Shelbye's CSON Notes Blog
Med-Surg Unit 1 Exam OutlineEar StuffStructure of EarExternal EarPinna is the cartilage embedded in the temporal boneExternal ear canal is the tube from the outside of your ear to the eardrum. Lined with wax (cerumen), sebaceous glands and hair folliclesTympanic membrane is your ear drumMastoid process is the bony ridge behind the pinnaMiddle Ear- space b/w inside of the tympanic membrane to the round and oval windowsEpitympanum has the 3 bonesMalleus/HammerIncus/AnvilStapes/StirrupsEustachian TubeDrains the stuff in your ear down the back of your throatInner Ear- proximal side of oval window to the distal end of the CN VIIISemi-circular canalsCochlea- the spiral thing. You can hear because of thisEndolymph and perilymph are fluids that cushion stuffOrgan of Corti- receptor end-organ of hearingFunction of EarHearingSound moves thru the canal to the TM (tympanic membrane/ear drum). TM moves which moves the 3 bones (malleus, incus, and stapes). These vibrations are sent thru the cochlea which has receptors in it that change the vibration to nerve signals. The impulse goes to the brain via the 8th CN and the brain interprets it. Viola.Changes with AgingEar wax (cerumen) dries out and is more easily impacted or stuck in places it shouldn’t be stuckTM isn’t as elastic, bony ossicles move less. They’re old so stuff gets stiffCochlea receptor hair thingies naturally degenerate and stop working. As you get older you lose the ability to hear high frequencies cause the receptors that are responsible for high frequencies wear out. Hearing acuity is diminishedOtotoxic DrugsAntibiotics like E-mycin, Vanco, Gentamycin, etc. Note the ending, -mycinDiruetics like Diamox, Edecrin, and LasixNSAIDs like Motrin, Indocin, Naprosyn, and SalicyatesMisc drugs like Tergretol, Quinine, and PlatinolDiseases of EarExternal Otitis Patho: Irritation/infection of the external earCausesAllergies- you’re allergic to cosmetics, earphones, hearing aids, etc. Bacteria/Fungus – pseudomonas, staph, strep, or aspergillusTrauma- you stab yourself in the ear, or whateverSystemic IllnessCan be a result of brain abscess or meningitis. There can be necrosis of the outer ear or nearby structures. There is a high mortality rateManagement of External OtitisAssessment – look for pain or itching, reduced hearing due to the ear being plugged or so swollen the sound can’t get in, and redness or swellingTreatment – reduce inflammation and pain, use warm heat on the ear, use topical antibiotics or steroids and/or systemic analgesics (for pain). FurunclePatho: Bacterial infection of the hair follicleS/S: intense pain to the touch, redness, edema. It may come to a purulent head (a white head full of pus)Treatment: heat and antibiotic drops (abx gtts)Teach: Hygiene for hearing aids, etc. Basically wash yo shit before you put it in your earClogged up ear due to Cerumen or Foreign BodiesCerumen may require softening prior to irrigation. Irrigate with a mix of water and hydrogen peroxide. Use 70 mL of solution at body temperature Foreign body you DON’T irrigate if it’s vegetable matter. If they are unfortunate enough to have a bug stuck in their ear kill it with mineral oil prior to removal. Do NOT irrigate if TM is perforated or otitis mediaOtotis MediaPatho: a condition of the middle ear which can be acute or chronic. It’s an infection and inflammation of the ossicles which affects the Eustachian tubes and mastoid bone. If left untreated you can develop conductive hearing lossAssessment: Look for pain with or without movement of the external ear. Is there a sensation of fullness in the ear? Is the hearing diminished? TM appearance varies; may be retracted, red, bulging or have decreased movementManagementNonsurgical – use warm heat, systemic abx (antibiotics) analgesics, antihistamines and decongestantsSurgical – myringotomy (tube put in TM) to drain fluid, tube placement for chronic OM. You want to keep fluid and objects away from the ear canal. Don’t use eardrops unless directed by a physicianMastoiditisPatho: infection and inflammation of the epithelial lining of the mastoid air cells in the bone. It’s secondary to otitis mediaAssessment: look for swelling behind the ear, pain with movement of tragus, pinna, or your head. You may develop cellulitis. TM can be dull, red, and immobile. May have swollen or tender lymph nodesManagementNonsurgical – abx effects are limited due to the bony structure Surgical – mastoidectomy with tymphanoplasty, basically remove part of the mastoid bone and try and rebuild the bony ossicles and TMComplications – damage to the nerves, vertigo, meningitis, and brain abscessTraumaCan be due to a direct blow, foreign object, or rapid change in the middle ear cavity pressureManagement is stressing prevention or repairing the damage thru surgeryNeoplasms (Tumors)TypesGlomus jugulare – benign vascular tumor from the jugular veinAdenocarcinomas or other CarcinomasAny kind of growth that disrupts conductive hearingTreatment: Surgery, radiation therapy, may lose hearing in the affected earTinnitus (Inner ear )Patho: It’s a continuous ringing or noise in the ear. Can range from a mild ring to a load roar.Possible Causes: presbycusis, otosclerosis, Meniere’s disease, medications, or exposure to loud noisesTreatment: you treat the cause, not the tinnitus itself Vertigo (inner ear)Patho: sense of whirling in spaceManagement: Treat the underlying cause and the associated symptoms, not the vertigo itself. Patient Education: Restrict head motion and move slowly. Maintain hydration. Use fall precautions like canes and walkers (cause they’re dizzy, they might fall, duh…). Dizziness (Inner ear)Patho: disturbed