Understanding Traumatic Brain Injury: Types, Effects, and Management

NRNP Finals 6560 coup-contrecoup injury - ANS Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds. Scalp laceration: what, effect, management - ANS Primary head injury profuse bleeding - signs of hypovolemia Apply direct pressure Suture/ staple laceration Lidocaine 1% with epi to control bleeding, not close to nose/ ears Skull fracture: types, effect, management - ANS Primary head injury Simple: no displacement of bone. Observe and protect spine Depressed: bone fragment depressing thickness of scull Surgery for debridement. Give tetanus and seizure precautions Basilar: fracture at floor of skull Raccoon eye - periorbital bruising battle's sign: mastoid bruising otorrhea/ rhinorrhea - halo sign: do not obstruct flow Give Ab's Oral intubation and oral gastric instead of nasal Brain injury: types, effect, management - ANS Primary head injury Concussion: reversible change in brain functioning loss of consciousness, amnesia Do not give opioids, admit for unconsciousness greater than 2min Contusion: bruising to surface of brain with edema Frontal and temporal region Brainstem contusion: posturing, variable temp, variable vital signs

N/V, dizziness, visual changes seizure precautions Hematoma - neuro: types, effect, management - ANS Epidural hematoma: commonly temporal/ parietal region with skull fracture, causing bleeding into epidural space Loss of consciousness Rapid deterioration: obtunded, contralateral hemiparesis, ipsilateral pupil dilation CT scan (non contrast) Treatment based on Brain trauma foundation. Surgical if greater than 30cm Subdural hematoma most common type of intracranial bleed Acute (hours): drowsy, agitated, confused, headache, pupil dilation, CT scan (noncontrast) surgery for 10mm thickness or 5mm midline shift or for worsening GCS Chronic (days): headache, memory loss, incontinence CT scan (noncontrast) Surgery: burr holes/ crani Cerebral edema/ ICP elevated/ herniation: symptoms, management - ANS decreased level of consciousness Blown pupil Cushing triad: HTN (widening pulse pressure), decreased resp rate, bradycardia (means increased intracranial pressure) Neuro exam components - ANS AVPU: awake, response to verbal stimuli, painful stimuli, unresponsive GCS: 8 or below is comatose Posturing: decorticate = arms, legs in decerebrate = arms, legs out Electrolyte imbalances in brain injury - ANS Hyponatremia: SIADH and cerebral salt wasting

Hypernatremia: DI (give mannitol) Management of traumatic brain injury - ANS - Consult neurosurgery - Limit secondary injury - Prevent hypotension (syst 90) and hypoxemia (PaO2 60). May give blood to improve tissue perfusion. - Treat cerebral edema: elevate bed, sedate, paralyse, mannitol, hyperventilation (PaCO2 25-30), during first 24hrs. - sedation and analgesia: opioids to reduce ICP (Fentanyl) with propofol. Could give Nimbex or Vec. to help oxygenate/ ventilate - steroids: avoid - Give mannitol or hypertonic saline for herniation: bolus then gtt. monitor serum osmolality, sodium, and bp. - Seizure precautions: give phenytoin or keppra - DVT prophylaxis: stockings, LMWH - head injury means spine injury until proven otherwise - hypothermia: can control ICP (89 - 91F) - decompressive crani: ICP refractory to tx - brain O2 monitoring (jugular vein O2 sats) ICP monitoring - ANS For: GCS 3-8 with abnormal CT and comatose pt's with normal CT and older than 40, posturing, hypotension. Normal value: 5-10 mmHg Recommend initiating treatment if ICP > 20 mmHG. Can calculate CPP (CPP = MAP - ICP). Should be 60 Brain death criteria - ANS Must have all: No spontaneous movement Absence brain stem reflexes (fixed/ dilated pupils, no corneal reflexes, absent doll's eyes, absent gag, absent vestibular response) Absence breathing drive/ apnea can't be declared brain dead when: hypothermia, drug intoxication, severe electrolyte/ acid-base imbalance

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

EEG, CTA of brain, Cerebral angiography, transcranial doppler Spinal cord trauma: cause and who - ANS - MVA, falls, acts of violence, sports, wounds - Rapid acceleration/ deceleration causes hyperextension (fall, rear-end collision)(central cord syndrome), hyperflexion (bilateral facet dislocation), vertical column loading (compression and then shattering from falls/ dive lands on butt, at C1 from diving), whiplash - Distraction injury: from hanging - penetrating trauma: from wound - pathologic fractures (osteoporosis/ cancer) mainly cervical spine. High mortality. More common in men more common in young than old Fractures and vertebrae - ANS Cervical: C1-C7. Flexible and small diameter so many fractures Thoracic (T1-T12): connected to ribs. Not common in fractures Lumbar: L1-L5: Very mobile, requires great force to fracture Sacral Spinal cord trauma assessment - ANS - History: mechanism of injury, pt's complaints, pre-hospital tx - Physical assessment: treat airway, breathing, circulation (ABC) first. Pulm complication common in quadriplegia. Assess respiratory status: injury above C3 is resp arrest. C5 - C6 spares diaphragm so breathing exists. - grade strengthening (0= no muscle contraction, 5 = full strength) - complete lesion: pt lacks all function below level of spinal cord damage. Poor prognosis. - incomplete lesion: parts of spinal cord intact - sensory function: start at no feeling then go to feeling - evaluate back (log-roll)

Motor assessment in spinal cord trauma - ANS If unable to do, # above: Deltoids (C4): shrug shoulder Biceps (C5): flex arm and push arms away Wrist (C6): try to straighten wrist while pt tries to flex Triceps (C7): extend arm and try to bend while pt prevents that Intrinsic (C8): fan fingers and push together Hip flexion (L2 - L4): bend knee and apply pressure Knee extension (L2-L4): extend knee with hip/ knee flexed key signs of spinal cord injury - various levels - ANS C2-C3: resp paralysis, flaccid paralysis, deep tendon reflexes loss C5-C6: diaphragmatic brething, paralysis of intercostal muscles, quadriplegia, anaesthesie below clavicle, areflexia, fecal/ urinary retention, priaprism T12-L1: paraplegia, anesthesia legs, areflexia legs, fecal/ urinary retention, priaprism L1-L5: flaccid paralysis, ankle/ plantar areflexia Multisystem impact of spinal cord injury - ANS Cardiovascular: - hypotension/ spinal shock. Fluid resuscitation (LR) - bradycardia; oxygenate well, normothermia, atropine - vasovagal reflex: limit suctioning length - Poikilothermy - venous thrombosis: dvt prophylaxis - orthostatic hypotension GI: - abdominal injuries: assess for abd distention - curling's ulcer: stress ulcer. Give ranitidine - gastric atony and ileus: NG to LIS - loss of bowel function: initiate bowel program GU:

- autonomic dysreflexia: HTN crisis from distended bladder or other noxious stimulu. Decompress bladder. - UTI Musculoskeletal: - paralysis - wounds Psychological: - ineffective coping, powerlessness, denial/ anger/ depression. Be honest with positivity, include pt, interdisciplinary approach Spinal cord lesions/ syndrome - ANS Anterior cord syndrome: weakness/ paralysis with loss of sense of pain and temp Posterior cord syndrome: can't feel touch and vibration Central cord syndrome: greater loss in upper extremities than lower Brown sequard syndrome: one side of spinal cord is damaghed by stab/ gun wound. Ipsilateral motor loss and contralateral loss of pain and temp sense. Extremities that can move have no feeling and that have feeling can not move. Spinal cord injury: diagnostics - ANS Cervical vertrebrea: lateral xr, then AP (swimmer view) Thoracic vertebrae: lateral and AP xr, view all 12 Lumbar: lateral and AP, view all 5 CT to check for bony fragments Films in flexion. extension to check for fractures Myelogram: detects compression of cord by herniated disks, bone or foreign matter

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

MRI: cord impingement, hematoma, infarct, contusion, hemorrhage. Spinal cord management - ANS - Consult neuro - Airway maintenance (do not hyperextend neck when intubating) - immobilization (cervical collar/ spine board) - intravascular fluid (neurogenic shock: warm, dry, brady) - monitor bp (avoid hypotension: keep MAP 85) - Foley - NG - AB for penetrating injury - room temp - good skin care - fixation of spine - fusion: attaching injured vertebrae Key features of dementia - ANS - General decrease in level of cognition - thinking, memory, reasoning - Behavioral disturbance - Interference with daily function and independence Not a disease, but group of symptoms by various diseases Alzheimer's disease - ANS most common form of dementia Neuritic plaques, neurofibrillary tangles, degeneration of cholinergic neurons causing irreversible neuronal damage. B-amyloid present in high levels. Effect: cerebral atrophy. Causes of brain degeneration - ANS Alzheimer's Parkinson's Huntington's Vascular: stroke, arteritis Infectious: HIV, Syphilis, Meningitis, Encephalitis CNS/ toxic: drug overdose Nutritional deficiency: Vit B12, folate deficiency Chronic seizures Lewy body dementia

symptoms of dementia - ANS - Slow onset - memory loss and confusion - problems with language - impaired abstract reasoning - aphasia, apraxia, agnosia - disorientation - poor judgement - emotional problems - sleeplessness Dementia labs/ diagnostics - ANS - History: family/ spouse report - Physical: neuro, cognitive examz: Mini mental State exam (score 23 or less is cognitive impairment), document in 3-6mo intervals - Labs: glucose, electrolytes, magnesium, calcium, liver tests, BUN/ creat, thyroid, Vit B12, HIV, CBC, ABG, cultures, drug screen - CT head/ MRI: for tumor/ infarction - PET scan: differentiate dementia type - EEG - Lumbar: rule out meningitis, neurosyphilis - XR chest: rule out CHF, COPD - ECG - Identify treatable cause DSM-V criteria for dementia - ANS 1. Memory impaired 2. At least two of these: aphasia, apraxia, agnosia, disturbance in executive functioning 3. Disturbance of one or two of these disrupts functioning 4. Disturbance not only during delirium Dementia management - ANS - supportive: living situation - treat underlying illness - stop nonessential meds - maintain nutrition - avoid restraints, except for safety - address safety issues

