185 - Med Surg Exam 1 Flashcards by Alayna Johnson

what are 4 types of oxygen devices?

Nasal cannula (1-6L)

Non-rebreather (10-15L, 100%O2)

Simple face mask (1-8L)

Venturi mask (1-10L)

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AKA “oropharyngeal airway”

Inserted by tilting head back, opening mouth, and inserting airway
* Tip pointed toward the roof of mouth

Oral airway

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Surgically created opening through the neck into the trachea

Causes:
- Resp. Failure
- Cancer (throat, thyroid, ect)
- Trauma (face, neck)
- Surgery

Tracheostomy tube

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AKA “nasopharyngeal airway”

Soft rubber tube inserted through the nose and extended to the base of the tounge

Nasal Airway

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Long tube inserted though the mouth or nose into the trachea
- Requires specialized training

Tubes are cuffed & have inflatable balloons that seal the trach preventing aspiration & facilitate mechanical ventilations

Endotracheal tubes

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What are the 9 steps for suctioning traches?

Sterile tech. & Face shield
Lube on tubing
Oxygenate patient before suction
Open vent during cath. insertion
Suction intermittently while rotating and moving cath back and forth while withdrawling
Suction no longer than 10-15 seconds
Rinse cath suctioning w/ NS
Oxygenate patient after suction
Document status before & after

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What are the 10 steps for proper trach care?

Standard precaution
suction before removing old dressings
Don sterile gloves
Use sterile solution (NS) to clean the inner cannula
Rinse and dry inner cannula. Reinsert into outer cannula
Cleans stoma and surrounding skin
Dont get solution into stoma
Change tracheostemy ties
Replace trach dressing w/ precut pad/ gauze
Tie the ties at sides

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What are 4 nursing responsibilities for a patient who has a trach?

Keep airway clean
Keep inner cannula clean
Prevent impairment of surroundings
Provide patient a means for communication

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What are nursing interventions for a patient who has a trach?

Evaluate - Look for secretions & suction

Provide - Constant airway humidification/ oxygenation

Change/clean - All equipment q8h or PRN

Remove - Water condensed in equipment tubing

Provide - Mouth care (moisturize lips), communication board/ tablet, & safety

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Device intended to mechanically control/ assist patients breathing by delivering predetermined % of O2 in breathing gas

Cause:
- Acute resp. failure who are unable to maintain adequate gas exchange in lungs

Ventilator

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Delivers constant preset amount of oxygenated air into a patient
- Most common/used

Gives breath for certain amount of time

Volume cycled

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Pushes air into lungs until a preset pressure is reached

Not widely used for continous mechanical vent

Delivers certain amount of pressure then cycles

Pressure cycled

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Delivers oxygenated air during a preset length of time
- mostly used w/ infants & children

Gives breath for certain amount of time

Timed cycled

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What are the 10 care essentials for patients on a vent?

Review communication board
Check vent settings (resp rate, tidal volume, peak (PIP))
Suction appropriately
Assess pain & sedation needs
Prevent infection
Prevent hemodynamic instability
Manage airway
Meet nutritional needs
Wean off vent
Education

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What 6 interventions would you provide for a patient on a vent?

Monitor settings to ensure they match
Ensure high & low pressure alarms are set
Have manual resuscitator & O2 avalible
Don’t allow water to accumulate in tubing
Monitor vitals & breath sounds, suction PRN
Establish communication methods

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Inserted from pleural space of lungs

Permits re-expansion of a collapsed lung in patients w/ hemo/pneumothorax, or plural effusion

Inserted at bedside or OR
- Places at 8th/9th intercostal space

Equipment:
- Collection chamber
- Water seal chamber
- Suction control chamber

Chest tube

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Lung infection that occurs when a person is on a vent for a long period
- Bacteria enters through the tube entering the patients lungs
- Major complication

Incidences in US range from 2-16 episodes/1,000 vent days

Tx: IV antibiodics

Ventilater-Associated-Pneumonia
(VAP)

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What are nursing interventions for a patient Dx with Ventilater-Associated-Pneumonia
(VAP)?

