Fundamentals 2

Diabetes and skin health

High glucose causes stiff arteries leading to poor perfusion. Decreased leukocyte function impacts healing. Diabetic neuropathy-delayed care. FEET HEALTH

Nutrition and Skin health

Protein: essential requirement for skin healing, in pressure injuries 30-35 kcals are necessary

Vitamin C: collagen synthesis

ZInc: cellular proliferation

Obesity: Moisture injuries, friction and shear forces, and fungal infections are more common. Fat tissue has low blood supply=risk of infection, hematomas, venous ulcers

Evisceration

Definition: medical emergency where internal organs protrude through a wound. Often after abdominal surgery

RISK: poor wound healing (obesity, malnutrion), steroid use, increased ab pressure, coughing, etc

NURSE: NOTIFY PROVIDER IMMEDIATLY, cover area in wet saline gauze

Moisture related skin damage 

Often Incontinence associated dermatitis (stool or urine) or Intertriginous Dermatitis (skin folds, may develop into fungal)

DX: BLANCHES.

TX: use dimethicone barrier wipes and keep area dry, separate folds w pillow case 

Smoking and wound healing

Smoking causes vasoconstriction=poor perfusion

Causes: Tissue hypoxia 

Primary Intention, secondary, and tertiary

Primary: Wound edges are approximated, so can be closed with sutures or staples EX: surgical incisions

Secondary: would edges are not approximated, heals w granulation from the bottom up-skintears/scrapes

Tertiary intention: wound kept open or reopened due to infection/swelling. Closed later

Staging Pressure injuries 

Stage 1: non-blanching redness

Stage 2: Partial skin loss, exposed DERMIS

Stage 3: full thickness loss, ADIPOSE TISSUE EXPOSED

Stage 4: full thickness and tissue loss BONE exposed 

Unstageable: Covered in eschar or slough so cant see the bed

Deep tissue: unstagable, non blanchable purple discoularation 

Lab Values associated with delayed wound healing

-Low platelets, Hgb, albumin

-Elevated WBC, glucose, bun and creatine

Skin cancer:

Malignant melanoma: existing mole that bleeds/changes shape

Basel Cell: most common, pearly white bump

Squamous cell: darker skin tones, firm red scaly patch

Left vs Right Heart Failure

Left: LUNGS-fluid backs up into the lungs, crackles, bloody sputum, orthopnea, signs of poor perfusion

Right: Fluid backs up in the BODY causing edema, weight gain, JVD, ascites

Cardiac output

Amount of blood that leaves the ventricles in one minute

Calculated by Stroke volume (volume of blood ejected each beat)x Heart rate

COMPENSATION: decreased stroke volume increased heart rate

Stroke volume- Detailed

Preload: amount in ventricle during diastole (stretch)

Afterload: resistance the ventricle has to overcome to push blood out (squeeze)

Contractility: force of contraction

Electrical conduction

SA node→atrial contraction→AV node→Bundle of His(along the septum)→Right/Left bundle branches→purjinkie fibers →ventricular contraction

Chest pain- respiratory vs heart vs musculoskeletal

Heart: pressure, sqeezing/burning sensation that is elevetated by rest. Spreads to neck and upper extremeties

Respiratory: sharp and stabbing, worse when you inhale. local and mostly unilateral worse when lying down

Musculoskeletal: Achy, sore, tender to touch. Local to ribs/muscles, hhurts with deep breaths and palpation

s4 vs s3

S3- from over filling ventricles, normal in younger than 30 active adults, HF in older

s4- non-compliant ventricles

Murmurs

Swishing noise from turbulent flow through valves

Systolic: between S1-s2, caused from mitral/tricuspid not closing all the way or aortic/pulm not opening all the way

Diastolic: S2-next S1, caused from mitral/tricuspid not opening all the way or aortdic and pulm not closing all the way. 

