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Hev's MS2 Final Cards
Hev's edited version
354
Nursing
Undergraduate 4
12/11/2013

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Cards

Term
What is general anesthia and what are its possible complications?
Definition
Patient is unconscious and paralyzed.
-CNS Depression
-Malignant hyperthermia: acute and life-threatening
-Hypoventilation
-Intubation complications
-Tissue injuries due to positioning
Term
Malignant hyperthermia
Definition
-Inherited condition
-R/T inhalation anesthetics and succinylcholine
-Symptoms can occur anytime after administration of triggering agent
-Treatment: Dantrolene sodium
Term
Regional anesthia
Definition
-Epidural (spinal is rare)
-Nerve block
-Infusion usually a combination of opioid and local anesthetic
-Chosen when patient is poor risk for general anesthia, when post-op analgesia is desired.
Term
What are some complications of regional anesthia?
Definition
-Systemic delivery or absorption
-Overdose
-Catheter movement
-Nerve damage
Term
What are the post-op nursing implications of regional anesthia?
Definition
-Monitor for appropriate level of analgesia
-Monitor for epidural catheter
-Monitor for complications
-Maintain patient safety
Term
What is moderate sedation?
Definition
-Procedural sedation: endoscopy, ED, bedside
-Reduced level of consciousness - pt. is arousable and can maintain airway (reflexes intact)
-Fast-acting, short-duration meds
Term
What equipment is needed at bedside for moderate sedation?
Definition
-Code cart for airway supplies (Ambu-bag, non-invasive and invasive airway devices)
-Suction
-Cardiac monitor/defibrilator
-BP cuff
Term
Nursing management for conscious sedation
Definition
-Requires extra training for MD & nurse
-Do not leave the bedside if you ar the primary nurse
-Patent IV site
-Monitor VS, airway, and CV status before, durign, and until patient is stable after procedure
-Hold PO until LOC improve and gag reflex is checked (if upper endoscopy)
Term
What are some intraoperative nursing diagnosis?
Definition
-Risk of bleeding
-Risk for infection
-Risk for injury and impaired tissue perfusion
-Risk for respiratory complications
Term
Post-Op Gi assessment and interventions
Definition
-Postoperative N/V common (30% of patients experience N or V after general anesthesia)
-Peristalsis may be delayed up to 24 hours
-Monitor for bowel sounds
-Delay giving solid foods if peristalsis slow to return
-Increase activity as tol
-Treate N/V (watch for aspiration)
-Monitor for ileus
Term
Management of NG tube for GI surgeries
Definition
-Assess drainage every 4 hours: quantity and quality
-Assess NGT is secured properly
-Verify placement each time before inserting anything
Term
What is the neurologic impact of delirium?
Definition
-Not a disease but a symptom: global cerebral function
-Acute
-Transient
-Reversible
-Symptoms: Decreased attention span and fluctuating confusion
-Requires urgent attention
Term
Primary wound healing
Definition
Incision closed: heals from outside in
-Dehiscence, evisceration: loss of incisional integrity seen most often between 5th and 10th days after surgery
Term
Secondary wound healing
Definition
Wound left open after surgery: heals from inside out
-Indications:
-Infected wounds
-Too much internal edema to close wound
-Too much trauma to close wound
Term
Fever in post-op patients
Definition
-Monitor for temp >101.5
-Fever in first 48 hrs
--Usually due to inflammatory response
--Unlikely to ve r/t surgical site infection but watch for malignant hyperthermia
--May be r/t pneumonia or UTI or other nosocomial infection
--Careful assessment and interventions to decrease risk of infection
-Check WBCs
-Remeber that older patients may blunted response to inflammation or infection
Term
What population is most at risk for anesthesia complications?
Definition
Patients with cardiac problems
Term
What 3 populations are most at risk for pulmonary complications during surgery?
Definition
-Older patients
-Those with chronic respiratory problems
-Smokers
Term
When can autologous blood donations be made?
Definition
Up to 5 weeks before surgery
Term
What are some alternative options for patients with religious or medical restriction to blood transfusions?
Definition
-Bloodless surgery
-Minimally invasive surgery
Term
What are some indicators of malignant hyperthermia?
Definition
-Tachycardia
-Increased end-tidal carbon dioxide level
-Increased body temp
Term
What are some possible intubation complications?
Definition
-Broken or injured teeth
-Swollen lip
-Vocal cord trauma
Term
When is the highest incidence of hypoxemia after surgery?
Definition
Occurs on the second postoperative day
Term
About how long does it take clean surgical wounds to heal at skin level?
Definition
2 weeks
Term
About how long does complete healing of all tissue layers with in the wound take?
Definition
May take 6 months to 2 years
Term
What technique should you use during dressing changes?
Definition
Aseptic technique
Term
What steps should you take if dehiscence or evisceration occurs?
Definition
-Remain with the patient
-Have the patient lie flat with knees bent to reduce intra-abdominal pressure
-Apply sterile, nonadherent dressing materials to the wound
Term
Hypokalemia
Definition
Decrease serum potassium level - increase risk for toxicity
Term
Hyperkalemia
Definition
Increased serum potassium level - increased risk for dysrythmias
Term
Ramsay sedation scale
Definition
Used to assess the level of sedation in a hospitalized patient
-Ranges from 1-6
1. Anxious/Restless
2. Co-operative, oriented, and calm
3. Responsive to commands only
4. Exhibiting brisk response to light glabellar tap or loud noise
5. Exhibiting sluggish response to light glabellar tap or loud noise
6. Unresponsive
Term
How does a nurse know that a patient is ready to transfer from PACU?
Definition
-Has a 9 or 10 on the recovery scale
-Is aware, oriented, alert
-Stable vital signs for 15-30 minutes
-Possess a core body temp not less than 96.8
-Have no acute bleeding
Term
How do you calculate nasogastric tube drainage?
Definition
Drainage in collection device minus amount of irrigant equals true amount of drainage
Term
Evisceration
Definition
Total separation of all wound layers and portrusion of internal organs through the open wound
Term
What are the 5 different categories of surgical procedures?
Definition
1. Diagnostic: performed to determine origin or cause
2. Curative: Performed to resolve a health problem
3. Restorative: Perfromed to improve pt.'s functional ability
4. Palliative: Performed to relieve symptoms of a disease process, but does not cure
5. Cosmetic
Term
Why are dysrhythmias a problem?
Definition
Because they affect cardiac output
Term
Automaticity
Definition
Initiate their own impulse (intrinsic pacemakers, not dependent on neuro)
Term
Excitability
Definition
Ions rapidly shift, depolarization.
Term
Conductivity
Definition
Transfer the electrical impulse from the muscle cell to muscle cell
Term
Contractility
Definition
Cardiac muscle continually convert an electrical signmal into mechanical action without rest
Term
If EKG measures electrical activity of the heart, how do we measure mechanical activity?
Definition
BP
Term
Ectopy or ectopic rhythm
Definition
Usually refers to extra or abnormal beats
Term
What is the order of pacemakers failure in the heart?
Definition
-SA Node (sinus)
-Atrial
-Junctional (AV node)
-Ventricular
Term
Average Stroke Volum (SV)
Definition
55-100 ml
Term
Average Cardiac Output
Definition
4-8 L/min
Term
Average blood volume
Definition
5L
Term
What are supportive care for symptomatic dysrhythmias?
Definition
-Assess cerebral & CV perfusion
-Give supplemental oxygen
-Check IV access, consider second line
-IVF-NS
-Stat EKG
-Stat labs: BMP, CBC, Coags, CK/Troponin
-RRT
Term
Symptoms of bradycardia
Definition
-Low BP
-Altered or loss of LOC
-Chest pain
-Heart failure
-Cool and clammy (shock state)
Term
Care for symptomatic bradydysrhythmias
Definition
-Airway, O2, IVF, and get EKG
-Call RRT/code and prepare to give Atropine rapid IV push and/or Pacing
Term
Symptoms of symptomatic tachydysrhythmias
Definition
-Low BP
-Altered or loss of LOC
-Chest pain
-Heart failure
-Cool and clammy
-Anxious
Term
Nursing care for symptomatic tachydysrhythmias
Definition
-Airway, O2, IVF, EKG
-Meds differ if SVT (Adenosine, Diltiazem) vs. VT (Amiodarone)
-Cardioversion if pulse and BP present
-Defib and CPR if no pulse or BP
Term
What area do EKG leads reflect?
Definition
Left ventricle
Term
Advantages pf "wireless" telemetry
Definition
-Real-time continuous monitoring of rhythm
-Allows immediate identification, assessment and treatment of dysrhythmia
-Does not restrict patient to bed
-Unusual events on telemetry are followed up with 12 lead EKG
Term
Advantages of 12 lead EKG
Definition
-Can measure amplitude (height) as well as time -- dx Myocardial ischemia &/or infarction and what part of the heart is affected.
