Exam 2 Flashcards

Question

MI: Priority Non Pharmacological Care (4)

Answer 1

- place two large bore IVs - Door-to-PCI within 120 minutes if need transfer to PCI-capable facility (90 min if PCI-capable hospital) - Balance myocardial oxygen supply and demand (use Bed rest w/ bathroom privileges and place upright for venous return, lower preload, decrease workload) - Prevent immobility complications (DVT, pneumonia) w/ early mobility and HOB 30 or more

Answer 2

Eligibility - Onset of STEMI within 12 hrs - <30 min after STEMI diagnosis Exclusion - Uncontrolled hypertension (need antihypertensives first) - Ischemic stroke within 3 months - Recent surgery, facial or head trauma - Unstable angina or NSTEMI

Answer 3

Action: lysis of acute thrombus to reopen obstructed coronary artery and restore blood flow; short half-life Care - Anticoagulants(heparin) for 48 hrs after - Antiplatelets (clopidogrel) for 14 days to 1 year after - Continue aspirin indefinitely - Bleeding precautions (gently handling, avoid venipunctures, apply add’l pressure) - STOP if IC bleeding or internal bleeding and give volume expanders and coagulation factors

Answer 4

- inflammation of pericardial sac during or after MI or CABG leads to pericardium irritation S/s - Cardiac Friction Rub (grating, scraping, leathery scratching at sternal border)- most common initial - Chest pain (exacerbated by deep breathing/coughing and supine)- most common - Pericardial effusion - ST elevation in all EKG leads Care - NSAIDS/Aspirin - Rest - Pericardiocentesis (removal of fluid)

Answer 5

- Watch for S/S of bleeding (hematoma, hypotension, tachycardia; Back pain (retroperitoneal bleeding)) - Assess insertion site and apply direct pressure if bleeding - HOB should be less than 30 degrees - Bedrest: Instruct to keep limb straight/minimize movement for 4-6 hrs

Answer 6

- Monitor neurovascular of affected extremity (distal pulses, cap refill, color, sensation, and temperature in involved extremity) - VS q15 for 1h, q30 for 1 hr, q1 for 4 hrs - Monitor for graft occlusion

Answer 7

- Watch for increased chest pain r/t thrombosis or transient coronary vasospasm - Monitor EKG for ST elevation - Give IV NTG - Monitor labs for hypokalemia

Answer 8

- Maintain hydration before and after (NS and/or sodium bicarb) - Check Crt, BUN, GFR prior - Avoid nephrotoxic drugs (NSAIDS, metformin)

Answer 9

- Chest pain stops due to return of blood flow - CK and troponin increase rapidly then decrease (a washout) - ST elevation returns to baseline (note Failure of fibrinolytic = inability to achieve 50% resolution of ST elevation within 60-90 minutes of med admin) - Reperfusion dysrhythmias (ex. PVCs, bradycardia, heart block, VT)- Usually self-limiting --> Care for PVCs: oxygen and correct f/e imbalance

Answer 10

Localized dilation of arterial wall that results in alteration in vessel shape and blood flow Causes - systemic HTN - Atherosclerotic changes in the thoracic and abdominal aorta - Blunt trauma - Pregnancy - Smoking

Answer 11

- CT w/ dye - May use NTG to dilate coronary arteries or BB to reduce HR for better visualization - Aortic Angiogram (uses dye) - Ultrasound (Can assess collapse of inferior vena cava during respiratory cycle) - Transesophageal Echocardiography (TEE) - less barriers so easier to see heart than Transthoracic; NPO prior

Answer 12

- may not have any - palpable, pulsatile mass in umbilical region to left of midline (avoid palpating)

Answer 13

- Outpatient management and education - Lifestyle (Weight loss, Smoking cessation) - BP control (most important) - Pain control - Prevention of complications i.e. Rupture

Answer 14

- Inpatient management- 1-hour assessments for 24-48 hrs in ICU - Evaluate the need for surgical repair (Prosthetic graft) - Abdominal (DO NOT PALPATE; listen to bruits) - BP checks w/ art line or in both arms ( HTN treated w/ vasodilator (sodium nitroprusside) or labetalol or clevidipine; Hypotension treated w/ vasopressors and volume replacement) - Heart (Monitor EKG for ischemia or dysrhythmias; Auscultate aortic murmur - Neurovascular checks (Bilateral peripheral pulses, Pain, pallor, paresthesia, paralysis, movement) - Pain assessments and management - Kidney function (Urine output) - Maintain calm environment (No heavy lifting, stress)

Answer 15

- Sudden onset of intense, severe, tearing pain localized in the chest, abdomen, or back when column of blood separates vascular layers S/s - Pain Radiates to back or lower extremities - Pulsatile mass in umbilical region of the abdomen to the left of midline - neuro (alt mental status or coma) - CV (severe HTN, limb ischemia, new murmur)

Answer 16

- CT - Transthoracic Echocardiography (TTE)--On chest and noninvasive w/ transducer on skin - Transesophageal Echocardiography (TEE)-- Down throat; lidocaine to reduce gag reflex, NPO prior - Chest X-R (only if mediastinum widened) - Aortogram (definitive invasive)

Answer 17

- Control of BP (IV antihypertensives or vasodilators) - control pain (opiates) - May need mechanical ventilation if profound hemodynamic instability - Emergency Surgery (Resection of the affected area w/ Graft placement and restoration of blood flow to major branches of the aorta)

Answer 18

Cardiac tamponade - Lethal r/t fluid accumulation in mediastinal space which impairs heart’s ability to pump - S/s: elevated and equalized filling pressures (CVP, PADP, PAOP); Decreased CO (Decreased BP, Muffled heart sounds, Sudden cessation of chest tube drainage); JVD, pulsus paradoxes - Care: emergency sternotomy or return to OR for clot retrieval Cardiogenic shock - Blood pressure support

