Med Surge Final

You can do this ;) -> see Exam 3 collection for Urologic, Renal, GI, and Nutrition

What are some medical interventions that can be done for Anaphylaxis?

-Administer Epinephrine, Benadryl, or a corticosteroid

What Nursing interventions should be made for a patient experiencing anaphylaxis?

-Maintain airway

-ABCs

-observe for edema/respiratory distress

-Prepare for intubation, IV fluids, and IV access

-Monitor vital signs

-Prepare patient and Family education

What are four manifestations of allergic rhinitis?

-sneezing

-runny nose

-nasal congestion

-itchy nose, throat, and eyes

What are common therapies for allergic rhinitis?

-avoidance therapy

-antihistamines (h1 receptor agonists)

-nasal sprays

What is the difference between first and second generation antihistamines?

First Gen:

-end in “amine” or “zine”

-side effects include: dry mouth, sedation, blurred vision, and urinary retention

Second Gen:

-end in “adine” or zine

-don’t cross the blood brain barrier so they are less sedating

How does a Nurse manage symptoms of a patient with a latex allergy?

-Remove latex from environment

-Medicate (mild: antihistamines, moderate: corticosteroids, severe: epinephrine)

-Monitor airways

-use latex free products

-place identifying band on patient and on sign on room

-document allergy

What Signs are associated with Stage 0 of HIV infection?

Too early for clinical signs

What signs are associated with Stage 1 of HIV infection?

-500 or greater cells/mm CD4 count

-CD4 % 26 or greater

-No aids defining conditions

What signs are associated with Stage 2 of HIV infection?

-CD4 Count between 200-499

-CD4 % 14-25

-No AIDs defining condition

What are signs associated with Stage 3 of HIV infection?

-CD4 count less than 200

-CD4 % less than 14

-Documentation of AIDS-defining condition

What signs are associated with the unknown stage of HIV infection?

-no data

-Documentation of AIDS-defining condition and no information on presence of AIDS-defining conditions

At what stage is the patient considered to have AIDS?

Stage 3

What cells does HIV primarily attack?

CD4 T-lymphocytes

(decreases immune system’s ability to fight infection)

What are common symptoms of acute retroviral syndrome?

-fever

-fatigue

-sore throat

-rash

-swollen lymph nodes

-night sweats

-flu-like symptoms

Why can HIV be dangerous even during the asymptomatic stage?

-Patient may have little to no symptoms

-virus is still actively replicating

-CD4 cells continue to decrease

-Patient can still transmit HIV to others

What symptoms are common during the chronic symptomatic stage?

-weight loss

-persistent fever

-chronic fever

-fatigue

-oral thrush

-swollen lymph nodes

-recurrent infections

-opportunistic infections begin to appear

What is the significance of a CD4 count below 200?

-indicates stage 3 HIV

-patient is diagnosed with AIDS

-Immune system is severely weakened

-high risk for opportunistic infections

What are opportunistic infections seen in AIDS?

-Pnemocystis pneumonia

-tuberculosis

-candidiasis

-kaposi sarcoma

-cytomegalovirus infection

What is the main goal of ART?

-Decrease viral replication

-delay disease progression

-preserve CD4 count

-prevent opportunistic infections

-improve survival and quality of life

Why is HIV called a retrovirus?

-It uses reverse transcriptase enzyme

- Converts viral RNA into DNA

-viral DNA inserts into the host cell DNA

-Virus then continues replicating

Is ART recommended for all HIV patients?

yes

How does ART treatment work?

Medicating using 3 active drugs from two or more drug classes

What are side effects of ART therapy medications?

-Lipoatrophy (loss of fat in cheeks, temples, or extremities)

-Lipodystrophy (increase abdominal size)

-Hepatotoxicity

-Neuropathy

-Osteoporosis

-Rashes

-Hyperlipidemia

-High cholesterol

-Nephrotoxicity

-Kidney stones

-GI irritation

-Anemia

What is the most important part of ART therapy?

medication adherence

What are the 7 classes of ART therapy medications?

-NRTIs

-NNRTIs

-Protease Inhibitors

-INSTIs

-Fusion Inhibitors

-CCR5 Antagonists

-Post Attachment Inhibitors

Regular lab work is necessary for ART treatment, what labs should be closely monitored?

