Medsurg II exam 1

What are standard precautions?

• used for everyone

• apply to blood, all bodily fluids, secretions, non-intact skin, mucous membranes

• goal is to reduce risk of transmission of microorganisms

• used for ALL patients regardless of diagnosis or presumed infection

• hand hygiene before and after using gloves and after touching contaminated surfaces

• covering mouth/nose while sneezing/coughing

• routine disinfection

Donning PPE

• Gown, mask, goggles, gloves

Doffing PPE

• gloves, goggles, gown, mask

  • alphabetical order

Airborne precautions

• Required for TB, COVID w/ aerosolizing procedures, varicella, measles, disseminated herpes zoster

• N95 mask, or CAPR or PAPR

• place patient in single pt, negative pressure

• mask on patient during transportation

Droplet precautions

• Flu, COVID, respiratory droplets,

• surgical mask + eye protection

• single room, mask when moving

Neutropenic precautions

• patient protection

• no live plants or outside food

Contact Precations

• MRSA, VRE, infections with draining wounds

• Gown, gloves, eye protection if risk of splash, single use patient equipment\

• wash hands or hand sanitizer, wipes with purple tops

Contact-enteric

• C diff, norovirus

• Gown, gloves, eye protection if risk of splash, single use patient equipment

• wash hands with soap and water, bleach wipes

VRE

• vancomycin-resistant enterococci

• more virulent than MRSA

• survive on environmental surfaces for weeks

COVID meds

• remdesivir

  • watch for nausea and increased liver function

There is HF and pleural effusion, when drained the fluid is clear, pale yellow, protein poor

transudative effusion ; you have to treat the underlying cause (HF) so like diuretics

COPD smoker risk factors

• smoker over 40

• 10 packs per year

What is the time frame for exercise induced bronchospasm

• will start within 10 mins of exercise

• resolves within 60 mins of rest

Hospital aquired pneumonia

• starts after at least 2 weeks of a hospital stay

• 48 hours?

patient has hair where they need to operate what do you use

clippers NEVER razor

What bronchodilator has a small therapeutic index

theophyline

what is a sign of sepsis

new organ dysfunction

What should you do prior to a bronchoscopy

12 hours NPO, sedative to help calm

GOLD 3 COPD - 2 hospitalizations, triple therapy

LABA, LAMA, and ICS

What is the treatment for pneumonia in hospital

• IV abx, afebrile for 48-72 hours

IV cefazolin given, itchy hives

• allergic reaction

• related to penicillin allergy

Patient has HF and was given IV fluids

• watch out for fluid over load

• listen for lung sounds (crackles)

• watch Is and Os make sure enough is going out

Pt has TB, wants to go home, education

• encourage the patient to sleep alone and spend as much time outside as possible

• deemed noncommunicable after 2 negative cultures

Atypical pneumonia for adults

• mycoplasma pneumonia

  • has characteristics of both viral and bacterial pneumonia

  • common in adults under 40

what is thick blood called?

polycythemia

What can cause liver and lung damage

• Alpha-1 Antitrypsin deficiency- AATD

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What is direct observational therapy

• watching the people take a pill directly

Central line that prevents CLABSI

subclavian and jugular

what are the calcified granulomas caused by TB

• gohns lesion

What are SIRS criteria

Two or more of:

• Temperature > 38 C or < 36 C

• Heart rate > 90 bpm

• Respiratory rate >20/min or PaCO2 <32 mmHg

• WBC>12,000 or <4,000 or >10% bands

List the first-hour priority actions for suspected sepsis

• obtain blood cultures BEFORE abx

• administer broad-spectrum abx within 1 hour

• measure lactate levvel

• begin IV fluid resuscitation

List four evidence-based measures to prevent central line-associated bloodstream infections (CLABSIs).

1. Hand hygiene before line manipulation
2. Maximal sterile barrier precautions during insertion
3. Chlorhexidine skin antisepsis
4. Daily review of line necessity with prompt removal

What measures prevent catheter-associated urinary tract infections (CAUTIs)?

• Avoid unnecessary catheterization

• use aseptic insertion technique

• maintain a closed drainage system

• keep the collection bag below bladder level

• remove catheters promptly when no longer needed

How do atypical presentations of infection in older adults differ from typical signs?

