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Respiratory
1. Pneumonia
A. Increased respiratory rate
B. Irritability and restlessness
C. Fever, shaking, crackles (lungs are filled with fluid)
D. Chills, productive cough (alveoli is filled with fluid)
E. Confusion and lethargy in elderly
F. Assess ABGs
G. Deep breath, cough, suction
H. Hint: irritability and restlessness are the first signs of cerebral
hypoxia
I. provide hydration
J. Difficulty breathingstiff lungshypoxia
K. Decreased breath soundscongested lungs
2. Always give steroids last
A. Follow with oral hygiene due to risk of super-infection
3. Singulair (a leukotriene)
A. chronic asthma
4. oral suctioning is not sterile
5. Mask, gloves, and goggles for suctioning
6. Acute Respiratory Failure
A. Ph less than 7.35
B. Oxygen less than 50
C. C02 greater than 50
1.
2.
3.
4.
5.
6.
7.
8.
Neurosensory
Encephalitis
A. Vitals
I. Widened pulse pressure
II. Bradycardia
III. Irregular respirations
IV. Eyes do not PERRLA
V. Elevate head of the bed to 30 or 45 degrees
Parkinsons
A. Dopamine
Hydrocephalus
A. IICP
B. 6th nerve defect
Meningitis
A. 3, 4, 6, 7, 8
Lumber puncture
A. Measure pressure in CSF
B. Indicate neuro disorders, infections, brain, or spinal cord damage
EEG
A. Avoid caffeine and hair products before the test
IICP
A. Compresses brain structures
B. Reduces blood flow
C. Widened pulse pressure
D. Bradycardia
E. Increased temp.
F. Cheyne-stokes
G. Administer oxygen and monitor intake and output
H. Elevate head of bed 30-45 degrees
Seizures
A. Prodromal
Cardiovascular
A. life-style modification
B. nitrates
C. antihypertensive
d. anti-coagulants
e. calcium-channel blockers
f. ACE inhibitors
g. anti-platlets
9. Arteriolosclerosis
A. arteries harden and thicken
B. vitals organs are not adequately perfused
C. kidneys are most affected
10. Buergers disease
A. inflammation and blockage of small and medium sized arteries of the
extremities
B. Caused by smoking (causes inflammation and constriction of blood
vessels)
C. claudication
D. numbness and tingling
E. skin ulcerations and gangrene
11. How to calculate mean arterial pressure
A. (SBP+2DP)/3
i. less than 60 indicates inadequate perfusion
12. PTT
a. 16-40 normally
13. Central venous pressure
A. 5-10 cm water
14. Stenosis-blood flow is impeded
15. regurgitation-backward leakage of blood
16. Mitral valve disorders (both sided heart failure)
17. Aortic disorders-left side heart failure
18. Avoid green leafy vegetables while taking warfarin
19. APPT with heparin: 60-80 seconds
Gastrointestinal System
1. Hiatal Hernia
A. Portion of the stomach protrudes through esophageal hiatus
B. Feeling of fullness
C. Feeling of suffocation and smoothing after meals (eating distends the
stomach, leading to decreased ability of the lungs to expand
D. Breathing difficulty
E. Anemia
F. *sit up after eating
2. GERD
A. Pain, burning, and dysphagia (scarring from irritation)
B. Eat low fat, high protein foods
C. Limit chocolate and mints
D. Avoid carbonated beverages
E. Proton pump inhibitors (zole)
F. H2 receptor blockes (dine)
G. Antacids
H. mucosal barrier fortifiers (sucralfate-Carafate)
I. Can lead to stricture and barrets esophagus
3. Peptic ulcer disease
J. antibiotics
K. Increase calories and fluids to heal fistulas
17. Ulcerative colitis
A. inflammation of large intestine and rectum
B. 10-20 liquid stools per day
C. rectal bleeding
D. increased bowel sounds
E. weight loss
F. *bloody diarrhea mixed with mucous
G. anemia
H. NPO
I. TPN
J. low-residue foods, low-fat, high protein, high calories food
K. Avoid milk and encourage bed rest
L. anti-diarrheals
M. sulasalazine
18. Irritable bowel syndrome
A. altered intestinal motility
B. diarrhea, constipation, or both
C. bloating and gas
D. Increase fiber and give laxatives for constipation
E. anti-diarrheals and increase fluids for diarrhea
F. avoid caffeine, dairy foods, and fructose
G. bulk-forming laxatives for constipation
H. anti-depressants
I. Imodium for diarrhea
19. Diverticulitis
A. inflammation or infection of blind pouches
B. pain
C. fever
D. weakness
E. diarrhea
F. anemia caused by rectal bleeding
G. do not do barium enema or colonoscopy during diverticulitis
H. liquid diet initially
I. low fiber diet
J. avoid laxatives
K. *signs of intestinal obstruction
L. acute phase: NPO or liquids
M. recovery: no fiber or foods
N. maintenance: high fiber with bulk forming laxatives. Avoid popcorn,
nuts, or seeds
20. Ileostomy drains liquid, increasing risk of skin breakdown
21. Pouch system is changed every 3-7 days
22. Cirrhosis
A. fatal scarring and fibrosis of liver tissue
B. Jaundice due to bilirubin build up
C. Pruritis & clay colored stools
D. ascites due to decreased albumin (albumin keeps fluid in vascular
space)
E. hepatomegaly
F. nausea due to toxin buildup
G. spider angiomas (decreased vitamin K)
H. increased medication sensitivity
OTHER GI NOTES
1. The barium swallow study detect anatomic and functional changes of the
esophagus, stomach, and small intestine.
