Advanced Med-Surg Nursing: Exam 2 Study Guide
This comprehensive study guide covers critical concepts for your Advanced Med-Surg
Exam 2, focusing on respiratory, endocrine, and fluid/electrolyte imbalances, along
with essential lab values and medication considerations.
I. Hematologic and Coagulation Parameters
Understanding these lab values and related medications is foundational.
Key Labs & Antidotes
●​ D-Dimer: 68−494 (Normal range). Elevated in PE.
●​ Warfarin (Coumadin):
○​ INR Target: 2−3 (therapeutic range).
○​ Antidote: Vitamin K (full effect in 5 days).
○​ Teaching: Consistent Vitamin K intake (e.g., leafy greens) in diet. Regular INR
monitoring is crucial.
●​ Heparin:
○​ aPTT Target: 46−70 seconds (therapeutic range).
○​ Antidote: Protamine Sulfate (fast onset).
○​ Teaching: Keep doctor appointments for lab monitoring.
●​ Platelets: 150,000−400,000/mm3.
○​ Thrombocytopenia: Platelets ≤50,000/mm3.
○​ Antiplatelet Meds: Aspirin, Clopidogrel, Enoxaparin.
Bleeding Precautions
●​ CHANT Acronym:
○​ Cirrhosis
○​ Hepatitis
○​ Alcohol overuse
○​ NSAIDs
○​ Tylenol overuse (liver damage)
●​ Signs of Bleeding: Black tarry stools, hematuria, epistaxis, petechiae, bruising.
●​ AVOID: Vitamin E, Ginseng, Ginkgo Biloba, Garlic, Omega-3, St. John's Wort
(increase bleeding risk).
Heparin-Induced Thrombocytopenia (HIT)
●​ Definition: Immune response causing platelet count to drop (below
150,000/mm3) typically 5−10 days after heparin initiation.
●​ S/S: DVT, PE, pain/swelling/tenderness in extremities, petechiae, bruising,
bleeding/oozing.
●​ Treatment: Platelet transfusion, alternative anticoagulants (e.g., direct thrombin
inhibitors like Lepirudin, Bivalirudin, Argatroban). Warfarin can be started once
platelet count recovers.
●​ Complication: Venous Thromboembolism (VTE).
II. Respiratory System: Gas Exchange & Critical Conditions
This section covers the core principles of ventilation and perfusion, focusing on acute
respiratory emergencies.
Ventilation & Perfusion (VQ Mismatch)
●​ Ventilation (V): Movement of O2​and CO2​in and out of the lungs.
●​ Perfusion (Q): Movement of O2​and CO2​in the blood throughout the body.
●​ VQ Mismatch: Imbalance between ventilation and perfusion, leading to
hypoxemia (low oxygen). Common causes: clots (PE), ARDS.
Arterial Blood Gases (ABGs) - CRITICAL TO KNOW!
●​ pH: 7.35−7.45
○​ <7.35 = Acidosis
○​ >7.45 = Alkalosis
●​ PaCO$_2$ (Respiratory): 35−45 mmHg
○​ <35 = Alkalosis
○​ >45 = Acidosis
●​ HCO$_3$ (Metabolic): 22−28 mEq/L
○​ <22 = Acidosis
○​ >26 = Alkalosis
●​ Key Relationship: If pH is low (acidosis), Potassium (K+) is often high
(Hyperkalemia).
●​ Hyperventilation: Leads to respiratory alkalosis (pH >7.45).
●​ Hypoventilation: Leads to respiratory acidosis (pH <7.35), K+ goes up.
●​ Electrolyte Imbalances: ALL electrolyte imbalances pose a seizure risk.
Pulmonary Embolism (PE) - EMERGENCY!
●​ Patho: Blockage of pulmonary artery, causing hypoxemia and impaired gas
exchange (V/Q mismatch).
●​ Causes: DVT (most common), air embolism, fat embolism (long bone fracture,
petechiae on chest), amniotic fluid embolism, inherited thrombophilia (Factor V
Leiden).
●​ Risk Factors: Estrogen therapy, oral contraceptives, smoking, obesity, immobility,
atrial fibrillation.
●​ S/S:
○​ Hypoxia: Sudden onset dyspnea, sharp/stabbing chest pain (pleuritic),
apprehension, restlessness, feeling of impending doom.
○​ Respiratory: Cough, hemoptysis (pink frothy sputum), diaphoresis, increased
RR, crackles, pleural friction rub.
○​ Cardiac: Tachycardia, S3/S4 heart sounds, distended neck veins, syncope,
cyanosis, hypotension.
○​ Other: Low-grade fever, petechiae on chest (specific to fat embolism).
Decreased SaO$_2$.
●​ Diagnosis: CT scan, high D-dimer, chest X-ray, MRA, ABGs (assess oxygenation).
●​ Treatment:
○​ Emergent: O2​(8-10 L via nasal cannula/face mask), high-Fowler's position,
telemetry, venous access, continuous pulse ox, assess RR every 30 mins.
○​ Medical: Anticoagulants (Heparin - quick onset, Warfarin - longer onset, long
duration), Thrombolytics (e.g., "-ase" drugs like Alteplase - for large clots,
given within 3−4.5 hours of symptom onset).
○​ Surgical: Embolectomy, Vena Cava Filter.
●​ Thrombolytic Contraindications ("ASE"): Active bleeding (e.g., peptic ulcer),
uncontrolled HTN (>180/110), recent surgery (within 2 weeks), CVA.
