👩🏾🎓- Respirtory, MH & Hepatic Test Flashcards
ABG normal values
Ph, PaCO2, PaO2, HCO3
Ph 〰️ 7.35-7.45
PaCO2 〰️ 35-45
PaO2 〰️ 80-100
HCO3 〰️ 22-26
Leptin
Hormone produced by fat cells
- Communicates to the hypothalamus satiety (the feeling of being full)
- Regulates energy expenditure or balance
⬆️ leptin vs ⬇️ leptin
⬆️ - increases energy expenditure decreased appetite = weight loss
⬇️ - decreased energy expenditure increased appetite = weight gain
Food-drug interactions
- Tyramine foods (cheese, aged,picked meat) + MAOIs (antidepressants) = ⬆️BP
- No milk with tetracycline
- Grapefruit increases blood level of medication & decreases elimination time
- Take antibiotics with food
- Licorice = ❤️ issues, ⬇️ BP, arrhythmias
Orlistat , lorcaserin , phentermine/topiramate
Orlistat- inhibits pancreatic lipase, thereby reducing dietary fat absorption
SE: loose stools, abd cramps, nausea
Lorcaserin- regulates appetite and increase the feeling of fullness after eating, so less food is eaten (for seizures and migraines)
Phentermine/topiramate- extended release is a combination medication
Roux-en-Y
Gastric bypass
A combination procedure that involves the creation of a restrictive 30-mL pouch and bypass of a portion of the small intestine
Can cause malabsorption
List the 3 short term life-threatening complications of bariatric surgery
Pulmonary embolism
Infection
Anastomosis leak**
Long term complications and side effects of bariatric surgery
- band slippage, obstruction, hernia
- esophageal erosion, ulcers, acid reflux
- vitamin deficiency, osteoporosis, anemia and dumping syndrome
Dumping syndrome
Manifestations
Occurs when stomach contents are rapidly “dumped” into the small intestine
Manifestations- n/v/d, abdominal pain, cramps, dizziness, bloating, belching, fatigue, heart palpitations, tachycardia
Normal range of HGB
12-18 g/dL
Normal range of HCT
38-49%
Normal range of albumin vs prealbumin
Albumin: 3.5-5.0 g/dL
Prealbumin: 19.5-35.8 mg/dL
Eteral feeding vs TPN
Enteral - used for those not getting adequate nutrition, but have fully functioning GI tract
TPN - used for those not getting adequate nutrition AND who do not have the full use of their GI tract
What to know about TPN
- monitor fluid, electrolyte and glucose levels closely
- ⬆️ risk of infection related to ⬆️ sugar intake
- risk of hyperglycemia, hypoglycemia, air embolism hypervolemia
Kubler-ross grief cycle
Stage 1 denial Stage 2 anger Stage 3 depression Stage 4 bargaining Stage 5 acceptance
Domain 7: Care of the imminently dying
-symptom management (pain, general discomfort, respiratory distress, delirium)
-stages of dying:
Early (accept its near)
Middle
Late (hours or days)
S&S of approaching death
Coolness Sleeping Disorientation Restlessness Incontinence Decrease in appetite & fluid intake Urine decrease Breathing-pattern change Respiratory congestion Decreased socialization
List the 8 domains of palliative care
- Structure and process of care (family education)
- Physical aspect of care
- Psychological & psychiatric aspects of care
- Social aspects of care
- Spiritual, religious and existential aspects of care
- Cultural aspects of care
- Care of the imminently dying
- Ethical and legal aspects of care
Passive vs active euthanasia
Passive- not directly causing death
“Allowing natural death”
Withdrawing or withholding life-sustaining therapy
Active- actively causing death
Clinical presentation of pulmonary embolism
Rapid onset:
Chest pain Dyspnea Tachypnea Apprehension Tachycardia Petechiae on chest Refractory hypoxemia Anxiety/restlessness
Refractory hypoxemia
Unresponsive to increasing oxygen
Treatment of pulmonary embolism
- oxygen
- anticoagulant (lovenox, heparin)
- thrombolytics
- embolectomy
- IVC filter
What does d dimer test for
Used to rule out the presence of an inappropriate blood clot (dvt, pe)
Acute respiratory failure
A change in respiratory gas exchange such that normal cellular function is jeopardized
PaO2 < 60 or PaCO2 > 50
Acute respiratory failure
Early, late findings
Early- dyspnea, restlessness, anxiety, fatigue, hypertension, diaphoresis, tachycardia, tachypnea
Late- confusion, somnolence, pink skin coloration, hypercapnia/hypoxia, lethargy, central cyanosis
When to intervene in ARF
Increased O2 need, increased HR, change in mental status, change in lung sounds, increased dyspnea, call MRT/RRT,