- cholinesterase inhibitors can improve symptoms mildly (because of cholinergic deficiency) - Alzheimer's related: meds very mild and temporary effect Medication for dementia - ANS Mild to moderate Alzheimer's: - Donezepil 5mg, then 10mg after 4-6 wks. Can cause syncope, brady, AV-block, N/V, weightloss - Rivastigmine. With food, can cause hypotension, syncope - Galantimine, 4mg for 4 wks, then 8mg 4 wks, then 12mg. Avoid in renal and liver failure Moderate to severe dementia: - Memantine (N-methyl-d-aspartate rec anatgonist), prevents progression. May be paired with donezepil. May cause Stevens-Johnson's For aggression: - Olanzapine (Zyprexa), Quetiapine (Seroquel), Risperidone, Ziprasidone. Short term. May cause tardive dyskinesia - Haldol may help too for unmanageable aggression. - Benzo's: Clonazepam. May cause paradoxical aggression. Lorazepam For emotional lability: - Imipramine - Setraline - Zoloft - Citalopram multiple sclerosis - ANS Disease with myelin sheath destruction causing disruptions in nerve impulse conduction. Acquired, immune-mediated. Relapses/ attacks/ exacerbations and remissions Etiology of MS - ANS More women than men Caucasians, more northern European Early onset, 20-40ies

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Measles, Herpes, Chlamydia, Epstein-Barr Classification of MS - ANS Relapsing - Remitting: Clear/ defined episodes of relapse and recovery. No progression between episodes and return to baseline. Most often initial presentation. Secondary progressive: As Relapsing- Remitting, but then progression between episodes. No return to baseline. Primary progressive: Continued disease progression. Minor improvements. Usually after 40yrs. Progressive relapsing. Progressive disease with relapses, and progression in between. Malignant MS: rapid onset, rapid deterioration Benign MS: No deterioration after 10 yrs MS symptoms - ANS Subjective: - Motor weakness, stiffness - Numbness, tingling, burning, pain - double vision, dysarthria, dysphasia, vertigo (brain stem) - visual deficits - gait ataxia, tremor, uncoordinated movements (cerebellum) - cognitive dysfunction: memory, processing - fatigue (common!) - sleep disorder - bladder, bowel dysfunction - seizures Objective: - decreased sensation of pinprick, vibratory, temp - Reflex changes: abnormal deep tendon, pos babinski, pos hoffman's - brain stem changes: nystagmus, hearing loss, tinnitus

- Cerebellar: ataxia, tremor, poor coordination - visual field changes - frontal lobe: cognitive dysfunction, emotional changes MS diagnostics - ANS - neuro exam - MRI (white matter lesions, lesions spinal cord, T1 and T2 lesions) (diagnostic!) - CSF analysis: elevated igG and oligoclonal bands in CSF but not serum MS management - ANS - consult neuro - no intervention for mild attack - Acute intervention for relapse with Glucocorticoid (po or iv) - symptom management meds - disease modifying meds: to reduce relapse, delay disability, and decrease MRI lesions: - Fingolimod. For relapsing. May cause brady, AV-block, HTN, diarrhea - Betaseron. For relapsing. May cause depression/ suicidality - Avonex. For relapsing. May cause flu-like symptoms - Rebof. For relapsing. May cause flu like symptoms - Glatiramer acetate. For Relapsing/ remitting. - Mitoxantrone. For sec progressive, progressive, or worsening relapsing/ remitting. Parkinson's disease: what, etiology - ANS Neurodegenerative disorder caused by depletion of dopamine-producing cells causing resting tremor, rigidity, slowness of movement. Age onset: 60 more men than women caucasians Environmental (metals such as copper) and genetic factors. Gene: PARK1 Symptoms and diagnostics of Parkinson's - ANS - Classic triad: resting tremors, rigidity, bradykinesia - Motor symptoms: postural instability can cause falls - Classic gait: diminshed arm swing, shuffling steps, bent forward, frozen gait - neuropsychiatric: depression, dementia, anxiety, psychosis, sleep disruption

- autonomic dysfunction: urinary incontinence, sexual dysfunction, constipation, impaired thermoregulation - Craniofacial: masked face/ expressionless, dysphagia, impaired sense of smell, drooling - H&P - CT and MRI to assess for differential Parkinson's treatment - ANS - consult neuro - Pharm to relieve symptoms and improve functioning: Carbidopa-levodopa standard treatment. - Can on/off phenomona with working/ not working of meds. Add catechol-O-methyltransferase - Adequate nutrition - Exercise Dopaminergic agents and Parkinson's - ANS Carbidopa-levodopa. Most effective drug. Use with rasagiline. May cause on/ off phenomena, dyskinesia, confusion, headache, hallucinatinos. Dopamine agonists and Parkinson's - ANS Pramipexole and Ropinirole May reduce risk for complications and alleviate symptoms. Mono or dual theraoy with levodopa. May cause N/V, dyskinesia, confusion. MAO-B inhibitors and Parkinson's - ANS Rasagiline Adjunct therapy May cause serotonin syndrome, dyskniesia, arthralgia, ataxia Amyotrophic lateral sclerosis (ALS): what and etiology - ANS Disease of motor neurons causing asymmetric weakness, in upper or lower extremity. Less likely to present with resp weakness, dysarthria or dysphagia Onset age: 50 Men more likely Familial is 10% of cases

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

unknown Average survival: 2-5 yrs Symptoms and diagnostics ALS - ANS Classified by number of upper and lower motor neurons in regions of brain Progressive weakness over weeks/ months Sensation intact Muscle atrophy Small muscle fasciculations Hyperreflexia Spasticity Serum CK elevated EMG: denervation Muscle biopsy: atrophic muscle fibers MRI: no abnormality Management of ALS - ANS Supportive and palliative: - Immobilty - Altered resp function: ventilation/ suction - Dysphagia/ poor nutrition - pain: pain management - Anxiety - Meds: riluzole. Can extend life by months but not cure. Low back pain - major syndromes - ANS 1. Back strain 2. Disk herniation 3. Osteoarthritis/ disk degenration; osteophyte (bone spur) 4. Spinal stenosis: narrowing spinal foramen leading to spinal nerve entrapment Specific findings for back pain - ANS - numbness - saddle anesthesia (CA, mass) - bowel, bladder dysfunction (emergency surgery)- pain worse at rest (CA, tumor, infection) - Discitis, epidural abcess (IV drug use) - Decreased rom

- Radiculopathy (pain down leg), not with OA - Crossover straight leg test: herniated disk - back, buttock, leg pain when ambulating (neurogenic claudication with spinal stenosis). Also positive straight leg raise test with spinal stenosis xr anteroposterior, to rule out scoliosis, bone spur MRI for soft tissue structure, bulging disk CT for bony imaging Transient Ischemic Attack (TIA): what, etiology - ANS Rapid onset of neurological deficit caused by focal brain, spinal cord, or retinal ischemia, resolves in 24hours. - atherosclerotic disease - cardiac emboli, from afib, mi, valvular disease - vasculitis, from lupus - hematologic causes (sickle cell, oral contraceptive) - high risk: older than 45, hx of thrombolytic event, history of spontaneous abortion, autoimmune, family hx - intracranial causes (brain tumor, seizures) - cocaine abuse - migraines TIA risk factors - ANS Important risk factor for stroke, especially in first week after Risk factors for TIA: - HTN - Cardiac disease (afib) - smoking - obesity - hyperlipidemia - elderly - DM - alcohol, recr drugs TIA symptoms - ANS Carotid artery syndrome:

- hemianopia, ipsilateral blindness - visual field cut - parasteshia/ weakness of contralateral arm/ leg/ face - dysarthria, aphasia - confusion - carotid bruit Vertebrobasilar artery syndrome: - bilateral visual disturbances - vertigo and ataxia - N/V - drop attacks TIA diagnostics - ANS - Lab: CBC, incl PT, PTT/INR, electrolyres, lipid profile - CT: may reveal ischemia or infarct - MRI: more sensitive than CT. Preferred for vertebrobasilar TIA - duplex US: to identify carotid stenosis - CT angio: to evaluate neck/ brain vessels (normal renal function required) - MR angio: can assess vessels. Good replacement for CTA. - echo or holter for cardiac concern/ assessment - TEE to assess aortic arch, left atrium, patent foramen ovale - cerebral angio if candidate for carotid endarterectomy TIA management - ANS - Address underlying risk factors (HTN, DM, hyperlipid, smoking, obesity) - Carotid TIA: surgery if more than 80% occluded. No surgery if less than 50% (cand do stent then). - anticoagulation: heparin - warfarin. Though newer agents (Eloquis). PTT 1.5 - 2.5 x patient's baseline. - Antiplatelet therapy: aspirin or plavix Stroke: what, etiology - ANS Rapid onset of neurological deficit lasting longer than 24hours. Leading cause of disability. Ischemic or hemorrhagic. 80% ischemic. - HTN - Cardiac disease (afib)

