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Med Surg Final

This was discussed in both IV and Med Surg: What does the nurse do if patient is showing signs of hypersesitivity to I.V. Administration? 1. Stop the infusion 2. begin a rapid infusion of normal saline to quickly dilute drug 3. Check VS 4. Notify Dr. Or RN 5. Admin emergency drugs as ordered.
ABC's Airway, Breathing, Circulation (except in neuro - LOC trumps all)
Maslow Physical, Safety, Psychological...
4 Rules of Prioritization: Acute beats chronic Fresh post-op beats other surgical client unstable beats stable The more vital the organ - the higher the priority (brain, lungs, heart, liver, pancreas, kidney)
If your patient changes status, what do you do? Notify the RN or physician, then do assessment
What are the steps of Nursing Process (ADPIE)? Assess, diagnose, plan, implement, evaluate In a question, remember to assess before you implement.
What is an ablative procedure? Removal or amputation
When do you begin discharge teaching for surgical patient? Preoperatively
How do you instruct patient to use incentive spirometer? Inspire and hold for 5 seconds
How often are VS checked with a post op patient? Every 15 minutes or less until stable, then every 1 hour for 4 hours, then every 4 hours for 2 days (or as often as needed)
What is contraindicated in surgeries involving intracranial, eye, ear, nose, throat, or spine? COUGHING
What is the purpose for incentive spirometry? prevent or treat atelectasis, improve lung expansion, improve oxygenation
How often do you need your patient to turn, cough and deep breathe? Q2H (turn is side-back-side/repositioning)
What devices are used post-operatively to prevent thrombus, embolus and infarct? Leg exercises, antiembolism stockings (TED HOSE), sequential compression devices.(Q2H)
From the cardiac quiz: What do you instruct your patient NOT to do with something or other? Cross their legs (I'm still trying to find this in the powerpoints. Let me know if you find it. Thanks)
What safety precautions do you need to take with a patient about to receive a pain med? Encourage your patient to go to the bathroom, put bed in lowest position with side rails up (not a restraint) and MONITOR every 15 minutes
When your patient is transferred from post op to their room on your floor should you be there? YES - you must be there
How do you position the post op patient? HOB up 45 degrees or position on side (to prevent aspiration)
What are S & S of shock? increased HR, increased respirs, decreased BP, thready pulse, cool clammy skin, restlessness (#1 reason for hypovolemic shock is blood loss)
When do you change a dressing on a post-op patient? After the first 24 hours. During the first 24H reinforce, circle the drainage and date and time. (should be assessed every 2-4 hours)(more than 300 ml of drainage in first 24H is ABNORMAL) Normal for slight increase in drainage when patient ambulates
What is your first action with evisceration? Cover with warm, moist sterile dressing (second action, call the surgeon)
How often should you encourage your post-op patient to turn cough and deep breathe? Q2H (turn them from side to back and then to side to prevent pneumonia)
What are the S & S of pulmonary embolism? Sudden chest pain, dyspnea, tachycardia, cyanosis, diaphoresis, hypotension
What are the nursing interventions for pulmonary embolism? HOB up 45 degrees, oxygen, notify doctor PE-POD (position, oxygen, doctor)
What non-mendical interventions can you do to comfort post op patient? decrease external stimuli, eliminate odors (r/t nausea)
What is the minimum urinary output per hour? 30 ml (50ml is average) (post-op report no urine output after 8 hours)
What does irritation of the phrenic nerve cause? Singultus (hiccups) this could be a reaction to anesthesia
How much fluid should any patient consume in 24 hours? 2000-2400 ml
How is infection process evidenced? This was on IV too. Elevated WBC count
How are dressings changed? Using sterile technique, clean middle, farthest, closest (cleanse in the direction of least contaminated to most contaminated)
What is the primary purpose of a wet to dry dressing? to mechanically debride the wound
Phases of wound healing: Inflammatory: first 6 days Reconstruction: 3-21 days granulation tissue starts to form Maturation: 21-days to three years scarring and strengthening
What pre-procedure and post procedure do you need to do with patient scheduled for lumbar puncture? Pre- encourage fluids/well hydrate Post- lie flat for 6-12 hours
What do you assess before angiography or CT (hint DYE) Do you have any allergies to iodine or shellfish? NPO after midnight (probably force fluids 3 liters but slides didn't say)
What do you assess prior to MRI? Do you have any metal appliances?
