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Med Surge 3 Final

QuestionAnswer
Central nervous system Brain and Spinal cord
Peripheral nervous system Peripheral nerves and Cranial nerves
Autonomic nervous system Sympathetic (adrenergic) and Parasympathetic (cholinergic)
Frontal lobe socialization, expressive speech (Broca's area)
Parietal lobe Sensory interpretation, Proprioception, and Body image
Temporal lobe Receptive language (Wernicke’s area)
Hippocampus Memory - deep in the temporal lobe
Occipital lobe Interpretation of vision
Brainstem Vital life center
Cerebellum "little brain" (Coordination, Fine motor movement, and Balance)
Vertebral column 33 vertebrae
First pair of spinal nerves leaves the cord above C1
Sympathetic nervous system Fight of flight (Dilated pupils) - general rule: speed up except GI tract
Parasympathetic nervous system general rule: slow down except GI tract
CN 1 Olfactory (S)
CN 2 Optic (S)
CN 3 Oculomotor (M)
CN 4 Trochlear (M)
CN 5 Trigeminal (B)
CN 6 Abducens (M)
CN 7 Facial (B)
CN 8 Acoustic (S)
CN 9 Glossopharyngeal (B)
CN 10 Vagus (B)
CN 11 Spinal accessory (M)
CN 12 Hypoglossal (M)
CN 3, 4, and 6 Tested together for eye movement
Miotic constricted pupils
Mydriatic dilated pupils
Altered LOC A decrease in response to surroundings
A&Ox4 person, place, time, situation
CSF in the brain 75 mL
3 things that work to keep balance water, blood, and CSF
Epidural hematoma between the skull and dura
Subdural hematoma acute, subacute, or chronic (NOT acute, life-threatening arterial bleeds)
ICP normal range 10-20
The earliest sign of serious impairment of brain circulation related to ICP throbbing headache
Mannitol osmotic diuretic (pulls fluid from different places, VERY important to get electrolytes); it does not cross an intact blood brain barrier
CPP Central Perfusion Pressure (needs to be >70 to have adequate O2)
CBF Cerebral blood flow
CBV Cerebral blood volume (75 mL at all times)
CPP MAP-ICP (70 or > = good CBF; <50 = Irreversible brain damage)
IICP Increased myocardial contractility
Herniation the most common, compression of brain tissue
Cushing's reflex/response/triad Increased BP, Decreased HR, Decreased RR
Widening pulse pressure assessment finding of IICP
Most serious complication of IICP brain herniation
IICP Diagnoses History and physical, CT (if contrast is used force fluids after), and Lumbar Puncture
Relieve IICP avoid trendelenberg position
Reduce metabolic demand of IICP avoid shivering (it increases ICP)
Generalized seizures whole brain Convulsive = Tonic (rigid muscle contraction - brief, sudden contraction), Tonic/Clonic (alternating contraction and relaxation) - most common Nonconvulsive = rigid and stiff (dead in the bed)
Epilepsy reocurring seizures
EEG electrical activity with or without stimulus that encompasses the whole head
CT for seizures ordered with an EEG to confirm diagnosis of seizures
Dilantin (Phenytoin) Treatment effect not immediate because it needs to get a therapeutic level - ALWAYS give Dilantin in NS - Stop tube feedings and hour before and after giving Dilantin and tube rinsed/flushed with water after SE = gingival hyperplasia
Celebrex (Fosphenytoin) Short term management
Dilantin and Celebrex therapeutic level 10-20
New admit for seizures most important plan of care is to place a sign above the bed
Post-ictal phase of a seizure let them rest, without rest they will seize again
HA categories Stress/tension, HTN, and vascular
Most effective way to diagnose a functional headache get a thorough history
Migraine auras Sensory - pain is NOT an aura
Migraine triggers Stress, Caffeine, foods high in tyramine and nitrates, smoke, and bright lights. Avoid smoking, aged cheese, and red wine.
