Med-Surg Unit 1 Exam Outline

Ear Stuff Structure of Ear

o External Ear Pinna is the cartilage embedded in the temporal bone External ear canal is the tube from the outside of your ear to the eardrum. Lined with wax

(cerumen), sebaceous glands and hair follicles Tympanic membrane is your ear drum Mastoid process is the bony ridge behind the pinna

o Middle Ear- space b/w inside of the tympanic membrane to the round and oval windows Epitympanum has the 3 bones

Malleus/Hammer Incus/Anvil Stapes/Stirrups

Eustachian Tube Drains the stuff in your ear down the back of your throat

o Inner Ear- proximal side of oval window to the distal end of the CN VIII Semi-circular canals Cochlea- the spiral thing. You can hear because of this Endolymph and perilymph are fluids that cushion stuff Organ of Corti- receptor end-organ of hearing

Function of Earo Hearing

Sound 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 Agingo Ear wax (cerumen) dries out and is more easily impacted or stuck in places it shouldn’t be stucko TM isn’t as elastic, bony ossicles move less. They’re old so stuff gets stiffo Cochlea 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. o Hearing acuity is diminished

Ototoxic Drugso Antibiotics like E-mycin, Vanco, Gentamycin, etc. Note the ending, -mycino Diruetics like Diamox, Edecrin, and Lasixo NSAIDs like Motrin, Indocin, Naprosyn, and Salicyateso Misc drugs like Tergretol, Quinine, and Platinol

Diseases of Earo External Otitis

Patho: Irritation/infection of the external ear Causes

Allergies- you’re allergic to cosmetics, earphones, hearing aids, etc. Bacteria/Fungus – pseudomonas, staph, strep, or aspergillus Trauma- you stab yourself in the ear, or whatever

Systemic Illnesso Can be a result of brain abscess or meningitis. There can be necrosis of the outer

ear or nearby structures. There is a high mortality rate Management of External Otitis

Assessment – 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 swelling

Treatment – reduce inflammation and pain, use warm heat on the ear, use topical antibiotics or steroids and/or systemic analgesics (for pain).

o Furuncle Patho: Bacterial infection of the hair follicle S/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 ear

o Clogged up ear due to Cerumen or Foreign Bodies Cerumen 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 media

o Ototis Media Patho: 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 loss

Assessment: 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 movement

Management Nonsurgical – use warm heat, systemic abx (antibiotics) analgesics, antihistamines and

decongestants Surgical – 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 physician

o Mastoiditis Patho: infection and inflammation of the epithelial lining of the mastoid air cells in the bone. It’s

secondary to otitis media Assessment: 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 nodes

Management Nonsurgical – 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 TM Complications – damage to the nerves, vertigo, meningitis, and brain abscess

o Trauma Can be due to a direct blow, foreign object, or rapid change in the middle ear cavity pressure

Management is stressing prevention or repairing the damage thru surgeryo Neoplasms (Tumors)

Types Glomus jugulare – benign vascular tumor from the jugular vein Adenocarcinomas or other Carcinomas Any kind of growth that disrupts conductive hearing

Treatment: Surgery, radiation therapy, may lose hearing in the affected earo Tinnitus (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

noises Treatment: you treat the cause, not the tinnitus itself

o Vertigo (inner ear) Patho: sense of whirling in space Management: 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…). o Dizziness (Inner ear)

Patho: disturbed sense of person’s relationship to spaceo Labyrinthitis

Patho: 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).

o Meniere’s Disease Patho: 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 movement

Management Nonsurgical

o Since they have vertigo use the safety precautions for vertigo, restrict salt and fluids, stop smoking

o Meds: Diruetics, nicotinic acid, antihistamines, antiemetics, and Diazapam Surgical

o Labyrinthectomy and endolymphatic decompressiono Acoustic Neuroma

Patho: A benign tumor of the CN VIII (8). May involve cerebellum. May damage hearing, facial movement and sensation.

