Med Surg ATI Review
Ch. 1 Health, Wellness, and Illness
• Variables
o Modifiable= can be changed, smoking, nutrition, health edu, sex practices, exercise
o Non modifiable= sex, age, developmental level, genetics
Ch. 2 Emergency Nursing Principles and Management
• Triage
o Resuscitation= level one
o Emergent= level two
o Urgent= level 3
o Less urgent= level four
o Nonurgent= level five, non life threatening condition require simple eval and care
management
• ABCDE
o Airway= maintain airway, head tilt/chin lift (do NOT perform if pt has spine injuryà
do modified jaw thrust maneuver), bag valve mask w/ 100% O2, nonrebreather w/
100% O2 use for spontaneous breathers
o Breathing
o Circulation
o Disability= loc
o Exposure= clothing
• Poisoning= use activated charcoal, gastric lavage (done w/I 1hr) aspiration
• Rapid response team= respond to emergency when pt has indications of rapid decline
• Cardiac emergency
o Vfib= defibrillate, CPR, admin IV antidysrhythmic (epi, amiodarone, lidocaine,
magnesium sulfate)
o Vtach
• Epi= stimulate alpha 1 (vasoconstrict), beta 1 (increase hr), beta 2 (bronchodilate), good for
superficial bleeding, increase bp, AV block and cardiac arrest and asthma
o s/e= htn crisis, dysrhythmias, angina
• Dopamine= renal blood vessel dilation, beta 1 increase hr, good for shock, hf
o s/e= dysrhythmias, angina
• Dobutamine= beta 1 increase hr, good for hr
Ch. 3 Neurologic Diagnostic Procedures
• Cerebral angiography= visualization of cerebral blood vessels, assess blood flow within
brain, id aneurysms
o Do NOT perform if pregnant, don’t eat food or fluids for 4-6hrs prior to procedure,
assess for allergy to shellfish or iodine b/c require use of contrast media, ask about
anticoag, assess BUN and creatinine; monitor area for clotting after procedure
• CT= cross section image
• EEG= id seizure activity and sleep disorder
o Wash hair b/f procedure, be sleep deprived, expose to flashing lights, hyperventilate
for 3-4 min
•
Glasgow coma scale= determine loc, best score is 15, score less than 8 is associate w/
severe head injury and coma
o Eye open (E)
§ 4= eye open spontaneously
§ 3= eye open to sound
§ 2= eye open to pain
§ 1= eye does not open
o Verbal (V)
§ 5= conversation is coherent and oriented
§ 4= conversation is incoherent and disoriented
§ 3= words are spoken but inappropriate
§ 2= sound made
§ 1= no sound
o Motor (M)
§ 6= commands followed
§ 5= local reaction to pain
§ 4= general w/drawal to pain
§ 3= decorticate posture (adduction of arms, flexion of elbows and wrists)
§ 2= decerebrate posture (extension of elbows and wrists)
§ 1= no motor response
• ICP monitoring= performed by neurosurgeon in operating room, used for GCS score of 8,
complication of infection
o Intraventricular catheter
o Subarachnoid screw/bolt
o Epidural or subdural sensor
• Increased ICP (normal 10-15)= IRRITABILITY first sign, severe headache, decrease loc,
dilated/ pinpoint pupils, altered breathing pattern (Cheyne-stokes), hyperventilation, apnea,
abnormal posturing
• Lumbar puncture= w/draw CSF to diagnose MS, syphilis, meningitis, void b/f procedure,
assume cannonball position, monitor puncture site, remain lying still on back after
procedure
o Complication= headache from leaking csf, give opioids/pain meds, increase fluid
intake
• MRI= remove jewelry, not claustrophobic, give earplugs
o w/ contrast dyes: assess for allergies for shellfish
o no jewelry, no metal implants (IUD, aneurysm clip, ortho joint, artificial heart valve,
pacemaker)
• PET= brain injury, determine tumor activity or response to treatment
• X-ray= can reveal fracture or curvature
Ch. 4 Pain Management
• Acute pain= protective, temporary, self limiting, resolves with tissue healing
• Chronic= last longer than 3 months, depression, fatigue, decreased level of function,
disability
• Nociceptive= damage to or inflame of tissue, throbbing, aching, localized
o Somatic= bones, joints, muscles, skin, connective tissue
o Visceral= internal organs
•
•
•
•
Neuropathic= abnormal or damaged pain nerves, phantom limb pain, diabetic neuropathy,
shooting, burning, pins and needles; responds to antidepressants, antispasmodic, muscle
relaxants
Pain assessment= location, quality, measures/intensity/severity, timing/onset/duration,
setting/ how it affects daily life, associated manifestations, aggravating/relieving factors
Nonpharm pain management= tens, heat, cold, massage, relaxation, imagery
Pharm management
o Nonopioid= mild-moderate pain, 4g apap, monitor for salicylism (tinnitus, vertigo,
decreased hearing), gi upset, bleeding
o Opioid= moderate-severe pain, around clock admin, cause constipation,
hypotension, urinary retention, n/v, sedation, respiratory depression, have naloxone
ready
Ch. 5 Meningitis
• Inflam of meninges, viral most common and resolves w/o treatment, bacterial is contagious
w/ high mortality
• Hib vaccine and MCV4 vaccine, especially in college students
• Findings= excruciating constant headache, stiff neck, photophobia, fever and chills, n/v,
altered loc, positive kernig sign (resistance and pain w/ extension of pt leg from flexed
position) positive Brudzinski sign (flexion of knee and hip w/ deliberate flexion of pt neck),
tachy, seizure, red macular rash, irritable
• Diagnostics= csf analysis (cloudyàbacterial, clearàviral, increased wbc, increased protein,
decreased glucose in bacterial)
• Care= isolation precautions, droplet precautions until 24 hrs after antibiotics, decrease
environmental stimuli, quiet environment, decrease bright light, bed rest hob 30 degrees,
avoid coughing and sneezing, seizure precautions
• Meds= antibiotics, anticonvulsant, analgesics
• Complications
o Increased icp= monitor loc, pupillary changes, impaired eom
o Siadh= monitor for dilute blood and concentrated urine
o Septic emboli
Ch. 6 Seizures and Epilepsy
• Seizures= abrupt, abnormal, excessive uncontrolled electrical discharge of neurons w/I
brain, altered loc, change in motor and sensory ability/ behavior
• Epilepsy= abnormal brain electrical activity w/ 2+ seizures, fever
• Risks= febrile state especially in children <2, head trauma, cerebral edema, infection,
metabolic disorder (hypoglycemia or hyponatremia), brain tumor, hypoxia, w/drawal, fluid
and electrolyte imbalances
• Triggers= excess stress, fatigue, excess caffeine, flashing lights
• Findings
o Generalized seizures= aura
o Tonic clonic seizure= tonic episode (stiffening of muscles), clonic episode (rhythmic
jerking) postictal phase of confusion and sleepiness
o Tonic seizure= stiffening of muscle, increased muscle tone, loc
o Clonic seizure= muscle contract and relax
o Myoclonic seizure= brief jerking or stiffening of extremities
o Atonic= muscle tone is lost
o Complex partial seizure= lip smacking, picking at clothes, zone out
• Diagnostics= eeg id origin of seizure, mri, cat, csf analysis
• Care= provide privacy, move furniture away, patent airway, turn pt on side to decrease risk
of aspiration, loosen restrictive clothing, don’t restrain, don’t open jaw, don’t use padded
tongue blade, document onset and duration of seizure, after seizure maintain in side lying
position, check vitals, perform neuro check, allow rest, reorient and calm pt
• Meds= phenytoin, needs blood tests, cause gingival hyperplasia, avoid ocp b/c decreased
effectiveness, avoid warfarin b/c decreased absorption
• Vagal nerve stimulator= device implanted in left chest wall, magnet over device at onset of
seizure, avoid mri and ultrasound and microwaves
• Wear medical id
• Complications= status epilepticus which is repeated seizure activity w/I 30 min, airway, o2,
est IV, ECG monitoring, pulse ox, admin diazepam or lorazepam push and IV phenytoin
Ch. 7 Parkinson’s Disease
• Characterized by tremor, muscle rigidity, bradykinesia, postural instability
• Caused by overstimulation of basal ganglia by Ach which occurs b/c degeneration of
substantia nigra which results in decreased dopamine
• Manifestations= slow, shuffling gait, masklike expression, difficulty chewing and
swallowing, drooling, difficulty w/ ADLs, mood swings, cognitive impairment
• Diagnostics= no definitive diagnostic procedure, based on manifestations
• Care= monitor swallowing and maintain adequate nutrition, thickened liquids, encourage
exercise like yoga, ROM, slow down speed and reduce risk of injury, speak slow pause
frequently and use alternate form of communication
• Meds
o Levodopa= increase dopamine levels in basal ganglia, carbidopa combo
§ Monitor for wearing offàneed for medication holiday
o Anticholinergics (bromocriptine)= control tremor and rigidity
§ Monitor for anticholinergic effects (dry mouth, constipation, urinary retention,
confusion)
• Complications= aspiration pneumonia (always have nurse watch eating, sit in upright
position and have suction ready)
Ch. 8 Alzheimer’s Disease
• 60%, age 60-70, memory loss, problems w/ judgment, changes in personality
• Risks= advanced age, genetic predisposition, environmental agents (herpes, toxic waste),
previous head injury
• Diagnostics= no definitive diagnostic until death w/ brain tissue exam, CAT scan
• Care= keep pt from stairs, remove/secure dangerous items in pt environment, structured
environment, use calendar for orientation, use short directions when explaining activity, be
consistent and repetitive, reminisce w/ pt about past, avoid overstimulation, frequent
reorientation to time place and person
• Meds
•
•
o Donepezil= prevent breakdown of ach
Edu= remove scatter rugs, install door locks that can’t be easily opened, good light on stairs
w/ colored tape, place mattress on floor, remove clutter
Stages
o Early= no impairment
o Mild cognitive decline= short term memory loss noticeable to relatives
o Moderate= personality changes, obvious memory loss
o Moderately severe= assist with ADL
o Severe late= increased episodes of urinary and fecal incontinence
o Very severe= inability to respond to environment, speak, and control movement,
inability to eat w/o assistance
Ch. 9 Brain Tumors
• Complications= SIADH b/c hypothalamus is being squished and cant regulate release of
ADH, DI
Ch. 10 Multiple Sclerosis
• Plaque in white matter of CNS which damages myelin sheath and interferes w/ impulse
transmission b/w CNS and body, relapse and remission, chronic disease w/ no cure
• Risks= 20-40, women
• Trigger relapse= virus, cold, physical injury, stress, pregnancy, fatigue, hot shower
• Findings= diplopia, decreased visual acuity, tinnitus, decreased hearing acuity, dysphagia,
dysarthria (slurred nasal speech), muscle spasticity, ataxia (muscle weakness), nystagmus,
bowel dysfunction, cognitive change, sex dysfunction
• Diagnostics= MRI reveals plaques on brain and spine
• Meds
o Cyclosporine= immunosuppressive used to reduce frequency of relapse
o Prednisone= reduce inflame in acute exacerbation
o Dantrolene/baclofen= antispasmodic used to treat muscle spasticity
Ch. 11 Headaches
• Triggers= allergies, intense odors, bright lights, fatigue, stress, anxiety, menstrual cycle,
foods w/ tyramine, msg, nitrites, milk products
• Migraine
o Photophobia and phonophobia (sensitivity to light and sound), N/V, stress and
anxiety, unilateral pain (behind eye or ear), family hist, 4-72hrs
o Stages
§ Aura= numbness and tingling of mouth and lips, visual disturbances (light
flashes, bright spots), physical activity worsens pain
§ w/o Aura= periods of stress
o Care= cool dark quiet environment, elevate HOB 30 degrees
o Meds
§ Mild= NSAIDS, antiemetics
§ Severe= triptan, sumatriptan to vasoconstrict, ergotamine to narrow blood
vessels and reduce inflame
o Edu= educate about foods w/ tyramine (pickles, caffeine, beer, wine, aged cheese,
artificial sweeteners, nuts), foods w/ msg or preservatives
• Cluster headache
o Brief episode of intense, unilateral, non-throbbing pain lasting 30min-2hr; occur
daily at same time for 4-12 weeks, during spring and fall, no warning signs, less
common than migraines, men b/w 20-50, tearing of eye w/ runny nose and nasal
congestion, facial sweating, drooping eyelid
o Meds= triptans, ergotamine
Ch. 12 Disorders of Eye
• Macular degeneration= central loss of vision, no cure, common cause of vision loss
o Dry= most common, block retinal capillary arteries
o Wet= new growth of blood vessels
o Blurred vision, loss of central vision, blindness
• Cataracts=opacity in lens of eye impairs vision
o Blurred vision, diplopia, painless loss of vision, absent red reflex
• Surgical removal of lens= lens correct refractive errors
• Edu= wear sunglasses, report infection, avoid bending sneezing coughing straining and
head hyperflexion, don’t tilt head to wash hair, avoid rapid jerky movements and driving
and sports, best vision is 4-6 weeks after surgery
• Glaucoma= disturbance of functional or structural integrity of optic nerve
o Primary open angle= aqueous humor outflow is decreased
§ Mild eye pain, loss of peripheral vision, elevated iop 22-32
o Primary angle closure= iop rises suddenly because angle between iris and sclera
suddenly close, onset is sudden, cause blindness
§ Rapid onset of elevated iop >30, blurred vision, halos, severe pain, nausea,
photophobia
o Diagnostics= tonometry (measures iop should be 10-21)
o Edu= eye med use every 12hrs, wait 5-10 min between eye drops, avoid touching tip
of applicator to eye, apply pressure to punctal occlusion
o Med
§ Pilocarpine= constricts pupil
§ Bb timolol=decrease iop, first line drug
§ Acetazolamide= decrease iop by decrease aqueous humor production
§ Mannitol= osmotic diuretic, used for angle closure, decrease iop quick
Ch. 13 Middle and Inner ear disorder
• Middle ear= otitis media, redness, bulging tympanic membrane, bubbles behind tm
o Risk=recurrent colds and otitis media, enlarged adenoids
• Inner ear= meniere disease, vertigo, tinnitus, sensorineural hearing loss, vomiting
o Risk= viral or bacterial infection, damage due to ototoxic med
• Otoscopy= pull up and back on adult and down and back of auricle on children, light
reflex should be visible from center of tm anteriorly
• Care= ototoxic meds can cause tinnitus and sensorineural hearing loss
o Antibioticsàgentamycin and erythromycin
o Diureticsà furosemide, e acid
o Nsaidsàaspirin
•
•
•
•
•
o Chemo agentsàcisplatin
Meds
o Meclizine= antihistamine and anticholinergic effect, treat vertigo
o Ondansetron= antiemetic, treat n/v
o Diphenhydramine= treat vertigo, cause urinary retention, sedation
o Scopolamine= anticholinergic, treat nausea, cause urinary retention and sedation
Edu= avoid alcohol and caffeine, rest in quiet dark room, space intake of fluid evenly,
decrease intake of salt
Stapedectomy= surgical removal of stapes
Cochlear implant= treat sensorineural hearing loss, microphone picks up sound and speech
processor and transmitter convert sound to electric impulses
Labyrinthectomy= surgical treatment for vertigo that removes labyrinthine
Ch. 14 Head Injury
• Cervical spine injury should always be suspected when head injury occurs
• Findings= CSF leakage from nose and ears (presence of halo sign clear or yellow tinted ring
surrounding drop of blood), increased icp (headache, decreased loc, dilated or pinpoint
nonreactive pupils, altered breathing pattern, apnea, cushing triadà LATE finding, severe
htn, wide pulse pressure, brady)
• Diagnostics= cervical spine films, CT, MRI
• Care= respiratory status priority, increased icp (should be 10-15, hypercarbia leads to
cerebral vasodilation, suction, maintain hob at 30 degrees, avoid extreme flexion/extension,
admin o2 to maintain pao2 >60, hyperventilate pt, give stool softener and avoid Valsalva,
maintain cervical spinal stability)
• Meds
o Mannitol= osmotic diuretic to treat cerebral edema; monitor fluid and electrolyte
status
o Barbiturates= placed in coma to decrease cell metabolic demand
o Phenytoin= prophylactically to prevent seizure
