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CCN > exam 4 > Flashcards

exam 4 Flashcards

1
Q

9 functions of liver

A

Bile formation and excretion

Metabolism of bilirubin (a by-product of breakdown of old RBCs)

Production of protein for blood plasma
(albumin) - albumin holds water in vascular space

Metabolism of carbohydrates, proteins, and fats

Conversion of ammonia to urea – ammonia

comes from breakdown of protein

Coagulation and anticoagulation

Metabolic detoxification

Metabolizing medications

Storage of minerals and vitamins

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2
Q

heptocytes

A

functional cell of the liver, secretes bile, performs metabolic functions

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3
Q

sinusoids

A

specialized vascular beds
lined with Kupffer cells
very permeable endothelium

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4
Q

kupffer cells

A

phagocytic
detoxify toxins
Produce vasoactive mediators

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5
Q

severity of alc withdrawal symptoms

A

are dose and time dependent

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6
Q

3 things that cause more serious alc withdrawal

A

Previous withdrawal, liver dysfunction, and other substance use

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7
Q

1st Q to ask when assessing alc withdrawal

A

when was the last drink

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8
Q

s/s of alc withdrawal and when do they start
- 4 early signs
- 5 moderate
- 5 severe

A

Symptoms: start 6-12 hours after last drink

Psychomotor agitation
Anxiety
Autonomic hyperactivity (tachycardia, sweating, HTN, fever) (EARLY SIGNS)
Increased hand tremor
Insomnia
Nausea or vomiting
hallucinations (severe)
Tonic-clonic seizures (severe)
delirium tremens(severe)
fluid, electrolyte imbalances (severe)
wernick-korsakoff syndrome (severe)

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9
Q

CIWA assessment cateogries 8

A

Nausea and vomiting
Tremor
Sweating
Anxiety
Agitation
Headache
Disorientation
Tactile, visual, and auditory disturbances

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10
Q

gold standard of tx for alc withdrawal

A

benzos (lorazepam)

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11
Q

how is blood supplied to the liver

A

most blood comes from GI tract via portal vein

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12
Q

who is at higher risk of seizures

A

people with previous hx of withdrawal

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13
Q

if pt having seizures, nurse should 4

A

implement seizure precautions ,
one-to-one observation,
monitor fluid and electrolyte status, and glucose monitoring.

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14
Q

when do hallucinations start to occur

A

12-24 hours

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15
Q

what 2 symptoms distinguish delirium tremens

A

disorientation and global confusion

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16
Q

nurse actions for alc withdrawal 4

A

Monitoring vital signs,

pulse oximetry

Assessment using the CIWA Scale q 4

Administration of (benzodiazepines) based on ciwa

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17
Q

how do benzos work

A

increases GABA = mimics depressive effects

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18
Q

therapeutic goal of benzo use

A

light somnolence (patient sleeps when not stimulated but is easily arousable).

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19
Q

Treatment of AWS Seizures, DTs and Refractory DTs vs AWS and what is goal

A

infusion of benzos + phenobarbital + BB
goal: reduce autonomic activity

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20
Q

wernickes encephalopathy

A

confusion, abnormal gait, and paralysis of eyes muscles caused by nutritional deficiency (especially thiamine (vitamin B1) deficiency) and NOT caused by AWS.

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21
Q

korsakoff syndrome

A

selective memory disturbances and amnesia that occurs commonly in AWS and with Wernicke’s encephalopathy.

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22
Q

how to treat wernicke korsakoff

A

thiamine for 3 days through IV infusion

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23
Q

how does nurse maintain and monitor fluid and electrolyte levels 9

what do electrolyte imbalances cause

A

weight
vital signs
I&O
BUN
creatinine
electrolytes (low K+, Mg, Phosp)
skin and mucous
edema
lung sounds

DYSRHYTHMIAS

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24
Q

all patients should have what consult

A

nutritonist

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25
Q

nurse action to counteract hypoglycemia

A

thiamine then IV glucose (cannot do glucose by itself)

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26
Q

most common cause of acute liver failure

A

alcohol

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27
Q

5 questions
to assess in overdose

A

1 question:Intent – is the ingestion intentional or unintentional? If an attempt to commit suicide, suicide precautions and a psychiatric consultation are indicated.

