Med/Surg Final 2

Unit 4

100

What is hypoxemia? What are some s/s of it? 

Hypoxemia is Low 02 level in blood circulation.

• rapid/slow breathing, tachycardia, sob, headache, coughing, wheezing, confusion, bluish color in skin, fingernails & lips

200

What is a  Pneumothorax?? What are some S/S of it?

Pneumothorax (PNThrx) is an accumulation of air in the pleural cavity that results in complete or partial collapse of the lung. Occurs in 50% of people with chest injuries. 2 types: Open (wound that allows air in and out freely when breathing) and Tension (Air enters the pleural space but does not escape causing pressure in the chest). 

• S/S:  Dyspnea, tachycardia, restlessness, anxiety, decreased movement of involved chest, diminished BS, and progressive cyanosis. In trauma a chest wound (sucking in) may be present. 

300

What are the events of an asthma attack? At what point is respiratory failure imminent?

The sequence is as follows: Airway inflammation that is triggered by allergens or irritants>  bronchoconstriction and edema, thickening of bronchial walls and the production of thick mucus> narrowed airways

!!! Respiratory distress is imminent when the is an Absence of Breath sounds!!

400

What is CF? What are some s/s, Tx options, and nursing care?

Cystic fibrous:  hereditary disorder, dysfunction of the exocrine glands and the production of thick, tenacious mucus

S/S: cough= 1st sign, productive thick and purulent, obstructs airway, Obstruction of pancreatic ducts: unable to provide pancreatic enzymes to GI track= Pts develop diabetes, Unable to absorb proteins, fats, and fat-soluble vitamins, Stools= bulky and foul smelling

• Men= become infertile and women= hard to become pregnant
• Lose more Na+ and Cl- in sweat – at risk for salt depletion
• Over time: ^dyspnea, decreasing exercise tolerance and weight loss
• Airway obstruction and decreased resistance to infections – leads to chronic infections, emphysema, atelectasis, and resp failure

Tx: pancreatic enzyme replacement, CPT, and aerosol and neb txs to reduce mucus viscosity

• Supplementary fat-soluble vitamins (A,D,E, and K)
• Dietary supplement of salt due to excessive sweating
• Chest PT and alternatives – flutter mucus clearance device, handheld vibrators, vest 
• ABT therapy (any route) and for long-term
• Bronchodilators, anti-inflammatory drugs, inhaled hypertonic saline, inhaled recombinant human deoxyribonuclease
• Lung transplantation and mechanical vents

Nursing care/ goals:  effective airway clearance, prevention or tx of infection, adequate nutrition, and effective self-health management by pt and fam

• Administer order meds pancreatic enzymes
• Educate on prevention of infection
• Maintain adequate nutrition, rest around meals
• Monitor stools (frothy, bulky stools indicate inadequate enzymes)
• Allow patient to have input in treatment plans

500

What is COPD? What are some S/S,  complications, Tx options, or pertinent Nursing care 

COPD: umbrella term for chronic bronchitis, emphysema, irreversible refractory asthma. increased production of mucus and chronic cough that persist for at least 3 months of the year for 2 straight years. Mucous obstructs airways & is trapped. 

Emphysema: degenerative,  nonreversible disease, enlargement of the airways beyond the terminal bronchioles. 2 types. may have one or both types

• Centriacinar: associated primarily with cigarette smoking and affects mainly the resp bronchioles
  • The bronchial walls enlarge and breakdown, but alveoli remain intact
  • Functional resp unit is unable to exchange O2 
  • Lungs hyperinflate→ leading to right sided heart failure
• Panacinar: associated with hereditary deficiency of the enzyme inhibitor alpha1-antitrypsin
• Bronchioles and alveoli are affected: effects gas exchange 

Complications: respiratory failure and heart failure, Infection, air pollution, continued smoking, left ventricular failure, MI, PE

S/S: chronic  bronchitis: color dusky to cyanotic, recurrent cough, hypoxia, acidosis, edematous, external dyspnea, hypercapnia (↑ RR), heavy cigarette smokers, digital clubbing. 

Pulmonary emphysema: ↑ CO2 retention, pursed lip breathing, dyspnea, skinnier, barrel chest, ineffective cough, orthopneic, external dyspnea, speaks in short sentences, anxious, use accessory muscles, leads to right sides HF, can only situp. 

