Medical Surgical - Final Exam Concept Guide

Final Exam Concept Guide Infection (signs/symptoms) Low WBC count, increased HR, increased Respirations, low BP, fever Wounds: red, draining, edema, heat Nursing interventions to decrease risk of pressure injuries Change position every 2 hours, padding (foam dressing, pillows), passive ROM, barrier cream, keep patient’s skin dry, ambulate, don’t put pressure on bony prominences, When moving a patient: use a lift device >35 lbs Dosage and calc (basic conversions) Look at practice quizzes* HIV/AIDS (s/s, labs (CD4 & CD8 counts) Patient with HIV: CD4 count= lower than normal (normal CD4 range= 500-1200) CD8= normal (normal CD8 range= 150-1000) Progresses to AIDS: CD4: less than 200 CD8: increased s/s: night sweats, Kaposi’s sarcoma, weight loss, fatigue, recurrent infections - Kaposi's sarcoma is a type of cancer that forms in the lining of blood and lymph vessels. The tumors (lesions) of Kaposi's sarcoma typically appear as painless purplish spots on the legs, feet or face. Lesions can also appear in the genital area, mouth or lymph nodes. AIDS decreases protein absorption Antiretroviral drugs (what do they do?) Prevents virus replication HIV/AIDS patients on these meds for life; cannot cure HIV entirely CD4 count should increase Viral load (amount of virus in an infected person’s blood): should go down Cataracts A cataract is opacity of the lens that distorts the image projected onto the retina and that can progress to blindness. No pain associated with cataracts, blurred vision, and reversible Assessment: a. Blurred vision and decreased color perception are early signs. b. Diplopia, reduced visual acuity, absence of the red reflex, and the presence of a white pupil are late signs. Pain or eye redness is associated with age-related cataract formation. c. Loss of vision is gradual. Glaucoma Increased IOP, painful, irreversible 10-21 mm Hg  When intraocular pressure increases it leads to compression of the retinal blood vessels and the photoreceptors and their nerve fibers resulting in hypoxemia and health of the tissue and loss of vision.  Primary open angel: most common type, affects both eyes, gradual loss of vision  Signs and symptoms: foggy vision, mild eye aching, headache  Late signs and symptoms after irreversible eye damage: halos around lights, losing peripheral vision, decreased visual perception that not improve with eyeglasses  Secondary and associated glaucoma POAG: Painless, and vision changes are slow; results in “tunnel” vision PACG: Blurred vision, halos around lights, and ocular erythema Pain assessment (pain scale, questions, vitals) -PQRST (where, when did it start, what makes it better or worse, dull or achy (quality)) -Therapeutic communication -It’s not just phantom limb pain, assess/ interview the patient Nonverbal signs of pain: grimacing, guarding, restless, vital sign changes (elevated BP, HR, respirations)  0-10 scale  grimacing, guarding, verbalization  PQRST assessment (provocation, quality, region, severity, timing)  Wong-baker faces pain scale (>3)  FLACC scale (face, legs, activity, crying, consolability)  CRIES scale (<6)  COMFORT scale (when patient cannot rate or describe pain) Diet for wound healing -High protein (chicken, beans, eggs, milk, yogurt, fish) -more calories, protein, fluid, vitamin A, vitamin C, and zinc Rheumatoid Arthritis and associated conditions -Rheumatoid arthritis is a chronic systemic inflammatory disease (immune complex disorder); the cause may be related to a combination of environmental and genetic factors. -Rheumatoid arthritis leads to destruction of connective tissue and synovial membrane within the joints. -Rheumatoid arthritis weakens the joint, leading to dislocation and permanent deformity of the joint. Complaining of bilateral pain; lab values= elevated ESR, RA factor (positive means they COULD have it, not definitive; could be elevated due to cancers, lupus, autoimmune disease) Arthrocentesis: diagnostic test for RA (see if it is cloudy) Complications: contractures, osteoporosis, stiffness, sjgoren syndrome, fibromyalgia, ?(1 more check 7:28pm) Rheumatoid Factor   Blood test used to assist in diagnosing rheumatoid arthritis Reference interval: Negative or less than 60 IU/mL Raynaud’s phenomenon Pale/blue discoloration of fingers and nailbeds on hands; wear gloves Associated with scleroderma Complications of Rheumatoid Arthritis RA increase risk for:  Osteoporosis.  Rheumatoid nodules.  Dry eyes and mouth. more likely to develop Sjogren's syndrome, a disorder that decreases the amount of moisture in the eyes and mouth.  Infections.  