Med Surg II Final Exam Study Guide
General Pointers:
Know diagnostic testing - what it is for, contraindications, complications.
Know risk factors, expected s/sx, expected treatments, Oh Me, Oh My’s – how to recognize, prevent, treat them.
Know nursing care, interventions, any special considerations (Safety Alerts), and medications commonly used for specific
disorders.
● Fluid and Electrolytes
○ Types of fluids, what used for, how they move, complications
○ Electrolyte imbalances Na, K, Ca, Mg- s/sx, what happens if too high or too low; what
causes them to be high or low; relate to other body systems- renal, cardiac, oncology,
neuro, endocrine, etc…
■ Sodium imbalance think . . . Brain
■ Potassium imbalance think . . . Heart
■ Calcium imbalance think . . . Neuromuscular conduction
● Hypocalcemia: Trousseau sign/Chvostek sign
■ Magnesium imbalance think . . . All systems
● Hypomagnesemia: associated with hypokalemia and hypocalcemia
○ Trousseau sign/Chvostek sign
○ IV therapy- monitoring, pt teaching
■ Monitoring
● Phlebitis- inflammation of the vein- charac. by pain and redness
● Infiltration- occurs when a soln or medication is inadvertently infused into
the tissue surrounding the vein, swelling common
● Extravasation- occurs when a vesicant such as vancomycin or
chemo which is able to cause blisters, infiltrates→ remove IV, notify
physician
■ Educate pts receiving TPN- monitor for s/sx of infection, change tubing set q 24
hours
○ FVE, s/sx, treatments
■ Aka hypervolemia
■ S/Sx
● Acute weight gain, peripheral edema and ascites, JVD, crackles,
SOB, ↑ BP, bounding pulse and cough, ↑ RR, ↑ urine output
● ↑ BP, ↑ HR, ↓ lab values
● Nursing management
○ I/Os, daily weight, assess lung sounds, edema, promote adherence
to fluid restrictions, avoid sources of excessive Na, promote rest
○ FVD, s/sx, treatments
■ Aka hypovolemia
■ Refers to water and electrolyte loss; may occur alone or in combination with other
imbalances
■ Loss of ECF exceeds intake ratio of water
● Electrolytes lost in same proportion as they exist in normal body fluids
■ Dehydration
● Not the same as FVD- loss of water alone with increased serum Na levels
■ S/Sx
● Acute weight loss, ↓ skin turgor, oliguria, ↓ BP, dizziness, weakness,
thirst and confusion, ↑ pulse, muscle cramps, nause, cool, clammy,
pale skin
■ ↓ BP, ↑HR, ↑ lab values (*Pt is dry, labs are high)
■ Nursing management
● I/Os at least q 8 hrs, daily weight, monitor VS, admin of oral fluids or
parenteral fluids
● Acid Base Balance
○ ABG interpretation
■ Acidosis vs Alkalosis: pH 7.35-7.45
■ Respiratory : PaCO2 35-45
■ Metabolic: HCO3 22-26
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■
■
○ Causes for imbalances and Treatment of imbalances
■ Normal plasma pH 7.35-7.45: hydrogen ion concentration
■ Kidneys regulate bicarbonate in ECF
■ Lungs, under control of medulla, regulate CO2, and thus the carbonic acid in ECF
■ Respiratory Acidosis
● Altered ventilation leading to CO2 retention
● Characterized by: low pH, elevated CO2 levels
● Body attempts to compensate by renal absorption of HCO3
● Low pH < 7.35; PaCO2 > 45
● Always due to respiratory problem with inadequate excretion of CO2
● With chronic respiratory acidosis, body may compensate, may be
asymptomatic; sx include: suddenly increased pulse, RR, BP; mental
changes; feeling of fullness in head; potential increased ICP
● Treatment aimed at improving ventilation
■ Respiratory Alkalosis
● Caused by an increased alveolar ventilation rate; acute alveolar
hyperventilation
● Hyperventilation ↓ serum CO2 in the lungs and blood
● ↓ CO2 ↓ carbonic acid and hydrogen ions in the blood
● Arterial pH levels rise
● High pH > 7.45; PaCO2 < 35
● Always due to hyperventilation
● Manifestations: lightheadedness, inability to concentrate, numbness and
tingling, sometimes loss of consciousness
● Correct the cause of hyperventilation
■ Metabolic Acidosis
● Increased accumulation of metabolic acids that rise in proportion to
bicarbonate
● Result in ↓ arterial pH
○ Stimulates respirations
○ Body’s attempt to compensate occurs rapidly and may reduce the
PaCO2 levels
● Low pH <7.35; low bicarbonate <22
● Most commonly due to kidney injury
● Manifestations: HA, confusion, drowsiness, ↑ RR and depth, ↓ BP, ↓
CO, dysrhythmias, shock; if ↓ is slow, pt may be asymptomatic until
bicarbonate is 15 mEq/L or less
● Correct underlying problem, correct imbalance- bicarbonate may be admin
● With acidosis, hyperkalemia may occur as K shifts out of cell
● As acidosis is corrected, K shifts back into cell, K levels ↓
● Serum Ca levels may be low with chronic metabolic acidosis- must be
corrected before treating acidosis
■ Metabolic Alkalosis
● Increased loss of acid
● Most through GI tract- vomiting, NGT suctioning, renal excretion
● Loss in metabolic acid causes an increase in the arterial pH level- results in
hydrogen ion concentration reduction
● Body compensates and creates state of hypoventilation to conserve PaCO2
levels
● High pH > 7.45; high bicarbonate > 26
● Most commonly due to vomiting or gastric suction- may also be due to meds
● Hypokalemia will produce alkalosis
● Manifestations: sx r/t ↓ Ca, respiratory depression, tachycardia
● Correct underlying disorder, supply chloride to allow excretion of excess
bicarbonate, restore fluid volume with NaCl solutions
● Diabetes
○ Differentiate type I and type II diabetes, s/sx, treatments
■ Type I Diabetes
● Insulin-producing beta cells in the pancreas are destroyed by a combination
of genetic, immunologic, and environmental factors (autoimmune- depletion
of insulin r/t beta cell destruction)
● 3 Ps + fatigue + weight loss
● Dx- HgbA1c, fasting blood glucose, random blood glucose
● Requires lifelong insulin treatment
● Monitor for complications- DKA very common in type I
● Results in decreased insulin production, unchecked glucose production by
the liver and fasting hyperglycemia
■ Type II Diabetes
● Insulin resistance and impaired insulin secretion
● 3 Ps + fatigue, poor wound healing, CV disease, visual problems, renal
insufficiency, or recurring infections
● Dx- HgbA1c, fasting blood glucose, random blood glucose
● Usually treated with OHA’s, may eventually need insulin
● Onset over age 30 years, increasing in children r/t obesity
● Slow, progressive glucose intolerance and may go undetected for years
■ S/Sx
● Depends on the level of hyperglycemia
● 3 Ps= polyuria, polydipsia, polyphagia
● Fatigue, weakness, vision changes, tingling or numbness in hands or feet,
dry skin, skin lesions or wounds that are slow to heal, recurrent infections
● Type I may have sudden weight loss
■ Treatment
● Main goal is to normalize insulin activity and blood glucose levels to reduce
the dev. of complications
● Management has 5 components: nutritional therapy, exercise, monitoring,
pharmacologic therapy, education
○ Differentiate HHS and DKA, s/sx, treatments
■ HHS (Hyperglycemic Hyperosmolar Syndrome)
● Caused by a lack of sufficient insulin; ketosis is minimal or absent
● Blood glucose >600
● Hyperglycemia causes osmotic diuresis, loss of water and electrolytes,
hypernatremia, and increased osmolality
● Sx: hypotension, profound dehydration, tachycardia, electrolyte imbalances,
variable neurologic signs caused by cerebral dehydration
● Infection is the most common preceding illness
● Treatment: rehydration w/ IV fluids, insulin, monitor F&E
■ DKA (Diabetic Ketoacidosis)
● Absence or inadequate amt of insulin resulting in abnormal metabolism of
carbohydrate, protein, fat
● Features: hyperglycemia, dehydration, acidosis
● Blood glucose >250