Pre and post op for EEG? PRE-Hold antidepressants and anticonvulsants for 24-48 hours POST- Wash the stinky sticky glue out of the hair.
What is the early phase of migraine headache? Prodromal phase may present with auras, parathesias, visual disturbance, stomach upset, hearing acuity (Recommended diet: restrict caf, choc, yogurt, fermented food)
What are the S & S of increased intracranial pressure (IICP)? (normal pressure 0-15) diplopia, HA, decreased LOC, slower response in pupils, also affects speech, motor function and VS, WIDENING PULSE PRESSURE, projectile vomiting, uncontrolled temp, seizures, pos. babinski
What's in cerebrospinal fluid? Glucose, no RBC, a few WBC
what is status epilepticus? prolonged seizure activity - longer than 30 minutes.
tonic phase contraction with excessive muscle tone
clonic phase jerky twitching
Nursing interventions for seizures: protect the head, maintain airway (turn them on their side), doc time length and type of movement. After seizure you may need to suction r/t increased secretions
M.S. autoimmune disorder causing demyelination of nerves, 1st symptom muscle weakness (65% return to baseline, 20% progressive. Avoid heat, cold and stress)
Parkinson's dopamine deficiency. 1st symptom painful muscle cramps. shuffling, propulsive gait, risk for falls, movement decreases tremors, inactivity worsens tremors
Myasthenia gravis Also autoimmune neuro disorder. S & S muscle weakness, ptosis (eye droop), diplopia (double vision), disarthria (disorganized speech), dysphagia. Focus on decreasing and preventing respir difficulties, family needs to know CPR.
Amyotrophic lateral sclerosis (ALS) (Michael Keaton "My Life") motor neurons in brain and spinal cord degenerate. It will end in death in 2-5 years respirtory failure, starts in single muscle group, lower limbs last.
Huntington's disease overactivity of dopamine pathways. Genetic, abnormal excessive involutary movements(chorea). No cure. Patient safety!Promote self care.
Trigeminal Neuralgia (5th cranial nerve) Excruciating, burning, facial pain, may need surgical intervention to sever 5th cranial nerve. Any stimuli can trigger it.
Bell's Palsey (7th cranial nerve) Inflammatory process involving facial nerve. PROTECT THE EYE if the lid doesn't close. Sunglasses, lubrication.
Guillain-Barre Syndrome auto-immune response to viral infection (viral infection 10-14 days before onset). This one starts at lower extremities and goes up the body. Patient may need vent before symptoms begin to improve. may need skin care, ROM exercises.
Tourette's Syndrome physical or verbal tick. Chronic or transient. My notes say emotional instability.
Encephalitis inflamation of gray and white matter of the brain.
Meningitis viral (mild) or bacterial (more serious) inflamation of meninges (dura mater/pia mater) covering of the brain. Early signs: STIFF NECK, HA, increased temp. Later positive kernig and Brudzinski's sign . Seizure precautions, bed in low position,
Concussion mild brain injury. Nausea, vomiting. post concussive syndrome can occcur 1 week to 1 year after injury
Contusion bruising of the surface of the brain r/t accelleration and deceleration injuries
Glasgow Coma Scale 1-15. 8 indicates coma.
Hematoma subdural - under the dura/covering - has highest mortality rate r/t not catching it in time.
Autonomic Dysreflexia exaggerated sympathetic response to spinal injury. Can be triggered by full bladder or fecal impaction which creates hypertensive crisis BP over 300. Raise head of bed, empty bladder or bowel.
Miniere's disease chronic disease of inner ear. vertigo, N/V, 8th cranial nerve, bedrest, restrict fluids, low salt diet
shilling test uses radioactive b12 to assess GI absorption of b12 (test for pernicious anemia)
Hemoglobin 12-18 (dozen to a dozen and a half)
S & S Anemia fatigue, SOB. (Check hemoglobin in COPD, emphysema pt's) Give O2, fluids, monitor VS
Aplastic Anemia bone marrow not making enough RBC's. congenital or r/t chemo, radiation
Pancytopenia bone marrow stops making everything. Infections common. May require splenectomy to stop destruction of RBC's. Don't bring patients fruit or flowers r/t bacteria
Sickle Cell Anemia HOP to it: hydration, oxygen, pain control. Both parents have to carry gene. Dehydration can cause crisis.
