ATI notes - Summary Care Adult Acute Ill Ii/Honors PDF

Preview

Summary

ATI notes....

Description

ATI notes

-

Chapter 1 Non-modifiable risk factors- age, gender, developmental level, gender. Modifiable rf- smoking, nutrition, exercise, health education, sexual practices.

Chapter 2 -

-

-

Triaging- triage based on acuity. Either emergent, urgent, and nonurgent (can wait for help.) Mass casualty event- will tag different patients as class 1, class 2, class 3, or class 4. They all have colors. 1 is red- immediate threat to life (respiratory, cadio, etc.) 2 is yellow- major injuries that require immediate treatment but aren’t life threatening. Class 3 is greenminor injury that does not require immediate attention (abrasion, laceration.) Class 4 is black- basically likely to die even if you give them medical attention (penetrating head wound.) Priorities- airway, breathing, circulation. Secure the airway with head tilt chin lift. D and E are disability (LOC) and E is exposure (remove wet clothing, provide blankets, warm IV fluids, etc.) If a patient has had poisoning- activated charcoal, lavage, or whole bowel irrigation. Rapid response- will do that when a patient is rapidly declining. Chapter 3- neurological diagnostic procedures

-

-

-

Cerebral angiogram- allows doctor to insert catheter in groin or neck and visualize blood clots in the brain. Will be using contrast dye- check if patient is pregnant, if allergic to shellfish or iodine, check renal function (BUN and Creatinine) to see if they can clear the dye. Also need to know if patient is on anticoagulant. No eating or drinking 4-6 hours before procedure. CT scan- same watch out for contrast dye. EEG- primarily used to detect seizures, can also test for sleep disorders or behavioral changes. Do not have to fast, do want to wash hair prior. Want patient to be sleep deprived!!!! Can trigger abnormal brain activity. May also expose patient to bright lights or ask them to hyperventilate. Usually takes about an hour. Glascow Coma scale- highest is a 15, anything less than 8 is associated with severe head injury and coma. Eye opening (4,) verbal response (5,) and motor response (6.)

-

-

-

-

-

-

-

-

-

-

Decorticate- adduction of arms, flexion of elbows and wrist toward core. Decerebrate- worse. Extension of elbows and wrist out. If someone has low GCS- will place ICP monitor in OR. Very high infection risk. Symptoms of increased ICP- early includes irritability. Severe headache, decreased LOC, weird pupil response, Cheyne stokes breathing, posturing. Normal ICP- Between 10 and 15. Lumbar puncture- can test for meningitis, syphilis, MS. Patient will empty bladder, lay on side in cannonball position, local anesthetic, insert needle. Afterwards, monitor puncture site and lay flat for hours. MRI- sometimes requires contrast dye, sometimes does not. Remove jewelry, check for claustrophobia, check for pacemaker/aneurism clips/etc, give patient ear clips. PET scan- checks for tumor activity/response to treatment. X-ray- can be used to see fractures on skull, etc. Chapter 4- pain management Categories of pain- acute- temporary and usually resolves. Chronicusually goes past 6 months and is associated with depression, fatigue, impaired functioning. Nociceptive pain- damage/inflammation of tissue (throbbing/aching.) Somatic is in bones, joints, muscle, etc. Visceral is in internal organs. Cutaneous- skin or subcutaneous tissue. Neuropathic pain- diabetic neuropathy, phantom limb pain (shooting, burning, or pins and needles. Usually treated with muscle relaxers antidepressants, or antispasmodic agents. Assessing pain- location, quality (dull, sharp, throbbing, etc,) intensity (numeric,) timing, setting (how affects daily life,) associated symptoms, aggravating versus relieving symptoms. Non-pharmacological- TENS- transcutaneous electrical nerve stimulation. Pharmacological- if pain level is mild or medium/moderate- likely treat with NSAIDs- need to watch amount of Tylenol person receives in a day- if over 4 grams have a risk for liver damage or toxicity. Salicylates (aspirin)- if complaining of GI upset, tinnitus, vertigo- can be a side effect. Opioids- for moderate to severe pain. Morphine, dilauded, fentanyl. Fentanyl is more for cancer pain. Want to administer these meds on a schedule, not PRN basis. Want to manage pain before it’s too severe. Side effects- constipation, orthohypo, urinary retention, N/V, sedation, respiratory depression, have order for NALAXONE. Chapter 5- Meningitis

