1
Q
idiosyncratic effect
A
•an uncommon, unexpected, or individual drug response thought to result from a genetic predisposition
2
Q
toxic effect
A
•a seriously adverse drug rxn caused by excessive dosing
3
Q
synergistic effect
A
•an increase in the effects of any or all of two or more drugs taken together
4
Q
adverse rxn/effect
A
- any noxious, unintended, and undesired result of taking a drug in appropriate doses
- NOT a side effect b/c side effects are harmless
5
Q
drug tolerance
A
•pt requires increased dosage of medication to achieve intended therapeutic benefit
6
Q
addictive behavior
A
•pt continues to take medication despite harmful effects
7
Q
physical drug dependence
A
•pt exhibits signs of withdrawal when a mediation is discontinued
8
Q
drug reliance
A
•pt develops an intense craving for a drug
9
Q
generic (nonproprietary) drug name
A
- noncommercial name assigned to a drug by US adopted names
- each drug has only ONE
- syllables at end indicate class
- Ex: acetaminophen
10
Q
enteral medication administration
A
•via GI tract
11
Q
sublingual medication administration
A
•via mucosa under tongue
12
Q
transdermal medication administration
A
•via skin patch
13
Q
parenteral medication administration
A
•via injection
14
Q
preoperative period
A
- begins when pt scheduled for surgery
- ends at time of transfer to OR
- time for pt and family teaching
15
Q
inpatient surgical procedures
A
- emergent- immediately
- urgent- put on schedule ASAP
- elective
16
Q
outpatient (ambulatory) surgery
A
- most often elective
- not acute
- Ex: cataract removal, hernia repair
17
Q
preoperative assessment
A
- physical, emotional, and psychosocial status prior to surgery
- Hx, meds, labs, allergies, anxiety, HTT
- blood donations
- discharge planning
18
Q
nurse role in informed consent
A
- clarify info, but NOT give new info
- witness pt signing form (must be done before pre-op meds)
- ensure correct site is selected
19
Q
preoperative teaching
A
•pain control •breathing/spirometer •ROM •anti-embolism •diet •invasive devices •anti-anxiety *demonstrate and then have pt state understanding and demonstrate
20
Q
high RBC/hematocrit indicates…
A
- high RBC production
* dehydration b/c blood is very concentrated
21
Q
venous thrombo-embolism (VTE)
A
- embolisms formed in venous blood due to venous stasis/pooling (legs/heart)
- can develop DVT or pulmonary embolus
22
Q
pts most at risk fro VTE
A
- immobile
- obese
- > 40 y/o
- hx of cancer
- spinal injury
- Hx of VTE, PE, varicose veins, edema
- oral contraceptives
- smoking
- hx decreased cardiac output (pooling blood in heart)
- hip fracture, total hip/knee surgery
23
Q
NPO prior to surgery
A
•6-8 hrs before general anesthesia
•3-4 hrs before local anesthesia
•goal is to prevent aspiration
*consult physician regarding regularly scheduled meds
24
Q
hypothermia during surgery
A
•increases chance of surgical/wound infection
•alters metabolism of meds
*why need to give pt warm blanket
25
prophylactic antimicrobials
* given 1 hr prior to incision
| * given to prevent surgical site infection
26
biggest concern of sedatives/opioids
•respiratory depression
27
Intraoperative care
•while pt is in surgery
28
holding area nurse
•monitors pt before surgery
29
circulating nurse
* coordinates all activities in OR
* sets up/checks equipment
* preps pt
* documents care/events
* counts sponges/instruments
30
scrub nurse
* sets up sterile field
* drapes pt
* hands sterile instruments
* supplies surgeon
* maintains sponge/equipment count
31
equipment/sponge counts
•performed 4 times
1. ) before
2. ) during
3. ) beginning of 1st closure
4. ) before final closure
32
anesthesia
* induced state of partial or fatal loss of sensation
* with or w/o loss of consciousness
* used to block nerve impulse, suppress reflex, relax muscle, achieve controlled unconsciousness
33
general anesthesia
* reversible loss of consciousness induced by inhibiting neuronal impulses in CNS
* causes analgesia, amnesia, unconsciousness, and loss of reflexes/tone
* used for major surgery or requiring major muscle rlx
34
inhaled anesthetics
* volatile gases/liquids dissolved in O2
* most controllable method
* few side effect
* limited muscle rlxn
35
IV anesthetics
* rapid
* contraindicated w/ kidney/liver dz
* increases resp. depression
* Ex: propofol
36
balanced anesthesia
