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diverticulitis, cirrhosis, hepatitis, diabetes DKA- HHNS transplants, DIC, HIV/AIDS, Blood transfusions, CVA, burns, terrorism, breast- ovarian and testicular cancer General review for final exam: 1.Delegation: CNA No assessment, no meds, no evaluation, no teaching, no monitoring, no (wound) irrigations, no parenteral feedings, tube feedings or colostomy irrigations, no feeding aspiration high risk clients, no dressing changes Yes can do tasks example, stool for occult, UA, 24 hour urine collection Vitals LPN No teaching, No evaluation, no IV meds, no unstable patients that need ongoing evaluation YES all other meds, wound irrigation, dressing change, cath placement 2. Priority: Assess ABCs first, (which patient do you see first) are they Hemorrhaging.dysphagia. LOC alterations K+ alterations. unstable labs. unstable heart lungs circulation breathing no one but RN can do this assessment, monitoring major systems at risk.. emergent or major change in conditions, need IV meds asapdiabetic crisis.s&sshock.major pain and u are doing something u can pass off blood sugar test and meal is arriving..signs of internal bleed..02 saturation failing..complex treatments like chest tubes at risk..IV pump problemswidening pulse pressurelowbp and high pulse..perfusion failure signslabs cva risk, hemorrhage risk, stroke risk, post op cardio surgery needs frequent assess

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Reportable incidents: major errors that harm life or limb damage and if visitors have emergency, report never goes in chart, nursing notes only to higher ups internally

3.Respiratory ----------------------- a. ABGs -ph 7.35-7.45 Paco2 35-45 mmHg (acid) hc03- 22-26 mEq/L (base) Pa02 80-100 mmHg Sa02 > 93% capillary hemoglobin saturation b. Chest Tubes pg. 342
Purpose remove air or fluid from pleural space Inserted in ED, OR, bedside- need informed consent Correct placement confirmed by chest x-ray Pt. should cough turn and deep breathe often to remove unwanted air and fluids and reexepand the lung REPORT more than 100mL/hour drainage, change to bright red drainage, sudden increase in drainage. ( f suction is too vigorous lung tissue can be harmed) Air removal anterior 2nd intercostal space Fluid removal posterior 8th or 9th intercostal space Sutured/connected to drainage tubing 1. collection chamber (holds up to 2000 ml) REPORT over 100mL/hr , sudden bright red or major increase in drainage 2. water-seal chamber (contains 2 cm of H2O) tip of tube under water prevents air from "backflowing" to pleural space. Should fluctuate with breathing. If Bubbling in water seal chamber increases or is vigorous and continuous it may be an air leak Normal intermittent, gentle bubbling is normal/expected as the air is being removed for treatment . If flux stops
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check for obstruction of the tube then check to see if lung has reexpanded and pneumothorax is resolved. 3. Suction control chamber applies controlled suction to chest drainage system (20 cm of water) Level of water controls degreee of suction. Gentle bubbling is expected finding. Care of patient (smeltzer 667-669) Tubing straight, below chest level connections tight If no fluctuation after insertion check for kinks in tubing or clots. Never milk or clamp without doctors order NURSING CARE Assess drainage Check tubing/drainage Observe for tidaling Breath sounds Pulse oximetry Positioning C & DB medicate if needed CHEST TUBE REMOVAL X-ray evaluates Suction discontinued for 24 hours with tubes still in Pre-medicate Sutures d/c Deep breath, exhale, bear down, (Valsalvas) remove Airtight dressing Re-assess

c. ARDS ( from ppt) ACUTE RESPIRATORY DISTRESS SYNDROME

(ARDS) pg. 443

Sudden, progressive ARF alveolar capillary membrane becomes damaged and intravascular fluid floods in "drowning " in your own lungs S&S Severe dyspnea, hypoxemia that does not improve with^O2 levels, lung compliance reduced, pulmonary infiltrates Most common cause - sepsis Pathophysiological changes 1. injury occurs 24-48 hrs. after lung insult: interstitial and alveolar edema, mild hypoxemia> resp alkalosis, lungs become less compliant, Initially dyspnea and tachypnea cough, restlessness, scattered crackles 2. proliferative phase 1-2 weeks after initial insult: lung compliance decreases, widespread fibrosis, ^fluid in lungs, decreased lung compliance, retractions, tachycardia 3. fibrotic 2-3 weeks after initial insult: gas exchange plummeting, pulmonary HTN, changes in LOC, crackles, rhonchi, hypoxemia, hypercapnia