●​ Nursing Management (Post-PE): Bleeding precautions (no IM/SubQ injections,
no ABGs, no invasive procedures for 24 hrs after thrombolytics). Handle patient
gently.
●​ Prevention of PE: Active/passive ROM, early ambulation, SCDs, prophylactic
anticoagulants, avoid constricting clothing, DO NOT PLACE PILLOWS BELOW
KNEES, alternate pressure mattress, peripheral circulation assessment q8h,
elevate affected limb 20 degrees, reposition q2h, no leg crossing, smoking
cessation.
●​ Anticoagulant Therapy Monitoring:
○​ Check for S/S bleeding (hematuria, blood in stool, ecchymosis, petechiae,
altered LOC, abd pain).
○​ Monitor VS (tachycardia, hypotension).
○​ Antidotes: Protamine Sulfate (Heparin), Vitamin K (Warfarin).
○​ Labs: aPTT (Heparin), PT/INR (Warfarin).
○​ Apply prolonged pressure to venipuncture sites. DO NOT MASSAGE SubQ
Heparin sites.
○​ Discharge Teaching: Electric razor, avoid injury, report any bleeding signs
immediately, take meds as prescribed, do not stop abruptly.
Venous Air Embolism (VAE)
●​ Cause: Entry of air into venous system (e.g., central line insertion, trauma).
●​ Emergency Intervention: Place patient in Trendelenburg and turn to LEFT
side (to trap air in right atria).
●​ S/S: Dyspnea, chest pain, tachycardia, heart murmur, hypotension, decreased
LOC, circulatory shock, sudden death.
●​ Prevention: Prime IV tubing, secure central line connections.
Acute Respiratory Failure (ARF) - EMERGENCY!
●​ Types:
○​ Hypoxemic: PaO$_2 < 60 \text{ mmHg}$ (low oxygen).
○​ Hypercapnic: PaCO$_2 > 50 \text{ mmHg}$ with pH <7.35 (high CO2​,
acidosis).
●​ Causes: VQ mismatch, overdose (low, slow RR), ventilation problems, trauma, PE,
sleep apnea.
●​ S/S: Dyspnea, changes in LOC (restlessness, confusion - #1 sign), tachycardia,
hypertension, dysrhythmias, decreased LOC, altered breath sounds, headache,
lethargy, seizures.
●​ Patho: Insufficient O2​to blood OR CO2​not removed from capillaries.
●​ Labs: ABGs (PaO$_2 < 60$, SaO$_2 < 90%$, respiratory acidosis).
●​ Nursing Interventions: O2​(keep PaO$_2 > 60-70$), high-Fowler's, deep
breathing, mechanical ventilation, intubation (assess ABGs pre/post).
●​ Meds: Bronchodilators.
●​ Critical Values: PaO$_2 < 60$ AND SaO$_2 < 90%;ORPaCO_2 > 45$ with pH
<7.35 AND SaO$_2 < 90%$.
Acute Respiratory Distress Syndrome (ARDS) - "White Lungs"
●​ Patho: Diffuse lung injury, alveolar-capillary membrane damage, extravascular
lung fluid dilutes surfactant leading to alveolar collapse. Lungs become stiff.
●​ Causes: Sepsis (most common), pneumonia, UTI, fluid overload, shock, trauma,
neuro injuries, burns, DIC, drug ingestion, aspiration, drowning, acute pancreatitis,
inhaled toxins, TPN feeding (bacteria in tubing).
●​ S/S: Respiratory acidosis, clear lung sounds initially (edema in interstitial space,
not airways), tachypnea (earliest sign), dyspnea, decreased breath sounds,
refractory hypoxemia (low PaO$_2$ despite high O2​delivery), change in LOC (#1
agitation, restless, confused), increased alveolar dead space. Later: hyperpnea,
noisy respirations, cyanosis, pallor, intercostal retractions.
●​ Labs: ABG (respiratory acidosis: low PaO$_2$, high PaCO$_2$).
●​ Diagnosis: Chest X-ray, ABG (pulmonary function test if stable).
●​ Nursing Interventions: Assess VS, lung sounds hourly; humidified O2​;
high-Fowler's or 30-40 degrees (rotate to prone position every few hours);
restrict fluids; intubation (pre/post ABG) and mechanical ventilation (PEEP); fluid
and nutrition support.
●​ Best Indicator of Improvement: ABG values.
●​ Meds: Diuretics, anticoagulants, corticosteroids, surfactant injection.
Mechanical Ventilation
●​ Purpose: Pumps air into lungs, provides temporary ventilation and oxygenation.
Goal: Wean off vent.
●​ Intubation: Done by MD, should be <15 seconds. If not, stop and re-oxygenate.
●​ Ventilator Associated Problems:
○​ Barotrauma: Damage from positive pressure (pneumothorax, SubQ
emphysema, pneumomediastinum).
○​ Ventilator-Associated Pneumonia (VAP): Dx by sputum culture, fever, chest
X-ray. Remove water from ET tube.
●​ Suctioning Artificial Airway:
○​ Indications: Coughing, SOB, audible secretions, increased PIP.
○​ Technique: Sterile technique, wear eyewear, wash hands. ONLY PRN, NOT
ROUTINELY. Pre-oxygenate with 100% O2​for 30 sec to 3 min. Suction ONLY
ON WAY OUT with twirling motion. Suction ≤10−15 seconds. AVOID SUCTION
BEFORE ABG (wait 20 mins). Assess lung sounds pre/post. Cuff pressure
≤30 cm H2​O. Hyperoxygenate 1−5 mins post-suction until baseline HR/O$_2$.
