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99 Cards in this Set
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- Back
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What are some triggers of SIRS?
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tissue trauma (burns, crush, surgery)
abscess-intra-abdominal extremities ischemic or necrotic tissue-pancreatitis, vascular dz, MI microbial-bacteria, viruses, fungi endotoxin release-gram - bacteria perfusion deficit-post-cardiac resuscitation, shock distal perfusion deficit |
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Name conditions that predispose a pt to DIC.
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malignancy
cardio hypo/hyperthermia infx/septicemia intravascular hemolysis acute liver dz pulmonary injury severe acidosis severe anoxia anaphylaxis tissue injury obstetric complications |
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what is the post-op management for ERCP?
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Monitor VS, gag reflex, urinary retention, respiratory depression, and s&s of pancreatitis (left flank pain, inflammation, nausea, and jaundice)
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What is the pre-op management for liver biopsy?
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coag labs, type/cross, NPO for 6 hrs
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What are the main labs to look at for liver dysfunction?
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Low albumin & high PT, then AST/ALT/LDH, increased INR, increased bilirubin, high ammonia and alkaline phosphatase
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What are some s&s of cirrhosis?
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wt loss, dyspepsia, abdominal pain, fever, anorexia, flatulence, changed bowel habit (steatorrhea)
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def: excessive accumulation of lipids w/in the hepatic cells due to increased blood glucose, increased synthesis of fatty acids, and decreased lipoprotein release.
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fatty liver
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What is the post-op management of liver biopsy?
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*montor for bleeding or shock for 24hs (abd distention, lightheaded)! Lie on RT side for 2 hrs, NPO for 2 hrs, bedrest, VS 1-2hrs initially, monitor biopsy site, teach pt s&s bleeding
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def: accumulation of free fluid in the peritoneal cavity.
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ascites
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What vital signs do you want to watch for when doing a paracentesis?
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*BP and HR; Hypotension and tachycardia from hypovolemia from lots of fluid being removed
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What needs to be done before the patient gets a paracentesis?
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Void or have a draining foley to avoid rupturing bladder.
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What is caused from retention of bile due to obstruction or infection of the bile ducts?
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biliary cirrhosis
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why does portal hypertension cause splenomegaly?
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Because blood flow is not going thru the liver as much as it should be, it stays and spleen becomes enlarged and congested. RBCs, WBCs, and platelets start to die off.
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What is the nursing management for excess fluid volume from liver failure?
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Daily weights and measure abdominal girth. Fluid and Na restriction, diuretics.
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Why does liver failure cause weight loss?
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From malnutrition because the liver is unable to metabolize carbs and fats, leading to changed bowel habits such as steatorrhea from malabsorption. Can't absorb fat soluble vitamins. Also, muscle protein is converted into glucose.
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def: sudden renal failure from hepatic failure.
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hepatorenal syndrome/ HRS
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What nursing care do you do for hypoglycemia in liver failure?
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Give D50 amp
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Why does someones with liver failure bruise or bleed easily?
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Because they are unable to absorb vitamin K in the intestines which produces clotting factors, and platelets are decreased from spenomegaly.
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what needs to be monitored post-op peritoneovenous shunt procedure?
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Fluid overload from shunting ascites fluid into circulation, HF, pulm edema, infx, electrolyte imbalance, endocarditis from nonsterile fluid
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What nursing care do you do for hepatic encephalopathy?
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Decrease ammonia levels by administering antibx (Neomycin, Flagyl) to reduce bacteria flora in bowel which reduces ammonia formation, administer Lactulose to prevent movement of ammonia into blood, administer laxative to remove ammonia, and low protein diet to prevent ammonia production
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What is the patho of lactulose in removing ammonia?
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Lactulose is converted to lactate in the bowel increasing acidity of the bowel. This keeps the ammonia in the colon and prevents it from transferring into the blood.
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what is a disadvantage for having a TIPS/ Transjugular Intrahepatic Portosystemic Shunt?
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risk for hepatic encephalopathy.
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Why is someone with liver failure at risk for infection?