• Older adults may present with subtle changes such as confusion, falls, decreased appetite

• functional decline

• fatigue rather than classic fever or elevated WBC

• Low-grade fever or absent fever is common.

What findings indicate progression to septic shock after initial fluid resuscitation?

Persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg AND lactate >2 mmol/L despite adequate fluid resuscitation

Which clients are at increased risk for sepsis?

• immunocompromised patients

• older adults

• those with chronic illness

• recent surgery/invasive procedures

• those with indwelling devices

Decolonization Protocol (Orthopedic/Cardiothoracic Surgery):

Intranasal mupirocin (twice daily) + chlorhexidine gluconate (CHG) bathing (daily) for up to 5 days to reduce Staphylococcus aureus colonization (both MSSA and MRSA)

Preoperative Antibiotic Prophylaxis:

Administer antibiotics 60 minutes before surgical incision and stop within 24 hours after surgery to reduce infection rates

Which clients are at highest risk for aspiration pneumonia when multiple risk factors are present?

Clients with problems swallowing, altered gag reflex, orogastric or NG tubes, and those requiring head-of-bed elevation below 30 degrees

Pneumonia Atypical Presentation in Older Adults:

Older adults often present with tachycardia, tachypnea, confusion, decreased appetite and functioning, but without fever or productive cough

Correct Sequence of Interventions (Pneumonia with Hypoxemia):

1. Oxygen therapy (treat hypoxemia first)

2. Specimen collection (obtain before antibiotics)

3. First antibiotic dose (administer promptly after specimen collection)

Treatment Failure Indicators (48-72 hours):

Persistent or worsening fever, hypoxemia, confusion, lack of improvement in respiratory rate or assessment findings, and failure to respond to therapy.

Opportunistic Pneumonia:

Infection of the lower respiratory tract in immunocompromised patients (HIV, malnutrition, chemotherapy, transplant). First-line treatment for Pneumocystis jiroveci pneumonia (PJP) is trimethoprim/sulfamethoxazole (IV or oral).

Sputum Collection for AFB:

Three consecutive sputum specimens collected at 8-24 hour intervals, with at least one early morning specimen 4. Sputum culture is the gold standard for TB diagnosis; initial microscopic examination checks for acid-fast bacilli (AFB)

Culture can take up to 6 weeks for definitive mycobacterial growth 4. For high suspicion cases, treatment starts while waiting for culture results

Four-Drug TB Therapy (Isoniazid, Rifampin, Pyrazinamide, Ethambutol):

Treatment consists of intensive phase followed by continuation phase 5. Nonadherence is a major factor in MDR-TB emergence and treatment failure 5. Directly observed therapy (DOT) involves providing drugs directly to patients and watching them swallow medications

For MDR-TB: sensitivity testing guides treatment; typically requires 5 drugs initially for 4-6 months, then at least 4 drugs for 18-24 months

Readiness to Resume Oral Intake After Bronchoscopy:

Do not allow patient to eat or drink until gag reflex returns (typically 2 hours post-procedure). Test by having patient sip small amount of water.

Immediate escalation needed for: hemoptysis (blood-streaked sputum expected in small amounts, but frank bleeding requires immediate action), dyspnea, decreased oxygen saturation, subcutaneous emphysema (especially after transbronchial biopsy - indicates pneumothorax), or chest pain.

Expected findings after bronchoscopy

Sore throat, hoarseness, blood-tinged sputum (small amounts).

Complications requiring escalation (bronchoscopy):

Hemorrhage, pneumothorax (after transbronchial biopsy - monitor for dyspnea, decreased breath sounds, chest pain), bronchospasm, laryngospasm.

Postoperative Atelectasis:

Collapsed, airless alveoli characterized by decreased or absent breath sounds and dullness to percussion over affected area 1. Most common cause is obstruction of small airways with secretions, especially in bed rest and postoperative patients

Pain control is critical because inadequate pain management prevents deep breathing, effective coughing, and mobility - all essential for lung expansion. Thoracotomy incisions are the most painful and require multimodal pain management

Prevention and treatment interventions: (atelectasis)

• Deep-breathing exercises

• Coughing

• Incentive spirometry

• Early mobility

Pleurisy

Sharp or stabbing pain during inspiration when inflamed pleura stretches; pleural friction rub heard over painful area; pain worsens with laughing/coughing; localized to portion of chest wall

Consolidation

Fluid-filled alveoli; dullness to percussion, increased tactile fremitus, bronchial breath sounds, crackles

Pleural Effusion

Fluid in pleural space; dullness to percussion, decreased/absent breath sounds, decreased tactile fremitus.