-Consistent method across all providers which allows good baseline across time
-12 leads reflect more areas of the heart
Term
What is a pathophysiology r/t ST depression and ST elevation?
Definition
Depression: Ischemia
Elevation: Infarction
Term
SA node
Definition
-Primary pacemaker-starts cardiac cycle
-Initiates atrial depolarization and synchronized atrial contraction
-EKG: P wave
-HR: 60-100
-Location in right atrium makes it vulnerable to atrial enlargement or distension
Term
Sinus tachycardia
Definition
-HR > 100
-Start with the assumption that ST is compensatory if HR is 150 or less
-Look for the cause, DO NOT treat rate without knowing cause
-ST>150-pt may become hemodynamically unstable if prolonged or compromised heart
Term
Atrial dsyrhythmias: A. Fib
Definition
-Most common dysrhythmias
-R/t aging, HTN, CAD, HR, damage to right atrium
-Multiple sites send out weak uncoordinated impulses-atria quiver, no coordinated contraction to push blood into ventricles (loos of atrial kick-10%-30%
-Can be chronic underlying lung problem
Term
When someone is on Coumadin what lab do you monitor?
Definition
INR
Term
2 problems with A. Fib
Definition
-Decreased cardiac output
-Risk for impaired cerebral perfusion: loss of contraction leaves blood sitting in atria->production of multiple small clots-> increased risk of stroke
Term
Diltiazem
Definition
Calcium channel blocker-see for rate control, slows AV node
Term
A. Fib: Tachy protocol, brady protocol
Definition
Tachy: IV diltiazem, followed by infusion
Brady: Check meds, hold inotropes, BB & CBC; may need permanent pacemaker
Term
Atrial flutter
Definition
-Caused by localized irritable spot that rapidly and persistently fires impulses, seen as flutter waves
-AV node does not pass on every one
-See how atria have different rae from ventricles, but al vent impluses originate from atria
Term
Synchronized cardioversion
Definition
-Treatment for a fib and a flutter
-All myocardial cells depolarize at once, allowing a refractory period for SA node to start first
-Done at bedside on telemetry unit or outpatient
-If non-urgent (pt asymptomatic), usually try "chemical" cardioversion first with meds
Term
Why must a patient be anticoagulated before a cardioversion?
Definition
If not anticoagulated, first strong beats of newly coordinated atria will send shower of clots to the brain . . . pt will have transesophageal echo
Term
Defibrilization
Definition
Depolarizing every cell in your heart at once
-Use if no pulse on patient
Term
AV node
Definition
-Secondary pacemaker
-Normal rate 40-60 bpm
-Only electrical connection between atria and ventricles
-PRI: measures time charge is held in the AV node so ventricles have time to fill
-Normal PRI: 0.12-0.20 sec
Term
Problems with AV blocks and Junctional Rhythms
Definition
-Rate too low:
AV blocks: Impulses blocked to ventricles and vent initiated rate is low
JR: inherent rate is 40-60
-Is patient symptomatic?
Yes: Follow Brady protocol
No: Check cardiac meds
Term
Bundle of His
Definition
Extension of AV node that splits into right and left bundle branches
-QRS: AV node firing & ventricular depolarization, initiating what?
-Normal QRS: < 0.12 sec
Term
Bundle branch blocks
Definition
-Not a dysrhythmia, but abnormal conduction pattern in the ventricles.
-One BB is damaged (usually due to MI) and does not conduct impulses
-Normal fast conduction in one ventricle but delayed cell-to-cell transmission in other
Term
Ventricular dysrhythmias
Definition
-Ventricular origin of rhythm
-Ectopic vent site takes over pacing
-R/t electrolyte imbalance (esp K+ and Mg++), hypoxia, ischemia, infarction, idiopathic
-"Downward displacement of pacemaker"-bad sign
Term
Slow ventricular rhythm
Definition
-If slow, the vent rhythm is usually called an "escape" rhythm: no rhythm initiated by SA or AV node, so ventricular site starts its own rhythm (to escape death)
-<40 we do not treat with antiarrhythmics
Term
Ventricular tachycardia
Definition
-Vent rate >100
-Treatment based on symptoms: with pulse or pulseless
-Pulse: tachy protocol if symptomatic
-No pulse: CODE
-AMIODARONE IV bolus, and then infusion x 18 hours
Term
Ventricular fibrillation
Definition
-No synchronized electrical activity in ventricles
-NO CARDIAC OUTPUT
-Loss of consciousness within seconds
-Code! Requires immediate CPR and defib
Term
Asystole
Definition
-No cardiac electrical activity, no cardiac output
-Code!
-ACLS does not recommend defibrillation for asystole
-Defib Resets the electrical system-no electrical activity to reset in asystole
Term
Pulseless rhythms
Definition
Call a code and start CPR
-V tach
-V fib
-Asystole
Term
Premature beats
Definition
-Not necessarily a problem
-Check for new onset, increased frequency, oxygenation, labs (especially lytes).
-Watch for new onset or increased frequency-might indicate precipitating condition that could cause heart dysrhythmias
-PAC-A. Fib
-PVCs-V. Tach
Term
Pacemakers
Definition
-Indications: chronically or intermittenly low rate that does not meet metabolic demands (low cardiac output)
-3rd degree heart block, slow a. fib, post-ablation
-No sinus pacemaker for ventricles
-Danger re intermittent a. fib
Override pacing: for SVT
Term
Implantable cardioverter-defibrillator (ICD)
Definition
Indications:
-Documented history of v. tach or v. fib, long QT syndrome
-Significant risk factor like familial history, severe heart failure
Usually combined with pacemaker, especially in HF patients who need biventricular pacing.
Able to convert with much less electricity (comfort, anxiety)
Term
Nursing care specific to CABG
Definition
-Cardiac perfusion
-Fluid overload
-Dysrhythmias: A. fib, V. arrhythmias, Pacemakers (temp)
-Pericarditis, pericardial effusion, cardiac tamponade
-Perfusion of graft extremity
-Telemetry
-"Off pump" v. "On pump"
Term
Minimally invasive CABG
Definition
-If only one bypass needed (LIMA to LAD)
-Endoscopic
-Robotic assisted
Term
How long does a CABG last based on donor grafts?
Definition
LIMA (left internal mammary artery): 90% patent after 10 years
SVG (Saphenous vein graft): 75% occluded after 10 years
Term
"Off pump" vs "on pump"
Definition
-'On pump': heart-lung bypass machine (extracorporeal)
Heart stopped and blood circulates via machine
ECMO: extracorporeal membrane oxygenation, non-surgical support for oxygenation and perfusion
-"Off pump"-no CP bypass adn heart stabilized mechanically with tools for surgery
Term
Heart valve surgery
Definition
-Single incision
-Valve sounds
-Biomechanical (porcine, autograft, or cadaver allograft) vs mechanical valve
Term
Pre-procedure for cardiac cath
Definition
-Look out for Heparin allergies (more common) HIT
-Left main CAD="widow maker", first artery off aorta
Term
Post-procedure cardiac cath: femoral access
Definition
-Check groin access every 15 minutes for first hour-palpate
-When there is a bleed, HR will rise first, then BP is the second sign
-Hemodynamically stable: Outcome for Care Plan, AEB
-Interventions are mostly about limiting mobility adn using pressure devices
Term
Cardiac cath: radial access
Definition
More the norm in Europe but becoming more popular in America
-It awesome because you have no activity restriction
-Just wear "button pressure device" for a few hours
Term
CABG
Definition
-Purpose is to improve cardiac perfusion
-These patients have fluid overload
-A. Fib is most common complication
-Will give beta blockers and temp pacemakers to fix rhythm
Term
Pulse pressure
Definition
Difference between systolic and diastolic
Term
Thoracic surgery
Definition
-Should chest tube fall out, cover with Vaseline gauze
-Atelectasis: diminished at bases
-Pleural effusion: crackles
-Toradol is very common for surgical pain (non-opioid, NSAID)
Term
Empiric treatment
Definition
Initiation of treatment prior to firm diagnosis
Term
Bypass considerations comparing donor sites
Definition
-Arteries are better than veins
-Patients with IMA bypass, pay attention to lungs
-Arteries do better than veins because they are made for the high flow
-SVG only last about 10 years, but LIMA last about 25 years
-Hypertension lowers life of grafts
Term
Heart valves (comparisons)
Definition
Valves: before surgery there will be "murmur," after surgery (with a mech valve) it will be a "tick" sound
-Autograft: will take your own pulmonic valve and replace aortic valve and then give you a new pulmonic valve
-Porcine/autograft valve: don't require anti-coag, have les s blood damage, but don't last as long (only 10 yrs)
-Mech valve: can last rest of life
Term
Ventilation
Definition
Airway and breathing
-includes entire respiratory system except alveoli
Term
Perfusion
Definition
Gas Exchange
-Alveoli only
Term
What can cause O2 to dissociate more or less rapidly?