Keep HOB 30-45 degrees

Oral care to decrease bacterial growth

If intubated, provide sedation “vacations” & evaluate extubation readiness
- Reflected by vitals & ABGs

Peptic ulcer disease (PUD) prophylaxis
- Pepcid, protonix

DVT prophylaxis
- Lovenox, heparin

IV antibiodics

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Bronchodilator
- Relaxes & dilates bronchial smooth muscles

Use: Asthma, emphasema, chronic bronchitis, ect (think lungs)
- Increases renal blood flow & anti-inflammatory

Side effects:
- Increase HR & BP

Interventions:
- vitals & safety
- Lung assessment

Theophylline

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Benzodiazepine, anti-anxiety, muslce relaxant, anti-convulsant
- Short acting

Use: Sedative (given in pre-op)
- Amnesia effect, produces sleep

Side effects:
- Drowsiness
- Confusion
- Hypotension
- Hepatotoxicity
- Low HR

Interventions: Vitals

Antidote: Flumazenil (Romazicon)

Midazolam

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Dissolves chemical bonds w/in mucus making it separate/ liquiefying/ reducing viscosity
- Given as nebulizer

Use: Pneumonia, emphysema, asthma, & bronchitis

Side effects:
- N/V
- Tachycardia
- Hypotension
- Rotten egg oder
- Bronchospams (adverse)

Interventions:
- Vitals
- monitor cough & bronchial secretions
- Record GI symptoms before/after therapy

Antidote for Tylenol OD - Given PO

Mucomyst (Acetyl Cysteine)

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Inhibits interaction of acetylcholine at recepter site on bronchial smooth muscle, resulting in bronchodilation

Use: Asthma, long term Tx or reversible bronchospasms associated w/ COPD

Adverse:
- Mouth dryness
- Throat irritation
- Dizziness
- Nasal congestion

Serious effects:
- Tachycardia
- Urinary retention
- Exacerbation of symptoms

Interventions:
- Vitals
- monitor cough & bronchial secretions
- Record GI symptoms before/after therapy

Ipratropium (Atrovent)

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Combination of anticholinergic bronchodilator & selective beta 2-adrenegic bronchodilators

Use: Treat/ prevent symptoms (wheezing/SOB) caused by ongoing lung disease (COPD, bronchitis, emphysema)

Side effect:
- headache
- Shaking, tremors
- Nervousness
- Dry mouth, stuffy nose

Interventions:
- Vitals
- monitor cough & bronchial secretions
- Record GI symptoms before/after therapy

Bromide/ Albuterol sulfate
(Duo-Neb)

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Corticosteroid - PO
- Decreases inflammation
- Caution w/ Diabetes (increases BS)

Use: severe inflammation, MS, asthma, COPD, pulmonary fibrosis

Side effects:
- Weight gain
- Depression, mood changes
- Poor wound healing
- Decreased immunity

Patient teaching:
- DO NOT STOP ABRUPTLY
- Taper off as Dr. directed

Prednisone

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**Deficiency of Pituitary hormone** (TSH - Secondary hypothyroidism) Deficiency of TSH decreases secretion of thyroid hormones S/s: * **Decreased metabolic rate** * Lethargy, forgetfullness, irritability * Headache, constipation * **Decreased HR, dyspnea** * **Swelling/edema, dry/thick skin** * Coarse hair Tx: * Hormone replacement therapy - most commonly Levothyroxine (Synthroid)

Hypothyroid

**Abnormal increased synthesis & secretions on the thyroid gland w/ overproduction of the thyroid hormone T3/T4** resulting inexaggeration of the metabolic processes - *Geaves disease & Multinodular goiter most common* S/s: * Weight loss, hair loss, insomnia * Intolerance of heat, **personality changes** * **Tachycardia, increased systolic BP/ HTN** * **Afib, increased metabolic rate** * **Edema to neck**, termors, **exophthalamos (eye buldging)** Tx: * **Radiation**: destroys thyroid tissue, decreases homrone production * **Surgery**: *Thyroidectomy* * **Drug therapy**: *Tapazole, PTU, Beta blockers, Iodides, Antithyroids, ect*

Hyperthyroid (Graves disease or Thyrotoxicosis)

What labs determine the diagnosis of hypothyroid?

Determination of free T4 & TSH * Free T4 is low w/ hypothyroidism

Large amounts of thyroid hormone enter the bloodstream during surgery or when patients w/ severe hyperthyroidism develop a severe illness of infection Approx. 12hrs after surgery is when s/s will occur S/s: - Tachycardia, cardiac dysrhythmias - Vomiting, fever, confusion

Thyroid Storm

What electrolyte deficiency may occur with a thyroidectomy?

