Adult Health

ADULT HEALTH Integumentary System 1 2 3 4 Unstageable Pressure Ulcer Staging Skin intact, non-blanchable with local redness Open, shallow, red/pink colour, no slough, intact or open blister Full thickness skin loss, possible visible fat, NO bone/muscle showing Full thickness skin loss with bone, tendon, or muscle showing Full thickness with slough (scabbing) or eschar (necrotic tissue) Wound Exudate: Serous – clear/straw; part of normal healing process Serosanguineous – pink (mix of blood and serous drainage); part of normal healing process Sanguineous – red (blood vessel trauma); uncommon in wounds Hemorrhage – frank blood from leaking blood vessel; uncommon Purulent – yellow, gray, or green; due to infection Shingles: Also known as Herpes Zoster. Due to reactivation of varicella-zoster in a pt with a history of chicken pox. Eruption occurs in a unilateral segmental distribution on the skin along the infected nerve Shingles is contagious to people who have never had chickenpox and to those who haven’t been vaccinated against the disease S/S: unilateral clustered skin vesicles, fever, burning/pain, pruritis Priority: 1. Pt should be on contact precautions 2. Pt should avoid scratching the area MRSA: Can appear as folliculitis or furuncles (C+S of skin will confirm presence of MRSA) Priority: 1. Contact precautions 2. Monitor pt for S/S of injection Burns: Superficial-thickness burn – damage to epidermis; pink/red with no blisters; heals in 3-6 days Superficial partial-thickness burn – damage into the dermis; pink/red with blisters and edema; heals in 10-21 days Deep partial-thickness burn – deeper into the dermis, red skin with white dry areas + no blisters due to dead tissue; heals in 3-6 wks Full-thickness burn – destruction of epidermis + dermis; waxy white, deep red, brown or black dry + hard skin; healing takes weeks-months (involves skin grafting) Deep full-thickness burn – injury extends to muscle/bone/tendons; skin is black and hard; healing takes months (involves skin grafting) Priority: 1. Airway patency (suction, ET tube, mechanical ventilation) 2. O2 3. VS 4. IV fluid replacement (prevents shock) 5. Keep pt warm 6. NPO 7. Assess for S/S of infx (fever, high WBC, purulent drainage, redness) Blood Level 1-10% 11-20% 21-40% 41-60% 61-80% Carbon Monoxide Poisoning S/S Normal level Headache, flushing, decreased vision, decreased cerebral function, slight breathlessness Headache, nausea/vomiting, drowsy, vertigo, confusion, pale skin, hypotension, tachycardia Coma, seizures Death 11 TED Stockings: Graduated compression that promotes venous return and decreases risk of VTE Priority: 1. Proper size 2. No folds/wrinkles 3. Wounds are covered with dressings Psoriasis: Autoimmune disease, causing rapid turnover of cells; no cure S/S: silver plaques on reddened skin Priority: 1. Avoid triggers (stress, trauma, infection) 2. Topical corticosteroids 3. Phototherapy 4. Medication (methotrexate) 5. Avoid alcohol Endocrine System Hypoglycemia Cold, clammy, irritable, pale, weak, diaphoretic Hyperglycemia Polyphagia, polyuria, polydipsia, blurred vision, fruity breath, hot + dry Insulin Type Rapid acting (Lispro, Aspart, Glulisine) Short acting (Regular) Intermediate acting (NPH) Long acting (Glargine, Detemir) Hormone Cortisol – adrenal gland Thyroid Onset <15 minutes 1-2 hrs Peak 3-6 hrs Duration 30-60 minutes 2-4 hrs 6-10 hrs 2-4 hrs 4-8 hrs 10-18 hrs 1-2 hrs NO PEAK Up to 24 hrs Hormone Imbalance HypoHyperAddison’s Cushing’s Lethargy, fatigue, muscle weakness, weight loss, Muscle weakness + wasting, moon face, truncal impotence, hypoglycemia, hypotension, obesity, hirsutism (masculine features in F), hyperpigmentation of skin hyperglycemia, HTN, fragile skin bruises easily, striae Addisonian Crisis on abdomen Priority: 1. Strict intake + output monitoring 2. Daily Caused by stress, infection, trauma, surgery. Can weights lead to hyponatremia, hyperkalemia, hypoglycemia, and shock *Lifelong glucocorticoid therapy Priority: Follow 5 S’s (salt replacement, sugar/ dextrose replacement, steroid replacement, support physiologic function, search for + treat cause) T4 is low, TSH is high T3 + T4 are high, TSH is low Lethargy, fatigue, weakness, cold intolerance, Irritability, fine tremors, heat intolerance, weight weight gain, dry skin, bradycardia, constipation, loss, smooth skin, palpitations + cardiac edema (myxedema), cardiac enlargement, goiter dysrhythmias, diarrhea, exophthalmos, HTN, goiter Myxedema Coma Due to persistently low thyroid production Thyroid Storm Due to uncontrollable hyperthyroidism 12 Parathyroid ADH – posterior pituitary Insulin - Pancreas S/S: hypotension, bradycardia, hypothermia, hyponatremia, hypoglycemia, edema, resp failure, coma *Levothyroxine is most commonly prescribed Hypocalcemia, hyperphosphatemia, tingling, muscle cramps, positive Trousseau’s + Chvostek’s sign, tetany, hypotension *Calcium gluconate IV, Vit D for enhancing absorption of Ca Diabetes Insipidus Large amount of urine excretion, polydipsia, dehydration, low urine specific gravity, fatigue, postural hypotension Priority: 1. Monitor electrolytes 2. Maintain fluid intake 3. Monitor intake + output, weight, serum osmolality, and urine specific gravity S/S: fever, tachycardia, HTN, agitation + tremors, confusion, seizures, delirium, coma Hypercalcemia, hypophosphatemia, fatigue, muscle weakness, bone deformities, anorexia, nausea/vomiting, weight loss, constipation, HTN *Calcitonin will decrease Ca release and increase Ca excretion Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Leads to water intoxication and hyponatremia Fluid overload, change in LOC, weight gain, HTN, tachycardia Priority: 1. Monitor neuro status 2. Monitor intake + output, weight, serum osmolality, and urine specific gravity 3. Restrict fluid intake 4. Administer diuretics 5. Seizure precautions Type 1 DM -Insulin deficiency (beta cells are destroyed). If insulin is not given, fats are metabolized for energy (which results in ketone production → acidosis) Type 2 DM -Lack or resistance to insulin Diabetic Ketoacidosis (DKA) -CBG 14-28 -Sudden onset, due to inadequate insulin dose -Hyperglycemia, high ketones in urine, confusion, fruity breath, ++ thirst, urination, Kussmaul’s respiration Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) -CBG >33 -Gradual onset, due to poor fluid intake. -Altered CNS function, ++ thirst, urination, lethargy, coma, no ketones in urine *For DKA + HHNS – give IV NS first, then when CBG is 250-300 mg/dL dextrose is added to IV fluids. K+ levels may be elevated due to acidosis and dehydration Dawn Phenomenon -Reduced tissue sensitivity to insulin (between 5-8am) causing pre-breakfast hyperglycemia Somogyi Phenomenon -Normal or elevated glucose level @ hs, hypoglycemia @ 2-3am causing increase in counterregulatory hormone, and by 7 am glucose levels are increased Metabolic Syndrome: 3 or more of the following factors are present, which increase pt’s risk for stroke, diabetes, and cardiovascular disease → abdomen obesity (male > 40 inches, female > 35 inches), high triglyceride level (> 150 mg/dL) , low HDL (male <40, female <50), HTN, or fasting blood sugar > 5.6 13 Hematology/Oncology System Cancer – uncontrolled cell growth leading to potentially serious health problems 1 2 3 4 5 Cancer Grading + Staging Grade Stage Cells differ slightly from normal cells + are well differentiated Carcinoma in situ Cells more abnormal and moderately differentiated Tumor limited to tissue of origin Cells very abnormal and poorly differentiated Limited local spread Cells are immature, undifferentiated, and cell of origin is Local and regional spread difficult to determine Distant metastasis Warning signs of ca: sore that doesn’t heal, indigestion, hoarseness, obvious change in wart/mole (ABCD), lump in breast, unusual bleeding Tests: Mammogram, Pap smear, rectal exam, colonoscopy, BSE, TSE, skin inspection Biopsy: definitive means of diagnosing cancer (surgical incision is made in the tissue which is then examined under a microscope) Chemotherapy: kills or inhibits reproduction of neoplastic cells and also kills normal cells (skin, hair, GI lining most affected) Radiation: destroys cancer cells with minimal exposure to normal cells. Effective only for tissues in direct path of radiation beam - Wash irradiated area with water + soap daily, do not remove the markings for the radiation beam, do not use powders/lotions/creams on skin @ radiation site, avoid any clothing or binding that will rub the skin too much @ the radiation site, avoid exposure to sun *Infection is a major cause of death in an immunosuppressed pt Sickle Cell Crisis: Sickled blood cell shape = RBC cannot carry oxygen Inadequate O2 or hydration worsens the sickling by making the RBCs clump together → vaso-occlusion Priority: 1. IV fluids (decreased blood viscosity) 2. Supplemental O2 Breast cancer: Non-modifiable risk factors: female > 50 yrs, 1st degree relative of person with breast ca, BRCA1 + BRCA2 mutations, hx of endometrial or ovarian ca, menarche before 12 yrs or menopause after 55 yrs Modifiable risk factors: smoker, alcohol consumption, high fat intake, sedentary life, hormone therapy postmenopause Breast Self Exam: Perform in shower when skin is slippery, use R hand to examine L breast (and vice versa), use small circular motions in a spiral motion to examine entire breast, check for lumps/hard knots/thickening of tissue In the mirror with hands at side: raise arms overhead and assess for any changes in shape of breasts/dimpling/change in nipple. Next, place hands on hip + press firmly (tightens pectoral muscles) and observe for changes in symmetry. When lying down, feel breasts in spiral motion Testicular Self Exam: Best to assess right after a shower (scrotal skin is relaxed/moist). Gently lift each testicle (should feel like an egg with no lumps), roll each testicle between thumb and middle finger to feel for lumps/swelling/mass. Notify physician if any changes are noted from one month to the next Post-Mastectomy: 14 Avoid overusing the affected arm during the first few months, keep affected arm elevated to avoid lymphedema, avoid strong sunlight on affected arm, do not let affected arm hang dependently, avoid constricting clothing + blood work + blood pressure assessment on affected arm Immune System HIV: Standard precautions are used; HIV is spread only when nonintact skin is in contact with pts blood, breast milk, semen, vaginal secretions Priority: 1. Protect pt from infection 2. Aseptic technique for all procedures AIDS: Viral disease due to HIV (T cells are destroyed → pt is at high risk for infection and malignancy) Incubation period can be up to 10 yrs S/S: low WBC, low plt, low CD4, high CD8, high IgG + IgA, weakness, fever, weight loss, leukopenia, night sweats, infections, neoplasms (Kaposi’s sarcoma), fungal infections, vital infections, bacterial infections High risk: hetero or homosexuals involved with high risk person, IV drug user, pt receiving blood products, healthcare workers, babies born to infected mom Priority: 1. O2 as needed 2. Monitor for infx 3. Standard precautions 4. Meticulous skin care Anaphylaxis: Immediate hypersensitivity reaction with release of histamine S/S: dizzy, paresthesia, pruritis, angioedema, urticaria, narrowing airway, wheezing, stridor, SOB, respiratory arrest, hypotension, tachycardia, cardiac arrest, abdo pain, nausea + vomiting Priority: 1. Patent airway 2. O2 administration 3. IV normal saline infusion 4. Prepare diphenhydramine and epinephrine SLE: S/S: butterfly rash, dry rash on upper body, fever, weakness, weight loss, photosensitivity, joint pain, red palms, anemia Priority: 1. Mild soap on skin 2. Frequent oral care 3. High vitamin and iron diet 4. Conserve energy and avoid direct sunlight exposure 5. Topical corticosteroids Scleroderma: Inflammation, fibrosis, and sclerosis of connective tissue; no cure S/S: pain, stiff muscles, pitting edema, tight, shiny, thick, and hard skin, dysphagia, contractures Renal crisis is a life-threatening complication → causes HTN due to narrowing of blood vessels going to kidney Lyme Disease: Due to Borrelia burgdorferi from tick bites S/S: ring shaped rash (can occur anywhere on body, not only @ site of bite) Priority: 1. Remove tick 2. ABX administration 3. Have pt avoid woody areas 4. Have pt wear long sleeved tops and long pants when outside 5. Use tick repellent Immunoglobulins IgA – viral protection IgD – unknown function IgE – allergy + parasitic infestation IgG – secondary antibody protection IgM – primary antibody protection 15 Neurological System Neuro Exam: GCS, PERRLA, CSMT (colour, sensory, motor, temperature), VS Cerebellum: 2 major functions: voluntary movement (test: finger tapping, finger to nose, heel to shin) + balance/posture (test: gait, heal to toe) Basilar Skull #: S/S: battle sign (bruise behind ear), periorbital hematoma (racoon eyes), CSF leakage from nose/ear Priority: 1. Support ABC 2. C-spine immobilization 3. Neuro monitoring Posture: Decorticate indicates non-functioning cortex Decerebrate indicates brainstem lesion LOC: *Most sensitive indicator of neuro status Pupils: Normal size: 3-5 mm Tonic Clonic Absence Seizures Tonic: Stiffening of muscles followed by loss of consciousness Clonic: hyperventilation + jerking of extremities Brief, no loss or change in muscle tone Appears as though pt is daydreaming More common in children Generalized jerking Sudden loss of muscle tone; pt may fall to floor as a result Succession of seizures without intervals of consciousness (can result in brain damage) Myoclonic Atonic Status Epilepticus Chronic seizures = epilepsy Priority: 1. Assist pt to lie down 2. Position on side (maintains patent airway, allows for drainage of secretions, and prevents tongue from occluding airway) 3. Loosen restrictive clothing 4. O2 as needed 5. Record time + duration of seizure 6. Never abruptly stop antiseizure meds 7. Good oral care to prevent gingival hyperplasia (from Phenytoin) 8. Use suction after seizure Increased ICP: Impedes