NR 340/341 COMPREHENSIVE SUMMARY & STUDY GUIDE

What You Need to Know for NR340/341: 3 bullet points for each topic and subtopic. (You can type for this assignment. Worth 45 points) Please print and keep in your ATI Binder. • Get out your Medical Surgical Books and prepare for Complex Adult Health • Advance Directives o End of Life Care and Issues *The support and medical care given during the time surrounding death. *It is emotionally hard for families to talk about final arrangements, but it is important to let your loved one do this in order to honor their choices. *It is important for the healthcare team to work together in order to manage pain control and symptom control using pharmalogical and nonpharmacological. • Pain Management o Patient Controlled Analgesia *A method of pain control that gives patients the power to control their pain. *A computerized pump called the patient-controlled analgesia pump, which contains a syringe of pain medication as prescribed by a doctor, is connected directly to a patient's intravenous (IV) line. *The patient must be the only one pressing the PCA pump. o Epidural Analgesia *An injection of local anaesthetic alone, or more commonly in combination with pain. *The injection is usually made in the lumber region at the L2/3 or L3/4 space. *The goal of an epidural is to provide analgesia, or pain relief, rather than anesthesia, which leads to total lack of feeling. • Sedation Medications o Benzodiazepines 1. can help to reduce anxiety and seizures, relax the muscles, and induce sleep. 2. long-term use is controversial because of the potential for tolerance, dependence, and other adverse effects. 3. Side effects can include dizziness, drowsiness, poor co-ordination, and feelings of depression. • Respiratory (Anatomy & Physiology, Pathophysiology) o Oxyhemoglobin Dissociation Curve 1. This curve describes the relationship between available oxygen and amount of oxygen carried by hemoglobin. 2. In a left shift condition (alkalosis, hypothermia, etc.) oxygen will have a higher affinity for hemoglobin. 3. In a right shift (acidosis, fever, etc.) oxygen has a lower affinity for hemoglobin. Blood will release oxygen more readily. o ABG analysis 1. pH: 7.35 – 7.45, PaCO2: 4.7-6.0 kPa, PaO2: 11-13 kPa, HCO3-: 22-26 mEg/L 2. An arterial-blood gas test measures the amounts of arterial gases, such as oxygen and carbon dioxide 3. Arterial blood gas test results may show whether: Your lungs are getting enough oxygen, Your lungs are removing enough carbon dioxide, Your kidneys are working properly. o Pulmonary Emboli 1. A condition in which one or more arteries in the lungs become blocked by a blood clot. 2. Symptoms include shortness of breath, chest pain, and cough. 3. Prompt treatment to break up the clot greatly reduces the risk of death. This can be done with blood thinners and drugs or procedures. Compression stockings and physical activity can help prevent clots from forming in the first place. o COPD: Diet and nursing management 1. High protein and increased fluid intake. 2. Limit sodium, to prevent fluid retention, which can worsen SOB. 3. Auscultate breath sounds and assess and monitor respirations/ breath sounds. o Chest Tube management 1. At least every 2 hours, document a comprehensive pulmonary assessment, inspect the dressing and site. 2. As a rule, avoid clamping/kinks in a chest tube. Clamping prevents the escape of air or fluid, increasing the risk of tension pneumothorax. 3. In the event of chest-tube disconnection with contamination, you may submerge the tube 1″ to 2″ below the surface of a 250-mL bottle of sterile water or saline solution until a new CDU is set up. This establishes a water seal, allows air to escape, and prevents air reentry. o Pulse oximetry 1. Medical device that indirectly monitors the oxygen saturation of a patient's blood, probe is placed on finger or ear lobe, probe light measures. 2. May be used for a single reading or continuous monitoring. 3. Used for sleep apnea, during or after surgery or procedures, see how well ventilation is working ect… o Pulmonary edema 1. A condition caused by excess fluid in the lungs. 2. Mild to extreme breathing difficulty can occur. Cough, chest pain, and fatigue are other symptoms. 3. Pulmonary edema is usually caused by a heart condition, pneumonia, exposure to certain toxins and drugs, and being at high elevations. o Cor Pulmonale 1. Causes the right ventricle to enlarge and pump blood less effectively than it should. The ventricle is then pushed to its limit and ultimately fails. 2.Symptoms: shortness of breath, tiredness, an increased heart rate, lightheadedness, chest pain, leg or feet swelling, wheezing, excessive coughing, fainting. 3. Untreated pulmonary hypertension is the most common cause of cor pulmonale. Other conditions include blood clots in lungs, COPD, sleep apnea, CF. o Continuous Positive Airway Pressure 1. A treatment method for patients who have sleep apnea. 2. Also is used to treat infants whose lungs have not fully developed. The CPAP machine blows air into the baby's nose to help inflate his or her lungs. 3. A form of positive airway pressure ventilator, which applies mild air pressure on a continuous basis to keep the airways continuously open in people who are able to breathe spontaneously on their own. o Tracheostomy Care 1. Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. Signs for suctioning: audible/visible secretions, signs of respiratory distress, desaturations on pulse oximetry. 2. Humidification must be replaced with fluids, saline bullets, humidifier in room or humidifier attached by trach collar. Without moisture, your mucus may become thick and hard to cough out. This will make breathing difficult. 3. If tracheostomy tube has an inner cannula, it is important to remove and clean the inner cannula or tube often. If tracheostomy has a disposable inner cannula, change it according to your health care provider’s instructions. o Airway devices: Low flow vs. High flow devices 1. Low-flow oxygen delivery systems consist of nasal cannula, nasal catheters, and trans tracheal catheters. 