48 Hour Cram Sheets for Med Surg
BRAIN TUMOR
48 Hour Cram
Sheets for Med Surg
Simplenursing.com Less Study Time HIGHER test scores!
Page 1 of 106
48 Hour Cram Sheets for Med Surg
BRAIN TUMOR
Table of Contents
1.
CANCER (ONCOLOGY) ...................................................................................................................... 7
BRAIN TUMOR...................................................................................................................................... 7
COLON CANCER.................................................................................................................................... 8
LEUKEMIA............................................................................................................................................. 9
OVARIAN CANCER .............................................................................................................................. 11
PROSTATE CANCER ............................................................................................................................ 12
PANCREATIC CANCER ......................................................................................................................... 13
2.
NEURO: CNS ................................................................................................................................... 15
ALZHEIMERS ....................................................................................................................................... 15
BRAIN TUMORS .................................................................................................................................. 17
CEREBERAL VASCULAR ACCIDENT (CVA) ........................................................................................... 18
EPILEPSY ............................................................................................................................................. 20
HEAD INJURY ...................................................................................................................................... 23
MULTIPLE SCLEROSIS (MS)................................................................................................................. 24
MENINGITIS........................................................................................................................................ 25
PARKINSON’S ..................................................................................................................................... 26
SEIZURE .............................................................................................................................................. 27
SPINAL INJURY.................................................................................................................................... 30
3.
NEURO: PNS ................................................................................................................................... 32
GUILLAIN-BAR SYNDROME ................................................................................................................ 32
MYASTHENIA GRAVIS ......................................................................................................................... 33
4.
GASTRO INTESTINAL (Lower) ......................................................................................................... 36
APPENDICITIS ..................................................................................................................................... 36
SBO (SMALL BOWEL OBSTRUCTION) ................................................................................................. 37
CONSTIPATION ................................................................................................................................... 38
HERNIA ............................................................................................................................................... 39
PARALYTIC ILEUS ................................................................................................................................ 40
ISCHEMIC BOWEL/COLITIS ................................................................................................................. 41
VOLVULUS .......................................................................................................................................... 42
DIVERTICUITIS .................................................................................................................................... 43
RESECTION OF INTESTINES ................................................................................................................ 44
Page 2 of 106
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
BRAIN TUMOR
INFLAMMATORY BOWEL DISEASE ..................................................................................................... 46
COLORECTAL CANCER ........................................................................................................................ 46
5.
ORTHOPEDICS (BONES) .................................................................................................................. 48
HIP FRACTURE .................................................................................................................................... 48
TOTAL KNEE REPLACEMENT (TKR) ..................................................................................................... 49
LONG BONE INJURY ........................................................................................................................... 50
OSTEOARTHRITIS (OA) ....................................................................................................................... 51
RHUMATOID ARTHRITIS (RA) ............................................................................................................. 52
GOUT .................................................................................................................................................. 53
6.
VASCULAR DISORDERS ................................................................................................................... 55
PAD (PERIPHERAL ARTERY DISEASE) .................................................................................................. 55
PVD (PERIPHERAL VASCULAR DISEASE) ............................................................................................. 56
ANEURYSMS ....................................................................................................................................... 58
7.
RESPIRATORY ................................................................................................................................. 60
ASTHMA ............................................................................................................................................. 60
BRONCHITIS ....................................................................................................................................... 61
COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE) ................................................................... 62
EMPHYSEMA ...................................................................................................................................... 63
HEMOTHORAX ................................................................................................................................... 64
PNEUMOTHORAX............................................................................................................................... 65
PNEUMONIA ...................................................................................................................................... 66
PULMONARY EMBOLISM ................................................................................................................... 67
RESPIRATORY FAILURE ....................................................................................................................... 68
TUBERCULOSIS ................................................................................................................................... 69
URI (UPPER RESPIRATORY INFECTION) ............................................................................................. 70
8.
CARDIAC (HEART) ........................................................................................................................... 71
ANGINA .............................................................................................................................................. 71
ARRHYTHMIAS ................................................................................................................................... 72
ACUTE CORONARY SYND. (ACS) ......................................................................................................... 73
ATRIAL FIBRILLATION (A-FIB) ............................................................................................................. 74
CARDIOGENIC SHOCK......................................................................................................................... 75
CABG (Coronary Artery Bypass Graft) ................................................................................................ 76
Simplenursing.com Less Study Time HIGHER test scores!
Page 3 of 106
48 Hour Cram Sheets for Med Surg
BRAIN TUMOR
CHF (Congestive Heart Failure) .......................................................................................................... 77
CAD (Coronary Artery Disease) .......................................................................................................... 78
HTN (Hypertension) ........................................................................................................................... 79
HYPERLIPIDEMIA (High Cholesterol) .................................................................................................. 80
9.
ENDOCRINE .................................................................................................................................... 81
DIABETES TYPE I ................................................................................................................................. 81
DIABETES TYPE II ................................................................................................................................ 82
HYPOGLYCEMIA ................................................................................................................................. 83
HYPERGLYCEMIA ................................................................................................................................ 84
DIABETIC KETOACIDOSIS (DKA).......................................................................................................... 86
10.
GALLBLADDER & LIVER & APPENDIX.......................................................................................... 87
APPENDICITIS ..................................................................................................................................... 87
CHOLECYSTITIS ................................................................................................................................... 88
HEPATITIS ........................................................................................................................................... 89
PANCREATITIS .................................................................................................................................... 90
CIRRHOSIS .......................................................................................................................................... 91
11.
KIDNEY (RENAL).......................................................................................................................... 93
ACUTE RENAL FAILURE (ARF) ............................................................................................................. 93
CHRONIC RENAL FAILURE (CRF) ......................................................................................................... 95
CHRONIC RENAL INSUFFICIENCY........................................................................................................ 96
NEPHROTIC SYNDROME..................................................................................................................... 97
KIDNEY STONES .................................................................................................................................. 98
GLOMERULONEPHRITIS ..................................................................................................................... 99
TURP (Trans urethral resection of prostate) .................................................................................... 101
URINARY TRACT INFECTION (UTI) .................................................................................................... 102
BPH (Benign Prostate Hypertrophy) ................................................................................................ 103
12.
WOMEN’s HEALTH ................................................................................................................... 104
UTERINE FIBROIDS ........................................................................................................................... 104
OVARIAN CANCER ............................................................................................................................ 105
13.
Bibliography ............................................................................................................................. 106
Page 4 of 106
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
BRAIN TUMOR
With over 8 years in the medical field, Mike Linares has worked both out in
the field on an Ambulance in the dangerous streets of Los Angeles County
and the in crazy busy the Emergency Rooms. Coupled with his passion for
teaching & desire to help other students and mixed with his chronic typpos
and bad grammmer, SIMPLEnursing.com was born to not only help his
fellow RN students, but nursing students worldwide.
"I hope you enjoy the valuable jewels that Simplenursing.com has to offer.
If so please let me know! I am a real person & I´d love to hear your
thoughts good or bad on Face book, Twitter, or Youtube."
Committed to Your Success, Mike
P.S.Feel free to Face book, Twitter, or Youtube me!! 
Mike Linares
Student Nurse Mentor & Certified EKG Instructor
HOW THIS WHOLE THING CAME TO BE...
Before Helping Multiple Successful Nursing Students
Excel I Was The "Drone" Nursing Student Working Too
Hard & Eventually I FAILED OUT of Nursing School.
Before Helping Hundreds of Struggling Nursing Students Reach Graduation Day & Before Becoming a
Student Nurse Mentor & Certified EKG Instructor, I Myself Was A Struggling "At Risk" Student Nurse
Drowning In My Books & Lost In Clinical.
I was that struggling student working full time in the Emergency Room at one of those
MEGA hospitals in Orange, California. I worked as an EMT aka a "medic" for 8 years
prior to failing out. I knew how to take care patients, I knew the basics of the ABCs of
basic life support, I knew how to take vital signs and how to fix minor injuries. I thought I
had enough experience to skate right through nursing school, I remember thinking "how
hard can it be" right?
After two semesters, I FAILED out of the Program.
I felt defeated, depressed and like a loser. It was one of the lowest points of my life.
Sitting in my room practically bawling my eyes out, I remember quotes my mom and
dad used to encourage me with, "son, whatever doesn´t kill you, Makes you Stronger" &
" Failing is Not a Bad Thing, As long as learn, become better, and NEVER EVER QUIT"
Simplenursing.com Less Study Time HIGHER test scores!
Page 5 of 106
48 Hour Cram Sheets for Med Surg
BRAIN TUMOR
My Clinial FAILURE form had bold red letters stating:
LACK In Prepared
LACK Organizational Skills
LACK Critical Thinking with Nursing Process
Ending with:
"able to return next semester contingent upon demonstrating INCREASED
COMPETANCIES in these core areas."
"NEVER GIVE UP!!" my mom & dad used to tell me, so I set out on a Quest
to develop a system to make Simplify Nursing School!
What Happened Next Might Surprise you,
In a systematic way to put all the "core competencies" of nursing school that instructors look for to
pass students. My quest was to make it SIMPLE first and foremost, by cutting out the fluff and getting
down to the nitty critty making it easier.
The Goal Was To Make A Simple System...
And the best part is it was really helping myself and other students in my class pass their tests when I
would share with them my strategies and systems to help them pass their tests without having to
memorize everything in the book!
This is where my mentoring for student nurses began.
That's when something clicked and everything changed for me.
It was like I had an Ah - HA moment!
At that moment I realized there are better, more predictable, and more low cost ways to get higher test
scores and have more critical thinking skills than the money I had been spending on dead end study
books that claimed to help but really just confuse me more.
I needed simplicity!!!
Within the next six months I had created over 27 different student help systems, strategies and tactics
that produced better results for me - some better than others.
Then over the next few semesters I tracked, tested, and tweaked each system until my students were
passing with a 82% or better on each and every test, 2 students being out of School for over 25 years
& coming back to score 94% on their EKG cardiac test! Truly amazing & truly making me proud to be
their mentor.
Page 6 of 106
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
BRAIN TUMOR
1. CANCER (ONCOLOGY)
DIAGNOSIS/PATHO
BRAIN TUMOR
Patho: Defined as an intracranial solid
neoplasm, or an abnormal growth of
cells in brain or central spinal canal. No
known cause or risk factor.
Graded as: low, intermediate or high
Can be located in several areas of the
brain:
-Healthy cells transform/mutate into
malignant cells upon exposure to certain
etiologic factors such as: Viruses,
Chemicals, and Physical agents. When
cells are malignant, they can metastasize
into tissues surrounding the area, to the
lymph nodes and lymphatic system, the
DATA
ACTION
Assess: Neurological status, ALOC,
worsening symptoms/impairment,
↑ICP
Vitals: Normal, until near death
S/S & PHYS. EXAM:
- Headache
-Nausea/Vomiting
-ALOC/Changes in speech, vision or
hearing
-Issues with gait, balance or walking
-Changes in mood, personality,
ALOC
-Memory problems/inability to
concentrate
- Seizures/Convulsions
-Muscle twitching/jerking
-Numbness/Tingling in extremities
Nursing Interventions:
Pharm: **DEPENDS ON
SIZE & TYPE OF TUMOR, AS
WELL AS OVERALL HEALTH
STATUS:
- Chemotherapy
Targeted therapy:
-Avastin/bevacizumab (for
Labs: Spinal tap, biopsy
Dx Tests: Neurological exam, MRI,
CT Scan, Angiogram
Simplenursing.com Less Study Time HIGHER test scores!
glioblastoma)
- Afinitor/everolimus (used
to treat a benign brain tumor)
Alternative Medicine:
-Acupuncture
-Hypnosis
-Music Therapy
-Relaxation Techniques
Pt. Ed: Referral to OT, PT,
ST (Speech therapy) and
tutoring (if child, and
learning/memory problems
Surgery: Removal of
tumor (If able to)
Page 7 of 106
RESPONSE
Nursing Dx:
-Disturbed Body Image r/t
changes in the structure and
function of the brain/body
-Fear r/t recent diagnosis and
unknown future
Pt. Goals/ Evaluation:
-Pt will verbalize concerns and
fears about body, self
perception and change of
lifestyle
-Pt will verbalize anxiety as well
as ways to reduce it/minimize
with it.
48 Hour Cram Sheets for Med Surg
COLON CANCER
blood, and system wide to other
organs/cavities.
(Most common types of brain
tumors/locations)
COLON CANCER
Patho: Colon cancer occurs in the
lower part of the digestive system.
Cancer in the colon can begin as small
benign clumps in the colon, known as
adenomatous polyps.
In time, these polyps can develop into
colon cancer.
Assess: Last Colonoscopy?
RISK FACTORS:
-Older Adult men/women
-Race (African-American)
-Genetic/Family history/Personal
Hx
-Diet high in red meat and fat and
low in fiber
-Inflammatory bowel diseases
The American Cancer Society 7
WARNING SIGNS for Cancer:
C – Change in bowel/bladder habits
A – A sore that that doesn’t heal
U – Unusual Bleeding/Discharge
T – Thickening/lumps in
breast/body
I – Indigestion/Difficulty swallowing
O – Obvious change in wart/mole
N - Nagging, coughing or
hoarseness
-Healthy cells transform/mutate into
malignant cells upon exposure to certain
Page 8 of 106
Nursing Interventions:
Pharm: Chemotherapy,
Radiation therapy, and
Targeted drug therapy
(bevacizumab/Avastin,
cetuximab/ Erbitux,
panitumumab/Vectibix and
regorafenib/Stivarga)
Pt. Ed: Maintenance of
Colostomy bag/care if
needed, returning for
testing, side effects of
meds/ colostomy bag,
support system
Surgery: Removal of
polyps (If possible), Partial
Colostomy, Full
colostomy/surgical removal
Vitals: Normal unless distressed
S/S & PHYS. EXAM:
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Anticipated loss of
physiological well-being r/t loss
of body part, change in body
function, change in lifestyle and
perceived potential death of
patient
-Situational low self-esteem r/t
disfiguring surgery,
chemotherapy or radiotherapy
side effects, e.g., loss of hair,
nausea/vomiting, weight loss,
anorexia, impotence, sterility,
overwhelming fatigue,
uncontrolled pain
Pt. Goals/ Evaluation:
-Pt will continue daily activities,
identify feelings and fears
towards lifestyle change and
diagnosis, Pt will understand
and verbalize the grieving and
death process
- Pt will verbalize acceptance of
diagnosis, control over health
48 Hour Cram Sheets for Med Surg
LEUKEMIA
etiologic factors such as: Viruses,
Chemicals, and Physical agents. When
cells are malignant, they can metastasize
into tissues surrounding the area, to the
lymph nodes and lymphatic system, the
blood, and system wide to other
organs/cavities. All cancers are staged
between I-IV, with Stage I being the least
severe and Stage IV being the most
severe.
- Change in your bowel habits
(diarrhea, constipation,
consistency)
- Blood in your stool
- Persistent abdominal discomfort,
such as cramps, gas or pain
- Feeling your bowel doesn't empty
completely
- Weakness/fatigue
- Unexplained weight loss
Labs: Stool sample to check for
blood or dead cancerous cells
Dx Tests: Colonoscopy, CT Scan
Assess:
LEUKEMIA
RISK FACTORS:
Patho: MALIGNANCIES OF THE BLOOD-Genetic/Family history:
FORMING CELLS:
- Philadelphia chromosome: DNA
exchange between chromosomes 9
& 22, creating an oncogene
- Li-Fraumeni syndrome: an
inherited mutation in a tumorsuppressor gene (TP53)
-Exposure to: Radiation, Benzene,
Cigarette smoke
-Down syndrome
-Healthy cells transform/mutate into
malignant cells upon exposure to certain
etiologic factors such as: Viruses,
The American Cancer Society 7
WARNING SIGNS for Cancer:
C – Change in bowel/bladder habits
A – A sore that that doesn’t heal
U – Unusual Bleeding/Discharge
Simplenursing.com Less Study Time HIGHER test scores!
status and demonstrate
utilization of support systems
and therapy as prescribed
Nursing Interventions:
(**Depends on type of
Leukemia, severity and Age
of Patient)
Pharm: Chemotherapy,
Radiation, Biological
therapy, Targeted Therapy
(Imatinib/Gleevec &
dasatinib/ Sprycel), Stem
Cell Transplant
Pt. Ed: DON’T WAIT TO
GET TREATMENT! TIMING
IS IMPORTANT! Know the
side effects of medication
as well as supportive
measures:
- Vaccines
- Blood/Platelet
Transfusions
Page 9 of 106
Nursing Dx:
- Pain r/t enlarged organs/
lymph nodes and treatment for
diagnosis
-Risk for infection r/t
compromised immune system
Pt. Goals/ Evaluation:
- Pt will report pain at tolerable
level and verbalize ways to
manage it
- Pt will identify signs and
symptoms of infection and
verbalize ways to minimize
chances of infection
48 Hour Cram Sheets for Med Surg
LEUKEMIA
Chemicals, and Physical agents. When
cells are malignant, they can metastasize
into tissues surrounding the area, to the
lymph nodes and lymphatic system, the
blood, and system wide to other
organs/cavities. All cancers are staged
between I-IV, with Stage I being the least
severe and Stage IV being the most
severe.
T – Thickening/lumps in
breast/body
I – Indigestion/Difficulty swallowing
O – Obvious change in wart/mole
N - Nagging, coughing or
hoarseness
- Antibiotics
- Analgesics for Pain
- Immunoglobulins
- Red & White cell growth
factors
Surgery: Removal of
spleen (if inflamed)
Vitals: Normal unless distressed
S/S & PHYS. EXAM:
- Fever/Night sweats
- Swollen lymph nodes (usually
painless)
- Feelings of fatigue, tiredness
- Easily bleeding or bruising, causing
bluish or purplish patches on the
skin/nosebleeds
- Frequent infections
- Bone/joint pain
- Unexplained weight loss/Anorexia
-Enlargement of the spleen or liver,
which can lead to abdominal
pain or swelling
- Red spots on the skin (petechiae)
(** If leukemia cells have infiltrated
the brain: headaches,
Page 10 of 106
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
OVARIAN CANCER
seizures, confusion, loss of muscle
control, and vomiting may occur)
Labs: Abnormal blood test, bone
marrow tests, genetic testing
Dx Tests: Chest X-Ray, Lumbar
puncture, MRI, CT Scan
OVARIAN CANCER
Patho: Cancer of the ovaries:
-Healthy cells transform/mutate into
malignant cells upon exposure to certain
etiologic factors such as: Viruses,
Chemicals, and Physical agents. When
cells are malignant, they can metastasize
into tissues surrounding the area, to the
lymph nodes and lymphatic system, the
blood, and system wide to other
organs/cavities. All cancers are staged
between I-IV, with Stage I being the least
severe and Stage IV being the most
severe.
Assess:
Assess for menstrual
cycle/ovulation history of patient
and family…
Most At Risk:
-Staring period at young age
-Ending period (Menopause) at
older age
-Never been pregnant (nulliparity)
-Frequent cycles
**10% are genetic and can be
tested for BRCA1 and BRCA2 gene
changes (mutations)
The American Cancer Society 7
WARNING SIGNS for Cancer:
C – Change in bowel/bladder habits
A – A sore that that doesn’t heal
U – Unusual Bleeding/Discharge
T – Thickening/lumps in
breast/body
I – Indigestion/Difficulty swallowing
O – Obvious change in wart/mole
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Chemotherapy
(carboplatin and paclitaxel)
Pt. Ed: Educate patient on
side effects of
chemotherapy, changes in
hormone levels due to
diagnosis and possible
hormonal side effects, as
well as ways to prevent
infection as patient will be
immunocompromised.
Surgery: “Surgical
Debulking”, where the
abdomen is cleared of all
masses, with NONE over
the size of 1 cm. Removal
of Ovaries/Fallopian tubes
(Salpingo-oophorectomy),
removal of uterus
(hysterectomy) or
omentum (omenectomy)
and Lymph node dissection
may be needed based on
Page 11 of 106
Nursing Dx:
- Pain r/t enlarged organs/
lymph nodes and treatment for
diagnosis
-Risk for infection r/t
compromised immune system
Pt. Goals/ Evaluation:
- Pt will report pain at tolerable
level and verbalize ways to
manage
- Pt will identify signs and
symptoms of infection and
verbalize ways to minimize
chances of infection
48 Hour Cram Sheets for Med Surg
PROSTATE CANCER
N - Nagging, coughing or
hoarseness
the severity of the
tumor(s).
Vitals: Normal unless distressed
S/S & PHYS. EXAM:
-Fatigue
-Abdominal/pain swelling
-Swelling of legs
-Shortness of Breath
-Changes in bladder/bowel habits
Labs: Genetic testing, Biopsy (if
needed), CA-125 Cancer Screening
blood Test (MAY be elevated but
not guaranteed)
Dx Tests: Ultrasound, CT Scan
PROSTATE CANCER
Patho:
Cancer of the prostate gland:
-Healthy cells transform/mutate into
malignant cells upon exposure to certain
etiologic factors such as: Viruses,
Chemicals, and Physical agents. When
cells are malignant, they can metastasize
into tissues surrounding the area, to the
lymph nodes and lymphatic system, the
Page 12 of 106
Assess:
Assess for Risk Factors: Pt/Family hx
of BPH and prostate cancer, MEN
OVER 40, African American, Obese
The American Cancer Society 7
WARNING SIGNS for Cancer:
C – Change in bowel/bladder habits
A – A sore that that doesn’t heal
U – Unusual Bleeding/Discharge
T – Thickening/lumps in
breast/body
I – Indigestion/Difficulty swallowing
O – Obvious change in wart/mole
N - Nagging, coughing or
hoarseness
Vitals: Normal unless distressed
Nursing Interventions:
Pharm: Chemotherapy,
Biological therapy,
Hormone therapy:
Luteinizing Hormone –
Release Hormone/LH-RH
(To Stop the release of
testosterone, such as
LUPRON, TRELSTAR,
ZOLIDEX)
Pt. Ed: Encourage
medication compliance, as
well as the importance of
check-ups/colonoscopy as
recommended by doctor.
Inform patient of side
effects of prostate cancer,
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Altered urinary elimination r/t
enlarged prostate and bladder
distension
-Risk for infection r/t surgical
procedure/immunocompromise
Pt. Goals/ Evaluation:
-Patient will maintain effective
voiding measures within limits
of his/her condition
- Pt will identify signs and
symptoms of infection and
verbalize ways to minimize
chances of infection
48 Hour Cram Sheets for Med Surg
PANCREATIC CANCER
blood, and system wide to other
organs/cavities. All cancers are staged
between I-IV, with Stage I being the least
severe and Stage IV being the most
severe.
PANCREATIC CANCER
Patho:
Cancer of the Pancreas, NO KNOWN
CAUSE!
-Healthy cells transform/mutate into
malignant cells upon exposure to certain
etiologic factors such as: Viruses,
Chemicals, and Physical agents. When
cells are malignant, they can metastasize
into tissues surrounding the area, to the
S/S & PHYS. EXAM:
- Urinary problems
- Decreased force in the urine
stream
- Blood in semen
- Erectile dysfunction
- Pelvic Discomfort
- Pain in Bone
including ERECTILE
DYSFUNCTION, and
encourage them to utilize
support system/
affection/coping skills.
Refer to support group.
Also ambulation and
catheter care after surgery.
Labs: PSA (Prostate Specific
Antigen) Level, Biopsy
Dx Tests: Ultrasound, DRE (digital
rectal exam)
Surgery: Freezing Prostate
tissue, Removal of
Prostate, remove the
testicles (orchiectomy)
Assess:
Assess for Risk Factors:
- Chronic pancreatitis
- Personal or family history of
pancreatic cancer
- Smoking/Excessive drinking
- Obese
- Diabetes
- African-American
- Family history of genetics that
can increase cancer risk
Nursing Interventions:
**THIS CANCER IS
USUALLY DIAGNOSED AT
VERY LATE STAGES DUE TO
IT’S ASYMPTOMATIC
NATURE
Pharm: Analgesics for
pain, Chemotherapy,
Targeted therapy,
Radiation therapy
The American Cancer Society 7
WARNING SIGNS for Cancer:
C – Change in bowel/bladder habits
A – A sore that that doesn’t heal
U – Unusual Bleeding/Discharge
T – Thickening/lumps in
breast/body
Simplenursing.com Less Study Time HIGHER test scores!
Pt. Ed: THE HEALING
PROCESS AFTER THE
WHIPPLE PROCEDURE IS
VERY LONG!
Surgery: WHIPPLE
PROCEDURE (removal of
head of pancreas, and
portion of small intestine
Page 13 of 106
Nursing Dx:
-Fear r/t recent diagnosis and
unknown future
-Risk for infection r/t surgical
procedure/immunocompromise
Pt. Goals/ Evaluation:
-Pt will verbalize anxiety as well
as ways to reduce it/minimize
with it.
- Pt will identify signs and
symptoms of infection and
verbalize ways to minimize
chances of infection
48 Hour Cram Sheets for Med Surg
PANCREATIC CANCER
lymph nodes and lymphatic system, the
blood, and system wide to other
organs/cavities. All cancers are staged
between I-IV, with Stage I being the least
severe and Stage IV being the most
severe.
I – Indigestion/Difficulty swallowing
O – Obvious change in wart/mole
N - Nagging, coughing or
hoarseness
Vitals: Normal unless distressed
S/S & PHYS. EXAM:
(**Can be asymptomatic)
- Yellowing of your skin and the
whites of your eyes (jaundice)
- Upper abdominal pain (can
radiate to back)
- Weight Loss/ Anorexia
- Depression
- Blood clots
(duodenum), gallbladder
and part of your bile duct.
Part of stomach may be
removed in addition. The
remaining parts of your
pancreas are reconnected
to the Patient’s stomach
and intestines to allow the
digestion of food.
