med surg final

what are some clinical manifestations of hypovolemia?

what are some clinical manifestations of hypovolemia?

weight loss, decreased skin turgor, concentrated urine output, oliguria, thirst, dry mucous membranes

how do you manage hypovolemia?

PO fluids then IV isotonic solution, close monitoring

what are some clinical manifestations of hypervolemia?

weight gain, ascites, edema, JVD, increased urine output, cardiac symptoms, respiratory symptoms (ex: crackles)

how do you manage hypervolemia?

symptom management, fluid restriction, discontinue IV fluids, diuretics, dialysis

how do you manage hyponatremia?

electrolyte replacement, fluid restriction, hypertonic saline (if there is neuro involvement), diuretics

how do you manage hypernatremia?

ensure adequate water intake; monitor sodium, I/O, & daily weights

how do you manage hypokalemia?

increase dietary intake, KCl replacement; monitor EKG & urine output

how do you manage hyperkalemia?

limit dietary intake, loop diuretics, Kayexalate, albuterol, calcium carbonate (to help prevent dysrhythmia), insulin or bicarb, dialysis; monitor EKG

how do you manage hypocalcemia?

IV calcium gluconate, calcium-rich diet, calcium & vitamin D supplements, paper bag breathing; monitor & treat pain/anxiety; seizure precautions (if severe)

how do you manage hypercalcemia?

loop diuretics, normal saline (if hypovolemic), increase weight-bearing activity, biphosphonates (which inhibits osteoclasts), removal of parathyroid

how do you manage hypomagnesemia?

dietary replacement, magnesium supplements; monitor potassium & calcium, cardiac monitoring, referral to abstinence program; seizure & fall precautions

how do you manage hypermagnesemia?

stop magnesium supplements, loop diuretics, hydration, hemodialysis, calcium gluconate

how long can you infuse a single unit of blood for?

1.5 to 2 hours, but no more than 4

what gauge catheter is used for blood transfusions?

18 to 20

what is an acute hemolytic reaction caused by & how is it managed?

infusion of incompatible blood

stop transfusion & notify provider, maintain BP

what is a febrile nonhemolytic reaction caused by & how is it managed?

antibody reaction to granulocytes or platelets in infused blood component

stop transfusion & notify provider, monitor vitals, possible administration of antipyretics, restart transfusion slowly

what is an allergic reaction caused by & how is it managed?

sensitivity to donor’s plasma proteins

stop infusion & notify provider, monitor vitals, possible administration of antihistamines, restart transfusion slowly

what is a circulatory overload reaction caused by & how is it managed?

administration rate higher than patient tolerance

stop infusion & notify provider, monitor vitals, elevate HOB, possible administration of diuretics & oxygen, restart transfusion slowly

what are the different IV access complications & what are their clinical manifestations?

phlebitis - red, inflamed, warm

infiltration - cold, swollen

central line complications include infection, occlusion, & air embolism

what are the normal values for PCO2?

35 (basic) - 45 (acidic)

what are the normal values for bicarbonate?

22 (acidic) - 26 (basic)

what are the normal values for pH?

7.35 (acidic) - 7.45 (basic)

how does the body compensate with respiratory acidosis?

renal absorption

how does the body compensate with respiratory alkalosis?

renal excretion

how does the body compensate with metabolic acidosis?

hyperventilation

how does the body compensate with metabolic alkalosis?

hypoventilation

what are the types of pain?

acute

neuropathic - associated with damage or disease affecting somatosensory nervous system, tingling/etc. (ex: phantom limb pain, fibromyalgia)

persistent - responds to interventions but reoccurs when therapies end

breakthrough - bursts of acute pain with controlled pain

chronic malignant - associated with cancer growth

nociceptive - stimulation of peripheral nerve fibers

cutaneous - superficial, sharp/itchy

somatic - deeper, dull/achy

visceral - organ pain (often referred to other locations)

what are the components of a pain assessment?

OPQRST-AAA (onset, provocation, quality, region/radiation, severity, timing; aggravating/alleviating factors & associated clinical manifestations)

how do you manage pain?

