A1 PASSERS REVIEW CENTER

MEDICAL SURGICAL CONCEPTS

DECEMBER 2011 PNLE REVIEW

Members of the BOARD OF NURSING and their SPECIALIZATIONS: Chairman Carmencita Abaquin, UP: MS neuro, sensory, endocrine, BURNS, ONCOLOGY, elderly care, RESEARCH Hon. Marco Sto. Tomas, St. Joseph College of Nursing: Funda, MCN, IMCI Hon. Leonila Faire, UP: renal transplant, RENAL DISORDERS, ENT, ophtha (cataract), OR Hon. Betty Meritt, UP: Psych: Child psychology, stress management Hon. Perla Po, UP: Psych: Therapeutic comm., psych drugs, nursing theories Hon. Amelia Rosales, Ortaez College of Nursing: MS Hon. Yolanda Arugay, PWU: CHN

ALPHABET OF PAIN:

P - recipitating Q - uality R egion/Radiation S - everity T - iming

 Crushing pain = MI Pounding occipital headache = HPNsive crisis in MAOI + Tyramine Knife like = Ectopic pregnancy, Pleurisy Gnawing = Gastric Ulcer

Radiating Pain:

Chest to arm = ANGINA Chest to back = MI Epigastrium to Right Scapula = CHOLECYSTITIS Epigastrium to Left Scapula = RENAL COLIC LUQ to Left shoulder = PANCREATITIS Labor = back pain to abdomen = TRUE LABOR

 McCafferey = Subjective definition Gate control theory Patient Controlled Analgesia (PCA) = ability to self dose TENS = nonnarcotic,noninvasive, inhibits transmission

Pain Medications:
OPIOIDS

Morphine Sulfate DOC (severe) Meperidine Fentanyl RR check Respiratory depression, hPN, urinary retention SE: elderly = constipation NALOXONE @ bedside Detoxification = Methadone

 NON- OPIOIDS NSAIDS = inhibits prostaglandin synthesis Cox 1 and 2 inhibitors ADJUVANT MEDICATIONS Antidepressants, Anticonvulsants = DOC neuropathic pain

PERIOPERATIVE NURSING
Preoperative Intraoperative Postoperative Members of the surgical team: Surgeon Surgical Assistant Anesthesiologist Circulating nurse Scrub nurse

CORONARY ARTERY DISEASE

3 Ss of Coronary Artery Disease Smoking Sex Sedentary lifestyle

Note: Potential for Thrombosis and embolism

Angina Pectoris
Types Occurrence Severity Relieve by drug and rest Stable Unstable During Unpredictable exertion Unchanging Increases with time Yes No

Note: Prinzmetal angina results from coronary artery VASOSPASMS.

Manifestations: 1. Diaphoresis 2. Dizziness 3. Chest pain common sign Squeezing (retrosternal) Radiates from chest to jaw and left arm

Precipitating factors: Exercise, Eating heavy meals, Emotions Extremes of temperature

NTG-vasodilator
Salient points: a. place sublingual (where vessels are visible) b. keep three tablets (note: interval of 5 minutes) c. dont follow with water (it will be deactivated by the GI tract) d. dont smoke after (the nicotine (vasoconstrictor) might antagonize the effect of the drug) e. if unrelieved, refer to physician f. side effect: headache g. it must be stored in a brown bottle container h. monitor heart rate If NTG patch: rotate the site, place in non-hairy part of the body

ASA-anti-platelet aggregation
Salient points: a. avoid green leafy vegetable b. monitor pulse rate c. Laboratory : platelets d. dont give with antihistamine, Heparin and Coumadin e. use soft bristle toothbrush and electric razor f. question if given to small children (associated in Reyes syndrome)

Beta-blockers to decrease BP and HR Laboratory interventions: a. ECG ST depression b. Cardiac catheterization ( note for the presence of atheroma)

Medical Interventions:
a. Coronary arteriogram Note: 1. Allergy to dye must be assessed 2. Artery (Femoral) is commonly used 3. Assess for bleeding after 4. Advise client to place affected leg in extension (usually with sandbag weighing 20 lbs for 8-12 hours)

b. Percutaneous Transluminal Angioplasty (PTCA) A balloon tip catheter will be inserted to crush the atheroma c. Coronary Artery Bypass Graft Saphenous vein is commonly used Assess the donor site (note : it should be warm and non-edematous

Myocardial infarction
Death of myocardial tissue due to abrupt interruption of coronary blood supply Etiologies: CAD, Vasospasm and Occlusion

Predisposing factors: Smoking Stress Sedentary lifestyle

Manifestations: 1. Dyspnea 2. Diaphoresis 3. Dysarhythmias 4. Chest pain Crushing (Substernal) Radiates from the chest to back

Comparison of Angina Pectoris and Myocardial Infarction

Problem
Pain and radiation

Angina Pectoris
Chest to arm

Myocardial Infarction
Chest to back

Duration
Relieve by rest Description

Less than 15 minutes

Yes Squeezing (retrosternal)

More than 15 minutes

No Crushing (substernal)

Laboratory Intervention: a. ECG ST segment elevated b. Cardiac enzymes-elevated CPK-MB and Troponin levels
Note: WBC in some extent is elevated

Nursing Interventions:

Consider: a. Semi-fowlers (promote airway) b. High-fiber, low fat and low Na diet c. Rest d. Drug (MONA)

1. Morphine to decrease oxygen demand Salient points: a. Monitor PR b. Have Narcan (antidote) at hand c. Can cause addiction (Note: consider Methadone) 2. Oxygen 3. Nitrates 4. Aspirin

Note:Clients who are able to climb stairs are usually ready to start sexual activities

CONGESTIVE HEART FAILURE

CHF can be Left-sided or Right-sided Left-sided CHF can lead to Right-sided CHF, but Right cannot lead to Left Lasix is given to both types of CHF CHF is the inability of the heart to pump blood towards systemic circulation

Left-Sided Heart Failure (LSHF) Can be caused by Rheumatic Heart Disease: Tonsillitis strep bacteria migrate to mitral valve RHEUMATIC HEART DISEASE mitral stenosis LSHF