Hypocalcemia Hypomagnesemia

low level of calcium in the blood (below 8) * *Results from diarrhea, inadequate dietary intake of vit. D, multiple blood transfusions, ect.* **hypoalbuminemia is the most common** S/s: * **Trousseau's sign** * **Chvostek's sign** * diarrhea * tingling of fingertips and mouth, severe muscle cramps * **laryngospasms** (most severe) * *Cardiac dysrhythmias, seizures* **treat with oral or IV supplements**

hypocalcemia

**Synthetic hormone - IV,IM, PO** **Use**: Hypothyroidism, Myxedema coma, Thyroid replacement **Side effects**: * Anxiety, tachycardia * Angina, HTN,palpitations, tachycardia * N/V/H, cramps * **Thyroid storm (Adverse)** * **Cardiac arrest (Adverse)** **Nursing considerations**: * Assess BP & pulses periodically * Daily weight (same time, clothes, ect) * Monitor cardiac status * Monitor vitals & labs **T3/T4** **BBW**: Obesity Tx - *Not taken to decrease weight* **Education**: * Don't switch brands unless approved * *Take in AM on **empty stomach** 30 min before food* * Monitor anticoagulent level & adjust dose PRN

Levothyroxine (synthroid, eltroxin, Levo-T)

**Use**: Makes thyroid hormones, bone & brain development in pregnancy **Route**: PO, IV **Side effects**: * Burning mouth, throat, and stomach * N/V/D/fever * **Weak pulse (adverse)** * **Coma (adverse)** * **Thyroid gland inflammaiton/cancer (adverse)** **Nursing considerations**: * Monitor HR * Monitor for hypersensitivity and GI bleed **BBW**: Hepatic disease, No breastfeeding **Education**: * Take prenatals or Iodine supplements if preg * Report abnormal bleeding

Iodine

**Use**: Prep for thyroidectomy, thyrotoxic crisis, hyperthyroidism, & thyroid storm **Route**: PO **Side effects**: * N/V/D/H * Vertigo * Rash, alopecia * Jaundice * Liver failure * Death **Nursing consideration**: * Assess for weight loss, fever, constipation, & weakness * Monitor T4 (increases) **BBW**: Hepatic disease, No breastfeeding **Education**: * Report redness, swelling, sore throat, mouth lesions, yellow skin/eyes, and dark stool/urine

Propylthiouracil (PTU)

*Inhibits the synthesis of the thyroid hormones* **Used after course of PTU** Used w/ a Lugol solution & SSKI (**5% iodine & 10% SSKI**) *Some relief w/in 24hrs* **Can cause discoloration to teeth & gastric upset**

Iodides

**Beta-blocker** **Affects heart & circulation** (blood flow through arteries & veins) **Use**: * Tremors * Angina, HTN, heart rhythm disorders * Other heart/circulatory conditions Side effects: * **Low HR & BP** * Lightheadedness * Wheezing * Liver problems Nursing innterventions: * **Always take BP & HR before giving med**

Propranolol (Inderal)

**Excessive cortisol** Hypersecretion of the adrenal cortex resulting in production of excess amounts of corticosteroids Causes: * **Endogenous** - Pituitary tumor/ Adrenal tumor * **Exogenous** - Prolonged admin. of high dose corticosteroids **S/s**: * Moon face, Buffalo hump * Trucal obestiy, purple straie on abd., breast, or butt * Hypokalemia, hyperglycemia, poor wound healing * HTN Tx/ interventions: * Drug therapy: Mitotane, Metyrapone * Radiation: Internally/Externally, destroys tissue * Surgery: **Transsphenodial hypophysectomy (*pituitary gland*), Adrenalectomy (*adrenal tumor*)** * Vitals & labs * Skin assessment * Educate on wearing a medical band * Monitor for SI * **Caution on long term use of some herbs (celery, juniper, licorice, & parsley - Causes hypokalemia)**

Cushings syndrome

What labs/tests can you use to Dx Cushings syndrome?

Labs: * Plasma cortisol levels (High) * ACTH (high) Tests: * Xray * CT, MRI * Angiography

What patient education would be provided for a Pt Dx w/ Cushings syndrome?

