Final Exam 2016 Flashcards
S/s liver disease/failure (RUQ)
Jaundice, pruritis(itchy), spider angiomas, red palms, anorexia, N/V, DULL right up quad pain, clay colored stool, fector hepaticus (sweet musty breath), portal HTN (ascites/varices), dark brown frothy urine, decrease u/o, hepatic encephalopathy, asterixis (liver flap), anasarca (fluid in skin), pleural effusion, leukopenia (NOTHING FRESH), K loss, confusion, male breasts, woman face hair, amenorrhea
Prevent liver disease
Avoid raw shellfish, vent room, protect skin, limit meds, limit ETOH
Interventions
Lotion, high calorie high carbs LOW PROTEIN, I&O, fluids, neuro: alarms, freq checks, elevate edema, pericentesis for ascites, respiratory: fowlers, arms out, conserve energy, nothing fresh, electrolytes
High PT/INR means?
Coumadin or liver disease
Most specific serum test for liver used to monitor tx
ALT
Post liver biopsy
Bed rest 12 hrs, lay ON SITE (pressure)
Portal HTN
Comp liver disease Ascites Peripheral edema Splenomegaly Increase venous pressure in portal circulation Varices HTN
Ascites main s/s and intervention
Abd pain, impaired respiratory, low u/o, low K, bacterial peritonitis
NA restrict
Diuretics
Paracentesis
Varices
Comp portal HTN (liver disease)
Bleeding/shock for esophageal varices
Gastric
Internal hemorrhoids
Caput medusae (around umbilicus)
Esophageal varices bleed tx
Caused from portal HTN
contributor: STRAINING, alcohol, coarse food
Stabilize and stop bleed (fluids, blood)
Tx w/ either sclerotherapy (heat), band ligation, balloon tamponade
Endoscopy interventions
Return of gag reflex, LOC, bleeding
Balloon tamponade care
For bleeding esophageal varices Patency Position via X-ray Saline lovage/NG suction Semi fowlers NPO Scissors at bedside
Shunting
Used after bleeding varices episode
Shunts blood out of portal vein
TIPS (non surgical)
COMPLICATION = ammonia build up
Hepatic encephalopathy
Life threat complication liver disease
Ammonia (normal 15-40)
Neurotoxic
Hepatic encephalopathy interventions
Limit protein Mental change Asterixis- Liver flap Hyperreflexia Fector hepaticus (musty sweet breath)
TX WITH LACTULOSE (bm to get rid ammonia)
Antibiotics
Electrolytes
Neuro asses Q2hrs
Hepatorenal syndrome
Life threat complication liver disease
Renal vasoconstrict –> renal fail
Liver transplant
Overall care liver disease
Rest No etoh, ASA, NSAIDS Manage s/s Prevent complication Diet
Liver fail
Jaundice Coagulation defects Encephalopathy Portal HTN Cerebral edema Electrolyte disturb Cardio abnormal Renal fail
Key w/ hepatitis management
Rest and nutrition
Hep incubation phase
Most infectious
Flu-like (malaise, anorexia, low grade fever, N/V, arthralgia (joint aches))
RUQ pain
one month
Acute/icteric phase hep
No fever
Jaundice, pruritis, dark tea urine, clay stooo
Anicteric
2-4weeks
Convalescent/posticteric phase hep
Gradual improvement
Malaise, fatigue
REST
2-4 months
Hep nutrition
High cal/card low fat/protein
Sm freq meals
Hep A
Fecal/oral, dirty water, raw shellfish
“Newsmaker”
Acute only
Hep A diagnostics
Anti-HAV (antibody to hep A)
Anti-HAV IgM (immunoglobulin=acute hep)
Anti-HAV IgG= (G=gone, past infection, future immunity)
Tx hep A
Vaccine prophylaxis
Immunoglobulin within 2 weeks
Hep B
Blood, body fluids, sex, needles ,perinatal
Lives on dry surface 7days
Carrier/infectious lifetime
HIV test
Chronic hep b
HBsAg positive 2x
Seen in very young
Interferon and antivirala
Hep c
Silent killer
Asymptomatic for yrs
No vaccine
Always infectious perinatal, percutaneous, permucosal
Symptoms usually jaundice/bruising/fatigue
HIV
antibody test
Colorectal cancer
Change in bowel pattern
Polyps
All abnormal need removed
Adenomatous/neoplastic linked cancer
Risk cancer increase w polyp size increase
Gradual/insidious onset (0 symptoms until advanced)
Polyp risk
Genetics IBD Age > 50 Increased red meat diet Lynch syndrome (born with hundreds polyps)
S/S polyps/colorectal cancer