SSx of LSHF:
Most of the symptoms of LSHF are RESPIRATORY: Pulmonary edema and congestion Dyspnea: Paroxysmal nocturnal dyspnea difficulty of breathing at nighttime Nursing intervention: give patient 2 to 3 pillows Orthopnea difficulty of breathing while lying down Nursing intervention: Position patient HighFowlers or Orthopneic position Productive cough, blood-tinged sputum Frothy salivation alveolar fluid in the mouth Abnormal breath sounds: Rales (crackles) and bronchial wheezing

Cardiovascular symptoms:
Pulsus alternans weak pulse followed by strong bounding pulse Can lead to arrhythmia Point of Maximal Impulse (PMI) is displaced laterally Fluid in the lungs pushes heart to one side Check apical pulse to determine the location of PMI Normal PMI is at the left midclavicular line between the 4th and 5th intercostals space (below the nipple). Note: if the PMI is displaced vertically (lower than normal) then the patient has cardiomegaly. S3 extra heart sound (Ventricular gallop) Note: S4 sound occurs in myocardial infarction

Right-Sided Heart Failure (RSHF)

SSx of RSHF:

Venous congestion blood goes back to superior & inferior vena cava Jugular vein distention Pitting edema Ascites fluid in the peritoneal cavity Weight gain Hepatosplenomegaly Jaundice Pruritus and urticaria Esophageal varices Generalized body malaise and anorexia

DIGOXIN
Indicated for Congestive Heart Failure Mechanism of digoxin: increases force of myocardial contractions, thereby increasing cardiac output The normal cardiac output is 3 to 6 L/min. Nursing Management when administering Digoxin: Check apical pulse rate: if below 60, withhold drug and notify the physician.

SSx of Dig toxicity: GI DISTURBANCES (Early Sign): Anorexia (loss of appetite is the most evident sign), nausea and vomiting, diarrhea Visual disturbances: photophobia, XANTOPSIA (seeing yellow spots), diplopia Confusion The antidote for dig toxicity is DIGIBIND

CARDIAC TAMPONADE HEART UNABLE TO PUMP BLOOD DUE TO ACCUMULATION OF FLUID (50 ML) IN THE PERICRADIAL SAC = restricts ventricular filling = LOW ventricular output Jugular vein distention hPN Muffled heart sound Increased CVP Pulsus paradoxus

HPN = above 140/90 ( 2 consecutive readings) Types: Essential = most common Secondary = due to Pheochromocytoma, SIADH Predisposing Factors: Smoking, DM, 60 years old and above Int.: 5 Ls = lose weight, low fat and low Na diet, limit alcohol, lifestyle modification, lipid, BUN, crea and ECG monitoring

SINUS TACHYCARDIA = cause: alcohol and caffeine; Tx: Beta blockers and digitalis SINUS BRADYCARDIA =Tx: Atropine sulfate ATRIAL FIBRILLATION = Bed rest, Cardioversion, Digitalis VFIB = Unconscious, NO CO = Code, CPR, Epinephrine

AV BLOCK = Cause: Digitalis toxicity, electrolyte imbalance, Tx: ECG PVC = Tx: Lidocaine, Oxygen VTACH = life threatening, cause: hypokalemia, Tx: Lidocaine

4 Types of COPD
Bronchitis bluebloater cyanosis with edema Asthma Bronchiectasis Emphysema pink-puffer acyanotic with compensatory purse-lip breathing

PSSx: Hemoptysis Wheezing blood in cough on expiration Reversible

PSSx: Barrel-chest

Irreversible Terminal stage

Bronchitis

Asthma

Bronchiectasis

Emphysema
Can lead to pneumothorax (air in pleural space),

Caused by allergic reaction

CO2 narcosis Caused by allergic reaction Hereditary

Surgery: Pneumonectomy (removal of 1 lung) Diagnosis: Bronchoscopy

Hereditary

Can lead to Cor Pulmonale (enlarged right ventricle)

Can lead to Cor Pulmonale

For all types of COPD: #1 cause is smoking Expect doctor to prescribe bronchodilators LOW-FLOW OXYGEN only so as not so suppress the respiratory drive

Aminophylline
Indicated for Chronic Obstructive Pulmonary Disease (COPD) Bronchodilators dilate the bronchial tree, thereby allowing more air to enter the lungs SSx of aminophylline toxicity: Tachycardia, hPN Palpitations CNS excitability: irritability, agitation, restlessness and tremors Nursing management for aminophylline: AVOID COFFEE will aggravate CNS excitability

PULMONARY EMBOLISM
Cause: Fat embolism ( long bone fracture) Initial sign: Restlessness chest pain of a "pleuritic" nature Cyanosis Tachycardia Diaphoresis Dysrythmias Chest pain (stabbing)

Priority: AIRWAY (O2 therapy) Heparin and Warfarin

Edema excess accumulation of fluid in the interstitial space Localized edema result of traumatic injury from accidents, surgery, local inflammation, burns Anasarca generalized edema cardiac, renal or liver failure

PITTING EDEMA SCALE

0 = None observed +1 = Minimal (< 2 mm) +2 = Depression 2 4 mm +3 = Depression 4 6 mm +4 = Depression > 7 mm

Infants and older adult are at higher risk for fluid related problems than younger adults; children have a greater proportion of body water than adults and the older adult has the least proportion of body water

HYPOKALEMIA

HYPERKALEMIA

Potassium less than 3.5 mEq/L Potassium greater than SSx of hypokalemia: 5 mEq/L Weakness, fatigue SSx of hyperkalemia: Decreased GI motility: constipation Irritability, Positive U Wave on ECG can lead to excitement arrhythmias Increased GI Metabolic alkalosis motility: diarrhea, Bradycardia (HR 60 to 100 bpm) abdominal cramps Rx for hypokalemia Peaked T wave K supplements: Oral KCl, Kalium durule can also lead to Foods rich in K: arrhythmia Fruits: Apple, Banana, Cantaloupe Metabolic acidosis Note: Green bananas have more K Vegetables: Asparagus, Broccoli, Carrots Also rich in K: orange, spinach, apricot

