Advanced Adult Health Nursing Comprehensive Medical Surgical Exam Blueprint

Advanced Adult Health Nursing Comprehensive Medical Surgical Exam Blueprint -By Khush  Chapter 11: Health care of the older adult: KNOW signs and symptoms of, treatment for, nursing management, medications used, and complications of specific disorders: Alzheimer’s Alzheimer’s Disease Cx: Increasing age, genes, environment, diet, inflammation, neurotransmitter, vacular, stress, neurotic plaques and acetylcholine alteration S/S: Slow onset, wandering, pacing, restlessness, depression, lost feeling Dx: Rule out other conditions Tx: Donepezil, Rivastigmine, memantine: cognition enhancers NurseMx: Asses, promote function/independence, nutrition, cognitive stimulation Chapter 13: Fluid and electrolyte, acid base disorders KNOW LAB VALUES: CBC, chemistries, coagulation, and inflammatory indicators. Signs and symptoms of electrolyte disorders, Treatment of electrolyte disorders, Physiology of acid base balance and imbalance, Regulation of acid/base, ABG interpretation, Treatment of abnormal ABG’s ( CHECK SHEET ATTACHED, labs, electrolytes, acid/base) Anticoagulants Monitor Reversal agent LMWH Platelets Protamine Sulfate Heparin PTT (25-35 sec) Protamine Sulfate Warfarin PT (11-14 sec)/INR (0.8-1.2) Vitamin K/FFP Chapter 14: Shock & multiple organ dysfunction Types, etiology, stages, complications, clinical manifestations, treatments, and nursing interventions Stages of Shock 1. Compensatory 2. Progressive 3. Irreversible Compensatory -SNS causes vasoconstriction, increased HR, increased heart contractility to maintain BP and CO -Body shunts blood from skin, kidneys, GI tract. Results in cool, clammy skin, hypoactive BS, decreased UO -Perfusion of tissues is inadequate -Acidosis occurs from anaerobic metabolism -RR inc due to acidosis, may cause compensatory resp alkalosis. Confusion can also occur Progressive -BP regulation can no longer compensate so BP/MAP decrease -Hypoperfusion to all organ with further vasoconstriction -Metal status further deteriorates from dec cerebral perfusion and hypoxia -Lungs start to fail because decreased pulmonary blood flow causes further hypoxemia, inc CO2 levels, alveoli collapse and pulmonary edema -MAP 70, GFR cannot be maintained causes acute renal failure -Liver, GI and hematological function affected -DIC may occur Irreversible -Cannot survive -Organ damage so severe that pt does not respond to tx -BP low -Renal, liver fail -Anaerobic metabolism worsens acidosis -Multi organ damage General Mx of shock -Fluid replacement: Crystalloid, colloid sln. First line! -Vasoactive meds • Norepi, dopamine, phenylephrine, vasopressin: they need fluid on board to work! (volume) SE: tachycardia and dec peripheral perfusion -Nutritional support -Modified Trendelenburg can help keep BP up. Report MAP 65 -VS q15min -Can monitor O2 Sat via central line (70%+) -Meds can be given thru central line if possible and titrated to effect: risk for extravasation Classifications of shock Hypovolemic: Decreased intravascular volume due to fluid loss Cardiogenic: Impairment or failure of myocardium Septic: Overwhelming infections causing relative hypovolemia Neurogenic: Loss of sympathetic tone causing relative hypovolemia Anaphylactic: Severe allergic reaction producing overwhelming systemic vasodilation, relative hypolvolemia Hypovolemic shock Cx External fluid loss: traumatic bleed Internal fluid shift: Intravascular to interstitial compartment (severe edema, ascites and dehydration) Mx -Fluids with 2 large bore IVs -Intraosseous cannulation if hard to get IV catheter in. NurseMx: -Administer blood, fluids safely -Need for blood transfusion based on amount of blood lost, response to crystalloid fluid, ABGs, need for oxygenation with use of Hbg. Cardiogenic shock **A-line: for continuous BP and arterial blood draw. Coronary: Myocardinal damage due to decrease in perfusion; MI, HF. Noncoronary: Conditions that stress the myocardium; hypoxia, acidosis, hypoglycemia, hypocalcemia, tension pneumo, PE, valve damage, tamponade, dysrhythmias, -In both, CO is compromised, BP drops, tissue perfusion is reduced Mx: -Correct cause: Coronary=PCI, CABG. NonCoronary=valve replacement, correct electrolyte replacement, correct dysrhythmia. -Limit further myocardium damage; increase cardiac contractility and dec ventricular afterload. -Initiate first line tx: O2, serial EKG, hemodynamic monitoring (a-line and pulmonary artery cath), labs (BNP, CK-MB), fluids, mechanical assistive devices (intra-aortic balloon, R/L ventricular assist devices Pharm therapy: - Dobutamine: Inotrope. - Nitroglycerin: Reduces preload - Dopamine: Sympathomimetic improved contractility - Other vasoactive meds - Antiarrhythmic meds: NurseMx: - Preventing cardiogenic shock by ID risk pt - Monitor hemodynamics - Meds, fluids; avoid overload - Monitoring UO Cirulatory Shock ; septic, neurogenic and anaphylactic shock. Definition: Intravascualar volume pools in peripheral vessels so not enough blood returns to the heart. Inability to vasocontrict Cx: Loss of sympathetic tone or relsease of biochemical mediators Manifestations: Dec venous return, decreased CO, decreased tissue perfusion Mx: -Fluid replacement to restore intravascular volume -Vasoactive meds to restore vasomotor tone -improve cardiac function -Nutrition Septic shock Definition: Inflammatory response leads to decrease tissue perfusion, increased capillary permeability and activation of coagulation system Cx: gram neg rods, gram positive cocci bacteremia S/S: Low BP, tachy, hyperthermia Tx: - ID and tx cx - Abx, fluids, vasopressors (epi, dopamine) - Nutrition within 1st 24hrs to address hypermetabolic state; enteral or parenteral feedings - No not tx hyperthermia unless 104+ Systemic inflammatory response syndrome (SIRS) Definition: overwhelming inflammatory response in the absence of infection that causes hypovolemia and dec tissue perfusion. May progress into sepsis Tx: ABx can be given for possible unrecognized infection Neurogenic shock **Sympath cause constriction and parasympathetic causes smooth muscle relax Definition: Vasodilatoin occurs due to loss of balance between sympathetic and parasympathetic stimulation. Pt experiences an enhances parasympathetic response during vasodilation. Cx: spinal cord injury, spinal anesthesia, other NS damage, hypoglycemia S/S: dry, warm skin, low BP, bradycardia, no perspiration in paralysed portion of body Tx: - ABC - Stabilze spinal cord - Atropine 0.5mg IV - Keep map 70+ - IV steroids - HOB 30 with spinal and epidural anesthesia - DVT prevention Anaphylactic shock Definition: Antibody-antigen reaction, allergic rxn (IgE) S/S: hypoTN, neurologic changes, resp distress, cardiac arrest Tx: Remove agent, BLS, epi, diphenhydramine, albuterol (to reverse histamine induces bronchial spasms) Diagnostic testing, normal values, and results Chapter 16: End of life Care of, interventions for, assessment of, appropriateness of treatments. Therapeutic communication with patient and family. Home care needs. Care of the dying client Communication -Reflect on your own experiences, values concerning illness, death -Allow pt and family to set agenda regarding depth of conversation -Allow pt sufficient time to reflect, respond -Avoid distraction -Avoid impulse to give advice -Assess understanding of own and pt -Discuss at time issue is addressed-MAKE TIME -Provide realistic reassurance -Assess pt preferences, spiritual, cultural practices Care Palliative care: Psychosocial, spiritual focused care. Multidisciplinary collaboration Hospice: Death accepted. Home or designated facility. Bereavement care for family End of life symptoms management - Pain - Dyspnea: even if it means to give a blood transfusion for temporary relief - Nausea/ anorexia - Weakness - Anxiety - Hydration - Delirium - Depression . Chapter 21: Respiratory care modalities KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, normal values, results, and complications of specific disorders: Chest tubes(indications for, removal of and complications), tracheostomy (indications for, suctioning), Assessment: Resp status: Look out for resp distress. Look out for tension pneumothorax from obstructed tubing (assess tubing as notify Md). SubQ emphysema (Crepitus): rice krispie on skin. If suspected mark area with marker and observe for expanding. Notify MD Watch of signs of recurring pneumothorax and pleural effusion Maintenance: Suction control Water seal chamber and air leak monitoring Recording drainage volume Titling: movement of fluid up and down from breathing. No titling may mean the its healed and can be taken out Do not clamp or milk tubes If there is an airleak. Start by observing pt, dressing, loops and connections Chest tube system must be lower than pt Chest tube removal: Daily chest x-rays As drainage slows, suction is discontinued Removed by primary care provider Pain management 30 min before Supplies: suture removal scissors, gauze, Vaseline gauze, tape and drape Instruct pt to perform Valsalva maneuver: forced exhalation and bear down Assess for resp distress, SOB, tachy. Get CXR call PCP Pleurodesis: technique to stick pleura to chest wall to prevent liquid there If accidentally comes out: occlusive dressing on site Trach indications • Obesity • COPD • Stroke pt • Neuromuscular issues • Airway obstruction/trauma • Too much secretions • Impaired cough reflex **O2 must be humidified because air is bypassing the nose and mouth to moisture it Fenestrated trach or Passy Muir : Speech is produced in the larynx. If there has been a laryngectomy then a voice box (Passy Muir) may be needed to speak and rehabilitation Trach tubes: • New trach comes out then ventilate and call a code. Cover stoma with sterile gauze and bag through mouth. Common to see bleeding post op but should not be excessive. New trach is hard to insert. Post op: may have blood sputum • Old trach comes out then put in obturator otherwise obturator only used then putting outer cannula into stoma • Perform swallow eval: if ok then can feed soft small meals. Must be upright to avoid aspiration • Takes a long time to heal but pt can change trach tube at home Oxygen delivery system • Trach can be attached to ventilator or • Trach collar for oxygen • Transtracheal oxygen: for Pt with chronic oxygen therapy needs. More comfortable and avoid nasal prong irritation. Flow rate can easily be adjusted and less O2 does to the surrounding Trach Complications • Tracheomalacia (too much cuff pressure) • Stenosis: narrowing • Fistula • Tracheo-innominate artery fistula from malposition of the tube because it will hit the artery can cause necrosis (emergency. S/S trach moving with heart beat) • Tube obstructions/dislodgement • Pneumothorax, infections and subq emphysema Suctioning (PRN) • Pt maybe restless, tachy or have dec SpO2 • Constant cough may be suction • Hyperoxygenate before (30 sec to 3 min before) • Never suction more than 10 sec • Reassess and if more suction needed again hyperO2 • Complication of suctioning: o Hypoxia: Prevented by hyperO2 o Tissue damage: do not suction going in o Infection o Vagal stimulation: low BP and brady o Bronchospasm