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Mod 1 Flashcards

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USMLE® Step 1 flashcards
1
Q

In the immediate postoperative period what is the first-line route of administration of analgesic delivery?

A

IV

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2
Q

What can be applied directly over the injection site prior to painful needle sticks?

A

Local anesthetic such as EMLA and L.M.A.X. ( lidocaine 4%)

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3
Q

What is the difference between tropical and transdermal drug delivery?

A

Transdermal requires drug absorption into the systemic circulation and tropical agents produce effects on the tissue immediately

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4
Q

How are intranspinal analgesic delivered?

A

By inserting a needle into the subarachnoid space or epidural space and injecting the analgesic agent or treading a catheter through a needle and taping it in place

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5
Q

When are temporary epidural catheters for acute pain management removed?

A

After 2-4 days

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6
Q

What is the most common opioids administered intraspinally?

A

Morphine
Fentanyl
Hydromorphone (dilaudid)

And are combined with a local anesthetic, most often ropivacaine (Naropin) or bupivavaine (marcaine)

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7
Q

What is the difference between opioid tolerant and opioid naïve?

A

Opioid naive: patients who are not chronically receiving opioid analgesics on a daily basis; and

Opioid tolerant: patients who are chronically receiving opioid analgesics on a daily basis.

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8
Q

What is authorized advent controlled analgesia?

A

When a patient is unable to use the PCA equipment a nurse or capable family member is authorized to manage the pain using the PCA

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9
Q

What is considered one of the safest and best tolerated analgesic agents?

A

Acetaminophen (Tylenol)

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10
Q

What is the most serious complication when taken acetaminophen?

A

Hepatotoxicity ( liver damage)

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11
Q

What is the primary underlying mechanism of NSAID (aspirin, IBUPROFEN and naproxen)?

A

Gastric ulceration and reduction in the GI productive prostaglandins

Administer small does for short time

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12
Q

What are the unwanted side effects of opioids?

A

Constipation, nausea, sedation and respiratory depression

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13
Q

What is the goal of titration?

A

Is to use the smallest does that provides satisfactory pain relief with the fewest adverse effects

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14
Q

What is the first sign of withdrawal?

A

Diaphoresis (sweating)

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15
Q

What is the recommended approach for treatment of pain in all types of pain and all age groups?

A

Multimodal analgesia

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16
Q

Equal analgesia

A

Equianalgesia

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17
Q

What is a normal response that occurs with repeated administration of an opioid for 2 or more weeks

A

Physical dependence

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18
Q

Sensitivity to pain is known as what?

A

Hyperalgesia

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19
Q

OHI is a result of what?

A

Changes in the central and peripheral nervous system that produces increased transmission of nociceptive signals

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20
Q

What is the opioid is the standard to which all other opioids are compared?

A

Morphine

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21
Q

Morphine is a hydrophilic drug which accounts for what?

A

It’s slow onset and long duration

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22
Q

What does hydrophilic mean?

A

Readily absorbed in aqueous solution

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23
Q

Fentanyl (sublimaze) is lipophilic opioid and as such it has what kind of onset and duration?

A

A fast onset and short duration

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24
Q

How often should a fentanyl duragesic be changed?

A

48 to 72 hours

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25
Q

What do you need to be careful of when it comes to a fentanyl transdermal patch?

A

The application of heat because it speeds up absorption of the transdermal fentanyl which can lead to life threatening respiratory depression

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26
Q

What medication has been removed or severely restricted on hospital formularies for the treatment of pain in efforts to improve patient safety?

A

Meperidine (Demerol)

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27
Q

What are the most common adverse effects of opioids?

A

Constipation, nausea, vomiting, pruritus and sedation

Respiratory depression is less common but most feared

In postop patients ileus can become a major complication

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28
Q

What is given to reverse significant opioid induced respiratory depression?

A

Naloxone (narcan)

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29
Q

When giving narcan for respiratory depression what should you do?

A

It should be diluted and titration led very slowly to prevent severe pain, hypertension, tachycardia, ventricular dysthymias, pulmonary edema and cardiac arrest

0.4 mg of naloxone and 10 mls of NS administer 0.5 ml over 2 min

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30
Q

What are first line analgesic agents for neuropathic pain?