Treatment: Craniotomy for removal of tumor

Hearing Losso Conductive Hearing Loss

Patho: 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.

o Sensorineural Hearing Loss Patho: 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 VIII

o This 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)

Management Surgical

o Tympanoplasty – they reconstruct all or part of your fucked up middle earo Stapedectomy – they use a prosthetic to replace your fucked up stapes

Nonsurgicalo Prevention (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 implants

Assistive Devices Hearing 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 fuck Stand 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 Stuff Basic Structure: Your eye is a spherical organ protected by a bony socket (orbit). It’s surrounded by 3 sinuses.

o Layers Outer layer (sclera) – white of the eye and the transparent cornea Middle layer (uvea) – choroid, ciliary body and iris Inner layer (retina) – the sensory layer

o Refractive Structures and Media Cornea, aqueous humor, lens and vitreous humor

Light passes thru the structures to the retina Each structure has a different density which refracts the light The refraction focuses the image on the retina

More In-depth Structureo External Eye

Canthus Conjunctiva Lacrimal Gland- your tear duct that keeps your eye moisturized. Muscles- there are 6 voluntary muscles to rotate and coordinate movement of your eye

o Internal Eye Scelera- keeps the shape of the eyeball. Lens- clear structure that sits behind the iris. Focuses light onto the retina Pupil- dark opening in the middle of the iris Iris- colored part of eye, muscles in the iris control the amount of light let into the eye Cornea- clear window in front of the pupil and the iris which always light into the eye Optic nerve- cable like structure which carries vision from the retina to the brain Vitreous- the clear gel like substance that fills the space in the eye between the lens and the

retina Retina- 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 details

o Nerves CN III, IV, VI – control extraocular muscles CN II – sight CN V – sensory portion of the blink reflex CN VII – lacrimal stuff

Assessment of the Pupilso Consensual 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.

o 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 Visiono Acuity – sharpness of vision

Far Distance Acuity

Use 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 letters

Near Distance Acuity Use the Rosenbaum Vision Screener. It’s 14 inches away from you. Used for people over

40 to look for difficulty readingo Color Vision – your ability to see colors, duh

Tests Ishihara Chart – numbers composed of 1 color of dots within a circle of dots of another

color. Like a blue 22 inside a green circleo Refraction – basically the process of changing what your eye sees into what your brain interprets

Emmetropia –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 blurry

Astigmatism- an abnormal curvature of your lens that makes the image blurry on the way to the retina

Presbyopia- 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 up

Aphakia- absence of the lens. Can be congenital or can be removed during cataract surgery Age Associated Changes

o Structure: You don’t have as much ocular muscle tone, the cornea flattens. Arcus Senillis is when your eye kindof bows outward

o Function: the lens is less elastic and shrinks and you can’t discriminate all colors as well as you used to Extraocular Conditions Affecting Vision

o Systemic DM, HTN, Lupus, Thyroid dysfunction, MS, Cardiac disease, and sarcoidosis (which causes

granulomas/inflammatory lesions to occur in the lungso Medications

Antihistamines, decongestion agents, oral contraceptives, beta blockers, corticoid steroids, and some antibiotics

Disorders of the Eyeo Eyelid Disorders

Types Blepharitis – 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 Disorders Warm moist compress and/or abx drops or ointments. You want to keep the area clean, avoid touching your eye, and wash your hands often

Eye 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 simultaneously

o Lacrimal System Disorders (tearing system, keeps your eyes moist) Keratoconjunctivitis sicca – common complaint of the elderly. Basically dry eye disorder

Change 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 surgery Random: If you don’t have enough tears you can develop corneal ulcers.

o Conjunctival Disorders Subconjunctival Hemorrhage

Assoc. w/ increased pressure in eye Also assoc. w/ trauma, HTN, blood dyscrasias Bright red under conjunctiva Painless No vision impairment Resolves 10-14 days

Conjunctivitis- 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

o Burning, itching, lots of tearing, vascular enjoyment (vessels are protruding and rich with blood), edema, infection (may even have drainage)

