Term
| what are normal levels for AST, ALT, and LDH? |
|
Definition
AST 0-40
ALT 0-40
LDH 100-200 |
|
|
Term
| what are two examples of mild liver dysfunction? |
|
Definition
| hepatitis (not always mild but can be) and mono |
|
|
Term
| What symptoms would you see with someone who has a mild liver dysfunction? (clinical data 3 things) |
|
Definition
elevated LFT's (correlate with damage)
hepatomegaly
RUQ pain (from stretched liver capsule) |
|
|
Term
| For moderate liver dysfunction you will still seeincreasinly elevated LFT, hepatomegaly and RUQ pain as with mild, but you will also see...? (7 things) |
|
Definition
signs of bile obstruction such as:
Jaundice
clay stool
dark urine
fat intolerance (first NVD)
dec absorbtion of ADEK (vits)
puritis (itchy)
inc PT time (due to dec vit K) |
|
|
Term
In additon to the symptoms seen in less severe liver dysfunction, in liver failure you will also see...?
can these people get better? |
|
Definition
Portal hypertention
3rd space fluids
generally these people can see an improvement in liver funct if its hepatitis if they rest, however too much activity or stress on the liver can cause a recovering pt to get worse again. |
|
|
Term
| To treat mild or mod liver dysfunction these 5 things should be implemented |
|
Definition
"RAMNA"
R- Rest, dec damand on liverr
A- Adequate diet, inc carb, prot,and vits(replace with multi and B vits)
M- Moderate fat, very diff from failure
N- no hepatotoxins, no alchol or tylenol
A- Add vitamin K if PT is increased |
|
|
Term
| what is the biggest risk we are concerned about when performing a liver biopsy? |
|
Definition
| Risk for bleeding during procedure (and after if enlarged) due to high vascularity. |
|
|
Term
| what other procedure is used to visualize the liver during the diagnostic work up of liver problems? |
|
Definition
|
|
Term
What Nursing care/ interventions are required before a liver biopsy is preformed
(2 items) |
|
Definition
Pre-op:
-Keep pt NPO
-check clotting and give blood products if needed |
|
|
Term
| what are the two procedures used to diagnose liver problems? |
|
Definition
|
|
Term
what is the post op nursing diagnosis for liver biopsy.
what are the nursing implications and interventions relater to post op for liver biopsy (4 things) |
|
Definition
nursing diagnosis: risk for bleeding.
nursing imp /int:
-compressing on dressing in RUQ
-have pt lie directly on right side to complress/clot
-stay in bed for few hours
-post procedure vitals every 15 mins X 4, then q30 x 2, then q 1 hr x 4 |
|
|
Term
| Name 6 possible causes of liver failure |
|
Definition
"tripple C, OVT"
-Cirrhosis; ETOH (laennex).
-Cardiac diseases; hepatomegaly from rt side heart failure.
-Cancer; metastatic (or primary) all s+s of liver failure
-Obstruction; biliary obstruction r/t structural probs of bile duct NOT gallstones
-Toxins; Tylenol overdose (mucomist antidote) or INH (TB drug that paco was on) avoid alc and tylenol on this drug, monitor INH lab
-Viruses: Hepatitis |
|
|
Term
Problems related to liver failure include:
6 things |
|
Definition
-Impaired bile excretion
-risk of bleeding
-risk of infection
-3rd spacing of fluids
-hepatic encephalopathy
-portal hypertention |
|
|
Term
| What causes impaired bile duct secretion? |
|
Definition
| obstruction of the bile duct within the liver itself from cirrhosis . necrosis and inflammation |
|
|
Term
| when bile is excreted in the urine what is the main characteristic change of the urine? |
|
Definition
| The urine is darker color |
|
|
Term
| when there is a lack of bile to the small intestines (ie its being excreted in urine instead of stool) what types of absorbtion is impaired?2 things |
|
Definition
|
|
Term
| when there is not a problem with the liver RBC's ususually break down to form _________ ___________ and is excreted in stool which gives it its characteristic brown color. |
|
Definition
|
|
Term
| impaired bile excretion results in 2 problems (nursing diagnosis) what are they and what imp/interventions does this have for nursing? |
|
Definition
-alt in nutrition related to fat intolerance. 1)put on low fat diet,2) put on an antinausea drugthat is less toxic to liver (phenergan is safe)
-alt in skin intedrity and comfort r/t puritis (deposit of bile salts). 1. alkaline bath badking soda or aveno to dec itching dec risk of skin breakdown
2.good skin care, dec perspiration change linens,turn often 3. short clean nails or mitts if cognitively impaired 4. use low dose benedryl 5. questran cholesterol dec drug binds with bile salts |
|
|
Term
| One problem with liver failure is risk of bleeding name 3 things this is related to. |
|
Definition
-Dec bile in intestine, causes dec absorbtion of vit K and dec liver production of vit K and decreased prothrom and other clotting factors
-Portal hypertention, causes spenomegaly, dest of RBCs and platelets, and causes GI bleeding
-Nutritional deficits; caused by dec synthesis of blood cells |
|
|
Term
| TO assess for risk of bleeding in liver disease name what to check in your assessment. 6 things |
|
Definition
-RBC
-Platelets
-PT
-brusing
-bleeding sites
-problems for surgery |
|
|
Term
| Treatment for risk of bleeding related to liver failure |
|
Definition
-vit K sc, IV or IM several times per week
-B vits for RBC synthesis
-transfuse: FFP replaces clotting factors, maybe PRBC, platelets (risk)
-Bleeding precautions, hold site for 5 mins, electric razor, soft toothbrush |
|
|
Term
| in liver disease name 5 things that cause a risk for infection |
|
Definition
"PRILL"
-Peritonitis; spontaneous bacterial peritonitis, colon bacteria to peritoneum
-Respiratory complications r/t ascites
( hypovent, atelect, pna, pleural effusion)
-Impaired skin integrity due to scratching from puritis
-Loss of phagocytotic cells (remove bacteria) that line liver.
