thenightnurse

[thenightnurse]

Guillain- Barre Syndrome

GBS is an autoimmune process that happens a couple of days or weeks after a viral or bacterial infection. Since it is a syndrome and not a disease, it is not it's own stand alone thing. It is a collection of clinical symptoms that manifest as an acute inflammatory polyneuropathy, the most common type of GBS beomg am acute inflammatory demyelinating polyneuropathy. AIDP for short.

We don't know exactly what causes this, but we know that a cellular and humoral immune reponse is at play, and that most cases happen after a viral or bacterial infection of the GI or upper respiratory tract. Cytomegalovirus is the most common virus cause.

The first symptoms include pain, numbness and tingling, and hypotonia of the limbs. Within 4 weeks areflexia kicks in along with paralysis of the limbs. Autonomic nervous system dysfunction occus along with orthostatic hypotension, hypertension and abnormal vagal responses.

The big problems that arise with GBS is the risk of respiratory failure which occurs as it progresses to innervate the nerves.

Most patients do normally just spontaneously recover after around a month, but some take a few months or even years to recover.

[thenightnurse]

Bell's Palsy

My mom had this shit in college lol

So Bell's Palsy is an acute peripheral facial paresis with no definitive cause. Basically it is when your facial muscles get really weak for some reason and we don't know why. It's the most common facial nerve disorder, and more specifically it is the facial nerve (nerve 7) being inflammed without any other diseases present.

It won't kill you, so it is benign, and it normally goes away after 3 weeks to 9 months, though some people have residual effects such as facial weakness or twitching.

Honestly it looks like a stroked out patient.

The treatment of this includes providing a moist heat, a gentle massage, and electrical stimulation to the nerves. Corticosteroids are started asap and they work best if gived before paralysis is complete.

[thenightnurse]

Seizure Drug therapy

There is no cure for seizures, so the goal of seizure medications and therapy is to prevent them from happening while also minimizing the toxic side effects. Most of the drugs work by stabilizing the nerve cell memvranes which prevents the spread of an epileptic discharge.

The primary drugs we use to treat most seizures include dilantin, tegretol, phenobarbital, divalproex, and mysoline.

Tegretol, aka carbamazepine: Things to know include not taking it with grapefruit, do not abruptly withdraw from the drug as it'll cause seizures, and to report to the doctor if they have any visual abnormalities.

ight I spent too much time on seizures. Time to go to migraines.

[thenightnurse]

Management of a Tonic-Clonic Seizure

It is important to document the assessment findings that you see when a seizure happens in order to help healthcare proffesionals determine the cause and type of seizures that are happening.

For the aural phase, assessment findings include:

•Peculiar sensations that might precede the seizure

•a loss of consciousness

•bowel and bladder incontinence (pissing themselve)

•tachycardia (fast heart rate)

•sweating

•warm skin

•flushing or blue skin

During the Tonic phase (when they're seizing and body is tight)

•continous muscle contractions

Hypertonic Phase

•extreme muscle rigidity for 5-15 seconds

Clonic phase

•Rigidity and relaxations alternating in repeated succesion

Postlictal Phase

•lethargy, altered LOC

•Confusion and headaches

•repeated seizures for several minutes

If in the hospital settings, the interventions, or things we do for the patient include ensuring the patient airway is clear and safe, protecting them from injury during seizures, padding the side rails and NOT restraining them. Make sure to remove or loosen tight clothing, establish IV access, and staying with the patient until the seizure has passed.

Medications that are often given to attempt to abort the seizure include phenobarbital, dilantin, and benzos such as valium, versed, and ativan. God i love benzos.

If the patient does not breathe after the seizure, then definitely assist with ventilations, and anticipate the need for intubation if the gag reflex is absent.

During the ongoing monitoring of the patient make sure to monitor vital signs, level of consciousness, O2 saturation, glasgow coma scale, and pupil size/reactivety.

Make sure you reassure and orient the patient after seizure. Make sure that you never force an airway between a patient's clenched teeth, and give IV dextrose for hypoglycemia.

[thenightnurse]

Seizure part 3

Focal Seizures.

Okay cool cool cool, so focal seizures are known as partial seizures or partial focal seizures. With these seizures they happen in one hemisphere, or half, of the brain, in a specific cortex. Where they occur will determine what effects they have on the body, and how they are manifested. For example, an discharge of electrons (aka a seizure) in the medial aspect of the postcentral gyrus of the right side of the brain might cause a patient to have paresthesia (the weird tingly sensation) in the left leg. Remember that the left half of the brain controls the right half of the body and vice versa.