HYPONATREMIA 135 145 mEq/L Etiologies less

HYPERNATREMIA more

Manifestations

Burns, SIADH, diuretic Diarrhea and IVF therapy and plain water use use N/V and Seizure Dry tongue, thirst Low sodium Fluid Volume Deficit Hypotension The initial sign of dehydration is THIRST (adults) or TACHYCARDIA (infants) Nursing Management: Force fluids (2 to 3 L/day), administer isotonic IV

HYPOCALCEMIA N: 4.5 5.5 mEq/L less

HYPERCALCEMIA more

Etiologies

Vit. D deficiency, removal of parathyroid gland

Tetany + Chvosteks + Trousseau

Excessive Vitamin D Calcium supplements

Manifestation

Test

ECG
DOC

Prolonged QT interval
Ca gluconate (PC)

Shortened QT interval
Calcitonin

HYPOCALCEMIA
Tetany involuntary muscle contraction SSx of hypocalcemia: Trousseau sign carpal spasm when BP cuff is inflated 150 to 160 mmHg Chvostek sign facial twitch when facial nerve is tapped at the angle of the jaw Complications of hypocalcemia: Arrhythmia and Seizure (Calcium deficiency is life-threatening!)

Nursing management for hypocalcemia: Administer Ca Gluconate IV Must be administered slowly to prevent cardiac arrest Excess Ca Gluconate Ca Gluconate toxicity seizure Antidote for Ca excess: Magnesium Sulfate Monitor for signs of MgSO4 toxicity (BURP): BP low Urine output low RR low PATELLAR REFLEX ABSENT important! earliest sign of MgSO4 toxicity

Electrocardiographic changes in electrolyte imbalance

Hypocalcemia: prolonged ST interval, prolonged QT interval Hypercalcemia: shortened ST segment, widened T wave Hypokalemia: ST depression, shallow, flat, or inverted T wave, prominent U wave Hyperkalemia: Tall peaked T waves, flat P waves, widened QRS complex, prolonged PR interval Hypomagnesemia: Tall T waves, depressed ST segment Hypermagnesemia: prolonged PR interval, widened QRS complex

 Client at risk for Potassium deficit? Client on nasogastric (NG) suction Food item contains the least amount of magnesium? Processed drinking water Foods with least amount of Potassium? APPLE (3 mEq of potassium per serving) Lettuce (less than 100 mg)

Risk for Hyperkalemia? trauma, burns, sepsis, or with metabolic or respiratory acidosis early stages of massive cell destruction cellular shifting K+ Sodium polystyrene sulfonate (Kayexalate) cation exchange resin, treats hyperkalemia Releases sodium ions in exchange for primarily potassium ions therapeutic effect 2 to 12 hours after oral administration and longer after rectal administration

 HYPONATREMIA - Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Postural blood pressure changes, rapid thready pulse, dry mucous membranes and intense thirst Diabetes Insipidus HYPERNATREMIA Avoid foods: high in sodium Processed oat cereals

Condition causing low serum calcium level? IMMOBILITY prolonged bed rest (long term effect) Indication of HYPERCALCEMIA? Generalized muscle weakness

Hyperparathyroidism client with 13 mg/dl Ca give Calcitonin(Calcimar) inhibits bone resorption AVOID: high doses of VITAMIN D (causative factor of Hypercalcemia) HYPOLCALCEMIA? + Trosseauss sign, + Chvosteks sign, hyperactive bowel sounds Calcium gluconate and calcium chloride treats tetany from acute hypocalcemia

Least amount of Calcium? BUTTER Hypomagnesemia indication? Loss of deep tendon reflexes Least amount of Phosphorous? ORANGE

Client with a nasogastric (NG) tube with irrigations Q shift. Laboratory Test Results: Potassium level of 4.5 mEq/L, Sodium level of 132 mEq/L Most appropriate solution to use for? NORMAL SALINE

pH

pCO2

HCO3

Normal

7.35 7.45

35 - 45

22 - 26

Respiratory Acidosis

Respiratory Alkalosis Metabolic Acidosis

Metabolic Alkalosis

N N

RESPIRATORY ACIDOSIS Causes COPD, Respiratory failure, Overdose, Atelectasis, Pulmonary edema, aspiration Manifestation Weakness, tachycardia, decreased LOC, headache Management Assess VS, Monitor ABG, CPT, TCDB

RESPIRATORY ALKALOSIS Hyperventilation, Anxiety, Pain, Ventilators

Lightheadedness, ringing of the ears, Tingling

Slow breathing, paper bag

METABOLIC ACIDOSIS Causes DKA, DIARRHEA, DM, ASA poisoning, renal failure Manifestation Headache, N/V, Kussmauls respiration, dysrythmias Management Administer Na bicarb, monitor I/O, Use seizure precautions

METABOLIC ALKALOSIS Vomiting, NGT, Diuretics and antacids Tingling, Dizziness, Bradypnea

Monitor VS, I/O, ABG

Types of Intravenous solutions

Isotonic 0.9 % saline (NS) 5% dextrose in water (D5W) 5% dextrose in 0.225% saline (D5W/ NS) Lactated Ringers Hypotonic 0.45% saline (1/2 NS) 0.225% saline (1/4 NS) 0.33% saline (1/3 NS)

Hypertonic 3% saline (3% NS) 5% saline 10% dextrose in water (D10W) 5% dextrose in 0.9% saline 5% dextrose in 0.45% saline 5% dextrose in LR Colloid Dextran Albumin

Peripheral venous sites to avoid: Edematous extremity, arm that is weak, traumatized or paralyzed, arm on same side with mastectomy, arm with AV shunt or fistula for dialysis, infected skin tissue

HYPERURICEMIA
Uric acid is a by-product of purine metabolism Foods high in uric acid: Organ meats, sardines, anchovies, legumes, nuts Tophi uric acid crystals Gout uric acid deposit in joints leading to joint pain & swelling, particularly affecting the great toes.

