336 Final Exam Study Cards

Study online at quizlet.com/_2ujuow

 336 Final Exam Study Cards
Study online at quizlet.com/_2ujuow

1. Acid-base • pH: acidic or basic

imbalance o acidic 7.35-7.45 basic
• CO2: carbon dioxide
o basic 35-45 acidic
• HCO3: bicarbonate
o 22-26
• PO2: O2 in plasma
o 80-100
• O2 Sat: amount of hemoglobin saturated with O2
ROME
o Respiratory Opposite Metabolic Equal
▪ Decreased pH = Increased CO2 - Respiratory Acidosis
▪ Increased pH = Decreased CO2 - Respiratory Alkalosis
▪ Decreased pH = Decreased HCO3 - Metabolic Acidosis
▪ Increased pH = Increased HCO3 - Metabolic Alkalosis
• 1st line of defense - buffers:
o Bicarbonate
o Phosphorous
o Protein (Hemeglobin)
• 2nd line of defense - respiratory system
o Compensates within seconds-minutes but does not last
o Defense against H+
▪ Hyperventilate - pCO2 lost - alkaline
▪ Hypoventilation - pCO2 retained - acid
▪ With excessive acid formation, the respiratory center in the medulla is stimulated, which results in increase in depth and
rate of respirations which leads to a decreased level of CO2
▪ With excessive base formation, the respiratory rate slows to promote and increased level of CO2
▪ If the respiratory system is the source of pH problem, it loses the ability to correct the problem.
▪ Lungs work on A/B disturbances that are primarily metabolic in nature
▪ Medulla oblongata increases rate and depth in response to CO2 changes in ECF
• 3rd line of defense - renal system
o Compensates within hours
o Defense against H+
▪ HCO3 - reabsorbed - alkaline
▪ HCO3 - excreted - acid
▪ If acidosis (increased H+), H+ is excreted in kidney before K+ ions causing hyperkalemia
▪ If alkalosis (decreased H+), H+ is retained and K+ ions are excreted causing hypokalemia
o Helps to control metabolic buffers by excreting acidic urine or alkaline urine
o If renal loses ability, then the respiratory system takes over.
• Respiratory acidosis
o Hypoventilation disorders
▪ COPD, obstructed airway, pulmonary edema (severe)/ARDS, pneumothorax, hemothorax, head injuries/stroke, cardio-
pulmonary arrest, drug overdose (barbiturates, narcotics), MS, polio, sleep apnea
o Symptoms
▪ Slow ineffective respirations, tachycardia, irregular pulse, restlessness, confusion (because of hypoxia), shortness of
breath with exertion, headache, paralysis, tremors, arrhythmias, N/V, cyanosis/pallor, increased ICP, coma
o Treatment
▪ Correct the cause
▪ Increase fluids with KCL
▪ O2 therapy or mechanical ventilation
▪ Bronchodilators
▪ Chest PT (clear secretions)
▪ Antibiotics to prevent pneumonia
▪ Avoid narcotics and sedation
• Respiratory alkalosis
o Hyperventilation disorders
▪ Fear, pain, anxiety, pneumonia or atelectasis, pulmonary emboli, cardiovascular accident (damage to medulla -
stroke/brain injury), high altitude anoxia, aspirin poisoning, fever/septicemia, excessive CVA (mechanical ventilation)
o Symptoms
▪ Rapid respirations, hyper-reflexia, tingling of the fingers and toes, irregular pulse/dysrhythmias, lightheadedness,
dyspnea, anxiety/panic, convulsions, hypokalemia, hypocalcemia
o Treatment
▪ Correct the cause
▪ Rebreath CO2, give O2 if hypoxic
▪ Decrease anxiety
▪ Sedatives/tranqulizers
▪ Decadron (if inflammatory)
▪ Diuresis/dialysis
▪ Mechanical ventilation (CMV)
• Metabolic acidosis
o Dehydration disorders
▪ Diabetes (ketoacidosis), shock/starvation, severe diarrhea (increase in elimination of bicarbonate ions), GI suction,
fistulas, systemic infections, pancreatitis, renal failure
o Symptoms
▪ Kussmaul Respirations, headache with restlessness, hypotension, apathy/depression, decreased level of consciousness -
coma, warm/flushed skin, weakness, abdominal pain, nausea/vomiting, anorexia
o Treatment
▪ Correct the cause
▪ IV/oral bicarbonate
▪ O2 therapy, mechanical ventilation
▪ Replace insulin/K/fluids
▪ Increase kidney function
▪ Increase fluid volume
▪ Assess level of consciousness and prevent injury
• Metabolic alkalosis
o Reduced K+
▪ GI suctioning, vomiting, diuretics/hypercalcemia, prolonged steroid therapy, excessive bicarbonate intake
o Symptoms
▪ CNS excitability, slow and shallow respirations, irregular pulse/tachycardia, hypotension, numbness, tetany -
convulsions, lethargy/weakness, disorientation
o Treatment
▪ Correct the cause
▪ NaCl and KCL IV replacement
▪ Acidifying meds:
• Acidifying salts
• Hydrochloride
2. Adenocarcinoma

o Symptoms: non-diagnostic
▪ Weight loss, nausea, vomiting, discomfort
▪ Treatment
• Palliative
• Surgical - partial/subtotal gastrectomy, gastrectomy with esophojejunostomy
o Chemo after and slowly advance diet to prevent dumping syndome
o Gastric neoplasm
▪ Nursing diagnoses
• Altered comfort, altered nutrition, ineffective coping, fear/anxiety, potential metastasis
o Provide emotional support!
▪ Gastroplasty/Gastric bypass
• Size of stomach is surgically reduced or bypassed
• 30cc capacity
• Used for morbid obesity
• Post-op: begin clear liquids within 24 hours and slowly advance to small frequent meals
• Great need for teaching and counseling before and after OR
• Lifestyle changes and many compliance issues.
3. Anti-coagulants These medications are used
to thin the blood so that clots
will not form. Lovenox may
be used to treat blood clots
or to decrease heart attacks
in patients who have
unstable angina or mild heart
attacks.

Most used:
- Coumadin (Warfarin)
- Lovenox (Enoxaparin)
- Fragmin (Dalteparin)
- Arixtra (Fondaparinux)

Side effects:
- Bleeding problems
- Headaches (Coumadin)
- Nausea or vomiting
(Coumadin)
- Irritation where the shot
is given
4. Anti- This medication is used to treat sudden diarrhea (including traveler's diarrhea). It works by slowing down the movement of
diarrhea the gut. This decreases the number of bowel movements and makes the stool less watery. Loperamide is also used to
meds reduce the amount of discharge in patients who have undergone an ileostomy. It is also used to treat on-going diarrhea in
people with inflammatory bowel disease.

▪ Loperamide (Imodium)
▪ Diphenoxylate (Lomotil (PO))
▪ Narcotics (IV or PO)

Side effects:
Dizziness, drowsiness, tiredness, or constipation may occur. If any of these effects persist or worsen, contact your doctor
promptly.
5. Asthma

• Intermittent, reversible airflow obstruction (airway inflammation or airway hyperresponsiveness - smooth muscle on the
outside of the airway constricts)
o May occur with exercise, upper respiratory illness, bronchoconstriction
o Constricts and tightens smooth muscles tightening the airway
• Asthma irritants and allergens
o Irritants
▪ Cigarette smoke, air pollution, cold air or changes in weather, strong odors, strong emotions, stress
o Allergens
▪ Animal dander, dust mites, cockroaches, pollen from trees and grass, mold, food
• Clinical manifestations
o Audible wheezing (exhalation), shallow, rapid respirations, dyspnea, increased cough (usually harsh), chest tightness, use of
accessory muscles
▪ Intensity of wheeze does not determine the amount of airway constriction
▪ Increased heart rate and BP, restlessness
o Diagnostic assessment
▪ ABG's (evaluate how well obtaining oxygen)
▪ Chest X-ray
• Rules out other cause of dyspnea, evaluates chest structure changes
▪ Hypoxia during attack
Asthma Medications
• Bronchodilators:
• Beta 2 Agonists
o Albuterol, Salmeterol, Pirbuterol acetate
▪ Relax bronchial smooth muscle to relieve bronchospasms and produce bronchodilation
▪ Used during an acute asthma attack
▪ Contraindicated with hypersensitivity to synoathomimetics or tachycardias
▪ Watch blood sugars, HR, BP
▪ Avoid caffeine
▪ S/E: tremors, nervousness, tachycardia, hypo/hypertension, hyperglycemia, blurred vision, muscle cramps, N/V,
dysrhythmias
• (Methyl)xantenes
o Aminophyline, Theophyline
▪ Bronchodilation due to smooth muscle relaxation, stimulating effects on CNS
▪ Used to treat bronchial constriction with COPD, and status asthmatics
▪ Theophyline: used for long-term asthma. Normal= 5-15
• S/E: GI issues, N/V, seizures if toxic
▪ IV Theophyline
• Monitor vitals and EKG
• Give with histamine blocker
• Draw blood levels every 6-12 months to assess toxicity
• Corticosteroids
o Dexamethasone (decadron), Flucticasone (flovent), Flunisolide (Nasarel), Budesonide (Rhinacort)
▪ Inhibits the inflammatory response in airways and reduces edema
▪ May aid in increasing responsiveness in bronchial smooth muscle to beta-agonists
▪ Oral or intranasal
• Mast cell stabilizer
o Cromolyn sodium, Intal, Crohom
▪ Used for allergies and exercise asthma
• Leukotriene receptor antagonist/LRA
 o Montelukast/Singulair, Zafirlikast/Accolate
▪ Protects against allergy triggers, reduces asthmatic symptoms
• Anticholinergics/vagal blockers
o Ipratropium/Atrovent
▪ Prevents bronchospasm, and reduces mucus production
6. Auscultation ▪ Active vs. absent
of GI ▪ Hyperactive (borborygmi) vs. hypoactive
▪ Bruits (bell of stethoscope)
▪ Friction rub (enlarged liver, inflamed peritoneum, tumors)
7. Beta- in low doses, acts relatively selectively at beta2-adrenergic receptors to cause bronchodilator and vasodilation; at
adrenergic higher doses, beta2 selectivity is lost, and the drug acts at beta2 receptors to cause typical sympathomimetic cardiac
agonists effects.

