Professional Documents
Culture Documents
Final
Study Guide
Altered LOC
Head Injuries
Cerebral Vascular Disease
Seizure Disorders
Brain Tumors
Brain Surgery
Diabetes Mellitus
Oxygen Therapy
Pneumonia
Tuberculosis ?
Asthma/COPD (Bronchitis, Emphysema)
Fractures
Hip Fractures
Amputations
Osteoarthritis
Orthopedic Surgery
Cancer
Womens Health
Osteoporosis
STDs
PUD
Gastritis
Intestinal Obstruction
Diverticulosis
Diverticulitis
CAD
MI
Angina Pectoris
EKG
Hypertension
PVD
CHF
Systemic Lupus Erythematosus (Not Included)
Rheumatoid Arthritis (Not Included)
Precautions Contact, Airborn, Droplet (Not included)
It can cause lateral displacement of the brain against the rigid structures of the skull.
Restriction of blood flow to the brain tissue decreasing O2 delivery and waste removal.
Cells within the brain become anoxic and cannot metabolize properly, producing ischemia, infarction, irreversible
brain damage, brain death.
Classifications
MRI Magnetic Resonance Imagery is used to evaluate patients with head injury when a more accurate picture
of anatomic nature of the injury is warranted and when the Pt is stable enough to undergo this longer diagnostic
procedure.
Cerebral angiography identifies supratentorial, extracerebral, and intracerebral hematomas and cerebral
contusions. Lateral and anteroposterior views of the skull are obtained.
Management Scalp injury
Basilar Skull Fractures
HOB 30 degree to reduce ICP and promote spontaneous closure of the leak.
Instruct patient to avoid blowing the nose & sneezing.
Depressed Skull Fractures
ABTs (antibiotics) therapy
Scalp is shaved and cleanse with copious amount of saline to remove the debris.
Surgical repair (non-depressed skull Fx usually do not required surgical TX)
Brain Injury (injury that is severe enough to interfere with normal functioning)
Closed (blunt) injury
Head rapidly accelerates and decelerates or collides with another object.
Brain tissue damage with no opening through the skull and dura.
Open injury
Object penetrates the skull and damages the soft brain tissue.
Penetrating injury
Concussion
Temporally loss of neurologic function (from dizziness to complete loss of consciousness) after a head
trauma with no apparent structural damage
Last from seconds to minutes
Frontal lobe: bizarre irrational behavior
Temporal lobe: amnesia and/or disorientation
Contusion
More severe than concussion
Bleeding
Loss of consciousness for more than few minutes
S&S depend on the extend of the cerebral edema
Residual vertigo and headaches are common
Diffuse axonal injury
Widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brain stem.
Severe injury leads to coma with decorticate and decerebrate posturing
Intracranial Hemorrhage
Intracranial hemorrhage
Collection of blood that develops within the cranial vault
Most serious brain injury epidural, subdural, or intracerebral hematoma
P. 1914
Epidural hematoma:
Blood collects between the dura and the skull
Classic sign: Lucid interval
Emergency with poss. obvious neurologic deficit and Resp. arrest within min.
TX: burr holes to decreased ICP immediately, craniotomy, both with drain
Subdural hematoma
Collection of blood between the dura and the brain
Cause: Trauma, coagulopathies, ruptured aneurysm but most common is venous in origin and is caused by a
rupture of small vessels that bridge the subdural space.
Acute: S&S within 24-48 hrs. AMS (altered mental status), pupillary signs, hemiparesis.
Sub-acute: S&S within 48hrs-2wks. S&S similar to Acute Subdural Hematoma
Chronic: repetitive minor head injuries. S&S appear wks-months. On-and-off severe headaches, mental
deterioration, seizures, and personality changes
TX: burr holes, craniotomy
Intracerebral hemorrhage
Bleeding into the brain tissue
Causes: HTN, ruptured vein/aneurysm, vascular anomalies, tumor, leukemia, hemophilia, aplastic anemia,
thrombocytopenia, and anticoagulant therapy.
S&S: Headache and neurologic deficits
TX: craniotomy, cranietomy (? Surgery depends on location and containment of blood)
Management includes supportive care, control of ICP, and careful administration of fluids, electrolytes, and
antihypertensives
will occur. K plays an important role in nerve conduction, muscle function, acid-base balance, and osmotic
pressure. Along with Ca and Mg, K controls the rate and force of contraction of the heart and thus cardiac
output. Evidence of a K deficit can be noted on an ECG by the presence of a U wave.
Ca The bulk of the bodies calcium (99%) is stored in the skeleton and teeth which act as huge reservoirs for
maintaining blood levels of calcium. About 50% of the blood Ca is ionized; the rest is protein bound. Only
ionized Ca can be used by the body in such vital processes as muscular contraction, cardiac function,
transmission of nerve impulses, and blood clotting. The amount of protein in the blood also affects calcium
levels because 50% is protein bound. Thus, a decrease is serum albumin will result in a decrease in total
serum Ca.
Mg Mg in the body is concentrated (40-60%) in the bone, 20% muscle, 30% within the cell itself, and 1% in
the serum, and is required for use of ADP as a source of energy. It is necessary for the action of numerous
enzyme systems such as carbohydrate metabolism, protein synthesis, nucleic acid synthesis, and contraction
of muscular tissue. Mg also regulates neuromuscular irritability and the clotting mechanism. Mg deficiency will
result in the drift of calcium out of the bones, possible resulting in abnormal calcification in the aorta and the
kidney. When there is decreased kidney function, greater amounts of magnesium are retained, resulting in
increased blood serum levels. Magnesium measurement is used to evaluate renal function, electrolyte status,
and evaluate magnesium metabolism.
Cl Chloride, a blood electrolyte, is the major anion that exists predominantly in the extracellular spaces as
part of sodium chloride or hydrochloric acid. Cl maintains cellular integrity through its influence on osmotic
pressure and acid-base and water balance. In an emergency, chloride is the least important electrolyte to
measure. However, it is especially important in the correction of hypokalemic alkalosis.
Ammonia NH3, an end product of protein metabolism, is formed by bacteria acting on intestinal proteins together
with glutamine hydrolysis in the kidneys. The liver normally removes most of this ammonia via the portal vein
circulation and converts the ammonia to urea. Because any appreciable level of ammonia in the blood affects the
bodys acid-base balance and brain function, its removal from the body is essential. The liver accomplishes this by
synthesizing urea so that it can be excreted by the kidneys.
BUN Blood Urea Nitrogen test which measures the nitrogen portion of urea, is used as an index of glomerular
function in the production and excretion of urea. Rapid protein catabolism and impairment of kidney function will
result in an elevated BUN level. The rate at which the BUN level rises is influenced by the degree of tissue
necrosis, protein catabolism, and the rate at which the kidneys excrete the urea nitrogen. A markedly increased
BUN is conclusive evidence of sever impaired glomerular function. In chronic renal disease, the BUN level
correlates better with symptoms of uremia than does the serum creatinine.
Serum osmolarity PT Prothrombin Time normal range 11.0 to 13.0 seconds. Prothrombin is a protein produced by the liver for
clotting of the blood. Prothrombin production depends on adequate vitamin K intake and absorption. During the
clotting process, prothrombin is converted to thrombin. The prothrombin content of the blood is reduced in patients
with liver disease. PT directly measures a potential defect in stage II of the clotting mechanism (extrinsic
coagulation system) through analysis of the clotting ability of five plasma coagulation factors (prothrombin,
fibrinogen, factor V, factor VII, and factor X). The PT is used also to evaluate disfibrinogenemia, evaluate the
heparin effect and coumarin effect, liver failure, and vitamin K deficiency.
PTT Partial Thromboplastin Time normal range 21-35 seconds, one stage clotting test, screens for coagulation
disorders. Specifically, it can detect deficiencies of the intrinsic thromboplastin system and also reveals defects in
the extrinsic coagulation mechanism pathway. Prolonged PTT occurs in congenital deficiencies, Heparin therapy,
Warfarin (Coumadin) therapy, Vitamin K deficiency, liver disease, DIC (disseminated intravascular coagulation)
fibrin breakdown products. Shortened PTT occurs in: extensive cancer, except when the liver is involved,
Immediately after acute hemorrhage, very early stages of DIC.
Serum ketones Level of concentration of ketones. Ketoacidosis vs Ketoalcolosis
ETOH level Ethanol is absorbed rapidly from the GI tract, with peak blood levels usually occurring within 40 to 70
minutes of ingestion on an empty stomach.Quantitation of alcohol level may be performed for medical or legal
purposes, to diagnose alcohol intoxication, and to determine appropriate therapy. Alcohol level must be tested as a
possible cause of unknown coma because alcohol intoxication mimics diabetic coma, cerebral trauma, and drug
overdose. This test is also used to screen for alcoholism and to monitor ethanol treatment for methanol
intoxication.
Toxicology the scientific study of poisons, their detection, their effects, and methods of treatment for conditions
they produce. Urine drug screen. Common Urine Drug Tests include Alcohol, Amphetamines, Analgesics,
Barbiturates, Benzodiazepines, Cocaine crack, Cyanide, LSD, Major tranquilizers, Marijuana, Opiates, PCP,
Sedatives Stimulants, Sympathomimetics.
ABGs Arterial Blood Gases measurement are obtained to assess adequacy of oxygenation and ventilation, to
evaluate acid-base status by measuring the respiratory and nonrespiratory components, and to monitor
effectiveness of therapy. They are also used to monitor critically ill patients, to establish baseline values in the
perioperative and postoperative periods, to detect and treat electrolyte imbalances, to titrate appropriate oxygen
flow rates, to qualify a patient for use of oxygen at home, and in conjuction with pulmonary function testing.
zGlasgow coma scale is a tool for assessing a patients response to stimuli. Scores range from 3 (deep coma) to
15 (normal).
zEye opening response Spontaneous 4, To Voice 3, To Pain 2, None 1
zBest Verbal Response oriented 5, Confused 4, Inappropriate words 3, Incomprehensible sounds 2,
none 1
zBest Motor Response Obeys command 6, localizes pain 5, Withdraws 4, Flexion 3, Extension 2, none 1
zCt scan Computed Tomography uses high-speed xray scanning to detect less apparent abnormalities. It is fast,
accurate, and safe diagnostic procedure that shows the presence, nature, location, and extent of acute lesions.
