Shock

Video found here.

Intracranial Pressure

The cranial vault contains brain tissue, blood and CSF--there is no room for anything else! If any of these components has a volume increase, there will be alteration in hemostasis. The pressure inside is 10-20 mmHg (normal ICP)-anything above 20 will compromise tissue perfusion.

Neuro Assessment

Frequent reassessments are essential to detect any changes in neurologic status. This in cludes:
*Cerebral Function
*Cranial Nerves
*Motor System
*Sensory System
*Reflexes

Glascow Coma Scale
Helps evaluate LOC. Scale evaluates Eyes, Motor and Verbal response. Use least invasive method to stimulate a response.
Changes in the level of consciousness is the most important and usually first indicator in deterioration of neurologic status.
Arousal is the lowest level of consciousness. It is imperative to protect the airway of a client with ALOC!

Nervous System

The nervous system is divided into the Central Nervous System and the Peripheral Nervous System.

Image found here.

Central Nervous System includes the brain and spinal cord.

Peripheral Nervous system includes nerves and the Autonomic Nervous System which consists of the Sympathetic Nervous System (fight or flight) and Parasympathetic Nervous System (rest and digest).

Image found here.

Hemodynamics

Normal bloodflow/conduction of the heart





Image found here.

Image found here.Image found here.

STROKE VOLUME is influenced by:
PRELOAD-degree of myocardial stretch just before systole
AFTERLOAD(aorta)-amount of resistance against which the left ventricle pumps
CONTRACTILITY-force fo the contraction

CARDIAC OUTPUT=SVxHR
Normal CO is 4-8 L/min

MAP (Mean Arterial Pressure)=Systolic pressure+2 diastolic pressures/3
MAP>60

CENTRAL VENOUS PRESSURE-Evaluates venous return and fluid volume status. Basically tells you your preload.
Normal CVP is 2-8 mmHg (same as JVD)

!High Risk Pregnancy! -the life or well being of the mother or infant is jeopardized by a biophysical psychosocial disorder coincidental with or unique to pregnancy.

Amniocentesis

Video found here.

Ultrasounds-abdominal or vaginal
Provides information regarding:
*Fetal activity
*Gestational age
*Fetal growth
*Visual assistance for invasive tests
*Fetal anatomy
*Placental anatomy
*Fetal well being

COOMB'S TEST
Screening test for Rh inbompatability
1:8 Ratio
ONLY GIVE REGAM TO MOTHER

Video found here.

Stroke

Neuro Exam:
General Aspects-Grooming, long and short term memory, language
LOC-first indicator of a problem A&Ox4, lethargic, stuporous, comatose
Equal muscle strength, coordination, gait, reflexes
V/S, LOC, PERRLA, Motor strength

Aphasia-total loss of comprehension and use of language
Dysphasia-difficulty with language comprehension or use.

Ischemic: Blockage
Hemoragic: Bleed
BASICALLY THE SAME EXCEPT FOR DRUGS!! (Don't want to give hemoragic aintibleeding meds!)

Parkinson's and strokes may look similar.



Video found here.



Video found here.

MS



Video found here.

Cholelithiasis

Attacks commonly follow meals rich in fats or may occur at night. suddenly awakening the patient. They begin with acute abdominal pain in the right upper quadrant that may radiate to the back. between the shoulders. or to the front of the chest; the pain may be so severe that the patient seeks emergency department care. Other features may include recurring fat intolerance. biliary colic. belching. flatulence, indigestion. diaphoresis. nausea. vomiting. chills. low-grade fever. jaundice (if a stone obstructs the common bile duct). and clay-colored stools (with choledocholithiasis).

Clinical features of cholangitis include a rise in eosinophils, jaundice, abdominal pain. high fever. and chills; biliary drrhosis may produce jaundice, related itching, weakness, fatigue. slight weight loss. and abdominal pain. Gallstone ileus produces signs and symptoms of small bowel obstruction - nausea. vomiting, abdominal distention, and absent bowel sounds if the bowel is completely obstructed. Its most telling symptom is intermittent recurrence of colicky pain over several days. Each of these disorders produces its own set of complications.

Video found here.

Info found here.

GI Drugs

Antacids-mask the real problem, interfere with absorption of other meds

Histamine H2 Antagonists-prevent stress/ulcer (zantac, pragoment, pro=ilosec/protonix)
Proton Pump Inhibitors-not for long term use since it INHIBITS

*KNOW*GI Stimulants-Reglan-increases peristalsois. Good for post op. Parasympathetic NOT FOR PARKINSON's

Digestive Enzymes-for cystic fibrosis-help break down food. Need for ALL snacks. Big tablets. If fat is present in stool (stedorhea) pt may be non compliant or med not working. Do not chew meds.

