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438 Cards in this Set
- Front
- Back
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Which is the most important electrolyte to check?
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Potassium
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What does it mean when the cardiac muscle is polarized?
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Electrically neutral
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What is depolarization?
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Contraction, systole, Sodium in, potassium out
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What is repolarization?
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Relax, diastole, potassium in, sodium out
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In PQRST, what is P?
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Atria depolarization, contraction
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In PQRST, what is QRS?
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Ventricular depolarization, contraction
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In PQRST, what is T?
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Ventricular repolarization
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What is the primary pacemaker of the heart?
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Sinoatrial (SA) node
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Where are the different places that could substitute for the pacemaker?
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* Atrioventricular node (AV node)
* Bundle of His * Right and left bundle branches * Purkinje fibers |
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What does the parasympathetic stimulation do?
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*cholinergic = slows down–Acetylcholine Released–Vagus nerve
*GI& GU opposite-increases tone, increases motility |
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What does the sympathetic NS do?
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•=speeds up–Catecholamine = Epinephrine,powerful vasoconstrictor………..
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What is preload?
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–The amount of stretch placed on the cardiac muscle just prior to systole/contraction. Directly related to amount of fluid in RV.
- Increasing volume to the heart increases preload. - more important on the right |
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What is afterload?
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–The force or pressure at which the blood is ejected from the ventricles
–Equated with systemic vascular resistance (SVR) |
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What is contractility?
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- actual beat
- contractile state of the heart (inotropic) |
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What are the symptoms of a right sided MI?
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* edema (blood backs up)
* look really sick (sicker than L sided) * hypotensive * bradycardic * diaphoretic * pale * possible jugular distention |
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What are the symptoms of a left sided MI?
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* pulmonary edema (backup is in the lungs)
* tachycardic * hypertensive |
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Which leads represent the inferior (posterior) right side portion of the heart?
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* 2
* 3 * AVF |
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Which leads represent the anterior left side portion of the heart?
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* V1
* V2 * V3 |
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Which leads represent the left lateral portion of the heart?
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* V4
* V5 * V6 |
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What is anasarca and which side MI would cause it?
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A pronounced generalized edema. A right sided MI would cause this.
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What are the modifiable risk factors for coronary artery disease (CAD)?
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* tobacco, alcohol & substance use
* occupation or work environment * exercise * sleep patterns * diet/ obesity * coping patterns/ social support * leisure activities * sexual activity - use of agents for erectile dysfunction * high cholesterol * hypertension * stress |
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What are the non-modifiable risk factors for coronary artery disease (CAD)?
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* age
* race * gender * hereditary factors (family history) * DM1 * past childhood illness (rheumatic fever -valves) |
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What is the mnemonic for questions to ask a patient about their chest pain?
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N - Normal baseline before symptoms started
O - Onset - when did start? Day, time, gradual, sudden P - precipitating or palliative - what brought it on, what triggers it, what makes it feel better/worse, what has not helped? Q - quality and quantity - describe the pain, what about right now? worse or better than before R - region or radiation - show me where, does the pain travel (like down arm or back) S - severity on a scale of 0-10, what is it at it's worst? does it cause you to stop or lay down? T - time - how long does the symptom last, how often does it happen, does it happen in association with anything such as before or after meals? |
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What are the electrolytes checked for cardiac?
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* sodium
* potassium * magnesium * calcium |
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What are the enzymes checked for cardiac?
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CPK (creatine phosphokinase) isoenzymes - can also break it down into MB (myocardial bands - over 5% is an MI), BB (brain bands - stroke) or MM (muscle markers - muscle injury)
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When is CPK detectable after onset of an MI?
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4 to 6 hours, peaks 18-24
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What is troponin and how does it relate to an MI?
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* Troponin is a by-product of muscle breakdown
* Can be broken down into I, T, C - I & T are very cardiac specific * Can be detectable in 3 hours after MI * stays elevated for 5-10 days * may be the best indicator for an MI |
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What are the labs run for a cardiac issue?
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* Electrolytes
* Enzymes * Troponin * BNP (B type natriuretic peptide) * Coagulation studies |
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What is BNP?
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B type natriuretic peptide. A hormone that is released by ventricles in response to ventricular volume expansion/ventricular stretch caused by heart failure. – the bigger the number,the more damage to the heart (around 100 means hospitalization for someone without a lung issue). It is a diagnostic serum tool for CHF.
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What are the coagulation studies?
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* PTT (Partial thromboplastin time)
* PT/INR (Prothrombin time/ International Normalized ratio |
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If patient is on Coumadin, what test will be run on the blood?
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PT/ INR
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In a hypertensive crisis, what drug will most likely be prescribed?
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Nipride
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Patient got full amount of adenosine, what will the doc order next?
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Cardiovert
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A flutter - what drugs?
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Cardizem
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SVT (supraventricular tachycardia) - what drugs?
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Adenosine
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Vtach no pulse - drugs?
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Amiodorone, lidocaine
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what is the treatment of choice for A-fib or A-flutter? What if it didn't work? What would be the next two steps?
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Cardizem, betablocker then defibrillator.
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If the QRS complex was wide, where is the issue coming from?
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From the ventricles.
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If the QRS complex was narrow, where is the issue?
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From the atria
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What drugs are used for V-fib or V-tach?
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Amiodarone or Lidocaine
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What kind of vessel is a central line put in?
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A vein.
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What is CVP and how is it monitored? What numbers should it be maintained at?
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Central venous pressure and is monitored through a central line. Should be between 2 and 8.
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What decreases hemodynamic pressure?
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* Hypovolemia
* vasodilation |
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What increases hemodynamic pressure?
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* Fluid overload
* R & L ventricular failure * Pulmonary hypertension * Stenosis of heart valves |
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What does central venous pressure measure?
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Right ventricular preload
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What do vasodilators do?
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Decrease preload (fluid to the heart) and afterload (pressure at which the blood is ejected from the ventricles)
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Does it matter how slowly or quickly you bring down someone's high blood pressure?
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Yes, must do it slowly or can cause a CVA (stroke).
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In a hypertensive crisis, what drug will most likely be prescribed?
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Nipride
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When do ST changes appear on the ECG?
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When there is a lack of O2 to the heart
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When are ST changes considered an MI?
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When ST changes appear in 2 or more leads in the ECG.
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What are the 3 main applications for an IABP (intra-aortic balloon pump)?
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* Cardiogenic shock (after MI)
* Low cardiac output (after cardiac surgery) * very unstable angina |
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What is the best prophylactic intervention for people with CHF?
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Implantable cardioverter defibrillator (ICD).
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What is the treatment for NO PULSE?
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CPR and shock with electricity
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Why should a patient with CHF stay away from salt?
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Salt will cause the body to retain water and the patient most likely already has anasarca.
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What does inverted T-waves indicate on an ECG? Is it reversible?
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There is myocardial ischemia. This is reversible.
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What does elevated (or depressed) ST segments indicate on an ECG? Is it reversable?
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Injury. Almost reversible.
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What do deep Q-waves indicate on an ECG?
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Necrosis. There is some dead myocardial tissue. It is non-reversible.
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What does a "non Q wave MI" mean?
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Means it did not affect all the layers of the heart. It is not "transmural" like the deep Q waves which means it did affect all the layers of the heart.
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A patient comes in with chest pain? What are the first things you do?
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* Oxygen
* CBC cardiac labs, enzymes, electrolytes * monitor (ECG) |
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What is the antidote for Heparin?
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Protamine Sulfate
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What is the antidote for coumadin?
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Vitamin K
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Intravascular hypovolemia can be secondary to blood loss. What hemodynamic measurement will be decreased and why?
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CVP would be decreased because of low blood volume.
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What is a nurse's role before cardiac surgery? Preoperatively.
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* Full History & physical
* baseline labs including anticoag studies * Chest X ray * EKG * ABG's for COPD patient * Patient education - relieve their anxiety and include the family |
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What is a nurse's role during cardiac surgery? intraoperatively
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Hemodynamic monitoring. It is very important
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What is a nurse's role after cardiac surgery? postoperatively
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* cardiac monitoring
* rewarming the patient * stabilizing and maintaining respiratory and hemodynamic functions * Volume resuscitation * maintain BP & CVP * maintain fluids (urinary output) * Control their pain - they are intubated and can't tell you they're in pain * monitor their mental status - a change could mean a sedation from meds or have a blood clot |
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What does the parasympathetic NS do to the GI?
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* Has cholinergic effects * Acetylcholine is released * Increases GI motility * SLUDGE * Heart rate decreases * BP goes down
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What does SLUDGE stand for?
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Salivation
Lacrimation (tears) Urination Digestion Gastric emptying Emesis |
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What does the sympathetic NS do to the GI?
