Advanced Med Surg Final Part 2 Everything Else

7/27/2019 Advanced Med Surg Final Part 2 Everything Else

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Advanced Med Surg Final Part 2 Everything Else

Question Answer What do you call the creation ofblood cells?

hematopoiesis

What are the two types of stemcells from which all blood cells areproduced?

Myeloid stem cells and Lymphoid stem cells

Which blood cells are created bylymphoid stem cells?

lymphocytes (b-lymphocytes and t-lymphocytes)

Which blood cells are created by

myeloid stem cells?

everything else: erythrocytes, platelets, neutrophils,

monocytes(macrophages), eosinophils andbasophils

The hormone Erythropoietin causesdifferentiation of the myeloid stemcell to become an erythrocyte.Where is erythropoietin produced?

in the kidneys (it is released when the kidneysdetect low levels of oxygen in the blood)

What is the condition called whenthere is an abnormally low numberof circulating RBC's AND anabnormally low oxygen

concentration?

anemia

What three labs are done to test foranemia?

CBC (complete blood count), Hgb (hemoglobin) andHct (hematocrit)

What deficiencies can producehypoproliferative anemia (defect inthe production of red blood cells)?

iron, folic acid, b12, erythropoietin

What are the 4 major causes ofanemia?

hypoproliferative defect (defect in production), bonemarrow defect, hemolytic defect (defect indestruction), blood loss

What are the three inheriteddisorders that cause hemolyticanemia?

sickle cell, thalassemia, G-6-PD anemia

What are three other causes ofhemolytic anemia?

autoimmune processes, mechanical heart valvesand infection.

What kind of anemia can becaused by trauma or surgical

blood loss


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complication?

What is the normal hemoglobinlevel for women?

12-16

What is the normal hemoglobin

level for men?13-18

What is the normal hematocrit levelfor women?

35-47%

What is the normal hematocritrange for men?

42-52%

What is hematocrit?it is the percentage by volume of packed red bloodcells in a sample

What is the normal red blood cellcount for women?

4.2-5.4 X10^6/microliter

What is the normal red blood cellcount for men?

4.6-6.2 X10^6/microliter

One of the signs of anemia ispallor. What causes pallor?

the body's response to anemia is vasoconstrictionto decrease circulation to extremities whichincreases circulation to vital organs.

What the other 6 labs that may beordered for a patient with anemia?

reticulocyte count, mean corpuscular volume(MCV), serum iron level, total iron binding capacity(TIBC), serum vitamin B12 level and serum folatelevel

What invasive procedure may bedone to determine cause ofanemia?

bone marrow aspiration and analysis

What compensatory mechanismswill affect the heart and lungs in apatient with anemia?

heart rate and respiration rate will increase to makemore oxygen available to the body.

What will happen to an anemicpatient when they attempt activity?

they will experience fatigue and dyspnea

Why do some patients with anemia

experience bone pain?

this is caused by increased activity in the bonemarrow as it attemps to increase production of

RBC's

What is the cause of headachesand dizziness in patients withanemia?

decreased oxygen to the brain

Why do patients with nutritionaldeficiency anemias experiencecompromised oral mucosa and

decrease in perfusion of the oral mucosa makes itmore prone to breakdown


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cheliosis (cracks at the corners ofthe mouth)?

Which type of anemia can manifestin the patient eating non-food items(pica)?

iron deficiency anemia

Which type of anemia exhibitsfingernail deformity as amanifestation? (brittle, rigid,concave)

this is seen exclusively with iron deficiency anemia

Which type of anemia producesneurological deficits such asparathesias, ataxia and confusion?

this is seen exclusively in B12 anemia

If a vitamin B12 deficiency iscaused by a faulty absorption of the

GI tract, what type of anemia isproduced?

pernicious anemia (a type of B12 anemia)

Why isn't the vitamin B12 absorbedbt the GI tract in perniciousanemia?

Intrinsic factor is normally secreted by cells in thegastric mucosa. The intrinsic factor binds with thedietary vitamin B12 and travels with it to the ileum,where the vitamin is absorbed.Without intrinsicfactor,orally consumed B12 cannot be absorbed.

What happens if the B12 is notabsorbed?

production of rbc's is diminished.

Is there any other forms of

pernicious anemia?

yes, if there is disease involving the ileum or the

pancreas, absorption is impaired.

Is pernicious anemia inherited?Probably, it tends to run in families and generallyoccurs in adults and elderly.

When are symptoms of perniciousanemia apparent?

not until the anemia is severe. The bodycompensates so well that it goes on unnoticed for along time.

Are there any complications ofpernicious anemia?

Sort of. Gastric cancer occurs at a higher incidencein patients with pernicious anemia so patientsshould be encouraged to have endoscopies every

1-2 years to screen for gastric cancer.What is the treatment for pernicoiusanemia?

monthly B12 injections IM

How is pernicious anemia tested? Schilling test. It uses radioactive B12 and measuresradioactivity in the urine. Another test can be doneto look for antibodies which bind to the B12-intrinsicfactor complex which prevents the B12 from binding


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to receptors in the ileum. Expensive.

What is the normal range for WBCcount?

5,000-10,000/mm^3

What is the normal range for

neutrophils?3,000-7,000/mm^3 (60-70% of WBC's)

What is the normal range foreosinophils?

50-400/mm^3 (1-3% of WBC's)

What is the normal range forbasophils?

25-200/mm^3 (0.3-0.5% of WBC's)

What is the normal range forlymphocytes?

1,000-4,000/mm^3 (20-30% of WBC's)

What is the normal range formonocytes?

