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-think hyperthyroidism sx Addison’s Disease^ -think hypothyroidism sx Cushing’s Disease Hyposecretion of glucocorticoids -not enough aldosterone = lose water (think diuretics..some block aldosterone) Hypersecretion of glucocorticoids -too much aldosterone = water retention Hypovolemia Hot HypervolemiaCold ( C ushing’s = C old) ↑ Hypoglycemia ( K ↑Ca ↓ Na (^) ↑ insulin production)(lose H2O, lose Na) ↓ Hyperglycemia ( K ↓Ca ↑Na (^) ↓(gain H2O, gain Na) insulin production) + ketoacidosis Wet skin Lethargy, fatigue, muscle weakness Dry skin (hyper = dryer) hyperglycemia = dry skinGeneralized muscle wasting, weakness Hypotension ( Weight loss ↓Na) Hypertension (Weight gain / Slow healing↑ Na) Decreased blood volume + shock Hyperkalemia = meta acidosis + arrhythmias Moon face, buffalo hump, obesity (trunk), thin skin, reddish-purple striae TREATMENT: hormone replacement Addisonian crisis TREATMENT: hypophysectomy, adrenalectomy -medical emergency -critical deficiency of glucocorticoids -generally follows acute stress, sepsis, trauma,
surgery, or omission of steroid therapy s/sx hyperpyrexia followed by hypothermia, coma, renal : severe abd pain, sudden profound weakness,
failure
Osteoporosis (excess cortisol = bones) ↑Ca reabsorption from
- fast Hyperthyroidism^ - slow Hypothyroidism
- -sympathetic NS sx↑ metabolism ↓-parasympathetic NS sx metabolism -nervousness, irritable, excitable, tachycardia, perspiration, flushed face, appetite, limp hair, wt loss, HTN exophthalmus, increased -extreme fatigue, dry skin, coarse hair, numbness and tingling of fingers, alopecia, wt gain -heat intolerance Iodine uptake ↑ -cold intoleranceIodine uptake ↓ Graves disease Myxedema coma
Removing tubes and things
Thyroid storm -tachycardia -delirium -coma -pt with hyperthyroidism is typically nervous and has insomnia. -don't place in same room with another pt with hyperthyroidism because too much stimuli. -place in private room. Chest tubes Have pt perform valsalva maneuver, or take and hold deep breath (have seen both in nclex books) NG tube PICC line Have pt take and hold a deep breathHave pt perform valsalva maneuver TPN line Valsalva maneuver Hyperglycemia hyperosmolar nonketotic syndrome (HHNKS) DKA -occurs in people with DM-2 -glucose > 800 ml/dL -occurs in peoplee with DM-1-glucose > 300-800 mg/dL -gradual onset of sx No ketosis/acidosis -sudden onset of sxKetosis/acidosis / FRUITY breath odor Polyuria, polydipsia, dehydration, mental status changes, wt loss, weakness, headache ↓BP Polyuria, dehydration, wt loss, dieresis ↓BP / Tachycardia Tx = fluid replacement, correct electrolyte imbalance, give insulin /Exercise Tx = give vasopressin IV Fluids / Reg. Insulin Skin warm/ dry and dry mucus memb / high Temp Kussmaul respirations (rapid and deep) -expected outcome = ↑ responsiveness
-anticholinergic drugsSympathetic NS (fight/flight)^ Parasympathetic NS -vasoconstriction Tachycardia^ -B blockers -vasodilation Bradycardia Dilated pupils Inhibits digestion Constricted pupils -constipation Inhibits nasal secretions Stimulates digestion -diarrheaStimulates nasal secretions
# # MASLOW’S
Lab values K 3.5 – 5.1 (no pee, no K) Na Mg 135 – 1451.6 – 2. Cl Ca 98 – 1078.6 – 10 Wbc Serum osmolality 4500 – 11000285 – 295 ↑ ↓ = dehydration= overhydration Hgb Hct 14-16.542-52% (3 x Hgb) Amylase 25-151 ↑ -aids in digestion with pancreatitis (acute 5x nml, chronic 3x nml) Albumin Fe 3.4 – 565- ALT/AST Uric acid 5-60/5-434.5 – 8 (men) (liver function tests) 2.5 – 6.2 (women) ↑ with gout
Lipase 10 – 140 ↑ in liver dz (Lipase = Liver) ↓Ca + Trousseau’s sign = arm + Chvostek’s sign = cheek CK enzymes MB = cardiac muscle BB = brain MM = skeletal Troponins Cl- -better indicator of detecting MI than CK’s Cystic Fibrosis IOP/ICP >6010- Urine specific gravity 1.010 – 1.025 > 1.030 dehydration Mantoux skin test >5mm with AIDS/HIV >10mm normal Sedimentation rate (ESR) -rate increases with more inflammation Men: 0-15mm/hr HbA1c Women: 0-20mm/hr-reflection of how well blood glucose levels have been controlled for the past 3-4 months -diabetics with good control = - increases = not good control 7% or less -hyperglycemia causes it to -High Triglycerides causes false + (high levels) -Kidney disease causes false – (low levels) ↑ 1cc 1cc 1ml15gtt 30cc 5cc 1oz1tsp 15cc 1mg 1Tbs1000mcg 60mg bid 1 grain2x a day tid qid 3x a day4x a day qod ac every other dayWith each meal hs At bedtime
