Seminar Exam 2 Flashcards
causes of SIADH
- inappropriate, continued secretion or action of ADH despite normal or increased plasma volume
- resulting in impaired water excretion
symptoms of SCC
- pain
- fatigue
- SOB
- loss of sensation
- loss of motivation d/t treatment (high dose opioids)
- anemia
- injured RBCs hemolyzing, making new ones (taxing on bone marrow), RBCs don’t carry as much oxygen, doesn’t deliver well, doesn’t get to tissues as well
etiologies of HHS
- pre-existing T2DM
- esp. elderly
- infection/sepsis
- CVA, MI, pancreatitis, GI bleed
- medication interactions
- TPN or enteral
- esp. elderly
- dialysis
- esp. elderly
cerebrospinal fluid
- clear, colorless, odorless fluid that fills ventricles, subarachnoid space and spinal cord
- cushions brain and spinal cord against injury (absorbs shock)
- food and wate removal system of brain
- 3rd circulation after blood and lymph
- made up of
- water, protein, oxygen, carbon dioxide
- electrolytes: Na, K, Cl, glucose
- 120-150 ml in circulation; 25 ml produced/hr, 500 ml/day
GI/other symtpoms suggesting adrenal insufficiency
- N/V
- abdominal pain
- general weakness
thinking associated with dementia
- cognitive decline with problems in memory plus one or more:
- aphasia
- apraxi
- agnosia
- executive functioning
define depression
- cluster of depressive symptoms (via SIG E CAPS depression criteria) is present on most days, for most of the time, for at least 2 weeks
- symptoms of such intensity they are out of the ordinary for individual
- biologically based illness affecting a person’s thoughts, feelings, behavior, and physical health
positioning and stimuli for pt with increased ICP
- positioning
- 30 degrees
- head and neck neutral for adquate venous draining
- minimize stimuli
- quite environment
- lights dim
- don’t cluster nursing interventions
symptoms of mild TBI
- # 1: LOC lasting few sec to minutes
- # 2: N/V - early symptom
- headahce, lightheadedness, dizziness
- confusion, tiredness, sleepiness
- blurred vision, ringing in ears
- bad taste in mouth
- sleep changes, behavior/mood changes
- trouble with memory, concentration, attention, thinking
- sensitivity to light/sound
define Addison’s disease
- adrenal insufficiency
- deficiency of glucocorticoids
- primary - issue with adrenal glands
- secondary - issue with pituitary
- tertiary - issue with hypothalamus
why high flow oxygen for croup?
- open airway
- improve oxygenation
- blows of CO2
- decreases inspiratory resistance by keeping nasopharyngeal area open
- support oxygenation by increasing pressure
- controlled by respiratory therapist or provider
sypmtoms of septic shock
- fever
- rigors
- hypotension
- tachycardia
- tachypnea
- oliguria
- restlessness
- N/V/D
cranial nerves
- olfactory
- optic
- oculomotor
- trochlear
- trigeminal
- abducen
- facial
- vestibular
- glossopharyngeal
- vagus
- accessory
- hypoglossal
management of neutropenia
- granulocyte-colony stimulating factor
- side effect: bone pain
- chemotherapy dose adjustment for subsequent regimens
- broad spectrum IV abx if sepsis suspected
- PO prophylactic abx
- patient education
paracrine hormone secretion
hormone acts locally by diffusing from source to target cells in neighborhood
overview of HHS
- hyperglycemia hyperosmolar state
- affects individuals with T2DM
- severe hyperglycemia, hyperosmolarity, dehydration
- absence of ketosis and acidosis
- severe hyperglycemia causes osmotic diuresis
managing PTSD
- not just a veteran’s disorder
- any life/health threatening injury can result in PTSD
- management is often overlooked
- nurses play a role
- treating a patient post injury
- seeing them in a return capacity
- assessing symptoms
nursing management of patient with increased ICP
- ID early
- airway
- CPP 60-100
- euvolemia
- positioning
- minimize stimuli
