Med/Surg ATI Final

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Glasgow Coma Scaleoptimum = 15 <8 = severe injury and coma 9-12 = moderate injury >13 = minor injurynormal ICP10-15 mmHgMRIs are safer forpregnant women because no radiationside effects of opioidsconstipation orthostatic hypotension urinary retention nausea/vomiting sedation respiratory depressionmeningitis vaccinesHib - infants pneumococcal polysaccharide vacine - HIV neisseria meningitidis - college kidssx of meningitisexcruciating headache stiff neck photophobia fever chills N/V altered LOC Kernig's sign - extending leg causes pain and resistant Brudzinski's sign - flexion of neck = flexion of extremitiesprecautions for meningitisdroplet - gown gloves mask may need goggles used for many respiratory infectionsprecautions for TBairborne - need n95 mask also used for chicken pox and measlesmeds to give during status epilepticusloading dose of diazepam or lorazepam + continuous IV phenytoinbenzotropinecogentin - anticholinergiccataracts sxdecrease in vision sensitivity to lightsmacular degenerationlose central visionopen angle glaucomalose peripheral visionclosed angle glaucomanausea and severe painretinal detachmentfloating spotsdiphenhydraminebenadrylmiddle ear infection sxassociated with colds, infection redness and inflammation pain drainageinner ear infection sxtinnitus vertigo dizziness problems with balance nystagmus - repetitive uncontrolled eye movementsototoxic drugsgentamicin amikacin metronidazole furosemide ibuprofen aspirin chemosx of inc ICPsevere headache deteriorating LOC pupils - dilated, pinpoint, asymmetrical, nonreactive altered breathing - cheynes stokes decorticate or decerebrate posturing flaccidity CSF leakage - clear fluid from nose/earshalo signyellow stain surrounded by blood on paper towel = CSFCSF tests positive forglucoseCushing reflexlate finding of inc ICP severe HTN wide pulse pressure bradycardiaICP increased byhypercarbia trach suction coughing blowing nose neck flexion or extension restrictive clothing valsalvahow to dec ICPkeep HOB at least 30 degrees maintain O2 sat > 92% maintain PaCO2 35-38 calm environmentsx of brain herniationfixed dilated pupils dec LOC cheynes stokes abnormal posture hemodynamic instabilitythrombolytic strokeclot forms in brainembolytic strokeclot forms in body and travels to brainsx of left side stroke(left side responsible for language, math, analytical thinking) expressive and receptive aphasia agnosia alexia - reading difficulty right hemiplegia slow cautious behavior depression and anger hemianopsia - loss of vision (will prob be right visual field)sx of right side stroke(right side responsible for visual and spatial awareness) overestimate abilities one side neglect - left side loss of depth perception/awareness of surroundings poor impulse control/judgment left hemiplegia left hemianopsiaanticoagulant used after strokeonly use aspirintPA windowwithin 4.5 hours of initial sxspastic neurogenic bladderL1 injury and above condom or indwelling catheterflaccid neurogenic bladderbelow L1 intermittent cath Credes methodbisacodyldulcolaxbaclofenmuscle relaxantdantrolenemuscle relaxantneurogenic shock sxbradycardia hypotension flaccid paralysis loss of reflexes paralytic ileusautonomic dysreflexiaextreme HTN severe headache flushing neck up nasal stuffiness feeling of doom SIT THE PATIENT UPnormal temp in celcius37false low pulse ox reading caused bynail polish inadequate peripheral circulation hypothermia decreased Hgb edema3 parts of chest tube drainage systemdrainage collection water seal suction controlexpected findings in chest tube drainage systemconstant bubbling ONLY in suction chamber tidaling ONLY in water chamberindication when water seal stops tidalinglung re-expansion or obstruction in the systemwhat to do if chest tube pops outapply sterile gauzeneeded in the room of pt with chest tubeO2 sterile water enclosed hemostat clamps occlusive dressingnasal cannulaFiO2 24-44% 1-6 L/minsimple face mask40-60% at least 1-6 L/min (should be at least 5)partial rebreather60-75% 6-11 L/minnonrebreather80-95% 10-15 L/minsx of hypercarbiarestlessness HTN headacheassist control ventilationdoes breathing for clientsynchronized intermittent mandatory ventilationincreases work of breathingpressure support ventilationadds pressure on inspirationPEEPprevent alveoli from collapsingCPAPsame pressure for inhale and exhaleBiPAPdifferent pressures for inhale and exhaleindependent lung ventilationused when pt has disease in one lungrisk of mechanical ventilationincreased thoracic pressure = dec venous return = dec CO/hypotension = RAAS/less urinary outputalbuterolshort acting beta agonist tremors and rapid HRipratropiumlong acting anticholinergic used for asthma dry mouththeophyllinenarrow therapeutic windowsalmeterollong acting beta