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411 Adult 3 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Pulmonary embolism is
Risk factors
Sign of DVT
Sign of fat embolism

A

Blockage of pulmonary artery by thrombus
- DVT, immobility, obesity, fractured long bone, smoking, CVC, pregnancy
- swelling in one leg greater than the other (homans sign)
- petechiae rash on chest

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2
Q

Virchows triad includes
Causes of each

A

Endothelial damage - smoking, HTN, surgery, catheter
hyper-coagulability - prothrombin, cancer, chemo, oral contraceptives or HRT, pregnancy, heparin induced thrombocytopenia, dehydration
stasis - immobility, polycythemia
(must have all 3 to form a clot)

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3
Q

Clinical manifestations of pulmonary embolism
Respiratory
Cardiac

A

Respiratory #1 symptoms- dyspnea, tachypnea, tachycardia, pleuritic chest pain, hemoptysis in severe cases
- acute pulmonary HTN, JVD, systemic hypotension, abnormal heart sounds & ECG

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4
Q

Diagnostic studies
Which is gold standard
If patient can’t have contrast

A

Arterial blood gasses - PO2 always low
BNP levels go up
CT angiography; requires IV contrast (pre-op considerations)
- pulmonary angiography is gold standard; most sensitive but invasive
- use VQ scan if no contrast

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5
Q

Non surgical management
Nasal cannula range of O2
Venturi mask used for
Partial non-rebreather delivers
Non-rebreather uses & delivery
% of oxygen on RA & per L

A

NC - 1L to 6L
VM - used for COPD with valves
PNRM - flap stays on, delivers ~80%
NRM - used in emergencies, delivers 100%, reservoir bag filled 2/3 before putting on patient
- oxygen on RA is 21% , each L adds 4%. So 2L NC = 28% O2

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6
Q

Medication management
Heparin & goal
Alteplase tPA
After 3rd day of heparin
Interventions

A

Anticoagulants (heparin) PTT norm is 25-35 (goal is 1.5-2x so ~ 70 PTT)
- used for emboli 0.5-1mg at clot
- start on warfarin
- assess bleeding, measure abdominal girth, inferior vena cava filter (IVC)

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7
Q

Acute respiratory failure due to

A

Hypoxemia (PaO2 < 60) or Hypercapnia (PaCO2 > 50) PH < 7.3

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8
Q

Clinical manifestations of acute respiratory failure
Dyspnea interventions
Medications in ARF

A

1 sign of poor oxygenation is Mental status change; others (dyspnea, tachycardia, cyanosis, ABGs- hypoxemia & hypercarbia)

  • oxygen therapy, CPAP or BiPAP (Bi for COPD)
  • bronchodilators (Albuterol; tachy side effect), corticosteroids (solumedrol), Benzo or morphine to calm anxiety & pain
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9
Q

Acute respiratory distress syndrome (ARDS) what happens
Highlights
Mortality rate
Main causes

A

Alveoli fill with fluid & collapse ; decreased surfactant
- persisting hypoxia even with 100% O2, pulmonary infiltrates seen on x-ray “whited-out” or “ground glass”
- 60% mortality in ARDS
- due to underlying causes; #1 reason is due to sepsis - shock

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10
Q

Interventions
Normal lvl vs ppl w ARDS
Normal tidal volume calc
Low Tidal volume in ARDS
Side effects of treatment

A

PEEP (positive end expiratory pressure) treatment for ARDS
- Normal PEEP is <5, treatment for ARDS starts at >5
- weight in kg x10ml = TV
- weight in kg x4-6ml = TV in ARDS
- BP is #1 side effect of PEEP, check BP before treatment

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11
Q

Important points of ARDS
Purpose of proning patient in ARDS

A

Alveoli permeability, white-out/ground glass X-ray, PEEP treatment
- proning patient eliminates compression of the lungs by the weight of the heart (full expansion)

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12
Q

ARDS complications of treatment & prevention
Ventilator associated pneumonia
Barotrauma & volutrauma
Stress ulcers
Renal failure