100-600/mm^3 (3-8% of WBC's)

What are the characteristics ofacute myeloid leukemia(AML)?

a defect in the stem cells that differentiate into allmyeloid 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 isvariable

What are the S&S of AML?

fever and infection, weakness & fatigue (fromanemia/decrease RBC), bleeding(r/tthrombocytopenia), pain from enlarged liver andspleen, gingival hyperplasia and bone pain.

What is the treatment for AML?aggressive chemo-induction therapy, bone marrowtransplant (BMT), or Peripheral Blood Stem CellTransplant (PBSCT)

What are the common sites ofinfection for patients with AML?

integumentary system, urinary tract, respiratorytract, oral mucosa (the risk of infection in the oralmucosa and skin are related to decreasedperfusion)

What are the four manifestations ofthrombocytopenia (low platelets)?

bleeding, bruising/hematoma, petechiea, internalbleeding such as GI/occult bleeding

What are 4 places that a patientwith AML may experience pain andswelling?

bone ,liver/spleen, lymph nodes (accumulateabnormal cells), gums (cells will be able to enterarterial blood but will get stuck in liver and spleenbefore enetering venous blood)

What part of the abdomen wouldthe patient experience liver pain?

right upper quadrant

What part of the abdomen would left upper quadrant


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the patient experience spleen pain?

What are the two types of chemoused with AML patients?

induction therapy and consolidation therapy

What is induction therapy?

HIGH dose of chemotherapy to eradicate leukemic

cells from bone marrow, normal stem cells are alsoeradicated (high risk for infection and bleeding)

What is consolidation therapy?

chemo given AFTER induction therapy toconsolidate the gains obtained. It is at much lowerdoeses and administered only after infections haveresolved and counts return to normal

What is the major complication ofchemotherapy?

Tumor lysis syndrome (when the cells aredestroyed, their contents are dumped into the bloodstream)

What are the three cellular

components that can cause themost problems in tumor lysissyndrome?

nucleic acids (converts to uric acid and causeshyperuricemia i.e. gout/joint pain, potassium,phosphorus

What is a manifestation ofhyperkalemia?

dysrhythmias

What are manifestations of hyperuricemia?

nausea/vomiting, acute monoarthritis (gout?), renalfailure (uric acid can clog nephrons in the kidney)

nausea/vomiting, acutemonoarthritis (gout?), renal failure

(uric acid can clog nephrons in thekidney)

tetany, cardiac dysrhythmias (most serious!)

What is the treatment of tumor lysissyndrome?

aggressive hydration for 24-28 hours prior toinduction chemotherapy, prophylactic admin of IVsodium bicarb (changes to alkalotic pH to preventuric acid from precipitating out to cause gout andrenal failure), admin of allopurinal, Kayexalate, lasix

What does allopurinal do? treats gout

What does Kayexalate do? removes potassium (causes diarrhea)

What does lasix do? removes more K+What else can be done to treattumor lysis syndrome if the othermedical interventions are noteffective?

hemodialysis

What medical intervention willfollow chemo in patient with AML?

BMT or PBSCT. The goal is for the client to beginmaking their own blood cells after the transplant


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What complication can arisefollowing a BMT or PBSCT?

graft-verses-host-disease (GVHD). Occurs in 50%of BMT and PBSCT recipients. Potentially Fatal!

What is GVHD?The recipients tissue is seen as foreign by the T-lymphocytes in the donated bone marrow

What are the three most commonorgans affected in GVHD?

skin(rash and loss of skin on hands , palms andsoles of feet, may extend over entire body), GI tract(hyperactivity: vomiting, severe diarrhea) and Liver(causing jaundice, ascites and diarrhea, also biliarystasis causing elevated serum liver enzymes)

What treatments are used after apatient develops graft-verses-host-disease? (not givenprophylactically)

Immunopupressant drugs:Sandimmune(cyclosporine), Methotrexate, Prograf(tacrolimus), Rapamune(sirolimus)

What is lymphoma? neoplasm of lymph origin

What are the two types oflymphoma?

Hodgkin's lymphoma and Non-Hodgkins lymphoma

What are the characteristics ofHodgkin's disease?

Unicentric origin(starts in one place, usually a lymphnode). REED STERNBERG CELLS (Know it!)common in 20's and after age 50. Excellent curerate with treatment, suspected viral etiology, familialpattern

What is the difference betweenleukemia and lymphoma?

location. leukemia the mutated cell/s are in the bonemarrow. Lymphoma: the mutated cell/s are in thelymph node.

What are the manifestations ofHodgkin's disease?

painless lymph node enlargement, puritis (as cellsget stuck in capillary bed), B symptoms:fever,sweats, weight loss (malignant cells have highermetabolic rate)

What is the treatment for Hodgkin'sdisease?

determined by the stage of the disease. Mayinclude chemo and/or radiation

Which lymphoma is associated withReed-Sternberg cells?

Hodgkin's

What is thrombopoietin?

a protein produced by the liver, kidney, smooth

muscle & bone marrow that stimulates theproduction of thrombocytes (aka platelets).

Which stem cells do thrombocytesdevelop from?

myeloid stem cells.

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

too many


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How many platelets does thepatient have if they havethrombocytopenia?

too few

What is it called when bone marrowmakes too many platelets and thecause is unknown?

ry thrombocythemia (also called essential

thrombocythemia/thrombocytosis)

What is secondary thrombocytosis?the cause of the overproduction of platelets isknown such as anemia, cancer, infection or surgery.

What is idiopathicthrombocytopenia purpura (ITP)?

abnormally low platelet count of unknown cause &patient presets with purpura (bruises) or petechiae(tiny bruises). Treatment is usually not necessaryunless platelets go below 50,000. Treatment canconsist of steroids,platelet transfusion, splenectomy

What is hemophilia?

group of inherited genetic disorders in which the

body does not make a particular clotting factor.There is no cure but medical management consistsof regular trasfusions of the missing clotting factor.

