Final Exam Flashcards

Question

Accidents: Falls in Older Adults Risk factors for falls (8) Fall risk Assessment (3)

Answer 1

Risk factors - Hx of falling (most important predictor of falls) - Multiple illnesses - Generalized weakness or decreased mobility - Changes in sensory perception (r/t age or drugs) - impaired body orientation r/t decreased sense of touch -> decreased reaction time - Urinary incontinence or nocturia - Communication impairment (disorientation, confusion) - Alcohol/substance abuse Assessment (fall risk assessment) - Observation of Gait (wobbly?); Footwear (closed toe? Sturdy?); assistive devices (cane? Walker? Glasses?)---Do they use them? - Past medical hx (Diabetic neuropathy?, arthritis?, peripheral neuropathy?) - Drug assessment (Drug side effects?) i.e. Antihypertensives and orthostatic hypotension; Opioids and CNS depressant effects of drowsiness and acute confusion

Answer 2

Impact of falls: fractures and fallphobia (esp if osteoporosis) Prevention - Ensure hydration b-c dehydration can cause incontinence due to bladder irritation - RN communicate hazards on their health literacy level - Safeguards (handrails, grab bars, slip proof rugs, adequate lighting) - No scatter rugs, slippery floors, clutter - Pt avoids going out on bad weather days (slippery or icy) - ask for help when needed esp. toileting - use assistive devices i.e hearing aids, glasses, walker, cane, - keep bed low and locked

Answer 3

- Intolerance to standard drug dosages (use “Start low and go slow” policy) - Opioid Use (increased due to use for acute and chronic conditions w/ persistent pain) - increased risk of adverse drug events due to polymedicine/polypharmacy

Answer 4

Metabolism (monitor liver function tests) - Decreased liver size - Decreased liver blood flow - Decreased serum liver enzyme activity Excretion (get renal function test esp. Crt clearance) - Increased BUN and Crt - Reduced renal blood flow - Reduced GFR and creatine clearance (leads to slower excretion; decreases by 6.5 mL/min per decade of life)

Answer 5

Absorption - Decreased GI motility - Decreased GI blood flow - Increased gastric pH Distribution - Smaller amount of total body water - Decreased albumin level - Increased ratio of adipose tissue to lean body mass (leads to increased storage of lipid-soluble drugs in tissue vs plasma) - Decreased cardiac output

Answer 6

- Poor communication with HCP r/t poor explanations due to educational limits, language barriers or difficulty hearing and vision - Make errors (Forget to take; Duplication (think 2 is better than 1); use wrong drugs - Take OTC drugs that interact with prescribed drugs (Ex. Clopidogrel, aspirin, warfarin for anticoagulation, ibuprofen for arthritis and garlic for hypertension = bleeding risk) - Discontinue drug therapy due to cost, fear of dependency or side effects) - use leftover drugs from previous illness - Borrow from others - Use more than one pharmacy

Answer 7

- Obtain complete drug list (OTC, prescribed, herbs, supplements) - Highlight all drugs that are part of Beers criteria ( drugs where harm > benefit for elderly (ex. Benadryl, ketorolac) - Assess for duplicate drugs (Ex. Warfarin from two pharmacies) - Give verbal and written information at appropriate knowledge level - Encourage to take drugs exactly as prescribed (do not share or borrow drugs) - Be Aware of common adverse drug events (ADEs) (Hypotension from HTN drugs; Edema; Syncope; Dehydration from diuretics)

Answer 8

- meperidine - oxycodone - cyclobenzaprine - digoxin (Should not exceed 0.125 mg daily except for a-fib) - Ticlopidine - fluoxetine - amitriptyline - diazepam - promethazine - diphenhydramine - ketorolac - short-acting nifedipine - ferrous sulfate (Should not exceed 325 mg daily) - chlorpropamide

Answer 9

- Encourage use of pill boxes or associating pills w/ daily events - Use large print on drug label for poor vision - Write drug regimen on bottle - Colored labels - Easy to open bottle caps for limited hand mobility and strength

Answer 10

Assessment - Geriatric Depression Scale (15 yes or no questions; > 10 = possible depression) Treatment - SSRI (takes 2-3 weeks to start working) - TCAs have anticholinergic properties and should not be used (side effects: acute confusion, severe constipation, urinary retention or incontinence) - Nonpharmacological: psychotherapy; reminiscence, music therapies

Answer 11

- Slow, progressive and chronic global impairment of intellectual function Prevention of cognitive changes in older adults - Cognitive training (learning new skill) - Physical and mental activity - Social engagement - Proper nutrition

Answer 12

- Have you ever tried to cut down on your drinking? - Have people annoyed you by criticizing your drinking? - Have you ever felt bad or guilty about your drinking? - Have you ever had a drink first thing in the morning to settle your nerves? (eye-opener)

Answer 13

SPICES or geriatric vital signs * Sleep disorders * Problems with eating or feeding * Incontinence * Confusion * Evidence of falls * Skin breakdown Risks: longer hospital stays, higher medical cost, death

Answer 14

Two problems - Skin breakdown (esp. pressure ulcers) - Skin tears esp. the old-old and those on chronic steroid therapy b-c increased capillary fragility) Care - Prevention of pressure ulcers ( Nutritional support (protein), turn, reposition q2h, mobility/activity plan of care, moisture barriers, good hygiene) - Use the Braden scale daily - Coordinate w/ RDN and WOCN - Assess skin q8h for reddened areas that do not blanch and report any open areas (Encourage UAP to report any reddened areas so RN can assess) - Use a gentle touch

Answer 15

- CO2 does not change with age - PaO2 decreases w/ age r/t V/Q matching changes (Expected value = 80 mm Hg minus 1 mm Hg for every year > 60) - Reduced size and function of the kidneys (Loss of nephrons; Decreased renal blood flow) - Underlying conditions that may result as one ages Ex. COPD (respiratory acidosis), DKA (metabolic acidosis)

Answer 16

- pH 7.35-7.45 - CO2 35-45 (Ventilatory failure if > 50) - HCO3- 22-26 - PaO2 80-100 mm Hg (never should be < 40)

Answer 17

- ph abnormal + one abn. value = uncompensated - ph abnormal + two abn. values = partial compensation - ph normal + two abn. values = full compensation (determine primary disorder by seeing if pH on acidic (7.35-7.4) or alkalinic side (7.4-7.45) of normal)

Answer 18

- slow growing squamous cell carcinoma Progression - Begins with mucosa that is chronically irritated - mucosa becomes tougher and thicker from irritation and genes for cell growth damaged - metastasis to Lymph nodes, muscles, bone i.e. nearby structural areas - fatal when metastasis to organs (lungs, liver)

Answer 19

Prognosis - dependent on location and extent of tumor - curable when treated early - fatal in 2 yrs if not treated due to airway obstruction Consequences - impaired gas exchange (inability to breath) - impaired nutrition (inability to eat) - impaired self-image (impaired facial appearance) - impaired communication (inability to speak)

Answer 20

Main: tobacco and alcohol (worse when together) Others - men more than women - > 60 yrs - poor oral hygiene - chronic laryngitis - voice abuse - chemical or dust exposure - long-term GERD - oral infection w/ HPV FAMILY HISTORY IS NOT A RISK FACTOR FOR HEAD AND NECK CANCER

Answer 21

- Pain - Lumps in mouth, throat, neck - Color changes in mouth or tongue (leukoplakia (white, patchy); Erythroplakia (red, velvety); black; gray; dark brown) - Oral lesion or sore that does not heal in 2 weeks (may have burning sensation from hot liquids or citrus juice - Persistent/unexplained oral bleeding - Numbness of mouth, lips, or face - Change in denture fit - Hoarseness or change in voice quality - Persistent, unilateral ear pain - Persistent/recurrent sore throat or difficulty swallowing - Shortness of breath - Anorexia and weight loss

Answer 22

Labs - chronic alcohol use or poor nutrition (low albumin) - metastasis to liver (increased AST, ALT) - metastasis to kidney (increased BUN, Crt) - CBC, Bleeding times, and blood chemistries - Urinalysis Diagnostics - direct and indirect laryngoscopy OR bronchoscopy under anesthesia to define extent of tumor - Biopsy to confirm diagnosis, tumor type, cell features, location, and stages - X-ray of skull, sinuses, neck, and chest - CT and MRI

Answer 23

- Radiation - chemo - surgery (laryngectomy-- requires trach)

Answer 24

- Airway obstruction (priority)- s/s: restlessness - Hemorrhage (esp. if wound exposes carotid artery)-- call RRT if blood leaking and do not touch b-c can rupture carotid artery; apply continuous pressure if carotid artery ruptures - wound breakdown (Risks: poor nutrition, long smoking hx, chronic alcohol use, wound contamination, radiation therapy prior to surgery) - Tumor recurrence - nutritional deficiencies (may have taste changes)

Answer 25

- Electronic devices (picture board, smart phone, computer) - Mechanical device (sound vibrates air inside mouth and throat while patient moves lips and tongue; produces robotic sound) - esophageal speech (patient burps swallowed air to produce speech; produces monotone sound)

Answer 26

- Suture line of stoma care q1-2h during first few days post-op then q4h - Surgical drain collects blood and drainage for 72 hrs post-op - Monitor and record amount and character of drainage; cap refill; and activity of major BVs in region (Secretions blood tinged for 1-2 days) - Report sudden increase or decrease of drainage to surgeon (may be clot if sudden stoppage of drainage)

Answer 27

- feeding tube usually for 7-10 days post-op and removed when swallowing is safe per Swallow study - PEG > NGT to prevent aspiration - give diet high in protein and calories - small amounts of food at a time - may need thickened liquids - collaborate w/ RDN and SLP b-c at risk for aspiration, speech, and nutritional problems

Answer 28

- tuck chin when swallowing - use supraglottic swallowing (Valsalva maneuver and swallow twice to clear food that may pool in pharynx; exaggeration of normal protective mechanisms) - observe for aspiration or aspiration pneumonia and report immediately (aspiration not possible after total laryngectomy b-c airway totally separated from esophagus) - NO oral intake until swallow study done - collab w/ SLP and RDN

Answer 29

- Avoid swimming - Lean forward and cover stoma when coughing, sneezing (may need to cover when laughing and crying as well) - Wear stoma guard or loose clothing to cover stoma to prevent water from entering airway when showering - Clean stoma with mild soap and water - Lubricate stoma with non-oil based ointment - use alt communication methods - use MedicAlert bracelet and emergency card for life-threatening situations

Answer 30

- Inspect insertion site( eyelets of tube should not be visible; s/s of infection (redness, purulent drainage, excess bleeding)) - Palpate Insertion Site (may have subQ emphysema if puffiness or crackling - Ensure Intact Dressing at Site - Assess/reassess Respiratory Status (breathing, pulse ox, breath sounds) - Observe Trachea (tension pneumothorax if shifted) - Assess/reassess Pain (give meds and reposition) - Encourage Cough, Deep Breathing, Incentive Spirometry

Answer 31

- Avoid kinks, Occlusions, or Loose Connections (should be straight) - Do NOT Strip/Milk Tubing - Keep Drainage System Below Level of Chest - Assess for “Tidaling” (water level rises inhalation and fall exhalation) - if not present, may be obstruction - bubbling seen on exhalation, forceful cough, position changes (EXCESS BUBBLING = air leak) - Always have at least 2 cm of water to prevent air from returning to patient in water seal chamber - Limit clamping of a chest tube b-c will increase pressure in pleural space and may cause tension pneumothorax - No need to disconnect chest tube for transport - never let drainage come in contact w/ tubes (can cause tension pneumothorax)

Answer 32

- Tracheal deviation from midline - Sudden onset or increased intensity of dyspnea - O2 sat <90% - Drainage greater than 100 mL/hr, fresh blood, sudden increase in drainage - Visible eyelets on chest tube - Chest tube falls out of the patient’s chest (cover the area with dry, sterile gauze; leave one side out so air can continue to escape chest and prevent tension pneumothorax) - Chest tube disconnects from the drainage system (put end of tube in a container of sterile water and keep below the level of the patient’s chest) - Drainage in tube stops (in the first 24 hours)

Answer 33

- Sarcopenia (age-related muscle atrophy) and weakened respiratory muscles - Decreased chest wall movement (stiffens) and size - Air trapping = increased residual volume causing thinned and enlarged alveoli - Reduced sensitivity to hypoxia and hypercarbia - Decreased pulmonary reserve - Decreased pulmonary perfusion capacity - increase Dyspnea - Difficulty coughing up secretions r/t decreased cilia beat frequency in airways - Decrease in ability to protect against environmental injury and infection (r/t decreased T-cell, nutrition, swallowing ability, and mucociliary clearance)

Answer 34

Minor complications: Laryngospasm/Bronchospasm, fever, vomiting, epistaxis Major complications - anaphylaxis - Cardiac (hypotension, arrhythmias, hemorrhage, CODING/ cardiopulmonary arrest) - respiratory (respiratory failure, hypoxemia, pneumothorax) - infection

Answer 35

Indications: Diagnosis (determine if occlusion of pulmonary artery, respiratory or perfusion problems esp. PE) Process - Ventilation: radiolabeled gas inhaled via mask into lungs - Perfusion: radioisotope injected into veins and travels to lung tissue Results - Normal= perfusion scan is normal - V/Q mismatch i.e. diminished radioactivity on perfusion scan indicates obstruction i.e pulmonary embolus Complications - Bleeding at injection site - infection at site - Allergy to injection dye (anaphylaxis)-- rare

Answer 36

Indications (at bedside by HCP) - Diagnosis (r/t hemoptysis; post-chest trauma; chest or face burn; post-aspiration; difficult intubation; airway obstruction) - therapeutic (reverse aspiration, help w/ difficult intubation; removal of secretions or growths; atelectasis) Post procedure Care - Observe sputum for hemorrhage (Expected: slightly bloody due to trauma) - Ensure gag reflex returns and anesthesia wears off before patient eats or drinks (about 2 hr)

Answer 37

Pre procedure Care - Chest x-ray - Clotting studies (PT, aPTT, Platelet) - ABGs (oxygen during procedure if hypoxemic) - No oral intake for 6-8 hrs to prevent aspiration Pre-op meds - Topical anesthetic - Benzo for sedation - Opioid for pain - Atropine to reduce vasovagal response and secretions - IM Codeine to reduce cough reflex

Answer 38

- Tracheal deviation (away from affected due to compression of heart) - Respiratory distress (dyspneic, cyanotic - Reduced or Absence of breath sounds on affected side (hyperresonance) - Distended neck veins - Hypotension - Hemodynamic instability (cyanotic, sudden chest pain, tachycardia)

Answer 39

Causes - Blunt or penetrating trauma - Lesser trauma if tendency to bleed (i.e. on anticoagulants) Classifications - Simple: < 1L blood loss (May not exhibit manifestations) - Massive: > 1L blood loss Interventions for massive (simple may resolve on own) - chest tube to remove blood and prevent infection - Fluids - Open thoracotomy if massive or persistent bleeding at 150-200 mL/hr over 3-4 hrs

Answer 40

- Respiratory distress (dyspnea, cyanosis, tachypnea) - Blood visible on chest x-ray - Hypovolemia - Decreased breath sounds (no extra sounds) - Shock possible (tachycardia) - Dull to percussion - Chest pain r/t hypoxia

Answer 41

- Respiratory failure (dyspnea, cyanosis,) r/t intrathoracic injury and inadequate diaphragmatic movement - Shock (decreased BP, increased HR) - Paradoxical movement of the chest (Inspiration: in; Expiration: out) leads to increased work of breathing - severe Pain and anxiety - Decreased chest expansion leads to decreased ventilation - Risk for hemothorax or pneumothorax - chest deformity and crepitation over fractured ribs

Answer 42

Description - Fractures of at least two neighboring ribs in two or more places or separation of rib from cartilage - Result of blunt chest trauma Care - Oxygen (or mechanical ventilation if respiratory failure or shock) - PEEP if severe hypoxemia and hypercarbia - Pain and anxiety management (talk slow, explain everything) - Promote lung expansion via deep breathing and positioning - Secretion clearance via coughing and tracheal suctioning - Monitor VS, ABG, f/e balance, vital capacity

