Extra Flashcards
Nephrotic syndrome
Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome:
Massive proteinuria – caused by increased glomerular permeability
Hypoalbuminemia – resulting from excess protein loss in the urine
Edema – specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities
Hyperlipidemia – related to increased compensatory protein and lipid production by the liver
Asthma & Ibuprofen
Two groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers), have the potential to cause problems for clients with asthma.
Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal polyposis.
Blood pressure
89mmhg of lower = shock
180mmHg or higher = Hypertensive crisis
MAP
Mean arterial pressure
60mmHg or high = good tissue perfusion
Temp
103 or higher
39 or higher
Med emergency
below 95 or 35 Hypothermia
Spo2
93% or higher = normal
88-92% normal for COPD and Sleep Apnea
Heart sound s3
heart after s2
Normal in CHF, Not normal in MI
Heart sound s4
fluid overload (normal for pregnant women)
Autonomy
freedom of choice, self determination
Autonomy is the right to make decisions for oneself (eg, informed consent). Although having an advance directive is an example of autonomy, requiring one violates this principle. The client has a right to refuse even if the nurse believes it is in the client’s best interest.
When a diagnosis is withheld, even if due to the nurse’s or family’s good intentions, it violates the principle of autonomy.
Justice
fairness, equal treatment
The principle of justice refers to treating all clients fairly (ie, without bias). Veracity is telling the truth as a fundamental part of building a trusting relationship.
Fidelity
faithfulness to commitments, following through
Fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected responsibilities of professional nursing practice and provides the basis of accountability (taking responsibility for one’s actions)
Beneficence
doing good
Beneficence means to do good (eg, implementing interventions to promote the client’s well-being).
Nonmaleficence
do no harm
…relates to protecting clients from danger when they are unable to do so themselves due to a mental/physical condition (eg, children, client with Alzheimer disease) and from a nurse who is impaired (Option 5).
Veracity
truthfulness
Ethical principles guide the nurse in making appropriate decisions and acting accordingly. They speak to the essence but not to the specifics of the law.
NEVER DELEGATE
Teaching
Assessment
Admissions (post-op or direct)
Education
Hemodynamic Monitoring: Arterial Line (red)
Catheter typically radial or femoral artery
Continuous blood pressure
ABG blood draws (must be an RN)
Hemodynamic Monitoring:
Central Venous Pressure
Sensor via central line catheter Sits in a venae cavae Good indicator of preload and pressure from the right side of the heart Often used in heart failure Expected CVP = 6-8 Elevated (worsening heart failure) Decreased (hypovolemia)
Hemodynamic Monitoring:
Pulmonary Pressure / Pulmonary Wedge Pressure
Sensor via Swan-Ganz catheter
Sits in the pulmonary artery
Good indicator of pulmonary hypertension
Can inflate balloon for pulmonary wedge pressure
Never inflate for prolonged periods of time
Never remove specialized syringe to inflate
Right sided heart failure
Edema (peripheral, dependent, generalized), JVD (what comes before the failing chamber) - Fluid backing up into SVC / IVC • Elevated CVP (critical care) - catheter above the right atria (6-8) — Pressure from right side of the heart — Worsening of R-side failure • Pulmonary Wedge Pressure (PWP) — Inflated balloon in the pulmonary artery — Also displays possible left-sided failure
Left sided heart failure
Fatigue, decreased Cardiac Output (CO), reduced circulation, perfusion, Shortness of Breath (SOB) • Pulmonary edema — Fluid backing up — Auscultation (crackles)
Echo
• Ultrasound (US) of the heart ( Ejection Fraction) • External procedure • TEE (transesophageal echo) - bariatric — 2L NS / sedate Diagnostic for HF, valvular disease, structural heart disease
Endocarditis
- Inflammation of the inner layer of the heart
* Commonly affects the valves
Cardiac Tamponade
- Narrowing pulse pressure
- Muffled heart sounds
- Pulsus parodoxus
- Tachycardia
- SOB
Aortic Aneurysms
- Thoracic or abdominal
- Palpable pulsing mass
- Rupture may manifest with radiating back pain
- Rupture is a medical emergency
Marfan Syndrome
• Abnormal weakening of the vessel lining
• Aneurysms are common
• Patients tend to be abnormally tall and thin
with long fingers
• Aortic dissection is a risk
Shocks
• Decreased perfusion to vital organs and tissues
— Kidneys are the first organ to fail decreased urine output
— Dangerous decrease in BP
• Fluids, vasopressors, and treat the underlying condition
Cardiogenic
• Decreased cardiac output due to poor heart functioning
— MI, HF, Cardiomyopathy
• Positive Inotropic Agents (Dobutamine, Dopamine, etc.)