agonistcor pulmonaleCOPD = inc pulmonary pressure = less blood flow through lungs = back up in right side of heart = enlargement and thinking in R atrium and ventricle = right sided heart failuresx of TBpersistent cough purulent or bloody sputum fatigue anorexia and weight loss night sweatsTB antibioticstake for 6-12 months many cause liver damage - don't drink report jaundice malaise or muscle weakness can cause hearing or vision damagepain meds for pneumo or hemothoraxopioidsbarotraumatrauma to lungs due to PEEPideal cholesterolless than 200HDL35-80LDLless than 130triglycerides40-160cardiac tamponade sxhypotension JVD muffled heart sounds paradoxical pulse - variance of 10mmHg or more in the systolic BP between inspiration and expirationblood sample via PICCtake out 10ml blood and discard use the next 10 ml flush with 10 ml NSphlebitiserythema pain or burning edema warmthinfiltrationswelling edema cool to touchextravasationinfiltration of vesicant that causes tissue deathtreatment of bradycardiapacemakertreatment of a fib or v tach with pulsesynchronized cardioversionv tach w/o pulse or v fibdefibrillationbefore cardioversionanticoagulant for 6 weekspost PCIbedrest and keep leg straightpost CABGmonitor temp - hypothermia monitor BP - hypo = collapse but hyper = rupture monitor electrolytes esp K+ monitor renal fxn monitor for signs of hemorrhagepotassium supplementsmust be diluted and admin slowlyangina sxprecipitated by stress relieved by rest or nitro sx < 15 min ST depressionMI sxoccur w/o stress relieved only by opioids sx > 30 min nausea, epigastric distress, dyspnea, anxiety, sweating ST elevation abnormal Q waveMI enzymesmyoglobin - 24 hrs CK-MB - 3 days troponin I - 7 days troponin - T 2-3 weeksMI thrombolyticsstreptokinase and alteplaseR side heart failureperipheral edema fatigue ascites liver enlargement anorexia JVDL side heart failuredyspnea bc back up in lungs organ failurenifedipineCCBdiltiazemCCBamlodipineCCBpulmonary edema sxpersistent cough with frothy pink sputum tachypnea orthopneadentist and valve disorderprophylactic antibioticsPAD sxintermittent claudication (pain with activity) dec pedal pulse loss of hair on lower extremity cold feet pallor rubor ulcers/gangrenetreatment of PADavoid cold dont wear restrictive clothingPVD sxbrown discoloration ankle ulcers distended superficial veins (vericose)treatment of PVDcompression socks elevate legsvirchow's triadhypercoagulability impaired blood flow damage to blood vesselsclopodigrelantiplatelet not anticoagulant so don't be as concerned about cuts/bleedingDIC with shockthousands of small clotshyponatremia sxhypothermia tachycardia thready pulse hypotension confused weak seizurehypernatremia sxrestless hyperthermia irritable muscle twitchinghypokalemia sxparasthesia confusion ST depression muscle cramps hypotensionhyperkalemia sxrestless irritable v fib peaked T wave widened QRSkayexalatesodium polystyrene sulfonatehypocalcemia sxparasthesia tetany hyperactive DTR chvosteks trousseauspallor meanspalebefore fecal occult testdont eat red meat dont take anticoagulantshow to prevent dumping syndromedecrease fluid intake low carb dietileostomy stoolconstant and liquidcolostomy stoolformed and follows normal bowel patternaluminum hydroxideantacid dont take other meds 1 hour before or aftergastric ulcer sx30-60 min after meal rarely occurs at night pain exacerbated by ingestion of foodduodenal ulcer sx1.5 to 3 hours after meal often occurs at night pain may be relieved by ingestion of food or antacidbowel perforation sxsevere epigastric pain abdomen is rigid and board like rebound tenderness **this is a surgical emergencycomplication of peptic ulcer/gastritis/bowel disordersgastric mucosa cannot properly produce intrinsic factor anymore which is necessary for B12 absorption. This causes pernicious anemiaindications of gastric bleedingcoffee ground emesis black tarry stoolsvagotomysevers nerve fibers that control gastric acid secretiontreatment of IBSavoid dairy eggs and wheat avoid alcohol and caffeine drink 2-3 L water/day high fiberdiet for ulcerative colitis and crohnshigh protein high calorie LOW FIBER avoid caffeine and alcohol small frequent mealsdiet for post-diverticulitishigh fiber low fat avoid seeds/indigestable food avoid alcoholperitonitis sxrigid board-like abdomen nausea and vomiting rebound tenderness tachycardia feverdiet for gallstoneslow fat avoid gas forming foodliver biopsy procedurelie on left side so right side is exposed then after it is over lay on the right side to dec bleedingcirrhosis diethigh carb high calorie low/moderate fat low protein if nitrogen is a concern high protein if not bc of malnutrition low sodiumasterixisflapping of hands, indicates hepatoencephalopathychecking AV fistulacheck for bruit and thrillreverse heparin ODprotamine sulfatedisequilbrium