-CD4 count

-viral load

-liver function

-kidney function

What precautions do HIV patients need to take to stop the spread of infection?

-Use condoms and protection for intercourse

-Don’t share needles

-inform all sexual partners

-don’t donate blood

-have sexual partners begin PrEP before exposure

-PEP for emergency exposure (start within 72 hours)

-Avoid sick individuals

-hand hygiene

What Nursing interventions should be taken when addressing the social care of a HIV patient?

-Depression and isolation are common

-encourage counseling/support groups

-address stigma and coping needs

What are the three levels of cancer prevention?

primary, secondary, and tertiary

What is primary cancer prevention?

Goal: prevent cancer from developing

Ex:

-smoking cessation

-vaccinations

-etc.

What is secondary cancer prevention?

Goal: early detection and screening

Ex:

-mammogram

-colonoscopy

-breast self exam

What is tertiary cancer prevention?

Goal: Preventing complications, reoccurrence, and worsening disease

Ex:

-chemotherapy

-radiation therapy

-surgery

-palliative care

What are the two main types of Radiation therapy for cancer?

External beam radiation

-brain tumors

Internal radiation (brachytherapy)

-breast, cervical, uterine, and prostate cancer

What should the nurse keep in mind about radiation toxicities?

-Localized

Side Effects: skin irritation, skin peeling/flaking, wet desquamation (breakdown with damage), hair loss, GI irritation, fatigue, low blood count

What Nursing Management Considerations should be kept in mind for the patient receiving radiation treatment for cancer?

-don’t scrub skin

-no lotions, heating or ice packs

-protect skin from su exposure

-fatigue and gi upset is common

-encourage foods high in protein and calories

-avoid pregnant women while radiation is active

-ALARA

-keep distance and shield as needed

-keep away from sick people

-fever is medical emergency

How does Chemo work?

-kills rapidly dividing cells (cancer cells but also kills other cells)

What happens if a vesicant medication leaks into the surrounding tissue (extravasation)?

-severe tissue damage and necrosis

Signs:

-pain

-burning

-swelling

-slowed infusion

-no blood return

Priority Nursing Action:

-stop infusion immediately

-aspirate drug

-notify provider

-administer antidote

Signs and Priorities for Hypersensitivity Reactions during Chemo

Signs:

-rash

-itching

-flushing

-wheezing

-dyspnea

-hypotension

-anaphylaxis

Priorities:

-Stop infusion

-Maintain airway

-administer emergency medication

-notify provider

What are major toxicities associated with chemotherapy?

-bone marrow suppression (most common) causing decreased WBC, RBC, and platelets (infection, anemia, and bleeding risk)

-GI irritation and lack of appetite

-Mouth inflammation

-Neurologic effects (peripheral neuropathy, numbness cognitive impairment)

-fatigue

-alopecia

What Nursing Management Priorities should be considered with Chemo?

-infection prevention

-fever monitoring

-bleeding precautions (soft toothbrush, electric razor, monitor bruising and bleeding)

-avoid alcohol based mouthwash

-avoid spicy/acidic foods

-support body image concerns

-include family support

What are manifestations of dislocation?

-severe pain

-loss of movement

-deformity

-selling

-limb shortening

-vascular damage

How does the nurse manage a dislocation?

-immobilize immediately

-reduction (put joint back in place)

-surgery

-pain management

-neurovascular assessment before and after reduction

What are the first priorities for managing a fracture?

-immobilize fracture

-control bleeding

-assess vascular status

-pain control

What is the difference between an open and closed reduction?

open = surgery to align bone

closed = mechanical alignment

What is the Nursing priorities for a patient with an external fixation for a fracture?

-pin site care

-monitor for infection

-neurovascular check

-prevent pin loosening

-Don’t adjust clamps

What is the nursing priority for an internal fixation for a fracture?

-infection prevention

-pain management

-mobility support

-DVT prevention

-neurovascular assesment

What is the purpose of traction?

-reducing pain and spasms

-immobiliing fracture

-maintaining alignment

What nursing priorities should be kept in mind when applying skin traction?

-skin assessment

-prevent skin breakdown

-let weights hang freely

-Do not move weights

-maintain body alignment

What nursing considerations should be made for a patient with skeletal traction?

