Sleep Apnea and STOP-BANG questionnaire

Sleep Apnea

• Upper airway obstruction by the soft palate or tongue is the most common cause
• Apnea decreases gas exchange, increases blood carbon dioxide levels, and decreases pH, leading to respiratory acidosis
• CPAP delivers continuous positive airway pressure based on the patient's breathing
• BiPAP times the air delivery with expiratory and inspiratory pressure
• Risk factors include obesity, smoking, large uvula, age, and short neck
• The STOP-BANG questionnaire assesses risk for obstructive sleep apnea (OSA); a "yes" to 3 or more questions indicates risk

STOP-BANG Questions

• Snoring
• Tiredness
• Observed as stopped breathing during sleep
• Treatment for high blood pressure
• BMI greater than 35
• Age greater than 50
• Neck circumference greater than 40cm
• Gender: Male
• If at risk, an overnight sleep study is recommended
• Modafinil manages daytime sleepiness associated with OSA and may help with narcolepsy but does not treat OSA

COPD (Chronic Obstructive Pulmonary Disease)

• Interferes with airflow and gas exchange

Emphysema (Pink Puffer)

• Air trapped in the lungs
• Loss of lung elasticity/hyperinflation

Chronic Bronchitis (Blue Bloater)

• Hypoxemia/tissue anoxia
• Acidosis
• Respiratory infections
• Cardiac failure, especially cor pulmonale
• Increased risk for developing pneumonia
• Smoking is the greatest risk factor
• Signs and symptoms: cough, cyanosis, weight loss, fatigue, wheezing, clubbing, fluid retention, edema, tripod position

Labs

• CBC, Serum ATT, H&H, ABGs, chest x-rays
• Electrolytes are affected by acidosis
• Low phosphate, potassium, calcium, and magnesium levels reduce muscle strength
• Medications include NSAIDs, corticosteroids, mucolytics, beta-adrenergic agonists, and cholinergic antagonists
• Pulse oximetry should be assessed, with a typical range of 88-92%
• Assess capillary refill, nutrition history, and respiratory status
• Oxygen therapy involves using up to 40% on a Venturi mask or up to 4 L via nasal cannula
• The goal of oxygen therapy is to reduce and treat hypoxia to help the patient return to their baseline
• Expiration is prolonged; patients can get air in, but have difficulty getting air out

Asthma

• Carbon dioxide is retained
• Airway obstruction involves inflammation and bronchoconstriction
• Aspirin and other NSAIDs can trigger an attack, which is not a true allergic response
• Signs and symptoms include wheezing, dyspnea, barrel chest, dry cough, high RR, and accessory muscle use

Interventions

• Chronic management includes bronchodilators and anti-inflammatories
• Use a rescue inhaler (SABA) when PEF is yellow/red
• Beta 2 agonists, such as albuterol and levalbuterol, are bronchodilators
• Cholinergic antagonists, such as ipratropium, are high and dry bronchodilators; carry with at all times
• Anti-inflammatories, such as corticosteroids ending in "-asone", do not help with bronchodilation
• A skin prick test or serologic test is used to identify allergens that trigger asthma
• Check calcium levels as bronco steroids can stunt growth when using LABA's
• LABS include ABGs
• Patient education involves using a peak expiratory flow (PEF) meter twice daily for the first 2-3 weeks to establish a baseline and ensure asthma is under control, then once daily; carry SABAs at all times

Pneumonia

• Excess fluid in the lungs results from an inflammatory response
• WBCs migrate to the infection, causing local capillary leak, edema, and exudate
• Any capillary leaks can spread infection; worst case goes into the bloodstream, causing sepsis
• Interferes with gas exchange; alveolar walls thicken
• Decreased chest expansion and lung compliance lead to decreased vital capacity
• Can be community-acquired vs. healthcare-acquired
• Older adults most common symptom is CONFUSION
• Other signs/symptoms: fever, chills, flushed, tachycardia, tachypnea, productive cough, bloody sputum, crackles in the lungs
• Prevent airway obstruction using bronchodilators and expectorants

Patient Education

• Avoid crowds
• Practice good handwashing
• Balance diet and fluids
• Get recommended Flu vaccine
• Get recommended Pneumonia vaccine and Prevnar vaccine: Use just pneumococcal vaccine under 2; Prevnar + pneumococcal vaccine: for 19-64 y/o with chronic respiratory problems (high risk), and 64 +

