Adult II- Test 2 Review

S4 S1 S2 S3

S1 is start of systole (tri and bi shutting)
S2 is start of diastole (aortic and pulmonic shutting)

SV x HR

Normal is 4-8L/min

in aortic arch and carotid sinus, stretch and pressure

- stimulation inhibits sympathetic NS --> decreased HR and peripheral vasodilation

Decrease in BP --> increased HR

respond to changes in Co2 and O2 an plasma pH

when stimulated they increase cardiac activity

- flushed sensation with dye

- bleeding, hematome, tompanade
- allergic reaction
- thrombus formation
- aortic dissection
- dysrhythmias
- MI
- stroke
- looping, kinking
- puncture of ventricles or cardiac septum or lung
- breaking off catheter
- infection
- death

- full disclosure
- understanding and comprehension
- voluntary

- nurse can only witness, not give informed consent

GROUND!! don't want pt to get electrocuted!!

Pentothal, Brevital
- less than 5 min, caution cause may not be intubated yet

- hangover

amidate and propofol

- caution with propofol in high triglyc pts (its lipids)

halothan, enflurane, desflurane

**big deep breaths after in PACU
** pain will come as soon as anesthesia out so monitor for this!!

- coughing
- laryngospasm
- increased secretions
- respiratory depression (especially when combined with narcotics)

- fentanyl
- Sufentanil
- Morphine
- Dilauded

NARCAN (naloxone)

Versed, Valium, Ativan

- some have a paradoxical reaction (hyperactive)

Romazicon (flumazeril)

Suzzinycholine (SUCCS)
- good for laryngospasms with ventilator also
*** must also be sedated!!!!!!
- make sure pt is able to expand chest post op as the reversal can wear off quickly!!!
- monitor reflexes and airway patency! if not good may beed ventilator!!

- antocholinergics

NEOSTIGMINE

Zofran, anapsine, scopalamine

KETAMINE
- used for quick anesthesia (like popping joint into place)
- may cause agitation and hallucinations

DANTROLENE (DANTRIUM)
- warming it speeds the process up
- should have 36 vials in OR and PACU

- need glucose, insulin, and calcium to treat the hyperkalemia caused from the muscle breakdown also! and bicarb to treat metabolic acidosis

- hyperthermia (late)
- rigidity of muscles (EARLY!)
- the muscle breaks down and can affect kidneys, and is deadly

tongue

i kg (2.2 lbs)

less than 95 degrees

Demoral (ONLY used for this)

q 4h for 48 hours after surgery

- no bowel sounds
- fever
- abdominal distention
- diarrhea
- bloody stools
**REPORT immediately

-cool, pale, mottled, decreas ed or absent pulses

- antibody reaction
- strep, ebstein barr
- Proteinuria, hematuria, increased BUN and creatinine, urine excretion os RBCs, WBCS, casts

** monitor pt with recent sore throat

- 5-21 days after group A beta hemolytic strep
- Generalized body edema and periorbital is first sign then ascites and body (including crackles, congestions, etc.)
- HTN (HTN emergency), hematuria, oliguria, proteinuria, abdominal pain/flank pain or asymptomatic

- rest, antihypertensives, restricted protein intake, antibiotics for strep

- takes over 1-2 years for everything to fully resolve (proteinuria)

- pulmonary hemorrhage
- glomerulonephritis
- p anti-glomerular basements membrante antibodies present

- tx with immunosupression, plasmapharesis, corticosteroids, renal transplant, dialysis

associated with ARF within weeks

acute that didn't resolve

- may may not recall hx of renal problems

- lots of proteinuria --> low labumin --> whole body edema (swollen toad)

- do a 24 hour urine protein, give ACE inh.
- will also get hyperlipidemia and low calcium storage
- loss of clotting factors
- thromboembolism, flank pain

allergy to shellfish

Extracorporeal shock wave lithotripsy (ESWL)

less than 4mm

pt has renal artery stenosis

may present with rapid HTN

- adult form is autosomal dominant
- treatment is like end stage renal disease

should be recorded seperately from other caths

- pt on bedrest while in place, avoid tension and pressure on it

never clamp it, notify MD if there is a decrease in output!