-Leukopenia (dec neutraphils) <4000wbc |
|
|
Term
| liver disease causes 3rd spacing of fluids this is related to 3 causes. Eventually it can lead to 5 possible complications. |
|
Definition
r/t:
-portal hypertension in portal vein forces fluids form vascular space
-Dec liver production of protien esp albumin (less osmotic force
-Dec metabolites of Aldosterone and ADH.
leads to complications such as:
-Ascites, in abdomen, most common
-peripheral edema, Pitting/weaping edema from skin (risk of breakdown)
-hypovolemia (low vasc vol), this state inc risk for hepatorenal syndrome
-renal failure r/t cirrosis and fluid shifts, bad outcome
-hypokalemia, k excreted due to inc aldosterone |
|
|
Term
| In prevention or treatment of 3rd spacing of fluids what is the general goal. |
|
Definition
| remove fluid slowly at 500-1000cc a day to prevent hypovolemia. |
|
|
Term
| When reating fluid overload r/t liver failure we want to reduce ________ and _____ while maintaining __________ function |
|
Definition
reduce:
ascites and peripheral edema
maintain kidney function |
|
|
Term
| traditional at home treatment for fluid overload related to liver failure is (3 things) |
|
Definition
bedrest, red activity to dec demands on liver
-low na diet 1gm/day
-diuretics (2, aldactone antagonizes aldosterone effects give orally, older drug, several days to work, k sparing (good) and 2. lasix high doses til we see U/O |
|
|
Term
| hospital treatment for fluid overload r/t liver failure includes: 8 things |
|
Definition
-25g of IV albumin to inc colloid pressure and draw fluid into vascular space, run fairly fast into pts but watch for pulmonary edema albumen usually 3.5-5.5
-paracentesis, cath Peritoneal space to reduce fluid at bedside, drain 1-3 L (fluid tends to reaccum from vascular to abdomen again, but do it anyway bc it helps breathing, and inc CO2
-daily wt want 500-1000cc dec/day
-monitor I+O want O>I byt not more than 500-1000
-measure ab girth ( not best fluid loss measurement)
-monitor BUN and CRE if up hypovolemic
-systolic BP, often hypotensive fluid exiting vascular
-Peritovenous shunt (levine shunt) |
|
|
Term
| when preparing for paracentesis name three nursing implications/interventions done to prepare the patient for the procedure |
|
Definition
-have the client void
-decompress bladder
-prevent knicking |
|
|
Term
during paracentesis what position should the pt be in?
what other 2 interventions should be preformed |
|
Definition
The pt should be in sitting position with abdomen hanging over, leaning on bedside table
-administer plasma expander as removing fluid
-give albumin IV or dextran (high molec IV draws fluid) |
|
|
Term
| after paracentesis name nursing imp/interv. |
|
Definition
-check for hematuria (nicked bladder), if inc ab pain prob nicked bladder or introduced bacteria
-ck vitals esp BP bc worried about making hlypovolemia worse. |
|
|
Term
| What is a peritovenous (levine) shunt and what is it used for |
|
Definition
it is an internal cath that removes ascitic fluid and puts back into circulation, connects Peritoneum. It is a LAST RESORT bc protein in fluid clots.
this is used bcause it helps move fluid to sup vena cava: respiration, 1 way valve prevents backflow, diahragn under skin can be pumped, abdominal binder to push fluid up. |
|
|
Term
| How would we know if a levine shunt is working? What would give us a clue that the pump isn't working? |
|
Definition
-should see norm BUN/CRE dec weight and girth
-isn't working if there is inc ascites |
|
|
Term
spontaneous bacterial peritonitis is caused by?
What symtoms will you see?
