Med-Surg Final Exam Study Guide

# Traction and Orthopedic Management

Traction is the application of a pulling force to promote and maintain skeletal alignment.
Therapeutic Effects (Tx): Primarily used to decrease muscle spasms and pain, realign bone fractures (fx), and correct or prevent deformities.
Principles of Traction: Weights are to hang freely at all times and must never be removed. Ropes must remain unobstructed. Traction equipment is placed by a Physical Therapist (PT). Nurses and patients must never remove weights or interfere with the traction setup.
Two Main Types of Traction:

Skeletal Traction: Involves screws inserted directly into the bone. Used for longer durations. Weight limit ranges from $25-40\,lb$ .

Pin Site Care: Assess sites for signs of infection, such as redness streaking up the extremity or purulent drainage at the pin site.
Complications: Related primarily to immobility, including atelectasis, pneumonia, constipation, urinary stasis (increasing risk for Urinary Tract Infection [UTI]), infection, and Venous Thromboembolism (VTE).

Skin Traction: Used primarily to decrease muscle spasms. Utilizes a Velcro boot, belt, or halter. Weight limit is significantly lower, between $5-10\,lb$ .

Management (MGMT): Avoid wrinkling or slipping of the traction bandage. Patients should shift positions but must not turn side to side.
General Nursing Measures for Traction:
Any form of traction requires the use of a trapeze bar to facilitate patient movement.
Assess skin for breakdown every $8$ hours or once per shift.
Assess pin sites: Normal/expected findings include crustiness with serosanguineous drainage and minimal redness.
Abnormal findings (not expected): Significant blood, redness extending up the leg, purulent drainage, or a foul odor. If present, clean the wound with saline or chlorhexidine (CHG), culture the wound, and contact the physician for an order.
Neurovascular Checks: Evaluate capillary refill, color of toes, ability to wiggle toes, and distal pulses.
Pain and General Assessment: Monitor hourly during rounds. Monitor for Deep Vein Thrombosis (DVT); the patient may be prescribed enoxaparin prophylaxis.

Osteoporosis Treatment and Prevention

Definition: Characterized by decreased bone mass, deterioration of the bone matrix, and diminished bone strength, leading to notable shrinking.
Primary Demographics: Postmenopausal women are most affected.
Risk Factors: Rheumatoid Arthritis (RA), sedentary lifestyle, alcohol (ETOH) and tobacco use, corticosteroid use, family history, previous history of fractures, Diabetes Mellitus (DM), inadequate Calcium and Vitamin D intake, low Body Mass Index (BMI), small-framed individuals (particularly Asian and Caucasian), malabsorption issues, and men over the age of $70$ .
Prevention: Nutrition, appropriate diet, supplements, cessation of smoking and ETOH consumption, weight loss, weight-bearing exercise (such as walking), and Bone Mineral Density (BMD) testing.
Education: Increase Calcium and Vitamin D in the diet. Perform $20-30$ minutes of low-weight-bearing exercises, such as walking or swimming.
Medication: Bisphosphonates (alendronate, ibandronate, risedronate, zoledronic acid).
Mechanism of Action (MOA): Inhibit osteoclasts, leading to decreased bone loss and increased bone mass.
Education: Administer on an empty stomach in the morning (AM). The patient must sit upright for $30$ minutes after administration. A dental exam is required prior to beginning therapy. Monitor serum creatinine levels if the medication is administered via IV.

Bone Fractures and Related Complications

Definition: A complete or incomplete disruption or continuity of bone structure, defined according to its specific type and extent.
Infection Risk: Compound fractures (where the bone opens through the skin) carry a high risk for infection.
Compartment Syndrome: A medical emergency involving increased pressure and decreased circulation within a muscle compartment.
Pathophysiology: Caused by an increase in compartment volume (edema, bleeding), a decrease in compartment size (restrictive cast), or both.
Signs and Symptoms (S/S): Edema, cyanosis, tingling, numbness, paresthesia, and pain that is unrelieved by medications.
Treatment (Tx): Fasciotomy.
Fat Emboli: A condition where fat travels through the blood to organs, causing blockages. This is most common after trauma or a break in a large bone, such as the femur or pelvis.
Signs and Symptoms (S/S): Decreased $O_2$ saturation, dyspnea, tachypnea, tachycardia, chest pain (CP), low-grade fever, crackles, and a petechial rash on the upper torso.
Treatment (Tx): Bed rest (BR), oxygen ( $O_2$ ), IV fluids (IVF), possible steroid administration, fracture immobilization, frequent vital sign checks, and raising the Head of Bed (HOB).