Med dx: H&P, reports of clinical manifestations, physical exam, PE, PFT (most reliable), MRI, CT, ABGs, spirometry w/bronchodilator, 6 min walk test w/ pulse ox. 

Med tx: GOAL= maintain symptom relief, slow disease progress, improve exercise tolerance, prevent /tx complications, START: stop smoking, drug & O2 therapy, pulmonary rehab & surgery.  

• Medication therapy: Avoid smoking,  have vaccines (flu and PNE)
  • TO QUIT SMOKING: switch arms to ↓irritation, may cause vivid dreams, 
  • Bronchodilators:  decrease airway resistance and work on breathing
  • Mild COPD: short acting inhalers 
  • Short-acting beta-adrenergic agonist:  Xopenex, Preventil, Ventolin
  • Short-acting inhaled anticholinergic: Sprivia, Atrovent
  • Moderate COPD: long-acting bronchodilators:  Advair, Symbicort (inhalers wipe with ETOH swab & rinse mouth out) 
  • Oral theophylline= weak bronchodilator, but effective when used with inhaler
  • Not used often: 1 – need blood work monitoring (level: 5-15) and 2 – potential for drug toxicity (seizures and fatal cardiac dysrhythmias)
  • Inhaled corticosteroids (Pulmincort, Entocort {cause thrush, rinse mouth post use} ) used with exacerbations, quick to reduce inflammation 
  • Long term steroid use is not recommended  s/e:  electrolyte imbalance, suppression of adrenal cortex, ↑risk for infection
• O2 therapy goal= PaCO @ 50-60mmHG, SPO@ above 90%, long term O2 therapy: O2 15 hrs per day
• Pulmonary rehab: benefits fade quickly. 
• Nutrition: malnutrition is highly r/t condition. ↑ calorie diets ↑ fat foods, freq meals, resting before meals. Look for wt gain for success. 

Tx for respiratory failure: Hospitalized at least yearly for exacerbations

s/s:changes in dyspnea, cough, sputum; r/t: smoking, infection, air irritants, heart failure, not taking meds

Tx: noninvasive positive pressure ventilation (NPPV), chest PT, aerosol bronchodilators, O2 therapy

Surgical: Bullectomy, Lung transplant

LVRS: lung volume reduction surgery, removal of 30% of the hyperinflated lung tissue so that remaining lung tissue can function better

Nursing care: obtain med hx, physical exam, eval meds, note posture/ skin color/ resp effort/ accessory muscles, assess ADLs, VS, pure lip breathing, chet shape, nail beds. 

Interventions: VS, ABGs, tachycardia, tachypnea, ↑CO2, ↓pH, increase meds, edu on smoking, no more than 2-3 L/ min O2, pursed lip breathing, admin bronchodilators.

Unit 6

100

What is stable vs unstable Angina?

• Stable: (exertional angina). Pain= burning, viselike, squeezing, radiates down the left arm, shoulder or jaw. Pt may ℅ N/V, diaphysis, dyspnea. Occurs w. Exercise and subsides w/ rest. (can use NITRO). Caused by: smoking, emotional stress, heavy meals 
• Unstable: ACS (acute coronary syndrome)- crescendo angina/ preinfarction angina. Unpredictable & more severe. Not relieved by NITRO or rest. Could be first sign of CHD. Admitted w/ workup. Tx aggressively. r/t NSTEMI, meds: nitrates, beta-blockers, anticoag therapy, Lovenox (antiplatelet)

200

What is Aortic Stenosis?  Notes some causes, S/S, complications from it, TX options, and relevant nursing care? 

Aortic Stenosis: When the valve cusps of Aorta becomes fibrotic and calcify.

•  Causes: Congenital malformation (in younger PTs) or from rheumatic fever, syphilis, or the aging process. 
• S/S: dyspnea on exertion, angina, and syncope.
• Late Sx:Fatigue, orthopnea, paroxysmal nocturnal dyspnea. Systolic murmur may be present. 
• Complications: If continued the LV will hypertrophy and compensate until AFIB disrupts the atrial kick  or until the LV hypertrophies  to the point of dysfunction with decreased cardiac output and MI.  Eventually the right side of heart fails. 
• Dx: CXRAY, Auscultation of aortic area, Echocardiogram, ETT
• TX: Digoxin, diuretics, low sodium diet, and activity restriction. Sure Tx: Baloon valvuplasty and aortic valve replacement. 
•  Nursing Care: Monitor bounding arterial pulse and widened pulse pressure. Treatment very similar to that of HF.