A

Anticonvulsants (anti seizure drugs) gabapentin (neurontin) and pregabalin (lyrica)

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31
Q

What contains the highest amount of water?

A

Muscle
Skin
Blood

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32
Q

Body fluids are contained in what compartments?

A 
Intracellular space (fluid in the cells) 
Extra cellular space (fluid outside the cells)
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33
Q

What is third space fluid shift?

A

Loss of the ECF into space that does not contribute to equilibrium between the ICF and the ECF

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34
Q

What is early evidence of third space fluid shift?

A

Decrease urine output despite adequate fluid intake

Other S/S that indicate intravascular fluid volume deficit FVD are:
Increased HR
Decreased BP 
Decreased central venous pressure 
Edema 
Increased body weight 
Imbalanced intake and output
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35
Q

Third space fluid shift occurs in patients who have what?

A 
Hypocalcemia 
Decreased iron intake 
Severe liver disease 
Alcoholism 
Malabsorption 
Immobility 
Burns
Cancer
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36
Q

What is the usual daily urine volume in the adult?

A

1 to 2 L

1500 ml per day output

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37
Q

What are the chief solute a in sweat?

A

Sodium, chloride and potassium

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38
Q

How much approximate fluid is lost through the skin as insensible perspiration?

A

500 ml/day

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39
Q

Lungs normally eliminate water vapor at a rate of what?

A

300 mls per day

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40
Q

What is the normal intake?

A

2500 mls

Water 1000 mls
Food 1300
Water of oxidation 200

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41
Q

How much water is lost through stools?

A

200 mls

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42
Q

What is the best indicator of I/Os?

A

Daily weights

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43
Q

1 oz is how many mls?

A

30 mls

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44
Q

What is osmolality?

A

It is the concentration of fluid that affects the movement of water between fluid compartments by osmosis

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45
Q

What is the normal BUN?

A

10-20 mg/dl

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46
Q

What are factors that increase BUN?

A 
Decreased renal function
GI bleed
Dehydration 
Increased protein intake 
Fever
Sepsis  
Decreased BUN 
End stage liver disease 
Low protein diet
Starvation 
Conditions with expanded fluid volume
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47
Q

What is the normal creatinine labs?

A

0.7-1.4 mg/dl

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48
Q

Why is creatinine a better indicator of renal function?

A

Because it does not very with protein intake and metabolic state

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49
Q

What is the normal hematocrit labs?

A

42%-52% for males

35%-47% for females

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50
Q

What conditions increase and decrease hematocrit?

A

Increase:
Dehydration
Polycythemia

Decrease:
Over hydration
Anemia

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51
Q

When does FVD or hypovolemia occur?

A

When the loss of ECF volume exceeds the intake of fluid

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52
Q

What causes FVD hypovolemia?

A 
Vomiting 
diarrhea 
GI suctioning 
Sweating 
Third space fluid shifting
Diabetes insipidus
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53
Q

What are the signs and symptoms of FVD hypovolemia

A 
Acute weight loss
Slow skin turgor
Oliguria 
Concentrated urine
Prolonged capillary refill
Low BP 
low CVP
Flattened neck veins 
Dizziness 
Confusion 
Elevated pulse
Sunken eyes
Muscle cramps 
Cool clammy skin
Pale skin
54
Q

What are the signs and symptoms of FVE hypervolemia?

A 
Acute weight gain
Peripheral edema 
Ascites 
Distended neck veins
Crackles
SOB
Bounding pulse
Cough
Increased respiratory rate
55
Q

What are contributing factors to potassium deficit hypokalemia?

A 
Diarrhea 
Vomiting
Gastric suctioning 
Corticosteroid administration 
Diuretic 
Bulimia 
Starvation
56
Q

What are S/S of potassium deficit hypokalemia?

