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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