-pin site care

-infection prevention

-neurovascular assessment

-let weights hang freely

-never remove wights

What should be assessed before and after cast, traction, surgery, and reduction?

-pain

-pallor

-pulse

-paresthesia (pin and needles sensation)

-paralysis

-pressure

What nursing considerations need to be applied BEFORE a cast is placed for a fracture?

-skin assessment

-neurovascular assessment

-remove jewelry

-explain procedure

What nursing considerations should be applied AFTER cast placement for a fracture?

-frequent neurovascular checks (every 1-2 hours for first 24 hours)

-ice for selling

-assess for pain/infection

-encourage fluids and fiber

What should the nurse tell the patient with the cast to report?

-increased pain

-numbness

-tingling

-foul odor

-drainage

-fever

-cold fingers/toes with pallor

What is compartment syndrome?

medical emergency caused by a complication of a fracture in which increased pressure inside muscle cuts off blood flow

What are manifestations of compartment syndrome?

-severe pain

-pallor

-paresthesia

-paralysis

-pulselessness

How do you treat compartment syndrome?

Bivalve cast or emergency fasciotomy (cutting connective tissue to relieve muscle pressure)

Why does VTE (DVT/PE) happen after fractures?

immobility + trauma + hyper-coagulability

How do you prevent VTEs?

-early ambulation

-SCDs

-anticoagulants

-leg exercises

-hydration

What are manifestations of hip fractures?

-severe hip/groin pain

-inability to bear weight

-limited movement

-affected leg is shortened and externally rotated

What is the medical management for a hip fracture?

-traction

-surgery

What is the proper pre-op nursing care for a hip fracture?

-pain management

-neurovascular checks

-maintain alignment

-prevent skin breakdown

-DVT prevention

-pulmonary hygiene

What is the proper post-op nursing management of a hip fracture?

-neurovascular assessment

-pain control

-dressing monitoring

-early ambulation

-DVT prevention

-prevent dislocation

What teaching shoud the patient recieve to prevent hip dislocation after hip replacement surgery?

-do not cross legs, bend hips more than 90 degrees, rotate leg, sit in low chairs, bend far forward

-use abduction pillow and elevated chairs and toilet seats

What is the proper Pre-Op Management for a patient preparing for an amputation?

-patient education for reason for surgery, prosthesis, and psychological support

-mobility training

-strengthening exercises

What is the proper post-op management for a patient that has received an amputation?

-monitor:

• vital signs

• surgical dressing

• bleeding

• infection

• pain

-apply compression dressing

-do NOT keep pillow under residual limb

-do NOT keep hip/knee flexed

-enourage ROM exercises

-Prone positioning

-monitor for phantom pains and sensations

-support body image

What is the proper nursing management for Osteomyelitis?

-prevention

-aggressive infection control

-pain control

-elevation

-ROM

-patient education

-immobilization

What are the risk factors for Osteoporosis?

-women

-old age

-postmenopause

-low calcium

-low vitamin D

-smoking

-alcohol

-sedentary lifestyle

-steroid use

What are manifestations of osteoporosis?

-vertebral fractures

-hip fractures

-height loss

-kyphosis

-back pain

What is the medical management for osteoporosis?

-calcium and vitamin D supplements

-encourage weght-bearing exercise

-avoid smoking and excess alcohol

What medications are used to treat osteoporosis?

Biphosphonates: Alendronate, Risedronate, supplements

What teaching should the nurse give patients taking Bisphosphonates?

Take first thing in the morning with a full glass of water, stay upright for 30 min, no food immediately after to prevent esophageal irritation

What Nursing interventions should be applied for a patient with osteoporosis?

-fall prevention

-pain control

-promote mobility

-prevent injury

-encourage fiber and fluids

What is the difference between osteoarthritis and Rheumatoid arthritis?

OA

-degenerative

-non-inflammatory

-asymmetric

-worse with activity

-short stiffness

-weight-bearing joints

RA

-autoimmune

-inflammatory

-symmetric

-long stiffness

-small joints first

What are manifestations of SLE?

-fatigue

-fever

-joint pain

-butterfly (malar) rash

-oral ulcers

-photosensitivity

-hair loss

-kidney problems

-chest pain

How is SLE diagnosed?

