Med/Surge Final
Cancer
 Chemotherapy
o Use of antineoplastic drugs that prevent the growth of new cells (both healthy ones and
malignant ones)
o Goal is to cure or control cancer
o Must be admin’ed in a monitored environment
o Routes: IV, oral, dose calculated by BSA
o Extravasation  IV chemo are classified by their potential to damage tissue if there is an
inadvertent leak from vein into surrounding tissue
 Chemotherapy Side Effects
o Hypersensitivity Reaction (HSR) – high risk with chemo agents with life threatening outcomes
within 1 hour of infusion or delayed hours afterward. Unexpected and associated with rash,
urticaria, fever, hypotension, cardiac instability, respiratory complications
o GI – N/V/D, constipation
o Hematopoietic – anemic (fatigue, fever/chills, lethargy), SOB, bruising/bleeding
o Renal – GFR, BUN, creatinine all affected, income/output, electrolyte values (potassium)
o Cardiopulmonary – HR, EKG, O2 sat, pulse, BP, ischemia, damaged valves
o Reproductive – menstruation, pregnancy
o Neurologic – confusion, orientation, mental status, extremity function, speech, cranial nerves
o Cognitive impairment – can’t recall info
o Fatigue
o Stomatitis
o Alopecia
o Myelosuppression – depression of bone marrow
o Leukopenia
o Neutropenia
 Chemo Effect on Cell Counts
o WBC – causes leukopenia (decreased WBC count), neutropenia (decreased granulocytes)
o Platelets – thrombocytopenia (low platelet counts), increases r/o bleeding and bruising, anemia
(fatigue, fever/chills, lethargy)
o Both cause increased r/o infection and bleeding
Pain
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Pain Management
Assessment and Reassessment
o Pain is subjective
o PT self-reports pain, pain scale 0-10, faces (0-3 milk, 4-6 moderate, 7-10 intense)
o Pain interview includes
 Location, intensity, quality, onset/duration, aggravating and relieving factors, effect of
pain on function and quality of life, comfort goal/function goal, others
 PQRST – Provoking events (what were you doing), quality (sharp, dull, tingling,
stabbing, burning, crushing), Region/radiation (focal, radiate different location?),
Severity (pain scale), Time frame (duration, when did it start, how long does it last?)
 FLACC scale – young children
 PAINAD – patients with advanced dementia
 CPOT – patients in critical care units
o Reassessing Pain
 Pain is assessed and reassessed and documented on a regular basis
 Reassessed with each new report of pain, before and after analgesic agents/interventions
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 Frequency of reassessment depends on stability of PT and guided by policy
Patient teaching with PCA
o Allows PTs to treat pain by self-administering doses of analgesic agents
o Recommended IV PCA for postop pain mgt
o Device programmed so PT can press a button to self-admin a dose at a set time interval as
needed
o PTs must understand relationships among pain, pushing the PCA button or taking the agent, and
pain relief
o PTs must be cognitively and physically able to use the equipment
o Benefit – recognizes only the PT can feel the pain and only the PT knows how much analgesic
will relieve it
o Not an unlimited amount of the drug, there is a limit and the staff can see how many time sthe
PT is pressing the button
Central Venous Access Device
 Patient Teaching for Self-Care of CVAD
 Parenteral Nutrition – Complication Prevention
Hematological
 Multiple Myeloma Complications
o Multiple Myeloma – malignant disease of the plasma cell (most mature form of B lymphocyte)
o Manifests as bone pain (80%) mostly back and ribs, osteoporosis and fractures RT bone
destruction, hypercalcemia, renal impairment and failure, anemia
o Plasma offers immunoglobulin support, so with multiple myeloma this protective factor is gone
o CRAB
 C – hyperCalcemia
 R – Renal impairment
 A – Anemia
 B – bone pain
o Big risk of infection
 Lymphoma – Dx of Hodgkin’s VS Non-Hodgkin’s
o Hodgkin’s
 The hallmark sign of Hodgkin’s Lymphoma is the Reed Sternberg Cell
 Reed Sternberg Cell – large, abnormal lymphocyte that may contain more than 1 nucleus
 Hodgkin’s is relatively rare and has a high cure rate
 Spread of Hodgkin’s, usually starts in the neck. Big trigger is Ebbstein-Barr virus.
