Final Exam: NR574/ NR 574 (NEW 2026/2027) Acute Care Practicum (Weeks 5–8) | Full Questions & Verified Solutions | Guaranteed A – Chamberlain

Final Exam: NR574/ NR 574 (NEW 2026/2027) Acute Care Practicum (Weeks 5–8) | Full Questions & Verified Solutions | Guaranteed A – Chamberlain Q. How often should a CK level be drawn and why? ANSWERS least every 6-12 hours to establish a peak level and then subsequently a downward trend. Q. Sylvie is a 26-year-old who presents to the emergency department (ED) after just finishing a full marathon. She complains of feeling lightheaded, nauseous, and has vomited twice since completing the race. Her legs feel tired, weak, and sore which she attributes to running 26.2 miles. She reports that she didn't stop to rehydrate as much as she would have liked because she was intent on finishing with her personal best time. She became very concerned when she went to use the restroom and noticed that her urine was dark - almost like tea. The AGACNP suspects rhabdomyolysis. Which test is needed to confirm the diagnosis? ANSWERS serum creatine kinase Q. Sylvie's EKG shows markedly elevated T waves and prolongation of the PR and QRS intervals. The AGACNP should anticipate which of the following results? ANSWERS hyperkalemia Q. Risk factors for acute intestinal obstruction? ANSWERS Adhesions from previous abdominal surgery Internal or external hernias Foreign bodies Feces Congenital issues (atresia, stenosis, cyst formation, intestinal duplication, and mal- rotation) Trauma (hematoma formation)Inflammation (inflammatory bowel disease, diverticulitis, radiation, and tuberculosis) Neoplasms including carcinomatosis, colon cancer, primary small bowel cancer, and extraintestinal malignancies such as ovarian cancer Endometriosis Volvulus Ischemic injury Intussusception Intraperitoneal abscess Q. Subjective findings of acute intestinal obstruction ANSWERS colicky abdominal pain (cramping periumbilical pain initially; later becomes constant and diffuse)abdominal pain often more severe with distal obstruction vomiting (more significant with proximal obstruction) abdominal bloatingobstipation Q. What key information should be discussed during H/P, if you are concerned for bowel obstruction? ANSWERS History should include essential elements such as previous abdominal or pelvic surgeries, comorbid conditions such as inflammatory bowel disease or malignancy. Q. Objective findings in a patient with intestinal obstruction? ANSWERS Key physical exam findings may include: Fever (systemic inflammation or strangulation) High-pitched, tinkling, bowel sounds (may be hypoactive or absent with complete obstruction) Abdominal distention (more significant with distal obstruction due to the greater volume of intraluminal fluid accumulation)Mild abdominal tenderness but no peritoneal findingsTender abdominal or groin masses (can represent incarcerated hernia) Signs of shock (tachycardia, hypotension, oliguria) Q. Significant abdominal tenderness with palpation should increase the NP's suspicion for? ANSWERS ischemia, peritonitis, or necrosis. Q. Why is a serum lactate useful in dx a bowel obstruction? ANSWERS Serum lactate (increased serum lactate should raise concern for strangulated obstruction) Q. What diagnostic imaging should be used for bowel obstruction? ANSWERS plain film xray Q. What will a plain film xray show if a patient has a bowel obstruction? ANSWERS Obstruction will reveal dilated loops of bowel and visible air-fluid levels which should prompt further studies.A horizontal pattern of dilated small bowel loops can be seen with small bowel obstruction (SBO) Q. Should barium contrast be given to a patient with a bowel obstruction? ANSWERS NO! Imaging studies requiring administration of barium are contraindicated in cases of high- grade or complete obstruction. Q. What does barium contrast do within the body with a bowel obstruction? ANSWERS Barium should NEVER be given orally to a client until the diagnosis of obstruction has been excluded completely as retained barium can cause concretions which create an additional source of blockage which can require surgical intervention in clients who may have otherwise recovered. Retained barium also severely limits the ability to interpret subsequent angiography or cross-sectional imaging. Q. Treatment of bowel obstruction ANSWERS Gen surg consult, NG tube (intermittent suction) for decompression, fluid rescusitation, electrolyte management as indicated, complete obstruction= immediate surgical intervention Q. Superior Vena Cava Syndrome (SVCS) ANSWERS SVCS is the clinical manifestation of SVC obstruction with severe reduction in venous return from the head, neck, and upper extremities. Q. What is responsible for the majority of SVCS cases? ANSWERS malignant tumors, such as lung cancer, lymphoma, and metastatic tumors. Q. Subjective findings with SVCS patients ANSWERS Commonly: neck and facial swelling (especially around the eyes) dyspnea, and cough other symptoms:hoarseness, tongue swelling, headaches, nasal congestion, epistaxis, hemoptysis, dysphagia, pain, dizziness, syncope, and lethargy. Q. What can cause symptoms of SVCS to become worse? ANSWERS bending down, laying supine, position changes. Q. Physical exam findings of SVCS ANSWERS dilated neck veins increase number of collateral veins covering the anterior chest wall cyanosis edema of the face, arms and chest. typically will be worse when the patient is laying supine Q. Treatment of SVCS ANSWERS symptomatic relief:diuretics w/ low sodium diet head elevation supplemental 02Radiation therapy is the primary treatment for SVCS. obstruction needs to be taken care of to relief symptoms. Q. Abdomen Pain in the RLQ Pain differentials ANSWERS appendicitis, ectopic pregnancy, nephrolithiasis, Q. ABD PAIN: "RUQ pain" is a red flag for.. ANSWERS cholecystitis, pancreatitis (referred pain) PNA/empyema hepatitis Q. ABD PAIN:: "LUQ pain" is a red flag for.. ANSWERS pancreatitis Q. ABD PAIN : "LLQ pain" is red flag for.. ANSWERS Diverticulitis ectopic nephrolithiasis, IBS Q. Periumbilical abdominal pain ANSWERS gastroenteritis early appy bowel obstruction Ruptured aortic aneurysm Q. Epigastric pain ANSWERS PUD, gastritis GERD pancreatitis MI pericarditis Ruptured AAA Q. Abdomen pain differential ANSWERS Appy gallstones, pancreatitis, diverticulitis, ulcer disease, esophagitis, GI obstruction, IBD, renal stone Q. Acute mesenteric ischemia (AMI) ANSWERS occurrence of abrupt cessation of blood flow to bowel, usually embolic or thrombotic in nature. Q. Risk factors for Arterio-Occlusive Mesenteric Ischemia ANSWERS Acute mesenteric arterial thrombosis -Acute mesenteric arterial embolism -Mesenteric venous thrombosis Q. Acute mesenteric arterial thrombosis causes ANSWERS aortic dissection/aneurysm, arteritis, atherosclerotic vascular disease, decreased output from congestive heart failure [CHF]or myocardial infarction [MI]) Q. Acute mesenteric arterial embolism causes ANSWERS emboli from fragments of proximal aortic thrombus cardiac emboli atheromatous plaque dislodged during surgery or catheterization Q. Mesenteric venous thrombosis causes ANSWERS vasopressors, cocaine, ergotamine, digitalis, and hypotension Q. Clients with severe acute abdominal pain that seems disproportional to physical exam findings, or that are resistant to opioid therapy, should be suspected as having ? ANSWERS Acute mesenteric Ischemia Clinical Tip: Clients often have a normal abdominal examination with mild to no tenderness to palpation in contrast with a report of severe abdominal pain. Q. When splanchnic perfusion fails to meet the metabolic demands of the intestines, resulting in ischemia tissue injury is what? ANSWERS Intestinal Ischemia Q. Embolis etiology involved with AMI includes ANSWERS afib recent MI soft atherosclerotic plaque infective endocarditis valvular heart disease