Cerebral edema, contusion, hematomas, subrachnoid & intraventricular hemorrhage, (infarction) hydrocephalus,
abd. Can Identify bleeding without contrast.
zMRI Magnetic Resonance Imagery is used to evaluate patients with head injury when a more accurate picture
of anatomic nature of the injury is warranted and when the Pt is stable enough to undergo this longer diagnostic
procedure.
zEEG Electroencephalography, an instrument used for receiving an recording the electric potential produced by
the brain cells. Electroencephalogram, a graphic chart on which is traced the electric potential produced by the
brain cells, as detected by electrodes placed on the scalp. The resulting brain waves are called alpha, beta, delta,
and theta rhythms, according to the frequencies they produce. Variations in brain wave activity are correlated with
neurologic conditions, psychologic states, and level of consciousness.
Altered LOC
Assessment
zMental status the degree of competence shown by a person in intellectual, emotional, psychologic, and
personality functioning as measured by psychologic testing with reference to a statistical norm. Alertness is
measured by the patients ability to open the eyes spontaneously or in response to a vocal or noxious stimulus. Pts
with severe neurologic dysfunction cannot do this.
zCranial nerves 12 pairs of nerves emerging from the cranial cavity through various openings in the skull.
Beginning with the most anterior, they are designated by Roman numerals and named:
Cranial Nerve I
Cranial Nerve II
Cranial Nerve III
Olfactory
Optic
Oculomotor
Cranial Nerve VI
Cranial Nerve V
Cranial Nerve VI
Cranial Nerve VII
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Cranial Nerve X
Vagal
Cranial Nerve XI
Cranial Nerve XII
Accessory
Hypoglossal
Smell
Visual acuity and visual fields
Muscles that move the eye and lid, papillary constriction, lens
accomodation
Muscles that move the eye
Facial sensation, corneal reflex, mastication
Muscles that move the eye
Facial expression and muscle movement, salivation, and tearing,
taste, sensation in the ear
Hearing and equilibrium
Taste, sensation in pharynx and tongue, pharyngeal muscles,
swallowing
Muscles of pharynx, larynx, and soft palate; sensation in external ear,
pharynx, larynx, thoracic and abdominal viscera; parasympathetic
innervation of thoracic and abdominal organs
Sternocleidomastoid and trapezius muscles
Movement of the tongue
Respiratory failure
zPressure ulcers from lack of mobility and being in one position for too long
zAspiration zVenous stasis Deep vein thrombosis
zMusculoskeletal deterioration loss of muscle tone an mass resulting from inactivity
zDisturbed GI function Constipation, peristalsis
Medical Management
zAssess for dryness (dehydration), inflammation and crusting (infection) Keep membranes moist
zProvide mouth care (remove crust, excess saliva, maintain moisture & dental integrity)
zApply moisturizing sol. to the lips.
NSG: Preserve corneal integrity
zClean with NS with sterile gauze to prevent dryness
zUse of artificial tears Q2hrs, as ordered (saline ampules)
zEye patches to prevent corneal damage and blindness
NSG: Thermoregulation
Causes of fever:
Infection
Drug reaction
Damage to the hypothalamus (if neurological then the fever will never go down! Mortality rate is high,
maybe 100%)
(low grade) dehydration
Use minimum amount of bedding to increase surface cooling.
Ischemic stroke
Large artery Thrombotic stroke-caused by atherosclerosis plaques of large vessels of the brain. Thrombus
formation and occlusion at the site of the atherosclerosis result in ischemia and infarction (a localized area of
necrosis in a tissue resulting from anoxia) (deprivation of blood supply)
Small artery Thrombotic stroke most common type of ischemic stroke.
Cardiogenic emboli - R/T cardiac dysrhythmias, usually atrial fibrillation, embolic strokes can also be associated
with valvular heart disease and thrombi in the left ventricle.
Watch for this is the worst headache of my life! this could definitely be ruptured anurism
CVA: Hemorrhagic
Account for 15% to 20% of cerebrovascular disorders and are primarily caused by intracranial or subarachnoid
hemorrhage
Subarachnoid hemorrhage results from a ruptured intracranial aneurysm (a weakening in the arterial wall) in
about half the cases.
Intracerebral hemorrhage in the elderly is cerebral amyloid angiopathy, which involves damage cause by the
deposit of beta-amyloid protein in the small and medium-sized blood vessels of the brain.
Secondary intracerebral hemorrhage is associated with arteriovenous malformations (AVMs), intracranial
aneurysms, intracranial neoplasms, or certain medications.
Symptoms are produced when a primary hemorrhage, aneurysm, or AVM presses on nearby cranial nerves or
brain tissue or, more dramatically, when an aneurysm or AVM ruptures, causing subarachnoid hemorrhage
(hemorrhage into the cranial subarachnoid space)
Normal brain metabolism is disrupted by the brains:
Being exposed to blood
Increased ICP by sudden bleeding into the brain (entry of blood into the subarachnoid space, which
compresses and injures brain tissue)
Secondary ischemia of brain tissue is caused by reduced perfusion and vasospasms that frequently
accompany subarachnoid hemorrhage
HTN (80%)
Diabetes
High cholesterol
Atherosclerosis
Obesity
Smoking
Phenylpropanolamine:
Chemical substance found in appetite suppressant drugs and in cold & cough agents related to the incidence of
hemorrhagic strokes.
CVA: Diagnostic tools
Plain CT scan of the brain (ischemic vs. hemorrhagic) (without contrast) any Pt with suspected stroke should
undergo a CT scan to determine the type of stroke, the size and location of the hematoma, and the presence or
absence of ventricular blood and hydrocephalus (blood in the subarachnoid space or ventricles impedes the
circulation of CSF. This test and the cerebral angiography provide information about the affected arteries, veins,
adjoining vessels, and vascular branches.
12 lead EKG: cardiac arrhythmias (study of the electrical conduction of the heart)
Carotid U/S: stenosis (an abnormal condition characterized by the constriction or narrowing of an opening or
passageway in a body structure) & atherosclerosis (a common disorder characterized by yellowish plaques of
cholesterol, other lipids, and cellular debris in the inner layers of the walls of arteries.
MRI Magnetic Resonance Imagery is used to evaluate patients with head injury when a more accurate picture of
anatomic nature of the injury is warranted and when the Pt is stable enough to undergo this longer diagnostic
procedure.
MRA the use of special MR imaging pulses to visualize the vascular sysem and identify regions of non-flowing
blood. It may be performed with or without contrast.
Cerebral angiography identifies supratentorial, extracerebral, and intracerebral hematomas and cerebral
contusions. Lateral and anteroposterior views of the skull are obtained.
Carotid angiography identify abnormalities or blockages pertaining to the arteries that supply the head and neck
Toxicology screen When diagnosing a hemorrhagic stroke in a patient younger than 40 years of age, some
clinicians obtain a toxicology screen for illicit drug use.
Lumbar puncture is performed if there is no evidence of increased ICP, the CT is negative, and subarachnoid
hemorrhage must be confirmed. Note: Lumbar puncture in the presence of increased ICP could result in brain
stem herniation or rebleeding.
Diagnostic tools
Initial nursing assessment
Respiratory failure
Pneumonia
Pressure ulcers
Aspiration
Venous stasis
Musculoskeletal deterioration
Disturbed GI function
CVA: Complications
Hemorrhagic
Cerebral hypoxia:
1.
2.
3.
4.
Administer supplemental O2
Maintain H&H at acceptable levels
Hydration to blood viscosity and improve cerebral blood flow
Seizure Tx, prophylaxis
Vasospasm:
1.
2.
3.
4.
Acute hydrocephalus:
1. Management of ICP with Mannitol
2. CSF drainage by lumbar puncture or ventricular catheter drainage
Systemic hypertension
Craniotomy any surgical opening into the skull, performed to relieve intracranial pressure, to control bleeding, or
to remove a tumor
Rupture of an aneurysm or AVM often produces a loss of consciousness for a variable period of time
Nuchal rigidity (pain and rigidity in the back of the neck) and back pain due to meningeal irritability.
Visual disturbances (visual loss, diplopia [double vision caused by defective function of the extraocular muscles or
a disorder of the nerves that innervate the muscles], ptosis [one or both eyelids droops because of an acquired
weakness of the levator]
CVA: Ischemic & Hemorrhage S&S
Numbness &/or weakness of face, arm, or leg, especially on one side of the body
Confusion or change in mental status
Changes of LOC, dizziness, headache
Aphasia -trouble speaking or understanding speech
Visual disturbances
Ambulatory difficulties difficulty walking, dizziness, or loss of balance or coordination
Lesion of the upper motor neurons results in lost of voluntary control over motor movements.
1st flaccid paralysis and loss/decreased deep tendon reflexes
Hemiplegia - paralysis of one side of body caused by a lesion (stroke) of the opposite side of the brain (most
common dysfunction)
Hemiparesis - weakness of one side of the body
Spasticity - Abnormal increase in muscle tone, 48hrs after when deep tendon reflexes re-appear
Ataxia - An impaired ability to coordinate movement, an unsteady gait.
Apraxia - inability to perform a previously learned action, as may be seen when a patient makes verbal
substitutions for desired syllables or words.
CVA:
S&S
Communication loss
Stroke is the most common cause of aphasia
Dysarthria difficulty in speaking, caused by paralysis of the muscles responsible for producing speech
Dysphasia - impaired speech
Aphasia - loss of speech (expressive, receptive, global)
Apraxia - inability to perform a previously learned action, as may be seen when a patient makes verbal
substitutions for desired syllables or words.
