long term indwelling foley, pregnancy, sexual activity in women. clinical manifestations: signs of infection, fever, chills, N/V, anorexia, back and/or flank pain, s/s UTI, painful urination, hematuria. labs: urinalysis, urine culture, blood culture, CBC, WBC, pyuria, bacteria, hematuria. treatment: hospitalization, antibiotics, fluid replacement, NSAIDs, nacrotics, antipyretics, surgical management. complications: scarring, chronic kidney disease, permanent damage, urosepsis, bacteria, bloodstream sepsis, mental status changes, fever, tachycardia, hypotension, oliguria, leukopenia.

Hyperparathyroidism (hypercalcemia, hypermag)

causes: calcium released from bones-break bones down, increased renal reabsorption-kidney stones (Ca stones). Clincal manifestations: kidneys, GI tract, plyuria, anorexia, constipation, weakness, fatigue, bone pain. labs: increased PTH, Ca, decreased Phosphorus treatments: increased fluids, push out calcium (oral&IV), 3000ml/day, diuretics, oral phosphates. s/s hypo/hyper calcium, low calcium diet, increased fluids and fiber (prone to constipation)

Lung Cancer

causes: cigarette smoking, tobacco, alcohol, obesity, unhealthy diet, family history, second hand smoking radon, occupational pollutants, asbestos. clinical manifestation: new cough, does not go away or changes into a chronic cough, hemoptysis, SOB, wheezing, hoarseness and chest pain, head/bone pain, weight loss, persistent cough, dyspnea, frequent episodes of pneumonia/bronchitis labs: chest xray, CT scan, biopsy-bronchoscopy assessments: monitor temp (increased temp infection), oxygen sat, appetite, weight, breath sounds, cough pain. treatment: chemotherapy, palliative care, wedge resection or lobectomoy, breathing techniques, taking breaks, smoking cessation, nutrition, medication, routine pain meds.

Urolithiasis (kidney stones)

causes: dehydration, caucasians> blacks, family history, age, obesity, DM (diabetes mellitus), gout, sodium intake, protein intake, recurring stones. clinical manifestations: severe pain, back pain, colicky (like severe labor pain), N/V, distention/obstruction of urine flow, oliguria, lower abdominal, genital pain, along w/ irritative voiding, hematuria, stones painful. treatment: less than 5mm spontaneously pass, "trial of passage", pain management, fluids, IV fluids and pain meds, antiemetics, flomax, cardura, terazosin. pain scale, inflammation, blockage of flow, hydronephrosis. complications: pain, hydronephrosis, pylonephritis, urinary obstuction/ retention, if not passed after 4 to 6 weeks, surgery, urosepsis, renal damange, avoid oxilate, chocolate, coffee, caffeine, alaochol.

Ischemic Stroke

causes: development of arthersclosis, plauge that can lead to complete vessel obstruction or rupture, coagulation disorders, hypercoagulability, sickle cell disease, stroke history, diabetes, cryptogenic. clinical manifestations: weakness of the right face, arm, leg, decreased sensation to right side, loss of vision, weakness of left side, decreased sensation of left side, difficulty with speech, swallowing, decreased LOC. Labs: CT scan, aPTT, PT, INR, MRI, doppler ultrasound carotid artery, cerebral angiography, TTE, TEE. treatment: TPA, tissue plasminogen activatior, aterial thromotic administration, TPA admin not after 4.5 hours. NO TPA if hemorrhagic. neuro assessment complications: nonviable or dead brain tissue, fragile tissue, cytotoxic edema, cerebral edema, inadequate blood flow & oxygenation. weakness or paralysis, agnosia, homonymous hemcanopia, apraxia, depression, receptive or expressive aphasia. Neuro check!

Parkinson's Disease

causes: environmental toxins (pesticides, herbicides), brain injury, brain tumor, antipsychotic medications, family history, genetics. clinical manifestations: resting tremors, muscle rigidity, slowness of movement, bradykinesia, loss of movement akinesia, postural instability, impaired balance and frequent falls, weakness, fatique, mood, cognitive & behavioral alterations, uncoordinated movements. slow shuffling gait, widening gait, masklike face, arms flexed at elbows & wrists stooped posture, rigidity, hips & knees slightly flexed.

