Advanced Med Surg Final Part 2 Everything Else

Question What do you call the creation of blood cells? What are the two types of stem cells from which all blood cells are produced? Which blood cells are created by lymphoid stem cells? Which blood cells are created by myeloid stem cells? Answer hematopoiesis Myeloid stem cells and Lymphoid stem cells lymphocytes (b-lymphocytes and t-lymphocytes) everything else: erythrocytes, platelets, neutrophils, monocytes(macrophages), eosinophils and basophils

The hormone Erythropoietin causes differentiation of the myeloid stem in the kidneys (it is released when the kidneys cell to become an erythrocyte. detect low levels of oxygen in the blood) Where is erythropoietin produced? What is the condition called when there is an abnormally low number of circulating RBC's AND an anemia abnormally low oxygen concentration? What three labs are done to test for CBC (complete blood count), Hgb (hemoglobin) and anemia? Hct (hematocrit) What deficiencies can produce hypoproliferative anemia (defect in iron, folic acid, b12, erythropoietin the production of red blood cells)? What are the 4 major causes of anemia? What are the three inherited disorders that cause hemolytic anemia? What are three other causes of hemolytic anemia? What kind of anemia can be caused by trauma or surgical hypoproliferative defect (defect in production), bone marrow defect, hemolytic defect (defect in destruction), blood loss sickle cell, thalassemia, G-6-PD anemia autoimmune processes, mechanical heart valves and infection. blood loss

complication? What is the normal hemoglobin level for women? What is the normal hemoglobin level for men? 12-16 13-18

What is the normal hematocrit level 35-47% for women? What is the normal hematocrit range for men? What is hematocrit? What is the normal red blood cell count for women? What is the normal red blood cell count for men? One of the signs of anemia is pallor. What causes pallor? What the other 6 labs that may be ordered for a patient with anemia? What invasive procedure may be done to determine cause of anemia? What compensatory mechanisms will affect the heart and lungs in a patient with anemia? 42-52% it is the percentage by volume of packed red blood cells in a sample 4.2-5.4 X10^6/microliter 4.6-6.2 X10^6/microliter the body's response to anemia is vasoconstriction to decrease circulation to extremities which increases circulation to vital organs. reticulocyte count, mean corpuscular volume (MCV), serum iron level, total iron binding capacity (TIBC), serum vitamin B12 level and serum folate level bone marrow aspiration and analysis heart rate and respiration rate will increase to make more oxygen available to the body.

What will happen to an anemic they will experience fatigue and dyspnea patient when they attempt activity? this is caused by increased activity in the bone Why do some patients with anemia marrow as it attemps to increase production of experience bone pain? RBC's What is the cause of headaches and dizziness in patients with anemia? Why do patients with nutritional deficiency anemias experience compromised oral mucosa and decreased oxygen to the brain decrease in perfusion of the oral mucosa makes it more prone to breakdown

cheliosis (cracks at the corners of the mouth)? Which type of anemia can manifest in the patient eating non-food items iron deficiency anemia (pica)? Which type of anemia exhibits fingernail deformity as a manifestation? (brittle, rigid, concave) this is seen exclusively with iron deficiency anemia

Which type of anemia produces neurological deficits such as this is seen exclusively in B12 anemia parathesias, ataxia and confusion? If a vitamin B12 deficiency is caused by a faulty absorption of the pernicious anemia (a type of B12 anemia) GI tract, what type of anemia is produced? Intrinsic factor is normally secreted by cells in the Why isn't the vitamin B12 absorbed gastric mucosa. The intrinsic factor binds with the bt the GI tract in pernicious dietary vitamin B12 and travels with it to the ileum, anemia? where the vitamin is absorbed.Without intrinsic factor,orally consumed B12 cannot be absorbed. What happens if the B12 is not absorbed? Is there any other forms of pernicious anemia? Is pernicious anemia inherited? When are symptoms of pernicious anemia apparent? Are there any complications of pernicious anemia? production of rbc's is diminished. yes, if there is disease involving the ileum or the pancreas, absorption is impaired. Probably, it tends to run in families and generally occurs in adults and elderly. not until the anemia is severe. The body compensates so well that it goes on unnoticed for a long time. Sort of. Gastric cancer occurs at a higher incidence in patients with pernicious anemia so patients should be encouraged to have endoscopies every 1-2 years to screen for gastric cancer.

What is the treatment for pernicoius monthly B12 injections IM anemia? How is pernicious anemia tested? Schilling test. It uses radioactive B12 and measures radioactivity in the urine. Another test can be done to look for antibodies which bind to the B12-intrinsic factor complex which prevents the B12 from binding

to receptors in the ileum. Expensive. What is the normal range for WBC 5,000-10,000/mm^3 count? What is the normal range for neutrophils? What is the normal range for eosinophils? What is the normal range for basophils? What is the normal range for lymphocytes? What is the normal range for monocytes? 3,000-7,000/mm^3 (60-70% of WBC's) 50-400/mm^3 (1-3% of WBC's) 25-200/mm^3 (0.3-0.5% of WBC's) 1,000-4,000/mm^3 (20-30% of WBC's) 100-600/mm^3 (3-8% of WBC's) a defect in the stem cells that differentiate into all myeloid cells: monocytes, granulocytes, erythrocytes, and platelets (not T-cells and b-cells). Most common type of non-lymphocytic leukemia, affects all ages & peaks at age 60, prognosis is variable fever and infection, weakness & fatigue (from anemia/decrease RBC), bleeding(r/t thrombocytopenia), pain from enlarged liver and spleen, gingival hyperplasia and bone pain. aggressive chemo-induction therapy, bone marrow transplant (BMT), or Peripheral Blood Stem Cell Transplant (PBSCT) integumentary system, urinary tract, respiratory tract, oral mucosa (the risk of infection in the oral mucosa and skin are related to decreased perfusion)

What are the characteristics of acute myeloid leukemia(AML)?

