MED SURG EXAM 1

How do you calculate FL gain or loss?

1L = 2.2 lbs (1kg)

Fluid volume EXCESS (hypervolemia) and how it presents

• Weight gain

• EDEMA

Fluid volume DEFICIT (hypovolemia) and how it presents

• Weight loss

• Dehydration

Hyponatremia

LOW SODIUM

low sodium = high water

• S/S: weight gain, edema

• neuro changes (seizure, coma)

• treatment: diuretics, 3%NaCl

Hypernatremia

HIGH SODIUM

high sodium = low water

• S/S: Dehydration, decreased urinary output

• neuro changes (seizure, coma)

• treatment: oral fluid (isotonic, hypotonic)

Hyperkalemia

HIGH POTASSIUM

• S/S: MURDER (muscle cramps, urine abnormalities, respiratory distress, decrease cardiac contractility, EKG changes, reflexes)

• Treatment: dialysis

Hypokalemia

LOW POTASSIUM

• S/S- 7 L’s: Lethargy, Lots of urine, Lethal cardiac dysrhythmias, Limp muscles, Leg cramps, Low shallow respirations, Low BP + HR

• treatment: potassium orally or IV

Hypercalcemia

HIGH CALCIUM

• S/S: bones, stones, abdominal groans, psychic moans

• treatment: weight-bearing exercises, fluids

Hypocalcemia

LOW CALCIUM

• S/S: CATS (Convulsions, Arrhythmias, Tetany, Spasms) Positive Trousseau’s OR Chvostek’s sign

IV Piggybacks

Primary bag should always be LOWER than the secondary bag

Hypotonic Solution

Hypo = Hippo → swelling

• used to treat HYPERNATREMIA

• 0.45 NS

Isotonic

SAME

• no major changes

• 0.9 NS, LR, D5W

Hypertonic

DEHYDRATES the cell

• used to replace electrolytes

• TPN

Lactated Ringers

Isotonic

• IDEAL FOR SURGERY, BURNS, + GI LOSSES

TPN

Used when pt. has limited to no oral intake

• Concentrated Carbs, Fats, Proteins, + Electrolytes

Central Venous Access Devices (CVADS)

Increased risk of systemic infection

PICC

CANNOT use arm for BP or Blood draw

• decreased infection rate than CVADs

Sprain

Ligament

• ankles, wrists, knees

• risk of avulsion fracture (bone tearing away)

Strain

Tendons

• lower back, calf, hamstring

treatment for sprains + strains

• NSAIDs

• RICE

Carpal Tunnel Syndrome (CTS)

Assessment + Manifestations

• Inflated BP cuff > SBP for 1-2 mins

• TINEL’S SIGN

• PHALEN’S MANEUVER

• THENAR MUSCLE ATROPHY

What does traction do?

Prevents or decreases pain + muscle spasms

• pulling force to attain realignment

Skin Traction

• short-term, before surgery

Skeletal Traction

• long-term

Superior Mesenteric Artery Syndrome

Squeezes stomach too tight (due to body jacket brace) and doesn’t allow GI to process correctly

• assess bowel sounds + treat w/ gastric

Nutrition for vertebral immobilization

• INCREASE protein

• INCREASE vit B,C,D

• INCREASE calcium, phosphorus, magnesium

• INCREASE fluid + fiber (because pt. isn’t moving)

VTE intervention

Anticoagulants

• warfarin, heparines, aspirin

• antiembolism stockings

• SCDs

• ROM exercises

Compartment Syndrome

Cast or Brace is too tight

• early recognition is crucial

• 6 P’s: Pain, Pallor, Pressure, Paresthesia, Pulselessness, Paralysis

• NOTIFY IF PAIN UNRELIEVED BY DRUGS

Fat Embolism

1. Hypoxemia

2. Neurologic abnormalities

3. Petechial Rash

• Careful immobilization of area and handling of long bone fracture!

What are ways to manage Fat embolism?

• Fluid administration

• coughing + deep breathing

• administer O2

Amputation Pharm + Nonpharm treatment

Pharm: gabapentin + pregabalin

Nonpharm: proper positioning!

• DO NOT DANGLE LIMB

• NO PILLOWS UNDER LIMB

• DO NOT SIT IN CHAIR MORE THAN 1 HOUR

Osteomyelitis

Severe infection of bone

• direct entry: via open wound

• indirect entry: blunt trauma

Osteomyelitis Manifestations

Acute: infection less than 1 month

• pain that worsens with activity + unrelieved by rest, fever, night sweats

Chronic: infection more than 1 month

• pain that worsens with activity, swelling

Diagnostics for Osteomyelitis

WBC = elevated means infection

MRI = can show early stages of osteomyelitis

Management for Osteomyelitis

• IV ANTIBIOTICS (oxacillin, clindamycin, vancomycin)

• surgical debridement

What is a concern for long term antibiotics used to treat osteomyelitis?