Treatmento Meds, infection control, WASHING HANDS!! Avoid makeup and other irritants

o Corneal disorders Causes

Keratoconus- the cornea turns into a sort of cone shape Dystrophies- 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)

o Bacterial Disruption of corneal epithelium Secondary to abrasion or trauma Treatments are topical or systemic antibiotics

o Viral

Herpes Simplex Pain and photophobia (light sensitivity) Treatment is topical antivirals like Viroptic

Ulcerations S/S of Corneal Disorders

Pain, decreased vision, cloudy/purulent fluid on the lids/lashes Cornea has a hazy/cloudy appearance Altered corneal light reflex

Interventions for Corneal Disorders Meds- antibiotics, steroids, NSAIDs drops or ointments Vision Enhancement- assist in use of functional vision and reduce irritants Surgery- Keratoplasty (corneal transplant)

Lens Disorderso Cataracts

Patho: lens fibers become compacted. The lens gradually loses its clarity and distorts the image of the retina

Etiology: aging, trauma, toxicity, associated, complicated S/S

Earlyo Blurred vision and decreased color perception

Lateo Diplopia, 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 pupils

Age Related Cataracts have no pain or redness!!! Cataract Surgery

Info about surgeryo Pre-op

Series of anesthetic and mydriatic drops pre-op Procedure done with anesthetic block and mild sedation, but your ass is

still awake Shitty lens taken out and new fancy lens implanted They will wear glasses to correct the vision before surgery and this helps

make the surgery easier or something. She said remember this…o Post-op

Wear a patch and protective shield Feels like you have sand in your eye

o Post op pain may indicate increased IOP (intra ocular pressure) or hemorrhageo Infection

Observe for increased redness, change in visual acuity, or tearing or photophobia, but white crusties are normal

o Bleeding from the incision, iris, or ciliary body. This can happen up to several days after surgery.

o Report changes in vision STAT! Discharge teaching

o Avoid activity that will increase IOP (Increased ocular pressure) Don’t bend from waist Don’t blow nose, sneeze, or cough Don’t strain with bowel movements Don’t vomit, don’t lie on the surgery side No heavy lifting

o Medication administrationo Eye protection with shield or glasses

Glaucomao Patho

Imbalance of aqueous humor production and outflow Aqueous humor build up = reduced blood flow to optic nerve and retina Normal IOP is 10-21

If higher, can cause tissue ischemia and death Damage begins in periphery and moved inward Untreated results in blindness

Early detection is very important in preventing this!!o Types

Primary open-angle glaucoma (POAG) Slow painless onset, reduced outflow of AH via chamber angle Most common of all types of glaucoma OPEN

o O= occasionally see halos around lightso P= peripheral vision loss, gradual Painless, Progressive vision losso E= early stage is asymptomatic, Enlarged optic cupo N= Not an emergency

Angle-closure glaucoma (acute) Rare Sudden onset, emergency situation Iris gets displaced and the chamber closes and becomes narrow, which blocks the

drainage of the AH (aqueous humor) Secondary

Sudden onset Secondary to disease that narrows the angle or increases the fluid volume in the eye

o Clinical Manifestation Early

Increase in IOP Diminished accommodation

Late Diminished visual field Decreased visual acuity not corrected with glasses Halos appear around lights H/A or eye pain Increased cup-disc ratio (pressure in your eye fucks up where everything is supposed to

be) Pale optic disk

o Treatment of Glaucoma Annual check of IOP (Prevention is key!!!) Meds: miotics, beta blockers, carbonic anhydrase inhibitors, and osmotic agents

o Surgical Treatment Laser

Makes 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 anymoreo Patient Education

IOP & desired range Vision loss & optic nerve damage Medications & effect on eyes Eye gtts & side effects How to instill eye gtts Regular exams with automated perimetry testing (Prevention is key!!)

