Common problems in acute care part 2 Flashcards

1
Q

First degree burn

A

Involves epidermis only.
Dry, red, no blisters.

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2
Q

Second degree, partial thickness burn

A

Extends beyond the epidermis.
Moist, blisters.

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3
Q

Third degree, full thickness burn

A

Extends from epidermis to dermis and underlying tissues, fat, muscles and/or bone.
Dry, leathery, black, pearly, waxy.
Not painful d/t nerves being destroyed.

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4
Q

Rule of 9’s

A

Approximately 1% of TBSA may be depicted by the size of the pts palm.
Each arm-9%
Each leg- 18%
Thorax- 18% front, 18% back
Head-9%
Perineum/genitals-1%

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5
Q

Fluid resuscitation in burns

A
  • Parkland formula: 4ml/kg x TBSA % burned during the first 24 hours, crystalloids.
  • Lack of fluid is grequently a major problem.
  • Fluid resuscitation begins at the time of the burn injury, not when the pt reaches the hospital burn center.
  • 1/2 of all fluid given in first 8 hrs, then 1/4 over next 8, then 1/4 over remaining 8 hours.
  • Monitor for metabolic acidosis which is expected during early resusciation phase.
  • Monitor for hyperkalemia during first 24-48hrs then hypokalemia following 3 days post burn d/t diuresis.
  • UO goal 30-50ml/hr
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6
Q

Indications for prophylactic intubation in burns

A

Laryngeal edema is a common and quick complication of some burns, immediate prophylactic intubation should occur with any evidence of the following:
* Burns to the face
* Singed nares or eyebrows
* Dark soot/mucus from nares and/or mouth

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7
Q

Burn center referral criteria

A

1.) Partial thickness burns >10% TBSA
2.) Burns that involve the face, hands, feet, genitalia, perineum or major joints.
3.) Third degree burns in any age group
4.) Electrical burns, including lightning injury
5.) Chemical burns
6.) Inhalation injury
7.) Burni njury in pts with preexisting medical disorders that could complicate management, prolong recovery or affect mortality.
8.) Any pts with burns and concomitant trauma
9.) Burned children in hospitals without qualified personnel or equipment for the care of children.
10.) Burn injury in pts who will require special social, emotional, or rehab interventions.

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8
Q

Giant cell arteritis

A

Also known as temporal arteritis
An inflammatory condition primarily affecting pts over the age of 50.
Causes inflammation of certain arteries, especially those near the temples.
Can lead to permanent blindness.
Accounts for 15% of all cases of fever of unknown origin in older adults.

S/S:
* HA
* Scalp tenderness
* Visual complaints
* Jaw claudication
* Temporal artery may be nodular, enlarged or tender
* Fevers sometimes >40c
* Chills/rigors

Lab/diagnostics:
* Very high ESR
* Normal WBC (tells you it’s not bacterial in nature)
* Temporal artery biopsy is gold standard

Management:
* Prednisone and referral

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9
Q

Assessment of the eye

A
  • Optic disc: doughnut like shaped with an orange/pink neuroretinal rim and a central white depression (called physiologic cup)
  • Cup/disk ratio: cup should not be more than 1/2 the size of the disc diameter, if larger consider glaucoma.
  • Arteries are brighter red and narrower than veins.
    –A:V ration 2:3 or 4:5
  • Macula: is centered temporal to the optic disk and is avascular
  • Fovea centralis looks slightly darker and lies in the center of the macular region. If macula difficult to visualize, have pt look directly into the light.
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10
Q

Diabetic retinopathy

A
  • Microaneurysms are the earliest detectable sign.
  • Ruptured microaneurysms result in retinal hemorrhages either superficially or deeper layers of the retina.
  • Cotton wool spots.
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11
Q

Arteriovenous (AV) nicking

A

When artery and vein intersect and create bridge.
Signs of chronic HTN

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12
Q

Arcus senilis

A

A cloudy appearance of cornea with grat/white circle around the limbus due to deposition of lipid material.
No affect on vision.

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13
Q

Conjuctivits

A

The most common eye disorder, also known as pink eye.
Inflammation/infection of the conjunctiva resulting from allergies, bacteria, viruses or STIs.

S/S:
* Itching/burning
* Redness
* Increased amounts of tears
* Blurred vision is possible
* Sensation of a foreign body in eye
* Swelling of eyelid
* Eyelids may show a crust of sticky, mucopurulent
* No pain in eye

**Management: **
Depends on type
* Chemical- No discharge, flush with NS. Self limiting
* Bacterial- Purulent discharge, antibiotic drops (fluoroquinolone)
* Gonococcal/chlamydial- copiouos purulent discharge, ceftriazone + azithromycin
* Allergic- Stringy, increased tearing discharge. Tx with oral antihistamines and refer to allertist/opthalmologist. Steroids should not be ordered in primary care due to possible increase IOP and activation of herpes.
* Viral- Watery discharge. If mild tx with saline drops or arterficial tears. If moderate tx with antihistamines and NSAIDs
* Herpetic- refer to opthalmologist

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14
Q

Corneal abrasion

A

Trauma to the eye resulting in interruption in the epithelial surface.

