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304 med surg
final review (all topics)
| Question | Answer |
|---|---|
| Fluid & Electrolytes | • Balance critical for organ function & homeostasis • Nurse role: assess, monitor labs/VS, identify imbalances • Fluids: intracellular (~2/3), extracellular (plasma) |
| Fluid Volume Deficit (Hypovolemia) Pathophysiology | • Causes: ↓ food/fluid intake, GI loss, trauma • S/S: weight loss, ↓ turgor, tachycardia, dry mucosa • Other: dizziness, confusion, thirst, ↑ Hgb/Hct • BP ↓, HR ↑ (compensation); ↑ BUN/Cr |
| Treatment for fluid volume deficit | • Tx: I&O, daily weights, monitor vital signs • Fluids: oral fluids if tolerated, IV fluids (NS/LR) |
| Nursing interventions for Fluid Volume Deficit | Monitor CMP Monitor vital signs and mental status Monitor skin turgor Daily weights with I/Os Medication Hx (concurrent diuretic use) |
| Fluid Volume Excess (Hypervolemia) Pathophysiology | • Cause: Na⁺ + water retention • S/S: edema, JVD, lung crackles, ↓ Hgb/Hct |
| Treatment for Fluid Volume Excess | sodium restriction (<2g daily intake) fluid restriction diuretics (Furosemide/Spironolactone) hemodialysis in severe cases |
| Hyponatremia Pathophysiology | serum sodium under 135 mEq/L Cause: vomiting, diarrhea, SIADH, diuretic use, adrenal insufficiency, diaphoresis S/S: hypotension, tachycardia, neuro changes (cerebral edema), headache, abdominal cramping |
| Hyponatremia treatment | sodium replacement NS/LR IV bolus hypertonic IV bolus if severe |
| Hypomagnesemia pathophysiology | Mg2+ <1.8 mg/dL S/S: tremors, muscle spasms, fatigue, weakness, arrhythmias |
| Hypomagnesemia treatment | IV Magnesium sulfate on infusion pump (NEVER IV PUSH) In case of Mg toxicity --> tx with Calcium Gluconate |
| Nursing Interventions for Hypomagnesemia | assess reflexes during Mg infusion b/c acute toxicity leads to decreased reflexes assess urine output monitor vital signs |
| Nursing Interventions for Hyponatremia | monitor skin for turgor/dry mucosa assess for mental status |
| Nursing Interventions for Fluid Volume Excess | assess lung sounds for crackles (pulmonary edema) assess for ↓ BUN and ↓ hematocrit assess electrolyte and kidney function monitor I/Os and weight monitor for dietary sodium restriction |
| Hypocalcemia Pathophysiology | Ca <8.5 mg/dL Causes: Malabsorption, osteoporosis, inadequate diet S/S: tetany, paresthesia, hyperactive deep tendon reflex, + Trousseau's Sign, Chvostek's Sign Risk for seizure, respiratory depression, laryngospasm, abnormal clotting, anxiety |
| Hypocalcemia precautions | Seizure and fall precautions padded side rail low bed height |
| Hypocalcemia treatment | IV calcium gluconate alternative - oral calcium + Vitamin D dietary: ↑ dark leafy green vegetables, dairy |
| Nursing Interventions for Hypocalcemia | monitor vital signs assess deep tendon reflexes (decreased Ca2+ = hyperactive reflex) cardiac monitor for cardiovascular status |
| Hypokalemia pathophysiology | K+ <3.5 mEq/L Causes: diuretics, insufficient intake, GI loss, diaphoresis S/S: muscle weakness, fatigue, cramps, constipation, arrhythmia |
| Hypokalemia treatment | IV pump KCl oral potassium supplements (ER tablet/powder) NEVER give IV potassium push (unless you really hate them lol) |
| Nursing interventions for Hypokalemia | cardiac monitoring for arrhythmia risk monitor ABG assess for digoxin or digitalis use |
| Hyperkalemia pathophysiology | K+ >5 mEq/L cardiac arrest risk S/S: muscle weakness, palpitation, chest pain, arrhythmia/MI Tall peaked T waves Prolonged PR interval |
| Nursing Interventions for Hyperkalemia | cardiac monitoring for MI/arrhythmia risk assess CMP and renal function monitor vital signs dietary education for high potassium foods assess FSG prior and 1h after to insulin administration |
| Hyperkalemia treatment | IV pump calcium gluconate (given first to stabilize heart rhythm) 10u regular insulin IV push + 50mL D50 dextrose oral Lokelma (binds to K+ in GI for elimination) bicarbonate for acidosis |
| Pain | Pain is subjective Use pain scales (numeric, FACES) |
| Administration of pain medications | Assess pain before and after medications Monitor vital signs before opioid administration |
| Nursing considerations for Opioid/Narcotics administration | avoid EtOH and heavy machinery assess for constipation assess respiratory depression, neuro changes monitor vital signs before med admin assess pain before/after med admin |
