Medical-Surgical Nursing Review

Communication in Medical-Surgical Nursing

• Impact of Communication on Sentinel Events: Poor communication was identified as one of the top root causes of sentinel events reported to The Joint Commission from the years $2011$ through $2013$.
• Medical Errors: Ineffective handoff communication is a primary contributing factor leading to medical errors according to research (Nether, $2018$).
• Therapeutic Communication: It is necessary for eliciting critical information from clients and families across all nursing settings and interventions. Key utility include:
  • Crisis intervention.
  • Ascertaining cultural awareness/influences on health.
  • Addressing religious and spiritual influences.
  • Assessing family dynamics.
  • Detecting sensory alterations (e.g., hearing loss, speech deficits).
• Professional Communication Characteristics: This involves the assimilation of nursing skills and knowledge integrated with dignity and respect, maintaining accountability and self-awareness.
  • Collegial: Professional relationship with peers.
  • Collaborative: Working together toward client goals.
  • Interdisciplinary/Interprofessional: Use of the SBAR format (Situation, Background, Assessment, Recommendations) for communication between nurses, providers, physical therapists, social workers, pharmacists, and lab technicians.
  • Confidentiality: Adherence to the Health Insurance Portability and Accountability Act (HIPAA) and ethical standards.
• Nonverbal Communication: Often more important than verbal cues. Body language, personal space, and verbal messages must be congruent.
  • Positive Body Language: Example includes leaning in toward a client while talking.
  • Proxemics: Most Americans maintain a distance of approximately $0.5$ meter ($1.7$ or $1\frac{1}{2}$ feet) when talking.
• Communication Standards:
  • Establish trust and offer self empathetically.
  • Demonstrate a nonjudgmental attitude by examining personal bias.
  • Use active listening.
  • Identify communication deficits and adjust to meet client abilities.
  • Clarify and validate client statements.
• Care Transitions: Transitions include shift changes, unit transfers, or moves to different care settings. Clear verbal communication and written records are critical during these times.

Health Promotion and Disease Prevention

• Definition of Health: The World Health Organization (WHO) defines health as "the state of complete physical, mental, and social well-being; not merely the absence of disease or infirmity."
• Health Promotion vs. Disease Prevention:
  • Promotion: Actions aimed at developing behaviors to maintain or enhance well-being.
  • Prevention: Actions aimed at safeguarding clients from real or potential health risks.
• Levels of Prevention:
  • Primary Prevention: Reducing health risks and increasing healthy behaviors. Examples: Immunizations, nutrition classes, smoke-free zones.
  • Secondary Prevention: Detecting disease early via screening. Example: Colonoscopy to detect colon cancer early.
  • Tertiary Prevention: Preventing disability/complications and providing for a peaceful death. Examples: Stroke rehabilitation, hip replacement rehab, hospice care.
• Behavioral Change Areas: Changing behaviors can prevent or modify chronic illness. Areas include:
  • Physical activity and nutrition.
  • Stress management.
  • Coping skills and support systems.
  • Spiritual perspective.
  • Cessation of alcohol and tobacco/marijuana (smoke contains toxins/carcinogens).

Teaching and Learning Process

• Definitions:
  • Teaching: A deliberate process of actions to bring about learning.
  • Learning: Acquiring new or modified knowledge, behaviors, skills, or values (only the learner can achieve this).
• Four Step Iterative Process:
  1. Assessment: Systematically assessing learning needs in three domains: Knowledge, Skills, and Values. Consider modifiable (knowledge base) and nonmodifiable (age, culture) characteristics, and readiness (motivation).
  2. Planning: Collaborating with the client to determine priorities and writing measurable behavioral goals/objectives.
  3. Implementation: Carrying out strategies (videos, groups) and involving family.
  4. Evaluation/Review: Determining if goals were met and altering strategies if necessary.