o Dysrhythmia Nursing interventions • Suction • Humidify O2 • Drainage positioning • IS, TCDB • CPT • O2 for COPD: Watch out for CO2 necrosis: When the body stops to respond to PaCO2 levels and drive off of Low PaO2 level to breath. Watch pt who is on O2. S/S: asterixis (flapping tremor of the wrist), muscle twitching, seizures, SOB, anxious, may be nonresponsive Complication of O2 therapy • Combustion • O2 toxicity: S/S: substernal discomfort, dyspnea, paresthesia’s, restlessness, atelectasis, infiltrate (use PEEP) • Drys mucous membranes • Infections Ventilator Associated Pneumonia Oxygen administration and pulse oximetry Chapter 23: Chest and lower respiratory tract disorders KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, normal values, results, and complications of specific disorders: pulmonary edema, pulmonary embolism, ARDS, acute respiratory failure, pneumothorax, tension pneumothorax, and hemothorax. Monitor Reversal agent LMWH Platelets Protamine Sulfate Heparin PTT (25-35 sec) Protamine Sulfate Warfarin PT (11-14 sec)/INR (0.8-1.2) Vitamin K/FFP Acute Resp Distress syndrome (ARDS) Watch *PEEP: keeps alveoli open. SE: pneumothorax, hypoTN, uncomfortable (may need neuromusc blocking agents) Definition: sudden pulmonary edema, infiltrates and hypoxemia which injures/inflammation alveolar capillary. Results in pulmonary edema or fluid in alveoli and lungs Patho: Inflammation causes V/Q mismatch • Alveoli are damaged • Airway is narrow • Possible atelectasis • Decreased compliance • Refractory hypoxemia: unreactive to oxygen and no left atrial pressure Cx: (anything that damages alveoli) Aspiration, drug overdose (OD), prolonged high O2 concentration, Smoke, infections, metabolic disorders, shock, trauma, surgery, fat or air embolism and sepsis S/s: rapid dyspnea and tachypnea. PaO2 not responding to O2 therapy. Mx: tx cause, supportive care, O2, intubation and PEEP, daily CXR, ABG **Flail chest: 3+ free floating ribs from fracture causing abnormal breathing appearance Dx: CXR, ABG, CT, labs Can cause **flail chest, *pneumothorax (air between pleurae), cardiac tamponade (compression of heart by fluid surrounding) pulmonary contusion, aortic rupture, rib fracture, airway obstruction and tracheobronchial diaphragmatic injury and hemothorax (concern about amount of bleeding in lung) Tension pneumothorax: WILL KILL. Air enters the pleural space from lung or airway and has no way out. Most dangerous if patient is on PEEP. No breath sounds will be observed on affected side. This will cause a shift in mediastinal pushing the heart, vessels AND trachea to the unaffected side. Blood flow is then compromised Chest tube use, monitoring, and complications: SEE ABOVE Chapter 26: Dysrhythmias and conduction problems KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, normal values, medications, results, and complications of specific disorders: Atrial fibrillation, pacemakers, and dysrhythmias Electrocardiography interpretation Rhythm Analysis 1. Regular (sinus) or irregular. Same spacing between R waves = regular. Irregular ventricular rhythm= emergency 2. P wave= Present, preceeding and upright (PPU). 1 P for every Q? 3. PR interval: from P to QRS. Represents atrial depolarization and AV node impulse delay. (0.12- 0.20 normal) 4. QRS complex (ventricular depolarization): Q: first neg deflection, R first pos deflection, S: neg deflection. NICE TIGHT AND UPRIGHT (less than 0.12). Multiple direction is bad! 5. ST Segment: Isoelectric: from end of QRS to T. Depressed or elevated= BAD 6. T wave (ventricular repolarization/rest): Usually positive and asymmetric. An ectopic stimulus can excite here and cause ventricular irritability, lethal dysrhythmias and arrest (R on T phenomenon) a. Tall: High K, High Ca, meds, myocardial ischemia, ANS effects b. Short: Low K 7. QT interval: Total ventricular depolarization and repolarization time. If prolonged can lead to Torsade de points (like v-tach) 8. U wave (repolarization of purkinje: If present follows T wave. a. Present in pt with low K HTN and heart disease Treatment for abnormal rhythms/dysrhythmias Chapter 29: Complications from heart disease KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, normal values, results, treatments, emergency treatments, and complications of congestive heart failure. Heart Failure Definition: the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. Lifelong disorder managed with lifestyle changes and medications Cx: Systemic HTN mostly but also CAD, drugs, valve disease, infections, dysrhythmias, DM, smoking, family hx, hyperthyroidism. Life expentency: 7/10 die within 10 yr of being DX. 50% of that live for only 5yr RAAS: CHF activates baroreceptors---stimulated vasomotor center in medulla----activates sympathetic NS--- increases epi and norepi---causes vasocontriction--- causes inc afterload, BP, HR ( angiotensin II from aldolserone release from kidney also causes vasocontriction) Right sided HF: RV cannot eject as much blood so blood back up into venous system • Edema, JVD, weight gain, ascites, enlarged liver and spleen Left sided HF: LV cannot pump blood effectively to systemic circulation • Thready rapid pulse, weakness, lightheadedness, tachy, confusion, dyspnea Worsening HF: orthopnea, angina, edema, weight gain 1-2 lb overnight Assessment: Edema, S3 gallop (sound of the remaining blood in the ventricle after S2 when mitral valve opens to fill left ventricle), MAY SEE HALOS AROUND LIGHTS, assess digoxin levels for toxicity since pt will be on dig, Dx: Echo, CBC for hemodilution due to fluid overload, BNP, Tx