Mz. Anticholinergic vs. Cholinergic Effects Part 2

CONGENITAL HEART DEFECTS Every congenital heart defect is either TRO TROUBLE UBLE or NO TROUBLE T R o u B L e R - L ! Blood shunts B ! Cyanotic T ! All CHD’s beginning with “T” are trouble Exception ! Left ventricular hyperplasic syndrome Examples&of&“Trouble”& • • • & & & & & & & & Tricuspid! Tricuspid!arterioles! Tetralogy!of!Fallot! Examples&of&“No&Trouble”& • • • • Ventricular!septal!defect! Patent!foramen!ovale! Patent!ductus!arterioles! Pulomary! All CHD kids have two things whether trouble or not: 1. Murmur 2. All get echocardiogram done (@ least 1) Four defects present in Tetralogy of Fallot: 1. V arieD D ! Ventricular Defect 2. P ictureS S ! Pulmonic Stenosis 3. O f A ! Overriding A orta 4. R ancH H ! Right Hypertrophy CRUTCHES, CANES, & WALKERS 1. How to measure: 2 - 3 finger widths below anterior anxillary fold to a point lateral to and slightly in front of foot 2. When the handgrip is properly placed, the angle of elbow flexion will be 30 degrees 3. Types of gaits: a. 2 - Point Gait i. Step One: Move one crutch and opposite foot together ii. Step Two: Move other crutch and other foot together iii. Remember: 2 points together for a 2 point gait iv. Examples: one knee replacement b. 3 - Point Gait i. Step One: Move two crutches and bad leg together ii. Step Two: move good foot by self iii. Remember: 3 point is called 3 point because three points touch down at once iv. Examples: Stairs c. 4 - Point Gait i. Step One: One crutch ii. Step Two: Opposite foot iii. Step Three: Other Crutch iv. Step Four: Other food v. Examples: total both knee right after surgery d. Swing Swing-- through: for two braced extremities i. Examples:: arthritis braced legs 4. When to use each gait a. Use the even numbered gaits (2&4 point) when weakness is evenly distributed (bilateral). Two point for mild problem; four-point for severe problem b. Use the odd numbered gait (3 point) when one leg is odd (unilateral problem) 5. Stairs: which foot leads when going up and down stairs on crutches? a. Remember: UP with the good; DOWN with the bad b. The crutches always move with the bad leg 6. Cane a. Hold can on the strong (unaffected) side b. Advance cane with the weak side for a wide base of support 7. Walkers a. Pick it up, set it down, walk to it b. Tie belongings to side of walker, not front c. Getting out of chair to walker- always push, never pull (same for cane, crutches) DELUSIONS, HALLUCINATIONS, & ILLUSIONS 1. Psychotic vs Non-Psychotic a. A non-psychotic person has insight & is reality based b. A psychotic person has NO insight and is NOT reality based 2. Delusions a. Definition: a delusion is a false, fixed belief or idea or thought. There is no sensory component. b. Three types of delusions: i. Paranoid or Persecutory: false, fixed belief that people are out to harm you. ii. Grandiose: False, fixed belief that you are superior iii. Somatic: False, fixed belief about parts of your body 3. Hallucinations a. Definition: a hallucination is a false, fixed sensory experience b. Five types of hallucinations: i. Auditory (most common* hearing) ii. Visual iii. Tactile iv. Olfactory v. Gustatory 4. Illusions a. Definition: An illusion is a misinterpretation of reality. It is a sensory experience. b. Differentiation between illusions & hallucinations: with illusions there is a referent in reality 5. When dealing with a patient experiencing