300

What are the primary Tx for essential and secondary HTN?

Primary HTN: 90-95% of all; Unknown cause but has many contributing factors: high sodium intake, DM, High BMI, and excessive ETOH.

S/S: Many people have no Sx. Occipital HA, light headedness, and epistaxis. Can also impair blood vessels in heart, kidney Dz, and blindness. 

Tx: Goal: To gradually reduce PVR and BP (>140/90 mmhg)

• Lifestyle modification (non pharmacologic) 1st method.
• Drug Therapy initiated if BP is still >160/100 after conservative therapy is tried after 3-6 months. Many people require more than one medication to achieve therapeutic goals. 
  • Meds: thiazide diuretics, ACE inhibitors, Angiotensin II receptor blockers, calcium channel blockers. Others include alpha1-adrenergic blockers, beta-blockers, central2 agonists and other centrally acting drugs and direct vasodilators. Refer to meds on pgs 683-684. 
  • Secondary HTN: R/t kidney disease, certain arterial conditions, some drugs, and occasionally pregnancy. Also narrowing of the aorta, ^ICP and vasoconstrictors.

400

Describe how a drop of blood travels through body?  Start from the right atrium. 

Deoxygenated blood flows from the right atrium, through the tricuspid valve, to the right ventricle. From the right ventricle the blood flows through the pulmonary valve, to the pulmonary artery, leading to the lungs where the blood picks up oxygen. Oxygenated blood flows back to the heart from the lungs through the pulmonary veins, dumping into the left atrium. From the left atrium, blood travels through the mitral valve (bicuspid), to the left ventricle. From the left ventricle, blood flows through the aortic valve, through the aorta, carrying oxygenated blood to the rest of the body.Arteries>areterioles> Capillaries>Venioles> Veins> Deoxygenated blood comes back from the cells to the superior and inferior vena cava, dumping the blood back into the right atrium.

500

Describe what EKG will show with these changes:

1. Rate slower than 60 BPM, all other characteristics WNL?

2. Rate Greater that 100 BPM, all other characteristics WNL, PT feels palpitations?

3. No Rate, no characteristics, QRS/T wave not present

4. Rate between 100-250 BPM,  Regular  P wave/PR interval are absent,  QRS is wide, appears bizarre, may appear like PVCs but T Wave opposite deflection to QRS. 

5. Atrial Rate greater than 400 if it can be determined, Ventricular rate 100-150, can appear  regular or irregular,  No P waves or PR, QRS  normal, T wave undeterminable. Baseline between QRS complex is wavy 

6. Rate usually normal; irregular due to PVCS, No P wave with PVC, QRS wide and bizarre,  T wave opposite deflection to the PVC

1. Sinus Bradaycardic

2. Sinus Tachycardia

3. Asystole 

4. Ventricular Tachycardia

5. Atrial fibrillation 

6. Premature Ventricular Contractions PVCs

Unit 7

100

What are some priority outcomes for pancreatitis?

• Pancreatitis:inflammation of the pancreas
• PAIN RELIEF (TO REDUCE OR RELIEVE PT’S PAIN) 
  • Normal fluid balance: monitor I&Os and vitals 
  • Absence from infection (maintain NRL temp or decreased WBCs
  • Adequate Oxygenation: keep RR at 12-20 bpm and 02 sats higher than 90%
  • Adequate nutrition
  • Reduced anxiety
  • Enhanced knowledge of illness

200

What nursing assessment  points are priority post abdominal aneurysm?

• Monitor for impaired urinary elimination. Watch I&Os, daily weights, BUN, creatinine, and electrolyte levels, and edema.
• Monitor abdomen for BS. If NG tube is in place it can cause irritation to  incision. Ensure suctioning is appropriate, watch for distension. 
• Make sure the PT has appropriate oxygenation. Encourage use of IS, use breathing exercises for pain control, and TC&DB. Monitor lung sounds frequently. 
• Monitor cardiac output: Watch VS and hemodynamics. Inspect for bleeding/hemorrhage, early signs of CV failure, ALERT physician if evidence is decreased! 
• Monitor for decreased peripheral perfusion: Including extremity color and warmth, id abnormal extremity could be cool, cyanotic/pallor color,  and/or pain.