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* Speeds things up in the cardiac system
* Decreases GI motility * Increases HR & BP |
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What causes portal hypertension?
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* Compression
* occlusion * Liver disease (most associated with cirrhosis) |
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What kind of ulcer is the most common?
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Duodenal because of all the activity and functions
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What is the subjective data of a GI history assessment?
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* Pain (onset & duration)
* Location (know the landmarks) * Any N/V/D * Color of any vomitus or odor * Does the pain radiate to the back * stools (character & color) * Any prolonged use of NSAIDs? |
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What past medical history would you explore for a patient with GI issue?
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•AAA(abdominal aortic aneurism) •Oldsurgeries(colostomy?)
•Trauma •Hepatitis •Pancreatitis(once, more likely to get it again) |
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**How do you perform an assessment on a GI patient? In what order and why?
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1. Inspection (check symmetry, masses, hernias, scars and dilated veins
2. Auscultation (start in lower right quadrant - listen for bowel sounds for up to 2 min if necessary) 3. Percussion (locates organs and air) 4. Palpation (to identify size of organs or abnormal masses - palpate pain area last) |
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What is rebound tenderness?
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When pain is felt AFTER hand is removed during palpation. Often is a symptom of an infection of the peritoneum.
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How often are normal bowel sounds heard?
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5-15 seconds
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How long do you listen for bowel sounds if you don't hear them?
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2 minutes
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Which area of the abdomen should be palpated last?
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The painful area.
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What is in the right upper quadrant of the abdomen?
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* Liver
* Gallbladder * Pylorus * Duodenum * Head of the pancreas * Portions of the ascending and transverse colon |
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What is in the left upper quadrant of the abdomen?
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* Left liver lobe
* Stomach * Spleen * Body of the pancreas * Portions of the transverse and descending colon |
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What is in the left lower quadrant of the abdomen?
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* Sigmoid colon
* Portion of the descending colon |
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What is in the right lower quadrant of the abdomen?
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* Cecum
* Appendix * Portion of the ascending colon |
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What is it called when the liver enzymes are elevated due to liver disease? (hint: doesn't have to do with a car)
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Transaminitis
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If in liver enzyme tests, the AST is double the ALT, what is most likely the reason?
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Alcoholic liver disease
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What is albumin?
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A major protein which is produced by the liver. Decreased in Liver disease.
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What can the ammonia level do to a person with liver disease?
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Causes mental status changes AKA Hepatic encephalopathy. Lactulose can help by bringing in water and displacing the ammonia.
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What are the most common diagnostic tests for problems with the abdomen?
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* Kidney, Ureter, Bladder (KUB x-ray) shows the lower GI tract
* Upper and Lower GI series, Barium Swallow (drinks milky white stuff to show up in xray) * Paracentesis - Fine needle aspiration of fluid in the peritoneal cavity * Abdominal Ultrasound (looking for fluid) * Abdominal CT scan * MRI * Endoscopy - camera down throat * Colonoscopy - camera up butt * Endoscopic Cholangiopancreatictography (ECRP) - endoscopy of gall bladder and pancreas |
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Name the antacids
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* Tums
* Rolaids * Milk of Magnesia (MOM) |
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Name the Histamine 2 receptor site antagonists
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* Tagamet
* Zantac * Pepcid(Important to give to GI bleed patients because acid can irritate the bleed site) |
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Name the Proton pump inhibitors.
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* Protonix
* Prilosec * Nexium * Prevacid |
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What are pancreatic enzymes given to a patient for?
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To replace the enzymatic activity of the pancreas (Mostly for CF patients). They are pancrease and Ultrase
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How do antidiarrheals work?
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Kaopectate, Pepto Bismol and immodium work by slowing the GI motility
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Name the stool softener
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Colace
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What are the bulk forming agents for laxatives?
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* Citrucel
* Metamucil |
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What is the bowel cleansing agent?
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Go Lytely
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What is the hyperosmolality laxative agent and how does it work?
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Lactulose. Works by drawing water into the colon and preventing absorption of ammonia into the colon.
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What are the stimulant laxatives and how do they work?
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* Dulcolax
* Senna * Ex-Lax(They increase peristalasis) |
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What is the softener that's also a stimulant?
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Glycerin
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What are the anti-emetics and how do they work?
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* Tigan
* Reglan * Zofran * Compazine (Increases gastric motility so won't get nauseous) |
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What are the nasoenteral feeding tubes? How long do they stay in?
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* Nasogastric (NG) tube (nose to stomach)
* Orogastric (OG) tube (mouth to stomach) * 4 to 6 weeks |
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What are the enterostomal feeding tubes? How long do they stay in?
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* Gastrostomy tube - right into the stomach
* Percutaneous endoscopic gastrostomy (PEG) * Jejunostomy tube - directly into the jejunum |
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**What is necessary with a feeding tube?
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To always check for placement before placing anything in it, to make sure it's not in the lungs. Can listen with a stethoscope and place air in the tube and listen for the whoosh of air.
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Why is a continuous feeding more beneficial than other types of feedings when using a feeding tube?
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Lowest risk of aspiration
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**What are the complications of enteral nutrition?
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* N/V
* Diarrhea (#1 complication) * Bloating * Constipation * Clogged tubes * Metabolic complications (BS, electrolytes) * Aspiration (if residuals are too high) |
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What are the different kinds of enteral feedings?
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* Continuous feedings (24 hours)
* Bolus feedings (up to 400cc 5-6 x day) * Intermittent feedings (slow drip 300-400cc 4-6 x day over 30 min) * Cyclic feedings (Total daily nutrition overnight - not good for patients with GERD) |
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What are the 2 types of parenteral nutrition?
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* Total Parenteral Nutrition (TPN - through a PICC) - given ONLY through a large central vein
* Peripheral Parenteral Nutrition (PPN) |
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What does a bag of TPN consist of?
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* Carbohydrates, dextrose & glucose (15-40%)
* Amino Acids & Protein (3-14%) * Lipids (some places hang separately 10, 20 or 30%) |
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How is a TPN bag prepared?
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* Nutritionist ordered
* Prepared by a pharmacist by strict aseptic technique * Some items may be added by pharmacist like heparin, insulin or electrolytes |
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What are the complications of TPN?
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* Hyperglycemia
* Fatty Liver Disease |
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What are the common GI disorders?
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* GI Bleeds
* Bowel obstruction * Pancreatitis * Hepatitis & Cirrhosis * Aortic Abdominal Aneurism (AAA) |
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Where does an upper GI bleed occur? How is it found?
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* esophagus
* stomach * duodenum * Endoscopy |
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Where does a lower GI bleed occur? How is it found?
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* Jejunum
* ileum * colon * rectum * Colonoscopy |
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Where does a peptic ulcer occur?
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* Gastric
* Duodenal |
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What causes 90% of peptic ulcers?
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H. Pilori
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What causes bowel obstructions?
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* adhesions
* scar tissue * hernias * masses * Crohn's disease * surgical ileus |
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How many bowel obstructions are typically in the small bowel?
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60-75%
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Where is the most common site affected in a large bowel obstruction?
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The sigmoid colon (where diverticulosis happens)
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**What are the symptoms of a bowel obstruction?
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* abdominal distention
* Pain * Decreased GI motility * May have diarrhea (stool leaking around obstruction) * Severe pain and vomiting a late sign |
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What is the treatment for a bowel obstruction?
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* IV fluids
* Oxygen * Pressors * NG tube (get out some air to relieve pressure)* Belly labs & films (CT, KUB) |
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What is the surgical treatment of a bowel obstruction?
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* Small bowel - laparoscopic lysis, reduction of volvus, or bowel resection
* Large bowel - bowel resection or laparoscopic decompression |
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What is a volvulus?
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A twisting of the bowel on itself
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What is pancreatitis caused by?
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* Gallbladder Disease - Can be caused by a gall stone blocking the sphincter of oddi. (More common in women)
* Alcohol abuse (More common in men) |
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What are the symptoms of pancreatitis?
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* Pain (epigastric pain following big meals)
* Elevated amylase and lipase |
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Why is history important for pancreatitis?
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Once they've had it, they're likely to get it again
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What are the different complications that can occur with pancreatitis?
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* Increased fluid & inflammation which can lead to cysts, abscesses or GI bleed
* Pulmonary issues like atelectasis due to shallow breathing and pleural effusion which can lead to ARDS * Cardiovascular issues like hemorrhagic or septic shock, prone to DIC * Renal failure secondary to shock * metabolic acidosis |
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What is the treatment for pancreatitis?
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* Hemodynamic monitoring
* Correct & replace fluids, electrolytes, blood, albumin * NG tube - patient NPO * Diet low in fat, high in protein & carbs |
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What is hepatitis?