Spiritual and Cultural Assessment

• Spiritual History (FICA Acronym):
  • F (Faith and Belief): "Do you consider yourself spiritual?" If no, "What gives your life meaning?"
  • I (Importance): "Have your beliefs influenced how you take care of yourself?"
  • C (Community): "Are you part of a spiritual or religious group?"
  • A (Address in Care): "How would you like your nurse to address these issues in your health care?"
• Prayer: A nurse should be honest if they are uncomfortable praying with a client, but can offer to stay with them while they pray.
• Cultural Diversity: Nurses must accept differences in ethnicity, social class, and language. Cultural traditions should be incorporated into care plans if they do not pose harm.

Complementary and Alternative Interventions

• Common Modalities:
  • Acupuncture/Acupressure: Used to decrease pain or balance "yin and yang."
  • Reiki: Japanese healing technique based on "life force energy" administered through "laying on hands."
  • Aromatherapy: Use of essential oils (e.g., sweet orange or grapefruit) to stimulate neurotransmitters or manage odors in hospice.
  • EMDR: Eye Movement Desensitization Reprocessing for PTSD.
  • Chocolate: Dubbed "the Prozac of plants," it increases serotonin and may help with PMS.
  • Coining: Traditional Asian practice of rubbing a heated coin on the body; creates welts that can be mistaken for abuse.
• Herbal Medications (Common Interactions/Uses):
  • Garlic: For hyperlipidemia; interferes with anticoagulants; side effect of bleeding.
  • Ginger: For nausea; potential potentiation of anticoagulants.
  • Ginkgo: For mental performance; vasodilator; synergistic with stimulants (caffeine).
  • Ginseng: For fatigue/erectile dysfunction; antiandrogen.
  • Kava: For anxiety; hepatotoxic; potentiates sedatives like benzodiazepines.
  • Ephedra: For weight loss/fatigue; can cause hypertension, MI, or stroke.
  • St. John’s Wort: For depression; numerous drug interactions.

Respiratory System: Pneumonia

• Description: Inflammation of the lower respiratory tract caused by infectious agents (Bacteria, Viral, Fungal, Chemical).
• Pathways to Lungs: Aspiration, Inhalation, and Hematogenous spread.
• High-Risk Groups: Infants under $2$ years; adults $65$ or older; cigarette smokers; immunocompromised; those with depressed gag/cough reflex.
• Nursing Assessment:
  • Tachypnea (accessory muscle use).
  • Abrupt onset of fever, shaking, chills.
  • Productive cough with pleuritic pain.
  • Egophony: "E" to "A" changes heard via stethoscope.
  • Tactile Fremitus: Increased vibrations felt when client says "$99$."
  • ABGs: Hypoxemia; $O_2$ saturation should be >90\text{%}, ideally >95\text{%}.
• Interventions:
  • Hydration of up to $3000\text{ mL/day}$ to liquefy secretions.
  • Deep breathing and incentive spirometer use every $2$ hours.
  • Assess sputum (color, odor like Pseudomonas).
  • Pneumonia and annual flu vaccinations.

Chronic Airflow Limitation (CAL/COPD)

• Chronic Obstructive Pulmonary Disease (COPD): Includes Emphysema (alveoli damage, air trapping) and Chronic Bronchitis (chronic sputum, airway thickness). Irreversible.
• Asthma: Intermittent, reversible airflow obstruction and wheezing.
• COPD Compensation: Chronic respiratory acidosis occurs; kidneys retain bicarbonate ($HCO_3^-$).
• Assessment Findings:
  • Barrel chest (overinflated lungs).
  • "Blue bloater" (cyanosis).
  • Crackles that disappear after coughing; wheezing.
  • Orthopnea and poor nutrition/weight loss.
• Interventions:
  • Tripod Position: Sitting up, leaning forward with arms on overbed table.
  • Pursed-Lip Breathing: Prolongs expiratory phase to prevent bronchiolar collapse.
  • $1$ to $2\text{ L}$ of $O_2$ per nasal cannula.
  • High-calorie, high-protein small frequent meals.
• Normal ABG Values (Adult):
  • pH: $7.35-7.45$
  • $PCO_2$: $35-45\text{ mmHg}$
  • $PO_2$: $80-100\text{ mmHg}$
  • $HCO_3^-$: $21-28\text{ mEq/L}$

