hesi medsurge review

ASSESSMENT Review Tips

Helpful Med-Surg Tips!

Angina Precipitating Factors: 4 E’s

  • Exertion: Physical activity and exercise that can trigger angina.

  • Eating: Consuming food can induce attacks due to increased metabolic demands.

  • Emotional distress: Stressful situations may lead to symptom exacerbation.

  • Extreme temperatures: Hot or cold weather can affect cardiac workload and induce angina.

Arterial Occlusion: 4 P’s

  • Pain: Severe discomfort indicating insufficient blood flow.

  • Pulselessness: Indicates absence of pulse in the affected area.

  • Pallor: Pale appearance of the skin due to reduced blood flow.

  • Paresthesia: Abnormal sensations such as tingling or numbness.

Congestive Heart Failure Treatment: MADD DOG

  • Morphine: Helps relieve dyspnea and anxiety.

  • Aminophylline: A bronchodilator used for respiratory distress.

  • Digoxin: Increases cardiac contractility and helps manage heart failure.

  • Dopamine: Enhances cardiac output and improves renal blood flow.

  • Diuretics: Reduces fluid overload and edema.

  • Oxygen: Provides supplementary oxygen to improve tissue oxygenation.

  • Gasses: Monitoring arterial blood gases for assessing respiratory function.

Heart Murmur Causes: SPASM

  • Stenosis of a valve: Narrowing of heart valve pathways.

  • Partial obstruction: Blockage causes turbulent blood flow.

  • Aneurysms: Bulges in blood vessels create abnormal flow.

  • Septal defect: Holes in the heart can cause abnormal flow patterns.

  • Mitral regurgitation: Backflow of blood through the mitral valve.

Heart Sounds: All People Enjoy the Movies

  • Aortic: 2nd right intercostal space; location for auscultation.

  • Pulmonic: 2nd left intercostal space; location for auscultation.

  • Erb’s Point: 3rd left intercostal space; listening point for heart sounds.

  • Tricuspid: 4th left intercostal space; listening point for heart sounds.

  • Mitral or Apex: 5th left intercostal space; location for auscultation.

Hypertension Care: DIURETIC

  • Daily weight: Monitoring weight changes for fluid retention.

  • Intake and Output: Tracking fluid balance is essential.

  • Urine output: Assessing kidney function and fluid status.

  • Response of blood pressure: Evaluating treatment efficacy.

  • Electrolytes: Monitoring electrolyte levels for imbalances.

  • Take pulse: Regular checking of heart rate.

  • Ischemic episodes or TIAs: Identifying transient ischemic attacks.

  • Complications: Being alert for conditions such as CVA (stroke), CAD (coronary artery disease), CHR (chronic heart failure), CRF (chronic renal failure).

Shortness of Breath (SOB) Causes: AAAPPP

  • Airway obstruction: Barriers to airflow leading to dyspnea.

  • Angina: Chest pain affecting breathing patterns.

  • Anxiety: Psychological factors can alter respiratory rates.

  • Asthma: Chronic condition causing airway constriction.

  • Pneumonia: Infection causing inflammation and fluid in the lungs.

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

  • Pulmonary Edema: Accumulation of fluid in the alveoli affecting gas exchange.

  • Pulmonary Embolus: Blockage in a pulmonary artery usually caused by blood clots.

Stroke Signs: FAST

  • Face: Look for drooping on one side of the face.

  • Arms: Notice if one arm drifts down when raised.

  • Speech: Check for slurred speech or inability to speak.

  • Time: Call emergency services immediately if any symptoms occur.

Compartment Syndrome Signs and Symptoms: 5 P’s

  • Pain: Severe pain out of proportion to injury.

  • Pallor: Skin paleness due to decreased blood flow.

  • Pulse declined or absent: Weakness or absence of pulse in the affected limb.

  • Pressure increased: Increased intra-compartmental pressure.

  • Paresthesia: Tingling or numbness in affected limbs.

Shock Signs and Symptoms: CHORD ITEM

  • Cold, clammy skin: Indicative of poor circulation.

  • Hypotension: Low blood pressure as a result of shock.

  • Oliguria: Reduced urine output indicating impaired kidney function.

  • Rapid, shallow breathing: Compensatory mechanism in response to falling blood pressure.

  • Drowsiness, confusion: Signs of inadequate cerebral perfusion.