Relation to pneumonia course:

Pleurisy can accompany pneumonia when infection/inflammation involves the pleura

Asthma triad (AERD): triggers

Nasal polyps, asthma, and sensitivity to aspirin/NSAIDs

• must avoid all salicylic acid and NSAIDS

medications to screen and avoid

• β-blockers (oral like metoprolol or eye drops like timolol) - cause bronchospasm 12

• ACE inhibitors (lisinopril) - cause dry, hacking cough that worsens asthma 12

• Sulfite-containing preservatives - in eye solutions, IV corticosteroids, some inhaled bronchodilators 12

• Food/drug additives: Tartrazine (yellow dye no. 5), sulfiting agents in fruits, beer, wine, salad bars

mild/moderate asthma attack

Talks in phrases, prefers sitting, not agitated; RR increased, no accessory muscle use; HR 100-120 bpm; O₂ sat 90-95%; PEF >50% predicted

severe asthma

Talks in words, sits hunched forward, agitated; RR ≥30/min, accessory muscles in use; HR ≥120 bpm; O₂ sat <90%; PEF ≤50% predicted

life-threatening asthma

Drowsy, confused, or silent chest

Controllers (long-term): asthma

Inhaled corticosteroids, LABAs, leukotriene modifiers - prevent symptoms and maintain inflammation control

Relievers (rescue): asthma

Short-acting β₂-agonists (SABA) - treat acute symptoms

SABA overuse risks:

Regular SABA use (even 1-2 weeks) causes airway hyperresponsiveness, decreased bronchodilator effect, increased allergic response, and eosinophilia 4. Reliance on SABA alone leads to overuse, increased exacerbations, ED/hospital visits, and increased mortality

Three-Zone System (Traffic Light Pattern): - spirometry

GREEN ZONE: 80-100% of personal best 34

• Doing well: No cough, wheeze, chest tightness, or shortness of breath

• Can do usual activities

• Action: Continue regular daily controller medications 3

YELLOW ZONE: 50-80% of personal best 34

• Asthma is getting worse: Cough, wheeze, chest tightness, or shortness of breath

• Waking at night due to asthma

• Can do some, but not all usual activities

• Action: Use quick-relief medicine (rescue inhaler); if no improvement or symptoms persist, contact provider 3

RED ZONE: Below 50% of personal best 34

• Medical alert: Very short of breath, quick-relief medicines have not helped

• Cannot do usual activities

• Symptoms same or worse after 24 hours in yellow zone

• Action: Take rescue medication and go to ED or call 911 immediately

Oxygen Saturation Targets for COPD:

Goal is SaO₂ >90% during rest, sleep, and exertion or PaO₂ >60 mm Hg 1. For moderate to severe COPD, provider may accept SaO₂ or PaO₂ >88% based on patient condition 1. O₂ therapy is only treatment linked to improved survival in COPD

COPD Exacerbation Findings:

Sudden change in usual dyspnea, cough, and/or sputum (different from daily patterns) 4. Respiratory infections are common cause 4. Frequency increases as disease progresses (average 1-2 per year) 4.

Activate rapid response team when: Severe respiratory distress, declining mental status, inability to maintain adequate oxygenation despite therapy, signs of impending respiratory failure.

ABG Interpretation in COPD:

Early stages: Normal or slightly decreased PaO₂; normal or slightly increased PaCO₂ 23.

Stable/compensated COPD (chronic): Low-normal pH, high-normal or above-normal PaCO₂, high-normal bicarbonate 23. Indicates partially or fully compensated respiratory acidosis 23. In fully compensated state, kidneys conserve HCO₃⁻ to increase pH to within normal range 23.

Acute change: pH drops below normal with elevated PaCO₂ and inadequate bicarbonate compensation - indicates acute respiratory acidosis superimposed on chronic condition

What is Cor Pulmonale?

Right-sided heart failure resulting from pulmonary hypertension 12. It is a late manifestation of COPD 23. Once cor pulmonale develops, prognosis worsens 12. Not all COPD patients develop cor pulmonale

Primary cause: Constriction of pulmonary vessels from alveolar hypoxia