PRN pain medications at regular intervals & titration to therapeutic levels, combined analgesics & adjuvant therapies, management of side effects

what are some considerations with assessment & management of pain?

common cultural background can encourage more qualitative care, language barriers, women may feel freer to report painful symptoms, men may need more opioid dosing to relieve pain

what are the stages of metastasis of cancer?

cell to cell, lymphatic system, blood, tumors (primary & secondary)

what is included in primary prevention of cancer?

risk factor modification (avoiding carcinogens), immunization against viral carcinogens

what is included in secondary prevention of cancer?

screening for early detection, genetic testing

what is included in tertiary prevention of cancer?

reducing morbidity & mortality, treatment & management of subsequent side effects

what are some complications of radiation & how are they managed?

irritation - use mild products

fibrosis

fatigue - have periods of activity within periods of rest

what are some complications of chemotherapy & how are they managed?

alopecia

bone marrow suppression

N/V/D

oral mucositis

hypersensitivity

peripheral neuropathy

cardiotoxicity

vesicant effects - make sure central lines, etc. are checked regularly

what are the components of preoperative care & what is the nurse’s role?

the nurse should complete pre-op checklist & ensure patient is ready for surgery

clarify information & ensure patient understanding, identify potential needs, prepare patient & family physically, mentally, & spiritually for surgery

what are the components of surgical informed consent & time-out?

name of patient, name of surgeon, surgery, body part, etc.

what are some complications of anesthesia?

hypoxia, hypo/hypertension, neurological risk (prolonged waking), muscle paralysis, anaphylaxis

malignant hyperthermia - acidosis, fever, muscle rigidity, tachypnea, unexplained tachycardia, ventricular dysrhythmias (hyperthermia is a late symptom); genetic relationship

what are some safety rules during the preoperative phase of surgery?

ensure privacy, surgical asepsis, check equipment & functioning, count instruments/sponges, consider allergies (ex: latex-free equipment for latex allergy)

what are some safety rules during the intra-operative phase of surgery?

time-out

what are some safety rules during the post-operative phase of surgery?

PACU - monitor respiratory function for hypoxemia, maintain patient safety

clinical unit - time of return, ABC, VS, neuro status, pain, wound dressing/drains, skin, urinary status, position, IV site & infusion, emotional state, call light within reach, contributing factors to delirium

what is the criteria for safe home discharge?

awake, alert, tolerating liquids, pain relief, VS WDL, voiding, no signs of bleeding, skin intact, no adverse reactions from surgery, understanding of all teaching

what are the components of discharge teaching for a post-operative patient?

symptoms to be reported, medication administration, wound/dressing care, activity level, dietary restrictions & modifications, follow-up, answer individual questions & concerns

what is included in the physical assessment of the respiratory system?

inspection - chest-rising, symmetry, skin color, LOC, speech pattern, orientation, accessory muscle use, mucous membranes

palpation - tactile fremitus, crepitus

percussion

auscultation - fine or coarse crackles/rales, rhonchi, wheezing, stridor, pleural friction rub

what are some clinical manifestations of influenza?

severe cold symptoms, fever, headache, myalgia, stuffy nose/sneezing, sore throat, chest discomfort, cough

how do you manage influenza?

anti-viral within the first 48 hours, antipyretics, supplemental oxygen; HOB elevation, adequate fluid & nutritional intake

droplet precautions

what ppe is used for droplet precautions?

mask, eye protection

what are some clinical manifestations of pneumonia?

fever, tachypnea, dyspnea, tachycardia, chills, cough, pleuritic chest pain, arthralgia, fatigue, dysrhythmias, hypotension, purulent or bloody sputum

how do you manage pneumonia?

outpatient if uncomplicated

supportive care, oxygen, fluids, antibiotics, bronchodilators, humidified oxygen; pulmonary hygiene, HOB elevation, nutritional support, activity grouping

droplet precautions

what are some clinical manifestations of tuberculosis?

cough that lasts 3 weeks or longer, hemoptysis, weight loss, night sweats

how do you manage tuberculosis?