Name three ways a patient not bornwith a clotting disorder can acquireone.

liver disease, overdose of anticoagulants, vitamin kdeficiency

What are the characteristics of fatembolism syndrome?

assoc w/ complete fractures when marrow isexposed and fat globules enter circ. Seen in longbone and pelvic fractures, crush injuries andmultiple fractures. Can cause transient

thrombocytopenia and immune system response.Onset 12-48 hrs of injury.

What are the respiratorymanifestations of fat embolismsyndrome?

hypoxia (decrease in O2 sat), dyspnea, tachypnea,crackles, edema, chest pain, productive cough(thick white sputim r/t edema), may progress toacute respiratory distress syndrome followed bycongestive heart failure.

at are the cardinal signs of venousocclusion?

pain and inflammation

What are the cardinal signs of

arterial occlusion?

5P's: pain, pallor, parasthesia, pulselessness and

paralysis

Hypoxia from fat embolismsyndrome can lead to what othermanifestations?

tachycardia and fever (usually greater than 103degrees)

What are the neurologicmanifestations of fat emolismsyndrome?

restless, irritability, confusion (due to poor perfusionto the brain or cerebral vessel emboli.


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What are the renal manifestationsof fat embolism syndrome?

the embolus can obstruct renal arteries producingoliguria or anuria. Free fat would be noted onurinalysis.

What is the best prevention for fatemolism syndrome?

early stabilization of fractures (the quicker thefractures are reduced, the lower the incidence of fatembolism syndrome. Also, maintain fluid andelectrolyte balance.

What is compartment syndrome?

a sudden and severe decrease in blood flow to thetissues distal to an area of injury. Usually happenswith a lower extremity. Caused by constriction froma cast or dressing or from hemorrhage or edemawithin the compartment.

What can be used to monitorcompartment pressure?

a wick catheter

What is is called when a cast issplit down both sides to relievepressure and allow for visualizationof the extremity?

bivalving

What are potential complications ofcompartment syndrome?

permanent motor and/or sensory deficits, necrosisand amputation

What is the treatment forcompartment syndrome?

keep the extremity at the level of the heart, notabove and not below. Bivalving. loosening splint.fasciotomy if the symptoms are not releived withinONE HOUR of the above interventions. A

fasciotomy is an incision with suction to removefluid.

What does PACU stand for? post anesthesia care unit

How long will a patient remain inPACU?

until the patient has resumed motor and sensoryfunction, is oriented, has stable VS and shows noevidence of hemorrhage or other complication ofsurgery.

What is the number one priority fora patient in PACU?

airway

What are the responsibilities of thePACU nurse?

assessment, maintaining patent airway, mantainingcardiovascular stability, releiving pain and anxiety,controlling nausea and vomiting, and facilitatingdischarge to home or hospital unit.

What assessments should thePACU nurse make?

assess drains/surgical dressing, assess infusionsas well as IV site, assess VS

How often should VS be assessed every 15 minutes until stable


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in PACU?

When should a systolic BP bereported?

below 90 unless consistent with pre-operative BP

The nurse should also report vital

sign trends that are concerning.What trends would be concerning?

HR trending up or down. O2 sat trending or down.

What can create a problem forPACU nurse maintaining a patentairway?

muscle relaxation due to anesthesia can lead tohypopharyngeal obstruction (anesthesia causes thetongue to fall back and obstruct the airway).

What are 4 signs the airway hasbeen obstructed?

choking, irregular respirations, decrease in O2 sat,cyanosis

How can you position the head tomaintain patent airway?

the head can be tilted back with the jaw held closed.

If a patient comes back from PACUwith an oral airway, when can it beremoved? (oral airway is a tubeinserted in the mouth that extendsbehind the tongue)

when evidence of a gag reflex returns. If they areawake and communicative, they have a gag reflex.

What should you do if the patientvomits?

turn head to the side and suction if needed.

What are sign of hemorrhage?

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)

What are appropriate interventionsfor hemorrhage?

apply pressure (not applicatble if bleeding isinternal), elevate legs 20 degrees with kneesstraight head and back is level with floor, give bloodtransfusion, transfer back to OR.

What is a common cause ofhypertension in a post op patient?

pain

What should you do for a patientwho is hypertensive due to pain?

give analgesic

What are two additional problemsthat can cause hypertension in postop patient?

hypoxia and bladder distension

What should you you if your patienthas hypertension due to hypoxiaand is also presenting withincreased respiration rate andincreased heart rate?

check airway, give supplemental O2, if already onO2 increase rate.


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What should you do if your patientis hypertensive due to bladderdistention?

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

What are causes of dysrhythmias ina post op patient?

electrolyte imbalances (replace electrolytes butinfuse slowly so kidneys don't shut down), alteredrespiratory function, pain, hypothermia (warmslowly), stress, analgesic agents,

What are appropriate interventionsfor releiving pain and anxiety?

assess patient comfort, administer analgesics asindicated (usually short acting opiods via IV), allowfamily to visit, address family and patient anxiety.

What is the FIRST thing should youdo if the patient states they arenaseaus?

turn them on their side, then provide antiemetics

What are some commonantiemetics?