recent cardiac or vascular catheterization. Q. Subjective findings of AMI ANSWERS severe, acute, unremitting abd pain strikingly out of proportion to the physical findings n/v/d, blood per findings are peritonitis and cardiovascular collapse. Q. Imaging to Diagnose AMI ANSWERS Gold standard: CT angio with a 1-mm or thinner cut should be used to detect mesenteric arterial occlusive disease. Q. Hepatic steatosis (fatty liver) ANSWERS Nonalcoholic hepatic steatosis, or nonalcoholic fatty liver disease (NAFLD), is one of the most common causes of chronic liver disease in the developed world.It is a spectrum of disease, ranging from hepatic fat accumulation without inflamma- tion to steatohepatitis, fibrosis, cirrhosis, and end-stage liver disease. Q. risk factors of hepatic steatosis ANSWERS NAFLD is strongly associated with insulin resistance, overweight/obesity, and metabolic syndromecan occur in thin people with paucity of adipose depots(lipodystrophy) Q. nonalcoholic steatohepatitis (NASH) ANSWERS a more severe form of nonalcoholic fatty liver disease. it consists of fatty accumulations plus liver-damaging inflammation. in some cases, this will progress to cirrhosis, irreversible liver scarring or liver cancer Q. Imaging used for NASH ANSWERS Hepatic US and CT scan. Unfortunately, at the present time, no imaging study can accurately distinguish simple fatty liver from NASH. Q. blood levels of acetaminophen correlate with severity of hepatic injury ANSWERS levels 300 ug/mL 4 hours after ingestion are predicative of the development of severe damage. Treatment of Tylenol OD gastric lavage supportive measures oral administration of activated charcoal or cholestyramine to prevent residual of the drug. activated charcoal and cholestyramine should be done how soon after ingestion or else they wont do anything? 30minutes from ingestion timegastric lavage should be done before other orals. N-acetylcysteine reduces markedly the severity of? hepatic necrosis N-acetylcysteine should be given when? 4-8 hours after ingestion if the blood levels of tylenol are 200ug/mL at 4 hours or 100 ug/mL at 8 hours. IV N-acetylcysteine dose loading dose: 140 mg/kg over 1 hour followed by 70 mg/kg every 4 hours for 15-20 doses. When is liver transplantation indicated in pt with tylenol OD? hepatic failure signs (jaundice, coagulopathy, confusion) occur after N-acetylcysteine dose, live transplant may be the only option. what does serum lactate tell us about the need for liver transplant? is serum lactate is 3.5 - likely will require liver transplant to survive. A 28-year-old woman is seen in a sexually transmitted disease clinic and is diagnosed with Chlamydia trachomatis. An HIV antibody test is ordered. Which one of the following statements is TRUE regarding laboratory-based HIV antibody tests that are approved for use by the United States Food and Drug Administration? Recent inocculation with the influenza vaccine is a known cause of a false-positive result A 31-year-old woman has exposure to HIV after a condom broke while having vaginal sex with her partner who has HIV. She has follow-up HIV testing related to this exposure. Which one of the following best describes the window period? The CDC recommends using 45 days as the window period for all laboratory-based IgM/IgG HIV-1/2 antibody immunoassays A 22-year-old man presents for follow-up after a recent diagnosis of HIV. He has an initial CD4 count of 390 cells/mm3 and his HIV RNA level is46,120 copies/mL; a baseline genotype resistance assay shows no evidence of antiretroviral resistance. He is motivated to start antiretroviral therapy and states that he can take medications without issue. According to the Adult and Adolescent Antiretroviral (ARV) Guidelines, which one of the following best describes the recommendations for starting antiretroviral therapy in treatment-naïve persons with HIV? Antiretroviral therapy is recommended for all persons with HIV A 51-year-old transgender woman (she/her/hers) with HIV has been stable for the last 3 years on an antiretroviral regimen of darunavir-cobicistat and tenofovir DF-emtricitabine. Despite changing to a healthier diet and increas- ing her exercise, lipid values remain elevated : total cholesterol 268 mg/dL, low-density lipoprotein (LDL) 198 mg/dL, high-density lipoprotein (HDL) 35 mg/dL, and triglycerides 220 mg/dL. She has a strong family history of car- diovascular disease, and her father had a myocardial infarction at age 52.She does not want to consider modifying the antiretroviral regimen but agrees to start lipid-lowering therapy. Which one of the following HMG-CoA reductase inhibitors ("statins") is contraindicated for use in this woman? Simvastatin What is a TIPS procedure? The TIPS procedure bypasses a portion of the hepatic circulation by shunting blood flow from the portal vein to the hepatic vein-This reduces portal pressure and minimizes back pressure on the splanchnic organs. This also decreases the likelihood of bleeding from the esophageal varies and reduces the amount of ascites *Hemorrhage is a significant risk during TIPS What is the treatment of choice for both type 1 and type 2 HRS? Liver transplant What medications are used to tx type 2 HRS? vasoconstrictors (terlipressin, midodrine in combination with octriotide, norepinephrine) combined with albumin. Bridge to transplant in Hepatorenal syndrome The combination of octreotide, midodrine, and albumin (triple therapy) is used to treat hepatorenal syndrome (HRS) often as a bridge to liver transplantation (LT). Module * Bridge to transplant* In clients who do not respond to medical therapy, are not candidates for TIPS but are candidates for liver transplantation or recovery for their liver disease, continuous renal replacement therapy can be utilized as a bridge to recovery or transplantation. HRS clients typically do not tolerate hemodialysis well. Joaquin is a 22-year-old male who presents to the emergency department (ED) with a 1-week history of headache, concentration difficulty, fatigue, nau- sea, and vague abdominal pain. He became concerned this morning whenhe noticed that the whites of his eyes appeared yellow. History is significant for epilepsy, which he has had since childhood but is well-controlled with antiepileptic medication. There is no known history of liver disease. Notable physical exam findings include scleral icterus, generalized abdominal tender- ness, and new-onset ascites. Urine alcohol and drug screen were negative. Labs reveal severe transaminitis, hyperbilirubinemia, hyperammonemia, and coagulopathy. The most likely diagnosis is Acute liver failure Chadwick presents to the ED following a suicide attempt. He reports swallowing approximately 10,000 milligrams (mg) of acetaminophen 4-hours ago. An hour ago, he began to develop generalized abdominal pain, nausea, and vomiting at which time he asked his brother to take him to the hospital. Shortly after arrival, he becomes confused and agitated. Labs reveal INR of 3.0, acute kidney injury (AKI) with creatinine 2.0, severe transaminitis, and lactic acidosis. Urine toxicology showed an acetaminophen level of 200 milligrams per kilogram. Serum alcohol was negative. The AGACNP knows that the best initial treatment for Chadwick is: Administer N-acetylcysteine (Mucomyst) Rhabdomyolysis Rhabdomyolysis is a potentially life-threatening condition that occurs following skeletal muscle injury.-dissolution of striated muscle (caused by trauma, extreme exertion, or drug toxicity;in severe cases renal failure can result) When the muscle injury occurs, what is released into the blood stream? muscle fibers release large quantities of potassium, phosphate, creatinine kinase(CK), and myoglobin, a small protein that binds oxygen, into the circulation.