Cerebrovascular Accidents (Strokes)

Definition: A medical emergency occurring when blood flow to part of the brain is blocked (ischemic) or a blood vessel bursts (hemorrhagic), preventing oxygen and nutrients from reaching brain tissue.
Nursing Monitoring: Both types require neurological checks every $1$ hour.
Ischemic Stroke: Disruption of cerebral blood flow caused by an obstructed vessel.
Causes: Large artery thrombosis, small penetrating artery thrombosis, cardiogenic embolus, or cryptogenic causes.
Signs and Symptoms (S/S): Numbness/weakness on one side of the face or body, confusion or decreased mental status, difficulty speaking or understanding speech, difficulty walking, dizziness, loss of balance, or a sudden severe headache.
Diagnosis (Dx): Any sudden neurological changes must be assessed. Identify one-sided signs and rule out similar pathologies like hypoglycemia.
Thrombolytic Therapy (tPa) Candidacy: Determined by the "time of last known well." Treatment must begin within $4.5$ hours of onset or within $45$ minutes of arrival to the Emergency Department.
tPa Specific Requirements: Patient must be $\ge 18$ years old, Platelets > $100,000$ , no signs of endocarditis, no trauma, brain surgery, or stroke within the last $3$ months, no enoxaparin within $24$ hours, PT < $15$ seconds, and INR < $1.7$ .
tPa Contraindications: Recent bleeding, recent surgery, or low platelet counts.
Diagnostics: CT scan (priority, within $25$ minutes of ED arrival), MRI/MRA, transcranial doppler, Transesophageal Echocardiogram (TEE), EKG, and carotid ultrasound (US).
Prevention: Smoking cessation, regular exercise, healthy weight/diet/blood pressure, low-dose aspirin (ASA), and surgical procedures (e.g., ablation for Afib).
Hemorrhagic Stroke: Bleeding into brain tissue, ventricles, or the subarachnoid space. Caused by intracerebral rupture of small vessels (related to HTN) or subarachnoid rupture of an aneurysm.
Signs and Symptoms (S/S): Severe, sudden headache ("worst headache of life"), N/V, decreased Level of Consciousness (LOC), and seizures.
Diagnostics: CT, MRI, and Lumbar Puncture (LP) (only if ICP is not increased and CT is negative).
Prevention: Management of Hypertension (HTN), cessation of smoking, and reduction/cessation of alcohol consumption.
Complications: Hematoma expansion, rebleeding, cerebral vasospasm, and acute hydrocephalus.
Management (MGMT): Bed rest (BR), antiseizure medications, analgesics, antipyretics, Sequential Compression Devices (SCDs), and possible craniotomy.
Perfusion Considerations: Frequent neuro checks via the NIH scale, aneurysm precautions, and Deep Vein Thrombosis (DVT) prevention.
Medications: Aspirin (ASA), clopidogrel, Heparin, or Warfarin (at provider's discretion).

