Med-Surg Final Exam Master Review Guide

Respiratory Pathophysiology: Atelectasis and Pneumonia

Atelectasis

• Definition: Partial or complete collapse of the alveoli (lung tissue).

• Etiology: Frequently observed in POST-OP patients due to immobility and shallow breathing.

• Clinical Manifestations:

  • Decreased or absent breath sounds, particularly in the lower lobes.

  • Fine, late inspiratory crackles.

  • Shortness of breath ($SOB$).

  • Increased respiratory rate ($RR$).

• Nursing Actions and Prevention:

  • Implementation of deep breathing and coughing (DB&C) exercises.

  • Incentive spirometry ($IS$) usage set to frequencies of $q1h$ while the patient is awake.

  • Early ambulation: Getting the patient out of bed ($OOB$) to a chair as soon as possible.

  • Hydration: Post-op patients lose electrolytes; encourage fluid intake. Large surgeries may require ordered Gatorade or specialized electrolyte drinks.

Pneumonia

• Pathophysiology: An infection causing inflammation of the alveoli, which subsequently fill with fluid or pus.

• Clinical Manifestations:

  • Audible crackles on auscultation.

  • Fever leading to secondary tachycardia (increased heart rate).

  • Increased metabolic rate resulting in elevated $O_2$ demand.

  • Leukocytosis (elevated White Blood Cell count).

  • Elderly Considerations: Geriatric patients may present with confusion and agitation rather than classic symptoms like fever or cough.

• Nursing Interventions:

  • Prioritize assessments using the $ABC$ (Airway, Breathing, Circulation) framework.

  • Perform thorough lung auscultation and clinical monitoring of vital signs.

  • Critical Sequence: Always obtain a sputum culture before initiating antibiotic therapy.

  • Administer antibiotics and supplemental Oxygen ($O_2$) as ordered to maintain oxygen saturation levels.

Obstructive Pulmonary Diseases: COPD and Asthma

Chronic Obstructive Pulmonary Disease (COPD)

• Key Features: Characterized by chronic air trapping and $CO_2$ retention.

• Acid-Base Profile: Patients are chronically in a state of Respiratory Acidosis (low pH and high $CO_2$).

• Physical Findings: Barrel chest, which is a clinical sign of chronic hyperinflation and trapped air.

• Hypoxic Drive: COPD patients rely on relatively low oxygen levels to trigger the respiratory center; over-oxygenation must be avoided.

• Oxygen Administration Guidelines:

  • Start with low flow: Typically $1 \text{ -- } 2\,L/NC$ or $24 \text{ -- } 28\%$ via a Venturi mask.

  • Venturi Mask: Recognized as the most precise and accurate oxygen delivery device available.

• Ventilation Support: Non-invasive ventilation such as $BiPAP$ or $CPAP$ is used for moderate exacerbations.

• Pursed-Lip Breathing: A technique taught to help patients expel trapped $CO_2$ and keep airways open for longer durations.

Asthma

• Definition: A reversible airway obstruction caused by bronchospasm, excessive mucus production, and inflammation.

• Clinical Presentation:

  • Wheezing (characteristic high-pitched expiratory sound).

  • Difficulty completing full sentences due to dyspnea.

  • Use of accessory muscles for breathing.

  • Adventitious breath sounds audible on both inspiration and expiration during an acute attack.

• Critical Medication Sequence:

  1. Bronchodilator (Rescue Inhaler) FIRST: Used to open the airway.

  2. Steroid Inhaler SECOND: Administered after the airway is dilated to allow the steroid to penetrate deeper into the pulmonary tissue.

• Contraindications: Beta-blockers are contraindicated in patients with asthma as they can induce bronchospasm.

Pleural Space Disorders and Chest Tube Management

Pneumothorax and Hemothorax

• Pneumothorax: Presence of air in the pleural space, leading to lung collapse.

  • Tension Pneumothorax: Characterized by tracheal deviation away from the affected side.

• Hemothorax: Presence of blood in the pleural space, leading to lung collapse and potential blood loss.

  • Clinical Signs: Hypotension and tachycardia.

• General Treatment: Insertion of a chest tube.

• Subcutaneous (SubQ) Emphysema: A complication where air enters the tissue under the skin, feeling like "Rice Krispies" or crepitus upon palpation.

Chest Tube Chamber Assessment

• Suction Chamber: Requires constant, gentle bubbling to indicate effective suction.

• Water Seal Chamber: Should demonstrate tidaling (fluid rising on inspiration and falling on expiration).

  • Absence of tidaling suggests a blocked tube or full lung re-expansion.

  • Continuous bubbling indicates an air leak within the system.

Pleural Effusion

• Definition: Abnormal fluid accumulation in the space between the lung and the chest wall.

• Types:

  • Transudative (Low Protein): Commonly caused by Heart Failure, cirrhosis, or nephrotic syndrome; fluid leaks due to pressure changes.

  • Exudative (High Protein): Caused by pneumonia, malignancy, Pulmonary Embolism ($PE$), or Tuberculosis ($TB$); fluid leaks due to inflammation/infection.

