ATI Exam Study Guide Medical Surgical Nursing

Medical Surgical Nursing Respiratory  ● Pulmonary function tests  ○ Effective way to evaluate    lung function   and capacity         ● Hypoxia or respiratory distress  ○ Priority intervention is placing the patient in a high Fowler position to facilitate  lung expansion ○ Encourage pursed lip breathing to facilitate emptying of alveoli  ○ Administer oxygen as prescribed  ○ Nasal flaring is important sign in infants  ● Bronchoscopy  ○ NPO 8-12 hours before procedure  ○ Post-procedure- keep  patient NPO until gag reflex returns ● Sputum culture  ○ Should be raised from deep within the bronchi such a sputum expectorated in the morning  ● Thoracentesis     ○ Removing fluid from chest cavity  a sitting position with their head resting over the bedside table ○ Place the patient in   ● Tuberculin skin test   ○ Must be read within 48-72 hours, induration larger than 10 mmindicatesapositive   test   ● Arterial blood gases       of acid-base          ○ Determine state balances   ○ Place sample on ice and send to lab for analysis   ● Breath Sounds ○ Adventitious  ■ Crackles, rhonchi, wheezes, pleural friction rub  ● Breath odors                Fruity ■ Ketoacidosis ○ Sweet and musty ■ Liver failure ○ Urine-like ■ Uremia, renal failure ○ Foul ■ Lung abscess, bronchiectasis ● Asthma ○ Recurrent episodes of labored breathing and wheezing ○ Etiology is extrinsic ■ Antigen-and antibody reaction is triggered by food, drugs, or inhaled particles ○ Treatment ■ Bronchodilators such as Albuterol ■ Nebulizers such as Atrovent ■ Place the patient in a high Fowler's ● Pneumothorax/Hemothorax ○ Partial or complete collapse of alungasaresultofaccumulationofairandbloodin the intrapleural space ○ Signs and symptoms ■ Respiratory distress, cough, hemoptysis, CP ■ Mediastinal shift to the unaffected side ● Chronic Obstructive Pulmonary Disease (COPD) ○ Includes emphysema, chronic bronchitis, bronchiectasis, bronchial asthma ○ Recurrent obstruction of airflow is the common link among these diseases ○ Patient teaching ■ Diaphragmatic and pursed lip breathing to help reduce the respiratory rate and increase alveolar ventilation ○ Treatment ○ ● ● ● ● ● ● ● ■ Low concentration oxygen however it is contraindicated in those with chronically elevated CO2 levels Emphysema ○ Loss of lung elasticity leading to destruction of alveoli ○ Characterized by barrel chest and clubbing in the fingers Pulmonary edema ○ Caused by fluid in the lungs when the heart left ventricle fails ○ Characterized by Pink, frothy sputum, dyspnea, confusion Pulmonary emboli ○ Occurs when a pulmonary artery is blocked by a thrombus originating from the peripheral vein ○ Characterized by dyspnea, cyanosis, unexplained hemoptysis, apprehension Chest tubes ○ Closed drainage used to remove fluid and air from the pleural space ○ Observe for fluctuation of fluid with each respiration in the Water Seal chamber ○ Continuous bubbling is abnormal in a water seal chamber, but normal in a suction control chamber ■ Observe for intermittent bubbling in the Water Seal chamber ■ Observe for continuous bubbling in the suction chamber ○ Do not clamp a chest tube during Transportation or ambulation ○ If the chest tube becomes dislodged, have the client exhale forcefully and apply a petroleum jelly gauze dressing over the site ○ If the drainage compartment brakes, clamp the tube nearest to the client until the system integrity can be reestablished Tuberculosis ○ Airborne precautions ○ Signs and symptoms ■ Productive cough, hemoptysis, night sweats, low grade afternoon fever, weight loss ○ Diagnostic tests ■ Acid fast bacteria sputum test x3 times ■ Mantoux skin test, tine test ○ Main difference between pneumonia and TB is the sudden onsetofchillsandfever in those with pneumonia Pneumonia ○ Droplet precautions ○ Inflammatory process of therespiratorybronchiolesandalveoliarespaceiscaused by infection ○ Signs and symptoms ■ Dry cough, productive, rusty colored sputum Pneumocystis carinii pneumonia ○ Infectious