Proventil (Albuterol)

Uses:
To control and prevent reversible airway obstruction caused by asthma or chronic obstructive pulmonary disorder
(COPD)
Quick relief for
bronchospasm
Longterm control agent for patients with chronic or persistent bronchospasm

Side effects:
Restlessness
cardiac arrhythmias
palpitation
sweating
nausea & vomiting
8. Beta- Treats high blood pressure
Blockers
Most used:
Lopressor (Metoprolol)
Toprol-XL (Metoprolol)
Tenormin (Atenolol) Inderal
(Propranolol) Zebeta
(Bisoprolol) Betapace
(Sotalol) Coreg (Carvedilol)

Common side effects:

Dizziness or
lightheadedness
Tiredness
gas or bloating
Heartburn
Constipation
Rash or itching
Cold hands and feet
9. Bladder cancer

• At risk: males over 50, smokers, people exposed to chemicals

• Exam: IVP, CT
• Symptoms:
o Painless, hematuria, frequency, change in urine color, burning when voiding, difficulty voiding
• Treatment:
o Cystectomy - removal of bladder
o Urinary diversions
▪ Ileal conduit: ureters into ileum, stoma with pouch
▪ Uretero-sigmoidostomy: ureters into sigmoid, urine exits rectum
▪ Ileal reservoir/kock's pouch: internal pouch from ileum, nipple valve - place catheter to drain urine
▪ Nephrostomy: external tubes drain renal pelvis
o Surgery
▪ Pre-op: type of diversion selected and discuss urine control, depending on selected diversion
▪ Post-op: assess drains/output, chart I&O, stoma care, support system
10. Braden Assessment (6 risks)

■ Braden Risk Assessment Scale

- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
11. Bronchitis

• Diffuse inflammation of the mucousal lining of the bronchial tree and excess mucus production
o Occurs after upper airway infections or chronic lung conditions
o Viral (most common - 90%) - clear sputum
o Bacterial - virulent sputum
o Lasts one - two weeks
• Symptoms
o Cough that begins dry/non-productive and progresses to productive with purulent sputum, low grade fever, substernal
(chest) burning, wheezes or crackles, malaise, headache
• Treatment
o Bed rest, fluids, nutrition, humidification, antipyretic,
o Expectorant - robitussin
o Antitussive - robitussin, tessalon, codeine,
o Antibiotics (IF bacterial)
o Smoking cessation
• Diagnosis
o Chest x-ray
12. Cataracts

■ Clouding of the lens with decreases visual acuity

■ 3 Types
• Subscapsular - back
• Nuclear - center
• Cortical - formed in lens convex and extends from outside of lens to center
■ Risk factors
• Aging
• Diabetes
• Congenital
• Trauma
• Toxins
• Excessive exposure to the sun
• Chronic corticosteroid use
■ Symptoms
• Early
- Blurred vision
- Poor color vision
• Late
- Diplopia
- Decreased acuity progressing to blindness
- Milky white pupil
■ Nursing care
• Snellen chart
• Increase light in room
• Provide adaptive devices (magnifying lens, large print, talking devices)
■ Medications
■ Cycloplegic mydriatic (Atropine 1% ophthalmic solution)
• Prevents pupil constriction for prolonged periods of time and relaxes muscles in the eye
• May cause photosensitivity
■ Surgical interventions
• Removal of the lens - in one or several pieces
• Replacement intraocular lens is inserted
■ Nursing Actions
• Postoperative:
- Prevent infection
- Administer ophthalmic medications
- Provide pain relief
- Teach self-care and fall prevention
■ Education
• Wear sunglasses
• Report signs of infection
• Avoid activities that increase IOP (bending over, sneezing, coughing, straining, head hyperflexion, restrictive clothing,
sex)
13. Chest
Tubes

• Purpose: remove air or fluid, and re-expand lung

• Diagnoses
o Pneumothorax (collapsed lung)
o Hemothorax (blood in lung)
o Postoperative chest drainage (thoracotomy or open-heart surgery)
o Pleural effusion (fluid in lung)
o Lung abscess (necrotic lung tissue)
• Closed chest drainage system
o 3 chambers
▪ Drainage (mark drainage)
▪ Suction (-20cm H2O)
▪ Water seal
• Dry system-atrium
o Uses valve, air leak indicator
• Wet system - pleurovax
o Uses water seal
• Assessment
o Fluid movement with inspiration - patency
o Assess for respiratory distress, air leaks, chest movements, crepitus, dressing, breath sounds and vital signs, fluid
replacement, ROM and increase activity, pain control
• Chest drainage rules
o Collection apparatus is below chest level
o Coil tubing in bed
o NO pins or clamps
o Assess patency of tubing
o Tape all connections
o Asepsis - extra vasoline gauze dressing
o I&O every 8 hours or less
o Suction 10-20cm of water
• Preprocedure
o Consent form
o Assess for allergies to local anesthetics
o Assist in to supine or semi-Fowler's
o Administer pain and sedation medications
• Postprocedure
o Vital signs, breath sounds, SaO2, color, and respiratory effort
o Encourage coughing and deep breathing
o Keep drainage system below client's chest level
o Document amount and color of drainage hourly for first 24 hours and then at least every 8 hours (report drainage > 70
mL/hr)
o Monitor tube insertion site for redness, pain, infection, and crepitus (air leakage in SQ tissue)
o Administer pain meds
o Obtain chest x-ray to verify placement
o Keep 2 enclosed hemostats, sterile water, and an occlusive dressing located at bedside
14. Chron's
Disease

o Cobblestone pattern (affects the GI wall)

o Autoimmune is stronger
o Mouth to anus
o More surgeries
o 5-6 stools a day
o Complications: obstruction, abscesses, fistulas, cancer of the small bowel and colon, malnutrition, anemia, bowel
perforation
▪ Hemorrhage is less common than ulcerative colitis
o Symptoms: diarrhea, abdominal pain, tenderness of the RLQ relieved by defecation, fever, fatigue, malaise, weight
loss, anemia, malnutrition
o Treatment
▪ Diet - well balanced, lactose free, and nutritional supplements (ensure), low roughage diet
• If severely malnourished or NPO, TPN is given
▪ Surgery only if complications (ex: bowel obstruction)
• Colon/bowel resection
• Fistulectomy
• Total colectomy with ileostomy
▪ Teach disease process, give emotional support, relieve symptoms
15. Congestive
Heart Failure

• Volume and resistance

• The heart is unable to pump blood throughout the body causing insufficient perfusion to organs with vital nutrients
and oxygen
o Results in low cardiac output
• Left-Sided Heart Failure
o Hear crackles in the lungs (back up of blood)
o Decreased perfusion
o Failure of the left ventricle to pump blood
▪ Decreased perfusion and cardiac output, and causes a weakened heart muscle
o Causes pulmonary congestion from increased pressure in pulmonary vessels
o Can be an acute or chronic condition
o Common causes are acute MI, cardiomyopathy, hypertension, and valvular disease
o Two types:
▪ Systolic (underfilling) - most common in elderly women with hypertension
• Heart is unable to contract and push blood
• Causes a decreased contractility and ejection fraction and an increase in ventricle end-diastolic pressure
o Drop in ejection fraction results in pulmonary congestion and inadequate tissue perfusion
• Results in increased diastolic pressure, ventricular dilation, and wall tension
• Underlying causes
o CAD, DM, HTN, arrhythmias, valvular stenosis, myocarditis, congenital heart disease, recreational or therapeutic
drug use, idiopathic cardiomyopathy

▪ Diastolic [remember by alphabet... abcDE - Diastolic Expand]

• Heart is unable to expand so it can't hold as much blood
• Causes a decreased stroke volume and decreased ventricular compliance
• Small ventricular chamber
• Results in ventricular stiffening preventing the ventricle to fill with blood.
• Underlying causes
o CAD, DM, HTN, aortic stenosis, hypertrophic cardiomyopathy, restrictive cardiomyopathy
o Underlying causes of left sided heart failure
▪ Acute heart failure, myocardial infarction, arrhythmias, myocarditis, drug induced (cocaine), sepsis
o Compensatory mechanisms (all add to the workload of the heart)
▪ Sympathetic nervous system - increases heart rate and blood pressure, decrease filling time
▪ Renin-Angiotensin System, aldosterone -increase fluid and preload, sodium retention
▪ BNP - opposite of RAS; sodium and fluid excretion, vasodilation
▪ Immune response - anti-inflammatory
▪ Vasopressin - vasoconstriction
▪ Myocardial hypertrophy - chronic overload, cardiac cells get bigger, slows relaxation and contributes to heart
failure once it reaches a certain point.
o Signs and symptoms of left sided heart failure
▪ Fatigue, confusion/restlessness, dyspnea on exertion (shortness of breath with activity), orthopnea (trouble
breathing), dyspnea at rest, oliguria, angina, pallor, weak peripheral pulses
o Pulmonary edema
▪ Life threatening complication
▪ Failure of the left ventricle to eject blood
▪ Blood accumulate and causes a rise in pressure of the lungs
▪ Fluid leaks across the pulmonary capillaries and pulmonary interstitum
▪ Signs and symptoms
• Frothy-pink sputum (blood in lungs), dyspnea, tachypnea, crackle sand wheezes, feelings of drowning (panic)
▪ Chest X-ray shows a lot of white/cloudiness (fluid is often white)
▪ Treatment
• High fowlers position and oxygen (2L then increase accordingly)
 • Auscultate lung sounds: listen for change and location of crackles (mark on back where crackles stop, because
usually moves upwards)
• IV access for diuretics - 100-120mg of Lasix if bad
• Document output
• Medications
o Potassium sparing diuretic, oral diuretic, bronchodilator, loop/thiazide (watch potassium), vasodilators, morphine
(for panic/fluids)
• Right Sided Heart Failure
o Back flow of blood in to the body
▪ Everything merges in to inferior and superior vena cava
▪ Increased pressure all over body
o Causes: Left sided heart failure, right ventricular MI, pulmonary congestion (increased pressures)
o Right ventricle does not empty
o Pressure and volume increase in systemic veins causing congestion and peripheral edema
o Signs and symptoms
▪ Fatigue/weakness, headache, shortness of breath, edema (feet, ankles, thighs, abdominal wall [ascites]), jugular
vein distention, anorexia, nausea, weight gain, polyuria, increased blood pressure
• Interventions
o Goal - determine the cause and extent of heart failure and improve cardiac function
o Complete medical history and assessment
▪ Vital signs: proportional pulse pressure in BP of < 25% means compromised cardiac output
▪ Listen for S3 and crackles/wheezes
▪ Assess for edema and take a daily weight to assess fluid retention
• 1L of fluid = 1kg = 2.2lbs
• Diagnostic tests
o Chest X-ray
o EKG
o Echocardiography [key diagnostic test]
▪ Looks at size and function of the valves, and motion of the ventricles
▪ Ejection fraction: measurement of percentage of blood ejected after the ventricles contract (normal amount is 65%)
• CHF patients may be as low as 10% and may require a pulmonary catheter
• Labs
o Serum electrolytes, BUN, creatinine, hematocrit and hemoglobin, BNP (B-type natriuretic peptide - counter balance
for RAS released by the ventricles to decrease preload), ABGs
Medications
• Drugs used to reduce afterload
o ACE Inhibitors: -oprils
▪ ACE - Angiotensin converting enzyme
▪ Decrease BP, preload, afterload
▪ Main side effects = angioedema, cough, electrolyte imbalance (decrease sodium)
▪ Suppresses RAS
▪ Increases stroke volume by causing arterial dilation and arterial resistance
o ARB: -sartans
▪ Suppress RAS
o Human B-type natriuretic peptides (nesiritide)
▪ Vasodilator and excretes water and sodium
• Drugs used to reduce preload
o Nutritional therapy: low sodium diet
o Diuretics: Loop (act on descending loops of Henle; potassium wasting)
▪ Watch for dehydration
▪ Enhance renal secretion of sodium and water
▪ Reduces systemic and pulmonary congestion
▪ Monitor for hypokalemia
o Venous vasodilators: Nitrates
▪ Decrease workload
▪ Returning vessels to normal capacity
▪ Improve ventricular function
▪ Not as effective over time because a tolerance gets built up
• Drugs that enhance contractility
o Digitalis
▪ Used for chronic heart failure and atrial fibrillation
▪ Used with ACE, beta blockers, and diuretics
▪ Reduces heart rate
▪ Inhibits the sympathetic nervous system
 Slows conduction through AV node
▪ Digitalis toxicity:
• Occurs in the presence of hypokalemia
• Symptoms: anorexia, bradycardia, fatigue, yellow vision
o Inotropic drugs
▪ Dopamine, Doubutrex: increase the force of contraction
o Beta-Adrenergic Blockers: -olols
▪ Reverses the sympathetic nervous system
▪ Improves the quality of life
▪ Vasodilation - decrease work load of heart
▪ Carvedilol - brings down BP, vasodilate
16. COPD