Answer 43

Definition - Physiologically defined condition w/ inadequate exchange of O2 & CO2 - Body is not able to meet the need for O2 at rest - most common organ failure in ICU Labs/Diagnostics - ABG analysis– most specific indicator for evaluating effectiveness of therapy (PaO2 < 60 mm Hg; Hypercapnia (HCO2 > 45)) - Blood/sputum cultures (may be done via bronchoscopy) - Electrolytes, urinalysis, CBC - Cardiac- 12 lead EKG; Pulmonary artery catheter if severe (all hemodynamic factors) - Thoracic CT and Chest x-ray

Answer 44

CNS - Restless - Headache - Decreased LOC (confused, drowsy) - ischemic-anoxic encephalopathy Cardiac - Decreased cardiac output (hypotensive, systolic HTN) - Dysrhythmias - Chest pain - palpitations - VTE (Prevent: SCDs, heparin) Pulmonary - respiratory distress (retractions, nasal flaring) - Rapid shallow breathing and Dyspnea/SOB - Tripod position - Active abdominal movement - Cyanosis

Answer 45

GI - Decreased GI blood flow - Ascites and Abdominal distention - Anorexia - NV - Constipation - Stress ulcers (Prevent: H2 antagonists, PPIS) Renal (Impaired renal blood flow (decreased urine output) Skin (Cool, clammy)

Answer 46

- Delivery system should be tolerated by patient AND lowest FiO2 to maintain O2 sat > 90% - Use positive pressure ventilation if intrapulmonary shunting present - Noninvasive okay unless rapid deterioration - Use A/C mode

Answer 47

- Relief of bronchospasm via smooth muscle relaxation (bronchodilators) - Reduction of airway inflammation (corticosteroids) - Reduction of pulmonary congestion (diuretics) - Treatment of pulmonary infections (antibiotics) - Reduction of severe anxiety, pain, and agitation (sedatives, analgesics, neuromuscular paralysis) - Sodium bicarbonate if metabolic acidosis severe (pH < 7.2), dysrhythmias, or refractory to therapy

Answer 48

Definition - sudden progressive form of acute respiratory failure - pulmonary manifestation of MODS Patho - Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid - Alveoli fill with fluid and collapse causing noncardiac pulmonary edema - Lung compliance drops and they become stiff Timing: within 1 week of problem

Answer 49

- chest x-ray (whited out, bilateral infiltrates) - ABGs (low PaO2 (refractory hypoxemia even w/ O2 administration) OR low PCO2 (due to hyperventilation then increases w/ fatigue) - PaO2/FiO2 ratio: < 200 due to poor lung function

Answer 50

- respiratory distress (tachypnea, dyspnea, use of accessory muscles, suprasternal retractions - cough - restless, apprehension - scattered crackles - weight gain or loss

Answer 51

- Tachycardia to bradycardia - Hypo to hypertension - Diaphoresis - Cyanosis - Pallor - changes in sensorium with decreased mentation (somnolence, agitation) - Extracardiac sounds

Answer 52

- drugs to regulate and increase BP (norepinephrine) - PRBCs for hemodynamic support - Fluid restriction and diuretics for pulmonary HTN - Treat underlying infection and trauma (i.e. sepsis) - Sedation and analgesia that balance both comfort and desired ventilatory status

Answer 53

- suction PRN for secretion clearance - give lowest oxygen (< 0.5 to maintain sat O2 > 90%) - Low tidal volume (6 mL/kg) to limit barotrauma and volutrauma - Use PEEP (positive end expiratory pressure) – 10-15 cm H2O adequate -- risk for barotrauma

Answer 54

Uses - Improves V/Q matching - Improves oxygenation in patients with ARDS b-c Good lung down to the ground ( least damaged lung in dependent position) - Reduces aspiration risk via mobilization of secretions - Decreases intrapulmonary shunting Contraindications - increased ICP or spinal cord injury - hemodynamic instability - recent abdominal surgery

Answer 55

Use - Helps with V/Q matching to improve oxygenation - Prevents further pulmonary complications r/t mechanical ventilation and bedrest Types - Kinetic therapy (> 40 degree continuous rotation)- Decreases VAP incidence - Continuous lateral rotation therapy (CLRT)-- <40 degree continuous rotation Complications - Dislodgment or obstruction of tubes/lines/drains - Pressure injuries (NURSE must still turn pt q2h) - Hemodynamic instability

Answer 56

- tube/drain obstruction (care: move out of way) - Hemodynamic instability - Massive facial edema - Pressure injuries (care: continue to turn as needed) - Aspiration - corneal ulcerations (care: lubricate and close eyes)

Answer 57

- Hospital-acquired pneumonia Prevention: HOB elevate, hand hygiene - Barotrauma (r/t rupture of overextended alveoli from excess pressure)--s/s: subQ emphysema, sternal pain, clicking sound over heart, friction rub Prevention: smaller volumes of PEEP - Volutrauma (r/t too much volume ventilating non compliant lungs) Prevention: smaller tidal volumes - Stress ulcers r/t decreased GI blood flow Prevention: PPIs, H2 antagonists, enteral nutrition - Renal failure r/t decreased renal blood flow, hypotension, hypoxemia, hypercapnia Prevention: limit nephrotoxic antibiotics

Answer 58

- q2h and as needed b-c increased bacteria r/t decreased saliva, poor mucosal status and dental plaque - Brush teeth and stimulate gums and tongue w/ swab - No glycerin, alcohol, hydrogen peroxide because drying effects - deep oropharyngeal suctioning for pooled secretions (painful for subglottic secretions so give pain meds or sedation) - 2% chlorhexidine q4-6h

Answer 59

- Pad pressure points if s/s of irritation - Lubricate nares, face, lip w/ nonpetroleum cream to prevent drying effect - Maintain cuff pressure (Low-pressure, high volume - Monitor cuff pressure every shift to maintain within 20-30 cm H2O (< 20 = increased risk of aspiration; > 30 = decreased blood flow to capillaries in tracheal wall (report to HCP))

Answer 60

- Hypoxemia r/t disconnected oxygen Care: stop suctioning if O2 < 90% - Atelectasis r/t suction catheter > ½ diameter of ETT and excessive negative pressure or prolonged suctioning - Bronchospasms r/t stimulation of airway w/ catheter Care: Give bronchodilator - Dysrhythmias (bradycardia, heart block, v-tach) r/t vagal stimulation Care: Stop suctioning and hyperoxygenate - Increased ICP - Airway trauma r/t impact of catheter in airways and excessive negative pressure - Infection

Answer 61

- Hyperoxygenate with 100% oxygen for 30-60 sec prior to suctioning and 60 seconds after suctioning - Use < 150 mm HG of suction to reduce hypoxemia, atelectasis and airway trauma - Limit number of times patient is suctioned - Suction 10-15 secs continuously on the way out to reduce hypoxemia, airway trauma, cardiac dysrhythmias (Intermittent suction during withdrawal leads to secretion dropping) - Suction mouth or nose after suctioning artificial airway

Answer 62

- Rhonchi or wheezes (usually not for crackles) - Coughing - visible secretions in airway or indicated by dyspnea - Sawtooth pattern on flow-volume loop on ventilatory - Increased peak airway pressure on ventilator - Acute respiratory distress (increased RR (indicates hypoxia), HR; restless; decreased O2 sat)

Answer 63

Definition: process of using an apparatus to facilitate transport of O2 and CO2 b/w atmosphere and alveoli to enhance pulmonary gas exchange Indications: Ventilation, oxygenation, airway and lung protection, secretions Types of ventilators - Positive-pressure: intubated and on machine via ETT or Trach; mechanical drive to force air into lungs - Negative-pressure: on machine but via mask; decrease atmospheric pressure around thorax to initiate inspiration

Answer 64

Mode of ventilation - Assist Control (AC) - Synchronized Intermittent Mandatory Ventilation (SIMV) - Continuous Positive Airway Pressure (CPAP) Rate: respiratory rate (6-30 breaths/min) Tidal volume (VT): volume or size of the breath (6-10 mL/kg (4-8 mL/kg in ARDS) Positive-end expiratory pressure (PEEP) - amount of pressure remaining in the lung at the END of the expiratory phase; keeps alveoli from collapsing (3-5 cm H2O) - Risks of too much PEEP: barotrauma, decreased venous return FiO2 - fraction of inspired oxygen (Range: 21%-100%) - prefer <50% to maintain O2 sat > 92% and PaO2 > 60 mm Hg

Answer 65

How it works - Delivers a “machine breath” every time, whether the pt. triggers the breath or the ventilator initiates the breath (time-triggered) - patient cannot generate spontaneous volume or flow rate Indications - Volume controlled AC if weak respiratory muscles but spontaneous breathing (Risk for volutrauma) - Pressure controlled AC if decreased lung compliance, increased airway resistance or risk for Volutrauma (Risk for hypercapnia) Care - Hyperventilation risk if patient increases their respiratory rate - Sedation may be needed to limit # of spontaneous breaths

Answer 66

How it works - Delivers a pre-set number of breaths at a set volume or pressure and flow rate. - Allows the patient to generate spontaneous breaths, volumes, and flow rates between the set breaths. - Detects a patient’s spontaneous breath attempt and doesn’t initiate a ventilatory breath – prevents breath stacking (A/C does not prevent breath stacking) Indications - Volume controlled if weak respiratory muscles but spontaneous breathing - Pressure controlled if decreased lung compliance, increased airway resistance or risk for Volutrauma (Risk for hypercapnia) - used for weaning Risk - May increase work of breathing and promote respiratory muscle fatigue when used for weaning

Answer 67

How it works? - Positive pressure applied only on patient- initiated breaths on inhalation to augment efforts (similar to PEEP but only on inhalation vs. expiration) - Patient's lung mechanics and efforts controls rate, inspiratory flow, and tidal volume Use: for pt w/ stable respiratory drive to overcome mechanical resistance Risk: Hypercapnia Pros - Reduces work of breathing - increases ventilatory synchrony - Can be used with SIMV or CPAP

Answer 68

How it works? - Positive pressure applied during spontaneous breaths (no ventilator breaths in PEEP or CPAP mode) - Pt controls rate, inspiratory flow, tidal volume - Similar to pressure support but without the additional inspiratory pressure Indication - used with masks for sleep apnea (negative pressure) - used with ventilator (positive pressure) - used for weaning

Answer 69

- Increased secretions (care: Suction PRN) - Oxygen toxicity (Continuous oxygen > 50% for > 24-48 hrs may injure lung and reduce tissue integrity) --Care: notify HCP if PaO2 > 90 mm Hg - Respiratory muscle weakness - Ventilator-Associated Pneumonia - Ventilator induced lung injury

Answer 70

CNS - Increased ICP r/t decreased cerebral venous return GI (prevent: NGT decompression, appropriate cuff inflation) - Gastric distention r/t air leaks around ETT or trach cuff and overcomes resistance of lower esophageal sphincter - Vomiting r/t pharyngeal stimulation from artificial airway - Hypomotility and constipation r/t immobility and paralytic agents, analgesics, sedatives Cardiovascular compromise - Decreased Cardiac Output r/t decreased venous return to right side of heart Psychological complications - need for alternative communication - Patient ventilator dyssynchrony (Risks: auto-PEEP, psychological distress, decreased effectiveness) Care: ventilator accommodates patient’s spontaneous breathing pattern OR patient is sedated

Answer 71

Early s/s: dyspnea, nonproductive cough, sternal chest pain, GI upset, crackles Late s/s: decreased vital capacity and compliance; hypoxemia, pulmonary edema, hemorrhage, hyaline membrane formation and atelectasis Care: notify HCP if paO2 > 90

Answer 72

Causes - Barotrauma r/t too much PEEP - Volutrauma r/t too much tidal volume - Atelectrauma r/t shearing r/t repeated opening and closing of alveoli - biotrauma r/t inflammatory-immune response (Leads to ARDS) Care - keep pressure at 32 or below cm H2O - use PEEP - tidal volume of 6-10 ml/kg

Answer 73

Awakening Breathing Coordination Delirium monitoring Early mobility

Answer 74

- Assess settings and do they correlate with presentation (any desynchrony?) - High pressure alarms = airway obstruction b-c patient ventilatory desynchrony, airway resistance or kinked tubing - Low pressure alarm = leak or oxygen not connected - If vent malfunctions, disconnect patient from vent and Ambu bag patient

Answer 75

Development of pneumonia 48-72 hrs after endotracheal or other artificial airway insertion intubation b-c tube bypasses normal defense mechanisms of lung Risk factors - severe illness - increased age - presence of ARDS or malnutrition - naso intubation b-c promotes aspiration - Gastric alkalization by enteral feeds and meds b-c promotes bacterial growth

Answer 76

- Hand hygiene - Elevation of HOB (30-45 degrees) to prevent GER and aspiration - Daily “sedation vacations” and assessment of readiness to extubate - Stress ulcer prophylaxis - DVT prophylaxis - Daily oral care (teeth, gums, and tongue) with chlorhexidine q2h - Adequate endotracheal tube cuff pressure (Keep at 20cm H20-decreases aspiration)

Answer 77

- hemodynamic instability - increased ICP - ongoing agitation or seizures - alcohol withdrawal - use of neuromuscular blocking agent

Answer 78

Mucolytics (Liquefy secretions to help with their removal) Bronchodilators (beta 2 agonists and anticholinergics) - Relax smooth muscles when air flow limitations Steroids (Reduce airway inflammation) Sedatives - provide comfort - Decrease work of breathing and prevent ventilator fighting Neuromuscular paralysis (Nimbex-Cisatracurium besilate) - Decreases oxygen consumption: - sedate and explain all procedures to patient if giving paralytic b-c they do not inhibit pain or awareness - risk for immobility complications so prevent skin breakdown, DVT, and atelectasis

Answer 79

- surgical changes in upper respiratory tract w/ laryngectomy - NGT - Difficulty swallowing r/t tracheostomy tube fixing larynx in place and cuff interfering with passage of food via esophagus - cuff pressure < 20 on trach tube (may partially deflate for easier swallowing)

Answer 80

Causes - electrolyte imbalance (hypokalemia, hypomagnesemia, hypocalcemia) - bradycardia - heart blocks - PVC - meds (antidysrhythmic (i.e. amiodarone), antibiotics, anesthetics, antidepressants, antiemetics, antipsychotics, opioids, sedatives) Risk: torsades de pointes (v-tach) Treatment: pacemaker, increase HR, stop meds, correct electrolytes

Answer 81

- deviated 3 small boxes up or down Non-ST elevation MI (NSTEMI) - No ST elevation - T waves may be tall and symmetric - troponin is elevated ST elevation MI (STEMI) - ST elevation in 2 or more consecutive leads - T wave inversion - troponin elevated as well

Answer 82

- widened QRS complexes (> 0.12) - impulses from sinus and atrial nodes fail - lead to decreased perfusion and potential for cardiac arrest

Answer 83

- Early ventricular contraction/irritability (misfiring in heart outside of SA node; unable to see P wave) Causes - electrolytes (hypokalemia, hypomagnesemia, - drugs (smoking, caffeine, alcohol,, - stress (infection or invasive procedure (cardiac cath, surgery)) - respiratory problems (hypoxemia, acidosis, COPD) - heart problems (cardiomyopathy, ventricular aneurysms, CHF, MI, sympathomimetic drugs)

Answer 84

Multifocal vs. Unifocal - Multifocal looks different and occur in different areas (more serious) - Unifocal look the same and occurring in same place of heart Repetitive Waves - 2 PVCs- Couplets (two consecutive PVC) - Bigeminy (after every normal beat) - Trigeminy (after every two normal beats) - 3 or more PVC's in a row = Nonsustained run of V-tach

Answer 85

- if new or symptomatic, call HCP - If > 3 in a row, call MRT and give amiodarone or beta blockers - Check labs for hypokalemia or hypomagnesemia - check perfusion (HR, BP, palpitations, decreased peripheral pulses) - request 12-lead EKG

Answer 86

- most common ventricular dysrhythmia - Repetitive ventricular firing greater than 140 beats/min - no P waves - Nonsustained V-tach = < 30 seconds (sustained can progress to v-fib)

Answer 87

- Cardiac (MI, HF, Dig toxicity,valvular dysfunction, cardiomyopathy, hypotension, SVT) - Electrolytes (hypokalemia, hypomagnesemia) - Meds (steroids, antidysrhythmic drugs which prolong QT) - Drugs(cocaine)

Answer 88

- slow pulse with amiodarone (alt: diltiazem, digoxin, lidocaine, procainamide) - use cardioversion (call HCP; can be elective or emergent) - give oxygen - Get informed consent and hold digoxin 48 hrs prior to elective cardioversion b-c increases risk of VF from shock