Preventative migraine medications taken every day - Inderal (beta blockers)
Sumatriptan (Imitrex) Abortive drug - take it to stop the entire migraine. Can only take twice a day and it has to have an hour in between doses
Antiemetics for headaches Zofran when they are nauseous, once they have vomited they need phenergan (must be diluted in at least 10 mL NS and given slowly - at least over 5 minutes)
Patient with the "worst headache of their life" tell them to go to the ED immediately
Malignancies May be primary, secondary, or rapid growing
Gliomas arise from neuroglia
Meningioma arise from the meninges
Neuromas arise from nerves
Pituitary Adenomas Responsible for hormone release (Prolactin, HGH, ACTH)
Angiomas Speculated that at least 40% of cerebral hemorrhage in people under 40 is related to angiomas
Grade 1 Tumor The tumor grows slowly, has cells that look similar to normal cells, and rarely spreads. May be removed surgically. Most likely a menengioma
Grade 2 Tumor The tumor grows slowly, but may spread into nearby tissue and may become a higher grade tumor. Most likely a glioma
Grade 3 Tumor The tumor grows quickly, is likely to spread into nearby tissue and the tumor cells look very different from normal cells. Most likely an oligdendroglia
Grade 4 Tumor Grows very aggressively Has cells that look very different from normal cells, and is difficult to treat successfully. Most likely an oligdendroglia
Embolic stroke most serious because it is acute. Usually results in atrial fibrillation.
TIA <24 hr in duration. One sided weakness (no bilateral paresthesias)
Left brain CVA o Right hemiplegia Expressive, receptive, or global aphasia Cognitive impairment Slow cautious behavior Right visual field defects
Right brain CVA Left hemiplegia Spatial-perceptual issues Hemi-neglect (Denial – neglect of the affected side (don’t realize that it is even still there)) Distractibility Poor judgment Left visual field defects
Patient who is right handed and experiences a left sided stroke right hemiparesis and speech is affected
Anterior Cerebral Artery Supplies the medial surface of the frontal lobe and the parietal lobes
Vertebral arteries Supply cerebellum, brainstem, spinal cord, medial and inferior aspects of temporal lobes. And the occipital lobes
Middle Cerebral Artery Artery that supplies the largest area of the cerebrum
Hemorrhagic CVA primarily caused by uncontrolled HTN
CT with Contrast Force fluids after and creatinine levels need to be checked
Dysphagia Feed on UNAFFECTED side, HOB up, and thickened liquids
Verbal deficits after CVA allow pt sufficient time - DON'T finish sentences for the pt
Walking aids after CVA When transferring patient from a chair to a wheelchair, do not have them lean forward and keep their good leg straight
Contusion Usually results in decreased LOC
Dextrose 5% becomes hypotonic when in the body but may be identified as isotonic
Hypertonic Solutions D5/0.45 NS and D5/0.9 NS
Isotonic Solutions 0.9% NS and LR
Spinal Cord Injuries Concussion Contusion Laceration Transection Shearing of vessels Hemorrhage Edema
Patient admitted from the ED following a MVC on a backboard with a c-collar and is alert and oriented talk to the trauma doctor, obtain a written order to remove the backboard after his c-spine has been cleared and leave the collar in place
Spinal Shock Flaccid paralysis, loss of reflexes below injury, hypotension, lasts less than 48 hours, temporary loss of motor and sensory function, temporary loss of reflexes and autonomic function
Autonomic Dysreflexia Drives BP dangerously high (300/160), severe HA and blurred vision
MS Progressive demyelinating disease of the CNS (progressive increasing weakness)
MS Tremor Intentional (Not resting)
Guillain Barre Number 1 concern = airway (check pulse ox and pulmonary function - peak flow)
Guillain Barre Diagnosis Serial peak flow rates - essential to evaluate ascending progression that involves the phrenic nerve
Guillain Barre Management Ventilatory/intubation/trach and IV immunioglobulin (must be hung at the same time every time)
Trigeminal Neuralgia Painful twitch
Trigeminal Neuralgia Medication Antiseizure medicaitons - Tegretol (Carbamazepine)
Trigeminal Neuralgia Goal prevent pain
Bells palsy more common in younger patients
Parkinson's Insufficient amounts of dopamine in the basil ganglia
Parkinson's cardinal findings Tremor at rest, Muscle rigidity, Bradykenesia, Shuffling gait
Parkinson's Mask like expression priority is the ability to chew and swallow
Parkinson's Medication toxicity acute confusion
Parkinson's Medication Sinemet – Ldopa often given in combination with Carbidopa,
Parkinson's walking education Teach pt to stop periodically when walking to prevent falling from propulsive gait – reduces the risk of falling
Myasthenia Gravis Easily fatigability, diplopia, ptosis (weak eye closure)
MG Diagnosis Tensilon Test
Anticholinesterase drugs give before meals to give the best chance of preventing aspiration – if breakfast is at 8:30, it needs to be given at least by 8. This medication must be given on time every time.