Anti-emetics: vomiting-give 30 min-3 hrs. before chemo-oral, injection, IV

Laxatives-

Anticholinergics-SNS

REVIEW SNS AND PNS!!!


Video found here.

Renal Calculi

Kidney Stones.

GI Disorders

GERD-symptomatic condition secondary to reflux of gastric contents into the lower esophagus (Reflux-what goes down comes back up).

Avoid cigarettes! Fatty foods, chocolate, peppermint, coffee, tea, milk. Eat small frequent meals. Avoid late evening and nocturnal snacking. Fluids between rather than with meals.
S/S:
*Heartburn (pyrosis)
*Dyspepsia (pain or discomofort centered in the upper abdomen)
Avoid caffiene, carbonated beverages, SNS drugs, decrease fat, increase fiber, avoid tight clothes.




Video found here.


Hiatal Hernia-part of stomach seeps over the diaphram. Typically occurs with pregnancy, obesity, heaving lifting.
VERY similar to GERD...heartburn, can be asymptomatic. Avoid anticholinergic meds. Eat small frequent meals.

Video found here.

Peptic Ulcer Disease (PUD) -ulcer on the lining of the stomach or duodenum
*Blood in emisis
*pH of intestine 7-8

Video found here.

Diverticulitis/osis
Diverticulosis=disease
Diverticulitis=inflammation/infection
AVOID SEEDS!!
Check bleeding (H&H and WBC for infection). No enemas during acute phases.
Osis-diet high fiver
Itis-low fiber, low residue

Video found here.

Cystitis

(UTI)-infection. fever, pain,
Prevention: FLUIDS, wipe front to back, avoid deodorants/bubble baths, urniate after intercourse.
Pyelonephritis-infection of the upper urinary tract (kidney), bladder up.
*PAIN
*Dysuria
*Pain at costovertebral angle

Video found here.

Cystitis
*Frequency/Urgency
*Suprapubic pain
*Dysuria
*Hematuria
*fever
*confusion (in older adults)

Video found here.

Tx: antimicrobials
^ FLUIDS!!
Prevention!

Male Reproductive Issues

Prostatis-inflammation/infection of prostate. TX: antibiotics, catheter

Benign Prostate Hyperplasia (BPH)
Non-cancerous USUALLY over age 60.
Tx: Continuous bladder irrigations, TURP
Sx: 3 Way foley -->no clots, bladder scan


Video found here.

TURP


Video found here.

Prostate CA
USUALLY over age 50.
hard pea sized nodule
S/S: lower back pain LATE: weight loss down legs EARLY; hematuria, frequency, weak stream, etc.

Digital Rectal Exam-image found here-good source for more prostate info.


Erectile Dysfunction
Causes: meds(HTN meds), spinal cord injuries, hypotension, psychological issues
Tx: Viagra SE:call Dr. if erection longer than 3hrs, visual changes (color vision), headaches, HYPERTENSION

Testicular Cancer-prevention: self exam, after warm shower. May have pain, mass, "dragging" feeling, abdominal pain. TEACH patients self examination techniques (p. 1433 Lewis)
Tx: chemo, sx, radiation.

Angina

Angina-chest pain

Chronic Stable Angina-caused by myocardial ischemia, usually secondary to CAD. Episodic pain lasting 5-15 min. Provoked by exertion, relieved by rest or nitro

Prinzmetal's Angina-caused by coronary vasospasm. Occurs at rest, triggered by smoking, may occor w/ or w/o CAD.

Unstable Angina-caused by rupture of thickened plaque, exposing thrombogenic surface. Occurs as new-onset angina, increasing frequency, duration or severety, occors at rest or with minimla exertion, refractory to nitro.

Tx: Nitrates

Female Reproductive Issues

Endometriosis-scar tissue build up

Video found here.

Pelvic Inflammatory Disease
Asymptomatic-high mortality rate. Symptomatic-become apparent right after menstruation (Pain, bleeding). Septic shock causes death. Can cause infertility.--Infection=fever, ^ WBC
Monitor H&H for blood loss.
S/S: PAIN, reproductive issues.
TX:
*Drug therapy (danocrine, GnRH agonists, oral contraceptives)
*Surgery (laparotomy to remove implants and adhesions, hysterectomy)

Video found here.

