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AH2 Final

Study Guide

Cause of acidosis anerobic metabolism
Shock and oliguria Caused by Aldosterone; blood shunts away from kidneys
Worsening shock kidneys fail, urine output decreases, systolic falls below 60
Labs and shock liver failure
Clotting factors and shock DIC
Define shock inadequate tissue perfusion
S/S of anaphylactic shock urticaria, respiratory distress, ABG's, wheezing
Medications and shock use Dopamine do not use morphine
Bleeding from surgical site apply pressure and elevate
Hemorrhage and fluids Normal saline
S/S of shock Start out normal BP with tachycardia
Types of Shock anaphylactic, cardiogenic, obstructive, distributive
Cardiogenic heart pump failure
Obstructive outside the heart blockage of blood flow
Distributive excessive dilation of blood vessels
Nursing Diagnosis and shock Ineffective Tissue Perfusion
Treatment for Burns Silver Sulfadiazine
Induce vomiting Do not use syrup of Ipecac, esophageal burns
Snake bite venom Wash with soap and water/keep patient calm
S/S of smallpox Shows on face and forearms
Nursing diagnosis for mania risk for injury
Medications for psychiatric emergency haloperidol (Haldol)
Treatment for near drowning Ventilation
Heat Exhaustion skin is cold, clammy reports dizziness, weakness, hypotension, faintness treat with oral fluids
Abdominal injury tenderness, distention, rigidity indicates abdominal bleeding and possibility of hypovolemia
Teaching for pacemaker monitor radial pulse for 1 min, irregular heart rate/ rhythm that is lower than pacemakers set rate can indicate malfunction also grounded appliances are safe; no MRI’s
Care for a patient in V-fibrilliation immediate defibrilliation, also patient will have absent peripheral pulses
MRI and pacemaker contraindicated
F waves very rapid P wavers appear as A-flutter
V-tach and dysrhythmias rhythm regular, heart rate 150-250 can lead to irregular rythm V-Fib
Treatment for sinus tachycardia decrease workload on the heart and treat cause
Location of sinus node Right atrium
PVC's and symptoms Dizziness, fatigue, lightheadedness
PAC and location in heart Atria
Depressed ST segment Ischemia
Brain voluntary movement, regulates heart rate Frontal lobes for voluntary movement and medulla for heart rate
Define neurotransmitter and parts of a neurons carries impulses over the synapse, Dendrite carries impules toward and Axon impulses away
Define Visceral sensory neurons transmits sensory or motor impulses from ANS and PNS to the CNS
Myelin Sheath electrically insulates neurons
Ascending tracks white matter/sensory impulses
Neuro Assessment Glasgow Coma scale
Cranial Nerves Oculomotor, III; Hypoglossal, tongue; Olfactory, sense of smell
Acetycholine and response stimulates muscle contraction
GCS score 15 is good, 7 indicates comatose Deterioration in pts condition, Notify PHCP stat
EEG and teaching Before the test make sure pts hair is clean and dry
Care for lumbar puncture bed flat for 6 to 8 hours, monitor puncture site, encourage fluids
MRI teaching assess no pacemaker, metal, tattoos, jewelry
Positive Babinski stroking the sole of the foot results in extension of great toe and fanning out of remaining toes
S/S of ICP headache, N, V, amnesia, drowsiness
Vitals & ICP Late indication characterized by bradycardia, irregular respirations, & arterial hypertension (widening pulse pressure)
Assess of headache pain keep diary, Aviod opioids
Treatment for tension headache relaxation techniques; massage; dark, quiet room.
Seizure care Prevent injury and maintain airway; put up the side rails and put pt on their side
Medications and seizures anticonvulsant phenytoin (Dilantin) most common; noncompliance can lead to status epilepticus
Diabetes Insipidus and brain injury Resulting in polyuria and polydipsa
Mannitol Assessment utilizes osmosis to pull fluid into the intravascular space and eliminate it via the renal system so you will have increased urination; monitor serum osmolarity and electrolytes
Concussion Cerebral concussion is considered a mild brain injury, characterized by headache, dizziness, or nausea and vomiting
Decadron and headache lessen the edema/swelling and reduce symptoms
S/S spinal shock immediately following injury, cord below injury stops functioning resulting in vasodialation, hypotension, and bradycardia; pt is unable to maintain temp (hypothermia) and reflexes below level of injury are lost causing retention of urine and feces
Teaching and Sinemet converts into dopamine in the brain; used to treat Parkinson’s disease; eat for shortly after (not with or before); may discolor urine and sweat
Teaching confusion calendars, clocks, personal items, seasonal decorations in pt’s environment; don’t correct them if delusional, instead focus on feelings; reduce stressors such as fatigue, overstimulation, pain; maintain usual routines
Treatment after craniotomy ICU; frequent neurologic assessments every hour for the first 24 hours; CT scan to assess edema; assess pt response to change in body image
Define TIA temporary blockage of blood to the brain
Rehab and stroke patient Rehab right away to help keep current functioning
Patho of multiple sclerosis degeneration of myelin sheath, inflamed nerves cause nerve impulses to slow down or become blocked
Teaching and Myasthenia gravis energy conservation, schedule activities when meds are at peak level, proper nutrition, s/s of crisis conditions, rest periods, avoid people with infections and exposure to cold
S/S of Guillain-Barre Ascending paralysis; plateau; descending resolution; pain, cramping or numbness
labs and Guillain Barre lumbar puncture with CSF analysis shows normal cell count with elevated protein, pulmonary function test
Treatment for trigeminal neuralgia dilantin, nerontin, and tegretol for nerve pain; baclofen and clonazepam may also be effective in controlling symptoms; alcohol injection; nerve block, surgery, radio-frequency ablation, or gamma knife radiosurgery
Bells palsy Treatment prevention of complications is goal,prednisone for 7-10 days to decrease inflammation, analgesics for pain, antiviral, moist heat & gentle massage, facial sling
Eye care for bells palsy to protect the eye: administer eye drops or eye ointment; teach patient to use a patch over the affected eye; advise patient to wear glasses or goggles especially when outside or in areas with particles in the air
Thymectomy and what disorder used to treat MG; decreases production of Ach receptor antibodies which decreases symptoms in most patients
Created by: laotracuata