Deep Vein Thrombosis and PE

Cause: A clot forms in one of the deep veins

Assessment: pitting edema, warm to the touch

Risk factor: Reduced mobility, Dehydration, Increased viscosity of the blood, Venous stasis

PVeinD vs PAD

VEINY: Voluptuous pulse, Edema, Irregular sores, NO sharp pain(dull), Yellow/brown ankles

PADC: Pain when walking, Absent pulses and hair loss/shiny skin, Dependent Rubor, Cool 

P wave measurement

P wave: less than .12sec

PR interval: 

0.12-0.20 sec

QRS complex:

0.06-0.12

Qt interval

0.36-0.44

ST segment

0.005-0.150

PR interval Duration meaning

Too long=Heart block, likely AV

too short: AV node is bypassed, fast HR

QRS duration meaning 

To wide: heartbeat did not og in ATRIA 

T wave evaluation

Inverted: repolarization altered: PE, PI etc

Flat: decreased repolar current, HYPOKALEMIA

Biphasic: ischemia

Tall: HYPERkalemia

SS of decreased cardiac output

Symptoms: Palpitations, anxiety, diaphoresis, SOB, syncope, weakness

Signs: LOC, hypotension, tachycardic, tachypnea, urine output, cool skin, pallor 

sinus brady cardia

CAUSE: hypoxia, hypothermia, well trained athlete

Symptoms: chest pain, hypotension, SOB, sweat

TX (only if symptoms); atropine

Sinus Tachycardia

CAUSE: fever, anemia, hypotension, PE< MI

TX: based on cause

Premature atrial contraction

Cause: hypoxia, excessive stimulation, digitalis toxicity, CAD, infection

TX: common in older adults, don’t treat until symptomatic

AFib

CAUSE: cardiomyopathy, pericarditis, HTN, valve disease, CAD< Pulmonary disease 

SS: Rapid ventricular rate= compensation, CLOTTING atria quivvering=blood pools=clots 

LOOK FOR NO P WAVES AND IRREGULAR RHYTHM
TX: anticoagulantsss

Atrial Flutter:

Cause: MI< severe mitral disease, Thyrotoxicosis, COPD, heart surgery

SS: SAW TOOTH, no p waves, no PR measurement, atrial pulse 250-300bm

TX: beta blockers, ca channel blockers, digoxin, Cardioversion if severe

Supraventricular tachycardia

CAUSE: charge OG above the ventricles(Atria/av node)

TX: vagal stimulation, adenosene (pushed slowly) and cardioversion

Junctional rhythm

CAUSE: charge within av node (40-60 bpm)

SS: Pwave absent or inverted

TX: symptoms, RED FLAG IF DROP IN BP/LOC

Premature ventricular Contraction

Cause: hypoxia, MI, electrolyte imbalance, EXCESSIVE STIMULANT (drug use/young people), HTN

SS: wide, early, and atypical qrs

VTACH:

Ventricular rate greater than 120

CAUSE: hypovolemia, hypoxia, acidosis, hypokalemia, hypoglycemia, hypotermia, Cardiac tamponade, MI, PE 

W pulse: amiodarone, electrolytes, cardioversion

W/O: CPR DEFIB AND EPINEPHRINE 

Torsade De Points

50% have symptoms

Cause: Hypomagnesemia, hypocalcemia, qt interval, anorexia

W/O pulse: CPR, Defib, Epinephrine=PREVENT WORSENING SYMTPOMS 

V-FIb

Cause: hypovolemia, hypoxia, hypo/hyperkalemia, hypothermia, MI, PE, cardiac tamponde

TX: Emergency, CPR defib

Pulseless electrical activity

WHY: electricity not strong enough to make a pulse or contraction

CAUSE: H&Ts (H-hypovolemia, hypoxia, hyper/hypokalemia, hypothermia) (T-tension pneuomothorax, cardiac tamponade, toxins, thrombosis)

TX: NO SHOCK, CPR