Med surg Flashcards
Glucose
70-110
High: 3 P’s polydipsia, poluria, polyphagia
low: confusion, irritability, diaphoresis
sympatheic response. if no tx for either then tragectory is seizure, coma, death
NA+
135-145 mEq/LHigh or Low sodium = confusion (change in neuro status) - affected by fluid balance
K+
3.5-5 mEq/LHigh or low dysrhythmia
High: diarrhea, cramping - acidotic states
Low: constipation, leg cramps - alkalotic states
Ca+
8.5-10.5
High: constipation, slowed reflexes, kidney stones
Low: tetany, increased reflexes, Chvosteks & trousseau, diarrhea
BUN
10-20 mg/dL
affected fluid balance and diet (protein intake - if eat a lot of protein then high if little protein intake then low.) Kidney function but not specific
10-20 is therapeutic drug range for dilantin (phenytoin and theophylline)
Creatinine
0.5-1.5 mg/dLSpecific to kidney function (based on muscle mass)
(Level is the same for therapeutic range digoxin and lithium)
WBC
5-10K mm3
if extremely low then sepsis (overwhelming will see immature bands or blasts - mature cells have died in the war). High = infection
Very high= leukemia
filgrastim increases WBC
Platelets
150-450K
High: clotting (anticoagulants, antiplatelets, hydration, therapeutic phlebotomy)
Low: bleeding (oprelvekin synthetic colony stimulating factor, soft toothbrush, electric razor, fall precautions)
Hgb
> 10 g/dL (10-15)
Low: anemia (sob, lethargic, pallor), pace activities
can give CSF epogen to increase H&H
HCT
35% or > up 48%
Low: anemia - see above
High: clotting
affected by fluid balance
Bilirubin
<1
High: jaundice, icterus, abdominal pain, clay stools, brown urine, increased risk of bleeding
MRI
Pre:
Make sure there is no metal in the client e.g. welders may have fragments in their eyes and not know it, older pace-makers, rods, etc. Also, are they claustrophobic? May need a benzo before the procedure. If MRA, check for allergies to shellfish or iodine. Hold glucophage the day of the procedure and hold for 48 hours after the procedure
Post:
It depends if it’s just a MRI (don’t need to do anything); a MRA (angiography which requires dye) need to increase fluids to flush out the dye or can cause renal dysfunction
CT with contrast
Pre:
check for allergies for shellfish or iodine. Hold glucophage the day of the procedure and 48 hours after
Post:
Hold glucophage 48hrs after the procedure. Increase hydration to excrete dye
Electroencephalogram (EEG)
Pre:
No lCNS stimulants or depressants before EEG e.g. no coffee/tea, chocolate, hold the client’s seizure meds (which would depress CNS). May sleep deprive them to increase likelihood of seizure
Post:
Nothing really post procedure
Arterial Blood Gas
Pre:
Allen’s test, check bleeding profile (PT/INR, PTT, Liver function) what meds are they on anticoagulants, antiplatelets or any bleeding disorders
Post:
Hold pressure for 5 minutes or even longer if on meds that cause bleeding.