immediate isolation with suspected TB in negative airflow room

isoniazid, rifampin, pyrazinamide, & ethambutol for 9 to 12 months; monitor temperature, oxygen, & breath sounds, support system, test family exposed

airborne precautions

what ppe is used for airborne precautions?

n95

how do you manage sinus bradycardia?

do not treat if asymptomatic

oxygen, atropine IVP, pacing

how do you manage sinus tachycardia?

vagal maneuver, beta blockers

how do you manage supraventricular tachycardia?

oxygen, vagal maneuver, adenosine IVP, beta blockers, CCBs, amiodarone, cardioversion, ablation

how do you manage atrial fibrillation?

medication to maintain rate control

how do you manage atrial flutter?

medication to maintain rate control

how do you manage asystole?

1. call a code

2. stay with the patient

3. CPR

4. IV access & fluids

5. epinephrine

6. no defibrillation until there is some kind of rhythm

how do you manage ventricular fibrillation?

CPR, ACLS drug protocol, immediate defibrillation

how do you manage ventricular tachycardia?

v-tach & awake, meds you must take (stable = vagal maneuver, lidocaine, amiodarone, cardioversion)

v-tach & a nap, you get a zap (unstable = CPR, defibrillation, epinephrine, vasopressin, amiodarone)

what are some clinical manifestations of chronic stable angina?

chest pain over a long period of time, pressure or burning sensation, transient ST depression

how do you manage angina?

nitro, beta blockers, CCBs, ACE inhibitors, ARBs; percutaneous coronary intervention

what are some clinical manifestations of acute coronary syndrome?

prolonged ischemia that is irreversible, NSTEMI

how do you manage acute coronary syndrome?

EKG, semi-fowlers position, IV access, MONA, thrombolytic therapy; stent placement, CABG

what are some clinical manifestations of unstable angina?

new onset, occurs at rest, worsening pattern

what are some clinical manifestations of a myocardial infarction?

unpredictable, sustained ischemia 80-90% due to thrombus formation

what are some clinical manifestations of prinzmetal’s angina?

occurs at rest (due to spasm in coronary arteries), transient ST elevation

*often seen with history of raynaud’s

what are some clinical manifestations of pericarditis?

friction rub, fever, orthopnea, diaphoresis, new or worsening pericardial effusion, pleuritic chest pain, EKG changes

how do you manage pericarditis?

aspirin, NSAIDs, corticosteroids; vitals, monitor pain, heart sounds, & EKG changes, HOB elevation

what are some clinical manifestations of endocarditis?

fever, petechiae, fatigue, confusion (in elderly), rigor, osler’s nodes, janeway lesions, new onset or changing murmur, weight loss, night sweats

how do you manage endocarditis?

IV antibiotics for 6 weeks or longer, valve repair/replacement; teach about oral hygiene & inform dentists

what are some clinical manifestations of coronary artery disease?

men - chest pain, MI as initial event

women - jaw/shoulder/back pain, nausea, higher HDL & lower LDL, palpitations, angina as initial event

how do you manage coronary artery disease?

oxygen, nitro, morphine (vasodilator), aspirin, beta blockers, statins; percutaneous transluminal coronary angioplasty (PTCA), CABG; monitor cardiac enzymes, creatinine, ha1c, lipid profile, & electrolytes

what is a complication of heart failure, what are some clinical manifestations, & how is it managed?

pulmonary edema

• sudden SOB, pink frothy sputum, tachycardia, chest pain, anxiety/fear, low SpO2

• oxygen, diuretics

what are some interventions for neutropenic precautions?

frequent handwashing, avoid crowds & sick people, safe food preparation, no live plants or flowers, private room in the hospital, monitor temperature, seek immediate care for fever

what are some interventions for thrombocytopenic precautions?

soft toothbrush, no flossing, electric razor for shaving, use shoes, avoid sexual intercourse, avoid blowing nose, stool softeners, apply pressure to lacerations for no less than 5 minutes, minimize sticks & blood draws (midlines are a great option)

what are some clinical manifestations of iron deficiency anemia?

pallor, fatigue, tachycardia, tachypnea, glossitis, spoon-shaped nails

how do you manage iron deficiency anemia?

