more review

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  More Review
• Endocarditis--strep, staph. Vegetative lesions. Flu like symptoms. Fever high as 103F Roth spots. Petechiae. Splinter hemorrhages. Numbness tingling. Oslers nodes are small and painful on fingers toes. Janeway lesions not tender. Heart murmur, enlargement, failure. Hemiparesis or change in LOC. PE. Splenic Embolization pain in LUQ radiates to left shoulder. Rigid Abdomen. Blood cultures + for causative organsism. Elevated WBC and ESR. Anemia. IV antibiot for 4-6 weeks--penicillin, amphotericin B. Arthralgia. Amox before dental work, childbirth.
• AAA 1 ½ times the stretch. 6:1 risk w/ first degree relative. Check yearly. Silent but may have prominent pulse in the abdomen when supine. Dx usually made when looking for something else. Rupture is Coming if---low back pain, abdominal pain, flank pain. Ruptured--intense low back pain. Lower abd pain, collapse, shock, mottling of lower extremities, decreased Hgb. Sx= resection of aneurysm. Low mortality stats if repaired before rupture, 5%. 50-80% mortality stat if repaired after rupture. Pre Op--compare peripheral pulses. Skin for color and temp, Mark pulses. During Sx- emboli risks from clamped aorta. Risks= MI, CHF, CVA, Kidney damage. Post Op= OUTPUT measured hourly. Assess for bleeding b/c heparin used during Sx. Check for Distal Arterial Perfusion= check for color pain level, motion sensation, temp. Check for distal arterial occlusion==darkened patches in soles/toes of feet. S/s of hemorrhage…drop in CV pressure. Drop in arterial pressure. Decreased urine output. Assess for spinal cord ischemia--assess motor and sensory function. Assess for pain from long incision. Assess for ischemic colitis--bloody diarrhea before bowel function is expected to return--normal return is 4-5 days post op. Assess mobility--OOB 1-2 days post op. discharge plan in 5-7 days. Lifting only to 5lbs. No driving. Showers ok. Assess family members after age 50.
• Hepatitis--pt hospitalized for dehydration or a prolonged PT. Rest, hydration. NO ETOH. Low fat high CHO diet. Corticosteroids. Need Vitamins B--liver can not absorb. K--for coags--C for healing. Education---Gamma globulin indirect contact for Hep A. Hep A vaccine for travelers. Hep B vaccine for health care workers, newborns, and adolescents. Prevention for Hep C. No vaccine for E.
• Cirrhosis--Early signs=vague, flu like. General weakness. Fatigue. Anorexia. Indigestion. Consitpation/diarrhea. Late signs= Jaundice, dry skin, pruitus. Edema. Ascites. Anemia. Bleeding. Infections (lost Kupfer cells). Menstrual irregular. Impotence. Gynecomastia. Renal failure. Dark amber urine. Clay colored stools.
  The Fs of distention= fluid, flatulence, fat, feces, fibroid tumors.
• Rupture of Esophageal varicies. Med emergency. IV fluids, lytes, volume expanders. Sengstaken-Blakemore tube to stop the hemorrhage. Meds= Vasopressin.--constricts the arterial bed. Somatistatin--decreases bleeding w/out vasocontriction. Propranolol--beta blocker to decrease portal pressure.
• Increased intracranial pressure--Bp up. Pulse down. Resps down.= cushings triad.
• Shock--BP down. Pulse up. Resps up.
• Tx for Hyperkalemia in ARF--Insulin +glucose IV. Sodium bicarb. Calcium gluconate IV. Dialysis. Kayexalate.
• Diet for ARF= decrease protein. Increase calories. Low K+ and low phosphorus (bananas, citrus, coffee). Low Na+. Increase iron.
• Colon Cancer locations of lesions= R. sided lesions--dull abd pain. Black tarry stools. L. sided lesions---bright red blood in the stool. Rectal lesions--tenesmus. Rectal pain. Constipation/diarrhea. Bloody stool.
• Hyperflexion of the neck--chin to chest
• Hyperextension of the neck--think falling down stairs chin first. Head back

Some more review for final

Lung Cancer
Late clinical manifestations= non specific= weight loss, anorexia, fatigue, n/v/ and hoarseness. Persistent pneumonitis. Hoarseness. Hemoptysis. Unilateral paralysis of the diaphragm. Dysphagia. Palpable lymph nodes in the neck. Medistinal involment will show cardiac signs and symptoms. Clinically silent, and the symptoms appear late. Persistent productive cough. Chest pain, dyspnea, wheezing. Unexplained fever.
CT scan is the single most effective non invasive technique for diagnosis.
NSCLC
Squamous cell
Adenocarcinoma
Large cell undifferentiated.
SCLC
Undifferentiated
Oat cell.

