MED SURGE QUIZ #1

Maslows Hierarchy of Needs

• air, water, food

• safety & security needs

• love/ belonging

• self confidence

• self- actualization (top goal)

What are the ABC’s

Airway

Breathing

Circulation

Signs to look for in PT

* airway

• pallor

• difficulty w/ speech

• use of accessory muscles

• obstruction

Signs to look for in PT

* Breathing

• restlessness

• decreased pulse ox

• abnormal RR

• nasal flaring

• ICS retractions

Signs to look for in PT

* circulation

• high BP (stroke?/rupture?)

• decreased BP (decreased perfusion → tissues & organs die)

• tachycardia

• diaphoresis

• blood clot

Emergent

PT’S needs w/ highest priority

• ABC/safety

• basic survival needs

  • PT goes to the ER

Urgent

Pt w/ medium & low priorities

• problems that require early resolution

• must handle B4 it becomes an emergency

  • ex: urinary retention

    • PT goes to urgent careN

Non-urgent

PT’s problem does NOT need immediate attention

* PT can wait to see PCP

Acute

abrupt onset & usually short course

* whats going on right now
* ex: broken arm

Chronic

long period of time & continuing disease process

* ex: diabetes/arthritis

Delegation for RN’s

* TEAACUP

Teaching

Evaluation

Assessment (initial)

Advanced Intervention

Collaboration

Unstable PT’s

Planning

5 Rights of Delegation

1. Right task

2. Right circumstances

3. Right person

4. Right supervision

5. Right direction/Communication

Right Task

know what each person can do

Right circumstances

PT should be stable & NOT require clinical judgement

* ex: UAP can move PT BUT if PT is unstable UAP should NOT ambulate

Right Person

person has proper knowledge & skills to preform task

Right Supervision

follow up & evaluate is required after each task

* was it done properly?

Right Direction/Communication

• have clear expectations

• ability to answer questions

• how should databe reported to the RN

Questions to ask (As the RN) when delegating

• “can this task be delegated safely?”

• “is the task with the scope of practice of the individual?”

• “is there anything about the PT’s condition/environment which would stop individual from preforming the task delegated?”

Delegation Red Flags

• LPN/UAP refusal to accept delegation

• incomplete direction

• failure to confirm expectations

• failure to communicate

Factors to Consider Before Delegating

• potential for harm?

• complexity of task?

• problem-solving needed?

• unpredictability of outcome

• level of interaction w/ PT

Roles of RN

• ALL MEDS

• admission assessment

• blood products

• care plan

• PT teaching

• UNSTABLE PT’s

• acute diseases

Roles of LPN

• vitals

• uncomplicated skills

• STABLE PT’S

• chronic disease

• oral/IM/SQ/patches/inhalers

Roles of UAP

• feeding

• hygiene

• basic skills

• STABLE PT’s

• chronic disease

• ambulation

Factors influencing Delegation

* what can RN delegate?

• stable PT’S

• requirements within caregiver job description

• minimal potential for harm

• when adequate supervision is needed

Factors to Consider when Assigning rooms to PT’s

• bed availability

• LOC

• PT acuity

• Age, gender, special needs

• staffing

• infectious disease

• attending physician

What does a Complete Blood Count entail?

• RBC

• Hemoglobin

• Hematocrit

• WBC

• PLT

Normal RBC count

3\.6-5.8 million/mm3

Normal Hemoglobin count

* (blood oxygen)

11\.7 - 17.3g/dL

Normal Hematocrit count

* (# of cells per solution )

36% - 52%

Normal WBC count

4,500 - 11,000/ cubic mm3

Normal PLT count

150,000 - 450,000/uL

What is ESR?