2. High-flow oxygen delivery systems consist of venturi mask, an air-entrainment or a blending system, aerosol generating device 3. A nasal cannula is not recommended for acute severe hypoxemia. • Cardiac (Anatomy & Physiology, Pathophysiology) o Blood Pressure Management, Cardiac Output 1. Cardiac output is simply the amount of blood pumped by the heart per minute. 2. Eating a diet that is rich in whole grains, fruits, vegetables and low-fat dairy products and skimps on saturated fat and cholesterol can lower your blood pressure 3. Drinking more water, adding more salt to diet, compression stockings are ways to increase blood pressure. o Rhythm interpretation (NSR, SB, ST, A fib, VT, VF, asystole) 1. NSR---- 2. SB------ 3. ST------ 4. A fib---- 5. VT--- --- 6. VF------ 7. asystole- o STEMI vs. NSTEMI 1. STEMI is a common name for ST-elevation myocardial infarction, which is a more precise definition for a type of heart attack. It's caused by a prolonged period of blocked blood supply that affects a large area of the heart. STEMI has a substantial risk of death and disability and calls for a quick response. An ECG will show elevated ST wave. Full blockage of the coronary artery. 2. NSTEMI stands for Non-ST-elevation myocardial infarction. Sometimes an NSTEMI is known as a non-STEMI. An ECG will show depressed ST wave or T-wave inversion this is known as a NSTEMI. Typically less damaging to your heart. Partial blockage of the coronary artery. 3. Although the clinical presentation and symptoms of NSTEMIs and STEMIs are the same, their waves look very different on an ECG. o cardiac enzymes 1. Myoglobin is released into circulation with any damage to muscle tissue, including myocardial necrosis. The benefit in myoglobin is that a detectable increase is seen only 30 minutes after injury occurs. 2. The enzymes troponin I and troponin T are normal proteins that are important in the contractile apparatus of the cardiac myocyte. The proteins are released into the circulation between 3 and 4 hours after myocardial infarction and remain detectable for 10 days following. 3. Creatine kinase ― also known as creatine phosphokinase, or CPK ― is a muscle enzyme that exists as isoenzymes. The CK level increases approximately 3 to 4 hours after MI and remains elevated for 3 to 4 days. o 12 Lead Findings for MI 1. A pathological Q wave is a Q wave that is more than 0.04 seconds in duration and more than 25% of the size of the following R waves in that lead (except for leads III and aVR). 2. One of the most significant findings of myocardial infarction is the presence of ST segment elevation. If the J point is greater than 2 mm above the baseline, it is consistent with an ST segment elevation myocardial infarction. 3. It is not possible to diagnose a non-ST segment elevation myocardial infarction by ECG alone. Patients are treated presumptively and diagnosis is made if the level of serum cardiac markers rise over several hours. o Heart Failure (Left vs. Right)  BNP 1. also known as B-type natriuretic peptide, is a hormone secreted by cardiomyocytes in the heart ventricles in response to stretching caused by increased ventricular blood volume. 2. BNP levels are higher than normal when you have heart failure. 3. High cardiac output states: Conditions such as sepsis, cirrhosis, and hyperthyroidism, which are associated with high cardiac output, may cause elevated levels of b type natriuretic peptides  echocardiogram with EF% 1. During an echocardiogram, sound waves are used to produce images of your heart and the blood pumping through your heart. This is the most common method to assess ejection fraction. 2. Ejection fraction is a measurement of the percentage of blood leaving your heart each time it contracts. 3. The left ventricle is the heart's main pumping chamber that pumps oxygenated blood through the ascending aorta to the rest of the body, an LV ejection fraction of 55 percent or higher is considered normal.  Cardiomyopathy 1. An acquired or hereditary disease of heart muscle, chambers become enlarged, this condition makes it hard for the heart to deliver blood to the body, and can lead to heart failure. 2. Symptoms include breathlessness, swollen legs and feet, and a bloated belly. 3. Drugs, implanted devices, surgery, and in severe cases, transplant, are treatments. o Valvular Disorders 1. Aortic stenosis: Narrowing of the aortic valve, obstructing blood flow from the left ventricle to the ascending aorta during systole 2. Pulmonic regurgitation: Insufficiency of the pulmonic valve causing blood flow from the pulmonary artery into the right ventricle during diastole 3. Pulmonic stenosis: Narrowing of the pulmonary outflow tract causing obstruction of blood flow from the right ventricle to the pulmonary artery during systole o Mean Arterial Pressure (MAP) 1. It is used to explain average blood pressure in a person during a single cardiac cycle. The actual pressure of blood against the arterial walls. 2. Normal MAP ranges are between 70 and 110 mm Hg. 3. When MAP falls below 60 for a considerable amount of time, organs may become deprived of the oxygen they need. o Angiogram: 1. A procedure that uses X-ray imaging to see your heart's blood vessels. The test is generally done to see if there's a restriction in blood flow going to the heart. 2. Because there's a small risk of complications, angiograms aren't usually done until after noninvasive heart tests have been performed, such as an electrocardiogram, an echocardiogram or a stress test. 3. Dye that's visible by an X-ray machine is injected into the blood vessels of your heart. The X-ray machine rapidly takes a series of images (angiograms), offering a look at your blood vessels.  