Pancreatitis
2 functions of the pancreas= endocrine--insulin and glucagon production and exocrine--digestive. Secretes 500-1000cc digestive juices/day.
Pancreatic Enzymes= Amylase breaks down starches. Chymotripinsinogent, elastase, trypsinogen break down proteins. Lipase, phospolipase A & B break down fats.
Pancreatitis is acute or chronic inflammation of the pancreas. Auto digestion (it is eating itself). The enzymes are activated BEFORE being secreted into the pancreatic duct. The cause may be----
Gall bladder disease 80%
ETOH abuse
Cysts, tumors, viral infection, trauma, surgery, mumps, steroids, thiazide, diuretics, oral contraceptives.
Assess
Pain--extreme abdominal pain umbilical pain that radiates to the back. Abd distention and decreased bowel sounds. N/v. chronic steatorrhea. Low grade fever. Tachycardia. Dyspnea. Hypotension, restless confused.
Sign of hemorrhage
Cullen’s sign= bluish color around the umbilicus.
Turners sign= bluish color on the flank.
Lab Tests
Just remember that everything is going to be up EXCEPT the serum calcium.
What is up
***Amylase is going to be up
Lipase
WBC--tissue damage inflamation
SGOT, SGPT, LDH--tissue destruction
Bilirubin--obstruction
Alkaline Phospatase
Down is the Ca+….hypocalcemia leads to Tetany so watch for signs.
Nursing
Reduce the anxiety. Anxiety stimulates the vagus nerve which will increase the secretions.
NPO--NO ICE CHIPS
IV therapy w/ I&O and daily weights.
DEMEROL--NO MORPHINE
Anticholinergics--reduction of enzymes. Decrease spasms of Oddi.
Calcium gluconate IV
Antibiotics
Antacids.
Histamine blockers
Ocreotide
Bedrest
NGT--removes gastrin
Mouth Care
Blood glucose
Diet is progressed from NPO to low fat bland diet high in CHO after inflammation is over.
NO Coffee. NO ETOH
Avoid heavy spicy meals.
Give pancreatic enzymes with meals.

The start of Final Review.

• Tricuspid Atresia
  This is a failure of the tricuspid valve development. There is no communication between the RA and the RV. There is no opening where the tricuspid should be. The blood is going to flow…into the Vena Cava then through an ASD or PDA to the left side of the heart. Then goes through a VSD to the RV to the lungs. You will see cyanosis. Palliative Sx is the same for TETs. Corrective Sx= Convert the RA into an outlet for the pulmonary artery called Fontan procedure. Survival stats= 80-90% w/ complications.
• Tetralogy of Fallot TOF. Remember the aorta is riding the septum. Cyanotic.
  4 defects=
  Ventricular Septal Defect. Pulmonic Stenosis. Overriding aorta. Right ventricular hypertrophy.

Unoxygenated blood enters the aorta.
The shunting in TOF varies.
Right to Left shunt….unoxygenated blood enters the aorta when the pulmonary vascular resistance is higher than the vascular resistance.
Left to right shunt….if systemic resistance is higher than the pulmonary vascular resistance.
S/S= Blue, cyanotic, squatting, clubbing, syncope.
Blue Spells, hyper cyanotic spells, TET spells. The O2 needs are not med by the blood supply usually during crying, feeding or defecation. The cause is an infundibular spasm which decreases the pulm blood flow and increases R to L shunt. The risks from these spells are brain damage, death, neuro complications, polycythemia and increased blood viscosity which increases the risk for CVA. To treat these spells the infant is placed in the knee chest position. Stay calm. 100% O2 via mask. Morphine SQ or IV to reduce the spasm. IV fluids and expanders to decrease the viscosity. More morphine.
Sx= Palliative= Blalock Taussig shunt. But not preferred treatment.
Complete repair= First year of life. Closes the VSD…resection of the infundibular stenosis with pericardial patch to enlarge the right ventricular outflow tract. This is open heart and post op complications include dysrhythmia and CHF. Survival stats are at 95%.