Myasthenia Crisis Sudden exacerbation of symptoms (ventilatory distress, increased muscle weakness, difficulty swallowing and talking), Tensilon test = pt improves, Give anticholinesterase medications
Cholinergic Crisis Sudden exacerbation of symptoms (abd cramping, diaphoresis, ventilatory distress, increased muscle weakness), Tensilon test = pt worsens, Give atropine antidote IV
MG Medication administration administer medications 30 - 60 minutes BEFORE meals to help with chewing and swallowing
Orthopedic overuse Keyboarding and Other repetitive joint actions
Bursitis Inflammation of the fluid filled sacs that prevent friction between bones in joints
Tendonitis Inflammation of the tendon sheaths and the synovial membrane
Bursitis and tendonitis treatment prolonged rest, intermittent ice and heat, NSAIDs
Carpel Tunnel Syndrome Irritation and Inflammation of the medial nerve
Carpel Tunnel Treatment Rest in neutral position Cockup splints (especially at hs)- Wrists in neutral position NSAIDS Surgery if risk of permanent nerve damage or extreme pain
Ganglion Cyst "Bible bumps" - forms at the dorsum of the wrist usually resulting from chronic overuse irritation. Tx = stop activity and possible surgery
Epicondylitis (tennis elbow) Pain radiates to dorsal, extensor surface of the forearm, NSAIDS and rest = treatment of choice
Effects of Chronic Immobility Pneumonia, DVT, pressure ulcers
Immobility Can produce degenerative changes. Caused by nonuse, lack of exercise, pain, weakened muscles, joint contractures (takes 24-48 hrs to develop), prolonged bed rest, and incorrect positioning in bed
Preventing immobility MOVE! (PT and OT can help), correct full turning, isometric exercises, ROM
Deep Tissue Injury Blue to deep bruising that you cannot tell whether the skin has been eradicated or not (patient’s who have fallen and laid in the same position for a period of time). Unable to be staged (usually found to be greater than a 4th stage pressure ulcer)
Rehab of immobility begins the instant nurses begin working with someone who has an immobility issue. Move what can be moved and do it often
Joint Strains Injury to a muscle or muscle and tendon
Strain Treatment Rest with moderate movement NSAIDS Analgesics Apply ice and elevate Ace bandage No heat in the first 24 hours
Joint Sprains Twisting injury to ligaments. Usually involves stretching and tearing of ligaments
Dislocation or subluxation of joints Pain with movement. Both require reduction and may require conscious sedation
Rotator Cuff Tear Tear in 1 or more of the SITs muscles, + drop test, Tender AC joint, unable to perform over the head activities, MRI needed, NSAIDS and possible surgery
Torn Ligaments Tear = higher risk in girls, causes knee instability issue, pain and loss of functions, rest, NSAIDs, and surgery. Prevention = 4 point knee muscle exercises
Meniscal Tears 2 crescent shaped cartilage discs attached to head of the tibia, allows knee to bed without pain, knee may "give away", loose cartilage may become trapped preventing extension, Rest NSAIDs and surgery
Osgood-Schlatter disease Painful swelling of the bump on the upper part of the shinbone, just below the knee (tibial tubercle). Thought to be caused by small injuries due to repeated overuse before the area has finished growing. Affects boys more than girls
Ruptured Achilles May occur suddenly, common in runners especially those that don't warm up. Sharp pain with inability to plantar flex, surgical repair and a cast (long term immobility of joint). Will never get back to 100%
Fractures Open or closed, complete or imcomplete, simple or compound, stable or unstable
Most dangerous fracture Open compound (r/t infection)
Oblique fx 45 degree angle
Spiral fx curves up or down the bone
Greenstick fx broken on one side - bone looks bent. Incomplete stable fracture
FX treatment (medication) NSAIDs/ Prostaglandins, morphine, possible surgery
Prostaglandins produced with the help of an enzyme called cyclooxygenase (AKA as Cox).
