General Medical/Surgical Conditions Flashcards
- A chronic, inflammatory, obstructive, non-contagious airway disease with varying levels of severity, characterized by exacerbations of wheezing and coughing
- A reversible condition characterized by increased responsiveness of the small airways to stimuli
Asthma
-Past medical history: allergies, episodes of cough and wheezing
-Shortness of breath: pursed-lip breathing, chest tightness
-Cough: increased and productive with presence of eosinophils, increased IgE levels
-Appearance of the chest: increased AP diameter during episode
-Respiratory Pattern: accessory muscle usage, tachypnea
-Color: cyanotic
-Diagnostic Chest percussion: hyper resonant/tympanic
-Breath sounds: diffuse wheezing, diminished breath sounds
-Physical appearance:
diaphoresis, anxious, speaks in short phrases
-Vital Signs: tachycardia, pulses paradoxes during severe episodes
Primary assessment of Asthma
Secondary assessment of Asthma
CXR
ABG
Pulmonary Function
During acute episode:
- increased A-P diameter
- translucent (dark) lung fields
- depressed or flattened diaphragms
CXR findings in Asthma
Pulmonary Function findings in Asthma
- Decreased flow rates
- Normal DLco
- Pre and post bronchodilator improvement: at least 12% and 200 mL increase in FEV1
- Oxygen therapy
- Aerosol therapy with SABA and anticholinergic (consider continuous aerosol therapy)
- Corticosteroids (oral or IVl)
- Close monitoring (PEFR)
- Intubation and mechanical ventilation if respiratory arrest occurs
- Consider adjunct therapies: Heliox, magnesium sulfate, subcutaneous epinephrine
Emergency room treatment for acute episodes of Asthma
Long Term Control of Asthma
- Bronchodilators (SABA, LABA, anticholinergic)
- Corticosteriods
- Asthma action plan (based on peak flow)
- Bronchopulmonary hygiene
- Environment control
- Marked cooling of core temperature (below 35 degrees C or 95 degrees F)
- Generally the result of sudden immersion in cold water or prolonged exposure to cold environments
Exposure/Accidental Hypothermia
Primary assessment for Exposure/Accidental Hypothermia
- Past medical history: history of near drowning or cold exposure
- Physical appearance: shivering, confused, poor coordination, cyanosis, peripheral vasoconstriction
- Vital signs: Decreased HR, RR, QT, temp
Secondary assessment for Exposure/Accidental Hypothermia
ABG: Moderate to severe acidosis with hypoxemia
If patients body temperature is less than 37C or 98.6 then the patients actual values will show
pH increased
PCO2 Decreased
PO2 Decreased
ABG - Exposure/Accidental Hypothermia
Typically analyzed at 37 degrees Celsius
-For hypothermic patients, ABG should be corrected to match patient’s temp
Treatment and management for MILD cases of Exposure/Accidental Hypothermia
Passive rewarming may be sufficient
- Warm, dry clothes
- Warm drinks
- Isometric exercises to increased heart production
- Check core temperature as soon as possible
Treatment and management for MODERATE cases of Exposure/Accidental Hypothermia, core temp >30C
Active rewarming may be required
- Warm water baths
- Warm blankets
- Heating pads
- Warm oral fluids when patient is alert
Treatment and management for SEVERE cases of Exposure/Accidental Hypothermia core temp of <30C
Active rewarming required
- Warm intravenous solutions
- Warm gastric lavage or peritoneal lavage
- Inhalation of warm gases
-Mechanical ventilation for indicated ventilatory failure
- An infectious inflammatory process that primarily affects the gas exchange area of the lung causing capillary fluid (serum) to pour into the alveoli.
- This process leads to inflammation of the alveoli, alveolar consolidation, and atelectasis
Extremely common
–Causes include: bacteria, virus, and aspiration
Infectious Disease/Pneumonia
Primary assessment of Infectious Disease/Pneumonia
- Past medical history: initially mimics a cold or flu, signs and symptoms may develop quickly, may have chest pain
- Shortness of breath: may be present
- Cough: productive, yellow/green sputum
- Chest findings: decreased expansion, increased tactile and vocal fremitus
- Respiratory pattern: tachypnea
- Color: cyanosis
- Diagnostic chest percussion: flat or dull
- Breath sounds: crackles, bronchial, whispered pectoriloquy
- Physical appearance: diaphoretic
- Vital signs: increased HR, BP, QT, temp
Secondary assessment of Infectious Disease/Pneumonia
CXR ABG Pulmonary function CBC Sputum Culture Special tests
- Increased density from consolidation and atelectasis
- Air bronchograms
- Pleural effusion
CXR finding in Infectious Disease/Pneumonia
Pulmonary function findings in Infectious Disease/Pneumonia
Decreased volumes and capacities (VT, VC, TLC)
CBC findings in Infectious Disease/Pneumonia
- Increased WBC with bacterial infection
- Decreased WBC with viral infection
Sputum findings in Infectious Disease/Pneumonia
Gram positive or gram negative organisms
Special tests for Infectious Disease/Pneumonia
- CT scan
- Acid fast stain for TB
- ELISA test for HIV
Treatment and management for Infectious Disease/Pneumonia
- Oxygen therapy
- Pulmonary hygiene therapy
- Hyperinflation therapy
- Mechanical ventilation for ventilatory failure
- VAP protocol for intubated patients
- Drug therapy
- Bedrest
- Adequate fluid intake
- Thoracentesis for large pleural effusion
Drug Therapy - Infectious Disease/Pneumonia
- Antibiotics determined by history, sputum culture
- Antipyretics to control fever
- Analgesics for pain
- Cough suppressants if necessary
Situation in which a victim survives a liquid immersion.