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- smoking - obesity - hyperlipidemia (ischemic, low cholesterol hemorrhagic) - elderly - DM - alcohol, recr drugs - female on contraception and smoking Education on stroke - five "suddens" - ANS Sudden: weakness speech difficulty visual loss dizziness severe headache ischemic stroke: what, etiology - ANS Thrombus in blood vessel in head or neck Predisposing: - atherosclerosis/ hyperlipidemia - HTN - DM - hypotension - smoking - trauma - afib, endocarditis, mitral stenosis (embolism) Ischemic stroke symptoms, based on location - ANS Middle cerebral artery: - Hemiplegia (upper and face mostly), hemianesthesia, heminopia - aphasia - neglect Anterior cerebral artery: - hemiplegia (lower mostly), primitive reflexes, confusion, behavioral changes if bilateral anterior Vertebral and basilar arteries: - LOC

- vertigo - dyshpagia, diplopia - ipsilateral CN findings - Contralateral sensory deficiency Deep penetrating branches of major cerebral infarction (lacunar infarction): - associated with poorly controlled HTN and DM - contralateral pure motor and sensory deficits - ipsilateral ataxia - dysarthria ischemic stroke diagnostics - ANS - CT head without contrast initially, preferable to MRI to rule out hemorrhage. Appears as area of density. - xr chest: possible cardiomegaly, neoplasm (metastasis brain suspicion) - Labs: CBC, Pt, PTT? INR, lipid profile, drug screen, alcohol level - ECG/ holter - MRI/ MRA (diffusion weighted more sensitive to detect cerebral ischemia) - CTA: vascular anatomy. Combine with CT perfusion which can show old infarct and salvageable areas. Ischemic stroke treatment - ANS - appropriate time goals - BP control: Only treat if higher than 220 syst and 120 diast., aortic dissection, or receiving t-PA. For t-PA goal goal is less than 185 syst/ 110 diast, before t-PA and less than 180 syst/ 105 diast. after. Use repeat labetolol or nicardipine drip. - Anticoagulation: IV Heparin, bridge to Warfarin (PTT 1.5-2.5 baseline). But newer meds better: Dabigatran, Apixaban (Eliquis - for stroke prevention in afib), Rivaroxaban (stroke prevention afib). No routine labs necessary for those. Not for hemorrhage, cautino after GI bleed - Antiplatelet: Aspirin or Clopidogrel - Mannitol and hypertonic saline for cerebral edema, on second on third day. Monitor serum osmolality. - Corticosteroids to reduce cerebral edema from tumor burden. - surgery for high grade extracranial carotid artery disease (greater than 70%) Time goals of stroke - ANS - ED eval within 10min - notify stroke team within 15min - CT scan within 25min

- CT scan interpretation within 45min - Thrombolytic (if appropriate) within 60min - Transfer to bed within 3 hrs t-PA - ANS - Pt needs to be in 3 - 4.5 hr window - Prior CT to assess for hemorrhage - need to have "last well known" - older than 18 - ischemic stroke - neurochecks q15min for 2hrs, q30min for 6 hrs, q1h till 24hrs Contraindications: - age greater than 80 - previous hemorrhage - previous stroke within 3mo - major surgery last 14 days - Urinary/ GI hemorrhage within 24 days - seizure - PTT and PT elevated - oral anticoag/ heparin with elevated PTT/ PT - glucose less than 50/ greater than 400 - SBP greater than 185 or DBP greater than 110 - active internal bleeding last 22 days Hemorrhagic stroke; what, etiology - ANS Resulting from bleeding into subarachnoid space or brain parenchyma SAH: ruptured saccular aneurysm arteriovenous malformation ICH: HTN Predisposing: HTN anticoag/ thrombolytic

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

cocaine alcohol hematologic disorders Symptoms SAH - ANS Sudden severe headache "thunderclap headche" or "worst headache of my life". Graded Hunt and Hess): 1: asymptomatic 2: moderate/ severe ha, stiff neck, no focal signs other than CN palsy 3: drowsy, mild focal deficit 4: stupor, hemiparesis 5: deep coma, decerebration Graded (Fisher): 1: no blood detected 2: diffuse/ vertical layers less than 1mm 3: localized clot/ vertical layer 1mm or more 4: intracerebral/ intraventricular clot with diffuse or nob SAH Symptoms ICH - ANS - HTN - ha - vomiting (especially cerebral) Basal ganglia: - eyes look to injury - decreased consciousness - contralateral hemiplegia Thalamic: - looking at nose - pinpoint pupils - coma - flaccid quadriplegia Cerebellar: - ipsilateral gaze paralysis - PERRLA - inability to stand/ walk

- facial weakness - gait ataxia - vertigo - dysarthria SAH diagnostics - ANS - CT head: ischemia or hemorrhage. Sensitive in first 3 days, after that consider LP. hard to see if smaller than 3mm. - LP is strong suspicion bit negative CT. - CSF: bloody ( 103 - 106 RBC), xantochromia (yellow, breakdown of blood) - CTA, prior to clot removal ICH diagnostics - ANS - CT without contrast, to confirm bleed and determine size/ site. May reveal structural abnormalities. - Cerebral angio: determine source as aneurysm or an AVM. - MRI/ MRA: structural abnormalities - CBC, PT/ PTT, electrolytes, liver enzymes, kidney function SAH management - ANS - ABC's - may place external ventricular drain if hydrocephelus - bedrest strict - cardiac monitoring - treat ha, no NSAIDS (bleeding risk) - no straining/ exertion - stool softener - seizure prophylaxis (Phenytoine or Levetiracetam) - maintain SBP less than 160, may use nicardipine drip, labetolol push, hydralazine of brady - cerebral edema: mannitol or hypertonic saline. - surgical cliiping or coil asap - treat cerebral vasospasm - rebleeding: between day 2 - 19. Repeat CT. - cerebral salt wasting: hyponatremia. Crystalloid fluid replacement when euvolemia: 3% saline for hyponatremia - manage fever ICH management - ANS - ABC, intubate/ give O2 - Control HTN. SBP: 140 - 150. Nicardipine, labetolol

- CPP: keep at 50 - 70 - pressors if SBP less than 90: Dopamine, epi, levo - maintain ICP less than 20 - mannitol for cerebral edema. For 5 days or less. check serum osmolality. Or 3% saline. - ventricular drain for hydrocephalus - keep euvolemia - seizure precautions (phenytoine, levetiracetam) - control fever - surgery if hemorrhage greater than 3cm cerebral vasospasm - ANS - cerebral vasospasms: between day 7 - 10 after aneurysm lasting till day 21 - symptoms: confusion, ams, neuro deficits, ha, increased icp. May cause infarction. - treat: calcium channel blocker: nimodipine. Symptomatic: tripe H. Hypervolemia, hypertension, hemodilution. Meningitis, what and etiology - ANS inflammation of arachnoid, dura mater, pia mater or spinal cord due to viral, bacterial, or fungal infection - predisposing: sinusitis, otitis, pneumonia, trauma, congenital malformation Bacterial meningitis - ANS Bacterial: - may be fatal in hours - exudate in subarachnoid space, thus thickened CSF and decreased flow Most commonly caused by: - streptococcus pneumoniae (infants) - neisseria meningitidis (school, college, spread of drainage/ blood) - haemophilus influenzae (daycare children - vaccine) - Escherichia coli/ emterobacter/ klebsiella (infants, elderly, immunocompromised) - Atypical: mycobacterium, listeria

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

viral meningitis, what and etiology - ANS Pia and arachnoid space filled with lymphocytes but not with exudate. benign and self-limited. In late summer/ early fall. Transmission via cough, saliva, fecal matter Caused by: enterovirus, mumps, varicella, herpes, rubella, cmv, epstein barr, HIV Fungal meningitis, what and etiology - ANS Most common in immunocompromised Causes: candida cryptococcus histoplasma aspergillus Meningitis findings and diagnostics - ANS - severe ha - stiff neck/ nuchal rigidity - phtophobia - fever - ams - cranial nerve palsy - seizures - kernig's sign: flex at knee, then hip, and extend knee. Causes pain and spasm of hamstring muscles - brudzinski's sign: flex head and neck to chest. Causes legs to flex at hips - n/v - purpura/ petechiae on trunk and le - exaggerated deep tendon reflexes - LP - CT before LP, for ams or focal neuro signs or for CSF bacterial meningitis signs but no organism - bld culture, sputum cult, cbc, bmp - antigen tests and HIV testing

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

LP in bacterial versus viral meningitis - ANS Bacterial: - Appearance: cloudy - Opening pressure: elevated (more than 180) - Cells: increased WBC's (100-5000, polynuclear) - Protein: increased (100-500) - Glucose: decreased (5-40) - Culture: bacteria present Viral: - Appearance: clear - Opening pressure: normal (less than 180) - Cells: increased WBC's (100-5000, mononuclear) - Protein: normal or slightly increased (less than 200) - Glucose: normal (greater than 45) - Culture: no bacteria Meningitis management - ANS AB's: - 2 -50 yrs: vancomycin plus ceftriaxone - older than 50 yrs: vancomycin, plus ampicillin, plus ceftriaxone - Meningococcal meningitis (college): penicillin or ceftriaxone if pcn allergy - H.influenzae: ampicillin or ceftriaxone - tuberculosis: isoniazid plus pyridoxine, rifampin - s. pneumoniae (infants): add dexamethasone - no hypotonic fluids - amphotericin B for fungal meningitis Cerebral abscess, what and etiology - ANS Infected space occupying lesion, from bacterial or fungal source (sinusitis, lung infection, skin infection, trauma) Cerebral abscess findings, diagnostics - ANS - ill appearing/ lethargic - signs of increased ICP (n/v, confusion/ ams) - stage 1: ha, chills, fever, confusion, speech disorder - stage 2 (expanding cerebral mass): signs and symptoms of brain tumor: ha, confusion, drowsy, stupor - Lab: increased WBC and ESR

