Med-Surg Final Review- Part 1
Increased Intracranial Pressure
S/S: First sign- Decreasing LOC, headache, vomiting without nausea, papilledema, changes in VS, Cushing’s
triad (late sign), Cheyne-Stokes respirations, posturing.
Cushing’s Triad: hypertension, bradycardia, widening pulse pressure (systolic ↑, diastolic stays the same)
Dx: Intracranial pressure monitoring device, skull radiography, CT, MRI, lumbar puncture, cerebral angiography.
Tx: Goal is to maintain cerebral tissue perfusion and blood pressure. Keep oxygen saturation at 95%, HOB
elevated 30 degrees, control temperature, administer anticonvulsants, Versed, antiemetics, etc to reduce the
chances of anything happening that could increase ICP.
IV: NS, LR, or 3% hypertonic saline. (Hypotonic or solutions with glucose can raise ICP.)
Autonomic Dysreflexia
Def: an exaggerated sympathetic nervous system response among those with a spinal cord injury above T6.
S/S: Severe HTN decreased HR, pounding headache, nausea, blurred vision, sweating, and anxiety. Can lead
to seizures, stroke, and death.
Causes: Full bladder, abdominal distention, constipation, skin pressure, skin breakdown, exposure to hot or cold
Prevent: administer antihypertensives, raise HOB, Foley catheter, and prevent triggers
Immobilization of Spinal Injuries
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The head and back are immobilized mechanically with a cervical collar and back support.
o Stabilizes the spinal column to help prevent movements which may lead to paralysis.
After pt is stabilized, the injured portion of the spine is further immobilized using a cast, brace, or surgery.
Traction is applied with weights and pulleys to decompress the spine.
A turning frame is used to change the pt’s position without altering the alignment of the spine.
Thyroid Gland- Hormones
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Thyroxine, T4; Triiodothyronine, aka T3
o Regulates (increases) body’s metabolic rate
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Calcitonin, aka thyrocalcitonin
o Regulates serum calcium levels,
o Secreted when serum calcium levels are high, inhibits shift of calcium from bones
Tetany (see hypocalcemia also)
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The main symptom of sudden and acute hypoparathyroidism
Develops when the parathyroid glands are accidentally removed during a thyroidectomy.
S/S: twitches, tingling, dysrhythmias, seizures, spasms, laryngospasm.
Signs: tap facial nerve mouth or jaw twitch or tighten = positive Chvostek’s sign
Inflate BP cuff  fingers spasm = positive Trousseau’s sign.
Tx: Calcium salts IV or PO
Antibiotic Therapy
Take ALL antibiotics prescribed.
Mastectomy
Simple: removal of entire breast
Radical: removal of all breast tissue, overlying skin, axillary lymph nodes, and underlying pectoral muscles
Modified Radical: same as radical but with the muscles left intact.
Post Op: Tamoxifen if ER+; elevate arm; no BPs, IV’s or sticks on affected side; no deodorant or shaving of
affected side; progressively exercise affected side.
Reconstruction: can be done immediately, or up to 1 year later.
Diabetes Insipidus
Pathology: Deficient or ineffective ADH
S/S: massive diuresis—up to 30L/day, dehydration, polyuria, polydipsia, polyphagia
Nsg: risk for fluid volume deficit--- strict I&O, daily weight
Tx: IV fluids, vasopressin, Lypressin nasal spray, DDAVP
Laryngeal Nerve Damage
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Severe, persistent hoarseness or inability to speak.
May be due to trauma during thyroidectomy.
Renal Scan
Intravenous Pyelogram
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Radiographic dye is injected IV to see how the dye is concentrated by the kidneys and then excreted.
Pictures are taken at 5-15 minute intervals
Observe for stones and abnormalities.
Prep: enemas, laxatives, fluids only or NPO for 8-10 hours before surgery, check for allergy to iodine or shellfish,
tell pt they will experience a warm, flush, feeling.
Teach: encourage fluids to flush out the dye, recognize s/s of allergic response.