meds (ABCDD): Ace, Arbs, BB, CC, diuretics (Lasix, bumuex, aldactone) , digoxin. Others: Natrecor, primacor, dobutamine (helps pump blood) May also develop renal failure, proteinuria, microalbuminuria from dec renal filtration **S3 normal in children, prego and athletes Mx: anticoagulants, daily weights, low Na, O2, may need ventricular assist devices or heart transplant, DASH (veggies, fruit, low dairy and low red meat cholesterol, Na=1500mg/day Hemodynamic monitoring, CVP, Arterial line, indications, measurements, assessment, and interventions Chapter 33: Hematologic disorders KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, normal values, results, and complications of specific disorder: thrombocytopenia Chapter 37: HIV and AIDS KNOW signs and symptoms of, goals and treatment for, nursing management, prioritization, medications used, diagnostic testing, normal values, results, nursing diagnosis, and complications of specific disorders: HIV and AIDS. HIV Transmitted: Blood, semen, vaginal secretions, breast milk, infant delivery (fluids contain free virions and infected CD4+ cells Prevention: education to reduce/eliminate risky behaviors. Use standard precautions Pathophys: Retrovirus targets cells with CD4 receptors on T lymphs, monocytes, dendritic cells and brain microglia -T lymps subdivide into CD4 and CD8. Normal CD 4 is 700-1000 -Primary stage: High levels of viral replication, widespread dissemination of HIV in body, destruction of CD4 lymph. CD8 increase killing of infected virus producing cells and they body produces antibodies. Remaining amount of virus in the body is called viral set point. The higher the viral set point the more poor the prognosis Staging Asymptomatic (CDC cat A and ATI Primary): CD4 500+ -after viral set point reached 8-10 yrs before major HIV complication develops. HIV virus vs immune system is equal. Can lead to generalized lymphadenopathy Symptomatic (CDC cat B and ATI Chronic): CD4 200-499 -increased susceptibility to infections, fever, diarrhea, shingles (2 episodes) AIDS (CDC cat C and ATI AIDS): CD4 200 -when Cat C is reached pt will stay in Cat C whether CD4 goes up or not. Can cx fungal, encephalopathy, Kaposi’s sarcoma, mycobacterium, pneumocystis pneumonia (PCP) HIV testing Done 3-12 weeks after infection body produces antibodies against virus ELISA: ID’s specific antibodies screening test Western Blot confirms positive result Saliva test: Orasure Blood Test: OraQuick Viral load test: -Measures plasma HIV RNA levels. Good predictor of the risk of HIV progression than the CD4+ count. Remember lower # = better prognosis -MRI brain: Will show enlargement and or hyper intense of the cortical sulci and ventricles, patchy, hyper intense lesions of which matter -MRI chest Tx ADHERE TO TX!!! -Antiviral meds offered when CD4 drops 350 and plasma HIV RNA 100,000+. Normally more than 1 antiviral given Nucleotide reverse transcriptase inhibitors (NRT), non-nucleotides (NNRT), Protease inhibitor (PI), Highly active antiviral Drug therapies (HAART) 2-3 drugs in 1 capsule for max effect: ex Kaletra and Atripula Goals: Sustained max suppression of viral load, restoration/preservation of immune function, improve quality of life/survival, prevent HIV transmission S/S FATIGUE Resp: SOB, chest pain cough, chest pain, resp failure, **PCP (most common, dx with sputum or biopsy), MAC, TB GI: weight loss, diarrhea, N,V, candidiasis, wasting syndrome, cachexia Oncological: Kaposi’s, B Cell lymphoma Neuro: Cognitive impairment, behavior change, encephalopathy, peripheral neuropathy, motor impairment, Cryptococcus, CMV, seizures Chapters 43: Musculoskeletal trauma KNOW signs and symptoms of, treatment for, nursing management, nursing assessment, medications used, diagnostic testing, normal values, results, and complications of specific disorders: types of fractures, pelvic fracture, stable and unstable pelvic fracture, post-operative care of pelvic fractures, humeral fracture treatment and compartment syndrome Fractures (looks deformed): disruption of continuity of a bone Comminuted: trauma Greenstick: one side is broken other is bent Open/compound: involves skin Spiral: fracture twist Avulsion: Fragment of bone pulled away from by a tendon and its attachment S/S: Pain, loss of function, shortening of extremity, crepitis, edema and ecchymosis Dx: X-rays, MRI, CT Tx: Immobilize promixal and distal to injury, Closed reduction: manipulation, alignment and maybe traction Open reduction: internal fixation: pins, plates and screws Tx avulsion: tx as soft tissue injury Grades of open fractures Grade I: Clean less than 1cm Grade II: Larger without extensive soft tissue damage or avulsions Grade III: Contaminated and extensive soft tissue damage. Skin, muscle, nerve and blood vessel damage. Can result in amputations NurseMx: Assess neuro!!!. CMS (circulation, motor and sensory) 6 Ps: Pain, pallor, uselessness, paresthesia , paralysis and pressure. If fracture is suspected quickly immobilize. Lower extremities must be bandaged together with unaffected extremity serving as a splint. Upper extremities: sling or bandaged to chest. ELEVATE EXTREMIT. Medicate for pain, turn Q2, nutrition and assist with elimination Complications Post Op: Osteomyelitis, fat embolism (mostly from long bones), gas gangrene, tetanus, Delayed wound healing, shock, DVT, PE, Nonunion (nonhealing), Malunion(malformations), Complex regional pain syndrome CRPS, Avascular necrosis by ischemia Compartment syndrome: Unrevealed swelling in 1+ muscle compartment leads to ischemia and nerve compression. Happens when perfusion