Endoscopy
Pre:
NPO 4-6 hours before to prevent aspiration
Post:
Gag reflex before anything PO
Cardiac Catheterization
Pre:
NPO 4-6 hours prior, check allergies shellfish, iodine, consent. Do not shave site, we only trim it
Post:
HOB less 30 degrees. Depends on closure device, maintain pressure, check site q15 minutes and distant pulses, bp/hr for internal bleeding. Hydration to remove dye from body,
Thoracentesis
Pre:remain still, assess their lungs, vital signs prior, consent, bleeding time, meds that may increase risk of bleeding
Post: CXR immediately after, assessment of lungs, vital signs immediately, could cause a pneumothorax
Nasal Cannula
0.5-6L, tissue damage around ears and nares, humidify if 3-4L or higher
Simple Face Mask
Cannot have less than 5-6 Liters or the client will rebreath their C02 and will have respiratory acidosis and have to be intubated
100% Nonrebreather
fill the reservoir bag with oxygen first before applying to client or will rebreath c02 and become acidotic
Respiratory
Complications:
atelectasis (collapsed alveoli), pneumonia
Interventions:TCDB q2h, ISE 10x hour while awake, pickle or accapella (blow into to loosen secretions), ambulate or at least sit up in chair, chest physiotherapy, hydration to thin secretions
Cardiac
Complications:
DVT, PE, orthostatic hypotension
Interventions:
ambulation, heparin sq or lovenox, sequentials, TEDS, fluids, change positions slowly
GI
Complications:
ileus, constipation, N/V
Interventions:
Ambulation, nasogastric tube if vomiting or ileus - NPO until bowel sounds return
GU
Complications:urinary retention, stones if they stay in bed too long, Catheter associated UTI (CAUTI)
Interventions:
Get them OOB - Gravity, lots of fluids,
Integumentary
Complications:pressure ulcers, dehiscence, eviscerate, wound infection
Interventions:
Turn q2hs, ambulate, use binder, splint when coughing, sterile dressing changes.
State 2 differences between an ileostomy and colostomy?
a. Consistency: Ileostomy= watery, continuous output. Colostomy= more formed- not continuous
b. Location: ileocecal (right lower quadrant - ileostomy); colostomy ascending, transverse, descending can irrigate colostomy but not ileostomy.
How often should an ostomy pouch/wafer be changed?
? 7-10 days or prn if there is a leak. Bag emptied? 2/3rd full
A client calls the clinic stating they have not had any output from their ileostomy for 2hrs. What is the best response by the nurse? State at least 2 things the nurse should tell the client.
a. hot liquids, knee chest, ambulate, change the wafer, warm shower, massage around it - if nothing needs to be seen = blockage
State 3 reasons a nurse would clamp a chest tube?
a. Looking for leaks (intermittently), changing the drainage container, or getting ready to remove it.
Equipment/Lines/Tubes required to administer
TPN:
filtered tubing, central line
Tubing feeding:
tubing set, formula, NGT, GT, JT
Nursing considerations (need to knows to prevent harm)
TPN:
daily labs, 2 nurses, monitor infection, check glucose levels, must change tubing q24hrs. Run out of TPN? dextrose 10-20% at same rate to prevent hypoglycemia, Monitor fluid balance
Tube feedings: NGT placement CXR before using. check blood glucose q6h check residuals q4h change the set q24h make sure enough free water Head of the bed 30 degrees or higher to prevent aspiration
State 3 factors that increase a client’s risk for falls
Age, medication, previous fall, uses equipment to ambulate (cane, walker), lines
How are crutches measured?
2-3 fingerbreadths below axillary
A client is being discharged home after hip surgery, what “hip precaution” teaching will you provide?
do not cross legs, do not bend over 90 degrees, chair height (upside down stop light), raised toilet seat. chairs with arms
What do nurses need to know about traction e.g. bucks or cervical
continuous never release, never change weights
State 2 nursing considerations when communicating with a client who is hearing impaired
quiet environment, face them, lighting, hearing aids in if they have them, set aside enough time to speak with client
A nurse is discharging home a client with a visual deficit. State 3 home safety interventions:
no chairs with wheels, no extension cords, or small animals, good lighting, no scatter rugs, paint edges of stairs bright colors
What can be delegated to an LPN
Anything the nurse cannot EAT (Evaluate, assess or teach), only have stable patients, chronic conditions.
State 3 nursing ethical principles:
autonomy,
veracity (telling truth),
fidelity (doing what you say you will do, keep your word), beneficence (doing good); nonmaleficence (not doing harm)
A client has a nasogastric tube for decompression.
. The nurse will set the suction gauge at 40-60 mmHg
What is the gold standard for NTG placement? CXR
A client is at risk for aspiration (difficulty swallowing) what should the nurse instruct the CNA to do when feeding the client?