• Airflow limitation disease (not reversible)

• Progressive and associated with abnormal inflammatory response of the lung
• Treatable and preventable, but no cure
• Risk factors
o Smoking (#1), occupational exposure (dust, chemicals), air pollution, deficiency of alpha 1-antitrypsin (genetic), history of
childhood lung disease
• Diseases that make up COPD
o Chronic Bronchitis
▪ Inflammation of bronchi and bronchioles
▪ Presence of cough and sputum production for at least 3 months in two consecutive years
• Loss of cilia in airways
• Airways swell and block with mucus
▪ Pathophysiology
• Exposure to irritants trigger the inflammatory response causing:
o Vasodilation, congestion, mucosal edema, bronchospasm
• Chronic inflammation of the airways results in:
o Thickened bronchial walls and increase in number and size of mucous glands
• Results in large amount of thick mucous and reduced or blocked airways-impaired airflow = CO2 retainer, low PO2,
respiratory acidosis
▪ Assessment findings
• Persistent cough and foul copious sputum
• Dusky color (cyanosis) - "blue bloater"
• Dyspnea (mild early), tachypnea
• Overweight (not able to exercise)
• Early right sided heart failure
o Pulmonary emphysema
▪ Abnormal permanent enlargement of airspaces
▪ Destruction of alveoli walls
▪ Pathophysiology
• Enzymes (protease) present in high levels break down elastin in the alveoli and small airways
• Alveolar sacs lose elasticity, small airways become narrow or collapse, resulting in:
o Decreased surface area for exchange
o Increased amount of "trapped" air
o Loss of elasticity and hyperinflation of lung
• Hyperinflation of the lung flattens the diaphragm and results in a weakened diaphragm and use of accessory muscles to
inhale and exhale
• Increased need for oxygen
• CO2 retention, chronic respiratory acidosis, and low PaO2
• Exchange is not going through at the alveolar level
▪ Assessment findings
• Progressive, constant dyspnea
• Normal to pink skin color - "pink puffer"
• Increased anterior/posterior chest diameter = barrel chest
• Tachypnea with difficulty exhaling
• No cough (unless of infection)
 • Small amounts of sputum
• Thin, wasted, and progressive weight loss
• Fatigue, anorexia
• COPD diagnosis
o Physical assessment with a health history
o 3 primary symptoms
▪ Chronic cough, sputum production, and dyspnea
o ABG's - evaluate abnormal oxygenation, ventilation, and acid-base status
o Sputum culture - evaluate for bacterial infection
o Hemoglobin and Hematocrit - determine polycythemia due to chronic hypoxia
o Chest X-ray - bilateral hyperinflation of lungs with flattened diaphragm, excludes alternative diagnoses
o CT scan - not routinely obtained by may differentiate diagnosis
o Screening for alpha 1 antitrypsin deficiency (if less than 45 and family history of COPD)
• Medical management
o Risk reduction (stop smoking and avoid irritants)
o Monitor disease
▪ Spirometric/PFT studies
▪ Prevent and treat exacerbations
▪ Prevent and minimize side effects from the treatment
▪ Prevent complications
▪ Reduce mortality and improve quality of life
▪ Medications
• COPD Complications
o Hypoxemia and acidosis
▪ Decreased oxygenation and increased carbon dioxide causes decreased tissue function
• Leads to respiratory failure and dysrhythmias
▪ Hesitant to intubate because they may not come off of it
▪ At home: humidifier, cover mouth in cold weather
o DO NOT GIVE COPD PATIENTS A LOT OF O2
▪ Hypoxia (decreased O2 in the body) is a COPD patient's trigger to breathe, taking away this trigger takes away ability to
breath on own.
o Respiratory tract infection
▪ Increased mucus production and poor oxygenation
• High risk for infection
• Streptococcus pneumoniae, Haemophilus influenzae
▪ Interventions: Avoid crowds, get vaccinated, increase fluids, increase protein, increase carbs, increase vitamin C, wash hands
regularly
o Cor pulmonale (heart failure)
▪ Air trapping, airways collapse, and stiff alveolar walls increase lung pressure = right sided heart workload
▪ Right heart chambers enlarge and thicken = right sided heart failure
• Nursing Interventions for COPD
o Position to maximum comfort
o Teach breathing techniques
▪ Diaphragmatic and pursed lip
o Monitor respiratory status every 2 hours
o Monitor effectiveness of oxygen (Low flow)
o Rest between activities and drink 2-3 liters of fluid daily
17. Decongestants These are alpha-agonists which on topical application as dilute solution (0.05-0.1%) produce local vasoconstriction.
Regular use of these agents for long periods should be avoided because mucosal ciliary function is impaired:
atrophic rhinitis and anosmia can occur due to persistent vasoconstriction.

Ephedrine
Levomethamphetamine
Naphazoline
Oxymetazoline
Phenylephrine

Side effects:
High blood pressure
Prostatic hyperplasia
Rebound nasal congestion
18. Diagnosis of ■ Defined as total & irreversible destruction of the brain & brain stem
brain death ■ Occurs when an injury to the brain causes it to swell and fill the capacity of the skull, thus preventing blood flow
to the brain.
■ Clinical exam and/or test are done to confirm brain death
Brain death is NOT a coma!
■ Artificial support may maintain body function temporarily

Tests:
■ Flat EEG indicative of no brain activity
■ Cerebral Arteriogram indicating no cerebral circulation
■ Cerebral Brain Flow Study indicating no cerebral perfusion
■ CBF is REQUIRED in patient's who have been hypothermic
19. Diarrhea o Causes: medications, diet, IBD, partial bowel obstruction, cancer, diverticulosis, infection, food allergies, lactose
intolerance, laxative overuse, etc.
o Complications: alteration in bowel elimination, fluid/electrolyte volume deficit
o Interventions: replace fluid/electrolyte imbalance PO or IV, eliminate the cause
o MEDICATIONS
▪ Imodium
▪ Lomotil (PO)
▪ Narcotics (IV or PO)
20. Differences between organ and Organ
tissue donation ■ Requires heart beat & vent
■ Remains in the ICU up until the OR
■ Recovered by transplant surgeons
■ Liver
■ Heart
■ Lungs
■ Pancreas
■ Kidneys
■ Intestines

Tissue
■ Referred at CTOD
■ Recovered by Indiana Donor Network Coordinator
■ Up to 24 hours to recover
■ Corneas
■ Heart Valves
■ Descending Thoracic Aorta
■ Skin
■ Bone
■ Veins/Arteries (males)
■ Fascia
■ Tendons
21. Different cultures (death) ■ Some cultures have more serious concerns about the physical body
■ Some grieve more demonstratively
■ Some will be angry
■ Some families will come together, others will turn on one another
■ Some will want more time
■ Do not stereotype
■ Do not pre-decide what they will do or want
■ Grant any request you can reasonably grant
■ If you aren't sure what they want, ask!
22. Different types of death related to Brain death:
organ donation ■ Hemorrhagic/Ischemic Stroke, Aneurysm
■ TBI caused by GSW or MVA
■ Smoke inhalation
■ Strangulation
■ Cardiac Arrest with prolonged "downtime"
■ Drug Overdose
■ Any Anoxic Injury

Circulatory Death:
■ Recovery of organs for transplantation from asystolic donor
■ Prior to acceptance of brain death DCD is the way ■ donation would happen
■ DCD donors must have significant neuro injury but will not progress to brain death
■ Family must 1st decide to withdraw care before we would approach for donation or they
must initiate donation conversation
23. Digoxin Digoxin is a cardiac glycoside which has positive inotropic activity characterized by an increase in the force of myocardial
contraction. It also reduces the conductivity of the heart through the atrioventricular (AV) node. Digoxin also exerts direct
action on vascular smooth muscle and indirect effects mediated primarily by the autonomic nervous system and an
increase in vagal activity.

Uses:
Heart failure
Supraventricular arrhythmias
Emergency heart failure

Side effects:
Headache
Weakness
Drowsiness
visual disturbances
mental status change
Arrhythmias
GI upset, anorexia
24. ESKD

• Progressive and irreversible destruction of kidney tissue

o Kidneys can tolerate 75-80% damage
o If caught early enough, can slow the progression (often asymptomatic)
• Vascular damage from diabetes can affect the kidneys (need to control blood sugar and blood pressure)
• Risk factors
o Acute kidney injury (#1 cause), poorly controlled diabetes, chronic glomerulonephritis, nephrotoxic medications, chronic
hypertension (#2), autoimmune disorders (lupus), polycystic kidney disease, older adult clients, African Americans, Native
Americans, and Asians
• Stages:
1. Minimal kidney damage with normal GFR (>90mL/min). Not a lot of symptoms
2. Mild kidney damage with mildly decreased GFR (60-90 mL/min). Not a lot of symptoms
3. Moderate kidney damage with moderately decreased GFR (30-60mL/min). Decreased renal reserve, 50% nephron loss.
When most people get diagnosed
4. Severe kidney damage with severely decreased GFR (15-30mL/min). Renal insufficiency, 75-80% nephron loss. Diuretics lose
effectiveness.
5. Kidney failure with little to no GFR (<15mL/min). ESRD, 90-100% nephron loss
• Clinical manifestation
o GFR <60 mL/min for 3 months
o Severe azotemia (waste accumulated in blood)
o Hyperkalemia, hypernatremia, hyperphosphatemia
o Metabolic acidosis and decreased erythrocyte production
o Urinary system
▪ Specific gravity fixed at 1.010
▪ Oliguria to anuria
o Endocrine system
▪ Hyperparathyroidism (hypocalcemia, hyperphosphatemia), hypothyroidism
o Hematologic system
▪ Anemia, bleeding and infection
o Cardiovascular
▪ HTN, CHF, uremic pericarditis, atherosclerotic, heart disease
o Respiratory
▪ Kussmal's respirations, pulmonary edema (pink, frothy sputum)
o GI
▪ Anorexia, N/V, uremic fetor (breath smells like urine), GI bleeding (ulcers)
o Metabolic system
▪ Hyperglycemia, hyperlipidemia, gout, hypoprotenemia, CHO intolerance
o Neurological
▪ CNS depression, peripheral neuropathy, tremors, ataxia
o Musculoskeletal
▪ Renal rickets
o Integumentary system
▪ Yellow/gray discoloration, pruritis, uremic frost (glistening of skin), ecchymosis
o Psychologic changes
▪ Emotional, withdrawal, depression and psychosis
• Hyperkalemia
o Dialysis
o D50 and insulin
o Ca Gluconate/carbonate - helps protect heart. Give 1st
o Sodium bicarbonate
o Kayexalate
 • Treatment
o Medications and nutrition
o Dialysis
▪ Remove end products of PTN metabolism (waste products)
▪ Control potassium
▪ Remove excess fluid
▪ Correct Acid/Base balance
o Hemodialysis
▪ Blood from body moves through a dialysis machine and back into the body
▪ Osmosis - pulls fluid
▪ Filtration and Diffusion - pulls particles
▪ Takes 3-5 hours 3 times a week, (200-500mL/hour)
▪ Grafts/Fistulas
• Graft-dacron shunt placed in arm, leg, or chest
• Fistula placed in artery/vein (if left handed, use right arm)
o Takes about 6 weeks to mature
o Assess: listen for a bruit and feel a thrill
o Check q 4 hours if new and q shift if old
▪ Complications
• Clotting/infection of access site (can't to heavy lifting with this arm)
• Anemia (H&H)
• Hypotension (Tachycardia)
• Disequilibrium syndrome:
o Blood becomes hypoosmotic and leaks out into the CSF and causes cerebral edema
o S/S: N/V, confusion, headache, restlessness, muscle cramps, twitcing, eventually seize and become hypotensive
o TX: slow/stop dialysis and use hypertonic solution to draw the fluid back into the vascular system
• Sepsis
o Peritoneal dialysis
▪ Peritoneum used as semi-permeable membrane
▪ Surgery to place catheter
▪ 4-5 exchanges in a 24 hour period
▪ Indications
• Treatment choice for the older adult
• Clients who are unable to tolerate anticoagulation
• Clients who have poor blood vessels
• Clients with infection
o Hemodialysis can spread the infection so use peritoneal
▪ Contraindications
• History of multiple abdominal surgeries
• Recurrent hernias
• Obesity with large abdominal and fat deposits
• Chronic back pain and severe COPD
• Consider cognitive abilities (not good if patient can't follow directions)
• Getting a kidney transplant
▪ Cycle
• Catheter, inflow - dialysate by gravity into the abdominal cavity (1-2L over 20-30 minutes)
• Dwell time - the dialysate remains in the abdomen (30min-8hrs)
• Drain - drains by gravity (15-30 mins)
o If not draining, switch position of patient. May give laxative.
• Warm dialysis before infusing (cold can cause cramping and pain)
• Sterile procedure
25. Esophageal
Disorders