Do not blow nose (after surgery) Monitor bleeding Wound care (**packing**) S/s of infection (*Smell breath & packing if drainage*)

What surgical intervention willl occur if their is a pituitary tumor causing Cushings disease?

Transsphenoidal microsurgery

Removal of adrenal glans **Post-op care**: * Admit to ICU * Monitor vitals for s/s of shock * monitor kidneys & strick I/Os * Give vasopressor to decrease BP & HR

Adrenalectomy

**Destructive disease process affecting adrenal glands that cause deficiencies of cortisol & aldosterone** * Most common cause is **auto immune (adrenal tissue destroed by antibodies formed by immune system)** Secondary adrenal insufficiency is the result of the hypothalamus or pituitary which caused decreased androgen & cortisol production * Include oituitary tumors, radiation therapy, ect **S/s**: * *Orthostatic hypotension* * **Skin hyperpigmentation** * **Hypoglycemia, hyponatermia, hyperkalemia** * Severe headaches, abd. pain, joint pain * **Wight loss**, weakness/fatigue * *Salt cravings* **Interventions/Tx**: * Restore fluids/ electrolytes * **Low K diet, high Na diet** * Replace adrenal hormone (**Hydrocortisol**) * *Assess for addisons crisis* * **Carry medical kit & 100mg od IM hydrocortisone/dexamethasone** * Take meds as ordered * Educate on **life long** therapy & monitoring

Addisons Disease (Adrenal Hypofunction of pituitary)

**Life threatening emergency caused by insuffieicient adrenocortical hormones** / sudden sharp drop in hormones **S/s**: * hypotension * Tachycardia * Dehydration (N/V) * High temp * Cyanosis * Progresses to vasomotor collapse/ possible death **Interventions/Tx**: * IV fluids (Isotonic/ Hypertonic/ **D5LR**) * *Hydrocortisone* * Electrolyes * **Dextrose** to restore normal BP

Addisons crisis

What electrolyte imbalances occur w/ Addisons disease?

Hypercalemia Hyperkalemia Hyponatremia Hypoglycemia *Tip: Hyper before Hypo*

What electrolyte imbalances occur w/ Cushings disease?

Hypocalemia Hypokalemia Hypernatremia Hyperglycemia *Tip: Hypo before Hyper*

**Steroid - PO/IV/IM** Use: * Severe inflammation, UC * Adrenal Insufficiency, COPD Side effects: * Depression, mood changes * Flushing, Increased appetite * HF, HTN Interventions: * Vitals & labs (CBC,BMP) * Monitor for depression

Hydrocortisone

**Steroid - PO** Use: * Adrenal insufficiency * **Addisons Disease** Side effects: * Flushing, *sweating* * **Seizures, HTN** * **Tachycardia**, *hyperglycemia* Interventions: * **Daily weight** * Vitals & labs (**CBC, BMP**)

Florinef (Flurocortisone)

Interferes w/ cortisone production **Cytotoxic substance** that is used as a palliative treatment for inoperable **Use**: Cushings diease

Mitotane (Lysodren)

Used in combination w/ mitotane for enchanced effects Use: Cushings disease

Metyrapone (Metopirone)

What are the 2 types of hypothyroid?

**Cretinism**: * Congenital hypothyroidism * 1/4000 births **Myxedema**: * Denotes severe hypothyroidism in adultes * Includes: Edema, to hands/face/feet/eye area (periorbital)

What are some interventions/ education for a Pt who is post-op from a thyroidectomy?

*Voice may be hoarse for 48hrs* *Turn neck slowly*, **Semi- fowlers position to enhance RR & decrease edema** Monitor incision site, labs, & vitals Assess for **hypocalcemia**: * *Chvostek/trousseau* * **Laryngospasm (most critical)** * Tetany, numbness/tingling in fingers/toes **Assess for hemorrhage, resp. distress, & thyroid storm** Lifelong thyroid replacement Assess resp. status

**Inhibits synthesis of thyroid storm by decreasing iodine use** in manufacture of thyroglobulin & iodothyronine Use: **Hyperthyroidism** Side effects: * Drowsiness * N/D/H * Enlarged thyroid * **Jaundice (adverse)** * **Hepatitis, nephritis (adverse)** * **Bone marrow supression (adverse)** * **Thrombocytopenia (adverse)** Interventions/education: * Assess for S/s of hypothyroism * **Monitor vitals & labs (liver function, T3/T4, TSH)** * **Daily weight**/ monitor weight * **Do not breast feed** * *Take as prescribed, DO NOT double dose*

