MED SURGE QUIZ #1

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Maslows Hierarchy of Needs

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1

Maslows Hierarchy of Needs

  • air, water, food

  • safety & security needs

  • love/ belonging

  • self confidence

  • self- actualization (top goal)

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2

What are the ABC’s

Airway

Breathing

Circulation

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Signs to look for in PT

  • airway

  • pallor

  • difficulty w/ speech

  • use of accessory muscles

  • obstruction

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Signs to look for in PT

  • Breathing

  • restlessness

  • decreased pulse ox

  • abnormal RR

  • nasal flaring

  • ICS retractions

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5

Signs to look for in PT

  • circulation

  • high BP (stroke?/rupture?)

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

  • tachycardia

  • diaphoresis

  • blood clot

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Emergent

PT’S needs w/ highest priority

  • ABC/safety

  • basic survival needs

    • PT goes to the ER

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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

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Non-urgent

PT’s problem does NOT need immediate attention

  • PT can wait to see PCP

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Acute

abrupt onset & usually short course

  • whats going on right now

    • ex: broken arm

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Chronic

long period of time & continuing disease process

  • ex: diabetes/arthritis

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Delegation for RN’s

  • TEAACUP

Teaching

Evaluation

Assessment (initial)

Advanced Intervention

Collaboration

Unstable PT’s

Planning

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5 Rights of Delegation

  1. Right task

  2. Right circumstances

  3. Right person

  4. Right supervision

  5. Right direction/Communication

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Right Task

know what each person can do

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Right circumstances

PT should be stable & NOT require clinical judgement

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

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Right Person

person has proper knowledge & skills to preform task

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Right Supervision

follow up & evaluate is required after each task

  • was it done properly?

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Right Direction/Communication

  • have clear expectations

  • ability to answer questions

  • how should databe reported to the RN

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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?”

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Delegation Red Flags

  • LPN/UAP refusal to accept delegation

  • incomplete direction

  • failure to confirm expectations

  • failure to communicate

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Factors to Consider Before Delegating

  • potential for harm?

  • complexity of task?

  • problem-solving needed?

  • unpredictability of outcome

  • level of interaction w/ PT

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Roles of RN

  • ALL MEDS

  • admission assessment

  • blood products

  • care plan

  • PT teaching

  • UNSTABLE PT’s

  • acute diseases

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Roles of LPN

  • vitals

  • uncomplicated skills

  • STABLE PT’S

  • chronic disease

  • oral/IM/SQ/patches/inhalers

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Roles of UAP

  • feeding

  • hygiene

  • basic skills

  • STABLE PT’s

  • chronic disease

  • ambulation

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Factors influencing Delegation

  • what can RN delegate?

  • stable PT’S

  • requirements within caregiver job description

  • minimal potential for harm

  • when adequate supervision is needed

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Factors to Consider when Assigning rooms to PT’s

  • bed availability

  • LOC

  • PT acuity

  • Age, gender, special needs

  • staffing

  • infectious disease

  • attending physician

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What does a Complete Blood Count entail?

  • RBC

  • Hemoglobin

  • Hematocrit

  • WBC

  • PLT

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Normal RBC count

3.6-5.8 million/mm3

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Normal Hemoglobin count

  • (blood oxygen)

11.7 - 17.3g/dL

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Normal Hematocrit count

  • (# of cells per solution )

36% - 52%

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Normal WBC count

4,500 - 11,000/ cubic mm3

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Normal PLT count

150,000 - 450,000/uL

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What is ESR?

  • what is the purpose?

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

  • <30mm/hr

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Normal Bleeding Time

3-8 min

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Clotting Studies

  • PT, PTT, INR

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

  • 11-13.5 seconds

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Bone Marrow Biopsy

  • PT prep

  • anxiety/pain

  • education(what to expect/feel)

  • postion

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Bone Marrow Biopsy Procedure

  • lasts 5-10

  • sedation

  • sterile procedure

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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

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Aplastic Anemia

bone marrow is NOT producing enough blood cells

  • decreased RBC, WBC, PLT

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Aplastic Anemia Complications

  • hypoxia

  • infection

  • hemorrhage

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Aplastic Anemia Nursing Care

  • neuro assessment

  • hand hygiene

  • oral care

  • avoid invasive procedure

  • prevent immobility

  • screen visitors for illness

  • bleeding precautions

  • increase fiber & fluid

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Polycythemia

increased in # of RBC

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Primary Polycythemia

chronic myeloproliferation disorder arising from chromosomal mutation in stem cell

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Primary Polycythemia Labs

Increased…

  • RBC

  • WBC

  • PLT

  • Hemoglobin

  • blood viscosity

  • blood volume

  • congestion of organs & tissues w/blood

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hypercoagulopathy

predisposed to clotting

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Secondary Polycythemia

hypoxia stimulates erythropoietin in kidneys

  • INCREASED RBC

    • body is trying to compensate to get more O2 around

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Secondary Polycythemia Complications

