08-20 Exam 1: 641 Patient Assessment

Front 1

list inter and extra -cellular ions by location with greatest concentration.

Mg Na Cl Phos K

Back 1

intra: K, Mg, P
extra: Na, Cl

Front 2

____ is the primary osmotic determinant of ADH release.

Back 2

Na

Front 3

Things to think about when you hear Na...

Back 3

Blood volume/pressure
Fluid status
Brain / nerve function

Front 4

What is the cofactor for ATPase? What is the exchange ratio Na/K?

Back 4

Mg
since we need ATP we must be pumping against the grad...
3Na out, 2K in

Front 5

What is the mechanism by which these medications affect K+ levels?

Spironolactone
Lisinopril
Insulin
Albuterol

Back 5

Spironolactone-CI of Aldosterone in the distal renal tubule, incr water and Na excretion and retaining K.

Lisinopril-↓ACE ↓AT2 = ↓aldosterone = less excretion of K+

Insulin incr abs of glucose = ↓ATP = ↓ATPase activity = ↑ SERUM potassium

Albuterol-stim ATPase = ↓ SERUM K+

Front 6

2. Describe how the following work to maintain Na homeostasis.

a. Antidiuretic hormone (ADH)
b. RAAS

Back 6

a. Antidiuretic hormone (ADH):
↑osmolality (water low) = ↑ADH = ↑ abs water in CD = dilutes high conc Na = ↓osmolality

b. Renin-Angiotensin-Aldosteron System (RAAS)
↓Na or low vol blood flow = ↑Renin = ↑AT2 =
1-vasocon
2-↑aldosterone (↑reabs Na/H2O)
3-↑ADH (H20 reabs)

Front 7

Describe how extracellular hyperkalemia may affect cardiac conduction.

Back 7

High levels of extracellular K increases the rate of membrane repolarization and increases the threshold making it more difficult to generate an action potential.

Front 8

Define the following terms in relation to kidney structure/function.

Back 8

Filtration-Blood flows into the glomerular apparatus and is filtered, removing waste products and recycling the blood back to the body.

Reabsorption-Some ions are lost during filtration and are reabsorbed through the renal tubules back into the blood stream.

Secretion-Other waste products

Front 9

Why is SCr thought of as a more accurate marker of glomerular filtration than BUN?

Back 9

Only renal dysfunction (nephron damage) increases SCr. BUN is affected by hepatic metabolism of protein, hydration and other factors that may reduce GFR. Thus SCr is the best marker for assessing kidney function.

Front 10

Define what a “CBC with a left shift” means.

Back 10

It refers to an increase in immature white blood cells, indicating an infection.

Front 11

What is the equation to correct for serum calcium levels in a patient with low albumin? When is it appropriate to use? Why do we adjust for it?

Back 11

SCa = measured SCa + (0.8 x [4 – SAlb])

Alb <4

50% of total SCa is bound to albumin while the rest is in its ionized, active form. If you have low albumin, you will therefore have high serum Ca even though your total levels of Ca may be normal.

Ca normally 8.5-10.5 mEq/L

Front 12

Describe what the liver fx tests (ALT, AST, INR, Alb) are measuring and how their results relate to liver function:

Back 12

AST Aspartate amino-transferase- high levels mean acute hepatic cellular damage. When the cells are damage, the enzymes are leaked into the blood where they are detected.

ALT Alanine amino-transferase- high levels mean acute hepatic cellular damage.

INR measures clotting time. These levels are increased in liver disease because you are not synthesizing enough Factor 7.

Albumin measures liver function. Albumin is synthesized in the liver.

Front 13

Describe what the following tests are measuring and how their results relate to liver function: (ALT, AST, Alb, INR)

Back 13

AST: aspartate aminotransferase – used to detect liver damage. When there is tissue damage, AST levels are higher than normal.
ALT: alanine transaminase – when the liver is damaged, it releases ALT. When compared to AST, ALT is more specific in detecting liver injury.
INR: international normalized ratio measures blood coagulation time. Since the liver is responsible for the production of coagulation factors, any detect in the liver would affect coagulation time.
Albumin: albumin is a protein made in the liver. If the liver is badly damaged, it can no longer produce albumin. Very low levels of albumin is a sign of liver damage.

