Med Surg Final
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| 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.
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| ABC's | Airway, Breathing, Circulation (except in neuro - LOC trumps all)
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| Maslow | Physical, Safety, Psychological...
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| 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)
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| If your patient changes status, what do you do? | Notify the RN or physician, then do assessment
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| What are the steps of Nursing Process (ADPIE)? | Assess, diagnose, plan, implement, evaluate
In a question, remember to assess before you implement.
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| What is an ablative procedure? | Removal or amputation
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| When do you begin discharge teaching for surgical patient? | Preoperatively
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| How do you instruct patient to use incentive spirometer? | Inspire and hold for 5 seconds
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| 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)
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| What is contraindicated in surgeries involving intracranial, eye, ear, nose, throat, or spine? | COUGHING
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| What is the purpose for incentive spirometry? | prevent or treat atelectasis, improve lung expansion, improve oxygenation
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| How often do you need your patient to turn, cough and deep breathe? | Q2H (turn is side-back-side/repositioning)
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| What devices are used post-operatively to prevent thrombus, embolus and infarct? | Leg exercises, antiembolism stockings (TED HOSE), sequential compression devices.(Q2H)
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| 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)
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| 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
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| When your patient is transferred from post op to their room on your floor should you be there? | YES - you must be there
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| How do you position the post op patient? | HOB up 45 degrees or position on side (to prevent aspiration)
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| 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)
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| 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
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| What is your first action with evisceration? | Cover with warm, moist sterile dressing (second action, call the surgeon)
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| 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)
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| What are the S & S of pulmonary embolism? | Sudden chest pain, dyspnea, tachycardia, cyanosis, diaphoresis, hypotension
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| What are the nursing interventions for pulmonary embolism? | HOB up 45 degrees, oxygen, notify doctor PE-POD (position, oxygen, doctor)
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| What non-mendical interventions can you do to comfort post op patient? | decrease external stimuli, eliminate odors (r/t nausea)
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| What is the minimum urinary output per hour? | 30 ml (50ml is average) (post-op report no urine output after 8 hours)
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| What does irritation of the phrenic nerve cause? | Singultus (hiccups) this could be a reaction to anesthesia
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| How much fluid should any patient consume in 24 hours? | 2000-2400 ml
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| How is infection process evidenced? This was on IV too. | Elevated WBC count
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| How are dressings changed? | Using sterile technique, clean middle, farthest, closest (cleanse in the direction of least contaminated to most contaminated)
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| What is the primary purpose of a wet to dry dressing? | to mechanically debride the wound
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| 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
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| 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
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| 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)
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| What do you assess prior to MRI? | Do you have any metal appliances?
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| 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.
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| 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)
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| 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
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| What's in cerebrospinal fluid? | Glucose, no RBC, a few WBC
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| what is status epilepticus? | prolonged seizure activity - longer than 30 minutes.
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| tonic phase | contraction with excessive muscle tone
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| clonic phase | jerky twitching
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| 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
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| M.S. | autoimmune disorder causing demyelination of nerves, 1st symptom muscle weakness (65% return to baseline, 20% progressive. Avoid heat, cold and stress)
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| Parkinson's | dopamine deficiency. 1st symptom painful muscle cramps. shuffling, propulsive gait, risk for falls, movement decreases tremors, inactivity worsens tremors
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| 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.
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| 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.
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| Huntington's disease | overactivity of dopamine pathways. Genetic, abnormal excessive involutary movements(chorea). No cure. Patient safety!Promote self care.
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| Trigeminal Neuralgia (5th cranial nerve) | Excruciating, burning, facial pain, may need surgical intervention to sever 5th cranial nerve. Any stimuli can trigger it.
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| Bell's Palsey (7th cranial nerve) | Inflammatory process involving facial nerve. PROTECT THE EYE if the lid doesn't close. Sunglasses, lubrication.
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| 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.
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| Tourette's Syndrome | physical or verbal tick. Chronic or transient. My notes say emotional instability.
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| Encephalitis | inflamation of gray and white matter of the brain.
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| 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,
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| Concussion | mild brain injury. Nausea, vomiting. post concussive syndrome can occcur 1 week to 1 year after injury
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| Contusion | bruising of the surface of the brain r/t accelleration and deceleration injuries
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| Glasgow Coma Scale | 1-15. 8 indicates coma.
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| Hematoma | subdural - under the dura/covering - has highest mortality rate r/t not catching it in time.