S/S:
* Intense pain in affected eye, worsens with time
* Tearing
* Redness

Lab/Diagnostics:
* Recent history of trauma to eye
* Sodium fluorescein stain detects abrasion

Management:
* Anesthetize the ye for thorough exam to ensure no foreign body
* Topical antibiotic ointmen may be prescribed, especially in pts who wear contact lenses
* Steroid drops are contraindicated
* Should heal in 24 hours, if not refer

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15
Q

Glaucoma

A

Increase IOP, can be open or closed
Open angle: chronic
Closed angle: acute (emergency)
Uknown cause

S/S:

Open angle chronic:
* Asymptomatic
* Elevated IOP (normal 10-20)
* Cupping of disk, usually 1st physical sign (icre cream scoop)
* Constriction of visual fields

Closed angle acute:
* Extreme pain
* Blurred vision
* Halos around eyes
* Pupil dilation or fixed

Lab/diagnostics:
* Tonometry, national screen >40

Management:
* Open angle chronic:
* Prostaglandin analogs (latanoprost)

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16
Q

Cataracts

A

Clouding and opacification of the normally clear lens of the eye
Highest cause of treatable blindness
Most common surgical procedure in pts over 65 yrs, senile cataracts

Causes:
* Aging (leading risk factor
* Heredity
* Trauma
* Toxins, drugs, tobacco, alcohol
* Congenital
* Diabetes
* UV ligh exposure

S/S:
* Painless
* Clouded, blured or dim vision
* Difficulty with vision at night
* Sensitivity to light and glare
* Fading/yellowing of colors
* Diplopia in single eye
* Halos around lights
* The need for brighter light for reading or activities
* No red reflex
* Opacity of lens

Management:
* Refer to ophlamologist

17
Q

Osteoarthritis

A

Degenerative joint disease with slow destruction of the articular cartilage.
Asymmetrical inflammation
Occurs in weight bearing joints + hands, fingers, wrists
Swelling and edema occur but no redness or heat complaints to joints.
Bouchards nodes: Occurs in proximal interphalangeal joints
Heberdens nodes: Occurs in distal interphalangeal joints
Stiffness/pain is better in the morning and worse as day progresses. Aggravated by activity and relieved by rest.

Can have genetic predisposition, increased incidence with age, obesity is an exacerbating factor, angular deformities of affected joints, limited ROM, crepitus possible.

Diagnostics:
* Synovial aspirate will be normal; clear/yellow
* X-ray will show narrowing of joint space, osteophytes, juxta-articular sclerosis, subchondral bone

Management:
* ASA, tylenol, NSAIDs (watch creatinine), COX-2 inhibitors (celexa)
Supportive care with weight loss, use of cane on opposite side, ICE (improves ROM), heat (decreases muscle spasms and relieve stiffness), PT, refer for joint replacement.

18
Q
A
18
Q

Rheumatoid arthritis

A

Systemic autoimmune disease causing inflammation of connective tissue.
Symmetrical
Will have swelling and edema with redness and heat complaints to joints.
Ulnar deviation, hands deviate outwards
Stiffness and pain worse in morning and get better as the day progresses.

Joints affected:
* Proximal interphalangeal joints (middle of finger)
* Metacarpophalangeal joints (Knuckles)
* Wrists

Autoimmune in nature, can cause fatigue, weakness, malaise, anorexia, weightloss.

Labs/diagnostics:
* ESR will be elevated
* Synovial aspirate will show inflammatory changes and WBCs
* X-ray will show joint swelling, progressive cortical thinning, osteopenia, joint space narrowing

Management:
* High dose ASA
* NSAIDs
* Disease modifying antirheumatic drugs (DMARDs)
-Corticosteroids
-Methotrexate (watch LFTs)
-Antimalarials (hydrochloroquine)
-Gold salt injections

Supportive care with early rheumatologist referral, rest, PT, surgery

19
Q

Systemic lupus erythematosus

A

A multisystem, inflammatory autoimmune disorder that affects primarily women of childbearing age.

S/S:
* Don’t really go together, random symptoms.
* If pt has random symptoms and is of child brearing age, think lupus.
* Butterfly rash

Lab/diagnostics:
* ANA will be positive
* Antiphospholipid antibodies should be investigated
* Anemia, leukopenia and thrombocytopenis are often present

Management:
* For mild symptoms: bedrest with midafternoon naps, avoidance of fatigue
* Sun protection
* Use topical glucocorticoids for isolated skin lesions
* NSAIDs, hydroxychloroquine, glucocorticoids and other therapies.

Durgs that implicate lupus like syndrome:
* Many CV meds and birth control pills.

20
Q

Gerotological considerations musculoskeletal

A

Physciologic changes:
* Sarcopenia: decreased muscle mass and strength occurs
* Lean body mass replaced by fat
* Redistribution of fat occurs
* Low bone mass develops
* Intervertebral disc regeneration
* Changes in stature wih kyphosis, heigh reduction

Possible findings/results:
* Decreased total body water
* Increased perentage of adipose tissue (until age 60, then decreased)
* Degeneration of cartilaginous tissues
* Fibrosis, deceased joint elasticity