Reglan(metoclopramide),Compazine(prochlorperazine),Phenergan(promethazine),Dramamine(dimenhydrinate),Vistaril/Atarax(hydroxyzine), Transderm-Scop(scopolamine), Zofran(ondansetron) p.466

What are complications associatedwith vomiting?

aspiration, compromised hemostaisis due toincreased abdominal pressure(which cancompromise suture lines and cause hemorrhage),myocardial ischemia and dysrhythmis due to

increased central venous pressure, pain

What patient population is atgreater risk for developing post-opcomplications?

elderly due to decrease in homeostaticmechanisms, and decreased physiologic reservesto manage stress, increased likelihood ofconfusion/delirium, decreased liver function cancuase patient to poorly metabolize anesthesia

What interventions are appropriatefor elderly post op clients?

monitor carefully/frequently. Assess confusion toexclude hypoxia, pain, hypotension, hypoglycemia,fluid loss. Assess need for lower dosages, assesshydration, anticipate extended time to recover from

anesthesia

What tool can we use to assessreadiness for discharge or tranfer (itis simialr to APGAR score forneonates)?

Aldrete score. A score of 0-2 is given for each of thefollowing catagories: activity, respiration, circulation,consciousness, O2 saturation.(ARCCO)

What must the Aldrete score be totransfer patient to step down un it?

8 or more. If patient does not reach 8 they aretransferred to intensive care.


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What kind of information shouldyou give before discharging apatient to home? (may also includea responsible adult in the teachingif appropriate)

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

What are potential complications ofsurgical wounds?

DVT, hematoma, infection (wound sepsis) andwound dehiscence and evisceration

How can DVT's be prevented?

early ambulation, anticoagulants (heparin, lovenox),compression stockings, leg exercises, adequatehydration, avoiding activities that constrict vesselsbehind the knees(blanket rolls, dangling at the edgeof the bed)

What are 4 contributing factors todeveloping dvt's?

stress response, increased stomach acid, lowcardiac output, venous staisis

What other factors can put patientsat greater risk for developingDVT's?

prior history of DVT's, malignancies/Cancer,trauma, indwelling venous catheters (piccs anddialysis access ports)

What are the manifestations ofhematoma?

bulging around incision, echymosis around incision

What is the treatment forhematoma?

if needed, surgical evacuation, can be done bysurgeon removing several sutures or staples

What accounts for 77% of sugicalpatient deaths?

sepsis

How long can it take for evidence ofwound infection to be apparent? up to 5 days

What are the manifestations ofwound infection?

fever/chills, increased WBC count, changes incharachter around the wound (reddness, swelling,warmth, tenderness, pain, purulent drainage)

What is sepsis?

Sepsis is systemic response to infection triggeringinflammation throughout the body. Thisinflammation creates microscopic blood clots thatcan block nutrients and oxygen from reachingorgans, causing them to fail.

What are some treatments thesurgeon may perform/order to treatwound infection?

removal of some of the sutures/staples, insertion ofa drain, incision for drainage, antibiotics

What is wound dehiscence? separation of the edges of a wound

What is wound evisceration?protrusion of intestine through open incision(associated with abdominal surgery)


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What should you do if your patient'swound eviscerates?

place patient in high fowlers, cover wound withsterile dressing soaked in saline, call the surgeon

What is the basic definition ofshock?

inadequate tissue perfusion (to deliver oxygen andnutrients to support the vital organs' cellularfunction, affects all systems of the body)

Why does shock affect all of thesystems of the body?

because all cellular activities run on oxygen

What are the three stages ofshock?

compensatory, progressive and irreversible

In the compensatory stage ofshock, the sympathetic nervoussystem releases catecholamines.What are the two catecholamines?

epi and nor-epi (stimulating the fight or flightresponse)

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 affectthe lungs?

It increases respiration rate to increase O2saturation

How does the epi and nor-epi affectthe kidneys?

it increases renin-angiotensin activation which leadsto an increased absorption of sodium and waterwhich leads to an increased preload and decreasedurine output.

How does the epi and nor-epi affectglucose?

the epi and nor-epi and cortisol increase bloodglucose levels

What is the desired result of theactivation of the sympatheticnervous system?

restoration of tissue perfusion and oxygenation

What happens to bloodflow/circulation during thecompensatory stage of shock?

the body shunts blood to vital organs including thebrain, heart and lungs

What are the consequences of thebody shunting blood to the vitalorgans?

decreased perfusion to other organs causinghypoxia. S&S include cool/clammy skin, hypoactivebowel sounds, decreased urine output,confusion(also due to respiatory alkalosis

What is the focus of medicalmanagement during thecompensatory stage of shock?

identify the cause, treat accordingly

What is the best nursingmanagement during thecompensatory stage of shock?

recognize the signs of shock, early intervention willproduce the best outcome. Unfortunaltely cellulardamage occurs before a drop in BP is noted.


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What are appropriate nursinginterventions for a patient in thecompensatory stage of shock?

minimize O2 demand to increase perfusion.sedation will decrease activity, opiod analgesic willdecrease pain and VS, use supplemental O2 and/ormechanical ventilation, keep them warm, givePRBC transfusion, reduce anxiety, promote safety

How are VS affected by thecompensatory stage of shock?

increased HR and RR, decreased BP and O2 sat.Pulse pressure will narrow, normal range is 30-40mmhg

How is O2 sat measured in apatient in the compensatory stageof shock?

since the blood was shunted to vital organs, thefinger probe will be ineffective. Continuous centralvenous oximetry will be used(SvcO2) and thenormal value for SvcO2 is 70%. Sublingualcapnometry may be used to measure PCO2 using aprobe under tongue

What can be used to measureskeletal muscle oxygenation?

Near-infared spectoscopy measures skeletalmuscle oxygenation. The normal value is greaterthan 80%. A probe is placed over the thenar muscleof the palm. My notes say we should KNOW THIS.

When does the patient move fromthe compensatory stage of shock tothe progressive stage of shock?

When the compensatory systems are unable tomaintain effective MAP.