300

What are some interventions for Liver cirrhosis PT?

• Good nutrition is essential for regeneration of liver tissue. encourage the patient to eat even if the patient isn't hungry. arrange a dietary consult and report likes and dislikes. make mealtimes as pleasant as possible. 
• schedule nursing care to encourage undisturbed rest.  assist the patient in change of position, TCDB, exercise extremities regularly (pt may be on bed rest) 
• patients are at risk of decreased skin integrity. relieve pruritus w. gentle bathing with mild soap & tepid water, thorough rinsing and moisturizing. keep pts nails short, you can use soft cotton mittens if pt still resumes scratching, if itching is severe medication may be ordered 
• elevate the HOB to promote breathing, sitting in a chair with feet elevated if allowed.
• handle pt gently r/t r/o hemorrhage, use a soft toothbrush/ swab for mouth care, apply firm pressure to injection sites to minimize oozing, pad side rails, may need an esophageal balloon to tx esophageal varices. 

400

What is hepatic encephalopathy and what are some S/S and Tx?

• When the liver fails and is unable to detoxify ammonia, which in excess will cause neurologic SX including cognitive disturbances, declining LOC, and change in neuromuscular function. If not reversed  PT will become unconscious (hepatic coma)! 
• S/S include hand tremor, personality changes, hyperventilation, and lethargy progressing to coma. 
  • Factors Precipitating: constipation, GI bleeding, hypokalemia, infection, opioids, dehydration, and renal failure. 
  • Tx with Lactulose  which promotes elimination of ammonia from the colon and discourages bacterial growth, making more acidic. Or Albumin dialysis, laxatives, and enema may be ordered to remove old blood and protein. 
  • If PTs have recurring encephalopathy  they may need a liver transplant. 
  • Restrict lean meats to avoid  additional ammonia.

500

What is the difference between a PEG tube and TPN? What specific procedures should you follow when administering? What are some S/S of complications with them?

The key difference between TPN and tube feeding is that total parenteral nutrition or TPN refers to the supply of all daily nutrition directly into the bloodstream, while tube feeding refers to the supply of nutrition through a tube that goes directly to the stomach or small intestine.

PEG Tube: 

• elevate the head of the bed to at least 30 degrees during the feeding and 30 mins after
• check for residual if more than 100 call the doctor and follow instructions , but not put it back 
• check ph to make sure the tube is in the stomach (pH of less than 5)
• stomach contents are grass green, clear and colorless or brown
• check residual (make sure it's properly digested)
• be sure to give the correct feeding 
• we are allowed to slow the feeding down but not speed up without a doctors order 
• initially started at a rate of 10-20ml/hr and increased by 10-20ml every 8-12h 
• change the administration set tubing bag every 24 hours
• bolus feedings given 2.5-5 ml/kg delivered over 20-30 mins
• For feedings FSBS checked Q6
• Dietician creates formula for PEG TUBE
• when taking out stomach contents make sure to put it back

Complications: diarrhea, nausea ← stop the tube feeding if this occurs, abdominal distention, hyper/hypoglycemia, constipation, dehydration, skin issues around the tube, peritonitis, obstruction or displacement of tubing, fluid imbalance

• dumping syndrome: cold sweat, diaphoresis, abd distention, dizziness, weakness, rapid pulse rate and diarrhea ← just look for sweating

TPN:Intravenous feedings can only provide: water, glucose, electrolytes, minerals & vitamins. Do not give any meds through. Why not peripheral: The superior vena cava rapidly diluted the hypotonic solution by the large, fast flowing volume of the blood it pumps. Meanwhile, never given through smaller veins because it would cause thrombophlebitis (inflammation of the vein) & not enough volume to dilute the solution. (PG 246) 

Complications: s/s of blood glucose changes: diaphoresis, lethargy; hyperglycemia (s/s sweet taste in mouth, confusion, polyuria) causes the pancreas to secrete more insulin may then cause hypoglycemia. 

infection at the site: redness, swelling, foul odor or purulent drainage, fever

circulatory overload: blood glucose or excessive diuresis

pulmonary complication, injury to the veins & arteries surrounding the TPN cath site, air embolism, infection, electrolyte imbalance, mineral deficiency.

never use a TPN line to administer drugs

DO NOT SPEED UP THE RATE TO CATCH UP IF YOU FALL BEHIND

?????

