Comprehensive Medical Surgical Exam Blueprint (1)

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