What are the characteristics of theirreversible stage of shock?

organ damage is so severe that that the patientdoes not respond to treatment and cannot survive.Renal and liver failure compounded by the releaseof necrotic tissue toxins creates an overwhelming

acidosis.

One of the treatments of all stagesof shock is fluid replacement akafluid recuscitation. What is acrystalloid fluid?

It is a fluid that is capable of passing through asemi-permenable membrane. The opposite, alcolloid fluid, is not capable of passing through asemipermeable membrane. Crystalloid solutionsexpant the interstitial space. Colloids expandplasma volume.

What are two isotonic crystalloidsolutions?

.9NS and lactated ringers. Lactated ringers containsa lactate ion NOT lactic acid, the solution convertsto bicarbonate to increase serum pH and make the

serum more alkalotic (this is used to treat acidosis)

What is a hypertonic crystalloidsolution used for fluid recisitation?

3%NS (more "stuff than .9NS). This solution has anosmotic effect and pulls fluid into the intervascularspace so you would need less of a hypertonic fluidthan an isotonic fluid to achieve the desired effect.

What does a colloid solution do? It is used to expand the fluid in the intravascularspace (so does a hypertonic solution but the colloid


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solution has a longer duration because itsmolecules are too large to pass through capillarymembranes. Less fluid is needed to expandvolume.)

What are two negative aspects ofcolloid solutions?

they are significantly more expensive and havegreater risk for anaphylactic/allergic reaction

What are the two types of colloidsolution?

natural and synthetic

What are two examples of asynthetic colloid solutions?

hetastarch and dextran

What other action does dextranhave that needs to be consideredwhen selecting a colloid solution?

it can interfere with platelet aggregation

What type of fluid replacement

would all blood products beconsidered?

colloid

What are six complications of fluidresusitation?

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

What action can be taken to reducethe risk of hypothermia wheninfusing la rge volumes of fluid?

warm the fluids before administration

How is abdominal compartmentsyndrome defined?

a leaking of fluid into the intra-abdominal cavitycausing pressure of greater than 12 mmHg withinthe intra-abdominal cavity(normal pressure in theabdominal compartment is 0-5 mmHg)

What problems can abdominalcompartment syndrome cause?

compromised venous return producing a decreasein cardiac output, elevation of the diaphragminterfereing with lung inflation and GI and renaldysfunction (intolerance to tube feeding, absentbowel sounds and decreased urine output)

What treatment is required in casesof abdominal compartmentsyndrome?

surgical decompression (fasciotomy (incision) withsuction)

What is the normal range forcentral venous pressure?

4-12 mmHg

How can venous O2 saturation(SvO2) be monitored in the critical

It is measured with central venous oximitry e.g.swan-ganz catheter placed peripherally and


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care setting?threaded through the heart and into the pulmonaryartery to get the best reading of mixed venoussaturation

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

The venous blood should be 75% saturated withoxygen(arterial blood should be 95-100%saturated)SvO2 is monitored because it is one ofthe earliest indicators of a threat to tissueperfusion(sepsis causes high SvO2 and lung orcadiac prob causes low SvO2)

What is the difference betweenSvO2 and ScvO2?

The difference is where the value is collected. Thebook only said that ScvO2 is measured with a CVPline and the normal values are slightly different withSvO2 and ScvO2.

What is a CVP line?it measures PRESSURE (not O2 sat). It is used tomeasure a clients response to fluid replacement.Normal pressure 4-12 mmHg.

What is the most important thing tomonitor in patients receiving largevolumes of crystalloid solutions?

monitor the lungs for adventitious breath soundsand signs and symptoms of interstitial edema (e.g.abdominal compartment syndrome)

What does an arterial BP line do? monitor arterial BP

What stimulates alpha adrenericreceptors?

catecholamines: epi and nor-epi

Where are alpha adrenergic

receptors located?

in blood vessels (arteries and veins) as well assmooth muscle in the GI tract, lungs kidneys and

integumentary system

What are the effects ofcatecholamines (epi and nor-epi)on the alpha adrenergic receptorsites?

constriction: vasoconstriction, bronchioconstriction,decreased motility in GI tract,

Where are beta 1 receptorslocated?

heart (one heart, two lungs)

What happens when beta 1receptors are stimulated?

heart rate and myocardial contraction increases

Where are beta 2 receptorslocated?

bronchioles/lungs, heart and skeletal muscles

What happens when beta 2receptors are stimulated?

vasodilation in the bronchioles, heart and skeletalmuscles

Which vasoactive receptorstimulators are used in thetreatment of shock?

all of them can be used in various combinationshowever vital signs need to be monitored every 15minutes or more often if necessary.


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How are vasoactive medicationsadministered in shock patients?

via central line ONLY becuase infiltration andextravasation of these drugs can cause tissuenecrosis. PUMP must be used.

Vasoactive drugs in the critical caresetting may be titrated frequently.What needs to be done each time atitration is made?

DOCUMENT each time the rate is changed

If you have an order to discontinuea vasoactive drug how should thedrug be discontinued?

SLOWLY, never take them off abruptly

What does a (positive)inotropicagent do?

it increases the contractions of the heart (improvescontractility, increases stroke volume, increasescardiac output)

What is a disadvantage of using an

inotropic agent?it increases the oxygen demand of the heart

What does a negative inotropicagent do?

decrease contractility and oxygen demand of theheart (not really discussed in this chapter but Ithought of we're going to learn one we should learnthe other too e.g. beta blocker, calcium channelblocker)

What are some positive inotropicagents discussed in the book?