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ARDS TREATMENT High flow systems high O2 concentrations examples: non rebreather, venturi, Common intubation & Mechanical ventilation to support alveolar ventilation Tidal volume volume of air inspired with each breath (if setting too low will cause hypoventilation) (if setting too high can cause lung damage) N/C or simple facemask typically is inadequate

d. Pneumothorax- collapse of space around the lung requiring thoracentesis or chest tubes pt. should inhale deeply to re-expand the lung
Air in the pleural space >Partial or complete collapse of the lung> Closed (blebs)/Open (invasive, trauma) >Tension pneumothorax rapid accumulation of air causes tension on heart and great vessels, medical emergency>Hemothorax blood in pleural space Causes trauma, anticoagulant therapy, pulmonary embolus, lung malignancy Clinical manifestations tachycardia, dyspnea, air hunger, oxygen desaturation, decreased or no breath sounds THORACENTESIS Insertion of large bore needle through chest wall into pleural space > Obtain specimen > Diagnostic evaluation > Removal of fluid > Instillation of medication

e. Thoracotomy care of the patient with a: surgical incision into the chest wall. Used to remove cancerous tumor from lung, remove a lobe or lung. Preop prep pt. to wake with chest tubes. Postop lung sounds important, monitor c tube drainage, give 02, ROM of operative shoulder, pulse ox, vitals. If pericardiocentesis fails this is an emergency 4. Cardiac ---------

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a. Beta blockers contraindicated in those with asthma it disables the sympathetic mechanism and thus blocks the dilating action of the airways; it lowers blood pressure b. review normal rhythm and the most common dysrhythmias (sinus, sinus tach, v tach, v-fib), myoglobin elevates 30-60 min/ troponin elevates 1 hour c. CABG ( graft in a coronary artery with a piece of venous or arterial blood vesses from client) review post op care 1. careful assessment for anginal pain which indicates graft failure 2. Will be on vent 6-24 hours 3. Will have chest tubes >100150 mL/hr is reportable 4. May have temporary pacemaker 5. On IV and Foley Fluids restricted 1500-2000 mL for mgt of edema 5. Prevent hypotension which can cause graft collapse 6. Prevent hypertension which can cause graft leak and bleeding 7. Keep temp stable at 96.8-98.6 prevent shivering 8. Replace K as needed to prevent dysrhythmia 9.beware cardiac tamponade- s&s sudden stop of CTube drainage/ JVD but clear lungs/ pulsus paradoxus 10. Monitor vitals, LOC and peripheral perfusion, lungs, heart monitoring. 11. A rise in temperature and WBC after 3-4 days indicates infection. 12. Slow return to activities without destabilizing from baseline- stop activity if blood pressure drop >20mmHG or pulse > 10bpm d. permanent pacemaker-teaching for patient with: the function is to maintain heart rate with electrical stim when patients own pacemaker fails to provide a perfusing rhythm. Can be set on demand or fixed rate. Spike preceeds the chamber paced on a EKG strip. 1. After surgical placement limit movement on operative side so you dont displace the leads. Leads can be single or dula chambered. Biventricular pacing is for moderate to sever heart failure to improve CO. Can be reprogrammed non invasively. Lithium batteries 10 year life. Nuclear batt 20 year life. Teach signs of batt failure. Report fever, signs of infection at insertion site, dizzy weak fatigue SOB chest pain or edema in ankles legs. Keep a
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pacemaker id card and wear medic alert braclet. Take daily pulse and joural it. No contact sports. Security detectors may be set off by device at airport or in stores. Dont use elec devices right over op site use& carry cell phone on opposite side. A "capture" is a spike followed by the desired chamber depolarizing. e. pericardiocentesis- (saunders 872)nursing actions with: Assess pain for pericarditis indicators: chest pain is anterior, radiates to left side neck shoulder back pain is grating, increased on inspiration, with mvmt, with cough, swallow may breathe shallowly. Pain is relieved with forward leaning position and worse in supine. Assess..pericardial friction rub Fever chills Fatigue malaise