  • Irritability: May be observed in both adults and children.

  • Tachycardia: Increased heart rate as a compensatory response.

  • Elevated or reduced central venous pressure: Changes in CVP signal fluid imbalance.

  • Multi-organ damage: Complications that can arise from prolonged shock.

Hypoglycemia Signs: TIRED

  • Tachycardia: Fast heart rate in response to low blood sugar.

  • Irritability: Behavioral changes due to low glucose levels.

  • Restlessness: Increased agitation due to energy deficit.

  • Excessive hunger: Drive to eat as body seeks glucose.

  • Depression and diaphoresis: Sweating and mood changes associated with hypoglycemia.

Hypocalcaemia Signs and Symptoms: CATS

  • Convulsions: Possible seizures from low calcium.

  • Arrhythmias: Irregular heartbeats related to electrolyte imbalances.

  • Tetany: Muscle spasms indicative of low calcium levels.

  • Stridor and spasms: Respiratory sounds from laryngeal spasms.

Hypokalemia Signs and Symptoms: 6 L’s

  • Lethargy: Fatigue or lack of energy related to low potassium.

  • Leg cramps: Painful muscle cramps often associated with electrolyte depletion.

  • Limp muscles: Weakness and reduced muscle tone.

  • Low, shallow respirations: Respiratory depression due to electrolyte imbalance.

  • Lethal cardiac dysrhythmias: Life-threatening heart rhythm irregularities.

  • Lots of urine (polyuria): Increased urine production possibly linked to diuretic effect.

Hypertension Complications: The 4 C’s

  • Coronary artery disease (CAD): Narrowing of coronary arteries leading to decreased blood flow.

  • Congestive heart failure (CHF): Heart's inability to pump sufficient blood to meet body's demands.

  • Chronic renal failure (CRF): Long-standing kidney disease resulting from hypertension.

  • Cardiovascular accident (CVA): Also known as a stroke, a sudden loss of brain function due to interrupted blood flow.

Traction Patient Care: TRACTION

  • Temperature of extremity is assessed for signs of infection: Monitoring extremities for infection is vital in traction patients.

  • Ropes hang freely: Ensuring ropes are not tangled or obstructed to maintain correct traction.

  • Alignment of body and injured area: Proper positioning is essential for healing.

  • Circulation check (5 P’s): Ensuring blood circulation is intact (pain, pallor, pulse, pressure, paresthesia).

  • Type and location of fracture: Understanding of the fracture is critical to management.

  • Increase fluid intake: Hydration is essential to prevent complications.

  • Overhead trapeze: Equipment that aids patient mobility and comfort.

  • No weights on bed or floor: Proper use of weights is essential for effective traction.

Cancer Early Warning Signs: CAUTION UP

  • Change in bowel or bladder: Any alterations should be investigated for possible malignancy.

  • A lesion that does not heal: Persistent lesions may indicate cancerous changes.

  • Unusual bleeding or discharge: Melena or hematuria can be signs of internal cancers.

  • Thickening or lump in breast or elsewhere: New lumps should be assessed for potential tumors.

  • Indigestion or difficulty swallowing: Could be symptoms related to esophageal cancers.

  • Obvious changes in wart or mole: Alterations in size, shape or color of moles may indicate skin cancer.

  • Nagging cough or persistent hoarseness: Should be evaluated for lung or throat cancer.

  • Unexplained weight loss: Significant weight loss without trying can be a red flag for cancer.

Pernicious Anemia

Leukemia Signs and Symptoms: ANT

  • Anemia and decreased hemoglobin: Low red blood cell counts lead to fatigue and pallor.

  • Neutropenia and increased risk of infection: Low white blood cells increase susceptibility to infections.

  • Thrombocytopenia and increased risk of bleeding: Low platelet counts can lead to uncontrolled bleeding.

Patients Who Require Dialysis: AEIOU (The Vowels)

  • Acid base imbalance: Dialysis is necessary to correct metabolic acidosis.

  • Electrolyte imbalances: Treatment for critical electrolyte derangements.

  • Intoxication: Dialysis used to remove certain toxic substances.

  • Overload of fluids: Managing fluid overload in renal failure.

  • Uremic symptoms: Signs of renal failure warranting dialysis.

Asthma Management: ASTHMA

  • Adrenergics: Use of bronchodilators like albuterol for symptomatic relief.