NO MORE THAN 3 PASSES. NO INSTILLATION OF SALINE.
○​ Effective Suctioning: Clear breath sounds on auscultation.
●​ "DOPE" Acronym for Sudden O$_2$ Sat Drop (Intubated Patient):
○​ Displacement
○​ Obstruction
○​ Pneumothorax
○​ Equipment problems
●​ Preventing VAP: Oral care with Chlorhexidine q12h (then suction), reposition
q2h, daily sedation vacation, elevate HOB 30-45 degrees, GI ulcer prophylaxis
(PPI, H2 blocker), SCDs, keep tubing clean.
●​ NG Tube (for Continuous Feeding): No bolus feeding.
●​ Bedside Essentials: Extra intubation setup, ambu bag, suction.
●​ Extubation Nursing Intervention: Warm humidified O2​with face mask, oral care
(sponge), NPO initially, high-Fowler's.
○​ Complications: Atelectasis, pneumonia.
○​ Prevention: Incentive spirometer, turn/cough/deep breath.
○​ Report to HCP: Stridor with inspiration (sign of laryngeal edema/airway
compromise).
●​ New Trach Care:
○​ #1 Priority: Check tightness of ties (one finger fit).
○​ Dislodged Trach (EMERGENCY!): If mature, insert new trach tube with
curved hemostat. If new/immature, cover stoma with occlusive dressing and
ventilate with ambu bag over nose and mouth.
●​ Ventilator Alarms: NEVER SILENCE ALARMS. Assess patient first!
○​ Low Pressure Alarm: LEAK/DEATH. Loss of connection/air leak, ET tube
displacement, disconnection.
■​ Intervention: Assess patient and connections.
○​ High Pressure Alarm: BLOCKAGE. Kinks in tubing, biting tube, excessive
secretions/mucus plug (suction), coughing, pulmonary edema, tension
pneumothorax (tracheal deviation).
■​ Intervention: Assess patient first. Suction if secretions, insert oral
airway/pain meds/sedate if biting, bronchodilators if wheezing, call HCP if
pneumothorax/unequal chest excursion. Empty water from tubing if
increased PIP with sigh.
Chest Trauma
●​ Initial Assessment: ABCs (O2​, patent airway), JVD, paradoxical respiration,
tracheal deviation, stridor, bilateral diminished breath sounds, accessory muscle
use.
Flail Chest - EMERGENCY!
●​ Definition: Fracture of ≥2 ribs in ≥2 places, leading to paradoxical chest
movement.
●​ Cause: Blunt chest trauma.
●​ S/S: Paradoxical respiration (inward thorax on inspiration, outward on expiration),
severe chest pain, dyspnea, cyanosis, tachycardia, hypotension, tachypnea,
shallow respirations, diminished breath sounds, hypoventilation (respiratory
acidosis). Can lead to respiratory failure.
●​ Nursing Interventions: High-Fowler's (unless spine injury), humidified O2​,
turn/cough/deep breath, bed rest, limit activity.
●​ Meds: Pain meds (opioids) - #1 priority for adequate ventilation.
●​ Treatment: Chest tube if hemothorax/pneumothorax. If respiratory failure:
mechanical ventilation, intubation.
Pleural Effusion
●​ Definition: Collection of fluid (>15 mL) in the pleural space. Leads to respiratory
acidosis.
●​ Causes: Pneumonia, CHF, lung cancer, TB, PE, renal disease, liver failure.
●​ S/S: Pleuritic pain (increases with inhale), progressive dyspnea, dry
non-productive cough, tachycardia, diminished breath sounds in lung base,
elevated temp, dull resonance on percussion, crackles.
●​ Diagnosis: Chest X-ray, CT (shows pleural effusion + mediastinal shift away from
fluid if effusion >250 mL).
●​ Interventions: Monitor breath sounds, high-Fowler's, encourage cough/deep
breath.
●​ Treatment: Thoracentesis. For recurrent effusions: chest tube, pleurectomy,
pleurodesis.
Thoracentesis
●​ Pre-Procedure: Stop blood thinners, informed consent, tripod position. Chest
X-ray (pre/post). Weigh patient pre/post. Measure fluid removed. Urinate before.
●​ Post-Procedure: Deep breaths, Chest X-ray. HOB semi-Fowler's. Lie on
unaffected lung.
●​ REPORT to HCP Immediately: Asymmetrical chest expansion, decreased breath
sounds, hyperresonance, deviated trachea (signs of pneumothorax/tension
pneumothorax).
●​ Complications: Pneumothorax, hemothorax.
Hemothorax
●​ Definition: Blood collects in pleural space, causing lung collapse.
●​ S/S: Dull resonance on percussion.
●​ Treatment: Chest tube.
Pneumothorax - EMERGENCY!
●​ Definition: Air in pleural space, lung not expanded. Affected side has reduced
breath sounds.
●​ Patho: Accumulation of air in pleural space, increased intrathoracic pressure,
decreased vital capacity, lung collapse.
●​ S/S: Reduced breath sounds, tracheal deviation, pleuritic "sharp chest pain,"
tachypnea, SubQ emphysema (crepitus), cyanosis, decreased chest expansion
unilaterally, JVD, hypotension, sucking sound (open pneumo), tachycardia.