Memory loss
Decreased attention span
Impaired ability to concentrate
Altered judgment
CVA:S&S Ischemic & Hemorrhage Stroke
Psychological effect:
segments of the endothelium and tunica media of the carotid artery, leaving a smooth tissue lining and facilitating
blood flow through the vessel. Surgery is done to prevent stroke)
Brain Aneurysm
Stroke Animation
CVA: Medical management
ischemic
Thrombolytic therapy
Prevent any exertion by assisting the patient with bathing, and dressing including toileting and the Valsalva
maneuver.
No enemas, however stool softeners are allowed
No TV, Radio, or reading
CVA: NSG interventions
Monitor for S&S of vasospasm:
Episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from
sudden excessive discharge from cerebral neurons.
Prodromal pertaining to early symptoms that may mark the onset of a disease.
known and the epilepsy is a symptom of another underlying condition, such as a brain tumor)
Metabolic and toxic conditions (renal failure, hyponatremia, hypocalcemia, hypoclycemia, pesticides)
Congenital malformations
Genetic predisposition
Perinatal injury
Postnatal trauma
Brain tumor, infection
Vascular disease (hypoxemia)
Drug or/and alcohol abuse
Alcohol withdrawal
Fever (childhood)
Allergies
Head trauma
Seizures: Triggering Factors
Stress
Sleep deprivation
Menses
Drug and alcohol ingestion or withdrawal
Change of seizure meds
Missed meds
Seizures: diagnostic tests
Metabolic panel
Drug toxicology
MRI is used to detect structural lesions such as focal abnormalities, cerebrovascular abnormalities, and
Seizure precaution:
Post-seizure:
Place pt on the side lying position to facilitate drainage of oral secretions (prevent aspirations).
Maintain a patent airway
The patient, on awakening, should be reoriented to the environment
If the patient becomes agitated after a seizure, use calm persuasion and gentle restraint
The patient may want to sleep for a while after the seizure so thats ok.
The
effects of maternal seizures, antiseizure medications, and genetic predisposition are all mechanisms that contribute
to possible malformation.
Valproic acid alters the effectiveness of birth control pills. The effectiveness of contraceptives is decreased by
antiseizure medications.
A series of generalized seizures that occur without full recovery of consciousness between attacks and lasting
over 30 minutes
Medical Emergency
Cumulative effects Vigorous muscular contractions impose a heavy metabolic demand and can interfere with
respirations. Some respiratory arrest at the height of each seizure produces venous congestion and hypoxia of the
brain. Repeated episodes of cerebral anoxia and edema may lead to irreversible and fetal brain damage.
Etiology
Unknown
Gliomas: 46% of all CNS tumors (Glial tissue)
Grades 1-4. 3&4 more invasive, faster growing and with poor prognosis.
Meningiomas: rarely malignant, cure with complete excision.
incidence
CT scan
MRI
Angiography
Hormone profile
Neurological exam (focal cranial nerve or motor deficits)
S&S
Headaches
Dull and aching
Increase intensity over wks
nd
2 to hydrocephalus or pressure over sensitive structures
New onset of seizures in adulthood
Hx of nausea & vomiting with headaches
Neurological S&S depending on the affected area of the brain.
Management
NSG
Spend time with patient to allow him/her to express fears and concerns
Referral to spiritual advisors, social workers, and mental health professional.
Referral to support groups and hospice care as needed
Increase ICP
Infections
Seizures
Neurological deterioration (nerve damage)
Bleeding
Fluid and electrolyte disturbances
Post-op management
Monitor ventricular drainage system (JPs)
Vital signs (Maintain temp >99.6)
Anti-seizure meds prescribed such as Dilantin and valium
Meds to reduce cerebral edema such as mannitol and Decadron
Post-op management
NSG
Assess Resp. function: (small degree of hypoxia increases cerebral ischemia)
Resp. rate and pattern
ABGs
Assess for hyperthermia (2nd to hypothalamus damage0
Neurologic assessment (a change in LOC or response to stimuli is the 1st sign of increased ICP)
Assess for seizure activity (record and report)
NSG: Post-op management
Maintain cerebral tissue perfusion
Type 2 diabetes accounts for up to 95 percent of all diabetes cases, affecting 8 percent of the population age 20
and older.
The prevalence of type 2 diabetes has tripled in the last 30 years, much of it due to an upsurge in obesity.
Diabetes afflicts 120 million people worldwide, and the World Health Organization estimates that number to
skyrocket to 300 million by 2025.
Mortality
Diabetes is the 5th leading cause of death in America.
Overall, the risk of death for people with diabetes is about 2 times that for people without diabetes.
Type 1 Diabetes
Acute onset, usually before 30
5-10 % of cases
Destruction of beta cell
Genetic predisposition, infections (virus), and autoimmune response
Production of little or no insulin
Insulin injections requirement
Type 1 Diabetes
Pathophysiology
Decreased or no production of insulin
Unchecked glucose production by the liver
Glucogenolysis & gluconeogenesis
Increased renal threshold for glucose (180-200 mg/dL). Glucosuria
Osmotic diuresis (loss of fluid and electrolytes with glucosuria)
Increased production of ketones (fat breakdown)
Type 2 Diabetes
Most common in obese people over 30
May go undetected for many years
Can be prevented or delayed with weight reduction and exercise
90-95% of cases
Controlled with oral agents, insulin, or a combination of both
Type 2 Diabetes
Pathophysiology
Insulin resistance
Less effective insulin to stimulate glucose uptake by the tissue
Less effective insulin to regulate glucose release from the liver
Impaired insulin secretion
Beta cells cannot keep up with the production of ineffective insulin, glucose levels rises
Gestational Diabetes
Any degree of glucose intolerance with its onset during pregnancy
Secretion of placental hormones causes insulin resistance
Occurs in up to 14% of pregnancies
After delivery blood sugar returns to normal, but with a risk of type 2 diabetes later in life.
Diabetes
S&S
Three Ps
Polyuria, polydipsia, and polyphagia
Fatigue and weakness
Sudden vision changes
Tingling and numbness in the hands/feet
Dry skin
Skin lesions that take long to heal
Recurrent infections
Diagnostic findings
Criteria to Dx Diabetes
Fasting plasma glucose > 126 mg/dL
Random plasma glucose > 200mg/dL on more than one occasion
Symptoms of diabetes
Diagnostic tests
Hemoglobin A1C 4 6 average glucose levels over lifetime of rbcs 120 days
(Glycosylated hemoglobin)
Long term measure of glucose control
Glucose attaching to the hemoglobin for the life of the RBC (5-7 % good control)
Urinalysis for protein, glucose, and ketones
BUN, Creat, urinalysis
Serum cholesterol and lipid profile
EKG and chest X-Ray for pulmonary and coronary pathology
Complications
Type 1 Diabetes
DKA
Type 2 Diabetes
HHNS a metabolic disorder of type 2 diabetes resulting from a relative insulin deficiency initiated by an
intercurrent illness that raises the demand for insulin; associated with polyuria and severe dehydration.
Complications
(target organ damage)
Retinopathy (eyes)
Peripheral neuropathy
Nephropathy and renal failure
Cardiovascular disease with lipid abnormalities
Erectile dysfunction
Infections
Foot and skin ulcerations
Prevention of Diabetes complications
kidney failure: 50%
(with better control of blood pressure and blood glucose levels)
Preventable
Blindness:
up to 90%
Amputation:
up to 85%
(with implementation of foot care programs that include regular examinations and patient education)
Death
disease: 40%
(with a 1% reduction in hemoglobin A1c test)
Management
Nutritional
Exercise
Monitoring
Pharmacologic therapy
Education
Nutritional management
Primary treatment for type 2 is weight reduction
Priority for a young patient with type1 is to meet the caloric requirements to enhance growth and development
Nutrition
3 meals with 3 snacks per day
Avoid simple sugars, and refined CHO
Caloric intake as follow: 30% protein, 20%fats, 50% CHO
Cholesterol 300 mg/day
Fiber 25 g/1000 calories
Food Pyramid
Diabetes
Dietary intake for small-frame woman
Choose these servings from each food groups to have 1,200 to 1,600 calories a day:
6 starches
2 milk and yogurt
3 vegetables 2 meat or meat substitute
2 fruit up to 3 fats
Diabetes: Exercise
Lower blood sugar levels by:
glucose uptake by muscles
Improves insulin utilization
Snack before or might suffer a hypoglycemic event
Snack should be low carb and sugar free
Controls lipids levels by:
high density lipoprotein
total cholesterol & triglycerides levels
Diabetes: Exercise
Teaching
Eat a snack before and after exercising to prevent hypoglycemia
Closely monitor blood sugar levels
Use proper foot wear
Inspect feet daily after exercise
Avoid exercise during periods of uncontrolled sugar levels
Diabetes
Education
Eat about the same amount of food each day.
Eat your meals and snacks at about the same times each day.
Do not skip meals or snacks.
Take your medicines at the same times each day.
Exercise at about the same times each day.
Diabetes
ABCs
A1C
Blood pressure monitoring
Cholesterol
The target LDL cholesterol for most people with diabetes is less than 100
Diabetes
Pharmacologic therapy
Insulin
Oral anti-diabetic agents
Diabetes Management
Oral antidiabetic agents (Cannot use during pregnancy) (p. 1170) (only insulin)
Sulfonylureas
Biguanides
Alpha glucosides inhibitors
Thiazolidinediones
Meglitinides
Agent
Onset
Peak
Duration
Baseline tests for lung function are recommended after the first 6 months of treatment and every year thereafter,
even if there are no pulmonary symptoms.