C.Diff

causes: excessive antibiotic use/history of c.diff antimicrobials, clindamycin, cephalosporins, fluroguinolones, age>64, duration of hospitalization, chemotherapy, nasogastic tube feedings, surgery, severe underlying causes, acid suppressing meds. clinical manifestations: diarrhea, inflammation, 3 or more watery stools. labs: increased WBC, Cdiff positive toxins, stool test, increased AST, ALT, PT, decreased HGB, HCT, albumin. treatments: wash hands, w/soap & water, nutriiton, wound care, bland food, barrier creams, hydration, limit exposure. complications: volume depletion (hypovolemia), renal insufficiency, electrolyte imbalances, hypoalbumin, hypokalemia, hypo/hyper Na, toxic megacolon, peritonitis, paralytic illius, sepsis.

Prostate Cancer

causes: family history, african american men, men 55 or older, diet low in fruits & vegetables, PSA level of 4 or greater, DRE results: large, palpable, prostate, urinary symptoms: obstruction, weak flow, distended bladder. clinical manifestations: trouble urinating, weak stream, elevated PSA, incomplete bladder emptying, frequency, urgency, urge incontinence, UTI, hematura, hysuria, perinal & suprapubic pain, erectile dysfunction, rectal symptoms, tenesmus. labs: digital rectal examinations (DRE), Prostate specific antigen (PSA) PSA>4.0, less than 2.5 recommended yearly testing, TNM (T=tumor, N=lymph nodes, M=metastasis). treatment: radiation, chemotherapy, hormone therapy (testosterone). complications: impitence, urinary incontinence, chemo-complications.

Colorectal Cancer

causes: high fat diet, obesity, bowel perforation, family history. clinical manifestations: change in bowel habits, including diarrhea, constipation. labs: occult blood test, biopsy, colorectal exam, colonscopy requires bowel prep, sigmoidscopy, CBC, decreased H&H= bleeding treatments: chemo-radiation, surgical, assess skin around stoma, NG tube, expected blood tinged mucous, post op, no stool until day 2-4. return of bowel sounds, tolerate food w/o N/V. complications: intestinal obstruction, absent bowel sounds, increased bowel sounds (body trys to get out defense), postop bleeding, abdominal distention, severe constipation.

Seizures

causes: traumatic brain injury, stroke, infaction, TIA, migraine, sleep disorders, cocaine, vasculitis, hydrocephalus, HTN, encephalophaty, increased intracranial pressure, eclampsia, fever, lupus, malaria, encephalitis, meningitis, renal failure, arrythmias, carbon monoxide poisoning, near drowning, hypo/hyper Na, hyper/hypo glucose, hypoCa, hypoMag, hypoparathryoid, ETOH withdrawal. clinical manifestations: labs: CT/MRI, EEG monitoring, vagal nerve stimulation, increased GABA needed, deep brain stimulation. treatment: airway protection, keep safe, anticonvulsants, antiepileptic, seizure precautions. complications: status epileptias, seizure activity > 5 min, head trauma, actue alcohol/drug withdrawal, metabolic disturbances, abrupt withdrawal of medication, respiratory, hypoxia-lorazpam, glucose monitor

Hodgkin's Disease (RH cells)

clinical manifestations: painless swelling lymph nodes of the neck, underarm, groin, low grade fever, drenching night sweats, weight loss> 10% in 6months. fatigue, itching, alchol induced pain, SOB as tumor enlarges. diagnosis/labs: chest xray, CT scan, PET scan (observe for metastisis), MRI, biopsy, CBC Assessment: monitor for complications, vital signs (fever), neurological status, lymph nodes, skin-itching, CBC, lower extremities, calcium levels. Risk of infection, disease process, treatment regimen, frequent rest peroids, diety s/s hypercalcemia, s/s SOB. Complications: superior vena cava syndrome: tumor pressing on spinal cord, fecial edema, SOB, chest pain, dysphagia, venous return impaired, lightheadednesss, mental status changes, thrombosis. spinal cord compression: pressure on cord, nerves, arteries, veins, neurological deficit or paralysis, from chemo or radiation, change in tumor size. Myelodysplasia (abnormal blood cell production, low RBC, WBC, platlets, low neutrophils so increased risk for infection. Tumor starts to metastis and bones starts to become involved and breakdown, increased calcium in blood stream leading to dehydration, polyuria, hypercalcemia.

