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558 Cards in this Set
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too much fluid in the vascular space |
hypervolemia
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describe how heart failure affects the body
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the heart is weak, CO decreased, decreased kidney perfusion, UO decreased
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how does heart failure affect the vascular volume
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volume stays in the vascular space
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definition of renal failure
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kidneys aren't working
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what 3 things have a lot of sodium and what do they cause
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alka seltzer, fleet enema, IVF with NA; causes H2O retention
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what is aldosterone
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steroid; mineralocorticoid
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where is aldosterone found
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adrenal glands; top of kidneys
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describe the process that causes aldosterone to be secreted
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blood volume gets low (vomiting, blood loss, etc), aldosterone secretion increases, causes retention of Na and H2O; blood volume goes up
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what does aldosterone cause the body to retain
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Na and H2O
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disease with too much aldosterone
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cushings (all steroids); hyperaldosteronism aka conn's syndrome
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disease with too little aldosterone
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addison's
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where is ANP found
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atria of the heart
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what does ANP do
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opposite of aldosterone; causes excretion of Na and H2O
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what does ADH do
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makes you retain H2O
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SIADH
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too much ADH
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symptoms of SIADH
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retian H2O; fluid volume excess; urine is concentrated; blood is dilute
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Diabetes Insipidus
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not enough ADH
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symptoms of DI
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lose H2O; fluid volume defecit; dilute urine; concentrated blood
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DI leads to
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shock from fluid volume defecit
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if urine specific gravity, sodium and hematocrit are up the fluid is
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concentrated
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if USG, Na and Hct are down the fluid is
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dilute
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where is ADH found
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pituitary between the eyes
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conditions that make you think pituitary problem
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craniotomy, head injury, sinus surgery, transphenoidal hypophysectomy or any condition that can lead to increased ICP
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another name for ADH
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vasopressin or desmopressin acetate
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s/s of fluid volume excess
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distended neck veins; peripheral edema, third spacing, increased CVP, wet lung sounds, polyuria, increased pulse, bp up, weight up
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what causes peripheral edema and third spacing with FVE
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vessels are too full and start too leak
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why does polyuria occur with FVE
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kidneys are trying to help you diurese
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treatment for FVE
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low Na diet, restrict fluids; daily weight; I&O; diuretics; bed rest; physical assessment
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why bed rest for FVE
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bed rest induces diuresis by release of ANP and decreases production of ADH
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fluid volume defecit aka
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hypovolemia
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hypovolemia if severe enough leads to
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shock
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s/s of FVD
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decreased weight, dry mucous membranes, decreased urine output, decreased bp, increased pulse, increased respirations, decreased CVP, tiny neck/peripheral veins, cool extremities, increased USG
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why is urine output decreased with FVD
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kidneys either aren't being perfused or they are trying to hold on to fluid to compensate
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tx for FVD
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prevent further losses, replace volume, watch for falls and prevent overload
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isotonic solution
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goes into vascular space and stays there
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examples of isotonic solution
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NS, LR, D5W, D51/4NS
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uses for isotonic solutions
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loss of fluid through N/V, burns, sweating, trauma
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best solution for blood admin
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NS
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which clients should we not give isotonic solutions to and why
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hypertension, cardiac disease or renal disease; can cause FVE, HTN or hypernatremia
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hypotonic solutions
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go into the vascular space then shift out into cells to replace cellular fluid
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examples of hypotonic solutions
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1/2NS, 0.33%NS, D2.5W
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uses for hypotonic solutions
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clients with HTN, renal or cardiac disease who have N/V, burns, hemorrhage, etc; used for dilution due to hypernatremia and for cellular dehydration
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what do we need to watch for when admin hypotonic solutions
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cellular edema; leads to FVD and decreased BP
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hypertonic solution
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volume expanders that will draw fluid into the vascular space from the cell
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examples of hypertonic solution
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D10W, 3%NS, 5%NS, D5LR, D51/2NS, D5NS, TPN, Albumin
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uses for hypertonic solution
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client with hyponatremia or has shifted large amounts of vascular volume to a 3rd space or has severe edema, burns, ascites
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what to watch for when admin hypertonic solution
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FVE
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Crystalloid aka
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isotonic
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Colloid aka
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hypertonic
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quick tip to remember IV solution
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Isotonic stay where I put it; hypOtonic go Out of the vessel; hypEr tonic Enter the vessel
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magnesium and calcium act like
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sedatives
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magnesium is excreted by
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the kidneys
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causes of hypermagnesemia
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renal failure, antacids
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s/s of hypermagnesemia
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flushing, warmth, vasodilation; weak muscle tone, decreased DTR, arrhythmias, decreased LOC, decreased pulse, decreased respirations
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tx for hypermagnesemia
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ventilator, dialysis, calcium gluconate