Insidious/gradual Non specific Problems w/ bleed, obstruction, perforation, fistula Recent weight loss Iron deficient anemia Rectal bleed Abd tender Bowel change Hepatomegaly/ascites
Descending colon tumor s/s
Bleed and diarrhea
Ascending colon tumor
Detected later, presents as bowel obstruction
Cancer detect
Sigmoidoscopy Q5 years Or Colonoscopy Q10 yrs Age 50+ Yearly feckless occult blood tests
Colorectal cancer geriatrics
Fatigue
Iron deficient
Minor bowel change/bleed
Tenesmus (feeling to have to poop)
colorectal cancer tx
Stage 1 hemicolectomy
Stage 2 resection w/ or w/o chemo
Stage 3 surgery and chemo
Stage 4 palliative
***bowel cleanse and antibiotics prior (ex miralax)
Low anterior reception (LAR)
Preserves sphincter function
Tx colorectal cancer
Chemo
Affects all systems
Ostomy care
High fiber
Increase fluids
What is celiac
Autoimmune genetic digestive disease
Malabsorption
Inflammation w/ gluten (wheat, barley, rye)
Celiac comp
Iron anemia, vit b/d deficient leading osteoporosis
Celiac s/s
Chronic diarrhea Steatorrhea (pale frothy floating poop) bc impaired fat absorb Abd pain, distention, N/V, constipation Growth fail (lack energy/appetite) Bruising/anemia Tetany Dehydration Hair thinning
Adult celiac s/s
Iron anemia Fatigue Bone/joint pain Depression Tingling hands/feet Seizures/migraines Canker sores in mouth Itchy dry skin rash
Celiac tx
Only 100% gluten free + steroids short term Vitamins Replace w/ corn & rice Low fat Compliance
Celiac crisis
Dehydration
Profuse watery diarrhea
Emotional disturb
Infection
Diverticulosis
Sacs in sigmoid no inflame or symptoms
Vague abd pain, bloating, flatulence, change bowel
Some bleeding
Diverticulitis
Inflammation w/ infection
Acute LLQ pain, mass
Infection s/s: fever, leukocytosis
Abscess
Maybe asymptomatic
Risk diverticular disease
Age
Low fiber/fluid
Low exercise
Congenital
Dx diverticular disease
Colonoscopy or rectal bleed
**Never colonoscopy w/ itis
Do CT scan with contrast **
Tx diverticulitis
NPO, rest, antibiotics, NG tube, IVF
Tx diverticulosis
High fiber Low fat/red meat Exercise/fluids Weight reduction Stool soften No straining
Acute pancreatitis
Life threat Sudden severe deep piercing radiating Abd pain LUQ or midepigastrum Decreased bowel sounds Increase pain AFTER meals N/V (vomit doesn't help) Dyspnea, jaundice, cyanosis S/S hypovolemic shock Grey turners (flank ecchymosis)/Cullen's sign (peri umbilical ecchymosis) Hypocalcemia (chvosteks, trousseaus)
Chronic pancreatitis
LUQ pain
Chronic heavy gnawing feelings not relieved by foods/antacids
Malabsorption: weight loss, jaundice & dark urine, steatorrhea (fatty stool), DM
Frothy urine/stool
Acute pancreatitis complications
Respiratory: effusion, ARDS (LUNG SOUNDS!!!!) Cardiac: shock Hypocalcemia: tetany Infection Compartment syndrome
Pancreatitis interventions
Pain NG auction NPO (maybe ppn) Semi fowlers Antacids, PPI, H2RA Slowly advance food (high carbs!) Education (no alcohol, diet) Pancreatic enzyme meds WITH meals
Two types of IBD
Chrons and Ulcerative colitis (UC)
Chronic inflammation; exacerbations &a remission
*no cure
Diff btwn chrons and UC
Chrons- all layers bowl, anywhere in GI, skip lesions, recurrence
UC- inner layer GI, starts in rectum -> continuous, pseudopolyps, cured w surgery, cancer risk, toxic mega colon more common (perforation)
Chrons s/s
Diarrhea
Abd pain
Weight loss (malabsorption)
UC s/s
Bloody stool***
Anemia, weight loss, dehydration, diarrhea
Abd pain (lower cramping)
Tenesmus
Toxic megacolon
Complication UC SEVERE abd pain Distention Fever Severe bloody diarrhea
Tx
NPO, rest, NG tube, IVF, steroids, antibiotics if no cure 24hrs -> colectomy
Systemic complication IBD
Finger clubbing Erythema nodosum Aphthous ulcers Conjunctivitis Thromboembolism Gallstones Osteoporosis
IBD dx
Colonoscopy (never w/ exacerbation)
Pharm tx IBD
5-ASA (reduce inflam)
Sensitive to sun w/ meds! Know bleeding s/s, orange skin/urine NORMAL
IBD diet
High calorie, high vitamin, high protein, low residue (no dairy)
Mechanical bowel obstruction
Small intestine