syndromeAV hemodialysis goes to fast and causes edema in the brainhyperlipidemia with peritoneal dialysisglucose gets into blood so there is always higher levels of glucose = insulin release = insulin resistance = hyperlipidemiacause of glomerulonephritisbeta-hemolytic streptococcal infectionsx of glomerulonephritishematuria - smoky or coffee colored urine dec urine output proteinuria pitting edema in lower extremitiesstages of AKIoliguria diuresis recoverydiet with kidney diseasehigh protein to replace the high rate of protein breakdown due to stress from illness restrict K+ during oliguria low phosphate and magnesium during oliguriaurine test confirming UTIpositive for leukocyte esterasesx of renal calculisevere pain hematuria - smokycalcium phoshate stone diet and medlimit animal protein and Na+ thiazides inc Ca2+ absorptioncalcium oxalate stone dietavoid oxalate sources: spinach black tea cocoa nutsviral skin testTzanckfungal skin testKOHbacterial skin testWood's light3 phases of burn careemergent - fluid resuscitation (first 24-48 hrs) acute - begins when fluid resuscitation is over and ends when the wound is covered by tissue rehabsuperficial burnepidermis pink and red sunburnsuperficial partial thicknessepidermis and part of dermis pink/red with blisters flame or scalddeep partial thicknessentire epidermis and dermis red to white edema exposure to hot object for a long time - tarfull thicknessextends into subcutaneous tissue not painful tan brown black white severe edema hot object for long timedeep full thicknessextend to muscle tendon bone black no edema chemical burnsinitial fluid shiftfluid shifts into interstitial HCT and Hbg inc sodium dec due to third spacing potassium inc due to cell destructionfluid mobilization phasefluid shifts back into vasculature HCT and Hgb dec sodium stays low potassium decfluid resuscitationNS or lactated ringers first 24 hours then colloid solnburn diet5000 calories per day high proteindiabetes insipidusdilute polyuria ADH deficiency - can't keep water in body water deprivation test urine osmo < 300 serum osmo > 300SIADHexcessive ADH small amounts of concentrated urine serum osmo < 270 such hemodilution is dangerous and requires fluid restrictiondexamethasone testwhen dexamethasone is given to Cushings patient there is not change in ACTH or cortisolnormal specific gravity1.010 - 1.025clonidine suppression testif pt has pheochromocytoma clonidine will not suppress release of epi, NE, or DACPM from SIADHmyelin sheath is destroyed from fluctuation in Na+ant. pituitary releasesTSHthyroid releasesT3 and T4 calcitonin - inhibits mobilization of calcium from bone = hypocalcemiaparathyroid releasesPTH = Ca2+ mobilization from bone = hypercalcemiahyperthyroidism sxnervous irritable diarrhea heat intolerance weight loss insomnia warm and sweaty tremors exophthalmos hair loss goiter bruit over thyroid glandthyroid storm/crisissudden large amounts of thyroid hormones released hyperthermia hypertension delirium vomiting abdominal pain hyperglycemia tachycardiasx of hypothyroidismfatigue cold intolerance constipation weight gain pale skin depression thinning hair joint/muscle pain swelling in face hands and feetlevothyroxine drug interactionsinc warfarin effects dec digoxin effectsmyxedemauntreated hypothyroidism life threatening dec RR dec CO dec HR hyponatremia hypothermia comaurine test for DMglucose and ketones in urinerapid acting insulinlispro aspart glulisine administer right before mealshort acting insulinregular insulin 30-60 min before mealintermediate acting insulinNPH or detemir NPH + regular = only acceptable combo draw up regular firstlong acting insulinglargine once daily at the same timewhat to do for hypoglycemia (<70)4-6 oz of fruit juice 15-20g sugar tabs 8-10 hard candies 1 Tbsp honey in unconscious admin glucagon or 50% then when they wake up give oral carbs1 carb exchange =15g carbswhen DM pt is sicktake blood glucose every 3-4 hr continue taking insulin and DM meds 4oz liquid per 30 min test urine for ketones call MD if glucose > 240DKA causesany form of physical or emotional stressHHS causesmedical condition such as MI older adults infection stressDKAblood glucose > 300 the 3 poly's mental status change blurred vision and headache ketogenesis occurs which causes: weight loss fruity breath Kussmauls metabolic acidosisHHSglucose > 600 polyuria and polydipsia mental status change blurred vision and headache seizures reversible paralysis the body is producing low levels of insulin so ketogenesis is not occurring but there is still no control over blood glucose levelstreating DKA and HHSprovide rapid isotonic soln (NS) follow with hypotonic fluid to inc fluid volume and maintain organ perfusion when serum glucose levels reach 250 add glucose to soln to dec risk of cerebral edema IV regular insulin