Dose
Pattern – single or repeated
Time of ingestion
Coingestants

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28
Q

labs to monitor in acetaminophen overdose 6

A

ABGS -ph
creatinine - bc renal damage
Pt/inr - rises 24-72 hours after ingestion
bilirubin
actaminophen levels
ASt/alt - greater than 1000 is toxicity

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29
Q

acetaminophen antidote

A

N-acetylcysteine (NAC)/Mucomyst

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30
Q

N-acetylcysteine (NAC)/Mucomyst
when to give
how to give
how it works

A

give 8-12 hours after ingestion to reduce hepatic injury

if alert and oriented can give orally

It limits formation/accumulation of toxic metabolite,

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31
Q

digoxin antidote

A

digibind

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32
Q

MgSo4 antidote

A

Ca gluconate

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33
Q

heparin antidote

A

protamine sulfate

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34
Q

warfarin(coumadin) antidote

A

Vit K

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35
Q

iron lead antidote

A

chelation

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36
Q

Lavage 3

A

insertion tube with Nacl
within 2-4 hours
Contraindicated in ingestion of caustic agents, sharp objects.

37
Q

high priority in overdose is

A

AIRWAY

38
Q

when to give activated charcoal

A

1 hour of ingestion

39
Q

cirrhosis leads to

A

portal hypertension
-> ascites

40
Q

ascites development

A

hypoalbuminemia -> leakage from plasma from the lymph -> Changes in capillary permeability and hydrostatic/oncotic pressure gradients

Release of nitric oxide causes vasodilation of the splenic artery, -> decreasing SVR and MAP, -> activating the renin-angiotensin-aldosterone (RASS holds onto water and salt), -> SNS and ADH causing water and sodium retention, the inability to excrete water causes dilutional hyponatremia, and renal blood flow is reduced resulting in hypoperfusion and decreased GFR.

41
Q

8 assesments for ascites

A

For shifting dullness in the abdomen with percussion

For peripheral edema (often pitting in the legs and feet)

Daily weight and I&O

For difficulty breathing and lung sounds

Abdominal discomfort and pain

For skin breakdown and jaundice

Orthostatic vital signs

42
Q

5 tx of ascites

A

alcohol abstinence

Sodium restriction of 2000 mg/day

Diuretic therapy

Fluid restriction

Paracentesis

43
Q

nursing resp for paracentesis

A

BEFORE
(time-out),
reassure the patient,
maintain sterile field
monitor hemodynamic status,
infuse albumin to replace protein as ordered.

AFTER
monitor hemodynamics
assess for pain,
assess fluid withdrawn and process any specimens,
maintain I&O,
monitor dressing for leaking,
monitor for complications.

44
Q

most serious complications of cirrhosis and portal hypertension.

A

bleeding varices - results from collateral circulation that develops to bypass the abnormally high pressure in the portal system

45
Q

assesment focus for bleeding varices 3***

A

hemodynamic status
fluid volume status.
somatostatin
prophylactic antibiotics for 7 days

46
Q

somatostatin

A

a hormone that inhibits vasodilator hormones and decreases portal pressure. Administered by IV bolus dose, followed by a continuous infusion for 3-5 days. – assess H and H

47
Q

endoscopic therapy

A

for bleeding varices tx
- sclerosing or banding to ligate the vessel. - repeated every 2-4 weeks until varices are eliminated
- surveillance every 6-12 months.

48
Q

TIPS

A

done to treat repeated or uncontrolled variceal bleeding.

A stent placed to decrease portal pressure thus reducing re-bleeding and formation of ascites.

49
Q

if someone has balloon tamponade what should be at bedside

A

scissors to cut balloon

50
Q

hepatic encephalopathy

A

is neuropsychiatric manifestations from ammonia resulting from a disturbance in the CNS because of liver failure.
s/s confusion to coma

51
Q

5 treatment for hepatic encephalopathy

A

Assessment of neurological status

Maintenance of the patient’s airway and preventing aspiration

Maintaining safety by preventing falls

Administration of lactulose or oral antibiotics (rifaximin).

TEMP restriction of protein intake from veg sources

52
Q

6 long term effects of burns

A

Temp regulation

Increased susceptibility to UV injury (wear sunscreen)

Decreased vitamin D synthesis (need vit D supplement/need osteoporosis screening younger)

Hypermetabolic state- increased HR and temp (need increased nutritional needs)

Prolonged immunosuppression

PTSD, anxiety etc

53
Q

percents of body burn

A

Head and neck – 9%
Arms – each 9%
Anterior and posterior trunk – 36%
Anterior and posterior legs – each 18%
Perineum – 1%

54
Q

burn that extends to subcut, muscle or bone

A

4th

55
Q

superficial/1st degree

A

epidural only

Skin is pink to red in color and slightly edematous.

These burns heal in 3-6 days.

TBSA not used

painful.

