M3 F/E Comfort Flashcards
Nociceptive vs Neuropathic
Nociceptive - pain response to noxious stimuli, “normal” pain
Neuropathic - abnormal processing of sensory input by nerves
NSAIDS that inhibit both COX 1 and 2
NSIAD that inhibits only COX 2
Ibuprofen, naproxen, diclofenac, ketorolac
Celecoxib
FACES pain scale can be used in children as young as
3
OPQRST
Onset
Provocation
Quality
Region/Radiation
Severity
Time
Hierarchy of pain measures
Attempt to obtain report
Consider pt condition
Observe - grimace, crying, restlessness
Observe vitals
Conduct analgesic trial
FLACC
For young children
Facial expression
Leg movement
Activity
Crying
Consolability
PAINAD
FLACC for patient sin AD
advanced dementia
CPOT
For patients in critical care who can not self report
Patterned after FLACC
Max acetaminophen
4000mg
Max ibuprofen
3200mg
NSAID toxicity effects
Gastric bleeding
Ulcerations
NSAIDS inhibit prostaglandins which can cause
Cardio Vascular problems
MI
pt with CAD
Coronary artery disease
can take NSAIDS?
NO
Opioid mu agonist
Opioid mu antagonist
Morphine
Hydromorphone
Fentanyl
Naloxone
Opioid induced hyperalgesia
Pain due to opioid meds
Drug used to wean people off opioids
Methadone
Basic adverse effects of opioids
NV
Pruritus
Hypotention
Constipation
Major opioid effects
Over sedation
Respiratory distress
Med to prevent nausea
GOOD FOR POST OP
Ondansetron
in pt with pruritus post op due to opioids, give
or
antihistamines - loratadine, cetirizine
just lower the opioid given
Recover pt from resp depression and over sedation using what drug
Naloxone
Pasero opioid scale
S-sleep easy to arouse
1 - awake/alert
2 - slightly drowsy, easy to arouse
3 - frequently drowsy, drifts off during conversation (UNACCEPTABLE)
4 - Somnolent not responsive (UNACCEPTABLE)
Neuropathic pain first line meds
Anticonvulsant
GABApentin and pregabalin
calcium channel blockers
NSAID or Acetaminophen for older adults
Acetaminophen
Greater risk for bleeds with nsaids
Acute kidney injury
Rapid loss of renal function
can result in metabolic acidosis and electrolyte imbalances like HYPERKALEMIA
Urine with AKI can be
Normal
Oliguria
Anuria
Oliguria numbers
Less than 400ml a day
Anuria
Less than 50ml a day
AKI can be caused by
hypovolemia
hypotension
reduced cardiac output
obstruction of kidney tubes by tumor, blood clot, kidney stone
AKI and RIFLE classification system
Risk
Injury
Failure
Loss
ESKD
GFM
ESKD
Glomerular filtration rate
End stage kidney disease
RIF
Risk - creatinine 1.5x baseline, GFR v 25%
Injury - creatinine 2x baseline, GFR v 50%
Failure - creatinine 3x baseline, GFR v 75%
LE
Loss - persistent acute kidney injury longer than 4 weeks
ESKD - injury longer than 3months
Phases of AKI
Initiation
Oliguria
Diuresis
Recovery
Initiation - start
Oliguria - serum concentration develops, THIS IS WHERE HYPERKALEMIA STARTS
Diuresis - glomerular filtration starts to recover, risk for dehydration which will re-raise creatinine and BUN
Recovery - 3-12 months for renal return, 1-3% reduction in GFR
AKI S/S
Oliguria
Anuria
Hypoperfusion
Shock
Low specific gravity
high BUN
HYPERKALEMIA
METABOLIC ACIDOSIS
Hyperkalemia leads to
Monitor
Cardiac arrhythmias
Ventricular tachycardia
Cardiac arrest
HEART
Metabolic acidosis occurs in AKI because
Kidney cant get rid of acid type metabolic waste
RRT
renal replacement therapy
AKI risk factors
Severity of injury
RRT requirement
Age
Comorbidities - kidney vascular respiratory diseases