Look at trends over last 24hrs/past couple days, activity level
⬇️ urine output= ⬇️ cardiac output
Acute respiratory distress syndrome
Causes
Widespread inflammation in the lungs/stiffening of the lungs and loss of compliance (elasticity)
Causes- sepsis, fluid overload, shock, trauma, neurological injuries, burns, DIC, aspiration
What is the number one cause of ARDS
Sepsis
P/F ratio
Formula, ranges
Formula- PaO2/FiO2
Normal > 500
Respiratory failure < 300
ARDS < 200
Low survival rate < 100
Clinical manifestations of ARDS
- Tachypnea
- Decreased breath sounds
- Dyspnea
- Refractory hypoxemia
- Decreased pulmonary compliance (due to alveoli damage)
- pulmonary infiltrates (increased alveolar fluid, pulmonary edema)
TRAILI
Treatment, cause
Transfusion related acute lung injury
Cause- giving expired packed RBC that causes ARDS, RBC good for 40 days
Treatment- fluid, analgesic, O2
Treatment of ARDS
- mechanical ventilation (PEEP, sedation/analgesia)
- prevention of nosocomial infection
- maintain nutritional status and fluid balance (⬆️ protein, calories, fluid)
- glucocorticoids May be used to decrease inflammatory response*
- prone position in severe situations
BiPAP
Patient receives two different levels of airway pressure
Higher pressure during inhalation assists with opening of the alveoli
Lower pressure during exhalation keeps the alveoli from collapsing during exhalation
CPAP
One continuous pressure throughout the respiratory cycle to help keep the alveoli open through inspiration and expiration
What is prone position
Lies flat with chest down and the back up
Barotrauma
Injuries caused by increased air or water pressure , such as during airplane flights or scuba diving
Pulmonary barotrauma
Too much air in lung stretched alveoli
Positive end expiratory pressure
Amount of pressure that is held in the lungs at the end of exhalation
Improves oxygenation by recruiting alveoli (restoring alveoli and reactivating surfactant)
Normal range 3-5 cmH2O water pressure
Synchronized intermittent mandatory ventilation
Mode of ventilation used to stimulate spontaneous breaths or to prevent respiratory alkalosis. Can be used as a weaning mode by decreasing mandatory breaths
Nurses role during intubation
Administer medications (sedation, analgesia, paralytic)
Confirmation of ETT placement by auscultation
Suctioning as requested
Hyperoxygenation between attempts
SpO2 monitoring
Ventilator bundles
Set or interventions for ventilator patients to prevent VAP
HOB > 30 degrees
DVT prophylaxis
Stress ulcer prophylaxis (prilosec)
Turning q2 hrs
VAP prevention (mouth care q2 hrs)
Functions of the liver
Blood storage
Blood filtration
Production of bilirubin
Synthesis & removal of clotting factors
Metabolism of carbs, fat and protein
Detoxify the blood
Storage area for fat soluble vitamins & iron
Clinical manifestations of hepatitis
Abdominal pain, irritability, pruritus (due to ⬆️ bilirubin), malaise, Fever, n/v, jaundice, oliguria, edema (ascites), clay colored stools & dark amber urine
Abnormal lab values related to hepatitis
Elevated liver enzymes (AST, ALT, GGT & LDH), alkaline phosphate, elevated bilirubin, elevated serum ammonia and decreased albumin
3 stages of hepatitis
Stage 1- preicteric stage (before jaundice) malaise, anorexia, weight loss, fatigue, n/v, RUQ abd pain, enlarged liver and lymph nodes, electrolyte imbalance, fever, arthralgia & skin rash
Stage 2- icteric statge (jaundice) jaundice, pruritus, light colored stools, brown urine, malaise
Stage 3- post icteric phase is decrease in fatigue, appetite returns to normal, lab work normalizes, pain subsides
Hepatitis A
Primarily spread through the oral route from food, water or shellfish that has been infected with the virus
Hepatitis B
Spread my blood, body fluids, during childbirth or through contact with a contaminated needle
Vaccination available in 3 shot series (1st, 2nd 1 month from first, 3rd 6 months from first; atleast 2 months from 2nd)
At risk population- male homosexuals, multiple sex partners, injection drug users, blood transfusions, transplants
Hepatitis C
Spread through blood, body fluids, childbirth
NO VACCINE
At risk population- IV drug users, dialysis, high risk sex behaviors, tattoos/piercing, blood transfusions
Hepatitis D
Not common in the U.S
REQUIRES HEP B TO REPLICATE
Transmitted via blood or body fluids