With focal seizures it is further divided into two types, simple and complex focal seizures.

With a simple focal seizure, the patient will remain conscious and alert, but might feel weird, or have unusual sensations. They might suddenly become really happy, sad, angry, etc. It might cause them to have new sensations that no one else is experiencing, might hear, smell, taste, see, or feel things that aren't actually there.

Opposite of this are complex focal seizures, wherein the patient will have a loss of consiousness or at least an alteration inhow aware they are of their surroundings, it might make them feel as if they are dreaming. It lasts anywehre from 30 seconds to 3 minutes and they go into a weird dreamlike setting, sometimes doing things that don't make sense, or doing nothing at all. Some things aren't too bad, smacking their lips, doing the same motion over and over again, but sometimes they might really fuck up and walk into traffic, take off their clothes, etc. After the seizure they will probably be tired and confused, and might not be able to return to their normal activities.

Here's where it gets even more annoying in terms of defining them. A focalized seizure starts at one side of the brain, but it doesn't have to stay there. It may actually spread to the entire brain which triggers a tonic clonic seizure. Like a shitty pokemon evolution. This is why it is hard to know which seizure is truly which. You might think your patient is having tonic-clonic (aka grand mal) seizures, but it is actually secondary (or coming after something, as a result of that something occuring) generalized seizure. There is a difference here though between the two. If a patient has Todd's Paralysis, which is a residual neurologic deficit that eventually goes away after the tonic clonic seizure, then it is actually a focal seizure that generalized secondarily, and not just a tonic clonic seizure. It's all convuluted and confusing, hence me stating earlier not to actually care too much about the differences.

There is however one seizure that I will point out due to it being unique and rather sad. Psychogenic Seizures. These seizures may resemble an epileptic seizure, and might even be diagnosed as one at first, however when EEG monitoring is done it is revealed that the brain is actually fine. Basically, the patient isn't actually having an epileptic seizure, there is no abnormal misfiring of neurons in the brain, yet they are suffering as if it were. It is actually due to some emotional or physical abuse that the brain can't deal with so it freaks out and decides that a seizure is a reasonable response. But it is actually fine.

[thenightnurse]

Seizures, part two.

So the next type of generalized seizure (meaning the whole brain is seizing) is known as a typical absence seisure. It used ot be called a petit mal. These often uccir in children and is pretty rare to continue once they reach youthood. Well, it either stops or it turns into a different and often types worse type of seizure. With this seizure, patients will have a brief staring spell that lasts for around 10 seoncds, often times unnoticed. They have a blank, daydreaming like look which can include blinking, chewing, hand movements, etc, and can last up to 20 seconds. It can happen up to a hundred times a day because the parents might not realize its happening and not seek treatment. Hyperventilating and flashing lights can cause these to occur. On an EEG (brain monitor) you will see a 3 Hz (cycles per second) spike and wave pattern that only occurs with this seizure. Thats key. I remember it by thinking absence seizure= being absent from reality.

The next type is an atypical absence seizure. So the differneces between an atypical and typical absence seizure are small, but there are differnces. These seizures can last up to 30 seconds, and unlike a typical absence seizure, atypical seizures have a gradual begging and end. Thats the key difference, a gradual onset and offset and an EEg showing spike and wave patterns less or greater than 3Hz, but not 3Hz.

I'm going to rush through the remaining generalized seizures at this point. There are myoclonic seizures which is when the person has a really sudden extreme jerking motion that often yeets them a good distance to the grand. It only lasts a few seconds but can happen several times in a row. To remember this you should know the etymology. Myo means muscle, and clonic means being aggravated. All your muscles are being aggravated and yeeting you around. Fun fact, the word myo, and muscle, is derived from the word mouse. Since the greeks thought that muscles looked like mice under the skin. Cute. Kinda.

An atonic seizure is when the person loses their muscle tone anf falls to the ground, lasting less than 15 seconds. They're often times still very much so conscious during it, and can get up and continue doing whatever afterwards. These people are most at risk for a head injury since they just drop like a sack of potatoes, and should wear a head protection helmet. The word makes sense, a- meaning not, and tonic meaning tone. No muscle tone.

Tonic seizures are, as you probably guess, when your muscles increase in tone and everything stiffens. This occus most often in sleep and effects the whole body. If they are awake and standing up they will probably fall down. It lasts less than 20 seconds and as with atonic seizures they will usually still be conscious.

Those are all types of generalized seizures, meaning that they are caused by the entire brain seizing. Next up I'll be talking about focal seizures.