* combo of IV drugs and inhaled agents
| * goal is sedation, amnesia, analgesia, immobilization
37
adjuncts to general anesthetic agents
* hypnotics
* opioid analgesics
* neuromuscular blocking agents (need other meds on board b/c will paralyze conscious pt)
38
malignant hyperthermia
* acute, life-threatening complication of drugs (anesthetics)
* begins when skeletal muscle exposed to agent
* causes increased Ca2+ levels in muscles
* causes increased muscle metabolism
* causes increase in serum Ca2+ and K+
* leads to metabolic acidosis (not enough O2 to cells), cardiac dysrhythmias, high body temp
* can occur during any point of anesthetic administration, maintenance, or recovery
* may be genetic
39
clinical manifestation malignant hyperthermia
* tachycardia/pnea
* elevated body temp
* muscle rigidity
* skin mottling
* cyanosis
* myobloinuria (muscle protein in urine)
* rise in tidal CO2 and decrease in O2 sat
40
local anesthesia
* loss of sensation w/o loss of consciousness
* motor fxn may/may not be affected
* topical, local infiltration, or regional
* often supplemented w/ sedative, opioid analgesics, hypnotics
* risk for aspiration low b/c cough/gag reflex intact
41
regional anesthesia
* blocks multiple peripheral nerves in specific body region
* field
* nerve
* spinal
* epidural
42
field anesthesia
•series of injections around operative field
43
nerve anesthesia
•injection into or around one nerve or group of nerves
44
spinal anesthesia
* injection into CSF in subarachnoid space
| * abdominal, pelvic, hip, knee surgeries
45
epidural anesthesia
* injection into epidural space
| * anorectal, vaginal, perinea, hip, lower extremity surgeries
46
moderate (conscious) sedation
* IV delivery of sedative, hypnotic, opioid drugs to reduce LOC for minor procedures w/o pt having discomfort
* pt responds to verbal stimuli, retains reflexes, and is easily aroused
* pt maintains airway
* often used for burn debridement
47
addressing malignant hyperthermia
* stop procedure and remove from anesthesia
* bag pt
* give IV Dantrolene muscle relaxant given for malignant hyperthermia
* may also have to give sodium bicarbonate
* lavage organs with cold water (addresses high temp)
48
which factor is of greatest concern for risk of infection during surgery
•diabetes mellitus
49
postoperative period
•begins w/ completion of surgery and transfer to PACU, ambulatory care unit, or ICU
50
PACU recovery room
* ongoing evaluation/stabilization of pt to anticipate, prevent, and manage complications after surgery
* priorities include resp. and circulation (bleeding)
51
circulating nurse AND anesthesia providers' role post-op
* transfer pt to PACU
| * give PACU nurses verbal hand-off reports
52
function return after surgery
1. touch
2. movement
3. pain
4. warmth
5. cold
53
readiness for discharge from PACU
* pt goes home or post surgical unit
* pt must take fluids orally and safely ambulate to bathroom w/ assistance
* pt must have aldrete score of 8-10, stable VS, no bleeding, return of reflexes, moderate drainage, and UOP of at least 30 ml/hr
* auscultation of bowel sounds
54
aldrete score
* used to monitor recovery from anesthesia
* scores from 0-2 in all areas
* greater score -> better
55
5 areas to determine aldrete score
1. ) activity
2. ) consciousness
3. ) respiration
4. ) O2 saturation
5. ) circulation
56
emergy care of pt w/ opioid overdose
* administer Narcan 1-2 mg IV every 2-3 min
* repeat until 10 mg reached if needed
* maintain open airway
* O2 if hypoxia present
* suction if vomiting
* don't leave pt alone
* monitor every 10-15 min until stable
57
post-operative complications
* airway obstruction
* hypoxia
* hypovolemic schock (massive loss circulating blood)
* paralytic ileus
* wound dehiscence or evisceration
* DVT
58
hypoxemia
* poor tissue perfusion
* highest incidence 2nd post-op day
* tx w/ airway maintenance, semi-fowlers, O2 therapy
59
major components of fluid in body
1.) intracellular (ICF)- ⅔
2.) extracellular (ECF)- ⅓
•ECF includes intravascular and interstitial
•fluid can move b/t
60
electrolytes
* minerals (salts) present in body fluids
* regulate fluid balance and hormone production
* strengthen skeletal structures
* serve as catalysts for nerve responses, muscle ctx, and metabolism
61
fluid volume deficit (FVD)
* fluid imbalance
* hypovolemia and dehydration