Abnormal body composition.  Carpal tunnel syndrome.  Heart problems. of hardened and blocked arteries  Lung disease.  Lymphoma. Therapeutic communication Acknowledge what patients are saying, If they say they aren’t feeling right, say “tell me more” Pressure ulcer staging Stage 1: red doesn’t blanch, stays red Stage 2: damage to dermis and epidermis, shallow and open, may appear as blister Stage 3: deep and goes to sub cutaneous but does not expose bone, muscle or tendon Stage 4: exposes bone, muscle, and tendon Unstageable: no idea can’t see underneath, too much tissue on top Fractures Open fracture is high risk for infection or external fixation device Cast; if complaining of hot spots may mean compartment syndrome • closed: clean break with bone separate but skin not broken • open: bone breaks skin • transverse: clean break and bones are together in skin • comminuted: fragmented pieces • impacted: broken slanted and pushing together • greenstick: chip in bone • oblique: curvy slanted break through the bone. Compartment Syndrome s/s: hot spots, edema, pain, swelling pressure buildup from internal bleeding or swelling of tissues surgical procedures: fasciotomy Hyperthermia/Hypothermia Hyper: fever (above 99.5) antipyretics, ice packs under arms, groin, and neck; take off layers of clothing, do not give warm blanket Hypo: (below 96.5) warm them up, blankets Wound terms (dehiscence/fistula/evisceration) Dehiscence: wound separates partially or fully but does not go through visceral layer Fistula: abnormal passage, two cavities connect together, happen with patients with scar tissue from previous surgeries Evisceration: goes through visceral layer, organs fall out; cover with saline soaked gauze or towels then call doctor, do not have to put organs back in CREST syndrome s/s of scleroderma C-calcinosis R- Raynaud's phenomenon, E-esophageal dysmotility, S-sclerodactyly, and T- telangiectasia. Lupus (signs/symptoms) -Chronic, progressive, systemic inflammatory disease that can cause major organs and systems to fail -Connective tissue and fibrin deposits collect in blood vessels on collagen fibers and on organs. -The deposits lead to necrosis and inflammation in blood vessels, lymph nodes, gastrointestinal tract, and pleura. -No cure for the disease is known, but remissions are frequently experienced by clients who manage their care well. Butterfly rash Sclera of lupus ? at risk for infection Wash hands Defenses against infection Primary: skin, response to infection (fever) Psoriasis A condition in which skin cells build up and form scales and itchy, dry patches Skin is dry, avoid alcohol and sun. Use steroid ointment Avoiding spread of MRSA Wash hands, PPE, contact room (gloves and gown?), use antibacterial soap on patients, washing hands between dressing changes Interventions for patients with compromised immunity Prevent infection, wash hands, wear a mask (neutropenic or reverse isolation contact precautions) Explain why you are wearing PPE Initiate TV, activities to get their mind off of it Inform, educate, express empathy Types of necrotic tissue (eschar, slough) Eschar is black and must be debrided off Slough is yellow and stringy Inadequate perfusion (signs/symptoms) s/s: cyanosis, diminished pulse, capillary refill greater than 3 seconds, purple/blue Chain of infection AIDS patient is host for chain of infection Medications to decrease inflammation NSAIDS Negative affect of NSAIDs: liver damage ?? NSAIDS to bones: delay healing Communication with hearing impaired clients Face to face, slowly and clearly Phases of wound healing and time frames Hemostasis (clotting), inflammatory phase (lasts 3-5 days), proliferation (regeneration), maturation (scar forms) Needlestick injuries and what to do Wash/flush area then report incident Progression from HIV to AIDS HIV is an infection that progresses in three stages: acute HIV infection, chronic HIV infection, and AIDS. During acute infection, HIV multiplies rapidly. As acute HIV infection progresses to chronic HIV infection, HIV multiplies less rapidly and HIV levels drop. However, as chronic HIV infection advances, HIV levels increase and the number of CD4 cells decreases. Declining CD4 cell levels indicate increasing damage to the immune system. Antiretroviral therapy (ART) can prevent HIV from destroying the immune system and advancing to AIDS. Maslow’s Hierarchy of Needs Physiological, safety and shelter, love and belonging, self-esteem, actualization Nursing interventions for Lupus including medications NSAIDs, topical hydrocorticsol, steroids Administer topical or systemic