on circulation to brain + functioning of nerve cells (→ can lead to brainstem compression + death) Cushing’s Triad (sign of increased ICP) = HTN, bradycardia, wide pulse pressure S/S: change in LOC*, headache, increased BP with widening pulse pressure, bradycardia, fever, pupil changes Priority: 1. Keep HOB @ 30 degrees (promotes venous drainage) but not more than 30 degrees (causes decreased cerebral perfusion) 2. Keep body midline/straight (flexion decreases drainage) 3. Stool softeners (prevents straining) 4. Calm environment (dim lights, low noise, etc. to prevent stress on body) 5. Suction if needed 6. Treat fever and body temp (shivering can increase ICP) 7. Teach pt about avoiding Valsalva maneuver CSF Assessment: Colour: normal – clear + colourless Content: normal – little protein + glucose, no WBC, no RBC, no microorganism Pressure: normal – 60-150 mmH2O 16 Volume: normal – 125-150 mL CSF appears as concentric rings (bloody fluid surrounded by yellow stain – Halo sign) when placed on a white background. It will test positive for glucose if a strip test is done Ischemic Stroke Due to blockage of blood flow → causes issue with brain tissue perfusion HTN is common (in order to maintain brain perfusion distal to the area of blockage) Avoid suctioning for > 10s to avoid increased ICP Priority: TPA to be given 3-4 hours from onset of S/S (contraindicated in thrombocytopenia, uncontrolled HTN, head trauma within past 3 months, major surgery within past 14 days) 1 Olfactory 2 Optic 3 Oculomotor 4 Trochlear 5 Trigeminal 6 Abducens 7 Facial 8 Acoustic 9 Glossopharyngeal 10 Vagus 11 Spinal accessory 12 Hypoglossal Hemorrhagic Due to bleed in brain (blood vessel ruptures) Seizure can occur due to high ICP, dysphagia Priority: 1. NPO 2. Neuro assessment 3. Prevent activities that increase ICP or BP 4. Stool softeners 5. Bed rest with body midline *Anticoagulants are contraindicated Cranial Nerve Assessments/Tests Smell test Inspect pupils, visual acuity (Snellen chart) + visual fields Pupil constriction + extraocular movement Extraocular movement (inferior adduction) Clench teeth + light touch Extraocular movement (lateral abduction) Facial movement (close eyes, smile, etc.) Hearing + Romberg test Gag reflex Say “ahhh” Turn head + lift shoulders Stick out tongue Autonomic Dysreflexia/Hyperreflexia: Due to SNS stimulation after injury @ T6 or higher. Most commonly caused by a noxious stimulus (usually distended bladder or constipation) It is a neurological emergency (can lead to hypertensive stroke) S/S: severe HTN, headache, diaphoresis above level of injury, bradycardia, piloerection, flushing, nausea Priority: 1. Monitor BP and provide antihypertensives if needed 2. Monitor bladder distention 3. Assess for bowel impaction 4. Remove restrictive clothing 5. HOB @ 45 degrees Frontal Parietal Temporal Occipital Cerebral Cortex Broca’s area for speech Emotions, reasoning + judgment, concentration Interpreting senses (taste, pain, touch, temp, pressure) Spatial perception Auditory Wernicke’s area for sensory + speech Visual Unconscious pt: S/S: unarousable, no response to pain, altered respirations, decreased response to cranial nerve test and reflex tests Priority: 1. Emergency airway equipment @ bedside 2. Assess circulation 3. Suction as needed 4. Semi Fowlers and avoid Trendelenburg 5. Reposition q2h 6. Keep NPO and assess for gag reflex before resuming diet 17 Wernicke’s encephalopathy: Can be due to low thiamine intake (Vit B1). Severe alcoholism can cause low absorption of B1 S/S: altered mental status, oculomotor dysfunction, ataxia Meningitis: Inflammation of arachnoid + pia mater of brain + spinal cord; bacterial or viral cause S/S: irritability, nuchal rigidity, headache, muscle pain, fever, tachycardia, photophobia, abnormal pupil assessment, Brudzinski’s (involuntary flexion of hip + knee when neck is flexed), Kernig’s (pt unable to straighten leg when it is flexed at the knee + hip), decreased muscle tone, CSF is cloudy with high protein + high WBC + low glucose Priority: 1. Droplet/contact precautions 2. Assess for signs of increased ICP 3. Keep HOB @ 30 degrees and avoid flexion of body 4. Seizure precautions 5. Prepare for lumbar puncture *Droplet precautions are not needed for viral meningitis (only for bacterial and meningococcal) Concussion Contusion Skull Fractures Epidural Hematoma Subdural Hematoma Intracerebral hemorrhage Head Injuries Jarring of brain, no loss of consciousness Retrograde amnesia can occur (amnesia regarding the event) Rest + light diet are encouraged Bruising to brain, can occur with subdural or extradural blood collection (e.g. linear, depressed, compound, comminuted) *Most serious hematoma; hematoma forms quickly Due to arterial bleed (middle meningeal artery) Forms between skull and dura mater Loss of consciousness and then pt feels better quickly “lucid interval” followed by quick decline in mental function Slow bleed from venous injury Blood vessel in brain ruptures, causing blood to leak inside brain Spinal Cord Injury: Total transection of cord = total loss of sensation, movement, and reflex below the level of injury (If injury is between C1-C8; quadriplegia. If injury is between T1-L4; paraplegia) C2-C3 injury is usually fatal Any injury @ C4 or above = respiratory difficulty Priority: 1. Always assume spinal cord injury with traumas until it’s ruled out 2. Immobilize pt on backboard 3. Body midline with head in neutral position 4. Maintain patent airway 5. Logroll pt if needed 6. Monitor ABGs to assess respiratory status Spinal Immobilization: C spine is needed if: concerning neuro exam, significant trauma, decreased LOC, intoxication, pt has another injury along with spinal injury, concerning spinal exam Cerebral Aneurysm: Can lead to rupture* S/S: headache, irritable, vision changes, tinnitus, nuchal rigidity, seizures Priority: 1. Bed rest 2. Calm + dark environment 3. Avoid any straining activities 4. Prevent HTN and pain Multiple Sclerosis: Demyelination of neurons which causes CNS degeneration S/S: weakness, ataxia, tremors/spasms, paresthesia, vision changes, dysphasia, bladder/bowel disturbances, hyperreflexia + positive Babinski, confusion, decreased perception to pain/touch/temperature 18 Priority: 1. Protect from injury 2. Assist with frequent bladder/bowel elimination 3. Regular exercise and rest 4. PT and SLP involvement 5. Fluid intake + low fat high fiber diet Myasthenia Gravis: Weakness + fatigue of voluntary muscles due to defective nerve impulses (due to insufficient ACh, increased cholinesterase [breaks down ACh], or muscles don’t respond to ACh) S/S: weakness, dysphagia, vision changes, difficulty breathing, potential respiratory paralysis/failure Priority: 1. Deep breathing + coughing 2. Suction + emergency equipment @ bedside 3. Prevent aspiration (high fowlers when eating) 4. Time exercise/activities for when pt has maximal muscle strength (muscles are stronger in the am and weaker in the pm) 5. Administer anticholinesterase 6. Avoid stress Myasthenia crisis