* tachy
62
hypovolemia (isotonic FVD)
* body loses fluid and electrolytes from ECF
* intravascular fluid lost
* can lead to hypovolemic shock
* thready pulse b/c pumping blood faster
63
dehydration (osmolar FVD)
•water, but not electrolyte loss
64
compensatory mechanisms for FVD
* SNS responses of thirst
* ADH release
* aldosterone release
65
hemoconcentration
•decrease in the volume of plasma in relation to # of RBCs
•increase in concentration of circulating RBCs
•increases in Hct, Hgb, electrolytes, and urine specific gravity
*expected in endurance athletes
66
FVD causes
* GI losses (vomit, diarrhea, etc)
* diaphoresis
* renal loses
* hemorrhage
* third spacing- retaining fluid in interstitial spaces (ascites, burns)
* altered fluid intake
* hyperventilation
* diabetes ketoacidosis
* fever
67
FVD subjective
* dizzy- poor perfusion to brain
* weak
* lethargic
* fatigue
68
FVD objective
* hyperthermia
* syncope
* tachycardia/pnea- compensate to maintain CO
* thready pulse- vasoconstriction in periphery
* hypotension
* oliguria
* confusion
* diminished cap. refill
69
FVD laboratory
* increased Hct
* increased serum osmolarity
* increased urine specific gravity and osmolarity
* hypernaturia
70
hypernatremia
•increased serum sodium or excessive water concentration in relation to sodium
71
FVD tx
* IV fluid replacement
| * crystalloids or collide, depending on how fluid was lost
72
is it better to replace fluids via PO or IV
* PO b/c normal body fxn
| * If urgent, give IV b/c it's fastest
73
crystalloids
```
•lactated ringers
•normal saline
•isotonic
•used for dehydration situation
*best IV fluid replacement
```
74
colloids
* blood transfusions
* larger molecules that help draw fluid into intravascular space
* most often used for hemorrhage, massive wound, etc
75
hypotensive postion
* on back w/ legs elevated
| * trendelenburg if crisis
76
acceptable UOP
•greater than 30 mL/hr
77
hypovolumetric shock
* decreased oxygen to organ/pressure to organ
* complication of FVD
* tx w/ O2, fluids, vasoconstrictors (increase central flow first)
78
fluid volume excess (FVE)
* fluid imbalance
* hypervolemia or over-hydration
* tachy
79
hypervolemia (isotonic FVE)
* both water and sodium are retained in high proportions
* blood volume increases
* severe cases can lead to pulmonary edema, heart failure, and hyponatremia
* bounding pulse
80
over hydration (osmolar FVE)
•more water than electrolytes gained
81
compensatory mechanism for FVE
* release of natriuretic peptides -> increased excretion Na+/H2O from kidneys
* decreased release of aldosterone
82
FVE risk factors
* heart failure, increased glucocorticosteroids (-> fld retention)
* kidney failure
* fluid shifts (burns, IV fluid admin)
* excessive Na+ intake
* excessive fluid intake w/o electrolytes (athletes)
83
FVE subjective
* confusion
* SOB
* lethargy
* muscle weakness
84
FVE objective
* tachycardia/pnea
* bounding pulse
* hypertension
* weight gain
* crackles
* edema
* JVD
85
FVE labs
* decreased Hct, serum osmolarity
* decreased BUN, creatinine, electrolytes
* respiratory alkalosis (dec. CO2/inc. pH)
* chest x-ray showing pulm. congestion
86
FVE tx
* limit fluid/Na+ intake
* admin diuretics
* admin O2
87
hypotonic solution
* osmolarity of less than 270 mOsm/L
* fluid into cells (lyse)
* 0.5% NS
88
hypertonic ECF
* osmolarity of greater than 300 mOsm/L
* fluid out of cells (crenation)
* 1.5% NS or 3% NS
89
isotonic ECF
* osmolarity of 270-300 mOsm/L
| * 0.9% NS
90
aldosterone
•excreted by the cortex of the adrenal gland in response to low Na+ levels
•prevents sodium and water loss
*retain fluid
91
anti-diuretic hormone (ADH)
•Produced in the posterior pituitary
•acts on kidneys to make kidneys reabsorb more water so that the body retains more fluid
*retain fluid
92
natriuretic peptides (NPs)
•released in response to barorecptors in the heart or vascular system detecting increased blood volume
*LOSE fluid
93
renin angiotension system
* in response to low BP, blood volume, blood O2, and blood osmolarity kidneys excrete renin
* renin catalyzes formation of angiotension I, which is converted to angiotension II (active form) by ACE
94
angiotension II
* vasoconstrictor
* causes nephrons to contract, decreasing UOP
* causes kidneys to release aldosterone
95
an ACE inhibitor would be classified as...
