185 FINAL EXAM Flashcards
Benzodiazepine, anti-anxiety, muslce relaxant, anti-convulsant
- Short acting
Use: Sedative (given in pre-op)
- Amnesia effect, produces sleep
Side effects:
- Drowsiness
- Confusion
- Hypotension
- Hepatotoxicity
- Low HR
Interventions: Vitals
Antidote: Flumazenil (Romazicon)
Midazolam
Dissolves chemical bonds w/in mucus making it separate/ liquiefying/ reducing viscosity
- Given as nebulizer
Use: Pneumonia, emphysema, asthma, & bronchitis
Side effects:
- N/V
- Tachycardia
- Hypotension
- Rotten egg oder
- Bronchospams (adverse)
Interventions:
- Vitals
- monitor cough & bronchial secretions
- Record GI symptoms before/after therapy
Antidote for Tylenol OD - Given PO
Mucomyst (Acetyl Cysteine)
Inhibits interaction of acetylcholine at recepter site on bronchial smooth muscle, resulting in bronchodilation
Use: Asthma, long term Tx or reversible bronchospasms associated w/ COPD
Adverse:
- Mouth dryness
- Throat irritation
- Dizziness
- Nasal congestion
Serious effects:
- Tachycardia
- Urinary retention
- Exacerbation of symptoms
Interventions:
- Vitals
- monitor cough & bronchial secretions
- Record GI symptoms before/after therapy
Ipratropium (Atrovent)
Corticosteroid - PO
- Decreases inflammation
- Caution w/ Diabetes (increases BS)
Use: severe inflammation, MS, asthma, COPD, pulmonary fibrosis
Side effects:
- Weight gain
- Depression, mood changes
- Poor wound healing
- Decreased immunity
Patient teaching:
- DO NOT STOP ABRUPTLY
- Taper off as Dr. directed
Prednisone
Deficiency of Pituitary hormone (TSH - Secondary hypothyroidism)
Deficiency of TSH decreases secretion of thyroid hormones
S/s:
* Decreased metabolic rate
* Lethargy, forgetfulness, irritability
* Headache, constipation
* Decreased HR, dyspnea
* Swelling/edema, dry/thick skin
* Coarse hair
Tx:
* Hormone replacement therapy - most commonly Levothyroxine (Synthroid)
Hypothyroid
Abnormal increased synthesis & secretions on the thyroid gland w/ overproduction of the thyroid hormone T3/T4 resulting inexaggeration of the metabolic processes
- Geaves disease & Multinodular goiter most common
S/s:
* Weight loss, hair loss, insomnia
* Intolerance of heat, personality changes
* Tachycardia, increased systolic BP/ HTN
* Afib, increased metabolic rate
* Edema to neck, termors, exophthalamos (eye buldging)
Tx:
* Radiation: destroys thyroid tissue, decreases homrone production
* Surgery: Thyroidectomy
* Drug therapy: Tapazole, PTU, Beta blockers, Iodides, Antithyroids, ect
Hyperthyroid
(Graves disease or Thyrotoxicosis)
What labs determine the diagnosis of hypothyroid?
Determination of free T4 & TSH
* Free T4 is low w/ hypothyroidism
Large amounts of thyroid hormone enter the bloodstream during surgery or when patients w/ severe hyperthyroidism develop a severe illness of infection
Approx. 12hrs after surgery is when s/s will occur
S/s:
- Tachycardia, cardiac dysrhythmias
- Vomiting, fever, confusion
Thyroid Storm
What electrolyte deficiency may occur with a thyroidectomy?