Answer 89

- Implement Code Blue/ ACLS Protocol - Defibrillate (priority after everyone clear and oxygen off) - CPR if no defibrillation and after defibrillation - Epinephrine q3 min if no HR and no pulse after IV established

Answer 90

- Total chaos in ventricle with no discernible waves or complexes - Ventricles quiver and no forward flow of blood which consumes oxygen - Non-perfusing rhythm (no BP, no HR, apnea; potential for seizures and acidosis) - fatal if not terminated in 3-5 min

Answer 91

- Morphine: For pain, anxiety, fear, reduces preload and afterload - Oxygen: To maintain >90% O2 sat - Nitroglycerin sublingual (vasodilation and increase cardiac output)--Risk for hypotension (hold if systolic <90 OR PDE5 inhibitor (sildenafil) in hx for erectile dysfunction or pulmonary HTN) - Aspirin (ASA): Prevents clumping of platelets and reduces mortality

Answer 92

Ischemia - transient and reversible due to O2 deprivation - Seen on ECG as T-wave inversion and ST depression Injury - injured but potentially viable tissue if circulation adequate - Seen on ECG as ST elevation Infarction (irreversible) - Area of dead muscle (necrosis) in the myocardium which becomes scar tissue - Delayed treatment = increased damage/area of infarction - Seen on ECG as pathologic Q waves (deeper and wider than normal)

Answer 93

- Angina (abrupt and not relieved by NTG); may be crushing, tightness, radiating - systolic murmur or S3/S4 sounds (r/t papillary muscle rupture, HF, pulmonary edema) - Pulmonary (dyspnea, tachypnea, crackles, wheezes) - Skin (diaphoresis) - Decreased cardiac outout) (tachycardia, hypotension, slow cap refill - Neuro (syncope, denial) - Muscular (weakness)

Answer 94

- Cardiac monitoring (12 lead EKG within 10 min of arrival to determine where MI is in the heart) - daily chest x-ray - echocardiogram

Answer 95

- troponin (q6-8h b-c not elevated immediately but elevated for 7-10 days) - Metabolic panel - CBC - B type natriuretic peptide (BNP) (Rule out heart failure)

Answer 96

Beta Blocker - Decrease mortality from ventricular dysrhythmias; lower BP, prevent reinfarction - Hold if in cardiogenic shock, heart failure, heart block (PR >0.24) or active asthma ACE Inhibitor and ARBs - Prevent ventricular remodeling and HF Anticoagulant (Heparin or Enoxaparin) - enhance perfusion - If thrombocytopenia, give direct antithrombotic (e.g., bivalirudin, argatroban)

Answer 97

- 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 98

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 99

- 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 100

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 101

Stool softener - prevent straining which can slow HR via vagal stimulation Inotropic (dobutamine, dopamine, milrinone) - Increase CO Diuretic - If elevated BNP, pulmonary edema, CHF exacerbation Amiodarone (antidysrhythmias) - If v-tach w/ pulse or a-fib w/ RVR

Answer 102

- 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 103

- 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 104

- 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 105

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

Answer 106

- 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 107

- 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 108

- 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 109

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 110

- 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 111

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

Answer 112

- 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 113

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 114

- 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 115

- 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 116

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 117

* 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 118

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

Answer 119

- 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 120

* 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 121

* 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 122

- 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 123

- 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 124

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

Answer 125

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 126

- 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 (No ketogenesis so no fruity breath and Rapid and shallow respirations vs kussmaul) - Severe dehydration

Answer 127

- 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 128

- 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 129

- 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 130

- 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 131

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 132

- 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 133

- 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 134

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 135

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 136

- 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 137

- 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 138

- 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 139

- 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 140

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 141

- 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 142

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

Answer 143

- 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 144

- 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 145

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 146

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 147

- 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 148

- 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 149

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 150

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 151

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 152

- 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 153

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 154

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 155

- 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 156

- 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 157

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

Answer 158

- 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 159

- 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 160

- 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 161

- 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 162

- 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 163

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 164

- 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 165

↑ 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 166

- 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 167

- 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 168

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 169

- 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 170

- 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 171

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 172

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 173

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 174

- 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 175

- 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)

Answer 176

- Organs systems decline (atrophy of kidney) - Decreased # of functional nephrons -> decreased GFR - More prone to development of AKI, CKD, and ESKD - higher risk for HTN and DM which cause ESKD - Risk for dehydration r/t sodium retention, increased dilution of urine, and decreased thirst perception

Answer 177

- Antibiotics (aminoglycosides) - Iodine Contrast-dye - Immunosuppressives (steroids, transplant meds) - NSAIDs - ARBs and ACEIs

Answer 178

- Sepsis or overwhelming infection - leading cause of death - Hypovolemia - Drug or medication-related - Cardiogenic shock

Answer 179

- Neurologic (coma, headache, inattentiveness, lethargy, seizures) - Hematologic (bleeding, immunosuppression, platelet dysfunction) - Skeletal (hyperphosphatemia, hypocalcemia, weak, brittle bones) - Cardiovascular (arrhythmias, Edema, heart failure, HTN, pericarditis, pericardial) - GI (anorexia, decreased appetite, hypomotility, glucose intolerance, hyperphosphatemia) - GU (amenorrhea, hematuria, proteinuria) - Dermatologic (dry skin, poor healing, pruritus) - Respiratory (Pleural effusions)

Answer 180

Risk - Crt 1.5x normal OR Crt increases ≥ 0.3 mg/dL Injury - Crt 2x normal Failure - Crt 3x normal OR ≥ 4 mg/dL Loss - Persistent AKI = complete loss of kidney function for more than 4 wks. ESKD - End-stage kidney disease

Answer 181

- Begins when the kidney is injured causing ischemia and decreased GFR - Ends when oliguria develops (goal to detect prior to this) - Duration: lasts from hours to days.

Answer 182

Duration: a range of 8-14 days depending on nonoliguric vs. oliguric. s/s - Urine production is < 400 cc for 24 hrs - Fluid overload (b-c inability to excrete water) Labs - Greatly reduced GFR and urine formation due to renal tubule damage - increased BUN, Creatinine, - Electrolyte disturbances (Hyperkalemia, hyperphosphatemia, hypocalcemia) - Metabolic acidosis

Answer 183

Duration: Lasts 7- 14 days - Occurs when cause of AKI corrected - GFR increases but nephrons still not fully functional - Unable to excrete some waste products - tubule scarring and damage and edema present - Urine > 400 cc in 24 hours (up to 2-5L/24 hr) -> high BUN (observe for dehydration)

Answer 184

Duration: lasts several months to 1 yr. - Normalization of F/E balance or onset of polyuria - Return of GFR to 70-80% normal (Normal GFR: 120) - Tubular edema resolves and renal function improves

Answer 185

Prerenal - Decreased perfusion (renal blood flow, BP, Low cardiac output, MAP < 65) cause kidney ischemia - Priority: establish hemodynamic stability Intrarenal - direct damage to kidneys - Priority: maintain renal perfusion, discontinue nephrotoxic drugs, treat cause Postrenal - obstruction of urine flow from kidneys - Priority: prevent UTI, remove source of obstruction, ensure catheter patency, maintain renal perfusion

Answer 186

Patho - Sepsis causes reduced perfusion to kidney -> hemodynamic instability and ischemia - Inflammation increases vascular permeability and causes third spacing Labs: elevated WBC and lactate plus AKI labs Care - Need rapid fluid resuscitation then vasopressors in septic shock - Avoid aminoglycosides - Prevention: MAP > 65

Answer 187

What is it? - release of myoglobin and creatine from damaged muscle cells after burns, trauma, crush injuries Risks - life-threatening hyperkalemia due to cell lysis - metabolic acidosis - AKI from myoglobin toxicity (myoglobinuria and hemoglobinuria) S/s - compartment syndrome - elevated CK, crt, K - dark brown or tea colored urine (myoglobinuria and hematuria) Primary treatment - IV crystalloid fluid resuscitation (NS, LR) - sodium bicarb for acidosis and to alkalize urine for myoglobin excretion - Mannitol to increase renal blood flow and GFR for myoglobin clearance

Answer 188

Heart failure and AKI - Several risk factors overlap - BP: 130/80 and normal range glucose recommended to prevent CKD and atherosclerotic changes (CAD, PAD) Respiratory failure and AKI - Mechanical ventilation (PEEP and positive-pressure) alter kidney via reduced renal blood flow, GFR, UOP - AKI increases inflammation and risk for ARDS which can lead to ventilation dependence

Answer 189

Risk factors: CKD, Crt > 1.5, dehydrated pts, CHF, advanced age (> 75) Prevention - Stop metformin day before and resume 48 hrs procedure w/ contrast dye (risk for lactic acidosis) - Promote hydration and avoid dehydration (IV fluids) before, during, and after - use lowest dose of dye - do not repeat dye doses within 48 hrs - Remove nephrotoxic drugs (NSAIDs, diuretics, ACEI, ARBs)

Answer 190

- metabolic acidosis (increased anion gap, low bicarb, low pH) - elevated BUN (not reliable indicator of AKI) - elevated Crt (late indicator) - Decreased Creatinine Clearance /GFR (<50) ->most accurate indicator of kidney function - BUN: Crt ratio (normal = intrarenal AKI; high = prerenal AKI from high BUN) - Electrolytes (hyperkalemia, hypocalcemia, hyperphosphatemia; hypo/hypernatremia) - Anemia (decreased H/H due to kidneys not producing erythropoietin)

Answer 191

- Chest pain or pressure - Fluid overload or loss (oliguria to diuretic) - Intravascular overload (CHF, pulmonary congestion, high BP) - Edema r/t fluid retention, low albumin, inflammation - Grey-turner sign (kidney trauma seen on flank) - Bruit = aneurysm or stenosis - Azotemia = uremia

Answer 192

Hyperkalemia (>5) - IV diuretics if making urine (dialysis if oliguria) - DICK (Dextrose, Insulin, Calcium gluconate, kayexalate) Hypocalcemia (< 8.5) - calcium and vitamin D supplements b-c risk for renal osteodystrophy Hyperphosphatemia (> 4.5) - give phosphorus binders w/ every meal - frequent skin care for pruritus - Limit phosphorus food (high protein aka meat, fish, dairy, additives, carbonated beverages)

Answer 193

IV Fluids - Crystalloids (NS, ½NS, LR) – to increase renal perfusion and output - avoid LR b-c has potassium) - Colloids (Albumin) – volume expanders to maintain hemodynamic stability Sodium Bicarbonate - For Metabolic acidosis - must be in separate line, no y-site connections Red blood cell production stimulation/production - Give iron, PRBCs, erythropoietin (epoetin alfa), vitamin B12, B6, folate - stress ulcer prophylaxis to prevent GI bleed Acetylcysteine (Mucomyst) - Used to reduce contrast-dye induced AKI

Answer 194

Purpose: stimulate UOP if fluid overload and functioning kidneys Loop (budesonide, furosemide) - Caution if sulfa allergy - Furosemide is ototoxic Thiazide (Hydrochlorothiazide) - Caution if sulfa allergy - Ineffective if GFR < 10 Carbonic anhydrase inhibitor - for metabolic alkalosis after aggressive diuresis to increase release of bicarb Potassium-sparing (spironolactone) - Weak diuretic - No potassium supplements

Answer 195

- Use: cerebral edema, excretion of toxins, increased ICP Action - Increases UOP and GFR via high plasma osmolality and water flow - increase cerebral blood flow by pulling water out of intracellular space but causes cerebral vasoconstriction as part of autoregulation Care - need filter - risk for hypernatremia, hypokalemia - need CVP to prevent hypovolemia

Answer 196

A = Acidosis (metabolic <7.1) or Azotemia E = Electrolyte Imbalance (hyperkalemia) I = Intoxication/Toxins (drug or alcohol) O = Oliguria or Overload of Fluid U = Uremia (azotemia with symptoms i.e. metallic taste in mouth, anorexia, muscle cramps, dyspnea, hiccups, uremic frost on skin, change in mentation, pericarditis (pericardial friction rub), neuropathy (paresthesia)) = Elevated BUN

Answer 197

- Separates and removes excess electrolytes, fluids, and toxins from blood - Loss of fluid over short period of time (3-4 hrs) Disadvantages - Needs Anticoagulation (heparin) - needs special nurse - Risks of hypotension, infection, graft-clotting, hemorrhage, and embolism - Contraindicated in hemodynamically unstable patient

Answer 198

- Monitor ultrafiltration hourly - add replacement fluid if large volume removed - Hemofilter change q24-48 hours - Anticoagulation (heparin) is required - Only in ICU - contraindicated if Hct > 45% or terminal illness

Answer 199

- hemodynamically unstable pt who requires removal of large volumes of fluid - Hypervolemic or edematous pts. unresponsive to diuretic therapy - Pts. with MODS (multi-organ dysfunction syndrome) - Ease of fluid management in pts requiring large daily fluid volume - Replacement for oliguria - Admin of TPN - Inability to be anticoagulated

Answer 200

- decreased ultrafiltration rate (risk for clotting) - place pt supine, lower container - filter clotting - reset up system and use anticoagulant - hypotension - clamp line - f/e imbalance - bleeding (hemorrhage) - Access dislodgement or infection - sterile dressing changes - EKG interference - assess pt - Air embolus - prime tube properly

Answer 201

Use - acute HF - unresponsive to diuretics - when azotemia or uremia not a concern b-c only fluid loss (no electrolyte loss) Notes * No replacement fluid added * Rate: 100 to 300 ml/ hour (slow) * Requires both arterial and venous access * Clots easily

Answer 202

Use: fluid and moderate solute removal via convection (urea, creatinine, and other small non-protein toxins) Notes * Must have MAP of 60 (BP driving force) * Rate: 5 -20 mL/min or up to 7- 30 L/24 hr * Replacement fluid is added

Answer 203

Use - fluid and max solute removal via diffusion (dialysate pumped concurrent to blood) - resistance to diuretics - severe uremia or critical acid-base problems Notes * most like traditional HD *Must have MAP of 70 (BP is driving force) *Rate: 500-800 mL/hr (more effective over days) *Replacement fluid added * Ideal for hemodynamically unstable in ICU b-c do experience abrupt fluid and solute changes

Answer 204

Use - max fluid and max solute removal via convection and diffusion - Combines CVVH and CVVHD - most complex Notes - Requires a MAP of at least 60 (BP driving force) - Replacement fluid is added

Answer 205

- Drugs (anticholinergics, diuretics, CNS depressants) - Diseases (Depression, Arthritis, Parkinson, Dementia) - Inadequate Resources (lack of support, lack of assistive devices, high cost of products) - Nocturia - urinary retention from age or drugs - weakened urinary sphincter - decreased bladder capacity

Answer 206

CNS - Confusion due to infection and delirium often seen - Neurodegeneration (Reduced brain volume and weight, blood flow) - Decrease in neurotransmitters (Ach, dopamine, serotonin, glutamate) - altered sleep-wake cycle (increases risk for delirium and dementia) - Increased blood brain barrier permeability (increased drug effects) - slower processing times and memory loss) Sensory - Decreased pupil size and reactivity (vision) - Decreased touch sensation (falls) - Reduced reflexes r/t neuronal loss (falls) - decreased taste, hearing, and smell

Answer 207

- LOC (earliest indicator of change in neuro status) - Motor function - pupillary function - respiratory function - vital signs

Answer 208

- Alert - Confused - Delirious (disoriented to time, patient, place and may have hallucinations) - Lethargic - Obtundent (dull indifference to any stimuli) - Stuporous (only respond to continuous stimuli) - Comatose (no response to any stimulus)

Answer 209

Arousal - ability to respond to verbal or noxious stimulus. (Verbal (calm then loud), sternal rub, trapezius muscle pinch) - Central stimulation preferred (trapezius muscle pinch or sternal rub) over Peripheral stimulation (nailbed pinch) for overall body response. - no need for noxious stimuli if follows commands Alert (LOC) Awareness (orientation to person, place, time, situation) if arousable

Answer 210

- Highest = 15 & lowest = 3. - < 7 = comatose i.e. “Less than 8, intubate”. - Never use GCS in place of complete neurologic assessment - does not account for patients with aphasia or mechanically ventilated. - Change in 2 or more points is significant

