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NCLEX preparation

QuestionAnswer
protein restricted diet renal disease, liver disease. Limit milk, meat, bread & starch.
Renal Diet Control amounts of protein, sodium, phos, calcium, potassium & fluids.
Low purine diet for gout, kidney stones. Limit fish, graviews, glandular meat, game.
Low residue/low fiber diverticulitis, colitis. Pokey whisk broom would damage the colon wall
microdrip factor 60 gtt/min
s/sx immediate blood transfusion rxn chills, diaphoresis, flank pain, rash, hives, itching, swelling, dyspnea, cyanosis, apprehension, tingling, numbness, headache.
s/sx delayed blood transfusion rxn fever, jaundice, decreased hct
s/sx transfusion rxn in an unconscious pt fever, tachy/bradycardia, hypotension, oliguria/anuria, weak pulse
How long to stay w/ pt during blood transfusion First 15 minutes of infusion.
transfusion rxn labs Elevated eosinophils, bilirubin, potassium
After transfusion rxn, risk for renal failure
blood transfusion through small gague cath (ie 24) RBCs hemolyse & potassium leaks out. Watch for ST elevation
Blood transfusion tubing in line filter, 18 or 19 GA filter
If a rxn occurs Stop the infusion. Change tubing & run saline @ TKO. Notify physician & blood bank. Return blood bag & tubing to the blood bank. Do not leave client alone. Monitor for life-threatening s/sx. vs q5 min. sLabs, blood & urine.
Droplet precautions Flu, meningitis, mumps, pneumonia, sepsis, sptrep. Mask.
Contact precautions multidrug resistant organism. C. diff, RSV, H1N1, staph, pink eye. gloves, gown
Transmission based precautions (airborne, droplet & contact) TB, varicella, measles. Neg pressure room. mask.
Wound dehisence separation of wound edges
Wound evisceration protrusion of internal organs. Stay w/ client. Have dr notified & supplies brought to the room. Pt in low fowlers w/ knees bent. Moist sterile dressing saturated w/ NS. Take VS & monitor for shock.
IS sit upright, mouth tighlyt around mouthpice, inhale slowly (between 600 - 900) hold breath for 5 sec, then exhale through pursed lips. 10x q h.
Trach If ET is required for 14+ days
Water Seal Chamber (chest tube drainage box) water moves up as client inhales & down with exhalation. Excessive bubbling indicates air leak.
Suction control chamber (chest tube drainage box) gentle bubbling is indicative of suction. Not a leak
Chest tube excessive bleeding >70-100 mL/hr. Also notify if drastic increase or bright red.
Lack of fluctuation in water seal chamber look for tube occlusion or dependent loop. Also may mean suction is not working properly. Or it may mean that the lung has reexpanded.
intermittent bubbling in the water seal chamber is expected intermittently with a pneumothorax because air is being drained from the pleural cavity.
continuous bubbling in the water seal chamber indicates air leak. Notify physician.
insertion site dressing occlusive dressing
keep at bedside at all times: clamp, sterile occlusive dressing & bottle of sterile water
If box of chest tube drainage system breaks insert end of tube into sterile water bottle
If tube comes out of patient pinch skin opening together & apply an occlusive sterile dressing, coer with overlapping pieces of 2" tape & call MD immediately.
linea nigra dark streak down the midline of abd r/t increased levels of melanocyte stim hormone
striae reddish purple stretch marks r/t increased levels of melanocyte stim hormone
Rhogam Given to Rh negative mothers at 28 weeks gestation
Rubella titer give postpartum if labs reveal a negative titer.
Normal Hbg when pregnant 10 or higher
Normal Hct when pregnant 30% or higher
Hep B vaccine can be given during pregnancy & is indicated for high risk populations
Proteinuria in pregnancy 2+ to 4+ may indicate infection or preeclampsia
Glycosuria may indicate diabetes but is also a common result of decreased renal threshold
Biophysical profile Noninvasive assessment of fetal movements & HR. "nonstress test"
Amniocentesis Best between 15 - 20 wks gestation. Looks for genetic disorders. Can be done later to evaluate lung maturity. Informed consent (invasive). u/s done to eval location of placenta. VS q 15. Supine during exam & left lateral post-op
Nonstress test evaluate FHR response to fetal movement.
Healthy Nonstress test result (reactive) 2+ FHR accelerations of at least 15 BPM lasting at least 15 seconds in assoc w/ fetal movement.
Contraction stress test oxytocin stim contractions. No late decels are desirable.
Threatened abortion bleeding & cramping without cervical change
Anemia assessment fatigue, headache, pallor, tachycardia, Hgb <10 Hct <30%
Chorioamnionitis Bacterial infection of the amniotic cavity from PROM, amniocentesis, vaginitis
Gest Diabetes effect on baby excess glucose crosses the placenta and baby makes extra insulin. Risk for hypoglycemia post-delivery. May be large in size.
DIC in pregnancy Rapid extensive formation of clots, resulting in bleeding & vascular occlusion. Tx underlying cause. Massage the uterus to avoid hemorrhage.
Ectopic Pregnancy Methotrexate may be given to prevent cell division. Monitor for bleeding.
Fetal death in utero can develop DIC in 3-4 weeks.
Hep B prevention in a newborn Infection of the baby is prevented by admin Hep B vaccine after birth.
Hematoma w/ delivery escape of blood into the maternal tissue postpartum. High risk with forcep delivery or injury to a blood vesel.
HIV in mother promptly remove maternal & suction blood ASAP after delivery. Give zidovudine as prescribed to mom during labor and delivery to prevent HIV transmission.
Hyperemesis Gravidarum nausea that lasts beyond the first trimester. Increased HCG. Multiple fetuses?
Hydatiform mole peripheral cells that attach to the fertilized ovum to the uterine wall develop abnormally. May become cancerous. Elevated HCG. larger than normal uterus. Avoid pregnancy for 1 year.
Gestational HTN complications abruptio placentae, DIC, thrombocytopenia, placental insufficiency, intrauterine growth restriction, fetal death
Gestational HTN interventions Monitor fetal growth, Mom's BP, encourage rest in lateral position, antihypertensive meds, minitor I&O, eval renal function
Interventions for mild preeclampsia L side lying bedrest, monitor I & O, Increase pro & carb intake, no added salt.
Interventions for severe preeclampsia admin mag sulfate, monitor for s/sx mag toxicity
Mag toxicity s/sx flushing, sweating, hypotension, depressed dtrs, CNS depression.
Mag antidote Calcium gluconate
Eclampsia seizures usually beginning with twitching around the mouth, then tonic 15-20 sec, then clonic for 1 min. Postictal sleep.
Incompetent cervix interventions band of nonabsorbable ribbon is placed around the cervix beneath the mucosa to constrict the internal os = "cervical cerclage". No intercourse, no heavy lifting, no prolonged standing
toxoplasmosis protozoan parasyte produces rash & flu-like infection from kitty litter/ raw meat. May result in spontaneous abortion.
Variable decel (VEAL CHOP) Cord Compression (wave form is not uniform in appearance)
Early decel (VEAL CHOP) Head compression
Accelerations (VEAL CHOP) OK/ WNL
Late Decels (VEAL CHOP) Placental insufficiency
Normal FHR @ term 120-160
Latent phase (stage 1 of Labor) 1-4 cm. ctx q15-30 min, 15-30 sec in duration & mild.
Active phase (stage 1 of Labor) 4-7 cm. ctx q 3-5 min, 30-60 sec in duration. Moderate intensity. Keep couple informed of progress.
Transition Phase (stage 1 of Labor) 8-10 cm. ctx q 2-3 min & are 45-90 sec in duration. strong intensity.
Stage 2 of labor Expulsion of fetus. Progress of labor is measured by descent of fetal head through birth canal.
Stage 3 of labor Separation of Placenta. 5-30 minutes after birth.
Schultze mechanism (placental detachment during labor) Most desirable way. center portion of the placental separates first and its shiny fetal surface emerges from the vagina.
Duncan mechanism (placental detachment during labor) "DIRTY DUNCAN" least desirable. Margin of he placental separates and the dull, red, rough maternal surface emerges from the vagina first. Roughness creates difficulty.
Stage 4 of labor 1-4 hrs postpartum. Fundus remains contracted, in midline & 1-2 finger widths below umbilicus. Massage uterus if needed. Breastfeeding support.
Initial Postpartum VS q15 min for 1 hr. q 30 min for 1 hr. hourly for 2 hours.
Episiotomy Ice packs first 24 hours, sitz baths, blot to dry instead of wipe.
C-section Post-op Turn, cough, deep breathe, encourage ambulation, monitor for endometritis (foul smelling lochia)
Abruptio placentae s/sx DARK RED vaginal bleeding uterine rigidity & pain. fetal distress (HR down), signs of maternal shock if bleeding is excessive. Risk of DIC.
Abruptio placentae s/sx interventions Admin fluid, blood products, as prescribed. O2 & Bedrest. L lateral lying if hypovolemic shock. Trendelenberg if indicated to get baby off the placenta.
Placenta previa painless, bright red vaginal bleeding. Uterus is soft, relaxed, and nontender.
Dystocia difficult labor that is prolonged or more painful.
Fetal distress FHR < 120 or >160, Meconium stained amntiotic fluid. Hyperactivity of fetus.Admin O2, stop oxytocin, lateral position.
Bladder distention displaces & prevents contraction of the uterus
Breastfeeding caloric increase 200-500 cal/day & additional fluids
Subinvolution Dirty Duncan placental delivery. Uterus fails to return to its normal size/ condition. Methergine provides sustained ctx of uterus.
A (APGAR) Apical Pulse - HR should be 120-160
P (APGAR) Pulmonary system- good vigorous cry
G (APGAR) Gym - Muscle tone
A (APGAR) Agitation - Responds with cry or active movement
R (APGAR) Redness - Body & extremity skin color normal/ Pink
APGAR 4-7 Gently stimulate. Rub back, admin O2
APGAR 0-3 Newborn requires resuscitation
Anterior fontanel closes Between 12 & 18 months of age
Norma/ Physiologic Jaundice begins when? After the first 24 hours. This is when baby's liver is responsible for the processing of RBCS. If Jaundice occurs before the first 24 hours, it is likely related to Mom's RH incompatibility.
