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