- coil extra tubing
- milk catheter
- have pt turn side to side

- temporary
- irrigate with no more than 5ml sterile saline

acute tubular necrosis

with the degree of obstruction

- fixed (they both increase at the same time and rate)

- when BUN increases faster than creatinine the problem is usually volume depletion, muscle breakdown, or increased intake of protein

> 1.025 with low Na concentration (because RAA has been activated to keeping Na)

< 400mL/day

fixed at 1.010 (normal because tubules are no longer responding)

high urine in sodium (can no longer conserve sodium)

- if cause is ATN, then urine would also have RBCs, WBCs, casts

can't secrete H or reabsorb bicarb --> metabolic acidosis --> Kussmaul respirations
--> kyperkalemia (make sure on cardiac monitor!!)
--> can't activate Vitamin D
--> hyponatremia (tubules can't conserve Na)
--> low calcium
--> increased phosphate
--> impaired RBC production/anemia--> infection risk

when K > 6 mEq

or if have dysrhythmias

- peaked T
- widening QRS
- ST depression
- V-fib

they have bowel sounds and not paralytic ileus or necrotic bowels

40 mEq

- infection and cardiorespiratory complications

hand flap, indicative of encephalopathy

urine output 1-3L per day (some may reach 5L)
- nephron still not fully functioning but can excrete wastes but can't concentrate urine

- hypovolemia
- hypotension
- hyponatremia
- hypokalemia

- when GFR, BUN, creatinine start to stabalize
- can last up to 12 months

#1- Fluid challenge

- diuretics (can't give thiazides when creatinine too low)
- dopamine to increase kidney perfussion

- Calcium channel blockers
- Nutrition (calories, TPN if needed)
- Protein restriction .6G/kg or 40G/day) for non dialysis and 1-1.5G/kg for dialysis pts)
- Na restricted to 60-90 mEq
- Fluid restricted (urine output + 600mL)

< 60 ml/min for 3 months (normal is 125 ml/min)- urine creatinine clearance measurement reflects this also

< 15 ml>mind
- require renal replacement therapy

- urine specific gravity 1.010
- increase BUN
- Increased serum creatinine and decreased creatinine clearance (most accurate indicators)
- hyperlipidemia
- hyperkalemia
- metabolic acidosis (can't produce bicarb)
- anemia (lack of erythropoeitin)
- infections
- HTN (RAA)
- CNS depression
- renal osteodystrophy (deactivation of Vitamin D)--> increased risk for fractures
- integumentary changes (dry, scaly, yellow-gray, pallor, pruritis)
- uremic halitosis
- hypercalcemia
- hypophosphatemia
- proteinuria
- albumin/creatinine ratio >300
- fixed BUN/creatinine ratio
- hyperparathryoidism (goes with calcium and phosphate)

**put them on a cardiac monitor because of hyperkalemia!!! fatal arryhtmias, most serious electrolyte disorder

- restrict K foods
- acute tx:
-- iv glucose and insulin
--calcium gluconate
-- kayexalate (causes diarrhea)
-- Sodium bicarb (K into cells, corrects acidosis)
- Dialysis

130/80

- sodium and fluid restrictions
- diuretics (no thiazides)
- Beta blockers, CCB, ACE in EARLY stages (pril)
* caution with used of ACE in FULL renal failure cause of hyperkalemia (debatable)

- sodium resitrcition
- potassium restriction
- phosphorus resitrction (1000 mg/day)
--milk, whole grains, dried beans, peas, and lentils, organ meats, nuts and seeds (BP), chocolate, cola
- iron (if ferritin < 100) and folic acid, maybe B12 supplements
- protein restriction
- fluid restrictions (UOP + 600 mL)

WITH each meal
may causes constipation

stop giving, or only occassional with H/H normalized

- Digoxin
- Antibiotis (vanco,gent)
- analgesics (demoral, NSAIDs)
- adjust diabetic agents

- no more than 1-3 kg between dialysis txs, KNOW dry weight and includes anything liquid at room temp, ice cream, jello, etc.

< 15 ml/min

- may take up to 3-4 months for fistula to "mature" and to be bale to use for dialysis
-best

- fill thrill, hear bruit

- thrombogenic
- easily infected

- temporary
- infections, thrombosis

- thrombosis/stenosis (thrill and bruit should be there)
- Infection
- Aneurysm (ischemia distal to site)
- high output HF

- blood pressure
- IV insertion
- venipuncture

- rapid shift in fluids
- cerebral edema--> neuro complications (N/V, confusion, HA, seizures)

- client choice
- less hazardous, but carries risk for peritonitis
- no vascular access needed, but does need catheter access device

warmed to body temperature

- inflow (fill)
- dwell (equilibrium)
- drain

-may take client 2 weeks to tolerate full volume

- cloudy return (indicates infection in peritoneum)
- fever
- rebound tenderness
- abdominal pain
- malaise
- nausea

- send outflow for specimen

PD
- difficult to treat
- can lead to peritonitis or abscess
- may require cath removal

- major cause is constipation
- check for kinks, position, signs of migration or clots
- make sure drainage bag is lower than pt
- try milking tube
- xray if migration suspected

MI and stroke

- followed by withdrawal of dialysis (make sure pt not depressed and is compitent when deciding, psych eval before)

Lungs should be better perfused than ventilated

ventilation is lower, perfusion is good still

ventilation is good but perfusion is not

0.8

PaO2 <60 while on 60% or more oxygen

AND/OR

PaCo2 > 48 and pH < 7.35

restlessness and agitation

ABGs

- pt could be trying to get risk of hydrogen so holding potassium

- ventilation perfusion scan
- pulmonary angiogram (most conclusive)
- spiral CT (less invasive, seeing more)

1:2

- increased 1:3 and 1:4 in COPD, etc.