Answer 19

- Foreign material in heart (Prosthetic heart valves, Implantable pacemakers , ICDs) - IV drug users (esp if right heart valves involved) - Strep throat infection (not completing full course of antibiotics) - Poor oral hygiene - Other heart problems (CHD, Valvular heart disease) - Body piercings - DM type 2

Answer 20

inflammation on the endothelial surface of the heart, specifically thrombotic-fibrin vegetation on the cardiac valves. - Noninfectious: thrombotic lesion on cardiac valve or endothelium - Infectious: Due to bacterial/fungal organism in blood (bacteremia) or on cardiac valve lesion; most common: Streptococci, staphylococci, and enterococci

Answer 21

- Cough and pleuritic chest pain - Fever w/ rigor, fatigue, malaise - Myalgias and joint pain - Heart murmurs - bleeding (Hematuria, Petechiae) Complications - Heart Failure (most frequent cause of death) - Embolic (CVA, PE, septic on fingers and toes (osler nodes, splinter hemorrhages), liver, splenomegaly, kidney, peripheral)

Answer 22

CBC- Elevated WBC Blood cultures- may be negative TEE- Visualize vegetations and abscesses Chest x-Ray- Detect nodular infiltrates, cardiomegaly, enlarged pulmonary vessels

Answer 23

Treatment - IV Antibiotics for 4-6 weeks (Broad Spectrum-- risk for kidney dysfunction, vestibular dysfunction, diarrhea (c-diff) or colitis - Surgery to replace valves, remove vegetation for persistent vegetation, valve dysfunction, perivalvular extension, antibiotic-resistant bacteria or fungus Key Patient education - Daily temp monitoring - Prophylactic antibiotics for invasive procedures (dental) if artificial valve, ICDs, pacemakers - Care for HF (activity, fluid and sodium restriction, diuretics, daily weights)

Answer 24

- Acute rapid or severe increase in blood pressure over 180/120 - results in new or progressive end-organ damage (heart (acute MI), the brain (stroke), or the kidney (kidney failure)) Goal by discharge: 140/90 or 130/90 if HTN, CKD, DM, or CAD

Answer 25

* CNS- Headache; Blurred vision; Change in LOC -> Coma, stroke, seizures * Cardiac- Chest pain of ACS or aortic dissection * Abdominal or back pain r/t aortic aneurysm or dissection * AKI i.e. Sudden absence of urine output; high Crt or BUN * Catecholamine excess = vasoconstriction

Answer 26

- Vasodilator (Sodium Nitroprusside; hydralazine if pregnant) - Beta Blockers (labetalol and esmolol) - ACE inhibitors (enalaprilat) - Calcium Channel Blockers (nicardipine) - Loop Diuretics

Answer 27

Indications: HTN emergencies, afterload reduction in severe HF Risks - cyanide toxicity (blurred vision, confusion, tinnitus) w/ long-term use - Hypotension r/t peripheral vasodilation - Headaches r/t cerebral vasodilation - Reflex tachycardia Care - start IV drip via titration (no more than 10-15% drop in BP in first 24 hrs) - nee art line and 2 IVs for monitoring - Protect bag and lines from light (usually in brown bag)

Answer 28

- Invasive catheter (Art-line least invasive) - 250-300 mm Hg pressure tubing with 0.9% NS flush solution - Transducer to convert physiologic signal into electrical energy - Bedside monitor to display volume of electrical signal on digital scale

Answer 29

- separate pressure bags for separate lines - place transducer at phlebostatic axis (midaxillary 4th intercostal space) while HOB 0-60 degrees every shift - zero transducer once a shift (open to atmospheric pressure and close to patient and flush solution) - monitor for bleeding, infection (CLABSI), air embolus, thrombus, dislodgement - alarms should always be audible - do fast flush square wave test to ensure waveform not over or underdamped - daily x-ray for placement

Answer 30

Continuous measurement of three BP parameters (Systole, Diastole, Mean arterial blood pressure (MAP)) Indications - Shock - Hyper or hypotension - Post-op for major surgery - Acute lung failure b-c need frequent ABGs

Answer 31

- perform Allen test to assess collateral circulation - assess wave form (Systole: highest point; Dicrotic notch: closure of aortic valve and start of blood flow into arterial vasculature; Diastolic: lowest point) - never put meds in ART

Answer 32

Range: 70-100 mm Hg Preferred - > 60 to perfuse coronary arteries - > 65 to perfuse brain and kidneys Equation: MAP= [(DBP(2) + SBP)/3)]

Answer 33

- Measures right ventricular end-diastolic pressure( filling pressures of the right side of the heart) and sits in superior vena cava Indicated for alteration in fluid volume (high = overload; low = dehydration) Catheter Placement - Subclavian (SC- better if > 5 days) - Internal jugular (IJ- has best blood flow and less risk for pneumothorax) - Femoral (if others inaccessible b-c higher risk for infection) Range: 2-5 mm Hg

Answer 34

- CVP (R atrial pressure and volume status b-c sits in superior vena cava)- Useful for blood samples, IV infusion, fluid injection for CO determination, CVP (Volume Status (EDV)) - PAP (pulmonary artery pressure) (L volume status b-c sits in pulmonary artery on L side) - Useful fo blood samples to measure Oxygen supply and demand (ventricular function (PVR, SVR) and SvO2) - Pulmonary Artery Occlusion Pressure (PAOP/Wedge Pressure) --5-12 mm Hg general range (Gives HCP the CO, SVO2, Cardiac index, preload) - Thermistor (Measure thermodilution CO)

Answer 35

Indications - Open heart surgery - Acute heart failure - Acute pulmonary HTN - Cardiogenic shock Special Care - must have ECG monitoring - must have defibrillator and emergency resuscitation nearby

Answer 36

Volume of blood ejected from the left ventricle in 1 minute Starling Law: force of ventricular blood volume ejection is related to preload (Volume of blood in the ventricle at end-diastole) and Amount of stretch (force) placed on the ventricle Equation: HR (# of beats per minute) X SV (amount of blood ejected by ventricle w/ each heartbeat) = CO Normal range: 4-6 L/min