o Dysphagia: difficulty swallowing

▪ Hiatal hernia, cerebrovascular accident (CVA), obstruction, tumor
o Achalasia: absence of peristalsis (food is not moving)
o Esophagitis: inflammation of esophagus
▪ Sliding hiatal hernia, tumors, chemo medications, reflux, gastric ulcers
26. Esophageal
Neoplasms

o Most are malignant and have a poor prognosis

o Symptoms: pain, dysphagia, heart burn, weight loss, chronic hiccups
o Diagnosis: Endoscopy, CT scan, MRI
o Treatment: Chemotherapy, radiation, OR- esophagogastrectomy
▪ Post-op: IV, PCA, O2, drains, NG (do not reposition), tube feedings, hyperalimentation/TPN
o Squamous cell esophageal cancer (upper 2/3 of esophagus)
▪ Caused by smoking and alcohol
▪ Surgical approach: esophagogoastrostomy, colon interposition
• Have to manage nutrition and weight, smoking cessation, oral hygiene (at risk for fistula between trach and
esophagus), bolus high in potassium and calories
27. Gastric Ulcer

o Assess for bacteria: blood test and/or breath test (look for creatinine)
o Treat with meds "triple therapy"
1. Bismuth or omeprazole
2. Flagyl/metronidazole
3. Amoxicillin or tetracycline or clarithromycin
▪ 2-4 times a day for 14 days
o Gastric surgery complications: Dumping syndrome
▪ Vasomotor symptom after eating caused by:
o Rapid emptying of gastric contents into the small intestines (days to months after surgery)
o Fluid shift into gut
o Abdominal distention/nausea
▪ Happens 30-90 minutes after eating
▪ Managed by diet:
o Low carb, high fat (more veggies and no milk)
o Decrease fluids during and after meals
o Rest after meals
28. Gastritis

▪ Acute - avoid irritants/contaminated foods

• Antibiotics, treat underlying cause
▪ Chronic - control symptoms, avoid irritants, diet management, correct anemia, rest
o Diagnosed: gastroscopy, biopsy, gastric analysis, B12 levels, CBC
o Medications: antiemetics, antacids, H2 blockers
o Diet: NPO, slowly advance diet
29. GERD

o Diagnosed by: endoscopy, barium swallow, esophageal manometry

o Cause: hiatal hernia
o Prevention: reduce weight, low fat diet, smoking cessation, eliminate caffeine, no alcohol, eating smaller meals,
drinking a lot of water
o Medications: antacids, H2 blockers, Prilosec, nexium, reglan
o Risk factors: age, obesity, sleep apnea, NG for four or more days, pregnancy, foods that decrease esophageal
sphincter
o Diet: avoid fatty foods, alcohol, caffeine, peppermint, chocolate, spicy and high acid foods, eat small meals
▪ Do not eat 2 hours before bed and elevate the head of the bed after eating
o Operation: nissen fundoplication for hiatal hernia
▪ Stretta procedure: laser surgery on sphincter to make stronger
30. GI Cancer CEA (colorectal cancer); CA-19 (pancreatic cancer)
Markers
31. GI Diagnostic
Studies

• Upper GI:
o Barium swallow
▪ Pre-op: NPO for 10 hours, no narcotics for 24 hours, drink 16oz of barium, takes approx. 30 minutes, expect chalky
white stools
o Gastroscopy... Esophagogastroduodenoscopy (EGD)
▪ Pre-op: NPO for 6-8 hours, no NSAIDS, consent forms, vitals, patient is sedated (propranolol), patient placed on
left lateral side, antistatic to the back of the throat
▪ Establish gag reflex before any liquids, food, or PO medications
• Lower GI:
o Barium Enema
▪ Pre-op: No red/orange/purple food or fluids, NPO 4-6 hours, no aspirin/anticoagulants
o Colonoscopy
▪ Looking for tumors, polyps, hemorrhage
▪ Pre-op: clear liquid diet, NPO, vital signs, consent
32. GI Meds ▪ Phenergan/Promethazine
• Prevent IV infiltration (only give IM)
• Dopamine antagonist (works well with chemo patients)
▪ Zofran/Ondansetron
• Usually given first
• Serotonin antagonist
▪ Dramamine/Dimenhyrinate
• Antihistamine
• Given for motion sickness
• Side effect - sedation
▪ Reglan/Metoclopramide
• Dopamine antagonist (works well with chemo patients)
• Post-op
▪ Inapsine/Droperidol
• Dopamine antagonist (works well with chemo patients)
• Side effect - hypotension, dizziness, drowsiness, headache, constipation, diarrhea
33. Glaucoma (acute and
chronic)
 ■ ACUTE
- Closed angle glaucoma (angle between the iris and sclera is decreased) PACG (Primary angle
closure glaucoma)
■ Rapid increase in intra-ocular pressure
■ Symptoms
■ Rapid onset of elevated IOP
■ Decreased or blurred vision
■ Seeing halos around lights
■ Pupils are nonreactive to light
■ Severe pain and nausea
■ Photophobia
■ CHRONIC
- Open angle glaucoma (angle between the iris and sclera is normal) POAG
■ Gradual increase in ocular pressure
■ Symptoms
■ Headache
■ Mile eye pain
■ Loss of peripheral vision
■ Decreased accommodation
■ Elevated IOP
■ Treatment
- Medical Emergency
- Medication to decrease IOP
■ Prostaglandin Analogs (latanoprost, bimatoprost)
■ Increase outflow of fluid from the eye
■ Opthalmic Beta-adrenergic blocking agents (betalol, carteolol, timolol)
■ Decrease IOP by reducing aqueous humor production
■ Carbonic Anhydrase Inhibitors (acetazolamide, dorzolamide)
■ Reduce IOP, dilate pupils, create eye paralysis (preoperatively)
■ Parasympathomimetics (epinephrine/Propene)
■ IV mannitol
■ Osmotic diuretic used in emergency for angle-closure glaucoma (quickly decrease IOP)
■ Ocular steroid (prednisolone)
- Surgical interventions
■ Laser trabeculectomy, iridotomy, or placement of shunt to improve flow of the aqueous humor
■ Nursing actions - Check IOP 1 to 2 hours postoperatively
- Client education
■ Avoid activities that increase IOP
■ Should not lie on operative side
■ Report lid swelling, decreased vision, bleeding or discharge, a sharp, sudden pain, or light
■ Diagnostic
- Tonometry - measures IOP
- Gonioscopy - used to determine drainage angle of the anterior chamber of the eyes
■ Nursing care
- Monitor clients for increased IOP
- Monitor for decreased vision and light sensitivity
- Assess clients for aching or discomfort around eye
- Treat pain and nausea with analgesics and antiemetics
34. Glucocorticoids

THESE DRUGS ARE USED IN THE TREATMENT OF CONDITIONS REQUIRING:

- SUPPRESSION OF THE IMMUNE SYSTEM
- DECREASE INFLAMMATORY RESPONSE

ALSO USED IN:

- ADDISON'S DISEASE.
- COPD
- IMMUNE DISORDERS
■ Prednisone
■ Dexamethasone
■ Cortisone
■ Methylprednisolone

Side Effects:
ACNE

POOR WOUND HEALING

ECCHYMOSIS

BRUISING

PETECHIAE

DEPRESSION

FLUSHING

SWEATING

MOOD CHANGES (DEPRESSION)

INSOMNIA

HYPOMANIA

HYPERTENSION

OSTEOPOROSIS

DIARRHEA

HEMORRHAGE
35. Grafting: types, care, site care ■ Homograft - Human cadavor skin
- Tested for disease
- Rejected for 2 weeks
■ Autograft - Pt. own skin
■ Heterograft - Pig Skin (another species)
- Temp. - 5 to 7 days
■ Amniotic membrane
- Lasts 48 hours
■ Cultured skin
- Use patient's own cells and grows skin
■ Artificial skin
- Epidermis and dermis - dissolves
■ Surgical excision: Excise thin layers of necrotic burn surface
- Bed of healthy dermis or subcutaneous fat
■ Wound covered by Autograft
- Skin from unburned area of body (donor) transplanted to cover wound (recipient)
36. Hearing loss (conductive and sensorineural) ■ Conductive
- Sound does not travel through the inner ear
- Causes
■ Wax build up
■ Malformation of outer ear, ear canal, or middle ear structure
■ Fluid in the middle ear from colds
■ Otitis media
■ Allergies
■ Perforated eardrum
■ Benign tumors
■ Infection in the ear canal
- Hearing aids
- Timpanoplasty
- Lateralization to effected ear
- Rinne vs Weber
■ Rinne normal
■ Sensorineural
- Sound distorted by defect in the inner ear
- Causes
■ Exposure to loud noise
■ Head trauma
■ Virus or disease
■ Autoimmune inner ear disease
■ Aging
■ Malformation of the inner ear
■ Meniere's Disease
■ Otosclerosis
■ Tumors
- Rinne vs Weber
■ Rinne test less bone
■ Sound stops earlier
37. Hemodialysis

Chronic kidney disease and acute kidney injury (also known as acute renal failure) cause the kidneys to lose their
ability to filter and remove waste and extra fluid from the body. Hemodialysis is a process that uses a man-made
membrane (dialyzer) to:

Remove wastes, such as urea, from the blood.

Restore the proper balance of electrolytes in the blood.
Eliminate extra fluid from the body.
For hemodialysis, you are connected to a filter (dialyzer) by tubes attached to your blood vessels. Your blood is
slowly pumped from your body into the dialyzer, where waste products and extra fluid are removed. The filtered
blood is then pumped back into your body.
 blood s t e pu ped bac to you body.

There are different types of hemodialysis. Talk about these with your doctor to decide which one might be best for
you.

