NUR 416 Final

Diabetes Mellitus

__ is a chronic multi system disease related to abnormal insulin production, impaired insulin utilization, or both. It is a serious health problem and its prevalence is increasing rapidly.

Spinal shock and neurogenic shock

About 50% of people w acute SCI experience a temporary neurologic syndrome known as __. This type of shock is characterized by decreased reflexes, loss of sensation, sf flaccid paralysis below the level of injury. This syndrome lasts days to months and may mask post injury neurologic function. __ is due to loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. These effects are generally associated w cervical or high thoracic injury (T6 or higher).

Basilar skull fracture

An ex of a skull fracture, a __ is a specialized type of linear fracture involving the base of the skull. S/s may include cranial nerve deficits, Battle's sign (post auricular ecchymosis-behind ear), and periorbital ecchymosis or raccoon eyes. Generally this fracture is associated w a tear in the dura and subsequent leakage of CSF. Rhinorrhea (CSF leakage from nose) or otorrhea (CSF leakage from ear) generally confirms that the fracture has transversed the dura. The risk of meningitis is high w CSF leak, so antibiotics should be administered to prevent. To test if the fluid is CSF test fir glucose; if blood is present then look for halo or ring sign since blood contains glucose. For this, drip on white gauze or towel and the blood will move to center and yellow ring around it if CSF present. For pt w basilar skull fracture, avoid NG tubes. If absolutely needed, insert under fluoroscopy.

Altered mental status

Burn management can be organized chronologically into three phases: emergent (resuscitative), acute (wound healing), and rehabilitative. Emergent phase manifestations can include shock from hypovolemia, blister, paralytic ileus (absent/decrease bowel sounds), shivering, and __.

Acute Coronary Syndrome (ACS)

CAD becomes either chronic stable angina or __ when ischemia is prolonged and not immediately reversible, which leads to unstable angina, non-ST segment elevation MI (NSTEMI), and ST-segment elevation MI (STEMI). Associated with deterioration of a once stable atherosclerotic plaque. Stable plaque ruptures, stimulating vasoconstriction w thrombus formation. Unstable lesions may be partially occluded by a thrombus manifesting as UA or NSTEMI or totally occluded by a thrombus manifesting as STEMI. Inflammation has a major role in causing unstable plaque. ((Ischemia is decrease is blood supply to heart tissue--beginning of this and infarction is end result when ischemia goes on for too long--tissue begins to die))

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CV: Cord injury above level T6 greatly decreases the affect of sympathetic nervous system. Bradycardia occurs-give atropine. Peripheral vasodilation reduces venous return to heart which decrease cardiac output resulting in hypotension (dopamine). Iv fluids or vasopressor drugs may be used to tx as well. Urinary: Acute phase=Urinary retention, Bladder atonic and over distended; Indwelling catheter is used to drain bladder intermittently every 3-4 hours-strict aseptic technique. Post acute phase=Bladder may be hyper irritable; Loss of inhibition from brain resulting in reflex emptying; chronic indwelling catheter increases risk of infection. Monitor s/s of UTI.

C4

Cervical injuries above level of __ cause total loss of resp function so mechanical vent is required to keep pt alive. Below C4, the result is diaphragmatic breathing if phrenic nerve is functioning. Spinal cord edema and hemorrhage can affect the phrenic nerve and cause hypoventilation due to decrease in vital capacity-mechanical vent may be needed initially. Cervical and thoracic injuries cause paralysis which results in pt not being able to cough to remove secretions leading to atelectasis and pneumonia. An artificial airway provides direct access for infection so hygiene and chest PT is important. Assisted coughing and tracheal suctioning may be needed.

Dysrhythmias Cardiogenic shock Acute pericarditis Dressler syndrome

Complications of MI include __ which are most common complication. Most common cause of death. Can be caused by ischemia, electrolyte imbalance, and SNS stimulation. Disrupts rhythm of heart which can cause tachycardia, bradycardia, or irregular HR all of which can be fatal. Heart failure is a complication that occurs when the heart's pumping action is reduced. Can be subtle or severe and s/s include dyspnea, restlessness, tachycardia, pulm congestion, S3 and S4 sounds, crackles, jugular vein distention. __ occurs when oxygen and nutrients supplied to tissues are inadequate bc left ventricular failure. When it occurs it has high mortality rate-needs aggressive management of maximize O2 delivery, reduce O2 demand, and prevent complications. Tx epinephrine and vasopressors. Other complications include __ which is an inflammation of visceral and/or parietal pericardium which may result in cardiac tamponade, decreased ventricular filling and emptying, and HF. Occurs 2-3 days after MI and is characterized by chest pain aggravated by inspiration, coughing, and movement of upper body. Sitting forward may relieve pain. Assess pt for presence of friction rub, possible fever, and possible hypotension or narrow pulse pressure. Dx w 12-lead ECG. Tx w NSAIDS, aspirin, or corticosteroids. __ is pericarditis w effusion and fever that develops 4-6 weeks after MI. Pt may experience pericardial pain, fever, friction rub, effusion, and arthralgia. Elevated WBC and sedimentation rate. Tx w short term corticosteroids.

CABG Stool softeners

Coronary re-vascularization w CABG surgery is recommended for pt who fail medical management, have left main coronary artery or three vessel disease, not candidates for PCI, failed PCI and continue to have CP, diabetes, or expected to have longer term benefits w CABG than w PCI. __ is placement of conduits to transport blood between aorta another major arteries. Requires sternotomy (opening of chest cavity) and cardiopulmonary bypass (blood into machine and returned to pt via pump). Allows surgeon to work w nonbearing heart while perfusion to organs is maintained. Uses veins and arteries for grafts. For a patient with ACS drug treatment typically begins w IV NTG which reduces pain and improves coronary blood flow by vasodilating. Dual anti platelet therapy (aspirin and clopidogrel) and anticoagulant drugs are used initially as well. Morphine is drug of choice when chest pain is unrelieved by NTG bc it vasodilator more intensely--mon bradypnea and hypotension. BB decrease oxygen demand by reducing HR and BP--used for pt not at risk for complications of an MI. ACE should be started within first 24 hours and continued indefinitely for pt recovering from STEMI of anterior or EF less than 40%--slows progression of HF. Antidysrhythmic drugs are most common for tx of dysrhythmias after an MI. Lipid lowering agents (statin, fibrates, niacin, cholestyramine) should be used for elevated triglycerides. __ should be used after an MI bc pt may be predisposed to constipation due to bedrest and opioid use. Nutrition should be NPO until stable then advance diet as tolerated to low salt low saturated fat and low cholesterol diet.

SBAR tool

Critical information needs to be transmitted quickly so that action can be taken. This is why nurses should use __ communication tool. This includes pt situation, background, assessment, and recommendation. The situation is where you should identify yourself and position, pt's name and current situation. Give clear, concise overview of pertinent issues. The background is where you state relevant hx and physical assessment pertinent to problem, tx and clinical course summary, and any changes noticed during physical exam. Assessment is where you offer conclusion about present situation. Summarize facts and give best assessment (what is going on). Recommendation is where you explain what you think needs to be done, what the pt needs and when.

Neurogenic

Distributive shock consists of neurogenic, anaphylaxis, and sepsis. __ is a hemodynamic phenomenon that can occur within 30 mins of a spinal cord injury at the fifth thoracic vertebra or above; it can last up to 6 weeks. The injury results in a massive vasodilation without compensation bc of loss of SNS vasoconstrictor tone. Leads to a pooling of blood in the blood vessels, tissue hypo perfusion, and ultimately impaired cellular metabolism. This causes decrease venous return and CO. S/s hypotension, bradycardia, temp dysregulation-hypothermia, dry skin, and poikilothermia (taking on temp of environment). Nursing care includes treatment of the hypotension and bradycardia with vasopressors (epinephrine/norepinephrine) and atropine; Fluids used cautiously as hypotension generally is not related to fluid loss; Monitor for hypothermia. If spinal cord then stabilize spine.