• Intra-aortic Balloon Pump
Hemorrhagic / Hypovolemic
- Loss of blood mass severe hypotension
* Stop the bleeding or loss of fluid (burns)
Neurogenic
- CNS damage
- Loss of blood pressure due to CNS trauma
- Loss of all tone in the vessels vasodilation
Anaphylactic
- Allergic response
- Epi-pens / antihistamine / diphenhydramine
- Vasodilation due to allergy
Septic
• Due to sepsis (severe infection)
— antibiotics
• Acute Respiratory Distress (ARDS) is a common complication
• Vasodilation
Adenosine
For: Supraventricular
Tachycardia (SVT)
- (give as fast as you can, lift the arm, and it will cause the heart to arrest; the hope is to revert back to normal sinus rhythm) —look at monitor —look at patient (symptomatic versus nonsymptomatic) —blood pressure • cardioversion (synchronized
Addisonian Crisis
med. emergency) Pathophysiology • Cortisol levels fall dangerously low • Often triggered by infection or stress Signs and Symptoms • N/V, abdominal pain • Fever • Chills • Skin rash • Hypotension Interventions • Immediate cortisol administration
Addison’s Disease
Down, Down, Down, Up, Down
Na, HTN, blood vol, K, Gluc
Pathophysiology • Adrenal Insufficiency • Hypocortisolism / Hypoadrenalism Signs and Symptoms • Fatigue / weakness • Weight loss / anorexia • Increased pigmentation of skin • Hypotension / hypoglycemia • Salt cravings • Painful muscles / joints • Norovirus, Diarrhea • Inability to cope with stress / intolerance to cold Interventions • Lifelong cortisol replacement
Cushing’s Syndrome
Up, Up, Up, Down, Up
Na, HTN, blood vol, K, Gluc
Pathophysiology • Elevated cortisol levels (hypercortisolism) • Often caused by overuse of steroid medications Signs and Symptoms • Weight gain / central obesity (abdominal) • Moon face • Thinning skin bruises easily • Fatigue / muscle weakness • Depression / anxiety • Hypertension • Increased urination / thirst Interventions • Stop the steroid medication • Removal of the adrenal glands
Hyperparathyroidism
Pathophysiology
• Excessive release of parathyroid hormone
• Hypercalcemia caused by the body pulling calcium
from the bones
Signs and Symptoms
• CNS issues (irritability, fatigue, confusion)
• Kidney stones
• Osteopenia/porosis fractures
Interventions
• Pharmacological (calcitonin, biphosphonates)
• Resection of the parathyroid
Hypoparathyroidism
Pathophysiology • Decreased production of parathyroid hormone • Leads to Hypocalcemia • Common complication post-thyroidectomy Signs and Symptoms • Muscle Tetany / Cramping • Paresthesias • Chvostek’s sign / Trousseau’s sign Interventions • Pharmacological (calcitriol, vitamin D, calcium gluconate) • Decrease intake of phosphorus
Hyperthyroidism
Pathophysiology • Elevated release of thyroid hormones Signs and Symptoms • Everything will speed up (metabolism) • Weight loss • Heat intolerance Interventions • Pharmacology (methimazole, propylthiouracil, iodine) • Radioactive iodine • Thyroidectomy Complications • Thyroid Storm — Severe symptoms of hyperthyroidism
Hypothyroidism
Pathophysiology • Decreased production of thyroid hormones Signs and Symptoms • Fatigue • Cold intolerance • Weight gain • Muscle weakness Interventions • Lifelong hormone replacement (levothyroxine) Complications • Myxedema coma
Radioactive Iodine Uptake Test:
• Give a small amount of radioactive iodine.
• Later measure how much is in the thyroid
to determine thyroid problems, specifically
hyperthyroidism.
