Joys NP

Sensitivity: True Positives; the degree to which those who have a disease screen/test positive

 

Specificity: True Negative; the degree to which those who do not have a disease screen/test negative


Sensitivity vs specificity… sensitivity is positive and specificity is negative. Know this backwards and forwards—like what would a high sensitivity say versus a low sensitivity, in about 3-4 of Phil’s questions. [SENSITIVITY: TRUE POSITIVES, THOSE WHO HAVE A DISEASE SCREEN/TEST POSITIVE. SPECIFICITY: TRUE NEGATIVES, THOSE WHO DO NOT HAVE A DISEASE SCREEN/TEST NEGATIVE]

There was a question where a patient had a multinodular goiter and wanted to know why the NP was not going to do periodic U/S and Fine needle biopsy in monitoring for some kind of cancer or complication. The answer I picked was that these tests were not very specific to detect the cancer. Another option was specificity.

[Initial screening should include TSH. Given the sensitive third-generation assays in the absence of symptoms of hyper or hypothyroidism further testing is not required. A study by Kelly et al indicated that in some patients with multinodular goiter, the risk of neoplasia can be effectively assessed with ultrasonography rather than with fine-needle aspiration biopsy.]

• Heart Disease (CAD)
• Colorectal Cancer
• Lower Respiratory disease
• Unintentional accident
• CVA stroke

• Lung cancer
• Ovarian cancer
• Breast cancer

• Lung Cancer
• Prostate cancer

• 1 Lung cancer
• 2 Colorectal cancer

• Start at your facility
• When initiating change, you always begin at the most local level and then progress upward and outward
• Begin at hospital level, then community level, then the region, then the state, then national

In treating patients, which comes first

• Gonorrhea
• Chlamydia
• Syphilis
• HIV
• TB

• Nonmaleficence: the duty to do no harm
• Utilitarianism: the right act is the one that produces the greatest good for the greatest number
• Beneficence: The duty to prevent harm and promote good
• Justice: The duty to be fair
• Fidelity: the duty to be faithful
• Veracity: the duty to be truthful
• Autonomy: the duty to respect an individual’s thoughts and actions

Consider the sample size

 

 

 

•  
• Level of significance: the probability level of which the results of statistical analyses are judged to indicate a statistically significant difference between groups
• A small confidence interval implies a very precise range of values

look at sample size & p value.

• 1 QA- A process for evaluating the care of patients using established standards of care to ensure quality
• 2 CQI- quality can be improved by Continually monitoring structure, process, and outcome

• Structure: inputs into care such as resources, equipment, or numbers and qualifications of staff
• Processes of care: Include assessments, planning, performing treatments and managing complications
• Outcomes: include complications, adverse events, short term results of treatment and long term results of patient health and functioning

• -Increase the quality and years of healthy life
• -Eliminate health disparities among Americans

• Law enforcement
• Municipal offices
• CPS/Schools
• Employers/Workman’s comp
• Life insurance

 

• -Doc calls from another center asking if you can tell him what kind of orders he should give for maintenance of patient… HIPPA.
• -Pt in ER not doing well, primary md calls: Give him info
• -NP working on ESRD research project. A colleague renal specialist asks for pt info on your patients: HIPPA breach.
• -Who enforces HIPPA- Office of Civil Rights / Health and Human Services
• -Who ISN'T required to follow HIPPA? Law enforcement/Municipal Offices, CPS/Schools, Employers/Workman’s Comp, Life insurance
• -Question about an insurance company calling to verify some patient appointments. You have to pick out that there is already a medical release signed by the patient. The answer is to give the requested information to them.

• Is there a medical release form signed by the patient?
• If so, then give the requested information to them

A tool for identifying prevention strategies to ensure safety… Why why why

 

• very basic question where RCA is the answer and the question is the definition
• RCA: tool for identifying prevention strategies to ensure safety, process to build a culture of safety & move beyond the culture of blame.

