Medical Surgical Nursing Lecture 2
I.
Homeostasis
A. The body’s tendency to maintain a state of physiologic _____________ in constantly
__________________conditions
II.
__________________
A. _______________ of body weight
B. Elderly  ________________________%
C. In & Out
1)Intake and output should be a__________________
2)Average daily intake/output : ____________________
III.
Electrolytes
A. Substances that dissociate in solution to form______________ = Electrically charged particle
B. Function’
1)Regulate ____________________
2)_______________-muscular activity
C. Key Electrolytes
1)Sodium (_____)
2) Potassium (_____)
3)Calcium (_____)
4)Magnesium (_____)
5)Chloride (_____)
D. Intracellular fluid (ICF): Fluid ______________ the cells _____% of body wt
E. Extracellular fluid (ECF): Fluid _______________of cells  _____% of body wt
1)Interstitial fluid: _________________the cells
2)Intravascular fluid: In the ___________________________________
3)Transcellular: Body fluids
IV.
Body Fluid Movement
A. Compartments separated by selectively _______________________ membranes
B. 4 ways to move
1)Osmosis
a) ______________ moves from an area of __________solute concentration to an
area of ____________ solute concentration
b) Isotonic solution: 
c) Hypertonic solution: 
d) Hypotonic solution: 
2)Diffusion
a) _________________ move from an area of ____________solute concentration
to an area of _______________ solute concentration
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b)
3)Filtration
a) ______________ & _________________move across membranes driven by
fluid ______________________
4)Active transport
a) Allows ______________to move into areas of high solute concentration but
requires cellular ________________________: Adenosine triphosphate / ATP
b)
V.
Nrs. Dx: Fluid Volume Deficit: AKA - dehydration
A. Causes
1)
GI fluid loss
2)
Excess urine output
3)
4)
Hemorrhaging
Inadequate fluid intake
B. S&S
1)
2)
3)
4)
5)
6)
C. Lab tests
1)
2)
3)
D. Nursing Plan
1)
2)
3)
4)
5)
VI.
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Fatigue
BP:
Pulse
Weight
Skin
Urine output
Serum osmolality
Hematocrit
Urine specific gravity
I&O
Vital Signs
Assess ________________________
__________________Weight
Assess _______________ status & __________________ sounds
6)
Assess ________________________ & _________________ membranes
7)
PUSH ____________________
8)
Educate
Nrs. Dx: Fluid Volume Excess
A. Usually due to: _________________ &_________________ retention: ______________
B. Causes
1)
_____________________ or _____________________ failure
2)
Too much _________________________ or _______________________
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3)
Medications
C. S&S
1)
BP
2)
Pulse Rate
3)
Pulse Strength
4)
Respiratory
5)
Weight
6)
Edema
7)
Serum osmolarity
8)
Hematocrit
9)
Specific gravity of urine
D. Interdisciplinary Team Treatment
1)
VII.
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Medications
a) __________________________________
2)
___________________ & ____________________ restriction
E. Nursing Plan
1)
Baseline ________________ & ____________________
2)
Monitor
a) ________________________________________________________
3)
Report:
a) ________________________________________________________
4)
Monitor Labs: Esp _____________________ &
______________________
5)
Administer ____________________________
6)
Fluid & Sodium _______________________________
7)
Provide
a) _________________________________________________________
8)
Educate
a) _________________________________________________________
Sodium Imbalance (________)
A. Normal Levels:
1)
___________- ___________ mEq/L
B. Hyponatremia
1)
_________ sodium level: __________________ mEq/L
2)
Causes
a) Water ___________________
a. _________________ or _____________ disease
b. Syndrome of Inappropriate secretion of AntiDiuretic Hormone
b) Sodium _______________
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3)
a)
b)
c)
d)
4)
a)
5)
a)
VIII.