-history

-full physical exam

-blood test

What medical interventions are appropriate for a patient with SLE?

-prevent organ damage

-medicate (corticosteroids, immunosuppressants, etc.)

-Avoid triggers (sun exposure, stress, infection, etc.)

-Routine screening

What causes gout?

hyperuricemia (too much uric acid)

What are clinical manifestations of gout?

-Swollen, red, infected, big toe
-sudden severe pain

-redness

-swelling

-tenderness

-kidney stones

How do you manage and prevent gout?

Treat with medications:

-colchicine

-NSAIDs

-Corticosteroids

-Allopurinol (NOT for acute attacks)

-Febuxostat

Prevent by:

Encourage:

-low purine diet

-weight loss

-hydration

-limit alcohol

-medication adherence

Avoid:

-red meat

-shellfish

-alcohol

-organ meats

What are manifestations of increased intracranial pressure?

-change in level of consciousness

-change in vital signs (low HR, high BP, altered resp.)

-pupillary changes

-papilledema

-impaired eye movement

-headache

-decreased motor function

-vomiting

What assessments should be made buy the nurse when assessing a patient with intracranial pressure?

-mental status

-cranial nerve function

-cerebellar function (balance and coordination)

-reflexes

-motor and sensory function

-Glasgow coma scale

-monitor for seizures

-maintain oxygenation

-medicate (mannitol and steroids)

What are manifestations of meningitis?

-headache

-fever

-nausea and vomiting

-nuchal(neck) rigidity

-positive Kernig sign (pain with straightening knee when hip is at 90 degrees)

-positive Brudzinski sign (involuntary knee/hip flexion with neck flexion)

-increased intracranial pressure

-seizures

-coma

How do you dx meningitis?

-CT scan

-lumbar puncture with cerebrospinal fluid analysis

How does the nurse manage meningitis?

-RAPID dx and treatment is CRUCIAL

prevention

-meningococcal vaccine

Management:

-antibiotics

-dexamethasone

-droplet precautions

-rest in a dark quiet room

-antipyretics for fever

-monitor nuero status and vital signs

-monitor daily wights, electrolytes, urine, and I’s and O’s

-keep door closed

What are the 2 types of ischemic stroke?

thrombotic and embolic

What are the 2 different types of hemorrhagic stroke?

intracerebral hemorrhage and subarachnoid hemorrhage (aneurysm rupture)

What is the difference between thrombotic and embolic stoke?

T: form in the brain artery

E: emboli forms somewhere else in the body and travels to the brains where it is lodged in the artery

What is a transient ischemic attack?

-a neurologic deficit typically lasting 1-2 hours

-result of temporary ischemia to a part of the brain

-warning of impending stroke

What are clinical manifestations of ischemic stroke?

-Hemiplegia

-hemiparesis

-akinesis

-affect changes

-intellectual dysfunction'

-incontinence

-aphasia/dysphasia

-dysarthria

How do you prevent ischemic stroke?

-health maintenience

-modifiable risk factors

-pharmacologics

What is the medical management for ischemic stroke?

-Fibrinolytic Therapy (tPA)

-Aspirin/Anti-Coagulants

-Close BP control

-Surgery

What is the medical management for hemorrhagic stroke?

-Hypertension treatment and prevention

-Bed rest

-sedation

-DO NOT USE anticoagulants

-seizure prophylaxis

-surgery

What actions should you encourage in a post-op patient to prevent complications during recovery such as pnemonia?

-coughing (if no hernia)

-deep breathing

--incentive spirometry

-splint when coughing

-turn every 1-2 hours

-early ambulation

What usually causes the post-op complication hypotension?

Fluid/blood loss during procedure

What do you do for the patient 1st when they arrive in the PACU?

-attatch ekg monitor

-apply O2 sensor

Who is the only person that can push the button for pain relief on a PCA?

the patient

What should patient output be at minimum?

0.5/kg/hr

In patients with ITP should have a minimum of how many platelets?

30,000

What are signs of decreased cardiac output?

-pallor

-decreased blood pressure

-increased respiratory rate

-weak pulse

What patient teaching needs to accompany giving Benadryl?

-CNS effects

-do not operate heavy machinery