Final Review Welcome to Ponder Web Design by nikeborome

VIEWS: 2 PAGES: 10

									                    Med-Surg Final Review- Part 1
Increased Intracranial Pressure
S/S: First sign- Decreasing LOC, headache, vomiting without nausea, papilledema, changes in VS, Cushing’s
triad (late sign), Cheyne-Stokes respirations, posturing.
         Cushing’s Triad: hypertension, bradycardia, widening pulse pressure (systolic ↑, diastolic stays the same)

Dx: Intracranial pressure monitoring device, skull radiography, CT, MRI, lumbar puncture, cerebral angiography.

Tx: Goal is to maintain cerebral tissue perfusion and blood pressure. Keep oxygen saturation at 95%, HOB
elevated 30 degrees, control temperature, administer anticonvulsants, Versed, antiemetics, etc to reduce the
chances of anything happening that could increase ICP.

IV: NS, LR, or 3% hypertonic saline. (Hypotonic or solutions with glucose can raise ICP.)



Autonomic Dysreflexia
Def: an exaggerated sympathetic nervous system response among those with a spinal cord injury above T6.

S/S: Severe HTN, decreased HR, pounding headache, nausea, blurred vision, sweating, anxiety. Can lead to
seizures, stroke, and death.

Causes: Full bladder, abdominal distention, constipation, skin pressure, skin breakdown, exposure to hot or cold

Prevent: administer antihypertensives, raise HOB, Foley catheter, prevent triggers



Immobilization of Spinal Injuries
   The head and back are immobilized mechanically with a cervical collar and back support.
        o Stabilizes the spinal column to help prevent movements which may lead to paralysis.
   After pt is stabilized, the injured portion of the spine is further immobilized using a cast, brace, or surgery.
   Traction is applied with weights and pulleys to decompress the spine.
   A turning frame is used to change the pt’s position without altering the alignment of the spine.



Thyroid Gland- Hormones
   Thyroxine, T4; Triiodthyronine, aka T3
        o Regulates (increases) body’s metabolic rate

   Calcitonin, aka thyrocalcitonin
       o Regulates serum calcium levels,
       o Secreted when serum calcium levels are high, inhibits shift of calcium from bones
Tetany (see hypocalcemia also)
   The main symptom of sudden and acute hypoparathyroidism
   Develops when the parathyroid glands are accidentally removed during a thyroidectomy.

S/S: twitches, tigngling, dysrhythmias, seizures, spasms, laryngospasm.
Signs: tap facial nerve mouth or jaw twitch or tighten = positive Chvostek’s sign
         inflate BP cuff  fingers spasm = positive Trousseau’s sign.
Tx: Calcium salts IV or PO




Antibiotic Therapy
Take ALL antibiotics prescribed.



Mastectomy
Simple: removal of entire breast

Radical: removal of all breast tissue, overlying skin, axillary lymph nodes, and underlying pectoral muscles

Modified Radical: same as radical but with the muscles left intact.

Post Op: Tamoxifen if ER+; elevate arm; no BPs, IV’s or sticks on affected side; no deodorant or shaving of
affected side; progressively exercise affected side.

Reconstruction: can be done immediately, or up to 1 year later.




Diabetes Insipidus
Patho: Deficient or ineffective ADH

S/S: massive diuresis—up to 30L/day, dehydration, polyuria, polydipsia, polyphagia

Nsg: risk for fluid volume deficit--- strict I&O, daily weight

Tx: IV fluids, vasopressin, Lypressin nasal spray, DDAVP


Laryngeal Nerve Damage
   Severe, persistent hoarseness or inability to speak.
   May be due to trauma during thyroidectomy.




Renal Scan
Intravenous Pyelogram
   Radiographic dye is injected IV to see how the dye is concentrated by the kidneys and then excreted.
   Pictures are taken at 5-15 minute intervals
   Observe for stones and abnormalities.

Prep: enemas, laxatives, fluids only or NPO for 8-10 hours before surgery, check for allergy to iodine or shellfish,
tell pt they will experience a warm, flush, feeling.

Teach: encourage fluids to flush out the dye, recognize s/s of allergic response.


