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Med-Surge Exemplars

Manifestations of Hypoglycemia *Reduced cognition *Tremors *Diaphoresis *Weakness *hunger *headache *irritability *Seizure *tachycardia *Restlessness *Depression
Manifestations of Hyperglycemia *polyuria *polydipsia *dehydration *fatigue *fruity odor to breath *Kussmaul breathing *Weight loss *hunger *dry skin *blurry vision *infections heal more slowly than usual
Treatment of hypoglycemia 15 grams of carbohydrates, protein, fat, glucose tabs
Treatment of hyperglycemia Insulin (glargine, lispro, metformin, regular)
Glargine long acting insulin (no peak)
Lispro short acting insulin
Metformin most common PO diabetes med
Regular short acting insulin ordered IV; a prescription and very cheap
Labs & Diagnostics for Hypo/hyperglycemia: Random Blood Glucose not fasting; below 140-150
Labs & Diagnostics for Hypo/hyperglycemia Fasting Blood Glucose no food 6-8 hours before testing; 70-100
Labs & Diagnostics for Hypo/Hyperglycemia Post-Prandial Glucose 2 hours after a meal; 70-100
Labs & Diagnostics for Hypo/Hyperglycemia Oral Glucose Tolerance Test before high carb meal and 30 mins to hour after, then 30 mins to hour after, etc
Labs & Diagnostics for Hypo/Hyperglycemia Hemoglobin A1C shows how BS has been over 3 months; an average
Foot Care Do's (Diabetics) *mild soap and water, pat dry *Nail care following bath or shower *Cotton wool separate overlapping toes *powder with cornstarch *socks are clean and absorbent *shoes need to be correct fit and leather *shake out shoes before putting on
Foot Care Don'ts (Diabetics) *use commercial remedies for removing calluses or corns *wear open-toe or open heel shoes *go barefoot *wear plastic shoes *heating pads/hot water bottles *stand or sit long periods of time or cross legs
Sick Days for Diabetics *Sports drinks, soups, fluids that replace electrolytes (high in carbs) *call Dr if unable to eat and replaced 4-5 meals with liquids *check glucose q 4-5 hours and urine for keystones *don’t be alone and get rest *no skipping meals
When do you go to the ER if you're Diabetic and Sick? *Decreased LOC *sick for more than 2 days *temp over 102 and doesn’t respond to meds or lasts more than 12 hrs *high resp rate *can’t tolerate fluids *glucose more than 240
How do you manage Type 1 Diabetes? *balance carbs with insulin doses *Encourage patient to eat moderately and experiment with diets to see what works best for them
How do you manage Type 2 Diabetes? *fewer, but healthier carbs *Encourage patient to eat moderately and experiment with diets to see what works best for them
What necessary/lifesaving skill should you teach a new Diabetic patient? How to check blood sugars
Manifestations of Pancreatitis (Acute) *Severe Pain (starts suddenly and becomes more severe with eating) *Nausea *Bloated *Distended *fever *increased HR *elevated BP *Cullen’s Sign *Grey Turner’s sign *low blood pressure *hypoxia *Pleural effusion/hypoxemia *steatorrhea
Manifestations of Pancreatitis (Chronic) *Severe Pain (in LUQ and is often constant) *nausea *bloated *Distended *fever *increased HR *elevated BP *Cullen’s Sign *Grey Turner’s sign *low blood pressure *hypoxia *Pleural effusion/hypoxemia *steatorrhea *Oily stools *Weight Loss
Interventions of Pancreatitis *NPO (TPN feeding) *Position for comfort *NG tube w/ suction for N/V (watch for metabolic acidosis & hypokalemia) *IV fluids
Treatment of Pancreatitis *Antibiotics *Morphine/hydromorphone *PPIs/H2 blockers (pantoprazole/famotidine IV) *Monitor stools; number and consistency *Electrolyte managment *nutritional support and electrolyte managment
What is the diet of pancreatitis? when diet is resumed, avoid alcohol, caffeine, spicy foods, fatty foods and eat: bland, low fat/high protein food, high carbs (unless glucose issues)
Teaching about Pancreatitis *Small, frequent meals *No smoking *don't chew pancreatic enzymes *Referral to Alcoholics Anonymous if needed
Manifestations of Bacterial Skin infection (non-necrotizing cellulitis) *Erythema *Warmth *localized pain *Edema *Exudate that contains pus/odor
Manifestations of Bacterial Skin infection (necrotizing soft tissue infections) *Fever *Tachycardia *Pain disproportionate to clinical findings *Disorientation *Lethargy *hypotension *firmness *ischemia *tissue necrosis *sepsis
