medsurg certification exam

nursing process

Assessment

Diagnosis

Planning

Implementation

Evaluation

adrenal glands purpose

aldosterone and cortisol are produced by the adrenals to cause the kidneys to retain sodium and fluid

pituitary gland

Under the influence of the hypothalamus, the pituitary regulates growth and controls other endocrine glands. stores and releases ADH from the hypothalamus to direct kidneys to retain fluids to maintain cellular osmotic pressure

parathyroid glands

small pea-like organs that regulate calcium and phosphate balance in blood, bones, and other tissues

assessment steps

Inspection

Palpation

Percussion

Auscultation

how to palpate for tactile fremitus

Say the word "ninety-nine" while hands are on their back.

Should be symmetrical

If the vibration isn't equal, there may be a collapse of lung tissue, fluid, or some type of blockage.

percussion

tapping on a surface to determine the difference in the density of the underlying structure; sounds are tympany, resonance, hyperresonance, dullness, flatness

tympany percussion

hollow drum sound produced when organ contains air (Stomach, intestine)

resonance

Hollow sound heard upon percussion of the chest wall; the percussion tone expected when percussing the lungs

hyperresonance

lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax

dullness

Thud like sound produced by dense tissue such as the liver, spleen or heart

flatness

heard over bones and muscle

austultation

intensity- level of sound in terms of loudness

frequency- low or high pitch

quality- distinguish between rumbling and musical types

Areas of Auscultation of the Heart

aortic, pulmonic, erb's point, tricuspid, apical

1st heart sound

AV valves closing (mitral and tricuspid), heard at apex of the heart

2nd heart sound

Closure of the semilunar valves. (Aortic Valve & Pulmonary Valve) heart at base of heart

Systole

Contraction of the heart- time between S1 and S2

Diastole

Relaxation of the heart, time between s2 and s1

P wave

atrial depolarization, impulse is in sinus node

QRS complex

ventricular depolarization and atrial repolarization

T wave

ventricular repolarization and relaxation so cells can regain a negative charge

U wave

repolarization of the purkinje fibers; can be present in hypokalemia

Gallop heart sounds

s3, occurs after s2. occurs in children and young adults, but may indicate CHF or L ventricular failure in older adults. s4 occurs before s1 which means ventricular hypertrophy- found in coronary artery disease/htn/aortic valve stenosis

Opening snap

A sharp, high-pitched click heard in early diastole related to opening of the abnormal valve in cases of mitral stenosis from rheumatic heart disease

Ejection click

brief high pitch click sound after s1; aortic stenosis

friction rub

described as grating, scratching sound of the heart indicative of pericarditis

murmur

caused by turbulent blood flow- characterized by location, timing in cardiac cycle, intensity (grade 1 to V), pitch, quality, and radiation

MAP

diastole x2 + systole / 3

Normal MAP

70-105 mmHg, need at least 60

cardiac output

The volume of blood ejected from the left side of the heart in one minute. HRxSV

normal is 5 L/min

Cardiac Index

CO/body surface area

stroke volume

the volume of blood pumped out by a ventricle with each heartbeat

SV= CO / HR

Pulmonary Vascular Resistance (PVR)

resistance in the pulmonary arteries and arterioles against which the R ventricle has to pump during contraction, if it is elevated then SV is usually low

Ankle Brachial Index

Comparison of the blood pressure in the leg vs. the arm; normal ratio is greater than 1

done to evaluate PVD

ventilation-perfusion ratio

the ratio between ventilation and perfusion in the lung; matching of ventilation to perfusion optimizes gas exchange

normal is 0.8

greater than 0.8 can mean hyperventilation, PE, hypotension

less than 0.8 can mean atelectasis, pneumonia, or lung disease

lung sounds

vascular breath sounds- low and soft, heard over peripheral lung space

bronchiovesicular- moderate and in the upper lungs

tracheal- high pitch

cranial nerves

1. Olfactory

2. Optic

3. Oculomotor

4. Trochlear

5. Trigeminal

6. Abducens

7. Facial

8. Vestibulocochlear

9. Glossopharyngeal

10. Vagus

11. Accessory

12. Hypoglossal

Cranial Nerve 1

olfactory

smell test

Cranial Nerve II

optic

-Function: sensory - carries impulse for vision

-Testing procedure: eye chart testing, visual field testing

cranial nerve III

Oculomotor (eye movement, pupil constriction)