Elevated WBC EKG changes A-fib and ST seg elevation Place in high fowlers or leaning forward, give pain meds( NSAIDS or c-steroids) Assess for friction rub, check blood culture results for organism, give appropriate antibiotics if bacterial cause, if the problem is chronic & constrictive give diuretics and digoxin, possible pericardectomy, Procedure: ask is pt. on ASA or thinners does doc want them to stop prior? , sedation , local anesthetic, pressure to the site after needle comes out, careful insertion by PCP, nurse monitors response of all surrounding organs & loc as lung kidney heart can be pierced, During procedure Q5 monitor & record ekg changes, vitals, pulmo art pressure, monitor comfort admin analgesics sedatives. Monitor for hypotension, cardiac arrest, pneumothorax liver laceration Post procedure: recurrence of tamponade , have defib nearby, atropine lidocaine epinephrine, frequent vitals, IV access, vital monitoring equip, get 12 lead ekg, cxr, monitor pericardial drainage Cardiac Tamponade results from pericardial effusion and causes dangerously low CO which must be managed with IV fluids, CXR, pericardiocentesis ASSESS : s&s =jvd+ clear lungs, low CO, narrow pulse pressure, heart sounds muffled, SOB
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Pericarditis is inflammation a/o infection around the heart of the pericardium, friction rub may come from an AMI, increased pressure on the heart can lead to cardiac tamponade and HF. The fluid accumulates in the sac tx is pericardiocentesis..

5. GI ---------------------------------------a. diverticulitis inflamed diverticulum pouches of intestinal walls, bleed, can burst Diverticulitis
50% of population have it by age 80 its a dilation or outpouching in intestianal wall Probably related to a low-fiber diet Tent to retain stool and bacteria can develop infection Exacerbation NPO to rest the bowel NG tube to drain out green bile Risk of peritonitis if the diverticulum ruptures So . . assess for rebound tenderness.

b. cirrhosis inflammation and necrosis of liver cells creates portal hypertension, healthy tissue is replaced with fibrous tissue chronic liver dysfunction can result. Causes include alcoholism, bile duct obstruction, R side heart failure, hepatoxins,
Cirrhosis Chronic, progressive degeneration and destruction of the liver cells Lobules are irregular size and shape Poor vascular flow, cells die 7

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Most common cause is alcoholism 95% of the time GI nausea vomiting bloated diarrhea fever enlarged liver jaundice Spidery angiomas Portal hypertension, palmar erythema that blanches, pruritus, from bile salts accums under skin Fetor hepaticus- breath is mousy Thrombocytopenia low platlets Leukopenia low WBperipheral neuropathy Folic acid and B12 might help with neuropathy as they are usually

c. hepatitis liver acute inflammation, edema, blood supply decreased, necrosis, portal hypertension, viral, ANV abd pain, jaundice, high risk for infection can cause liver failure Hepatitis
Means inflammation of the liver ABCDE different things causing it Bilirubin will be elevated in all cases Standard precautions are substantial protection Hep A is an RNA virus anal oral transfer Hep B DNA virus blood secretions has vaccine If person has antiHB that person has immunity to it should build up once you get the vaccine, but it does not always take so titer it to find out if it's working at all and maybe get it again. No cure adequate nutrition to regenerate hepatocytes and plenty of rest. If you get HEP B dont drink alcohol for at least 1 year, careful with liver metabolized meds, usu condoms, test and vaccinate family members HEP C sex tattoos piercing IV drugs transfusion. Interferon and ribavibrin is a treatment but not a cure. Many Hep C patients also have HIV due to high risk behaviors HEP D RNA anal oral poor sanitation is D is helper of HEP B that joins in the fun 8