Hashimoto’s Thyroiditis
• Autoimmune disorder leading to underactivity
of the thyroid gland (hypothyroidism)
• More common in women
• Hypothyroidism signs and symptoms
• May be caused by high intake of selenium
or iodine
Graves’ Disease
Pathophysiology • Autoimmune disorder leading to overactivity of the thyroid gland (hyperthyroidism) • More common in women over 20 Signs and Symptoms • Similar to hyperthyroidism • Exophthalmos (bulging eyeballs) Interventions • Similar to hyperthyroidism • Immunomodulators • Steroids
Goiter
Pathophysiology • Enlarged thyroid — Lack of iodine in the diet — Tumor or nodules on thyroid • Enlarged lymph node Signs and Symptoms • Visible enlargement and ability to palpate • May be benign or toxic • Dizziness when raising arms above head Interventions • Monitoring • Surgical Complications • Dysphagia • Respiratory distress
Diabetic Ketoacidosis (DKA)
Pathophysiology
• When the body does not have enough glucose
or does not have enough insulin to get glucose into
cells for energy, the body begins breaking down fat
for energy, creating ketones which are toxic.
Causes
• Uncontrolled Type 1 DM
• Stress on the body and not enough glucose or
insulin in circulation leading to ketone production.
Signs and Symptoms • Polydipsia and Polyuria • SOB and fruit-scented breath • N/V, weakness and confusion • Kussmaul Breathing — Fast and deep Diagnostic Testing: • Glucose level > 600 • Ketones in urine Interventions • F&E replacement to combat dehydration • Insulin.
Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
Pathophysiology • When there is a high glucose level in the body, kidneys remove that glucose. • When removing glucose, body also removes water causing dehydration and hyperosmolarity Causes • Eventually, due to dehydration, the kidneys cannot release any more glucose leading to hyperglycemia • More prevalent in Type 2 DM • Takes weeks to develop • Commonly affects older people (decreased thirst mechanism) • Can be caused by illness or infection • Long standing dehydration • DM not being managed properly Signs and Symptoms • Sugar levels above 600 • Polyuria and Polydipsia • Hot and dry (may see fever) • Sleepy and confused • May lead to seizures, coma, and death Interventions • Fluids and insulin • K+ may be given
Foot Ulcers / Infection
• Decreased sensation due to arterial insufficiency • Wet-to-dry dressing for open wounds — Place a wet or moist dressing on the wound and do not remove until the dressing is dry. • Prevention is key — Keep the feet clean and dry — Daily inspections — Use of lotion to prevent cracking of the skin — Wear cotton socks and tight fitting shoes — Careful not to clip toenails too close
Glycosated Hemoglobin (A1C)
• Gives a 3 month outlook on glucose management
of your patient
• Glucose regulation, diet, exercise
• The higher the A1C, the more unregulated
the glucose in the patient. A higher level
of intervention will be likely.
• Begins with diet and exercise, than oral
antidiabetic agents, than insulin replacement
Mixing Insulins:
- Inject air into long acting insulin (NPH)
- Inject air into short acting insulin (Regular)
- Aspirate short acting insulin (R)
- Aspirate long acting insulin (N)
Draw R before N (RN)
Regular before NPH
Clear before Cloudy
Never shake insulin
Keep it refrigerated
Diabetes Insipidus
Cause • Lack of Antidiuretic Hormone (ADH) Signs and Symptoms • Frequent Urination • Dehydration Hypovolemia Hypotension Dizziness • Rebound Tachycardia • Hyperosmolar blood - becomes concentrated Interventions • Vasopressin
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Cause • Too much Antidiuretic Hormone (ADH) Signs and Symptoms • Decreased urine output • Fluid retention hypervolemia hypertension • Hypoosmolar blood - becomes dilute — hyponatremia Interventions • Water restriction (ice chips) • Diuretics • Vasopressin Antagonist
Diabetes Insipidus
Excessive urine output and thirst, dehydration, weakness, administer pitressin
Cause • Lack of Antidiuretic Hormone (ADH) Signs and Symptoms • Frequent Urination • Dehydration Hypovolemia Hypotension Dizziness • Rebound Tachycardia • Hyperosmolar blood - becomes concentrated Interventions • Vasopressin