[thenightnurse]

I’m back bitches.

Lets talk about seizures.

Like most things dealing with the brain, we are able to understand the gist of it without fully understanding it. Seizures are transient, uncontrolled electrical discharges of neurons in the brain that interrupt normal functioning. Transient meaning that they last a short amount of time then its over. Epilepsy is often times used interchangably with seizures, but that's not accurate. Epilepsy is a disease that makes you more prone and at a greater disposition to having seizures, it does not innately mean having seizures.

Cool. Now what causes seizures?

Well, there are different possible causes, and the most common causes very by each age group.

For the younglings, aka from 6 months out of the womb to little walking two year olds, the most common causes include severe birth injuries, congenital defects (brain didn't come out right :( sadly) infections, and just overall weird metabolism errors. Shit genetics essentially.

From 2 to 20, infections, trauma, random genetic factors and birth injuries are the most common causes.

Those between 20 and 30 often suffer due to structual lesions like brain tumors, vascular diseases, or brain trauma.

Those over 50 often suffer due to strokes or metastatic brain tumors, aka cancers that started elsewhere and metastasized, or moved over to the brain.

One third of all epilepsy cases are actually idiopathic, having no specific cause. This is known as Idiopathic generalized epilepsy. Thats a lot of cases man. Really goes to show we don't know whats happening.

When seizures occur it fucks up the brain and causes scar tissue, known as gliosis, to form and it causes a negative cascade of sorts, since scarring is believed to fuck up the brain more, causing more seizures, causing more scarring, etc. I actually had a patient who has had seizures for the last 15 years of his life and whose brain is so messed up that he can't even stand up without having a seizure. He is also somewhat retarded now (not a derrogatory term) due to his brain being so fried and scarred from years of seizures. It sucks man.

Clinical Manifestations!

Okay so this is the bit where we describe what the seizures cause to happen in a person. Different seizures cause different things, but the main thing to know for the real world is that there are type tpes, generalized and focal.

When thinking of generalized seizures, think of general anesthesia and how that is anesthesia that puts you out completely (generalized seizures involve your whole brain), vs localized which is only to a specific place. In the same vein, focal seiszures are specific to one part of the brain With focal seizures the patient is often times still somewhat alert, but with generalized they tend ot lose consciousness or have it altered.

With generalized seizures, you can divide them into two overall descriptions, having a probable altered consciousness or only having a brief or possible altered consciousness. It honestly gets really blurry (pun intended) the differences between them all and it doesn't matter too much for people to understand the difference, that's mainly for the doctos to deal with, but I'll go over them anyways. Feel free to skip the next bunch of information.

So, the most common generalized siezure is known as the tonic-clonic seizure, aka the grand mal seizure. French for big bad. Thanks french people. This is the one you see in the movies, the patient losing consiousness and falling to the ground and then beocming very stiff (tonic phase) for 20 seconds or so, and then they begin jerking like crazy for another 30 seconds or so (the clonic phase). I remember it by thinking tonic= toned and tight, and clonic= shaking like a clown. Patients become blue (cyanosis) start to salivate a lot, they might bite their tongue or cheek, and they may piss themselves because they can't control their body. After the seizure they have muscle soreness (all the muscles were just being used), feel tired, and probably will go to sleep. Here's the key bit, they will have no memory of the seizure.

[thenightnurse]

Benign Prostatic Hyperplasia and Prostate Cancer

First and foremost, what is BPH (Benign Prostatic Hyperplasia). It is an enlargement of the prostate gland which leads to the disruption of urine outflow from the bladder. The prostate (aka the male G spot and organ responsible for quite a few sex hormones) is located just under the bladder. The urethra (tube that carries urine from the bladder to the penis) passes quite literally, through the prostate, theres a little triangle it goes through. Well because the prostate enlarges it causes it to essentially clamp the tube shut.

As you can imagine, most patient with BPH will have lower urinary tract symptoms, such as difficulty starting a stream or decreased blood flow. Though we aren’t sure what causes it we do know it is related to hormonal changes, namely an excessive accumulation of DHT in prostate glands. Because of that, being of an older age is one of the greatest risk factors (then is obesity and alcohol consumption). It develops in the inner part of the prostate, and that’s the most important finding, the location, not the size. ;) 

The clinical manifestation are what you would imagine, decreased caliber of urine stream, hesitation in initiating a void, nocturia, recurring UTI’s (since you’re also unable to actually fully empty your bladder) and the feeling of not emptying your bladder. 