delusions, hallucinations or illusions, first ask yourself, “What is their problem?” a. Functional Psychosis b. Psychosis of Dementia c. Psychotic Delirium 6. Functional Psychosis a. These are: i. Schizophrenia ii. Schizoaffective Disorder iii. Major Depression iv. Mania b. Patient has the potential to learn reality c. Four steps: i. Acknowledge how they feel ii. Present reality iii. Set a limit iv. Enforce the limit 7. Psychosis of dementia a. These are: i. Alzheimers ii. Senility iii. Organic Brain Syndrome iv. Post Stroke v. Wernickes b. This patient has a destructive problem and cannot learn reality. c. Two steps: i. Acknowledge their feelings ii. Redirect 8. Psychotic delirium a. Description: Episodic, temporary, sudden onset, dramatic, loss of reality, secondary to a chemical imbalance b. Two steps: i. Acknowledge their feeling ii. Reassure (it will get better, I will keep them safe) 9. Loosening of association a. Flight of Ideas: stringing phrases together b. Word salad: string words together c. Neologisms: making up new words 10. Narrowed self self-- conc conce e pt: a. when a PSYCHOTIC refuses to: i. Leave the room and refuses to change their clothing ii. Action- do not make them! Tell them they can wait until they are ready 11. Ideas of reference a. When you think everyone is talking about you DIABETES MELLITUS 1. Definition: DM is a error of glucose metabolism a. (vs Diabetes Insipidus polyuria, polydipsia leading to dehydration) 2. Types: a. Type I i. I nsulin dependent ii. J uvenile Onset iii. K etosis prone (tend to make ketones) b. Type II i. “Non” all the above ii. “Non” insulin dependent iii. “Non” juvenile onset iv. “Non” ketosis prone 3. Signs and Symptoms a. P olyuria b. P olydipsia c. P olyphagia 4. Treatment a. Type I i. Diet (3) ii. Insulin (1) iii. Exercise(2)) b. Type II i. Diet (1) ii. Oral hypoglycemics (3) iii. Activity (2) c. Diet (type II) i. Calorie restriction ii. Need to eat 6x a day d. Insulin acts to lower blood sugar i. Types of insulin Type&of&Insulin& REGULAR&(clear,!short! acting,!rapid;!IV)& NPH&(cloudy,! intermediate!acting)! HUMALOG&(Insulin& Lispro)&(Worlds! fastest!acting;!give! with!meals)! Lantus&(Glargine)& (long!acting!insulin)! Onset& 1!hour! Peak& 2!hours! Duration& 4!hours! 6!hours! 8-10!hours! 12!hours! 15!minutes! 30!minutes! 3!hours! Slow!absorption! No!peak,!therefore!no! risk!of!hypoglycemia! 12-24!hours! ii. Check expiration date 1. After open new expiration date 20-30 days after opening iii. Refrigeration: optional for opened; necessary for unopened e. Exercise Potentiates (decreases) insulin: i. If more exercise, need decrease insulin ii. If less exercise, need increase insulin f. Sick days i. Take insulin (even if not eating!) ii. Take sips of H20 to prevent dehydration iii. Stay as active as possible 5. Complications of DM a. Low Blood Sugar in Type I DM (=insulin shock) [Hypoglycemia] i. Causes: 1. Not enough food 2. Too much exercise 3. Too much insulin ii. Danger: 1. Permanent brain damage iii. Signs and Symptoms 1. Cerebral impairment & vasomotor collapse (blood vessel wall muscles don’t have enough E to maintain tone) ! slurred speech, staggered gait, abnormal reaction time, uncontrolled emotions, lowered BP, increased pulse, skin pale, cold, clammy, inattentive to social boundaries iv. Treatment 1. Administer rapidly metabolizable Carbohydrates (sugar) b. c. d. e. f. 2. Ideal combination: food with sugar