-Also, removal of cancer on
tail of Pancreas if possible
Labs: Biopsy, Blood tests: CMP,
CA 19-9 (Tumor Marker), CEA
(Carcinogen Embryonic Antigen),
Serum Amylase, Fecal Fat, Lipase,
Stool Trypsin
Dx Tests: Ultrasound, MRI, CT
Scan, Endoscopic Ultrasound (EUS),
Endoscopic retrograde cholangiopancreatography (ERCP)
Page 14 of 106
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
ALZHEIMERS
2. NEURO: CNS
DIAGNOSIS/PATHO
ALZHEIMERS
Patho: The most common cause of
Dementia in older adults. This disease is
progressive and is marked by impaired
memory and thinking skills. The classic
neuropathology findings in AD include
amyloid plaques, neurofibrillary tangles,
and synaptic and neuronal cell death.
DATA
ACTION
Assess: Use GLASCOW/COMA SCALE (see
below), LOC, Advancement of disease, ADL
issues (speak to caretaker if any) Degree of
Memory loss, Motor function, reflexes,
speech, cognition, affect
Nursing Interventions:
Pharm:
Cholinesterase Inhibitors:
-Donepezil
-Galantamine
NMDA Antagonist:
-Memantine
Selective Serotonin Reuptake
Inhibitors (SSRI’s):
-Citalopram
-Paroxetine
Anti-Anxiety Meds:
-Lorazepam
- Oxazepam
Vitals: ↑BP & ↑Pulse (May indicate ↑
Cranial pressure)
S/S & PHYS. EXAM:
STAGES:
1. Mild – Slow and gradual progression of
decline of intellectual activity; loss of
energy/drive, difficulty learning
2. Moderate – Evident deterioration.
Client can’t remember address/phone
number. Memory gaps, decreased
hygiene, memory gaps, mood swings,
paranoia, anger, jealousy and apathy. Fulltime care needed.
Pt. Ed: **Education is better
Simplenursing.com Less Study Time HIGHER test scores!
absorbed by the Caretaker; as
the patient may not be a
reliable source to remember
Have clocks, calendars and
personal items in clear view.
Speak in short phrases/words.
Speak slowly. Assess vital
signs/Neuro status. Identify
threats to patient’s safety.
Review all meds patient is
taking, use family to obtain
history.
Page 15 of 106
RESPONSE
Nursing Dx:
-Altered urinary
and bowel
elimination r/t
cognitive
impairment and
loss of muscle
tone
- Self-care deficit
r/t cognitive
impairment and
physical
limitations
Pt. Goals/
Evaluation:
-Pt will identify
need to
urinate/defecate
and/or understand
the need for
assistance with
these activities
-Pt will identify
need to
urinate/defecate
and/or understand
the need for
48 Hour Cram Sheets for Med Surg
ALZHEIMERS
3. Moderate to Severe- Repeated
instructions needed. Inability to recognize
common items and perform simple tasks.
Patient wanders a lot. Client is a danger to
himself. TOTAL CARE NEEDED.
4. Late- Client becomes unable to read or
write. Bunted emotions, loses ability to
talk and walk. STUPOR AND COMA…
**DEATH SECONDARY TO INFECTION AND
CHOKING
Surgery: None available at this
time
Labs: Genetic testing for gene (APOE-e4)
& Autosomal Dominant Alzheimers disease
(ADAD) to indicate likelihood of having
disease
Dx Tests: Physical exam, Neuro exam,
Mental status tests
Page 16 of 106
Simplenursing.com Less Study Time HIGHER test scores!
assistance with
these activities
48 Hour Cram Sheets for Med Surg
BRAIN TUMORS
BRAIN TUMORS
Patho: Brain tumors may be classified
into several groups: those arising from the
coverings of the brain (e.g., Dural
meningioma), those developing in or on
the cranial nerves (e.g., acoustic
neuroma),
Those originating with in brain tissue and
metastatic lesions originating elsewhere in
the body. Tumors of the pituitary and
pineal glands and of cerebral blood vessels
are also types of brain tumors. Relevant
clinical considerations include the location
and the histology character of the tumor.
Tumors may be benign or malignant. A
benign tumor CAN BE SERIOUS!! If occurs
in a vital area and can grow large enough
to have effects as serious as those of a
malignant tumor.
Assess: Neuro exam, Head to toe
assessment, Assess coordination
Vitals:
Severe headache in the morning,
increased when coughing, bending
Convulsions
Signs of increased intra-cranial pressure:
blurred vision, nausea, vomiting, decreased
Auditory function, changes in vital signs,
aphasia.
Changes in personality
Impaired memory
Natural disturbance of taste
Classic triad:
o Headache
o Papilledema (intra-ocular pressure)
o Vomiting
S/S & PHYS. EXAM:
Labs: Blood & Urine tests, Biopsy
Dx Tests: MRI, Functional MRI (fMRI) CT
Scan, Angiogram, Brain Scan, Diffusion
Tensor Imaging (DTI), Positron Emission
technology (PET Scan), Bone Scan
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: (Depends on size and
location of the tumor)
Radiation Therapy,
Chemotherapy, Medications to
reduce ICP (Mannitol), Anticonvulsants, Analgesics
(**All prn, depending on
situation)
Pt. Ed: Caregiver information
about assistance with ADL’s,
keeping up with check-ups,
options of care/symptom relief,
support groups,
communication with medical
personnel and sources
Surgery: Surgery if possible to
remove tumor (Depends on
size, location and degree of
damage if removed)
Page 17 of 106
Nursing Dx:
-Acute pain r/t
tumor and
increased
intercranial
pressure
-Anxiety r/t
unknown future
after surgery,
cognitive
impairment and
health issues.
Pt. Goals/
Evaluation:
-Pt will verbalize
pain level using
numeric chart or
“FACES” chart, as
well as ways to
reduce/treat pain
-Pt will verbalize
anxiety as well as
ways to reduce
it/minimize with it.
48 Hour Cram Sheets for Med Surg
CEREBERAL VASCULAR ACCIDENT (CVA)
CEREBERAL VASCULAR
ACCIDENT (CVA)
Patho: *Commonly referred to as
Stroke or “Brain attack”. In a stroke, the
sudden interruption of blood supply to
areas of the brain results in cerebral
necrosis and impaired cerebral
metabolism, which permanently damages
brain tissues and produces focal
neurologic deficit of varying severity. A
cerebral aneurysm is prone to rupture,
which causes blood to leak into the subarachnoid space (and sometimes into
brain tissue, where it forms a clot),
resulting in increased intracranial pressure
(ICP) and brain tissue damage
-In a TIA, there is a temporary decrease in
blood flow to a specific region of the
brain, but there is no necrosis of brain
tissue. The symptoms (lasting seconds to
hours) produce transient neurologic
deficits that completely clear within 12 to
24 hours.
Assess: Assess for ALOC, change in
speech/mental status, aphagia, dysphagia,
visual disturbance, loss of balance,
coordination, sudden SEVERE headache
Vitals: ↑Pain
S/S & PHYS. EXAM:
Stroke
-Hemiplegia and sensory deficit
-Aphasia (impairment may be in speaking,
listening, writing, or comprehending,
Most cases are mixed expressive and
receptive).
-Hemipoeis – weakening of one side
-Unilateral neglect of paralyzed side
-Bladder impairment
-Possibly respiratory impairment
-Impaired mental activity and psychological
deficits/ALOC
-STROKE: F-A-S-T – Face, affect, smile,
-Transient Ischemic Attack
-Temporary loss of consciousness or
dizziness
-Paresthesias
-Garbled speech
-Cerebral aneurysm
-Blurred vision and headache
Signs and symptoms of ICP
-Nuchal rigidity and pain on neck
movement
-Photophobia
Labs: Urinalysis, Lumbar Puncture, brain
biopsy
Page 18 of 106
Nursing Interventions:
Pharm: (Depends on type/
cause)
-Aspirin
-TPA (“Clot Buster”): Given
within first 3-4.5 hours as
indicated. ***TPA
CONTRAINDICATIONS
Intercranial hemorrhage,
internal bleeding, recent
trauma/surgery in last 3 mos.,
uncontrolled hypertension
-Anticoagulants/Anti-platelets
Pt. Ed: Watch for signs of
bleeding/hemorrhage/Stroke,
blood tests as requested,
control Hypertension &
diabetes, maintain diet low in
saturated fat, and exercise as
advised. QUIT SMOKING! Drink
moderately/stop drinking. If
trouble communicating, utilize
props/tools, If physical
ailments, utilize tools to assist
in mobility, join a support
group/obtain emotional
support.
Surgery:
FOR CLOTS:
Mechanical removal of clot,
Carotid endarterectomy
FOR HEMHORRAGING:
-Coiling
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Ineffective
Cerebral Tissue
Perfusion
-Impaired physical
mobility r/t
neuromuscular
involvement:
cognitive
impairment,
perceptual
impairment,
paresthesia,
weakness
Pt. Goals/
Evaluation:
-Pt will maintain
improved/usual
cognition, LOC and
motor/sensory
function
-Pt will
maintain/increase
function, of
affected body part
or compensatory
body part
48 Hour Cram Sheets for Med Surg
CEREBERAL VASCULAR ACCIDENT (CVA)
Dx Tests: CT Scan, MRI, Carotid Doppler,
EKG, ECG, cerebral arteriogram, magnetic
resonance angiogram
Simplenursing.com Less Study Time HIGHER test scores!
-Surgical Clipping
-Surgical AVM removal
-Intracranial bypass
Page 19 of 106
48 Hour Cram Sheets for Med Surg
EPILEPSY
EPILEPSY
Patho: A disorder involving abnormal,
sudden discharge of electrical activity in
the brain. Epilepsy is not a singular
disease, but is heterogeneous in terms of
clinical expression, underlying etiologies,
and pathophysiology . As such, specific
mechanisms and pathways underlying
specific seizure types may vary. Epileptic
seizures are broadly classified according to
their site of origin and pattern of spread.
Assess: ASSESS FOR SAFE
ENVIRONMENT WHILE PATIENT IS
SEIZING! Maintain patent airway (Good to
position the patient side-lying) Initiate
seizure precautions/protect client from
injury. DOCUMENT THE SEIZURE!!
(Precipitating factors, type, duration,
behavior before, during and after seizure/
aka “Postictal phase”, and if incontinent)
Vitals: ↑TEMP, ↑HR, ↓BP
S/S & PHYS. EXAM:
Sensory/Thought:
o Black out/Loss of consciousness
o Confusion
o Deafness/Sounds
o Electric Shock Feeling
o Spacing out
o Out of body experience
o Visual loss or blurring
Nursing Interventions:
Pharm: Dilantin,
Phenobarbital, Tegretol,
Depakote, Valium, Klonopin,
Pt. Ed: Adherence to
medication regimen as well as
contra-indications and side
effects!
Surgery: Removal of anterior
temporal lobe (For partial
epilepsy/seizures), Usually in
children: hemispherectomy,
corpus callosotomy (separating
of nerve fibers that connect the
two sides of the brain)
Emotional:
o Fear/Panic
o Pleasant feeling
Physical:
o Chewing movements
o Convulsion
o Difficulty talking/Drooling
o Eyelid fluttering/rolling
o Falling down
o Foot stomping
o Hand waving
o Inability to move
o Incontinence
o Lip smacking/Making sounds
o Shaking
Page 20 of 106
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Low self-esteem
r/t social role
changes, loss of
control and stigma
associated with
disease
-Risk for
Trauma/Suffocatio
n r/t loss of
consciousness,
coordination,
weakness and
reduced
muscle/sensation
Pt. Goals/
Evaluation:
-Pt will verbalize
concerns and fears
about body, self
perception and
change of lifestyle
-Pt will verbalize
understanding of
factors that
contribute to
trauma during a
seizure, pt will be
aware of seizure
precautions that
should be utilized,
especially by
48 Hour Cram Sheets for Med Surg
EPILEPSY
CLASSIFIED AS GENERALIZED OR FOCAL:
Generalized:
1. Tonic-clonic (grand-mal) Seizure: This
seizure causes you to lose consciousness
and often collapse. Your body becomes
stiff during what's called the "tonic" phase.
During the "clonic" phase, muscle
contractions cause your body to jerk.
2. Absence (petit mal) Seizure: During
these brief episodes, you lose awareness
and stare blankly. Usually, there are no
other symptoms.
3. Myoclonic Seizure: These very brief
seizures cause your body to jerk, as if
shocked by electricity, for a second or
two. The jerks can range from a single
muscle jerking to involvement of the entire
body.
4. Clonic Seizure: This seizure cause
rhythmic jerking motions of the arms
and legs, sometimes on both sides of your
body.
5. Tonic Seizure: Tonic seizures cause
your muscles to suddenly stiffen,
sometimes for
as long as 20 seconds. If you're standing,
you'll typically fall.
o Staring
o Stiffening
o Swallowing
o Sweating
o Teeth clenching/grinding
o Tongue biting
o Twitching movements
o Breathing difficulty
o Tachycardia
o Bruising
o Difficulty talking
o Injuries
o Sleeping
o Exhaustion
o Headache
o Nausea
o Pain
o Thirst
o Weakness
o Urge to urinate/defecate
caretaker, family
or friend
Labs: CBC, Glucose, CSF (cerebral spinal
fluid) analysis, Blood Culture (To rule out
infection
Dx Tests: EEG, MRI, CT Scan, PET Scan,
ECG
Simplenursing.com Less Study Time HIGHER test scores!
Page 21 of 106
48 Hour Cram Sheets for Med Surg
EPILEPSY
6. Akinetic or Atonic Seizure: This seizure
causes your muscles to relax or lose
strength, particularly in the arms and legs.
Although you usually remain conscious, it
can cause you to suddenly fall and lead to
injuries. These seizures also are called
"drop attacks"
FOCAL SEIZURES
1. Simple Focal Seizure: During these
seizures, you remain conscious although
some people can't speak or move until the
seizure is over. Uncontrolled movements,
such as jerking or stiffening, can occur
throughout your body. You also may
experience emotions such as fear or rage
or even joy; or odd sensations, such as
ringing sounds or strange smells.
2. Complex Focal Seizure: During these
seizures, you are not fully conscious and
may
appear to be in a dreamlike state. Typically,
they start with a blank stare. You may
involuntarily chew, walk, fidget, or perform
other repetitive movements or simple
actions, but actions are typically
unorganized or confused
3. Secondarily Generalized Seizure:
These seizures begin as a focal seizure and
develop
Into generalized ones as the electrical
abnormality spreads throughout the brain.
When the seizure begins, you may be fully
conscious but then lose consciousness and
Experience convulsions as it develops.
Page 22 of 106
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
HEAD INJURY
HEAD INJURY
Patho: brain injuries can be classified
as traumatic or acquired, with additional
types under each heading. All brain injuries
are described as either mild, moderate, or
severe.
Traumatic Brain Injury
Traumatic brain injury is a result of an
external force to the brain that results in a
change to cognitive, physical, or emotional
functioning. The impairments can be
temporary or permanent
Acquired Brain Injury
An acquired brain injury is an injury to the
brain that is not hereditary, congenital,
degenerative, or the result of birth trauma.
Acquired brain injury generally affects cells
throughout the entire brain.
A. Direct injury: Depression of skull,
Direct injury or skull fracture
B. Blow to head: Blow to the skull
that may move the brain to a point
which can cause damage to
vessels or veins, contusion or
hematoma
Assess: Perform Neuro assessment,
Assess for ALOC, Signs of confusion,
bleeding/CSF in ears (halo sign), Assess
intracranial pressure (Shouldn’t exceed 2025mmHg) Monitor MAP (Keep above
90mmHg), Elevate HOB to 30°, Monitor
vital signs/ABG’s
Vitals: ↑PAIN, may have ↑TEMP and/or
↑↓BP (depending on Injury)
S/S & PHYS. EXAM:
(Symptoms depend on the severity and
distribution of brain injury)
-A common manifestation is loss of
consciousness, ranging from a few minutes
to 1 hour or longer
-Ecchymosis may be seen over the mastoid
(Battle’s sign)
-CT scan may reveal the area that is
contused or injured X-Rays may reveal skull
fractures
Bloody spinal fluid suggests brain
laceration or contusion
-Brain injury may have various signs,
including altered level of conscious-ness,
pupil abnormalities, altered or absent gag
reflex or corneal reflex, neurologic deficits,
change in vital signs (e.g. respiration
pattern, hypertension, bradycardia),
hyperthermia or hypothermia, and sensory,
vision or hearing impairment
-Signs of a post-concussion symptoms may
include headache, dizziness, anxiety,
irritability, and lethargy
-In acute or sub-acute subdural hematoma,
changes in level of consciousness, papillary
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Analgesics, Mannitol,
Lasix, barbiturates,
corticosteroids
Pt. Ed: Inform patient of signs
and symptoms of ICP, confirm
understanding of treatment
regimen including medication,
drains, etc. Communicate with
family for signs of worsening
condition and allow them to
voice concerns.
Surgery: To relieve excessive
fluid/ICP (May install a drain),
“Bone Flap” removed to relieve
pressure, Removal of
hematoma
Page 23 of 106
Nursing Dx:
-Ineffective
Cerebral Tissue
Perfusion
-Impaired physical
mobility r/t
neuromuscular
involvement:
cognitive
impairment,
perceptual
impairment,
paresthesia,
weakness
Pt. Goals/
Evaluation:
-Pt will maintain
improved/usual
cognition, LOC and
motor/sensory
function
-Pt will
maintain/increase
function, of
affected body part
or compensatory
body part
48 Hour Cram Sheets for Med Surg
MULTIPLE SCLEROSIS (MS)
C. Rebound/Contrecoup Injury:
Rebound of cranial contents an
cause an injury of the head on the
OPPOSITE side of injury. Also
known as contrecoup injury
MULTIPLE SCLEROSIS (MS)
Patho: REMEMBER! MS, Myelin Sheath!!
Demyelination of nerve fibers within long
conducting pathway of spinal cord and
brain.
Impaired transmission of never
impulses.
Degenerative changes myelin sheath
are scattered irregularly throughout the
central
nervous system. Nerve axon also
deteriorates. The areas involved are not
consistent when it comes to deterioration
thereby showing the signs and symptoms
appear whenever the nerve conduction is
interrupted
-There are periods of remission also,
however there are cases that symptoms are
exacerbated especially when nerve impulse
travel through the patchy never fibers.
Page 24 of 106
signs, hemiparesis, coma, hyper-tension,
bradycardia, and slowing respiratory rate
are signs of expanding mass
Labs: Na, Mg, PTT, aPTT, Platelets, BAC,
renal function
Dx Tests: MRI, CT scan, EEG, X-Ray
Assess: Assess for cognitive, sensory and
physical impairment, pain,
numbness/paresthesia, extreme fatigue
and inflammation. Also assess for
medication adherence
Vitals:
S/S & PHYS. EXAM:
-Spastic weakness – the most common
sign
-Charcots Triad: A combination of
symptoms that includes nystagmus,
intention tremor (motor weakness in
coordination), scanning speech which is
elicited by slowing enunciation with
tendency to hesitate at beginning of a
word.
Nursing Interventions:
Pharm:
-Immuno-suppressants to
reduce exacerbation: (Avonex
IM weekly), Betaseron
(Subcut), Copaxone (Subcut)
-For muscle spasicity/tremors:
Neurontin, Baclofen,
Clonazapam
-For Urinary Problems:
Ditropan, Detrol
-For sexual Dysfunction: Viagra
-Depression: Zoloft. Prozac
-Fatigue: Provigil, Symmetrel
Pt. Ed:
1. Self-Injection techniques
2. Promote independence
Visual disturbances
3. Self-Catheterization
Nausea/Vomiting
4. Promote exercise daily, with
Urinary retention or urinary incontinence fall precautions
5. Injury Prevention
Dysphagia (difficulty in swallowing)
6. Stress reduction and immune
Ataxia (decreased coordination)
support to avoid infection
Labs: CSF Analysis
Hyper-emotions as well as euphoria
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx
-Impaired physical
mobility r/t
neuromuscular
involvement:
cognitive
impairment,
perceptual
impairment,
parasthesia,
weakness
-Ineffective
individual coping
r/t uncertainty of
course of MS
Pt. Goals/
Evaluation:
-Pt will maintain/
increase function,
of affected body
part or
compensatory
body part
48 Hour Cram Sheets for Med Surg
MENINGITIS
Dx Tests: MRI (Will show sclerotic
patches brain/spinal cord)
MENINGITIS
Patho: Meningitis is the inflammation of
the protective membranes covering the
central
nervous, known collectively as the
meninges.
Meningitis can be caused from a direct
spread of a severe infection such as an ear
infection or sinus infection. In some cases,
meningitis is noted after head trauma or
an injury to the head or brain. There are
several causes of meningitis: Bacterial
infection, Viral infection, Fungal
infection, A reaction to medications, A
reaction to medical treatments, Lupus,
Some forms of cancer, A trauma to the
head or back. Anyone can catch
Surgery: None available at this
time
Assess: MONITOR TEMPERATURE!!
Extremely high temp can be fatal. Assess
for ALOC, Pain, sensory
awareness/response
Vitals: TEMP, PAIN
S/S & PHYS. EXAM:
-Fever
-Nuchal (Neck) Rigidity/Pain/tenderness
-Loss of appetite
-Difficulty swallowing.
-Anorexia/vomiting
-Poor skin turgor/dry mucous membranes
Labs: CSF Analysis
Dx Tests: Lumbar puncture/spinal Tap
Nursing Interventions:
Pharm: IV Antibiotics
(Rifampin/Vancomycin)
Pt. Ed: Sit patient in
comfortable position with
adequate neck support, reduce
environmental stimuli/stress,
monitor hydration, antibiotics,
seizure precautions
Surgery: N/A
meningitis. This is especially true if your
immune system is weak.
Simplenursing.com Less Study Time HIGHER test scores!
Page 25 of 106
-Pt will verbalize
acceptance of
diagnosis, control
over health status
and demonstrate
utilization of
support systems
Nursing Dx:
-Pain r/t acute
condition
- Risk for infection
transmission r/t
contagious nature
of organism
Pt. Goals/
Evaluation:
-Pt will verbalize
pain level using
numeric chart or
“FACES” chart, as
well as ways to
reduce/treat pain
-Initiate infection
precautions and
antibiotic therapy
as ordered
48 Hour Cram Sheets for Med Surg
PARKINSON’S
PARKINSON’S
Patho: Parkinson’s disease is a slowly

progressive degenerative neurological

disorder caused by the loss of nerve cell

function in the basal ganglia. Loss of nerve

cells in the substantia nigra causes a
reduction of dopamine production.
Dopamine is the neurotransmitter
essential for such functions as control of
posture, supporting the body in an upright
position and voluntary motions.
Assess: Assess for the 4 Cardinal signs of
Parkinson’s:
1. Resting tremor
2. Rigidity
3. Bradykinesia
4. Postural instability
*PATIENT IS A FALL RISK!
Vitals: Normal, unless distressed
S/S & PHYS. EXAM:
Nursing Interventions:
Pharm: Depends on
age/severity:
- Carbidopa/Levodopa
therapy
- Dopamine Agonists
- Anticholinergics
- MAO-B Inhibitors
- COMT Inhibitors
Pt. Ed: Assistance with ADL’s,
Caretaker info, important
information regarding the
disease and depression,
Surgery: None at this time
-Tremor (rhythmic, purposeless, fine
trembling, quivering movement), resting
or passive
tremor
-Muscle rigidity (stiffness seen with
resistance to passive muscle stretching),
cogwheel
rigidity
-Akinesia (loss of movement) and
bradykinesia (slowness of voluntary
movement and speech)
-Mask-like expression
-Dysphagia (difficulty of swallowing)
-Monotonous speech
-Postural disturbances (stooped posture,
shuffling gait, broad-based turns)
Page 26 of 106
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Impaired physical
mobility r/t
neuromuscular
involvement:
tremors, muscle
rigidity, weakness
-Self care deficit
r/t neuromuscular
weakness,
decreased
strength and loss
of muscle control/
coordination,
cognitive changes
& postural
changes
Pt. Goals/
Evaluation:
-Pt will maintain/
increase function,
of affected body
part or
compensatory
body part
-Pt and caretaker
will verbalize
understanding of
physical, cognitive
and emotional
limitations due to
diagnosis
48 Hour Cram Sheets for Med Surg
SEIZURE
-Generalized muscle fatigue
-Cognitive changes (impaired memory,
depression)
-Drooling
-Constipation
-Orthostatic hypotension
- Urinary dysfunction
Labs: NONE YET! Specialized imaging
centers may have Brain Scans to measure
dopamine and metabolism of brain, as
well as genetic disposition/Biological
marker
Dx Tests: NONE YET! (A neurologist will
diagnose based on history and symptoms)
SEIZURE
Patho: A disorder involving abnormal,
sudden discharge of electrical activity in
the brain. Epilepsy is not a singular
disease, but is heterogeneous in terms of
clinical expression, underlying etiologies,
and pathophysiology. As such, specific
mechanisms and pathways underlying
specific seizure types may vary. Epileptic
seizures are broadly classified according to
their site of origin and pattern of spread.
Assess: ASSESS FOR SAFE
ENVIRONMENT WHILE PATIENT IS
SEIZING! Maintain patent airway (Good to
position the patient side-lying) Initiate
seizure precautions/protect client from
injury. DOCUMENT THE SEIZURE!!
(Precipitating factors, type, duration,
behavior before, during and after seizure/
aka “Postictal phase”, and if incontinent)
Vitals: ↑TEMP, ↑HR, ↓BP
S/S & PHYS. EXAM:
Sensory/Thought:
o Black out/Loss of consciousness
o Confusion
o Deafness/Sounds
o Electric Shock Feeling
o Spacing out
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Dilantin,
Phenobarbital, Tegretol,
Depakote, Valium, Klonopin,
Pt. Ed: Adherence to
medication regimen as well as
contra-indications and side
effects!