Hypocalcemia
S/S: Tingling in the extremities and the area around the mouth (circumoral paresthesia), muscle and abdominal
cramps, carpopedal spasms referred to as Trousseau's sign, mental changes, positive Chvostek's sign (spasms
of the facial muscles when the facial nerve is tapped, laryngeal spasms with airway obstruction, tetany (muscle
twitching), seizures, bleeding, and cardiac dysrhythmias. The client has hypocalcemia if the total serum
calcium level is below 8.8 mg/dL (normal range, 9 to 11 mg/dL) or the ionized calcium level is below 4.4 mg/dL
(normal range, 4.4 to 5.4 mg/dL).

   Keep emergency tracheostomy tray, mechanical ventilation equipment, artificial airway, and
    endotracheal intubation equipment at the client’s bedside if hypocalcemia is severe.
   IV line for the emergency administration of calcium.
   The nurse observes frequently for respiratory distress and notifies the physician immediately if this problem
    occurs.
   Until hypocalcemia is corrected, the nurse must assist the client with activities of daily living (ADLs).
    Movement, noise, and other environmental disturbances can trigger muscle contractions or convulsions.
    Thus, minimizing all forms of stress is essential until serum calcium levels approach normal and symptoms are
    relieved.
   Dietitian consult




Cushing’s Syndrome
Def: Hypersecretion of the adrenal cortex resulting in excess cortisol and other adrenal cortex hormones.

Causes:         Endogenous: Pituitary tumor, adrenal gland neoplasm, carcinoma of lung or other tissue.
                Exogenous: Prolonged high doses of corticosteroids.

S/S: muscle weakness, truncal obesity, hirsutism, deep voice, irregular periods, HTN, hypokalemia,
hyperglycemia, hypernatremia, increased cortisol levels.

Tx: Depends on cause; slow tapering off of steroids, radiation, surgery (partial removal of pituitary gland to
decrease ACTH secretion

Meds: Aldactone for bilateral benign adrenal tumor. Chemo or other drugs that interfere with ACTH.

Nsg: high risk of infection
Subtotal Thyroidectomy (see Thyroidectomy for more info)
Pt. will only need thyroid replacement meds for a few months.




Exfoliative Dermatitis




HIV
Transmitted by: blood, semen, vaginal secretions, and breast milk

Risk Factors: unprotected sex, contact with infectious fluids, sharing needles, receiving multiple blood
transfusions, use of non-sterile tattooing equipment,

AIDS: HIV converts to AIDS when the T4 cell count level goes from the normal 800 to 1200


Burn Injury
Rule of Nines:
        Head and neck = 9%
        Right arm = 9%
        Left arm = 9%
        Posterior trunk = 18%
        Anterior trunk = 18%
        Right leg = 18%
        Left leg = 18%
        Perineum = 1%

Superficial burn: pink to red and painful, sunburn, 1st degree

Superficial Partial thickness burn: painful, blistered, weepy, 2nd degree

Deep Partial thickness burn: painful, thick blisters or weepy edema, sensitive to cold, 3 rd degree.

Full thickness burn: affects skin, fat, muscle, and bone. May be red, white, or black (eschar), often painless. 4th
degree

Fluid Resuscitation: Baxter Formula
(3-4cc) x (kg of wt) x (% of body burned)= total CCs to be given in 24 hours
        ½ to be given in the first 8 hours
        ¼ to be given in the 2nd 8 hours
        ¼ to be given in the 3rd 8 hours

Nsg interventions: reverse isolation, foley catheter, I&O is measured hourly, medicate with Morphine 30 minutes
before dressing change, monitor for infection, high protein/high calorie diet.
Diabetes Mellitus
Type 1: no insulin production; requires injections for life

Type 2: insulin resistance and or inadequate secretion

S/S: polyphagia, polydipsia, polyuria, elevated BSL

Dx:     FSBS > 200
        Fasting serum glucose > 110 (must fast for 8 hours)
        Urine sugar and acetone
        Glucose Tolerance Test
        Hgb A1C > 7% shows that the pt is not controlling hyperglycemia
                       7%=avg. BSL of 150

Emergency Complications:
      Acute Hypoglycemia (BSL < 70)
             s/s: diaphoresis, nervousness, shakiness
             Check blood sugar immediately
      Diabetic Ketoacidosis (DKA)
             s/s: Kussmaul’s respirations, fruity breath, 3 p’s, BSL > 300
             primarily a problem with type 1
      Hyperglycemic hyperosmolar nonketonic syndrome (HHNKS)
             s/s: BSL > 600, but not ketone formation, comatose
             Pt is still producing some insulin: Type 2

Ketones: products of fatty acid metabolism
    indicates breakdown of fats for energy, a sign that diabetes is out of control.
    can lead to DKA.
    Instruct pt to test again in a few hours
    DO NOT exercise, call MD if moderate or large amounts found in urine.