Dobutrex/dobutamine, Inotropin/dopamine,Adrenalin/epinephrine, Primacor/milrinone

What does a vasodilator do?stimulates beta 2 receptors, reduce preload andafterload and reduce oxygen demand of the heart

What is a disadvantage to usingvasodilators?

hypotension

What vasodilators are discussed inthe book?

Tridil/nitroglycerin, Nipride/nitroprusside

What is a vasopressor agent?it increases blood pressure by vasoconstriction(stimulates alpha 1 receptor sites) also called anti-hypotensive agent

What are disadvantages of using

vasopressor agents?

increased afterload, increased cardiac workload,compromised perfusion to the skin, lungs and GI

tract

What vasopressor agents arementioned in the book?

Levophed/norepinephrine, Inotropin/dopamine,Neo-Synephrine/phenylphrine,Pitressin/vasopressin

Nutritional support is an importantpart of the management of shock.What is the preferred method of

Enteral is preferred becuase it uses the GI systemto support its integrity (e.g. OG, NG tube).Glutamine (an essential amino acid) is usually


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nutritional support?added to support immunologic function by feedinglymphocytes and macrophages.

Stress ulcers are common inacutely ill patients due todecreased perfusion to GI tract.What drugs can be administered toprevent ulcer formation?

antacids, H2 receptor blockers and proton pumpinhibitors (they reduce gastric acid secretion andincrease pH)

What H2 receptor blockers arediscussed in the book?

Pepcid/famotidine and Zantac/ranitidine

What proton pump inhibitors arediscussed in the book?

Prevacid/lansoprazole

I am skipping eye, ear and malereproductive system for now.(Weeks 4 and 5)

I will add them to the end...if I have time.

What is cholelithiasis? gall stones

What are the two types of gallstones?

pigment stones and cholesterol stones

Which type of gall stone is moreprevalent?

cholesterol stones (75-90%)(pigment stones areonly 10-25%)

What are the physicalmanifestations of cholelithiasis?

epigastric fullness or mild gastric distress followinga large or fatty meal

What are the risk factors for

cholelithiasis?

females, over 40, use ofcontraceptives/estrogens/clofibrate/allopurinal

(these meds cause increase in proportion ofcholesterol in bile), DM, biliary staisis, cirrhosis

What do oral contraceptives,estrogens, clofibrate and allopurinoldo to the bile?

increases the proportion of cholesterol (changes therecipie)

What is cholecystitis? acute inflammation of the gall bladder

What are the two types ofcholecystitis?

calculous (90% of cases) and acalculous

Calculous cholecystitis is caused

by stones, what can causeacalculous?

major surgical procedures, trauma, burns, torsion,

primary bacterial infection of the gallbladder,multiple blood transfusions

What are the manifestations ofcalculus cholecystitis?

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), elevatedbilirubin (itching, jaundice), dark urine and gray


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stool

Which vitamins may be deficient incases of cholecystitis?

fat soluble

What are complications of calculus

cholecystitis?

necrosis/gangrene, perforation can lead to

peritonitis

What are common manifestationsof liver disorders?

HEPATOCELLULAR FAILURE. decreased albumenproduction leading to ascites, decreased productionof clotting factors leading to bruising and bleeding,increased aldosterone r/t low albumen producingwater and sodium retention to increase intervascvolume

Glucose metabolism is disruptedwith liver disorders, what can thiscause?

hyper or hypoglycemia

Hormone metabolism is alsoimpaired with liver disorders, whatcan this cause?

feminine characteristics in males and irregularmenses in females

Bile production is decreased in liverdisorders, what can this lead to?

impaired fat absorption and digestion, impairedabsorption of fat soluble vitamins (which can lead tovitamin k deficiency causing clotting disorders)

What are effects of jaundice in liverdisorders?

impaired liver function disrupts the conversion andexcretion of bilirubin. unconjugated/indirect bilirubinlevels rise. Stool is clay colored, urine is dark r/tbilirubin excretion of the kidneys.

Portal hypertension is also amanifestation of liver disorder, whatis its effects?

increased pressure in the venous return from thegut, spleen and surface vessels of the abdomen.The result is dilation of the vessels and formation ofcollateral circulation. Also esophageal varices,hemorrhoids, splenomegaly, ascites

How can portal hypertension affectthe kidneys?

it disrupts blood flow and the kidneys are unable toaccomadate the fluid shift causing hepatorenalfailure

What is Cirrhosis?

end stage of chronic liver disease, progressive,

irreversible and leads to liver failure. Excessivescarring from inflammation and necrosis.Complications depend on amount of liver damage.

What are the three types ofcirrhosis?

alcoholic/laennecs(end stage of toxic hepatits),biliary cirrhosis(bile flow obstruction), post-hepatic/post necrotic cirrhosis(caused by viral hep bor c)


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Portal hypertension is acomplication of cirrhosis, what canthe portal hypertension cause>?

enlarged spleen: which will remove blood cells at anincreased rate(wbc, rbc, platelets) leading toaplastic anemia

What is portal systemencephalopathy? (alsocomplication of cirrhosis)

evated serum ammonia levels. early signs includeLIVER FLAP which are involuntary jerkymovements while trying to maintain a fixed position.primarily effects upper extremities. personalitychanges, agitation, restlessness, impaired

judgement,slurring

What are late signs of portalsystem encephalopathy?

confusion, disorientation, incoherence

What does ammonia do to thebrain?

increases intercranial pressure and irritates thecerebrum

What is spontaneous bacterialperitonitis?

rigid abdomen (hard to detect if the have ascites)

can lead to septicemia or septic shock since theyare alread hypovolemic

What meds should be avoided inpatients with cirrhosis?

these matabolized by the liver: barbs, seditives,hypnotics, acetaminophen

What two diuretics can be used toreduce fluid retention and ascites?

spironolactone (first choice because it competes forreceptor sites with aldosterone and stops retention)and furosemide/lasix

Why is the laxative lactulose used? it reduces serum ammonia

Why is the antibiotic neomycin

used?

also reduces serum ammonia

Why are antihypertensive agentsused?

reduce portal hypertension

Why is iron and folic acid given? to treat aplastic anemia

why is vitamin k given? to boost clotting factor production

Why are antacids prescribed? prevent gastric ulcers

What med is given to controlbleeding of esophageal varices?

vasoconstrictor sandostatin

What is abdominal paracentesis?removes fluid from ascites: 4-6L, give albumenconcurrenly to prevent drop in bp, have client voidprior to procedure, client will be seated with feet onfloor.