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Jaundice is bilirubin buildup it means liver is not functioning properly but does not prove hepatitis In black patient look in hard palate of mouth eyes palms soles of feet IN All hepatitis Inflamed liver tissue Hepatocytes broken down Kuppfer cells proliferate and enlarge Bile flow can be interrupted Clay colored stools appear when liver can not excrete bilirubin Preicteric phase 1-21 days anorexia, malaise, RUQ pain, GI symptoms, HA, diarrhea Ictereric phase Jaundice as bilirubin diffueseinto tissues 2-4 weeks post icteric tired, fatigue malaise, enlarged liver 2-4 months can go on to become chronic hepatitis or cirrosis or liver failure or hepatocellular carcinoma

d. Diabetic Humalog (fastest with meals simulates pancreas must eat 40% of food onset 5-15
minutes tray in front of them or have started eating) Glucose lows and highs cause earlier complications neuropathy retinopathy etc. in patients at younger ages important to stay in range maintain it. If patient is HUNGRY probably hypoglycemic, loc changes, mentation changes, #1 check glucose 9

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#2 fruit juice alternative -10-15 CHO # 3 check vitals # 4 high carb high protein snack #5 document Hypoglycemia <70 confused irratible sweaty shaky "drunk" hungry

e. DKA, acidosis is key component here usually type I diabetics ketones in urine, dehydration, Depleted electrolytes NA K Cl Ph. Mg. Tachycardia Abd pain
DRY mouth Kussmauls for acidosis Ketone fruity breath PCO2 low HCo3 low Combative, physical ACTION #1 IV fluids (0.9% NS isotonic or 0.45% hypotonic not glucose or hypertonic) #2 K for hypokalemia #3 EKG 10

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#4 Insulin bolus or infusion IV Signs of correction: A&O x4 Acting appropriate Glucose normal but NOT too low

f. HHNS usually type II, no acidosis but extremely high blood glucose levels, dehydration HHNS
Just enough insulin to prevent acidosis/ketosis Type II Osmotic diuresis Weakness 3POLYS- thirsty peeing and hungry Common cause infection illness Older with comorbidities Hypovolemic NURSE ACTION #1 LARGE bore IV for fluid replacement #2 regular insulin #3 monitor e-lytes #4 cardiac monitoring Older so be careful not to give fluid overload lungs kidneys heart are at risk 11

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When you hit 300-235 mg/dL glucose call the doctor for orders dangerous to put them in hypoglycemia and hard to bring back up. At this point doctor may even add in some glucose as fluid restoration continues.

Intensive insulin therapy 3 or more daily injections plus long acting Lantus Type I Meal coverage Glucose checks 4-6x/day Regular onset 30 min peaks 2-4 hrs

6.Transplants------------------watch for rejection S&S acute etc. Organ transplantation Kidney and bone marrow needs extensive matching If develop fever and decreased urine output CALL THE PCP= infection and failed function Transplant rejection The best drugs are: Calcineurin inhibitors: Cyclosporine Prograf Inhibitors- most effectiveHyperacute rejection minutes to hours after transplantation, no treatment, transplanted organ removed Acute rejection days to months after, T lymphocytes attack foreign organ, reversible with additional immunosuppresive, corticosteroids
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Fever, malaise, ^WBC, HTN, graft tenderness, deteriorating renal function/ organ may be enlarged Chronic occurs over months or years and is irreversible, no definitive therapy, treatment supportive Transplantation - treatment Immunosuppresives prevent rejection Combinations work better Calcineurin inhibitors most effective Corticosteroids Mycophenolate lymphocyte specific inhibitor Sirolimus renal transplant

7.DIC------------------clotting all over and causing organ necrosis Disseminated intravascular coagulation Bleeding and thrombotic disorder (abnormal clotting) Accelerated clotting Decreases in clotting factors- used up super fast and then depleted Uncontrollable hemorrhage Not a disease abnormal response of the normal clotting cascade Most often complication of sepsis - pg. 552 DIC
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PT and PTT prolonged, increased Fibrinogen level lower (^risk of bleeding) Platelet count decreased (platelets used up because clotting and bleeding occurring simultaneously) WBC ^ - can be with infection not DIC Clinical manifestations Bleeding/clotting Oozing blood (from IVs, venipunctures) Hematomas Occult hemorrhage Hemoptysis Tachycardia/hypotension GI bleed Hematuria Vision changes purpura Treatment Diagnose quickly Stabilize the patient (O2, volume replacement) Treat underlying condition Blood products (FFP, platelets)
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Heparin or LMWH