External Bleeding
Arterial lacerations are evident when the blood is squirting with a lot of force in a rhythmic fashion.

3 treatments:
        1. Direct pressure
        2. Elevation
        3. Pressure points (pulse site between the heart and laceration)
                    Carotid, axillary, brachial, radial, femoral, popliteal, pedal

Tourniquet is used as a last resort because it can cause tissue death and can lead to amputation.

Uncontrolled bleeding can lead to shock.
Blood Transfusion
       Saline is the only fluid that can be given with blood.

Transfusion Reactions
Complication          Signs and Symptoms              Cause(s)                   Action

 Incompatibility        Hypotension, rapid pulse       Mismatch between           Stop the infusion of blood.
 reaction               rate, difficulty breathing,    donor and recipient        Infuse the saline at a rapid rate.
                        back pain, flushing            blood groups               Call for assistance.
                                                                                  Administer oxygen.
                                                                                  Raise the feet higher than the
                                                                                  head.
                                                                                  Be prepared to administer
                                                                                  emergency drugs.
                                                                                  Send first urine specimen to
                                                                                  laboratory.
                                                                                  Save the blood and tubing.


 Febrile reaction       Fever, shaking chills,         Allergy to foreign         Stop the blood infusion.
                        headache, rapid pulse,         proteins in the            Start the saline.
                        muscle aches                   donated blood              Check vital signs.
                                                                                  Report findings.

 Septic reaction        Fever, chills, hypotension     Infusion of blood that     Stop the infusion of blood.
                                                       contains                   Start the saline.
                                                       microorganisms             Report findings.
                                                                                  Save the blood and tubing.

 Allergic reaction      Rash, itching, flushing,       Minor sensitivity to       Slow the rate of infusion.
                        stable vital signs             substances in the          Assess the client.
                                                       donor blood                Report findings.
                                                                                  Be prepared to give an
                                                                                  antihistamine.

 Circulatory            Hypertension, difficulty       Large volume or            Reduce the rate of infusion.
 overload               breathing, moist breath        rapid rate of infusion;    Elevate the head.
                        sounds, bounding pulse         inadequate cardiac         Give oxygen.
                                                       or kidney function         Report findings.
                                                                                  Be prepared to give a diuretic.

 Hypocalcemia           Tingling of fingers,           Multiple blood             Stop the blood infusion.
                        hypotension, muscle            transfusions               Start saline.
                        cramps, convulsions            containing                 Report findings.
                                                       anticalcium agents         Be prepared to give CaCl
DIC- disseminated intravascular coagulation
     Can happen as a complication of shock.
     Normally, when you are injured, certain proteins in the blood become activated and travel to the injury site
      to help stop bleeding. However, in persons with DIC, these proteins become abnormally active.
     Small blood clots form within the blood vessels. Some of these clots can clog up the vessels and cut off
      blood supply to various organs such as the liver or kidney. These organs will then stop functioning. Over time,
      the clotting proteins become ―used up.‖ When this happens, the person is then at risk for serious bleeding
      from even a minor injury.
     This disorder can result in clots or, more often, in bleeding. The bleeding can be severe.

Risk factors for DIC include:
     Blood transfusion reaction
     Cancer, including leukemia
     Infection in the blood by bacteria or fungus
     Pregnancy complications (such as retained placenta after delivery)
     Recent surgery or anesthesia
     Sepsis (an overwhelming infection)
     Severe liver disease
     Severe tissue injury (as in burns and head injury)

Dx:
         PTT – high
         Platelets – low
         PT – high

Tx: The goal is to determine and treat the underlying cause of DIC. Blood clotting factors will be replaced with
plasma transfusions. Heparin is sometimes used.