* what is the purpose?

a blood test that can show if you have inflammation in your body

*

Normal Bleeding Time

3-8 min

Clotting Studies

* PT, PTT, INR

measures how long it takes for a clot to form in a blood sample

* 11-13.5 seconds

Bone Marrow Biopsy

• PT prep

• anxiety/pain

• education(what to expect/feel)

• postion

Bone Marrow Biopsy Procedure

• lasts 5-10

• sedation

• sterile procedure

Bone Marrow Biopsy Post Care

• apply pressure

• cover w/ sterile dressing

• check for infection

• pain relief

• wear bandage for 24 hrs

• NO tub/showers for 24 hrs

Aplastic Anemia

bone marrow is NOT producing enough blood cells

* decreased RBC, WBC, PLT

Aplastic Anemia Complications

• hypoxia

• infection

• hemorrhage

Aplastic Anemia Nursing Care

• neuro assessment

• hand hygiene

• oral care

• avoid invasive procedure

• prevent immobility

• screen visitors for illness

• bleeding precautions

• increase fiber & fluid

Polycythemia

increased in # of RBC

Primary Polycythemia

chronic myeloproliferation disorder arising from chromosomal mutation in stem cell

Primary Polycythemia Labs

Increased…

• RBC

• WBC

• PLT

• Hemoglobin

• blood viscosity

• blood volume

• congestion of organs & tissues w/blood

hypercoagulopathy

predisposed to clotting

Secondary Polycythemia

hypoxia stimulates erythropoietin in kidneys

* INCREASED RBC
* body is trying to compensate to get more O2 around

Secondary Polycythemia Complications

• CVA

• MI

• PE

Secondary Polycythemia Clinical Manifestations

• headache

• dizziness

• dyspnea

• angina

• weakness

• intermittent claudication

• flushing of face

• L.upper abdominal pain

Polycythemia & Perfusion

when NOT perfused properly → toxation might occur

* heart/brain/kidney must perfuse

Collaborative Care

* polycythemia

• hydration therapy!!!!

  • give enough fluid to keep blood flowing

  • eval Pt I & O

• small frequent meals (decreased demand for O2

• reduce blood volume & viscosity

• decrease bone marrow activity

• ambulate (decrease clot formation)

Thrombocytopenia

decrease in PLT(

Thrombocytopenia Lab values

• <50,000 → at risk for spontaneous bleed

• <5,000 → at risk for GI hemorrhage/ CNS bleed

Nurs. Implementation

* Thrombocytopenia

• monitor signs of bleeding

• ID PT’s @ risk

• Monitor lab values

• check for bleeding (nose,mouth, urine, BM)

• PT teaching

PT teaching for Thrombocytopenia

• use electric razors

• NO Motrin/aspirin

• use smaller needles

Neutropenia

decreased WBC

• ↓ neutrophils = ↓ immune response

• neutrophils are the primary phagocytic cell & are the body 1st line of defense

• classic signs of infection/inflammation may NOT occur

Neutropenia Diagnostic Studies

absolute neutrophil count (ANC)

* total WBC count \* the % of neutrophils

ANC

@ risk for bacterial infection

ANC

MODERATE risk for bacterial infection

ANC

SEVERE risk for bacterial infection

Diagnosing neutropenia

Peripheral blood smear

* assess fro immature cells

Bone marrow biopsy

Collaborative Care

* neutropenia

• teaching about preventing infection

• be alert for any complaints that might indicate infection

• blood cultures

• STRICT hand hygiene

• private room

• avoid fresh fruit & veg

Neutropenic fever

>100.4° F

Neutropenic Precautions

• private room

• hand washing

• NO fresh fruit/veg/flowers

• NO sick visitors

Leukemia Cell Problems

• WBC overproduce

• WBC overcrowd bone marrow

  • therefore…RBC & PLT are not being made

What is Leukemia?

the accumulation of immature cells due to loss of regulation in cell division

• no single causative agent

• combo of genetic & environmental influences

Leukemia Clinical Manifestations

• inadequate production of normal bone marrow

• anemia

• thrombocytopenia (decrease PLT)

• decrease in # and function of WBC’s

Nursing Care Leukemia

* acute intervention

• administer meds & monitor for side effects

• help PT develop coping strategies

• assess labs for effect of drugs

Nursing Care Leukemia

* ambulatory/home care

refer PT and family to survivor networks

Lymphomas

* Hodgkins Disease

Malignant

* caused by proliferation of abnormal multi nucleated cells located in lymph nodes
* Reed-Sternberg Cells