Hypocalcemia
S/S: Tingling in the extremities and the area around the mouth (circumoral paresthesia), muscle and abdominal
cramps, carpopedal spasms referred to as Trousseau's sign, mental changes, positive Chvostek's sign (spasms
of the facial muscles when the facial nerve is tapped, laryngeal spasms with airway obstruction, tetany (muscle
twitching), seizures, bleeding, and cardiac dysrhythmias. The client has hypocalcemia if the total serum
calcium level is below 8.8 mg/dL (normal range, 9 to 11 mg/dL) or the ionized calcium level is below 4.4 mg/dL
(normal range, 4.4 to 5.4 mg/dL).
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Keep emergency tracheostomy tray, mechanical ventilation equipment, artificial airway, and
endotracheal intubation equipment at the client’s bedside if hypocalcemia is severe.
IV line for the emergency administration of calcium.
The nurse observes frequently for respiratory distress and notifies the physician immediately if this problem
occurs.
Until hypocalcemia is corrected, the nurse must assist the client with activities of daily living (ADLs).
Movement, noise, and other environmental disturbances can trigger muscle contractions or convulsions.
Thus, minimizing all forms of stress is essential until serum calcium levels approach normal and symptoms are
relieved.
Dietitian consult
Cushing’s Syndrome
Def: Hypersecretion of the adrenal cortex resulting in excess cortisol and other adrenal cortex hormones.
Causes:
Endogenous: Pituitary tumor, adrenal gland neoplasm, carcinoma of lung or other tissue.
Exogenous: Prolonged high doses of corticosteroids.
S/S: muscle weakness, truncal obesity, hirsutism, deep voice, irregular periods, HTN, hypokalemia,
hyperglycemia, hypernatremia, increased cortisol levels.
Tx: Depends on cause; slow tapering off of steroids, radiation, surgery (partial removal of pituitary gland to
decrease ACTH secretion
Meds: Aldactone for bilateral benign adrenal tumor. Chemo or other drugs that interfere with ACTH.
Nsg: high risk of infection
Subtotal Thyroidectomy (see Thyroidectomy for more info)
Pt. will only need thyroid replacement meds for a few months.
Exfoliative Dermatitis
HIV
Transmitted by: blood, semen, vaginal secretions, and breast milk
Risk Factors: unprotected sex, contact with infectious fluids, sharing needles, receiving multiple blood
transfusions, use of non-sterile tattooing equipment,
AIDS: HIV converts to AIDS when the T4 cell count level goes from the normal 800 to 1200
Burn Injury
Rule of Nines:
Head and neck = 9%
Right arm = 9%
Left arm = 9%
Posterior trunk = 18%
Anterior trunk = 18%
Right leg = 18%
Left leg = 18%
Perineum = 1%
Superficial burn: pink to red and painful, sunburn, 1st degree
Superficial Partial thickness burn: painful, blistered, weepy, 2nd degree
Deep Partial thickness burn: painful, thick blisters or weepy edema, sensitive to cold, 3 rd degree.
Full thickness burn: affects skin, fat, muscle, and bone. May be red, white, or black (eschar), often painless. 4th
degree
Fluid Resuscitation: Baxter Formula
(3-4cc) x (kg of wt) x (% of body burned)= total CCs to be given in 24 hours
½ to be given in the first 8 hours
¼ to be given in the 2nd 8 hours
¼ to be given in the 3rd 8 hours
Nsg interventions: reverse isolation, foley catheter, I&O is measured hourly, medicate with Morphine 30 minutes
before dressing change, monitor for infection, high protein/high calorie diet.