Complications that can occur involve bladder calculi, which are little stones that form in the bladder since it never fully empties, and renal failure caused by hydronephrosis. This is when the bladder eventually gets way too full and actually ends up backing up into the kidneys. 

Diagnostic Studies: When the serum creatinine is below 1. That’s when we start to look into BPH, and when the PSA (prostate Specific Antigen) is above a 4. We start to look to see if the pt has cancer.

There are a few drugs and procedures we do to fix the problem.

One of the most common drugs is Finasteride or Dutasteride, which are 5 alpha reductase inhibitors. These drugs work by inhibiting the 5 alpha reductase enzyme which is responsible for making testosterone hit the way it does. Well since BPH thrives on testosterone, and we are preventing there from being a lot of testosterone, the prostate gland eventually begins to shrink in size. Emphasis on the word eventually, as it takes 3-6 months for any improvement to occur. Since there’s decreased testosterone, there are also hormonal changes that can occur such as decreased libido, decreased volume of ejaculation, and erectile dysfunction.

Since most people are unable or unwilling to wait that long, we often times give alpha adrenergic receptor blockers such as Flomax or Prazosin. They work by relaxing smooth muscles in the prostate which facilitates urinary flow. Improvements occur in 2-3 weeks instead of months. Since they relax smooth muscles though, they also decrease blood pressure, so if the patient has a naturally low BP, we might think otherwise about giving it. On a similar note, side effects include orthostatic hypotension, dizziness, retrograde ejaculation, and nasal congestion.

If these treatments don’t work, then we move onto surgery. Transurethral Resection of the Prostate, aka TURP. This is the golden standard for taking care of BPH. They thread a tube up the penis and into the actual urethra, shaving and cauterizing the prostate until there is enough room for liquids to flow. The catheter that is inserted actually is a three way catheter and provides irrigation and hemostasis to the area. Fun stuff. The urine post surgery appears Hawaiian punch in color, since it is tinged with blood and prostate cells. If it were to come out viscous bright red there would be a problem (a hemorrhage probably) and the doctor would have to get involved. Belladonna and Opium are two medications given to help relax bladder spasms from occurring. 

So the question you might have now is, well why did you put BPH and Prostate Cancer together? Good question. It’s because they’re almost the same thing. Though we aren’t sure if BPH is a risk factor for Prostate Cancer (the science on it changes every couple of years), the effects almost mirror each other, except that Prostate Cancer has pain that radiates across the lumbosacral area, hips, and legs. To protect against it/to get diagnosed you should get your PSA levels checked every two years, especially once you hit age 55. PSA levels should be between 0-4. Most of the tumors occur in the outer aspect of the gland (remember that BPH occurs in the inside).

[thenightnurse]

*14 when they're asleep.

“Respiratory rate of…uh,18…”

[thenightnurse]

Todays events:

0430 Woke up. Breakfast of two bagels with almond butter and a cup of coffee.

0515 Went to the gym. Front squatted 195 for 5x5 and deadlifted 315 for 5x2

0615 Study Session

0800 Class for a few hours

1300 Lunch with a friend

1400 Study Session

1900 Will grab dinner then watch a movie at a friend's place

2200 Shower, stretch, then sleep.

Not the most interesting day but pretty productive so far.

[thenightnurse]

Gastroesophageal Reflux Disease

Let’s discuss GERD. So the way food normally travels is into the mouth, down the esophagus, through the lower esophageal sphincter and then into the stomach. From there is passes into a bunch of other organs and such, but we’re focusing on just this upper region for now.

So the actual disease of GERD is a chronic reflux of gastric contents into the esophagus, which is to say that the food you ate, which is now mixed up with a bunch of acids, is going back up into the wrong pipe, instead of down. 

The main causes of it include an incompetent lower esophageal sphincter, so that lower band of muscle which normally closes up after you swallow food, doesn’t properly close. It would be the equivalent or your anal sphincter not properly closing and you just have shit leaking out of you. Not pleasant. A hiatal hernia is also a common reason,  which is when your body makes a little pocket above the sphincter where stomach contents then collect, also not fun. Next up is decreased esophageal clearance. So normally when your sphincter is open some stomach acid can accidentally splash inside the esophagus, but it’s no big deal since your esophagus pushes everything down, and any leftover acid is neutralized by your mouth saliva, but in this case your esophagus isn’t able to push food fully into your stomach and so it sits there in the bottom of your stomach, getting acid splashed on it and becoming way too acid. Similar to this is decreased gastric emptying which is when your stomach itself doesn’t push food into the small intestines, causing it to get backed up and therefore backing up into the esophagus. This is commonly associated with gastroparesis caused by diabetes. The nerves are killed off by the chronic inflammation and high sugar content of diabetes and are no longer able to tell the muscles to contract. These are the main causes of GERD.