Nursing Management for Gout: Force fluids (2 to 3 L/day) Rx: Allopurinol [Zyloprim] drug of choice for gout Most common side effect: allergic reaction (maculopapular rash) Rx: Colchicine drug of choice for acute gout

PEPTIC ULCER
Gastric Ulcer Gnawing epigastric pain occurring 30 minutes to 1 hour after meals Aggravated by eating (because acid secretion increase at meal time) leads to weight loss Relieved by vomiting (because acid is expelled out) No pain at hours of sleep (HCl production decreases at hours of sleep) More common in persons older than age 50
Duodenal Ulcer Gnawing epigastric pain occurring 2-3 hours after meals Relieved by food (because the pyloric sphincter, at the junction of stomach and duodenum, closes upon eating to concentrate food in the stomach) causes weight gain Not relieved Pain at hours of sleep (because gastric emptying continuous at hours of sleep) More common between ages 25 and 50

Esophageal varices = secondary to portal HPN Dx test: Upper GI Series or Barium swallow Sengstaken Blakemore tube AVOID: ASA Worst complication: Bleeding

HIATAL HERNIA Heartburn Regurgitation Dysphagia Small frequent feedings Fowlers after eating for 1 H

GERD Gastro-Esophageal Reflux Disease Common cause: Pyloric stenosis Manifestations: Heartburn, N/V (Note: Metabolic alkalosis) Nursing intervention:

Avoid SPICES, COFFEE, Nicotine, cola Barium swallow Consider liquid diet Elevate head of the bed

DUMPING SYNDROME
Rapid emptying of the stomach Commonly occurs 5- 30 minutes after meals (early), 2- 3 H (late) Manifestations: Diaphoresis, drowsiness, dizziness, diarrhea Diet: HIGH FAT, HIGH CHON, LOW CHO Small frequent feedings Lie down after eating

CROHNS (REGIONAL ENTERITIS) Transmural, Ileum/Ascending colon

ULCERATIVE COLITIS Mucous ulceration, Rectum/lower colon

Cause
Age

Unknown, Jewish, envtl. factors

20 30, 40 60

Unknown, Jewish, familial, envtl. factors

15 - 40

Bleeding Not common; stool Severe: stool with with pus and mucus blood, pus, mucus Fistulas Common Rare

CROHNS (REGIONAL ENTERITIS) Perianal involvement Diarrhea Abdominal pain Weight loss Severe

ULCERATIVE COLITIS Mild

5 6 stools/day

20 30 watery stools/day

Severe + +

Diet: low fiber, TPN, AZULFIDINE (Sulfasalazine)

APPENDICITIS RLQ pain Appendectomy Pain monitoring AVOID: hot compress, enema Sign of Peritonitis: Rigid boardlike abdomen

DIVERTICULITIS = LLQ pain, rectal mass, rectal bleeding LIVER CIRRHOSIS = RUQ abdominal pain, jaundice, note: ASTEREXIS, Rx: LACTULOSE CHOLECYSTITIS = Murphys sign, Low fat diet, steatorrhea PANCREATITIS = Cullens sign and Turners sign, Lab: Amylase and Lipase

HYPOTHYROIDISM All body systems are DECREASED except WEIGHT and MENSTRUATION! decreased CNS: drowsiness, memory problems (forgetfulness) decreased v/s: hypotension, bradycardia, bradypnea, low body temp decreased GI motility: constipation

HPYERTHYROIDISM All body systems are INCREASED except WEIGHT and MENSTRUATION! increased CNS: tremors, insomnia increased v/s: hypertension, tachycardia, tachypnea, fever increased GI motility: diarrhea

HYPOTHYROIDISM decreased appetite (anorexia) but with WEIGHT GAIN [low metabolism causes decreased burning of fats and carbs] This leads to increased serum cholesterol atherosclerosis (hardening of arteries due to cholesterol deposits) Because of increased cholesterol, hypothyroid patients are prone to hypertension, myocardial infarction, CHF and stroke

HPYERTHYROIDISM increased appetite (hyperphagia) but with WEIGHT LOSS [high metabolism causes increased burning of fats and carbs]

HYPOTHYROIDISM

HPYERTHYROIDISM

decreased metabolism causes decreased perspiration DRY SKIN and COLD INTOLERANCE
Menorrhagia (excessive bleeding during menstruation) Nursing Management for hypothyroidism: Low calorie diet Warm environment

increased metabolism causes increased perspiration MOIST SKIN and HEAT INTOLERANCE
Amenorrhea (absence of menstruation) Pathognomic sign: EXOPHTHALMOS Nursing Management for hyperthyroidism: High calorie diet Cool environment

Type I DM Insulin-dependent Juvenile onset type (common among children) Non-obese Brittle disease

Type II DM Non Insulin-dependent Adult/Maturity onset type (common among 40 y.o. & above) Obese Non-brittle disease

Etiology: Hereditary Symptomatic Characterized by Weight Loss Treatment: Insulin

Complications: Diabetic Ketoacidosis (DKA) Sodium Bicarbonate (NaHCO3) administered to treat acidosis Can lead to coma

Etiology: Obesity Asymptomatic Characterized by Weight Gain Treatment: Oral Hypoglycemic Agents (OHA) Complications: Hyper-Osmolar NonKetotic Coma (HONCK) Non-ketotic, so no lipolysis
Can also lead to coma Can lead to seizure

HYPERGLYCEMIA

SSx: 3Ps (Polyuria, Polydipsia, Polyphagia) Nursing Management: Monitor Fasting Blood Sugar (Normal FBS is 80 to 100 mg/dL)

Addisons disease Hyposecretion of adrenal hormones

Sugar : hypoglycemia Salt : hyponatremia, with hyperkalemia Sex : decreased libido Hypoglycemia (T-I-R-E-D) Tremors/Tachycardia Irritability Restlessness Extreme fatigue Diaphoresis/Depression