sense of person’s relationship to spaceLabyrinthitisPatho: an infection of the labyrinth as a result of otitis media, cholesteatoma, middle or inner ear surgery, URI or mononucleosis. Pt’s will have complaints of tinnitus, hearing loss, vertigo, and N/V. Complications can cause meningitis and there is a risk of permanent hearing loss.Treatment: Systemic abx, antiemetics (to treat the N/V), safety precautions like the ones used for vertigo (cause they can have vertigo with this). Meniere’s DiseasePatho: An overproduction or decreased reabsorption of endolymphatic fluid. There is a distortion of the inner canal system, dilation of cochlear duct, and damage to the vestibular system. The 3 distinct characteristics of this are tinnitus, vertigo, and unilateral sensorineural hearing loss. It’s associated with a viral or bacterial infection, allergies, and long-term stress.S/S: Severe attacks with symptom free periods, severe H/A, increased tinnitus, a full feeling in the affected ear, severe vertigo, and rapid eye movementManagementNonsurgicalSince they have vertigo use the safety precautions for vertigo, restrict salt and fluids, stop smokingMeds: Diruetics, nicotinic acid, antihistamines, antiemetics, and DiazapamSurgical Labyrinthectomy and endolymphatic decompressionAcoustic NeuromaPatho: A benign tumor of the CN VIII (8). May involve cerebellum. May damage hearing, facial movement and sensation. Treatment: Craniotomy for removal of tumorHearing LossConductive Hearing LossPatho: Something is in the way blocking sound so you can’t hear correctly. Usually corrected with minimal damage. Can be caused by inflammation or obstruction of external or middle ear, changes in the TM and otosclerosis. Sensorineural Hearing LossPatho: Inner ear nerve or sensory fiber damage. There isn’t something blocking the sound getting from outside your head to your brain like conductive hearing loss, but something is wrong in your body fucking up the process. It’s often permanent, usually has a gradual onset, and is often bilateral. A lot of times people are unaware it’s going on. They lose high-frequency hearing and they can’t tell the difference b/w soft consonants. They’ll have high pitched tinnitus and may have vertigo. Causes Damage to the inner ear or CN VIIIThis can happen b/c of prolonged exposure to loud noise, ototoxic meds, HTN and arteriosclerosis, infections, Meniere’s Disease, or presbycusis (hearing loss due to increasing age)ManagementSurgicalTympanoplasty – they reconstruct all or part of your fucked up middle earStapedectomy – they use a prosthetic to replace your fucked up stapesNonsurgicalPrevention (early detection) and preservation of what you still have, meds for the underlying pathologies causing the hearing loss, and assistive devices like hearing aids or cochlear implantsAssistive DevicesHearing Aids – mini electronic amplifiers. Make sure to educate the pt on care and maintenance of the hearing aid. Tell them to use the lowest setting that works. You don’t want them using them on high if they don’t need it cause then they’ll fuck up their ear more. They’ll also have to learn to filter out the background noise. Cochlear Implants – Used for sensor neural hearing loss. There are electrodes implanted in the inner ear and a computer attached to the external ear. The computer on the outside transmits and converts sound waves to electronic impulses to the electrodes on the inside which stimulate your nerve fibers.Talking to someone who is deaf as fuckStand in front of them, get their attention before speaking to them, speak to the ear that works better, and minimize distractions. Also, have them repeat the info back to you so you know they got it. Don’t shout; they’re not retarded, they’re deaf. Shouting also raises the sound frequency making it harder for them to hear you.Eye StuffBasic Structure: Your eye is a spherical organ protected by a bony socket (orbit). It’s surrounded by 3 sinuses. LayersOuter layer (sclera) – white of the eye and the transparent corneaMiddle layer (uvea) – choroid, ciliary body and irisInner layer (retina) – the sensory layerRefractive Structures and MediaCornea, aqueous humor, lens and vitreous humorLight passes thru the structures to the retinaEach structure has a different density which refracts the lightThe refraction focuses the image on the retinaMore In-depth StructureExternal EyeCanthusConjunctivaLacrimal Gland- your tear duct that keeps your eye moisturized. Muscles- there are 6 voluntary muscles to rotate and coordinate movement of your eyeInternal EyeScelera- keeps the shape of the eyeball. Lens- clear structure that sits behind the iris. Focuses light onto the retinaPupil- dark opening in the middle of the irisIris- colored part of eye, muscles in the iris control the amount of light let into the eyeCornea- clear window in front of the pupil and the iris which always light into the eyeOptic nerve- cable like structure which carries vision from the retina to the brainVitreous- the clear gel like substance that fills the space in the eye between the lens and the retinaRetina- the delicate layer of tissue in the back of the eye that collects the light that enters your eye ( sensory layer, inner layer)Macula- the specialized area in the retina which allows us to see fine detailsNervesCN III, IV, VI – control extraocular musclesCN II – sightCN V – sensory portion of the blink reflexCN VII – lacrimal stuffAssessment of the PupilsConsensual Response: constriction of the left pupil when light is shown only on the right pupil or visa versa. Basically what one eye does, the other one does too. If you eyes are working properly then your eyes are working