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how do we admin calcium gluconate
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IVP very slowly
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causes of hypercalcemia
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hyperparathyroidism aka too much PTH; thiazides; immobilization
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what happens when serum Ca gets too low
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PTH kicks in and pulls Ca from the bones and puts it in the blood thereby increasing serum calcium
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s/s of hypercalcemia
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brittle bones, kidney stones, decreased DTR, weak muscle tone, arrhythmias, decreased LOC, decreased pulse, decreased respirations
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tx of hypercalcemia
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movement, fluids, phospho soda and fleet enema, steroids, phosphorus in diet, vitamin D, calcitonin
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Ca has inverse relationship with
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phosphorus
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how do we add phosphorus to our diet
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protein
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too little magnesium or calcium act like
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not enough sedative
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causes of hypomagnesemia
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diarrhea, alcoholism
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why does diarrhea cause hypomagnesemia
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lots of Mg in intestines
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why does alcohol cause hypomagnesemia
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suppresses ADH (causes diuresis) and it's hypertonic (draws fluid into vascular space causing diuresis)
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s/s of hypomagnesemia and hypocalcemia
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rigid muscles, seizure possibility, stridor/laryngospasm, + Chvosteks, +Trousseaus; arrhythmias, increased DTR, mind changes; swallowing problems
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tx for hypomagnesemia
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Mg; check kidney function, seizure precautions, eat mg
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causes of hypocalcemia
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hypoparathyroidis, radical neck, thyroidectomy
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tx for hypocalcemia
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Vit D, phosphate binders, IV Ca
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when giving IV Ca pt must always have
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heart monitor
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foods high in Mg
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spinach, mustard greens, summer squash, broccoli, halibut, turnip greens, pumpkin seeds, peppermint, cucumber, green beans, celery, kale, sunflower seeds, sesame seeds, flax seeds
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Na level in body is dependent on what
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how much water you have in your body
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Hypernatremia aka
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dehydration; too much Na, not enough H2O
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causes of hypernatremia
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hyperventilation, heat stroke, DI
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s/s of hypernatremia
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dry mouth, thirsty, swollen tongue
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tx for hypernatremia
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restrict Na, fluids, daily weight, I&O, lab work
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hyponatremia aka
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dilution; too much H2O, not enough Na
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causes of hyponatremia
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drinking H2O for fluid replacement; psychogenic polydipsia, D5W, SIADH
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s/s of hyponatremia
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headache, seizure, coma
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tx for hyponatremia
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Na, no H2O; if having neuro probs, give hypertonic saline, 3% or 5% NS
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potassium is excreted by
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kidneys
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if the kidneys are not working well, potassium will go
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up
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causes of hyperkalemia
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kidney trouble, aldactone
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s/s of hyperkalemia
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begins with muscle twitching proceeding to weakness then flaccid paralysis; life threatening arrhythmias
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tx of hyperkalemia
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dialysis if kidneys arent working; calcium gluconate; glucose and insulin; kayexalate
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K and ? Have an inverse relationship
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Na
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ECG changes with hyperkalemia
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bradycardia, tall and peaked T waves, prolonged PR intervals, flat or absent P waves, widened QRS, conduction blocks, Vfib
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causes of hypokalemia
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vomiting, NG suction, diuretics, not eating
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s/s of hypokalemia
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muscle cramps, weakness, life threatening arrhythmias
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ECG changes with hypokalemia
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U waves, PVCs, Vtach
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tx of hypokalemia
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give K, aldactone (retains K), eat more potassium
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foods high in K
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spinach, fennel, kale, mustard greens, brussel sprouts, broccoli, eggplant, cantaloupe, tomatoes, parsley, cucumber, bell pepper, apricots, ginger root, strawberries, avocado, banana, tuna, halibut, cauliflower, kiwi, oranges, lima beans, potatoes, cabbage
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Acid Base chemicals controlled by lungs
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CO2, acid
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acid base chemicals controlled by kidneys
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bicarb and hydrogen
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how do the kidneys compensate for acid base balance
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remove acid through urine; hold on or excrete bicarb
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how long do the kidneys take to compensate for acid base balance
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hours to days
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how do the lungs compensate for acid base balance
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exhale CO2; hypoventilation retains CO2; hyperventilation eliminates CO2
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how long do the lungs take to compensate acid base balance
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quickly; seconds to minutes
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respiratory acidosis
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lung problem; too much CO2
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resp acidosis: hypo or hyper ventilating
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hypoventilating
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what organ compensates for resp acidosis
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kidneys
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how do kidneys compensate for resp acidosis
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excrete acid, secrete bicarb into blood
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causes of resp acidosis
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retaining CO2; mid abdominal incision (leads to hypoventilation), narcotics, sleeping pills, pneumothorax, collapsed lung, pneumonia
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s/s of resp acidosis
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HA, confused, sleepy, coma, hypoxic, restless, tacycardia
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tx of resp acidosis
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oxygen, fix breathing problem, chest tubes, TCDB
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resp alkalosis
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lung problem; losing CO2
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respiration rate of resp alkalosis
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hyperventilating
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what organ compensates for resp alkalosis
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kidneys
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causes of resp alkalosis
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hysterical, acute aspirin overdose