Ocular Chamber Disorderso Vitreous Hemorrhage

Bleeding into vitreous cavity R/T: ageing, trauma, systemic disease May c/o seeing red haze, black dots Red reflex diminished Heals 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 Disorders

o Hypertensive retinopathy High DBP (diastolic blood pressure) r/t narrowing of retina arterioles Arterioles appear like copper wire & nicking Localized ischemia “soft wool” appearance May result in retinal detachment May c/o HA & vertigo Treatment – manage HTN

o Diabetic Retinopathy Directly r/t BG (blood glucose) control and length of disease Background DR Proliferative DR

Retinal detachmento Patho

Separation of sensory retina from pigmented epithelium C/O bright flashes of light, floating dark spots, or curtain over visual field

o Treatment Cryotherapy- prevents any further detatchment Photocoagulation Diathermy

Scleral 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 problem

Macular Degeneration- gradually destroys sharp, central visiono Types

Atrophic (dry) Sclerosing of retina capillaries Macular cells – ischemic & necrotic Rod & cone photoreceptors die Reduce risk by nutrition therapy

Exudative (wet) Detachment of pigment epithelium in macula Blood & fluids accumulate under macula & form scar

o Management of Macular Degeneration Atrophic

Maximize use of remaining vision Exudative

Laser treatment – seal leaking blood vessels Traumatic Disorders

o Types Hyphema – a hemorrhage in the anterior chamber. Looks red in the colored part of your eye Contusion – 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 laceration

o S/S of Eye Trauma Pain or mild discomfort. May have reduced vision or photophobia. May also have edema and

redness of the eye and surrounding tissueso Management of trauma

Ice to reduce edema, bed rest, and eye drops, eye rest, and surgery (if you need it) Ocular Melanoma

o Patho: cancer of the eyeo Symptoms: blurred vision, increased IOP, reduced visual acuity, and change in iris coloro Treatment: surgery and/or radiation therapy

Blindnesso Affects any or all aspects of vision (color, light, image, movement, and/or acuity)o 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 Surgeryo What it does: Reshapes the corneal tissue and corrects refraction errors. It doesn’t alter aging processes

of the eye. There is also no guarantee Types

Radial 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.

o Contraindications for Refractive Surgery If you have an unstable cornea or refraction, a current eye infection, or a condition with adverse

cornea healing (like steroid use, immunosuppression, or elevated IOPo Complications of Refractive Surgery

Ablation Complications – raised area in ablation site Diffuse Lamellar Keratitis – inflammatory reaction of lamellar interface Central Island and Decentered Ablation – shift of the center of ablation site FYI – ablation just means removal of tissue

Instillation of Ophthalmic Medicationso Wash 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 lectureo Topical Anesthetics

Used before procedures to prevent pain. Don’t rub your eyes. These aren’t for home use. Examples are tetracaine and pontocaine

o Topical Steroids Used 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-Op

o Anti-Infectives Can 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 Ocuflox

With 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 Herplex

o Antibiotic-Steroid Combinations Make 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)

o Beta Blockers Used for glaucoma cause they decrease IOP by reducing AH production and doesn’t cause

papillary constriction

Make 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.

o Miotics Used 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 Miostat

o Mydriatics and Cycloplegics These 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 Atropine

o Nonsteroidal Anti-Inflammatory Agents Used 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 Acular

Respiratory Stuff Atelectasis – 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/So S/S

Cough, low grade fever (probably linked to inflammation distal to the obstructed airway), dyspnea, tachycardia, tachypnea, pleural pain, and central cyanosis

Acute 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 anxious

o Assessment Findings Decreased 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 areas

o Who’s at risk? Post op patients – b/c they’ve been under anesthesia Immobilized pt’s – cause they’re not moving and their lungs are getting lazy Pt’s experiencing pain – b/c they hurt so much they don’t want to move and TCDB Altered lung defense mechanisms – smokers, people who are intubated, etc.