  • CVA

  • MI

  • PE

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Secondary Polycythemia Clinical Manifestations

  • headache

  • dizziness

  • dyspnea

  • angina

  • weakness

  • intermittent claudication

  • flushing of face

  • L.upper abdominal pain

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Polycythemia & Perfusion

when NOT perfused properly → toxation might occur

  • heart/brain/kidney must perfuse

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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)

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Thrombocytopenia

decrease in PLT(<150,000)

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Thrombocytopenia Lab values

  • <50,000 → at risk for spontaneous bleed

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

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Nurs. Implementation

  • Thrombocytopenia

  • monitor signs of bleeding

  • ID PT’s @ risk

  • Monitor lab values

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

  • PT teaching

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PT teaching for Thrombocytopenia

  • use electric razors

  • NO Motrin/aspirin

  • use smaller needles

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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

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Neutropenia Diagnostic Studies

absolute neutrophil count (ANC)

  • total WBC count * the % of neutrophils

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ANC <1000

@ risk for bacterial infection

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ANC <500-1000

MODERATE risk for bacterial infection

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ANC <500

SEVERE risk for bacterial infection

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Diagnosing neutropenia

Peripheral blood smear

  • assess fro immature cells

Bone marrow biopsy

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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

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Neutropenic fever

100.4° F

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Neutropenic Precautions

  • private room

  • hand washing

  • NO fresh fruit/veg/flowers

  • NO sick visitors

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Leukemia Cell Problems

  • WBC overproduce

  • WBC overcrowd bone marrow

    • therefore…RBC & PLT are not being made

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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

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Leukemia Clinical Manifestations

  • inadequate production of normal bone marrow

  • anemia

  • thrombocytopenia (decrease PLT)

  • decrease in # and function of WBC’s

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Nursing Care Leukemia

  • acute intervention

  • administer meds & monitor for side effects

  • help PT develop coping strategies

  • assess labs for effect of drugs

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Nursing Care Leukemia

  • ambulatory/home care

refer PT and family to survivor networks

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Lymphomas

  • Hodgkins Disease

Malignant

  • caused by proliferation of abnormal multi nucleated cells located in lymph nodes

    • Reed-Sternberg Cells

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Lymphomas

  • Non-Hodgkins

malignant neoplasm of the immune system

  • B & T cells

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Clinical Manifestations

  • Hodgkins Disease

  • enlarged cervical, axillary, inguinal nodes

  • fever

  • fatigue

  • night sweats

  • weight loss

  • chills

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Clinical Manifestations

  • Non-Hodgkins

-painless lymph nodes

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

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Diagnosing Lymphomas

  • nodes biopsy

  • xray

  • bone marrow studies

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Staging Lymphomas

  • stage 1

isolated to one lymph node

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Staging Lymphomas

  • stage 2

at 2 or more sites

  • same side

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Staging Lymphomas

  • stage 3

at both sides of diaphragm or spleen

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Staging Lymphomas

  • stage 4

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

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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

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Thrombocytopenia Bleed Precautions Mnemonic

  • RANDI

Razor → electric

Aspirin → NO

Needles → small gauge

Decrease needle sticks

Injury → prevent

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What is Multiple Myelomas?

cancer of the bone marrow

  • destroys bone → bone breaks down

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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

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Multiple Myelomas Clinical Manifestations

  • skeletal pain

  • symptoms develop slowly

  • fatigue

  • bone pain

  • easy bruising

  • bone fractures/degradation (@ risk for hypercalcemia)

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Multiple Myelomas Mnemonic

  • OLDCRAB

OLD age

Calcium Elevated (hypercalcemia)

Renal failure

Anemia

Bone lytic lesions

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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

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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

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Non-Modifiable Cancer Risk Factors

  • age

  • sex

  • race

  • family medical HX

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Modifiable Cancer Risk Factors

  • alcohol

  • tobacco

  • diet

  • sun exposure

  • infectious disease

  • chemicals

  • radiation

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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

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Types of Tumors

  • Malignant Tumors

ARE CANCEROUS

  • can invade other ares of the body (metastasize)

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Malignant Tumors

  • Carcinoma

skin and tissues lining internal organs

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Malignant Tumors

  • Sarcoma

bone, connective, and supportive tissues

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Malignant Tumors

  • Leukemia

starts in blood

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Malignant Tumors

  • Lymphoma & Myeloma

immune system

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Malignant Tumors

  • CNS

brain & spinal cord

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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

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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

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Diagnosing Cancer

Biopsy is the only definitive means of diagnosing cancer

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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

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Radiation Therapy

DESTROYS CANCER CELLS

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Types of radiation therapy

  • systemic radiation

administration of IV radioactive targeted substances

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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

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