Hypocalcemia
Hypomagnesemia
low level of calcium in the blood (below 8)
* Results from diarrhea, inadequate dietary intake of vit. D, multiple blood transfusions, ect.
hypoalbuminemia is the most common
S/s:
* Trousseau’s sign
* Chvostek’s sign
* diarrhea
* tingling of fingertips and mouth, severe muscle cramps
* laryngospasms (most severe)
* Cardiac dysrhythmias, seizures
treat with oral or IV supplements
hypocalcemia
Synthetic hormone - IV,IM, PO
Use: Hypothyroidism, Myxedema coma, Thyroid replacement
Side effects:
* Anxiety, tachycardia
* Angina, HTN,palpitations, tachycardia
* N/V/H, cramps
* Thyroid storm (Adverse)
* Cardiac arrest (Adverse)
Nursing considerations:
* Assess BP & pulses periodically
* Daily weight (same time, clothes, ect)
* Monitor cardiac status
* Monitor vitals & labs T3/T4
BBW: Obesity Tx - Not taken to decrease weight
Education:
* Don’t switch brands unless approved
* Take in AM on empty stomach 30 min before food
* Monitor anticoagulent level & adjust dose PRN
Levothyroxine (synthroid, eltroxin, Levo-T)
Use: Makes thyroid hormones, bone & brain development in pregnancy
Route: PO, IV
Side effects:
* Burning mouth, throat, and stomach
* N/V/D/fever
* Weak pulse (adverse)
* Coma (adverse)
* Thyroid gland inflammaiton/cancer (adverse)
Nursing considerations:
* Monitor HR
* Monitor for hypersensitivity and GI bleed
BBW: Hepatic disease, No breastfeeding
Education:
* Take prenatals or Iodine supplements if preg
* Report abnormal bleeding
Iodine
Use: Prep for thyroidectomy, thyrotoxic crisis, hyperthyroidism, & thyroid storm
Route: PO
Side effects:
* N/V/D/H
* Vertigo
* Rash, alopecia
* Jaundice
* Liver failure
* Death
Nursing consideration:
* Assess for weight loss, fever, constipation, & weakness
* Monitor T4 (increases)
BBW: Hepatic disease, No breastfeeding
Education:
* Report redness, swelling, sore throat, mouth lesions, yellow skin/eyes, and dark stool/urine
Propylthiouracil (PTU)
Inhibits the synthesis of the thyroid hormones
Used after course of PTU
Used w/ a Lugol solution & SSKI (5% iodine & 10% SSKI)
Some relief w/in 24hrs
Can cause discoloration to teeth & gastric upset
Iodides
Excessive cortisol
Hypersecretion of the adrenal cortex resulting in production of excess amounts of corticosteroids
Causes:
* Endogenous - Pituitary tumor/ Adrenal tumor
* Exogenous - Prolonged admin. of high dose corticosteroids
S/s:
* Moon face, Buffalo hump
* Trucal obestiy, purple straie on abd., breast, or butt
* Hypokalemia, hyperglycemia, poor wound healing
* HTN
Tx/ interventions:
* Drug therapy: Mitotane, Metyrapone
* Radiation: Internally/Externally, destroys tissue
* Surgery: Transsphenodial hypophysectomy (pituitary gland), Adrenalectomy (adrenal tumor)
* Vitals & labs
* Skin assessment
* Educate on wearing a medical band
* Monitor for SI
* Caution on long term use of some herbs (celery, juniper, licorice, & parsley - Causes hypokalemia)
Cushings syndrome
What labs/tests can you use to Dx Cushings syndrome?
Labs:
* Plasma cortisol levels (High)
* ACTH (high)
Tests:
* Xray
* CT, MRI
* Angiography
What patient education would be provided for a Pt Dx w/ Cushings syndrome?
Do not blow nose (after surgery)
Monitor bleeding
Wound care (packing)
S/s of infection (Smell breath & packing if drainage)
What surgical intervention willl occur if their is a pituitary tumor causing Cushings disease?