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During assessment of delirious or potentially delirious pt use STOP, THINK, MEDICATE. Stop: Do any medications (especially benzo-diazepines) need to be stopped or lowered? Is the patient on the minimal amount of sedation necessary? Do any titration strategies need to be used, such as a targeted sedation plan or daily sedation cessation? Do the sedative drugs need to be changed? Think: Toxic situations like CHF, shock, dehydration • Deliriogenic medications; New organ failure; Hypoxemia; Infection or sepsis; Immobilization; Non-pharmacologic interventions employed= Glasses, hearing aids, reorientation, sleep protocols,noise control; K+ or electrolyte problems. Medicate: No FDA-approved drug to treat delirium; Haloperidol (Haldol) and atypical antipsychotics (ziprasidone [Geodon], quetiapine [Seroquel]); Traditionally recommended medication class to treat delirium; Little evidence to support treatment; All patients receiving antipsychotics should be routinely monitored for side effects, especially QT prolongation

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Emergency tx for heady injury: -Patent airway with cervical spine stabilization -Intubate if GCS <8 -Give O2 100% non rebreather mask -IV access w two large bore catheters to infuse NSS or LR -Control external bleeding w sterile pressure dressing -Remove pt's clothing -Maintain pt warmth w blanketts, warm IV fluids, overhead warming lights, warm humidified O2 -Monitor VS, LOC, O2 %, cardiac rhythm, GCS, pupil size and reactivity -Anticipate possible intubation if gag reflex is impaired or absent -Assume neck injury with head injury -Assess for rhinorrhea otorrhea and scalp wounds -Administer fluids cautiously to prevent fluid overload and increased ICP

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First degree burn (partial thickness): Epidermal tissue only affected. Erythema, blanching on pressure, mild swelling, no vesicles or blister initially. Not serious unless large areas involved. i.e. sunburn. Second degree burn (deep PT): Involves the epidermis and deep layer of the dermis. Fluid-filled vesicles -red, shiny, wet, severe pain. Hospitalization required if over 25% of body surface involved. i.e. tar burn, flame Third/Fourth degree burn (full thickness): Destruction of all skin layers. Requires immediate hospitalization. Dry, waxy white, leathery, or hard skin, no pain bc nerve endings are gone. Exposure to flames, electricity or chemicals can cause 3rd degree burns.

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For all shock: Nursing assessment begins w ABCs. Focused assessment of tissue perfusion: Vital signs - Peripheral pulses - Level of consciousness - Capillary refill - Skin (e.g., temperature, color, moisture) - Urine output; Brief history - Events leading to shock - Onset and duration of symptoms; implement health promotion; identify at risk pt (older adults, debilitating illness, immunocompromised, surgery/trauma pt); prevent shock by monitoring fluid balance, hand hygiene to prevent infection, continuous PO, ABG analysis, most pt will be intubated, continuous ECG, monitor urine output, monitor temp and skin, bowel sounds- ngtube drainage for occult blood, stool for OB; Nutrition is vital to decreasing morbidity from shock-Initiate enteral nutrition within the first 24 hours- Initiate parenteral nutrition if enteral nutrition contraindicated or fails to meet at least 80% of caloric requirements- Monitor protein, nitrogen balance, BUN, glucose, electrolytes; Evaluate CVP above 8, normal temp, normal PAWP, urine output >0.5 mL/kg/hr, O2 >90%

Neurogenic bowel

GI: If the SCI has occurred above the level of T5, the primary GI problems are related to hypo motility. Decreased GI motor activity contributes to the development of paralytic ileum and gastric distention (measure girth). A NG tube for intermittent suctioning may relieve the gastric distention. Metoclopramide (Reglan) may be used to tx delayed gastric emptying. Stress ulcers may develop bc excess release of HCl acid in stomach-prevent w PPI and H2. Abdominal bleeding may occur and is difficult to diagnose bc pt does not experience pain/tenderness. Loss of voluntary neurologic control over the bowel results in a __. Spinal shock or injury of T12 or below, the bowel is areflexic and sphincter tone is decreased. As reflexes return, the bowel becomes reflex, sphincter tone is enhanced, and reflex emptying occurs. Both can be managed w regular bowel program coordinated w gastrocolic reflex to minimize incontinence. Use daily rectal stimulant or manual evacuation

Hep C Hep D Hep B and C carriers for life*

HepA: transmitted through fecal-oral, contaminated food or drinking water. Dx w + hepatitis A IgM which indicates acute hepatitis, jaundice and increase ALT. Acute not chronic. Vaccinate children & at risk persons to prevent and hand hygiene. Prevent w hand washing, environment sanitation, screen food handlers. HepB: transmitted through blood/body fluids. If IgM B in blood after 6 months than it is chronic. Can be acute or chronic.Prevent w HBV, protected sex, no sharing needles, screen donated blood, use disposable needles. __: blood or body fluids; avoid infected blood products, needles, sexual activity unprotected.Same prevent as B. __: same as HepB--can't live w/o HepB. Chronic infection to acute liver failure. No vaccine __: fecal-oral route--contaminated water supply outbreaks. Found in asia, africa, mexico.

Nonoperative tx for SCI involves traction or realignment which eliminates damaging motion injury site. If traction became displaced maintain head and call for help. Maintain weights, look for frayed rope, prevent infection and assess drainage, wrenches by bed, hydrogen peroxide clean pins, etc. The decision to perform surgery is based on evidence of cord compression, progressive neuro deficit, compound fracture of vertebrae, bony fragments that may dislodge and penetrate cord, and penetrating wounds of the spinal cord or surrounding structures. Surgery is called a laminectomy. Kinetic therapy is continual side-to-side slow rotation >200 turns/day; Manual or automatic-Reduces pressure ulcers & cardio-resp. complications-Risk for motion sickness. Overall Goals: Optimal level of neurologic functioning; Minimal to no complications of immobility; Learn skills, gain knowledge, and acquire behaviors to care for self; Return to home and community.

Immediate postinjury goals include maintaining a patent airway, adequate ventilation, and adequate circulating blood volume and preventing extension of cord damage. Immobilize and stabilize cervical spine w cervical collar and supportive blocks. Establish IV access w two large bore IVs to infuse NSS or LR. Assess for other injuries and control external bleeding. Obtain CT scan or cervical X-ray. Ongoing assessment includes VS, LOC, O2 saturation, cardiac rhythm, urine output. Keep pt warm. Monitor urine retention and HTN. Anticipate need for intubation if gag reflex absent. Once stable, obtain hx of incident and thorough assessment. Use logrolling to move pt. immobilization, maintenance of HR and BP (atropine and dopamine); NG tube; intubation if needed; O2; indwelling catheter if urine retention; IV fluids, stress ulcer prophylaxis, DVT prophylaxis, bowel/bladder training.

Clients with burns of 25% TBSA or who are intubated generally require a NG tube inserted to prevent aspiration and removal of gastric secretions

Inhalation injury s/s: Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators. Change in respiratory pattern may indicate a pulmonary injury. The client may: become progressively hoarse, develop a brassy cough, drool or have difficulty swallowing, produce expiratory sounds that include audible wheezes, crowing, and stridor. Lower Airway Injury-Auscultate the chest for wheezes. If wheezes disappear, this indicates impending airway obstruction--intubate. If suspected perform a bronchoscopy to assess and tx w 100% O2 if not intubated.

Pneumothorax ABG: pH: 7.35-7.45 below acidotic and above alkalotic PaO2: 80-100 PaSa: 93-100% PaCO2: 35-45 HCO3: 22-26 PTT: 25-35 seconds INR: .8-1.2 but on

Mechanical vent is set to PEEP at 5 cm to open collapsed alveoli--mon resp status bc it can cause __ if too high and BP bc it causes hypotension. ventilator associated pneumonia (host defenses, contaminated equipment, invasive monitoring devices, aspiration, prolonged vent)-avoid w strict hand hygiene and ventilator bundle (elevate bed 35-40 degrees, daily sedation holidays, PUD prophylaxis, DVT prophylaxis, daily PO care w chlorhexidine); barotrauma which is rupture of over distended alveoli during vent which can lead to emphysema, pneumothorax-avoid w minimizing O2 w permissive hypercapnia which is allowed to rise over normal; volutrauma results in alveolar fractures caused by large tidal volumes

Mitral valve regurgitation

Mitral valve function depends on intact mitral leaflets, mitral annulus, chordae tendineae, papillary muscles, left atrium, and LV. Any defect in these can result in regurgitation. __ allows blood to flow backward from LV to LA bc of incomplete valve closure during systole. Caused by MI, chronic rheumatic heart disease, mitral valve prolapse, papillary muscle dysfunction. Acute MR causes pulm edema and chronic MR causes left atrial enlargement and ventricular hypertrophy-->decrease CO. Acute s/s include thready peripheral pulses and cool/clammy extremities. Chronic s/s include asymptomatic until LV failure--weakness, fatigue, palpitations, dyspnea, orthopnea, PND, peripheral edema, S3, and murmur that is loud holosystolic at apex. Listen at 5 ICS midclavicular line.