Acute exacerbation of MG S/S: tachycardia, increased RR, HTN, SOB, cyanosis, bowel/bladder incontinence, decreased urine output, no cough/swallow reflex Priority: 1. Increase anticholinesterase meds Cholinergic crisis Too much Ach due to overmedication with anticholinesterase S/S: cramps, nausea/vomiting, vision changes, pallor, muscle twitching, hypotension Priority: 1. Hold anticholinesterase meds 2. Provide antidote = atropine sulfate Edrophonium test: used to diagnose MG + differentiate between myasthenia crisis and cholinergic crisis To diagnose MG: edrophonium will cause muscle strength improvement. Negative for MG = no improvement in muscle strength/deterioration in muscle strength To differentiate between MC and CC: If after edrophonium, muscle strength improves = MC; pt will need more medication. If after administration, weakness worsens = CC; pt is overmedicated with anticholinesterase and needs atropine sulfate given *Pt is at risk for Vfib/cardiac arrest during this test Parkinson’s Disease: Dysfunction of extrapyramidal system due to low dopamine levels S/S: bradykinesia (slow movement), monotone speech, tremors + pill rolling, jerky movements, restlessness, blank facial expression, drooling, difficulty swallowing/speaking, lack of balance + shuffling gait Priority: 1. Soft diet high in calories, protein, and fiber 2. Increase fluid intake 3. Safety measures 4. PT and rehab 5. Avoid food high in B6 (blocks effect of antiparkinsonian meds) 6. Avoid MAOIs (can cause hypertensive crisis) Bell’s Palsy (Facial Paralysis): Lower motor neuron lesion of CN 7 resulting in paralysis of one side of face; recovery usually in a couple weeks. Does not affect vision, balance, or extremity motor function S/S: flaccid facial muscles Priority: 1. Facial muscle exercises 2. Protect eyes from becoming dry (artificial tears, wear patch @ night) 3. Provide oral care 4. Have pt chew on unaffected side Guillain Barré: Acute infection (respiratory infx, gastroenteritis) causing neuronitis of cranial and peripheral nerves (leads to myelin sheath destruction) S/S: potential respiratory failure, pain/hypersensitivity, weakness of lower extremities, progressive weakness of upper extremities, high protein in CSF Priority: 1. Monitor respiratory status (prepare for resp support) Amyotrophic Lateral Sclerosis: Degeneration of motor system (no changes in sensory, autonomic, or mental status); no cure S/S: respiratory difficulty (at the end of the disease, resp muscles are affected leading to death), muscle weakness, dysphagia 19 Musculoskeletal System Strain Stretching of muscle or tendon Priority: 1. Cold + heat application 2. Exercise 3. antiinflammatory + muscle relaxant meds Sprain Stretching of ligament (twisting motion or stepping on uneven surface); S/S: pain + swelling Priority: 1. Rest 2. Ice 3. Compression 4. Elevation 5. Cast Fractures: Closed/Simple – skin over # is intact Open – bone is exposed to air (break in skin) *watch for infection; cover the wound with a sterile dressing Comminuted – bone is crushing into several fragments Complete – bone is completely separated into 2 parts Compression – # bone is compressed by other bone Depressed – bone fragments are pushed inward Greenstick – one side of bone is broken, and other side is bent (common in children) Impacted – part of # bone is driven into another bone Incomplete - # line does not extend the entire width of bone Oblique - # line runs on an angle Pathological - # due to weakness of bone structure Transverse – bone # is straight across S/S: pain, decreased muscle strength, obvious deformity, crepitation + edema, muscle spasms Interventions: open or closed reduction, internal or external fixation, traction, or cast Buck’s Traction: ensure proper body alignment, that weights hang freely and don’t touch floor, do not remove/lift weights without MD order, ensure that pulleys are not obstructed, elevate foot of bed, and check ropes for fraying Complications of #: fat emboli, pulmonary emboli, compartment syndrome, infection, avascular necrosis Priority: 1. Immobilize extremity 2. Monitor neurovascular status Cast care: Keep cast elevated, allow 24-72 hrs for cast to dry, handle a wet cast with palms of hands, turn the extremity q1-2hrs to allow air circulation, use hair dryer on cool setting to help with drying process (do NOT use heat), do not insert any objects into cast to relieve itching, monitor for S/S of infection, keep cast clean + dry Fat Embolism: Can occur after a fracture (long bone fractures are greatest risk) S/S: hypoxemia, change in LOC, tachycardia, hypotension, SOB Priority: 1. O2 as needed 2. IV fluids 3. Monitor respiratory status 4. Bed rest Compartment Syndrome: Pressure increases in a muscle group (usually after cast being put on) → decreased blood flow, tissue ischemia, neurovascular impairment After 4-6 hours of this syndrome, neurovascular damage is irreversible S/S: paresthesia, limb pain, pressure, pallor, pulselessness distal to area, paralysis Priority: 1. Notify doctor 2. Fasciotomy to relieve pressure buildup 3. Loosen restrictive cast Crutches: Priority: 1. Proper measurement (2-3 finger widths between axillae and arm piece, elbows flexed 20-30 degrees) 2. Stand on pts affected side when ambulating 3. Do not rest axillae on axillary bars 4. Stop ambulation if numbness/tingling occurs in hands/arms 20 Avascular necrosis: When a # disrupts blood supply to bone → bone death Hip post-op: Hip fractures commonly hemorrhage, whereas femur fractures are at risk for fat emboli Priority: 1. Avoid internal + external rotation and hip flexion that’s greater than 90 degrees 2. Monitor for delirium 3. Keep HOB 30-45 degrees for meals only 4. Avoid weight bearing on affected leg 5. Keep post-op leg extended, supported, and elevated when standing up 6. Monitor neurovascular status of extremity 7. Avoid crossing legs and any activity that requires bending Amputation post-op: Priority: 1. Monitor for bleeding/drainage 2. Explain phantom limb pain 3. Do not elevate residual limb on pillow 4. First 24 hrs = elevate food of bed (reduces edema), after 24 hrs = keep bed flat (prevents flexion contracture) 5. After 24-48 hrs = prone position (stretches muscles) Rheumatoid Arthritis Chronic systemic inflammation leading to destruction of connective tissue + synovial membrane in joints. Ultimately leads to dislocation and permanent deformity of joint S/S: inflammation of joints, pain + stiffness in the morning, muscle atrophy, spongy joints, weight loss Priority: 1. Rheumatoid factor blood test confirms diagnosis 2. ROM exercises 3. Balance between rest + activity 4. Prevent flexion contractures 5. Avoid weight bearing on inflamed joints 6. PT and OT 7. Use chairs with high backs 8. Use a small pillow when laying down Osteoarthritis Deterioration of articular cartilage in peripheral and axial joints; mostly on weight-bearing joints (hips, knees, hands) S/S: pain that increases with activity and decreases with rest, pain increases with temp change, Heberden’s or