Intracranial Pressure (ICP) and Brain Tumors

Intracranial Pressure: The pressure exerted by brain tissue, blood, and Cerebrospinal Fluid (CSF) inside the cranial vault.
Normal Range: $0-10\,mmHg$ .
Early Signs of Increased ICP: Disorientation, restlessness, increased respiratory effort, pupil changes (dilation), weakness, and headache.
Late Signs of Increased ICP: Changes in Level of Consciousness (LOC), decreased Pulse Rate (PR) and Respiratory Rate (RR), projectile vomiting, hemiplegia, and loss of brain stem reflexes.
Diagnostics: CT, MRI, PET, cerebral angiography, and transcranial doppler. Lumbar puncture (LP) must be avoided as it increases ICP further.
Management: Avoid coughing, bend at the knees only, and maintain seizure precautions.
Medications: Mannitol is used to reduce ICP; dexamethasone is used for swelling.
Surgical Intervention: A Burr Hole may be required if swelling does not respond to other interventions.
Cushing’s Triad: A late-stage medical emergency signaling imminent brain herniation. Signs include:

Hypertension (with widened pulse pressure)
Bradycardia
Irregular Respiratory Rate (RR)

Brain Tumors: Grow as a mass or infiltrate tissue, occupying space in the skull. Effects are caused by inflammation, compression, and infiltration.
Primary Tumors: Originate from brain cells (usually glial cells). They progress locally and rarely metastasize. The $5$ -year survival rate is $33.4\%$ .
Glioma: Most common intracerebral tumor (types: Astrocytoma, glioblastoma, oligodendroglioma, ependymoma, medulloblastoma).
Meningioma: Benign, encapsulated tumor of arachnoid cells; slow-growing; more common in middle-aged women.
Acoustic Neuroma: Tumor of the $8^{th}$ cranial nerve; slow-growing. S/S include hearing loss, tinnitus, vertigo, staggering gait, and painful facial sensations.
Pituitary Adenomas: Common in older women; rarely malignant. Symptoms relate to pressure and hormonal changes (TSH, $T_3$ , $T_4$ , cortisol).
Secondary Tumors: Twice as common as primary. Metastatic (METS) from lung, breast, GI tract, pancreas, kidneys, or skin.
Systemic Symptoms: Increased ICP, headache, visual field disturbances, seizures, behavioral changes, vomiting, and localized symptoms.
Medical Management: Options include surgery, radiation, chemotherapy, and anticonvulsant medications (e.g., Keppra, gabapentin, phenytoin).

Seizure Disorders and Epilepsy

Seizures: Episodes of abnormal motor, sensory, autonomic, or psychic activity resulting from sudden, excessive discharge from neurons.
Manifestations: Muscle rigidity, tonic-clonic activity, loss of consciousness, eyes rolling back, incontinence, tongue chewing, oral secretions, and blood in the mouth.
Diagnosis: History and Physical (H&P), EEG, and MRI.
Seizure Management (During Event): Protect the patient from injury, time the seizure, turn the patient on their side, and place nothing in the mouth.
Seizure Management (Post-Seizure): Priority is airway management. Reorient the client, allow for rest, and initiate fall precautions. Expect weakness, soreness, fatigue, and lethargy.
Precautions: Pad side rails and keep suction at the bedside at all times.
Epilepsy: Characterized by recurrent, unprovoked seizures; more common in women and older adults. Management includes antiseizure meds, surgery, or vagus nerve stimulation.
Medications: Carbamazepine, levetiracetam (Keppra), phenytoin, and valproate. Ativan is used during active seizures.

Dysphagia and Aspiration Precautions

Dysphagia: Difficulty swallowing, often seen in conditions like Stroke, Parkinson’s (decreased dopamine), Myasthenia Gravis (Ach junction issues), ALS (motor neuron loss), and Multiple Sclerosis (myelin destruction).
Diagnosis: Requires a swallow study. Patients must remain NPO (nothing by mouth) if they fail, requiring aspiration precautions.
Management: If a swallow screen is failed on a weekend, the patient remains NPO until evaluated by speech therapy. Fluids and calories are provided via IV.
Oral Care: Provide every hour using minimal water.
Aspiration Precautions:

Elevate HOB to $90$ degrees.
Use a "chin tuck" technique when swallowing (if not NPO).
Provide small bites; ensure the patient swallowed before the next bite.
Maintain suction at the bedside.