together. Makes sense. Accommodation: Both pupils constrict equally as an object, such as a pen, approaches the nose. The right eye doesn’t get small while the left one stays big. Kind of the same concept as above in the sense that they are working together but I think more with accommodation is that your pupils change in size depending on where the object is your trying to focus on is.Aspects of VisionAcuity – sharpness of visionFar Distance AcuityUse the Snellen chart. You’re comparing your vision to that of a perfect 20/20. You stand 20 feet away and read the chart from the big E down to the tiny lettersNear Distance AcuityUse the Rosenbaum Vision Screener. It’s 14 inches away from you. Used for people over 40 to look for difficulty readingColor Vision – your ability to see colors, duhTestsIshihara Chart – numbers composed of 1 color of dots within a circle of dots of another color. Like a blue 22 inside a green circleRefraction – basically the process of changing what your eye sees into what your brain interpretsEmmetropia –ideal, a person would see perfectly. The picture is refracted perfectly right on the retina.Hyperpoia –farsighted, the picture doesn’t have enough time to become perfect before it hits the retina, so it’s blurry. Myopia – nearsighted, the picture is refracted perfectly before it hits the retina, so when it gets to the retina it’s blurryAstigmatism- an abnormal curvature of your lens that makes the image blurry on the way to the retinaPresbyopia- loss due to age, usually appears around age 45. Eye structures harden or are less elastic so they don’t work as well. It affects your near vision, old people can’t see things close upAphakia- absence of the lens. Can be congenital or can be removed during cataract surgeryAge Associated ChangesStructure: You don’t have as much ocular muscle tone, the cornea flattens. Arcus Senillis is when your eye kindof bows outwardFunction: the lens is less elastic and shrinks and you can’t discriminate all colors as well as you used toExtraocular Conditions Affecting VisionSystemicDM, HTN, Lupus, Thyroid dysfunction, MS, Cardiac disease, and sarcoidosis (which causes granulomas/inflammatory lesions to occur in the lungsMedicationsAntihistamines, decongestion agents, oral contraceptives, beta blockers, corticoid steroids, and some antibioticsDisorders of the EyeEyelid DisordersTypesBlepharitis – chronic bilateral inflammation of the eyelid margins. Will have crustations. Involved the hair follicles. Resistant to treatment and require strong antibiotics. It’s an infection. Two types, either staph or something else. Staph is more serious. Entropion - turning inward of the edge of the eyelid. You will see it more in the elderly. Sometimes you can’t even see the eyelids.Ectropion - turning outward of the lower edge of the eyelid. Ageing, loss of tone of the skin, and infections can cause this. Looks droopy.Hordeolum – a stye. Can be acute. Usually you have an infection of the glands of the eyelids, usually caused by staph. Gets red, inflamed, swollen, very uncomfortable. Treatment is usually warm compresses applied directly to the lid or topical antibiotics. Will clear up on its own in about a week or so. Chalazion - chronic inflammation of the sebaceous glands in the eyelid. The lid is swollen, tender, red, and painful. Treatment is about the same for the stye.Strabismus- “cross eye” the pt can’t consistently focus on an object. One eye deviates in another direction. Can possibly have double vision.Treatments of Eyelid DisordersWarm moist compress and/or abx drops or ointments. You want to keep the area clean, avoid touching your eye, and wash your hands oftenEye Irrigation (Random I know, but this is where she had it in her slides…) Assess the visual acuity before you start (so you know you didn’t fuck it up during the irrigation). Use proparacain hydrochloride. Have them lay down supine with the affected eye downward (so you don’t get stuff from the bad eye into the good eye). Flush with normal saline going from the inner corner to the outer corner. If both eyes are affected then flush them simultaneouslyLacrimal System Disorders (tearing system, keeps your eyes moist)Keratoconjunctivitis sicca – common complaint of the elderly. Basically dry eye disorderChange in composition of tears, lacrimal gland or tear distribution. Problems in the quality or quantity of tears. Feels like sand or irritation in their eyes. Associated with meds, chronic disease, aging, injury, and surgeryRandom: If you don’t have enough tears you can develop corneal ulcers. Conjunctival DisordersSubconjunctival HemorrhageAssoc. w/ increased pressure in eye Also assoc. w/ trauma, HTN, blood dyscrasias Bright red under conjunctivaPainlessNo vision impairmentResolves 10-14 daysConjunctivitis- most common ocular disease worldwide. “Pinkeye” Types are allergic, infectious, and trachoma (bilateral conjunctivitis in children that will cause blindness. Super very much bad news…S/S Burning, itching, lots of tearing, vascular enjoyment (vessels are protruding and rich with blood), edema, infection (may even have drainage)TreatmentMeds, infection control, WASHING HANDS!! Avoid makeup and other irritantsCorneal disordersCausesKeratoconus- the cornea turns into a sort of cone shapeDystrophies- scarring, erosions of the eye (Over 20 different types) Can affect all parts of the cornea. Usually inherited and progress gradually. Keratitis- corneal ulcers (often caused by dirty ass contacts)Bacterial Disruption of corneal epitheliumSecondary to abrasion or traumaTreatments are topical or systemic antibioticsViralHerpes SimplexPain and photophobia (light sensitivity)Treatment is topical