@ShopWithKey on Etsy
Med-Surg Exam Concepts
o Crutches
Place body weight on crutches
Advance unaffected leg onto the stair
Shift weight from crutches to unaffected leg
Bring crutches and affected leg up to the stair
o Closed-suction drain nursing interventions
Negative-pressure device
Doesn’t require wall suction
*Compress the drain reservoir after emptying (creates negative pressure)
Do not need to put below bed (doesn’t use gravity)
o External fixation device
Surgeon applies the external fixation device directly to the client’s bone to form a
rigid structure around the affected extremity
Casts, boots, or splints are applied directly to the leg for internal fixation
Client should wear external fixation device continuously for a period of 4-6 weeks
Nurse should teach the client to perform care of the wound and pin sites at
home
Use crutches with rubber tips
Prevents the client from slipping and decreases fall risks
Only the provider should adjust the client’s external fixation device in order to
maintain bone alignment
o Long-term mechanical ventilation complications
Decreased cardiac output and hypotension, related to positive pressure from
mechanical ventilation inhibiting blood return to the heart
Fluid retention related to decreased cardiac output
Stress ulcers, related to elevated levels of HCl in the stomach
Increase risk for systemic infection and require pharmacological treatment
Hyponatremia, secondary to fluid retention
o Postoperative nursing interventions following mastectomy
Instruct client that the drain will remain in place for 1-3 weeks after surgery and will
be removed when there is 25 mL of output or less in a 24-hour period
Instruct client to start exercising the arm on side of surgery 24 hours after surgery
Elevate arm on surgical side on a pillow to promote lymphatic fluid return
Nurse should elevate the head of the client’s bed to at least 30 degrees to promote
drainage from the surgical site and facilitate breathing
o Patient teaching for active tuberculosis
Sputum specimens are necessary every 2-4 weeks until there are three negative
cultures
After 3 negative cultures, the client is no longer considered infectious
Client’s infection is usually no longer contagious after taking TB medications for 2-3
weeks
Family members do not need to follow airborne precautions because they have
already been exposed to TB
@ShopWithKey on Etsy
o
o
o
o
o
o
o
A follow-up evaluation of the client’s TB should be performed using a chest x-ray
because the TB skin test is no longer considered accurate after a person has tested
positive
Nursing interventions following total hip arthroplasty
Assist client to maintain legs in abduction
Client should not flex hip greater than 90 degrees to prevent hip dislocation
Nurse should place a pillow between client’s legs to prevent hip dislocation
Nurse should not keep client’s hip internally rotated, as this can lead to hip
dislocation
Patient teaching on kidney organ donation
Client who is recipient of organ donation will require lifelong immunosuppressive
therapy to protect against transplant rejection
A healthy donor who has one kidney can manage the body’s urinary excretion
requirements
Client’s nonfunctioning kidney remains in the body until transplant surgery, unless
the client has chronic kidney infection or pain
A client who receives a kidney from live donor has a lower rate of transplant rejection
Client who receives a kidney from a live donor has a lower rate of transplant
rejection because the donor is often more medically compatible than a donor
who is deceased
Patient teaching about prevention of atherosclerosis
Smoking cessation
Maintain an appropriate weight
Eat a low-fat diet
MRSA precautions for health care professionals
Client should wear an isolation gown and wash hands before being transported from
the room to prevent spread of micro-organisms
Nurse should bathe client using warm water and a chlorhexidine solution to prevent
the spread of micro-organisms
Use dedicated assessment equipment when assessing the client and leave in room to
prevent cross-contamination with other clients
Mode of transmission = contact
Nephrostomy expected findings
Red-tinged urine during the first 12-24 hours
Normal BUN
Increased urine output (notify provider for decreased UO)
NOTIFY PROVIDER FOR BACK PAIN
Can indicate the tube is dislodged or clogged
Nursing interventions for dysrhythmias
Defibrillation for ventricular tachycardia or ventricular fibrillation
Cardioversion for all other dysrhythmias
CPR for a client who is pulseless or not breathing
Lidocaine IV bolus for a client who has ventricular dysrhythmia
Seizure precautions
Client should limit intake of alcohol or caffeine, minimize stress, fever, and fatigue to
prevent triggering a seizure
@ShopWithKey on Etsy
o
o
o
o
o
o
Nurse should keep 2-3 side rails up to prevent falls
Keep client’s bed in lowest position to prevent falls
Ensure client has patent IV access in the event that the client requires medication to
stop seizure activity
Nursing interventions for blood transfusions
Priority = check for the type and number of units of blood to administer
Obtain baseline vital signs for comparison
Describe blood transfusion to promote client understanding
Ensure client has a large-bore IV access to prevent hemolysis during transfusion
Patient teaching for insulin lispro
Rapid-acting insulin that the client can use in conjunction with intermediate or longacting insulins
Client should inject the medication subcutaneously into the abdomen, upper thigh, or
arm
Nurse should instruct client that insulin lispro is rapid-acting and the client should
administer immediately before eating or immediately after eating
Instruct the client to continue taking insulin lispro as prescribed during times of
illness, and notify provider of the illness
Patient teaching for metformin
Decreases the amount of glucose produced in the liver and increases tissue sensitivity
to insulin
Client should take metformin with or immediately following meals to improve
absorption and to minimize GI distress
Clients typically lose weight when beginning metformin due to N/V
Adverse effect = rash
Evisceration nursing interventions
Priority = call for help
Cover the wound with sterile, saline-moistened dressing to protect organs
Monitor client’s vital signs to monitor for complications
Place client in supine position to promote blood flow to organs
Blood transfusion complication interventions
Bacterial transfusion reaction = antibiotic
Manifestations: hypotension, tachycardia, shock
Febrile transfusion reaction = antipyretic, acetaminophen
Manifestations: tachycardia, fever, hypotension, chills
Circulatory overload from transfusion: loop-diuretic, furosemide
Manifestations: dyspnea, hypotension, hypertension, distended neck veins
Allergic transfusion reaction: antihistamine, diphenhydramine
Manifestations: urticarial, itching, flushing, bronchospasms, anaphylaxis
Central venous catheter nursing interventions
Place client in Trendelenburg position with a rolled towel between client’s shoulder
blades
Position facilitates the insertion of the catheter by dilating blood vessels of the
client’s neck and shoulders
Goes into subclavian vein
@ShopWithKey on Etsy
o Hormone replacement therapy adverse effects
Urgent effects (contact provider)
Calf pain (indicates DVT)
Numbness of the arms (indicates possible CVA)
Intense headache (indicates possible CVA)
Nonurgent effects (manifestation of menopause)
Night sweats
Vaginal dryness
o Thoracentesis nursing interventions
After thoracentesis, client should deep breathe to re-expand lungs
Place client in upright position with arms resting on an overhead table to widen the
intercostal space and spread ribs for tube insertion
Nurse should assist a client who cannot sit up into a side-lying position with
the affected side up
Client should receive local anesthetic for the procedure and will not require NPO
status after midnight
Instruct client to resume activity within 1 hour following procedure
o Arterial lines nursing interventions
Used to obtain arterial blood gases and monitor hemodynamic pressures
Most appropriate position of a client while recording values obtained from an arterial
line is supine with the head of the bed elevated up to 60 degrees
Nurse should place a pressure bag around the flush solution of 0.9% sodium chloride
because the pressure from an artery is greater than that of the line
o Patient teaching of heparin
Instruct the client to report any bleeding or bruising to provider
Instruct the client to avoid flossing
Instruct client to apply firm pressure to injection site 1-2 minutes but to avoid
massaging
Instruct the client to use an electric razor when shaving to reduce the risk of cuts to
the skin
o Patient teaching for ureterostomy
During procedure, client’s bladder is removed and the ureters are brought to the skin
surface of the abdomen to form a stoma from which urine will flow into ostomy bag
Client will not have urge to void
Drink 2-3 L of fluid per day to reduce mucus formation and maintain hydration
Client should cut the opening of the skin barrier 1/8-inch wider than the stoma to
minimize irritation of the skin from exposure to urine
Client should avoid using moisturizing soaps to clean the skin around the stoma
because it will prevent the pouch from adhering to the skin
o COPD expected findings
Increase in PaCO2, because COPD retains PaCO2 due to the weakening and the
collapse of the alveolar sacs, which decreases the area in lungs for gas exchange and
causes the PaCO2 to increase above the expected reference range
pH below expected range
Increased HCO3 levels
Low oxygen level
@ShopWithKey on Etsy
o Chronic glomerulonephritis expected findings
Metabolic acidosis
Hyperkalemia
Kidney failure results in decreased excretion of potassium
Anemia, as a result of decreased RBC production
Hyperphosphatemia, as a result of decreased excretion of phosphorus through kidneys
o Patient teaching for venous insufficiency
Maintain an exercise regimen, such as routine walking, to decrease venous stasis
Avoid sitting or standing for prolonged periods of time due to risk of developing
DVT or skin breakdown
Apply a clean pair of graduated compression stockings each day and clean soiled
stockings with mild detergent and warm water by hand
Elevate legs above heart level while in bed to facilitate venous return and avoid stasis
o Sedimentation rate increases when a client has any type of inflammatory process
o Drug and herb interactions
Kava and Valerian can cause CNS depression when taken with bupropion
Feverfew and naproxen can impair platelet aggregation and place the client at risk for
bleeding
St. John’s Worst can decrease effect of atorvastatin
o Erythropoietin patient teaching
A client should have adequate iron stores for erythropoietin therapy to be effective, so
provider may prescribe iron supplements
Goal of therapy is to increase level of hematocrit in clients with anemia
When medication is effective, client should have a decrease in fatigue and an
improvement in activity tolerance
Can result in hypertension
o Holter monitor
Records and transmits electrical impulses of the heart and alerts the nurse to
dysrhythmias, myocardial injury, or conduction defects
Allows the client freedom of movement while cardiac activity is recorded
o Patient teaching for metered dose inhaler
Breath in slowly a
nd deeply while administering the medication to receive the maximum effect
Rinse the plastic case and cap of the inhaler with warm running tap water once daily
or soak it in a pint of water with 2 oz. of vinegar once a week
Client should hold breath for 10 seconds after inhaling so medication can move deep
into airways
Wait at least 1 min between puffs on inhaler so each dose has adequate time for
maximum effectiveness
o Patient teaching for radiation treatment
Client should not remove markings until the course of radiation is complete because
radiation markings ensure consistent dose delivery to the target area
Client should avoid exposure of irradiated skin areas to the sun for at least 1 year after
completing radiation therapy
Skin in radiation path is especially sensitive to sun damage
@ShopWithKey on Etsy
o
o
o
o
o
o
o
Head and neck radiation can damage the salivary glands and cause dry mouth,
predisposing client to mucositis
Rinse mouth with plain water or 0.9 NaCl
Compartment syndrome manifestations
Results from a decrease in blood flow in the extremity because of a decrease in the
muscle compartment size due to a cast that is too tight
Diminished pulse or pulselessness, due to lack of distal perfusion cause by a decrease
in the muscle compartment size
Capillary refill greater than 2 seconds due to lack of distal perfusion and venous
congestion cause by a decrease in the muscle compartment size
Pain that increases with passive movement
Patient teaching for AIDS
Client should clean toothbrush weekly in the dishwasher or in a bleach solution
Client should avoid eating raw fruits and vegetables that can contain bacteria and
cause infection
Client should avoid drinking a glass of liquid that stands for 60 min or more to reduce
risk of drinking contaminated liquids
Check temperature daily to identify a temp greater than 100 degrees
Early manifestation of infection
Nursing interventions for flail chest
Prepare the client for positive pressure ventilation to promote lung expansion and
stabilize the pressure within the client’s chest
Administer analgesics to alleviate pain while breathing and achieve optimal lung reexpansion
Client can have hypotension and dyspnea
Do not have client do activity that can further decrease cardiac output
(Valsalva maneuver)
Do not give anticoagulants, because client already at risk for bleeding
Position client on opposite side of flail chest to promote lung expansion
Medication that increases risk for osteoporosis = corticosteroids
Nursing interventions for plasmapheresis
Check electrolyte levels before and after therapy
Can cause citrate-induced hypocalcemia
Assess and palpate the access site every 2-4 hours for the presence of a bruit or thrill
Instruct client to report redness or swelling at the access site, because it’s an
indication of infection
Assess and document vital signs at least every 8 hours to identify complications with
treatment
Zenker’s diverticulum
Also called pharyngeal pouch
Herniation of the esophagus occurring through the cicopharyngeal muscle in the
midline of the neck
Repair is accomplished through an open incision in the client’s neck
Incisions for surgeries
Right subcostal incision = open cholecystectomy
@ShopWithKey on Etsy
o
o
o
o
o
o
o
Midline abdominal incision = gastric surgery
Umbilical incision = umbilical hernia repair
Hypokalemia
Decreases smooth muscle contraction
Decreased peristalsis
Hypoactive bowel sounds
Burn nursing interventions
Hand burn – wrap the fingers individually to allow for functional use of the hand
while healing occurs
Nurse should instruct the client to perform range of motion exercises to each
finger every hour while awake to promote function of the injured hand
Nurse should instruct the client to take pain medication 30 minutes before a dressing
change to decrease the level of pain during the procedure
Client who undergoes surgery to receive skin grafts for full-thickness burns should
elevate and immobilize the graft site with cotton pressure dressings for 3-5 days
following the procedure
This prevents the graft from dislodging and allows for revascularization of the
wound
Nurse should instruct the client to change the dressing every 12-24 hours to allow for
wound inspection
Client should observe the wound closely for manifestations of increased
redness, warmth, drainage, edema, or foul odor (signs of infection)
Magnesium sulfate IV bolus
Used to treat cardiac dysrhythmias, such as torsades de pointes and refractory
ventricular fibrillation
Monitor client closely because adverse effects can impact the CNS, cardiovascular
system, and respiratory system
Respiratory paralysis = life-threatening adverse effect of magnesium sulfate
Depressed cardiac function, including heart block
Systemic vasodilation and hypotension
Hypomagnesemia
Hyperreflexia
Hypermagnesemia
Hyporeflexia
Fluid overload manifestations
Distended neck and hand veins
Pale, cool skin
Skin pitting/edema
Increased blood pressure
Anaphylactic reaction
Monitor airway
Prepare to administer oxygen then epinephrine
Manifestations:
Facial flushing (vasodilation)
Hypotension
Urinary incontinence
@ShopWithKey on Etsy
o Lyme disease
Vector-borne illness transmitted by the deer tick
Disease course occurs in three stages beginning with joint and muscle pain in stage I
If left untreated, symptoms continue throughout stage II and by stage II become
chronic
Other chronic complications include memory problems and fatigue
Affects the body systemically, involving neurologic, musculoskeletal, and cardiac
systems
Cardiac manifestations: carditis and dysrhythmias
Treated with antibiotics
Stage II will be prescribed 30-day course of antibiotics
Take the full course of antibiotics
o IV urography
Uses contrast media
Ask for allergy to shellfish, iodine
Watch closely for anaphylactic reaction
o Swollen lips
Pain at IV site = possible IV infiltration
Contrast media places client at risk for extravasation of tissues
Decreased urine output can indicate renal impairment from contrast media
Expected finding = pink-tinged urine
Encourage client to increase fluid consumption
o Verapamil patient teaching
Client should monitor heart rate and blood pressure while taking this medication and
inform the provider if pulse is less than 60/min
Client should avoid drinking grapefruit juice while taking medication because places
client at risk for toxicity
Constipation is an adverse effect
Increase fiber intake
o Epoetin alfa patient teaching
Monitor blood pressure while taking this medication because hypertension is a
common adverse effect and can lead to hypertensive encephalopathy
Client requires adequate intake of iron (red meat), folic acid (cereals), B12 vitamin
while taking this medication because they are essential for making erythrocytes
Increased appetite is an indication of a therapeutic response to this med
Client should increase amount of protein in diet while receiving chemo to decrease
risk for infection
o Diabetic ketoacidosis nursing interventions
Give regular insulin IV bolus
Regular insulin is a fast-acting insulin that can be effective within 10 minutes
when administered IV
Treatment goal for a client who has DKA is to reduce blood glucose level by 50-75
mg/dL every hour, which requires a fast acting insulin
o NPH insulin
Long-acting insulin
Onset: 1.5-4 hours
@ShopWithKey on Etsy
o Blood transfusion (PRBCs)
Nurse should remain with the client for the first 15-30 minutes of the infusion
because hemolytic reactions usually occur during the infusion of the first 50 mL of
blood
Nurse should use 0.9% sodium chloride when transfusing blood to prevent clotting or
hemolysis of RBCs
Nurse should ensure the name and number on the client’s ID band matches the name
and ID number on the blood label
Client’s ID, blood compatibility, and expiration date of blood should be verified by
TWO nurses
Nurse should transfuse packed RBCs within 2-4 hours based upon the client’s age
and cardiovascular status
Longer infusion times increase the risk for bacterial contamination of the
blood product
o Extracorporeal shock wave lithotripsy (ESWL)
Procedure to break up renal calculi so that the fragments pass down the ureter, into
the bladder, and through the urethra during voiding
Following the procedure, the nurse should strain the client’s urine to confirm
the passage of stones
Fever following procedure is a complication that is a result of micro-organisms from
an underlying UTI colonizing or pyelonephritis
Decrease in urine output following the procedure is a complication caused by stone
fragments obstructing urine flow
Bruising on the LOWER BACK or FLANK of the affected side caused by repeated
shock waves is normal
o Pain management
Acetaminophen is used for relief of mild to moderate pain but has a maximum dose
of 4 grams per 24 hr for adults
Reduced dosage of 3 g per 24 hr is recommended for older adult clients
Common adverse effect of ibuprofen is GI bleeding, and older adult clients have an
increased risk for GI toxicity and bleeding
Meperidine is contraindicated for older adult clients experiencing pain
Potential accumulation of the toxic metabolite normeperidine can result in
CNS toxicities
Oxycodone causes constipation
Nurse should monitor and initiate a bowel regimen to minimize constipating
effects
o Seizure nursing interventions
DO NOT INSERT ANYTHING IN CLIENT’S MOUTH
Supplemental oxygen is not usually necessary during seizures
Nurse should not restrain the client in any way during the seizure but instead should
clear the area of objects close to the client to prevent injury
Nurse should loosen tight, restrictive clothing to prevent injury and suffocation
o Cushing’s disease manifestations
Oversecretion of glucocorticoids (cortisol)
Muscle atrophy, especially extremities
@ShopWithKey on Etsy
o
o
o
o
o
o
Truncal obesity with fatty neck, back, and shoulders
Bruising and striae from fragile vessels
Electrolyte imbalances
Hypertension, full bounding pulses (fluid overload)
Granulating wounds
Appropriate dressings include hydrocolloid and transparent film dressing
Hydrogen peroxide should not be used on wounds because it destroys newly
granulated tissue
Use wound cleansers or 0.9% sodium chloride to irrigate the wound
Nurse should use a 30-60 mL syringe with a 18-19 gauge catheter to deliver the ideal
pressure of 8 pounds per square inch when irrigating the wound
To maintain healthy granulation tissue, the wound irrigation should be
delivered between 4-15 psi
Hepatitis C
Enzyme immunoassay (EIA) is completed to screen a client who has suspected hep C
virus to confirm the diagnosis and identify the hep C antibodies
Levels of ALT are elevated in acute cases of hepatitis
Levels of total bilirubin are elevated in clients who have hepatitis and in clients who
have jaundice
Detached retina
Separation of the retina from the epithelium
Occurs because of trauma, cataract surgery, retinopathy, or uveitis
Clients typically report the sensation of a curtain being pulled over their visual field
“Curtain closing over eye”
May report sudden flashes of light or floating dark spots
Usually painless