Front 14

Describe the steps in bilirubin metabolism

Back 14

Unconjugated biliruben: spleen b/d Hgb = heme. Then bound to albumin -> liver -> glucuronic acid conjugates the biliruben -> bile -> gut -> bacteria break conj bili to urobilinogen -> some in feces -> some abs -> some to blood -> kidne -> urine

Most of this conjugated biliruben goes into the bile.

Front 15

What may an elevated conjugated bilirubin level indicate?

Back 15

An elevated conjugated bilirubin levels indicate a possible blockage in the liver, bile ducts, as well as hepatitis. Elevated bilirubin can also be caused by an increase in RBC breakdown

Front 16

What is a central venous catheter (aka central line, central IV)?
How is it different from a peripheral line (aka peripheral IV)?

Back 16

A central venous catheter is a catheter placed into a large vein in the neck, chest or groin. It is used to administer medications or fluids, obtain blood tests, and directly obtain measurements such as central venous pressure.

PICC line is a form of intravenous access. The entry point is in the periphery of the body (ie: extremities). It is not surgically inserted, therefore making it less invasive.

Front 17

Under what circumstances would a central venous catheter be preferred over a peripheral line?

Back 17

A central line is easier to put in. Also, because of the entry point of the central venous catheter, medications put in through this method would reach the heart faster.

Front 18

What is a PICC line?
How is it different from a central venous catheter?

Back 18

A PICC (peripherally inserted central catheter) line is a form of intravenous access. The entry point is in the periphery of the body (ie: extremities). It is not surgically inserted, therefore making it less invasive.

Under what circumstances would a PICC line be preferred over a central venous catheter?
Central venous catheter is inserted in the chest, neck or groin. A PICC can be used for a longer period of time than a central venous catheter.

Front 19

Compare and contrast the features of a tunneled catheter (i.e. Hickman catheter) vs. a subcutaneous port (i.e. Port-a-cath).
Under what circumstances would one be preferred over the other?

Back 19

A tunneled catheter is a type of central venous catheter that is inserted into a vein at one location and tunneled under the skin to the second exit site. Passing the catheter under the skin helps prevent infection and provides stability. A subcutaneous port is a tube surgically placed into a blood vessel and attacked to a disk placed under the skin. Since a subcuteanous port is more invasive, it is used more long-term. The subcuteaneous port is entirely underneath the skin.

Front 20

Describe the function of an arterial line (i.e. Art-line or A-line)

Back 20

It is a thin catheter inserted in an artery. It is used in the severely ill to monitor blood pressure when it is difficult to obtain a cuff pressure. It is also used to obtain samples for arterial blood gas measurements. A-lines are not used to administer medications.

MONITORING ONLY NOT USED FOR DRUG DELIVERY

Front 21

Provide a reason for why each of the following medications CANNOT be crushed and given through an NG (naso-gastric = into stomach) tube

Back 21

liquid filled
buccal
slow release
oropharyngeal irritation
enteric coating

Front 22

During hospital rounds, you notice a nurse administering liquid ferrous sulfate into a patient’s PEJ tube. Is it an appropriate site of administration? Why or why not?

Back 22

A PEJ (Percutaneous Endoscopic Jejunostomy) tube is a feeding tube that is put inside an outer tube that goes to the stomach. The tube goes directly into the small intestine (jejunum). This is not an appropriate site for liquid sulfate because liquid sulfate is mainly absorbed through the duodenem, before the jejunum.

Front 23

Identify whether the following patients are bradycardic, tachycardic, bradypneic, tachypneic, or have normal heart rate or respiratory rate.

48 year old male with a heart rate of 108, respiratory rate of 16

3 year old female with a heart rate of 154, respiratory rate of 27

24 year old female with a heart rate of 62, respiratory rate of 13

Newborn male with a heart rate of 166, respiratory rate of 48

Back 23

tachycardi, normal respiratory rate (60-100/12-20)

Tachycardic, tachypneic

Bradycardic, normal respiratory rate

Tachycardic, tachypneic

Front 24

Ausculation

Back 24

a physical assessment technique that involves listening for sounds over body cavities to determine presence and quality of heart, lung and bowel sounds

Front 25

Describe what an auscultory gap is.

Back 25

When manually measuring blood pressure, the auscultory gap is the period when the systolic pressure fades away and reappears at a lower pressure point.

Front 26

Reabsorption of BUN is directly related to...

Back 26

... salt and water reabsorption (↑salt and water reabsorption, ↑ in BUN reabsorption)

Front 27

A decrease in GFR will cause an ____ in SCr

Back 27

increase

Front 28

So why even draw a BUN?