What are the treatments? |
|
Definition
bowel bacteria that multiplies when contacts peritoneal fluid
Manisfests with temp, chills, tight/rigid ab, pain
treat by taking a culture during peratocentesis, give antibiotics, tends to reoccur so treat occordingly |
|
|
Term
| what interventions can be taking for someone with impaired skin integrity related to weeping edema? |
|
Definition
special mattress
turn frequently wrap skin, hard to manage |
|
|
Term
| What causes hepatic encephalopathy? |
|
Definition
| due to collection of ammonia in blood due to metab of protein in liver, cirrhotic liver unable to convert ammonia to urea and there therefore does not excrete it via kidneys, blood bypasses cirrhotic liver via collateral circulation so proper breakdown does not occur |
|
|
Term
| what is the best indicator of hepatic enceph? what does NOT predict the degree of mental status changes |
|
Definition
LOC
Level of ammonia does not predict the degree of enceph |
|
|
Term
| what are some precipitating events of hepatic enceph? 2 things |
|
Definition
-increased protien intake
-worsening liver function which can happen due to infection and remiss? maybe remission? going off diet, GI BLEED (blood is protien), not taking meds, taking hepatoxic drug like tylenol |
|
|
Term
| what are the cognitive signs of early hepatic enceph? |
|
Definition
| fuzzy thinking, lethargy, apraxia , poor handwriting, asterixis (hand flap) |
|
|
Term
| what are the late stages of hepative enceph? |
|
Definition
| stupor, coma, fetid fecal smell |
|
|
Term
| what are the 6 guidelines for treating acute hepatic enceph? |
|
Definition
safety-accompany everywhere
low protien diet- even lower than before 10-20 g every couple of days
antibiotic- destroy ammonia producing bacteria in colon, medicine can be toxic (niomyocin is otoxic and nephrotoxic so only give for 2 wks)
lactulose (cephulac)- laxitive works in lg intestines increases and hastens excretion of ammonia in stool.
Avoid low K,- kidney produces ammonia if hypokalemic
avoid sedatives -bc it makes monitoring mental status difficult |
|
|
Term
what is the goal for acute enceph when using laculose (cephulac)?
how often will it be given?
what will you worry about while monitoring a person on laculose?
what is the basis for continuing with lactulose? |
|
Definition
goal- to produce 2-3 stools per day hold if 6 stools once you reestab baseline ammonia goal is trying to prevent reaccumulation.
it should be given q 1h until ammonia dec, neuro status will be way off might need to give as enema or po within few hours you can dec freq.
worry about hypokalemia, dehydration, cramping
basis for continuing is based on mental status not ammonia level, this is a problem if they are also on a benzo (such as alcohol withdrawal) bc its hard to eval mental state, err on side of caution and assume mental status change is from benzos |
|
|
Term
| what is the normal pressure in the portal vein? |
|
Definition
5-10 mmhg
port HYT is 25mm hg |
|
|
Term
| What causes portal hypertention with esophageal and gastric varices? |
|
Definition
| due to cirrhosis and scarring, impaired blood flow through liver causes buildup in portal vein, leads to further backup of blood in organs that drain to portal vein and causes varices (outpouching of veins), stomach ( gastric varices), and hemmroids in the rectum, spleen (splenomegaly), and esophogus (esophageal varices) |
|
|
Term
| what can be done to prevent GI bleeds caused by portal hypertention: 4 |
|
Definition
-avoid valsava manuver
-avoid constipation/and rectal procedures , use laxitives
-Beta blockers (propanolol) this vasocontricts stomach veins primarily vasodialating, but words on internal organs to contrict specific drug
-dietary changes: avoid spicy food, chew well, avoid alcohol |
|
|
Term
| what do you do to treat an acute GI bleed caused by portal hypertention 5 thgings |
|
Definition
-must get endoscopy
-balloon tampenade (blakemore-sengstaker)
-medication to cause vasoconstriction
-admin blood products
-prevent further bleeds with transjugular intrhepantic portal shunt |
|
|
Term
| name drugs or drug combos given to cause vasocontriction to stop acute GI bleeds caused by portal hypertention? 2 |
|
Definition
- somatostatin IV (drug of choice)
- vasopressin IV, need high doses but has cardiac and stroke side effects due to vasoconstriction, must give with NITROPASTE to dilate coronary arteries (always in combo) |
|
|
Term
what blood products are given for an acute GI bleed? 2
what is given for volume replacement?
how is circulation monitored? |
|
Definition
PRBC
FFP
volume replacement with norm saline
circ monitored by foley |
|
|
Term
Name all lumens in a balloon tampenade (blakemore sengstaker) and what they do
what risks come with this type of tube
how long can these tubes be in place? |
|
Definition
lumen 1: NG Drainage, clots, blood, flush with lavage
2: gastric ballon inflates stomach with 100cc air, holds tube in place and directly
3: esophageal balloon directly compress esophageal wall; fill with air and measure pressure q 4 hours, need enough to compress (greater than 25 mm hg, but don't want too much)
lumen 4: oral suction on topof esophageal balloon
-NPO no place for spit if swallow, aspiration risk
risks
-risk of balloons: bleeding, airway obstruction, aspiration, might need to intubate to ensure patent airway, need to protect nose from hige tube, tape tube to helpmet/ traction bc too big to tape to head
how long?
-24-48 hrs inflate and deflate as needed. |
|
|
Term
what does a trasjugular intrahepatic portal shunt do?
