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CEREBRAL CONCUSSION

stimulate nerve cells, are released in excessive amounts as the result of the injury. The resulting cellular excitation causesneurons to fire excessively. This creates an imbalance of ions such as potassium and calcium across the cell membranes of neurons (a process like excitotoxicity). Since the neuron firing involves a net influx of positively charged ions into the cell, the ionic imbalance causes cells to have a more positive membrane potential (i.e. it leads to neuronal depolarization). This depolarization in turn causes ion pumps that serve to restore resting potential within cells to work more than they normally do. This increased need for energy leads cells to require greater-than-usual amounts of glucose, which is made into ATP, an important source of energy for cells The brain may stay in this state

In both animals and humans, MTBI can alter the brain's physiology for hours to weeks, setting into motion a variety of pathological events.Though these events are thought to interfere with neuronal and brain function, the metabolic processes that follow concussion are reversed in a large majority of affected brain cells; however a few cells may die after the injury. Included in the cascade of events unleashed in the brain by concussion is impaired neurotransmission, loss of regulation of ions, deregulation of energy use and cellular metabolism, and a reduction in cerebral blood

of hypermetabolism for days or weeks. At the same time, cerebral blood flow is relatively reduced for unknown reasons, though the reduction in blood flow is not as severe as it is in ischemia. Thus cells get less glucose than they normally do, which causes an "energy crisis". Concurrently with these processes, the activity of mitochondria may be reduced, which causes cells to rely on anaerobic metabolism to produce energy, which increases levels of the byproduct lactate. For a period of minutes to days after a concussion, the brain is especially vulnerable to changes in intracranial pressure, blood flow, andanoxia.

flow. Excitatory neurotransmitters, chemicals such as glutamate that serve to

According to studies performed on animals (which are not always applicable to humans), large numbers of neurons can die during this period in response to slight, normally innocuous changes in blood flow. Concussion involves diffuse (as opposed to focal) brain injury, meaning that the dysfunction occurs over a widespread area of the brain rather than in a particular spot. Concussion is thought to be a milder type of diffuse axonal injury because axons may be injured to a minor extent due to

symptoms, especially those of a psychological nature, are more likely to be caused by reversible pathophysiological changes in cellular function that occur after concussion, such as alterations in neurons' biochemistry. These reversible changes could also explain why dysfunction is frequently temporary. A task force of head injury experts called the Concussion In Sport Group met in 2001 and decided that "concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury."

stretching. Animal studies in which primates were concussed have revealed damage to brain tissues such as small petechial hemorrhages and axonal injury. Axonal damage has been found in the brains of concussion sufferers who died from other causes, but inadequate blood flow to the brain due to other injuries may have contributed to the damage. Findings from a study of the brains of dead NFL athletes who received concussions suggest there is lasting damage to the brain after experiencing one; this damage can lead to a variety of other health issues. The debate over whether concussion is a functional or structural phenomenon is ongoing. Structural damage has been found in the mildly traumatically injured brains of animals, but it is not clear whether these changes would be applicable to humans. Such changes in brain structure could be responsible for certain symptoms such as visual disturbances, but other sets of

DENGUE HEMORRHAGIC FEVER

Once inside the skin, dengue virus binds to Langerhans cells (a population of dendritic cells in the skin that identifies pathogens). The virus enters the cells through binding between viral proteins and membrane proteins on the Langerhans cell, specifically the C-type lectinscalled DC-SIGN, mannose receptor and CLEC5A. DC-SIGN, a non-specific receptor for foreign material on dendritic cells, seems to be the main point of entry. The dendritic cell moves to the nearest lymph node. Meanwhile, the virus genome is replicated in membrane-bound vesicles on the cell's endoplasmic reticulum, where the cell's protein synthesis apparatus produces new viral proteins, and the viral When a mosquito carrying dengue virus bites a person, the virus enters the skin together with the mosquito's saliva. It binds to and enterswhite blood cells, and reproduces inside the cells while they move throughout the body. The white blood cells respond by producing a number of signaling proteins, such as interferon, which are responsible for many of the symptoms, such as the fever, the flu-like symptoms and the severe pains. In severe infection, the virus production inside the body is greatly increased, and many more organs (such as the liver and thebone marrow) can be affected, and fluid from the bloodstream leaks through the wall of small blood vessels into body cavities. As a result, less blood circulates in the blood vessels, and the blood pressure becomes so low that it cannot supply sufficient blood to vital organs. Furthermore, dysfunction of the bone marrow leads to reduced numbers of platelets, which are necessary for effective blood clotting; this increases the risk of bleeding, the other major complication of dengue fever. RNA is copied. Immature virus particles are transported to the Golgi apparatus, the part of the cell where some of the proteins receive necessary sugar chains (glycoproteins). The now mature new viruses bud on the surface of the infected cell and are released by exocytosis. They are then able to enter other white blood cells, such as monocytes and macrophages. The initial reaction of infected cells is to produce interferon, a cytokine that raises a number of defenses against viral infection through theinnate immune system by augmenting the production of a large group of proteins mediated by the JAK-STAT pathway. Some serotypes of dengue virus appear to have mechanisms to slow down this process. Interferon also activates the adaptive immune system, which leads to the generation of antibodies against the virus as well as T cells that directly attack any cell infected with the virus.Various antibodies are generated; some bind closely to the viral proteins and target them for phagocytosis (ingestion by specialized cells and destruction), but some bind the virus less well and appear instead to deliver the virus into a Viral reproduction part of the phagocytes where it is not destroyed but is able to replicate further.