A 
Fatigue 
Anorexia 
Nausea
Vomiting 
Muscle weakness 
Polyuria 
Decreased bowel motility 
Ventricular a systole fibrillation 
Paresthesias
Leg cramps 
Low BP 
Ileus
Hypoactive reflexes
57
Q

What will you see on an ECG with potassium deficit hypokalemia?

A

Flattened T waves, prominent U waves, ST depression, prolonged intervals

58
Q

What will you see on an ECG with potassium excess hyperkalemia?

A

Tall tented T waves, prolonged PR intervals and QRS duration, absent p waves,ST depression

59
Q

When is a fluid challenge test done?

A

When the health care provider need to determine whether the depressed renal function is caused by reduced renal blood flow secondary to FVD or from acute tubular necrosis from prolonged FVD

60
Q

1L of fluid is how much weight?

A

1 kg or 2.2 lbs

61
Q

What would you use dextrose 5% in water for?

A

Fluid loss
Hypernatremia

Special consideration:
Not for long term use
Becomes hypotonic when dextrose metabolizes
Don’t use for resuscitation; can cause hyperglycemia
Use caution in renal and cardiac disease

62
Q

0.9% sodium chloride NS is used for what?

A 
Shock
Hyponatremia
Blood transfusion 
Resuscitation 
Fluid challenge
Metabolic alkalosis 
Hypercalcemia
Patients with diabetic ketoacidosis

Don’t use on patients with heart failure, edema, hyernatremia; can lead to overload

63
Q

How is peripheral edema monitored?

A

By measuring the circumstances of the extremity with tape marked in millimeters

64
Q

What is the most abundant electrolyte in the ECF?

A

Sodium

65
Q

What are normal concentration of sodium?

A

135-145 mEq/l

66
Q

Hyponatremia cause the cell to do what?

A

Swell as water is pulled in from ECF

Hypernatremia causes cells to shrink

67
Q

To maintain potassium Balance what must be functioning and why?

A

The renal system because 80% of the potassium excreted daily leaves the body by way of the kidneys

68
Q

What are sources of potassium?

A 
Fruit juice 
Bananas 
Melons
Citrus fruit 
Fresh and frozen vegetables 
Lean meat
Milk
Wholegrains 
Avocado 
Chocolate 
Nuts
69
Q

If an infusion pump is not used to administer potassium what could happen?

A

If someone does an IV push or intramuscularly it could replace the potassium too quickly and stop the heart

70
Q

A patient with a potassium infusion has less than 20 mls per hour for 2 consecutive hours what should you do?

A

Stop the infusion

No pee no K

71
Q

When should increased potassium levels be anticipated?

A

When extensive tissue trama has occurred

Burns
Crushing
Severe infection
Lysis of malignant cells after chemotherapy

72
Q

When potassium levels are dangerously high over ( over 7mEq/l) what is Necessary to administer?

A

IV calcium gluconate

73
Q

Although calcium gluconate is not injectable what do you want to monitor for as a result of the rapid IV administration?

A

Blood pressure to detect hypotension

74
Q

When monitoring patients for hyperkalemia where should the pulse be taken?

A

Apical

75
Q

What is the normal total calcium level?

A

8.6-10.2 mg/dl

76
Q

Hypocalcemia is common in what patients?

A

Patients with renal failure because these patients have elevated serum phosphate levels

77
Q

What is the most characteristics manifestation of hypocalcemia and hypomagnesemia?

A

Tentany

78
Q

What is chvostek’s sign?

A

A twitching of muscles enervated by facial nerve when the region that is about 2 cm anterior the earlobe is tapped

79
Q

What is trousseau sign?

A

Can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm HG above systolic pressure with in 2-5 min there is carpal spams

80
Q

What may occur because hypocalcemia increases irritability or the central nervous system as well as peripheral nerves

A

Seizures

81
Q

Acute symptomatic hypocalcemia is life threatening and requires prompt treatment with IV administration of what?

A

Calcium salt

82
Q

What should calcium be deluted with so it doesn’t cause cardiac arrest?

A

D5W and administered as slow as a IV blouse or a slow IV infusion using a pump

83
Q

What foods are high in calcium?