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s/s of resp alkalosis
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lightheaded, faint, peri oral numbness, numbness and tingling in fingers and toes
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tx for resp alkalosis
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paper bag breathing, sedate client to increase resp rate, treat cause, monitor ABGs
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metabolic acidosis
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retaining hydrogen or do not have enough bicarb
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which organ compensates for metabolic acidosis
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lungs
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resp rate of metabolic acidosis
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increased, kussmauls
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causes of metabolic acidosis
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DKA, starvation, renal failure, severe diarrhea
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why does DKA and starvation cause metabolic acidosis
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cells are starving for glucose, so body will break down protein and fat, produces ketones which are acidic
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s/s of metabolic acidosis
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depends on the cause; symptoms of hyperkalemia-muscle twitching, muscle weakness, flaccid paralysis, arrhythmias; increased resp rate
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tx of metabolic acidosis
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treat cause; IV push bicarb
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metabolic alkalosis
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retaining too much bicarb and excreting hydrogen
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causes of metabolic alkalosis
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loss of upper GI content, too many antacids, too much IV bicarb
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s/s of metabolic alkalosis
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depends on cause; observe LOC; hypokalemia-muscle cramps and arrhythmias
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tx of metabolic alkalosis
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fix problem; replace potassium
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metabolic acidosis is usually assoc with what increased electrolyte
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hyperkalemia
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metabolic alkalosis is usually assoc with what decreased electrolyte
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hypokalemia
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why do the old and young have an increased risk of death with burns
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old=delayed healing, less subq fat; young=body surface area
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why does plasma seep out into tissues after burns
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increased capillary permeability
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how long does it take to cause permanent damage to the kidneys
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20 mins
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why is epinephrine secreted after burns
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causes vasoconstriction, shunting blood to vital organs
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most common airway injury
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carbon monoxide poisoning
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tx for carbon monoxide injury
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oxygen
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burns to the neck and face indicate what
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potential airway injury
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what formula is used to determine body surface area burned
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rule of 9s; head and neck-9%, arms-9% each, truck-18% front and back each, genitals-1%, legs-18% each
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most important aspect of burn management
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fluid replacement
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why is it important to know when the burn occurred
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fluid therapy in the first 24 hours is based on time burn occurred NOT when treatment was started
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how do we determine how much to fluid to give for burn therapy
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calculate what is needed for first 24 hours and give half of that volume during the first 8 hours (Parkland formula)
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if a burn client is restless what should we think and which is the priority
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inadequate fluid replacement, pain, hypoxia (priority)
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what is a more adequate representation of a client's fluid volume, weight or urine output
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urine output with burns; weight for everything else
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signs of airway injury
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singed facial hair, black flecks in sputum, sores on oral mucosa, stridor
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when a client's respirations are shallow what are they retaining
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CO2
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what does albumin do for us
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holds onto fluid in the vascular space
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why are IV meds preferred over IM with burns
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acts faster, less damage, good circulation
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4 things to check for circulatory
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cap refill, pulse, temp, color
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escharotomy
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relieves the pressure and restores the circulation, cuts through the eschar
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fasciotomy
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relieves the pressure and restores circulation but cut is much deeper into the tissue, goes through eschar and fascia
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how often do we measure urine output with burn victim
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hourly
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what drug is ordered to flush out kidneys
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mannitol
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why do burn victims become hyperkalemic
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K is inside the cell, burns cause cells to rupture which deposits K in serum
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what type of ulcer is specific to burn patients
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curlings ulcer
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what amount of gastric residual is bad
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>50
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labs to check for proper nutrition and nitrogen balance
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pre albumin*, total protein or albumin
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superficial thickness burns
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formally called first degree; damage only to epidermis
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partial thickness burns
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second degree burns; damage to entire epidermis and varying depths of the epidermis
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full thickness burns
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third degree burn; damage to entire dermis and sometimes fat
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how do we manage burns on hands
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wrap fingers separately, use splints to prevent contractures
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#1 complication of perineal burns
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infection
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type of isolation for burn patients
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reverse isolation
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mycin drugs lead to what problems
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ototoxicity and/or nephrotoxicity
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how do we check for nephrotoxicity
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BUN and creatinine increasing
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how often can a donor site be reharvested from
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every 12-14 days
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if a skin graft become blue or cool what does this mean
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poor circulation
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why do we roll Qtips over grafts
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to pull out air and exudate to allow graft to adhere and heal
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how long do we flush chemical burns
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15-20 mins
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why do electrical burns have 2 wounds