Hematocrit Liver enzymes Platelet count Serologic studies (demonstrate antibodies to Dengue viruses) Serum studies from samples taken during acute illness and convalescence (increase in titer to Dengueantigen)

Tourniquet test (causes petechiae to form below the tourniquet) X-ray of the chest (may demonstrate pleural effusion)

Treatment Because Dengue hemorrhagic fever is caused by a virus for which there is no known cure or vaccine, the only treatment is to treat the symptoms.

A transfusion of fresh blood or platelets can correct bleeding problems Intravenous (IV) fluids and electrolytes are also used to correct electrolyte imbalances

Oxygen therapy may be needed to treat abnormally low blood oxygen Rehydration with intravenous (IV) fluids is often necessary to treat dehydration

Exams and Tests

Supportive care in an intensive care unit/environment

Arterial blood gases Coagulation studies Electrolytes

Outlook (Prognosis) With early and aggressive care, most patients recover from dengue hemorrhagic fever. However, half of untreated patients who go into shock do not survive.

BLIGHTED OVUM / ANEMBRYONIC GESTATION


An anembryonic gestation (aka blighted ovum) is a pregnancy in which the very early pregnancy appears normal on an ultrasound scan, but as the pregnancy progresses a visibleembryo never develops. In a normal pregnancy, an embryo would be visible on an ultrasound by six weeks after the woman's last menstrual period. An anembryonic gestation is characterized by a normal-appearing gestational sac, but the absence of an embryo. It likely occurs as a result of early embryonic death with continued development of the trophoblast. When small, the sac cannot be distinguished from the early normal pregnancy, as there may be a yolk sac, though a fetal pole is not seen. For diagnosis, the sac must be of sufficient size that the absence of normal embryonic elements is established. The criteria depends on the type of ultrasound exam performed. A pregnancy is anembryonic if a transvaginal ultrasound reveals a sac with a mean gestational sac diameter (MGD) greater than 13 mm and no yolk sac, or an MGD >18 mm with no embryo. If a transvaginal exam is not performed, the criteria for a transabdominal scan is a MGD of 25 mm or more without an embryo or an MGD of 20 mm or more without a yolk sac. Rather than do a transvaginal exam at the time of the initial visit, many centers prefer to do only a transabdominal study and offer mothers a followup ultrasound 10 days later to see if a normal pregnancy subsequently develops.

Several management options exist for anembryonic pregnancies which have not miscarried on their own. A blighted ovum, also called an anembryonic pregnancy, occurs when a fertilized egg develops a placenta and membrane but no embryo often due to chromosomal abnormalities in the fertilized egg. A blighted ovum usually occurs in the first few weeks of pregnancy, often before a woman even knows she's pregnant. With a blighted ovum, a woman may miss a period and have a positive pregnancy test. This is because the placenta secretes human chorionic gonadotropin (HCG), a pregnancy hormone. Symptoms of early pregnancy such as fatigue and breast tenderness are possible as well. But when the placenta stops growing and hormone levels decrease, the pregnancy symptoms subside. At this point, minor abdominal cramping and light spotting or bleeding are possible. An ultrasound will show an empty gestational sac. A blighted ovum eventually results in miscarriage. Some women choose to wait for the miscarriage to happen naturally, while others take medication to trigger the miscarriage. In some cases, a procedure called dilation and curettage (D&C) is used to remove the placental tissues. Most women who've had a blighted ovum go on to have successful pregnancies. If you experience multiple consecutive miscarriages, you might consider testing to identify any underlying causes. After having been diagnosed with a blighted ovum a few weeks after finding

Anembryonic gestation is one of the causes of miscarriage of a pregnancy.

out we were pregnant, I learned a lot about it and here are some of them:

A blighted ovum ( also called an anembryonic pregnancy) is a fertilized egg which implants in the uterus, and begins to develop a gestational sac. The fertilized egg, however, fails to form beyond the sixth week and is absorbed back into the uterus. The placenta continues to grow, and the body is usually slow to catch on that the pregnancy is gone.

many women miscarried blighted ovum pregnancies without knowing what had happened. Today, however, technology has improved to the point that an ultrasound can examine exactly what is going on inside the womb. Due to this technology, the diagnosis of a Blighted Ovum is becoming more common. In most likelihood the reason is random chromosomal accident (further research suggests a 4 in 5 chance that the cause is chromosomal in this situation). In some cases, the egg or the sperm may be of poor quality. The age of the parents may contribute to this factor although this diagnosis happens to all ages. Occasionally the cause may be something other than chromosomal, such as low hormone levels. This is rare but in these cases a treatable condition might be the cause. For example, a low hormone level may have caused early termination of the pregnancy. In these cases, hormone pills such as progesterone may work. If repeated blighted ovums occur, artificial fertilization may be an answer. Genetic testing in the case of multiple losses may be advised to rule out genetic problems. The most common (and hurtful) misconception is that there never was a baby. There was an embryo. There is no way to know how much of the baby formed and when the baby was absorbed. Someone actually suggested to me that my body was confused and that my little one only existed in my mind.