disease most commonly associated with HIV ○ Requires a total laryngectomy ○ Watch for pink, frothy sputum, which is indicative of congestive heart failure and pulmonary edema ○ Watch for white colored sputum, which is indicative of asthma and chronic bronchitis ○ Watch for green colored sputum, which is indicative of bronchitis, lung abscess, pneumonia, and tuberculosis ○ Watch for red colored sputum, which is indicative of bronchogenic carcinoma or tuberculosis ● Bronchodilators ○ Relax smooth muscles and increased respirations by the effect on the beta adrenergic receptors in the bronchioles ○ Ex; epinephrine (adrenaline), Albuterol ● Anticholinergic bronchodilators ○ Prevent bronchospasms caused by acetylcholine ○ Ex; atrovent, atropine (monitor for tachycardia and hypertension) ● Methylxanthine bronchodilator ○ Relax smooth muscles of the tracheobronchial tree ○ Ex; Aminophylline, Theophylline (watch for tachycardia, hypotension, arrhythmias, GI distress, Tremors, anxiety, headache) ■ Toxic levels can cause arrhythmias and seizures ● Anti-inflammatory agents ○ Mast cell stabilizers inhibit the release of histamine, glucocorticoids reduce inflammation and act as bronchodilators ○ Ex; cromolyn sodium, glucocorticoids, prednisone ● Tuberculosis medications ○ Isoniazid, Rifampin, pyrazinamide, ethambutol ■ Expect all excretions to be orange in color on Rifampin Cardiovascular and Peripheral Vascular Disorders ● Electrocardiogram ○ Record of the heart's electrical activity to determine types and extent of heart damage, cardiac irregularities, and electrolyte imbalances ● Cardiac catheterization ○ Insertion of a catheter into the heart vessels surrounding the heart ○ Collects data such as pressure measurement of various Chambers, cardiac output, determination and confirmation of the presence of coronary vessels ○ Complication includes myocardial infarction, there for chest pain should be reported immediately ● Holter monitor ○ Tape recorded ambulatory EKG ○ Monitor cardiac cycle for 24 hours ○ Teach client to keep a diary and record major activities ● ● ● ● ● ● ● ● ● ● Serum enzymes ○ Elevation of enzymes such as SGPT, LDH, and CK will show myocardial damage ○ CK, CK-MB, and troponin 1 are all more definitive tests Stable Angina ○ Severe chest pain lasting 5 to 10 minutes ○ Relieved by rest or nitroglycerin Unstable Angina ○ Not relieved by rest or nitro ○ Can progress to MI ○ Will NOT show ST elevation Variant, prinzmetal's Angina ○ Coronary vasospasm at night Myocardial Infarction ○ Cardiac muscle is destroyed to the interruption or insufficient blood supplytoone of the major coronary arteries for prolongs time ○ Classic ■ ST elevation Heart Failure ○ Group of symptoms which results from decrease pumping effectiveness of the heart ○ Left-sided ■ Congestion occurs mainly in the lungs due to inadequate ejection of the blood into systemic circulation ■ Produces primarily pulmonary signs and symptoms such as orthopnea, cough, and crackles ○ Right-sided ■ Congestion occurs systemically due to inadequate pumping of the blood from the systemic circulation into the lungs ■ Symptoms include peripheral edema, ascites, jugular vein distention, and hepatomegaly Acute Pulmonary Edema ○ Due to excessive quantity of fluid in the pulmonary interstitial spaces ○ Presenting symptoms include moist rales, and pink, frothy sputum ○ Measured by the depth of the depression of the thumb Disorders of the peripheral vascular system ○ Narrowing, obstruction, or damage to the arteries or veins resulting in ischemia, a lack of blood flow to the tissues or organs involved or Venous stasis Arterial disease ○ Pain is provoked by exercise and activity, relieved by rest, worsened with elevation ○ Intermittent claudication refers to leg pain that occurs after exercise and is relieved after rest Buerger's disease ● ● ● ● ● ○ Also known as thromboangiitis obliterans ○ Recurring inflammation of the small and medium arteries and veins of the lower extremities ○ Usually the result of occlusion of the