●​ Diagnosis: Chest X-ray (air/fluid white, lung tissue black).
●​ Treatment: Thoracentesis or chest tube (drains air, restores negative pressure).
●​ Types:
○​ Spontaneous Pneumothorax (EMERGENCY): Rupture of pulmonary bleb.
Causes: smoker, high altitude, scuba diving. Treatment: Chest tube.
○​ Open Pneumothorax (EMERGENCY): Opening in chest wall (gunshot, knife).
Treatment: Cover open area with sterile gauze and tape on 3 sides only;
chest tube.
○​ Tension/Closed Pneumothorax (EMERGENCY): Blunt chest injury, rib
fracture, mechanical ventilation with PEEP. Air enters on inhale but cannot
escape, pressure builds, lung gets smaller.
■​ S/S: JVD, tracheal deviation to unaffected side, asymmetrical thorax,
extreme respiratory distress, absence of breath sounds on one side,
hemodynamic instability, pleuritic pain.
■​ Treatment: Needle thoracostomy, chest tube.
Chest Tubes
●​ Purpose: Drain fluid or air from pleural space, restore normal negative pressure,
reinflate lung.
●​ Indications: Pleural effusion, hemothorax, pneumothorax.
●​ Key Principles:
○​ Drainage system MUST BE BELOW CHEST LEVEL.
○​ 3 Chambers:
1.​ Suction Control Chamber: Gentle, steady continuous bubbling (indicates
suction is working).
2.​ Water Seal Chamber: Tidaling/fluctuation (steady rise and fall with
breathing) is normal. NO CONTINUOUS BUBBLING (indicates air leak BAD!). Intermittent bubbling is normal for air leak monitor.
3.​ Collection Chamber: Report drainage >70 mL/hr to HCP (especially
bright red blood after first hour). Document dark blood.
●​ Nursing Interventions for Stopped/Decreased Drainage: #1 Assess patient. #2
Auscultate lung sounds (priority: diminished breath sounds). #3 Turn, cough,
deep breath; reposition. NEVER EMPTY SYSTEM (replace entire unit).
●​ Disconnected from Patient: Have patient cough and exhale immediately. Apply
occlusive petroleum gauze dressing secured on 3 sides (to allow air to escape).
●​ Essential Bedside Supplies: Sterile connector, sterile occlusive dressing
(petroleum gauze), padded Kelly clamps, sterile saline (20cc).
●​ Disconnected from Collection Chamber (without contamination): Aseptic
swab and reconnect.
●​ Damaged Water Seal Chest Tube: Place distal end into 250 mL sterile saline.
●​ Chest Tube Removal: Instruct client to "take deep breath, hold it and bear down
(Valsalva maneuver)." Follow with chest X-ray.
●​ DO NOT: Milk/strip chest tube (unless specific order), see continuous bubbling in
water seal/air leak chamber, clamp chest tube during transport (unless specific
order or brief for troubleshooting), see tube eyelets.
●​ Notify HCP/Rapid Response if: Trach deviation from midline, sudden increased
dyspnea, O2​<90%, drainage >70 mL/hr, visible eyelets, chest tube falls out (cover
with dry sterile gauze), chest tube disconnects from drainage system (put end in
sterile water below chest), drainage stops in first 24 hours.
●​ Subcutaneous Emphysema: "Snap, crackle, pop" under skin (crepitus). Mark
area with sharpie; should not grow.
III. Endocrine System: Thyroid and Adrenal Glands
This section delves into the complex world of thyroid and adrenal disorders,
emphasizing their impact on metabolism and critical patient management.
Hyperthyroidism (Graves' Disease)
●​ Patho: High T3​and T4​, low TSH. High metabolism. Low Calcium. "Running to the
grave."
●​ Causes: Tumor, autoimmune disease.
●​ Diagnosis: Elevated T3​, T4​.
●​ S/S (Thyrotoxicosis): Personality changes, agitation, nervousness, fine tremors,
weakness, muscle aches, paresthesia, heat intolerance, weight loss despite
increased appetite, smooth/soft skin/hair, palpitations, cardiac dysrhythmias
(tachycardia, A-fib), hypertension, diarrhea, exophthalmos (protruding eyes),
diaphoresis, goiter, anxiety.
●​ Nursing Interventions: NEVER PALPATE THYROID. Provide rest, sedatives,
cool/quiet environment, daily weights. Avoid fiber.
●​ Diet: High calorie, avoid stimulants (caffeine).
●​ Meds:
○​ Propranolol: (Non-selective beta-blocker). Avoid if COPD/asthma (Beta-2
effect on lungs). Masks hypoglycemia. Reduces HR/tremors.
○​ Antithyroid Meds: Propylthiouracil (PTU) - higher dose, liver toxic (yellow
skin/eyes), pregnancy safe. Methimazole - NOT for pregnancy. Both
suppress immune system (report fever/malaise, avoid crowds). Teach s/s of
hypothyroidism (weight gain, low HR, cold intolerance) may indicate need for
lower dose.
●​ Treatment: Radioactive iodine therapy, subtotal thyroidectomy, Lugol's solution
(decreases thyroid production).
●​ Teaching for Radioactive Iodine: Use separate toilet for 2 weeks, sit to urinate,
flush 3 times with lid closed. Clean splashes with paper towel and bag. If
incontinent, use condom cath/gel brief. Laundry separate. Avoid contact with
pregnant women, infants, young kids for 1st week (stay 3 feet away, limit 1 hr
exposure). Don't share utensils/toothbrush. WILL NEED LEVOTHYROXINE FOR
LIFE.