antivirals like ViropticUlcerationsS/S of Corneal DisordersPain, decreased vision, cloudy/purulent fluid on the lids/lashesCornea has a hazy/cloudy appearanceAltered corneal light reflexInterventions for Corneal DisordersMeds- antibiotics, steroids, NSAIDs drops or ointmentsVision Enhancement- assist in use of functional vision and reduce irritantsSurgery- Keratoplasty (corneal transplant)Lens DisordersCataractsPatho: lens fibers become compacted. The lens gradually loses its clarity and distorts the image of the retinaEtiology: aging, trauma, toxicity, associated, complicatedS/SEarlyBlurred vision and decreased color perceptionLateDiplopia, reduced visual acuity, absence of red reflex (an orange red reflection from the retina when you use an optholmascope and look at it). You don’t see the orange because of the cloudiness keeps the light from going thru the lens to the retina, and white/cloudy pupilsAge Related Cataracts have no pain or redness!!! Cataract SurgeryInfo about surgeryPre-opSeries of anesthetic and mydriatic drops pre-opProcedure done with anesthetic block and mild sedation, but your ass is still awakeShitty lens taken out and new fancy lens implantedThey will wear glasses to correct the vision before surgery and this helps make the surgery easier or something. She said remember this…Post-opWear a patch and protective shieldFeels like you have sand in your eyePost op pain may indicate increased IOP (intra ocular pressure) or hemorrhageInfectionObserve for increased redness, change in visual acuity, or tearing or photophobia, but white crusties are normalBleeding from the incision, iris, or ciliary body. This can happen up to several days after surgery. Report changes in vision STAT!Discharge teachingAvoid activity that will increase IOP (Increased ocular pressure)Don’t bend from waistDon’t blow nose, sneeze, or coughDon’t strain with bowel movementsDon’t vomit, don’t lie on the surgery sideNo heavy liftingMedication administrationEye protection with shield or glassesGlaucomaPathoImbalance of aqueous humor production and outflowAqueous humor build up = reduced blood flow to optic nerve and retinaNormal IOP is 10-21If higher, can cause tissue ischemia and deathDamage begins in periphery and moved inwardUntreated results in blindnessEarly detection is very important in preventing this!!TypesPrimary open-angle glaucoma (POAG)Slow painless onset, reduced outflow of AH via chamber angleMost common of all types of glaucomaOPENO= occasionally see halos around lightsP= peripheral vision loss, gradual Painless, Progressive vision lossE= early stage is asymptomatic, Enlarged optic cupN= Not an emergencyAngle-closure glaucoma (acute)RareSudden onset, emergency situationIris gets displaced and the chamber closes and becomes narrow, which blocks the drainage of the AH (aqueous humor)SecondarySudden onsetSecondary to disease that narrows the angle or increases the fluid volume in the eyeClinical ManifestationEarlyIncrease in IOPDiminished accommodationLateDiminished visual fieldDecreased visual acuity not corrected with glassesHalos appear around lightsH/A or eye painIncreased cup-disc ratio (pressure in your eye fucks up where everything is supposed to be)Pale optic diskTreatment of GlaucomaAnnual check of IOP (Prevention is key!!!)Meds: miotics, beta blockers, carbonic anhydrase inhibitors, and osmotic agentsSurgical TreatmentLaserMakes a hole in the iris and allows the fluid to drain out normally. Your normal drain hole is fucked up, so they make a new hole! Or they can burn holes in your eye. Standard surgery Create new drainage for AH or destroy structure responsible for AH production. This is the old way they do things, but not really anymorePatient EducationIOP & desired rangeVision loss & optic nerve damageMedications & effect on eyesEye gtts & side effectsHow to instill eye gtts Regular exams with automated perimetry testing (Prevention is key!!)Ocular Chamber DisordersVitreous HemorrhageBleeding into vitreous cavityR/T: ageing, trauma, systemic diseaseMay c/o seeing red haze, black dotsRed reflex diminishedHeals itself but may require vitrectomy (removal of the gel/vitrious from the eyeball and replaces it with a clear fluid similar to the stuff that was in there in the first place)Retinal DisordersHypertensive retinopathyHigh DBP (diastolic blood pressure) r/t narrowing of retina arteriolesArterioles appear like copper wire & nickingLocalized ischemia “soft wool” appearanceMay result in retinal detachmentMay c/o HA & vertigoTreatment – manage HTNDiabetic RetinopathyDirectly r/t BG (blood glucose) control and length of diseaseBackground DRProliferative DRRetinal detachmentPathoSeparation of sensory retina from pigmented epitheliumC/O bright flashes of light, floating dark spots, or curtain over visual fieldTreatmentCryotherapy- prevents any further detatchmentPhotocoagulationDiathermyScleral Buckle- take plastic or silicone sponge thing that they sew onto the retina to hold it in place and not drop anymore. Holds it in place like a belt buckle holds your fat ass in your pants. Best treatment for this problemMacular Degeneration- gradually destroys sharp, central visionTypesAtrophic (dry)Sclerosing of retina capillariesMacular cells – ischemic & necroticRod & cone photoreceptors dieReduce risk by nutrition therapy Exudative (wet)Detachment of pigment epithelium in maculaBlood & fluids accumulate under macula & form scarManagement of Macular DegenerationAtrophicMaximize use of remaining visionExudativeLaser treatment – seal leaking blood vesselsTraumatic DisordersTypesHyphema – a hemorrhage in the anterior chamber. Looks red in the colored part of your eyeContusion – blow to the