cardiac catheterization 1. A procedure used to diagnose and treat cardiovascular conditions. A long thin tube called a catheter is inserted in an artery or vein in your groin, neck or arm and threaded through your blood vessels to your heart. 2. Cardiac catheterization is done to see if you have a heart problem, or as a part of a procedure to correct a heart problem your doctor already knows about. 3. Risks of cardiac catheterization are: Bruising, Bleeding, Heart attack, Stroke, Damage to the artery where the catheter was inserted, irregular heart rhythms (arrhythmias).  contrast dye concerns 1. Patients with impaired kidney (renal) function should be given special consideration before receiving iodine-based contrast materials by vein or artery. Such patients are at risk for developing contrast-induced nephropathy, in which the pre-existing kidney damage is worsened. 2.Pregnant patients should have a discussion with her referring physician and radiologist to understand the potential risks and benefits of the contrast-enhanced scan. 3. Some conditions increase the risk of an allergic or adverse reaction to iodine-based contrast materials. Such as previous adverse reactions to iodine-based contrast materials, history of asthma, history of allergy, dehydration, medications such as beta blockers or NSAIDs.  Care for a patient following angiogram. 1. Patients need to lie flat for several hours to avoid bleeding if the catheter was inserted in the groin. During this time, pressure may be applied to the incision to prevent bleeding and promote healing. 2. Patients should drink plenty of fluids to help flush the dye from their body. 3. Assess pressure dressing frequently, may be kept on for at least one day. o Medications:  β-Blockers 1. Beta-blockers work by blocking the effects of epinephrine (adrenaline) and slowing the heart's rate, thereby decreasing the heart’s demand for oxygen. 2. Sudden withdrawal can worsen angina and cause heart attacks. 3. Side effects of beta-blockers are common but usually mild: fatigue, cold hands, diarrhea, headache, SOB, depression.  ACE Inhibitors 1. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that narrows your blood vessels and releases hormones that can raise your blood pressure. 2. Possible ACE inhibitor side effects include: Dry cough, hyperkalemia, fatigue, dizziness, headaches. 3. ACE inhibitors can cause some areas of your tissues to swell (angioedema). If it occurs in the throat, the swelling can be life-threatening.  Anticoagulation meds with labs 1. Heparin requires close monitoring because of its narrow therapeutic index, increased risk for bleeding, and potential for heparin-induced thrombocytopenia. Monitoring includes thorough head-to-toe patient assessments for potential side effects, and laboratory monitoring. 2. The aPTT is most commonly used as a global measure of a patient’s overall anticoagulation. 3. The International Normalized Ratio (INR) is the recommended method for monitoring warfarin, and the target goal is set by the provider, based on clinical indication.  fluid volume concerns 1. Dehydration is defined as a 1% or greater loss of body mass as a result of fluid loss, where the body has less water than it needs to function properly. Symptoms include impaired cognitive function, headache, fatigue, and could lead to hypotension/ tachycardia. 2. Excessive fluid volume arises when there is retention of both electrolytes and water in proportion to the levels in the extracellular fluid. Patients with acute fluid overload may present with a sudden onset of acute dyspnea secondary to pulmonary edema (accumulation of fluid in the lungs). 3. Capillary refill time (CRT) is a good measure of the fluid present in the intravascular fluid volume.  Digoxin 1. Used to treat heart failure, a fib, SVT, cardio myopathy, arrhythmias. 2. May cause headaches or dizziness. 3. It is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat. This leads to better blood circulation and reduced swelling of the hands and ankles in patients with heart problems.  Nitroglycerin (vasodilators) 1. Nitroglycerin is used to prevent angina (chest pain) caused by coronary artery disease. This medicine is also used to relieve an angina attack that is already occurring. 2. The extended-release capsules are used every day on a specific schedule to prevent angina attacks. The oral spray, sublingual powder, and sublingual tablets work quickly to stop an angina attack that has already started or they can be used to prevent angina if you plan to exercise or expect a stressful event. 3. It works by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its work load.  Vasoconstrictors 1. Vasoconstrictor drugs cause contraction of muscle cells in the walls of blood vessels, narrowing their internal diameter and raising blood pressure. 2. Given for hypotension, shock, renal perfusion, bronchospasms and allergic reactions. 3. When administering vasoconstrictors it is important to monitor vitals, cardiac rhythm, pulses. • Gastrointestinal (Anatomy & Physiology, Pathophysiology) o Peptic Ulcer Disease 1. Ulcers occur when stomach acid damages the lining of the digestive tract. 2. Common causes include the bacteria H. Pylori and anti-inflammatory pain relievers including aspirin. 3. Upper abdominal pain is a common symptom.  Gastric vs. Duodenal 1. Upper part of the small intestine (duodenal). 2. inside of the stomach lining (gastric) 3. Other risk factors known to increase your risk for developing gastric and duodenal ulcers include: being 70 years old or older, drinking alcohol, history of peptic ulcers, and smoking, untreated stress.  stress ulcers 1. A stress ulcer is a single or multiple mucosal defect which can become complicated by upper gastrointestinal bleeding during the physiologic stress of serious illness. 2. Stress ulcer can be diagnosed after the initial management of gastrointestinal bleeding, the diagnosis can be confirmed by upper GI endoscopy. 