Definition
pH
Term
What are normal values for ABGs?
Definition
pH: 7.35-7.45
PaCO2: 35-45
HCO3: 22-26
PaO2: 80-100
Term
What are signs and symptoms of impaired gas exchange?
Definition
Restlessness, irritability, confusion, significant decrease in oximetry results, decreased PaO2, and increased PaCO2 levels
Term
Virchow's triad
Definition
Risk factors for VTE
1. Circulatory stasis
2. Endothelial injury
3. Hypercoagulable state
Term
D-Dimer
Definition
Protein present in blood after coagulation cascade triggered. Negative result usually RULES OUT thrombus (Positive result requires follow up testing as also increased in DIC)
Term
Heparin management
Definition
-Follow aPTTs closely: check 6 hours after every dose change, every 12-24 hours when stable. Goal: 1.5-2.5 times control
-Always get independent double-check
-Works quickly: half-life one hour
-Reversal agent: Protamine sulfate
Term
Why would you only use Lovenox or LMWH if patient is stable?
Definition
Because Lovenox lasts much longer than heparin (half a day as opposed to an hour)
Term
Arixtra
Definition
Newer class of anticoagulant--can be used with history of HIT
Term
Warfarin
Definition
-For outpatient therapy and then long-term prophylaxis (6 mos)
-Therapeutic INR 2.0-3.0
Term
IVC filters
Definition
-DVT/PE with contraindication to anticoagulation
-DVT/PE despite anticoagulation
-Chronic DVT/PE
Term
Acute Respiratory Failure
Definition
-Unable to maintain gas exchange for adequate tissue perfusion
--PaO2<60; PaCO2>50, acidosis
-May be ventilatory or alverolar or mixed etiology
Term
Acute Respiratory Distress Syndrome
Definition
Acute respiratory failure with these indicators
-Hypoxemia that persists even when 100% oxygen is given
-Progressive respiratory distress 24-48 hrs after ALI
-Symptoms based on alveolar dysfunction and massive inflammatory response
-Often r/t acute lung injury
-High mortality rate
-Treatment is symptomatic and supportive
Term
What are causes of ARDS (direct injury factors)?
Definition
-Pulmonary infection
-Aspiration
-Near-drowning
-Inhalation of toxic gases or smake
-Lung contusion
Term
What are causes of ARDS (indirect injury factors)?
Definition
-Sepsis
-TRALI or massive transfusion
-Cardiopulmonary bypass
-Pancreatitis
-Burns
-Shocks
Term
Pulmonary edema
Definition
Accumulation of fluid in pulmonary interstitial spaces (lung tissue) and then in alveoli r/t fluid overload or pump failure.
-cardiogenic: usually a severe form of left-sided heart failure
-Non-cardiogenic: r/t ARDS
Term
Signs and symptoms of pulmonary edema
Definition
-MEDICAL EMERGENCY!
-Sudden onset of dyspnea
-Crackles usually to lung apex and that do not clear with cough
-Cough with frothy pink sputum
-Anxiety, restlessness, agitation, cool and moist skin, tachycardia, JVD
Term
Pulmonary edema treatment
Definition
-Oxygen, positioning
-Diuretics-usually start with IV lasix stat!
-Morphine
-Nitroglycerin: decreases preload and afterload
-Inotropes to increase contractility--dobutamine
Term
Pleural effusion caused by transudate
Definition
fluid from fluid overload
Term
Pleural Effusion caused by exudate
Definition
Fluid from inflammatory process in pleura
Term
Signs and symptoms of pleural effusion
Definition
-Dyspnea
-Cough, non-productive unless underlying pneumonia
-Pleuritic chest pain
-Decreased or absent breath sounds
-Pleural friction rub
-Signs of generalized fluid overload (if transudative)
Term
Diagnosis and treatment of pleural effusion
Definition
-Diagnosed with CXR
-Treatment: Drain effusion (thoracentesis, chest tube); treat cause
Term
What are two types of chest trauma?
Definition
-Blunt force
-Penetrating injury
-CXR standard and effective for diagnosing chest trauma
Term
Pneumothorax
Definition
Loss of integrity of pleura, loss of negative pressure, collapse of affected lung or lobe.
Term
What is tension pneumothorax in blunt trauma?
Definition
-Complication of pneumothorax
-Fatal if left untreated: air enters pleural space but can't leave
-Pressure accumulates and pushes toward/compresses unaffected lung and heart including great vessels. Seen in tracheal deviation towards unaffected side.
-Decreased CO and cardiopulmonary collapse.
Term
Assessment of pneumothorax
Definition
-Inspection: Resp effort, rate, chest wall motion, obvious trauma
-Auscultation: decreased BS over affected area
-Palpation: Subcutaneous emphysema (crepitus), fractures (grating or unstable ribs)
Term
Treatment of pneumothorax
Definition
-Urgent/Emergent: Needle aspiration
-Chest tube insertion for continuous negative pressure suction to reinflate lung.
Term
Hemothorax
Definition
-Massive vs simple blood loss into thoracic cavity-1500 ml dividing point
-Treat with insertion of chest tube; surgery indicated if more than 1500-2000 ml initial drainage or 2000ml/hr x3 hrs
Term
Chest tube placement
Definition
-Placement varies depending on whether hemo- or pneumothorax
-May have multiple chest tubes
-Often placed at bedsid
-Nursing responsibilities are to monitor the patient
Term
What are the different purposes of each chamber in a Chest Tube Drainage system?
Definition
-Chamber 1: collects fluid draining from patient
-Chamber 2: water seal prevents air from re-entering patient's pleural space and shows if pt. has air leak
-Chamber 3: suction control of system
Term
Management of chest tube drainage systems
Definition
Patient: Resp assessment; dressing q 48 hrs, vasoline gauze for airtight seal; site
Drainage system: Do not "strip" chest tube. Can increase intrathoracic pressure.
-Keep lower than patient's chest
-Assess for air leak (bubbling in water seal chamber)
Term
What should you do if chest tube falls out or tubing separates?
Definition
-Vaseline gauze dressing for chest tube falling out
-If tubing separates you could clamp for a minute-but risk for tension pneumothorax; most likely just reconnect it
Term
What are the major concerns of rib fractures and flail chest and what is the treatment for this?
Definition
-They could cause more damage
-Treatment is usually to stabilize chest and let ribs heal on own
Term
Venturi masks
Definition
-Higher levels of oxygen delivery--control of amount of oxygen is determined by dial, not just flow meter setting.
-More controlled and precise deliver (24-50%)
-Control is not at flow meter, it's on the dial on the mask
Term
Non-rebreather
Definition
-100% FiO2 when flowmeter at 15L and flaps intact
-Bag should remain slightly inflated
-No humidifier
-Patients on 100% NRB are considered unstable--monitor closely and escalate appropriately
Term
Nursing management for patient requiring intubation
Definition
-Maintain aggressive respiratory support (bag with flow meter at 15L) until intubation
-Verify tube placement (end-tibal CO2 and CXR as well as breath sounds).
-Stabilize the tube and mark the depth to monitor placement.
Term
Indications for trach
Definition
-Long term mechanical ventilation, patient intubated for more than 2 weeks
-Facial trauma
-Head and neck surgery
-Failed ET intubation
Term
What are the indications for having a cuffed or uncuffed trach tube?
Definition
Must have cuffed tube for mechanical ventilation; when getting better will uncuff so you can breath around trach.
-Fenestrated tube so you can talk
Term
Care for the patient with a tracheostomy
Definition
-Trach care every shift (sterile procedure)
-Cuff pressure can cause mucosal ischemia. Prevent tissue damage.
--Use minimal leak and occlusive techniques.
--Check cuff pressure often.
--Prevent tube friction and movement.
-Prevent/treat malnutrition, hemodynamic instability, hypoxia
Term
Complications of suctioning
Definition
-Hypoxia
-Tissue (mucosal) trauma
-Infection
--Sterile vs. clean, home vs. hospital
-Vagal stimulation, bronchospasm (if happens, stop suctioning)
-Cardiac dysrhythmias from induced hypoxia (if happens, stop suctioning)
Term
Why would a patient experience hypoxia from suctioning trach?
Definition
-Ineffective oxygenation before, during and after suctioning
-Prolonged suctioning time
-Excessive suction pressure
-Too frequent suctioning
-Use of catheter that is too large for the airway (pediatric)
Term
What is the difference between CPAP and BiPAP?
Definition
CPAP is one pressure, and BiPAP is two pressures
Term
Mechanical ventilation
Definition
-Most positive pressure
--During inspiration pressure generated pushes air into lungs
--Bipap also with preset expiratory (PEEP) positive end expiratory pressure
-Most often used for patients with hypoxemia and progressive alveolar hypoventilation with respiratory acidosis
Term
Potential ventilator complications
Definition
-Cardiac: hypotension and fluid retention; hypotension caused by pp that increases chest pressure and inhibits blood return to the heart.