● Ketoacidosis is reflected in low serum bicarbonate, low pH, low pCO2,
Kussmaul's respirations- ketone bodies in blood and urine
● Treatment: rehydration with IV fluid, IV continuous infusion of regular
insulin
● Monitor blood glucose, renal function, UOP, ECG, electrolytes, VS, lung
assessments for signs of fluid overload
○ Hyper vs Hypoglycemia, when to intervene
■ Hypoglycemia
● Abnormally low blood glucose level (below 50-60 mg/dL); too much insulin
or oral hypoglycemic agents, excessive physical activity, and not enough
food
● Adrenergic sx: sweating, tremors, tachycardia, palpitations, nervousness,
hunger
● CNS sx: inability to concentrate, HA, confusion, memory lapses, slurred
speech, drowsiness
● Severe hypoglycemia: disorientation, seizures, LOC, death
● Management
○ If pt is conscious and can swallow- give 15 g of fast acting carbs- 3
or 4 glucose tablets, 4-6 oz juice or regular soda
■ Retest BG in 15 min
○ If pt cannot swallow or is unconscious- SubQ or IM glucagon (1
mg) or 25-50 mL of 50% dextrose solution IV
■ Hyperglycemia
● 3 P’s, fatigue, weakness, vision changes, tingling or numbness, recurrent
infections
○ Complications of Diabetes- acute and chronic
■ Long-term complications
● Macrovascular: accelerated atherosclerotic changes, coronary artery disease,
cerebrovascular disease, peripheral vascular disease
● Microvascular: diabetic retinopathy and nephropathy
● Neuropathic: peripheral neuropathy, autonomic neuropathies, hypoglycemic
unawareness, neuropathy, sexual dysfunction
● Surgical
○ Phases of care -- what is priority in each
■ Preoperative phase: begins when the decision to proceed with surgical
intervention is made and ends with the transfer of the pt onto the operating
room (OR) bed→ Intraoperative phase: begins when the pt is transferred
onto the OR bed and ends with admission to the PACU (post anesthesia
care unit) → Postoperative phase: begins with the admission of the pt to
the PACU and ends with a follow-up evaluation in the clinical setting or
home
■ Preoperative
● Preadmission testing initiates nursing process
○ Lots of assessments
○ Verify completion of pre op diagnostic testing
● Preoperative Assessment: Health hx, physical exam, meds and allergies
(latex is a biggie), nutritional, fluid status, dentition, drug or alcohol use,
respiratory and CV status, hepatic, renal function, endocrine function,
immune function, previous meds, psychosocial factors, spiritual, cultural
beliefs
● Special considerations- pts who are obese (respiratory compromise), pts
with disabilities, pts undergoing ambulatory or emergency surgery
● Nursing interventions: providing pt education, TCDB, IS, mobility, pain
management, cognitive coping strategies, reducing anxiety/fear, maintaining
pt safety, managing nutrition/fluids, preparing bowel, preparing skin
● Number 1 priority in preop is completing Preop checklist
■ Intraoperative
● Prevention of infection- surgical asepsis
● Intra op complications: anesthesia awareness, NV, anaphylaxis, hypoxia,
resp complications, hypothermia, Malignant hyperthermia, infection
● Malignant hyperthermia (a reaction to volatile gas- usually succinylcholinegeneral anesthesia- genetic mutation- see rxn generally 1 hr after general
anesthesia admin- often in younger pts- Ca++ shifts & causes muscle
rigidity- txt is a muscle relaxer Dantrolene, Ryanodex- temp goes up and ice
packs and cooling is next step)
○ Early signs: ↑ HR, ↓ BP; Late signs: ↑ temp, dark urine, ↑ K,
resp acidosis
● TIME OUT
○ Pause for cause
○ Stop: verify pt, site, procedure, surgeon
○ Happens before pt is put under and before incision is made
● Nursing interventions: reduce anxiety, reduce latex exposure, prevent
positioning injury, protect pt from injury, serve as pt advocate, monitor and
manage potential complications
■ Postoperative
● Resumption of motor and sensory function, oriented, stable VS, no evidence
of hemorrhage or other complications of surgery
● Assessment: respiratory, pain, mental status/LOC, general discomfort
● Maintaining a patent airway: provide supplemental oxygen, keep HOB
elevated, may require suctioning, turn pt if vomiting occurs
● Maintain CV stability: assess IV lines, potential for hypotension, shock,
hemorrhage, hypertension, dysrhythmias
● Post op dressing: first dressing changed by surgeon, sterile technique
○ Don’t touch for 24 hours
○ Safety measures in surgical environment
■ Unrestricted zone: street clothes allowed
■ Semi Restricted zone: scrub clothes and caps
■ Restricted zone: scrub clothes, shoe covers, caps, masks
■ Surgical asepsis – skin prep
■ Environmental controls: air filtration, sterile equipment
○ Required documentation/papers
■ Informed consent
● Should be in writing before non emergent surgery
● Legal mandate
● Surgeon must explain the procedure, benefits, risks, complications
● Nurse clarifies information and witnesses signature
● Consent is valid ONLY when signed before administering psychoactive
premedication
● Consent accompanies pt to OR
○ Monitoring, prevention of post-op complications
■ VTE/PE- call surgeon immediately→ redness, warmth, calf pain,
tenderness, swollen (remove SCD), PE- SOB rapidly, O2 sat drops, call
rapid→ sit pt up, give O2
■ Hematoma - apply pressure, call surgeon
■ Infection- call surgeon
■ Wound dehiscence and evisceration- get sterile saline soaps & place on pt, call
surgeon immediately
● Pain
○ Assessing pain (personal and subjective experience)
■ O- onset of pain- when did it start
■ P- provocation- what causes the pain
■ Q- quality- can they describe it (sharp, dull, aching, stabbing)
■ R- region/radiation- where does it hurt & does it radiate anywhere else
■ S- severity- numeric rating 0-10
■ T- time and duration- how long has pt been having pain
■ AAA- aggravating, alleviating, associated sx- what makes the pain better/worse,
does the pain cause any other sx
○ Pain scales
■ Numeric rating scale- adults who are A&O x4- rate 0-10
■ Wong-Baker FACES pain rating scale- can be confusing for different cultures
■ Verbal descriptor scale
■ Visual analog scale
■ The Hierarchy of Pain measures- nonverbal patient
■ FLACC- young children- facial expression, leg mvmt, activity, crying,
consolability
■ PAINAD- patients with advanced dementia who are not able to verbalize needs
■ CPOT- patients in critical care
○ Management of pain
■ Effective and safe analgesia
■ Optimal relief
■ Comfort function goal (pt stated pain goal)
■ Responsibility of all members of healthcare team
■ Pharmacologic: multimodal- routes (PO,IM,IV,PCA, patches, topical), dosing
(start with lower dose and go up if needed)
■ Patient-controlled analgesia (PCA)
● Cancer
○ Diagnostics of cancer
■ Determine presence, extent of tumor
■ Identify possible disease metastasis
■ Evaluate functions of involved and uninvolved body systems and organs
■ Obtain tissue and cells for analysis, including evaluation of tumor stage and grade
■ Diagnostic evaluation dependent upon: suspected cancer subtype, possible disease
location, and expected extensiveness of the disease
■ Lab tests
■ Imaging- CT, MRI, PET scan, chest, x-ray
■ Biopsy- taking tissue samples through incisional, excisional, fine needle, or bone
marrow
■ Endoscopic procedures- to view different areas of the body
○ Prevention of cancer
■ Primary prevention: reducing the risks of disease through health promotion and
risk reduction strategies
● Risk factor modification, immunization, chemoprevention
■ Secondary prevention: screening and early detection activities that seek to identify
precancerous lesions and early stage cancer in individuals who lack s/sx of cancer