Back 28

The BUN: SCr ratio can provide information regarding volume status and renal dysfunction

Front 29

Roles of Phos in body (4):

Back 29

Essential element in phospholipid cell membranes & nucleic acids
Regulates metabolism of carbohydrates, fats, and proteins
Used in red blood cells—affect delivery of O2 to tissues
ATP
Muscle contractility, electrolyte transport, neurologic function, etc

Front 30

Roles of Ca in body besides bone density (3):

Back 30

Involved in CELL SIGNALING
Bone metabolism
Muscle excitation / contraction

Front 31

When extracellular calcium is low, PTH...

Back 31

↑Ca rel fr bones
↓Ca renal excretion
↑Vit D

Front 32

At high concentrations, Ca and Phos can...

Back 32

combine to form crystals

Front 33

What is Hct

Back 33

Calculated value
% RBC in volume whole blood
1 unit of blood (PRBC) =
incr Hct by 2-4%

Front 34

Why draw a CBC w/ diff?

Back 34

A diff helps determine cause of leukocytosis

Diff NLMEB 60,30,6,3,1
Nobody = Neutrophils (60%)
Likes = Lymphocytes (30%)
My = Monocytes (6%)Educational = Eosinophils (3%)
Background = Basinophils (1%)

Front 35

Fever blister or cold sore

Back 35

HERPES SIMPLEX

Front 36

matching labs to organs...
ALT, AST, INR, Alb

Liver, kidney, panc, brain

Back 36

all to liver, and then AST to everything else

Note that ALT is only found in the liver.

Front 37

is INR a good indicator of acute liver fucntion?

Back 37

Yes

Front 38

Most blood clotting factors are made by...

Back 38

hepatocytes

Front 39

PT time measures these factors...

Back 39

2-5-7-10

Front 40

In most liver diseases both ____ and ____ bilirubin tend to be ____. However, an increase in ____ ____ only may mean that the biliary (liver secretion) ducts are obstructed.

Back 40

conjugated
unconjugated
elevated
direct bilirubin

Front 41

Sg measures..
pH measures..

Back 41

urine density = hydration
kidney ability to maint acid/base balance

Front 42

QUEST SCHOLAR
What is it used for?
What does it stand for?

Back 42

QEST

Quickly and accurately assess pt
--current complaint (SCHOLAR)
--other meds
--coexisting conditions and allergies

Establish pt. appropr. self-care candidate
--No severe sympt
--No self-treat to avoid med care

Suggest self care strat
--med
--gen measures

Talk with pt.
--medication
--admin
--adv eff and how to manage
--follow up

SCHOLAR

Symptoms
Characteristic
History
Onset
Location
Aggrav factors - makes worse
Remitting factors - makes betr

Front 43

List the vitals...(think TPRP + BP)

Back 43

Temperature (T)
Blood pressure (BP)
Pulse (P or HR or RRR)
Respiratory rate (R)
Pain scale (5th vital sign)

Front 44

Things to remember about taking BP

Back 44

--record EVEN numbers
--continue listenting until 20mmHg below DBP, then deflate
--inflate 20-30mmHG above pulse obliteration level
--cuff and arm at heart level
--foot and back support
--no talking/active listening
--forgetting the systolic is a huge source of error

Front 45

Describe the traditional problem-oriented approach to patient care.

Back 45

1. Gather info
2. Eval info
3. ID pt spec probs
4. Develop care plan
5. Document plan
6. Communicate plan
7. Monitor

Front 46

STEP
is used for?
stands for?

Back 46

therapeutic alternatives

safety
tolerability
efficacy
pt factor
simplicity

Front 47

SMART
is used for?
stands for?

Back 47

therapeutic goals and outcomes

specific
measurable
achievable
related
time bound

Front 48

Gather Info

Back 48

FH
SH + lifestyle
occupation
educ lvl
QOL (quality of life)
Meds
Risk factors
Prognosis
Med problems

Front 49

Eval info

Back 49

evaluate it

Front 50

Pt specific problems

Back 50

Indic - unnecessary, need additional drug therapy
STEPS

correct dose
financial
adherence
culture belief
medication phobias



drug interactions


Effect - needs diff drug prod, dosage too low

Safety - ADR, dosage too high

Compliance - non adherence

severity vs. likelihood chart

Front 51

What to look for in correct drug dose?

Back 51

Appropriate for indication, weight,age, organ function