Treatments of Bacterial Skin infections *Surgical Debridement *Bactoban ointment (if MRSA) *Antibiotic *Debridement *Decolonization strategies *Appropriate dressing
Labs/Diagnosis of Bacterial Skin infections *blood culture/sensitivity *CBC with differential *serum electrolytes *C-reactive protein *Wound tissue biopsy *identification of gas in subcutaneous tissues by CT scan
Teaching about Bacterial Skin infections *Hand washing *How to care for their wound *Manifestations of infection
Manifestations of Superficial Surgical Site infection *Purulent drainage *Organisms isolated from sterile culture from wound *pain and tenderness *localized swelling *erythema *Heat
Treatment of Superficial Surgical site infection *antibiotics *adequate nutrition status
Interventions of Superficial Surgical site infection *Ensure sterile technique *Report S/S of infection or dehiscence immediately *Frequently assess wound site *Sterile dressing change *prevent hypothermia during surgery *Know risk factors of infection *Record output and characteristics of drainage
Labs/Diagnostics of superficial surgical site infection *blood culture/sensitivity *CBC with differential *serum electrolytes *C-reactive protein *identification of gas in SC tissues by CT scan *Wound tissue biopsy (All of this is at a Surgical site)
Teaching about Superficial Surgical Site infection *Medication schedule and side effects (including pain meds) *follow up with physician *wound care instructions *Drain care instructions *Recommended activity level *Diet *Potential complications *Call Dr with: excessive bleeding, S/S of infection
Dehiscenence Total separation of wound edges, with no bowels/organs showing
Evisceration protrusion of intestinal contents
Treatment of Dehiscenece Cover with NS soaked pad and notify physician
Treatment of Eviceration Cover with NS gauze and prepare them for emergency surgery! (NPO, call surgeon, etc)
When is dehiscenence and Evisceration likely? in elderly, obese, malnourished, on steroids, and later in post-op period (days 5-10)
What should you teach patient to do to prevent dehiscence and evisceration? When you cough/laugh hold a pillow over the site to stabilize/brace it
Manifestations of Ischemic Stroke *headache *mental changes *aphasia *respiration issues *reduced cough/swallow reflex *agnosia *incontinence *seizures *hemiparesis/hemiplagia *emotional liability *Horner's syndrome *visual changes *hypertension *vomiting *Apraxia
Treatments of Ischemic Stroke Thrombolytic therapy (recombinant tissue plasminogen activator) Lorazepam/antiepileptics Calcium channel blockers stool softeners analgesics antianxiety drugs Surgery (angioplasty with stenting, endarterectomy, extracranial-intracranial bypass)
Interventions of Ischemic Stroke *Neural assessment/vitals q 1-2 hrs *Monitor ICP *emotional support *improve mobility *communication/swallowing *ECG & cardiac enzymes *serum electrolyte (na+) *I&O *HOB >30 degrees *aspiration/bleeding precautions *frequent repositioning
Labs/Diagnostics of Ischemic Stroke *CT scan *MRI *Dopplar Ultrasound of cartoid arteries *cerebral angiography *echocardiography (TEE and TTE) *Hypercoagubility (lupus anticoagulant, anticardiolipin antibodies, protein C activity, protein S activity, and factor V Leiden mutation)
Teaching about Ischemic Stroke how to be involved in care/what diagnosis means What to look for/when to activate EMS patient-specific/family risks for stroke Smoking cessation Medications for secondary prevention of stroke (reduce BP/hypercholestrolemia, prevent blood clotting)
Simple Partial Seizure manifestations Consciousness not impaired, labored speech/inability to speak, symptoms are subjective and vary greatly. This can lead to generalized seizure
Complex partial seizure manifestations Always a loss of consciousness, lip smacking and drooling, chewing, precipitated by aura during which patient is unaware of environment and can't respond to stimuli
Absence Seizure brief loss of consciousness that lasts 5-10 seconds, minimal to no alteration of muscle tone, no recall of incident
Myoclonic Seizure No postictal phase, brief contraction of muscle, one side of the body or can be both sides