eyeball and surrounding tissue (also called a black eye)Lacerations – A tear/cut on your eyelids and/or cornea from foreign objects.Penetration – a stab like penetration into your eye. Getting poked, not slashed like a lacerationS/S of Eye TraumaPain or mild discomfort. May have reduced vision or photophobia. May also have edema and redness of the eye and surrounding tissuesManagement of traumaIce to reduce edema, bed rest, and eye drops, eye rest, and surgery (if you need it)Ocular MelanomaPatho: cancer of the eyeSymptoms: blurred vision, increased IOP, reduced visual acuity, and change in iris colorTreatment: surgery and/or radiation therapyBlindnessAffects any or all aspects of vision (color, light, image, movement, and/or acuity)Management: Teach ways to function with existing vision (if they have any), orient them to the new environment, assist them with ambulation, and have the staff come in and identify themselves and their purpose for being in the room for them to not feel threatened/confused/angry or whatever…Refractive SurgeryWhat it does: Reshapes the corneal tissue and corrects refraction errors. It doesn’t alter aging processes of the eye. There is also no guaranteeTypesRadial Keratotomy (RK) Photorefractive Keratectomy (PRK) – treats myopia and hyperopia with or without astigmatism. A laser is applied directly to the cornea. With myopia they decrease the curvature of the cornea and with hyperopia they increase the curvature of the cornea. There is going to be post op pain due to the corneal abrasion.Laser-Assisted In Situ Keratomileusis (LASIK) – it’s better than PRK for severe myopia. Used to correct residual myopia after cataract surgery. They flatten the anterior curvature of cornea. They make a flap with microkeratome and “shave off” layers of your cornea. They can use implantable devices combined with LASIK for more severe problems.Contraindications for Refractive SurgeryIf you have an unstable cornea or refraction, a current eye infection, or a condition with adverse cornea healing (like steroid use, immunosuppression, or elevated IOPComplications of Refractive SurgeryAblation Complications – raised area in ablation siteDiffuse Lamellar Keratitis – inflammatory reaction of lamellar interfaceCentral Island and Decentered Ablation – shift of the center of ablation siteFYI – ablation just means removal of tissueInstillation of Ophthalmic MedicationsWash your hands before and after, wear gloves. Put pt in supine or sitting up with head tilted back. Create a pocket with the lower lid (squish the sides of the lower lid to make the middle come out). Put the meds into this pocket and have the pt gently close their eye. Teach about possible side effects of whatever med you are using. Kinds of Meds at the end of her lectureTopical AnestheticsUsed before procedures to prevent pain. Don’t rub your eyes. These aren’t for home use. Examples are tetracaine and pontocaineTopical SteroidsUsed for inflammatory conditions of the eyes, eyelids, anterior chambers, lens and uvea (steroids inhibit inflammation so if you’ve got a problem with inflammation then you’d use these…) Would use long term if you had glaucoma or cataracts. These predispose the pt to local infection. Examples are Ocu-Pred, Dexotic, and Fluor-OpAnti-InfectivesCan be abx, antifungal, antiviral. Make sure and clean exudates from the eye before giving the drops. Since they have an infection, you may need a culture before starting the drops (to see what it is they’re infected with and to use the appropriate drops). As always with these guys it’s important to complete the full course of meds. Examples are Gentamycin, Tobrex, and OcufloxWith antiviral agents make sure and refrigerate/protect solution from light. Monitor pt for itching lids and burning eyes because drug sensitivity is common. Examples of these are Viroptic and HerplexAntibiotic-Steroid CombinationsMake sure you know the use and side effects for each drug alone, cause when given together they’ll get the same… If component A causes itchiness then if you give AB it will still cause itchiness… Example are Tobra-Dex (tobramycin and dexamethasone) and Maxitrol (neomycin and dexamethasone)Beta BlockersUsed for glaucoma cause they decrease IOP by reducing AH production and doesn’t cause papillary constrictionMake sure to apply mild pressure at the tear duct to prevent the drops from getting in there (this would cause systemic absorption). Examples are Timpotic and Betagan. MioticsUsed to treat glaucoma because they constrict the pupil to improve AH outflow by increasing iridocorneal angle. Gives them little pupils. Constricting the pupil may cause decreased visual acuity in low light settings, so make sure and tell them not to drive at night and to be safe, all that crap. Examples are Isopto Carbine and MiostatMydriatics and CycloplegicsThese are given prior to ophthalmic exam or procedures. The Mydriatics dilate and paralyze the pupil (making them huge!). The Cycloplegic paralyzes the ciliary muscle and dilates the iris. These both have a short duration. They cause blurring of vision when dilated. And since the pupils are open wide they will be photophobic, so make sure and tell them to wear sunglasses, avoid sun exposure, etc. Examples are Cyclogyl and AtropineNonsteroidal Anti-Inflammatory AgentsUsed for chronic eye conditions and inflammation. Make sure and monitor for bleeding in the eye because these meds can disrupt platelet aggregation and if they are bleeding it won’t stop. The patient CANNOT wear soft contact lenses because the med interacts with the material the contact is made out of and this interaction increases the risk of infection. Examples are Voltaren