o 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 crazy

Pneumonia (Read Brunner pg 639, the Nursing Process of Pneumonia)o Info/Patho

Inflammation of the lung parenchyma (functional part of any organ or tissue) Most common cause of death from infectious disease in the US 7th Leading cause of death in the US

o Types Community Acquired

Most prevalent in the winter and spring Most commonly caused by S. pneumonia Mycoplasma – occurs mostly in older children and adult (it’s the most contagious)

o Spread by droplets thru person to person H. influenza – affects elderly people and those with comorbidities Viral – most common in infants and children (uncommon in adults) Immunocompromised adults

o Cytomegalovirus, herpes simplex, adenovirus, and respiratory syncytial virus Hospital 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 admission Predisposition due to impaired host defense

o They’re already in the hospital which means they’re sick already, so they’re more likely to get pneumonia

Immunocompromised Host Pneumonia (PCP) Caused by pneumocystis carinii Usually bugs that have a low virulence

o The 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 town

Often the initial complication of AIDS Subtle onset leading to progression of dyspnea, fever, and nonproductive cough

Aspiration Pneumonia Endogenous 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. aureus How can we prevent it?

o Follow the rules for patients receiving tube feedings and continuous TPN/HAL. o Protect the airway of patients who are vomiting!

Clinical Manifestationso Symptoms depend on the causal organism and presence of underlying diseaseo H/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).

o If the pt has strep pneumonia these symptoms will be severe Assessment and Diagnostic findings

o Hx – possibly recent URI. You always want a thorough history… always

o Physical 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 factorso Conditions producing mucus or bronchial obstruction (like COPD or cancer)o Immunosuppressed or neutorpenic personso Smokingo Prolonged immobility and shallow breathingo Depressed cough reflex or abnormal swallowingo Pt’s with tubes in their throats (NPO patients)o Supine positioning (cause they’re laying down, makes it easier to aspirate)o Being drunk (suppresses the body’s reflexes so they’re a little slow to react)o Anethesia, sedatives, or opioids (causes respiratory depression)o Advanced age (when we get old we have a depressed cough, everything slows

down)o Antibiotic therapy- antibiotics can kill off good bacteria along with the bad oneso Respiratory therapy- since they are in there a lot they have more chances of

spreading bugso Healthcare workers transmission

Medical Managemento Antibiotic Therapy

Macrolides (Zythromax), Clarithromycin, Doxycline, and Flourquinolones Supportive Therapy

o Hydration- to loosen the secretionso Antipyreticso Warm, moist inhalationso Antihistamines and nasal decongestantso Bed resto Oxygenation (if needed)

Complications- these are usually the people who haven’t looked for treatment until it gets super bad…

o Pleurisy- inflammation of the pleurao Atelectasis and pleural effusiono Superinfectionso Shock and respiratory failure

What can the nurse do?o Maintain and improve airway patency

Lift the HOB up, hydrate them, suction themo Monitor respiratory and oxygenation status, promote rest and conserve airway,

promote fluid intake, maintain nutrition, promote patients’ knowledge, and maintain infection control measures!!!

Pneumococcal Vaccinationo Recommended for high risk groups

Over 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 Tuberculosis

o Info/Patho: Described as “cheesy masses.” It’s an infectious disease primarily affecting the lung parenchyma (but can spread elsewhere). It’s airborne in transmission

o Why is there an increase in TB? HIV/AIDS increase, immigration, poverty, malnutrition, overcrowding, inadequate healthcare,

homelessness, etc.o Risk factors

Close contact with TB infected persons Immunocompromised Substance and alcohol abuse

Malnutrition, they don’t really take care of themselves, etc Inadequate healthcare Pre-existing medical conditions

DM, Chronic Renal Failure, Cancer, etc. Immigration from countries with and increased prevalence Institutionalization

Prison, long term care facilities, psych wards, etc. Healthcare workers performing high risk procedures

People who suction, perform bronchoscopys, etc. o Clinical Manifestations

Low grade fever, cough, night sweats, fatigue, weight loss, nonproductive or productive cough, hemoptysis (coughing up blood). Think of Doc Holliday on Tombstone.

o Assessment and Diagnostic findinds Hx and physical

Where have you been? Tuberculin skin test CXR (usually in upper lobes) Acid-fast bacillus smear