• Signs/Symptoms: Dyspnea, decreased or absent breath sounds on the affected side, dullness to percussion, chest heaviness, pleuritic chest pain, and decreased $O_2$ saturation.

• Management:

  • Treat the underlying cause.

  • Diuretics (e.g., Lasix) for transudative/HF-related effusions (Monitor Potassium ($K^+$) levels post-administration).

  • Thoracentesis for large or symptomatic effusions.

Thoracentesis Procedure

• Positioning: Patient sits upright, leaning forward over an overbed table to widen intercostal spaces.

• Post-Procedure Priority:

  • Monitor for pneumothorax (most common complication), bleeding, and re-expansion pulmonary edema.

  • Obtain a post-procedure chest X-ray to confirm the absence of pneumothorax.

  • Closely monitor respiratory status and $O_2$ saturation.

Advanced Respiratory Conditions and ABG Interpretation

Pulmonary Edema and Embolism

• Pulmonary Edema: Fluid backup into the lungs, usually from left-sided heart failure.

  • Classic Sign: Pink, frothy sputum.

  • Treatment: Diuretics (Lasix), oxygen, and High Fowler’s positioning.

• Pulmonary Embolism (PE): A blood clot (from $DVT$ or $A-Fib$) blocking pulmonary vasculature.

  • Signs: Sudden onset dyspnea, decreased $O_2$ sat, chest pain, cyanosis, and tachycardia (No ST elevation).

  • Treatment: Supplemental oxygen and Heparin anticoagulation.

Bronchoscopy and COVID-19

• Bronchoscopy Pre/Post-Op: Post-procedure, assess for the return of the gag reflex before allowing oral intake. Monitor for laryngospasm and bleeding.

• COVID-19: Fluid fills the alveoli; prone positioning is utilized to improve oxygenation. Requires droplet precautions.

ABG Interpretation (ROME Mnemonic)

• Respiratory Opposite: pH and $CO_2$ move in opposite directions.

• Metabolic Equal: pH and $HCO_3$ move in the same direction.

• Normal Values:

  • pH: $7.35 \text{ -- } 7.45$

  • $CO_2$: $35 \text{ -- } 45\,mmHg$

  • $HCO_3$: $22 \text{ -- } 26\,mEq/L$

  • $O_2 \text{ Sat}$: $95 \text{ -- } 100\%$

Cardiovascular System: Myocardial Infarction ($MI$)

Pathophysiology and Complications

• Mechanism: Obstruction of coronary arteries leading to muscle ischemia and infarction.

• Complications:

  • Arrhythmias (most common).

  • Left ventricular failure and cardiogenic shock.

  • Papillary muscle rupture leading to acute mitral regurgitation.

  • Ventricular arrhythmias ($V-tach, V-fib$).

Diagnostic Markers and EKG Changes

• Cardiac Markers:

  • Troponin: The hallmark, most specific marker. Rises in $3 \text{ -- } 6\,hours$, peaks at $24\,hours$.

  • CPK-MB: Rises in $4 \text{ -- } 8\,hours$, normalizes by $72\,hours$.

  • Myoglobin: Earliest marker ($1 \text{ -- } 3\,hours$), though non-specific.

  • BNP: Indicates heart failure or fluid overload.

• EKG Changes:

  • ST Elevation: Damage/Infarction ($STEMI$).

  • ST Depression: Ischemia/Angina.

  • T-wave inversion: Older infarct.

Immediate Nursing Actions (MONA Protocol)

• Priority Reality: In clinical practice, Nitroglycerin is usually given BEFORE Morphine.

• Stepwise Order:

  1. Obtain IV access immediately.

  2. Provide $O_2$ supplementation.

  3. Administer Nitroglycerin ($SL$) $x3$, spaced $5\,minutes$ apart.

  4. Administer Aspirin ($antiplatelet$).

  5. Administer Morphine for unrelieved pain (reduces pain and preload).

  6. Perform a 12-lead EKG.

  7. Maintain NPO status.

  8. Start Heparin (prevents further clotting; does NOT dissolve existing clots).

Heart Failure and Angina Profiles

Angina: Stable vs. Unstable

• Stable: Predictable; occurs with exertion; relieved by rest or one Nitroglycerin dose.

• Unstable: Unpredictable; occurs at REST; new-onset or changing pattern; considered a medical emergency.

Heart Failure ($HF$)

• Hallmark Lab: BNP < 100\,pg/mL is normal; elevations indicate fluid overload.

• Left-Sided (Pulmonary): Blood backs up into pulmonary circulation. Symptoms include crackles, dyspnea, pink frothy sputum, and orthopnea.

• Right-sided (Systemic): Blood backs up into systemic circulation. Symptoms include Jugular Vein Distension ($JVD$), peripheral edema, hepatomegaly, and ascites.

• Auscultation: $S3$ indicates fluid overload/heart failure; $S4$ indicates hypertension ($HTN$).

Hypertension and Vascular Disorders

Hypertensive Crisis

• Threshold: Systolic > 210\,mmHg or Diastolic > 101\,mmHg.