-As an unbound protein, myoglobin is excreted by the kidneys but can precipitate and cause renal tubular obstruction. What happens to myoglobin in Rhabdo? myoglobin is release from skeletal muscle during injury. it binds to oxygenin excessive amount, as see with rhabdo, it is unbound. when unbound it has to be excreted through the kidneys which can cause renal tubular obstruction. Risk factors of Rhabdomyolysis Trauma, muscle compression, or ischemiaHeat-related causesInfection with bacteria or viruses that can directly attack the muscleMetabolic factorsGenetic factorsMedications that may cause direct myotoxicity Toxins which may cause indirect myotoxicity Exertional activity Nutritional supplements which contain substances that may induce muscle injury Subjective findings of Rhabdo (patient) muscle pain, dark urine and muscle weakness.Other symptoms commonly associated with rhabdomyolysis can be nonspecific such as fever, nausea, and vomiting, which developed over hours to days Physical exam findings in Rhabdo muscle tenderness soft tissue swellingbruisingskin changes consistent with pressure necrosis muscle weakness confusion, delirium, agitation anuria Rhabdomyolysis is diagnosed when the following are present: (2) dark urine or an acute neuromuscular illness without other symptoms PLUS an acute elevation in serum creatine kinase (typically at least five times the upper limit of normal). Lab work for Rhabdo CK, serum myoglobin, urine myoglobin CBC w/Diff, LFT, electrolytes, Renal function, serum tox, PTT/aPTT What is the most reliable testing for diagnosis of rhabdo? Creatinine kinase (CK) CK will be markedly elevated, typically 1000 IU/L (normal = 45-260 IU/L) with start rising between 2-12 hours of injury and will peak at 24-72 hours Do you need an EKG for rhabdo? Yes. assessing for arrhythmias associated with hypocalcemia and hyperkalemia. continuous cardiac monitoring is recommended What is the initial management of a rhabdo patient? FLUIDS & electrolyte maintenance. Rhabdo fluid administration is recommended for what? The initial management of rhabdomyolysis includes fluid resuscitation to prevent end-organ damage such as acute renal failure. Fluid treatment for rhabdo consist of...? Isotonic sodium chloride fluid initiated ASAPrate: 400 mL/hrstitrate to maintain a urine output of at least 200 mL per hour. If a patient with rhabdo has a CK level greater than 15,000 IU/L, how much fluid should the patient receive? at minimum 6L of fluid are required What electrolyte abnormalities occur with rhabdo? Hyperkalemia, Hypocalcemia, Hyperuricemia Hyperphosphatemia How is hyperkalemia treatment in rhabdo patients? Treatment of hyperkalemia consists ofIV glucose sodium bicarbonate insulin, sodium polystyrene sulfonate;in severe or refractory cases, hemodialysis is sometimes required. differential diagnosis of SLE SLE should be considered as a differential diagnosis in a young person who presents with glomerulonephritis, pleural effusion, cytopenia, pericarditis, or pleurisy that does not have another underlying etiology.The differential may include: -rheumatoid arthritis-mixed connective tissue disease -Sjogren's syndrome-multiple sclerosis -malignancies. systemic lupus erythematosus (SLE) autoimmune disease in which immune system attacks connective tissue throughout body such as in joints and skin SLE clinical manifestations Facial rash (BUTTERFLY RASH in 80%), arthritis, arthralgie, photsensitivty, pleurisy, pericarditis, anemia, thrombocytopenia- Fatigue, alopecia, Reynaud's syndrome, renal disorders/damage, seizures, cogni- tive/neuropsych, mouth/nose ulcers classic triad of symptoms for SLE The classic triad of symptoms associated with SLE includes fever, arthralgia, and rash ANA testing for SLE most important autoantibody test is ANA because 95% of patients will test positive at the onset of symptoms. high titer IgG antibodies to anti-double-stranded DNA (anti-dsDNA) are specific for SLE diagnosis. "SOAP BRAIN MD" is used for? Diagnostic criteria for SLE must include at least 4 of the criteria listed, which can be remembered by the mnemonic SOAP BRAIN MD mnemonic for SLE stands for? S - serositis (pleuritis, pericarditis, peritonitis) O - oral ulcers (painless) A - arthralgia/arthritis P - photosensitivity B - blood disorder (anemia, thrombocytopenia, hemolytic anemia) R - renal involvement (nephritic or nephrotic disorders) A- ANA+ I - immunologic phenomenon (anti-SM, Anti-dsDNA, Ro, La, Anti-histone) N - neurologic phenomenon (altered mental status, seizures, stroke, headache) M - malar rash D - discoid rash Lorenzo is newly admitted with pancytopenia, fever, joint pain, and a malar rash. The nurse practitioner suspects SLE. Which of the following tests is most useful in diagnosing this condition? antinuclear antibody Jean-Louis was admitted with a diagnosis of acute kidney injury (AKI). He does not have a history of previous renal dysfunction but does have a history of SLE The urinalysis reveals significant proteinuria. Which of the following diagnostic tests is required when lupus nephritis is suspected? Renal Biopsy rheumatoid arthritis (RA) arthritis with swelling, stiffness, pain, and degener- ation of cartilage in joints caused by chronic soft tissue inflammation; may result in crippling deformities; an autoimmune disease rheumatoid arthritis clinical manifestations. Common symptoms include warm, tender, swollen joints, and joint stiffness.-swan neck deformity- hyperextension of PIP with flexion of DIP (distal interpha- langeal) -Boutonniere deformity-firm nontender nodules that adhere to the periosteum, tendons, or bursae-fatigue, malaise, fever, anorexia, weight loss, and depression-ulnar deviation Juan has a history of rheumatoid arthritis and is taking methotrexate7.5mg once per week. He reports an acute increase in pain and swelling from baseline for the last 2 days, primarily affecting both hands and both knees. The nurse practitioner suspects an acute RA flare. What is the most appropriate intervention? Prednisone 40 mg daily then taper over two weeks Antiphospholipid Syndrome (APS) Clinical Manifestations of antiphospholipid syndrome DVT PEpregnancy morbidity migraines strokes/TIA livedo reticularis differentials of fibromyalgia Fibromyalgia presents with a multitude of gener- alized symptoms making the differential diagnosis quite broad.-systemic lupus erythematosus (SLE),-Sjogren's syndrome, -gluten sensitivity, -hypothyroidism,-polymyalgia rheumatica,-mixed connective tissue disease, -multiple sclerosis, -myasthenia gravis. Lo-Wei has fibromyalgia and complains of poorly controlled pain, in- creased fatigue, and difficulty sleeping. She has a body mass index (BMI)of 31 and a history of depression. She reports that she has been frequently forgetting to take her medications (duloxetine and gabapentin). Which of the following are the most appropriate interventions for Lo-Wei? medication compliance, exercise program, and sleep hygiene program A 28-year-old woman is seen in a sexually transmitted disease clinic and is diagnosed with Chlamydia trachomatis. An HIV antibody test is ordered. Which one of the following statements is TRUE regarding laboratory-based HIV antibody tests that are approved for use by the United States Food and Drug Administration? Recent inocculation with the influenza vaccine is a known cause of a false-positive result Heparin-induced thrombocytopenia (HIT) Development of IgG antibodies against heparin- bound platelet factor 4 (PF4). Antibody- heparin-PF4 complex acti- vates platelets leading to thrombosis and thrombocytopenia. Features of HIT ThrombocytopeniaTimingType of heparin type of patient thrombosis HIT Thrombocytopenia (plt count) platelet count of 100,000 or decrease in platelet count by 50% from pre treatment value What is the time frame that a patient will start showing signs of HIT? within 5-14 days after starting heparin can occur sooner if pt has received heparin within the