Sudden onset
Cardiovascular dysfunctions
Murmur: sustained swishing or blowing sound caused by turbulent blood flow
through a valve, vessel, or heart chamber
S4 (atrial gallop): involves an extra heart sound that occurs before S1, resulting from
decreased ventricular compliance
Pericardial friction rub: scratchy, high-pitched sound associated with infection,
inflammation, or infiltration and can be a manifestation of pericarditis
S3 (ventricular gallop): extra heart sound immediately following S2, and is caused by
decreased vascular compliance
Compensatory shock manifestations
Increase of heart rate
Narrowing of pulse pressure – body’s attempt to maintain homeostasis and tissue
perfusion
Systolic blood pressure decreases
Diastolic blood pressure increases
Increase in respiratory rate to 20/min or greater
Hypoactive bowel sounds
CT scan contraindications
Allergy to:
@ShopWithKey on Etsy
o
o
o
o
o
Shellfish
Iodine
Eggs
Milk
Chocolate
History of (because of increased risk of renal failure):
Diabetes mellitus
Renal impairment
Heart failure
Type I diabetes and illness
Continue insulin regimen when ill to prevent hyperglycemia
Notify provider if moderate to large ketones appear in urine
Monitor glucose levels every 4 hours when ill
Notify provider if blood glucose level is greater than 250
Amphotericin B adverse effects
Damage to kidneys (nephrotoxic)
Hypokalemia
Hyponatremia
Hypomagnesemia
Bone marrow suppression and a decreased hematocrit
Hypertonic dehydration manifestations
Elevated sodium level
Skin turgor tents
Turgor more reliable than limbs on older adult clients
Respiratory rate increases because decreased vascular volume decreases oxygen and
perfusion
Urine specific gravity greater than 1.030 indicates a decrease in urine volume and an
increase in osmolarity
Homonymous hemianopsia
Blindness in the same visual field of both eyes caused by damage to the optic tract or
occipital lobe
Necessary to turn head to see entire visual field
Occurs with strokes
Diabetic patient teaching on travelin
Instruct client to take additional pairs of shoes and change shoes several times
throughout the day to prevent injury to feet
Purchase shoes that are not open-toed sandals or have straps between the toes
as they can result in foot injury
Should not wear the same pair of shoes for consecutive days
Instruct client to carry-on insulin, rather than placing it in luggage and avoid exposing
insulin to excessive hear, cold, light, and shaking as it can degrade insulin
Client can store unfilled needles in a plastic bag in the bottom of luggage if
desired
Prefilled syringes must be refrigerated and stores with needles facing upward
to prevent needle clogging
@ShopWithKey on Etsy
o
o
o
o
o
o
Client should test urine for ketones during sick days or when glucose levels are
consistently higher than 240
Do not adjust insulin levels based on weight gain
Kidney transplant
Transplant can come from living or deceased donor
Lifelong immunosuppressive therapy is necessary for the organ recipient
When a kidney comes from a deceased donor, it may not function immediately,
requiring the recipient to continue hemodialysis post-operatively
Cardiovascular disease is major cause of death following a kidney transplant
Meds that can alter allergy skin tests:
ACE inhibitors
Beta-blockers
Theophylline
Nifedipine
Glucocorticoids
Adverse effects of morphine
Cough suppression
Instruct client to cough at frequent intervals to reduce risk of accumulating
fluids in respiratory tract
Slows motility and causes constipation
Nurse may have to administer a laxative or stool softener
Urinary retention
Frequently monitor urinary output and check for bladder distention
Pupillary constriction (miosis)
Client at risk for injury due to impaired vision
Provide adequate lighting when client is awake
Cushing’s triad
Irregular respirations
Severe hypertension
Bradycardia
Occurs in clients with increased intracranial pressure
UTI health promotion
Take showers instead of tub baths to prevent bacteria (present in bath water) from
entering the urethra
Drink 2-3 L of fluid daily to keep urine dilute and flush bacteria out of urinary tract
Encourage client to wear underwear made of cotton, which provides improved
airflow through the perineal area
Empty bladder before and after intercourse
TB health promotion
Inform client that are no longer contagious after 2-3 weeks of continuous medication
therapy or following 3 consecutive negative sputum cultures, which are obtained
every 2-4 weeks
Instruct client to cover mouth when sneezing or coughing, and to place contaminated
tissues in a PLASTIC bag for disposal
Airborne precautions are not necessary in home because household members have
already been exposed to TB
@ShopWithKey on Etsy
o
o
o
o
o
o
o
Client should wear a mask in public
Family members in the same household with client should be screened for TB to
foster early detection and treatment
Cardiac catheterization
Hematoma formation nursing interventions
Greatest risk = bleeding
Apply firm pressure to stop bleeding
Gout patient teaching
Avoid aspirin and diuretics as these meds are known to precipitate an attack that
causes pain and inflammation in the joints
Follow a low-purine diet and avoid foods, such as organ meats and shellfish, to
prevent precipitating an attack
Should eat and drink food such as citrus fruits/juice, milk, and other dairy products to
increase urinary pH
Increasing urinary pH decreases the risk of precipitating an attack
Client should take prescribed colchicine, indomethacin or corticosteroid
Allopurinol is used to lower uric acid after initial manifestations of an acute
attack have resolved
Upper GI series with barium contrast discharge teaching
Instruct the client to increase fluid intake to facilitate the elimination of the barium
(contrast media) used during the test
Instruct the client to take a laxative to eliminate the barium
Expect stools to appear chalky white until the barium is completely eliminated
Typically takes 24-72 hours
Increase fiber intake
Diabetes insipidus manifestations
Low urine specific gravity
Between 1.001 and 1.005
Hypernatremia
Hypotension due to dehydration caused by excessive excretion of urine
Weak peripheral pulses
Polydipsia
Polyuria
Closed-chest drainage system for pneumothorax
Nurse can gently milk the chest tube to release clots
Bubbling in water seal chamber ceases when the lungs re-expand
Presence of tidaling in the water seal chamber results from the client’s inhalation and
exhalation and
Compartment syndrome manifestations
Pain at surgical site when moving
Pallor
Cold temperature
Paraesthesia of extremity
Right-hemispheric CVA manifestations
Visual spatial deficits and loss of perception
Left hemianopsia
@ShopWithKey on Etsy
o
o
o
o
o
One-sided neglect
Left-hemispheric CVA manifestations
Expressive aphasia
Right hemiplegia
One-sided neglect
Cardiac medications
Dopamine: give to client in cardiogenic shock because produces inotropic effect and
improves cardiac output by strengthening force of contractions
Increases blood pressure by causing vasoconstriction of blood vessels
Nitroglycerine: vasodilator that decreases cardiac preload and afterload
Decreases blood pressure
Nitroprusside: vasodilator that decreases cardiac preload and afterload by causing the
arterial and venous smooth muscles to relax
Decreases cardiac output
Decrease blood pressure
Morphine: opioid analgesic and vasodilator that can decrease cardiac preload and
afterload
Decreases blood pressure
Oxygen delivery systems
Nonrebreather mask
Provides the highest concentration of oxygen (80-95%)
Use for client who has unstable respiratory status
Venturi mask
Use for client who requires an exact oxygen flow
Delivers oxygen concentration between 24-50%
Use for COPD
Simple face mask
Use for client who requires short term supplemental oxygen
o Does not usually fit well and can lead to skin breakdown
Can deliver oxygen concentration between 40-60%
Partial rebreather mask
Use for client who can sustain adequate oxygen saturation levels with a
mixture of room air and oxygen
Allows a portion of room air to be inhaled along with oxygen, diluting oxygen
concentration to a range between 60-75%
Rheumatoid arthritis patient teaching
Client should consume a balanced diet high in nutrients, such as protein, vitamins,
and iron to promote tissue repair
Nurse should instruct client to alternate heat and cold applications to decrease joint
inflammation and pain
Application of cold can relieve joint swelling
Application of heat can decrease joint stiffness and pain
Regular exercise is important to prevent stiffness
C. diff contact precaution interventions
@ShopWithKey on Etsy
o
o
o
o
o
Remove protective gloves before leaving the room of a client with contact
precautions
Leave a dedicated stethoscope in the room for blood pressure monitoring to avoid
spread of infectious organisms to other clients
Cardiac measurements
Cardiac output: heart rate times stroke volume, measures the amount of blood ejected
by the heart over 1 minute
Echocardiogram: non-invasive ultrasound procedure, evaluates heart valve function
and structure
Telemetry: detects the ability of cardiac cells to generate a spontaneous and repetitive
electrical impulse through the heart muscle
Cardiac catheterization: measurement of coronary artery blood flow
Pancreatitis expected findings
Decreased calcium and magnesium levels, due to fat necrosis
Elevated amylase level
Blood transfusion reactions
Hemolytic reaction
Result from incompatible blood products and create a systemic inflammatory
response
LOW BACK PAIN
Hypotension
Tachycardia
Apprehension
Allergic transfusion
Can occur up to 24 hours following a transfusion
Anaphylaxis
Urticaria
Bronchospasm
Circulatory overload
Occurs when infusion rate is faster than client can tolerate
Hypertension
Restlessness
Bounding pulse
Autonomic dysreflexia
Diaphoresis above the site of spinal cord injury
Sudden, significant rise in blood pressure
Bradycardia
Severe headache
Flushing
Tachypnea
Interventions:
First > ELEVATE HEAD OF BED
Cirrhosis lab findings
Increased prothrombin time
Elevated bilirubin
Elevated ammonia
@ShopWithKey on Etsy
o
o
o
o
o
o
o
o
Decreased albumin
Cardiogenic shock manifestations
Hypotension
Tachypnea
Cool, clammy skin
Decreased urinary output
IM needle aspiration protocol
If aspiration has blood it indicates improper needle placement
Medication and needle are now contaminated
Nurse should dispose of medication and obtain a new dose of mediation,
syringe, and needle
Hypocalcemia
Manifestation of kidney failure
Occurs in dialysis treatments
Manifests as muscle cramping and tingling in extremities
Administer a calcium supplement > calcium carbonate
Pneumonia nursing interventions
Monitor for confusion, because pneumonia can cause hypoxia
Encourage client to use incentive spirometer every hour while awake
Drink at least 2 L of fluid daily
Maintain SaO2 at 95% or higher to prevent hypoxia
Levothyroxine
Calcium supplements work as antacids and interfere with meds
Nurse should instruct client to avoid taking calcium within 4 hours of levo
administration
Mannitol
Osmotic diuretic that caused increased diuresis
Adverse effects:
Nasal congestion
Can cause edema
o Report crackles/pulmonary edema to provider
Radiation patient teaching
Do not remove ink markings
Client should gently wash the radiation area with hands using warm water and mild
soap to protect skin from further irritation (NOT A WASHCLOTH)
Client should avoid being in direct sunlight during radiation treatments and for at
least a year following the conclusion of therapy
Client should avoid exposing the treatment area to heat as this can cause further
irritation to the skin
Sublingual nitroglycerin
Instruct client to allow the tablets to dissolve under the tongue or between cheek and
gums
Moisten mouth if dry
Onset of relief should begin 1-3 minutes after administration
If client’s chest pain has not eased in 5 minutes, client should take another
tablet and call 911
@ShopWithKey on Etsy
o
o
o
o
o
Nitroglycerin is inactivated by heat, light, and moisture
Nurse should instruct the client to keep the medication in its original dark
glass container with the lid closed tightly
Client should take the medication at the onset of angina, regardless of food intake
Instruct client to lie down after taking the medication because hypotension can occur
quickly, leading to dizziness and syncope
Sealed radiation implant nursing interventions
Nurse should keep a lead-lined container and forceps in the client’s room in case of
accidental dislodgement of the implant
Restrict each visitor to 30 minutes per day to limit exposure to radiation
Nurse and other hospital staff should wear a dosimeter badge when in the client’s
room to monitor exposure to radiation
Nurse should keep all soiled linens in the client’s room until the client has had the
radiation implant removed
Fat embolism
Occurs from broken bone
Manifestations:
Dyspnea
Tachypnea
Decreased arterial oxygen level
PICC line nursing interventions
Flush with 5-10 mL of normal saline before and after medication administration to
prevent medication interaction from occurring and to ensure client receives the full
dose
Change gauze dressings on site every 48 hours and transparent dressings every 7 days
When removing transparent dressing, nurse should remove it by gently pulling
it from the sides to avoid dislodging the catheter
Nurse should administer an intermittent IV bolus dose of heparinized saline to flush a
PICC line when it is not in use
Plan to administer a thrombolytic agent (alteplase) in the event a PICC line becomes
clotted and a blood return cannot be obtained
Warfarin
Want INR between 2-3
Heparin
Therapeutic range is 1.5-2 times the expected reference range of 30-40 seconds
@ShopWithKey on Etsy
MED SURG LECTURE STUDY GUIDE
1. NERVOUS SYSYEM
Procedures
Cerebral Angiography
Visualization of cerebral blood vessels; detects defects, narrowing or obstruction of
blood vessels in the brain
Pre-procedure: NPO 4-6 hr prior; assess for allergy to shellfish or iodine, hx of
bleeding or anticoagulants, labs (BUN, creatinine)
Post-procedure: monitor for clotting; assess insertion site; assess extremity distal to
puncture site; apply pressure over artery if and notify provider if bleeding occurs
CT Scan
Cross sectional images of cranial cavity; detects tumors, infarctions, abnormalities,
treatment response and need for biopsies
Pre-procedure: NPO at least 4 hr prior; assess for allergy to shellfish or iodine; labs
(BUN, creatinine); remove jewelry; place pillows to prevent back pain
Glasgow Coma Scale
Determines neurologic function, LOC and response to treatment; used for head
injuries, space-occupying lesions, cerebral infarctions and encephalitis
ICP Monitoring
Device inserted into cranial cavity; used for Glasgow scale of 8 or less or less
High risk of infection
Inc. ICP S/S: irritability (early sign), restlessness, HA, dec. LOC, pupil abnormalities,
abnormal breathing, abnormal posturing (decorticate or decerebrate)
Normal ICP 10-15 mmHg
Lumbar Puncture
Taking sample of patient CSF from spinal canal for analysis; used to diagnose MS,
syphilis, meningitis and infection
Pre-procedure: pt. should void first; position in cannonball position or stretch over
bedside table
1
@ShopWithKey on Etsy
Post-pt. lay flat for several hours
CSF leakage may lead to severe HA; administer pain medication and increase fluids
Epidural blood patch if needed
MRI
With or w/o contrast dye
Assess for pt. allergy to shellfish or iodine; assess for hx of claustrophobia
Have pt. remove all jewelry and have no metal implants (pacemaker, artificial heart
valve, IUD, etc.)
Meningitis
Inflammation of the meninges (membranes surrounding brain and spinal cord)
Viral is most common and usually resolves on its own without tx
Bacterial is highly contagious and has a high mortality rate; requires antibiotics
Prevention: Hib vaccine (children), MCV4 vaccine (given before going to college)
S/S: HA, neck rigidity, photophobia, N/V, positive Kernig and Brudzinski’s signs
o Kernig: pt. is supine, bring up leg and to straighten it, would be painful
o Brudzinski: pt. is supine, lift neck up, causes pain and causes pt. to flex knees
Diagnosis: lumbar puncture
o Bacterial-cloudy fluid and dec. glucose content, elevated protein and WBC
o Viral-clear fluid, elevated protein and WBC
Droplet precautions, quiet environment, low lighting, elevated HOB (30 degree),
monitor for s/s of inc. ICP, avoid coughing and sneezing, seizure precautions
Phenytoin-anticonvulsant
Seizures
Uncontrolled electrical discharge of neurons in the brain; epilepsy (chronic seizures)
Risk factors: fever, cerebral edema, infection, exposure to toxins, brain tumors,
hypoxia, ETOH and drug withdrawal, F/E imbalances
Triggers: stress, fatigue, caffeine, flashing lights
Types:
o Tonic-clonic: may or may not preceded by aura (visual/auditory
disturbance), tonic episode (stiffening of muscles and loss of consciousness),
clonic episode (1-2 minutes of rhythmic jerking of extremities), post-ictal
phase (confusion and drowsiness)
o Absence: loss of consciousness for a few seconds; blank stare/eye
fluttering/lip smacking/picking at clothes
o Myoclonic: brief stiffening of extremities
o Atonic: loss of muscle tone; high fall risk
o Status epilepticus: repeated seizure activity within 30 minutes or single
seizure that lasts longer than 5 minutes; medical emergency
Diagnosis: EEG
Turn pt. on side, loosen restrictive clothing, never insert an airway or restrain them,
clear the area, document onset and duration, check pt. VS, reorient pt., implement
seizure precautions (padding bedrails)
Meds: phenytoin
Craniotomy removes tissue from brain that is causing seizures
Parkinson’s and Alzheimer’s’
Parkinson’s
2
@ShopWithKey on Etsy
Caused by degeneration of substantia nigra resulting in too little dopamine and too
much acetylcholine
S/S: tremor, muscle rigidity, slow shuffling gait, bradykinesia (slow movements),
mask-like expression, drooling, difficulty swallowing
Monitor swallowing and food intake; thicken food and have pt. sit upright to eat;
suction equipment available for aspiration; encourage ROM and exercise; assist with
ADLs as needed
Levidopa-carbadopa: increases dopamine levels
Benztropine: anticholinergic
Alzheimer’s
Non-reversible dementia that results in memory loss, personality changes and
problems with judgement
Stages:
o 1: not much impairment
o 2: forgetfulness, but no memory problems
o 3: mild cognitive deficits; short-term memory loss noticeable to family
members
o 4: personality changes; obvious memory loss to others
o 5: assistance with ADLs is necessary
o 6: incontinence; pt. may start to wander
o 7: impaired swallowing; ataxia; no ability to speak
Maintain structured environment; short directions; repetition; avoid
overstimulation; use single day calendar; provide frequent reorientation; maintain
routine toileting schedule
Home safety: remove rugs, install door locks, good lighting, mark step edges with
colored tape
Medications: donepezil (prevents breakdown of acetylcholine; improves pt. ability
to perform ADLs)
MS, ALS and MG
MS
Autoimmune disorder that causes plaque to develop in white matter in CNS
Risk factors: 20-40 years old, female
Triggers: temp. extremes, stress, injury, pregnancy, fatigue
S/S: double vision, nystagmus, muscle spasticity and weakness, bowel or bladder
dysfunction, cognitive changes, tinnitus, hearing issues, dysphagia, fatigue
Medication: immunosuppressive agents (cyclosporine, prednisone), muscle
relaxants (dantrolene, baclofen)
ALS
Degenerative neurological disorder of upper and lower motor neurons; results in
progressive paralysis
Resp. paralysis in 3-5 years; no cure
S/S: muscle weakness, muscle atrophy
Maintain patent airway, suction as needed, intubate as needed, monitor for
pneumonia and resp. failure
Medication: riluzole (slow deterioration of motor neurons; extends life 2-3 months)
3
@ShopWithKey on Etsy
MG
Autoimmune disorder that causes severe muscle weakness; antibodies interfere
with acetylcholine at neuromuscular junction
S/S: muscle weakness (worse with activity), diplopia, dysphagia, impaired
respirations, drooping eyelids, incontinence
Diagnosis: Edrophonium (determines if MG exacerbation or cholinergic crisis); if
symptoms improve then it is MG, if symptoms get worse than it is a cholinergic crisis
(give atropine)
Maintain patent airway, encourage periods of rest, provide small frequent highcalorie meals, pt. sit upright when eating, thicken liquids, administer lubricating eye
drops, tape eyes shut at night to prevent corneal damage
Medication: anticholinesterase agents (neostigmine), immunosuppressants
Plasmapheresis (remove antibodies), thymectomy (removal of thymus)
Migraine, Cluster Headaches, Macular Degeneration and Cataracts
Migraine
Risks/Triggers: allergies, bright lights, fatigue, stress, anxiety, menstrual cycles,
certain foods (MSG, tyramine, nitrites)
S/S: photophobia, N/V, unilateral pain (behind one eye or ear)
Can happen with or without aura (visual disturbance)
Pain persists between 4-72 hours
Cool and dark environment, avoid trigger foods, reduce stress
Medications: NSAID (ibuprofen, acetaminophen for mild migraine), antiemetics,
sumatriptan, ergotamine
Cluster Headaches
S/S: severe, unilateral, nonthrobbing pain that radiates to forehead, temple and/or
cheek, facial sweating, nasal congestion
Lasts 30 min-2 hours; occur daily at same time for 4-12 weeks
More common in men aged 20-50
Medication: sumatriptan, ergotamine
Macular Degeneration
Central loss of vision; top cause of vision loss over age of 60; no cure
S/S: blurred vision, loss of central vision, blindness
Cataracts
Opacity in lens of eye that impairs vision
S/S: dec. visual acuity, progressive and painless loss of vision, diplopia, halo around
lights, photosensitivity, absent red reflex
Tx: surgery
o Pt. should wear sunglasses, avoid increasing IOP (don’t bend over at waist,
avoid sneezing/coughing/straining, avoid hyperflexion of head and
restrictive clothing), best vision will occur 4-6 after surgery
Glaucoma and Meniere’s Disease
Glaucoma
Increase in IOP d/t issue with optic nerve; leading cause of blindness
Types:
o Open-angle: most common; decreased aqueous humor outflow; gradual
increase in IOP; mild eye pain, loss of peripheral vision
4
@ShopWithKey on Etsy
o
Closed-angle: angle between iris and sclera closes completely causing
sudden increase in IOP; severe pain and nausea
