ANCC Adult Gerontology Acute Care Comprehensive Exam Latest

ANCC Adult Gerontology Acute Care Cardiac Index - 2-4 SVR/Afterload - 800-1200 MAP - mean CVx80/CO PA pressure - 15-30 Wedge PCWP pressure - 6-12 Hypovolemic Shock Parameters - Preload CVP decreased, SVR afterload increased, CI decreased, Oxygen delivery Decreased, Venous Oxygen saturation increased Types of hypovolemic shock - Hemorrhage, burns, pancreatitis Cardiogenic shock parameters - CVP preload increased, SVR afterload increased, CI decreased, oxygen delivery decreased, SV02 decreased Types of cardiogenic shock - Post mi, malignant dysrhythmia, acute myocarditis Obstructive shock parameters - Preload either, SVR increased, CI decreased, oxygen delivery decreased, SV02 decreased Types of obstructive shock - Tension pneumo, cardiac tamponade, PE Distributive shock parameters - Preload CVP decreased, afterload SVR decreased, CI increased, SV02 decreased, oxygen delivery increased Types of distributive shock - Septic shock, anaphylaxis, neurogenic shock CVP Preload - 2-8 Cardiac Output - 4-8 MAP - 70-90 Fractional Excretion of NA 1% - Prerenal state of kidney dysfunction (i.e. dehydration) Fractional Excretion of NA 2% - ATN (acute tubular necrosis) CPP equation - MAP-ICP SIADH Hyposmolar hyponatremia "inappropriate water retention" - serum sodium low, serum osmo low 280, urine osmo high 100, no dehydration, tx restrict fluids if neuro symptoms give 3%NS DI Hyperosmolar hypernatremia dry - Serum sodium high, serum osmo high 290, urine osmo low 100, urine spec grave 1.005 (urine is like water), urine sodium 20, dehydration, if serum Na 150 give D5W to replace ½ volume deficit in 12-24 hours, avoid rapid lowering of Na, DDAVP for acute situations Serum Osmo - 280 Urine Osmo - 300-800 Sodium - ~140 Total cholesterol - 200 Triglycerides - 150 HDL - 40 LDL - 100 Management of pulm edema - 02, sitting up, morphine 2-4mg, Lasix 40, another Lasix 40 if needed Left heart failure - LUNGS, dyspnea at rest, rales, wheezing, generally healthy except acute event, S3, murmur of mitral regurg Right heart failure - JVD, hepatomegaly, peripheral edema MR ASS - Mitral regurg, aortic stenosis, systolic murmurs MS ARD - Mitral Stenosis, aortic regurg, diastolic Mitral murmur locations - 5th ICS, apex Aortic murmur locations - 2nd or 3rd ICS, base S1 - AV valves closed, SL open S2 - SL closed, AV open Cardiac blood flow - SVC,RA, tricuspid, RV, pulmonic valve, pulmonary artery, lungs, pulmonary veins, LA, mitral, LV, Aortic valve, aorta, body Cushing's - Moon face, buffalo hump, hypertension, HYPERglycemia, HYPERnatremia, HYPOkalemia, tx depends on cause (stop meds, tumor) Addison's ADRENOcorticoid deficiency - Remember: SEX, SALT, and SUGAR Deficient cortisol, androgens, and aldosterone, hyperpigmentation in buccal mucosa, tanning, HYPOtension, scant hair, HYPOglycemia, HYPOnatremia, HYPERkalemia, cosyntropin is the rule out for addison's, manage: referral, glucorticoid, hydrocortisone, fludrocortisone inpatient: hydrocortisone and fluids HYPERthyroidism/Grave's - TSH LOW, T3 High, Grave's Disease, bulgy eyes, weight loss, fine thin hair, smooth skin, a fib Specialist referral, propranolol, methimazole, PTU, lugol's Thyroid crisis - PTU or Methimazole with adjunct within 1 hour Lugol's propranolol, hydrocortisone No ASA Hypothyroidism - (TSH assay most sensitive test) TSH ELEVATED, T4 LOW hasimototo's most common, LOW AND SLOW, cold intolerance, weight fain, brittle nails, brady, hypoactive BS, Levothyroxine 50-100mcg Myxedema Coma - AIRWAY, fluid replacement PRN, levothyroxine 400mcgIVx1 Subacute thyroiditis - Treated symptomatically with propanonlol Pheocromocytoma - Labile hypertension, TSH normal, postural hypotension, plama-free metanephrines to rule out, CT to confirm, surgical removal, postop: hypotension, adrenal insufficiency, hemorrhage urine catecholamines, alpha blockers phentolamine DKA - -intracellular dehydration, kussmaul, hyperglycemia 250, ketonemia, hyperkalemia Management: 1L first hour500ml/hr, 0.1/kg/hr, glucose 250 change to D51/2 when switching to subq insulin, inititate subQ insulin 2-3 hours prior to stopping insulin drip HHNK (Hyperosmolar Hyperglycemic NON KETOSIS) - Type 2 DM, super elevated glucose 600, hyperosmolar 310, normal anion gap, elevated hgbA1c, normal pH Management: massive fluid replacement, overall deficit usually 6-10L, 15U regular insulin IV followed by 10-15U subq Dawn Phenomenon - "Dawn Rising", elevated glucose at night and high in AM, increase the bedtime dose of insulin Somogyi Effect - Nocturnal hypoglycemia, elevated glucose at 0700 due to rebound, reduce or omit bedtime dose (need to know the glucose in the middle of the night) Serum Cr - .5-1.5, most sensitive renal marker BUN - 10-20, can fluctuate independent of creatinine and due to specific causes (i.e. GI bleed/dehydration) Normal fasting glucose level - 60-99 Type I DM - HLA-DR3/DR4 association, ketone development, islet cell antibodies Polyuria, polydipsia, polyphagia, random plasma glucose 200, impaired glucose tolerance 100-125, bring back in to repeat test Consult dietary, if ketones present need insulin 0.5u/kg/day 2/3 AM 1/3 PM Type II DM - Obesity and syndrome X, skin infections, recurrent vaginitis, no ketones present in blood/urine, start with weight control and diet Sulfonylureas most widely prescribed stimulate pancreas to make more insulin Biguanides- adjust for sulfonyurleas but cannot be used alone-Metformin-standard of care with diagnosis of Type 2 lactic acidosis is a side effect Syndrome X - Obesity, hypertension, abnormal lipid profile WHO ladder of pain management - 1. Start with non opioid 2. maintain initial + opioid, 3. don't lose the initial non-opioid and add stronger pain medication (morphine, hydromorphone, fentanyl, etc) breakthrough pain= fentanyl patch Non-infectious Post operative fever - Ask what do his lungs sound like? Atelecatisis is most common cause, dehydration with bellies, drug reactions (ampoh, Bactrim, procainamide, isoniazide) Fluids, pulmonary toilet Infectious post-op fever - Usually seen with elevated WBC, left shift, bands Tension Headache - Most common HA, generalized Migraine Headache - Classic=aura common= no aura