last 3 months what type of heparin is HIT more commonly associated with? unfractionated heparin diagnosis of HIT 50% drop in platelet count from baselineIncludes antibody immunoassay (ELISA) and functional platelet activation assays (serotonin release assay [SRA] & heparin-induced platelet activation assay [HIPA]) Management of HIT stop heparin give alternative anticoagulant do not give platelet transfusions do not give warfarin until plt count returns to baseline level -if warfarin was given, give vit k to restore INR to normal evaluate for thrombus-particularly DVT When heparin is stopped after dx of HIT, what anticoagulant should be used? argatroban (Acova)-used specifically to tx HITbivalirudin (angiomax) fondaparinux (arixtra) rivaroxaban (xarelto) what anticoagulant should not be given to a patient with HIT? Warfarin IF warfarin was given to a patient with HIT, what should you do? stop the medication, give vitamin K and wait until INR returns to baseline number. The adult gerontology acute care nurse practitioner (AGACNP) is com- pleting a preoperative assessment on Ava, a 28-year-old female client whois recovering from a non-emergent cholecystectomy. The following abnormal findings are noted : white blood cells (WBC) 7.4 x 109/L; hemoglobin (Hgb)14.4 gm/dL; hematocrit (Hct) 8%; Platelets 40 x 109/L. The remaining CBCparameters and a comprehensive metabolic panel are normal. Ava denies recent illnesses, bleeding, or history of bleeding disorders or medication use except for omeprazole which she has been taking for more than 6 months. Which of the following is the most likely diagnosis in the differential? Immune thrombocytopenia Sunil was involved in a motor vehicle crash (MVC) two days ago. He had an immediate exploratory laparotomy and repair of a grade 2 liver laceration. He was directly admitted to the intensive care unit (ICU), post-operatively. While assessing Sunil, the AGACNP notices oozing of blood from his central and arterial line sites, along with bleeding from the surgical site. What is the most appropriate next action? Order a CBC, aPTT, PT/INR, fibrinogen, and D-dimer Leonard is admitted with pneumonia. When evaluating his morning labs, the AGACNP noticed that his platelets have decreased from 170 x 109/L to 60 x109/L. Leonard has been receiving enoxaparin for deep vein thrombosis (DVT) prophylaxis and the 4Ts score strongly suggests HIT. Which of the following should be performed first? Discontinue all sources of heparin Disseminated Intravascular Coagulation (DIC) Complex, acquired disorder in which clotting and hemorrhage simultaneously occur intravascular activation of coagulation with loss of localization arising from different causes that can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction. Risk factors of DIC Sepsis, Cardiac arrest, Trauma, Obstetric complications (amniotic fluid embolism, eclampsia, retained placenta), Cancer, Hypersensitivity reactions (blood transfusion reaction, anaphylaxis) Clinical presentation of DIC In the hospital setting, tell-tale signs of DIC are common manifestations of vascular thrombosis and bleeding:-Microvascular thrombosis (common occult cause of organ failure in DIC)-Macrovascular thrombosis (DVT, PE) -Bleeding (petechiae, purpura, or distal extremity necrosis, sudden bleeding from wounds, surgical sites, or intravenous lines, shock, internal hemorrhage (gastroin- testinal (GI), intracranial, etc.) what are Lymphomas? are solid tumors of the immune system, or lymphoid tissue, such as the lymph nodes, spleen, thymus, etc. What are the two categories of lymphomas? Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Hodgkin's lymphoma Hodgkin lymphoma (HL), formerly known as Hodgkin's disease, is a lymphoid neoplasm of mature B-cell lymphocytes. Risk factors for Hodgkin's Lymphoma The incidence is much higher in males, Caucasians, and young adulthood.Human immunodeficiency virus (HIV) clients are at high risk. family history of HL. prior infection with the Epstein-Barr Virus (EBV), the pathogen causing mononucleosis, exposure to benzene. What are the 2 types of Hodgkin's lymphoma nodular lymphocyte predomi- nance Hodgkin lymphoma (NLPHL) & classical Hodgkin's Lymphoma (cHL) nodular lymphocyte predominance Hodgkin lymphoma (NLPHL) 5% of HL cases characterized by the presence of lymphocyte-predominant cells affected cells sometimes referred to as "popcorn cells" due to their similarity in appearance popcorn cells are variants of Reed-Sternberg cells most common in young adulthood (30-50 years) and males slow-growing good prognosis for recovery highly curable with a slight risk of transforming into aggressive non-Hodgkin lymphoma classic Hodgkins lymphoma (cHL) most common of all HL cases (95%) characterized by the presence of Hodgkin and Reed- Sternberg cells in affected lymph nodesfour (4) subtypes: nodular sclerosis, lymphocyte-rich, mixed cellularity, and lympho- cyte- depleted Subjective findings in Hogkin's Lymphoma Painless lymphadenopathy is the most common presenting symptom and typically originates in the cervical lymph nodes.Clients complaining of "B" symptoms (unexplained fever, drenching night sweats, significant unintentional weight loss) are more likely to have more advanced stages of the disease. Additional clinical findings may include: - fever pattern with cyclical increases and decreases-cough, chest pain, or dyspnea if a mediastinal mass is present or if there is lung involvement -pain at the site of extranodal disease (if present) or a disease complication such asGI bleeding-alcohol intolerance (specific finding that occurs in less than 10% of HL clients)-bone pain -pruritus What are "B" symptoms of lymphoma? Imply more widespread disease: -Fever-Weight loss-Night sweats Pel-Ebstein fever Fever lasting 3-10 days followed by non-fever state of similar length; characteristic of Hodgkin's disease and certain other lymphomas objective clinical findings in Hodgkin lymphoma -lymphadenopathy (com- mon sites include the axilla, inguinal or cervical region; less common sites include occipital and epitrochlear regions)-splenomegaly-hepatomegaly and a positive abdominal fluid wave if ascites is present -nephrotic syndrome-possible evidence of breast, abdominal, or testicular mass -Waldeyer's tonsillar ring Painful vs painless adenopathy. what should you be thinking? Clinical Pearl: Painful adenopathy - think infection; Painless adenopathy - think malignancy Differential Diagnosis of Hodgkin's lymphoma Sarcoidosis-Tuberculosis-Non-Hodgkin Lymphoma -EBV infectious mononucleosis -Drug-induced adenopathies -Small cell lung cancer -Syphilis-Toxoplasmosis Gold standard dx for hodgkin's lymphoma An excisional lymph node or fine needle aspirate with biopsy is typically regarded as the gold standard diagnostic test for HL. Reed-Sternberg cells, or their variant cells, are characteristic of HL and guide in identifying subtypes of the disease. Stage I: HL Stage 1: Localized disease; single lymph node region or single organ Stage II: HL Stage II: Two or more lymph node regions on the same side of the diaphragm Stage III: HL Stage III: Two or more lymph node regions above and below the diaphragm Stage IV: HL Stage IV: Widespread disease; multiple organs, with or without lymph node involvement how is HL differentiated from non-hodgkin's lymphoma? Lack of Reed-Sternberg cells distinguishes NHL from HL as well as the differences in biological and clinical characteristics What is Non-Hodgkin's Lymphoma (NHL)? NHL is a malignancy of mature B, T, and natural killer (NK) cells that arise in lymph nodes and lymphatic tissue found in organs, or in some cases, bone marrow and blood. Ira is a 40-year-old male who was admitted to the hospital for a decreased appetite, bone pain, fatigue, fever, chills, night sweats, and unintentional weight loss (20%) in the last month. He has no family