- prevent increased metabolic demand
- pharmacologics
- ventricular drainage
- monitor for complications
nursing interventions for HHS
- vitals
- insulin, monitor BG hourly
- fluid replacement with NSS
- I&O
- monitor/treat electrolytes
- monitor for thromboembolic event
- formation promoted by dehydration, immobility, critical illness
- education
medical interventions for HHS
- restore fluid balance
- 0.9%, D545% when BG = 250-300
- 1-2 L in first 2 hours
- may need upt o 12 L in first 24-36 hrs
- insulin
- SC or IV bolus
- gtt not typically needed
define incretins
intestinal hormones releasedin response to meals which enhance insulin production
hypertonic saline to decrease ICP/metabolic demand
- if mannitol is not effective
- 3% continuous infusion or 5% bolus
- to combat effects of inappropriate influx of sodium into cells
SCD overview
- SCD vs SCA (anemia)
- SCA = diagnosis; SCD = presentation; SCC = crisis
- problems begin at 5-6 mo
- average life expectancy 40-60 yrs
- 90% to age 20; 50% to age 50
define TBI
nondegenerative, noncongenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness
managing Addisonian crisis
- maintain hemodynamic stability and adequate tissue perfusion
- restore normal levels of cortisol, fluid, electrolytes
- hormone replacement w/ exogenous steroids - lifesaving
- cortisol syring and ID bracelet for outpt
- treat underlying cause
sequelae of vena cava syndrome
- laryngeal edema
- cerebral edema
- decreased CO with hypotension
- pulmonary embolus
delirium onset
sudden: hours to days
examples of prerenal kidney injury:
absolute decrease in effective blood volume
- vascular: hemorrhage
- skin: severe burns, diaphoresis
- GI: V/D
- renal: polyuria (diuretics, severe glycosuria)
- endocrine: diabetes insipidus
- fluid pooling (peritonitis, pancreatitis)
define superior vena cava syndrome
- obstruction of blood flow thru superior vena cava
- malginant mediastinal tumors cause approximately 80% of SVC cases
- 70% from lung cancer
assessing cranial nerve XI
accessory - shrug shoulders, turn head
diagnosing thyroid storm
- decreased TSH
- increased T3, T4
- elevated CPK (rhabdo) b/c everything activated
- elevated alk phos, creatinine phosphokinase levels
treatment for hyperviscosity syndrome
- plasmopheresis
- symptom management
- treatment of causative factor
onset of depression
recent unexplained changes in modd present for at least 2 weeks
delayed N/V
after 24 hours and up to 7 days after chemo administration
causes of pain for cancer patients
- cancer
- diagnostic procedures
- cancer treatment
- radiation can be painful
- pre-existing conditions
mini mental status exam
- orientation
- attention and concentration
- memory
- long & short term
- retention & immediate recall
- calculations - count back from 10-1
- abstract reasoning and judgment
- “don’t count chickens before they hatch”
contraindications of using hypertonic saline in ICP
- CHF (salt overload)
- ICP < 20 mmHg
- volume overload
- CVP > 15 mmHg or PAOP > 12
- serum sodium > 160 mEq/L
- chronic hyponatremia
- DI
endocrine glands
- hypothalamus
- pituitary
- pineal
- thyroid
- parathyroid
- adrenals
- pancreas
- intestines
- ovaries, testes
management of spinal cord compression
- high corticosteroids - immediate intervention
- resection of tumor
- radiation
- chemotherapy - but not all chemos cross the BBB
- pain management
nursing diagnoses for septic shock
- infection - actual
- imbalanced nutrition - less than body requirements
- risk for electrolyte imbalance
- risk for imablanced fluid volume
function of insuline
transports glucose into cells
S/Sx of hypoglycemia
- shakiness, dizziness, sweating
- hunger, headache
- pale skin
- moodiness, behavior changes
- tingling around mouth
- clumsiness
- seizure, confusion, LOC, coma
how does low Hgb factor into resiratory distress?
