BULLETS IN MEDICAL SURGICAL NURSING



MEDICAL – SURGICAL NURSING

BULLETS

✓ Chest X ray ( painless procedure

✓ Bronchoscopy

o AtSO4

▪ Anticholinergic ( mimics SNR

▪ Decreases saliva ( dry mouth

o NPO 6 to 8 hours

o Local anesthesia ( check gag reflex before feeding

✓ ABG

o Hyperventilation ( decreased CO2 ( increased blood pH ( respiratory alkalosis

o Hypoventilation ( increased CO2 ( decreased blood pH ( respiratory acidosis

o Diarrhea ( decreased HCO3 ( decreased blood pH ( metabolic acidosis

o Vomiting gastric content ( decreased HCL ( increased blood pH ( metabolic alkalosis

o Vomiting blood ( decreased O2 ( anaerobic metabolism ( formation of lactic acid ( decreased blood pH ( metabolic acidosis

o Blood pH ( normal 7.35 to 7.45 ( If increased ( alkalosis; If decreased ( acidosis

o Partial CO2 ( normal 35 to 45( If increased Respiratory Acidosis; if decreased Respiratory Alkalosis

o Partial HCO3 ( normal 22 to 26 ( If increased Metabolic alkalosis; If decreased metabolic acidosis

✓ Cancer of the larynx ( CS, alcohol and over usage of voice (choir member)

o A - nterior neck mass

o B – urning sensation with hot beverages / Bad breath

o C - hange in the voice (hoarseness)

o D – ysphagia/dyspnea

✓ Chronic Obstructive Pulmonary Disease

o Chronic Bronchitis

▪ Blue bloater

▪ Excessive mucus production

o Asthma

▪ Periods of bronchospasm and bronchoconstriction

o Emphysema

▪ Disequilibrium of elastase and antielastase

▪ Pink puffer

o Manifestations

▪ A – LTERATION IN

• LOC ( decreased O2

• Thoracic anatomy ( over distention of alveoli ( TD = APD ( barrel chest

• Skin

o Temperature ( cool clammy skin

o Color ( pale to cyanotic

• ABG ( Respiratory acidosis ( Increased CO2

▪ B – reathing ( difficulty, purse lip ( expiration > inhalation ( removal of excess CO2 (diet low CHO)

▪ C – ough (mucus production); Chronic hypoxia (2 to 3 lpm of O2 therapy, decreased O2 demand by rest and SFF) ( clubbing of the fingers and decreased TP to the kidneys causing polycythemia

▪ D – ecreased Metabolism

• Anorexia ( weight loss (high calorie diet) ( fatigue ( weakness

✓ Bronchodilators

o Theophylline and aminophylline

▪ Primary effect ( stimulates beta 2 receptors ( smooth muscle relaxation ( bronchodilation

▪ Side effect ( stimulates beta 1 receptors ( increases cardiac rate ( need not to notify the physician

▪ Adverse effect ( hypotension ( monitor BP ( sign of toxicity

▪ Evaluation ( check breath sounds

✓ Acute Respiratory Distress Syndrome

o Causes

▪ A – spiration

▪ R – espiratory trauma (embolism)

• fracture ( embolism ( ARDS

▪ D – rug toxicity (ASA)

▪ S – epsis and shock

• Vomiting, bleeding, dehydration( hypovolemia ( shock ( ARDS

o Syndrome

▪ Severe hypoxia

▪ Bilateral infiltrates

▪ Dyspnea

✓ Pulmonary embolism

o Restlessness ( earliest

✓ Water Seal System

o Drainage Bottle ( marked the level every shift

o Water seal bottle

▪ Presence of fluctuation ( normal

▪ Absence of fluctuation ( lungs are fully expanded ( assess first patient (X ray ( confirm) OR presence of obstruction