Answer 37

- pressures resulting from volume coming into ventricles (end diastolic pressure) Factors on left and right side - Left side (Pulmonary artery diastolic pressure and pulmonary artery occlusion pressure) - Right (CVP aka right atrial pressure) - increased (hypervolemia, regurgitation of valves) How to reduce - diuretics - vasodilators - fluid restrictions

Answer 38

- resistance left ventricle must overcome to circulate blood/ overcome systolic ejection Factors - Left (SVR-- high SVR = decreased CO) - Right (PVR) - increased (HTN, vasoconstriction) = increased cardiac workload Care - to reduce, ACEI, ARBS, vasodilators (sodium nitroprusside, NTG) - to increase, vasopressors and IV fluids (preferably w/ art-line)

Answer 39

The heart’s ability to stretch and contract Relation - Afterload/SVR increases, contractility decreases - Preload increases, contractility increases - If ventricle overdistended, contractility decreases Drugs: - Cardiac glycoside (digoxin) - Inotropic drugs (dobutamine, dopamine, milrinone - Oxygen (Hypoxia = negative inotrope)

Answer 40

* Polyuria (r/t osmotic diuresis from excess glucose in urine; leads to hypokalemia) * Polydipsia * Polyphagia (R/t cellular starvation of glucose so need insulin vs food to push glucose into cells) * Ketonuria and ketonemia -> metabolic acidosis -> hyperkalemia * Kussmaul respirations (to blow off excess CO2 from anion gap) – compensatory respiratory alkalosis * Acetone exhaled (fruity odor) * Hemoconcentration and Hyperviscosity * Hypovolemia (low CVP, high HR, low BP) and hypoperfusion * Hypoxia -> lactic acid production * Pain (headache, abdominal * fatigue, weakness)

Answer 41

- Glucose > 250 mg/dL - Low bicarbonate level (<18 mEq/L) - Acidosis (pH <7.30) - Moderate or severe ketonemia and ketonuria - Anion gap > 12

Answer 42

- Illness/infection (most common = UTI) - Increased metabolic demand (Pregnancy, trauma, hospital or surgery, Growth spurts) - Psychosocial (stress, eating disorders, depression) - mismanagement of sick days (not taking insulin when sick) - Drugs (steroids, insulin shortage or malfunction in pump) - heavy sugary drinks

Answer 43

- due to insulin deficiency preventing glucose from entering cells - Lipolysis (Triglycerides to glycerol and free fatty acids ) -> Ketogenesis (Free fatty acids -> Ketones (Ketonemia and ketonuria, and Acetone (fruity breath via lung excretion) -> Metabolic Acidosis (low bicarb; anion gap > 12 - Glycogenolysis (glucagon leads to release of glucose from liver and skeletal muscle stores to increase glucose level in blood) - Gluconeogenesis (breakdown of fats) into glucose in absence of insulin) -> Hyperglycemia -> attempt to get rid of excess glucose leads to osmotic diuresis (Causes dehydration, hypotension, tachycardia, tissue hypoxia, shock)

Answer 44

- Leukocytosis - Urine: High specific gravity and osmolality - Glucosuria (Osmotic pull of glucose increases output) - BUN, Crt increase b-c risk for kidney impairment r/t decreased organ perfusion - K, Na, PO4 excreted in urine (may be low) - Serum osmolality (hyperosmolality)

Answer 45

* NS 1 Liter w/n first hour * Then NS 1/2 at 250-500ml/hr * When glucose < 200, change to D5W 1/2NS at 150-250ml/hr to prevent hypoglycemia and cerebral edema via replenishing cellular glucose

Answer 46

* replace sodium w/ fluids * If hypokalemic, give K immediately before insulin * If not hypokalemic, give 20-30 mEq of K+ within 2-3 hrs of treatments * If hyperkalemic, insulin and volume expansion will correct * Replace phosphate if < 1 mg/dL

Answer 47

- 0.1 unit/kg Regular Insulin IV Bolus (onset: 15 min) followed by 0.1 unit/kg/hr via continuous IV pump - Glucose should drop 50-70 points/hr - Switch to SubQ regular insulin 2 hours before discontinuing continuous pump - Patient must be stable w/ consistent glucose level, no ketosis, and able to eat prior to switch to subQ

Answer 48

- Hourly glucose checks until stable (once stable, q2-4h) - Use accuchecks unless CVP or art-line w/ blood conservation system - rate of blood glucose change = 50—70 (More important than actual level) - Monitor appearance, VS, I & O and Labs: BUN, Crt, K, ABGs - NPO until glucose is stable

Answer 49

- Blood glucose below 200 mg/dL - Serum bicarbonate above 18 mEq - pH greater than 7.3 - absence of ketones in urine and blood

Answer 50

Fluid volume overload r/t HF or kidney disease - Care: oxygen, reduce infusion, elevate HOB, assess fluid status Hypokalemia or Hyperkalemia - Care: ECG monitoring, potassium chloride Hyponatremia - Care: NGT intermittent suctioning if NV Cerebral edema - Care: hourly neuro assessment esp sudden headache, confusion, pupils Infection - Care: oral care, repositioning, sterile technique, check venipuncture sites q4h Hypoglycemia - Care: stop IV insulin, give D50 or subQ glucagon q15 until glucose > 70

Answer 51

- Blood glucose > 600 mg/dL - Arterial pH > 7.3 - Serum bicarb > 18 mEq/L - Serum osmolality > 320 mmol/kg (risk for coma if > 350) - Absent or mild ketonuria - Severe dehydration

Answer 52

- Geriatric b-c higher risk for dehydration b-c decreased thirst perception, urine concentration; and increased diuretic usage - Illness (UTI, pneumonia, pancreatitis, sepsis) - Perfusion morbidities (MI, stroke) - Stress of critical illness (trauma, surgery, stress hormones: cortisol, glucagon, epinephrine) - Drugs (glucocorticoids, diuretics, phenytoin, beta blockers, CCB)