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Inflammation of the liver. Can be acute or chronic.
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What are the causes of non-infectious hepatitis?
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* Excessive alcohol
* Autoimmune disorders * Metabolic or vascular disorders |
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What are the causes of infectious (viral) hepatitis?
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A - food borneB - sexual contactC - needles, sex D - won't get unless you have BE - contaminated food, water or uncooked meat (rare)
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What is cirrhosis?
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An inflamed, fatty liver, caused primarily by alcoholism. Can lead to liver failure
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**What is hepatic encephalopathy?
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A state of mental functioning as a result of the inability of the liver to remove ammonia and other toxins from the blood. Lactulose can remove ammonia from the blood.
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What are the symptoms of cirrhosis?
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* Severely malnourished
* jaundiced * ascites * Severely abnormal bleeding times |
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What are the conditions that can lead to liver failure?
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* Hepatitis
* Cirrhosis * Pancreatitis * Gallbladder Disease |
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Describe an Abdominal Aortic Aneurism
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* Can develop over time. Less than 5cm, watch. * Over 5cm, need surgical repair.
* Antihypertensives can help keep it from rupturing. * A classic sign of an impending rupture stabbing abdominal pain radiating to the back with HTN and tachycardia. If ruptures, prognosis is not good. |
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What is the difference between the parietal pleura and the visceral pleura?
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* Parietal pleura lines the chest wall
* visceral pleura lines the lung parenchyma |
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What is in the mediastinum?
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–Containsthe heart, esophagus, great vessels
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Where does the end of an ET tube sit?
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Just above the bronchi bifurcation called the Carina.
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What is the only vein with deoxygenated blood?
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Pulmonary Vein
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What is anything that clogs the alveoli called?
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A shunt (even pneumonia)
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What is respiratory diffusion?
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Gas exchange. Movement of CO2 and O2 between the alveoli and the capillaries.
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What is respiratory transport or perfusion?
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–Movementof O2 from the alveoli to the cells –Movementof CO2 from the cells to the alveoli–(problemshere is called “dead space” – pulmonary embolism) problem with blood flow
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What is respiratory ventilation?
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Inhale/ exhale. Movement of air between the alveoli and atmosphere
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What can hinder the process of ventilation?
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* Impeding movement of the diaphragm (ascites, trauma)
* Changes in transpulmonary pressure (Pulmonary HTN, L sided HF) * Anything hindering lung compliance (Lung disease, COPD, pulmonary fibrosis) * Airway resistance (asthma) |
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What is alveolar dead space?
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alveoli that are ventilated but not perfused, and where, as a result, no gas exchange can occur
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What are PFTs?
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* Pulmonary Function Tests
* Examines the body’s ability to move air in and out of alveoli for gas exchange/diffusion. Examines total lung capacity. |
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What is tidal volume?
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the volume of air inhaled and exhaled with each breath. Can be manipulated with mechanical ventilation
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**What should be discussed on a respiratory history?
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* Dyspnea - When did it start? What makes it better or worse?
* Chest pain - need to figure out if it's respiratory or cardiac (are they congested?). Is there more pain on inhalation? Is the pain relieved with nitro? Is it exertional? * Is there sputum production with a cough? Yellow or green means bacterial. Over 3 months of cough with sputum means chronic bronchitis * Family history * Social/ working history - smoke? environmental exposure? |
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What is Kussmaul breathing?
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* Rapid and labored breathing.
* Normal with diabetic ketoacidosis (not enough bicarb - too much acid) |
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What is Cheyne-Stokes breathing?
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Breathing with periods of apnea. Seen in end of life, drug OD, Increased ICP, Severe CHF
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What should be done first during a respiratory physical exam?
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Always look first:
* Is the respiratory rate fast or slow (tachypnea may mean fever) * Labored breathing (accessory muscles used?) * Cyanosis of skin, lips or fingers (late sign of hypoxia) * barrel chested? * chest expansion equal? (pneumothorax?) * Trachea Midline (tension pneumothorax?) * Chest deformities or scars? |
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What is crepitus or subcutaneous emphysema?
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* Pockets of air under the skin
* secondary to a traumatic injury/ pneumothorax * small pockets of alveoli that burst secondary to too much PEEP |
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What are the lung sounds?
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* Clear
* Diminished (COPD, pneumonia) * Wheezes (asthma) * Rhonchi (coarse breath sounds - pneumonia) * Rales, fine or coarse (crackles - fluid accumulation) * Stridor (life threatening) |
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What is SaO2?
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O2 level in the blood (O2 combined with hemoglobin)
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What is PaO2?
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Partial pressure of oxygen in the blood (O2 dissolved in the plasma)
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What is a friction rub and what does it signify?
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Grating sound heard more with inspiration than expiration resulting from the visceral and parietal pleura rubbing against each other. Can be seen in pleurisy, pneumothorax and pleural effusion.
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What is the normal range for serum pH? What if it's above or below?
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7.35 - 7.45
Below is acidosis Above is alkalosis |
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What is the normal range for CO2? What if it is above or below?
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35 - 45
Below is alkalosis Above is acidosis |
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What is the normal range for bicarb (HCO3)? What if it is above or below?
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22-26
Above is alkalosis Below is acidosis |
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What mnemonic helps with analyzing ABGs?
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ROME
Respiratory Opposite Metabolic Equal |
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What are some causes of respiratory acidosis?
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* Hypoventilation (too sedated)
* CNS depression (from narcotics) * Pneumothorax * COPD |
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What are some causes of respiratory alkalosis?
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* Hyperventilating
* Anxiety * Fever |
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What are some causes of metabolic acidosis?
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* Diarrhea
* Chronic Renal Failure * Diabetic Ketoacidosis * Aspirin overdose * Rhabdomyolysis (causes renal failure) |
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What are some causes of metabolic alkalosis?
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* vomiting
* too much drainage with an NG tube * Ingestion of too many antacids |
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What are the respiratory diagnostic tests?
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* Chest X-ray
* Ventilation-perfusion scan * Pulmonary Function test * Bronchoscopy * Thoracentesis * Sputum Culture |
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**What are the pulmonary treatments to improve bronchial hygiene?
|
* Cough and deep breathing (prevents atelectasis, keeps secretions moving & prevents pneumonia)
* Chest physiotherapy (position of bad lung up, good lung down, postural drainage - trendelenburg or reverse trendelenburg, or percussion/ vibration) |
|
|
Which mask delivers the highest amount of O2 before intubation?
|
Non-rebreather mask
|
|
|
**Why are COPD patients called "CO2 retainers"?
|
COPD patients live at higher levels of CO2, so if they are given high levels of oxygen, their body recognizes it as too much oxygen and it may knock out their drive to breathe. If O2 is bumped up, (an already high) CO2 is also bumped up and high CO2 levels can cause respiratory arrest.
|
|
|
What is a cricoid?
|
An emergency cut in the throat to aid in breathing
|
|
|
When would a nasopharyngeal airway be used instead of an oropharyngeal airway?
|
An NPA is used in unconscious patients where the tongue relaxes and would block a passage for an oropharyngeal airway.
|
|
|
What is empyema?
|
Pus in the pleural space. Would be removed with a chest tube
|
|
|
What kinds of chest tubes are there and what are they called?
|
* Wet system - Ocean
* Dry system - Oasis |
|
|
What is a hemothorax?
|
Blood in the pleural cavity (trauma)
|
|
|
What is a pneumothorax?
|
Air in the pleural space
|
|
|
What is a tension pneumothorax?
|
Trachea deviates away to one side, pressure will build up in the chest, decreased cardiac output, decreased veinous return from the heart. Needle in the chest is needed to relieve pressure
|
|
|
**What are the modes of ventilation?
|
* Assist-control or CMV (full support)
* Synchronized intermittent mandatory ventilation (Pt. can breathe in addition RR set) * Continuous Positive airway pressure (CPAP - used to wean off vent) * Bilevel PAP - same as CPAP but not as invasive |
|
|
**What are the pressure modes added to modes of ventilation?
|
* Pressure support ventilation (PSV) - helps with inhalation, spontaneous breaths. Adjustable and used to augment breaths
* Positive end-expiratory pressure (PEEP) - extra pressure with exhalation with a pt. still dependent on vent. Can cause low BP and high ICP |
|
|
**What settings are located on a ventilator?
|
* Tidal volume
* Respiratory rate * FiO2 * Pressure limit |
|
|
What is pleural effusion?
|
•Accumulation of pleural fluid secondary to increased fluid formation
|
|
|
What are the symptoms of pleural effusion?
|
* SOB
* chest pain * tachypnea * hypoxemia |
|
|
When is a thoracentesis needed?