There may be no bleeding to signal a problem; later, the woman may notice a brown discharge. Sometimes a woman will have a loss without ever knowing she was pregnant. Others will discover the pregnancy and all will appear well throughout much if not all of the first trimester. She may not realize she has a blighted ovum until her healthcare provider fails to detect a heartbeat or an ultrasound reveals an empty gestational sac. Since the placental tissue generates the making of pregnancy hormones, many women with a blighted ovum feel pregnant but are destined to lose the pregnancy. In past decades,

Obviously there was something wrong with him or her and that is the reason she stopped forming. To suggest that he or she never existed at all, even for a moment, in my opinion devalues the little life that could have been. It also devalues all of the pain that we feel when we find out that the baby is gone. Just because the little angel is gone by the time the loss is discovered doesnt mean that he or she never was. The body has reacted to the existance of that little onehowever brief his or her presence was.

When should the baby be able to be seen by ultrasound, or when should the lack of seeing a baby via transvaginal ultrasound be evidence of a blighted ovum? By the 8th to the 9th week, assuming the pregnancy is dated correctly, the baby/heartbeat should be able to be detected via ultrasound. The gestational sac can be visualized as early as four and a half weeks of gestation and the yolk sac at about five weeks. The embryo can be observed and measured as early as five and a half weeks, via transvaginal ultrasound with a full bladder. Ultrasound can also very importantly confirm the site of the pregnancy is within the cavity of the uterus. Hormone levels may be monitored in order to check on the pregnancy. Human chorionic gonadotropin (hCG), is produced during pregnancy, made by cells that form the placenta. They can first be detected by a normal blood test about 11 days after conception and at about 12 14 days by a urine test. In general they will double every 72 hours. The levels will reach their peak in the 8 11 weeks of pregnancy (the third month) and then will decline and level off for the remainder of the pregnancy. A decline early on might aid in confirming a pregancy loss, such as a blighted ovum. Purposes
Is an alternative procedure that can be used instead of

hemodialysis to remove waste products or toxins that have accumulated as a result of acute or chronic renal failure.

Remove the end products of protein metabolism, such as urea and creatinine, from the blood.

Maintain a safe concentration of serum electrolytes. Correct acidosis and replenish the bloods bicarbonate buffer system. Remove excess fluid from the blood. Equipments

PERITONEAL DIALYSIS

Solution storage. At the beginning of the session, you connect bags of dialysis solution to tubing that feeds the cycler. Most systems include a separate tube for the last bag because this solution may have a higher dextrose content so that it can work for a day-long dwell time. Disposal container or drain line. After the used solution is weighed, it's pumped to a disposal container that you can throw away in the morning. With some systems, you can dispose of the used fluid directly by stringing a long drain line from the cycler to a toilet or bathtub. Procedure Preparation Before catheter insertion, the client must be fully prepared. The client needs to know exactly what will happen and what to do during the dialysis process, and what kind of results can be expected from the treatment. Informed consent must be obtained. Baseline weight, vital signs, and blood chemistries provide important data for later comparison. Mild sedation may be provided. The bladder and the bowel should be emptied. The abdomen is shaved and prepped.

Catheter Insertion Catheter insertion may be performed in the operating room or at bedside under local anesthesia.

The preferred insertion site is 3-5 cm below the umbilicus, an area that is relatively avascular and has less fascial resistance. For the placement of an acute rigid stylet catheter, an incision is made, and a stylet or a large bore needle is inserted through the incision.

Fluid is infused to expand the peritoneal cavity to stabilize the catheter and reduce the risk of infection.

If dialysis is to begin immediately, the equipment needs to be entirely ready with the dialysate warmed to 37 C (98 F) in order to optimize clearance of uremic metabolites; all tubing is flushed to prevent air from entering the cavity.

HEMODIALYSIS

Unless contraindicated, heparin is administered(heparin: natural clot preventer) blood flows through a semipermeable membrane in one direction. Dialysis solution surrounds the membranes and flows in the opposite direction. Dialysis solution is: Highly purified water Sodium, potassium, calcium, magnesium, chloride and dextrose Either bicarbonate or acetate, to maintain a proper pH Via the process of diffusion, wastes are removed in the form of solutes (metabolic wastes, acid-base components and electrolytes) Solute wastes can then be discarded or added to the blood

is a treatment / procedure act to separate the blood from residual substances / toxins carried by flowing blood through the membrane semi permeable where waste or toxic substances are diverted from the blood into the dialysate fluid is then discarded, while the blood back into the body.

Ultrafiltration removes excess water from the blood After cleansing, the blood returns to the client via the access Nursing Management Caring for the access (Health teaching) Wash the access with soap and warm water each day, and always before dialysis. Do not scratch the area or try to remove scabs. Check the area daily for signs of infection, including warmth and redness. Check that there is blood flow in the access daily. There should be a vibration (called a thrill) over the access. If this is absent or changes, notify your healthcare provider. Sometimes, flow monitoring is done during the dialysis treatment using ultrasound (sound waves). The flow monitoring measures the speed of blood flow during dialysis treatment.

Purpose

Remove the end products of protein metabolism, such as urea and creatinine, from the blood.

