Exam Flashcards
Type of angina pectoris
Stable angina
Predictable and consistent pain, relieve by rest or nitroglycerin
Unstable angina
Unpredictably increase symptoms frequency and severity, may not relieve by TNG, predictably an MI coming
Intractable angina
Severe chest pain and recurrent condition after medical treatment
Variant angina
Pain at rest with reverisble ST elevation, caused by coronary vasospasm, rare, very painful. Can be controlled by TNG
Silent ischemia
Evidenced with ischemia symptoms yet no pain reported from the client
Pain of angina
- Describe as tightness, choking or heavy sensation
- At retrosterno or radiate to neck jaw, shoulder, back or arm
- S/s shortness of breathe, dizziness, nausea, vomitting
- Subside by trinitroglycerin nitroglycerin
Treatment of angina
TNG, NTG
calcium channel blocker agent
Aspirin
Heparin
Combination therapy
Nursing intervention for angina pain
1.Drink 2L water daily
2. Immediately stop all activity and sit ir rest on bed( semi-fowlers position)
3. Continuius monitoring: vital sign, respiratory distress, any pain, ECG can be assessed
4. Administer TNG / NTG and reassess pain, up to 3 dose
5. If can be relieved by TNG / NTG, then not MI
Angina-preventing pain
Observe the level of activity cause prodromal symptoms of pain
Plan activities accordingly
Alternate rest period in activities
Family and client education
Difference between ACG and MI
ACG is plaque rupture but artery hvnt completely blocked
MI means permanent destroyed myocardium
Reduced blood flow from rupture of an plaque, caused complete occlusion
Clinical menifestation of MI
1.Sudden chest pain unless rest or medication
2. Heartburn, nausea, anxiety, cool, pale skin, increased hr rr
Lab test of cardiac enzyme
Troponin T / I
Protein found in myocardial cells
Regulate myocardial contractile process
Creatine kinsse
Cardiac-specific isoenzyme , more when damaged
Myoglobin
Heme protein for transporting oxygen
Hypertension
Normal BP below 120/80
Elevated 120-129/<80
High blood pressure >130/>80
Risk factors of HT
Smoking
Obese
Physical inactivity
Alcohol
ICP
Pressure exerted by volume of intracranial content
Normally 3-15mmHG
In disease of injury, csf increase because of decrease cerebral perfusion and cause ischemia, cell hence dead and cause more edema
Autoregulation: blood vessel adjust their width to maintain constant blood flow( co2+ vasodilation -vasoconstriction)
Early sign of ICP
Restlessness, confusion, increase drowsiness, hard to breath
Weakness in one side of extremity
Late sign of increased ICP
Vasomotor change: increase SBP, low hr, high temp
Cushion triad: Bradycardia, HT bradypnea
Loss of brain stem reflexes
Pupillary, cornela, gag, swallow reflexes, near of death
Glascow coma scale
Eye opening response 4
Verbal response 5
Motor response 6
Total 15, lower than 8 is comatose
How to monitor ICP
Ventriculostomy 腦室造口手術
Intracranial surgery
Craniotomy 開顱手術
Purpose: remove tumor/ relief ICP/ evacuate blood clot
Craniectomy 顱骨切除手術
Purpose: remove a portion of skull
Cranioplasty 顱骨成形術
Purpose: Repair skull defect with plastic or metal plate
Burr hole 鑽孔
Purpose: provide assess to ventricle for shunting
Aspirate hematoma/ abscess
Infectious neurological disorder
Meningitis
Brain abscesses 腦腫膿
Encephalitis 腦炎
Creutzfeldt-Jakob disease
Meningitis
Definition: inflammation of the meninges, which are the membranes and fluid space surrounding the brain and spinal cord
Types:
Septic: bacteria- streptococcus
Aseptic: viral infection, brain abscesses
Menifestation:
headache
Behavioural change
Stiff snd painful neck
Photophobia 畏光
Nursing management for meningitis
- Continuous assesment to vital sogn and level of consciousness
- Prevent complications associated with immobility
- Infection control precautions
Brain abscesses
Infection of brain tissue
More affecting to immunocompromised client
Preventable by treating mastoiditis, dental infection
Manifestation: morning strong headache, fever, vomiting, s/s of increasing ICP
Encephalitis
Acute inflammation of brain tissue
Cause by viral infection (herpes simplex/ fungal infection)
Manifestation: headache, fever, confusion, change in LOC
Medical management: acyclovir for HSV, amphoterecin fro antifungal treatmemt
Creutzfeldt-Jakob disease/ variant
Csused by prions, which is resistant to sterillization