Anemia

• Characterized by low number of circulating RBCs, hemoglobin, or both
• Hemoglobin is required for gas transport
• First 5 months of life, infants use fetal hemoglobin
• RBCs have a shorter lifetime
• Less alveolar surface for gas exchange
• Smaller airways & immature respiratory systems
• Check blood count to see if more iron is needed in the diet

Treatment

• Epogen

Labs

• Hgb
  • Females 12-16 g/dL
  • Males 14-18 g/L
• Hct
  • Females 37-47%
  • Males 42-52%
• RBC
  • Females 4.2-5.4 million/uL
  • Males 4.7-6.1 million/ul

Chest Tube/Trach

• Chest tube
• After surgery, a chest tube is placed
• Two tubes are placed: anterior and posterior with airtight dressings
• Chamber 1: drainage collection
• Chamber 2: water seal to prevent air from re-entering
• Chamber 2 should always contain at least 2 cm of water to keep air from re-entering
• Light bubbling shows air is being evacuated from chest
• When bubbling stops, it's done or kinked, check
• Inhale & exhale show bubbles (tidaling) → NORMAL
• Large amounts of bubbling is not good = leak in system
• Must place drainage system below the chest
• Monitor hourly in the 1st 24 hrs, making sure chamber 1 fluid is not filling up more than 70 ml/hr or near the tubing = (if so, causes pneumothorax)
• If tube falls out, keep below the patient's chest, cover with sterile gauze and call RRT
• ONLY clamp if you suspect some kind of leak or crack in the tubing
• Clamp is padded so it won't cause more cracks in tubing
• Only time we would do this, is if we were disconnecting it

Infection

• Signs and symptoms: fatigue, pain, NV, GI upset, malaise
• Will appear flushed, pallor, sweaty
• Fever, coughing, foul smelling discharge, swelling, warm area

Labs

• CBC- shift to the left (increase in immature neutrophils)
• Culture & sensitivity- trying to figure out where the infection is
• CRP will increase & ESR will increase
• Anything invasive places patient at risk for infection
• IV site
• Catheters
• Central lines
• Primary prevention- HYGIENE, vaccinations, infectious control practices
• Collaborative interventions- antipyretics, rest & comfort, antimicrobial therapy (cultures important for this)
• Nutrition- increase PROTEIN & CALORIES!!, getting plenty of fluids to help flush out the infection

Elimination

• Stress incontinence- Leakage of small amounts of urine during physical movement, during lifting or exercise, or after sneezing, coughing, or laughing - Most common type - Kegel exercises help with this!

• Urge incontinence-**Leakage of large amounts of urine at unexpected times, including when sleeping - **Sudden urge to urinate - **Occurs in people who can't suppress the contraction signal from the detrusor muscle

• Overactive bladder-**Urinary frequency and urgency with or without urge incontinence, ALL THE TIME

• Functional incontinence- **Untimely urination due to some type of physical disability

  • **Not able to reach the bathroom in time
  • **Some type of obstacle or cognitive impairment, making them unable to recognize the urge to go
  • **Bc of physical disabilities, obstacles, and cognitive issues → Prevents them from reaching the toilet and going to the bathroom
  • Dementia patients, immobile patients, etc.

• Mixed incontinence- stress & urge

• Transient- *Temporary leakage based on some type of situation

Examples

    - Taking a new med, making them leak urine
   - Infection
   - Pregnancy, Has cold → leaks urine when coughing
   - **Once situations resolve, won't have issues

Chole

• Surgical removal of gallbladder
• Open- takes 4-6 weeks to heal, 6 inch deep
• Lap- minimally invasive, healing time is shorter
• Use of Flexible scope w/ camera in order to visualize and remove gallbladder
• CO2- Will inflate the abdomen with CO2, in order to expand, visualize, & remove gallbladder (anesthesia)
  • Shoulder pain side effect
• Patient care- @ risk for blood clots. SCDs & compression socks
• Gallbladder ultrasound every 6 months for 1st year of therapy (To determine the effectiveness of drugs)
• Extracorporeal shock wave lithotripsy (ESWL)
  • To break up gallstones
  • For patients who are not a candidate for surgery or pts with small stones
  • Pt teaching- report any diarrhea, n/v, Severe abdominal pain → especially if pain radiates to shoulders