Vit K Admin IM 0.5-1mg in vastus lateralus to prevent bleeding (liver= clotting factors)
Erythromycin ointment opthalmic insitillation to prevent bacterial eye infections.
Remove umbilical clamp After 24 hours. Keep clean & dry. Seap & water only.
Circ care Petroleum jelly gauze expcet for plastibell. Replace dressing when soaked. Milky covering over glans is expected.
Thermoregulation no brown fat deposits which produce heat. Can not shiver. Keep well wrapped. Bathe in a warm environment (isolette)
kernicterus bili crosses blood brain barrior resulting in permanent neuro damage.
Hyperbilirubinemia interventions Early, frequent feedings, keep baby well hydrated. Phototherapy.
Phototherapy cover eyes & genital area. Leave everything else exposed. Expect green stool & urine. Reposition q2h. Remove eye covers q shift.
Erythroblastosis fetalis Hemolytic anemia due to antibody-antigen rxn. Jaundice that develops before 24 hrs. Edema. Admin Rhogam to mom to prevent in next child. Exchange transfusion.
Sepsis (which leads to DIC) Pallor, tachypnea, tachycardia, poor feeding, abd distention, unstable temp.
ADHD meds stimulants. will suppress appetite, cause weight loss, nervousness, tics, insomnia and increased BP.
cerebral palsy Impaired movement & abmonaml posturing (spisthonos). extreme irritability & crying, feeding difficulties, stiff/rigid arms & legs, delayed dev. milestones.
decerebrate extension: separation of arms & legs outward
decorticate flexion: "core" pulling arms & legs inwards.
ventriculoperitoneal shunt ventricle to peritoneum CSF drainage. Extra tubing can coil in peritoneum.
ventriculoatrial shunt CSF drains into the R atria
Reye's Syndrome Encephalopathy from flu/ varicella that results in cerebral edema and fatty changes in the liver
Spina Bifida Occulta Not visible. No neuro deficits. Vertebral arches fail to close in the lumbosacral area
Spina Bifida Cystica Protrusion of the spinal cord, its meninges, or both. Incomplete closure of vertebral and neural tubes resulting in sac-like protrusion in the lumbar or sacral area with varying degrees of nervous tissue involvement.
meningocele protrusion of meninges and sac-like cyst containing csf in mdline of lumbosacral. Usually no neuro involvement.
myelomeningocele protrusion of the meninges, CSF, nerve roots and a portion fo the spinal cord. Nero involvement.
strabismus tx patch the good eye to strengthen the weak eye
direction to pull the ear in an adult up
direction to pull the ear in a child down
Epistaxis (nosebleed) sit up, lean forward, apply continuous pressure for at least 10 minutes.
Persistent epistaxis If 10 min of pressure ineffective, pack nostrils with cotton or wadded tissue and ice the bridge of the nose.
epiglotititis r/t lack of HIB vaccine. presents w/ drooling, tripod positioning. Do not place anything in the mouth (no culture, no oral temp, to visualization of the pharynx) may cause spasm.
Bronchiolitis / RSV inflammation of bronchioles. Mucus production. Avoid cough suppresants. Interferes w/ airway clearance.
Cystic Fibrosis characteristics Very thick, tenacious secretions obstruct resp, GI, and reproductive systems. pancreatic enzyme deficiency, progressive lung disease, sweat gland dysfunction resulting in increased salt & chloride in sweat.Frothy, foul stool.Delayed puberty & infertility
Cystic Fibrosis dx + sweat chloride test, mec ileus/ intestinal obstruction.
SIDS death, under 1, unknown cause. Place infant supine to sleep.
SIDS risk factors 2nd hand smoke, prenatal substance abuse, overheating, extra stuff in crib.
plagiocephaly flattening of one spot of the head. Alter head position when laying baby to sleep
Atrial septal defect oxygenated blood flows from L atria back into the R atria. Atrium enlarge. Decreased CO. Surgery
Atrioventricular canal defect. r/t downs. murmur present. Mild to mod CHF, cyanosis w/ crying. Decreased CO Surgery
Patent ductus arteriosus does not close as it should within the first few weeks of life. machinery-like murmur w/ bounding pulses. May give Indocin (prostaglandin) to facilitate closure, or surgery may be needed.
Ventricular septal defect Opening in ventricular septum. murmur. Most close within first year.CHF present. Decreased CO. May need suregery.
Pulm Stenosis cyanosis, CHF, Decreased CO, cath lab to dilate the narrowed valve.
Tetralogy of Fallot VSD, pulm stenosis, overriding aorta and R vent hypertrophy. Palliative shunt to increase pulm blood flow. Or complete surgical repair.
s/sx tetralogy of Fallot "tet spells" (aka blue spells) of cyanosis during crying, feeding or defacating. Poor growth, clubbing, squatting.
Esophageal atresia / tracheoesophageal fistula esophagus terminates does not connect with stomach properly & may connect with trachea.
s/sx esophageal atresia / tracheoesophageal fistula the 3 c's coughing, choking, cyanois. regurgitation & vomiting.
Hypertrophic pyloric stenosis narrowing of the pyloric sphincter area, the connection between the stomach & the duodenum.
Celiac disease Intolerance to gluten (from wheat, baarley, rye, and oats.
Hirschprung's disease paralysis of a portion of the colon (usually rectal colon) Colon becomes distended & filled with stool. Ostomy or anastamosis is needed.
Intussusception telescoping of the colon within itself. May reduce itself. Dr. may order NG for decompression, fluids fever, LOC changes, BP/ HR changes and resp distress. Dr may need to perform hydrostatic reduction. SURGICAL EMERGENCY.
Omphalocele abdominal contents protrude through umbilical ring, usually w/ intact peritoneal sac. Cover w/ sterile NS gauze & plastic-wrap like dressing. NPO prep for surgery.
Encorporesis constipation w/ fecal incontinence. Due to enlarged rectum cause by chronic constipation
Constipation monitor for hypernatremia, hyperphosphatemia w/ mult enemas. Decrease sugar/ milk intake.
hypernatremia thirst, dry, sticky mucous membranes. flushed skin, fever, n/v, oliguria, lethargy
hyperphospatemia tetany, weakness, dysrhythmias, hypotension
IBS irritation resulting in increased motility. self-limiting. Poss r/t stress.
Imperforate anus. Anal atresia membrane covering opening or rectum does not meet up with rest of colon. surgery required. Post-op position side lying with hips elevated.
Poison Ingestion Assess the child. Treat child first (ABCs) not the poison. Terminate exposure to the poison (empty mouth, flush skin), ID the poison, prevent absorption of poison, Document.
Acetaminophen OD first 2-4h malaise, N/V, sweat, pallor, weakness. 24-36h: improves. Hepatic involvement for 7 days. May be perm. Give mucomyst in juce or soda (smells horrible)
Giardiasis (intestinal parasite) daycare centers. anti parasytes: flagyl (metronidazole) or other "zole" meds. wash hands.
Pinworms (intestinal parasite) common & easily transmitted. Perianal itching. tape test. Inspect anus & perform tape test while child is asleep. Loop of transparent tape against the anus overnight& given to the dr.-"zole" meds. MR meds in 2 weeks. all family tx'ed. wash hands
Phenylketonuria (PKU Heel prick. If +, repeat test & further diagnostic eval needed to verify. Restrict phenylalanine intake (restrict protein & aspartame)
Strep throat heart = rheumatic fever kidney = glomerulonephritis skin = scarlet fever
chrypotorchidism tx HCG for an older child
bladder exstrophy (bladder outside) extrusion of bladder through the abdominal wall. Bladder in transparent sac. Monitor renal function. Cover with sterile plastic wrap type dressing to prevent drying out & allow for drainage.
Impetigo contagious strep skin infection
Pediculosis capitis (lice) 7-10 days incubation period. Can survive 48 hrs away from host. nits can hatch in 7-10 days x contamination is still posssible in 10 days.
Pediculocide does not kill nits. Extra fine tooth metal nit comb must be used to remove. gloves worn. discard brushes (boil in water for 10 min.)
Scabies parasitic skin disorder caused by an infestation of saracoptes scabiei. Elimite, Kwell or Lindane rx. Do not use Kwell/ lindane under 2 y.o.
hip dysplasia uneven legs & uneven folds on legs
scoliosis one shoulder up, one down. One hip up, one down. brace worn 16-23 hrs/day.
Sicle Cell predisposing factors Heterozygous for Hgb S, African-american descent.
Sickle Cell Crisis causing factors poor hydration, poor oxygenation result in sickling of the RBCs. RBCs clump & occlude capillaries, hemolysis & anemia may ensue. Cell shape may be perm if sickling occurs mult times.
Tx Sickle Cell crisis O2, fluids, blood transfusion, round the clock pain meds, high cal/pro diet, folic acid supplements, abx as prescribed.
Sickle Cell exacerbation positioning keep extremities extended, elevate HOB no more than 30 degrees, do not elevate legs.
Iron Deficiency anemia Iron stores depleted, which is required for RBC production. Due to blood loss, metabolic demands, GI malabsorption, dietary insufficiency.
Aplastic Anemia deficiency of circulating erythrocytes r/t arrested production in bone marrow. Dx w/ bone marrow asp.
Hemophelia Bleeding disorder. identify coag deficiency so tx w/ specific replacement can be implemented.
Hemophelia predisposing factor X linked mom to baby. Boys get the disease, girls are carriers. May also be a gene mutation.
Types of Hemophilia Hemophilia A (Factor VIII) Hemophilia B (Factor IX)
Hemophilia tx Monitor for bleeding, bleeding precautions, admin replacement factors, DDAVP (synth vasopressin)
VonWillebrand's Disease Factor VII. Heredetary bleeding disorder
Beta-Thalassemia (Anemia) reduced production of the globin chains in Hgb. Both parents must be carriers. Mediteraneans, italians, greeks, syrians. Goal to maintain Hgb levels. Bone marrow transplant. Splenectomy if splenomegaly present.
Hodgkins Disease mallignancy of the lymph nodes. Linear lymph nodes, predictable pattern.
Rubeola (measles) rash, runny eyes, cough. Rash is red, maculopapular starting at face & working down to feet. Red spots w/ blue-white center & red base in buccal mucosa
Mumps fever, headache, anorexia, jaw/ear pain, orchitis. airborne droplet precautions.