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entrance and exit
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what is the first thing someone with electrical injury needs
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heart monitor for Vfib potential
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what 2 substances build up with electrical burns and cause kidney damage
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myoglobin and hemoglobin
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why do electrical burns often result in amputation
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circulatory system does not recover easily
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#1 cause of preventable cancer
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tobacco
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when should women do a monthly self breast exam
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over age 20 at days 7-12 of cycle
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when are yearly clinical breast exams required
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over 40 and every 3 years for 20-39
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what things should not be done prior to pap smears
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douce, sex
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when should mammograms begin
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yearly starting at age 40
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when should colonoscopies begin
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age 50 then every 10 years
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men should do monthly testicular exams starting when
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15yo
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brachytherapy
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internal radiation; unsealed, sealed or solid
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describe unsealed internal radiation
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client and body fluids emit radiation; isotope is given IV or PO; radioactive for 24-48 hours
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describe sealed or solid radiation
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client emits radiation; body fluids are NOT radioactive; implanted close to or in the tumor
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patients with internal radiation should have visitors stay at least how many feet away
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6 ft
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what do you do if radiation implant becomes dislodged and you can see it
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gloves, lead lined container
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teletherapy and beam radiation are types of ? Radiation
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external
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usual side effects of external radiation
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erythema, shedding of skin, altered taste, fatigue, pancytopenia
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usual side effects of chemotherapy
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alopecia, N/V, mucositis, immunosuppression, anemia, thrombocytopenia
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vesicant
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type of chemo that if infiltration occurs will cause necrosis
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s/s of extravasation
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pain, swelling, no blood return
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what do we do if extravasation of chemo occurs
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stop the infusion, ice packs
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# 1 risk factor for cervical cancer
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HPV
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other risk factors for cervical cancer
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repeated STDs, multiple sexual partners, smoking, prolonged hormonal therapy, family hx, immunosuppression, sex at young age, multiple pregnancies
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s/s of cervical cancer
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painless vaginal bleeding; watery, blood tinged vaginal discharge; pelvic pain; leg pain along sciatic nerve; flank/back pain
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test that diagnoses cervical cancer
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pap smear
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tx for cervical cancer
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electrosurgical excision, laser, cryosurgery, radiation and chemo for late stages, conization-remove part of cervix; hysterectomy
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risk factors for uterine cancer
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estrogen therapy without progesterone; positive family history; late menopause; no pregnancy
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major symptoms of uterine cancer
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post menopausal bleeding; watery/bloody vaginal discharge, low back/abd pain, pelvic pain
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tx of uterine cancer
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hysterectomy
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what is a radical hysterectomy
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may remove all of pelvic organs; may have colostomy or ileal conduit
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why is it important to prevent abdominal distention after abdominal surgery
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don't want tension on suture line; can cause dehiscence and evisceration
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why is high fowlers a bad position for abdominal surgery clients
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blood pools in pelvis
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risk factors for breast cancer
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1st degree relative with dx; high dose radiation prior to age 20; period onset prior to 12; menopause after 50; no pregnancy; first birth greater than 30
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s/s of breast cancer
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change in appearance of the breast or lump
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most common area for breast cancer to occur
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upper outer quadrant; tail of spence
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tx of breast cancer
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surgery, chemo, hormonal therapy, radiation
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after sx for breast cancer what do we do with arm on affected side
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keep elevated; no BP, blood draws, ANYTHING FOREVER on affected side; encourage brushing hair, squeezing balls and flex/extend elbow to promote new circulation to grow
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leading cause of cancer death worldwide
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lung cancer
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s/s of lung cancer
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hemoptysis, dyspnea, hoarseness, cough, change in endurance, chest pain, pleuritic pain on inspiration, displaced trach
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is resp depression normal or abnormal after a bronchoscopy
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abnormal; slow is good; slow and depressed are different
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tx for lung cancer
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lobectomy, pneumonectomy
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lobectomy
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remove part of lung
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pneumonectomy
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remove entire lung
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s/s of laryngeal cancer
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hoarseness, lump in neck, sore throat, cough, problems breathing, earache, weight loss, no early signs
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tx of laryngeal cancer
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total laryngectomy, radiation, chemo, speech rehab
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total laryngectomy includes removal of
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vocal cords, epiglottis, thyroid cartilage
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after laryngectomy clients will have
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permanent tracheostomy
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s/s of colorectal cancer
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change in bowel habits, constipation, diarrhea, narrowing of stool; blood in stool, cramping abdominal pain, weakness, fatigue, anemic, abdominal fullness, unexplained weight loss
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colectomy
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part of colon removed
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abdominoperineal resection
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removal of colon, anus, rectum
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what clients do we not take rectal temps on
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thrombocytopenic, abdominoperineal resection,immunosuppressed
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major symptom of bladder cancer
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painless intermittent gross/microscopic hematuria