▪ Intermittent bubbling ( normal

• Absent ( obstruction

• Continuous ( leakage

o Suction Control ( continuous bubbling ( normal

✓ Risk factors for cardiovascular disorders

o R – ace ( non modifiable

o I – ncresed blood pressure ( modifiable

o S – tress ( SNR ( increased BP and CR, vasoconstriction ( modifiable

o K – nowing sedentary life style ( modifiable

o F – at foods( atherosclerosis ( modifiable

o A – lcohol (modifiable) / Age ( above 40 (non modifiable)

o C – igarette smoking ( vasoconstriction (nicotine) ( modifiable / Contraceptive pills ( clotting of blood ( thrombus formation

o T – ype A behavior (modifiable) ( competitiveness, perfectionist ( high stress level

o O – besity

o R – esult of DM ( lipolysis ( increased fatty acids ( atherosclerosis

o S – ex (gender ( males > female (before menopausal because estrogen decreases PVR) after menopausal female eversible}[inverted T wave] ( Injury [elevated ST segment] (> male

✓ Decreased TP in heart ( Ischemia (Angina) {r necrosis (MI) {irreversible}[pathologic Q wave/permanent in the ECG]

✓ Eating a heavy meal, strenuous exercise, sex, exposure to cold ( Decreased blood flow (heart)( decreased TP (heart)( decreased O2 (heart)( anaerobic respiration ( production of lactic acid ( PAIN ( management decreased O2 demand by rest and SFF

✓ Angina

o Pain relieved by rest and NTG

o NTG

▪ Vasodilation ( orthostatic hypotention ( move gradually ( Monitor BP

▪ Store in a dark and amber container

▪ Effective ( tingling sensation ( no need to notify physician

▪ Maximum of 3 tablets with 5 minute interval

✓ MI

o Pain relieved by Morphine SO4

▪ Narcotic analgesic

▪ Can cause respiratory depression ( monitor RR and O2 saturation

▪ Antidote ( narcan

✓ Cardioversion ( synchronous

✓ Defibrillation ( unsynchronous

✓ Buerger’s disease ( CS ( vasoconstriction ( stop CS ( common in men

✓ Raynaud’s ( stress and cold ( vasoconstriction ( common in female

✓ Congestive heart failure

o Left sided ( pulmonary

▪ Dyspnea

▪ Crackles

▪ Polycythemia ( due to decrease O2 to the kidneys

▪ Clubbing of the fingers ( due to prolonged hyxia

▪ Orthopnea

o Right sided ( systemic

▪ Hepatomegaly

▪ Distended neck veins

▪ Edema

▪ Portal hypertension

▪ Ascites ( weight gain

▪ Varicose veins

o Digoxin

▪ Cardiac glycoside

▪ Positive inotrophic effect ( increased strength of myocardial contraction

▪ Negative chronotrophic effect ( decreased cardiac rate ( monitor CR ( never give if CR below 60 bpm

▪ Adverse effect

• V – omitting

• A – norexia

• N – ausea

• D – iarrhea

• A – bdominal pain

• REMEMBER: earliest ( GI; late ( halo vision

• Antidote ( Digibind

✓ Decreased RBC ( Activity in tolerance, Fatigue, provide rest, Anemia

✓ Decreased Platelets ( Prone to bleeding, avoid parenteral injection, appl pressure on injection site, high risk for injury

✓ Decreased WBC ( prone to infection, reverse isolation

✓ Increased WBC ( presence of infection

✓ First Day/Newly diagnosed ( Knowledge deficit

✓ Diuretic

o D – iet ( high K diet except aldactone

o I – input and Output ( expected increased output

o U – ndesirable effect electrolyte imbalance (K)

o R – ecord weight ( expected decreased weight

o E – lderly ( special precaution

o T – ake in AM and with food

o I – ncreased orthostatic hypotension ( monitor BP and move gradually

o C – ancel alcohol because of mild diuretic effect

✓ Heparin ( anticoagulant ( prevent further enlargement of clot not dissolve them ( monitor APTT/PTT ( antidote protamine SO4

✓ Coumadin ( anticoagulant ( prevent further enlargement of clot not dissolve it ( monitor PT ( vitamin K is the antidote

✓ Urokinase/Streptoase ( dissolves the clot

✓ Pernicious anemia ( absence of intrinsic factor (gastric surgery)( problem in absorption of Vitamin B12 ( beefy red tongue schilling’s test ( definitive test ( 24 hour urine collection ( life long Vitamin B12