A
  • prevent by proper hand-washing & elevating HOB 45 degrees
  • rupture of alveoli due to high pressure ; ventilate with smaller tidal volume , allow hypercapnia
  • initiate early enteral feeding, anti-ulcer agents
  • due to hypotension & hypoxemia or nephrotoxic drugs (vancomycin)
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13
Q

Endotracheal tube placement time
Before inserting tube
Intubation attempt
Verifying placement
Stabilizing tube
When is sedation contraindicated

A

Can only be in place for 10-14 days
- hyper-oxygenate
- cannot attempt longer than 30 seconds, less than 15 is ideal
- auscultate or check end tidal CO2 lvls (litmus strip) ; confirm with chest Xray
- mark level of tube at the incisor tooth (gum line if no teeth)
- sedation contraindicated for neuro injuries

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14
Q

Assist control ventilation
Synchronized intermittent mandatory ventilation
CPAP
Rate of ventilator
FiO2 is

A
  • ventilator takes over, allows for rest
  • delivers preset rate at preset tidal volume, patient initiates own breath
  • cannot use CPAP unless patient is awake; only used to wean off mechanical ventilation
  • typically set between 10-14 because it is going straight to lungs
  • oxygen level delivered to patient, always set by doctor, determined based on patients PaO2
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15
Q

Peak inspiratory pressure rises (PIP)
ET tube assessment (DOPE)
If patient declining
High RR due to
High pressure due to
Sudden decrease in pressure

A
  • increased if there is resistance in airway or pinched tubing
  • dislodgement, obstruction, pneumothorax, equipment failure
  • disconnect vent, suction first, bag breathe & call a code
  • water in ventilator
  • biting tube, mucous plug, pneumo
  • vent disconnected
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16
Q

Subcutaneous emphysema is
Steps of extubation

A

Tear in trachea on intubation causes air to release under skin (bubble wrap)
- hyper-oxygenate patient, suction tube & deflate cuff ; wean off with SIMV, CPAP & T-piece

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17
Q

Strategies for prevention of Ventilator associated pneumonia

A

Elevate HOB, subglottic suction above balloon of tube, brush teeth & chlorohexidine mouth rinse, ulcer prophylaxis, proper hand washing

18
Q

ABGs PaCO2 & HCO3 ranges
Respiratory Acidosis
Metabolic acidosis

Respiratory alkalosis
Metabolic alkalosis

A

(PaCO2 35-45) (HCO3 22-28)
- PH <7.4 , PaCO2 > 45
- PH <7.4, HCO3 < 22

  • PH >7.4, PaCO2 < 35
  • PH >7.4, HCO3 > 28
19
Q

Main hepatotoxic drugs

A

Tylenol
Niacin
Tetracycline
Methotrexate (chemo drug)

20
Q

Encephalopathy results from
Stage I encephalopathy signs
Stage II
Stage III
Stage IV

A

Build up of ammonia
- confusion, behavior changes, slurred speech
- Asterixis (hand flapping), continued mental changes
- stuporous, hyperreflexia, asterixis
- unarousable, NO ASTERIXIS, positive babinski’s, musty breath

21
Q

Manifestations of liver failure
Diagnostic findings
Intervention post biopsy

A

Encephalopathy, Cerebral edema, ascites, spider nevi
- ammonia > 50 (normal: 9.5-49), elevated ALT & AST, bilirubin, protein
- pt must lay on right side to assist clotting

22
Q
  • Management of hepatic encephalopathy
  • Jaundice
  • coagulopathies
A
  • lactulose (binds ammonia ; doesn’t work without bowel movement), neomycin (given through bowel), Decrease protein intake
  • proper skin care
  • vitamin K (mefetin ; only absorbed in intestine)
23
Q

Types of chronic liver failure
- laennec’s
- postnecrotic
- biliary

A
  • due to alcoholism
  • hepatitis C or drug induced
  • inflammation of bile ducts, biliary obstruction
24
Q