Normal IOP-10 to 21 mmHg
Medications: pilocarpine (constrict pupil), BB (timolol decreases aqueous humor
production), mannitol (osmotic diuretic for closed angle)
Eye drops: administer one drop in each eye twice a day; wait 5-10 minutes b/w eye
drops; never touch tip of applicator to eye; lightly massage lacrimal duct after
instilling drop
Post-surgery: avoid activities that increase IOP (straining, coughing, sneezing,
hyperflexion)
Meniere’s Disease
Inner ear disorder that results in tinnitus, unilateral sensorineural hearing loss and
vertigo
S/S: vomiting and balance issues
Risk factors: viral or bacterial infections, ototoxic medications
Pull auricle up and back for adults; back and down for children; membrane should be
pearly gray and intact
Medications: antihistamine (diphenhydramine), AC meds, antiemetics
o Watch for urinary retention and sedation
Avoid caffeine and ETOH; rest in quiet and dark environment when having vertigo;
space intake of fluids; decrease salt intake
Surgery: stapedectomy or cochlear implants
Head Injury and Stroke
Head Injury
First priority is to stabilize cervical spine
Inc. ICP S/S: irritability, restlessness, HA, dec, level of consciousness, abnormal
pupils, abnormal posturing, abnormal breathing, Cushing’s Triad (severe HTN,
widening pulse pressure, bradycardia)
Avoid and reduce hypercapnia (hyperventilate pt., avoid suctioning, elevated HOB,
teach pt. to avoid coughing and straining)
Medications: mannitol, pentobarbital (induce coma), phenytoin, morphine
Surgery: craniotomy
Complications: brain herniation (downward shift of brain tissue); fixed dilated pupils,
dec. LOC, abnormal respirations and posturing; hematoma; intracranial
hemorrhaging, SIADH
Stroke
Types
o Hemorrhagic: ruptured artery or aneurysm
o Thrombotic: clot in cerebral artery
o Embolic: blood clot from another part of the body travels to cerebral artery
Risks: smoking, HTN, diabetes, Afib, hyperlipidemia
S/S: visual disturbances, dizziness, slurred speech, weak extremity, facial droop
o Left hemisphere stroke S/S: issues with language/math/analytical thinking;
expressive aphasia (inability to speak or understand language); reading or
writing difficulty; right-sided hemiparesis
5
@ShopWithKey on Etsy
o
Right hemisphere stroke S/S: issues with visual/spatial awareness;
overestimate abilities; poor judgement and impulse control; one-sided
neglect; left-sided hemiparesis
o Left = language, right = reckless
Monitor BP, assess swallowing and gag reflex, thicken liquids, pt. should swallow
with head and neck flexed forward, reposition frequently, teach pt. to use scanning
technique (turn head from direction of unaffected side to affected side)
Medications: anticoagulants, antiplatelets, thrombolytics (should be given w/i 4-5 of
initial symptoms of stroke)
Carotid artery angioplasty with stinting
Spinal Injury
Can result in paraplegia (below T1) or quadriplegia (cervical regions)
Neurogenic shock: hypotension, dependent edema, temp. regulation issues
Upper motor neuron injury (above L1): spastic muscle tone, spastic neurogenic
bladder
Lower motor neuron injury (below L1): flaccid muscle tone, flaccid neurogenic
bladder
Medications: glucocorticoids (reduce edema), vasopressors (hypotension), muscle
relaxers (baclofen, dantrolene), stool softeners
Autonomic dysreflexia: occurs for injuries above T6; caused by stimulation of SNS
w/o adequate response from parasympathetic nervous system; extreme HTN,
severe HA, blurred vision, diaphoresis
o Sit pt. up, notify provider, determine cause of dysreflexia (distended
bladder, fecal impaction, tight clothing, undiagnosed injury),
antihypertensives
Pain Management
Types of Pain
o Acute: protective, temporary, resolves with tissue healing
S/S: fight-or-flight, tachycardia, HTN, diaphoresis, anxiety, muscle
tension, guarding, grimacing, moaning, flinching
Treat underlying problem
o Chronic: ongoing or recurrent, lasting longer than 3 months
S/S: lowered VS, depression, fatigue, dec. level of functioning,
disability
Focus on pain relief
o Nociceptive: damage/inflammation of tissue; somatic (bones/muscle/skin)
vs visceral (internal organs)
S/S: throbbing, aching, localize
Opioid and nonopioid meds
o Neuropathic: abnormal/damaged nerves; phantom limb pain included
S/S: intense shooting, burning, “pins and needles”
Antidepressants, antispasmodics, muscle relaxants
NSAIDs
o For mild to moderate pain
o Monitor for salicylism (tinnitus, vertigo, dec. hearing); bleeding with long
term use
o No more than 4 g of acetaminophen/day
6
@ShopWithKey on Etsy
Opioid analgesics
o For moderate to severe pain
o Sedation precedes respiratory depression
o AE: constipation, N/V, respiratory depression, urinary retention, orthostatic
hypotension
Increase fluids and fiber intake; rise slowly and avoid sudden
position changes; monitor I/O; antiemetics; rise slowly or lie still
when nauseous
Naloxone-reversal agent
PCA (Patient-controlled analgesia)
o Client is the only one who should push button
o Notify nurse if pump does not control pain
2. RESPIRATORY SYSTEM
ABGs, Bronchoscopy, Thoracentesis
ABGs
Normal ranges:
o pH (7.35-7.45); below 7.35 is acidosis; above 7.45 is alkalosis
o PaO2 (80-100 mmHg)
o PaCO2 (35-45 mmHg);
o HCO3 (21-28)
o SaO2 (95-100%)
Performed by RT
o Allan’s test: compress ulnar and radial arteries
Put pressure on site for at least 5 minutes; 20 min or more if pt. on anticoagulants
Air embolism-immediately place pt. on left side in Trendelenburg position
Bronchoscopy
Allows provider to visualize pt. airway, take samples and suction
Pre-procedure: NPO 4-8 hours; give ordered meds (atropine, antianxiety, lidocaine)
Post-procedure: evaluate pt. LOC; assess return of gag reflex before pt. can eat or
drink
Expected Findings: sore throat, dry throat, small amount of blood-tinged sputum
Thoracentesis
Provider surgically perforates chest wall to enter pleural space to obtain specimens,
inject meds or remove air/fluids
Pleural effusion: collection of fluid in pleural space; compresses lungs
o S/S: chest pain, SOB, cough
Intra-procedure: pt. sits upright; remain totally still; amount of fluid removed should
not exceed 1L or risk of cardiovascular collapse
Post-procedure: monitor pt. respiratory status
Complications: mediastinal shift, bleeding, infection, pneumothorax
o S/S of pneumothorax: deviated trachea, pain on affected side, unequal
movement of chest during breathing, air hunger, tachycardia, shallow
respirations
7
@ShopWithKey on Etsy
Chest Tubes
Inserted into pleural space to drain fluid, blood or air, re-establish negative pressure
and facilitate lung expansion; used to diagnose pneumothorax, hemothorax, pleural
effusion, pulmonary empyema or post-op chest drainage
Pre-procedure: consent form; teach pt. that breathing will improve when tube is in
place; supine or semi-Fowler’s; pain and/or sedation meds
Intra-procedure: assist with insertion of tube, dressing application and set up of
drainage system
Post-procedure: assess VS/breath sounds/color of drainage q 4 hr; coughing and
deep breathing; report excessive drainage (more than 70mL/hr) or red/cloudy
drainage; semi to high-Fowler’s; don’t strip or milk tubing
Complications:
o Air leak-connection is not taped securely; monitor for continuous bubbling;
notify PCP of leak and apple clamp to determine location of leak as
prescribed
o Disconnection, Removal-client should exhale and cough to remove air for
space; immerse end of tube in sterile water to restore seal; dress area with
dry, sterile gauze
o Tension pneumothorax-tracheal deviation, absent breath sounds on
affected side, distended neck veins, resp. distress, asymmetry of chest,
cyanosis
Removal:
o Pain meds 30 min before removal
o Client should bear down (Valsalva maneuver) during removal
o Apply airtight sterile petroleum jelly gauze dressing
Oxygen Delivery, Mechanical Ventilation
Oxygen Delivery
Device Types
o Nasal cannula: 1-6 L/min; provide humidification for air over 4L/min
o Face mask: 5-8 L/min
o Partial rebreather: 6-11 L/min; adjust oxygen flow to keep bag from
deflating
o Nonrebreather: 10-15 L/min; keep reservoir bag 2/3 full; assess valve and
flap hourly
o Venturi: 4-10 L/min; provides most precise oxygen delivery
o Aerosol/Face Tent: pt. with facial trauma or burns
S/S of hypoxemia:
o Early signs: restlessness, irritability, tachypnea, tachycardia, pale skin, HTN,
nasal flaring, use of accessory muscles, adventitious breath sounds
o Late signs: confusion, cyanosis, bradypnea, bradycardia, hypotension,
dysrhythmias
S/S of oxygen toxicity: nonproductive cough, substernal pain, nasal congestion, N/V
fatigue, HA, sore throat
Avoid combustion (no smoking, no synthetic/wool fabrics)
Mechanical Ventilation
Low vs. High pressure alarm
o Low: disconnection, cuff leak, tube displacement
8
@ShopWithKey on Etsy
o
High: excess secretions, pt. biting tubing, kinks, tubing, pulmonary edema,
bronchospasms, pneumothorax
o High Kink, Low Leak
Suction oral and tracheal secretions, reposition tube every 24 hours, provide
frequent oral care, monitor for skin breakdown, have resuscitation and intubation
equipment at bedside, encourage cough/deep breathing/incentive spirometer after
tube removal, encourage frequent position changes
Pneumonia, Asthma, COPD
Pneumonia
Inflammation of lungs d/t viral or bacterial infections
S/S: fever, SOB, chest pain, dyspnea, cough, confusion (older adults), crackles,
wheezes
Labs: sputum sample before antibiotics; elevated WBC; dec. PaO2
Diagnoses: chest x-ray (consolidation)
Position pt. in High Fowler’s position; administer oxygen; encourage coughing/deep
breathing/incentive spirometry; encourage inc. fluid intake
Meds: antibiotics, bronchodilators (albuterol), glucocorticoids
Asthma
Chronic inflammatory disorder of the airway that is intermittent and reversible
S/S: wheezing, coughing, prolonged exhalation, low SaO2, barrel chest, use of
accessory muscles
Diagnosis: pulmonary function tests (FVC, FEV1)
Meds: bronchodilators (albuterol/SABA; salmeterol/LABA); SABA for acute attack;
LABA for maintenance; AC meds (ipratropium); corticosteroids
Status asthmaticus-airway obstruction that is unresponsive to typical treatment;
medical emergency; prepare for intubation
COPD
Combination of emphysema (loss of lung elasticity and hyperinflation of lung tissue)
and chronic bronchitis; irreversible; most common risk factor is smoking
S/S: dyspnea upon exertion, crackles, wheezes, barrel chest, clubbing, use of
accessory muscles, hyperresonance, dec. SaO2 levels, rapid and shallow breathing
SpO2 will be on low side and expected
Labs: inc. hematocrit; dec, PaO2 (below 80); inc. PaCO2 (greater than 45);
respiratory acidosis
Position in High Fowler’s position; encourage coughing/deep breathing/incentive
spirometry; proper nutrition (inc. calories and protein); breathing techniques
(abdominal or pursed lip breathing)
Meds: bronchodilators, anti-inflammatory meds, mucolytics (acetylcysteine,
guaifenesin)
Complications: right-sided HF (dependent edema, JVD, enlarged liver)
Tuberculosis
Infectious disease in lungs caused by mycobacterium tuberculosis
S/S: cough that lasts more than 3 weeks, night sweats, lethargy, unintended wt. loss,
purulent or bloody sputum
Diagnosis: Quantiferon Gold test; Mantoux text (skin test); chest x-ray; sputum
culture (acid-fast bacilli)
o Area of induration (hardness) of 10 mm of more-positive for TB
9
@ShopWithKey on Etsy
5 mm for immunocompromised pt
o Those who have had a BCG vaccine may get false positive from Mantoux test
Private, negative air flow room; airborne precautions (N95 mask)
Screen family members for TB; teach pt. that sputum samples will be needed every
2-4 weeks; no longer infectious after 3 negative sputum samples
Meds: 6-12 month period; isoniazid, rifampin, pyrazinamide, ethambutol
o Risk for liver damage; no ETOH
Pulmonary Embolism, Respiratory Emergencies
Pulmonary Embolism
Life threatening blockage in pulmonary vasculature often caused by DVT
Risk factors: immobility, OC, smoking, obesity, Afib, surgery, long bone fracture
S/S: anxiety, feeling of impending doom, pain on inspiration, dyspnea, pleural
friction rub, tachycardia, tachypnea, hypotension, petechiae, diaphoresis
Diagnosis: CT scan; D-dimer (should be under 0.4 mcg/mL)
Meds: anticoagulants (heparin, warfarin); thrombolytics (alteplase, streptokinase)
o Heparin antidote: protamine sulfate
o Warfarin antidote: vitamin K
Surgery: embolectomy, vena cava filter (prevents new emboli from entering)
Place pt. in High Fowler’s position, administer oxygen
Teach pt. to get frequent blood draws to monitor PT and INR (warfarin); maintain
consistent intake of vitamin K (warfarin); smoking cessation; compression stocking;
increase mobility; risk of bleeding (avoid NSAIDs, soft toothbrushes, electric razors)
o Therapeutic INR:2-3
Respiratory Emergencies
Pneumothorax: lung collapses d/t air in pleural space; hyperresonance with
percussion
Tension pneumothorax: air enters pleural space during inspiration but can’t exit;
tracheal deviation
Hemothorax: blood accumulates in pleural space; dull percussion
Flail chest: chest wall expansion is limited d/t multiple fractured ribs; paradoxical
chest wall movement
Common S/S: resp. distress, reduced/absent breath sounds on affected side
Oxygen, benzos, opioids, chest tube insertion
3. CARDIOVASCULAR
Cardiac Labs and Monitoring
Labs
Cardiac enzymes are released into bloodstream in response to ischemic event
o CKMB-specific to heart; should be 0; elevated for 2-3 days
o Troponin-most accurate and specific to heart
Troponin-T should be less than 0.1; elevated for 10-14 days
Troponin-I should be less than 0.03; elevated for 7-10 days
o Myoglobin-elevated d/t heart damage or skeletal muscle damage; should be
less than 90 mcg/L; elevated for 24 hours
Cholesterol normal ranges:
o Total-less than 200
o HDL-over 55 for women; over 45 for men
o LDL-under 130
10
@ShopWithKey on Etsy
o Triglycerides- 35 and 135 for women; 40 and 160 for men
Hemodynamic Monitoring
Able to obtain pressure inside veins, arteries and heart
o CVP, PAWP, CO
CVP should be between 2-6 mmHg; greater than 6 indicates HF
PAWP should be between 6-15 mmHg; greater than 15 indicates HF
CO should be between 4-8 L/min; lower than 4 indicates HF
Level transducer with phlebostatic axis (4th intercostal space, midaxillary line), zero
system, confirm placement with x-ray
Vascular Access, IV complications
Vascular Access
PICC line-used for long-term administration of antibiotics, TPN or chemo; tip
inserted and positioned into lower 3rd of superior vena cava
o Assess site every 8 hours; flush regularly to maintain patency
Flush with 10 mL syringe or bigger
o Flush meds with 10 mL of normal saline before, between and after each
medication
o Withdraw 10 mL of blood to discard, and then with draw 10 more mL for
labs; flush line with 20 mL of normal saline
o Never take BP on arm that has PICC line
Implanted port-long-term access; common in chemo patients
o Access with a non-coring Huber needle
IV Complications
Phlebitis
o S/S: erythema, pain, warmth, edema, induration or cord-like veins, red
streak
o Discontinue infusion, remove catheter, apply warm compress
Infiltration-fluid going into surrounding tissue rather than vein
o S/S: edema, coolness, taught skin, pale skin
o Discontinue IV, use cool or warm compresses, elevation
Air embolism
o S/S: SOB
o Place pt. on left side in Trendelenburg position, provide oxygen, notify
provider
Catheter embolus
o Place tourniquet high on extremity, prepare pt. for surgery
Fluid overload
o S/S: distended neck veins, inc. BP, tachycardia, SOB, crackles, edema
o Slow rate of infusion, sit pt. upright, administer diuretics as ordered
PCI, CABG, Peripheral Bypass Graft
PCI
Percutaneous coronary intervention-helps to open coronary arteries
Should be performed within 3 hours of onset of MI symptoms
3 types:
o Atherectomy-removal of plaque from vessels
o Stent placement
11
@ShopWithKey on Etsy
o
PTCA (percutaneous transluminal coronary angioplasty)- balloon insertion
and inflation to widen arterial lumen
Pre-procedure: NPO, assess for allergies to shellfish and iodine, check kidney
function
Post-procedure: monitor for bleeding, check pulses/color/capillary refill on
extremity distal to site
Complications:
o Artery dissection-monitor for signs (hypotension, tachycardia)
o Cardiac tamponade
o Bleeding/hematoma at insertion site
o Embolism
o Retroperitoneal bleeding-monitor for signs (flank pain, hypotension)
o Restenosis of the vessel-monitor for signs (chest pain, EKG abnormalities)
CABG
Coronary artery bypass graft-bypass one or more coronary arteries d/t blockages or
persistent ischemia; saphenous vein is often used
Monitor pt. BP carefully; HTN can cause bleeding from graft; hypotension can cause
collapse of graft
Closely monitor chest tube for excess drainage (150 mL/hr or more) indicates
hemorrhage
Teach pt. to treat angina with sublingual nitroglycerin (let dissolve under tongue,
rest and wait 5 minutes, take a 2nd dose under tongue and call 911 if still
experiencing, take no more than 3)
Smoking cessation, heart healthy diet, cardiac rehab program
Peripheral Bypass Graft
Helps to restore blood flow to an extremity d/t peripheral arterial disease
Pre-procedure: obtain consent, NPO 8 hours before procedure, monitor pedal
pulses/capillary/skin color and temp
Post-procedure: bed rest for 18-24 hours with legs straight; avoid sitting for long
periods of time or crossing legs; wear antiembolic stockings; monitor for
compartment syndrome (worsening pain, swelling, taught skin)
Angina, Myocardial Infarction
Angina
Chest pain that occurs d/t inadequate blood flow to the heart
3 types:
o Stable-occurs when exercising but stops at rest or after nitroglycerin
o Unstable-occurs at exercise or at rest; over time severity, duration, and/or
episodes increases
o Variable-coronary artery spasming; occurs at rest
If pain is unrelieved by rest or nitroglycerin, and last more than 30 minutes it is an
MI.
Myocardial Infarction
Risk factors: male, postmenopausal women, HTN, smoking, hyperlipidemia, stress,
inactivity, diabetes
S/S: anxiety, chest pain, nausea, diaphoresis, pallor, tachycardia, cool/clammy skin
Labs: elevated CKMB, Tropinin-I, Troponin-T and myoglobin, EKG changes (ST
depression or elevation, abnormal Q wave, T wave inversion
12
@ShopWithKey on Etsy
o Troponin most specific and accurate lab for diagnosing
Meds: nitroglycerin, analgesics, BB, thrombolytics, antiplatelets, anticoagulants
Complications
o HF
o Cardiogenic shock-signs (tachycardia, hypotension, dec. UOP, altered LOC,
dec. peripheral pulses, chest pain)
Peripheral Arterial Disease (PAD)
Trouble getting blood flow into the legs
Cause: atherosclerosis
Risk factors: HTN, diabetes, smoking, obesity, hyperlipidemia
S/S: pain in legs during exercise that is relieved with dependent positioning, dec.
capillary refill/pedal pulses, lack of hair on calves, thick toenails, pallor with
elevation, dependent rubor (redness), wounds that appear on toes
Teach pt. to walk until the point of pain, then stop and rest before walking a little
more; avoid crossing legs and/or restrictive clothing; maintain warm environment
(wear insulated socks); avoid cold/stress/caffeine/nicotine
Meds: antiplatelets (aspirin, clopidogrel); statins
Surgery: angioplasty, peripheral bypass braft
Complications:
o Graft occlusion (reduced peripheral pulses, inc. pain, pallor/cold extremity);
o Compartment syndrome (numbness, pain with passive movement, edema);
Peripheral Venous Disorders (PVD)
Blood flow into legs but it can’t circulate back to the heart
Venous Thromboembolism (VTE)
o Risk factors: Virchow’s Triad (impaired blood flow, hypercoagulability,
endothelial injury); hip and knee replacement surgery; HF; immobility; OC;
pregnancy
o S/S: calf or groin pain, edema in extremity, warmth, hardness over blood
vessel, SOB (clot has traveled)
o Diagnosis: venous duplex ultrasound; labs (d-dimer)
o Elevate extremity, never place pillow or wedge under knee, warm/moist
compresses, don’t massage limb, compression stockings, watch for s/s of PE
o Meds: anticoagulants, thrombolytics
Venous Insufficiency-incompetent valves in deeper veins
o Risk factors: sitting and standing in one place for long periods, obesity,
pregnancy
o S/S: aching pain, heavy feeling in legs, brown discoloration of legs (stasis
dermatitis), edema, venous stasis ulcers (ankles, clear drainage)
o Elevate legs, avoid crossing legs/restrictive clothing, compression stocking
(put on in morning)
Varicose Veins-enlarged superficial veins
o Risk factors: female, jobs that require prolonged standing, pregnancy,
obesity, family history
o S/S: distended and torturous superficial veins, aching, pruritis
o Therapeutic procedures
Sclerotherapy-chemical injection that closes off veins
Vein stripping
13
@ShopWithKey on Etsy
Laser treatment or radio frequency treatment
Hypertension
Primary-no known cause
o Risk factors: family history, excess sodium intake, inactivity, obesity, stress,
race (African-Americans), hyperlipidemia
Secondary-cause is d/t disease or medication
o Risk factors: kidney disease, Cushing’s syndrome, pheochromocytoma
S/S: HA, dizziness, visual issues
Levels:
o Pre-HTN: SBP 120-139; DBP 80-80 mmHg
o Stage 1: SBP 140-159; DBP 90-99 mmHg
o Stage 2: SBP greater than or equal to 160; DBP greater than or equal to 100
mmHg
o Hypertensive crisis: SBP over 240; DBP over 120 mmHg
Meds: diuretics, CCBs, ACE inhibitors, ARBs, BB
Take BP regularly, limit ETOH intake, consume DASH diet (high in fruits, veggies and
low fat dariy; low in sodium and fat), wt. loss, smoking cessation, reduce stress
Complications: Hypertensive crisis (severe HA, blurred vision)
Hemodynamic Shock and Aneurysms
Hemodynamic Shock
4 types:
o Cardiogenic-cardiac pump failure d/t HF, MI and/or dysrhythmias
o Hypovolemic-blood loss d/t trauma, surgery, or burns; fluid losses d/t GI loss
(vomiting, diarrhea, diuresis)
o Obstructive-blockage of great vessels (PE, tension pneumothorax, cardiac
tamponade)
o Distributive-extreme vasodilation
Septic-endotoxins in blood stream from infection; gram-negative
bacteria most common
Neurogenic-lack of sympathetic tone in the body d/t trauma or spinal
shock
Anaphylactic-antigen-antibody reaction d/t exposure to allergen;
medical emergency
S/S: hypoxia, hypotension, tachypnea, tachycardia, weak pulses, dec. UOP (less than 30
mL/hr),
o Anaphylactic S/S: wheezing, angioedema, rash
Labs: inc. serum lactic acid, abnormal ABGs, cardiac enzymes (cardiogenic), dec.