Answer 53

- Pancreas makes insufficient insulin for glucose needs (enough to prevent ketosis but not enough to prevent hyperglycemia - No ketogenesis so no fruity breath and Rapid and shallow respirations vs kussmaul - Gluconeogenesis (glucagon in liver creates glucose) - Hyperosmolar -> Osmotic diuresis -> Severe Dehydration (hypovolemia, oliguria) -> hyperglycemia (b-c conserves glucose and water) -> hyperosmolality (worsened) - Hemoconcentration (Increased blood viscosity r/t hyperglycemia -> Risk for clot, VTE, infraction)

Answer 54

- Elevated Hct - Low K, PO4 b-c lost in urine - Elevated BUN and Creatinine r/t lack of kidney perfusion

Answer 55

- NS 1 liter/hr for massive fluid replacement - Once hemodynamically stable (look at CVP or PAOP) or serum Na reaches 140mEq/L change to 1/2NS. - When plasma glucose reaches 300mg/dL, change to D5W 1/2NS 150-250 ml/hr - 0.15 unit/kg Regular Insulin IV Bolus followed by 0.1unit/kg/hr - subQ insulin once glucose stable and adequate food intake - Correct electrolytes (Potassium is added based on serum level (give if < 3.3))

Answer 56

- reduced glucose metabolism r/t increased visceral fat and decreased lean muscle mass - reduced insulin production r/t decreased pancreatic islet function (unable to regulate and metabolize glucose concentrations) - Type 2 DM more common in older adults - DM in older adults = increased institutionalization and reduced functional status - DM presents as thirst, confusion, infection, poor wound healing in older adults - increased DM complications (ESKD, blindness, heart disease, CVA, neuropathy, depression, sexual dysfunction, periodontal disease)

Answer 57

- Decreased kidney function so reduced elimination of sulfonylurea and insulin - Reduced epinephrine and glucagon release r/t hypoglycemic unawareness - Impaired motor skills interfere w/ ability to correct glucose levels

Answer 58

- cold intolerance (hard to distinguish from hypothyroidism) r/t decreased metabolism - dilute urine and dehydration risk r/t decreased ADH production - reduced thyroid hormone secretion (may not have s/s of hypothyroidism) - hypothyroidism is most common thyroid problem in older adults - start low and go slow w/ levothyroxine b-c risk of angina, dysrhythmias, HTN

Answer 59

Central Diabetes Insipidus AKA neurogenic DI - Hypofunction of the posterior pituitary gland or hypothalamus leads to ADH (vasopressin) deficiency - no ADH = kidneys not told to concentrate urine so lose excess H2O Nephrogenic Diabetes Insipidus - Inability of kidney tubules to respond to circulating ADH Dipsogenic Diabetes Insipidus - Compulsive water drinking (> 5 L/day)

Answer 60

Neurogenic - Head trauma - resection of pituitary tumor (malignancy) - craniotomy (surgery) - congenital disorders - infection (encephalitis, meningitis) - increased ICP Nephrogenic - pyelonephritis - Polycystic kidney disease - Drugs (lithium carbonate and demeclocycline)

Answer 61

- High Serum Na+ > 145 mEq/L - High Serum Osmolality > 295 mOsm//L (Normal: 275-295) - Low Urine Osmolality < 300 mOsm/L - Low Urine specific gravity < 1.005

Answer 62

- Dehydration (decreased skin turgor, dry mucous membrane, tachycardia, hypotension/hypovolemia, hemoconcentration, constipation, LOC change) - large dilute urine (polyuria and nocturia ; > 3L/24 hr) w/o hyperglycemia, diuretics, or fluid challenge - Polydipsia

Answer 63

General - volume resuscitation (oral or IV hypotonic) - may need lifelong care for chronic DI w/ daily weights (ED if > 2.2 lb overnight) - monitor for fluid balance (overload or dehydration)- need urinary catheter Central DI - Vasopressin (antidiuretic and vasoconstrictor): risk for HTN, angina, vasospasm (MI, CVA) so not preferred - Desmopressin (DDAVP- strong antidiuretic w/ little effect on BP - preferred Nephrogenic DI - Hydrochlorothiazide (HCTZ) - reduces amount of urine via resorption of sodium and water in proximal nephron

Answer 64

Purpose: measure ADH and determine type of DI Procedure: give ADH (vasopressin) Results - If condition improves, there is central DI - If condition does not improve, there is nephrogenic DI

Answer 65

- More ADH than needed to maintain normal blood volume and serum osmolality - Excessive water reabsorbed at kidney tubule -> dilutional hyponatremia and overhydration - Increased kidney filtration of water inhibits Renin and aldosterone which prevents sodium resorption

Answer 66

- Pituitary gland problems - Malignancy (bronchogenic small cell carcinoma) - Skull fracture - Pulmonary infection or impairment - Meds that release or potentiate ADH (insulin, vasopressin)

Answer 67

- Hyponatremia (less than 125 mEq/L) - Decreased Serum Osmolality – < 275 mOsm/L - increased Urine osmolality – >100 mOsm/L - Elevated urine sodium - Elevated urine specific gravity (> 1.030)

Answer 68

- GI: loss of appetite, NV - Dilutional hyponatremia (Lethargy, NV, Headache, hostility, disorientation) - Severe Neurological Symptoms (Serum Sodium< 120 mEq/L)- > Decreased LOC, Seizures/ Coma, Apprehension - Hypothermia r/t CNS disturbance - Full and bounding pulse r/t increased fluid volume - Decreased DTR’s - Weight gain but no edema b-c water not salt is retained - Decreased urine output - increased thirst (polydipsia)