Cool, now that we know what causes it, let’s talk about the signs and clinical manifestations. First and foremost is pyrosis and dyspepsia. Pyrosis is the medical term for heartburn, from the Greek word for fire, ohh I might do a word of the day for this one. Dyspepsia is the word for indigestion, the feeling of bloating or fullness, stomach uncomfortability. Along with that we have hoarseness, a sore throat, a choking feeling. You can suffer from wheezing, coughing, or dypnea (shortness of breath). You can also feel a chest pain (also known as angina) which some people think is a heart attack, understandably so. 

Complications and issues that occur because of GERD: First is esophagitis, which is an inflammation of your esophagus. As a side note, the ending -itis, means inflammation of, so if you ever see that on a word just know that the body part is inflamed. Now chronic GERD and esophagitis can lead to Barrett’s esophagus, which is when the normal lining of the esophagus turns into tissue that resembles the lining of the intestines, which, first off, ew, but more importantly, is a major precursor to esophageal cancer, which it also not pleasant. The last major complication is the risk for aspiration, wherein you get that acid or food into your lungs, which is terrible for a myriad of other reasons. 

Diagnostic studies done to determine the cause or to fully diagnose it include an EGD with a biopsy (biopsy to check the tissues to see if the pt has Barrett’s esophagus) and a Barium Swallow Test.

Best ways to prevent or stop GERD is to stop smoking, avoid alcohol, lose some weight, elevate the head of your bed 4-6 inches/sleep on more pillows,  avoid additional physical stressors, and nutritional changes, notably avoiding foods that you know cause food (spicy foods lol), avoiding milk and consuming small frequent meals. Avoid eating 2-3 hours before bedtime and avoid nocturnal snacking as everything moves a bit slower when you’re asleep and laying down.

Now onto the drug therapy portion! The most common and arguably most over-prescribed medication right now (more than any opioid) are PPI’s, Proton Pump Inhibitors. General run down of them: they work by inhibiting the proton pumps that are responsible for Hydrogen secretion in the stomach, the H+ is whats responsible for making your stomach acidic, so this prevents muscle acidity. These are the medications that end in “prazole”, think Pantoprazole, aka Protonix. They’re best taken before the first meal of the day and are taken once a day. It takes a while for them to kick in and can cause headaches, diarrhea, and constipation. There’s an increased risk of fractures, and patients can develop C.diff since the stomach is no longer acidic enough to keep it at bay.

Next up we have H2 receptor blockers. They work by blocking the action of histamine on H2 receptors which then decreases HCL production and secretion. They’re also taken an hour before or after a meal. With these you want to be wary of drug toxicity with other drugs like coumadin.

Antacids are a cheap over the counter medication that are effective but are very short lived. Examples of this include Magnesium Hydroxide (which can cause diarrhea), Calcium Carbonate/Calcium Citrate (which can cause constipation), and others. Most of the can affect the absorption of other drugs, namely tetracyclines and quinolones, both of which are antibiotics. 

The last major group of drugs are cytoprotective drugs. While most other drugs work by decreasing something in the body, HCL, Hydrogen, etc, these drugs work by stimulating the lining of the stomach to produce more mucous which then covers and protects things ulcers that have formed. The two main ones are Cytotec and Carafate. Cytotec works by decreasing the HCL secretions (on top of the increasing mucous) and is administered with meals. It can cause diarrhea, flatulence, and miscarriages. In fact that drug is also known as misoprostol and is used in Maternity for abortions. Carafate is a cytoprotective drug that is to be taken ACHS (before meals and at night time), and 30 minutes before antacids. It binds to digoxin and other medications so it will decrease their effectiveness. This one works by binding to the mucous and forming a paste like substance.

That’s all I got for now lol.

[thenightnurse]

Abdominal Diagnostic Studies

Let’s discuss some common abdominal diagnostic studies!

First and foremost is the Barium Swallow exam. This is an imaging test that uses the metal Barium and X-rays in order to view your upper GI tract, focusing on your esophagus, mouth and throat. The actual “drink” is this milky looking viscous substance. The metal in it coats yours insides so that your GI tract can be properly imaged by the X-ray. You should not consume anything by mouth, for at least 8 hours before the procedure, we want everything inside to have settled down, in fact you shouldn’t even chew gum as that stimulates peristalsis, aka the moving of your intestines.  Afterwards, it’s best if you drink as much liquids as possible, increase your fiber, and even administer laxatives if need be. The goal post is to flush all the barium out of you. Not the most pleasant, but helps to rule out a lot of diseases.

