Exam 2 Part 2 Flashcards
type of spinal cord injury:
damage that eliminated all innervation below injury =
complete
type of spinal cord injury:
injury allows some function below injury =
incomplete
*more common
causes of secondary SCI
- Hemorrhage
- Ischemia
- Hypovolemia
- Impaired tissue perfusion
- Edema
type of primary SCI
- Hyperflexion (head forward)
- Hyperextension (head backward)
- Axial loading / vertical compression
- Excessive rotation (twisting)
- Penetrating trauma
- Distraction (pulling head up from body)
type of sci: pulling head up from body =
distraction
CV involvement with SCI above … what does those CV changes look like?
T6 (bradycardia, hypotension, dysrhythmias)
Resp involvement with SCI above…
C3-c5
dermatome vs myotomes
derm = Zones of sensory motor function
myo= zones of muscle function
plegia vs paresis
plegia = paralysis
paresis = weakness
when does spinal shock occur and how long does it last?
-occurs immediately after injury
-lasts 48 hours to weeks
T or F: spinal shock results in temporary but complete loss of motor sensory reflex and autunomic function
true!
when and how do we use a quad cough
- use hands to push on their diaphragm when they breathe out
indication: secretions that cant be suctioned or reduced coughing ability
autonomic dysrefelxia occurs from sustained triggering stimuli at or below….
T6
stimuli that can cause autonomic dysreflexia =
◦ Full bladder / UTI
◦ Bowel distension, impaction, constipation
◦ Circumferential compression - thorax, abd, scrotum, or extremities
◦ Tight clothing
◦ Temp
◦ Pain / pressure
(7) sxs of autonomic dysreflexia:
- SNS- Increase in systolic and diastolic BP (sudden drastic increase in BP– risk for stroke!)
- Reflex Bradycardia - comes from increasing BP
- Severe HA
- Nasal congestion
- Diaphoresis (above injury) cold or goose bumps below
- Flush skin
- anxiety
non pharm intervenrtions for SCI
- spinal cord stabilization
- traction
- log roll
- surgery
- rehab
- no BLT
meds for SCI
- muscle relaxers
- steroids
- pain mangement
- BP manafgemnt
- stool softeners
special muscle relaxant we give for SCI?
‣ Intrathecal baclofen
‣ Given right at site of spinal cord injury
term, TBI:
- Sudden and profound injury to the brain
◦ GSW
◦ Blow to the head
◦ Fall - Considered “complete” at the time of impact
direct
term, TBI:
- Injury from force applied to another body part with rebound effect
- Movement of the brain w/i the skull
Ex
◦ Whiplash
◦ Rear end MCV
◦ Skane baby syndrome
indirect
causes of secondary TBI (4)
◦ Hypotension - MAP < 65
◦ Hypoxia PaO2 80-100
◦ Inc intracranial pressure (aka intracranial hypertension)
◦ Cerebral edema
ICP > ____ = neurons die
22
term, TBI:
- Skull fract or pierced
- Brain and dura contaminated
Ex
◦ Foreign obj penetration
◦ Linear
◦ Depressed
◦ Comminuted
◦ Basilar*
open
term, tbi:
* Skull maintains integrity
* Compilations with ICP
Ex
◦ Contusion
◦ Cerebral lacerations
closed
findings of basilar skull fracture:
- leaking CSF
- blood in ear
- ecchymosis behind ear (battle sign) or around eye
- loss of smell/hearing
- impaired facial nerve
mild vs moderate vs severe TBI: loss of consciousness
mild: disorient, loss of consc up to 3o min
moderate: loss of consc 30 min- 6 hour
severe: loss of cosc >6 hour
mild vs moderate vs severe TBI imaging
mild= no damage
moderate= focal or diffuse injury seen
severe = focal or diffuse in vessels or ventricles , can see injury early on
GCS moderate vs severe TBI
moderate = 9-12
severe = 3-8
who is going to ICU for ICP monitoring- mild, mod, or severe TBI?
severe
s/s of TBI
neuro changes, battle/raccoon eyes, muscle changes, visual changes, N/V, loc changes, halo sign
most common cause of death from TBI =
increase ICP –> herniation
re tbi:
what is an uncal herniation
◦ Shift of temporal lobe (uncus)
◦ Pressure on oculomotor nerves
◦ Dilated nonreactive pupils
re tbi: what is central herniation?
◦ Shift downward - towards brain stem
◦ Cheyne-strokes resp
◦ Pinpoint nonreactive pupils
◦ Hemodynamic instability
way to reduce ICP (non pharm)
◦ Prevent coughing / bearing down
◦ HOB 30-45 degrees
◦ do not cluster care- will increase ICP
TBI management general
- decrease icp
- bp management
- o2
- seizure precautions
- mannitol
- lasix
- swall eval
- nutrition management
what kind of line do we need in order to give hypertonic saline?
central line –> vessicant
precautions with craniectomy?