Answer 69

- Meds (hypertonic NaCl, Vaptans, Diuretic(if normal Na)) - Fluid restriction (usually 500 -1000 mL/day) - Oral care for comfort and to prevent dry mouth - If they need any free water, use saline vs tap water - Monitor for complications (I &O, daily weights, fluid status q2h; neuro status hourly if any changes in LOC) - Always seizure precautions and reduce stimulation if SIADH

Answer 70

- Hypertonic saline (3%NaCl) when Na level is too low to prevent extra volume - do not want rapid sodium increase (want gradual increase 8 mEq/L in 24 hr to prevent osmotic demyelination) - Monitor Na+ and K+ q4h during acute phase of sodium replacement

Answer 71

Indication: euvolemic hyponatremia in SIADH Action: excretes water and conserves sodium (aqua diuresis) Risks - For Conivaptan, hypotension (contraindicated in hypovolemia) - For Tolvaptan, black box warning for rapid hypernatremia (risk for CNS demyelination) AND liver failure

Answer 72

- heat intolerance (fever, diaphoresis) - Cardiac (SVT, systolic HTN, a-fib, PVC, HF, hypovolemia, pulmonary edema) - GI (Jaundice, NVD, abd pain, increased appetite, weight loss; enlarged spleen - CNS (agitation, insomnia, delirium, lethargy, seizures, stupor, coma, emotional instability) - Muscle (weakness and wasting; increased DTR, tremors) - Pulmonary (tachypnea) - Epithelium (goiter (no palpate); exophthalmos; pretibial myxedema; vision changes; thin hair )

Answer 73

- high T3 and T4 - Hyperglycemia - Decreased TSH - Hypercalcemia (confusion, short QT, bradycardia, increased DTR) - > 10.5 - metabolic acidosis

Answer 74

Action: block synthesis and release of thyroid hormone Care – must be enteral route - Avoid crowds and sick people b-c they reduce immune response (agranulocytosis i.e cough, fever, inflammation, rash) - Report s/s hypothyroidism (cold intolerance, weight gain) - If PTU, report hyperpigmentation (darkening of urine or yellow coloring of skin) b-c could be liver failure - If methimazole, report pregnancy b-c teratogenic

Answer 75

- isotonic and glucose solutions for fluid replacement to correct dehydration and prevent hyponatremia - Thyroidectomy (if swallowing or breathing difficult) - Antithyroid drugs (PTU and methimazole) - Radioactive iodine to remove goiter (give after antithyroid therapy; do not give if pregnant; radiation precautions) - Beta blockers (Propranolol (Inderal)) to control myocardial demand and slow HR and AV conduction rate (need ECG monitoring and CVP line) - reduce hyperthermia (acetaminophen, fan, cooling blanket)- NO ASPIRIN b-c increases free thyroid hormone via inhibition of binding - give steroids to prevent conversion of T4 to T3

Answer 76

- Autoimmune (Graves) - increased metabolic demand (Stress, Infection, Surgery or trauma, Pregnancy, DKA) - abruptly stopping antithyroid meds - Excess thyroid hormone intake (levothyroxine) - Iodine-induced hyperthyroidism r/t amiodarone - radioactive iodine therapy or excess iodine

Answer 77

- Cardiac (anemia, hypotension, bradycardia, peripheral vasoconstriction, cardiomegaly, narrow pulse pressure, prolonged QT/PR)- risk for shock and cardiac tamponade - Pulmonary (hypoventilation) - GI: constipation, anorexia, abdominal distention) - cold intolerance (< 36.1) - CNS (blank facial expression, apathy, slow speech, depression, delirium, stupor, coma) - Skin (thick tongue w/ husky voice, brittle/thin nails and hair, nonpitting edema (weight gain), poor wound healing - Muscle (decreased DTR, paresthesia of hands and feet r/t hyaluronic acid deposits) - Renal (decreased GFR, specific gravity, urine osmolality and output) b-c decreased blood flow

Answer 78

- Low T3 and T4 - Hypoglycemia - Increased TSH - Hyponatremia (confusion, NV) - metabolic acidosis/respiratory acidosis - hypercholesterolemia (r/t incomplete metabolism)

Answer 79

- give IV levothyroxine then PO (risk for angina and dysrhythmias) - take on empty stomach - give IV NS, glucose, steroids as needed - mechanical ventilation for hypoventilation and respiratory acidosis - warm blankets for hypothermia - emollient and repositioning for skin (rough, edema, risk for breakdown) - continuous ECG monitoring b-c risk for dysrhythmias - communicate slowly and in written form b-c decreased comprehension - fiber and fluids for constipation

Answer 80

- older adults - hashimoto (autoimmune) - Infection, trauma, stress - cold exposure - interruption of medication (levothyroxine) - Impaired perfusion (MI or stroke) - Thyroid damage r/t amiodarone, surgery - Meds (lithium, thiocynates, aminoglutethimide, sodium or potassium perchlorate or cobalt)

Answer 81

- decreased GI blood flow and motility - decreased Gastric emptying - increased risk of dehydration (decreased thirst sensation)-> constipation - More prone to GI bleeds b-c more prone to h. pylori - Decreased absorption -> nutrient deficiency and anemias - decreased swallowing = risk for aspiration and malnutrition

Answer 82

Prevent hypovolemic or hemorrhagic shock - large bore IV for IV crystalloids, blood products (plasma, platelet, PRBCs) - if esophageal varices, avoid frequent swallowing or activities that could rupture varices like vomiting or straining - give Supplemental oxygen to Increase oxygen delivery and tissue perfusion Nasogastric Tube Placement (NGT) - Purpose: Gastric lavage to confirm bleeding via irrigation w/ NS; aspiration prevention, decompression (low suction); feeding - Care: Do Not place if esophageal varices ; Lie on left side; Secure to gown; irrigate q4h w/ NS

Answer 83

What is it? - direct visualization and evaluation of GI tract (for lesions, mucosal changes, obstructions, motility dysfunction, bleeding Types EGD - esophagus to duodenum - evaluate upper GI bleed, chronic gastritis Colonoscopy: rectum to distal ileum - screens for colon cancer, evaluate UC Sigmoidoscopy: sigmoid colon - screen for Crohn's disease Endoscopic retrograde cholangiopancreatography (ERCP) - visualize the liver, gallbladder, bile ducts, and pancreas - evaluate pancreatitis, cholecystitis