dietary intake (leafy greens, red meat, beets, beans, fortified grains), supplements (educate about black tarry stools)

what are some clinical manifestations of vitamin b12 deficiency?

depression, confusion, dementia (when chronic), weakness

how do you manage vitamin b12 deficiency?

dietary intake (fish, milk, eggs, meat), supplements

*vegans are at high risk for vitamin b12 deficiency

what are some clinical manifestations of folic acid deficiency?

pallor, fatigue, tachycardia, neurological issues, increased risk of bleeding

how do you manage folic acid deficiency?

dietary intake (dark green vegetables, dried beans, nuts, carbs, grains, bran), supplements, prenatal vitamins

what are some interventions for the treatment of leukemia?

bone marrow aspiration/biopsy to diagnose

chemotherapy, bone marrow transplant

what are some interventions for seizure precautions?

oxygen, suction, padded rails, nothing in the mouth

what are some interventions for a patient during a seizure?

turn patient, maintain airway, monitor oxygen, protect from injury, observe, place in a recovery position, document

how do you manage bacterial meningitis?

antibiotics, decrease ICP (anti-inflammatories, pain management, fever management, anti-seizures, diuretics, HOB elevation), bedrest, clear liquids

how do you manage viral meningitis?

discontinue antibiotics, manage symptoms

how do you manage headaches & (more specifically) cluster, tension, & migraine headaches?

general - rule out life-threatening causes, headache diary, identify & avoid triggers, regular meals & fluid intake, consistent sleep habits

cluster - triptans, oxygen, preventative measures (CCBs, anti-seizures, melatonin, nerve blocks, deep brain stimulation)

tension - acetaminophen, NSAIDs, sedatives, muscle relaxers, preventative measures (TCAs, anti-seizures)

migraine - pain management, abortive therapy (ASA or NSAIDs with caffeine during aura), preventative measures (beta blockers or CCBs, anti-seizures, TCAs, SSRIs, Botox)

what are some clinical manifestations of encephalitis?

altered mental status, hemiparesis, tremors, seizures, cranial nerve palsies, personality changes, memory impairment, amnesia, photo/phonophobia, increased ICP

what are some complications of hypopituitarism?

decreased ACTH - hyponatremia, hypotension, hyperkalemia, hypoglycemia

decreased TSH - low metabolism

decreased LH & FSH - sexual dysfunction

decreased GH - dwarfism (in children), osteoporosis (in adults)

what are some complications of hyperpituitarism?

increased ACTH - hypernatremia, hypertension, hypokalemia, hyperglycemia

increased TSH - high metabolism

increased GH - gigantism (in children), acromegaly (in adults)

what are some clinical manifestations of syndrome of inappropriate ADH?

unusual clinical presentation, scant urine output (with increased urine specific gravity), hyponatremia (leading to anorexia), nausea, malaise, headache, irritability, confusion, weakness

how do you manage syndrome of inappropriate ADH?

fluid restriction, 3% NS, & diuretics (for hyponatremia), monitor neuro status, I/O, sodium, skin integrity, & signs of fluid overload, seizure precautions

what are some clinical manifestations of diabetes insipidus?

polyuria, polydipsia, & nocturia from low ADH

how do you manage diabetes insipidus?

fluid replacement, desmopressin/pitressin, monitor vitals (hypotension, tachycardia), daily weights, I/O, serum sodium, & osmolality

what are some clinical manifestations of addison’s disease?

bronze/dark/hyperpigmented skin, vitiligo, fatigue, weakness, anorexia/weight loss, dehydration, hypotension, hypoglycemia, emotional lability

how do you manage addison’s disease?

IV fluids, electrolyte replacement, corticosteroids; fall risk, assess for hypotension & hypoglycemia

what are some clinical manifestations of cushing’s syndrome?

thin skin, hyperglycemia, depression, moon face, buffalo hump, truncal obesity, hirsutism, oily skin, weight gain, fluid overload/edema, higher risk of infection, loss of bone density

how do you manage cushing’s syndrome?

overnight dexamethasone suppression test

monitor cortisol levels, suppression tests, serum electrolytes, etc., prevent complications associated with fluid overload, changes in immune status, skin integrity, & bone structure