3. The presence of a stress ulcer adds another complication to your other medical conditions that lead to the ulcer. o Esophagogastroduodenoscopy: EGD 1. A procedure to diagnose and treat problems in your upper GI (gastrointestinal) tract. The tube is put into your mouth and throat. Then it is slowly pushed through your esophagus and stomach, and into your duodenum. 2. Some possible complications that may occur with an upper GI endoscopy are: infection, bleeding, a tear in the lining (perforation) of the duodenum, esophagus, or stomach. 3. Patient will not be allowed to eat or drink anything until their gag reflex returns. This is to prevent choking. o Role of the Liver 1. The liver's main job is to filter the blood coming from the digestive tract, before passing it to the rest of the body. 2. The liver also detoxifies chemicals and metabolizes drugs. 3. The liver also makes proteins important for blood clotting and other functions.  Portal system 1. The hepatic portal system consists of numerous veins and tributaries, including the hepatic portal vein. 2. The portal venous system drains blood from the gastrointestinal tract to the liver, this means that any compounds and substances that are absorbed from the small intestines will pass through the liver before going back to the heart. 3. Large veins that are considered part of the portal venous system are the: hepatic portal vein, splenic vein, superior mesenteric vein, inferior mesenteric vein. o Liver failure 1. Loss of liver function, occurs suddenly or gradually. 2. Causes include a reaction to a medication, high doses of acetaminophen, hepatitis infection, alcohol abuse, and advanced fatty liver. 3. Yellowed skin and eyes (jaundice) along with belly pain and swelling are symptoms of liver failure.  Cirrhosis 1. Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism. 2. The liver damage done by cirrhosis generally can't be undone. But if liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited and, rarely, reversed. 3. The most common causes are: Chronic alcohol abuse Chronic viral hepatitis (hepatitis B and C), Fat accumulating in the liver (nonalcoholic fatty liver disease).  Hepatitis 1. Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. You're most likely to get hepatitis A from contaminated food or water or from close contact with a person or object that's infected. 2. Hepatitis B is a serious liver infection caused by the hepatitis B virus (HBV). The virus is passed from person to person through blood, semen or other body fluids. It does not spread by sneezing or coughing. 3. Hepatitis C infection is caused by the hepatitis C virus. The infection spreads when blood contaminated with the virus enters the bloodstream of an uninfected person. • Labs: o Bilirubin 1. If your bilirubin levels are higher than normal, it’s a sign that either your red blood cells are breaking down at an unusual rate or that your liver isn’t breaking down waste properly and clearing the bilirubin from your blood. 2. An orange-yellow substance made during the normal breakdown of red blood cells. Bilirubin passes through the liver and is eventually excreted out of the body. 3. Lower than normal bilirubin levels are usually not a concern. o Albumin 1. You need a proper balance of albumin to keep fluid from leaking out of blood vessels. Albumin gives your body the proteins it needs to keep growing and repairing tissue. It also carries vital nutrients and hormones. 2. Having surgery, getting burned, or having an open wound raises your chances of having a low albumin level. 3. An abnormal serum albumin level, may be a sign that your liver or kidneys aren’t working correctly. It could also mean that you have a nutritional deficiency. o AST, ALT 1. The normal range of values for AST is about 5 to 40 units per liter of serum (the liquid part of the blood). 2. The normal range of values for ALT is about 7 to 56 units per liter of serum. 3. These enzymes are normally predominantly contained within liver cells and to a lesser degree in the muscle cells. If the liver is injured or damaged, the liver cells spill these enzymes into the blood, raising the AST and ALT enzyme blood levels and signaling liver disease. o Alkaline Phosphatase 1. The normal range of alkaline phosphatase in blood is 20 to 140U/L, although this can vary from lab to lab. 2. Elevated levels are associated with cancer, bone, liver, and kidney diseases 3. Alkaline phosphatase helps with bone and teeth mineralization o Ammonia 1. Most ammonia in the body forms when protein is broken down by bacteria in the intestines. The liver normally converts ammonia into urea, which is then eliminated in urine. 2. Ammonia levels increase when the liver is not able to convert ammonia to urea. This may be caused by cirrhosis or severe hepatitis or reyes syndrome, heart failure, kidney failure. 3. 9.5-49 micrograms per deciliter (mcg/dL) (NORMAL)  Portal HTN 1. Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. 2. This increased pressure in the portal vein may lead to the development of large, swollen veins (varices) within the esophagus, stomach, rectum, or umbilical area (belly button). Varices can rupture and bleed, resulting in potentially life-threatening complications. 3.Causes: Cirrhosis, blood clots, schistosomiasis, or unknown.  Hepatic encephalopathy 1. A condition that causes temporary worsening of brain function in people with advanced liver disease, when a damaged liver doesn't remove toxins from the blood. 2. Early symptoms include forgetfulness, confusion, and breath with a sweet or musty odor. Advanced symptoms include shaking of the hands or arms, disorientation, and slurred speech. 3. Treated with ammonia reducer, antibiotics, electrolyte repletion.  Esophageal Varices and balloon tamponade 1. EV- Abnormal veins in the lower part of the tube running from the throat to the stomach. 2. Esophageal varices usually develop when blood flow to the liver is blocked. They often occur in people with advanced liver disease. 