Next up is an esophagogastroduodenoscopy, and EGD for short. Much shorter. This is the gold standard when it comes to viewing your stomach and insides, and once again we require patients to have not taken anything, be it food or liquids, 8 hours before the procedure. Also no smoking. After all the consent forms are signed, the IVs are started (so that they can provide you with medications throughout the visit), and you’ve taken some medications, the EGD begins. Side note, the medications they will give include a sedative, probably a good old Xanax, and some topical anesthetics for the back of your throat, to stop you from gagging, but I’m sure you won’t gag ;) The actual EGD is a long tube with a flashlight and a camera attached to it that they thread down your throat and into the stomach or whichever upper GI system they need to get to. They look around for anything out of place, pull the tubing out, wait for your gag reflex to return ;) and then send you home. You can be in and out in less than an hour. Expect a sore throat and some hoarseness afterwards.

Very similar to the EGD is the ERCP, which is short for endoscopic retrograde cholangiopancreatography. The only difference between the two is that the ERCP is used to examine the common bile duct (CBD) and the pancreatic duct. I was very dissapointed to find out that my patient who was going to receive CBD was going to receive this diagnostic test, and that I wasn’t going to get him high af. The medication that is THC and CBD is called Dronabinol/Marinol

Next up is the good old colonoscopy. The thing that most men fear for some reason. So there’s a shit ton of cancers that happen in the colon, pun intended, and the best way to visualize it is with the colonoscopy. It allows for a direct visualization of the large intestines up to the ileocecal valve, this is the valve that separates the small and the large intestines. You know how the previous exams start from the mouth and then go down? Well this one goes the other way. Through your anus and rectum and then throughout your large intestine. The most important thing for a patient to do is to have a clear liquid diet and complete the bowel prep the day before and morning of the test. It’s not a pleasant experience as it involves sitting on a toilet for a few hours drinking a gaudy liquid thing and shitting your guts out, but if you don’t do it then doctor can’t get a proper visualization of your colon (large intestine), and that’s kinda the whole point. They send patients away if you have eaten anything or haven’t completed the bowel prep. And trust me, they know.

Last major one on the list is the sigmoidoscopy. This is very similar to the colonoscopy, in fact it is a type of colonoscopy I guess, since the sigmoid is part of the colon itself, but since it is so close to the rectum and the doctor and his tubing don’t have to go so far, you won’t be required to undergo the whole bowel prep, just a simple enema. Still not pleasant I assume. This can be done at your general doctors office, no hospital visit required.

Some other exams you should know about but I won’t get into much detail: Fecal Analysis exam, or as I call it, a shit kit, this can check anything from nutrition absorption issues (for example the pancreas releases the enzymes that break down fat, so if we see high fat in your shit we might have you undergo an ERCP for followup), possible cancers, and possible infections. A hematest aka Occult Blood Test checks for issues with blood gasses, antigens and infections. Few other tests but I have to get to class now lol.

[thenightnurse]

[thenightnurse]

Nausea and Vomiting:

Causes: Nausea and subsequent vomiting is almost never its own disease, but rather the bodys natural response to a disease. The medulla oblongata is responsible for detecting triggers that the body is going under duress, be it a physical sickness or some other form of extreme bodily stress. As a result it tells the abdominal muscles to contract and vomit in an attempt to remove possible toxins from the body.

This response can be triggered from many different sights, smells, illnesses, food passing though your system slowly, exercise, anxiety, and many drugs.

Clinical Manifestations of chronic nausea and vomiting include anorexia, weakness, fatigue and dehydration.

Of these, we are going to focus on dehydration for a minute.

As a result of dehydration, your body will attempt to hold onto as much of its water as possible, causing decreased urine output. Tenting, which is when your skin is unable to snap back to its original position when pulled upon, is present, predominately in the forearms. Increased thirst is also common as the body is attempting to re hydrate yourself.

Another common and major side effect is electrolyte imbalances, namely hypokalemia, hyponatremia, and hypochloremia. Of these, hypokalemia is arguably the worst, as potassium is responsible for maintaining proper heart rhythms and an imbalance can lead to anything from tachycardia to arrhythmias.  

The first thing to do if a patient has episodes of nausea and vomiting is often to make them NPO, which is to say nothing by mouth (latin nil per os) until the patient is able to tolerate a clear liquids diet. After this we move them onto a BRAT diet, which consists of Bananas, Rice, Applesauce and Toast. This is because it is easily digestible and does not irritate the stomach. Safe foods to eat.