Non-Hodgkin's (no RH cells)

clinical manifestations: painless swelling lymph nodes of the neck, underarm, groin, low grade fever, drenching night sweats, weight loss> 10% in 6months. fatigue, itching, alchol induced pain, SOB as tumor enlarges. diagnosis/labs: chest xray, CT scan, PET scan (observe for metastisis), MRI, biopsy, CBC Assessment: monitor for complications, vital signs (fever), neurological status, lymph nodes, skin-itching, CBC, lower extremities, calcium levels. Risk of infection, disease process, treatment regimen, frequent rest peroids, diety s/s hypercalcemia, s/s SOB. Complications: superior vena cava syndrome: tumor pressing on spinal cord, fecial edema, SOB, chest pain, dysphagia, venous return impaired, lightheadednesss, mental status changes, thrombosis. spinal cord compression: pressure on cord, nerves, arteries, veins, neurological deficit or paralysis, from chemo or radiation, change in tumor size. Myelodysplasia (abnormal blood cell production, low RBC, WBC, platlets, low neutrophils so increased risk for infection. Tumor starts to metastis and bones starts to become involved and breakdown, increased calcium in blood stream leading to dehydration, polyuria, hypercalcemia.

Neutropenic Precautions

handwashing, avoid crowds, avoid sick people, wash all fuids&vegetables will prior to eating, best to avoid fruits with bumps in them such as raspberries, monitor temp daily, for fevers seek immediate treatment, no live plants or cut flowers, avoid standing water even in home appliances such as humidifiers, take all medications, private room hospitals, NO rectal temps, supp, or enemas, no small children, no live vaccines, wear mask, don't stock them multiple times, group tasks.

Ventricular Tachycardia

no identifiable P or QRS wave, ECG shaking look Causes: hypovolemia, hypoxia, acidosis, hypokalemia, hyperkalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, MI, PE Treatment: chest compressions, defibrillation, medications (amiodarone, epinephrine, vasopressor)

Cancer

s/s: change in bowel or bladder, a sore that won't heal, unusual bleeding or discharge, thickening or lump in breast or any part of the body, indigestion of difficulty swallowing, obvious change in a wart or mole, nagging cough or hoarseness risk factors: tobacco, reproductive factors, occupational exposures, radiation, alcohol, microbes, obesity, family history, unhealthy diet. prevention: Primary: avoiding things that are known to cause cancer (don't smoke, use sunscreen, exercise) secondary: screenings for cancers. Tertiary prevention: treatment once you have it manage s/s.

Asytole

treatment: CPR, epinephrine, treat the cause.

Anemias

Iron deficiency: Causes: infection, inadequate diet, peroids of blood loss, growth, pregnancy, infants, children, hemorrhage, chronic blood loss. Clinical manifestations: swelling of the tongue (glossitis), spoon shaped finger nails (koilo....) tachycardia, tachypnea, fatigue, pallor, SOB, blood loss, cognitive impairment. Labs: CBC (HCT & HGB) decreased Treatment: O2, management of N/V, constipation, change in stool black (normal), iron supplements, vit C. fortified cereal, beans, red meat, dark chocolate, leafy greens, spinach, broccoli, peas, beets, ingestion of vit C, oranges, grapefruit. Complications: adverse effects CHF, renal failure, thermoregulation, immune dysfunction, psychomotor abnormalities, cognitive impairment Vitamin B12: Causes: malabsorption, cirrhosis, alcoholism, poor nutrition, long term vegetarian. Clinical manifestations: neuro deficits, altered mental status, visual disturbances, numbness, psychiatric effects. Labs: CBC (H&H) decreased Treatment: eat b12, decrease alcohol, follow-up lab work, prenatal teaching, diet, clams, diary, seafood, eggs, cheese, tuna, b12 injections, Complications: comorbidities, cancer risk, impairs DNA synthesis, fatigue, dizziness, pallor, SOB, orthostatic hypotension. Folic Acid: Causes: malabsorption, alcoholism, bariatric/colon surgery. Clinical manifestations: pallor, tachypnea, pacytopnea, low platelets, dizziness, fatigue, confusion. Lab: CBC- HGB Treatment: increase intake of folic acid, supplements, increased nutrition, cereal, avocadoes, bananas, soy beans, rice, citrus, popya, pinto beans. Complications: neural tube underdeveloped, decreased perfusion, delayed development. Sickle cell: Causes: genetic, fever, liver/kidney disease Clinical manifestations: sudden onset of pain, deoxygenation, fatigue, pallor, SOB, swelling of joints. Labs: genet