Polycythemia too many RBC's. Blood becomes thick, static, clots, increases heart workload. S & S HTN, chest pain, CHF, risk for DVT, MI, CVA
Agranulocytosis WBC's less than 200. No fruit or flowers! Handwashing, Asepsis
4 types Leukemia ALL ages 3-10 AML most common, age 60+, bone marrow transplant CLL age 60+, survival 4-10 years CML second most common, age 45-55 most treatable
Thrombocytopenia platelets below 100,000. Possible splenectome (spleen loves platelets)Teach to use soft toothbrush, electric razors, avoid chips, popcorn, hot beverages
Hemophelia A Men only, missing clotting factor 8, hereditary. Protect from internal (food) and external trauma. No asprin
Hemophelia B Males or females. Clotting factor 9
Multiple Myeloma swiss cheese bones. Ca+ comes out of bones into bloodstream. Bone pain, fracture, hypercalcemia. #1 safety-prevent falls.
Lymphangitis blood poisoning, inflamation of one or more lymphatic vessels. Fever chills, painful infection Tx: ATB's, moist heat, elevate
Lymphedema clog, can't remove fluid, very painful. Tx: diuretics, STB's, compression devices, pain management. Meticulous skin care needed. Turn frequently. Low sodium diet.
Malignant Lymphoma - NON-Hodgkin's Lymphoma group of malignant solid tumors, PAINLESS ENLARGED CERVICAL NODES,risk for infection. Tx: radiation, chemo, bone marrow transplant
Hodgkin's Disease Giant multinucleus lymphocytes "Reed-Sternburg Cells" Night sweats, need to treat it early
Nursing Interventions for Client with Lymphatic Disorder: 1. allow patient to rest. encourage quiet activity. 2. Handwashing and protect from infection 3. No one with S & S of infection can visit.
Leukocytosis & Leucopenia Leukocytosis elevated WBC's Leucopenia insufficient WBC's
Natural Immunity active - body's own immune response passive - breastmilk
Artificial Immunity active - immunizations passive - immunoblobulins
attenuated vaccine weakened like virus e.g. flumist
Hypersensitivity abnormal or excessive response to stimulus e.g. pollens, danders, foods
4 classes of hypersensitivities level 1: body releases histamine in response to pollen, food etc. Level 2: cytotoxic, ABO incompatibility Level 3: inflamatory process, autoimmune, lupis, rheumatiod arthritis Level 4: delayed response 2-3 days e.g.tb test
Anaphylaxis life threatening reaction e.g. venoms, penicillin, iodine, stings, food (stridor, swelling, hives, wheezing) Tx: benadryl, epi, O2, medical alert ID
Blood hypersensitivity ha, nausea, flushing, chest pain, hives, STOP TRANSFUSION, ADMINISTER SALINE, CALL DR
Transplants Immunosupressive drugs given so protect patient from infection!
Systemic Lupis Erythmatosis assess for skin lesions, avoid sun
Progressive Systemic Sclerosis AKA Scleroderma abnormal growth of connective tissue, skin hardens causing contractures, organd will harden as well. Pain management
Normal immune response B cells are first response. T cells take longer.
HIV Immune dysfunction CD4 counts CD4 600-1200 normal CD4 200-499 minor immune problems CD4 below 200 severe immune problems
HIV testing 95% test positive in 3 months 99% test positive in 6 months
HIV early S & S fever, night sweats,weight loss, fatigue (body is working hard, need adequate caloric intake and hydration)
HIV antibody testing 2 ELISA then Western Blot
Most common opportunistic AIDS disease: Pneumocytosis carinii pneumonia (PCP) wear gown, mask, gloves, fever, night sweats, productive cough, SOB. TX: ATB's
Second most common AIDS disease: Carposi's Sarcoma cancer. Reddish purple spots on the skin. Tx: radiation, chemo
HIV Tx: multiple drugs, monitor CD4, 100% compliance!
Carcinoma malignant tumors of epithelial cells
sarcoma malignant tumors of connective tissue
Cancer staging 1 cancer in situ 2 tumor limited to organ 3 extensive local and regional spread 4 metastisis
Duke's staging system colorectal cancer
Created by: Merrill15888