* diuretic
* lowers BP b/c blocks production of angiotension II
* commonly used for mild HTN
96
sodium
•major electrolyte found in ECF (intravascular), body fluids, and secretions
•essential for maintenance of acid-base and fluid balance, transport mechanisms, and nerve conduction
*imbalances cause NEURO problems
97
expected serum sodium levels
•135-145 mEq/L
98
hyponatremia
•serum Na+ level less than 136 mEq/L
•net gain of H2O or loss of Na-rich fluids
•delays/slows depolarization of membranes
•H2O moves from ECF to ICF (cerebral edema)
•Na+ loss via GI, renal, skin
•also caused by increased ECF H2O
*dehydrated OR over hydrated
99
hyponatremia s/s
* serum Na+ level less than 136 mEq/L (BMP)
* serum osmolarity less than 280 mOsm/kg
* heart failure
100
hyponatremia tx
```
•fld restriction
•loop diuretics and ACE inhibitors
•admin hypertonic sol. (3% NaCl)
•high Na+ food intake
*can't correct too quickly
```
101
hypernatremia
* serum Na+ level greater than 145 mEq/L
* cells depleted of fld needed to fxn
* causes hypertonicity of serum (water out of cells) -> dehydration
102
hypernatremia s/s
* serum Na+ level greater than 145 mEq/L
* serum osmolarity greater than 300 mOsm/kg
* Cushing syndrome
103
hypernatremia tx
* for fluid loss: admin hypotonic/isotonic fld
| * for excess Na+: water intake and loop diuretics
104
potassium
•major cation of ICF
•vital role in cell metabolism, nerve impulse transmission, cardic/lung fxn, etc
*imbalances cause CARDIAC problems
105
expected K+ level
•3.5-5 mEq/L
106
hypokalemia
•serum K+ below 3.5 mEq
•results from increased loss of K+ from body
•may be from from movement of K+ into cells (insulin high)
•Lasix (furosimide) cause K+ loss
*key s/s is fluttering chest
107
hypokalemia s/s
•hypotension
•weak pulse
•confusion
•serum K+ below 3.5 mEq
•atrial blood gases reveal metabolic alkalosis (pH > 7.45)
*irregular EKG- inverted T waves (CARDIAC issues)
108
hypokalemia tx
* encourage K+ intake
* admin K+ PO (best b/c absorbed better thru GI)
* admin K+ IV (NEVER bolus)
109
hyperkalemia
* K+ Level of more than 5.0 mEq/L
* results of increased K+ intake, movement of K+ out of cells, and inadequate renal excretion
* causes include intake, tumor lysis, diabetes
* can be caused by salt substitute -> K+ overdose
* poses risk for cardiac arrhythmias and cardia arrest
110
hyperkalemia s/s
•K+ Level of more than 5.0 mEq/L
•atrial blood gases reveal metabolic acidosis (pH < 7.45)
•oliguria/diarrhea
•irregular pulse
•irregular EKG shows vent. fibrillation, peaked T waves, widened QRS
*CARDIAC issues
111
hyperkalemia tx
* Decrease K+ intake
* Administer Calcium Gluconate or Calcium Chloride
* Administration if IVF along with D50 and insulin- K+ movement to ICF
* Administer loop diuretics- K+ excretion
* Administer Kayexalate (sodium polystyrene)- K+ excretion in stool
112
calcium
* electrolyte found in cells, bones, and teeth
* essential for CV, nervous, and endocrine fxn
* role in blood clotting and bone/teeth formation
* important in depolarization of membranes
* s/s involving SKELETAL MUSCLE
113
expected Ca2+ levels
•9-10.5 mg/dL
114
hypocalcemia
* serum Ca2+ less than 9 mg/dL
* bradycardia
* hyperactive bowel sounds
* hypotension
* osteoporosis
* muscle cramps (SPASMS)
* risk of seizure/fall
* Trousseau's sign- wrist spasm with BP cuff
* Chvostek's sign- cheek muscle twitch when tap
115
hypocalcemia tx
* replace Ca2+ PO and IV
| * admin vit. D
116
hypercalcemia
```
•serum Ca2+ greater than 10.5 mg/dL
•lethargy
•paresthesia
•mscl WEAKNESS
•excitable tissues are less sensitive to normal stimuli, therefore it is harder for muscles to contract
•causes faster clotting time
*high risk for DVT
```
117
hypercalcemia tx
* stop intake of calcium and vitamin D
* admin of isotonic sol to restore balance
* discontinue thiazide diuretics
* admin of Phosphorous, Lasix, calcium binders
* dialysis
118
expected phosphorus level
* 3.0 - 4.5 mg/dL
| * s/s involve SKELETAL MUSCLES
119
hypophosphatemia
* serum phos < 3.0 mg/dL
* doesn't affect body fxn except in chronic situations
* RECIPROCATES Ca2+, so effects similar to HYPERCALCEMIA
* risks include malnutrition, antacids, alcoholism, hyperglycemia, etc
* muscle weakness
120
hypophosphatemia tx
* Discontinue antacids, calcium supplements
* IV phosphorous only given when levels below 1 mg/dL
* Increase intake of phosphorous rich foods (fish, chicken, beef, pork, organ meats, nuts, whole grains)
121
hyperphosphatemia
* serum phos >4.5 mg/dL
* same as HYPOCALCEMIA in regards to s/s and tx
* muscle spasms
* hypoparatyroid/kidney dz
122
magnesium
•electrolyte found mostly in bones
•small amt in cells and ECF
•important for skeletal muscle contraction, metabolism of carbohydrates, ATP formation, cell growth (preggo)
*s/s involve DTRs
123
expected Mg2+ level
•1.3-2.1 mEq/L
124
hypomagnesemia s/s
* serum Mg2+ less than 1.3 mEq/L