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s/s of prostate cancer
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s/s of BPH: hesitancy, frequency, frequent infections, nocturia, urgency, dribbling; painless hematuria
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dx of prostate cancer
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hard, nodular prostate; increased PSA
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increased alkaline phosphatase or acid phosphatase indicates
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cancer metastasis to the bone
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most common s/s of stomach cancer
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burn and abdominal discomfort
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other s/s of stomach cancer
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loss of appetite, weight loss, bloody stools, coffee ground vomitus, jaundice, epigastric and back pain, feeling of fullness, anemia, stool + for occult blood, achlorhydria, obstruction
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Two major complications of gastrectomy
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dumping syndrome, B12 deficiency
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which 3 hormones does thyroid produce
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T3, T4 and calcitonin
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function of calcitonin
|
decreases serum Ca levels by taking Ca out of blood and putting into bone
|
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what substance do we need in our diet to make thyroid hormones
|
iodine
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hyperthyroidism aka
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graves disease
|
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s/s of hyperthyroidism
|
nervous, weight loss, sweaty/hot, exopthalmos, decreased attention span, increased appetite, irritable, fast GI motility, increased BP/HR, bigger thyroid
|
|
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serum T4 and T3 would be up or down in hyperthyroid patient
|
increased
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tx for hyperthyroidism
|
propylthiouracil (PTU), methimaole (tapazole); iodine compounds, beta blockers, radioactive iodine, surgery
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|
|
what do antithyroid meds do for hyperthyroid pt
|
stop the thyroid from making thyroid hormones
|
|
|
how do iodine compounds help hyperthyroid pt
|
decrease size and vascularity of gland
|
|
|
how do beta blockers help hyperthyroid pt
|
decrease myocardial contractility, could decrease CO, decreases HR/BP, decreases anxiety
|
|
|
we do not give beta blockers to which 2 types of pt
|
asthmatics or diabetics
|
|
|
hypothyroidism aka
|
myxedema
|
|
|
when hypothyroidism is present at birth it's called
|
cretinism
|
|
|
s/s of hypothyroid
|
no energy, fatigue, slow GI motility, weight gain, cold, slow slurred speech, no expression
|
|
|
tx for hypothyroidism
|
synthetic thyroid hormones
|
|
|
people with hypothyroidism also tend to have what other disease
|
CAD
|
|
|
parathyroid secretes
|
PTH
|
|
|
what is the function of PTH
|
pulls calcium from bones and places in blood
|
|
|
s/s of hyperparathyroidism
|
similar to hypercalcemia and hypophosphatemia; sedated
|
|
|
tx of hyperparathyroidism
|
partial parathyroidectomy
|
|
|
s/s of hypoparathyroidism
|
similar to hypocalcemia and hyperphosphatemia; non-sedated
|
|
|
tx for hypoparathyroidism
|
IV calcium; phosphorus binding drugs
|
|
|
examples of phosphorus binding drugs
|
renagel, phos-lo, os-cal
|
|
|
two parts of adrenal gland
|
adrenal medulla and adrenal cortex
|
|
|
the adrenal medulla secretes
|
epinephrine and norepinephrine
|
|
|
pheochromocytoma
|
adrenal medulla problem; benign tumors that secrete epi and norepi in boluses
|
|
|
s/s of pheochromocytoma
|
increased bp, increased HR, flushing/diaphoretic
|
|
|
how do we diagnose pheochromocytoma
|
VMA test; 24hr urine; looking for increased epi and norepi (aka catecholamines)
|
|
|
when doing 24 hour urines which specimens do we discard
|
throw away first voiding (keep the last)
|
|
|
tx of pheochromocytoma
|
surgery to remove tumor
|
|
|
adrenal cortex secretes
|
glucocorticoids, mineralocorticoids and sex hormones
|
|
|
what do glucocorticoids do
|
change your mood, alter defense mechanisms, breakdown fat and proteins, inhibit insulin
|
|
|
type of mineralocorticoid
|
aldosterone
|
|
|
function of aldosterone
|
retian Na and H2O; lose K
|
|
|
too much aldosterone leads to
|
FVE and hypokalemia
|
|
|
too little aldosterone leads to
|
FVD and hyperkalemia
|
|
|
addisons disease means
|
not enough steroids
|
|
|
s/s of addisons disease
|
hyperkalemia (muscle twitching, weakness, flaccid paralysis), anorexia, nausea, hyperpigmentation, decreased bowel sounds, GI upset, vitiligo, hypotension (FVD), decreased NA, increased K and hypoglycemia
|
|
|
untreated addisons will lead to
|
shock
|
|
|
tx of addisons
|
combat shock; increase Na; I&O; daily weight; mineralocorticoid drugs
|
|
|
cushings means
|
too many steroids
|
|
|
s/s of cushings
|
growth arrest, thin extremities/skin, increased risk of infection, hyperglycemia, psychosis to depression, moon faced, truncal obesity, buffalo hump, oily skin/acne, women with male traits, poor sex drive, high BP, CHF, weight gain, FVE
|
|
|
tx of cushings
|
adrenalectomy, quiet environment, avoid infection
|
|
|
diet of cushings pt pre treatment should include what
|
increased K, decreased Na, increased protein, increased Ca
|
|
|
what might appear in urine of cushings pt
|
ketones, glucose
|
|
|
s/s of type 1 diabetes
|
polyuria, polydipsia, polyphagia
|
|
|
tx for type 1 diabetes
|
insulin
|
|
|
metabolic syndrome includes
|
insulin resistance, obesity, increased triglycerides, decreased HDL, increased BP, CAD
|
|
|
when do we screen for gestational diabetes
|
24-28 weeks
|
|
|
complications of gestational diabetes for baby
|
increased birth weight and hypoglycemia
|
|
|
majority of calories for diabetics should come from
|
complex carbs
|
|
|
why are diabetics prone to CAD
|
sugar destroys vessels like fat
|
|
|
why a high fiber diet for diabetics
|
slows down glucose absorption in intestines therefore eliminating sharp rises and falls
|
|
|
how do oral hypoglycemics work
|
stimulate pancreas to make insulin
|
|
|
how is insulin dose determined
|
blood sugar is normal and there are no ketones or glucose in urine
|
|
|
clear insulin aka
|
regular
|
|
|
cloudy insulin aka
|
NPH
|
|
|
lantus is a ? Acting insulin
|
long
|
|
|
only type of insulin given IV
|
regular
|
|
|
regular or NPH first
|
regular (clear to cloudy)
|
|
|
glycosylated hemoglobin
|
average of blood sugar over past 3 months
|
|
|
ideal goal for HbA1c
|
4-6% or less (ADA says <7%)
|
|
|
s/s of hypoglycemia
|
nausea, cold clammy skin, confusion, shaky, HA, nervous, increased pulse
|
|
|
which IV fluids for DKA
|
NS first; when BS reaches 300 switch to D5W to prevent hypoglycemia
|
|
|
how is HHNK or HHNC different from DKA
|
no acidosis
|
|
|
normal blood flow route
|
superior and inferior vena cava, RA, RV, pulmonary artery, lungs, pulmonary veins, LA, LV, aorta, body
|
|
|
preload
|
amount of blood returning to heart
|
|
|
afterload
|
pressure in aorta and peripheral arteries that LV pumps against
|
|
|
stroke volume
|
amount of blood pumped out of ventricles with each beat
|
|
|
CO =
|
HR X SV
|
|
|
factors that affect CO
|
HR, certain arrhythmias, blood volume, decreased contractility
|
|
|
s/s of decreased CO
|
decreased LOC, chest pain, SOB, cold clammy skin, decreased urine output, weak peripheral pulses
|
|
|
3 arrhythmias that affect CO
|
Vfib, asystole, pulseless Vtach
|
|
|
chronic stable angina is usually caused by
|
CAD
|
|
|
what relieves pain of chronic stable angina
|
rest and/or nitro
|
|
|
how often do we take nitro
|
1 every 5 mins X 3 doses
|
|
|
why do we hold metformin 48 hours after a cardiac cath
|
it is hard on kidneys and so is dye
|
|
|
for cardiac cath pt, check allergies to
|
shellfish, dye
|
|
|
what does mucomyst do for cardiac cath pt
|
helps break up dye
|
|
|
5Ps to asssess for extremities
|
pulselessness, pallor, pain, paresthesia, paralysis (skin temp and cap refill also)
|
|
|
cardiac cath pt must have leg remain straight for how long
|
4-6 hours
|
|
|
if a cardiac cath pt experiences unstable chronic angina, what should we expect
|
impending MI
|
|
|
s/s of MI or unstable angina
|
pain, cold and clammy, BP drops, CO decreased, increased WBCs, increased temp, ECG changes, vomiting
|
|
|
STEMI means we should do what
|
ST elevation MI; heart attack; cath lab for PCI in <90 mins
|
|
|
NSTEMI means we should do what
|
non elevation st segment MI; less worrisome; dx with cardiac enzymes
|
|
|
CPK-MB
|
cardiac specific isoenzyme; increased with damage to cardiac cells; elevates in 3-12 hours and peaks in 24
|
|
|
troponin
|
cardiac biomarker with high specificity to myocardial damage; elevates within 3-4 hrs and remains elevated up to 3 weeks
|
|
|
Troponin T levels
|
< 0.20
|
|
|
Troponin I levels
|
< 0.03
|
|
|
myoglobin
|
increases within 1 hr and peaks in 12; negative results are good
|
|
|
most sensitive cardiac marker for indication of MI
|
troponin
|
|
|
what untreated arrhythmia puts client at risk for sudden death
|
Vfib
|
|
|
how do we treat Vfib
|
shock then epi, amiodarone
|
|
|
what drugs are given to prevent recurring episodes of Vfib
|
amiodarone and lidocaine
|
|
|
important side effect of amiodarone
|
hypotension
|
|
|
tx of MI, unstable angina
|
oxygen, aspirin, nitro, morphine
|
|
|
goal of fibrinolytics
|
dissolve clot blocking blood flow to heart which decreases size of infarction
|
|
|
how soon do we need to admin fibrinolytics
|
6-8 hours after ONSET; within 30 mins of ED arrival
|
|
|
major complication of fibrinolytic
|
bleeding
|
|
|
absolute contraindications to fibrinolytics
|
intracranial neoplasm, intracranial bleed, suspected aortic dissection, internal bleeding
|
|
|
PCI
|
percutaneous coronary intervention
|
|
|
major complication of angioplasty
|
MI
|
|
|
if pt experiences chest pain after PCI what do we do
|
call dr asap; reoccluding