You need at least 3 specimens, and it’s preferable to get them early morning on consecutive days

Sputum cultureo Mantoux Test

The 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 population A 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!

o To get diagnosed with TB, you have to have a positive CXR, acid-fast bacillus smear, and a positive sputum culture!

o Medical Management Chemotherapy agents for 6-12 months Have to consider drug resistance Primary, Secondary, and Multidrug

o First Line Medications INH, Rifampin, Pyrazinamide, and Ethambutol are the first 4 that they use!

o Treatment Guidelines Initial 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)

o Prophylactic Treatment Administered 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 TB

Pleural Effusiono Info/Patho

Collection of fluid in the pleural space Usually secondary to other diseases May be a complication of:

Heart failure, TB, Pneumonia Pulmonary infections, nephritic syndrome Connective tissue disease, pulmonary embolus, brochogenic carcinoma

Transudates are filtrates of plasma Exudates are buildup of fluid in tissues or cavities Empyema is accumulation of thick purulent fluid in the plural space

o S/S Caused by the underlying disease and the size of the effusion Pneumonia- fever, chills, pleuritic pain Malignant effusion- dyspnea and coughing Large effusion – dyspnea Small effusion – minimal or no dyspnea

o Assessment and Diagnostic Findings Decreased or absent breath sounds, decreased fremitus, and dull flat sound on percussion If severe pt may be in respiratory distress and the trachea may deviate Physical exam, chest CT, thoracentesis

o Medical Management Discover the underlying cause Prevent reaccumulation of fluid Relieve discomfort, dyspnea, and respiratory compromise

If 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 it

o What is the Nurse’s Responsibility? Assist with thoracentesis Pain management Education of pt and family

Pulmonary Edemao Info

Abnormal accumulation of fluid in the lung tissue and/or alveolar space Back 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 failure Can be caused by hypervolemia or sudden increase in the intravascular space

o S/S Respiratory Distress Increased dyspnea, air hunger Central cyanosis Anxiety and agitation Foamy, frothy, or blood-tinged secretions b/c fluid leaks into the alveoli and mixes with air Possible confusion or stupor Develops pretty quickly

o Assessment and Diagnostic findings CXR Tachycardia Crackles on auscultation Pulse ox and arterial blood gases

Pulse ox will decrease and ABG’s are going to show worsening hypoxemiao Medical Management

Cardiac Cause Improve left ventricular function using vasodilators, administering O2

Fluid Overload Cause Diuretics, fluid restriction, O2, possible intubation. Always monitor response of pt

Pulmonary Embolismo Info

Obstruction of the pulmonary artery or one of its branches by a thrombus Caused by trauma, surgery, pregnancy, heart failure, age > 50, hypercoaguable states, prolonged

immobility. o S/S

Depends on the size and location Dyspnea is most frequent s/s Tachypnea Chest pain (usually sudden) Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis. Sometimes like a

feeling of impending doom

o Massive PE Defined by the degree of hemodynamic instability Occludes the outflow tract of the main pulmonary artery or the bifurcations

They’s fucked up and most of the time they die super quicko Assessment and Diagnostic Findings (For Massive PE)

CXR (will usually be normal) EKG Peripheral vascular studies (Looking for DVT in legs ) ABG analysis (may be normal) Ventilation-perfusion scan (Best one)

Called a VQ lung scan Shows the percentage of perfusion and ventilation in different areas of the lungs. If there

is a mismatch, there is usually a high probability of PEo Prevention

Try and prevent the DVT Active leg exercises Early ambulation Elastic pressure stockings

Anticoagulant therapy SCD’s

o Medical Management O2 therapy – may require intubation Leg compression devices Anticoagulation therapy Thrombolytic therapy Surgical intervention

Embolectomy – find where the clot is and grab it and take it out. Very risky, don’t do it very often

Inferior vena cava filter (pg. 666 good picture). Have to be on cumadin if they have one of these

o Nursing Care How can you minimize the risk of PE?