What are its cons? |
|
Definition
it prevents future GI bleeds, it does this with a shunt that connects portal vein to hepatic vein, not all blood will bypass liver, dec portal pressure to prevent bleeding. pregormed in radiology under conscious sedation.
cons: bypassing liver inc risk of hepatic encephalothapy bc you can't detox substances. |
|
|
Term
| Name the 4 general signs/symptoms of hepatitis |
|
Definition
1 RUQ pain: inflamed liver stretches liver capsule
2 NV and anorexia : fat intolerance
3.Jaundice
4.symptoms of acute viral infection: fever, aches pains chills |
|
|
Term
| how is hep a transmitted? |
|
Definition
| fecal-oral contaminated shellfish, igest and digest virus excrete in stool endemic to some countries. |
|
|
Term
| what is the route of transmission of Hep B and C |
|
Definition
|
|
Term
| what is the incubation period of hep a |
|
Definition
|
|
Term
| what is the incubation period of hep B and C |
|
Definition
|
|
Term
| what is the infectious period of hep A, B, and C |
|
Definition
|
|
Term
| which is the most contagious of all the hep itis viruses |
|
Definition
|
|
Term
| which hepititis is most serious if contracted and lives longest outside the body |
|
Definition
|
|
Term
| what lab test can be done to check for HAV infection |
|
Definition
|
|
Term
| what lab test can be done to check for HBV infection |
|
Definition
HBsAg (surface antigen)
Anti-HBcIgM (Core AB) |
|
|
Term
| what lab test can be done to check for HCV infection |
|
Definition
|
|
Term
| what lab test can be done to check for HAV immunity? |
|
Definition
| Anti HAV IgG, if they had virus or vaccine |
|
|
Term
| what lab test can be done to check for HBV immunity? |
|
Definition
|
|
Term
| what lab test can be done to check for HCV immunity? |
|
Definition
|
|
Term
| what type of post exposure protection can you receive for hep A, how long does it last, how soon do you need to get it |
|
Definition
| immunoglobulin, antibodies from someone else, lasts for 3 months, get it right away even if within 2 weeks. |
|
|
Term
| what type of post exposure protection can you receive for hep B |
|
Definition
|
|
Term
| what type of post exposure protection can you receive for hep C? |
|
Definition
|
|
Term
| what is the carrier status of Hep A |
|
Definition
| N/A get over disease totally |
|
|
Term
| what is the carrier status of Hep B |
|
Definition
| HBsAg; carrier still feels tired and test positive, they are at risk for cirrhosis and liver canacer |
|
|
Term
| what is the carrier status of Hep C |
|
Definition
| Anti-HCV; positive viral load, liver biopsy and enzymes confirm disease, carrier has persistent symptoms, test positive, and carrier status spreads to other people |
|
|
Term
| what can you do to prevent HEP A? |
|
Definition
| HAV vaccine, and handwashing, standard precautions |
|
|
Term
| what can you do to prevent HEP B? |
|
Definition
| HBV vaccine, safe sex, no needle sharine universal precaustions, screen blood |
|
|
Term
| what can you do to prevent HEP C? |
|
Definition
| no needle sharing, blood screen |
|
|
Term
| what treatments are available for Hep A |
|
Definition
| no treatments, resolves on its own, rest, mod low fat diet and vit K |
|
|
Term
| what treatments are available for Hep B |
|
Definition
| Interferon, makes everyone sick; sc injection 3x q wewek N/V, depression, neutrapenia, (infection risk), ribavivon, give concurrently with IF causes anemia |
|
|
Term
| what treatments are available for Hep C |
|
Definition
| never clear virus, develop chronic infection, causes inflammation and scarring with time, HCV cirrhosis, leading cause of liver transplant in US |
|
|
Term
| what are characteristics of the HEP A virus |
|
Definition
| symptoms similar to flu, less serious |
|
|
Term
| what are characteristics of the HEP B virus |
|
Definition
| Fatigue, anorexia, fever, abdominal discomfort, joint pain arthralgias, rashes, enlarged tender liver, light stools dark urine, jaundice |
|
|
Term
| what are characteristics of the HEP C virus |
|
Definition
| fatigue ana, fever ab discomfort, joint pain, rashes, enlarged tender liver, light stools, dark urine, jaundice (live HEP B) PLUS similar to HBV, more severe dymptoms might require extended hospitalization for exteded periods. |
|
|
Term
| frontal lobe responsible for |
|
Definition
| thinking memory jedgement personality motor contralaterally, speech smell |
|
|
Term
| parietal lobe is responsible for |
|
Definition
| sensation temperature touch pain pressure speech written |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| coordination gate(lesions present safety issue |
|
|
Term
| pons/ medulla responsible for |
|
Definition
| HR, Respiration, body temp. compression, dangerous |
|
|
Term
| which lobes are supplied blood by the anterior verebral artery ACA |
|
Definition
|
|
Term
| the middle cerebral art MCA supplies which lobes |
|
Definition
|
|
Term
| which art is a common site of CVA? and what does it cause |
|
Definition
| the middle cerebral art, causes aphasia, weakness on one side, risk for aspiration and impaired swallowing |
|
|
Term
| what is a carotid endartectomy |
|
Definition
| removal of plaque in the carotid to treat CVA, risk of creating TIA/CVA by dislodging, common site at bifurcation of ECA and ICA (internal and external coratid) |
|
|
Term
| what is the normal cerebral perfusion Pressure CPP |
|
Definition
|
|
Term
| how do you calculate the CPP |
|
Definition
| MAP-ICP=CPP (pushing force -resistance force) |
|
|
Term
|
Definition
|
|
Term
| How do you calculate the mean arterial pressure MAP |