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Change in LOC, decrased deep tendon reflexes, tachycardia, N,V,A, HA, administer Declomycin, Diuretics
Cause • Too much Antidiuretic Hormone (ADH) Signs and Symptoms • Decreased urine output • Fluid retention hypervolemia hypertension • Hypoosmolar blood - becomes dilute — hyponatremia Interventions • Water restriction (ice chips) • Diuretics • Vasopressin Antagonist
Grey Turner’s Sign
Bruising of the flank
• Indicative of pancreatic necrosis with retroperitoneal or intra-abdominal bleeding
Charcot’s Triad
→ Abdominal pain
→ Fever
→ Jaundice
Cholangitis
• Pathophysiology — Infection of the common bile duct — Medical Emergency • Causes — Gallstone obstruction
• Signs and Symptoms — Charcot’s Triad → Abdominal pain → Fever → Jaundice • Diagnostic Testing — ERCP to identify — Blood Culture to determine bacteria • Interventions — ERCP with lithotripsy to break up stones
Tube Feedings
• Feedings have 24 hour shelf life • Assessing residual and effectiveness of the feedings — 50% or more residual being aspirated → discard the residual → half the rate of the pump — 50% or less residual → push it back in → keep the rate • Confirmation — RN → Aspirate content (note color, clear is not good) → Push air, auscultate for bubbling → Gold-Standard is always XR — Feedings can not begin until confirmation by XR → Risk for pushing food into the lungs causing pneumonia and death
Peritonitis
• Causes — Peritoneal Dialysis — Rupture of organs • Signs and Symptoms — Abdominal pain and distention — Rigid / Board-like Abdomen • Treatment — Surgical abdominal washout — Antibiotics • Complications — Sepsis
Disseminated Intravascular Coagulation (DIC)
Pathophysiology • Minor trauma causing platelets to be used up • May be a complication of sepsis Signs and Symptoms • Abnormal Bleeding - Oozing from the IV sites – May present with complaints of wetness on the arm or inspection of dried or blood around the IV • Prolonged aPTT and PT Interventions • Treat the underlying problem • Platelets and FFP
Vaccinations
Immunology
Humoral Immunity - antibodies or immunoglobulins, at birth
Acquired Immunity - learned by infection or vaccination
Cell-Mediated Immunity- B and T cells
• SCID (severe combined immunodeficiency)
• HIV/AIDS
Herd Immunity - indirect protection when the majority of a population is vaccinated
• 95% needed to enjoy the benefit of herd immunity
Hepatitis A (2 rounds)
Hepatitis B (3 rounds)
Varicella (chickenpox) / Herpes Zoster (shingles)
• Virus reactivates in the ganglia (nerves) → severe pain → rash forms
TDAP (Tetanus, Diphtheria, Pertussis) - q5 years
Hib (influenzae) - q1 year
• Attenuated virus (alive)
• Will my child receive the immunization today even if they’re sick?
– No, the child will receive the shot when they come back in for their next visit.
• Injection reactions
– Small fever
– Pain at injection site
• Allergy alert
– Eggs
Human Papillomavirus
• Boys and girls
• Prevents cervical, oropharyngeal, anal cancers
Pneumococcal ( q5 years )
• High risk populations (elderly and immunocompromised)
Meningococcal (q3-5 years)
• High risk populations (elderly and immunocompromised)
• People living in tight quarters
• Dorms (college)
• Service members (military)
MMR (Measles, Mumps, Rubella)
Systemic Lupus Erythma
Pathophysiology
• Systemic disease affecting multiple
organs (heart, lungs, skin, liver, kidneys,
nervous system)
• Commonly affects African Americans and women
Signs and Symptoms
• Systemic Inflammation
• Pericarditis
• Butterfly rash, photosensitivity, fatigue
Interventions
• Steroids, Immunomodulators
Aplastic Anemia
Production issue — bone marrow is not producing enough
Red Blood Cells (RBC’s)
• Treat with epoetin alfa
• Renal failure / chemo - radiation to bone marrow
Hemolytic Anemia
Destruction issue — the RBC’s are being lysed/sliced
• Bilirubin is released from the hemoglobin when it is destroyed
• Hemolytic jaundice versus physiological jaundice (liver)
Sickle Cell Anemia
The RBC’s coagulate together when they are not oxygenated
because they sickle
• Most common in African American women
• Sickle cell crisis (coagulate in joints and block blood flow)
— causes pain