|
when effusion is more than 1 cm
|
|
|
What can a thoracentesis cause?
|
A pneumothorax
|
|
|
What are the nursing interventions regarding ventilation?
|
* Suction patient frequently
* keep patient sedated * monitor pulmonary status * monitor ABGs * After insertion of ETT, listen to LS - if not left LS, it may be in the R mainstem * get a CXR to confirm |
|
|
What are the complications of mechanical ventilation?
|
* aspiration (need HOB at 30 degrees)
* pneumothorax (may need a chest tube) * barotrauma (collapsed alveolar due to pressure changes during inspiration) * Ventilator associated pneumonia (VAP) * Decreased cardiac output (secondary to increased pulmonary pressure, too much PEEP = increased pulmonary HTN affecting decreased venous return |
|
|
**What kind of nutritional needs are required for patients on mechanical ventilation?
|
* extra protein
* extra calories |
|
|
What are the symptoms of pneumonia?
|
* fever
* diminished LS * tachycardic * congested * 02 sats are low * May be hypoxic |
|
|
What is the management of pneumonia?
|
* antibiotics
* bronchodilators * steroids * O2 * nutrition * hydration (easier to expectorate) * rest |
|
|
How is pneumonia diagnosed?
|
* CXR (Every day or every other day during illness)
* sputum culture * CBC * blood cultures |
|
|
What is the #1 reason for a pleural effusion?
|
CHF
|
|
|
What is a pulmonary embolism?
|
* Part of a deep vein thrombosis that has traveled and lodged in the pulmonary arteries.
* A result of a DVT |
|
|
What are the symptoms of a PE?
|
* SOB
* hypoxic * anxious * tachycardic * hypotensive |
|
|
How is a PE diagnosed?
|
* Serum D-dimer (clotting series)
* chest CT * VQ scan or pulmonary angiogram |
|
|
How is a PE managed?
|
Anticoagulation. Heparin or Lovenox at first then PO coumadin for approximately 6 months
|
|
|
How are DVTs prevented?
|
* anticoagulation
* Teds elastic stockings * SCDs |
|
|
**What are the anticoagulation studies?
|
* PT (Prothrombin Time)
* PTT (Partial Prothrombin Time) or APTT * INR (International Normalized Ratio |
|
|
**What is the goal of the anticoagulated patient?
|
To be 2X greater than normal ranges
|
|
|
**What are the symptoms of COPD?
|
* Central cyanosis
* barrel chested * Low SATs (80's not uncommon) * Diminished LSs or wheezes * Smoking history |
|
|
**What is the non-pharmacologic management of the COPD patient?
|
* Low O2
* education * drug therapy * nutrition * exercise |
|
|
**What is the pharmacological management of the COPD patient?
|
* Bronchodilators (albuterol)
* Steroids |
|
|
What is chronic bronchitis?
|
Chronic bronchitis is an inflammation of the main airways in the lungs that continues for a long period or keeps coming back. Categorized in text as a productive cough. (more than 3 months per year)
|
|
|
What are the symptoms of chronic bronchitis?
|
* cough that produces sputum
* SOB * frequent respiratory infections that worsen symptoms * wheezing * continues for more than 3 months of the year |
|
|
What is the management of chronic bronchitis?
|
There is no cure cure for chronic bronchitis. The goal of treatment is to relieve symptoms and prevent complications.
* antibiotics * bronchodilators |
|
|
What is asthma?
|
•A chronic inflammatory disease of the airways
•Airway hyper responsiveness to various stimuli •Variable airway obstruction •Resolves spontaneously or after using a bronchodilator |
|
|
What are the symptoms of asthma?
|
* wheezing
* hypoxic |
|
|
What are the diagnostic tests for asthma?
|
* CXR
* PFT |
|
|
What is the management of asthma?
|
* Bronchodilators
* steroids * education to prevent exacerbation and optimize pharmacotherapy * know triggers (animals, dust, mold, etc) |
|
|
Describe ARDS (Acute respiratory distress syndrome)
|
* Caused by direct or indirect pulmonary injury (near drowning, aspiration, shock, DIC)
* first sign is flash pulmonary edema (pink frothy sputum) * There is diffuse alveolar-capillary membrane damage that increases membrane permeability. This leads to improper gas exchange, hypoxemia and pulmonary edema |
|
|
What are the diagnostic studies for ARDS?
|
•Blood cultures
•Blood gas •CXR •Lung compliance will be poor, airway resistance,and pressure •Keep prone 16-18 hours a day for lungcompliance, allowed a little higher CO2 (permissive hypercapnia), medically paralyze them and sedatethem •Put on a lot of PEEP |
|
|
*In an LFT, if elevated Alkaline Phosphatase is found. What is likely the cause?
|
Alcoholic Liver Disease
|
|
|
What is sclerotherapy?
|
variceal ligation
|
|
|
**If a patient came in with chest pain and had more pain on inhalation, what is the cause of the chest pain and what else would you expect to see?
|
The patient would have a pneumothorax and there would be no breath sounds on the affected side.
|
|
|
**What are normal O2 sats?
|
93-99%
|
|
|
**When is a pulse oximeter not reliable?
|
* On a patient in shock
* On a patient in cardiac arrest * patient with poor perfusion |
|
|
What is FiO2?
|
The amount of O2 being received by patient.
|
|
|
What is the difference between SpO2 and SaO2?
|
SpO2 is saturation measured by pulse oximetry - it is an indirect measurement
SaO2 is O2 saturation in the blood - a direct measurement |
|
|
Why should people who are hyperventilating breathe into a paper bag?
|
Because by hyperventilating they are taking in too much oxygen. By breathing into a paper bag, they rebreathe some of their own CO2
|
|
|
What's a VAP bundle?
|
Ventilator associated pneumonia prophylaxis
* HOB 30 degrees * PPIs * good oral care |
|
|
**Why do COPD patients need nutritional counseling?
|
* malnutrition is present in 50% of COPD patients admitted to the hospital
* malnutrition results in wasting of respiratory muscles * a nutritional assessment is required to address the nutrition needs of the patient and restore the muscle strength |
|
|
In filtering the blood going in the kidney, what is the blood called and what is the path that it takes?
|
Afferent - from Renal Artery-to Kidney-Branched into afferent arteriole-glomerulus-filtered
|
|
|
After filtering the blood in the kidney, what is the blood called, leaving the kidney, and what is the path that it takes?
|
Efferent - from Efferent arteriole-leaves Kidney to Renal Vein
|
|
|
What is specific gravity?
|
The test that displays the kidney's ability to concentrate urine. The higher the number, the more concentrated it is
|
|
|
What is creatinine?
|
A protein that is supposed to be excreted in urine. If it is not excreted, it remains in the blood and should not be very high in the blood
|
|
|
What is BUN?
|
Blood urea nitrogen. Affected by dehydration, volume depletion, shock and hypovolemia. Should be excreted in the urine. An increase in BUN means a decrease in renal perfusion or volume.
|
|
|
What is the normal ratio between BUN and creatinine?
|
10:1 ie BUN 8-20mg/dL over creatinine .6-1.2
|
|
|
What is serum osmolality?
|
Measurement of particles in a solution..Concentration………Equals the concentration of particles in plasma. Increases with dehydration and decreases with overhydration
|
|
|
Name some conditions of high serum osmolality.
|
* dehydration
* Diabetes Insipidous * Hyperglycemia * Hypernatremia |
|
|
What does a renal angiogram show?
|
Assessing Renal Perfusion of the Renal Artery. Poor renal perfusion over time causes too much production of Renin Hence too much vasoconstriction = HTN and eventually CRF (chronic renal failure) ie DM
|
|
|
What's an important way to assess the kidneys?
|
* Compare patient's weight from previous day or shift.
* Assess I's and O's - everything measurable (IV fluids, foods with high water content, drinks, not 3CCs of lovenox) |
|
|
What are the signs and symptoms of dehydration?
|
* Dry
* decreased UO * low BP * may have increased (Hemato)Crit * Serum Osmolality be increased |
|
|
What does hemodialysis do?
|
• Removes urea,creatinine, and uric acid
• Removes excess water • Maintains appropriate levels of electrolytes |
|
|
What are the three different kinds of access for a patient to be dialysized?
|
1 - vascular catheter (done in emergencies at the wrist
2 - A-V fistula (artery & vein are anastomosed - there's a bruit & thrill) 3 - Synthetic vascular graft (man made) |
|
|
What are the blood vessels called leaving the body for dialysis?
|
* Afferent. The blood leaves the body through an artery. (A for afferent and A for artery)
* The dialysis machine takes the place of the kidney, so the vessels in and out are the same as in and out of the kidney. |
|
|
What are the blood vessels called going back to the body from dialysis?
|
Efferent. The blood returns to the body in a vein.
|
|
|
When are blood pressure meds given on dialysis days and why?
|
They are given either after or up to 6 hours before because the medication will be cleaned out of the blood during dialysis.
|
|
|
What is the role of the dialysis nurse?
|
To closely monitor the electrolytes and the amount of fluid removed or not removed from the blood.
|
|
|
What are the causes of acute renal failure?
|
* Prerenal - MI, rhabdomyolysis, any surgery requiring a heart/ lung machine, shock, dehydration
* Intrarenal - Damage to the kidney itself - pyelonephritis, glomerulonephritis, acute tubulor necrosis * Postrenal - obstruction of flow out of the kidney - tumors, masses, stones, BPH (benign prostatic hypertrophy) |
|
|
What is the assessment of AKI?
|
* Prerenal - has the patient had surgery? Have they had an MI or shock?