o Morphine= analgesic to control pain
• Craniotomy= decrease cerebral edema, monitor icp, hob 30 degrees, infratentorial keep pt
flat and on side for 24-48hr to prevent pressure on neck incision site
• Complications= brain herniation (down shift of brain tissue due to cerebral edema) cause
fixed dilated pupils, decrease loc, Cheyne stokes respiration, hematoma and intracranial
hemorrhage, di or siadh, cerebral salt wasting (hypona and hypovolemia)
Ch. 15 Stroke
• Hemorrhagic= ruptured artery or aneurysm
• Thrombotic= ischemic stroke b/c blood clot in cerebral artery
• Embolic= ischemic stroke b/c embolus travel from one part of body to cerebral artery
• Risks= htn, dm, smoking
• Findings= visual disturbances, dizzy, slurred speech, weak extremity
o Left hemisphere= language, math, analytical thinking
§ Expressive and receptive aphasia (inability to speak and understand language)
§ Alexia= difficulty reading
•
•
•
•
•
§ Agraphia= difficulty writing
§ Right extremity hemiplegia
§ Hemianopsia = loss of visual field in one or both eyes
o Right hemisphere= visual and spatial awareness
§ Overestimate ability
§ Unilateral neglect= ignore left side
§ Poor impulse control and judgment
§ Left hemiplegia
§ Visual changes
Diagnostics= mri, ct, cat
Care= notify dr if bp > 180 or 110 means ischemic stroke, monitor vitals, assess swallow
and gag reflex, speech language pathologist, have pt eat in upright position w/ neck flexed
forward, have suction, maintain skin integrity by reposition and use padding, maintain safe
environment and reduce fall risk, homonymous hemianopsia (loss of same visual field in
both eyes), instruct pt to use scanning technique (run head from unaffected to affected side)
when eating and ambulating
Meds= thrombolytic meds w/I 4.5 hr of symptoms
Carotid artery angioplasty with stent
Complications= dysphagia and aspiration (assess gag reflex, begin w/ thick liquids)
Ch. 16 Spinal Cord Injury
• Cervical region result in quadriplegia, paralysis of all four extremities and trunk
• Injury below T1 result in paraplegia
• C4 and above pose great risk for impaired spontaneous ventilation and phrenic nerve
• Findings= inability to feel light tough, inability to discriminate b/w sharp and dull, absent
dtr, flaccidity of muscles
• Neurogenic shock= monitor for hypotension, dependent edema, loss of temp regulation
• Injury above L1 will have spastic muscle tone after neurogenic shock and spastic bladder
• Pt who have injury below L1 will convert to flaccid type of paralysis and flaccid bladder
• Care= daily stool softener and bowel schedule
• Meds
o Glucocorticoids= decreased edema of spinal cord
o Vasopressors= no epi and dopamine treat hypotension during neurogenic shock
o Atropine= treat brady
o Baclofen and dantrolene= treat severe muscle spasticity
• Complications= orthostatic hypotension (thigh high hose and change position slow),
autonomic dysreflexia (stimulation of SNS and inadequate response of PNS, lesion above
T6; cause extreme htn, sudden severe headache, pallor below lesion, blurred vision,
diaphoresis)
Ch. 17 Respiratory Diagnostic Procedures
• ABG
o pH= 7.35-7.45
o PAO2= 80-100
o PACO2= 35-45
o HCO3= 21-28
•
•
•
•
o SAO2= 95-100%
Arterial puncture= obtain heparinized syringe for sample collection, perform Allen’s test
prior to arterial puncture to verify patent radial and ulnar circulation, compress ulnar and
radial arteries simultaneously, pt. often experience pain w/ repeated ABG level check, hold
direct pressure over site for at least 5 min or 20 min if on anticoagulant therapy
Air embolism= place pt on left side in Trendelenburg position, monitor for SOB, chest pain,
anxiety, air hunger
Bronchoscopy= visualization of larynx, trachea, bronchi
o Biopsy
o Aspiration of deep sputum
o Maintain pt on NPO 4-8hr
o Admin atropine, viscous lidocaine, local anesthetic throat spray
o Assess for presence of gag reflex, small amt. of blood tinged sputum is expected
Thoracentesis= surgical perforation of chest, instill medication into pleural space and
remove fluid
o SOB, cough
o Position pt sitting upright, instruct pt to remain absolutely still
o Amt of fluid removed is limited to 1L at a time, monitor vital signs and respiratory
status hourly
o Complications
§ Mediastinal shift
§ Pneumothorax= collapsed lung, deviated trachea, pain on affected side,
increased heart rate
§ Bleeding= hypotension
§ Infection
Ch. 18 Chest Tube Insertion and Monitoring
• Inserted into pleural space to drain, fluid, blood or air
• System
o Water seal= sterile fluid to 2cm, allows air to exit from pleural space on exhalation
and stops air from entering w/ inhalation, keep chamber upright, TIDALING OF
WATER IS EXPECTED, cessation of tidaling signals lung re-expansion or obstruction
w/I system, continuous bubbling indicates air leak
o Suction= -20cm h20, continuous bubbling
• Encourage coughing and deep breathing every 2hr
• Check water seal level every 2hr and add fluid as needed
• Document amt and color of drainage hourly for first 24hrs and then at least every 8hr,
report excess drainage greater than 70 to provider
• Monitor chest tube insertion site, position pt in semi-high fowler position, obtain cxr to
verify chest placement
• Keep two enclosed hemostats, sterile water and occlusive dressing at bedside
• Clamp chest tube ONLY when prescribed, do NOT strip or milk tubing
• Complications
o Monitor water seal chamber for continuous bubbling which means air leak
•
o If tubing separates instruct pt to exhale as much as possible and to cough to removes
as much air as possible from pleural space
o If chest tube drainage system is compromised immerse end of chest tube in sterile
water to restore water seal
o If chest tube is accidentally removed dress area w/ dry sterile gauze
o Tension pneumothorax= prolonged clamping of tubing, assess for tracheal deviation,
absent breath sounds on one side, respiratory distress, asymmetry of chest
Chest tube removal= deep breath, exhale, bear down (Valsalva), apply airtight sterile
petroleum jelly gauze dressing
Ch. 19 Respiratory Management and Mechanical ventilation
• Nasal cannula= 1-6L
• Simple face mask= 5-8 L
• Partial rebreather= 6-11L, must keep reservoir bag inflated
• Nonrebreather= 10-15 L, keep reservoir bag 2/3 full, delivers highest o2 concentration,
perform hourly assessment of valve and flap
• Venturi mask= most precise o2 concentration
• Aerosol mask/face tent= facial trauma and burns
• O2 therapy need= used for hypoxemia (blood) and hypoxia (tissue)
o Early findings= tachy, tachypnea, restless, pale, htn, respiratory distress (accessory
muscles, nasal flaring, adventitious breath sounds)
o Late= confusion/stupor, cyanotic, brady, bradypnea, hypotension, cardiac
dysrhythmias
• Complications
o O2 toxicity= nonproductive cough, substernal pain, nasal stuffiness, n/v, headache,
sore throat, hypoventilation; always use lowest o2 necessary to maintain adequate
O2
§ Normal for COPD to have O2 of 92%
• Edu= no smoking, cotton gown, no volatile flammable materials
• CPAP= sleep apnea
• BIPAP= COPD, ventilatory assistance
• ET tube= inserted through nose or mouth into trachea
o Suction oral and tracheal secretions to maintain tube patency
o Low pressure alarm= low exhaled volume due to disconnection, cuff leak, tube
displacement
o High pressure alarm= excess secretions, biting tubing, kinks in tubing, coughing,
pulmonary edema, bronchospasm, pneumothorax
o Admin analgesics, sedatives, neuromuscular blocking agents, perform frequent
gentle skin and oral care
o Have manual resuscitation bag w/ face mask and o2 readily available at pt bed, have
reintubation equipment at bed
o Following extubation assess o2 and vitals every 5 min, encourage coughing and
deep breathing, reposition pt to promote mobility of secretions
Ch. 20 Acute Respiratory Disorders
•
•
•
•
Rhinitis= inflam of nasal mucosa, caused by virus or allergen
o Runny nose (rhinorrhea), nasal congestion
o Encourage rest (8-10hr/day) and increased fluid intake (2000mL/day), use cough
etiquette and hand hygiene
o Antihistamines or decongestant meds
Sinusitis= encourage use of steam humidification, nasal decongestants
Flu= highly contagious acute viral infection
o Severe headache and muscle aches, chills, diarrhea, fever
o Antivirals= w/I 24-48hrs after onset of manifestations
o Vaccination is encouraged for everyone older than 6 months of age
o Complications= pneumonia affects older adults
Pneumonia= confusion manifestations in older adult, chills, sob, difficulty breathing,
tachypnea, chest pain (sharp), crackles and wheezes, coughing
o Lab tests= sputum culture and sensitivity done b/f starting antibiotic therapy, chest xray will show consolidation of lung tissue, pulse ox will be less than 95%
o Care= high fowler, admin breathing treatment and meds, o2, deep breathing w/
incentive spirometry, increased work of breathing requires increased calories,
encourage fluid intake of 2-3 L/day, antibiotics, bronchodilators (albuterol), anti
inflam (glucocorticoids like fluticasone and prednisone) monitor for decreased
immunity and hyperglycemia and black tarry stools and fluid retention and wt gain
and canker sores
Ch. 21 Asthma
• Chronic inflame disorder of airways that results in intermittent and reversible
• Risks= smokes, air pollutants (environmental allergies)
• Findings= coughing, wheezing, prolonged exhalation, poor o2 saturation, barrel chest
• Care= high fowler, o2 therapy, provide rest periods
• Meds
o Bronchodilators (inhalers)
§ Short acting beta agonist= albuterol, watch for tremors and tachy
§ Anticholinergic= ipratropium, observe for dry mouth
§ Methylxanthines= theophylline, use only when other treatments are
ineffective, monitor for toxicity
§ Long acting beta agonist= salmeterol, asthma attack prevention
o Anti-inflam
§ Corticosteroids= decreased immune function, hyperglycemia, black tarry
stools, fluid retention and wt gain
§ Leukotriene antagonist
• Complications= status asthmaticus (life threatening episode of airway obstruction
unresponsiveness to common treatment)
o Admin IV fluids, o2, bronchodilators, epi
Ch. 22 Chronic Obstructive Pulmonary Disease
• COPD= emphysema (loss of lung elasticity and hyperinflation of lung tissue) and chronic
bronchitis (inflame of bronchi)
•
•
Risks= advanced age, smoking, AAT deficiency, air pollution
Finding= chronic dyspnea, crackles and wheezes, rapid and shallow respirations, use of
accessory muscles, barrel chest, hyperresonance on percussion due to trapped air
(emphysema), dependent edema b/c of right sided hf, clubbing of fingers and toes,
decreased o2 saturation levels
• Labs= increase hct due to low o2, abg (hypoxemia pao2 less than 80, hypercarbia increases
paco2 greater than 45), expected pulse ox less than 95%
• Care= high fowlers, encourage effective coughing, deep breath incentive spirometer,
increased calories, diaphragmatic (abdominal) breathing, lie on back w/ knees, pursed lip
breathing (take a breath in through nose and out through lips/mouth)
• Meds
o Bronchodilators
§ Short acting beta agonist= albuterol, watch for tremors and tachy
§ Cholinergic antagonist= ipratropium, observe for dry mouth
§ Methylxanthine= theophylline, use only when other treatments are
ineffective; serum levels for toxicity
o Anti-inflam agents
§ Corticosteroids= decrease in immunity function, monitor for hyperglycemia,
report black tarry stools, fluid retention and wt gain
§ Leukotriene antagonist
o Mucolytic agents= thin secretions
§ Acetylcysteine
§ Guaifenesin
• Therapeutic procedures= chest physiotherapy uses percussion and vibration
• Edu= referrals to assistance programs (food delivery systems), portable o2
• Complications= respiratory infection, right sided heart failure (air trapping increased
pulmonary pressure, enlarged and tender liver, distended neck veins, dependent edema)
Ch. 23 Tuberculosis
• Caused by mycobacterium tuberculosis
• Screen family members of pt w/ TB
• Risks= close contact, low ses, immunocompromised (HIV, chemo), crowded
• Manifestations= persistent cough longer than 3 weeks, purulent sputum, fatigue and
lethargy, wt loss and night sweats
• Lab tests
o Quantiferon gold is blood test
o Mantoux test= should be read 48-72 hrs, induration of 10mm is +, or 5mm is + for
immunocompromised pts, pt who received BCG vaccine will have false +
o Acid fast bacilli smear and culture= obtain 3 in the early morning sputum
• Care= wear n95 mask, place pt in – airflow room
• Meds= 6-12 months, 4 meds
o Rifampin= hepatotoxicity, secretions will be orange, interfere with ocp
o Isoniazid= monitor for hepatoxicity (jaundice) and neurotoxicity (tingling in hands
and feet)
o Pyrazinamide= observe for hepatoxicity
o Ethambutol= visual acuity, ocular toxicity
•
o Streptomycin= ototoxicity
Sputum samples are needed every 2-4 weeks to monitor therapy effectiveness, no longer
infectious after 3 consecutive negative sputum cultures
Ch. 24 Pulmonary Embolism
• Enters venous circulation and forms blockage in pulmonary vasculature, most common
cause is dvt
• Risks= oral contraceptive use and estrogen therapy, hypercoagulability, obesity, surgery, a
fib, long bone fractures
• Findings= anxiety, feelings of impending doom, dyspnea and air hunger, tachy,
hypotension, tachypnea, petechiae
• Labs= d-dimer, CT (most commonly used)
• Meds
o Anticoagulants= heparin, enoxaparin, warfarin prevent clots from getting larger or
additional clots from forming
§ Monitor bleeding times (prothrombin time and INR for warfarin, aPTT for
heparin)
o Thrombolytic therapy= alteplase dissolve blood clots, monitor for evidence of
bleeding
• Therapy= embolectomy (surgical removal of embolus), vena cava filter (prevent further
emboli from reaching the pulmonary vasculature)
• Edu= weekly blood draws, promote smoking cessation, avoid long periods of immobility,
wear compression stockings to promote circulation, avoid crossing legs, monitor intake of
foods high in vitamin K (green leafy vegetables can reduce anticoagulant effects) if taking
warfarin, schedule monitoring for PT and INR, avoid taking aspirin, use electric shavers and
soft bristled toothbrush, avoid blowing nose too hard
• Complications
o Hemorrhage= risk for bleeding increases due to anticoagulant therapy
Ch. 25 Pneumothorax, Hemothorax, and flail chest
• Pneumothorax= presence of air or gas in pleural space
o Tension= air enters pleural space during inspiration through one way valve and is
not able to exit upon expiration
o Hemothorax= accumulation of blood in pleural space
• Flail chest= at least 2 ribs on one side are fractured, paradoxical chest wall movement
• Risks= blunt chest trauma, closed/occluded chest tube
• Findings= respiratory distress (tachypnea, tachy, hypoxia, dyspnea, use of accessory
muscles), tracheal deviation to unaffected side, reduced or absent breath sounds on affected
side, asymmetrical chest wall movement, hyperresonance on percussion due to trapped air
(pneumothorax), dull percussion (hemothorax)
• Meds
o Benzos= sedatives, decrease anxiety
o Opioid agonist= pain meds, treat moderate to severe pain
• Therapy= chest tube insertion to drain fluid or blood or air
Ch. 26 Respiratory Failure
• Findings= rapid shallow breathing, tachy, hypotension, retractions, decreased SaO2 <90%,
adventitious breath sounds, arrhythmias
• Care= patent airway and monitor respiratory status every hour
Ch. 27 Cardiovascular Diagnostic and Therapeutic Procedures*
• Cardiac enzymes= released into bloodstream when heart muscle suffers ischemia
o Troponin T= 0 normal range; elevated w/i 2-3hr shows mi, lasts 10-14 days
o Troponin I= 0 normal range; elevated w/i 2-3hr shows mi, lasts 7-10 days
o Creatinine kinase= 0% normal range
o Myoglobin= less than 90 is normal range, elevated shows skeletal muscle damage
too
• Cardiac tests
o Cholesterol should be less than 200