- diminishes oxygen-carrying capacity
- could accelerate respiratory decompensation
unilateral hippus
- rhythmic contraction/dilation of pupil not in response to or need for accomodation due to light change
- can be normal but not if not baseline
identifying patient at risk for ICP
- be aware of pt condition and complications
- frequent neuro assessments q15min - 4h
- vitals indicating increased ICP
- changes can be subtle
- need serial assessments
nursing interventions to decrease ICP
- positioning
- head in neutral position and HOB at 30 to facilitate venous return
- decrease stimuli
- avoid clustering care, lights off, quiet
- avoid valsalva
- suction when appropriate, not routinely; stool softeners/avoid constipation
sickle cell admission criteria
- most patients can tell when they need to be admitted
- still need to determine if it’s the right course of action
- most will be followed by a specialist
- most common cause of admission is intractable pain for more than 4 hours despite meds and supporting measures
- beyond that:
- vitals, performance based i.e. inability to maintain SpO2 > 95% w/o support, DOE above baseline, etc.
- tend to be dyspneic anyway, but much worse during crisis
define hyperleukocytosis
- elevated WBC > 4,500 - 10,000 cells/ul
- when caused by malignancy:
- frequently occurs in patients with AML experiencing acute leukemia
Broca’s area
verbal, expressive speech (in frontal lobe)
define neuropathic pain
caused by damage to peripheral or CNS - difficult to treat
define cancer-related refractory pain
when pain cannot be adequately controlled despite aggressive measures
AKI S/Sx
- increased BUN/Cr, altered BUN/Cr ratio
- decreased urine output (earliest sign)
- decreased creat clearance (24 hr urine collection)
- altered serum/urine osm as kidney cannot maintain appropriate systemic water balance
- fluid overload, pulm edema, metabolic acidosis
- d/t renal excretion of electrolytes and losing bicarb d/t decreased kidney fxn
- thirst, weakness, confusion, N/V, dry skin, pruritis
incidence of diarrhea in cancer patients
50-90% when receiving chemo
hypophosphatemia
- normals: 2.5-4.5 (critical = 1.0)
- Sx: heart failure, N/V, seizures, coma, musc weakness, resp failure
- needed for ATP production
- causes: sepsis, DKA, malnutrition, alcoholism
- Tx: PO or IV Na or K phos
- caution: monitor for resp failure; use Na not K phos for repletion in renal failure
refractory N/V
occuring b/c of failure of prophylactic and breakthrough meds to control symptoms
treatment of Cushing’s syndrome
- depends on cause
- decrease/stop steroid use
- pituitary tumor may require surgery
- adrenalectomy - usually only for malignancy
preventing increased metabolic demand in patients with increased ICP
- manage fever
- antipyretics
- cooling blanket
insulin types
pronator drift
- one arm drifts down vs the other
- sign of focal lesions causing motor deficit
treating thyroid storm
- cardiac and respiratory stabilization
- B-adrenergic antagonists to control BP
- antithryoid meds
- antipyretics, antibiotics if necessary
- I/O, daily waits
- cooling measures (avoid shivering)
- intubation if necessary
what underlying conditions increase chances of subarachnoid bleed?
HTN and cardiac issues
definition of malignant pleural effusions
- abnormal collection of fluid btwn pleural lining of lung and wall of chest cavity
- fluid will re-accumulate if malignant
- neoplasms of lung, breast, ovary, and lymphomas cause +75% of cases
ramifications of sickled RBCs
- decreased oxygen flow to multiple organs
- anoxic injury
- edema
- across the body
- large areas affected
what withdrawal can kill you?