Surgery: Removal of anterior
temporal lobe (For partial
epilepsy/seizures), Usually in
children: hemispherectomy,
corpus callosotomy (separating
of nerve fibers that connect the
two sides of the brain)
Nursing Dx:
-Low self-esteem
r/t social role
changes, loss of
control and stigma
associated with
disease
-Risk for Trauma/
Suffocation r/t loss
of consciousness,
coordination,
weakness and
reduced
muscle/sensation
Pt. Goals/
Evaluation:
Page 27 of 106
48 Hour Cram Sheets for Med Surg
SEIZURE
o Out of body experience
o Visual loss or blurring
Emotional:
o Fear/Panic
o Pleasant feeling
CLASSIFIED AS GENERALIZED OR FOCAL:
Generalized:
1. Tonic-clonic (grand-mal) Seizure: This
seizure causes you to lose consciousness
and often collapse. Your body becomes
stiff during what's called the "tonic" phase.
During the "clonic" phase, muscle
contractions cause your body to jerk.
2. Absence (petit mal) Seizure: During
these brief episodes, you lose awareness
Page 28 of 106
Physical:
o Chewing movements
o Convulsion
o Difficulty talking/Drooling
o Eyelid fluttering/rolling
o Falling down
o Foot stomping
o Hand waving
o Inability to move
o Incontinence
o Lip smacking/Making sounds
o Shaking
o Staring
o Stiffening
o Swallowing
o Sweating
o Teeth clenching/grinding
o Tongue biting
o Twitching movements
o Breathing difficulty
o Tachycardia
o Bruising
o Difficulty talking
o Injuries
o Sleeping
o Exhaustion
o Headache
o Nausea
o Pain
o Thirst
o Weakness
o Urge to urinate/defecate
Simplenursing.com Less Study Time HIGHER test scores!
-Pt will verbalize
concerns and fears
about body, self
perception and
change of lifestyle
-Pt will verbalize
understanding of
factors that
contribute to
trauma during a
seizure, pt will be
aware of seizure
precautions that
should be utilized,
especially by
caretaker, family
or friend
48 Hour Cram Sheets for Med Surg
SEIZURE
and stare blankly. Usually, there are no
other symptoms.
3. Myoclonic Seizure: These very brief
seizures cause your body to jerk, as if
shocked by electricity, for a second or
two. The jerks can range from a single
muscle jerking to involvement of the entire
body.
4. Clonic Seizure: This seizure cause
rhythmic jerking motions of the arms
and legs, sometimes on both sides of your
body.
5. Tonic Seizure: Tonic seizures cause
your muscles to suddenly stiffen,
sometimes for
As long as 20 seconds. If you're standing,
you'll typically fall.
6. Akinetic or Atonic Seizure: This seizure
causes your muscles to relax or lose
strength, particularly in the arms and legs.
Although you usually remain conscious, it
can cause you to suddenly fall and lead to
injuries. These seizures also are called
Labs: CBC, Glucose, CSF (cerebral spinal
fluid) analysis, Blood Culture (To rule out
infection
Dx Tests: EEG, MRI, CT Scan, PET Scan,
ECG
"drop attacks"
FOCAL SEIZURES
1. Simple Focal Seizure: During these
seizures, you remain conscious although
some people can't speak or move until the
seizure is over. Uncontrolled movements,
such as jerking or stiffening, can occur
throughout your body. You also may
experience emotions such as fear or rage
or even joy; or odd sensations, such as
ringing sounds or strange smells.
Simplenursing.com Less Study Time HIGHER test scores!
Page 29 of 106
48 Hour Cram Sheets for Med Surg
SPINAL INJURY
2. Complex Focal Seizure: During these
seizures, you are not fully conscious and
may
Appear to be in a dreamlike state.
Typically, they start with a blank stare. You
may
involuntarily chew, walk, fidget, or perform
other repetitive movements or simple
actions, but actions are typically
unorganized or confused
3. Secondarily Generalized Seizure:
These seizures begin as a focal seizure and
develop
Into generalized ones as the electrical
abnormality spreads throughout the brain.
When the seizure begins, you may be fully
conscious but then lose consciousness and
Experience convulsions as it develops.
SPINAL INJURY
Patho: Spinal cord injuries cause myelopathy or damage to white matter or
myelinated fiber tracts that carry signals to
and from the brain. It also damages gray
matter in the central part of the spine,
causing segmental losses of interneurons
and motorneurons. Spinal cord injury can
occur from many causes, including:
-Trauma such as automobile crashes, falls,
gunshots, diving accidents, war injuries,
etc.
-Tumors such as right, ependymomas,
astrocytomas, and metastatic cancer.
-Ischemia resulting from occlusion of
spinal blood vessels, including dissecting
aortic aneurysms, emboli, arteriosclerosis.
Page 30 of 106
Assess: ABC’s!! For reflexes, response to
stimuli and level of injury, Neuro-exam!
(GLASCOW COMA SCALE):
Nursing Interventions:
Pharm: None at this time to
TREAT, but
methylprednisolone/Solumedr
ol may be given as medication
to treat ACUTE spinal injury
Pt. Ed: Assistance with ADL’s
as needed, PT to become
adjusted to
wheelchair/prosthesis,
Psychological care to deal with
mental aspect of the loss,
catheter care as needed,
avoiding pressure ulcers/self
care
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Impaired physical
mobility r/t
neuromuscular
involvement:
sensory/
perceptual
impairment,
parasthesia,
weakness
-Low self-esteem
r/t social role
changes, loss of
control and recent
diagnosis
48 Hour Cram Sheets for Med Surg
SPINAL INJURY
-Developmental disorders such as spina
bifida, meningomyolcoele, and other
Neurodegenerative diseases, such as
Friedreich’s ataxia, spinocerebellar ataxia,
etc.
-Demyelinative diseases, such as
Multiple Sclerosis.
-Transverse myelitis, resulting from spinal
cord stroke, inflammation, or other causes
-Vascular malformations, such as arteriovenous malformation (AVM), dural
Arteriovenous fistula (AVF), spinal
hemangioma, cavernous angioma and
Aneurysm.
Surgery: None at this time for
parasthesia, but surgery may be
required to remove bone
fragments (if any), or further
secure the spine to prevent
deformity.
Vitals: DEPENDS ON THE INJURY!!
S/S & PHYS. EXAM:
-Impaired physical mobility
-Disturbed sensory perception
-Acute pain
-Anticipatory grieving
-Low self-esteem
-Constipation or bowel incontinence
-Impaired urinary elimination
Labs: N/A
Dx Tests: CT Scan, MRI, X-Ray
Simplenursing.com Less Study Time HIGHER test scores!
Page 31 of 106
Pt. Goals/
Evaluation:
-Pt will maintain
function, of
unaffected body
parts or
compensatory
body parts as well
as correctly
utilizing support
and assistive
devices
-Pt will verbalize
concerns and fears
about body, self
perception and
change of lifestyle
48 Hour Cram Sheets for Med Surg
GUILLAIN-BAR SYNDROME
3. NEURO: PNS
DIAGNOSIS/PATHO
GUILLAIN-BAR SYNDROME
DATA
Patho: Guillain-Barré syndrome is the result of a cellmediated and humoral immune attack on peripheral
nerve myelin proteins that causes inflammatory
demyelination. With the autoimmune attack, there is an
influx of macrophages and other immune-mediated
agents that attack myelin, cause inflammation and leave
the axon unable to support nerve conduction
Assess: Asses for S/S of
ARDS! Assess respiratory
status, monitor VS and ECG,
Monitor for infection and
signs of progression
Vitals:   HR, B P
S/S & PHYS. EXAM:
Autonomic changes:
o Tachycardia, bradycardia,
hypertension, or orthostatic
hypotension
o Increased sweating
o Increased salivation
o Constipation
Other Symptoms:
-Dyskinesia (inability to
executive involuntary
movements)
-Weakness usually begins in
the legs and progress upward
(ascending paralysis)
-Hyporeflexia (decreased
DTRs)
-Paresthesia (numbness),
clumsiness
-Blindness
-Inability to swallow
(dysphagia) or clear secretions
Page 32 of 106
ACTION
RESPONSE
Nursing Interventions:
Pharm: Plasmapheresis, IVIG
(IV Immunoglobulin),
Analgesics as needed
Pt. Ed: Healing/recovery time
may take up to 2 years.
Referral to PT, OT, RT & ST
(Speech therapy), educate
patient on strategies to
prevent
complications/immobility
Surgery: Laminectomy
(Remove portion of the
vertebrae) Diskectomy
(Removal of herniated disk),
Spinal Fusion (Fusion of
vertebrae via the spinal
process by using a bone graft)
Nursing Dx:
-Ineffective
breathing
pattern r/t
respiratory
muscle weakness
or paralysis,
decreased cough
reflex and
immobilization
-Impaired
physical mobility
r/t
neuromuscular
involvement:
cognitive
impairment,
perceptual
impairment,
paresthesia,
weakness
Simplenursing.com Less Study Time HIGHER test scores!
Pt. Goals/
Evaluation:
-Pt will maintain
patent airway,
demonstrate
effective
48 Hour Cram Sheets for Med Surg
MYASTHENIA GRAVIS
-Alternate
hypotension/hypertension Arrhythmias
Labs: Lumbar Puncture
Ganglioside Antibody tests
Dx Tests: MRI, Pulmonary
Function tests, Nerve
conduction test, EMG
(Electromyography)
MYASTHENIA GRAVIS
Patho: In myasthenia gravis, antibodies directed at the
acetylcholine receptor sites impair transmission of
impulses across the myoneural junction. Therefore, fewer
receptors are available for stimulation, resulting in
voluntary muscle weakness that escalates with continued
activity… 80% of people with myasthenia gravis have
either thymic hyperplasia or a thymic tumor, and the
thymus gland is believed to be the site of antibody
production
Assess: Assess for
Respiratory status/ABC’s,
patent airway, progression of
deterioration, muscle wasting.
Also assess for factors that
can contribute to
exacerbation:
-Infection
-Pregnancy
-Stress/Fatigue
-Pregnancy
-Increase in body temp/fever
- Non-Compliance with meds
Vitals: TEMP
S/S & PHYS. EXAM:
Simplenursing.com Less Study Time HIGHER test scores!
breathing
pattern and
show evidence
of adequate
oxygenation
-Pt will maintain/
increase
function, of
affected body
part or
compensatory
body part
Nursing Interventions:
Pharm: Anticholinesterase
medications (Atropine is the
antidote), Pyridostimine,
IMMUNOSUPPRESANTS:
Prednisone, Azathioprine (A
cytotoxic med),
Plasmapheresis, IVIG (IV
Immunoglobulin), Analgesics
as needed
Pt. Ed: Importance
medication compliance,
Aspiration precautions –
Watch amount and
consistency of food as well
scheduling feedings during
peak times of medication
effect. Grouping ADL’s and
Page 33 of 106
Nursing Dx:
-Impaired gas
exchange, r/t
ineffective
breathing
pattern and
muscle weakness
-Risk for
aspiration r/t
difficulty
swallowing
Pt. Goals/
Evaluation:
-Pt will maintain
patent airway,
demonstrate
effective
48 Hour Cram Sheets for Med Surg
MYASTHENIA GRAVIS
-Ptosis - check palpebral
fissure for drooping of upper
eyelids
implementing rest periods,
referral to speech therapy and
support (MG Foundation of
America)
Surgery: Thymectomy
(Excision of the thymus)
-Double vision
-Mask like facial expression
-Weakened laryngeal muscles
leads to dysphagia (difficulty
of swallowing, without food)
-Hoarseness of voice
-Respiratory muscle weakness
leads to respiratory arrest
-Extreme muscle weakness
especially during activity or
exertion in AM
Labs: Edrophonium Choride
(TENSOLIN IV TEST) – If given
and after 5 minutes
Page 34 of 106
Simplenursing.com Less Study Time HIGHER test scores!
breathing
pattern and
show evidence
of adequate
oxygenation
-No aspiration
will occur.
Patient and
patients family
will verbalize
understanding of
aspiration risk
48 Hour Cram Sheets for Med Surg
MYASTHENIA GRAVIS
symptoms are relived, it is
considered a positive test for
MG) Serum Acetylcholine
Receptor Antibody test)
Dx Tests: MRI, EMG
(Electromyography)
Simplenursing.com Less Study Time HIGHER test scores!
Page 35 of 106
48 Hour Cram Sheets for Med Surg
APPENDICITIS
4. GASTRO INTESTINAL (Lower)
DIAGNOSIS/PATHO
APPENDICITIS
Patho: Appendicitis is usually caused by
blockage of the lumen of the appendix.
Obstruction causes the mucus produced
by mucous appendix suffered dam. The
longer the mucus is more and more, but
the elastic wall of the appendix has
limitations that lead to increased intraluminal pressure. These pressures will
impede the flow of lymph resulting in
mucosal edema and ulceration. At that
time there was marked focal acute
appendicitis with epigastric pain. If the
flow is disrupted arterial wall infarction
will occur followed by gangrene
appendix. This stage is called
appendicitis gangrenosa. If the appendix
wall fragile, there will be a perforation,
called perforated appendicitis.
Page 36 of 106
DATA
ACTION
RESPONSE
Assess: For guarding, with pain
in RLQ, Positive McBurney’s sign
(Pain located the right side of
abdomen, located 1/3 the
distance from the anterior
superior iliac spine to
the umbilicus):
Nursing Interventions:
Pharm: PAIN MANAGEMENT
& ANTIBIOTICS UNTIL
SURGERY!! Continue after
surgery as well. Possibly blood if
lost in surgery.
Pt. Ed: Avoid applying heat to
the area, Monitor for
signs/symptoms of infection,
mobility after surgery
Surgery: APPENDECTOMY!
**Must remove before
appendix perforation– CAN
CAUSE SEPTIC SHOCK!! Patient
will notice a “Sudden relief of
pain” which is a BAD SIGN!!
Abdomen will become rigid,
fever will SPIKE!
Nursing Dx:
-Acute pain r/t inflammation
of tissues
-Risk for infection r/t
Inadequate primary
defenses/surgery/perforation
of tissues
Vitals: TEMP
S/S & PHYS. EXAM: Aching
pain that begins around your
navel and often shifts to your
lower right abdomen. The pain
occurs when you apply pressure
to your lower right abdomen
THEN, release the pressure on
that area. When released, the
Pt. will feel A LOT of pain!!
(REBOUND TENDERNESS!!) Pain
that worsens if you cough, walk
Simplenursing.com Less Study Time HIGHER test scores!
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and verbalize
ways to manage it
-Pt will show no signs of
infection including: Elevated
temperature, WBC count, as
well as pain and swelling at
incision site
48 Hour Cram Sheets for Med Surg
SBO (SMALL BOWEL OBSTRUCTION)
or make other jarring
movements, also Nausea,
Vomiting, Loss of appetite, Lowgrade fever, Constipation,
Inability to pass gas, Diarrhea,
Abdominal swelling
Labs: WBC, CBC, hematologic
tests pre-surgery
Dx Tests: CT scan/Ultrasound
to assess for appendicitis,
SBO (SMALL BOWEL
OBSTRUCTION)
Patho: Intestinal contents, fluid and gas
accumulative above the intestinal
obstruction. The abdominal distention
and retention of fluid reduce the
absorption of fluids and stimulate more
gastric secretion. With increasing
distention, pressure within the intestinal
lumen increases, causing a decrease in
venous and arteriolar capillary pressure.
This causes edema, congestion,
necrosis and eventual rupture or
perforation of the intestinal wall, with
resultant peritonitis. Reflux vomiting
may be caused by abdominal distention.
Vomiting results in a loss of hydrogen
ions and potassium from the stomach,
leading to a reduction of chlorides and
potassium in the blood and to metabolic
alkalosis. Dehydration and acidosis
develop from loss of water and sodium.
Assess: Observe and palpate
abdomen for swollen/tender
areas and lump, Listen to bowel
sounds (or absence of), Assess
for signs of perforation and
sepsis/septic shock
Vitals: TEMP
S/S & PHYS. EXAM:
- Cramping intermittent
abdominal pain
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Inability to have a bowel
movement/ pass gas
- Swelling of the abdomen
(distention)
-Bad breath
Labs: Serum chemistry, BUN,
Creatinine, CBC, WBC,
Urinalysis
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Stool Softener,
STIMULANT Laxative
Pt. Ed: eat foods high in fiber,
drink lots of liquids
Surgery: Laparoscopy, or
Surgical Removal (For complete
strangulation)
Nursing Dx:
-Deficient Fluid
Volume related to
nausea/vomiting, fever or
diaphoresis
-Acute Pain related to
intestinal blockage, distention
and rigidity
Pt. Goals/ Evaluation:
-Pt will demonstrate normal
vital signs, balanced input and
output
- Pt will report pain at
tolerable level and verbalize
ways to manage it
Page 37 of 106
48 Hour Cram Sheets for Med Surg
CONSTIPATION
With acute fluid losses hypovolemic
shock may occur.
CONSTIPATION
Patho:
Constipation, costiveness, or
irregularity, is a condition of the
digestive system in which a person
experiences hard feces that are difficult
to expel. This usually happens because
the colon absorbs too much water from
the food. If the food moves through the
gastro-intestinal tract too slowly, the
colon may absorb too
much water, resulting in feces that are
dry and hard. Defecation may be
extremely painful, and in severe cases
(fecal impaction) lead to symptoms of
bowel obstruction
Causes of constipation:
-Diet
-Hormones
-Anatomical a side effect of medications
(Opiates/Narcotics)
-An illness or disorder
Page 38 of 106
Dx Tests: Abdominal X-RAY, CT
Scan
Assess: For signs of bowel
obstruction
Vitals: PAIN
S/S & PHYS. EXAM:
- Pass fewer than three stools a
week
- Hard stools
- Excessive strain during bowel
movements
- A sense of rectal blockage
- Have a feeling of incomplete
evacuation after having a bowel
movement
- Need to use manual
maneuvers to have a bowel
movement, such as finger
evacuation or manipulation of
your lower abdomen
Nursing Interventions:
Pharm: Stool softeners,
Laxatives
Pt. Ed: Stick to diet high in
fiber, Know/PREVENT CAUSES:
-Anal fissure
-Bowel Obstruction
-Colon Cancer
-Bowel Stricture (Narrowing of
Colon)
-Abdominal/Rectal Cancer
Surgery: Bowel obstruction
removal if needed
Labs: Blood tests for hormone
imbalances
Dx Tests:
-Barium studies to look for
obstruction of the colon
-Colonoscopy to look for
obstruction of the colon
-Sigmoidoscopy
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Altered bowel elimination r/t
low-fiber diet/inactivity
-Alteration in Nutrition: Less
Than Body
Requirements related to loss
of appetite/pain
Pt. Goals/ Evaluation:
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
-Pt will report desire to eat,
achieves an adequate
Nutritional intake, Avoidance
of irritating foods, increased
awareness of dietary
management and relief of
pain.
48 Hour Cram Sheets for Med Surg
HERNIA
HERNIA
Patho: When part of an internal organ
bulges through a weak area of muscle.
There are several types of hernias,
including:
-Inguinal: in the groin(most common
type Think, “IN-GROINial”
-Umbilical: around the belly button
- Incision, through a scar
- Hiatal, a small opening in the
diaphragm where the upper part of the
stomach can move up into the chest
-Congenital diaphragmatic: A birth
defect that requires surgery
SIDE VIEW:
Assess: Palpate for mass,
Auscultate for bowel sounds!
ABSENCE OF BOWEL SOUNDS
COULD INDICATE
STRANGULATION F HERNIA, A
MEDICAL EMERGENCY!! This
strangulation can lead to:
OBSTRUCTION, ISCHEMIA,
NECROSIS, AND PERFORATION!
Vitals (Strangulation): TEMP,
HR
S/S & PHYS. EXAM:
INGUINAL:
-BUMP/Bulge in groin/testicles
-Burning or tenderness
-Pain when lifting something
heavy or when exercising
-Pressure in the groin or thigh
HIATAL:
-Acidic taste in the mouth
- Belching
- Difficulty swallowing
- Epigastric pain/ burning (Can
be from the stomach area up to
the mouth)
- Heartburn/Indigestion
- Nausea/ Vomiting
UMBILICAL:
-BUMP/Bulge near umbilical
area
-Burning or tenderness
-Pain when lifting something
heavy or when exercising
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Analgesics for pain,
stool softeners
Pt. Ed: Hernias are common.
They can affect men, women
and children. A combination of
muscle weakness and straining,
such as with heavy lifting, might
contribute. Some people are
born with weak abdominal
muscles and may be more likely
to get a hernia.
Surgery: Surgical repair of
hernia a.k.a. Minimally Invasive
Inguinal Hernia Repair (MIIHR),
Herniorraphy laparoscopic
repair
Page 39 of 106
Nursing Dx:
-Pain r/t abdominal swelling
and pressure
-Risk for infection r/t
abdominal mass/obstruction
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and verbalize
ways to manage it
-The patient will remain free
from signs or symptoms of
infection
48 Hour Cram Sheets for Med Surg
PARALYTIC ILEUS
-Pressure in abdomen
Labs: WBC’s
Dx Tests: Barium Swallow w/
Flouroscopy, X-RAY, Physical
exam
PARALYTIC ILEUS
Patho: Paralytic ileus is the occurrence
of intestinal blockage in the absence of
an actual physical obstruction. This type
of blockage is caused by a malfunction in
the nerves and muscles in the intestineimpairing digestive movement. Causes
include: Electrolyte imbalances,
gastroenteritis, appendicitis,
pancreatitis, surgical complications, and
obstruction of the mesenteric artery,
which supplies blood to the abdomen.
Certain drugs and medications, such as
opioids/sedatives, can cause ileus by
slowing peristalsis (contractions that
propel food through the
digestive tract)
Page 40 of 106
Assess: Presence of bowel
sounds,
Vitals: N/A (See S & S below )
S/S & PHYS. EXAM:
- Abdominal swelling, distension
or bloating
-Constipation
-Diarrhea
-Foul-smelling breath
-Gas
-Absent bowel sounds
-Nausea w/without vomiting
- Stomach pain/spasms
Labs: N/A
Dx Tests: CT w/ Contrast, XRays, Clinical Evaluation
Nursing Interventions:
Pharm/TX: NG Tube w/
Continuous suction, Fluid and
Electrolyte replacement,
Pt. Ed: Avoid opiods and
anticholingergics.
Common causes of Paralytic
Ileus:
-Appendicitis
-Botulism
-Certain medications, such as
opiates/ sedatives
-Diabetic ketoacidosis (DKA)
-Electrolyte imbalance
-Gastroenteritis
-Neonatal necrotizing
enterocolitis (disease that
causes death of intestinal tissue
in newborns)
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
-Risk for shock r/t lack of body
fluid volume
Pt. Goals/ Evaluation:
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
-Pt will exhibit stable vital
signs, consistently stable
input and output, as well as
satisfactory fluid and
nutritional intake to meet the
patients specific needs and
avoid shock
48 Hour Cram Sheets for Med Surg
ISCHEMIC BOWEL/COLITIS
ISCHEMIC BOWEL/COLITIS
Patho: Ischemia occurs secondary to
hypo-perfusion of an intestinal
segment. When hypo-perfusion occurs,
collateral blood flow may preclude or
minimize ischemia; however, the regions
of the intestine with a solitary arterial
supply, and the watershed areas, are
both at increased risk of developing
ischemia. The degree of intestinal injury
is dependent on the duration and
severity of ischemia.
-In turn, Ischemia can cause Acute or
sub-acute mucosal sloughing and
ulcerations. The loss of the mucosal
barrier allows for bacterial translocation
and toxin absorption. Re-perfusion injury
can also occur if blood supply is reestablished after a prolonged
interruption. Segments of bowel which
do not cause acute necrosis or
perforation can heal with stenosis or
stricture. These can cause ischemic
bowel disease with long-term effects
Assess: For signs and
symptoms of sock/infection
Vitals: TEMP/ HR, BP (if
shock)
S/S & PHYS. EXAM:
Abdominal pain:
o Abdominal pain is usually
worse after meals and may be
suddenly severe
o Cramping abdominal pain
o Generalized abdominal pain
o Upper/Lower abdominal pain
Abdominal tenderness
o Right lower abdominal
tenderness
o Left lower abdominal
tenderness
o Right upper abdominal
tenderness
o Left upper abdominal
tenderness
o Upper abdominal tenderness
o Lower abdominal tenderness
Blood in the stool:
o Black stool
Simplenursing.com Less Study Time HIGHER test scores!
-Obstruction of the mesenteric
artery, which supplies blood to
the abdomen
-Pancreatitis
-Surgical complications
Surgery: Colonoscopic
decompression, cecostomy
(RARELY)
Nursing Interventions:
Pharm: IV fluids, Antibiotics (to
prevent infection) Treatment
for comorbidity/ underlying
condition (Ex.- CHF)
Pt. Ed: AVOID
VASOCONSTRICTORS!!
Surgery:
IF NEEDED (Depending on the
Cause), Surgery to:
-Remove dead/ischemic tissue
-Bypass/Repair blockage in
intestine/intestinal artery
-Repair a hole in your colon
- Remove part of intestinal tract
that is narrowed/causing a
blockage
Page 41 of 106
Nursing Dx:
-Risk for shock r/t inadequate
tissue perfusion
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
Pt. Goals/ Evaluation:
-Pt will exhibit stable vital
signs, consistently stable
input and output, as well as
satisfactory fluid and
nutritional intake to meet the
patients specific needs and
avoid shock
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
48 Hour Cram Sheets for Med Surg
VOLVULUS
that can be: Mild and chronic or acute
and resolved.
VOLVULUS
Patho: A volvulus is a bowel
obstruction with a loop of bowel that has
abnormally twisted on itself
Strangulating obstruction is obstruction
with compromised blood flow; it occurs
in nearly 25% of patients with smallbowel obstruction. It is usually
associated with hernia, volvulus, and
intussusceptions. Strangulating
Page 42 of 106
o Rectal bleeding
o Red stools
o Maroon stools
o Constipation
o Indigestion
o Diarrhea
o Nausea/Vomiting
o Anorexia
Labs: ↑WBC, Blood in GI Tract
Dx Tests: Cinical Assessment,
Endoscopy, Angiogram, Doppler
Ultrasound or CT Scan of
Abdomen
Assess: Auscultate for highpitched bowel sounds, “rushing”
sounds or absence of bowel
sounds
Vitals: ↓BP, ↑HR, ↑TEMP
(Signs of infection/Shock)
S/S & PHYS. EXAM:
-Severe abdominal pain
-Nausea
-Vomiting (A lot of Bile)
-Bloody Stools
-Abdominal Distension
-Palpable Mass
Nursing Interventions:
Pharm: Analgesics for pain,
antibiotics for infection, IV Fluid
replacement to facilitate
perfusion and prevent shock
Pt. Ed:
-Smaller feedings are
recommended, because large
quantities of food overload the
stomach and promote gastric
reflux.