●​ Complication: Thyroid Storm (Thyrotoxic Crisis) - EMERGENCY!
○​ First Sign: Temperature increase of 1 degree - TELL HCP IMMEDIATELY.
○​ S/S: High fever, severe tachycardia, systolic hypertension, N/V/D, agitation,
tremors, anxiety, irritability, restless, confusion, SEIZURES, delirium, coma,
tetany. Hyperventilation (alkalosis), low K+.
○​ Interventions: Patent airway, iodides, Propranolol (slowly over 3 mins),
glucocorticoids (e.g., "-sone" drugs), VS, EKG, non-salicylate antipyretics,
cooling blanket (for fever), methimazole. NO LEVOTHYROXINE.
Thyroidectomy (Pre-Op/Post-Op)
●​ Pre-Op: VS, weight, electrolytes, assess for hyperglycemia, administer antithyroid
meds. Teach cough/deep breath exercises.
●​ Post-Op:
○​ Airway is #1: Assess airway frequently (1st 12 hours). Keep trach set, O2​,
suction at bedside. Stridor is a sign of obstruction.
○​ Monitor for Hypocalcemia: Low Ca++ (Chvostek's, Trousseau's signs indicate tetany). Give calcium gluconate for tetany.
○​ Positioning: Semi-Fowler's, avoid neck flexion, stress on sutures.
○​ Expected Findings: Hoarseness (normal initially). High T3​/ T4​expected
post-op due to hormone release.
○​ Report to HCP:
■​ Total Thyroidectomy: Signs of Tetany (from low Ca++).
■​ Partial Thyroidectomy: Signs of Thyroid Storm.
○​ Complications: Laryngeal nerve damage (airway obstruction, dysphonia,
high-pitch voice, stridor, dysphagia, restlessness), Hypothyroidism (requires
lifelong levothyroxine), Tetany (low Ca++), bleeding (frequent swallowing,
saturated dressing, tight dressing), tracheal edema (hoarseness).
○​ Critical Rescue: Stridor, dyspnea, low O2​sat, cannot swallow, drooling,
frequent swallowing are all signs of airway obstruction - call rapid response!
Also, temperature increase of 1 degree = impending thyroid crisis.
Hypothyroidism (Hashimoto's)
●​ Patho: Low T3​, T4​; decreased body metabolism. High TSH, high Ca++. "Sloth from
Zootopia."
●​ Causes: Lithium, post-thyroidectomy, autoimmune, radioactive therapy, iodine
deficiency (rare).
●​ S/S: Lethargy, fatigue, weakness, muscle aches, paresthesia, cold intolerance,
weight gain, dry skin, thin hair/body hair loss, bradycardia, constipation,
generalized puffy face, forgetfulness/memory loss, menstrual disturbances,
sometimes goiter, easy bruising, skinny extremities/large midsection ("Gru"
appearance).
●​ Interventions: Monitor VS (especially HR), thyroid replacement meds, warm
environment, avoid sedatives/opioids (can precipitate myxedema coma). Teach to
report chest pain, tachycardia, restlessness, nervousness, insomnia. Avoid fiber
(interferes with medication absorption).
●​ Meds: Levothyroxine (Synthroid). Take on empty stomach in AM with full glass of
water, for life. Do not double dose if forgotten.
○​ Side Effects to Report: Palpitations, dyspnea, chest pain, diarrhea,
tachycardia, SOB, HTN.
●​ Diet: Low calories, fiber (for constipation).
●​ Complication: Myxedema Coma - EMERGENCY!
○​ S/S: Low BP, low HR, severe lethargy, hypothermia, low Na+, hypoglycemia,
generalized edema, respiratory failure, coma, drowsy, memory impaired.
Hypoventilation (acidosis), high K+.
○​ Interventions: Monitor every 2 hours, patent airway, mechanical ventilation,
HOB 30 degrees, aspiration precautions, IV fluids (hypertonic solution), IV
levothyroxine, IV glucose, IV corticosteroids. Assess temp hourly, BP, LOC,
electrolytes. Warm blanket.
○​ Teaching: Depression/sadness should improve with meds.
Hypoparathyroidism
●​ Patho: Low parathyroid hormone (PTH), low Ca++, low Mg++, high Phosphate.
●​ Causes: Post-thyroidectomy, surgery/radiation, parathyroidectomy, congenital
dysgenesis, hypomagnesemia.
●​ S/S: Numbness/tingling in face/extremities, muscle cramps
(abdomen/extremities), positive Chvostek's/Trousseau's signs, signs of tetany
(bronchospasm, laryngeal spasm - BAD!, carpopedal spasm, dysphagia,
photophobia, cardiac dysrhythmias, seizures), hypotension, anxiety, irritability,
depression, diarrhea.
●​ Nursing Interventions: VS, S/S hypocalcemia/tetany, seizure precautions. Trach
set (O2​, suction) at bedside. Administer Ca gluconate IV. Thiazide diuretics
(conserve Ca++).
●​ Meds: Calcitriol (increases Ca++), Mg sulfate, Calcium gluconate IV, Thiazide
diuretics, phosphate binders.
●​ Diet: High Ca++ (green leafy veggies, soy products), low phosphorus. Vitamin D
supplements (aids Ca++ absorption). AVOID milk, yogurt, processed cheese
(high in phosphorus).