Tonic-clonic seizure rigidity, rhythmic jerking of extremities, incontinent of urine/stool, lasts 1-2 minutes, postictal phase lasts several hours
Atonic Seizures head drop to severe fall to the ground with brief loss of consciousness, may require a helmet (high risk for falling/injury)
Treatments of Seizures *give medications consistently to maintain therapeutic levels *Keppra or Klonopin for prevention *DON'T administer warfarin with phenytoin *Vagal nerve stimulation *anterior lobe resection *partial corpus callostomy
Interventions of Seizures *Seizure precautions (airway, oxygen mask, suction equipment, IV access, side rails up and padded, get rid of clutter) *LEFT side during & after seizure *Check for patient airway *Calm/Dark environment *Patient safety highest priority! *Low carb diet
What are the interventions for status epilepticus? Airway, breathing, circulation. ABGs monitored. Give benzos first
Diagostics/Labs for seizures *CT *MRI *Electroencephalogram (EEG) *sleep test *CBC *BMP (infection) *Cortisol (stress levels could cause it)
Teaching for Seizures Social service resources for medication evaluation of employee safety Vocational rehabilitation may be subsidized Can't drive until 6 month after last seizure & physician & driving department both have to clear you medication management medical alert
Relapsing-remitting Multiple Sclerosis new symptoms appear and old ones worsen/relapse
Secondary progressive Multiple Sclerosis initially relapsing-remitting, now has gradual worsening of the disease
Progressive relapsing Multiple sclerosis progressive with gradual onset of symptoms from the onset, relapses may or may not recover
Primary progressive Multiple Sclerosis gradual progression with no remissions, may have temporary plateaus
Manifestations of Multiple Sclerosis *Blurred vision (diplopia) *numbness or weakness in one or more limbs *tingling or pain *electric shock with head movement *dizziness *muscle tremors/spasticity *lack of coordination *unsteady gait *fatigue
Treatment of Multiple Sclerosis *NO CURE; manage symptoms *NSAIDs *steroids *opioids *stool softeners *Gabapentin (nerve pain) *bronchodialators *neurotin (nerve pain) *physical therapy (water therapy) *manage anxiety
Interventions of Multiple Sclerosis rest periods balance exercise/rest/nutrition provide easy to swallow food free clutter family support facilitate communication Assess neuromuscular function Assess vision/eye movement assess skin integrity assess ADLs/bowel/bladder walker/cane
Labs/diagnostics of Multiple Sclerosis *Diagnosis of exclusion *repeated MRIs looking for lesions *CSF analysis *Genetics/Hx *nerve conduction studies
Teaching about Multiple Sclerosis *Avoid stress *avoid overheating *medication adherence *promote independence *S/S of exacerbation *disease process and prognosis
Cardinal Symptoms of Parkinson's Disease *bradykinesia *resting tremors *rigidity *postural instablility
Manifestations of Parkinson's Disease *stooping posture *slow, shuffling gait *pill rolling *dysphagia *drooling *depression *mask-like face *hypophonia *rapid mood swings
Treatment of Parkinson's Disease *Drug therapy (anticholinergics, dopamine-receptor agonists, dopamine precursors) *Thalamotomy (surgery) *Drug holidays for patients on long term drug therapy when drug tolerance is reached *Deep brain stimulation
Interventions of Parkinson's Disease *Fall precautions *Consults with PT/OT, speech, psychosocial, dietary *allow extra time for interventions *bowel/bladder regimen *assessment q 4 hrs (prn for anxiety/depression/sleepiness) *monitor for pressure ulcers
Labs/Diagnostics of Parkinson's Disease *No specific diagnostics; we try to rule out other things *progressive decline in motor ability *2 or more cardinal symptoms in abscence of other causes CT/MRI PT/OT assessments CSF for dopamine levels PTET or SPECT scans (due to other health probs)
Teaching about Parkinson's Disease *Family support/coping *keep room/house free of clutter *focus on patient's strengths *exercises to strengthen muscles *teach to use cane or walker if needed *facilitate independence *restrict caffeine
Manefestations of BPH *difficulty starting flow of urine *weak stream *dribbling/interruptions during urination *bed-wetting *bladder infection/stones *increased pressure in kidney *incontinence *feeling that bladder not emptied *urinary retention