-Encourage to eat slowly and
to chew all food thoroughly so
that it can pass easily into the
stomach
Labs: Stool Sample,
Blood/Electrolyte abnormalities
(↓Na, K, Chl. r/t vomiting), ↑HG Surgery: Surgical repair of
& WBC’s (r/t strangulation)
Volvulus
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Ineffective breathing pattern
r/t abdominal distension
interfering with normal lung
expansion
-Ineffective tissue perfusion:
GI r/t bowel obstruction
Pt. Goals/ Evaluation:
-Pt will exhibit normal
breathing pattern, effective
depth, and report little to
know difficulty breathing as
well as Sp02 within normal
limits for patient
-Pt will exhibit stable vital
signs, consistently stable
input and output, as well as
satisfactory fluid and
nutritional intake to meet the
48 Hour Cram Sheets for Med Surg
DIVERTICUITIS
obstruction can progress to infarction
and gangrene in as little as
6 h.
Dx Tests: Upper GI X-ray WILL
SHOW “COFFEE BEAN SIGN → )
Barium enema, CT scan
DIVERTICUITIS
Assess: Auscultate for ↓Bowel
sounds
Vitals: ↑HR, ↑RR, ↑TEMP
S/S & PHYS. EXAM:
-Tenderness, usually in the LLQ
(left lower quadrant)
-Bloating or gas
-Fever and chills
-Nausea and vomiting
-Anorexia
Labs: ↑WBC’s, ↓H&H
Dx Tests: Abdominal X-Ray,
colonoscopy, barium enema
Patho: Diverticulitis is a common
digestive disease particularly found in
the large intestine. Diverticulitis
develops from diverticulosis, which
involves the formation of pouches
(diverticula) on the outside of the colon.
Diverticulitis results if one of these
diverticula becomes inflamed.
Simplenursing.com Less Study Time HIGHER test scores!
patients specific needs and
avoid shock
Nursing Interventions:
Pharm: Analgesics/Pain
Management, Bulk Laxatives,
Stimulant Laxatives, Saline
Laxatives, Stool softeners,
Antibiotics such as
Metronidazole (FLAGYL),
Antisposmodics
Pt. Ed:
Risk Factors for Dicerticula:
• Low-fiber diet
• Chronic constipation
• Obesity
Risk Factors for Diverticulitis:
• Bacteria / food trapped in
diverticula
• Infection/Inflammation
• Most common site for
diverticulitis is the Sigmoid
colon, because of fecal masses
that irritate and increase
pressure in the colon.
Page 43 of 106
Nursing Dx:
-Pain r/t inflamed bowel and
possible peritonitis
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and verbalize
ways to manage it
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
48 Hour Cram Sheets for Med Surg
RESECTION OF INTESTINES
Surgery: To remove the
diseased/infected part of colon
Assess: For signs of infection,
peritonitis, shock
Patho: Small bowel resection is surgery
Vitals: TEMP
to remove part or all of your small
S/S & PHYS. EXAM: Depends
bowel. It is done when part of your small
on the reason for bowel
bowel is blocked or diseased. The small
resection surgery! Many
bowel is also called the small intestine.
diseases or ailments can lead to
Most digestion (breaking down and
this surgery s an option
absorbing
(Cancer? Polyp Groths?
nutrients) of the food you eat takes place
Tumors?)
in the small intestine.
Labs: CBC
Dx Tests: Abdominal
Ultrasound, CT Scan, EKG, Chest
X-Ray,
RESECTION OF INTESTINES
Page 44 of 106
Nursing Interventions:
Pharm: Enema, Antibiotics,
Analgesics for pain, IV Fluids,
Anesthesia
Pt. Ed: BOWEL PREP!!
If you have laparoscopic
surgery:
-You will have 3 - 5 small cuts in
your lower belly. The surgeon
will pass a camera
and medical instruments
through these cuts
-You may also have a cut of
about 2 to 3 inches if your
surgeon needs to put a hand
inside your belly to feel the
intestine or remove the
diseased segment
-Your belly will be filled with gas
to expand it. This makes it easy
for the surgeon to see
and work
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Pain r/t inflamed bowel and
possible peritonitis
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and verbalize
ways to manage it
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
-The patient will remain free
from signs or symptoms of
infection
48 Hour Cram Sheets for Med Surg
RESECTION OF INTESTINES
If you have open surgery, you
will probably have a cut about
6 inches long in your mid-belly:
-Your surgeon will locate the
part of your small intestine that
is diseased
-Then your surgeon will put
clamps on both ends of this part
to close it off
-The surgeon will remove the
diseased part
In both kinds of surgery:
-If there is enough healthy small
intestine left, your surgeon will
sew or staple the healthy ends
of the small intestine back
together
-If you do not have enough
healthy small intestine to
reconnect, your surgeon will
make an opening called a
stoma through the skin of your
belly. Your small intestine will
be attached to the outer wall
of your belly. Stool will go
through the stoma into a
drainage bag outside your
body. This is called an
ileostomy. The ileostomy may
either be short term or
permanent
Simplenursing.com Less Study Time HIGHER test scores!
Page 45 of 106
48 Hour Cram Sheets for Med Surg
INFLAMMATORY BOWEL DISEASE
INFLAMMATORY BOWEL
DISEASE
Patho:
CROHNS!!
Ulcerative colitis
• Is an inflammatory disease of the
submucosal layer of the colon and
rectum characterized by continuously
occurring ulcerations and shedding of
intestinal epithelium. Fat deposits and
muscular hypertrophy result in a narrow,
short, and thickened bowel.
COLORECTAL CANCER
Patho: Colorectal cancer is a disease in
which normal cells in the lining of the
colon or rectum begin to change, start to
grow uncontrollably, and no longer die.
These changes usually take years to
develop; however, in some cases of
hereditary disease, changes can occur
within months to years. Both genetic and
Page 46 of 106
Assess: Color, volume
frequency and consistency of
stools, monitor F&E levels for
dehydration
Vitals:  TEMP (Low-grade)
S/S & PHYS. EXAM:
CROHNS!!
Ulcerative colitis
• Severe diarrhea containing
pus, blood and mucosa
• Abdominal cramping and
tenderness, fever
• Anorexia and weight loss
• Usually occurs in the
descending colon and rectum
Labs: H&H, C-Reactive protein,
WBC,
Dx Tests: Abdominal X-Ray
Assess: Risk factors of colon
cancer, Recently changed bowel
habits
Vitals: Normal unless infection,
possibly TEMP
S/S & PHYS. EXAM:
Ascending (Right) Colon Cancer
-Occult blood in stool
-Anemia
-Anorexia and weight loss
Nursing Interventions:
Pharm: Anti-Diarrheals,
Aminosalicyates (5-ASA’s),
Immune Modulators (Humira),
TPN, Corticosteroids,
Multivitamin and supplemental
Iron,
Pt. Ed: Refrain from foods that
can be irritating to the bowel!
 Oral fluids,
Surgery: IF needed,
Proctolectomy with Ileostomy/
Colectomy with ileostomy
Nursing Dx:
-Pain r/t inflamed bowel
-Impaired bowel elimination
r/t constipation and
decreased dietary intake
Nursing Interventions:
Pharm: Analgesics for pain
Pt. Ed: Don’t miss your annual
checkups!! Use of colostomy
bag, avoid food that cause odor
and gas, Medical supply stores
locally to obtain bags/materials
Nursing Dx:
-Anticipatory grieving r/t
change in body function and
perceived potential death of
patient
- Disturbed body image r/t
loss of diseased body
part/loss of good health
Surgery: Colostomy
Simplenursing.com Less Study Time HIGHER test scores!
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and verbalize
ways to manage it
-Bowel Elimination as
evidenced by Comfort of
passage of stool, stool is soft
and formed, passage of stool
is achieved without aids
48 Hour Cram Sheets for Med Surg
COLORECTAL CANCER
environmental factors can cause the
changes. Initially, the cell growth appears
as a benign (noncancerous) polyp that
can, over time, become a cancerous
tumor. If not treated or removed, a
polyp can become a potentially lifethreatening cancer. Recognizing and
removing
precancerous polyps before they
become cancer can prevent colorectal
cancer!
Pt. Goals/ Evaluation:
-Pt will identify and express
feelings appropriately,
verbalize understanding of
the dying process, and
support to cope
- Client will discuss concerns,
what to expect after
chemo/surgery, and ways to
limit anxiety about body
image
-Abdominal pain above
umbilicus
-Palpable mass
Distal Colon/Rectal Cancer
-Rectal bleeding
-Changed in bowel habits
-Constipation or Diarrhea
-Pencil or ribbon – shaped stool
- Tenesmus
-Sensation of incomplete bowel
emptying
Dukes’ Classification of
Colorectal Cancer
-Stage A: Confined bowel
mucosa, 80-90% 5-year survival
rate
-Stage B: Invading muscle wall
-Stage C: Lymph node
involvement
-Stage D: Metastases or locally
unresectable tumor, less than
5% 5-year survival rate
Labs:
Dx Tests: Colonoscopy
Simplenursing.com Less Study Time HIGHER test scores!
Page 47 of 106
48 Hour Cram Sheets for Med Surg
HIP FRACTURE
5. ORTHOPEDICS (BONES)
DIAGNOSIS/PATHO
HIP FRACTURE
DATA
Patho: Fracture pathophysiology includes
cortical disruption, peri-osteal damage, and
damage to the intra-medullary and cancellous
architecture. Histomorphometric studies have
shown that cortical thinning and some decrease
in trabecular bone mass and connectivity can be
seen especially in Osteoporosis suggesting a
lower quality of bone, and thus decreased
mechanical strength resulting in fracture. An
age-related decline in osteocyte viability has
also been observed in experimental studies. An
inflammatory response also occurs following
fractures of the proximal femur.
Page 48 of 106
Assess: For
Hemhorrage and
SHOCK!! **ALSO
ASSESS for distal
pulses to ensure
circulation! Observe
for signs of thrombophlebitis, report
immediately
Vitals: PAIN, BP,
HR,
S/S & PHYS. EXAM:
-Inability to move
immediately after a fall
-Severe pain in your
hip or groin
-Inability to put weight
on your leg on the side
of your injured hip
-Stiffness, bruising and
swelling in and around
your hip area
-Shorter leg on the side
of your injured hip
-Turning outward of
your leg on the side of
your injured hip
ACTION
Nursing Interventions:
Pharm: Analgesics for pain, Antibiotics
for surgery prep, FLUIDS/BLOOD as
necessary, ***
Pt. Ed: Instruct client regarding
fracture
healing process, diagnostic procedures,
treatment and its complications, home
care, daily activities, diet, restrictions
and follow-up. Encourage fluid intake
and high protein, high vitamin, highcalcium diet. Teach the client
appropriate crutch walking
techniques
Surgery: Hip Fracture repair, specific to
injured site:
Simplenursing.com Less Study Time HIGHER test scores!
RESPONSE
Nursing Dx:
-Pain r/t injury
-Risk for Shock r/t
blood loss/Injury
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Pt will show signs of
adequate tissue
perfusion including
stable vital signs and
fluid status
48 Hour Cram Sheets for Med Surg
TOTAL KNEE REPLACEMENT (TKR)
Labs: CBC, PTT, PT,
INR, H&H
Dx Tests: X-RAY of
Hip, MRI
TOTAL KNEE REPLACEMENT (TKR)
Patho: Knee replacement, or knee
arthroplasty, is a surgical procedure to replace
the weight bearing surfaces of the knee joint to
relieve the pain and disability of osteoarthritis.
It may be performed for other knee diseases
such as rheumatoid arthritis and psoriatic
arthritis. In patients with severe deformity from
advanced rheumatoid arthritis, trauma, or long
standing Osteo- arthritis, the surgery may be
more complicated and carry higher risk. Osteoporosis does not typically cause knee pain,
deformity, or inflammation and is not a reason
to perform knee replacement.
Other major causes of debilitating pain include
meniscus tears, cartilage defects, and ligament
tears. Debilitating pain from osteoarthritis is
much more common in the elderly. Knee
replacement surgery can be performed as a
partial or a total knee replacement. In general,
the surgery consists of replacing the diseased or
damaged joint surfaces of the knee with metal
Assess: Assess
wound/surgical
incision for signs and
symptoms of infection
following surgery and
for signs of shock, for
pain, extreme
shortening, circulation/
neurovascular status
Vitals: PAIN, HR,
RR
S/S & PHYS. EXAM:
Signs/Symptoms of
whatever injury is
causing the need for
surgery! For Example…
-Pain
-Inflammation
-Difficulty moving your
knee
-Popping/Clicking of
knee
-Joint Pain/Stiffness
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Anti-Coagulants,
NSAIDS/Analgesics for pain (Including
Morphine PCA)
Pt. Ed: The operation typically involves
substantial postoperative pain, and includes
vigorous physical rehabilitation. The recovery
period may be 6 weeks or longer and may
involve the use of mobility aids (e.g. walking
frames, canes, crutches) to enable the
patient's return to preoperative mobility. Use
of helpful items such as toilet seat extender,
Exercises to reduce risk of DVT
Surgery: TKR is the surgery!
Page 49 of 106
Nursing Dx:
-Pain r/t surgical
procedure
-Impaired mobility r/t
injury/recent surgery
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Patient will show signs
and verbalize effective
ways to properly
mobilize using
tools/physical
assistance provided
48 Hour Cram Sheets for Med Surg
LONG BONE INJURY
and plastic components shaped to allow
continued motion of the knee.
-Lack of range of
motion
LONG BONE INJURY
Labs: PT, PTT/INR,
CBC, H&H
Dx Tests: X-Ray, MRI,
Bone Scan
Assess: Distal
pulses/neurovascular
status, signs of
infection, range of
motion, complications
Patho: When a bone is broken, the
periosteum and blood vessels in the cortex,
marrow, and surrounding soft tissues are
disrupted. Bleeding occurs from the damaged
ends of the bone and from the neighboring soft
tissue. A clot (hematoma) forms within the
medullary canal, between the fractured ends of
the bone, and beneath the periosteum. Bone
tissue immediately adjacent to the fracture dies.
This necrotic tissue along with any debris in the
fracture area stimulates an intense
inflammatory response characterized by
vasodilation, exudation of plasma and
leukocytes, and
infiltration by inflammatory leukocytes and
mast cells. Within 48 hours after the injury,
vascular tissue invades the fracture area from
surrounding soft tissue and the marrow cavity,
and blood flow to the entire bone is increased.
Page 50 of 106
Vitals: PAIN, HR,
RR
S/S & PHYS. EXAM:
-Pain at site
-Edema/swelling
-Decreased range of
motion
-Pressure at site
-Muscle Spasms
Nursing Interventions:
Pharm: Analgesics for pain
Pt. Ed: Instruct client about restrictions
like not bending at waist or sitting with
Buck traction and not turning below the
waist with Russell traction. Encourage
client verbalize feelings and problems
regarding fracture.
Labs: CBC, H&H PT,
PTT/INR
Dx Tests: X-RAY, MRI
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Pain r/ injury
- Risk for peripheral
Neurovascular
dysfunction
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Pt will maintain
adequate tissue
perfusion AEB palpable
pulses, skin warm and
dry, normal sensation,
stable vital signs, and
adequate urinary
output for patient.
48 Hour Cram Sheets for Med Surg
OSTEOARTHRITIS (OA)
OSTEOARTHRITIS (OA)
Patho: The most common form of arthritis.
It causes the deterioration of the joint cartilage
and formation of reactive new bone at the
margins and subchondral areas of the joint. This
chronic degeneration results from a breakdown
of chondrocytes, most often in the hips and
knees. Osteoarthritis occurs equally in both
sexes after age 40.
The earliest symptoms appear in middle age
and progress with advancing age. Depending on
the site and severity of joint involvement,
Assess: For
contributing factors
such as:
-Female
-Aging
-Metabolic Disease
-Smoker
-Obesity
-Repetitive use/abuse
of Joints
Surgery: Repair as needed
Nursing Interventions:
Pharm: NSAIDS, Corticosteroids, Topical
analgesics
Pt. Ed: Safe use of mobility devices
provided, Correctly performing exercises
as prescribed/treatment plan, physical
therapy, prevention of complication,
immuno-suppression caused by steroid
use
Surgery: Total Joint arthroplasty, total
joint replacement as required
Vitals: PAIN
S/S & PHYS. EXAM:
Simplenursing.com Less Study Time HIGHER test scores!
Page 51 of 106
Nursing Dx:
-Acute Pain r/t
distension of tissues
-Impaired physical
mobility r/t skeletal
deformity
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
48 Hour Cram Sheets for Med Surg
RHUMATOID ARTHRITIS (RA)
disability can range from minor limitation of the
fingers to near immobility in persons with hip or
knee disease. Progression rates vary; joints may
remain stable for years in the early stage of
deterioration.
RHUMATOID ARTHRITIS (RA)
Patho: Rheumatoid arthritis (RA) is a chronic,
systemic inflammatory disorder that may affect
many tissues and organs, but principally attacks
the joints producing an inflammatory synovitis
that often progresses to destruction of the
articular cartilage and ankylosis of the joints.
Rheumatoid arthritis can also produce diffuse
inflammation in the lungs, pericardium, pleura,
and sclera, and also nodular lesions, most
common in subcutaneous tissue under the skin.
Although the cause of rheumatoid arthritis is
unknown, autoimmunity plays a pivotal role in
its
Page 52 of 106
-Joint pain
-Joint stiffness
-Joint tenderness
-Limited range-ofmotion
-Crepitus (crackling,
grinding noise with
movement)
-Joint effusion
(swelling)
-Local inflammation
-Bony enlargements
and osteophyte
formation
Labs:
Dx Tests: Bone scan,
Dual Energy X-Ray
Absorptiometry Scan
(DEXA-Scan)
Assess: For
contributing factors
such as:
-Female
-Physical and
Emotional Stress
-Young to middle age
-Family History
Vitals: PAIN
S/S & PHYS. EXAM:
-Tender, warm,
swollen joints
-Pt will maintain a
position with absence r
limitation of
contractures, and
display
techniques/behaviors
that enable
continuation of
activities
Nursing Interventions:
Pharm: NSAIDS, Corticosteroids,
Disease Modifying Anti-Rheumatic
drugs (DMARDs) like METHOTREXATE,
LEFLUNOMIDE, BIOLOGIC RESPONSE
MODIFIERS (BRM) administered
parenterally HUMIRA, ENBREL
Pt. Ed: Use of mobility devices and
safety, prevention of
infection/complications, Physical therapy
exercises/Rehab,
Surgery: Total Joint arthroplasty, total
joint replacement as required
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Acute Pain r/t
distension of tissues
-Impaired physical
mobility r/t skeletal
deformity
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Pt will maintain a
position with absence r
48 Hour Cram Sheets for Med Surg
GOUT
chronicity and progression. About 1% of the
world’s population is afflicted by rheumatoid
arthritis, women three times more often than
men. Onset is most frequent between the ages
of 40 and 50, but people of any age
can be affected. It can be a disabling and painful
condition, which can lead to substantial loss of
functioning and mobility. It is diagnosed chiefly
on symptoms and signs, but also with blood
tests (especially a test called rheumatoid factor)
and X-rays. Diagnosis and long-term
management are
typically performed by a rheumatologist, an
expert in the diseases of joints and connective
tissues.
-Morning stiffness that
may last for hours
-Firm bumps of tissue
under the skin on your
arms (rheumatoid
nodules)
-Fatigue, fever and
weight loss
Labs: Positive
Rheumatoid factor,
synovial fluid analysis,
antinuclear antibody
test, Erythrocyte
sedimentation rate, CReactive protein
Dx Tests: X-Ray, MRI
Assess:
GOUT
Vitals:
Patho: Gout is a disorder of purine metabolism
S/S & PHYS. EXAM:
characterized by elevated uric acid levels with
-Intense joint pain.
deposition of urate crystals in joints and other
Gout usually affects
tissues. High uric acid levels result from
the large joint of your
decreased excretion of uric acid (90% of cases)
big toe, but it can
due to a wide variety of causes. The disorder
occur in
may progress from an asymptomatic stage
your feet, ankles,
through acute gouty arthritis, to chronic
knees, hands and
tophaceous gout.
wrists. The pain is likely
to be most severe
within the
first 12 to 24 hours
after it begins.
Simplenursing.com Less Study Time HIGHER test scores!
limitation of
contractures, and
display
techniques/behaviors
that enable
continuation of
activities
Nursing Interventions:
Pharm:
Short-Term Relief: Corticosteroids,
Ibuprofen/ NSAIDS, Colchicines **DO
NOT TAKE ASPIRIN, AS IT CAN RAISE
URIC ACID LEVELS IN THE BLOOD!
Uricosuric agents (Help to increase
elimination of uric acid by the kidneys)
Xanthine oxidase inhibitors (decreases
uric acid production by the body)
Colchicine (prevents flare-ups during the
first months you have gout and are
taking other medicines to lower uric acid
levels)
Page 53 of 106
Nursing Dx:
-Impaired Physical
Mobility r/t pain
Pt. Goals/ Evaluation:
-Patient will show signs
and verbalize effective
ways to properly
mobilize using
tools/physical
assistance provided
48 Hour Cram Sheets for Med Surg
GOUT
-Lingering discomfort.
After the most severe
pain subsides, some
joint discomfort may
last from a few days to
a few weeks. Later
attacks are likely to last
longer and affect more
joints.
-Inflammation and
redness. The affected
joint or joints become
swollen, tender and
red.
Pegloticase (Krystexxa) Last resort, for
Gout that hasn't responded to other
treatment.
Pt. Ed: Obesity, Excessive alcohol
intake, Meats and fish high in purine and
diuretics can cause Gout to flare up.
Complications include erosive deforming
arthritis, uric acid kidney stones, and
urate nephropathy caused by hyperuricemia. Utilize rest periods to minimize
additional pain.
Surgery:
Labs: Uric Acid
Dx Tests:
Page 54 of 106
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
PAD (PERIPHERAL ARTERY DISEASE)
6. VASCULAR DISORDERS
DIAGNOSIS/PATHO
DATA
DX:
PAD (PERIPHERAL ARTERY DISEASE)
Patho: Peripheral ARTERIAL disease (PAD) is a systemic
atherosclerotic process for which the major risk factors are similar
to those for atherosclerosis in the carotid, coronary, and other
vascular beds. Among the traditional risk factors for PAD, those
with the strongest associations are advanced age, smoking, and
diabetes mellitus. More recently, a number of nontraditional risk
factors for PAD have also been recognized. This article briefly
reviews the pathophysiology of PAD and the
evidence supporting established and emerging risk factors for its
development.
Simplenursing.com Less Study Time HIGHER test scores!
ACTION
Assess: Assess skin
for: Dependent
rubor, cyanosis,
ulcers, gangrene,
decreased sensation
or pulses
Vitals: Cap Refill,
Unequal/Weak
Pulses,  Pain
S/S & PHYS. EXAM:
Painful cramping in
your hip, thigh or calf
muscles after
activity, such as
walking or climbing
stairs (inter-mittent
claudication), Leg
numb-ness or
weakness, Cold
feeling in your lower
leg or foot, especially
when compared with
the other leg, Sores
on your toes, feet or
legs that won't heal,
A change in the color
of your legs, Hair loss
or slower hair
growth on your feet
Nursing
Interventions:
Pharm: Anticoags: (Heparin,
Lovenox, Aspirin,
Coumadin), AntiPlatelets (Trental,
Plavix), Vasodilators
(Isoxsuprine,
papaverine)
Pt. Ed: Good foot
care, do not cross
legs, stop smoking,
regular exercise,
healthy diet,
monitor/report
symptoms
Surgery:
Angioplasty, Arterial
revasculartization,
artherectomy,
arterial bypass (at
arterial blockage),
thrombectomy
Page 55 of 106
RESPONSE
Nursing Dx:
-Chronic pain r/t
intermittent
claudication/ischemia
-Activity intolerance r/t
peripheral oxygen supply
and demand
- Risk for impaired skin
integrity r/t altered
circulation/sensation
Pt. Goals/ Evaluation:
-Client will report
increased comfort level
and adequate pain
control
- Client will demonstrate
increased tolerance to
physical activity and
utilize the use of rest
periods
-Client will be free from
signs of impaired skin
integrity during their
hospital stay.