No vaccine
Hepatitis E
Transmitted via fecal-oral route
Most common mode of transmission: contaminated drinking water
No vaccine
Hepatitis G
Spread by blood transfusions
Discovered in 1996
Acute disease, little known, no vaccine
Nursing management of hepatitis
Vitamin k for prolonged bleeding
Antihistamines for pruritus
Antiemetics
Questran
Diet (⬆️ carbs & ⬇️ fat) (Na restriction)
Hepatitis is a reportable disease
What is questran and what does it do
Drug used to rid body of extra bile this decreasing pruritus
Bile acid-binding resin
Cholecystitis
Inflammation of the gallbladder due to an obstruction of bile flow
Cholelithiasis
Gallstones
3 types- cholesterol stones, pigmented, mixed
Clinical manifestations of cholecystitis
None or RUQ pain (colicky)
Sometimes rebound tenderness or guarding, indigestion, fever, tachycardia, referred pain to shoulder/scapula
Occurs 3-6hrs after high fat meal or lying down
Murphy’s sign
Pain on palpation of RUQ during deep inspiration
Hepatobiliary iminodiacetic acid scan
Studies the production and flow of bile
Visualizing the liver, gallbladder, bile ducts and small intestine
Endoscopic retrograde cholangiopancreatography
Visualizes the common bile duct for gallstones
Cholangiogram
Used during OR to visualize the biliary tree & remove gallstones
Treatment of cholecystitis
-diet (avoid fried foods, ice cream, dairy products, red meats, heavy alcohol use)
Choose foods low in saturated fats (rice, potatoes, pasta, yogurt, fruits, lean meats, whole grains)
- NPO to prevent excretion of cholecystokinin which is activated when eating and causes gallbladder to release bile, which causes pain
- Demerol/meperidine
- lithotripsy and oral meds to dissolve stones
PREFERRED METHOD IS LAPAROSCOPIC SURGERY
Pancreatitis
Cause
Inflammation of the pancreas
Occurs from the release of pancreatic enzymes that “auto digest” the pancreas
Cause by- gallbladder disease, chronic alcohol intake, smoking, trauma, viral infections, drugs
Clinical manifestations of acute pancreatitis
Sudden onset of epigastric pain in the LUQ or mid abdomen that radiates to the back/shoulder blades, tachycardia, tachypnea, hypotension, Fever
Pain characterized as deep and very sharp (intense within minutes of eating foods high in fat content or lying down)
Not relieved by vomiting 🤮
Abdominal discoloration (turners/Cullen’s Sign)
Grey turners Sign vs Cullen’s Sign
Grey turners Sign- (flank bruising)
Cullen’s Sign- (peri umbilical bruising)
Amylase vs lipase
Amylase- enzyme that aids in the digestion of carbs
Lipase- aids in the digestion of fat. Only enzyme produced in pancreas
Treatment of Acute pancreatitis
NPO (IV fluids)
Opioid analgesics, anticholinergics, histamine blockers and pancreatic enzymes
Complications of acute pancreatitis
- sterile (areas free of bacteria) and infected (caused by bacteria) necrotizing pancreatitis , can lead to sepsis, shock & multiple organ failure
- pancreatic hemorrhage
- pseudocysts, encapsulated areas of fluid that contain pancreatic enzymes. If it becomes infected its known as an abscess
- respiratory complications
Clinical manifestations of chronic pancreatitis
Upper abdominal pain which can spread to the back and feels worse after eating or drinking
N/v, weight loss, diarrhea, pale or clay colored stools, jaundice, DM and steatorrhea
Clinical manifestations of pancreatic cancer
Pain, jaundice, and weight loss
Exhibitionistic disorder
Achievement of sexual excitement through genital exposure , usually to an unsuspecting stranger
Fetishistic disorder
Recurrent, intense sexual arousal from use of an inanimate object or from a very specific focus on a non genital body part
Frotteuristic disorder
Act of touching or rubbing one’s genitals up against another nonconsenting person
Sexual masochism disorder
Act of being humiliated or made to suffer in order to achieve sexual excitement
Sexual sadism disorder
Experiencing sexual arousal in response to the extreme pain, suffering or humiliation of others
Transvestic disorder
Sexual atousal from cross dressing
Voyeuristic disorder
Sexual arousal from observing an unsuspecting person who is naked , disrobing or engaged in sexual activity
Covert sensitization
is a form of behavior therapy in which an undesirable behavior is paired with an unpleasant image in order to eliminate that behavior.