In-center hemodialysis. You go to a hospital or a dialysis center. Hemodialysis usually is done 3 days a week and
takes 3 to 5 hours a day.
Home hemodialysis. After you are trained, you do your dialysis treatments at home. Hemodialysis is usually done 3
days a week (or every other day). Discuss with your doctor how long each session needs to be. A session could be
as long as 6 hours, which may help you feel better.
Daily home hemodialysis. After you are trained, you do your dialysis treatments at home. Hemodialysis is done 5 to 7
days a week. Each session takes about 3 hours.
Nocturnal home hemodialysis. After you are trained, you do your dialysis treatments at home. Hemodialysis is done 3
to 7 nights a week. Each session is done overnight (about 6 to 8 hours).
Before treatments can begin, your doctor will need to create a site where the blood can flow in and out of your body
during the dialysis sessions. This is called the dialysis access. The type of dialysis access you have will depend in
part on how quickly you need to begin hemodialysis.

There are different types of access for hemodialysis:

Fistula. A fistula is created by connecting an artery to a vein in your lower arm. A fistula allows repeated access for
each dialysis session. It may take several months for the fistula to form. A fistula may not clot as easily as other
dialysis access methods. A fistula is the most effective dialysis access and the most durable. Complications include
infection at the site of access and clot formation (thrombosis).
Graft. A vascular access that uses a synthetic tube implanted under the skin in your arm (graft) may be used if you
have very small veins. The tube becomes an artificial vein that can be used repeatedly for needle placement and
blood access during hemodialysis. A graft does not need to develop as a fistula does, so a graft can sometimes be
used as soon as 1 week after placement. Compared with fistulas, grafts tend to have more problems with clotting or
infection and need to be replaced sooner. A polytetrafluoroethylene (PTFE or Gore-Tex) graft is the most common
type used for hemodialysis.
Venous catheter. A tube, or catheter, may be used temporarily if you have not had time to get a permanent access.
The catheter is usually placed in a vein in the neck, chest, or groin. Because it can clog and become infected, this
type of catheter is not routinely used for permanent access. But if you need to start hemodialysis right away, a
catheter may be used until your permanent access is ready.
Hemodialysis for acute kidney injury may be done daily until kidney function returns.

What To Expect After Treatment

About once a month, you will have blood tests to make sure you are getting the right amount of hemodialysis. These
tests are done to help find out how well hemodialysis is working. Your weight before and after each session will be
recorded, as will the length of time it takes to complete the dialysis session. If you have hemodialysis at home, you
will need to keep records of your weight before and after each session and the length of each session.

Why It Is Done

Hemodialysis is often started after symptoms or complications of kidney failure develop. Symptoms or complications
may include:

o Signs of uremic syndrome, such as nausea, vomiting, loss of appetite, and fatigue.
o High levels of potassium in the blood (hyperkalemia).
o Signs of the kidneys' inability to rid the body of daily excess fluid intake, such as swelling.
o High levels of acid in the blood (acidosis).
o Inflammation of the sac that surrounds the heart (pericarditis).

Hemodialysis is sometimes used when acute kidney injury develops. Dialysis is always used with extra caution in
people who have acute kidney injury, because dialysis can sometimes cause low blood pressure, irregular heart
rhythms (arrhythmias), and other problems that can make acute kidney injury worse.

How Well It Works

Hemodialysis may improve your quality of life and increase your life expectancy. But hemodialysis provides only
about 10% of normal kidney function. It does not reverse chronic kidney disease or kidney failure.

Dialysis has not been shown to reverse or shorten the course of acute kidney injury. But it may be used when fluid
and electrolyte problems are causing severe symptoms or other problems. Some people who develop acute kidney
 injury stay dependent on hemodialysis and will go on to develop kidney failure.

Risks

Most complications that occur during dialysis can be prevented or easily managed if you are monitored carefully
during each dialysis session. Possible complications may include:

o Low blood pressure (hypotension). This is the most common complication of hemodialysis.
o Muscle cramps.
o Irregular heartbeat (arrhythmia).
o Nausea, vomiting, headache, or confusion (dialysis disequilibrium).
o Infection, especially if a central venous access catheter is used for hemodialysis.
o Blood clot (thrombus) formation in the venous access catheter.
o Technical complications, such as trapped air (embolus) in the dialysis tube.

Long-term complications of dialysis may include:

o Inadequate filtering of waste products (hemodialysis inadequacy).

o Blood clot (thrombus) formation in the dialysis graft or fistula.
o Cardiovascular disease (heart disease, blood vessel disease, or stroke).
38. Hepatitis

• Inflammation of the liver

• Causes: virus, alcohol, toxins, gallstones
• Symptoms: Early non-specific and vague
o Jaundice, fatigue, abdominal pain (RUQ), loss of appetite, N/V, dark urine (CDE), diarrhea (A), joint pain (BD)
• Hepatitis A (HAV)
o Fecal-oral route: water and food contamination
o Intubation 2-6 weeks
o Infectious 2 weeks before to 1 week after treatment
o Immunity: life-time after exposure
o Prevention: sanitation and care when traveling
o High risk: IV drug users, male homosexuals
▪ Destroyed by bleach
▪ Can pass from person to person
o Vaccine: Hepatitis A - peds, travelers, high risk behavior
o IgM: IM doses to all exposed within 2 weeks
o Treatment - care related to symptoms and prevent spreading (hand hygiene, bleach, washing clothes separately
• Hepatits B (HBV)
o Blood/body fluid exposure: contaminated needles, sexual transmission, prenatal
▪ Transmitted via skin and mucous membranes
o Intubation 4 weeks - 6 months
▪ Commonly develops 60-90 days after exposure
▪ Infectious: from exposure (even if asymptomatic) until enzymes return within normal limits
o More susceptible if immunocompromised
o Immunity only with vaccine
▪ Assess titer - shows if the vaccine is working
o Prevention - avoid high risk behaviors, standard precautions, vaccine
o At risk: medical personnel, children, multiple sex partners, IV drug users, prison inmates, travelers, male homosexuals
o Complications: chronic hepatitis B, cirrhosis, liver cancer, death
o Treatment: care related to symptoms, and prevent the spread to others
39. Herpes Zoster

Reactivation of the dormant varicella-zoster virus in pts who had chickenpox.

Multiple lesions in on the skin area innervated by the infected nerve: minor irritation to severe, deep pain
■ Lasts several weeks /w fever, malaise
■ Postherpetic neuralgia - Pain occurs after lesions resolved for many weeks.
■ Contagious: To anyone not had chickenpox OR not vaccinated
■ Vaccine for adults (@ highest risk) - 50 years>
40. Hiatal Hernia

o Sliding: part of the stomach slides through the opening above the diaphragm
o Rolling: fundus of stomach herniates through the diaphragm alongside the esophagus
▪ Symptoms: heartburn, regurgitation, chest pain, dysphagia, belching, occult bleeding
▪ Diagnosed by endoscopy or barium swallow
▪ Diet: avoid fatty foods, alcohol, caffeine, peppermint, chocolate, spicy and high acid foods, eat small meals
▪ Post-op: turn, deep breathe (avoid coughing), NG (DO NOT REPOSITION), IV, PCA
• Watch and assess eating because of swallow problems
41. Histamine Histamine H2-receptor antagonists, also known as H2-blockers, are used to treat duodenal ulcers and prevent their
blockers (H2 return. They are also used to treat gastric ulcers and for some conditions, such as Zollinger-Ellison disease, in which
Antagonist ) the stomach produces too much acid. In over-the-counter (OTC) strengths, these medicines are used to relieve
and/or prevent heartburn, acid indigestion, and sour stomach. H2-blockers may also be used for other conditions as
determined by your doctor.

■ Ranitidine
■ Famotidine
■ Cimetidine

Uses:
Treatment and
prevention of heartburn,
acid indigestion, and sour stomach

Side effects:
Dizziness
Arrhythmias
Drowsiness
Headache
Nausea
42. Hyperkalemia

hyperkalemia: [K+] > 5.5

usually K+ balance is maintained until GFR < 10
prevent by avoid K-sparing diuretics and cautious use of ACEIs and ARBs in later stage CKD
causes:
o acidosis, which causes K+ to shift out of cells and into the ECF
investigation: peaked T waves on EKG
treatment depends on EKG findings
o EKG changes concern for arrhythmias
IV calcium chloride or calcium gluconate to modify myocardial excitability
onset in 1-3 min with duration of 30-60 min
repeat every 30-60 minutes until EKG normalizes
won't lower the hyperkalemia!
o use a K+ binder to lower total body potassium
sodium polystyrene sulfonate exchanges Na+ for K+ in the colon
takes 2-3 hours to work
o dialysis to remove excess potassium
o get K+ back into cells
glucose (or not if hyperglycemic) and insulin to increase intracellular uptake of
K+
onset in 5-10 min with duration of 2 hours
sodium bicarb IV over 5 minutes if acidosis is present
albuterol to increase intracellular uptake of K+ (stimulates β-cells in pancreas to
make insulin)
onset of 30-40 min with duration of 2-6 hours
may not work in 20% of people
43. Hypoxia

Hypoxia is arbitrarily defined as PaO2 < 60 mm Hg = O2 of 90%

Symptoms:
- Changes in the color of your skin, ranging from blue to cherry red
- Confusion
- Cough
- Fast heart rate
- Rapid breathing
- Shortness of breath
- Sweating
- Wheezing

Causes:
- Lung diseases such as chronic obstructive pulmonary disease (COPD), emphysema, bronchitis, pneumonia, and
pulmonary edema (fluid in the lungs)
- Strong pain medicines and other drugs that hold back breathing
- Heart problems
- Anemia (a low number of red blood cells, which carry oxygen)
- Cyanide poisoning (Cyanide is a chemical used to make plastics and other products.)
44. Hysterectomy

• Total vaginal hysterectomy

• Total abdominal hysterectomy
o Laprascopic, horizontal bikini cut
• Patient care
o Similar for other abdominal surgeries, vaginal/abdominal bleeding, incentive spirometer, manage vitals and pain,
urinary output, intactness of incision
o Emotional needs and physical changes
o Activity (no driving on narcotics)
o Sex (not for 6 weeks)
o Follow up and monitor for complications
45. Interventions to Medications to decrease IOP
decrease IOP ■ Miotics/Cholinergics/Parasympathomimetics (echothiophate, carbachol, pilocarpine)
• Constrict the pupil and contract the ciliary muscle
• Increase blood flow to the retina
• Prevent further damage
• SE: blurry vision, may be more difficult to see in dim light, systemic effects (headache, flushing, increased saliva,
sweating)
■ IV mannitol (emergent treatment for PACG)
• Osmotic diuretic, quickly decreases IOP
■ Ocusert System
• Thin eye disk with time-release dose of pilocarpine
Placed in upper or lower cul-de-sac of eye
Released over 1 week, replaced every 7 days

Avoid activities that increase IOP (bending over, sneezing, coughing, straining, head hyperflexion, restrictive
clothing, sex)
46. Irritable Bowel
Syndrome

o Disease 1/5 people have (more women than men)

o Spastic bowel/colon, functional colitis, colitis
o Characterized by alternating periods of constipation and diarrhea
▪ Causes: stress, hormones, medications, lactulose intolerance, low fiber, low residue diet
o Symptoms: intermittent abdominal pain (dull or continuous) relieved by defecation, changing elimination
patterns (diarrhea and/or constipation, abdominal bloating, flatulence, abdominal tenderness, N/V
o Diagnostics: no test, just eliminate other disorders
o Diet: eliminate upsetting foods
▪ Low lactulose, reduce gas forming foods, avoid caffeine/alcohol, increase dietary fibers and fluids
▪ Chew gum to stimulate peristalsis
o Medications
▪ Anti-diarrhea (Imodium) after each loose stool
▪ Stimulate peristalsis (Zelnorm/tegaserod) before meals for constipation prevention
▪ Anti-depressants
▪ Bulk-forming laxatives (Metamucil) 2-3x a day
▪ Anticholnergics (bentyl) to reduce pain and relax bowel
▪ Enzymes/probiotics
47. Isolation Protective Isolation because burn pts. are severely immunosuppressed so we must protect them.