90 degrees, chin tuck, no straws, speech and swallow
Metoprolol
beta blocker
blocks beta 1 receptor on the heart to slow Heart rate
heart rate and decrease blood pressure (blocks sympathetic response)
<60 & BP (SBP<90)
People with respiratory disorders because it affects beta 2 receptors causing bronchoconstriction
Diabetics - check blood glucose more frequently - masks hypoglycemia
change positions slowly, do not stop abruptly, do not overheat yourself
Accupril
Ace inhibitor -pril
interferes with the Renin-Angiotensin - Aldosterone system
Check BP and Potassium levels (could be high because hold onto K+); Umbrella BP protocols ; S/E: hacking cough; Adverse reaction : angioedema
Warfarin
anticoagulant
interferes with clotting cascade
careful with NSAIDS increased risk of bleeding. Antidote: Vitamin K or Aquamephyton, Fresh Frozen Plasma (FFP).
Teaching: Do not drastically change your diet; soft toothbrush, electric razor, no contact sports, report excessive bleeding or bruising.
Lab: PT/INR if A-fib 2-3, if mechanical valve 2.5-3.5 or 4
Digoxin
Cardiac glycoside
or positive inotrope (increases contractility), negative chronotropic (decreases heart rate)
increases ventricular contractility to improve cardiac output
Therapeutic range: 0.5-1.5 (if near 2 then patient will have symptoms of toxicity) visual disturbances green/yellow halos, N/V
Check at the bedside: Apical pulse for 1 minute if <60 hold
Also check potassium - if low can cause toxicity.
How do you determine effectiveness? clearer lungs, decreased edema, no SOB or improved breathing, energy.
Furosemide
loop diuretic
increase urine output and potassium (waster)
Check BP, Potassium, fluid balance check weights (daily), effective if ease of breathing, clearer lungs, decreased edema, lowered BP monitor urine output.
Aspirin
antiplatelet, antipyretic, NSAID
Anti-platelet - makes them less sticky - effects the platelet for the life of the platelet which is 10 days
No one under 18 or Reye syndrome (liver failure)
Take with food - gastric distress and ulcers
Toxicity: tinnitus - ringing in the ears
Phenytoin
anti-seizure/
anti-epileptic
seizure threshold - increase to prevent seizures
Therapeutic range: 10-20
Causes birth defects
Decreases effectiveness of oral contraceptives - use barrier
Gingival hyperplasia, good oral care
pink urine is normal, Tube feedings hold 1 hour before and after
If given IV no dextrose or it will crystallize
Dexamethasone
steroids (-asone or one)
antiinflammatory
Do not stop abruptly or cause an adrenal crisis. Must taper the drug.
Long term: Moon Face, truncal obesity, thin extremities, buffalo hump, cataracts, osteoporosis, hirsutism, weight gain, fluid retention
As soon as take the medication - early signs: hyperglycemia, risk for infection, slow wound healing.
Cardizem
calcium channel blocker
ion influx
At bedside check: Heart Rate & Blood Pressure, prolong QT interval on ECG
Umbrella for drugs that lower BP
Simvastatin
anti cholesterol medications
works directly on the liver to slow production of cholesterol
Given night because the liver is more active at night.
LFT before starting medication and monitor LFTs
Adverse reaction: rhabdomyolysis
Do not ingest grapefruit juice.
Report abdominal pain, jaundice, icterus, dark urine, clay stools
Monitor cholesterol: Total = <200
HDL>60
LDL<100
Lorazepam
benzodiazepine
works on CNS
antidote: flumazenil or romazicon monitor respiratory rate safety precautions highly addictive tolerance and withdrawal
Morphine sulfate
Opioid pain medication
CNS
Antidote: naloxone/narcan
monitor Respirations hold if <12
tolerance/dependence
What is the maximum score on the Glasgow Coma Scale
15 (lowest is 3)
Which nerve is affected in Bell’s Palsy?
CN VII (know all CN and how they are tested)
What is Cushing’s triad?