Important Drugs -olol = B-blocker (↓HR, ↓BP) -pine = Ca channel blocker ( -pril = ACE inhibitor ( -sartan (similar to ACE inhib) – for pt allergic to ACE inhib.↓BP) vasodilate↓HR, ↓BP)
Think “I” (thin kid) Nephritis^ Think “O” (round kid) Nephrotic Syndrome (Nephrosis) Periorbital edema, facial edema High BP ↑L (^) oedema (ascites), periorbital edemaw BP Anorexia ↓UO Lethargy, pallor, anorexia↓UO Hematuria Pallor, irritability, lethargy Swollen abd, labia, scrotum Proteinuria ↑BUN, creatitine, ASO titer (pt reports strep Massive proteinuria infection before) Treatment: antibiotics, antiHTN Treatment: steroids
Digoxin - -monitor K and Mg (low levels and increase toxicity) -therapeutic level < 2 (0.8 – 1.5) Toxicity = nausea/anorexia (early signs), green halos, ↓UO -If given with lasix, monitor K! -pt with hypothyroidism is more sensitive to dig ( -Ca can make toxicity worse (↓Ca = ↓K) ↓K) -usual dose = 0.25mg/day - - ↓↑ workload of heart andintracellular Ca ↑myocardial function Theophylline -assess apical pulse before admin-for asthma or COPD -don’t give with food/drinks that contain caffeine
Mental Health
MgSO4 *for eclampsia *tocolytic
-therapeutic level = 4-7.5 Toxicity -flushing - -pulmonary edema↓RR, DTR, BP, UO Drugs that stimulate B1 and B2 B1 = 1 heart (increase HR) B2 = 2 lungs (dilate lungs) Clozapine -antipsychotic -risk for agranulocytosis -give pt anticholinergic to help this (Benztropine – Cogentin) – also give this with Tetracycline Thorazine-take on empty stomach -dairy can bind with it and prevent absorption -no Ca, Mg, Al, Fe (prevent absorption) Li toxicity -therapeutic level = 0.5 – 1.2 Toxicity = N/V, muscle weakness, severe diarrhea, tinnitus, blurred vision Lidocaine toxicity Lasix toxicity -drowsiness and CNS disturbances-renal failure (↓OU), blood dyscrasias, hearing loss Methergine (prevent postpart bleed) ↑ ctx (increase contractions, prevent postpart bleed, subinvolution) ( m ethergine = m ore) Terbutaline Bethanechol ↓-cholinergic med ctx (stop contractions/ preterm labor) -10-50mg 3-4x/day -tx for urinary retention Fosamax Morphine -take on empty stomach!Toxicity = pinpoint pupils, ↓RR Dilantin -causes urine to change colors -only give with NS Diuretics -some block aldosterone (Aldactone) = K sparing -aldosterone retains H2O and Na, loses K Infusion rate too fast? Clomipramine Hypotension (Anafranil)^ “Ana” is depressed because of her OCD -tricyclic antidepressant -can also be used for OCD Clonidine Coumadin -HTN and opiate w/dMonitor PT Heparin Antidote = vitamin KMonitor aPTT Antidote = protamine sulfate
# Cranial Nerves
Precautions
I II OlfactoryOptic SmellCentral/peripheral vision III IV OculomotorTrochlear Pupil constrictionHave pt follow tip of finger V VI TrigeminalAbducens Jaw strength6 cardinal movements of eyes VII VIII FacialAcoustic Facial symmetryEars –hearing IX X GlossopharnygealVagus Taste, uvula midline, etcTaste, uvula midline, etc. XI XII AccessoryHypoglossal Neck, shoulderMidline tongue Standard -uniform level of caution that should be used in -primary goal = prevent transmission of nosocomial infection -hand hygiene all patients -gloves -misc barriers (mask, eye protection, face shield, gown) Contact -in addition to standard -used for organisms that are easily spread by skin-to-skin contact, or by contact with items in pt’s environment -may place pt in private room -masks are not needed, doors do not need to be closed Examples -antibiotic-resistant organisms -enteric infections with low infectious dose -c-diff -GI, respiratory, skin, wound infections or colonization with multidrug-resistant bacteria -RSV -highly infectious skin infections: diphtheria, herpes, impetigo, pressure ulcers, scabies, shingles -conjunctivitis -ebola
Food