o Ldl (lousy cholesterol)= less than 130
o HDL (happy cholesterol)= greater than 45-55
o Triglycerides= less than 150
• Echo= ultrasound of heart, diagnose valve disorders, cardiomyopathy, and ejection fraction,
noninvasive
• Stress test= walk on treadmill or pharmacological stress test w/ adenosine
o Fast for 2-4hr b/f procedure, avoid tobacco, alcohol, caffeine b/f test
o Requires 12 lead ECG
• Hemodynamic monitoring= CVP, PAP, PAWP
o Arterial line= provide continuous info about changes in bp and permit w/drawal of
arterial blood
§ Used for hf (low CO w/ increased pressures)
§ Place pt in supine or Trendelenburg position
§ Level transducer w/ phlebostatic axis (4th intercoastal space, midaxillary line)
§ Zero system w/ atmospheric pressure, b/c hemodynamic pressure lines must
be calibrated to read 0
§ Compare arterial bp to noninvasive bp
• Angiography= invasive diagnostic procedure used to evaluate presence and degree of
coronary artery blockage; insert catheter into femoral or brachial vessel and thread into
right or left side of heart in coronary artery and then inject contrast media
o Pre= Maintain NPO for 8hrs, Assess for iodine/shellfish allergy (contrast media),
assess renal function prior to admin dye
o Post= assess vital every 15 min for 4hrs, every 30 min for 2hr, every hr for 4hrs,
assess groin site for bleeding and hematoma formation, document pedal pulse, color
and temp., admin antiplatelet or thrombolytic agents, monitor urine output and
admin iv fluids
o Pt w/ stent will receive anticoag therapy for 6-8 weeks, have regular labs done, avoid
activities that cause bleeding (soft toothbrush, electric razor)
o Complications
§ Cardiac tamponade= fluid accumulation in pericardial sac
•
•
•
Manifestations= hypotension, jvd, muffled heart sounds, paradoxical
pulse (variance of 10 or more in systolic bp b/w expiration and
inspiration)
Perform pericardiocentesis
Vascular access
o Central iv therapy
§ PICC= up to 12 months, tip is positioned in lower 1/3 of SVC, long term
admin of chemo, antibiotics, tpn
• Post= confirm placement w/ xray, no venipuncture or bp taken in arm
w/ picc, use 10mL syringe for flushing picc, 5mL of heparin when not
using
o Implanted port= long term (1+ year) need for vascular access, chemo, access w/
noncoring needle
o Complications
§ Phlebitis= erythema, pain, warm over site, edema, vein indurated, red streak,
cord like vein
§ Infiltration= swelling, coolness
§ Occlusion= thrombosis/emboli coagulate and cause occlusion, do NOT force
fluid if resistance is met
Ch. 28 Electrocardiography and Dysrhythmia Monitoring*
• Client needs to remain still and breathe normally
• Dysrhythmia treatments
o Brady= atropine or pacemaker
o Afib, supraventricular tachy, vtachy with pulse= amiodarone, adenosine, verapamil,
cardioversion
o Vtachy w/o pulse or vfib= amiodarone, lidocaine, epi, defibrillation
• Pt receive anticoagulation for 4-6 weeks prior to cardioversion
• Have emergency equipment available, staff stand clear of pt, monitor vitals, patent airway,
ecg
• Complications= embolism (PE, CVA, MI)
Ch. 29 Pacemakers *
• Pacemaker=electrically stimulate heart when natural pacemaker of heart fails to maintain
acceptable rhythm
o Permanent
§ Fixed rate (asynchronous)= constant rate w/o regard for hearts electrical
activity
§ Demand mode (synchronous)= detect hearts electrical impulses and fires at
preset rate only if hearts intrinsic rate is below certain level
• Diagnostics= symptomatic brady, complete heart block, sick sinus syndrome
• Post= minimize shoulder movement w/ sling, assess for hiccups (indicate generator is
pacing diaphragm)
• Edu= carry pacemaker id card at all times, take pulse daily at same time, device delivers a
shock and someone touching the pt will feel electrical impulse but not harmful, no contact
sports or heavy lifting for 2 months, never place items that generate magnetic field directly
over pacemaker generator (garage door opener or strong magnet), no MRI, it will set off
airport security
• Complications= infection, pneumothorax, hemothorax, arrhythmias
Ch. 30 Invasive Cardiovascular procedures*
• PCI= nonsurgical procedure performed to open coronary arteries
• Atherectomy= break up and remove plaques
• Stent= placement of mesh wire
• Percutaneous transluminal coronary angioplasty= inflating a balloon to dilate arterial lumen
• Should be performed w/I 3hrs
• Subjective data= chest pain, pain radiate to jaw, left arm, shoulder; womenà dyspnea,
nausea, fatigue, diaphoresis
• Objective date= ST elevation, depression or nonspecific ST changes
• NPO status for 8hr, assess pt for iodine/shellfish allergy, assess renal function
• Admin sedatives (midazolam, fentanyl), monitor vitals, assess insertion site, document pedal
pulse, lie in bed for 4-6hrs after procedure, admin antiplatelet or thrombolytic agents,
admin iv fluids, avoid strenuous exercise, restrict lifting, anticoagulation therapy for 6-8
weeks, regular lab tests, avoid activities that cause bleeding
• Complications= artery dissection cause hypotension and tachy, cardiac tamponade cause
hypotension and jvd and muffled heart sounds and paradoxical pulse, restenosis cause
report of chest pain
• CABG= chest pain
o Edu= inform pt of importance of coughing and deep breathing, splint incision,
endotracheal tube and mechanical ventilator for airway management following
surgery, sternal incision and possible leg incision, 1-2 mediastinal chest tubes,
arterial line for monitoring
o Use saphenous vein to bypass obstruction in one or more of the coronary arteries,
core temp lowered
o Maintain patent airway, monitor heart rate, monitor bp (hypotensionàgraft collapse,
htnà bleeding from grafts and sutures), monitor chest tube patency and drainage,
volume >150 sign of hemorrhage, assess and control pain (anginal pain), monitor
fluid and electrolyte status, prevent and monitor for infection
o Edu= treat angina with sublingual nitroglycerin, heart healthy diet, quit smoking,
hypothermia
• Peripheral bypass graft= saphenous vein, improve blood supply to area normally served by
blocked artery
o Subjective data= numbness, burning pain to lower extremity w/ exercise which
might stop w/ rest, numbness or burning pain to lower extremity at rest, relived by
lowering extremity below level of heart
o Objective data= absent pulses to feet, dry hairless shiny skin on calves, muscles
atrophy, skin is cold and dark colored, feet and toes mottled and dusky and thick
toenails
o Edu= NPO for 8hrs prior to surgery, advise pt to not cross his legs
o Assess and monitor vital signs, maintain bp (hypotension might reduce blood flow to
graft, htn might cause bleeding), monitor peripheral pulses and cap refill and skin
color/temp., maintain bed rest for 18-24hr, leg should be kept straight during this
time, apply anti-embolic stocking promote venous return
o Complications= compartment syndrome (tissue swelling/bleeding w/I compartment
or reduced blood flow to area), worse pain, swelling and tense or taut skin,
fasciotomy to relieve compartmental pressure
Ch. 31 Angina and Myocardial Infarction*
• MI= pain unrelieved by rest or nitroglycerin and lasting for more than 15 min, associated w/
nausea, epigastric distress dyspnea, anxiety, diaphoresis
• Angina=exertion or stress, relieved by rest or nitroglycerin, symptoms last less than 15 min
o Stable= occurs w/ exercise or relieved by rest or nitroglycerin
o Unstable= occurs w/ exercise at rest but increases in occurrence, last longer than
15min, severity and duration
o Variant= coronary artery spasm occurring during periods of rest
• Risk factors= male gender or postmenopausal women, htn, tobacco use, hyperlipidemia,
metabolic disorders (diabetes), stress
• Findings= anxiety, feeling of impending doom, chest pain, nausea, cool clammy skin,
tachy, diaphoresis
• Diagnostic
o ECG= MI (t wave inversion, st segment elevation)
o Cardiac cath
• Meds
o Nitroglycerin prevents coronary artery vasospasm and reduces preload, decreasing
myocardial o2 demand, treat angina, cause orthostatic hypotension, stop activity and
rest, place nitroglycerin under tongue if not unrelieved in 5 min call 911 and take
another and another w/I 5 min, headache is common s/e of med, sit and lie down
slowly
o Bb= slow hr, hold med if pulse is less than 60, avoid giving to asthma
o Thrombolytic= alteplase give w/I 6hr of infarction, assess for c/I (active bleeding,
pud, hist of stroke, recent trauma), monitor bleeding times (pt, aptt, inr, cbc), give
streptokinase slowly to prevent hypotension
o Antiplatelet agent= aspirin, cause gi upset and tinnitus
o Anticoagulant= heparin and enoxaparin, monitor pt and aptt, inr and cbc, monitor
for hemorrhage
• Complications= heart failure/cardiogenic shock; tachy, hypotension, inadequate urinary
output, altered loc, respiratory distress, decreased peripheral pulses and chest pain
Ch. 32 Heart Failure and Pulmonary Edema*
• Left sided failure= dyspnea, orthopnea, nocturnal dyspnea, fatigue, pulmonary congestion,
cough, crackles, frothy sputum, decreased cap refill
• Right sided failure= jvd, dependent edema, ab distention, ascites, nausea, anorexia, liver
enlargement
• Lab test elevated bnp (>300) confirms hf
• Diagnostics
•
•
•
•
o Hemodynamic monitoring= increased central venous pressure, increased pulmonary
wedge pressure, increased pulmonary artery pressure, decreased co
o Ultrasound= decreased ejection fraction
Monitoring= daily wt, I and o, o2, high fowlers, encourage bed rest, assist with adl, restrict
fluid intake and sodium intake
Meds
o Diuretics= cause hypok, decrease preload
o Acei= reduce afterload, angioedema, cough, increase k
o Arb and ccb decrease afterload
o Inotropic agent= dig, increase contractility, improve co, take apical hr for 1min, hold
med if less than 60/min, take dose at same time each day >2hr b/w antacid, report
sign of toxicity like fatigue, muscle weakness, confusion
o Bb
o Vasodilators
Therapy= vad (mechanical pump that assist heart), heart transplant (end stage hf,
immunosuppressant therapy)
Complications= pulmonary edema (dyspnea at rest, pink frothy sputum, crackles; place in
high fowler and maintain patent airway)
Ch. 33 Valvular heart disease*
• Causes
o Stenosis= narrowed opening that impeded blood moving forward (calcification and
atherosclerosis)
o Insufficiency/improper closure= blood flow back (regurgitation)
o Congenital/ marfan syndrome
o Htn
o Rheumatic fever (Strep)
o Infective endocarditis (strep)
• Finding= murmur, crackles
• Diagnostics= chest xray, ecg, echo
• Meds
o Diuretics= furosemide; reduce preload, remove excess extracell fluid, admin slow
over 1-2 min, cause hypok, eat foods high in k (dried fruit, nuts, bananas, potatoes)
o Afterload reducing agents= acei, bb, ccb
o Inotropic agents= dig; count pulse 1 min, report toxicity (fatigue, muscle weakness,
confusion, visual changes)
• Procedures= percutaneous balloon valvuloplasty (inflate balloon at stenotic lesion to open
fuse commissures), valve replacement
• Edu= prophylactic antibiotic use b/f invasive dental or respiratory procedure
Ch. 34 Inflammatory Disorders*
• Risks= iv substance us, rheumatic fever, strep infection, overcrowding, low ses
• Findings
o Pericarditis= inflame of pericardium, chest pressure/pain, pericardial friction rub,
sob, relief of pain when sitting and leaning forward, dyspnea w/ hiccups
o Rheumatic endocarditis= strep pharyngitis, lesion in heart, fever chest pain, sob, rash
on trunk and extremities, friction rub, murmur, muscle spasm
o Infective endocarditis= infection of endocardium, strep, iv substances use, fever flu
like manifestations, murmur, petechiae, red streaks under nail bed
• Lab tests= blood cultures to detect bacterial infection, elevated wbc, elevated esr and crp,
throat culture to detect strep infection
• Meds
o Antibiotics= treat infection
o Nsaids= treat fever and inflame
o Glucocorticosteroids= treat inflam
• Therapy= pericardiocentesis (aspirator pericardial fluid)
• Complications= cardiac tamponade
Ch. 35 Peripheral Vascular Diseases*
• PAD= lower extremities inadequate flow of blood, caused by atherosclerosis
o Risks= htn, hyperlipidemia, dm, smoking, obesity, sedentary
o Findings= burning, cramping, pain in the legs during exercise (intermittent
claudication), pain that’s relieved by placing legs at rest in dependent position,
decreased cap refill, decreased pulse, loss of hair on lower calf, dry scaly mottle
skin, thick toenails, pallor of extremity with elevation, dependent rubor, ulcers and
gangrene of toes
o Care= exercise to build up, walk to point of pain stop and rest and then walk a little
farther, provide warm environment and wear insulated socks, avoid stress, caffeine,
nicotine, avoid crossing legs, refrain from wearing restrictive garments
o Meds
§ Antiplatelet= clopidogrel, aspirin, reduce blood viscosity, increase blood flow
o Procedure= balloon and stent to open and help maintain patency of vessel, laser
assisted angioplasty, vaporize atherosclerotic plaque and open artery, bypass graft to
reroute circulation around arterial occlusion
§ Monitor vitals, peripheral pulse, cap refill, keep on bed rest with limb straight
for 2-6hr b/f ambulation
§ Mark location of pedal and dorsalis pulse, monitor bp, hypotension can result
in increased risk of clotting or graft collapse, htn increases risk of bleeding
o Complications
§ Graft occlusion= absent or reduced pedal pulses, increased pain or change in
extremity color or temp
§ Compartment syndrome= tingling, numbness, worse pain, edema, pain on
passive movement
• PVD
o VTE= blood clot form as result of venous stasis
§ Risks= Virchow triad (hypercoagulability, impaired blood flow, damage to
blood vessels), hip surgery, total knee replacement, heart failure, immobility,
pregnancy, ocp
§ Findings= calf or groin pain, tender, sudden onset of edema, warmth,
induration and hardness over involved blood vessel, SOB and chest pain (PE)
§ Diagnostic= venous duplex ultrasonography
Care= elevation of extremity above level of heart but avoid using knee gatch
or pillow, warm moist compress, do NOT massage, thigh high compression
or antiembolism stocking
§ Meds
• Heparin= prevent formation of other clots and enlargement of existing
clots (monitor aptt and platelet count, have protamine (antidote)
• Low molecular wt heparin
• Warfarin= therapeutic effect takes 3-4 days to develop, monitor pt and
inr, have vitamin k (antidote), do NOT fluctuate in diet of green leafy
vegetables
• Thrombolytic therapy= dissolve clots, use electric instead of blade
razor and brush teeth with soft toothbrush
Venous insufficiency= incompetent valves in deep veins of lower extremities, venous
stasis ulcers
§ Risks= sitting or standing in one position for long period of time, obesity,
pregnancy
§ Finding= brown discoloration of ankles, edema, stasis ulcers around ankles
§ Care= elevate leg above heart when in bed, wear stockings after legs have
been elevated
Varicose veins= enlarged, twisted superficial veins
§ Risk=female, older than 30, prolonged standing, pregnant, obesity, family
history
§ Finding= superficial veins
§ Lab test= Trendelenburg test (supine position with legs elevate)
§ Therapy= sclerotherapyàchemical solution is injection into varicose vein,
vein strippingà removal of large varicose veins that can’t be treated
Lab tests= d dimer test is positive indicate thrombus formation
Findings= aching pain, heaviness
§
o
o
o
o
Ch. 36 Hypertension*
• BP >140/90, poorly controlled bp affects heart, brain, eyes, kidneys
• Risk factors
o Primary= family hist, excess na, physical inactivity, obesity, alcohol, black, smoking,
hyperlipidemia, stress
o Secondary= kidney disease, cushing, pheochromocytoma
• Findings= asymptomatic, headaches, dizzy, visual disturbances
• Meds