* occurs in conjunction w/ hypocalcemia
* HYPERACTIVE DTRs (spasm)
* tetany
* seizures
* psychosis
125
hypomagnesemia tx
* discontinue drugs that cause mag loss
* IV replacement when loss is severe
* Oral replacement (can cause diarrhea)
126
hypermagnesemia
```
•serum Mg2+ > 2.1 mEq/L
•renal dz
•lethargy
•HYPOACTIVE DTRs (weakness)
•coma
•bradycardia
•hypotension
*use of laxatives poses major risk
```
127
hypermagnesemia tx
* discontinue oral and parenteral magnesium
* give fluids free of mag
* loop diuretics
* calcium to reduce the cardiac side effects
128
weight of 1 L water
* 2.2 lbs
| * 1 kg
129
use of laxatives
* hypermagnesemia
| * hypokalemia
130
mental status assessment
* LOC
| * orientation (x3)
131
levels of consciousness
* alert
* lethargic- drowsy
* stuporous- require stimulation to arouse
* comatose- unconscious
132
rapid neuro assessment
* mental status
* movement of extremities
* pupil size/rxn to light
* glasgow coma scale
133
Glasgow Coma Scale
* used to determine LOC and monitor changes following injury, tx, etc
* Eye opening
* Motor response
* Verbal response
* 15 = normal neuro function
* 7 = coma
134
what can pass thru BBB
* glucose
* O2
* CO2
* alcohol
* anesthetics
* water
135
damage to cerebrum
•contralateral impact
136
damage to cerebellum
•ipsilateral impact
137
seizure
•abrupt, abnormal, excessive, and uncontrolled electrical discharge of neurons within the brain
•may cause alterations in LOC, motor/sensory ability, and/or behavior
•can be generalized (6 types), partial, or unclassified
*generalized involve BOTH hemispheres
138
primary (idiopathic) epilepsy
* chronic recurring abnormal brain electrical activity
* dx based on hx and labs to rule out other causes
* considered a syndrome
* due to imbalance of nts (GABA)
139
tonic-clonic seizure
•generalized
•used to be known as grand mal
•may (rarely) begin with aura (altered sense)
•begins for few sec w/ tonic episode and loc
•clonic episode follows tonic
•clonic phase followed by postictal phase
*lasts 2-5 min
140
tonic episode
* stiffening of muscles
| * breathing may stop (cyanosis)
141
clonic episode
* rhythmic jerking of extremities
* breathing may be irregular (cyanosis)
* can have biting of tongue/cheek
142
postictal phase
* period of confusion, fatigue, agitation, and lethargy following a tonic-clonic seizure
* lasts up to an hour
143
tonic seizure
* rare type of generalized seizure where only tonic phase is experienced
* 30 sec -> several min
* abrupt increase in muscle tone
* autonomic changes (HR, RR)
* loc
144
clonic seizure
* rare type of generalized seizure where only clonic phase is experienced
* several minute duration
* muscles ctx and rlxn
145
absence seizure
* generalized
* most common in children
* loc lasting few sec
* blank staring
* automatisms
* return to baseline after seizure
146
automastim
* involuntary behavior
* lip smacking
* eye fluttering
* picking at clothes
147
myoclonic seizure
* generalized
* brief jerking/stiffening of extremities (sym/asym)
* lasts for few seconds
148
atonic (akinetic) seizure
* generalized
* few second period of muscle tone loss
* followed by period of confusion (postictal)
* frequently results in falling
* most resistant to drug therapy
149
partial (focal/local) seizure
* begin in part of ONE cerebral hem.
| * complex or simple
150
complex partial seizure
* automatisms
* loc (black out) for 1-3 min
* amnesia possible prior to and after seizure
* temporal lobe usually involved
151
simple partial seizure
* consciousness maintained
* unusual sensations (aura)
* deja vu
* autonomic abnormalities (HR, flushing, epigastric discomfort)
* unilateral extremity movement
* pain or offensive smell
152
unclassified (idiopathic) seizure
* occur fo no known reason
| * account for ½ of all seizure activities
153
seizure risks
* genetics
* febrile state
* head trauma/cerebral edema/tumor
* abrupt cessation of drugs/etoh
* infection/toxins
* metabolic disorder
* hypoxia
* fluid/electrolyte imbalances
154
seizure triggers
* increased physical activity
* stress
* hyperventilation
* fatigue
* excessive caffeine/etoh intake
* flashing lights
* chemical exposure
155
seizure first aid
```
•keep self/others calm
•ease pt to floor w/ soft under head
•turn pt on side (maintains airway)
•time seizure
•remove glasses, jewelry, etc
•do NOT restrain or put object in mouth
*call 911 if longer than 5 min, dyspnea, pain, etc
```
156
nursing interventions during seizure
* PRIORITY: keep pt from injury
* maintain airway (be ready to suction)
* ease pt to floor
* turn pt on side
* remove loose items
* don't retrain/put object in mouth
157
nursing interventions post-seizure
* keep pt on side
* take VS
* assess for injuries
* perform neurological check
* reorient/calm pt
* place bed in lowest position and pad rails
* maybe start IV or O2
* try to ID trigger/aura
158