3. When inserted into the esophagus or stomach, balloon catheters are intended to stop bleeding such as from vascular structures—including esophageal varices and gastric varices—in the upper gastrointestinal tract.  GI Bleed (Hemoglobin) 1. Also known as gastrointestinal hemorrhage, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. 2. Significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. 3. Low hemoglobin levels are associated with upper gastrointestinal bleeding  Proton Pump Inhibitors 1. Main action is a pronounced and long-lasting reduction of stomach acid production. 2. Used to prevent GERD, heal inflammation in the esophagus. 3. Work best when they are taken 30 minutes before your first meal of the day.  Total Parental Nutrition and Peripheral Parental Nutrition 1. Nursing actions: daily weights, I & O’s, Glucose checks, monitor electrolytes. 2. If it is administered into the largest vein in your body, the Superior Vena Cava, and it provides the majority of your nutritional needs, it is called Total Parenteral Nutrition (TPN). 3. If the nutritional solution is given into veins outside the Superior Vena Cava, it is called Peripheral Parenteral Nutrition, or PPN.  Enteral Feeding 1. Delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach, duodenum or jejunum. 2. Should be considered for malnourished patients or those at risk of malnutrition who have a functional gastrointestinal tract but are unable to maintain an adequate or safe oral intake. 3. Access through nosogastric NG, nasojejunal NJ, Percutaneous endoscopic gastrotomy PEG. o Pancreatitis: labs and diet 1. Blood tests to look for elevated levels of pancreatic enzymes, stool test to measure levels of fat. 2. You'll stop eating for a couple of days in the hospital in order to give your pancreas a chance to recover. 3. Diet: increase fluids, choose a low fat diet rich in fresh fruits/vegetables/whole grains/ lean protein. • Neurological (Anatomy & Physiology, Pathophysiology) o Increased Intracranial Pressure: patient management 1. Mannitol can also be used and works through osmotic diuresis, that is it draws the edema out of the cerebral tissues to decrease ICP. It also improves blood flow. 2. Monitor early S/S: Disorientation, purposeless movements, pupillary changes, weakness in one extremity or hemiplegia, headache (constant). 3. Methods to reduce the pressure from increasing further include elevating the patient’s head to thirty degrees, keeping their neck in a neutral position, avoid over hydration, maintain a normal body temperature and maintain a normal oxygen and carbon dioxide level.  Cushing’s Triad 1. Signs: Hypertension and a widening pulse pressure (the difference between the systolic and diastolic BP), Bradycardia, Bradypnoea. 2. Cushing’s triad is seen when increased ICP decreases the cerebral blood flow significantly. A response is triggered that increases arterial pressure in order to overcome the increased ICP. 3. If treatment does not occur to stabilize the ICP, herniation of the brain stem and occlusion of the cerebral blood flow can occur with dire consequences o Glasgow Coma Scale 1. Provides a practical method for assessment of impairment of conscious level in response to defined stimuli. GCS of < 15 warrant close attention and reassessment. 2. A declining GCS is concerning in any setting and should prompt assessment of the airway and possible intervention. 3. Clinical management decisions should not be based solely on the GCS score in the acute setting. o Neurological Assessment 1. Assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. 2. Mental status testing, cranial Nerves, muscle strength/tone/bulk, reflexes coordination, sensory function, gait. 3. May be done; During a routine physical, Following any type of trauma, To follow the progression of a disease. o Subdural and Epidural Hematoma 1. Epidural bleeding occurs between the skull and dura 2. Subdural bleeding occurs between the dura and arachnoid (often life threatening) 3. Both caused by trauma or other injury to your head o Basilar Skull Fracture (signs and symptoms) 1. A basal fracture occurs in the floor of the skull: the areas around the eyes, ears, nose, or at the top of the neck, near the spine. 2. Symptoms that can indicate a fracture include: swelling and tenderness around the area of impact, facial bruising, bleeding from the nostrils or ears. 3. Basilar skull fractures tend to more likely affect younger and most active part of population in the ages of 20 to 50 years. Males at higher risk. o Seizures 1. can cause changes in your behavior, movements or feelings, and in levels of consciousness. 2. S/S; Uncontrollable jerking movements of the arms and legs, A staring spell, Temporary confusion, Loss of consciousness or awareness, Cognitive or emotional symptoms, such as fear, anxiety or déjà vu. 3. The most common cause of seizures is epilepsy. Sometimes seizures happen because of: high fever, lack of sleep, low blood sodium, trauma, and brain tumor.  Status Epilepticus 1. When a seizure last too long or when epileptic seizures follow one another without recovery of consciousness between them. 2. Nonconvulsive Status Epilepticus, This term is used to describe long or repeated absence or focal impaired awareness (complex partial) seizures. 3. Convulsive Status Epilepticus, This term is used to describe the more common form of emergency situation that can occur with prolonged or repeated tonic-clonic (also called convulsive or grand mal) seizures. Most tonic-clonic seizures end normally in 1 to 2 minutes, but they may have post-ictal (or after-effects) symptoms for much longer. This makes it hard to tell when a seizure begins and ends. o Spinal Cord Injury (Level of Cord Involvement) 1. Complete, all motor function below injury lost. Incomplete some function sill present below affected area. 2. Tetraplegia. Also known as quadriplegia, this means your arms, hands, trunk, legs and pelvic organs are all affected by your spinal cord injury. 3. Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs.  