● Noninvasive screening tests, evaluation of family hx for genetic syndromes
■ Tertiary prevention: efforts focus on monitoring for and preventing recurrence of
the primary cancer as well as screening for development of secondary
malignancies in cancer survivors
● Reducing morbidity & mortality, treatment & management of SE
○ Risk factors, complications
■ Most common risk factor for cancer is exposure to a carcinogen
● Carcinogen- internal or external exposures that predispose individuals to
DNA destruction- could result in cellular mutation that may lead to a
malignant transformation of cells
■ Carcinogens alone are unlikely cancers triggers
■ Complications: infection, septic shock, bleeding, hemorrhaging
○ Chemo, radiation- precautions, complications
■ Chemo precautions:
● Nurses go through training to be able to administer chemo- must use mask,
gown, gloves & goggles to administer IV
● Double gloves to administer oral chemo
● Chemo is mixed in the pharmacy under a vented hood in a controlled area
● Empty bags must be disposed of in biohazard receptacles
● Double glove and double flush
● Implemented until 48 hrs after last dose
■ Side effects of chemo:
● Infection- from myelosuppression of chemo- neutropenic precautions and
proper hand hygiene implemented
● Bleeding- from myelosuppression- manifests as pancytopenia (all 3 types of
blood cells are low)
● N/V, diarrhea- antiemetic prior to chemo
● Mucositis- mouth ulcers, educate pt on strict oral care- mouth rinses,
brushing teeth, magic mouthwash swish & spit
● Alopecia- hair loss- address psychosocial aspects of txt
● Abstinence- must be practiced bc body fluids contain chemo
● Fatigue
■ Radiation precautions
● Pt placed in private lead wall room
● If nurse is pregnant or breastfeeding cannot care for pt
● Children should not visit pt
● Staff limit exposure to pt to 30 min/shift & need to wear a Geiger badge
● Staff encouraged to stand on far end of room, wear a lead apron, not turn
away, double layer gloves, double flush toilet when disposing of body fluids
■ Radiation complications
● SE of external radiation- skin irritation and burns- fibrosis of tissue can
occur
● Hematology
○ RBC disorders
■ Anemia
● Lower than normal hemoglobin and fewer than normal circulating
erythrocytes; a sign of an underlying disorder
● Hypoproliferative: defect in production of RBCs
○ Caused by iron, vitamin B12, or folate deficiency, ↓
erythropoietin production, cancer
● May also be caused by blood loss
● Manifestations: fatigue, weakness, malaise, pallor or jaundice, cardiac/resp
sx, tongue changes (beefy sore red- pernicious, smooth red- iron deficiency),
nail changes (spoon shaped), angular cheilosis (ulcerations in corner of
mouth), pica
● Medical management: correct or control the cause, transfusion of packed
RBC’s, txt to the specific type
○ Dietary therapy: dark leafy vegetables, seafood, meats, seeds, nuts,
beans
○ Iron or vitamin supplementation: iron, folate, B12 (seafood, meats,
eggs, cheese)
○ Transfusions
● Give iron with vitamin C to help with absorption
■ Sickle cell disease and crisis
● Sickle cell crisis- brought on by hypoxic episodes and cold temps;
intermittent episodes
● Acute vaso-occlusive crisis- painful, leads to hypoxia, inflammation,
necrosis
● Aplastic crisis- infection from human parvovirus
● Sequestration crisis- pooling of sickled cells in organs; children- spleen;
adults- liver, lungs
● Complications: hypoxia, ischemia, infection, dehydration, CVA, anemia,
CKD, HF, impotence, poor compliance, substance abuse
● Priority in a crisis: pain management, oxygenation, hydration
■ Polycythemia Vera
● A rare blood disease in which your body makes too many red blood cells;
the extra red blood cells make your blood thicker than normal; blood clots
can form more easily
● Proliferative disorder of the myeloid stem cells
● Sx: ruddy complexion, splenomegaly, high BP, pruritus, erythromelalgia
(burning sensation in the fingers and toes)
● Risks include thrombosis complications (CVA, MI) and bleeding from
dysfunctional platelets
● Txt: phlebotomy, chemotherapeutic agents to suppress marrow function,
aspirin for pain, platelet aggregation inhibitors
● Secondary polycythemia Vera
○ Increased volume of RBCs
○ Excessive production of erythropoietin from reduced amounts of
oxygen, cyanotic heart disease, nonpathological conditions or
neoplasms
○ Medical management
■ Treatment not needed if condition is mild
■ Treat underlying cause
■ Therapeutic phlebotomy
○ WBC disorders
■ Neutropenia
● Decreased production or increased destruction of neutrophils (<2000/mm3)
● Increased risk for infection- monitor closely
● *Absolute Neutrophil Count (ANC) of <1000
○ Slightest temp (99.9) is very serious
● Txt depends on the cause
● Mainly in pts undergoing chemo and radiation txt for cancer
● Neutropenic precautions: REVERSE ISOLATION, avoid crowds, no small
children, no fresh cut flowers, fruit/vegs with skin is fine, cook meats
thoroughly, HAND HYGIENE
○ Bleeding disorders
■ Thrombocytopenia: reduced number of platelets below the average range of
150,000 to 450,000/mm^3
● Not a disease but rather a complication of other disorders
● Clinical manifestations: easy bruising and petechiae
● Oh Me, Oh My: bleeding!
■ Types of thrombocytopenia:
● ITP
○ Autoimmune
○ Acute- more in children- followed by viral or immunizations- rapid
onset- resolves spontaneously
○ Chronic- in women in teenage years to young adult- slower onsettriggered by meds or autoimmune
○ Txt depends on level of thrombocytopenia present
● Hemophilia
○ Inadequate clotting factors VIII & IX
○ Very concerned with bleeding
○ Minor cuts can lead to significant blood loss
○ Spontaneous bleeds
○ Hereditary disease- mothers who carry it can pass to their offspring
○ Txt: clotting factor replacement, FFP, cryo
● DIC
○ Triggers: Results from trauma or severe tissue injury; MVA, burns,
sepsis, shock, cancer, toxins
○ Altered hemostasis mechanism causes massive clotting in
microcirculation; as clotting factors are consumed, bleeding
occurs; sx r/t tissue ischemia and bleeding
○ Labs that we are going to look at: Platelet count, Fibrin
degradation products (used with D-dimer), PT, Fibrinogen levels
○ Most are in critical care- high mortality rate
○ Multi-system organ failure
○ Treatment: Fix underlying cause, correct tissue ischemia, replace
F&E, maintain BP, replace coagulation factors, use heparin or
LMWH
■ Ex: sepsis - IV antibiotics
● HIT
○ Complication associated with heparin administration
○ Thought to be some type of immune response to the medication
○ Body forms new clots, plt count ↓, 5-10 days after initial start
of infusion
○ Treatment: Stop heparin- start other anticoagulant such as
Argatroban
○ Blood administration and reactions
■ Have on order→ type and crossmatch ordered
■ Verify consent, explain procedure, take VS, use hand hygiene and wear gloves, 20
gauge needle
■ Obtain packed RBCs from blood bank, double check with another nurse- start
within 30 min of obtaining blood
■ Start blood slowly, stay with pt 15 min, obtain set of VS, increase rate if no
changes
■ Have 4 hrs to finish, monitor VS after first 15 min then hourly after
● Can delegate to UAP but it is on you
■ Get final set of VS when procedure is over, dispose of bag and tubing properly
■
● Neuro
○ Stroke- causes, s/sx, treatments, complications
■ BEFAST (balance, eyes, face, arm, speech, time)
■ Ischemic stroke
● Disruption of the blood supply caused by an obstruction, usually a thrombus
or embolism, that causes infarction of brain tissue