| Non-pharmacological pain management | comfort measures repositioning music therapy guided imagery |
| Nonverbal indicators of pain | tachycardia diaphoresis increased respiratory rate facial expression |
| wound care/skin breakdown | risk for immobility, decreased consciousness, increased moisture for skin breakdown (incontinence) friction when moving pt *documentation of ALL skin ulcers* |
| Management for skin breakdown | turn Q2h keep skin dry/barrier creams mobilization |
| Nursing Interventions for skin breakdown | monitor for infection (erythema/drainage/fever) dressings per order (with possible debridement) adequate nutrition with high protein (dietician referral) monitor serum albumin levels |
| Perioperative Nursing Phases | Pre, Intra, Post |
| Pre-op phase | labs and informed consent (provider obtained with nurse witness) know surgical site establish IV line and give med admin pt to use bathroom prior to anxiolytic use d/t fall risk |
| Wound dressings | Wet vs dry dressings Protective barriers w/o dressing (passive dressings) Filler dressings for deeper wounds Debridement of tissue |
| anesthesia risks/complications | anaphylaxis malignant hyperthermia respiratory depression/hypoxia hypothermia |
| Malignant Hyperthermia pathophysiology | cause: anesthesia adverse reaction (emergency) early S/S: tachycardia (>150 BPM) late S/S: rapid fever, muscle rigidity |
| Malignant Hyperthermia treatment | IV fluids (to cool) Dantrolene (reverse symptoms) |
| types of anesthesia and complications | local epidural - hypotension d/t vasodilation spinal - headache d/t CSF leak |
| Intra-op phase | monitor patient for anesthesia complications (malignant hyperthermia/anaphylaxis/respiratory depression) |
| Post-op phase | transfer to PACU (post anesthesia care unit) assess respiratory/neuro/cardiac status |
| Post-op phase nursing interventions | cardiac monitor + BP monitor + SpO2 + respiratory rate assess pain assess alertness notify MD STAT for hypotension - hypovolemia/blood loss risk (5 min BP triage) assess peripheral pulse assess airway (laryngeal stridor) |
| laryngeal stridor | *Medical emergency* hypopharyngeal obstruction d/t lower jaw and tongue falling backwards audible noisy/irregular respirations from choking declining SpO2 |
| Reglan considerations | NO Reglan (Metoclopramide) IV push d/t ADR -- tardive dyskinesia Use IVPB administration assess for facial movement disorder |
| Discharge considerations | Aldrete score 7+ for discharge need stable BP, respiratory function, O2 sat, alertness No driving/heavy machinery |
| Post-op complications | Hypovolemia from post-surgical hemorrhage Risk for increased pain Risk for altered airway patency (d/t vomiting) Risk for PNA (if not using incentive spirometer) |
| Incentive Spirometer | device for taking slow deep breaths --> helps clear out secretions and improve lung functions especially in post-surgical setting |
| Interventions for respiratory disorders | #1 priority is ABC (Airway Breathing Circulation) sit pt up O2 administration (cannula, facemask, non-rebreather, venturi) |
| Pneumonia Pathophysiology | inflammation of lung parenchyma d/t mycobacteria/fungi/virus Risk factors: CHF, DM, alcoholism, COPD, AIDS, cystic fibrosis, influenza S/S: cough, fever/chill, confusion, SOB, chest pain, fatigue Risk for septic shock or respiratory failure |
| Pneumonia treatment | O2 and IV fluids Abx (for bacterial PNA only) antipyretics for fever antitussives/decongestants/antihistamines |
| Nursing interventions for Pneumonia | assess respiratory status and vital signs monitor secretions and cough for quality/changes assess lung sounds for wheezing/rhonchi/diminished sounds hand hygiene |
| Antibiotic tx for Bacterial Pneumonia | usually use broad spectrum prior to culture (Zosyn) S. Pneumoniae + S. Aureus commonly seen |
| Pneumonia prophylaxis | pneumococcal vaccine for young adults (19+), immunocompromised and booster for elderly (65+) |
| Aspiration Pneumonia | d/t inhalation of foreign material causing inflammatory reaction (dysphagia/stroke pts) need swallow evaluation |
| Nursing considerations for Tube Feeding | check placement of PEG tubes and NG tubes NG tubes can go into lungs and cause aspiration PNA |