Treatments/interventions of BPH *watchful waiting *Meds: 5 aplpha reductase inhibitors and alpha-adrenergic blockers *Herbal: Saw Palmetto, African Plumb, Cernilton, South African star grass *Surgeries
Surgeries to treat BPH *Transurethral Resection of Prostate (TURP) *Continuous Bladder irrigation *Prosectomy *Laser surgery *Transurethral Needle Ablation (TUNA) *Prostatic stents *Water-induced Thermotherapy and transurethral Ethanol Ablation
Labs/Diagnosis of BPH *Digital rectal examination *prostate-specific antigen (PSA) level
Teaching about BPH *Avoid excess fluids in the evening *avoid tranquilzers and over-the-counter meds that contain decongestants *explain "watchful waiting" *drug therapy education *importance of follow-up *care of surgical/invasive treatment sites
Manifestations of Colorectal Cancer *unexplained weight loss *change in bowel habits *rectal bleeding/blood in stools *persistant abdominal discomfort *feeling bowel doesn't empty completely *weakness *bowel obstruction
Treatments/Interventions of Colorectal Cancer *chemotherapy *radiation therapy *colectomy/hemicoloectomy *abdominoperineal resection *Colostomy *Screening
Labs/Diagnostics of Colorectal Cancer *EARLY DETECTION IS KEY *Colonoscopy (gold standard)/virtual colonoscopy *Biopsies taken/polyps removed *Fecal occult blood test *Lower GI series *Double-contrast barium enema *Sigmoidoscopy *Fecal DNA testing *Wireless capsule endoscopy
Teaching about Colorectal Cancer Lifestyle factors/risk factors that contribute to risk of colorectal cancer preoperative teaching r/t ostomy care Bowel prep Pain/pain management prevent post-op complications
Lifestyle factors that contribute to risk of colorectal cancer lack of regular exercise, low fruit/vegetable intake, low fiber/high fat diet, being overweight, alcohol consumption, and tobacco use
Other risks that contribute to risk of colorectal cancer Personal/family history of colorectal cancer, adenomatous polyps (also a family history of them), inflammatory bowel disease (IBD) for 10 years or more.
Manifestations of Prostate Cancer *May not have any symptoms at first *trouble urinating *weak stream of urine *hesitancy *sensation of incomplete emptying of the bladder *frequency *urgency *urge incontinence *urinary tract infection
Treatment/Interventions of Prostate Cancer *Radiation & Brachytherapy (radioactive seeds/pellets placed in prostate) *Cryotherapy *ablative hormone therapy *Radial prostatectomy
Diagnostics/Labs of Prostate Cancer *Prostate Specific Antigen (PSA) test for detection of early prostate cancer *Digital Rectal Examinations *Prostatic Biopsy
Teaching about Prostate Cancer Education of disease brachytherapy (absence of sex for 2 weeks after start & use condom) chemotherapy/radiation Signs of infection Prevention: increased foods with selenium Risk: consumption of calcium/ingestion of greater than 7 multivitamins/week
Manifestations of Urolithiasis *Severe pain (colicky pain with nausea and vomiting) *Bladder distention * obstruction of urine flow *hematuria
Treatments/Interventions of Urolithiasis Ureteroscopy percutaneous nephrolithotomy extracorporeal shock wave lithotripsy opioids Antiemetics Alpha-adrenergic blockers Strain urine&stone to lab surgery if causing obstruction/uncontrolled pain IV fluids <5mm pass naturally, >10mm=surgery
Labs/Diagnostics of Urolithiasis *Noncontrast CT scan (diagnostic of choice) *Kidney Ureter bladder (KUB) x ray *Ultrasound (in children and pregnant females because you don’t want to expose them to too much radiation)
Teaching about Urolithiasis *Increase fluids to 3L/day *Diet: limit sodium, increase intake of citrate, avoid foods high in oxalate *strain urine *call provider for fever or chills *Avoid fluids that could cause dehydration
Manifestations of IBD persistent diarrhea, abdominal pain or cramps, fever, weight loss, fluid imbalances, malnutrition, mouth ulcers, anemia, blood from rectum, joint/skin/eye irritation, and delayed growth
Manifestations of Crohn's RLQ pain, strictures and adhesions are common, can lead to fistula/abcess/peritonitis (large and small intestine); short bowel syndrome. Happens in "patches" in bowel.