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- LP (CT prior to LP): elevated opening pressure, mildly elevated protein - CT - MRI: reveals necrosis vs edema Cerebral abscess treatment - ANS - AB based on microbiology - surgery and debridement when abscess is greater than 2.5cm Encephalitis, what and etiology - ANS Acute inflammation of the brain - most commonly caused by herpes simplex virus - tick infestation - west nile virus - toxoplasmosis (AIDS pt's) - CMV - rabies Encephalitis findings and diagnostics - ANS - lethargy - unstable vitals - nystagmus, photophobia - n/v - nuchal rigidity - ha - pos babinski - Lab: CBC, liver, BMP, fluid cultures - LP: elevated WBC, normal or slightly elevated protein, normal or slightly elevated glucose - EEG - IgM meausring in serum and CSF, pos in CSF - CT - MRI Encephalitis treatment - ANS - IV fluids - resp and circulatory support - anticonvulsants - monitor for SIADH - for HSV: acyclovir

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- report to CDC encephalopathy, what and etiology - ANS Dysfunction of brain caused by disease (process) Hepatic, hypertensive, metabolic, hypercapnic cause Thiamine deficiency (wernicke) encephalopathy, findings and diagnostics - ANS - ha - ams - confusion - ammonia may be elevated - CSF analysis - EEG - MRI encephalopathy treatment - ANS - ABC's - correction underlying cause - anticonvulsant therapy Seizure/ epilepsy, what and etiology - ANS Seizure: abnormal neuronal discharge within brain Epilepsy: recurrent, unprovoked seizures - unknown cause - metabolic disorders (acidosis, hypoglycemia, hypoxia, alcohol withdrawal) - CNS infection - tumor - noncompliance with epilepsy meds Focal seizures - ANS one cerebral hemipshere: - without dyscognitive features (aware). May have sensory changes, autonoic (sweating, flushing), sppech arrest, aura, psychic symptoms - with dyscognitive features (unaware). most common seizure. Simple partial seizure followed by loss of awareness. Automatisms. Begins with aura often.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Generalized seizures - ANS - typical absence seizures: sudden loss of consciousness (5-30sec), mild clonic/ tonic movements, several times/ day - atypical absence seizures: longer loss of consciousness, obvious motor signs - generalized tonic-clonic seizures: discharge throughout cerebral cortex. Abrupt start with outcry, loss of consciousness/ falling, resp arrest, tonic and clonic movement, urinary incont, 2-5min, postictal state status epilepticus - ANS a prolonged seizure (longer than 5min) or situation when a person suffers two or more convulsive seizures without regaining full consciousness Requires aggressive tx medical emergency Seizure diagnosis - ANS -EEG/ 24 hrs: focal abnormalities: partial seizure, generalized abnormalities: generalized seizures - CT head - LP if CT or MRI did not show anything - CBC, BMP - ua: drug screen - elevated prolactin Seizure management - ANS - supportive - open airway, left side laying, do not force anything in mouth (airblade) - IV with NS - ECG, bp - benzodiazepine first treatment: ativan, diazepam, midazolam (may give midazolam IM if no IV present) - Phenytoin, loading dose 20mg/kg - Fosphenytoin, can be given faster than phenytoin - if still seizing after 1hr: propofol - taper drugs, never stop abruptly

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Dermatitis Medicamentosa (Drug Eruptions) - ANS Abrupt, widespread, and symmetric eruption. If exposed before, it may take only very little to elicit response again. Predisposing factors for dermatitis medicamentosa - classification - ANS Type 1: immediate-type immunologic reaction: by IgE. Looks like: urticaria and angioedema of skin and mucosa, and fall in bp (anaphylactic shock) Type 2: cytotoxic reaction. drug causes lysis of cells or produce antibodies. Type 3: serum sickness, drug-indiced vasculitis. Looks like: vasculitis, urticaria-like lesion, arthritis, nephritis, alveolitis, hemolytic anemia, thrombocytopenia type 4: morbiliform. Cell-mediated. Drug erruption with eosinophilia and systemic syndromes (DRESS). Allergic reaction causing systemic reaction, presenting as hepatitis, pneumonia, lymphadenopathy, nephritis. May last 2-6wks after start med. Often: anti-epileptocs, B-blocker, allopurinol. General points for dermatitis medicamentosa - ANS - Amoxicilllin/ ampicillin/ penicillin: common cause urticaria and maculopapular allergic skin reaction - Cephalosporin can cause reactions to pcn allergic patients. Third generation less likely than first generation. - Red man syndrome caused by vancomycin. Responds to slowing of rate. - ACE-inhibitors associated with chronic cough and angioedema - B-blocker can precipitate asthma. - Anticonvulsants and sulfonamides most common cause of toxic epidermal necrolysis and Stevens-Johnson syndrome. - May give Prednisone and hydrocortisone before IV contrast is suspected allergy Dermatitis medicamentosa: symptoms and diagnostics - ANS - abrupt onset

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- bright erythema - facial edema/ involvement - swelling tongue - itching - fever/ chills - symmetric distribution of skin reaction - arthralgia - possible: sob, wheezing, hypotension - if urticaria and angioedema present, then mast cell degranulation, so repeat reaction is likely. - maculopapular rash, most often on trunk - ecxematoid rash - photodermatitis - may have: hemolytic anemia, liver/ kidney dysfunction, serum sickness (rash, fever, malaise) - clinical diagnosis - blood work no value - eosinophil count greater than 1000 - skin biopsy - challenge dosing - if anaphylactic reaction not likely - serum renal/ liver if indicated Dermatitis medicamentosa, management - ANS - Withdraw drug - may be only thing necessary - Epi0.5-1ml IV or SQ relief from urticaria and angioedema. Repeat after 20min up to three doses - Oral/ IV antihistamine: benadryl or Ranitidine - Severe cases: Prednisone, taper slowly - Bronchodilators for wheezing Cellulitis: what - ANS Infection of dermis and subcutaneous tissue. Caused by gram Pos cocci and staph. aureus (for dm) as well as gram neg. E.coli. Fungi for neutropenic patients. H. influenza for facial and upper extremities.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Cellulitis, general comments - ANS - break in skin precedes cellulitis, - Risk factors: trauma, underlying skin lesion, diabetes, pedal edema, venous/ lymphatic compromise, IV drug use - may be next to necrosis or abscess - often lower extremities - complicated by DVT Cellulitis findings - ANS - tenderness, pain, swelling, erythema, warmth - rapid increase intensity and spread - fever, chills, malaise - sepsis possible - erythema with indistinct margins; warmth and tenderness - enalargement and tenderness of regional lymphnodes - red streaks from site (lymphatic spread: lymphangitis) - erythema and tenderness few cm from site - Lymphnode enlargement and lymphangitis: cellulitis. - Blood culture and wound culture - Rule out: DVT and necrotizing fasciitis, which should be suspected in very sick pt with bullae, crepitus, anesthesia of involved skin, skin necrosis, rhabdo, DIC Cellulitis treatment - ANS - AB: cover streptococci and staphylococci, with penicillin, Cephalexin, Dicloxacillin. If allergy to pcn: erythromycin or clindamycin. - Inpt AB: nafcillin, Cefazolin, Vanco for MRSA suspicion, - Hospitalize very sick or immunocompromised and treat with vanc. - Immobilization and elevation of limb - moist heat - low dose, long-term pcn for recurrent cellulitis Herpes Zoster (shingles): what, etiology - ANS Reactivation of latent varicella-zoster virus, characterized by unilateral pain present 48hrs before rash. Rash: single dermatome: vesicular or bullous erruption - older than 50 - impaired immune system, lymphoma, fatigue - can have postherpic pain for up to 1mo

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Herpes Zoster findings and diagnostics - ANS - Prodormal pain symptoms (sharp), burning, itching in affected spot - malaise, low grade fever, headache - allodynia - lymphadenopathy, 1 -2 days prior - grouped vesicles on erythematous tender base along nerve group - papules appear within 24hrs and progress to vesicles and bullae within 48hrs, then pustules with cloudy fluid. Crusts for 7-10days. - ECG during prodormal: rule out cardiac disease - VZV antigen detection - positive Tzanck test - viral culture Herpes Zoster management - ANS - consult ophthalmology for HZ on tip of nose - antiviral therapy for 50-50-50: 50hrs or less since onset, 50yrs or older, more than 50 lesions - Acyclovir 5/ day. Adjust for renal impairment. - pain control with opioids - Moist dressing: water, saline 15min qid - Hydroxizine for pruritis - postherpetic neuralgia pain: Lidocaine patch, Pregabalin - pregnant women should avoid Skin cancer: 2 main types, etiology - ANS Basal cell carcinoma: most common type. - Fair skinned people. - Waxy, pearly appearance. - Slowly grows 1-2cm over years. - Limited capacity to metastasize. - sun exposure before age 14 - rare in brown/ black people - face/ neck

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Squamous cell carcinoma. - Non-healing ulcer/ wart-like. - From actinic/ solar keratosis. - Can metastasize (especially on lip, oral cavity, tongue, and genitals) - Result of exogenous carcinogens. - more male - smokers: lip - females: legs BCC and SCC findings and diagnostics - ANS BCC: - nodule or ulcerative tumor: small, pearly, waxy. Translucent borders, elevated and shiny fine telangiectasis - superficial BCC: erythematous scaly macule with threadlike border SCC: - firm, skin to red- colored nodule on damaged skin - central ulceration - scaling and crusting - on head/ neck - Biopsy, shaved (for raised lesions), or punch biopsy (small distinct bordered lesion), incisional biopsy (large lesion) - Curettage and electrodesiccation in three cycles for BCC lesions smaller than 1cm = gold standard Skin cancer: BCC and SCC, management - ANS - consult dermatologist - cryosurgery - microscopically remove, to ensure clear borders - radiotherapy only for very large - prophylaxis therapy: 5- Fluorouacil or Imiquimod - sunscreen Melanoma: what, etiology - ANS Tumor with dark pigmentation, flat or raised, irregular borders, greater than 6mm - Leading cause of death from skin disease - avoid blistering sun radiation