Strict infection control practices (physical isolation in a private room, use of gloves and gowns during patient
contact)
48. Laws regarding organ/tissue Over 70% of all Licensed Drivers in Indiana are donor designated (DD)
donation
Supports the right for an individual's decision to become a donor

DD status is verified by Indiana Donor Network via BMV/Registry Records

DD is shared with hospital staff & family

The donor's decision is carried out

49. Loop Diuretics
 • FUROSEMIDE
o LASIX
• THERAPEUTIC
o antihypertensive
• PHARMACOLOGIC
o loop-or-high-ceiling type diuretics
• TREATS
o Acute edema associated w liver cirrhosis, renal impairment, or HF
• MECHANISM OF ACTION
o prevents the reabsorption of sodium & chloride by blocking the symporter in the loop of helena
• ROUTE/DOSAGE
o PO (20-80 mg), IV (20-40 mg), IM (20-40 mg)
• METABOLISM
o Hepatic
• EXCRETION
o Renal
• ADVERSE EFFECTS
o Dehydration, electrolyte imbalance can cause dystythmias. Dizziness & syncope due to
hypertension. May cause metabolic alkalosis
• BLACK BOX
o excessive amount can lead to a profound diuresis.
• CONTRAINDICATIONS & PRECAUTIONS
o hypersensitivity to furosemide or sulfonamide antibiotics, anuria, hepatic coma, or severe fluid or
electrolyte depletion.
• DRUG INTERACTIONS
o digoxin (decrease k+ decrease effectiveness) & other k+ depleting drugs. Lithium (increase toxicity),
alcohol (adds to diuretic action)
• OVERDOSE TX
o supportive w replacement fluids and electrolytes and the possible administration of a vasopressor
• NURSING RESP / PT TEACHING
o Monitor VS during diuresis and through periods of dosage readjustment
Consider Orthostatic Hypotension (Monitor BP reclining, sitting, & standing)
Obtain Freq Lab test = CBC
Eat K+ rich foods daily
50. Meniere's
 ■ Pathology
- Dilation of the endolymphatic system by either overproduction or decreased reabsorption of endolymphatic fluid
■ Risk Factors
- Emotional or endocrine disturbance
- Spasm of internal auditory artery
- Head trauma
- Allergic reaction
- Increased salt intake
- Smoking
- Infections
■ Symptoms
- Vertigo
- Nausea
- Fluctuating hearing loss and tinnitus
- Hearing loss increases with each attack
- Ataxia
- Nystagmus
- No pain or loss of consciousness
- No symptoms between attacks
- Manifestations become less severe with time
■ Treatment
- MEDICATIONS
■ Atropine
■ Sedative
■ Antihistamines, anticholinergics, calcium channel blockers
■ Diuretics
■ Meclizine hydrochloride (Antivert)
■ Antiemetics
■ Niacin (vasodilating)
■ Prevent injury during vertigo attacks
■ Bedrest-quiet environment
■ Assistance with walking
■ Move head slowly
■ Fluid & sodium restriction
■ No smoking
■ Surgery
- Endolymph drainage and insertion of a shunt
- Labrinthectomy
51. MRSA

■ Mild folliculitis to extensive furuncles

■ Easily spreads on body and to other people:
- Direct skin contact, clothing and objects
■ Not "killed" by antibacterial soaps or most topical and oral antibiotics
- Vancomycin kills
■ Incidence: Communal environments
- Hospitals, long term facilities, prisons, etc.
■ 1% of population
■ Cause: Long term use of unnecessary antibiotics
■ Symptoms:
- Small red bumps
- Deep, painful abscesses on skin
- Burrow deep - life-threatening in blood (declining)
■ Culture: Tissue/fluid/nasal secretion - 48 hr
■ Treatment: Drain wound and/or antibiotic
- Vancomycin
■ Prevention
- Contact Isolation if pt. has MRSA
■ Gown and gloves
- Hand washing & Standard precautions
- Keep wounds covered
- Personal items separate
- Wash linens/clothing:
■ Soap & hot water
52. Mydriatic and miotic eye medications ■ Atropine - Dilates pupils; dries out eyes
• Mydriatic drug
• Photosensitivity
■ Phenylephrine - Dilates pupils
• Mydriatic drug
■ Acetazolamide, pilopine, phospholine - Decreases pressure in the eyes
• Miotic drugs
• Constrict pupils and allows for better circulation of aqueous humor
53. Myocardial
Infarction (MI)

• Myocardial tissue abruptly and severely deprived of oxygen resulting in death of the myocardial tissue.
o Permanent loss of contraction of the affected area
o Goal: limit infarct size and prevent/treat complications
• Types of MI:
o NSTEMI... Non ST elevated MI
▪ Partial thickness of heart
o STEMI... ST elevated MI
▪ Full thickness of heart
• Causes:
o Atherosclerosis (#1 cause)
▪ Fatty plaques build up on the inner walls of arteries
o Embolus: moving clots
 o Spasms
o High demand of oxygen vs. inadequate supply of oxygen
• Symptoms:
o Discomfort greater than 30 minutes that is unrelieved by rest or nitroglycerine, anxiety, shortness of breath,
N/V, diaphoresis
o Pain occurs without a cause usually in the morning and relieved only by opioids
o Pain radiates to the left arm, back, and/or jaw
• Diagnosis: if 2/3 of these are positive then most likely the patient is having a MI
o Symptoms, history, 12 lead EKG, enzyme elevation, echocardiogram, cardiac cath.
• Cardiac markers
o CK-MB
o Troponin I or T
o Myoglobin (elevated in the first ½ hour but is not cardiac specific)
• Treatment
o Monitor patient - EKG
o Pain relief
▪ Nitroglycerine (sub-lingual or IV)
▪ Morphine IV
▪ Oxygen
▪ Position of comfort
▪ Quiet and calm environment
o Thrombolytics
▪ Fibrinolytics dissolve thrombi in coronary arteries and restore myocardial blood flow
▪ Complete sustained reperfusion of coronary arteries in the first few hours after MI has decreased mortality
• Streptokinase (streptase), Alteplase (activase)-TPA not after 4 hours, Urokinase (Abbokinase), Antistreptace
(eminase), Tenecteplase (TNKase)
▪ Nursing care with Thrombolytics
• Identify suitable candidates
• 3 IV sites and baseline EKG
• Assess for a decrease in chest pain
• Monitor for reperfusion dysrhythmias (PVC's, sinus bradycardia, ventricular tachycardia)
• Assess minor oozing from puncture sites and gingival bleeding
• Assess re-occlusion or re-infarction and for major hemorrhage or stroke
▪ Contraindications
• Pregnancy, surgery within the last ten days, endocarditis, pericarditis
o PTT (intrinsic pathway): Heparin
▪ 25-35 seconds
o PT/INR (extrinsic pathway): Warfarin (coumadin)
▪ 11-14 seconds/0.8-1.2
• Heparin induced Thrombocytopenia
o Platelet count is less than 100,000
o Hypersensitivity to heparin - may develop chills, fever, urticaria
o Nursing action: stop heparin
▪ Give Aquamephyton for Coumadin
• Vitamin K is contraindicated in Coumadin
▪ Give protamine sulfate for heparin
• Other medications for MI
o Calcium channel blockers, beta blockers, ACE inhibitors or ARBs, glycoprotein IIB/IIIa inhibitors
• Percutaneous cardiac interventions
o Angioplasty
▪ Uses a balloon to smash plaque against the lumen of the artery
o Athrectomy
▪ Atherosclerotic tissue is shaved from the intima of the vessel
o Stent
▪ Mesh is placed against the sides of the artery to hold it open
o Laser
▪ Laser energy is aimed and released at plaque
• Coronary artery bypass surgery (CABG)
o Revascularization by routing blood supply around the arterial obstruction
o Pre-op
▪ Informed consent, teaching, diagnostic cath, patient assessment
• Coags, carotids, respiratory, renal, infection
o Post-op
▪ In ICU
 ▪ Frequent assessments
• CT's, PAP cath, AL, temporary pacemaker, fluid and electrolyte balance
▪ Complications
• Shock, sepsis, ARDS, renal failure, CVA, MI, hypo/hypertension, bleeding, hypothermia
• Complications of MI
o Dysrhythmias, CHF, pulmonary edema, cardiogenic shock, recurrent MI, Emboli (pulmonary or cerebral),
pericarditis, ventricular aneurysm, ventricular rupture
• Medications
o Emergency (MONA)
▪ Morphine - pain; causes respiratory depression
▪ Oxygen
▪ Nitroglycerin - decrease chest pain, arterial and venous dilation; should not be given to systolic less than 90
mm Hg
▪ Aspirin - prevent clot formation; contra. In bleeding disorder, active peptic ulcer disease, hepatic disease
54. Nephrectomy

PREOPERATIVE CARE
• Report abnormal laboratory values to the surgeon. Bacteriuria, blood coagulation abnormalities, or other
significant abnormal values may affect surgery and postoperative care.
• Discuss operative and postoperative expectations as indicated, including the location of the incision (Figure 27-4)
and anticipated tubes, stents, and drains. Preoperative teaching about postoperative expectations reduces anxiety for
the client and family during the early postoperative period.
POSTOPERATIVE CARE
• Provide routine postoperative care as described in Chapter 7.
• Frequently assess urine color, amount, and character, noting any hematuria, pyuria, or sediment. Promptly report
oliguria or anuria, as well as changes in urine color or clarity.Preserving function of the remaining kidney is critical;
frequent assessment allows early intervention for potential problems.
• Note the placement, status, and drainage from ureteral catheters, stents, nephrostomy tubes, or drains. Label each
clearly. Maintain gravity drainage; irrigate only as ordered. Maintaining drainage tube patency is vital to prevent
potential hydronephrosis. Bright bleeding or unexpected drainage may indicate a surgical complication.
• Support the grieving process and adjustment to the loss of a kidney. Loss of a major organ leads to a body image
change and grief response. When renal cancer is the underlying diagnosis, the client may also grieve the loss of
health and potential loss of life.
• Provide the following home care instructions for the client and family.
a. Teach the importance of protecting the remaining kidney by preventing UTI, renal calculi, and trauma. See Chapter
26 for measures to prevent UTI and calculi. Damage to the remaining kidney by UTI, renal calculi, or trauma can lead
to renal failure.
b. Maintain a fluid intake of 2000 to 2500 mL per day. This important measure helps prevent dehydration and
maintain good urine flow.
c. Gradually increase exercise to tolerance, avoiding heavy lifting for a year after surgery. Participation in contact
sports is not recommended to reduce the risk of injury to the remaining kidney. Lifting is avoided to allow full tissue
healing. Trauma to the remaining kidney could seriously jeopardize renal function.
d. Teach care of the incision and any remaining drainage tubes, catheters, or stents. This routine postoperative
instruction is vital to prepare the client for self-care and prevent complications.
e. Instruct to report signs and symptoms to the physician, including manifestations of UTI (dysuria, frequency,
urgency, nocturia, cloudy, malodorous urine) or systemic infection (fever, general malaise, fatigue), redness, swelling,
pain, or drainage from the incision or any catheter or drain tube site. Prompt treatment of postoperative infection is
vital to allow continued healing and prevent compromise of the remaining kidney.
55. Nephrotoxic Drugs Nephrotoxic drugs - Antibiotics/Anti-infectives
• Amphotericin B
• Colistimethate
• Methicillin
• Polymyxin B
• Rifampin
• Sulfonamides
• Tetracycline hydrochloride
• Vancomycin
Nephrotoxic drugs - Aminoglycoside Antibiotics
• Gentamicin
• Kanamycin
• Neomycin
• Netilmicin sulfate
• Tobramycin
Nephrotoxic drugs - Chemotherapy agents
• Cisplatin
• Cyclophosphamide
• Methotrexate
Nephrotoxic drugs - Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
• Celecoxib
• Flurbiprofen
• Ibuprofen
• Indomethacin
• Ketorolac
• Meclofenamate
• Meloxicam
• Nabumetone
• Naproxen
• Oxaprozin
• Rofecoxib
• Tolmetin
Nephrotoxic drugs - Other Drugs
• Acetaminophen
• Captopril
• Cyclosporine
• Fluorinate anesthetics
• Metformin
• D-Penicillamine
• Phenazopyridine hydrochloride
• Quinine
56. Oral Infection o Stomatitis (inflammation of mouth), Candidiasis (Thrush), Herpes simplex
▪ Prevention: avoid trauma, irritating foods, tobacco, alcohol, reduce stress, good oral hygiene
▪ Nutrition: eat soft, bland diet
▪ MEDICATIONS:
• Nystatin: antifungal, PO liquid
• Difiucan: antifungal, PO
• Zovirax: antifungal, PO
• Antibiotics
57. Oral Neoplasms