| COPD pathophysiology | d/t chronic emphysema vs chronic bronchitis Risk factor for smoking/2nd hand smoking Use of accessory muscles/sternocleidomastoid muscle and tripod positioning for impaired breathing Barrel chest 1:1 AP: transverse ratio |
| Chronic bronchitis (COPD) pathophysiology | Blue Bloater S/S: cyanosis, hyperventilation, increased sputum, hypoxia, hypercapnia, clubbing, fatigue, coarse voice, accessory muscle use |
| Hypercapnia | increased CO2 levels in blood, commonly seen in COPD/chronic bronchitis |
| Chronic bronchitis nursing considerations | Avoid excessive O2 supplementation d/t hypercapnia and respiratory depression risk 2-3 L O2 max usually 91-92% O2 sat Ask normal baseline O2 sat for patients |
| Chronic Emphysema (COPD) pathophysiology | Pink Puffer S/S: barrel chest, hyperventilation, pink skin complexion, hypercapnia |
| COPD treatment | Smoking cessation Bronchodilators (albuterol) Anticholinergics Corticosteroids (prednisone, solumedrol) Antibiotics Mucolytics/antitussives O2 supplementation PRN (2-3L low flow) Pneumonia and flu vaccinations |
| COPD nursing considerations | monitor CBC for infection with corticosteroid use |
| Asthma pathophysiology | Chronic inflammatory airway disease of hyperresponsiveness, mucosal edema and mucus production Strong allergy component (IgE mediated) S/S: cough, chest tightness, wheezing, dyspnea Reversible with tx |
| Asthma nursing interventions | Education on identification and avoidance of triggers Avoidance of cigarette smoke Assess lung sounds Ask for intubation Hx (indication of severity) *SILENT CHEST = MEDICAL EMERGENCY* |
| Asthma treatment | SABA- Albuterol (SABA short acting beta agonist - rescue inhaler) LABA - long acting beta agonist Nebulizers Leukotriene modifiers (allergy) IVPB Magnesium (smooth muscle relaxant for wheezing) |
| Anaphylaxis pathophysiology | Severe life threatening allergic reaction S/S: rash, neuro changes, respiratory difficulty, angioedema, bradycardia/tachycardia, hypotension, syncope, diaphoresis, N/V, anxiety, laryngeal edema, stridor Intervention dependent on severity |
| Anaphylaxis treatment | #1 line - 1:1000 epinephrine IM (EpiPen) Benadryl (antihistamine) Pepcid (H2 blocker) Albuterol O2 supplementation IV fluids if not contraindicated |
| Retinal detachment pathophysiology | S/S: shade or curtain coming across vision of eyes, bright flashing lights, floaters cause: trauma, DM, age MEDICAL EMERGENCY |
| Retinal detachment tx | only surgical treatment scleral buckle vitrectomy |
| Glaucoma pathophysiology | "silent thief of vision" open angle (chronic) vs closed angle (acute med emergency) S/S: blurry vision, halos, difficulty focusing, difficulty adjusting to low light, eye pain, headache |
| Glaucoma treatment | Betablocker (Timolol) - need lifelong therapy Cholinergic (Pilocarpine - ADR risk mostly used for closed angle) Assess for concurrent B-blocker use |
| Cataract Post-surgical Considerations | Verbal discharge teaching Avoidance of lying on surgical side Resume activities as directed by MD Avoid strenuous activities (>15 lbs) Avoid bending/stooping for extended time Avoid holding in sneeze and with open mouth |
| Conductive hearing loss | Inefficient sound transmission through outer/middle ear into inner ear Causes: ear canal damage/occlusion, tympanic membrane damage, middle ear diseases |
| Sensorineural Hearing loss | Damage to inner ear (cochlea or auditory nerve) Causes: Congenital, Ototoxic drugs, Severe infections, Tumors |
| Weber test | Tests bone conduction AC>BC = normal AC<BC = conductive hearing loss |
| Rinne test | Tests tuning fork on top of head Sound lateralizes to worse ear = conductive hearing loss Sound lateralize to better ear = sensorineural hearing loss |
| Mastoiditis pathothysiology | Inflammation of mastoid cells in middle ear d/t infection |
| Nursing considerations for the deaf | Use low tone and normal voice Speak slowly and distinctly Face impaired ear Use gestures/facial expressions Provision of whiteboard |
| Mastoiditis treatment | IV Antibiotics Oral Antibiotics Mastoidectomy if necessary |
| Meniere's Disease pathophysiology | Abnormal inner ear fluid balance d/t endolymphatic sac malabsorption or endolymphatic duct obstruction S/S: Vertigo, tinnitus, pressure in ear, N/V |
| Meniere's Disease treatment | Sodium restriction 1-1.5 g/daily intake (reduce ear fluid) Meclizine Ondansetron |