Cushings syndrome Hypersecretion of adrenal hormones

Sugar : hyperglycemia Salt : hypernatremia, with hypokalemia Sex : hirsutism, acne, striae Hyperglycemia (P-P-P) Polyuria Polydypsia Polyphagia Note: DM is a complication of Cushings

Decreased tolerance to stress due to decreased steroids can lead to ADDISIONIAN CRISIS

Increased steroids cause decreased WBC (Leukopenia) IMMUNODEFICIENCY Note: Steroids takers (athletes,body builders) experience ssx of Cushings Hypernatremia with Fluid Volume Excess Hypertension Edema Weight Gain Pathognomonic Sx of Cushings: Moon-face Buffalo hump Obese trunks Pendulous Abdomen Thin extremeties

Hyponatremia Hypotension Dehydration Weight Loss

Hyperkalemia Irritability, agitation Diarrhea, abdominal cramps Peak T waves arrhythmia

Hypokalemia Weakness, fatigue Constipation Prominent U wave can also lead to arrhythmia Hirsutism, acne and striae due to increased sex hormones Other signs: Depression Easy bruising Increased masculinity in women

Decreased sexual urge and loss of pubic and axillary hair Pathognomonic sx: Bronze-like skin Decreased cortisol causes pituitary gland to secrete Melanocytestimulating hormone

Management: Management: Steroids (2/3 dose in AM and 1/3 dose in Potassium-sparing diuretics: Aldactone PM) [Spironolactone] promotes excretion of sodium while retaining potassium DO NOT GIVE LASIX Limit fluids Increase potassium in the diet

Icteric skin and sclerae is termed Jaundice = a sign of HEPATITIS Note: Icteric skin with normal sclerae is termed Carotinemia = a sign of PITUITARY GLAND TUMOR, not hepatitis Kernicterus (Hyperbilirubinemia) can lead to irreversible brain damage

Ammonia is a by-product of protein metabolism; toxic substance metabolized by the liver into a non-toxic substance (urea), which is then excreted by the kidneys Increase in serum ammonia can cause HEPATIC ENCEPHALOPATHY (Liver cirrhosis) Normal liver is scarlet brown; liver with cirrhosis is covered by fat deposits (fatty liver) The primary cause of hepatic encephalopathy is MALNUTRITION The major cause of hepatic encephalopathy is ALCOHOLISM Alcoholism causes Thiamine (B1) deficiency (Alcoholic beriberi) Ammonia is a cerebral toxin.

Early sign of Hepatic Encephalopathy: ASTERIXIS flapping hand tremors. This is the EARLIEST SIGN OF HEPATIC ENCEPHALOPATHY.

Late Signs of Hepatic Encephalopathy: Headache Restlessness Fetor hepaticus (ammonia-like breath) Decreased level of consciousness HEPATIC COMA Note: The primary Nursing Intervention in hepatic coma is AIRWAY [Assist in mechanical ventilation]

Arterial Occlusion
Color Edema Nails Pain Pulse
Temperature

Venous Occlusion
Ruddy Severe Normal Homans sign Normal

Pallor ( - ) or minimal Thick & brittle *Intermittent Claudication (-)

Ulcer

Cold Dry

Warm Wet

BUERGERS DISEASE OR THROMBOANGITIS OBLITERANS Inflammation of arteries thrombus formation occlusion of vessel Unknown, RF: Smoking Men

RAYNAUDS DISEASE

Constriction of arteries Coldness, pain and pallor of the fingertips or toes Unknown Women

20 -35 Intermittent claudication Paresthesia Cyanosis of legs

UTZ Amputation Bypass graft AVOID: Smoking

18 - 40 Raynauds phenomenon Tingling sensation Burning pain on the hands and feet UTZ Avoid COLD temp. and nicotine AVOID SHARPS

STRAIN VS. SPRAIN STRAIN = overstretching MUSCLE or TENDON SPRAIN = overstretching LIGAMENTS

OSTEOPOROSIS
Primary - menopause Secondary steroids RF: Age Alcohol and caffeine Asian and Caucasian Absence of mobility High Ca and Vit D, Calcium supplement

OSTEOARTHRITIS RF: obesity, repetitive use of joints with previous damage Joint pain and stiffness Affects: WEIGHT BEARING JOINTS Heberdens nodes - DIP Bouchards nodes - PIP

RHEUMATOID ARTHRITIS Pain usually in the morning Joint involvement: SYMMETRICAL Starts in the hands, wrist and feet = deformities: spindle-shaped Dx test: Arthrocentesis (+) = cloudy, dark yellow

GOUTY ARTHRITIS
Gout or podagra Deposition of uric acid crystals in the joint = Poor metabolism of purine TOPHI Rx: Allopurinol, Colchicine, Probenecid Diet: low purine, increase fluids

Emergency Department Triage:

Emergent (Red) Priority 1: life threatening injuries, needs immediate attention Trauma, chest pain, respiratory distress or cardiac arrest Urgent (Yellow) Priority 2: requires treatment and whose injuries have complications that are not life threatening provided treated within 1-2H, continuous evaluation every 30-60 minutes thereafter Simple fracture, asthma without respiratory distress, fever, HPN, abdominal pain, or renal stone

Nonurgent (Green) Priority 3: local injuries, no immediate complications, can wait for hours for treatment, evaluation every 1-2 H thereafter Minor lacerations, sprain or cold symptoms Expectant (Black)

ABCD of Basic Life Support for the Health Care Provider: Airway Breathing Circulation Defibrillation or definitive treatment

When to stop CPR: STOP ONLY IF Pulse and respiration returns Emergency medical help arrives Admnistration of automated external defibrillator A physician declares victim dead/deceased Non-health care setting: if rescuer is exhausted and physically unable to do CPR

Sympathetic Nervous Parasympathetic System (SNS) Nervous System (PNS) Fight or aggression Flight or withdrawal response response Also termed adrenergic or Also termed cholinergic or parasympatholytic sympatholytic response response The neurotransmitter for The neurotransmitter for the SNS is norepinephrine the PNS is acetylcholine (Ach) All body activities are All body activities are DECREASED except INCREASED except GIT! GIT!