  • Steroids: Anti-inflammatory medications for long-term control.

  • Theophylline: Medication that acts as a bronchodilator and anti-inflammatory.

  • Hydration: Administer intravenous fluids as needed.

  • Mask: Providing oxygen therapy for compromised respiratory function.

  • Antibiotics: Given for associated respiratory infections to reduce exacerbation.

Hypoxia: RAT (signs of early) BED (signs of late)

  • Signs of early hypoxia (RAT):

    • Restlessness

    • Anxiety

    • Tachycardia and tachypnea

  • Signs of late hypoxia (BED):

    • Bradycardia

    • Extreme restlessness

    • Dyspnea

Pneumothorax Signs: P-THORAX

  • Pleuretic pain: Sharp pain aggravated by breathing.

  • Trachea deviation: Shift of trachea towards the unaffected side in tension pneumothorax.

  • Hyperresonance: Increased resonance during percussion of the chest.

  • Onset sudden: Symptoms usually arise abruptly.

  • Reduced breath sounds (& dyspnea): Diminished breath sounds alongside difficulty breathing.

  • Absent fremitus: Decreased tactile fremitus due to air in pleural space.

  • X-ray shows collapsed lung: Diagnostic imaging confirms pneumothorax.

Transient Incontinence Causes: DIAPERS

  • Delirium: Reversible confusion affecting continence.

  • Infection: UTIs can lead to transient urinary incontinence.

  • Atrophic urethra: Age-related changes leading to urine leakage.

  • Pharmaceuticals and psychological: Medications may cause incontinence.

  • Excess urine output: Can occur in certain medical conditions.

  • Restricted mobility: Physical limitations can contribute to incontinence.

  • Stool impaction: Can create pressure that leads to urinary leakage.

Dealing with Constipation

  • Definition: Difficulty or infrequent passage of stools; stools may be hard and dry.

  • Causes: Can include irregular bowel habits, psychogenic factors (such as depression), inactivity, chronic laxative use or abuse, obstruction, medications, and inadequate fiber/fluid intake.

  • Management: Encourage exercise, a diet high in fiber, and adequate fluid intake to alleviate symptoms.

Dealing with Dysphagia

  • Definition: Alteration in the client’s ability to swallow.

  • Causes: Includes obstruction, inflammation, edema, and certain neurological disorders.

  • Management: Modifying food texture and liquid consistency aids nutritional intake.

    • Positioning: Clients should be placed in an upright or high-Fowler’s position.

    • Oral Care: Improves sense of taste before meals.

    • Eating Facilitation: Encourage small bites, thorough chewing, and allow adequate eating time.

    • Avoidance: Refrain from thin liquids and sticky foods to minimize aspiration risk.

Dumping Syndrome

  • Definition: Complication following gastric surgeries affecting digestion.

  • Symptoms: Includes nausea, distention, cramping pains, diarrhea within 15 minutes after eating, plus weakness, dizziness, rapid heartbeat, and potential hypoglycemia.

  • Management:

    • Meal Frequency: Small, frequent meals are indicated.

    • Nutritional Composition: Include protein and fat at every meal, and avoid concentrated sugars.

    • Fluid Intake: Consume liquids 1 hour before or after meals (dry diet).

Gastroesophageal Reflux Disease (GERD)

  • Definition: Leads to indigestion and heartburn due to acidic gastric juices' backflow into the lower esophagus.

  • Management:

    • Weight Loss: Important for overweight clients.

    • Eating Habits: Avoid large meals and snacks before bed.

    • Trigger Foods: Avoid citrus fruits, spicy foods, and carbonated beverages, along with items that decrease lower esophageal sphincter (LES) pressure (alcohol, caffeine, chocolate, fatty foods, peppermint, spearmint, and smoking).

Peptic Ulcer Disease (PUD)

  • Definition: Erosion of the stomach or duodenum mucosal layer.

  • Causes: May be due to infection with Helicobacter pylori or chronic NSAID use.

  • Management:

    • Eating Frequency: Avoid frequent meals/snacks to reduce gastric acid secretion.

    • Substance Restrictions: Avoid alcohol, cigarette smoking, aspirin, NSAIDs, coffee, black pepper, spicy foods, and caffeine.

Lactose Intolerance

  • Definition: Inadequate supply of lactase leading to difficulty digesting lactose.

  • Symptoms: Include distention, cramps, flatus, and diarrhea.