-Lung: barotrauma-trauma to lungs from positive pressure
-GI: stress ulcers
-Infection: ventilator-acquired pneumonia (VAP)
-Muscle deconditioning
Term
Lung cancer
Definition
-leading cause of cancer deaths worldwide
-Poor long-term survival due to late-stage diagnosis
-Bronchogenic carcinomas: arises from bronchial epithelium, most primary lung cancers from here
-Paraneoplastic syndromes
-Staged to assess size/extent of disease
-Etiology and genetic risk
Term
Hypoxemia
Definition
Low levels of oxygen in the blood
Term
Hypoxia
Definition
Decreased tissue oxygenation
Term
Goal of oxygen therapy
Definition
Use the lowest fraction of inspired oxygen to have an acceptable blood oxygen level without harmful side effects
Term
Low-flow oxygen delivery systems
Definition
O2 delivery is variable and depends on patient's breathing pattern since room air dilution occurs
-Nasal cannula
-Simple face mask
-Partial rebreather mask
-Non-rebreather mask
Term
High-flow O2 systems
Definition
Deliver accurate O2 levels that meet patient's O2 needs when properly filtered (delivers concentration from 24% to 100% at 8L to 15L/min)
-Venturi mask
-Aerosol mask
-Face tent
-Tracheostomy collar
-T-piece
Term
How does noninvasive positive-pressure ventilation (NPPV) work?
Definition
Uses positive pressure to keep alveoli open and improve gas exchange without the need for airway intubation, using O2 and just room air
Term
When would use NPPV?
Definition
To manage:
-Dyspnea
-Hyperabia
-Acute exacerbations of COPD
-Cardiogenic Pulmonary edema
-Acute asthma attacks
Term
What are the 3 ways that home O2 therapy can be provided?
Definition
1. Via an O2 concentrator
2. Compressed gas in a tank or cylinder
3. Liquid O2 in a reservoir
Term
Patient instructions for home trachostomy care
Definition
-Instruct patient to use shower shield over trach tube when bathing to prevent water from entering airway
-Teach to cover airway to protect it during the day, filter the air entering the stoma, keep humidity in airway, and enhance appearance
-Teach to increase humidity in home and instruct pt. to instill normal saline into artificial airway 10-15 times a day
-Wear medical alert bracelet
Term
Hallmark of respiratory failure
Definition
Dyspnea
Term
Flail chest
Definition
Inward movement of the thorax during inspiration, with outward movement during expiration
-Often occurs in high-speed vehicular crashes, is more common in older patients, and has a high mortality rate
Term
Pulmonary contusion
Definition
-A potentially lethal injury and the most common chest injury
-Often follows injuries caused by rapid deceleration during vehicular accidents with hemorrhage occurring in and between the alveoli
-The resultant respiratory failure develops over time rather than immediately
Term
Sepsis Statistics
Definition
-11th leading cause of death in the United States
-6% of all deaths
-Most common cause of death in non-cardiac ICUs
- >1 million cases in 2010
Term
3 types of host defenses:
Definition
1. Inadequate - overwhelming infection (death)
2. Adequate - infection control = regulation (survival)
3. Excessive - sepsis/organ dysfunction -> out of control immune response and death
Term
4 stages from infection to severe sepsis
Definition
infection/trauma -> SIRs ->sepsis -> severe sepsis
Term
SIRS
Definition
Systemic Inflammatory Response Syndrome - A clinical response arising from a nonspecific insult
Term
SIRS criteria:
Definition
- Temp >= 38 C or <= 36C
- HR >= 90 beat/min
- Resp >= 20/min
- WBC >= 12,000 or <= 4,000 or >10% immature neutrophils
Term
Sepsis
Definition
SIRS with a presurred or confirmed infection
Term
Severe Sepsis
Definition
Sepsis with >=1 sign of organ failure:
- Cardiovascular
- Renal
- Respiratory
- Hepatic
- Hematologic
- CNS
- Unexplained metabolic acidosis
Term
Septic Shock
Definition
Severe sepsis with hypotension refractory to adequate fluid resuscitation
Term
Multiple Organ Dysfunction Syndrome (MODS)
Definition
Altered organ function in an acutely ill patient such that homeostatic regulation is lost
Term
Risk factors for Sepsis
Definition
-Infections:
Bacteremia
Community acquired pneumonia
Hospital acquired pneumonia
UTI
Meningitis
Wound infection or cellulitis
Peritonitis
MDRO
- Age
-Critically ill
-Invasive lines (CVC, Foley, ET tube/trach)
-Chronic diseases (co-morbidities)
-Immunocompromised
-Malnourished
-Intra-abdominal surgery
Term
Source of infection in all surgical patients most commonly found in the ___?
Definition
Colon
Term
Initiating factors:
Definition
-Infection (but blood cultures negative 40% of time)
-Ischemia
-Trauma
-Shock
-Surgery, especially abdominal
-Burns
-Aspiration
-Pancreatitis
-Immunodeficiency
-Transfusion reaction
Term
Mortality _____ with the number of SIRS symptoms:
Definition
Increases
Term
What causes sepsis not to progress?
Definition
-Homeostatic mechanisms remain effective
-Genetic differences
-Early identification
-Rapid intervention—”Early goal-directed therapy”
Term
Cardiovascular dysfunction:
Definition
-Endothelial dysfunction → increased capillary permeability → systemic vasodilation and loss of intravascular volume
-Decreased vascular tone → venous pooling/third spacing → decreased volume of blood returning to heart (preload) → decreased cardiac output
-Hypotension →hypoperfusion of end organs
-Tissue and organ edema→ hypoperfusion of end organs → organ dysfunction
Term
What do you monitor for cardiovascular dysfunction?
Definition
Monitor for:
-SBP < 90, especially if refractory to fluids
MAP < 65
-Need for vasopressors to maintain pressure (ICU and ED only)

-Severe sepsis if low BP responds to fluids
-Septic shock if low BP does not respond to fluids (refractory) and needs vasopressors to maintain SBP & MAP
Term
Respiratory Dysfunction:
Definition
-Lungs are very vascular and very sensitive to hypoperfusion and edema—usually one of the first signs of trouble
-Pts require more O2 to maintain their saturation r/t increased cellular oxygen demand.
-May need to be intubated & vented for ARDS
Term
What do you monitor for respiratory dysfunction?
Definition
Monitor for:
-Increase in O2 by 2L or 28% FiO2 in last 24 hours
-Drop in O2 sat >5% for at least 4 hours that occurred in the last 24 hours
Term
Renal Dysfunction:
Definition
Not related to a chronic problem (CRF, CKD)
increased demand on the kidneys to conserve fluids and remove toxins AND decreased renal tissue perfusion and intravascular volume deficit → AKI (acute kidney injury)
Term
What do you monitor for renal dysfunction?
Definition
Monitor for:
-Acute increase in creatinine >50% from baseline
-UOP < 0.5ml/kg/hr (quick method to calculate: half their weight in kg=minimum uo in ml/hr)
-Patient requiring ACUTE hemodialysis
Term
Hematologic Dysfunction:
Definition
-Not related to a chronic problem or anticoagulation meds
-Problems with bleeding AND clotting
Platelet levels can drop below 100 if they have been activated by an inflammatory process and consumed.
-INR may increase beyond the normal limits if the sepsis process has activated a condition known as disseminated intravascular coagulation (DIC).
-May develop petechiae or bleeding from IV sites, or have septic emboli which cause gangrene
Term
What do you monitor for Hematologic Dysfunction?
Definition
Monitor for:
-Platelet count < 100,000
-INR increase over the upper normal limit
-Mottling or cyanotic extremities
Term
Metabolic Dysfunction:
Definition
-Lactic acidosis r/t cells switching to anaerobic metabolism due to hypoxia & hypoperfusion
-Adrenal exhaustion—give low dose steroids
-Hyperglycemia—maintain tight glycemic control (“don’t feed the bacteria”)
Term
What do you monitor for Metabolic Dysfunction?
Definition
Monitor for:
-pH < 7.30
-Lactate Level > 2.4
Term
Hepatic Dysfunction:
Definition
-Not related to CHRONIC problem
-Due to primary infection in liver (exposure to bacteria) or secondary due to “gut-barrier failure” due to increased capillary permeability or edema
Term
What do you monitor for Hepatic Dysfunction?
Definition
Monitor for:
-ALT > 72 (reflects liver functioning)
-Total Bilirubin > 2 (total bilirubin will rise with increased stress on the body)
Term
CNS Dysfunction:
Definition
-Not related to CHRONIC problem (dementia)
-Hypoxia and hypoperfusion cause altered LOC (delirium)
Term
What do you monitor for CNS Dysfunction?