Answer 84

- If contrast dye involved, ask about shellfish allergies and check kidney function (BUN, Crt, urine output) - If sedation or anything down throat, check gag reflex before oral feedings (risk for aspiration, vasovagal stimulation, oversedation) - Ensure HCP gets informed consent - need Two large IV catheters - NPO 6-12 hrs prior - Bowel prep if lower GI

Answer 85

- bleeding labs and VS (low H/H; low BP, high HR, decreased peripheral pulses) - Change in LOC (r/t dehydration or anemia) - Coffee ground emesis r/t gastric acid converting hemoglobin to brown hematin - Bright red emesis r/t profuse bleeding with little contact with gastric secretions - Hematochezia (bright red stools) – rectum or sigmoid (lower GI bleed) - Melena (black, tarry, or dark red stools) due to digestion of blood in upper GI bleed - Gastric perforation (sudden severe abd pain w/ rebound tenderness and rigidity plus fever, leukocytosis, tachycardia)- emergency

Answer 86

Endoscopy - achieve control of GI bleeding via cauterization, vasopressin, or embolic material Angiography (has contrast dye) - evaluate status of GI circulation, cirrhosis, portal HTN, intestinal ischemia Abdominal x-ray - visualize bowel obstruction and perforation GI bleeding scan - evaluate presence and location of of active GI bleed not detected on EGD and assess need for arteriogram MRI - identify tumors, abscesses, hemorrhages, and vascular abnormalities

Answer 87

Liver Biopsy - For liver failure, cirrhosis, or hepatitis (or diagnosis GI bleed) - Pre-op: NPO 6 hrs prior, blood drawn for coagulation - Post-op: position on right side and bed rest 6-8 hrs - Complications: damage to other organs, peritonitis (r/t gallbladder leakage of bile), hemothorax, infection US - more sensitive than x-ray for liver problems Hepatobiliary scan (HIDA scan) - visualize the gallbladder and liver and determine patency of the biliary system w/ dye - Results: decreased bile flow = obstruction - Care: NPO 2-4 hr prior; usually no sedation but be still CT - evaluate abdominal vascular space

Answer 88

Misoprostol - Prevention of GI bleed - contraindicated if pregnant Vasopressin (Pretessin) - prevent esophageal varices rupture via decreasing portal HTN - not preferred unless pt in shock - Risk for systemic vasoconstriction (chest pain, HTN, HF, dysrhythmias, phlebitis, CVA), bradycardia, fluid retention Sandostatin (Octreotide) – preferred to prevent esophageal varices rupture unless pt in shock - Decrease portal venous pressure when acute bleeding and cirrhosis - Risk for hyper/hypoglycemia when initiating drip Epinephrine - Vasoconstrictor agent

Answer 89

- acute gastritis (inflammation of gastric mucosa) - Perianal ulcerations/ fistulas (usually pyuria and fecaluria) -- may need skin barrier if draining b-c intestinal fluid enzymes are caustic - hemorrhage/Perforation (lower GI bleed) - abscess formation - toxic megacolon (dilation leads to ileus then gangrene and peritonitis) - intestinal malabsorption (esp folic acid and vitamin B12)-> malnutrition -> weight loss - Anemia (r/t slow bleeding and poor nutrition) - nonmechanical bowel obstruction (r/t inflammation, edema - > fibrosis and scar tissue) - extraintestinal (polyarthritis, erythema, cholelithiasis, oral and skin lesions, iritis, osteoporosis)

Answer 90

Peptic Ulcer disease - Gastroduodenal mucosal breakdown results in damaged blood vessels from acid secretions r/t H. pylori, NSAIDs, steroids - Diagnostic: anti H.pylori antibodies (IgG or IgM OR C13 urea breath test) - discontinue antacids and PPI a week prior Stress-related erosive syndrome (SRES) - Acute erosive gastritis covers mucosal lesions; common in ICU - Increased stress = increased gastric acid secretion - decreased mucosal blood flow = ischemia and degeneration of mucosal lining - Reason for prophylactic PPI or H2 antagonists

Answer 91

Esophagogastric Varices rupture - r/t portal HTN and liver dysfunction diverting blood from high pressure to low pressure - Risk w/ increased abdominal pressure (vigorous physical exercise, heavy lifting); hard dry food, chest trauma Exacerbated by medications (anticoagulants, steroids, NSAIDS) Conditions (Hepatitis, necrotizing pancreatitis, Acute liver failure))

Answer 92

Antacids - mag = diarrhea and avoid if CKD - calcium or aluminum = constipation - give 1-2 hrs within other drugs OR after meals H2 antagonists (Famotidine-Pepcid) - dose at bedtime - risks: CNS toxicity (confusion,deliruim) and thrombocytopenia Proton pump inhibitors (Pantoprazole-Protonix) - Can give w/ antacids - risk for VAP and C-diff Sucralfate (mucosal barrier) - dissolved in water to form slurry, not crushed - hold feedings before and after - No antacids within 30 minutes

Answer 93

- RLQ Abdominal Pain and/or distention - Peritonitis (guarding, masses, rigidity, tenderness) - High pitched sound on auscultation r/t narrowed bowel loops - Diarrhea (5-6 nonbloody stools a day - Steatorrhea (mucusy fatty stools) - Fever r/t fistula, abscess, severe inflammation

Answer 94

- Inflammatory disease causing thickening of walls of small intestine, colon, or both (esp. terminal ileum) - Recurrent with remissions and exacerbations. - Strictures and deep ulcerations (cobblestone appearance) - less severe than Ulcerative Colitis