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a. ___________________
b. ___________________
c. ____________________
S&S
Anorexia
______________
_______________ changes
_____________________________ & ______________________
Dx tests
______________________ electrolyte level
Tx
More ___________________________  _____________________
b) Less ____________________________  _____________________
C. Hypernatremia
1)
_____________ sodium levels: ____________________ mEq/L
2)
Common causes
a) Water loss
a. __________ drinking
b. _____________________
c. D______________________ or D_____________________
b) Sodium Retention
a. Tube feeding without __________________________
b. IV with _______________
3)
S&S
a) __________________________
b) Altered _____________________ status
c) ____________________ mucus membrane
d) Postural _____________________________________
e) Skin: ________________________ & ________________________
4)
Tx.
a) ________________________ water
Potassium Imbalance (________)
A. Normal levels: __________________ mEq/L
B. Hypokalemia
1)
_______________ potassium levels: ______________________ mEq/L
2)
Common causes:
a) __________ loss: _________________________________________
3)
S&S
a) ________&___________
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b) Anorexia
c) __________________ weakness
d) Dysrhythmias
4)
TX
a) Potassium ___________________________
a. Natural sources:
i. Fruit:__________________________________________
ii. Veg: ___________________________________________
C. Hyperkalemia
1)
______________ potassium levels: ________________________ mEq/L
2)
Common Causes:
a) #1 ___________________ failure
3)
IX.
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S&S
a) Dys_____________________________  _____________________
b) ______________&_______________: diarrhea
c) _______________________weakness
4)
Dx tests
a) Serum ____________________________
b) ___________
c) ____________________________ function:
a. ______________: Blood Urea Nitrate
5)
Rx. Loop ___________________: Lasix
6)
Nrs. Dx: At risk for injury
a) Monitor: ___________________________
b) Monitor ___________________________
7)
Nrs. Dx: Decreased cardiac output
a) Monitor: __________________________ & apical _________________
b) Monitor: _______________________________
Calcium imbalance (_________)
A. Hypocalcemia
1)
_______________ serum calcium levels:
2)
Common causes:
a) _________________________ectomy
b) ________ dietary intake
c) Lack of ____________ exposure
d) ____________________________
3)
Function of Ca in the body:
a) Healthy ____________________________
b) Muscle ________________________ & _________________________
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4)
a)
b)
c)
d)
e)
f)
5)
a)
b)
S&S
_______________________
a. Paresthesia:
b. Muscle _________________________
____________ Chvostek’s sign
____________ Trousseau’s sign
____________rhythmias
_______________ Cardiac output
_______________ BP
Dx test
______________ calcium level
_______________ Parathyroid hormone levels
6)
X.
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Tx
a) Ca _________________________
b) Natural sources of Ca: ______________________________________
B. Hypercalcemia
1)
_______________ serum calcium levels
2)
Common Causes
a) Hyper____________ thyroidism
b) Cancer
c) _________________________________
d) _________________ failure
3)
S&S
a) ___________________ weakness
b) _______________ reflexes
c) ______________________________
d) _______________rhythmias
e) BP:___________________________
f) Urine output_____________________
4)
Dx tests
a) Serum __________________ level
b) PTH
c) ECG
5)
Rx
a) ___________________________________
Magnesium Imbalance (____________)
A. Hypomagnesaemia
1)
_____________ serum magnesium levels
2)
Common Cause: ______________________________
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3)
XI.
XII.
XIII.
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S&S
a) Weak _______________
b) Tetany:
a. + _______________________________
b. + _______________________________
c) Dys____________________________
d) ________________________________
Structure & Function of the Integumentary System
A. 2 regions
1)
_______________________
a) ____________________ part
b) Melanin: _________________________________
c) Ketatin: _________________________________
d) Function: ____________________________
2)
_______________________
a) ___________________ layer
b) Contains:
a. __________________ vessels
b. _____________________ endings
c. _____________________ vessels
d. ____________________ follicles
e. Sebaceous ____________________________
f. ____________________ glands
Skin Assessment
A. History
1)
C/O:
a) Onset
b) Duration
c) Characteristics
d) Relief
e) Exacerbation
2)
Changes:
B. Assess ____________ skin area
1)
S&S
2)
Measure
Common Skin Lesions
A. Macule, patch
1)
_______________ , non-palpable change in skin__________________.
2)
Macule :________________________ Patch ___________________
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3)
e.g. ________________, Mongolian spots
B. Papule, plaque
1)
___________________ , solid, palpable mass with circumscribed border.
2)
Papule: _____________________Plaque ____________________
3)
e. g._____________________, warts, psoriasis
C. Nodule, tumor
1)
Elevated, ___________palpable mass extending into dermis
2)
Nodule:_________________Tumor____________________________
D. Vesicle, bulla
1)
Elevated, ______________filled, round/oval shaped, palpable mass with
________________________ translucent walls
2)
Vesicle_____________________Bulla___________________________
3)
e.g. herpes simplex, chicken poxs, _______________________
E. Wheal
1)
___________________, often reddish, ____________________borders,
caused by diffuse fluid in the tissue rather than free fluid in a cavity
2)
e.g.: Insect bites, _________________________
F. Pustule
1)
Elevated pus-filled vesicle or bulla with circumscribed border.