hematocrit and hemoglobin (hypovolemic), positive blood cultures (septic)
Give oxygen, prepare for intubation, place pt. flat with legs elevated for hypotension
Meds: dobutamine, vasopressin, epinephrine, colloids, antibiotics (septic)
Complications: MODS, DIC (micro-clots in the body; causes ischemia and bleeding)
Aneurysms
Widening or ballooning in the wall of a blood vessels
Types:
14
@ShopWithKey on Etsy
o
o
Abdominal aortic (AAA): flank and back pain, pulsating abdominal mass
Aortic dissection: stabbing/ripping feeling in abdomen and back, hypovolemic
shock (hypotension, tachycardia, dec. pulses, N/V, diaphoresis)
o Thoracic aortic: severe back pain, SOB, difficulty swallowing, pain
Manage BP (SBP between 100-120 mmHg); antihypertensives; monitor VS closely;
monitor cardiac rhythms/ABGs/UOP
4. HEMATOLOGIC
Hematologic Lab Values, Blood Transfusions
Hematologic Lab Values
RBC: 4-6 million per microliter
WBC: 5,000-10,000
Platelets: 150K-400K
Hemoglobin: 12-18; 8 or below for blood transfusion
Hematocrit: 37-52%
PT: 11-12.5 sec
aPTT: 30-40 sec; heparin range: 1.5-2.5x the normal range
INR: 0.8-1.1; warfarin range: 2-3
Blood Transfusions
A: can get A or O
B: can get B or O
AB: can get all types (A, B, AB, O)
O: can get O
Rh compatibility: negative patients that receive positive blood can result in
hemolysis; negatives get negatives
Use 20-gauge catheter or bigger; confirm pt. id/blood compatibility/expiration date
with another RN; prime administration set with 0.9% sodium chloride; never give
meds through blood transfusion tubing
Reactions: stop the transfusion, administer 0.9% sodium chloride through a separate
line, send blood back to lab
Types of Reactions
o Acute Hemolytic: low back pain, fever, chills, hypotension, tachycardia,
tachypnea
o Febrile: fever, chills, hypotension, tachycardia; administer antipyretics
o Mild Allergic: itching, flushing, urticaria (hives); give diphenhydramine
o Anaphylactic: wheezing, dyspnea, cyanosis, hypotension
o Circulatory Overload: dyspnea, tachycardia, tachypnea, crackles, HTN, JVD;
reduce rate of transfusion and give diuretics
Anemia and Coagulation Disorders
Anemia
Deficiency of RBC
Causes: blood loss, sickle cell, iron-deficiency (most common in children and
pregnant women); B12 deficiency (pernicious anemia); folic acid deficiency; bone
marrow suppression
Encourage intake of iron-rich foods; iron supplements
Provide folic acid supplement; large doses can mask B12 deficiency
B12 supplement
Coagulation Disorders
15
@ShopWithKey on Etsy
ITP-idiopathic thrombocytopenia purpura; autoimmune disorder where lifespan of
platelets in body is decreased and increases risk of hemorrhaging
DIC-disseminated intravascular coagulation; clotting factors are depleted through
formation of micro-clots in the body; can cause ischemia and risk of bleeding
S/S: bleeding, oozing or trickling of blood from incision, petechia, tachycardia,
hypotension
Administer blood, platelets and clotting factors; oxygen; replace fluid volume;
implement bleeding precaution (electric razor, soft toothbrush)
Meds: immunosuppressants/corticosteroids (ITP); anticoagulant/heparin (DIC)
Fluid Volume Deficit and Excess
Deficit
Hypovolemia-loss of water and electrolytes
Dehydration-loss of water
Causes: GI losses (vomiting, diarrhea), diuretics, hemorrhaging, diaphoresis, DI,
kidney disease, hyperventilation, DKA
S/S: hypotension, tachypnea, tachycardia, weak pulses, fatigue, weakness, thirst,
dry mucous membranes, GI upset, oliguria, dec. skin turgor, dec. capillary refill,
flattened neck veins, diaphoresis
Labs: inc. hematocrit/osmolarity/sodium/BUN/urine specific gravity
Fluid replacement, daily wt., monitor I/O, notify provider if urine is less than 30
mL/hr, fall precautions
Complications
o Hypovolemic shock-modified Trendelenburg, oxygen
Excess
Causes: HF, steroid use, kidney dysfunction, cirrhosis, burns, excess sodium intake
S/S: HTN, tachycardia, tachypnea, bounding pulses, wt. gain, edema, ascites,
dyspnea, crackles, distended neck veins
Labs: dec. hematocrit/hemoglobin/osmolarity/BUN/urine osmolarity/urine specific
gravity
Semi- to High-Fowler’s position, daily wt., notify provider of 1-2 lb wt. in 24 hr period
or 3 lb. wt. gain in a week, limit fluid and sodium intake, diuretics
Complications
o Pulmonary edema-dyspnea, pink frothy sputum; diuretics, sit pt. upright
At high risk for skin breakdown
Electrolytes: Sodium and Potassium
Sodium
Maintains ECF osmolarity, skeletal muscle contraction, cardiac contraction and nerve
impulse transmission
Normal range: 135-145
Hyponatremia
o Causes: diaphoresis, diuretics, kidney disease, hyperglycemia, HF, SIADH,
older age
o S/S: hypothermia, tachycardia, rapid thread pulse, hypotension, HA,
confusion, muscle weakness, fatigue, cramping, hyperactive bowel sounds,
nausea, seizure, dec. DTR
o Restrict fluid intake if d/t overload; IV fluid (LR or 0.9% isotonic saline);
assess LOC; high-sodium diet
16
@ShopWithKey on Etsy
Hypernatremia
o Causes: NPO, DI, heatstroke, burns, diaphoresis, kidney failure, Cushing’s
disease, excess sodium intake, older age
o S/S: hyperthermia, tachycardia, orthostatic hypotension, restlessness,
irritability, muscle twitching, seizures, coma, N/V, anorexia, dry mucous
membranes, thirst
o Oral hygiene; assess LOC; increase fluids; isotonic IV fluids
o Daily wt., low-sodium diet
Potassium
Used for cell metabolism, nerve impulse transmission, functioning of
cardiac/lung/muscle tissues and acid-base balance
Normal range: 3.5-5.0
Hypokalemia
o Causes: overuse of diuretics, Cushing’s disease, GI fluid loss, kidney disease,
water intoxication, TPN, alkalosis
o S/S: dec. BP, thread weak pulse, altered mental status, anxiety, confusion,
coma, elevate T wave, ST depression, prolong PR interval, weakness, N/V,
dec. DTR, shallow breathing, abdominal distention
o Monitor UOP; monitor cardiac rhythm; monitor for digoxin toxicity;
potassium-rich foods (avocados, bananas, broccoli, dairy, whole grains)
Hyperkalemia
o Causes: chronic illness, diuretic use, DKA, tissue damage, hyperuricemia
o S/S: slow irregular pulse, hypotension, restlessness, irritability, weakness,
flaccid paralysis, paresthesia, oliguria, diarrhea
o Loop diuretics, kayexalate, avoid foods high in potassium
Electrolytes: Calcium and Magnesium
Calcium
Inverse relationship to phosphorus
Calcium acts as a gatekeeper for sodium and action potentials
Normal range: 9-10.5
o Call 911
Bone and teeth formation; nerve and muscle functioning; clotting
Hypocalcemia (below 9)
o Causes: Vitamin D deficiency, hypoparathyroidism, thyroidectomy,
hyperphosphatemia, pancreatitis
o S/S: positive Chvostek’s signs (tap on cheek causing facial twitching), positive
Trousseau’s sign (inflated BP cuff causes finger spasms), muscle spasms,
numbness and tingling in lips and fingers, GI upset, dec. HR, hypotension
Chvostek=cheek
17
@ShopWithKey on Etsy
o Increase calcium intake
Hypercalcemia (above 10.5)
o Causes: hyperparathyroidism, long-term steroid use, bone cancer
o S/S: constipation, dec. deep tendon reflexes, kidney stones, lethargy
Magnesium
Used for nerve and muscle function, bone formation, heart function, biochemical
rxns
Normal Range: 1.3-2.1
Hypomagnesemia
o Causes: GI loss, diuretics, malnutrition, ETOH abuse
o S/S: hyperactive DTR, tetany, seizures, constipation, ileus
o Increase magnesium-rich foods; magnesium supplements will cause
diarrhea
Hypermagnesemia
o Causes: kidney disease, excess laxative/sodium intake that contain
magnesium
o S/S: hypotension, muscle weakness, lethargy, respiratory/cardiac arrest
Acid Base Imbalances
Respiratory Acidosis-d/t hypoventilation
o pH below 7.35
o PaCO2 above 45
o S/S: tachycardia, tachypnea, shallow breathing, pale/cyanotic skin,
confusion
o Oxygen, bronchodilators
Respiratory Alkalosis-d/t hyperventilation or salicylate toxicity
o pH above 7.45
o PaCO2 below 35
o S/S: tachypnea, deep and rapid breathing, anxiety, chest pain, dysrhythmias
o Reduce anxiety
Metabolic Acidosis-d/t DKA, kidney failure, diarrhea, pancreas or liver failure
o pH below 7.35
o HCO3 below 22
o S/S: bradycardia, hypotension, weak pulses, dysrhythmias, Kussmaul
respirations (deep and rapid breathing), warm flushed skin
o Administer insulin for DKA, give sodium bicarbonate
Metabolic Alkalosis-d/t antacid overdose, GI losses
o pH above 7.45
18
@ShopWithKey on Etsy
o HCO3 over 26
o S/S: tachycardia, dysrhythmias, muscle weakness
o Antiemetics
5. GASTROINTESTINAL
Gastrointestinal Lab Values, GI Diagnostic Procedures
Gastrointestinal Lab Values
AST/ALT: 0-35
Amylase: under 220
Lipase: under 160
Bilirubin: less than 1
Albumin: 3.5-5.0
Ammonia: 10-80
GI Diagnostic Procedures
Colonoscopy-visualize pt. anus, rectum and entire colon; moderate sedation; clear
liquid diet and laxatives prior; NPO before procedures
EGD-visualized pt. esophagus, stomach and duodenum; NPO for 6-8 hours
Sigmoidoscopy-visualize pt. anus, rectum and sigmoid colon; no anesthesia; clear
liquid diet and laxatives (polyethylene glycol); NPO
GI series- identifies abnormalities in GI system (ulcers, tumors, obstructions); pt.
drinks barium; clear liquid diet; NPO; no smoking or chewing gum before procedure;
teach pt. that stools will be white
TPN and Paracentesis
TPN
Used for pt. with malabsorption issue, malnourished, hypermetabolism or NPO for
prolonged time
Given through central line (i.e. PICC line); don’t push any other meds/fluids through
this line
Gradually increase and decrease flow rate; change tubing and bag every 24 hours;
use micron filter; closely monitor daily wt./ BS/electrolytes/I and O
o BS every 4-6 hours
If new TPN bag not ready, hand D10 bag until it arrives
Monitor IV site for infection
Paracentesis
Insertion of a needle through abdomen to remove fluid from peritoneal cavity;
ascites pt.
Pre-Procedure: consent form, pt. should empty their bladder, obtain
VS/wt./abdominal circumference before and after
Post-Procedure: monitor for s/s of hypovolemia, albumin if prescribed
Bariatric Surgery, NG Tubes and Ostomies
Bariatric Surgery
Used for pt. who is morbidly obese
Pt. should eat nutrient-dense foods after surgery; no milk or sweets
Eat 6 small meals a day; don’t consume liquids with meals
Eat slowly
Monitor for s/s of dumping syndrome: cramping, diarrhea, nausea, diaphoresis,
tachycardia, hypotension
NG Tubes
19
@ShopWithKey on Etsy
Used for pt. with intestinal blockage; suction gastric contents to allow for bowel
decompression and rest
o S/S: vomiting, abnormal bowel sounds, abdominal pain and distention
Chest x-ray to confirm placement; aspirate gastric contents during assessment
Assess bowel sounds, abdominal girth, NG placement, nasal mucosa for breakdown,
electrolytes and I/O
Encourage ambulation
Ostomies
Performed when pt. bowel is injured or a disease requires a part of the bowel to be
removed
Ileostomy-creates opening in ileum (small intestine); more liquid output
Colostomy-opening in large intestine; more solid output
Inspect stoma (should be red or pink, moist), empty bag when ¼ to ½ full, pt. can use
breath mint in bag to decrease odor, avoid food that cause excess odor, cut opening
in skin barrier no more than 1/8 inch bigger than the stoma
GERD and Esophageal Varices
GERD
Gastric contents back up into the esophagus causing pain and mucosal injury
o Barrett’s epithelium: esophageal cells mutate and are likely to become
cancerous
Risk factors: obesity, smoking, ETOH use, older age, pregnancy, ascites, hiatal hernia,
supine position, diet high in fatty/fried/spicy foods, caffeine, citrus fruit
consumption
S/S: dyspepsia (indigestion), throat irritation, bitter taste, burning pain that is worse
when laying down, chronic cough
Meds: Antacids (give 1-3 hours after meals; don’t give with other meds); H2receptor antagonists (ranitidine); PPI (pantoprazole); prokinetic agents
(metoclopramide)
Surgery: fundoplication (wrapping fundus of stomach around esophagus)
Avoid fatty/fried/spicy foods, eat smaller meals, remain upright after meals, avoid
tight fitting clothing, wt. loss, elevate HOB at night
Esophageal Varices
Swollen, fragile blood vessels in esophagus that can hemorrhage and cause
excessive bleeding
Risk factor: portal HTN (inc. BP in veins from intestine to liver)
S/S: elevated liver enzymes (AST/ALT), tachycardia, hypotension, dec. Hct and Hgb
Meds: non-selective BB (propranolol), vasopressin
Surgery: sclerotherapy, variceal band ligation, trans-jugular shun, esophageal gastric
balloon tamponade
Peptic Ulcer Disease, Irritable Bowel Syndrome and Intestinal Obstruction
PUD
Erosion in mucosa in esophagus, stomach and/or duodenum
Risk factors: H. pylori infection, chronic NSAID use, stress
S/S: N/V, heartburn, bloating, bloody emesis or stool, pain
o Gastric ulcer-pain worse 30-60 min after meal, during day and when eating
o Duodenal ulcer-pain worse 2-3 hours after meal, at night, feels better when
eating or taking antacids
20
@ShopWithKey on Etsy
Diagnosis: EGD
Meds: antibiotics (metronidazole, amoxicillin, clarithromycin, tetracycline); H2receptor antagonist; PPI; antacids; mucosal protectant (sucralfate)
Avoid acid producing foods (milk, caffeine, spicy foods); avoid NSAIDs
Complications:
o Perforation (severe epigastric pain, rigid board-like abdomen, hypotension,
tachycardia)
IBS
Causes abdominal pain, gas, diarrhea or constipation
Avoid dairy/eggs/wheat products/ETOH/caffeine; increase fiber and fluid intake;
keep diary of food intake
Meds: alosetron (IBS w/ diarrhea); lubiprostone (IBS w/ constipation)
Intestinal Obstruction
Causes: mechanical (surgical adhesions, tumors, diverticulitis, fecal impactions);
non-mechanical (paralytic ileus, neurogenic/vascular disorder, electrolyte
imbalances, inflammation)
S/S: abdominal distention, obstipation (severe constipation), abdominal pain, high
pitched bowel sounds heard above obstruction, hypoactive bowel sounds below
obstruction
o Small obstruction s/s: projectile vomiting w/ fecal odor, sever F/E
imbalances, metabolic alkalosis
o Large obstruction s/s: diarrhea, ribbon-like stools
NPO, NG tube placement, IV fluids
Surgery: colon resection (results in colostomy), lysis of adhesion
Ulcerative Colitis, Chron’s and Diverticulitis
Ulcerative Colitis
Inflammation of colon resulting in continuous lesion in colon
S/S: LLQ pain, fever, 15-20 liquid stools a day, stools contains mucus/pus/blood,
abdominal pain and distention
Labs: dec. Hgb and Hct, dec. albumin, inc. ESR/CPR/WBC
Risk factors: genetics, Caucasian, Jewish descent, stress, autoimmune disorders
Meds: 5-aminosalicylates (sulfasalazine), corticosteroids (prednisone),
immunosuppressants (cyclosporine), antidiarrheals (loperamide)
Monitor for s/s of peritonitis (N/V, rigid board like abdomen, fever, tachycardia)
Monitor I/O and electrolytes (hypokalemia)
Diet: high protein, high-calorie, low-fiber; avoid caffeine and ETOH; small, frequent
meals
Chron’s Disease
Inflammation and ulceration of small intestine resulting in sporadic lesions; risk of
fistulas
S/S: RLQ pain, fever, 5 loose stools a day, fatty stools (steatorrhea), abdominal
distention and pain
Labs: dec. Hgb and Hct, dec. albumin, inc. ESR/CPR/WBC
Risk factors: genetics, Caucasian, Jewish descent, stress, autoimmune disorders
Meds: 5-aminosalicylates (sulfasalazine), corticosteroids (prednisone),
immunosuppressants (cyclosporine), antidiarrheals (loperamide)
Monitor for s/s of peritonitis (N/V, rigid board like abdomen, fever, tachycardia)
21
@ShopWithKey on Etsy
Monitor I/O and electrolytes (hypokalemia)
Diet: high protein, high-calorie, low-fiber; avoid caffeine and ETOH; small, frequent
meals
Diverticulitis
Inflammation of diverticula (pouches formed off colon); can lead to perforation and
peritonitis
S/S: LLQ pain, N/V, fever, chills
Labs: dec. Hgb and Hct; inc. WBC
Meds: antibiotics (metronidazole), analgesics
NPO or clear liquid diet during exacerbations; low fiber diet, eventual high fiber diet;
avoid seeds/nuts/popcorn
Monitor for peritonitis (N/V, rigid board like abdomen, fever, tachycardia)
Cholecystitis and Pancreatitis
Cholecystitis
Inflammation of gallbladder usually caused by gall stones
Risk factors: female, high-fat diet, obesity, genetics, older age
S/S: RUQ pain that radiates to right shoulder, pain, N/V, jaundice, clay-colored
stools, steatorrhea, dark urine, pruritis, dyspepsia, excess gas
Labs: inc. WBC, bilirubin, pancreatic enzymes, liver enzymes (AST/ALP)
Lithotripsy to break up gall stones
Cholecystectomy is removal of gallbladder
o Typically done laparoscopically; shoulder pain is expected after operation
o Ambulate often
o Open-approach: T-tube may be placed in bile duct
Record drainage, report excess drainage (1000 mL/day or more),
empty drainage bag every 8 hours, assess pt. tolerance for eating
before removal
Consume low-fat diet; avoid gas-causing foods; wt. loss
Complications: pancreatitis, peritonitis
Pancreatitis
Autodigestion of pancreas by pancreatic digestive enzymes that are prematurely
activated before reaching intestines
Risk factors: bile tract disease, ETOH abuse, GI surgery, trauma, medication toxicity
S/S: severe LUQ or epigastric pain that may radiate to back or left shoulder, N/V,
Turner’s sign (ecchymosis on flanks), Cullen’s sign (blue-gray discoloration at
umbilicus), jaundice, ascites, tetany
22
@ShopWithKey on Etsy
Labs: inc. amylase/lipase/WBC/bilirubin/glucose; dec. calcium/magnesium/platelets
NPO; NG tube placement; antiemetics; insulin to prevent hyperglycemia; IV fluids
and electrolytes; opioid analgesics; pancreatic enzymes with meals and snacks
o Progress to bland and low-fat diet
No ETOH consumption; smoking cessation; stress reduction
Complications: chronic pancreatitis, pancreatic pseudocyst, Type I diabetes
Hepatitis and Cirrhosis
Hepatitis
Inflammation of liver
Causes: Hep A-E; ETOH abuse; autoimmune
Hepatitis A: fecal-oral
Hepatitis B and C: blood and bodily fluids
o No vaccine for Hepatitis C
Risk factors: IV drug use, unprotected sex, travel to underdeveloped countries,
crowded areas, piercings and tattoos
S/S: flu-like symptoms (malaise, fever), jaundice, dark urine, clay-colored stools
Labs: inc. ALT/AST/bilirubin
Hep A resolves w/o tx; chronic Hep B and C use antivirals
Cirrhosis
Normal liver tissue is replaced with fibrotic tissue
Causes: viral hepatitis, toxins, medications, chronic alcoholism, chronic biliary
obstruction
S/S: jaundice, ascites, petechiae, spider angiomas, palmer erythema, pruritis,
confusion, fatigue, GI bleeding, fruity breath odor, peripheral edema
Labs: inc. AST/ALT/bilirubin/ammonia; dec. serum
protein/albumin/RBC/Hgb/Hct/platelets
Diagnosis: liver biopsy (most definitive), ultrasound, CT scan, MRI
Monitor and maintain strict I/O; restrict fluid and sodium; elevate HOB; diet (highcarb, moderate fat, high protein, low sodium); several small meals a day; measure
abdominal girth daily; wash skin with cool water; ETOH recovery
Meds: Lactulose (when encephalopathy is present), diuretics
Paracentesis for ascites: void bladder prior to procedure; supine position with HOB
elevated
Long-term: liver transplant
Complications: encephalopathy d/t build up of ammonia, esophageal varices
6. GENITOURINARY
Renal System Labs and Diagnostic Tests
Renal System Labs
Creatinine: 0.6-1.2
BUN: 10-20
Urine Specific Gravity: 1.01-1.025; no glucose, ketones, protein or nitrites
Diagnostic Tests
Cystography/Urography-invasive; determine abnormalities in urinary system;
include contrast dye
o Assess for allergy to shellfish and iodine
o NPO after midnight; bowel prep (laxative or enema); increase fluid intake
post-procedure; expected that urine may be pink-tinged
23
@ShopWithKey on Etsy
o
Monitor for infection (cloudy or foul-smelling urine, urgency, positive nitrite
or leukoesterase in urine)
Hemodialysis, Peritoneal Dialysis and Kidney Transplant
Hemodialysis
Helps to eliminate excess fluid, electrolytes and waste products from the body
Typically done 3x/week
Pre-Procedure: check for vascular access (patency of AV shunt; listen for bruit or feel
for thrill); check distal pulses; assess pt. VS/labs/wt.
Intra-Procedure: monitor BP (expect it to decrease); monitor for cramping, N/V and
bleeding
Post-Procedure: monitor BP and labs (expect to be decreased); compare wt. for
before and after procedure
o 1 L of fluid = 1 kg
Increase protein intake after dialysis; avoid carrying on arm with access site; avoid
sleeping on arm with access site; encourage hand exercises after fistula insertion
Complications: disequilibrium syndrome (N/V, dec. LOC, seizures); hypotension
Peritoneal Dialysis
Instill and dwell hypertonic in peritoneal cavity to remove waste products
Pre-Procedure: assess pt. wt., warm dialysis solution, use sterile technique when
accessing catheter
Intra-Procedure: monitor inflow and outflow of solution (outflow should be lower
than pt. abdomen); monitor color of outflow (should be clear and yellow)
o Bloody outflow indicates infection
Complications: peritonitis, protein loss, hyperglycemia, poor inflow/outflow
Kidney Transplant
Pre-Procedure: immunosuppressant therapy
Post-Procedure: monitor UOP (should be over 30 mL/hr); monitor for infection;
monitor for organ rejection (fever, HTN, pain at site)
Rejection
o Hyperacute: w/i 48 hours; fever, HTN, pain at site; immediate removal of
organ
o Acute: 1 week to 2 years; oliguria, anuria, fever, HTN, tenderness over
kidney; immunosuppressive meds
o Chronic: months to years; azotemia, fluid retention, electrolyte imbalance,
fatigue; conservative tx until dialysis is needed
Consume low fat and sodium, high fiber and protein diet; avoid contact sports
Glomerulonephritis
Inflammation of glomerular capillaries in the kidneys
Risk factor: streptococcal infection, Lupus, HTN, diabetes
S/S: dec. UOP, fluid volume excess (wt. gain, edema, HTN, dyspnea)
Labs: throat culture for strep; ASO titer, inc. urine specific gravity, hematuria,
proteinuria, inc. WBC and ESR
GFR through 24 hr urine collection for creatinine
Monitor wt. (wt. gain of 2 lb or more in 24 hour period; 5 lb in a week is concerning);
monitor I/O and labs; restrict fluids, sodium and protein intake; antibiotics; diuretics;
corticosteroids
24
@ShopWithKey on Etsy
Plasmapheresis-filter pt. blood to remove antibody complexes that cause
glomerulonephritis
Acute Kidney Injury (AKI) and Chronic Kidney Disease
Acute Kidney Injury (AKI)
The sudden loss of kidney function
3 types:
o Pre-renal: dec. blood flow to kidneys d/t sepsis, shock, hypovolemia,
vascular obstruction
o Intra-renal: direct damage to kidney d/t trauma, hypoxic injury or chemical
injury
o Post-renal: obstruction leaving the kidney d/t stone, tumor or BPH
4 phases:
o Onset
o Oliguria: peeing little urine; 100-400 mL in 24 hr
o Diuresis: peeing a lot of urine
o Recovery: can take up to 1 year
Diet: restrict potassium, phosphate and magnesium; increase protein intake
Chronic Kidney Disease
Gradual loss of kidney function
Risk factors: older age, dehydration, AKI, diabetes, HTN, chronic episodes of
glomerulonephritis, medications, autoimmune diseases
Stages:
S/S: JVD, HTN,
dyspnea, tachypnea, crackles, edema, lethargy, uremic frost, pruritis
Labs: inc. creatinine/BUN/potassium/phospohorus/magnesium; dec.
sodium/calcium/Hgb/Hct; blood and protein in the urine
Weigh pt. at same time daily; diet (high-carb, moderate-fat, restrict
sodium/potassium/phosphorus/magnesium intake)
Risk for skin breakdown; prepare pt. for hemodialysis; promote frequent rest
periods; avoid NSAIDs, contrast dye and magnesium-containing antacids
Meds: digoxin, polystyrene, erythropoietin, furosemide
Urinary Tract Infections (UTI) and Pyelonephritis
UTI
Infection in lower urinary tract usually caused by E.coli
25
@ShopWithKey on Etsy
Risk factors: female, pregnancy, menopause, sexual intercourse, wet bathing suit,
frequent baths, urinary catheters, incomplete bladder emptying
S/S: abdominal pain, dysuria, urinary frequency and urgency, fever, N/V, hematuria,
pus in the urine, cloudy and foul-smelling urine, confusion (older adults)
Urinalysis: positive for WBC, bacteria, leukocyte esterase and nitrites
Meds: antibiotics, phenazopyridine (urine can turn orange-red)
Complications: urosepsis (hypotension, tachycardia, tachypnea, fever);
pyelonephritis
Prevention: wipe front to back; drink a lot of water; good hygiene; empty bladder
regularly; urinate before and after sex; cranberry juice; avoid bubble bath and
perfume-containing feminine products
Pyelonephritis
Bacterial infection in the kidney, usually caused by E. coli
Risk factors: BPH, kidney stones, pregnancy, incomplete bladder emptying
S/S: costovertebral tenderness, fever, flank or back pain, N/V, tachycardia,
tachypnea, HTN, chills
Labs: urinalysis positive for WBC, bacteria, leukoecyte sterase and nitrites; inc.