What are the S&S of AML?

What is the treatment for AML?

What are the common sites of infection for patients with AML?

What are the four manifestations of bleeding, bruising/hematoma, petechiea, internal thrombocytopenia (low platelets)? bleeding such as GI/occult bleeding bone ,liver/spleen, lymph nodes (accumulate What are 4 places that a patient abnormal cells), gums (cells will be able to enter with AML may experience pain and arterial blood but will get stuck in liver and spleen swelling? before enetering venous blood) What part of the abdomen would the patient experience liver pain? What part of the abdomen would right upper quadrant left upper quadrant

the patient experience spleen pain? What are the two types of chemo used with AML patients? What is induction therapy? induction therapy and consolidation therapy HIGH dose of chemotherapy to eradicate leukemic cells from bone marrow, normal stem cells are also eradicated (high risk for infection and bleeding) chemo given AFTER induction therapy to consolidate the gains obtained. It is at much lower doeses and administered only after infections have resolved and counts return to normal Tumor lysis syndrome (when the cells are destroyed, their contents are dumped into the blood stream) nucleic acids (converts to uric acid and causes hyperuricemia i.e. gout/joint pain, potassium, phosphorus dysrhythmias nausea/vomiting, acute monoarthritis (gout?), renal failure (uric acid can clog nephrons in the kidney)

What is consolidation therapy?

What is the major complication of chemotherapy? What are the three cellular components that can cause the most problems in tumor lysis syndrome? What is a manifestation of hyperkalemia? What are manifestations of hyper uricemia?

nausea/vomiting, acute monoarthritis (gout?), renal failure tetany, cardiac dysrhythmias (most serious!) (uric acid can clog nephrons in the kidney) aggressive hydration for 24-28 hours prior to induction chemotherapy, prophylactic admin of IV What is the treatment of tumor lysis sodium bicarb (changes to alkalotic pH to prevent syndrome? uric acid from precipitating out to cause gout and renal failure), admin of allopurinal, Kayexalate, lasix What does allopurinal do? What does Kayexalate do? What does lasix do? What else can be done to treat tumor lysis syndrome if the other medical interventions are not effective? What medical intervention will follow chemo in patient with AML? treats gout removes potassium (causes diarrhea) removes more K+ hemodialysis BMT or PBSCT. The goal is for the client to begin making their own blood cells after the transplant

What complication can arise following a BMT or PBSCT? What is GVHD?

graft-verses-host-disease (GVHD). Occurs in 50% of BMT and PBSCT recipients. Potentially Fatal! The recipients tissue is seen as foreign by the Tlymphocytes in the donated bone marrow skin(rash and loss of skin on hands , palms and soles of feet, may extend over entire body), GI tract (hyperactivity: vomiting, severe diarrhea) and Liver (causing jaundice, ascites and diarrhea, also biliary stasis causing elevated serum liver enzymes)

What are the three most common organs affected in GVHD?

What treatments are used after a Immunopupressant drugs: patient develops graft-verses-hostSandimmune(cyclosporine), Methotrexate, Prograf disease? (not given (tacrolimus), Rapamune(sirolimus) prophylactically) What is lymphoma? What are the two types of lymphoma? What are the characteristics of Hodgkin's disease? neoplasm of lymph origin Hodgkin's lymphoma and Non-Hodgkins lymphoma Unicentric origin(starts in one place, usually a lymph node). REED STERNBERG CELLS (Know it!) common in 20's and after age 50. Excellent cure rate with treatment, suspected viral etiology, familial pattern location. leukemia the mutated cell/s are in the bone marrow. Lymphoma: the mutated cell/s are in the lymph node. painless lymph node enlargement, puritis (as cells get stuck in capillary bed), B symptoms:fever, sweats, weight loss (malignant cells have higher metabolic rate)

What is the difference between leukemia and lymphoma? What are the manifestations of Hodgkin's disease?

What is the treatment for Hodgkin's determined by the stage of the disease. May disease? include chemo and/or radiation Which lymphoma is associated with Hodgkin's Reed-Sternberg cells? What is thrombopoietin? Which stem cells do thrombocytes develop from? a protein produced by the liver, kidney, smooth muscle & bone marrow that stimulates the production of thrombocytes (aka platelets). myeloid stem cells.

How many platelts does the patient have if they have thrombocytosis too many (also called thrombocythemia)?

How many platelets does the patient have if they have thrombocytopenia?

too few

What is it called when bone marrow ry thrombocythemia (also called essential makes too many platelets and the thrombocythemia/thrombocytosis) cause is unknown? What is secondary thrombocytosis? the cause of the overproduction of platelets is known such as anemia, cancer, infection or surgery. abnormally low platelet count of unknown cause & patient presets with purpura (bruises) or petechiae (tiny bruises). Treatment is usually not necessary unless platelets go below 50,000. Treatment can consist of steroids,platelet transfusion, splenectomy group of inherited genetic disorders in which the body does not make a particular clotting factor. There is no cure but medical management consists of regular trasfusions of the missing clotting factor.

What is idiopathic thrombocytopenia purpura (ITP)?

What is hemophilia?