A 
Milk products 
Green 
leafy vegetables 
Canned salmon
Sardines 
Fresh oysters
84
Q

Anaphylactic shock

A

Circulatory shock state resulting from a severe allergic reaction producing an overwhelming systemic vasodilation and relative hypovolemia

85
Q

Hypovolemic shock

A

Shock state resulting from decreased intravascular volume due to fluid loss

86
Q

Neurogenic shock

A

Shock states resulting from loss of sympathetic tone causing relative hypovolemia

87
Q

Septic shock

A

Circulatory shock states resulting from overwhelming infection causing hypovolemia

88
Q

Systemic inflammatory response syndrome (SIRS)

A

Overwhelming inflammatory response in the absence of infection causing relative hypovolemia and decreased tissues perfusion

89
Q

Shock

A

A clinical syndrome that results from inadequate tissue perfusion creating an imbalance between the delivery of and requirement for oxygen and nutrients that support cellular function

90
Q

What response is common in all types of shock?

A

Hypoperfusion of tissue
Hypermetabolism
Activation of the inflammatory response

91
Q

What must the mean arterial Pressure (MAP) exceed for cells to receive oxygen and nutrients?

A

65 mm HG

92
Q

What is cardiac output?

A

Is the product of stroke volume the amount of blood ejected from the left ventricle durning systole

93
Q

How is peripheral resistance determined?

A

By the diameter of the arterioles

94
Q

What is the equation to find the MAP?

A

Means arterial= cardiac output X peripheral resistance

95
Q

How do the kidneys regulate BP?

A

By releasing renin

96
Q

What are the stages of shock?

A

Compensatory stage 1
Progressive stage 2
Irreversible stage 3

97
Q

Chances is survival increase when shock is identified and aggressively treated within how many hours?

A

6 hours

Especially septic shock

98
Q

What happens in the compensatory stage of shock?

A

The BP will remain WNL vasoconstriction will increase the heat rate, stimulation of sympathetic nervous system release catecholamines ( epinephrine/ norepinephrine). The body shunts blood to the brain, heart and lungs causing the skin to become cool and pale bowel sound to be hypo active, and urine out put to decrease

99
Q

What are the nursing intervention for shock?

A

IV fluids and oxygen labs ( base deficit and lactic acid levels) blood glucose and serum sodium levels will be elevated

Monitor trends in vital signs

100
Q

How is pulse pressure calculated?

A

By subtracting the diastolic measurement from the systolic measurement

101
Q

What happens during progressive stage shock?

A

BP can no longer compensate the MAP falls below normal limits
Patients are clinically hypotensive( systolic

102
Q

What happens in irreversible (or refractory) stage of shock?

A

The organ damage is so severe that the patient does not respond to treatment and cannot survive

103
Q

What should be done to manage all types of shocks in all stages?

A

Support of respiratory function
Fluid replacement
Vasoactive medications to restore vasomotor tone and cardiac function
Nutritional support

104
Q

What are the types of guild provided to a shock patient?

A

Crystalstalloids and colloids

Isotonic crystalloid solution are often selected because they contain the same concentration of electrolytes as extracellular fluid (may cause interstitial edema)

Colloids are used to treat hypoperfusion and may cause anaphylactic reaction and patients must be monitored closely

105
Q

What is a normal central venous pressure?

A

4 to 12 mm HG or cm H2O

106
Q

What is the most common shock?

A

Hypovolemic shock

107
Q

What is hypovolemic shock caused by?

A

By external fluid loss, as in traumatic blood loss slot by internal fluid shifts as in severe dehydration , severe edema or ascites

108
Q

When does cardio genie shock occur?

A

When the hearts ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues

109
Q

Why should a fluid bolus never be given rapidly?

A

Because administration in patients with cardiac failure may result in acute pulmonary edema
(Infants and elderly)

110
Q

When does circulatory shock occur?

A

When intravascular volume pools in the peripheral blood vessels

111
Q

What cause septic shock ( warm shock)?

A

Widespread infection or sepsis

112
Q

What are S/S of SIRS?

A

Temp: >100.4 or 90pm
RR: > 20 breaths per min
WBC: > 12,000 cells/mm

113
Q

What is neurogenic shock?