Antibiotic med that impact kidneys
VamcoMYCIN
GentaMYCIN
TobraMYCIN
cyclosporine
Interstitial nephritis - inflammation in kidney can also be caused by what analgesic
NSAID’s
Managing AKI
Fluid balance based on daily weight
Monitor for fluid excess - give furosemide (diuretic)
Dialysis - hemodialysis HD or CRRT
Fluid excess indicators
Dyspnea
Tachycardia
Crackles
Distended neck veins
CRRT
Continuous renal replacement therapy
Most lifethreatening problems with AKI
Hyperkalemia
ECG to watch for in hyperkalemia
Tall, tented or peaked T waves
Hyperkalemia S/S
MURDER
Muscle weakness
Urine output increase
Respiratory failure
Decreased cardiac contractility -v in HR and pulse
Early on muscle twitches and cramps
Rhythm changes - Peak T waves, Prolonged PR interval
As potassium level rises cardiac and other muscle function
DECLINES
MED EMERGENCY
Med for hyperkalemia
take _h to work
Kayexalate
(sodium polystyrene sulfonate)
6
When ECG changes occur with hyperkalemia give this combination IV
it will
watch for
arrange for
Dex50%
Insulin
Calcium
shift potassium back to cells
hypoglycemia
emergency dialysis
AKI pt may go into metabolic acidosis, may need what med
Sodium bicarbonate
In AKI, phosphate may rise, control with
calcium
hyperphosphatemia S/S
same as hypocalcemia
Paresthesia
Tetany
cramps
spasms
Numbness around MOUTH (CIRCUMORAL)
If pt gains or does not lose weight with AKI suspect
hypertension
AKI diet
what not to eat
High CARB, will spare protein for recovery
NO sodium potassium or phosphorus
(bananas, citrus or dairy)
Nursing with AKI
Monitor Fluids and Electrolytes -know aforementioned S/S
Reduce metabolic rate -by preventing infections, do blood and urine cultures regularly and act promptly
Promote pulmonary function -turn cough and prevent atelectasis
Provide skin care -breakdown due to edema, excoriation due to deposits, bathe in cool water
Reduce metabolic rate AKI
-by preventing infections, do blood and urine cultures regularly and act promptly
Promote pulmonary function AKI
turn cough and prevent atelectasis
Provide skin care
-breakdown due to edema, excoriation due to deposits, bathe in cool water
Erythropoietin is produced by the kidneys so a chronic kidney disease will result in
ANEMIA
What electrolytes go up with Kidney diseases
Potassium Sodium Phosphorus
With kidney failure, an increase in urea causes blood uremia. This damages what organ and creates what injurys
Heart
Pericarditis - s/s friction rub
Pericardial effusion/tamponade - s/s paradoxical pulse, hypotension, JVD
1 complication of dialisis and CKD
Cardiovascular disease
other dialysis complications that are worsened by procedure
HF
CAD
Stroke
When pt is on dialysis give meds
AFTER
Propofol med type
Anesthetic
B2 agonists and K+
Decrease potassium levels
GABApentin and other anticonvulsant Calcium Chanel Blockers can be used for what pain
BURNS
First thing to give a pt suspected of MI
other MI meds
Low dose aspirin
beta blockers
ace inhibitors
HF
Heart failure 101
heart is unable to pump enough blood to meet body’s needs
Primary cause of HF
CAD
deprives heart of O2
Other causes of HF
MIs
Hypertension
Cardiomyopathy (disease of myocardium)
Valvular failure
Kidney failure
Which layer is myocardium
Middle Muscle
Most common HF is _
results in decreased….
Systolic
blood ejected from ventricles
As this progresses it strains heart causing it to enlarge and dilates chambers, this causes apoptosis of cells and fibrosis.