  • Dietary Recommendations: Encourage avoidance of high lactose foods such as milk, cream soups, cheese, and ice cream.

Diverticulosis and Diverticulitis

  • Prevention: High-fiber diet to decrease colon pressure.

  • Management during Diverticulitis: Low-fiber diet prescribed to reduce bowel stimulation and avoid seeds/husks.

Cholecystitis

  • Definition: Inflammation of the gallbladder affecting bile storage and release for fat digestion.

  • Dietary Management: Limit fat intake, with caution regarding foods like coffee, broccoli, and highly seasoned foods, and tailor diet to client's needs.

Acute Renal Failure (ARF)

  • Definition: Abrupt decline in renal function, often caused by trauma, sepsis, or medications.

  • Symptoms: Hyponatremia, hyperkalemia, hypocalcemia, and hyperphosphatemia may occur.

  • Diet Therapy: Dependent on ARF phase and cause.

Pre-End Stage Renal Disease (pre-ESRD)

  • Definition: Diminished renal reserve characterized by increased serum creatinine.

  • Goals of Nutritional Therapy:

    • Protein and Phosphorus Limitation: To preserve renal function.

    • Glucose and Hypertension Control: Managing both factors is essential.

    • Protein Recommendations: Must balance between not too high (to prevent breakdown of body protein) and not too low.

  • Dietary Recommendations:

    • Limit meat intake.

    • Limit dairy to ½ cup/day.

    • Restrict high-phosphorus foods like peanut butter, bran, cola.

    • Control sodium intake to manage blood pressure.

    • Use vitamins/minerals only as prescribed.

End Stage Renal Disease (ESRD)

  • Definition: Condition requiring dialysis or transplant with GFR < 25 mL/min.

  • Nutritional Goals: Maintain fluid status, blood pressure, and chemistry levels.

    • Dietary Recommendations: High-protein, low-phosphorus, low-potassium, low-sodium diets with fluid restrictions.

    • Caloric Intake: 35 cal/kg of body weight to maintain protein stores.

    • Phosphate Binders: Required at meals/snacks to control phosphorus levels.

    • Calcium and Vitamin D Supplementation: Needed due to altered metabolism.

    • Sodium and Potassium: Intakes adjusted based on lab values and individual needs.

Nephrotic Syndrome

  • Definition: Condition resulting in protein loss in urine.

  • Goals of Nutritional Therapy: Minimize edema, replace lost nutrients, reduce renal damage.

  • Dietary Recommendations: Encourage sufficient protein and low-sodium intake.

Nephrolithiasis (Kidney Stones)

  • Primary Intervention: Increasing fluid intake to prevent stone formation.

  • Risk Factors: Excessive intake of protein, sodium, calcium, and oxalates increase risk of stones.

Test Taking Tips

Prioritization

  • Prioritization incorporates:

    • Clinical decision-making.

    • Priority setting.

    • Organizational skills.

    • Resource utilization.

    • Time management.

    • Evaluation of care.

  • Importance of Assessment: A thorough assessment is critical for accurate clinical decisions.

Orders of Prioritization

  1. Treat immediate threats to a patient’s survival or safety. Examples include obstructed airways, unconsciousness, or psychological crises (ABC’s - Airway, Breathing, Circulation).

  2. Address actual problems, such as nausea or full bowels/bladders needing intervention.

  3. Treat urgent actual or potential problems not recognized by patients or families, like post-op complication monitoring or medication teaching.

  4. Manage problems needing help in the future, such as providing self-care education.

Principles for Prioritization

  • Systemic before local issues.

  • Acute concerns before chronic ones.

  • Actual problems take precedence over potential issues.

  • Listen and don’t assume; verify clinical conditions through assessments.

Maslow’s Hierarchy of Needs

  • Address physiological and safety concerns before psychological and esteem issues.

Organizational Skills

  • Manage time effectively, combining nursing tasks (e.g., physical assessment with hygiene tasks).

Use of Resources

  • Collaborate with healthcare team members to ensure efficient care (e.g., turning, lifting, and catheter insertion).

  • Utilizing assistance can enhance patient safety and care quality.

Evaluation of Care Plan

  • Continuously evaluate and modify care plans based on patient outcomes and needs.

Inspirational Quote

  • "Nurture your mind with great thoughts; to believe in the heroic makes heroes." - Benjamin Disraeli