Complex Adult Health Exam 2 Review

Shock: 1. Hypovolemic- Loss of circulating volume. How do we treat? 100% 02 w/ non-rebreather mask, anticipate & prepare for intubation, insert multiple large bore IVs, administer fluid replacement as ordered. Clinical manifestations? Restlessness (early sign), Increase rate and depth of breathing, vasoconstriction maintains B/P, tachycardia & weak thready pulse, low urine output, skin becomes cold, clammy, and cyanotic, thirst, coma (late sign). 2. Anaphylactic- Severe allergic reaction Treatment: Remove trigger, 100% 02, insert IV and administer IVFs, IV epinephrine, antihistamines, corticosteroids, inhaled bronchodilators, Teach EpiPen. 3. Neurogenic Shock- Excess parasympathetic activity (low vitals). Treatment: Administer IVFs, IV meds: atropine, vasoactive (constricts vessels) drips, heparin, Prepare for transcutaneous pacing Nursing management: Raise HOB slowly, apply venous thromboembolism prophylaxis. 4. CVP- Central venous pressure is an assessment of venous return, blood volume and, indirectly, of cardiac output. Increased: CVP is increased by either an increase in venous blood volume or by a decrease in venous compliance. Normal range is 8 to 12 mmHg. What does that mean? Fluid overload, cardiogenic shock, HF, Pulmonary artery stenosis, Left ventricular failure. Emergency: 1. How do we stabilize a suspected neck injury? Stabilize the spine with: • Cervical collar (C-collar) •Cervical immobilization device (CID) | 2. Unstable pelvic fracture management: External fixation, w/ strict bed rest. 3. Flail Chest- what does it look like? paradoxical/asymmetric chest wall movement. The area of the chest that's been traumatized will draw in when pt. breathes in, while the rest of the chest expands outward. 4. Triage- ABCs (Airway is always 1"), then Breathing & Circulation. 5. START triage method: → image 6. Blood transfusion: Supplies needed? Blood Unit, Blood administration set w/ filter, 0.9 NS, 18 or 20 G needle. Incorrect blood from lab- what now? 7. Primary survey- Focuses on ABCs, vitals, family presence, Get resuscitation adjuncts (labs, ECG, nasogastric/orogastric, Oxygen/ventilation, pain management, comfort Neuro: 1. Epidural hematoma- EXPECTED findings: brief lucid interval (A/O), then decrease LOC, N/V. 2. CSF- what does it look like? Where could it drain from? CSF looks like a halo around blood. May leak from nose (rhinorrhea) or ear (otorrhea). Test for glucose to confirm. 3. Stroke S/S: → image How do we diagnose: Neuro/Motor assessment, FAST, Glasgow Coma Scale. Nursing management: Avoid pulling on pt. shoulder (dislocation risk), posterior leg splints, footboards, or high-topped shoes to prevent footdrop. Hand splints to decrease spasticity. Treatment: Alteplase for Ischemic Stroke w/in 3 hrs. of start of symptoms. 4. Bacterial meningitis Treatment: Antibiotics (Cephalosporins) stroke on richt sido • Paralyzod loft did Nursing management: Give fluids, Meds, decrease stimuli, Pain management, HOB 30 degrees, transmission precautions, normothermia. EXPECTED clinical manifestations: Headache, stiff neck, fever, sensitive to light, altered mental status, muscle pain, Kernig's sign (leg won't extend when lying flat & cause pain), and Brudzinski's sign (passive flexion of neck elicits hip & knee flexion). 5. Autonomic Dysreflexia: Clinical manifestations: HTN, 6. Nursing interventions to lower ICP: Mannitol, & Hypertonic Saline, suction as needed, discourage coughing, 7.Increasing ICP clinical manifestations: Early: Restlessness, Anxious, Irritability, Disoriented, Behavior changes. Late: Severe HA, projectile vomiting, Nausea, seizures, papilledema. Cushing Triads: (Late sign of ICP- vitals changes) Increase systolic B/P, weak pulse, Irregular breathing and pattern. -GSC: when to alert HCP: decreasing GCS/ changes in LOC. → image. -Decorticate posturing: Flexor; Feet & Hands moved in towards body. -Homonymous Hemianopsia- Nursing management -Left and right brain stroke- clinical manifestations of both Burns: 1. Triage- think Airway first 2. Burns to the head/chest- priority assessment? Respiratory obstruction. 3. Rule of nines: → Image 4. Type of fluid used in burn patients: Lactated Ringers (LR) 5. Nursing management/plan of care for burns of abdomen and lower extremities: May develop compartment syndrome, pt. may have decrease nutrient absorption, and Gl motility. TPN may be needed. Promote restoration of mobility. 6. EXPECTED lab work in burn patients: Initial Fluid Shift (first 24 hrs.): Elevated Hgb/Hct. Low sodium. Potassium increase. Fluid Mobilization: Low Hct/hgb. Low Na. K+ increases. High glucose, metabolic acidosis, slight hypoxemia, Low protein & albumin levels. 