- alcohol
- benzos
die of seizures - status epilepticus
types of infectious oncologic emergencies
- neutropenic fever
- septic shock
MRI
- most sensitive (neurological, radiological) but takes an hour
- evaluates
- tissue
- vessel integrity
- structural changes
sequelae of malignant pericardial effusion
- pericarditis
- cardiac tamponade
airway/breathing assessment of TBI patient
- oxygenation and ventilation
- hypercarbia may increase ICP
assessing cranial nerve I
olfactory - smell
most common causes of intranreal injury
- ATN 2/2 ischemia (prerenal) (90%)
- nephrotoxic agents
- IV hydration before contrast and hold other nephrotoxic meds (glucophage, metformin)
- rhabdo: aggressive hydration, bicarb administration to buffer kidneys
metabolic stress response r/t Addison’s disease
- relative adrenal insufficiency d/t acute or critical illness
- hyperglycemia d/t insulin resistance with cortisol production and increased glucagon production to provide energy for body
- initial 24 hour “ebb” followed by hypercatablic “flow”
- cold, low flow followed by breaking down of body to make energy
- derangement in thyroid function d/t acute/critical illness
excitatory amino acids r/t TBI
- mechanism of secondary injury
- TBI leads to significantly elevated excitatory a.a.
- particulalry glutamate and aspartate
- leads to cell swelling and neuronal death
- d/t inappropriate influx of Na and Cl depites neuronal salt wasting (against concentration)
- may lead to decreased stores of ATP and increased free radical production
cancer-related causes of hypercalcemia
- multiple myeloma
- lung cancer
- breast cancer
implication of using a sedating agent for ICP
- hypotension which may decrease CPP > 60 mmHg
- may need pressor support
- propofol b/c it’s short acting
- pain meds b/c propofol not a pain med
types of hallucinations
- auditory
- olfactory
- tactile
- visual
- gustatory
define Cusing’s syndrome
excess of glucocorticoids
prevalence of TBI
- 1.5 million people
- 1/3 of all injury-r/t deaths
what to ensure if someone is having a hallucination?
- safety of patient and others
- explain behavior
Sx of Addisonian crisis
- refractory hypotension
- steroids to stabilize
- fluids and pressors won’t work
- syncope
- confusion, severe lethargy
- psychosis, slurred speech
- convulsions
- fever
define myxedema coma
- life threatening disorder d/t severe hypothyroidism
- more in women over 60
strain or deformation of tissue r/t TBI
- due to primary injuries
- three kinds
- compressive: causing physical damage, ischemia, infarct
- tensile: streching
- shear: distortion produced by tissue sliding over tissue
do you need consent from parents to do an LP?
no, because it’s diagnostic (despite the fact that it’s invasive)
causes of intratubular obstruction (leading to intrarenal injury)
- cellular debris
- myoglobin casts
- uric acid crystals
common cancer-related causes of anorexia-cachexia
- chemotherapy/radiation
- head & neck cancers - cannot eat
- severe mucositis/esophagitis
- mouth to rectum
- intubation
secondary insut r/t TBI
- after initial insult
- reaction to insult
- resulting in chain of events w/ ongoing sequelae
why woudl TBI cause SIADH?
injury to pituitary and hypothalamus
early signs of respiratory distress in children
- nasal flaring
- retractions
- intercostal (mild); substernal/costal (moderate); supraclavicular/sternal (severe)
- abdominal breathing
- declining pulse ox
- decreased breath sounds, shallow breathing
- tachycardia, bradycardia
causes of TBI
- MVA
- assaults
- repeat axonal shearing d/t sports impacts
- any physical blow to or rapid movement of head
symptoms of tumor lysis syndrome
- oliguria - cellular debris blocking renal tubules
- cardiac arrhythmias - d/t electrolyte disturbances
- seizures
- volume overload, pulm edema - d/t treatment to flush contents out
- hypertension
- altered mental status
- lethargy
- weakness
circulation assessment in TBI patient
- continuous hemodyanmic monitoring (art line, CVP)
- facilitate maintenance of adequate CPP and necessary with vasoactive drugs
- hypertonic/normotonic fluids, colloids, blood products if using pressors
- otpimize hgb levels and monitor for coagulopathy
- thromboprophylaxis with SCDs, no heparin until bleed stable
Cheyne-Stokes breathing
- during ICP
- like fish out of water
- breathe fast, then slow, then shallow, then deep