Consult case management

•  
• Case management- mobilize, monitor, and control resources that a patient uses during course of an illness while balancing quality and cost
• (moves patient through the system appropriately)

• -covers inpatient/hospitalization
• -skilled nursing facility services
• -home health services associated with inpatient event
• -hospice associated with inpatient event
• -Most individuals qualify to receive benefits at 65 years of age

• -Covers physician services
• -Outpatient hospital services
• -Laboratory and diagnostic procedures
• -Medical equipment
• -Some home health services

•  
• -Medicare pays 80% of the patient’s bill for physician services and the patient pays 20%
• -NPs and CNS receive 85% of physician reimbursement for services provided in collaboration with a physician

• -A+B=C
• -Medicare Advantage
• -Patients entitled to Part A and enrolled in Part B, are eligible to receive all of their health care services through one of the provider organizations under part C (HMOs, PPOs, etc)
• (no fee)

(MONTLY PREMIUM) Limited prescription DRUG coverage, with co-pay

• c 
• Form a standardized Tx plans for all pts that can be used by all healthcare staff

•  
• Think quality assurance – standards of care 

D

Share the information he requests

• C
• Continue to research alternative treatments

C- SNF- Subacute nursing facility

c 

• - Call the resident to clarify the patient was not confused when he signed the first consent
• Was the patient able to:
• Communicate, understand, reason, differentiate
• Remember CURD

Meet with all who participated in the code and have a one-time briefing

•  
• Risk management
• Action taking initiatives
• Correction and education

Ask if the patient has an advanced directive

• Problem focused: A limited examination of the affected body area or organ system
• Expanded problem focused: A limited examination of the affected body area or organ system and any other symptomatic or related body areas or organ systems

• Detailed: An extended examination of the affected body areas or organ system and any other symptomatic or related body area or organ system
• Comprehensive: A general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area or organ system

Serum osmolality (usually2X NA) (275-295mosm/kg)

•  
• Urine Sodium (10 to 20mEq/L)

•  
• Distinguish renal from non-renal causes

•  
• Urine specific gravity (1.010 to 1.030)

• Urine NA >20 = renal salt wasting (problem with the kidneys
• Urine NA<10 = renal retention of sodium to compensate for extra renal fluid losses (problem other than the kidneys)

• 1 water excess- results in low plasma osmolality, the extracellular fluid volume states may be low volume, normal volume, or high volume
• 2 Hypovolemic w/urine NA <10 mEq/L
• Dehydration, Diarrhea, vomiting

• 3.Hypovolemic w/urine NA>20 mEq/L
• Low volume and kidneys cannot conserve Na
• Diuretics, ACE inhibitors, Mineralocorticoid deficiency

• 1.Hypervolemic, hypotonic hyponatremia
• Need to restrict water
• Edematous states, CHF, Liver disease, Advance renal failure

• 2.Hypertonic Hyponatremia
• Serum osmolality >290 mosm/kg
• Hyperglycemia: Usually from HHNK
• Osmolality is high and the Na is low

• Treat based on cause
• Treat underlying condition
• If hypovolemic, give NS IV
• If urine sodium>20, treat cause
• If hypervolemic, implement water restriction
• If the patient is symptomatic, give NS IV with a loop diuretic
• If CNS symptoms are present, consider 3% NS IV with loop diuretics

• Usually due to excess water loss; always indicates hyperosmolality (ie water deficit of water). Excess sodium intake is rare
• Severe hypernatremia with hypovolemia should be treated with NS IV followed by ½ NS
• Hypernatremia with euvolemia should be treated with free water (D5W)
• Hypernatremia with hypervolemia should be treated with free water and loop diuretics, may need dialysis

• Causes
• chronic use of diuretics,
• GI loss, excess renal loss and alkalosis.
• Elevated serum epi in trauma pts may contribute to hypokalemia
• Signs/symptoms
• Muscular weakness, fatigue and muscle cramps, constipation or ileus due to smooth muscle involvement
• If sever (K<2.5mEq/L), may see flaccid paralysis, tetany, hyperreflexia and rhabdomyolysis (check cK)
• Laboratory/Diagnosis

Decreased amplitude on ECG, broad T waves, Prominent U waves, PVCs, V-tach, or V-fib

• Oral replacement if >2.5 mEq and no ECG abnormalities
• IV replacement at 10 mEq/hr if cannot take p.o.
• If <2.5mEq or severe signs/symptoms are present, give 40mEq/L/hr IV-check q3hrs and institute continuous ECG monitoring
•     Mg++ deficiency frequently impairs K+ correction