Methimazole (Tapazole)

Done before each radial artery puncture to ensure adequate collateral circulation * *Does not happen if other blood supply is not accurate* How to perform: * Occlude radial & unlar arteries & have pt make a fist * Maintain pressure on arteries and have pt open hand * Release pressure on ulnar side * **Hand is pale is occlusion, color restored if adequate circulation** *Blood sample drawn from radial artery after positive test result*

Allen test

Used to liquiefy & metabolize resp. secretions & deliver medications Suspend liquid particles of bronchodilators or inactive fluids such as water or saline delivered by a nebulizer

Areosol therapy

Delivers humidifies aersol through large tubing, which may be connected to an O2 mask or hand held device Have patient sit up right and slowly inhale deeply, hold breath briefly, & exhale slowly Pt may require deep breathing & coughing tech, postural drainage, suctioning or a combination of these tech to clear the secretions

Nebulizer

Fits around the face & directly into the nares by 2 prongs Low flow O2 **1-6L/ min** FiO2: **0.24-0.40 (24-40% O2)**

Nasal Canula

FiO2: **0.35-0.55 (35-55% O2)** Flow rate: **6-10L/ min** * Min flow rate of 6L/min is necessary to prevent any chance of CO2 build up from occuring

Simple O2 mask

FiO2: **0.7 (70%)** Specific flowmeter setting for desired FiO2

Ventimask / Venturi mask

What are some interventions for airway obstruction?

Admin antimicrobuals, decongestant, & expectorants as ordered Deep breathing, & a good cough to break up secretions * ***Antitussive medications** can be given if pt become fatigue by coughing* * *Pts w/ weak cough may need suctioned* Encourage *position change Q2h* to help mobilize secretions Chest physiotherapy, aerosol therapy Provide tissue & a receptable for disposal of secretions * **Note amount, color, consistancy** **Auscultate lung sounds frequently** to assess interventions

How do you assess gas exchange?

Monitor vitals, lung sounds, & skin assessment Alert for S/s of hypoxemia: * **Restlessness, tachycardia, tachypnea** ABG meaures, report abnormalities to HCP Monitor hemoglobin (Hgb) * *low levels indicate reduced O2-carrying capacity of RBCs* Elevate HOB, maintain O2 therapy as ordered **Semi-fowlers** to decrease pressure of abd. organs on diaphram so pt can breath easier

What are some interventions for a pt who is fatigues & dyspnic?

Restrict activity for pt w/ pneumonia * Ranges from complete bed rest to limited activity Organize care to prevent overtiring & allow period of uninterrupted rests Provide assistance as needed (ADLs) until pt can do them on own, evaluate tolorance of ADL Keep converations short & encourage visitor to not tire pt

What are some interventions for inadequate nutrition?

Assess clients usual dietary habits to provide baseline information * **Individualize diet** **Monitor weight** same time every day before breakfast using the same scale **Monitor albumin, electrolyes, glucose, & BUN/Cr to detect inadequate nutrition**

What is the typical diet for a Pt w/ pneumonia & what interventions would you implement?

Diet: **High protien, soft diet** **Interventions**: * *Provide diet as ordered* * *Document intake* * Assess w/ feeding if needed * Provide *oral care before & after meals* * Elevate HOB * Arrange tray in attractive & convenient manner * If O2 required, apply NC * If fatigued easily, do frequant small meal

T/F - Iodized salt is the best way to obtain adequate amounts of Iodine in the diet of someone Dx w/ hyperthyroidim

True

Characterized by excessive output of dilute urine Classified as: * **Nephrotoxic** - Inherited defect in which renal tubules of kidney do not respond to ADH, resulting inadequate water reabsorption by kidneys * **Neurologic (central / hypothalamic)** - Can result from hypothalamic tumors, head trauma, infection, surgical procedures (hypophysectomy) or metataic tumors originating in lungs. *Triggered by CVA, aneurysm, or intracranial hemorrhage* * **Dipsogenic** - Disorder of thirst timulation. *When pt ingests water, serum osmolality decreases causing reduced vasopressin secretion*. Other factors are associated by habitual water intake/ psych. conditions

Diabetes Insipidus (DI)