Autonomic Dysreflexia: patient management 1. It makes your blood pressure dangerously high and, coupled with very low heartbeats, can lead to a stroke, seizure, or cardiac arrest. 2. Frequent vital monitoring, especially BP. Frequent urination. Monitor for s/s of infection. Proper skin care and turns to avoid sores. 3. Patient should sit up as much as possible. • Immune System o Difference between immune and inflammatory reaction 1. Immune: recognition and binding of an antigen by its specific antibody or by a previously sensitized lymphocyte. 2. Inflammatory: occurs when tissues are injured by bacteria, trauma, toxins, heat, or any other cause. The damaged cells release chemicals including histamine, bradykinin, and prostaglandins. These chemicals cause blood vessels to leak fluid into the tissues, causing swelling. 3. S/S inflammatory: pain, heat, redness, swelling, loss of function. S/S of Immune, itching or hives, swelling of throat or tongue, SOB, dizziness, nausea. o Labs: WBC (High and Low) 1. Low: (leukopenia) may be caused by autoimmune disorder, bone marrow problems or cancer, certain medications, viral illness, radiation exposure. 2. High: may have an infection or inflammation, immune system disorder or a bone marrow disease, reaction to medication, acute stress, trauma, pregnancy. 3. Doctor may ask you to stop taking certain medications, including over-the-counter supplements or vitamins, for several days before the sample collection occurs.  Vancomycin 1. Commonly used for c. diff and staph aureus. 2. Side effects; abd pain, nausea, vomiting. 3. Serious side effects, allergic reaction, ringing in the ears, hearing loss, change in amount if urine. o Virus vs. Bacterial infection 1. Virus: common cold, flue, sore throat… no antibiotics. 2. Bacteria: strep throat, TB, whooping cough, UTI… yes antibiotics. 3. Virus are host that invade your body to stay alive, have a vaccine to prevent.  Tuberculosis (meds, labs, isolation) 1. PPD skin test, QuantiFERON-TB Gold in-Tube test and T-Spot 2. Isoniazid, Rifampin (Rifadin, Rimactane), Ethambutol (Myambutol) Pyrazinamide 3. Airborne precautions • Endocrine (Anatomy & Physiology, Pathophysiology) o Diabetes Mellitus (Type 1 & 2) 1. Result in too much sugar in the blood (high blood glucose). 2. Type 2, non-insulin dependent, make insulin, but their cells don't use it as well as they should. Doctors call this insulin resistance. 3. Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin.  Insulin and PO medication management of blood sugar 1. The goal is to keep your daytime blood sugar levels before meals between 80 and 130 mg/dL and your after-meal numbers no higher than 180 mg/dL two hours after eating. 2. Insulin, given after glucose check. Short acting, rapid acting, intermediate acting, long acting, all given through needle or insulin pump. 3. PO meds such as metformin or rosiglitazone cause liver to produce less glucose.  Important Patient education 1. Healthy diet and exercise for both. 2. Low blood sugar: Have 15 to 20 grams of a fast-acting carbohydrate, retest in 15 min, if still low have another snack 15-20 grams, repeat. 3. Early s/s of low blood sugar; sweating, shakiness, hunger, dizziness, fatigue, blurred vision, irritability. o Diabetic Keto-acidosis: causes, signs & symptoms 1. Causes: An infection or other illness, Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system. 2. S/S excessive thirst, frequent urination, nausea, abd pain, SOB, fruity scented breath, confusion. 3. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.  Treatment for DKA 1. FR: fluids will replace those you've lost through excessive urination, as well as help dilute the excess sugar in your blood. 2. ER: electrolytes through a vein to help keep your heart, muscles and nerve cells functioning normally. 3. Insulin reverses the processes that cause diabetic ketoacidosis, until blood is no longer acidotic.  Labs 1.Glucose check- check blood sugar level 2.Urine analysis- check for ketones 3. Blood electrolyte tests- check blood acidity o Hyperosmolar Hyperglycemic Syndrome: causes, signs & symptoms 1. A complication of type 2 diabetes. It involves extremely high blood sugar (glucose) level without the presence of ketones. 2. Extremely high blood sugar (glucose) level>600. Extreme lack of water, Decreased alertness or consciousness, infection, heart attack or stroke. 3. S/S: weight loss, increased thirst, dry mouth and tongue, confusion, weak, nausea, fever, seizures.  Treatment for HHS 1. At the start of treatment, the goal is to correct the water loss. This will improve the blood pressure, urine output, and circulation. Blood sugar will also decrease. 2. Fluids and potassium will be given through a vein (intravenously) 3. High glucose level is treated with insulin given through a vein.  Labs 1. Blood osmolality, concentration. 2. Keytone test 3.Sodium, BUN, creatinine. o Cushing’s Disease/Syndrome (adrenal cortex and cortisol) 1. The most common cause is the use of steroid drugs, but it can also occur from overproduction of cortisol by the adrenal glands. 2. Signs are a fatty hump between the shoulders, a rounded face, and pink or purple stretch marks. 3. Treatment options include reducing steroid use, surgery, radiation, and medication. o Addison’s Disease (adrenal cortex and cortisol) 1. adrenal glands produce insufficient amounts of the hormone cortisol and sometimes aldosterone, too. 2. this deficiency of cortisol can result in a life threatening Addisonian crisis characterized by low blood pressure. 3. Symptoms tend to be non-specific and include fatigue, nausea, darkening of the skin, and dizziness upon standing. 4. Treatment involves taking hormones to replace those not produced by the adrenal glands. o Hyperthyroid: 1. The production of too much thyroxine hormone. It can increase metabolism. 2. Symptoms include unexpected weight loss, rapid or irregular heartbeat, sweating, and irritability, although the elderly often experience no symptoms. 