| Peripheral Arterial Disease pathophysiology | Chronic illness of plaque/platelet aggregation in peripheral arteries S/S: INTERMITTENT CLAUDICATION, aching, cramping, fatigue/weakness leg pain relieved by rest in early stage -> resting pain Toe ulcers |
| Peripheral Arterial Disease Nursing Education | Dangle legs over side of bed for leg pain Exercise education (walking/isometrics) Smoking cessation Stress reduction (BP management) |
| Peripheral Vascular Disease pathophysiology | Vascular disorder preventing venous blood return to heart Increased risk of MI/stroke, DVT/PE Ankle ulcers |
| Virchow's Triad | Risk factor for vascular thrombosis -Endothelial damage -Venous stasis -Altered coagulation |
| Hyperlipidemia | Elevated blood serum lipids (triglycerides/cholesterol) - LDL <100 mg/dL optimal Stroke/MI and vascular disease risk factor |
| Hyperlipidemia treatment | Dietary modification with low cholesterol Weight loss and exercise Statin therapy (need CMP and CK monitor) |
| Venous thrombus embolism risk factors | Virchow's Triad (altered coagulation, endothelial damage, venous stasis) Smoker Oral contraceptive Long periods immobilization/venous stasis (sitting/lying down) |
| Hypertension pathophysiology | elevated BP S/S: Headache, dizziness, blurred vision, tachycardia |
| Hypertension treatment | Sodium restriction (<2g daily) Calcium channel blocker (Amlodipine) Angiotensin Receptor Blocker (Losartan) Angiotensin Converting Enzyme Inhibitor (Lisinopril) Beta-blocker (Metoprolol) Diuretics/Thiazides (HCTZ) |
| ACE Inhibitor ADR | Angioedema (occurs within days to months to years) Lisinopril, Enalapril |
| Diabetes Mellitus Type 1 Pathophysiology | Autoimmune destruction of insulin producing pancreatic B-cells (absolute insulin deficiency) Genetic component, childhood development Need lifelong insulin therapy S/S: Polyuria, polydipsia, polyphagia, hypoglycemia, dizziness, diaphoresis DKA risk |
| Diabetic Ketoacidosis | Abnormal metabolism of carbs/protein/fats due to lack of insulin, acidosis d/t elevated ketone bodies S/S: Hyperglycemia, Dehydration, Serum and urine ketone elevation, vomiting |
| Diabetes Mellitus Type 2 Pathophysiology | Acquired insulin resistance/deficiency HHS (Hyperosmolar Hyperglycemic State) S/S: Polyuria, polydipsia, polyphagia, hypoglycemia, dizziness, diaphoresis |
| Hyperosmolar Hyperglycemic State | DMT2 complication with minimal/absent ketosis |
| DKA/HHS treatment | IV fluids for dehydration with I/Os IV insulin Monitor electrolytes (hypokalemia risk with insulin infusion) |
| Diabetes management | Oral medications and insulin Diet education Skin care and foot care education (toe, toenail, foot wound check) Exercise with carbohydrate snack Proper vaccination schedule d/t higher risk of infection |
| Basal Bolus Regimen | Basal insulin = long acting insulin (lantus) Bolus insulin = short acting insulin (Humalog) |
| Peptic ulcer disease pathophysiology | Erosion of mucus membrane in the stomach, pylorus or esophagus H. Pylori infection NSAID overuse Increased gastric acid production Smoking/EtOH use |
| Nursing Considerations for PUD | Assess PHx - Diet and lifestyle - prior H. Pylori or stomach infection - NSAID use |
| Acute pancreatitis pathophysiology | Obstruction of pancreatic duct leading to back up of enzymes and digestion and inflammation of pancreas S/S: Severe abdominal pain, back pain, N/V, shock symptoms, hypotension, tachycardia |
| Chronic pancreatitis pathophysiology | Progressive inflammatory disorder of pancreas with destruction and replacement of fibrotic tissue -> obstruction of pancreatic/bile ducts S/S: Abdominal pain (recurrent), weight loss, N/V, frothy/foul smelling stool |
| Acute pancreatitis treatment | IV fluids for hydration and electrolyte/fluid correction NPO status Monitor CMP and pancreatic markers |
| Chronic pancreatitis treatment | IV fluids for hydration and electrolyte/fluid correction Monitor CMP and pancreatic markers |
| Hiatal hernia pathophysiology | Herniation of upper portion of stomach thru the diaphragm into the thorax S/S: heartburn, chest pain, bloating, burping, dysphagia *airway precautions* |
| Hiatal hernia treatment | Surgery if severe Lifestyle modification with smaller more frequent meals |
| Diverticulitis pathophysiology | Inflammation of diverticulum S/S: (LLQ) abdominal pain |
Created by:
sleepingbear