• Causes include excess intake, renal failure, drugs (ie NSAIDs) hypoaldosteronism, and cell death. Shifts of intracellular K+ to the extracellular space occure with acidosis
• K+ increases 0.7mEq/L with each 0.1 drop in pH
• Signs/symptoms :
• Weakness, flaccid paralysis, abd distention, diarrhea
• Laboratory/diagnosis :– Tall Peaked waves

• Exchange resins (Kayexalate)
• As the resin passes through the gastrointestinal tract, the resin removes the potassium ions by exchanging it for sodium ions.
• If K+>6.5mEq/L or cardiac toxicity or muscle paralysis is present, consider:
• Insulin 10 U with one amp D50 (pushes K+ into the cell)

• Total calcium= 2.2-2.6mmol/L (8.5-10.5mg/dl)
• ionized calcium= 1.1-1.4mmol/L (4.5-5.5mg/dl)

• it is useful to measure the ionized calcium level when the serum albumin is not within normal range
• The amt of total calcium varies with the level of serum albumin
• 50% of calcium is bound to albumin, a normal calcium level in the presence of a low albumin level suggest the patient it hypercalcemic
• Corrected calcium (mg/dl) =measured total Ca (mg/dl) + 0.8
•     Or 4.0 – serum albumin
•         0 represents the avg albumin level

• causes include hypoparathyrodism, hypomagnesemia, pancreatitis, renal failure, severe trauma, and multiple blood transfusion
• signs and symptoms – think overdrive. Increased DTRs, muscle/abd cramps, Trousseau’s/chvostek’s sign, convulsion,
• 3. Laboratory/diagnosis: prolonged QT interval

• Check pH – look for alkalosis
• Check PTH and mg levels
• If acute, IV calcium gluconate
• If chronic, oral supplements, vit D, aluminum hydroxide

• Causes include hyperparathyroidism, hyperthyroidism, Vit D intoxication, prolonged immobilization,
• Signs and symptoms – think sluggish
• Fatigue, muscle weakness, depression, anorexia, N/V, constipation
• Severe hypercalcemia can cause coma and death
• Serum Ca++ >12 is considered a medical emergency

• Respiratory acidosis
• Causes: Results from decreased alveolar ventilation – decrease RR
• Signs and symptoms
• Somnolence and confusion, coma, hand tremors with contraction/jerking of muscles, increased ICP
• Lab
• pH<7.35, pCO2>45mmHg, Serum HCO>26mEq/L
• low serum chloride(<93) in chronic patients

• Narcan – 0.04 to 2mg
• Improve ventilation, intubate if necessary (GCS<8)
• Increase rate on ventilator

• Respiratory Alkalosis
• Causes: Hyperventilation decreases arterial pCO2 and increase pH.
• Signs/symptoms
• Decreased cerebral blood flow ->decrease ICP
• Light-headedness, anxiety, paresthesia, stoking glove tingling, tetany if very severe
• Lab
• pH>7.45, pCO2<35, HCO3 low if chronic

• Manage underlying cause
• If acute hyperventilation syndrome, have patient breath into a paper bag
• Decrease rate of ventilator as needed
• Sedation may be necessary
• Rapid correction of chronic alkalosis may result in metabolic acidosis

• Hallmark sign is low serum HCO3
• Measurement of anion gap lends some clues toward evaluating the cause and considering treatments

Anion gap = [(Na+) + (K+)] – (HCO3 + Cl-)

•  
• If the anion gap increased, the clinical situation is generally more acute

• Increased Anion gap
• DKA
• Alcoholic KA
• Lactic acidosis
• Drug or chemical anion
• Normal Anion gap
• Diarrhea
• Ileostomy
• Renal tubular acidosis
• Recovery from DKA

• Increased gap
• Underlying disorder must be treated
• Fluid resuscitation
• HCO3 generally not indicated if acidosis is due to hypoxia or DKA
• HCO3 is indicated if significant hyperkalemia is present
• Normal gap
• Bicitra 10-30cc with meals and h.s.
• This is citric acid/sodium citrate used to make urine less acidic to prevent metabolic acidosis