DIC Bleeding and thrombotic disorder Accelerated clotting low clotting factors Can develop uncontrollable hemorrhage Accellerated clotting Decrease in clotting factors Not a disease a response to something stims clotting cascade Usu complication of sepsis Pts. are critically ill and elderly DIC development means move to ICU now Hematomas Raised bruises Occult hemorrhage Hemoptysis Tachycardia and hyotension body inate response to bleeding Hematuria GI bleeding Oozing from venipunctures

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Vision change Purpera spots purple DIAGNOSE and TREAT QUICKLY to stabalize Treat underlying condition Blood FFP platelets PRBCs Heparin and Lovenox ( low molec lb) for the clotting problem Find a balance to deal with bleed and clotting issues Septic, elders mothers during pregnancy and delivery Normal platelet 150-400,000 low is thrombocytopenia Normal RBC 4.5-5.6 million WBC 5-10,000 HGB 12-16 (know for lab exam)

8.HIV/AIDS--------------------stages, treatments, precautions

Human Immunodeficiency Virus Transmission body fluids (blood, semen, vaginal secretions, and breast milk)
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Large amount of virus must enter body of susceptible host Viral load (amount of viruses) important Not spread casually

Pg. 544, Sole HIV Sexual transmission Unprotected sexual contact Most cases men who have sex with men Greater for the partner that receives semen

Blood needle sticks (wash needle stick, bleed) puncture wounds HIV Perinatal transmission from HIV infected mother

Pathophysiology RNA to DNA (retroviruses) only can replicate if living inside a cell Clinical manifestations

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Acute infection flulike symptoms, fever swollen lymph glands, sore throat, HA, malaise, diarrhea (may test negative at first) These symptoms occur 1-3 weeks after initial infection - high viral load, CD4 T cell count falls temp.

Clinical manifestations Early chronic infection interval between untreated HIV and AIDS 11 years CD4 T above 500 Fatigue, HA, low grade fever, night sweats, persistent generalized lymphadenopathy

Not realized infected so may continue high risk behavior Clinical manifestations Intermediate chronic infection CD4 T count falls to 200-500, viral load increased, symptoms worse. Oropharyngeal candidiasis, shingles, Kaposi sarcoma, oral hairy leukoplakia (painless white raised lesions on lateral aspect of tongue)

Treat with an antifungal swish and swallow med Clinical manifestations Late Chronic diagnosis of AIDS not made until: (develops at least one) CD4 T cell count below 200 cells
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Development of opportunistic infections Development of opportunistic cancers Wasting syndrome AIDS dementia complex HIV/AIDS Opportunistic diseases are slow to develop and progress HIV encephalopathy can develop Risk for Injury HIV 12:40 body fluid transmission A large amount of virus has to enter body of susceptible host and then there has to be a viral load so amount of virus is important- it is not spread casually Standard precautions against all fluids/secretions same as general patient Double glove wont help a needle stick Precautions Any time you will pierce body, IM sub Q, glucose, nasal oral eyes urine drains dressing change mask for coughing sneezing IV with blood oozing blood backflow be cautious Wash your hands best way to protect yourself during bath never know what type of body fluids you'll encounter if runny nose coughing peri area Foley stoma outputs Bed changes cause you dont know whats on sheets
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Assessments typically not unless vomiting, outputs secretions Stool urine No need when you hang a new IV bag Sex semen recipient higher risk then other Needle sticks wash and squeeze it out Perinatal transmission RNA virus that goes to DNA virus Can only replicate if its inside a living cell Acute /early/chronic Count above 500 Infection Early initially: flulike symptoms 1-3 weeks after initial infection Fever swollen lymph nodes diarrhea sore throat HA malaise Will test negative at first Have high viral load T cell count falls temporarily Usually 11 years until AIDS is full blown When T-cells are at about 500 not yet considered fatigue headache fever low grade night sweats swollen glands may not realize for a long time that they are infected