●​ Teaching: Medical Alert bracelet.
Hyperparathyroidism
●​ Patho: High parathyroid hormone (PTH), high Ca++, high Mg++, low Phosphate.
"Moans, groans, stones."
●​ Causes: Parathyroid tumor/cancer, congenital hyperplasia, neck trauma/radiation,
secondary to Vit D/Ca++ deficiency, CKD, ESKD.
●​ S/S: Fatigue, muscle weakness, skeletal pain, tenderness, bone deformities,
anorexia, N/V, epigastric pain, weight loss, constipation, hypertension, cardiac
dysrhythmias, renal stones/kidney stones, fractured bones.
●​ Nursing Interventions: VS (BP), EKG, I&O, fluids.
●​ Meds: Phosphates (block Ca++ absorption), Calcitonin (puts Ca++ back into
bones), Mg++, Bisphosphonates (inhibit bone resorption), Loop diuretics
(Furosemide, Bumetanide - excrete Ca++ and K+). Monitor Ca++, Phos, K+.
●​ Diet: High fiber, moderate calcium.
●​ Teaching: Exercise program (avoid inactivity).
●​ Treatment: Parathyroidectomy (surgical removal).
●​ Pre-Parathyroidectomy: Electrolytes (Ca++, Phos, Mg++) should be near
normal.
●​ Post-Parathyroidectomy: Monitor RR, trach set at bedside, VS, semi-Fowler's,
assess neck dressing for bleeding. Monitor for Hypocalcemic crisis (Ca++ >14),
tingling/twitching in face/extremities, +Chvostek's/+Trousseau's (tetany), changes
in voice/hoarseness, laryngeal nerve damage. Administer Ca++ and Vit D.
Adrenal Gland Disorders (Corticosteroids)
●​ Steroids Affect:
1.​ Cortisol: Sugar (glucose metabolism)
2.​ Aldosterone: Salt (fluid/electrolyte balance)
3.​ Androgens: Sex and hair
Addison's Disease (Adrenal Insufficiency)
●​ Patho: Absence of all three steroids. Fatal if untreated. Requires lifelong
glucocorticoid steroids. Low glucose, low Na+, high K+, high Ca++. "ADD a zone"
of steroids.
●​ Causes: Autoimmune (most common), secondary to cancer, infections (TB, HIV),
trauma, adrenal hemorrhage.
●​ S/S: Everything low except high pigmentation and high K+: Lethargy, fatigue,
muscle weakness, GI disturbances, weight loss, menstrual changes/impotence,
hypotension, hyperpigmented skin (bronze), dehydration, skinny appearance,
depression, low temp, cold intolerance, alopecia. Stress can kill them.
○​ Low Na+: Seizures, changes in LOC.
○​ High K+: Cardiac arrest (EKG changes: A-fib, asystole, tall peaked T waves).
●​ Nursing Interventions: VS (BP), daily weights, I&O, WBC, assess K+, glucose,
Na+, Ca++. Administer glucocorticoid/mineralocorticoid meds. IV glucocorticoid
steroids, IV hypertonic solution (Normal Saline with 5% Dextrose). Decrease K+
(Kayexalate). Cardiac monitor.
●​ Meds: Fludrocortisone (assess for fluid overload).
●​ Complication: Addisonian Crisis (Adrenal Crisis) - EMERGENCY!
○​ Causes: Stress, infection, trauma, surgery. High K+ (lethal).
○​ S/S: Severe headache, severe abdominal/leg/low back pain, general
weakness, irritability, confusion, severe hypotension, shock, death.
○​ Interventions: Administer high-dose IV hydrocortisone replacement, IV fluids,
VS (BP), neuro checks, I&O, monitor labs (Na+, K+, blood glucose). Protect
from infection, bedrest, quiet environment. Steroid IV.
●​ Teaching: Lifelong corticosteroids. Increase steroids during stress (illness,
surgery, trauma). Avoid infection, limit visitors, avoid strenuous exercise/stressful
situations, avoid OTC meds. Wear medical alert bracelet. DO NOT STOP
STEROIDS ABRUPTLY. Increase Na+ and fluids, restrict K+.
●​ Steroid Precautions: Weight gain (report 1 lb in 1 day), increased risk of
infections, hyperglycemia, osteoporosis (risk for cataracts - get eye exams). Taper
off slowly.
●​ Diet: High protein, high carb, high Na+. Calcium and Vit D supplements (prevent
osteoporosis).
●​ Priority: Addison's patients are priority over Cushing's due to seizure and lethal
high K+ risk from low Na+.
Cushing's Syndrome
●​ Patho: Excessive cortisol from adrenal cortex. High Na+, high sugar, low K+, low
Ca++. "Cushiony," "GRU" appearance.
●​ Causes: Long-term steroid use (e.g., for lupus, MS, RA, asthma, COPD), tumor
(e.g., small cell lung cancer).
●​ S/S: Generalized muscle atrophy/wasting, weakness, moon face, buffalo hump,
truncal obesity with thin extremities, supravalvular fat pads, weight gain, hirsutism
(manly hair growth), high sugar, high Na+, low K+, low Ca++, high BP, fragile skin,
easy bruising, red/purple striae on abdomen/upper thighs, petechiae,
osteoporosis, increased pigmentation.
●​ Nursing Interventions: VS (BP), I&O, monitor labs (WBC, glucose, high Na+, low
K+, high Ca++). Daily weights.