Who is affected by benign prostatichyperplasia?

Half of all men over age 60

What are the two chemicals estrogen and DHT (a derrivative of tesosterone).


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thought to cause BPH?

What is BPH?

Hyperplasia means an increase in the number ofcells. The prostate enlarges which causesmechanical obstruction of the urethra and urethralspasms.

What are the clinical manifestationsof BPH baused by obstruction andirritation?

frequency, urgency, nocturia, hesitency anddecreased force of stream.

What other manifestations can apatient with BPH have?

fatigue, anorexia, nausea and vomiting

What are potential complications ofBPH?

UTI's. Accumulation of nitrogenous wasteproducts(elevated BUN) also called azotemia.Renal failure from the backing up of urine into theureters and kidney.

What treatment may be used in lowrisk, less aggressive cases ofcancer such as prostate cancer?

radiation therapy

What are some complications ofusing radiation therapy on theprostate?

proctitis, enteritis, cystitis (everything in the region isexposed to radiation)

What are the two types of radiationtherapy used with prostate cancer?

1. external beam radiation therapy (EBRT) 2.Brachytherapy

What are the characteristics ofexternal beam radiation therapy?

the treatment is done 5 days per week for 7 weeks

using CyberKnife. CyberKnife is a robotic radiationdelivery. This treatment may also be used to treatbone metastasis.

What are the characteristics ofBrachytherapy?

radioactive seeds are surgically implanted into theprostate.

What radiation precautions wouldyou need to teach a patient whowas implanted with radioactiveseeds in their prostate?

1.avoid close contact with pregnant women andinfants for two months. 2. Wear a condom duringintercourse for 2 weeks. (Oh yeah, and assign thisclient to the nurse and PCA least likely to bepregnant...why do I always get the radioactive

patients???)Who is affected by testicularcancer?

It is the most common cancer to affect men ages18-30.

What is the prognosis for testicularcancer?

it is highly treatable and curable.

What are the risk factors fortesticular cancer?

Cryptorchidism (undescended testicle), familyhistory of testicular cancer, personal history of


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testicular cancer, race/white

What are the manifestations oftesticular cancer?

a mass or lump on the testicle. backache.abdominal pain.weight loss. generalized weakness.

What is the best way to ensureearly detection?

monthly testicular self-exam (TSE)and annual

testicular exam (Best done in the shower in warmwater. Look for lump or anything abnormal.

What is the treatment for testicularcancer?

Orchidectomy (removal of testicle). Retroperitoneallymph node dissection if there has been lymph nodeinvolvement (open or laproscopic). Radiationtherapy. Chemotherapy.

What is the condition in which theforeskin cannot be retracted overthe glans of an uncircumcisedpenis?

phimosis

What is a contributing factor forphimosis?

Lack of hygeine. This leads to imflammation,adhesions and fibrosis.

What is the treatment for phimosis?anti-inflammatory (topical steroid to reduceinflammation) applied to foreskin.

How common is penile cancer?Rare, it only accounts for 1% of all male cancercases.

What are risk factors associatedwith penile cancer?

Lack of circumcision. Poor genital hygiene.Phimosis. HPV. Smoking.

What visual changes does a person

with glaucoma experience? a narrowing of the visual field.

What is glaucoma?

Glaucoma is a slowly progressive eye condition thatcauses damage to the optic nerve. Because thereare usually no symptoms early on in the disease,about half of the people with glaucoma do not evenknow they have it.

There are atleast 20 types ofglaucoma, but what are the 4 maintypes?

1. open angle 2. closed angle 3. congenitalglaucoma and 4. secondary glaucoma

What visual changes does a personwith glaucoma experience? a narrowing of the visual field.

What is glaucoma?

Glaucoma is a slowly progressive eye condition thatcauses damage to the optic nerve. Because thereare usually no symptoms early on in the disease,about half of the people with glaucoma do not evenknow they have it.


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There are atleast 20 types ofglaucoma, but what are the 4 maintypes?

1. open angle 2. closed angle 3. congenitalglaucoma and 4. secondary glaucoma

When is glaucoma consideredcongenital?

when it occurs in infants under the age of 1

What is secondary glaucoma?may be associated with eye diseases, otherdiseases and side effects of medications.

What are the three types of openangle glaucoma listed in thepowerpoints?

1. chronic open angle glaucoma 2. normal tensionglaucoma 3. ocular hypertension

What are the three types of closedangle/angle closure glaucomaslisted in the powerpoint?

1. acute angle closure 2. subacute angle closure 3.chronic angle closure

For the most part which or the to

types of glaucoma (open andclosed) progresses slowly and thepatient may not even realize theyhave it until they have significantvision loss?

open angle

For the most part which or the totypes of glaucoma (open andclosed) is an acute medicalemergency creating so much painthat the individual usually seeks

medical treatment?

closed angle

What are the 4 types ofexaminations used in glaucomaevaluation, diagnosis andmanagement?