Answer 95

- Decreased Hgb/Hct (slow blood loss) - Elevated WBC/CRP/ESR (inflammation) - Hypokalemia, hypomagnesemia, hyponatremia, hypochloremia (diarrhea) - Hypoalbuminemia (malnutrition and lost protein in stool)

Answer 96

- differentiate UC and Crohn's Disease i.e. complications, mucosal patterns, depth of disease Safety - void after to remove contrast - NPO prior to procedure - expect light colored stools b-c barium is white

Answer 97

- Aminosalicylates (ER Mesalamine) - Glucocorticoids (Methylprednisolone) - risk for infection - Antidiarrheal drugs (w/ caution b-c risk for toxic megacolon) - Immunosuppressive drugs/ Biologics - risk for infection - antibiotics if peritonitis - pain medication for pain

Answer 98

- recore accurate I & O for calorie counts - proper hydration - TPN (if severe and malnutrition present) - high calorie, high protein, high vitamin, low fiber diet - if fistulas, need up to 3,000/day - Avoid caffeine, alcohol, milk, gluten

Answer 99

- Laparoscopic Surgeries - Small bowel and ileocecal resections - Stricturoplasty: increases bowel diameter

Answer 100

Basics - inflammation of pancreas due to premature activation of enzymes - Inflammation worsened due to leukocyte clustering around hemorrhagic and necrotic areas - Proteolysis: split proteins of peptide bonds leading to thrombosis and gangrene Main Causes - Gallstone migration - Alcoholism - Other causes: ERCP, tumors, meds, hypocalcemia, trauma

Answer 101

- Trypsin- causes autodigestion and fibrosis - Phospholipase – destroys phospholipids of cell membranes leading to pancreatic and adipose tissue necrosis - Lipase – fat necrosis -> pancreatic necrosis - Kallikrein and chymotrypsin – increased cap permeability and vasodilation (edema, hypovolemia) - Elastase – hemorrhage r/t dissolution of elastic fibers for BVs

Answer 102

- high amylase (Normal 25-125) - high lipase (Normal 20-240) - elevated longer - high trypsin and elastase - AST >250 units/L (liver involvement) - Increased LDH (> 350) - hyperbilirubinemia - Leukocytosis (>16,000/mm3) and thrombocytopenia - Hyperglycemia (>200 mg/dL; no diabetic history) r/t decreased insulin from destroyed islet cells - Hypocalcemia and hypomagnesemia - Also present ( increased BUN, ALP, ESR, CRP; Hypoalbuminemia; Hypertriglyceridemia)

Answer 103

- epigastric to periumbilical abdominal pain (boring i.e going through body) - Nausea and Vomiting - Shock s/s (tachycardia, hypotension, diaphoresis) - Hypoactive bowel sounds - Peritonitis (Abdominal tenderness, guarding, distention, tympany, rigidity) - Severe jaundice (swelling of pancreas head, blocking bile) - Palpable abdominal mass = pseudocyst or abscess - Dull to percussion = pancreatic ascites - Grey Turner sign (gray-blue discoloration of the flanks) r/t Pancreatic hemorrhage - Cullen sign (discoloration of the umbilical region) r/t Pancreatic hemorrhage

Answer 104

- Abdominal CT with contrast (gold standard) --diagnosis pancreatitis, r/o pancreatic pseudocyst - Abdominal ultrasound --check for liver, gallbladder, biliary system; Gas, ascites, obesity may interfere w/ viewing - ERCP

Answer 105

Pain - w/ hydromorphone (morphine causes sphincter of Oddi spasm) - relieved by knee-to-chest or fetal position - ulcer prophylaxis (H2 antagonist and PPI) Nutrition - NPO to rest pancreas - small frequent meals afterwards - mod to high carb, low fat, high protein - avoid caffeine (coffee, tea, cola) and alcohol - NGT if vomiting, obstruction or distention Fluids and electrolytes - IV crystalloids (LR) - correct hypocalcemia, hypomagnesemia, and hyponatremia as needed

Answer 106

Systemic - Hypovolemic or hemorrhagic shock r/t third spacing - Acute necrotizing pancreatitis -> Multi-organ damage (ARDs, AKI, paralytic ileus, GI hemorrhage , DIC, Type 2 DM) Local - Pancreatic pseudocyst (pancreatic fluid enclosed in non epithelialized wall) w/ Risks: peritonitis (if rupture), erode BVs (hemorrhage), bacterial infection (abscess), invade surroundings (obstruction) -- may drain on own

Answer 107

Basics of ALF - severe and sudden liver cell dysfunction (necrosis of hepatocytes), coagulopathy, and hepatic encephalopathy Basics of Cirrhosis - Irreversible scarring of the liver - Early stage: liver enlarged and firm from fat - Progression: liver atrophy and harder -> decreased function due to scar tissue

Answer 108

- yellow skin (jaundice) or sclera (icterus) - Changes in color of urine (dark) or stool (clay colored) - Pruritus (itching) or rash or dry skin - Ascites (r/t portal HTN and hypoalbuminemia)- risk for orthopnea or dyspnea; posture problems - Asterixis (downward flapping of hands when arm dorsiflexes wrist) - Pulmonary (hyperventilation) - CNS (Headache; Hepatic encephalopathy r/t breakdown of blood brain barrier) --Increased ICP and cerebral edema - Coagulation (Palmar erythema, Spider nevi, Bruises) - Peripheral edema

Answer 109

↑ ALT, AST, ALP (ALT more liver specific) - Normal ALT: 10-40 m, 9-32 f - Normal AST: 8-40 m, 6-34 f - Normal ALP: 35-150 ↑Bilirubin (Normal: < 1) - decreased fecal bilirubin ↑ LDH (Normal: 110-220) ↑ Ammonia (risk for hepatic encephalopathy Decreased Albumin (b-c reduced synthesis) Anemia, thrombocytopenia, and leukopenia Prolonged PT and INR r/t decreased prothrombin production - Normal PT: 10-13 s - Normal INR: 0.9-1.3 ↑ BUN