Normally Unicentric, one node has the malignancy and then it spreads
 Manifestations – painless lymph node enlargement, pruritus, B symptoms (fever, sweats,
weight loss) means disease is progressing
o Non-Hodgkin’s
 Absence of Reed Sternberg Cell
 Spread is normally multi-site, spread is unpredictable, localized is rare
 Manifestations - lymphadenopathy, B symptoms, symptoms associated w/
lymphomatous masses
 Blood Transfusions
o Indications
 Volume replacement and oxygen-carrying capacity
 Symptomatic anemia
 Bleeding due to severe low platelets
 Prevent bleeding when platelets are less than 5,000
o Administration procedure
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Admin requires knowledge of correct administration techniques and complications
Informed consent necessary
Steps
 Apply PPE as required
 Prepare and prime Y-type tubing with NS
 Rotate blood bag gently back and forth a few times and spike it
 Transfuse at a rate of approx. 2mL/min for the first 15 minutes, observe client
carefully for any s/s of adverse reactions (itching, hives, rash, flushing, dyspnea)
 Stay w/ client and take vitals every 5-15 mins
 If no adverse effects noted, increase transfusion rate to the rx’d rate to ensure
blood is transfused within the time frame allowed (no longer than 4 hours)
 Once all blood is admin’ed, flush tubing with NS, obtain vitals, discard blood
admin equipment and document
 Nurse job to prepare patient, type and cross, administer, monitor, educate
Anticoagulation
o PT Teaching: Warfarin
 Administer same time each day to keep them within therapeutic window
 Medic alert tags – in case PT is unresponsive
 Appointments for blood tests – warfarin PT must get tests done every month
 Drug to drug interactions
 Symptoms of bleeding
 Vitamin K reverses effectiveness of warfarin
o Interpretation of Lab Results for Therapy
 PT (prothrombin time)
 Measures activity of the extrinsic pathway
 Measures effectiveness of warfarin
 Reference range (9.5-12 seconds)
 Therapy range (1.5-2x the baseline value)
 INR (international normalized ratio)
 Same thing
 Reference range (1)
 Therapy range (2-3.5)
o Assessment for Complications
 Bleeding
 Red/brown urine
 Black/bloody stool
 Severe HA or stomach pain
 Joint pain, discomfort, swelling
 Vomiting of blood or coffee ground material
 Coughing up blood
Fluid and Electrolytes
 Fluid Volume Deficit (Hypovolemia)
o Manifestations
 Acute weight loss
 Decrease in skin turgor
 Oliguria
 Concentrated urine
 Capillary refill time prolonged
 Decreased BP
 Flattened neck veins
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 Dizziness
 Weakness
 Thirst and confusion
 Increased pulse
 Muscle cramps
 Sunken eyes
 Nausea
 Increased body temperature
 Cool, clammy, pale skin
 Dehydration
 Severity of manifestations depends on degree of fluid loss, s/s can develop rapidly
o IV Therapy Indications
 To provide water, electrolytes, nutrition
 To replace water loss and correct electrolyte deficits
 To administer medications and blood products
 Who needs H2O replacement? Dehydrated patients, patients on diuretics
Hypo/hypercalcemia
o Manifestations
 Hypo – tetany, circumoral numbness, paresthesias, hyperactive deep tendion reflexes,
Trousseau sign, Chvostek sign, seizures, respiratory symptoms of dyspnea and
laryngospasm, abnormal clotting, anxiety
 Hyper – polyuria, thirst, muscle weakness, intractable nausea, abdominal cramps, severe
constipation, diarrhea, peptic ulcer, bone pain, ECG changes, dysrhythmias
o Interventions
 Hypo – IV calcium gluconate, seizure precautions, oral calcium and vitamin D
supplements, exercises to decrease bone calcium loss, PT teaching
 Hyper – treat underlying cause, IV fluids (furosemide, phosphates, calcitonin,
bisphosphonates), increase mobility, encourage fluids, dietary teaching, fiber for
constipation, ensure safety
Hypo/hyperkalemia
o Manifestations
 Hypo – ECG changes, dysrhythmias, dilute urine, excessive thirst, fatigue, anorexia,
muscle weakness, decreased bowel motility, paresthesias
 Hyper – cardiac changes, dysrhythmias, muscle weakness, paresthesias, anxiety, GI