Chicken pox macular rash that appears on trunk & scalp moving to face & extremities. contact & droplet precautions.
pertussis increased severity of cough w/ loud whooping inspiration.
diphtheria low-grade, fever, malaise, sore throat. Foul, mucopurulent nasal discharge. admin diphtheria antitoxin, abx.
poliomyelitis fever, malaise, anorexia, nausea, headache, sore throat, abd pain, sore/stiff trunk/neck/limbs. Poss progression to CNS & paralysis.
Scarlet Fever Nasopharyngeal secretions of infected persons/carriers.white strawverry tongue, red strawberry tongue. Flushed cheeks. Sandpaper-like rash that starts in groin, armpits & neck. Malaise, abd pain. sloughing of skin on palms & soles.
Erythema Infectiousum (5th disease) Erythema slapped cheek appearance. maculopapular rash appears, symmetrically distributed on extremities prox to distal.
Mono epstein-barr virus. Lymphadenopathy & hepatosplenomegaly. Monitor for s/sx of splenic rupture.abd pain, LUQ pain,& L shoulder pain.
Rocky mountain spotted fever tick bite. Fever, malaise, anorexia, vomiting, headache, myalgia.
MRSA community acquired cover wounds. High risk: daycares, prisons, athletes, military, IV drug users. May cause sepasis, cellulitis, endocardigtis, TSS,
Vaccine guidelines IM: 1" 23-25 GA Vastus Lateralis or deltoid; SQ 5/8" 25 GA lateral upper arms/ ant thighs. Side effects: fever, soreness, swelling,localized redness. Cool compresses for first 24 hrs, then warm after that.
vaccine adverse rxn file report w/ health dept.
Immunization record day/month/year/manufacturer & lot #. Name, address, title of person administering the vaccine, site & route of admin.
Hep B vaccine Birth, 1 mo, 6 mo
Vaccine group for 2,4,6 mo DTap, Hib, IPV, PCV, RV
12 mo vaccines MMR, Hep A, Varicella, and Hib
Guardasil vaccine Given @ 12 yrs old
Herpes Zoster (shingles) reactivation of varicella-zoster virus (chickenpox) dormant in the dorsal nerve root ganglion . Eruptions occur in segments on the skin along the infected nerve after several days of discomfort.
dx of herpes zoster (shingles) Tzanck smear & viral culture. Increased Lymphocytes
L/t effects of shingles postherpetic neuralgia remains after lesions resolve.
Herpes simplex 1 cold sores
Herpes simplex 2 STD
Herpes zoster contagious to those that have never had the chicken pox or the vaccine
Herpes zoster s/sx unilateraly clustered skin vesicles (blisters) along the nerve track (trunk, thorax or face), burning/pain, pruritis (itching), fecer, malaise, parasthesia.
Vaccination for shingles recommended adults 60+
Tx for shingles Antivirals acyclovir, or other -"cyclovir" meds.
Poison Ivy dermatitis. Papulovesicular lesions (bumps & Blister)
Frostbite rewarm rapidly. Rewarming may be painful. do not massage or use dry heat - may damage tissue.
Psoriasis chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches. Itching, silvery, white scales on raised, reddened round plaquest. Usually on scalp, knees, elbows. Yellowing nails w/ thickening & pitting.
Psoriasis tx Retin A Aspirin cream, methyltrexate. Avoid OTC meds. Do not scratch. Keep skin lubricated. Light cotton clothing. Reduce stress (causes flare-ups)
Pressure ulcer skin & tissue compressed between bony prominence & external surface resulting in ischemia, inflammation & necrosis. Difficult to heal.
Stage I pressure ulcer skin intact. red. does not blanch.
Stage II pressure ulcer skin not intact. partial thickness loss of dermis. shallow open ulcer w/ red-pink wound bed or as intact or open ruptured serum filled blister
Stage III pressure ulcer full thickness skin loss extends into dermis & subq tissue. Poss undermining/ tunneling
Stage IV pressure ulcer Full thickness skin loss w/ bone tendon or muscle exposure
Superficial thickness burn (pretend the word thickness isn't even there!) injury to the epidermis. Blood supply still intact. mild to severe erythema. no blisters. skin blanches. burn is painful & eased w/ cooling.
superficial partial thickness burn injury deeper into the dermis. blood supply reduced. Large blisters & edema. mottled pink to red base. broken epidermis. wet,shiny,weeping. Painful & sens to cold air.
Deep partial thickness burn deep into skin dermis. no blister. dead tissue is thick. wound surface is red & dry w/ white areas. may not blanch. moderate edema.
full thickness burn. destruction of the epidermis & dermis. grafting may be required. dry/hard/leathery eschar. edema under eschar. sensation reduced/absent. removal of eschar required for healing.
Deep full thickness burn burn extends beyond skin into underlying fascia and tissue. no sensation. Grafts required.
Thermal burns exposure to hot things/steam/flame
Chemical burns strong acids, alkalis, or organic compounds
Electrical burn heat caused by electrical energy as it paasses through the body. Internal tissue damage. Identify type of current, contact site & duration of contact. AC is more dangerous than DC b/c can cause vfib and long bone/ vertebral fx.
Smoke inhalation injury/ Carbon monoxide poisoning colorless,odorless,tasteless gas that has an affinity for hgb 200x greater than oxygen.
Graft: amniotic membrane change q 48h. allows epithelialization but does not become vascular
allograft/ homograft cadaver skin rejection can occur within 24h
xenograft/ heterograft animal tissue (pig) replace q 2-5 days. no muslim or jewish culture.
Cultured skin graft grown in lab from sm. specimen of peidermal cells from an unburned part of the patient's body.
Psoriasis tx Retin A, coal tar & phototherapy (UV irradiation)
Acne meds benzoyl peroxide, doxycycline, erythromycin, tetracycline
Burn meds silver sulfadiazine. Broad spectrum of activity against gr -, gr + and yeast. Released slowly from the cream. Prevent sepsis in burn pts. apply 1/16" film. keep burn covered at all times. may cause leukopenia and interstitial nephritis.
Stage 1 lymphoma neck
stage 2 lymphoma axilla
Stage 3 lymphoma trunk
stage 4 lymphoma groin
carcinogens chem: tobacco, drugs, industrial chemicals. phys: ionizing rad, UV rad, chron irriritation, tissue trauma viruses: oncoviruses ie: epstein barr, Hep B, HPV. H.Pylori infection = gastric cancer
Cancer Grade I "definitely a breast cell" easy to differentiate. mild dysplasia. well differentiated.
Cancer Grade II "looks like a breast cell" moderate dysplasia mod. differentiated
Cancer Grade III "Might be a breast cell" severe dysplasia. poorly differentiated.
Cancer Grade IV "what kind of cell is that?" severe dysplasia. Undifferentiated.
Grading vs staging Grading determines the extent of cellular change. Staging determines how far the cancer has spread
Cancer Stage 0 In situ. "pre-cancer"
Cancer Stage 1 Limited to tissue of origin
Cancer stage 2 Limited local spread
Cancer stage 3 Extensive local and regional spread
Cancer stage 4 Distant metastasis
Prophylactic surgery removal of tissue at risk
curative surgery all gross & microscopic tumor is removed or destroyed
control surgery debulking procedure. decreases the number of cancer cells and increases the liklihood that other methods (chemo, rad) will work.
Palliative surgery to improve quality of life (pain control)
Reconstructive surgery improve quality of life. restores appearance or function
Chemotherapy kills/inhibits reproduction of neoplastic cells & kills normal cells. Side effects: fatigue, alopecia, N/V, mucositis, skin change, myelosuppression (neutropenia, anemia and thrombocytopenia)
Gout secondary to cancer chemo = cellular distruction & release of DNA which breaks down into ammonia.
Radiation therapy destroys cancer cells w/ minimal exposure of normal cells.
external beam radiation (teletherapy) rad source is external. skin self care: mild soap/water/hand (no washcloth)avoid sun/heat/pressure/rubbing. pat to dry.
Brachytherapy Inside the patient.Client emits radiation and can pose a hazard to others.
Unsealed rad source Oral/IV/instillation into body cavity. Pt is radioactive for 48hrs.
Sealed rad source Rad implant placed in tumor. Client emits rad, but excreta are not radioactive. No sex for 7-10 days for female if cervical/ vaginal.
leukemia overproduction of leukocytes (WBCs). Decreased RBCs, WBCs, and immature WBCs. Anemia, Overt bleeding, risk for infection. .
hodgkins lymphoma malignancy of the lymph nodes that orginates in a signle lymph node or chain of nodes. Follows a path. Predictable. Easier to tx than non-hodgkins lymphoma
non hodgkins lymphoma malignancy of the lymph nodes that does not follow a predictable path.
multiple myeloma bone marrow is "marshmallow mush" no RBC, WBC or platelets being produced in the marrow. Abnomral plasma cells produce abnormal antibody The myeloma protein or the "bence-jones" protein. Decresed immunoglobulin and antibodies.
Multiple myeloma labs urinalysis: bence Jones proteinuria, osteoporosis, elevated calcium, elevated uric acid levels.
Multiple myeloma risk for Risk for renal failure, spinak cord compression/fx/paralysis.
Cervical cancer risk factors HPV, smoking, promiscuity
Prevention of cervical cancer Pap smears, guardasil x 3 series of injections at age 11-12
S/sx cervical cancer painless vaginal postmenstrual and postcoital bleeding. fould smelling or serosang vag discharge, anorexia/weight loss, fisutla symptoms, pelvic/back/leg/groin pain.
Cryosurgery freezing tissue w/ probe. no sex while watery discharge occurs (which will be several weeks)
Conization. cone shaped area of the cervix is removed.
Pelvic exenteration removal of alll pelvic contents: bowel, vagina, bladder. recurrent cancer if no evidence of tumor outside the pelvis.
exenteration post-op no strenuous activity for up to 6 months. perineal opening may drain for several months. ileal conduit & colostomy care teaching.
Ovarian cancer asymptomatic, exploratory laparotomy. Elevated tumor marker CA-125.
tx ovarian cancer external rad if invaded other organs. Intraperitoneal radioisotopes for stage I. chemo for most stages. Intraperitoneal chemotherapy . hysterechtomy & bilat salpingo-oophorectomy w/ debulking.
Breast cancer gene ERCA broca gene. may be linked to ovarian cancer
Hormonal/Reproductive cancer metastasis pathway lungs, liver, and bone or intra-abdominally to the peritoneal cavity.
