(1) Common problems in acute care Flashcards
Acute Pain - what is the duration
< 6 months caused by tissue damage
Chronic Pain - What is the duration
Continual or episodic pain of >6 months
Acute versus chronic pain
acute < 6 months
chronic > 6 months
Dislocated knee playing tennis. What type of pain
Somatic
Cutaneous - describe
Skin
What type of pains is Cholelithiasis - gall bladder pain?
Visceral
Visceral - describe
Around internal organs
What type of pain is Sciatica?
Neuropathic
Neuropathic pain - describe
Along nerve pathway injury or compression
What type of pain is Herpes zoster?
Neuropathic
Somatic - describe
Soft tissue
WHO ladder of pain management
3 step initiative - cancer, anesthesia
- Non-opioid +/- adjuvants
- Non-opioid +/- adjuvants + mild narcotic
- Non-opioid +/- adjuvants + moderate narcotic
WHO ladder of pain management
Breakthrough cancer pain
Sustained release patch
When discussing pain management, what is an adjuvant
Not typically used for pain management: Antidepressants Muscle relaxers Sedatives Anti-anxiety Anti-seizure
Q!
58 year old korean male, complains of chest pain 4/10, pallor, reluctant to answer questions. What would cause NP to admit the patient to Chest pain unit?
Ethnicity -
stoic asian cultural - taught not to express pain
Q!
Cancer patient with break-through pain on MSO4. What is the best next step?
Add a fentanyl patch
What is normal body temp in C?
37 degrees = 98.6F
What is a fever in C?
38.3 = 101.5 F
Causes of fever - that require antibiotics
Bacterial, viral, rickettsial, fungal, or parasitic infections
All other causes - do not require antibiotics
Patient shows up to ER with high fever, history of taking anti-psychotics. Which is priority? and what is likely diagnosis? A. Analgesics B. Antibiotics C. IVF D. PRBC
Likely diagnosis Malignant hyperthermia
C. IVF - flush it out
Non-infectious post-op fever. What are the first questions?
What do lungs sound like?
What is I&O?
What is the 3 leading causes of non-infectious post-op fever?
- Atelectasis
- Dehydration
- Drug reactions
What drugs cause Non-infectious post-op fever?
Amphotericin B Trimethorpim-sulfamethoxazole Beta-lactam Procainamide Isoniazid (INH) Alpha-methyldopa Quinidine ect...
Can someone have a drug reaction with a 2nd dose of the drug?
Yes
Causes of INFECTIOUS post-op fever
- Left shift - bandemia
- Surgical sites
- Catheters
is WBC > 30,000 due to infection?
Not likely
look more towards leukemia
Q! - Post-op patient fever for 3 days WBC 15,000 Eosinopils 9% Blood cultures negative What is diagnosis?
Drug Fever
Rationale -
Viral infection - Eosinophilia - allergic reaction
Bacterial infection - cultures negative
Malignant hyperthermia - Happens immediately after succinylcholine
Malignant Hyperthermia
Succinylcholine given with anesthesia
Increase temp
Remove stimulus
Give IVF and Dantrolene
All of the findings are expected with cluster headaches except? A. Nasal congestion, rhinorrhea B. daily peri-orbital pain C. Precipitated by alcohol D. Vice like pain
D. Vice-like pain
Pain with cluster headache
– pain around eye
Headache evaluation (5)
Chronology Location and duration Associated activity Associated symptoms Triggers
3 major types of headaches
Tension
Migraine
Cluster
Tension Headache
S/S, Labs, Management
Most common - 90% of headaches S/S - vice like generalized no focal neurological symptoms Management - Relaxation OTC analgesics
Tension Headache -
S/S, Labs, Management
Most common - 90% of headaches S/S - vice like generalized no focal neurological symptoms Management - Relaxation OTC analgesics
Migraine types (2)
Classic migraine (migraine with aura)
Common migraine (migraine without aura)
Migraine
Female
Late adolescence/early adulthood
Family history +
Migraine incidences
Female
Late adolescence/early adulthood
Family history +
Migraine Triggers
Emotional/physical stress Lack/excess sleep Missed meals Specific foods Alcohol Menstruation Use of birth control Nitrates Changes in weather
Migraine Symptoms
Unilateral, lateral throbbing episodically May be dull/throbbing Build up gradually Focal neurologic disturbances -- numbness, visual, clumsy Photophobia and phonophobia
Migraine diagnosis
IF new migraine - rule out organic causes
- BMP, CBC
- VDRL - neuro syphilis
- ESR
- CT scan of head with neuro findings
Migraine management
Avoid triggers
Relax/stress management
Prophylactic daily therapy if >2-3xmo
– topiramate, gabapentin, amitryptyline, propanolol
Migraine management of acute attack
Rest in dark/quiet room
ASA
sumatriptan (imitrex) 6mg SQ at onset x 3
Imitrex 25mg PO at onset
Cluster headache - causes
causes Middle-aged man Alcohol s/s Severe - unilateral periorbital pain daily Occurs at night < 2 hours Ipsilateral nasal congestion Rhinorrhea Eye redness
What is the black box warning for tricyclic antidepressants?
Prolongation of the QT
Cluster headache treatment
100% O2
Sumatriptan 6mg SQ
Ergotamine tartrate aerosol inhalation
Sumatriptan is given to treat?
Cluster headaches and migraines
Nutritional support
What is the normal Albumin level & what does low albumin look like?
3.5-5
< 3.5 Protein malnutrition
< 2.7 – edematous
What gives you the earliest indication of malnutrition?
Pre-albumin
What is the normal hemoglobin?
When do we transfuse?
Women 12-15.5
Men 13.5-17.5
Transfuse < 8/24
– in certain patients 7 might be acceptable
Why do men have higher H&H than women?
Testosterone stimulates erythropoietin production.
What is the hemoglobin/hematocrit ratio?
1/3
Hemoglobin 10 - hematorcit 30
1 Unit PRBC should affect your H&H by how much?
Hemoglobin up by 1
Hematocrit up by 3
Clinical observation of Good nutrition
Clear nail beds free of ridges Pink moist mucous membranes Skin is shiny Musculature Hair not easily plucked
Determining the type of Nutritional Support
Use the gut if you can
- > 6 weeks - Enterostomal Tube (PEG)
- < 6 weeks - NGT
- —-At risk for aspiration? uses Duodenal tube (nasoduodenal tube)
NO gut
- -> 2 weeks - Central vein (also needed if 10% dextrose or more)
- < 2 weeks - PIV
Complications of Enteral support (7)
Aspiration Diarrhea Emesis GI bleeding Mechanical obstruction of the tube Hypernatremia Dehydration
Complications of Parenteral Nutritional Support (8)
Pneumothorax Hemothorax Arterial laceration Air emboli Catheter thrombosis Catheter sepsis Hyperglycemia HHNK
Re-feeding syndrome
low phosphorus
What are some changes you can make if diarrhea r/t enteral feeding occurs? (3)
Dilute solution
If on bolus feeding - change to continuous
Decrease rate
Q! - Suspected CLABSI. What is best intervention? A. Start antibiotics B. Cultures C. Change wire D. D/C line
If suspected - GET IT OUT
D. D/C line - pull line to get the tip
Q! - What does protein-rich supplementation do?
Aids in post op healing
Q! - What value is most critical in a cachexia patient? A. Mag B. Na C. K D. Ca
K - most critical
Q! - If a patient on TPN is in sepsis, What labs are appropriate A. Blood cultures B. CBC C. LFT D. BMP
D. BMP - glucose and electrolytes