Which then leads to _ heart failure
Heart failing to properly _
Diastolic
fill
Left side HF blood backs up into _
Right side HF blood backs up into _
Lungs
Body
Heart sound indicating Left HF
S3
Orthopnea
S/S of
Difficulty breathing when lying flat
LHF
Dry hacking cough
becomes full of frothy pink/tan sputum over time
LHF
Where does blood collect in Right HF
JVD
Dependent Edema
Ascites
Hepatomegaly
both L and R failure is called
Congestive HF
HF treatment goals
Improve cardiac function
Reduce symptoms
Stabilize patient condition
Delay HF progress
Promote heart health
Diuretics for HF
Loop
Thiazide
Aldosterone antagonist
Loop diuretic
Furosemide
Good for severe overload
Thiazide diuretic
HCTZ
Metolazone
Lowers K+ quickly
Aldosterone antagonists
Spironolactone
Potassium sparing diuretic
ACE inhibitors
April
Angiotensin system blockers
promote vasodilation and diuresis
Retain Potassium
ACE inhibitor adverse effect
Cough not responding to treatment
Increased K+
Increased Creatinine
ARBs MOA
ending
work on angiotensin renin system like ACE inhibitors, but specifically stop things at angiotensin II as opposed to the whole system
artan
Remembering ARBs endings
ARBs ArTan
ARBs and K+
will also increase
Beta-blocker MOA
Block adverse effects of Sympathetic nervous system
Relax blood vessels
Beta Blocker med ending
beta bLOLckers
lol
Beta blockers can cause _
so are contraindicated in diseases such as
Bronchiole constriction
Bronchospasms, asthma
Dioxin moa
Increases FORCE of contractions
Slows conduction through AV nodes
Digoxin is a TOXIN
S/S
Nausea
Visual disturbances
Confusion
Bradycardia
Hypokalemia and digoxin
Will INCREASE Digoxin toxicity
Digoxin can not be given if pt has _ failure
Renal
Sodium amount with HF
2g/day
Prolonged QRS indicates
treated with
desynchronization of right and left ventricles
Pacemaker
Cardiac arrest
associated with
Heart stop
Hyperkalemia
Potassium sparing diuretic
Spironolactone can lead to
Hyperkalemia
B2 agonists cause potassium level to _
via…
decrease
shift back into cells
Calcium gluconate
manage cariad arrest
cardiotoxicity
hypocalcemia
due to hyperkalemia or hypermagnesemia
Severe hyperkalemia first line agent
Calcium gluconate
Calcium gluconate 101
Increases threshold potential thus restoring normal gradient of K+
PRE renal failure
Categories
failure before the renal system
Volume depletion - GI loss, hemorrhage, diuresis
Impaired cardiac efficiency - Shock, HF, MI
Vasodilation - Anaphylaxis, sepsis, antihypertensive meds
Intra renal failure
Failure within the renal system
causes
Ischemia - Hemoglobinuria, Rhabdomyolysis, Pigment nephropathy
Nephrotoxic agents - Aminoglycosides, ACEs, Heavy metals, NSAIDs, Radiopaque contrast
Ineffective processes - glomerulonephritis, pyelonephritis
Hemoglobinuria causes
Transfusion reaction
Anemia
Rhabdomyolysis/myoglobinuria causes
Trauma
Crush injury
Burn
Aminoglycoside antibiotics
Gentamicin Tobramycin
Postrenal failure
System past the kidneys
Causes
BPH
Blood clots
Calculi
Tumors
4 Phases of Acute Kidney injury
Initiation
Oliguria
Diuresis
Recover
AKI initiation
Initial insult
ends with oliguria
AKI oliguria
Increase in serum concentration
CREATININE
uric acid
POTASSIUM
MAGNESIUM
400ml or less output in 24h
AKI Diuresis
signals that GFR is recovering
Labs will stabilize, then DECREASE
Observe for DEHYDRATION,
if this happens uremic symptoms will increase
AKI Recovery
Lasts 3 to 12months
Lab values return to normal
AKI S/S
DROWSINESS
Dry skin and mucous membrane
Headache
Muscle twitching
Seizures
AKI prevention
PAY SPECIAL ATTENTION to wounds burns and other precursors of sepsis
Treat infections and shock PROMPTLY
antibiotic and fluids
MONITOR renal function
Monitor renal function
Urine output
Lab values
Maintenance of fluid balance is based on
DAILY BODY WEIGHT
BP
I&O
AKI Fluid excess S/S
Dyspnea
Tachycardia
JVD
Crackles
Diuresis meds
Furosemide
Mannitol
Spironolactone
Dialysis types
Hemodialysis
Peritoneal dialysis
CRRT
Hemodialysis
Circulates large volumes