- losing autonomic control
pharmacologic management of cancer-related N/V
- antiemetic regimen based on emetic potential of chemo
- 5-HT3 receptor antagonist (ondansetron)
- NK1 receptor antagonist (emend)
- cannabis
- benzodiazepines (for anticipatory)
- corticosteorids (dronabinol)
common symptoms of dying
- pain
- extremity coolness
- restlessness
- somnolence
- agonal or cheyne-stokes breathing
- loss of appetite
- gurgling
- decreased urine or recal output
- incontinence
lab studies r/t Addison’s disease
- azotemia
- low serum cortisol
- low urinary 17-OH-steorids
- failure to respond to various “stimulation tests” by icnreasing cortisol output
- Cosyntropin stim test
conditions that affect cerebral blood flow and cerebral blood volume
common progression for addicts
- PO opioids to heroin
- dependence to addiction
top cancer new cases in 2016 by type
- breat
- lung and bronchus
- prostate
- colorectum
- urinary
- melanoma of skin
sickle cell trait
- autosomal recessive - one copy of gene
- does not cause SCD
- generally a “benign” disease but rare reported cases of disease process becoming health threatening
- lowered performance in athletes
- potential sickling in high stress, low oxygen states, high altitude exposure, potential SCC in high acuity illness
- patients should be alerted when SCT b/c can give it to children
define thrombocytopenia
- decrease in circulating platelets
- < 150,000/ul
- goal for leukemia patients is 10,000
symptoms of neutropenia
- fever
- malaise
- tachypnea
- tachycardia
- hypotension
- mucositis/esophagitis
- recurrent sinusitis and otisis
- cough
PTSD trigger
- severity is irrelevant
- what matters is effect on patient
- how nurse navigates patient through difficult and life-long injury
- patients may be ashamed “this thing” “screwed them up”
- not realizing its extended time under stress that did the damage, rather than the one trigger (which they usually blame)
- self blame and shame are part of PTSD
cortisol r/ stress response
- maintains homeostasis
- cardiovascular
- metabolic
- immunologic
criteria for involuntary admission
- harm to others
- harm to self
- self neglect
define caregiver role strain
difficulties assuming and functioning in caregiver role as well as associated alterations in caregiver’s emotional and phsyical health that can occur when care demands exceed resources
define nociceptive pain
injury to body tissues
causes of N/V in cancer patients
- chemotherapy
- radiation
- infection
define anorexia-cachexia
- anorexia - involuntary loss of appetite
- cachexia - weakness and wasting d/t severe chronic illness
treating hypoglycemia
- recognize early
- IV dextrose, glucose tablet, simple sugar
- followed by complex carb/protein, glucagon SC if severe
- follow IV D50 with continuous D5 infusion
- check serial glucose q15 min until stable
- watch for long-acting agents that could cause drop in serum glucose
sequelae of hyperviscosity syndrome
- congestive HF
- ischemic acute tubular necrosis
- pulm edema with multi-organ system failure
tests for hyperleukocytosis
- CBC
- elevated WBC count
- can be > 100,000/ul in acute leukemia
- bone marrow biopsy and aspiration
assessing cranial nerve VIII
vestibular - hearing and balance
CPP
- cerebral perfusion pressure
- CPP = MAP - ICP
- optimatally, 60-70 mmHg in TBI patient
- reflects that cerebral perfusion is impacted by interaction of systemic BP and ICP
- may need pressors to optimize MAP/CPP while trying to maintain ICP as low as possible
pharmacologic management of diarrhea in cancer patients
- rule out C.diff
- imodium
- psyllium
- octreotide
- lamotil
- glutamine (for bone marrow pts to improve gut health)
- vitamin E (bone marrow pts to improve gut health)
medulla
- inside of adrenal glands
- connected with sympathetic division of autonomic nervous system
- produce catecholamines
- epi, norepi, dopa
basal-bolus insulin concept
- basal insulin to suppress hepatic glucose production between meals
- bolus insulin to meet post-meal insulin requirement
- may reduce hypoglycemia
sickle cell and critical care admission
- acute chest with EKG changes / + trop or increasing trop
- inability to maintain SpO2 >90% with significant oxygen support
- declining mental status
how does agitation in a child with respiratory distress manifest?
low oxygen level
why does cancer occur?