Maintain a safe concentration of serum electrolytes. Correct acidosis and replenish the bloods bicarbonate buffer system. Remove excess fluid from the blood. Procedure Patients circulation is accessed

Take care to avoid traumatizing the arm where the access is located; do not wear tight clothes, jewelry, carry heavy items, or sleep on the arm. Do not allow anyone to take blood or measure blood pressure on this arm. Rotate needle sites on the access. Use gentle pressure to stop bleeding when the needle is removed. If bleeding occurs later, apply gentle pressure; call a healthcare provider if bleeding does not stop within 30 minutes or if bleeding is excessive. Antihypertensive drugs are not given the morning of dialysis as they can cause severe hypotension during the treatment. Nitroglycerin patches, digitalis and anticoagulants are also held Consult with the dialysis nurse to coordinate the timing of medications. Before the patient goes to the dialysis, do a physical assessment and obtain a complete set of vital signs and weight. Assess patient more frequently in the hours after dialysis treatment is completed.

ASTHMA

Asthma is a chronic (long-term) lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. The coughing often occurs at night or early in the morning. Asthma affects people of all ages, but it most often starts during childhood. In the United States, more than 22 million people are known to have asthma. Nearly6 million of these people are children. Overview The airways are tubes that carry air into and out of your lungs. People who have asthma have inflamed airways. This makes the airways swollen and very sensitive. They tend to react strongly to certain inhaled substances.

When the airways react, the muscles around them tighten. This narrows the airways, causing less air to flow into the lungs. The swelling also can worsen, making the airways even narrower. Cells in the airways may make more mucus than normal. Mucus is a sticky, thick liquid that can further narrow your airways. This chain reaction can result in asthma symptoms. Symptoms can happen each time the airways are inflamed. Figure A shows the location of the lungs and airways in the body. Figure B shows a cross-section of a normal airway. Figure C shows a cross-section of an airway during asthma symptoms. Sometimes, asthma symptoms are mild and go away on their own or after minimal treatment with an asthma medicine. Other times, symptoms continue to get worse. When symptoms get more intense and/or more symptoms occur, you're having an asthma attack. Asthma attacks also are called flareups or exacerbations (eg-zas-er-BA-shuns). It's important to treat symptoms when you first notice them. This will help prevent the symptoms from worsening and causing a severe asthma attack. Severe asthma attacks may require emergency care, and they can be fatal. Outlook Asthma can't be cured. Even when you feel fine, you still have the disease and it can flare up at any time. However, with today's knowledge and treatments, most people who have asthma are able to manage the disease. They have few, if any, symptoms.

They can live normal, active lives and sleep through the night without interruption from asthma. You can take an active role in managing your asthma. For successful, thorough, and ongoing treatment, build strong partnerships with your doctor and other health care providers.

TROPONIN I

How is it used? Troponin tests are primarily ordered for people who have chest pain to see if they have had a heart attack or other damage to their heart. Either a troponin I or a troponin T test can be performed; usually a laboratory will offer one test or the other. Troponins are sometimes ordered along with other cardiac biomarkers, such as CKMB or myoglobin. However, troponins are the preferred tests for a suspected heart attack because they are more specific for heart injury than other tests (which may become positive in skeletal muscle injury) and remain elevated for a longer period of time. The troponin test is used to help diagnose a heart attack, to detect and evaluate mild to severe heart injury, and to distinguish chest pain that may be due to other causes. In patients who experience heart-related chest pain, discomfort, or other symptoms and do not seek medical attention for a day or more, the troponin test will still be positive if the symptoms are due to heart damage. When is it ordered? The troponin test will usually be ordered when a patient with a suspected heart attack first comes into the emergency room and then may be repeated at 6 and 12 hours later. It is sometimes ordered along with other tests such as CK, CKMB, ormyoglobin. Typically, 2 or 3 troponin tests are done over a 12- to 16-hour period. In patients with stable angina, a troponin test may be ordered if the patients symptoms get worse, occur when the patient is at rest, and/or no longer ease with treatment. These are all signs that the angina is becoming unstable, which increases the risk of a heart attack or other serious heart problem in the near future. What does the test result mean? Normally, cardiac troponin levels are so low that they cannot be measured. Even slight elevations may indicate some degree of damage to the heart. When a patient has significantly elevated troponin concentrations, then it is likely that the patient has had a heart attack or some other form of damage to the heart. When a patient with chest pain and/or known stable angina has normal troponin values, then it is likely that their heart has not been injured. Troponin values can remain high for 12 weeks after a heart attack. The test is not affected by damage to other muscles, so injections, accidents, and drugs that can damage muscle do not affect troponin levels. Troponin may rise following strenuous exercise, although in the absence of signs and symptoms of heart disease, it is usually of no medical significance. Is there anything else I should know? Increased troponin concentrations should not be used by themselves to diagnose or rule out a heart attack. A physical exam, clinical history, and ECG are also important. Some people who have a heart attack will have normal troponin concentrations, and some people with increased troponin concentrations have no apparent heart injury. Troponin levels may also be elevated with acute or chronic conditions such as myocarditis (heart inflammation), congestive heart failure, severe infections, kidney disease, and certain chronic inflammatory conditions of muscles and skin.