● Sx: numbness or weakness of face, arm, or leg, especially on one side,
confusion or change in mental status, trouble speaking or understanding
speech, difficulty in walking, dizziness, loss of balance, perceptual
disturbances
● Txt: thrombolytic therapy (tPA), elevate HOB, maintain airway and
ventilation
● Complications: decreased cerebral blood flow, inadequate oxygen delivery
to brain, pneumonia
■ Hemorrhagic stroke
● Caused by bleeding into brain tissue, the ventricles, or subarachnoid space
● Brain metabolism is disrupted by exposure to blood, ICP increases by blood
in the subarachnoid space, compression or secondary ischemia from reduced
perfusion and vasoconstriction causes injury to brain tissue
● Sx: severe HA, early and sudden changes in LOC, vomiting, bleeding
● Complications: vasospasm, seizures, hydrocephalus, rebleeding,
hyponatremia
○ Seizures- s/sx, treatments, complications
■ Abnormal episodes of motor, sensory, autonomic, or psychic activity resulting
from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons
■ Variety of sx from simple staring episode to prolonged convulsive movementsdepends on the area of the brain affected (aura, dizziness, hand or mouth
movements)
■ Focal: motor and non-motor sx; may or may not lose consciousness
■ Generalized: more tonic-clonic movements; preictal and postictal phases; loss of
consciousness
■ Precautions: IV access, padding of side rails, suctioning equipment, oxygen at the
bedside, bed locked, lowered, 3 side rails up
■ Oh Me Oh My: Status Epilepticus- seizure >5 minutes or seizures back to back
without full recovery of consciousness b/w them
● IV access- lorazepam and midazolam- 1st line treatment
○ S/sx, causes, treatments, complications
■ Multiple sclerosis
● Autoimmune attack on brain and spinal cord
● A progressive immune related demyelination disease of the CNS
● Clinical manifestations vary and have different patterns depending on where
lesion occurs
● Frequently the disease the relapsing and remitting; has exacerbations and
recurrences of sx, including fatigue, weakness, numbness, difficulty in
coordination, loss of balance, pain and visual disturbances
● Medical management: disease-modifying therapies; interferon β-1a and
interferon β-1b, glatiramer acetate, and IV methylprednisolone
● Sx management of muscle spasms, fatigue, ataxia, bowel and bladder
control
■ ALS “Lou Gehrig disease”
● Loss of motor neurons in the anterior horn of the spinal cord and loss of
motor nuclei of the lower brainstem
● Progressive weakness and atrophy of muscles’ cramps, twitching, lack of
coordination, spasticity, deep tendon reflex brisk and overactive, difficulty
speaking, swallowing, breathing
● Dx based on sx
● No cure
● Riluzole (Rilutek) slows progression
● Interventions focus on maintaining or improving function, well-being, and
quality of life
● Acute care management: dehydration, malnutrition, pneumonia, respiratory
failure
■ Myasthenia gravis
● Autoimmune disorder affecting the myoneural junction
● Antibodies directed at acetylcholine at the myoneural junction impair
transmission of impulses
● Manifestations: initially sx involve ocular muscles; diplopia and ptosis;
weakness of facial muscles, swallowing and voice impairment (dysphonia),
generalized weakness (risk for aspiration)
● Motor disorder- no loss of sensation or coordination
● Dx: Tensilon test- if weakness sx improve- indicates MG
● Medical management: anti-cholinesterase medications and
immunosuppressive therapy, IVIG, plasmapheresis, thymectomy
● Ensure adequate ventilation, NGT is pt cannot swallow
■ Guillain-Barre
● Autoimmune disorder with acute attack of peripheral nerve myelin
● Rapid demyelination may produce respiratory failure and autonomic
nervous system dysfunction with CV instability
● Most often follows a viral infection
● Manifestations: weakness, paralysis, paresthesias, pain, and diminished or
absent reflexes, starting with the lower extremities and progressing upward;
bulbar weakness; autonomic sx include tachycardia, bradycardia, HTN or
hypotension
● Medical management: medical emergency, requires intensive care
management with continuous monitoring and respiratory support,
plasmapheresis, IVIG reduce circulating antibodies
● Early detection of life-threatening complications resp failure, cardiac
dysrhythmias, DVT, PE
● Musculoskeletal
○ Osteomyelitis
■ Infection of the bone
■ Occurs because of: extension of soft tissue infection, direct bone contamination,
bloodborne spread from another site of infection
■ Organisms: MRSA, proteus and pseudomonas spp., E. coli
■ S/sx of infection, localized pain, edema, erythema, fever, drainage
■ Relieving pain: immobilization, elevation, admin prescribed analgesics
■ Improving physical mobility: activity is restricted, gentle ROM to joints above
and below affected part, participation in ADLs within limitations
■ Prophylactic abx, ensure adequate hydration, vitamins, proteins
○ Joint replacement
■ Used to treat severe joint pain and disability and for repair and management of
joint fractures or joint necrosis
■ Frequently replaced joints include the hip, knee, and fingers
■ Joints include the shoulder, elbow, wrist, and ankle may also be replaced
■ Hip precautions:
●
○ Fractures
■ Closed or simple- no break in skin
■ Open or compound/complex- wound extends to the bone, skin is broken
● Grade I: 1 cm long clean wound
● Grade II: larger wound without extensive damage
● Grade III: highly contaminated, extensive soft tissue injury, may have
amputation
■ Intra-articular: extends into the joint surface of a bone
■ Manifestations: acute pain, loss of function, deformity, shortening of the
extremity, crepitus, local swelling and discoloration, dx by sx and radiology
■ Emergency management: immobilize the body part, splinting: joints distal and
proximal to the suspected fracture site must be supported and immobilized, assess
6 P’s, open fracture: cover with sterile dressing to prevent contamination, do not
attempt to reduce the fracture
■ Medical management:
● Fracture reduction: restoration of the fracture fragments to anatomic
alignment and positioning
● Closed: uses manipulation and manual traction, traction may be used (skin
or skeletal)
● Open: internal fixation devices hold bone fragment in position (metallic
pins, wires, screws, plates)
● Immobilization: external (cast, splints) or internal fixations
○ Internal vs external treatment; complications of these treatments
■ External fixation devices:
● Used to manage open fractures with soft tissue damage
● Provide support for complicated or comminuted fractures
● Elevate to reduce edema
● Monitor for s/sx of complications, including infection
● Pin care
■ Traction: the application of pulling force to a part of the body
● Purpose: reduce muscle spasms; reduce, align and immobilize fractures;
reduce deformity; increase space b/w opposing forces
● Skin or skeletal
○ Complications of fractures/musculoskeletal injuries
■ Early complications of fractures:
● Shock- hypovolemic from hemorrhage
● Fat embolism- piece of fat from long bone- embolus travels- PE
● VTE, PE- prophylaxis, SCD, TED hose
■ Delayed complications of fractures:
● Delayed union, malunion, nonunion
● Avascular necrosis of bone
● Complex regional pain syndrome (CRPS)
● Heterotrophic ossification
■ Complications of brace, splint, cast:
● Compartment syndrome- occurs from increased pressure in a confined
space, compromised blood flow, ischemia and irreversible damage within
hours
○ Assess then notify physician- emergency fasciotomy may be
necessary
● Pressure ulcer- caused by inappropriately applied cast