status epilepticus
•potential seizure complication
•prolonged seizure activity occurring over 30-min time frame
•decreased O2
•inability brain to return to normal fxn
*require immediate tx to proven loss of brain fxn, organ failure, dysrhythmias, etc
159
acute seizure
* seizures occurring in greater intensity, number, or length than usual, or different clusters
* tx w/ lorazepam (Ativan) or diazepam (Valium) to prevent progression into status epilepticus
160
anticonvulsants (AEDs)
•tx to control seizures to some degree
•pt often requires combo for control
•doses adjusted to achieve therapeutic blood levels with least amount of side effects
•oral hygiene important when taking
*CANNOT be stopped abruptly
•educate pt on drug/food interactions (GF juice)
161
vagal nerve stimulation (VNS)
* surgical intervention for seizures
* device implanted into left chest wall and connected to electrode on left vagus nerve
* pt activates device w/ magnet when experiencing trigger/aura
* device administers intermittent stimulation of brain via stimulation of vagal nerve at rate specific to pt needs
162
excision of portion of brain
* surgical intervention for seizure
* removal/interruption of brain tissue causing seizure activity
* mainly used for partial seizures
* pt is awake/alert during operation
* high risk procedure
163
lorazepan (Ativan)
* acute seizure tx to prevent progression into status epileptics
* anti-anxiety, BZD, and anti-convulsant
* give 4 mg over 2 min (slow IV push)
164
diazepam (valium)
* acute seizure tx to prevent progression into status epileptics
* anti-convulsant, anti-anxiety, BZD, and skeletal muscle relaxer
* give 4 mg over 2 min (slow IV push)
165
phenytoin (Dilantin)
•acute seizure tx to prevent progression into status epileptics
•anti-convulsant and anti-dysrhythmic
•50 mg/min (IV pump w/ NS)- loading dose
•decreases effectiveness of warfarin and oral contraceptives
*can also be used as a maintenance therapy
166
cerebral vascular accident (CVA)
* disruption in the cerebral blood flow secondary to ischemia from thrombosis, hemorrhage, or embolism
* aka: stroke, cerebral infarction, or brain attack
167
hemorrhagic stroke
* occur secondary to ruptured artery or aneurysm
* prognosis poor b/c of amt ischemia and increased ICP caused by collection of blood
* prognosis better if stroke caught early, bleeding ceased, and clot evacuated
168
thrombotic stroke
•occurs secondary to development of blood clot on an atherosclerotic plaque in a cerebral artery
•clot gradually shuts off artery and causes ischemia distal to occlusion
•symptoms evolve over period of hrs-days (often preceded by TIA)
*occlusive
169
embolic stroke
•occur secondary to embolus traveling from another part of body to cerebral artery
•brain blood distal to occlusion immediately shut off, causing loc to occur
*occlusive
170
transient ischemic attack (TIA)
* mini stroke (warning stroke)
* caused by thrombotic clot but blockage is temporary
* sx occur rapidly but last 1-5 minutes
* warning signs almost same as stroke
* usually no permanent damage
171
reversible ischemic neurological deficit (RIND)
* caused by thrombotic clot, but blockage temporary
| * similar to TIA, but lasts longer (up to 24 hrs)
172
sx left hem stroke consequences
* language, math, and analytic thinking
* expressive, receptive, global aphasia
* agnosia- inability to recognize objects
* alexia- reading diff.
* agraphia- writing diff.
* hemianopsia, hemiplegia, hemiparesis
173
sx right hem stroke consequences
* abnormalities in spatial perception, proprioception, and judgment/impulse control
* hemianopsia, hemiplegia, hemiparesis
* depth perception- overestimate
174
risk for increased ICP
•blood from hemorrhage
•cerebral edema
•inflammation
*normal: 10-15 mmHg
175
CVA nursing interventions
* depends on sequelae (condition consequence of stroke)
* monitor VS
* assist w/ feeding
* aid in ambulation
* maintain safe environment
* take measures to prevent DVT
* seizure precautions
176
thrombolytic meds
•given for CVA
•recombinant tissue plasminogen activator (rtPA, Retavase)
•admin within 3-4.5 hrs of onset of sx
•contraindicated if hemorrhagic stroke or pt on anticoagulants
*have to rule out hemorrhagic stroke w/ MRI before initiating
177
antiplatelets
* low dose ASA-acetylsalicylic acid (aspirin) given within 24-48 hrs. following a stroke to prevent further clot formation
* Give within 4.5 hrs. of initial symptoms
178
anticoagulates
* controversial tx for CVA
* high risk of intracerebral hemorrhage
* Heparin, enoxaparin (Lovenox), warfarin (Coumadin)
179
AEDs for stroke
* phenytoin (Dilantin), gabapentin (Neurontin)
* usally only if patient develops seizures
* gabapentin may be given for paresthetic pain in affected extremity
180
CVA surgical interventions
* carotid artery angioplasty w/ stenting
| * carotid endarterectomy- open artery by removing atherosclerotic plaque (common for TIA)