●​ Treatment: Taper off steroids. Surgical removal of endocrine gland (requires
lifelong steroids). Hypertonic saline.
●​ Teaching: Medical alert bracelet.
●​ Diet: Low Na+, low sugar. No processed/canned foods. Well-balanced diet.
●​ Complications: Hyperglycemia (clot risk, infection, delayed wound healing).
●​ Report to HCP: Irregular apical HR (either high or low).
Pheochromocytoma
●​ Patho: Rare tumor in adrenal medulla (usually benign) causing excessive
catecholamine release. Leads to severe hypertension.
●​ S/S: Severe headache (especially back of head), visual changes, palpitations,
diaphoresis.
●​ Nursing Interventions: BP Management is KEY. Administer antihypertensives.
DO NOT PALPATE ABDOMEN (can release catecholamines and cause severe
HTN).
●​ Report to HCP: Light yellow "halo" drainage from nose (CSF leak post-op),
severe persistent headache, nuchal rigidity & high fever (meningitis).
●​ Teaching: No alcohol, smoking, caffeine, nicotine. Avoid tyramine-containing
foods (similar to MAOI diet: no aged cheese, salami, chocolate, red wine).
Hypertensive crisis can occur 1 hour after consuming tyramine.
●​ Treatment: Transsphenoidal Hypophysectomy (tumor removal through nose).
●​ Post-Op Teaching (Transsphenoidal Hypophysectomy): Breathe through
mouth for 2-3 days, deep breaths (no coughing - increases ICP), no brushing
teeth for 2 weeks (can floss), don't bend at waist (increases ICP), no blowing
nose, increase fluid intake, no straining (increases ICP), HOB 30 degrees.
Decreased sense of smell for 3-4 months is normal. Self-administer prescribed
hormones (cortisol, thyroid, gonadal).
●​ Post-Op Care: Neuro assessment hourly for 24 hours, I&O. Avoid constipation.
Monitor nasal drip.
IV. Fluid & Electrolyte Imbalances / Pituitary Disorders
Understanding fluid balance and the impact of ADH is crucial for these conditions.
Diabetes Insipidus (DI)
●​ Patho: Posterior pituitary gland issue ("dry inside"). Deficiency of ADH
(Antidiuretic Hormone - "adds H2​O"). Polyuria & polydipsia. High Na+ (seizure
risk), low BP.
●​ Causes: Brain injury or surgery, nephrogenic DI.
●​ S/S: Polyuria (1−2 L/hr), diluted urine, polydipsia, dehydration, low urine specific
gravity, fatigue, muscle pain, weakness, headache, postural hypotension,
tachycardia, sunken eyes.
●​ Nursing Interventions: VS, neuro checks, cardio status, fall precautions (postural
hypotension). Monitor electrolytes, dehydration. IV fluids (Hypotonic saline). I&O,
daily weights.
●​ Meds: Vasopressin IV, Desmopressin (nasal spray). Assess for headache, thirst,
high BP, fluid overload, weight gain.
●​ Complications: Dehydration, electrolyte imbalance (high Na+, high BP).
●​ Teaching: Avoid Na+ foods, avoid liquids that cause diuresis. Medical alert
bracelet.
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
●​ Patho: "Swimming inside." Excess ADH. Low Na+, high water retention.
●​ Causes: Brain surgery/trauma, stroke, meds, stress, small cell lung carcinoma.
●​ S/S: Fluid overload, LOC changes (headache, confusion - first sign, cerebral
edema risk for seizures), weight gain WITHOUT edema, high BP, tachycardia,
anorexia, low urine output, concentrated urine, high urine specific gravity.
●​ Nursing Interventions: VS, cardiac, neuro checks, safety, signs of ICP, seizure
precautions. HOB max 10 degrees (to promote venous return to heart and
decrease ADH release). I&O, daily weights. Restrict fluid (800−1000 mL/day).
Monitor urine osmolality. IV fluid (Hypertonic saline). Loop diuretics. Vasopressin
antagonists. Replace Na+. Restrict H2​O 500−600 mL/day.
●​ Meds: Vasopressin antagonists (Tolvaptan PO, Conivaptan IV), loop diuretics
(Furosemide, Bumetanide - NO HCTZ). Vasopressin decreases urine output,
increases BP.
●​ Complications: Water intoxication (Na+ off), seizures (limit visitors, low light,
rest).
○​ Water Intoxication S/S: Headache, vomiting, acute confusion.
●​ Priority with Low Na+: Assess neuro status.
V. Diabetes Mellitus Complications
Understanding the differences between DKA and HHS is crucial for appropriate
nursing care.
Diabetic Ketoacidosis (DKA) - EMERGENCY!
●​ Patho: Sudden onset. Complication of Type 1 DM with severe insulin deficiency.
Metabolic acidosis. Blood sugar >300. Ketones present. K+ goes up (initially, then
drops with treatment). Easier to fix than HHS.
●​ Causes: Infection (sepsis), stress, skipped insulin doses, illness, inadequate
insulin.
●​ Risk Factors: Type 1 DM, infection, stressors, inadequate insulin dose.
●​ S/S (Ketosis): Kussmaul respirations (deep, rapid breathing), fruity breath odor,
N/V, abdominal pain, dehydration, electrolyte loss. Polyuria, polydipsia, weight
loss, dry skin, sunken eyes, soft eyeballs, lethargy, coma. Hyperglycemia (>300),
high Na+, ACIDOSIS (low pH, high K+ initially).