Bouchard’s nodes, joint swelling may be minimal, crepitus Priority: 1. Pain + corticosteroid meds 2. Avoid flexion of knees + hips 3. Avoid large pillows when laying 4. Apply cold pack when joint is inflamed 5. Rest 6. Balance activity + rest 7. Limit activity when in pain Osteoporosis: Risk factors – smoking, early menopause, alcohol use, family hx, female, increasing age, low calcium intake, sedentary life, thin/small frame, European or Asian race Pts with osteoporosis are at an increased risk for pathological fractures Gout: Build up of urate crystals in joints (due to high uric acid in body) S/S: painful joints, tophi (hard nodules), pruritis, renal stones Priority: 1. Low purine diet (avoid organ meats, wine, and aged cheese) 2. High fluid intake 3. Avoid alcohol 4. Bed rest during painful attacks 5. Heat or cold application during pain Respiratory System Supplemental O2 Delivery: Nasal cannula 1-6 L/min; FiO2 24-44% Face mask 5-8 L/min; FiO2 40-60% *Monitor for risk of aspiration 4-10L/min; FiO2 24-55% 6-15 L/min; FiO2 70-90% Rate of flow needs to keep the bag full; FiO2 60-100% Venturi mask Partial rebreather mask Nonrebreather mask For pt with airflow limitation + long term O2 use For short term O2 therapy + for emergencies For pts in acute respiratory failure For pt with deteriorating resp status 21 Description Drainage chamber Water seal chamber Air leak monitor Suction control chamber Dislodgment Tubing Removal Chest Tube Wet Suction Dry Suction Suction regulated by height of water in the Suction monitor bellow controls amount of suction suction control chamber Monitors drainage (colour + amt – normal is <100 cc/hr). Located right below the tube that comes from the patient Water fluctuates with inspiration + expiration (if NO fluctuation = lung has re-expanded or there is a kink) Excessive bubbling indicates an air leak. If your patient has a pneumothorax (air in pleural cavity), intermittent bubbling may be seen and is OK Filled with water (amt of suction depends on Amt of suction is controlled by moving the dial on height of water). Bubbling = good this area This chamber is right below the tube connected to suction Cover area with sterile dressing; tape 3 sides so that air can escape but not enter Keep free from kinks, clots, and stagnant fluid; keep the entire system below pts chest Position in semi-fowlers, perform Valsalva maneuver and hold breath Tuberculosis: Skin is assessed 48-72 hrs post administration of TB Negative: redness without induration Positive: induration > 15 mm in healthy individuals, OR induration > 10 mm in immunocompromised pts (e.g. children under 4, IV drug users, recent immigrant from high prevalence TB country, homeless), OR induration > 5 mm in high risk pts (e.g. HIV, organ transplant pts, recent contact with TB person) • Positive and NO SYMPTOMS OF TB → CXR to be done • Positive and SYMPTOMATIC OF TB → sputum culture to be collected Latent Asymptomatic, no TB transmission, normal CXR, no sputum needed to be collected Active Cough, fever, chills, weight loss, anorexia, fatigue, TB can be transmitted, abnormal CXR, positive sputum culture S/S: fatigue, lethargy, anorexia, weight loss, chills, fever, chest pain Priority: 1. Droplet precautions (N95 mask) 2. 6 air exchanges per hour 3. Pt to wear mask if leaving room Ventilator Alarms: High pressure: increased secretions, tube kink, pt biting on tube or coughing Low pressure: tube disconnected, pt stopped breathing Flail Chest: S/S: paradoxical respirations (chest moves in with inspiration and out with expiration; opposite of normal), severe pain, SOB, cyanosis, tachycardia, hypotension, increased RR, decreased lung sounds Priority: 1. Fowlers position 2. Provide supplemental O2 3. Coughing + deep breathing 4. Analgesics 5. Bed rest 6. Prep for intubation Influenza: Viral respiratory infection S/S: acute fever, headache, fatigue, sore throat, cough Priority: 1. Monitor lung sounds 2. Rest 3. Fluid intake 4. Administer antivirals, antipyretics 22 Pneumothorax: Air in pleural space = lung collapses and can push heart + great vessels towards other lung Open pneumo: opening in chest wall allows air into pleural space Tension pneumo: blunt chest injury S/S: no breath sounds on affected side, cyanosis, SOB, hypotension, chest pain, subcutaneous emphysema (crepitus on palpation), sucking sound (with open chest wound), tachycardia, increased RR, tracheal deviation to unaffected side (with tension pneumo) Priority: 1. Chest wound dressing 2. Apply O2 3. Fowlers position 4. Prep for chest tube insertion Asthma: Airway inflammation + hyperresponsiveness to stimuli (e.g. allergens, exercise, irritants) leading to smooth muscle constriction, mucus secretion, obstruction of airways, air trapping, respiratory acidosis, and hypoxemia S/S: wheezing, SOB, coughing, chest tightness *Status asthmaticus → life threatening emergency Priority: 1. Keep airway patent 2. Administer systemic corticosteroids (e.g. prednisone, methylprednisolone) COPD: Airflow limitation resulting from small-airway disease and parenchymal destruction Includes emphysema (damaged alveoli) and bronchitis (airway swollen + filled with mucous) S/S: cough, SOB, wheezing + crackles, weight loss, barrel chest, orthopnea, hyperinflation of chest, ABG shows respiratory acidosis + hypoxemia Remember that a normal SPO2 is 88-92%; do not try to raise the SPO2 level higher than this (a lower SPO2 level is what stimulates a COPD patient to breathe!) *short acting bronchodilator (Ventolin) to be given Pneumonia: Acute inflammation of lungs due to bacterial, viral, fungal infection Inflammation → stiffening of lungs → low lung compliance → hypoxia Sputum C+S will confirm the organism Aspiration pneumonia: can occur in a community or health care facility setting and results from inhalation of foreign matter, such as vomitus or food particles, into the bronchi (most common in older patients, patients with a decreased level of consciousness, and those receiving nasogastric tube feedings) S/S: fever, pleuritic pain (pain that is sharp and increases during inspiration), tachypnea, wheeze, accessory muscle use with breathing, change in LOC, sputum production Priority: 1. Droplet precautions 2. Supplemental O2 3. Monitor LOC 4. Deep breathing + coughing 5. Semi-fowlers to assist with breathing 6. Chest physiotherapy to mobilize secretions 7. Fluid intake to thin the secretions 8. ABX administration Pleural Effusion: Collection of fluid in pleural space preventing lung from fully expanding S/S: pleuritic pain, SOB, dry cough, tachycardia, fever, decreased breath sounds over area Priority: 1. Prep pt for thoracentesis 2. Keep pt in Fowlers 3. Monitor breath sounds Empyema: Priority: 1. Treat infection 2. High Fowler’s 3. Coughing and deep breathing 4. Thoracentesis or chest tube for drainage Pulmonary Embolism: Thrombus lodges into branch of pulmonary artery (can also be due to fat emboli from fracture of a long bone) 23 S/S: blood tinged sputum, chest pain, cough, cyanosis, JVD, SOB, feeling of impending