FX treatment (ortho) Splints to avoid joint movement, crutches to avoid weight bearing, canes to limit weight bearing
FX ER management RICE, if open - cover with sterile dressing, stop bleeding, check pulses, splint
Traction for fx helps maintain alignment and reduce muscle spasms
Pt in traction reports severe pain from muscle spasms Check body alignment
Bucks Traction Decrease spasm, hip fractures
Russell's traction Buck;s with a double pulley and knee sling
Bryant's traction for children with a fractured femur
Pelvic traction helps with muscle spasm (back and pelvic fx)
Skeletal traction pins/external fixation
Electrical stimulation used in fx that are not healing appropriately, can be internal or external
Pin care sterile supplies but clean procedure. Site can be covered with a 4x4 but is not needed if the area is dry
Casting rigid immobilization device applied after swelling as past peak point (usually 72 hrs)
Plaster Cast 48 hrs to dry and must be kept dry
Fiberglass cast 1 hr to dry and may blow dry if it gets wet (no more than 10 min on low heat)
Nursing priorities in cast care Distal vascular checks (swelling), distal neuro checks (sensation and motion), checking for hot spots indicating infection or possible cast compression
Rib fractures Biggest issue is pain and the ability to deep breathe. No use of restrictive devices, pillow used for splinting with coughing
Flail chest nonsymmetrical chest with breathing. Highly unstable chest wall that interferes with ability to ventilate. may require ventilator and PEEP.
Complications of fx Hemorrhage, infection, mal/non/dys alignment, compartment syndrome, DVT, gangrene, fat emboli,
Compartment syndrome Muscle pressure builds up too much and the blood supply is impeded and the muscles do not get adequate oxygen
Forearm Compartments 2
Thigh Compartments 3
Lower leg compartments 4
Compartment Syndrome s/s deep, throbbing, unrelenting PAIN
Volkman’s Contracture Contractured wrist and fingers of affected hand – secondary to impaired arterial blood flow Unable to extend fingers Diminished color, temperature, and pulsations distally Permanent damage in hours if arterial circulation not restored
Amputations Surgical removal of all or part of a limb.
Diabetic foot amputation Partial sims - best type of amputation to get because the patient can still walk (with a stump sock on)
Stump Care Elevate, ACE, Clean and DRY surgical wound, encourage movement of affected limb, monitor drainage pain and infection, stump sock after dressing comes off. Goal is to keep the limb health for fitting of prosthesis.
Disorders of the back Pain or discomfort associated with the actual vertebral column, the nerves emanating from within the vertebral column, and, or the muscles articulating with the vertebral column.
Low back pain L4-5 and L5-S1
Low cervical region pain C2-5 is most common
Back strain twisting, bending, and lifting
Acute sharp pain muscular
burning and sharp pain nerve involvement
dull and aching pain chronic issue
Sciatica or radiculopathy pain that radiates down one or both legs
Back pain management Focused on history and physical. Pt is treated symptomatically for up to 4 weeks (rest and relaxation, analgesics, stress reduction, muscle relaxants), no heavy lifting, NSAIDs, Medrol dose pack for anti-inflammatory, heat and cold therapy
Back pain may be self limited 40% remit in one week 60 -80 % remit in 3 weeks 90 % remit in two months May be chronic (up to 3 mo)
Degenerative Disk Disease May be injured by trauma and/ or wear and tear disorders that cause the nucleus pulposus to herniated through the annulus
Degeneration and/or herniation of intervertebral discs Discs become more fibrous with age because of wear and tear L4 to S1 most common sites Cervical vertebrae the 2nd most common site
Back pain diagnosis MRI = diagnostic tool of choice, myelogram, EMG possibility
Medical Management: Cervical Neck Non-operative, rest, cervical collar, pain management, possible traction
Discectomy Removal of the disc. May be donw with spinal fusion
Laminectomy Removal of boney processes that allows the visualization of the nerves and the removal of pathology
Hemilaminectomy Removal of the lamina and part of the vertebral arch
Foraminotomy Increasing the space in the intervertebral foramen to allow more space for the nerve
Nursing Management: Neck Cervical Discectomy and fusion, neck collar, bedrest, immobility of neck, pillow under shoulders and head, log rolling, routine dressing care (do not change)
Bone Cancer Malignancy within bone structure. Metatstatic is most common. CT, MRI, labs - Hypercalcemia is commonly found because of bone breakdown.