An abscess is a cavity containing pus and surrounded by inflamed tissue, formed as a result of a localized infection. Description of Abscess

ABCESS

An abscess may develop, enlarge or subside, depending on whether microorganisms or leukocytes (white blood cells) gain the upper hand in any one of a number of locations in the body. Abscesses may develop in any organ and in the soft tissues beneath the skin in any area. Common sites include the breast, gums and peri-rectal area. Rarer sites include the liver and the brain. Common sites for abscesses under the skin include the axilla (armpit) and the groin. These two areas have a large number of lymph glands that are responsible for fighting infection. A collar-button abscess is one in which a small abscess cavity under the skin connects via a sinus to (channel) to a much larger one in deeper tissues. Causes and Risk Factors of Abscess

Abscesses can be caused by minor breaks and punctures of the skin, obstruction of sweat glands and oil (sebaceous) glands, and inflammation of hair follicles. They contain dead cells, bacteria, and other debris, which causes inflammation and pain. Common bacteria, such as staphylococci, are the most common cause, although the bacillus responsible fortuberculosis is an important abscess-forming type. Fungal infections sometimes cause abscesses, while amoebae (single-celled protozoal parasites) are an important cause of liver abscesses. The infection usually reaches an organ via the bloodstream or penetrates tissues under the skin via an infected wound or bite. People with weakened immune systems may be more prone to abscesses or may have more severe ones. Symptoms of Abscess Abscesses tend to get worse as time goes on. Symptoms include tenderness or pain and the site of the abscess being warm to the touch. Symptoms of discomfort or pain depend mainly on the site of the abscess, though larger ones - since they are a source of infection within the body can cause fever, chills, sweating, and malaise. Abscesses close to the skin usually cause inflammation with redness, increased skin temperature and tenderness. Tuberculous abscesses are the exception; hence their introduction as cold abscesses. Call your doctor if you have a high fever, or if the abscess is larger than inch across, is near your rectal area or groin, or if red streaks are radiating out from the abscess.

Diagnosis of Abscess An abscess is diagnosed clinically by means of the history and a physical exam, demonstrating a tender mass with overlying erythema (redness). Treatment of Abscess Small abscesses may be helped by applying warm compresses to the area several times a day. This will sometimes promote spontaneous drainage of the abscess which is important since the primary treatment of abscesses is to drain them. However, it is also important to not attempt to drain an abscess yourself. This can lead to trauma of the surrounding tissue and potentially help spread the underlying infection.

INTERNAL JUGULAR VEIN INSERTION


(Central Venous Pressure [CVP] Monitoring)

In the

central

venous inserts a

For intermittent CVP monitoring: Disposable CVP manometer set, leveling device (such as rod from a reusable CVP pole holder or a carpenters level or rule), additional stopcock (attach the CVP manometer to the catheter), extension tubing (if needed), I.V pole, I.V solution, I.V drip chamber and tubing, dressing materials, tape. For continuous CVP monitoring: Pressure monitoring kit with disposable pressure transducer, leveling device, bedside pressure module, continuous I.V flush solution, pressure bag For withdrawing blood samples through the CV line: Appropriate no. of syringe for the ordered tests, 5- 10 ml syringe for the discard sample. For using an intermittent CV lines: Syringe with normal saline solution, syringe with heparin flush solution.

pressure (CVP) monitoring, practitioner catheter through a vein and advances it until its tip lies in or near the right atrium. Because no major valves lie at the junction of the vena cava reflects back to the catheter. When connected to a manometer, the catheter measures CVP, an index of right ventricular function.Normal CVP ranges from 2 to 6 Hg (5 to 10 cm H2O). and at right end atrium, diastole pressure

Purpose CVP monitoring helps to assess cardiac function To evaluate venous return to the heart To indirectly gauge how well the heart is pumping. Provide access to large vessels for rapid, high volume fluid administration and allows frequent blood withdrawal for laboratory samples.

For removing a CV catheter: Sterile gloves, suture removal set, sterile gauze pads, antimicrobial ointment, dressing, tape. Assisting with CVP placement Adhere to institutional Policy and Procedure. Obtain history and assess the patient. Explain the procedure to the patient, include:

Equipments

local anesthetic

trendelenberg positioning

draping limit movement

need to maintain sterile field.

post procedure chest X-ray Obtain a sterile, flushed and pressurized transducer assembly Obtain the catheter size, style and length ordered. Obtain supplies: Masks Sterile gloves Line insertion kit Heparin flush per policy Position patient supine on bed capable of trendelenberg position Prepare for post procedure chest X-ray The CVP catheter is an important tool used to assess right ventricular function and systemic fluid status. How is it used? CKMB levels, along with total CK, are tested in persons who have chest pain to diagnose whether they have had a heart attack. Since a high total CK could indicate damage to either the heart or other muscles, CKMB helps to distinguish between these two sources. If your doctor thinks that you have had a heart attack and gives you a clotdissolving drug, CKMB can help your doctor tell if the drug worked. When the clot dissolves, CKMB tends to rise and fall faster. By measuring CKMB in blood several times, your doctor can usually tell whether the drug has been effective.

MYOGLOBIN- CREATININE KINASE (CK- MB)


When is it ordered?