Myeloid Leukemia (AML)

Leukemia: Infection, bleeding, neutropenic precautions) Clinical manifestations: swollen lymph nodes, fatigue, pallor, SOB, petechia, nosebleeds, low grade fever. Labs: CBC, thrombocytopenia, anemia, leukocytosis, neutropena, bone marrow biopsy. assessment: neutropenic precautions, vital signs temp and pain, bruising bleeding, fatigue pallor, dizzy, SOB, bleeding precautions, s/s of infection, fatigue.

Hepatitis

Liver Inflammation (sudden and massive) a&e-fecal b,c,d,f&g- blood complications: biliarystone, build-up of medications (toxic) clinical manifestations: elevated temp and pulse (inflammation), jaundice, fatigue, decreased appetite, elevated LFT, mild-flu like symptoms assessment: vital signs, hepatic diet: small frequent meals with moderate protein, limit fat, vitamin supplements, folic acid, thiamine, multivitamin, avoid alcohol. Labs/diagnostics: elevated bilirubin, ALT and AST, GGT and alkaline phosphate, hepatitis panel, low albumin, usg, CT scan, liver biopsy interventions: bedrest, avoid hepatic meds, PRN pain meds and antiemetics, interferon for hep c treatment, questran itching and cholestrol breakdown.

Bone Marrow Depression (biopsy)

Purpose: thrombocytopenia, anemia, leukemia, metastatic tumors. Interventions: check vitals, CBC, PT, INR, PTT, platelet count, medication lists, position patient based on biopsy site. Apply pressure 5-10 min or until bleeding stops, apply sterile dressing, patient to rest several hours, leave dressing in place 24 hours, report saturated dressing or bleeding, instruct s/s of infection, 5-10 days later. Avoid invasive procedures. Education: avoid bearing down, use stool softeners, daily skin inspection, avoid flossing when platelets very low, avoid invasive procedures, needle sticks, surgery, dental procedures, injections, protect from injury.

Hypercalcemia

Causes: Clinical Manifestations: abdominal pain, constipation, bone pain, decreased deep tendon reflexes, hypertension, thirst, lethargy, muscle weakness Treatment: IV fluids, loop diuretics, bisphosphates

Hypocalcemia

Causes: Clinical Manifestations: anxiety, confusion, irritability, paresthesias, Chvostek/Trousseau sign, tetany, twitching, tremors Treatment: IV calcium, oral supplements (calcium tablets, tums)

Hypothyroidism (decreased T3&4, increased TSH)

Causes: "decreased metabolism" thyroid surgery, radioactive iodine therapy, middle age women (30-60). Clinical manifestations: goiter, fatigue, decreased LOC, decreased mentation, decreased energy, increased sleeping, weight gain, Non-pitting edema (periorbital edema), decreased HR, RR, Cardiac output, constipation, thinning hair, always cold, low temp, dry skin, hair loss, apathy, lethargy, facial eyelid edema, anorexia, brittle nails. labs: decreased T3&T4, increased TSH treatment: synthroid, daily weights, constipation, decreased metabolism, increased constipation, life long therapy, take meds in AM, s/s: hyperthyroidism, start low and increase as needed or decreased meds PRN. might take a year to get dosage right. monitor vital signs: decreased HR, RR, Temp. complications: Myxedema coma (emergency); hypoxia, F&E imbalance, hyponatremia, hypoglycemia, hypotensive, ICU, ventilator support, meds needed to increase BP, HR. cytomel, warm blankets, monitor LOC. fatigue, obesity, decreased metabolism, cardiac complications.

Respiratory Acidosis

Causes: CNS depression (trauma, over sedation, anesthesia, high cord injury), pneumothorax, hypoventilation, bronchial obstruction, atelectasis, severe pulmonary infection, heart failure with pulmonary edema, massive PE, multiple sclerosis Clinical manifestations: dyspnea, restlessness, hypoventilation, tachycardia, hypoxemia, respiratory distress, decreased responsiveness, CNS depression, confusion, increased CO2, dysrhythmia, hyperkalemia, Lab: VS, high K, chest xray, CBC, ABG, assessment neuro, telemetry, EKG Treatment: bronchodilators, oxygen, treat hyperkalemia (kayexalate, insulin, albuterol), antibiotics, chest physiotherapy, chest tube if pneumothorax, ventilator if severe, reverse sedation, diuretics for heart failure.