A. laxatives and fluids are given after the test
2. The barium enema study detects changes of the large intestine.
3. Clear liquid diet indicated for endoscopic studies.
4. Monitor cardiac and respiratory functions after EGD procedure
14. Cirrhosis: normal liver cells are replaced with scar tissue
15. Regular functions of the liver:
A. synthesis of clotting factors
B. metabolism of hormones (aldosterone, ADH, estrogen and testerone)
C. synthesize albumin (maintains normal colloid pressure)
D. carb, protein, and fat metabolism
E. filtration of drugs
F. storage of vitamins and minerals
16. Early stages of cirrhosis: enlarged liver, jaundice, GI disturbances,
abdominal discomfort
16.late stages: enlarged spleen, ascites, bleeding tendencies, esophageal
varices, dyspnea, pruritis, clay-colored stools
17. end-stage: heptatis encephalopathy
18. Encourage rest, decreased fluid intake, high-calorie, low-protein, lowsodium, low-fat diet, assess abdominal girth, diuretics, lactulose, IV fat
soluble vitamins and albumin
A. low-protein due to the bodys inability to secrete ammonia, lowsodium to prevent ascites, low-fat diet due to the livers inability to break
down fats
19. Varices in the esophagus bleed due to coughing, trauma, and vomiting
20. Murphy sign
A. extreme pain on deep inspiration: cholecystitis
21. Greatest risks for pancreatitis are those suffering from alcohol abuse,
liver, and gallbladder disease
22. Do not give ice chips and hard candies to prevent stimulation of pancreas
23. Major complication of liver biopsy is hemorrhage, so assess PT prior to
procedure
24. GGT assesses possibility of alcohol abuse
25. Fatty foods have no direct effect on diverticulitis
26. Ginger root has antiemetic, analgesic, and sedative properties
27. Bariatric surgery results in the construction of a small pouch in the
upper part of the GI. Overfilling of the pouch leads to nausea
28. *Zenkers diverticulum is an outpouching of the esophagus near the
hypopharyngeal spincter. Risk for aspiration
29. Weight can cause a non-alcoholic fatty liver
30. Beta-blockers are given in cirrhosis to prevent esophageal varrices
bleeding
31. Positioning the client on the right side after a liver biopsy splints the
puncture site to prevent and decrease bleeding.