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Intermediate 200-500 T cell count symptoms worse thrush shingles karposis sarcoma oral hairy leukoplakia white lesions on tongue need treatment with antifungal swish and swallow Won't want to eat its painful Late chronic AIDS diagnosis T cell below 200 Opportunistic infection Cancer wasting syndrome Dementia Many meds are available more being developed but very expensive Encephalopathy risk of injury

9. Blood transfusions---------------------watch for rejection response, steps of giving blood and steps to stop in case of rejection 10. CVA----------------------------------- thrombus in the brain LOC changes, dizzy, confused CVA
Stroke brain attack Ischemia to part of brain Or hemorrhage HTN is # 1 highest risk Higher risk in males HTN CHF COPD migraines a. fib smoking diabetes hyperlipidemia arthrosclerosis STROKE CVA 85 % ischemic clot cuts supply of blood to brain tissue 15 % hemorrhagic usually from un controlled HTN

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RIGHT STROKE- Risk of Injury, restless, rowdy Probs with: Depth perception Denial of problems Short attention span/ memory Impulsive keep trying to get up do things unsafe that you ask them not to do Personality alterations may act unlike themselves let family know its not their fault Sense of time is off Effects on opposite side

Terms and issues with stroke Anopsia vision defect hemianopsia field cut Diploplia- double vision Aphasia language expressive cant say it/ receptive dont understand words Agnosia sensory impaired understanding of sensory stimuli, nerve is sending message cant understand it- occup therapy will help with this Apraxia motor impaired purposeful movement Dysarthria oral muscle wont work for speech Emotional lability Impaired memory / judgement Incontinence of stool or bowel will usually resolve over time LEFT STROKE larynx, language, swallowing aspitration risk, powerlessness as cant express self falls risk gag reflex problems 22

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Teach people with vision cuts probs to scan field of cision for safety

Suspected stroke On arrivial at hospital with S&S of stroke: Might give them CT scan to locate/confirm but its a rush as the thrombolytics need to be on board w/in 3 hours of onset of stroke Flaccidity O2 BP Blood sugar HOB elevated Alignment to keep cerebral blood flow patent Body temp keep controlled S & s increased ICP: diuretics Romberg test- close eye standing and wobble cant balance at all its sensory ataxia No TPA for hemorrhage stroke or history of bleed problems Thrombolytics folo with anticoagulants to prevent future clots Coumadin Asa Anticonvulsants HA terrible may contraindicate platlet and coag inhibitors as sign of brain bleed stroke LOC checks Listen to heart for arrythmia

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Glasgow coma RN tx. Scd/teds ROM for flaccid weak Watch for edema on weak side dont call it bad elevate edema areas May need feedings Dysphagia will usually resolve over time but many need speech therapy and tube feedings for a while nurse stay in room while they eat, chin down, take time, safe Thickened diet, nectar of honey thick Dont finish their scentences Place Items w/in reach on the strong physical and visual side Dont approach from visually weak side Bladder train up to commode or bedpan Q 2 to cut off incontinence at the pass Get them as ADL independent as possible Dont pull from under axilla to move em in bed you can hurt shoulders so use pull sheet Before PO meds give a sip of water or ice chips first to see how they are swallowing Will go home on some clot prevens medicine HOB always above 30 degrees to prevent aspiration

11. Shock------------------------------------------circulation /perfusion failure to vital organs Cardiogenic/Hemorrhagic Septic/Spinal