- when abnormal cells proliferate uncontrollably
- malignant cells evade apoptosis
- create own blood supply (angiogenesis)
- greater than 1 cubic mm
- internal or external factors
- gene mutations vs radiation, chem exposure
breakthrough N/V
occuring despite prophylactic meds
adjuvant therapy for N/V in cancer patients
- acupuncture/acupressure
- aromatherapy & massage
- guided imagery
- music therapy
- progressive muscle relaxation
PO opiods - the monster we created
- pain as 5th vital sign
- American Pain Society lobbies AMA and ANA in early 1990s for this recognition, adopts catchphrase in 1996
- adopted by J.Co and CMS as standard of care
- CMS uses in payment system
- patients only give good reviews when NOT in pain
neuro assessment of TBI patient
- cranial nerve assessment limited by sedation
- cough/gag with yankauer
- blink (saline drops)
- pupil symmetry, reactivity, tracking
- response to stimulus, localization of pain
ischemic vs hemorrhagic stroke on CT
- bleeding looks dark on CT
- immediate phase of ischemic stroke looks normal
- absence of blood
- ok for TPA
continuous renal replacement therapy - overview
- sick, hemodynamically unstable patients
- venous-venous access
- methods vary
- direction of flow
- dialysate used
- type of molecule or fluid removed
- circuit can replace/balance electrolytes
tests for tumor lysis syndrome
- BMP
- hyperkalemia
- hyperphosphatemia
- hypocalcemia
- hyperuricemia
- elevated BUN, creat
- ABG or VBG
- metabolic acidosis
causes of spinal cord compression in cancer patients
tumor putting pressure on spinal cord
function and types of androgens
- responsible for masculine characteristics (testosterone)
- also precursors of estrogens
processes regulated by pituitary
- growth
- BP
- pregnancy, childbirth, lactation
- sex organ function
- thyroid function
- metabolism
- water, osmolarity
- thermoregulation
treatments for SCC
- meds when reticulocyte count > 10
- may have standing orders if followed by specialist
- treatments:
- oxygen (2L NC then titrate) for comfort
- opioid pain meds
- anti-inflammatory meds (toradol, ibuprofen)
- for secondary inflammation processes, not pain - opens capillaries, slows crisis, decreases pain
- fluids (NSS bolus, 1-2L) to move clumped blood vessels (dehdyration is a trigger)
PTSD symptoms
- nightmares - flashbacks (invasive memories)
- hypervigilance
- inability to sleep
- change in social dynamic to ensure you don’t get hurt again
- avoiding triggers
what intubation changes need to be made based on arterial blood gas, and what does ABG show?
Vent settings: 100% FiO2; Rate 40; TV 120; PEEP 5
ABGs: pH 7.5; CO2 29; O2 104; HCO3 25; BE +1
- slow down rate and decrease FiO2
- respiratory alkalosis - hyperventilated
Wernicke’s area
reception and understanding of language (temporal lobe)
establishing/maintaining airway in patient with increased ICP
- RR, depth, rhythm
- cyanosis
- intubate, less than 8
- oxygenation
- ABGs
- PaO2 and PaCO2 WDL
- correct acid/base
- hyperventilate to lower ICP but ONLY temporarily - not standard practice b/c reduces perfusion d/t acidosis
tests for brain mets / increased ICP
- CT - most common
- PET - more in outpt
- MRI
- brain biopsy
- BMP
- electrolyte imbalances if mets to pituitary gland and meninges
symptoms of hyperleukocytosis
- dyspnea
- fatigue
- mucosal bleeding
- change in mental status
- EKG changes
acute pain management for cancer patients
- epidural anesthesia (rare)
- local anesthetic infusion
- gabapentin
- paracoxib
- opioids
- tramodol
- hypnotherapy
- music therapy
patho of acute chest syndrome
- multiple sickled RBC/emboli block pulmonary vasculature
- pain and SOB and other SCC sx
- elevated trop may be marker for pulm HTN
- correlate more with indices of hemolytic burden (amount of RBC hemolysis, debris) like low Hct, elevated LDH, bili
- not frequent indicator for SCD patients
- correlate with EKG - anoxic injury to heart is a threat
- correlate more with indices of hemolytic burden (amount of RBC hemolysis, debris) like low Hct, elevated LDH, bili
estimating ET tube in children
size of pinky
motor assessment
- 0 = no muscle contraction
- 1 = trace contraction by palpating while pt attempts to contract
- 2 = actively move muscle without gravity
- 3 = actively move against gravity, not resistance
- 4 = move against some reistance
- 5 = overcomes resistance (normal)
is cranial nerve palsy contra- or ipsilateral?
