Med Surg Unit 3 Exam

Homeostasis definition

body’s ability to maintain internal stability despite changes in the external environment.

Patho of SIRS

inflammation triggered by a noninfectious/infectious stimuli that activates cytokines. The deregulated cytokine storm causes a tremendous inflammatory response that can lead to organ dysfunction or death

Purpose of red blood cells

carries oxygen throughout the tissues of the body and Co2 back to the lungs to be exhaled

Risk factor for blood clot formation (2)

Inactivity or smoking; advanced age (>60 y/o), blood clotting disorders, fractures, atrial fibrillation, estrogen therapy

Sickle cell anemia – fatigue symptom explanation

sickle-shaped RBCs have shorter lifespan (10 to 20 days) compared to normal RBCs (120 days). This leads to inadequate oxygen being transported to the cells of the body

Valve replacement surgery

damaged heart valve is removed and replaced with a new valve d/t narrowing/leaking valve; can either be mechanical valve or a tissue valve

Chronic respiratory acidosis

COPD may manifest in the client’s daily life via coughing, SOB. They may experience mental health disorders, esp. anxiety and depression

Deep vein thrombosis

pain, swelling, redness at the site d/t the veins being dilated

Fluid volume deficit

tachycardia, hypotension, orthostatic hypotension, thirst, decreased skin turgor, flattened neck veins, decreased urinary output, muscle cramps, lightheadedness, and dry mucous membranes. Neurologic manifestation (e.g., confusion) THINK OF DEHYDRATION!

Headache – type of hemorrhage suspected

Intracranial hemorrhage

Hypocalcemia electrolyte imbalance

Increased neuromuscular excitability (e.g., TETANY; SEIZURES; POSITIVE TROUSSEAU'S SIGN–flexion of joints and finger hyperextension; POSITIVE CHVOSTEK’S SIGN– facial muscle twitch when cheek is tapped; PROLONGED QT INTERVAL on EKG)

Impending cardiac arrest

DYSPNEA (MOST COMMON IN FEMALES), profound fatigue, pain in the back, flu-like manifestations, N/V, abdominal pain, CHEST PAIN (MOST COMMON IN MALES), lightheadedness and syncope, racing heartbeat

Iron deficiency anemia

SOB, fatigue, heart palpitations described as “bounding,” pallor

Iron deficiency anemia – fatigue in client that is breastfeeding

A pregnant client may feel fatigue d/t depleted iron stores as newborn feeds

Metabolic alkalosis

neurological alterations (e.g., confusion); hypoventilation as a compensatory mechanism, muscle weakness, paresthesia, ventricular and atrial tachyarrhythmias

Respiratory alkalosis

SOB (hyperventilation)

Signs of shock (most common manifestations)

tachycardia, tachypnea, hypotension, abnormal mental status, mottled skin, cold and clammy extremities, oliguria, hyperlactatemia, metabolic acidosis

Worsening hyponatremia

alterations in the neurological status (e.g., lethargy and confusion), hyperactive reflexes, and seizures (THIS IS A MEDICAL EMERGENCY)

BUN level in relation to fluid volume deficit

BUN may be elevated in fluid volume deficit (range 10 to 20 mg/dL); reflects renal function/hemoconcentration

D-dimer

a blood test used for diagnosing blood clots.

Low D-dimer result

may indicate no blood clot present

Elevated D-dimer result

may indicate a blood clot. COULD BE PRESENT IN PREGNANCY OR POSTOP. EXPECT FURTHER TESTING ORDERS FROM PHYSICIAN.

Sodium level in relation to hypernatremia

Elevated sodium level; should be obtained q2-4H while the in treatment for hypernatremia

Troponin T test

<0.1 ng/mL (elevated levels indicates cardiac muscle injury as soon as 2 to 3H following incident)

Anaphylactic shock

Occurs d/t exposure to allergen. PRIORITY NURSING CARE MNEMONIC– EPI (administer EPINEPHRINE, PROTECT airway, INSERT two large-bore IV access for fluids)

Cause for metabolic acidosis

loss of bicarbonate via the kidneys/GI tract (e.g., diarrhea/vomiting, DKA, uremia, kidney disease, liver failure)

Client at risk for shock

frequent assessment and early recognition

Clients at highest risk following surgical procedures (CABG)

COPD, Coronary artery disease, peripheral vascular disease, cerebral vascular accident, renal disease, obesity, frailty, DM

Hypomagnesemia following an MI – risk for

cardiovascular dysrhythmias

Immediate intervention for fluid volume excess

ABCs (assess airway, ensure patent airway via High Fowler’s), administer diuretics as prescribed, restrict fluids, monitor I&O and weight

Priority assessment of suspected shock

ABCs

Risk factors for deep vein thrombosis

identify how long they have been on bedrest, reports of pain

Risk factors for fluid volume deficit

GI bleeding, burns, excessive sweating, and third-space losses, diuretic use, chronic kidney disease, dehydration

Altered perfusion definition

The inadequate flow of blood and oxygen to the organs and tissues, which can lead to decreased cellular oxygen, heart failure, and other serious conditions

Intracellular space

contains the majority of the TBW. Prone to experiencing the greatest water deficit.

Lifespan of normal red blood cells

120 days

Osmosis

water moves across a permeable membrane from an area of greater water concentration to an area of lower water concentration or from a diluted to a more concentrated solution.

Patho of hypovolemic shock

severe vasodilation from infection (loss of volume = decreased perfusion)

Patho of sepsis

SIRS + infection

Pulmonary embolism location

lungs

Risk factors for abdominal aortic aneurysm (AAA)

family hx. of aneurysm and smoking

Thrombus

a blood clot that develops in a location that can block necessary blood flow (e.g., vein/arteries)

Warfarin

anticoagulant used to treat blood clots. IMPLEMENT BLEEDING PRECAUTIONS FOR CLIENTS TAKING WARFARIN