-

-

-

-

-

-

Meningitis- inflammation of the meninges (membranes that surround brain and spinal cord.) Viral is more common. Bacterial is more dangerous and contagious. Prevention- HIB vaccine, MCV4 vaccine. Teenagers usually get it before college because of crowded living conditions. Symptoms- headache, neck stiffness, photophobia, fever, chills, N/V, altered LOC, positive Kernig sign and Brudsinzkis sign, tachy, seizures, rash, irritability with increased ICP. Budzinski’s sign- lay patient flat and pull up on their neck, will flex in knees. Remember by “bro that hurts my neck when you pull on it.” Kernig’s- laying down, knee is flexed, try to straighten leg. “Kernig starts with K, knee starts with K.” Diagnostics- get CSF sample. Bacterial will be cloudy, viral will be clear. Either way will see increased WBC and elevated protein. If bacterial- may see decreased glucose value. If you suspect patient has meningitis- DROPLET PRECAUTIONS. If viral can have standard precautions 24 hrs after antibiotics have been started. Maintain quiet environment, dim lights, minimize ICP with HOB elevated 30 degrees, no straining, seizure precautions. Meds- antibiotic, antiseizure, steroids, pain meds. Complications- increased ICP (irritability,) SIADH (concentrated urine, dilute blood,) septic emboli. Chapter 6- seizures and epilepsy Seizure- premature firing of neurons in the brain. Epilepsy- reoccurring abnormal brain electrical activity. RF- genetic, fever (kids under 2,) head trauma, cerebral edema, infection, hypoglycemia, hyponatremia, exposure to toxins, brain tumor, hypoxia, drug or alcohol withdrawal, fluid/electrolyte imbalances. Triggers- stress, fatigue, caffeine, flashing lights. Generalized- tonic-clonic. Sometimes begins with an aura. After aura will have tonic episode- stiffening of muscles and loss of consciousness. After is clonic episode- 1-2 minutes of jerky moves of extremities. After is post-ictal phase including sleepiness and confusion. Can only have tonic, or clonic seizure. Absent seizure- common in school-aged children, looks like they’re spacing out. Smacking of lips, eye fluttering, picking at clothes. Myoclonic- brief. Atonic- lose muscle tone, often associated with falling. EEG- may identify reason of seizure MRI or CT Sample of CSF fluid to check for infection. Lower patient to the ground, on side, loosen clothing, do not restrain, nothing in mouth, onset and duration. Keep in side lying after seizure,

-

-

-

-

-

-

-

check VS, neuro checks, re orient, seizure precautions, determine trigger. Meds- AED. Phenytoin- will have blood tests. Causes hyperplasia of the gums. Decreases oral contraceptives and Coumadin/warfarin. Surgical- vagal nerve stimulator. Hold magnet over if feeling aura of seizure. Avoid microwaves and MRI’s. May have surgical removal of brain tissue causing seizure. Status epilepticus- prolonged seizure over at least 30 mins. Protect airway, IV access, EKG, pulse ox monitoring. Might give valium or Ativan/continuous phenytoin. Chapter 7- Parkinsons A disease that mostly affects motor function. Balance between dopamine and acetylcholine in body- in Parkinson’s acetylcholine is too high and dopamine is too low. Substantia nigra degenerates. High acetylcholine overstimulates the basal ganglia. Symptoms- tremor, muscle rigidity, bradykinesia, postural instability, slow/shuffling gait, mask expression, difficulty chewing and swallowing, drooling, ADL difficulty, eventually mood swings/cognitive impairment. No sure diagnostic- diagnosed by symptoms. Nurs considerations- monitor swallowing, thicken liquids, ROM exercises, yoga, slow down walking speed, speak slowly, may need alternate forms of communication. Meds- Levodopa. Often combined with carvodopa and that is called sinemet. Levodopa increases dopamine, carvodopa is added for less side effects. Sometimes patient has to take medication holiday where they stop taking it then start it up again. Anticholindergics- can decrease acetylcholine. Be aware of opposite SLUDD effects. Complications- aspiration pneumonia. Someone should be in attendance when patient is eating, upright position, and suction available. Chapter 8- Alzheimer’s Disease Responsible for about 60% of all dementia cases. Usually occurs after 65. Memory loss, personality changes, problems with judgement. RF- exposure to toxic waste, herpes virus, head injury. Pages 82 and 83 go through Alzheimer’s stages. Stage 1- no impairment. Stage 2- mild cognitive decline- don’t really see memory problems. Stage 4- also mild cognitive decline but DO have short term memory loss. Stage 4- moderate cognitive decline- personality changes and moderate memory loss. Stage 5- patient will likely need help with ADL’s. Stage 6- severe- likely frequent fecal and urinary incontinence. Stage 7- lose ability to speak and move- no eating without assistance, speech unrecognizable.