Maintain bedrest and limit activity PCI Thrombolytic therapy Bleeding

It is important to rapidly diagnose and treat a patient with ACS to preserve cardiac muscle. Initial management of the pt with chest pain most often occurs in the ED. Obtain a 12-lead ECG and start continuous ECG monitoring. Position pt in semi-fowler's position and initiate oxygen by nasal cannula to keep PO above 93%. Establish an IV route to provide an access for emergency drug therapy (2 large bore). Give SL nitroglycerin and aspirin (chewable) if not given before arrival at ED. Morphine sulfate is given for pain unrelieved by NTG. (MONA). Pt usually receives ongoing critical care where ECG monitoring is continuously available. Dysrhythmias are tx according to protocol. Monitor vital signs fq and __ and __ for 12-24 hours w a gradual increase. For a confirmed MI (STEMI/NSTEMI) __ is the first line of tx for pt with this. The goal is to open the blocked artery within 90 mins of arrival to facility that has a cardiac cath lab. It locates blockage, assess severity, and evaluate left ventricular function. Goal is 90 mins from door to cath lab. Balloon angioplasty and drug eluting stents are placed. This reduces the need for CABG surgery. STEMI can use thrombolytic therapy. UA or NSTEMI, the pt is tx w aspirin, heparin, or glycoprotein inhibitor. Also coronary angiography and PCI can be performed once stable. __ is used for STEMI when PCI not available. It stops infarction process by dissolving thrombus. Give with 6 hours of onset--ideally with 1 hr. It is given IV. Each hospital has protocol for giving this, but typically draw blood to obtain baseline and start 2-3 IV sites. Complete invasive procedures prior to therapy. Monitor closely for signs of __. Assess for signs of reperfusion which is when return of ST segment to baseline best marker. IV heparin is given to prevent re-occlusion.

Tetraplegia Paraplegia Conus medullaris syndome *assess incontinence

Level of injury can be cervical, thoracic, lumbar, or sacral. If cervical cord is involved then paralysis of all four extremities occurs, called __. If thoracic, lumbar, or sacral the result is __ which is paralysis or loss in the legs. The degree of spinal cord may be complete or incomplete (partial). Complete results in total loss of sensory and motor function below level of injury. Partial results in a mixed loss of voluntary motor activity and sensation and leaves some tracts intact. A syndrome associated w partial is __ which results from damage to conus (lowest portion of SC) and cauda equina (lumbar and sacral nerve roots)-causes flaccid paralysis of lower limbs and flaccid bladder and bowel.

Skin graft procedure done during acute phase. Used for full-thickness and deep partial-thickness wounds. Temporary or permanent coverage. Can be own pt's skin, porcine skin, bovine, or cultured epithelial autografts which is pt's grown skin. Post op care maintain dressing, use aseptic technique, Graft should look pink if it has taken after 5 days, Skeletal traction may be used to prevent contractures, Elastic bandages may be applied for 6 mo to 1 year to prevent hypertrophic scarring. Protect skin from sun for 3 months after burn.

Nutrition-Initially NPO. Begin oral fluids after bowel sounds return. Do not give ice chips or free water-lead to electrolyte imbalance. Administer meds with juice or milk. High protein, high calorie. 5000 calories/day, accurate calorie counts important, ask family to bring in food they like to eat, weigh patients daily, monitor lab values (albumin 3.5-5, pre albumin 15-36, protein, iron levels). Nonsurgical: removal of exudates and necrotic tissue, cleaning the area, stimulating granulation and revascularization and applying dressings. Debridement may be needed-Done with forceps and curved scissor or through hydrotherapy (application of water for treatment). Only loose eschar removed Blisters are left alone to serve as a protector -controversial. Wound dressing: After burn wounds are cleaned and debrided, topical antibiotics are reapplied to prevent infection. Standard wound dressings are multiple layers of gauze applied over the topical agents on the burn wound. (Silver sulfadiazine ((Silvadene)) or Mafenide acetate).

S4

On examination during an MI, pt's skin may be ashen, clammy, and cool to touch. In response to release of these, BP and HR may be elevated initially and then later BP drop due to decrease CO. Crackles may be present may persist for several hours to several days suggesting left ventricular dysfunction. Jugular venous distention, hepatic engorgement, and peripheral edema may indicate right ventricular dysfunction. Abnormal sounds suggesting ventricular dysfunction are S3 and __, in addition to a loud holosystolic murmur developing. The pt may experience n/v which can result from reflex stimulation of the vomiting center caused by severe pain. Also can result from vasovagal reflexes. The temp of pt may increase within first 24 hours to 100.4 (38) and may last for as long as a week due to systematic inflammatory process caused by myocardial death.

Potassium, insulin, narcotics, chemo, heparin

PINCH drugs must be double checked with another nurse: ________

Potassium

Skin: Potential for skin breakdown-leads to infection & sepsis; Poikilothermism= temperature regulation problems: check temperature; Interruption of SNS (Neurogenic shock);↓Ability to sweat or shiver-More common with high cervical injury. Monitor protein, albumin (3.5-5), and pre albumin (15-35). Protect thermal injuries. Assess skin daily, reposition q2, pressure relieving devices. Other: Need decrease Na and __; high protein and calorie diet to prevent infection and skin breakdown. High fiber and dietary supplements. Prevent DVT and PE which is leading cause of death in SCI Reproductive may have priapism or loss of sexual function.

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TOTAL BODY SURFACE AREA (TBSA): Superficial burns are not involved in the calculation. Lund and Browder Chart is the most accurate because it adjusts for age. Rule of nines divides the body - adequate for initial assessment for adult burns. RULES OF NINES: Head & Neck = 9%; Each upper extremity (Arms) = 9%; Each lower extremity (Legs) = 18%; Anterior trunk= 18%; Posterior trunk = 18%; Genitalia (perineum) = 1%

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The P wave represents time for the passage of the electrical impulse through the atrium causing atrial depolarization (contraction). Normal P waves are upright, smooth, round without notches or peaks. The P wave is found preceding the QRS complex. The PR interval (PRI) is the time it takes from the onset of atrial activation in SA node to the onset of ventricular activation in Perkinges cycle. Measured from beginning of P wave to beginning of QRS complex. Normal PRI is 0.12-0.20 and should be constant. The QRS complex represents depolarization of the ventricles; the QRS complex follows the P wave. Measure from beginning of Q wave which is first downward deflection after P wave; R wave is first upward deflection in QRS; S wave is downward deflection after R wave. The QRS interval is measured fro beginning to end of complex and it represents time taken for depolarization (contraction) of both ventricles (systole). Normal duration is 0.6-0.10 seconds but should be less than 0.12. The QT interval measured from beginning of QRS to end of T wave. Represents time taken for entire electrical depolarization and repolarization of ventricles. Normally .34-.43 seconds but can be corrected for age, gender, and HR. Prolonged QT's can predispose individuals to sudden cardiac death.

Glasgow coma scale

The __ is a quick, practical, and standardized system for assessing the LOC. The areas assessed are pt's ability to speak, obey commands, and open eye when a verbal or painful stimulus is applied. Minor injury is 13-15, moderate is 9-12, and severe is 3-8. Under 8 is comatose. Eye response gets up to 4, verbal up to 5, and motor up to 6 points.

Another complication in acute phase is Curling's ulcer, a type of gastroduodenal ulcer characterized by diffuse superficial lesions including mucosal erosion. It is caused by a generalized stress response to decreased blood flow to GI tract. The pt has increased acid secretion. Prevent this by feeding pt asap after burn. Antacids, H2 blockers, and PPI used prophylactically. Rhabdomylsis is a muscular complication mainly in electrical burns bc muscle breaks down. Muscle pain/cramps.