corticosteroids, salicylates, and nonsteroidal anti-inflammatory drugs as prescribed for pain and inflammation. Bed baths (where you begin) Start on their face; cleanest to dirtiest Clients at risk f\or compromised immunity Cancer patients, autoimmune, post-operative, immunocompromised, older adults Age related changes to the skin Older adults skin becomes thinner, less elastic, dryer, loose sub q fat Contact precautions (contact, droplet, contact (bleach), airborne, neutropenic) TB: airborne, N95 mask, negative pressure room, gown and mask -Ask patient if they recently traveled, know of the exposure, have s/s of cough, fever, night sweats Airborne: for patients with infections that spread via droplet nuclei smaller than 5 microns -includes TB, measles, and varicella Droplet: for patients with infections that spread via droplet nuclei larger than 5 microns -includes rubella, meningococcal pneumonia, and Streptococcal pharyngitis Contact: for patients who have infections that spread via direct contact or contact with environment -includes vancomycin resistant enterococci, methicillin resistant staphylococcus aureus, and scabies HIV teaching 1.Educate about high-risk behaviors and the importance of avoiding high-risk behaviors. 2. Identify the methods of transmission of HIV. 3. Emphasize the importance of abstinence from sexual contact, such as intercourse. 4. Emphasize the importance of using safe condoms if intercourse is planned. 5. Identify the resources available for support and other issues. SMART goals Risk for falls: client will have zero falls throughout the end of the shift S-Specific M-Measurable A-Attainable R-Realistic T-Timely Osteoarthritis teaching for managing pain/edema Degenerative Joint Disease (DJD) Results in bone rubbing against bone in the joint space causing joint pain and stiffness leading to decreased mobility and muscle atrophy -Presence of Heberden’s nodes (top of finger) or Bouchard’s nodes (hands) (middle knuckle) Pain Management: 1.Administer medications as prescribed, such as acetaminophen or topical applications; if acetaminophen or topical agents do not relieve pain, NSAIDs may be prescribed. Muscle relaxants may also be prescribed for muscle spasms, especially those occurring in the back. 2. Prepare the client for corticosteroid injections into joints as prescribed. 3. Position joints in function position and avoid flexion of knees and hips. 4. Immobilize the affected joint with a splint or brace until inflammation subsides. 5. Avoid large pillows under the head or knees. 6. Provide a bed or foot cradle to keep linen off of feet and legs until inflammation subsides. 7. Instruct the client in the importance of moist heat, hot packs or compresses, and paraffin dips as prescribed. 8. Apply cold applications as prescribed when the joint is acutely inflamed. 9. Encourage adequate rest Crepitus Describes any grinding, creaking, cracking, grating, crunching, or popping that occurs when moving a joint Occurs in patients with osteoarthritis Side effects of NSAIDS (bleeding)        indigestion – including stomach aches, feeling sick and diarrhea stomach ulcers – these can cause internal bleeding and anemia; extra medicine to protect your stomach may be prescribed to help reduce this risk headaches drowsiness dizziness allergic reactions in rare cases, problems with your liver, kidneys or heart and circulation, such as heart failure, heart attacks and strokes Gout dietary recommendations and triggers Interventions: Provide a low-purine diet as prescribed, avoiding foods such as organ meats, wines, and aged cheese. 2. Encourage a high fluid intake of 2000 mL/day to prevent stone formation. 3. Encourage a weight reduction diet if required. 4. Instruct the client to avoid alcohol and starvation diets, because they may precipitate a gout attack. 5. Increase urinary pH (above 6) by eating alkaline ash foods (i.e., green beans, broccoli). 6. Provide bed rest during acute attacks, with the affected extremity elevated. 7. Monitor joint range-of-motion ability and appearance of joints. 8. Position the joint in mild flexion during acute attack. 9. Protect the affected joint from excessive movement or direct contact with sheets or blankets. 10. Provide heat or cold for local treatments to affected joint as prescribed. 