Airborne -in addition to standard -for pt with serious illnesses transmitted by airborne droplet nuclei Examples -measles -varicella (and disseminated zoster) Droplet -TB-in addition to standard Examples -flu -pertussis -adenovirus -mumps / rubella Tyramine (Korsakoff Psychosis= tyramine deficiency)
-avoid with -figs, avocados, bananas, papaya, raisins -aged cheese, yeast, yogurt, sour cream MAOIs , migraines -soybeans, beer, red wine -beef, liver, sausage, bologna, deli meat -chocolate Purine -avoid with -fish, sardines -liver, beef, chicken, sausage, organ meats gout Gluten Vitamin K -avoid with Celiac’s disease (antidote for Coumadin)^ -broccoli, cabbage, turnips -fish, liver -coffee, tea (caffeine) Vitamin B12 (thiamine) -found in animals, nuts, whole grain cereals -pt with cirrhosis needs a diet high in B Calcium -eggs -green leafy veggies Potassium -potatoes -bananas -spinach -raisins -dates -oranges Iron -dried apricots-can give with Vitamin C (tomato juice, OJ) -clams -liver, beef, shrimp -turkey -cereal -pasta Folic acid -liver -papaya -legumes, vegs, spinach -nuts, bran, cereal -fruit, yeast, asparagus Acid ash diet -avoid milk = makes urine alkaline
Misc Med/Surg diseases Guillain-Barre Syndrome - ↑ weakness (ascending) -neuro problem = acute infection of cranial and peripheral nerves -pt c/o respiratory infection or GI infection in past med hx -immune system overreacts and destroys myelin sheath -major concern = problems breathing s/sx = paresthesis, lower extremity weakness, gradual progressive Myasthenia Gravis weakness, possible resp failure, cardiac probs, high protein in CSF-eye problems -sedatives make sx worse -neuro prob -weakness and fatigue -have pt do things in am -defect in transmission of nerve impulses -give meds before meals s/sx = weakness, fatigue, difficulty chewing, dysphagia, weak/hoarse voice, resp failure, ptosis, diplopia, decreased breath sounds -everything pretty much slows down and gets weak Tensilon test -if pt shows improvement after tx = dx = used to dx Hirschspring’s dz -mega-colon -results in mechanical obstruction b/c of inadequate motility s/sx = failure to gain weight, abd distention, vomiting, foul smelling stools (not with newborns I think…), constipation alternating with diarrhea ribbon-like and B-thalassemia -too much Fe -autosomal recessive disorder -decreased production of 1 of the globin chains in the synthesis of Hgb -chelation drug therapy (gets rid of Fe)
Hip replacement -avoid extreme external, internal rotation -avoid adduction -no side-lying on operative side -maintain abduction with pt in supine position or on non-operative side -do not cross legs -place pillow b/w legs to maintain abduction Wernicke-Korsakoff syndrome -neuro disorder -acute encephalopathy -chronic psychosis Multiple myeloma -caused by deficiency in Vit B / Tyramine deficiency-↑Ca caused by bone destruction is the primary concern Pancreatitis -encourage fluids (dilutes Ca)-do not give morphine! (irritates pancreas) -pain is severe and unrelenting in epigastric area and radiates to back -observe for ↓UO, ↑HR -diet = -typically rest GI by making pt NPO but give lots of IV fluids ↓fat, ↓protein, ↑carbs, K supplements (+) Turner’s sign = bruiselike discoloration in flank (+) Cullen’s sign = bluish hemorrhage around umbilicus Dumping syndrome -limit fluids with meals -early sx = sweating and pallor -5-30 min after eating Fat embolus -also vertigo, tachycardia, desire to lie down-tachypnea -tachycardia -dyspnea Air embolus -chest pain -dyspnea -lightheadedness -nausea -dizziness -hypoxia -anxiety - ↓↑BPHR Liver biopsy -position pt on right side to help decrease risk of hemorrhage -don’t let pt cough = can cause bleeding (^5) Peptic ulcer dzth^ dz -not contagious after rashPrimary sx of perforation = board-like abd and shoulder pain (blood) Asthma Coffee ground emesis = slower internal bleeding-diminished wheezing in a child with asthma indicates possible Posturing worsening of asthmaDecerebrate = cerebellum problem De -Decorticate is more favorable than decerebrate (thought it was other way around?)corticate = cortex problem
Cardiovascular