history of malignancy and no personal history of cancer or autoimmune disease. He reports having mononucleosis in his late 20's. Physical exam reveals nontender, mobile, cervical lymphadenopathy as well as supraclavicular lymphadenopathy and splenomegaly. Vital signs are unremarkable except a low-grade fever of 100.6° Fahrenheit (F) (38.1° C). CBC reveals lymphocytosis, thrombocytopenia, and anemia. Subsequently, an excisional cervical lymph node biopsy was per- formed for suspicion of lymphoma. The pathology report reveals no presence of Reed-Sternberg cells. Which type of lymphoma is this, HL or NHL? NHL Venita was recently diagnosed with Hodgkin's lymphoma. A comprehen- sive workup revealed that the disease is localized in three lymph node regions located above the diaphragm (cervical and axillary regions). Venita exhibits which stage of HL? Stage II Leukemia Leukemia is a broad term referring to cancers of the blood or bone marrow that primarily affect the leukocytes, or white blood cells (WBCs). what are the 4 types of Leukemias? acute myeloid leukemia (AML), chronic myeloid leukemia (CML),acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL). objective clinical findings in AML fever infection acute hemorrhage lymphadenopathy petechiae/purpura papilledema/retinal infiltrates hepatosplenomegaly gingival hypertrophy subjective clinical findings in AML The medical history should include poten- tial risks including chemical exposures, radiation, previous cancer, chemotherapy treatment, and family history of cancer.ROS: clients with AML are typically related to thrombocytopenia, anemia, leukocy- tosis, and/or leukopenia. Common symptoms, which may have developed gradually (over weeks to months) or abruptly, include but are not limited to: anorexia weight loss fatiguefever (with or without identified infection) easy bruising or bleeding bone pain cough headache Flow cytometry flow cytometry, a technique used to detect and measure physical and chemical characteristics of a population of cells, must be performed to distinguish AML from ALL and to identify the AML subtype. diagnostic criteria for ALL ALL is diagnosed by the presence of greater than or equal to 20% bone marrow lymphoblasts after cytogenetic, immunologic, and molecular testing of bone marrow aspirate. what diagnostic testing should be done for suspected ALL CBC with differential peripheral smearbone marrow aspirate with biopsy. A coagulation panel serum electrolytes liver profile panel BUN/creatinine LDH uric acid levelsDirect smears of the bone marrow are essential to confirm the diagnosis of ALL as well as to differentiate ALL from AML. What is CML (chronic myeloid leukemia)? CML is a myeloproliferative neoplasm that results in the uncontrolled production of multiple cell lines including eosinophils, basophils, and mature (or maturing) granulocytes.CML is generally slow-growing cancer but if untreated can become acute leukemia that is difficult to treat What are the stages of CML 1.Chronic phase 2.Accelerated phase 3.Blast phase what are the characteristics of Stage 1: Chronic phase of CML This phase is characterized by 10% blasts (immature WBCs) in the blood and bone marrow. AML clients may be asymptomatic.The majority of cases are diagnosed during this stage. what are the characteristics of Stage 2: Accelerated phase of CML This phase is characterized by 10-19% blasts in the blood and bone marrow or 20% basophils in the peripheral blood. Additional deoxyribonucleic acid (DNA) damage and CML cell mutations occur during this stage. what are the characteristics of Stage 3: Blast phase of CML This phase is characterized by 20% blasts in the blood and bone marrow.WBCs become difficult to control (leukocytosis).Fever, splenomegaly, weight loss, and general malaise are common symptoms in this stage. Diagnostic criteria of CML A CML diagnosis is definitively made by identification of the Philadelphia chromosome, the BCR-ABL1 fusion mRNA, or BCR-ABL1 fusion gene in peripheral blood or bone marrow cells. The Philadelphia chromosome in the bone marrow aspirate needs to be what precent at time of diagnosis for CML? greater than 90% of clients at the time of CML diagnosis. what will the peripheral blood smear show in CML? early myeloid cells such as nucleated red blood cells, metamyelocytes, myelocytes, and myeloblasts what will the liver panel show in CML at time of diagnosis? The liver profile panel will often demonstrate hyperbilirubinemia which results from increased bone marrow turnover.Uric acid and vitamin B12 levels are also often elevated. Management of CML includes: -managed by oncology specialty teams-Treatment options vary and are also individualized based upon the client's performance status, co-morbidities, and CML phase.-Med: Tyrosine kinase inhibitors (TKIs) first line-supportive care What is the first line medication class used for the treatment of CML? Tyrosine kinase inhibitors (TKIs) are typically the drug of choice for clients who present in the chronic phase. (stage 1)-TKIs typically have very mild side effects and are well tolerated. The most commonly used TKIs for CML include: imitanib, bosutinib, nilotinib, ponatinib, and dasatinib. Splenic irradiation or splenectomy may be required for those in what stage of CML? -Late stage-who develop significant pain secondary to splenomegaly or leukapheresis -may be performed for clients with WBC 300,000 μL. Stem cell transplantation is reserved for which CML patients? clients who fail to achieve remission with or those who fail imatinib and second-generation TKIs. what complications are associated with CLL? -infections,-autoimmune complications including cytopenias, vasculitis, neuropathies, thrombo- cytopenia, glomerulonephritis-secondary malignancies: skin, prostate, and breast cancers. -transformation into lymphomas what is Richter's transformation in terms of CLL complications? occurs when CLL transforms into aggressive diffuse large B-cell lymphoma which has a median survival rate of only 6 to 16 months. What is hemophilia? Hemophilia is a disorder of blood clotting caused by anX-linked recessive defect (spontaneous or hereditary).-Most hemophilia cases are inherited, and the disease commonly affects males more than females.-Hemophilia results from impaired secondary hemostasis due to a defect in the coagulation cascade. Hemophilia is classified by identifying the deficient clotting factor: what are the 3 clotting factors? hemophilia A (factor VIII) ~ 80 % of cases hemophilia B (factor IX) ~ 20% of cases hemophilia C (factor XI) ~ very rare 1% what things should you ask a patient with suspected hemophilia in regards to bleeding? Clients with suspected or diagnosed hemophilia should be assessed for -prior bleeding episodes;-abnormal bleeding with menstrual cycles,-dental procedures, or surgical intervention; -family history of bleeding disorders;-family history of work-up for bleeding disorders. Clinical Tip: Petechial bleeding is a common sign of platelet disorders, NOT coagulation disorders such as hemophilia. Hemarthrosis Hemarthrosis is a condition of articular bleeding, that is into the joint cavity. This can occur after an injury or, more commonly, in bleeding disorders such as hemophilia. Patients will typically present with pain, swelling and a decreased range of motion of the involved joint. management of hemarthrosis -receive factor concentrate infusion within 2 hours of presentation with joint bleeding.