vessels by a thrombus formation ○ Occurs largely in younger male to smoke ○ First clinical signs and symptoms include a bluish color toanextremityorafeeling of coldness in the affected limb Raynaud's disease ○ Intermittent construction of cutaneous blood vessels precipitated by exposure to cold, emotional stress, caffeine ingestion, tobacco use ○ Usually in women from the ages of 16 to 40 ○ Patient teaching should include wearing protective cotton gloves ○ Allen's test ■ Used to evaluate circulation in the hand; the patient willmakeafistandthe nurse will compress the ulnar and radial artery to blanch the hand ■ The patient is asked to open the hand as the nurse releases pressureonone or the other arteries ■ Color returns to hand confirms perfusion Leg measurements to detect swelling ○ Should be done with a patient in dorsal recumbent position ○ Positive homan’s sign will show the presence of thrombophlebitis, which occurs when there is pain in the calf of the leg when the foot is dorsiflexed Aneurysm ○ Localized or diffuse dilation or outpouchings of the vessel wall ○ Patients may complain of back pain or a neurologic pain ○ Patients who complain of sudden onset angina may indicate a rupture or dissection ○ Objective findings ■ pulsating mass, either abdominal, in the chest wall, or in the periumbilical region Varicose veins ○ Abnormally lengthened, dilated, superficial veins, usually  saphenous, result from incompetent valves especially in the lower extremities ○ Goal is to promote venous return by encouraging frequent walks, discouraging prolonged sitting, and discouraging sitting with crossed legs ○ Treatment ■ Vein ligation and stripping ■ Post-opcareincludeselevationoftheextremities,compressionstockings,an anticoagulant therapy ■ Ensure that compression stockings are removed twice a day for a half hour each to ensure skin integrity Arterial ulcers ○ Caused by peripheral vascular disease ○ Arterial stasis ulcers ■ Usually on the tips of toes and indicates arterial insufficiency ■ Progressive disorder that leads to further risk of impaired tissue integrity ● Venous ulcers ○ Caused by chronic venous insufficiency from a clot, varicose vein, valve defects, prolonged immobility, heart failure ● Bruit ○ Caused by turbulent blood flow through stenotic blood vessels ○ Always check clients with dialysis shunt for the presence of bruits and thrills indicating patency ● Deep vein thrombosis ○ To prevent ■ Moving and exercising the legs frequently ○ When already formed ■ Ensure the patient stays on bed rest ● Pacemakers ○ Report uncontrollable hiccupping immediately, as it can indicate a dislodgement ○ Prevent rigorous arm and shoulder movements for 6 weeks after insertion ● Arteriosclerosis ○ Loss of elasticity, thickening, and hardening of arterial walls ○ Usually precedes angina pectoris and myocardial infarction ○ Most common type is atherosclerosis caused by plaque Hematologic, Immune System, & Cancers ● Type and screen ○ AB+/- is universal recipient ○ O- is universal donor ● Transfusions ○ Most common transfusion reaction is fever ○ Only other solution that can be given is normal saline ○ Must be transfused within 4 hours ○ If reaction is suspected, stop transfusion, keep IV access, and replaced transfusion with normal saline ○ If hives is the only reaction during a transfusion, proceed at a lower rate ● HIV ○ CD4 cell count lower than 200 ○ Transmitted through blood, semen, vaginal secretions, urine, feces, saliva and tears ○ Can be vertically transmitted through pregnancy and through vaginal birth ● Essential hypertension ○ No known cause ● Sexual dysfunction drugs ○ Caution with certain antihypertensive drugs ● Buerger's disease ● ● ● ● ● ● ● ● ● ○ Also known as thromboangiitis obliterans, which is a chronic inflammation of the arteries and veins, causing secondary inflammation of nerves ○ Exercises help to promote emptying of the blood vessels by gravity Smoking cessation ○ Largest goal of buerger's disease and Raynaud's disease Live vaccinations ○ Contraindicated in