32. Grey-Turner sign in pancreatitis-blood-stained exudates from the pancreas
indicates a severe disease process
33. Patients with IBS have mucous in stools
34. Bowel strictures in Crohns disease can lead to obstruction
35. Patients are placed in side-lying position after anorectal surgery
36. Asprin decreases risk of colon cancer
37. Peristalsis do not return for 3-5 days after abdominal surgery
DIABETES
1. Type I
A. Glucose usually 350 and above
B. Ketonuria
C. Bicarbonate less than 15
D. Clients are usually thin and under 30
2. Type II.
A. *nonketotic hyperosmolar hyperglycemia
B. Plasma hyperosmolality
C. Dehydration
D. change in mental status
3. Assessment:
A. Breaks in skin
B. Dental caries and fungal infection
C. Cataracts and diabetic retinopathy
D. Chest pain and shortness of breath
E. Hair loss on extremities with non-palpable pulse, pallor, and
ulcerations
F. Edema of face, hands, feet, and urinary retention
G. Neuropathies
H. night time diarrhea
I. vaginal dryness and frequent yeast infections
4. Take meds according to insulin peak times
5. Eat bedtime snacks
6. Wash feet daily but DO NOT soak! Dry them well
7. Do not moisturize feet between toes
8. Sandles should be avoided
9. Do not wear garters or elastic topped socks
10. Stress and illness can cause hyperglycemia
11. Hypovolemia (polyuria)
Oral meds
1. Sulfonylureas (Glyburide & glipizide)
A. stimulates the release of insulin from pancreas and tissues take up
glucose more easily
B. hypoglycemia is adverse reaction
C. Give with meal once daily
2. Biguinides (metformin)
A. inhibit hepatic glucose production and increase sensitivity of tissue
to insulin
B. GI disturbances
3. Thiazolidinediones (actos & avandia)
A. decrease insulin resistance to the tissues
B. weight gain and edema
4. Alpha-glucosidase inhibitors
A. decrease blood glucose absorption
B. take with first bite of each meal
5. Meglitindes
A. same as sulfonylureas
*Insulins
1. Rapid acting
A. Humalog & Novolog
B. 5-15 minutes onset
C. 45-1.5 hours peak
D. Give within 5-15 minutes of meal
2. Short acting
A. Regular insulin
B. 30-60 minutes onset
C. 2-3 hours peak
3. Intermediate
A. NPH & Humulin L
B. 1-2 hours onset
C. 6-12 hours peak
4. Long acting
A. Lantus
B. 4-8 hours onset
C. 14-20 hours peak
D. Give at bedtime
E. Bottle is shaped differently than regular insulin, but is clear
F. Do not shake or mix with other insulins
1.
2.
3.
4.
5.
6.
Diabetic ketoacidosis
Body breaks down fat-ketones
Metabolic acidosis
decreased LOC
hypovolemia (excess sugar and fluid is excreted)
electrolyte imbalances (hyperkalemia)
Kussmaul respirations to blow off excess acid
Other notes
1. post-pandrial glucose is less than 140
2. A1C: 4-7%
3. Diabetics have increased risk for infection
4. Cool, clammy skin is often seen in hypoglycemia
5. in diabetic ketoacidosis, the skin is flushed due to dehydration and poor
skin turgor
A. Administer IV saline, potassium and insulin
6. A bedtime snack is not needed with long-acting insulin
7. Exercising with glucose levels exceeding 250 and ketonuria increases
secretion of glucagon, growth hormone, and catecholamines, casuing the liver
to release more glucose
Fluids Imbalances
1. Organs involved:
A. kidney (fluid and electrolyte, acid-base balances)
B. lungs (acid-base balance, rid 300 ml of fluid)
C. heart (kidney perfusion)
D. adrenal gland (secrete aldosterone)
E. pituitary gland (secrete ADH)
F. parathyroid gland
2. Fluid volume deficit:
A. loss of water, electrolytes remain normal, but sodium increases)
B. Decreased skin turgor
C. oliguria
D, dry and sticky mucous membranes
E. weak, rapid pulse
F. Elevated BUN (measures excretory function of kidney)
G. elevated Creatnine
H. Increased serum osmolarity (amount of solvent is decreased)
I. Elevated Hgb and Hct
J. Replace isotonic fluids because water is hypotonic
K. Strict I & o
L. Increased urine osmolality (due to concentrated urine)
i. 1.001-1.030
3. Fluid volume excess:
A. Body retains water, sodium level decreases
B. Heart, renal, liver failure
C. Peripheral edema
D. bounding pulse with increased BP
E. distended neck and hand veins
F. dyspnea