Definition
Monitor for:
-Altered LOC from BASELINE
-Reduced Glasgow Coma Scale
Term
Sepsis Bundles:
Definition
-A series of evidence-based therapies that, when implemented together, achieve better outcomes than when implemented individually.
-This bundle of interventions must be completed 100% of the time within 6 hours for patients with severe sepsis, septic shock and/or lactate >4 mmol/L (36 mg/dL)
Term
Sepsis Resuscitation: within 6 hours of identification:
Definition
-Give oxygen to keep oxygen sat > 94%
May need 100% oxygen per non-breather
May need to be intubated and ventilated
-Obtain 2 separate blood cultures BEFORE starting antibiotic, also other cultures
-Initiate antibiotic therapy as soon as BC drawn.
-Fluid resuscitation—may need significant volume. Normal saline first choice
-Monitor for fluid overload…
-Measure lactate level
-Insert urinary catheter to monitor hourly urine output.
Term
Sepsis Management Bundle: within 24 hours
Definition
-Efforts to accomplish these goals should begin immediately, but may be completed within 24 hours
-Administer low-dose steroids for septic shock in accordance with a standardized ICU policy.   
-Maintain adequate glycemic control.
-Prevent excessive inspiratory pressures on mechanically ventilated patients.
Term
Medications for Sepsis:
Definition
-Vasopressors—start with norepinephrine
-Corticosterioids
-Low dose
-For septic shock for BP refractory to fluids and pressors

Important note: Xigris is no longer on the market, not proven to be effective.
Term
Problems with Severe Sepsis Management:
Definition
-Inconsistency in early diagnosis
-Inadequate volume resuscitation
-Late or inadequate use of antibiotics (7% increase in mortality for each hour antibiotics are delayed)
-Failure to:
support adequate cardiac output
control hyperglycemia
use low tidal volumes and pressures in acute lung injury
treat adrenal inadequacy
Term
Nursing Role for Sepsis:
Definition
-Infection prevention & control
Assessment, early identification
-Implementing medical interventions and monitoring effectiveness or lack thereof
-Implement POC to prevent standard complications re immobility & hospitalization
ex/ DVT, pressure ulcer, etc
-Patient and family education and support
Term
Level 1 trauma center
Definition
-Has OR on standby 24/7
-Has to have enough patient's necessitate this and give experience
Term
Important information to get when a trauma patient is first admitted
Definition
Mechanism of injury
-Blunt, penetrating, MVA, fall, GSW, blast, burn, etc.
-Predict types of injury
-Helps plan for appropriate care adn equipment.
Allergies
Significant PMH
Term
What do the ABCDE of the primary survey stand for?
Definition
Airway
Breathing
Circulation
Disability
Exposure
Term
Revised trauma score
Definition
0-4 with 0 being really bad and 4 being not as bad.
Term
Glasgow coma scale
Definition
Scale that aims to give objective data on patient's consciousness. 3-15 with 3 being a deep coma. It assesses verbal response, verbal response, and motor response.
Term
Primary survey: Circulation
Definition
-Check all peripheral pulses
-2 large-bore IVs
-NS or LR, PRBCs
-Assess for hemorrhagic shock (tennis scores, love, 15, 30, 40)
Term
Primary survey: Disability
Definition
-Basic neuro exam
-Gross motor and sensory exam
-AVPU
Alert
Responsiveness to voice
Responsiveness to pain
Unresponsive
-Glasgow Coma Scale
Term
Mass Casualty Incidents
Definition
One in which the number of people killed or injured in a single incident is large enough to strain or overwhelm the resources of local EMS providers
Term
Homeostatic functions of skin
Definition
-Barriers to microorganisms
-Protections from injury via barrier and sensation
-Maintain F/E balance
-Regulate body temp
-Regenerate itself
-Provides personal identity
Term
Local responses to burn: Zones of injury
Definition
-Zone of coagulation: irreversible tissue damage
-Zone of stasis: low perfusion, potentially salvageable tissue
-Zone of hyperemia: Increased perfusion r/t inflammatory response; will recover
Term
Classification of Burns
Definition
-Depth & degree of injury
-Extent of burn: percentage of body area
-Location
Term
What criteria is essential for skin regrowth after a burn?
Definition
Dermis is present
Term
Burns: Depth & degree of injury
Definition
-Different terminology but essentially the same criteria
-First, second, third degree burns
-Superficial-, partial-, full-, deep full-thickness
-Minor, moderate, major-ABA criteria
--Based on depth, extent, and location, type of burn
--Burn center referral criteria
Term
ABA Burn Criteria
Definition
-Minor: Superficial: BSA < 50% (sunburns)
-Moderate: Superficial: BSA > 50%; Partial thickness: BSA <30 %; Full thickness: BSA <10%
-Major/Critical: Partial Thickness: BSA > 30%; Full Thickness: BSA >10%; Inhalation injury; Inhalation injury; Any partial or full thickness burn involving the hands, feet, joints, face, or genitals
Term
Superficial Partial Thickness
Definition
Superficial dermal burn
-Necrosis confined to upper third of dermis
-Zone of necrois lifted off viable wound by edema
-Small zone of injury
Term
Partial Thickness
Definition
Deep Dermal Burn
-Necrosis involving majority of skin layers
-Zone of necrosis adherent to zone of injury
-Smaller edema layer
Term
Full Thickness Burn
Definition
No remaining viable dermis
Term
Rule of Nines
Definition
Adult: 9% head, 9% arms, 18% legs, 18% chest 18% back; 1: perineum
Term
Inflammatory response r/t burns
Definition
-Increased capillary permeability
-Vasodilation
-Massive fluid shifts from blood vessels into tissue--capillary leak syndrome
-SIRS
Term
Burns: Airway
Definition
-Extensive burns may lead to massive edema: obstruction may result from upper airway swelling
-High risk of airway involvement: Burns on head, neck, chest or burned in an enclosed space; singed nasal hairs; Soot in nostrils or sputum
-Mechanisms of injury r/t heat or smoke: Direct injury and cellular damage (external)
-Inflammatory changes
Term
Burns: Airway Obstruction
Definition
-Damage may not show for 8-24
-Assessment:
Tachypnea, dyspnea, stridor or cough
Use of accessory muscles
Dry, reddened mucous membranes
Swollen uvula
Drooling
Hoarseness
Dry, reddened mucous membranes
-Treatment: 100% NRB, bronchodilators, suctioning, bronchoscopy
-Be prepared to intubate early
Term
Burns: Breathing
Definition
In resuscitative or urgent phase: Gas exchange
-Hypoxia
-Carbon monoxide poisoning or toxic gases
-Smoke inhalation
-ARDS
Term
Burns: Fluid Resuscitation
Definition
-IVF: Lactated Ringers
-The lactate in LR is metabolized into bicarb by the liver, which can help correct metabolic acidosis
Term
Parkland formula for burns
Definition
-Calculates fluid requirements for burn patients in first 24-hours
-4 X wt in kg X TBSA burned = 24 hr fluids
First half of fluid delivered in first 8 hrs
Second half delivered over 16 hrs
-Adust based on patient response to avoid overhydration and increased fluid overload
Term
IVF after 1st 24 hours
Definition
-Maintenance fluids-usually changed to D5 1/2NS with KCL
-Basal rate + insensible fluidloss (both involve calculations)
-Complications of over-hydration:
Compartment syndromes: extremity, chest, abdominal
ARDS
Term
Compartment syndrome
Definition
Compartment syndrome is a serious condition that involves increased pressure in a muscle compartment. Lead to muscle and nerve damage and problems with blood flow
Term
Burns: Labs
Definition
-Hgb, Hct elevated as a result of fluid volume loss
-Serum elecrolytes: Na+ decreased (trapped in interstitial fluid (edema) and lost through plasma leakage; hyperkalemia at first due to cell injury/death, then hypokalemia
-BUN/Creatinine
-ABGs-Metabolic acidosis
Term
Collaborative and nursing management goals
Definition
-Maintain respiratory function
-Restore fluid balance
-Thermoregulation
-Prevent infection
-Restore skin integrity
-Adequate pain control
-Adequate nutrition
-Provide emotional support
Term
Nursing Care for Burns
Definition
-Pain Management
-Monitor ECG
-IV access (multiple)
-Management perfusion needs (maintain hourly urine output 0.5mg/kg)
Term
What are the most painful burns?