Diabetes Mellitus
Type 1: no insulin production; requires injections for life
Type 2: insulin resistance and or inadequate secretion
S/S: polyphagia, polydipsia, polyuria, elevated BSL
Dx:
FSBS > 200
Fasting serum glucose > 110 (must fast for 8 hours)
Urine sugar and acetone
Glucose Tolerance Test
Hgb A1C > 7% shows that the pt is not controlling hyperglycemia
7%=avg. BSL of 150
Emergency Complications:
Acute Hypoglycemia (BSL < 70)
s/s: diaphoresis, nervousness, shakiness
Check blood sugar immediately
Diabetic Ketoacidosis (DKA)
s/s: Kussmaul’s respirations, fruity breath, 3 p’s, BSL > 300
Primarily a problem with type 1
Hyperglycemic hyperosmolar nonketonic syndrome (HHNKS)
s/s: BSL > 600, but not ketone formation, comatose
Pt is still producing some insulin: Type 2
Ketones: products of fatty acid metabolism
 Indicates breakdown of fats for energy, a sign that diabetes is out of control.
 Can lead to DKA.
 Instruct pt to test again in a few hours
 DO NOT exercise; call MD if moderate or large amounts found in urine.
External Bleeding
Arterial lacerations are evident when the blood is squirting with a lot of force in a rhythmic fashion.
3 treatments:
1. Direct pressure
2. Elevation
3. Pressure points (pulse site between the heart and laceration)
 Carotid, axillary, brachial, radial, femoral, popliteal, pedal
Tourniquet is used as a last resort because it can cause tissue death and can lead to amputation.
Uncontrolled bleeding can lead to shock.
Blood Transfusion
Saline is the only fluid that can be given with blood.
Transfusion Reactions
Complication
Signs and Symptoms
Cause(s)
Action
Incompatibility
reaction
Hypotension, rapid pulse
rate, difficulty breathing,
back pain, flushing
Mismatch between
donor and recipient
blood groups
Stop the infusion of blood.
Infuse the saline at a rapid rate.
Call for assistance.
Administer oxygen.
Raise the feet higher than the
head.
Be prepared to administer
emergency drugs.
Send first urine specimen to
laboratory.
Save the blood and tubing.
Febrile reaction
Fever, shaking chills,
headache, rapid pulse,
muscle aches
Allergy to foreign
proteins in the
donated blood
Stop the blood infusion.
Start the saline.
Check vital signs.
Report findings.
Septic reaction
Fever, chills, hypotension
Infusion of blood that
contains
microorganisms
Stop the infusion of blood.
Start the saline.
Report findings.
Save the blood and tubing.
Allergic reaction
Rash, itching, flushing,
stable vital signs
Minor sensitivity to
substances in the
donor blood
Slow the rate of infusion.
Assess the client.
Report findings.
Be prepared to give an
antihistamine.
Circulatory
overload
Hypertension, difficulty
breathing, moist breath
sounds, bounding pulse
Large volume or
rapid rate of infusion;
inadequate cardiac
or kidney function
Reduce the rate of infusion.
Elevate the head.
Give oxygen.
Report findings.
Be prepared to give a diuretic.
Hypocalcemia
Tingling of fingers,
hypotension, muscle
cramps, convulsions
Multiple blood
transfusions
containing
anticalcium agents
Stop the blood infusion.
Start saline.
Report findings.
Be prepared to give CaCl
DIC- disseminated intravascular coagulation
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Can happen as a complication of shock.
Normally, when you are injured, certain proteins in the blood become activated and travel to the injury site
to help stop bleeding. However, in persons with DIC, these proteins become abnormally active.
Small blood clots form within the blood vessels. Some of these clots can clog up the vessels and cut off
blood supply to various organs such as the liver or kidney. These organs will then stop functioning. Over time,
the clotting proteins become “used up.” When this happens, the person is then at risk for serious bleeding
from even a minor injury.
This disorder can result in clots or, more often, in bleeding. The bleeding can be severe.
Risk factors for DIC include:
 Blood transfusion reaction
 Cancer, including leukemia
 Infection in the blood by bacteria or fungus
 Pregnancy complications (such as retained placenta after delivery)
 Recent surgery or anesthesia
 Sepsis (an overwhelming infection)
 Severe liver disease
 Severe tissue injury (as in burns and head injury)
Dx:
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PTT – high
Platelets – low
PT – high
Tx: The goal is to determine and treat the underlying cause of DIC. Blood clotting factors will be replaced with
plasma transfusions. Heparin is sometimes used.