and protein (& maybe starch) 3. If unconsciousness: Nothing! Glucagon IM, Dextrose IV, never anything in mouth! High Blood Sugar in Type I DM- DKA Diabetic Coma [Hyperglycemia] i. Causes: 1. Too much food 2. Not enough insulin 3. Not enough exercise 4. #1 cause is acute viral upper respiratory infection within the last week or two ii. Signs and Symptoms 1. D ehydration (appear dry, hot, flush, HA, pulse weak, thready, increase in temp) 2. K etones (in urine & blood); increase in K+; Kussmaul respirations 3. A cidodic; acetone (fruity) breath; anorexia with nausea iii. Treatment 1. IV with regular insulin @ 200/hr at high flow rate Low Blood Sugar in Type II DM (Hypoglycemia) i. Treatment is the same as for low BGM in Type I Diabetes High Blood Sugar in Type II DM (Hyperglycemia) i. Called HHNK (or HHNC): 1. Hyperosmolar, hyperglycemic, non-ketotic coma ii. This is dehydration iii. Signs & symptoms are like S&S of dehydration 1. Including: increased temp iv. Treatment: rehydrate (glucose will usually turn to normal on own) Long term complications are related to two problems: i. Problems with tissue perfusion ii. Peripheral neuropathy (nerve damage) Which lab test is the best indicator of LT BGM control (compliance/effectiveness) ? Hemogl Hemoglobin obin A1C i. HA1 C for dx ! >6.5 ! DM/pre DM ii. Monit Monito o ring tx ! >7.0 out of control DRUG TOXICITIES DRUG& Lithium!(antimania)! Lanoxin!(uses!#1!CHD!#2!atrial! arrhythmias)!! Aminophylline!!(airway! antispasmodic)! Dilantin!(seizures)! Bilirubin!(not!a!drug)! • • • THERAPEUTIC&LEVEL& 0.6-1.2! 1-2! >!2.0! >2! 10-20! >20! 10-20! Elevated!hyperemibilirubin! 10-20! Toxic!>20! >20! Kernicterus* • Bilirubin!>20;!crosses!BBB! in!CSF-!invaded!brain! causes!encephalitis! meningitis! Opisthotonos* • Position!of!extension!seen! with!kernicterus* • Arching!d/t!bili!irritation!in! brain* • Place!this!child!on!his/her! side* Total bilirubin: 0-1.0 mg/dl Direct (conjugated) bilirubin: 0-0.3 mg/dL Indirect (unconjugated) bilirubin: 0-0.3 mg/dL TOXIC&LEVEL& DUMPING SYNDROME VERSUS HIATAL HERNIA & HIATAL&HERNIA&(2& chambered&stomach)& DEFINITION& • • SIGNS&&&SYMPTOMS& Treatment& 1. HOB!during!&!1!hour!after! meals& 2. Amount!of!fluids!with!meals& 3. Carbohydrate!content!of! meals& DUMPING&SYNDROME& Regurgitation!of!acid!into! • esophagus,!because!upper! stomach!herniates!upward! through!the!diaphragm!! Gastric!contents!move!in!the! ! wrong!direction!(UP!instead! • of!DOWN)!direction!at!the! correct!rate! Upper!GI!S/S:! • Indigestion! • Heart!burn! • GERD! • Chest!pain! 1. Raise!HOB!(High! Fowlers)! 2. High!Fluids! 3. High!Carbs!(Decrease! Protein)! Post!op!gastric!surgery! complication!in!which! gastric!contents!dump!too! quickly!into!the!duodenum! Gastric!contents!move!in!the! correct!(DOWN)!direction!at! the!wrong!(too!fast)!rate! Lower!GI!S/S! • Acute!lower!abdominal! distress:!diarrhea,! cramping,!gas,!abdominal! pain,!cramping,!guarding,! splinting,!rigidity,! distension! • Drunk!(look),!all!blood! going!to!gut!not!brain!(! cerebrally!impaired;! confused! • Shock:!blood!in! parasympathetic!system;! pale,!cold,!clammy,! decreased!BP,!rapid!pulse! • D&S&hypoglycemis! 1. Low!HOB! 2. Low/Restricted!fluids-! in!between!meals! 3. Low!Carbs!