Name three ways a patient not born liver disease, overdose of anticoagulants, vitamin k with a clotting disorder can acquire deficiency one. assoc w/ complete fractures when marrow is exposed and fat globules enter circ. Seen in long bone and pelvic fractures, crush injuries and multiple fractures. Can cause transient thrombocytopenia and immune system response. Onset 12-48 hrs of injury. hypoxia (decrease in O2 sat), dyspnea, tachypnea, crackles, edema, chest pain, productive cough (thick white sputim r/t edema), may progress to acute respiratory distress syndrome followed by congestive heart failure.

What are the characteristics of fat embolism syndrome?

What are the respiratory manifestations of fat embolism syndrome?

at are the cardinal signs of venous pain and inflammation occlusion? What are the cardinal signs of arterial occlusion? Hypoxia from fat embolism syndrome can lead to what other manifestations? What are the neurologic manifestations of fat emolism syndrome? 5P's: pain, pallor, parasthesia, pulselessness and paralysis tachycardia and fever (usually greater than 103 degrees) restless, irritability, confusion (due to poor perfusion to the brain or cerebral vessel emboli.

What are the renal manifestations of fat embolism syndrome? What is the best prevention for fat emolism syndrome?

the embolus can obstruct renal arteries producing oliguria or anuria. Free fat would be noted on urinalysis. early stabilization of fractures (the quicker the fractures are reduced, the lower the incidence of fat embolism syndrome. Also, maintain fluid and electrolyte balance. a sudden and severe decrease in blood flow to the tissues distal to an area of injury. Usually happens with a lower extremity. Caused by constriction from a cast or dressing or from hemorrhage or edema within the compartment. a wick catheter

What is compartment syndrome?

What can be used to monitor compartment pressure?

What is is called when a cast is split down both sides to relieve bivalving pressure and allow for visualization of the extremity? What are potential complications of permanent motor and/or sensory deficits, necrosis compartment syndrome? and amputation keep the extremity at the level of the heart, not above and not below. Bivalving. loosening splint. fasciotomy if the symptoms are not releived within ONE HOUR of the above interventions. A fasciotomy is an incision with suction to remove fluid. post anesthesia care unit until the patient has resumed motor and sensory function, is oriented, has stable VS and shows no evidence of hemorrhage or other complication of surgery.

What is the treatment for compartment syndrome?

What does PACU stand for? How long will a patient remain in PACU?

What is the number one priority for airway a patient in PACU? assessment, maintaining patent airway, mantaining What are the responsibilities of the cardiovascular stability, releiving pain and anxiety, PACU nurse? controlling nausea and vomiting, and facilitating discharge to home or hospital unit. What assessments should the PACU nurse make? assess drains/surgical dressing, assess infusions as well as IV site, assess VS

How often should VS be assessed every 15 minutes until stable

in PACU? When should a systolic BP be reported? below 90 unless consistent with pre-operative BP

The nurse should also report vital sign trends that are concerning. HR trending up or down. O2 sat trending or down. What trends would be concerning? What can create a problem for PACU nurse maintaining a patent airway? What are 4 signs the airway has been obstructed? How can you position the head to maintain patent airway? muscle relaxation due to anesthesia can lead to hypopharyngeal obstruction (anesthesia causes the tongue to fall back and obstruct the airway). choking, irregular respirations, decrease in O2 sat, cyanosis the head can be tilted back with the jaw held closed.

If a patient comes back from PACU with an oral airway, when can it be when evidence of a gag reflex returns. If they are removed? (oral airway is a tube awake and communicative, they have a gag reflex. inserted in the mouth that extends behind the tongue) What should you do if the patient vomits? What are sign of hemorrhage? turn head to the side and suction if needed. bleeding from incision, hypotension, tachycardia, disorientation, restlessness, anxiety, oliguria, pale/cool skin (r/t vasoconstriction)(however just cool skin may be r/t temp in OR)

apply pressure (not applicatble if bleeding is What are appropriate interventions internal), elevate legs 20 degrees with knees for hemorrhage? straight head and back is level with floor, give blood transfusion, transfer back to OR. What is a common cause of hypertension in a post op patient? What should you do for a patient who is hypertensive due to pain? pain give analgesic

What are two additional problems that can cause hypertension in post hypoxia and bladder distension op patient? What should you you if your patient has hypertension due to hypoxia check airway, give supplemental O2, if already on and is also presenting with O2 increase rate. increased respiration rate and increased heart rate?

What should you do if your patient is hypertensive due to bladder distention?

Palpate first to determine if bladder is distended. Make sure foley catheter is not kinked (you may also need to flush the foley if there is a mucus plug preventing urine from draining), if they are not cathed you should straight cath them

electrolyte imbalances (replace electrolytes but What are causes of dysrhythmias in infuse slowly so kidneys don't shut down), altered a post op patient? respiratory function, pain, hypothermia (warm slowly), stress, analgesic agents, assess patient comfort, administer analgesics as What are appropriate interventions indicated (usually short acting opiods via IV), allow for releiving pain and anxiety? family to visit, address family and patient anxiety. What is the FIRST thing should you do if the patient states they are turn them on their side, then provide antiemetics naseaus? Reglan(metoclopramide), Compazine(prochlorperazine), Phenergan(promethazine), Dramamine(dimenhydrinate), Vistaril/Atarax(hydroxyzine), TransdermScop(scopolamine), Zofran(ondansetron) p.466

What are some common antiemetics?