Thyroidectomy
Pre-op: admin antithyroid meds for several weeks, teach to avoid neck strain,
Post-op: HOB elevated 30° or more, ice bag to neck, trach set at bedside, suction equipment, VS q1-4 hrs,
check dressing and back of neck for bleeding,
Monitor for: Airway obstruction (restlessness, tachycardia, dyspnea), laryngeal nerve damage (severe hoarsness
or inability to speak), hemorrhage (check dressing and back of neck), tetany, thyroid crisis
Total thyroidectomy will require lifelong replacement of thyroid hormones; Take meds exactly as prescribed
Components of Immune System
ABG’s
Normal: 80-100 mmHg
Shock: below 60 mmHg
If SpO2 (oxygen saturation) is above 90%, the PaO2 is most likely 60 mmHg or above.
Gastric Surgery
Post-Op: No ASA or NSAIDS, will need lifetime injections of B12
Side effect can be dumping syndrome
o Occurs due to decreased size of stomach or loss of vagus nerve prevents normal pacing of chyme
movement
o Fluid is drawn out of the blood within 15-30 min of eating to moisten food
o S/S: BP falls, becomes dizzy, diaphoretic and weak, cramps, hyperactive bowel sounds, urge to
defecate
o Teach: Usually resolves within a few months; lay down after meals until dumping syndrome resolved;
6 meals/day: low carb, mod. fat, high protein; drink fluids between meals, not with them; may have
chronic diarrhea-do good skin care
Hemoglobin and Nutrition
Foods rich in iron enhance hemoglobin production.
Fractures
Immobilize joints on both sides of possible fracture.
Splint in the position found
4 interventions:
 check pulses
 immobilize
 ice
 elevate
5 P’s when assessing and charting a fracture:
 Pain
 Pallor
 Pulses
 Paresthesia- nerve damage, numbness, tingling
 Paralysis
Wound Healing
Primary intention: wound layers are sutured together and well approximated. Heals relatively fast with minimal
scarring
Secondary intention: granulating tissue fills the wound. Edges are not approximated. Healing is slow, and
happens from the bottom up. Needs moisture.
Complication of wet dressing left on too long: maceration
If dressing is stuck: moisten with sterile saline and pull gently.
Cold Injury
IV access can be difficult to obtain because the cold causes vasoconstriction.
Places other than arms, hands, and legs for IV access: subclavian, jugular, and femoral
Areas most affected by cold injury: hands, feet, nose, cheeks
S/S:
1. Pain,
2. Tingling,
3. Numbness
How to re-warm: warm blankets, warm oral fluids, and warm IV fluids
Highest risk: elderly- more susceptible because of loss of sub-q fat, diminished circulation, and reduced neural
control of circulation
Treatment goal: Temp > 95°, good circulation and warmth to tissues without tissue cellular damage
Chemotherapeutic Agents
Tissue Plasminogen Activator (t-PA)
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Used for treatment of ischemic stroke.
“Clot buster”- will dissolve the clot in the brain
Must start within 3 hours of the onset of symptoms.
Will dissolve all clots… so make sure there are no wounds.
Erythropoietin
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Secreted by the kidneys to stimulate RBC production
Decreased O2 in blood triggers this response
Pts with renal failure are deficient in erythropoietin
Morphine
Up to 50mg/hr PCA for burn pts.
Tattoos
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Pigments are not FDA approved
Interfere with MRI- poor picture quality
Infection: Hep. B, C, HIV, tinea corporis (tx with antifungals), Staph (tx with topical ATB x10 days)
Skin Care: avoid soaking, do not touch area, cover with ATB cream, good hand hygiene, wash area TID with
antibacterial soap and pat dry, apply lotion x2 weeks, avoid direct sunlight to area x4 weeks.
Removal: painful, never looks like it did pre-tattoo.
Piercings
Healing Time:
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Ear lobe: 6-8 wks
Ear cartilage: 4mo-1yr
Eyebrow: 6-8 wks
Nostril: 2-4 mo
Tongue: 4 wks
Lip: 2-3 mo
Navel: 4mo-1yr