Peak of 30 to 90 minutes
DKA
Caused by NO insulin production (or small amounts)
Hyperglycemia
Dehydration with electrolyte loss
Acidosis
Diabetes
DKA
Markedly inadequate amounts of insulin. (without insulin there is no glucose uptake by the cells therefore the liver
produces more glucose)
Excessive production of ketones bodies (p. 1180)
insulin= lipolysis= free fatty acids + glycerol
Fatty acids convert to ketones
DKA
No insulin glucose uptake
Metabolic acidosis
DKA
S&S
Hyperglycemia = Polyuria & dehydration
Deficits of Na, PO4, Mg levels
Marked hypokalemia (serum level may appear normal due to hypovolemia and shift from the cell due to metabolic
acidosis)
Kussmaul Resp. (to compensate the metabolic acidosis)
CNS depression
Nausea, polyurea, thirst
ketonuria
DKA Treatment
Continuous administration of insulin IV
Fluids and electrolytes replacement
HHNKS (Hyperglycemic hyperosmolar Nonketotic Syndrome)
Insulin resistance (poor quality)
Hyperglycemia & hyperosmolarity
Altered level consciousness
Minimal/absent ketosis
Electrolyte imbalance (Na)
Dehydration
HHNKS
S&S
Profound dehydration
Hypotension & tachycardia
AMS (from sensory deficits to seizures)
RESPIRATORY DISORDERS
Class notes:
atelectisis: lung collapse; there is not expansion of the lungs they collapse
When the hemoglobin decrease pt has problem with respirations and carrying of oxygen
People living at high altitudes have increased hemoglobin and when coming to the city they get short of
breath, respirations problem.
Person with fever administer O2 because O2 increase with increased metabolic rate
Hyperventilate when anxious. CO2 is blown out and become alkaline. Respiratory alkalosis.
treat pneumonia with antibiotics before doing a sputum collection but it create a resistance. First you need
to get sputum then treat it.
Airbone: TB
cyanosis: central bluish color, not just the finger nail beds
COPD is irreversible. Happens through the years. Takes time to get to this point.
Asthma is reversible because you are able to treat it but is always there
Polycythemia: because there is impaired gas exchange and pt needs to produce more RBCs
Low flow oxygen in pts with COPD because they have an increased CO2 levels and more than 2 liters of
O2 would make the pt stop breathing
Lungs remain inflated, dont recoil back and interfere with gas exchange. Has barrel chest. A lot of air tap in
the lungs. Looks black
High levels of CO2 lungs not able to recoil back. The gas exchange is impaired. There is more blood flow
to the lungs to bring O2 but CO2 goes to the arterial blood and the CO2 levels remain high in the blood.
There is more pressure.
You should administer low levels of O2 because if you give high levels of O2 pt stops breathing
Kidneys try to compensate from acidosis retaining HCO3. has to be good kidneys. Body try to compensate
by reataining HCO3.
Carboxyhemoglobin: is the combination of carbon monoxide with hemoglobing and is hard to break the
bonds 25 time more harder
OXYGEN THERAPY
Oxygen: the cardiac and respiratory systems supply the body with oxygen demands
Ventilation: is the process of moving air into and out of the lungs. A major muscle is the diaphragm,
innervated by the phrenic nerve with exits the spinal cord at the 4th cervical vertebra. Any process that
changes the bronchial diameter or width affects airway resistance and alters the rate of airflow for a given
pressure gradient during respiration. Factors that determine the lungs compliance are the surface tension
of the alveoli, and the connective tissue of the lungs. Compliance is determined by examining the volume
pressure relationship in the lungs and the thorax. Increased compliance occurs if the lungs have lost their
elasticity and the thorax is over distended. Low compliance if the lungs are stiff.
Inspiration: the diaphragm and external intercostals muscles contract to create a negative pressure that
increases the size of the thorax. It is an active process, stimulated by chemical receptors in the aorta
Expiration: it is a passive process that depends on the elastic recoil properties of the lungs. Clients with
COPD lose elastic recoil of the lungs and the thorax.
Perfusion: Respiratory gases are exchange in the alveoli and the capillaries of the body tissues. (Blood
flow to the lungs and tissue). Most oxygen is transported by hemoglobin in the form of oxyhemoglobin. The
pulmonary circulation is considered a low pressure system because the systolic blood pressure in the
pulmonary artery is 20 to 30 mm Hg and the diastolic pressure is 5 to 15 mm Hg. Perfusion also is
influenced by alveolar pressure. Pulmonary artery pressure, gravity, and alveolar pressure determine the
patterns of perfusion.
Diffusion: it occurs at the alveolocapillary membrane where molecules move from areas of higher
concentration to an area of lower concentration. Increased thickness of the membrane impedes diffusion
because gases take longer to transfer across seen in pulmonary edema, infiltrates, and effusions,
emphysema, pneumothorax, and lobectomy. Is the process by which oxygen and carbon dioxide are
exchanged at the air blood interface.
Toxic inhalants: reduces the amount of available hemoglobin to transport oxygen. Carbon monoxide is the
most common toxic inhalants; this bond is 200 times greater than the one with oxygen.
Airway obstruction
Hyperventilation: excess ventilation more than required to eliminate the normal venous carbon dioxide
commonly seen in anxiety, infections, drugs, or acid base imbalances.
Acid base imbalance: the body tries to compensate for metabolic acidosis by producing a respiratory
alkalosis
COPD: inappropriate administration of excessive oxygen results in hypoventilation because this type of
client has adjusted to high levels of carbon dioxide and their stimulus to breath is a low oxygen level. If
excessive O2 is given the O2 requirement is satisfied and the stimulus to breath is negated.
Hypoventilation: ventilation is inadequate to meet the bodys demand or to eliminate sufficient carbon
dioxide commonly seen in atelectasis (collapse of the alveoli).
dysrrhythmias
cardiac arrest
convulsion
unconsciousness
death
Hypoxia: low O2 concentration at the cellular level. Causes: low hemoglobin level, high altitudes, cyanine
poisoning, pneumonia, shock and impaired circulation as in multiple ribs fractures. Can occur from either
severe pulmonary disease or from extrapulmonary disease affecting gas exchange at the cellular level. The
need for oxygen is assessed by ABGs analysis and pulse oximetry as well as by clinical evaluation.
Apprehension
Restlessness
inability to concentrate
dizziness
behavioral changes
Cyanosis: a late sign of hypoxia although is a not reliable measure of oxygen status. Peripheral cyanosis
is often a result of vasoconstriction. Is a bluish coloring of the skin, is a very late indicator of hypoxia. The
presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. A
patient with anemia rarely manifest cyanosis, and a patient with polycythemia may appear cyanotic may
appear cyanotic.
The airway is patent when the trachea, bronchi, and large airways are free from obstructions. Airway
maintenance requires adequate hydration to prevent thick, tenacious secretions. Proper coughing removes
secretions and keep the airway open.
Implementation - Humidifier: adds H2O to the gas. It helps loosen and mobilize pulmonary
secretions. Needed when O2 therapy >4 liters. Nebulizer: adds moisture or medication to the
inspired air. It improves clearance of pulmonary secretions.
OXYGEN SUPPLY
Device
Flow rate
O2 concentration
Nasal canula
1 L-6L
24%-44%
Face mask
5L-8L
40-60%
Venti mask
2-14 L
28-55%
Non-rebreather
---------
100%
When the atmosphere is 21% and you give 1 liter you increase concentration.
Respiratory system
Cough: although cough is a reflex that protects the lungs form the accumulation of secretions or
the inhalation of foreign bodies, it can also be a symptom of a number of disorders of the
pulmonary system or it can be suppressed in other disorders. It results from the irritation of the
mucous membranes anywhere in the respiratory tract. The stimulus that produces a cough may
arise form an infectious process or from an air bone irritant such as smoke, smog, dust, or a gas. A
dry, irritative cough is characteristic of an upper respiratory tract infection or viral origin. Coughing
at nighttime may herald the onset of left-sided heart failure or bronchial asthma. A cough in the
morning with sputum production may indicate bronchitis. A persistent cough may affect a patients
quality of life and may produce embarrassment, exhaustion, inability to sleep, and pain. Cough
suppressants must be used with caution, because they may relieve the cough but do no address
the cause of the cough.
o
Sputum production: a patient who coughs long enough almost invariably produces sputum.
Violent coughing causes bronchial spasm, obstruction, and further irritation of the bronchi and may
result in syncope (fainting).
Bacterial infection: a profuse amount of purulent sputum thick and yellow, green, or rustcolored.
Pulmonary edema: profuse, frothy, pink material, often welling up into the throat
Infection: foul-smelling sputum and bad breath point to the presence of a lung abscess,
bronchiectasis and infection caused by fusospirochetal or other anaerobic organisms.
Relief measures: if the sputum is too thick for the patient to expectorate, is
necessary to increase water content through adequate hydration and inhalation of
aerosolized solutions. Smoking is contraindicated because it interferes with ciliary
action, increases bronchial secretions causes inflammation. The nurse encourages
adequate oral hygiene and wise selection of food. Also, encourage the patient and
family to remove sputum cups, emesis basins and soiled tissues properly
Chest pain: chest pain associated with pulmonary conditions may be sharp, stabbing, and
intermittent. Chest pain may occur with pneumonia, pulmonary embolism and pleurisy. The nurse
assesses the quality, intensity, and radiation of pain and identifies and explores precipitating
factors and their relationship to the patients position. Analgesic medications may be effective in
relieving chest pain.
Wheezing: is often major finding in a patient with bronchocostriction or airway narrowing. Oral or
inhalant bronchodilator medications reverse wheezing in most instances
Clubbing of the fingers: is a sing of lung disease that is found in patients with chronic hypoxic
conditions, chronic lung infections, or malignancies of the lung.
Hemoptysis: expectoration of blood form the respiratory tract is a symptom of both pulmonary and
cardiac disorders. Diagnostic evaluation to determine the cause includes several studies: chest xray, chest angiography, and bronchoscopy.