Hypercalcemia weakness, incoordination, anorexia, n/v, short QT and ST, bradycardia, LOC changes
Osteoarthritis/DJD Chronic, progressive degeneration of the hands and weight bearing joints such as the knee, hip, and lumbar vertebrae. Most common disorder of joints Causes chronic join pain especially with early movement
Rheumatoid Arthritis A connective tissue disorder Inflammatory based arthritis Autoimmune response occurs in the synovial fluid
Osteoarthritis Risk Factors Over 40, obesity, wear and tear, trauma, congenital, inflammatory, poor posture, prolonged steroid use
Osteoarthritis Goals Prevent disease or halt progression, maintain joint mobility, prevent deformity, reduce pain
Osteoarthritis joint pain deep aching pain, especially upon wakening, limited ROM, improves with movement, related to temperature. Joint stiffness usually lasts less than 30 minutes
Rheumatoid Arthritis Joint pain swelling, warmth, erythema, bilateral and symmetric. Joint stiffness > 30 minutes
Heberden’s Nodes hard nodules or boney swellings around the distal interphangeal joints - late stages of OA
Bouchard’s Nodes Similar to Heberden’s but develop around the proximal interphangeal joint
OA and RA diagnosis X-rays, lab tests (inflammatory indicators: ANA, ESR, CRP)
OA and RA prevention maintain normal weight, physical activity, minimal wear and tear
OA Management No cure - goal is to stop progresion. Pain management: tylenol, NSAIDs
Cox 1 Ibuprofen, Advil
Cox 2 Inhibitors Celbrex
Joint replacement Need for joint replacement commonly associated with mobility, pain and/or stability issues secondary to Osteoprosis, OA, RA, Fx, trauma
Hip replacement Removal of the head of the femur followed by placement of a prosthetic implant of the head of the femur and/or socket
Knee Replacement Replacement of knee joint with femoral (distal) component and tibial component
Complications of joint replacement infection, hemorrhage
Hip Dislocation Prevention: Posterior Surgical Approach worry more about dislocation. NO internal rotation, do not adduct hip past midline, do not sit on low chairs, lean forward, or put on shoes without extension equipment
Hip Dislocation Prevention: Anterior Surgical Approach Greater chance for them to have hemorrhage because of vessel location. No external rotation, do not flex hip greater than 90 degrees, don't sit on low chairs or lean forward while sitting. Do not raise knee higher than hip, don't pivot on involved leg
Hemorrhage r/t joint replacement Joint replacements commonly lose a lot of blood - Surgeons will often have patients donate their own prior to surgery: Autologous - Can only donate 2 units within a 59 day period. Monitor VS, drainage, and H & H
Neurovascular Compromise Assess color, temperature, and movement. Monitor for swelling and/or deep throbbing unrelenting pain, pain with movement
DVT Assess for pain, swelling, temperature changes. TEDS - remove no more than 1 hour tid. SCDs
Time line for complications Wrong Move (disslocation) - anytime Wind (pneumonia) - 48 hrs Water (UTI/Bladder)- 48 to 72 hrs Wound (Infection)- 72 to 96 hrs Walk (DVT)- 72 to 120 hrs
Osteoporosis A metabolic, age related bone disorder in which bone demineralization causes decreased bone density, bone loss, decreased bone mass, and bone weakening
Primary Osteoporosis More in women
Secondary Osteoporosis More in men r/t steroids and smokers
Osteoporosis Goals prevention of bone loss, deformity and complications, and fractures
Osteoporosis Assessment loss of height, low back pain, kyphosis, pathologic fractures (wrist, hip, vertebral)
Osteoporosis Prevention Adequate calcium, vitamin d, and protein, weight bearing exercise, avoid ETOH, caffeine, and smoking, HRT
Osteoporosis Diagnosis Decrease in serial height, DEXA scan, spot scans, labs (Ca, Vit D3, Ph, alkaline phosphatase)
Osteoporosis Management Encourage regular weight bearing exercises (walking, biking, low impact aerobics)
Bishosphonates inhibit osteoclast function thus suppressing bone loss. Fosamax, Boniva, Calcitonin, Reclast, selective estrogen receptor modulators, parathyroid hormone agonist, biophosphate. Medications can be given daily
Fosamax once a week, sitting or standing up 30 min
Boniva Once a month, sitting or standing up 30 min
Calcitonin Daily nasal sprain then IM/SQ
Reclast IV once a year
Selective estrogen receptor modulators Evista
Parathyroid Hormone Agonist Forteo
The nurse is reviewing a prescription for a pt receiving drug therapy for the prevention of osteoporosis and the Pt has HTN the nurse should question a prescription for hormone replacement therapy
Systemic Lupus Erythematosus An auto immune disorder that results in an exaggerated production of autoantibodies. Characterized by exacerbations and remissions
SLE symptoms vague symptoms: x-rays to rule out arthritis, labs and endocrine studies r/t weight loss, weakness….play the rule out game to properly diagnose
SLE skin Butterfly rash across the face, papules, erythema, purpura, sensitivity to sunlight