3. Treatments include radioactive iodine, medications, and sometimes surgery.  Labs 1. Blood test: TSH 2.Readio iodine uptake test 3. H and P, thyroid scan  Medications 1. beta blockers 2. radioactive iodine 3. ropylthiouracil and methimazole o Hypothyroid: 1. A condition in which the thyroid gland doesn't produce enough thyroid hormone. 2. Major symptoms include fatigue, cold sensitivity, constipation, dry skin, and unexplained weight gain. 3. Untreated hypothyroidism can cause a number of health problems, such as obesity, joint pain, infertility and heart disease.  Labs 1. Blood test TSH 2. A low level of thyroxine and high level of TSH indicate an underactive thyroid. 3. Follow with a thyroid hormone test if needed.  Medications 1. Daily use of the synthetic thyroid hormone levothyroxine (Levothroid, Synthroid, others). 2. Treatment with levothyroxine is usually lifelong, but because the dosage you need may change, your doctor is likely to check your TSH level every year. 3.Benefits of treatment may take 1-2 weeks. o Diabetes Insipidus 1. A disorder of salt and water metabolism marked by intense thirst and heavy urination. The condition is caused by a hormonal abnormality and isn't related to diabetes. 2. Complications: dehydration and electrolyte imbalance. 3. Depending on the form of the disorder, treatments might include hormone therapy, a low-salt diet, or drinking more water. o Syndrome of Inappropriate ADH 1. In this condition, the body retains water instead of excreting it normally in urine. This process upsets the body's balance of minerals called electrolytes, especially sodium. 2. Nausea and vomiting, headache, confusion, weakness, and fatigue may be experienced. 3. Treatments include fluid restriction and, possibly, medications to adjust electrolyte balance. • Renal (Anatomy & Physiology, Pathophysiology) o Intake and Output 1.Output should be at least 30 ml an hour 2. Output measured by graduated cylinder, hats, Foley caths. 3.All fluid measured, food, drink, medications. o Erythropoietin 1. Erythropoietin promotes the formation of red blood cells by the bone marrow. 2. Erythropoietin (EPO) is a hormone produced by the kidney. 3. Promote the development of red blood cells. Initiate the synthesis of hemoglobin, the molecule within red blood cells that transports oxygen. o Transurethral resection of the Prostate (TURP) 1. A surgery used to treat urinary problems due to an enlarged prostate. 2. TURP is generally considered an option for men with moderate to severe urinary problems that haven't responded to medication. 3. Avoid strenuous activity, such as heavy lifting, for four to six weeks or until your doctor says it's OK. Also Sex. o Acute and Chronic Renal Failure 1. Acute kidney failure can occur when: You have a condition that slows blood flow to your kidneys, You experience direct damage to your kidneys Your kidneys' urine drainage tubes (ureters) become blocked and wastes can't leave your body through your urine. 2. Diseases and conditions that cause chronic kidney disease include: Type 1 or type 2 diabetes, High blood pressure, glomerulonephritis, PKD, Obstruction of UT, kidney infection. 3. Chronic kidney disease can progress to end-stage kidney failure, which is fatal without artificial filtering (dialysis) or a kidney transplant.  Diet and Patient management 1.Assess I and O’s , monitor weight. 2. Low sodium, low phosphorus. 3.Avoid processed meats  Prerenal, Intrarenal and Postrenal causes of renal failure 1.Pre, caused by decreased renal perfusion, often because of volume depletion) 2.Intra, (caused by a process within the kidneys) 3.Post, (caused by inadequate drainage of urine distal to the kidneys)  Labs: • BUN/Creatinine 1. When kidney function slows down, the BUN & creatinine level rises 2. Creatinine is a waste product in your blood that comes from muscle activity. 3. Urea nitrogen is a normal waste product in your blood that comes from the breakdown of protein from the foods you eat and from your body metabolism. • GFR, 1. Your GFR tells how much kidney function you have. It may be estimated from your blood level of creatinine. 2. If your GFR falls below 30 you will need to see a kidney disease specialist 3. GFR below 15 indicates that you need to start treatment • Potassium, Sodium, Phosphorus, Calcium 1. Whether you need to change the amount of high- potassium foods in your diet depends on your stage of kidney disease. 2. If your level is too high, your doctor may ask you to reduce your intake of foods that are high in phosphorus 3. To help balance the amount of calcium in your blood, your doctor may ask you to take calcium supplements and a special prescription form of vitamin D. 4. A potassium level that is too high or too low may weaken muscles and change your heartbeat. Ask doctor about potassium level.  Dialysis 1. removing waste, salt and extra water to prevent them from building up in the body, helps control BP 2. keeping a safe level of certain chemicals in your blood, such as potassium, sodium and bicarbonate 3. You need dialysis when you develop end stage kidney failure --usually by the time you lose about 85 to 90 percent of your kidney function and have a GFR of <15.  Renin Angiotensin Aldosterone System 1. The most important system involved in the regulation of systemic blood pressure, renal blood flow and glomerular filtration rate 2. Renin is an enzyme released by the juxtaglomerular cells of the kidneys in response to low blood pressure. 3. Renin catalyzes a reaction that converts the angiotensinogen protein into angiotensin I, which is a precursor hormone that is converted to an active hormone called angiotensin II by an enzyme known as angiotensin-converting enzyme in the lungs  Hemodialysis vs. Peritoneal dialysis 1. H: hemodialyzer is used to remove waste and extra chemicals and fluid from your blood. Access is made by joining an artery to a vein under your skin to make a bigger blood vessel called a fistula. 