|
Definition
| 2/3r DBP - 1/3rd SBP (SBP +2 (DBP/3) |
|
|
Term
| What important info about BP do we need to keep in mind for people with head injuries |
|
Definition
| need to let it be a little higher around 150 to ensure brain perfusion |
|
|
Term
| what is the nursing diagnosis for increased ICP? |
|
Definition
| Altered tissue perfusion r/t inc ICP |
|
|
Term
| In what types of pts would ICP be our primary concern |
|
Definition
| head injuries, brain tumors, infections, post brain surgery |
|
|
Term
| when someone has had a stoke what is our primary concern, what is our second concern |
|
Definition
| first concern is arterial blood flow, second is ICP |
|
|
Term
| our goals in treated ICP is (3 things) |
|
Definition
1. Dec ICP dehydrate brain, prefer vasoconstriction,inc venous drainage by inc HOB
2. Preserve Brain funct
3. Prevent complications of immobility (pna, vasovagal, DVT, etc) |
|
|
Term
| how often should you assess neurological status in a pt with inc ICP |
|
Definition
| q 1-2 hours c it is our most sensitive measure LOC AXOX3 follwo commands simple/complex, memorory how has LOC changed |
|
|
Term
| when unconcious assess LOC by? |
|
Definition
Response to pain
-use glascow coma scale, sternal rub, pinch arms |
|
|
Term
| what is the normal response to pain? |
|
Definition
|
|
Term
| decribed highest to lowest LOC of unconcious person...do highest, high, low, lowest |
|
Definition
highest - purposeful withdrawal
high- decorticate with legs extened flex or internally rotate shoulder
low- decerebrate with legs extended, extend, externally rotate your shoulder
lowest-no response flaccid |
|
|
Term
| what is the least helpful indicator of ICP |
|
Definition
|
|
Term
| even though vitals are the least helpful indcator of ICP typically we see cushings triad, what does this mean |
|
Definition
-inc BP
-dec resp rate
-dec heart rate
this is opposite shock |
|
|
Term
what are the 3 things that the glawscow coma scale measures
what does an 8 or below suggest? |
|
Definition
-eyeopeing: spontaneous, to name, to pain, not opening 1-5
-motor response, deg of response to commands 1-5
-Verbal: level of complrehension, nonverbal, confusion 1-5
an 8 or below suggests poor neuro function, but not irriversible, use to compare from baseline |
|
|
Term
| name signs and symptoms of increased ICP |
|
Definition
| change in LOC, Projectile vomiting not proceded by nausea, and changein pupil response and size (dilate) |
|
|
Term
When someone has inc ICP due to a serious head injury what is the first pharmalogical intervention and how does it work
what would you expect to happen once med is given?
what is more effective continuous or bolus? |
|
Definition
Mannitol 20-25% IV bolus, (osmotic diuretic)
used to dehydrate brain to allow room for expansion, pulls fluid into vascular space to promote diuresis
-expect u/o to increase
-bolus more effective than continuous drip (req filter on tubing) |
|
|
Term
| What diuretics do we use to create a mildly dehydrating effect on the brain |
|
Definition
lasix IV push aor edercrin
-monitor u/o |
|
|
Term
| where is decadron (dexamethasone) never used? |
|
Definition
|
|
Term
decadron is used for inc ICP to...
how much given and how |
|
Definition
dec inflammatory process for head inj and dec ICP
-not for stroke
IV bolus 10mg gollowed by 4mg q 4 hrs taper off. |
|
|
Term
| Decadron a steroid causes certain side effects, what needs to be done to treat these side effects: 4 things |
|
Definition
-Fingersticks with ss insulin (inc glucose)
-GI bleeding, give with good if oral, if NPO give H2 blocker
-sodium and water retention: monitor weight and BP
-taper off steroid to prevent adrenal insufficiency (transplant and adrenalectomy are the only lifelong steroid pts) |
|
|
Term
| for someone with inc ICP we would hold anti hypertensive medications if the systolic is |
|
Definition
|
|
Term
| what is the fluid restriction placed on all people with head injuries and stroke |
|
Definition
| 1500cc/24 hours, not as strict as renal slightly dehydrate |
|
|
Term
| hypoxia and inc co2 causes vasodialation and inc ICP what is used to treat this |
|
Definition
-oxygen is used 2-4 L \ 40-60%
face mask
-hyperventilation via a ventilator to control respiratory rate requires medication to relax, blows off co2, only ventilate for 24 hours because they can become reliant on ventilator, might need help ventilating anyway if decreased, respiratory rate from brain stem swelling
avoid suctioning bc it inc sICP |
|
|
Term
|
Definition
| head of bed less than 30 dec to promote arterial blood flow to brain |
|
|
Term
| In general for inc ICP for positioning we want |
|
Definition
neck straight no kinks to occlude jug vein
avoid extreme hyperflexion
don't elevate feet
avoid inc IAP and ICP
DO NOT ALLOW PT TO HELP TURN
do not inc HOB over 30 deg for stroke |
|
|
Term
| with inc ICP we need to control body temp what generally happens and what medication is given and how often |
|
Definition
fever inc cerebral metabolic rate and will require more blood flow to head
give tylenol 650mg q 4 h around the clock to prevent fever which is common with head injury |
|
|
Term
| how should nursing activities be scheduled with an inc ICP pt, what type of environment is conducive to recovery |
|
Definition
don't cluster nursing activities,
warm calm environment, enocourage family to touch and visit, music and touch dec ICP, don't talk outside room because it inc anxiety and ICP |
|
|
Term
how can ICP be monitored?
how does it work to dec ICP?
what are the cons?