manifestations
o Interventions
 Hypo – potassium replacement, increased dietary potassium or IV for severe deficit,
monitor for ECG changes, monitor ABGs, monitor for early s/s, monitor PTs receiving
digitalis for toxicity, admin IV potassium only after adequate urine output has been
established
 Hyper – monitor ECG, assess labs, monitor I&Os, obtain apical pulse, limit intake of
potassium, admin of cation exchange resins (Kayexalate PO or enema, compound that
attracts/withdraws potassium from blood to GI tract and into your poop). Emergent care –
IV calcium gluconate, IV sodium bicarbonate, IV regular insulin and hypertonic dextrose,
beta-2 agonists, dialysis
Hypo/hypernatremia
o Manifestations
 Hypo – poor skin turgor, dry mucosa, HA, decreased salivation, decreased blood
pressure, nausea, abdominal cramping, neurologic changes
 Hyper – thirst, elevated temperature
o Interventions
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Hypo – treat underlying condition, Na replacement, water restriction, meds, I&Os, daily
weights, lab values, CNS changes, encourage dietary sodium, monitor fluid intake,
effects of meds (diuretics, lithium), give normal saline
 Hyper – gradual lowering of serum sodium levels via infusion of hypotonic electrolyte
solution, diuretics, assessment for abnormal H2O loss and low water intake, assess for
OTC sources of sodium, monitor for CNs changes,
Acid Base Disturbances
o Acidosis
 Metabolic – low pH, low bicarbonate
 Most commonly due to kidney injury
 Respiratory – low pH, high PaCO2
 Always RT respiratory problem with inadequate excretion of CO2
(hypoventilation)
o Alkalosis
 Metabolic – high pH, high bicarbonate
 Most commonly due to vomiting or gastric suction, or medications (long term
diuretics)
 Respiratory – high pH, low PaCO2
 Always due to hyperventilation
o Manifestations
 Metabolic Acidosis
 HA, confusion, drowsiness, increased RR and depth, decreased BP, decreased
CO, dysrhythmias, shock, if decrease is slow, PT may be asymptomatic until
bicarb is 15 or less
 Metabolic Alkalosis
 s/s decreased calcium, respiratory depression, tachycardia, s/s hypokalemia
 Respiratory Acidosis
 Sudden increased pulse, respiratory rate, BP. Mental changes, feeling of fullness
in head. Increased ICP
 Respiratory Alkalosis
 Lightheadedness, can’t concentrate, numbness and tingling, sometimes loss of
consciousness
o Interventions
 Metabolic Acidosis
 Treat underlying problem, correct the imbalance
 Bicarbonate may be administered
 Measure I&Os, BUN, creatinine, electrolytes
 As acidosis is corrected, potassium shifts back into cells which treats
hyperkalemia
 Monitor potassium levels
 Ca may be low
 Metabolic Alkalosis
 Tx underlying disorder
 Supply chloride to allow excretion of excess bicarbonate
 Restore fluid volume with sodium chloride solutions
 Respiratory Acidosis
 Improve ventilation (naloxone for OD’s), incentive spirometer, sitting up, deep
breathing/coughing exercises
 COPD PTs may live in chronic state of respiratory acidosis
 Respiratory Alkalosis
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Correct the cause of hyperventilation
Respiratory
 Chest Tube Drainage System
o Proper Functioning & Maintenance
 Negative pressure principle
 Suction control, water seal
 Systems have a suction source, a collection chamber and a mechanism to prevent air from
reentering the chest with inhalation
 Wet or dry is how it works
 Fill water chamber up to 20 and that chamber should be bubbling
 Collection chamber – document drainage, mark chamber with date and time
 Water seal chamber – keep it filled at the zero line, inspect for NO bubbles
 Suction control chamber – keep it filled at 20 off suction, should see bubbles when
attached to suction
 Change in ITP makes column rise and fall which is normal and expected
 Pulmonary Embolus
o Manifestations
 Dyspnea
 Chest pain (sudden, pleuritic) not same as MI pain
 Anxiety, apprehension
 Fever
 Tachycardia
 Syncope
 Cough, hemoptysis (coughing up blood)
 Diaphoresis
 Bronchiole constriction
 Shock
 Perfusion imbalance