○ Pt reports painful “hotspot” and tightness
○ Cut window in cast for inspection- dressing applied
● Disuse syndrome- muscle atrophy and loss of strength
○ Txt: isometric exercises, muscle setting exercises
■ Complications of orthopedic surgery:
● Hypovolemic shock
● Atelectasis
● Pneumonia
● Urinary retention
● Infection
● DVT, PE
● Constipation or fecal impaction
○ Key assessments with musculoskeletal injury
■ Assess neurovascular status using 6 P’s: pain, poikilothermia, pallor,
pulselessness, paresthesias, paralysis
○ Amputations
■ Amputation may be congenital or traumatic or caused by conditions such as
progressive peripheral vascular disease, infection, or malignant tumor
■ Amputation is used to relieve sx, improve fxn, quality of life
■ assessment : neurovascular status and fxn of affected extremity or residual limb
and of unaffected extremity, s/sx of infection, nutritional status, psychological
status and coping
■ Complications: postoperative hemorrhage, infection, skin breakdown, phantom
limb pain, joint contracture
■ Prone position prevents contracture, putting a light sand bag on residual limb
relieves pain, residual limb shaping with ACE wrap
■ Avoid abduction, external rotation, flexion, turn frequently
● Respiratory
○ Oxygen therapy
■ Cylinder, piped-in, concentrator
■ Classified as low flow or high flow
■ Devices: nasal cannula, oropharyngeal catheter, masks, transtracheal catheter
○ Know s/sx, management, complications of:
■ Asthma
● Chronic inflammatory disease of the airways that causes
hyperresponsiveness, mucosal edema, and mucus production
● Inflammation leads to cough, chest tightness, wheezing and dyspnea
● Largely reversible; spontaneously or with treatment
● Allergy is strongest predisposing factor
● S/sx: wheezing, dyspnea, cough, increased sputum, increased RR, chest
tightness inability to speak full sentences (attack)
● Dx: PFTs, peak expiratory flow
● Txt: quick relief meds- beta2-adrenergic agonists, anticholinergics; long
acting meds- corticosteroids, leukotriene modifiers; asthma action plan
● Complications: status asthmaticus- life threatening emergency
○ Doesn’t respond to rescue inhalers, can lead to resp. Failure
○ Txt: IVFs, bronchodilators, O2, steroids
○ Listen to lung sounds- if absent or diminished- medical
emergency- resp failure- may require intubation & mech
ventilation
■ COPD
● Slowly progreesive respiratory disease of airflow obstruction
○ Emphysema, chronic bronchitis
○ Chronic bronchitis- cough and sputum production for at least 3
months in each of 2 consecutive years; ciliary function is reduced,
bronchial walls thicken, bronchial airways narrow and mucus may
plug airways; alveoli become damaged, fibrosed, and alveolar
macrophage function diminishes
○ Emphysema- abnormal distension of air spaces beyond the
terminal bronchioles with destruction of the walls of the alveoli;
decreased alveolar surface area increases in “dead space,” impaired
oxygen diffusion; hypoxemia results
● 3 primary sx: chronic cough, sputum production, dyspnea; weight loss due
to dyspnea, “barrel chest”
● Complications: respiratory insufficiency and failure, pneumonia, chronic
atelectasis, pneumothorax, cor pulmonale
● Medical management
○ Promote smoking cessation, providing supplemental oxygen,
pneumococcal vaccine, influenza vaccine, pulmonary rehab
○ Medications: bronchodilators, MDIs- beta adrenergic agonists,
muscarinic antagonists; corticosteroids, abx, mucolytics,
antitussives
■ Pneumonia
● Inflammation of the lung parenchyma caused by various microorganisms,
including bacteria, mycobacteria, fungi, and viruses
● Clinical manifestations:
○ Streptococcal: sudden onset of chills, fever, pleuritic chest pain,
tachypnea, respiratory distress
○ Viral, mycoplasma, or Legionella: relative bradycardia
○ Other: respiratory tract infection, HA, low-grade fever, pleuritic
pain, myalgia, rash, pharyngitis
○ Orthopnea, crackles, increased tactile fremitus, purulent sputum
● Medical management: admin of appropriate antibiotic; fluids, oxygen for
hypoxia, antipyretics, antitussives, decongestants, antihistamines
● Problems: sepsis and septic shock, respiratory shock, atelectasis, pleural
effusion, delirium
■ Tuberculosis
● S/sx: low grade fever, cough- nonproductive or mucopurulent; hemoptysis,
night sweats, fatigue, weight loss, rust colored sputum
● Early identification and txt of pt with active TB is so important
● Place on airborne precautions, person entering room must wear N95, place
in private room with (-) pressure, pt must wear mask if they leave room
● 6-9 month antibiotic therapy- isoniazid, rifampin
● Complications: respiratory failure, pleural effusions
○ Tracheostomies- care, complications
■ Surgical procedure in which an opening is made into the trachea
■ Provides improved comfort and patient safety while allowing for the removal of
tracheobronchial secretions to prevent aspiration of oral or gastric secretions in an
unconscious or paralyzed patient, to bypass an upper airway obstruction and/or to
permit the long-term use of mechanical ventilation
■ Complications: pneumothorax, infection, tracheostomy dislodgement
■ ***keep an obturator, new trach kit, and a pair of sterile hemostats at bedside
■ If dislodgement occurs, use the sterile hemostats to keep the site open, stay with
pt, call MD and call rapid
■ Nurses cannot replace the trach
■ Continuous monitoring, maintain patency by proper suctioning, semi-fowler,
admin analgesia and sedatives if ordered, provide effective means of
communication
○ Chest tubes- care and complications
■ Chest drainage systems have: a suction source, a collection chamber for pleural
drainage, and a mechanism to prevent air from reentering the chest with
inhalation
■ Wet (water seal) or dry suction control
■ Why? Pneumothorax-air or hemothorax- blood
■ Chest tube purpose: reinflation of a collapsed lung, removal of fluid and air from
pleural space
■ Nursing care:
● Drainage chamber: measure drainage min q 8 hrs, report is output is cloudy
or >70 mL/hr of bright red drainage; do not empty drainage, change out if
full of drainage
● Water-seal chamber: check water level frequently, refill as needed;
occasional bubbles and fluctuation are expected; fluctuation stopsobstructed lines or lung has re-expanded- check connections;
constant bubbles- may be indicative of air leak- briefly clamp tube, if
bubbling ceases possible chest tube is out of chest- notify provider→
if bubbling doesn't stop, leak in chest tube drainage system, system
needs to be replaced
● Assess level of suction- wet vs dry
○ Water level or dial determines the amount of suction, not the wall
● Tubing
○ Never milk the tube; assess for kinks or loops; never clamp the
tubing; ensure connections are intact
● Dressings
○ Vaseline gauze; reinforce only; no drainage is normal; assess for
s/sx of infection
■ Accidents
● Tube removal: ask pt to exhale, cover site with vaseline gauze, tape 3 sides
only
● Container breakage: clamp tubing, insert end into sterile water, unclamp
■ Chest tube removal
● Criteria for removal: minimal drainage, absence of air leak, stable resp
status, coagulation status WNL
● Procedure: pt takes a deep breath, exhales, holds it, sitting straight up or
over bedside table, sutured closed, apply vaseline gauze
● Endocrine
○
○
○
○
Thyroid, parathyroid, pituitary, adrenal
Compare/contrast hyper-/hypoS/sx, treatments
Glands, hormones involved
■ Anterior pituitary tumor
● Growth hormone- tumor in adult: acromegaly; tumor in child: gigantism
● Cause: hypersecreting tumor