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a. cardiogenic shock is the failure of the heart as a pump reduced cardiac outputnecrosis of the left ventricle main goal is to maintain oxy and perfusion and improve CO. Early findings hypotension (lower than baseline systolic<90 diastolic<30mmHg ) urine output decline cold clammy skin poor peripheral pulses tachycardia pulmonary congestion tachypnea, disoriented, restless, confused, chest pain ongoing. Action: IV morphine, 02, intubate-ventilate, diuretics (lower fluid congestion), nitrates(dilate) ,vasopressors +inotropics (maintain perfusion), possible intraaortic balloon pump for perfusion and CO, reperfusion tx PTCA or CABG, watch ABG, UO, distal pulses b. septic shock What pathophysiologic processes occur with ss? What are the effects of these processes on the patients vascular system, volume? A microorganism invades such as bacteria, fungi or a virus, which leads to a vasodilation reaction then leads to the activation of inflammatory response, the coagulation system is activated and clots form creating a maldistribution of blood volume, this causes decreased venous return then decreased cardiac output resulting in decreased tissue perfusion. (Sole 2009, p. 328, 329) c. Spinal shock neurogenic shock a sudden depression of reflex activity in the spinal cord below injury level and within one hour of injury shock occurs it can last days or months. Muscles go paralyzed, flacced and have no reflexes. When reflexes return the shock is over. Assess for flaccid paralysis, no reflexes below injury, bradycardia, paralytic ileus, hypotension. ACTion watch for hypotension &bradycardia. Asses bowel sounds, monitor for retention of urine and feces, supportive measures and monitoring for resolve d. Anaphylactic shock serious immediate hypersensitivity reaction systemic. ACTion establish airway, give epinephrine, Benadryl or corticosteroids, measures to control extent of shock

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e. Hemmorhagic or hypovolemic shock loss of circulatory volume. ACTion elevate legs, notify PCP, find cause, give 02, watch LOC, watch for >pulse<bp. Watch I&O, assess tem color turgor skin and mm, elevate legs Give : 02, IV fluids, blood, colloids

12. Labs K+ 3.5-5 > 5 hyperKalemia PROBLEMS: HR slow weak irregular, hypotension, EKG changes, tall peaked T waves, flat P, wide QRS, long PR. Resp skel muscles can be so weak that resp failure results. NM twitch, cramp, paresthesia LATE flaccid paralysis. GI hyperactive, diarrhea. TX: K excreting diuretics, if renal function is weak give Kayexalate, Dialysis, IV hypertonic glucose >moves K into cells < 3.5hypokalemia life threatening compromises every body system. CAUSES: xs diuretics, c-steroids, vomiting , diarrhea, xs ng suction, renal disease that impairs K reabsorption, alkalosis, xs insulin, defecit by dilution PROBLEMS: pulse-weak, thready, irregular, ortho hypo, weak peripheral pulses, EKG changes ST depressed, flat-inverted T wave, U wave, Resp shallow ineffective breathing from weakness, weak breath sounds, NM weakness>flacid paralysis, anxiety>confusion>coma, diminished deep tendon reflexes, GI hypoactive>constipation> abd distended> p. ileus N/V renal: ^urine output, low urine specific gravity

WBC 5000-10000 (cancer may alter) <5000 at risk for infection,"left shift" means immature WBC count is high= overwhelming infection, bone marrow depression >10,000 system is fighting

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infection very high numbers indicate adults have died in battle sending young ones out to fight platelets 150,000-400,000 <150,000 risk of bleeding out , bleed precautions monitor for s&s of hemorrhage >400,000 high risk of embolis-thrombis clotting ABGs, RBC-4-6 million (cancer/ bone marrow suppression may alter numbers produced or maturity of cells released) <4million anemia, weak tired, low 02 blood loss >6 million 3rd spacing, dehydration, HGB.- Female: 12-15g/dL Male: 13.5-17 g/dL (may indicate anemia, blood loss wen low) HCT. Female: 35-47% males: 42-52% (so 35-50% roughly) (helps identify anemia, blood loss, can be high in dehydration, low in dilution) Glucose 60-110 hypoglycemia < 60 sweaty, shaky, ^HR> (<40) confused, HA, drowsy, irrational, dizzy, slurred spch, combative>(<20) disoriented>LOC altered>seizures hyperglycemia >110 DKA >300 acidosis, dehydration, hypoperfusion to all organs tissues, kussumal&fruity, e-lyte imbalances coma or HHNS >800 dehydration, e-lyte imbalance, CNS, LOC alterations INR 1 is normal/measures effects of oral anticoagulants Warfarin target INR is 2-4 times control when on aPTT <36 seconds/ Heparin target 1.5-2.5 times normal value or 60-90 seconds