Paranoid personality disorder
A pervasive, persistent, and inappropriate mistrust of others
–Individuals with this disorder are suspicious of others’ motives and assume that others intend to exploit, harm, or deceive them.
–The disorder is more common in men than in women.
Clinical manifestations of paranoid personality disorder
-Insensitive to the feelings of others
–Oversensitive
–Tends to misinterpret minute cues
–Magnifies and distorts cues in the environment
–Does not accept responsibility for his/her own behavior
–Attributes shortcomings to others
Schizoid personality disorder
Characterized primarily by a profound defect in the ability to form personal relationships.
–Failure to respond to others in a meaningful emotional way
Clinical manifestations of schizoid personality disorder
-Aloof and indifferent to others
–Emotionally cold
–No close friends, prefers to be alone
–Appears shy, anxious, or uneasy in the presence of others
–Inappropriately serious about everything and has difficulty acting in a light-hearted manner
Schizotypal personality disorder
A graver form of the pathologically less severe schizoid personality pattern
–Affects approximately 1 to 2 percent of the population
Clinical manifestations of schizotypal personality disorder
•Magical thinking •Ideas of reference •Illusions •Depersonalization •Superstitiousness •Withdrawal into the self -Exhibits bizarre speech pattern. –When under stress, may decompensate and demonstrate psychotic symptoms. –Demonstrates bland, inappropriate affect.
Clinical presentation of cirrhosis
Ascites
Portal hypertension with esophageal varices (increased pressure in blood vessels leads to enlargement of esophagus vessels)
Hepatic encephalopathy (caused by increased levels of ammonia in brain causing mental changes including coma LEADS TO ASTERIXIS & FETOR HEPATICUS)
Coagulopathy, hepatorenal syndrome, spontaneous bacterial periotonitis, jaundice, skin changes (spider angiomas & Palmer erythema)
Clinical manifestations of cirrhosis
Dull pain in RUQ
Hypo/hypertension
SOB
⬆️ abdominal girth, weight changes
⬆️ bleeding
Jaundice, dark urine, clay colored stools or melena
Mental changes
Cirrhosis diagnostic studies
⬆️ liver enzymes
⬇️ albumin & ⬆️ serum bilirubin levels
⬆️ ammonia levels
Long prothrombin time
⬇️ platelets
Collaborative care of cirrhosis
Rest
Administration of b-complex vitamins (water soluble & not stored in body)
Avoidance of alcohol, aspirin, Tylenol & NSAIDS
Treatment of ascites
- sodium restriction
- albumin
- diuretics
- tolvaptan (samsca) vasopressin receptor antagonist used to correct hyponatreimia results in water excretion and ⬆️ Na levels
- HOB elevated
- paracentesis
- transjuglar intrahepatic portostemic shunt (used if ascites doesn’t respond to diuretics)
Paracentesis
the perforation of a cavity of the body or of a cyst or similar outgrowth, especially with a hollow needle to remove fluid or gas.
Collaborative care for bleeding varices
Supportive measures for acute bleed
- fresh frozen plasma
- packed RBC’s
- vitamin supplements including B & K (aquamephyton)
- proton pump inhibitors (protonix)
- lactulose (keeps protein & ammonia in gi tract. Then acts as laxative to push it out)
- antibiotics
Sengstaken-blakemore tube
Short term treatment for severe varices only used up to 24-36 hrs
Scissors should be kept beside for emergencies
BMI ranges
Underweight, ideal, overweight, obese (class 1&2), morbid
Underweight < 18.5
Ideal body weight 18.5 - 24.9
Overweight 25 - 29.9
Obese > 30
Class 1: 30-34.9
Class 2: 35-39.9
Morbid < 40 or 100lb over ideal body weight