o Diuretics= increase k excretion or k sparing (spironolactone)
o Ccb= verapamil, amlodipine, diltiazem; hypotension, constipation, avoid grapefruit
o Acei= cough, angioedema
o Arb= cause hyperk, angioedema or hf, avoid foods high in k
o Aldosterone receptor antagonist= cause hypertriglyceridemia, hypona, hyperk, NO
salt substitutes
o BB= metoprolol, hypoglycemia, sex dysfunction, fatigue, weakness
o Central alpha agonist= clonidine, cause sedation, orthostatic hypotension
•
•
Monitor bp, hyperk and salt substitute, less than 2g na, limit alcohol, dash diet, avoid high
fat and na food, wt reduction, smoking cessation, stress reduction
Htn crisis= severe headache, >240/120, blurred vision, dizzy, use iv antihtn like
nitroprusside or nicardipine
Ch. 37 Hemodynamic Shock*
• Hemodynamic shock= inadequate tissue perfusion
o Cardiogenic= failure of heart to pump
o Hypovolemic= decrease in intravascular volume
o Obstructive= impairment of heart to pump effectively b/c blockage of great vessels
o Distributive= widespread vasodilation and increase cap permeability
§ Neurogenic= head trauma, spinal cord injury
§ Septic= evidence of infection, gram - bacteria
§ Anaphylactic= allergen exposure
• Findings= hypoxia, tachypnea, angioedema (anaphylactic), wheezing, decreased bp, tachy,
decreased urine output
• Test= increased lactic acid, increased troponin (cardiogenic), decreased hgb and hct
(hypovolemic), blood culture (septic)
• Diagnostics= arterial line insertion, pulmonary artery catheter insertion, ecg and echo and
cardiac cath (cardiogenic and obstructive), esophagogastroduodenoscopy (hypovolemic)
• Care= o2, vitals, cardiac rhythm, urine output hourly report less than 30, loc, 100%
nonrebreather facemask, prepare to intubate, place pt flat with legs elevated
• Meds
o Noepi= strengthen cardiac contraction and increase co
o Vasopressin= vasoconstriction
o Epi= bronchodilator, increase hr
o Isotonic crystalloids or colloids= hypovolemic volume replacement
o Diphenhydramine= anaphylactic shock
o Na nitroprusside= cardiogenic shock, reduce afterload and preload
o Vancomycin
• Therapy= intubation, needle decompression and chest tub insertion
• Complications= mods, dic
o Admin platelets, clotting factors blood products, monitor pt ptt, assess for bleeding
Ch. 38 Aneurysms*
• Aneurysm= widening or ballooning in wall of blood vessel
• Risks= male, atherosclerosis, htn, tobacco, age
• AAA= most common, flank or back pain, pulsating ab mass (do NOT palpate)
• Thoracic aortic aneurysm= severe back pain (most common), cough, sob, difficulty
swallowing
• Aortic dissection= sudden onset of tearing ripping and stabbing ab or back pain,
hypovolemic shock (diaphoresis, n/v, decreased peripheral pulses, hypotension, tachy)
• Diagnostics= x ray, ct and ultrasonography
• Care= vitals every 15 min, monitor hemodynamic findings, abg, hourly urine output 30ml,
maintain iv access
•
•
•
Meds= priority intervention pressure between 100-120 during emergency, admin antihtn
Procedure= ab aortic aneurysm resection (elective surgery to manage aaa of 5.5cm)
Complications= aneurysm rupture is life threatening emergency, result in massive
hemorrhage, shock and death, greater than 6cm w/ htn are greater risk of death
Ch. 39 Hematologic Diagnostic Procedures*
• WBC= 5000-10000
• RBC= 4-6million
• Platelets= 150,000-400,000
• Hgb= 12-18
• Hct= 37-52%
• Aptt= 30-40sec (1.5-3 times control value)
• Pt= 11-12.5 sec
• Inr= 2-3 on warfarin
• Bone marrow biopsy= diagnose blood disorders leukemia and cancer
o Place pt in prone or side lying position to expose iliac crest
Ch. 40 Blood and blood product transfusion*
• Analogous transfusion= pt blood is collect in anticipation of future transfusion, donate 6
weeks prior
• Blood type
o A= a antigen, b antibody
o B= b antigen, a antibody
o AB= AB antigen, no antibodies
o O= no antigens, A and B antibodies
o Rh+ can’t be given to Rh• Large bore iv access 18-20 gauge, verify w/ two RN to verify blood produce, pt and #,
prime blood admin set w/ NaCl
• Remain w/ pt 15-30 min
• Complications
o Acute hemolytic= chills, fever, low back pain, tachy, flushing, hypotension
§ Stop transfusion
o Febrile= chills, increase 1 degree, flushing, shaking, muscle stiffness, headache,
nervousness
§ Stop transfusion, admin antipyretic
o Allergic= itching, urticaria, flushing
§ Stop transfusion, admin antihistamine
o Anaphylactic= bronchospasm, laryngeal edema, shock
§ Stop transfusion, admin epi and o2
o Circulatory overload= crackles, dyspnea, jvd, tachy
§ Slow infusion
Ch. 41 Anemias*
• Anemia= low amt of circulating rbc, hgb concentration, low o2
•
o Causes= blood loss, inadequate rbc production, increased rbc destruction,
deficiency of folic acid, iron, b12
o Risk factors= menorrhagia, defective hgb (sickle cell), pica (eating chalk), bone
marrow suppression (aplastic anemiaà decreased rbc)
o Findings= pallor, fatigue, numbness and tingling of extremities, dyspnea on exertion,
tachy, dizzy/syncope, nail bed deformity
o Increase dietary intake of iron, vitamin b12 and folic acid
o Meds= ferrous sulfate, iron dextran (use z track), epo (increase production of rbc,
monitor hgb and hct 2X a week), b 12 (cyanocobalaminà if lack intrinsic factor can
have irreversible malabsorption, receive b12 injections on monthly basis), folic acid
(large dose can mask b12 deficiency)
o Edu= take with vitamin C to increase oral absorption
o Complications= hf
Iron deficiency anemia= common in kids, adolescents, pregnant women
Ch. 42 Coagulation Disorders*
• Idiopathic thrombocytopenic purpura= autoimmune disorder life span of platelets is
decreased
o Risk factors= female, autoimmune, recent virus (kids)
• DIC= clotting and anticlotting mechanisms occur at same time
• Findings= spontaneous bleeding from gums, oozing/trickling or flow of blood from incisions
or lacerations, petechiae, ecchymoses, tachy, hypotension
• Lab tests= decrease hgb, decreased platelet levels
Ch. 43 Fluid Imbalances*
• Hypovolemia causes= vomiting, diarrhea, diaphoresis, diuretics, ascites, np,
hyperventilation, dka
o Risks= older adults b/c diminished thirst reflex
o Findings= tachy, thready pulse, hypotension, tachypnea, dizzy, thirst, oliguria,
diminished cap refill, cool clammy skin, sunken eyeballs, poor skin turgor and
tenting
o Lab test= increase hct, increased BUN >25, increased urine specific gravity > 1.025,
increased serum osmolarity > 295
o Care= monitor I & O and report < 30 output, admin iv hydration, initiate fall
precaution, encourage pt to change position slow, drink liquids
o Complications= hypovolemic shock (admin o2, colloids, crystalloids,
vasoconstrictors)
• Hypervolemia causes= hf, kidney disease, cirrhosis, od na, prolonged corticosteroid use
o Findings= tachy, bounding pulse, htn, tachypnea, ascites, crackles, dyspnea,
peripheral edema, distended neck veins
o Labs = decreased hct, hbg, serum and urine osmolarity, and BUN
o Care= monitor i&o, monitor daily wt, maintain na restricted diet, fluid restrictions,
admin diuretics, position in semi fowlers and reposition every 2hr to avoid skin
breakdown, pressure reducing mattress and assess bony prominence
o Edu= notify provider if gain 1-2lbs in 24hrs or 3lbs in a week
o Complications
§
Pulmonary edema= tachy, dyspnea at rest, frothy pink sputum
• Admin o2
Ch. 44 Electrolyte imbalances
• Electrolyte levels
o Na= 135-145
o Ca= 9-10.5
o K= 3.5-5
o Mg= 1.3-2.1
o Cl= 98-106
o Ph=3-4.5
o BUN=10-20
• Hypona= na<135
o Risks= diuretics, ng suction, kidney disease, hf, siadh, v/d
o Findings= hypothermia, tachy, hypotension, confusion, muscle weakness, seizures
o Care= PO fluids, na w/ food and fluids, hypertonic solution admin 3% nacl slowly
• Hyperna= na >145
o Risks= DI, excess na retention (kidney failure, cushing syndrome)
o Findings= thirst, hyperthermia, tachy, orthostatic hypotension, irritability, muscle
twitching, dry mucous membranes
o Care= 0.45%nacl, h20 intake and decrease na intake
• Hypok
o Risks= diuretics, v/d, prolonged ng suctioning
o Findings= ecg disturbances (dysrhythmias), constipation, paralytic ileus
o Care= encourage foods high in k (avocado, broccoli, dairy, dried fruit, cantaloupe,
bananas, juices, citrus, oral supplement)
o Complications= dysrhythmias
• Hyperk
o Risks= k sparing diuretics, acidosis (dka)
o Findings= ecg disturbance, increased motility (diarrhea)
o Care= observe for nausea and colic, avoid foods high in k, receive furosemide,
combo of glucose and insulin admin to promote uptake of k by cells, kayexalate
promote k excretion, admin nahco3 to reverse acidosis
o Meds= loop diuretic (furosemide)
• Hypoca= less than 9, inverse to ph
o Risks= thyroidectomy, hypoparathroidism, vitamin d deficiency, pancreatitis
o Findings= tetany, muscle twitches, painful muscle spasm, positive Chvostek sign (tap
cheek and trigger facial twitch), positive trousseau sign (hand spasm w/ sustained bp
cuff inflation)
o Care= encourage foods high in ca, dairy, dark leafy green vegetables
• Hypomagnesemia= less than 1.3
o Risks= malnutrition, ethanol ingestion
o Findings= increase nerve impulse transmission, + Chvostek and trousseau sign,
hypoactive bowel sounds, paralytic ileus
o Care= admin oral or iv magnesium sulfate, oral magnesium cause diarrhea, dark
green vegetables
Ch. 45 Acid-Base imbalances
• Greater concentration of hydrogen the more acidic and lower the pH
• Buffers
o Chemical protein buffers= first line of defense
o Respiratory buffers= second line of defense, control level of h ions in blood through
control of co2 levels
o Kidney buffers= third line of defense, control movement of bicarb; high h ions means
bicarb reabsorption, low h ions means bicarb excretion
• Compensation= normal pH 7.35-7.45
• Respiratory acidosis= caused by hypoventilation and obstruction, causes increased CO2
o Manifestations= ineffective, shallow, rapid breathing
o Care= o2, patent airway, ventilatory support, bronchodilators
• Respiratory alkalosis= caused by hyperventilation from fear anxiety or salicylate toxicity,
results in decreased co2
o Manifestations= rapid deep respirations
o Care= anxiety reduction and breath into bag (rebreathing technique)
• Metabolic acidosis= results from excess production of h ions, dka, aspirin, kidney failure,
diarrhea, decreased hco3
o Manifestations= dysrhythmias, brady, weak peripheral pulses, hypotension, rapid
deep respirations (kussmaul respirations), warm dry skin, hyperk
o Care= admin insulin, admin antidiarrheal, admin nahco3
• Metabolic alkalosis= results from oral ingestion of excess amt of base (antacids), vomiting,
ng suction, increased hco3
o Care= antiemetics, fluids and electrolyte replacement
• ABG
o First look at pH, 7.35-7.45
§ <7.35=acidic
§ >7.45= alkalosis
o PaCO2, 45-35
§ >45= respiratory acidosis
§ <35= respiratory alkalosis
o HCO3, 22-26
§ <22= metabolic acidosis
§ >26= metabolic alkalosis
o Uncompensated= pH is outside expected range and so is PaCO2 or HCO3
o Partially compensated= pH, HCO3 and PaCO2 are out of range
o Fully compensated= pH is w/I expected range but PaCO2 and HCO3 are out of
range
Ch. 46 Gastrointestinal Diagnostic Procedures
• Liver function tests= expected ALT and AST <40, bilirubin <1
• Pancreatitis= expected amylase <100, lipase <100
• Albumin= 3.5-5; decreased shows malnourished and hepatic disease
• Ammonia= <100, elevated in liver disease
• Fecal occult blood test= test for c diff, gi bleeding, occult blood
•
•
•
•
o += blood in GI from ulcer, colitis, cancer
Endoscopy= used for anemia, ab discomfort, ab distention or mass
o Colonoscopy= enter through anus, moderate sedation, left side w/ knee to chest,
bowel prep, clear liquid diet (avoid red, purple, orange fluids), NPO after midnight
o EGD= insertion of endoscope through mouth, NPO 6-8 hr
Sigmoidoscopy= visualize sigmoid colon, no anesthesia, left side, bowel prep, clear liquid
diet 24hr b/f procedure, NPO after midnight
Complications
o Hemorrhage= tachy, tachypnea, hypotension
o Aspiration
GI series= done w/ or w/o contrast, drink barium prep
o Clear liquid/low residue diet, NPO after midnight, avoid smoking or chewing gum
(increases peristalsis)
o Increase fluid intake to promote elimination of contrast material
o Stools will be white for 24-72hr until barium clears
Ch. 47 Gastrointestinal Therapeutic Procedures
• Enteral feedings= comatose, intubated, difficulty swallowing
o Complications= check residual every 4-6hr, hold for residual volume of 100-200mL
• TPN= through central line, given for inability to absorb nutrition, hypermetabolic state,
chronic malnutrition, obtain daily labs, change tubing and solution bag every 24hr, filter
tubing to collect particles from solution, check glucose every 4-6hr for first 24 hrs, keep
dextrose 10% in water at bedside
• Complications
o Air embolism= clamp catheter and place pt on left side in Trendelenburg position,
admin o2 and notify dr
o Infection= observe central line for local infection (erythema, tenderness, exudate), do
NOT use TPN line for other IV bolus fluids and meds
• Paracentesis= insert needle through ab wall into peritoneal cavity, relief of ab ascites
pressure, used for respiratory distress
o Verify pt has signed consent, void, put in upright position, review vitals, wt, measure
ab girth, admin sedation
o Check vitals and wt and measure ab girth after procedure, admin iv bolus fluids or
albumin
• Bariatric surgery= resume fluids and restrict to 30mL and increase in frequency and volume,
provide six small meals a day, observe for dumping syndrome (cramps, diarrhea, tachy,
dizzy, fatigue)
• NG decompression= intestinal obstruction to decompress
o Vomiting, absent bowel sounds (paralytic ileus) or high pitched (obstruction), ab
pain, ab distension
o Assess bowel sounds and ab girth after placement, monitor for displacement
(Decrease in drainage, increase n/v, distention)
• Ostomies
o Ileostomy= surgical opening in ileum, frequent liquid stools
o Colostomy= surgical opening in large intestine, formed stools
o Stoma should appear pink and moist, empty ostomy bag when ¼ to ½ full
o Complications= ischemia (pale pink or bluish purple stoma, dry)
Ch. 48 Esophageal Disorders
• GERD= content and enzyme backflow into esophagus
o Risks= obesity, old, eat fatty fried foods chocolate caffeine peppermint spicy food
tomatoes citrus alcohol, increased ab pressure from obesity, pregnancy, bending at
waist, ascites
o Findings= pain worsens with position of bedding, straining or laying down, pain
occurs after eating, throat irritation (chronic cough, bitter taste in mouth), pain is
relieved by drinking water or sitting up or taking antacids
o Diagnostics= egdà barretts epithelium (premalignant cells)
o Meds
§ Ppi= pantoprazole or omeprazole reduce gastric acid
§ Antacids= aluminum hydroxide neutralize excess acid; take 1-3 hrs after
eating and at bed, separate from other meds by at least 1hr
§ Histamine 2 receptor antagonist= ranitidine, famotidine reduce the secretion
of acid
§ Prokinetics= metoclopramide increased motility of esophagus and stomach;
monitor pt for eps
o Therapy
§ Fundoplication = wrap fundus of stomach around esophagus
§ Avoid offending foods, avoid large meals, sit up, avoid eating b/f bed, avoid
tight clothes, lose wt, elevate head of bed
• Esophageal varices= swollen, fragile blood vessels generally found in submucosa, occur as
result of portal htn, due to cirrhosis of liver, hemorrhage is medical emergency
o Findings= hypotension, tachy
o Lab tests= hgb, hct, elevated ammonia
o Diagnostics= endoscopy
o Care= est. iv with large bore needle
o Meds= nonselective bb like propranolol to decrease hr and reduce hepatic venous
pressure, vasopressor to vasoconstrict
o Complications= hypovolemic shock (tachy, hypotension)
Ch. 49 Peptic Ulcer Disease
• Erosion of mucosal lining of stomach, esophagus or duodenum, caused by gram – h pylori