and AcularRespiratory StuffAtelectasis – closure or collapse of alveoli due to incomplete filling of air. Can be acute or chronic. It’s primarily detected on x-ray and by S/SS/SCough, low grade fever (probably linked to inflammation distal to the obstructed airway), dyspnea, tachycardia, tachypnea, pleural pain, and central cyanosisAcute S/S may have marked respiratory distress, meaning it’s obvious they can’t breathe. If laying flat they will have a lot of difficulty breathing and they may be anxiousAssessment FindingsDecreased breath sounds (cause the lung is fucked up and not working as well as it should), crackles over the affected area (cause the spot is collapsed and rubbing against itself) and the CXR (Chest X-Ray) may reveal patchy infiltrates or consolidated areasWho’s at risk? Post op patients – b/c they’ve been under anesthesiaImmobilized pt’s – cause they’re not moving and their lungs are getting lazyPt’s experiencing pain – b/c they hurt so much they don’t want to move and TCDBAltered lung defense mechanisms – smokers, people who are intubated, etc. What can the nurse do? TCDB, encourage early mobilization, IS (incentive spirometer), suck secretions out to make it easier for them to breathe, use aerosol nebulizer treatments, and relieve the pt’s pain. They are more willing to work with you if they aren’t hurting like crazyPneumonia (Read Brunner pg 639, the Nursing Process of Pneumonia)Info/PathoInflammation of the lung parenchyma (functional part of any organ or tissue)Most common cause of death from infectious disease in the US7th Leading cause of death in the USTypesCommunity AcquiredMost prevalent in the winter and springMost commonly caused by S. pneumoniaMycoplasma – occurs mostly in older children and adult (it’s the most contagious)Spread by droplets thru person to personH. influenza – affects elderly people and those with comorbiditiesViral – most common in infants and children (uncommon in adults)Immunocompromised adultsCytomegalovirus, herpes simplex, adenovirus, and respiratory syncytial virusHospital Acquired Pneumonia (Nosocomial)Happens when pt has been in the hospital. There is a high mortality rate associated with this. Onset of symptoms more than 48 hours after admissionPredisposition due to impaired host defenseThey’re already in the hospital which means they’re sick already, so they’re more likely to get pneumoniaImmunocompromised Host Pneumonia (PCP)Caused by pneumocystis cariniiUsually bugs that have a low virulenceThe bugs aren’t that great at causing disease, but since the guys with this are already immunocompromised the bugs are able to get in there and go to townOften the initial complication of AIDSSubtle onset leading to progression of dyspnea, fever, and nonproductive coughAspiration PneumoniaEndogenous or exogenous substances into the lower airway. It’s most commonly caused from bacteria aspirated from your mouth or upper airways. Common pathogens are S. pneumonia, H. influenza, and S. aureusHow can we prevent it?Follow the rules for patients receiving tube feedings and continuous TPN/HAL. Protect the airway of patients who are vomiting! Clinical ManifestationsSymptoms depend on the causal organism and presence of underlying diseaseH/A, low grade fever, pleuritic pain, myalgias (generalized pain everywhere), sometimes a rash, pharyngitis (painful throat), SOB when laying down (called orthopnea), poor appetite, diaphoretic, purulent sputum (shit ton of mucus). If the pt has strep pneumonia these symptoms will be severeAssessment and Diagnostic findingsHx – possibly recent URI. You always want a thorough history… alwaysPhysical exam, CXR, blood culture (bug could cause bacteremia), and sputum exams (you want to know what the bug is so we can give them the correct antibiotics)Risk factorsConditions producing mucus or bronchial obstruction (like COPD or cancer)Immunosuppressed or neutorpenic personsSmokingProlonged immobility and shallow breathingDepressed cough reflex or abnormal swallowingPt’s with tubes in their throats (NPO patients)Supine positioning (cause they’re laying down, makes it easier to aspirate)Being drunk (suppresses the body’s reflexes so they’re a little slow to react)Anethesia, sedatives, or opioids (causes respiratory depression)Advanced age (when we get old we have a depressed cough, everything slows down)Antibiotic therapy- antibiotics can kill off good bacteria along with the bad onesRespiratory therapy- since they are in there a lot they have more chances of spreading bugsHealthcare workers transmissionMedical ManagementAntibiotic TherapyMacrolides (Zythromax), Clarithromycin, Doxycline, and FlourquinolonesSupportive TherapyHydration- to loosen the secretionsAntipyreticsWarm, moist inhalationsAntihistamines and nasal decongestantsBed restOxygenation (if needed)Complications- these are usually the people who haven’t looked for treatment until it gets super bad… Pleurisy- inflammation of the pleuraAtelectasis and pleural effusionSuperinfectionsShock and respiratory failureWhat can the nurse do?Maintain and improve airway patencyLift the HOB up, hydrate them, suction themMonitor respiratory and oxygenation status, promote rest and conserve airway, promote fluid intake, maintain nutrition, promote patients’ knowledge, and maintain infection control measures!!!Pneumococcal VaccinationRecommended for high risk groupsOver 65 years old, chronic illness, functional/anatomical asplenia (don’t have a spleen), special environments (people who are around it constantly), immunocompromised people.Do not give in the 1st trimester of Pregnancy!!!!Pulmonary TuberculosisInfo/Patho: Described as “cheesy masses.” It’s an infectious disease