 Right ventricular failure
 Pneumonia
o Risk Factors
 Underlying disorders/diseases
 Heart failure, diabetes, alcoholism, COPD, AIDS
 Influenza
 Cystic fibrosis
 PCP: Pneumocystis pneumonia – type that AIDS patients get
 Autoimmune diseases
 Medications
 Obesity
 Age
 COVID
 Sedentary lifestyle
 Pneumothorax
o Clinical Manifestations
 Sharp, stabbing chest pain that worsens with inspiration
 Shortness of breath
 Bluish skin RT hypoxia
 Fatigue
 Rapid breathing and heartbeat
 Dry, hacking cough
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Atelectasis
o Clinical Manifestations
 Difficulty breathing
 Tachycardia
 Coughing
 Chest pain
 Skin and lips turning blue
 Wheezing
 Rapid, shallow breathing
 Low grade fever
DVT Prophylaxis
o Nursing Interventions
 Sequential compression devices
 Heparin
 Warfarin/coumadin
 Blood thinners
 Anticoagulation medication
 Assess for S/S of DVT/PE/VTE
 Exercises to avoid venous stasis
 Early ambulation
 Antiembolic stockings – always on for high risk PTs
 If known DVT in leg – do not use antiembolism stockings/devices
Cardiovascular
 Hypertension
o PT Education on Metoprolol
 Take with meal or just after am meal
 Take it at the same time each day
 Do not crush or chew
 Do not abruptly stop the medication, rebound HTN
 Monitor blood pressure
 S/E – dizziness, insomnia, depression, fatigue, nightmares, sexual dysfunction
o Complications of Diuretic Use
 Fluid volume deficit
 Dehydration
 Dizziness
 Headaches
 Muscle cramps
 Joint disorders
 Impotence
 Percutaneous Transluminal Coronary Angioplasty (PTCA)
o Post-procedure assessment
 Hospital based procedure
 PTs receive IV heparin or a thrombin inhibitor
 Remain flat in bed and keep affected leg straight until the sheaths are removed, then
elevate HOB
 Assess for bleeding
 Assess for hematoma formation
 Relieve pain, maintain adequate tissue perfusion, maintain body temperature, promote
health and community-based care
o Complications
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Coronary artery dissection, perforation, abrupt closure, vasospasm
Acute MI, serious dysrhythmias (VTACH), cardiac arrest
Post-procedure – abrupt closure of coronary artery, bleeding at insertion site,
retroperitoneal bleeding, hematoma, arterial occlusion
R/o acute kidney injury from contrast agent
Bleeding at puncture site (color changes in skin, hematomas, hard skin)
Lack of perfusion to affected extremity, limb ischemia
Retroperitoneal bleeding manifests as back pain, confirm with Hg and HCT levels they
would be dropping
Angina
o Assessment
 PT may describe tightness, choking, heavy sensation
 Frequently retrosternal and may radiate to the neck, jaw, shoulders, back or arms (usually
left)
 Anxiety frequently accompanies the pain
 Other symptoms may occur – dyspnea, SOB, dizziness, nausea, vomiting
 Pain subsides with rest or NTG (typical angina)
 Unstable angina – increased frequency and severity and is not relieved by rest and NTG,
requires medical intervention
o Treatment
 NTG (Nitroglycerin) – a vasodilator, hopefully takes chest pain away. Can cause HOTN
 Rest
 Decrease myocardial oxygen demand and increase oxygen supply
 MONA
 Morphine
 Oxygen
 Nitroglycerin
 Aspirin
 Medications
 Oxygen
 Reduce and control risk factors
 Reperfusion therapy may also be done
Heart failure
o Clinical Manifestations
 Ejection fraction <40%
 Dyspnea, orthopnea, cough, pulmonary crackles, weight gain, dependent edema,
abdominal bloating or discomfort, ascites, JVD, sleep disturbance, fatigue (right sided)
 Decreased exercise tolerance, muscle wasting/weakness, anorexia/nausea, unexplained
weight loss, lightheadedness, confusion, altered MS, resting tachycardia, daytime oliguria
with recumbent Nocturia, cool or vasoconstricted extremities, pallor or cyanosis (left
sided) S3, ventricular gallop
o Evaluation for Improvement
 Promote activity and reduce fatigue
 Relieve fluid overload symptoms
 Decrease anxiety or increase PTs ability to manage anxiety
 Encourage PT to verbalize ability to make decisions
 Educate
 Evaluate ejection fraction
 Treat s/s