• Risks= h pylori, nsaid and corticosteroid use, severe stress
• Findings= heartburn, bloating n/v, pain or burning sensation of midepigastrium or back,
hematemesis, melena
• Care= monitor orthostatic changes, tachy, restrict milk, caffeine, decaf coffee, spicy foods,
and nsaids
• Meds
o Antibiotics= metronidazole, amoxicillin, clarithromycin, tetracycline eliminate h
pylori; complete full course of meds
o Histamine 2 receptor antagonist= ranitidine, famotidine suppress secretion of gastric
acid
o Ppi= pantroprazole
•
•
•
o Antacids= magnesium hydroxide, 1-2hr after meals, give 1-2 apart from other meds
o Mucosal protectants= sucralfate coats ulcer and protects from acid, admin on empty
stomach 1hr b/f meals and at bed
Complications= perforation/hemorrhage (severe epigastric pain, ab can become tender and
rigid, rebound tenderness), dumping syndrome (limit fluid, don’t drink w/ meals but 1hr
prior and following meal, high protein, high fat, low fiber and low carb diet, avoid milk and
sugar)
Gastric ulcer= pain occur 30-60 min after meal, pain exacerbated by eating
Duodenal ulcer= pain occurs 1.5-3hr after meal, pain during night, pain relieved by eating
or antacid
Ch. 50 Acute and Chronic Gastritis
• Gastritis= inflam in lining of stomach
• Chronic= can lead to pernicious anemia and h pylori
• Risks= h pylori infection, nsaid corticosteroid use, alcohol, smoking, caffeine, excess stress,
autoimmune disease
• Findings= upper ab pain or burning can increase or decrease after eating, ab bloating,
hematemesis and stools with occult blood, black tarry stools
• Diagnostics= endoscopy
• Care= small frequent meals and encourage eat slow, avoid alcohol, caffeine and foods that
cause gastric irritation, reduce stress, monitor for gastric bleeding
• Meds
o Histamine 2 antagonists= famotidine, take oral dose w/ meals
o Antacids= take on empty stomach, wait 1hr to take other meds
o Ppi= pantoprazole, allow 60 min b/f eating, do not crush or chew
o Prostaglandins= misoprostol, reduce gastric acid secretion don’t take if pregnant
o Mucosal barrier= sucralfate, protective coating over mucosa, allow 30 min b/f or
after to give antacid, take on empty stomach
o Antibiotics= eliminate h pylori
• Complications= gastric bleed (fluid replacement, monitor ng tube for blood), dehydration
(monitor fluid intake and urine output, electrolytes), pernicious anemia (need monthly
vitamin b12 injections)
Ch. 51 Noninflammatory bowel disorders
• Hernia= displacement of bowel through weakness of ab muscle
• Risks= male, advanced age, increased intra ab pressure from pregnancy or obesity
• Findings= protrusion or lump at site
• Care= avoid coughing, straining and lifting
• Ibs= d/c, consume 2-3l fluid per day, increase fiber intake (30-40g day)
o Findings= cramping pain in ab, change bowel pattern, ab bloating, belching, d/c
o Diagnostics= change bowel pattern, ab distension, feeling defecation isn’t complete
and presence of mucus w/ stools
o Care= reduce stress, limit intake of irritating agents (gas foods, caffeine and alcohol),
keep food diary
o Meds
•
§ Alosetron= ibsd
§ Lubiprostone= ibsc
Intestinal obstruction
o Mechanical= caused by tumor or postsurgical adhesion, diverticulitis, hernia
o Nonmechanical= paralytic ileus, neurogenic disorder, vascular disorder, electrolyte
imbalance
o Small and large= ab distension, high pitch above and hypoactive below obstruction
o Small= profuse, sudden projectile vomiting with fecal odor
o Large= diarrhea or ribbon like stools around impaction
o Diagnostics= ct
o Care= npo
o Therapy=ng tube, oral hygiene every 2hr
o Surgery= colon resection, colostomy; clamp ng and assess tolerance prior to
removal, clear liquids, clamp tube after eating
Ch. 52 Inflammatory Bowel disease
• UC= edema and inflame in rectum and sigmoid colon, entire length of colon, mucosa and
submucosa
o Findings= left lower quadrant pain, fever, 15-20 stools that contain mucus, blood or
pus, ab distention, tender
o Tests= decrease hct and hgb, increased esr, increased wbc, increased c reactive
protein, decrease albumin
o Diagnostics= colonoscopy, barium enema, ct
o Therapy= colectomy, ileostomy
• CD= all bowel layers, entire gi tract from mouth to anus
o Findings= right lower quadrant pain, fever, five loose stools with mucus or pus, ab
distention, tender, steatorrhea
o Tests= decreased hct and hgb, increased esr, increased wbc, increase c reactive
protein, decreased albumin
• Diverticulitis= inflame and infection of bowel mucosa caused by bacteria, food or fecal
matter trapped in diverticula
o Findings= pain in left lower quadrant, fever, chills
o Care= consume clear liquid diet, low fiber, add fiber once solid foods are tolerated,
avoid seeds or nuts or popcorn
o Therapy= colon resection
• Risks= genes, white, jewish, smoking
• Care=monitor for perforation (fever, severe ab pain, vomiting), npo and tpn, high protein,
high cal and low fiber food, avoid caffeine and alcohol, small frequent meals, monitor
electrolytes
• Meds
o 5 aa= sulfasalazine
o Corticosteroids= reduce inflame and pain; risk of infection and hyperglycemia
o Immunosuppressants= cyclosporine, avoid crowds, monitor for infection
o Immunomodulators= suppress immune response infliximab, avoid crowds, increased
risk of infection
o Antidiarrheal= loperamide
•
o Antimicrobial= ciprofloxacin, metronidazole
Complications= peritonitis (rigid, board like ab, nv, rebound tenderness, tachy) place pt in
fowler, admin o2, ng, npo
Ch. 53 Cholecystitis and Cholelithiasis
• Cholecystitis= inflam of gallbladder wall caused by gallstones obstructing bile ducts which
causes bile to back up and gall bladder to become inflamed
• Cholelithiasis= presence of stone in gallbladder
• Risks= females, high fat diet, obese, genetics, older
• Findings=sharp pain in right upper quadrant, intense pain after ingestion of high fat food,
dyspepsia, eructation (burping), flatulence, clay colored stool, steatorrhea, dark urine,
pruritus
• Labs= increased wbc, bilirubin increased amylase and lipase increased w/ pancreatic
involvement
• Diagnostics= ultrasound visualize gallstones, ab x ray or ct visualize calcified gallstones
and enlarged gallbladder, hepatobiliary scan
• Therapy
o Lithotripsy= shock waves used to break up stones, used on nonsurgical candidates of
normal wt, small cholesterol based stones
o Cholecystectomy= shoulder pain is normal, removal of gallbladder, discharged w/I
24hr if laparoscopic
§ Elevate t tube above level of ab, monitor and record color of drainage, clamp
tube 1hr b/f and after meals, assess stools for color (clay colored until biliary
flow reestablished, should return to brown in week and diarrhea is common),
low fat diet, avoid gas forming foods (beans, cabbage, cauliflower, broccoli)
• Complications= peritonitis
Ch. 54 Pancreatitis
• Secrete digestive enzymes that break down carb, protein and fat which activate prematurely
in pancreas
• Chronic pancreatitis leads to fibrosis
• Risks= biliary tract disease, gallstones, alcohol use, gastrointestinal surgery, hyperlipidemia,
hyperparathyroidism, trauma, penetrating ulcer, med toxicity
• Findings= severe epigastric pain radiating to back, left flank or left shoulder pain, worse
lying down, relieved in fetal position, n/v, wt loss, turner sign, Cullen sign, jaundice, warm
moist skin, fruity breath, ascites, tetany (+ trousseau and Chvostek sign)
• Labs= increase amylase and lipase, increase wbc, decrease Ca and Mg, increase serum liver
enzymes and bilirubin (>1), increased glucose
• Care= npo, tpn, bland diet with no caffeine, small frequent meals, antiemetic, no alcohol,
no smoking, limit stress, pain management, monitor blood glucose, insulin, monitor
electrolyte and hydration
• Meds
o Opioids
o Pancreatic enzymes= aid w/ digestion of fats and proteins when taken w/ meals and
snacks
• Edu= alcohol abuse program
• Complications= pseudocyst (leakage of fluid out of pancreas), dm 1
Ch. 55 Hepatitis and Cirrhosis
• Viral hepatitis is most common but can also be caused by drug or toxin
• Viral
o A= transmitted fecal-oral (contaminated food/water or close contact)àvaccine
preventable
o B= transmitted through blood/body fluids (sex, drugs, mom)àvaccine preventable
o C= transmitted through blood/body fluids (sex, drugs)
• Risk for hepatitis= dirty needles, piercings, tattoos, sex, contaminated food, travel in
underdeveloped countries, prison or crowded living conditions
• Symptoms hepatitis=flu (fever, vomiting), dark urine, clay stool, jaundice, increased ast and
alt >40, increased bilirubin >1
• Diagnose with biopsy
• No cure, antiviral meds, leads to cirrhosis, liver cancer and failure
• Cirrhosis= scarring of liver because prolonged inflame
o Post-necrotic= viral hep
o Laennex= chronic alcohol use
o Biliary= chronic biliary obstruction/autoimmune disease
• Risk= alcoholics, hep, drugs
• Symptoms= fatigue, ab pain, ascites, pruritis, confusion, mentation, encephalopathy, gi
bleed, esophageal varices, jaundice, petechiae, palmar erythema, spider angiomas,
peripheral edema, asterixis, fetor hepaticus (fruity breath)
• Lab values= elevated alt and ast and bilirubin, protein (less than 6-8) and albumin (less than
3.5-5) will be decreased, decreased hct and hgb and platelets and rbc, elevated ammonia
• Diagnosis= biopsy, ultrasound, ct scan and mri
• Care= sit upright at 30 degrees with feet elevated, o2, wash with cold water and apply
lotion, strict I and O, lactulose (binds ammonia to be excreted for encephalopathy, cause
hypoK), high carb and high protein and low fat and Na, measure ab girth daily, bb, K, void
b/f paracentesis, smaller more frequent meals
• Transplant= pt will be on immunosuppressants
Ch. 56 Renal diagnostic procedures
• Labs
o Creatinine= increases w/ kidney disease
o Bun= dehydration affects it, increased w/ kidney disease
o Urinalysis= collect early morning specimen, observe color, specific gravity (1.011.025), drug metabolite, glucose, ketone bodies, protein
• CT complications= dye can cause aki, shellfish allergy or iodine contraindicated, increase
hydration after procedure
• Cystoscopy, cystourethroscopy
o NPO after midnight, laxative or enema for bowel prep
• Excretory urography
o Bowel cleanse w/ laxative or enema, NPO after midnight
Ch. 57 Hemodialysis and Peritoneal Dialysis
•
•
•
Dialysis= rid body of excess fluid and electrolytes, eliminate waste products
Hemodialysis= vascular access
o Patency of long term devices, presence of bruit, palpable thrill, distal pulses, avoid
measuring bp, admin injections, performing venipunctures or inserting iv on this arm
o Assess vitals, lab values (BUN, creatinine, electrolytes, hct) and wt
o 3x a week for 3-5hr session, two needles, one into artery and other into vein
o Monitor for complications such as hypotension, cramping, vomiting, bleeding,
heparin prevent clotting of blood, have protamine sulfate ready to reverse heparin
o Post= decrease bp and changes in lab values, compare pt pre wt w/ post wt, increase
protein intake over pre-dialysis limitations, avoid lifting heavy objects w/ access arm,
avoid carrying objects that compress extremity, avoid sleeping on top of extremity,
perform hand exercises that promote fistula maturation
o Complications
§ Clotting/infection of access site= anticoag prevent blood clots, monitor for
hemorrhage, use surgical aseptic technique during cannulation
§ Disequilibrium syndrome= rapid decrease of bun and circulating fluid
volume, cerebral edema, increase icp, n/v change in loc, seizures, agitation;
slow dialysis exchange, take anticonvulsant
§ Hypotension= infuse iv fluids or colloid, slow dialysis exchange, lower head
of bed
§ Anemia
§ Infectious disease
Peritoneal dialysis= instillation of hypertonic dialysate solution into peritoneal cavity, dwell,
drain dialysate and waste products, use in older adults or unable vascular access
o Pre= pt feel full when dialysate is dwelling and discomfort
o Intra= record amt of inflow compared to outflow, monitor color (clear to yellow) of
outflow, signs of infection (fever, bloody, cloudy frothy dialysate return), warm
dialysate prior to instilling, keep outflow bag lower than pt ab
o Complications
§ Peritonitis= fever, purulent drainage, redness, swelling, cloudy or discolored
drained dialysate
§ Protein loss= increase diet intake of protein over predialysis restriction
§ Hyperglycemia= monitor glucose
§ Poor dialysate inflow or outflow= obstruction or twisting of tubing,
constipation is common cause, milk tubing to break up fibrin clots, tell pt to
avoid constipation and use softener and consume diet high in fiber
Ch. 58 Kidney Transplant
• End stage kidney disease
• Post= assess urine output, should be greater than 30ml, abrupt decrease in urine output
indicates rejection, monitor for manifestations of infection (dyspnea, fever, incisional
drainage, redness), rejection (fever, htn, pain at transplant site), encourage pt to turn, cough
and deep breathe to prevent pneumonia, maintain continuous bladder irrigation, admin
immunosuppressive meds (cyclosporine) to prevent rejection and monoclonal antibodies
(basiliximab or daclizumab)
•
•
Edu= low fat diet to decrease cholesterol, high fiber to avoid constipation, increase protein,
avoid concentrated sugar or carbs to control glycemic factors, avoid contact sports
Complications
o Hyperacute= occur w/I 48hrs after surgery, antibody mediated response small blood
clots, not reversible
o Acute= 1week to 2 years after surgery, increased doses of immunosuppressive meds
o Chronic= occurs gradually over months to years
Ch. 59 Polycystic Kidney Disease, Acute Kidney Injury, Chronic Kidney Disease
• Acute kidney injury
o Phases
§ Oliguria= 100-400ml/24hr for 1-3 weeks
§ Diuresis= large amt of fluid occurs and last 2-6 weeks
§ Recovery= 12 months
o Types
§ Prerenal=reduction of blood flow to kidneys
• Risks= renal vascular obstruction, shock, decreased renal profusion,
sepsis, hypovolemia
§ Intrarenal= trauma, antibiotics, contrast dye, heavy metals
§ Postrenal= stone, tumor, prostate hyperplasia
o Labs
§ Creatinine increases
§ Bun increases to 80-100 in one week
o Nutrition= implement k phosphate, na and magnesium restriction, high protein diet
• Chronic kidney disease
o Older adults are at increase risk related to aging, lack of thirst, higher risk for
dehydration
o Stages
§ 1= gfr greater than 90
§ 2= gfr 60-89
§ 3= gfr 30-59
§ 4= gfr 15-29
§ 5= gfr <15
o Drink at least 2L water daily, stop smoking, control diabetes and htn
o Risks= aki, dm, nephrotoxic meds, htn, autoimmune disorders (sle)
o Findings= lethargy, slurred speech, tremors, jerky movements, jugular distention, hf,
sob, tachypnea, crackles, anemia, vomiting, pruritus, uremic frost
o Labs= hematuria, proteinuria, decrease in specific gravity, increase bun w/ increase
creatinine, decreased na and ca, increased k and phosphorus and mg
o Diagnostics= kub, ct, mri
o Care= 2.2lb wt increase is 1L of fluid retained, restrict na, k, phosphorous and mg,
diet high in carbs and moderate in fat, monitor wt gain, skin care
o Meds= avoid nsaids, contrast dye, epo (stimulate production of rbc), ferrous sulfate,
furosemide (loop diuretic to excrete excess fluids)
o Edu= avoid antacids w/ mg, take rest periods from activity
Ch. 60 Infections of Renal and Urinary system
• Uti=caused by ecoli, untreated lead to pyelonephritis and urosepsis
o Risks= female, short urethra, close proximity of urethra to rectum, sex, pregnancy,
synthetic underwear, wt bathing suits, frequent baths or hot tubs, indwelling urinary
catheter, stool incontinence, dm, incomplete bladder emptying
o Findings= lower ab discomfort, nausea, urinary frequency and urgency, dysuria,
fever, vomiting, cloudy or foul smelling urine, confusion in older adults, urosepsis
(hypotension, tachy, tachypnea, fever)
o Labs= urinalysis (bacteria, wbcà pyuria, positive leukocyte esterase and nitrates)
