EXAM 1 REVIEW MEDSURG 2

Contact Precautions

• Review institutional policy; textbook says gown only if soiling likely, but in practice BOTH gloves & gown are worn for all contact-precaution rooms.
• Typical diagnoses: major draining wounds, impetigo, lice/scabies, diarrhea from C. difficile, large HSV lesions, etc.

Common Integumentary Disorders

Dermatitis (Delayed hypersensitivity)

• Teach avoidance of irritants; skin care with mild, lukewarm bathing.
• Prevent overheating, scratching; never pop vesicles.

Acne

• Two types:
  • Acne vulgaris (teens): gentle washing + OTC benzoyl-peroxide gels.
  • Acne rosacea (adult onset).
• Do not squeeze pustules → pushes debris deeper → scarring/infection.

Psoriasis

• Non-contagious; inflamed, scaly plaques (lighter vs. darker skin pictures).
• Helpful measures: limited sunlight, dermatologist-approved emollients, humidifier, topical steroids.
• Prevent skin trauma/infection (scratches → new lesions).

Stevens–Johnson Syndrome / Toxic Epidermal Necrolysis (TEN)

• Severe allergic skin necrosis; .
• 90 % involve mucous membranes.
• Triggers: meds (Tegretol, Dilantin, Bactrim/Septra, etc.), infections, malignancy.
• Treat like burns; high mortality if unrecognized.

Bacterial Skin Infections

• Cellulitis: dermis & subQ infection.
• Furuncles/carbuncles, impetigo (post-lice scratches) – treated with antibiotics.

Viral Lesions

• HSV-1: orolabial; HSV-2: genital (either can cross sites). Direct contact spread. Lemon-balm cream can shorten outbreaks.
• Herpes zoster (shingles): unilateral dermatomal vesicles; only occurs after varicella infection. Extremely painful; vaccine recommended for older adults.

Fungal Infections

• Opportunistic (onychomycosis, tinea pedis, cruris, capitis…).
• Keep skin folds/toes dry; tea-tree oil or even BID Vicks® may help nails.
• Diabetics: avoid lotion between toes → maceration/ulcers.

Parasitic Infestations

• Lice (head, body, pubic) & scabies common in crowded/low-income settings.
• Primary symptom = intense pruritus.
• Must repeat treatment in 7 days; fine-toothed comb for nits.
• Items that cannot be laundered → seal in plastic ≥72 h.
• Watch for secondary impetigo, cellulitis.

Skin Cancer – ABCDE Rule

• Asymmetry, Border irregularity, Color variation, Diameter >6\,\text{mm}, Evolution.
• Basal cell, squamous cell, melanoma (least common, most deadly).
• Prevention: sunscreen, avoid tanning beds, yearly skin checks for numerous nevi.

Pressure Injuries

• Common over bony prominences; use Braden Scale (sensory, moisture, activity, mobility, nutrition, friction/shear).
• Staging:
  • Stage 1: non-blanchable erythema
  • Stage 2: partial-thickness dermis
  • Stage 3: full-thickness to subQ, crater
  • Stage 4: exposed bone/tendon; deep tissue
  • Unstageable: eschar/slough obscures depth.
• Do NOT use wet-to-dry; maintain moist wound bed with modern dressings.

Burns

• Primary priority: AIRWAY.
• Secondary: fluid/electrolyte balance (capillary leak).
• Infection becomes major after 48–72 h.
• Classification:
  • Rule of Nines (adult): head 9 %, each arm 9 %, each leg 18 %, anterior trunk 18 %, posterior 18 %, perineum 1 %.
  • Depth: 1° (epidermal), 2° superficial & deep partial, 3° full-thickness, 4° to bone.
• Escharotomy for tight circumferential burns (prevent compartment syndrome).

Head & Spinal Cord Injuries

Traumatic Brain Injury (TBI)

• Causes: falls, MVCs, assaults.
• Mildest form = concussion.
• Coup–contrecoup: brain hits skull front & back.
• Concussion care: cognitive rest (limit screens/homework), light activity OK, monitor for HA, dizziness, N/V.

Skull Fracture Signs

• Battle sign (mastoid bruising), raccoon eyes.
• Clear otorrhea/rhinorrhea → test for CSF halo sign.

Intracranial Pressure (ICP)

• Normal $0–15\,\text{mmHg}$; treat $\ge 20\,\text{mmHg}$.
• Early sign: ↓ LOC.
• Late Cushing’s triad: ↑SBP + widening pulse pressure, bradycardia, irregular/rapid respirations → emergency.
• Management: HOB 30°, neck midline, avoid cough/blow nose, mannitol, hyperventilation (raise RR on ventilator), possible ventricular drain.

Post-craniotomy Nursing

• Maintain head/neck alignment; seizure precautions; no nose-blowing.

Spinal Cord Injury (SCI)

• Level determines function (Table 22-1):
  • Above C5 → ventilatory support.
• Halo vest: never loosen unless patient supine.
• Autonomic Dysreflexia (T6 ↑)
  • Triggered by noxious stimulus (full bladder, tight clothes).
  • S/S: severe HA, flushing above lesion, extreme HTN.
  • Intervene: sit up, remove stimulus, call provider.