CK-MB is usually ordered along with total CK in persons with chest pain to determine whether the pain is due to a heart attack. It may also be ordered in a person with a high CK to determine whether damage is to the heart or other muscles. Increased CK-MB can usually be detected in heart attack patients about 3-4 hours after onset of chest pain. The concentration of CK-MB peaks in 18-24 hours and then returns to normal within 72 hours. Although CK-MB is a very good test, it has been largely replaced by troponin, which is more specific for damage to the heart. What does the test result mean? If the value of CK-MB is elevated and the ratio of CKMB to total CK (relative index) is more than 2.53, it is likely that the heart was damaged. A high CK with a relative index below this value suggests that skeletal muscles were damaged. Is there anything else I should know? Severe injury to skeletal muscle can be significant enough to raise CKMB levels above normal, but such injury doesnt usually cause a high relative index. Strenuous exercise may also increase both CK and CK-MB. If your doctor suspects injury to both heart muscle and skeletal muscle, troponin is a more accurate test for identifying aheart attack. Sometimes persons who are having trouble breathing have to use their chest muscles. Chest muscles have more CKMB than other muscles, which would raise the amount of CKMB in the blood.

Persons whose kidneys have failed can also have high CKMB levels without having had a heart attack. Rarely, chronicmuscle disease, low thyroid hormone (T3, T4, TSH) levels, and alcohol abuse can increase CKMB, producing changes similar to those seen in a heart attack.

ARTERIAL BLOOD GAS

interferes with tissue oxygenation and normal neurological and muscular functioning. Significant changes in the blood pH above 7.8 or below 6.8 will interfere with cellular functioning, and if uncorrected, will lead to death. Arterial blood gas analysis is an essential part of diagnosing and managing a patients oxygenation status and acid-base balance. The usefulness of this diagnostic tool is dependent on being able to correctly interpret the results. This self-learning packet will examine the components of an arterial blood gas and what each component represents and interpret these values in order to determine the patients condition and treatment. Acid-Base Balance The pH is a measurement of the acidity or alkalinity of the blood. It is inversely proportional to the number of hydrogen ions (H+) in the blood. The more H+ present, the lower the pH will be. Likewise, the fewer H+ present, the higher the pH will be. The pH of a solution is measured on a scale from 1 (very acidic) to 14 (very alkalotic). A liquid with a pH of 7, such as water, is neutral (neither acidic nor alkalotic). The normal blood pH range is 7.35 to 7.45. In order for normal metabolism to take place, the body must maintain this narrow range at all times. When the pH is below 7.35, the blood is said to be acidic. Changes in body system functions that occur in an acidic state include a decrease in the force of cardiac contractions, a decrease in the vascular response to catecholamines, and a diminished response to the effects and actions of certain medications. When the pH is above 7.45, the blood is said to be alkalotic. An alkalotic state So how is the body able to self-regulate acid-base balance in order to maintain pH within the normal range? It is accomplished using delicate buffer mechanisms between the respiratory and renal systems. Lets examine each system separately. The Respiratory Buffer Response A normal by-product of cellular metabolism is carbon dioxide (CO2). CO2 is carried in the blood to the lungs, where excess CO2 combines with water (H2O) to form carbonic acid (H2CO3). The blood pH will change according to the level of carbonic acid present. This triggers the lungs to either increase or decrease the rate and depth of ventilation until the appropriate amount of CO2 has been re-established. Activation of the lungs to compensate for an imbalance starts to occur within 1 to 3 minutes. The Renal Buffer Response In an effort to maintain the pH of the blood within its normal range, the kidneys excrete or retain bicarbonate (HCO3--). As the blood pH decreases, the kidneys will compensate by retaining HCO3-- and as the pH rises, the kidneys excrete HCO3-- through the urine. Although the kidneys provide an excellent means of regulating acid-base balance, the system may take from hours to days to correct the imbalance. When the respiratory and renal systems are working together, they are able to keep the blood pH balanced by maintaining 1 part acid to 20 parts base.

Acid-Base Disorders Respiratory Acidosis Respiratory acidosis is defined as a pH less than 7.35 with a PaCO2 greater than 45 mm Hg. Respiratory Alkalosis Respiratory alkalosis is defined as a pH greater than 7.45 with a PaCO2 less than 35 mm Hg. Metabolic Acidosis
Metabolic acidosis is defined as a bicarbonate level of less than 22

Acid-fast bacilli (AFB) are a group of rod-shaped bacteria (bacilli). They get their name because they can be seen and counted under the microscope when smeared on a slide and treated with a special "acid-fast" staining procedure. There are a several types of bacteria that may be detected in this manner; however, the most common and medically important acid-fast bacilli (AFB) are members of the genus Mycobacterium. Mycobacterium tuberculosis is one of the most prevalent and infectious species of mycobacteria. Most samples that are submitted for AFB smears and cultures are collected because the doctor suspects that a person has a lung infection caused by M. tuberculosis (TB). Another group of bacteria referred to as non-tuberculous mycobacteria (NTM), can also cause infections. However, only a few of the more than 60 species of mycobacteria that have been identified cause infections in humans. They include:

mEq/L with a pH of less than 7.35. Metabolic Alkalosis


Metabolic alkalosis is defined as a bicarbonate level greater than 26

mEq/liter with a pH greater than 7.45.