Answer 211

Eye opening (4-1) - spontaneously - to speech - to pain - none Verbal Response (5-1) - oriented - confused (appropriate language but disoriented) - inappropriate - incomprehensible (mumbles, moans, groans) - none Motor response (6-1) - obeys commands - localizes pain (spontaneous w/ purpose away from noxious stimuli) - withdraws from pain (does not cross midline but moves away) - flexion to pain (Decorticate) - extension to pain (decerebrate) - brainstem dysfunction - none

Answer 212

Posturing - denote decorticate (flexion), decerebrate (extension), or flaccid after peripheral noxious stimuli Reflexes - DTRs (achilles, quadriceps, biceps, triceps) should be present - corneal (CN 5 and CN7) should be present - pharyngeal/gag (CNIX and CNX) should be present - Babinski, grasping, rooting if > 2 yrs = brainstem lesion or herniation

Answer 213

Muscle size and shape - any atrophy Muscle tone - via passive movement - flaccid, hypotonia, hypertonia Muscle strength - via active movement - graded 0 to 5 - pronator drift (arm held out and pronated then drops due to weakness)

Answer 214

Size, shape, symmetry - pupils should be equal b/w 2-5 mm - any new discrepancy = significant b-c may be herniation or increased ICP) Reaction to light - should be direct and consensual response - Dilated, nonreactive or oval shape= CN III (oculomotor compression) - Pinpoint & fixed = brainstem dysfunction/ loss of sympathetic control from opioid - Asymmetric, loss of reaction, unilateral/bilaterally dilated = brain herniation Eye movement - use H test if conscious - If unconscious, use doll’s eye reflex or ice caloric text

Answer 215

”Doll’s eyes” - Action: turn head side to side quickly while someone holds eyes open (DO NOT DO IF CERVICAL INJURY) - positive = eyes move in opposite direction of head movement = intact brainstem. - Negative = eyes stay fixed and midline or move in same direction as head movement = significant brainstem injury Cold caloric test” - Action: place 20-100 ml of ice water in ear while head raised to 30 degrees (HCP ensures tympanic membrane is intact first)- very NOXIOUS - Positive: eyes turn toward ear with water in it - Negative: disconjugate/abnormal or absent reflex = degree of brainstem injury

Answer 216

Initial - increased BP - Increased HR and CO - Decreased RR (hypoventilation i.e. hypoxemia and hypercapnia lead to cerebral vasodilation = increased ICP - Temp (hypo or hyperthermia b-c unable to regulate) Late (Cushing's Triad- opposite of shock) - Increased SBP (widened pulse pressure - Abnormal respirations/Airway status (Cheyne stokes, cluster breathing, apnea) - Bradycardia

Answer 217

Use: gold standard rapid noninvasive test for TBI, vascularity, mass lesions Care - Serial CT to detect changes (increased ICP or midline shifts) - May be w/ or w/o contrast dye (need contrast dye care i.e. hydration, allergy check, kidney check, previous reactions (antihistamine or corticosteroids if mild reactions previously)) - Stay w/ patient during procedure to monitor neuro, VS, and ICP - keep patient flat

Answer 218

Use: Allows visualization of lumen of vessels to provide info on patency, size (narrowing or dilation), irregularities, occlusion (thrombosis) i.e. aneurysm, vasospasm, AV malformation, carotid artery disease, vascular tumor, stroke Contraindications: renal insufficiency, bleeding, cardiac instability Care - NPO for 4 hrs prior b-c sedated - Uses contrast dye (check for allergies and check kidney function; enhance hydration) - Bedrest for 8-12 hrs after - Care similar to cardiac cath (Keep patient flat and leg straight for 2-6 hrs, monitor puncture site and pulses after procedure) - Monitor: VS, Neuro and neurovascular q15 for 1 h

Answer 219

MRI - more detail than CT to show subtle details (small tumors, cerebral infarct, CNS infections and inflammation, malignancy, metastatic lesions, spinal cord injury - Requires patient to be motionless in tight space for long time (blindfold, music, or light sedation may be needed) - Remove all metal from pt body and clothing (do not use if ICP monitoring) EEG - Looks at electrical impulses to view seizure activity, cerebral infarct, metabolic encephalopathies, alt LOC, infectious disease, head injury, confirm brain death X-ray - Identify fractures (except basilar), anomalies, or possible tumors - may be unnecessary if CT

Answer 220

Use: visualize CSF and analyze to diagnose meningitis Contraindications - increased ICP associated with space-occupying lesion, mass or trauma b-c risk of brain herniation - increased bleeding risk (anticoagulants, thrombocytopenia, coagulopathies) Care - Monitor for changes in neuro or breathing pattern - properly align patient (flexed lateral) - Do CT first to rule out mass, lesion, or trauma prior to LP if increased ICP suspected

Answer 221

- AEDs to prevent seizures - Antipyretics and cooling blankets to decrease metabolic demand. - sedation and antihypertensives to reduce CPP - hypertonic saline (keep Na on high side of normal and reduce cerebral edema) - Steroids (decrease cerebral edema and inflammation) - Diuretics (mannitol or furosemide) - Opioids (fentanyl, morphine) and sedatives (propofol)- smallest amount b-c interferes w/ neuro exam - Neuromuscular blocking agents – must use ICP monitor b-c not able to get neuro exam w/ these

Answer 222

Early - Decreased LOC (earliest) - behavior changes (restlessness, irritability, confusion) - speech changes (aphasia - sensorimotor changes (CN dysfunction, ataxia, motor dysfunction, change in muscle tone) Late - Severe headache - Nausea and vomiting (may be projectile) - Seizures (usually within first 24 hours after stroke) - Cushing triad (very late sign): - Abnormal posturing (very late sign): Decerebrate or Decorticate - Pupillary changes: fixed, constricted, dilated - Papilledema (edema and hyperemia due to increased blood flow to eye)

Answer 223

- pressure needed to ensure blood flow to brain - MAP - ICP = CPP Normal range: 50-70 ( CPP < 30 = neuronal hypoxia and cellular death) Notes - Increased ICP -> decreased CPP and causes cytotoxic edema - maintain SBP > 90

Answer 224

Use: monitoring or treatment via draining CSF in EVD (external ventricular drain) for TBI, ICH, stroke, meningitis, hepatic encephalopathy, Normal range ICP: 5-15 mmHG (Persistent elevation > 20 remains most significant factor associated with fatal outcomes Care for device - Need waveform (3 notches) along w. numeric value - Zero device once per shift - Check for catheter dislodgement or kinks in tubing - Transducer must be leveled w/ ear (external auditory meatus) once a shift - Do not move HOB b-c misaligns transducer and changes drainage - reinforce but do not change cranial dressings

Answer 225

Contraindication: coagulopathy Complications: - Ventriculitis (decrease risk w/ antibiotic impregnated catheter) - Meningitis - Post-op hemorrhage, - Decreased drainage (increases ICP)

Answer 226

S/s - CSF leak (otorrhea, rhinorrhea) - Battles sign (ecchymosis behind the ear over mastoid process) - Raccoon eyes (purplish discoloration around eyes) - Palsy of CN VII Care - detect w/ CT - NO NGT for this client! (rule out basilar fracture b-c can accidentally insert into brain)

Answer 227

Mild brain injury (GCS 13-15 and d/c home) w/ brief loss of neurologic function, particularly loss of consciousness. Diagnostic: based on hx S/s - Loss of consciousness (few minutes to hour) -> anterograde or retrograde amnesia - confusion/disorientation/dizziness - irritability/headache - NV - ringing in ear - may have long term secondary effects (CTE or post concussion syndrome)

Answer 228

- bruising of brain (blood collects) due to acceleration-deceleration injuries - coup (at point of impact) or contrecoup (secondary opposite point of impact) Diagnostic: CT S/s - inability to concentrate - numbness and tingling - issues speaking - risk for intracerebral hematoma or hemorrhage - risk for cerebral edema - may need surgery

Answer 229

- Arterial Bleeding (FAST) into the space between the skull and outermost layer of the dura mater S/s - Severe, localized headache (sleepy) - Dilated and fixed pupil on impact side - Brief loss of consciousness followed by a period of lucidity then rapid deterioration of LOC (Walk – Talk – Die phenomenon) Care: Requires EMERGENCY surgical evacuation to remove blood and cauterize vessels

Answer 230

- Venous bleeding (SLOW) into the space between the dura and above the arachnoid space. - Most frequently seen intracranial hemorrhage Risk factors: - Coordination or balance disturbance - Anticoagulants Care: craniectomy or craniotomy

Answer 231

- ABCs = priority (b-c risk for Hypoxia, hypercapnia; Hypertension/Hypotension, fever) - need controlled hyperventilation and hypothermia - Continuous and Frequent Neurologic Assessment and GCS q1h for early detection and treatment - Assess electrolytes q6h if diuretics used - Spine precautions (cervical collar, supine, neutral, log roll) until cervical injury ruled out) - Seizure precautions - Use Foley and PEG/ NG for strict I & O measurement - Avoid noxious stimuli (excess suctioning, coughing, irritation, clustering care) - Early consults: OT/PT/SLP/social work/organ donation

Answer 232

- head, hip or neck flexion - clustering of nursing procedures - unnecessary suctioning - PEEP > 20 cm H2) - vomiting (antiemetics) - Constipation and straining (stool softeners) - Coughing (lidocaine)

Answer 233

- Decrease in lean body mass - Increase in body fat - Decline in muscle strength (osteoporosis, fractures, immobility) - Decreased sensation - polypharmacy (fall risk w/ benzos, SSRIs, TCA, neuroleptics, and AEDs = highest risk of falls) - frailty (decreased muscle mass, poor nutrition, diminished cognition)

Answer 234

- autoimmune disease - demyelination of peripheral nerves causes inflammatory peripheral neuropathy - TEMPORARY

Answer 235

- sensory and neuro assessment q1h - no cure but hasten recovery w/ Plasmapheresis, IVIG, and steroids for inflammation - Respiratory care (may need ventilatory support)- admitted to ICU if requires respiratory support - Pain management (opioids) - Nutritional management (NG or OG tube if swallowing difficulties) - Communication boards or writing if on ventilator and has strength - Initiating OT and PT rehabilitation

Answer 236

- Chronic autoimmune disease - Destruction of myelin (fatty and protein materials) sheath that cover certain fibers in the brain and spinal cord - Slows or stops impulse transmission via neuronal injury and muscle atrophy - Periods of remission and exacerbation

Answer 237

Musculoskeletal/mobility - Muscle weakness and spasticity (paresthesia, flexor spasms) -> paralysis - Intention tremors (when doing activities) i.e. dysmetria - Ataxia Visual - Nystagmus - Diplopia - Decreased acuity (blurry) - Scotoma (change in peripheral vision) Audio - Decreased hearing acuity - Tinnitus - Vertigo (dizziness)

Answer 238

- Autoantibody attack on the acetylcholine receptor sites (AChRs) in the muscle end plate membranes - Inadequate ACh = result which prevents muscle contraction - exacerbations and remissions

Answer 239

- Fatigue/extremity weakness -> Respiratory muscle compromise - Poor posture - Ptosis/ diplopia - Dysarthria (difficulty speaking) - Dysphagia (difficulty swallowing) --Risk for aspiration - Loss of bowel and bladder control

Answer 240

-Initial muscle weakness and pain - bilateral paresthesia, ataxia -> paralysis - Ascending paralysis (flaccidity to respiratory paralysis) over 2-3 weeks then plateaus - No effect on LOC or cerebral function (may have CN dysfunction) - Decreased DTR Complications - Pulmonary (atelectasis, pneumonia, pneumothorax) - Autonomic dysfunction (HTN, Tachycardia -> beta blocker needed)

Answer 241

- autoimmune antibodies - CSF analysis (Elevated CSF protein with normal cell count) - Nerve conduction studies (Reduced conduction in GBS)

Answer 242

Use: GBS, MG Action: Removes circulating antibodies assumed to cause disease from blood then reinfuse blood (similar to dialysis) Pre-procedure - place vascular Cath - need informed consent Contraindications: sepsis, hemodynamic and venous access complications

Answer 243

Use: GBS Minor discomforts ( mild fever/chills, myalgia, and headache) Major complications (anaphylaxis, retinal necrosis, AKI) Contraindications: hypercoagulable states, renal failure, hypersensitivity

Answer 244

Procedure: patient in controlled environment and given acetylcholine or edrophonium (acetylcholinerase inhibitor) Result (observe or take before and after pics of ptosis) Symptoms improve = MG crisis Symptoms worsen = cholinergic crisis Risks - cardiac dysrhythmias and cardiac arrest (bradycardia, hypotension, bronchospasm, syncope) - Ach Toxicity: lacrimation, salivation, hyperhidrosis, abdominal cramping, diarrhea Care - Antidote = atropine - Have continuous BP, O2, and cardiac monitoring - contraindicated w/ asthma or cardiac diseases

Answer 245

Myasthenic crisis - Acute exacerbation of MG from enough anticholinesterase drugs (too little Ach) - s/s: dysphagia, nasal regurgitation, nasal speech, jaw or tongue weakness, decreased facial sensation, dyspnea, acute respiratory failure - Treat: Mestinon (pyridostigmine);IVIG or plasmapheresis; respiratory support w/ artificial airway Cholinergic crisis - Acute exacerbation of muscle weakness caused by too much anticholinesterase drugs (too much Ach) - Treat: atropine

Answer 246

Non-surgical Management - Ventilator support (ETT or noninvasive) - Pulmonary support (CPT, vibration, airway clearance; adequate nutrition, f/e balance) - Promote mobility to prevent DVT and other immobility complications Surgical Management - Thymectomy (take thymus out)-

Answer 247

- Ice pack test (Procedure: place ice pack for 2 min and see if ptosis improves) - Thyroid function - CT: show thymus gland abnormalities or confirm presence of thymoma (tumor outside thymus) - Antibodies to acetylcholine receptor antibody (AChRs) - Repetitive nerve stimulation (RNS) or Electromyography (EMG): show impaired neuromuscular transmission - Tensilon test Note: MRI not used b-c contrast can worsen weakness

Answer 248

Mestinon (pyridostigmine) (Cholinesterase (ChE) inhibitor drug) - Gold standard for MG (no impact on autoimmune response) - enhances functional AChRs by increasing ACh release Immunosuppressants (steroids, cyclosporin, methotrexate) - reduce autoimmune process and progression - avoid crowds and report s/s of infection; don’t stop steroids abruptly b-c adrenal insufficiency IVIG or Plasmapheresis - If severe w/ bulbar dysfunction or respiratory insufficiency

Answer 249

- CSF: elevated proteins and increased WBC count - CSF electrophoresis: increased myelin basic protein and presence of increased IgG - MRI (shows at least two areas of diffuse random or patchy areas of plaque in white matter of CNS ) = definitive finding - Evoked potential testing (Visual evoked response (VER)): identify impaired transmission along optic nerve pathway

Answer 250

Speech - Dysarthria (difficulty speaking) - Dysphagia (difficulty swallowing) Cognitive changes - memory loss, impaired judgment, inattention - Mood swings (euphoria; depression) - Pain -> hypoalgesia (decreased pain sensation) Elimination/repro - Urinary retention (Spastic bladder) - Constipation - Decreased sexual function (sensation, interest, erection)

Answer 251

- Immunosuppressive therapy (Cyclophosphamide (Cytoxan); methylprednisolone (Solu-Medrol)) - Anticholinergic agents for overactive bladder - Antispasmodics (baclofen or tizanidine) for muscle spasticity which cause pain - Antiepileptics (carbamazepine) and TCA for paresthesia - Analgesics-- pain

Answer 252

- secondary mechanism of spinal cord injury - medical emergency - Loss of vasomotor tone -> systemic vasodilation -> hypotension and hypoperfusion (give fluids) - Bradycardia (give atropine and norepinephrine)

Answer 253

- Temporary (Happens immediately and usually lasts 48h but can Last up to 4-12 weeks) - complete paralysis/weakness below injury (may lack reflexes and have priapism) - Decreased bowel sounds and gastric distention -> hypotonic bowel - must resolve before level of injury can be determined