contralateral - motor nerves cross over
presentation of acute chest syndrome
- diffuse chest pain
- non-reproducible
- moving arms, deep breathing doesn’t make it hurt
- pain is just always there
treatment for malignant pleural effusions
- typically palliative in nature
- thoracentesis
- if life expectancy < 1 mo
- pleurx catheter
- tube thoracostomy
- if life expectancy 1-3 mo
- pleurodesis
- after thoracostomy
- if life expectancy > 3 mo w/ no contraindications
sickled cells
- aren’t malleable
- hard, get caught in capillaries, and block
- don’t carry oxygen as well
populations at risk for TBI
- young (15-30) with highest mortality 15-24
- >57 years
- low income
- unmarried
- ethnic minorities
- inner cities
- men
- h/o substance abuse
- pmh TBO
opioids during SCC
- above what an opioid-naive person would take
- usually on medium to high dose chronic opioids
- in ED:
- standard three course tx: 3 rounds IV pain meds with benadryl on dose #1 and #3
- 2-6 mg dilaudid q2h, 4-10 mg q2h
- PRN q2-4h push meds, but sometimes PCA
- don’t ignore/forget the patient
- double check dosing cap
symptoms of malignant pericardial effusion
- chest pressur or pain
- SOB
- nausea
- abdominal fullness
- difficulty swallowing
- change in mental status
static or quasistatic loading r/t TBI
- mechanism of primary injury
- occurs when slowly moving object traps head against rigid structure
- injury occurs 2/2 squeezing resulting in skull fractures
- speed not significant
additional management of cancer-related anorexia/cachexia
- PO supplements - Ensure
- nutrition consult
- monitor “nutrition” labs (can affect wound healing)
- albumin
- pre-albumin
- total protein
define Cushing’s Triad
- widened pulse pressure
- increased systolic and decreased diastolic
- bradycardia
- abrnoaml respiratory pattern
define cancer-related breakthrough pain
sudden, brief pain during period when chronic pain is generally well-controlled
Glasgow Coma Scale
hypernatremia
- normals: 135-145 (critical above 160 - cerebral dehydration and coma)
- Sx: confusion, N/V, hyperreflexia/twitching, seizures, peripheral edema
- causes: bicarb, renal water loss (diuretics, Cushing’s syndrome, DKA/HHNK), GI loss, insensible loss
- Tx: water repletion with hypotonic fluids, natriuresis with thiazide diuretics
pharmacologic management of cancer-related anorexia/cachexia
- cannabis
- corticosteroids
- progestins - stimulate progesterone
- total enteral nutrition
- total parenteral nutrition
define neutropenia
decrease in circulating neutrophils via CBC differential
less than 2000 is technically neutropenic
nursing management of SCC
- make pt comfortable
- advocate for effective pain management while protecting patient
- overmedication of patients and terrified interns (2mg morphine q4h is not effective)
- watch patient for worsening Sx
- acute chest, priapism, intractable pain at previously therapeutic med levels, decline in oxygenation and ability to sustain oxygenation
- ensure comfortable, functional discharge
what elements of the CBC are concerning for NICU baby?