See if their at risk and put them on prophylactic stuff Monitor pharmacological therapy Manage oxygen therapy Monitor pain and anxiety

Lung Cancero Info

Leading cancer killer among men and women in the US 70% has spread to lymphatics and other sites by the time of diagnosis

o Types Small Cell

15-20% of tumors Most commonly associated with smoking Rare for a nonsmoker to develop <1% Metastasis occurs early

Non-Small Cell Squamous Cell 20-30%

o Centrally located and arises more commonly in the bronchi Adenocarcinoma 30-40%

o Most prevalent and doesn’t prefer male over femaleso Occurs peripherally and often metastasizes

Large Cell 10%o Fast growing and arises peripherally

o Risk factors Tobacco smoke, second hand smoke

Cancer is 10x more common in smokers than non smokers Environmental and occupational exposures Gender Genetics Diet Underlying respiratory disease

o S/S Often asymptomatic until late in the course of the disease Cough or change in chronic cough Dyspnea Hemoptysis or blood tinged sputum Pain Fever Hoarseness, dysphagia, head and neck edema, pleural effusion Cancer of the lung should be suspected in people with repeated and unresolved upper respiratory

infections!o Assessment and Diagnostic Findings

Respiratory symptoms in heavy smokers CXR (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 bronchoscopy Needle aspiration Variety of scans

o Medical Management Surgical resection

Primarily used for non-small cell tumors Cure rate depends on size/type of tumor Lobectomy takes out part of the lung Pneumonectomy takes out all of the lung

Radiation therapy Useful for nonsurgical tumor Small % of patients Radiation is toxic to normal tissue, so it’s not the best thing in the world to try. Many

complications Chemotherapy

Not usually a cure. Can alter the tumor growth. Is going to help with the metastasis that’s going on in the body

Palliative therapyo Nursing Care

Educate Manage symptoms Maintain airway Monitor for complications Reduce fatigue Provide support

Chest Trauma Stuff Blunt trauma

o Info Results from sudden compression or positive pressure inflicted on the chest wall Most common causes are MVAs, falls, bike crashes, etc. Can be life threatening!

Fractures- most are benign and will fix themselves on their owno Sternal

Most common in MVAo Rib

Most common type of chest trauma Can cause laceration of subclavian artery or vein (first 3 ribs) Injury to spleen and liver (lower ribs)

o S/S Sever pain, point tenderness Eccymosis (lots of bruising in that area) Crepitus Swelling in the area

o Assessment and Diagnostics CXR Pulse ox and ABG’s

o Treatment Reduce pain, monitor for complications Chest binders (wrap them up) Make them do TCDB (to reduce chances of pneumonia or atelectasis) Usually heal in 3-6 weeks

Flail Chesto Info

Complications from steering wheel injury 3 or more ribs fractured in 2 or more sites Free floating rib segments

When you breath in the flail section sucks in and when you breath out they go out Chest wall loses stability Respiratory impairment

o Medical management

Depends on how big of an area is affectedo Types

Small Flail Chest Clear the airway thru positioning, coughing, deep breathing, and suctioning

Mild-Moderate Flail Chest Monitor fluid intake, relieve chest pain, lung expansion, and secretion management

Severe Flail Chest Intubated and on mechanical ventilation

Pulmonary contusiono Info

Associated with flail chest Abnormal accumulation of fluid in interstitial and intraalveolar spaces Can be caused by blunt trauma Damage to lung resulting in hemorrhage and edema

o S/S Decreased breath sounds Tachycardia Chest pain Blood tinged sputum and secretions

o Medical Management Maintain airway Provide adequate oxygen Control pain

Penetrating Traumao Info

Being shot and stabbed is the most common Pneumothorax

Simple- 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 shift

o S/S Pain Air hunger Central cyanosis Increased use of accessory muscles Hypotension and tachycardia Diaphoresis

o Medical Management Evacuate air or blood (thoracentesis followed by a chest tube)

Randoms I had at the end of my stuff…

o 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 smoke

o Allergies are the most predisposing factor when dealing with asthma.