doom, hypotension, tachypnea, tachycardia Priority: 1. HOB elevated 2. Administer O2 3. ABG 4. Anticoagulants Gastrointestinal System Retroperitoneal Hemorrhage: S/S: hypoT, back pain, Grey-Turner sign, hematoma, decreased distal pulses Colostomy: Priority: 1. Keep liquid stool from leaking out (causes skin irritation due to the digestive enzymes) 2. Change bag q5-10 days 3. Increase fluid intake to prevent dehydration 4. Empty bag when 1/3 full Ulcerative Colitis Chron’s Chronic inflammation leading to poor absorption of nutrients Inflammation that can occur anywhere in GI tract Begins in rectum and spreads upward S/S: fever, cramps, diarrhea, weight loss, dehydration Colon is edematous + bleeding lesions form During acute episode, priorities are same as UC S/S: frequent bloody diarrhea, abdo pain, fever, fatigue, weight loss Priority: 1. NPO 2. IV fluids 3. Monitor stools 4. Low fiber diet with vitamin supplements Bowel Perforation: S/S: abdo guarding + pain + distention, fever, pale, tachycardia + tachypnea Paracentesis: Removal of fluid from peritoneal cavity, performed @ bedside (pt is in upright position @ edge of bed) Priority: 1. VS + weight pre-procedure 2. Have pt void 3. Upright position 4. Dry sterile dressing @ puncture site 5. Measure fluid removed GERD: Heartburn, epigastric pain, dyspepsia, nausea + vomiting, pain with swallowing Have pt avoid peppermint, chocolate, coffee, fried foods, carbonated drinks, and alcohol (irritants) *Antacids, H2 receptor antagonists, or PPIs are given as medication Colonoscopy: Lining of large intestine is examined (biopsies can be performed) with the pt in a L side lying position (knees to chest) Prep: clear liquid diet day before with colon cleansing meds given, NPO @ midnight Diverticulosis: Usually discovered during colonoscopy; asymptomatic and no treatment needed Can develop into diverticulitis → treated with ABX and clear liquid diet ERCP: Examination of hepatobiliary system with endoscope down the esophagus Prep: NPO before procedure Post procedure: monitor for return of gag reflex and for signs of perforation 24 Peptic Ulcer Disease: IF PUD is gastric → hematemesis, if PUD is duodenal → melena stool Esophageal Varices: Monitor for rupture and hemorrhage – life threatening* Enteral Feeding: Abdo cramping can occur if feed is too fast or too cold Priority: 1. HOB @ 30-45 degrees pre+post feed 2. Tube flushes pre+post feed 3. Assess bowel function Dysphagia: Pt is at an increased risk of aspiration pneumonia Priority: 1. Thickened liquids 2. HOB in high fowlers 30 mins post-meal 3. Swallow twice before another bite 4. Avoid OTC cold medications (they have anticholinergic effects – decrease saliva) Gastritis: Acute gastritis = Stomach inflammation due to contaminated food S/S: abdo discomfort, nausea, vomiting, headache, reflux Chronic gastritis = due to H. pylori S/S: nausea, vomiting, heartburn, sour taste in mouth, Vit B12 deficiency Priority: 1. NPO 2. Avoid irritating foods (spicy food, caffeine, alcohol) 3. Take antibiotics and antacids Dumping Syndrome: Rapid emptying of gastric content into S.I after a gastric resection S/S will occur 30 mins after eating: nausea, vomiting, abdo cramps, diarrhea, tachycardia, weakness/dizzy, borborygmic (loud gurgling abdo sound) Priority: 1. Eat small meals and avoid fluids while eating 2. Lie down after meals 3. Avoid sugar, salt, and milk 4. Eat high protein, high fat, and low carbs Cholecystitis: Acute (associated with gallstones) or chronic (due to inefficient bile emptying) inflammation of gallbladder S/S: nausea, vomiting, flatulence, *epigastric pain radiating to R scapula 2-4 hrs after fatty food, RUQ pain, guarding, rebound tenderness, mass in RUQ, *Murphy’s sign (cannot take deep breath because of pain when fingers are pressed on hepatic margin), tachycardia Obstruction in gallbladder = jaundice, orange urine, steatorrhea + clay coloured stool, pruritis Priority: 1. NPO 2. NG decompression 3. Eat small, low fat meals Cirrhosis: Destruction of hepatocytes = scar tissue formation Complications: portal HTN (due to flow obstruction), ascites (due to congested hepatic capillaries that leads to plasma leakage), bleeding esophageal varices, jaundice (liver cannot metabolize bilirubin), portal systemic encephalopathy (change in LOC due to failure of liver to detoxify ammonia - a neurotoxic agent) Priority: 1. Provide vitamin supplements 2. Restrict sodium and fluid intake 3. Enteral or parenteral feeds 4. Diuretic medications for ascites 5. Weigh pt daily 6. Monitor LOC 7. Administer lactulose (facilitates excretion of ammonia) 8. Administer ABX (inhibits synthesis in bacteria and decreases ammonia production) 9. Avoid opioids and sedatives 10. Teach importance of alcohol abstinence 11. Monitor ammonia levels 12. To help with pruritis: cut nails short, calamine lotion, cool/wet cloths, cholestyramine, avoid hot showers 25 Appendicitis: *Rupture can occur quickly = leads to peritonitis and sepsis S/S: pain in periumbilical area radiating to RLQ, abdo pain @ McBurney’s point, abdo rigidity, fever, nausea + vomiting, abdo guarding Priority: 1. NPO 2. IV fluids to prevent dehydration 3. Do not palpate or apply heat to abdo (increases risk of rupture = peritonitis) 4. Apply ice packs 5. Avoid laxatives/enemas Hepatitis Goal: rest the inflamed liver to reduce demands and increase blood supply Pre-icteric – flu-like symptoms (fever, malaise) Icteric – jaundice, elevated bilirubin, dark urine, clay coloured stool Post-icteric – jaundice decreases, urine and stool colour return to normal Transmission Notes Hep A Fecal-oral (contaminated food, Common in young children water, poorly washed utensils) Incubation period – 2-6 wks Infectious period – 2-3 wks before and 1 wk after jaundice HAV antibodies found in blood Priority: 1. Hand hygiene* 2. Stool + needle precautions 3. Hep A vaccine Hep B Blood/body fluid (IV drug users + Common in all age groups healthcare workers) Incubation period – 6-24 wks Hep B surface antigen (HBsAg) will disappear in 6 wks.. if not = pt is a carrier Hep C Same as Hep B Incubation – 5-10 wks HCV antibody found in blood Hep D Only occurs with presence of Hep Common in Mediterranean + Middle East areas B Incubation – 7-8wks Hep D antigen (HDAg) found in blood Hep E Fecal-oral (waterborne virus) Incubation – 2-9 wks IgM + IgG antibodies to Hep E (anti-HEV) found in blood Priority: 1. Strict hand hygiene 2. Pt not to share bathroom 3. Pt to use their own towels, utensils, razors, etc. 4. Avoid alcohol 5. Small, frequent high carb low fat meals 6. Pt is not to donate blood Constipation: Priority: 1. Ambulate as tolerated (increases peristalsis) 2. High fiber diet (softens stool) 3. Drink 2-3 L/day 4. Bowel regimen 5. Avoid caffeine (promotes diuresis which causes dehydration) Irritable Bowel Syndrome: Chronic uncontrolled inflammation causing edema, ulcers, bleeding, and extreme fluid loss S/S: abdo cramps, pain, diarrhea, dehydration, weight loss/cachexia, anemia (due to active bleeding), 5-10 diarrhea BM/day