* Intrarenal - is the patient on gentamycin? aminoglycosides? Rhabdomyolysis? * Postrenal - does the patient have a history of kidney stones? * labs show high K+, high BUN, high creatinine |
|
|
What is a nephrotoxin and give a couple of examples.
|
* Anything toxic to the kidneys.
* Aminoglycosides (Antibiotics ending in 'mycin') * IV contrast dye |
|
|
What is the management of hyperkalemia and why?
|
* Insulin brings glucose and potassium with it back into the cells (potassium leaves the cells to neutralize blood glucose causing hyperkalemia)
* D50 so the serum glucose does not go too low * Bicarb helps to neutralize the acidic environment (potassium & glucose are very acidic) |
|
|
Give an example of a condition causing post-renal failure.
|
Hydronephrosis (Kidneyor bladder becomes distended secondary to a stone/renal calculi)
|
|
|
Give an example of a condition causing intrarenal failure.
|
* Cystitis (infection of the bladder)
* pyelonephritis (infection of the kidney) |
|
|
What are the functions of the brain stem?
|
* Heart rate
* breathing * blood pressure |
|
|
What is important information for the neuro exam?
|
1 - Mental status (most critical) - GCS
2 - Motor function - Do they respond to commands? Squeeze hands? withdraw? posturing? inequalities? 3 - Pupillary changes (pinpoints - opiates, brain stem damage, dilated - cocaine, crack & PCP) 4 - Vital Signs (HR, BP & T are late findings - respiratory patterns will be the first VS to change with a head injury) |
|
|
What are the responses to stimuli listed from best to worst?
|
1 - reach toward stimulus
2 - withdraw from painful stimulus 3 - decorticate posturing (flexion) 4 - decerebrate posturing (extension) 5 - no response |
|
|
What is Cushing's Triad?
|
A vital sign trend that may be a sign of impending herniation and increased ICP.
* Bradycardia * Irregular respirations * Rising systolic BP * Decreasing diastolic BP (widening pulse pressure) (BIRD) |
|
|
What is fasciculation?
|
Involuntary twitching of the feet or toes after succinylcholine is administered. Could indicate a spinal cord lesion
|
|
|
What is tonic-clonic movements?
|
•Jerking muscularactivity seen in seizing patients.
|
|
|
What are some signs of trauma or infection in the neuro exam?
|
* Battle sign
* Raccoon sign * CSF from nose or ear * Meningitis * Increased ICP |
|
|
What is a Battle Sign?
|
A bruise behind the ear may have resulted from a basilar skull fracture
|
|
|
What is a raccoon sign?
|
Periorbital edema and bruising may have resulted from a zygomatic (or orbital) fracture
|
|
|
If a patient is seen in the ER for head trauma and they have a runny nose, what should be done and why?
|
The nasal mucus should be tested for glucose because it may be cerebral spinal fluid
|
|
|
What happens to the LOC in IICP?
|
The LOC goes down as the ICP goes up.
|
|
|
What are the levels of consciousness?
|
* Alert (normal)
* Awake (may sleep more but otherwise normal) * Lethargic (drowsy but follows commands) * Obtunded (follows simple commands but drowsy) * Stuporous (hard to arouse, inconsistent with commands) * Semicomatose (does not follow commands or speak coherently) * Comatose (may respond with reflexive posturing or may not respond at all) |
|
|
If a patient is behaving as though he's had an ischemic event (CVA or stoke), how long of a window is there to administer t-PA?
|
3 hours from onset of symptoms. If woke up with them, may not be a candidate.
|
|
|
What are the three 3 parts that make up the brain in the skull?
|
1 Blood
2 CSF 3 Brain tissue |
|
|
What is the Monroe Kelly doctrine?
|
A compensatory system of auto regulation. If there is too much CSF in the brain, it will compensate by absorbing more fluid or reducing blood flow. If there is swelling, it will reduce CSF. Happens in other systems as well
|
|
|
What is the goal of auto-regulation?
|
Maintain perfusion and keep down Increased ICP.
|
|
|
What is normal ICP?
|
0-15mm Hg
|
|
|
What is normal cerebral perfusion pressure (CPP)?
|
NR 60-100mm Hg (at least 60 is needed for brain injured patients)
|
|
|
Why is ICP monitoring important?
|
Intraventricular catheters are important to monitor ICP to help predict outcomes by closely tracking pressure trends because they tell us what therapies are working.
|
|
|
What is the first tier therapy for head injury?
|
1. Mannitol administration
2. Respiratory Support 3. Analgesia, sedation & paralytics 4. Control and decrease external stimuli |
|
|
What does mannitol do for ICP?
|
It is a diuretic to reduce the fluid in ICP. Very thick and hypertonic.
|
|
|
When suctioning a person with a head injury, need to hyper-oxygenate first. Why?
|
Suctioning out O2 as well. Need to use PEEP sparingly because pulmonary pressures can cause IICP.
|
|
|
Why is sedation necessary for a patient with a head injury?
|
Need to keep the patient calm. Agitation can increase all the pressures in the body.
|
|
|
Why is it necessary to decrease stimuli for a patient with a head injury?
|
Loud noises and stimuli can increase pressures in the body.
|
|
|
What do seizures lead to?
|
* Hypercapnia
* Hypoxia |
|
|
What is hypercapnia?
|
Excessive CO2 in the bloodstream caused by inadequate respiration (hypoventilation).
|
|
|
How do you stop acute tonic-clonic activity?
|
* Ativan/ Lorazapam
* Valium/ Diazepam |
|
|
What is postictal?
|
The state after a seizure. Patient may be tired, confused, disoriented, HA
|
|
|
What is the most common neurologic issue?
|
Stroke
|
|
|
What are some medications are given for seizures?
|
* Tegretol
* Klonipin * Neurontin * Lamictal * Depakote * Topomax |
|
|
What is the difference between primary and secondary brain injury?
|
* Primary is the mechanism that caused the injury
* Secondary the results such as IICP, seizing, herniation, etc. |
|
|
What are the different kinds of head injuries?
|
* Acceleration (something fast hits the head)
* Acceleration - Deceleration (moving head hits a non-moving surface * Coup-contre coup (Head it struck and bounces back) * Rotational injury (anything that causes you to flip and roll - shearing injury for the brain) |
|
|
What is the most sensitive indicator of IICP?
|
Level of consciousness
|
|
|
A patient is brought in to the ED and the nurse is informed that the patient is under the influence of PCP. What will the nurse observe in the patient's pupils? What else will cause this?
|
The patient's pupils will be dilated. Crack or cocaine will also cause this.
|
|
|
A patient is brought in to the ED and the nurse is informed that the patient is under the influence of heroin. What will the nurse observe in the patient's pupils? What else will cause this?
|
The patient's pupils will be pinpoints. Heroin is an opiate and opiates cause this. Brain stem damage can also cause this.
|
|
|
What are the stages of shock?
|
* Stage 1 - Non-progressive stage
* Stage 2 - Progressive stage * Stage 3 - Irreversable |
|
|
Describe stage 1 of shock
|
* Non-progressive stage (compensated)
* Relatively normal * Cerebral infusion intact * Reversible |
|
|
Describe stage 2 of shock
|
* Stage 2 - Progressive Stage (decompensated)
* Noticeable changes, tachycardia, tachypnea * Change in LOC * Reversible if treated appropriately |
|
|
Describe stage 3 of shock
|
* Stage 3 - Irreversible
* Temp down, pulse down, RR down, Hypotensive * Profound decrease in cerebral perfusion |
|
|
What are the Signs of shock?
|
* Hypotension (MAP is also low)
* Tachycardia & Tachypnea * Altered mental Status * Later stage = decreased urine output * Metabolic Acidosis |
|
|
What are the classifications of shock?
|
1. Hypovolemic shock
2. cardiogenic shock 3. anaphylactic shock 4. neurogenic shock 5. septic shock |
|
|
What is shock?
|
•A serious life-threatening condition where there is a decrease in overall tissue circulatory perfusion. Perfusion is decreased to the point where the body cannot meet circulatory metabolic demand.