not for vascular compromised patients
CRRT
filters small volumes good for vascular compromised pts
Peritoneal
Hypertonic fluid goes in belly for a time
then it is removed
high chance of infection, leakage, bleeding
In peritoneal, what goes in
must come out
Peritoneal dialysis can ambulate T/F
T
Dialysis Diet restrictions
Protein
Potassium
Sodium
Can you use dialysis cites for draws
NO
only dialysis
Dialysis complications
Clots
Cell lysis
Infection
Fluid balance
Most life threatening problems with AKI
Hyperkalemia
^K+ and ECG
Peak T
Prolonged QR interval
^K+ S/S
IRRITABILITY
abdominal cramping
diarrhea
paresthesia
muscle weakness
^K+ and muscle weakness
slurred speech
hypoxemia
paralysis
as K+ increases
CARDIAC FUCTION DECLINES
^K+, give
Kayexalate
Sorbitol
If pt has ^K+ and is hemodynamically unstable give
IV D50, insulin, Calcium replacement
As calcium goes up what goes down
Phosphorus
Since most meds filter though kidneys, in AKI doses will be
REDUCED
PT with severe acidosis may need what med
what procedure
Sodium Bicarbonate
dialysis
AKI weight is done
daily
Diet for AKI
HIGH CARB
after diuretic phase also HIGH PROTEIN
Foods to avoid in AKI
Potassium (citrus, bananas)
Phosphorus (coffee)
AKI nursing management
Monitor F/E
Reduce metab rate (BEDREST)
Promote pulm function
Prevent infection
Provide skin care
Pulm function
Turn
Cough
Take deep breaths
Prevent infection
Avoid urinary cath
Heart FAILURE
Faulty valves
Arrhythmias
Infarction
Lineage
Uncontrolled BP
Recreational drugs
Envadors
Most common cause of Right HF
Left HF
strongest ventricle
Left
Low ejection fraction is anything less than
40
Left HF S/S
DROWNING
Dyspnea
Rales (crackles)
Orthopnea (sit to breath)
Weakness
Nocturnal dyspnea
Increased HR
Nagging cough
Gaining weight
Right HF S/S
SWELLING
Swelling of extremities and LIVER
Weight gain
Edema (pitting)
Large neck veins JVD
Lethargy
Irregular HR, A fib
Nocturia
Girth increase
HF tests
BNP
CXR
Echocardiogram
Heart cath
Nuclear stress test
HF can be exacerbated by
Na increase
Fluid increase
Infection
Renal failure
HF can be maintained with
Meds
Diet
Treatments
Nursing interventions for HF
Assess peripheral swelling
Assess pulmonary issues
Assess responsiveness to meds
Check labs
Assess diet
Assess safety
Response to HF meds assessment
DAILY WEIGHT
BP - ace arbs
HR - digoxin
Check labs and HF
Hypokalemia
Hyperkalemia
due to ace arbs or potassium sparing diuretics
BUN
Creatinine
Digoxin level
BNP
Cardiac and fluid restrictions for HF
normal
record
Normal amount is 2L
I&O
Edema treatment for HF
elevate legs - venous return
high fowlers - breathing
Vasodilators with HF can cause
Orthostatic Hypotension
FALL RISK
Dietary sodium restrictions
2g a day
HF vaccinations
Flu
Pneumonia
illness exacerbates HF
HF daily maintenance
Aerobic exercise
DONT stop meds
STOP smoking/drinking
Teach early signs of HF problems
Early signs of HF problems
Can not tolerate normal activity (SOB)
Need pillow at night to sit up and breath
Rapid unexplained weight gain
Meds for HF
Always Administer Drugs Before A Ventricle Dies
Ace inhibitors
Arbs
Diuretics
Beta blockers
Anticoagulants
Vasodilators
Digoxin
First line med for HF
ACE
S/S of digoxin toxicity
VISION changes
yellow green halos
NV
Digoxin range
0.5 to 2
With digoxin monitor what vital
PULSE
no less than 60
Types of pain
Surgical
Injury
Burn
Disease
Categories of pain
Persistent
Acute
Intermittent
Chronic
Negative effects of pain on body
Stress
Immune system v
infection ^
wound healing v
vasoconstriction = v perfusion
hypermetabolism = hyperglycemia
Indicators of pain
Facial expression
Body movement
Muscle tension
Anion gap is the difference between _ and _
Cations (sodium, potassium)
Anions (chloride bicarbonate)
Predominant cation
predominant aniona
Sodium
Chloride
^ in anion gap indicates
metabolic acidosis
v in anion gap =
metabolic alkalosis
AKI and anion gap
increase in gap due to retention of acids
Anion gap is a rapid measurement of identifying acid base _
IMPALANCES