56
Q

superficial 2nd degree

A

epidermis and part of dermis
bright red in color, moist, with fluid-filled blisters
increased sensation and pain
21 days
little scaring

57
Q

deep 2nd degree

A

involve the epidermis + entire dermis.
white/waxy,
capillary refill is decreased.
less pain and decreased sensation.
3 weeks
scarring

58
Q

full thickness/3rd degree burns

A

all layers

Wound color ranges

no capillary refill

wound is dry, firm, leathery

no sensation to pressure, no pain

need skin grafting.

59
Q

major burn area percent

A

> 20%

60
Q

which burns for which zones

A

Zone of inflamm: superficial
Zone of stasis: superificial or deep 2nd
Zone of coag: 3rd

61
Q

most common cardiac change with burns

A

hypovolemic burn shock.

62
Q

2 components of burn shock

A

The cellular component results from damage to cells in the burn itself.

The CV component=Release of inflammatory mediators suppress myocardial contraction

systemic edema ->
massive decrease in circulating blood->
hyperviscosity of blood (can lead to dvt)
->and slowed capillary circulation

63
Q

critical nursing function for burn shock

A

fluid and electrolytes!!!

64
Q

gold standard for fluid monitoring after first 24 hours

A

urine output

65
Q

burn resuscitation fluid is successful when

A

0.5-1.0 mL/kg/ HOUR achieved after 2 hours of maintence fluids

66
Q

fluid resuscitation required when

A

burns involving > 20% TBSA

67
Q

fluid amount resucitation determined by

A

The Parkland Formula is commonly used: (4 mL/kg) * % of TBSA burned administered in the first 24 hours.

After the first 24 hours, fluids are given at a maintenance rate with urine output guiding replacement

68
Q

preferred fluid for resuscitation

A

Lactated Ringer’s solution

69
Q

Burns that extend around the circumference of the neck, chest, abdomen, and extremities (think tourniquet) are at risk for

A

compartment syndrome

70
Q

For patients with burns around the abdomen,

A

bladder pressure (measured through the indwelling urinary catheter WITH A PRESSURE SENSOR) to measure intra-abdominal pressure (> 30 mmHg indicate abdominal hypertension)

71
Q

tx for compartment syndrome

A

escharotomy

72
Q

what is escharotomy

A

provider uses a scalpel or electrocautery to cut through the eschar, releasing tension and permitting blood flow to the area.

73
Q

nurse responsibilties for escharotomy

A

sterile guaze for 24 hours
monitoring for blood loss/edema

74
Q

if Patients with singed scalp or facial hair, changes in the mucosal lining of the oropharynx, including presence of soot, hoarseness, edema, or blisters

A

evaluate for inhalation injury

75
Q

monitoring resp function include 6

A

vital signs,
ABGs,
lung sounds,
chest x-ray,
bronchoscopy
carboxyhemoglobin levels.

76
Q

respiratory support interventions 4

A

elevating the HOB,
turning and repositioning,
administration of humidified O2,
suctioning as needed.

77
Q

intervention for inhalation injury

A

Early intubation

NG/OG tube- to decompress the stomach/ enteral nutrition.

78
Q

patient with suspected CO poisoning

A

high-flow O2 at 90-100% or hyperbaric O2 therapy.

79
Q

GI changes in burns 6

A

hypermetabolic state
Urea and creatinine levels in urine increase.
Body weight drops quickly.
Delayed healing,
muscle wasting
bone loss

80
Q

GI assessments in burns 4

A

bowel sounds,
bowel movements,
presence of nausea/vomiting,
abdominal distention and tightness (remember abdominal compartment syndrome)

81
Q

lab values 3 and other assessments 2
to monitor for blood loss from ulcers

A

h and h
nitrogen- 24 hour urine collection
gluoce checks
I and O
dly weights

82
Q

renal chnages in burn 4

A

GFR decreased
urine output decreased
BUN and Cr rise
dark brown urine

83
Q

how to monitor urine output for burns

A

catheter

84
Q

foundation of burn wound management

A

early exicision to remove eschar and debris

85
Q

how long are dressings on burns

A

3 days

86
Q

silver sulfadiazine

A

topical medication for bacteria
Application is painless
does not penetrate eschar.

If a rash occurs, the medication is discontinued

87
Q

madenide acetate

A

bacterial cream
NOT ANTI FUNGAL
penetrates eschar and application can be painful.

MONITOR FOR FUNGAL INFECTION

discontinuing if a rash develops.

88
Q

portal vein supplies

A

75% of blood flow and 50% of oxygen from nutrient-rich blood in the entire GI tract

CCN (9 decks)

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