*Breast Cancer ERCA gene, family hx. Mass felt during BSE. metastasis via lymph nodes. Asymmetry. bloody/clear nipple discharge. dimpling.
*breast cancer tx chemo, radiation, hormonal manipulation: use of meds to compete w/ estrogen receptor sites
Tamoxifen Competes w/ estrogen for tumor receptor sites. Estrogen dependent tumors can't grow if estrogen can't fit into the receptor site.
When to empty the JP drain any time there is any fluid in it. Don't want it to get full & lose suction.
Gastric cancer inner lining of the stomach with invasion to the muscle and beyond in advanced disease. H. pylori.
complications of gastric cancer hemorrhage, obstruction, metastasis, dumping syndrome
gastric cancer risk factors h.pylori infection & diet of spiced food, smoked,salted,seasoned, processed food. also smoking, alcohol and nitrate ingestion. Hx ulcers.
Pancreatic cancer highly malignant, rapidly growing cancer from epithelium of the ductal system.
adenocarcinoma cancer of a glandular tissue
cancerous pancreas BAD NEIGHBOR!!! Keeps the liver up all night by partying & liver can't stack the NH4 ammonias. Pts will smell like urine/ammonia
s/sx pancreatic cancer n/v, jaundice, anorexia, glucose intolerance, clay-colored & fatty stool. abd pain
tx pancreatic cancer Rad, chemo, whipple procedure.
whipple major stomach re-route. involves pancreas, stomach, CBD & jejunum.
intestinal tumors arise from adenomatous polyps
complications of intestinal tumors bowel perf, peritonitis, abscess, fistula, hemorrhage & obstruction
who to consult for colostomy/ileostomy enterostomal therapist determines where to place the stoma
pre-op prep low-fiber diet 1-2 days. bowel prep.
Empty colostomy bag when? 1/3 full
WNL stoma colo pink or red. Dk blue/purple/black indicates compromised circulation; notify MD.
colostomy stool consistency liquid post-op.May be more formed after healing, but depends on placement. LRQ=liq, transverse=semi-formed, L side=more formed
Ileostomy post-op drainage dk green & progression to yellow with food. Stool is liq. Risk for dehydration & electrolyte imbalance because the colon does not get to reabsorb like it should.
Lung cancer one of the leading causes of cancer-related deaths in the US.
lung mets one of the most common places for mets, esp hormone dependent cancers.
dx of lung cancer by CXR, CT, MRI.
lung cancer interventions humidify O2, fowlers position. resp therapist tx, activity as tol w/ rest periods.
Laryngeal cancer malignant ulcerations w/ underlying infiltration.
Dx of laryngeal cancer laryngoscopy & biopsy.
risk for laryngeal cancer smoking, alcohol, asbestos, wood dust.
s/sx laryngeal cancer persistant hoarseness/sore throat, lump in throat, burning sens in throat, dysphagia, change in voice quality, dyspnea.
tx of laryngeal cancer rad if limited to sm. area in one vocal cord. chemo. surgery; from cord stripping to laryngectomy.
psych-soc aspect of laryngeal cancer pre-op: establish a new method of communication. Prep for rehab & speech therapy.
Prostate cancer slow growing, androgen dependent malignancy of the prostate gland.
s/sx prostate cancer poss asymptomatic. hard, pea-like nodule felt upon digital rect. exam, hematuria.
tx prostate cancer Transurethral resection of the prostate (TURP) scope into urethra, excision of prostate, suprapubic prostatectomy, retropubic prostatectomy, perineal prostatectomy.
post op TURP Monitor for TURP syndrome (severe hyponatremia) due to continuous bladder irrigation (CBI) which is given to prevent cath obstruction.
suprapubic prostatectomy tons of urine drainage. Change dressing often. Monitor for hemorrhage. Causes sterility.
retropubic prostatectomy minimal drainage. sterility
perineal prostatectomy lithotomy position. incision by rectum. minimal bleeding. risk for infection. Incont. common.sterility. Teach perineal exercises.
bladder cancer s/sx painless hematuria, freq, urgency, dysuria, clot-induced obstruction, bladder wash specimens & biopsy confirms dx.
ureterostomy ureter-ostomy connection. Pt must wear a urine collection pouch
urine conduits ureters connect to conduit of a section of intestine. Must wear a urine collection pouch
sigmoidostomy ureters connect to colon. pee out rectum
kock's pouch pouch made out of ileal resevoir which fuctions as a bladder. regular Self-cath
oncological emergency: sepsis r/t decreased WBC & DIC. chemo kills good cells as well as bad cells. Liver tries to fight infection the only way it knows how by increasing clotting factor (not helpful) sends pt into DIC.
Prevent sepsis - DIC rxn by early recognition of high risk pts & admin abx and anticoags IV as prescribed
SIADH Some tumors can secrete inappropriate ADH (or similar hormones) resulting in dilutional hyponatremia because the body retains water.
s/sx hyponatremia weakness, anorexia, fatigue, weight gain, confusion, personality changes, seizure, coma, death.
spinal cord compression r/t cancer either from occlusion due to tumor or spinal cord collapse.
Hypercalcemia r/t cancer "holding cup of milk & smiling thinking of mom" 8.5-10 = WNL Ca2+ lvl. bone damage raises serum Ca2+ levels. mets to bone = late cancer.
s/sx hypercalcemia fatigue, anorexia/N/V, constipation, polyuria, weakness, EKG changes
Superior Vena Cava syndrome compression/ obstruction.
s/sx SVC syndrome s/sx: edema of face/eyes & tight shirt collar.
complications of SVC syndrome hemorrhage, LOC change, decreased CO, airway obstruction, hypotension.
tx SVC syndrome rad therapy, poss surgical placement of stent.
Tumor lysis syndrome DNA/purine= uric acid= gout & renal failure. cell lysis = K+ release = hyperkalemia & poss MI
Tumor lysis sundrome tx meds that increase excretion of purines = allopurinol / Zyloprim
Tamoxifen anti-estrogen med for the tx of cancer. causes facial hair & deepening of voice.
Side effects of antineoplastics mucositis, alopecia, anorexia/N/V, diarrhea, anemia, neutropenia, thrombocytopenia, infertility.
Neupogen granulocyte colony stimulating factor to tx neutropenia. increases WBCs
Epogen erythrocyte colony stimulating factor to tx anemia. Increases RBCs.
Side effect of all colony stimulating factors Neupogen & epogen can cause bone pain. They are making the bone marrow work harder!
Adrenal glands secrete.... the 4 S's sugar: glucocorticoids salt: mineralcorticoids sex: androgens SNS: adrenolin
TSH secreted by the ant pituitary to get the thyroid to function. If thyroid unresponsive, TSH is elevated. T3 & T4 are not released by the thyroid & thyroid enlarges aka "goiter"
Radioactive iodine uptake/ thyroid function test "brachytherapy" radioactive iodine given PO or IV. Pt & excreta are radioactive
hypocalcemia +trusseau (thumb w/ bp) +chokovski (cheek twitch)
Hypopituitarism decreased "stimulating hormones" Growth H, Luetininzing H (gonads), TSH, adrenocorticotropic (ACTH), ADH.
tx hypopituitarism ADH if peeing into hypovolemia LOL. Oxytocin if no menstrual period.
hyperpituitarism cushings disease, acromegaly present. prep for usually a transphynoidal hypophysectomy (removal of pituitary)
Diabetes Insipidus Latin for "to flow" Pt lacks ADH. Literally pees themselves into hypovolemia.
Diabetes insipidus interventions Vasopressin or DDAVP may be prescribed by injection, intranasally or orally.
SIADH posterior pituitary produces too much ADH (no PP) and pt retains water.
s/sx SIADH fluid overload, anorexia/N/V, hyponatremia, LOC change, waight gain.
*addison's disease need to add the hormones in. Missing the adrenal hormones: the 4 s's sex (androgens), SNS (adrenoline) salt (mineral corticoids) and salt (mineral corticoids)
Addisonian crisis LIFE THREATENING condition caused by adrenal insufficiency related to by stress, infection, surgery, or withdrawal of corticosteroids
s/sx addisonian crisis headache, pain in leg/back/abd, weakness, irritability,confusion, hypotension, shock.
tx addisoniean crisis epi-pen, cortisol, glucocorticoids
*Cushings syndrome "cushion of extra adrenal hormones" the 4 s's. too much glucocorticoids CBG elevated. Pancreas secretes extra insulin to store as fat. thigh muscles get broken down for glyconeogenesis.
tx for cushings syndrome adrenalectomy (now has addison's disease).
Hypothyroidism (slow) cold intolerance, dry skin, loss of body hair, puffy eyes, face, goiter. Weight gain, lethargy. Risk for myxedema coma (hypothyroid coma) Tx: synthroid
Hyperthyroidism (fast) thyrotoxicosis, goiter, cardiac dysrhythmias (a fib, tachy), exophthalmos (protruding eyeballs), weight loss, heat intolerance.
Hyperthyroid tx antithyroid meds, iodine, thyroidectomy
Thyroid storm uncontrollable hyperthyroidism (can happen during thyroid surg) T3 & T4 excessively released. Surg removal of thyroid. antiarrhythmia meds, cooling blankets, antithyroid meds.
s/sx of parathyroid damage (or any hypoparathyroidism) poss during thyroidectomy hypocalcemia & tetany. Numbness & tingling. admin calcium gluconate.
Hypocalcemmia s/sx trousseau's sign (thumb) chvostek's sign (cheek spasm), numbness & tingling in face. Muscle cramps in abd/ extremities. tetnay. dysrhythmias, seizures, hypotension, anxiety, irritability, death.
Hyperparathyroidism increased serum Ca2+ levels. Hold up your cup of milk & think of mom =) relax into coma, asystole, apnea. Muscle weakness, constipation, anorexia/N/V.