• Oral Neoplasms
o Erythroplakia: red velvety patch
o Leukoplakia: white, "smoker's patch"
▪ Can scrape off tongue
▪ Chronic irritation, mostly benign
▪ Mainly caused from tobacco
o Oral Hairy Leukopenia (OHL): malignant
o Squamous cell
▪ 90% of oral cancers
▪ Caused from chewing/smoking
▪ Lesions are red and on lips, cheeks, tongue, esophagus,
▪ Slow growing
▪ Prevention: no tobacco
▪ Biopsy (diagnosis and staging), radiation, and surgery
58. Ototoxic meds

■ Aminoglycosides (kanamycin, neomycin, streptomycin, gentamycin)

■ Loop diuretics (furosemide, ethacrynic acid, bumetandie)
■ Antineoplastics (Cisplatin) - chemotherapy drug
■ Salicylates (aspirin)
■ Quinine (used to treat malaria)
■ Tea tree oil
59. Ovarian cancer

• Tests
o Chest X-ray, CT, Ultrasound-transvaginal, Ca-125, liver enzymes if ascites
• Risk factors
o Older than 40
o Nulliparity (never having kids)
o Family history of breast cancer
o Family history of ovarian cancer
o Diabetes
o Older than 30 with first pregnancy
o Breast or colorectal cancer
o Infertility
o Early period/late menopause
o Endometriosis
o Obesity
• Symptoms
o Abdominal pain, tenderness
o Gas/bloating
o Abdominal distention
o Fatigue
• Diagnosis of ovarian cancer comes later because of vagueness of symptoms
• Breastfeeding reduces the risk for ovarian cancer
60. Pancreatitis

• Acute: inflammation of the pancreas

o Caused by alcohol (most common), chronic hepatitis, biliary surgery, infection, pregnancy
o Pathology: autodigestion, necrosis of blood vessels, inflammation
o NHP = necrotizing hemorrhagic pancreatitis
• Symptoms: sever LUQ, epigastric, and back pain, vomiting, anorexia, abdominal distention, weight loss, gray-blue
discoloration of the abdomen, hypo or absent bowel sounds, hypotension, jaundice, elevated glucose, hypovolemic
shock
• Diagnosis: elevated glucose, amylase, lipase, bilirubin, low calcium, CT/MRI, U/S, abdominal X-ray, endoscopy
• Treatment: eliminate cause, improve comfort and symptoms, avoid complications
o If caused by gallstones, ERCP is done with sphincterotomy of sphincter of Oddi
▪ Fatty acids are combining with calcium and not being digested
o Cullen's sign = bruising around umbilicus
o Gray Turner's = bruising of flan
61. Peptic
Ulcer

o Symptoms: pain (chest pain), heartburn, N/V, belching

o Complications: hemorrhage, perforation, pyloric obstruction, recurrent symptoms
o Most common sites: lesser curvature (gastric ulcer), after pyloric sphincter (duodenal ulcer)
o Contributing factors to ulcers: increased acid/pepsin, impaired mucosal barrier, irritants (smoking, NSAIDS, ASA,
caffeine, steroids, alcohol), hereditary, associated diseases (COPD, cirrhosis, arthritis, Crohn's (IBD)), stress, bacteria
(gastric) - H. pylori causes more than 75%
▪ Stress ulcer: physiologic and psychological response to major stressors (trauma, illness, surgery)
• Symptoms: pain, improvement after eating, chest pain, dysphagia, weight loss, anemia
• Complications: GI hemorrhage, perforation, pyloric obstruction
• Diagnoses: CBC, occult stool, gastric analysis, gastroscopy, upper GI
• Treatment:
o Medical - conservative works
o Surgical - partial gastrectomy, gastroenterostomy (connection between stomach and jejunum) (billroth I or II),
vagotomy (one or more vagus nerve branches are cut to reduce gastric secretion) or pyloroplasty
o Total gastectomy for severe bleeding
62. Peritoneal dialysis

o Uses peritoneum to filter everything

o Big risk of peritonitis (biggest complication)
o If clogs (fluid doesn't come back)
o Laxative (increase peristalsis)
o Change position (put head of bed up)
63. Phases of recovery (Emergent, Acute, Rehab); Pt. needs, Emergent phase 1
interventions/care, nursing priorities and complications of each phase First phase/Emergent - First 48 hours
■ Goals:
- Secure airway - #1
- Fluid replacement & cardiovascular function- #2
- Prevent infection and complications
- Maintain body temperature
- Provide emotional support
- Blood vessels become leaky - give them enough fluid
■ Give half of fluid in first 8 hours
■ Parkland formula (will not be tested) - fluids for 24
hours = (4 х kg х %burn)
Acute phase 2
Begins 36 to 48 hr after injury until wound closure is
completed (6 - 8 weeks)
■ Care focus - continued assessment and maintenance
of all systems and healing processes
- Maintenance of cardiovascular/respiratory
- Nutrition
- Burn wound care
- Pain control
- Psycho-social interventions
Rehabilitative phase 3
Begins with wound closure & ends when pt. returns to
highest functioning (months - years - lifetime)
- Psychosocial adjustment: Permanent limitations,
grieving process
- Prevention of scars and contractures: ROM,
positioning, ambulating, pressure garments
- Finish cosmetic grafting: Image changes for life
Goal: Resumption of pre-burn activity and work
64. Pneumonia

• Inflammation of the lower respiratory tract. Pathogens penetrate the airway and multiply in alveolar spaces resulting in
inflammation in interstitial spaces, alveoli, and bronchioles
• Fluid and exudates form as organisms multiply
• Most of the time infectious: bacterial/viral
o Can be from aspiration
• Pathophysiology
o White blood cells move into alveoli and cause alveolar wall thickening
o Fluid fills the alveoli, protecting the organisms and facilitating movement into other alveoli, resulting in the spread of
infection
▪ Leads to a ventilation-perfusion mismatch
• Sputum
o Colorless = non-infectious
o Creamy yellow = staphylococcus
o Green = pseudomonas
o Currant jelly = klebsiella
• Risk factors
o Elderly are at the highest risk
o Chronic existing condition (i.e. COPD)
o History of tobacco use/alcohol
o Poor nutritional status
 o Mechanical ventilation
o Aspiration
o Immunocompromised
o Morbidly obese
• Ventilator associated pneumonia
o Airway infection that develops at least 48 hours after a patient is intubated
o Leading cause of death related to hospital acquired infections
o Develops as a result of aspiration of stomach contents or when bacteria from the oral cavity or sinuses and trachea
develop on the endotracheal tube
o Prevent by giving good oral care and raising the head of the bed
• Breath sounds
o Crackles (if interstitial and alveolar fluid is present)
o Wheezes (related to inflammation or excaudate in the airways)
o Bronchial breath sounds (over areas of consolidation)
o Increased tactile fremitus and dull percussion
o Chest expansion (diminished sounds or unequal on inspiration)
• Diagnostic tests
o Sputum (collected right in the morning when patient wakes up)
o CBC - elevated WBC
o Blood cultures and electrolytes
o Chest X-ray: shows consolidated areas where air is not going
• Prevention
o Vaccine for adults 50 and older and then a booster every 5 years
o Annual influenza vaccine
o Good hygiene
o Smoking cessation, health, rest, avoid crowds and ill people
• Treatment
o Oxygen, IV fluids, nebulizer treatments, antibiotics (broad spectrum to more specific), analgesics for pain (codeine)
• Complications
o Hypoxemia - due to alveolar consolidation or capillary shunting
o Pleural effusion - collection of fluid in pleural spaces
o Pleurisy - friction between layers of pleura, causing pain
o Ventilatory failure - lungs are unable to move gas in and out of the lungs, resulting in hypoxemia and hypercapnia
65. Pneumothorax

• Collapsed lung
• Spontaneous/closed/tension
• Open - sucking chest wound
• Hemothorax: blood
o Increased dyspnea, pain in inspiration, chest tightness, increasing restlessness, agitation, hypotension, tachycardia,
tachypnea, asymmetrical chest movement, breath sounds are absent on the affected side, tracheal deviation toward
unaffected side, crepitus, hyper-resonance
• Diagnosis and Treatment:
o Assess breath sounds, vital sounds, and heart sounds
o Chest X-ray, oxygen, pain control, antibiotics
o Chest tubes inserted on effected side
o Open: occlude open wound
o Spontaneous/closed: talc into pleural space or abraded parietal pleura if recurrence
• Tension pneumothorax = emergency situation
66. Pre and post- Pre-op
op eye care ■ Medical emergency
■ Provide information to allay fears
■ Restrict activity and head movement
■ Place eye patch over affected eye or both eyes to reduce eye movement
■ Avoid activities that increase IOP
■ Administer drugs per order
- Mydriatic drops - inhibit pupil constriction and accommodation
- Anti-emetics (vomiting increases IOP)
- Analgesics
67. Pressure ulcers: Prevention,
assessment, healing stages

■ Tissue damage cause: Skin and underlying soft tissue compressed between a bony prominence
and an external surface for an extended period.
■ Mechanical forces cause ulcers:
- Pressure
- Friction
- Shear
■ Braden Risk Assessment Scale
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
■ High Risk Patients
- Mental status changes
- Immobility
- Poor nutritional status
- Incontinence and/or moisture
- Friction and shear
- Obesity
- Older adults
- History of Ulcers
■ Staging
- Stage I Pressure Ulcer - Skin intact: redness that does not blanch. [darker skin: changes from
surrounding skin in color temperature, consistency and/or sensation]
- Stage II Pressure Ulcer - Partial thickness loss into epidermis or dermis: abrasion, blister or
shallow crater
- Stage III Pressure Ulcer - Full thickness loss: No exposure of bone, tendon, or muscle; deep
crater, may tunnel
- Stage IV Pressure Ulcer - Full thickness loss exposed muscle, tendon or bone, tunneling; slough
and eschar present
68. Psoriasis