VCJD may caused by infected beef
No treatment
Prevention of disease transmission, blood and body fluid precaution
Location of subdural/ intracerebral/ Epidural hemorrhages
Epidural hemorrhage
Between skull and dura
Subdural hemorrhage
Hemorrhage developed between dura and cerebral
Intracerebral hemorrhage
Haemorrhage developed in brain
Endocrine system
Anterior pituitary glands:
hyper: cushing syndrome, gigantism, acromegaly
Hypo: dwafism, panhypopituitarism
Neurotransmitter-) Hypothalamas-) Thyroid releasing hormone-) thyroid-) liver-) target organ
Blood test for thyroid
1. Serum t3 t4
2. Serum tsh
3. Thyroid antibodies
Thyroid disorder
Hyperthyroidism
Hypothyroidism
Gooter
Thyroiditis
Thyroid cancer
Hypothyroidism vs hyperthyroidism
Serum level: low vs high
Metabolic rate: low vs high
Goiter: endemic goiter vs graves’ disease
Skin: pale and cold vs flush and warm
Temperature tolerance: cold intolerance vs heat intolerance
Eyes: normal vs exophthalmos
Cardiovascular: bradycardia with enlarged heart vs tachycardia+ higher BP
Nervous system:
Body weight:
Treatment for hypothyroidism- synthetic levothyroxine replacement therapy
Hyperthyroidism
Excessive secretion of thyroid hormone
Graves disease= most common hyperthyroidism
Rapid pulse, warm skin, flushed, bulging eyes, increased appetite, weight loss, elevated systolic BP
Thyroid storm- cause severe hyperthyroidism
Manifestation:
High fever
Extreme tachycardia
Altered neurological or mental state
Parathyroid glands- posterior thyroid gland (4)
Maintain calcium & phosphorus balance
Hyperparathyroidism
s/s:
elevated serum calcium, bone decalcification, renal calculi,
Fatique, muscle weakness
Management: parathyroidectomy, hydration therapy
Hypoparathyroidism
Caused by thyroidectomy, parathyroidectomy
S/s: numbness, tingling in extremities, stiffness in hand and feet, bronchospasm, anxiety, irritability, depression
Adrenocoritcal insufficiency - Addison’s disease
S/s bronze pigment skin, hypoglycemia, change of body hair, postural hypotension, weakness, weight loss.
Cushing syndrome
S/s: thining scalp, increased facial hair, thin extremities, moon face, buffalo humps, trunk obesity,
Diagnosis(有咩問題):
risk of injury (weakness)
Risk of infection (inflammatory response)
Self-care deficit (weakness, fatigue, muscle wasting)
Impaired skin integrity (edema)
Disturbed body image (altered physical appearance, impaired sexual functioning)
Ineffective coping (mood swings, depression)
Goals
Decrease risk of injury
Decrease risk of infection
Improve skin integrity
Improve self image
Diabetes mellitus
Functions of insulin
Disease hyperglycemia to defeat insulin secretion
Insulin- 1. transport and metabolise glucose for energy
2. Stimulate storage of glucose in the liver and in muscle as glycogen
3. Signal the liver to stop releasing glucose
Type 1 diabetes: autoimmune attacks insulin producing cells, acute onset with <30yo
Type 2 diabetes: body less sensitive to insulin, less tolerate to glucose, usually >30yo, slow and progressive
Initially diet and exercise treatment
Risk factors of type 1 type 2 diabetes
Type 1: genetic issue and also immunologic issue
Type 2: family history, obesity, age, HT, impaired glucose intolerance.
Clinical manifestation of diabetes
Polyuria, polydypsia, polyphagia, fatigue, numbness of extremities, slow healing skin lesion
Acute complication of diabetes:
1. Hypoglycemia
2. Diabetic ketoacidosis
- Abnormally low blood glucose rate (2.8-3.3)
Cause: too much insulin, too little food
Manifestation: sweating, tremor, cns issue cannot concentrate
Solution: dextrise solution
- Absense of insulin-) abnormal metabolism of carbohydrate
Manifestation: hyperglycemia, dehydration, acidosis
Treatment: rehydrate in iv fluid
Reverse acidosis and restore electrolyte balance.
Education of diabetes
- Education on disease process and pharmacological treatment
- Demonstration: demonstrate for self-monitoring blood glucose
- Current diet, habbit in included in lifestyle modification
- Continue education related to exercising, meal planning, stress management
Short/ long term goals for diabetes dm
Short: routine glucose monitoring
Stick with the plan
Maintain blood glucose level to avoid or stop diabetes related complication
Long:adjusted diet, consistant exercise, lose weight, stop smoking.