Lymphomas

* Non-Hodgkins

malignant neoplasm of the immune system

* B & T cells

Clinical Manifestations

* Hodgkins Disease

• enlarged cervical, axillary, inguinal nodes

• fever

• fatigue

• night sweats

• weight loss

• chills

Clinical Manifestations

* Non-Hodgkins

\-painless lymph nodes

enlargement may occur with s/s dependent on area of disease

Diagnosing Lymphomas

• nodes biopsy

• xray

• bone marrow studies

Staging Lymphomas

* stage 1

isolated to one lymph node

Staging Lymphomas

* stage 2

at 2 or more sites

* same side

Staging Lymphomas

* stage 3

at both sides of diaphragm or spleen

Staging Lymphomas

* stage 4

started in lymphoma & spread to at least 1 body organ outside the lymphatic system

Collaborative Care

* Lymphoma

• localized radiation (stg 1)

• surgery

• combo of chemo w/localized radiation (stg 4)

• high dose combo of chemo w/radiation

• stem cell replacement

Thrombocytopenia Bleed Precautions Mnemonic

* RANDI

**R**azor → electric

**A**spirin → NO

**N**eedles → small gauge

**D**ecrease needle sticks

**I**njury → prevent

What is Multiple Myelomas?

cancer of the bone marrow

* destroys bone → bone breaks down

Multiple Myelomas Etiology

• neoplastic plasma cells infiltrate bone marrow & destroy bone

• neoplastic cells produce an excess amount of myeloma protein & cytokines which play a role in bone destruction

Multiple Myelomas Clinical Manifestations

• skeletal pain

• symptoms develop slowly

• fatigue

• bone pain

• easy bruising

• bone fractures/degradation (@ risk for hypercalcemia)

Multiple Myelomas Mnemonic

* OLDCRAB

OLD age

Calcium Elevated (hypercalcemia)

Renal failure

Anemia

Bone lytic lesions

Multiple Myelomas

* Nurs. management

• MAINTAIN ADEQUATE NUTRITION

  • flush out calcium/keep blood dilute so stones dont form

• Move PT carefully (avoid fractures)

• ambulation as tolerated

• pain management

What is Cellular Regulation?

• all functions carried out within a cell to maintain homeostasis

• response to extracellular signals

• the way each cells produces an intracellular response

Non-Modifiable Cancer Risk Factors

• age

• sex

• race

• family medical HX

Modifiable Cancer Risk Factors

• alcohol

• tobacco

• diet

• sun exposure

• infectious disease

• chemicals

• radiation

Types of Tumors

* benign tumors

NON CANCEROUS

• can often be removed

• in most cases do not reoccur

• cells DO NOT spread to other areas of body

  • ex: lipoma

Types of Tumors

* Malignant Tumors

ARE CANCEROUS

* can invade other ares of the body (metastasize)

Malignant Tumors

* Carcinoma

skin and tissues lining internal organs

Malignant Tumors

* Sarcoma

bone, connective, and supportive tissues

Malignant Tumors

* Leukemia

starts in blood

Malignant Tumors

* Lymphoma & Myeloma

immune system

Malignant Tumors

* CNS

brain & spinal cord

Cancer Risk Factors

PREVENTION IS KEY

• some cancers are related to viruses → can be prevented by vaccine

• 1/3 of all cancer are related to dietary factors & lack of physical activity

• identify risk factors & early detection

7 Signs of Cancer

• CAUTION

Change in bowel habits

A sore that does not heal

Unusual bleeding or discharge from body

Thickening or lump in breast/body

Indigestion or difficulty swallowing

Obvious change in wart or mole

Nagging cough

Diagnosing Cancer

Biopsy is the only definitive means of diagnosing cancer

What are the 3 main factors the TNM stage is based on?

1. original tumor size & whether or not tumor has grown into nearby areas

2. whether or not cancer has spread to lymph nodes

3. whether or not cancer has spread to distant areas of the body

Radiation Therapy

DESTROYS CANCER CELLS

Types of radiation therapy

* systemic radiation

administration of IV radioactive targeted substances

Types of radiation therapy

* External beam radiation (teletherapy)

delivery of radiation from a source placed at some distance from the target site in the RT department