• CHF in children.
  The heart is not meeting the demand of the body. Seen a lot when there is increased blood flow to the lungs or problems w/ the left side of the heart .
  The subtle signs= poor feeding, irritable, tired when feeding and lethargy.
  2 things happen
  I. Impaired myocardial function…Seeing tachycardia, weak pulses, decreased BP and a gallop rhytm. Fatigue restless, anorexia, pale cool mottled extremites. Diaphoresisi. Cardiomegaly. Decreased urinary output.
  II. Systemic Venous congestions…seeing weight gain. Hepatomegaly. Peripheral edema, per orbital edema. Ascites. Neck vein distention. Rales, resp distress…retractions, nasal flaring.
  Therapeutic Management Goals
• Improve cardiac function by increasing the contractility and decreasing the after load. Decrease the preload…remove accumulated fluid and sodium retention.
• Decrease the cardiac demands…control the work of the pt.prevent cold stress. Treat infections. Semi fowlers position. Sedation. Rest.
• Decrease O2 consumption to improve tissue oxygenation.
  Digitalis is a Cardiac glycoside--improves contractility. Increases the force of contraction--positive inotropic. Decreases the heart rate--negative chronotropic. Slows the conduction of impulses through the AV node--negative dromotropic. Enhances duresis indirectly by increases renal perfusion…..
  Concerning Digoxin and Pediatrics.
  Elixer
  IV
  The dose is calculated in micrograms. 1000ug=1 mg. The digitalizing dose is given to bring the serum dig into a therapeutic range. The maintenance dose is 1/8 of the digitalizing dose.
  The therapeutic range is from 0.8-2ug/L
  Check the apical pulse for one full min is a must. For infants hold the med for pulse below 90-110 bpm. For older children do not give if apical is less than 70 bpm.
  Signs of Dig Toxicity= bradycardia. Anorexia. Nausea. Vomit often unrelated to feedings. No interest in eating. Decreased oral intake.
  Other meds and treatments.
  ACE inhibitors Vasotec and Capoten to reduce the after load on the heart which makes it easier to pump.
  For severe CHF other inotropic meds given IV in the ICU = dopamine, dobutamine, Amrinone to improve contractility.
  Diuretics= to remove fluid and sodium…but CAUTION a fall in the serum K+ can potentiate the effects of digoxin and there is then an inceased risk of toxicity.
  
  Cancer of the Larynx
  At risk= smoking and ETOH. Pollution. Nutritional deficiency. Family predisposition. Vocal straining.
  Early signs= hoarseness. lump in neck, pain in throat when drinking hot fluids or juice.
  Late Signs= Dysphagia, Dyspnea, Foul breath. Chronic cough. Hemoptysis. Sore throat or sores in throat.
  Signs of Metastasis= Enlarged cervical lymph nodes. Weight loss. General debility. Otalgia.
  Most are squamous cell.
  Laryngectomy 3
  Partial--½ or more of the larynx removed. High cure rate stats. It is a vertical midline incision. Trached first few days. VOICE HOARSE. No dysphagia.
  Supraglottic--removes hyoid bone. Epiglottis and false cords. It is radical neck dissection. Tracheotomy. NG tube for 2 weeks. Voice is preserved. Post op dysphagia because some muscles removed.
  Total--removes hyoid bone. Epiglottis, cricoid cartilage and 2-3 rings of the trachea. Permanent tracheal stoma. NO VOICE. It is radical neck dissection.
  Complications= resp distress. Hemorrhage. Infection.
  Post op--be alert for serious complication of rupture of carotid artery. If it happens apply direct pressure. Call for help. And provide emotional support until it can be ligated.
  