Cyanosis: a bluish coloring of the skin is a very late indication of hypoxia. The presence or
absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. In the
presence of a pulmonary condition, observing the color of the tongue and lips assesses central
cyanosis. Peripheral cyanosis results from decreased blood flow to a certain area of body, as in
vasoconstriction of the nail beds or earlobes from exposure to cold.
PNEUMONIA
Pneumonitis: inflammatory process in the lung tissue that may predispose or place pt at risk for microbial
invasion.
7th leading cause of death in the United States, and in those over 65 years of age the 5th leading cause.
Pneumonia classification:
Community acquired pneumonia: (CAP) onset prior to hospitalization or within the first 48 hours of
hospitalization. The causative agents for CAP are S. pneumoniae, H. influenzae, Lengionella,
Pseudomonas aeruginosa.
o
Pneumonia caused by s. pneumoniae is the most common CAP in people younger than 60
years of age. Most prevalent in winter and spring. Lives in the upper respiratory tract. It may occur
as a lobar or bronchopneumonic form in patients of any age and may follow a recent
mycoplasma pneumonia occurs most in children and young adults and is spread by person to
person.
H. influenzae: affects elderly people and those with COPD, alcoholism, diabetes mellitus. Chest xray may reveal multibolar, patchy bronchopneumoniae or areas of consolidation (tissue that
solidifies as a result of collapsed alveoli or pneumonia).
Hospital acquired pneumonia: (HAP): onset 48 hours after admission. Also know as nosocomial
pneumonia. Occurs when at least one of the three conditions exits: host defenses are impaired, and
inoculum of organisms reaches the lower respiratory tract and overwhelms the hosts defenses. The
common organism responsible for HAP include the pathogens E. coli, h. influenzae, serratia marcescens,
p. aeruginosa, MRSA, s. pneumoniae.
o
Pseudomonal pneumonia: occurs in patients who are debilitated, those with altered mental
status, and prolonged intubation
MRSA: highly virulent. Patients with MRSA are isolated in a private room, and contact precautions
are used.
Pneumonias from E. coli, proteus, serratia are characterized by destruction of lung structure
and alveolar walls, consolidation and bacteremia.
Broncho pneumonia: pneumonia that is distributed in a patchy fashion, having originated in one or more
localized areas whitin the bronchi and extending to the adjacent surrounding lung parenchyma.
Lobar pneumonia: substantial portion of one or more lobes. An entire lobe is consolidated.
Alcoholism: alcohol suppresses the bodys reflexes, may be associated with aspiration, and
decreases white cell mobilization and ciliary motion.
COPD: condition that produces mucus or bronchial obstruction and interfere with normal lung
drainage.
Appetite is poor
Sputum is purulent
Headache
Pleuritic pain
Myalgia
Pharyngitis
Mucopurulent sputum
Consolidation CXR
The diagnosis of pneumonia is made by history, physical exam, chest x-ray, blood culture CBC
(increased WBC), sputum examination
The sputum example is obtained by having pt rinsing the mouth with water, breath deeply, cough
deeply, and expectorate the raised sputum. Also, it may be obtained from a bronchoscopy.
Pneumonia Management
o
O2 administration
Endotracheal intubation
Mechanical ventilation
The recommended duration of treatment for pneumoccocal pneumonia is 72 hours after the patient
become afebrile. Patient with most other forms of pneumonia caused by bacterial pathogens are
treated for 1 to 2 weeks after they become afebrile. Those with atypical pneumonia are usually
treated for 10 to 21 days.
Improve airway patency: remove secretions is important. The nurse encourage hydration.
Humidification may be used to loosen secretions and improve ventilation. The nurse encourages
the patient to perform an effective, directed cough. Chest physiotherapy is important. Change
position and after that encourage patient to breathe deeply and cough.
Promote fluid intake: encourage fluid intake of at least 2 liter per day, unless contraindicated
Maintain adequate nutritional intake: fluids such as Gatorade may help provide fluid, calories, and
electrolytes. In addition, IV fluids and nutrients may be administered if necessary
Promote rest
Activity intolerance
EMPHYSEMA
Impaired gas oxygen and carbon dioxide exchange results from destruction of the walls of overdistended
alveoli.
An abnormal distention of the air spaces beyond the terminal bronchioles with destruction of the walls of
the alveoli.
It is the end stage of a process that has progressed slowly for many years.
The alveolar surface area in direct cotact with the pulmonary capillaries continually decreases causing
impaired oxygen diffusion, which leads to hypoxemia.
In the later stages of the disease CO2 elimination is impaired resulting in an increased CO2 in arterial
blood ( hypercapnia) and causing respiratory acidosis.
Right sided heart failure ( cor pulmonale) is one of the complications of emphysema.
Hypercapnea:
o
Respiratory acidosis
Types of emphysema
Weight loss
Polycythemia
Central cyanosis
Occupational exposure
Air pollution
Genetic abnormalities
Cigarette smoking
Obstruction of air flow, and air becomes trapped behind the obstruction
Cough
Sputum
Dyspnea on exertion
Weight loss due to dyspnea and the use of energy and accessory muscles for respiration
Barrel chest
Anxiety
Fatigue
Perfusion
Diffusion
Ventilation
ABGs
Spirometry
CXR
Electrolyte studies
Emphysema - Complications
o
Respiratory insufficiency
Respiratory failure
Pneumonias
Atelectasis
Pneumothorax
Cor pulmonale
Emphysema - Management
o
Bullectomy
Lung transplant
Oxygen therapy
Hypoxemia: stimulates breathing, high flow of O2 will suppress the respiration drive
Promoting smoking cessation: the nurse must discuss smoking cessation strategies with the
patient. The nurse should educate the patient regarding the hazards of smoking and cessation
strategies and provide resources regarding smoking cessation, counseling and formalized
programs available in the community
Improve gas exchange and airway clearance: monitor patient for dyspnea and hypoxemia. The
nurse instructs the patient in directed or controlled coughing. Chest physiotherapy with postural
drainage, intermittent positive pressure breathing, increased fluid intake.
Promote self -care: emphasize the importance of setting goals, avoiding temperature extremes,
and modifying lifestyle.
Monitor complications: the nurse must assess for various complications of COPD such as
atelectasis, infections. Cognitive changes, increased dyspnea, tachypnea, tachycardia, hypoxemia.
The nurse monitors pulse oximetry values to assess the patients need for oxygen and administer
supplemental oxygen.
COPD
Currently COPD is the fourth leading cause of mortality and the 12th leading cause of diability in the
USA.
5th leading cause of death among men and 4th for women, 3rd cause of home care services
Chronic bronchitis
o
Disease of the airway, is defined as the presence of cough and sputum production for at least 3
months in each of two consecutive years.
Inspired irritants
Genetics
Occupational exposure
Air pollution
Activity intolerance
SOB, wheezing
Hypoxemia
Polycythemia
Cyanosis
Pulmonary hypertension
Bronchodilators
Expectorants
Chest physiotherapy
Antibiotics
Steroids (late)
Low-flow oxygen
Nutrition: counseling about meal planning and supplementation is part of the rehabiliation
process. Continual monitoring of weight and interventions as necessary are important part
of the care of patients with COPD.
Respiratory hygiene
Techniques to relieve dyspnea (pursued lips breathing): pursued lip breathing helps slow
expiration, prevent collapse of small airways, and control the rate and depth of respiration.
It also promotes relaxation, which allows patients to gain control of dyspnea and reduce
feeling of panic
ASTHMA
Asthma is chronic inflammation disease of the airways that causes airway hyperresponsivenss, mucosal
edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma
symptoms: cough, chest tightness, wheezing, and dyspnea.
Asthma differs from other obstructive lung diseases in that it is largely reversible, either
spontaneously or with treatment.
Mucous production
Bronchi obstruction
Step 2: mild persistent (symptoms more than two weeks, but less than once/day)
ASTHMA Triggers
o
Airway irritants (air pollutants, cold, heat, weather changes, strong odors or perfume, smoke)
Exercise
Medications
Gastroesophageal reflux
Attacks: night or early morning ( circadian variations that influence airway receptor thresholds)
Chest tightness
Hypoxemia
Central cyanosis
Increased eosinophils
Spirometry
ABGs
Hypoxemia
ASTHMA Complications
o
Status asthmaticus
Respiratory failure
Pneumonia
Atelectasis
Leukotriene modifiers ( are potent bronchoconstrictors that also dilate blood vessels and
alter permeability
Breath sounds
Pulse oxymetry
Vital signs
Administer fluids
noncompliance
A fracture is a break in the continuity of the bone. It happens when there is trauma to
the bone.
Complete fracture: complete cut in the bone. Require surgery most of the time. Aligning
of the bones.
Incomplete: greenstick (irregular) it doesnt go directly to the bone. The bones still attach.
Open fracture: the piece of bone comes out through the skin.
Grade 2: clean wound but larger. Not too much trauma to the skin
Stress fracture: you can hardly see it on an x-ray. Common in athletes (runners, aerobic
instructors). It is a fine fracture. Most common in lower extremities
#1 pain
Loss of function
Deformity
Pain at fractures is constant. Immobilize first the extremeties and then administer
analgesics
Prevention:
o
Vitamin D, calcium
Activity
Smoking
Alcohol intake
Goal: reduction, immobilize extremities, to regain normal strength and function through
rehab
Priority:
o
Open fracture: cover the bone with sterile dressing to prevent further
contamination with normal saline to keep moist. Then proceed with
immobilization.
Place the pt in traction. The weight should be hanging so it can pull the skin.
Complications
Compartment syndrome
Fat embolism
Thromboembolus
The difference between fracture pain and compartment syndrome pain is that
compartment syndrome pain is unrelieved.
The first thing you do is elevate the extremities to relief pressure and pain in
compartment syndrome
Do not document that the patient has dorsalis pedis pulse when there is a cast covering
the foot.