Cancer of the Larynx and Lung

• Larynx Cancer: Linked to alcohol and tobacco. Earliest sign is hoarseness or vocal change lasting $>2$ weeks.
  • Laryngectomy Care: Humidify air (natural pathway is gone); keep suction at bedside; monitor for bleeding/occlusion (greatest risks in first $24$ hours).
• Lung Cancer: Leading cause of cancer death. Related to cigarette smoking (80\text{%}-90\text{%} of cases).
  • Surgical Options: Thoracotomy, Pneumonectomy (position on operative side/back), Lobectomy (uses chest tubes).
  • Chest Tube Maintenance: Keep tubing below chest level; monitor for "tidaling" (fluctuation with breathing); continuous bubbling in water seal suggests air leak; do not clamp if disconnected (place end in sterile water).

Pulmonary Tuberculosis (TB)

• Description: Communicable disease caused by Mycobacterium tuberculosis transmitted by airborne droplets.
• Assessment: Fever with night sweats, weight loss, cough, hemoptysis. Positive sputum culture.
• Skin Test (TST/Mantoux): Positive in healthy clients if induration is $\ge 10\text{ mm}$. BCG vaccine causes false positives.
• Isolation: Hospitalized clients require respiratory isolation.
• Drug Therapy: Must be taken for $9$ to $12$ months. Skipping doses is a public health hazard.

Renal System: Acute Kidney Injury (AKI)

• Urine Output Standards: Normally $1\text{ mL/kg/h}$. Adult daily average is $1500-2000\text{ mL}$.
• AKI Phases:
  1. Oliguric Phase: $<400\text{ mL/day}$ (adults). Increased BUN, Creatinine, and Potassium; decreased Sodium and pH; fluid overload.
  2. Diuretic Phase: $>400\text{ mL/day}$ (up to $10\text{ L/day}$). Decreased fluid volume and Potassium; low urine specific gravity ($<1.020\text{ g/mL}$).
  3. Recovery Phase: GFR returns to 70\text{%}-80\text{%} of normal.
• Electrolytes: Potassium safety range is $3.5-5.0\text{ mEq/L}$. Hyperkalemia signs: dizziness, muscle cramps, cardiac irregularities.

Chronic Renal Failure (CRF) and End-Stage Renal Disease (ESRD)

• Etiology: Progressive, irreversible damage resulting in uremia.
• Management:
  • Low-protein, low-sodium, low-potassium, low-phosphate diet.
  • Phosphate binders (e.g., calcium carbonate) taken with food.
  • Fluid allowance: $500$ to $600\text{ mL}$ plus previous day's output.
• Uremia: Caused by protein metabolism waste. GFR is the indicator for protein consumption level.

Urinary Tract Infections (UTI) and Obstruction

• UTI Risk Groups: Diabetics, pregnant women, men with prostatic hypertrophy, catheterized clients.
• Symptoms: Frequency, urgency, dysuria, flank pain, confusion in older adults.
• Education: Consume $3\text{ L/day}$ of fluid; avoid citrus juices/alcohol; void every $2-3$ hours; take antibiotics around the clock.
• Calculi (Stones): Severe spastic pain is called "colic." Flank pain indicates kidney/upper ureter stones; radiating pain to scrotum indicates lower ureter/bladder stones.
• Management: Strain all urine; provide narcotics on a scheduled interval (not PRN) during attacks.

Benign Prostatic Hyperplasia (BPH)

• Surgical Treatment (TURP): Transurethral resection of the prostate.
• Post-TURP Care:
  • Large three-way indwelling catheter ($30\text{ mL}$ balloon) for continuous bladder irrigation (CBI).
  • Use only sterile isotonic saline for irrigation to prevent fluid shift.
  • Normal drainage is reddish pink, clearing to light pink within $24$ hours.
  • Inform client that some bleeding and small clots are normal during healing.