Answer 254

- assess neurological status ( GCS <8 = intubate) q1h for 4-6h - Assess for hemorrhage (internal bleeding; may need blood) - Determine level of injury based on ROM, paralysis, DTRs, weakness Nonsurgical management - ABCs (evaluation respirations and perfusion) q2-4h - spinal precautions (collar, bed rest, log roll, jaw thrust) - ventilation ( no nerve blocking agents; often difficulty weaning) - pulmonary support (suctioning, chest percussion, incentive spirometer) - Traction (skeletal, halo fixation)- assess for infection and bleeding; do not adjust - Prevent complications (musculoskeletal, integumentary, elimination)

Answer 255

- Shock (hypovolemic, spinal, neurogenic) - Cardiac (Dysrhythmias esp. if C3-C5 level, symptomatic bradyarrhythmias, treated w/ atropine or inotropic meds then pacemaker; DVT; orthostatic hypotension) - Pulmonary complications (O2 < 92%, atelectasis, pneumonia, respiratory paralysis) - Musculoskeletal complications ( contractures, osteopenia, osteoporosis, heterotopic ossification (bony overgrowth onto muscle) ---Care: PT/OT for ROM exercises, foot drop splints, hand splints, celecoxib to prevent heterotopic ossification - Integumentary complications (Risk for pressure ulcers, temp dysregulation, VTE) -- use cooling blanket prior to antipyretics - Elimination complications (Risk for abdominal distention, constipation, fecal impaction; Spastic bladder if upper SCI; flaccid bladder if lower SCI) -- care: Foley and stool softeners; bowel program (Fluids, fiber, proper position, physical activity, reflex stimulation) - Autonomic dysreflexia (EMERGENCY)

Answer 256

- Methylprednisolone (Medrol) for edema and inflammation - Baclofen for spasms (risk for CNS depression, hypotension; OR Hallucination and seizures if sudden withdrawal) - Stress ulcer prophylaxis (PPI) - IV fluids and vasopressor support to keep SBP > 90 and MAP > 85-90 to prevent hypotension - Dextran (plasma expander) to increase capillary blood flow in spinal cord and prevent/treat hypotension - Atropine sulfate to treat bradycardia if pulse < 50-60 beats/min

Answer 257

- Restrictive clothing - Pressure area (Epididymitis or scrotal compression; Sheet wrinkles or hard objects) - UTI - Irritation of hemorrhoids - Pain - Distended bladder (Areflexic (neurogenic) bladder) - Constipation (fecal impaction)

Answer 258

S/s - Vasodilation above level of injury (Severe HTN, severe headache, nasal stuffiness, blurred vision, spots in visual field, Flushing, Diaphoresis, goosebumps, JVD, apprehension) - Bradycardia - Vasoconstriction below level of injury (Pale, Cool, No sweating) Risks - cerebral hemorrhage - seizures - stroke

Answer 259

Basics - Exaggerated sympathetic response to stimuli in people w/ high level SCI (T6 or higher) Care - Raise HOB to reduce BP - Treat the cause i.e. remove impact, check catheter, loosen clothes, identify UTI, examine for pressure ulcer - Notify MRT - Monitor BP q10-15 min - Give nifedipine or nitrate to lower BP

Answer 260

- Xerosis (dry, cracked, itchy skin) --Worsened by inadequate water intake or environmental conditions; interventions: moisturizers, natural oils - Seborrheic keratosis (Noncancerous growths) - Cancer (skin cancer)-- avoid hot day, protective clothes, sunscreen, check sin - Skin tears (wound from shear, friction, and or blunt force which separates skin layers) - Pressure ulcers --assess w/ Braden Scale

Answer 261

- Less elastic r/t collagen depletion - Drier ((less moisture) so prone to dermal-epidermal separation, reduced subQ blood flow, decreased dermal lymphatic drainage - More fragile b-c epidermis thins, BVs break easy - Decreased wound healing r/t decreased cytokine and growth factor production; diminished inflammatory response and reduced cell proliferation - increased breakdown r/t incontinence, immobility, diarrhea

Answer 262

- partial thickness of 10% TBSA - Any full thickness/ 3rd degree - Burn to face, genitals, major joints, perineum, hands, feet - special Injuries (electrical, inhalation, chemical, frostbite) - Burn w/ preexisting conditions (DM, pulmonary, cardiac, kidney, or CNS disorders) that increase risk of mortality - Burn injury + former trauma (fracture)

Answer 263

Components - chest (18%) - back (18%) - genitals (1%) - Each leg (18%- one side = 9%) - Each arm (9%- one side = 4.5%) - Head (9%- face = 4.5%) Tidbits - Circumferential from shoulder to elbow = 4.5% - Palmar surface of hand = 1%

Answer 264

- Must be accurate for burn shock interventions, calculation of TBSA, and caloric needs - Quickest way to calculate size of burn injury in adults - Do not include first degree burns in rule of nines

Answer 265

Epidermal burn (not included in rule of nines) s/s - Red, erythema - Painful, Tender which resolves in 48-72 hrs - Possible swelling Care - Heals in 2-7 days - Pain relief - Anti-Pruritics - Oral fluids

Answer 266

- involves all of epidermis and part of underlying dermis S/s - Light to bright red or mottled appearance - Blanch w/ pressure due to inadequate perfusion - Bullae OR wet and weeping blisters due to microvessel injury increasing permeability and causing leakage of plasma into interstitium - Extremely painful - sensitive to air currents Care - Uncomplicated heals in 7-21 days w/ minimal scarring - IV fluids

Answer 267

Burn involving entire epidermal layer and deeper layers of the dermis w/ Severe blood supply impairment S/s - Red with patchy white areas that blanch with pressure - Turns from white to yellow due to dermal necrosis and surface coagulated protein - NO blister formation Care - Extensive healing time (up to 6 weeks) -- full-thickness if infected, inadequate perfusion, or more trauma - Spontaneous healing (hypertrophic scarring and contractures due to unstable epithelium) - Surgical excision - Skin grafting

Answer 268

- All 3 layers of skin involved so skin does not grow back on its own S/s - Pale white or charred, red or brown - Leathery and dry - bleed from vessel damage - Painless (May have background or procedural pain) - Insensitive to palpitation - systemic effects on f/e balance, infection, metabolism, thermoregulation Treatment - Does not heal by epithelialization or on its own - Skin grafting

Answer 269

- Most common type of burn - Most at risk: <2 yrs. (scalds) AND > 60 yrs. - Temperature and duration of contact determine extent and depth of injury

Answer 270

Notes - Highest incidence in children - risk for tissue destruction, contracture formation, acid-base balance. Rhabdomyolysis Amount of damage determined by - Type and voltage of circuit - Resistance (insulation) - Pathway of transmission through body (More serious than outside appearance due to current traveling inside the body and damaging inner tissues) - Duration of contact

Answer 271

- Usually localized from high dose radiation (accelerators, cyclotrons, medical treatment) or prolonged sun - Appearance similar to thermal injury (Differentiate based on timing of injury and clinical manifestations) - Care: not extensive (may need fluids and anti-pruritic)

Answer 272

Amount of injury determined by - Concentration of chemical - duration of contact - chemical action (alkaline more severe than acid) - amount of tissue Care - Remove contacts prior to flushing eye - Remove contaminated clothing and shoes - Flush area w/ large amounts of water for hours after injury - Neutralization can worsen injury

Answer 273

Resuscitation/Emergent - Begins at the time of injury and continues for about 48 hrs - ends when capillary integrity restored and plasma volume repleted - 1st hour after injury is crucial Acute - begins after resuscitation (36-48 hr) w/ diuresis (end of edema) - lasts until complete wound closure is achieved - Early eschar excision and grafting = early resolution of inflammation and better healing Rehabilitative - Begins with major wound closure to return to optimum level of health (independence and maximum function) - Usually about 6 months to 2 yrs but may take a lifetime b-c ends when highest level of functioning reached.

Answer 274

- Save patient's life (maintain vital organ function and perfusion) - Minimize complications and disability (wound healing and prevention of infection) - Prepare for rehabilitation and definitive care

Answer 275

- Age (higher risk if <2 or > 60) - How did it happen? (mechanism of injury) - rule out trauma, fractures, abuse - Assess source and cause - Where did it happen? (time and place; think CO poisoning if in confined space) - Assess for known allergies - Assess status of tetanus immunizations - significant medical history (preexisting conditions, current meds)

Answer 276

- Maintain adequate oxygenation (airway) - Maintain adequate fluid balance (circulation to prevent hypovolemic shock from fluid shift) - Promote adequate tissue perfusion (may need w/ art line or CVP; remove watches/jewelry which can have tourniquet effect) - Maintain body temperature (risk for hypothermia via evaporation and radiation) - Prevent infection - Keep patient comfortable w/ analgesics and emotional support

Answer 277

Goal: avoid ARDS, pneumonia, pulmonary edema s/s of airway damage - Assess ( singed nasal hairs or eyebrows, hoarseness, facial burn carbonaceous sputum, drooling) - Sudden stop of stridor or wheezing = unable to breath (EMERGENCY) - Facial edema = intubate prior to airway closing - Hypoxemia (tachypnea, agitation, anxiety, upper airway obstruction) Care: 100% oxygen

Answer 278

- Ventilator support (100% oxygen, (low tidal volume, high PEEP, permissive hypercarbia) - HOB elevated - Early intubation - Mobilize and remove secretions (cough, deep breathing, suctioning, bronchodilators, early mobility, elevate HOB) - Careful fluid resuscitation to prevent pulmonary edema - Cervical precautions if possibility of instability - Nebulized heparin (increase airway clearance of debris)

Answer 279

Concerns - chest restriction (reduced expansion and compliance) w/ circumferential full thickness chest burns Care - Escharotomy to chest wall ASAP - Monitor ABGs and O2 sat (Respiratory acidosis -> respiratory alkalosis) - Monitor respiratory rate and effort - Monitor for cyanosis (late sign)

Answer 280

Goal: maintain end organ perfusion and avoid fluid overload Concerns - Under resuscitation = inadequate cardiac output = inadequate perfusion and wound conversion (AKI, cardiovascular collapse, death from shock) - Over resuscitation = excess wound edema -> moderate to severe pulmonary edema -> decreased perfusion of unburned tissue Care - Requires accurate fluid resuscitation - No diuretics - Assess HR, BP, pulses, cap. Refill, I & Os, LOC (perfusion to brain) - Continuous EKG (May need nontraditional placement of leads due to burn locations)- initial if electrical wound or preexisting hear condition

Answer 281

- common cause of death in the emergent phase (Higher TBSA (>20%) = higher chance of shock) - Loss of fluid from vascular compartment to area of injury - Leads to blisters and edema from damaged blood vessels increasing permeability to protein and water Effects - hypovolemic shock - tissue trauma - increased PVR (leads to pulmonary edema) - decreased myocardial contractility and cardiac output b-c increased SVR

Answer 282

Parkland Formula - 4cc LR * body weight in Kg* % TBSA burned - ½ given over first 8 hours post-injury - ½ given over the following 16 hours post-injury Tips - LR via large bore (18 G or 20 G) IV - LR > NS b-c matches ECF - Plasma replacement and isotonic fluids used after 24 hours to increase circulating volume

Answer 283

- urine (hemoglobinuria, myoglobinuria) - inadequate fluid replacement (hypoperfusion, hypovolemia) - inadequate UOP (edema, elevated BP) - Change in LOC (lethargy, confusion) Care - Monitor labs (BUN, Crt, GFR, K/Na), PO4 - Assess urine (color, bloody, myoglobin, odor, particles, foamy) - Monitor UOP and specific gravity - May need dialysis (hemodialysis or CRT) - Place foley (if TBSA > 20% or perineum burn)

Answer 284

Effects of stress response - Paralytic Ileus and gastric dilation (also due to burn shock, hypokalemia, SNS response to trauma) - stress ulcer (Curling’s ulcer) - Decreased GI activity (also due to hypovolemia and neurologic injury) Care - Initial NPO - Abdominal exam q2h then q4h (incl. eval for abdominal compartment syndrome) - Place NGT or OGT to low intermittent suction (Prevention of aspiration, distention, emesis) - Administer GI prophylaxis (PPI, H2A, sucralfate, antacids) - Enteral nutrition (Purpose: increase intestinal flow, intestinal blood flow, and GI motility)

Answer 285

Clinical manifestations - arterial insufficiency due to wound edema, circumferential burns (leads to ischemia and necrosis) - Diminished to absent peripheral pulses - Loss of muscle function Care - Assess neurovascular integrity q6h ( Pulselessness, pallor, pain, paresthesia, paralysis, poikilothermy) - Doppler flow probe (evaluate arterial pulses) - escharotomy if circumferential burn to restore circulation and allow swelling - Extend and elevate extremities to decrease peripheral edema and enhance venous return - Avoid crossed legs, dependent positions, pillows behind knees

Answer 286

Effects due to stress response - Overwhelming stress leads to bone marrow suppression, anemia, and infection Care - IV antibiotics - Meticulous wound care (hand hygiene) - Wound monitoring ( for exudate, odor, warmth, fever, and color) - Supportive care (isolation techniques w/ dedicated equipment) - Blood transfusions b-c prone to anemia

Answer 287

Types - background (physiological including damage and exposure of nerve endings) r/t ROM, routine activities - Breakthrough which is not relieved by routine pain meds - Procedural (PT, OT, dressing changes, splints) When to manage pain - Only after IV fluid resuscitation is underway - Not initial priority b-c pain sensation diminished if well oxygenated and wound covered - Premedicated prior to procedural care

Answer 288

Contracture: shortening of scar over joint and causes functional deficit Prevention - Physical and occupational therapy - Passive and active ROM to prevent complications - Splint (Keep joints fully extended in anatomical position on pillows) - no pillow behind head if face burn to prevent flexion of neck

Answer 289

- Daily observation and assessment - Multiple dressing changes (application and reapplication of clean, dry dressing. - skin graft must be placed on clean, viable, tissue - Analgesics and sedatives (morphine, midazolam (versed), hydromorphone) to prevent procedural pain - Topical antibiotics (silver sulfadiazine, mafenide acetate cream, bacitracin, silver) to control/decrease bacterial colonization - Refer to Burn Center (delivers all therapy incl. rehabilitation and can perform personnel training and burn research)

Answer 290

- Hgb, Hct, & BUN HIGH (Due to fluid volume loss) - Glucose HIGH (Due to stess response - Na+ LOW (Due to trapped in wound edema, fluid loss, vomiting, NGT drainage, diarrhea) - K+ HIGH or LOW (High due to release from damaged cells, metabolic acidosis, impaired kidney function (hemoglobinuria, myoglobinuria, decreased renal perfusion) --> Care: correct acidosis (no DICK) OR Low due to massive fluid loss or hemodilution) - pH LOW (Due to metabolic acidosis - Total protein & albumin LOW (Due to loss via burn wound) - WBC initial rise then drop as immune system unable to sustain its defenses. (may be sepsis)

Answer 291

- Reduce BMR via preventing catecholamine release i.e. from pain, fear, anxiety, cold - use IV in resuscitation phase (no subQ or IM b-c unpredictable absorption - use nonpharmacological (imagery, hypnosis, virtual reality, distraction) - use opioids (NSAIDs and acetaminophen only if no risk for bleeding)

Answer 292

- Early continuous enteral feeds - Caloric needs are about 5000 kcal/day due to high BMR - High-protein, high-carbohydrate foods - May need supplmental albumin, iron, zinc, calcium, phosphate, potassium

Answer 293

Goal: remove devitalized (nonviable) tissue down to bleeding stable tissue to control inflammation and remove contaminated tissue to prepare for grafting Types - Mechanical (via scissors or forceps) - Enzymatic (via topical substance to loosen and dissolve eschar) - Surgical (gold standard in OR once hemodynamically stable)

Answer 294

Goal: maintain moist environment while limiting exposure to prevent hypothermia and bacteria exposure Notes - Done in a hydrotherapy tub, cart shower, shower, or bedside - Hydrotherapy limited to 30 min to prevent hypokalemia

Answer 295

Skin care - Discoloration of scar fades with time but not invisible and may not fully go away - Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch - Healed areas must be protected from direct sunlight for 1 year - use lotion for itching Mobility - Engage in PT, OT - exercise important Emotional - praise minor and major accomplishment - use group therapy

Answer 296

- pressure garments which reduce scar blood flow, help organize collagen, prevent venous stasis and edema - Scar massage via providing moisture, stretching scar, and preventing contracture - High SPF sun protection via preventing long term pigment change - Silicone gel sheeting via maintaining scar hydration and reduce tension - Laser therapy - Steroids for hypertrophic scars via inhibiting fibroblast growth