|
|
|
CABG
|
coronary artery bypass graft
|
|
|
diet changes after CABG
|
decreased fat, salt and cholesterol
|
|
|
when can sex be resumed after CABG
|
when pt can walk stairs or block with no discomfort
|
|
|
s/s of heart failure
|
weight gain, ankle edema, SOB, confusion
|
|
|
natural pacemaker of heart
|
SA node
|
|
|
leading cause of heart failure
|
hypertension
|
|
|
s/s of left sided heart failure
|
pulmonary congestion, dyspnea, cough, blood tinged frothy sputum, restlessness, tachycardia, S3, orthopnea, nocturnal dyspnea
|
|
|
s/s of right sided heart failure
|
enlarged organs, edema, weight gain, distended neck veins, ascites
|
|
|
systolic heart failure
|
heart can't contract and eject
|
|
|
diastolic heart failure
|
ventricles can't relax and fill
|
|
|
a lines are placed in what artery
|
radial
|
|
|
allen's test
|
checks for alternative circulation in wrist
|
|
|
bnp
|
secreted by ventricular tissues in the heart when ventricular volumes and pressures in heart are increased
|
|
|
bnp can show us what
|
positive for HF if CXR does not indicate problem
|
|
|
what does digoxin accomplish
|
stronger contraction, slower heart rate, increased cardiac output, increased kidney perfusion
|
|
|
normal digoxin levels
|
0.5-2
|
|
|
s/s of digoxin toxicity
|
anorexia, N/V; arrhythmias and vision changes
|
|
|
before administering digoxin we check
|
apical pulse
|
|
|
what electrolyte disturbance increases risk for digoxin toxicity
|
hypokalemia
|
|
|
diuretics do what to preload
|
decrease preload
|
|
|
when a pt has heart failure we report a weight gain of how much
|
2-3 lbs (or more)
|
|
|
s/s of pulmonary edema
|
severe hypoxia; sudden onset; breathless; restless/anxious; productive cough
|
|
|
how do we position pt with pulmonary edema
|
upright, legs down; improves CO; promotes pooling in lower extremities
|
|
|
cardiac tamponade
|
blood, fluid or exudates have leaked into pericardial sac
|
|
|
s/s of cardiac tamponade
|
decreased CO, CVP will be increased, dropping BP, muffled or distant heart sound, distended neck veins
|
|
|
untreated cardiac tamponade leads to
|
shock, paradoxical pulse (pulsus paradoxus), narrowed pulse pressure
|
|
|
tx of cardiac tamponade
|
pericardiocentesis to remove fluid from around the heart; surgery
|
|
|
hallmark sign of acute arterial occlusion
|
intermittent claudication (pain)
|
|
|
s/s of arterial occlusion
|
coldness, numbness, decreased peripheral pulses, atrophy, bruit, skin/nail changes, ulcerations
|
|
|
what is the rule for elevating or dangling to increase perfusion to veins or arteries
|
elevate veins, dangle arteries
|
|
|
buergers disease
|
inflammation of arteries and veins which causes vasoconstriction of vessels
|
|
|
raynauds disease
|
painful vasoconstriction that turns white red and blue; can cause ulceration
|
|
|
s/s of DVT
|
edema, tenderness, warms
|
|
|
how do we position extremity with DVT
|
elevate to increase blood return and decrease pooling
|
|
|
mania is characterized by
|
continuous high, labile emotions, flight of ideas, delusions, constant motor activity, inappropriate dress, altered sleep patterns, spending sprees, poor judgement, no inhibition, hypersexual, exploit others, manipulation, decreased attention span, hallucinations
|
|
|
how do we address delusions
|
no arguing; no talking about delusion; let them know you accept it but don't believe it
|
|
|
Manic clients are most comfortable in what kind of setting
|
one to one relationships; limit group activities
|
|
|
s/s of schizophrenia
|
create their own world; inappropriate, flat or blunted affect; disorganized thoughts; rapid thoughts; echolalia; neologism; delusions; hallucinations; child like mannerisms; religiosity
|
|
|
obsession
|
recurrent thought
|
|
|
compulsion
|
recurrent act
|
|
|
stage 1 of alcohol withdrawal
|
mild tremors, nervous, nausea
|
|
|
stage 2 of alcohol withdrawal
|
increased tremors, hyperactive, nightmares, disorientation, hallucinations, increased pulse, increased bp
|
|
|
stage 3 of alcohol withdrawal
|
most dangerous, severe hallucinations, grand mal seizures
|
|
|
alcohol detox protocol usually includes
|
thiamine injections, multivitamins, and perhaps magnesium
|
|
|
chronic problems assoc with alcoholism
|
korsakoff's syndrome, wernicke's syndrome
|
|
|
korsakoff's syndrome
|
disoriented to time; confabulate
|
|
|
wernicke's syndrome
|
emotions labile, moody, tire easily
|
|
|
s/s of chronic alcohol complications
|
peripheral neuritis, liver and pancreas problems, impotence, gastritis, mg and K loss
|
|
|
antabuse
|
deterrent to drinking; causes pt to vomit when exposed to any alcohol including cough syrup, aftershave, etc
|
|
|
s/s of anorexia
|
distorted body image, preoccupied with food but won't eat, periods stop, decreased sexual development, exercise, weight loss, perfectionist
|
|
|
s/s of bulimia
|
overeat then vomit; teeth decay; laxative and diuretic use; strict dieter, faster, exerciser; binges are alone and secret; normal weight
|
|
|
ECT is used for
|
severe depression and manic episodes
|
|
|
potential side effects of ECT
|
grand mal seizures, temporary memory loss
|
|
|
what do we give pt before ECT
|
anectine - to relax muscles
|
|
|
main cause of glomerulonephritis
|
streptococcal infection
|
|
|
s/s of glomerulonephritis
|
sore throat, malaise, HA, increased BUN & Creatinine, sediment/protein/blood in urine, flank pain, increased bp, facial edema, decreased UO
|
|
|
tx of glomerulonephritis
|
get rid of strep, I&O, daily weight, fluid replacement, dialysis
|
|
|
dietary needs for glomerulonephritis
|
decreased protein, decreased na, increased carbs
|
|
|
what is glomerulonephritis
|
inflammatory reaction in the glomerulus
|
|
|
nephrotic syndrome
|
inflammatory response in glomerulus forming big holes allowing protein to leak into urine
|
|
|
total body edema
|
anasarca
|
|
|
problems assoc with protein loss
|
blood clots, high triglycerides and cholesterol
|
|
|
causes of nephrotic syndrome
|
bacteria or viral infections; NSAIDS, cancer and genetic predisposition, systemic disease like lupus or diabetes, strep
|
|
|
s/s of nephrotic syndrome
|
proteinuria, hypoalbuminemia, edema, hyperlipidemia
|
|
|
causes of pre renal failure
|
hypotension, decreased heart rate, hypovolemic, any form of shock
|
|
|
intrarenal failure
|
damage has occurred inside the kidney
|
|
|
causes of intra renal failure
|
glomerulonephritis, nephrotic syndrome, dye used in tests, drugs, malignant HTN, severe vascular damage from DM
|
|
|
post renal failure
|
urine cannot get out of kidney
|
|
|
causes of post renal failure
|
enlarged prostate, kidney stone, tumors, ureter obstruction, edematous stoma
|
|
|
s/s of renal failure
|
increased creatinine and bun; anemia, HTN, HF, anorexia, N/V, itching frost, acid base, fluid or electrolyte imbalances
|
|
|
two phases of acute renal failure
|
oliguric phase and diuretic phase
|
|
|
oliguric phase of acute renal failure
|
decreased UO, FVE, increased K
|
|
|
diuretic phase of acute renal failure
|
increased UO, FVD (shock), decfreased K
|
|
|
CAPD
|
continuous ambulatory peritoneal dialysis
|
|
|
CCPD
|
continuous cycle peritoneal dialysis; catheter connected to cycler at night
|
|
|
complications of peritoneal dialysis
|
infection, constanst sweet taste, hernia, altered body image/sexuality, anorexia, low back pain
|
|
|
dietary needs of peritoneal dialysis client
|
increase fiber and protein
|
|
|
CRRT
|
continuous renal replacement therapy
|
|
|
who uses CRRT
|
fragile cardiovascular status and acute renal failure pt
|
|
|
s/s of kidney stones
|
pain, N/V, WBCs in urine, hematuria*
|
|
|
tx of kidney stones
|
pain meds, increase fluids, maybe surgery, strain urine, extracorporeal shock wave lithotripsy
|
|
|
endocrine function of pancreas
|
insulin
|
|
|
exocrine function of pancreas
|
digestive enzymes
|
|
|
#1 cause of acute pancreatitis
|
alcohol
|
|
|
#2 cause of acute pancreatitis
|
gallbladder disease
|
|
|
#1 cause of chronic pancreatitis
|
alcohol
|
|
|
s/s of pancreatitis
|
pain that increases with eating; abdominal distention/ascites, abdominal mass, fever, N/V, jaundice, hypotension
|
|
|
what does it mean if a pt has a rigid board like abdomen
|
peritonitis
|
|
|
cullens sign
|
bruising around umbilical area, sign of pancreatitis
|
|
|
gray turners sign
|
bruising around flank area; sign of pancreatitis
|
|
|
how do we diagnose pancreatitis
|
increased lipase and amylase, increased WBC, increased blood sugar, increased ALT/AST, increased serum bilirubin
|
|
|
tx for pancreatitis
|
pain control, NPO,NG tube, decrease acid, decrease inflammation, daily weights
|
|
|
increased blood pressure in liver is called
|
portal hypertension
|
|
|
s/s of cirrhosis
|
firm, nodular liver; abdominal pain; chronic dyspepsia; change in bowel habits; ascites; splenomegaly; decreased serum albumin; increaseded ALT&AST; anemia
|
|
|
if cirrhosis is left untreated it becomes
|
hepatic encephalopathy/coma
|
|
|
what substance is increased with cirrhosis
|
ammonia
|
|
|
what drug should we never give to pt with liver problem
|
tylenol
|
|
|
antidote for tylenol overdose
|
mucomyst
|
|
|
paracentesis
|
removal of fluid from peritonial cavity
|
|
|
diet considerations for cirrhosis
|
decrease protein; low NA diet
|
|
|
what is the normal protein breakdown process
|
protein breaks down to ammonia; the liver converts ammonia to urea; kidneys excrete the urea
|
|
|
build up of ammonia does what to LOC
|
decreased LOC,
|
|
|
s/s of hepatic coma
|
minor mental changes/motor problems; difficult to wake; asterixis; handwriting changes; decreased reflexes; slow EEG; ammonia breath
|
|
|
asterixis
|
flapping wrist tremor
|
|
|
tx of hepatic coma
|
lactulose, cleaning enemas, decreased protein in diet, monitor serum ammonia
|
|
|
cause of bleeding esophageal varices
|
high bp in the liver forces collateral circulation to form (stomach, esophagus, rectum)
|
|
|
tx of bleeding esophageal varices
|
replace blood, VS, CVP, O2, octreotide lower liver BP, sengsaken blakemore tube, cleansing enema, lactulose, saline lavage
|
|
|
sengstaken blakemore tube purpose
|
to hold pressure on varice
|
|
|
s/s of peptic ulcers
|
burning pain usually on the mid epigastric/back area; heartburn
|
|
|
after gastroscopy, pt is NPO until when
|
gag reflex returns
|
|
|