Cardiovascular System: Angina and Myocardial Infarction (MI)

• Angina: Chest pain when myocardial $O_2$ demand exceeds supply. Relieved by rest and nitroglycerin.
• MI: Necrosis of heart muscle due to blood supply deficiency. Pain is sudden, not relieved by rest or nitroglycerin.
• MONA Protocol: Administer Morphine, Oxygen, Nitroglycerin, and Aspirin.
• Markers: Cardiac-specific Troponin T ($cTnT$) and Troponin I ($cTnI$) are sensitive markers for myocardial injury.
• Risk Factors: Desirable Cholesterol is $<200\text{ mg/dL}$; LDL $<100\text{ mg/dL}$; HDL $>60\text{ mg/dL}$.

Peripheral Vascular Disease (PVD) and Hypertension

• Hypertension: Persistent BP $\ge 140/90\text{ mmHg}$ on two occasions. Noncompliance is the #1 cause of stroke.
• PVD Comparison:
  • Arterial: Smooth, shiny skin; loss of hair; cool temperature; sharp pain (intermittent claudication); pallor on elevation, rubor on dependency.
  • Venous: Brown pigment at ankles; warm temperature; persistent aching pain; relieved by elevation; cyanotic when dependent.
• AAA (Abdominal Aortic Aneurysm): Most common symptom is abdominal/back pain or feeling heart beating in abdomen. Bruit heard over aorta. Post-op risk: kidney damage (monitor BUN $10-20\text{ mg/dL}$ and Creatinine $0.6-1.2\text{ mg/dL}$; ratio $20:1$).

Dysrhythmias and Heart Failure (HF)

• A-Fib: Chaotic activity in AV node; no true P waves; irregular rhythm. Risk for stroke (needs anticoagulants).
• V-Fib: Cardiac emergency; NO cardiac output; requires immediate CPR and defibrillation.
• Pacemakers: Synchronous (fires on demand if HR falls) vs. Asynchronous (fixed rate).
• Left-Sided HF: Pulmonary edema; symptoms include dyspnea, crackles, cough, fatigue.
• Right-Sided HF: Peripheral edema; symptoms include weight gain, distended neck veins, ascites, hepatomegaly.
• Digoxin: Withhold and call provider if apical HR $<60\text{ bpm}$.

Gastrointestinal System: PUD and IBD

• Peptic Ulcer Disease (PUD): Often caused by H. pylori. Pain is relieved by food. Complications include hemorrhage and perforation.
  • Dumping Syndrome: Secondary to rapid entry of hypertonic food into jejunum. Manage with high-protein, high-fat, low-carbohydrate small meals; lie down after eating.
• Crohn Disease: Cobblestone appearance of mucosa; terminal ileum common; unrelieved pain; requires low-residue, high-protein diet.
• Ulcerative Colitis: Affects superficial mucosa of large intestine/rectum; constant bloody diarrhea ($10-20$ stools/day).

Liver, Pancreas, and Gallbladder

• Cirrhosis: Liver scarring. Signs: Fetor hepaticus (fruity/musty breath), Asterixis (flapping tremor), Ascites.
  • Lactulose: Used to decrease rising ammonia levels via stool excretion.
• Pancreatitis: Inflammation (often due to alcohol). Severe midepigastric pain; Grey Turner sign (flank bluish color); Cullen sign (periumbilical bluish color).
  • Treatment: NPO status; NG tube to suction; Semi-Fowler's position.
• Cholecystitis: Gallbladder inflammation. Avoid fried/fatty foods. Jaundice/clay-colored stools indicate blockage.

Endocrine: Thyroid and Adrenal Disorders

• Hyperthyroidism (Graves): Weight loss, tachycardia, heat intolerance, exophthalmos. Treat with thyroid ablation or PTU.
  • Thyroid Storm: Life-threatening; fever, agitation, hypertension.
  • Post-Thyroidectomy: Monitor for tetany (due to accidental parathyroid removal); checks for Chvostek and Trousseau signs indicating low calcium ($<9.0\text{ mg/dL}$).
• Addison Disease: Adrenocortical deficiency. Fatigue, postural hypotension, hyperpigmentation (bronzing). Needs lifelong hormone replacement.
• Cushing Syndrome: Excess adrenocorticoid activity (Moon face, Buffalo hump, truncal obesity, striae).