Answer 297

Frostnip - superficial cold injury w/ no tissue damage - causes pain, numbness, pallor or waxy appearance - Care: resolves w/ body heat or warmth Frostbite - freezes and causes tissue damage - use arteriography once rewarmed to exam perfusion

Answer 298

1st degree or Grade 1 frostbite (Least severe) - increased blood flow to area (hyperemia) - Edema formation 2nd degree or Grade 2 frostbite - Partial thickness skin necrosis - Large, clear to milky fluid filled blisters

Answer 299

3rd degree or Grade 3 frostbite - Small blisters w/ dark fluid - Body part = COOL, blue, numb, no blanching w/ pressure - Requires debridement b-c full thickness and subQ necrosis 4th degree or Grade 4 frostbite (Most severe) - Blisters over carpal or tarsal - Body part = numb, COLD, bloodless - Extends into muscle and bone - Amputation if gangrene or compartment syndrome develops

Answer 300

Rewarming - Rapid rewarming w/ Body heat (hands on face or under arms) - for frost nip or superficial OR w/ Water bath (hydrotherapy)- 37-39 C (99-102 F) for 2nd degree or higher (trunk first to prevent aftershock) - Never apply dry heat b-c increases tissue damage - Prevent refreezing once thawed - warm IV fluids (May need to hold (except vasopressors) if core body temp < 86 F (30 C)) Positioning - Supine to prevent OH - Gentle handling to prevent v-fib - Elevate above heart to decrease tissue edema Care - Analgesics w/ IV opiates and ibuprofen to decrease inflammation and secondary injury - Other Drugs: Antibiotics (topical and systemic), tetanus immunization, no caffeine or alcohol - Assess for compartment syndrome (6 Ps) compare affected to unaffected - Never massage area or compress

Answer 301

- Antihypertensives - Antihistamines - Antidepressants - sedatives - Dopamine agonists - Appetite suppressants - Anti-ulcer drugs - Antineoplastics - Corticosteroids - Prolonged hormones (estrogen, testosterone)

Answer 302

- Disabilities: Cognitive, Developmental, and Physical - Newly unpartnered (separated, widows, divorced) have new sexual paradigm - Sexual Orientation: LGBTQIA+ (engage in more high risk behaviors; Higher risk for mental distress, cardiovascular disease, obesity, disability) - Medical Treatments (radiation, chemo, certain meds) - High-Risk behaviors (multiple partners, casual partners, refrain from safe sex) - Underlying Medical Conditions (mental health, CAD, mobility, HIV/AIDS, respiratory, infectious disorders, DM, cancer)

Answer 303

- Screening for STIs (chlamydia, gonorrhea, HIV) - level of risk based on sexual behaviors, multiple partners, adolescent onset intercourse, hx of STIs, unsafe sexual behavior, sharing IV, unprotected sex - Screening for IPV - Pap tests q3 years b/w 21-65; after 65 no need unless high risk or cancer in past 20 yrs; No need if hysterectomy unless hysterectomy done for cervical or precervical cancer - Mammogram – annual for women > 45 yrs (q2y if > 55 if life expectancy > 10 yrs) - PSA – men > 50 yrs - self screenings (breast exam, testicular self exam)

Answer 304

- Medications (Antibiotics for STIs, Hormone replacement therapy (HRT) and lubricants for postmenopausal, PDE-5, prostaglandins, testosterone for ED) - Surgical procedures (hysterectomy, penile implant, vasectomy, mastectomy, prostatectomy) -- can impair sexual interest, feelings of attractiveness, cause ED - Cognitive-Behavioral therapy– counseling - kegels to strengthen pelvic muscles

Answer 305

Myths - sexual desires diminish with age and cognitive impairment - Sexual intercourse is only for young, healthy people for procreation - All older adults are heterosexual ( The presence of older adults as being LGBTQ is not often considered a possibility) Reality - Sexual thoughts, desires and actions continue throughout all decades of life - Sexuality is Vital part of ones holistic being from birth to death - Older adults have various sexual orientations

Answer 306

- Cultural aspect of wellbeing - Provides for expressions of affection and passion - Enhances arousal of life - Enriches communication

Answer 307

- Lack knowledge and comfort with sexual health issues i.e. safe sex practices, positions to accommodate health needs - normal aging changes (menopause; decreased estrogen and testosterone) - pathological aging changes (cognitive impairment, language barrier, meds) - body image (worry or discomfort w/ wrinkly and saggy skin; believe not attractive) - Fear of discussing sexuality (esp. if LGBT) - Cultural and religious beliefs toward sexuality - Environmental barriers (Privacy and Consent in nursing home, assisted living facility, or family home)

Answer 308

Environment - Quiet and private area (w/ or w/o partner presence) - Respectful manner (respect diversity, autonomy, responsive, guidance) - AVOID rigid standards of identify (gender identity is a spectrum) Components of assessment - Health history & review of systems - 5 “P”s: partners, practices, protection from STDs, past history of STDs and prevention of pregnancy- omit pregnancy - Drug review (bipolar, cholesterol, DM) - Physical assessment (s/s of abuse) - cognitive assessment ( ability to give consent) - Diagnostics (mammogram, CT, MRI, US, HST) - self-assessment (nurse must be comfortable discussing sexuality)

Answer 309

- Have you disclosed your gender identity and sexual orientation to your primary health care provider? If you have not, may I have your permission to provide that information to members of the health care team who are involved in your care? - General: How do you express your sexuality? What concerns do you have about fulfilling your continuous sexual desires? - Aging changes: In what ways has your relationship with your partner changed as you have aged? - Inquiry: What info or interventions can I provide to help you to fulfill your sexuality? What questions do you have about your continuous sexual needs and function? - Abuse: Inquire about sexual assault or abuse (Notice nonverbal indicators: Bruises? Scared when communicating with you?) - Living arrangement: Does anyone live with you in your household? Are you in a relationship with someone who does not live with you? - Testing: If you have a sexual partner, have you or your partner been evaluated about the possibility of transmitting infections to each other? - Protection: If you have more than one sexual partner, how are you protecting both of you from infections such as hepatitis B, hepatitis C, or HIV? - Social support: Whom do you consider to be your closest family members?

Answer 310

P: obtaining PERMISSION from the client to initiate sexual discussion LI: Providing the LIMITED INFORMATION needed to function sexually SS: giving SPECIFIC SUGGESTIONS for the individual to proceed with sexual relations IT: providing INTENSIVE THERAPY surrounding the issues of sexuality for that client

Answer 311

- Menopausal s/s: hot flashes, difficulty sleeping, mood changes Vaginal - Thinning, stiffening, drying, smoothing, shortening of the vaginal wall and canal - Decreased or delayed vaginal lubrication (lead to dyspareunia) - Labia, clitoris endometrium atrophy - Graying and thinning of vaginal hair - Loss of tone and elasticity of pelvic muscle - Loss of fat pad over pubic symphysis -> pain from direct pressure over bone. Breasts - Increased flabbiness and fibrosis of breasts - Granular and lobular feeling - Decreased erection of nipples

Answer 312

- Graying and thinning of pubic hair - Increased drooping of scrotum and loss of rugae - Prostate enlargement (Risk for urethral obstruction) - Impotence (erectile dysfunction-ED) -> More direct stimulation required to experience a weaker erection. - longer refractory time (Loss of erection quicker after orgasm and takes more time to regain erection)

Answer 313

Heart disease - Narrowing and hardening of arteries changes blood vessels so blood does not flow freely - Results: inability to relax during sex (post-MI), aphasia (post-stroke), clogged blood vessels -> ED - Medications effects: Antihypertensives (BB, CCB, clonidine, thiazides) -> impotence, ejaculatory disturbances; Cholesterol lowering medications (statins) -> impact sexual health. Diabetes - Result: impaired sexual function, ED in men, vaginal infections and dryness in women -Care: glucose control; hypoglycemics may affect sexuality

Answer 314

Depression - Result: decreased desire, intimacy, sexual activity - Med effects from TCAs, SSRIs, MAOIs: decreased libido, ED Cancer - advanced age most important risk factor - Women: breast cancer and mastectomy -> loss of sexual interest and femininity - Men: Prostate cancer, BPH, prostatectomy -> urinary incontinence and ED

Answer 315

- immunity decline -> increased risk for infection after HIV exposure - late diagnosis b-c aches and pains of HIV/AIDS resemble normal aging or Afraid or ashamed of being testing - Increased risk for cardiovascular disease, dementia, DM, osteoporosis, frailty, cancer, mental illness (depression, addiction) - Lack knowledge about HIV/AIDS transmission and prevention - no cure but antiretrovirals can slow progression and maintain immune function ( use in older adults = complicated b-c of comorbidities)

Answer 316

- If diagnosed or treated for hepatitis or TB - If you or partner had blood transfusion between 1978 and 1985 - if you or partner ever had blood transfusion or operation in a developing country - if b/w 13 and 64 years old at least once (If over 65, ask doctor about frequency of testing)

Answer 317

Manifestations - hyposexual (complete loss of sexual desire) - hypersexual (may be inappropriate i.e. sexual remarks, propositions, groping, grabbing, obscenities, public masturbation, aggression and irritability) Treatment - benzos for hypersexuality - give privacy, respect, calm response if masturbating - recognize sexual needs and determine if capacity to consent if others involved (if unable to consent, HCP needs to step in and prevent unwanted sexual advances) - boundary setting - support and education for caregivers - same gender caregivers

Answer 318

Education - normal and pathological sexual changes with aging. - Safe sex practices (condom, dental dam) - Alternative sexual positions if uncomfortable or not possible - Discuss changes openly w/ partner - promote healthy lifestyle (limit alcohol, smoking cessation, healthy diet, exercise, stress management, adequate sleep) b-c impaired health = impaired sexuality

Answer 319

Use: ED Care - Risk for hypotension (DO NOT TAKE WITH NITRATES) - For Viagra (sildenafil citrate) and Levitra (vardenafil), need sexual stimulation w/n 30 min to an hour to promote erection (Take 1 hr prior to sexual intercourse) - For Cilalis (tadalafil), erection can be stimulated over longer period (36 hrs)--Take 2 hr prior to intercourse - NO GRAPEFRUIT JUICE

Answer 320

- Remissions and exacerbations (mainly women from stress or light) - autoimmune complexes deposit in body systems causing excessive inflammation, overactive immunity, and loss of tissue integrity leading to organ failure and death - Death from vasculitis, lupus nephritis, cardiac problems (pericarditis) - type III hypersensitivity w/ antibody complexes that deposit in tissues

Answer 321

Integumentary - Butterfly rash (red, macular, scaly, dry facial rash over the cheeks and nose in the shape of a butterfly) (nonscarring) - Coin-shaped lesions (discoid rash) on the face, scalp, and sun-exposed areas (causes scarring) - Sensitivity to sunlight (photosensitivity) - Chronic lesions on the mucous membranes of the mouth and throat (ulcers in mouth and throat) - Lupus profundus: skin of face darkens and cheek volume decreases as vasculitis destroys fatty tissue beneath skin - Alopecia Neurologic - seizures w/o previous hx - psychosis without previous history

Answer 322

Hematologic/immunity problems - hemolytic anemia (most common) - decreased white blood cells (leukopenia) and decreased lymphocytes (lymphopenia) - decreased platelets (thrombocytopenia) - Presence of antinuclear antibodies (ANA) - may have false positive syphilis test - intermittent fever (unexplainable GI - anorexia

Answer 323

Musculoskeletal - Chronic fatigue - Polyarthritis--Nonerosive arthritis of two or more bilateral peripheral joints (painful and swollen) - Muscle inflammation (myositis) due to synovial inflammation but no erosion of bone and cartilage Cardiac - Pericarditis (inflammation; s/s: chest pain, tachycardia, myocardial ischemia - Value thickening - Murmurs Kidney - Persistent casts and protein in the urine due to glomerular damage (proteinuria = foamy) = lupus nephritis - Hematuria - Fluid retention (change in UOP)

Answer 324

Goal: Aim is to treat the disease aggressively until remission. General care - Meds for inflammation (topical steroids, immunosuppressives, anti-malarial, NSAIDs, belimumab) - tylenol and moist heat can reduce joint pain (cold only is strained or sprained) - skin care (mild soap, dry and lotion; avoid harsh substances) Prevention of exacerbation - Avoid high-impact exercises but continue low impact and strength building exercise to increase endurance - Avoid UV light (sunlight, fluorescents) b-c exacerbates entire disorder ( SPF 30, no midday sun, umbrella, long sleeves, large hat outdoors) - Avoid smoking and nicotine

Answer 325

Action/Purpose - decreases inflammation - anti clotting effects for vasculitis to prevent VTE - Reduces risk for skin lesions via reducing UV light absorption Care - Teach pts to have frequent eye exam b-c risk for retinitis (irreversible loss of central vision)

Answer 326

Purpose: control inflammation and suppress overactive immune system if steroids ineffective or intolerable in CNS or renal lupus Care - risk for infections or exacerbation of dormant infections so avoid crowds and ill people - Report any early sign of infection to HCP

Answer 327

Use - topical for inflammation and skin changes - systemic used for intense SLE pain, inflammation, immunosuppression Risks - Early: acne, sodium and fluid retention, HTN, insomnia, mood instability (easy crying, euphoria, nervousness)) - Chronic: Cushing’s syndrome i.e. fat redistribution (moon face, buffalo hump); PUD; fragile skin (easy bruising, stretch marks, delayed wound healing), Osteoporosis; osteonecrosis; Thinning scalp hair; hirsutism, susceptibility to infections Care - Increase dosage in exacerbation and then taper in remission - Do not stop abruptly to prevent adrenal crisis

Answer 328

Indications - Preferred and only treatment for irreversible, progressive, end-stage organ disease to improve quality of life and extend survival - quantified reduced life expectancy Recipient assessment - comprehensive health eval w/ multiple labs, tests, procedures - Physical and mental health eval w/ psychiatric and social screening - Evaluation of social support - Evaluation for chemical dependence - Evaluation of commitment to adhere to strict lifetime medical regimen - Receive all vaccinations prior to transplant b-c more effective if not immunosuppresed

Answer 329

- Criteria: irreversible coma and family decides to withdraw care, GCS < 5, ICU, Must rule out - hypothermia (<32 C), - Hypotension (SBP < 90) - drug toxicity – do drug screen, hx, and calculation of clearance - neuromuscular blocking agent (Can interfere w/ cerebral motor response) - electrolyte, acid-base, or endocrine dysfunctions Diagnostics - EEG – no brain activity - Cerebral angiography – no cerebral perfusion - Transcranial Doppler - Cerebral scintigraphy

Answer 330

Cerebral motor responses - No cerebral response to pain (nail bed or supraorbital ridge pressure) - GCS < 5 Brainstem reflexes - Pupillary reflexes (absence of light reflex; usually round, oval or irregular shaped) - Oculocephalic reflex – absent Doll’s eyes (no doll’s eyes if cervical injury or TBI) - Oculovestibular reflex – absent ice caloric (Observe 1 min and allow 5 min b/w each ear) - Corneal reflexes – absent CN5 and CN7 - Gag and cough reflexes – absent pharyngeal (CN IX and CNX) Absence of respiratory drive - Apnea testing b-c loss of brainstem function = loss of central controlled breathing leading to apnea - Mechanical ventilation

Answer 331

Organ procurement organization (OPO) - part of health team but separated from decision to withdraw care - manages donor assessment, obtains authorization, and facilitates recovery after criteria met - Guides information giving process to the family (Successful donation r/t deep, close and open OPO relationship) - Goal: get organs suitable for transplant Nurse - Links hospital to OPO (Call OPO w/ demographic info, admitting diagnosis, and current neurologic status) - Do initial work-up (VS, I & O, assessments, labs, ensure diagnostics done) - Self-assessment around organ donation - Refer anyone w/ imminent cardiac or brain death to OPO (CMS requirement) w/n 1 hour

Answer 332

- Patient demographics (age, sex, race) - Person’s history (conditions, medical and surgical procedures, social history) - Hospital’s plan of care for patient - History of current illness - Current medications - determine organ suitability - Initial labs: blood type, disease testing (HIV, CMV, Hepatitis, syphilis, EBV) - initial diagnostics: x-ray, 12-lead EKG

Answer 333

Criteria - not brain dead but sufficient, irreversible, unsurvivable condition - cessation of circulatory or respiratory function - irreversible and unsurvivable condition Categories - controlled (family makes decision to withdraw care) - uncontrolled (unexpected code)