• Spinal Cord injuries
  4 types of injury. Hyperflexion&Hyperextension (think car wreck). Axial Loading (think fall from ladder). Excessive Rotation.
  Complete (total cord transection) or Incomplete (partial cord transection).
  Injuries affect motor & sensory fx at and below the level of the injury.
  Spinal shock= areflexia (loss of reflex fx). Decrease in BP & bradycardia. Below the injury paralysis and no sensation and no diaphoresis. Check for distended bladder. Lasts days or months.
  Paraplegia= paralysis of lower body. Injury level in the thoracic spine or lower.
  Tetraplegia= Quad= injury in the cervical spine=arms, legs, trunk and pelvic paralysis.
  Maintain patent airway. Cervical injury edema.
  Meds
  High does Corticosteroids within 8 hours.
  Mannitol to decrease edema around the spinal cord
  Baclofen=muslce relaxer to reduce plasticity
  Dextran= prevents BP from dropping and improves the capillary blood flow.
  Traction= tongs such as the Gardner Wells or Crutchfield. Halo.
  Weights hang free.
  Do not remove.
  Clean tongs with betadine
  Assess for infection.
  Sx
  Surgical immobilization….via anterior/posterior decompression and fusion w/ bone grafts. Decompression w/ laminectomy will remove bony fragments that cause compression…remove the foreign body causing compression. Fusion-anterior/posterior using Harrington rods.
  Orthotics
  SOMI=sterno occipital mandibular immobilizer
  CTLSO= cervical thoracic lumbar sacral orthotic.
  Complications may include= DVT. Orthostatic hypotension. Autonomic Dysreflexia.
  Nursing Interventions
• Promote Adequate Breathing and airway clearance--I am not going into this as we should know this by now! But I will say that if suctioning is needed--be careful because this can stimulate the vagus nerve which can lead to bradycardia and cardiac arrest.
• Improving mobility--maitain proper body alignment at all times. Feet are prone to foot drop. Use splints removing and reapplied q 2 hours. Trochanter rolls to prevent external rotation of the hip. If the pt is not on a rotating bed do not turn unless the spine is stable and the MD must order. PROM to avoid contractures.
• Promote adaptation to sensory and perceptual alterations.
• Maintain skin integrity--Prevent pressure ulcers. They can happen very quickly.
• Maintain Urinary Elimination--intermittent cath. Teach family. Neurgenic bladder. Prevent UTI--increase fluid, high acid fluids, no ETOH, avoid alkaline fluids.
• Improve Bowel function--paralytic ileus from Neutrogena paralysis of the bowel. NG tube to relieve distention and prevent aspiration. Bowel activity usually returns in a week. After BS are heard pt given high calorie, high protein, high fiber diet.
  Remember Again that the Emergency Autonomic Dysreflexia
  1. Immediately the head of bed up and BP q 5 min,
  2. Rapid Assess to find the cause and alleviate
  3.Urinary Cath but never drain more than 700cc--can lead to Hypovolemic shock.
  4. Check for fecal mass. Topical anesthetic for 10-15 min…then remove.
  5. Check skin for pressure
  6. Remove all stimulus.
  7. Report to MD immediately if BP does not drop.
  Meds for Autonomic Dysreflexia.
  Nitropaste-vasodilator
  Arfonad IV / Apresoline IV--ganglionic blocker to lower BP fast. relaxes arteriolar smooth muscle.
  Low spinal anesthetic at L4 in nothing works.
  Prevention=antihypertensives.
  
• Burns- Some nursing Care. NG tube to decompress. Foley Cath for I&O--HOURLY! Putting a lot of fluids in so we need to see what is coming out. Urine glucose levels. Pain relief. Continuous assessment of extremity pulses and ventilation. Emotional support. Check for GI bleed--stool for OB, coffee ground emesis.
  Nursing care for pt w/ grafts
  Occlusive dressing. Check for infection and foul smell. If the graft is dislodged cover w/ sterile saline dressing. Keep the pressure off and elevate. The donor site is more painful than the burn site!
  Pain is severe and may need PCA pump w. morphine.
  For Rehab…..help the pt set realistic goals and include the pt in decision making…give them some control.
  S/S of smoke inhalation damage from burns
  Focus on signs of resp and cardiac involvement. Burned nasal hair. Cyanotic lips. Hard time talking, facial burns, Dyspnea, Tachypnea, Cough, Stridor, Hoarseness, Sooty sputum. Rales, Wheezes, Rhonchi.

Burns

The relationship is between duration + temp.
Superficial Partial Thickness Burn= First degree burn=Epidermis and maybe some dermis. soothed by cooling. reddened, blanches with pressure. no scar. peeling. recovery in 1 week. ie: sun burn, or low intensity flash.
Deep Partial Thickness=Second Degree burn=epidermis and upper dermis, portion of deeper dermis. Pain! Blistered, mottled red base, weeping surface, edema. Infection may convert this to full thickness. ie: scalds, flash flame.
Full-Thickness= Third Degree burn= epidermis, all of dermis and some SQ and may involve muscle or bone. Symptoms= NO PAIN! shock, hematuria. Wound may look dry, pale white, leathery or charred. Fat may be exposed. Edema. Need grafting.
Priority
Rescuer should stay safe.
ABCs
Airway-C-spine immobilization.
Breathing- 100% O2
Circulation-
Neuro-may be very alert w/ deficits later. So gather information now.
Deal with the wounds last.
Then find out how they were burned and Med history
MED History includes
A=allergies
M=medications
P=past illness
L=last meal
E=events that preceded injury
Management
Stop the burning process= flush chemical burns, remove contacts, cool water to stop the burning.
Airway management= humidified O2 @100%. Smoke inhalation is the leading cause of death in burn pt. The hemoglobin loves CO better than O2. it creates carboxyhemoglobin which competes with the O2.
Fluids.
Next to the respiratory system fluid and lytes are next in line.
The body is going to try and conserve fluids and can lead to kidney failure. A decreased BP+decreased cardiac output leads to shock.
LR is infused via a large bore IV.
Most common formula is the Parkland/Baxter formula=4ml pf LR x body weight in kg x % of BSA burned= the fluid replacement. 1/2 of that is given the first 8 hours. Then 1/4 for the next 8 hours. And then again 1/4 of that for the next 8 hours. Of course this depends also on the clinical picture. Assess--heart rate, BP, urine output HOURLY.
This is what is happening during the emergent phase... concerning fluids
General dehydration as plasma leaks through the damaged capillaries. Blood volume is reduced secondary to plasma loss, decrease in BP, and decreased cardiac output. Decreased urinary output secondary to fluid loss, decreased renal blood flow, Na+ and water retention. To much K+ because of massive cellular trauma releases K+ into the extracellular fluid. Na+ deficit because it is trapped in edema fluid and because of the K+ shift. Metabolic Acidosis because of a loss of bicarbonate ions that goes with sodium loss. Hemoconcentration-elevated hematocrit because liquid blood component is lost into the extracellular space.