Hypokalemia

Causes: GI loss, renal loss, diarrhea, vomiting, NG suctioning, excessive use of enemas, laxatives, anorexia, bulimia, excessive diuretic usage Clinical manifestations: weakness, lethargy, hyporeflexia, ECG changes (ST depression), PVCs, nausea/vomiting, constipation, abdominal cramping, hypoventilation, respiratory distress, respiratory arrest, skeletal muscle weakness or cramping. Treatment: increase dietary intake or supplementation, slow K, KCL liquid, powder, tablets, IV replacements. Peripheral IV, Central line, **Never give IV push Complication: muscle weakness and cramping, decreased GI motility, cardiac dysrhythmias, respiratory failure, cardiac or respiratory arrest, death.

Airway Management

Nasal cannula: 1-6L/min Simple facemask: 5-10L, 40-60% O2, short term use Venture mask: 4-6 L/min, 24-60%, COPD patients Non-rebreather: min 10L/min, up to 90% O2, keep bag inflated at all times.

Hypomagnesmia

Causes: Clinical Manifestations: paresthesias, tetany, twitching, tachycardia, n/v, seizures, anorexia, dysrhythmias: rapid heart rate and PVCs, ventricular tachycardia, emotional liability, deep tendon reflexes increased. Treatments: IV replacement, Magnesium 2 g in 100mL NS or D5W over 1 hour, magnesium tablets, IV push code blue situation

Hypophosphetemia

Causes: Clinical Manifestations: weakness, slurred speech, irritability, confusion, increased bleeding Treatments: phosphorous supplementation, Neutra-phos powder, KPhos IV replacement

Hypermagnesemia

Causes: Clinical manifestations ECG changes, widened QRS, hypotension, bradycardia, drowsiness, lethargy, decreased deep tendon reflexes Treatment: increase fluids

Hyperphosphetemia

Causes: Clinical manifestations: muscle cramps, paresthesia, weakness, decreased DTRs, ECG changes Treatments: PhosLo capsules, oral phosphate-binding drugs, If normal renal function, IV NS & loop diuretics

Pneumonia

Cause: COPD, recent hospitalization, less than 5, greater than 65, heart problems, immunosuppressed, ventilator, smoking, consuming alcohol, chronic disease, malnutrition, HIV, AIDs/ Cancer. Clinical Manifestations: obstruction of bronchials, decreased gas exchange, cough, fever, chills, tachycardia, tachypnea, dyspnea, pleural pain, malasia, respiratory distress, decreased breath sounds, productive cough, overall not feeling well, rhonchi, wheezing. Labs: c-reactive, sputum testing, WBCs, CRP, lactic acid (sepsis), blood cultures, chest xray, ct scan, altered mental status, RR>30, hypotension temp <95 or >104, pH 7.35. Treatment: bronchodilators: albuterol, antibiotics, oxygen, increased IV fluids to thin secretions, get secretions out, breathing techniques. Turn cough, deep breath, oral care, ambulation, take all antibiotics, rest, hand hygiene, monitor s/s. Complications: sepsis, decreased urinary output, hospital/community acquired, MRSA, apsiratio, acidity gastric contents, agitation, confusion, lung collapse.

Cushing's Disease

Cause: age, pituitary radiation, severe hypertension, severe hypokalemia. Clinical manifestations: hypervolemia, increased BP, buffalo hump, thin skin, truncal obesity, (abdominal/belly fat), moon face, purple striae, hyperglycemia, male/female features, hyperkalemia, increased acid, GI distress, bruises, petechiae, edema, decreased immunity, osteoporosis, irritability, anxiety, personality changes. Labs: BMP: hyperglycemia, hypernatremia, hypokalemia, decreased BUN. U wave. Treatment: avoid crowded areas, prevent infection, radiation (stop hypersecretion), diuretics (spironolactone), dietary: decreased Na, K rich, blood sugar, skin. Care, monitor/call MD fiver, emotional support, wear med bracelet. Complications: hypervolemia, hyperglycemia, increased risk for skin breakdown, cardiac dysrhythmias, MI & stoke.