Mycobacterium africanum causes a disease similar to TB in certain parts of the world Mycobacterium avium-intracellulare complex (MAC) can cause a lung infection in immunosuppressed patients, such as the elderly and those with AIDS; this infection is not contagious but can be difficult to treat as it tends to be highly resistant to antibiotics.

ACID FAST BACILLUS

Other mycobacterial species, such as Mycobacterium marinum, grow in water, such as fish tanks, and can cause skin infections, while other rapidly growing mycobacteria can infect wounds and prosthetic devices.

What is being tested?

A few mycobacteria, such as Mycobacterium bovis, can sometimes be transferred from animal to human.

most common). They are fairly sensitive and specific when they are paired with positive AFB smears; when they are done on samples that are AFB negative by smear, they tend to be less accurate. These methods are approved for respiratory samples and must be confirmed with an AFB culture, but they do provide the doctor with a quick answer, allowing him to isolate potentially infectious patients and minimize the spread of the disease. Guidelines from the Centers for Disease Control and Prevention (CDC) recommend that people with signs and symptoms of TB have at least one sample tested using nucleic acid amplification to be used in conjunction with AFB smear and culture.

An AFB smear, which can provide presumptive results in a few hours, is a valuable tool in helping to make decisions about treatment while culture results are pending. Typically, several AFB smears from different samples are screened for AFB since the number of bacilli may vary from sample to sample and day to day. If acid-fast bacilli are present on any of the smears, a mycobacterial infection is likely. Since M. tuberculosis is the most common cause of respiratory infections with mycobacteria, a presumptive diagnosis of TB can be made, but other follow-up testing must be done to positively identify the acid-fast bacilli as either M. tuberculosis or another mycobacteria species. Patient samples are processed for AFB cultures at the same time as the smears. Mycobacteria grow more slowly than other types of bacteria so positive identification of the species that is/are present may take days to several weeks, while negative results (no mycobacterial growth) can take up to 6 to 8 weeks to confirm. Tests that may be done in addition to an AFB smear and culture include:

Susceptibility testing for cultures that are positive will determine the bacteria's susceptibility or resistance to drugs most commonly used to treat the infection.

Since TB is transmitted by airborne droplets from respiratory secretions, it is a public health risk. It can spread in confined populations, such as correctional facilities, nursing homes, and schools. Those who are very young, elderly, or have diseases and conditions, such as AIDS, that compromise their immune systems tend to be especially vulnerable. AFB smears and cultures can help track and minimize the spread of TB in these populations and help determine the effectiveness of treatment. How is the sample collected for testing? Since M. tuberculosis and M. avium most frequently infect the lung (pulmonary disease), sputum is the most commonly tested sample. Sputum is phlegm, thick mucus that is coughed up from the lungs. Usually, three to five early morning samples are collected (on consecutive days) in individual sterile cups.

Molecular tests for TB that detect the genetic components of mycobacteria have been developed to help decrease the amount of time necessary for a presumptive diagnose of tuberculosis. These include genetic probes and molecular TB testing. They amplify/replicate pieces of the microorganisms' genetic material to detect mycobacteria in body samples in less than 24 hours and can narrow the identification to a complex of mycobacteria (a combination, of whichM. tuberculosis is the

If a person is unable to produce sputum, the doctor may collect respiratory samples using a procedure called a bronchoscopy. Bronchoscopy allows the doctor to look at and collect samples from the bronchi and bronchioles. Once a local anesthetic has been sprayed onto the airway, the doctor can insert a tube into the bronchi and smaller bronchioles and aspirate fluid samples for testing. Sometimes, he will introduce a small amount of saline through the tubing and into the bronchi and then aspirate it to collect a bronchial washing. Since young children cannot produce a sputum sample, gastric A chest X-ray is a picture of the chest that shows your heart, lungs, airway, blood vessels, and lymph nodes. A chest X-ray also shows the bones of your spine and chest, including your breastbone , ribs , collarbone , and the upper part of your spine . A chest X-ray is the most common imaging test or X-ray used to find problems inside the chest. A chest X-ray can help find some problems with the organs and structures inside the chest. Usually two pictures are taken, one from the back of the chest and another from the side. In an emergency when only one X-ray picture is taken, a front view is usually done. Doctors may not always get the information they need from a chest X-ray to find the cause of a problem. If the results from a chest X-ray are not normal or do not give enough information about the chest problem, more specific X-rays or other tests may be done, such as a computed tomography (CT) scan, an ultrasound, an echocardiogram, or an MRI scan. Why It Is Done A chest X-ray is done to: Help find the cause of common symptoms such as a cough, shortness of breath, or chest pain.

washings/aspirates may be collected. This involves introducing saline into the stomach through a tube, followed by fluid aspiration. If the doctor suspects TB is present outside of the lungs (extrapulmonary), a condition fairly common in AIDS patients, he may test the body fluids and tissues most likely affected. For instance, one or more urine samples may be collected if he suspects TB has infected the kidneys. A needle may used to collect body fluid from joints or from other body cavities, such as the pericardium or abdomen.

CHEST X-RAY

Find lung conditions-such as pneumonia, lung cancer, chronic obstructive pulmonary disease (COPD), collapsed lung (pneumothorax), or cystic fibrosis-and monitor treatment for these conditions.