Near drowning
Wet drowning - glottis relaxes and allows water to flood the lungs
Dry drowning - the glottis spasms and prevents water from entering the lungs
Primary assessment of Near drowning
- Past medical history: swimming pool, ocean, lake
- Cough: frothy pink stable bubbles
- Respiratory pattern: ranges from tachypnea to apnea
- Color: cyanosis
- Breath sounds: crackles and rhonchi
- Physical appearance: confused, unconscious, comatose
- Vital signs: increased HR, BP, QT, hypothermia
Secondary assessment of Near drowning
CXR
ABG
- Initially can be normal
- Fluffy infiltrates
- Pulmonary edema
CXR findings in Near drowning
Treatment and management of Near drowning
- O2 therapy at 100%
- Intubate and MV with PEEP for apnea or patients who can’t maintain a PaO2 of 60 torr on FiO2 of < 50%
- Inotropic agents
- Diuretics
Warming of the victim in hospital - Near Drowning
- IV administration of heated solutions
- Heated lavage of the gastric, intrathoracic, pericardial and peritoneal spaces, or the bladder and rectum
- Heated blankets
- Warm baths
- ECMO for severe cases
Near Drowning - If neck injury is suspected, intubated patient with
Flexible bronchoscope
Decreased renal function secondary to diabetes mellitus or renal insufficiency
Diabetes/Renal failure
- Past medical history: history of diabetes mellitus, renal disease
- Respiratory pattern: may exhibit Kussmaul breathing
- Breath sounds: rales if CHF present
- Physical appearance: alert, lethargic, confused, comatose, unresponsive, pedal edema
Primary assessment of Diabetic/Renal failure
Secondary assessment of Diabetic/Renal failure
- ABG: Metabolic acidosis
- Urine output: Decreased <500 mL/day
- Blood glucose level: > 160 mg (Diabetic)
Treatment and management of Diabetic Patients
Closely monitor glucose levels, ABG, watch for signs of respiratory failure
Treatment and management of Renal Failure
Carefully monitor intake and output, electrolytes, watch for signs of CHF
Acquired dysfunction of the immune system
- Transmission by trans placental, route (newborns) or by semen or body fluids of affected persons.
- Can also occur from blood transfusions, intravenous drug use or medical use of blood products
AIDS
- Past medical history: IV drug abuse, blood transfusions, previous pneumonia
- Color: pallor
- Physical appearance: weight loss, nocturnal diaphoresis, frequent herpes simplex infections
- Vital signs: recurrent fever
- Sign and Symptoms: diarrhea, lymphadenopathy
Primary assessment of AIDS
Secondary assessment of AIDS
- Special tests: Positive HTLV III or HIV from an ELISA test
- Bronchoscopy: To obtain tracheal washings or lung biopsy which may be positive for Pneumocystis carinii/Jiroveci
Treatment and management of AIDS
- Do not order culture and sensitivity tests. pneumocystis carinii/Jirovecii (carinii) can’t grow outside of the body
- Utilize standard/universal precautions
- Infection may be treated with monthly pentamidine (NebuPent) aerosol therapy
- TB is endemic in this population
AIDS - Pneumocystis carinii/Jirovecii (carinii) infection is treated prevented with
Pentamidine (NebuPent) aerosol therapy.