CDIFF

Manifestations of Lupus

• BUTTERFLY RASH

• Vascular lesions → sun exposed areas

• arthritis component

Education for Lupus

• Pregnancy: coordinate pregnancy with decrease in symptoms, some may not be advised to get pregnant

• Strong adherence to meds doesn’t guarantee no flares

Medications for Lupus

HYDROXYCHLOROQUINE

• educate pt. on getting eye exams on this med

Fibromyalgia Manifestations

pain that is widespread and burning

• headache, jaw, facial pain

• nonrestorative sleep = FATIGUE

Fibromyalgia Diagnostics

Must meet 2 criteria

• Pain is experienced in 11/18 tender points over the past week

• History of widespread pain noted for at least 3 months

• Fatigue, cognitive symptoms

Education of Fibromyalgia

Treat the symptoms

• REST

• pt. teaching: overexertion can TRIGGER pain but immobility can leat to pain and stiffness

Management of Fibromyalgia

Minimize triggers + irritants

• LIMIT intake of sugar, caffeine, alcohol

Stress management

• biofeedback, imagery, CBT

Medications for Fibromyalgia

• Pregablin

• Zolpidem (for sleep)

Rheumatoid Arthritis

• SYSTEMIC, SYMMETRICAL INFLAMMATION

• pain, morning stiffness

Rheumatoid Arthritis Manifestations + Deformities

• ULNAR DRIFT

• Reynaud’s

Diagnostic testing for Rheumatoid Arthritis

• Synovial Fl. Analysis

• ANA

Pharm. for Rheumatoid Arthritis

METHOTREXATE (DMARD)

• toxicity risk

• TERATOGENIC → no pregnant women

RA Management/Education

• 8-10 hrs of sleep a day + daytime rest

• modify activities

• Maintain movement

Nonpharm for Rheumatoid Arthritis

Heat + Cold Therapy

• cold (10-15 mins)

• hot (20 mins)

Gout Manifestations

• PAIN, increased skin temp, swollen joints

• urate crystals in synovial fluid

Pharm for Gout

• Allopurinol → FIRST CHOICE for PREVENTION (decreases production of uric acid)

• Colchicine → GIVE WITHIN FIRST 12 hours of attack (ACUTE)

• Probenecid → Increases excretion of uric acid

Nonpharm for Gout

• immobilize great toe or joint affected

• INCREASE FL (excretes crystals)

• AVOID purine rich foods (alcohol, beer, protein, red meats, anchovies/sardines)

Neurogenic Shock

Loss of SNS innervation (can be reversible - motor + sensory issue)

• T6 OR HIGHER

• LOW BP + HR

• Plan: IV FL. VASOPRESSORS (phrine ending)

Spinal Shock

Loss of reflexes + sensation BELOW the level of SCI

• ANY area of spinal cord

• Decreased reflexes and loss of sensation

Management of Skin for patients unable to move

Consider:

• BR, nutritional status, weight gain/loss, pressure points, waffle mattress

• Bed turn every 2 hours, Chair every 15-30 mins

Trigeminal Neuralgia (FACE) Manifestations

TN 1:

• ABRUPT onset, WAVES of excruciating pain

TN 2:

• CONSTANT aching, burning, crushing, stabbing (lower intensity than TN 1)

TN 1 Management

Antiseizures → Carbamazepine +oxcarbazepine

TN 2 Management

Tricyclic Antidepressants, Analgesics + opioids

TN MANAGEMENT

• know triggers

• complete hygiene @ analgesic peak (with soft bristle toothbrush + warm water)

• eye exam regularly

• protect face against extreme temps

Bells Palsy Management

Protection of affected eye

• eye drops, eye shield

Drink from unaffected side

Good oral hygiene

Bells Palsy Medication

Corticosteroids (decreases inflammation)

Acyclovir (for virus)

Bells Palsy Diagnostics

No definitive testing → mainly what we see and what pt tells us

Gullain Barre Manifestations

SYSTEMIC WEAKNESS + ASCENDING PARALYSIS

• increased HR, numbness + tingling

Gullain Barre Assessments

Assess: neuro, respiratory, motor + sensory, VS

Osteoarthritis

a progressive slow + noninflammatory condition of joints

• Degeneration of cartilage → BONE ON BONE RUBBING

Osteoarthritis Manifestations

• Pain INCREASES with activity

• Joint stiffness (crepitus)

• ASSYMETRY

• HERBS + BOUCHARDS

Osteoarthritis Medication

NSAIDS (ibuprofen 200 mg x4 day) + MISOPROSTOL

Osteoarthritis Management

• lose weight

• decrease hazards

• stop smoking

Osteoblasts

BUILD

Osteoporosis

a chronic progressive metabolic bone disease - bone resporption EXCEEDS bone deposition

• LOW BONE MASS

• Deterioration of bone

• SILENT thief (slowly robs skeleton of its resources)

Osteoporosis Diagnostics

Dual-energy X-ray absorptiometry (DEXA) → GOLD STANDARD

Management of Osteoporosis

• proper nutrition, exercise (walking), calcium + vit. D

• Women 19-50 need 1000mg calcium, 51> need 1200mg calcium

Medication for Osteoporosis

• Calcium + Vitamin D (sunlight, eggs, mushrooms, fish)

• Alendronate (Bisphosphonates)

→ Take with full glass of water

→ Take 30 mins before other food/meds

→ Sit upright for 30 mins after