Priority: 1. Monitor hgb 2. Monitor intake + output Acute Pancreatitis: Sudden inflammation causing mild-severe discomfort S/S: Cullen’s sign (discoloured abdo + periumbilical area), Turner’s sign (blue discolouring of flanks) Priority: 1. NPO 2. NG tube to suction 3. Parenteral nutrition 4. Avoid alcohol Total Parenteral Nutrition: Avoid stopping it abruptly as it can lead to hypoglycemia Priority: 1. Monitor CBG (glucose is main component of TPN) 2. Monitor S/S of hyperglycemia (polyphagia, polydipsia, polyuria) 26 ALT and AST: Enzymes released when hepatic cells are inured Small Bowel Obstruction Large Bowel Obstruction Rapid onset nausea + vomiting, intermittent abdo pain, abdo Gradual onset of S/S, cramping abdo pain, abdo distention, distention complete constipation, no flatus Priority: 1. NPO 2. NG tube insertion 3. IV fluids 4. Manage pain Paralytic Ileus: Temporary halting of peristalsis for 24-48 hrs after a bowel procedure (no bowel sounds will be auscultated) Stool Type: Small, dry, hard → constipation Light gray/clay colour → biliary obstruction Mucus in stool → ulcerative colitis Greasy, fatty, foamy → pancreatitis Black, tarry → upper GI bleed Bright red (melena) → lower GI bleed Blood on surface of stool → hemorrhoids Cardiovascular System Angina: Stable – chest pain with exertion/activity, relieved with rest or nitro Unstable – chest pain that is unpredictable, may or may not be relieved with nitro Variant/Prinzmetal’s – chest pain due to coronary artery spasm, may occur @ rest Myocardial Infarction: S/S: chest pain/pressure, diaphoresis, dyspnea, anxiety Female-specific S/S: fatigue, indigestion, shoulder or jaw pain Acute MI = ST elevation in localized leads Priority: 1. ABC, VS assessment 2. ECG + cardiac marker bloodwork 3. O2 if needed 4. Nitroglycerin, morphine Percutaneous Coronary Intervention: Catheter inserted into femoral or radial vein and advanced into the pulmonary artery to obtain information about the structure and performance of the chambers, valves, and coronary circulation Procedure will improve coronary artery patency + increase cardiac perfusion Complications: thrombosis, stent occlusion, hematoma, limb ischemia Peripheral Arterial Disease Decreased blood flow to lower extremities due to atherosclerosis Intermittent claudication (muscle pain), hair loss, decreased peripheral pulses, cool + dry skin, gangrene, thick nails, ulcers Coronary Artery Disease Obstruction/narrowing of a coronary artery due to atherosclerosis Chest pain, palpitations, SOB, syncope, fatigue, cough Mechanical Valves: Pt needs to be on lifetime anticoagulant therapy to avoid thromboembolism 27 Cardiac Electrical Activity: SA node AV node Bundle of His Main pacemaker initiating every heartbeat Generates impulses 60-100 beats per minute Receives impulse from SA node If SA node does not work, then AV node will take over and sustain a HR of 40-60 beats per minute Separates into left and right bundle branches, located in the ventricles Can act as the pacemaker of the heart if SA and AV node fail; HR between 20-40 beats per minute Pacemaker: Device that provides electrical stimulation to maintain HR when pts intrinsic pacemaker (SA node) fails to provide a rhythm Vertical spike will appear on ECG indicating a pacing stimulus (spike before p wave = atrial pacing, spike before QRS complex= ventricular pacing) Priority: 1. Report swelling/redness/drainage 2. Teach pt how to take pulse; tell them to notify MD if pulse is too low 3. No cellphone over the site 4. No MRIs 5. Microwaves are safe 6. Avoid heavy lifting after surgery Congestive Heart Failure: Heart unable to meet metabolic needs of the body due to pumping issue → blood backs up into lungs (left sided HF) and/or body (R sided HF) L sided R sided Pulmonary congestion, SOB, tachypnea, crackles, cough, HTN Edema, JVD, abdo distension, weight gain, HTN Priority: 1. High Fowlers 2. Supplemental O2 3. Administer diuretics 4. Monitor output 5. Fluid and sodium restriction 6. Monitor weight daily 7. Monitor number of pillows used to facilitate breathing while sleeping Mean Arterial Pressure (MAP): Average pressure in systemic circulation; calculated by: SBP + (DBP x 2) /3 Normal MAP = between 60-70 for proper organ perfusion Low MAP = organs are underperfused and can become ischemic Central Venous Pressure (CVP): Measurement of R ventricular preload Normal CVP = 2-8 mmHg High CVP = volume over load (S/S: edema, weight gain, tachypnea, crackles, bounding pulse) Cardiac Tamponade: Fluid accumulation in the pericardium S/S: pulsus paradoxus, high CVP, JVD with clear lungs, muffled heart sounds, low cardiac output, narrow pulse pressure Priority: 1. IV fluids 2. Pericardiocentesis Cardiac Inflammation: Pericarditis Inflammation of pericardium, causing compression of the heart S/S: sharp pleuritic chest pain that’s worse during inspiration + coughing (and relieved when leaning forward), pericardial friction rub, fever, fatigue Acute pericarditis = ST elevation in all leads Myocarditis Inflammation of myocardium Endocarditis Inflammation of lining of heart + valves S/S: Fever, pericardial friction rub, murmur, S/S of CHF, fatigue, tachycardia, chest pain S/S: Fever, weight loss, fatigue, murmur, CHF, petechiae + splinter hemorrhages in nail beds, clubbing of fingers 28 Priority: 1. High Fowlers 2. Pain meds, NSAIDS ABX administration 3. Monitor for tamponade (pulsus paradoxus, JVD, narrow pulse pressure, tachycardia, muffled heart sounds) Priority: 1. O2 if needed 2. Periods Priority: 1. Rest 2. TEDs 3. Monitor for of rest 3. Avoid overexertion 4. S/S of emboli/thrombus 4.ABX Pain meds, anti-dysrhythmics, ABX Thrombus Formation: Venous stasis, hypercoagulability, injury to venous wall, pregnancy, ulcerative colitis, oral contraceptive use, fractures BNP: BNP > 100 = pt is in heart failure BNP is produced when ventricles stretch from high blood volume, and when there are high levels of extracellular fluid Shock: Hypotension, tachycardia, weak/thread pulse Blood Pressure Normal 120-80 Pre-hypertension SBP 120-139 DBP 80-89 Stage 1 HTN SBP 140-159 DBP 90-99 Stage 2 HTN SBP > 160 DBP >100 Hypertensive Crisis SBP > 180 DBP > 120 Hypertensive Crisis can cause organ damage and is to be treated immediately S/S: headache, confusion, change in vision, change in LOC, tachycardia, tachypnea, cyanosis DVT: Presents as warm skin + calf or groin pain with or without swelling Risk factors → Virchow’s Triad (decreased flow/stasis, endothelial damage, hypercoagulable state) Priority: 1. Elevate extremity 2. Avoid pillow under knees 3. Do not massage the area 4. Apply anti embolism stockings 5. Measure circumference of thigh or calf 5. Apply warm, moist compress as needed 6. Antithrombolytics 7. Avoid prolonged sitting Defibrillation: Synchronizer switch must be turned on Cardioversion shock must be delivered on R wave (if delivered on T wave = can lead to a lethal arrhythmia) Sinus Bradycardia Regular 40-60 bpm PR Interval QRS 0.12-0.20 s 10 s Treat underlying cause (stimulants, withdrawal, hypoxia, MI) Sinus 