(Increase! Protein)! ELECTROLYTES KALEMIAS&do!the!same!the!prefix!except!for!heart&rate!and!urine&output& HYPERKALEMIA ↑ HR ↓ U UO O HYPOKALEMIA ↓ HR ↑ UO ! & & & & & & & & & & & & & & & CALCEMIAS&do!the!opposite!the!prefix.!No!exceptions.![&!anything!to!BP]! HYPERCALCEMIA ↓ & & & & & & & & & & & & & & & HYPOCALCEMIA ↑ ! ! ! ! ! ! ! ! ! ! ! Two!signs!of!neuromuscular!irritability! associated!with!low&calcium:& 1. Chovostek’s&sign&↑ Tap cheek ! spasm 2. Trousseau’s&sign&↑ & &&&&&&&Put!on!BP!cuff!and!arm!goes!into!carpal! spasm(!arm!looks!like!swan!neck)! MAGNESEMIAS&do!the!opposite&the!prefix! Note:!In!a!tie,!never!pick!Mg.!If!symptom!involves!nerve!or!skeletal!muscle,!pick!Calcium.!For!any! other!symptom,!pick!Potassium& HYPOMAGNESEMIA ↑ HYPERMAGNESEMIA ↓ ! & & & & & & & & & & & & & & & NATREMIAS& HYPERNATREMIA “E” ! dehydration • • • • • & & & & & & & & & & & & & & Poor!skin!turgor! Dark!urine! Hot!flushed!skin! Increase!urine!specific!gravity! Weak,!thready!pulse! • • HYPONATREMIA “O” ! over load Increased!weight! edema! The earliest sign of any electrolyte disorder is numb numbn n ess (paresthesia) & tingling The universal sign/symptom of electrolyte imbalance is muscle (paresis) weakness ELECTROLYTE TREATMENT 1. Never push Potassium IV [Fatal] 2. Not more than 40 mEq of K+ per liter of IV fluid [clarify if over 40] 3. Give D5W with regular insulin to decrease K+ [carrier mediated transport] 4. Kayexalate [K-exit-late] a. Puts drug in gut, full of sodium; Na picked up by bloodstream; Doesn’t need that much + charge, so body exchanges for K, diarrhea) b. B/C is slow ! do this with D5W + insulin ENDOCRINE OVERVIEW Thyroid 1. Hyperthyroidism (Hyper-Metabolism) i. Signs & Symptoms 1. ↓ weight ♦ tachycardia ♦↑ BP♦ Agitation♦ Restlessness♦ nervousness ♦ diarrhea♦ ↑ energy energy♦ bulging eyes ♦ warm♦ <3 organ most effective ii. Graves Disease [literally run self into grave] iii. The problem is hyperthyroidism. Treatment options: 1. Radioactive Iodine a. Watch out for urine [DANERGOUS] i. Use private bathroom ii. Flush 2-3 times 2. PTU (Protothyroidircil) *sp a. Cancer drug-knocks out cells metastizing problem- agranulocytosis (↓ WBC) b. Education- isolation, wear mask, no kids 3. Surgical removal a. Thyroidectomy (remove thyroid) i. T otal thyroidectomy 1. Need lifelong T3, T4 hormone replacement 2. At risk for hypocalcemia (bc at risk for loosing parathyroid gland) 3. S/S hypocalcemia: tetany a. Earliest sign: paresthesia ii. Subtotal thyroidectomy 1. At risk for thyroid storm 2. S/S thyroid storm: a. Very high fever >104 F b. Very high V/S c. Psychotic Delirium *life threatening priority 3. Treatment a. Wait out: either die, come out, give O2 and lower body temp b. Tx focuses on saving the brain until they come out of it c. Lowering body temp: i. Ice packs: on axilla, axilla, groin, groin, back, neck ii. Cooling blanket iii. Post-op risks 1st 12 hours airway&hemorrhage • **after first 12 ours it is assumed that the patient is stable • Post-op risks 12-48 hours for calc c ium ((tetany) tetany) TOTAL: ↓ cal • Post-op risks 12-48 for SUBTOTAL: Thyroid storm 2. Hypothyroidism (Hypo-Metabolism) a. Signs & Symptoms i. ↑ weight♦ cold♦ sluggish♦slow♦ decreased BP♦bradycardia♦ hair and nails brittle♦decreased E b. c. d. e. Name of disease: mxyedema Treatment: thyroid pills Caution: DO NOT sedate these patients! (already ↓ ) Surgical Implication: call anesthesiologist and ask if thyroid pills should be held. Do not do well with anesthesia Adrenal Cortex Diseases (start with letters A or C) 1. Addison’s Disease a. Under secretion (too little) of adrenal cortex b. Signs & Symptoms