• Characterized by high plasma HCO3 and compensatory pCO2 rarely exceeds 55mmHg
• If pCO2 is >55mmHg, superimposed resp acidosis is likely
• Causes- post hypercapnia alkalosis, NG suction, vomiting, diuretics
• S/S- weakness and hyporeflexia may be present if K+ is very low
• Labs – pH >7.45, HCO3>26, pCO2>45
• Serum K+ and Cl is decreased
• May see increased anion gap

• Correct volume deficit with NaCl and KCL
• Discontinue diuretics
• H2 blockers in patients with GI loss
• Acetazolamide 250-500mg IV q4-6hrs if volume replacement is contraindicated
•     Diamox is a water pill the helps patient pee out bicarbonate

• Each arm = 9%
• Each leg = 18%
• Thorax – 18%
• Back = 18%
• Head = 9%
• Perineum/genitals = 1%

• First degree= Dry, red, no blisters, epidermis only
• 2nd degree (partial thickness) = moist, blisters beyond epidermis
• 3rd degree (full thickness) = dry, leathery, black, pearly, waxy; extends from epidermis to dermis to underlining tissues, fat, muscle and/or bone

• prophylactic intubation if there are:
• burns to face,
• singed nares or eyebrows
• dark soot/mucous from nares and/or mouth
• Fluid resuscitation 4ml/kg X TBSA (total body surface area) during first 24hrs
• General rule ½ of all the fluid requirement needed during the first 24 hrs are administered with the first 8hrs of injury
• Maintain normal temp (37-37.5C)

Partial thickness

• facial involvement
• 2nd degree burn/partial thickness >10% TBSA
• face, hands, feet genitalia, perineum, or major burns
• 3rd degree
• electric, inhalation, and chemical

• Lyme disease rash
• Caused by a bite of a tick
• Usually identified by Erythema Margins and Bullseye rash
• Treatment
•      Doxycycline or Oral amoxicillin
•      Typically resolves in about 1-2weeks with tx

Ethnicity (underestimates pain, taught to be stoic. Pain is probably much more severe)

Order PO Abx

Give IVF (flush it out. This is neuroleptic malignant syndrome)

Drug fever (eos – allergic rxn. Normal is 1-4%)

Eosinophils are a type of disease-fighting white blood cell. This condition most often indicates a parasitic infection, an allergic reaction or cancer. You can have high levels of eosinophils in your blood (blood eosinophilia) or in tissues at the site of an infection or inflammation

• The concept of nitrogen balance is the difference btw nitrogen intake and loss reflects gain or loss of total body protein.
• If more nitrogen (protein) is given to the patient than lost, the patient is considered to be anabolic or “in positive nitrogen balance”. If more nitrogen is lost than given, the patient is considered to be catabolic or “in negative nitrogen balance”.
• A nitrogen balance within −4 or −5 g/day to +4 or +5 g/day is usually considered “nitrogen equilibrium”.
• Maintain nitrogen balance along with metabolic needs

K+ (refeeding syndrome. hypokalemia. also hypophosphatemia)

Refeeding syndrome is clinical complications from fluid and electrolyte shifts during aggressive nutritional rehab of malnourished patients:  hypophos, hypokal, vitamin def., CHF, peripheral edema, rhabdo, seizures, hemolysis

• Phos (refeeding syndrome. hypokalemia. also hypophosphatemia)
• Hypophosphatemia more relevant during refeeding

BMP (And monitor LFTs weekly)

Migraines and cluster headaches

sumatriptan, almotriptan, zolmitriptan...

Therapeutic touch/reiki

patient gets a booster if they have a dirty wound and haven’t had a tetanus shot in five years.