(ICP) widened pulse pressure, bradycardia, irregular respirations
Where is a ventriculostomy drain leveled to?
forman monroe, tragus of the ear
Which eye disorder has a loss of central vision?
cerebellum (C for coordination);
frontal (Be Expressive - personality , expressive aphasia - Brocas);
temporal (hearing, receptive aphasia, wernickes);
parietal is sensation; occipital is vision
State 2 interventions you would do if clear drainage was observed draining from the nares of a client with a basilar skull fracture? (state 2)
- halo test; mustache dressing. High risk for CNS infection = nuchal rigidity
What are the cardinal signs of Parkinson’s Disease?
TRAPI
Tremors, rigidity, akinesia (bradykinesia slow movement), Postural instability
How is autonomic dysreflexia treated? Who is at risk?
T6 spinal injury or above, high bp caused by a stimulus below the injury usually bladder distention or constipation or tight clothing. Sit them up, look for the problem. If SBP >170 give BP medication.
State 2 things a nurse needs to know about traction (Gardner wells or Bucks)
- continuous traction
2. Do not change weights
State 2 vasopressors.
epinephrine, norepinephrine, dopamine, dobutamine, vasopressin
vasodilators: Nitroglycerin, nitroprusside
Where is the phlebostatic axis located?
right atrium (4th ICS mid axillary)
V tach pic
What is it?___VTach___________________Treatment: __Check for pulse if have one then cardiovert; if pulseless treat as VFib - defibrillate ASAP, CPR until defibrillator is obtained.
SVT pic
What is it? _SVT__Treatment: vagal maneuvers (stimulate parasympathetic system) bear down, cough, blow through a straw, put face in ice water; doctor can carotid massage; adenosine 6, 12, 12 = 30 mg rapid iv push followed 20 mL of saline
What are signs and symptoms of pericarditis?
friction rub, pain relieved if leaning forward, and NSAIDS
Which type of valve replacement requires life-long anticoagulants?
mechanical (biological do not, but need to get a new biological every 8-10 years whereas mechanical is for life).
How does a venous ulcer differ from an arterial ulcer?
In arterial disease there is not enough blood, blood is warm and it carries all the nutrients. So decreased blood flow to lower extremities will not have edema, will be cool (lack of the warm blood), scarce hair and thick toenails because lack of nutrients, wounds are deep and edges are well circumscribed, weak pulses
Venous insufficiency is just the opposite, no problem getting to the feet but blood pools in the feet due to incompetent valves make it difficult for the blood to return to the right side of the heart so edema, warm feet, good pulses, toenails are fine and hair is not patchy. Wounds are shallow with irregular borders
What medication(s) would you use to lower systemic vascular resistance?
vasodilators, antihypertensives
Interpret the following ABG:
pH 7.20, pC02 32, Hc03 18, Pa02 70
Metabolic Acidosis, partial compensation, hypoxemia
What would cause a low pressure alarm on a ventilator?
disconnected, pneumothorax, leak, tracheostomy cuff is down.
High pressure alarm: stiff non compliant lungs, increased secretions in tube, biting the tube, kink in the tube
What is the cardinal sign of ARDs?