The acute phase of burn care begins w mobilization of extracellular fluid and subsequent diuresis. Takes 72 hr to 2 weeks. Concludes when PT wounds are healed of FT are covered by skin grafts. Care is directed toward continued assessment and maintenance of the cardiovascular and respiratory system. Complications: pneumonia can cause resp failure requiring vent, infection-monitor for signs (Topical antibiotics - Silvadene) and tetanus vaccine. Weight daily without dressings or splints and compare to pre-burn weight. A 2% loss of body weight indicates a mild deficit. A 10% or greater weight loss requires modification of calorie intake. Infection can lead to septic shock. Signs include conversion of PT to FT, ulceration of healthy skin at burn site, erythematous, excess drainage, smell, slough of grafts, altered LOC, oliguria, metabolic acidosis.

Burn shock Obtain client's pre-burn weight (dry weight) to calculate fluid rates**Calculations based on weight obtained after fluid replacement is started are not accurate because of water-induced weight gain

The emergent phase is the time required to resolve the immediate, life threatening problems resulting from burn injury. Usually lasts between 24-48 hours. The greatest initial threat to pt w major burn is hypovolemic shock. It is caused by massive shift of fluids out of the blood vessels as a result of increased capillary permeability and can begin as early as 20 mins post-burn. S/s of __ is decreased BP ad tachycardia. Edema is also a main concern. Unconscious or altered mental is usually caused by hypoxia associated w smoke inhalation or head trauma. Tx involves airway patency fq by intubation, establishing IV access for fluid resuscitation (Parkland formula), wound care to prevent infection (debridement-removing necrotic skin), keep patient warm bc shivering loses O2, pt will become edematous so take off jewelry, IV morphine for pain, tell them you're doing everything you can for support. *IV therapy formula is calculated from the time of injury Parkland most common know how=4mLx70kgx50% (1/2 of total in 8 hr and 1/4 in second 8 hr)=only crystalloid (LR). Tetanus immunization is given prophylactically to burn pt, VTE prophylaxis. Acute tubular necrosis can be an issue if hypovolemic--carefully monitor fluid replacement and labs.

Mental status

The first indication of failure is a change in __. Other early s/s is tachycardia, tachypnea, and mild HTN. A severe morning HA may suggest hypercapnia occurred overnight bc it increases dilation and ICP. Specific s/s to the RF is rapid, shallow breathing; orthopnea; tripod position; dyspnea; PLB; retractions. Cyanosis is a late sign of resp failure. Dx w assessment, ABG analysis, chest X-ray, CBC, sputum, ECG, urinalysis, V/Q lung scan, pulmonary artery catheter. CVP-should be 2-12

Stenosis or regurgitation

The heart contains two atrioventricular valves (mitral and tricuspid) and two semilunar valves (aortic and pulmonic) which control blood flow. Valvular heart disease is defined according to the valve or valves affected and type of functional alteration: __ or __. Pressure on either side of an open valve is normally equal. In a stenotic valve the valve is narrower so forward blood flow is impaired. The amount of stenosis is seen in pressure difference (higher difference, higher stenosis). Regurgitation or leaky valve is an incomplete closure of valve resulting in backward flow of blood (valve leaflets do not close completely-decrease CO). Occur mainly bc congenital conditions.

Syndrome of inappropriate antidiuretic hormone (SIADH)

The hormones secreted by the posterior pituitary, antidiuretic hormone and oxytocin are produced and stored in the hypothalamus and transported and stored to pituitary gland. Overproduction or over secretion of ADH results in a condition known as __-water intoxication. Caused by malignant tumors, head injury, stroke, gillian-barre syndrome, lupus, infection, drug therapy (opioids, chemo, etc), hypothyroidism, COPD, HIV. ADH increases the permeability of the renal distal tubule and collecting duct, which leads to reabsorption of water into circulation. Extracellular fluid volume expands, plasma osmolality declines, glomerular filtration rate increases, and sodium declines below 120. Pt displays thirst, dyspnea, and fatigue. Experiences low urine output and increased weight. As sodium falls manifestations become more severe including vomiting, cramps, muscle twitching, and seizures. Cerebral edema may occur which causes lethargy, confusion, HA, seizures, coma. Tx directed at underlying cause. Meds that stimulate release of ADH should be avoided or d/c. If s/s are mild and Na >125 tx may be fluid restriction to 800-1000 mL. If Na <120 the IV hypertonic NSS may be administered. Loop diuretic Lasix should be used but only if Na is at least 125. Monitor K for diuretic use. Daily weights and I and O. Hard candy and ice chips can be used to manage thirst. Safety concerns w confusion-assess LOC q2hr. Demeclocycline for chronic SIADH to block effects of ADH on renal tubules absorption.

Hypoxemia Hypercapnia

The major function of the respiratory system is gas exchange. This involves the transfer of O2 and CO2 between atmospheric air and circulating blood within the pulmonary capillary bed. Acute respiratory failure results when one or both of these gas exchanging functions are inadequate (insufficient O2 to blood/inadequate removal of CO2 from lungs). This can result in __ which causes a decrease in arterial O2 (PaO2) and O2 saturation. The PaO2 is less than or equal to 60 on 60% O2. It can be acute (mins-hr) or chronic (more than 7 days). Referred to as oxygenation failure. Tx w oxygen supplement. Another result could be __ which causes an increase in arterial PaCO2. The PaCO2 >45 and pH <7.35--can be acute or chronic. Referred to as ventilatory failure. Many pt experience both.

CPAP

The major goals of care for acute respiratory failure include maintaining adequate oxygenation and ventilation. Interventions include O2 therapy, mobilization of secretions (acetacystaline-to thin), and positive pressure ventilation. O2 also improved when pt moved to prone. The primary goal of O2 therapy is to correct hypoxemia. Goal is to keep PaO2 at 55 to 60 mm Hg or more and SaO2 at 90% or more at the lowest O2 concentration possible. Retained secretions may cause or exacerbate ARF. They can be mobilized through effective coughing (huff coughing-cough while saying huff OR staged cough-leaning forward), adequate hydration and humidification, chest PT (augmented coughing, percussion), airway suctioning, and ambulation. Positive pressure ventilation can be use, as well as a noninvasive PPV such as __ or BiPAP-contraindicated w increase secretions, facial trauma, decrease LOC, high O2 requirement, or hemodynamic instability**.

CSF tx: if rhinorrhea or otorrhea are present notify physician immediately. HOB may be raised to decrease pressure so that tear cans real. Loos collection pad may be placed under nose or over ear. Do not place in ear or nose cavities. Instruct pt not to sneeze or blow nose. NG tubes should not be used and nasotracheal suctioning should not be performed on these pt due to high risk of meningitis.

The pt w a head injury always has potential to develop increased ICP (cushing triad-bradycardia, irregular RR, wide PP). Also look for ominous sign of bilateral dilated fixed pupils. Associated w higher mortality rates and poorer functional outcomes. Assess for a HA may be continuous or worse in morning and for pupil dysfunction. If pt has increased ICP then goal is to have O2=100, and CO2 35-45. Elevate HOB to at least 30 degrees for ICP. Prevent extreme neck flexion, turn slowly, avoid coughing and straining, and avoid hip flexion to prevent further IICP.Use NG tube as needed to control abdominal distention. Maintain vent needs. Eye problems may include loss of corneal reflex which may need lubricating eyedrops or taping eye shut to prevent abrasion. Periorbital ecchymosis decreases w time but cold and than later warm compresses provide comfort. Diplopia can be relieved w eye patch.

Partial thickness or Full thickness

The tx of burns is related to the severity of the injury. Severity is determined by depth of burn, extent of burn calculated in percent of total body surface area, location of burn, and pt risk factors (age, past medical hx). Depth can be either __ or __. Partial Thickness is superficial (first degree/epidermis) or deep (second degree/dermis). Full-Thickness is full thickness (third and fourth degree/hypodermis or bone)

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When septic shock is suspected draw labs for lactate and blood cultures 2x. Start broad spectrum antibiotic within 1 hour of septic shock. Give fluid (30 ml/kg crystalloid for hypotension or lactate ≥ 4mmol/L) for goal to increase preload volume/CVP. For hypotension after fluid resucitation: Vasopressors for goal to keep MAP > 65mm Hg. Measure central venous pressure (CVP)- keep 8-10; Measure central venous oxygen saturation (ScvO2) keep > 70 %; Re-measure lactate if initial lactate was elevated; Blood glucose control (< 180); DVT and GI prophylaxis.