SLE Diagnosis history and physical. Blood tests revealing anemia, thrombocytopenia, leukocytosis or leukeopenia, positive ANA (antinuclear antibodies), urine to see if there is any hematuria
SLE treatment no cure - supportive treatment. NSAIDs and Corticosteroids (single most important medication - need to check BS, they mask infection), immunosuppressive agents (reserved for the most seriously ill patients)
Vagnintis vaginal discharge, may be watery or thick, cottage cheese appearance, itching redness, and irritation
Gardnerella vaginalis Fish like odor, plated or glitter cells
Oral Candidiasis oral lesions. redness, pain, common after inhaled steroid use and chemo. Give nystatin
The nurse is performing an oral assessment on a pt and notes white-plaque-like lesions on the tongue, palate, pharynx, and buccal mucosa. When patches are wiped away the underlying surfaces are red and sore. What disorder does the nurse suspect? candida albicans
HIV a retrovirus that invades certain lymphatic cells such as helper T cells or CD4 cells (cell wall receptor cells) and macrophages and leads to their destruction and ultimately loss of effective immune functioning.
AIDS a wasting syndrome resulting from HIV infections that is characterized by immune system failure
B cells offer humoral (Body fluid/blood) immunity and are antibody producing
T cells offer cellular immunity and directly attack viruses and other invaders
Stem cells from bone marrow migrate to the thymus where they are converted to T cells
Helper Ts react to antigens and activate the immune system; T cells secrete cytokines that attract and activate B cells
seroconversion Once the HIV infection occurs and despite the virus being inactive antibodies are formed against it. Go from HIV (+) to (-)
Classification/Stages of HIV/AIDS Once the patient reaches a particular level or category he/she stays in that category
Primary Infection (Acute HIV infection) The point from infection to the development of antibodies to HIV
viral set point the balance between HIV and the body’s response to it. The higher the viral set point the poorer the prognosis.
HIV Asymptomatic (CDC Category A) Virus present but in low enough levels that it does not cause sx except for persistent lymphadnopathy. Focus on maintaining health and good defense responses.
HIV Symptomatic (CDC Category B) Symptoms begin to arise (treat the symptoms). Immunocompromised, fever, diarrhea, hairy leukoplakia, thrombocytopenic purpura
AIDS (CDC Category C) Virus infection is now considered full blown AIDS. Symptoms expand and entitlements begin
HIV/AIDS diagnosis Often not diagnosed until viral load is high and symptoms are advanced. Requires several screenings.
Ora Quick Rapid HIV-1 test Uses less than a drop of blood is much more rapid, which allows for earlier intervention and education. Tests the progression of HIV into AIDS
HAART (combination therapy) a regimen consisting of two antiretroviral agents inhibitors plus a protease inhibitor OR two protease inhibitors and one antiretroviral agent (2 and 1). Antivirals and Protease inhibitors
HIV/AIDS nursing management Supportive approach by body systems symptoms and stage. Emotional support, education, and social stigma and confidentiality.
Snellen Alphabet/Chart Numerator = the distance between the patient and the chart Denominator = the distance from which a person with normal vision could read the lettering
Low Vision – Blindness a general term describing visual impairment that requires patients to use devices and strategies (magnifying glass) in addition of corrective lenses to perform visually based tasks
Best Corrected Visual Acuity (BCVA) 20/70 - 20/200
20/80 to 20/100 still be able to read at near normal levels with optic aids
20/200 t0 20/400 may be able to read slowly with optical aids
loss of visual light perception BCVA that does not exceed 20/200 in the best eye and a widest visual field diameter of 20 degrees or less
Blindness causes diabetic retinopathy, macular degeneration, glaucoma, cataracts, aging
Blindness management Visual aides for magnification and vision enhancement, orientation to and frequent scanning of environment, using a clock for placement
Impaired vision decreased ability to see objects clearly. refractory or nonrefractory
Refractory: Hyperopia Inability to see NEAR objects clearly because of a failure to accommodate - Light focuses in front of retina. Most common (Far sighted)
Refractory: Myopia Inability to see DISTANT objects clearly because of a failure to accommodate - Light focuses behind the retina. Most common in children (Near sighted)
Refractory: Presbyopia Natural loss of accommodation caused by changes in lens accommodation (usually hyperopic in nature)- Poor near vision, Almost 100% of 60 year old require glasses
Refractory: Astigmatism Curvature issues in the lens or other part of the optic apparatus that results in a refractive error- Easily corrected
Refractory: Anisometria Different refractory errors in each eye. May be congenital or acquired.