-

-

-

-

Diagnosis- doctor may try to run tests to rule out other causes with MRI and CAT scan. Until patient dies its hard to know if it was alzheimers. Nurs interventions- re-orient, have calendar, short/simple directions, reminisce, avoid over-stimulation, stick to routine with toileting schedule. Home-safety- do not want scatter rugs, install door locks, good lighting, colored tape on edge of stairs, remove clutter, put mattress on floor later on. Meds- Donepezil- increases acetylcholine and helps improve cognition, behavior, and function. Brain tumors- if patient has it. Hypothalamus can become damaged which can lead to SIADH and DI. Chapter 9- irrelevant

-

-

-

-

-

-

Chapter 10- MS, ALS, Myasthenia’s Gravis MS- autoimmune disorder that results in plaque in the white matter of the CNS. Plaque damages the myelin sheath which interfered with impulse transition with CNS and the rest of the body. No cure. Affects people between the ages of 20-40, mostly women. Has periods of relapsing and remitting. Things can cause relapse- cold environment, viruses, physical injury, stress, pregnancy, fatigue, hot baths or showers. Symptoms- diplopia, tinnitus, dysphagia, slurred nasal speech, muscle spasms and weakness, nystagmus, bowel and urinary dysfunction, impaired judgement, memory loss, sexual dysfunction. Diagnosis- MRI will show plaques in the brain and spine. Nurs care- meds include cyclosporine (immunosuppressive,) prednisone (decreases inflammation,) muscle relaxerdantrolene/baclofen. ALS- degenerative disorder of upper and lower motor neurons. Progressive paralysis that starts in extremity, moves to center of body, eventually affects resp muscles which causes resp failure then death usually within 5 years. Cause is unknown. No cure. Symptoms- muscle weakness, muscle atrophy, difficulty swallowing, RESP PROBLEMS- ATI will talk about patent airway and suctioning when needed. Med- riluzole- helps add months to life of patient. Glutamate antagonist which can help the deterioration of motor neurons. Complications- pneumonia, resp failure due to weakness of resp muscles. Myasthenia’s gravis- MG. Autoimmune disorder that causes muscle weakness. Antibodies prevent uptake of acetylcholine at neuromuscular junction. Periods of exacerbation/remission.

-

-

-

-

-

-

-

-

-

-

-

Exacerbation causes similar to MS. Symptoms- hyperplasia of the thymus gland. Muscle weakness, diplopia, difficulty swallowing, bowel/bladder problems, resp problems. UNIQUE is drooping eyelids (Ptosis.) Diagnosis- symptoms similar to cholinergic crisis. To determine thisgive edrophonium which increases acetylcholine and if symptoms improve they have MG, if they worsen it was probably cholinergic crisis. Have atropine on hand its antidote!!!!!!!! Patient care- ABC’s, patent airway, O2, intubation, suctioning nearby, rest periods, sit upright, thickeners to food, eye care (lubricating eye drops,) may need to tape eye shut. Meds- Pyridostigmine and Neostigmine. Can help improve muscle strength. Inhibits breakdown of acetylcholine. Immunosuppresants may be used. Therapeutic procedure- plasmaphoresis- removes antibodies to help improve symptoms. Thymectomy- remove thymus gland to help allow patient go into remission. Chapter 11- headaches Can be triggered by allergens, odors, bright lights, fatigue, anxiety, stress, hormone changes (menstrual cycles,) foods with tyramine, MSG, nitrates, milk products. Migraines- photophobia, phonophobia (sensitivity to loud noises,) nausea, vomiting, unilateral pain behind ear or eye. Family history is strong RF. Typically last between 4-72 hrs during periods of stress or hormonal cycle. Sometimes people have aura- visual disturbance, tingling of mouth. Interventions- cool, dark, quiet environment. Elevate HOB 30 degrees. Can try NSAID’s/antiemetic for mild. Severe headachesumatriptan that causes vasoconstriction. Ergotamine also vasoconstricts and reduced inflammation. Reduce intake of tyramine, MSG, etc. Cluster headaches- brief episodes of intense, unilateral, nonthrobbing pain that happens between 30 min-2 hours. Daily at the same time for 4-12 weeks in the spring and fall. No aura. Less common than migraines. Men between 20-50. Other symptoms- tearing of eye, runny nose, nasal congestion, facial sweating, ptsosis. Meds are basically the same as migraines. Chapter 12- disorders of the eye Macular degeneration- causes loss of eyesight in people over 60. Can be dry or wet. Symptoms- blurred vision, loss of central vision, can cause blindness. No cure. Nurse care- foods high in antioxidants, keratin, B12, Need help with transportation, etc.