Diabetes Mellitus (DM)

• Diagnosis: FPG $\ge 126\text{ mg/dL}$; HbA1c \ge 6.5\text{%}; OGTT $\ge 200\text{ mg/dL}$.
• Type 1: Insulin deficiency; ketoacidosis (DKA) risk.
• Type 2: Insulin resistance; HHNKS risk (extreme hyperglycemia $>600\text{ mg/dL}$ without ketones).
• Insulin Strategy: Draw Regular (clear) insulin first, then NPH (cloudy).
• Foot Care: Wash daily; do not soak; dry between toes; cut nails straight across; no barefoot walking.

Musculoskeletal: Osteoporosis and Fractures

• Osteoporosis: Demineralization. T-score $\le -2.5$. Risk: Postmenopausal white women. Encourage weight-bearing exercise and Calcium/Vitamin D.
• Bisphosphonates (Alendronate): Take with full glass of water $30$ min before food; stay upright for $30$ minutes.
• Fractures: Assess the 5 Ps: Pain, Paresthesia, Pulse, Pallor, Paralysis.
  • Fat Embolism: Risk in first $36$ hours post-long bone fracture. Sign: Confusion due to hypoxemia.
• Amputation: Elevate residual limb for first $24$ hours (to reduce edema) but NOT after $48$ hours (prevents contracture). Turn to prone position $3\text{ times/day}$.

Neurosensory: Vision and Hearing

• Glaucoma: Increased IOP ($>22\text{ mmHg}$); painless peripheral vision loss. Pilocarpine used for pupillary constriction.
• Cataract: Opacity of lens; blurred vision. Post-op: Wear eye shield at night; avoid lifting $>5\text{ lb}$.
• Hearing Loss:
  • Conductive: Sound doesn't travel well to inner ear (wax, infection); helped by hearing aids.
  • Sensorineural: Inner ear/cranial nerve VIII damage; sound is distorted.

Neurology: Head and Spinal Injury

• Glasgow Coma Scale: Max $15$, Min $3$. Score $\le 7$ indicates coma.
• Increased ICP Indicators: Change in level of consciousness is most important. Vital signs (widening pulse pressure, erratic breathing). Keep head of bed at $30-45\text{ degrees}$; avoid hip flexion.
• Autonomic Dysreflexia: Lesions at/above $T6$. Triggered by bladder/bowel distention. Causes dangerously high BP and bradycardia.
• Myasthenia Gravis: Acetylcholine receptor antibodies. Ptosis, dysphagia, muscle weakness improved by rest.
• Parkinson’s: Coarse tremor at rest (pill rolling), masklike affect, shuffling gait. Pathology: Dopamine/acetylcholine imbalance.
• Stroke: Thrombotic or Hemorrhagic. Right brain lesion affects left body (impulsive). Left brain lesion affects right body (aphasia).

Burns and Fluid Resuscitation

• Depth:
  • 1st Degree: Superficial; dry; painful.
  • 2nd Degree: Partial-thickness; blisters; moist.
  • 3rd Degree: Full-thickness; leathery; painless.
• Rule of Nines (Adult): Head 9\text{%}, Arms each 9\text{%}, Legs each 18\text{%}, Trunk Front 18\text{%}, Trunk Back 18\text{%}, Perineum 1\text{%}.
• Stages:
  1. Emergent (Resuscitative): Begins at injury to reversal of capillary permeability ($48-72$ hours). Focus: Preserve organ function.
  2. Acute: From diuresis to nearly closed wounds. Focus: Infection control, nutrition ($5000\text{ cal/day}$).
  3. Rehabilitation: Physical/psychosocial adjustment.
• Inhalation Burn Signs: Singed nasal hair, hoarseness, sooty mucus.