Hyperglycemia (usually from HHNK

Serum osmolality >290

Diuretics

(Na<10 is nonrenal cause. Diuretics are associated with renal cause, Urine Na >20)

• Hypokalemia
• \

• Lab/diagnostics
• Decreased amplitude on ECG
• Broad T waves
• Prominent U waves
• PVCa, V-tach, or V-fib

• Insulin dependent/juvenile diabetes.
•     Ketone development usually occurs
• Polyuria, polydipsia, polyphagia
• FBG >126 on 2 separate occasions, Hgb A1c >7, elevated BUN/Creatinine, Ketonemia, Ketonuria
• Ketones = insulin therapy 0.5 u/kg/day

• Adult onset, circulating insulin exists enough to prevent ketoacidosis, but is inadequate to meet pt insulin needs
•     Associated with metabolic syndrome
• Polyuria, polydipsia, recurrent vaginitis in women
• No ketones in blood/urine
• Oral antidiabetic medication- glipizide

Happens when the patient is hypoglycemic at 0300 but rebounds with an elevated blood glucose at 0700

 

Tx: reduce or omit the at bedtime dose of insulin

Results when tissue becomes desensitized to insulin nocturnally. The blood glucose becomes progressively elevated throughout the night, resulting in elevated glucose levels at 0700

 

 

Add or increase the at bedtime dose of insulin

• State of intracellular dehydration as a result of elevated blood glucose levels. Acute complication of type 1 DM
• Kussmaul breathing, Altered LOC, fruity breath
• Serum glucose >250, acidosis <7.30, low HCO3, pCO2, hyperkalemia,
• NS at least 1L, ½ NS, then D5 ½ NS, IV insulin 0.1u/Kg/hr

• Usually occurs as a complication of type 2 DM, pts cannot produce enough insulin to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion
• Polyuria, changes in LOC, hypotension, tachycardia
• Serum glucose >600, Osmo>310, elevated Hgb A1c, normal pH
• NS IV for massive fluid replacement (6-10L), then ½ NS, followed by D5 ½ NS

• Onset most commonly btw 20-40 yrs of age, Grave’s disease is the most common presentation
• Everything is increased-weight loss, heat intolerance
• Low TSH, elevated T3, T4
• Propranolol for symptomatic relief, radioactive iodine used to destroy goiters

• Cause/Etiology: Pituitary deficiency of TSH- known as hashimoto’s thyroiditis
• S/S: Everything slows down-weight gain, cold intolerance
• Labs: High TSH, Low T3 and T4 (T4 can be normal)
• Mgmt: Levothyroxine 50-100 mcg qday 1-2 weeks until symptoms stabilize; > 60 years of age decrease dosage

Thyroid crisis/storm is a result of untreated hyperthyroidism

 

Tx- is anti-thyroid It works by decreasing the amount of thyroid hormone produced by the thyroid gland and blocking the conversion of thyroxine (T4) to triiodothyronine (T3).

 

Propylhiouracil 150-250mg q6hrs OR Methimazole 15-25mg q6 with other instructions

                                -i.e propranolol 0.5-2gm IV q4 or PO 20-120mg q6

Myxedema Coma is a state of decompensated hypothyroidism

•  
• Protect airway: Mechanical vent as needed
• Fluid replacement, as needed
• Levothyroxine 400mcg IV X1, then 100 mcg qday
• Support hypotension
• Slow rewarming with blankets (not hyperthermia blankets): avoid circulatory collapse
• Symptomatic care

• Cause: ACTH hypersecretion by the pituritary or chronic administration of glucocorticoids
• SS: Moon face with buffalo hump
• Labs: Hyperglycemia, Hypernatremia, hypokalemia, Leukocytosis, elevated plasma cortisol in the a.m.
• Tx: Depends on the cause
•    D/C medication inducing symptoms
•    Transphenoidal resection of a pituritary adenoma
•    Surgical removal of adrenal tumors
•    Resection of ACTH secreting tumors
•    Manage electrolyte balance

• Causes/itiology: Deficient cortisol, androgens and aldosterone, pituitary failure resulting in decreased ACTH
• S/S: Hyperpigmentation in buccal mucosa and skin creases (especially knuckles, nail beds, nipples, palmar creases, and posterior neck)
• Labs: Hypoglycemia, hyponatremia, hyperkalemia, plasma cortisol <5mcg/dl @0800, cosyntropin
• Mgmt: Glucocorticoid and mineralocorticoid replacement
•     Inpatient- Hydrocortisone (Solu-Cortef) 100-300 mg IV initially with NS; replace volume with D5NS at 500cc/hr X4 hrs and then taper per condition