Appendicitis

Cause: laxative, malignant tumors, twisting and kinking, edema of wall bowel, adhesions, infection. Assessment: vital signs, I&O, rebound tenderness, WBC w/differential, make NPO, IV fluids. Clinical manifestations: fever, tachycardia, fluid loss, pain, cramping periumbilical, anorexia, nausea, vomiting, right sided pain, mcburneys point, rebound tenderness, Rovsigns sign, left sided pain palpation, right sided pain Labs: WBC increased, CT scan, appendectomy w/laparoscopy, CBC. Treatments: NPO status, IV fluids, turning, coughing, deep breathing, antibiotics, incentive spiromenter. Complication: gangrene, perforation, peritonitis: firm ridge board like abdomen, abrupt change in pain, change in BP or HR, fever, emergency surgery.

HIV/AIDS

Cause: sexual transmission, IV drug use, occupation exposure (needle sticks), transmission during pregnancy, breast feeding. Clinical manifestations: flu-like symptoms, low grade fever, fatigue, aches, feeling generally unwell, swollen lymph nodes, diarrhea, cough, weakness, N/V, dysphagia, difficulty swallowing, SOB, dyspnea, exertion, new onset headache, vision changes, pain, night sweats, lymphadenopathy, weight loss, skin lesions, blurred vision. Labs: CD4+ count and viral load. Increased viral load= high HIV load AIDS: less than 200. 500-200 (HIV). less than 200 (AIDS) Treatment: 3 meds needed to help fight disease, life-long treatment, no live vaccines, decreased immune response, monitor: temp, pulse, RR, oxygen, weight trends, CD4+, viral load, adherence, TB status, immune status, depression. Medications: tenofoiver/Retrovir, nevirapine/efavirenz, tionavir, aplovair. Complications: decreased immune response, increased risk for infection, vaginal candidiasis, diabetes, fever, fatigue, bacterial infections, immune reconstruction, inflammatory syndrome.

Atrial Fibrillation (no P wave)

Controlled AF AV node maintain HR < 100 bpm (60-100) Uncontrolled AF HR between 100-149 bpm "dizziness, palpitations, irregular O2" AF w/ RVR HR > 150 "symptoms, No P wave" Causes: cardiomyopathy, pericarditis, pulmonary disease, HTN, valvular disease, coronary artery disease. Complications: loss of CO and blood clots, HF and stroke Treatment: anticoagulation, beta-blockers, digoxin, calcium channel blockers, cardioversion, TEE, catheter ablation.

PCA pumps/ IV push pain

Pain control Risk factors: inadequate pain control; older adults, substance abusers, language barriers. Assessment: location, intensity, quality, onset and duration, alleviating or relieving factors, effect of pain on quality of life and functional status, comfort and function goal. Pain scales. Capnographic monitoring Clinical management: Nonopioids, opioids, adjuvant analgesics (nerve blocks, lidocaine patch), NSAIDs Side effects: constipation, nausea, vomiting, pruritus, sedation, respiratory depression. Don't dilute IV push medication.

Preoperative care/post opertive superficial surgical site infection/complications

Patient safety: anesthesia, environmental factors (flammable gas, fire risk in OR), positioning injuries, surgical care improvement projects (SCIP): make sure patient is comfortable position, prevention of infection, prevention of cardiac events, prevention of venous thromboembolism; SCDs/TED hose, lovenox, aspirin. Causes: allergies, medication, experiences with surgery, anesthesia, decreased immunity, decreased muscle mass, post op delirium, decreased nutritional status, increased risk of perfusion issues, genetic metabolism. Priorities: accurate weight/height, client has voided/cath, skin prep such as shower, bath/shower w/ antimicrobial soap. Informed consent, nurses roles/education, site marking by MD & patient. Labs: urinalysis, CBC, electrolytes, creatinine, BUN, clotting, type and cross match, chest xray, EKG Treatment/education: regulations concerning valuables, jewelry, dentures, food and fluid restrictions, NPO after midnight, foley, NG tubes, enemas, preop meds, OR, transport, skin prep, postanesthesia. Pain management plan, respiratory care, incentive spirometry, deep breathing, coughing splinting, leg exercises, early ambulation, turning Complications: malignant hyperthermia (genetic metabolism, extremely elevated temp, tachycardia, dysrhythmias, muscle rigidity, hypotension; treatments: meds, fluids, ice), respiratory- hypoventilation, aspiration, pneumonia, DVT, PE, cardiac complications, constipation, urinary retention. Anesthesia: general: total loss of consciousness, loss of motor control, loss of reflexes, intubation & mechanical ventilation. Local: topical or by local infiltration, Ex: skin cancer removal or closure of skin wound. Regional: nerve block, epidural, spinal. Moderate sedation: reduces pain & awareness, able to maintain own airway. Breathe on their own, used for endoscopy (colonoscopie