pressure falls before tissue pressure. Can be measured with Wick Catheter. Non- treatment=necrosis S/S: Pain worse with PROM(passive), paresthesia, pale, numbness and throbbing Tx: Fasciotomy to leave the pressure CRPS: Due to damage of the nervous system including nerves that control the blood vessels and sweat glands therefore the damaged nerves are no long able to control blood flow, sensations and temperature to the affected area -s/s: pain, edema, hyperesthesia, stiffness, discoloration Fat embolism: within 48hrs of long bone fracture. Released into vasculature and travel to small blood vessels -s/s: Hypoxia, confusion, resp distress, tachy, fever, and cutaneous petechiae Clavicle fracture: Goal to align shoulder Humeral neck: Support and immobilize arm (sling) Humeral shaft: Monitor neurovascular status Elbow: Monitor for volkmanns contracture (acute compartment syndrome from swelling and damange to brachial artery. For volkmans: assess distal extremity and ability to extern all fingers Chapter 49: Hepatic disorders KNOW signs and symptoms of, treatment for, nursing management, medications used, nutrition, teaching, diagnostic testing, normal values, results, and complications of specific disorders: liver disease, cirrhosis, and hepatitis: viral, A,B, and C. Hepatic Dysfunction Cirrhosis: liver becomes hard and small Cx: Alcoholism (looks like santa: red face, ascites in abd), infections, anoxia, metabolic disorders, nutritional deficiencies, hypersensitivity Mx: Jaundice, portal HTN (from obstructed blood flow into liver and so blood backs up into spleen), ascites, varices, haptaic encephalopathy (loss of brain function when liver doesn’t remove toxins), nutritional deficiencies, thrombocytopenia, hepatomegaly, splenomegaly Jaundice: yellow/green body tissue: lips, sclera, skin, dt increased bilirubin • Hemolytic: DT increases destruction of RBC so increases bili. Normal liver cannot excrete fast enough • Hepatocellular: inability of damaged liver to clear normal amounts of bilirubin • Obstructive: Occlusion of bile duct from gallbladder stone, tumor, inflammation etc. Therefore bile cannot flow normal into the intestine and gets backed up into liver where its absorbed into the blood and carried to the rest of the body • Hereditary hyperbilirubinemia: increases bili DT genetics Portal hypertension: Increase in BP within portal venous system dt to blockage in the liver causes blood to back up in the veins to the stomach, spleen, pancreas and intestine. Because the blood is backed up, the blood uses the veins in the esophagus, and rectum/anus to get back to the heart around the liver. This causes ascites and esophageal varices • Ascites: damaged liver= failure to make aldosterone. This causes sodium and water retention by kidneys. Large amounts of albumin rich fluid accumulate in peritoneal cavity by 3rd spacing (albumin attracts water), S/S: SOB, F/E imbalance • Esophageal varices • Fluid overload • Pulmonary congestion Hepatic Cirrhosis • Alcoholic • Post necrotic scar tissue from virus: • Biliary: scarring around bile ducts Mx: intermittent fever, abd pain, epistaxis, ankle edema, ascites, jaundice, weightloss, clubbing NurseMx: • Focus on onset of symptoms • Discuss alcohol abuse only with client • Diet intake • Exposure to toxic agents • Mental status • Ability to do ADL, job and social • Monitor for bleeding, fluid volume change and labs NurseDx: • Acitivty • Imbalanced nutrition • Impaired skin integrity Risk for bleeding • Fecal-oral • Incubation: 15-50 days. Illness: 4-8 wks • Dx: Liver enzymes and Hep A antibody • Mx: Flu like, low fever, anorexia. Later: jaundice, dark urine, indigestion, liver/spleen enlargement • Px: Hand washing, safe water, proper sewage disposal, vaccine • Tx: Bed rest, small frequent meals, immunoglobin if not previously vaccinated Hep B (HBV) • Blood to blood, saliva, semen, sexually, delivery • Incubation: 1-6 mths • Dx: Liver enzymes, Hep B surface antigen, hep B e antigen, hep B DNA • Mx: same as hep A • Tx: small freq meal, bed rest, decreases symptoms . Chronic Hep B: alpha interferon and antiviral agents. If exposed and unvaccinated Hep B immune globulin (Gamma Globulin) • Px: Vaccine, precuatins, blood screening, disposable syringes, HH Hep C • Blood • Most common • Dx: Liver enzymes, Hep C RNA • Mx: Leads to cirrhosis or cancer • Tx: Antiviral, interferon and ribavirin Hep D • Blood transmission • Hep B ppl are at risk • Liver failure and cirrhosis more likely Hep E • Fecal-oral, waterbourn • Incubation: 15-65 days • Abrupt onset. Not chronic Chapter 50: Biliary disorders KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, normal values, results, treatments for, and complications of specific disorders: choleycytitis, and pancreatitis. Pancreatitis: inflammation of pancreas Can lead to death. Acute disease does not usually lead to chronic Acute pancreatisis: Pancreatic duct becomes obstructed and enzymes back up causes auto digestion (enzymes destroy own tissue) and inflammation. Can lead to hypovolemic shock (pancreatic blood/fluid leaks into abd cavity), FE imbalance, sepsis, bleeding and thrombosis (from damage of near-by blood vessels) Chronic pancreatitis: Destroys pancreas secreting cells Cx: ETOH, choleliathiasis, bacteria, viral, trauma, PUD, hyperlipidemia, hypercalcemia, meds. Gallstones lodge in Ampulla of Vater and obstruct flow Dx: Elevated Lipase (5-10 times high), amylase, glucose, bili, WBC, US, CT S/s: Rigid board like abd (acute pancreatitis), severe pain, Cullen’s sign (bruising around umbilicus), Turner’s sign (Flank bruising form