o Meds= fluoroquinolones (antibiotics), phenazopyridine (bladder analgesic, will turn
urine orange)
o Edu= drink at least 3L fluid daily, bathe daily, empty bladder every 3-4hr, urinate b/f
and after sex, drink cranberry juice to decrease risk of infection, wipe front to back,
avoid bubble bath, avoid wet bathing suit, avoid tight clothing
• Pyelonephritis
o Findings= nausea, cva tenderness, flank and back pain, fever, tachy, tachypnea, htn,
vomiting
o Labs= positive leukocyte esterase and nitrites wbc and bacteria, serum creatinine
and bun are elevated, c reactive protein is elevated, esr is elevated
o Meds= opioid analgesics, antibiotics
o Complications= septic shock, chronic kidney disease, htn
• Glomerulonephritis= can lead to end stage kidney disease, following infection, develop
over 20-30 years
o Risks= recent infection (strep), sle
o Findings= oliguria, htn, difficulty breathing, wt gain, pitting edema in lower
extremities, red brown colored urine
o Labs= urinalysis shows rbc and protein, throat culture, bun and creatinine increased,
antistreptolysin o titer increase, increased esr, increased specific gravity, increased
wbc
o Care= monitor fluids and electrolytes, na restrictions, dialysis or plasmapheresis
o Meds= antibiotics, anti-htn, diuretic (decrease excess fluid), corticosteroids (decrease
inflame)
o Edu= monitor i&o, monitor daily wt, fluid restriction, protein restriction if azotemia
(buildup of nitrogen waste), increased bun
o Complications=pulmonary edema, anemia (decrease epo), give iron and epo
Ch. 61 Renal Calculi
• Urolithiasis= presence of calculi (stones) in urinary tract
• Majority of calculi are composed of calcium phosphate or oxalate or uric acid, most expel
calculi w/o invasive procedures
• Risks= males, metabolic defect (increased intestinal absorption or decreased renal excretion
of ca), high alkalinity or acidity of urine, urinary stasis, urinary retention, dehydration
• Findings= sever pain (renal colic), flank pain that radiates to ab, urinary frequency or
dysuria, fever, diaphoresis, pallor, n/v, tachy, tachypnea, oliguria/anuria if calculi obstruct,
hematuria
• Diagnostics= x-ray of kidney ureters or bladder, ct or mri
•
•
•
•
•
Care= strain all urine to check for passage of calculus and save calculus for lab analysis,
increase oral intake to 3l/day, encourage ambulation to promote passage of calculus
Meds= opioid analgesics, nsaids for mild to moderate pain, spasmolytic meds like
oxybutynin
Therapy
o Lithotripsy= use sound, laser or shock wave energy to break calculi into fragments,
moderate (conscious) sedation and ecg monitoring during procedure, strain urine
following, bruising is normal, pt will have hematuria
Edu= limit intake of food high in animal protein and na and reduce ca intake for ca stone,
avoid oxalate and limit na intake for oxalate stone, decrease intake of purine sources and
take allopurinol to prevent formation of uric acid in uric acid stone
Complications
o Obstruction= notify dr immediately
o Hydronephrosis= urine back up and causes distension
Ch. 62 Diagnostic and therapeutic procedures for female reproductive disorders
• Pap test= use to id precancerous and cancerous cells of cervix, start at age 21 to screen for
cervical cancer, every 3 years if normal
o Pre= not menstruating, does not use vaginal meds, douch or sex w/I 24hrs, empty
bladder
o Post= minimal bleeding
• Biopsy= pap tests that are atypical or abnormal
o Post= rest for first 24 hrs after procedure, abstain from sex, avoid douche, vaginal
creams or tampons until discharge has stopped (2 weeks), avoid lifting heavy object
for 2 weeks, report excess bleeding, fever or foul smelling drainage to dr
• Endometrial biopsy= assess for uterine cancer, abnormal bleeding
o Pre= analgesic, discomfort and cramping is expected, empty bladder
o Post= spotting can be present for 1-2 days, abstain from sex, douche until all
discharge has stopped (2 weeks), have pt notify dr of heavy bleeding
• HIV= ELISA test and then western blot to confirm diagnosis
• Mammogram= start at age 40
o Pre= avoid deodorant, lotion, powder, not pregnant
• Hysterectomy= remove uterus b/c uterine cancer, fibroids, endometriosis, genital prolapse
o Post= monitor vitals, monitor breath sounds and bowel sounds, monitor urine
output, take thromboembolism precautions, monitor blood loss
o Edu= pt ovaries have been removes watch for menopausal manifestations, restrict
activity for 6 weeks, avoid tampons, notify dr of temp over 100, foul smelling
drainage from incision, pain redness, swelling in calf or burning on urination
Ch. 63 Menstrual Disorder and Menopause
• Average age of menarche= 12
• Menstrual cycle last 28 days
• Ovulation occurs around day 14
• Menstruation 4-9 days
• Menopause is when ovulation ceases and menstrual cycles stop, around 52
•
•
•
•
•
Menstrual disorders
o Amenorrhea= common cause is low % of body fat in women who are in sports or
strenuous physical activity, anorexia
o Pms= irritability, impaired memory, depression, poor concentration, mood swings,
bloating, wt gain, headache, back pain
o Endometriosis= overgrowth of endometrial tissue that extends outside uterus into
fallopian tubes, common cause of infertility
Labs= hgb and hct below range due to excess blood loss, ca125 elevated in ovarian cancer
Diagnostics= endometrial biopsy (test for uterine cancer), transvaginal ultrasound (uterine
fibroids)
Meds
o Ocp= decrease manifestations of pms, dysmenorrhea and dub
o Diuretic= treat bloating and wt gain
o Leuprolide= treat endometriosis, cause birth defects so use contraception
o Nsaids= pain and discomfort related to pms
o Oral iron supplements= treat anemia associated with dub
o Fluoxetine= treat emotional and physical manifestations of pms
Menopause= complete when no menses for 12 months
o Findings= hot flashes, atrophic vaginitis, decreased vaginal secretions, mood swings,
decreased bone density
o Meds
§ Hormone therapy= suppress hot flashes associate with menopause, prevent
atrophy of vaginal tissue, reduce risk of fractures due to osteoporosis
• Adverse effects= coronary heart disease, mi, dvt, stroke, breast cancer
• Edu= quit smoking, avoid knee high stocking and tight clothes, report
unilateral leg pain, edema, warmth and redness, avoid sitting for long
periods, stretch legs, mi (pain b/w shoulders)
Ch. 64 Disorders of Female Reproductive Tissue
• Cystocele= protrusion of posterior bladder through anterior vaginal wall
o Risks= obesity, old age, loss of estrogen
o Findings= urinary frequency/urgency, stress incontinence
• Rectocele= protrusion of anterior rectal wall through posterior vaginal wall
o Risks= pelvic structure defects, obesity, constipation
o Findings= constipation, pelvic/rectal pressure/pain
• Risks= females following menopause, constipation
• Care
o Vaginal pessary= removable rubber plastic or silicone devices inserted into vagina to
provide support and block protrusion of other organs into vagina
o Kegal exercises= strengthen pelvic floor, contract circumvaginal and perirectal
muscles, increase contraction period to 10 seconds follow each contraction period
w/ relaxation period of 10 seconds
• Fibrocystic breast condition
o Risks= premenopausal
o Findings= tender lumps, palpable rubberlike lumps in upper outer quadrant
o Diagnostics= breast ultrasound to confirm
Ch. 65 Diagnostic Procedures for Male Reproductive Disorders
• Enlargement of prostate gland is benign and called bph, prostate cancer is one common
form of cancer in men
• Psa= perform prior to dre b/c rise in psa can occur due to irritation that occurs upon
palpation during dre
• Dre= reveals abnormality, location of potentially cancerous prostate lesion is determined by
ultrasonography and confirmed by biopsy
• Psa and dre for men older than 50, black and men w/ family history of prostate cancer
should begin screening earlier, diminished flow and retention of urine
• Psa should be 2.5, greater than 4 requires further eval
• Dre= abnormal finding include abnormally large and hard prostate w/ irregular shape or
lumps
Ch. 66 Benign Prostatic Hyperplasia
• Prostate gland enlarges in adult males as they age
• Findings= urinary frequency, urgency, hesitancy, incontinence, incomplete emptying of
bladder, dribbling post void, nocturia, diminished force of urinary stream, straining w/
urination, hematuria
• Psa= rule out prostate cancer
• Dre= reveal enlarge smooth prostate
• Transrectal ultrasound w/ needle aspiration biopsy= rule out prostate cancer
• Finasteride= decrease production of testosterone in prostate gland
o Edu= impotence and decrease in libido are possible adverse effects, women who are
pregnant should avoid contact w/ tablets and semen of pt
• Tamsulosin= cause relaxation of bladder outlet and prostate gland, cause postural
hypotension
• Prostatic stent
• TURP= indwelling three way catheter, rate of cmi is adjusted to keep irrigation return pink
or lighter, if it appears ketchup that means bleeding is arterial w/ clots and nurse should
increase cbi rate, if catheter is obstructed (bladder spasms, reduced irrigation outflow) then
turn off cbi and irrigate w/ 50ml, contact surgeon if unable to dislodge clot, balloon will
cause pt to feel continuous need to urinate, admin analgesics, antispasmodic, antibiotics,
stool softeners
o Edu= drink 12 8oz glasses of water, avoid bladder stimulants such as caffeine and
alcohol, urine becomes bloody stop activity, rest and increase fluid intake, contact
surgeon for persistent bleeding or obstruction
Ch. 67 Musculoskeletal Diagnostic Procedures
• Arthroscopy= allows visualization of internal structures of joint, don’t do if infection or lack
of joint mobility
o Apply ice for first 24hr after procedure, elevate extremity for 12-24hrs, notify
provider of changes such as swelling, increased joint pain, thrombophlebitis,
infection (redness, swelling, purulent drainage)
• Nuclear Scans
o Bone scan= radioactive isotope injection 2-3hr b/f scan, bone scans can detect
hairline bone fractures, tumors, and diseases of bone
o Gallium and thallium scan= pt receive radionuclide injection 4-6hr b/f scan, scan
takes 30-60min and require sedation to help pt lie still during that time, repeat scan
24,48, 72hrs
o Pre= assess for allergy to radioisotope, explain need to lie still during entire
procedure
o Post= encourage pt to drink fluids to increase excretion of radioisotope
• DXA= presence/extent of osteoporosis, baseline at age 40, remove metallic objects
• Emg= determine presence of muscle weakness, place thin needles in muscle under study,
record activity during muscle contraction, neuromuscular disorders, flex muscle during
needle insertion
Ch. 68 Arthroplasty
• Arthroplasty= surgical removal of diseased joint and replacing it w/ prosthetic, knees and
hips, eliminate pain, restore joint motion, improve pt functional status and qol, joint
crepitus, joint swelling
o c/i= recent or active infection, arterial impairment of affected extremity
o Pre= EPO prescribed several weeks preop to increase hgb for pt who has mild
anemia, teach pt about autologous blood donation, remind pt to scrub surgical site
w/ prescribed antiseptic soap night b/f and morning of surgery to decrease bacterial
count on skin and lower change of infection, tell pt to take antihtn and other meds
w/ sip of water morning of surgery
• Knee arthroplasty= cpm machine prescribed to promote motion in knee, turn it off during
meals, position of flexion of knee are limited to avoid flexion contractures, avoid knee
gatch and pillows placed behind knee, place on pillow under lower calf and foot, apply ice
or cold therapy, monitor neuro status every 2-4hrs
o Meds= analgesics, peripheral nerve blockade, antibiotics, anticoag
• Hip arthroplasty= hgb and hct continue to drop for 48hr after surgery, blood transfusions
are common for hgb levels less than 9, early ambulation, place pillow or abduction device
b/w legs when turning to unaffected side, monitor for new joint dislocation (acute onset of
pain, pop, shortened affected extremity)
o Meds= analgesics, antibiotics, anticoagulant
• Edu= elevated seating and raised toilet seat, abduction pillow, externally rotate toes, use
extended handles on shoehorns and dressing sticks to prevent flexion greater than 90
degrees, avoid flexion of hip greater than 90 degrees, do not cross legs, do not internally
rotate toes
• Complications= manifestations of pe/dvt (scd while in bed)
Ch. 69 Amputations
• Elective due to complications of pvd, traumatic injury, malignancy
• Findings= altered peripheral pulses (use doppler), differences in temp of extremities
(becomes cool), altered color of extremities (gangrene, cyanosis), lack of sensation in
affected extremity
• Traumatic amputation= apply direct pressure, elevate extremity above heart to decrease
blood loss, wrap severed extremity in dry sterile gauze and place in sealed plastic bag,
submerge in ice water
•
Phantom limb pain= admin bb, admin antiepileptics, recognize pain is real, teach pt how to
push residual limb down and support on soft pillow
• Prosthetic= shaped and shrunk residual limb, wrap stump in figure 8, use stump shrinker
sock, use air splint, perform limb strengthening exercise
• Complications= contracture (ROM exercises and proper positioning immediately after
surgery, have pt lie prone for 20-30min several times a day, discourage prolonged sitting)
Ch. 70 Osteoporosis
• Low bone density b/c rate of bone resorption (osteoclasts) excess bone formation
(osteoblasts), osteopenia is precursor
• Prevention= diet adequate in vitamin d (fish, egg yolks, fortified milk and cereal), calcium
(milk, green veggies, fortified orange juice and cereals, red and white beans), limit
carbonated drinks, sun 5-30 min twice a week, wt bearing exercise
• Risks= female, family hist, thin, lean, older than 60, postmenopausal, low ca and vitamin d,
smoking, high alcohol, excess caffeine consumption, lack of physical activity,
hyperparathyroidism, long use of corticosteroids and anticonvulsants
• Findings= reduced ht, acute back pain, hist of fractures, kyphosis
• Diagnostics= DXA scan
• Care= ca food, ca and vitamin d supplementation take with food, sun exposure, wt bearing
exercise, remove throw rugs, adequate lighting, clear walkways
• Meds
o Calcitonin salmon
o Estrogen= increase risk of breast and endometrial cancer and dvt
o Raloxifene
o Alendronate= risk for esophagitis, take w/ 8oz water in morning b/f eating, remain
upright for 30 min after taking
• Therapeutic procedures= orthotic devices; immobilize spine, log roll out of bed, joint
repair/ arthroplasty
Ch. 71 Musculoskeletal Trauma
• Closed simple fracture= does not break through skin
• Open compound fracture= disrupts skin integrity, causing open wound and tissue injury w/
risk of infection
• Complete fracture= goes through entire bone
• Incomplete fracture= goes through part of bone
• Comminuted fracture= has multiple fracture lines splitting the bone into multiple pieces
• Displaced fracture= bone fragments that are not in alignment
• Oblique fracture= fracture occurs at oblique angle and across bone
• Spiral fracture= fracture occurs from twisting motion (common w/ physical abuse)
• Risks= post-menopause, osteoporosis, falls, crashes, diseases
• Findings= crepitus, deformity, muscle spasm, edema, ecchymosis
• Care= stabilize, elevate limb above heart and apply ice, initiate and continue neuro checks
at least every hour
o Neuro= every hr for first 24hrs, and every 1-4hrs, pain, sensation, skin temp, cap
refill, pulses, movement
o Handle plaster cast w/ palms not fingertips until cast is dry, elevate cast above level
of heart during first 24-48hrs, instruct pt to not place foreign objects inside cast, use
hair dryer blowing cool air to relieve itching, report areas under cast that are painful