✓ Gastritis ( LUQ pain

✓ Gastric ulcer ( affected area stomach ( pain (precipitated by food intake ( increased HCl) ( pain relieved by antacids

✓ Duodenal ulcer ( affected area duodenum ( pain (2 hour after eating) ( pain relieved by food

✓ Ulcers ( bleeding ( (+) occult blood test (guiac)( high fiber diet, avoid red meat, iron, steroids, NSAIDs, indomethacin

✓ Vagotomy ( resection of vagus nerve ( decreased cholinergic stimulation ( decreased HCl and gastric movement

✓ Dumping syndrome ( tachycardia and weakness ( 3 D’s (diarrhea, diaphoresis and dizziness) ( fluids after meals, lie down after meals and SFF

✓ Appendicitis ( RLQ pain ( avoid heat pads ( cause rupture ( signs of ruptured appendix ( sudden cessation of pain, elevation of temperature and WBC

✓ Diverticulitis ( LLQ pain ( low fiber diet

✓ Diverticulosis ( high fiber diet

✓ Ulcerative colitis ( bloody diarrhea 20 to 30 times a day ( fluid volume deficit

✓ Liver cirrhosis ( alcohol and malnutrition (laennec’s), infection and drugs (post necrotic), RSCHF (cardiac) and biliary obstruction (biliary)

o Portal hypertention can lead to

▪ Blood shifted to the different collateral

• Esophageal varices

• Spider angioma (face and neck)

• Caput medusae (abdomen)

• Hemorrhoids (rectal)

• Management avoid rupture ( avoid shouting, valsalva maneuver

▪ Increased hydstatic pressure ( fluid shifting ( ascites

o Decreased albumin ( decreased oncotic / colloidal osmotic pressure ( fluid shifting ( ascites ( management high protein diet

o CHON metabolism ( by product ammonia ( liver cannot convert to urea ( increased level of ammonia in the brain ( Alteration of LOC and changes of behavior and asterexis (hepatic encephalopathy ( management low CHON diet and lactulose for removal of ammonia

✓ Hepatitis A ( fecal oral ( prone plumber

✓ Hepatitis B ( body secretion ( prone working in a dialysis

✓ Cholecystitis ( 5 F’s (fair, female, fat, fertile and forty) ( RUQ pain ( after ingestion of fatty food ( demerol to relieved pain

✓ Cholecystectomy ( T tube ( level of the incision site ( drain excess bile

✓ Pancreatitis ( alcohol ( autodigestion ( LUQ pain

✓ Anterior Pituitary gland

o Growth hormone

▪ Increased before the closure of the epiphysis of the long bones ( gigantism ( tall

▪ Increased after the closure of the epiphysis ( acromegaly ( big hands (big gloves), big feet (big shoes) and big head (big hat)

▪ Decreased ( dwarfism

o Prolactin

▪ Increased ( galactorrhea

▪ Decreased ( decreased milk production

o ACTH

▪ Increased ( secondary cushing’s

▪ Decreased ( secondary addison’s

o TSH

▪ Increased ( secondary hypethyroidism

▪ Decreased ( secondary hypothyroidism

✓ Posterior pituitary gland

o ADH

▪ Increased ( water retention ( oliguria ( edema (fluid volume excess) and weight gain ( concentrated urine ( increased urine specific gravity

▪ Decreased ( water excretion ( polyuria ( dehydration (fluid volume deficit and weight loss) ( diluted urine ( decreased urine specific gravity

✓ Parathyroid gland

o Parathormone

▪ Increased ( increased calcium in the blood and decrease calcium in the bones ( stone formation and decreased bone mass ( osteoporosis ( management increased water intake

▪ Decreased ( hypocalcemia ( calcium supplement

✓ Thyroid Gland

o Increased (hyperthyroidism)

▪ T3 and T4 ( increased BMR ( hyperactive ( inability to focus ( insomia ( increased catabolism ( weight loss ( increased appetite ( increased peristalsis ( Diarrhea ( fluid volume deficit ( Increased CR and RR (due to increased BMR)