The equipment typically used for chest x-rays consists of a wall-mounted, box-like apparatus containing the x-ray film or a special plate that records the image digitally and an x-ray producing tube, that is usually positioned about six feet away. The equipment may also be arranged with the x-ray tube suspended over a table on which the patient lies. A drawer under the table holds the x-ray film or digital recording plate. A portable x-ray machine is a compact apparatus that can be taken to the patient in a hospital bed or the emergency room. The x-ray tube is connected to a flexible arm that is extended over the patient while an x-ray film holder or image recording plate is placed beneath the patient.

Find some heart problems, such as an enlarged heart, heart failure, and problems causing fluid in the lungs (pulmonary edema), and to monitor treatment for these conditions.

Look for problems from a chest injury, such as rib fractures or lung damage. Find foreign objects, such as coins or other small pieces of metal, in the tube to the stomach (esophagus), the airway, or the lungs. A chest X-ray may not be able to see food, nuts, or wood fibers. See an X-ray of a coin in the esophagus

See if a tube, catheter, or other medical device has been placed in the proper position in an airway, the heart, blood vessels of the chest, or the stomach. How To Prepare Tell your doctor if you are or might be pregnant. A chest X-ray usually is not done during pregnancy because the radiation could harm the unborn baby (fetus). But the chance of harm to the fetus is very small. If you need a chest X-ray, you will wear a lead apron to help protect your baby. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results mean. To help you understand the importance of this test, fill out the medical test information form. What does the equipment look like?
How is treatment determined?

LIPID PROFILE

Element A lipid profile measures total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides. A physician may order a lipid profile as part of an annual exam or if there is specific concern about CVD, especially coronary artery disease. The National Cholesterol Education Program recommends that individuals age twenty and over have a fasting lipoprotein profile every Treatment is determined by your overall risk of coronary heart disease. Based on the results of lipid tests and other major risk factors, your target LDL cholesterolis identified. If your LDL-C is above the target value, you will be treated. Your target LDL-C value is:

Optimal <100 >60 <150 <200 <4

Borderline 130159 3545 150199 200239 5

High risk 160+ <35 >200 >240 >6

LDL Cholesterol HDL Cholesterol Triglycerides Total Cholesterol Cholesterol to HDL Ratio

Blood Lipids and Lipid Transport Lipids are insoluble (does not dissolve) in water but are soluble (dissolves) in alcohol and other solvents. When dietary fats are digested and absorbed into the small intestine, they eventually re-form into triglycerides , which are then packaged into lipoproteins . Dietary fats, including cholesterol , are absorbed from the small intestines and transported into the liver by lipoproteins called chylomicrons. Chylomicrons are large droplets of lipids with a thin shell of phospholipids , cholesterol, and protein . Once chylomicrons enter the bloodstream, an enzyme calledlipoprotein lipase breaks down the triglycerides into fatty acid and glycerol . After a 12- to 14-hour fast, chylomicrons are absent from the bloodstream. Thus, individuals who are having a lipid profile done should fast overnight to ensure that chylomicrons have been cleared. The liver removes the chylomicron fragments, and the cholesterol is repackaged for transport in the blood in very low-density lipoproteins (VLDLs), which eventually turn into low-density lipoproteins (LDL). LDL cholesterol (LDL-C)the "bad cholesterol"consists mainly of cholesterol. Most LDL particles are absorbed from the bloodstream by receptor cells in the liver. Cholesterol is then transported throughout the cells. Diets high in saturated fats and cholesterol decrease the uptake of LDL particles by the liver. LDL

Less than 100 mg/dL (2.59 mmol/L) if you have heart disease or diabetes. Less than 130 mg/dL (3.37 mmol/L) if you have 2 or more risk factors. Less than 160 mg/dL (4.14 mmol/L) if you have 0 or 1 risk factor.

The first step in treating high LDL-C is targeted at changes in lifestyle specifically, adopting diets low in cholesterol, saturated fat and trans unsaturated fats (trans fats) and participating in moderate exercise. You may be referred to a dietician for advice in making dietary changes. If low-fat diets and exercise are not adequate to lower LDL cholesterol to the target value, drug therapy would be the next step. There are several classes of drugs that are effective in lowering LDL. You may be prescribed one of these. Your LDL will be checked at regular intervals to assure that the drug is working. If the drug does not result in reaching your target LDL-cholesterol, your doctor may increase the amount of drug or possibly add a second drug. OPTIMAL, BORDERLINE, AND HIGH LEVELS FOR EACH COMPONENT Element Optimal Borderline High risk

particles are also removed from the bloodstream by scavenger cells, or macrophages, which are white blood cellsthat bury themselves in blood vessels such as arteries. Scavenger cells prevent cholesterol from reentering the bloodstream, but they deposit the cholesterol in the inner walls of blood vessels, eventually leading to the development of plaque. High-density lipoproteins (HDLs) are a separate group of lipoproteins that contain more protein and less cholesterol than LDL. HDL cholesterol (HDL-C) is also called "good cholesterol." HDL is produced primarily in the liver and intestine, and it travels in the bloodstream, picks up cholesterol, and gives the cholesterol to other lipoproteins for transport back to the liver.