Sympathetic Nervous System (SNS)

Parasympathetic Nervous System (PNS)

increased blood flow to brain, heart and skeletal muscles increased BP, heart rate bronchodilation and increased RR: increase oxygen intake urinary retention FLUID VOLUME EXCESS Fluids are withheld by the body to maintain circulating volume

normalized blood flow to vital organs

decreased BP, heart rate bronchoconstriction, decreased RR

urinary frequency FLUID VOLUME DEFICIT

Sympathetic Nervous System (SNS)

Parasympathetic Nervous System (PNS)

pupillary dilation: MYDRIASIS: increase environmental awareness during aggression

pupillary constriction: MIOSIS

decreased GIT activity: Increased GIT: CONSTIPATION and DRY DIARRHEA and MOUTH: INCREASED SALIVATION Blood flow is decreased in the GIT because it is the least important area in times of stress

DRUGS WITH SNS effects:

Adrenergic/Parasympatholytic agents: Epinephrine [Adrenalin] Antipsychotics: Haloperidol [Haldol], Chlorpromazine [Thorazine], etc. Side effect of Thorazine: Atopic Dermatitis (eczema) and foul-smelling odor Side effect of all antipsychotics: Sx of PARKINSONS DISEASE, therefore antipsychotics are given together with antiparkinson drugs

Anti-parkinsonians: Cogentin, Artane Pre-operative drug: Atropine Sulfate (AtSO4) given before surgery to decrease salivary and mucus secretions

DRUGS WITH PNS effects:

Anti-hypertensives: Methyldopa for pregnancy induced hpn (PIH) -blockers (-olol): Propranolol [Inderal], atenolol, metoprolol ACE inhibitors (-pril): Enalapril, Ramipril, Lisinopril, Benazepril, Captopril Side effect of ACE inhibitors: AGRANULOCYTOSIS and NEUTROPENIA (blood dyscrasias always asked in board!)

DRUGS WITH PNS effects:

Calcium channel blockers (Calcium antagonists) Nifedipine [Procardia], Verapamil [Isoptim], Dialtiazem [Cardizem] NURSING ALERT: Anti-hypertensives are not given to patients with CHF or cardiogenic shock (Drug will cause a further decrease in heart rate Death) Rx for Myasthenia Gravis: Pyridostigmine [Mestinon] Neostigmine [Prostigmin]

INCREASED ICP
Predisposing factors: Head injury Tumor Localized abscess (pus) Hydrocephalus Meningitis Cerebral edema Hemorrhage (stroke) Note: For all causes of increased ICP, the patient should be positioned 30 to 45 (Semi-Fowlers)

Early Signs of Increased ICP Change or decreased level of consciousness (restlessness to confusion) Irritability and agitation Disorientation to lethargy to stupor to coma Remember: The 4 levels of consciousness: Conscious Lethargy Stupor Coma

Late Signs of Increased ICP Changes in v/s Increased BP: WIDENING PULSE PRESSURE increased systolic pressure while diastolic pressure remains the same Note: narrowing pulse pressure is seen in SHOCK (inadequate tissue perfusion). Decreased Heart rate (bradycardia) Decreased Respiratory rate (bradypnea) Cheyne-Stokes respiration hyperpnea followed by periods of apnea

Vital signs

BP
Heart Rate Resp Rate Temp

Increased ICP increased decreased decreased high

Shock

decreased
increased increased low

Pulse Pressure

widening

narrowing

Headache, papilledema, PROJECTILE VOMITTING Papilledema is edema of the optic disc in the retina, leading to irreversible blindness Projectile vomiting due to compression of the medulla, which is the center for vomiting.

 Abnormal Posturing: Decorticate posture abnormal flexion, due to damage to the corticospinal tract (spinal cord & cerebral cortex) Decerebrate posture abnormal extension, due to damage to upper brain Note: Flaccid posture is lost muscle tone, not found in increased ICP (found in poliomyelitis).

Unilateral dilation of pupils Uncal herniation herniation of uncus (in temporal lobe) puts pressure on Cranial Nerve III which controls parasympathetic input to the eye, causing unequal pupillary dilation (ANISOCORIA) Possible seizure

Nursing Management for increased ICP

Maintain patent airway and adequate ventilation To prevent hypoxia (inadequate O2 in tissues) and hypercarbia (increased CO2 in blood)

Early Signs of Late Signs of Hypoxia Hypoxia Restlessness Bradycardia Agitation Cyanosis Tachycardia Dyspnea Extreme Restlessness

 Assist in mechanical ventilation: Ambubag or Mechanical Ventilator Hyperventilate or hyper-oxygenate client to 100% before and after suctioning Position Semi-Fowlers Elevate head of bed 30 to 45 with neck in neutral position unless contraindicated to promote venous drainage. Monitor v/s, I&O and neurocheck (neurovital signs) Prevent complications of immobility (turn to side) Prevent further increase of ICP

 Instruct client to avoid activities leading to Valsalva maneuver (bearing down) Avoid straining of stool: administer laxatives/stool softeners: Bisacodyl [Dulcolax] Avoid excessive coughing: administer antitussives (cough suppresant): Dextromethorphan [Robitussin] Note: common side effect of antitussives is drowsiness, so avoid driving or operating heavy machinery Avoid vomiting: administer anti-emetic: Phenergan [Plasil] Avoid bending, stooping, lifting heavy objects

Osmotic diuretics Mannitol [Osmitrol] Check BP before administering; mannitol can lead to low fluid volume hypotension Monitor strictly I & O and inform physician if output is less than 30 cc per hour Mannitol is given as side-drip (piggy-back) Regulate at FAST-DRIP to prevent crystallization [formation of precipitates in tubing] clogged IV line Note: KVO rate is 10 to 15 gtts per minute Inform client that he will feel a flushing sensation as the drug is introduced.

 Loop Diuretics Furosemide [Lasix] Nursing management for loop diuretics is the same as for Osmotic diuretics Lasix is given IV Push (from ampule) Best given AM to prevent sleep disturbances. Lasix given PM will prevent restful sleep due to frequent urination.