2)
e.g. ______________, impetigo, carbuncles
XIV. Older Skin
A. Normal changes
1)
__________Subcutaneous tissue
2)
Dermal___________________
3)
__________________Elasticity
4)
__________________Turgor
5)
__________________Hair and nail growth
XV. Dx test:
A. ____________________________: Skin sample
B. Nrs. Responsibility
1)
______ consent signed
2)
Supplies
3)
Apply _________________________
4)
Send __________________________to the lab
XVI. Pressure Ulcers / __________________________ ulcers
A. _________________________________ lesions
1)
External ____________________________________ 
2)
Friction
3)
Shear
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B. Pressure ulcer pathophysiology
1)
Pressure  _________ blood flow  ___________ oxygen 
__________________  _________________  ulceration
C. High Risk Areas:
1)
______________ prominence
a) _________________________
b) Greater trochanter
c) Sacrum
d) Ischia
e) Shoulder
D. High Risk Clients
1)
________________________
2)
________________________
3)
Incontinent
4)
Nutritional _________________________
5)
________________________
E. Complications
1)
_________________________
2)
_________________________
a) Sepsis
b) ____________________________ infection
c) _______________________________
d) Osteomyelitis
3)
Quality of ________________
4)
$
5)
_________________________
F. Prevention
1)
_________________________
2)
Clean & ________________________
a) Clean with ___________________________
b) Moisturizer (non-_______________________ based)
c) Skin protection ________________________________
d) B&B program
3)
Avoid __________________________
4)
___________ pressure
a) ______________________  mobility
b) ________________________________
c) Pressure reducing ______________________
d) Float ________________________________
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e) No _______________________________
5)
Well Balanced
a) ________________________________
b) Preferences
c) Provide _________________________ & ________________
d) Snacks & __________________________
e) Supplements
f) Lab Values
G. Description of Ulcers / Assessment
1)
________________ ulcer
2)
_______________________
3)
_______________________
4)
Wound ____________________________
5)
Granulation __________________________
6)
Necrotic _____________________________
7)
Wound ______________________________
8)
___________________________
9)
S&S of ______________________________
10)
__________________________________
H. Staging
1)
Stage 1: Persistent non-blanchable erythema of ________________skin
2)
Stage 2: _______________ -thickness skin loss involving epidermis,
dermis, or both. Ulcer is ________________ and presents as an abrasion, blister,
or shallow crater.
3)
Stage 3: ____________ -thickness skin loss involving damage or necrosis
of subcutaneous tissue that may extend down to, but _________ through,
underlying fascia.
4)
Stage 4: ___________ -thickness skin loss with
extensive___________________ , tissue necrosis, or damage to muscle, bone, or
supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts
may also be present.
5)
Unstagable: Full thickness tissue loss in which __________________
(yellow, tan, gray, green or brown), ___________________________ (tan, brown
or black), or both in the wound bed cover the base of the ulcer.
I. Wound documentations
1)
Granulations Tissue
a) Intermediate step in ________________________________
b) Very ___________________________
c) Appearance: _________________________________
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2)
a)
b)
3)
a)
b)
c)
Slough
_______________________________ tissue
Appearance
a. _________________ mass
b. Color: _____________________________________
c. Easily confused with _____________________ tissue
Eschar
_________________________ tissue
Color: __________________________________________
Appearance:
a. Leathery, ________________ & ___________________
b. Soft, with purulent _____________________: ____________
J. Nursing Diagnosis: Impaired Tissue Integrity
1)
Document: ___________________ progress
2)
Do not _______________________ stage
3)
Dressings
a) Keep wound bed _____________________________
b) Keep surrounding tissue ______________&____________________
c) Do not use ______________________________ agents
K. Nursing Diagnosis: Risk for Infection
1)
Wound _________________________
2)
Medication: _______________________
3)
Culture
4)
S&S of infection: ___________________________________________
L. Nursing Diagnosis: Alt. nutrition, less than body req1uirement
1)
Nutritional ____________________
2)
Daily ____________________
3)
_________ protein
4)
Lab: _____________________________
M. Surgical Management
1)
Stage ___________-_____________
2)
Risk to ________________________
3)
All wounds with ___________________ tissue, should be _________
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