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

What is the purpose of Tonometry? to measure IOP (intraocular pressure)

What is the purpose ofOpthalmascopy?

to inspect the optic nerve

What is the purpose of

gonioscopy?

to examine the filtration angle of the interior

chamber.

What is the purpose of perimetry?to assess vision fields (determine progression ofvisual field defects)

What is the focus of medicalmanagement of glaucoma?

the goal is to prevent further optic nerve damageand maintain iop within a range unlikely to causeoptic nerve damage.

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


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for glaucoma? See table 58-4

agonists:reduce production &increase outflow3.beta-blockers:decrease production 4.alphaadrenergic agonists:decrease production 5.carbonicanhydrase:decrease production 6.prostaglandinanalogs:increase outflow

What are the 5 ways surgery canbe used to manage glaucoma?

1. laser tribeculoplasty 2.laser iridotomy 3.filteringprocedures 4.tribeculectomy 5. drainage implants orshunts

Nursing management: focuses onteaching, what should you teachglaucoma patient?

Teach client to maintaqin therapeutic regimin tomaintain lifelong control of condition. Emphasizeadherence to prevent further vision loss. Teach useand effects of meds. Teach side effects such asvision alterations.

What psychosocial needs will aclient with glaucoma have?

Provide support and interventions to aid the patientin adjusting to vision loss and potential vision loss.

What is the name for opacity orcloudiness of the lens?

cataracts (everything gets blurry)

Who gets cataracts?by age 80 more than half of all americans havecataracts. It is a leading cause of disability in the US

What are risk factors associatedwith cataracts?

aging, associated ocular conditions, toxic factors,nutritional factors, physical factors, systemicdiseases and syndromes.

What are the glaucoma meds

written on the instructor copy of theslides?Cholinergics/miotics:pilocarpine,carbachol/

Adrenergic agonists:dipivefrin, epinephrine/Beta-blockers:betaxolol,timolol/Alpha-adrenergic

agonists:apraclonidine,brimonidine/Carbonicanhydrase inhibitors:acetazolamide,methazolamide,dorzolamide/Prostaglandin analogs:latanoprost,bimatoprost

What are the clinical manifestationsof cataracts?

Lens opacity. Painless, blurry vision. Sensitivity toglare. Reduced visual acuity. Light scattering andreduced contrast sensitivity.

What are other effects of cataracts?Other effects include myopic shift, astigmatism,diplopia (double vision), and color shifts includingbrunescens (color value shift to yellow-brown)

What are the diagnostic tests forcataracts?

ophthalmoscope, slit-lamp, or inspection

What are the 4 types of cataractsurgery?

1. Intracapsular cataract extraction (ICCE)2.Extracapsular cataract extraction (ECCE) 3.Phacoemuslification 4. Lens replacement

What is Intracapsular cataract removes entire lens, rarely done today


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extraction (ICCE)?

What is Extracapsular cataractextraction (ECCE)?

maintains the posterior capsule of the lens,reducing potential postoperative complications

What is Phacoemuslification?

an ECCE which uses an ultrasonic device to suction

the lens out through a tube; incision is smaller thanwith standard ECCE

What is Lens replacement?

after removal of the lens by ICCE or ECCE, thesurgeon inserts an intraocular lens implant (IOL).This eliminates the need for aphakic lenses,however, the patient may still require glasses.

What is pre-op care for cataractsurgery?

Usual preoperative care for ambulatory surgery,Dilating eye drops or other medications as ordered

What teaching should you providepatient following cataract surgery?

Instruct patient to call physician immediately ifvision changes; continuous flashing lights appear;

redness, swelling, or pain increase; type andamount of drainage increases; or significant pain isnot relieved by acetaminophen

What is appropriate education postcataract surgery?

Avoid eye straining, Avoid rubbing or placingpressure on eye, Avoid lifting more than 5 lbs,bending, coughing, sneezing etc Preventconstipation, Use eye shield at bedtime, Wipeexcess drainage with sterile cotton away fromcanthus

Cataract health teaching:

Report to surgeon: sharp, sudden pain in the eye,

bleeding or increased discharge, lid swelling,decreased vision, or flashes of light or floatingshapes. Avoid activities that might increaseIOP.Review procedure for use of eyedrops.

Do you get the impression that theperson who write the eye lecturealso wrote the neuro lecture?

???

What is retinal detachment?Defined as: Separation of the sensory retina andthe RPE (retinal pigment epithelium)

What are manifestations of retinaldetachment?

Sensation of a shade or curtain coming across thevision of one eye, bright flashing lights, suddenonset of floaters

How is retinal detachmentdiagnosed?

assess visual acuity, assessment of retina byindirect ophthalmoscope, slit-lamp, stereo fundusphotography, and fluorescein angiography.Tomography and ultrasound may also be used


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What is conjunctiva? thin, transparent membrane covering anteriorsurface of the eye

What are the two types of bacterialconjunctivitis?

Chlamydia Conjunctivitis Inclusion Conjunctivitis

What are the two types of viralconjunctivitis?

Allergic Conjunctivitis Toxic Conjunctivitis

What kinds of treatment can beused with conjunctivitis?

Opthalmic Medications:Antibiotic, Antiviral, Anti-inflammatory Most Delivered Topically. Eyeirrigations, Soaking lids with warm salinecompresses Some by Subconjunctival Injection,Some by Intravenous Infusion

What are appropriate nursingdiagnoses for conjunctivitis?

Risk for infection Proper hand washing Teachinstillation of eye drops Risk for disturbed sensoryperception: visual Assess vision with & without

corrective lenses Use of sunglasses

What is Uveitis?inflammation of all of part of this vascular layer. Redand painful but no mucus secretion.

Advanced Med Surg Final Part 2 Everything Else

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