‘hotspot’ will have increased drainage, warm to touch have odor and indicate
infection
o Traction=promote and maintain alignment of injured area, realign bone fragment
§ Bryant= used for congenital hip dislocation in kids
§ Bucks= preop for hip fractures
§ Assess neuro every hr for 24hrs, avoid lifting or removing wts, ensure wts
hang freely and aren’t resting on floor, notify provider if pt experiences severe
pain from muscle spasm unrelieved w/ meds or repositioning, move pt in halo
traction as unity, use heat/massage as prescribed to treat muscle spasms
§ Pin site= drainage and redness, loosening of pins, tenting of skin at pin site,
pin care is provided once a shift (1-2 times a day)
§ Meds=analgesics, muscle relaxants, antibiotics
o External fixations= pins and wires are attached to rigid external frame
o Open reduction and internal fixation= visualize fracture through incision in skin and
internal fixation w/ plates, screws, pins, rods and prosthetics
• Complications
o Compartment syndrome= when pressure w/I one or more muscle compartments
compromises circulation resulting in ischemia
§ Pain, paresthesia (early manifestation), paralysis (late manifestation), pallor
and cyanotic, pulselessness (late manifestation), palpated muscles are hard
and swollen from edema, surgical incision is made through SQ tissue and
fascia of affected compartment to relieve pressure
o Fat embolism= 12-48hrs following long bone fracture or w/ total joint arthroplasty,
fat globules from bone marrow released into vasculature and travel to small blood
vessels in lungs, impaired organ perfusion
§ Dyspnea, increased RR, respiratory distress, tachy, confusion, petechiae (late
manifestation)
o DVT/PE= apply antiembolism stockings, scd, admin anticoags
o Osteomyelitis= bone pain, erythema, edema, fever, leukocytosis, treat w/ 3 months
of iv and oral antibiotics, surgical debridement, hyperbaric o2 treatment can
promote healing in chronic cases
Ch. 72 Osteoarthritis and low back pain
• Osteoarthritis= progressive deterioration of articular cartilage, bone spur growth at joint
ends, degenerative, pain with activity that improves at rest, localized, overwt, Heberden’s
and bouchards nodes, NOT systemic or symmetric; stop smoking
o Risk= adults > 60, women, repetitive stress on joints, obesity
o Findings= joint pain and stiffness, crepitus, enlarged joint, Heberden’s nodes distal
interphalangeal joints, bouchards nodes at proximal interphalangeal joints
o Edu= balance rest with activity, heat to alleviate pain and ice for acute inflame,
splinting, assistive devices, PT
o Meds= apap 4000mg a day, topical nsaids, capsaicin (use gloves, avoid touching
eyes or applying over broken skin, burning sensation of skin after application is
•
normal), glucosamine (makeup cartilage), injections (glucocorticoids treat local
inflam, hyaluronic acid)
o Total joint arthroplasty = all else fails, replace total joint
o Monitor kidney function, report black tarry stool
RA= synovial membrane inflame resulting in cartilage destruction and bone erosion,
inflame, pain at rest after immobility (morning stiffness, all joints, underwt, swan neck and
boutonniere deformities of hands, systemic affect lungs, heart skin and extra articular,
symmetrical, positive RA factor
Ch. 73 Integumentary Diagnostic Procedures
• Bacterial infection= bathe daily using antibacterial soap, remove crusted exudate so
antibacterial topical medication can penetrate into lesion
o Meds= superficial skin infection are treated w/ topical antibacterial cream or
ointment, if cellulitis present, treat w/ systemic antibiotic therapy
o Culture and sensitivity should be done b/f antimicrobial therapy, 24-48hr results
§ Culture= id pathogen
§ Sensitivity= id effect antimicrobial agent have on micro-organism, if
microorganism is killed it is sensitive, if not killed it is resistant
• Viral lesion= apply compress of burros solution for 20min, 3x a day to promote formation
of crust and healing
o Meds= topical treatment w/ acyclovir
o Tzanck smear= determine if lesion is viral
• Fungal meds= clotrimazole cream is applied to infected skin 2x a day and for 1-2 weeks
after lesions are no longer present
o Koh test= determine if lesion is fungal
• Biopsy= confirm or rule out malignancy, punch, shave or excisional biopsy
o Mild discomfort, report excess bleeding or signs of infection
Ch. 74 Skin Disorders
• Psoriasis= skin disorder characterized by scaly, dermal patches and caused by
overproduction of keratin, autoimmune disorder w/ periods of exacerbations and remission,
commonly present on elbows, knees, trunk, scalp, sacrum and lateral aspects of extremities
o Findings= scaly patches, bleeding stimulated by removal of scales, lesions on scalp,
elbows, knees, sacrum, lateral areas of extremities
o Meds
§ Corticosteroids= triamcinolone, use occlusive dressing w/ plastic wrap after
applying topical med, leave in place up to 8hrs each day
§ Tar prep= can cause staining of skin and hair
§ Vitamin d= increased risk of skin cancer
§ Methotrexate= monitor liver function test and can cause bone marrow
suppression
§ Cyclosporine= immunosuppressant, increase risk of infection and
nephrotoxicity
o Edu= don’t get live vaccines, report signs of infection
o Therapy= PUVA (give psoralen followed by UV to decrease proliferation of
epidermal cells) can cause skin cancer
• Dermatitis= topical steroid therapy
Ch. 75 Burns
• Severity of burns= determined by percentage of total body surface area
• Rule of nines
o Arm= 9%
o Head= 9%
o Front torso=18%
o Leg= 18%
o Perineum=1%
• Lund and browder= more exact measuring method
• Palmar method= quick method, palm of hand is equal to 1% tbsa
• Phases
o Emergent= 24-48hrs, priorities include securing airway, fluid replacement, managing
pain, wound care
o Acute= ends with closure of wound
o Rehabilitative= prevent scars
• Superficial= no blisters
• Superficial partial thickness= damage to entire epidermis and some part of dermis, pink to
red, blisters, no eschar
• Deep partial thickness= damage to entire epidermis and deep into dermis, red to white, no
blisters, eschar soft and dry
• Full thickness= damage to entire epidermis and dermis, extend into subQ, red black yellow
or white, no blisters, severe edema
• Deep full thickness= damage to all layers of skin, extend to muscle, tendons, bone, black
no edema
• Inhalation damage= singed nasal hair, eyebrows and eyelashes, sooty sputum, hoarseness,
wheezing, edema of nasal septum, smoky smell
• Labs
o Resuscitation
§ Elevated hct and hgb b/c loss of fluid volume and fluid shift into interstitial
space (third spacing)
§ Decreased na due to third spacing
§ Potassium increased due to cell destruction
o Fluid remobilizations= begins 48-72hrs
§ Hgb and hct decreased
§ Decreased na
§ Decreased k
• Care= stop burning, flush chemical burns with water, provide warmth, educate family to
avoid greasy lotion, tetanus, provide humidified o2, initiate IV access with large bore
needle, admin half of total IV fluid volume w/I first 8hr and remaining volume over next
16hrs, bp is average or low, avoid routes other than IV, restrict plants and flowers, restrict
consumption of fresh fruits and veggies, limit visitors, hypercatabolic state require 5000
calories/day, double or triple 4-12 days, require enteral therapy or tpn, active and passive
rom, apply pressure dressings to prevent contractures and scarring
• Meds
•
o Silver nitrate= apply with gauze dressing
o Silver sulfadiazine= transient neutropenia
o Skin coverings
§ Allograft= human cadaver, partial and full thickness
§ Xenograft= animal
§ Cultured= grow from small specimen from unburned area
§ Artificial= shark cartilage or beef collagen
Amt of fluid replacement= (4ml)(wt in kg)(% body burned)
Ch. 76 Endocrine Diagnostic Procedures
• Posterior pituitary= secretes ADH, causes kidney to reabsorb water
o Deficiency of ADH= DI, excrete large amts of dilute urine
o Excess ADH= SIADH, kidney retain water, urine becomes concentrated, urinary
output decreases
• Water deprivation test= measures kidneys ability to concentrate urine, controlled
dehydration, help ID DI
• SIADH= increased urine osmolality, increase in urine specific gravity >1.025
• Adrenal cortex
o Excess production of cortisol= cushing disease
o Lack of cortisol= Addison
• Dexamethasone suppression test
o Screen for cushing disease, no decrease is production of acth and cortisol
o Increase in cortisol after admin of acth is expected but if cortisol does not increase
after admin it is + for Addison disease
• Adrenal medulla= hypersecretion of catecholamines from tumor cause pheochromocytoma
(tachy, htn, diaphoresis)
• Diabetes
o Fasting blood glucose= fast 8hr prior to blood sampling
§ >110= DM
o Oral glucose tolerance test= fast for 10-12hr prior to test, consume specific amt of
glucose then obtain blood samples at 30 min, 1 hr, 2hr, 3hr and 4hr
§ >140=DM
o HbA1C= average blood glucose level for past 120 days
§ >6.5%= DM
• Thyroid and anterior pituitary gland
o Hyperthyroid= high T3 and T4, low TSH
o Hypothyroid= low T3 and T4, high TSH
Ch. 77 Pituitary Disorders
• DI= results from deficiency of ADH
o Primary= lack of adh b/c defect in hypothalamus or pituitary gland
o Secondary= lack of adh b/c infection, tumor, head trauma or brain surgery
o Nephrogenic= inherited, renal tubules do not react to adh
o Findings= polyuria (abrupt onset of excess urination), polydipsia (excess thirst),
fatigue, dehydration, sunken eyes, tachy, hypotension, absence of skin turgor, dry
mucous membranes
•
o Labs= decrease urine specific gravity <1.01, decrease urine osmolality <200,
increased serum osmolality >300, increased serum na, increased serum k
o Diagnostics= water deprivation test, vasopressin test (differentiates central from
nephrogenic di, admin vasopressin SQ and obtain urine sample for osmolality)
o Meds= adh replacement (desmopressin and vasopressin)
o Care= monitor wt daily, eat high fiber diet, monitor for dehydration
SIADH= excess release of ADH
o Risks= tumors, head injury
o Findings= serum na decrease, confusion, seizures, coma, death, fluid volume excess,
tachy, htn, crackles in lungs, distended neck veins
o Labs= increased urine na, increased urine osmolarity, decreased serum na,
decreased serum osmolarity
o Care= restrict oral fluids to 500-1000mL, monitor I&O, daily wt
o Meds= loop diuretic
o Therapy= hypertonic sodium chloride iv fluid
o Complications= water intoxication, cerebral edema, severe hyponatremia (seizure
precautions)
Ch. 78 Hyperthyroidism (video 84)
• Anterior pituitary produces tsh and thyroid produces t3 and t4, caused by graves
• Symptoms= Low tsh, hypermetabolic, nervous, irritable, hot, wt loss, insomnia, diarrhea,
warm flushed skin, exophthalmos, sweaty, htn, tachy, dysrhythmia, high t3 and t4
• Care= Increased calories, monitor wt, tape eyelids closed, avoid palpating thyroid, ptu med,
leukopenia, thrombocytopenia, propranolol for tachy, iodine solutions, radioactive iodine,
not pregnant, laxative, don’t share utensils, thyroid replacement, high fowlers, laryngeal
nerve damage, monitor for hypocalcemia (can damage hyperparathyroid gland, muscle
twitching, positive Chvostek’s and trousseaus sign, prednisone used to reduce post op
edema
• Thyroid storm= sudden surge of hormones, stress infection of surgery
o Symptoms= htn, delirium, tachy, vomiting, chest pain
o Give apap, cool sponge bath, ptu, propranolol
Ch. 79 Hypothyroidism (video 85)
• Not enough t3 or t4, caused by hashimotos, creteinism (infants), common in women
o Primary= thyroid gland is problem
o Secondary= anterior pituitary isn’t producing enough tsh
o Tertiary= hypothalamus isn’t producing enough trh
• Symptoms= cold, fatigue, constipation, wt gain, pale skin, thinning hair, brittle fingernails,
depression, brady, hypotension
• Labs= low t3 (70-200) and t4 (4-12), increased tsh, anemia
• Care= frequent rest, dietician, low cal high bulk diet, activity, no fiber laxatives,
levothyroxine (start low, take 1-2 hrs b/f breakfast), skin care, extra clothing, no electric
blankets
• Complication=myxedema coma (untreated, stress, low respiration, decreased co, cerebral
hypoxia, hypothermia, brady, hypotension)
Ch. 80 Cushing Disease/syndrome (video 86)
• Cushing= too much cortisol
• Hypothalamus produce crhàanterior pituitary produce acthàadrenal cortex produce
cortisol
• Long term glucocorticoid use can cause
• Symptoms= fatigue, joint pain, depression, increased infection, thin skin, htn, dependent
edema, tachy, gastric ulcers, truncal obesity, moon face, buffalo hump, wt gain, fractures
and bone pain, hyperglycemia, unusual hair growth, acne
• Lab levels= increased cortisol, decreased Ca and K, increase glucose and Na levels,
dexamethasone depression test
• Care= decrease Na in diet and increase K and protein and ca, fall risk, prevent infections,
skin care, spironolactone (k sparing diuretic), chemo, hypophysectomy (surgical removal of
pituitaryà assess drainage for glucose or halo sign (yellow on edge and clear in middle),
avoid coughing and blowing nose and sneezing, straining and bending over at waste, avoid
brushing teeth), adrenalectomy (hormone replacement for rest of life, monitor for adrenal
crisis)
Ch. 81 Addison’s Disease (video 87)
• Not enough cortisol, autoimmune
• Symptoms= slow developing, hyperpigmentation, wt loss, craving salt, fatigue, n/v
• Labs= hypona, hyperk, hyperca, hypoglycemia, acth stimulation test (plasma cortisol levels
won’t rise in primary)
• Care= monitor fluid and electrolyte, hydrocortisone/prednisone (s/e=hyperglycemia, bone
loss, pud, increase risk of infection), insulin, ca, sodium bicarb, loop diuretic
• Addisonian crisis= discontinued med or caused by infection
Ch. 82 Diabetes (video 88-90)
• Chronic hyperglycemia because inadequate insulin or insulin resistance
• Increased risk of cardiovascular disease, htn, kidney disease, neuropathy, retinopathy,
peripheral vascular disease, stroke
• Black, Indian, Hispanic at greater risk for developing diabetes
• Type 1= destruction of b cells because autoimmune disorder
• Type 2= obesity
• Gestational= pregnant
• Risk factors= htn, obesity, inactivity, hyperlipidemia, smoking, elevated crp, genetics
• Symptoms= blood glucose >250, polyuria, polydipsia (dehydration), weak pulse,
polyphagia, metabolic acidosis, kussmaul respirations, fruity breath, headache, n/v,
seizures, coma, ab pain, can’t concentrate
• Diagnosis= casual blood glucose >200, fasting blood glucose >126, oral glucose tolerance
test at 2 hrs >200; must have 2 findings on 2 separate days, a1c <7 is well regulated
• Care= insulin, monitor for hypoglycemia (shaky, confusion, sweating, headache, lack of
coordination, blurred vision, seizure)à<70 give 15-20g of carb if conscious, give glucagon
if unconscious
o Rapid acting (lispro/Humalog)= onset w/I 15 min, peak 30-1 hr, duration 3-4hr
o Short acting (regular/humalin, novalin)= onset 30-1 hr, peak 2-3 hr, duration 5-7 hr
•
•
•
•
o Intermediate (nph)= 1-2, 4-12, 18-24; used b/w meals and at bedtime, can be mixed
o Long (glargine)= do NOT mix, 1hr, NO peak, 24hr
o Rotate injection sites, at 90 angle
o Clear before cloudy
Metformin (biguanide, reduce production of glucose, increase tissue sensitivity to insulin,
slow carb in intestines, take with food), glipizide (decrease blood sugar levels, increase
sensitivity to insulin, 30 min b/f meals, avoid alcohol), pioglitazone ( reduce production of
glucose, increase tissue sensitivity to insulin), repaglinide (stimulate insulin release from
pancreas 15-30 min b/f meal), acarbose (slow carb absorption, take with first bite of meal)
Foot care= inspect daily, wash with warm water and mild soap, dry thoroughly, apply
lotion NOT between toes, foot powder, podiatrist, trim nails straight across after shower,