A

Vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation

114
Q

What is neurologic shock caused by?

A

Spinal cord injury
Spinal anesthesia
Or other nervous system damage

115
Q

What cause anaphylactic shock?

A

Severe allergic reaction when patients who have already produced antibodies to a foreign substance develop a systematic antigen antibody reaction

116
Q

What are the sings and symptoms of anaphylactic shock?

A 
Headache 
Lightheaded 
Nausea
Vomiting
Acute abdominal pain 
Pruritus 
Impeding doom
Generalized flushing 
Difficulty breathing 
Bronchi spasm
Cardiac dysthymias 
Hypotension
117
Q

What are normal blood glucose levels?

A

70-110

118
Q

What are the stages of general anesthesia?

A

Stage 1: beginning anesthesia
Stage 2: excitement
Stage 3: surgical anesthesia
Stage 4: medullary depression

119
Q

What might the. Patient experience in stage 1 of anesthesia?

A

As the patient. Breathes in the anesthetic mixture, warmth, dizziness and feeling of detachment may be experienced. The patient may have ringing, roaring or buzzing in there ears.

120
Q

what is Stage II of anesthesia characterized by?

A

characterized by variously by struggling, shouting, talking, singing, laughing, or crying is often avoided if anesthetic administered smoothly & quickly. Pupils dilate, but contract if exposed to light, pulse is rapid, & respiration may be irreg. Pt should not be touched except restraint is needed. (Restraint should never be placed over operative site as this increases circulation to that area & increases potential for bleeding)

121
Q

when is stage III of anesthesia reached?

A

is reached by continued administration of anesthetic vapor or gas. The patient is unconscious & lies quietly on the table. Pupils are small but contract when exposed to light. Respirations are regular, pulse rate & volume are normal, skin pink or slightly flushed.

122
Q

When is stage IV of anesthesia reached?

A

this stage is reached when too much anesthesia has been administered. Respirations are shallow, pulse is weak & thready, pupils are dilated & no longer respond to light. Cyanosis develops, & without intervention, death rapidly follows. If this stage develops, anesthesia is discontinued immediately & CPR is initiated to prevent death.

123
Q

what is Malignant hyperthermia?

A

a rare inherited muscle disorder that is chemically induced by anesthetic agents.

124
Q

what are the initial symptoms of Malignant hyperthermia?

A

Tachycardia (>150) is often the earliest sign, along with Sympathetic nervous stimulation that lead to ventricular dysrhythmia, hypotension, decreased cardiac output, oliguria (decreased output), & later, cardiac arrest. With abnormal transport of Ca, rigidity or tetanus like movements occur, often in the jaw. The rise in temp can increase 1-2 C (2-4 F) q 5 minutes. The core body temp can reach or exceed 42 C (104 F) in a short time & must be Properly monitored & recorded

125
Q

what can you give for Malignant hyperthermia?

A

Dantrolene sodium (Dantrium)

126
Q

Diazepam (valium, dizac)

A

Amnesia; hypnotic; preoperative medication. Good sedation. Prolonged duration. Residual effects for 20-90 hr; increased effect with alcohol.

127
Q

Kertamine (ketalar)

A

induction, occasional maintenance (IV or IM). Short acting; patient maintains airway; good in small children and burn patients. Large doses may cause hallucinations and respiratory depression. Need darkened, quiet room for recovery; often used in trauma cases.

128
Q

Midazolam (versed)

A

Hypnotic; anxiolytic; sedation; often used as adjunct to induction. Excellent amnesia; water soluble (nopain with IV injection); short acting. Slower induction than thiopental. Often used for amnesia with insertion of invasive monitors or regional anesthesia.

129
Q

Profofol (diprivan)

A

Induction and maintenance; sedation with regional anesthesia or MAC. Comes in a glass bottle and is milky white. Rapid onset; awakening in 4-8 min. May cause pain when injected. Short elimination half life 34-64 min

130
Q

what medications may mask presence of infection by impairing normal inflammatory response?

A

corticosteroids

Medical- Surgical (9 decks)

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