What is important about the positioning? |
|
Definition
-via a ventricular drain,
-use to Drain off extra fluid if needed
-risk of menigitis with ventricular drain, holes in skull
-position is very imp bc if too low fluid will drain out and if too high can't drain, people come to floor with drain, if need to move pt, must clamp drain. |
|
|
Term
| what are other risk issues for people with inc ICP (generally speaking) |
|
Definition
-falls have a sitter side rails, bed alarm , restaints as ordered/last resort, accompany to bathroom
-eyes, protect if unconscous, tape shut to prevent corneal abrasion; lubricate drops
-seisure precautions high risk during 72 hours after injury or surgery due to progressively inc swelling
-give dilantin prophalactically , req loading dose
-have suction available, airway padded side rails at bedside
if acute seizure treat with benzos IV. |
|
|
Term
| what do you need to preform if a stoke is suspected? |
|
Definition
preform CVA differential to RO other causes
ie finger stick to ro diabetic shock, could be an overdose, treat with narcan, hypoxia give O2, cardiac arrythmia: EKG
need to do CT early to determine if stroke is ischemic or hemmorrhagic |
|
|
Term
| treating an ischemic stroke |
|
Definition
-neuro assess
-fibrolytic drugs in less than 3 hours
-anticoag drugs if greater than 3 hours
hep iv bolus 5000units Bolus, coumadin
-need PTT within therapeutic levels, antiplatlet drug too, either asprin or plavix
-positioning HOB less than 30 for 3 days to improve arteri flow and BR for atleast 24 hours maybe 72 if critical
-fall precautions
-DVT prophylaxis
-consults with speech, Phys therapy , OT: ADLs eval
-aspiration risk give thicket
-cardiac monitor afib=stroke
-monitor I/O
-guiac all stool due to anti-coag
-NPO due to aspiration risk possible feeding tube |
|
|
Term
| what causes pancreatitis? |
|
Definition
| premature activation of trypsin, elastase, and lipase cause autodigestion of pancreas which are usually realeased in response to good in GI |
|
|
Term
| what kinds of problems are caused by pancreatitis? |
|
Definition
inc cap permeability and breakdown of blood vessel fibers, leading to edema, fluid shifts, hlypovolemia, peritonitis if fluid leaks to peritoneal space and hemmorhage and bleeding with pancreas
-cell necrosis can occur, causing inc release of toxins, enzymes, and inflam mediator that futher complicates inc capillary permeability
-leads to risk for shock infection pulonary complications. peritonitis, and ileus |
|
|
Term
| what causes pancreatitis? |
|
Definition
| chronic alcohol use, or gallstones obstructing common bile duct. |
|
|
Term
| what are some common symptoms of mid eoigastric pain that occurs due to pancreatitis? |
|
Definition
-assoc with eating
-radiates to back
-feel better if curl in to ball, feel worse if on back
-NVD w/ steatorhea, elevated temp
-s+s of dehydration: tachycardia, hypovolemic
-biliary abostruction, inflam from pancreas disrupts biliary ducts |
|
|
Term
| What is used to diagnose pancreatitis? |
|
Definition
-CT, US or Both
-lab values of amalase lipase etc in blood stream should be in gi only
-elevated WBC, HCT, HGB, BUN, CRE, LFTs
-hypocalcemia, loss of protein so calcium follows
-bilirubin levels |
|
|
Term
| main issues related to pancreatitis |
|
Definition
-pain -treat with demoral
-fluid volume deficit give normal saline 120-150 q H to prevent dehydration
monitor central venous pressure of right atria, should be between 4-10 cm of water 10-12 overload, less than 4 is dehydration
-nutrition TPN or Jtube, H2 blocker prot pump inhib, provide oral enzymes as needed or tolerated, when advancing diet ask, are there enough enzymes to digest?
-will require long term replacement of pancreatic enzymes
-hyperglycemia- less insulin
-hypocalcemia
-atelectasis / pleural effusion
ELEVATE HOB |
|
|
Term
| for acute treatment of spinal cord injries you must |
|
Definition
-maintain airway, ventilate as needed
-stabilize spine
-diagnose and relieve cord compression ct scan , MRI better for edema, xray
-prevent further injry, steroids within 8 hrs give 30 mg/kg IV bolus over 15 mins wait 45 mins resume with cont drip at 5.4 mg/kg. hour over 23 hours
-manage spinal shock (loss of reflex below injury, disrupt of signal between upper and lower motor neurons
-bradycardia, flaccid paralysis, paralytic ileus, hypotension , subsided with return of anal reflex, DTR may not return yet.