creatinine/BUN/ESR/CRP
Meds: antibiotics, opioid analgesics
Complications: septic shock (hypotension, tachycardia, fever), CKD if recurrent, HTN
Urolithiasis
Stone in urinary system (calculi); may be made of calcium phosphate, calcium
oxalate or uric acid
Risk factors: male, damage to urinary tract lining, highly acidic/alkaline urine, urinary
retention, dehydration
S/S: severe pain (flank, radiates to abdomen), dysuria, fever, diaphoresis, pallor,
tachypnea, tachycardia, oliguria, hematuria, N/V
Monitor I/O; strain pt. urine; increase fluid intake; increase ambulation; limit intake
of animal-based protein and high-sodium food (calcium phosphate); limit oxalaterich food (spinach, rhubarb, strawberries, beets, nuts, chocolate, tea); for uric acid,
limit purine-rich foods (meat, whole grains, legumes)
Meds: opioid analgesics, NSAIDs, antispasmodic (oxybutynin)
Lithotripsy-laser or shockwave energy to break up stone so that it is easier to pass;
moderate sedation; pt. will sometimes have bruising at site; some blood in urine;
keep straining urine
Stenting-hold open urinary tract
Ureterolithotomy-surgical extraction of the stone
7. REPRODUCTIVE
Female Reproductive Procedures and Disorders
Female Reproductive Procedures
Pap smear-tests for cancerous cells in cervix; age 21 get it done every 3 years
Mammogram-tests for breast cancer; annually starting at 40
o Remove deodorant and lotion from axillary region
Female Reproductive Disorders
Menorrhagia-excessive menstrual bleeding in amount and/or duration
Amenorrhea-no menses; pregnancy or anorexia
26
@ShopWithKey on Etsy
PMS-hormonal imbalance prior to period; irritability, depression, breast tenderness,
bloating, HA
Endometriosis-overgrowth of endometrial tissue outside of uterus; common cause
of infertility
Menopause-cessation of menses; for at least 12 months
o S/S: hot flashes, vaginal dryness, mood swings, dec. bone density
o Meds: hormone therapy (increases risk for embolism)
Smoking cessation, avoid knee-high stockings/tight socks, avoid
sitting for long periods of time, monitor for s/s of DVT (unilateral leg
swelling, pain, warmth, redness), s/s of MI (GI upset, pain that
radiates to left shoulder)
Cystocele-protrusion of bladder through anterior vaginal wall
Rectocele-protrusion of rectum through posterior vaginal wall
o S/S: obesity, chronic constipation, older age, birth where forceps were used,
family hx
o Vaginal pessary-provides support and block protrusion of other organs
o Kegel exercises
o Surgical repair
Fibrocystic breasts-benign condition causing development of fibrotic connective
tissue and cysts in the breasts
o S/S: breast pain, rubber like lumps in upper outer quadrant of breast
o Diagnosis: breast ultrasound
Male Reproductive Procedures and Disorders
Male Reproductive Procedures
PSA-prostate specific antigen; measures amount of protein produced by prostate;
elevated levels indicate prostate cancer or BPH
o Perform before DRE
o Annually from age 50
o Greater than 4 is elevated
DRE-digital rectal exam; checks for prostate enlargement/hardness/irregularities
Male Reproductive Disorders
BPH-enlargement of prostate gland that impairs urine flow from the bladder
o S/S: urinary frequency, urgency, retention, hesitancy, post-void dribbling,
hematuria, recurrent UTI
o Labs: inc. PSA, WBC (if UTI), creatinine/BUN (kidney reflux)
o Meds: finasteride, tamsulosin
o Prosthetic stent
o TURP-trans-urethral resection of the prostate; continuous bladder irrigation
with NS or prescribed solution; keep outflow a light pink color; turn of CBI if
catheter is obstructed and irrigate with 50 mL with large piston syringe
Pt. will have continuous urge to urinate; increase fluid intake; avoid
caffeine/ETOH; stop activity and rest if urine is bloody
Meds: analgesics, antispasmodics, prophylactic antibiotics, stool
softeners
8. MUSCULOSKELETAL
Musculoskeletal Diagnostic Procedures and Arthroplasty
Musculoskeletal Diagnostic Procedures
27
@ShopWithKey on Etsy
Arthroscopy-visualize internal structure of a joint; CI if pt. has infection in joint, or
can’t flex the joint at least 40 degrees
Nuclear scan-radioactive injection 4-6 before scan; bone scan that detects tumors,
fractures and bone disease
DXA-dual x-ray absorptiometry; determines bone density and diagnose osteoporosis
Electromyography-electrical potential generated in a muscle; identifies cause of
muscle weakness
Arthroplasty
Replacement of diseased joint with a prosthetic joint; used for RA, osteoarthritis,
trauma or congenital defect
o Osteoarthritis S/S; joint pain, swelling, crepitus
o CI: current/recent infection, arterial insufficiency in affected extremity
Pre-Op: epoetin alfa, blood donation, scrub with antiseptic soap night
before/morning of surgery
Post-Op: monitor/prevent DVT; monitor for PE
o Knee: continuous passive motion machine; do not pillows under knee; keep
leg extended; analgesics, antibiotics, anticoagulants; ice packs;
neurovascular checks q 2-4 hr; don’t kneel or do deep knee bends
o Hip: apply antiembolic stockings; early ambulation and foot exercises;
abduction pillow b/w pt. legs, don’t cross legs; no hip flexion greater than
90 degrees; ensure feet don’t become internally rotated
S/S of dislocation: severe pain on affected extremity, popping noise, shortened
appearance of affected extremity, internal or external rotation of extremity
Amputations
Traumatic event resulting in severed limb: wrap limb in dry, sterile gauze and place
into sealed bag, submerge in ice water
Risk factors: severe infection, severe peripheral arterial disease
o S/S of inadequate blood flow: dec. pulses, cyanosis, wounds, cool skin, dec.
sensation
Post-Amputation: emotional/psychological support; phantom limb pain; keep limb in
dependent position; prevent hip flexion contractures (prone position for 20-30 min
multiple times a day); shrink residual limb by wrapping in a figure 8 pattern when
fitting for prosthetic; ROM exercises
o Meds: BB, antiepileptic, antispasmodics, antidepressants
Osteoporosis
Low bone density and fragile, porous bones; rate of bone reabsorption exceeds the
rate of bone formation
Risk factors: female, thin lean body, insufficient calcium/Vitamin D intake, smoking,
ETOH abuse, excess caffeine intake, inactivity, hyperparathyroidism, long term
steroid and anticonvulsant use
S/S: back pain, fractures, kyphosis (abnormal curvature of thoracic spine), reduced
height
Diagnosis: DXA
Meds: calcitonin, estrogen, raloxifene, alendronate
Sufficient calcium/Vitamin D; weight bearing exercises; home safety measures to
prevent falls (no rugs, mark steps clearly, adequate lighting)
Fractures and Complications from Fractures
28
@ShopWithKey on Etsy
Fractures
Closed-doesn’t break skin surface
Open/Compound-breaks skin surface
Complete-all the way through the bone
Incomplete-part way through the bone
Compression-one or more bones in the spine weaken and collapse
Spiral-may indicate abuse
Risk factors: osteoporosis, long-term steroid use, trauma, bone cancer, substance
abuse
S/S: pain, crepitus, deformity, muscle spasms, swelling/edema, ecchymosis
Stabilize affected area; elevated limb; apply ice; regular neurovascular assessment
Meds: antibiotics, analgesics, muscle relaxants
Surgery:
o External fixation-external frame with pins that enter bones
o Open reduction-internal fixation-pins, plates, screws and rods internally
Neurovascular Assessment: pain level, sensation, skin temp, capillary refill, pulses,
ability to move extremity
Fracture Complications
Compartment syndrome-increased pressure w/i muscle compartment that impairs
blood flow to extremity
o S/S: pain w/passive movement, paresthesia (numbness/tingling), paralysis,
pallor, pulselessness
o Fasciotomy-incision into muscle to release pressure and restore blood flow
Fat embolism-occurs more in long bone or hip fracture; fat from bone marrow
moves into lung vasculature
o S/S: dyspnea, confusion, tachypnea, tachycardia, petechiae on upper body
Osteomyelitis-bone infection
o S/S: bone pain, erythema, edema, fever, inc. WBC
o Long term antibiotic therapy
o Surgical debridement
o Hyperbaric oxygen therapy
Immobilization Devices
Casts
o New plaster casts should be handled with gloves on and using palm of hands
o Elevate extremity for 24-48 hrs
o Use hairdryer on cool setting when itching; s/s of infection (hot spot,
malodorous odor, inc. drainage)
Traction
o Skin-pulling force attached to pt. skin to immobilize extremity and decrease
muscle spasms; Bryant (child hip dysplasia; B) and Buck’s traction (adult hip
fracture; A)
29
@ShopWithKey on Etsy
o
Skeletal-screws inserted into bone; used for long bone fractures
o
Cervical-halo; used for cervical spine fractures; wrench should be attached
to vest for CPR
Nursing Care: frequent neurovascular checks; don’t lift or remove weights; weight
should be hanging freely and not on the ground; muscle spasms prevention (meds,
heat, repositioning); move pt. as a whole unit in halo traction; pin site care ( 1 qtip
per pin site); monitor for s/s of infection (inc. drainage, redness, loosening of pins,
skin tenting at pin site_
Osteoarthritis and Osteoarthritis vs Rheumatoid Arthritis
Osteoarthritis
Progressive degeneration of articular cartilage in a joint
Risk factors: older age, female, obesity, smoking, repetitive stress on joints
S/S: joint pain/stiffness, crepitus, enlarged joint, Heberden’s nodes (distal phalange
joints), Bouchard’s nods (proximal phalange joints)
30
@ShopWithKey on Etsy
o
Apply ice and/or heat for pain; splinting; assistive devices; physical therapy; TENS
(transcutaneous electrical nerve stimulation)
Meds: oral analgesics (acetaminophen or NSAIDs), topical analgesic (capsaicin),
glucosamine, steroid injections
o Capsaicin-apply with gloves and don’t apply to broken skin
Osteoarthritis vs RA
Osteoarthritis-degenerative; more pain with activity, less pain with rest; affects
specific joints; nodes; negative rheumatoid factor
RA-inflammatory; autoimmune; pain at rest, less pain with activity; all joints are
affected and symmetrical; deformities (swan neck, boutonniere); positive
rheumatoid factor
9. INTEGUMENTARY
Integumentary Diagnostic Procedures and Skin Disorders
31
@ShopWithKey on Etsy
Integumentary Diagnostic Procedures
Culture and sensitivity
o Standard precautions; apply warm compresses 2x/day for comfort from
bacterial infections
Biopsy-removal of tissue sample in order to confirm or rule out malignancies
o Intra-procedure: establish a sterile field, local anesthesia, apply pressure to
site to control bleeding
o Post-procedure: teach pt. to report bleeding or s/s of infection; check
incision daily; client should return to PCP in 7-10 days if sutures used
Skin Disorders
Psoriasis-overproduction of keratin that results in dry, scaly dermal patches
o Risk factors: infection, skin trauma, genetics, stress, seasons, hormones,
obesity, female
o S/S: reddened, thickened skin with silvery white scales (vulgaris); erythema
and scaling, dehydration, hyperthermia or hypothermia (exfoliative);
reddened areas that eventually crust over (palmoplantar); pitting, crumbling
nails
o Steroids; vitamin D; vitamin A; methotrexate; cyclosporine; tar preparations
Vitamin A CI in pregnancy
Tar can stain skin and hair; apply at night
Dermatitis
o Risk factors: exposure to allergens, stress, genetics
o S/S: pruritis, thickened areas of skin; rash
o Steroids (hydrocortisone), antihistamine, immunosuppressants (tacrolimus)
o Don’t scratch affected areas; use products with no fragrance; apply cool
damp compresses; oatmeal baths
Burns
Types: heat, chemical, electrical, thermal, radiation
Rules of Nines
S/S of impending loss of airway: hoarseness, brassy cough, drooling, difficulty
swallowing, audible wheezing/crowing/stridor
Minor burns: stop burning process; apply cool water over injury; flush chemical
burns with water; cleanse with mild soap and water
Meds: opioid analgesics, silver nitrate, silver sulfadiazine, gentamicin
Complications: airway injury, wound infection, F/E imbalances, muscle and joint
mobility (contractures and scarring)
10. ENDOCRINE
Endocrine Diagnostic Procedures
32
@ShopWithKey on Etsy
Endocrine Diagnostic Procedures
Water deprivation test-measures kidney’s ability to concentrate urine; identifies
causes and types of DI
o Pre-procedure: withhold fluids; establish IV access, monitor for dehydration
o Intra-procedure: complete fluid restriction; ask pt. to empty bladder; weigh
pt.
Dexamethasone suppression test-determines if dexamethasone has an effect on
cortisol level
Plasma-free metanephrine test-identifies pheochromocytoma
o Pre-procedure: avoid caffeine/ETOH/meds/physical exercise/stress
Fasting blood glucose; HbA1c
Acromegaly, Diabetes Insipidus (DI) and SIADH
Acromegaly
Excess growth hormone that causes an increase in the size of body part
Risk factors: adulthood, benign tumors
S/S: severe HA, visual issues, joint pain, inc. ICP, barrel shaped chest, inc. head size,
enlarged hands and feet
X-rays, CT, MRI, cerebral angiography
Meds: dopamine agonists (bromocriptine), somatostatin (octreotide), growth
hormone receptor blocker (pegvisomant)
Hormone therapy is lifelong; avoid activities that inc. ICP; rinse mouth frequently;
high fiber diet
Diabetes Insipidus
Deficiency of ADH that results in excessive urination, thirst, fluid intake and
electrolyte imbalance
Risk factors: head injury of tumor around pituitary gland; lithium carbonate;
demeclocycline; older adults
S/S: polyuria, polydipsia, nocturia, fatigue, dehydration, sunken eyes, tachycardia,
hypotension, dry mucous membranes
Monitor VS/UOP/CVP/labs (K, Na, BUN, creatinine); weigh daily; fall precautions; ski
and mouth care
Teach pt. to weigh self daily; eat high-fiber diet; monitor for s/s of dehydration;
prevent water intoxication; avoid ETOH
SIADH
Excessive release of ADH leading to reabsorption of water and suppression of RAAS
Risk factors: malignant tumors, inc. intrathoracic pressure, head injury, meningitis,
stroke, TB, meds
S/S: confusion, lethargy, Cheyne-Stokes respirations, tachycardia, HTN, crackles,
bounding pulses, wt. gain, N/V/D, hostility, oliguria, muscle cramps
Seizure precautions; flush all enteral and gastric tubes with 0.9% sodium chloride;
weigh pt. daily; restrict fluids; reduce environmental stimuli
Meds: tetracycline (demeclocycline), furosemide, vasopressin antagonist (tolvaptan)
Complications: water intoxication, cerebral/pulmonary edema, severe hyponatremia
Hyperthyroidism and Hypothyroidism
Hyperthyroidism
Excessive production of thyroid hormones resulting in the body entering a
hypermetabolic state
33
@ShopWithKey on Etsy
Risk factors: Graves’ disease, toxic nodular goiter
S/S: heat intolerance, wt. loss, warm sweaty skin, weakness, emotional lability,
menstrual irregularities (amenorrhea), dec. fertility, tremors, hyperreflexia,
exophthalmos (bulging eyes), thinning hair, photophobia
Diagnosis: ultrasound, ECG, radioactive iodine uptake
Meds: PTU, BB, iodine solutions
Surgery: thyroidectomy
o Pre-procedure: PTU 4-6 prior, iodine 10-14 prior, BB, high protein and carb
diet
o Post-procedure: semi-Fowler’s, avoid neck extension, deep breathing
exercises, monitor for hypocalcemia
Complications: hemorrhage at incision, thyroid storm/crisis, airway obstruction,
hypocalcemia and tetany, nerve damage
Hypothyroidism
Inadequate amount of thyroid hormone
Risk factors: women (30-60), inadequate iodine intake, radiation therapy
S/S: cold intolerance, wt. gain, pale skin, depression, bradycardia, hypotension,
swelling in face/hands/feet, fatigue
Diagnosis: ECG, radioisotope scan
Avoid electric blankets or other heating devices; low calorie high bulk diet;
antiembolism stockings; regular skin care
Meds: levothyroxine (lifelong therapy)
Complications:
o Myxedema-resp. failure, hypotension, bradycardia, hyponatremia,
hypoglycemia coma
34
@ShopWithKey on Etsy
Cushing’s Disease and Addison’s Disease
Cushing’s Disease
Over secretion of adrenal hormones
S/S: wt. gain, bone pain and fractures, muscle wasting, striae, hirsutism,
hyperglycemia, bruising and petechiae, tachycardia, dependent edema (buffalo
hump)
Meds: ketoconazole, hydrocortisone
Meds are lifelong; foods high in calcium and vitamin D; good hygiene; daily weighing
Surgery: hypophysectomy (removal of pituitary gland); adrenalectomy (removal of
adrenal gland, either unilateral or bilateral)
Complications: perforated viscera/ulceration, bone fractures, infection, adrenal
crisis
Addison’s Disease
Insufficiency of adrenal hormones
Risk factors: cancer, TB, autoimmune dysfunction, radiation therapy, steroid
withdrawal, pituitary neoplasm
S/S: wt. loss, salt craving, hyperpigmentation, weakness, N/V, abdominal pain,
severe hypotension, dehydration
35
@ShopWithKey on Etsy
Maintain safe environment; monitor for hypoglycemia and hyperkalemia
Meds: hydrocortisone, prednisone, cortisone, fludrocortisone
Complications: Addisonian crisis (acute drop in adrenocorticoids), hypoglycemia,
hyperkalemia, hyponatremia
Diabetes Mellitus (DM)
Type 1-autoimmune dysfunction that destroys beta cells (produce insulin)
Type 2-progressive condition d/t inability of cells to responds to insulin; obesity,
sedentary lifestyle
S/S: hyperglycemia, polydipsia, polyphagia, HA, N/V, acetone/fruity breathy odor,
slow wound healing
Meds: insulin, metformin, glipizide, glyburide, repaglinide, pioglitazone, acarbose,
sitagliptin
o
Rotate injection sites; inspect feet daily; keep taking insulin when sick
Complications: CV disease, diabetic retinopathy/nephropathy/neuropathy, DKA
36
@ShopWithKey on Etsy
11. IMMUNE
Immune Diagnostic Procedures
WBC- normal range is 5,000-10,000
o Leukopenia-less than 4k
o Leukocytosis-greater than 10k
o Neutropenia-neutrophil count less than 2,000
o Left shift-increase in immature neutrophils
Radioallergosorbent test-blood test to determine sensitivity to allergens
Skin test-intradermal injections or scratching the skin with potential allergens
o Pre-procedure: have equipment to treat anaphylaxis; avoid taking
corticosteroids and antihistamine 48hr-2 weeks before test
o Post-procedure: assess for reactions; remove all solutions; teach pt. about
desensitizing and avoidance options; follow diet that eliminates allergens
Immunizations
Herpes zoster-one time dose for those older than 60
Contraindications
o DTaP-encephalopathy w/i 7 days following prior dose of vaccine
o MMR-pregnancy
o Varicella-pregnancy; allergic rxn to gelatin or neomycin
o Hep A-latex allergy
o Hep B-allergy to yeast
o HPV-pregnancy; allergy to yeast or latex
37
@ShopWithKey on Etsy
HIV/AIDS
Risk factors: unprotected sex, multiple sex partners, occupational exposure, IV drug
use, blood transfusion
S/S: chills, rash, anorexia, wt. loss, night sweat, HA, sore throat, weakness, fatigue
Diagnosis: HIV viral load test; HIV drug resistance testing; liver profile, biopsies and
testing stool for parasites
Meds: antivirals (meds ending in -vir)
Good hygiene, safe sex, well-balanced diet, avoid raw foods
Complications: opportunistic infections, wasting syndrome, F/E imbalance, seizures
d/t HIV encephalopathy
Lupus, Gout, Fibromyalgia and RA
Lupus
Autoimmune disorder that results in chronic inflammation and destruction of
healthy tissue
Risk factors: women (20-40), African-Americans/Native Americans/Asians
S/S: butterfly rash over face, alopecia, pericarditis (friction rub present), fever,
anemia, Raynaud’s phenomenon (vasospasm in response to cold), joint
pain/swelling/tenderness
Meds: NSAIDs, corticosteroids (prednisone), immunosuppressants (methotrexate),
antimalarial (hydroxychloroquine)
38
@ShopWithKey on Etsy
Avoid UV or prolong sun exposure; pregnancy risks; avoid crowds and sick
individuals; avoid harsh hair treatments; steroid creams for skin rash
Complications: lupus nephritis, pericarditis, myocarditis
Gout
Systemic disease d/t disruption in purine metabolism resulting in uric acid crystals
being deposited in joints and tissue
Risk factors: obesity, CV disease, trauma, ETOH use, starvation dieting, diuretics, CKD
S/S: sever joint pain, redness/swelling/warmth of affected joint
Meds: NSAIDs, corticosteroids (prednisone), antigout (colchicine), allopurinol
(chronic gout)
Low-purine diet (no organ meats or shellfish); limit ETOH use; limit stress; increase
fluid intake
Fibromyalgia
Chronic pain syndrome
Risk factors: women (30-50); deep sleep deprivation; hx of rheumatologic
conditions, chronic fatigue, or Lyme disease
S/S: mild to severe fatigue, sleep disturbances, HA, jaw pain, depression, GI upset,
visual changes, numbness and tingling in extremities
Meds: SNRI (duloxetine), anticonvulsant (pregabalin), NSAIDs, tricyclic
antidepressant (amitriptyline)
Develop sleep routine; avoid caffeine and ETOH
Rheumatoid Arthritis
Risk factors: female, genetics, EBV, stress
S/S: pain at rest and with movement, morning stiffness, joint pain, lack of function,
joint swelling and deformity, fever, muscle weakness, lymph node enlargement, dry
mouth, pain on inspiration, reddened sclera
Apply heat or cold; assist with physical activity; provide safe environment; muscle
relaxation; small, frequent meals; foods high in vitamins, protein and iron
Meds: NSAIDs, COX-2 inhibitors, corticosteroids (prednisone),DMARDs
Total joint arthroplasty; plasmapheresis
Complications: secondary osteoporosis, vasculitis (organ ischemia), Sjorgen’s
syndrome (dry eyes, mouth and vagina)
Cancer
Risk factors: older age, immunosuppression, race, genetics, exposure to
chemicals/tobacco/ETOH, air pollution, chronic disease, sun/UV/radiation exposure,
diet (high in fat, red meat, low in fiber)
39
@ShopWithKey on Etsy
Diagnosis: biopsy, genetic tests, CT scan, MRI, PET scan, ultrasound, x-ray
Treatment: chemotherapy, radiation therapy, hormone therapy, immunotherapy,
photodynamic therapy, tumor excision or reduction
Reference Chapter 92 for different types of cancers; not writing all that
Meds: NSAIDs, opioids, antidepressants, anticonvulsants, corticosteroids, muscle
relaxants, local anesthetics
Alternative therapy: TENS, relaxation techniques, imagery, distraction, acupuncture,
hypnosis, peer group, heat or cold
40
@ShopWithKey on Etsy
Med Surg Final Study guide
◊ Care of the Elderly – Gerontologic Principles, Theories , Common disorders, etc
o Normal aging changes
Changes in the body cells
Number of cells is reduced
Reduction in lean body mass
Total body fat increases
Decrease in intracellular fluid
Changes in physical appearance
Hair loss, gray hair and wrinkles
Atrophy of body fat
Loss of tissue elasticity
Reduction in skin fold thickness
Decrease in stature
Changes in respiratory system
Reduction in respiratory activity
Less lung expansion
Increased residual capacity and reduced vital capacity
o Residual capacity: how much you breath in
o Reduced vital capacity: how much you breath out
High risk for respiratory infection
Changes in cardiovascular system
Valves become thick and rigid
Heart muscle loses efficiency
o Reduced cardiac output
Reduced elasticity of blood vessels
Increased peripheral resistance
Changes in GI system
Tooth loss is not a normal part of aging
Less acute taste sensations
Increased risk of aspiration, indigestion and constipation
Effect on esophageal motility
Atrophy of the small and large intestines
Changes in urinary system
Reduction in renal blood flow and filtration
Reduced bladder capacity
o Urinary frequency, urgency and nocturia
Incontinence is NOT a normal part of aging
Changes in reproductive system
Males
o Reduction in sperm count
@ShopWithKey on Etsy
o Prostatic enlargement
Females
o Atrophy
o Estrogen depletion
Changes in musculoskeletal system
Atrophy and reduction in the number of muscle fibers
Tendons shrink and harden
Reduction in bone mineral and mass
Increased risk of fracture
Changes in nervous system
Reduction in nerve cells, cerebral blood flow and metabolism
Slower reflexes, delayed responses and changes in balance
Changes in sleep patterns
Changes in sensory organs- vision
Presbyopia
o The inability to focus or accommodate properly
Narrowing of the visual field; decreased peripheral vision
Pupil less responsive to light
Potential for macular degeneration
Opacification of the lens
o Potential for cataracts
Distortion in depth perception
Arcus senilis
o Opaque white ring: Fat deposits can cause a partial or
complete glossy white circle to develop around the
periphery of the cornea
Decline in visual acuity
Changes in sensory organs- hearing
Presbycusis
o Progressive hearing loss due to age
Related changes to the inner ear
Distortion of high pitched sounds
Accumulation of cerumen
Alteration in equilibrium
Changes in sensory organs
Loss of ability to smell
Altered sense of taste
Reduction in tactile sensation
Changes in the endocrine system
Decreased thyroid gland activity
Altered release of insulin
ACTH secretion decreases with age
@ShopWithKey on Etsy
Delayed and insufficient release of insulin
Decreased tissue sensitivity to circulating insulin
Reduced ability to metabolize glucose
Changes in integumentary system
Skin is less elastic, more dry and more fragile
Thinning and graying of hair
Reduced sweat gland activity
o Risk for overheating
Change in immune system
T cell activity declines
Decline in cell mediated immunity
Potential for infection
Potential for reactivation of dormant varicella- zoster and
Mycobacterium tuberculosis
Changes in thermoregulation
Lower normal body temperature
Reduced ability to respond to cold temperature
Differences in response to heat
Changes in the mind
Causes of psychological changes
Changes in memory
Intelligence and aging
Learning ability and aging
Attention span
o Chronic conditions
Arthritis (most prevalent)
HTN
Hearing impairment
Cardiac disease (leading cause of death)
Visual impairment
Orthopedic deformities/impairments
Diabetes
Chronic sinusitis
Hay fever, allergic rhinitis (without asthma)
Varicose veins
o Developmental tasks
Erikson
Challenge is to accept/ find meaning in life lived
Uniqueness/ accomplishment
8th stage
o Ego integrity (adequate) vs. despair (inadequate)
Maslow
@ShopWithKey on Etsy
Biological
Psychological
Ethical
Spiritual
o Theories
Biological theories of aging
Stochastic Theories:
o cross linking theory- ex. radiation or chemical reaction
results with the reduction in tissue elasticity associated with
age related changes
o Free radical and lipofuscin- reactive molecules containing
an extra electrical charge that are generated from oxygen
metabolism.