181
CVA complications
* dysphagia
* aspiration
* unilateral neglect
182
homonymous hemianopsia
* visual field loss on same side of both eyes
* left: due to abrasion on right side of brain (has visual pathways for left hemifield of both eyes)
* right: due to abrasion on left side of brain (has visual pathways for right hemifield of both eyes)
183
consequences of increased ICP
* hyperthermia b/c pressure on thalamus
* widening of pulse pressure
* decreasing HR
184
FAST
* facial drooping
* arm weakness
* slurred speech
* time- call 911
185
recombinant tissue plasminogen activator (rtPA)
•thrombolytic NZ (Activase)
•can be used to reverse ischemic stroke (thrombolitic/embolitic) if given w/ 3-4.5 hrs of initial sx
*only used for clot in brain (not used for DVT)
186
anosognosia
•an inability to acknowledge the reality of the physical impairments resulting from stroke
187
dysarthria
•slurred speech
188
before angiogram
* verify no iodine or shellfish allergy
| * verify baseline creatinine/BUN level to make sure kidney fxn normal
189
bone marrow
•responsible for production of RBCs, WBCs, and platelets
190
erythropoiesis
•RBC production
•kidney releases (possibly in response to hypoxia) erythropoietin (GF)
•also need iron, B12, folic acid, copper, B6, cobalt, and nickel
*RCB last 120 days
191
hematocrit
•percentage of packed RBCs per dL of blood
192
anemia
•abnormally low RBCs, Hgb, and/or hematocrit
•results in diminished O2 carrying capacity and deliver to tissues/organs
*goal of tx is to restore/maintain adequate tissue oxygenation
193
anemia causes
* blood loss
* inadequate RBC production (hypoproliferative)
* increased RBC destruction (hemolytic)
* Fe, folic acit, erythropoietin, and/or B12 deficiency
194
iron-deficiency anemia
•due to inadequate intake, most common in children, adolescents, and preggo
•due to blood loss is common in older adults
*menstruating women can develop secondary to menorrhagia
195
cardiac s/s anemia
* tachycardia
* orthostatic hypotension
* palpations, murmors, gallops
* angina
* heart failure
196
respiratory s/s anemia
* dyspnea on exertion
| * decreased O2 sat
197
integumentary s/s anemia
* pallor
* cool to touch
* cold intolerance
* brittle nails
198
musculoskeletal s/s anemia
* weakness
* malaise
* fatigue
199
neurologic s/s anemia
* headache
* somnolence
* forgetfulness
* dizziness
* depression
200
Hgb levels in anemic
•mild: 10-14 g/dL
•moderate: 8-10 g/dL
•severe: < 8 g/dL
* < 10 g/dL when clinical manifestations show
201
types of anemia
* sickle cell
* G6PD deficiency
* autoimmune hemolytic
* vit B12 deficiency
* folic acid deficiency
* aplastic- exposure to myelotoxic agents (radiation, virus, etc)
202
normal RBC levels
•m: 4.7-6.0 million/mm^3
•f: 4.2-5.4 million/mm^3
*4.5-6
203
normal HCT levels
* m: 50-57 ml/dL (50-54%)
| * f: 37-48 ml/dL (37-48%)
204
normal Hgb levels
* m: 14-18 g/dL
| * f: 12-16 g/dL
205
screening for anemia
* CBC w/ RBC indices
* reticulocyte count
* platelet count
* morphology (wright stained blood smear)
* serum ferritin, serum iron, and total iron binding capacity
* bone-marrow aspiration/biopsy
206
mean corpuscular volume (MCV)
•RBC indices that determines size of RBCs
•normocytic, microcytic, or macrocytic
•helps determine cause of anemia
*86-98
207
mean corpuscular Hgb (MCH)
•RBC indices that determines amnt of Hgb per RBC
•normochromic or hypochromic
*27-32
208
mean corpuscular Hgb concentration (MCHC)
•RBC indices that indicates Hgb amnt relative to size of cell
*32-36%
209
normal MCV, MCH, MCHC
* normocytic/normochromic anemia
| * possible causes are acute blood loss and SCD
210
decreased MCV, MCH, MCHC
* microcytic/hypochromic anemia
| * caused by Fe deficiency, chronic illness, or chronic blood loss
211
increased MCV
* macrocytic anemia
| * caused by B12 deficiency or folic acid deficiency
212
total iron binding capacity (TIBC)
* indirect measurement of serum transferrin (Fe transporter)
| * elevated level indicates Fe-deficiency anemia
213
serum ferritin test
•indicates total iron stores in body
214
serum iron study
* measures amnt of Fe in blood
| * low levels indicate Fe-deficiency anemia
215
bone marrow aspiration/biopsy
* used to diagnose aplastic anemia
| * indicates bone marrow failure to produce RBCs, platelets, and/or RBCs
216
hemochromatosis
* too much Hgb
| * causes iron overload
217
polycythemia vera
•too many RBCs
218
hemolytic anemia
* due to excessive destruction of RBCs (or SCD)
* splenomegaly and jaundice
* followed by acceleration of erythropoises
* response to trauma, infection, chemical exposure, autoimmune rxns
219
hemolytic anemia tx
* steriods
* spenectomy
* chemo
* plasma exchange
* immuno-suppressant agents
220
iron-deficiency anemia (IDA)
* chronic hypochromic, microcytic anemia caused by insufficient supply of Fe2+
* impairs ability of RBCs to carry O2