primarily affecting the lung parenchyma (but can spread elsewhere). It’s airborne in transmissionWhy is there an increase in TB?HIV/AIDS increase, immigration, poverty, malnutrition, overcrowding, inadequate healthcare, homelessness, etc.Risk factorsClose contact with TB infected personsImmunocompromised Substance and alcohol abuse Malnutrition, they don’t really take care of themselves, etcInadequate healthcarePre-existing medical conditions DM, Chronic Renal Failure, Cancer, etc. Immigration from countries with and increased prevalenceInstitutionalizationPrison, long term care facilities, psych wards, etc.Healthcare workers performing high risk proceduresPeople who suction, perform bronchoscopys, etc. Clinical ManifestationsLow grade fever, cough, night sweats, fatigue, weight loss, nonproductive or productive cough, hemoptysis (coughing up blood). Think of Doc Holliday on Tombstone. Assessment and Diagnostic findindsHx and physicalWhere have you been? Tuberculin skin testCXR (usually in upper lobes) Acid-fast bacillus smearYou need at least 3 specimens, and it’s preferable to get them early morning on consecutive daysSputum cultureMantoux TestThe TB skin test thing that we got before coming to school and what we practiced on each other. Intradermally! Read the test 48 to 72 hours. If it’s longer than 72 hours it can underestimate the reaction.A reaction has has occurred when induration and erythmia are present. A reaction of 5mm or greater is significant in a person who fits the risk population (HIV population or someone who is in contact with a TB populationA reaction of 10mm is positive in pt’s who have normal or mildly impaired immunity. Just because you get a positive TB test doesn’t mean you have TB! To get diagnosed with TB, you have to have a positive CXR, acid-fast bacillus smear, and a positive sputum culture! To get diagnosed with TB, you have to have a positive CXR, acid-fast bacillus smear, and a positive sputum culture!Medical ManagementChemotherapy agents for 6-12 monthsHave to consider drug resistancePrimary, Secondary, and MultidrugFirst Line MedicationsINH, Rifampin, Pyrazinamide, and Ethambutol are the first 4 that they use! Treatment GuidelinesInitial treatment phase:Multiple medication regimen administered daily for 8 weeks (those first 4 mentioned earlier). You’re considered noninfectious if you’ve taken the meds every day for 3 weeks! Continuation treatment phase:Lasts for 4-7 months (INH+Rifampin) or (INH + Rifapentine)Prophylactic TreatmentAdministered to people at risk for 6-12 months. If someone in your house has TB you’re taking these meds for 6-12 months!If you’re taking prophylactic treatment you have to have your liver enzymes and renal functioning monitored for every month. You also have to have sputum tests and acid fast bacillus tests to make sure you’re not getting TBPleural EffusionInfo/PathoCollection of fluid in the pleural spaceUsually secondary to other diseases May be a complication of:Heart failure, TB, PneumoniaPulmonary infections, nephritic syndromeConnective tissue disease, pulmonary embolus, brochogenic carcinomaTransudates are filtrates of plasmaExudates are buildup of fluid in tissues or cavitiesEmpyema is accumulation of thick purulent fluid in the plural spaceS/SCaused by the underlying disease and the size of the effusionPneumonia- fever, chills, pleuritic painMalignant effusion- dyspnea and coughingLarge effusion – dyspneaSmall effusion – minimal or no dyspneaAssessment and Diagnostic FindingsDecreased or absent breath sounds, decreased fremitus, and dull flat sound on percussionIf severe pt may be in respiratory distress and the trachea may deviatePhysical exam, chest CT, thoracentesisMedical ManagementDiscover the underlying causePrevent reaccumulation of fluidRelieve discomfort, dyspnea, and respiratory compromiseIf someone has a pluerual effusion and we drain it, it’s going to reaccumulate in a few days if you don’t fix the problem causing itWhat is the Nurse’s Responsibility?Assist with thoracentesisPain managementEducation of pt and familyPulmonary EdemaInfoAbnormal accumulation of fluid in the lung tissue and/or alveolar spaceBack up of blood in the pulmonary vasculature. Results from inadequate left ventricular function, causes and increased microvascular pressure. Fluid begins to leak into the interstitial space and alveoli. SEVERE, LIFE THREATENING CONDITION!!!Most common cause is left sided heart failureCan be caused by hypervolemia or sudden increase in the intravascular spaceS/SRespiratory DistressIncreased dyspnea, air hungerCentral cyanosisAnxiety and agitationFoamy, frothy, or blood-tinged secretions b/c fluid leaks into the alveoli and mixes with airPossible confusion or stupor Develops pretty quicklyAssessment and Diagnostic findingsCXRTachycardiaCrackles on auscultationPulse ox and arterial blood gasesPulse ox will decrease and ABG’s are going to show worsening hypoxemiaMedical ManagementCardiac CauseImprove left ventricular function using vasodilators, administering O2Fluid Overload CauseDiuretics, fluid restriction, O2, possible intubation. Always monitor response of ptPulmonary EmbolismInfoObstruction of the pulmonary artery or one of its branches by a thrombusCaused by trauma, surgery, pregnancy, heart failure, age > 50, hypercoaguable states, prolonged immobility. S/SDepends on the size and locationDyspnea is most frequent s/sTachypneaChest pain (usually sudden)Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis. Sometimes like a feeling of impending doomMassive PEDefined by the degree of hemodynamic instabilityOccludes the outflow tract of the main pulmonary artery or the bifurcationsThey’s fucked up