Surgical, cancer, diverticular disease
Non mechanical bowel obstruct
Paralytic ileus (post op) Neuro or vascular
Bowel Obstruction pathophysiology
Hyper bowel sounds above, absent below
Distention -> third spacing
Can lead to hypovolemic shock
Bowel ischemia -> necrosis -> perf-> septic shock
Small bowel obstruction
Rapid dehydration Intermittent pain Freq projectile vomit (orange, brown) Greatly increase distention Borborygmi (loud bowel sounds) above obstruction Hypovolemia
Large bowel obstruct
Slow dehydration Persistent cramping pain Rare/gradual vomit increase distention Borborygmi (loud bowel sounds) above obstruction Hypovolemia
Obstruction dx
Ct
Abd X-ray
Tx obstruction
Must resolve in 24 hrs NPO NG tube IVF I & O Pain
GERD s/s
Pyrosis (burning in esophagus) Dyspepsia (indigestion) Regurgitate Hyper salvation Dysphasia Odynophagia (pain w swallow) Globus sensation (lump in throat) Non cardiac chest pain
Esophagitis
Common comp GERD
inflammation esophagus
Ulcers -> structures/dysphasia
Tx with sucralfate*** to coat esophagus
Barret’s esophagus
Lining lower esophagus changes
Precursor cancer
Freq heartburn, gnawing epigastric pain, bleed, perf
Tx: endoscopic ablation therapy
GERD teaching
Low fat, small freq meals No caffeine, beer, milk, carbonation Don't drink/eat before bed Normal body weight No tight clothes Elevate HOB
H2RB
Before meal PPI
Antacid
Prokinetic
PPI side effect
Osteoporosis
IBS s/s
Alter bowel pattern Abd pain/distention Bloating Constipation/diarrhea/both Excessive flatulence
- no fluids with meals
Cholecystitis
Obstruction gallbladder from stones Emergency S/s: Indigestion Pain RUQ radiate shoulder Abd rigidity Fever Jaundice Increased labs
Cholecystitis care
NPO rest Fluids NG tube Dressing
Cholelithiasis
Intolerance fatty food Severe pain (biliary colic) Obstructive jaundice Dark amber urine Clay stool
Tx
Surgery
ERCP
ESWL (shock wave)
ERCP
Pt left side
Gag/cough reflex post procedure
Peripheral artery disease
Intermit claudication (pain/cramps) Paresthesia Pallor when legs up (no blood) Rubor when legs down (blood pooling) Rest pain No periph pulses
Dx: ankle brachial index
Percutaneous transluminal balloon angioplasty
Balloon tipped cath in stenotic vessel, inflates to compress plaque and stretch vessel –> stent
(PAD tx)
Post surgical PAD nsg care
Avoid knee flexed position and prolonged sitting (cuts circulation)
ABI
pulses
6 Ps of acute arterial ischemia
Pain Pallor Pulsessness Paresthesia Poikilothermia (coldness) Paralysis (advanced stage)
- caused from clot that cuts off blood supply
Care for arterial embolism
SUPINE
Venous leg ulcer
Near medial malleolus Edema Exudate Superficial IRREGULAR shape Red/yellow color Pain worsens when dangling legs
venous insufficiency
Aching/crampy Present pulses Stasis dermatitis Warm Thick/tough skin Brown/leathery skin
Arterial ulcer
In feet areas Very painful or no pain Deep CIRCULAR shape Ulcer pale black No edema or drainage
PQRST assessment for angina
Pain Quality Radiating Severity Timing
Acute coronary syndrome
Is an MI just different types (stemi/nonstemi)
Most cardiac specific biomarker
Troponin
Tx ACS
Acute coronary syndrome (MI)
Oxygen, ASA, NTG, Morphine
“M-A-N-O”
PCI within 90 min
1 complication MI
Dysrhythmias
Post PCI care
SUPINE, leg straight, insertion site, pressure when sheath removed, distal extremity
PDA
Patent ductus arteriosus
Widening pulse pressure
Bounding pulse
Acyanotic
Aortic stenosis
Limit activity
Acyanotic
Tetralogy of fallot
Pulmonary stenosis
Right ventricular hypertrophy
Ventrical septal defect
Overriding of aorta
Dx: cyanosis, Tet spells
Tet spells
With activity that increases O2 demand
Tachypnea, tachycardia, irritable, crying, cyanosis, KNEE TO CHEST POSITION to compensate (calm the child down)
Normal CO, MAP, and EF
CO: 5-7
MAP > 60
EF > 60
Normal K
3.5-5
Normal pH
Normal CO2
Normal bicarbonate
PH 7.35-7.45
CO2 35-45
Bicarbonate 22-26
Left HF
PND
Pulmonary
2 ACE inhibitor examples
Captopril
Lisinopril
HF !!!!!