Type I DM No insulin produced. Fats are metabolized that produce ketonemia (acidosis)
Type II DM Insulin can stabilize fat & pro metabolism but not carbohydrate metabolism
Metabolic syndrome AKA syndrome X at risk for developing DM II, abd obesity, hyperglycemia, hypertension, high triglycerides, and low HDL level
s/sx of diabetes I and II Hyperglycemia aeb polyuria, polydipsia, polyphagia, blurred vision, weight loss, slow wound healing, vag infections, weakness, parasthesias, poor circulation, atherosclerosis (
side effect of metformin May traumatize the pancreas leading to pancreatitis
Dawn phenomenon cellular regeneration during sleep (5-8 AM) causes liver to release glycogen resulting in hyperglycemia
Somogyi phenomenon Hypoglycemia occuring at about 2-3 AM. Prevent w/ bedtime snack of fats & protein (long lasting)
Mild hypoglycemia CBG < 60. Pt fully awake. Hungry, nervous, sweating, tachycardia, tremor, palpitations. Give simple carb
Moderate Hypoglycemia CBG < 40. Confusion, double vision, drowsiness, emotional changes, headache, irrational, combative, light headed, numb lips & tongue, slurred speech. Give simple carb.
Severe Hypoglycemia CBG < 20 difficulty arrousing, disoriented, Loss of consciousness, seizures. injection of glucagon if at home. MR in 10 min if pt remains unconscious. May give D50 IV in the hospital. Notify the physician. Give small meal when awake.
DKA severe insulin deficiency. Cant use PO carbs, body breaks down fats & ketones are a biproduct.
tx DKA ICU. Rapid NS or 1/2NS. Go to D5NS when CBG reaches 250- 300. IV regular insulin drip titrated to flowsheet.
HONK Extreme hyperglycemia without ketosis or acidosis present in type II DM
tx HONK Fluid, electrolyte & insulin replacement.
Diabetic retinopathy glycosylated Hgb damages retinal capillaries. eventually hemorrhage. Perm vision change & blindness
s/sx diabetic retinopathy sudden loss of vision from retinal detatchment, blurred vision from macular edema, cataracts result from lens opacity.
Diabetic nephropathy microvascular kidney damage from glycosylated hgb
s/sx nephropathy microalbuminuria, thirst, fatigue, anemia, wight loss, malnutrition, freq UTIs neurogenic bladder.
diabetic neuropathy gen deterioration of nervous system due to microvascular damage.
s/sx neuropathy parasthesia, decreased reflexes, pain, burning, poor peripheral pulses, skin breakdown, infection, weakness, dizziness, postural hypotension, gastroparesis, diarrhea/constipation/incont., impotence.
Diabetes & surgery probable: hold metformin/ glucophage (and other oral antidiabetics) but check with dr.'s orders/ call doc. Intra-op admin short/rapid insulin to maint CBG < 200. Post-op admin IV D5 & insulin as prescribed until able to eat.
diabetes & post-op complications risk for impaired healing, risk for cardiovascular & renal complications
Hot & dry sugar high (hyperglycemia)
cold and clammy needs some candy (hypoglycemia)
Aspart Rapid acting: 15 min onset (prandial)
Regular Short acting: 30 min onset (prandial)
NPH Intermediate acting: 90 min onset (basal)
ERCP Endoscopic retrograd cholangiopancreancreatography. Gallbladder to pancreas.
ERCP post-op NPO until gag reflex returns. monitor for signs of perforation or peritonitis.
GERD avoid peppermint, chocolate, coffee, fried/fatty foods, carbonation, alcohol, smoking. avoid anticholinergics & NSAIDS.
Gastritis due to irritation (NSAIDs, aspirin, highly seasoned/ irritating foods) High risk for B-12 deficiency r/t loss of stomach tissue.
Peptic ulcer disease "some kind of ulcer" could be anywhere.
Gastritis due to irritation (NSAIDs, aspirin, highly seasoned/ irritating foods) High risk for B-12 deficiency r/t loss of stomach tissue.
Peptic ulcer disease "some kind of ulcer" could be anywhere.
vagotomy eliminates vagal impulses that stim HCL secretion. Neural alteration results in Reduced PNS stimulation & Results in tachycardia due to SNS stimulation.
Dumping Syndrome rapid emptying of stomach folowing any stomach surgery. occurs 30 min after eating
s/sx dumping syndrome N/V, cramps, diarrhea, palpitation, tachycardia, perspiration, weakness, dizziness, hypoglycemia.
pancreas response to dumping syndrome rapid relase of insulin. Hypoglycemia
Vit B12 deficiency s/sx pallor, fatigue, weight loss, smooth, beefy red tongue, jaundice.
Vit B12 deficiency Deficiency of intrinsic factor leads to pernicious anemia. Necessary for intestional absorption of B12.
Bariatric surgery reduction of gastric capacity. ie: gastric bypass, gastroplasty, circumgastric banding.
hiatal hernia Heartburn, regurgitation / vomiting
cholecystitis r/t gallstones or inefficient bile emptying.
s/sx cholecystitis N/V, belching, flatus, epigastric pain after fatty foods. Murphy's sign cannot take a deep breat w/ fingers on hepatic margin
s/sx of biliary obstruction jaundice, dk orange/foamy urine, steatorrhea, clay colored feces.
Cirrhosis chronic, progressive disease of the liver characterized by degeneration & destruction of hepatocytes
Portal hypertension r/t cirrhosis persistent increase in pressure in the portal vain that develops as a reuslt of obstruction to flow.
Ascites r/t cirrhosis accumulation of fluid in the peritoneal cavity that results from venous congestion of the hepatic capillaries
*Laennec's cirrhosis cirrhosis is alcohol induced, nutritional or portal. Cellular necrosis causes scar tissue w/ fibrotic infiltration of the liver.
*Postnecrotic Cirrhosis Complication of hepatitis or hepatotoxins (ie excessive tylenol)
*Biliary Cirrhosis Bad Neighbor! biliary obstruction, bile stasis and inflammation resulting in severe obstructive jaundice. From pancreas or gallbladder
*Cardiac Cirrhosis R sided CHF (back up on I-5, cant get through vena cava)results in enlarged, congested liver. Liver becomes anoxic.
esophageal varices r/t cirrhosis fragile, think walled, distended veins in the esophagus that bleed easily. Special eT tube to "tamponade" or apply pressure to stop the bleeding.
Coag defects r/t cirrhosis missing clotting factors. Unable to absorb vit K without bile.
Jaundice r/t cirrhosis Liver unable to metabolize bilirubin
Portal systemic encephalopathy Liver can't stack NH4, kidneys can't excrete incomplete ammonia. Pee smelling pt. Increased ammonia in serum crosses blood-brain barrier. Give lactulose.
Hepatorenal syndrome progressive renal failure assoc w/ hepatic failure.
Cirrhosis assessment: asterixis ulnar nerve irritation due to ammonia. rapid, nonrhythmic extensions & flexions in the wrists & fingers
Cirrhosis assessment: fector hepaticus fruity, musty breath odor (ammonia)
Diet for cirrhosis If ammonia up, give low pro diet.
Cirrhosis meds to avoid no opioids, sedatives, barbituates or hepatotoxic meds. NO HALDOL. may use soft restraints.
Hepatitis Inflammation of the liver r/t virus, bacteria or exposure to meds/hepatotoxins
Hepatitis A & E "vowel" from the bowel. Fecal contamination. Poor hand washing. Or bad fish swam in sewer contaminated water.
Hepatitis BCD Bloodborne, body fluid.
Preicteric stage of hepatitis "flu-like" no jaundice
Icteric stage of hepatitis icteric = "itching" appearance of jaundice. elevated bili. dark/tea colored urin, clay colored stool.
Posticteric stage of hepatitis jaundice decreases & everything returns to normal
Pancreatitis Pain in L shoulder. Bad neighbor clay stool. No digestive enzymes. no insulin.
Pain Med for pancreatitis Demerol. Causes less smooth muscle spasm (sphincter of oddi)
Ulcertive colitis Poor absoprtion of nutrients. Begins in rectum and works upward. Poss surg needed: stoma, or resevoir creation from bowel.
Crohns disease. inflammatory disease anywhere inthe GI tract. Most often the terminal ileum.
appendicitis pain most intense @mcburneys pt. Elevated WBC. do not apply heat, may cause rupture.
Diverticulitis diet low fiber, low residue. Pain & fever. Hx diverticulosis.
Hemorrhoids due to portal hypertension, straining, irritation or increased venous or abdominal pressure.
Tx hemorrhoids stool softeners, witch hazel/Tucks.
H2-receptor antagonists "idine" ie Ranitidine (zantac) Nizatidine (axid) give before meal
proton pump inhibitor "zole" pantoprazole. give before breakfast
antacids give after meals
tx of h.pylori triple or quadruple therapy w/ variety of medications (including an antibiotic) Nexium, amoxil, clarithromycin. for example
Bulk-forming laxatives metamucil, salad =), absorb water into the feces to produce large, soft stools.
stimulants bisacodyl, senna. irritates colon = rapid transit
surfactants docusate, colace. Inhibits water absorption so water will stay large & soft.
Osmotic golytely, MOM, mag citrate, fleets.
Lubricants ie mineral oil. Inhibits absoprtion of fat sol vitamins.
diarrhea meds ID & tx underlying cause, tx dehydration, replace F & E, relieve abd discomfort & cramping. OPIOIDS
V-Q scan (ventilation - perfusion) eval of patency of pulm airways and blood flow to the lungs. May req. IV radionuclide.
Pulse-ox 96-100 WNL. Lower than 91% notify the MD. lower than 85, hypoxia of tissues. <70% = life threatening.
ABG PCO2 35-45 CO2=acid that is exhaled (respiratory)
ABG HCO3 22-26 HCO3=Bicarb renally excreted (metabolic)
Percussion & vibration contraindicated in fx ribs kidney infection osteoporosis multiple myeloma
COPD patient on O2 pt is used to chronic hypercapnia. Drive to breathe is not r/t high CO2, but is r/t low O2. Must only give 1-2 liters of O2 to keep the patient breathing.
Simple face mask min 5L/min
partial rebreather 6-15 L /min
Assist-control ventilation Vent takes over work of breathing for the client. Pt initiates breath, vent admin programmed volume. Pt may breathe too often & vent still gives full breath. Risk for resp alkalosis.
SIMV synchronized intermittent mandatory ventilation pt breathes spont. at own rate & tital vol between vent breaths. Is used as a primary or weaning vent. setting.
SIMV for weaning When used in weaning mode, number of SIMV breaths is gradually decreased. Clined gradually resumes spontaneous breathing.
Pressure support (on vent) for weaning predetermined pressure set on vent to assist pt in resp effort. With weaning, pressure is gradually decreased
Flail chest r/t blunt chest trauma. risk for hemothorax & rib fx. loose segment moves paradoxically to expansion & contraction of the chest wall.