Ideal blood glucose level
Before meal 4-7mmHG
After meal 9(1) 8.5(2) mmHG
Goals
Before meal 4-7
After meal: type 1 <9 type 2 <8.5
BMI<25
Prevent fluctuation of blood glucose level
Decrease serum lipid level if needed
Long term complication of diabetes
Macrovascular: accelerated atherosclerotic disease, coronary artery disease, cerebralvascular disease
Microvascular: nethropathy
Neuropathic: peripheral neuropathy, autonomic neuropathy, sexual dyfunction
Visual and auditory
Impaired vision
Myopia: nearsighted
Hyperopia: farsighted
Astigmatism: distortion due to irregularity of cornea
Glaucoma
Glaucoma
Damaged optic nerve related to increased intraocular pressure Caused by increased aqueous humor
Patho of glaucoma:
1. Aqueous production is not balanced
2. Aqueous outflow blocked builds up pressure within the eye
3. The increased intraocular pressure cause irreversible mechanical or ischemic issue
S/s of glaucoma
Progression vision field defects
Peripheral vision loss
Difficult to adjust eye into low lighting
Aching/ discomfort around eyes
Diagnosis of glaucoma （點揾）
Tonometry to assess IOP
Perimetry to assess vision loss
Treatment for glaucoma
Goal: prevent further optic damage
Maintain IOP in a level doesn’t bring damage
Surgery:
Laser trabeculoplasty
Laser iridotomy
Cataract
Defin: cloudiness of the lens
Risk factor:
Aging
Poor nutrition
Physical factors- blunt trauma, electric shock
Clinical manifestation:
Painless yet blurry vision
Sensitive to glare
Reduce visual acuity
Double vision, color shifts
Surgery for Cataract
Phacoemulsification
An ECCE that uses ultrasonic device suction which has smaller cut than traditional ECCE
Lens replacement
Replace the intraocular lens after ECCE removed old lens
Retinal disorder
Retinal detachment
Retinal vascular disorder
Macular degeneration 黃斑病變
Check Ear：middle ear endoscopy 中耳內窺鏡
Guidelines communicating with impaired hearing patient
1. Low tone normal voice
2. Speak slowly and distinctly
3. Reduce background noise and distraction
4. Speak to less impaired ears
5. Use gesture and facial expression
6. Write if necessary
Tympanic membrane perforation 穿鼓膜
Acute otits: 耳炎
Streptococcus pneumonia
Usually seen in kids
Treatment: antibiotic
Tympanotomy
Chronic otitis media: recurrent of acute symptoms
Damage tympanic membrane, mastoid
Surgery: tympanoplasty
Middle ear surgical
Tympanoplasty reconstruct the tympanic memebrane
Ossiculoplasty reconstruct the bone of middle ear
Mastoidectomy remove diseased bone, mastoid air cells
Common sport injury
Contusion, strains, sprains, dislocation
Prevent sport injury:
1. Wear proper equipement e.g. running shoes for runner, wrist guard for skaters
- Effective training
- Stretching before engaging in a sport
- Change in activity should be gradually
- Modify activity to minimise injury and promote healing
- Be aware of limits snd capabilities
Fracture types
Complete fracture 完整斷開
Incomplete fractures 未斷晒
Comminuted fracture 粉碎
Closed fracture: does not break the skin
Open / compound / complex fracture: skin / membrane extends to the fracture
Clinical manifestation of fracture
Pain
Loss of function
Deformity
Shorten of extremity
Local swelling
Urinary elimination
*urinary tract infection
Upper: pyelonephritis
Lower:
1. Cytitis
2. Prostatitis
3. Urethritis
Urinary incontinence
- Stress incontinence
- Urge incontinence
- Functional incontinence
- Iatrogenic incontinence
Stress incontinence
Loss of urine through intact urethra without detrusor contraction when intravesical pressure excedd urethral pressure.
Pressure of
Intravesical pressure increase when sneezing, coughing, changing position. Dysfunction of urethral sphincter
Cause:
women: vaginal delivers, decrease ligament and pelvic floor support
Men: Benign prostatic hyperplasia 前列腺發大
Urge incontinence
Involuntary loss of urine associated with strong urge to void the urine, which cannot be suppressed
Can aware but cannot reach toilet in time
Uninhibited detrusor contraction
Cause: neurological dysfunction-) uncontrolled contraction
Functional incontinence
Unable to identify the needs to void due to physical / cognitive impairment
E.g. Alzheimer’s dementia.