*Nonstochastic theories – view aging as a result of genetically
programmed physiological mechanism within the body that control the
process of aging
o Wear and tear theories- repeated use and injury of the body
over time as it performs its highly specialized functions.
o Evolutionary theories- genetics. Process of mutation and
natural selection.
o Biogerontology- the study of the connection between aging
and disease process
o Apoptosis- programmed cell death
o Genetic theory- programmed theory of aging , animals and
humans are born with a genetic program or biological clock
that predetermines life span
o Autoimmune reactions- thymus and bone marrow are believed
to affect the aging process
o Neuroendocrine and neurochemical theories- aging is a result
of changes in the brain and Endocrine glands.
o Radiation theories- radiation may induce cellular mutations the
promote aging
o Nutrition theories- good nutrition
Sociological Theories of aging
o Disengagement theory
views aging as a process in which society and the individual gradually
withdraw, or disengage
Activity theory
o Asserts that an older person should continue a middle-aged
lifestyle, denying the existence of old
Continuity Theory
@ShopWithKey on Etsy
o Also referred as developmental theory, relates personality
and predisposition toward certain
Subculture Theory
o Views older adults as a group with distinct norms, beliefs,
exceptions, habits, and issues that separates them from the
rest of society.
Age stratification theory
o Society is stratified into age groups
Psychological theories of aging
o Developmental tasks
Adjusting to ones infirmities, developing a sense of satisfaction with the life
that has been lived, and preparing for death
o Gerotranscendence
o Recent. Aging entails a transition from rational, materialistic meraperspective to a
cosmic and transcendent vision
◊ Prof. Issues - Critical Thinking – Think like a nurse – standards of practice, safety
& quality in clinical practice, JCAHO NPSG, therapeutic communication
o Professional Nursing Issues
Critical thinking
Recognized as a broad term for a learned skill
Described as knowing how to learn, reason, think creatively,
generate ideas, make decisions and solve problems
Ability to solve problems by making sense of information
Clinical reasoning is a problem solving activity in which critical
thinking is used to examine pt. care issues
o Involves using knowledge from many fields
National patient safety Goals (NPSG)
Joint commission issues NPSGs for each of its accreditation
programs
Promote specific improvements in pt. safety by providing health
care organization with evidence based solutions to persistent safety
problem
Focus on system wide solutions
Competencies:
o Patient identification
Use at least 2 pt. identifiers
o Eliminate transfusion errors
o Reporting critical results of tests/labs
o Labeling of meds, containers and solutions
o Reduce likelihood of pt. harm associated with anticoagulant
therapy
o Hand hygiene guidelines
@ShopWithKey on Etsy
o Implement EBP to prevent health care associated infections
o Implement EBP to prevent central line associated
bloodstream infections
o Implement EBP for preventing surgical site infections
o Comparing current meds with those ordered for pt. while in
hospital
o Reconciled list of meds
o Identify pts. At risk for suicide
o Pre-procedure verification process
Mark the procedure site
Time out before the procedure
Teamwork and collaboration
Safety and quality improvement
Delegation in nursing practice
o The right task
o Under the right circumstances
o To the right person
o With the right direction and communication
o Under the right supervision and evaluation
o QSEN competencies
Patient centered care
Delivery of nursing care
Continuum of patient care
Informatics and technology
Information and technology in practice
Clinical information systems and electronic health record
Nursing informatics
Computer language
Evidence based practice
PICOT
o Patient/ population
o Intervention
o Comparison or comparison group
o Outcomes
o Time period
Quality improvement
SBAR
o Situation
o Background
o Assessment
o Recommendation
Safety
@ShopWithKey on Etsy
Teamwork and collaboration
Interdisciplinary team members
Coordinating care
o Communication
o Case management
o Clinical pathways
o Delegation and assignment
o ANA
American Nurses Association
Professional specialty organization
Largest nursing organization
Standards of practice
Declares the authority for the practice of nursing is based on a contract
with society that acknowledges professional rights and responsibilities and
mechanisms for public accountability
Knowledge and skills derived from society’s expectations ad needs
Nursing: “is the protection, promotion and optimization of health and
abilities, prevention of illness and injury, alleviation of suffering through
the diagnosis and treatment of human response and advocacy in the care of
individuals, families, communities and populations”
o Regulatory agencies vs. professional groups vs. quality groups
Regulatory agencies
Enforce standards for the safe use for restraint devices
The optimal goal for all pts is a restraint free environment
Always consider and implement alternative to restraints first
I.E TJC and CMS
Professional groups (Most important is ANA)
have numerous roles in promoting quality patient care and
professional nursing practice. These include developing standards
of practice and code of ethics, supporting research and lobbying
for legislation and regulation. Major nursing organizations also
promote research into the causes of errors, develop strategies to
prevent future errors and address nursing issues that affect the
nurse’s ability to deliver patient care safety. Many nurses join a
professional organization to keep current in their practice and
network w/ others who are interested in a particular practice area.
Quality groups
many government agencies and nonprofit or education
organizations are working to promote patient safety by improving
health care quality. (QSEN)
o Therapeutic communication
Definition
@ShopWithKey on Etsy
Communication used in health care setting to support, educate and
empower people to cope with difficult health related issues,
including a wide range of non-verbal behaviors and activities,
including and not limited to reading, art expression, touch and
writing
Active listening
Focus on pt. and what is being said
Use direct eye contact
Use min. nonverbal cues
Use non-judgmental facial expressions
No premature judgment
Circular questions
Focus on the interpersonal context in which an illness occurs
Designed to identify family relationships and differences in the
impact of an illness on individual family members
Open ended questions
Designed to permit pt. to express problem or health need in his
own words
Focus questions
Variation of open ended question which limits response to a
specific area and requires more than a yes or no answer
Closed ended questions
Limits the amount of information received
Useful in emergency situations
o Goal is to obtain information quickly
Therapeutic listening responses
Are intended to show pt. that nurse is present as a partner in
helping pt., understand a change in health status and best ways to
cope with it
Clarification
Seeks to understand the message of the pt. by asking more
information or for elaboration on a point
Restatement
Active listening strategy used to broaden a pts. Perspective or
when nurse needs to provide a sharper focus on a specific part of
communication
Repeat parts of message in question form, can obtain information
needed without raising pt.’s defenses
Paraphrasing
Response strategy designed to help pt. elaborate on content of
verbal message
@ShopWithKey on Etsy
Take original message and transform it into own words without
losing meaning of pt.’s response
Provides new understanding for the pt. to hear it in a new way
Reflection
ALWAYS a statement
Listening response focusing on emotional overtones of message
Helps clarify important feelings and experiences with their related
intensity in relation to a particular situation or event
Parroting
Rephrasing what is said in the form of a question
Summarization
Listening skill used to review content and process
Summarization pulls several ideas and feelings together from
previous interaction
Purposeful form of communication designed to help a pt. achieve
identified health related goals through participation in a focused
relationship
Should be empathetic
Designed for learning
Assure the pt. that someone will be there with them
Make illness more bearable
Reinforce their self-esteem and support the natural healing powers
of a person
Purpose
Provide a safe place for pt. to explore meaning of illness
Provide information and emotional support that each person needs
to achieve max. health and well being
Each person and conversation is unique
◊ Medication Administration: Principles, techniques – PO, IM, SQ, ID and IV routes.
(PB and IV Push)
o Medication administration
Nursing responsibilities
Assessment of the medication order
o Correct meds
Assess the meds in the drawer or pillbox
Assess the pt.’s ability to self-administer
Determine if meds should be received at a given time
Administer meds correctly and closely monitor their effects
Pt. and family education about proper med administration and
monitoring
Don’t delegate any part of the med administration process to CNA
Use the nursing process to integrate med therapy into care
@ShopWithKey on Etsy
Patient rights
To be informed of the name, purpose, action and potential
undesired effects of a med
To refuse a med regardless of the consequence
To have qualified nurses or dr assess a med history, including
allergies and use of herbals
To be properly advised of the experimental nature of med therapy
and given written consent for its use
To receive labeled meds safely without discomfort in accordance
with the six rights for med administration
To receive appropriate supportive therapy in relation to medication
therapy
To not receive unnecessary med
To be informed if meds are part of a research study
Med administration “rights”
Right patient
o NBA
o 2 identifiers
Name
Date of birth
o Check allergies
Right medication
o Check both generic and brand names
Right dose
o Calculations
o Crush/ scored
o Safe mL/h
Right route
o How to take medication
I.e. PO, IV, IM, etc.
Right time
o Relative 30 minute window
30 minutes before/ after specific time
Right documentation
o Nothing happened without documentation
o BP/HR/P/pain scale/ temperature/ location/how patient
tolerated
Right to refuse
o Pt. can say no to medication
o Routes
Oral
Swallow meds
@ShopWithKey on Etsy
Eye
Cream or drops into eye
Ear
Cream or drops into ear
Buccal
Placing the solid med in the mouth against the mucous membranes
of the cheek until it dissolve
Acts locally on the mucosa or systemically as it is swallowed in a
person’s saliva
Teach pt. to alternate cheeks with each subsequent dose to avoid
irritation
Don’t chew or swallow
Don’t take any liquids with
Sublingual
Placed under the tongue to dissolve
Readily absorbed
Shouldn’t be swallowed
Don’t drink anything until the med is completely dissolved
Suppository
Melt at body temperature
May be administered by rectum or vagina
Inhalant
Carried into the respiratory tract through the vehicles of air,
oxygen or steam (Can be local or/and systemic)
Usually used orally or nasally
Topical
Applied directly to the skin surface (Can be local or/and systemic)
o Injectable
ID (Intradermal)
Injection into the dermis just under the epidermis
o Anatomical sites
Inner forearm
Upper back
o Needle size
25, 27, 29 gauges
o Syringe
½”-5/8” (length of needle)
Amount of fluid that can be injected
Less than/equal to 1 mL
TB= 0.2 mL
o Technique
Insert needle 5 – 10 degrees
@ShopWithKey on Etsy
The bevel of the needle is pointed up
There needs to be a small bleb resembling a
mosquito bite appearing on the surface
If bleb doesn’t appear after needle
withdrawal there is a good chance the meds
entered the SQ tissue and test won’t be valid
SQ (subcutaneous)
Injection into tissues just below the dermis
o Anatomic sites
Posterior aspect of the upper arms
Abdomen from below the costal margins to the iliac
crests
Anterior aspect of the thighs
Alternative sites:
Scapular areas of the upper back
Upper ventral or dorsal gluteal areas
o Needle size (Size of hole at tip of needle)
25, 27, 29 gauges
o Syringe
1/2'”-5/8” (Length of needle)
Up to 1 mL (injectable fluid)
o Technique
Pinch the skin
Enter the skin at either 45 degree or 90 degree angle
IM (intramuscular)
Injection into a muscle
o Anatomical sites
Deltoid
Hip
Thigh
o Needle size
21, 22, 23 gauges (Size of hole at tip of needle)
Length of Needle
o If obese a larger syringed is need i.e.
3 inches
o Syringe
Deltoid (amount of fluid that can be injected)
0.5-1 mL
Hip (amount of fluid that can be injected)
2 mL
Thigh (amount of fluid that can be injected)
2.5 mL
@ShopWithKey on Etsy
o Technique
Insert needle at 90 degree angle
o Z-track method
Recommended when administering IM injections
Used to minimize local skin irritation by sealing the
medication in muscle tissue
To use method:
Put a new needle on syringe after preparing
the med so no solution remains on the
outside needle shaft
Select an IM site
Place ulnar side of the non-dominant hand
just below the site and pull the overlying
skin and subcutaneous tissues approximately
2.5-3.5 cm laterally or downward
Hold the skin in this position until the
injection has been administered
Clean skin with antiseptic swab
Inject needle deep into the muscle
Grasp the barrel of the syringe with the
thumb and index finger of non-dominant
hand
Slowly inject med at a rate of 10 sec/mL
o The needle remains inserted for 10
seconds to allow the meds to
disperse evenly rather than
channeling back up the track of the
needle
Release the skin after withdrawing the
needle
o This leaves a zigzag path that seals
the needle track where tissue planes
slide across one another
o Meds can’t escape from the muscle
tissue
Results in less discomfort and decrease the
occurrence of lesions at the injection site
IV push (intravenous)
Injection into a vein
o Anatomic site
Into IV
Hand
@ShopWithKey on Etsy
Forearm
Possible neck
o Needle size
No needle
o Syringe
2-3mL
o Technique
Clean injection port of lock with antiseptic swab
Insert syringe containing NS into port of IV lock
Pull back gently on syringe plunger and look for
blood return
Flush IV lock with NS by pushing slowly on
plunger
Remove saline flush syringe
Clean port of lock with antiseptic swab
Insert syringe contain prepared meds into injection
port
Inject meds with amount of time recommended
After administering, withdraw syringe
Clean port with antiseptic
o Flush injection port by attaching syringe with NS. Inject NS flush at same rate
med was delivered
◊ Care of the Operative Patient – Pre-Op, Intra-Op, Post-op and considerations for
the Elderly, including immobility
Implementation: Preoperative
Informed consent
o Legal issue
o It is the surgeon’s responsibility to explain the procedure
to the client and obtain an informed consent.
o Competence
Level of consciousness
Legal age
Voluntariness: actually wants the surgery
Informed of:
Procedure
Alternatives
Right to refuse
Consequences
o Phone consent may be obtained if necessary but 2 RN’s
must listen and sign
@ShopWithKey on Etsy
o Implied Consent:
In emergency situations only, occurs if unconscious
patient cannot verbalize consent
Surgery will take place if doctor believes situation is
life-threatening and patient will die without
surgery
Surgery will be done but must make effort to
contact family
Reasons for Preop. Meds.
o Reduce anxiety
o Promote relaxation
o Reduce pharyngeal secretions
o Prevent laryngospasm
o Inhibit gastric secretions
o Decrease amount of anesthetic required for induction and
maintenance of anesthesia
o Nurse responsibilities regarding preop. Meds
Before meds given
Meds may be “on-call to OR”.
Make sure consent is signed prior to any
meds.
5 (7) rights of meds administration.
After administration of meds
Side rails up.
Call light within reach.
Instruct pt. to call for help.
Bed in low position / safety issues.
Instruct dry mouth.
Instruct meds cause drowsiness.
Limit disruptions: patient needs to be calm
and relaxed / turn off bright lights / pull
curtains
Monitor for hypotension and respiratory
distress
Preoperative teaching
o Preoperative teaching includes:
Postoperative exercises designed to prevent
complications
@ShopWithKey on Etsy
Tours/directions of hospital waiting room, surgical
suite, PACU, and other hospital rooms
Anticipated postoperative IV, PCA, NG tube,
pumps, drains, ventilator, etc.
Questions and answers from client and family
Determination of pain level and ways to alleviate
pain
Day of Surgery
Physical preparation
o NPO will make mouth dry, offer oral hygiene to refresh
them
o Hairpins, clips, wigs, hairpieces need to be removed. With
the client’s permission, long hair may be braided to
prevent matting.
o Prosthesis is also removed. These include eyes, dentures,
contact lenses, eyeglasses.
Hygiene: shower
GI: may need enema
Vital signs
o Vital signs are obtained and documented. Health care
facilities have a checklist that needs to be completed and
specific surgery-related documentation. Refer to your
specific institution.
Documentation
Preoperative meds
o Antibiotics, sedatives, or hypnotics.
Immediate Preoperative Care
Physical care
o Preparing the skin
Shower and bathing (hospital gown)
Reduces number of microbes on skin
Preparing the gastrointestinal tract
o Enemas – reduces colonic bacteria
o Restricting food and fluids – because they can aspirate
Nutritional care
o Provide adequate nourishment
o Total parenteral nutrition
Spiritual care
@ShopWithKey on Etsy
Preoperative teaching
o Coughing and deep breathing
Deep breathe three times prior to cough – helps to
stimulate cough reflex and mobilize secretions =
more effective cough.
o Extremity exercises
o Ambulation and turning
o Pain control
o Equipment
Tubes and drains (NG, O2, IV)
Hemovac or Jackson Pratt suction / drain
care
empty when 1/3 – 2/3 full
o Intravenous infusion devices
o TED hose, Venodynes, Sequentials (SCD’s)
o Pulse oximeter
Before surgery
o Psychosocial assessment: Excessive stress response can be
magnified and affect recovery
Anxiety:
Can impair cognition, decision making, and
coping abilities
Can arise from lack of knowledge and
unrealistic expectations, conflict with
interventions of surgery like blood
transfusions with religious beliefs
o Nurse should identify beliefs and
discuss them with the surgeon
Information can lessen anxiety
Fears:
Death or disability
o May prompt postponement
o Influences outcomes
Pain
o Confirm drugs will be available
Mutilation / altering body image
Anesthesia
Disruption of life functions
@ShopWithKey on Etsy
o
o
o
o
o
o Range from fear of permanent
disability to temporary loss
o Includes concerns of family and
financial reasons
Hope: May be the strongest positive coping
mechanism
Never deny or minimize hope
Provide support to patient
Cultural and Spiritual Assessment
Chart review
H & P exam
UA
CBC
Serum electrolytes
Chest XR
ECG
Room Prep.
Surgical attire worn by all people entering OR
Electrical and mechanical equipment checked for
proper function
Aseptic technique used when instruments placed
Basic Aseptic Technique
o Center of sterile field is site of
surgical incision
o Only sterile items in field
o Protective equipment (face shields,
caps, gowns, gloves
Transferring patient
Patient transferred into OR after prep.
Have enough staff to lift, guide, and prevent
patient from falling, as well as injury to staff
Use caution with monitor leads, IV’s, and catheters
Scrubbing, gowning, and gloving
Cleanse hands and arms by scrubbing with
detergent and brush
Eliminates dirt and oil
Decreases microbes
Inhibits rapid regrowth of microorganisms
@ShopWithKey on Etsy
o Preparing Surgical Site
Scrub or clean around the surgical site with
antimicrobial agents
Use a circular motion from clean to dirty (inward
out)
Allow to fully dry
Hair may be removed with clippers – NEVER
SHAVE: CAN CAUSE INFECTION
Intraoperative Surgical Phase: Surgical Team
Circulating nurse – Must be RN
o Responsibilities are:
Reviewing the preoperative assessment
Establishing and implementing the intraoperative
plan of care
Providing for continuity of care postoperatively
o Needs to assist with:
ET intubation
Blood administration
Sterile techniques
Non-sterile equipment
Sponge count verification
Instrument count verification
Completion of written records.
Scrub nurse – can be an RN, licensed practical nurse , or surgical
tech
o Follows designated scrub procedure
o Gowned and gloved in sterile attire
o Maintains sterile environment
o Passes instruments to DR
Preoperative holding area
o The preoperative holding area is where the client meets
the anesthesiologist, IV is inserted, assessments are
completed, and postoperative instructions are verified.
o The client's name is verified by arm band and chart.
o A chart review is conducted to ascertain that all consent
forms, allergies, medical history, physical assessment, and
test results are present.
o A surgical time out is called!
@ShopWithKey on Etsy
The surgical time out is a Joint Commission
requirement. This protocol is used to prevent
wrong surgery mishaps. A mark is placed at the site
of surgery to verify the right client, procedure, site,
and any implants.
Admission to the operating room
o Usually clients are transferred to the OR via a gurney.
Some hospitals will allow the client to walk in. The client is
placed on the table with a safety strap in place.