pupil reflex test and eye motion

cranial nerve IV

trochlear

eye movement

move eyes down and out and in

cranial nerve V

Trigeminal - chewing

face & mouth touch & eye movement

cranial nerve VI

abducens

lateral movement of eye

cranial nerve VII

Facial - controls most facial expressions (puff cheeks out/smile/raise eyebrows)& secretion of tears & saliva & taste

cranial nerve VIII

Vestibulocochlear (hearing and balance)

weber rinne test

cranial nerve IX

Glossopharyngeal - Gag reflex, swallowing, taste in posterior 1/3 of tongue

cranial nerve X

Vagus - senses aortic blood pressure & slows heart rate & stimulates digestive organs & taste/ gag swallow and cough

cranial nerve XI

Accessory: sternocleidomastoid & trapezius muscle, shoulder shrugging, head movement

cranial nerve XII

Hypoglossal

tongue movement- stick tongue out

NIH Stroke Scale (NIHSS)

A 42 point scale used to assess the severity of stroke

LOC

best gaze (horizontal eye movement)

visual (visual fields)

facial palsy (facial symmetry)

mofor of arm

motor of leg

limb ataxia (finger to nose and heel to shin)

sensory (grimace or withdraw from pinprick)

best language (describe action of pictures)

dysarthria (reads or describes words on list)

distinction and inattention (visual spatial neglect)

Intracranial Pressure (ICP)

cushing's triad: increased SBP with widening pulse pressure, bradycardia, and dec respirations

normal is 1-15 mmHg

Cerebral Perfusion Pressure (CPP)

CPP = MAP - ICP

pressure required to maintain adequate blood flow to brain

bowel sounds

absent if nothing heard for 2-5 minutes

hypoactive only 1 sound in 2 min

normal sound heard every 5-20 seconds

hyperactive 5-6 sounds in <30 seconds

osmolality

number of electrolytes and other molecules per kg/urine

measures concentration or dilution

dehydration= increased osmolality

Specific gravity of urine

1.010-1.030

weight of urine

arterial insufficiency

Decreased or absent hair on legs

Thin, shiny, atrophy, cool skin

Pale looking extremities

Absent or weak pulses on palpation

dorsum of foot ulcers

pain: intermittent claudication- do not cross legs

venous insufficiency

brown discoloration

edematous

ulcers near medial malleoluous

pulses palpable

pain: ache, cramp- elevate legs

nociceptive pain

Somatic (cutaneous tissue/bone/joints/ mucles) or visceral (organs) pain caused by injury to body tissues, most common type of pain seen in an acute care setting

Mini-Mental State Examination (MMSE)

Brief 30-point questionnaire test that is used to screen for cognitive impairment; commonly used to screen for dementia.

Mini-Cog Test

Assesses dementia by having patients remember and repeat three common objects and draw a clock face indicating a particular time. score out of 5

Hamilton Anxiety Rating Scale

evaluates for the presence and degree of subjective somatic and psychic anxiety

Beck Depression Inventory

a multiple-choice questionnaire assessing symptoms of depression

sodium

135-145

extracellular fluid

Hyponatremia

causes: SIADH, ketoacidosis, burns...

Nausea

Muscle cramps

Confusion

Muscular twitching, coma

Seizures

Headache

Hypernatremia

from: renal disease, diabetes insipidus, fluid depletion

You are 'fried' or S.A.L.T.

F - Fever (low grade), flushed skin

R - Restless (irritable)

I - Increased fluid retention and increased BP

E - Edema (peripheral and pitting)

D - Decreased urinary output, dry mouth

S = Skin flushed

A = Agitation

L = Low-grade fever

T = Thirst

potassium

intracellular fluid, skeletal and cardiac muscles affected

Hypokalemia

Fatigue, Anorexia, N/V, Muscle cramps with hyporeflexia, Decreased GI motility, Dysrhythmias, Paresthesia and tetany, Flat T waves on ECG

Hyperkalemia

M.U.R.D.E.R.