Cystocele/Rectocele
TX:
*Sx
*Kegal Exercises

Video found here.

Cancer
Risks: PID, smoking, sex before 17, multiple sexual partners
Prevention: Annual exam, PAP
DX: biopsy, self breast exam-after cycle or same day of q month for hysterectomy
S/S: foul smell, bleeding, lower back/leg pain, weight loss, leakage from vagina, hematuria, painless (painful later) mass, bloody/clear nipple discharge
Tx:
Radiation-stand at head of the bed. <20 style="font-weight: bold;">Hysterectomy-no heavy lifting. No sex for 3-6 wks.
Abdominal sx is BIG risk for DVT.
ABC!!

Post Mastectomy-No BP, injections, venipunctures on affected side. Watch for edema, elevate, begin ROM exercises immediately, post op. teaching!!

Renal Failure

Video found here.

Renal Structure and Function

Urine formation, excretion of wastes, regulation of acid-base balance, water balance and RBC production.



Video found here. NOTE: There are millions of nephrons!

Assessment
Subjective Data:
*Hx
*Pain
-Kidney
-Flank
_Abdomen
-Scrotal
-GI

Objective Data
*V/S
*Voiding Patterns
*Bladder Scan
*Palpate
*DRE (Digital Rectal Exam)
*Edema/Skin color/Turgor
*Weight (I&)!!!-->30 mL/hr is normal output)

Hypertension

High blood pressure. 120/80 is normal bp reading.

BP should be taken with patient sitting or lying.

Orthostatic/Postural BP taken with patient laying, sitting and standing.

S/S:
*H/A
*dizziness
*visual chances
*nose bleeds
*VA changes
*fatgue

Diastolic > 140=Hypertensive Crisis-->How fast did they get there??

Compliance is a big issue with hypertensive patients.

KIDNEY IS THE PRIMARY ORGAN DAMAGED

If BP drops, elevate legs!

Congestive Heart Failure (CHF)

Condition in which the pumping of the heart becomes impaired and is unable to meet the body's demands.

NEED A LOT OF REST. Pulse O2 is 93-95%

Etiology:
Diabetes

Tx:
Upright (High/Semi Fowler's)
Nitrate
Diuretics (Laxix)
O2

I&O is important! We want to get rid of fluid. Pts. with CHF are almost always on fluid restrictions. (WEIGHT IS MOST ACCURATE MEASUREMENT OF FLUID!!) Na+ restriction.

Left-Sided Failure: Blood backs up the left ventricle and atrium and into the pulmonary veins, increasing the pressure in the veins forcing blood into the lungs.

S/S:
*Dyspnea, orthopnea (Night-proxysmal nocturnal dyspnea)
*Cough
*Fatigue
*restlessness & anxiety

Decreased cardiac output, poor tissue perfusion leads to cardiac hypertrophy (gets larger)


Right Sided Failure:
*Primarily caused by left sided failure

S/S:
*Fluid and pressure in venous system
*Edema (pitting)
*Hepatomegaly
*Anorexia
*Nocturia
*Weakness
*Ascites
*Distended jugular veins

More of a systemic affect.

Diagnostic Studies:
*Echocardiogram
*Angiogram
*MUGA Scan-Evaluates heart size, ventricular wall motion, ejection fraction
*Blood Tests
*Chest X-Ray
*Labs--Electrolyte imbalances from diuretics
Watch for anemia

Assessment:
Changes in LOC, restlessness, confusion
Labored resepiration, adventitous sounds
JVD-distention?
Urinary output
Periph. cap refill, periph pulses





Video found here.




Video found here.

Antiplatelets

Prevent platelet adhesion-inhibit platelet aggregation. Very beneficial in the prevention of heart attacks, TIAs and strokes.

Acetylsalicylic Acid (ASA)-Aspirin

Contradictions:
*GI Bleeding
*Long term use can alter liver, renal and clotting function (GET LABS FIRST TO MONITOR!!)

Do not give on an empty stomach
Check bleeding tendencies

Adverse Effects:
*Salicylate Poisoning -->See slide
*GI bleeding
*Bronchoconstriction

Plavix

INR

Anticoagulants

Prevent the formation of clots. Can be used prophylactically (preventatively).

ALWAYS LOOK AT LAB VALUES!