100

What can you educate on how to prevent immobility in PT?

• rotational bed therapy: promotes pulmonary hygiene, peristalsis, & urinary bladder emptying. 
• careful positioning: maintains joining function, muscle tone, & range of motion. 
• active and passive exercises 
• continuous passive range of motion machines: prevent contractures.

200

Why would insulin be given during a stroke?

Due to PT's developing hyperglycemia in the acute phase of stroke may represent the body's stress in response to stroke; even w/o DM.

• needed for glucose over 200mg/dl. for the first few days blood glucose will be tested 1-2 hours for pts receiving thrombolytic therapy and every 6 hours for others.

300

What are some complications of rapid infusions w/ a subclavian line?

Speed shock, damage to the veins/arteries, cardiac arrest, headache, tightness in chest, syncope

400

What are some nursing actions for IV vesicant use??

Drugs that are especially toxic to subq tissues are called vesicants. Common drugs are  vasopressors, potassium chloride, antineoplastic agents, and any solution that has a PH <5  or >9 i.e. D10W, calcium gluconate, Dobutrex, and amphotericin B (fungizone)

S/S: similar to that  of infiltration, area may be pale and puffy, can feel hard and cool. 

• Stop the infusion  ( DO NOT REMOVE LINE UNTIL PHYSICIAN GIVES ORDERS) restart in a different vein. 
  • Elevate the affected arm to promote reabsorption of excess fluid.
  • Notify physician.
  • Be sure to use a large soft vein and the smallest appropriate cannula, ensure placement is correct before administering vesicant drugs. 
    • Then flush after it is given

500

You have a multitude of PTs and various ABG results, Decipher which? Double points for compensation?

PT 1: PH:7.60, PaCO2: 40, HCO3: 33

PT 2: PH:7.27, PaCO2: 50, HCO3: 26

PT 3: PH:7.35, PaC02: 27, HCO3: 18

PT 4: PH:7.58, PaCO2: 32, HCO3: 15

PT 1: Metabolic Alkalosis, no compensation

PT 2: Respiratory Acidosis, no compensation

PT 3: Metabolic Acidosis with Compensation

PT 4: Respiratory Alkalosis with compensation

??????

100

What are some TX options for homonymous hemianopsia in acute setting?

• acute care: put things on the side where they can see so you do not stress them out. manage chronic conditions
• rehab care: maximize functional abilities and to teach new wars to compensate for losses. stabilization of vital signs with no further neurological deficit indicated the rehab phase.

200

Explain the difference between arterial (PAD) vs circulatory(Venous) issue r/t toes??

• PAD- ulcers on tips of toes feet, lateral medialis around ankle. perfectly round nice clean even borders, decreased or absence of peripheral pulses. multi wrapped compression system, loss of hair nice shiny skin, cool 
• PVD- mainly around ankles and lower legs, wounds are crazy looking not symmetrical, more bleeding, no pulse and edema, warm,

300

Why are COPD patient at risk for nutritional deficits?

• Due to decreased energy, poor resistance to infection and Obesity. No special diet indicated but High calorie / high fat foods may be recommended if not obese, small frequent meals, and resting before meals.

400

What are possible Nursing Dx for CVA? Note 3 interventions with rationale

• inadequate oxygenation: elevate the head of bed 25-30 degrees to improve oxygenation, good hydration to thin respiratory secretions for easier expectoration  of secretions that may be blocking the airway, suctioning and frequent position changes can help to prevent aspiration and promote removal of secretions.  

• Potential injury r/t seizure activity, confusion, motor & sensory impairment, increased ICP, hemorrhage after recombinant tissue plasminogen activator administration.

  • it is important to raise the head and side rails & pad them according to agency protocol to reduce trauma if the patient strikes the rails 

  • safety precautions are essential for confused pts. orient pt surroundings and explain why they should not get up unassisted 

  • a bed check system may be of more benefit when the patient is having difficulty understanding directions. 