Genitourinary Health: Urinary Tract Infections and Catheterization

Urinary Tract Infection (UTI): Can be upper or lower. E. coli is the most common causative agent.
Risk Factors: Females, Diabetes Mellitus (DM), pregnancy, neurological disorders, gout, altered states, immunosuppression, and obstruction.
Lower UTI (Cystitis, Prostatitis, Urethritis):
S/S: Burning, frequency, nocturia, incontinence, pain, hematuria, back/flank/abdominal pain, and confusion in the elderly.
Medications: Nitrofurantoin, cephalexin, ciprofloxacin, levofloxacin, ampicillin, amoxicillin, trimethoprim-sulfamethoxazole.
Symptom Management: Phenazopyridine (Azo) treats symptoms (not the infection); increase fluids to $2-3\,L/day$ ; void every $2-3$ hours.
Upper UTI (Pyelonephritis): Infection of the renal pelvis, tubules, and interstitial tissue.
Acute Pyelonephritis: S/S include chills, fever, leukocytosis, bacteriuria, pyuria, low back/flank pain, CVA tenderness, and N/V.
Chronic Pyelonephritis: Usually results from recurrent infections. Can lead to kidney scarring, non-function, and CKD. S/S include fatigue, poor appetite, polyuria, and weight loss.
Prevention Education: Void before and after sex; wipe front to back; use alternative birth control while on antibiotics (antibiotics make oral birth control ineffective); increase water intake; avoid caffeine; wear cotton underwear; prefer showers over baths.
Foley Catheters: Primary cause of CAUTIs (Catheter-Associated Urinary Tract Infections).
Purpose: Used for surgery, epidurals, wound management near genitalia, or acute urinary retention.
Insertion: Must be a strict sterile procedure. Bag must be kept below the bladder level. The balloon is usually inflated with $10\,mL$ of sterile water.
Sizing: Measured on the French (Fr) scale ( $10$ to $24\,Fr$ ).
Removal: Fully deflate the balloon before pulling to avoid urethral damage.
Perineal Care (Catheter Patients): Start at the meatus (cleanest) and work down to the bifurcation/tubing using a warm, soapy cloth.
Females: Clean labia downward (pubis to rectum); use a clean area of the cloth for each stroke.
Males: Clean head (glans) in a circular motion starting at the meatus; retract and replace foreskin for uncircumcised patients.

Renal Pathophysiology: Stones, AKI, and CKD

Urolithiasis and Nephrolithiasis: Stones in the urinary tract or kidney.
S/S: Intense pain, hematuria, N/V, flank pain, abdominal pain.
Management: Opioids, NSAIDs, fluids. Surgical options include ESWL (shock waves). Urine must be strained to analyze fragments.
Acute Kidney Injury (AKI): Rapid loss of renal function.

Prerenal: Decreased circulation/perfusion to healthy kidneys. Findings: Increased BUN/Creatinine, High USG, Low UOP, Low Sodium ( $Na^+$ ).
Intrarenal: Actual damage to kidney structures (glomeruli, tubules). Findings: Increased BUN/Creatinine, High $Na^+$ ( $Na^+$ ), Low USG.
Postrenal: Obstruction (stones, BPH, tumors). Findings: Increased BUN/Creatinine.

Phases of AKI:

Initiation: Insult to start of oliguria.
Oliguria: UOP < $400\,mL$ in $24$ hours; accumulation of urea, creatinine, uric acid, potassium, and magnesium.
Diuresis: Renal function begins to recover; UOP increases; labs stabilize.
Recovery: Can take months; laboratory values return to normal.

Management: Monitor drug levels for toxicity; diuretics, IVF, and high-carb/low-sodium/potassium/phosphorus diet.
Chronic Kidney Disease (CKD): Kidney damage or GFR < $60\,mL/min$ for $3$ or more months.
S/S: Increased creatinine, decreased Calcium ( $Ca^{2+}$ ), increased Phosphorus, anemia (decreased RBCs/H&H), and fluid retention.
CKD Stages (by GFR):
Stage 1: $\ge 90\,mL/min$
Stage 2: $60-89\,mL/min$
Stage 3: $30-58\,mL/min$
Stage 4: $15-29\,mL/min$
Stage 5: $\le 15\,mL/min$ (ESKD)
CKD Medications: ACE Inhibitors (Lisinopril), ARBs (Losartan), Furosemide, Epoetin, Phoslo (phosphate control), Calcitriol ( $Ca^{2+}$ ), and Sodium Bicarbonate.