2. P: Peritoneal cavity is slowly filled with dialysate through a placed catheter. The blood stays in the arteries and veins that line your peritoneal cavity. Extra fluid and waste products are drawn out of your blood and into the dialysate. 3. Average life expectancy on dialysis is 5-10 years, however, many patients have lived well on dialysis for 20 or even 30 years. • Care of access devices 1.Fistula, monitor for swelling and redness, keep clean (before and after treatments), no BP in fistula arm, notify physician of any pain or fever. 2.Exit site for peritoneal dialysis should be ekpt dry, avoid local trauma, normal saline and pure soap to clean, monitor for infection. 3.PD: In addition to aseptic techniques, routine antibiotics may be recommended by the physician to further prevent bacterial infections. o Glomerulonephritis 1. Inflammation of glomeruli remove excess fluid, electrolytes and waste from your bloodstream and pass them into your urine. 2.S/S: Pink or cola-colored urine from red blood cells in your urine (hematuria), Foamy urine due to excess protein (proteinuria), HTN, edema. 3.Causes: Post-streptococcal glomerulonephritis. Bacterial endocarditis. Viral infections. • Hematology (Anatomy & Physiology, Pathophysiology) o Erythropoiesis 1. Process by which new RBC's are produced 2. Takes about 4 days 3. All blood cells are formed in the bone marrow. This is the erythrocyte factory, which is soft, highly cellar tissue that fills the internal cavities of bones. o Anemia 1. A deficiency of hemoglobin in blood due to a decrease in number of erythrocytes, a decrease in the amount of hemoglobin, or both. 2. Symptoms may include fatigue, skin pallor, shortness of breath, lightheadness, dizziness, or a fast heartbeat. 3. Iron supplements may be used for iron deficiency. Vitamin B supplements maybe used for low vitamin levels. Blood transfusions may be used for blood loss. Medications to induce blood formation may be used if the body’s blood production is reduced.  Labs: • Hemoglobin, 1. If hemoglobin is abnormal or low, the cells in your body will not get enough oxygen. 2. For men, anemia is typically defined as hemoglobin level of less than 13.5 gram/100 ml 3. For women as hemoglobin of less than 12.0 gram/100 ml. • Platelets, 1. Thrombocytopenia, When you don't have enough platelets in your blood, your body cannot form clots. 2. less than 150,000 platelets per microliter 3. Platelets, in general, have a brief lifespan in the blood (7 to 10 days), after which they are removed from circulation. • WBC 1. 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L) 2.Decreased in anemia 3. Leukopenia is the medical term used to describe a low WBC count.  Foods high in iron  1. Iron-enriched pastas, grains, rice, and cereals  2. Fish, especially shellfish, sardines, and anchovies  3. Meat: beef, pork, or lamb, especially organ meats such as liver o Clotting Cascade 1. Each step produces a new protein which acts as an enzyme, or catalyst, for the next step 2. The extrinsic pathway is triggered by a chemical called tissue factor that is released by damaged cells. 3. The intrinsic pathway is triggered by blood coming into contact with collagen fibers in the broken wall of a blood vessel. 4. Both pathways eventually produce a prothrombin activator. The prothrombin activator triggers the common pathway in which prothrombin becomes thrombin followed by the conversion of fibrinogen to fibrin. o Blood Transfusion process 1. A blood transfusion is a routine medical procedure in which donated blood is provided to you through a narrow tube placed within a vein in your arm. 2. This potentially life-saving procedure can help replace blood lost due to surgery or injury. A blood transfusion also can help if an illness prevents your body from making blood or some of your blood's components correctly. 3.  Reaction 1. More common reactions include allergic reactions, which might cause hives and itching, and fever. 2. Acute immune hemolytic reaction. Your immune system attacks the transfused red blood cells because the donor blood type is not a good match. 3. Graft-versus-host disease. In this condition, transfused white blood cells attack your bone marrow. • Blood Type 1.A, B, AB, O 2. In addition, each person's blood is either:Rh-positive, or Rh-negative. 3. Type O negative blood is safe for just about everyone. People with type O negative blood are referred to as universal donors.  Blood Products: o PRBCs 1. Also known as red cell concentrate and packed cells, are red blood cells that have been separated for blood transfusion. 2. Packed red blood cells are typically given in situations where the patient has either lost a large amount of blood or has anemia that is causing notable symptoms. 3. In an adult patient without an increase in red cell destruction, administration of one unit of packed red cells increases the hematocrit or Hb concentration by about 3% or 1 g/dL respectively o Platelets 1. Platelets are tiny blood cells that help your body form clots to stop bleeding. 2. A normal platelet count is 150,000 to 450,000 platelets per microliter of blood. 3. o FFP 1. 2. 3. o Albumin 1. 2. 3. o Disseminated Intravascular Coagulation 1. 2. 3. • Miscellaneous o Delirium vs. Dementia 1. 2. 3. o Pressure Ulcer Prevention 1. 2. 3. o Role of albumin in the cardiovascular system (Osmotic pull) 1. 2. 3. o IV Fluids:  Isotonic 1. 2. 3.  Hypotonic 1. 2. 3.  Hypertonic 1. 2. 3. o Fluid & Electrolytes (Normal, highs and lows)  Potassium 1. 2. 3.  Sodium 1. 2. 3.  Calcium 1. 2. 3.  Phosphorus 1. 2. 3.  Magnesium 1. 2. 3. o Thrombolytic Therapy 1. 2. 3. o MRI vs. CT scan 1. 2. 3. o Radiation Implant management for Cancer Therapy 1. 2. 3. o Types of Isolation 1. 2. 3. o Integumentary System 1. 2. 3. o Morphine, Dilaudid 1. 2. 3. o Steps to starting an IV line, IVPB management, IV bolus 1. 2. 3.  IV Lines: Peripheral vs. Central (PICC, CVC) 1. 2. 3. o Collaborative Care (Team Members) 1. 2. 3.