Intraoperative nursing Care:
o The focus of intraoperative care is to prevent injury and
prevent complications related to anesthesia, surgery,
positioning, and equipment use.
o Maintain safety and prevent injury
Positioning
Equipment
Maintain surgical asepsis
Assist with wound closure
The perioperative nurse is an advocate for
the client during surgery and protects the
client’s dignity at all times.
o Monitoring
Monitoring body temperature
Monitoring for emergencies (MH,
Cardiac/Respiratory arrest, allergic reactions)
Malignant hyperthermia: genetic d/o
Uncontrolled skeletal muscle contraction
leading to potentially fatal hyperthermia;
Related to anesthesia; Screening test –
muscle bx.
VIP – Anesthesia Hx, personal and familial.
Latex allergy precautions
o Documentation of care - everything
Moving and transporting
Postoperative Surgical Phase
Immediate postoperative recovery
o When a client is admitted to the PACU a “hand off”
communication is done.
@ShopWithKey on Etsy
o This is a Joint Commission Client Safety Goal.
o Reports on IV or blood products, special concerns,
anesthesia, BP, EKG and pulse oximetry are discussed.
o Focus will be on monitoring and maintaining the airway,
respiratory, circulatory, and neurological status as well as
pain management.
Discharge from the PACU
o Clients are discharged from the PACU when their
temperature is controlled, ventilatory and oxygenation
status are back to baseline, no complications are present,
minimal pain and nausea, controlled wound drainage,
adequate urine output and fluid and electrolyte balances
are observed.
o Many health care facilities use the ADRETE score or the
Postanesthesia Recovery Score.
o Another hand off report must be done when transferred
to another floor
Recovery in ambulatory surgery
o Ambulatory surgery centers usually have two recovery
phases.
Phase I is the same for inpatient surgery.
Phase II consists of clients being moved to a room
with medical recliner chair, tables, and foot rests.
o As indicated, clients are given light snacks and fluids.
Clients can go home when they score 18 or above on the
post-anesthesia recovery assessment.
Postoperative convalescence
The speed of convalescence depends on the type of surgery, risk factors,
pain management, and postoperative complications.
Post op Nursing Assessment: (Nurse must assess the VS, LOC, condition
of dressing, drains, comfort level, IV fluid status, and urinary output after
surgery)
Airway and respiration
o Patency, rate, rhythm, symmetry, breath sounds, color of
mucous membranes
o Keep O2 between 92% - 100%
o TCDB and encourage use of IS
@ShopWithKey on Etsy
Especially concerned with the elderly, smokers,
and those with a history of lung disease.
Circulation
o Heart rate, rhythm, BP, capillary refill, nail beds, peripheral
pulses
Complications can result from blood loss, side
effects of anesthesia, electrolyte imbalances, and
depression of circulation.
Temperature control
o Malignant hyperthermia
Anesthesia depresses body functioning by lowering
metabolism.
Malignant hyperthermia causes hypercarbia,
tachypnea, tachycardia, PVCs, unstable BP,
cyanosis, skin mottling, and muscular rigidity. Left
untreated, the client can die.
Fluid and electrolyte balance
o IV, I&O, compare baseline lab values
Measure intake (usually IV) and output (which will
include urine, surgical drains, gastric drainage,
drainage from wounds, and any insensible fluid
loss).
Daily weight
o Neurological functions
LOC, gag and pupil reflexes
o Skin integrity and condition of wound
Check skin for rashes, petechiae, abrasions or
burns.
Check wound for drainage.
Document the amount, color, odor, and
consistency of drainage on dressings.
Most common drainage will be
serosangiuneous
Genitourinary
o Urinary function returns in 6 to 8 hours.
o An epidural or spinal anesthesia will often prevent the
client from feeling fullness. Palpate the lower abdomen
just above the symphysis pubis for bladder distention.
@ShopWithKey on Etsy
o With a foley, expect 30 – 50 mL’s or urine output per hour
Gastrointestinal
o Anesthesia slows motility. Often faint / absenr bowel
sounds heard over all 4 quadrants
o When you hear 5 to 30 loud gurgles per minute in each
quadrant, peristalsis has returned.
o High-pitched tinkling sounds accompanied with gastric
distention suggest the bowel is not functioning properly
o Abdominal distention may result from gas but it can be a
late sign of bleeding or paralytic ileus
o NG tube is in place, you will assess it for patency, color,
and amount of drainage.
Comfort
o Use pain scale to assess pain.
o You will use the preoperative pain assessment to
determine how much pain the client is willing to accept.
o Pain should be addressed ever 1 – 4 hours depending on
the clients condition
o Pain will limit the client’s ability to use incentive
spirometer or cough, deep breathe, and turn.
Post-Op Implementation
Maintaining respiratory function
o Start pulmonary intervention early. (TCDB and IS)
o Consider suctioning for clients who are too weak or who
are unable to cough
o Atelectasis – prevent pneumonia
Preventing circulatory complications
o Foster circulation.
Client should perform
apply anti-embolism stockings or SCDs
encourage early ambulation
Administer anticoagulants (aspirin, Coumadin or
Lovenox).
Achieving rest and comfort
o Administer pain medications.
o Make sure to medicate clients before painful dressing
changes or therapies that can cause pain
Postoperative Nursing Care
@ShopWithKey on Etsy
Assess and protect the airway, circulation, renal system and
neurological status
o Older adult w/ impaired liver / kidney Fx: may take longer
to regain orientation.
Maintain normal blood pressure
Monitor for return of sensation, motion, and consciousness
Assess for normothermia
o Monitor for hypothermia in elderly especially
o Monitor temperature, provide warm blankets, booties
Assess for perfusion
o Hypoxemia = decreased O2 saturation; low levels of
oxygen in the blood…a problem
o Keep O2 sat > 90-92% - if below, give O2!
o Communicate with MD
RN goal is to assist patient to an uncomplicated return to safe
physiologic functioning after a procedure by providing safe,
knowledgeable nursing care to patient and their families.
Always protect patient’s airway & circulation.
Assess the surgical site
Monitor the wound, drainage tubes, and intravenous lines
Monitor for nausea / maintain open airway
o Preferred recovery position: Lateral Sims – side lying
allows pt. tongue to fall forward and mucus or vomitus to
drain from mouth.
o Turn pt’s head to one side.
o Have suction nearby.
DO NOT change surgical dressing unless MD ordered…usually 1 st
drsg change done by surgeon on POD#1
Promote comfort
o Incisional pain: splint incision w/ pillow
Maintain safety
o maintain airway, monitor respirations, O2 sats.
o side rails up, do not let them get up
o frequently re-position
o call light in reach
o SAFETY is # 1 RN priority in the post-op patient other than
airway
o Common complicating conditions in Elderly Surgical Patients
@ShopWithKey on Etsy
Infection
Malnutrition
Cardiac failure
F & E imbalance
Pressure Ulcers
Atelectasis / Pneumonia
o More common in heavy smokers, obese pt. Hx of
bronchitis, COPD. The elderly have decreased pulmonary
function, decreased tidal volume and loss of protective
airway reflexes
o Bacterial pneumonia - leading cause of infection-related
death in the older adult
Incidental hypothermia
o cool OR rooms, exposure of skin or incision site for draping
or prep, impaired thermoregulation mechanisms,
decreased cardiopulmonary reserves.
Acute confusion, delirium
o Influenced by type of anesthesia, pre-existing depression,
dementia and pre-op meds taken.
o Altered mental status – infection may present as
confusion, lethargy and anorexia
Joint stiffness, contractures
o Osteoporosis and immobility during surgery. In elderly:
there is decreased muscle mass, decreased bone mass,
ossification of cartilage in joints.
o Stooped posture and gait change.
Hypoxia
o Restlessness in elderly pt can be sign of hypoxia.
Reactions similar to pain sx.
Pain: Stay ahead of the pain game…give pain med as scheduled if
no reason not to
Constipation – anesthesia slows down peristalsis
Paralytic ileus
o non-mechanical obstruction of the bowel from paralysis of
the bowel wall usually as a result of localized/ generalized
peritonitis / shock and sometimes effects of anesthesia
@ShopWithKey on Etsy
* Elderly already have comorbidities; makes them very
susceptible to common complications
◊ Care of Wounds, Skin, Drains etc
◊ Antibiotics administration –
o why
What is an Infection
Definition: and infection is a problem from an external organism
or the immune system may not be working properly
Situations that can cause immune system to fail:
o Overwhelming infection
o Stress to body systems
Critical illness – most common
Surgery
Trauma
Age
o How - Antibiotics
Defined as:
Chemical compounds that inhibit or abolish the growth of
microorganisms, such as bacteria, fungi, or protozoans
Classified as either:
Bactericidal: kills bacteria
Bacteriostatic: prevents bacteria from dividing
Further Divisions:
o Narrow vs. Broad Spectrum Antibiotics
Narrow spectrum (PCN, Azithromycin, Vancomycin)
Affect limited # or microorganisms
Zooms in on known microorganism causing
the infection
Less likely to destroy normal flora
Broad Spectrum (Cephlosporins, Fluroquinolones)
Affect a wide range of microorganisms
Useful in treating an infection when the
cause is unknown
Often destroys normal flora
o common reasons
To treat a current infection
To prevent infection / people at risk for infection
Prophylaxis treatment
@ShopWithKey on Etsy
◊
◊
◊
◊
◊
◊
◊
o Nursing Implications
C & S should be taken before therapy is started so antibiotics do not
effect results
Insure medication is given at correct time, as timing is important to
maintain therapeutic level of drug
Always ask of any allergies before administration, especially to any other
antibiotic as this increasing the risk of reactions to similar antibiotics
Be aware of mechanism of metabolism and necessary blood work to
monitor
Some drugs like vancomycin require peak (Highest level of drug
without causing adverse effects) and trough (Lowest amount of
drug needed to keep medicine working) levels
Keep alert for side effects / neg. reactions
Know what to do in an emergency, know where crash cart is and
resources that might be needed
Keep alert for drug to drug interactions and food to drug interactions
Use comfort measures for side effects
Educate patient
Fluid and Electrolyte Balance, IV fluids, IV management, IV Therapy principles
(sites, complications, etc) Know about NA, K+, Ca, Mg – normal &significance of
abnormal.
Care of the Diabetic patient – patho (DM 1 vs DM 2) , diagnostic tests, medical and
nursing care. Medication, exercise, and diet management and prevention and
treatment of complications, including patient teaching. DKA, HHNS, ABG –
metabolic acidosis
ECG – rules for interpretation –NSR, know lethal rhythms and 12 Lead ECG
Care of patients with Thyroid disorders – hypo/ hyper, medications, labs, and
treatments – Surgery, radioactive iodine, post op surgical care of thyroidectomy.
Care of the patient with Respiratory Conditions - patho, diagnostic tests, medical
and nursing management - specific to asthma, CAL/ COPD, pneumothorax,
pneumonia, Pulmonary edema, pulmonary embolism and pulmonary effusion
Oxygenation Principles: ABG’s, O2 therapy, Signs & Sx of Resp distress
Care of Patients with Renal Conditions: General Principles, Diagnostic testing,
Signs and Symptoms, Diseases: Pre, Intra, and Post Renal- UTI, Pyelonephritis,
Kidney stones, CIN, - medical intervention .Significant lab values Creat., BUN, and
GFR–values, CA and Phosphate balance – normal, sgns & sx of high and low,
Metabolic Acidosis Acute and Chronic- Stages, Renal Failure Dialysis – peritoneal
vs hemodialysis, chronic systemic symptoms.
@ShopWithKey on Etsy
◊ Men’s Health Disorders – Nursing Care - BPH, TURP, CBI, ED including
medications, diagnostic tests, and surgical interventions.
◊ Vascular Disorders: Arterial vs. Venous Peripheral Vascular disease. Signs,
Symptoms, treatments consequences
o Arterial disorders
Clinical Manifestations
Intermittent claudication
Rest pain
Decreased pulses
Decreased wounded healing
Discoloration
o Starts with raynoud (bluish at tips of figners)
o Then goes pale
Due to spasms and poor circulation
o Then goes red / purple
Body over compensates for decrease circulation
Spasms stop
Throbbing occurs
Hair loss
o Caused due to poor circulation
Treatments
Medical management
o Promote arterial flow
Rest with legs down
Gravity helps to promote circulation to the lower
limbs
o Reduce risk
o Smoking cessation
o Control comorbid diseases
o Exercise
o Prevent injury
Surgical management (revascularization)
o Endovascular
Angioplasty
Atherectomy
Stent placement
o Arterial bypass and reconstruction
Complications
@ShopWithKey on Etsy
Limb Ischemia
Amputation
o Type
Open (guillotine)
Closed (flap)
Traumatic
o Client’s attitude
Can cause a lot of anxiety and depression
Change in body image can cause many difficulties
for people
o Phantom limb sensation and pain
When part of a limb is removed some of the nerves
remain behind
Nerve is so used to receiving signals from the limb
that the nerves will still think the limb is there
Acute Arterial Occulsion
o Etiology and pathophysiology
Trauma, embolism, thrombosis
This is a surgical emergency because symbolizes
tissue is dying
Must intervene ASAP to get circulation back to the
area or can lead to amputation
o Clinical manifestations (six Ps)
Pain
Pulselessness
Poikilothermic (Goose Bumbs)
Pallor
Paresthesias
paralysis
Abdominal Aortic Aneurysm
o Classification
Location and gross appearance
Classifications of all aneurysms
True: wall forms the bulging
o At least one vessel layer still intact
False: Blood not contained
o Not an aneurysm
o Disruption of all layers of arterial
wall
@ShopWithKey on Etsy
o Results in bleeding contained by
surrounding structures
o Clinical manifestations
Asymptomatic: felt at 5 cm
o Diagnosis
Physical and ultrasonography—
computed tomography (CT)
Surgical intervention
o Nursing Management
HTN the most common risk factor
If the AAA occurs above the renal artery will affect
the blood flow to the kidneys and everything below
Most dangerous spot
If it burst, will kill you
o There is no real treatment
Just manage BP
Aortic Dissection
o Etiology and classification
Separation of aorta
Type A involves ascending aorta
o Occurs in people with acromegaly
o Risk is getting T-boned in a car
accident
Type B does not involve ascending aorta
o Clinical manifestation:
abrupt pain; knife-like
tearing sensations
HTN
diminished pulses
o Complications:
cardiac tamponade
o Emergent management:
lower blood pressure (BP)
pain control
Peripheral Arterial Disorders
Raynaud’s syndrome
o Vasospastic or obstructive
o More hand problems
Thromboangiitis obliterans
(Buerger’s disease)
@ShopWithKey on Etsy
o Inflammatory disease
o Problem mostly in legs
o Venous Disorders
Acute Disorders
Thrombophlebitis
o Inflammation of the vein due to a clot
Chronic Venous Disorders
Varicose veins
Chronic venous insufficiency
Venous stasis ulceration
o Lymphedema
Etiology
Impaired transcapillary fluid
transport
Clinical manifestation
Unilateral edema of the limb
Management
Surgical removal of lymph node
◊ Care of Patients with Gastrointestinal Problems: General - Etiology-Patho
Complications Diagnostic testing, Signs and Sx, Nutritional Disorders; General
Nursing and medical treatment, patient teaching, Liver biopsy, EGD, Colonoscopy,
etc. Consider all interventions for colon cleansing
o Diagnostic Testing
Radiologic Studies
Barium Studies
o Upper gastrointestinal series: Swallow
o Lower gastrointestinal series: Enema
o Is able to show organs
o Nursing implications
Push fluids
Stool softener
Movement as tolerable
Virtual colonoscopy
o A pill with a little camera on it is swallowed and the
patients have to have an eye out for the camera every time
they have a BM.
Endoscopy –
o EGD
Scope that is inserted down throat to view part of
the stomach and small intestines
@ShopWithKey on Etsy
Must check gag reflux since throat is numb
If patient has an ostomy the
o Upper GI endoscopy
Useful in assessing LES competence, degree of
inflammation, scarring, strictures
Monitoring pH of stomach contents and esophagus
Liver Biopsy
o Sample of tissue is taken
o Liver is very vascular though so must be careful of
bleeding
o Usually patient is placed on the right side
The placement is too try to contain the bleeding
that often occurs due to the very vascular organ
Pressure is put on the surgical cite and this position
also helps to promote drainage
o Signs of loss of blood
Increased pulse
Decrease blood pressure
Fatigue
Pale
Mental status changes
Signifiys too much loss has occurs
Check for bruising
Liver Function Studies
o AST
o ALT
◊ Upper GI Diseases & conditions: GERD, Hiatal Hernia, Gastritis, PUD, Dumping
Synd.
o GERD
Not a disease but a syndrome
Clinically significant symptomatic condition or histopathologic alteration
Secondary to reflux of gastric contents into lower esophagus
Etiology and Pathophysiology
No single cause
Results when
o Defenses of lower esophagus are overwhelmed by reflux of
gastric contents into esophagus
Predisposing factors / risk factos
o Hiatal hernia
Pouching out of stomach through the diaphragm
@ShopWithKey on Etsy
o Incompetent lower esophageal sphincter (LES)
Antireflux barrier
o Decreased esophageal clearance
o Decreased gastric emptying
o Obesity
o Pregnant women
o Smoking
HCl acid and pepsin secretions reflux—cause irritation and
inflammation
Intestinal proteolytic enzymes and bile salts add to irritation.
o The degree of inflammation depends on the amount and
composition of gastric reflux and on the ability of the
esophagus to clear the acidic contents.
Incompetent LES
o Primary factor in GERD
o Results in ↓ in pressure in distal portion of esophagus
Gastric contents move from stomach to esophagus.
Can be due to certain foods (caffeine, chocolate)
and drugs (anticholinergics)
Symptoms of GERD
Heartburn (pyrosis)
o Most common clinical manifestation
o Burning, tight sensation felt beneath the lower sternum and
spreading upward to throat or jaw
o Felt intermittently
o Relieved by milk, alkaline substances, or water
Regurgitation
o Effortless return of food or gastric contents from stomach
into esophagus or mouth
o Described as hot, bitter, or sour liquid coming into the
mouth or throat
o Can mimic angina
GERD-related chest pain can mimic angina. It is
described as burning or squeezing and can radiate to
the back, neck, jaw, or arms. Unlike angina, GERDrelated chest pain is relieved with antacids.
Dyspepsia
o Pain or discomfort centered in upper abdomen
Hypersalivation
Most individuals have mild symptoms.
@ShopWithKey on Etsy
o Heartburn after a meal
o Occurs once a week
o No evidence of mucosal damage
Persistent reflux that occurs more than twice a week is considered
GERD.
No mucosal damage in the beginning
Complications of GERD
Related to direct local effects of gastric acid on esophageal mucosa
Esophagitis
o Inflammation of esophagus
Barrett’s esophagus
o Replacement of normal squamous epithelium with
columnar epithelium
o Precancerous lesion
o Barrett’s esophagus is also known as esophageal
metaplasia. Metaplasia is the reversible change from one
type of cell to another type and is generally caused by some
sort of abnormal stimulus.
Respiratory
o Due to irritation of upper airway by secretions
o Cough
o Bronchospasm
o Laryngospasm
o Cricopharyngeal spasm
o Potential for asthma, bronchitis, and pneumonia
Dental erosion
o From acid reflux into mouth
o Especially posterior teeth
Lifestyle modifications
Avoid triggers
o Sit up when eating
o Don’t eat too late
o Avoid certain foods that increase influx
o Stop smoking
Nutritional therapy
Decrease high-fat foods.
Take fluids between rather than with meals.
Avoid milk products at night.
Avoid late-night snacking or meals
@ShopWithKey on Etsy
Avoid chocolate, peppermint, caffeine, tomato products, orange
juice.
Weight reduction therapy
Drug therapy (Same for GERD /
Two approaches
o 1. Step up
Start with antacids and OTC H2R blockers, and
progress to prescription H2R blockers and finally
PPIs.
Proton pump inhibitors (PPIs) and
histamine-2-receptor (H2R) blockers are the
most common and effective treatments for
symptomatic GERD.
o Step down
Start with PPIs, and titrate down to prescription
H2R blockers and finally OTC H2R blockers and
antacids.
Histamine (H2)-receptor blockers
o Decrease secretion of HCl acid
o Reduce symptoms and promote esophageal healing in 50%
of patients
Proton pump inhibitors (PPIs)
o Decrease gastric HCl acid secretion
o Promote esophageal healing in 80% to 90% of patients
o May be beneficial in ↓ esophageal strictures
o Headache: Most common side effect
Prilosec, Nexium, Aciphex
Antacids
o Quick but short-lived relief
o Neutralize HCl acid
Does effect the amount of HCl just changes the pH
level to more neutral
o Taken 1 hour before meals or 2 hours after meals and other
meds
Because can effective absorption of other meds
o Maalox, Mylanta
Acid protective
o Used for cytoprotective properties
Coats lining of stomach / esophag
o Sucralfate (Carafate)
@ShopWithKey on Etsy
Surgical therapy
Necessary if
o Conservative therapy fails
o Medication intolerance
o Barrett’s metaplasia
o Esophageal stricture and stenosis
o Chronic esophagitis
o Hiatal hernia
Nissen and Toupet fundoplications
o Tightens sphincter
Nursing management for GERD
Avoidance of factors that cause reflux
o Stop smoking
o Avoid alcohol and caffeine
o Avoid acidic foods
Reduce stress / learn stress reduction techniques
Loss weight (less pressure of LES)
Small frequent meals
o 6 small meals a day = less reflex
Elevate head of bead 30 degrees (Semi fowlers)
Do not lay down 2-3 hrs after eating
o Causes acid to move more towards the LES
Avoid late night eating
o Hiatal hernia
Pouching out of stomach through the diaphragm
Do not strain / pick up heavy objects
Can worsen GERD because the stomach to pouching out above the
diaphragm
Reflex
Diagnosis
Upper G
o Checks to see in swallowing is working and can check for
protrusion of gastric fundus
o Peptic Ulcer Disease (PUD)
Erosion of GI mucosa resulting from digestive action of HCI
An ulcer is an opening between the musical membrane and the tissue
Ulcers can develop in
o Lower esophagus
o Stomach
Common place because it is an area of high acidity
@ShopWithKey on Etsy
o Duodenum
Common place because it is an area of high acidity
o Margin of gastrojejunal anastomosis after surgical
procedures
Any portion of the GI tract that comes into contact
with gastric secretions is susceptible to ulcer
development.
Occurs from decay or breakdown in the mucosal lining
Acute Vs Chronic
Depends on degree/duration of mucosal involvement
Determined by severity and depth of invasion into mucosal lining
Acute
o Superficial erosion or mucosa, may penetrate into the
submucosal layer
o Minimal inflammation
o Short duration, resolves quickly when cause is identified
and removed
Chronic
o Muscular wall erosion with formation of fibrous tissue
o Long duration—present continuously for many months or
intermittently
o More common than acute erosion
o chronic ulcer may penetrate the entire wall of the stomach.
Etiology and Pathophysiology
Develops only in the presence of an acid environment
Excess of gastric acid not necessary for ulcer development
Stomach normally protected from autodigestion by gastric mucosal
barrier
o Surface mucosa of stomach is renewed about every 3 days.
With an ulcer the Mucosa can continually repair itself, except in
extreme instances.
o Water, electrolytes, and water-soluble substances can pass
through barrier.