Medications!

Medications used to treat N&V are known as antiemetics.

Phenothiazines include compazine and phenergan. 

Antihistamines include vistaril and Bonnie. They are a receptor antagonist and are often used for allergy relief. They have an anticholinergic effect, which means that they dry you out. Because of this we do not administer it to people with glaucoma or old people. As a bonus, they can be used for boat trips to prevent dizziness. 

Anticholinergics- a common one is transderm scopolamine, these medications are responsible for drying you out. Side effects are: can’t see, can’t spit, can’t piss, can’t shit. 

Prokinetic- Common medication for this is reglan. Side effects include making you have to shit, and prolonged use includes tardive dyskinesia.

Seretonin 5ht4 receptor antagonists include Zofran and Aloxi.

Neurokinin 1 Receptor Antagonist- Varubi

Other useful drugs: Dranabinol (medical THC) and Dexadron

That’s all I got. Just rambling until I take my test.

[thenightnurse]

Word of the Day: Cholelithiasis

Definition: The presence of gallstones/ the disease caused by gallstones. Gallstones are known as choleliths.

Etymology: From the greek words chole -bile, lith -stone, and iasis -process. 

Rating: 4/10 Pretty boring and straight forward, its interestingness is overshadowed by its brother choledocholithiasis.

[thenightnurse]

Mac Millers Overdose; A Case Study

Mac Miller was and is one of my favorite rappers of all time. A man that everyone respected, both within the hip hop landscape and within society as a whole. His willingness to speak about his ongoing depression and drug addictions made it possible for others to discuss their own issues publicly. His songs have definitely helped me at several dark moments, especially The Divine Feminine during my freshman and sophomore years of college, and when I almost failed out of nursing. With his posthumous release of that album Circles, I would like to take a minute and discuss the circumstances of his death.

 I mean him no disrespect, all I have is love for the man.

On September 7th, 2018 Mac Millers personal assistant found him unresponsive in his home studio. His assistant began performing CPR on him until the paramedics arrived where he was pronounced dead. The coroner determined that he had died from an accidental drug overdose due to a “mixed drug toxicity of fentanyl, cocaine, and alcohol”. I am going to focus primarily on the fentanyl, as that, compounded with alcohol was probably the main cause. Cocaine would cause a stroke rather than an overdose.

Fentanyl

Fentanyl is a synthetic opioid pain reliever. Opioids are a class of drugs that are found naturally in the opium poppy plant, and produce pain relief. Most drugs are based from plants, which is why natural medicines work. Plants such as the poppy plant, marijuana, tobacco, Bael, Tulsi, Henna, Lavender, Neem, etc., all have medicinal properties that we have then “perfected” to make our own drugs.

Well in our brains we have some proteins called opioid receptors that are attached to nerve cells thoughout the body notably in the brain and spinal cord. The opioids attach to these receptors and block the pain message, but they block more than just these pain signals, they also block the presynaptic dopamine transmitter (these are big words you don’t need to know), which is part of the mesolimbic system (the system responsible for rewarding yourself and making you feel good), and when this is inhibited dopamine (the molecule responsible for making you feel good) is released. Since the presynaptic dopamine transmitter is blocked, you keep more dopamine out and about which means you stay feeling good for longer and for a lot stronger.

You know how we have an heroin epidemic throughout America? Well fentanyl is basically a synthetic version of that, but it is literally 50 times more potent. Think of methamphetamine and dextroamphetamine (the majority compound of adderall.) We derived amphetamines from ephedra, a plant from China. If you chew it it’ll help treat your asthma and congestion, its where we get ephedrine from (which I’m about to take to help with a cutting cycle to lose weight real quick, I can talk about it later). So like heroin, we get dextroamphetamines from nature and it is just slightly tweaked and cleaned up. Then we take it and alter its molecular componenents on the 5th carbon group and now we have this drug which is 50 times more potent and dangerous. That’s the same thing with fentanyl and heroin. Fentanyl is like the meth of opioids.

3 mg is enough to kill the average male.

So remember how I said that there are opioid receptors throughout the entire body? Well there are µ-opioid receptors located on the surface of neurons in the brainstems respiratory center, the place responsible for how you are able to breathe without thinking about it. Well it also slows down those receptors which is what causes respiratory depression. Well when you breathe less you get less oxygen and that’s kind of necessary for living. In fact it can lead directly to respiratory arrest, which is where you stop breathing altogether. 