→ CONTACT PCP IMMEDIATELY

• Acute pancreatitis
  • **Immune system prematurely activates pancreatic enzymes that destroy ductal tissues and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas.
• Severity=depends on the extent of inflammation
  • **Severe is NHP (necrotizing hemorrhagic pancreatitis) - Bleeding pancreatic tissue with fibrosis and tissue death

- Pancreas (exocrine)-enzymes that break down fats, starches protein //

• ENDOCRINE- secrets insulin & glucagon HALLMARK= enzymatic fat necrosis of the endocrine and exocrine cells of the pancreas caused by the enzyme lipase. - **Fatty acids are released during this lipolytic process and combine with ionized calcium to form a soaplike product.
• Risks- alcoholism, blunt trauma, GALLSTONES, cholecystitis
• Complications- pulmonary edema, pleural effusion, type II diabetes, hypovolemia, renal failure, necrosis, paralytic ileus
• s/s- gallstones, jaundice, hyperglycemia, fever, tachycardia, low BP, respiratory issues

Labs

  - Increase in pancreatic & liver enzymes
   - Increase in WBCs and ESR
  - DECREASED CA and MG

• Meds- Morphine or Dilaudid, antiemetics
• IV fluids, NPO (food stimulates enzyme production)
• Chronic pancreatitis
• Progressive and destructive disease of the pancreas that has periods of exacerbations and remissions.
• Risks- male, ALCOHOLISM!!, fam history LOSS of exocrine function of pancreas
• s/s- dark urine, jaundice, 3 p's, abdominal pain/tenderness Drug therapy- pancreatic enzyme replacement, H2 blockers (decreases acid production), analgesics, insulin therapy (can become diabetic)
• HIGH calories (4,000-6,000 per day)
  • Avoid high fatty foods, alcohol Education
    • Take pancreatic enzymes with meals and snacks and follow with a glass of water.
    • if you swallow the capsule, pierce the gelatin casing and place the contents in applesauce.
    • No chewing the pills

UTI

• Risk factors- age, obstruction, stones, sexual activity, use of antibiotics s/s- dysuria, hematuria, burning sensation, frequency, retention, suprapubic tenderness or fullness LABS- UA, serum WBC (shift to the left), pelvic ultrasound or CT Drug therapy- antibiotics (cipro or amoxicillin), antispasmodics, bladder analgesic (Pyridium)
• increase fluids, cranberry juice, avoid coffee & tomato products, Pt education- pyridium can turn pee orange/reddish color
• Wipe front → back
• Wash peri area before sex
• Pee before & after sex

Renal Calculi

• Percutaneous nephrostomy- Placement of catheter through skin, into the kidney to drain urine (trying to get rid of kidney stones)
  • If the kidney stone is identified as being too large to pass on it's own
• OR → if we treat it and the pt is still not able to pass it and excrete on their own AND it's causing irritation & damage to kidney (bc it is lodged in the kidney) -Can lead to bleeding around the kidney
• Shockwave- breaking up stones into teeny tiny fragments
• Ureteral stent- Stent will be placed to go around the stone or obstruction in the ureter (temp)
  • Monitor for s/s of infection

Pain

• Gate control theory
• gating mechanisms located along the central nervous system regulate or block pain impulses.
• Pain impulses pass through when a gate is open and are blocked when a gate is closed. Closing the gate is the basis for nonpharmacological pain-relief interventions. Smaller diameter= Conducts excitatory pain stimuli → Sends towards the brain
• Larger diameter=Slows down & inhibits the transmission of pain impulses in the spinal cord Blocks pain impulse & closes gate
• Close the gate→ hot/warm compress, apply pressure
• TENS UNIT- feel prickly sensations, pins & needles
• Pain assessment in older adult- allow ample time to respond, head nodding & squeezing eyes are nonverbal signs of pain
• Infants- NONVERBAL CUES essential for pain. Inconsolable!!! Won-baker faces scale= for VERBAL children
• Ask for verbal pain scale/faces 1st, then look at cognitive non-verbal cues. High level of pain is a PRIORITY, they are unstable
• Respiratory Rate LESS than 8 → Give Narcan Treat after ABC
• Assess Obese & Older people more drug stay in fat/system longer

Cancer

• Chemo side effects
  • Alopecia, weight loss, N/v, mucositis, will feel exhausted/fatigued, food will taste like metal, CA LEVELS INCREASE, CIPN!!!, chemo brain
• Neutropenia- no fresh fruits/veggies/flowers, limit # of visitors, no litter boxes or animal cages Call doc when fever is above 100*
• Chemo-CENTRAL LINE, NEVER PERIPHERAL IV Where chemo PPE!!!!
• Radiation
  • Pt gets a private room & bath, keep the door closed as much as u can, proper disposal of garbage, lead apron, pregnant nurses should NOT care for these pts!