Transsphenoidal microsurgery
Removal of adrenal glans
Post-op care:
* Admit to ICU
* Monitor vitals for s/s of shock
* monitor kidneys & strict I/Os
* Give vasopressor to decrease BP & HR
Adrenalectomy
Destructive disease process affecting adrenal glands that cause deficiencies of cortisol & aldosterone
* Most common cause is auto immune (adrenal tissue destroyed by antibodies formed by immune system)
Secondary adrenal insufficiency is the result of the hypothalamus or pituitary which caused decreased androgen & cortisol production
* Include oituitary tumors, radiation therapy, ect
S/s:
* Orthostatic hypotension
* Skin hyperpigmentation
* Hypoglycemia, hyponatermia, hyperkalemia
* Severe headaches, abd. pain, joint pain
* Wight loss, weakness/fatigue
* Salt cravings
Interventions/Tx:
* Restore fluids/ electrolytes
* Low K diet, high Na diet
* Replace adrenal hormone (Hydrocortisol)
* Assess for addisons crisis
* Carry medical kit & 100mg od IM hydrocortisone/dexamethasone
* Take meds as ordered
* Educate on life long therapy & monitoring
Addisons Disease (Adrenal Hypofunction of pituitary)
Life threatening emergency caused by insuffieicient adrenocortical hormones / sudden sharp drop in hormones
S/s:
* hypotension
* Tachycardia
* Dehydration (N/V)
* High temp
* Cyanosis
* Progresses to vasomotor collapse/ possible death
Interventions/Tx:
* IV fluids (Isotonic/ Hypertonic/ D5LR)
* Hydrocortisone
* Electrolyes
* Dextrose to restore normal BP
Addisons crisis
What electrolyte imbalances occur w/ Addisons disease?
Hypercalemia
Hyperkalemia
Hyponatremia
Hypoglycemia
Tip: Hyper before Hypo
What electrolyte imbalances occur w/ Cushings disease?
Hypocalemia
Hypokalemia
Hypernatremia
Hyperglycemia
Tip: Hypo before Hyper
Steroid - PO/IV/IM
Use:
* Severe inflammation, UC
* Adrenal Insufficiency, COPD
Side effects:
* Depression, mood changes
* Flushing, Increased appetite
* HF, HTN
Interventions:
* Vitals & labs (CBC,BMP)
* Monitor for depression
Hydrocortisone
Steroid - PO
Use:
* Adrenal insufficiency
* Addisons Disease
Side effects:
* Flushing, sweating
* Seizures, HTN
* Tachycardia, hyperglycemia
Interventions:
* Daily weight
* Vitals & labs (CBC, BMP)
Florinef (Flurocortisone)
Interferes w/ cortisone production
Cytotoxic substance that is used as a palliative treatment for inoperable
Use: Cushings disease
Mitotane (Lysodren)
Used in combination w/ mitotane for enchanced effects
Use: Cushings disease
Metyrapone (Metopirone)
What are the 2 types of hypothyroid?
Cretinism:
* Congenital hypothyroidism
* 1/4000 births
Myxedema:
* Denotes severe hypothyroidism in adults
* Includes: Edema, to hands/face/feet/eye area (periorbital)
What are some interventions/ education for a Pt who is post-op from a thyroidectomy?
Voice may be hoarse for 48hrs
Turn neck slowly, Semi- fowlers position to enhance RR & decrease edema
Monitor incision site, labs, & vitals
Assess for hypocalcemia:
* Chvostek/trousseau
* Laryngospasm (most critical)
* Tetany, numbness/tingling in fingers/toes
Assess for hemorrhage, resp. distress, & thyroid storm
Lifelong thyroid replacement
Assess resp. status
Inhibits synthesis of thyroid storm by decreasing iodine use in manufacture of thyroglobulin & iodothyronine
Use: Hyperthyroidism
Side effects:
* Drowsiness
* N/D/H
* Enlarged thyroid
* Jaundice (adverse)
* Hepatitis, nephritis (adverse)
* Bone marrow supression (adverse)
* Thrombocytopenia (adverse)
Interventions/education:
* Assess for S/s of hypothyroism
* Monitor vitals & labs (liver function, T3/T4, TSH)
* Daily weight/ monitor weight
* Do not breast feed
* Take as prescribed, DO NOT double dose
Methimazole (Tapazole)
Fits around the face & directly into the nares by 2 prongs
Low flow O2 1-6L/ min
FiO2: 0.24-0.40 (24-40% O2)
Nasal Canula
FiO2: 0.35-0.55 (35-55% O2)
Flow rate: 6-10L/ min
* Min flow rate of 6L/min is necessary to prevent any chance of CO2 build up from occuring
Simple O2 mask
FiO2: 0.7 (70%)
Specific flowmeter setting for desired FiO2
Ventimask / Venturi mask
What are some interventions for airway obstruction?