Pulm Contusion interstitial hemorrhage assoc w/ intra alveolar hemo. risk for ARDS
open Pneumothorax environmental air enters through chest wall & pleura.
spontaneous pneumothorax rupture of pulmonary bleb (pimple pops in the lung)
tension pneumothorax blunt chest injury or build up of pressure from PEEP/vent.
Acute resp failure insufficient O2 transported to the blood or inadq CO2 is removed from the lungs. Compensatory mechanism fails.
causes of Acute resp failure mech abnormality of the lungs/chest wall, defect in resp center of brain, impairment in resp muscles.
s/sx Acute resp failure SaO2 lower than 90, PaCo2 > 50 w/ acidemia
Acute resp failure intervention identify & tx underlying cause. Admin O2 to keep PaO2 level higher than 60-70.
Core pulmonale blood can't leave R ventricle to get to the lungs. R ventricle enlarges.
Asthma interventions Monitor peak flow "blow to max capacity"
COPD interventions pursed lip breathing. diaphragmatic/abd breathing. monitor weight. sm freq meals.
SARS virus. begins w/ fever & mild resp symptoms. develops dry cough & dyspnea within a week.
PNA Elevated WBC & ESR
Influenza fever, muscle aches, headaches, fatigue, weakness, anorexia, sore throat, cough, rhinorrhea. Can give acyclovir.
Legionnaire's disease PNA r/t stangnat O2 Not contagious.
pleural effusion "pocket of fluid" thoracentesis. chest tube. if recurrent, pleurectomy or pleurodesis.
empyema pleural effusion w/ pus
pleurisy pleural-itis. Literally inflammation of the pleural membranes. Pleural friction rub. knife like pain
pulmonary embolism immobility causes a blood clot to travel from Leg-SVC-R atria-R ventricle -artery of lung.
s/sx pulm emboli blood in sputum, restlessness, cough, chest pain, crackles wheezes, cyanosis, dyspnea, impending doom, hypotension, shallow resp, tachypnea, tachycardia
pulm emboli interventions rapid response, elevate HOB, admin O2, VS, poss heparin, ABG,document
Histoplasmosis inhaled fungus from spores in contaminated soil.
sarcoidosis inhaled virus-like thing that creates tuburcule blockage. Cause unknown
Tuburculosis mycobacterium tubuerculosis. exudative response causes pneumonitis & development of granulomas in the lung "tubucles". Body doesn't know what to do with it so the body covers it with a sticky substance.
Goal of TB tx prevent transmission, control symptoms & prevent progression of the disease
TB transmission airborne by droplets. risk of transmission is reduced after 2-3 wks of TB meds
TB progression droplet enters lungs, bacteria form a tuburcle lesion.. body encapsulates the tubercle leaving a scar. If encapsulation does not occur, can travel via lymphatic system & cause inflammatory response
TB related granulomatous inflammation TB travels through lymph & primary lesions form. may become dormant & re-activate when ill/poor sleep/compromised. In active phase, may cause necrosis & cavitation resulting in damage to various parts of the body.
predisposing factors travel? mental health facilities, under 5, older, crowded, abuses drugs/alcohol
s/sx TB fatigue, lethargy, anorexia, weight loss, low-grade fever, chills, night sweats, persistent cough, mucus & blood in sputum, chest tightness, dull chest pain
Sputum culture definitive dx
mantoux skin test not necessarily active disease. indicates previous exposure or presence of dormant disease. PPD intradermally in forearm. Read 48-72hrs afterwards. Look for 5mm or larger red bump
Quantiferon TB gold test 24 hr blood test
TB hospitalization - pressure room. door kept tightly closed. vent to outside environment. 6 exchanges of fresh air per hour. RN wears particulate respirator when caring for pt, gown & gloves. Pt wears mask if has to leave the room.
bronchodilators -"rol" meds ie albuterol. Always give first if ordered with another med (glucocorticoid) bronchodilator.
glucocorticoids -"one" or "onide" inhaled steroids to treat inflammation. Rinse after using. Can cause caries/fungal infections.
Isoniazid TB med. 1 yr tx duration. hepatotoxic, neurotoxic.
Apex of the heart Is at the bottom. Picture an upside down letter A in the point of a valentines heart
Base of the heart Is at the top. Picture a sideways letter B in the top bumps of a valentines heart
Afterload blood pressure that must be overcome as blood enters the heart
Preload blood pressure that must be overcome as blood exits the heart.
Name the two atrioventricular valves tricuspid valve & mitral valve. Draw TM (like trademark) on your valentines heart in order
Name the two semilunar valves the pulmonic and the aortic.
SA node pacemaker of the heart 60-100 BPM. Controlled by SNS & PNS. Shown as the P wave on tele
AV node tells ventricles to beat. If SA is not firing, AV will pace at 40-60
Bundles of His continuation of AV node in the intraventricular septrum. electrical activity here is the QRS complex. Damage to the ventricles causes a widened QRS.
S1 Heard at apex (one point= S1) atrioventricular valves close
S2 Heard at base (two bumps = S2)when semilunar valves close
elevated troponin & myoglobin probably MI, call cath lab
CK MB myocardial bruise
CK BB brain brus
CK MM muscle mass
Potassium cardiac If K+>5, ST elevations are likely
Hypocalcemia cardiac ventricular dysrhythmias, prolonged ST & QT intervals & CARDIAC ARREST
Digital subtraction angiography uses contrast dye. assess for allergies to seafood, iodine or radiopaque dyes.
Allergy to iodine/seafood? pre-med w/ antihistamine & corticosteroids
*PTCA Percutaneous transluminal coronary angioplasty Balloon cath to flatten the plaque.
*PTCA post-op meds plavix, aspirin, heparin, to prevent clots
Laser assisted angiography plaque is vaporized
Atherectomy cut out the plaque
CABG saphenous vein, internal mammary artery or other arteries are used to bypass the lesions. Used when medical mgmt is ineffective or occlusion is severe
Heart transplant EKG change 2 P waves because a portion of the patient's original atria remains in the body
Innervation of transplanted heart no innervation. No vagal stimulation. No angina
HR of transplanted heart approx 100 bpm & slow response to exercise. Pt must be on a rate controller medication
Sinus Brady Tx if pt is symptomatic. Admin atropine sulfate as prescribed to increase HR to 60
Sinus Tach Decrease the HR by treating the underlying cause
Afib risk for stroke. Admin coumadin & heparin. Admin meds as prescribed to control ventricular rhythm. Risk for hyperkalemia. RBC clots = cell lysis & potassium release
Multifocal PVCs Risk for vtac
Vtac No cardiac output. 3 pvcs or more. Admin O2 & antidysrhythmic
Pacemakers Artifical SA node creates a P wave
Coronary Artery diseas narrowing or obstruction of one or more coronary arteries as the result of atherosclerosis
atherosclerosis accumulation of lipid-containing plaque in the arteries.
LDL lousy lipids!
HDL healthy lipids!
EKG change w/ blood flow reduction ST depression, T wave inversion
EKG change with infarction ST elevation, followed by T wave inversion & abnormal Q wave.
Blood lipid levels may be elevated & cholesterol lowering meds may be prescribed to prevent plaques.
CAD tx PTCA, laser angioplasty, stent, CABG.
CAD meds nitrates to dilate coronary arteries & decrease preload & afterload
Angina chest pain r/t inadequate myocardial oxygen/ ischemia
Stable angina exertional. r/t activity/emotional state. relieved w/ nitro
Unstable angina preinfarction angina r/t unpredictable degree of exertion/emotion. increasing in severity & occurance. Nitro may not help.
Variant angina vasospastic angina. may occur at rest. attacks may be assoc w/ ST elevation
Inretractable angina chronic, incapacitating angina unresponsive to interventions.
preinfarction angina assoc w/ coronary artery insufficiency. >15 min. s/sx worsening cardiac ischemia. Occurs after MI.
Angina pain substernal, crushing, squeezing pain. May be in the shoulder, arms, jaw, neck or back. Unaffected by respiration movements. Usually lasts less than 5 minutes (but can last 15-20 min). Relieved by nitro (if not, MI!)
MI myocardial tissue is abruptly and severely deprived of oxygen
MI risk factors atherosclerosis, CAD, elevated cholesterol levels, smoking, HTN, obesity, inactivity, impaired glucose tolerance, stress. CK MB, Troponin, myoglobin,
MI interventions after the acute episode BR 24-36hrs ROM exercises to prevent thrombus. Verbalize feelings. Cardiac rehab.
Heart failure inability of the heart to maintain adequate CO to meet the metabolic needs of the body r/t impaired pumping activity. May have congestion in lungs & periphery.
Most heart failure begins where? Left ventricle & progresses to failure of both vetnricles
Acute pulm edema fluid backs up into the lungs. MEDICAL EMERG! pt will literally drown in own fluid if unresolved.
Acute pulm edema tx high fowlers, admin O2, assess pt quickly, IV access, admin diuretics & morphine, insert foley, intubation & vent if needed.
Acute pulm edema meds Digoxin, diuretics, ACE inhibitors, Beta blockers & vasodilators
diet potassium rich. K+ may be depleted w/ diuretic use.
Cardiogenic shock Another name for heart failure.
Pericarditis inflammation of the pericardium. may lead to heart failure or cardiac tamponade. Precordial pain aggrivated by respirations
Myocarditis inflammation of the myocardium r/t pericarditis. s/sx of heart failure
Endocarditis inflammationof teh inner lining of the heart and valves
Risk factors mitral valve prolapse, valve replacement, iv drug users
Ports of entry oral cavity (ie dental work, strep throat), cutaneous invasion, infection, invasive procedures, surgery
Cardiac Tamponade Pericardial effusion, squeezes heart, decreased CO
*Valvular heart disease valves can not completely open or close completely decreasing CO.
Mitral Stenosis Valve thickens & narrows preventing blood from flowing from L atrium to left ventricle
Mitral insufficiency valve does not close. blood flows back up into L atria resulting in pulm HTN.
cardiomyopathy chronic disorder of the heart muscle. tx is palliative. shortened life span.
dilated cardiomyopathy lack of muscle; walls too thin. Can't pump. Stasis/clots
hypertrophic cardiomyopathy muscle too thick. No room left for blood
restrictive cardiomyopathy fibrosed walls can't expand or contract. chambers are narrowed. Stasis/ clots
DVT + homans sign (pain w/ foot flexion) calf/groin tenderness. Poss swelling. warm, tender skin
Venous insufficiency prolonged venous hypertension which stretches & damages veins/valves. hemorrhoids esophageal varices.