• Cause: Release of ADH occurs independent of osmolality or volume dependent stimulation
•     Inappropriate Water retention, Tumor production of ADH, Skull fractures/head trauma
• S/S: Neurologic changes from hyponatremia, hypothermia, headache, seizures, decreased DTRs
• Labs: Hyponatremia-yet euvolemic, decreased serum osmolality <280, increased urine osmolality >100, urine NA >20

Treat underlying cause

- If serum Na >120 restrict total fluids to 1000ml/24

- If serum Na 110-120 without neuro symptoms, restrict 500ml/24h

- If serum Na <110 or neuro symptoms present, replace with isotonic or hypertonic saline and Lasix at 1-2mEq/h, monitor NA, K+ losses hourly and replace

Can be related to Central or Nephrogenic

• Central: related to pituritary or hypothalamus damage resulting in ADH deficiency
• Nephrogenic: due to defect in the renal tubules resulting in renal insensitivity to ADH

• S/S: Thirst/cravings for water (fluid intake 5-20L/day), polyuria (2-20L/day), weight loss, fatigue, changes in LOC
• Labs: Hypernatremia, Elevated BUN/Cr, serum osmo>290, Urin Osmo<100, urine specific gravity low <1.005.
•     -Vasopressin challenge test is positive in central DI and negative in Nephrogenic DI
• Mgmt: If serum Na>150 give D5W IV to replace ½ volume deficit in 12-24hrs – rapid lowering can cause cerebral edema
• When Na <150 substitute ½ or .9NS
• DDAVP 1-4ug IV or SQ q12-24hrs for acute situations
• Maintenance dose of DDAVP is 10 q12-24hrs intra nasally

Is a rare but serious disease resulting from excess catecholamine release characterized by paroxysmal or sustained hypertension; almost always due to a tumor of the adrenal medulla

 

S/S- labile Hypertension, diaphoresis, hyperglycemia, severe headaches, palpitations, tremor, tachycardia, weight loss, postural hypotension

• Lab/ Diagnostics: Plasma free metanephrienes –used to help detect or rule out tumor – (fastest test)
• TSH is normal, CT of adrenals used to confirm and localize tumor
• Assay of urine 24hr collection-
• Mgmt: Surgical removal of tumor is treatment of choice
• Treat symptoms

• S1-closure of Mitral/tricuspid (AV)valves, opening of aortic/pulmonic (similumar) valves
• S2-closure of aortic/pulmonic valves, opening of mitral/tricuspid valves
• Systole-is period between S1 and S2
• Diastole- is period between S2 and S1

• S3: “Ken-Tuck-y” this happen with increased fluid status
• e CHF or pregnancy
• S4: “Ten-ne-ssee” this happens with there are stiff ventricular walls
• e MI, left ventricular hypertrophy, chronic hypertension

1/6=Barely audible

2/6=Audible but faint

3/6=Moderately loud; easily heard

4/6=Loud; associated with a thrill

5/6=Very loud; heard with one corner of stethoscope off the chest wall

6/6=Loudest

• Mitral stenosis:
• Mid-diastolic; apical “crescendo” rumble
• Loud S1 murmur
• Low pitched
• Mitral regurgitation:
• S3 with systolic murmur at 5th ICS MCL(apex)
• May radiate to the base or left axilla
• Musical, blowing, or high pitched

• Aortic Stenosis
• Systolic, blowing harsh murmur at 2nd right ICS
• Usually radiating to the neck
• Aortic regurgitation
• Diastolic, blowing murmur at 2nd left ICS

• Systolic HF: inability to contract results in decreased CO
• Diastolic HF: inability to relax and fill results in decreased CO
• Acute HF: abrupt onset usually follows acute MI or valve rupture
• Chronic HF: develops as a result of inadequate compensatory mechanisms that have been employed over time to improve CO

• Acute HF is Left sided HF
•    Dyspnea at rest
•    Coarse rales over all lung fields
•    Wheezing frothy cough
•    Appears generally healthy except for the acute event
•    S3 gallop
•    Murmur of mitral regurgitation (systolic murmur loudest at the apex)

• Chronic HF is right sided HF
• JVD
• Hepatomegaly, splenomegaly
• Dependent edema: as a result of increased capillary hydrostatic pressure
• Paroxysmal nocturnal dyspnea
• Appears chronically ill
• Abd fullness
• Displaced PMI
• Fatigue on exertion
• S3 and/or S4