● Sx: acromegaly- large hands, feet, features (later in life) ; gigantism- tall
stature (early in life)
● Txt: medication, growth hormone receptor blocker, surgery to remove tumor
● Nursing care: ↑ ICP, meningitis, CSF leak, DI- all complications of
transsphenoidal hypophysectomy
○ ↑ ICP: change in LOC, lethargic, confused- elevate HOB, no
straws, no bending, coughing, sneezing
○ Meningitis: prevent by providing good mouth care, soft bristle
toothbrush; s/sx: nuchal rigidity, fever, HA, photophobia
○ CSF leak: cannot prevent, recognize early; salty taste, HA, yellow
halo drainage- HOB flat
○ DI: damage to posterior pituitary- recognize early; I/Os with large
amounts of dilute urine; urine specific gravity < 1.005; notify
surgeon
■ Posterior Pituitary
● Diabetes insipidus
○ Cause: central nephrogenic (renal tubules don’t respond to ADH)
○ Sx: FLUID LOSS: polydipsia, polyuria, nocturia, normal blood
sugar, dehydration
○ Txt: hydration, vasopressin, desmopressin (synthetic ADH, nasal
spray)
○ Nursing care: hypovolemia (BP ↓, HR ↑), dehydration, Na
imbalance
○ Urine specific gravity <1.005
○ Hyponatremic/hypernatremic: change in LOC, seizure precautions
● SIADH
○ Cause: tumors- brain, lung, NSAIDS
○ Sx: FLUID GAIN, hyponatremia
○ Txt: medication, hypertonic 3% saline, fluid restriction
○ Nursing care: coma, seizures
○ Fluid volume overload
○ Dilutional hyponatremia
○ 3% saline given to slowly correct Na imbalance
○ Medication- declomycin (abx)- SE is diuresis- low dose to help
excrete water
■ Thyroid
● Hypothyroidism- Hashimoto’s
○ Slow
○ Causes: autoimmune
○ Sx: goiter, fatigue, weight gain, constipation, dry hair, thick nails
○ Txt: thyroid replacement medication
○ Nursing care: monitor for myxedema coma
○ Low BP, bradycardia, ↓ temp, ↓ BS, fatigue
○ Myxedema- fatty deposits on face in subq tissue
○ Medication- levothyroxine (Synthroif)- take 1st thing in
morning on empty stomach- wait 30 min to eat- can ↑ HR,
lifelong lab monitoring
○ Oh Me Oh My: Myxedema coma
■ Dev thick, large tongue, extreme slowing, monitor airway
■ Txt: steroids, IV levothyroxine, IV fluids
■ Risk: extreme cold temps, infection
■ Life threatening- lethargic, HR plummets
● Hyperthyroidism- Graves
○ Causes: autoimmune
○ Sx: goiter, weakness, insomnia, tachycardia, weight loss, diarrhea,
palpitations, exophthalmos, thyroid bruit
○ Txt: medication, iodine, ↑ fluid intake, thyroidectomy
○ Nursing care: thyroid storm, hypoparathyroidism, bleeding, airway
compromise, laryngeal nerve damage
○ BS ↑, temp ↑
○ Remove thyroid- worry about airway, bleeding- check dressing,
trach kit at bedside
○ Oh Me Oh My: with thyroidectomy- remove parathyroid→
hypocalcemia→ tetany/stridor
○ Thyroid storm- too much synthroid or untreated hyperthyroidism;
stress
■ Severe tachycardia,a tachypnea, fever, sweating, ↑
BP, fluid volume deficit→ hypovolemic shock
■ Parathyroid
● Hypoparathyroidism- Hypocalcemia
○ Causes: autoimmune, congenital, surgical removal
○ Sx: hypocalcemia, numbness/tingling, tetany, Chvostek and
Trousseau’s signs
○ Txt: ↑ Ca intake and vitamin D supplements
○ Nursing care: monitor for hypocalcemia and laryngospasm
○ If parathyroid is removed during thyroidectomy- tetany,
laryngospasm- trach kit at bedside, listen for stridor
● Hyperparathyroidism- Hypercalcemia
○ Causes: adenoma
○ Sx: polyuria, anorexia, abdominal pain, bone pain
○ Txt: ↑ fluid intake, ↓ calcium and vitamin D intake, avoid
thiazide diuretics, parathyroidectomy
○ Nursing care: monitor for hypercalcemia and kidney stones
○ Oh Me Oh My: hypercalcemic crisis: Ca >14- treat with calcitonin
& corticosteroids, push Ca back into bones
■ Adrenals
●
● Hypo- Addison’s
○ Cause: autoimmune
○ Sx: tan looking skin, weakness, fatigue, weight loss,
hypoglycemia, hypotension, N/V
○ Txt: daily hydrocortisone medication
○ Nursing care: adrenal crisis, hypovolemia, hypotension
○ Not enough salt and sugar- low Na and glucose
○ Need replacement of steroids- hydrocortisone (Cortef) life long
○ Oh Me Oh My: adrenal crisis- life threatening
■ Salt and sugar way too low
■ Severe hypovolemic shock- brought on by stress, illness,
surgery
■ *Hypotension, hypoglycemia
■ IV D5NS- replace sugar; steroids
● Hyper- Cushing’s
○ Cause: autoimmune, tumor in anterior pituitary
○ Sx: thin skin, truncal obesity, abdominal striae, moon face, buffalo
hump
○ Txt: surgery to remove tumor (transsphenoidal hypophysectomy)
○ Nursing care: infection, GI bleed, fractures, HTN, hypokalemia
○ Too much aldosterone and cortisol
○ Hirsutism - women
○ Check BS q 6 hrs- may be on insulin to control BS
● Pheochromocytoma
○ A hormone secreting tumor that can occur in the adrenal medulla
○ Sx: flushing, HTN, tachycardia, palpitations, anxiety, tremor,
weight loss
○ Txt: surgery to remove tumor, medication to control sx
○ Nursing care: hypoglycemia, post op bleeding, adrenal crisis,
stroke
○ Oh Me Oh My: hemorrhagic stroke- severely hypertensive, worst
HA ever; systolic > 300, diastolic > 150
■ Adrenalectomy
■ Keep pt calm, dim lights, quiet environment, keep pt sitting
up >45 degrees
○ Surgical interventions and complications
● Vascular
○ HTN causes, s/sx, management, complications
■ Manifestations: usually no sx other than elevated blood pressure; sx related to
organ damage are seen late and are serious: retinal and other eye changes, renal
damage, IM, cardiac hypertrophy, stroke
■ Risk factors: smoking, obesity, physical inactivity, dyslipidemia, DM,
microalbuminuria or GFR <60 mL/min, older age, family hx
■ Lifestyle modifications: weight reduction, DASH diet, decreased Na intake,
regular physical activity, reduced alcohol consumption
■ Pharmacologic therapy: decrease peripheral resistance, blood volume; decrease
strength of myocardial contraction; diuretics, beta blockers, alpha1 blockers,
vasodilators, ACE inhibitors, ARBs, CCBs, direct renin inhibitors
■ Complications: L ventricular hypertrophy, MI, heart failure, TIA, CVA, renal
insufficiency and CKD, retinal hemorrhage
○ Peripheral vascular disease (PAD, PVD)- s/sx, treatments, complications
■ Peripheral Artery Disease (PAD)
● Inadequate tissue perfusion leads to ischemia and necrosis
● Stages: intermittent claudication- pain w/ exercise→ rest pain→
gangrene
● Limb ischemia: chronic/critical- cellulitis, infections, ulcer, gangrene; acute:
complete blockage, embolus (most common), 6 P’s
● Nursing interventions: assess pulses and skin, administer antihypertensives,
Plavix; position- dependent, no crossing legs
● Medical interventions: angioplasty, fem-pop bypass
● Improving peripheral arterial circulation
○ Exercises and activities: walking, graded isometric exercises; stop
smoking, stress reduction
● Do NOT elevate
■ Peripheral Venous Disease (PVD)
● Deoxygenated blood cannot return to heart, pools, does not affect pulse
● Thickened, edema, tough
● ankle/shin ulcers, irregular in shape
● Can wear TEDs, can elevate, worry about DVT/PE
○ Carotid Artery Disease
■ Atherosclerosis of the carotid arteries
■ Dx: bruit, carotid duplex (ultrasound of of the neck) able to see if there is
blockage or turbulent blood flow or plaque buildup
■ Prevention of ischemic stroke is the goal
● Medication compliance, lifestyle changes- diet, exercise
■ Txt: carotid endarterectomy- removes plaque from carotid artery; cannot perform
if 100% blockage
○ DVT/PE- s/sx, management
■ DVT
● Clot in a large vein, deep vein
● Risk factors: surgical pt, pregnant, cancer, immobile, oral contraceptives
● Virchow’s triad: endothelial damage, venous stasis, altered coagulation
● Prevention: VTE prophylaxis, once DVT confirmed- no SCDs- causes clot
to dislodge and travel
