Final Exam Review:
1. If I push the endotracheal tube too far, where will it go? Right lung so we will have absent
breath sound in the left lung. Right bronchus intubation
2. TIPS (Transjugular Intrahepatic Portosystemic Shunt): in Portal hypertension to decrease the
gastric varices bleeding by decreasing the portal venous pressure
a. This procedure reduces the portal venous pressure and decompresses the varices, thus controlling
bleeding
3. Difference between embolic and thrombotic stroke: how do you explain it to a patient in a way that
they understand?
a. Ischemic Stroke:
i. Inadequate blood flow to the brain from partial or complete occlusion of an artery causes
ischemia distal to the occlusion
ii. 80% of all stroked are ischemic strokes usually thrombolytic should work
iii. It can be thrombotic or embolic
iv. Atherosclerosis, a hardening and thickening of arteries, is the major cause of ischemic stroke. It
can lead to thrombus formation and contribute to emboli.
v. Thrombotic stroke: clot formation there
vi. Embolic stroke: it means it came from somewhere else
1. Thrombotic and embolic are almost the same except that embolic means the blood clot came
from somewhere else in the body you had clot in your carotid and it went to your brain
b. Thrombotic stroke:
i. Thrombosis occurs in relation to injury to a blood vessel wall and formation of a blood clot.
ii. Result of thrombosis or narrowing of the blood vessel
iii. Most common cause of stroke
iv. Lacunar strokes are typically asymptomatic lacunar infarcts can be seen in MRI
1. When we do the MRI in 60-70 years old patient we may see minor infarcts it means the
patient had lacunar strokes but it was totally asymptomatic
c. Embolic Stroke:
i. Occurs when an embolus lodges in and occludes a cerebral artery
ii. Second most common cause of stroke
iii. Rapid occurrence of severe clinical symptoms (loss of consciousness or neurologic deficits)
iv. Onset is usually sudden and may or may not be related to activity
v. Patient usually remains conscious, although he may have a headache
vi. Basically patient has big clot that immediately starts to travel to the brain symptoms:
dysarthria, weakness
vii. We will not miss the embolic stroke
,4. If a person has anaphylactic shock, what is the best way to figure out if the patient is doing ok?
What is the first thing you want to check? Airway, Oxygen saturation
- Anaphylactic shock can lead to respiratory distress due to laryngeal edema or severe bronchospasm, and
circulatory failure from the massive vasodilation.8 The patient has a sudden onset of symptoms, including
dizziness, chest pain, incontinence, swelling of the lips and tongue, wheezing, and stridor. Skin changes include
flushing, pruritus, urticaria, and angioedema. In addition, the patient may be anxious and confused and have a
sense of impending doom.
5. Identify an infections process. Lab results will be given, look at the lab results and figure out what
is happening: if the WBC count is high, maybe there is an infection; if the WBC count is going too
low after you start antibiotics neutropenia
Normal WBC: 5,000 to 10,000 mm3
6. What is the concentration of epinephrine that we give for anaphylactic shock? 1:1,000; if we give
IV because there is no choice of giving it intramuscular then the concentration will be 1: 10,000
a. Remember:
i. 1 mg epi is in 10ml (preloaded syringe) usually we give 3-5 ml in anaphylactic shock
if we are giving IV 0.3-0.5mg.
ii. For ventricular fibrillation we give 1mg
iii. For anaphylactic shock: 0.3-0.5mg
iv. IV: 1:10,000; IM: 1:1,000
7. If someone has shock or cardiac failure especially in heart failure, what do we want to monitor
frequently? Breath sounds (very important) because the heart starts to fail
8. African American has jaundice, where do you check for it? Hard palate
9. Select all that apply, S/S of hyperthyroidism, and hypoglycemia
a. Hyperthyroidism:
i.
Exophthalmos (bulging eyes),
ii.
cannot sit in one place, hyperactivity, decreased attention span, emotional lability
iii.
Sweating, diaphoretic
iv.Warm, sweaty, flushed skin with velvety-smooth texture
v.High HR, tachycardia
vi.losing weight, increased appetite
vii.
Diarrhea,
viii.Anxiety,
ix.Irritability,
x.Insomnia, interrupted sleep
xi.Fatigue, exercise intolerance
xii.
Tremors (place paper on hands and you will notice tremors), hyperreflexia, hyperkinesia,
xiii.Intolerance to heat,
xiv.Light or absent menstrual cycle
xv.Libido initially increased in both men and women, followed by a decrease in libido as the
condition progresses
xvi. Vision changes, retracted eyelids, global lag
xvii. Hair loss
xviii. Goiter
xix. Elevated systolic blood pressure and widened pulse pressure
xx. Auscultation of thyroid gland bruit
b. Hypoglycemia:
, i. Cool, clammy skin
ii. Tachycardia
iii. Diaphoresis
iv. Tachycardia
v. Weakness, fatigue
vi. Irritability, anxiety
vii. Mild shakiness
viii. Mental confusion
ix. Sweating, diaphoresis
x. Palpitations
xi. Headache
xii. Lack of coordination
xiii. Blurred vision
xiv. Seizure
xv. Coma
10. Best way to measure to look at fluid volume, without using interventional technique like I&O:
weight accounts for insensible loss
11. In acute renal failure there are three phases: diuresis, oliguria, anuria
a. In oliguria, how many ml/hr is the urine output? Less than 400 ml/24 hr
b. AKI is comprised of four phases:
■ Onset – Begins with the onset of the event, ends when oliguria develops, and lasts for hours to
days.