aspiration, compromised hemostaisis due to increased abdominal pressure(which can What are complications associated compromise suture lines and cause hemorrhage), with vomiting? myocardial ischemia and dysrhythmis due to increased central venous pressure, pain What patient population is at greater risk for developing post-op complications? elderly due to decrease in homeostatic mechanisms, and decreased physiologic reserves to manage stress, increased likelihood of confusion/delirium, decreased liver function can cuase patient to poorly metabolize anesthesia

monitor carefully/frequently. Assess confusion to exclude hypoxia, pain, hypotension, hypoglycemia, What interventions are appropriate fluid loss. Assess need for lower dosages, assess for elderly post op clients? hydration, anticipate extended time to recover from anesthesia What tool can we use to assess Aldrete score. A score of 0-2 is given for each of the readiness for discharge or tranfer (it following catagories: activity, respiration, circulation, is simialr to APGAR score for consciousness, O2 saturation.(ARCCO) neonates)? What must the Aldrete score be to 8 or more. If patient does not reach 8 they are transfer patient to step down un it? transferred to intensive care.

What kind of information should you give before discharging a patient to home? (may also include a responsible adult in the teaching if appropriate)

written and verbal instructions regarding follow-up care, complications, wound care, activity, medications, diet. Also include perscriptions, phone numbers and actions to take if complications occur. Do not let patient drive home!

What are potential complications of DVT, hematoma, infection (wound sepsis) and surgical wounds? wound dehiscence and evisceration early ambulation, anticoagulants (heparin, lovenox), compression stockings, leg exercises, adequate hydration, avoiding activities that constrict vessels behind the knees(blanket rolls, dangling at the edge of the bed) stress response, increased stomach acid, low cardiac output, venous staisis

How can DVT's be prevented?

What are 4 contributing factors to developing dvt's?

What other factors can put patients prior history of DVT's, malignancies/Cancer, at greater risk for developing trauma, indwelling venous catheters (piccs and DVT's? dialysis access ports) What are the manifestations of hematoma? What is the treatment for hematoma? What accounts for 77% of sugical patient deaths? bulging around incision, echymosis around incision if needed, surgical evacuation, can be done by surgeon removing several sutures or staples sepsis

How long can it take for evidence of up to 5 days wound infection to be apparent? What are the manifestations of wound infection? fever/chills, increased WBC count, changes in charachter around the wound (reddness, swelling, warmth, tenderness, pain, purulent drainage) Sepsis is systemic response to infection triggering inflammation throughout the body. This inflammation creates microscopic blood clots that can block nutrients and oxygen from reaching organs, causing them to fail.

What is sepsis?

What are some treatments the removal of some of the sutures/staples, insertion of surgeon may perform/order to treat a drain, incision for drainage, antibiotics wound infection? What is wound dehiscence? What is wound evisceration? separation of the edges of a wound protrusion of intestine through open incision (associated with abdominal surgery)

What should you do if your patient's place patient in high fowlers, cover wound with wound eviscerates? sterile dressing soaked in saline, call the surgeon What is the basic definition of shock? Why does shock affect all of the systems of the body? What are the three stages of shock? inadequate tissue perfusion (to deliver oxygen and nutrients to support the vital organs' cellular function, affects all systems of the body) because all cellular activities run on oxygen compensatory, progressive and irreversible

In the compensatory stage of shock, the sympathetic nervous epi and nor-epi (stimulating the fight or flight system releases catecholamines. response) What are the two catecholamines? What does the epi and nor-epi affect the heart? increases heart rate, increases BP, increases heart contractility which lead to increased cardiac output.

How does the epi and nor-epi affect It increases respiration rate to increase O2 the lungs? saturation it increases renin-angiotensin activation which leads How does the epi and nor-epi affect to an increased absorption of sodium and water the kidneys? which leads to an increased preload and decreased urine output. How does the epi and nor-epi affect the epi and nor-epi and cortisol increase blood glucose? glucose levels What is the desired result of the activation of the sympathetic nervous system? What happens to blood flow/circulation during the compensatory stage of shock? restoration of tissue perfusion and oxygenation the body shunts blood to vital organs including the brain, heart and lungs

decreased perfusion to other organs causing What are the consequences of the hypoxia. S&S include cool/clammy skin, hypoactive body shunting blood to the vital bowel sounds, decreased urine output, organs? confusion(also due to respiatory alkalosis What is the focus of medical management during the compensatory stage of shock? What is the best nursing management during the compensatory stage of shock? identify the cause, treat accordingly recognize the signs of shock, early intervention will produce the best outcome. Unfortunaltely cellular damage occurs before a drop in BP is noted.

What are appropriate nursing interventions for a patient in the compensatory stage of shock? How are VS affected by the compensatory stage of shock?

minimize O2 demand to increase perfusion. sedation will decrease activity, opiod analgesic will decrease pain and VS, use supplemental O2 and/or mechanical ventilation, keep them warm, give PRBC transfusion, reduce anxiety, promote safety increased HR and RR, decreased BP and O2 sat. Pulse pressure will narrow, normal range is 30-40 mmhg since the blood was shunted to vital organs, the finger probe will be ineffective. Continuous central venous oximetry will be used(SvcO2) and the normal value for SvcO2 is 70%. Sublingual capnometry may be used to measure PCO2 using a probe under tongue Near-infared spectoscopy measures skeletal muscle oxygenation. The normal value is greater than 80%. A probe is placed over the thenar muscle of the palm. My notes say we should KNOW THIS.

How is O2 sat measured in a patient in the compensatory stage of shock?

What can be used to measure skeletal muscle oxygenation?