Ascites is
Clinical manifestations
Treatment

A

Fluid accumulating in abdomen
- distended abdomen, respiratory insufficiency, positive fluid wave test
- paracentesis, diuretics, give albumin/protein (not jahovah witness)

25
Q

What does portal HTN cause
What shouldn’t you do

A

Cause splenomegaly, esophageal varices, hemorrhoids, ascites
- don’t palpate the spleen (risk for rupture)

26
Q

Risk with esophageal varices
Clinical manifestations
Management
Emergency management

A

Life threatening severe blood loss if ruptured
- hematemisis (coffee ground or bright red), hematochezia (red blood stool)
- vasopressin or octreotide (med of choice), treatment of choice is sclerotherapy, TIPS if bleeding doesn’t stop
- Blakemore tube with esophageal stents to put pressure on varices & stop bleeding

27
Q

Splenomegaly leads to
Who can’t receiver liver transplant
Nursing education for liver transplant

A

Pancytopenia (all values are low)
- pt with liver failure related to alcoholism, unless they’ve been 12 months in recovery program
- avoid large crowds (immunosuppressive therapy)

28
Q

Causes of Acute pancreatitis
Manifestations
How to relieve pain
Lab values
Management
Nutrition

A
  • biliary tract disease (gallstones/obstruction), excessive alcohol intake
  • severe epigastric pain, weight loss, jaundice, absent bowel sounds, cullens or grey turners sign
  • lying in fetal position (knees to chest)
  • lipase lvls rise after amylase & stay elevated for 2 weeks ( > 160), calcium decreases, BUN increase
  • NPO, IV fluids & pain control via IV drugs
  • jejunal feedings; weighted tube, no air vent,
29
Q

Chronic pancreatitis most common
Signs & symptoms
Management
Nutrition therapy

A
  • chronic calcifying pancreatitis (alcohol induced)
  • Develop DM1, steatorrhea (pale, bulky, frothy stool)
  • proton pump inhibitors, analgesics, enzyme replacement (PERT; amylase, lipase), insulin
  • TPN feeding (change Q24), low fat high caloric diet (4-6K calories)
30
Q

Enzyme replacement

A
  • take with meals/snacks & follow with water
  • administer enzymes after antacid
  • do not mix in protein foods
31
Q

Pancreatic abscess is
Characterized by / treated

A

Most serious complication of pancreatitis; always fatal if untreated
- high fever / drainage & antibiotics

32
Q

Pancreatic cancer key features
Surgical management
Post-op care

A
  • jaundice (clay colored stools & dark urine), abdominal pain & weight loss, new diagnosis of DM, enlarged spleen, ascites
  • whipple procedure, stent for obstruction,
  • CHECK for abdominal rigidity #1 thing
33
Q

Mechanical intestinal obstruction
Non mechanical obstruction
Non mechanical manifestations
Small bowel obstruction manif
Large bowel obstruction manif
Management

A
  • adhesions, fibrous band, Chron’s, tumors
  • paralytic ileus or adynamic ileus (hypokalemia, peritonitis, ischemia)
  • hiccups, abdominal distention, borborygmi, ribbon stools
  • upper abdominal distention, profuse vomiting, electrolyte imbalance, metabolic alkalosis
  • lower abdominal distention, no vomiting, ribbon like stools, no electrolyte imbalance, acidosis
  • NPO, NG tube, IV fluids, alvimopan (entereg)
34
Q

What is peritonitis
Manifestations
Diagnostics
Management

A

Life threatening acute inflammation of peritoneum
- rigid & distended abdomen, N/V, decreased bowel sounds, tachycardia, fever, oliguria, hiccups
- leukocytosis, peritoneal lavage, paracentesis
- IV fluids, daily weight, NG suction, antibiotics, semi-fowlers, peritoneal irrigation

35
Q

Hypoparathyroidism results in
Signs & symptoms
Lab values
Treatment
Interventions