-The goal of factor concentrate infusion for hemarthrosis is an activity level of approximately 50 percent.Clients with hemophilia B should receive 50 to 60 units/kg of factor IX. If a patient has Hemophilia A and presents with hemarthrosis, what med- ication should they receive -Clients with hemophilia A should receive 25 units/kg of factor VIII. -within 2 hours of presentation with joint bleeding -If bleeding does not resolve, a higher dose may be required. Clients with joint bleeding as a result of trauma often require a higher target factor activity level. If a patient has Hemophilia B and presents with hemarthrosis, what med- ication should they receive Clients with hemophilia B should receive 50 to 60 units/kg of factor IX-within 2 hours of presentation with joint bleeding-If bleeding does not resolve, a higher dose may be required. Clients with joint bleeding as a result of trauma often require a higher target factor activity level. Clinical findings in hemophilia: Musculoskeletal Spontaneous hemarthrosis (bleeding into the joint space) is the hallmark of the disease -Recurrent bleeding in the joint capsule can result in chronic, debilitating hemarthroses causing synovial thickening, or synovitis, leading to progressive joint deformity. -Hematomas into the muscle of distal parts of the limbs may lead to external compression of arteries, veins, or nerves that can evolve into compartment syndrome -Hemarthrosis is a clinical diagnosis based on complaints of pain, erythema, and swelling in the affected joint, reduced mobility, and corresponding history. Clinical findings in hemophilia: Intracranial Intracranial hemorrhages (ICH)may occur spontaneously or following trauma. Hemorrhages may occur several weeks after the initial trauma has occurred. In clients with moderate to severe hemophilia, even minor trauma may result in ICH. Clinical findings in hemophilia: GI/GU Genitourinary (GU) tract-Hematuria is common. Bleeding may arise from the kidneys or bladder and can persist for days to weeks.Gastrointestinal (GI) tract-Hematemesis or melena may occur from swallowed blood after epistaxis.-Bleeding may also occur from esophagitis, gastritis, peptic ulcers, diverticula, or polyps. Clinical findings in hemophiliaL ENT Ear, nose, and throat (ENT)-Epistaxis is common and can be prolonged and severe but is usually self-limiting.-Bleeding from oral mucosa and gingiva can occur following dental procedures or from trauma. aPTT will be ______ in clients with hemophilia A or B. prolonged Clients with hemophilia A will have a _______ factor level? diminished factor VIII level Clients with hemophilia B will have a _____ factor level? low factor IX level Management of Life-threatening Acute Bleeding: Hemophilia A Acute bleeding is managed with urgent infusions of factor concentrate. -The goal of factor concentrate infusions is the production of a factor activity level of80 to 100 percent. -Clients with hemophilia A should receive 50 units/kg of factor VIII -Following this initial dose, factor concentrate dosing should be administered at specific intervals based upon trough and peak factor levels. Management of Life-threatening Acute Bleeding: Hemophilia B Acute bleeding is managed with urgent infusions of factor concentrate. -The goal of factor concentrate infusions is the production of a factor activity level of80 to 100 percent.-clients with hemophilia B should receive 100-120 units/kg of factor IX.-Following this initial dose, factor concentrate dosing should be administered at specific intervals based upon trough and peak factor levels. In patient with hemophilia, if they present with bleeding from the gums, after an oral surgery or from the GI tract, what medication is recommended and why? Antifibrinolytic therapy can be useful for stabilizing clots Meds: e-amino caproic acid (EACA) or TXAthis is to prevent fibrin degradation by plasmin. Hemophilia: TXA dosing -1 week or longer -25mg/kg 3-4 times per day hemophilia: EACA dosing -1week or longer -loading dose: 200mg/kg (max: 10g) -followed by 100mg/kg (max 30g/day) q 6 hrs. Hemophilia: Emicizumab what is it used for and what is the dosing? Emi- cizumab is a monoclonal antibody approved for use as a prophylactic agent against bleeding in infants, children, and adults with hemophilia A. -Initial dosing in adult clients is 3 mg/kg once weekly via subcutaneous injection for four weeks. -Maintenance dosing is 1.5 mg/kg once weekly or 3mg/kg once every 2 weeks or 6 mg/kg once every 4 weeks. hemophilia: DDAVP what is it used for? DDAVP is a synthetic vasopressin analog that causes a transient rise in FVIII and VWF but not FIX (desmopressin acetate tablets) (will work in type A not type B) -can be administered intranasally, subcutaneously, or intravenously prior to elective procedures in clients with mild hemophilia A. These clients must receive a test dose with a documented response prior to elective administration. A 13-year-old boy is brought to the emergency department after falling from his bicycle. He presents with a large, painfully swollen knee; aspiration shows gross hemarthrosis. On further questioning, the client's parents say that he bruises easily and has frequent nosebleeds. His maternal uncle had similar bleeding difficulties. Which of the following laboratory studies should prompt the AGACNP to suspect the presence of hemophilia? Normal platelet count, prolonged aPTT, normal PT Which of the following genetic markers are used to diagnose CML? Philadelphia chromosome Jerome is a 72-year-old client who presents to the emergency department (ED) with an acute exacerbation of chronic obstructive pulmonary disease (COPD). A review of symptoms reveals SOB, wheezing, and increased rescue inhaler over the last 2 ngs also include unintentional weight loss ( 10% in 6 months), fever, and night sweats. Vital signs are as follows: temp 98.6°F; HR 90; bp130/82; rr 22; o2 sat 91% on 2L nasal cannula. physical exam reveals diminished breath sounds in both lower lobes with expiratory wheezing. He is mildly tachypneic,does not exhibit any other signs of increased work of breathing, and can speak in full sentences. painless, mobile, cervical lymphadenopathy along with splenomegaly. (CBC) reveals WBC 27.0 x 109/liter; (Hgb) 10.2 g/deciliter; (Hct) 31%; platelets 90 x 109/liter; absolute neutrophils 28%, and lymphocytes 70%. What diagnoses is the cause of the abnormal CBC? CLL Leukocytosis is the broad term for an elevated white blood cell (WBC) count, typically above 11.0x10^9/L, on a peripheral blood smear collection. Lymphocytosis high lymphocyte count, is an increase in white blood cells called lymphocytes. Lymphocytes help fight off diseases, so it's normal to see a temporary increase after an infection. indicators for poor prognosis following near drowning situation. Submersion or resuscitation lasting more than 25 minutes, apnea, pH 7.41, and Glasgow coma scale (GCS) 5 are a prognostic signs. clinical findings of near drowning patient panic and agitation lethargy, stupor, or coma hypothermia hypotension cyanosis pulmonary edema bradycardia or tachycardia arrhythmia cardiac arrests secondary traumatic injuries (paresthesia, paralysis, extremity deformity, etc.) Management near drowning and post drowning -intubation/supplemental 02-remove all wet clothes-fluid and electrolyte replacement as needed w/ serial BMP-NG/OG for gastric decompression (if aspirated, can quickly lead to PNA) -minimum of 6-8 hrs tele monitoring Guiselle is an 18-year-old female who was admitted 8 hours ago after a near-drowning incident. EMS reports that she fell into a swimming pool at a party and was unable to swim. It was reported that a family member rescued her from underwater after she had been submerged for approximately 2 min- utes. She arrived with oxygen at 5 Liters (L) via nasal cannula. Now, Guiselle reports shortness of breath and anxiousness. She has difficulty talking in complete sentences. Vital signs are : Blood pressure 122/72; Heart rate 122; Respiratory rate 32; Oxygen saturation 88% on 5 L oxygen. What is the most likely underlying cause of Guiselle's distress? Adult respiratory distress syndrome (ARDS) LaVelle was brought to the emergency department by EMS. He arrived on a backboard with a cervical collar in place. LaVelle was found submergedin a pool by a family member; the circumstances surrounding the event are unknown. The family reports that LaVelle is a good swimmer and often swims in the home pool alone. You note that his breaths are shallow and slow. Heis minimally conscious and does not answer questions or follow commands. Pupils are 2 mm and slow to react. Vital signs are Blood pressure 98/42; Heart rate 138; Respiratory rate 10; Oxygen saturation 88 on 100% non-rebreather mask. What is the AGACNP's most appropriate action for LaVelle? Intubation and mechanical ventilation risk factors for drowning summer months access to water children lower socioeconomic status ethnic minority rural population inability to swim or overestimation of swimming capabilities risk-taking behaviors alcohol or drug use, near or in the water medical conditions (epilepsy, stroke, myocardial infarction [MI], etc.) hypothermia dry drowning time frame less than an hour after inhaling water. secondary drowning - sometimes called "delayed drowning," or "silent drown- ing.