Answer 110

- Reduce Ammonia (lactulose or nonabsorbable antibiotics) - force out ammonia - stress ulcer prophylaxis (PPI, H2 antagonists) - Treat GI bleeding (Vitamin K, PRBCs, platelets, coagulation factor replacement, plasma or Beta blocker) - antibiotics to prevent infection - definitive treatment = liver transplant - paracentesis or diuretics for ascites (pre-op: coagulation labs, void, and give vitamin K if high INR) - avoid too many drugs b-c liver cannot metabolize (NSAIDS, acetaminophen, alcohol, smoking)

Answer 111

- Viral hepatitis (HCV) - Drug-induced or toxin liver damage (alcohol, acetaminophen) - Infections - Hypoperfusion (shock, thrombosis, ischemia, - Metabolic disorders (Reye syndrome, Wilson disease, galactosemia, frustose intolerance) - surgery

Answer 112

- Impaired bilirubin conjugation (Result: jaundice) - Decreased clotting factor production (Result: bleeding) - Depressed glucose synthesis (Result: hypoglycemia) - Decreased lactate clearance (Result: metabolic acidosis -> respiratory alkalosis) - infection - altered carb, protein, glucose metabolism - Hepatic encephalopathy and Acute Neurologic changes (Care: Give mannitol, elevate HOB 30, treat fever HTN, minimize stimulation; may need restraints) - Respiratory failure (ascites -> increased abdominal pressure -> shallow breathing ->atelectasis) - care: intubation - Cardiac dysrhythmias due to acidosis, hypoxemia, cerebral edema

Answer 113

- Portal hypertension (Risks: Splenomegaly, ascites, Bleeding esophageal varices (distended veins), hemorrhoids) - Coagulation defects (result: bleeding) - Biliary obstruction (Decreased bile production = decreased absorption of fat soluble vitamins i.e vitamin K and jaundice and itching) - Portal-systemic encephalopathy (PSE) with hepatic coma S/s: sleep disturbance, mood disturbance, mental status change, speech problems, asterixis (hand flap) Late s/s: altered LOC, impaired thinking, neuromuscular problems r/t nonrhythmic extension and flexion of wrists and fingers - Hepatorenal syndrome S/s: oliguria, elevated BUN, Crt, urine osmolarity - Spontaneous bacterial peritonitis r/t ascites or hypoproteinemia S/s: abd pain, fever, chills, tenderness; worsened encephalopathy, increased jaundice Drug of choice: antibiotics

Answer 114

Types - Blunt trauma (MVA, Falls, Assault, Contact sports) - Penetrating trauma (Gunshot wounds, stabbing, impalement) Risks - Hemorrhage - Hollow viscus perforation (stomach, intestine) r/t GI bleeding and septic shock (intestinal contents can leak into peritoneum) - Peritonitis - Increased intra-abdominal pressure -> organ dysfunction (S/s: decreased CO, decreased tidal volume, increased pulmonary pressure, decreased UOP, hypoxia, taut tense abdomen) --Normal IAP: 5-7

Answer 115

Inspection - Location of entry and exit sites - Cullen’s sign (umbilicus) - Grey Turner’s sign r/t RTB or pancreatic injury (flank) - Hematoma in flank r/t kidney injury - Distended abdomen r/t perforation or ruptured BV Auscultation - Diminished Bowel sounds/ - presence of Friction Rub Percussion/Palpation - Rebound tenderness r/t peritoneal inflammation - Rigidity - Ruptured Spleen has Ballance’s Sign (dullness) or Kehr’s sign (Left shoulder pain)

Answer 116

- NGT for decompression and evaluate drainage - Peritoneal lavage ( NS catheter in abdominal cavity flushed to assess for blood) - Chest radiograph: Fractured ribs - Arteriogram: May show vascular injuries - Liver and spleen scan - Pyelogram (kidney scan w/ contrast dye) - Abdominal or pelvic CT scan: retroperitoneal hematoma, liver or spleen injury, ruptured viscus (bowel) (PREFERRED) - FAST (Focused Assessment and Sonogram for Trauma): Quick assessment of abdomen in radiology

Answer 117

- Decreased hgb and hct levels - Increased serum amylase level or lipase from ischemia of pancreas - Increased lactate = mesenteric hypoperfusion or sepsis - Increased WBC count b-c stress - Hematuria - Positive Stool Guaiac b-c GI bleed

Answer 118

- Optimize hemodynamic status w/ fluids - Transfusion protocol to minimize blood loss - Prevent infection (Pneumococcal, meningococcal vaccines if splenectomy) - Stabilize injuries (drains to prevent hematoma; Embolization to decrease spleen blood loss; surgical repair) - TPN until bowel healed

Answer 119

Tagged red blood cell scanning - identify location of bleed and treat if able to view EGD - thermal therapy: heat to cauterize the bleeding vessel - injection of sclerosing therapy (epi or alcohol, hypertonic saline) to induce localized vessel vasoconstriction and sclerosing to form thrombosis - intraarterial embolization - Endoscopic variceal ligation: band or clip around bleeding site to obstruct and control bleeding (Risk: mucosal ulcers)

Answer 120

Indication: ascites or prevent esophageal varice rupture Procedure: stent placed b/w systemic and portal venous system to redirect portal blood, decrease portal HTN, and decompress varices to control bleeding Risks: hepatic encephalopathy, elevated pulmonary artery pressure, bleeding

Answer 121

- cannot tolerate enteral nutrition (i.e GI bleed) - extensive burn injuries - poor wound healing - specific GI disease (UC, Crohns, GI fistula) - hepatic failure - pancreatitis - malignant diseases - malnourished

Answer 122

- need central line and filter b-c hyperosmolar - Keep it going! (Dextrose 10 % if bag not ready) - Scheduled Accuchecks q6h - IV site assessment (phlebitis) - Maintain aseptic technique - change bags/tubing per protocol (typically q24h)

Exam 2 Flashcards

(146 cards)