manage autonomic dysreflexia (risk for stroke) |
|
|
Term
treatment to manage spinal shock involves
name position, drug, etc |
|
Definition
"D RAT"
-Dopamine (vasopressors to maintain BP btw 100-110 only give if adq fluid vol)
-Replace fluid loss
-Atropine IV to inc heart rate (spinal shock is the only kind that slows heart rate)
-Trendelenberg position |
|
|
Term
| why does autonomic dysreflexia occur after spinal shock? |
|
Definition
-if injury is above level of T6 outflow is disturbed
-noxious stimuli (full bladder or impacted stool) elicits a symp reflex response bc body is unable to elicit a pain response, bc higher levels of symp control are damged, body is unable to vasoconstrict, reflex sympathetic control dominates., this WILL occur after resolution of spinal shock. |
|
|
Term
| Characteristics of autonomic dysreflexia are: |
|
Definition
-sudden hypertension
-bradycardia
-above injury: HA stuffiness, flushing (para trying to combat symp)
-below injury vasospasm, spastic paralysis, pallor, goosebumbs (piloerection). |
|
|
Term
what are the treatments for autonomic dysreflexia? short term
what is the goal of the treatment? |
|
Definition
-elevate HOB, high fowlers
-call MD report vitals monitor BP q 15 mins
-loosen clothing / teds
-check for full bladder or fecal impaction (disimpact)
-check room temp
-nitrates of hydralazine to dec BP
the goal of the treatment is to remove noxious stimuli |
|
|
Term
| Long term treatment of spinal cord injury is |
|
Definition
-monitor for resp insufficiencies and GI bleeds dt uncontrolled para (h2 blck)
-immobility probs
-urological comp (need to remove cath after hourly monitoring complete to prevent UTI and sepsis
-UMN (reflexic bowel), above level of T12 reflex bladder may manage with suprapubic pressure
-bowel training, encourage fluids fiber and stool softeners prn, timing for reflexic and areflexic bowel |
|
|
Term
| what can you do for UMN (reflexic bowel) |
|
Definition
| stim anal reflex if bowel training does not work |
|
|
Term
| what can you do for LMN (areflexic bowel) |
|
Definition
-start training on empty bowel (clean out with enema)
-admin lax 8-12 h before scheduled BM, do less with time (dangerous)
-dive hot tea, coffee , prune juice, etc 1/2 hour before BM to force toward anus
-give suppository (L side), transfer to commode
- if that doesn't work back to bed, place on right side to use gravity to move stool to rectum and/ or reapply abdominal binder |
|
|
Term
| sc injuries from c1-3 usually require a ______while an injury at C3-6 affects ______. if injury is anywhere above level of T6 __________ ________ will occur |
|
Definition
-ventillator
-diaphram innervation
-autonomic dysreflexia |
|
|
Term
| injuries above the level of T12 are |
|
Definition
|
|
Term
| injuries below the level of T12 are called |
|
Definition
|
|
Term
| what are the early complications of fractures? 5 things |
|
Definition
-injury from bone fragments, bleeding and hemmorrhage
-compartment syndrome
-fat emboli (young males and old women)
-Thrombolemboli (DVT), most common
-wound infection |
|
|
Term
| what is compartment syndrome? |
|
Definition
| Bleeding and swelling contained within muscle sheath compresses muscle and causes ischemia |
|
|
Term
what are the symptoms that characterize compartment syndrome?
What must be done to relieve compartment syndrome? |
|
Definition
symptoms: severe pain at area, pale cool, tingling, parastesia, pain inc with passive motion
-need to reduce swelling with fasciotomy (cutting muscle and sheath to relieve pressure) |
|
|
Term
|
Definition
| -fat is released into blood stram and traels to lungs, leads to ARDS |
|
|
Term
| what symptoms characterize a fat emboli? |
|
Definition
| early confusion, anxiety, possible chest pain, dyspnea and tachycardia, later sweating and pallor, hypoxemia |
|
|
Term
| what lab changes will you see in a person with a fat wmboli |
|
Definition
| inc ESR (used to differentiate from thrombus bc indicates an inflam response), inc serum lipase , dec RBC and platelets, albumin and ca |
|
|
Term
what are the goals and treatments with fat emboli
what position should this person be in |
|
Definition
goal is to dec inflam, give sterroids, if that doesn't work need ICU and ventillator,
position high fowlers and oxygen (immediately)
call md |
|
|
Term
| what are some of the later complications of fat emboli 3 things |
|
Definition
-osteomyelitis rt infection
--avascular necrosis, blood supply to bone disrupted common with hip
-delayed union, non union malnutrition (req refracture) |
|
|
Term
| what are the nursing consideration for taking care of fractures |
|
Definition
-initial icepack and limb elevation
-neuro assessment is crucial, temp sensation, movement, color, pulses, cap refill
-pin care-normal saline or hydrogen peroxide q d TID look for infection
-cast care
-traction
-pain management , analgesics, muscle relaxants |
|
|
Term
| when taking care of someone in a cast for a fracture name 3 things that need to be considered/adressed |
|
Definition
-if tingling when initially put on elevae for 15 mins and recheck
-protect skin under cast, no scratching, use benedryl if needed
-odor bleeding if excessive bleeding surgeon must cut hole in cast to examine wound |
|
|
Term
| What is osteoarthritis? what causes it |
|
Definition
it is a wear and tear disease, degenerative joint disease, non inflammatory asymmetric cartilage loss with a deterioration of remaining cartilage, bony overgrowths, and joint deformities
-caused by genetics, metabolic problems, joint trauma, occupation, obesity |
|
|
Term
| what are the s+s of osteoarthritis |
|
Definition
pain during movement relieved by rest (opp of RA)
minimal pain early in the day with inc pain as day goes on
crepitus , popping bone nodules, spurs, muscle atrophy |
|
|
Term
| what are the treatment goals of osteoarthritis, medications used to reach these goals |
|
Definition
relieve pain and stress in joints, lose weight
slow progression, especially with nutrition and losing weight
rest and good positioning, heat.