BB example
Metoprolol
Digoxin and digoxin toxicity
Increase force contraction and slows conduction in HF
toxicity: nausea, blurred vision, halos, dysrhythmias
HF symptom recognition teaching
FACES:
Fatigue Activity limitation Cough Edema SOB
Reasons why went into HF exacerbation (acronym)
A3 I3 E
Arrhythmia
Angina
Anemia
Indiscretion of meds
Infarction
Infection
Endocrine
Another name for ADHF
Pulmonary edema
Early sx ADHF
Tachypnea
Decrease O2 sat
“Donkey and cart up hill” interventions (3) for ADHF
Can either unload cart to get uphill (diuretics)
Have donkey go around hill (vasodilators)
Push donkey to go uphill (inotropes)
Takotsubo
Stress related syndrome in women that mimics cardiomyopathy until cath
Weird teaching about mouth to prevent IE
Prevent gum infections/tooth decay
Prophylactic antibiotics for dental cleanings
IE s/s
Flu Murmur HF Splinter hemorrhages Petechiae Olsers nodes Janeways lesion
PTBV
Percutaneous transluminal balloon valvuloplasty
Cath lab
Balloon prevents stenosis in valve
Extremity CMS, pressure dressing
INR range onnnnnn Coumadin
2.5-3.5
Takes longer to work
Immediate post op for heart replacement
Lethal arrhythmias and rejection
Cor pulmonale
From copd (pulmonary artery HTN) -> increase work of R side heart -> right sided HF
S/s COPD
Weight loss
Chronic cough
Dyspnea
Sputum
Bacterial pneumonia sputum color
Purulent
HAP
More virulent pneumonia
Onset 48hrs or longer after admission
IHI ventilator bundle
Sedation vacation Chlorhexidine rinse Elevate HOB Ulcer prophylaxis DVT prophylactic
S/s lung cancer
Silent Persist cough Sputum volume/blood Pneumonitis sx Chest shoulder back pain Dyspnea wheezing strider
Systemic (late) Bone/joint pain Weight loss Anorexia Fatigue N/V Hoarseness
2 main issues w/ end stage lung cancer
Dyspnea (air hunger)
Pain
TB manifestations
DRY cough -> productive
Fatigue, weight loss, night sweats, fever (flu like)
Dyspnea
Hemoptysis (cough blood)
Tuberculin skin test
Screening if infected
PPD objected read 48-72 hrs
Positive TB skin test
Redness NOT positive, hardness (induration) is
If it’s over 15 induration = low risk
5 = immunosuppressed, recent exposure
10 = immigrant, high risk setting, IV drug users
Doesn’t mean disease present (exposed or vaccinated)
Should have CXR***
Dx TB
Sputum culture (8 weeks) (and H&P and CXR)
Positive TB sputum smear infection time
2 weeks
Avoid public
TB meds
Rifampin INH (causes hepatitis--> avoid alcohol)
Main reason for TB tx fail and how to solve
Non-adherence
DOT (direct observed therapy)- watch them swallow meds
ARDS
Severe dyspnea/hypoxemia UNRESPONSIVE to O2
Infiltrates on CXR
ARDS tx
O2 + PEEP (positive end expiratory pressure to open alveoli) Manage underlying cause Lateral rotation therapy PRONE position (tummy) Nutrition
Acute respiratory failure
50/50
o2 50
CO2 50
When is trach tube consider for pt on vent
If on vent longer than 10-14 days (damage)
Flail chest
Floating seg ribs from fractures
Paradoxical chest movement
Croup s/s
Harsh barking cough
Hoarseness
Inspiratory strider
LTB most common type
(Epiglottitis = emergency!)
