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NSG308 Adult Health2
Final study guide
| Question | Answer |
|---|---|
| Monroe-Kellies Hypothesis | skull is fixed space -> increase in tissue/blood/CSF volume = compensation from other brain component |
| Increased Intracranial Pressure | - Monroe Kellie hypothesis - Normal ICP 10-20 mmHg - High CO2 = vasoconstriction + low CO2 = vasodilation Early Sx: LOC change, restlessness, confusion, pupillary/ocular change, unilateral weakness, HA Late Sx: Cushing's Triad, projectile vomiting, worsening LOC Tx: hyperosmotic agent, diuretics, corticosteroids, antiseizures, Ventriculostomy |
| Cushing's Triad | - Bradycardia - irregular respiration - Widening pulse pressure *seen in ICP* |
| Increased Intracranial Pressure Nursing Interventions | - HOB @ 30° + neutral head/neck position - Avoid hip flexion, Valsalva, abdominal distension - Quiet environment - Monitor for CSF leak if ventriculostomy |
| CSF leak precautions | - Elevate HOB - Loose collection pad - No sneezing/nose blowing - No NG tube - No nasotracheal suctioning |
| Ventriculostomy | - catheter -> lateral ventricle via burr hole - Continuous ICP measurement + Therapeutic CSF drainage - Drip chamber @ tragus - Need to tare w/ positional change - >20 ICP = call provider |
| Traumatic Brain Injury/Head Injury | - Diffuse vs Focal (eg. concussion vs contusion/hematoma/laceration) - Need airway/C-spine stabilization -> assume neck injury until clear - Intubation if Glasgow Coma Scale <8 Dx: CT Head |
| Epidural Hematoma | - Bleeding between dura and skull (neuro emergency) - Classic pattern: initial LOC -> briefly LUCID -> rapid LOC decline Tx: surgery |
| Subdural Hematoma | bleeding between dura and arachnoid layer - Acute: 24-48 hrs - Subacute: 2-14 days - Chronic: weeks-months -> common in older adult w/ vague Sx |
| Basilar skull fracture | Signs: Battle's Sign, raccoon eyes, possible CSF rhinorrhea/otorrhea - Test CSF drainage w/ glucose strip - ABx for meningitis ppx |
| Battle's Sign | - Bruising behind ear - Sign of basilar skull fracture |
| Traumatic Brain Injury/Head Injury Management | - Airway/C-spine stabilization |
| Glasgow Coma Scale | - Tool for evaluating level of consciousness Mild: 13-15 Moderate: 9-12 Severe: 3-8 (needs intubation) |
| Craniotomy | surgical opening of skull |
| Craniectomy | excision of portion of skull |
| Cranioplasty | repair of cranial defect w/ plate |
| Burr Holes | small opening in skull for exploration, ventricular access or hematoma aspiration |
| Transient Ischemic Attack (TIA) | - Transient neuro dysfunction w/o acute infarction - Symptoms <1 hr - Medical emergency -> work up |
| Ischemic CVA | - Thrombotic (HTN/DM link) - preceded by TIA - Embolic -> Sudden onset; usually unconscious |
| Hemorrhagic CVA | - Less common form of CVA, more fatal - Intracerebral hemorrhage (HTN common cause) - Subarachnoid hemorrhage (ruptured cerebral aneurysm cause) |
| Cerebrovascular Accident (CVA) | - BE-FAST screening tool - TIA vs Ischemic vs Hemorrhagic - Damaged brain hemisphere affects opposite side of body Dx: CT or MRI Tx: tPA (confirm ischemic stroke first) |
| CVA Nursing Priorities | - Airway/aspiration precaution - Assess neuro frequently - Monitor ICP + vital signs - DVT prevention - Put items + teachings on affected side |
| tPA | - Tissue plasminogen activator (converts to plasmin to break down) Tx for ischemic stroke d/t embolus - ONLY for ischemic CVA tx - Assess neuro + vital signs - Assess for bleeding!!! |
| Spinal Cord Injury Classification | - Level: Cervical vs Thoracic vs Lumbar vs Sacral - Degree: Complete vs Incomplete - Mechanism: Hyperflexion vs Hyperextension vs Flexion-rotation (most unstable) vs Axial loading |
| Brown Sequard Syndrome | Incomplete spinal cord injury - damage to one side of the spinal cord Sx: ipsilateral motor loss, contralateral pain + temp loss |
| Cauda equina/Conus Medullaris Syndrome | Incomplete spinal cord injury - compression of nerve roots at the bottom of the spinal cord - flaccid, lower motor neuron pattern |
| Anterior cord Syndrome | Incomplete spinal cord injury - ischemia causing reduced blood flow to 2/3 anterior spine - motor + pain/temp loss - touch and position is preserved |
| Spinal Shock | NEUROLOGIC - decreased reflexes + loss of sensation - flaccid paralysis below injury - Masks true post-injury neuro status - Lasts from days to weeks - Risk of autonomic dysreflexia |
| Neurogenic Shock | HEMODYNAMIC (but result from SCI) - Loss of vasomotor tone from injury at T6 and above -> massive vasodilation - Hypotension + Bradycardia (opposite of hypovolemic shock) _ poikilothermia |
| Autonomic dysreflexia Pathophysiology | Emergency spinal cord injury @ T6 and up after spinal shock resolves - #1 trigger distended bladder/rectum Sx: severe hypertension (up to SBP 300mmHg), bradycardia, flushing/diaphoresis (above injury), pale below injury Tx: Remove cause of distension + rapid acting HTN med |