Hyperglycemia (increased sugar, decreased insulin)

Type 1: autoimmune process, rapid onset, children, young adults. Total insulin deficiency, beta cells are destroyed, Bone and/or pancreas issues. Clinical Manifestations: polyuria, polydipsia, polyphagia, weight loss, glucose-urine, fatigue. Type 2: the body doesn't produce enough insulin or is resistant to the insulin, onset in adults, produces some insulin but not enough for demand (more common than type 1) Change in dietary/ exercise, weight loss; insulin not always used the way its needed. Clinical manifestations: fatigue, poor wound healing, cardiovascular disease, visual disturbances, renal insufficiency, recurring infection, darkening of skin. Labs: hemoglobin A1C < 6.5 (what you want, however higher number bad) Fasting glucose < 126; glucose 70-110. Treatment: rapid acting (Humalog/novolog) 15-30 min, intermediate (NPH) 30-60min, long acting (lantus) 1-1.5 hr. Complications: decreased immune response, increased infection rate, prolonged hyperglycemia causes: CV, diabetes neuropathy, kidney damange, neurological effects, peripheral neuropathy, autonomic neuropathy.

Blood Transfusions

Platelet: given for low platelet counts, active bleeding, scheduled for invasive surgery. If platelets < 20,000. Packed blood cells: given to replace cells lost from trauma, surgery, oncology Plasma: given to replace blood volume and clotting factors Granuloxyte (WBC): given rarely to neutropenic patients. Responsibilities: Pre-transfusion: Verify prescription with another RN, test donor's/recipients blood for compatibility (type and crossmatch), verify patent IV access before picking up blood from blood bank, obtain informed concent for administration of blood products, verify patient's identity with another RN, examine blood bag label, attached tag, and requisition slep for ABO and Rh compatibility with the patient and another RN, check expiration date with another RN, inspect blood for discoloration, gas bubbles, cloudiness, baseline VS. During transfusion: provide education, begin transfusion slowly stay with paitnet first 15 to 30 minutes, check vital signs more frequently as per agency policy, ask patient to report unusual sensations (chills, SOB, hives, itching) administer blood products per protocol, assess for hyperkalemia, assess for fluid volume overload, infuse over 1.5 to 4 hours. Must be infused by 4 hours. This will be given with NS. Blood transfusion reactions: Febrile reaction: chills, fever, headache, flushing, tachycardia, anxiety Allergic reaction: gives, pruitus, facial flushing, SOB, bronchospasm, anxiety. Hemolytic reaction: low back pain, hypotension, tachycardia, fever, chills, tachypnea, hemoglobinura, immediate onset. Nurse response: STOP TRANSFUSION!! And notify MD. Change tubing, treat symptoms, O2, fluids, epinephrine, recheck type and crossmatch. Obtain 2 samples of blood, UA test, monitor fluid/electrolytes, evaluate serum calcium.

Insufficient Nutrition/ Protein Calorie Malnutrition/ Vitamin Deficiencies/ Obesity/ BMI

Pre albumin: 16-30, albumin: 3.5-5.5, blood glucose 70-110, A1C <6.5, lipid profile, electrolytes, H&H. Zinc: dermatitis, impaired taste, growth low, low level phosphate; copper deficiency, renal damage, N/V, diarrhea. Vit A: night blindness, loss of appetite, bone pain, hypercalcemia Vit B: wernicks encephalophathy, w/neruodegeneratiion, toxicity rare Magnesium: hypertension, dysrhythmia, preclampsia; increased calcium excretion. B3: pellagra-dermatitis, diarrhea, dementia, death; abnormal glucose, metabolism flushing, nausea, vomiting. B12: pernicious anemia, psychiatric disorders; uknown Biotin: hairloss Vitamin C: bleeding tendency, scurvy; inhibits zinc absorption, urinary stones. Vitamin D: rickets, bone disease, muscle pain, falls; hypercalcemia, renal stones, calcification. Copper: anemia, skin lesion, neurlogic disease, bone fragility; wilson's disease, neuro/liver damage. Iron: anemia, fatigue, poor growth Obestiy/BMI: Insufficient nutrition: BMI under 19, 8& weight loss in the past 4 months, bedrest, dysphagia, failed swallow test, anorexia nervosa, injury/ trauma, cancer. NPO, clear or full liquids diet. 30> overweight