0.12-0.20 s 10 s No treatment unless symptomatic (Low BP, LOC)  P wave Sinus (1 P before each QRS, all P waves same morphology)  Rhythm Rate Sinus Tachycardia Regular 100-60 bpm Notes Paroxysmal Atrial Tachy (PAT) or SVT 29 Sinus Prolonged ( 0.20 s) Sinus PR lengthens progressive ly until a QRS drops  Not measurable  Fibrillatory (f waves)  Not measurable 10 s Unstable PAT (low BP/LOC/urine output/chest pain): cardioversion Stable PAT: sedation, vagal maneuver, bolus adenosine 10 s No isoelectric line Control ventricular rate: diltiazem A flutter < 48 hrs long: cardioversion A flutter > 48 hrs long: anticoagulate before attempting cardioversion 10 s Control rate first (CCB – diltiazem) A fib < 48 hrs long: cardioversion or anticoagulate A fib > 48 hrs long: anticoagulate before attempting cardioversion Unstable A fib: cardioversion STAT 10 s Produced no symptoms and requires no treatment 10 s Also called Wenckebach To differentiate b/w nonconducted PAC: NPAC will have abnormal P wave and is premature Usually asymptomatic because ventricular rate is often normal 10 s Usually ventricular rate is slow Stokes-Adams syncope is caused by sudden slowing of the heartbeat Treatment is usually a pacemaker 10 s Atria and ventricles beat independently of each other Symptoms: hypotension, dyspnea, heart failure, chest pain, Stokes-Adams syncope Treatment: pacemaker Varies greatly Idioventricular Rhythm Regular 30-40 bpm Absent Not measurable Wide ( 0.12s) Ventricular Tachycardia Regular 140-250 bpm Absent Not measurable Wide ( 0.12s)  Sinus (P wave has no relationship with QRS) Some P waves may be hidden  Sinus (2 or 3 P Normal or waves before prolonged. each QRS) PR is consistent  First degree block Regular That of underlying rhythm Second degree (Type 1) block Atrial: Atrial: That of regular underlying Ventr: rhythm irregular Ventricular: less than atrial rate Second degree (Type 2) block Regular Atrial: That of underlying rhythm Ventricular: less than atrial rate Third degree block Atrial: Atrial: That of regular underlying Ventr: rhythm regular Ventricular: 4060 bpm Sawtooth (F waves)  Atrial Fibrillation (Afib) Irregular Atrial: 400 + bpm Ventricular: less than atrial Not measurable  Atrial Flutter (Aflutter) Regular Atrial: 250-400 bpm Ventricular: less than atrial TP waves  140-250 bpm  Regular A very slow rhythm originating in the ventricles If continuous, treat immediately (atropine, pacing, vasopressor) IVR < 20 bpm: agonal rhythm Stable + Pulse: amiodarone bolus over 10 mins, once rhythm converts: amiodarone infusion. If amio is unsuccessful = cardioversion Unstable + Pulse: Sedate the pt, cardioversion, maintenance infusion of amiodarone Ventricular Fibrillation 30 None None Absent Not measurable Absent No pulse + unconscious: defibrillate at 200 J. If arrest is unwitnessed, CPR for 2 minutes before initial shock If unsuccessful, start CPR, establish IV line, and intubate when possible Epinephrine 1mg IVP q3-5 min CPR for 2 minutes Defibrillate at 200 J Asystole None None Absent Not measurable Absent Start CPR, establish IV line, intubate when possible Epinephrine 1 mg IVP q3-5 mins Atrial Fibrillation: Increases the risk of stroke → pt needs to be on anticoagulants (e.g. warfarin) Priority: 1. Monitor INR if on warfarin 2. Monitor change in heart rate 3. Monitor circulation Renal System Creatinine Level: Will only increase once at least 50% of kidney function is lost Acute Kidney Injury: S/S (occur due to retention of nitrogenous wastes, fluids, and inability to regulate electrolytes): decreased UO, increased fluid volume (HTN, edema, CHF), changes in LOC, uremia (anorexia, nausea, vomiting, pruritus) Priority: 1. Monitor electrolytes 2. Monitor BP 3. Monitor intake + output along with daily weight 4. Renal diet (low protein, high carb) 5. Dialysis if needed Chronic Kidney Disease: Normal – GFR > 90 Mild CKD – GFR 60-89 Moderate CKD – GFR 30-59 Severe CKD – GFR 15-29 End stage KD – GFR < 15 *Requires dialysis (process of filtering pt’s blood; removes wastes and maintains buffer system of body) Pt’s are @ risk for fluid overload and hyperkalemia Priority during dialysis: 1. Monitor for hypovolemia/shock (due to blood loss) 2. Monitor for bleeding 3. Hold antihypertensives and meds that could be removed during dialysis (e.g. water-soluble vitamins, ABX, digoxin) 4. Monitor for arterial steal syndrome in pts with internal AV fistula (too much blood is sent to vein that arterial perfusion to hand is compromised) 5. Palpating a thrill or auscultating a bruit ensures that a fistula is patent UTI: Lower UTI – urethritis, cystitis (due to ascending pathogens such as E. coli); S/S: frequency, urgency, burning Upper UTI – pyelonephritis (due to urine reflux from bladder into ureters or obstruction causing inflammation); S/S: calculi, stricture, enlarged prostate 31 Reproductive System Continuous Bladder Irrigation: Removes clotted blood from bladder post-TURP (3-way catheter is used) S/S to report: pain/spasm (indicates obstruction), output < input (indicates clot or kink) *Titrate irrigation rate so that urine is light pink HPV: Females should have Pap smear @ 21 years old Pubic Lice: Priority: 1. Lice shampoo 2. Remove nits with fine tooth comb 3. Wash belongings separately from others 4. Sexual partners to be treated as well Urinary Tract Infection: Common kidney infection due to lack of proper hygiene and indwelling catheters Priority: 1. ABX administration 2. Monitor for confusion in the elderly Inserting a Foley Catheter: 1. Gather equipment. 2. Explain procedure to the patient 3. Assist patient into supine position with legs spread and feet together 4. Open catheterization kit and catheter 5. Prepare sterile field, apply sterile gloves 6. Check balloon for patency. 7. Generously coat the distal portion (2-5 cm) of the catheter with lubricant 8. Apply sterile drape 9. If female, separate labia using non-dominant hand. If male, hold the penis with the non-dominant hand. Maintain hand position until preparing to inflate balloon. 10. Using dominant hand to handle forceps, cleanse peri-urethral mucosa with cleansing solution. Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from sterile field. 11. Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely coiled in palm of dominant hand. 12. In the male, lift the penis to a position perpendicular to patient's body and apply light upward traction (with nondominant hand) 13. Identify the urinary meatus and gently insert until 1 to 2 inches beyond where urine is noted 14. Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size) 15. Gently pull catheter until inflation balloon is snug against bladder neck 16. Connect catheter to drainage system 17. Secure catheter to abdomen or thigh, without tension on tubing 18. Place drainage bag below level of bladder 19. Evaluate catheter function and amount, color, odor, and quality of urine 20. Remove gloves, dispose of equipment appropriately, wash hands 21. Document size of Foley and amount of cc inserted into balloon 32