-where helmet when out of bed
3 criteria for breath death/organ donation
- irreversible unresponsive coma
- absence of brain stem reflexes
- apnea (no spont. breath over vent)
term: type of cirrohsis:
caused by hep C or is drug induced
post necrotic cirrhosis
term: type of cirrohsis:
caused by chronic alcoholism
Laennec’s
term: type of cirrohsis:
caused by biliary obstruction or autoimmune disease
biliary cirrhosis
cirrhosis patho real quick
Liver takes in blood from GI through the portal vein –> build up of blood in portal vein because it cannot move through due to scar tissue –> backs up into GI tract
compensated vs decompensated cirrhosis
Compensated disease= Scarring is present but liver can still function
Decompensated disease= liver *failure *with symptoms
Decompensated and acute liver failure are the same thing
complications from cirrhosis include
- Portal Hypertension
- Ascites
- Esophageal Varices
- Hepatorenal Syndrome- impact on kidneys, palliative care involvement at this stage
- Hepatic Encephalopathy- build up of toxins
- And coagulation problems, jaundice and peritonitis
whats the big deal with portal hypertension? what does is allow for?
blood has resistance going through liver –> backs up into GI organs –> new veins form allowing liver bypass –> unfiltered blood enters circulation
2 causes of ascites re: cirrhosis
-
Increased hydrostatic pressure from portal hypertension pushes fluid out
—>Plasma protein leaks out of vessels (less plasma protein in blood) –> not enough protein to pull fluid back into vasculature - Liver can’t make enough albumin –> dependent edema in rest of the body/LE
esophageal varices- why do they happen? what make it worse?
backing up of blood from portal hypertension
* Heavy lifting
* Exercise
* Dry, hard food
* Intubation/NG tube
—- can also just happen without aggrevating factors so you SOL
hepatic enphalopathy is caused by thre backup of what chemical?
ammonia!
signs of hepatic enceph.
-sleep/mood/mental/speech changes
progressing to altered LOC/neuromuscular/coma (stave IV)
things that can lead to hepatic enceph.
- GI bleed
- High protein diet
- Infection
- Hypovolemia (third spacing)
- Hypokalemia
- Constipation
ANYTHING that INCREASES ammonia!
patho of hepatorenal syndrome
Increased ascites > pressure on renal artery > decreased blood flow to kidney > renal failure > end of line
hepatorenal urinary output is
<500 ml/ day
relationship of NASH/ NAFLD/Cirrhosis
NAFLD –> NASH –> Cirrhosis
cirrhosis assessmnt findings
-weight loss
-RUQ pain
- petechiae
- palmar erythema
- GI bleed
- jaundice
- ascites
- spider angioma
- peripheral edema
- asterixis
- fetor hepaticus (fruity musty breath)
- gynecomastia
- amenorrhea
- impotence
- caput medusae
AST/ALT ratio for alcoholic liver disease =
> 2
interventions for cirrhosis
- -Na 1-2 g / day
- -paracentesis
- -vitamins
- -diuretics
- -bleeding precautions
- -resp support
- screening for varices
cirrhosis patients are at risk for what kind of peritonitis ?
Spontaneous Bacterial Peritonitis
- lacks obvious source
- give ABX
- diagnosed with paracentesis
drug to give for esophageal varices?
beta blocker - propranolol
Reduces Heart rate and hepatic venous pressure (reduces risk of bleeding)
bleeding esophageal varices are chill or not chill? and what we gonna do>?
not chill- emergency!
lay on side, head down if hypovolemic , 2 large bore Ivs, get BP high enough that they can go down for procedure
re surgical interventions for bleeding esoph. varices: a shunt that bypasses the liver?
TIPS
re surgical interventions for bleeding esoph. varices: a shunt that bypasses the liver?
TIPS
drugs for bleeding esoph. varices?
- Vasopressors – levophed, epinephrine
- IV Ocreotide- simatostatin shunts blood away from GI
- IV Protonix
- Fluids
- Blood products
- Antibiotics –> GI bleeding is often caused by infection so treat as if
hepatic encph interventions
- moderate protein diet
- lactulose (3-4 stools/day)
- rifaximin - decreases rate of ammonia
3 biggest patho developments of pancreatitis
-low calcium
-bleeding
-pus formation/necrosis
assessment finding for pancreatitis
- steatorrhea
- boring mid-epigastric pain that worsens in supine
- n/v
- fever
- tachy
- hypotension
- diaphoresis
- abd guarding
- dimished bowel sounds
- cullens sign
- grey turners sign
pancreatitis complications
- Infection/ SEPSIS
- Hemorrhage/ Shock
- Necrosis
- ARDS/ ALI: Acute Respiratory Distress Syndrome and Acute Lung Injury
- Renal Failure
- Pneumonia
- Paralytic ileus
- Jaundice
- Diabetes
2 key labs for pancreatis
elevated amylase and lipase
what kind of pain meds we giving for pancreatitis?
IV opioid
best way to relieve pancreatisit pain?
NPO
pancreatitis interventions
- IVF
- IV opioids
- Monitor Ca
- Antiemetics
- Activity as tolerated
- NG tube
- NPO
- skin integrity
- education
- monitor glucose
where do we put feeding tube in for pancreatitis?
Tube feet into small intestine below ligament of treitz
–> bypasses pancreas area
what is chronic pancreatitis?
-progressive
-remission/exacerbation
-fibrosis
-loss of exocrine function forever –> treat with enzymes
pain meds for chronic panc?
non oipoid
pancreatic enzyme admin
Do not crush
Take with food
In conjunction with antacids
Prevents pain with digesting food
Put in dobhoff if it is clogged
what is a whipple done for? what happens?
pancreatic cancer
- Removal of proximal head of pancreas, duodenum, part of jejunem, part or all of stomach and gallbladder
Anastomosis of pancreatic duct, common bile duct, stomach and jejunem
whipple complications
- Diabetes
- Bleeding
- Infection
- Bowel obstruction
- Abscess from leaking
- Pneumonia
- Fistula- leaking that finds its own pathway
- Peritonitis