COPD -use a high-flow venture mask to deliver O controlled, specified amount of O s/sx : dyspnea on exertion, barrel chest, clubbed fingers and toes Complications of mitral stenosis -thromboembolism -rheumatic fever (common complication of CHF) -endocarditis -pulmonary HTN -pulmonary edema Hemolytic transfusion rxn -headache -tachycardia -HTN and Hypotension -apprehension, sense of impending doom -fever, chills -DIC Autologous transfusion rxn - - s/s of infestion ( greatest risk) low back pain,^ chest pain Inotropic and Chronotropic Drugs Inotropics -affect force of muscle ctx (-) inotropic effects = (+) inotropic effects = ↑ ↓ myocardial contractile forcemyocardial contractile force (b-blockers) Chronotropics -affects HR (-) chronotropic effects = (+) chronotropic effects = ↓ ↑ HR (parasym NS, acetylcholine) HR (sym NS), epi, atropine) Digoxin (+) inotropic (-) chronotropic Drugs for HTN (-) inotropic (-) chronotropic Diagnostic tests 1. 2. Troponins are more specificCK-MB Coronary arteriogram -femoral artery is used – keep pt on bedrest with HOB slightly elevated for several hours - ↑HR in recovery may be a sign of hemorrhage (common Cardiac tamponade complication)-fluid around heart -pt may c/o heavy / fullness around heart
Medications and Insulin
*exercise = insulin needs increase *baby born to diabetic mom is at risk for hypoglycemia (give extra feedings of formula) Diabetes - Insulin
First priority of care for pt with cardiovascular problem ↓ ↑ cardiac workloadmyocardial oxygenation Left = Lung L-sided Heart Failure^ Jugular vein distention R-sided Heart Failure^ - gallop rhythm HF in children Dyspnea Tachypnea EdemaWt. gain Gallop rhythm: S3, S4 Fine crackles AscitesHepatomegaly Wheezing, rhonchi Tachycardia TachycardiaFatigue Oliguria (fluid retention) *acute pulmonary edema *mitral stenosis Glucocorticoids (cushings = hyperglycemia) Meds that^ ↑^ Insulin requirements^ Sulfonylrureas Meds that^ ↓^ Insulin requirements Li Rifampin (TB) QuinidineQuinine (malaria) Progestins (oral contraceptives) Nicotine ACE inhibitorsNaproxen Phenytoin Ca-channel blockers Indomethacin (gout, RA, OA)Salicylates Clonidine Morphine B-blockers Heparin
Rapid Onset^ Peak^ Common types^ Misc. Midmorn- trembling/wkness^ 15min^ 1-2h^ Aspart (novalog) Lispro (humalog)^ Clear, sliding scale, no IV, pump, can mix with I, L
ROME Respiratory opposite ACID / BASE BALANCE Metabolic equal
MISC
LR -corrects dehydration, Na depletion -replace GI losses 0.45% NaCl^ Hypotonic -dehydration D5W 0.9% NaCl^ Hypertonic
↓ ↑ pHpH ↑↓ COCO 22 Respiratory acidosisRespiratory alkalosis ↓ ↑ pHpH ↓↑ HCOHCO 33 Metabolic acidosisMetabolic alkalosis
Fire in patients room? PACE / P = get patient out / R = Rescue patients RACE A = activate fire alarm, rescue other patients C = close door to confine fire E = extinguish fire
Strategies
MISC: Presence of glucose in nasal discharge = fluid is CSF Catecholamines -dopamine, epi -released during times of stress Thyroidectomy – monitor Ca and P Chemo treatment - ↑ uric acid levels in blood d/t massive cell destruction Calmette-guerin vacc -mantoux test will always be positive = vacc for TB CO Allergy to bananas/kiwis = allergy to latex 2 in blood = vasodilation Acute pain sx = If a question asks you to select a goal for a pt, make sure the answer you pick is an actual goal! ↑BP, ↑HR, ↑RR, ↑perspiration, ↓body T, ↑dilated pupils (wide eyed with fear)
- maintain Okeep HOB elevated to promote proper ventilation = no, this is an intervention 2 Allergy to eggs = no flu shot Dx test to confirm TB = sputum culture Infiltration Phlebitis = inflammation, redness, heat, swelling, tenderness = cool to touch, swelling, tenderness, decreased rate, blanching of skin HTN-crisis - give phentolamine: vasodilates Best area to check a dark-skinned patient for: Petechiae = oral mucosa, conjuntivae Cyanosis = palms/soles of hands and feet Jaundice = sclera Look for umbrella answer – if all the answers are correct, does one contain the others? Which one is not like the other? Look for opposites, look for similar answers to find the one that isn’t the same (rapid pulse, tachycardia…) ABCs Like dz can room with like dz. Assess before you implement! - Unless no further assessment is needed(Clean pt with Clean pt / Dirty with Dirty) Safety 1 Maslow’sst - IMPORTANT