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PT ( fibrin clot formation) 9-12 seconds normal+/- 2seconds. Keep levels at <30 seconds when on therapy BUN 8-25 mg/dL Creatinine 0.6-1.3

14 questions on new material 13. skin, Classification of Depth , 1st degree suburn dry red pain 2nd degree blisters wet, Capillary
refill present with blanching 3rd degree charred Dry, leathery, deep sub q destruction white black nerves destroyed. Grafts stages of recovery: Stage 1 ends when fluid loss and edema stops a few days 2-5 careful fluid balance Acute phase is stabalization of fluid balance To wounds covered by grafts

resussitive fluid imbalance until stable, ------- until wounds covered , -------rehab function and return to adls psych pain adapting ROM Rehabilitative 6mo -2 years long

Burns inclass lecture Get chemicals off brush then flush flush flush Electrical outer skin may look normal Check extrem mvmt and get on cardiac monitor Wheezes indicate airway constrictd RBC hemolysis Adynamic ileus no bowel sounds

Foley want 50mL / hr urine outut 28

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If wheezes drop off bad sign of increasing problem Hypermetabolic 5000 calories per day to protect body from this eggnog Lactated ringers is good but watch the K 1st degree, superficial, sunburn red dry hurts heals quickly 2nd degree deep partial painful blisters red wet cap refill blanching nerves involved painful 3rd degree full thickness no cap refill charred black or waxy white, skin eschar peels off sloughs,

14. terrorism,

Botulism soil bacteria

Plague only effective if administered immediately Streptomycin or gentamicin drug of choice Tularemia Gentamicin treatment of choice Hemorrhagic fever caused by several viruses Ribavirin effective in some cases Anthrax bacterial spores inhaled resp failure antibiotics Cipro will help stop systemic toxins released by spores cause lung tissue hemorrhage and destruction Botulism spore forming anerobe lethal bacterial neurotoxin can kill person<24hours get it out of system induce vomiting give enemas ventilator antitoxin no vaccine Plague septicemic most dangerous strepto or gentamycin best only works if given immediately otherwise wont beat plague Hemorrhagic fever ebola ribavibrin may work but no real treatment wil bleed easily so avoid breaking skin rodents and mosquitos cause it Chemical Serin lung paralysis Phosgene resp distress Mustard gas burns blisters Radioactive dust shower decontam

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15. Cancer BREAST Heredity (first degree relative) Hormonal regulation Hormone replacement therapy (HRT) (physical inactivity, dietary, fat intake, obesity, alcohol intake) (environmental chemical, pesticide and radiation exposure) BRCA-1 and BRCA-2 mutations Hormone replacement therapy prolonged use can inc risk Alcohol Envorio BRAC 1 & 2 mutations dont suppress tumors if mutates Poor diet, inactive >60 yrs old lobular ductal invasive arises from ducts insitu local non invasive malig/metastatic spreads complications : from treatment lymph flow, recurrance

lumpectomy modified mast tumor and nodes radiation often primary shrinks chemo shrinks 30

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cytotoxic drugs hormonal blocks estrogen pre menopausal women younger women biologic therapy stims nat defense to see and attack tumor cells T tumor N nodes M metastisis 0-1 stage 1-4

Ovarian cancer Cause unsure family hist no pregnancies >age > chance high fat diet > number of ovulation cycles hormone replacement oral contraceptives decrease the risk of ovarian pain not an early issue may feel constipated or not hungry but may advance far before woman checks itout. PAP smears do not detect it s1 ovaries hysterectomy chemo s2 s3abd cavity s4systemic metastatic often young women and family bearing interrupted radioactive implants laundry urine feces are safe, oral mucose undamaged limit how much time rn spends with patient for exposure

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big concern is family process problems

Testicular cancer Usually young in teens 20s swelling lump heavy dull ache Metastisis cough sob hemoptysis back pain dysphagia Frequent self exams Orchiectomy is the treatment if surgery is decided Take sperm before if desired

16. 10 math questions 100 total questions

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