perforation after gastroscopy is indicated by
|
pain, bleeding, trouble swallowing
|
|
|
why do we not allow smoking, gum, mints or nicotine patches before upper GI studies
|
smoking increases stomach motility and stomach secretion
|
|
|
gastric ulcer
|
pain is usually 1/2 to 1 hour after meals; food doesn't help but vomiting does; vomit blood
|
|
|
duodenal ulcer
|
night time pain and 2-3 hours after meals; food helps; blood in stool
|
|
|
hiatal hernia
|
hole in diaphragm is too large and stomach moves up into thoracic cavity
|
|
|
s/s of hiatal hernia
|
heartburn, fullness after eating, regurgitation, dysphagia
|
|
|
tx of hiatal hernia
|
small frequent meals; sit up 1 hr after eating; elevate HOB; surgery
|
|
|
dumping syndrome
|
stomach empties too quickly and client experiences severe side effects usually secondary to gastric bypass, gastrectomy or gall bladder disease
|
|
|
s/s of dumping syndrome
|
fullness, palpitations, faintness, weakness, cramping, diarrhea
|
|
|
tx of dumping syndrome
|
semi recumbent with meals; lie down after meals; no fluids with meals; decrease carbs
|
|
|
what side should pt lay on to keep food in stomach
|
left side
|
|
|
ulcerative colitis
|
ulcerative inflammatory bowel disease just in the large intestine
|
|
|
crohns disease
|
regional enteritis; inflammation and erosion of the ileum; can be found anywhere
|
|
|
s/s of ulcerative colitis and crohn's
|
diarrhea, rectal bleeding, weight loss, vomiting, cramping, dehydration, blood in stools, anemia, rebound tenderness, fever
|
|
|
rebound tenderness indicates
|
peritoneal inflammation
|
|
|
tx for ulcerative colitis/crohn's
|
total colectomy, kock's iliostomy, J pouch for colitis; we try not to do surgery for crohn's but may remove just the affected area
|
|
|
what consistency will ileostomy drain
|
liquid always due to location
|
|
|
a colostomy in the ascending or transverse colon will result in what consistency of waste
|
semi liquid stools
|
|
|
a colostomy in the descending or sigmoid colon will result in what consistency of waste
|
semi formed or formed stools
|
|
|
which colostomies do we irrigate
|
descending and sigmoid
|
|
|
when is the best time to irrigate a colostomy
|
same time everyday after a meal
|
|
|
#1 problem with appendicitis
|
rupture
|
|
|
s/s of appendicitis
|
generalized pain that eventually localizes in right lower quadrant; rebound tenderness; N/V; anorexia
|
|
|
mcburney's point
|
right lower quadrant where appendicitis pain localizes
|
|
|
how do we dx appendicitis
|
increased WBC, ultrasound, CT
|
|
|
tx of appendicitis
|
surgery; most laparoscope
|
|
|
why do we use central line with TPN
|
full of particles
|
|
|
why do we discontinue TPN gradually
|
to prevent hypoglycemia
|
|
|
what labs must we check regularly when on TPN
|
accuchecks Q6H; urine for ketones and glucose; daily weight
|
|
|
how long can TPN stay hung
|
24 hours
|
|
|
most frequent complication assoc with TPN
|
infection
|
|
|
position for inserting a central line
|
trendelenburg to distend veins
|
|
|
if air gets into central line how do we position pt
|
left side trendelenburg
|
|
|
normal pupil size
|
2-6mm
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oculocephalic reflex
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dolls eye; assess brain stem function; youwant a positive response; eyes move opposite of head turn; only assess this in an unconscious pt
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oculovestibular reflex
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assesses brain stem function; irrigate ear with cool water; eyes will move towards irrigated ear and rapidly back;
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babinski or plantar reflex
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lateral aspect of foot is stroked and toes flex or curl up
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normal babinski for adult
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negatibe babinski (toes roll under)
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normal babinski for less than 1 year of age
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positive; toes curl up
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reflex scale
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0-absent; 1-present, diminished; 2-normal; 3-increased but not necessarily pathological; 4-hyperactive
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puncture site for lumbar puncture
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lumbar subarachnoid space (3rd-4th)
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complications of lumbar puncture
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meningitis
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s/s of meningitis
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watch for chills, fever, positive Kernigs and Brudzinski, vomiting, nuchal rigidity, photophobia
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CSF should look
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clear and colorless (water)
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most common complication of lumbar puncture
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HA
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kernigs sign
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positive when hip is flexed 90 degrees then extending clients knee causes pain
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brudzinski sign
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positive when flexing clients neck causes flexion of hips and knees
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the dura is torn with what type of skull fracture
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open fracture
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basal skull fractures cause bleeding from
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EENT
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battles sign
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bruising over mastoid
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raccoon eyes
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periorbital bruising
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which type of skull fractures usually require surgery
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depressed
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concussion
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temporary loss of neurologic function with complete recovery
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signs of increased ICP
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difficulty awakening/speaking, confusion, severe HA, vomiting, pulse changes, unequal pupils, one sided weakness; flaccid extremities, absent reflexes, fixed and dilated pupils, projectile vomiting, decerebrate and decorticate posturing
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skull contusion
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brain is bruised with possible surface hemorrhage; unconscious for longer than concussion and may have residual damage
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intracranial hemorrhage
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small hematoma that develops rapidly and may be fatal; a massive hematoma will develop slowly and may allow client to adapt
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epidural hematoma
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rupture of middle meningeal artery (fast bleeder)
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tx of epidural hematoma
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burr holes, clot removal, control ICP
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subdural hematoma
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usually venous bleed; can be acute, subacute or chronic
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tx of subdural hematoma
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acute-immediate craniotomy and remove clot, control ICP
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autonomic dysreflexia
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spinal cord injury above T6 causes syndrome characterized by severe HTN and HA, bradycardia, nasal stuffiness, flushing, sweating, blurred vision and anxiety
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what can cause autonomic dysreflexia
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distended bladder, constipation, painful stimuli
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how do you tell CSF from other drainage
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positive for glucose or halo test (CSF settles out around bloody spot)
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why do head injury victims not need restrains
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makes ICP increase
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normal ICP
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<=15
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decerebrate posturing
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arched spine, plantar flexion; worst
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decorticate posturing
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arms flexed inwardly; legs extended with plantar flexion
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tx of increased ICP
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osmotic diuretics, steroids, control temp, decrease suctioning/coughing; no restraints; restrict fluids; elevate HOB, head midline; space nursing interventions
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thoracentesis
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fluid is being removed from pleural space
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why do clients need chest tubes
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lung has collapsed
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where do we place chest tube for removal of air
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upper anterior chest; 2nd intercostal space