○ Heparin drip- not to prevent, already has DVT or PE and trying to
treat it
○ Heparin SubQ, lovenox SubQ, TED hose, early ambulation, ROM
■ PE
● Clot moved to lung; air, tumor, or fat
● Greatest risk- pt with a DVT
● Dx: CT, doppler to confirm DVT
● Nursing txt: elevate HOB, oxygen, assess O2, VS, admin heparin, coumadin
● Medical txt: IVC filter
● Preventative measures for DVT/PE
○ Application of graduated compression stockings, pneumatic
compression devices, early ambulation, SubQ heparin or LMWH,
lifestyle changes- weight loss, smoking cessation, regular exercise
○ Abdominal aortic aneurysm
■ Localized sac or dilation formed at a weak point in the wall of the artery
■ Classified by its shape or form
● Saccular- project from only one side of the vessel
● Fusiform- when an entire segment becomes dilated
■ Often asymptomatic- found by accident
■ Aortic bruit
■ Pulsating abdominal mass
■ Aortic duplex
■ Prevention of dissection or rupture is the goal
■ Major goals: BP control, early identification of rupture, postop care, smoking
cessation
■ Avoid straining, constipation
■ Life threatening- can bleed out within minutes
■ Hypovolemic shock, hypotension, tachycardia- lose consciousness- monitor BP
and HR
■ burning/tearing sensation, N/V, fainting, diaphoresis
■ Bedrest 6 hrs post op
● Cardiovascular
○ Assessments, diagnostics, labs
○ Risk factors, causes, s/sx, treatments, procedures
■ Coronary Artery Disease (CAD)
● Patho- obstruction of blood flow, atherosclerosis
● Clinical manifestations: asymptomatic, ischemia leads to angina
○ Stable angina- occurs with physical activity, subsides w/ rest
○ Unstable angina- pain that does not subside w/ rest or NTG
○ Txt of angina: E-MONA (ECG, morphine, oxygen, nitroglycerin,
aspirin)
● Dx: labs, stress test, cardiac catheterization
● Txt: diet, exercise, meds, PTCA
● Risk factors: cigarette smoking, hyperlipidemia, HTN, DM, obesity,
sedentary lifestyle, stress, excessive alcohol consumption, gender, race, age,
heredity
● Oh Me Oh My: acute coronary syndrome- acute onset of myocardial
ischemia that results in myocardial death if definitive interventions do not
occur promptly
■ PCI/CABG
● Coronary artery bypass graft
● Uses a section of a vein or artery to bypass the vessel occlusion in the heart
● Internal mammary artery and saphenous vein
● Median sternotomy, cardiopulmonary bypass pump
● Post CABG life threatening emergency
○ Cardiac tamponade: bleeding into sac around heart results in
increased pressure, impairs ventricular filling and decreases CO
○ Pulses paradoxus classic sign→ >10 mmHg decrease in
systolic BP during inspiration
○ Treated by surgical pericardiocentesis
○ Often occurs after removal of temporary pacing wires but still rare
■ Myocardial Infarction
● 2 types: STEMI and NSTEMI
● STEMI- complete occlusion- no perfusion→ irreversible damage
● NSTEMI- ischemia and a partial blockage, can be reversible
● If the occlusion occurs in the L main coronary artery→ sudden death
(widowmaker)
● Call 911, do not put in car and drive to ED- life saving measures can be
implemented in the ambulance that cannot be implemented in a car
● Troponin- go to marker when determining if pt has had MI- within 4 hrs
levels rise and can stay for up to 10 days- drawn upon admission and q 6
hours for 2 more lab draws- 3 total
● If pt had STEMI, cath lab cleared- goal: 90 min from door to intervention
■ Heart Failure
● A clinical syndrome resulting from structural or functional cardiac disorders
that impair the ability of the ventricles to fill or eject blood
● HF is recognized as a clinical syndrome characterized by s/sx of fluid
overload or inadequate tissue perfusion
● Most HF is a chronic, progressive condition managed with lifestyle changes
and medications
● R-sided: viscera and peripheral congestion, JVD, dependent edema,
hepatomegaly, ascites, weight gain
● L-sided: pulmonary congestion, crackles, s3 or “ventricular gallop,” dyspnea
on exertion, low O2 sat, dry nonproductive cough, oliguria
■ Valvular diseases- IE and valve disorders
● Regurgitation: the valve does not close properly, and blood backflows
through the valve
● Stenosis: the valve does not open completely, and blood flow through the
valve is reduced
● Valve prolapse: the stretching of an atrioventricular valve leaflet into the
atrium during diastole
● Murmur on auscultation, HF sx- depending on valve
● Txt: valve repair/replacement
● Infective Endocarditis- usually develops in people with prosthetic heart
valves or structural cardiac defects; also occurs in pts who are IV drug
abusers and in those with debilitating disease, indwelling catheters, or
prolonged IV therapy
○ Inflammation of the heart caused by an infection
○ Vegetation on the valves
○ Clinical manifestations: Osler’s nodes, Janeway’s lesions, murmur
○ Txt: IV abx, valve repair/replacement
○ Oh Me Oh My: embolism
■ Cardiomyopathy
● Occurs when the muscle of the heart becomes weak, thick, rigid, or enlarged
causing the heart to possibly develop structural changes
● Weakened heart muscle- ineffective pumping, dysrhythmias
● Dilated- weak contraction r/t L ventricle enlargement, hypertrophic- L
ventricle stiffens, thickens, enlarges; seen in youth with sudden cardiac
death, restrictive- affects mostly elderly, impaired filling as a results of
ventricular stiffening
● Clinical manifestations: angina, HF sx
● Oh Me Oh My: HF, dysrhythmias, thrombosis
● Surgery: septal myectomy, ventricular remodeling, LVAD, heart transplant
■ Dysrhythmias- causes, treatments
● Disorders of formation or conduction (or both) of electrical impulses within
heart; can cause disturbances of rate, rhythm, both rate and rhythm
● Sinus bradycardia (HR<60 bpm)
○ Causes are hypoxia and/or hypothermia
○ Txt: atropine 0.5 mg IVP
○ Still see P wave and QRS complex
○ Sx: chest pain, syncope, SOB, hypotension, diaphoresis
● Sinus tachycardia (HR>100 bpm)
○ Causes are fever, anemia, hypotension, PE, MI
○ Txt: based on pt sx and causes
○ Sx: dizziness, fainting, lightheadedness, SOB, anxiety, sweating,
palpitations, hypotension
○ Still see P wave and QRS complex
● Atrial fibrillation
○ Causes: cardiomyopathy, pericarditis, pulmonary disease, HTN,
valvular disease, CAD
○ Txt: anticoagulants, beta blockers, dig, CCB, cardioversion,
ablation
○ High risk for stroke- blood pools in atria
○ Cannot see P wave but can see QRS complex
● Atrial Flutter
●
●
●
●
○ Causes: MI, valvular disease, thyrotoxicosis, COPD, CABG, dig
toxicity
○ Txt same as A fib
Ventricular Tachycardia
○ Causes: hypovolemia, hypoxia, acidosis, K imbalance,
hypoglycemia, hypothermia, toxins, tamponade, MI, PE
○ Txt: emergent with antiarrhythmic, electrolytes, cardioversion
○ No P wave, QRS big and wide
○ VT with a pulse vs VT without a pulse- always check for a pulse
first then intervene
○ If a pt has a pulse, txt is the same as A fib, amiodarone drip,
antiarrhythmic
○ If pt doesn’t have a pulse, begin CPR and call code
Ventricular Fibrillation
○ Causes are the same as V tach
○ Txt: emergency, defibrillation “d-fib for v-fib”
○ Quivering of ventricles, no cardiac output, pt is in arrest
○ Txt CPR with ACLS & emergency defibrillation
Asystole
○ No measurable heart electrical activity
○ A straight or flat line is produced on cardiac monitor
○ Compressions should be started immediately
○ CPR, epinephrine area treatment- there is no electrical impulse to
shock- always check a pulse before starting CPR
PEA- pulseless electrical activity
○ Electrical impulses but no muscle contraction
○ Rhythm on monitor but no palpable pulse
○ Treatment: CPR with ACLS; palpate the pulse!