Coumadin (Warfarin)-used for continued treatment.
*Only oral anticoagulant
*Monitor-->Prothrombin time (PT) and International Normalized Ratio (INR)

-Well absorbed in the GI tract subcutaneously
-Does not cross placenta or breast milk
-Hypersensitivity and bleeding are contradictions
-CONTRADICTIONS with renal/hepatic, retinopathy, ulcers, spinal cord or brain injuries, pregnancy (don't want pt. to bleed out!!)
-Antecdote is Vitamin K

BLEEDING SIDE EFFECT
Watch for bleeding, petichiae
AVOID high Vitamin K foods! (They enhance clotting)
Injection is given in 5/8 in. 26-28 guage needle
May be used until oral therapy is adequate.

May be used with heparin until it is adequate alone.



Heparin-used for acute treatment.
*Sub Q or IV
*Monitor -->Partial Thromboplastin Time (PTT) OR Activated Partial Thromboplastin Time (APTT)

-Well absorbed in the GI tract subcutaneously
-Does not cross placenta or breast milk
-Hypersensitivity and bleeding are contradictions
-CONTRADICTIONS with renal/hepatic, retinopathy, ulcers, spinal cord or brain injuries, pregnancy (don't want pt. to bleed out!!)
-Antecdote is protaminie sulfate

BLEEDING SIDE EFFECT
Watch for bleeding, petichiae
AVOID high Vitamin K foods! (They enhance clotting)
Injection is given in 5/8 in. 26-28 guage needle
May be used until oral therapy is adequate.

DVT (Deep Vein Thrombosis)

Disorder involving a thrombus (blood clot) in a deep vein, most commonly the iliac and femoral veins.

Patho-Localized platelet aggregation and fibrin entrap RBCs, WBCs and more platelets to form a thrombus (frequently in the valve cusps of veins where venous stasis occurs). May lead to an emboli.


Video found here.




Video found here.

Assessment:

Subjective Data:
*Pain/Tenderness in calf or groin

Objective Data:
*Warmth
*Edema
*Extremities measurements
*+ Homan's -->controversial

Diagnosic Studies: Ultrasound, D-dimer, CT


Nursing Diagnosis:
Ineffective peripheral tissue perfusion

Goals:
*PREVENTION!!!
*Adequate blood flow to extremities
*No pulmonary embolism (PE)

Interventions:
*Affected leg circumference
*Doppler
*Bed Rest (Do NOT massage extremity)
*Elevate Leg
*Warm moist packs
*Compression stockings
*Anticoagulants - COUMADIN & HEPARIN
*DO NOT WALK ON LEG!!
*Monitor for S/S of PE (SOB, chest pain)

Patient Teaching:
*Need for frequent f/u with blood tests
*Side effects of drugs-blood in urine or stool, unusual bleeding, severe h/a or stomach pain, weakness, dizziness, change in LOC, cold blue or painful feet.
*Avoid trauma or injury that may cause bleeding
*Avoid NSAIDS and alcohol
*Avoid Vitamin K
*Contact EMS immediately if CP, SOB, palpitations or feeling of passing out is experienced.

Cardiac Assessment/Flow of the Heart

Preload-the volume of blood in the ventricles at the end of diastole.
Afterload-Resistance left ventricle must overcome to circulate blood.

SYSTOLE=contraction
DIASTOLE=relaxation

Cardiac Assessment:
Subjective Data:
*Past health Hx
*Medications (current and past)
*Sx and other Tx

Objective Data:
*V/S
-orthostatic/postural BPs and HRs should be monitored while pt. is lying, sitting and standing. Normally there is a reduction of up to 15 mm HG in the SBP and 3-5 mm HG in the DBP from the lying to standing position. HR should not increase more than 20 bpm from supine to standing position.
*Auscultation
-PMI/Apical pulse (Point of maximal impulse)-->when PMI is below the fifth ICS and left of the midclavicular line, the heart may be enlarged.
*Peripheral pulses

SEE p.749 for ABNORMALITIES!!

Terms:
Bruit-turbulent blood flow in an artery
Thrill-Vibration
Heaves-lifts (almost visualized pulses)/Pulsation

Pg. 740 Lewis


I found this video here.

Preload-the volume of blood in the ventricles at the end of diastole.
Afterload-Resistance left ventricle must overcome to circulate blood.

SYSTOLE=contraction
DIASTOLE=relaxation

Hypertension Treatment Drugs

Diuretics
*Thiazide
*Loop
*K+ Sparing

Vasodilators

Ace Inhibitors

Check BP, HR, RR and pulse ox

SE: Impotence, pulmonary issues, hypotension

Contradictions: Renal and hepatic, viagra and hypotension
CAN BE TOXIC IF PT HAS HYPOTENSION



I found this video Here.