When does the patient move from When the compensatory systems are unable to the compensatory stage of shock to maintain effective MAP. the progressive stage of shock? What are the characteristics of the irreversible stage of shock? organ damage is so severe that that the patient does not respond to treatment and cannot survive. Renal and liver failure compounded by the release of necrotic tissue toxins creates an overwhelming acidosis.

It is a fluid that is capable of passing through a One of the treatments of all stages semi-permenable membrane. The opposite, al of shock is fluid replacement aka colloid fluid, is not capable of passing through a fluid recuscitation. What is a semipermeable membrane. Crystalloid solutions crystalloid fluid? expant the interstitial space. Colloids expand plasma volume. What are two isotonic crystalloid solutions? .9NS and lactated ringers. Lactated ringers contains a lactate ion NOT lactic acid, the solution converts to bicarbonate to increase serum pH and make the serum more alkalotic (this is used to treat acidosis) 3%NS (more "stuff than .9NS). This solution has an osmotic effect and pulls fluid into the intervascular space so you would need less of a hypertonic fluid than an isotonic fluid to achieve the desired effect. It is used to expand the fluid in the intravascular space (so does a hypertonic solution but the colloid

What is a hypertonic crystalloid solution used for fluid recisitation? What does a colloid solution do?

solution has a longer duration because its molecules are too large to pass through capillary membranes. Less fluid is needed to expand volume.) What are two negative aspects of colloid solutions? What are the two types of colloid solution? What are two examples of a synthetic colloid solutions? What other action does dextran have that needs to be considered when selecting a colloid solution? What type of fluid replacement would all blood products be considered? What are six complications of fluid resusitation? they are significantly more expensive and have greater risk for anaphylactic/allergic reaction natural and synthetic hetastarch and dextran it can interfere with platelet aggregation

colloid pulmonary edema, fluid volume excess, generalized edema, anaphylactic reaction(colloids), hypothermia (caused by rapid infusion of large volumes of fluid), and abdominal compartment syndrome related to third spacing

What action can be taken to reduce the risk of hypothermia when warm the fluids before administration infusing la rge volumes of fluid? How is abdominal compartment syndrome defined? a leaking of fluid into the intra-abdominal cavity causing pressure of greater than 12 mmHg within the intra-abdominal cavity(normal pressure in the abdominal compartment is 0-5 mmHg) compromised venous return producing a decrease in cardiac output, elevation of the diaphragm interfereing with lung inflation and GI and renal dysfunction (intolerance to tube feeding, absent bowel sounds and decreased urine output)

What problems can abdominal compartment syndrome cause?

What treatment is required in cases surgical decompression (fasciotomy (incision) with of abdominal compartment suction) syndrome? What is the normal range for central venous pressure? How can venous O2 saturation (SvO2) be monitored in the critical 4-12 mmHg It is measured with central venous oximitry e.g. swan-ganz catheter placed peripherally and

care setting?

threaded through the heart and into the pulmonary artery to get the best reading of mixed venous saturation The venous blood should be 75% saturated with oxygen(arterial blood should be 95-100% saturated)SvO2 is monitored because it is one of the earliest indicators of a threat to tissue perfusion(sepsis causes high SvO2 and lung or cadiac prob causes low SvO2) The difference is where the value is collected. The book only said that ScvO2 is measured with a CVP line and the normal values are slightly different with SvO2 and ScvO2. it measures PRESSURE (not O2 sat). It is used to measure a clients response to fluid replacement. Normal pressure 4-12 mmHg.

What is the normal value of SvO2 (venous oxygen saturation) and why is it monitored?

What is the difference between SvO2 and ScvO2?

What is a CVP line?

What is the most important thing to monitor the lungs for adventitious breath sounds monitor in patients receiving large and signs and symptoms of interstitial edema (e.g. volumes of crystalloid solutions? abdominal compartment syndrome) What does an arterial BP line do? What stimulates alpha adreneric receptors? Where are alpha adrenergic receptors located? What are the effects of catecholamines (epi and nor-epi) on the alpha adrenergic receptor sites? Where are beta 1 receptors located? What happens when beta 1 receptors are stimulated? Where are beta 2 receptors located? What happens when beta 2 receptors are stimulated? Which vasoactive receptor stimulators are used in the treatment of shock? monitor arterial BP catecholamines: epi and nor-epi in blood vessels (arteries and veins) as well as smooth muscle in the GI tract, lungs kidneys and integumentary system constriction: vasoconstriction, bronchioconstriction, decreased motility in GI tract, heart (one heart, two lungs) heart rate and myocardial contraction increases bronchioles/lungs, heart and skeletal muscles vasodilation in the bronchioles, heart and skeletal muscles all of them can be used in various combinations however vital signs need to be monitored every 15 minutes or more often if necessary.

How are vasoactive medications administered in shock patients?

via central line ONLY becuase infiltration and extravasation of these drugs can cause tissue necrosis. PUMP must be used.