* high risk are females, elderly, blood loss pt, alcoholics
221
s/s IDA
* pallor
* glossitis
* cheilitis (inflammation of lips), stomatitis (inflammation of oral mucus membrane), mouth fissure
* thin, febrile, brittle
* weak
* headache
* dyspnea
222
diagnostics of IDA
* peripheral blood smear reveals microcytic/hypochromic RBCs
* Hgb < 8 g/dL
* Fe level 10 micrograms/dL
* TIBC increase (trying to signal more iron to come)
* occult blood-fecal and urine
* GI endoscopy
223
IDA tx
* encourage intake
* PO iron supplement (w/ OJ or vit C to absorb best)
* Iron dextran- IM
* transfusion packed RBCs
* discontinue anti-acids, coffee, tea b/c impair Fe absorption
224
Megaloblastic anemias
* group of disorders caused by impaired DNA synthesis, resulting in defective and large RBCs (megaloblasts)
* most are caused by Cobalamin (B12) and folic acid deficiencies
225
pernicius anemia
•lack of intrinsic factor found in GI mucosa, which is necessary for B12 (extrinsic factor) absorption
•develops slowly (dx older)
•higher risk w/ GI tumors, GI issues, and/or hypothyroidism
*B12 deficiency
226
s/s pernicius anemia
* low Hgb, Hct, cobalamin, and RBC
* weakness/fatigue
* jaundice
* glossitis (inflammed tongue)
* memory/personality changes
* depression/irritability
* diminished senses/coordination
* GI symptoms
* positive schilling test
227
Schilling test
* measures urinary excretion of vitamin B12 for diagnosis of pernicious anemia and a variety of other malabsorption syndromes
* give 2 doses B12 PO
* collect 24 hr urine
228
tx pernicious anemia
•parenteral/intranasal admin of B12
•Fe supp. to increase erythropoiesis
•encourage B12, and fortified cereal intake
*need lifelong tx
229
folic acid deficiency anemia
* megaloblastic anemia
* decreased RBC, Hgb caused by impaired production r/t decreased folate level
* higher risk if poor nutrition, malabsorption syndromes (Crohn's), anticonvulsant/oral contraceptive use, alcoholism, anorexic
230
s/s folic acid deficiency anemia
* slow onset
* thin, emaciated
* electrolyte imbalance
* serum folate < 4 ng/mL
231
iron sources
* red/organ meat
* leafy greens
* egg yolks
* almonds
* legumes
* dried fruit
232
B12 sources
* meat/poultry
* eggs
* milk products
* fortified cereals
233
folic acid sources
* beans/legumes
* citrus fruits/juice
* fortified bread, cereals, pasta, etc
234
homologous blood transfusion
•blood from donor used
235
autologous blood transfusion
* pt blood collected in anticipation of future transfusion
* donated 5 wks- 72 hrs prior to elective surgery
* eliminates risk of alloimmunization (immune response to antigens)
236
intraoperative blood salvage
•blood loss during surgeries recycled thru cell-saver machine and transfused intraoperative
237
whole blood transfusion
* massive blood loss
| * pt needs O2-carrying capacity and vol. increase
238
Packed RBC transfusion
* whole blood with ⅔ of plasma removed
* severe anemia
* moderate blood loss
* less danger of fluid overload
* transfusion of choice
* should not exceed 4 hrs transfusing
239
platelet transfusion
* concentrate of platelets suspended in small amnt of original plasma
* bleeding from thrombocytopenia or abnormal platelet fxn
* chemo-induced bone marrow failure
* transfuse over 15-30 min
240
fresh frozen plasma transfusion
* anti coagulated clear liquid portion of blood separated from whole blood by centrifugation
* used to reverse excessive anticoagulation
* clotting factor deficiencies associated w/ hemorrhagic tendency
241
admin blood products
* ensure type and Rx order
* cross match before getting from blood bank
* verify blood and pt #
* make sure no allergy, hx rxn, etc
* use 20-gauge needle
* infuse w/ NS (NOT meds)
* remain w/ pt for first 15 min
242
hemolytic transfusion rxn
* during first 15 min, chills, fever, urticaria (rash), tach, pain/tight chest, SOB, cloudy urine
* stop blood (keep NS)
243
febrile transfusion rxn
* during first 15 min, sudden fever/chills, headache, flushing, anxiety, muscle pain
* give antipyretics (avoid aspirin)
244
bacterial (sepsis) rxn
* rapid onset of hypotension, fever, chills, vomit, diarrhea, and shock
* tx: stop transfusion and treat septicemia (abx, IV fluid, vasopressors, steroids)
245
allergic transfusion rxn
* antihistamine admin 15-30 min prior to transfusion to preven
* s/s: urticaria, edema of face, asthma attack, flushing/itching
* tx: stop transfusion and KVO w/ NS
246
circulatory overload transfusion rxn
* higher risk if have renal/cardiac insufficiencies
* s/s: cough, dyspnea, headache, hypertension, tach, JVD
* tx: pt upright, O2 therapy, diuretics, morphine
247
RBC count
* m: 4.7-6.1 million/uL
* f: 4.2-5.4 million/uL
* decreased level indicates anemia
248
WBC count
* 5,000-10,000/uL
* elevated evidence of infection
* decreased evidence of immunosuppression
249
pancytopenia
•low RBC, WBC, and platelets