 Corticosteroids: Dexamethasone [Decadron] to decrease cerebral edema Side-effect of steroids: respiratory depression Mild analgesics: Codein Sulfate Anticonvulsants: Dilantin [Phenytoin]

ALZHIEMERS DISEASE
A type of dementia (degenerative disorder characterized by atrophy of the brain tissue) Caused by Acetylcholine (Ach) deficiency Irreversible Predisposing factors: Aging Aluminum toxicity Hereditary

SSx of Alzheimers (5 As):

Amnesia partial or total loss of memory

The type of amnesia in Alzheimers is ANTEROGRADE AMNESIA. 2 types of Amnesia:
Anterograde amnesia loss of short-term memory Retrograde amnesia loss of long-term memory

Agnosia inability to recognize familiar objects Apraxia inability to perform learned purposeful
movements (using objects [toothbrush] for the wrong purpose)

Anomia inability to name objects Aphasia inability to produce or comprehend language

 The type of aphasia in Alzheimers is RECEPTIVE APHASIA. 2 types of Aphasia:

Expressive aphasia (Brocas aphasia) inability to speak positive nodding nursing management is the use of a PICTURE BOARD damage to Brocas area (in frontal lobe), which is the motor speech center Receptive aphasia (Wernickes aphasia) inability to understand spoken words positive illogical/irrational thoughts can hear words but cannot put them into logical though damage to Wernickes area (in temporal lobe), which is the language comprehension center

The drugs of choice for Alzheimers are Donepezil [Aricept] or Tacrine [Cognex] The drugs work by inhibiting cholinesterase (an enzyme that breaks down acetylcholine), thereby increasing the levels of acetylcholine in the brain Best given at bedtime

MULTIPLE SCLEROSIS (MS)

Chronic intermittent disorder of the CNS characterized by white patches of demyelination in the brain and spinal cord Characterized by remission and exacerbation Common among women 15 to 35 y.o.

Predisposing factors: Idiopathic (unknown) Slow-growing viruses Autoimmune Note: other autoimmune diseases: Systemic Lupus Erythematosus (SLE), hypo & hyperthyroidism, pernicious anemia, myasthenia gravis

S & Sx of Multiple Sclerosis Visual disturbances

BLURRED VISION is the INITIAL SIGN of MULTIPLE SCLEROSIS Diplopia (double vision) Scotoma (blind spot in the visual field)
Impaired sensation to touch, pain, pressure, heat and cold

Tingling sensations Paresthesia (numbness)

Do not give hot packs to patients with MS. Because of decreased heat sensitivity, heat application can cause burns.

Mood Swings Patients with MS are in a state of euphoria Impaired motor activity Weakness spasticity paralysis Impaired cerebellar function ATAXIA (unsteady gait) Scanning speech Urinary retention and incontinence Constipation Decrease in sexual capacity CHARCOTS TRIAD: A N I

Diagnostic Procedures for Multiple Sclerosis Cerebral analysis through lumbar puncture reveals increased IgG and protein MRI reveals site and extent of demyelination LHERMITTEs SIGN continuous contraction and pain in spinal cord following laminotomy confirms diagnosis of MS

Nursing Management for Multiple Sclerosis

ACTH (steroids) to reduce swelling and edema prevents paralysis resulting from spinal cord compression
Steroids are best administered AM to mimic the normal diurnal rhythm of the body Give 2/3 of dose in AM, 1/3 of dose in PM ACTH is also administered in Motor Vehicular Accidents leading to spinal injury prevents inflammation that can lead to paralysis

 Muscle relaxants: Baclofen [Liorisal] and Dantrolene Sodium [Dantrium]

Can be used to treat hiccups, which is caused by irritation of the phrenic nerve.

Interferons to alter immune response Immunosuppresants Diuretics to treat urinary retention

 Bethanecol Chloride [Urecholine] cholinergic drug used to treat urinary retention; given subQ Side effects of Bethanecol: Bronchospasm and
Wheezing, so always check breath sounds 1 hour after administration. Normal breath sounds are bronchovesicular.

Propantheline Bromide [Pro-Banthine] antispasmodic drug to treat urinary incontinence

Provide relaxation techniques Deep breathing, yoga, biofeedback Maintain siderails to prevent injury secondary to falls Prevent complications of immobility Turn to side q 2 h, q 1 h for elderly patients, q 30 minutes on the affected extremity Provide catheterization Avoid heat application To treat constipation: Provide high fiber diet

To treat UTI: Provide ACID-ASH DIET (acidifies urine to prevent bacterial infection)

Acid-ash diet consists of Grape, Cranberry, Plums, Prune Juice, Pineapple Women are more prone to UTI Male UTI is often related to post-coitus
Male must urinate after coitus to prevent urine stagnation

CEREBROVASCULAR ACCIDENT (STROKE)

Partial or complete obstruction in the brains blood supply. Common sites of thrombotic stroke:

Middle cerebral artery Internal carotid artery

The leading cause of CVA is THROMBUS formation (attached clot)

A dislodged thrombus becomes an EMBOLUS (free-floating clot) very dangerous if it goes to the BRAIN, HEART or LUNGS
CVA causes increased ICP.