Venous insufficiency s/sx stasis dermatitis or brown discoloration along the ankles. Edema, ulcers with uneven edges & pink wound bed
Unna Boot dressing constructed of gauzed moistened with zinc oxide - MD to change weekly
Peripheral artery disease arterial occlusion deprives the lower extremities of oxygen & nutrients. usually related to atherosclrosis.
PAD s/sx exercise (gradual increase) to encourage collateral circulation. walk to point of claudication stop & rest then go a little farther. do not cross legs, avoid cold, wear socks & warm shoes.No tobacco or coffee (vasoconstrictive) no heating pads!
Raynaud's disease Red, White, & Blue. Blanching of extremity, followed by cyanosis during vasospasm, then reddened when vasospasm is relieved. Vasospasm of the upper & lower extremity arteries
Raynaud's disease tx wear warm clothing in the winter.
aortic aneurysms dilation of arterial wall. Must control BP ASAP to reduce pressure and avoid rupture.
aortic resection excision of the aneurysm & replaced with graft that is sewn end to end.
aneurysm assessment feel thrill, hear bruit
Normal bp 100-120/60-80
prehypertension 120-140/80-89
Stage 1 HTN 140-159/90-99
Stage 2 HTN 160+/100+
s/sx HTN initially asymptomatic.
Goals of HTN tx lessen the extent of organ damage (blindness, stroke, Heart failure, HTN crisis, renal failure)
s/sx heart failure (in general) dyspnea, orthopnea, pallor, tachycardia, blood-tinged sputum/frothy, wheezing, crackles, anxiety, apprehension, sweating, clammy & cold skin, cyanosis, nasal flaring, accessory berathing muscles, hypocapniea,tachypnea
L sided heart failure specific s/sx PULMONARY SYSTEM effected: pulm congestion, dyspnea, tachypnea, crackles, dry cough, nocturnal dyspnea, Increased BP or decreased BP. (retaining water or pump failure)
R sided heart failure specific s/sx dependent edema (legs & sacrum, JVD, abd distention, hepato & splenomegaly, anorexia, CIRCULATORY SYSTEM effected: nausea, weight gain, nocturnal diuresis, swollen fingers/hands
Inotropic Digozin dopamine, dobutamine, primacor inamrinone. slow, strong contractions. "little engine that could... I KNOW I can I KNOW I can!"
Digoxin flu-like synmptoms, vision changes
Loop diuretics Lasix. potassium loss. not for immediate diuresis. for htn & peripheral edema. Not for renal failure patients. may cause toxicity with digoxin, corticosteroids, lithium.
Thiazide diuretics Hydrochlorothiazide. Potassium loss. RAPID diuresis. for HTN, pulm edema, heart failure & renal disease.
ACE inhibitors "pril" stops at the lungs does not covert to angiotensin II. Can cause a cough
Angiotensin II receptor blockers "sartan" kidneys don't get stimulated to release aldosterone. No vasoconstriction
Nitrates produce vasodilation. decrease preload & afterload and reduce myocardial oxygen consumption. Not for hypotensive or increased ICP.
Beta blocker blocks adrenergic receptors. No adrenoline effect on heart.
Calcium Channel Blocker "ipines" & verapamil. decrease contractility of the heart. relaxes the heart. Decreased BP.
Adrenergic Agonists. dobutamine, dopamine, epinepherine, Isoproterenol, norepi. Stim SNS response & increased HR
Function of kindeys maintain acid-base balance, excrete waste products of metabolism, secrete renin and erythropoietin
RAAS Renin-Angiotensin I-travel to lung-Angiotensin II-vasoconstriction - kidneys hypoperfused & release Renin.
Renin grabs the water, grabs the salt, throws out K+
Potassium homeostasis increases in serum K+ level stim secretion of aldosterone.
Blood Urea Nitrogen (BUN Liver must stack Nitrogen in 4s in order for Renal excretion to occur. May also be elevated in dehydration, high protein diet and stress.
Serum creatinine 0.6-1.3
IV pyelography IV radiopaque dye. Allergic to reddish shellfish? iodine?
Acute renal failure Rapid loss of kidney function due to renal cell damage.
prerenal outside the renal system: hypovolemia, decreased CO, infection.
intrarenal tubular necrosis, kidney infection, obstruction , nephrotoxicity
postrenal between the kidney and the urethral meatus. bladder neck obstruction, bladder cancer, calculi, postrenal infection.
oliguric phase of renal failure minimal output. Elevated BUN & cretinine, Hyperkalemia, decreased sodium (Can't pull back in the DCT), hypervolemia
diuretic phase of renal failure rapid decrease in volume. risk for shock. Gradual decline in BUN & creatinine. Hypokalemia, hyponatremia, hypovolemia.
Recovery phase 1-2 yrs. stabilization of BUN & creat,
Anemia r/t renal failure erythropoietin = decreased RBC production.
GI bleed r/t renal failure. Urea is broken down by intestinal bacteria to ammonia which irritates the gI mucosa
EKG changes with hyperkalemia wider QRS w/ tall T waves, ST elevation
Pruritis since kidneys can't excrete wastes, body expels urate crystals out via the skin. "urate frost" monitor for skin breakdown
Uremic syndrome "another name for renal failure" simply accumulation of nitrogenous waste.
Hemodialysis subclavian vein catheter filled with heparin & capped to maintain patency between tx.
assessment findings over AV fistula auscultate for bruit & palp for thrill
Interventions for AV shunt (exterior) wrap dressing completely around the shunt & keep it dry & intact. cannula clamps at bedside in case of accidental disconnection. NO BP/IV/blood draws on shunt extremity
Disequilibrium syndrome rapid change in the compositionof the extracellular fluid which occcurs during hemodialysis resulting in hyperosmotic CSF & cerebral edema
s/sx disequilibrium syndrome n/v, headache, HTN, restlessness & agitation, confusion, seizures, muscle cramps
Hemodialysis complications air embolus, disequili brium syndrome, electrolyte alterations, encephalopathy, hemorrhage, hepatits, hyptension, sepsis, shock
AIR EMBOLISM EMERGENCY stop dialysis L trendelenberg notify MD admin O2 VS document
peritoneal dialysis osmosis/filtration move solutes & fluid from high concentration to low concentration across the peritoneal membrane. Diasylate gos throguh abdominal wall and flows out a tube into a collection bag.
Kidney transplant old kidneys stay. New kidney is placed on the iliac crest (closer to the bladder. No peritoneal dialysis. Immunosuppresants for life
Cystitis/ UTI usually from Ecoli (stool bacteria)
Urosepsis UTI to sepsis
urethritis inflammation of the urethrea
ureteritis inflammation of the ureters. poss r/t pyelonephritis
pyelonephritis kidney. Can lead to renal failure
glomerulonephritis inflammation of the glomeruli from an antigen-antibody rxn from an immune response elsewhere in the body. Ie: strep throat.
nephrotic syndrome R/t glomerular damage. Protein in the urine. Hypoalbumineamia.Protein in the urine. erlipidemia.
Polycystic kidney disease cyst: irritation in the kidney. HYpertrophy of the kydnesy , leading to rupture, scars. leads to renal failure. inheritet. shows up at 30-40 yrs old.
Hydronephrosis Full bladder urine backs up the ureter resulting in a fluid filled kidney.
Renal calculi anywhere in the urinary tract.
Urolithiasis urinary calculi in the ureter
Calcium phosphate, calcium oxalate, struvite stones acid foods to prevent: cranberry, prune, plum
Struvite stones too much purine (DNA distruction) reduce organ meats, gravy, red wine sardines. Rx allopurinol
cystine stones alkaline foods L/T abx rx alkaline diet
Cystoscopy Cath(s) inserted beyond the stone to pull out the stone
Extracorporeal shock wave lithotripsy ultrasonic waves delivered to the area of the stone to disintegrate it. Stones are passed in the urine (NPO 8 hrs before)
kidney tumores usually a complete nephrectomy. Difficult to get a free border. May lose adrenals (ADDISONS!)
Wilms tumor develops in peds in kidney.
Epididymitis spermatic cord inflamed. R/t STD or UTI.
Benign prostatic hypertrophy "ivy-like" overgrowth of prostate around the bladder. TX w/ trup.
Bladder Trauma Car accident/ full bladder. N/V, pain, hematuria
Renal fluorquinolones: Cipro/ -"oxacin" may need to be taken on an emtpy stomach, may cause phlebitis.
Phenazopyridine UTI analgesic
Cyclospirine prevent organ rejection. Acts on T lymphocytes
Prednisone prevent organ rejection
Erythropoietic Epogen, Aranesp, Mircera
Leukopoietic Neupogen, neulasta, leukine
Thrombopoietic neumega
miDriatic Atropine (SNS Stim) Big pupil, canal of schlemm compressed. minimal drainage occuring
MIoTIC PILoCARPINE Small pupil, canal of schlemm wide open. facilitates drainage
Cataract opaque lens. lens removed surgically one eye per procedure
Cataract post-op do not lie on operative side. Elevate HOB 30 or higher. No coughing, straining, bending over, stool softener, position belongings on non-op side.
Glaucoma group of ocular diseases resulting in increased intraocular pressure. Can damage optic nerve & result in blindness. Can go unnoticed; central vision is unaffected.
tx glaucoma Lifelong. Medic alert bracelet. give MIoTICS to make the pupil small and give the canal of schlemm room to be wide open to facilitate drainage.
diamox diuretic for the eyes
Retinal detatchment cover both eyes to prevent further detatchment. surgery is needed. Scleral buckling procedure. Avoid straining.
Meniere's syndrome / endolymphatic hydrops tinnitus, unilateral senorineureal hearing loss and vertigo r/t overabundance of endolyphatic fluid. safety measures
meniere's syndrome progression occurs in attacks, lasts for several days, pt incapacitated during attacks. Injury prevention is top priority. Initial hearing loss is reversable but over time, hearing loss becomes permanent w/ progressive nerve damage.
meniere's syndrome surgical intervention shunt for drainage, resection of the vestibular nerve.