seeping of blood). Acute Chronic Severe abd pain Recurrent attacks of upper abd and back pain with vomiting Abd guarding Weight loss N/V Steatorrhea Fever, jaundice, confusion, and agitation Can become hypoxic, renal failure, hypovolemia and shock NurseMx: • Pain: Analgesics, NG suction to relieve nausea and distention, oral care Cholycystectomy post operative care Chapter 54: Renal disorders KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, normal values, results, home care instructions and complications of specific disorders: acute renal failure, prerenal, intrarenal, post renal, chronic renal failure, and end stage renal failure • Recovery S/s: Decreased UO at first, sp gr 1.010, increased BUN, Cr Tx: Causes, treat hyperkalemia ,dialysis . Chronic Kidney Disease (CKD, CRF, ESRD) Definition: decrease in GRF for 3+ mths. 90% nephron function destroyed. End productos of protein metabolism accumulate in blood (Uremia) Cx: DM, HTN, CV disease, obesity, glomerulonephritis, pyeleonephritis, polycystic, congenital, nephrotoxins, NSAIDs, cancer, prolonged inflammation, meds (aminoglycoside, gentamycin, vanco, cyclosporin) S/S: age, underlying conditions, weakness, tremors, dry flaky skin, edema, crackels, muscle cramps, CHF, HTN, perpheral neuripathy, amenorrhea, infertiliy, bone pain, confusion, pericarditis, hyperlipidemia/kalemia, tamponade Dx: • Elevated Bun, Cr, K, phos, • Low hgd, hct, iron, GFR • KUM, CT, MRI, US, cystoscopy, biopsy, IVP, metabolic acidosis Tx: Cause, control BP, glucose, dialysis (hemodialysis or peritoneal) Hemodialysis: permanent port put it. Pt has to get dialysed 3 times a week Peritoneal dialysis: done at home 4-6 times a day MedMx: • Hyperphosphatemia and hypocalcemia binder. To inhibit GI absorption of mineral. Given with meal. CaCO: oscal, Ca acetate: PhosLo, Sevelamer HCL: Renagel (phos binder) • Anemia: Erthropoeitin, IV ferrous sulfate • CV meds: HTN meds • Antiseizure: Diazepam, phenytoin • Hemodialyiss or peritoneal dialysis: for RI, ARF, CRF, OD, hyperkalemia, hypervolemia: works with diffusions, osmosis, and ultra filtraion (neg presssure to remove water) HD Hemodialsys needs vascular access: • Arteriovenous fistula in forearm: 2-3 months to mature • AV graft arm, thigh or chest. Graft between artery and vein subcutanously • Vas caths, trialysis: Large boar cath into subclavian, femoral, internal jugular. • Tunneled caths: Groshung, hickman, quinton. Temp access • Risk of hemothorax, pneumothorax, infection, embolism, msucle cramps, HA, clotted access, dysrrythmias, hypotension • 3-4 hrs/ day, 3 times a week. Can cause sleep disturbances Hemodynamically unstable pt • CRRT (continous renal replacement therapies): • CVVHD (Continous venovenous hemofiltration): better tolerated because it’s much slower than CRRT. Requires critical care • Complicatoins: Hypotension, anemia, infections, Hep B,C and…… o Disequlibrium syndrome: Rapid decrease in BUN and volume causes cerebral edema (ICP). S/S: LOC, seizures, agitations, NV. Tx: slow exchange rate Peritoneal diaylsis: Remove toxic substances and reestablish normal fluid and electrolye balance. Pt who is not able to do HD, renal transplant pt or have. Peritoneal membrane is like a semipermeable membrane. Sterile dialysate into cath and is left (dwell time), then drained (fill, dwell and drainage). Use mask and steril gloves • Complications: Peritonitis (cloudy drainage), Dialysis types, assessment, complications, and nursing management. COVERED ABOVE Chapter 62: Burn injuries KNOW signs and symptoms of, inhalation injury, treatment for, nursing management, medications used, diagnostic testing, results, rule of nines, and complications of burns Severity of burns - TBSA% - Depth - Location - Age - Causative agen - Presence of other injuries - Involvement of resp system - Overall health of client: oldies may have poor healing ability due to comorbidities Rule of 9s More than 25%: local and systemic response 25%: local response Depths: 1st degree: Superficial- epidermis ex sunburn - Pink/red, may have pain/blisters but no scars 2nd degree: partial: epidermis, Portions of dermis ex scalds and chemicals - Red white, blisters, edema, scarring 3rd degree: Full thickness: Epidermis, dermis and possible subq and connective tissues ex flame and electric - Pain free, black, white leathery, scarring , eschar, loss of function 4th degree: Full thickness, fat, fascia, muscle and/or bone (prolonged exposure) Physiologic Changes CV: Fluid loss greatest first 24-36 hrs. Anemia DT RBC damage and shock. Fluid shift and shock DT tissue hypoperfusion and organ hypofunction. Then edema forms from increases perfusion and loss of capillary integrity. Electrolytes: hyponatremia from fluid loss causing NA to shift from interstitial to vascular and hyperkalemia from damaged cells (hemolysis). More protein in extravascular space Systemic response: Release of cytokines and other mediators Pulmonary: -Upper airway: May cause obstruction by edema causes by face/neck burns. Other upper airways issues; singed nasal hair, hourse cough, stridor, bloody sputum, labored breathing. -Inhalation below glottis: Loss of ciliary action, hypersecretion, mucosal edema, bronchospasm and atelectasis. Carboxyhemoglobin causes tissue hypoxia Tx: 100% O2 (humidify) Dx: ABG, bronchoscopy Complications: resp failure, ARDS and pneumonia -Renal: prerenal failure DT carbon monoxide= dec urine. (hemoglobin and myoglobin occlude renal tubules. -GI: Paralytic ileus (DT absence of peristalsis and gastric distension) and curlings ulcer (duodenal erosion -Thermoregulation: hypothermia