-

-

-

-

-

-

-

-

Cataracts- opacity in the lens of the eye that impairs vision. Diplopia, blurred vision, glare/light sensitivity, halo around lights. Progressive and painless. Won’t have red reflex. Large print books, magnifying lens, Cataract surgery- remove lens of eye and add replacement lens. After surgery- wear sunglasses, report signs of infection (yellow/green discharge,) avoid activites that increase intraocular pressure/ IOP (do not bend at waist, avoid sneezing, straining, do not hyperflex head, avoid tilting head back, no housekeeping, no sports, no driving.) Best vision won’t be attained for 4-6 weeks. Glaucoma- either functional or structural issue with optic nerve. Openangle or closed-angle. Open-angle is like a kitchen sink with partial blockage. Closed is complete blockage and IOP rises suddenly. Leading cause of blindness. Open angle- mild eye pain and loss of peripheral vision. Elevated IOP. Normal is between 10 and 21. Closed- severe pain, nausea, photophobia, rapid elevated IOP. Haloes, blurred vision. Tonometry- measures IOP Interventions- prescribed eye meds every 12 hours. Wait 10-15 mins in between eye drops. Don’t touch eye. Put pressure on inner corner of eye. Pylocarpine, beta-blockers (tymolol,) mannitol (decreases IOP.) Acetazolamide. Encourage to limit activites that increase IOP. Chapter 13- ear disorders Otitis media- middle ear infection. RF- recurrent colds, resp infections, enlarged adenoids. Symptoms- red and inflamed ear canals, inflamed/bulging tympatic membrane. May see fluid or bubbles behind tympatic membrane. Meniere’s disease- tinnitus, unilateral hearing loss, vertigo. Inner ear disease. RF for inner ear disease- bacterial infection, damage due to ototoxic medication. Symptoms- ringing, alteration in balance, vomiting. When looking in ear- for adults pull up and back and for kids down and back. Should see light reflects at 5 o clock in right ear and 7 o clock in left ear. Ototoxic meds- gentamicin, metronidazole, furosemide, NSAIDs, chemotherapy agents. Meds for ear problems- antihistamines or anticholinergics. Meclizine is antihistamine and anticholinergic used to treat vertigo. Droperidolfor nausea and vomiting- can cause postural hypotension. Benadryl/diphenhydramine for vertigo and nausea- watch for urinary retention and sedation. Anticholinergic- cant pee can’t see can’t spit can’t shit. Nurs teaching- avoid caffeine and alcohol, space intake of fluids, decrease salt intake.

-

Surgical- patient could have stapendectomy, cochlear implant, labrothectomy. Chapter 14- Head injury

-

If someone has sustained a head injury- likely at risk for CSI. Stabilize cervical spine until injury has been ruled out. Assess for increased ICP- headache, decreased LOC, irritability (one of the first signs,) pupils, Cheyne stokes breathing. Cushing’s reflex- severe hypertension, bradycardia, widened PP. Stain- halo blood surrounded by yellow which is CSF. ABC’s for priority- airway, then minimize ICP, keep CO2 down to keep ICP down- may need to hyperventilate. Avoid suctioning!!!!! Meds for head injury- mannitol. Can cause electrolyte imbalances. Pentobarbitol- can put the patient into a coma to decrease metabolic demands of the body. PhenytoinSurgical- craniotomy- if subratentoral surgery- HOB at least 30 degrees. If infratentorial craniotomy- flat on side for 24-48 hrs. Complications- brain herniation- fixed dilated pupils, irregular resps, abnormal posturing. DI or SIADH due to pressure on hypothalamus. Cerebral salt wasting- can cause hyponatremia and hypovolemia.

-

-

-

-

-

Chapter 15- strokes/CVA Hemorrhaging- ruptured artery or aneurism Thrombotic- blood clot in cerebral artery. Embolic- blot clot that travels from other part of body to cerebral artery. RF- HTN, DM, smoking, obesity, Visual disturbances, slurred speech, dizziness, facial drooping, weak extremity. Ati likes to ask about differences between stroke on left and right side. Left sided stroke- language, math, analytical thinking, expressive and receptive aphasia, reading/writing difficulty, right extremity hemiplegia, hemionopsia. Right sided- visual/special awareness, poor impulse control and judgment, one sided neglect, left hemiplegia, visual changes. Diagnosis- MRI, CT, CAT scan. Monitor BP closely- systolic above 180 and diastolic above 110- can indicate ischemic stroke. SWALLOWING issues. Check for gag reflex, have suction equipment, flex neck forward. Reposition patient frequently- at risk for pressure ulcers. ATI- hemonymos hemionopsia- USE SCANNING TECHNIQUE. Meds- thrombolytic- anything that ends in plase. Give within 4.5 hours of initial symptoms of stroke.

-

Surgical intervention- carotid artery angioplasty with stenting. Complications- dysphasia, aspiration.

Practice quiz notes Cardio - Bradydysrhythmia can cause confusion. - Pericarditis- causes friction rub. - Endocarditis- valvular disease can result. - PAD= dependent rubor. Hair loss in legs -

Endocrine - Take metformin after a meal - High blood pressure can potentiate thyroid storm - Hoemone replacement- calf pain, numbness, and headache

Stroke - Left hemisphere- expressive aphasia...