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From decreased Kupffer cells that filters bacteria, decreased immunoglobulins and WBC (splenomegaly), and malnutrition.
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which age group are at the most risk for trauma?
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age group 15-24
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What is the acronym MIST stand for?
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Hearing the paramedics report
Mechanism of injury Injuries found and suspected Signs (RR, O2, P, BP) Treatment given |
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What is included in the primary survey of a trauma patient?
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a. Quickly id life threatening injuries
b. Airway: voice, air exchange c. Breathing: breath sounds, chest wall, neck veins d. Circulation: mentation, skin color, pulse, bleeding e. Disability: pupils, extremities, AVPU |
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What are the s&s of a pt in hypovolemic shock?
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tachycardia, hypotension, tachypnea, vasoconstriction, decreased U/O, narrowed pulse pressure, decreased mental status
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What is the formula for CPP?
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CPP=MAP-ICP
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What can hypErventilation do to the CPP?
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causes vasoconstriction which DECREASES CPP
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What can hypOventiliation do to the ICP?
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causes vasodilation which INCREASES ICP
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What systolic BP do you want for pt with brain injury?
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>90
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What are the S&S of Cushing's Triad/Reflex in trauma pt?
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increase in BP with widening pulse pressure, slowing HR, resp depression/abnormal pattern (if herniation, prep for burr holes)
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which depth of burn contains little to no pain?
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full-thickness/3rd degree because pain receptors are destroyed
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which depth of burn contains no blisters or scarring, and no systemic response?
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superficial partial-thickness/1st degree
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which depth of burn is very painful?
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deep partial thickness/2nd degree because pain receptors are exposed
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which depth of burn contains blisters or moist surface?
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deep partial thickness/2nd degree
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What is the biggest risk for a pt in the emergent phase of burn management?
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hypovolemic shock from massive fluid shifts out of blood vessels
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what vaccine is given to all burn patients?
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tetanus vaccine
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Which abdomen problem has diffused pain in cramping waves over 5-15 mins
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intestinal obstruction
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How is peritonitis different from appendicitis in symptoms?
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Peritonitis has diffused pain rather than localized.
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def: palpation of LLQ causes pain in the RLQ
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Rovsing's Sign
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def: RLQ pain while you flex the hip and knee and rotate the leg
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obturator
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which abdomen problem can have colic Pain in RUQ, epigastric area, can radiate to shoulder or back?
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cholecystitis
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which abd problem can have N/V/D, abd distention w/high pitched BS, diffuse tenderness & guarding
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intestinal obstruction
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which abd problem can be similar to shock?
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peritonitis
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def: RLQ pain while you provide resistance against the patient lifting/flexing the right thigh
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Psoas
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What is considered hypercalcemia?
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>10.5
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When is hypercalcemia a medical emergency?
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>12
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What are some symptoms of SIADH?
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low Na/hyponatremia
wt gain, weakness anorexia, n/v personality changes seizure, coma |
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What drug is used for breast cancer?
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Tamoxifen
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What is the drug Samsca for and how does it work?
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For pts with SIADH, it works by getting rid of fluid without losing Na.
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What are the treatment for hypercalcemia?
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Administer biphosphate to prevent further bone resorption.
Admin diuretics and hydrate pt to promote U/O to prevent renal failure |
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def: accumulation of fluid in the pericardial sac
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cardiac tamponade
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What are the 4 major s&s of tumor lysis syndrome?
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hyperuricemia
hyperkalemia hyperphosphatemia hypocalcemia |
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What is the tx for hyperuricemia in TLS?
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Allopurinal (used for Gout) to decrease uric acid concentration.
Make sure to hyperhydrate to dilute uric acid. Diuresis, and maintain alkaline urine by giving Nabicarb IV fluids. |
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What are the tx for SIADH?
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Strict I/O.
Admin Samsca so Na won't be loss. 3% NaCl if Na <114-severe Neuro assessment. |
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When is a person considered in SIADH?
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when Na falls <130, serum osmolality <280, urine osmolality <330
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What S&S do you look for in superior vena cava syndrome?