Seizures & Epilepsy

• Epilepsy = chronic, recurrent seizures (abnormal cortical discharge).
• Types:
  • Generalized: bilateral, LOC seconds→minutes.
  • Absence: brief (seconds) starring, no LOC loss.
  • Tonic–clonic: rigidity + jerking, post-ictal fatigue.
• Status epilepticus: $\ge5\,\text{min}$ continuous or serial seizures w/o recovery; emergency – risk permanent damage.

Seizure Precautions & First Aid

1. Pad rails, have O₂, suction, oral airway ready.
2. During event: protect head, turn to side, DO NOT restrain or put objects in mouth.
3. After: VS, O₂, glucose check, allow sleep, document.

Transient Ischemic Attack (TIA) & Stroke (CVA)

• TIA: neuro deficit <1 h, warning sign of impending stroke.
• Stroke types: Ischemic (clot, most common) vs Hemorrhagic.
• Recognition FAST: Face droop, Arm weakness, Speech difficulty, Time to call 911 & note last known well (eligibility for tPA).
• Post-stroke: keep NPO until bedside swallow; then speech eval.
• Aspirin ↓ platelet aggregation (not a "blood thinner"). Anticoagulants/antiplatelets held 24 h post-tPA.

Central Nervous System Infections

• Meningitis: nuchal rigidity, sudden fever, HA; positive Brudzinski & Kernig signs. Vaccinate dorm students.
• Encephalitis: photophobia, lethargy, seizures.

Headache Disorders

• Migraine: with or without aura; throbbing pain 4–72 h; dark quiet room, cold compress, trigger diary; triptans, ergots, preventives.
• Cluster & tension headaches distinguished by pattern & triggers.

Trigeminal Neuralgia

• Severe unilateral facial pain; triggers: light touch, chewing, cold drinks. Nutrition risk → use lukewarm soft diet.

Bell’s Palsy

• Acute unilateral CN VII paralysis; droop + inability to close eye.
• Care: eye patch, artificial tears, early corticosteroids, antivirals.

Degenerative & Peripheral Nerve Disorders

Parkinson’s Disease

• Dopamine deficiency; classic triad: tremor (pill-rolling), rigidity, bradykinesia; shuffling gait, hypophonia.
• Med: carbidopa-levodopa + supportive therapy, home safety.

Multiple Sclerosis (MS)

• Autoimmune demyelination; remitting–relapsing most common.
• S/S: motor, sensory, coordination, cognitive changes.
• No cure; disease-modifying drugs, low-impact exercise (swimming), manage fatigue.

Alzheimer’s Disease

• Progressive dementia; definitive plaques/tangles only on autopsy; maintain routine, safe environment, meaningful simple tasks (fold towels).

Amyotrophic Lateral Sclerosis (ALS)

• Motor neuron degeneration → progressive paralysis "outside-in"; cognition intact.
• Alternate rest/activity; eventual ventilatory failure.

Guillain–Barré Syndrome

• Autoimmune ascending paralysis ("toes up"); peaks ~14 d.
• Monitor swallowing & respiratory effort; may need walker; majority recover within 6–12 mo.

Post-Polio Syndrome

• Decades after polio: new weakness, pain, fatigue; warm-water exercise beneficial.

Huntington’s Disease

• Autosomal dominant (50 % inheritance); onset 40-50 y; chorea, cognitive & mood decline; death 15–20 y.

Myasthenia Gravis

• Autoimmune NM-junction disorder; ptosis, diplopia, chewing/swallowing difficulty.
• Small frequent meals; speech therapy for diet textures.

Restless Leg Syndrome

• Urge to move limbs at night; assess iron; dopaminergic & iron therapy; sleep hygiene.

Musculoskeletal & Connective Tissue Disorders

Soft-Tissue Injuries

• Sprain = ligament tear; Grades 1-3.
• Strain = muscle/tendon tear.
• Dislocation = complete joint displacement; subluxation partial.
• Treatment for most: RICE (Rest-Ice-Compression-Elevation) ± immobilizer/sling.

Fractures

• Types: transverse, oblique, spiral, comminuted, greenstick, open (compound), etc.
• Stabilization: closed/open reduction, internal/external fixation, traction, casts.
• Complications:
  • Osteomyelitis
  • Non-union
  • Fat embolism: petechiae chest/neck/axilla, dyspnea, neuro changes.
  • Compartment syndrome: pain unrelieved by meds, 6 P’s → fasciotomy.

Cast Care

• Keep dry, no objects inside, neurovascular checks, elevate first 24–48 h.

Osteoarthritis (OA) vs Rheumatoid Arthritis (RA)

Total Hip Replacement Precautions (first 3 mo)

• May lie on operative side.
• No leg‐crossing; keep abduction pillow when turning.
• Do not flex hip >$90^{\circ}$; avoid low chairs.
• Continue ordered exercises.

Osteoporosis

• Low bone density → fragility fractures.
• Calcium-rich diet/supplements, weight-bearing exercise.
• Bisphosphonate administration:
  • Take with full glass of water $30–60\,\text{min}$ before food/meds.
  • Remain upright $30–60\,\text{min}$ afterward.

Paget Disease

• Accelerated bone turnover → enlarged, weak bones; protect from fractures; firm mattress, brace, ergonomics.

Amputation

• Post-op: residual-limb shaping, prevent contractures, psychosocial support; possible prosthesis training.