Nonrefractory: Retinal disorders degeneration, tears, detachments, hemorrhages
Nonrefractory: Glaucoma A group of ocular disorders characterized by increased intraocular pressure that if unresolved will result in damage to the optic nerve and microinfarction causing loss of visual field
Glaucoma May be open angle or closed angle - 3rd leading cause of blindness in the US
Primary Open Angle Glaucoma (POAG) Is a primary issue of angled tissue in the anterior chamber that results in resistant flow of the aqueous humor - Most common form
Primary Angle Closure Glaucoma (closed angle) Resistance/blocking of aqueous humor between the posterior surface of the iris and lens, which places pressure against the pupil close proximity to the pupil - Rare, constitutes a medical emergency
Cataracts A decrease in transparency of the lens that interferes with visual acuity, protein coagulations cause the formation of opaque areas in the lens
Macular Degeneration results in loss of central vision, usually in older adults - gradual onset
Strabismus deviation from symmetrical movement. AKA Tropias
Esotrophic crossed eyed
Exotrophic deviates outward
Hypertrophic deviates up
Hypotrophic deviates down
Conjunctivitis Acute injection or redness of the conjunctiva. May be viral (watery drainage), bacterial(muco-purulent drainage), allergic (watery drainage).
Eye trauma occurs as the result of blunt or penetration injury because of foreign bodies, chemicals, lacerations, blunt force trauma, traumatic enuculation, chronic eye dryness
Presbyopia Progressive decrease in near vision - may still have 20/20 vision, requires reading glasses, usually after age 40
Open angle glaucoma s/s silent in early stages, bilateral, mild to dull ache, halos around lights, blurred vision, loss of visual acuity is not corrected by glasses, headache
Closed angle glaucoma s/s ACUTE - rapid onset, unilateral pain, conjunctivitis, cloudy cornea, photophobia, blurred vision
Cataracts s/s decreased visual acuity, glare, distorted vision, altered color perception
Retinal detachment s/s flashing lights, veiling (most common), floaters
Fluorescence tape and a Wood Lamp ascertain abrasive trauma - Paper tape with orange dye that stains the abrasion green so it is easier to see
Ear infections: external canal otitis externa - more in swimmers
Ear infections: inner ear otitis media - more in kids
External Otitis Inflammation of the external canal. Pain and fullness, pain when lifting up the pinna, yellow/green foul smelling discharge, canal is red and edematous
Cholesteatoma In growth of skin, debris that leads to chronic infection of the mastoid bone and possible the inner ear
Otitis Media Acute infection of the inner ear. Complication of URI, sinusitis, tonsillitus, allergic rhinitis. Usually short term. Otalgia, fullenss, fever, hearing loss
Meniere’s Disease Abnormal fluid in the inner ear. May be vestibular or cochlear. Usually unilateral.
Meniere’s Disease: Cochlear sensoineural hearing loss, tinnitus
Meniere’s Disease: Vestibular extreme vertigo, n/v
Meniere’s Disease Management low Na diet, antihistamines, antiemetic, diuretics
Vertigo Eyes get very big when changing positions to try to stop themselves if they are spinning. Patient has to get used to it because there is no cure
Hearing Loss 3rd most common disorder above 65. Can be conductive or sensoinural.