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thoracic and neck JVD
trunk and upper extremity edema facial edema & redness SOB, high RR, choking sensation chest pain & cough |
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What is the best indicator of prognosis for spinal cord compression?
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neurological function before treatment
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What are some s&s for hypOcalcemia?
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tetany, muscle cramps, seizures
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What are the 3 main symptoms of neurogenic shock?
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hypotension, hypothermia, bradycardia
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What 3 components does the brain consist of?
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tissue, blood, CSF
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Def: As one of the brain components increase, the other two decrease to maintain normal ICP.
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Monro-Kellie Hypothesis
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Def: the sum total of the pressures exerted by the 3 components.
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ICP (0-15)
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What does increased PaCO2 cause in the brain?
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dilation increasing CBF
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What is the formula for CPP?
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MAP-ICP
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What is the best and most sensitive indicator of change of mental status?
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LOC
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What is the range for CPP?
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60-100
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What does a decorticate position look like?
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elbows flexed
doggie paddle |
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What is the Cushing's Triad?
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When pt has hypertension, bradycardia w/bounding pulse, and altered respirations
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What range of MAP do you need to maintain normal CPP?
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>90
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What class of drugs would you give for MAP of 90-100?
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Vasopressors to constrict vessels
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Which type of shock results in massive vasodilation and loses SNS compensation ability including vasoconstriction.
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neurogenic shock
results in hypotension, bradycardia, hypothermia |
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Def: intense adrenergic response w/sweating, HTN, facial flushing, headache, and chills while in shock?
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autonomic hyperreflexia
trigger could be urine retention or constipation |
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Which type of shock results in INITIAL flaccidity, sensation and reflexes under injury?
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spinal shock
return after few days or wks |
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What type of pneumothorax is like a one-way valve?
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tension pneumothorax
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What is responsibe for O2 exchange and alveolar expansion?
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surfactant
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What is the best way to confirm a pneumothorax?
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cxr
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What is the BP like in tension pneumothorax?
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hypotension
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What are the other s&s of tension pneumothorax
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mediastinum shift
tracheal deviation JVD absent breath sounds on affected side |
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which lung dz can cause tension pneumothorax?
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asthma
COPD/chronic bronchitis Emphysema |
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How do you dress a sucking chest wound?
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Vented drsg with only 3 sides down to let air vent out and decrease pneumothorax
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Which chest injury results in paradoxical chest wall movement?
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flail chest
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What is the tx for a pulmonary embolism?
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tPA if within first 3 hrs, need to confirm it's not a hemorrhage first!
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What are s&s of flail chest?
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paradoxical chest movement
unequal chest expansion SOB, shallow tachypnea, tachycardia |
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Which feature of the mechanical ventilator needs to be monitored for flail chest?
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PEEP
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Which side do you turn the pt on for flail chest?
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affected side to stabilize with tape, then unaffected side
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What do you tell the patient to do if they go into status asthmaticus?
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Sit up and use accessory muscles to breathe.
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What is a sign of impending respiratory failure?
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Declining mental status, PCO2 >42
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What is decreased in respiratory structure in elderly? (3)
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decrease in elastic recoil, chest wall compliance, and working alveoli
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What happens to AP diameter in elderly?
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AP diameter INCREASES
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What defense mechanism declines in the elderly? (4)
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cough force
immunity cilia macrophage function |
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What type of pneumonia is acquired within first 2 days in the hospital or onset in the community?
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community acquired
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What is a sign of pneumonia in the elderly?
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confusion or stupor
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What type of pneumonia is acquired after being 48 hrs or longer in the hospital?
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nocosomial or hospital acquired
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What happens to the BP in pt w/pulmonary embolism?
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decreases-hypotension
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blood leaving the heart without gas exchange is an example of:
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shunt
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What setting do you want for mechanical ventilation for ARDS?
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limited tidal volume, PEEP to open up alveoli until FiO2 is 60 or less.
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What do u need to watch out for when PEEP is used in ARDS?
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hypotension from decreased CO.
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