Admin antimicrobuals, decongestant, & expectorants as ordered
Deep breathing, & a good cough to break up secretions
* Antitussive medications can be given if pt become fatigue by coughing
* Pts w/ weak cough may need suctioned
Encourage position change Q2h to help mobilize secretions
Chest physiotherapy, aerosol therapy
Provide tissue & a receptable for disposal of secretions
* Note amount, color, consistancy
Auscultate lung sounds frequently to assess interventions
How do you assess gas exchange?
Monitor vitals, lung sounds, & skin assessment
Alert for S/s of hypoxemia:
* Restlessness, tachycardia, tachypnea
ABG meaures, report abnormalities to HCP
Monitor hemoglobin (Hgb)
* low levels indicate reduced O2-carrying capacity of RBCs
Elevate HOB, maintain O2 therapy as ordered
Semi-fowlers to decrease pressure of abd. organs on diaphram so pt can breath easier
What are some interventions for a pt who is fatigued & dyspnic?
Restrict activity for pt w/ pneumonia
* Ranges from complete bed rest to limited activity
Organize care to prevent overtiring & allow period of uninterrupted rests
Provide assistance as needed (ADLs) until pt can do them on own, evaluate tolorance of ADL
Keep converations short & encourage visitor to not tire pt
What are some interventions for inadequate nutrition?
Assess clients usual dietary habits to provide baseline information
* Individualize diet
Monitor weight same time every day before breakfast using the same scale
Monitor albumin, electrolyes, glucose, & BUN/Cr to detect inadequate nutrition
What is the typical diet for a Pt w/ pneumonia?
Diet: High protien, soft diet
what interventions would you implement for a Pt w/ pneumonia?
Interventions:
* Provide diet as ordered
* Document intake
* Assess w/ feeding if needed
* Provide oral care before & after meals
* Elevate HOB
* Arrange tray in attractive & convenient manner
* If O2 required, apply NC
* If fatigued easily, do frequant small meal
T/F - Iodized salt is the best way to obtain adequate amounts of Iodine in the diet of someone Dx w/ hyperthyroidim
True
Rare chronic condition that causes the body to produce too much urine and feel extremely thirsty
Classified as:
* Nephrotoxic - Inherited defect in which renal tubules of kidney do not respond to ADH, resulting inadequate water reabsorption by kidneys
- Neurologic (central / hypothalamic) - Can result from hypothalamic tumors, head trauma, infection, surgical procedures (hypophysectomy) or metataic tumors originating in lungs. Triggered by CVA, aneurysm, or intracranial hemorrhage
- Dipsogenic - Disorder of thirst timulation. When pt ingests water, serum osmolality decreases causing reduced vasopressin secretion. Other factors are associated by habitual water intake/ psych. conditions
Diabetes Insipidus (DI)
Affects ONLY epidermis - mildest
S/S:
* Pink/red
* Painful, minor swelling
* Dry w/o blisters
* Blanches
* No vesicles
Healing time:
* 3-6 days
* Superficial layer overskin may peel off in 1 or 2 days
Ex: Sunburn
Superficial Burn (1st Degree)
Affects epidermis & dermis
S/s:
* Painful
* Large, moist, weepy blister
* Pale, pink, red
Ex: severe sunburn, large blister
Superficial partial thickness burn (2nd degree)
Exposed dermis
* Skin, fat, muscle
S/s:
* Large, thick walled blister/edema
* weeping, cherry red
* Painful, sensative to cold air
Tx:
* Hospitalization
* monitor for shock
* Keep covered
Deep partial thickness burn
Involves epidermis, dermis, & underlying tissues including fat, muscle, & bone
S/s:
* Dry, leathery, eschar
* May be red, brown, black, or white
* Lacks sensation
Tx:
* Hospitalization
* monitor for shock
* Keep covered
Full thickness burn
What are the percentages of each body part involved in the rule of nine?