Neuro

Neuro Disorders
Myasthenia Gravis
The problem is with neurotransmission, a defect in acetylcholine receptors sites. Fatigue of the voluntary muscles. Dry eye corneal abrasion. Eyes droop. Fatigue of the resp muscles and limb muscles. The pt eventually choke on food because of difficulty swallowing. The tensilon test= pt given short acting anti-cholinesterase (tensilon or edrophonium chloride) this enhances neurotransmission and improves symptoms, this is short term. Atropine is given to reduce the side effects of the tensilon which is bradycardia, sweating, and cramping. If the pt has a positive test, the pt may be ordered drug therapy with anticholinesterase meds. Mestinon, Prostigmin. MUST be given on time. Side effects=abd pain, diarrhea, increased Oropharyngeal secretions. Other treatments=Corticosteroids given. Cytotoxic meds may be given, such as Imuran and cytoxan…why they work is still unknown. IVIG. Plasmapheresis. No cure. Surgical Tx= thymectomy results in clinical improvement. Produces antigen specific immunosuppression. It takes a year to start working because of the life span of the circulating T cells.
Myasthenic CRISIS
Severe generalized weakness and respiratory failure. After stress such as infection, high temp, surgery. Need Ventilatory support. ADLs, chest PT, suctioning.
Cholinergic CRISIS
From overmedicating with Anticholinergics. Can mimic the s/s of myasthenic crisis. It is differentiated by the tensilon test…ie…the pt in myasthenic crisis will improve after the tensilon. Stop all anticholinesterase med! Atropine sulfate to reduce increased, excessive secretions.
Nsg Care= teaching….use of meds on time and to keep a diary. .s/s of crisis. How to save energy, space activity, organize the house.…how to avoid aspiration soft food, neck slightly flexed
…eye care.
Parkinsons disease
Reduced amount of dopamine. Signs and symptoms= rigid, resting tremor, bradykinesia, a loss of postural reflexes. Bradyphrenia. Memory problems. Drooling dysphagia, speech problems, constipation, urinary frequency. Treatment= Eldepryl--protects the neurons and reduces the need for Levodopa till later. Levodopa--provides the missing dopamine. Amantadine--Anticholinergics that is given to reduce the symptoms and increases the release of dopamine from the storage sites. Sometimes pt need a drug holiday to find other drugs that may work when the current treatment not working.
Nsg care= routine for personal care. Safety. AROM, PROM, rigid facial expressions may hide true feelings. Thicken liquids. Eat sitting up…..
Multiple Sclerosis.
Demyelinating disease…nerve fibers of brain and spinal cord. Lesions throughout the white matter…some in the grey matter. There is an inflammatory response that attacks the myelin. Could be an autoimmune problem with a viral trigger…unknown. Exacerbations and remissions. MRI will demonstrate white matter lesions. New drug therapy= Avinex--interferon beta-1a--weekly IM
Betaseron--interferon beta 1b recombinant every other day SQ. Major side effect = suicidal tendency, depression. Older drug therapy= Corticosteroids. Cytoxan may produce temporary remission. Signs and symptoms= blurry vision, double vision, dysphagia, facial weakness, numbness, pain, paralysis, abnormal gait, tremor, vertigo, incontinence, short term memory loss, trouble finding words. Other meds to reduce the symptoms.
Nsg Care= self care balance. Urinary retention--straight cath or texas. Bowel routine. Skin integrity.