Phases of Burn injury 1. Emergent or resuscitative phase: Onset of injury to completion of fluids 2. Acute/Intermediate phase: Beginning of diuresis to wound closure 3. Rehab: wound closure to return to optial physical and psychosocial Emergent (0-48hr) -Prevent rescuer injury and stop victim injury -ABC -IV access, shock -Wound assessment and initial tx -Hx and stabilize spine -Transfer to burn center: if 10%, full thickness, or burn in area requiring special attn.. Pain relief, indwelling catheter. -Fluid, Foley - 20-25% burn: insert NG and suction - ECG for electrical burn -pain meds IV -support **Mx of shock in emergent phase: Fluid resuscitation determined by UO 0.5-1.0ml/kg/hr goal. Maintain SBP of 100mmhg and UO 30-50ml, Na at near- normal levels. Give colloids (blood/plasma) or crystalloids (Na or LR). IF UO more than 50ml/hr then dec IV rate. Give 50% of fluid in 8hrs and other 50% next 16 hrs. Monitor Na. More fluids for large and delayed burns. Acute/Intermediate phase: Capillaries regain integrity and fluid moves back to intravascular -48-72hrs post injury -Assess and ABC -Prevent infection, wound care, pain mx, nutrition -primary bacterial infection is intestinal tract -Private rooms, use cap, gown, mask, glove -Careful Abx use -Complications: HF, pulm edema, sepsis, ARDS, visceral damage from electrical burns Rehabilitation phase: Started as early as possible -Goal: ROM, prevent contractures through splinting, decrease edema, prevent skin breakdown, ADL -focus is would healing, support, self image, lifestyle, ADL, quality of life -Pt may need reconstructive surgery to improve function and appearance -Compression socks: to promote circulation and encourage parallel orientation of collagen to improve scare formation and improve mobility Chapter 66: Neurological dysfunction KNOW signs and symptoms of, assessment, treatment for, nursing management, medications used, diagnostic testing, and complications of specific disorders: increased ICP, Cushing’s triad, and seizures Increased Intracranial pressure Monro-Kellie Hypothesis: A change in either CSF, tissue or blood in the brain will cause change in volume of the others Cx: injury, diseases, subarachnoid hemorrhages Can lead to: decreased cerebral perfusion, ischemia, cell death and further edema, neuro decline, may shift brain tissue and cause herniation- fatal (compensation to maintain a normal ICP of 10- 15mmHg is accomplished by shifting/displacing CSF -Autoregulation: Brains ability to change diameter of blood vessels to maintain cerebral blood flow. -CO2: Decrease in CO2 results in vasocontriction. Increased CO2=vasodilation=increase in cerebral blood flow and increased CO2. Pg 1943 -Normal ICP 10-15 -Normal CPP (cerebral perfusion pressure) 70-100 . CPP 50=permanent neuro damage -CPP=MAP-ICP S/S: EARLY: Change in LOC, restless, confusion, drowsiness, inc resp effort, purposeless movement, pupillary changes, impaired ocular movement, weakness or 1 side/extremity, HA (constant or inc by movement/straining), blurred vision LATE: Resp and vasomotor changes, increases systolic pressure, widening pulse pressure, slow HR, tachy/brady fluctuations, inc temp, Stupor (reacting only to loud or painful stimuli)-coma, Cheyne-stokes (slow inc in resp then apnea), loss of brainstem reflexes (pupil, gag, corneal, swallowing - Cushing’s triad: Bradycardia/pnea, hypertension. Can lead to decortication, decerebration or flaccidity. NurseMx: Frequent neuro checks, GCS, pupil checks, cranial nerves, VS, ICP, HOB 0-30 as ordered, avoid hip flexion, Valsalva, abd distention (assess q1h). Maintain quiet and no stress. Cluster care to avoid quiet disruption **NO LP because sudden release of pressure can cause brain herniation ICP monitoring: to dec pressure, measure pressure and provide CSF sampling/drainage Tx: -Craniotomy -Osmotic diuretics; mannitol, furosemide (loop to reduce cerebral edema) -corticosteroids -Stool softeners -Dobutamine, levophed to maintain CPP 70 -Fluid restrictions Complications; -Brainstem herniation -Diabetes insipidus (Dec ADH secretions) -SIADH -CSF leak/infections - Reduced cellular metabolic demand to improve oxygenation -Generalized Seizures: Involve the whole brain -Febrile seizures: from infection/neuro decline Cx: Cerebrovascular disease, hypoxemia, head injury, HTN, CVS infections, metabolic/toxic conditions, brain tumor,drug and alcohol withdrawal, allergies, epilepsy, stress, CV dieases in elderly, fever in children. Status Epilepticus: Series of generalized seizures (30mins) causes cerebral anoxia and edema. Life threatening S/s: Partial: shake, slurring, jerking Generalized: tonge biting, tonic (rigidity)-clonic (jerking), drowsiness after convulsion, absent seizures can happen Tx: ABC, Diazepam, Lorazepam, Propofol, Phenytoin, phenobarbital, Valproic acid, gabapentin Mx: ABC, nothing into mouth, do not restrain, keep safe, observe s/s before, during and after seizure. Educations: MedAlert bracelet, Aura alert, med compliance, avoid triggers Chapter 68: Neurologic trauma KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, normal values, results, and complications of specific disorders: head injury, skull fractures, increased ICP, and GCS Head Injury Definition: injury to the scalp, skull or brain commonly causes by MVA. Higest risk in males 15- 24 yr, 5yr and elderly. Anyone with head injury is assumes to have spine injury until rules out (place cervical collar and align spine) Primary brain damage: Due to initial damange (the explosion) - Contusions (bruising), lacerations, damage to blood vessels, object penetrations