Thyroidectomy
Pre-op: admin antithyroid meds for several weeks, teach to avoid neck strain,

Post-op: HOB elevated 30° or more, ice bag to neck, trach set at bedside, suction equipment, VS q1-4 hrs,
check dressing and back of neck for bleeding,

Monitor for: Airway obstruction (restlessness, tachycardia, dyspnea), laryngeal nerve damage (severe hoarsness
or inability to speak), hemorrhage(check dressing and back of neck) , tetany, thyroid crisis

Total thyroidectomy will require lifelong replacement of thyroid hormones; Take meds exactly as prescribed


Components of Immune System




ABG’s
Normal: 80-100 mmHg

Shock: below 60 mmHg

If SpO2 (oxygen saturation) is above 90%, the PaO2 is most likely 60 mmHg or above.
Gastric Surgery
Post-Op: No ASA or NSAIDS, will need lifetime injections of B12

Side effect can be dumping syndrome
        o Occurs due to decreased size of stomach or loss of vagus nerve prevents normal pacing of chyme
            movement
        o Fluid is drawn out of the blood within 15-30 min of eating to moisten food
        o S/S: BP falls, becomes dizzy, diaphoretic and weak, cramps, hyperactive bowel sounds, urge to
            defecate
        o Teach: Usually resolves within a few months; lay down after meals until dumping syndrome resolved;
            6 meals/day: low carb, mod. fat, high protein; drink fluids between meals, not with them; may have
            chronic diarrhea-do good skin care




Hemoglobin and Nutrition
Foods rich in iron enhance hemoglobin production.



Fractures
Immobilize joints on both sides of possible fracture.

Splint in the position found

4 interventions:
     check pulses
     immobilize
     ice
     elevate
5 P’s when assessing and charting a fracture:
     Pain
     Pallor
     Pulses
     Paresthesia- nerve damage, numbness, tingling
     Paralysis


Wound Healing
Primary intention: wound layers are sutured together and well approximated. Heals relatively fast with minimal
scarring

Secondary intention: granulating tissue fills the wound. Edges are not approximated. Healing is slow, and
happens from the bottom up. Needs moisture.

Complication of wet dressing left on too long: maceration

If dressing is stuck: moisten with sterile saline and pull gently.
Cold Injury
IV access can be difficult to obtain because the cold causes vasoconstriction.
       Places other than arms, hands, and legs for IV access: subclavian, jugular, and femoral

Areas most affected by cold injury: hands, feet, nose, cheeks

S/S:       1. Pain,
           2. Tingling,
           3. Numbness

How to re-warm: warm blankets, warm oral fluids, warm IV fluids

Highest risk: elderly- more susceptible because of loss of sub-q fat, diminished circulation, and reduced neural
control of circulation

Treatment goal: Temp > 95°, good circulation and warmth to tissues without tissue cellular damage




Chemotherapeutic Agents




Tissue Plasminogen Activator (t-PA)
          Used for treatment of ischemic stroke.
          ―Clot buster‖- will dissolve the clot in the brain
          Must start within 3 hours of the onset of symptoms.
          Will dissolve all clots… so make sure there are no wounds.


Erythropoietin
          Secreted by the kidneys to stimulate RBC production
          Decreased O2 in blood triggers this response
          Pts with renal failure are deficient in erythropoietin


Morphine
Up to 50mg/hr PCA for burn pts.



Tattoos
          Pigments are not FDA approved
          Interfere with MRI- poor picture quality

Infection: Hep. B, C, HIV, tinea corporis (tx with antifungals), Staph (tx with topical ATB x10 days)

Skin Care: avoid soaking, do not touch area, cover with ATB cream, good hand hygiene, wash area TID with
antibacterial soap and pat dry, apply lotion x2 weeks, avoid direct sunlight to area x4 weeks.

Removal: painful, never looks like it did pre-tattoo.
Piercings
Healing Time:
               Ear lobe: 6-8 wks
               Ear cartilage: 4mo-1yr
               Eyebrow: 6-8 wks
               Nostril: 2-4 mo
               Tongue: 4 wks
               Lip: 2-3 mo
               Navel: 4mo-1yr

								
To top