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- age: between 30 and 50 - fair skin, blue eyes, blond - twice risk if sunburned young - twice the risk with many nevi - head/ neck/ trunk for males, lower extremities for females Melanoma: findings and diagnostics - ANS - change in pigmented lesion: - bleeding/ ulceration bad sign - scaling - texture change, irregular border - bigger than 6mm - color change - itching ABCDEE changes: Assymetric shape Border irregularity Color change Diameter greater than 6mm Elevation Enlargement/ increase in size Surgical biopsy: full thickness total excisinoal biopsy. Do not shave, curette, or electrodesiccate melanoma Melanoma staging - ANS Clark staging: Level 1: epidermis - in situ Level 2: invasion of papillary dermis Level 3: invasion of interface of papillary, reticular dermis Level 4: invasion of reticular dermis Level 5: invasion subcutaneous fat Breslow staging: Thin: less than 0.75m depth Intermediate: 0.76 - 3.99mm depth Thick: greater than 4mm depth

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Melanoma Management - ANS - dermatologist - follow up q3-6mo - Based on stage: Less than 1mm: wide excision 1mm. No lymphnode dissection 1-4mm thick: wide excision 2mm. Nodal biopsy recommended. Lymphatic mapping. 4mm thick: wide excision more than 4mm - Adjuvant therapy: hem/ onc. Alpha-interferon Types of wounds - ANS Acute: Acute surgical: clean/ contaminated Traumatic wound: clean/ contaminated Chronic: Arterial: ischemia from arterial occlusive disease Venous: venous return disorder Diabetic: from hyperglycemia and per neuropathy Pressure: prolonged pressure Factors that delay wound healing - ANS - pressure - decreased tissue perfusion/ oxygenation - incontinence - infection - dm - poor nutrition - steroids - immunusuppression - aging Wound findings, specifics - ANS - Pain - Arterial: claudication - Venous: lower extremities heavy and sore - Neuropathy: numbness, tingling - Arterial, venous, diabetic: poor healing Wound depth, levels - ANS - Superficial - Partial thickness: through epidermis, partially into dermis

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- Full thickness: through epidermis and dermis and some subcut layer. Muscle/ bone may be involved. - Undermining and tunneling Wound colors - ANS Red: healthy Yellow: debridement/ cleaning needed Black: necrotic Findings arterial and diabetic ulcers - ANS - On toes and below ankles (arterial) - plantar surfaces of feet (diabetic) - diminished pulse - shiny, cool le skin - no leg hair - thick toe nails - deep ulcer with smooth wound margins, small amount of drainage/ necrosis Findings venous ulcers - ANS - lower legs, above ankle - varicoses present - edema of le - warm le - superficial, granulating ulcer with irregular margins, with heavy drainage Findings pressure ulcer - ANS - On bony prominences - Stage 1: skin intact, but skin non blanchable - Stage 2: partial thickness loss - Stage 3: full thickness loss, deep craterlike - Stage 4: full thickness and extensive destruction with tissue necrosis Diminished arterial and venous flow diagnostics - ANS - Doppler, reduced PVR waveforms - Digital plethysmography: systolic toe pressure. Normal is 80-90% - Transcutanous oxygen measurements: higher than 30, wound will heal. Lower than 20, will not heal - Venous doppler ultrasound: may show clots or incompetent valves Refer to vascular surgeon when - ANS Urgent: - gangrene

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- tendon/ bone visible - cellulitis - severe infection - ankle-brachial index less than 0.5 Semi-urgent: - TCPO2 measurement higher than 30 - weak/ absent pulse - ankle/brachial index 0.5-0.8 Routine: -ankle/ brachial 0.8 Management arterial ulcer - ANS - wet to moist dressing - collagenese, apply to ulcer directly - no surgery - calcium alginates - no occlusive dressings - analgesics - treat underlying condition Management venous ulcer - ANS - Elevate leg - nonadherent dressing under compression - Compression therapy - sharp debridement if cellulitis/ infection - collagenese - treat underlying condition - AB's: cephalexin or erythromycin if allergic to pcn. Or cefazolin iv - Linezolid or Vanco if MRSA suspicion - Analgesics Management diabetic ulcer - ANS - Increase insulin or oral hypoglycemic - no weight bearing - incision/ drainage as indicated - PRN topical antimicrobial - non-occlusive/ non adherent dressing - enzymatic debridement: collagenese

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- AB's: mild: cephalexin, amoxicillin, for MRSA: doxycillin or bactrim moderate: levofloxacin and severe MRSA: vanco. severe: vanco - analgesic - wet to moist dressing qid Management of pressure ulcers - ANS - positioning - support surfaces - skin barrier products - hydrocolloids - debridement - cleansing: NS. Irrigation for dirty. - keep ulcer moist - topical AB's PRN - diet: increased protein/ high caloric diet - analgesics PRN Types of burns - ANS - Thermal; flames, hot objects. Most common type of burn - Chemical; necrotizing agents - electrical; causes damage to nerves and tissues - inhalation injury; smoke/ hot air. Incl Carbon monoxide - cold thermal; frostbite Categories of burns - ANS - First: painful, dry, red, no blisters, epidermis only - Second: severly painful, moist blisters, beyond epidermis, infection barrier destroyed - Third: not painful/ nerve destroyed, leathery, black/white, pearly, from epidermis to dermis to underlying tissue/ fat/ muscle/ bone Extent of burns measurement - ANS Rule of nines: - each arm: 9% - each leg: 18% - thorax: 18% front, 18% back - head: genitals 9% - perineum/ genitals: 1%

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Fluid resuscitation in burns - ANS - 2-4ml/kg x total body surface area in first 24/hrs - Asap. Even before hospital. - Half of all fluids within first 8 hrs. - Give crystalloids (NS/ LR), no colloids (albumin, plasma) - Urine output should be 30-50ml/hr - Monitor for hyperkalemia first 24-48 hrs, after that hypokalemia. General burn management rules - ANS - rinse chemical injuries in water, no other products - wrap area in clean, dry towel (not wet, to keep body temp) - dressing before treatment: wrap in ns and sterile towels - maintain normothermia (warming blankets, etc) - analgesics (morphine), only iv - topical ab options: silvadene, sulfamylon, collagenase - intubate for one of these: burn to face, singed nares/ eyebrows, dark soot from nares, hoarseness, drooling, difficulty swallowing. AND bronchoscopic laryngeal edema Transport to burn center for - ANS - 2nd degree, more than 10% TBSA - 3rd degree - electrical burn - chemical burn - inhalation injury - burned children - burn injury is big risk for mortality carbonmonoxide poisoning - ANS - CO replaces Hgb - Cause: home furnace/ gas and car exhaust - signs: ha, dyspnea, confusion, n/v, tachy, seizures, coma, death - Give 100% O2 - potential hyperbaric oxygen chamber Laceration treatment - ANS Cleanse (NS) Debridement (for contaminated wound) (potential excision) Control of hemorrhage - pressure, elevation, ligation, tourniquet Closure (do not close contaminated wound)

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Suturing - ANS - not too tight - choose smallest suture size - remove after 5-7 days or 10 days on trunk and extremities Nerve block for laceration - ANS - 1% lidocaine with epinephrine, do not exceed 7mg/kg or 4mg/kg without epi - or Procaine - choose small needle (30gauge) Aneurysm: what and types - ANS Dilation of arterial wall because of abnormal weakening, often from sudden increase in bp Types: Berry (saccular) - congenital aneurysm of cerebral vessel. - Common in adults - Asymptomatic Fusiform - tapered at both ends - common in vertebrobasilar system Mycotic - bacterial cause/ infection Traumatic Locations of intracranial aneurysms and effect of rupture - ANS - Most in carotid system: anterior communicating artery, posterior communicating artery, middle cerebral artery - some in posterior circulation: basilar and vertebral Rupture result: - subarachnoid hemorrhage - intraventricular hemorrhage - intracerebral hemorrhage

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- subdural hematoma Risk factors for intracranial aneurysm - ANS - hereditary/ familial - smoking - women above 50 (postmenopausal) - alcohol use - 7mm risk for rupture Intracranial symptoms and diagnostics - ANS - asymptomatic until rupture, then SAH - warning leaks (small amount of blood) hours prior to rupture: headache, neck stiffness, nausea - eye hemorrhage on ophthalmologic exam - aneurysm with mass effect (bigger than 25mm): headache, palsy of CN 3 (pupils), brain stem dysfunction - CT . Very sensitive within 24hrs. Less after 5-7 days. - CTA - MRI best for detecting thrombus in aneurysmal sac - CTA, help in therapeutic decision making - WBC and ESR up in ruptured aneurysm Intracranial aneurysm management - ANS - Surgery: consider for warning symptoms (headache, neuro signs) and salso consider comorbodities. - early surgery (within 72hrs of bleed) is desirable - clipping, wrapping, embolization - or manage nonsurgically as SAH Aneurysm complications - ANS Vasospasm - 3 or 4 weeks after tx - give calcium channel blockers (nimodipine) Rebleeding - risk within 2-24hrs of 1st hemorrhage - prevent htn - give antifibrinolytic agents: transexamic acid. If given in first 2 wks after bleed reduces risk for rebleed.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Hydrocephalus - may require shunt placement, ext ventricular drain, lumbar drain Seizures Increased intracranial pressure arteriovenous malformation (AVM) - ANS a vascular malformation that is a tangle of abnormal blood vessels connecting arteries and veins in the brain; has increased risk of bleeding and decreases normal oxygen flow to local tissues (no capillary bed for gas exchange) Treat with: embolization, surgical excision Dural arteriovenous fistula - ANS Fistula between artery and vein in dura matter. Signs: tinnitus, headache Treat with: embolization, surgical excision Chiari malformation - ANS part of cerbellum herniates down through foramen magnum Treat: surgery Hydrocephalus: what, etiology - ANS Excessive amount of CSF in cerebral ventricles. Can be acute or normopressure - oversecretion CSF - obstruction of CSF (tumor/ lesion) - impaired absorption - head injury Hydrocephalus classification - ANS Communicating: - from impaired absorption or overproduction - after aneurysmal rupture