●​ Nursing Interventions:
1.​ Restore Blood Volume: #1 IV infusions of 0.9% NS then 0.45% NS.
2.​ Insulin Therapy: IV regular insulin (ONLY regular can be given IV). During IV
insulin, give K+ (as insulin pushes K+ into cells).
3.​ Glucose Management: Add D5W (IV dextrose) when blood glucose reaches
250−300 mg/dL.
○​ Monitor VS, urine output, mental status, O2​, blood glucose, K+ level (hourly
sugar checks). Assess hydration status (cap refill, stabilized BP, warm skin,
urine output).
●​ Potassium IV Precaution: Need ECG monitoring. NEVER PUSH IV K+ (DEATH).
10−20 mEq/hr MAX via IV infusion (slow infusion due to burning).
●​ Labs: Serum glucose >300, positive ketones (1:2 dilution), pH 7.35 or less, positive
urine ketones.
Hyperglycemic Hyperosmolar State (HHS)
●​ Patho: Gradual onset. Extreme hyperglycemia WITHOUT ketoacidosis (enough
insulin present to prevent fat breakdown). Primarily in Type 2 DM. No ketones.
Alkalosis (can be normal pH, but not acidosis). Harder to fix than DKA.
●​ Risk Factors: Type 2 DM, infection, poor fluid intake, stress.
●​ S/S: Altered CNS function with neuro symptoms, extreme dehydration, electrolyte
loss. Hyperglycemia (>600), NO KETONES, NO ABDOMINAL PAIN, hypotension.
●​ Nursing Interventions:
1.​ #1 Fluid Replacement: 0.9% NS initially.
2.​ Electrolyte Correction.
3.​ Insulin Therapy: Administer regular insulin IV.
○​ Hourly sugar checks. Assess hydration status (cap refill, stabilized BP, warm
skin, urine output). Monitor blood sugar, EKG, neuro checks (Glasgow Coma
Scale - eye, verbal, motor response). Check electrolytes (low K+, high Na+).
●​ ICU Patient: Assess for hypoglycemia after giving IV insulin.
●​ Labs: Glucose >600, no ketones (serum ketones negative), BUN up, Creatinine
up, high Na+, low K+.
Sick Day Rules (ALL Diabetics)
Tell HCP when ill.
Monitor blood glucose every 4 hours.
Test urine for ketones when blood glucose >240 mg/dL.
Continue diabetic meds unless HCP says otherwise.
Prevent dehydration: drink 8−12 oz (240−360 mL) sugar-free liquid every hour
awake. If blood glucose is below target, drink sugar-containing fluids.
●​ Continue to eat meals at regular times. If unable to tolerate solids due to nausea,
consume easily digestible foods/liquids with usual carb content.
●​ Call HCP if: Persistent N/V, moderate to high ketones, blood glucose elevation
after 2 supplemental doses of insulin, fever over 101.5∘F or increasing/persisting
>24 hours, untreated diarrhea.
●​ Get plenty of rest.
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VI. General Nursing Interventions & Safety
Remember these overarching principles for patient care.
Key Assessment Findings & Actions
●​ Respiratory System Assessment: Priority is gas exchange. For dyspnea, assess
onset, relieving factors, interference with ADLs, and presence of stridor.
●​ Immediate Gas Exchange/Perfusion Issue: Cyanosis.
●​ Normal Sputum: Thin, clear, odorless, <90 mL/day.
●​ Abnormal Sputum: Excessive pink frothy sputum (pulmonary edema),
rust-colored sputum (bacterial pneumonia).
●​ Post-Procedure Pneumothorax Risk: Highest after thoracentesis, lung biopsy.
●​ Absent Breath Sounds Post-Lung Biopsy: Immediate action - obtain pulse ox
reading and call rapid response.
●​ Thoracentesis Pre-Procedure: Consent is paramount.
●​ Chest Tube Drainage: Notify surgeon immediately if >70 mL/hr (may indicate
internal bleeding). Maximum after 4 hours is 100 mL.
●​ Chest Tube Disconnection from Drainage System: Place end of disconnected
tube into container of sterile water positioned below chest.
●​ Leak in Chest Tube System: Continuous bubbling in water seal chamber (BAD!).
●​ Chest Tube Safety: Keep padded clamps at bedside.
●​ Mediastinal Chest Tube: Immediate intervention needed for tracheal deviation,
sudden SOB, drainage >70 mL, disconnection at Y site.
●​ Post-Extubation: Hoarseness is expected.
●​ Mechanical Vent Suctioning Indications: Rhonchi, audible secretions in ET
tube, increased PIP.
Important Patient Safety Notes
●​ Addison's Disease: Assist client to change positions slowly (due to orthostatic
hypotension).
●​ Hyperaldosteronism: Expected diuretic is Spironolactone (removes water,
increases Na+, conserves K+).
●​ Diabetes Insipidus: AVOID restricting fluid (life-threatening dehydration).
●​ SIADH: Expected labs: Increased urine Na+, K+ 2.9, urine specific gravity 1.053,
serum Na+ 119.
●​ Cushing's Disease (long-term): Moon face, truncal obesity, thin easily damaged
skin, extremity muscle wasting.
This extensive breakdown should give you a solid foundation for your exam. Focus on
understanding the "why" behind each intervention and the critical signs of
deterioration. Good luck studying!