■ Oliguria – Begins with the kidney insult, urine output is 100 to 400 mL/24 hr with or without
diuretics, and lasts for 1 to 3 weeks. Edema, elevated BUN, creatinine, and potassium; increased
specific gravity; acidosis; heart failure, dysrhythmias
■ Diuresis – Begins when the kidneys start to recover, diuresis of a large amount of fluid occurs,
and can last for 2 to 6 weeks. Urine output increased by diuresis of up to 4,000 to 5,000 mL/day,
indicating recovery of damaged nephrons; decreased specific gravity; hypotension and fluid and
electrolyte imbalances are a concern
■ Recovery – Continues until kidney function is fully restored and can take up to 12 months
12. If we give the patient thrombolytic, should we put her on bleeding precautions? Yes, no razor
blades
a. Contraindications (active bleeding, peptic ulcer disease, history of CVA, recent trauma).
b. Effects of bleeding (mental status changes, hematuria).
c. Monitor for petechiae, ecchymosis, bleeding of the gums, nosebleeds, and occult or frank blood
in stools, urine, or vomitus.
d. Institute bleeding precautions (avoid IVs and injections – use smallest gauge needle in injection
is needed, apply pressure for approximately 10 min after blood is obtained, handle client gently
and avoid trauma).
e. Instruct the client about measures to prevent bleeding (use electric razor and soft-bristled
toothbrush, avoid blowing nose vigorously – blow gently without blocking with nasal passages,
ensure that dentures fit appropriately).
f. Instruct the client to avoid the use of NSAIDs.
g. Teach the client to prevent injury when ambulating (wear closed-toes shoes, remove tripping
hazards in the home) and apply cold if injury occurs.
, h. Apply ice to the area of trauma
i. Avoid trauma to rectal tissue: do not take rectal temperature, do not administer enemas,
administer well lubricated suppositories and with caution
j. No flossing – floss gently (?)
k. Avoid hard foods
l. Avoid contact sports
m. Do not take aspirin or aspirin containing medication
13. If a patient has ascites, cirrhosis, all the things that you will monitor, what are the intervention?
Select all that apply
Cirrhosis of Liver:
- Extra Note: Cirrhosis is a chronic progressive disease of the liver characterized by extensive
degeneration and destruction of the liver cells poor cellular nutrition, hypoxia (from inadequate blood
flow and scar tissue). It is in insidious, prolonged course, usually after chronic liver disease
- Most common causes: chronic hepatitis C and alcohol induced liver disease (Laennec Cirrhosis)
o Extra note: common problem with alcoholic patient is protein malnutrition
- Chronic inflammation and cell necrosis can also cause cirrhosis
- Manifestations:
o Extra note: early symptoms may include fatigue diagnosis may not be discovered until they
present with symptoms of more advanced liver disease
o Jaundice extra note: Jaundice occurs as a result of the liver’s decreased ability to conjugate
and excrete bilirubin
o Edema
o Ascites
How do we assess/diagnose ascites? remember 3 words:
1. Shifting dullness is a key when we do percussion, when we turn the patient
and percuss again the dullness shifts
2. Fluid thrill when we tap on one side we fell the vibration on the other side
3. Distended veins
o Spider angioma be careful about this Extra notes: they are small, dilated blood vessels
with a bright red center point and spider-like branches. They occur on the nose, cheeks, upper
trunk, neck, and shoulders.
o Palmar erythema redness in the palm be careful, this is very common in rheumatic heart
disease with endocarditis Extra note: (a red area that blanches with pressure) is located on the
palms of the hands.
Extra notes: Skin lesions because of an increase in circulating estrogen as a result of
the damaged liver’s inability to metabolize steroid hormones
o Generalized pruritis
o Coagulation problems *any time there is problem with clotting, check out the liver for sure!
o What is the drug that we give in gastritis that can cause gynecomastia? Simetidine – histmain
receptor blocker because it affects the liver and it can decrease the libido liver is responsible
for sex hormones so if the liver is dying the sex hormones will not be produced properly in
men, low testosterone can cause gynecomastia and also sever decreased libido, and loss of
axillary and pubic hair, testicular atrophy, impotence (these are due to increased estrogen)
very common with liver disease
- Extra Notes: Hematologic problems of Cirrhosis