Sepsis

Risk factors: infections, surgical procedures, pneumonia, UTI pressure injury Complications: organ failure and death Clinical manifestations: purulent discharge, acidotic, increased lactic level, fever Lab/Diagnostics: increase lactic acid over 2, decrease BP, increase HR. RR and temp, platelets less than 100,000, 2 blood cultures, treatments: fluid resucitation, antibiotics, and steriods. any 2 of the following and new to the patient: Temp < 98.6 <100.9 HR > 90 RR > 20 WBC > 12 <4 1 of the following: SBP <90 (drop of 40 points from baseline) Lactic acid > 2 Cr> 2 w/o renal failure Bilirubin > 2 w/o liver disease new Dx of respiratory failure PLT < 100 INR > 1.5 w/o warfarin

Thrombocytopenia (normal platelet 150,000-400,00)

Risk for Bleeding! Clinical manifestations: bruising, petechia, bleeding around gums, nosebleeds, bleeding from GI. Diagnosis: bone marrow aspiration, arteriogram, venogram/ ultrasound

Renal Failure

Stage 1: kidney damage with normal GFR 90 or above; your MD find cause and treatment. Stage 2: 60-89; your doctor will estimate how quickly your disease is progressing, control BP & blood glucose, continue to monitor. Stage 3: 30-59; MD check for complications, anemia, bone disease, begin treatment. Continue monitoring Stage 4: 15-29; decide what type of treatment you want if kidney failure develops, continue to monitor and treat. Stage 5: Kidney failure below 15; start dialysis, have kidney transplant or choose palliative care, continue to monitor and treat. Clinical Manifestations: peri-orbital edema, lower extremity edema, uremic frost (skin feels sandy, & itching), extreme fatigue; worse after dialysis or when BUN/Creatinine are extremely elevated. Labs: BUN/creatinine diagnostic increased; GFR: function/stages; RBC, HGB, & HCT: decreased; Urine protein increased; electrolytes: K Increased, Mag increased, phosphorus increased, calcium decreased. Treatment: healthy diet, exercise, monitor I&O, if pulled to much fluid off might need to fluid resuscitate, status of swelling, vitamin supplementation, renal replacement therapy, prevent infection, Lasix, foley usage, oxygen, EKG (peaked T wave, elevated HR), chest xray. Monitor fluids. Avoid foods: high in sodium, cheese, processed meats, salted butter, margarine, canned vegetables, canned soup. Foods high in potassium bananas, potassium, potatoes, tomatoes, avacadoes, grean leafy vegetables, milk, citrus fruit/juice, pineapple, squash, beans. Foods high in phosphorous, whole grain products, most cereals, milk and cheese, beans and nuts. Dialysis: hemodialysis: they pull x amount of fluids out over about a 4 hour period. Continuous dialysis: since patient isn't tolerating all at once; Peritoneal dialysis: can be done at home, increased risk for infections. Educat

Chemotherapy

antineoplastic agents, administered IV & PO, doesn't differentiate cancer and normal cells, heart & liver affected. Infection prevention: appropriate PPE/ protective clothing, comfort pain control, nausea control, nutrition improvement, education, psychological, mouth care, liver enzyme monitor, safe body fluid handling (double glove), assessment: neuro, cardiac, kidney, I&O, GI, give nausea medication 30 min prior to chemo, reverse PPE precautions. Stem cells & bone marrow: clients w/ leukemia, donated to give to needed clients. Side effects: rgjection, bleeding, infection, pain, swelling. priorities: infection=kills healthy WBC, bleeding=thrombocytopenia, ABCs=decreased O2 sat, neuro changes, nausea, vomiting=nutrition, safety=patient/nurse, PPE, free of infection, fall prevention, pain, mylosuppression/attacking all stem cells in bone marrow, neutropenic precautions.