| Autonomic dysreflexia Treatment | - Sit upright @ 45 dg head of bed - Find + remove cause (check bladder first then bowel) - Loosen tight clothing - Monitor BP + notify provider - Rapid acting HTN med if persistent elevation |
| Autonomic Dysreflexia Nursing Priorities | - Airway, breathing, circulation (FIRST) - rigid cervical collar + backboard - Maintain SBP >90 mmHg - Repositioning + pressure relief Q15 min on chair - Transfer by logroll |
| Respiratory Priorities for Spinal Cord Injuries | - Above C4 = total loss of breathing function (mechanical breathing) - Below C4 = diaphragmatic breathing w/ risk of insufficiency - Respiratory complication leading cause of death after SCI |
| Systemic Lupus Erythematosus | Chronic inflammatory AI disease w/ unpredictable remission + flares - Auto-Ab form against cell nucleus + immune complex deposit in capillary basement of kidney/heart/skin/brain/joints - Lupus nephritis = leading cause of death - Infection commonly lethal -> fever = likely infection vs flare Dx: ANA titer (present in 97%), Anti-DNA (50%), Anti-smith (30-40%), ESR/CRP Tx: NSAIDs (mild), antimalarials (steroid-sparing), corticosteroids (severe), immunosuppressives (reduce steroid use) |
| Systemic Lupus Erythematosus Clinical Manifestations | - Dermatologic: butterfly rash, photosensitivity, discoid lesion, oral ulcer - MSK: polyarthralgia w/ morning stiffness (1st complaint), arthritis (95%), swan neck - Renal: mild proteinuria -> lupus nephritis (leading cause of death) - Hematologic/infectious: anemia/leukopenia/thrombocytopenia, infection (major death cause) |
| Systemic Lupus Erythematosus Nursing Education | - Sun protection (photosensitivity) - Reduce exposure to triggers = stress/fatigue/infection/drugs - Avoid live vaccine on immunosuppressive therapy |
| Shock | Syndrome of decrease tissue perfusion + cell metabolism - Cardiogenic vs Hypovolemic vs Distributive vs Obstructive |
| Stages of Shock | - Initial (1): cell metabolism shift to anaerobic + minimal Sx - Compensatory (2): SNS activation (HR/vasoconstriction/increase CO) + blood shunting from skin/kidney/GI + RAAS activation - Progressive (3): compensatory mechanism fail -> BP drop + edema -> organ failure begins - Refractory (4): irreversible organ damage |
| Cardiogenic Shock | d/t pump failure Sx: tachycardia, hypotension, narrow pulse pressure, pulm congestion |
| Hypovolemic shock | - Absolute (bleed or GI loss) vs Relative (3rd spacing) - Compensation: increased cardiac output/HR initially - Lead to decrease stroke volume + central venous pressure/pulmonary artery wedge pressure (CVP/PAWP) |
| Anaphylactic shock | Sudden onset s/p allergen exposure Sx: angioedema, wheezing/stridor, urticaria, respiratory distress Tx: Epinephrine (first line) + antihistamine |
| Shock Management | - Fluid resuscitation (hypovolemic + septic + anaphylactic) - Vasopressor for hypotension -> keep MAP >60-65 mmHg for perfusion - NO trendelenburg -> decrease breathing + increase ICP |
| Septic Shock Management Bundle | - Labs: Lactate + blood Cx -> repeat lactate - Broad spectrum ABx (within 1 hr) - Hypotension -> vasopressors PRN + 30 mL/kg NS - Measure central venous pressure + central venous O2 sat |
| Sepsis | Severe infection affecting multiple organs - Progression: Infection -> SIRS -> sepsis -> septic shock Sx: fever/hypothermia, tachycardia/tachypnea, hypotension, abnormal WBC - Multiple Organ Dysfunction Syndrome (MODS): 2+ organs failing/needing support -> 75% mortality risk |
| Multiple Organ Dysfunction Syndrome | - 2+ organs failing/needing support -> 75% mortality risk - Septic shock complication |
| Triage | "To sort" - determine acuity -> most critical patient treated first |
| Primary Survey | - ABCDE = Airway/alertness -> Breathing -> Circulation -> Disability -> Exposure - Jaw thrust procedure for neck/spinal injury with LOC |
| Secondary Survery | - Focused H/P - Head to toe assessment - Pain management - Emotional support - Dx studies - Transfer preparation |
| Heat Emergency Nursing Priorities | Heat cramp (rest/fluids) -> heat exhaustion (cooling /fluids) -> heat stroke (ABCs/rapid cooling) - Risk of rhabdomyolysis (+ myoglobinuria) + DIC with heat stroke |
| Frostbite Nursing Priorities | - Rewarming - Analgesia - Possible amputation |
| Hypothermia Nursing priorities | - ABCs - Rewarming - Correct acidosis - Remove wet clothing |
| Poisoning Emergencies Treatment | Activated charcoal (most effective within 1 hr ingestion) - May absorb/neutralize antidote if given too closely - Contraindication: diminished bowel sound/paralytic ileus |
| Mass Casualty Triage Tags | - Red: Life threatening injury - Green/yellow: Non-life threatening injury (~2/3 patients) - Blue: Expected to die - Black: Dead *Triage happens much faster than ED triage* |
| Emergency vs Mass casualty incident (MCI) | Emergency: extraordinary event manageable w/ existing resources MCI: overwhelm community ability to respond w/ existing resources |
| NIMS | national incident management system - DHS coordinated |
Created by:
sleepingbear