• Increased T3 ( heat intolerance

▪ Calcitonin ( decreased calcium in the blood ( tetany ( compensatory ( calcium withdraws from the bones ( bone destruction (complication)

▪ PTU ( decreased synthesis of TH ( watch out for SE (similar to signs and symptoms of hypothyroidism) ( watch out for agrunulocytosis (fever, skin rash and sore throat)

▪ Lugol’s solution ( decreased released of TH ( before thyroidectomy ( decreased vascularity of the thyroid gland

o Decreased (hypothyroidism)

▪ T3 and T4 ( decreased BMR ( hypoactive ( sleeps a lot ( decreased metabolism ( weight gain ( anorexia ( decreased peristalsis ( constipation ( decreased CR and RR due to decreased BMR

▪ T3 ( cold intolerance

▪ Calcitonin ( hypercalcemia ( stone formation

▪ Synthroid and Proloid ( increased TH

✓ Adrenal Gland

o Incresead (cushing’s)

▪ Glucocorticoids ( hyperglycemia and decrease wound healing

▪ Mineral corticoids ( increased aldosterone ( sodium retention and potassium excretion ( hypernatremia and hypokalemia

• Hypernatremia ( water retention ( oliguria ( edema (moon face,buffalohump, fluid volume excess and weight gain) ( concentrated urine ( increased urine specific gravity ( low sodium diet

• Hypokalemia ( weakness ( Prominent U wave ( high potassium diet

▪ Epinephrine and Norepinephrine ( Increased BP and CR

▪ Sex hormones

• Males ( gynecomastia and falling of hair

• Females ( hirsutism and deepening of the voice

o Decreased (addisons)

▪ Glucocorticoids ( hypoglycemia and inability to cope with stress

▪ Mineralcorticoids ( decreased aldosterone ( sodium excretion and potassium retention ( hyponatremia and hyperkalemia

• Hyponatremia ( water excretion ( polyuria (dehydration, fluid volume deficit and weight loss) ( diluted urine --. Decreased urine specific gravity ( increased fluids and Na

• Hyperkalemia ( weakness ( tall or peaked T waves ( low K diet

▪ Epinephrine and Norepinephrine ( decreased BP and CR

✓ Diabetes Mellitus

o Type I ( absolutely no insulin ( thin ( insulin

o Type II ( insufficient insulin ( obese ( OHA

o Diet ( 50% CHO, 30% Fats, 20% CHON

o Exercise ( Increased uptake of glucose ( Decreased insulin requirement

o Oral hypoglycemic agent (OHA)

▪ Stimulates pancreas to produce insulin

o Insulin

▪ SC; IV if DKA

▪ Never massage the area

▪ Never administer cold insulin

▪ Rotate the site of injection

• PREVENTS LIPODYSTROPHY

▪ Mix

• Aspirate clear first

• Inject air to cloudy first

o Hypoglycemia

▪ W – eakness

▪ H – unger pangs

▪ A – alteration of LOC

▪ T – achycardia and tremors

▪ A – bdominal pain

▪ B – blurring of vision

▪ C – ool clammy skin

▪ D – iaphoresis

▪ Give ( orange juice (simple sugars)

o DKA ( increased lipolysis increased ketones

o Hyperglycemia ( polyuria, polydipsia, polyphagia, kussmaul breathing, glycosuria, ketonuria and warm flush skin

o Glycosylated hemoglobin ( reflect BSL for the past 3 to 4 months ( most accurate

o Foot care

▪ Podiatrist

▪ Avoid removing corns and calluses

▪ Cut toe nails straight across

▪ Avoid walking bare foot

✓ Hepatitis A ( fecal oral

✓ Hepatitis B ( body and bloody secretions (hemodialysis)

✓ Peritoneal Dialysis

o Diasylate output is decreased ( turn patient from side to side

o Complication ( infection ( monitor WBC and temperature, diasylate is cloudy ( boardlike and rigid abdomen ( peritonitis

o Don’t include diasylate solution in the output of the client

o Expected ( decreased weight ( monitor weight before and after ( decreased createnine and BUN