Troponin

There are a few different ways to diagnose unstable angina and MI. Take a detailed health hx of pain, risk factors, health hx. The primary diagnostic for whether a person has UA or MI is an ECG and serum cardiac markers. The ECG shows changes in QRS complex, ST segment, and T wave caused by ischemia and infarction. Distinguish between STEMI and NSTEMI. Pt w STEMI tend to have more extensive MI with a pathologic Q wave seen on ECG. Pt w UA or NSTEMI usually do not develop pathologic Q waves. __ increases 4-6 hours after onset of MI, peak 10-24 hr, and return to base over 10-14 days. CK-MB increases at 6 hours, peaks 18 hr, and returns to normal 24-36 hr. Myoglobin is released after 2 hours and peaks 3-15 hours. Other measures that can be used when these methods do not confirm is exercise or pharmacologic stress test, echo, and cardiac cath.

Octreotide

Tx acromegaly with surgery called hypophysectomy. Most done by endoscopic transsphenoidal approach. Entry through upper lip and floor of nose to remove tumor. If entire pituitary gland is removed pt will require hormone replacement. No teeth brushing post-op, no coughing, nose blowing, no use of straws--prevent CSF leakage. Elevate HOB 30 degrees. This avoids HA a fq post op problem. Monitor neuro function. Drug therapy is used in pt who have had inadequate response to surgery and/or in combination w radiation therapy. The primary drug used for acromegaly is __, that reduces GH levels to normal. Given subcutaneous injection three times a week.

Shock SIRS (systemic inflammatory response syndrome)-tissue edema, neutrophil enlargement MODS (multiple organ dysfunction syndrome)-CV, lung, GI, liver, CNS, renal, skin

_ is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. This results in an imbalance between the supply of and demand for oxygen and nutrients. The exchange of oxygen and nutrients at cellular level is essential to life. There are four main categories of this: cariogenic, hypovolemic, distributive, and obstructive. Shock leads to __ which is a systemic inflammatory response to a variety of insults including infection, ischemia, infarction, and injury. This can than lead to __ which is failure of two or more organ systems in an acutely ill pt--prognosis is bad for this, 70-80% death. A goal should be to prevents SIRS from progressing to MODS. Monitor fq for early s/s of deterioration. SIRS Criteria: T >101°F or <96.8°F • RR >20 • HR > 90 • WBC >12,000 or <4,000 • ∆ MS • Plasma BS >140 in non-diabetic

Hep C

_ is both acute and chronic illness. Acute is asymptomatic which can be hard to detect unless dx w lab test. Most common cause is IV drug use and outbreaks among HIV pos men who have sex w men. Majority of these pt will have the virus develop into chronic. Most are unaware of their infection. Results in a potentially progressive liver disease w 20-30% of these pt developing cirrhosis. Most common cause of chronic liver disease. Pt w blood transfusion before 1992 are at high risk.

Mitral valve prolapse

_ is when leaflets prolapse or are pushed back into the atrium during systole; abnormality of mitral valve leaflets and papillary muscles or chordae. It is usually benign with valve closing effectively. But some complications can occur including MR, SCD, HF. Most pt are asymptomatic. Only 10% have symptoms. Many can be picked up with a murmur. Confirmed w an echo. S/s include murmur louder at systole, dysrhythmias that can cause palpitations, dizziness, CP unresponsive to nitrates. Tx w BB and valvular surgery for MR. Teaching involves antibiotic prophylaxis if MR is present, take meds as prescribed, healthy diet and avoid caffeine or other OTC stimulants, exercise routine, contact health care provider if s/s worsen or develop.

Atrial fibrillation

_: is characterized by a total disorganization of atrial electrical activity bc of multiple ectopic foci, resulting in loss of effective atrial contraction. The dysrhythmia may be paroxysmal (spontaneous) or persistent (lasting more than 7 days). Most common dysrhythmia. Usually occurs in pt w underlying heart disease. P waves are replaced w chaotic fibrillatory waves. Ventricle rate between 60-100 is a.fib w controlled response. A. fib w rate over 100 is uncontrolled. PRI not measurable but QRS is normal. Results in decrease CO. Thrombi form in aria bc of blood stasis--can lead to stroke. Tx involves decrease ventricular response to less than 100 beats/min, prevention of stroke, and conversion to sinus rhythm. Drugs used for rate control is CCB, BB, digoxin, dronedarone/amiodarone. Electrical conversion may be needed. Anticoagulation therapy is needed.

Obstructive shock

__ develops when a physical obstruction to blood flow occurs with a decreased CO, increase after load, and variable left ventricular filling pressures. Causes include cardiac tamponade, PE, tension pneumothorax (decrease/absent lung sounds-tachypnea), tumors, valvular heart disease, wall future or defect. Rapid assessment and tx are needed to prevent further hemodynamic compromise and possibly cardiac arrest. Tx w mechanical decompression for pericardial tamponade (pericardiocentesis), tension pneumothorax a tube or needle insertion, PE w thrombolytic therapy (retelplase/tPA) and anticoagulants.

Heady injury

__ includes any injury or trauma to the scalp, skull, or brain. A serious form of head injury is traumatic brain injury. Motor vehicle collisions (motorcycles and no helmet/no seatbelt) and falls are the most common causes of head injury. Other causes of head injury include firearms, assaults, sports related, recreational injuries, and war related injuries. Males are twice as likely to sustain a TBI than females. High potential for a poor outcome. Deaths occur at 3 points after injury: immediately, 2 hours after injury, and approx 3 weeks after injury. The GCS score on arrival is a good predictor of survival. Below 8 indicates 30-70% chance of survival, and a score above 8 indicates greater than 90% survival rate.

Hyperosmolar hyperglycemic syndrome (HHS) For DKA and HHS monitor administration of IV fluids & insulin therapy-concern of cerebral edema*

__ is a life threatening syndrome that can occur in the pt w diabetes who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion. Less common than DKA. Has higher mortality rate than DKA related to severe metabolic changes and delay in diagnosis. Caused by infection, severe diarrhea, burns, peritoneal dialysis, MI, and hypertonic feedings (TPN). Lab values include BG >600 and increase in serum osmolarity. Ketones are absent or minimal in the blood. Constitutes a med emergency. Management similar to DKA.Immediate IV admin insulin and .9 or .45 NaCl. Usually requires greater volumes of fluid replacement. Hemodynamic monitoring to avoid fluid overload. When glucose level fall to approx 250, add IV fluid w glucose to prevent hypoglycemia. Fluid losses may result in milder K deficits that require replacement. Assess VS, urine output, lab values, and cardiac monitoring. Once pt is stable, initiate attempt to detect and correct underlying cause.

Hepatic encephalopathy

__ is a neuropsychiatric manifestation of liver disease. The neurotic effects of ammonia. The liver is unable to convert ammonia to urea, so the ammonia levels increase. Crosses blood-brain barrier and produces neuro toxic effects. A manifestation of this is asterixis (flapping tremors)--if pt tries to stretch arms this happens. Felor hepaticus is a musty sweet odor of pt breath that also occurs during this. The goal of management of hepatic encephalopathy is reduction of ammonia. Ammonia in the intestines is reduced w lactulose, a drug that traps ammonia in the gut. Given orally, enema, or NGT. Laxative effect rids the ammonia thru the colon. Antibiotic such as rifaximin may also be given if pt does not respond to lactulose. Prevent constipation-give fluids. Neuro assess q 2 hr (orientation, reflexes, pupils).