Gastrointestinal Disorders: IBD and Ostomy Care

Crohn’s Disease (Regional Enteritis): Subacute/chronic inflammation through all GI layers (Mouth to Anus).
S/S: Fatty stools, diarrhea ( $5-20\times/day$ ), RLQ pain, malnutrition, anemia, dehydration, and low Potassium ( $K^+$ ).
Ulcerative Colitis: Ulcerative inflammation of the colon and rectum.
S/S: Diarrhea ( $5-20\times/day$ ) with mucus, blood, and pus; LLQ pain; skin irritation; Low Potassium ( $K^+$ ).
Complications: Toxic megacolon, perforation, and increased risk for colon cancer.
Nutrition: Low residue, high protein, high calorie. Avoid cold foods, smoking, and milk.
Ostomy Care:
Stoma Appearance: Should be moist, shiny, and pink/deep red. Oval/round and soft.
Stool Consistency: Ascending (fluid), Transverse (liquid), Descending (semi-formed), Sigmoid (formed).
Pouch Management: Empty when $1/3$ to $1/2$ full. Change bag every $5-7$ days. Measure stoma frequently; bag should have a $1/8$ inch ( $3\,mm$ ) gap.
Dietary Cautions: Avoid gassy, spicy, or odor-producing foods.

Upper GI Pathology and Management

H. Pylori: Bacterial infection detected via Urea Breath Test (ingest carbon capsule, test breath in $10-20$ minutes).
Prep: Avoid antibiotics/bismuth for $1$ month and PPIs for $2$ weeks prior to test.
Treatment: Triple therapy (1 PPI, 2 Antibiotics) or Quadruple therapy (1 PPI, 2 Antibiotics, Bismuth salt).
Hiatal Hernia: Part of the upper stomach moves into the lower thorax. S/S include pyrosis (heartburn), regurgitation, and fullness after eating. Management includes small meals and remaining upright after eating.
Pharmacology:
NSAIDs: Inhibit COX enzymes. Nonselective (ibuprofen, aspirin) vs Selective (Celebrex). Major side effect is GI ulcers and occult bleeding.
H2 Receptor Antagonists: Block histamine to reduce acid (e.g., Carafate/Sucralfate). Take before meals to coat the stomach.
Peritonitis: Inflammation of the peritoneum. Signs include a rigid, board-like abdomen and distention. Requires emergency surgery and IV antibiotics.
Total Parenteral Nutrition (TPN): Administered via Central Line or PICC. Contains protein, carbs, fats (lipids), etc.
Monitoring: Check glucose, weights, and Daily I&O. Use aseptic technique for dressing changes every $7$ days. Taper off; if bag runs out, infuse $D_{10}$ to prevent hypoglycemia.
Nasogastric (NG) Tube: Tip to nose, ear, xiphoid. Confirm with CXR. Turn suction off for $30-60$ minutes after medications.