48 Hour Cram Sheets for Med Surg
PVD (PERIPHERAL VASCULAR DISEASE)
and legs, Slower
growth of your
toenails, Shiny skin
on your legs, No
pulse/weak pulse in
your legs or feet, ED
in men
Labs: Total
Cholesterol, LDL
(Lousy Cholest.), HDL
(Happy Cholest.),
Lipids, Triglycerides
Dx Tests:
Angiogram, Exercise/
Stress Test, Skin
temperature studies,
Oscillometry
Dx:
PVD (PERIPHERAL VASCULAR
DISEASE)
Patho: Peripheral VASCULAR disease, also
known as arteriosclerosis obliterans, is
primarily the result of athero-sclerosis. The
atheroma consists of a core of cholesterol
joined to proteins with a fibrous
intravascular covering. This process may
gradually progress to complete occlusion of
medium and large arteries. The disease
typically is segmental, with significant
variation from patient to patient. Vascular
Page 56 of 106
Assess: Cool, brown
skin, Edema, ulcers,
pain, Normal or
decreased pulses,
open wounds
Vitals: Cap Refill,
Unequal/Weak
Pulses,  Pain
S/S & PHYS. EXAM:
The most common
symptom of peripheral
vascular disease in the
legs is pain in one or
both calves, thighs, or
hips. The pain usually
occurs while you are
Nursing Interventions:
Pharm: Anti-coags: (Heparin,
Lovenox, Aspirin, Coumadin),
Pt. Ed: Good foot care, do not
cross legs, stop smoking, regular
exercise, healthy diet,
monitor/report symptoms, avoid
extreme temperatures, Use TED
hose/Compression stockings
Surgery: thrombectomy,
Angioplasty, Arterial
revasculartization,
artherectomy, arterial bypass (at
arterial blockage)
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
- Ineffective Tissue Perfusion:
peripheral r/t interruption of
vascular flow
-Ineffective health maintenance r/t
deficient knowledge regarding
disease process
Pt. Goals/ Evaluation:
-Pt. will demonstrate adequate
tissue perfusion AEB palpable
peripheral pulses, and warm and dry
skin
48 Hour Cram Sheets for Med Surg
PVD (PERIPHERAL VASCULAR DISEASE)
disease may manifest acutely when
thrombi, emboli, or acute trauma
compromises perfusion. Thromboses often
occur in the lower extremities more
frequently than in the upper extremities.
Multiple factors pre-dispose patients for
thrombosis. These factors include sepsis,
hypotension, low cardiac output,
aneurysms, aortic dissection, bypass grafts,
and underlying atherosclerotic narrowing of
the arterial lumen. Emboli, the most
common cause of sudden ischemia, usually
are of cardiac origin (80%); they also can
originate from proximal atheroma, tumor,
or foreign objects. Emboli tend to lodge at
artery bifurcations or in areas where vessels
abruptly narrow. The femoral artery
bifurcation is the most common site (43%),
followed by the iliac arteries (18%), the
aorta (15%), and the popliteal arteries
(15%).
walking or climbing
stairs and stops when
you rest. This is because
the muscles' demand for
blood increases during
walking and other
exercise. The narrowed
or blocked arteries
cannot supply more
blood, so the muscles
are deprived of oxygen
and other nutrients. This
pain is called
intermittent (comes and
goes) claudication. It is
usually a dull, cramping
pain. It may also feel like
a heaviness, tightness,
or tiredness in the
muscles of the legs.
Cramps in the legs have
several causes, but
cramps that start with
exercise and stop with
rest most likely are due
to intermittent. When
the blood vessels in the
legs are completely
blocked, leg at night is
very typical, and the
individual almost always
hangs his or her feet
down to ease the pain.
Hanging the legs down
allows for blood to
passively flow into the
distal part of the legs
Simplenursing.com Less Study Time HIGHER test scores!
-Pt. will verbalize understanding of
the disease process and adhere to
the prescribed medication regimen
Page 57 of 106
48 Hour Cram Sheets for Med Surg
ANEURYSMS
Labs: Total
Cholesterol, LDL
(Lousy Cholest.), HDL
(Happy Cholest.),
Lipids, Triglycerides
Dx Tests: Isotope
Studies, Ultra-Sonic
flow detection
Doppler Studies,
Venous Pressure
measurements
Assess: For
increasing severity of
symptoms, **SUDDEN
Dx:
ANEURYSMS
Patho: An aneurysm is a permanent localized dilation
of an artery. This can enlarge the artery. The locations
can differ, as well as the type and how they form, with
DISSECTING being the most life-threatening:
Types/Location:
1. AORTIC
2. CEREBERAL
3. PERIPHERAL
Page 58 of 106
RELIEF OF A PAINFUL
ANUERYMS IS A BAD
SIGN!! LIKELY MEANS
THAT THE ANUERYSM
HAS RUPTURED AND
IMMEDIATE SURGERY
IS REQUIRED!!
Vitals: HR (Weak
pulses distal to
aneurysm), BP,
RR
S/S & PHYS. EXAM:
1. AORTIC: AAA
(Abdominal Aortic
Aneurysm) w/
gnawing pain/pulsing
in abdomen/back,
Thoracic Aortic
Nursing Interventions:
Pharm: Pre-surgical
Meds/Antibiotics, AntiHypertensives (to reduce blood
pressure and decrease a chance
of rupture), Beta Blockers,
Calcium Channel Blockers,
Vasodilators, Anti-Lipid/Plaque
meds (STATINS!)
Pt. Ed: Reduce stress, STOP
SMOKING!! Lower BP, Healthy
Diet/Lifestyle, Monitor changes
to doctor, adhere to medication
regimen.
Surgery: Open abdominal
Chest repair, Endovascular
Repair (Aneurysm not removed
but strengthened):
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Risk for deficient fluid
volume r/t potential
hemorrhage
-Fear/Anxiety r/t
emergency condition
Pt. Goals/ Evaluation:
-Pt will show no signs of
hypovolemia/shock, and
maintain fluid and
electrolytes within
acceptable levels for
Patient
-Pt will verbalize fears
and Anxiety and ways to
cope with such fears
48 Hour Cram Sheets for Med Surg
ANEURYSMS
Aneurysm : Pain
radiates up to jaw,
neck,
coughing/hoarseness,
shoulder blade pain.
2. CEREBERAL:
Aneurysm in brain,
“Worst headache of
your life”,
nausea/vomiting,
pain behind eyes,
,
3. PERIPHERAL:
Pulsations, pains and
sores in extremities,
also gangrene (due to
lack of circulation)
Labs: Blood work
such as Hg and Hct,
Coags, checking for
bleeding, monitoring
for signs of
hypovolemia
Dx Tests:
Ultrasound,
Echocardiogram,
Angiogram, MRI, CT
Scan
Simplenursing.com Less Study Time HIGHER test scores!
Page 59 of 106
48 Hour Cram Sheets for Med Surg
ASTHMA
7. RESPIRATORY
DIAGNOSIS/PATHO
ASTHMA
Patho: Bronchial asthma is a
chronic inflammatory disease of the
airways, associated with recurrent,
reversible airway obstruction with
intermittent episodes of wheezing
and dyspnea. Bronchial hypersensitivity is caused by various
stimuli, which innervate the vagus
nerve and beta adrenergic receptor
cells of the airways, leading to
bronchial smooth muscle
constriction, hypersecretion of
mucus, and mucosal edema.
Page 60 of 106
DATA
ACTION
RESPONSE
Assess: Assess for change in
skin color/cyanosis, use of
accessory muscles/labored
breathing (Is this an attack or
emergency?) Also changes in
mentation/ALOC
Vitals:  Shallow RR
(Commonly with Audible
Wheezing), HR during
attacks
S/S & PHYS. EXAM:
Feeling of tightness in the
chest, difficulty in breathing or
shortness of breath, wheezing,
coughing (particularly at
night).
Labs: O2/cap. Refill,
hypoxemia
Dx Tests: Chest X-Rays, &
Pulmonary Fx tests:
Forced Vital Capacity/FVC
(Volume of air exhaled from
full inhalation to full
exhalation), Forced Expiratory
Volume in the first
Second/FEV1 (Vol. of air blown
out as hard as possible in the
first SECOND of the most
Nursing Interventions:
Pharm: PREVENTATIVE THERAPY:
(Flovent, Serevent, Singulair) RESCUE
DRUGS (Albuterol, Atrovent,
Theophylline)
Pt. Ed: STOP SMOKING!! Adhere to
medication regimen as prescribed,
Reduce stress, monitor symptoms daily
especially signs of an attack, report
increasing symptoms to doctor.
Surgery: N/A
Nursing Dx:
-Activity Intolerance r/t
energy shift to meet muscle
needs for breathing to
overcome airway
obstruction
-Anxiety r/t inability to
breathe effectively
-Ineffective breathing
pattern r/t anxiety
Simplenursing.com Less Study Time HIGHER test scores!
Pt. Goals/ Evaluation:
-the patient will be able to
demonstrate
behaviors to improve
airway clearance
-Client will report ability to
breathe comfortably
48 Hour Cram Sheets for Med Surg
BRONCHITIS
BRONCHITIS
Patho: Bronchitis is an
inflammation of the air passages
within the lungs. It occurs when the
trachea (windpipe) and the large and
small bronchi (airways) within the
lungs become inflamed because of
infection or other causes.
forceful exhalation after the
greatest inhalation & Peak
Expiratory Flow (Fastest
airflow reached at any time
during exhalation)
Assess: Assess respiratory
rate, depth. Note use of
accessory muscles, pursed lip
breathing, Inability to speak.
Evaluate level of activity
tolerance.
Vitals: RR,
S/S & PHYS. EXAM:
Chronic Bronchitis:
History of productive cough
that lasts 3 months per year
for 2 consecutive years,
Persistent cough, known as
smoker’s cough usually in cold
weather, Persistent sputum
production, Recurrent acute
respiratory infection, Dusky
color leading to cyanosis,
Clubbing of fingers
Labs: O2/cap. Refill,
hypoxemia, H&H
Dx Tests: Chest X-RAY,
Sputum test, Pulmonary FX
Tests (See above)
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Antibiotics for infection, Cough
meds/Expectorants, NSAIDS
Pt. Ed: STOP SMOKING!! Adhere to
medication regimen as prescribed,
Reduce stress, monitor symptoms daily
especially signs of an attack, report
increasing symptoms to doctor.
Surgery: N/A
Page 61 of 106
Nursing Dx:
-Ineffective airway
clearance r/t excessive
thickened mucus secretion
-Anxiety r/t potential
chronic condition
Pt. Goals/ Evaluation:
-Client will demonstrate
effective coughing and clear
breath sounds
-Client will identify,
verbalize, and demonstrate
techniques to control
anxiety.
48 Hour Cram Sheets for Med Surg
COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)
Assess: Assist patient to
assume position of comfort
(ex. Elevate head of bed,
encourage patient to lean on
Patho: COPD disrupts airway
side bed table
dynamics, resulting in obstruction of
or sit on the edge of the bed
airflow into or out of the lungs.
Vitals: RR (Shallow)
Chronic Bronchitis: Hypertrophy and
S/S & PHYS. EXAM: Chronic
hypersecretion in goblet cells and
cough, SOB while performing
bronchial mucus glands leading to
ADL’S (dyspnea), Frequent
increased sputum secretions,
respiratory infections,
bronchial congestion, narrowing of
Cyanosis, Fatigue, Producing a
bronchioles, and small bronchi.
lot of mucus/
Emphysema: Increased size of air
phlegm/sputum), Wheezing
spaces (i.e. “dead space”) with loss of
Labs: ABG’s, H&H, O2
elastic recoil of lung due to
Dx Tests: Chest X-RAY,
hyperinflation of distal airways
Sputum test, Pulmonary FX
causing airway obstruction.
Tests (See above), &
Destruction of alveolar walls and
Spirometry
diffuse airway narrowing causes
resistance to airflow because of loss
of supporting structure and
bronchospasm further impede
airflow.
COPD (CHRONIC
OBSTRUCTIVE PULMONARY
DISEASE)
Page 62 of 106
Nursing Interventions:
Pharm: Short and long acting
Bronchodilators (tiotropium (Spiriva)
salmeterol (Serevent) formoterol
(Perforomist), OXYGEN!
Pt. Ed: STOP SMOKING!! Adhere to
medication regimen as prescribed,
Reduce stress, monitor symptoms daily
especially signs of an attack, report
increasing symptoms to doctor.
*Alternate activity and rest periods to
prevent fatigue
Surgery: Lung Reduction, Lung
Transplant **For selected cases only,
end-stage COPD
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Activity intolerance r/t
imbalance between oxygen
supply and demand
-Ineffective Health
Maintenance r/t deficient
knowledge regarding care
of disease
Pt. Goals/ Evaluation:
-Client will participate in
physical activity and
demonstrate appropriate
changes in heart rate,
breathing rate and blood
pressure
-Client will follow mutually
agreed health maintenance
plan
48 Hour Cram Sheets for Med Surg
EMPHYSEMA
EMPHYSEMA
Patho: Decreased pulmonary
elastic recoil. At any pleural pressure,
the lung volume is higher than
normal. Additionally, the altered
relation between pleural and
alveolar pressure facilitates
expiratory dynamic compression of
airways. Such compression limits
airflow during forced expiration and,
in severe instances, during tidal
expiration. Another factor
contributing to airflow limitation is
disease of the airways,
both large and small. In general,
patients with relatively pure
emphysema maintain blood gases in
or near the normal range until very
late in their course. PaO2 is
maintained because of the preserved
matching of ventilation and
perfusion as alveolar walls are
destroyed. PaCO2 is maintained
because the ventilatory response to
CO2 is not usually impaired. It is not
clear why patients who are
categorized clinically as "chronic
bronchitics" are more likely to
respond to an increased flowresistive work of breathing by
hypoventilating. Physical findings in
emphysema are not specific.
Radiologic changes are insensitive
Assess: Assess for signs
and symptoms of hypoxia and
hypercapnia, Monitor/record
blood gas examination,
examine trend in the increase
or decrease in PaO2 or PaCO2
Vitals: RR
(SOB/Adventitious lung
sounds), HR, O2
S/S & PHYS. EXAM:
Shortness of Breath, Rapid
Breathing, Chronic Cough
(With or Without Sputum),
Wheezing, Reduced Exercise
Tolerance, Loss of Appetite
Leading to Weight Loss, Barrel
Chest
Labs: CBC, O2, ABG’S
Dx Tests: Chest X-RAY,
Pulmonary Fx Tests, CT scan
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Bronchodilators, Expectorants,
Corticosteroids, Oxygen
Pt. Ed: STOP SMOKING!! Adhere to
medication regimen as prescribed,
Reduce stress, monitor symptoms daily
especially signs of an attack, report
increasing symptoms to doctor.
*Alternate activity and rest periods to
prevent fatigue
Surgery: Lung Reduction, Lung
Transplant **For selected cases only,
Emphysema NOT caused by smoking
Page 63 of 106
Nursing Dx:
-Activity intolerance r/t
imbalance between oxygen
supply and demand
-Ineffective Health
Maintenance r/t deficient
knowledge regarding care
of disease
Pt. Goals/ Evaluation:
-Client will participate in
physical activity and
demonstrate appropriate
changes in heart rate,
breathing rate and blood
pressure
-Client will follow mutually
agreed health maintenance
plan
48 Hour Cram Sheets for Med Surg
HEMOTHORAX
and are of less value than physiologic
measurements.
HEMOTHORAX
Patho: Roughly Translated,
HEMOTHORAX means blood (HEMO)
in the pleural cavity (THORAX). This
condition can be caused by a number
of factors, when anything penetrates
the pleural wall causing blood to
enter the pleural space, including a
gun shot wound or stabbing. A
hemothorax is managed by removing
the source of bleeding and by
draining the blood already in the
thoracic cavity. Blood in the cavity
can be removed by inserting a drain
(chest tube) in a procedure called a
tube thoracostomy. Usually the lung
will expand and the bleeding will
stop after a chest tube is inserted.
The blood in the chest can thicken as
the clotting cascade is activated
when the blood leaves the blood
vessels and is activated by the
pleural surface, injured lung or chest
wall, or contact with the chest tube.
Page 64 of 106
Assess: Trauma (penetrating
or blunt) Signs of Shock or
Arrest
Vitals: O2 Sat, RR, HR
S/S & PHYS. EXAM: Dyspnea,
Cyanosis, Tachypnea,
Hyperventilation, Dullness on
percussion,
Diminished/Absent lung
sounds
Retained Hemothorax: In this
case, patients can be hypoxic,
short of breath, or in some
cases, the retained
hemothorax can become
infected (empyema).
Labs: H& H, CBC, Red Blood
Cell, ABG’s, PT, INR
Dx Tests: Chest X-Ray ,
Thoracentesis, MRI
Nursing Interventions:
Pharm: Oxygen, Morphine/ analgesics
for pain, Antibiotics for infection
Pt. Ed: Sit in High-Fowlers, Monitor
chest tube/dressing
Surgery: Chest tube insertion/
drainage system
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Deficient Fluid Volume r/t
blood in pleural space
-Ineffective breathing
pattern r/t chest pain/lung
injury
Pt. Goals/ Evaluation:
-Patient will maintain blood
pressure, pulse, body
temperature and breathing
patterns within acceptable
range for patient
-
48 Hour Cram Sheets for Med Surg
PNEUMOTHORAX
As the blood thickens, it can clot in
the pleural space (leading to a
retained hemothorax) or within the
chest tube, leading to chest tube
clogging or occlusion. Chest tube
clogging or occlusion can lead to
worse outcomes as it prevents
adequate drainage of the pleural
space, contributing to the problem of
retained hemothorax.
PNEUMOTHORAX
Patho: Pneumothorax refers to gas
within the pleural space. Normally,
the alveolar pressure is greater than
the intrapleural pressure, while the
intrapleural pressure is less than
atmospheric pressure.
Therefore, if a communication
develops between an alveolus and
the pleural space or between the
atmosphere and the pleural space,
gases will follow the pressure
gradient and flow into the pleural
space. This flow will continue until
the pressure gradient no longer
exists or the abnormal
communication has been sealed.
Since the thoracic cavity is normally
below its resting volume, and the
lung is above its resting volume, the
thoracic cavity enlarges and the lung
Assess: Trauma (penetrating
or blunt) Signs of Shock or
Arrest
Vitals: O2 Sat, RR, HR
S/S & PHYS. EXAM: Dyspnea,
Cyanosis, Tachypnea,
Hyperventilation, Dullness on
percussion,
Diminished/Absent lung
sounds
Labs: H& H, CBC, Red Blood
Cell, ABG’s, PT, INR
Dx Tests: Chest X-Ray ,
Thoracentesis, MRI
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Oxygen, Morphine/ analgesics
for pain, Antibiotics for infection, O2
Pt. Ed: Sit in High-Fowlers, Monitor
chest tube/dressing, verbalize signs of
infection, medication compliance
Surgery: Chest tube insertion
Nursing Dx:
-Ineffective Breathing
pattern r/t decreased lung
expansion
- Risk for Suffocation r/t
dependence on external
device (Chest Tube)
Pt. Goals/ Evaluation:
-Pt will establish a normal
and effective breathing
pattern with ABG’s within
normal range for patient
-Pt will recognize need for
assistance to prevent
complications
Page 65 of 106
48 Hour Cram Sheets for Med Surg
PNEUMONIA
becomes smaller when a
Pneumothorax develops.
-A tension Pneumothorax is a
medical emergency and occurs when
the intrapleural pressure exceeds
atmospheric pressure, especially
during expiration, and results from a
ball valve mechanism that promotes
inspiratory accumulation of pleural
gases. The build-up of pressure
within the pleural space eventually
results in hypoxemia and respiratory
failure from
compression of the lung.
PNEUMONIA
Patho: Pneumonia is an acute
inflammatory disorder of lung
parenchyma that results in edema of
lung tissues and movement of fluid
into the alveoli. These impair gas
exchange resulting in hypoxemia.
Pneumonia can be classified in
several ways. Based on microbiologic
etiology, it may be viral, bacterial,
fungal, protozoa, myobacterial,
mycoplasmal, or rickettsial in origin.
Based on location, pneumonia may
be classified as broncho-pneumonia,
lobular pneumonia, or lobar
pneumonia. Broncho-pneumonia
Page 66 of 106
Assess: For respiratory
shock, abnormal sputum, Fluid
status
Vitals:
S/S & PHYS. EXAM:
Tachypnea, Tachycardia,
Crackles, Productive cough, 
WBC,  O2 Sat. Dyspnea w/
Pleural pain, chills, fever,
diaphoresis
Labs: WBC, Sputum culture
and sensitivity (C&S)
Dx Tests: Chest X-Ray, Pulse
Oximetry
Nursing Interventions:
Pharm: Antibiotics, Antipyretics, antiinflammatory, bronchodilators
Pt. Ed: Medication
Administration/compliance,
Pneumonia/Influenza vaccine
Surgery: chest tube/Thoracentesis
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Impaired gas exchange r/t
changes in alveolar
membrane
-Ineffective airway
clearance r/t inflammation
and secretion build-up
Pt. Goals/ Evaluation:
-Pt will show improved
ventilation and gas
exchange,
-Pulmonary Ventilation is
adequate with no secretion
build-up
48 Hour Cram Sheets for Med Surg
PULMONARY EMBOLISM
involves distal airways and alveoli;
lobular pneumonia, part of the lobe;
and labor pneumonia, the whole
lobe.
PULMONARY EMBOLISM
Patho: A thrombus that has
separated from its site of origin
travels through the circulation to the
inferior vena cava. The right ventricle
pumps this thrombus to the
pulmonary arteries where the
thrombus
finally lodges. PE may occur singly or
multiply. They can be microscopic in
size or be big enough to occlude the
major branches of the pulmonary
artery. Recurrent PE may gradually
obstruct the pulmonary vasculature
and ultimately lead to chronic
obstructive pulmonary hypertension
and cor pulmonale.
Assess: Respiratory Status
and Vital signs, IV access, Signs
of Stroke/Shock, Position of
comfort/HIGH FOWLERS
Vitals:  HR,  O2 Sat. 
RR (Dyspnea)
S/S & PHYS. EXAM:
*PETICHIAL RASH PRESENT
WITH FAT EMBOLISM! Chest
Pain, Anxiety, Diaphoresis,
Pleural Effusion,
crackles/cough
Labs: D-dimer, H&H, CBC
Dx Tests: Chest X-Ray, MRI,
Pulmonary Angiography
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Anti-thrombolytics/clotbusters (tPA if within 3 Hour time
frame) , Anticoagulants, OXYGEN
Pt. Ed: Follow up on labs (PT/INR),
Report new symptoms/worsening pain.
Preventative measures/ medication ,
Dietary precautions (Vitamin K),
Bleeding Precautions, Follow up on
PT/INR
Surgery: Embolectomy, Vena Cava
filter
Page 67 of 106
Nursing Dx:
-Impaired gas exchange r/t
decreased pulmonary
perfusion
-Acute Pain r/t pulmonary
flow obstruction
Pt. Goals/ Evaluation:
-Pt will demonstrate
improved ventilation and
adequate oxygenation as
evidenced by ABG’s within
normal limits for patient
-Pt. will report pain at a
comfortable and tolerable
level
48 Hour Cram Sheets for Med Surg
RESPIRATORY FAILURE
Assess: Chest Pain, SOB,
Restless, anxiety, confusion,
Patho: Respiratory failure can arise
**ASSESS FOR SIGNS OF
from an abnormality in any of the
SHOCK
components of the respiratory
Vitals:  RR, HR, O2,
system, including the airways,
BP
alveoli, central nervous system (CNS),
S/S & PHYS. EXAM:
peripheral nervous system,
Bluish coloration of the lips or
respiratory muscles, and chest wall.
fingernail, Confusion or loss of
Patients who have hypoperfusion
consciousness, Fainting or
secondary to cardiogenic,
change in level of
Hypovolemic, or septic shock often
consciousness or lethargy
present with respiratory failure.
Fatigue, Irregular heart rate
(arrhythmia), Rapid breathing
(tachypnea) or shortness of
breath
Labs: CBC, Chem Panel,
Serum Creatinine Kinease &
Troponin (To rule out MI) and
TSH (To rule out
hypothyroidism)
Dx Tests: Monitor location of
embolism if any, Chest X-Ray,
RESPIRATORY FAILURE
Page 68 of 106
Nursing Interventions:
Pharm: Oxygen, Diuretics (Lasix),
Nitroglycerin (To reduce preload/
afterload), Morphine
(Pain/Venodilation), Beta2 Agonists
(Albeuterol, Terbutaline), Atrovent,
Corticosteroids (Methylprednisolone)
Pt. Ed: Sit in a position of comfort
(one that promotes effective breathing)
such as High Fowlers, medication
compliance, Oxygen use and need,
report new/worsening symptoms.
Surgery: Tracheotomy/Ventilator if
needed, (AIRWAY IS ALWAYS #1!!),
Lung Transplant (if eligible)
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Ineffective breathing
pattern r/t decreased lung
compliance
-Impaired respiratory
function r/t inability to
maintain adequate
oxygenation of the
respiratory tract and
perfusion of oxygen
Pt. Goals/ Evaluation:
-Pt will report ability to
breathe comfortably and
-Client will exhibit positive
signs of perfusion including
O2 Sat. levels and ABG’s
within normal patient limits
48 Hour Cram Sheets for Med Surg
TUBERCULOSIS
TUBERCULOSIS
Patho: Tuberculosis is an infectious
disease caused by the Myobacterium
Tuberculosis. Transmission occurs
when droplet nuclei are produced
form an infected person’s coughs or
sneezes. (AIRBORNE ROUTE). If
inhaled, tubercle bacillus settles in
the alveolus and infection occurs,
with alveolocapillary dilation and
endothelial swelling. The incubation
time for TB is 4 to 8 weeks. TB is
usually asymptomatic in primary
infection. The risk of TB is a higher in
older people who have close contact
with a newly diagnosed TB
patient, those who have TB before,
gastrectomy patients, and those
affected with diabetes mellitus. The
aging process weakens the immune
system, further increasing the
likelihood of tubercular infection in
older adults.
Assess: *AIRBORNE
ISOLATION PRECAUTIONS!!
Assess Lung sounds,
Hemoptysis, Monitor
Liver/Kidney function
Vitals:  TEMP (low grade)
S/S & PHYS. EXAM: Cough,
Hemoptysis, Low grade
fever/NIGHT SWEATS,
Anorexia/Weight-loss,
Malaise/Fatigue
Labs: POSITIVE Sputum
Culture for for acid-fast
bacillus (AFB), Serum analysis,
Serum Analysis QFT-G
(Quantiferon Tuberculosis Gold)
Dx Tests: Chest X-RAY,
Mantoux Tuberculin skin test
(TST)
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm:
COMBINATION DRUG THERAPY:
Isonazid (INH), Rifampin, Pyrazinamide,
Streptomycin, Ethambutol
Pt. Ed: Prevent the spread of this
airborne infection! Practice good hand
hygiene, cover mouth when coughing or
sneezing, ensure medication
compliance as well as diligent follow up
appointments
*AS A MEDICAL PROFESSIONAL, ALL
DIAGNOSED CASES OF TB MUST BE
REPORTED TO LOCAL/STATE HEALTH
DEPARTMENT!