•More demand and less perfusion •Hypo-perfused state at the cellular level•Eventually can become systemic leading to multi organ failure •Electrolyte disturbances |
|
|
What are the compensatory mechanisms of shock?
|
* Tachycardia
* tachypnea * aldosterone & ADH to improve fluid balance |
|
|
For shock, do we want vasodilation or vasoconstriction?
|
Vasoconstriction to help increase perfusion
|
|
|
What do vasopressors do?
|
Increase MAP (Mean arterial pressure) and BP
|
|
|
What do ianotropes do?
|
Increase contractility of the heart
|
|
|
What is the #1 medication used in shock?
|
Levophed (which is norepinephrine)
|
|
|
What is dopamine?
|
An ianotropic and a vasopressor
|
|
|
What are the distributive kinds of shock?
|
* Anaphylaxis
* Spinal Cord injury (neurogenic) * Sepsis (ASS) |
|
|
What is the nursing management during fluid resuscitation?
|
* Warmed fluids (the patient is cool from vasodilation)
* Monitor for pulmonary edema (if fluids given too quickly - may end up on a vent) * Elevate lower extremities (better venous return) * Monitor VS, O2, Mentation, UO & labs |
|
|
What is the #1 cause of cardiogenic shock?
|
MI
|
|
|
What is cardiogenic shock?
|
It is shock secondary to an MI, usually a Left ventricular MI. If the left ventricle is more than 40% failed, the afterload is too decreased causing multi-system failure because of no systemic perfusion. The ejection fraction is less than 35%
|
|
|
What are the signs and symptoms of cardiogenic shock?
|
* Chest pain
* Thready rapid pulses * Distended neck veins * Pulmonary congestion (crackles, rales, gurgles)(less than 50% chance of survival if all 4) |
|
|
What are the labs of cardiogenic shock?
|
* Elevated cardiac enzymes
* BNP (how much fluid overload) * ECG changes * Echocardiography * Pulmonary artery pressures |
|
|
How can pulmonary artery pressures be measured?
|
SWAN measures CVP, left ventricular pressure, and if there's too much fluid.
|
|
|
What is the treatment for cardiogenic shock?
|
* Judicious fluids with diuretics and nitrates
* Monitor and replace electrolytes, especially K+, * Narcotic analgesics,but watch the SaO2 and Hypotension * Treat rhythm disturbances * Possible cardioversion or pacing * Left ventricular assistive devices: IABP * SWAN line can help to see if these help |
|
|
What do vasopressors do for treatment of shock?
|
They augment the coronary and cerebral blood flow during a low flow state associated with shock
|
|
|
What do vasodilators do for treatment of shock?
|
Relaxes vascular smooth muscle and reduces SVR (systemic vascular resistance), allowing for improved forward flow which improves cardiac output.
|
|
|
What do diuretics do?
|
Decrease plasma volume and peripheral edema?
|
|
|
What is afterload?
|
It is the pressure in the wall of the left ventricle during ejection. Afterload can also be described as the pressure that the chambers of the heart must generate in order to eject blood out of the heart.
|
|
|
What does HTN do to afterload?
|
Increases the left ventricular (LV) afterload because the LV must work harder to eject blood into the aorta
|
|
|
What is the definition of chronotropic?
|
A medication, or effect, that changes the heart rate and rhythm by affecting the electrical conduction system.
|
|
|
What is the definition of inotropic?
|
A medication, or effect, that changes the force of the heart's contractions (contractility).
|
|
|
What is anaphylactic shock?
|
* It is an allergic reaction resulting from the body being exposed to a specific allergen.
* Eosinophils are increased as well as mast cells and H1 and H2 * Loss of blood vessel tone, systemic vasodilation, broncho-constriction, and uticaria |
|
|
What is the treatment for anaphylactic shock?
|
* ABCs
* Epinephrine 3-5 mL 1:1000 concentration * Isotonic Fluids * Antihistamines such as Benedryl * Vasoconstrictors if hypotension or circulatory collapse |
|
|
What is neurogenic shock?
|
* Typically caused by a spinal cord injury above T6 (sympathetic nerve synapses are here so parasympathetic NS takes over)
* Results from loss of in sympathetic nerve tone causing peripheral vasodilation * Subsequently, decreased tissue perfusion leading to potential cell death (organ multi-system dysfunction) * Usually happens within 6 weeks |
|
|
How do you treat neurogenic shock?
|
An alpha drug minidrine to help with vasoconstriction and increase BP
|
|
|
What is the number one cause of septic shock?
|
Infection
|
|
|
What is septic shock?
|
Severe potentially fatal illness caused by infection into bloodstream. High mortality rate.
|
|
|
What happens with septic shock?
|
* Initiated by infection
* Decreased vascular tone (vasodilation) * Release of cytokines causing vasodilation and increased capillary permeability - fluid leaks into vascular space * Neutrophils and phagocytes stick to vessel walls causing further vasculature damage. * 3rd spacing - patient is hypovolemic and edematous so may need fluids and diuretics at the same time |
|
|
What are the signs and symptoms of shock?
|
* changes in LOC
* tachypnea * fever (or hypothermic) * decreased UO * diminished peripheral pulses * edematous (3rd spacing) |
|
|
What is SIRS?
|
Systemic Inflammatory Response System. A precursor to sepsis
|
|
|
What are the signs of SIRS?
|
2 or more criteria of
* Temp >100.4 or <96.8 * HR > 90 * RR >20 or PCO2 >32 * WBC >12,000 or <4,000 >10% bands |
|
|
How do you treat septic shock?
|
* antibiotics
* restoring volume with LR (crystalloid fluids) and albumin to pull fluid back into vasculature * Monitor for fluid overload with PA catheter * Dopamine/ Dobutamine/ Levophed * Feed them asap |
|
|
Describe multi-organ system diIsfunction
|
* Usually happens from septic shock
* Failure of one organ leads the second... * Lungs are primarily affected followed by kidney and heart * Can be primary or secondary (caused by direct injury or result of septic shock leading ARDS, etc.) * irreversible |
|
|
Describe blunt injuries
|
* No break in the skin
* acceleration/deceleration causes * can often lead to mortality because cannot see the injury |
|
|
Describe penetrating injury
|
* break in the skin
* Gun Shot wound is high velocity - was it close range or distant? * Entrance and exit site? * Stab wounds and impalement are low velocity |
|
|
When a patient is brought into the ED with trauma, what questions need to be asked?
|
* What was the mechanism?
* Where was the patient injured? * How was the patient found? * GSW - close range or distant? |
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What is the primary survey of a trauma patient?
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A - Airway - suction, intubate if needed
B - Breathing - RR, color, LS, chest wall movement - trachea midline? C - Circulation - Pulses, bleeding, 2 Lg bore IVs, fluid or vasopressors, crystalloids, blood product D - Disabilities- GCS, AVPU, Seizures? pupil fixed?E - Exposure - undress patient, contusions, bruising, rib fractures can cause pneumothorax |
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What is the secondary survey of a trauma patient?
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F - Full set of VS, Family presence
G - Get LMNOPs - Labs, More detailed head to toe, Naso or Orogastric insertion, P - Pain (assess), Quality, Radiating, Severity and Timing (onset) U - Urinary Catheter (to measure UO) |
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What are the signs and symptoms of hypovolemia?
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* Pale skin
* Diaphoresis * Tachycardia * Hypotension * Possible confusion or disorientation |
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Name the types of thoracic injuries
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* Fractured Ribs
* Flail chest * Pneumo (or Hemo) thorax * Pulmonary Contusions |
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What is Flail chest?
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Commonly caused from blunt trauma, the ribs are broken and no longer moving with the diaphragm (one half may be moving and not the other half). Pain meds are particularly important here so they continue to breathe deeply.
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What is a pulmonary contusion?
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Bruised lung or lungs. Can cause atelectasis and if bad enough, can cause consolidation where the lungs fill up with blood. Usually improves within 72 hours.
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What is the nursing care and treatment of Thoracic injuries?
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* O2
* PEEP for flail chest to keep alveoli open * Chest tube insertion for pneumo or hemothorax and flail chest * Needle decompression for tension pneumothorax * Judicious fluid management -symptoms can mimic CHF, so this must be done cautiously |
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What are the signs and symptoms of thoracic injuries?