- occurs following a submersion incident in which the guest appears fine at first but within 24 hours shows signs of drowning mild hypothermia 32.2° C - 35° C (86-95F)initial thermoregulatory response correlates with excitation -shivering- hypertension-tachycardia- tachypnea-vasoconstriction fatigue, impaired judgment, and apathy follow the initial response moderate hypothermia 28° C - 32.1° C (82.4-89.7F)bradycardiaatrial dysrhythmias bradypneadecreased level of consciousness (LOC) and hyporeflexia hypotension mydriasis shivering may stop decreased renal blood flow severe hypothermia Severe 28° C (82F) apnea coma anuria acute pulmonary edema ventricular dysrhythmias cardiopulmonary arrest death As the body is rewarmed, vasodilation occurs facilitating the rapid return of cold peripheral blood to the heart. This blood contains lactic acid from inadequate tissue perfusion that has pooled in the periphery. These effects may cause the client to deteriorate briefly before improvement, a phenomenon called "rewarming acidosis" or "rewarming shock". Frostbite Actual freezing of tissue fluid resulting in damage to the skin and underlying tissue -typically hands and feet Frostbite symptoms feeling of burning and pain, followed by progressive loss of sensationSkin affected varies in appearance and ranges from pale and non-blanchable to purple with blisters to black and necrotic. Frostbite treatment Rapid rewarming with warm water (do NOT wait) -99-104F-for 30-60 minutes-do not use hot air dehydration is encountered commonly w/ chronic hypothermia and most will benefit from IV crystalloid bolus. NS or LR? WHY? NS is preferred. -the liver in hypothermic pt ineffectively metabolizes lactate Passive external rewarming Passive external rewarming can be used alone for mild hypothermia.Warmed blankets are used to insulate the client's body heat.Room temperature should be maintained between 80-82° Fahrenheit (F). Doors should be kept closed to keep heat in and keep temperatures consistent.The disadvantage to passive external rewarming is that the core temperature rises very slowly. Active external rewarming Active external rewarming may be combined with passive external methods.-Heating blankets include pads that circulate warm water and electric blankets that provide warmth on a timer.-Circulating warm whirlpool baths may be used if available. This treatment is most beneficial in clients with hypothermia and frostbite.-Forced warm air is one of the most common methods of warming clients in the hospital, especially after surgery. Special "blanket" covers with perforations are used that allow the circulation of warm air to flow over the client. Active internal rewarming -An esophageal warming probe can be used to heat the core blood supply through warmed circulating water.-Central venous warming catheters use warmed water circulation to rewarm blood as it flows through a central vessel. -Extracorporeal Membrane Oxygenation (ECMO) circulates blood outside the body through a warmer and then returns the warmed blood to the client. This method requires systemic anticoagulation and insertion of a specialized ECMO catheter. ECMO is not available at all hospitals. common causes for hypothermia Environment: Immersion; Freezing temper- atures; Inadequate thermal insulation; Prolonged indoor exposure to cold elements such as air conditioning (elderly) or ice baths (athletes) Drug-induced: Alcohol; Phenothiazines; Sedative-hypnoticsDisruption of skin integrity: Burns; Severe trauma Metabolic: Hypoadrenalism; Hypopituitarism; Hypothyroidism Iatrogenic: Aggressive fluid resuscitation; Heatstroke treatment Neurologic: Traumatic brain injury; Stroke; Brain tumor Rule of 9's Head and neck = 9% Upper Ex = 9% each Lower Ex = 9% each Front trunk = 18% Back trunk = 18% classifications of burns: minor total body surface area (TBSA) 10% in an adultTBSA 5% in children or the elderly the amount of full-thickness burn 2% classifications of burns: moderate TBSA 10-20% in an adultTBSA 5-10% in children or the elderly the amount of full-thickness burn is 2-5%high-voltage injury possible inhalation injury circumferential burn co-existing health problems classifications of burns: Major TBSA 20% in an adultTBSA 10% in children or the elderly the amount of full-thickness burn is 5% high voltage injury known inhalation injury significant burns to the face, joints, hands, or feet associated injuries from trauma/event what is optimal urine output for a burn patient The optimal urine output is at least 0.5 milliliter/kilogram/hour (mL/kg/hr). when should a patient be transfered to a burn center? burns 20% TBSA burns to face/head/neck burns to genitals circumferential extremity or chest burns full-thickness burns 5% burns over joints burns with inhalation injury electrical burns Symptoms of CO poisoning headache, dizziness, loss of consciousness, nausea/vomiting, chest pain, confusion Treatment of CO poisoning High flow oxygen (100%) is appropriate treatment Parkland formula for fluid resuscitation PARKLAND FORMULA = TBSA x Weight (kg) x 4 = Total amount of fluid needed you calculated your burn patients total fluid rescusitation, half the amount should be given half should be given in the first 8 hours, which is calculated from the time of injury NOT the time of arrival. The other half of the fluid is given over the next 16 hours. preferred fluids for burn patient fluid resuscitation Lactated Ringer's solution is the recommended crystalloid used in burn resuscitation, how often should a BMP be drawn for burn patients? -q4-8hrs in large burns.-assessing renal and electrolytes-Electrolytes must be replaced often due to large fluid shifts and fluid resuscitation. Hypokalemia is common. what is the CBC used for at baseline of a burn pt -initial hemoconcentration. As fluids are provided, a decrease in hemoglobin and hematocrit should be expected due to the administration of large fluid volumes. Transfusion may also be necessary. what does a serum lactate tell us with burn patients? -elevated lactate is an indicator of hypoperfusion, which occurs with under-resuscitation, poor end-organ perfusion, and/or heavy necrotic tissue burden CO levels great than ___ indicate ____? -5-consistent w/ CO exposure at what level would a patient be symptomatic with CO exposure? 10 what is a fatal level of CO 50 If urine output is below 0.5 mL/kg/hr for two consecutive hours, what does it mean? the client is likely under resuscitated and requires more fluids. Jerome has 75% TBSA 2nd and 3rd degree burn injuries. He weighs 80 kilograms (kg). Based on the Parkland formula how much fluid should Jerome receive in the first 8 hours? 12 L Parkland formula is TBSA x weight x 4ml. Half of this is given in the first 8 hours. 