Acromegaly

__ is a rare condition characterized by an overproduction of growth hormone. The mean age at the time of diagnosis is 40-45 years old. Most often occurs as a result of benign pituitary tumor (adenoma). The changes from excess GH occur over a number of years and may go unnoticed. Pt may experience enlargement of hands and feet w joint pain that can be mild to crippling. Carpal tunnel may be present. Thickening and enlargement of bony and soft tissues on face, feet, and head occur. Enlargement of tongue results in speech difficulties and the voice deepens bc of hypertrophy of the vocal cords. Sleep apnea may occur bc upper airway narrowing. Skin becomes thick, leathery, and oily. May experience peripheral neuropathy and proximal muscle weakness. Women may have menstrual disturbances. Visual changes may occur due to pressure on optic nerve. HA are common.

Sepsis Severe sepsis Septic shock Drug therapy: -Norepinephrine (Levophed) • Max dose is 10mcg/min • Central line preferred - Epinephrine • Can be substituted or as an additional drip -Phenylephrine (neosynephrine) all cause restlessness and possible worsening bradycardia -Inotropes Dobutamine and dopamine (potent can cause tissue slough)

__ is a systemic inflammatory response to a documented or suspected infection (SIRS + infection). __ is sepsis complicated by organ dysfunction w a mortality rate high as 50%. __ is presence of sepsis w hypotension despite adequate fluid resuscitation, along with inadequate tissue perfusion resulting in tissue hypoxia. The main organisms that cause sepsis are gram negative and gram positive bacteria. Sources include pneumonia, UTI, acute abdomen infection, meningitis, skin/soft tissue infection, bone/joint infection, wound infection, blood stream catheter infection, endocarditis, implanted device infection. S/s include increase coagulation and inflammation, decrease fibrinolysis (formation thrombi, obstruction of microvasculature). Could be in hyper dynamic state where CO increased and SVR (systemic vascular resistance) is low for more than 24 hours which is a fq finding for w hypotension and MODS. Resp failure ic common as well as hyperventilation which causes resp alkalosis. If it progresses may need mechanical vent. Tx includes vasopressors to keep MAP >65 (a-line recommended for BP monitor). (Culture and antibiotics within hour)

Delirium

__ is an acute change in consciousness accompanied by inattention and either a change in cognition or perceptual disturbance. There are three types: Hyperactive: Agitation, restlessness, attempts to remove catheters, emotionally labile. Hypoactive: Flat affect, withdrawal, apathy, lethargy, decreased responsiveness. Mixed: Combination of hypoactive and hyperactive. It is associated w increased length of stay, ventilator time, mortality, and long term neuro deficits. It is undetected and untreated in many pt. Assess for presence of delirium by using baseline risk factors to identify susceptibility, pre-existing dementia, history of baseline hypertension, alcoholism, admission severity of illness. Standardized assessment tools to detect delirium that would otherwise go undetected: __ andIntensive Care Delirium Screening Checklist (ICDSC). The CAM-ICU asks acute change or fluctuating course of mental status, inattention (squeeze my hand), altered LOC (RASS level), disorganized thinking (will rock float on water).

Anaphylactic shock

__ is an acute, life threatening hypersensitivity (allergic) reaction to a sensitizing substance (drug, chemical, vaccine, food, insect venom). The reaction quickly causes massive vasodilation, release of vasoactive mediators (histamine), and an increase in capillary permeability. Fluid leaks from vascular space into interstitial. Can cause resp distress due to laryngeal edema or severe bronchospasm, and circulatory failure from massive vasodilation. The pt has a sudden onset of s/s including dizziness, CP, incontinence, swelling of lips and tongue, wheezing, stridor. Skin changes include flushing, pruritus, urticaria, and angioedema. May be anxious or confused. A pt can have severe allergic reaction leading to anaphylactic shock after contact, inhalation, ingestion, or injection w allergen. Managing this can be done w prevention and screenings. Epinephrine is drug of choice to tx this bc it causes vasoconstriction and bronchodilation. IV diphenhydramine is given to block massive release of histamine. Maintain a patent airway bc of the edema or bronchoconstriction-nebulized bronchodilators (albuterol), aerosolized epinephrine, endotracheal intubation or cricothyroidotomy may be necessary; Aggressive fluid replacement colloids and IV corticosteroids if significant hypotension persists after 1-2 hours of aggressive therapy.

Alarm fatigue

__ is excess exposure to alarms which causes desensitization, which leads to ignoring. Practices to reduce this is proper skin prep for ECG electrodes (wash electrode area w soap and water, dry with washcloth or gauze, and/or use sandpaper on electrode to roughen small area of skin--no alcohol)--change daily; customize alarm parameters and levels on ECG monitors; customize delay and threshold settings on O2 saturation via PO monitors or disposable PO and change daily; provide initial and ongoing education on devices with alarms.

Ineffective endocardititis Osler's nodes

__ is an infection of the endocardial layer of the heart. The endocardium is the innermost layer of the heart and heart valves. Subacute typically affects those w preexisting valve disease and has a clinical course that may extend over months. Acute affects those w healthy valves and manifests rapidly and progressively. Can also be classified based on cause (IV drug abuse, fungal endocarditis, or site of involvement-prosthetic valve endocarditis). It occurs when blood turbulence within heart allows causative organism to infect previously damaged valves or other endothelial surfaces. Bacterial (most common): Streptococcus viridans, Staphylococcus aureus. Other organisms: Viruses and fungi. S/s include left sided embolizationL brain, limbs, liver, spleen and right sided is lungs and heart (valve dysfunction,HF, dysrhythmias, sepsis). ((it is an infection; diagnose w blood cultures, 2 sets 30 mins apart, not from central line—take from arms. Other s/s of IE are nonspecific and can involve multiple organ systems. For general: chills, fever, weakness, fatigue, anorexia. For subacute arthralgia, myalgia, abdominal discomfort, weight loss, HA, clubbing fingers. Vascular manifestations of IE include splinter hemorrhages (black longitudinal streaks) on nail beds, petechiae on conjunctivae, lips, mucosa, ankles, feet, armpit, knee; __ painful, tender, red or purple pea size lesions; janeway lesions (flat, painless red spots) on palms and soles; Roth's spots are retinal lesions.

Diabetes insipidus

__ is caused by a deficiency of production or secretion of ADH. Results in excessive U.O. & plasma osmolality. May be transient or chronic. Caused by tumor or injury to hypothalamus or posterior pituitary gland. Manifestations include polyuria, severe polydipsia, low specific gravity <1.016, serum osmolality >295, hypernatremia, fatigue from nocturia, change in LOC: irritability to coma, ypotension, tachycardia-->Shock. Tx includes correcting underlying cause. A goal is maintenance of fluid and electrolyte balance. Fluid and hormone therapy is cornerstone of tx. Fluids are replaced orally or IV, depending on pt's condition and ability to drink copious amounts of fluids. Check for glucosuria to prevent osmotic diuresis, hormone replacement with ADH (vasopressin/Pitressin) SC, IM, IV, long-term therapy with desmopressin acetate (DDAVP) nasal spray.

Diabetic ketoacidosis (DKA) -If not tx, pt will develop depletion of sodium, K, chloride, magnesium, and phosphate. Vomiting will result in fluid and electrolyte losses. Hypovolemia can lead to shock which can result in renal failure. Pt becomes comatose and death will be inevitable.

__ is caused by a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration. Precipitating factors include illness, infection, inadequate insulin dose, undiagnosed type 1 diabetes, poor self management, change in diet/lifestyle, neglect, and stress*. Dehydration occurs w s/s of poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. Early s/s may include lethargy and weakness. As pt becomes severely dehydrated, the skin becomes dry and loose, and the eyes become soft and sunken. Abdominal pain may be present and accompanied by anorexia, nausea, and vomiting. Chasmal respirations are body's attempt to reverse metabolic acidosis through the exhalation of excess CO2. Acetone is noted on breath as sweet, fruity odor. Lab findings include blood glucose greater than or equal to 250, pH less than 7.30, serum bicarb less than 16, and moderate tp large ketones in urine or serum. Tx initially ensure patent airway, admin O2 nasal cannula, establish IV access w large bore catheter w NaCl .45% or .9% and add dextrose when BG approaches 250, regular insulin drip continuous 0.1 u/kg/hr. Goal is to lower BG of 36-54 mg/dl/hr. Continuously monitor VS, cardiac rhythm, urine output, and O2. Assess breath sounds for fluid overload and monitor serum glucose and K. Admin bicarb if severe acidosis <7.