Application of cold packs and removal of dressing you need to call physicians
To test for tightness of the cast put your finger in and you should be able to put some
The nurse needs to assess the cast edges for erythema and irritation
Handle cast by grabbing it from the bottom. Do not grab it from the top. You may cause
indentation on the cast
45-70% with orthopedic surgeries develop DVT. You need to administer anticoagulant
postoperative to the pt
You need to take pt to bed, call the physician. Provide pain medication, keep pt as flat as
possible
AMPUTATION
Perform at the most distal point that will heal successfully. The site of
amputation is determined by two factors: circulation in the part and functional
uselfuness.
Contributing factors
Trauma
Congenital deformities
Chronic osteomyelitis
Malignant tumors
Advantages
Relieve symptoms
Improve function
Complications
Influencing factors:
Muscle and skin perfusion are evaluated with Doppler flow meter,
segmental BP readings, and PaO2 levels. The circulatory status of the
extremity is evaluated through physical examination and diagnostic
studies.
Management:
Nursing implementation
osteomyelitis. The nurse instructs the patient and family in wrapping the
residual limb with elastic dressings. Monitor signs and symptoms of
infection. Proper handling of limb
Prevention of contractures
FRACTURES
o
A fracture is a break in the continuity of bone and is defined according to its type
and extent.
Fractures occur when the bone is subjected to stress greater that it can absorb.
Direct blows, crushing forces, sudden twisting motions, and extreme muscle
contractions cause fractures.
Risk factors:
Tumor
Osteoporosis
Osteomyelitis
Osteomalacia
Diagnostic tools
Types of fractures
Closed fracture (simple fracture): is one that does not cause a break in
the skin.
Grade III is highly contaminated, has extensive soft tissue damage, and
is the most severe.
Stress fracture
Fine fracture line that results from indirect trauma to the bone.
Pain: the pain is continuous and increases in severity until the bone
fragments are immobilized.
Loss of function: after the fracture the extremity cannot function properly
because normal function of the muscles depends on the integrity of the
bones to which they are attached. Pain contributes to the loss of
function.
Weight bearing and physical activity makes the bone stronger and
reduces calcium loss
Avoid smoking
Management:
Emergency care:
Reduction:
Fractures complications:
Fat embolism: at the time of fracture, fat globules may diffuse into the
vascular compartment because the marrow pressure is greater than the
capillary pressure. The fat globules may occlude the small blood vessels
that supply the lungs, brain, kidneys, and other organs. The onset of
symptoms is rapid, usually within 24 to 72 hours of injury. Presenting
features include hypoxia, tachypnea, tachycardia, and pyrexia. Cerebral
disturbances are manifested by mental status changes varying from
headache and mild agitation to delirium to coma. Immediate
immobilization of fractures, minimal fracture manipulation, adequate
support for fractured bones during turning and positioning, and
maintenance of fluid and electrolyte balance are measures that may
reduce the incidence of fat emboli.
Cast care:
Nursing implementation:
Pruritus:
o
The nurse must never ignore complaints of pain from the patient in a
cast because of the possibility of problems, such as impaired tissue
perfusion or pressure ulcer formation.
Skin traction
OSTEOMYELITIS
Osteomyelitis etiology:
Open fracture
A minor trauma:
o
Diabetes
Immuno-compromised patients
The elderly
Fever
Excessive sweating
Chills
Diagnostic tools:
Management:
ORTHOPEDIC SURGERY
Surgical procedures:
Joint replacement:
o
Complications:
Nursing interventions:
Post op:
Nursing diagnostic
Hip fracture
Elderly people who have brittle bones from osteoporosis and who tend
to fall frequently have high incidence of hip fracture. The patient who
has sustained a hip fracture frequently has a comorbid condition
(cardiovascular, pulmonary, renal and endocrine). There are two major
types of hip fracture. Intracapsular fractures are fractures of the neck of
the femur. Extracapsular fractures are fractures of the trochanteric
region. Avascular necrosis is common in femoral neck fractures.
Management:
Nursing intervention:
prevent DVT. The nurse assess every 4 hours for DVT. Change
positions every 2 hours.
6/11
It affects women and men but women have more symptoms than men
There are changes in the joints. It happens over time. The joint become rough and softer
The joint becomes thinner and the bones would rub together
Joint mice: bones become spur a small moveable stone formed in or near a joint, usually a knee.
Risk factors:
By 40 years old most people have osteoarthritis pain. They are asymptomatic, asymmetrical,
redness, swelling, and tenderness at the heberdens nodes,
Patient is so stiff that takes time (usually 30 minutes or so) and a lot of activity to start the day.
They should take warm shower
Crepitus and limited ROM in weight bearing joints. Crepitus is associated with gas gangrene,
rubbing of bone fragments, air in superficial tissues, or crackles of a consolidated area of the lung
in pneumonia.
Manifestations:
Bad Weather affects joints - Rising humidity and falling barometric pressure often
aggravates the symptoms
Hip: point at groin, buttocks, medial side of the thigh or knee. Pain is poorly differentiated.
Lowering the body becomes different.
Knee; pain with motion with decreased flexion, vagus deformity, crepitus.
Spine: a lot of pain. Patient tells you lower back pain. Weakness of lower extremeties,
decreases reflexives and leg pain
Goal: control pain, disability, pt be able to perform ADL as much as possible with less assistance
Treatment:
Aquatic exercise: increase joint flexibility, muscle strengths and increase self -confidence.
Surgery:
Arthrodesis: immobilization
Arthroplasty: diseased joint components are replaced with artificial joint products
Rheumatoid arthritis
specific joints
Primary affects weight bearing
joints
body
Nursing intervention:
o
OSTEOPOROSIS (a disorder characterized by abnormal loss of bone density and deterioration of bone tissue, with
an increased risk or fracture)
o
Female 80%
types:
Risk factors:
A diet high in acid forming foods is counteracted by the body by releasing calcium from the
bone into the bloodstream
people who consumed a diet rich in alkaline forming fruits and vegetables have higher bone
mass
called the silent thief (no warning signs). No S and S until fractures occurs
Bone density test (DEXA Dual Energy Absorptiometry): an imaging technique that uses two
low-dose X-Ray beams with different levels of energy to produce a detailed image of body
components. It is used primarily to measure bone mineral density
Screening guidelines:
Treatment:
Sources: low fat dairy products, canned salmon, vegetables, almonds, cereals,
pasta, grains
Exercises: walking
Smoking cessation
Drugs:
Administer analgesia, provide periods of rest, assess ABD for constipation, provide
safe environment, teach pt about proper body mechanics
6/14
STDs
Trichomoniasis (trichomonas) a vaginal infection caused by the protozoan trichomonas vaginalis
Off-white, yellow, greenish purulent discharge, foul smelling drainage, itching, irritates vagina
The cervix looks like a strawberry. It is called strawberry cervix. Cervix has petechiae which are tiny
purple or red spots appearing on the skin as a result of tiny hemorrhages within the dermal or submucosal
layers.
Treatment:
o
If it doesnt go away. They need to call CDS because there is resistance and they would tell what to
do. They would take report.
CHLAMYDIA (a genus of microorganisms that live as intracellular parasites, have a number of properties in
common with gram negative bacterias)
Whenever you treat a patient with Chlamydia you need to treat for Gonorrhea
Pelvic inflammatory desease (PID), it is the main sign and symptom of Chlamydia
Men diagnostic test: you need to collect the first voided urine in the morning
Treatment:
o
GONORRHEA
Transmission: Direct contact with exudates via sex or neonatal passage through birth canal.
Men has discharge. Purulent urethral discharge (white, yellow, green color)
Complications:
Infertility
Ectopic pregnancy
Prostatitis
Sterility
Gonorrhea is the only STD that would cause low grade fever
Diagnostic test for males: you need to collect the first voided urine in the morning
When patient had low grade fever and discharge there is possibility that he/she has gonorrhea
Treatment:
SYPHILIS (an STD caused by the spirochete Treponema pallidum, characterized by distinct stages of effects over
a period of years.)
Has 3 stages
Invades through intact skin or mucous membranes. Goes to the lymph nodes
Secondary stage is the most contagious stage (you can get it by kissing).
Rash
Tertiary stage:
o
Appearance of soft rubber tumors, called gummas, that ulcerate and heal by scarring. Gummas
form anywhere on the surface of the body and in the eyes, liver, lungs, stomach, or reproductive
system.
Diagnosis
o
RPR (rapid plasma reagin test): an agglutination examination, the test detects two groups of
antibodies. The first is a nontreponemal reagin directed against a lipoidal agent resulting from the
Treponema pallidum infection. The second is an antibody directed against the Treponemal
pallidum organism itself.
Nursing intervention
HERPES GENITALIS (a chronic infection caused by type 2 herpes simplex virus (HSV2), usually transmitted by
sexual contact which causes painful vesicular eruptions on the skin and mucous membranes of the genitalia of
males and females.)
Person get herpes when person comes in contact with the vesicles
Complications: cervical cancer, pregnant women should have C section HSV2 may be transmitted to the
newborn by direct contact with infected tissue during natural child birth.
Treatment: Sitz bath, analgesia, Acyclovir (an antiviral agent) taken PO results in partial control of the S&S
GENITAL WARTS (a small soft, moist pink or red swelling of the genitals that becomes pedunculated and may be
painless. The growth may be solitary, or a cauliflower-like group may be present in the same area of the genitalia.)
Estrogen and progesterone receptors, are present in some breast cancers. Estrogen and progesterone
affect the rate of cells division and thus affect the risk of breast cancer by causing proliferation of breast
epithelial cells. Thus drugs that block these receptors may be useful in treating tumors with the receptors.
Tamoxifen for example.