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* Dyspnea (priority)
* Hemoptysis (coughing up blood) * SQ emphysema (rice krispies) * Anxiety/ restlessness * Pain - important to treat * Accessory muscle use (can't take deep breaths) * Stridor * Tachypnea |
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Name the different types of cardiac Injuries
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* Cardiac contusions (most common)
* Penetrating cardiac injury (75%-90% fatal) * Cardiac Tamponade * Aortic Injuries (almost always fatal) |
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What is cardiac tamponade?
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When the pericardial space around the heart fills with blood - life threatening
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What are the signs and symptoms of cardiac injuries?
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* Chest Pain
* Dyspnea * Chest wall ecchymosis - bruise over heart * Cardiac dysrhythmias * Murmurs and extra heart sounds * Beck's triad |
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What is Beck's Triad?
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* Muffled heart sounds
* Decreased BP * Distended neck veins |
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What is a thoracotomy?
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Surgical incision into the chest wall
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Describe abdominal trauma
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* Solid organs are usually damaged with blunt trauma because they are encapsulated - look for bruising
* Hollow organs such as the intestines, stomach, gall bladder and bladder are more likely to be damaged from penetrating trauma. They spill contents into the peritoneal cavity * Typically more than one organ is involved |
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When there is trauma to the esophagus and diaphragm, how is it diagnosed and treated?
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* Diagnosed with an endoscopy, ultrasound or CT scan
* Treatment: NPO, antibiotics, NGT surgical repair |
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When there is trauma to the stomach and small bowel, how is it diagnosed and treated?
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* Diagnosed by blood in NGT or DPL (Diagnostic peritoneal lavage
* Treatment: Surgery, watch for sepsis or peritonitis |
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When there is trauma to the duodenum or pancreas, how is it diagnosed and treated?
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* Diagnosed by CT, MRI or X-ray
* Treatment: Repair and drain lacerations, TPN, or enteral feedings |
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When there is trauma to the colon, how is it diagnosed and treated?
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* Diagnosed by CT, MRI or X-ray
* Exploratory laparotomy, ostomy and/ or antibiotics |
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When there is trauma to the liver, how is it diagnosed and treated?
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* Diagnosed by CT or MRI
* Treatment: surgery, segmental resection. Coagulopathies common. Watch for signs of bleeding |
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When there is trauma to the spleen, how is it diagnosed and treated?
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* Diagnosed by positive Kehr's sign, positive DPL or CT scan * Treatment: NGT, splenorrhaphy or splenectomy. There will be problems with infection, adrenal insufficiency and DIC |
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When there is trauma to the kidney, how is it diagnosed and treated?
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* Diagnosed by Helical CT, ultrasound or Intravenous Pyelogram
* Treatment: Bed rest, catheterization if external organs are intact; low dose dopamine (increases blood flow to the kidneys) |
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When there is trauma to the bladder, how is it diagnosed and treated?
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* Diagnosed by gross hematuria, X-ray, CT or MRI
* Treatment; If external injuries, cystography before catheter insertion. Suprapubic catheter. |
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What is the Kehr's sign?
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Left upper quadrant pain that radiates to the left upper shoulder
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A pneumonia vaccine is particularly important for what kind of patient and why?
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A patient who has had a splenectomy because they will have particular problems with the immune system
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What is carboxyhemoglobin and what causes it?
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A condition where carbon monoxide binds with hemoglobin instead of oxygen. Caused by CO from gas, burning wood, coal or oil. Treated by 100% O2
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What is the treatment for a patient who overdosed?
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1. Is the patient stable? Are you safe to care for them?
2. 2 large bore IVs 3. ECG, Foley, NG tube (good for gastric lavage) 4. Labs for everything 5. Gastric Lavage and activated charcoal 6. If patient is coherent give charcoal PO |
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What labs would be run for a patient who overdosed?
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* CBC
* Chem 12 * LFTs * Coagulation tests * Cardiac enzymes for possible tricyclic ODs * ASA & Tylenol level * UA (for pregnancy) * DSU 7 (tox screen) |
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What does a tox screen test for?
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* Benzos * Barbiturates * Marijuana * Cocaine * Oxycodone * Methamphetamines (BOMB.COM) |
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What is the antidote for opiates such as heroine and morphine?
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Narcan or Naloxone
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What is the antidote for benzodiazepines or tranquilizers (meds ending in "pam")?
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Romazicon or Flumazenil
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What are the signs and symptoms of nerve agent (organophosphate) poisoning?
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SLUDGE (cholinergic stimulation)
* Salivation * Lacrimation * Urination * Defecation * Gastric Upset * Emesis |
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What is the antidote for nerve gas exposure?
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Atropine/ Anticholinergic therapy
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What do you check often for a tricyclic antidepressant OD?
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Cardiac enzymes and ECG
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What OTC drug can cause hepatic failure and how do you treat it?
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Tylenol. Activated charcoal (smells like sulfur)
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What OTC drug can cause a GI bleed?
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Aspirin
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What is blood made up of?
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45% cellular55% liquid (plasma)
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How do we check how quickly blood is clotting?
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* PTT or APTT (checks for heparin) * PT (checks for coumadin)* INR (checks for coumadin)
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What is the antidote for heparin?
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Protamine Sulfate
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What is the antidote for Coumadin?
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Vitamin K
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What are the infusions for blood loss?
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* Fresh frozen plasma (works on Factors 1 & 8)
* Cryoprecipitate (works on Factors 1 & 8) * Desmopressin acetate (works on factor 8) |
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What is the only gland that is palpable?
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Thyroid
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What is the immune response?
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A 4 step process
1. Lymphocytes (antibodies) 2. Compliments (15 proteins from the liver) 3. Phagocytosis (monocytes become macrophages once they migrate to a site) 4. Cytokines (or interleukins) |
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What are lymphocytes?
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WBCs made from stem cells:
1. B-cells made in the bone marrow (B-bone) 2. T-cells made in the thymus (T-thymus) |
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What kind of T-cells are there?
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There are 2 kinds of T cells:
1. T-cells that are antigen specific (memory) 2. T4 cells - helper cells (most abundant kind) |
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What kind of cells does HIV affect the most?
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T4 cells (helper cells)
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What does it mean when it is said that a WBC count is high with a 'left shift'?
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There are lots of baby neutrophils meaning that all the mature cells have been used up and all that's left to fight is immature neutrophils. Not good.
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What is a CBC with a differential?
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A typical CBC run with an additional study of the different white blood cells.
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What are the different kinds of WBCs?
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* Neutrophils (a lot means a big infection)
* Eosinophils (elevated in allergic reaction) * Lymphocytes (elevated in viral infection) * Monocytes (non-specific phagocytosis- viral) |
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What are the 2 kinds of transplantation?
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* Solid organ (such as liver, kidney or heart)
* Stem cell (bone marrow) |
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What are the complications of solid organ transplantation?
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* Organ rejection (can happen 3 months post)
* Infection (#1 complication - anti-rejection drugs hide signs & symptoms) * Bleeding * GI complication (secondary to steroid therapy) |
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What are the complications of stem cell transplantation?
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* Graft failure (body may not accept it)
* Graft Vs. Host (graft doesn't recognize the host) |
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What is ELISA testing and what can cause a false positive result?
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* Detects the presence of HIV antibodies
* Lupus can cause a false positive |
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What are the signs and symptoms of HIV?
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* Most common in history is night sweats and palpable swollen lymph nodes
* The higher the viral load, the worse it is * HIV patients are categorized by CD4 (T-cell) counts (500-1200 is normal, 350 consider treatment, 200 is considered AIDS) |
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What is the #1 complication of HIV? How is it treated?
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* Pneumonia
* Treat with Bactrim |
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What is cryptococcal meningitis?
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A meningitis that it caused by breathing in dust or dried bird droppings. Common in HIV patients and causes neuro changes.
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What is the management of HIV?
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Antiretroviral drugs:
* Nucleoside Reverse Transcriptase Inhibitors (AZT or Retrovir)- keeps viral load down and CD4 up aka NRTIs * Non-nucleoside Reverse Transcriptase Inhibitors aka NNRTIs * Protease inhibitors(All three need to be taken together) |
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What is the #1 side effect of antiretroviral drugs?
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* Bone Marrow suppression
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What are some common side effects of antiretroviral drugs?
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* Liver problems
* skin rashes * HTN * hyperglycemia * osteoporosis * lactic acidosis |
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What are some common disorders of RBCs?
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* Polycythemia * Acquired Hemolytic anemia * Megaloblastic anemia * Iron Deficiency Anemia |
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What is the most common anemia and what causes it?
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Iron deficiency anemia caused by lack or iron or a chronic slow bleed
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What are the signs and symptoms of iron deficiency anemia?
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* Pale
* Lethargy * cold * Tachycardic * hypotensive |
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What is commonly seen in Chronic renal failure patients?