Answer 334

Goal: preservation of organ function via oxygenation, thermoregulation, perfusion Duration - brain death until organ procured - immediate transport for heart and lungs - transport within 6-20 hrs for pancreas and liver - transport within 24 hrs for kidney and tissues

Answer 335

- MAP < 70 - SBP > 170 - HR < 60 or > 130 - Temp < 36.5 C or > 37.8 C - UOP < 75 or > 250 - Glucose < 90 or > 180

Answer 336

General - Transfer care to OPO - Discontinue all prior orders. - Assess BP, HR, temp, CVP, PAOP q1h - accuchecks q2h - Labs q4h (CMP, CBC, ABGs, coags) GI - Pantoprazole 40 mg IV every 24 h, first dose now - NGT to low intermittent suction (if present). Medications: - Artificial tears q1h to prevent corneal drying - antibiotics as previously ordered - Most anticonvulsants, pain medications, Laxatives, GI, motility agents, eve drops, anti-hypertensives, antinausea agents, subQ heparin, osmotic agents (mannitol), and diuretics are unnecessary during donor care and will be discontinued automatically

Answer 337

Pulmonary - mechanical ventilator parameters as previously set. - Continue routine pulmonary suctioning and side-to-side body positioning. - Continue chest tube suction or water seal as previously ordered (if present) - Albuterol and Atrovent (ipratropium unit dose per aerosol every 4 h Hemodynamic - Maintain head of bed at 30 to 40 degrees elevation. - Warming blanket to maintain body temperature above 36.5° c. - Maintain SCDs. - IV: D5% in 0.45% NS plus 20 KCL per liter at 75 ml/h. - Vasoactive medication infusions (dopamine, norepinephrine) at previously ordered concentrations and infusion rates

Answer 338

- Advance age (> 75) - Co-existing malignancy (except liver cancer for liver transplant) - Severe multi-organ dysfunction - Severe chronic disabling illness (CT disease, neurologic disease) - Severe deconditioning i.e. unlikely to survive major surgery - Psychiatric illness i.e. MDD, suicidal, dementia, poorly controlled - Active drug or alcohol abuse - Active infection (treat first) - Excessive obesity - Noncompliance w/ current pharm (incl. uncontrolled HIV) - unwillingness to receive blood products

Answer 339

Hyperacute - Immediate (w/n 1 hr) graft failure (w/ complement activation, endothelial damage, inflammation, thrombosis) due to humoral immunity - Seen w/ ABO incompatibility - Prevent w/ induction therapy and preformed antibody testing - Care: Remove organ ASAP Acute - Weeks to months after transplant placement - Cell-mediated and causes cell damage and inflammation - Care: methylprednisolone, antithymocyte globulin, IVIG, monoclonal antibodies Chronic - Occurs at various times and progresses for years - Due to humoral and cellular mediated immunity - organ deteriorates due to chronic inflammation, initial smooth muscle proliferation, diffuse scarring, and occlusion of organ vasculature -> tissue ischemia and necrosis

Answer 340

Heart - Endomyocardial biopsies via right IJ to evaluate for perivascular infiltration (risk for perforation (cardiac tamponade, pneumothorax) - AlloMap (measures genes expressed by activated T cells to mark rejection)- biopsy confirms Lungs - PFTs - Transbronchial biopsy Liver - LFT’s (AST, ALT, ALP, serum bilirubin, PT, gamma-glutamyltransferase) - ERCP, hepatoiminodiacetic acid scanning, transhepatic cholangiography - Liver biopsy

Answer 341

Pancreas - Serum amylase and glucose not reliable - Glucose elevation = late finding of rejection - Kidney biopsy or increased crt b-c usually both transplanted - Pancreas too fragile for biopsy - Decreased urine amylase if bladder exocrine drainage Kidney - Assessment of renal function (increased creatinine) - Renal biopsy

Answer 342

Goal: prevent allograft rejection to suppress activation of immune response while minimizing med toxicities Types - Induction: provide intense post-op immunosuppression when risk of rejection is high and produce tolerance of graft (ex. Cytolytic (depleting)- destroy T-cells (ex. Antithymocyte globulin, alemtuzumab) OR Nondepleting- prevent T cell proliferation (ex. Basiliximab)) - Maintenance: provide immunosuppression throughout patient’s life to prevent rejection (ex. Triple drug regimens: Corticosteroid (Methylprednisolone (solumedrol)); Antimetabolite (Azathioprine (Imuran)); Calcineurin inhibitor (Cyclosporine (Neoral) or tacrolimus (Prograf))) - Rejection: reverse acute cellular or antibody-mediated rejection (ex. methylprednisolone, antithymocyte globulin, IVIG, monoclonal antibodies)

Answer 343

Indications - Severe HF (may be r/t chemo, radiation, tumor, congenital defect) unable to be medically or surgically managed - Nonischemic cardiomyopathy (idiopathic, viral, valvular) - Coronary artery disease Specific contraindications - Severe liver and kidney dysfunction - Diabetes Mellitus (only if s/s of end organ damage i.e. nephropathy, neuropathy, retinopathy

Answer 344

Assessment - typical: low CO, dysrhythmias, second p wave on EKG, cardiac tamponade, hypotension - s/s of hyperacute rejection: hemodynamic collapse, Cyanosis of donor heart (REMOVE ASAP) - s/s of infection i.e. CMV is common ( fever > 100.4, cough Meds - isoproterenol (beta agonist) for chronotropic/HR support (increase HR, CO, decrease PVR) – may need temp pacing - Dopamine and epinephrine for inotropic support (stop after 24-48 jrs) Care - aseptic technique in all procedures (lines and dressing changes - Prevent CMV w/ antiviral (valganciclovir) or CMV immunoglobulin prophylaxis

Answer 345

General rejection - Rub (pericardial friction) - Electrocardiogram voltage decreased - JVD - Edema (peripheral, sudden onset) - Cardiac dysrhythmias (atrial, bradycardia) - Tiredness - Intolerance of exercise - Onset of low-grade fever (report) - New S3 or S4 heart sound - Enlarged cardiac silhouette - Pulmonary crackles, wheezes - Increased weight - Shortness of breath - Onset of hypotension - Disturbance in mood - Echocardiogram findings (systolic function, left ventricular mass thickness) Chronic - Coronary artery disease i.e. cardiac graft vasculopathy which causes ischemic injury, HF, sudden death (seen in chronic rejection)

Answer 346

Heart-lung - end-stage cardiopulmonary (Congenital anomalies w/ pulmonary HTN, pulmonary HTN w/ irreversible right-sided HF, parenchymal lung disease w/ right HF) - pulmonary disease who has exhausted medical manage w/ capacity for full rehabilitation (cystic fibrosis) Single-lung - End-stage pulmonary disease w/o end-stage cardiac disease (Ex. Severe COPD, interstitial lung disease, cystic fibrosis, alpha-antitrypsin deficiency, Pulmonary fibrosis)

Answer 347

- give fluids for hemodynamic support - give Diuretics if overloaded - low dose dopamine for 34-48 hrs (inotropic support and kidney vasodilation) - Prostaglandin and nitroprusside for systemic and pulmonary vasodilation - Pleural drainage from chest tube drain (Tube removal when drainage < 200 ml/24 hrs w/o air leak)

Answer 348

Assessment - S/s of hyperacute rejection: bleeding (> 100 ml/hr in chest tube), infection, DVT, PE, MODS - Ischemic-reperfusion injury- disrupts pulmonary lymphatics and increases vascular permeability -> edema - Monitor CVP, PAOP, daily weights, BP b-c lungs very sensitive to fluid imbalance (pulmonary edema from overload or prerenal azotemia from hypovolemia) - Bronchoscopy to assess for complications i.e. stenosis, dehiscence, INFECTION, rejection Pulmonary - mechanical ventilation w/ extubation within 24-48 hrs - Suction PRN for airway clearance - Early mobilization to minimize complications (Risk for pulmonary embolus, atelectasis, phrenic nerve injury, gas trapping, reintubation, pulmonary infections, VAP) - Nitric oxide to decrease PAOP and improve oxygenation

Answer 349

Chronic - Chronic allograft dysfunction (CLAD) – obstructive or restrictive (restrictive if fibrotic changes in upper lobes and restrictive PFTs) Acute - Bronchiolitis obliterans syndrome (BOS) --- IRREVERSIBLE decline in forced expiratory volume w/ measurements 3 weeks apart (FEV in PFT) due to dense fibrotic scar tissue affecting small airways

Answer 350

Single lung – Pros: shorter intubation, shorter stay, less need for cardiopulmonary bypass - Risks: lung hyperinflation leading to graft compression (mediastinal shift and respiratory failure) Double lung – Pro: higher success rate and quality of life; preferred in cystic fibrosis or bronchiectasis - Risk: If pulmonary HTN, placed on cardiopulmonary bypass doing procedure to avoid right HF Lung volume reduction surgery (LVRS) - Done if end stage lung disease w/ comorbidities that make them ineligible for single or double lung transplant - Procedure: reduce lung volume via wedge resection of emphysematous tissue which reduces hyperinflation, increases elastic recoil and expiratory flow Living donor lobar lung transplantation (bilateral lower lobe transplant from two donors) - Done if patient too ill to wait for cadaver lung - Disadvantage: higher risk for complications b-c two donors

Answer 351

Indication: irreversible acute or chronic liver disease that is progressive and no effective therapy (Ex. HCV, Cholestatic disease, biliary atresia, metabolic disorders in pediatric patients) Priority is sickest patient Donor suitability - ABO compatibility and similar body size - Extended donor criteria allows older age, older liver, HCV livers - potential for ischemic cholangiopathy if DCD vs DBD

Answer 352

- For hepatic encephalopathy, frequent neuro checks, lactulose, antibiotics - For portal HTN, elevate HOB, esophageal bleeding procedures, TIPS, Propanolol - Provide nutritional support --Fat soluble vitamins (E, D, K, A) and protein supplements - For Ascites, do Paracentesis w/ aseptic technique to prevent spontaneous bacterial peritonitis (SBP), diuretics, colloids - Sodium restriction

Answer 353

Signs of Liver graft non function - hemodynamic instability - Progressive deterioration of kidney function - Coagulopathies and abnormal LFTs (LFTs should peak on 3rd to 4th day them decrease) - Hypoglycemia w/o insulin admin - ventilatory dependence Acute rejection - Early s/s: LFT elevation, fever, change in bile (decrease in bile output, change in color or viscosity of bile) - Late s/s: jaundice, malaise, dark urine, clay colored stools Chronic -leads to loss of transplant or salvage w/ plasmapheresis due to destruction and loss of bile ducts

Answer 354

Assessment - Pulmonary (ABGs, pulse ox, breath sounds) - Monitor Total body fluid vs intravascular fluid via art line, CVP, PAOP, PADOP, I & O, drains, bile totals - Monitor Coagulopathy risk for blood loss - Monitor Electrolytes (magnesium and potassium) --- High levels= AKI; low levels = diuretics or calcineurin inhibitor (hypomagnesemia and seizures) - Monitor or improved neurologic status i.e. resolution of hepatic encephalopathy - Monitor LFTs (ALT, AST, ALP, total bili) Pulmonary - Extubated 12-24 hrs once awake and anesthesia wears off - Prevent VAP (HOB 30 degrees, turn q2h, oral care, early mobility) - Pulmonary hygiene after extubation (incentive spirometry; turn, cough, deep breath; CPT) - Meds (bronchodilators, prophylactic antimicrobial)

Answer 355

Hemodynamic - Reestablishment of normal body temp (hypothermia = common))---Care: rewarm w/ blankets, heating lamps, head covers - Correct fluid w/ albumin, plasma, dopamine, prostaglandin, platelets, vitamin K Nutrition - check prealbumin - TPN if oral delayed - remove NGT when output minimal, bowel sounds return, patient extubated Other - Pain (analgesics may mask deterioration in mental status so do alongside nonpharmacological - Glucose control (ideal < 150) – altered by steroids, graft function, calcineurin inhibitors, diabetes - Kidney function (risk for AKI w/ cyclosporine, tacrolimus, poor liver function)- Manage by avoiding nephrotoxic drugs, use CKRT, hemodialysis - Infection risk due to immunosuppression (aseptic techniques, hand hygiene; remove invasive lines as early as possible)

Answer 356

Indications - ESKD (DM and HTN = leading causes of ESKD) Types - Deceased kidney donation (DCD or DBD) and matched ABO blood type and HLA - Living kidney donation from relative - Living kidney paired donation (KPD)-- Donation exchange w/ another living donor-recipient pair allows exchange when family members incompatible

Answer 357

Kidney - recipient kidney not removed - need dialysis until kidney functional Complications - Hypovolemia - Care: monitor UOP and need 1:1 fluid replacement - Electrolytes (hypokalemia, hypomagnesemia, hypocalcemia)- care: replace as needed, Monitor q4-6h along w/ BUN and crt - Hemorrhage (low H/H)- Care: Monitor CBC and platelet q4-6h; blood transfusion, prevent clots - Bladder (bladder spasms)- Care: irrigate and aspirate foley catheter in case of clots; opiates and antispasmodics to relax bladder - Infection risk (i.e., Candida, PCP, CMV, EPV, HSV) - Care: aseptic technique, standard precautions, handwashing, discontinue invasive lines, limit visits, monitor subtle temp, WBC, wound drainage changes

Answer 358

Acute - Increased tenderness over kidney site (flank tenderness) - Decreased UOP (oliguria, anuria) - Fever (> 37.8 C) - Rapid weight gain (4-6 lb in 24 hrs) and Swelling of hands and feet– fluid retention - increased BP - decreased urine specific gravity Chronic - gradual increase in BUN and crt - electrolyte imbalances (hyperkalemia, hyperphosphatemia, hypocalcemia - fatigue

Answer 359

General - Native pancreas not removed - Head of pancreas placed down for exocrine drainage Enteric (bowel) exocrine drainage - similar to normal physiology - Pancreatic enzymes drain into bowel and are excreted w/ stools - Problems: peritonitis; unable to measure pancreatic enzymes Bladder exocrine drainage - Pancreatic enzymes excreted w/ urine - Problems: recurrent UTI, prostatitis, urethritis, urinary catheter occlusion (more viscous urine), hematuria (urine viscous and irritating), metabolic acidosis (urine bicarb loss) - Advantage: measurement of urinary amylase for rejection - Care: continuous bladder irrigation

Answer 360

Indication - type 1 DM - allow normal glucose control w/o exogenous insulin Post-op medical management - ABC( oxygenation, hemodynamics, cardiac status) - Monitor for f/e problems if done w/ kidney transplant i.e. IV fluids, I & O, Electrolytes (K, BUN, crt) - Place NGT for 24-48 hrs post-op - Place continuous insulin drip to prevent hyperglycemia until graft functional - frequent blood glucose monitoring

Answer 361

Changes - Decreased nonspecific general and specific adaptive immunity -> more severe and frequent infections - Cell-mediated immunity declines so less and slower recognition of pathogens - Increase in comorbidities and frailty - fewer neutrophils and lymphocytes -> negative TB test, no leukocytosis - reduced antibody-mediated immunity -> reason they need boosters to generate new antibodies S/s of infection - acute mental status changes - anorexia - generalized weakness - urinary incontinence - falls

Answer 362

- Body’s exaggerated defense response to noxious stressors (massive trauma, burns, pancreatitis, Sepsis) Characterization - Temp > 38.3°C (101°F) or < 36°C (96.8 °F) - HR > 90 - RR > 20 OR respiratory alkalosis - WBC > 12,000 or < 4,000

Answer 363

Sepsis (Leading cause of hospital death) - life threatening organ dysfunction due to dysregulated response to infection - All ICU are at risk esp. immunosuppressed or central lines Septic shock – subset of sepsis in which circulatory, cellular, metabolic abnormality and organ failure increases mortality - hypotension requiring vasopressors after volume resuscitation to maintain MAP 65

Answer 364

Cardiovascular - DIC (platelet dysfunction) - Decreased myocardial contractility (decreased SV and ejection fraction) from ischemia - increased temp *initially* (possible hypothermia) - hypotension (decreased cap refill Skin - mottling - edema from leaky capillareies Pulmonary - PaO2/FiO2 ratio < 300 = ARDS - pulmonary edema - Hypoxia (tachypnea, low o2 sat Fluid - oliguria Neurologic - acute change in mentation