Lifelong disorder with exacerbations and remissions

■ Scaling disorder with underlying dermal inflammation; possibly autoimmune reaction
- Overgrowth of epidermin
■ Psoriasis vulgaris - most often seen
- Thickened red covered in white
■ Treatment of Psoriasis
- Corticosteroids
- Tar preparations
- Other topical therapies
- Ultraviolet light therapy
- Systemic therapy:
■ Biologic agents
■ Cytotoxic agents
■ Immunosuppressants
- Emotional support
69. Renal Calculi

• Kidney stones
• Causes (unknown)
o Immobility, family, reduced vitamin D, urine stasis
• Symptoms
o Pain-sharp and sudden, severe (colic)
o Flank pain - stone in kidney or ureter
o N/V, chills, fever, diaphoresis, urinary frequency, dysuria, anuria, pallor, hematuria
• Diagnostic tests
o Urinalysis
▪ Increased RBC, WBC, and Bacteria
o Radiology
▪ KUB, IVP
o CT or MRI
o Ultrasound or Cytoscopy
• Non-surgical treatment
o Increase fluid intake to 3000mL/day
o Medications that prevent the absorption of calcium (thiazide diuretics and phosphates)
o Spasmatic agents (anticholnergics)
o Opioids for pain relief
o Cytoscopy
o Percutaneous nephrostomy
o Lithotripsy
▪ Percutaneous, ESWL
• Application of sound or laser waves to break stone into smaller pieces, easier to expel
• Strain the urine afterwards
• Hematuria post-op and bruising on back may occur
70. Retinal
detachement

■ Gradual or sudden flashes of light

■ Loss of portion of visual field
■ Floaters
■ Increase in blurred vision
■ "curtain being drawn down"
71. R/L Heart Left-sided heart failure
Failure
The heart's pumping action moves oxygen-rich blood as it travels from the lungs to the left atrium, then on to the left
ventricle, which pumps it to the rest of the body. The left ventricle supplies most of the heart's pumping power, so it's
larger than the other chambers and essential for normal function. In left-sided or left ventricular (LV) heart failure, the
left side of the heart must work harder to pump the same amount of blood.

There are two types of left-sided heart failure. Drug treatments are different for the two types.

Systolic failure: The left ventricle loses its ability to contract normally. The heart can't pump with enough force to
push enough blood into circulation.
Diastolic failure (also called diastolic dysfunction): The left ventricle loses its ability to relax normally (because the
muscle has become stiff). The heart can't properly fill with blood during the resting period between each beat.

Right-sided heart failure

The heart's pumping action moves "used" blood that returns to the heart through the veins through the right atrium
into the right ventricle. The right ventricle then pumps the blood back out of the heart into the lungs to be
replenished with oxygen.

Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure. When the left ventricle
fails, increased fluid pressure is, in effect, transferred back through the lungs, ultimately damaging the heart's right
side. When the right side loses pumping power, blood backs up in the body's veins. This usually causes swelling or
congestion in the legs, ankles and swelling within the abdomen such as the GI tract and liver (causing ascites).
72. Rule of 9s

Head - 9%
Arms -9% each
Thorax-18% each side
Legs-18% each
Perineum-1%
73. Skin Cultures ■ Tzanck smear
- Viral infections (Herpes)
- Will not identify EXACT virus
■ Swab culture
- Bacterial infections
■ Potassium hydroxide (KOH) test
- Fungal infections
■ Fungal culture (swabbed)
■ Skin biopsy
- If organ thought to be cancerous
74. Talking with families ■ Be professional
(death) ■ Be careful how you speak in public areas
■ If you are not affected by the death, you must still be aware
■ Have a way to respectfully communicate that a patient has died
■ Offer to make phone calls, write things down for them
■ Be compassionate
■ Don't pretend you understand
■ Don't equate it to something else
■ Do not oversimplify
■ Do stay in the room when you can
■ Do prepare them for seeing their loved one
■ Do give time
■ Be direct—use the word "dead" or "death"
■ Give them the opportunity to brace for impact (can they come in? are they in a place where you speak
directly? Have them sit down)
■ Don't wait to communicate
■ Be honest—especially if the death is unexplained
75. Testicular
cancer

• Most common malignancy in men 15-34 years of age

• Testicular self-exam after shower, roll testes in fingers feeling for lumps, report change in size, shape, and
consistency
• Non-germinal (cells that produce testosterone)
• Germinal (sperm producing cells) - most common for cancer
o Seminomas (best type of cancer because of outcome)
o Nonseminomas - metastasize quickly
• Symptoms
o Painless lumps or swelling of testes, heaviness, swelling of groin lymph nodes
• Risk factors
o Age, ethnicity (caucasion), history of undescended testicle, HIV
• Labs
o Alpha-fetoprotein (AFP), Beta human chorionic gonadotropin (hCG), ultrasound, CT, MRI, Screenings
76. TURP w/ CBI

• 23 hour hold, small glands and poor surgical risk

• May need to be repeated
• Pre-op: anesthetic
• Post-op: push fluids because of irritates urethra, monitor for hemorrhage
o More clots = more irrigation
o Watch for infection and take vital signs
• Continuous bladder irrigation
o 3 way urinary catheter with 30-45 mL retention balloon
o Uncomfortable urge to void continuously
o Antispamatic medication for bladder spasms
o If no output, stop irrigation and manually have to irrigate
• TURP complications
o Urethral trauma, urinary retention, bleeding, infection (antibiotics and force fluids)
77. Types and depths of burns

Superficial-thickness wound - 1st Degree

■ Heals in 3 - 6 days
■ Sunburn or steam burn
■ Top layers of epidermis
■ Blanches with pressure
■ Mild discomfort
■ Chief complaint is pain
■ Resolves within 2 to 3 days
■ Does require medical intervention
■ Itching after healing

Partial-thickness wound - 2nd Degree

■ Superficial partial-thickness wounds
- Heals in 10 - 21 days
■ Deep partial-thickness wounds
- Heals in 2 - 6 weeks
■ Usually all of epidermis is burned
■ Possible dermis
■ Weeping blisters
■ Extremely painful
■ Most will heal on their own
■ Scarring may be worse
■ If deep enough, a skin graft may be performed
■ Decreases healing time

Full-thickness wounds
■ Will not heal - must be grafted

Deep full-thickness wounds - 3rd Degree

■ Will not heal - Must be grafted, even bone
■ Epidermis, dermis, start in sub-q
■ White, charred red/brown
■ Leathery
■ May see fat
■ Painless (nerve endings have been burned through
■ Will not heal on their own
■ Require skin graft
■ Vulnerable to fluid/electrolyte balance, temp. changes, infection
78. Ulcerative
Colitis

o Only affects mucosa/submucosa layers

o Rectum to sigmoid
o Watery, mucous, bloody stools
o 15-20 stools a day
o Can't absorb nutrients as well
o Symptoms: rectal bleeding, anemia, nutritional impairment, fatigue, anorexia, weakness, abdominal cramps in the LLQ
▪ Diagnostics - exam stool for blood and mucous, color and size, hematocrit and hemoglobin, WBC, colonoscopy,
rectal bleeding
▪ Nursing care - relieve abdominal cramping and diarrhea, emotional support
▪ Diet - lactose free, no caffeine, no raw fruits/veggies, increase bulk forming (bran), high calorie drinks (ensure)
▪ Teaching - weigh everyday, dietary changes, assess stools, avoid stress
▪ Complications - megacolon, electrolyte imbalance, dehydration
o Treatment
▪ Colon resection: if small, remove
▪ Temporary loop ileostomy
▪ Total proctocolectomy with permanent ileostomy (remove colon)
• Stoma always on the right side
o Should be pink, moist, and have discharge
• Kock (continent ileostomy)
o No bag, cath every 4 hours to drain
o Tenesmus - constant feeling of defecation
o Megacolon - colon becomes very large because it's filled with stools
79. Upper GI
Bleeding

o Common causes: varicose veins in esophagus - common in alcoholics

o Pharmacology: antacids, histamine H2 antagonist/receptor blockers, mucosal barriers/healing agents (prostaglandin
analogues), anticholinergic (decrease secretions), antibiotics, ANS stimulant, antiemetic
80. Urinalysis

• Urine specimen - first thing in the AM, midstream, catheter, 24 hour collection
• pH = 4.8-7.5 (acidic)
• Specific gravity = 1.003-1.030
• WBC = 0-4
• RBC = 0-3
• Proteins = not normally in urine
• Color = urochrome pigment
• Odor = Ammonic
• Turbidity = clear
• Glucose = not seen in urine until B.S. > 220
• Ketones = not seen in urine... byproduct of fatty acid material
81. UTI

• More common in women and causes urinary retention

• E. coli is the most common bacteria causing UTI
• Upper - kidney (pyelonephritis)
• Lower - urethra (urethritis), bladder (cystitis), prostate (prostatitis)
• Risk Factors
o Structure/function, catheter, sexual intercourse, enlarged prostate, foley, hygiene, being female, age, history of UTI, diabetes,
pregnancy, immunosuppression, on antibiotics, frequent stools
• Symptoms
o Dysuria, cloudy urine, urgency, foul odor, fever, confusion (especially in elderly)
• Interventions
o Antibiotics, cranberry juice, increased fluids, teaching over wiping patterns, avoiding bubble baths and wet bathing suits, no
catheters, cotton underwear, not holding urine
• Diagnostic procedures
o Urinalysis, urine culture and sensitivity, voiding cysto-ureterography, cystoscopy
• Patient issues
o Pain, impaired urinary elimination, teaching needs
• Pyelonephritis
o Inflammation of kidney and renal pelvis
o Acute (active bacterial infection)
o Chronic (repeated infections)
o Symptoms
▪ Flank pain (back pain), fever/chills, headache, malaise, anorexia, N/V, cloudy urine with strong odor, urgency, frequency,
nocturia
o Treatment
▪ Meds- analgesics, antiemetics, antidiarrheal, increase fluids, check UA, treat underlying cause
82. Wounds care:
debridement,
escharotomy

Debridement
- Mechanical: 2X or >daily by hydrotherapy/water through tub or shower
- Enzymatic: application of enzyme agents, (collagenase)
- Surgical: knife, dermabrader
- Dressing changes
- Leave areas open
- Use antibiotic
- Moist dressing will dry in wound; pull out dead tissue
- Form of debridement
- Healthy red/pink
- Eschar - dead or necrotic "tissue" that is nonviable
Escharotomy - surgically remove circumferential burn eschar strictures -improves circulation and/or ventilation
83. Xanthenes Relaxes bronchial smooth muscle, causing bronchodilator and increasing vital capacity that has been impaired by
bronchospasm and air trapping; actions may be mediated by inhibition of phosphodiesterase, which increases the
concentration of cyclic adenosine monophosphate; in
concentrations that may be higher than those reached clinically, it also Inhibits the release of slow-reacting
substance of anaphylaxis

Theophylline
(Elixophyllin)

Uses:
Bronchospasm of COPD
Bronchial asthma
Chronic bronchitis

Side effects:
Nausea Vomiting
Palpitation
Hyperglycemia
Anxiety
Insomnia