Conductive hearing loss Loss of sound conduction from the external and middle ear to the inner ear
Sensoineural hearing loss Hearing loss related to impaired function of the inner ear, primarily the cochlea and CN VIII
Weber test Bone conduction to test for lateralization of sound. Conductive loss will lateralize to the affected ear Sensorineural loss will lateralize to the better ear
Rinne test Bone and air conduction timing test Usually air conducts longer and louder than bone Conductive loss BC ≥ AC Sensorineural loss AC > BC
Skin layers Epidermis, Dermis, Subcutaneous layer
Skin assessment equipment strong direct lighting, small centimeter ruler, penlight, gloves, special procedures: wood's light and magnifying glass
Koilonychia anemia
Paronychia inflammation of surrounding tissue
Leukonychia related to trauma
Clubbing COPD
ABCDE rule Asymmetry, border, color, diameter, elevation
Macule flat
Papule raised <.5cm
plaque cirrhosis
nodule little bumps that feel hard
urticaria hives
vesicle <.5cm, small pox or chicken pox. raised and fluid filled
bulla > .5cm. raised fluid filled lesion
pustule raised lesion with puss in it
crust impetigo
scale cirrhosis
fissure cracks
erosion pressure ulcers
ulcer stages 1-3 and unstagable
excoriation children and older people who do not have their diaper changed
Primary lesions macule, papule, patch, plaque, nodule, wheal, tumor, uticaria, vesicle, cyst, bulla, pustule
Secondary lesions crust, scale, fissure, erosion, ulcer, excoriation, scar
Open Comedones blackheads
Meningococcemia Petechiae, purpura, ecchymoses Child appears ill, hypotensive, and tachycardic
Rockey Mountain Spotted Fever Maculopapular to petechial. Rash appears on the thenar eminence and flexor surfaces of the wrist and ankles. Palms and soles are usually affected HA, myalgia
Stevens-Johnson Syndrome (SJS) Vesicles to bullae. More shallow that SJS and TEN Child appears less ill that with SJS and TEN Positive Nikolsky sign – skin reddens, fluid collects underneath, and the skin rubs off leaving a raw base
Malignant Skin Lesions use ABCDE rules of examination
Beau’s line Transverse furrow or groove across the nail that extends to the nail bed. Occurs with any trauma that temporarily impairs nail formation, such as acute illness, toxic reaction, or local trauma.
Habit-Tic Dystrophy Depression down middle of nail or multiple horizontal ridges. Due to continuous picking of cuticle by another finger of same hand, which causes injury to nail base and nail matrix.
Burns an alteration in skin integrity resulting in tissue loss or injury caused by heat, chemical, electrical or radiation
Dry heat burn
moist heat hot water
chemical burn battery acid
electrical burn a/c and d/c
radiation burn gamma, beta
First-degree burn superficial, involves only the epidermal layer, never blisters, heals spontaneously
Second-degree burn dermal partial thickness, involves epidermal and dermal layers, pink moist and painful, gets blisters
Hand burns bad due to loss of functionality
Third-degree burn full thickness, nerve, muscle, and tendons, involves epidermal, dermal, subcutaneous layers and nerve endings. Formed eschar on skin
First-degree burn presentation erythema, edema, painful, blanching
Second-degree burn presentation very painful, ooxing, erythema, shiny, wet
Third-degree burn presentation eschar, edema, white or charred, little or no pain
Immediate or Emergent Phase Resuscitative stage lasts from the onset of injury through the successful fluid resuscitation – Stabilization. Determination whether to transport patient to a burn center - family travel is not considered
Estimation of Burn Size Fluid amounts are calculated using the % of body burned. Rule of Nines - Divides teh TBSA into areas - best for adults and children over 10
Rule of Nines face = 9% arms (shoulder through fingers) = 9% each front of body = 18% back of body = 18% legs (front and back) = 18% each Perineum = 1% each
Consensus Formula 2-4 mL x kg of body weight x % TBSA burned. Half is given in the first 8 hours then the next half given over 16 hours.
Acute or Intermediate Phase begins 48-72 hours after a burn injury. continue to reassess respiratory and CV status, F&E, and nutritional status. Pharmacological therapy and wound management
Rehabilitative Phase most costly and longest phase. Must be interdisiplinary.
Burns Blood Chemistry Increased K, Decreased Na, total protein, and decreased albumin
Burn Hematoloty Increased HGB and HCT, decreased fibinogen, platelets, and WBCs
Burns Assessment Assess airway, breathing, and circulation, neck and face burns need to be intubated immediately, give O2, check for signs of shock, establish 2 large bore IVs (14 or 16), determine history of injury (AMPLE)
Transferring burn patient do not apply creams, family travel is not considered, and a physician must call the burn center and speak to the physician to get the patient transferred
Nurse's role in transferring a burn patient make sure paperwork is complete and goes with pt, and give the nurse receiving the pt a complete report.
Created by: lpurcell08