G. All lab values decreased (hemodilutional state with diluted urine)
H. Diuretics
I. Fluid and salt restriction
J.Strict I & O
K. Weigh daily
Electrolyte Imbalances
1. Sodium: 135-145
2. Potassium: 3.5-5
3. Calcium: 9-10.5
4. Magnesium: 1.3-2.1
5. Chloride: 95-105
6. Phosphate: 3-4.5
Abnormalities and common
causes
Hyponatremia
-diuretics
-hypotonic solutions
-sweating
Hypernatremia
-water deprivation
-watery diarrhea
-renal failure
Hypokalemia
-diuretics
-vomiting
-NG suctioning
Hyperkalemia
-oliguria
-renal failure
-acidosis
Hypocalcemia
-renal failure
-hypoparathyrodism
-malabsorption
S/Sx
Treatment
- muscle weakness
(decreased excitability
of cell membranes)
-seizures
-muscle cramps
-twitching
-lethargy and confusion
Thirst
-tachycardia (heart is
trying to pump around
what little fluid is
left)
-dry mouth
-irritability
-muscle weakness
(potassium is needed for
muscle contraction)
-decreased GI motility
-dysrhythmias
-paresthesia
-slow, difficult
respirations
(respiratory muscles are
weak)
-bradycardia
-dysrhythmias
-flaccid paralysis
(excessive potassium
interferes with muscle
contraction)
-diarrhea
-numbness and cramps
-tingling of extremities
-convulsions (muscles
contract)
-positive trousseau sign
(hyperexcitability of
hand muscles)
-positive chvosteks
sign (hyperexcitabilty
-restrict fluids
-hypotonic or hypertonic
saline solutions
-increase dietary sodium
-restrict sodium
-increase water intake
Hypercalcemia
-hyperparathyroidism
of facial muscles)
-laryngeal spasms
-increased DTRs
-constipation
-polyuria
-polydipsia
-dysrhythmmias
-respiratory arrest
(sedative respiratory
muscles)
-decreased bowel sounds
(intestines are sedated)
-muscle weakness
(sedated muscles)
-administer calcitonin
(moves calcium into the
bones)
-IV phosphate
Hypomagnesemia
-alcoholism
-diabetic ketoacidosis
-malabsorption
-administer magnesium
sulfate
Hypermagnesemia
-renal failure
-flushing
-hypotension
-drowsiness
-depressed respirations
-hypoactive reflexes
-bradycardia
-BP decreases
(vasodilation)
-facial flushing and
warming (vasodilation)
-sedated respiratory
muscles
-parestheias
-muscle weakness
-cardiomyopathy
-respiratory failure
-(SIGNS AND SYMPTOMS OF
HYPERCALCEMIA)
-tentany symptons
(SIGNS AND SYMPTOMS OF
HYPOCALCEMIA)
Hypophosphaemia
-alcohol withdrawal
Hyperphosphatemia
-renal failure
Administer aluminum
hydroxide
-administer vitamin D
Other notes
1. hyponatremia caused by hypervolemia: fluid restriction
Acid-base balance
1. 20 bicarbonate to 1 carbonic acid ratio
2. Respiratory acidosis
A. Pulmonary disease
B. Sleep apnea
3. Respiratory alkalosis
A. over-ventilation
B. response to hypoxia
C. fever
4. Metabolic acidosis
A. lactic acidosis
B. ketoacidosis
C. acid ingestion
5. Metabolic alkalosis
A. Gastric drainage
B. vomiting
C. burns
Peri-operative
1. Surgical risks
A. young and old
B. obese and malnourished
C. dehydrated
D. clients with any infection
E. cardiac conditions
F. blood coagulation disorders
G. upper respiratory tract infections and COPD
H. renal disease (renal insufficiency)
I. diabetes due to delayed healing and possibility of wound infection
J. Use of anticoagulants
K. use of antibiotics (may be incompatible to anesthesia)
L. diuretic use (electrolyte imbalances)
M. steroids
N. vitamin E use
2. Client has to be 18 to sign surgical consent form
Pre-operative
1. Client teaching:
A. Coughing and deep breathing
B. Supporting the wound by splinting
C. leg exercises
D. Turning, positioning, ambulation
E. Recovery room procedures
F. Type of dressing, NG tubes, drains, foley catheter
Intra-operative
1. report changes in pulse, temperature, respirations, and blood pressure to
surgeon
.
1. Signs
A.
B.
C.
D.
Postoperative
of shock and hemorrhage
hypotension
tachycardia
narrowed pulse pressure
cold, moist skin
2. Post-op care
A. Pulmonary
i. Airway (check gag reflex)
ii. Bilateral breath sounds
iii. Deep breathing and coughing
B. Neuro
i. LOC
ii. Reflexes
C. Circulation
i. Vital signs
ii. Peripheral perfusion
D. GI
i. Bowel sounds
ii. Distention
E. GU
i. Urinary output
ii. Intake and output
*malignant hyperthermia
*somogyi/dawn effect
*smoking-pack years