immunosuppressed patients and pregnant women Anemia ○ Mostcommonsymptomsincludefatigueandactivityintolerance,pallor,tachypnea, irritability, generalized weakness ○ Iron deficiency anemia ■ Provide the patient with frequent rest periods ○ Pernicious anemia ■ These patients are susceptible to gastric carcinomas ■ B12 injections for life ○ Iron Replacements should be diluted and given throughastrawtopreventstaining of the teeth ■ If given via IM injection, use z track method to ensure it will not stain skin ■ If given orally, give with orange juice to enhance absorption Sickle cell anemia ○ Clots fast, causes pain ○ Avoid acute episodes by avoiding tight clothing, strenuous exercise, cold temperatures (vasoconstriction), smoking Hemophilia ○ X-linked recessive bleeding disorder, only passed from Mom to male son ○ Patient should be instructed to avoid contact sports Leukemia ○ Risk for injury from infection or bleeding related to pancytopenia Multiple myeloma ○ Most common assessment finding is pathological fractures Thrombocytopenia ○ Decreased number of platelets, which are necessary for clot formation ○ Symptoms ■ Petechiae and bruising DIC ○ The patient begins to hemorrhage after initial hypercoagulability uses up all the clotting factors in the blood (simultaneous bleeding and clotting) ○ Occurs in massive crush injuries, burns, allergic responses ○ The body's clotting ability is exhausted because it is trying to repair somanyareas with coagulation ○ Treatment ■ Heparin (prolongs the time needed for blood to clot, but it doesnotthinthe blood) ● Epistaxis ○ Have the clients it up and lean slightly forward to avoid vascular pressure on the nose and avoid aspiration of blood ● Immunity ○ Passive ■ Antibodies are obtained from another source ■ Natural- mother to fetus ■ Acquired- injection of antibodies ○ Active ■ The individual will produce their own antibodies ■ Natural- the individual hasrecoveredfromadiseaseandacquiredantibodies and memory cells specific for that pathogen ■ Acquired- from a vaccine ● Breast cancer ○ Hard or irregular axillary nodes, skin dimpling, nipple retraction, elevation, and discharge ○ Self exams should be performed monthly, ○ Mammography begins at age 35, yearly ● Cervical cancer ○ Pap smear is a screening tool used for this ● Overall cancer ○ General symptoms include anemia, weakness, weight loss ○ Most common sites of tumor migration ■ Lymph system, lungs, bone, liver, and brain ● Testicular cancer ○ Occurs between the age of 18 and 35 years, mostly in white men ○ Largest risk factor ■ Undescended testicles ○ Normal testes ■ Should feel like small hard boiled eggs, not firm and hard ■ Feel with thumb and forefinger ● Hodgkin's lymphoma ○ Painless progressive enlargement of one or more lymph nodes, as well as the presence of reed-sternberg cells ● Non-Hodgkin's lymphoma ○ Multiple lymph nodes and lymphoid tissues are involved ● Chemotherapeutic drugs ○ Produce bone marrow depression, resulting in a reduced red blood cell count, white blood cell count, and platelet count ○ Anemia, leukopenia, thrombocytopenia ● Radium implant ○ Forceps and containers should be in patients room, never touch with bare hands ○ Decrease time at the bedside and keep radiation exposure to a minimum Gastrointestinal System ● GI bleeding ○ Test for hematocrit and hemoglobin ○ When this occurs high up in the GI tract, the stools will appear black and tarry, as well as sticky ○ When is occurs in the lower portion of the GI tract, the stools will appear bright red ● Vomiting ○ Bright red blood will indicate rapid bleeding ○ Coffee ground blood will indicate slow bleeding ● Diarrhea ○ Occurs with the use of magnesium containing antacids ○ Can lead to transient lactase deficiency ○ Patient teaching ■ Avoid milk when having diarrhea ● Constipation ○ Potential side effects of antacids that contain aluminum ● Fecal impaction ○ Seepage of liquid stools will be a Hallmark sign ● Biliary obstruction ○ Stool will be seen as light, gray, or clay-colored ● H-pylori ○ Used to