Side effects- alopecia, fatigue, aversion to red meats, sterility, skin sensitivity, dry mouth, diff swallowing, tooth decay, difficult breathing, SOB, shoulder stiffness, N/v

• HIGH protein & CAL!!! Frequent, smaller mealsLung Cancer
• Smoking is #1 cause, exposure to asbestos, air pollution
• metastasis→ brain, bone, liver, lymph nodes, pancreas s/s usually appear late hoarseness, cough, dyspnea, wheezing, rusty sputum, chest tightness
• test/labs- sputum test, thoracentesis, xray & CT scans
• Post pneumonectomy- lay on opposite OR affected side- see Dr orders
• Chest tubes hehe Breast/ovarian CA:

Metastasis

• Metastasis→ bones, liver, lungs, brain
• DCIS, LCIS >> localized // infiltrating carcinoma is INVASIVE //inflammatory breast cancer = invasive & peau d'orange
• s/s- dimpling in the skin, fixation, nipple retractions, lumps, peau d orange
• Risks: fam history, early menarche, late menopause, lack of breastfeeding, birth after 30, BRCA1 and 2, more than 1 drink per day
• Labs- liver enzymes, calcium, & ALP INCREASED
• Imaging- mammogram, ultrasound, MRI, chest x ray, ct
• OVARIAN- survival rates are LOW bc caught in late stages
  • Risks- BRCA 1 or 2, over 50
  • Vague, abdominal & GI symptoms (easy to ignore this) s/s- gi upset, stomach pain, urinary frequency, weight loss, vaginal bleeding!!!
• Ascites → increased liver enzymes!
• Lymphedema

Treatment

Surgery- remove tumors, debulk if too big Exploratory laparotomy- dx, treat, stage ovarian tumors Hysterectomy

• Lymph node removal
• CHEMO used most often Avoid sex, tampons, douchs 6 weeks after Surgey
• Make sure they are healing well DO NOT lift heavier 5-10 pounds, avoid jogging, no active bleeding, don't sit for too long, advance directives
• Post op- ambulate day after surgery to prevent blood clots

Glucose regulation

• process of maintaining optimal blood glucose levels. Counterregulatory hormones- increase blood glucose by actions opposite of insulin when more energy is needede glucagon- Prevents hypoglycemia by trigering the release of glucose from storage sites in liver and skeletal muscle insulin prevents hyperglycemia by triggering the release of glucose from storage sites in the liver & skeletal muscle
• SOMOGYI EFFECT- "so low yo-yo because of low to high Starts extremely low hypoglycemia overcompensation → raising the blood sugar Body releases glucagon & epinephrine, which increases blood sugar= rebound -Hormones → glucagon → increases Blood sugar What happens with UNTREATED NIGHTTIME HYPOGLYCEMIA? Might wake up around 3 am... this is when we have to check glucose levels.

interventions= increase food intake in evening/bedtime snack, lower insulin dose

Dawn PHEΜΟΜΕΝΟΝ- "sunrise" between 2-8 AM

• Insulin resistance- overnight release of counterregulatory hormones (cortisol, glucagon, epinephrine, etc.) increases insulin resistance, causing bs to rise insifficent antidiabetic medication dosage may need to adjust & increase the dose
• Carb snacking at bed time, causing bs to shoot up interventions=log insulin & food intake, if they wake up with high blood sugar in the AM check their glucose levels around 2-3 AM
• HYPOGLYCEMIA= less than 70 (severe is less than 50) "Cold & clammy give them candy"
• CONFUSED, weakness, hungry, irritable, headache inervention=give them a carb/sugar, juice. CHECK IN 15 MINUTES!!!
• Euglycemia → normal
• Pre and post prandial (after eating, at least 2 hours) post prandial -Hyperlycemia Severe - Sliding scales → usually starting at 150 Regulating glucose=INSULIN helps the cells absorb glucose, reduces BS & providing cells w/ glucose for energy