WBC: 30 Hgb: 14 Hct: 36 Plt: 200,000 6 bands 42 segs
WBC is elevated (should be 5-21)
hypermagnesemia
- normals: 1.8-3.0 (critical = 9.0)
- Sx: skeletal muscle weakness, neuromuscular blockade, cardiac and vascular relaxation –> asystole, hypotension
- causes: renal failure, antacid or laxative abuse
- tx: treat cause, HD may be required, calcium gluconate
- caution: profound hypermagnesemia can cause cardiac arrest
define thyroid storm
- aka thyrotoxicosis
- life threatening disorder d/t excessive concentrations of T3 and T4
- may be manifestation of hyperthyroidism
- everything is “sped up”
causes of aneurysms
- hereditary weakness of vessel wall
- HTN
- atherosclerosis
- injury
- infection
etiology of SCD
- autosomal recessive
- evolutionary protective mechanism against malaria
- likely originated in sub-Saharan Africa (W. and central)
- also in Indian subcontinent (S. Asia), Arabian Peninsula, Adriatic Sea nations (Turkey, Greece, Cyprus, Syria, N. Israel)
sensory assessment
- superficial sensation
- light touch
- pain
- deep sensation
common causes of cancer-related anemia
- hemorrhage
- leukemia
- bone marow failure (where RBCs are made)
- d/t chemo, radiation, infection, tumor
- autoimmune dx
- hepatitis
- poor diet
nursing interventions for DKA
- monitor ABGs
- monitor BG q1-2h
- monitor I&O
- replace and monitor electrolytes
- educational needs
classifying intracranial hematomas
where the bleed is located
- epidural - rapid arterial, 10-15% mortality
- subdual - venous, acute or chronic, 90% mortality
- intracerebral
treatment for disseminated intravascular coagulation
- blood product administration
- pressure on sources of bleeding
- rhinorocket for epistaxis
- heparin if plt count high enough to break up clots
- tx of causative factor
causes of tumor lysis syndrome
- after irritation or treatment of malignancy
- usually occurs with rapidly proliferating, treatment responsive diseases
- can be spontaneous in high-grade hematologic malignancies
components of neuro exam
- history
- visually assess
- prior neuro disease?
- TIA’s, stroke, seizures
- look appropriate?
- dress, speech, posture
causes of disseminated intravascular coagulation
- inappropriate activation of clotting cascade
- thrombosis and hemorrhage
- causes:
- leukemia
- transfusion rxn
- pregnancy complications
- injury/trauma
hyperphosphatemia
- normals: 2.5-4.5 (critical = 5.0)
- Sx: neuromuscular excitability, delirium, coma, prolonged QT, vent dysrrhythmias
- causes: chronic kidney failure, severe catabolic states
- Tx: phosphate binding agents (PO or NSS) to increase renal excretion
hypokalemia
- normals: 3.5-5.3 (critical = 2.5)
- Sx: respiratory muscle weakness, EKG changes (ventricular irritability)
- causes: GI or renal loss, shift to intracellular space, drugs (esp. loop diuretics)
- Tx: IV or PO K chloride or gluconate (try to replete to 4.0)
- caution: in DKA, true systemic levels will be deranged by an insulin drip
- never replate more than 10 mEq/hr d/t arrhythmias
legal documents r/t death and dying
- advanced directive
- POLST
- power of attorney
- DNR/DNI
adverse effects from haloperidol (Haldol)
tardive dyskinesia
gateway to addiction for veterans
- loss of job fears
- effect on VA benefits
- stigma in and out of VA/tricare system
- have to sign papers that they have a psychiatric disorder
- stigmatizes psych dx and veternas
symptoms of hyperviscosity syndrome
- confusion / change in mental status
- seizures
- ataxia
- parasthesias
- retinal hemorrhages
- SOB
- hypoxemia
- acute respiratory failure
- hypotension
- spontaneous gum bleeding
- epistaxis
- rectal bleeding
- menorrhagia
sedation/analgesia to decrease ICP/metabolic demand
- sedation should always be accompanied by analgesia
- sedated patients can still feel pain
- pain and agitation increase metabolic demand