diagnose stomach ulcers ● Barium contrast ○ The patient should expect an x-ray and a radiopaque ○ The barium should be eliminated from the patient system after it has been introduced the colon to prevent constipation, Mass formation, and possible bowel obstruction ● Upper GI diagnostic tests ○ Patient must be NPO, receive a laxative prep, and push fluids after procedure ○ The patient must remain NPO until the gag reflex returns ● Colonoscopy ○ Pre-procedure includes laxative prep as well as a clear liquid diet that avoids red colored juices and jello ○ Every 10 years ● Sigmoidoscopy ○ Pre-procedure involves an enema ● Gallbladder series ○ Advise the patient to avoid fatty foods prior to the procedure ● Stomatitis ● ● ● ● ● ● ○ Inflammation of the oral cavity as a result of trauma or disease ○ Symptoms ■ Excessive salivation and halitosis ○ Patient teaching ■ Bland diet and cold drinks Esophageal hernia ○ Also known as a hiatal hernia ○ Herniation of a portion of the stomach through the esophageal opening in the diaphragm ○ Risk factors ■ Obesity, ascites, muscle weakness, and tumors ○ Symptoms ■ May be asymptomatic or complain of heartburn and reflux, the patient may also complaining of chest pain while lying down ○ Treatment ■ Sleep with the head of the bed elevated advise the patient toremainupright for 30 minutes after all meals GERD ○ Reflux of stomach contents into the esophaguscauseregurgitation,heartburn,and irritation ○ Patient teaching ■ Small, frequent meals, increase fluid intake and avoid caffeine, alcohol, coffee, spicy foods, Citrus, and chocolate Peptic ulcer disease ○ Patients commonly experienced an aching, burning feeling and gnawing in their epigastric region ○ The patient will feel more intense pain on an empty stomach ■ Meals help to relieve pain ○ Complication includes bleeding ■ Aspirin should be avoided because it contains salicylates which areirritating to the gastric mucosa ○ Patient teaching ■ Avoid alcohol, smoking, stress, salicylates ○ Treatment ■ Triple therapy including two antibiotics and a proton pump inhibitor (omeprazole) or an H2 antagonist (ranitidine) Gastric Ulcers ○ Pain when eating Duodenal Ulcers ○ Pain is relieved by eating Cholecystitis ○ Inflammation of the gallbladder caused by stones (cholelithiasis) Symptoms ■ Pain in the right upper quadrant, sometimes occurs after eating a meal consisting of fried or fatty foods ■ Can radiate to the back ○ Acute phase ■ Patient should be NPO and slowly advance to clear fluids and then alowfat, bland diet as tolerated Hepatitis ○ Inflammation of the liver ○ Symptoms ■ Jaundice, fever, fatigue, loss of appetite,n/v,abdominalpain,jointpain,dark urine, clay colored stools, and diarrhea (only A) ○ Type A ■ Transmitted by excreta, contaminated food products, infected blood transfusion ■ Fecal-oral route ○ Type B ■ Transmitted by blood transfusion or ingestion, sexual route or body secretions, sharing needles ○ Type C ■ Transmitted by contaminated blood ■ No vaccine Pancreatitis ○ The process of autodigestion when thepancreaticenzymesareactivatedwhilestill in the pancreas, not when they reach the intestines where this is supposed to occur ○ Patient teaching ■ Avoid alcohol ■ Patient will be NPO and slowly advance from clear liquid to a low-fat, small, frequent meal regimen Appendicitis ○ Periumbilical pain followed by elevated temperature, anorexia, nausea, and vomiting ○ Pain is localized at mcburney's point, between the umbilicus and the right iliac crest ○ Rovsing’s sign ■ Occurs when palpation of the left lower quadrant causes pain in the right lower quadrant Diverticulitis ○ Inflammation of the diverticula and surrounding intestine ○ Diverticulosis ■ The presence of multiple inflamed diverticula ○ Diverticula ○ ● ● ● ● ● ● ● ● ● ● ● ● ■ Outpouching of the intestinal mucosa through the smooth muscle of the intestinal wall at any point in the GI tract ○ A deficiency in fiber has been associated with this condition ○ Patient teaching ■ Liquid or soft diet during the acute phase, advancingtoahighfiberandbulk