Parkinsons Disease
A chronic progressive disorder of the CNS characterized by degeneration of DOPAMINE-producing cells in the substancia nigra of the midbrain and basal ganglia. Parkinsons disease is irreversible

Predisposing factors: Lead and carbon monoxide poisoning Arteriosclerosis hardening of an artery Hypoxia Encephalitis

 High doses of drugs:

Antihypertensives: Reserpine [Serpasil] and Methyldopa [Aldomet] Anti-psychotic agents: Haloperidol [Haldol] and Phenothiazines
Recall: Anti-hypertensives have PNS effects, Anti-psychotics have SNS effects

Side effects of Reserpine: DEPRESSION and BREAST CANCER Note: Reserpine is the only antihypertensive with a major side effect of depression patient becomes SUICIDAL Nursing management for suicidal patients: PROMOTE SAFETY (remove equipment that patient can use to harm himself)

SSx of Parkinsons disease:

Early sign: PILL-ROLLING TREMORS pathognomonic sign of Parkinsons Second sign: BRADYKINESIA (slowness of movement)
cogwheel rigidity intermittent jerking movement Stooped posture Shuffling Gait, Propulsive Gait

 Overfatigue Mask-like facial expression Decreased blinking of the eyes Difficulty in arising from sitting position Monotone speech Mood: Lability (depressed) prone to suicide, therefore PROMOTE SAFETY Increased salivation (drooling)
Prepare suction app at bedside

Autonomic changes: Increased sweating and lacrimation Seborrhea (oversecretion of sebaceous gland) Decreased sexual capacity

Nursing management for Parkinsons

Rx Anti-Parkinson agents: Levodopa (L-dopa) [Larodopa] short-acting anti-parkinson Mechanism: increases levels of dopamine Side effects: GIT irritation (nausea and vomiting) ORTHOSTATIC HYPOTENSION always asked in the board exam! Arrhythmia Hallucination Confusion

 Anti-Parkinsonians

Larodopa Sinemet Symmetrel Artane and Cogentin Benadryl Parlodel

Nursing management for L-dopa Best given with meals to avoid GIT irritation Inform client that his urine and stool may be darkened Instruct client to avoid foods rich in Vit B6 (Pyridoxine): cereals, green leafy vegetables and organ meats Pyridoxine reverses the therapeutic effect of levodopa

 Carbidopa [Sinemet] long-acting antiparkinson Mechanism: same as levodopa Side effects: Hypokinesia Hyperkinesias Psychiatric symptoms: EXTRAPYRAMIDAL SYMPTOMS

 Amantadine HCl [Symmetrel] Mechanism: same as levodopa Side effects: Tremors Rigidity Bradykinesia

 Anticholinergics: [Artane] and [Cogentin] Anticholinergics are given to relieve tremors Mechanism of action: inhibits acetylcholine Side-effects: SNS effects Antihistamines: Diphenhydramine [Benadryl] Antihistamines also relieve tremors Side effect for adults: drowsiness Patient should avoid driving and operating machinery Side effect for children: CNS excitability hyperactivity (paradoxical effect for young children < 2 y.o.)

 Dopamine agonists: Bromocriptine [Parlodel] Relieves tremors, rigidity and bradykinesia Side-effect: Respiratory depression, therefore CHECK RR

 Maintain siderails, to prevent injury related to falls Prevent complications of immobility: Turn to side q 2, q 1 if elderly Diet should be low-protein in AM, high-protein in PM (give milk before bedtime)
High-protein diet induces sleep (Tryptophan is a precursor to melatonin, the sleep hormone)

Increase oral fluid intake and high-fiber diet to prevent constipation

Increase intake of bran and psyllium; use bulk-forming laxatives [Metamucil]

Assist in ambulation Safety precautions: Patient should wear flat rubber shoes, and use grab bars

MYASTHENIA GRAVIS
A neurovascular disorder characterized by a disturbance in the transmission of impulse fro nerve to muscle cells at the neuromuscular junction leading to DESCENDING MUSCLE PARALYSIS. More common in women aged 20 to 40.

Etiology: idiopathic, related to autoimmune For unknown reasons, the body is producing cholinesterase which destroys acetylcholine, the neurotransmitter for muscle movement, leading to muscle weakness.

s/Sx:

Initial Sign: PTOSIS (drooping of upper eyelid) Diplopia Masklike facial expression Dysphagia Hoarseness Respiratory muscle weakness respiratory arrest (Prepare tracheostomy set at bedside) Extreme muscle weakness especially during activity or exertion

Dx test:

TENSILON TEST
Tensilon (Edrophonium HCl) is a short acting anticholinesterase Tensilon is administered via IV push If patient has MG, symptoms will be temporarily relieved (for 5 to 10 minutes)

CSF analysis reveals elevated cholinesterase levels

URINARY TRACT INFECTION

Burning pain on urination Urinary frequency Hematuria Flank pain; costovertebral angle tenderness Mgt: ACID ASH diet, increase fluid intake, perineal care Rx: SULFA DRUGS (trimethoprim, bactrim) AVOID: bubble baths

NEPHROLITHIASIS, UROLITHIASIS
PF: Acid or oxalate stones Renal colic radiating to groin Abdominal or flank pain Hematuria Mgt: Ambulation, increase fluids Removal of stones DOC: Morphine Caused by acid = ALKALINE ASH Caused by uric = PURINE-FREE Caused by oxalate = ACID - ASH

BPH Nocturia and decrease force of urine stream Elevated PSA Recommend: DRE annually Herbal: Saw palmetto TURP: Cystocylsis

ACUTE RENAL FAILURE

3 phase: OLIGURIC- u.o less than 30 cc/H (2 weeks) DIURETIC u.o 3-5 L/day (2-3 weeks) CONVALESCENT 2- 10 months Monitor weight, I/O Rx: Diuretics Low CHON diet and low potassium

CHRONIC RENAL FAILURE

NV, Dyspnea, HPN Dx: Creatinine clearance Int. weigh patient, safety (alt. LOC) Hyperphosphatemia = AMPHOGEL to bind phosphate UREMIC frost (urea crystals on skin) = wash with plain water DIALYSIS

GLAUCOMA = Halo vision, headache, loss of peripheral vision Tonometry(IOP) , Perimetry (visual field) DOC: Miotics(TIMOLOL), high fiber diet CATARACT = PAINLESS BLURRY VISION, CLOUDY OPACITY RETINAL DETACHMENT = curtain like vision

OTITIS MEDIA frequent pulling of ear (manifestation), pain, tinnitus, redness Myringotomy MENIERES DISEASE = triad: vertigo, sensorineural hearing loss, nystagmus Priority: safety Caloric test Diamox reduces fluid pressure Diet: Low sodium diet

When a person really desires something, all the universe conspires to help that person to realize his dream. Paulo Coehlo