Surgery: N/A
Page 69 of 106
Nursing Dx:
-Ineffective breathing
pattern related to
acute infection and
decreased lung
capacity
-Risk for infection (spread)
r/t lowered
resistance/suppressed
inflammatory process
Pt. Goals/ Evaluation:
- Pt’s breathing will return
to rate and pattern within
their normal limits
-Pt will exhibit minimal or
no signs of infection.
48 Hour Cram Sheets for Med Surg
URI (UPPER RESPIRATORY INFECTION)
URI (UPPER RESPIRATORY
INFECTION)
Patho: A URI is a common infection
that affects the nose, throat and
airways. Caused by Bacteria and
Viruses, this type of infection is very
common and contagious as well.
Examples include:
Sinus infection, Common Cold (aka
Rhinitus) nasopharyngitis,
Laryngitis, Laryngotracheitis, and
Tracheitis
The common time of occurrence is in
the winter months, from September
to March.
Page 70 of 106
Assess: Lung breath sounds,
labor of breathing, cough,
related symptoms
Vitals:  Temp
S/S & PHYS. EXAM: Itchy,
watery eyes, nasal discharge,
nasal congestion,
Sneezing, sore throat, cough,
head- ache, fever, malaise,
fatigue, weakness, muscle
pain
Labs: Sputum/Culture
Dx Tests: Sputum/Culture,
Rapid strep test (if suspected),
Monospot test (If enlarged
lymphnodes/Mono
suspected), and
Allerfy/Asthma evaluation
Nursing Interventions:
Pharm: Treat the cause! If infection
(strep throat, epiglottitis & bacterial
sinusitis): Antibiotics, Common cold
(Can only treat symptoms) with
Tylenol/NSAID’s for fever/body aches,
Steriods for broncho-inflammation, &
Decongestants for nasal issues.
Pt. Ed: Decongestants are NOT
recommended for Pt’s w/ high BP.
Surgery: N/A
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-ineffective Airway
Clearance related to
thick secretions and airway
obstructions
-Acute pain r/t swelling in
throat
Pt. Goals/ Evaluation:
-Pt will be able to cough
effectively and
clear own secretions, and
maintain patency of airway
and had clear breath
sounds
-Patient will report relief of
pain with analgesic
administration
48 Hour Cram Sheets for Med Surg
ANGINA
8. CARDIAC (HEART)
DIAGNOSIS/PATHO
ANGINA
Patho: Basic term for “Chest Pain”.
Commonly assoc. w/ CAD, 
cholesterol & plaque in vessels.
Triggered by phys. Activity/stress. SNS
sys. Activates vasoconstriction of
vessels… smaller tube brings more O2
back to heart, brain and lungs, where it
is needed most. 2 types:
Stable: caused by  phys. Activity, but
stops when activity stops. STABLE
STOPS!
Unstable: Even after stopping activity,
pain is still there. May be due to
blockage/clot in artery, or a clot that
becomes loose as the vessels shrink
and expand. Lack of O2 to heart…Can
lead to MI/ Ischemia!!
DATA
Assess: Vital signs/pain such as
facial grimacing, rubbing of neck or
jaw, reluctance to move, increased
blood pressure, and tachycardia.
Vitals:  BP,  HR, O2 SAT
S/S & PHYS. EXAM:  pain (May
radiate down L arm), SOB,
Diaphoresis/Cool/Clammy skin,
Syncope, anxiety
Labs: Cardiac Enzymes,
Cholesterol/Lipids, H&H
Dx Tests: EKG, Echocardiogram,
Stress test, Angiogram
Simplenursing.com Less Study Time HIGHER test scores!
ACTION
Nursing Interventions:
Pharm: M – O – N – A
MORPINE (Pain mgmt, last resort,
can numb Pt./mask symptoms)
OXYGEN (O2 to left ventricle)
NITROGYLCERIN ( vasodilation)
**Contraindicated in Pts on
Vasodilators/Viagra!
ASPIRIN (Breaks up congregating plts)
*Position Pt. in Semi-Fowlers
position.
Pt. Ed: NO smoking, healthy diet,
limit sodium, exercise program, 
stress,  cholesterol,  BP
Surgery: Angioplasty/Stent, CABG
to check for and clear blockage if
present.
Page 71 of 106
RESPONSE
Nursing Dx:
-Acute Pain r/t
decreased
myocardial blood
flow
-Activity Intolerance
r/t acute
pain/dysrhythmias
Pt.
Goals/Evaluation:
-Patient will be free
from pain, maintain
stable vital signs and
show no visual signs
of pain
-Pt. will demonstrate
 tolerance to
activity. Assess
effectiveness of nitro;
assess vital signs,
pain control, as well
as Pt. S/S and EKG for
any sign of
infarction/
arrhythmias.
48 Hour Cram Sheets for Med Surg
ARRHYTHMIAS
ARRHYTHMIAS
Patho: Disturbance in impulse
formation/conduction/communication.
4 TYPES: Suppressed Automaticity (SA
node doesn’t fire effectively/up to
speed, can lead to Pacemaker
Placement), Enhanced Automaticity
(Can result in multiple arrhythmias,
ATRIAL & FIB. due to increased
rate/impulse) Triggered Activity (An
early or late depolarizations can
trigger/ precipitate Ventricular
arrhythmias… EX: torsades de pointes,
Digoxin Toxicity) & Re-entry (Current or
past MI/infarction/scarring or a block
at a node can conceal accessory
pathways and cause the re-entry of the
conduction signal in the heart.
Page 72 of 106
Assess: Assess and record
apical pulse, peripheral pulses,
blood pressure, capillary filling time,
fluid intake/output, and skin for
striped skin, skin color, edema,
temperature, diaphoresis.
Vitals:  Pain, Change in
HR/Rhythm, O2,  BP
S/S & PHYS. EXAM: Palpitations (a
feeling of skipped heart beats,
fluttering or feeling that your heart is
"running away"). Pounding in your
chest, Dizziness/ Syncope, SOB, Chest
discomfort, Weakness or fatigue
(feeling very tired).
Labs: ECG/EKG, no blood tests to
determine.
Dx Tests: EKG
Nursing Interventions:
Pharm: OXYGEN! Nitro
(Vasodilator)
RX Depends on the Arrhythmia:
PSVT/WPW Synd/A-Flutt: Diltiazem,
Adenosine (Slows Vent. Rate by 
AV Block). Digoxin (Supraventricular
Arrhythmias)
Pt. Ed: Report  S/S to Physician,
Limit salt intake, Monitor B/P, Follow
up with meds as prescribed, DO NOT
take nitro w/ other Vasodilators like
Viagra, Monitor BP/HR/Daily weights
Surgery: Pacemaker to regulate
heart rate, Cardio-aversion, Vagal
Stimulation (Temporary)
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Activity intolerance
r/t decreased cardiac
output
-Decreased cardiac
output r/t altered
electrical conduction
Pt.
Goals/Evaluation:
-Patient will
participate in phys.
Activity with
appropriate changes
in vital signs.
-Patient will
demonstrate
adequate cardiac
output AEB: BP, HR
and Rhythm within
normal parameters
for Patient and
without pain.
48 Hour Cram Sheets for Med Surg
ACUTE CORONARY SYND. (ACS)
ACUTE CORONARY SYND.
(ACS)
Patho: Acute coronary syndrome is a
term used for any condition brought on
by sudden, reduced blood flow to the
heart. Can be chest pain you feel
during a heart attack, or chest pain you
feel while you're at rest or doing light
physical activity (unstable angina). It is
believed that atherosclerotic plaque
ruptures in the artery, resulting in clot
formation and vasoconstriction, thus
leading to decreased cardiac output.
The “Freeways”/ Arteries of your heart
become blocked or Jammed.
Assess: Reported Pain, BP, Apical
HR & Urinary output.
Vitals: Pain, BP, HR & O2
(may lead to bradycardia/inadequate
perfusion)
S/S & PHYS. EXAM: Chest pain,
Referred pain, N/V, SOB, Diaphoresis
& Anxiety
Labs: Cholesterol, Triglycerides,
Blood Glucose, Serum Lipid levels
Dx Tests: EKG (To rule out MI),
Computed tomography coronary
angiography (CTCA), Angiogram (To
determine blockage, if any)
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Depends on the lipid levels,
but most commonly used are the
“Statins” (ex. Atorvastatin/Lipitor,
Rosuvastatin/Crestor)
Pt. Ed: Modify common risk factors,
including: Smoking, Tobacco use,
Diet, Exercise, Stress, Alcohol Use
Surgery: Angioplasty, Stent/Balloon
placement, CABG if necessary.
Page 73 of 106
Nursing Dx:
-Decreased cardiac
output r/t ischemia
-Acute pain r/t
myocardial issue
damage r/t
inadequate blood
supply.
Pt.
Goals/Evaluation:
-Patient will
demonstrate
adequate cardiac
output AEB: BP, HR
and Rhythm within
normal parameters
for Patient and
without pain.
-Pt. will report that
pain management
regimen is
satisfactory to pain
tolerance standards.
48 Hour Cram Sheets for Med Surg
ATRIAL FIBRILLATION (A-FIB)
ATRIAL FIBRILLATION (A-FIB)
Patho:
1. Primary arrhythmia in the absence of
identifiable structural heart disease
2. Secondary arrhythmia in the absence
of structural heart disease but in the
presence of systemic abnormality that
predisposes the individual to the
arrhythmia
3. Secondary arrhythmia associated
with cardiac disease that affects the
atria
CAN BE: Acute, Chronic, and
Lone/Primary.
- Acute AF: This has an onset within 2448 hours of the causative event and
usually converts spontaneously or in
response to an antiarrhythmic agent
(cardioversion).
- Chronic AF - The most debilitating
form of AF because of its abrupt onset.
It may be persistent or permanent,
requires int./TX by cardioversion to
sinus rhythm.
Page 74 of 106
Assess: Pulses, urine output, bloodtinged sputum, EKG strip & SIGNS of
STROKE (ALOC, changes in speech,
motor function, or facial droop)
Vitals:  HR (Up to 350-600 Atrial
BPM)  BP (r/t  Cardiac output)
S/S & PHYS. EXAM: Palpitations,
Dyspnea, Pulmonary edema, Signs of
cerebrovascular insufficiency,
fatigue, distended jug. veins,
Labs: PT, PTT, INR, H&H, EKG
Dx Tests: Trans-esophageal
electrocardiogram (TEE) to assess for
signs of clots BEFORE cardioversion.
Physiologic Mapping Studies (Before
MAZE procedure)
Nursing Interventions:
Pharm: Calcium Channel Blockers
(Diltiazem), Antidysrhythmics
Amioderone (Unlabeled use), &
Anticoagulants (Heparin, Coumadin,
Lovenox)
Pt. Ed: Advise Pt on blood thinners
that regular blood tests may be
required, to take caution as excessive
bleeding may occur.
Surgery: Cardioversion, Radiofrequency Catheter Ablation (Creates
scar tissue to defer abnormal
pathways/rhythms of A-fib) & “Maze
Procedure” (usually performed with
CABG, sutures are strategically placed
to prevent electrical circuits from
causing AF) & Pacemaker implant.
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Decreased Cardiac
Output r/t altered
electrical conduction
-Activity intolerance
r/t decreased cardiac
output
Pt. Goals/
Evaluation:
-Patient will display
adequate cardiac
output AEB Pt’s
BP/HR/Rhythm are in
normal parameters
for the client.
-Patient will
participate in phys.
Activity with
appropriate changes
in vital signs.
48 Hour Cram Sheets for Med Surg
CARDIOGENIC SHOCK
CARDIOGENIC SHOCK
Patho: Signs and symptoms of
cardiogenic shock reflects the nature of
the circulation/
patho of heart failure.
MI/Dysrrhythmias and
Cardiomyopathies cause heart damage
resulting in decreased cardiac output,
BP out of artery to the vital organs.
 Blood flow to coronary arteries 
Oxygen to the heart leading to
ischemia and  Heart's ability to
pump, thus causing inadequate
perfusion of body tissues = SHOCK
Assess: Signs of inadequate tissue
perfusion, including: Pulse, muscle
weakness, metabolic acidosis,
shallow respirations, tachycardia,
cool, clammy skin.
Vitals:  HR,  BP, RR,
O2/Cap. Refill,  Temp.
S/S & PHYS. EXAM: Anxiety,
restlessness, altered mental state
due to decreased cerebral perfusion
and
subsequent hypoxia. Hypotension
due to decrease in cardiac output.
Rapid/weak/thready pulse,
tachycardia, Cool/clammy/mottled
skin, Distended jugular veins. Oliguria
Labs: ABG’s (For signs of acidosis)
as well as CVP (Central Venous
Pressure) Hemodynamic monitoring,
H&H, CK-MB/Cardiac panel to rule
out MI.
Dx Tests: EKG, Echocardiogram
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Meds to reverse shock:
Dopamine and dobutamine (to
improve cardiac
contractility), Vasopressors (Nitro),
Epinepherine, Norepinepherine,
Fluids
(Blood/Plasma/Platelets/Crystalloids/
Colloids), Diuretics (Lasix, HCTZ),
Oxygen
Pt. Ed: Teach Pt. how to reduce
controllable risk factors for heart
disease. Encourage attendance
Ensure the patient understands the
medication prescribed.
Surgery: Immediate re-perfusion (Pt
is taken to Cardiac Cath. Lab and
immediate Left sided heart
catheterization, PCI (Percutaneaous
Coronary Intervention) stent/balloon.
*Pt. may be intubated/on ventilator
for O2 support
Page 75 of 106
Nursing Dx:
-Altered tissue
perfusion
(cardiopulmonary)
r/inadequate cardiac
output
Pt.
Goals/Evaluation:
Circulation status;
Cardiac pump
effectiveness; Tissue
perfusion:
Cardiopulmonary,
Cerebral, Renal,
Peripheral; Vital sign
status *Evaluate for
signs of
arrhythmia/MI/Shock
to prevent relapse.
Assess Pt’s vital signs
for values within
acceptable limit.
48 Hour Cram Sheets for Med Surg
CABG (Coronary Artery Bypass Graft)
CABG (Coronary Artery
Bypass Graft)
Patho: Essentially Building a “SIDESTREET” The occluded coronary arteries
are bypassed with the client’s own venous
or arterial blood vessel or synthetic grafts.
The internal mammary artery (IMA) is the
best choice for success over a long period
of time for patency. Recommended for
patients that do not respond to other
forms of medication and treatment Other
indications include: Angina with 50% or
more occlusion of main Coronary artery
that cannot be stented, Acute
MI/Cardiogenic shock, Ischemia with heart
failure, Valvular disease, coronary arteries
not suitable for Percutaneaous
transluminal coronary angioplasty (PTCA),
or those who have signs of ischemia or
pending MI after PTCA.
Page 76 of 106
Assess: Signs of anxiety, decreased
cardiac output/Hemodynamics, chest
pain, and feeling of impending doom.
Assess pulses, heart rate, EKG and O2
perfusion, Pre/Post Op. Pt. Ed. and
allergies.
Vitals: O2,  BP,  Peripheral
pulses,  RR
S/S & PHYS. EXAM: Pt may be
grimacing, chest pain, SOB, Tacypnea,
arrhythmias/elevated ST wave, JVD,
ALOC
Nursing Interventions:
Pharm: O2, Aspirin, Heparin/
Lovenox/Coumadin, Nitro for chest
pain
Pt. Ed: Schedule uninterrupted
rest/sleep periods, assistance
with/Early ambulation, Turn, Cough,
Deep breath as ordered, monitor site
for signs of infection/bleeding
Surgery: CABG is the surgery!
AFTER CABG: Observe for ALOC,
Labs: Cardiac enzymes, ABG,
Cholesterol, Lipids
Dx Tests: EKG, PTCA, Echocardiogram, Stress test
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
- Risk for reduced
cardiac output r/t
depressed cardiac
function
- Risk for bleeding r/t
incision site/surgery
- Anxiety r/t
surgery/hospital stay.
Pt. Goals/
Evaluation : Patient
will be able to
demonstrate
hemodynamic
stability such as
stable blood pressure
and adequate cardiac
output
48 Hour Cram Sheets for Med Surg
CHF (Congestive Heart Failure)
CHF (Congestive Heart Failure) Assess: Apical pulses for Rate/Rhythm,
Patho: Heart failure means the tissues of
the body are temporarily not receiving as
much blood and oxygen as needed.
Whether acute or chronic, there is much
risk associated with Heart Failure, each set
of systems assoc. w/ a side of the heart
(see next column) Think ANATOMICALLY:
The two upper chambers are called atria
and the two lower chambers are called
ventricles. The right atrium and right
ventricle receive blood from the body
through the veins (DE-OXYGENATED) and
then pump the blood to the lungs. The left
atrium and left ventricle receive blood
from the lungs and pump it out through
the aorta into the arteries (OXYGENATED),
which feed all organs and tissues of the
body with oxygenated blood. Because the
left ventricle has to pump blood to the
entire body, the LEFT VENTRICLE a
stronger pump than the right ventricle.
Assess skin for pallor/cyanosis, Monitor
urine output for decrease, and dark
concentrated urine. ALOC
Vitals: O2,  HR,
S/S & PHYS. EXAM: Dysrhythmias
Left-sided heart failure
*Dyspnea on exertion or orthopnea
*Moist crackles on lung auscultation
*Frothy, blood-tinged sputum
*Tachycardia with S3 heart sound
*Pale, cool extremities
* Peripheral and central cyanosis
*peripheral pulses, capillary refill
time * urinary output (<30 ml/hour)
*Fatigue* Insomnia/restlessness
Right-sided heart failure
* Dependent pitting edema (peripheral
and sacral) * Weight gain * Nausea/
anorexia Jugular vein distention (JVD)
* Hepatomegaly, ascites or weakness
Left and right-sided heart failure:
*Cardiomegaly
*Vascular congestion of lung fields
*Electrocardiogram identifies
hypertrophy or MI/damage
ABG (Arterial blood gas) studies reveal
decreased partial pressure of arterial
oxygen (95%),
Labs: ABG, Cardiac Enzymes
Dx Tests: EKG, PTCA, Echo-
Nursing Interventions:
Pharm: O2, Diuretics, as indicated
Pt. Ed: Fluid/Sodium restriction,
Combine ADL’S/Alternate breaks,
Relaxation/  Stress,
Surgery: Heart Transplant is
ULTIMATE CHOICE, but if not, VAD
(Ventricular Assist Device *usually
used as a bridge until surgery), PLV
(Partial Left Ventriculectomy),
Endoventricular Circular Patch, Acorn
Cardiac Support Device, Myosplint
Pt. Goals/
Evaluation :
- The patient will be
able to display vital
signs within
acceptable limits,
dysrhythmias
controlled and no
symptoms of failure.
cardiogram, Stress test
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
- Decreased cardiac
output r/t impaired
cardiac function
- Excessive fluid
volume r/t impaired
excretion of sodium
and water
- Impaired gas
exchange r/t
excessive fluid in
interstitial space of
lungs/alveoli
Page 77 of 106
48 Hour Cram Sheets for Med Surg
CAD (Coronary Artery Disease)
CAD (Coronary Artery
Disease)
Patho: Chronic disease of the
Coronary arteries, where over time
plaque has built up and hardening has
occurred causing a “narrowing” of the
artery walls, similar to a “TRAFFIC JAM”
on the freeway… LESS LANES ARE
OPEN! Because of this, the built-up
plaque can occlude partially (causing
stable angina) or completely (Causing
UNSTABLE angina).
Assess: Pain, anxiety, Activity
intolerance,
Vitals: BP, HR , Cap. Refill
time/Oxygenation
S/S & PHYS. EXAM:
-Angina
-Nausea and vomiting
-Dizziness and syncope
-Diaphoresis clammy skin
-Apprehension or a sense of impending
doom
Nursing Interventions:
Pharm: Cholesterol meds (STATINS),
Nitro for Chest Pain, Antiplatelets/Anti-Coagulants
Pt. Ed: Healthy diet, exercise as
directed by doctor
Surgery: Angioplasty, Stent/Balloon
placement, CABG
Labs: Lipids, Cholesterol
Dx Tests: Echocardiogram, Stress
test, Angiogram
Nursing Dx:
- Acute pain related
to the imbalance o
myocardial oxygen
supply and demand.
- Ineffective tissue
perfusion related to
myocardial ischemia
and decreased
cardiac output.
- Anxiety related to
pain, feeling of
impending doom,
lifestyle
changes/diagnosis of
CAD.
Pt. Goals/
Evaluation: Reduce
pain, Prevent angina
episodes by
balancing
rest/activity, achieve
and maintain a
suitable blood
pressure for patient.
Page 78 of 106
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
HTN (Hypertension)
HTN (Hypertension)
Patho: Chronic High Blood pressure
due to some or a combination of many
factors/Imbalances in the body. When
blood volume falls or blood flow to the
kidneys decreases, juxtaglomerular
cells in the kidneys secrete renin into
the bloodstream. In sequence, renin
and angiotensin converting enzyme
(ACE) act on their substrates to
produce the active hormone
angiotensin II, which raises blood
pressure in two ways. First, angiotensin
II is a potent vasoconstrictor; it raises
blood pressure by increasing systemic
vascular resistance. Second, it
stimulates secretion of aldosterone,
which increases re-absorption of
sodium ions and water by the kidneys.
The water reabsorption increases total
blood volume, which increases blood
pressure.
Assess: Headache
Vitals: HR BP:
S/S & PHYS. EXAM:
Headache, dizziness, blurred vision,
nausea/vomiting, chest pain, SOB.
Heart attack, CHF, Stroke or transient
ischemic attack (TIA), Kidney failure,
Eye damage with progressive vision
loss, Peripheral arterial disease
causing leg pain with walking
(claudication), Aneurysms
Labs: BP in all extremities, Checking
regularly
Dx Tests: No DX tests are necessary,
except when determining secondary
causes such as Renal Disease,
Diabetes, and Atherosclerosis. Can
use an EKG to determine the level of
cardiac involvement.
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Beta Blockers (Metropolol,
Atenolol, Carvedilol *BETA BLOCKERS
like to LOL!! ) Diuretics (Aldactone,
Furosemide, HCTZ), ACE Inhibitors,
Calcium Channel Blockers,
Vasdilators
Pt. Ed: Monitor Blood Pressure
Daily, Daily weights, side effects of
meds, Modifiable risk factors
Surgery: May need surgery to repair
damage caused by chronic
hypertension, such as aneurysm
repair, kidney transplant/Dialysis,
CABG
Page 79 of 106
Nursing Dx:
-Ineffective health
maintenance r/t
deficient knowledge
of disease process
- Risk for prone
behavior r/t lack of
knowledge about the
disease
Pt. Goals/
Evaluation:
-Pt will verbalize
understanding of
disease process
-Pt will check BP daily
and report significant
changes
-Pt will adhere to
medication regimen
-Pt will adhere to
ordered low salt diet
and exercise regimen
-Pt will change
modifiable risk
factors
48 Hour Cram Sheets for Med Surg
HYPERLIPIDEMIA (High Cholesterol)
HYPERLIPIDEMIA (High
Cholesterol)
Patho: Hyperlipidemia is an excess of
fatty substances called lipids, largely
cholesterol and triglycerides, in the
blood. It is also called hyperlipoproteinemia because these fatty
substances travel in the blood attached
to proteins. This is the only way that
these fatty substances can remain
dissolved.
Page 80 of 106
Assess: What is the Pt.’s diet? Any
past problems/family Hx of high
cholesterol? Is the Pt. Taking
medication for it? Associated
Diseases/Dx… Palpate pulses, assess
distal pulses for circulation, assess
pulses for bruit
Vitals: BP
S/S & PHYS. EXAM:
Cholesterol/Lipid levels, May be
obese, may have associated chest
pain, SOB,  Cap. Refill/ 
Circulation, Unequal pulses
Labs: Total Cholesterol, HDL,
LDL, Lipid Panel, Triglycerides
Dx Tests: Angiogram,
Echocardiogram, Stress test
Nursing Interventions:
Pharm: Statins! STATINS, STOP!
(Atorvastatin, Simvastatin,
Lovastatin) Fibric Acids (Advicor,
Tricore)
Pt. Ed: Modify diet/exercise,
compliance with medication, report
new symptoms immediately.
Surgery: Stent/Balloon, CABG,
angioplasty
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Inadequate
perfusion of body
tissues r/t
interruption of
vascular flow
- Insufficient
knowledge r/t
disease process
Pt.
Goals/Evaluation:
-Pt will verbalize
understanding of
healthy diet and
exercise
-Pt. will be able to
state modifiable
factors
-Pt. will adhere to a
specific medication
regimen to reduce
cholesterol levels in
body
48 Hour Cram Sheets for Med Surg
DIABETES TYPE I
9. ENDOCRINE
DIAGNOSIS/PATHO
DIABETES TYPE I
Patho: Diabetes Mellitus (DM)
is a chronic metabolic disorder
caused by an absolute or relative
deficiency of insulin, an anabolic
Hormone. Type 1 diabetes
mellitus can occur at any age and
is characterized by the marked
and progressive inability of the
pancreas to secrete insulin
because of autoimmune
destruction of the beta cells. It
commonly occurs in children,
with a fairly abrupt onset;
however, newer antibody tests
have allowed for the
identification of more people
with the new-onset adult form of
type 1 diabetes mellitus called
latent autoimmune diabetes of
the adult (LADA). These patients
are dependent on exogenous
insulin. Type 1 diabetes
(formerly called juvenile-onset
or insulin-dependent diabetes),
accounts for 5% to 10% of all
people with diabetes. In Type 1
diabetes, the body’s immune
DATA
ACTION
RESPONSE
Assess: For signs of
hyperglycemia &
hypoglycemia!