Thermal burns Chemical burns Smoke and inhalation burns Electrical burns

__ is caused by flame, flash, scald, or contact with hot objects. Most common type of burn. __ are result of contact w acid, alkalis, and organic compounds. __from breathing hot air or noxious chemicals can cause damage to the respiratory tract. Three types can occur: metabolic asphyxiation, upper airway injury, and lower airway injury. __ result from intense heat generated from an electrical current. Direct damage to nerves and vessels causing tissue anoxia and death can occur.

Spinal cord injury

__ is caused by trauma or damage to the spinal cord. It can result in either a temporary or permanent alteration in the function of the spinal cord. With improved tx, even the very young pt can anticipate a long life. The potential for disruption of individual growth and development, altered family dynamics, economic loss in terms of employment, and high cost of rehab and long term health care are the major problems. Young men between 16-30 have greatest risk. Older adults also have a great risk. Usually result form trauma. Most common is vehicle collisions (42%), falls (27%), violence (15%), sports injuries (7%), and other misc (8%). Primary injury is the initial mechanical disruption of axons as a result of stretch or laceration. It can be cord compression by bone displacement, interruption of blood supply to cord, or traction resulting in pulling of cord. Penetrating trauma, is caused by gunshot and stab wounds which can result in tearing and transection. Secondary injury is ongoing, progressive damage that occurs after initial injury. Apoptosis (cell death) can occur for weeks or months after initial injury. Hemorrhages appear within 1 hour and by 4 hours infarction may be present. By 24 hours permanent damage may occur bc of edema. Prognosis not determined for 72 hours.

Unstable angina Acute MI

__ is chest pain that is new in onset, occurs at rest, or has a worsening pattern. The pt with chronic stable angina may develop this or it may be first clinical sign of CAD. It is unpredictable and is an emergency. It occurs with increasing frequency and is easily provoked by minimal or no exertion, during sleep, or even at rest. Woman's symptoms continue to go unrecognized as heart related. These s/s include fatigue, SOB, indigestion, GI discomfort, and anxiety. Typical s/s of this is chest pain that radiates to shoulder, arm, jaw, neck, back; tightness, squeezing, choking feeling in chest; SOB; sweating; discomfort that exists at rest or after taking medication. __ occurs because of sustained ischemia, causing irreversible myocardial cell death (necrosis). When a thrombus develops there is no blood flow to the myocardium distal to blockage resulting in necrosis. Cardiac cells can withstand ischemic condition for 20 mins before cell death begins. Earliest tissue to become ischemic is the subendocardium (innermost layer). If ischemia persist, it takes approx 4-6 hours for entire thickness of heart muscle to become necrosed. The heart loses contractile function. S/s include severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration; persistent heaviness, pressure, tightness, burning, constriction, crushing usually in substernal, retrosternal, or epigastric; may radiate to neck, jaw, arms, or back; may occur at rest, asleep, awake; common in early morning hours and usually lasts 20 mins or longer--more severe than anginal pain. Some women may experience atypical discomfort, SOB, fatigue.

Aortic valve stenosis

__ is generally found in childhood, adolescence, or young adulthood. In older adults, it is a result of rheumatic fever or degeneration. Degenerative is most common bc of aging and wearing out. Symptoms develop when the valve becomes one third its size. Symptoms include classic triad of syncope, angina, exertional dyspnea (left ventricular heart failure). Auscultation reveals normal or soft S1, diminished or absent S2, systolic murmur--harsh, aortic; prominent S4. This issue causes obstruction of flow from left ventricle to aorta. This leads to left ventricular hypertrophy, which increases myocardial oxygen consumption. This results in ↓CO, pulmonary hypertension, and HF.

Ascites

__ is the accumulation of serous fluid in peritoneal or abdominal cavity. Common manifestation of cirrhosis. Peripheral edema sometimes precedes ascites, but in some pt its development coincides w or occurs after ascites. Due to impair liver synthesis of albumin. limit sodium 250-2000mg/day, give diuretics (spironolactone, furesomide), may need albumin infusion, paracentesis for removal if needed. Paracentesis: Needed if resp is impaired; Patient voids immediately before to avoid bladder puncture; High Fowler's position or sitting on side of bed; Monitor for fluid and electrolyte imbalances; Monitor dressing for bleeding/leakage; Monitor for Vital signs for s/s hypovolemia post procedure (may require albumin infusion); Ultrasound guidance---ascites hypokalemia-muscle weakness, dysrhythmias, tachycardia, HTN

Aortic valve regurgitation

__ is the backward blood flow from ascending aorta into left ventricle during diastole. This results in volume overload. With chronic AR, left ventricle tries to compensate by dilation and hypertrophy occur of LV. Myocardial contractility declines and blood volume in left atrium increases. This leads to pulmonary hypertension and right ventricular failure. Acute is caused by IE, trauma, aortic dissection and chronic is caused by RHD, congenital bicuspid aortic valve, syphilis. S/s of acute include dyspnea, cp, hypotension, cardiogenic shock and chronic may be no s/s for years--exertional dyspnea, orthopnea, PND, angina, water hammer pulse, soft or absent S1, S3 or S4 sounds.

Defibrillation 200-360 Synchronized cardioversion 50-150

__ is the tx of choice for VF or pulseless VT. Rapid defibrillation (within 2 mins) is critical to successful pt outcome. Involves the passage of an electric shock through the heart to depolarize the cells. The goal is that the following repolarization of cells will allow the SA node to resume the role of the pacemaker. The output is measured in joules or watts per second. Biphasic machines deliver 120-200 joules. Monophasic deliver 360 joules. After first shock, start CPR immediately w chest compressions. Can be manual or automatic devices. Manual requires you to interpret rhythms, determine need for shock, deliver shock. AED can detect rhythms and advise the user to deliver a shock using hands free defibrillator pads. __ is therapy of choice for pt w stable VT, a. fib. A synchronized circuit in the defibrillator deliver shock that occurs on R wave. Synchronizer switch must be turned on. If pt is awake then sedate them before w midzolam and maintain airway. Start w 50-150 joules for biphasic and 100 for monophasic.

Hypovolemic shock primary goal of drug therapy is to correct decrease tissue perfusion (vasopressin, norepinephrine)

__ occurs after a loss of intravascular fluid volume. The volume is inadequate to fill vascular space. This causes a decrease in venous return to right atrium which results in decreased preload volume and cardiac output. Decreased tissue perfusion for cellular metabolism. Despite normal BP, organs are poorly perfused due to a reduction in blood flow. Sympathetic over activity leads to vasoconstriction in order to maintain BP. A pt may compensate for loss of 15% of total blood volume (750mL). Further loss 15-30% (1500mL) results in SNS response-tachycardia, increase CO, increase RR and depth. Stroke volume, CVP (less than 8), and PAWP are decreased bc of decreased circulating blood volume. Pt may be anxious and have decreased urine output. Tx involves fluid replacement w 2 large bore IVs or central line (crystalloids-3:1* 3 crystalloid for every lost NSS, 0.9% Lactated ringers OR colloids-1:1 albumin, dextran=warm fluids including blood products; monitor temp), blood (RBS/platelets)-used for loss 30% or more immediately. Identify and correct cause by stop bleeding or GI losses, provide supplemental O2. Goal for CVP is 15 and PAWP 10-12.