-Administer in Semi-fowlers position
Treat TB with
18-24 month course of INH, rifampin, ethambutol, streptomycin
Any surgical procedure performed on structures within the thoracic cavity
- Lung repairs or resections
- Tracheal / mediastinal repairs or resections
- Pneumonectomy or lobectomy
- Cardiac surgery: valve replacements, bypass grafts
Thoracic Surgery
Primary Assessment of Thoracic Surgery
- Past medical history: carcinoma, heart disease
- Shortness of breath: may be present
- Cough: nonproductive, or may include hemoptysis
- Appearance of the nail beds: clubbing with chronic hypoxemia
- Diagnostic chest percussion: may be dull/flat over affected area
- Breath sounds: may be diminished over affected area
Secondary assessment of Thoracic Surgery
Routinely performed pre-operative basic laboratory testing
- CXR
- Pulmonary function
- -both may be abnormal with lung pathology
Treatment and management of Thoracic Surgery PRE-OPERATIVE
Hyperinflation therapy (IS/SMI, IPPB)
Treatment and management of Thoracic Surgery POST-OP
- Hyperinflation therapy (IS/SMI, IPPB)
- Prevention of infection
- Monitor chest drainage systems
- Observe for post-op complications
-MV if indicated
Any injury or surgical procedure performed on the skull and or brain
- Traumatic brain injury
- Tumors
- Aneurysms
- Cerebrovascular accidents
- Seizures
Head Trauma/Surgery
Primary assessment of Head Trauma/Surgery
- Past medical history: tumors, headaches, cranial bleeds, trauma, slurred speech
- Respiratory pattern: Irregular rhythm, Cheyne-Stokes breathing
- Level of consciousness: altered LOC
- Pupillary response: abnormal
Secondary assessment of Head Trauma/Surgery
- Special Tests
- ICP monitoring
- -normal 5-10 mmHg
Special Tests for Head Trauma/Surgery
Glasgow Coma Scale, CT, MRI, PET scans
Treatment and management of Head Trauma/Surgery
- Oxygen therapy: maintain PaO2 level near 100 torr
- Mechanical ventilation
Mechanical ventilation for Head Trauma/Surgery
- Reduce PaCO2 level to 25-30 torr to treat acute elevations in ICP (iatrogenic hyperventilation)
- Minimize mean airway pressure by utilizing low PEEP and PIP
- Set low pressure and exhaled volume alarms appropriately
Medications used to treat Head Trauma/Surgery
- Barbiturates for sedation
- Mannitol to decrease ICP
- Dilantin (phenytoin) for seizures
Any injury or surgical procedure performed on the neck and/or spine
- Traumatic injury
- Tumors
- Spine deformities
Neck and Spinal Injury/Surgery
Primary assessment of Neck and Spinal Injury/Surgery
- Past medical history: fall, accidents, tumors
- Appearance of the neck/spine: bruises over affected area
- Respiratory Pattern: may be apnea with severe damage to spine
- Level of consciousness: altered
Secondary assessment (Special Tests) of Neck and Spinal Injury/Surgery
- CT
- MRI
Treatment and management of Neck and Spinal Injury/Surgery
- Oxygen therapy to treat or prevent hypoxemia
- Stabilize the neck and spine to minimize movement
- Maintain patent airway
- -modified jaw thrust technique
- -Intubate with flexible bronchoscope
-Support ventilation, oxygenation, circulation and perfusion as indicated by bedside assessment and laboratory testing
Any surgical procedure performed on structures within the abdominal cavity
- Gall bladder
- Stomach
- Liver
- Colon
- Uterus
- Appendix
Abdominal Surgery
Primary assessment of Abdominal Surgery
- Past medical history: abdominal pain, bleeding, family and social history
- Respiratory pattern: may be tachypneic
Secondary assessment of Abdominal Surgery
- Routinely perform pre-op basic laboratory testing
- Pre-op pulmonary function testing (basic spirometry testing)
Treatment and management of Abdominal Surgery PRE-OP therapy
Hyperinflation therapy (IS, IPPB)
Treatment and management of Abdominal Surgery POST-OP therapy
- Hyperinflation therapy (IS,IPPB)
- Prevention of infection
- Analgesics as needed
- Observe for post-op complications: increased pressures, decreased static lung compliance, hypovolemic shock
- Mechanical ventilation if needed
Surgical removal of the larynx
Causes:
- Carcinoma of the upper airway
- Trauma
Laryngectomy
Following Laryngectomy
- There is nor longer a connection between the upper and lower airways, and the patient has a permanent stoma
- The patient can not be orally or nasally intubated.
- If mechanical ventilation is required. insert an endotracheal tube into the laryngectomy opening
Primary assessment of Laryngectomy
Past medical history: upper airway carcinoma
Secondary assessment of Laryngectomy
Routinely perform basic laboratory testing
Treatment and management of Laryngectomy
- Use meticulous suctioning technique (watch for bleeding/clots post-op)
- Cool aerosol will help keep secretions thin in the early post-op period
- Laryngectomy tube is removed after 3 to 6 weeks, at that time the stoma is considered stable and permanent
- Monitor basic laboratory tests