Definition
Superficial partial-thickness burns
Term
Thermal burns
Definition
-Most common type of burns: heat transfer from external source
-Causes: Flames, Scalds from hot foods or liquids, including steam (70% of peds patients)
-Prevention: Home water heaters < 120 F
-Hot food, liquid out of children's reach
Term
Electrical burns
Definition
-Most common cause: adults: occupational; children: household
-May not be much external damage (look for entrance and exit sites)
-Deeper wounds from current traveling through the body, course may be erratic through body
-Special precautions for electrical burns: EKG and cardiac monitoring; C-spine precautions
Term
Radiation burns
Definition
Cause
-Overexposure to sun
-Radiation treatment for cancer
-Industrial accidents
Prevention
-Educate public to protect against UV exposure
-Educate about safety measure in industrial setting
Term
Chemical Burns
Definition
Cause
-Skin contact with caustic chemicals
Treatment
-Remove all contaminated clothing
-Thoroughly irrigate affected area
-May need specific counter-agent
Prevention
-Keep chemicals in a safe place
-Know how to neutralize chemicals
-Occupational training
Term
Inhalation burns
Definition
Cause
-Inhalation of heated air and smoke
Incidence
-More in elders, inability to escape fire
Prevalence
-20% to 30% of patients in burn centers
-Majority of burn injury deaths from smoke inhalation
-77% increased mortality rate with cutaneous injuries
Term
Functions of the Nervous System
Definition
-What: Direct all physiological, cognitive, and psychological activities
-Why: Coordinates homeostasis
-How: Gather sensory information, integrateit, and respond to it via motor activity
Term
Diagnostics for spinal cord injury
Definition
-CT is now standard--more sensitive and specific than regular x-rays
-Must assess entire spine
Labs:
CBC
ABG
UA
Lactate
Term
Spinal cord injury
Definition
An insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function
Term
Plegia vs. Paresis
Definition
Plegia: complete lesion
Paresis: some muscle strength is preserved
Term
Tetraplegia (or quadriplegia)
Definition
-Injury of teh cervical spinal cord
-Patient can usually still move his arms using the segments above the injury (e.g. in a C7 injury, the patient can still flex his forearms, using the C5 segment)
Term
Paraplegia
Definition
-Injury involving the thoracic or lumbo-sacral cord, or cauda equina (T1 and distal)
Term
Hemiplegia
Definition
-Paralysis of one half of the body
-Usually in brain injuries (e.g. stroke, TBI)
Term
Complete vs. Incomplete SCI
Definition
-Complete: no sensory, morot or autonomic funciton below the level of injury
-Incomplete: some sensory, motor or autonomic function below the level of injury
-Can't be determined until after spinal shock resolves
Term
Most common levels of SCI?
Definition
-Tetraplegia: C5
-Paraplegia: T12
Term
Spinal Shock
Definition
-Transient physiological depression of cord function below the level of injury
Symptoms:
-Complete loss of all neurologic function (including reflexes and rectal tone)
-Initially hypertensive but then becomes hypotensive
-Flaccid Paralysis
Lasts several hours to days until reflex arcs below the level of injury recover
Term
Neurogenic Shock
Definition
-Results from unapposed parasympathetic stimulation
-Most commonly seen with SCI above T6
-Classic Triad of symptoms: Hypotension, Bradycardia, Peripheral vasodilation
Differentiate from spinal shock, hemorrhagic shock, and hypovolemia shock-how?
Term
Autonomic Dysreflexia
Definition
Can result from any noxious stimuli below the level of injury, which triggers limited sympathetic hyperactivity.
-Most commonly caused by:
-Bladder and bowel distention
-Any trauma or injury: blisters, burns, fractures, appendicitis
-Pregnancy
-Can cause HTN crisis which can lead to seizures, stroke, and death
Term
Most common causes of death after acute phase of SCI
Definition
-Pneumonia
-Pulmonary emboli
-Septicemia
Term
Adrenal glands release which chemicals?
Definition
-Cortisol
-Aldosterone
-Testosterone
-Epinephrine and norephinephrine
Term
Cortisol
Definition
-Released under stress response
-Increases blood sugar
-Fat, protein, CHO metabolism
-Anti-inflammatory, anti-immune response
Term
Corticosteroid medication
Definition
-Common cause of Cushing's and Addisons syndromes
-Do not suddenly stop, must be tapered off
-Monitor for:
-Emotional labile, may develop acute psychosis
-Risk for injury
-Risk for infection
-Skin integrity
-High blood glucose levels
Term
Adrenal Pheochromocytoma
Definition
-Tumor in adrenal medulla that causes increased catecholamines production
-Intermittent episodes of sympathetic overstimulation
-Treated by surgery
Term
Diabetes Insipidus
Definition
-Common in brain cancer, neurosurgical and TBI patients
-Diagnostics: UO > 4L/24 hrs; USG <1.005
-Meds: DDAVP by inhaler (may be lifelong)
Term
SIADH
Definition
-Treatment
Fluid restriction
Raise sodium steadily bu slowly (watch for pum edema)
Vasopressin antagonist
Term
Hashimoto's
Definition
Hypothyroidism (autoimmune)
symptoms are the same as hypothyroid
Term
Graves disease
Definition
Hyperthyroidism
Term
Parathyroid hormone
Definition
Calcium
Term
What is the most common source of iodine?
Definition
Seafood
Term
Implications of hyperthyroidism
Definition
-Chest pain - Order TSH
-Nutrition
-Drug metabolism

-Post-Op thyroidectomy
-Anterior neck surgery
-Thyroid storm
-I-131 therapy
Term
Implications of hypothyroidism
Definition
-Peri-Operative
-Drug Metabolism
-Increased risk of complications
-Poor energy level
Term
DKA and HHNS differences
Definition
-DKA has ketones, kussmaul respirations, develops rapidly, BS >300
-HHNS has hyperosmoloarity, no ketones, slower development, BS >500
Term
Treatment priorities for DKA and HHNS
Definition
First: fluid balance
-IVF rehydration started before insulin
-Start with NS 1-2 L in 1-2 hours
-Then complete rehydration over 24 hours
Hyperglycemia: controlled decrease via insulin infusion (not SQ)
-Electrolyte balance
-Watch for complications: seizures, cerebral edema
Term
What do stool studies evaluate?
Definition
- Function and integrity of the GI tract
- Detect the presence of infections, protozoa, parasites, and blood in the stool
Term
What is the priority care after a patient has an upper endoscopy examination?
Definition
Check for the return of the gag reflex before offering fluid or food, to avoid aspiration
Term
What should you asses for in patients who have endoscopies?
Definition
-Bleeding
-Fever
-Severe pain
Term
What should you check for in patients who have just had a colonoscopy?
Definition
Passage of flatus before allowing fluids or food
Term
Why does Gastroesophageal Reflux Disease (GERD) occur?
Definition
As a result of reflux, or backward flow, of gastrointestinal contents in to the esophagus
Term
What are symptoms of GERD?
Definition
-Dyspepsia
-Belching
-Flatulence
-Difficult or painful swallowing
Term
Hiatal hernia
Definition
Protrusion of a portion of the stomach through the esophageal hiatus of the diaphragm into the chest
Term
What are the symptoms of a hiatal hernia?
Definition
Most patients are asymptomatic, but some have daily symptoms similar to those with GERD
Term
What are some key points to remember when caring for patients with esophageal disorders?
Definition
-Remain with dysphagic pt. during meals to prevent/assist with choking episodes
-Teach oral exercises and correct positioning aimed at improving swallowing
-Elevate head of bed by 6 in. when sleeping to prevent nighttime reflux
-Instruct patient to sleep in right side-lying position to minimize the effects of nighttime episodes of reflux
Term
What are the most common stomach disorders?
Definition
-Gastritis
-Peptic ulcer disease
-Gastric cancer
Term
What is Gastritis?
Definition
Inflammation of the gastric mucosa
Term
What can cause acute gastritis?
Definition
Inflammation of the gastric mucosa or submucosa after exposure to local irritants or other cause
Term
What is the most common bacterial cause of gastritis?
Definition
H. Pylori
Term
What are the symptoms of acute gastritis?
Definition
Mild to severe epigastric discomfort, anorexia, cramping, nausea and vomiting, abdominal tenderness and bloating, hematemesis, or melena
Term
What are the symptoms of chronic gastritis?
Definition
Few symptoms unless ulceration occurs
Term
What is the gold standard diagnostic tool for gastritis?
Definition
Esophagogastroduodenoscopy via an endoscope with biopsy
Term
What is priority management for gastritis?
Definition
-Supportive care for relieving symptoms (acute gastritis healing is spontaneous, usually occurring within a few days)
-Removing cause of discomfort
Term
What is a peptic ulcer?
Definition
Mucosal lesion of the stomach or duoenum
Term
What are 3 types of ulcers?
Definition
-Gastric ulcers
-Duodenal ulcers
-Stress ulcers
Term
What causes peptic ulcer disease?
Definition
Results when mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin
Term
What are the complications associated with peptic ulcer disease?
Definition
-Hemorrhage
-Perforation
-Pyloric obstruction
-Intractable disease
Term
What are the signs of perforation of a peptic ulcer into the peritoneal cavity?
Definition
The patient has a rigid, boardlike abdomen accompanied by rebound tenderness
Term
What are the primary goals of drug therapy for peptic ulcers?