Vasoactive drugs in the critical care setting may be titrated frequently. DOCUMENT each time the rate is changed What needs to be done each time a titration is made? If you have an order to discontinue a vasoactive drug how should the SLOWLY, never take them off abruptly drug be discontinued? What does a (positive)inotropic agent do? it increases the contractions of the heart (improves contractility, increases stroke volume, increases cardiac output)

What is a disadvantage of using an it increases the oxygen demand of the heart inotropic agent? What does a negative inotropic agent do? What are some positive inotropic agents discussed in the book? What does a vasodilator do? What is a disadvantage to using vasodilators? decrease contractility and oxygen demand of the heart (not really discussed in this chapter but I thought of we're going to learn one we should learn the other too e.g. beta blocker, calcium channel blocker) Dobutrex/dobutamine, Inotropin/dopamine, Adrenalin/epinephrine, Primacor/milrinone stimulates beta 2 receptors, reduce preload and afterload and reduce oxygen demand of the heart hypotension

What vasodilators are discussed in Tridil/nitroglycerin, Nipride/nitroprusside the book? What is a vasopressor agent? What are disadvantages of using vasopressor agents? What vasopressor agents are mentioned in the book? Nutritional support is an important part of the management of shock. What is the preferred method of it increases blood pressure by vasoconstriction (stimulates alpha 1 receptor sites) also called antihypotensive agent increased afterload, increased cardiac workload, compromised perfusion to the skin, lungs and GI tract Levophed/norepinephrine, Inotropin/dopamine, Neo-Synephrine/phenylphrine, Pitressin/vasopressin Enteral is preferred becuase it uses the GI system to support its integrity (e.g. OG, NG tube). Glutamine (an essential amino acid) is usually

nutritional support?

added to support immunologic function by feeding lymphocytes and macrophages.

Stress ulcers are common in acutely ill patients due to antacids, H2 receptor blockers and proton pump decreased perfusion to GI tract. inhibitors (they reduce gastric acid secretion and What drugs can be administered to increase pH) prevent ulcer formation? What H2 receptor blockers are discussed in the book? What proton pump inhibitors are discussed in the book? I am skipping eye, ear and male reproductive system for now. (Weeks 4 and 5) What is cholelithiasis? What are the two types of gall stones? Which type of gall stone is more prevalent? What are the physical manifestations of cholelithiasis? What are the risk factors for cholelithiasis? Pepcid/famotidine and Zantac/ranitidine Prevacid/lansoprazole I will add them to the end...if I have time. gall stones pigment stones and cholesterol stones cholesterol stones (75-90%)(pigment stones are only 10-25%) epigastric fullness or mild gastric distress following a large or fatty meal females, over 40, use of contraceptives/estrogens/clofibrate/allopurinal (these meds cause increase in proportion of cholesterol in bile), DM, biliary staisis, cirrhosis

What do oral contraceptives, increases the proportion of cholesterol (changes the estrogens, clofibrate and allopurinol recipie) do to the bile? What is cholecystitis? What are the two types of cholecystitis? Calculous cholecystitis is caused by stones, what can cause acalculous? What are the manifestations of calculus cholecystitis? acute inflammation of the gall bladder calculous (90% of cases) and acalculous major surgical procedures, trauma, burns, torsion, primary bacterial infection of the gallbladder, multiple blood transfusions due to obstruction there may increase in pressure, inflammation, autolysis, fever, RUQ pain (excruciating, may radiate to back or right shoulder, N/V, apparent several hours after eating), elevated bilirubin (itching, jaundice), dark urine and gray

stool Which vitamins may be deficient in fat soluble cases of cholecystitis? What are complications of calculus necrosis/gangrene, perforation can lead to cholecystitis? peritonitis HEPATOCELLULAR FAILURE. decreased albumen production leading to ascites, decreased production of clotting factors leading to bruising and bleeding, increased aldosterone r/t low albumen producing water and sodium retention to increase intervasc volume hyper or hypoglycemia feminine characteristics in males and irregular menses in females

What are common manifestations of liver disorders?

Glucose metabolism is disrupted with liver disorders, what can this cause? Hormone metabolism is also impaired with liver disorders, what can this cause?

impaired fat absorption and digestion, impaired Bile production is decreased in liver absorption of fat soluble vitamins (which can lead to disorders, what can this lead to? vitamin k deficiency causing clotting disorders) impaired liver function disrupts the conversion and What are effects of jaundice in liver excretion of bilirubin. unconjugated/indirect bilirubin disorders? levels rise. Stool is clay colored, urine is dark r/t bilirubin excretion of the kidneys. increased pressure in the venous return from the Portal hypertension is also a gut, spleen and surface vessels of the abdomen. manifestation of liver disorder, what The result is dilation of the vessels and formation of is its effects? collateral circulation. Also esophageal varices, hemorrhoids, splenomegaly, ascites it disrupts blood flow and the kidneys are unable to How can portal hypertension affect accomadate the fluid shift causing hepatorenal the kidneys? failure What is Cirrhosis? end stage of chronic liver disease, progressive, irreversible and leads to liver failure. Excessive scarring from inflammation and necrosis. Complications depend on amount of liver damage. alcoholic/laennecs(end stage of toxic hepatits), biliary cirrhosis(bile flow obstruction), posthepatic/post necrotic cirrhosis(caused by viral hep b or c)

What are the three types of cirrhosis?