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Noncommunicating: - obstruction in ventricle, thus no communication with subarachnoid space - from lesions or tumors hydrocephalus signs - ANS Acute: - papilledema - ha - n/v - gait change - upward gaze Normopressure: Triad: dementia, gait disturbance, urinary incontinence hydrocephalus management - ANS Acute: ext ventricular drain Chronic: ventricular shunt Ventriculostomy- surgical Brain tumor - ANS Primary: originating in brain Secondary: metastases Most common: gliobastoma multiforme Most common brain tumors - ANS Gliobastoma multiforme - nonspecific symptoms, focal deficits as tumor grows - rapid course, poor prognosis Astrocytoma - longer course - variable prognosis - might do total surgical removal Meningioma - compresses instead of invading neural structure - common with advancing age

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- surgical treatment, potentially with radiation Brain tumor signs and diagnostics - ANS - progressive neuro deficit - ha - seizures - MRI, procedure of choice - CT to also look at other body parts - EEG for seizures - CT angio to asses vessels - barin biopsy for definite diagnosis - metastatic work-up necessary Brain tumor management - ANS - oncologist - chemo - radiation - corticosteroids: dexamethasone (start H2-blockers simultaneously) - mannitol for sever cerebral edema - anticonvulsants for repeated seizures Guillain-Barre syndrome, what, etiology, prognosis - ANS Acute, rapidly progressive inflammatory demyelinating radiculoneuropathy: motor greater than sensory resulting in increased msucular weakness, mild sensory loss, auronomic dysfunction. Often following an infection. Cause: myelin destruction or complexes attacking axons and nerve conduction Max deficit by week 4. - possible autoimmune - antecedent infection - incidence increases with age - more men Improvement may take months. May keep mild disability. Guillan Barre signs and diagnostics - ANS - symmetric, rapidly progressive muscle weakness and parasthesia, beginning in legs and moving up. Can lead to total paralysis/ death

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- reduced deep tendon reflexes - more weakness than sensory loss - may have hyperesthesia - dysphagia - respiratory paralysis - autonomic dysfunction: tachycardia, bp fluctuations, cardiac arrythmia - CSF: elevated fluid protein, but may be only after couple of weeks - leukocytosis - may require lp - will find: demyelatino of peripheral nerves or inflammation of myelin sheath - antibodies: GM1 or amti-GQ1b - slowed conduction on electromyography Guillan barre management - ANS - no known cure - consult neuro - icu - intubation - immunomodulating treatment and plasmapharesis (first line!) - no corticosteroids - prevent thromboembolic events (hep sq q8h) - pain control (especially during reinnervation) - GI prophylaxis - H2 blocker - protect skin - rom - nutrition management - rehab Myastenia Gravis (MG): what and etiology - ANS Disorder of neuromuscular junction resulting in pure motor syndrome: fluctuating muscle weakness most notable after prolonged muscle use Cause: autoimmune attack on acetylcholine receptor at the postsynaptic membrane. Mild and intermittent or sudden severe onset more women early adulthood, equal later in life

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Myastenia Gravis symptoms and diagnostics - ANS - Ptosis - Diplopia - facial weakness - fatigue from chewing - neck weakness - more upper than lower limb weakness - resp weakness - may cause severe quadriparesis - Antibody testing: ACHR and MUSK pos - increased jitter on electromyography - Edrophonium test (Tensilon): in MG will have brief improvement when given Edrophonium. No improvement if cholinergic crisis - MRI/ C - Thyroid function tests: may have thyroid disease - Vit B 12 low, pernicious anemia - ANA, RA factor pos - normal LP Myastenic crisis - ANS Defined by resp failure, requiring mechanical ventilation, following increasing muscle weakness and diplopia. More likely in MUSK positive. This often follows an infection, stress, steroid change, drug exposure myastenia gravis treatment - ANS - neuro -Symptom mamagement with: Pyrodostigmine bromide - slows down degradation. Monitor for cholinergic adverse effect: n/v, diarrhea, bronchial secretions, cramps. - Immunomodulating therapy: Prednisone, taper to low maintenance. Azathriopine. - Management of impending crisis: intubate. And give rapid immunomodulating therapy: IVIG. Can also do plasmapharesis. Removes antibodies. GCS measures - ANS The GCS measures the following functions: Eye Opening (E) 4 = spontaneous

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

3 = to sound 2 = to pressure 1 = none NT = not testable Verbal Response (V) 5 = orientated 4 = confused 3 = words, but not coherent 2 = sounds, but no words 1 = none NT = not testable Motor Response (M) 6 = obeys command 5 = localizing 4 = normal flexion 3 = abnormal flexion 2 = extension 1 = none NT = not testable GCS outcomes - ANS Severe: GCS 8 or less Moderate: GCS 9-12 Mild: GCS 13-15 Ectopic pregnancy: what, etiology - ANS Implantation of fertilized ovum in other place than endometrium, often fallopian tube Could be caused by: PID, especially gonorrhea and chlamydia endometriosis IUD tubal tumors On Clomid smoking Most common cause for maternal mortality

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Ectopic pregnancy findings and diagnostics - ANS - missed period, then continued intermittent bleeding - sudden, sharp abdominal pain, diffuse pelvic pain, and radiation to shoulders/ neck - fainting, vertigo - n/v - right or left pelvic pain - hypovolemic shock signs - cullen sign - normal uterine size - adnexal mass - bimanual exam painful with cervical motion tenderness - unilateral rebound tenderness - Hgb and HCT low with leukocytosis - HCG greater than 1500 but lower than what it should be for gestational age - no intrauterine gestational sac - ultrasound Ectopic pregnancy management - ANS - outpt lap: salpingectomy - outpt methotrexate therpay - central line if hemodynamically unstable - blood transfusions - Cefoxitin for empiric gram neg and pos coverage - pain control with percocet - biweekly HCG Methotrextae therapy: - Criteria: less than 6 wks, tubal mass smaller than 3.5cm, no embryonic motion, no renal/ hepatic disease, hemodynamic stability - Pretreatment: transvaginal us, HCG level, liver and renal function labs, blood type, CBC, bone marrow tests - contraindictations: intrauterine pregnancy, immunodeficiency, methitrexate sensitivity, low blood counts, hemodynamically unstable, pulm disease, liver or renal failure, breastfeeding, tubal rupture - either single dose or multiple dose regimen

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

PID (salpingitis): what, etiology, cimplications - ANS inflammation of upper female genital tract, by bacterial infection - very common - most common caused by: gonorrhea and chlamydia - Or: H ingluenzae and Gardnerella, streptococci, gram neg rods, mycoplasma hominis - trauma and surgery can also cause it - sexually active, multiple partners - reduced socioeconomic status - sexual exposure to urethritis - 3 weeks after IUD placement - douching - during period - smoking/ substance abuse May cause: - infertility - tubal pregnancy - tubo-ovarian abscess - recurrent PID - infectious perihepatitis (Fitz-Hugh and Curtis Syndrome) PID/ salpingitis findings and diagnostics - ANS - purulent vaginal discharge - bleeding cervix - cervical motion tenderness (chandelier sign) - abd rebound tenderness - ruq abd pain (with Fitz-High and Curtis Syndrome) - assess last period - STI hx - contraception use - sexual hx - pregnancy test - drug allergy - CDC criteria

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

CDC PID/ salpingitis criteria - ANS Needs to have one of these: - uterine/ adnexal tenderness - cervical motion tenderness And potentially: - fever - purulent vaginal discharge - elevated ESR - gonorrhea or chlamydia - WBC up Definite: - evidence from endometrial biopsy - tuboovarian abscess on US - lap.scopic abnormalities consistent with PID PID/ salpingitis management - ANS - Early and aggressive tx of STIs will prevent PID - Admit for: surgical emergencies, coexisting pregnancy, failure to respond to tx - notify sexual partners - test for cure after 7days - rescreen for gonorrhea and chlamydia after 4-6 wks - remove IUD - test for HIV - no douching - no sex - bed-rest semi-fowlers - Tylenol Inpatient: - Cefotetan or Cefoxitin - Doxycycline - Clindamycin or Metronidazole with Doxy for abscess Or: - Clindamycin - Gentamicin Continue till 24-48hrs after improvement

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Outpt: - Ceftriaxone - single dose - Doxycycline - Metronidazole Or: - Cefoxitin - Doxycycline with Metronidazole Vaginitis - what - ANS Most commonly: bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis Vaginitis, findings - ANS - vaginal discharge - vulvar itching/ irritation - vaginal odor - asymptomatic On speculum exam: - Bacterial vaginosis: adherent, thin, milky foul/ fishy smelling discharge - Candidiasis: thick, clumpy, white cottage cheese discharge. Inflammation, erythema - Thrichomoniasis: frothy, gray/ yellow/ green discharge. Cervical petechiae: strawberry cervix. Vaginitis, diagnostics - ANS Bacterial vaginosis: Amsel criteria: - vaginal PH greater than 4.5 - clue cells on wet mount - whiff/ fishy odor test - milky- white discharge, adherent to vaginal wall Candidiasis: wet mount: pseudohyphae and or budding yeast Thrichomoniasis: - wet mount: motile trichomonads seen - vaginal PH greater than 4.5 - culture