Epiglottitis
Type of croup: EMERGENT! strider at rest Cyanosis Severe agitation Retractions CANT DRINK FLUIDS
Croup (LTB) management
Patent airway (home care usually) Moist air Room temp oral fluids Cool mist Steroids
Cardinal signs of Epiglottitis (4 D)
Drooling
Dysphasia
Dysphonia
Distressed inspiration
(Never examine epiglottis until intubation equipment available- NPO)
Bronchiolitis
Commonly from RSV
Most common ped. Respiratory infection
No cough but trouble breathing s/s
CONTACT/droplet precautions
Cystic fibrosis
Inherited
Mucus in bronchioles, intestine, pancreatic/bile ducts)
Increase Cl and Na in sweat !
No cure
S/s cystic fibrosis
Poor growth Bulky greasy stool or STEATORRHEA (difficulty absorbing) Freq colds/cough Thick sticky secretions Cor pulmonale Diabetes
Cystic fibrosis tx
Airway clearance therapy
Mucolytics
Pancreatic enzyme capsule
WITH meals to breakdown high fat foods in CF
Adrenal cortex
Cortisol (metabolism and stress)
Aldosterone (k/na for bp regulation)
Addisons
Adrenal cortex insufficiency Hyper pigment Low Na, low glucose High K Muscle weakness Neuro
Steroids (increase in times of stress)
** increase Na intake **
Cushings
Excessive ACTH (from pituitary to adrenal cortex->cortisol) From long term steroids; can be hypothalamus, pituitary, or adrenal
High Na, high glucose Low K Moon face Muscle atrophy(low K) HTN buffalo humo Facial hair Na and water retention Thin fragile skin, acne Fat tummy Facial hair
Taped down steroids
Primary hyper aldosteronism
Excess aldosterone (adrenal cortex) Tumor HTN Low k Low Ca (tetany, paresthesia, weakness, cramps, dysrhythmias) High Na (sodium retention, K excretion)
K sparing diuretic
Na restrict, K supplements
Adrenal medulla
Epi/norepi
Vasoconstrict; “fight or flight”
Pheochromocytoma
Adrenal medulla tumor EXCESSIVE catecholemines (epi/norepi) Pounding headache Tachycardia HTN Diaphoresis Flushing Hyperglycemia Tremor Anxious
Give antiHTN
Don’t palp abd
Anterior pituitary
ACTH, TSH, GH
Acromegaly
Excess GH Sweat Mood disorders Enlarged hands/feet Deep voice Thick facial features Hyperglycemia Thick leathery skin Large lips
Pituitary tumor
Gland bear face/eyes
Headache
Visual disturb
Hypo or hyper secretion s/s
Tx transphenoidal hypophysectomy
Transphenoidal hypophysectomy
Removal of pituitary (secretes ADH so at risk for DI) need lifelong hormones
Neuro assess
CSF drainage
Nasal packing
HOB up
Avoid straining *** (sneeze, lift, blow nose)
Posterior pituitary
ADH (water balance)and vasopressin
Low osmolality=more dilute
SIADH
Excess ADH increase H2O absorb, dilute Na (low osmality) Water retention low Na Weight gain Muscle weakness Lethargy Low u/o Headache Confusion THIRST
Tx fluid restrict (<1000), diuretics, IV hypertonic
DI
Deficient ADH LARGE amounts dilute urine, increasing serum osmolality, hypernatremia Low sp gravity (<1) Polydipsia Polyuria U/o > 20L Weakness Dehydration
Tx fluid replace, vasopressin
Dignostic for thyroid disease
TSH
high= hypoactive thyroid
Low= hyperactive
Thyroid hormone needs what
Iodine (in salt)
Goiter
Enlarged thyroid gland
Swallowing/airway problems
Hashimoto’s thyroiditis
Autoimmune
High TSH
hypothyroid