and most of the time they die super quickAssessment and Diagnostic Findings (For Massive PE)CXR (will usually be normal)EKGPeripheral vascular studies (Looking for DVT in legs )ABG analysis (may be normal)Ventilation-perfusion scan (Best one)Called a VQ lung scanShows the percentage of perfusion and ventilation in different areas of the lungs. If there is a mismatch, there is usually a high probability of PEPrevention Try and prevent the DVTActive leg exercisesEarly ambulationElastic pressure stockingsAnticoagulant therapySCD’sMedical ManagementO2 therapy – may require intubationLeg compression devicesAnticoagulation therapyThrombolytic therapySurgical intervention Embolectomy – find where the clot is and grab it and take it out. Very risky, don’t do it very oftenInferior vena cava filter (pg. 666 good picture). Have to be on cumadin if they have one of theseNursing CareHow can you minimize the risk of PE? See if their at risk and put them on prophylactic stuffMonitor pharmacological therapyManage oxygen therapyMonitor pain and anxietyLung CancerInfoLeading cancer killer among men and women in the US70% has spread to lymphatics and other sites by the time of diagnosisTypesSmall Cell15-20% of tumorsMost commonly associated with smokingRare for a nonsmoker to develop <1%Metastasis occurs earlyNon-Small CellSquamous Cell 20-30%Centrally located and arises more commonly in the bronchiAdenocarcinoma 30-40%Most prevalent and doesn’t prefer male over femalesOccurs peripherally and often metastasizesLarge Cell 10%Fast growing and arises peripherallyRisk factorsTobacco smoke, second hand smokeCancer is 10x more common in smokers than non smokersEnvironmental and occupational exposuresGenderGeneticsDietUnderlying respiratory diseaseS/SOften asymptomatic until late in the course of the diseaseCough or change in chronic coughDyspneaHemoptysis or blood tinged sputumPainFeverHoarseness, dysphagia, head and neck edema, pleural effusionCancer of the lung should be suspected in people with repeated and unresolved upper respiratory infections!Assessment and Diagnostic FindingsRespiratory symptoms in heavy smokersCXR (can usually only identify large masses, not small)CT scan (can find the smaller ones)Sputum Cytology (can’t be used to make a diagnosis)Fiberoptic bronchoscopyNeedle aspirationVariety of scansMedical ManagementSurgical resectionPrimarily used for non-small cell tumorsCure rate depends on size/type of tumorLobectomy takes out part of the lungPneumonectomy takes out all of the lungRadiation therapyUseful for nonsurgical tumorSmall % of patients Radiation is toxic to normal tissue, so it’s not the best thing in the world to try. Many complicationsChemotherapyNot usually a cure. Can alter the tumor growth. Is going to help with the metastasis that’s going on in the bodyPalliative therapyNursing CareEducateManage symptomsMaintain airwayMonitor for complicationsReduce fatigueProvide supportChest Trauma StuffBlunt traumaInfoResults from sudden compression or positive pressure inflicted on the chest wallMost common causes are MVAs, falls, bike crashes, etc. Can be life threatening! Fractures- most are benign and will fix themselves on their ownSternalMost common in MVARibMost common type of chest traumaCan cause laceration of subclavian artery or vein (first 3 ribs)Injury to spleen and liver (lower ribs)S/SSever pain, point tendernessEccymosis (lots of bruising in that area)CrepitusSwelling in the areaAssessment and DiagnosticsCXR Pulse ox and ABG’s TreatmentReduce pain, monitor for complicationsChest binders (wrap them up)Make them do TCDB (to reduce chances of pneumonia or atelectasis)Usually heal in 3-6 weeksFlail ChestInfoComplications from steering wheel injury3 or more ribs fractured in 2 or more sitesFree floating rib segmentsWhen you breath in the flail section sucks in and when you breath out they go outChest wall loses stabilityRespiratory impairmentMedical managementDepends on how big of an area is affectedTypesSmall Flail ChestClear the airway thru positioning, coughing, deep breathing, and suctioningMild-Moderate Flail ChestMonitor fluid intake, relieve chest pain, lung expansion, and secretion managementSevere Flail ChestIntubated and on mechanical ventilationPulmonary contusionInfoAssociated with flail chestAbnormal accumulation of fluid in interstitial and intraalveolar spacesCan be caused by blunt traumaDamage to lung resulting in hemorrhage and edemaS/SDecreased breath soundsTachycardiaChest painBlood tinged sputum and secretionsMedical ManagementMaintain airwayProvide adequate oxygenControl painPenetrating TraumaInfoBeing shot and stabbed is the most commonPneumothoraxSimple- spontaneous and we don’t know what caused it. Air enters the pleural space thru some kind of breach. Maybe an air filled bleb or blister on the lung. Can happen to a normal pt or a pt with emphysema.Traumatic- happen when a laceration happens to the lung itself (gunshot, stab, rib poking it, etc). Tension- Air enters the pleural space from a lacerated lung or from a small opening or wound in the chest wall. Can cause the trachea to shiftS/SPainAir hungerCentral cyanosisIncreased use of accessory musclesHypotension and tachycardiaDiaphoresisMedical ManagementEvacuate air or blood (thoracentesis followed by a chest tube)Randoms I had at the end of my stuff…Genetic abnormalities with Emphasima- alpha 1 Antitrypsin deficiency is one of the most commonly genetically linked lethal diseases among Caucasians. It predisposes young people to lobular emphysema even if they don’t smokeAllergies are the most predisposing factor when dealing with asthma. ................
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