Definition
1. Provide pain relief
2. Eliminate H. pylori infection
3. Heal ulcerations
4. Prevent recurrence
Term
What is important to know if a patient has an active GI bleed?
Definition
This is a life-threatening emergency and requires supportive therapy to prevent hypovolemic shock and possible death
Term
What are 3 general guidelines to keep in mind when caring for patients with stomach disorders?
Definition
1. Identify patients at risk for gastritis and peptic ulcer disease, especially older adults who take large amounts of NSAIDs and those with H. Pylori
2. Teach patients with abnormal symptoms, such as abdominal tenderness, abdominal pain that is relieved by food or pain that becomes worse 3 hours after eating, dyspepsia, melena, and/or distention to consult with physician immediately
3. For patients who have undergone a gastrectomy, collaborate with dietitian and instruct the patient regarding diet changes to avoid distention and dumping syndrome
Term
What is Irritable Bowel Syndrome?
Definition
A functional GI disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating
Term
Manning criteria
Definition
List the characteristic symptoms, including abdominas pain relieved by defecation or falling asleep or associated with changes in stool frequency or consistency, abdominal distension, the sensation of incomplete evacuation of stool, and presence of mucus with stool passage
Term
Why would a patient with IBS have a hydrogen breath test?
Definition
When small intestinal bacterial overgrowth or malabsorption of nutrients is present, excess hydrogen is produced
Term
What are some interventions you need to implement for a patient with IBS?
Definition
-Health teaching
-Drug therapy
-Stress management
Term
What patient education should be included for patients with IBS?
Definition
-Teach patients to avoid GI stimulants, such as caffeine, alcohol, and milk and milk products
-Teach patients to manage stress
Term
What is a hernia?
Definition
A weakness or defect in the abdominal muscle wall through which a segment of the bowel or other abdominal structure protrudes
Term
What is the risk for a strangulated hernia?
Definition
Can cause ischemia and bowel obstruction, requiring immediate intervention
Term
What is an intestinal obstruction?
Definition
Common and serious disorder caused by a variety of conditions and is associated with significant morbidity
Term
What should you assess in a patient with a nasogastric tube?
Definition
Check every 4 hours for:
-Proper placement
-Patency
-Output
Term
What is appendicitis?
Definition
An acute inflammation which occurs when the lumen of the appendix is obstructed, leading to infection as bacteria invade the wall of the appendix
Term
What are the causes of appendicitis?
Definition
-Fecaliths
-Malignant tumors
-Worms
-Other infections
Term
What is the difference between the risks for slow onset and rapid onset appendicitis?
Definition
-An abscess may develop in slow onset
-A rapid process may result in peritonitis
Term
What are the complications of peritonitis?
Definition
They are all serious, some examples are:
-Gangrene
-Perforation
Term
What lab tests would you look for in appendicitis?
Definition
WBCs "shift to the left," and if the elevation is greater than 20,000 it may indicate a perforated appendix
Term
What should you do with a patient admitted for suspected or known appendicitis?
Definition
Keep them NPO to prepare for the possibility of emergency surgery and to avoid making inflammation worse. Surgery is required ASAP.
Term
What is peritonitis?
Definition
A life-threatening, acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity
Term
What are the cardinal signs of peritonitis?
Definition
-Abdominal pain
-Tenderness
Term
What is gastroenteritis?
Definition
An increase in frequency and water content of stools or vomiting related to infection and inflammation of the mucous membranes of the stomach and intestinal tract, usually self-limiting unless complications occur
Term
What should you be concerned about with a patient with gastroenteritis?
Definition
Weakness and cardiac dysrhythmias may be the result of loss of potassium from diarrhea
Term
What is inflammatory bowel disease?
Definition
Usually refers to disorders of the GI tract with no known etiology, such as ulcerative colitis and Crohn's disease, but may be idiopathic
Term
What is ulcerative colitis?
Definition
Creates a widespread inflammation of the rectum and rectosigmoid colon, associated with periodic remissions and exacerbations
Term
What are the symptoms of ulcerative colitis?
Definition
-Patient's stool typically contains blood and mucus
-Patient's report tenesmus
-An unpleasant and urgent sensation to defecate
-Lower abdominal colicky pain
Term
What should you instruct the patient about activity after treatment for ulcerative colitis?
Definition
Activity is generally restricted because rest can reduce intestinal activity, provide comfort and promote healing
Term
What is the most definitive test for diagnosing ulcerative colitis?
Definition
A colonoscopy
Term
What should you assess for in a patient with an ileostomy?
Definition
Coping strategies and identify support systems
Term
What is Crohn's disease?
Definition
An inflammatory disease of the small intestine, the colon, or both. It is a slowly progressive, unpredictable, and a recurrent disease with involvement of multiple regions of the intestine with normal sections in-between
Term
What are the signs and symptoms of Crohn's disease?
Definition
-Severe diarrhea
-Malabsorption of vital nutrients
-Anemia is common
-Fistulas are common with acute periods
Term
What is a fistula?
Definition
An abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect
Term
What are the complications of fistulas?
Definition
-Systemic infections
-Skin problems
-Malnutrition
-Fluid and electrolyte imbalances
Term
What are the treatments of the patients with a fistula?
Definition
-Includes nutrition and electrolyte therapy
-Skin care
-Prevention of infection
Term
What are diverticula?
Definition
Pouch-like herniations of the mucosa through the muscular wall of any portion of the gut, but most commonly in the colon
Term
What is the difference in the food a patient with diverticulosis should eat compared with a patient with diverticulitis?
Definition
Teach patients with diverticulosis to eat a high-fiber diet; diverticulitis requires a low-fiber diet, such as avoid nuts, foods with seeds, and GI stimulants
Term
What is the risk associated with diverticulitis?
Definition
Can result in rupture of the diverticulum with peritonitis, pelvic abscess, bowel obstruction, fistula, persistent fever or pain, uncontrolled bleeding
Term
What is cirrhosis?
Definition
An extensive irreversible scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis
Term
What are the most common causes for cirrhosis?
Definition
Alcoholic liver disease and Hep C
Term
What are the risks associated with hepatic cell damage?
Definition
May lead to portal hypertension, ascites, bleeding esophageal varices, coagulation defects, jaundice, portal-systemic encephalopathy with hepatic coma, hepatorenal syndrome and spontaneous bacterial peritonitis
Term
What should the nurse make certain is done for a patient with cirrhosis and a GI bleed?
Definition
These patients should receive antibiotics on admission to the hospital
Term
How long does it take for hepatitis to be considered chronic?
Definition
When liver inflammation lasts longer than several months, usually defined as 6 months
Term
What puts people more at risk for gallstones?
Definition
-If they are female
-Obesity
-Pregnancy
-Estrogen
-Birth control pills
Term
What pathologies could happen as a result of acute pancreatitis?
Definition
Severe, life-threatening complications sucha s jaundice from swelling of the head of the pancreas, calculi or pancreatic pseudocyst, transient hyperglycemia from release of glucagon, left lung pleural effusions, and total destruction of the pancreas leading to type 1 diabetes
Term
What would the nurse be concerned about in a patient with severe pain in the mid-epigastric area or left upper quadrant?
Definition
Pancreatitis
Term
What is the priority patient care for patients with acute pancreatitis?
Definition
-Relieving symptoms
-Decreasing inflammation
-Anticipating or treating complications
Term
What is the focus of caring for a patient with chronic pancreatitis?
Definition
-Manage pain
-Assist in maintaining a sufficient nutritional intake
-Prevent recurrence
Term
What is an alternative way to measure a patient's nutritional status if BMI is unavailable?
Definition
Measure patient's calf circumference
Term
What type of patients are likely to receive total enteral nutrition using a feeding tube?
Definition
-Those can eat but cannot maintain adequate nutrition intake by oral intake of food alone
-Those who have permanent neuromuscular impairment and cannot swallow
-Critically ill patients
Term
What are some complications related to tube feeding?
Definition
-Irritation
-Sinusitis
-Tissue erosion
-Pulmonary compromis
Term
Refeeding syndrome
Definition
A life-threatening metabolic complication that can occur when nutrition is restarted for a patient who is in a starvation state
Term
How often should a nurse check gastric residual volumes for a patient on tube feeding and why?
Definition
Every 4-6 hours or per agency policy, because overfeeding is a serious problem
Term
Who is a candidate for bariatric surgery?
Definition
-Those who have repeated failure of nonsurgical intervention
-A BMI equal to or greater than 40
-Morbid Obesity
Term
What are indicators of malnutrition?
Definition
-Weight loss of 5% in 30 days
-Weight loss of 10% in 6 months
-BMI <18
Term
Dumping syndrome
Definition
Vasomotor symptoms that occur as a result of rapid emptying of food into Small Intestine, occurs around 30 minutes after eating; often seen with Gastric Bypass
Term
Dumping syndrome symptoms and treatment
Definition
Symptoms:
-Vertigo
-Tachycardia
-Syncope
-Sweating
-Pallor
-Palpitations
Treaments: Small meals, low CHO
Term
What are Small Intestine Bowel Obstruction S&S, Diagnostic findings, and medical management?