• First nursing intervention is always fluids and then treat pain
Pernicious Anemia
Deficiency of B12 (cobalamin)
• Sore, red tongue
• Easy bruising
• Intrinsic factor (made inside the stomach) is needed to absorb
B12 into the body
• Subtotal gastrectomy or total gastrectomy
— intrinsic factor is no longer produced
Iron Deficiency
• Common in intestinal disorders
• Supplements (take with orange juice to aid in absorption)
• Injections (if oral supplements cannot be tolerated)
— refer to Iron (Ferrous Sulfate) in the Pharmacology Overview
• Foods that are high in iron
— leafy greens, meats
Chlamydia
- Bacterial
* Discharge / dysuria
Genital herpes
- Viral
- Lesions (sores) —> painful
- Herpes Simplex (Cold Sores)
Urinalysis / Dipstick Test
• Specific Gravity
(1.005-1.035) — Higher more concentrated (dehydrated) — Lower more dilute (well hydrated) • Color — Straw-colored → acute kidney injury — Amber-colored → dehydration — Clear → well hydrated and healthy • Bacteriuria • Calciuria • Urine K • Proteinuria • Ketonuria • Hematuria • Glucose
Gonorrhea
• Bacterial
• Discharge / dysuria
• In women, if left untreated may cause
complications
• Pelvic Inflammatory Disease (PID)
— May lead to infertility
— Lower abdominal pain
Trichomoniasis
- Parasite infects the vaginalis
* Discharge
Syphilis
• Bacterial
• Primary , Secondary , Tertiary (infects the brain,
dementia
• Painless sore → Chancre
Compound (open)
- Risk for fat embolism
- Fat embolism becomes pulmonary embolism.
- Risk for infection
Comminuted
- Crush injury
- Multiple small pieces of bone
- Surgery with rod placement may be needed.
Spinal -
decompress the spine
RN Considerations for traction
• Assess skin and pinsites for skin breakdown,infection
• Neurovascular checks
– Monitor pulses, sensation, movement,
color, etc.
• DO NOT touch any piece of the traction
• Turn the patient per physician orders – Q2hr specific orders required
– Logroll if needed
• Isometric exercises to prevent muscle atrophy – Flexion and relaxation of a muscle without movement
Skeletal -
pins, screws, wires
Bryant’s -
pediatrics for hip or femur
Skin (Buck’s) -
common in lower extremites
Spiral
- Often the result of child abuse.
* Confirm the story matches the injury
Rhabdomyolysis
Pathophysiology – Rapid breakdown of muscle (skeletal)
– Crush injury – Medications (statins) – May be fatal if left untreated
• Signs and Symptoms – Extreme quick onset pain
– Kidney Failure
→ Myoglobinuria (brownish color)
• Diagnostics – Labs → Creatine Kinase → D-Dimer → Hyperkalemia – Urinalysis • Interventions – IV Fluids – Treat the S&S
Compartment Syndrome
Build up of pressure in the third-space around the artery
Pressure eventually occludes the artery causing distal loss of blood flow
Crush injury, Casts, Burns
Can lead to death (MEDICAL EMERGENCY)
Signs and Symptoms – Loss of distal pulses (dorsalis pedis, posterior tibial) – Extreme pain – Swelling in the extremity
• Interventions – Faciotomy
→ Incision into the muscle /facia to release the pressure – Remove the cast
Burns
Pathophysiology – 30% or more is a MEDICAL EMERGENCY – Third spacing of fluid – Destruction of cells leads to release of potassium • Signs and Symptoms – Hypovolemia → Hypotension – Shock (circulatory collapse) – Hyperkalemia – PVC’s – ECG changes
• Interventions – Monitor vitals and heart rhythm – Fluid resuscitation – Lactated Ringers – Albumin – Expected outcome or an improvement will show adequate urine output.
Traumatic Brain Injury
• Pathophysiology — Concussion — Coup contrecoup Injury (whiplash) — Shaken baby syndrome — Intracranial hemorrhage (leads to stroke) — Brain herniation (will lead to brain death) • Signs and Symptoms — Signs and symptoms are presented below in ICP and Glasgow Coma Scale assessments.
• Intracranial Pressure (ICP)
— ICP monitoring → Normal = 5-15mmHg — Pupillary dilation → PERRLA → Blown pupils (unilateral or bilateral) — Level of consciousness → Glasgow Coma Scale (decrease in) — Headache, nausea, vomiting — Cushing’s Triad → Apnea, bradycardia, widening pulse pressure (systolic minus diastolic) → Emergency (call HCP/MD)
— Partial Seizures
→ Singular part of the brain
— Generalized Seizures
→ Both hemispheres