Head (Front & back)
Arms (Front & back)
Abd (2 sections - upper/lower (Front & back))
Legs (Front & back)
Groin (Front & back)
Head (Front & back) - 4.5%
Arms (Front & back) - 4.5%
Abd (2 sections - upper/lower (Front & back)) - 9%
Legs (Front & back) - 9%
Groin (Front & back) - 1%
When is fluid resuscitation the most critical in a burn pt?
24-48 hrs after injury
I/O’s strictly monitored to prevent shock
What is the most common skin infection for a burn patient that is found in the U.S?
Methicillin-resistant staphylococcus aureus (MRSA)
Releases chemicals that cause increased capillary permeability
* Tissue injury caused by thermal/chemical/ect. burns
Permits excess Na to enter the cell & allows K to escape into the extracellular compartment
Shift causes edema & decreases cardiac output, & decline in blood volume (Olguria, hypovolemic shock)
* 18-36 hrs after injury, capillary permeability normalizes & reabsorption of edema fluid begins. Cardiac o/p normalizes & increases to meet increased metabolic demands
Decreased blood flow a ileus may occus
Stress ulcer may occur (Curling ulcer)
Pathophysiology of Burn injuries
What is the most common skin infection for a burn patient that is found OUTSIDE of the U.S?
Acinetobacter
What lab should you draw for a military pt who has returned to the U.S for treatment?
Culture on admission to rule out any infection (Acinetobacter / MRSA)
Begins when burn starts & ends when fluid shifts stabilize
* First 12-48 hrs critical
S/s:
* Hemoconcentration (Increased Hct)
* Acute renal failure (ARF), olguria
* Hyperkalemia, hyponatremia
* Hypovolemic shock
* Metabolic acidosis
* Risk of cardiac dysrhythmias
Tx:
* ABCs, ABGs
* Start IV (PIV/central)
* Insert cath. & NGT, tetanus prophylaxis
* Pain managment/assessment & tetanus
* Clean/debride wounds, topical antibiodics
* Blood for baseline blood studies (Hct, electrolytes)
* Assess for smoke inhalation injury - intubate if needed
* Hydrotherapy (softens eschar), escharotomy
* ROM, skin graft
Emergent / hypovolemic stage of burn injury
(1st of 3 stages of burn injuries)
Begins 48-72 hrs after fluids stabilize
* Some marked when all but 10% of burn wounds are closed or until all wounds are closed
S/s:
* Hemodilution (decreased Hct)
* CHF risk
* Metabolic acidosis
* Hypokalemia, hyponatremia
* Circulatory overload / hypervolemia (Main concern)
* Polyuria (kidney problem - Insert fowly cath)
Acute/Diuretic stage of burn injury
(2nd of 3 stages of burn injuries)
Goal: Prevent infection & return pt to “normal”
* Can take months
Overlaps w/ acute stage
* Starts when pt is stable
PT/OT begin tx
Interventions:
* Restore independence
* Adjusting to body image
* Preventing contractures
* Coping
Rehabilitation stage of burn injury
(3rd of 3 stages of burn injuries)
Which burn may blister, peel & heal w/ minimal long-term effects?
A) Partial-thickness
B) Full-thickness
C) Deep Partial-thickness
Chpt 57 pg 1165
A) Partial-thickness
Which burn is often covered by a thick, leathery layer of burned tissue/eschar that shelters microorganisms & inhibits healing?
A) Partial-thickness
B) Full-thickness
C) Deep Partial-thickness
Chpt 57 pg 1165
B) Full-thickness
Removal of debris & necrotic tissue from a wound
* Eschar must be removed or healing will not take place
Types:
* Surgical excision: Escharotomy
- Mechanical: Removing eschar/ necrosis w/ scissors/ forcepts
- Enzymatic: Use of topical medications containing enzymes capable of dissolving necrotic tissue. (Cause pain & bleeding)
Debridement
What is the goal of wound care after a burn injury?
Promote healing
Prevent infection
Controll heat loss
Retain function
Minimize disfigurement