Secondary Injury: Damage after initial insult over hours and days - Due to cerebral edema, ischemia or chemical changes associated with trauma, Inc ICP, hemorrhage Mx: Depend on location and severity -Scalp wounds: Tend to bleed heavily. Can lead to infections -Skull fracture: break in the continuity of the skull. Open or closed, usually have localized persistent pain. Skull fractures Types - Simple: linear break in bone - Comminuted: Splintered, multiple fracture line - -depressed: Skull bones displaced downward - Basilar: fracture at base of bone; can cause bleed/CSF from nose, pharynx and ears -Battle’s sign: Ecchymosis behind ears (over mastoid) -CSF leak: halo sign; ring of fluid around the blood stain from drainage (AKA rhinorrhea or otorrhea) -Raccon eyes; bilateral periorbital ecchymosis. Assess: LOC, pupillary abnormality, VS, HA, seizures Tx: -Linear: BR, observation -Communiuted and depressed: Surgery in 24 hrs -Basillar: CSF drainage and observe for meningitis Med: Dexamethasone, Abx NurseMx: -Monitor otorrhea, rhinorrhea, halo sign. -don’t blow nose, cough or sneeze; sneeze thru mouth is needed -Aseptic tech for dressing change -Call MD for change in LOC, vomiting, blurred vision, slurred speech, prolonged HA, stiff neck, seizures GCS Chapter 70: Oncologic or degenerative neurologic disorders KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, and complications of specific disorders: Parkinson’s and brain tumors Parkinson’s Disease Definition: Progressively debilitating disease that grossly affects motor function which is caused by decreased levels of dopamine due to destruction of cells in the substantia nigra in the basal ganglia. Other cx include; genetics, atherosclerosis, excess free radicals, viral, head trauma, antipsychotic meds, environment S/s (4 cardinal signs) -Tremor (disappear with movement) -Muscle rigidity -Bradykinesia: Slow movement with shuffling gait -Postural instability : Head bent forward -Others: depression, dementia, autonomic symptoms (sweating, flushing, OH, urinary retention, constipation), sleep issues Dx: Hx, presence of 2 of 4 cardinal signs. Rule out other conditions Mx: Control symptoms and optimize functioning. Levodopa/Carbidopa. Dopamine agonists (bromocriptine) and anticholinerigic (benzotropine) -Thalamotomy and pallidotomy to relieve symptoms by stimulating thalamus to block nerve pathways to decrease tremors but has to be ablated -Deep brain stimulation: stimulates dopamine release NurseMx: Meds on time, assess swallowing, monitor mental/cognitive status, interdisciplinary collaboration with speech, Pt and OT, watch rugs, footwear, unclutter and have well lit rooms. Can be constipated from anticholinergic Improving mobility - ROM - Postural exercises - PT - Frequent rest periods - Proper shoes - Use assistive devices - Daily exercise and stretching - Warm baths/ massages- Brain tumors S/S depend on location, size and compression of associated structures. Pressure on tissue dec CSF, inc ICP, Inc cerebral edema and neurological effects S/s: -Localized/generalized neurologic symptoms -Inc ICP symptoms -HA -Vomiting -Visual disturbances Pituitary adenoma: Hormonal changes Acoustic neuroma: Loss of hearing, tinnitus and vertigo Others: Papilledema (optic disc swelling seen with opthalascope), dysarthria (Slow, slurred speech), dysphagia, vertigo, hemiparesis (1 side weakness), memory changes DX -Neuro exam -CT,PET,MRI,EEG,biopsy,Angiography -Cytological study of cerebral spinal fluid -+Romberg -+ Babinski (Extending toes,fanning) Mx -Depends on type, location and accessibity of tumor -Surgery: tumor removal or decompression to relieve symptoms -Radiation: External bean and brachytherapy (seed insertion) -Chemo -Meds: nonopiod analgesics, corticosteroids, anticonvulsants, H2 antagonists, antiemetics Chapter 71: Infectious disease Infection control and use of precautions Infectious organisms KNOW signs and symptoms of, treatment for, nursing management, medications used, diagnostic testing, normal values, nutrition, and complications of specific disorders: HIV (ABOVE) and syphilis Chapter 72: Emergency nursing Primary survey, ABCDE, Triage Guidelines for Mx - Triage - Primary survey - ABCDE - Poisonings - Cardiac EMG Triage: Sorts pt by hierarchy based on severity of health problems and the immediacy with which these problems must be tx -Emergent: Life threatening injuries -Urgent: Serious, not immediately life threatening. See within 1 hr -Nonurgent: Less severe address within 24 hrs -Fast Track: Simple first aid or basic primary care Primary Survey: Focuses on stabilizing life threatening conditions. Done in 60 seconds -Airway, c-spine -Remove clothing for access -ABCDE: Disability and Exposure: Prevent hypothermia, preserve evidence, place clothing in paper bag ** if trauma then do not cut through/disrupt any tears, blood stains or dirt and place each item in an individual bag. Hang wet clothing to dry Alterations in temp: -Hyperthermia: ABC, cool pt and monitor ECG -Hypothermia: Restore normal temp in controlled mannor Ingested poisoning Tx: - Remove or inactive poison - Maintain vital organ systems - Give antidotes eg acetylcysteine - Monitor for SE of poison or meds - Monitor VS, LOC, ECG, UP - Determine what, when, and how substance ingested - Age/ weight and health history - If antidotes don’t work gastric lavage and activated charcoal - Poison can also be diluted with fluids **Gastric lavage effect if preformed within 1 hr of ingestions. Activated charcoal only works if substance is absorbed with charcoal Nursing management and interventions