○ Renal
■ Risk factors, s/sx, treatments, causes, complications:
● Pyelonephritis
○ Caused by an untreated bladder infection or a lower UTI or some
type of obstruction in the urinary tract that leads to stagnant urine
○ Sx: pain, burning upon urination, frequency, nocturia,
incontinence, hematuria
○ “UTI++” UTI sx + flank pain + sx of infection
○ Assessment of urine, urinalysis, and urine cultures- get a UA w/
cultures before starting abx
○ Complications: sepsis (urosepsis), AKI, CKD
○ Relieve pain, increase fluid intake, avoid urinary tract irritants,
frequent voiding, pt education on prevention
● Bladder cancer
○ More common after age 55; smoking increases risk
○ S/sx: visible painless hematuria
○ Dx: ureteroscopy, CT, MRI
○ Medical management: depends on grade/stage of tumor- chemo,
radiation
○ Surgical management: TURP, fulguration, bacille Calmette-Guerin
treatment, cystectomy, urinary diversion
● Glomerulonephritis
○ Acute Nephritic Syndrome: Glomerulonephritis
■ Manifestations: hematuria, edema, azotemia,
proteinuria, HTN, ↓ GFR, ↓ excretion of Na
■ Common cause is group A beta hemolytic strep infection
■ May be mild or may progress to acute kidney disease or
death
■ Medical management: antibiotics, corticosteroids,
immunosuppressants
■ Nursing management: monitor BP, BUN, creatinine, UA,
UOP; monitor I/Os; educate on dietary changes
○ Chronic Glomerulonephritis
■ Renal insufficiency or failure: asymptomatic for years as
glomerular damage increases before s/sx develop
■ Abnormal lab test results: urine with fixed specific gravity,
casts, proteinuria, electrolyte imbalances and
hypoalbuminemia
■ Medical management determined by sx
■ Causes: HTN, diabetes, autoimmune- good pastures, lupus
■ Assess BP, F&E imbalances, neurologic status, emotional
support, education in self-care
● Renal transplant
○ Txt of choice for ESRD
○ Donors: living or deceased
○ With living donor, both parties must meet criteria to be considered
for transplantation: both free from infection, both must complete
psychosocial evaluations
○ Post op assessment: pain, F&E status, patency and adequacy of
urinary drainage system
○ Complications: rejection, bleeding, pneumonia, infection, DVT
○ Analgesic meds, promote airway clearance and effective breathing
pattern, TCDB, IS, positioning, monitor UOP, use strict asepsis
with catheter, monitor for s/sx of bleeding, encourage leg
exercises, early ambulation
● Acute vs chronic renal failure
○ Acute kidney injury is a reversible syndrome that results in ↓
GFR and oliguria
■ Causes: hypovolemia, hypotension, reduced CO, HF,
obstruction of kidney or lower urinary tract, obstruction of
renal arteries or veins
■ Pre-renal, intra-renal post-renal
■ 4 stages: initiation, oliguria, diuresis, recovery
○ Chronic renal failure is a progressive, irreversible deterioration of
renal function that results in azotemia
■ Causes: DM, HTN, chronic glomerulonephritis,
pyelonephritis, obstruction, medications
■ 5 stages: stage 5 ESRD, GFR < 15, dialysis
■ Complications: hyperkalemia, pericarditis, pericardial
effusion, pericardial tamponade, HTN, anemia, bone
disease and metastatic calcification
● Dialysis- Hemodialysis and Peritoneal
○ Hemodialysis
■ Filtration of the blood using a machine to remove toxic
nitrogenous waste from the blood & removes excess fluid
■ Catheter is temporary vascular access, double lumen large
bore catheter- placed surgically
■ Red lumen- blood pumped from the pt through the dialyzer,
returns to pt through blue lumen
■ Risk factors for catheter: infection, hematoma,
pneumothorax
■ Requires vascular access to filter blood
● AV fistula- created by anastomosing a vein to an
artery; 2-3 months to mature
● AV graft- established by connecting an artery &
vein using synthetic tubing
■ Complications: Pulmonary edema, Hypotension, Muscle
cramping, Dysrhythmias, Dialysis disequilibrium
○ Peritoneal
■ Filters waste and excess fluid using the peritoneal cavity in
the abdomen
■ PD catheter placed in abdomen
■ Complications: infection/peritonitis, leakage, bleeding,
slow drain time/no drain
■ Instill→ dwell→ drain (all done by gravity)
● BPH and TURP
○ Benign prostatic hyperplasia; enlarged prostate; NOT cancer
○ Manifestations: those of urinary obstruction, urinary retention, and
UTIs
○ Sx depend on severity : dysuria, hesitancy, sensation of incomplete
bladder emptying
○ Medical txt: alpha-adrenergic blockers, measures to reduce pain
and spasms
○ Surgical txt: minimal invasive therapy, surgical resection, TURP
○ Complications: hemorrhage and shock, infection, VTE, catheter
obstruction
○ Gastrointestinal
■ GERD- s/sx, management
● Common disorder marked by backflow of gastric or duodenal
contents into the esophagus that causes troublesome sx and/or
mucosal injury to the esophagus→ excessive reflux may occur
because of an incompetent lower esophageal sphincter, pyloric
stenosis, hiatal hernia, or a motility disorder
● GERD is associated with: tobacco use, coffee drinking, alcohol
consumption, gastric infection with H. pylori
● Management: low fat diet, avoid caffeine, tobacco, beer, milk, food
containing peppermint or spearmint, and carbonated beverages; avoid eating
or drinking 2 hours before bedtime; elevate HOB 30 degrees
■ Hernias- s/sx, management, complications
● Occurs when the opening in the diaphragm through which the esophagus
passes becomes enlarged & part of the upper stomach moves up into the
lower portion of the thorax
● Sliding hernia: occurs when the upper stomach & gastroesophageal junction
are displaced upward & slide in and out of the thorax
● Paraesophageal hernia: occurs when all or part of the stomach pushes
through the diaphragm beside the esophagus
● Present with s/sx similar to those of GERD
● Meds: antacids, histamine receptor antagonists, proton pump inhibitors
● Educate pt to elevate HOB 30 degrees, lie on R side following meals, weight
maintenance, wear non-restrictive clothing, eat meals 2 hrs before lying
supine
● Txt: Nissen fundoplication, laparoscopic is gold standard
■ Ulcers- risk factors, s/sx, management, complications
● Erosion of a mucus membrane forms an excavation in the stomach, pylorus,
duodenum, or esophagus
● Associated with infection of H. pylori
● Risk factors: excessive secretion of stomach acid, dietary factors, chronic
use of NSAIDs, alcohol, smoking, and familial tendency
● Manifestations: dull, gnawing pain or burning in the midepigastrium;
heartburn and vomiting
● Treatment: meds, lifestyle changes, occasionally surgery
● Duodenal ulcer: improves with food or antacids, aggravated by fasting
● Gastric ulcer: worsened by eating, does not improve with antacids
● Complications:
○ Hemorrhage- occurs suddenly and severely
■ Sx similar to those of hypovolemia: weakness, dizziness,
cool/moist skin; loose, tarry stools, coffee ground emesis
■ May go into hypovolemic shock
■ Notify provider, monitor VS, admin IV fluids or blood,
place NGT
○ Perforation- contents are spilling out, can lead to severe infection
(peritonitis)
■ Rigid abdominal muscles, sudden onset of pain,
hypoactive/absent bowel sounds, abdomen distended
■ Notify provide, monitor VS, fever, keep NPO, insert NGT
if ordered
○ Penetration
■ Occurs gradually, involves penetration of ulcer through
adjacent organs
■ Referred pain, ensure pt remains NPO
○ Pyloric obstruction
■ Interferes with normal passage of gastric contents
■ Sx include: fullness, gastric reflux, weight loss, abd pain
■ Make pt NPO, insert NGT
■ Inflammatory bowel disease- s/sx, management
● Crohn’s disease
○ Less severe, typically no blood/mucus in diarrhea, electrolyte
disturbance, entire bowel wall, may actually penetrate wall, skips
lesions, cobblestone appearance
○ No cure
● Ulcerative colitis
○ 5-30 times per day, blood/mucus/pus in diarrhea,
hypoalbuminemia, mucosa/submucosa layers, continuous lesions
○ Management: bowel rest with TPN, meds, psychosocial
assessments
○ Can be cured with colectomy
● Attainment of normal bowel elimination patterns
■ Appendicitis- s/sx, diagnostics, management
● Appendix becomes inflamed and edematous as a result of becoming kinked
or occluded by a fecalith or lymphoid hyperplasia
● Common in individuals 10-19
● GOLD standard for dx- CT scan
● Clinical manifestations: severe RLQ rebound tenderness ( pain upon
removal of pressure at McBurney’s point)
● Txt: pain management, appendectomy
● Priority nursing intervention: make pt NPO
● Complications: gangrene, perforation, rupture, peritonitis
● Nurse will position pt for OR- supine with HOB elevated 30-45 degrees w/
knees flexed or side-lying w/ knees flexed
■ GI cancers- complications of treatments
● Esophageal cancer
○ Complaints of dysphagia
○ Treatment : radiation, chemo, CAM, esophagectomy, ablation
○ Complications: dysphagia, N/V, effects of chemo (stomatitis,
mucositis, N/V, neutropenia, diarrhea)/radiation (ulceration of
skin, blistering, fibrosis of esophagus)
● Gastric cancer
○ Treatment: chemo, radiation, surgical removal of tumor
○ Following a partial gastrectomy, may experience a complication
known as dumping syndrome- occurs when partially digested food
enters the small bowel rapidly causing distension
■ Early s/sx: sweating, dizziness, tachycardia, pallor,
palpitations
■ Management: consuming smaller, more frequent meals;
consume solids; liquids at different times
■ Hepatitis, cirrhosis, pancreatitis- s/sx, management
● Hepatitis
○ A & E: fecal-oral route
○ B & C: blood-borne
○ D: only people with hep B are at risk
○ Prevention: good handwashing, wearing gloves
● Cirrhosis
○ Manifestations: liver enlargement, portal obstruction, ascites,
infection and peritonitis, varices, GI varices, edema, vitamin
deficiency, anemia, mental deterioration
○ Promote rest, improve nutritional status, provide skin care, reduce
risk of injury
○ Complications: bleeding & hemorrhage, hepatic encephalopathy,
fluid volume excess
● Pancreatitis
○ Acute: pancreatic duct becomes obstructed, and enzymes back up,
causing autodigestion and inflammation of the pancreas
○ Chronic: progressive inflammatory disorder with destruction of the
pancreas; cells are replaced by fibrous tissue; pressure within the
pancreas increases, obstructing the pancreatic and common bile
ducts