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| 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.
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| Miniere's disease | chronic disease of inner ear. vertigo, N/V, 8th cranial nerve, bedrest, restrict fluids, low salt diet
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| shilling test | uses radioactive b12 to assess GI absorption of b12 (test for pernicious anemia)
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| Hemoglobin | 12-18 (dozen to a dozen and a half)
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| S & S Anemia | fatigue, SOB. (Check hemoglobin in COPD, emphysema pt's) Give O2, fluids, monitor VS
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| Aplastic Anemia | bone marrow not making enough RBC's. congenital or r/t chemo, radiation
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| 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
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| Sickle Cell Anemia | HOP to it: hydration, oxygen, pain control. Both parents have to carry gene. Dehydration can cause crisis.
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| Polycythemia | too many RBC's. Blood becomes thick, static, clots, increases heart workload. S & S HTN, chest pain, CHF, risk for DVT, MI, CVA
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| Agranulocytosis | WBC's less than 200. No fruit or flowers! Handwashing, Asepsis
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| 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
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| Thrombocytopenia | platelets below 100,000. Possible splenectome (spleen loves platelets)Teach to use soft toothbrush, electric razors, avoid chips, popcorn, hot beverages
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| Hemophelia A | Men only, missing clotting factor 8, hereditary. Protect from internal (food) and external trauma. No asprin
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| Hemophelia B | Males or females. Clotting factor 9
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| Multiple Myeloma | swiss cheese bones. Ca+ comes out of bones into bloodstream. Bone pain, fracture, hypercalcemia. #1 safety-prevent falls.
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| Lymphangitis | blood poisoning, inflamation of one or more lymphatic vessels. Fever chills, painful infection Tx: ATB's, moist heat, elevate
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| 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.
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| Malignant Lymphoma - NON-Hodgkin's Lymphoma | group of malignant solid tumors, PAINLESS ENLARGED CERVICAL NODES,risk for infection. Tx: radiation, chemo, bone marrow transplant
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| Hodgkin's Disease | Giant multinucleus lymphocytes "Reed-Sternburg Cells" Night sweats, need to treat it early
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| 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.
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| Leukocytosis & Leucopenia | Leukocytosis elevated WBC's
Leucopenia insufficient WBC's
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| Natural Immunity | active - body's own immune response
passive - breastmilk
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| Artificial Immunity | active - immunizations
passive - immunoblobulins
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| attenuated vaccine | weakened like virus e.g. flumist
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| Hypersensitivity | abnormal or excessive response to stimulus e.g. pollens, danders, foods
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| 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
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| Anaphylaxis | life threatening reaction e.g. venoms, penicillin, iodine, stings, food
(stridor, swelling, hives, wheezing)
Tx: benadryl, epi, O2, medical alert ID
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| Blood hypersensitivity | ha, nausea, flushing, chest pain, hives, STOP TRANSFUSION, ADMINISTER SALINE, CALL DR
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| Transplants | Immunosupressive drugs given so protect patient from infection!
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| Systemic Lupis Erythmatosis | assess for skin lesions, avoid sun
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| Progressive Systemic Sclerosis AKA Scleroderma | abnormal growth of connective tissue, skin hardens causing contractures, organd will harden as well. Pain management
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| Normal immune response | B cells are first response. T cells take longer.
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| HIV Immune dysfunction CD4 counts | CD4 600-1200 normal
CD4 200-499 minor immune problems
CD4 below 200 severe immune problems
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| HIV testing | 95% test positive in 3 months
99% test positive in 6 months
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| HIV early S & S | fever, night sweats,weight loss, fatigue (body is working hard, need adequate caloric intake and hydration)
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| HIV antibody testing | 2 ELISA then Western Blot
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| Most common opportunistic AIDS disease: Pneumocytosis carinii pneumonia (PCP) | wear gown, mask, gloves, fever, night sweats, productive cough, SOB. TX: ATB's
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| Second most common AIDS disease: Carposi's Sarcoma | cancer. Reddish purple spots on the skin. Tx: radiation, chemo
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| HIV Tx: | multiple drugs, monitor CD4, 100% compliance!
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| Carcinoma | malignant tumors of epithelial cells
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| sarcoma | malignant tumors of connective tissue
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| Cancer staging | 1 cancer in situ 2 tumor limited to organ 3 extensive local and regional spread 4 metastisis
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| Duke's staging system | colorectal cancer
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