Manifestations of Ulcerative Colitis large intestine; diarrhea 15 or more/day; blood mucus and pus, LLQ pain; teresmus (bowel urgency)
Treatment/Intervention of IBD *rest bowel and control inflammation *F&E regulation *medications, surgery, correction of nutritional deficit and psychosocial needs *aminosalicylates (sulfasalazine) * immunomodulators (inflizimab, adalimumab) * steroids
Manifestations of IBD *Uveitis, scleosing cholangitis, nephrolithiasis, cholelithiasis, joint disorders, skin disorders, and oral ulcerations *Malnutrition is very common
Complications of Crohn's fistulas and bowel obstruction
Labs/Diagnosis of IBD colonoscopy
Does Crohn's or Ulcerative Colitis have worse diarrhea? Ulcerative Colitis (15 or more a day)
Teaching about IBD *avoid crowds *get a TB test every year *importance of regular follow-ups and colonoscopy *medication teaching *importance of adequate nutrition
Obesity Comorbidities diabetes, hypertension, hyperlipidemia, cardiac disease
Class 1 BMI 30.0-34.9
Class 2 BMI 35.0-39.9
Extreme BMI greater than 40
Treatment/Interventions of Obesity *Weight loss therapy *diet therapy *increased physical activity *behavior therapy *bariatric surgery: restrictive procedure, malabsorptive procedure, combination procedure *Orlistat *lorcaserin *phentermine topiramate
Labs/Diagnostics of Obesity *BMI *ECG if they are at risk for cardiac disease *overnight sleep test if they have apnea *RUQ ultrasound to identify fatty liver disease *transvaginal ultrasonography for ovarian cysts
Teaching about Obesity *diet teaching *post op teaching *medications side effects *wound care *S/S to report (SOB, tachycardia, severe abd pain, s/s of infection, rigors) *dumping syndrome *Available support groups
S/S of Dumping Syndrome nausea, vomiting, diarrhea, diaphoresis, tachycardia, salivation, fatigue, dizziness
Manifestations of Apendicitis *peritonitis and gangrene (life-threatening) firm, ridged, board-like abdomen *abrupt change in pain, BP, HR *highest occurrence in 10-19 year olds; affects males more than females *McBurney’s point
McBurney's Point where someone has pain with appendicitis during the later stages; it’s a hallmark sign
Treatments/Interventions of Apendicitis *appendectomy *no management for acute *temp & HR, intake & output post surgery, pain, rebound tenderness, WBC/differential *position supine w/ HOB at 30-40 degress *comfort measures *provide ice to right lower quadrant post surgery
Labs/Diagnostics of Apendicitis *Diagnosis by CT scan (gold standard) *WBC > or = 20,000 indicates perforation *ultrasound
Teaching about Apendicitis *avoid the use of laxatives and enemas *take full course of antibiotics *teach wound care *turn, cough, deep breathe and use of incentive spirometer 10 times every hour *encourage early ambulation
Manifestations of Diverticulitis *perforation (complication) *abd pain over area *fever/leukocytosis *a mass @ involved area *increased flatus, anorexia, abdominal bloating &distention, diarrhea/constipation *stools w/mucus and blood *bleeding near vessels
Treatment/Interventions of Diverticulitis *broad spectrum antibiotics for uncomplicated diverticulitis *pain medications prn *IV antibiotics, bowel rest, IV fluids, check CBC *monitor vitals, serum potassium (may be low), pain and mental status *NG suction/provide oral care *Low fiber diet
Labs/Diagnostics of Diverticulitis *plain flat-plate abdominal x-rays and a CT scan *WBC monitored for elevations initially related to inflammation and possible infection
Teaching about Diverticulitis *avoid laxatives and enemas *increasing fiber from new fruits and veggies in diet *avoid straining, bending, and lifting *weight reduction *complete antibiotic therapy as prescribed
Manifestations of Peptic Ulcer Disease *PAIN is most common *duodenal ulcers and gastric ulcers *remissions and exacerbations
Which type of Peptic Ulcer is aggravated by fasting and improved with food and antacids? Duodenal Ulcer
Which type of Peptic Ulcer is worsened with eating and there is no relief from antacids? Gastric Ulcer
Treatment/Interventions of Peptic Ulcer Disease *pain relief, ulcer healing, prevent recurrence, and reduction of complications *antibiotics and PPI for H. pylori *acid suppression (antacids and H2 receptor agonist) *surgical interventions w/ nonhealing and bleeding ulcers
Lab/Diagnostics of Peptic Ulcer Disease *serum antibody testing *urease breath testing *stool antigen testing *CBC to rule out ulcer perforation/peritonitis (increased WBC)/anemia (low hematocrit) *diagnosed during upper endoscopy, lab and radiological testing
Teaching about Peptic Ulcer Disease *advise to avoid aspirin/NSAIDs, spicy foods, and beverages with caffeine *take meds as prescribed *avoiding eating within two hours of bedtime