11. Administer medications such as analgesic, antiinflammatory, and uricosuric agents as prescribed. Natural passive immunity (what is it?) Passive immunity is provided when a person is given antibodies to a disease rather than producing them through his or her own immune system. Receiving antibodies from external sources; maternal-fetal transfer of immunoglobulins and breastfeeding Short lasting Labs used for kidney function (bun/creatnine) BUN (Blood urea nitrogen) [increased BUN]= fluid volume deficit [decreased BUN]= fluid volume excess Normal BUN range= 10 to 20 mg/dL Urea nitrogen is the nitrogen portion of urea, a substance formed in the liver through an enzymatic protein breakdown process. b. Urea is normally freely filtered through the renal glomeruli, with a small amount reabsorbed in the tubules and the remainder excreted in the urine. c. BUN and creatinine ratios should be analyzed when renal function is evaluated. d. Normal reference interval: 10 to 20 mg/dL (3.6 to 7.1 mmol/L) e. Elevated levels indicate a slowing of the glomerular filtration rate. f. Elevated values occur in the following: burns, dehydration, GI bleeding, increase in protein catabolism (fever, stress), renal disease, shock, urinary tract infection g. Below normal values occur in the following: fluid overload, malnutrition, severe liver damage, syndrome of inappropriate antidiuretic hormone Creatinine: Creatinine is a specific indicator of renal function. b. Increased levels of creatinine indicate a slowing of the glomerular filtration rate. c. Instruct the client to avoid excessive exercise for 8 hours and excessive red meat intake for 24 hours before the test. d. Normal reference interval: Male: 0.6 to 1.2 mg/dL (53 to 106 mcmol/L); female: 0.5 to 1.1 mg/dL (44 to 97 mcmol/L) e. Elevated values occur in severe renal disease. f. Below normal values occur in diseases with decreased muscle mass such as muscular dystrophy and myasthenia gravis. Dosage and calc (ml—oz, mcg—mg, ml—tbsp) 1oz= 30ml 15ml= 1 tbsp 1000 mcg= 1mg Compartment syndrome s/s  A painful condition that occurs when pressure within the muscle builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.  Acute compartment syndrome is a medical emergency. It is usually causes by a severe injury. Without treatment is can lead to permanent muscle damage.  Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency, it is caused by athletic exertion  Most common in tibia and forearm  Related to muscle, blood vessels and nerves are caught with in the fascia leading to the increase in the venous pressure resulting edema  The edema leads to increasing pain which is unrelieved with pain meds  The edema continues to increase and leads to tissue necrosis ad possible infection  If unrelieved could lead to amputation distal to the compartment syndrome  May appear 6-8 hours following injury or take up to 2 days  Pain, pressure, paralysis, paresthesia, pallor, pulselessness s/s of lupus and affected organs b. Erythema of the face (malar rash; also called a butterfly rash) c. Dry, scaly, raised rash on the face or upper body d. Fever e. Weakness, malaise, and fatigue f. Anorexia g. Weight loss h. Photosensitivity i. Joint pain j. Erythema of the palms k. Anemia l. Positive ANA test and lupus erythematosus preparation m. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level s/s: alopecia, Nursing process (ADPIE—Assess, diagnose, plan, implement, evaluate) Guidelines for ice packs (on/ff) The use of ice is most effective in the first 1 to 3 days after an injury 20 minutes Neurovascular assessment Neurovascular assessment is performed to detect early signs and symptoms of acute ischemia or compartment syndrome. The neurovascular assessment of the extremities is performed to evaluate sensory and motor functions “neuro” and peripheral circulation “vascular”. The components of the neurovascular assessment include: pulses, capillary refill, skin color, temp, sensation and motor function. Pain and edema are also assessed Neurovascular impairment: 6 P’s (pain, pallor, paresthesia, pulselessness, paralysis, poikilothermia) Communicable diseases -A communicable disease is one that is spread from one person to another through a variety of ways that include: contact with blood and bodily fluids; breathing in an airborne virus; or by being bitten by an insect Spread through:     physical contact with an infected person, such as through touch (staphylococcus), sexual intercourse (gonorrhea, HIV), fecal/oral transmission (hepatitis A), or droplets (influenza, TB) contact with a contaminated surface or object (Norwalk virus), food (salmonella, E. coli), blood (HIV, hepatitis B), or water (cholera); bites from insects or animals capable of transmitting the disease (mosquito: malaria and yellow fever; flea: plague); and travel through the air, such as tuberculosis or measles. National patient safety goals (who publishes) -Published by the Joint Commission