75 x 80 x 4= 24L/2= 12L. Neal was involved in a house fire. He sustained burns to the head, neck, face, chest, and bilateral upper extremities. Neal was intubated by EMS before arrival. What are the AGACNP's priority diagnostic studies for Neal? Carboxyhemoglobin (CO) level & ABGs Harleen sustained a 50% TBSA burn injury. The time of injury was 6 hours ago. The nurse reports that Harleen's urine output has decreased to 10ml/hr for the last two hours. What is the most appropriate intervention by the nurse practitioner? Provide 1L rapid bolus of lactated ringers (LR) Rationale: Urine decrease in a burn injury in the first 24 hours is generally going to be met with a fluid challenge. Burns require a large volume of fluids; some require upwards of 30L of fluid in just the first24 hours. Thermal injury causes an overwhelming fluid shift with most intravascular fluid shifting into the tissues and the third space. That fluid has to be replaced quickly. Urine output, lactic, CVP, acidosis are all signs of change in fluid status in a burn client. Hepatorenal syndrome (HRS) functional form of renal failure that occurs primarily in pt with cirrhosis and ascites. Type 1 hepatorenal syndrome is characterized by... -rapidly progressive renal impairment-doubling of initial serum Cr to greater than 2.5mg/dL over a period less than 2 weeks -without liver transplant prognosis is very poor Type 2 hepatorenal syndrome is characterized by... moderate form of renal failure-serum Cr levels between 1.5 to 2.5 mg/dLreduction in GFR with elevation in serum creatinine-associated with a more indolent course and improved survival compared to type 1 Risk Factors of hepatorenal syndrome Dilutional hyponatremia Previous episodes of ascites Presence of esophageal varices Poor nutritional statusInfections such as spontaneous bacterial peritonitisSevere urinary sodium retention (urine sodium 5 milliequivalents/liter [mEq/L]) Large-volume paracentesis without albumin replacementAcute alcoholic hepatitisLow mean arterial blood pressure (map 80 mm Hg) subjective clinical presentation of hepatorenal syndrome Most clients with HRS have a known diagnosis of acute or chronic liver disease and present with nonspecific symptoms including:-dysgeusia (altered taste perception)-malaise -fatigue-decreased urine output. objective clinical presentation of hepatorenal syndrome HRS has no characteristic physical exam findings.It is important to assess the client for stigmata of chronic liver disease including: -spider nevi-scleral icterus-lower extremity edema asterixis-abdominal distention-fluid wave-paraumbilical hernia-bruits. Diagnostic criteria in hepatorenal syndrome osis with ascites ase in Cr 0.3 mg/dL within 48 hrs or 50% increase from baseline within a7 day period response to a 2 consecutive day diuretic withdrawal and volume expansion w/albumin 1g/kg body ce of nephrotoxic drug macroscopic signs of structural kidney injury (proteinuria 500 mil- ligrams/deciliter[(mg/dL], microhematuria with 50 red blood cells per high-power field, and/or abnormal renal ultrasonography) What is the Creatinine criteria when diagnosing hepatorenal syndrome increase in serum creatinine of-greater than or equal to 0.3 mg/dL or -greater than or equal to 50% increase from baseline Cr this is within a 7 day period. What surgical intervention is used to treat hepatorenal syndrome? TIPS Procedure TBI (traumatic brain injury) clinical findings headache dizziness fatigue memory loss confusion difficulty concentrating nausea and/or vomiting drowsiness, stupor, coma blurred or double vision seizure coma irregular or dilated pupils cranial nerve palsy speech impairment motor weakness or paralysis Types of Traumatic Brain Injury -Traumatic: damage acquired from an external force-Non-traumatic-Congenital: damage or malformation in the brain that occurs before birth Causes of Traumatic Brain Injury falls assaults sports injuries motor vehicle accidents abuse (shaken baby syndrome, domestic violence) gunshot wounds workplace injuries causes of TBI, nontraumatic stroke (embolic, hemorrhagic, ischemic)meningitis encephalitis seizure electrical shock tumors metabolic disorders hypoxianeurotoxic substances causes of congenital TBI cerebral palsy anencephalyencephaloceleChiari malformations congenital hydrocephalus microcephaly Cushing's triad three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation objective findings of intracranial HTN -changes in the level of consciousness -Cushing's triad (suggestive of brainstem compression) bradycardia hypertension altered respiratory pattern -headache (continuous that worsens in the morning) -seizures -changes in speech-papilledema or pupillary changes-oculomotor palsies-decreased motor functiondecerebrate (extensor) posturing indicates more serious damage decorticate(flexor) posturing projectile vomiting (not preceded by nausea) Decorticate posturing -"flexor posturing" or "mummy baby" (thimummy preservation)-adduction of arms (arms fold to chest); flexion of elbows and wrists Decerebrate posturing -"extensor posturing";-abduction of arms, elbow and wrist extension A concussion is considered a mild traumatic brain injury (MTBI) deciding factor for TBI intubation (clinical pearl) Clinical Tip: Remember"less than 8, intubate!" when evaluating a client with TBI. Most concussions result in a loss of consciousness. True or False False Nigel is brought to the emergency department by EMS. He was riding a bicycle without a helmet and was struck by a car at a low rate of speed while crossing an intersection. His initial GCS was 14 upon arrival. EMS reports, according to witnesses at the scene, that Nigel sustained a brief loss of consciousness of 5 minutes (min). He has a large hematoma to the frontal scalp and multiple skin abrasions to his extremities. A non-contrast CT of the head was normal and Nigel's follow-up GCS improved to 15.Classify Nigel's TBI as mild, moderate, or severe? Nigel's TBI is mild. The initial GCS for clients with mild TBI is usually between 13- 15.Radiographic imaging of the brain with CT or MRI will be normal. Which of the following findings would the nurse practitioner (NP) expect to observe in Nigel? Select all that chedizziness retrograde amnesia nausea/vomiting drowsiness irritability seizure fixed and dilated pupils clear rhinorrhea Battle's sign or raccoon eyes Headache, dizziness, retrograde amnesia, nausea/vomiting, drowsiness, anxiety, irritability, labile mood, sleeping more or less than usual with a normal head CT are characteristic of mild TBI. Nigel may have had a brief initial LOC, although one is not required to make the diagnosis. Concussion symptoms tend to improve over time, with most clients returning to nor- mal within a couple of weeks. Coma, seizures, abnormal pupils, otorrhea/rhinorrhea, battle's sign, and raccoon eyes are all indicative of a moderate to severe head injury. Katie was an unrestrained driver involved in a motor vehicle accident. Her vehicle sustained a moderate impact to the driver's side front door as she was struck by a vehicle that went through a red light. Katie's initial GCS at the scene (reported by EMS) was 12 but improved en route to the hospital. Upon arrival to the trauma room, her initial neurological exam revealed no focal neurological deficits and her GCS was 14.While in the CT scanner, Katie deteriorated and became somnolent. The scan was stopped. The NP examines Katie in radiology. Her GCS is now 8 and her left pupil is fixed and dilated at 7 millimeters (mm). This presentation is most characteristic of which type of TBI? Acute epidural hematoma What is the priority action? Intubate Mild TBI guidelines for diagnostic imaging non-contrast head CT in clients who sustain head trauma WITH a loss of consciousness (or have post traumatic amnesia) if one or more of the following are present:headache vomiting age 60 years drug or alcohol intoxication short term memory deficits