  • get sufficient help or use mechanical devices to assist the patient in and out of the bed. 

  • The cornea is susceptible to injury when not protected & in healthy patients, kept moist by the closed eyelid & the blink reflex. artificial tears may be used to provide moisture. 

  • no not place objects where the patient cannot see or feel & check those areas frequently. 

  • monitor for s/s of ICP: change in LOC, elevated BP, deterioration of motor function, new HA, n/v. 

  • medical interventions: diuretic & barbiturate drugs, hyperventilation, surgical intervention. 

• potential for fluid imbalance r/t inadequate inadequate intake or excessive diuresis

• strict I/O records, VS, and assess mouth moisture.

  • monitor labs: specific gravity, electrolytes & hematocrit. 

  • look for s/s of fluid volume excess (s/s later in the guide) report to the RN and explain to the pt and family why the pt may need to be on the fluid restriction. 

  • monitor for signs of fluid volume deficit (s/s later in the guide) 

  • place fluids within sight of the pt on the non-paralyzed side. may need to use spill proof containers, feed slowly if pt has dysphasia. 

  • have suction equipment setup, use thickening agents if necessary. 

• inadequate nutrition r/t dysphasia, inability to feed self, inability to chew. 

• NG tube, TPN may be ordered. aggressive tx is delayed until rehab. 

  • pt may need assistance feeding. 

  • if pt had a NG or peg you must check placement, be certain formula & rate is correct. keep the head slightly elevated to prevent aspiration. gently cleanse the nairs several times a day. if diarrhea occurs, notify PCP and formula may need to be changed. 

  • pt may develop hyperglycemia so make sure s/s are monitored. 

• elevated body temp r/t effects of neurologic impairment and/or metabolic process.

  • monitor temp and tx elevations properly with antiemetic drugs. always assess for underlying infection. 

• potential for impaired cognition r/t inadequate cerebral circulation 

• orient pts: introduce yourself as often as necessary, remind pts where they are & tell them what is being done and why. 

  • be sure that eyeglasses and hearing aids work and are worn if the pt normally wears them. 

  • place clocks and marked calendars in view. 

  • instructions and information should be concise & repeated as needed. 

  • a familiar person can be helpful with a confused pt. if the visitor is startled, provide guidance to the visitor on how to deal with the behavior. 

• inability to communicate effectively r/t aphasia

• use brief clear statements accompanied by gestures, pictures, and facial expressions. 

  • use questions that can be answered with “yes” or “no” may allow the pt to respond more easily. pause attentive and allow the pt to respond. 

  • speech therapy may be initiated once the medical condition is stable. 

• there are about 15 ND and NI on page 411-416

500

What are some important PT teaching topics for HCTZ, Albuterol, Cardizem,  and Lasix?

•  Albuterol (Proventil) Bronchodilator: Do not exceed Rxed dose. Reinforce to PT rinsing mouth out after using inhaler. Avoid excessive caffeine. Monitor PT’s resp/CV status. Pg 455
• Teach how to properly use inhaler. Note they should prime before use and wash 1x/week and air dry. Encourage PT to report sx of allergic reaction 
• Diltiazem (Cardizem) Vasodilator: Monitor PTs BP and HR. Check for edema. Instruct PT to limit caffeine, avoid ETOH/smoking, and swallow ER tablet (DO not chew). Teach how to manage postural hypotension. Teach them how to take radial HR. Note to take drug with or after meals. Not to discontinue abruptly. Avoid OTC cold meds.  Pg 621,627
• Furosemide (Lasix) Diuretic:  Monitor glucose in DM PTs. Encourage K+ rich foods. Educate on how to prevent orthostatic Hypotension by changing positions slowly. Avoid prolonged sitting. pg 807
• HCTZ-HydroDuril (Microzide) Diuretic: Monitor for hyperglycemia in DM PTs. Monitor PT’s taking digoxin for low potassium levels. Encourage K+rich foods. Pg 807 
• Take in AM to avoid nocturia (nighttime urination). Note they should weigh selves at same time each day. Encourage pt to report decreased urination, muscle cramps, weakness, and unusual bleeding/bruising. from med book