Cardiogenic shock Drug therapy: All given via central line Nitrates to decrease workload of heart by dilating reduce preload w diuretics (furosemide) and morphine reduce after load w vasodilators (nitro)-given in glass bottle reduce HR and contractility w BB (do not give if low ejection fraction) and Inotropes (dobutamine)

__ occurs when either systolic or diastolic dysfunction of the heart's pumping action results in reduced cardiac output. Causes include MI, cardiac injury, severe HTN, dysrhythmias, pneumothorax. S/s include tachycardia, hypotension, narrow pulse pressure, pulmonary congestion, decrease renal perfusion, decrease cerebral perfusion. If you can hear S3 this indicates HF. Tx goal is to restore blood flow to myocardium by restoring balance between oxygen supply and demand. Pt may have congestion, rales, cyanosis, increase RR and decrease O2-tx w O2, ABG analysis, chest X-ray; tachycardia, dysrhythmia, decrease BP and cap refill-continuous tele/BP monitoring, brain natriuretic peptide monitor, renal problem-monitor urine output 30mL/hr, monitor fluid, BUN, creat, electrolytes; neuro-reorient, ongoing assess; skin-prevent pressure ulcers, skin care; GI-assess bowel sounds, GI ulcer prophylaxis w PPI/H2 receptor (famotidine), monitor GI bleed/H&H. If pt comes in w MI prevent cardiogenic shock w O2 supplementation

Hypoglycemia

__ occurs when there is too much insulin in proportion to available glucose in the blood. S/s include mood changes, trembling, pallor, diaphoresis, dizziness, blurred vision, HA, fatigue, hunger, seizures, coma. Caused by alcohol without food, too little food, too much insulin, too much exercise without adequate food, diabetic med taken wrong time, loss of weight without change in insulin, and use of BB. BG drops below 70 and the autonomic NS is activated. Initial tx involves obtain blood glucose. If pt is awake give 15 g of quick acting carb (4-6 oz of regular soda or OJ, 8-10 life savers, 1 tbsp of syrup or honey, 4 tsp of jelly, or glucagon-common SE is nausea). If worsening or unconscious, give pt IV or subcutaneous admin of 50% glucose. Wait 15 min and check again--if still low repeat. Once glucose is stable, give long acting carb plus protein (crackers w pb or cheese) if next meal is more than 1 hour away. Notify HCP or ER if not stable after 2 admin of carbs.

Mitral valve stenosis

__ usually results from rheumatic heart disease. Less common causes are congenital, RA, and lupus. Scarring occurs on the valve leaflets and chord tendineae. The mitral valve takes pm a fish mouth shape. Results in decreased blood flow from left atrium to left ventricle. This causes an increase in left atrial pressure and high pulmonary vasculature. The overload left atrium places pt at risk for a. fib. S/s include exertion dyspnea caused by reduce lung compliance, loud S1 heart sound, murmur (low pitch diastolic rumble) best heard at apex/mitral area, fatigue, palpitations (a.fib), hoarseness from enlarged atria pressing on laryngeal nerve, hemoptysis(coughing of blood from pulm HTN), chest pain, and seizures or a stroke. Emboli can arise from left atrium secondary to a.fib.

Sinus tachycardia

__: The conduction pathway is the same as that in normal sinus rhythm. The sinus rate is faster at 101 to 200 beats/minute, the rhythm is regular. Rate increases due to vagal inhibition or sympathetic stimulation. Associated with stressors such as exercise, fever, pain, hypotension, hypovolemia, anemia, hypoxia, hypoglycemia, MI, hyperthyroidism. Drugs that can cause include epinephrine, norepinephrine, atropine, caffeine, pseudoephedrine. S/s include dizziness, dyspnea, hypotension, angina. Tx involves tx underlying cause. If due to pain-->pain management. In clinically stable pt, vagal maneuvers can be attempted, IV BB (metoprolol), adenosine, or CCB (diltiazem) can be given to reduce HR. In unstable pt, synchronized cardioversion is used.

Autonomic dysreflexia

__: acute uncontrolled HTN and bradycardia. Most common precipitating factor is distended bladder or rectum. Manifestations: Hypertension- elevated up to 300 systolic; Throbbing headache- in SCI, measure BP with this complaint; Marked diaphoresis above level of injury; Bradycardia - 30-40 bpm; Piloerection; Flushing of skin above level of injury; Blurred vision / spots in visual field; Nasal congestion; Anxiety; Nausea. Nursing intervention: Elevate head, notify HCP; Assess for and remove cause; immediate catheterization; remove stool impaction if cause; remove constrictive clothing and tight shoes; Patient and family teaching. Tx nefidpine after it is resolved.

Atrial flutter

__: an atrial tachydysrhythmia with recurring, regular, sawtooth-shaped flutter waves from a single ectopic focus in the atrium. Rarely occurs in healthy heart. Associated w CAD, HTN, mitral valve disorder, PE, chronic lung disease, cardiomyopathy, hyperthyroidism, and use of drugs such a digoxin, epinephrine. Atrial rate is 200-350 beats/min and ventricular 150 beats/min. Rhythm is regular. The flutter waves represent atrial depolarization followed by repolarization. PRI is not measurable but QRS is usually normal. High ventricular rates and loss of atrial kick decrease CO. This can cause HF. Pt is also at risk for stroke bc of is for thrombus formation in atria from stasis of blood. Warfarin (INR 2-3) is given to prevent and give at night. Goal in tx is slow ventricular response--BB and CCB. Cardioversion may be performed to convert to normal sinus rhythm in an emergency if pt becomes unstable. Anti-dysrhytmic drugs can also convert to normal rhyrn (Amiodarone, Ibutilide). Radiofreqeuncy catheter is done in EPS lab-involves catheter placed in right atrium to burn defect.

Ventricular tachycardia

__: is a run of three or more PVCs. It occurs when an ectopic focus or foci fire repeatedly and the ventricle takes control as the pacemaker. Life threatening bc of decreased CO and possibly development of VF which is lethal. Rhythm may be regular or irregular. Ventricular rate is 150-250 beats/min. The P wave is usually buried in the QRS complex and the PRI is not measurable. QRS is distorted in appearance and wide (greater than .12 sec in duration). The T wave is in the opposite direction of the QRS complex. Can be stable (pulse) or unstable (pulseless). Sustained VT causes severe decrease of CO=hypotension, pulm edema, cardiopulmonary arrest. Must be treated quickly even if it only occurs briefly bc it may recur or VF may develop. Precipitating causes must be identified and tx. If pt is stable tx with anti-dysrhythmics (amiodarone, IV procainamide.) Cardioversion is used if drug therapy ineffective. VT w/o pulse is tx w CPR and rapid defibrillation followed by admin of vasopressors (epinephrine) and anti-dysrhythmias (amiodarone) if defib is unsuccessful. Common cause hypokalemia**

Ventricular fibrillation

__: is a severe derangement of the heart rhythm characterized on ECG by irregular waveforms of varying shapes and amplitude. This represents the firing of multiple ectopic foci in the ventricle. Mechanically the ventricle is "quivering" with no effective contraction and consequently no CO occurs. A lethal dysrhythmia. Occurs in acute MI, procedures w catheters that may stimulate ventricles, electric shock, hyperkalemia, hypoxemia, acidosis, drug toxicity, and in chronic HF and cardiomyopathy. HR is not measurable. Rhythm is irregular and chaotic. The P wave is not visible, and the intervals are not measurable. Results in an unresponsive, pulseless, and apnea state. If it is not rapidly treated the pt will not recover. Tx consists of immediate initiation of CPR and advanced cardiac life support (ACLS) w use of defibrillation and drug therapy (epinephrine, vasopressin).

Varices Bleeding Sengstaken-blakemore tube

__are large collateral veins that form in lower esophagus, abdominal wall, peritoneum, and rectum. Gastric and esophageal varices are at high risk for bleeding. May develop where collateral and systemic circulation communicate--gastric/esophagus, caput medusa (ring around umbilicus), and hemorrhoids. Life threatening--if bleed occurs pt may have melena (dark sticky blood feces) or hematemesis (vomiting blood). Main goal for gastric and esophageal varies is to prevent __--avoid alcohol, aspirin, and NSAIDS. When varice bleeding occurs the first step is to stabilize pt and manage airway. IV therapy is initiated and may include administration of blood products. Drug therapy may include octreotide or vasopressin. At time of endoscopic tx, band ligation or sclerotherapy may be used. Banding is placing small rubber band around base of enlarged vein. Sclerotherapy is injection of solution into varices. Balloon tamponade may be used for acute hemorrhage. Mechnically compresses varices. The __ tube is most common-has two balloons, gastric and esophageal, w three lumens-one for G, one for E, and one for G aspiration. *Label each lumen to avoid confusion, deflate balloons for 5 mins q 8-12 hr to prevent necrosis, cannot swallow so spit saliva, and keep scissors at bed for rapid deflation, check patent, verify pos w X-ray, mon aspiration pneumonia, semi-fowler,oral/nasal car.e Nonsurgical: TIPS-shunt between systemic and portal venous is created to redirect blood. Surgical: portacaval and distal splenorenal shunt.