Answer 365

- Microorganism enters -> inflammation/immune response activation -> systemic = uncontrolled and dysregulated so imbalance b/w oxygen supply, demand, and consumption - Vasodilation -> hypotension - increased metabolic rate - Endothelial damage -> Leaky capillaries -> decreased blood circulating volume (reduce preload and CO)-> worsening hypotension (microcirculatory failure) - Coagulation dysfunction: microscopic clotting (DIC = depleted coagulation) –> hypoxia - Apoptosis of immune cells -> immunosuppression, secondary infection, further inflammation

Answer 366

- Lactate Acidosis (> 2) due to anerobic metabolism - increased total bili - Hyperglycemia in absence of diabetes (Glucose >120) – stress response - increase in crt w/o hx of kidney problems (>2.0 for men) (>1.4 for women) - High or low WBC (bandemia i.e. left shift of neutrophils i.e. > 10% in immature forms) - Inflammatory markers (increased CRP and procalcitonin) - Positive blood culture (may not be present) - H/h, fibrinogen and platelets low due to DIC

Answer 367

Compensatory - Tachycardia r/t SNS, metabolic, and adrenal gland stimulation - Widened PP (low DBP due to vasodilation; High SBP due to high CO) - Full bounding pulse - Skin: Pink, Warm, flushed w/o cyanosis Progressive - ABGs: respiratory alkalosis to metabolic and respiratory acidosis - LOC: disoriented, confused, combative, lethargic - UOP decreases - Depressed WBC count - Skin: cool, clammy, pallor, mottled, cyanosis

Answer 368

CO/CI - High: Septic - Low: cardiogenic, hypovolemic, anaphylactic, neurogenic, obstructive PAOP and CVP - High: cardiogenic, obstructive - Low: Septic, hypovolemic, anaphylactic, neurogenic SVR - High: cardiogenic, Hypovolemic, obstructive - Low: Septic, anaphylactic, neurogenic MAP - Low: all

Answer 369

- Obtain cultures before antibiotic therapy - Primary goal: eradicate the cause via early detection and broad spectrum antibiotics - Remove infection via surgical debridement of infected or necrotic tissue; drain abscesses; Remove invasive devices that may be causing problem - Obtain labs – Lactic acid is a gold standard (grey tube put on ice); CBC (bands, WBC), CMP, CRP, PCT, INR - Obtain IV or CVC for Isotonic IVF at 30 mL/kg to reverse dehydration and hypotension

Answer 370

Pulmonary - Intubation and mechanical ventilation w/ PEEP and low tidal volume if ARDS - VAP prevention: HOB 45, sedation vacation, - prone positioning - avoid neuromuscular blocking agents Other - Vasopressors and inotropes if shock develops i.e. no response to fluids (norepinephrine/Levophed = gold standard after fluids) - reassess lactate level, VS, ABC - Lines needed: foley, art line if vasopressors - Nutritional support (enteral w/ protein)

Answer 371

- Steroids if adrenal insufficiency from stress of sepsis OR hypotensive after fluid and vasopressors to limit SIRS - Insulin to maintain glucose b/w 140 and 180 - Heparin to limit inappropriate clotting and prevent excessive consumption of clotting factors - Blood products (plts, ffp, PRBCs, clotting factors)-if Hgb < 7 - Platelets first to improve clotting if <100000 - sodium bicarb if pH <7.2 (usually none for lactic acedemia) - stress ulcer prophylaxis

Answer 372

- Consumptive coagulopathy Syndrome that arises as a complication of other serious or life-threatening conditions including Sepsis, shock, tissue injury Patho - excessive clotting w/ formation of thousands of small clots everywhere - small clots use clotting factors and fibrinogen faster than they can be produced -> leads to poor CLOTTING. - Thrombosis and fibrinolysis -> inflammation and Microvascular damage -> organ injury -> MODS - Decreased perfusion -> hypoxia and ischemia.

Answer 373

s/s - Petechiae and ecchymoses - Blood may ooze from the gums, other mucous membranes, and venipuncture sites and around IV catheters. - hypoxia and ischemia from microclots Diagnostic - elevated fibrinogen, coagulation, D-dimer - low platelets Tx: - Heparin (bolus then gtt) first b-c stops clotting cascade (target aptt 1.5-2.5x normal; normal 30-40sec, - Fresh frozen plasma & cryoprecipitate

Answer 374

- Acute, widespread process of impaired tissue perfusion in all body system - Imbalance between cellular oxygen supply and demand. - MAP <60 or evidence of hypoperfusion

Answer 375

Initial – cardiac output (CO) ↓ = ↓ tissue perfusion but MAP compensated - overall metabolism is aerobic Compensatory – the body naturally attempts to maintain CO, BP, and perfusion via SNS, RAAS Progressive - the body fails to meet tissue needs and compensation is ineffective - emergency b-c apoptosis, tissue ischemic, anoxia begin Refractory – the body becomes unresponsive to interventions and therapy - syndrome is considered irreversible even if MAP corrected - progresses to MODS if 2 or more systems fail

Answer 376

Distributive - Abnormality in the vascular system produces maldistribution of circulating blood volume (vasodilation, pooling in venous and capillary beds, cap leaks) so ineffective organ perfusion - Anaphylactic: severe antibody-antigen reaction - Neurogenic-loss of sympathetic tone - Septic-dysregulated response to microorganism -> massive vasodilation Obstructive - indirect pump failure: problem outside the heart impairs ability of heart to pump effectively (inadequate filling or contraction) - Ex. cardiac tamponade, massive pulmonary embolism, tension pneumothorax, PAD, pulmonary HTN, pericarditis, thoracic tumors

Answer 377

Hypovolemic - Loss of circulating or intravascular volume due to loss of intravascular integrity, increased cap permeability, or decreased colloid pressure - Ex. Dehydration, poor clotting (hemorrhage) Cardiogenic - Impaired ability of the heart to pump and perfuse blood to body - Ex. Massive MI, cardiomyopathy, dysrhythmias

Answer 378

Renal - AKI due to vasoconstriction, hypoperfusion - glycosuria and acetone in urine Muscular - muscle weakness - loss of DTRs Hematologic - DIC - impaired blood production r/t inflammation, bone marrow, kidney, liver failure GI - GI tract failure - Liver failure - Pancreatic failure

Answer 379

- Serum lactate (Hyperlactatemia due to inadequate oxygenation and anaerobic metabolism) - Level and duration predictive of morbidity and mortality - Serum bicarbonate (detected w/ serum CO2 which are low w/ metabolic acidosis b-c reflection of bicarb) - SVO2 levels ((mixed venous gas i.e., blood extracted after blood returns to right side of heart) = 60-80% (lower w/ poor perfusion) – need PA line - Base deficit from ABGs (reflects tissue acidosis and severity of shock)

Answer 380

Major Focus: Optimize Tissue perfusion Assess for shock: any patient w/ change in LOC, increase in pain, or increase in anxiety Care - Pulmonary gas exchange (airway, mechanical ventilation, supplemental oxygen) - fluids (crystalloids and colloids) - Do meds (vasoconstrictors, vasodilators, inotropes, antidysrhythmic) - Nutritional supplementation (enteral within 24-48 hrs; Parenteral after 7 days if enteral not possible) - Glucose control (140-180 to decrease infection, renal failure, sepsis, death) - Sodium Bicarb if pH < 7.2

Answer 381

Vasoconstrictors - Increase afterload (SVR), BP, MAP via increase SVR, venous return, contractility - Choice: Epi for anaphylaxis; Norepinephrine is gold standard for all other shocks (may add on other vasopressors) - Risks: Chest pain (angina and ischemia); AKI and oliguria w/ high dose; Hypertension; Extravasation (vasoconstriction, tissue ischemia, tissue necrosis) - Do not give dopamine b-c worsens tachycardia and cause dysrhythmias Vasodilators - Decrease preload, afterload or both - Used in cardiogenic shock to unblock coronary arteries in AMI - Care protect from light b-c degrades them - Risk: systemic vasodilation and hypotension esp if nitrate w/ PDE-5 inhibitors

Answer 382

Inotropes - Increase contractility and maintain BP and tissue perfusion - Dobutamine and milrinone seen most in cardiogenic shock - Risk: hypertension; transient hypotension; chest pain (angina or infarction) Antidysrhythmics - Influence HR and rhythm by suppressing or controlling dysrhythmias - Amiodarone used in v-fib, v-tach - Adenosine used in SVT (short half-life so large bore IV and quick admin and connected to machine

Answer 383

Hyperdynamic (early) - Decreased PAOP, SVR, CVP, - Increased oxygen consumption - Increased CO, CI, HR - Heart failure or inadequate fluid resuscitation if unable to increase CO w/ low SVR Hypodynamic (heart failure, cardiogenic shock, death) - Increased SVR, CVP, - Decreased oxygen delivery and consumption - Decreased CO/CI, contractility, compliance

Answer 384

Cardiovascular - ineffective perfusion (hypotension) - ventricular failure - Microvascular thrombi r/t endothelial injury from hypoxia and cytokines Neurologic - CNS hypoperfusion -> SNS, Cardiac, thermoregulatory, respiratory dysfunction - Coma Pulmonary - ARDS - Respiratory acidosis to respiratory alkalosis - Acute lung failure r/t microembolic, vasoconstriction, increased pulmonary cap permeability -> cyanosis

Answer 385

Support oxygen transport: - Establish a patent airway. - Initiate mechanical ventilation w/ PEEP or oxygen. - Administer fluids (crystalloids, colloids, blood, and other blood products). - Administer meds (vasopressors, vasodilators, antidysrhythmics) - Prone positioning Identify underlying cause of inflammation and treat - Remove sources of infection or contamination (Surgery: early fracture stabilization, removal of infected organ, tissue, burn excision; antibiotics)

Answer 386

- Sepsis/SIRS - Shock - Trauma/burns/surgery due to ischemia-reperfusion events from hemorrhage, blunt trauma, SNS vasoconstriction - Acute pancreatitis - Aspiration - Multiple blood transfusions - 65+ due to decreased organ reserve and comorbidities

Answer 387

- Progressive physiologic failure of two or more organ systems due to systemic, self-perpetuating inflammation - Persistent hypermetabolism causes widespread vascular endothelium and organ damage - Homeostasis cannot be maintained without intervention – Poor prognosis Etiology - Organ dysfunction may be the direct consequence of an initial insult (primary MODS) i.e. Posttraumatic pulmonary failure, thermal injuries, AKI, invasive infections - manifest latently and involve organs not directly affected in the initial insult (secondary MODS) i.e. Liver and GI inflammation -> inflammation elsewhere due to auto catabolism

Answer 388

Decrease oxygen demand - Administer sedation or paralytics. - Temp control (antipyretics and external cooling measures) - Pain control (analgesics - Rest and Position for comfort - Reduce anxiety (sedatives, education, calm, quiet environment) Prevent and maintain surveillance for complications - enteral nutrition to preserve organ function - Monitor Hemodynamics, Serum lactate, Respiratory status - Prevention: handwashing, aseptic technique, understand entrance mechanisms

Answer 389

- Skin: pale and cool w/ delayed cap refill - Flat JVD - CNS: Thirst; slight anxiety -> anxiety, restless - Tachycardia - Postural hypotension w/ Narrow pulse pressure (increased DBP and decreased SBP) - Tachypnea (ABGs = respiratory acidosis to alkalosis; O2 sat 90-95%) - Decreased UOP w/ decreased urine sodium (but increased urine osmolality and specific gravity)

Answer 390

- ABGs (metabolic acidosis due to high lactate, low bicarb, high base deficit) - Renal – Oliguria to anuria, high BUN and Crt, hyperkalemia (from anaerobic metabolism and dehydration) - Skin – ashen, cold, clammy w/ delayed cap refill -> cyanosis - CNS: thirsty, Decreased mental status/loc (sense of impending doom, confused) - Cardiac: Rapid weak pulse (NEED DOPPLER); dysrhythmias - O2 sat = 75-80% - Hgb/Hct (increased if fluid shift or dehydration; decreased if hemorrhage)

Answer 391

- Skin – mottled, cyanotic, diaphoretic, cold, dusky - Severe lactic acidosis - UOP ceases - CNS: Pt confused and agitated -> loss of consciousness - Cardiac: Loss of peripheral pulses and cap refill; Marked peripheral vasoconstriction = increased SVR - Pulmonary: Slow shallow respirations, O2 sat < 70%

Answer 392

- ABC and VS q15 min - Fluid resuscitation via large bore (crystalloids = 1st) - Meds: vasopressors (norepinephrine) intropes - Position: legs raised, trunk flat w/ head and shoulders above chest but no more than 30 degree - stay w/ pt until resolved - Limit fluid loss: limit blood sampling, observe for line disconnection, direct pressure to bleeding sites

Answer 393

Labs - increased BUN, crt - increased BNP - Increased Troponin - ABGs (respiratory alkalosis to respiratory and metabolic acidosis) Diagnostic: echo ( confirms cardiogenic shock; noninvasive measure of PAOP and ejection fraction

Answer 394

- Skin: cool, pale, moist, dusky - Pulmonary Edema (crackles, rhonchi, dyspnea, tachypnea, JVD) - Chest pain - Dysrhythmias w/ S3, S4 - Diminished heart tones due to decreased contractility - Pulse (weak, thready) w/ tachycardia - CNS: anxiety, delirium, decreased LOC - Narrow pulse pressure w/ hypotension (SBP <90 - renal: anuria, decreased urine sodium (increased urine SG and osmolality)

Answer 395

General - Mechanical Ventilation (intubation) - Fluids (crystalloids, colloids, blood products) - Inotropes (milrinone, dobutamine) - Vasoconstrictors if inflammation - Diuretics – to reduce preload - Vasodilators only w/ inotrope or after shock resolved - Antidysrhythmic Invasive - If MI, revascularization by fibrinolytics, PCI, CABG - Mechanical circulatory assist devices ( Intra-aortic balloon pump (IABP), Percutaneous ventricular support device (VAD i.e. Impella device), Extracorporeal membrane oxygenator) Nursing - Limit myocardial oxygen demand (analgesics, sedatives, positioning for comfort, meds for afterload and dysrhythmias, limit activities, calm and quiet environment, patient education) - Enhance myocardial oxygen supply (supplemental oxygen, monitor RR, give meds, devices)

Answer 396

- Type of distributive shock causing fluid shift and vasodilation - result of an immediate Antibody-antigen hypersensitivity reaction (IgE-mediated or non-IgE mediated) - may be Biphasic reaction: symptoms reappear after 1-72 hrs of resolution

Answer 397

- Skin: diaphoresis, pruritus, erythema, angioedema, warmth, urticaria - CNS: apprehension, syncope, doom, restless, low LOC - Respiratory: laryngeal edema (tightness, lump, hoarse, stridor); bronchospasms (wheeze, dyspnea); mucus plug - Circulatory: vasodilation (hypotension, flat JVD, reflex tachycardia) - Muscle: weakness - GI and GU: NVD, cramping, incontinence

Answer 398

Remove or prevent antigen - prevent w/ assessment of allergies & response after med, blood or blood product Reversal effects of inflammatory/immune response - If mild, Epinephrine (first line) via IM q5-15 min w/ 0.2 mg – 0.5 mg (0.3-0.5mL) of a 1:1000 dilution - If severe, epinephrine titrated to maintain BP (0.05-0.1mg (1mL) of a 1:10,000 dilution IV over 5 min OR continuous if persistent hypotension, Promote adequate tissue perfusion - IV fluids (crystalloid or colloid) and rapid Inotropes and vasopressors via large bore IV - Position: legs up, supine, head and shoulder above trunk

Answer 399

- H1 antagonist -Benadryl (Diphenhydramine) via slow IVP to block histamine - H2 antagonist- Pepcid (Famotidine) to reduce histamine release and control cutaneous reactions - Corticosteroids (Methylpredisone) to prevent prolonged or delayed reaction (not used in immediate treatment) - IV glucagon for bronchospasm and hypotension if patient on beta blocker due to limited response to epi - Inhaled beta agonists for bronchospasm unresponsive to epinephrine

Answer 400

- treat cause: pericardiocentesis for cardiac tamponade, tPA for PE, chest tube for tension pneumothorax - Maintain BP: fluids and vasopressors

Final Exam Flashcards

(424 cards)