PaO2 > 60%
SaO2 > 90%

**verify CODE status!!

high O2 greater than 60% of O2 for longer than 48 hours (intubated pts)

not a vent so can use if...

- low carb, high lipids
- Pulmo cal
- don't want carbs cause glucose breaks into Co2

- Right sided heart cath to measure pressures

perfect storm for pulmonary embolism

- venous stasis
- altered coagulability
- damage to vessel wall

- normal level indicates Pulm embolism unlikely, elevated is possibility (not for sure, not diagnostic)

- reversible
- bronchospasm
- bronchial wall edema
- increased mucus
- overinflated lungs/hyperventilation and stuff

- respiratory fatigue --> acute respiratory failure
--> hypercapnia, hypoxia, resp acidosis, decreased CO, circulatory collapse, cardiac arrest

* can't stop with intubation cause spasms are way down in bronchioles

can't speak sentences
lethargy and confusion
silent chest
bradycardia
resp acidosis and hypocemia (Co2 >45 and O2 <60)

- wall destruction of alveoli
- loss of recoil/collapse
- retained secretions
- gas trapping
- pulmonary artery constriction

put on antibiotics and flu shots!!

- especially chronic bronchitis pts

- pts must call MD if changes in sputum

- increased number of mucus-secreting glands
- swelling and inflammation
- hypertrophy of mucosa of bronchial tree
- thick tenacious mucus
- destruction of cilia

Dyspnea and hyperventilation

complete or partial collapse of lung

- aire in intrapleural space

- hemothorax- blood in intrapleural space
- Closed- no external wound (spontaneous pneumothorax with rupture of small blebs)
- Open-
- Tension

- cover with vented dressing secured on 3 out of 4 sides
- medical emergency!

- from open or closed pneumothorax
- could be caused by vented dressing not venting or clamped or blocked chest tube
- emergency!

one of the signs of pneumothorax
- feels like bubble wrap under skin, sounds like rice crispies

below atmospheric pressure
inspiration- -8 to -10
expiration- -4 to -5 cm H2O

purulent pleural fluid (associated with lung abscess or pneumonia)

sitting on edge of bed with arms on edge of table for thorocentesis

can also lay down with affected side up

- Collection chamber (receives fluid and air from chest cavity)
- water seal chamber (one way air valve, always want water in the chamber)
- Suction control chamber

- to apply suction if needed
- typically 20 cm of water
- amount of suction is regulated by the amount of water in the chamber, not the amount of suction applied to system
- suction is usually ordered to -20 cm H2O (can go up to -40 too)

- If it is a dry suction control chamber there is no water. To increase suction you have to turn the dial on drainage system, vacuum source will not increase the pressure

- 2 cm water
- initially brisk bubbles of aire in chamber as pneumpthorax is evacuated
- during normal use there will be intermittedn bubbling during exhalation, coughing, or xneezing
- want normal fluctuation (tidling) of water during I and E. Rises with inspiration and falls with expiration (opposite with mechanical ventilation).
- If bubbling increases there could be an air leak
- if it ceases or tidling ceases then lungs could be reexpanded or blocked also

- no milking or stripping of chest tube without Dr order
- stat chest xray after insertion
- Never clamp with a dr's order (unless quickly checking for air leaks)
- auscultate lungs and check for subcu emphysema around site
- keep clamp by bedside for emergencies of massive airleak, etc.

- apply 3 sided gauze, 1 side vented
- notify MD and stat chest x-ray
- assess resp status
- monitor vital signs

- if it just came off the drainage system, quickly recommect and have pt cough and exhale to stabilize negative pressure, reestablish water seal

- medicate pt before!!
- gravity drained for 24 hours before removal
- cut sutures, check if will need vaseline gauze
- valsalva as it is being removed
- airtight dressing and assess for drainage
- post chest x-ray with "wet" reading (quick reading)
- ausc. lungs and assess resp status
- vitals

- 5-10 (4-9)

atelectasis (hurts to breath), #1 sign is pain

- s/s of pleural effusion
- fever
- night sweats
- weight loss
- cough

(sounds like TB)

aspiration

- arrhythmias
- HR drops 20 bmp
- HR increases 40 bpm
- SpO2 drops < 90%