Definition
S&S:
-Colicky severe abd pain, N&V
-Absence of stool or flatus
-Late sign: fecal vomiting
Dx:
-X-ray and CT show abnormal amount of air/fluid in intestine
MM:
-Decompression with NG tube and bowel rest
-If worsens and bowel at risk for ischemia, bowel resection
Term
What are the S&S and Diagnostics of Large Intestine Bowel Obstruction?
Definition
S&S: (slower onset than SBO)
-Constipation
-Abd distension
-Eventually fecal vomiting
DX:
-Abd X-ray
-CT reveal a distended colon
Term
Functions of the renal system
Definition
-Fluid and electrolyte balance
-Blood filtration-remove waste products of the body's metabolic processes in the form of urine
-Acid-base balance
-Blood pressure regulation
-Erythropoetin production
-Vit D production
Term
Average renal blood flow
Definition
1 L/min
Term
Calculating urine output
Definition
Wt in Kg/2 = # cc/hr
Term
Glomerular filtration rate
Definition
Stage 1: kidney damage (90 or more GFR-ml/min)
Stage 2: kidney damage (60-80)
Stage 3: kidney damage (30-59)
Stage 4: kidney damage (15-29)
Stage 5: Kidney failure: ESRD (less than 15)
Term
Types of renal failure
Definition
-Acute kidney injury (AKI): sudden onset and frequently reversible with supportive care
-Chronic Kidney Disease (CKD): gradual onset over months to years
-End-stage Renal Disease (ESRD)
Term
RIFLE criteria for Acute Kidney Injury
Definition
Defines 3 grades of increasing severity of AKI
Risk
Injury
Failure
2 outcome classes
Loss
End-stage kidney disease
Term
Types of Acute renal failure
Definition
Prerenal failure – results from conditions that interrupt the renal blood supply; thereby reducing renal perfusion (hypovolemia, shock, hemorrhage, burns impaired cardiac output, diuretic therapy).
Postrenal failure – results from obstruction of urine flow.
Intrarenal failure – results from injury to the kidneys themselves (ischemia, toxins, immunologic processes, systemic and vascular disorders).
Term
Symptomatic treatment for AKI
Definition
-Hyperkalemia (urgent)
Kayexalate (binds with K+ for excretion in stool)
IV insulin
IV glucose
-Oxygen
-Medications (Diuretics sometimes)
-Dialysis: Hemodialysis, or continuous renal replacement therapy CRRT-ICU only
Term
Dialysis: IV catheters
Definition
-Special large-volume high-flow catheters
For acute dialysis--temporary uncuffed
For chronic dialysis if patient has lost or is not a candidate for AV or AV shunt
-DO NOT FLUSH! Filled with heparin to avoid clotting
Term
CKD
Definition
progressive decline in kidney function that correlates with loss of nephron
-Symptoms occur when overall renal function is less than 20-25% of nephrons remain
-ESRD: 90% nephron loss--uremic syndrome
Term
Dietary restriction for CKD
Definition
-Low protein
-Low potassium, sodium, phosphorus
Term
Fluid restrictions
Definition
-Replace urinary output plus 500ml
-methods to manage thirst such as hard candy and ice
Term
Care of the patient on Peritoneal Dialysis
Definition
Peritonitis is a major concern (“risk for infection”)—STERILE PROCEDURE
Wear mask and sterile gloves for procedure. Put mask on pt.
Assess drained “effluent” for clarity. Cloudy effluent is sign of peritonitis (like urine).
Assess for abdominal pain, hyperactive BS, diarrhea, unusual abd distention.
Notify MD immediately for any abnormal findings. Send specimen of effluent for C&S, WBCs
Term
Types of immunity
Definition
-Natural acquired immunity
-Artificial acquired immunity: mild if any symptomatic response but still immunogenic
-Natural passive immunity
-Artifical passive immunity: short-term (IVIG, RhoGam)
Term
Drugs that affect the immune system
Definition
-Allergies: Corticosteroids, antihistamines, epinephrine
-Immunosuppressants: corticosteroids, cyclosporins, tacrolimus
-Boosting the immune system: Interferons, neupogen, IVIG
-Vaccinations
Term
3 types of live vaccinations
Definition
1. Varicella
2. Zoster
3. Measles, mumps, rubella
Term
Characteristics of metastatic neoplasms
Definition
-Rapid and uncontrolled growht
-No contact inhibition; loose adherence; and migration
-Non-functional
Term
7 early warning signals of cancer (CAUTION)
Definition
1. Change in bowel or bladder habits
2. A sore that does not heal
3. Unusual bleeding or discharge
4. Thickening or a lump in the breasts, testicles, or elsewhere
5. Indigestion or difficulty in swallowing
6. Obvious change in the size, color, shape, or thickness of a wart, mole or mouth sore
7. Nagging cough or hoarseness
Term
Neutropenic precautions
Definition
Strict aseptic technique for all invasive procedures, avoid unnecessary lines and tubes
Limit visitors (healthy adults only)
Private room and supplies—do not bring in common supplies (ie, BP machine)
Call for temp >100.5 , monitor for early s/s infection
Monitor WBC and ANC daily
No fresh flowers in room
Diet: “neutropenic diet” (no fresh fruits or veggies, or undercooked food)
Pt & family education
Term
Biologics, including immunotherapy for cancer treatment
Definition
Cytokines
-Interferons—improve immune response, decrease rate of cancer cell growth
-Interleukins—improve immune response against cancer cells
-Hematopoietic growth factors
Thalidomine—decrease angiogenesis
Monoclonal antibodies—target specific antigens (CLL, non-Hodgkins, melanoma)
Vaccines
BCG therapy—bladder cancer only
Side effects— flu-like symptoms, severe allergic reactions
Term
Bone marrow transplants
Definition
Done in special units or on oncology floor
For hematopoietic cancers
High dose chemo or radiation to destroy pt’s own bone marrow— pts are extremely ill
New stem cells are infused after matching HLA antigens
-Autologous
-Allogenic
New WBCs, RBCs, platelets within 2-4 weeks
Immunosuppression takes months to 1-2 years to resolve.
Term
Oncologic emergencies
Definition
Infection: sepsis, DIC
Procoagulant: DVT & PE
F/E imbalance: SIADH, hypercalcemia
Compression by tumor:
-Spinal cord compression
-SVC syndrome
Response to therapy: tumor lysis syndrome
Term
DNR, DNAR, AND, Comfort Care
Definition
DNR: Do Not Resuscitate
DNAR: Do Not Attempt Resuscitation
AND: Allow Natural Death
Comfort Care: must also have DNR/AND
POLST– Physician Orders for Life-Sustaining Treatment
Term
Physician's Orders for Life-Sustaining Treatment (POLST)
Definition
Orders that specifically address different treatments that patients can have.
Covers CPR as well as ACLS orders
Also give providers information about patient’s GOAL :
-From aggressive curative care to comfort care only
-Directs specific ACTIONS to be taken or held (see example POLST orders)
Term
Physician's Orders for Life-Sustaining Treatment (POLST)
Definition
Orders that specifically address different treatments that patients can have.
Covers CPR as well as ACLS orders
Also give providers information about patient’s GOAL :
-From aggressive curative care to comfort care only
-Directs specific ACTIONS to be taken or held (see example POLST orders)
Term
Pain meds for palliative care
Definition
Opioids: scheduled and PRN for breakthrough pain
Neuroleptics for neuropathic pain
Multiple routes may be utilized (po, IV, SC, buccal, dermal)
Term
Dyspnea in palliative care
Definition
Goal is relief of subjective dyspnea, not physical signs of respiratory effort
Treat cause when possible:
-Radiation to shrink obstructive tumors
-Dexamethasone to treat inflammatory lung conditions
-Pleural drainage for effusion
-Bronchodilators for asthma
-Paracentesis for abdominal pressure on lung expansion
Symptomatic treatment:
-Oxygen
-Opioids
Term
"Death rattle"
Definition
Oropharyngeal relation and upper airway secretions--very distressing to families. Treat with anit-cholinergics (scopolamine, hyoscyamine, glycopyrrolate, and atropine) and positioning
Term
Hospice care
Definition
Requires physician certification that patient has less than six months to live
-Barrier to patients receiving hospice care with both physicians and patients/families
-Uncertainty of remaining length of life
Palliative care in an EOL context: addresses quality of life (QOL) issues but also emotional, social, spiritual, and financial preparation for death.
Term
Futile care
Definition
The use of considerable resources without a reasonable hope that the patient would recover to a state of relative independence or be interactive with his or her environment.
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