refractory hypoxemia needs mechanical ventilation and high PEEP
Bronchitis
Cause:
smoking, pollution
s&s:
Blue bloater
increased H&H d/t constant release of erythropoietin
eventually right-sided HF (Cor Pulmonale)
02 sats 88-91%
test/tx: pulmonary function tests inhalers (beta 2 agonists - terol; anticholinergics - tropium; and inhaled steroids - cort or asone) mucolytics low dose steroids low oxygen via NC
education:
stop smoking
teach about medications: what order to take inhalers,
do not stop steroids abruptly (if they are taking them)
Pursed lip breathing (helps keep alveoli open longer for better gas exchange)
Emphysema
cause:
smoking, pollution or genetic (do not have alpha 1 antitrypsin)
s/sx:
Pink puffer - able to oxygenate themselves but using accessory muscles
02 sats 88-91%
test/tx: Pulmonary function tests inhalers (same as bronchitis above) low dose steroids low oxygen via NC
education:
Same as above for Bronchitis
Also, diaphragmatic breathing (largest muscle- less 02 use when using diaphragm instead of accessory muscle to breath)
Asthma
cause:
allergens
genetic
s/sx:
allergens
genetic
test/tx: Peak flow meter Green is good yellow need to change med regime red take rescue inhaler and call 911
education:
take medications as prescribed, how to use the peak flow meter, should be used everyday, try to avoid triggers
Tuberculosis
cause:
underdeveloped populations, crowded living conditions, immunocompromised
s/sx:
Night sweats, weight loss, hemoptysis
tests/tx:
Positive sputum culture Acid Fast Bacilli,
CXR
education:
Must wear surgical mask when out in public or around people, take meds as prescribed (ethambutol, INH, Rifampin or Streptomycin) after 3 negative sputum cultures then they can stop taking the meds
Pneumothorax
cause:
Tall thin young males are at high risk for spontaneous pneumothorax, pple with COPD have blebs on their lungs puts them at risk, a client on a ventilator that has noncompliant lungs or trauma
s/sx:
absent or dim lung sounds (if small); tracheal shift to the unaffected side if large
treatment/test
Chest tube needs to be placed to restore negative pressure and re-expansion of the lung
education:Pain control with PCA, about chest tube - when ambulating etc.
TCDB (pulmonary toileting)
Hyperglycemia
treatment:
insulin
Hypoglycemia
treatment:
15’s (15 grams of simple carbohydrate, recheck blood glucose in 15 min, another 15 grams of simple carbs if not in range but if in range then 7.5 g of complex carbohydrate so blood sugar does not plummet)
if confused or not conscious then give glucagon sq or IM or Dextrose 50% IVP if they have an IV - never give PO if not fully conscious - will aspirate
Rapid (Lispro, Aspartate) (-logs)
onset:
5-15min
Peak:
{1.5 (1-2)
Regular Insulin (-lin)
onset:
30 mins
peak: 3 hrs (2-4)
NPH
onset:
60 mins
peak: 6 hrs (4-8 hrs)
Long acting
onset:
60 mins
peak:
no peak
basal rate
State the 2 differences between HHNKS and DKA:
a. __Hyperglycemia hyperosmotic nonketotic syndrome - no acidosis, no ketones - type II diabetics (Blood glucose 600-1000)
b. DKA acidosis, ketones, Type I 400-600
What labs would the nurse expect for a client admitted with adrenal crisis?
adrenal cortex (think of the hormones aldosterone, cortisol and sex hormones): aldosterone: holds onto NA & water gets rid of potassium - so what if no aldosterone? get rid of NA+ and water and hold onto K+= hyponatremia, hypotension, hyperkalemia
Cortisol: if present have increase in glucose; if don’t have cortisol = hypoglycemia
Adrenal crisis= hyperkalemia, hyponatremic, hypotension, hypoglycemic
What are the complications (emergency) of hypothyroid and hyperthyroid?
a. Hypothyroid emergency/complication: myxedema coma - give synthroid (thyroid hormone)
b. Hyperthyroid emergency/complication: thyroid storm - treat symptoms High BP, High temperature-
Using the rule of nines and Parkland formula calculate fluid resuscitation for first 8 hours:
Burns to the face, entire right arm, entire chest and abdomen, entire right leg and groin. Client weighs 68kg
face: 4.5, right arm: 9, chest and abdomen: 18, entire right leg:18, groin: 1= 50.5 x 4mL x 68= 13,736/2 = 6868 first 8hrs (has to be infused within 8hrs of the when the burn occurred e.g. if burned at 1000, then it must be infused by 1800) then the rest over the next 16 hours 6868/8= 858.5
Hepatitis
Know ABC Immunoglobulins vaccinations body fluids contaminated water/feces liver dysfunction
treatment:
immunoglobulin
vaccinations
Cholecystitis
female, fair fat, forty and fertile
right up quad/shoulder/back pain after fatty/spicy meal, N/V
treatment:
diet, cholecystectomy
Acute Pancreatitis
alcoholism or stone is lodged in common bile duct, smoke
acute abdominal pain, n/v , increased lipase and amylase
treatment:
rest the stomach, nasogastric tube, stop drinking and smoking
or removal of the stone
Compare and contrast Glomerulonephritis and Nephrotic Syndrome - how are they similar and how are they different?