Cardiovascular Fundamentals, Diagnostics, and Arrhythmias

Blood Flow: Vena Cava → RA → Tricuspid → RV → Pulmonary Valve → Pulmonary Artery → Lungs → Pulmonary Vein → LA → Mitral Valve → LV → Aortic Valve → Aorta.
Cardiac Conduction/Output:
P wave (atrial depolarization), QRS (ventricular depolarization), T wave (ventricular repolarization).
CO: $HR \times SV$ ( $3-6\,L/min$ ).
Ejection Fraction: $55-75\%$ ; decreased in Heart Failure.
Preload: Stretch at end of diastole. Afterload: Pressure during ejection.
Digoxin: Therapeutic level $0.5-2.0$ . Toxicity: halos, N/V. Low Potassium ( $K^+$ ) increases risk.
Labs: Troponin (<0.1; baseline and $3\,hr$ recheck), BNP (<100 indicates heart failure), Potassium ( $3.5-5.0$ ), Calcium ( $9.0-10.5$ ).
Coagulation: aPTT (Heparin, medicated $70-90$ ; Antidote: Protamine Sulfate). PT/INR (Warfarin, medicated INR $2.0-3.0$ ).
Hypertension (BP):
Stage 1: $130-139/80-89$ . Stage 2: >140/90.
Arrhythmias:
Sinus Bradycardia (<60): Treat with Atropine or Dopamine if symptomatic.
Sinus Tachycardia (>100): Treat with Beta Blockers, CCBs, or vagal maneuvers.
Atrial Fibrillation: "Irregularly irregular," no P waves. Risk for Stroke/Embolus. Treat with Diltiazem, Digoxin, or cardioversion.
Ventricular Tachycardia (VT): Repetitive ectopic firing ( $140-180\,bpm$ ). Pulse: cardiovert. No pulse: CPR/Defibrillate.
Ventricular Fibrillation (V-fib): Chaos, no pulse. CPR and ASAP Defibrillation.
Asystole: Flatline. CPR and Epinephrine. Cannot shock.

Heart Failure and Respiratory Care

Right Sided HF: Systemic. S/S: JVD, edema, ascites, liver enlargement.
Left Sided HF: Lungs. S/S: Crackles, pink-frothy sputum, dyspnea, orthopnea.
HF Education: Daily weights (notify HCP if >1-2\,lbs/day or >3\,lbs/week).
Nitroglycerin: Potent vasodilator. Take $1$ tablet $q5\,min \times 3$ . Call EMS after first dose if not relieved.
Respiratory Oxygen Delivery:
Nasal Cannula: $1-6\,L/min$ ; humidify over $4\,L$ .
Simple Mask: $5-8\,L/min$ .
Nonrebreather: $10-15\,L/min$ (gives $100\%$ oxygen).
Venturi Mask: $4-10\,L/min$ .
Arterial Blood Gases (ABGs):
Normals: pH ( $7.35-7.45$ ), $CO_2$ ( $35-45$ ), $HCO_3$ ( $22-26$ ).
Respiratory Acidosis: Low pH, High $CO_2$ (COPD, Pneumonia).
Respiratory Alkalosis: High pH, Low $CO_2$ (Hyperventilation).
Metabolic Acidosis: Low pH, Low $HCO_3$ (DKA, Renal failure).
Metabolic Alkalosis: High pH, High $HCO_3$ (Vomiting/Suctioning).
Lung Conditions:
TB: Airborne (N95/Negative pressure). RIPE meds (Rifampin turns urine orange; Pyrazinamide causes gout/high uric acid).
Chest Tubes: Suction control should bubble constantly; water seal should only tidale. Never clamp the tube. If it comes out of the patient, apply Vaseline gauze taped on $3$ sides.
Ventilator Alarms: High pressure (kinks, secretions). Low pressure (disconnection, leak).

Endocrine Disorders

Thyroid Disorders:
Hyperthyroidism (High and Hot): Graves’ disease. Exophthalmos (artificial tears). High $T_3/T_4$ , low TSH.
Thyroid Storm (Emergency): Fever >101.3, Tachycardia >130. Give Methimazole/PTU.
Hypothyroidism (Low and Slow): Hashimoto’s. Fatigue, weight gain. Give Levothyroxine (take empty stomach, AM).
Myxedema Coma: Severe low BP/temp/BG. Emergency.
Adrenal Disorders:
Cushing’s (Excess Cortisol): Buffalo hump, moon face, truncal obesity. Risk for infection.
Addison’s (Low Cortisol): Skin hyperpigmentation, low BP, low sodium, high potassium. Give Hydrocortisone. Elevated legs in recumbent position.
Diabetes Insipidus (DI): ADH deficiency. Dilute urine (USG $1.001-1.005$ ). Severe dehydration/thirst. Give Desmopressin.
SIADH: Excess ADH. Concentrated urine, hyponatremia. Fluid restriction and seizure precautions (if using $3\%$ saline).