M - Muscle weakness

U - Urine, oliguria, anuria

R- Respiratory distress

D - Decreased cardiac contractility

E - ECG changes

R - Reflexes, hyperreflexia,

calcium

transmits nerve impulses and regulates muscle contraction

Hypercalcemia

Muscle weakness, Constipation, Anorexia, N/V, Polyuria, Polydipsia, bradycardia

tx: loop diuretics, IV fluids, phosphate

Hypocalcemia

hypoparathyroid, vit d deficiency

C.A.T.S.

C - Convulsions

A- Arrhythmias

T - Tetany (involuntary contraction of muscles)

S - Spasms and seizures

Positive Chvostek's or Trousseau's sign

tx; calcium gluconate

phosphorous

neuromuscular and RBC function, provides structure for teeth and bones

2.4-4.5

Hypophosphatemia

severe protein calorie malnutrition, excessive antacid use, burns, DKA

irritability, tremors, seizures, hemolytic anemia, decreased heart function

Hyperphosphatemia causes

renal failure, excess phosphorus, excess vitamin D, acidosis, hypoparathyroidism, chemotherapy

Hyperphosphatemia S/S

tachy, muscle cramping, n/d

magmesium

carb and protein metabolism, neuromuscular function, cardiac function

Hypomagnesemia causes

chronic diarrhea, CKD, pancreatitis, laxative use, hyperthyroid, hypoparathyroid

Hypomagnesemia S/S

Twitching

Paresthesias

Hyperactive reflexes

Irritability

Confusion

Positive Chvostek's or Trousseau's sign

Shallow respirations

Tetany

Seizures

Tachycardia

Tall T waves and depressed ST segment

Hypermagnesemia causes

DKA, renal failure, addisons disease, hypothyroid

Hypermagnesemia S/S

Flushing, Hypotension, Drowsiness, Lethargy, Hypoactive reflexes, Depressed respirations, Bradycardia

metabolic acidosis s/s

DEPRESSED

-Similar to respiratory acidosis

-CNS depression; drowsiness, confusion, h/a

-flushed skin

-arrhythmias

-Nausea

respiratory acidosis s/s

hypoventilation and CO2 retention

Drowsiness

Disorientation

Dizziness

Headache

Coma

↓BP

Rapid/Irregular HR

Warm, flushed skin

Seizures

Hypoventilation

Hypoxia

Cyanosis

metabolic alkalosis causes

severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3

metabolic alkalosis s/s

EXCITED

-diaphoresis

-N/V

-↑ neuromuscular excitability, confusion, tremors, muscle cramps

-shallow breathing

-EKG changes, tachy

-seizures

respiratory alkalosis causes

hyperventilation, PE, anxiety, pain/fever/exercise

Respiratory Alkalosis S/S

EXCITED

Deep-rapid, breathing, dizziness, agitation, circumoral and peripheral paresthesias, carpopedal twitching, muscle weakness.

Thyroid Stimulating Hormone (TSH)

stimulates secretion from thyroid gland

increased in hypothyroidism (and low FT4)

decreased in hyperthyroidism (and high FT4)

FT4 - Thyroxine

FT4 is just a little part of the total thyroxine

FT4 is available to the tissues

FT4 is the metabolically active form of thyroxine

Hematocrit

The percent of the volume of whole blood that is composed of red blood cells

WBC differential count

percentages of different types of leukocytes in the blood

PT range

11-12.5 seconds

PTT (partial thromboplastin time)

25-35 seconds

aPTT

21.0-35.0 seconds

platelet count

150,000-400,000

BUN/Creatinine Ratio

10:1

clinical pathways

written tools that direct the tx of a specific group of patients according to their diagnosis

liver biopsy position

right side lying with pillow or small towel under puncture site for at least 3 hours

leg amputation position

elevate limb for only 24 hours, lay prone a couple of times a day

acute coronary syndrome

impairment of blood flow through the coronary arteries, leading to ischemia of the heart muscle

stable angina, unstable angina, variant angina

stable angina

Exertional onset

Prompt relief with nitroglycerin