Cerumen removal irrigation (slow process) may soften with glycerin or mineral oil. hydrogen peroxide may also be prescribed. Can only be done if tympanic membrane is intact. contraindicated with tubes, perf membrane.
administering eye drops pull lower lid down against cheek. squeeze drop into conjunctival sac.
Lumbar puncture contraindicated in pts w/ increased ICP. Brain stem will drop resulting in herniation
Lumbar Puncture spinal needle through L3-L4 into the subarachnoid spaceto obtain CSF or measure pressure, or instill meds/ dye.
Lumbar puncture prep empty bladder pre-op 40-50 min procedure.
Cerebral angiography Assess for iodine/red shellfish/ dyes
Neuro assess LOC speak to client lightly touch painful stimuli (sternal rubsupraorbital pressure/trapezius squeeze)
Neuro assess elevated temp increases MBR of the brain
pinpoint pupils drugs or pons damage
Bilat, dilated, fixed pupils ominous sign
One dilated pupil compressed cranial nerve 3
Decorticate pull arms in together towards core
Decerebrate ceparate arms w/ wrists flexed outward
Babinski "whee" spreads toes. If healthy, pt should pull futt away
Corneal reflex loss of blink reflex. move cotton ball toward eye dysfunction of cranial nerve V
Gag Reflex Loss of gag reflex dysfunction of cranial nerve IX and X
Brudinski's sign of meningeal irritation move pts head, involuntary response of pt flexing hip & knee (bending @ buttinski)
Kernig's sign of meningeal irritation pt unable to straighten leg when flexed @ knee.
glascow coma scale 15 is highest <8 = coma
Earliest indicator if increasing ICP altered LOC
s/sx increased ICP altered LOC Headache abnormal respirations rise in blood pressure with widening pulse pressure Elevated temp vomiting pupil change
Concussion jarring of the brain within the skull with no loss of consciousness
Contusion bruising injury of the brain tissue
Epidural hematoma most serious. tear in meningeal artery. Possible loss of consciousness, gets up "I'm OK", then slips into coma.
Tetraplegia C1 to C8 all 4 extremities
Paraplegia T1-L4 only lower extremities
Resp difficulty in spinal injuries above C4
Autonomic dysreflexia follows spinal shock. caused by visceral distention from a distended bladder or impacted rectum. May lead to hypertensive stroke.
s/sx autonomic dysreflexia severe headache, hypertension,flushing above injury, pale below injury, nasal stuffiness, nausea, dilated pupils, blurred vision, sweating, piloerection (goosebumps), apprehension
s/sx spinal shock flacid paralysis, loss of reflex activity below level of injury, bradycardia, paralytic ileus, hypotension.
Stroke Cerebrovascular accident (CVA) cerebral anoxia >10 min w/ edema and congestion.
Dx stroke CT scan, electroencephalography, cerebral arteriography, MRI
TIA warning sign of impening stroke
Perm disability post CVA can't be determined until the cerebral edema subsides.
carotid endarterectomy pull clot out of carotid
Causes stroke trombosis, embolism, hemorrhage (vessel rupture)
Expressive aphagia understands what is said but can not communicate in return
Agnosia can't recognise familiar things/people
Apraxia can't perform skilled movements.
Receptive aphagia unable to understand the spoken and written word
Global/mixed both understanding & communicating is imapired
Neglect syndrome pt unaware of existance of paralyzed side. Teach pt to touch and use both sides of the body
MS demyelinization of the neurons
s/sx MS weak, fatigued, ataxia, vertigo, tremors, spasticity of lower extremities, parasthesia, blurred vision, double vision, blindness, nystagmus, dysphagia, urgency, frequency, positive babinski
Myastesia gravis insufficient ach, excessive achesterase resulting in reduced transmission
s/sx myasthesia gravis weakness, fatigue, dysphagia, ptosis, diplopia, weak/hoarse voice, dyspnea, resp paralysis & failure.
Myasthesia gravis tensilon test IM injetion lasts 10 minutes for dx only. Not for l/t use. Does cure s/sx for 10 min.
Parkinson's degenerative disease r/t depletion of dopamine.
tx parkinsons levadopa
s/sx parkinsons tremors in hands & fingersmonotonous speech, mask like face, drooling, pacing, jerky movements.
Guillan Barre reversible. acute infectious neuronitis of cranial and peripheral nerves. Immune system overreacts and destroys meylin sheath. Follows cold/flu. Recovery takes years
s/sx guillan barre parasthesia, pain, weakness of lower extremities, gradual progressive weakness of upper extremities and facial muscles.
guillan barre nursing interventions prepare to initiate resp support, pain management, monitor cardiac status
Amyotrophic Lateral Sclerosis (aka Lou Gherig's ) progressive, degenerative disease involving the motor system. No cure. Care is toward tx of teh symptoms. Probably opt for DNI
Encephalitis meningitis
meningitis inflammation of the arachnoid & pia mater of the brean & spinal cord
presdisposing factors: meningitis skull fx, brain/ spinal surgery, Upper resp virus, nasal spray use, compromised immune system
s/sx meningitis nuchal rigidity, kernig's sign, brudzinski's sign. lethargy, photophobia, decreased LOC. seizure precations.
Pneumococcal meningitis resp isolation
interventions for meningitis elevate HOB 30 degress, avoid neck flexion & extreme hip flexion.
Anticonvulsant meds dilantin, tegretol, klonopin, "barbital"s, ativan
Pain med for neuro Codiene (no increased ICP)
Pain med for stomach Demerol (no smooth muscle spasms)
Pain med for heart morphine (decreases cardiac muscle O2 demand)
Med for decreasing ICP mannitol
Bone scan used to ID, eval, and stage bone cancer before and after tx. radioisotope injected iv. excreted in urine, not harmful to others.
Strain excessive stretching of muscle/tendon. cold, heat, antiinflammatory, muscle relaxers
sprains excessive stretching of a ligament r/t twisting RICE
Internal Fixation Fracture screws, plates, pins or rods that hold the fragements in place. Poss prosthesis to replace damaged part of bone. Immediate bone strength
External fixation skeletal pinks through bone fragments to a rigid external support
Traction pulling force in two directions to reduce and immobilize a fx. provides proper bone allignment & reduces muscle spasms.
Bucks traction Hold hand out in stop sign "the buck stops here"
traction interventions ensure weights hang freely do not remove/lift weights without Rx ensure pulleys are not obstructed & ropes move freely place knots in the ropes to prevent slipping.
skeletal traction mechanical adhesion to bone involving pins/wires/tongs
skin traction elastic bandage, foam boot, sling. cervical skin traction relieves muscle spasms of upper extremities & neck
compartment syndrome decreased blood flow, ischemia, neurovascular impairment. Irreveresible within 4-6 hrs
s/sx compartment syndrome pain in limb, tissue distal to area is pal or edematous, pain w/ passive mvmt, loss of sensation, pulselessness (late sign!)
avascular necrosis fx interrupts blood supply to a section of bone
Crutch walking 3 point non wb walking with crutches
crutch sizing should be 2-3 finger spacing between axillae and the arm pieces. never rest on arm pieces
Intracapsular hip fx femoral head is broken within the joint capsule
Extracapsular hip fx at greater trochanter open reduced internal fixation w/ nail plates, screws, pins, wires
Post-o interventions for hip fx surg maint leg & hip in proper alignment. No internal or external rotation. Turn to unaffected side. Elevate HOB 30-45 while eating only
Herneation, intervertebral disk pain, parasthesia, numbness, weakness in upper extremities. cervical collar for cervical herniation
Lumbar disk herniation most often occurs between L4-S1 weakness, diminshed reflexes, muscle spasms, pain, sciatica
Disk surgery indicated when spinal cord compression is suspected or symptoms do not respond to conservative tx
amputation keep tourniquet bedside, prevent contractures. elevate foot of bed first 24 hrs only. after 24 hours, position prone to stretch muscles to prevent contractures, do not elevate residual limb on pillow. Massage skin toward suture line.
post-amputation prosthesis prep pres limb against pillow, progressively working towards firmer surfaces.
rheumatoid arthririts chronic systemic inflammatory disease leads to destruction of connective tissue & synovial membreane within the joint. stress & fatigue exacerbate condition.
Vasculitis complication of rheumatoid arthritis leads to organ or organ system malfunction/failure caused by tissue ischemia
osteoarthiritis prog. degeneration of articular cartilage causes bone buildup and loss of cartilage in peripheral and axial joints. cause unknown
cause of osteoarthiritis trauma, aging, obesity, genetic changes, smoking
Osteoporosis metabolic disease loss of calcium leading to fragile bones assoc w/ immobility, alcoholism, malnutrition, or malabsoption
Kyphossis of the dorsal spine AKA dowager's hump assoc w/ ostoporosis
Gout systemic disease. urate crystals deposit in joints. disorder of purine metabolism. Swelling & inflam of the joints. excruciating pain. urate crystals on skin pruritis.
antigout meds zyloprim
lyme disease tick bite. gently remove tick with tweezers. avoid wooded, grassy areas esp in summer. spray with tick spray before going outside. examine body when returning for ticks.
4-5 week autoimmune response to tick bite erythema migrans
incubation period for AIDS 10 yrs or longer
HAART Highly active antiretroviral therapy. AZT, ZDV, zovirax
Anxiety attack (severe) feels like a heart attack. Feeling that something bad is about to happen
Panic dread, terror, impending doom
PTSD re-experiences the event
OCD preoccupation with persistently intrusive thoughts and ideas
somatoform disorders worry/complaints re: phys illness without physical findings. Was suggested to subconscious by news/ movie/ etc.
Lithium therapeutic index 0.5-1.3
intervention for hallucination diversion/distraction
Alcohol withdrawals signs peak 24-48 hrs, then rapidly disappear (unless it progresses to DTs)
Meds to prevent DT Librium or ativan
Antabuse alcohol deterent. court ordered. Must notify courts if noncompliant. Must abstain at least 12 hrs prior.
SSRIs celexa, lexapro, luvox, paxil, zoloft, prozac
Atupical Wellbutrin
MAOI Marplan, Parnate, Nardil, Emsam
Caution w/ MAOIs avoid Tyramine in aged & exotic foods. May cause hypertensive crisis.
Benzodiasepines "pam" "lam" for anxiety
Created by: Shelley Southard Shelley Southard on 2010-12-28



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