Destroyers of mucosal barrier
o Helicobacter pylori – most common cause of PUD
Produces enzyme urease
Mediates inflammation, making mucosa more
vulnerable
o Aspirin and NSAIDs
Inhibit syntheses of prostaglandins
@ShopWithKey on Etsy
Cause abnormal permeability
Take with food (like milk) to decrease the
breakdown or mucosal lining
o Corticosteroids
↓ rate of mucosal cell renewal
↓ protective effects
o Lifestyle factors
Alcohol, coffee, smoking, psychologic stress
o Gastric Ulcers
Occur in any portion of stomach
Western countries—less common than duodenal ulcers
Prevalent in women, older adults
Peak incidence >50 years of age
Although gastric ulcers can occur in any portion of the stomach, they are
most commonly found in the antrum.
Gastric ulcers are more likely than duodenal ulcers to result in
hemorrhage, perforation, and obstruction.
Risk factors
H. pylori
Medications
Smoking
Bile reflux
o Duodenal Ulcers
Occur at any age and in anyone
↑ between ages of 35 and 45 years
Account for ~80% of all peptic ulcers
Familial tendency
Person with blood group O ↑ risk
Associated with increased HCl acid secretion
H. pylori is found in 90% to 95% of patients.
Not all individuals with H. pylori develop ulcers.
Increased risk of duodenal ulcers in those with
COPD
Cirrhosis of liver
Chronic pancreatitis
Hyperparathyroidism
Chronic renal failure
Zollinger-Ellison syndrome
@ShopWithKey on Etsy
o are condition characterized by severe peptic ulceration,
gastric acid hypersecretion, elevated serum gastrin levels,
and gastrinoma of the pancreas or duodenum.
Smoking and alcohol use
Duodenal ulcer pain
Midepigastric region beneath xiphoid process
Back pain—if located in posterior aspect
2 to 5 hours after meals
“Burning” or “cramplike”
Tendency to occur, then disappear, then occur again
o Clinical Manifestations of ulcers in general
Pain high in epigastrium
1 to 2 hours after meals, and pain increases with food
“Burning” or “gaseous”
Food aggravates pain as ulcer has eroded through gastric mucosa.
Not all patients with gastric or duodenal ulcer will experience pain or
discomfort. Silent peptic ulcers are more likely to occur in older adults and
those taking NSAIDs.
The presence or absence of symptoms is not directly related to the
size of the ulcer or the degree of healing.
o Complications
Three major complications include
Hemorrhage
o Most common complication of peptic ulcer disease
o Develops from erosion of
Granulation tissue found at base of ulcer during
healing
Ulcer through a major blood vessel
o Signs/symptoms
Vomiting
Coffee ground emesis
o Occurs when vomit had been
exposed to acid
Stool
Black and tarry
o Blood went through acid
o Signifies upper GI bleed
Reddish in color
o Signifies lower GI bleed
o Might be similar to blood color
@ShopWithKey on Etsy
o Might have clots
Perforation
o Most lethal complication of peptic ulcer
o Common in large penetrating duodenal ulcers that have not
healed and are located on posterior mucosal wall
o Perforated gastric ulcers often located on lesser curvature
of stomach
o Mortality rates higher with perforation of gastric ulcers
The older age of the patient with gastric ulcer, who
often has other concurrent medical problems,
accounts for the higher mortality rate.
o When ulcer penetrates serosal surface with spillage of
contents into peritoneal cavity
o Size proportionate to length of time ulcer existed
Small perforations seal themselves, resulting in a
cessation of symptoms.
Large perforations: Immediate surgical closure
o Clinical manifestations
Sudden, dramatic onset
Severe upper abdominal pain spreads throughout
abdomen.
The pain radiates to the back and is not
relieved by food or antacids.
Tachycardia, weak pulse
Rigid, board-like abdominal muscles
Good significance that a rupture has
occurred
Shallow, rapid respirations
Bowel sounds absent
Nausea/vomiting
Give meds, make pt NPO, NG Tube
History reporting symptoms of indigestion or
previous ulcer
o Bacterial peritonitis may occur within 6 to 12 hours.
The contents entering the peritoneal cavity from the
stomach or duodenum may contain air, saliva, food
particles, HCl acid, pepsin, bacteria, bile, and
pancreatic fluid and enzymes.
As fluid moves into the abdominal cavity,
hypovolemia occurs as a result of third spacing.
@ShopWithKey on Etsy
Distention may occur due to build-up of
fluid in the 3rd spacing
o Difficult to determine from symptoms alone if gastric or
duodenal ulcer has perforated
o Therapy for perforation
Stop spillage of gastric or duodenal contents into
peritoneal cavity.
Restore blood volume
Replaced with lactated Ringer’s and
albumin solutions
Blood replacement in form of packed RBCs
may be necessary.
NG tube is placed into stomach.
Continuous aspiration
Placement of tube near to perforation site
facilitates decompression.
Gastric outlet obstruction
o Scar tissue that forms which leads to obstruction and causes
back up
o Obstruction due to
Edema
Inflammation
Pylorospasm
Fibrous scar tissue formation
All contribute to narrowing of pylorus.
o Early phase: Gastric emptying normal
o Over time, ↑ contractile force needed to empty stomach
o Hypertrophy of stomach wall
o After long-standing obstruction
Stomach dilates and becomes atonic.
Look for free air on an x-ray
Will signify opening in wall of GI tract
o Clinical manifestations
Usually long history of ulcer pain
Pain progresses to generalized upper abdominal
discomfort.
Pain worsens toward end of day as stomach
fills and dilates.
Relief obtained by belching or vomiting
Vomiting is common. Often projectile
@ShopWithKey on Etsy
The vomitus contains food particles that
were ingested hours or days before the
vomiting episode. An offensive odor is often
noted because the contents have been in the
stomach for a long time.
Constipation is a common complaint.
Dehydration, lack of roughage in diet
Swelling in stomach and upper abdomen
Loud peristalsis
Visible peristaltic waves
If stomach grossly dilated, may be palpable
o Therapy for Gastric outlet
Decompress stomach.
Correct any existing fluid and electrolyte
imbalances.
NG tube inserted in stomach, attached to continuous
suction
Continuous decompression allows
Stomach to regain its normal muscle tone
Ulcer to begin to heal
Inflammation and edema to subside
Watch patient carefully for signs of distress or
vomiting.
As residual ↓, solid foods added and tube removed
All considered emergency situations
o Diagnostic Studies for Ulcers
To determine presence and location of ulcer
Similar to those used for acute upper GI bleed
Endoscopy with biopsy
Most often used
o Endoscopy is the most accurate diagnostic procedure.
Allows for direct viewing of mucosa
Determines degree of ulcer healing after treatment
During procedure, tissue specimens can be obtained to identify H.
pylori and rule out gastric cancer.
Tests for H. pylori
Noninvasive tests
o Serum or whole blood antibody tests
Immunoglobin G (IgG)
@ShopWithKey on Etsy
Will not distinguish between active and recently
treated disease
o Urea breath test
Can determine active infection
o Stool antigen test
Not as accurate as breath test
Invasive tests
o Endoscopic procedure
o Biopsy of stomach
Rapid urease test
Barium contrast studies
X-ray studies
Laboratory analysis
CBC
o Anemia
Urinalysis
Liver enzyme studies
Serum amylase determination
o Pancreatic function
Stool examination
o Presence of blood
o Collaborative Care for PUD
Medical regimen consists of
Adequate rest
Dietary modification
Food and beverages irritating to patient are avoided or eliminated.
o Foods that commonly cause gastric irritation include hot,
spicy foods and pepper, carbonated beverages, caffeinecontaining beverages, alcohol, and broth (meat extract).
Bland diet may be recommended.
Six small meals a day during symptomatic phase
Drug therapy
H2R blockers
o Frequently used
o Block action of histamine on H2 receptors
↓ HCl acid secretion
↓ conversion of pepsinogen to pepsin
↑ ulcer healing
PPIs
@ShopWithKey on Etsy
o Block ATPase enzyme—important for secretion of HCl
acid
o ↑ effective than H2R blockers—reducing acid and
promoting healing
Antibiotics
o Eradicates H. pylori infection
o Most important in treatment if
H. pylori present
o No single agent has been effective in eliminating H. pylori.
o Usually lasts 7-14 days
Antacids
o Adjunct therapy for PUD
o Increase gastric pH by neutralizing HCl acid
o Effects on empty stomach 20 to 30 minutes
o If taken after meals, may last 3 to 4 hours
Anticholinergics
o Occasionally used
o ↓ cholinergic stimulation of HCl acid
o ↓ gastric motility: Not used for gastric outlet obstruction
Anticholinergics are associated with a number of
side effects, such as dry mouth and skin, flushing,
thirst, tachycardia, dilated pupils, blurred vision,
and urine retention.
Cytoprotective therapy
o Protect and line the mucosal layer
Hallmark drug therapy for PUB – Triple therapy
o PPI or H2 blocker to reduce amount of acid
o Antibiotics for the H. Pylori
o Antacids like pepto
Decreased the acidity / pH of acid
Also is cytoprotective of mucosal lining
Elimination of smoking and alcohol
Long-term follow-up care
Stress management
Complete healing may take 3 to 9 weeks.
Should be assessed by means of x-rays or endoscopic examination
Aspirin and nonselective NSAIDs may be stopped.
o Surgical therapy
Uncommon because of antisecretory agents
Indications for surgical interventions
@ShopWithKey on Etsy
Unresponsive to medical management
Concern about gastric cancer
Can occur due to gastric outlet obstruction
Surgical procedures
Gastroduodenostomy
o Partial gastrectomy with removal of distal 2/3 stomach and
anastomosis of gastric stump to duodenum
Gastrojejunostomy
o Partial gastrectomy with removal of distal 2/3 stomach and
anastomosis of gastric stump to jejunum
Vagotomy
o Severing of vagus nerve
o Can be total or selective
Pyloroplasty
o Surgical enlargement of pyloric sphincter
o Commonly done after vagotomy
o ↓ gastric motility and gastric emptying
o If accompanying vagotomy, ↑ gastric emptying
Postop Complications
Most common
o Dumping syndrome
↓ ability of stomach to control amount of gastric
chyme entering small intestine
Large bolus of hypertonic fluid enters intestine
↑ fluid drawn into bowel lumen
Occurs at end of meal or 15 to 30 minutes after
eating
Symptoms include
Weakness, sweating, palpitations, dizziness,
abdominal cramps, borborygmi, urge to
defecate
Last no longer than an hour
o Postprandial hypoglycemia
Variant of dumping syndrome
Result of uncontrolled gastric emptying of a bolus
of fluid high in carbohydrate into small intestine
↑ blood sugar
Release of excessive amounts of insulin into
circulation
@ShopWithKey on Etsy
Secondary hypoglycemia occurs with symptoms ~2
hours after meals.
Symptoms include sweating, weakness, mental
confusion, palpitations, tachycardia, and anxiety
o Bile reflux gastritis
Surgery can result in reflux alkaline gastritis.
Prolonged contact of bile causes damage to
gastric mucosa.
Continuous epigastric distress that ↑ after
meals
o Vomiting relieves the distress, but
only temporarily.
May result in back diffusion of H+ ions
through gastric mucosa
PUD may reoccur
o Prolonged contact with bile,
especially bile salts, causes damage
to the gastric mucosa and chronic
gastritis and recurrence of PUD.
◊ GI Interventions – NG tubes, Enteral Meds, Ostomies and Tube Fdgs., and TPN
o NG tubes
Salem Sump nasogastric tubes are dual lumen tube allows for safer
mucontinuous and intermittent gastric suctioning.
The large lumen allows for easy suction of gastric contents,
decompression, irrigation and medication delivery.
The smaller vent lumen allows for atmospheric air to be drawn into
the tube and equalizes the vacuum pressure in the stomach once
the contents have been emptied.
This prevents the suction eyelets from adhering to and damaging the
stomach lining.
Argyl Salem Sump Anti-Reflux Valve
BLUE TO BLUE if you have to add it
The anti-reflux valve provides clinicians and patients with the
highest quality of NG tube care.
When attached and maintained properly, the ARV prevents
stomach contents from exiting the vent lumen.
o This prevents unnecessary patient gown and bedding
changes and reduces the risk of exposure to potential
infectious materials.
@ShopWithKey on Etsy
o This ARV allows the vent lumen to neutralize the vacuum
pressure in the stomach when the contents are fully
evacuated.
Dale Nasogastric Tube Holder
STATLOCK Stabilization Devices are a more effective alternative
to tape in helping improve clinical outcomes, quality of care and
economic efficiencies.
The STATLOCK Nasogastric Stabilization Device is ideal
stabilization for nasogastric and feeding tubes.
o Available in adult and pediatric sizes.
o Purpose of NG tubes
Decompress / drain stomach
if stomach is full and nothing is being excreted, patient will vomit
Gavage -feedings/medications
Lavage - irrigation
wash/flush if bleeding, or can use to administer charcoal in an
overdose
◊ Enteral Medications
o do not add medications directly to tube with feedings
can be harmful to mix them
mixing them disrupts the sterility of enteral formula
can cause drug - food/formula interactions
o Administer each medication separately through an appropriate access site
drug classifications will help a provider in deciding whether a drug should
be administered via an enteral feeding tube
like enteric coated or sustained released because these medications
cannot be crushed and therefore shouldn’t be administered through
the feeding tube
o Upon administering medications the nurse must dilute the solid or liquid as
appropriate and administer using a clean oral syringe
use sterile water and not tap water
tap water usually contains many pathogens
o Must flush with at least 15 mL sterile water before and after administering meds
and between each medication
decreases chance of obstruction
◊ Ostomies
o Ostomies are described according to location and type
o Types of Ostomies
Cecostomy
Colostomy
ascending
transverse
@ShopWithKey on Etsy
descending
sigmoid
o the more distal an ostomy is the more formed the feces are
Ileostomy
Continent Ileostomy
ileoanal reservoir surgery
o Ostomies may be permanent or temporary
A temporary ostomy may be needed if there is trauma to the area and the
area needs rest. The only way to rest the bowel is to not have anything
going through it
◊ Tube Feedings
o Gastric Feeding tubes
NG salem
DObhoff - small bore tubes
PEG (Percutaneous Endoscopic Gastrostomy)
o Small Bowel Feeding tubes
Jejunostomy tube -PEJ
o Long term tube feedings
Dobhoff type – soft bore, weighted, designed to be located in duodenum
Indications for use
o A small-bore, flexible silicone tube usually inserted into the
nose with a weighted tip that should preferentially be past
the pylorus
o Used for nutrition in patients who
Require mechanical ventilation
Have an altered mental status
Have swallowing disorders
o It is a narrow-bore (3mm-8 French, 10 Frand 12 Fr) which
can be left in place for 6 weeks or more
Causes less local irritation than nasogastric tubes
Unlike a large-bore nasogastric tube, it is not
attached to suction - AND
Cannot be aspirated for residual check with tube
feedings
Placement
o The feeding tube has a weighted metal tip and a guide wire
for insertion
The side hole is usually located just proximal to the
tip
o Tip of feeding tube should be in 2nd or 3rd portion of
duodenum
o Most, however, are placed in the stomach
@ShopWithKey on Etsy
o Placement of the tube is checked by a post-insertion
radiograph centered on the region of the lower chest and
upper abdomen
GOLD STANDARD TO CHECK FOR
PLACEMENT OF ANY TUBE IS A CHEST
XRAY
Other methods include
Air bolus method
testing the pH of fluid that comes out of tube
o Once the guide wire is removed, it is not re-inserted
Complications
o About 2% tracheopulmonary complications – such as
aspiration
o Positioning in the stomach
If the tube is placed too proximally, there is a risk of
aspiration
o Inadvertent insertion into the tracheobronchial tree
The tube is more likely to enter to the right main
bronchus and lower lobe bronchus because of the
wider diameter and straighter course than the left
main bronchus
o Perforation of pleura by guide wire or tube
Pneumothorax
o Intracranial placement
Very rare
PEG Tube
Jejunostomy type
o Administering Tube Feedings
Three methods for administering
Continuous drip
Intermittent drip
Bolus feeding
Safety measures that need to be checked prior to administering a tube
feeding
Patient
Position
Placement
Patency
Residual
Steps to med administration
Validate order: feeding type, amount, route, rate
ID Patient
@ShopWithKey on Etsy
Position patient
check for residual
o pulling back and look to see how much fluid is left tells
how well the patient is tolerating the feedings
the more fluid the less it is being tolerated
Check patency
o Flush with room temp water
Admin feeding
Follow with water - flush again
o prevents blockage of tube
Record I&O in chart
Lab Values
Electrolytes
Sodium: 136-145 mEq/L
Maintains cell fluids; helps nerves
communicate
Deviation: changes in neurological
complications; seizure precautions
Potassium: 3.5-5.0 mEq/L
Cardiac complications
Too much: stops heart (asystole)
Too little: cardiac electrical instability
and ventricular dysrhythmias
Chloride: 98-106 mEq/L
Total calcium: 9.0-10.5 mg/dL
Needed for bones, teeth, nerve
impulses, muscle contraction, blood
clotting
Muscle/cardiac implications r/t
contractility
Imbalance: tingling, spasms
Magnesium: 1.3-2.1 mg/dL
Cardiac implications
Too much: muscle weakness,
hypotension, bradycardia
Too little: ventricular
tachycardia/fibrillation
Prevents K+ from being excreted: too
little decreased K+ levels heart
problems
Phosphorus: 3.0-4.5 mg/dL
Blood
WBC: 5,000-10,000/mm3
Neutrophils: 45-75%
Lymphocytes: 16-46%
Monocytes: 4-11%
Eosinophils: 1-8%
Basophils: 0-3%
RBC
Male: 4.7-6.1 million/mm3
Female: 4.2-5.4 million/mm3
Hgb
Male: 14-18 g/100 mL
Female: 12-16 g/100 mL
Hct
Male: 42-52%
Female: 37-47%
Platelet: 150,000-400,000/mm3
MCV: 80-90 mm3
MCH: 27-31 pg/cell
MCHC: 31-37% Hb/cell
ESR
Male: 0-17 mm/h
Female: 0-25 mm/h
Iron
Male: 80-180 mcg/dL
Female: 60-160 mcg/dL
Albumin: 3.1-4.3 g/dL
Bilirubin
Total: 0-1.0
Unconjugated (indirect): 0.2-0.8 mg/dL
Conjugated (direct): 0.1-1.0 mg/dL
Cholesterol
Total: < 200 mg/dL
LDL (bad): < 100
HDL (good): > 40
Triglycerides: < 150 mg/dL
Kidneys
BUN: 10-20 mg/dL
Creatinine
Male: 0.6-1.2 mg/dL
Female: 0.5-1.1 mg/dL
GFR: 90-120 mL/min
Ammonia: 15-110 mg/dL
Urine specific gravity: 1.015-1.030
Urine pH: 4.6-8.0 (average 6.0)
Urinalysis
Negative for: glucose, RBC, WBC,
albumin
Bacteria < 1000 colonies/mL
Clotting
PT: 11-13 sec
1.5-2x normal value if on Coumadin
INR: 0.7-1.8
2-3 if on Coumadin
PTT: 25-40 sec
1.5-2x normal value if on heparin
Blood Glucose
Glucose: 70-105 mg/dL (fasting)
Postprandial: 70-140 mg/dL
Too much: polydipsia, polyphagia,
polyuria
Too little: chills, diaphoresis, hunger,
altered LOC
HgbA1c: < 6.5%
< 7% for diabetics
ABG
pH: 7.35-7.45
PaCO2: 35-45 mmHg
PaO2: 80-100 mmHg
HCO3: 22-26 mmol/L
Cardiac
Creatinine phosphokinase MB (CK-MB): 30-170
units/L
Increases 4-6 hours after MI and
remains elevated for 24-72 hours
Troponin: < 0.2 ng/dL
Gold standard for determining if there
was an MI
GI/Endocrine
Stomach pH: 1.5-2.5
Liver enzymes
ALT/SGPT: 8-20 units/L
AST/SGOT: 5-40 units/L (Kaplan says 820 units/L)
ALP: 42-128 units/L
Total protein: 6-8 gm/dL
Pancreatic enzymes
Amylase: 56-90 IU/L
Lipase: 0-110 units/L
Prothrombin time: 0.8-1.2
TSH: 0.5-5.0 mcU/mL
Med Levels
Digoxin: 0.5-2.0 ng/mL
Lithium: 0.8-1.4 mEq/L
Dilantin: 10-20 mcg/mL
Theophylline: 10-20 mcg/mL
@ShopWithKey on Etsy
Patient Type
Position
Arm elevated on pillow
Turn only to unaffected side and back
W
Promotes lymphatic flu
accumulating (decreas
Semi-Fowler’s (HOB usually about 30-45
degrees); Head midline, no head flexion
Do not position client on side where there is a
removed bone flap
Side-lying
Reduces ICP by allowin
head. Head flexion wil
side where there is a b
ICP.
Allows secretions to dr
prevents aspiration.
COPD/Respiratory Distress
High Fowler’s
Elevate HOB 90 degrees
Tripod or orthopneic position
Increases maximum lu
for more ventilation an
Enema administration
Left-lateral or Sim’s position
Allows solutions to flow
natural direction of the
Leg amputation
Elevate affected limb on pillow x 24 hours only Reduces edema post-o
Prone as tolerated, 20-30 mins at a time, at
hours, DO NOT elevate
least twice daily
lead to contractures. P
stretch out hip and leg
flexion contraction.
Head midline
Reduces swelling and e
Semi-Fowler’s to Fowler’s (30 to 45 degrees)
Support neck while turning/moving
Mastectomy
Head injury/surgery
Immediate post-op/post procedure (in clients
who aren’t yet alert)
Thyroidectomy
Shock
1
Modified Trendelenburg
This will aid in perfusio
head without causing p
@ShopWithKey on Etsy
Thoracentesis
Seated upright at side of bed, with an overbed table in front of client.
This will exposure requ
procedure.
Liver biopsy
During
After
During: On the client’s left side to exposure
liver area (which is on the right).
After: On the client’s right side.
Left side during the pro
area for biopsy site. Ri
will use gravity to help
Paracentesis
Seated upright in chair or semi-Fowler’s in
bed.
To exposure area for p
assist in insertion of ne
Nasogastric or gastrostomy tubes
Nasogastric insertion
NG/GT feeding, irrigation
High Fowler’s for NG insertion.
HOB at least 30 degrees (semi-Fowler’s) for
NG/GT feeding, irrigation.
Laminectomy
Keep client straight
Logroll the client
For insertion: It will aid
off the trachea and op
For NG/GT feed and irr
To prevent aspiration o
To avoid twisting of th
cause complications.
CVA
Ischemic – Usually flat
Hemorrhagic – HOB 30 degrees
Ischemia – Head flat to
Hemorrhagic – HOB 30
S/P Cardiac catherization
Bedrest x 6 hours
Affected extremity straight
HOB no more than 30 degrees
This position avoids pr
site. Client can turn fro
must avoid pressure on
Maternal patient with dizziness
Left lateral
As the uterus enlarges, pres
increases. This pressure com
causes blood pressure to dro
and accompanying symptom
Turning the client on her left
vena cava, restoring normal
pressure.
Ischemic
Hemorrhagic
2