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Iron Deficiency anemia
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What is acquired hemolytic anemia and what causes it?
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It is a premature destruction of RBCs caused by - infectious agent such as malaria - RBC fragments from a pathological process such as vasculitis, sickle cell anemia, DIC or drugs such as NSAIDs or cephalosporins
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What is polycythemia?
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Disorder categorized by increased RBC production resulting in increased Crit & increased RBC cell mass. Can lead to decreased tissue oxygenation, thick blood and vascular insufficiency. High risk for clots
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What can cause polycythemia?
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Decreased perfusion in the kidneys causes the kidneys to release erythropoietin to increase RBC production in the bone marrow. Patients with DM or CRF have decreased perfusion in the kidneys and the lack of O2 stimulates the kidneys to release erythropoietin.
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How is polycythemia treated?
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* Serial phlobotomy
* leeches * give back O2 (BiPAP, quit smoking, etc.) |
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What is megaloblastic anemia?
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A deficiency in folate and B12
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What are the disorders of hemostasis?
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* Immune Thrombocytopenic Purpura (ITP)
* Thrombotic Thrombocytopenic Purpura (TTP) |
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What is Immune Thrombocytopenic Purpura (ITP)?
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Platelet destruction - two types
* Acute form seen in childhood that resolves itself * Chronic form in adulthood caused by a virus |
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What is Thrombotic Thrombocytopenic Purpura (TTP)?
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* The body does not recognize platelets, becomes sensitized. Platelets cause occlusion of blood vessels.–Clots everywhere.. Head, kidneys. Very serious
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What is the treatment for Thrombotic Thrombocytopenic Purpura?
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* Plasmapheresis every few weeks
* steroids |
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What are the symptoms of Thrombotic Thrombocytopenic Purpura?
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* Fever
* Thrombocytopenia * bruising * kidney failure * hemolytic anemia * neuro symptoms |
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What is plasmapheresis?
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Treatment for TTP. Similar to dialysis. Gives back good stuff
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What is DIC?
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Disseminate Intravascular Coagulation. An event tells the body to clot, the blood starts to coagulate throughout the body then depletes the body of it's platelets and coagulation factors. The body starts to bleed from everywhere. Life threatening.
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What hormones are made in the anterior pituitary gland?
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* TSH (Thyroid stimulating hormone)
* ACTH (Adrenocorticotropic hormone) * FSH & LH (sex hormones) * Growth Hormone |
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What does thyroid stimulating hormone do?
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Stimulates the thyroid to make T3 & T4.
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What is T4 and what does it do?
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T4 is thyroxine and it, with T3, is responsible for the generalized metabolic rate, growth and development.
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In hyperthyroidism, what is the level of TSH?
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It is low because the CNS learns that the levels of T3 and T4 are high so it tells the anterior pituitary to reduce production of the TSH.
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What does ACTH do?
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It stimulates the adrenal cortex gland to make glucocorticoid, or cortisol, which is a steroid.
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What is cortisol?
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* A glucocorticoid (a steroid), it is a major anti-inflammatory that affects glucose, protein and fat metabolism
* Is a major anti-inflammatory so it inhibits the immune process * When administering a steroid, it will increase plasma glucose because it stimulates glucagon |
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What can an elevation in ACTH be caused by?
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Cushing's syndrome
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What disease is caused when not enough ACTH is produced?
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Addison's disease
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What hormone's are produced by the posterior pituitary?
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* ADH (Antidiuretic hormone)
* Oxytocin |
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What does antidiuretic hormone do?
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* It decreases the production of urine by increasing the reabsorption of H20 in the distal renal tubules
* It is released in response to decreased blood volume, hypovolemia, the body’s effort to hold on to H20 |
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What are the 3 major stimuli for regulation of ADH secretion?
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1-Plasma Osmolality (increases initially to secrete more ADH to hold onto more fluid) will be high in dehydration
2-Changes in ECF (extra cellular fluid – outside the cells) volume (increases) 3-Changes in arterial BP (increases) |
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What does the thyroid do?
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Regulates metabolism
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What does the parathyroid gland do?
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Located behind the thyroid, it produces parathyroid hormone when calcium is needed. Will stop producing it when calcium levels are too high.
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What is the main function of the parathyroid hormone?
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To maintain the body's calcium levels for proper nerve and muscular activity. If calcium levels are low, there will be muscular issues.
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What does the pancreas do?
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Secretes insulin, digestive enzymes and glucagon. Islets of Langerhauns in pancreas make insulin.
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What are 4 hormones produced in the pancreas?
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* Pancreatic polypeptide * Glucagon * Somatostatin (PIGS) |
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What does insulin do?
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* Lowers BS, it is secreted in response to too much glucose in the blood, it helps transport glucose back into the cells for energy
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What is IDDM?
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Insulin Dependent Diabetes Melitis
* is decreased production of insulin |
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What is NIDDM?
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Non Insulin Dependent Diabetes Melitis
* is an adequate production of insulin, but too much adipose tissue so not enough insulin to cover a large area (as in obesity) |
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What is glucagon?
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Stimulates the conversion of glycogen to glucose in the liver when glucose levels dip too low between meals
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What are the hormones produced in the Adrenal gland?
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* Medullary hormones
* Cortical hormones |
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What are the medullary hormones?
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* Epinephrine
* Norepinephrine * Dopamine |
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What is another name for the medullary hormones?
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Catecholamines
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What are the 2 types of corticosteroids?
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1. Glucocorticoids (Cortisol)
2. mineralcorticoids (aldosterone) |
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What is the primary mechanism for regulating aldosterone?
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The renin-angiotensin process regulates and secretes aldosterone.
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What does aldosterone do?
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Holds onto sodium and H20
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What can cause pituitary tumors?
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Thyroid stimulating hormones (thyroid hormones are regulated by the anterior pituitary)
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What is Grave's Disease?
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Hyperthyroid
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How are thyroid abnormalities diagnosed?
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With a radioactive iodine uptake test. The patient swallows the iodine and the thyroid either sucks it all up (or doesn't) and then an x-ray is performed which will show all the iodine in the thyroid (or won't show up). Also a good scan for thyroid cancer.
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What are the symptoms of Graves disease?
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* Enlarged palpable thyroid
* exophthalmos (eye bugged out) * Tachycardia * Weight Loss * Diaphoresis |
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What is Trousseau's sign?
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A carpopedal spasm of latent tetany indicating hypoparathyroidism, or low calcium.
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What is Chvostek's sign?
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When the face is touched, it twitches, indicating tetany or hypoparathyroidism, or low calcium
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What is a good tool for diagnosing an endocrine issue?
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Comparing weight from the last appointment.
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What is the end result of the renin-angiotensin system?
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Vasoconstriction and aldosterone
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What is A1C?
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Indicates the average level of serum glucose in the previous 2 to 4 months. Used to monitor the effectiveness of DM treatment or diagnosis.
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What are ketones?
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Substances that are produced when fat cells break down in lieu of increased carbohydrate’s. Ketones are acidic.
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What are 4 endocrine disorders?
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1. Thyroid dysfunction
2. Adrenal Gland Dysfunction 3. Anti-diuretic Hormone Dysfunction 4. Diabetic emergencies |
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What is myxedema? Myxedema coma.
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Hypothyroidism. Myxedema coma occurs when the body's compensatory responses to hypothyroidism are overwhelmed by a precipitating factor such as infection, MI, or CVA.
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What is an excess of ADH?
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* Syndrome of inappropriate antidiuretic hormone (SIADH).
* Body holds onto too much H2O * Decreased serum osmolality because of overhydration * Decreased UO |
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What is a deficiency of ADH?
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* Diabetes Insipidus
* Kidneys excrete a large amount of urine * Can lead to hypovolemia in a patient that is not alert * Can have altered mental status |
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What is diabetic ketoacidosis?
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* A critical illness that exhibits hyperglycemia, metabolic acidosis & electrolyte imbalances.
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What are the symptoms of diabetic ketoacidosis?
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* Thirsty
* Frequent urination * Weak * Tired * Dehydrated * Hyperventilation (Kussmaul's breathing) |
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What is the treatment for diabetic ketoacidosis?
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* Fluid replacement
* Insulin therapy * Correct electrolyte imbalances (often K+) * Watch for arrhythmias * Restore metabolic function (Bicarb) |
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What is another name for Addison's Disease?
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Adrenal Crisis
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What's another name for ADH?
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Vasopressin
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What are the signs and symptoms of Addison's Disease or Adrenal Crisis?
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* HA
* Weakness * Fatigue * N/V * belly pain * orthostatic hypotenstion * skin color changes |
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What is the treatment for Addison's disease?
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* Steroids
* Fluids |