Risk factors
o
Genetic
Alcohol
Obesity
Early menarche and late menopause (high risk). Should be late menarche and early menopause (
reduces the risk)
Screening by:
o
Breast cancer genetic screening test which is a blood test used to detect the presence of breast
cancer genes.
Breast cancer self examination: Go around the breast with your finger pads in a clock wise motion
until you reach the lymph nodes in the arm pit. Can be performed standing or in supine position.
Should be performed on the 7th day from the first day of your period. Look for drainage, size,
lumps, retraction
Diagnosis by:
o
Mammography - Breast imaging of non-palpable lesions, Baseline mammogram between the age
of 35 40 years-old
MRI
Biopsy
Treatment:
o
Drug therapy - Tamoxifen if the tumor is influenced by estrogen receptor proteins, an anti-estrogen
drug is given
Surgical
Radical mastectomy - Removal of breast, lymph nodes, pectoralis major and minor
Implantation of a prosthesis
Transverse Rectus Abdominis Myocutaneous Flap (TRAM flap): go into the abdomen,
remove muscle from the ABD and reconstruct the breast. One complication is hernia.
Chronic gastritis (may be cause by either benign or malignant ulcers of the stomach or by H. pylori)
o Bacterial or viral infection (infection by a virus is contagious)
o Excess stomach acid caused by:
heavy smoking
alcohol use
Caffeine
o improper diet such as spicy, greasy foods
o Non-steroidal anti-inflammatory meds
o Cortisone
o Stress
Intestinal Obstruction
Caused by any condition that prevents the normal flow of chyme through the intestinal lumen
Intestinal obstruction Classifications
Simple:
Mechanical blockage of the lumen by lesions, (most common fibrous adhesions). Is an intraluminal
obstruction or a mural obstruction from pressure on the intestinal wall occurs.
o Adhesions, hernias, tumors, inflammatory disorders, stenosis, strictures, abscess.
Functional:
o Failure of motility (paralytic ileus). The intestinal musculature cannot propel the contents along the
bowel. The blockage can be temporary and the result from surgery.
o Examples: amyloidosis, muscular dystrophy, endocrine disorders such as diabetes and
neurological disorders such as parkinsons disease.
Most bowel obstructions occur in small intestine. Adhesions are the most common cause of small bowel
obstruction, followed by hernias and neoplasms. Other causes can be twisting of the bowel (
intussusception, volvulus). Most obstruction in the large bowel occur in the sigmoid colon. The most
common cause are carcinoma, diverticulitis, inflammatory bowel disorders and benign tumor.
Intestinal obstruction
Distention
Shock
In the large intestine dehydration occurs more slowly than in the small intestine because the colon can
absorbs its fluids contents. Adenocarcinoid tumor account for the majority of large bowel obstructions.
Most tumors occur beyond the splenic flexure.
Diverticular Disease
Diverticular Disease
In the Western societies 30% of the population is affected at age 60, and 50% over age 80 (with
Diverticulosis)
Developing countries life expectancy is much lower, no comparison is poss.
Most cases are asymptomatic, discovered incidentally with endoscopies and barium enemas.
The exact cause of diverticulosis has not been identified. A low intake of dietary fiber is considered a
predisposing factor
Almost all patients have colonic involvement (it affects the lower part of the large intestine such as sigmoid
colon because thats where more pressure is exerted on the walls of the colon) due to higher intraluminar
pressure.
Over time the contracted colonic musculature, working against greater pressure to move small, hard stools
develop hypertrophy, thickening, rigidity, and fibrosis.
Diverticulosis looks like swiss cheese which is why you shouldnt eat seeds and peanuts.
Bowel contents can accumulate in the diverticulum ( a saclike herniation of the lining of the bowel that
extends through a defect in the muscle layer.) causing inflammation and infection
Diverticular Disease Risk Factors
Believe to arise after many years of diet deficient in fiber
Hereditary (unknown)
Abnormal connective tissue disorders (sclerodema, Marfan syndrome, etc)
Diverticular Disease
Complications
o Lower GI bleeding
o Diverticulitis (infestation of the holes in the walls of colon, swelling and possible complications such
as peritonitis)
o Fistulas (tunnelling of hole to other tissue or organs
o Constipation
Uncomplicated Diverticulosis
o More than 2/3 of patients
Sign&Symptoms
sign and symptoms of diverticulosis are relatively mild and include bowel irregularities with intervals of
diarrhea, nausea, anorexia, and bloating or abdominal distention
with repeated local inflammation of the diverticula the large bowel may narrow with fibrotic strictures,
leading to cramps, narrow stools, and increased constipation.
Weakness, fatigue, and anorexia are common symptoms
If the condition is untreated can lead to septicemia
Chronic constipation
ABD pain (left lower quadrant, tenderness and abdominal pain/ sigmoid involvement so either
diverticulosis or itis)
Fluctuating bowel habits
Mild left lower quadrant tenderness upon assessment
Mild cramps
Bloating
Uncomplicated Diverticulosis Management
High fiber diets
Fiber supplements
Fiber Containing Foods
Fruits
o Apple, raw, with skin1 medium =3.3 g
o Peach, raw1 medium = 1.5 grams
o Pear, raw1 medium = 5.1 grams
o Tangerine, raw1 medium = 1.9 grams
Diverticulitis
Diverticulitis Complications
A fistula is an abnormal connection of tissue between two organs or between an organ and the skin
E.g., diverticulitis to the bladder - feces passing thru the urine
The organs usually involved are the bladder (most common), small intestine, and skin.
Peritonitis ( abdominal pain, rigid-board like abdomen, loss of bowel sounds and signs and symptoms of
shock occur during peritonitis)
abscess formation ( tenderness, palpable mass, fever, and leukocytosis)
Bleeding ( noinflamed or slightly inflamed diverticula may erode areas adjacent to arterial branches,
causing massive rectal bleeding)
Diverticulitis Signs & Symptoms
Mild to moderate aching ABD pain (left lower quadrant)
Constipation or loose stools
N&V (nausea & vomiting)
Low grade fever and chills
Left lower quadrant tenderness with palpation (guarding is 10 on pain scale of 0 to 10)
(+) stool occult blood (area is irritated and could have a perforation, wbc count in the 20 & 30, fever)
Perforation: Systemic presentation (which could lead to peritonitis and systemic infection such as sepsis)
Leukocytosis
Test questions you do not do a colonoscopy on someone with suspected diverticulitis because the area is so
inflamed and damaged and the scope can perferate the wall.
Diverticulitis Diagnostic tools
KUB X-Ray: Free ABD air represents perforation (there is serous fluid and no air or gas in the peritoneum)
Colonoscopy and barium enema (avoid during the initial stage because of the risk of perforation)
ABD CT Scan (Abscess formation, wall thickening, inflammation obstruction, etc)
CT scan is the diagnostic test of choice if the suspected diagnosis is diverticulitis; it can also reveal
abscesses.
Laboratory tests that assist in diagnosis include a complete blood cell count, revealing and elevated WBC
(5000-10,000 normal values)
Diverticulitis Management
Mild symptoms: outpatient with clear liquids diet and broad spectrum ABTs. (No laxatives, no fleets
enemas and pt needs to go on liquid diet.)
Antibiotics are prescribed for 7-10 days
The liquid diet is recommended because increase stool volume, decrease colonic transit time, and reduce
intraluminal pressure.
Pts with fever, increased pain and unable to tolerate PO diet needs hospitalization.
Severe cases, immuno-suppressed, elderly, and those with co-morbid disease require acute hospitalization
Diverticulitis Hospital patients
NPO No eating
IVF ( intravenous fluid)
NGT placement (ileus)
IV ABTs (to cover anaerobic and gram negative bacteria) for 7-10 days
An opiod is prescribed (DEMEROL) for pain relief. Morphine is contraindicated because increase
intraluminar pressure in the colon.
Diverticulitis Surgical Management
20-30% of the 1/3 of cases need surgical intervention
Required for large abscesses and peritonitis
1sr stage diseased segment of the colon is removed. Proximal colon brought out to form a temporary
colostomy. This is done through traditional surgical or laparoscopically.
2nd stage: After inflammation and infection subsides the colon can be reconnected electively.
The double barrel temporary colostomy is then reanastomosed in a later procedure
Diverticulitis Prognosis
Reoccurs in 1/3 of patients which warrant elective surgical resection.
Assessment: ask the patient about the onset and duration of pain. Past and present elimination patterns,
review dietary habits, history of constipation with periods of diarrhea, tenesmus, abdominal bloating, and
distention. Auscultate bowel sounds, palpate four quadrants, and inspect stools for mucus, blood, pus.
Temperature, BP is monitored.
Diverticulitis Nursing Diagnosis
Altered nutrition: Less than body requirement R/T dietary restrictions, N&D, and ABD pain (someone who is
NPO)
Pain R/T intestinal inflammatory process, pt unable to move bowels for days, etc.
Constipation R/T inadequate dietary intake of fiber
Impaired skin integrity (perianal) R/T diarrhea (extremely acidic damages the skin)
Infection, risk for (even if the infection is self evident)
Goal: attainment and maintenance of normal elimination patterns, pain relief, and absence of complications
Diverticulitis Nursing Implementation
1. Nutrition:
Recommend daily intake of fluid at least 2 l per day (if pt doesnt have renal or cardiac problems)
Dietary consult
Daily weight
Monitor lab results (albumin) normal values are adult/elderly: 3.5-5 g/dl or 35-50 g/L
Offer frequent small meals (6 per day, snacks and shakes like glucerna & jevity)
Monitor Parenteral alimentation
Diverticulitis (NSG)
2. Pain:
Provide optimal pain relief with prescribed analgesics (opiods like Demerol)
Assess effectiveness of analgesics 30min after administration
Teach non-invasive pain relief methods; relaxation techniques
Assess location, intensity, aggravating & alleviating factors, radiation, onset
Diverticulitis (NSG)
3. Constipation:
Teach diet high in fiber: fresh fruits with skin, whole grain breads and cereals, vegetables,
Encourage increase fluid intake (8-10 glasses of H2O/day)
Establish a regular time for evacuation
Explain the hazard of enema and laxative use
Increase ambulation and level of activity
Diverticulitis (NSG)
4. Skin integrity:
Use of skin protecting cream
Keep skin clean and dry
Consult with dietitian: increase protein and CHO intake
Monitor serum albumin level (3.5-5)
Monitor skin integrity, turn & reposition q2h
Protect bony prominence areas
Refer to wound team
Diverticulitis (NSG)
5. Infection:
Assess for S&S of infections, especially temp.