Meds
vits: C , protein glucosamine chondroitin
pain meds ie OTC NSAIDS, prescript NSAIDS narcs, muscle spasm relievers heat warm bath/showers
-joint replacement is last resort. |
|
|
Term
| what intervention take place pre op for hip replacement |
|
Definition
|
|
Term
| What are post op interventions/implications for total hip replacement? |
|
Definition
-lay flat avoid dislocation of hip joint
-supine with slight HOB elevation
-abduction devices / log roll btw legs
-don't cross midline
-elevate HOB to 30 to eat
-watch for signs of dislocation, ie pain, shortening of affected leg, leg rotation
-medicate for pain
-dressings and drains, ask doc how much drainage expected
-monitor for DVT
-monitor brused area of hop for expansion
ambulate within 24-48 hours |
|
|
Term
| what are 3 complications of total hip replacement? |
|
Definition
| infection, bleeding, subluction |
|
|
Term
| what is rheumatoid arthritis |
|
Definition
| an autoimmune disease characterized by inflam of synovial membranes, differs from osteo arthritis in that joints DO NOT rub together. |
|
|
Term
| early s+s of Rheumatoid arthritis |
|
Definition
joint inflam
systemic fever,
weakness
anorexia
parastesias |
|
|
Term
| late s+s of rheumatoid arth |
|
Definition
| deformaties of writst joint, ulnar deviation finger deformities, muscle atrophy, systemic compl inc mod to severe pain with morningstiffness, osteoporosis, anemia, fatigue, wt loss, peripheral neuropathy vasculitis causes ischemia of arterial and may show up as small bown spots in nail beds (ind larger probs) , pericarditis, fibrotic lung disease |
|
|
Term
| what are you likely to see upon assessment of someone with rheumatoid arthritis? |
|
Definition
| swollen and warm hand joints elevated ESR |
|
|
Term
| what are interventions taken for someone with rheumatoid arthritis |
|
Definition
| Nsaids or other anti inflams (steriods TNF, monoflonal antibody) heat rest postitioning, sellf care, manage fatigue by correcting anemia, pacing activities |
|
|
Term
| when is the typical onset of Osteoarthritis and who is more likely to be affected |
|
Definition
| after 60 more likely to be female |
|
|
Term
| which type of arthritis is exacerbated by stress? |
|
Definition
|
|
Term
| which arthritis is considered a degenerative disease? |
|
Definition
|
|
Term
| what areas of the body are you more likely to experience pain with osteoarthritis |
|
Definition
| in weight baring joints verts and hands but not usually phalanges. |
|
|
Term
| what are the differences in labs btween rheumatoid and osteoarthritis? |
|
Definition
| RA has RH factor and elevated ESR and ANA while OA has a normal or only slightly elevated ESR |
|
|
Term
|
Definition
| metabolic disease caused by bone demineralization, dec bone density and fractures of hip, writst (distal) and vertebral column |
|
|
Term
| How is osteoporosis diagnosed and what are the criteria for osteopenia vs osteoprosis? |
|
Definition
it is diaganosed by looking at bone mineral density test (T scores)
osteopenia is low bone mass between -1 to -2.5
osteoporosis is bone mass less than -2.5 |
|
|
Term
| what are the risk factors for osteoporosis |
|
Definition
| age greater than 60, history in family, white or asian, thin, lean build, low lifetime ca intake, estrogen, and androgen deficiency, smoking alcohol immonility and lack of excercise |
|
|
Term
| what are common s+s of osteoporosis |
|
Definition
| hump kyphosis of spine, shortened height, sharp acute back pain, tenderness, restriction of movement suggest comopression or vertebral fractures, constipation, abdom distention, and reflux esophagitis respiratory compromise |
|
|
Term
| what are interventions to be taken with a pt with osteoporosis |
|
Definition
| drug thereapy with estrogen , ca, vit D, biphosphonates, selective estrogen receptor modulators, calcitonin, androgens, diet therapy, fall prevention pain management, orthotic devices |
|
|
Term
| what are causes of back pain |
|
Definition
| slopped disk (herniated nucleus pulposus HNP, bone spurs, muscle ligament strain |
|
|
Term
| what are the most common sites of back pain |
|
Definition
| cervicle 5/6 and lumbar 4/5 |
|
|
Term
| nursing interventions for back pain including positioning |
|
Definition
| williams position when in bed, bed board or firm mattress, excercise (pt consult), muscle relaxants, NSAIDS epidural steroids, ice or heat. |
|
|
Term
| what are the possible surgical interventions for back pain |
|
Definition
-percutaneous laser disk decompression (new) or microdiskectomy removes herniated disk portion from nerve root via laser needle or microscopic surgery
-diskectomy open surgery with part of disk removed
-laminectomy : open syrgery removes bone and disk parts
-spinal fusion: disk removed and vertebrae fused with bone grafts |
|
|
Term
| what is the post op care for lumbar spinal surgery? |
|
Definition
-check VS, neuro and reflexes every 2-4 hours, looking for fever and hypotension and change.
-check dressing for blood and CSF (glucose)
-log roll q 2 hrs or UOOB (spinal fruse needs bed rest for 24-48 hours
-prevent DVT
-manage pain
-monitor bowel sounds |
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