7. Absent bowel sounds- what next? NG tube placement for gastric lavage and TPN. 8. Burns to hands, feet, and joint nursing management: wrap fingers individually from hand Encourage mobility to prevent contractures. 9. What type of diet to help promote healing? Extra calories and protein._ Exam 2 Review 70 QS AKI/CKD: 1. AKI- Creatinine: >1.3 and low GFR means bad kidneys. 2. Peritoneal dialysis: Signs of infection: cloudy/ bloody drainage, fever Peritonitis: fever, abdominal pain, ascites, n/v. 3. Diets for End Stage Renal Disease patients: Low Potassium (2-4 grams/day), Low Sodium (2-4 grams/day), Low Phosphorus (<1,000 mg/day), Low Protein (0.6 - 0.8 g/kg/per day). Fluid restriction. High calories, fats, and carbs. 3. Oliguric phase clinical manifestations: Low urine output. Low sodium levels. Fluid overload. 4. Labs associated with AKI: Elevated BUN, Creatinine, Potassium. Low pH, bicarbonate, Hct & Hgb. Urinalysis: cast, cellular debris. Decrease specific gravity. 5. EXPECTED lab work for CKD: Low GFR levels, High BUN, Creatinine, Potassium. Low pH and bicarbonate levels. Low Hct & Hgb. Urinalysis: cast, proteinuria, glycosuria, erythrocytes, leukocytes. 6. Nursing management for CKD patients: Monitor electrolytes (k+), Hydrate carefully. Risk for bleeding. Monitor for dialysis complications. Low Na, K, phosphate diet. Fluid/protein restrictions. 7. Low protein diet needed- why? To reduce workload on the kidneys. 8. Assessing an AV graft/fistula: Feel for a thrill and Listen for a bruit. Endo: 1. Hypoglycemia- clinical manifestations: cool, clammy skin, shaky, diaphoresis, weakness, fatigue, confusion, irritable, anxiety, headache, blurred vision, tachycardia. 2. DKA- clinical manifestations: polyuria, polydipsia, polyphagia, kussmaul's respirations, metabolic acidosis w/ ketones in urine, acetone breath, altered mental status, blurred vision, headache, weak, rapid pulse, orthostatic hypotension, anorexia, N/V, abdominal pain. 3. Addison's disease- cause: hyposecretion of adrenal cortex hormones caused by autoimmune disease, TB, adrenalectomy, tumor, HIV, or abrupt cessation of steroid medication. 4. Cushing's disease- cause: Hypersecretion of the glucocorticoids caused by hyperplasia of the adrenal cortex or pituitary gland tumor. From exogenous use of steroid medications. clinical manifestations: moon face, buffalo hump, upper body obesity, thin extremities, striae, osteoporosis, hyperglycemia, hypernatremia, hypokalemia, hypocalcemia, hirsutism, amenorrhea, elevated triglycerides and HTN. 5.Diabetes Insipidus- Clinical manifestations: Hypotension, weak pulse, tachycardia, hyperglycemia, increase urinary output, dehydration symptoms, hemoconcentration. Plan of care: daily weights, monitor urine output, assess B/P & HR, fluid/electrolyte balance. Treatment: Lifetime desmopressin, vasopressin, thiazide diuretics. Assessment: monitor urine specific gravity to monitor fluid status, decrease urine specific gravity and urine osmolality, water deprivation test, vasopressin test, MRI, 24-hour urine. 6. Hep A- how to prevent transmission: hand hygiene, & vaccination for ages 2 and older. Exam 2 Review 70 Qs 7. Hep B- Intramuscular injection steps: 3 fingers below the acromion process, insert needle at a 90-degree angle. 8. Hep C- precautions: No IV drug use, unprotected sex, blood products; organ transplant before 1992, no blood-to-blood contamination. Avoid high risk behaviors, no vaccine available. GI: 1. Cirrhosis- EXPECTED findings: jaundice, N/V, hepatomegaly, anorexia, esophageal varices, ascites, bleeding tendencies or DIC (liver impacts synthesis of clotting factor) 2. Hepatic encephalopathy- accumulation of ammonia and toxins in blood causes altered mental status. nursing management: lactulose, avoid high protein, monitor fluid/electrolytes, neuro checks. clinical manifestations: 3. Pancreatitis- which labs will be elevated? Amylase, Lipase, glucose, and triglycerides. EXPECTED findings: Cullen's sign, Turner sign, sudden LUQ pain, hiccups, N/V, anorexia, fever, HTN, pain after meals or when lying down, weight loss, steatorrhea. 4. CHRONIC pancreatitis- signs that they should be evaluated by their HCP/hospital: Upper abdominal and back pain w/ vomiting!| 5. Anorexia/malnutrition- EXPECTED lab work: Low Serum prealbumin, albumin, transferrin, lymphocytes, vitamins. 6. TPN- Nursing management: Keep HOB 30-45-degree angle, residual, maintain infusion, prevent infection. Things to monitor: Fluid overload, glucose levels, aspiration, constipation, vomiting, diarrhea, dehydration, skin breakdown, tube clogged, tube placement, body weight,