Iatrogenic incontinensce
Involuntary loss of urine due to medical factors
Urolithiasis
Nephrolithiasis
75% are calcium stone, caused by hypercalcemia, hypercalciuria
15% are struvite stone
How to prevent kidney stone
Daily 2L of water if no contraindicated
Avoid intake of oxalate-containing food ( strawberries, tea, peanuts)
Maintain regular toileting habit
Kidney surgery pre-op + post-op
Preoperation
1. Evaluate kidney function
2. Ensure optimal renal function
3. Encourage fluid intake to promote increased excretion
4. Antibiotics
5. Undergo coagulation studies
6. Recognise and verbalise concerns with patients and family
Post-op:
Monitor for complication
1. Hemmorhage and shock
2. Liquid and blood imbalance
3. Infection
4. Urinary tract obstructed
5. Abdominal distention
6. Deep vein thrombosis
Kidney surgery post-operation and monitor for common complications
- Respi
Monitor rate, depth and pattern of respiration - Status
Vital sign
Skin colour & temperature
Urine output
Drainage output - Pain
Monitor and manage wound care
Abdominal distension - Urinary drainage
Monitor for amount, colour, type and characteristics
Common complication
Hemorrhage and shock
Fluid & blood imbalance
Infection
Urinary tract obstruction
Deep vein thrombosis
Digestive system assesment order
Inspection, auscultation, palpation, percussion.
Pqrst
Provocation
Quality
Region
Severity
Time
Appendicitis
Infection of appendix
Usually age 10-30
Small, finger-like, attaching caecum
Insufficient emptying leads to obstruction
Appendicitis manifestation
- Vague (模糊) epigastric or periumbilical pain, dull and not localized
-) right lower quadrant pain, sharp and well localized, distinct - The appendix may be ruptured if pain suddenly stops without any medical intervention
- Low grade fever, nausea, vomiting, loss of appetite
- Rebound tederness, intense pain released under pressure
- Loacl tenderness at McBurney’s point
- Constipation, laxatives shd not be used
Appendicitis complications
Perforation of appendix (usually 24hrs later)
Abscess formation
Portal pylephlebitis
Appendicitis-goals
Pain management
Prevention of fluid volume deficit
Reduce anxiety
Eliminate infection
Maintaining skin integrity
Attaining optimal nutrition
Appendicitis post-op
Continuous monitoring vital sign
Pain relief by high fowlers position (reduce tension on the organs)
Pain medication
Iv infusion
Allow fluid diet if bowel sound presents
Discharge care:
Wound care
Appoinment for suture removal 5-7 days later
Avoid heavy lifting
Resume normal activity after 2-4 weeks
Pneumonia education
- Encourage breathing exercise to promote lung expansion
- Teach the client proper administration of antibiotics
- Encourage the client on observing their medical intolerance and potential side effects of using antibiotics
- Introduce symptoms that client should consult physicians
- Encourage client to return to the clinic to follow up chest x-ray and physical examination
- Encourage patient to quit smoking
- Encourage patient to obtain adequate nutrition
- Encourage client to promote rest and conserve energy
- Monitor potential complications e.g. persistent recurrent fever
- Gradually increase activity after fever subside
Pneumonia patient education
- Encourage client to do breathing exercise to promote lung expansion.
- Instruct client to administrate antibiotic correctly
- Instruct client to observe their medical intolerance and potential side effects of using antibiotics
- Instruct symptoms that should consult physicians
- Instruct patient to be aware of complications such as persistemt recurrent fever
- Encourage client to return to office to follow up the chest x-ray and physical examination
- Encourage quit smoking
- Encourage adequate nutrition intake
- Promote rest and conserve energy
- Increase level of activity gradually after fever subside
Surgical of ears
Tympanoplasty 修補耳膜
Ossiculoplasty 修補耳骨
Mastoidectomy 切乳突
Peritonitis complication
Sepsis
Shock
Intestinal obstruction
Tuberculosis test
Tuberculin test ( the mantoux method)
Inject small amount of TB antigen into skin
React and form a bump >10mm then positive
Aims if chest drainage
Aims to remove excessive air, fluid or blood.
By placing vacuum suction tube in pleural space, maintain the negative pressure of the lung
Skin infection
Bacteria vs viral infection
Bacteria: follicultis
Viral: herpes zoster / herpes simplex
Fungal: tinea pedis / tinea capitis
Bacterial treatment: mupironcin, apply on lesion several times per day, last 5-7 days
Education:
1. Do not share towel, soap…
- Shiwer daily with antibacterial soap.
- Never squeeze the blister or pimple.
- For viral, use acyclovir for zoster and simplex
Viral education:
1. Do not share towels and soap
2. Use clean towel and wash cloth everyday
3. Keep skin fold and feet dry
4. Wear clean, dry cloth, avoid tight cloths, avoid synthetic underwears. Avoid wet bathing suit, plastic sleepers