Portal hypertension is a enlarged spleen: which will remove blood cells at an complication of cirrhosis, what can increased rate(wbc, rbc, platelets) leading to the portal hypertension cause>? aplastic anemia What is portal system encephalopathy? (also complication of cirrhosis) What are late signs of portal system encephalopathy? What does ammonia do to the brain? What is spontaneous bacterial peritonitis? What meds should be avoided in patients with cirrhosis? evated serum ammonia levels. early signs include LIVER FLAP which are involuntary jerky movements while trying to maintain a fixed position. primarily effects upper extremities. personality changes, agitation, restlessness, impaired judgement,slurring confusion, disorientation, incoherence increases intercranial pressure and irritates the cerebrum rigid abdomen (hard to detect if the have ascites) can lead to septicemia or septic shock since they are alread hypovolemic these matabolized by the liver: barbs, seditives, hypnotics, acetaminophen

spironolactone (first choice because it competes for What two diuretics can be used to receptor sites with aldosterone and stops retention) reduce fluid retention and ascites? and furosemide/lasix Why is the laxative lactulose used? it reduces serum ammonia Why is the antibiotic neomycin used? Why are antihypertensive agents used? Why is iron and folic acid given? why is vitamin k given? Why are antacids prescribed? What med is given to control bleeding of esophageal varices? What is abdominal paracentesis? also reduces serum ammonia reduce portal hypertension to treat aplastic anemia to boost clotting factor production prevent gastric ulcers vasoconstrictor sandostatin removes fluid from ascites: 4-6L, give albumen concurrenly to prevent drop in bp, have client void prior to procedure, client will be seated with feet on floor.

Who is affected by benign prostatic Half of all men over age 60 hyperplasia? What are the two chemicals estrogen and DHT (a derrivative of tesosterone).

thought to cause BPH? What is BPH? Hyperplasia means an increase in the number of cells. The prostate enlarges which causes mechanical obstruction of the urethra and urethral spasms.

What are the clinical manifestations frequency, urgency, nocturia, hesitency and of BPH baused by obstruction and decreased force of stream. irritation? What other manifestations can a patient with BPH have? fatigue, anorexia, nausea and vomiting

UTI's. Accumulation of nitrogenous waste What are potential complications of products(elevated BUN) also called azotemia. BPH? Renal failure from the backing up of urine into the ureters and kidney. What treatment may be used in low risk, less aggressive cases of radiation therapy cancer such as prostate cancer? What are some complications of using radiation therapy on the prostate? proctitis, enteritis, cystitis (everything in the region is exposed to radiation)

What are the two types of radiation 1. external beam radiation therapy (EBRT) 2. therapy used with prostate cancer? Brachytherapy What are the characteristics of external beam radiation therapy? What are the characteristics of Brachytherapy? What radiation precautions would you need to teach a patient who was implanted with radioactive seeds in their prostate? Who is affected by testicular cancer? the treatment is done 5 days per week for 7 weeks using CyberKnife. CyberKnife is a robotic radiation delivery. This treatment may also be used to treat bone metastasis. radioactive seeds are surgically implanted into the prostate. 1.avoid close contact with pregnant women and infants for two months. 2. Wear a condom during intercourse for 2 weeks. (Oh yeah, and assign this client to the nurse and PCA least likely to be pregnant...why do I always get the radioactive patients???) It is the most common cancer to affect men ages 18-30.

What is the prognosis for testicular it is highly treatable and curable. cancer? What are the risk factors for testicular cancer? Cryptorchidism (undescended testicle), family history of testicular cancer, personal history of

testicular cancer, race/white What are the manifestations of testicular cancer? What is the best way to ensure early detection? a mass or lump on the testicle. backache. abdominal pain.weight loss. generalized weakness. monthly testicular self-exam (TSE)and annual testicular exam (Best done in the shower in warm water. Look for lump or anything abnormal.

Orchidectomy (removal of testicle). Retroperitoneal What is the treatment for testicular lymph node dissection if there has been lymph node cancer? involvement (open or laproscopic). Radiation therapy. Chemotherapy. What is the condition in which the foreskin cannot be retracted over the glans of an uncircumcised penis? What is a contributing factor for phimosis? What is the treatment for phimosis? How common is penile cancer? What are risk factors associated with penile cancer? phimosis Lack of hygeine. This leads to imflammation, adhesions and fibrosis. anti-inflammatory (topical steroid to reduce inflammation) applied to foreskin. Rare, it only accounts for 1% of all male cancer cases. Lack of circumcision. Poor genital hygiene. Phimosis. HPV. Smoking.

What visual changes does a person a narrowing of the visual field. with glaucoma experience? Glaucoma is a slowly progressive eye condition that causes damage to the optic nerve. Because there are usually no symptoms early on in the disease, about half of the people with glaucoma do not even know they have it.

What is glaucoma?

There are atleast 20 types of 1. open angle 2. closed angle 3. congenital glaucoma, but what are the 4 main glaucoma and 4. secondary glaucoma types? What visual changes does a person a narrowing of the visual field. with glaucoma experience? Glaucoma is a slowly progressive eye condition that causes damage to the optic nerve. Because there are usually no symptoms early on in the disease, about half of the people with glaucoma do not even know they have it.

What is glaucoma?

There are atleast 20 types of 1. open angle 2. closed angle 3. congenital glaucoma, but what are the 4 main glaucoma and 4. secondary glaucoma types? When is glaucoma considered congenital? What is secondary glaucoma? What are the three types of open angle glaucoma listed in the powerpoints? when it occurs in infants under the age of 1 may be associated with eye diseases, other diseases and side effects of medications. 1. chronic open angle glaucoma 2. normal tension glaucoma 3. ocular hypertension

What are the three types of closed 1. acute angle closure 2. subacute angle closure 3. angle/angle closure glaucomas chronic angle closure listed in the powerpoint? For the most part which or the to types of glaucoma (open and closed) progresses slowly and the patient may not even realize they have it until they have significant vision loss? For the most part which or the to types of glaucoma (open and closed) is an acute medical emergency creating so much pain that the individual usually seeks medical treatment? What are the 4 types of examinations used in glaucoma evaluation, diagnosis and management? What is the purpose of Opthalmascopy? What is the purpose of gonioscopy? What is the purpose of perimetry? What is the focus of medical management of glaucoma?

open angle

closed angle

1. Tonometry 2. Opthalmascopy 3. Gonloscopy 4. Perimetry

What is the purpose of Tonometry? to measure IOP (intraocular pressure) to inspect the optic nerve to examine the filtration angle of the interior chamber. to assess vision fields (determine progression of visual field defects) the goal is to prevent further optic nerve damage and maintain iop within a range unlikely to cause optic nerve damage.