Alcohol works on the same receptors to also depress respiratory functions, and so taking them at the same time multiplies the effects of each other, creating a much stronger high, but also a much higher risk for respiratory depression.

That is what ultimately and tragically killed Mac.

Now this is not at all what Mac was expecting. Earlier that week Mac had actually purchased pills of what he thought was oxycodone, while in reality it was fentanyl counterfeited as oxycodone, as they have a similar effect, but fentanyl being much easier to produce. He proceeded to snort the laced pills along with Xanax and cocaine, (Xanax, a benzodiazapine I can go into detail later, along with many personal anecdotes), where he soon after met his untimely young death. Rest in peace Mac, much love forever. Circles is an instant classic and I’ll be bumping it all night long.

As a general disclaimer,  do not advocate the buying and using of drugs for hedonistic purposes. That being said, here are some tips to make sure you stay safe while doing so.

If you ever buy drugs from online, always go with the assumption that it is not what you actually want. I can almost guarantee you that if you purchase from the Empire Market that your Xanax and Ativan is always going to be just fentanyl pressed with corn starch. The same goes for adderall or any amphetamines, it will be either cocaine or meth (probably meth) pressed with corn starch. This is most definitely not from personal experience. There are many reagent tests you can do at home to verify the drugs yourself, in fact there are test strips for almost every drug that you can purchase off of any common website to check your own drugs. Always carry Narcan and Flumazenil if you are ever to engage in such activities with friends to ensure you can revive them. Stay safe.

[thenightnurse]

Pancreatic Cancer

Probably one of the top five worst cancers to get, though to be fair none of them are exactly good to get. A terrible prognosis with very few clinical manifestations which is why most patients only get diagnosed with it days before their death. 

It’s what killed Steve Jobs, Alan Rickman, Patrick Swayze, and many others.

Pancreatic adenocarcinoma is the full medical term that most patients hear. Adeno derived from the Greek word adēn meaning ‘gland’, and carcinoma from the Latin word cancer, which is actually from the Greek word karkinos which meant crab. This is because the swollen veins around the cancerous tumors looked like the limbs of a crab.

I’m going to write this post with the assumption that you as the reader know how cancers are able to kill you, and will instead write about that at a later point. 

Causes of Pancreatic Cancer: We aren’t actually certain of what causes it, however there are extremely high risk factors associated with it; namely tobacco smoking and obesity. To be fair, these two traits are associated with almost every disease.

Why is Pancreatic Cancer so deadly?: There are very few symptoms of pancreatic cancer when it starts out, and often times patients and doctors don’t recognize it as such. Some pain the the upper abdomen. It isn’t until the patient is anorexic, has extreme weight loss, jaundice and steatorrhea do we realize that the patient might have pancreatic cancer. Steatorrhea is the presence of excess fat in feces, and its associated with pancreas diseases since the pancreas is the organ that namely deals with secreting enzymes that breakdown food, namely fat enzymes.  And that’s the key to beating cancer, finding it early enough and getting rid of it. Which is why the healthcare field pushes for people to get annual physicals along with frequent screenings.

At this point the cancer has most likely metastasized (spread beyond just the original organ) to the liver and lungs. Only 10% or so of patients are diagnosed when the cancer is still only in the pancreas and are able to have it surgically removed (the surgery performed is called a Whipple Procedure). For most people they don’t have their diagnosis until much later, and the prognosis (likely course of the disease) is very bad. In fact the only cancers that rival it in terms of being the worst are heart cancer and brain cancer. 

Since most patients cancers have metastasized, they are unable to have surgery performed, and as a result need to undergo chemotherapy instead. Chemotherapy isn’t that effective against the cancer either, and to top it off pancreatic cancer shows an intrinsic chemotherapeutic resistance through use of a dense stromal reaction that impairs drug delivery, which means to say that the cancer is able to use the body’s ability to create a scar and pervert and corrupt it to create its own protective body, effectively shielding itself from having the chemotherapy drugs delivered to it. Freaky shit, absolutely terrible disease.

Diagnostic Tests:

Ultrasound on the abdomen, MRI, CT Scan, CA 19-9 test.

Personal Anecdote: On my first nursing clinical rotation I was on a hepato pancreo billiary floor, where they specialized on post Whipple procedures. All of the patients there had pancreatic cancer and had beaten it. I didn’t realize how rare and dangerous it was, or how brave and incredibly tough all of those patients were. I wish I hadn’t acted so flippant and factitious about cancer to my friends at that time. Only much later did I realize that while yes, humour is a great coping mechanism, cancer really fucking sucks.