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- nucleic acid amplification test Vaginitis treatment - ANS - Enclose to partner and treat - no sex Bacterial vaginosis: - Metronidazole PO or intravaginally - Tinidazole Candidiasis: - Fluconazole PO - Butoconazole intravaginally Thrichomoniasis: - Metronidazole While pregnant: Metronidazole or Clindamycin Chlamydia, what and etiology - ANS Parasidic STI producing reproductive tract complications. Caused by: C. trachomatis. Transferred by body fluids - both sexes, younger than 25 - annual screening for sexually active adolescents and not using contraceptives, pregnant, or abortion May cause: Women: - PID - ectopic pregnancy - infertility - late onset postpartum endometritis Men: - Epididymitis - urethritis, conjuctivitis, arthritis, skin lesions Newborn: - conjunctivitis - pneumonia

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Chlamydia findings - ANS Female: - asymptomatic - postcoital bleeding - lower abd pain - dysuria - painful sex - purulent discharge Male: - asymptomatic - dysuria - penile discharge, thick - unilateral testicular pain/ swelling - Fever - abd pain: guarded and rebound - genitalia: edema, ulcerations, lesions, erythema - speculum: red vaginal walls, red cervix, purulent discharge, cervical lips eroded - bimanual exam: cervical motion tenderness (Chandelier sign), adnexal pain, uterine pain - male inspection: meatus edge red and swollen, unilateral testicular pain Chlamydia diagnostics - ANS - Gold standard: McCoy cell culture (takes 2-6 days for results) - Non culture tests: not as sensitive but results available sooner - wet mount: polymorphonuclear cells - test for syphillis and gonorrhea - HIV testing - Hep B testing Chlamydia management - ANS - Azithromcyin or Doxycycline - May give Erythromycin or Ofloxacin Pregnant: - Azithromycin or Amoxicillin - Or Erythromcyin

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- treat partner and evaluate last sexual partners - test of cure after 3 wks - no sex - use condom - report to health department Gonorrhea, what and etiology - ANS Bacterial STI, can be symptomatic or asymptomatic. Most commonly in cervix for women. Caused by N. Gonorrhoeae, gram negative, from GI tract, oropharynx, anorectum. Incubation period: 3-7 days - more male to female exposure than other way around Can cause: - PID - ectopic pregnancy - infertility - Perihepatits (Fitz-Hugh and Curtis syndrome) - Epididymitis Gonorrhea findings - ANS Female: - asymptomatic 80% Early: - dysuria/ frequency - purulent discharge - labial pain/ swelling - lower abd pain - pharyngitis Late: - fever - abnormal periods - n/v - joint pain/ swelling Male: - asymptomatic usually Early:

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- dysuria/ frequency - white discharge - pharyngitis Late: - yellow/ green discharge - epididymitis - lower abd pain - fever - Abd pain: guarding, referred, rebound - Hyperperistalsis - Painful, enlarged Bartholin and Skene glands - urethral discharge - red vaginal wall -purulent drainage from cervix - adnexal pain and masses - cervical motion tenderness - red and swollen penile shaft Gonorrhea diagnostics - ANS - Corner stone diagnosis: perform throat and endocervical culture for oral/ vaginal sex - rectal exam for anal sex - check for Chlamydia and syphilis and HIV - leukocytosis - ESR up - males: one hour after voiding Gonorrhea management - ANS - Ceftriaxone single - Azithromycin or Doxy 7 days Pregnant: - Azithromycin - Tell sexual partners and treat, and screen also for chlamydia - no sex - test for cure after 3mo - hospitalize for disseminated gonococcal infection

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- report to health department Herpes simplex virus: what and etiology - ANS Recurrent, incurable viral infection of genital or orofacial skin, with fluid containing eruptions on red base. two strains: HSV-1 and HSV-2. HSV-1: - herpes labilialis (cold sores) and herpes keratitis - gingivostamitits: children and adults - healing of lesions after 3 wks - more common HSV-2: - mostly genital - later in life, more severe and recurrent - lesions heal in 2-3 wks - Transmitted by vaginal, anal, oral contact/ very close physical contact - improper use of condom genital herpes findings - ANS - Flulike symptoms - pharyngitis - itching, pain - urinary retention and dysuria - le weakness - hyperparesthesia - small, multiple painful vesicles over external genitalia - painful ulcerating papules - white necrosis on cervix - inguinal lymphadenopathy - extragenital cutaneous lesions on hips/ buttocks Recurrent: - precipitated by trauma, period, stress, illness, fever, sun - local burning, itching, tingling - lesions in 3 days, resolve in 7 days

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

genital herpes diagnostics - ANS - Tzanck smear: immediate results and sensitive - collect specimen from vesicular lesion - HSV culture (test of choice). Results in 7 days - Western blot also accurate Herpes management - ANS - No cure First episode: - Acyclovir Pregnant: - Doxycycline Recurrent: - Acyclovir - suppressive tx if more than 6/ year Teaching on sexual transmission Human Papillomavirus (HPV), what and etiology - ANS Infection at basal cell layer that causes genital warts, cervical abnormalities, and cancer Low risk for ca: HPV 6 and 11 and low grade cervical changes High risk for ca: HPV 16 and 18 Incubation: week to months for warts, years for cancer Most common STD HPV findings and diagnostics - ANS - no findings often - genital warts: cauliflower like, smooth/ flat papules, warts in areas of coital friction - visual inspection of genital warts - biopsy for: uncertain diagnosis, immunocompromised, worsening lesions despite tx, persistent ulceration

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

HPV management - ANS - Pap smear for all sexually active women - tx will treat infectivity but not cure - sinecatechins ointment or imiquimod on warts until gone - Cryotherapy - Partner exam not necessary - all women age 9-26 should get vaccine Syphilis, what and etiology - ANS Systemic STI with 4 stages: primary, secondary, latent, tertiary. caused by treponema pallidum. Incubation period: 21 days. Infection at site of inoculation: small sore. Syphilis findings - ANS Primary: - Chancre (painless, indurated ulcer). heals in 1-5 days. - regional lymphadenopathy Secondary: - Flulike symptoms - maculopapular rash on palms and soles of feet 2-6 wks after infection - patchy alopecia - wartlike lesions in mouth, throat, cervix - resolves in 12 wks Latent: - infectious for one year then noninfectious - blood test still pos for T pallidum Tertiary: - gummatous syphilis (soft granulomatous tumor) - cardiovascular syphilis - neurosyphilis Syphilis diagnostics - ANS - Dark field microscopic exam and direct fluorescent antibody test - VDRL and RPR test, 1 - 2 wks till results - Treponemal specific test

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Syphilis management - ANS Early, primary, secondary, latent: - benzathine penicillin Tertiary, exl neurosyphilis: - benzathine penicillin Neurosyphilis: - aqueous crystalline penicillin or procane penicillin - If allergic to pcn. Desensitize first. - Follow up after 3 and 6mo - Treat sexual partners presumptively - Report to health department Acetaminophen toxicity findings and diagnostics - ANS - N/V at 24-48 hrs - RUQ pain - Hypotension - Hypothermia - Hepatotoxicity; jaundice, prolonged bleeding time, hepatic encephalopathy - Draw labs after 4 hrs of ingestion - Toxicity/ liver injury at more than 7.5gr, but at lower doses for preexisting liver injury - monitor q24hrs: ALT, AST, BUN, creat, PT, bili, metabolic acidosis, lactic, alk phos, phosphate, PH Acetaminophen toxicity management - ANS - Activated charchoal, within 4 hrs after ingestion (10grams per 1 gr acetaminophen) - Remove charcoal with gastric lavage before Acetylcysteine - Acetylcysteine, within 8-10hrs of ingestion. PO or IV Alcohol toxicity findings and diagnostics - ANS - N/V - emotional lability - impaired coordination - facial flushing/ diaphoresis - resp depression - electrolyte imbalance

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- nystagmus/ diplopia - hypotension - hypoglycemia - coma Blood level - 50 - 100%: mild toxicity - 100 - 300% moderate toxicity - more than 300% severe toxicity Alcohol toxicity management - ANS - ABC's - hemodialysis to reduce ethanol levels - IV glucose - Thiamine for at least 3 days - multivitamin/ folic acid/ fluids/ electrolytes Antidysrhythmic drug overdose findings and diagnostics - ANS (From Lidocaine, Procainamide, etc) - N/V - diarrhea - blurred vision - bradycardia - hypotension - cardiovascular collapse - tinnitus - delirium/ psychosis - serum levels may confirm overdose - bradycardia with AV block - prolonged QRS - ventricular arythmia's - Torsade's - Acute lung injury - low blood counts - drug induced lupus with procainamide Antidysrhythmic drug overdose management - ANS - ECG

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- Charcoal with NG - For bradycardia: atropine or pacing - Isoproterenol to maintain HR greater than 60 Barbiturate overdose: what, findings, diagnostics - ANS Phenobarbital - confusion - slurred speech - ataxia/ impaired coordination - CNS depression/ stupor - Drowsiness/ coma - Hypothermia - Resp depression - absent reflexes - miosis (pupil constriction) Barbiturate overdose management - ANS - airway/ ventilation - charcoal for cooperative/ stable pt's - hemodynamic support/ vasopressors Benzodiazepine overdose: what, findings, diagnostics - ANS Clonazepam, Diazepam - Drowsiness - confusion - slurred speech - unsteady gait - resp depression - hypoactive reflexes Benzodiazepine overdose management - ANS - monitor BP and respiration - Flumazenil - gastric lavage