wear shoes, cotton or wool socks
Care= never skip meals, 15g carb is 1g exchange, lose wt, >240 call provider or have fever
over 101.5
Complications= cvd (monitor bp and cholesterol), retinopathy (yearly eye exam),
neuropathy, nephropathy (monitor I and O), avoid alcohol apap and nsaids, 2-3L fluid per
day
Ch. 83 Complications of diabetes (video 91)
• DKA= type 1, high sugar levels >300, rapid onset, metabolic acidosis, ketones
o Risk= undertreated, missed dose of insulin, infection
o Symptoms= gi upset, n/v, ab pain, fruity breath, kussmaul respirations
o Care= treat underlying cause, fluid replacement isotonic, insulin, monitor K, sodium
bicarb, monitor blood glucose below 200
o Teach to monitor glucose frequently and never skip insulin dose when ill, hydrate,
3L of water, >240 glucose or fever contact provider
• HHS= type 2, >600, gradual onset, dehydration
o Risk= old adults, decreased kidney function, infection, stress
Ch. 84 Immune and Infectious Disorders Diagnostic Procedures
• WBC= 5000-10000
o Leukopenia= <5000, autoimmune disease, overwhelming infection
o Leukocytosis= >10000, infection
o Neutropenia= neutrophil <2000, chemo
o Left shift= increase in immature neutrophils
• Types of WBC
o Neutrophils= increased w/ acute bacterial infection, 55-70%
o Lymphocytes= T & B cells increased w/ chronic bacterial or viral infection (mono,
mumps and measles) 20-40%
o Monocytes= increased w/ protozoal infections and viral infections, 2-8%
o Eosinophils= increased w/ allergic reactions, parasitic infections, 1-4%
o Basophils= increased w/ leukemia, 0.5-1%
• Skin testing= intradermal injections or scratching superficial layer
o Avoid taking antihistamines from 48hr – 2 weeks, assess reactions after 15-20 min
Ch. 85 Immunizations
•
•
Vaccines are made from killed viruses or live, attenuated (weakened) viruses
Immunity
o Active natural= body produces antibodies in response to exposure to live pathogen
that enters body naturally
o Active artificial= develops when vaccine is given and body produces antibodies in
response
o Passive natural= occurs when antibodies pass from mother to fetus through placenta
and breast milk
o Passive artificial immunity= occurs after antibodies in immune globulin are given,
immediate protection
• Admin= give antipyretic for fever, apply cool compress for local tenderness and mobilize
extremity, document admin of vaccine, date, route, site, type, manufacturer, lot number,
expiration date, pt name address and signature, include nurse name title and address of
facility, give IM in deltoid and SQ in upper arm or thigh
o Tdap= give booster every 10 years
o Mmr
o Varicella= 2 doses
o Pneumococcal vaccine= immunocompromised, chronic diseases, smokers, long
term care facilities
o Hep a and b= high risk individuals, health care
o Flu= annually for all adults
o Meningococcal= admin dose to students up to age 21 entering college and living in
dorms
o HPV= first dose, then 2 months later second dose, then 6 months after first dose get
third dose
o Zoster vaccine= one time dose for all adults older than 60 years
• c/i= anaphylactic reaction to vaccine, common cold and minor illness are NOT c/I,
immunocompromised
o MMR= anaphylactic reaction to eggs, gelatin or neomycin
o Varicella= anaphylactic reaction to gelatin or neomycin, pregnant
o Flu= egg allergy, BUT CDC says to still get it
o HPV= latex allergy
• Adverse effects=tenderness at injection site, low fever
Ch. 86 HIV/AIDS
• HIV= retrovirus that’s transmitted through blood and body fluids, target cd4+ lymphocytes
(t cells)
o Stage 1= cd4 t lymphocyte count >500
o Stage 3= AIDS
§ Findings= candidiasis, herpes, Kaposi sarcoma, TB, wasting syndrome, cd4
count <200
• Risk factors= unprotected sex, multiple sex partners, occupational exposure, perinatal
exposure, iv drug use
• Findings= chills, rash, nausea, wt loss, headache, sore throat, night sweats
• Diagnostics= elisa, w. blot
• Meds= art
•
•
Edu= hand hygiene, avoid raw food, avoid pet litter, safe sex, frequent follow up to monitor
cd4 and viral load, ID support system
Complications= TB, Kaposi sarcoma, cytomegalovirus, herpes, pneumocystis jiravecli
pneumonia
Ch. 87 Lupus Erythematosus, Gout, fibromyalgia
• SLE= autoimmune, chronic inflamm and destruction of healthy tissue, connective tissue of
multiple organs
• DLE= only affects skin
• Risk factors= women 20-40, black, Asian, native American
• Findings= fatigue/malaise, alopecia, pleuritic pain, joint pain, swelling, tenderness, fever,
lymphadenopathy, Raynaud’s, erythematous rash over nose
• Diagnostics= ana, c3 and c4 decrease due to depletion secondary to an exaggerated inflam
response, increased bun and creatinine
• Meds= nsaids, corticosteroids, methotrexate, antimalarial
• Edu= avoid sun, use steroid cream
• Complications= kidney transplant, pericarditis, myocarditis
Ch. 88 Rheumatoid Arthritis
• Affects joints bilaterally and symmetrical, wbc attack synovial tissue, becomes inflamed and
thick
• Risk= female, 20-50
• Findings= morning stiffness, fatigue, joint swelling, joint deformity is late sign, finger, hands,
wrists, knees, foot joints are generally affected, subcutaneous nodules, fever, reddened
sclera, lymph node enlargement
• Diagnostics= ra factor antibody 1:40-1:60, elevated esr, positive c reactive protein, + ana
titer, elevated wbc, arthrocentesis (synovial fluid aspiration by needle, increased wbc and rf
present in fluid), x ray determine degree of joint destruction
• Care= hot shower for morning stiffness, cold for edema, safe environment, pt and ot
• Meds= nsaids, antimalarial, methotrexate, plasmapheresis (removes circulating antibodies
from plasma which decrease attack on client tissue)
• Complications= sjogrens syndrome (triad of symptoms like dry eye mouth and vagina)
Ch. 89 General Principles of Cancer
• Risks= increased age, race, genes, exposure to chemicals, tobacco, alcohol, diet high in fat
and red meat, sun uv light or radiation
• Findings= TNM (tumor, node, metastasis)
• Complications= malnutrition (increased risk for wt loss and anorexia, presence of
carcinoma in body increased amt of energy required for metabolic function, cancer can
impair body ability to ingest, digest and absorb nutrients, adverse effects of treatment can
affect desire for food or ability to eat N/V, changes in taste anorexia)
Ch. 90 Cancer screening and Diagnostic Prcedures
• Caution
o Change in bowel or bladder habits
o A sore that doesn’t heal
o Unusual bleeding or discharge
o Thickening or lump in breast or elsewhere
o Indigestion or difficulty swallowing
o Obvious change in warts or moles
o Nagging cough or hoarseness
• Biopsy= definitive diagnosis
• Imaging studies used as secondary tools (Ct, mri, pet, ultrasound)
Ch. 91 Cancer treatment options
• Tumor excision
• Chemo= damage cells dna and destroy rapidly dividing cells, unintentional harm done to
normal rapidly proliferating cells, such as those found in mucous membranes of gi tract,
hair follicles and bone marrow
o Complications
§ Immunosuppression/neutropenia= monitor temp, wbc, fever greater than 37.8
(100) should be reported immediately, anc < 1000 should implement
neutropenic private room, restrict ill visitors, avoid invasive procedures, keep
dedicated equipment in pt room, admin filgrastim (CSF) to stimulate wbc
production
• Edu=avoid crowds, take temp daily, avoid fresh fruits and vegetables
and undercooked meat and fish and eggs pepper and paprika, avoid
yard work gardening or changing pets litter box, avoid fluids that have
been sitting at room temp for longer than 1hr, wash all dishes in hot
soapy water or dishwasher, wash glasses and cups after each use,
wash toothbrush daily in dishwasher or rinse in bleach, do NOT share
toiletry or personal hygiene items w/ others
§ N/V=admin antiemetics b/f chemo and for several days after each treatment,
remove vomiting cues, admin megestrol to increase appetite, perform mouth
care prior to serving meals to enhance appetite
• Edu= avoid drinking liquids during meals, pt select foods that are cold,
encourage consumption of high protein, high cal nutrient dense foods
and meal supplement
§ Alopecia= effect on self image, discuss options, occur 7-10 days after
treatment
§ Oral effects
• Mucositis= inflame in mucous lining of mouth to stomach
• Avoid glycerin based mouth wash or mouth swab, use nonalcoholic
anesthetic mouth washes, discourage consumption of salty, acidic or
spicy foods, offer oral hygiene b/f and after each meal, use lubricating
or moisturizing agents
• Edu= soft bristle toothbrush, soft, bland foods that are high cal
§ Anemia= monitor for fatigue, pallor, dizzy and sob, schedule rest periods
b/w, admin epo and ferrous sulfate
§ Thrombocytopenia= monitor for occult and blood in stools, avoid iv and
injections, apply pressure for 10 min after blood is taken, use electric razor
and soft toothbrush, avoid blowing nose, avoid nsaids, prevent injury
•
•
•
Radiation= tattoos that guide positioning of external radiation source, gently wash skin over
irradiated area w/ mild soap and water, dry area thoroughly using patting motions, do NOT
remove or wash off radiation tattoos, do NOT apply powders, ointments, lotions,
deodorants, or perfumes to irradiated skin, wear soft clothing, avoid tight or constricting
clothes, do NOT expose irradiated skin to sun
Hormone therapy= use androgen for estrogen dependent and estrogen for testosterone
dependent
o Tamoxifen
Immunotherapy= biological response modifier
o Interleukins and interferons
Ch. 92 Cancer Disorders
• Skin cancer= sunlight exposure is leading cause
o Squamous cell= epidermis, rough scaly lesion
o Basal cell= small waxy nodule, most common
o Melanoma= new moles, most deadly
o Findings= asymmetry (one side does not match other), borders ( ragged, notched,
irregular, blurred edges), color (lack of uniformity in pigmentation), diameter (width
greater than 6mm), evolving change in appearance (shape, size, color, ht, texture)
o Treatment
§ Chemo= topical 5 fluorouracil cream
§ Cryosurgery= freeze and destroy isolated lesions by applying liquid nitrogen
§ Excision
• Leukemias= cancers of wbc, overgrowth of leukemic cells prevents growth of blood
components (platelets, rbc, mature leukocytes), infection is leading cause of death, lack of
platelets increase pt risk of bleeding
• Lymphomas= cancer of lymph nodes
o Prevent infection, hand hygiene, restrict raw foods, prevent injury
o Therapy= chemo, radiation, bone marrow transplant (destroy bone marrow, replace
w/ healthy stem cells)
• Thyroid cancer = risk include female, diet low in iodine, radiation exposure
o Finding= change in size shape of thyroid, palpable nodules or irregularities
o Monitor airway patency, assess swallowing
o Therapy= rai, thyroidectomy
• Lung cancer= prognosis is poor, cigarette smoking
o Findings= chronic cough, dyspnea
• Colorectal cancer= begins as polyp and is benign in early stages
o Findings= blood in stool
o Recommend annual fobt for pt age 50-75, colonoscopy in age 50 and every 10 years
• Breast cancer= high genetic risk, early menarche, late menopause, prolonged use of ocp,
cigarette smoking, hrt, obesity
o Findings= skin changes (peau d orange), dimpling, breast tumors (small, irregular,
firm, nontender, nonmobile), nipple discharge, nipple retraction or ulceration
o Therapy
§ Hormone therapy= leuprolide, tamoxifen
§ Chemo/radiation
Surgery= have pt wear sling while ambulating to support arm, avoid admin
injections, taking bp or obtaining blood from pts affected arm and place sign
above bed, encourage early arm and hand exercises to regain full rom, do not
wear constrictive clothing
• Cervical cancer= infection w/ hpv 90% cases, pap screen by 21 years of age or 3 years
following first sex
• Prostate cancer= risks high fat and black
o Findings= urinary hesitancy, recurrent bladder infection, urinary retention, blood in
urine and semen (late), significant residual urine after voiding a small amt of urine
o PSA= greater than 4 indicates possible prostate disease, instruct pt to get prostate
screening after 50, insure psa is assess prior to DRE
o Meds= leuprolide
Ch. 93 Pain management for pt who have cancer
• Palliative cancer pain management provides comfort and reduce pains rather than curing
cancer, goal of palliative pain management is to reduce pain to improve qol
• Meds= nonopioid, opioids, antidepressant (reduce depression, decrease neuropathic pain),
anticonvulsants, corticosteroids (reduce swelling), skeletal muscle relaxants (muscle
spasms), systemic local anesthetics (infusion pump), topical local anesthetic (lidocaine
patch), epidural or intrathecal, regional nerve blocks
• Alternatives= tens (low voltage electrical impulses), heat or cold, pressure, massage or
vibration, acupuncture
Ch. 94 Anesthesia and Moderate Sedation
• General anesthesia= inhalation (NO), IV anesthetic (benzos, Propofol)
o Phases
§ Induction= initiation of IV access, preop meds given, secure airway
§ Maintenance= performance of surgery, airway maintenance
§ Emergence= completion of surgery, removal of assistive airway device
o Meds= opioids, benzos, antiemetics (decrease postanesthetic n/v), anticholinergics,
sedatives, neuromuscular blocking agents
o Complications
§ Malignant hyperthermia= tachy first, dysrhythmias, muscle rigidity,
hypotension, tachypnea, skin mottling, cyanosis, myoglobinuria (protein in
urine)
• Stop surgery, admin IV dantrolene (muscle relaxant), admin 100% O2,
obtain ABGs, infuse iced IV NaCl, apply cooling blanket
• Moderate sedation= admin sedatives/opioids to point where pt relaxes enough that surgeon
can perform minor procedure w/o discomfort for pt, yet pt retains protective reflexes (gag
reflex), is easily arousable and maintains patent airway
• Pre=NPO 6hr prior to procedure, clear liquids up to 2hr b/f surgery, verify pt signed
informed consent, remove dentures
• Intra=assess loc, cardiac rhythm, respiratory status and vitals
• Post= monitor and document vitals and loc until pt is fully awake, assessment criteria return
to pre-sedation levels
o Discharge= vitals stable for 30-90 min, ability to tolerate orals fluids, ability to
urinate, no N/V SOB or dizzy
§
Ch. 95 Preop Nursing Care
• Verify that informed consent is completed, signed, and witnessed, scheduled meds (antihtn,
anticoags, antidepressants) can be held until after surgery, ensure pt remains NPO for 6hrs
for solids and 2hrs for clear liquids b/f surgery, prophylactic antibiotics admin w/I 1hr of
surgical incision
• Informed consent= responsibility of PROVIDER to obtain consent after discussing risks and
benefits of procedure, the nurse is NOT to obtain consent for provider UNDER ANY
CIRCUMSTANCE, nurse can clarify info that remains unclear but NOT provide any new
info, NURSE ROLE is to witness pt signing of consent form after pt acknowledges
understanding of procedure and to notify provider if pt has more questions or appears to not
understand info
o Must be 18 or emancipated, mentally capable of understanding risk, NOT under
influence of meds that affect decision making or judgment
Ch. 96 PostOp Nursing Care
• Airway=assess blood o2 saturation, assess respiratory pattern, rate, and depth, assess
symmetry of breath sounds, auscultate lung sounds, suction accumulated secretions
• Circulation= observe for internal bleeding, assess for hypervolemia and hypovolemia,
assess skin color, temp, sensation, assess and compare peripheral pulses, monitor ekg,
monitor fluid and electrolyte balance
• Vitals= obtain vitals until stable
• I&O= review I& O, urine output less than 30 can indicate hypovolemia
• Surgical wound= check dressings and admin pain meds
• Discharge= stable vitals, no evidence of bleeding, return of reflexes, minimal or absent n/v,
wound drainage that is minimal to moderate, urine output at least 30mL/ hr