What is the pharmacologic therapy 1.cholinergics:increase outflow 2.adrenergic

for glaucoma? See table 58-4

agonists:reduce production &increase outflow 3.beta-blockers:decrease production 4.alpha adrenergic agonists:decrease production 5.carbonic anhydrase:decrease production 6.prostaglandin analogs:increase outflow 1. laser tribeculoplasty 2.laser iridotomy 3.filtering procedures 4.tribeculectomy 5. drainage implants or shunts Teach client to maintaqin therapeutic regimin to maintain lifelong control of condition. Emphasize adherence to prevent further vision loss. Teach use and effects of meds. Teach side effects such as vision alterations. Provide support and interventions to aid the patient in adjusting to vision loss and potential vision loss. cataracts (everything gets blurry) by age 80 more than half of all americans have cataracts. It is a leading cause of disability in the US aging, associated ocular conditions, toxic factors, nutritional factors, physical factors, systemic diseases and syndromes. Adrenergic agonists:dipivefrin, epinephrine/Betablockers:betaxolol,timolol/Alpha-adrenergic agonists:apraclonidine,brimonidine/Carbonic anhydrase inhibitors:acetazolamide,methazolamide, dorzolamide/Prostaglandin analogs: latanoprost,bimatoprost

What are the 5 ways surgery can be used to manage glaucoma? Nursing management: focuses on teaching, what should you teach glaucoma patient? What psychosocial needs will a client with glaucoma have? What is the name for opacity or cloudiness of the lens? Who gets cataracts? What are risk factors associated with cataracts? What are the glaucoma meds written on the instructor copy of the slides? Cholinergics/miotics:pilocarpine, carbachol/

Lens opacity. Painless, blurry vision. Sensitivity to What are the clinical manifestations glare. Reduced visual acuity. Light scattering and of cataracts? reduced contrast sensitivity. Other effects include myopic shift, astigmatism, What are other effects of cataracts? diplopia (double vision), and color shifts including brunescens (color value shift to yellow-brown) What are the diagnostic tests for cataracts? What are the 4 types of cataract surgery? What is Intracapsular cataract ophthalmoscope, slit-lamp, or inspection 1. Intracapsular cataract extraction (ICCE)2. Extracapsular cataract extraction (ECCE) 3. Phacoemuslification 4. Lens replacement removes entire lens, rarely done today

extraction (ICCE)? What is Extracapsular cataract extraction (ECCE)? What is Phacoemuslification? maintains the posterior capsule of the lens, reducing potential postoperative complications an ECCE which uses an ultrasonic device to suction the lens out through a tube; incision is smaller than with standard ECCE after removal of the lens by ICCE or ECCE, the surgeon inserts an intraocular lens implant (IOL). This eliminates the need for aphakic lenses, however, the patient may still require glasses. Usual preoperative care for ambulatory surgery, Dilating eye drops or other medications as ordered Instruct patient to call physician immediately if vision changes; continuous flashing lights appear; redness, swelling, or pain increase; type and amount of drainage increases; or significant pain is not relieved by acetaminophen

What is Lens replacement? What is pre-op care for cataract surgery? What teaching should you provide patient following cataract surgery?

Avoid eye straining, Avoid rubbing or placing pressure on eye, Avoid lifting more than 5 lbs, What is appropriate education post bending, coughing, sneezing etc Prevent cataract surgery? constipation, Use eye shield at bedtime, Wipe excess drainage with sterile cotton away from canthus Report to surgeon: sharp, sudden pain in the eye, bleeding or increased discharge, lid swelling, decreased vision, or flashes of light or floating shapes. Avoid activities that might increase IOP.Review procedure for use of eyedrops.

Cataract health teaching:

Do you get the impression that the person who write the eye lecture ??? also wrote the neuro lecture? What is retinal detachment? What are manifestations of retinal detachment? How is retinal detachment diagnosed? Defined as: Separation of the sensory retina and the RPE (retinal pigment epithelium) Sensation of a shade or curtain coming across the vision of one eye, bright flashing lights, sudden onset of floaters assess visual acuity, assessment of retina by indirect ophthalmoscope, slit-lamp, stereo fundus photography, and fluorescein angiography. Tomography and ultrasound may also be used

What is conjunctiva?

thin, transparent membrane covering anterior surface of the eye

What are the two types of bacterial Chlamydia Conjunctivitis Inclusion Conjunctivitis conjunctivitis? What are the two types of viral conjunctivitis? What kinds of treatment can be used with conjunctivitis? Allergic Conjunctivitis Toxic Conjunctivitis Opthalmic Medications:Antibiotic, Antiviral, Antiinflammatory Most Delivered Topically. Eye irrigations, Soaking lids with warm saline compresses Some by Subconjunctival Injection, Some by Intravenous Infusion Risk for infection Proper hand washing Teach instillation of eye drops Risk for disturbed sensory perception: visual Assess vision with & without corrective lenses Use of sunglasses inflammation of all of part of this vascular layer. Red and painful but no mucus secretion.

What are appropriate nursing diagnoses for conjunctivitis? What is Uveitis?