Vitals: HR, BP (Longterm)
S/S & PHYS. EXAM: The 3
P’s! POLURIA, POLYPHAGIA,
POLYDIPSIA! Extreme thirst,
frequent urination,
drowsiness, lethargy,
increased appetite, sudden
weight loss for no reason,
sudden vision changes, sugar
in urine, ketones in urine,
heavy or labored breathing,
unconsciousness
Labs: Fasting plasma
glucose of 126 mg/dL or
greater, Random plasma
glucose of 200 mg/dL greater,
Glucose tolerance test,
HbA1c, ABG’s, electrolytes,
Urine glucose tests, Thyroid
function
Dx Tests: Same as labs
Nursing Interventions:
Pharm: Insulin!
Pt. Ed: Insulin compliance (maintain normal
range!), Do not stop taking insulin if within normal
range! Diet management, education on the signs of
hypo/hyperglycemia, long term education for
complications, foot care, med-alert bracelet, “SICK
DAY RULES”:
Nursing Dx:
-Risk for infection r/t
high glucose levels
-Lack of knowledge
r/t disease process
*EXAMPLE of Insulin Times (See you School/Hospital
book/policy):
Surgery: N/A, unless organ
complication as needed
Simplenursing.com Less Study Time HIGHER test scores!
Page 81 of 106
Pt. Goals/
Evaluation:
-Pt. will take proper
precautions and
verbalize signs and
symptoms of
infection
-Pt will be able to
verbalize
understanding of
disease process and
daily management
regimen
48 Hour Cram Sheets for Med Surg
DIABETES TYPE II
system destroys the cells that
release insulin, eventually
eliminating insulin production
from the body. Without insulin,
cells cannot absorb sugar
(glucose), which they need to
produce energy.
DIABETES TYPE II
Patho: Type 2 diabetes mellitus
occurs when the pancreas
produces insufficient amounts of
the hormone insulin and/or the
body’s tissues become resistant
to normal or even high levels of
insulin. This causes high blood
glucose (sugar) levels, which can
lead to a number of
complications if untreated. Type
2 diabetes is a chronic medical
condition that requires regular
monitoring and treatment.
Treatment, which includes
lifestyle adjustments, self-care
measures, and sometimes
medications, can control blood
glucose levels in the near-normal
range and
Minimize the risk of diabetesrelated complications. Type 2
diabetes accounts for around
85% of all people with diabetes.
Page 82 of 106
Assess: Sign of
Hyperglycemia, HHS
(Hyperglycemic
Hyperosmolar State)
Vitals: HR, BP (Longterm)
S/S & PHYS. EXAM: Any
symptoms of DM Type 1,
recurring or hard-to heal skin,
gum or urinary tract
infections, drowsiness,
tingling of hands and feet,
itching of skin and genitals.
Labs: Fasting plasma
glucose of 126 mg/dL or
greater, Random plasma
glucose of 200 mg/dL greater,
Glucose tolerance test,
HbA1c, ABG’s, electrolytes,
Urine glucose tests, Thyroid
function
Dx Tests: N/A
Nursing Interventions:
Pharm: Anti-diabetic drugs, insulin as needed
Pt. Ed: Teach strategies to prevent HHS, Regular
monitor blood glucose, adherence to insulin
regimen, regular blood tests, monitor for long term
effects
Surgery: N/A
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Risk for infection r/t
high glucose levels
-Lack of knowledge
r/t disease process
Pt. Goals/
Evaluation:
-Pt. will take proper
precautions and
verbalize signs and
symptoms of
infection
-Pt will be able to
verbalize
understanding of
disease process and
daily management
regimen
48 Hour Cram Sheets for Med Surg
HYPOGLYCEMIA
HYPOGLYCEMIA
Patho: Hypoglycemia, also
called low blood glucose or low
blood sugar, occurs when blood
glucose drops below normal
levels. Glucose, an important
source of energy for the body,
comes from food. Carbohydrates
are the main dietary source of
glucose. Rice, potatoes, bread,
tortillas, cereal, milk, fruit, and
sweets are all carbohydrate-rich
foods. After a meal, glucose is
absorbed into the bloodstream
and carried to the body's cells.
Insulin, a
hormone made by the pancreas,
helps the cells use glucose for
energy. If a person takes in more
glucose than the body needs at
the time, the body stores the
extra glucose in the liver and
muscles in a form called
glycogen. The body can use
glycogen for energy between
meals. Extra glucose can also be
changed to fat and stored in fat
cells. Fat can also be used for
energy. When blood glucose
begins to fall, glucagon-another
hormone made by the pancreassignals the liver to break down
glycogen and release glucose into
Assess: For tachycardia,
diaphoresis, weakness,
anxiety, ALOC
Vitals: HR, BP
S/S & PHYS. EXAM: COLD
& CLAMMY = NEED SOME
CANDY Hypoglycemia causes
symptoms such as hunger,
shakiness, nervousness,
sweating, dizziness or lightheadedness, sleepiness,
confusion, difficulty speaking,
anxiety, weakness
*Hypoglycemia can also
happen during sleep: Some
signs of hypoglycemia during
sleep include:
crying out or having
nightmares, finding pajamas
or sheets damp from
perspiration, feeling tired,
irritable, or confused after
waking up
Labs: Blood Glucose test
Dx Tests:
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Glucose Tabs/Glucagon! 15g of fast- acting
Carbs (fruit juice, candies, honey)
Pt. Ed: Knowledge of signs and symptoms of
hypoglycemia, ways to alleviate, Dietary
recommendations
Surgery: N/A
Nursing Dx:
-Risk for
complications r/t
low glucose levels
-Risk for Infection r/t
altered body
functions
To Help you remember…
Pt. Goals/
Evaluation:
-Pt will be free from
complications and
verbalize signs of
hypoglycemia
-Pt will be free from
infection and
verbalize signs of
infection, as well as
proper hand hygiene
Page 83 of 106
48 Hour Cram Sheets for Med Surg
HYPERGLYCEMIA
the bloodstream. Blood glucose
will then rise toward a normal
level. In some people with
diabetes, this glucagon response
to hypoglycemia is impaired and
other hormones such as
epinephrine, also called
adrenaline, may raise the blood
glucose level. But with diabetes
treated with insulin or pills that
increase insulin production,
glucose levels can't easily return
to the normal range.
HYPERGLYCEMIA
Patho: High levels of serum
glucose are excreted in the
kidneys, causing glycosuria which
can lead to excessive osmotic
diuresis (polyuria). The impact of
polyuria would cause excessive
fluid loss, and
followed the loss of potassium,
sodium and phosphate. Due to
lack of insulin the glucose cannot
be converted into glycogen to
increase blood sugar levels and
hyper-glycemia occurs. The
kidneys cannot resist
hyperglycemia, and cannot filter
out and absorb the amount of
glucose in the blood. The sugar,
which absorbs all the excess
Page 84 of 106
Assess: For general
appearance of patient, signs
of DKA/HHS
Vitals: Temp
S/S & PHYS. EXAM: HOT &
DRY = SUGAR HIGH,
Frequency in urination,
Thirst, Dry mouth, Urination
at night, Drowsiness or
fatigue, Loss of weight,
Increase in appetite, Slow
healing of wounds, Blurriness
in vision, Dry and itchy skin,
Rapid loss in weight,
Unconsciousness, Increased
confusion or drowsiness,
Breathing difficulty, Dizziness
when you stand up, Coma
Nursing Interventions:
Pharm: Depends on need!! Can take “anti-diabetic
pills (Glyburide, Metformin) also INSULIN, as
prescribed, many also be given in a insulin pump.
Pt. Ed: Diet and exercise regimen should be
followed as prescribed by doctor.
Surgery: N/A
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Ineffective
management of
therapeutic regimen
r/t deficient
knowledge of
disease process
-Risk for unstable
blood glucose r/t
deviation from
normal range
Pt. Goals/
Evaluation:
-Pt will verbalize
understanding of
proper care and
testing of blood
sugar as well as the
48 Hour Cram Sheets for Med Surg
HYPERGLYCEMIA
water removed with the urine is
called glycosuria. In glycosuria,
some water is lost in the urine,
called POLYURIA. Polyuria results
in intracellular dehydration,
which will stimulate the thirst
center so that patients will feel
constantly thirsty, so the patient
will continue to drink and have
POLYDIPSIA. The lack of insulin
production will cause a decrease
in glucose transport into the cells
so the cells are starved of food
and stores carbohydrates, fats
and proteins to be depleted.
Because it is used to burn as fuel
the body, then the client will feel
hungry and eat, known as
POLYPHAGIA. Failure to restore
the body's homeostasis situation
will lead to hyper-glycemia,
hyperosmolar, excessive osmotic
diuresis and dehydration. Central
nervous system dysfunction due
to transport
oxygen to the brain disorder can
result in a coma.
Hemoconcentration increases
the blood viscosity (Thickness)
which may lead to the formation
of blood clots, thromboembolism, cerebral infarction,
heart.
Labs: Blood Glucose, A1c,
Glucose tolerance test
Dx Tests: Same as above
Simplenursing.com Less Study Time HIGHER test scores!
prescribed
medications to
manage it
-Pt will maintain
blood glucose level
within healthy limits
of the patient’s
condition.
Page 85 of 106
48 Hour Cram Sheets for Med Surg
DIABETIC KETOACIDOSIS (DKA)
Assess: For hyperglycemia,
Acetone (FRUITY) Breath,
ALOC, Orthostatic
Patho: Diabetic ketoacidosis is a
Hypotension
serious complication of diabetes
Vitals: HR, BP
that occurs when your body
S/S & PHYS. EXAM: N/V,
produces very high levels of
ABD pain, Exacerbated
blood acids called ketones.
Polyuria, Polydipsia and
Diabetic ketoacidosis develops
Polyphagia, ALOC,
when you have too little insulin
weak/rapid pulse, Orthostatic
in your body. Insulin normally
hypotension, Kussmaul’s
plays a key role in helping sugar
respirations, blurred vision,
(glucose) which is a major source
headache, FRUITY BREATH!!
of energy for your muscles and
Labs: Blood Glucose! (CAN
other tissues — enter your cells.
VARY FROM 300-800MG/dL
Without enough insulin, your
OR MORE!) ABG’s, CBC,
body begins to breaks down fat
Chem 7 (To assess body for
as an alternate fuel. In turn, this
dehydration/shock)
process produces toxic acids in
Dx Tests: Same as above
the bloodstream called ketones,
eventually leading to diabetic
ketoacidosis if untreated.
DIABETIC
KETOACIDOSIS (DKA)
Page 86 of 106
Nursing Interventions:
Pharm: REGULAR INSULIN! (IV @ 0.1 mg/kg/hr)
Saline/Fluids (To make up for body losses),
ELECTROLYTES as needed (ex. Potassium)
Pt. Ed: Proper testing of blood sugar, verbalization
on signs/symptoms of DKA. “Sick Day Rules” , Teach
strategies to prevent DKA
Surgery: N/A
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Imbalanced
nutrition less than
body requirements
r/t biological factors
-Knowledge
deficient (learning
need) r/t condition/
treatment regimen,
self-care,
Pt. Goals/
Evaluation:
-Pt will maintain
homeostasis and be
free from signs of
malnutrition
-Pt will verbalize
understanding of
condition/disease
process and
signs/symptoms of
complications
48 Hour Cram Sheets for Med Surg
APPENDICITIS
10. GALLBLADDER & LIVER & APPENDIX
DIAGNOSIS/PATHO
Dx:
APPENDICITIS
Patho: Appendicitis is usually
caused by blockage of the lumen
of the appendix. Obstruction
causes the mucus produced by
mucous appendix suffered dam.
The longer the mucus is more and
more, but the elastic wall of the
appendix has limitations that lead
to increased intra-luminal
pressure. These pressures will
impede the flow of lymph
resulting in mucosal edema and
ulceration. At that time there was
marked focal acute appendicitis
with epigastric pain. If the flow is
disrupted arterial wall infarction
will occur followed by gangrene
appendix. This stage is called
appendicitis gangrenosa. If the
appendix wall fragile, there will be
a perforation, called perforated
appendicitis.
DATA
Assess: For guarding, with pain in RLQ,
Positive McBurney’s sign (Pain located the
right side of abdomen, located 1/3 the
distance from the anterior superior iliac spine
to the umbilicus):
Vitals: TEMP
S/S & PHYS. EXAM: Aching pain that begins
around your navel and often shifts to your
lower right abdomen. The pain occurs when
you apply pressure to your lower right
abdomen THEN, releases the pressure on that
area. When released, the Pt. will feel A LOT of
pain!! (REBOUND TENDERNESS!!) Pain that
worsens if you cough, walk or make other
jarring movements, also Nausea, Vomiting,
Loss of appetite, Low-grade fever,
Constipation, Inability to pass gas, Diarrhea,
Abdominal swelling
Simplenursing.com Less Study Time HIGHER test scores!
ACTION
RESPONSE
Nursing Interventions:
Pharm: PAIN
MANAGEMENT &
ANTIBIOTICS UNTIL
SURGERY!! Continue
after surgery as well.
Possibly blood if lost in
surgery.
Pt. Ed: Avoid applying
heat to the area,
Monitor for
signs/symptoms of
infection, mobility after
surgery
Surgery:
APPENDECTOMY!
**Must remove before
appendix perforation–
CAN CAUSE SEPTIC
SHOCK!! Patient will
notice a “Sudden relief
of pain” which is a BAD
SIGN!! Abdomen will
become rigid, fever will
SPIKE!
Nursing Dx:
-Acute pain r/t inflammation
of tissues
-Risk for infection r/t
Inadequate primary
defenses/surgery/perforation
of tissues
Page 87 of 106
Pt. Goals/ Evaluation:
- Pt will report pain at
tolerable level and verbalize
ways to manage it
-Pt will show no signs of
infection including: Elevated
temperature, WBC count,
as well as pain and swelling
at incision site
48 Hour Cram Sheets for Med Surg
CHOLECYSTITIS
Labs: WBC, CBC, hematologic tests presurgery
Dx Tests: CT scan/Ultrasound to assess for
appendicitis,
Assess: For RUQ Epigastric pain, jaundice,
contributing factors:
THE 5 F’S!! Female, Forty, Fat, Fertile, Family
CHOLECYSTITIS
Hx
Patho: “INFLAMMATION OF THE Vitals:  Temp, BP/HR (r/t Pain)
GALLBLADDER” One of the most
S/S & PHYS. EXAM: Nausea/ vomiting,
common types of cholecystitis is
Tenderness in the right abdomen, Fever, Pain
acute cholecystitis. This is when
that gets worse during a deep breath, Dark
the onset of inflammation of the
colored urine, Pain for more than 6 hours,
gallbladder is sudden and intense, particularly after meals.
with fast progression of the
Labs: CBC, WBC, Liver Fx Tests,
disease. More often than not, the Amylase/Lipase Levels
inflammation is caused due to
Dx Tests: Ultrasound, Hepatobiliary scan,
obstruction of the bile duct, which Endoscopic Retrograde
is known as calculous
Cholangiopancreatography (ERCP),
cholecystitis, as they are caused
Cholangiography, Abdominal X-RAY
due to gallstones, or cholelithiasis.
There are other causes of acute
cholecystitis as well, such as
ischemia, chemical poisoning,
motility disorders, infections with
protozoa, collagen disease,
allergic reactions, etc. The
obstruction results in gallbladder
distension, which results in edema
of the cells lining the gallbladder.
The lining wall of the gallbladder
may eventually undergo necrosis
Dx:
Page 88 of 106
Nursing Interventions:
Pharm: Analgesics,
Antiemetics,
Anticholinergics,
Antibiotics,
Ursodeoxyxholic Acid
(Urso) to internally break
up stones if possible
Pt. Ed: Manage a lowfat diet & exercise
program, Care of T-Tube
if sent home with one,
Prevent “Dumping
Syndrome”:
Surgery:
Sphinterectomy with
stone removal with
ERCP, Extracorporeal
Shock Wave Lithotripsy
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Acute pain r/t
obstruction/spasm
-Risk for deficient fluid
volume r/t excessive losses
due to vomiting
Pt. Goals/ Evaluation:
-Pt will report pain at
tolerable level and verbalize
ways to manage it
-Pt will show evidence of
adequate fluid volume by:
stable vital signs, moist
mucus membranes, good
skin turgor, and urine output
within normal level for
patient
48 Hour Cram Sheets for Med Surg
HEPATITIS
and gangrene, which is known as
gangrenous cholecystitis.
Dx:
HEPATITIS
Patho: Inflammation that
spreads to the liver (hepatitis) can
be caused by infection by viruses
and toxic reactions to drugs and
chemicals. Basic functional units
of the liver are called lobules, and
these units are unique because
they have their own blood supply.
Disruption of the normal blood
supply to the cells causes hepatic
necrosis and damage to liver cells.
After passing his time, the liver
cells become damaged &
eliminated from the body by the
immune system response and
replaced by new cells of a healthy
liver. Therefore, most clients who
have hepatitis recovered with
normal liver function.
(ESWL) to break up small
stones, Cholecystectomy
Assess: Depends on the type! Type B & C
may be ASYMPTOMATIC, Type A can cause
“Flu-like” Symptoms,
Vitals: Fever most common
S/S & PHYS. EXAM: Circulation problems
(only toxic/drug-induced hepatitis), Dark urine,
Dizziness (only toxic/drug-induced hepatitis),
Drowsiness (only toxic/drug-induced hepatitis),
Enlarged spleen (only alcoholic hepatitis),
Headache (only toxic/drug-induced
hepatitis),Hives, Itchy skin, Light colored feces,
the feces may contain pus, Yellow skin, whites
of eyes, tongue (jaundice)
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm:
*SPECIFIC TO TYPE AND
SYMPTOMS:
-Treat Symptoms for
TYPE A
-Anti-viral drugs for TYPE
B & C: Penginterferonalpha 2B (PEGLNTRON)
Pt. Ed: PREVENT
SPREAD OF INFECTION!
Wash hands, Vaccines
for Types A & B, Avoid
“High-Risk” Behaviors
such as unprotected sex,
sharing/using unclean
needles, blood-to-blood
contact, *NOT ELIGIBLE
TO DONATE BLOOD
Surgery: Liver
transplant if eligible
(Type C)
Page 89 of 106
Nursing Dx:
-Fatigue r/t decreased
metabolic energy production
-Risk for deficient fluid r/t
altered clotting factors (Hep
C) or vomiting/anorexia (HEP
A) and altered body
chemistry
Pt. Goals/ Evaluation:
-Pt will report increased
energy and is able to
participate in ADL’s
- Pt will show evidence of
adequate fluid volume by:
stable vital signs, moist
mucus membranes, good
skin turgor, and urine output
within normal level for
patient
48 Hour Cram Sheets for Med Surg
PANCREATITIS
Labs: Hepatitis Virus Panel, Antibody/Antigen
tests
Dx Tests: Liver Biopsy
Dx:
PANCREATITIS
Patho: Pancreatitis is an
inflammatory disease, which
varies in severity from mild to
severe. Factors determining the
severity of pancreatitis are not
known. It is generally believed
that the earliest events in the
evolution of acute pancreatitis
lead to premature intra-acinar cell
activation
Page 90 of 106
Assess: For contributing factors such as:
1. Excessive alcohol/drug use
2. Gallstones
3. Infection
4. Blunt Abdominal Trauma
5. Surgical trauma/manipulation
Also… TURNER’s SIGN (Bruising between the
last rib and the top of the hip) & CULLEN’s
SIGN (Bruising of fatty tissue around umbilicus)
Vitals: TEMP, HR, Sometimes BP
S/S & PHYS. EXAM:
Nursing Interventions:
Pharm: Antibiotics,
Opiod analgesics/Pain
meds (Demorol is
CONTRAINDICATED!),
Anticholinergics,
Pancreatic enzymes,
Proton pump inhibitors
(Omeprozole/Prilosec),
TPN
Pt. Ed:
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Acute pain r/t obstruction of
pancreatic bile
ducts/inflammation
-Risk for deficient fluid
volume r/t loss of fluid from
vomiting/gastric suction
Pt. Goals/ Evaluation:
-Patient will report
controlled/relief of pain, and
adhere to medication
regimen
48 Hour Cram Sheets for Med Surg
CIRRHOSIS
of digestive zymogens and that
those enzymes, once activated
cause acinar cell injury. Recent
studies have suggested that the
ultimate severity of resulting
pancreatitis may be determined
by
events which occur subsequent to
acinar cell injury. These include
inflammatory cell recruitment and
activation as well as the
generation and release of
cytokines and other chemical
mediators of inflammation.
Dx:
CIRRHOSIS
Patho: A CHRONIC liver disease
characterized by an irreversible
scarring of the liver. This extensive
scarring causes a disruption in the
normal function of the liver. The liver
is a very important organ that
functions in the body to help:
-Store Blood Sugar (as GLYCOGEN)
-Produce Bile (TO DIGEST FOOD)
-Filter out toxins/wastes in blood
stream (INCLUDING
DRUGS/ALCOHOL)
 Signs and symptoms of acute pancreatitis
include:
-Abdominal pain to the upper quadrants,
radiates to the clients back and worsens after
meals
-Nausea and vomiting
-Tenderness on the abdomen
 Signs and symptoms of chronic pancreatitis
include:
-Upper abdominal pain
-Indigestion
-Sudden weight loss
-Steatorrhea (oily, foul smelling stools)
Labs: Liver enzymes, Bilirubin, Pancreatic
enzymes
Dx Tests: CT w/ contrast
Assess: For signs of Jaundice/Liver failure,
ALOC, Contributing factors
Vitals: RR,
S/S & PHYS. EXAM:
EARLY STAGE:
-Enlarged Liver
-GI Disturbances
-Jaundice
-Weight Loss
LATE STAGE:
-Small/Nodular Liver
-Ascites
-Splenomegaly
-Esophogeal Varices/Coughing up blood
- Dyspnea
- Pruitis
Simplenursing.com Less Study Time HIGHER test scores!
-Take Pancreatic
enzymes before meals
and snacks
-High caloric diet/needs
-NO ALCOHOL! (Refer to
program as needed)
-Limit fat intake
-Follow up with all
appts/lab work
- Pt will show evidence of
adequate fluid volume by:
stable vital signs, moist
mucus membranes, good
skin turgor, and urine output
within normal level for
patient
Surgery: N/A (Unless
eligible for transplant,
ALCOHOL & DRUG
RELATED NOT ELIGIBLE)
Nursing Interventions:
Pharm: Diuretics (Lasix,
Aldactone), Flagyl (to
reduce bacteria in
intestine), Lactulose to 
Ammonia, supplemental
vitamins, PPI’s
(Prevacid), Albumin (to
decrease ascites)
Nursing Dx:
-Imbalanced Nurtrition: less
than body requirements r/t
poor nutrition and
nausea/vomiting
-Fluid volume excess r/t
compromised regulatory
mechanism and excessive
fluid/ sodium intake
Pt. Ed:
-NO ALCOHOL! 
Referral to TX Program if
needed
-Follow Dietary
guidelines for condition
Pt. Goals/ Evaluation:
-Pt will exhibit no further
signs of malnutrition and
show weight gain
appropriate for body.
Page 91 of 106
48 Hour Cram Sheets for Med Surg
CIRRHOSIS
-Manufacturing proteins in the blood
that assist in clotting and oxygen
transport
-Helps to break down fat/produce
cholesterol
CONTRIBUTING FACTORS:
-Excessive Alcohol (Laennec’s)
-Post Necrotic (r/t
Hepatitis/chemicals)
-Billiary Disease
-SEVERE Right-sided heart failure
Page 92 of 106
- Clay colored stools, TEA colored Urine
Labs: Liver enzymes, Bilirubin, H&H,
hematologic testing, WBC, PLT’s, CBC, PT, INR
& AMMONIA (Could indicate hepatic
encephalopathy)
Dx Tests: MRI/ULTRASOUND for Liver size
(EARLY stages will be LARGE, Later stages of
cirrhosis will be small/nodular) Remember:
“If SIR ‘ROHSIS’ gets to a party EARLY, then
he’s LARGE and in charge… if he gets there
LATER, he will be NODDED at and SMALL”
- Bleeding
precautions/Risk for
bleeding
Surgery: Transplant
(*ONLY IF ELIGIBLE!! Will
not be a candidate if
alcoholic/drug related)
Simplenursing.com Less Study Time HIGHER test scores!
-Patient will maintain stable
fluid volume AEB vital signs
within normal range,
balanced I&O
48 Hour Cram Sheets for Med Surg
ACUTE RENAL FAILURE (ARF)
11. KIDNEY (RENAL)
DIAGNOSIS/PATHO
ACUTE RENAL FAILURE
(ARF)
Patho: An acute and abrupt
decrease in renal function; usually
caused by: Trauma, allergic
reactions, Kidney stones drug
overdose and shock.
REMEMBER!! Your kidneys and your
Glomeruli are like your “Washing
Machine”…. And wash and filter out
your blood… helping excrete waste
products through urine!
DATA
ACTION
Assess: Oliguria ( 400 ml/day
for onset of ARF), Then diuresis
as it progresses toward recovery
(4,000-5,000 ml/day)
Vitals: BP, TEMP
S/S & PHYS. EXAM:
Dizziness, Dry mouth,
hypotension,
Tachycardia, Thirst, Weight loss
Nursing Interventions:
Pharm: TREAT THE CAUSE!!
Electrolyte ImbalancesHYPERKALEMIA: Kayexalate (Usually
given by enema)
ANEMIA: EPOGEN (Procrit)
 PHOSPHATE /  CALCIUM: PHOSLO,
CALCUM ACETATE
Diuretics (as directed)
Labs: BUN, Creatinine and
Potassium (Will be ),
Dx Tests: Assess cause! If
TRAUMA, may need CT /
Ultrasound. If INFECTION, C&S
(Culture and Sensitivity). If
KIDNEY STONES/TUMOR,
CT/MRI/Ultra- sound
Pt. Ed:
Adhere to diet:
OLIGURIC PHASE:  Protein,
Potassium,  Carb
DIURESIS PHASE:  Protein, Calorie,
Restricted Fluids (As indicated), Bed
rest in Oliguric Phase, Dialysis as
ordered.