A

Decrease absorption of calcium & decreased excretion of phosphate
- positive chvosteks & trousseaus sign, tingling, tetany, bands on teeth
- calcium <8.5, phosphate >4.5, 24hr urine cAMP lvls are decreased
- IV calcium, calcitriol PO, calcium & vitamin D
- Eat foods high in calcium but low in phosphorus (milk yogurt cheese), get eye exams

36
Q

Hyperparathyroidism S/S
Lab values
Treatment
Meds
Interventions

A
  • nephrolithiasis (stones), N/V, GI problems, psychosis/coma when Calcium >12
  • calcium >10.2, phosphate < 3 , cAMP levels increased, BMD scan
  • # 1 is parathyroidectomy (EMERGENCY EQUIPMENT AT BEDSIDE), assess for changes in voice
  • Cinacalcet
  • monitor I&O Q2H, low calcium diet (avoid rice, almond milk, cheese, soybeans)
37
Q

Addison’s disease is
Signs & symptoms
Diagnostic test
Lab values
Meds
Interventions

A

Adrenal insufficiency (low ACTH)
- muscle weakness/fatigue, anorexia, salt cravings, hypotension, hypercalcemia, hypoglycemia
- ACTH provocation test (give ACTH inj), response is absent in primary, response is increased in secondary
- hypoglycemia, Hyponatremia, hyperkalemia
- steroids (-sone)
- never restrict salt or give diuretics

38
Q

Cushing’s disease is
S/S
Testing & lab values
Meds
Nutrition
Care for hypophysectomy

A

Hypersecretion of cortisol, too much ACTH
- moon face, trunk obesity, bounding pulse, muscle atrophy, purple striae, hirsutism
- dexamethasone suppression test / hyperglycemia, Hypernatremia, hypokalemia, hypocalcemia
- ketoconazole, periactin, signifor
- low sodium diet (2g), high caloric & calcium rich diet
- maintain nasal packing, monitor nasal drip for yellow color; test glucose

39
Q

Hyperaldosteronism is
S/S
Treatment
Medications

A

Increased secretion of aldosterone
- hypokalemia, EKG changes, Hypernatremia, HTN, polydipsia
- #1 choice is adrenalectomy; surgery not performed till potassium is corrected
- spironolactone (K+ foods: potatoes, spinach, leafy greens)

40
Q

Diabetes insipidus is caused by
Signs & symptoms
Testing
Med for DI
Interventions

A

ADH deficiency due to kidney or pituitary defect, or drug induced by lithium
- polyuria 4-30L/day, polydipsia, Hypernatremia, dehydration, weak thready pulse, hypotension
- 24Hr urine; output >4L/day, specific gravity < 1.005
- Desmopressin (DDVAP); given nasally (check for deviation or ulcers)
- monitor water toxicity; acute confusion, weight gain > 2.2lbs

41
Q

SIADH due to
S/S
Lab values
Treatment
Interventions

A

ADH excess; #1 cause small cell lung cancer, #1 drug related: fluoroquinolones
- water retention, fluid overload (CHF; JVD, crackles, S3), Hyponatremia <125 high risk for seizures, coma
- concentrated urine (specific gravity >), Hyponatremia
- tolvaptan & conivaptan (cannot exceed 12meq), hypertonic saline 3% must run low & slow (20ml/hr)
- NEVER increase sodium 1-2meq/hr or it causes demyelination, restrict fluids, seizure precautions

42
Q

Pheochromocytoma is
S/S
What can cause a HTN crisis
Treatment
Interventions

A

Tumors that release catecholamines
- intermittent sever HTN, profuse diaphoresis, impending doom, headaches
- NEVER PALPATE ABDOMEN, avoid foods with tyramine (aged cheese, wine)
- #1 choice adrenalectomy, (hydrate before & ensure BP under control)
- monitor BP consistently, teach to avoid smoking & caffeine

411 Adult 3 (3 decks)

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