✓ Heart block ( decreased tissue perfusion

✓ Parkinson’s diasease

o Decreased dopamine in the basal ganglia ( levodopa to increased dopamine ( avoid Vit B6 foods

o Cardinals signs ( tremors (non intentional) ( muscle rigidity ( bradykinesia

o Pill rolling

o Microphonia ( ask your client to speak aloud to be aware

o Artane and Cogentin ( anticholinergic ( decreased muscle rigidity

✓ Myasthenia Gravis

o Tensilon test ( confirmatory test

o Decreased Acetylcholine and increased cholinesterase

o Muscle weakness ( priority airway

o NO tranquilizer, Morphine SO4, Muscle relaxant and neomycin

o Cholinergics (mestinon) ( increased muscle strength ( antidote ATSO4

▪ Undermedication ( myasthenic crisis ( give cholinergics

▪ Over medication ( cholinergic crisis ( give ATSO4

✓ Multiple Sclerosis

o Demyelinization of the myelin sheath

o Charcoat’s triad

▪ Intentional tremors

▪ Scanning of speech

▪ Nystagmus

o Visual disturbances ( diplopia

✓ Pancreatitis ( autodigestion ( alcohol ( bleeding ( shock

o Elevated amylase

✓ Rheumatoid Arthritis

o No specific diagnostic test

o NSAID’s and ASA (antipyretic, analgesic and anti-inflammatory)

o Synovitis ( Pannus formation ( fibrous ankylosis (limited joint movement) ( Bony ankylosis (joint fixation)

o Avoid flexion and promote prone position

✓ Gouty Arthritis

o Increased uric acid ( allopurinol and avoid organ meats (liver) ( tophi (ears)

✓ Osteoarthritis

o Most common ( related with aging

o Pain after weight bearing exercise or activity ( rest to relieved pain ( weight reduction

✓ Diverticulitis ( LLQ pain and low fiber diet

✓ Cyclophosphamide (Cytoxan) ( can cause hemorrhagic cystitis ( to avoid increased fluid intake

✓ Vincristine (Oncovin) ( increased fiber in the diet

✓ Iron supplement (When is the best time to take (empty stomach), How is best taken (with orange juice)

✓ Steroids and NSAID’s

o DEATH ( inflammation

o BIRTH ( side effects

▪ B – one marrow depression ( prone to infection ( monitor temperature and WBC

▪ I – ncreased gastric irritation ( take it with food or after meals

▪ R – enal toxicity

▪ T – innitus

▪ H – epato toxic

✓ Cataract ( common cause is aging (senile) ( opacity of the lens ( position on the unaffected side

✓ Glaucoma ( increased IOP ( decreased of peripheral vision first ( halo, tunnel and gun barrel vision ( miotics (constricts pupils) ( avoid ATSO4 (dilates pupil)

✓ Retinal detachment ( trauma ( blood clots ( floating spots ( dependent position( scleral buckling

✓ Avoid Increased Intraocular pressure ( PRIORITY

o Avoid vomiting, coughing, valsalva maneuver, lifting heavy objects, bending, crying

✓ Meniere’s ( Triad ( tinnitus, impaired hearing loss and vertigo ( low Na diet

o Vertigo ( imbalance ( high risk for injury ( decreased vertigo by focusing on one side of the room ( assume a flat or reclining position

✓ ASA ( 8th cranial nerve damage ( tinnitus, impaired hearing loss and vertigo

✓ Antibiotics ( allergic reactions

✓ Normal Values

o BUN = 10 – 20 mg/dl

o Calcium = 9 to 10.5 mg/dl

o Creatinine = 5 to 1.5 mg/dl

o GTT = 70 to 115 mg/dl

o O2 sat = 97 to 98%

✓ Signs and Symptoms of Increased Intracranial Pressure

o B – lood pressure and temperature are elevated

o R – espiratory and cardiac rate are decreased

o A – lteration of LOC

o I – rritability

o N – ote for projectile vomiting

o S – eizure

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