• Treatment: Administer Nitroprusside. Aim to reduce Blood Pressure ($BP$) by $25\%$ within the first hour; do not drop too rapidly.

PAD vs. PVD

• Peripheral Arterial Disease (PAD): Pale, cold extremities; weak pulses; intermittent claudication (hallmark pain with walking); dry ulcers; dependent rubor.

• Peripheral Venous Disease (PVD): Edematous, normal temperature; pulses present; aching pain relieved by elevation; pitting edema; wet, weeping ulcers.

EKG Rhythms and Clinical Interventions

• A-Fib: No P-waves, irregularly irregular. High risk for stroke. Treat with Heparin and Cardioversion if symptomatic.

• Bradycardia: HR < 60\,bpm. Symptomatic treatment is Atropine.

• Asystole: Flatline. Perform CPR and Epinephrine. DO NOT DEFIBRILLATE.

• V-Tach / V-Fib: Lethal rhythms. If V-Tach has a pulse, cardiovert. If pulseless V-Tach or V-Fib, DEFIBRILLATE IMMEDIATELY.

Cardiac and Neuro-Clinical Procedures

• Pacemaker: Spike appears before the QRS complex. If spike is absent post-op, check for disconnected leads.

• Cardiac Cath Lab: Priority is to check the most distal pedal pulse first. Post-stent therapy involves Plavix (clopidogrel) and Aspirin.

• CABG Complication: Cardiac Tamponade (Beck’s Triad: Hypotension, Muffled Heart Sounds, $JVD$).

• Arterial Line: Always perform an Allen’s Test first.

• Valvular Disease: Murmurs are present. Stenosis is a stiff valve; Regurgitation is a leaky valve.

Electrolyte Imbalances and Management

Potassium ($K^+$) ($3.5 \text{ -- } 5.0\,mEq/L$)

• Hypokalemia: Caused by Lasix or GI losses. Causes muscle weakness and arrhythmias. Give IVPB slowly; NEVER IV Push.

• Hyperkalemia: Caused by renal failure. Signs: Peaked T-waves. Protocol: 1. Calcium Gluconate (cardioprotective), 2. Insulin + D50, 3. Kayexalate.

Sodium ($Na^+$) ($135 \text{ -- } 145\,mEq/L$)

• Hyponatremia: Confusion, seizures, coma. Restrict fluid.

• Hypernatremia: Dehydration, bounding pulses, intense thirst. Give oral fluids or $0.45\%\,NS$ slowly.

Calcium ($Ca^{2+}$) ($8.5 \text{ -- } 10.5\,mg/dL$)

• Hypocalcemia: Chvostek sign (cheek tap) and Trousseau sign (BP cuff hand spasm). Risk of laryngospasm.

• Hypercalcemia: Bone pain, stones, constipation. Risk of respiratory arrest.

Gastrointestinal and Endocrine Disorders

• Ulcers: Gastric (pain WITH eating, weight loss) vs. Duodenal (pain RELIEVED by eating).

• Cirrhosis: Hepatic Encephalopathy (High Ammonia) treated with Lactulose (therapeutic diarrhea).

• Hepatitis: A (Fecal-Oral), B (Body fluids/Blood), C (Blood/Transfusion).

• Diabetes: Type 1 (No insulin, prone to DKA) vs. Type 2 (Insulin resistance, prone to HHS).

• Diabetes Sick Day Rules: NEVER skip insulin; blood sugar rises with infection.

• Thyroid Storm: Emergency hyperthyroidism. High fever, tachycardia. Treat with PTU FIRST, then Beta-blockers, then Iodine solution.

• Addisonian Crisis: Severe hypotension/circulatory shock. Occurs from abrupt steroid cessation.

• SIADH vs. DI: SIADH (Excess ADH, Hyponatremia, Fluid retention, High Urine Specific Gravity); DI (Lack of ADH, Hypernatremia, Excess urination, Low Urine Specific Gravity).

Neurological Emergencies and Conditions

• Monroe-Kellie Hypothesis: Rigid skull space requires compensation between Blood, CSF, and Brain tissue.

• Increased ICP: Early sign is Altered LOC. Late sign is Cushing’s Triad (Bradycardia, Bradypnea, Widened Pulse Pressure). Treat with Mannitol.

• Stroke: Perform non-contrast CT FIRST. Ischemic strokes get tPA within $3 \text{ -- } 4.5\,hours$. Hemorrhagic strokes must never receive tPA.

• Meningitis: Bacterial (Cloudy CSF, Low Glucose, High Protein) vs. Viral (Clear CSF, Normal Glucose). Droplet precautions required.

• Glasgow Coma Scale (GCS): Max $15$, Min $3$. If $GCS \leq 8$, the patient is comatose and requires intubation consideration.

• Parkinson's: Dopamine depletion. Pill-rolling tremor, shuffling gait. Major fall risk. Treated with Sinemet (Levodopa/Carbidopa).

• Seizure Safety: Lateral position, clear environment, do not insert anything into the mouth, time the seizure.