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Betablocker and calcium overose: what, findings, treatment - ANS Labetolol, metoprolol Amlodipine, Nicardipine, Diltiazem Bradycardia, hypotension, rhythm changes - Give Gluconate/ Glucagon and calcium chloride - Atropine for bradycardia - Monitor and treat electrolyes (K) - charcoal - ECG and possible pacing carbon monoxide poisoning findings - ANS - SOB - HA - confusion/ ams - n/v - weakness - blurred vision - parkinsonism - dysrythmia's - cardiac arrest - HF - resp depression - hypoxia - elevated carboxyhemoglobin level - Sinus tach - ST depression and PVC's - metabolic acidosis carbon monoxide poisoning management - ANS - 100% O2 with mask or intubation - may require hyperbaric O2 if carboxyhemoglobin levels are greater than 25%, or pregnant, or ams

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Opioid toxicity: what, findings, treatment - ANS Codeine, heroin, methadone, opium, morphine, oxycodone - hypothermia - ams/ drowsiness/ coma - resp depression - miosis - ECG - ventilatory support - Narcan 0.4-2mg q2-3min Lithium toxicity findings - ANS - n/v - muscle weakness/ tremor/ rigidity - ataxia - dementia/ delirium - lithium level greater than 1.5 - hyperglycemia - AV-block/ prolonged QT - DI - seizures - leukocytosis - stupor/ coma Lithium toxicity management - ANS - bolus NS - charcoal ineffective - gastric lavage for acute ingestion - within 1 hr - diuretics for lithium greater than 2-2 mEq - hemodialysis - benzodiazepine for seizures Hymenoptera stings: what and findings - ANS Bees, wasps, ants - Painful wheel/ hive from venom, IgE-mediated - anaphylaxis rare but possible - sever urticaria

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- bronchospasm/ laryngospasm - n/v - hypotension Hymenoptera stings, management - ANS - Remove stinger (don't squeeze/ pinch) - oral antihistamine (benadryl) - steroid taper (severe cases) Anaphylaxis: - band application above sting with band (no occlusion of arterial artery) - ice area - elevate legs - epi 0.5-1mg q15min PRN respiratory compromise - benadryl 50mg IV once - Corticosteroid 250mg Widowspider bite findings - ANS - pinprick - slightly red site - symptoms 1hr post bite - spasmodic muscle pain - resp distress - tachycardia - htn - n/v - ha - anxiety Widowspider bite management - ANS - ice site - ABC's - Dilaudid for pain - Lorazepam for muscle spasms Brown spider bite findings - ANS - painless bite - unnoticed - 2-8hrs post bite: red, pruritic, localized, painful swelling - 12-18hrs post bite: small, vesicle with irregular border redness/ swelling - blister ruptures and redness becomes darker, spreading downward

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- 5-7 days: necrosis - necrosis sloughs and leaves ulcer that takes weeks to heal Children: systemic hemolysis - fever - ha - malaise - RF - shock - seizures - coma - death Brown spider bite management - ANS - Ice site - daily, local wound care - tetanus prophylaxis Scorpion sting findings - ANS - no allergic reaction - immediate, intense pain - swelling/ bruising Systemic signs: - hypersalivation - dysphagia - visual changes/ rolling eyes - resp distress - htn - muscle spasms/ paralysis Scorpion sting management - ANS - ice site - analgesics - tetanus prophylaxis - ABC's - may give b-blocker for svt - may give antivenin for severe symptoms Dog, cat, human bites treatment/ facts - ANS - may cause infection, may rinse out with NS or LR to prevent infection

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- give prophylactic AB, augmentin - determine rabies status for animal bites - leave wounds to hands and le open - wound older than 6hrs, leave open Palliative extubation, management - ANS - remove unnecessary treatment - treat pain (HR, RR, expression): morphine, fentanyl, versed - remove mechanical ventilation in stepwise fashion, while assessing and treating pain ANA Code of Ethics for Nurses - ANS -In all professional relationships, practices with compassion & respect -Primary commitment is to patient, family, group, community -Promotes, advocates, protects health, safety, & rights of patients -Responsible & accountable for his/her own patient care practice -Owes same duty to self as to others, with integrity, competence, growth -Participates in improving ethical and safe, high quality health care environments -Participates in advancement of profession with research -Collaborates with other health professionals & public to protect human rights, reduce health disparities -Profession of nursing, as represented by associations/members...responsible for values & integrity & shaping social policy Autonomy - ANS the right to make their own decisions based on their own beliefs and values, for the patient Veracity - ANS being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to patient distress Beneficence - ANS Action should promote good Non-malfeasance - ANS Ethical concept requiring that an action do no harm, or do less harm than good Justice - ANS All patients have a right to be treated fair and equally by others.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

AACN Clinical Standards for Acute Care Nurse Practitioners - ANS • perform comprehensive advanced health assessments • order and interpret the full spectrum of diagnostic tests and procedures • formulate a differential diagnosis to reach a diagnosis, and • order, provide, and evaluate the outcomes of interventions. The ACNP provides comprehensive advanced nursing care across the continuum of health care services to meet the individualized needs of patients with acute, critical, and/or complex chronic health conditions. ACNPs do not require physician supervision or oversight as may be defined in collaborative practice arrangements to fulfill their role. - The ACNP elicits relevant data and information concerning patients with acute, critical, and/or complex chronic illnesses or injury - The ACNP analyzes and synthesizes the assessment data in determining differential diagnoses for patients with acute, critical, and/or complex chronic illnesses or injury. - The ACNP identifies individualized goals and outcomes for patients with acute, critical, and/or complex chronic illness or injury - The ACNP develops an outcomes-focused plan of care. - The ACNP implements the interventions identified in the interprofessional plan of care for patients with acute, critical, and/or complex chronic illness or injury. - The ACNP evaluates the patient's progress toward the attainment of goals and outcomes AACN professional standards for Acute Care Nurse Practitioners - ANS - The ACNP evaluates his or her clinical practice in relationship to institutional guidelines, professional practice standards, and relevant statutes and regulations. - The ACNP maintains current knowledge of best practices. - The ACNP collaborates with the patient, family, and members of the interprofessional team across the continuum of care. - The ACNP integrates ethical considerations into all areas of practice congruent with patient and family needs and values and the ANA Code of Ethic

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

- The ACNP engages in organizational systems and processes to promote optimal outcomes. - The ACNP incorporates evidence-based diagnostic strategies, therapies, and complementary health alternatives to achieve optimal fiscally responsible outcomes. - The ACNP leads in the practice setting and in the profession. - The ACNP promotes respect for colleagues and the interprofessional team through the implementation of standards supporting a healthy work environment. - The ACNP evaluates and enhances the quality, safety, and effectiveness of care across the continuum of acute care service - The ACNP enhances knowledge, attitudes, and skills through participation in research, translation of scientific evidence, and promotion of evidence-based practice. ICD 10 vs CPT - ANS The ICD-10 procedural coding system (ICD-10-PCS) is used by facilities (e.g., hospital) to code procedures. CPT codes are, and will continue to be, used by physicians (and other providers) to report professional services. credentialing vs privileges - ANS Credentialing is a formalized process that incorporates established guidelines to confirm that a health care provider possesses sufficient qualifications, licensure, training, and abilities to practice at a nationally approved standard of care. Privileging is a process that authorizes a provider to perform a specific set of care services that the agency determines the provider is qualified to perform Macule - ANS A circumscribed, flat area of discoloration that is less than 10 mm* in diameter. Example: Freckle Patch - ANS A circumscribed, flat area of discoloration that is greater than 10 mm* in diameter. Slight scale may or may not be present. Example: Vitiligo Papule - ANS A circumscribed, elevated, solid lesion that is less than 10 mm* in diameter.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Example: Wart plaque - ANS A circumscribed, elevated, solid lesion that is greater than 10 mm* in diameter and is usually broader than it is thick. Example: Psoriasis Weal - ANS Transient, circumscribed, edematous papules or plaques caused by swelling in the dermis. Wheals may manifest with erythematous borders and pale centers and/or a narrow peripheral zone of pallor or vasoconstriction. Example: Urticaria Ulcer - ANS A circumscribed loss of the epidermis and at least upper dermis. Ulcers are further classified by their depth, border, shape, edge, and the tissue at its base. Example: Venous stasis ulcer Bulla - ANS A large, raised, circumscribed blister that is greater than 10 mm* in diameter and is fluid filled. The fluid can be clear, serous, hemorrhagic, or purulent. Example: Pemphigus vulgaris Cyst - ANS A closed cavity or sac containing fluid or semisolid material. A cyst may have an epithelial or endothelial lining. Example: Epidermal inclusion cyst Pustule - ANS A purulent (pus filled) vesicle. Pustules are filled with neutrophils and may be white or yellow. Not all pustules are infected. Example: Bacterial folliculitis Vesicle - ANS A small, superficial, circumscribed blister that is less than 10 mm* in diameter and is fluid filled. The fluid may be clear, serous, hemorrhagic, or purulent. Example: Herpes zoster Purpura - ANS Bleeding into the skin that results in violaceous (violet or purple) discoloration that varies according to its duration and does not blanch with

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

pressure. Purpura includes petechiae and ecchymoses. When purpuric lesions are palpable, they represent vasculitis (vascular inflammation). Example: Henoch-Schönlein purpura petechiae - ANS Tiny, 1- to 2-mm (pinpoint to pinhead size) nonblanchable purpuric macules resulting from the rupture of small blood vessels. Color may be red, purple, or brown. Example: Rocky Mountain spotted fever

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Untitled document - 2023-12-31T125027.950

Related Documents