Also…. Daily weights, Monitor I&O’s
Surgery: N/A unless needed for
kidney stones/trauma
STAGES:
Phase 1. Onset
ARF begins with the underlying
clinical condition leading to tubular
necrosis (Ex. hemorrhage, which
Simplenursing.com Less Study Time HIGHER test scores!
Page 93 of 106
RESPONSE
Nursing Dx:
-Fluid Volume excess
related to compromised
regulatory mechanism
(renal failure)
-Risk for infection r/t
altered immune
functioning
Pt. Goals/ Evaluation:
-Fluid volume will be
within normal limits for
patient and homeostasis
will be achieved.
-Pt will show no signs or
symptoms of infection
prior to discharge
48 Hour Cram Sheets for Med Surg
ACUTE RENAL FAILURE (ARF)
reduces blood volume and renal
perfusion. If adequate treatment is
provided in this phase then the
individual's prognosis is good.
Phase 2. Maintenance
A persistent decrease in GFR and
tubular necrosis characterizes this
phase. Oliguria is often present
during the beginning of this phase.
Efficient elimination of metabolic
waste, water, electrolytes, and acids
from the body cannot be performed
by the kidney during this phase.
Therefore, azotemia, fluid retention,
electrolyte imbalance and metabolic
acidosis occurs. The patient is at risk
for heart failure and pulmonary
edema during this phase because of
the salt and water retention.
Phase 3. Recovery
Renal function of the kidney
improves quickly the first five to
twenty-five days of this phase. It
begins with the recovery of the GFR
and tubular function (BUN and serum
Creatinine stabilize). Improvement in
renal function may take up to a year
as more nephrons regain function.
Page 94 of 106
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
CHRONIC RENAL FAILURE (CRF)
Assess: For contributing factors
such as: Diabetes (Leading
Cause), Uncontrolled HTN,
Patho: Progressive, long-term
Chronic Glomerularnephritis,
failure of kidney function. This is an
Congenital Kidney Disease,
IRREVERSIBLE condition that can only
Pyelonephritis, Ethnicity (African
be corrected by regular dialysis or
American, Native American &
kidney transplant, or will be terminal.
Asian).
Chronic renal failure can be present
for many years before you notice any
Vitals:  BP
symptoms. If your doctor suspects
S/S & PHYS. EXAM: increased
that you may be likely to develop
urination (especially at night),
renal failure, he or she will probably
decreased urination, blood in
catch it early by conducting regular
the urine (not a common
blood and urine tests. If regular
symptom of chronic renal
monitoring isn't done, the symptoms
failure) urine that is cloudy or
may not be detected until the
tea-colored
kidneys have already been damaged.
MORE SERIOUS S&S:
Some of the symptoms, such as
Puffy eyes, hands, and feet
fatigue - may have been present for
(edema), High BP, fatigue,
some time, but come on gradually,
shortness of breath
and may not be noticed or attributed
loss of appetite,
to kidney failure.
nausea/vomiting (common
symptom), thirst, bad taste in
TYPES:
the mouth or bad breath, weight
loss, persistent itchy skin,
muscle twitching or cramping,
yellowish-brown tint to the skin
Labs: BUN/Cr, Kidney Fxn
Tests,  GFR
Dx Tests: Ultrasound/Biopsy
CHRONIC RENAL FAILURE
(CRF)
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: ANEMIA: EPOGEN (Procrit)
 PHOSPHATE /  CALCIUM: PHOSLO,
CALCUM ACETATE, also: BLOOD
TRANSFUSION if necessary
HEMODIALYSIS!! (Can be in hospital, or
at home/Peritoneal)
Nursing Dx:
-Impaired urinary
elimination r/t effects of
disease, need for dialysis
-Fatigue r/t effects of
chronic anemia and
uremia
Pt. Ed: Monitor electrolyes, BP (For
HTN), Strict I&O’s, RENAL DIET,
Meticulous skin care. Dialysis
Education! Based on the type,
schedule, at home or in facility.
Pt. Goals/ Evaluation:
-Patient will maintain
effective voiding
measures within limits of
his/her condition
-Pt will state that he/she
is able to accomplish
ADL’s with minimal
assistance by utilizing rest
periods
Surgery: Kidney Transplant (if
needed/eligible)
DIALYSIS:
Page 95 of 106
48 Hour Cram Sheets for Med Surg
CHRONIC RENAL INSUFFICIENCY
Assess:
Vitals:
S/S & PHYS. EXAM:
(aka, END STAGE RENAL FAILURE/
-anemia (may begin earlier than
END-STAGE RENAL DISEASE)
this) easy bleeding and bruising
Patho: This is a long-term
-Headache
condition caused by several factors!!
-Fatigue (more than normal or
Diabetes is a common one…
usual )and weakness
Remember the washing machine that
-Mental symptoms such as
is your kidneys? Chronic high blood
ALOC/confusion, inability to
sugar increases the blood’s viscosity,
concentrate
much like putting cement in a
-Nausea, vomiting, anorexia &
washing machine and expecting it to
thirst
work the same! This “syrupy” blood
-Muscle cramps, muscle
can reduce blood flow, oxygen
twitching
transport, and necrosis. Very similar,
-Nocturia
HYPERTENSION can cause the same
-Numb sensation in the
problem. If there is too much water
extremities
filtering through your
-Diarrhea
Glomeruli/washing machine, it
- Itchy skin/Eyes
CANNOT work the way it needs to!!
-Grayish complexion, can also be
Thus causing LOW GLOMERULAR
yellowish-brownish tone
FILTRATION RATE (GFR).
-Generalized Edema (more than
Remember, ONCE THESE
you had while in advanced renal
GLOMERULI DIE, THEY CANNOT
failure, and most likely in the
HEAL AND RETURN TO NORMAL!
feet and/or ankles)
Causes kidney death!!
-SOB (due to fluid in the lungs,
anemia)
End Stage Renal Disease is technically
-Hypertension
that last phase of the above renal
CHRONIC RENAL
INSUFFICIENCY
Page 96 of 106
Nursing Interventions:
Pharm: ANEMIA: EPOGEN (Procrit)
 PHOSPHATE /  CALCIUM: PHOSLO,
CALCUM ACETATE, also: BLOOD
TRANSFUSION if necessary
HEMODIALYSIS!! (Can be in hospital, or
at home/Peritoneal)
Nursing Dx:
-Impaired urinary
elimination r/t effects of
disease, need for dialysis
-Fatigue r/t effects of
chronic anemia and
uremia
Pt. Ed: Monitor electrolyes, BP (For
HTN), Strict I&O’s, RENAL DIET,
Meticulous skin care. Dialysis
Education! Based on the type,
schedule, at home or in facility.
Pt. Goals/ Evaluation:
-Patient will maintain
effective voiding
measures within limits of
his/her condition
-Pt will state that he/she
is able to accomplish
ADL’s with minimal
assistance by utilizing rest
periods
Surgery: Dialysis, Kidney Transplant (if
eligible)
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
NEPHROTIC SYNDROME
conditions, with manifestations and
signs/symptoms usually indicating
the need for dialysis and transplant.
KIDNEY FUNCTION IS DOWN TO 1015%
-Decreased sex drive
-Decreased urine output
NEPHROTIC SYNDROME
Assess: Edema, usually starts
with eyes), Massive Proteinuria,
Pallor, Anorexia
Nursing Interventions:
Pharm: Corticosteroids (Prednisone),
Diuretics (LASIX), Salt-poor Albumin
Vitals: BP
S/S & PHYS. EXAM:
-Hypoalbuminemia (low level of
albumin in the blood)
-Proteinuria (Protein in urine)
-Edema (Starts w/ eyes, then
systemic, called ANASARCA)
-Hypercholesterolemia (high
level of cholesterol in the blood)
-Hematuria (blood in urine)
- Ascities
- Oiliguria
- Anorexia
- Malaise
- Nausea
Pt. Ed: Maintain Diet:
-SODIUM
-POTASSIUM
- CALORIE
-Moderate PROTEIN
Aeseptic techniques (To prevent
infection)
-Bed rest to preserve renal function
-Daily Weights/ I&O’s
Patho: auto-immune “Body is
attacking itself”… The big “NERF
BALLS OF PROTEIN” are let through
the once tight-knit net of the
Glomeruli. This disorder consists of
PROTEIN WASTING (Proteinuria)
which occurs as a result of diffuse
glomelular damage. Proteinuria
occurs because of changes to
capillary endothelial cells, the
glomerular basement membrane
(GBM), which normally filters serum
protein selectively by size and
charge:
Labs: GFR, BUN, Cr, CBC,
Electrolytes
Dx Tests: Biopsy, Ultrasound,
CT (NO CONTRAST due to kidney
fxn)
Surgery: N/A
Labs: Protein (For
Hypoalbuminuria), CBC, Urine
(HYPERalbuminuria, meaning
the protein is NOT in the blood
Simplenursing.com Less Study Time HIGHER test scores!
Page 97 of 106
Nursing Dx:
-Excess fluid volume r/t
compromised regulatory
mechanism
-Activity intolerance r/t
generalized edema
Pt. Goals/ Evaluation:
-Patient was able to
display stable weight, vital
signs within patient’s
normal range, and nearly
absence/ reduction of
edema.
48 Hour Cram Sheets for Med Surg
KIDNEY STONES
where it should be, but in the
Urine)
Dx Tests: Kidney Biopsy
KIDNEY STONES
Patho: Kidney stones (renallithiasis) are small, hard deposits that
form inside your kidneys. The stones
are made of mineral and acid salts.
Kidney stones have many causes and
can affect any part of your urinary
tract — from your kidneys to your
bladder. Often, stones form when
the urine becomes concentrated,
allowing minerals to crystallize and
stick together.
Page 98 of 106
Assess: For passing of stones
(Strain Urine), Hx or Risk for
Kidney stones, Pain Mgmt
Vitals:  BP, HR
S/S & PHYS. EXAM:
Severe pain in the side and back,
below the ribs, Pain that spreads
to the lower abdomen and groin,
Pain that comes in waves and
fluctuates in intensity
(SPOSMOTIC PAIN) Pain on
urination, Pink, red or brown
urine, Cloudy or foul-smelling
urine, Nausea/vomiting,
Persistent urge to urinate,
Frequent urination, Fever and
chills (if infection is present)
Labs: Calcium, Uric Acid, Urine
(For sediments/Minerals)
Dx Tests: Ultrasound, CT SCAN,
ABD X-ray
Nursing Interventions:
Pharm: NARCOTICS for PAIN
MANAGEMENT!! Also FLUIDS to help
Flush/Pass stone, Corticosteroids for
Inflammation, as well as Antisposmotics
Pt. Ed: Report increasing pain, or
feeling of “Passing Stone”. Drink LOTS
of fluids to promote passing. Refrain
from foods that may contribute to
stone formation, Foods that contain
high levels of OXYLATE, including:
Peanuts, rhubarb, spinach, beets, choc
olate and
sweet potatoes
Surgery: Surgical removal of stones as
needed
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Acute pain r/t
Inflammation/obstruction,
and abrasion of urinary
tract by migration of
stones.
-Altered urinary
Elimination
Pt. Goals/ Evaluation:
-Pt will report pain as
“tolerable” and verbalize
ways to distract
themselves from pain
-Pt will show an adequate
urinary output for their
status/condition
48 Hour Cram Sheets for Med Surg
GLOMERULONEPHRITIS
GLOMERULONEPHRITIS
Patho: Antibody reaction
SECONDARY to infection else ware
inside the body. SAME
INFLAMMATION, DIFFERENT CAUSE!
The initial reaction is usually either
an upper respiratory infection or skin
infection due to group A betahemolytic Streptococcus. This leads
to the formation of an antigenantibody reaction. It is followed by
the release of a membrane-like
material from the organism into the
body’s circulation. Antibodies
produced react against the
glomerular tissue, thus forming
immune complexes. The immune
complexes become trapped in the
glomerular loop and cause an
inflammatory reaction in the affected
Assess: Contributing Factors
such as: Recent Tonsillitis,
Pharyngitis or STREP! Also Flank
or Abdominal Pain
Vitals: BP, TEMP
S/S & PHYS. EXAM:
Pink or cola-colored urine from
red blood cells in your urine
(Hematuria), Frothy urine due to
Proteinuria, Hypertension,
Edema (with swelling evident in
your face, hands, feet and
abdomen) Fatigue (from anemia
or kidney failure)
Labs:  BUN,  Creat.  WBC’s
RBC’s/Hgb
 Urine RBC’s,  Spec. Gravity
Dx Tests:
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm:
-Penicillin (For Strep)
-Corticosteroids (For inflammation)
-Anti-hypertensives (For  BP)
Pt. Ed: Bed rest during acute phase,
Patient can resume normal
activities gradually as symptoms
subside. Diet:  Calories,  Protein,
 Sodium,  Potassium,  Fluids.
Hand hygiene, prevent contact with
infected people.
-Monitor intake and output/daily
Weight
-Teach Pt. to report peripheral edema
or the formation of ascites.
-Explain to the patient taking diuretics
They may experience orthostatic
hypotension and dizziness when
changing positions quickly
Page 99 of 106
Nursing Dx:
- Acute pain r/t edema of
kidney
-Imbalanced Nutrition,
Less than body
requirements r/t
anorexia/restrictive diet
Pt. Goals/ Evaluation:
-Pt will report pain as
“tolerable” and verbalize
ways to distract
themselves from pain
-Pt will be free from signs
of malnutrition and
verbalize understanding
of proper diet for
condition/disease process
48 Hour Cram Sheets for Med Surg
GLOMERULONEPHRITIS
Glomeruli. Changes in the glomerular
capillaries REDUCE GFR, thereby
allowing passage of blood cells and
protein into the infiltrate, and
reducing the amount of sodium and
water that is passed into the tubules
for reabsorption. This affects the
vascular tone and permeability of the
kidney, resulting to tissue injury.
Page 100 of 106
-Light microscopy: Enlarged
Glomeruli with exudation of
neutrophils
-Immunnofluorescent
microscopy: Granular pattern of
immuno-globulin deposition
-Electron microscopy: reveals
electron dense humps (immune
complex) on the epithelial side
of glomerular basal membrane
Surgery: N/A
Simplenursing.com Less Study Time HIGHER test scores!
48 Hour Cram Sheets for Med Surg
TURP (Trans urethral resection of prostate)
TURP (Trans urethral
resection of prostate)
Patho: The process by which the
enlarged portion of the prostate
(BPH) is removed by an endoscopic
instrument.
TURP (Transurethral Resection of the
Prostate) is the most common procedure
used to treat BPH. It can be carried out
through endoscopy. The surgical and
optical instrument is introduced directly
through the urethra to the prostate,
which can then be viewed directly. The
gland is removed in small chips with an
electrical cutting loop. This procedure,
which requires no incision, may be used
for glands of varying size and is ideal for
patients who have small glands and for
those who are considered poor surgical
risks. Newer technology uses bipolar
electrosurgery and reduces the risk of
TURP syndrome (hyponatremia,
hypovolemia).TURP usually requires an
Assess: For signs of shock or
blockage, monitor and maintain
indwelling catheter/Irrigation,
also ASSESS FOR TURP
SYNDROME! (Cluster of
manifestations as the result of
absorbing fluids during irrigation
through prostate tissue causing:
ALOC, Bradycardia,
Hyponatremia, N/V,
Hypo/Hyper- tension)
Vitals:  TEMP
S/S & PHYS. EXAM:
-Urgency/Frequency of urination
-Abdominal straining
-Nocturia
-Impairment of size and force of
stream/ Intermittent hesitancy
-Incomplete bladder emptying
-Terminal dribbling
-Dysuria
-Eventual renal failure from
urinary obstruction
Labs: PSA- Prostate Specific
Antigen to test for BPH
Dx Tests: Digital Rectal Exam,
Cytoscopy
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Narcotics for pain and to
prevent/decrease bladder spasm,
FOR BPH:
Urinary Antibiotics, Alpha-Blocker
Meds (To promote urinary flow, such as
FLOMAX), Enzyme inhibitors (To
decrease size of Prostate, such as
AVODART / PROSCAR
Pt. Ed: TURP rarely causes erectile
dysfunction, but may trigger retrograde
ejaculation because removal of the
prostatic tissue at the bladder neck can
cause seminal fluid to flow backward
into the bladder rather forward
through the urethra during ejaculation.
Surgery: THIS IS THE SURGERY!
Page 101 of 106
Nursing Dx:
-Acute pain r/t incision,
bladder irrigation, bladder
spasms
-Risk for urinary retention
r/t Obstruction of urethra
catheter with clots
Pt. Goals/ Evaluation:
-Pt will report pain as
“tolerable” and verbalize
ways to distract
themselves from pain
-Pt will show an adequate
urinary output for their
status/condition
48 Hour Cram Sheets for Med Surg
URINARY TRACT INFECTION (UTI)
overnight hospital stay. Urethral
strictures are more frequent than with
(non-trans-urethral procedures, and
repeated procedures may be necessary
because the residual prostatic tissue
grows back.
URINARY TRACT INFECTION
(UTI)
Patho: A urinary tract infection
(UTI) may occur in the bladder,
where it is called cystitis, or in the
urethra, where it is called urethritis.
Upper tract infection results in
pyelonephritis. Most UTIs result from
ascending infections by bacteria that
have entered through the urinary
meatus but some may be caused by
hematogenous spread. UTIs are
much common in females because
the shorter female urethra makes
them more vulnerable to entry of
organisms from surrounding
structures (vagina, periurethral
glands, and rectum).
Page 102 of 106
Assess: For kidney pain
Vitals: TEMP (Infection)
S/S & PHYS. EXAM:
-Burning sensation at the start of
urination
-Uncomfortable pressure above
pubic bone
-Fullness in rectum (in men only)
-Small amount of urine, despite
urge to urinate (DYSURIA)
-Irritability (in children only)
-Abnormal eating (in children
only)
Nursing Interventions:
Pharm: Antimicrobial (Sulfonamides,
UNLESS ALERGIC!! THEN, Bactrim or
Macrodantin)
Pt. Ed: FLUIDS!! Also cranberry juice,
WIPE FROM FRONT TO BACK!! Just
think of my song… “I GOT ANOTHER
UTI!... DON’T SAY I DON’T KNOW HOW
TO WIPE!!” Women (You have shorter
Urethras): Avoid bubble baths, VOID
AFTER SEX, Wear cotton underwear.
Surgery: N/A
Labs: Urine C&S, WBC
Dx Tests: N/A
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Dx:
-Acute Pain r/t
inflammation of urinary
tract
-Urinary retention r/t
acute condition
Pt. Goals/ Evaluation:
-Pt will report pain as
“tolerable” and verbalize
ways to distract
themselves from pain
-Pt will show an adequate
urinary output for their
status/condition
48 Hour Cram Sheets for Med Surg
BPH (Benign Prostate Hypertrophy)
BPH (Benign Prostate
Hypertrophy)
Patho: As males age, production
of androgenic hormones decreases,
causing an imbalance in
androgen and estrogen levels and
high levels of dihydrotestosterone,
the main prostatic
intracellular androgen.
-Other causes of Benign prostatic
hyperplasia (BPH) include:
o Neoplasm
o Arteriosclerosis
o Inflammation
o Metabolic Imbalance
o Nutritional disturbances.
Assess: DRE (Digital Rectal
Exam) to check for enlargement
of prostate, Assess for
history/family hx of BPH
Vitals: ↑TEMP
S/S & PHYS. EXAM:
-Urgency/Frequency of urination
-Abdominal straining
-Nocturia
-Impairment of size and force of
stream/ Intermittent hesitancy
-Incomplete bladder emptying
-Terminal dribbling /Dysuria
-Eventual renal failure from
urinary obstruction
Labs: PSA- Prostate Specific
Antigen to test for BPH, Urine
culture, Blood test/Clotting
studies
Dx Tests: Digital Rectal Exam,
Cytoscopy, Ultrasound
Simplenursing.com Less Study Time HIGHER test scores!
Nursing Interventions:
Pharm: Urinary Antibiotics, AlphaBlocker Meds (To promote urinary flow,
such as FLOMAX), Enzyme inhibitors (To
decrease size of Prostate, such as
AVODART / PROSCAR
Pt. Ed: If you require TURP: Rarely
causes erectile dysfunction, but may
trigger retrograde ejaculation because
removal of the prostatic tissue at the
bladder neck can cause seminal fluid to
flow backward into the bladder rather
forward through the urethra during
ejaculation.
Surgery: TURP!
Page 103 of 106
Nursing Dx:
- Acute pain r/ t mucosal
Irritation: bladder
distention
& urinary infection
-Urinary retention r/t
mechanical obstruction/
enlarged prostate
Pt. Goals/ Evaluation:
-Pt will report pain as
“tolerable” and verbalize
ways to distract
themselves from pain
-Pt will show an adequate
urinary output for their
status/condition
48 Hour Cram Sheets for Med Surg
UTERINE FIBROIDS
12. WOMEN’s HEALTH
DIAGNOSIS/PATHO
UTERINE FIBROIDS
Patho:
Benign Fibroid tumors on the uterine muscle. Also known
as “Myoma”. Can be as small as an apple seed or grow as
big as a grapefruit. There could be one, or MANY. Cause is
unknown, but over 80% of women have some type of
fibroids in their life.
DATA
ACTION
Assess: Location of pain
(For medication and
assessment of
complications) On a scale
of 1-10, Physical exam
Vitals: Not usually, but…
↑HR (If in pain), ↓(If
loosing fluid/shock)
S/S & PHYS. EXAM:
-Pelvic Pain
-Pelvic Pressure
-Hyper Menhorrhea
-Pain during sex
-Lower back pain
-Abdominal Distension
-Frequent Urination
Nursing Interventions:
Pharm: Analgesics for pain,
Hormone therapy as needed,
Antibiotic if surgery
Pt. Ed: Common in young
African American women,
Family history of fibroids,
Obese, Age 30+, and eating a
lot of red meat/pork
Surgery: To remove
mass/part of reproductive as
necessary per patients
situation (Myoectomy,
Hysterectomy), Endometrial
Ablation, Fibroid Ablation,
Uterine Fibroid Embolisation
Labs: Hormone Levels,
CBC, PTT/INR, H&H
Dx Tests: Physical exam,
ultrasound, CT scan, MRI,
Hysteroscopy,
hysterosalpingiogram
Page 104 of 106
Simplenursing.com Less Study Time HIGHER test scores!
RESPONSE
Nursing Dx:
-Acute Pain r/t
Inflammation of
Uterus
-Anxiety r/t changes
in health status
Pt. Goals/
Evaluation:
- Pt will report pain at
tolerable level and
verbalize ways to
manage it
-Client will report
reduced anxiety level,
ways to reduce
anxiety, and
understanding of
diagnosis/health
process
48 Hour Cram Sheets for Med Surg
OVARIAN CANCER
OVARIAN CANCER
Patho: Cancerous growth, originating from different
parts of the ovary:
Contributing Factors:
-Over 40
-Never been Pregnant OR
-First pregnancy after 30 years of age
-Family hx of ovarian, breast, or colon cancer
-Hx of Dysmenorrhea or heavy breathing
-Hormone replacement therapy
-Infertility medication use
Simplenursing.com Less Study Time HIGHER test scores!
Assess: Assess for risk
Factors-Over 40 y/o
-Nulliparity/First
pregnancy age 30+
-Family history of ovarian,
breast or colon cancer
-Dysmenhorrea/heavy
bleeding
-Hormone replacement
therapy
-Use of fertility
medications
Nursing Interventions:
Pharm: Chemotherapy and
Radiation as needed
Pt. Ed: Genetic testing for
risk, Check-up for
reoccurrence (CA-125 Blood
test/HE-4) , signs and
symptoms of reoccurrence,
side effects of
chemo/medications
Surgery: Surgery to remove
diseased parts as needed
Vitals: Normal, unless
septic
S/S & PHYS. EXAM:
Labs: CA-125 Blood test
(35 u/ml= ABNORMAL)
Dx Tests: Intra-Vaginal
Ultrasound, Pelvic Exam
Page 105 of 106
Nursing Dx:
-Anxiety r/t
prognosis, lack of
knowledge of disease
process and threat of
malignancy
- Disturbed body
image r/t loss of
diseased body
part/loss of good
health
Pt. Goals/
Evaluation:
-Client will report
reduced anxiety level,
ways to reduce
anxiety, and
understanding of
diagnosis/health
process
- Client will discuss
concerns, what to
expect after
chemo/surgery, and
ways to limit anxiety
about body image
48 Hour Cram Sheets for Med Surg
OVARIAN CANCER
13. Bibliography
Ebersole, P., Hess, P., Touhy, T.A., Schmidt Logan, A., & Jett, K. (2008) Toward healthy aging: Human
needs and nursing response ( 7th ed.). St. Louis, MO: Mosby.
Eliopoulous C. (2009). Gerontological nursing. ( 7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Grodner, M., Long, S., & Walkingshaw,B.C. (2007). Foundations and clinical application of nutrition: A
nursing approach ( 4th ed.). St. Louis, MO: Mosby.
Ignatavicius, D. D., & Workman, M. L. (2010). Medical-Surgical nursing (6th ed.). St. Louis, MO: Saunders.
Lowdermilk, D.L.,& Perry, S.E. ( 2007) . Maternity & women’s health care (9th ed.). St. Louis, MO: Mosby.
Lehne, R.A. (2010). Pharmacology for nursing care (7th ed.). St. Louis, MO: Saunders.
Lilley, L. L., Harrington, S., & Snyder, J.S. (2007). Pharmacology and the nursing process (5th ED.). St.
Louis, MO: Mosby.
Roach, S. S.,& Ford, S. M. (2008). Introductory clinical pharmacology. Philadelphia, PA: Lippincott Williams
& Wilkins.
Smeltzer, S. C., Bare, B.G., Hinkle, J. L., & Cheever, K.H. ( 2008). Brunner and Suddarth’s textbook of
medical-surgical nursing ( 11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Simplenursing.com Less Study Time HIGHER test scores!
Page 106 of 106