strep infection undetected/not treated - damaged kidneys, more permeable losing large cells albumin and red blood cells. Low albumin look like pillsbury dough boy (edema) frothy coca cola urine (frothy album and coca cola is red blood cells) ; red blood cells anemic. - treat glomerulonephritis antibiotic, go slow with replacing albumin.
If glomerulonephritis is not treated properly then they will develop nephrotic syndrome - irreversible chronic renal failure - go ahead and replace albumin.
What are the 3 phases of acute renal failure?
1) anuric/oliguric,
2) diuresis
3) recovery
What are 3 types (causes) of acute renal failure?
pre-renal (volume);
intrarenal (drugs aminoglycoside);
post-renal (enlarged prostate or stone)
Hemodialysis
3 days a week for few hours
complications:
hypotension
disequilibrium syndrome (too fast removal of BUN) slow the rate
use heparin= so risk of bleeding
Peritoneal Dialysis
several exchanges a day
with dwell times
complications:
peritonitis
fluid overload
Rheumatoid Arthritis
symmetrical joint destruction/deformities swan neck, boutonniere Rheumatoid factor (RF), ANA (antinuclear antigen) stiff when joints not used e.g. waking up in the morning - feel better with movement
treatment: DMARDs Disease modifying antirheumatic drugs plaquenil steroids methotrexate
Osteoarthritis
unilateral
wear and tear
pain occurs with use of the joints
treatment:
steroids
surgery
OTC: chondroitin
Gout
build up of uric acid in the small joints can be in fingers and toes
(usually great toe)
very painful inflamed
Exacerbated by dehydration
treatment:
prophylactic use of
Probenecid (helps excrete (pee) out the uric acid)
Allopurinol (decreases the production of uric acid
Colchicine for acute episodes
Indomethacin
Heparin 20,000 units/500 mL D5W to infuse at 800 units/hr IV. What rate will you program into the pump?
800units x 500/20,000=
Answer: ________20_____________
Dopamine 5 mcg/kg/min has been ordered. Available is Dopamine 2 grams/250 mL. The patient weighs 150lbs. How many mL/hr will you program the pump to deliver? (REMEMBER DO NOT PUT IN THE LABEL ONLY THE NUMBER AND ROUND TO THE HUNDREDTH FOR THIS PROBLEM)
5 x 68.18kg x 60min x 250mL/2,000,000mcg=
Answer: ________2.56 mL/hr______________
Cardizem drip 100mg/150mL. Order titrate 10-20mg/hr to keep HR <100. Infusing is 18mL/hr. How many mg/hr is this patient receiving?
100mg: 150mL :: Xmg: 18mL= 150X= 1800 = 1800/150= X
Answer: _____12 mg/hr_______________
A 1 liter fluid challenge of normal saline has been ordered for your patient in acute renal failure to infuse over 1 hour and 15 minutes.
1000mL/1.25hr=
Answer: ____800mL/hr_________________
No pump is available. How many gtts/min will you deliver using a 10gtt/mL tubing set.
1000mL x 10gtt factor/75minutes =
Intake 3 Tbsp (15mL x 3= 45mL)of soup 2 tsp (5ml x 2= 10mL) of creamer 4 oz (30mL x 4= 120mL) of jello 0.5 liters of water (500mL) IVPB 100mL
Intake: _______________
Output
Urine output 1.2L (1200)
8 oz of emesis (30 x 8=240)
0.25L of nasogastric contents (250ml)
Answer: Fluid Balance is __(state number value)_________________ then circle one of these (+/-)
Take total intake and subtract total output to get balance:
Output: __________________