Class 1: No limitation of physical activity

Class 2: slight limits of physical activity but comfortable at rest (fatigue, palpitations, dyspnea, or angina)

Class 3: Marked limits of physical activity but comfortable at rest – 3 pillows

Class 4: Severe; inability to carry out any physical activity without discomfort (signs and symptoms while at rest)

• Hypoxemia and hypocapnia on ABG
• BMP usually normal unless chronic failure is present
• U/A
• CXR=pulmonary edema, kerley B lines, effusion
• ECHO=will show contractile/relaxation, valve fx, EF
• ECG=my show underlying Problem-Acute MI, dysrhythmia
• PFT for wheezing during exercise

• Non-Pharmacologic
• Na restriction
• Rest/activity balance
• Weight reduction

• Pharmacologic
• ACE inhibitors
• Diuretics: Thiazide, loop
• Anticoagulation therapy for A-fib

• 02 at 1-2L while awaiting ABG
• place in sitting position
• Morphine 2-4mg IVP PRN
• Lasix 40mg IVP repeat 10 mins if no response
• If severe bronchospasm present give inhaled bronchodilator
• If severe, afterload and preload reduction with nipride and hydralazine
• If CI remains low, dobutamine 2.5-20ug/kg/min;
•     if SBP<100 dopamine 5-20ug/kg/min is preferred

• Non-African-American
•    Thiazide Diuretics (screen for sulfa allergy, monitor lytes)
•    Calcium channel blockers (monitor HR, may cause HA, flushing, or bradycardia)
•     ACE1 (avoid ARB, avoid with K+>5.5)
•     ARB (avoid ACE, contraindicated in pregnancy, avoid K+>5.5)
• African American
•     Thiazide diuretics (increases excretion of Na & H2O)
•     CCB
• Adult>18 with CKD with or without diabetes
•     ACE (causes vasodilation, blocks Na and water retention)
•     ARB
•     Regardless of race or other medical condition

• Treatment goal for initial treatment is 1 month:
• Increase dose or add second drug
• Continue to assess monthly until goal is reached
• Do not use an ACE1 and ARB together
• Refer to hypertensive specialist if 3 or more drugs are needed

• BP > 180/110 without progressive target organ dysfunction
•     -May or may not be associated with severe HA, SOB, nose bleed, or severe anxiety

• Management –oral therapies
• Clonidine (catapress)- preprevents vasoconstriction, causes vasodilation, and slow HR. Do not D/C abruptly=rebound HTN
• Captopril (Capoten)-
• Nifedipine (Procardia)
• Loop diuretics

• BP >180/120 with target organ dysfunction
• May occur at a lower BP if complicated by evidence of impending or progressive target organ dysfunction

• Management- IV agents, critical care, art line needed
• BP should be lowered to 160-180 systolic or to less than 105 diastolic (no more than 25% within minutes to 1-2hrs) and then gradually lowered over several days with oral therapy
• Common agents- Nicardipine, Nipride

• Malignant Hypertension
• Hypertensive encephalopathy
• Intracranial hemorrhage
• Unstable angina
• Acute MI
• Acute LV failure with pulmonary edema
• Dissecting aortic aneurysm
• Eclampsia

Angina- decreased blood flow through the vessel that leads to tissue ischemia

 

• Types:
•    Stable (classic or chronic) occurs with physical activity
• Prinzmetal’s (variant) occurs at various times, even rest
• Unstable (pre-infarction, rest or crescendo, coronary syndrome)
• Microvascular (metabolic syndrome)

• Metabolic syndrome
• is a cluster of conditions — increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and diabetes.

• Physical Exam Findings
•     May see signs of peripheral arterial disease
•     Levine’s sign= Clenched fist sign
•     Transient S4 not uncommon during angina

• Signs and symptoms
•     Characteristic chest discomfort lasting several min
•     Exertional is usually precipitated by physical activity; subsides with rest
•     Nitroglycerin shortens or prevents attacks

• ECG may be normal- with down sloping or ST segment, or T-wave peak or inversion
• Exercise ECG
• Serum lipid levels should be elevated
• Coronary angiography is the definitive diagnostic procedure but not indicated solely for diagnosis

Total