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where do we place chest tube for removal of drainage
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laterally in lower chest; 8th or 9th intercostal space
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purpose of CDU
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to restore normal vacuum pressure in pleural space
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3 chambers of CDU
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drainage collection, water seal, suction control
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when a wet suction system is being used correctly what should we see in suction control chamber
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slow gentle continuous bubbling
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what should we see in water seal chamber
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tidaling: slight rise and fall of water as client breathes
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when do we notify physician regarding chest tube drainage
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100mL or greater in 1st hour or if change in color to bright red
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what causes tidaling to stop with CDU
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lung has reexpanded, kink or clot in tubing, dependent loop present in system
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what if chest tube is accidentally pulled out
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sterile vaseline gauze taped down on 3 sides
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type of dressing needed when chest tube is removed
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vaseline gauze taped down al 4 sides
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s/s of hemothorax or pneumothorax
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SOB, increased HR, diminished breath sounds on affected side, less movement on affected side, chest pain, cough
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tx of hemothorax/pneumothorax
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thoracentesis, chest tubes, daily CXR
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tension pneumothorax
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pressure has built up in chest/pleural space and has collapsed the lung pushing everything to the opposite side
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mediastinal shift
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pressure pushes everything to other side
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s/s of tension pneumothorax
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subq emphysema, absence of breath sounds on one side, asymmetry of thorax, resp distress
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why can a tension pneumothorax be fatal
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accumulating pressure compresses vessels which decreases venous return which decreses preload and CO
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tx of tension pneumothorax
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large bore needle is placed into 2nd ICS to allow excess air to escape, find cause, chest tube
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open pneumothorax
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sucking chest wound; opening through chest that allows air into pleural space
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most common injuries from chest trauma
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fx of ribs/sternum
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s/s of rib/sternum fx
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pain & tenderness; crepitus; shallow respirations
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tx of rib/sternum fx
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non narcotic analgesic; nerve block to assist with productive coughing; support injured area with hands
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flail chest
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multiple rib fx
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s/s of flail chest
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pain, paradoxical chest wall movement, dyspnea, cyanosis, increased pulse, hypoxia, pain
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tx of flail chest
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stabilize area, intubate, ventilate
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s/s of pulmonary embolism
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hypoxemia*, decreased PO2, increased Ddimer, SOB, cough, increased resp rate, positive VQ scan, positive spiral CT, hemoptysis, increased pulse, chest pain, atelactasis, pulmonary HTN
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tx of pulmonary embolism
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oxygen, ABGs, ventilator, pain mgmt, anticoagulant
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s/s of bone fracture
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pain, tenderness, unnatural movement, deformity, shortening of extremity, crepitus, swelling, discoloration
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why does extremity shorten when fx occurs
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caused by muscle spasm
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tx of fracture
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immobilize bone ends and adjacent joints; support fx above and below site; move extremity as little as possible
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complications of bone fx
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shock, fat embolism, compartment syndrome, healing problems
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with what type of fractures do we see fat embolisms
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long bones
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symptoms of fat embolism
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petechiae or rash on chest, conjuntival hemorrhages, snow storm on CXR
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what is compartment syndrome
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increased pressure in limited space; fluid accumulates in tissue and impairs perfusion; muscle becomes swollen, hard and painful
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complications of compartment syndrome
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nerve damage and possible amputations
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tx of compartment syndrome
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elevate extremity, loosen cast to restore circulation, fasciotomy
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delayed union of fx
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healing doesn't occur at normal rate
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non union of fx
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failure of bones to reunite; may require bone grafting
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mal union of fx
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deformity at fx site
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purpose of traction
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decreases muscle spasms, reduces, immobilizes
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traction should be intermitten or continuous
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continuous
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skin traction
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used short term to relieve muscle spasms and immobilize until surgery; skin is not penetrated
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type of skin traction
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bucks-used most with hip and femoral fractures
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skeletal traction
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applied directly to bone with pins and wires; used for prolonged amounts of time
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abduction or adduction with hip replacement
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abduction
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purpose of trochanter roll in hip replacement
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prevent external rotation
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complications of hip replacement
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dislocation, infection, avascular necrosis, immobility problems
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s/s of dislocation after hip replacement
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shortening of leg, abnormal rotation, can't move extremity, pain
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purpose of CPM
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continuous passive motion; prevents formation of scar tissue
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first intervention to decrease phantom pain after amputation
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diversional activities
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how should stump be shaped after amputation and why
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cone shaped for prosthesis
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why is it okay to massage the stump
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promotes circulation and decreases tenderness
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how do we toughen stump
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press into soft pillow then firm pillow then bed then chair
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how does pt walk on crutches
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2" below axilla, rest on hands; stairs=up with good and down with bad
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