Assess ABD for distention & bowel sounds
Administer ABTs as ordered
Administer IVF as ordered
Obtain specimen to lab ad culture for C&S
CAD
Coronary Artery Disease
Overall ratio is 4:1 (men vs. women) but before age 40 the ratio is 8:1
Abnormal lipid metabolism and/or excessive intake of cholesterol and saturated fats.
Fibrous cap formation over the stable lesion which becomes calcified
Family history
Age
Gender
Metabolic syndrome
HTN
Diabetes mellitus
Physical inactivity
Cigarette smoking
Ratios
Smoking cessation
Treatment of dyslipidemia
Anti-platelet therapy
ASA 81-325mg/daily
ACE inhibitors
Myocardial Infarction
Coronary spasm
Polycythemia vera
50% men and 63% of women with sudden cardiac death, had no previous symptoms.
Myocardial Infarction
Risk Factors:
CAD
Smoking
Diabetes Mellitus
HTN
Hyperlipedemia
Aging
Personality type A
Myocardial Infarction
Diagnostic tools:
EKG
Cardiac Enzymes
LDH
Troponin
Thallium scan
CXR
Myocardial Infarction S&S
Pain radiation
N/V
Diaphoresis
SOB
Apprehensive
Ashen color
Hypotension
Tachycardia
New murmurs
MI - Medical Management
M Morphine Sulphate
O Oxygen Therapy
N Nitroglycerin
A Aspirin
MI - Medical Management
Meds
O2 demand
O2
Thrombolytics
Analgesics
ACE inhibitors
Beta-Blockers
MI - NSG:
Relieve pain
Reduce anxiety
Hypertension (HTN)
Hypertension
Pressure exerted on the wall of the arteries during diastole and systole.
Influencing factors:
cardiac output, distension of the arteries, blood volume, blood velocity, and blood viscosity.
Hypertension
Secondary hypertension:
o Known etiology:
Chronic kidney disease
Coartation of the aorta
Thyroid/parathyroid disease
Chronic steroid therapy and Cushing syndrome.
others
Regulating Systems:
Renin-angiotensin-aldosterone System
Peripheral resistance
Insulin resistance
Hypertension Classifications:
Pre-hypertension:
o SBP 120-139 & DBP 80-89 mm Hg
Stage 1 HTN:
o SBP 140-159 & DBP 90-99 mm Hg
Stage 2 HTN:
Obesity
Physical inactivity
ETOH
African American
Family history
Hypertension Target organ damage:
Angina
Heart failure
CVA
Kidney failure
Retinopathy
Hypertension: S&S
Retinal changes
Hypertension: MEDS
Diuretics
- blockers
ACE inhibitors
Angiotensin 2 antagonists
vasodilators
Hypertension: NSG
Assist in developing a health maintenance plan (set realistic goals) (smoking, exercise, diet, and stress)
Hypertension:
HTN animation
Situation in which blood pressure must be lowered within few hours. (Brunner & Suddarth)
Close Hemodynamic monitoring is required, most patients are admitted to intensive care units.
Life threatening side effect of medications is a sudden drop in blood pressure which requires immediate
action to restore blood pressure to allow appropriate tissue perfusion.
o SBP>90 mm Hg
Inability of the heart to pump sufficient blood to meet the needs of the tissues of oxygen and nutrients.
Fluid overload and inadequate tissue perfusion.
Heart abnormality that leads to decreased systole and/or diastole (contraction and/or filling)
CHF Etiology:
Incidence increases with age. Most common cause of hops. of people older than age 65
(p. 789)
Increase head of the bed 8-10 inches with the use of pillows of blocks under the bed with arms
supported by pillows.
Echocardiogram (EF)
Cardiac cath
CXR
ECG
Labs:
Electrolytes
BNP
TSH
CBC
U/A
CHF: Diagnostic tools
BNP
Goal:
o
Meds:
o
o
o
o
o
CHF: NSG
V/S
Daily weights
Educate to avoid excessive fluid intake (fluid restriction), smoking cessation, and ETOH.
Accurate I&O
Auscultate lungs
Angina Pectoris
Angina Pectoris
Result of insufficient blood flow R/T significant obstruction of a major coronary artery.
Arteriosclerosis
o Thickening, hardening, loss of elasticity, and calcification of the arterial wall.
Atherosclerosis
o Yellowish plaque of lipids and cellular debris in the inner layer of the arterial wall.
Angina Pectoris Influencing Factors:
Eating a heavy meal: blood flow to the mesenteric area which blood supply to the coronaries.
Surgery:
o PTCA
o CABG
o Intra-coronary stents.
Angina Pectoris Medications:
Nitroglycerin:
Dilates veins and arteries (systemic vasodilator)
myocardial oxygen consumption
coronary blood flow
preload
Beta adrenergic blocking agents:
myocardial Oxygen consumption by blocking -adrenergic sympathetic stimulation
BP, myocardial stimulation
Use cautiously with Asthma and Diabetes (mask hypoglycemia symptoms)
Calcium Channel Blockers
o SA node automaticity and/or AV node conduction
o Relax blood vessels. Prevent/treat vasospasm
o Dilates smooth muscle wall of coronary arteries
o Workload of the heart
Anti-platelets & anticoagulant
ASA
Plavix
Ticlid
Heparin
Angina Pectoris Oxygen administration:
Increase oxygen delivered to the myocardium to decrease pain
EKG
EKG - Properties of Cardiac Cells
Automaticity:
o Ability to spontaneously generate and discharge an electrical impulse
Excitability:
o Ability to respond to an electrical impulse
Conductivity:
o Ability to transmit an electrical impulse from one cell to another
Contractility
o Ability to shorten and lengthen its muscle fibers
Extensibility:
o The ability of the cell to stretch.
EKG - Electrical Impulses
Depolarization
o Contraction of the cardiac cell (electrical activation)
o systole
Repolarization
Relaxation of the myocardial cell (recovery)
Diastole
Depolarization of one electrical cell stimulates adjacent cells causing a propagation of the electrical
stimulus producing an electrical current.
EKG
Records the electrical current of the cardiac cells as waves in a paper/strip.
EKG - Electrical Conduction System
SA node (sinoatrail)
o Called the pacemaker cells because they poses the highest level of automaticity.
o Discharge impulses at a rate of 60-100 beats/min
AV node (atrioventricular)
o Escape pacemaker. Discharge impulses at a rate of 40-60 beats/min
Bundle of His (R + L branches)
Purkinje fibers
o Escape pacemaker. Discharge impulses at a rate of 30-40 beats/min
P wave: (atrial contraction)
o Atrial depolarization. Spread of the impulse from the SA node through the atria.
QRS wave: (ventricular contraction)
o Ventricular depolarization. Spread of the impulse through the ventricles.
T wave:
o Later phase of ventricular Repolarization
One heart beat = P-QRS-T sequence
Type 1:
o 10-15% of patients.
o Plaque formation limited to the aorta and the common iliac arteries.
o Higher incidence among young adults (ages 40-55)- heavy smokers + hyperlipidemia.
Type2:
o 25% of patients
o Involves the aorta, the common iliac artery, and external iliac artery.
Type 3:
o Most common, affects 60-70% of patients.
o Affects the aorta, iliac, femoral, popliteal, and the tibial arteries.
Peripheral Vascular Disease S&S
Claudication
Rest pain
Gangrene
Hair loss
Dependent Rubor
Claudication
Pain and numbness or weakness in the calves, thighs, or buttocks produced by exercise and relieve after a
few minutes of rest.
Reproducible pain
Ischemic Rest Pain
Pain at rest, nocturnal located across the dorsum of the foot at the metatarsal heads.
Impending gangrene.
PVD - Medical Management: Meds
Propionyl-L-carnitine 1g BID
o Increases walk distance
Stent angioplasty
Thomboendarterectomy
Arterial bypass
Hyperbaric oxygen
PVD - Surgery Complications
Percutaneous procedures:
Distal emboli
Contrast nephropathy
Puncture site complications:
Hematoma
Pseudo aneurysm
Arteriovenous fistulas
Retroperitoneal hemorrhage
Occlusion
PVD - Prognosis
Emboli
Thrombus
Trauma
PVD - Acute Limb Ischemia
Characteristics of acute ischemia (6 Ps)
Pallor
Pulselessness
Poikilothermia
Paralysis
PVD - Arterial Embolism
Emergent embolectomy
Endarterectomy
PVD - Arterial Embolism: Complications
Renal failure
Amputations
PVD - Arterial Embolism: Prognosis
Trauma
Polycythemia
Dehydration
Hypercoagulopathy
Cardiac failure
Stroke
Ventilatory support
Paralysis
Lengthy surgery
It is estimated that about 20% of patients with new DVT have an underlying malignancy.
Others:
Advance age
A blood group
Obesity
Multiple pregnancies
Oral contraceptives
IBS
Dull ache
Tightness
Tachycardia
Duplex ultrasound
PVD - DVT: Complications
Pulmonary Embolism
Varicose veins
Anticoagulation with Heparin to reach a goal of PTT (partial thromboplastin time) of 1.5-2 times normal).
Arterial Occlusion
DVT (venous)
Hx of CHF, recent Sx, trauma, neoplasia, oral contraceptives, and/or prolonged inactivity.