forming diet after the pain subsides ■ Provide High residue diet with brand that is high in protein, calories, vitamins, and iron Crohn's disease ○ Cannot be cured by surgical intervention ○ Affects all layers of the bowel wall, from the mouth to the anus, most often the terminal ileum ○ Symptoms ■ Malaise, fever, rectal bleeding, abdominal pain, fistulas, ulcers ○ High risk for developing colon cancer Ulcerative colitis ○ Can be cured by surgical intervention ○ Symptoms ■ Rectal bleeding, rare to see masses or fistulas ○ Begins in the rectrum and proceeds up to the cecum Pernicious anemia ○ Caused by the failure to absorb vitamin B12 because of a deficiency and intrinsic factor from the gastric mucosa ○ Treatment ■ Vitamin B12 injections monthly for life Dumping syndrome ○ Rapid emptying of large amounts of food into the small bowel following a gastrectomy ○ Patient teaching ■ Encourage drinking liquids between meals instead of with meals Liver biopsy ○ Patient will lie on their left side to expose the liver ○ Post procedure, the patient will be lying on their right side to prevent hemorrhage Colostomy ○ In the descending colon, will consist of formed and soft stools ○ Irrigation ■ 1000 cc's of tap water that is 100 to 105 degrees ■ Bottom of the irrigation bag should be placed at the client's shoulder level Abdominal surgery ○ Peristalsis is temporarily halted and usually does not return for one to two days Sucralfate (Carafate) ○ Coats a duodenal ulcer ○ Can cause constipation Omeprazole (Prilosec) ○ Proton pump inhibitor that inhibits gastric acid production ● Cimetidine (Tagamet) ○ Histamine antagonist that blocks the secretion of hydrochloric acid ● Metoclopramide (reglan) ○ Increases gastric motility and gastric emptying Renal System ● BUN ○ Blood urea nitrogen analysiswillindicatetheabilityofthekidneystoexcretewaste products ○ Will be elevated in renal failure, dehydration, and malnutrition ● Renal concentration test ○ Evaluate the ability of the kidney to concentrate urine ○ Measured by specific gravity (1.001-1.035) ● Intravenous pyelogram ○ IVP, injection of contrast dye for visualization of the absence, presents, location, size, and configuration of each kidney, the feeling of the renal pelvis, an outline of the ureters ● Cystoscopy ○ Visualization of the urethra and bladder ● Urinalysis ○ Can test for several disorders including diabetes mellitus, dehydration,UTI,kidney trauma, and glomerulonephritis ○ This test reflects the damage to the glomeruli with the resultant leaking ofprotein and red blood cells ● Urine sample ○ Culture and sensitivity can be collected by a clean catch and identifies bacterial count as well as the Infectious agent and it's antibiotic sensitivity ● Creatinine clearance test ○ The best indicator of kidney's filtration function ○ Measures the amount of creatinine filtered by the glomeruli over 24 hours ● Serum creatinine level ○ Best indicator of the status of glomerular filtration ● 24-hour urine collection ○ Empty bladder completely and discard the urine ○ Save all the urine for the next 24 hours ● Acute renal failure (acute kidney injury) ○ Specific gravity of the scanty output will be low because the kidney is unable to concentrate water ○ Can be caused by pyelonephritis and glomerulonephritis ● ○ Patient at high risk include untreated streptococcal infection, bowel incontinence, and renal reflux ○ Rapid onset of oliguria accompanied by a rising BUN level and serum creatinine ■ Typically this is reversible ○ Other symptoms include anorexia, nausea, vomiting, azotemia,weightgain,altered mental status ○ Patient teaching ■ Low protein, sodium, and potassium ■ High carbohydrates ● Glomerulonephritis ○ Inflammation of glomerulus that leads to leakage of RBCs and protein into urine ○ Causes ■ Post strep infection ○ Symptoms ■ HTN, decreased GFR, edema, tea colored urine from hematuria, elevated BUN, proteinuria ○ Treatment ■ Monitor BP, fluid status, watch for hyperkalemia, limit sodium, ensure adequate intake of potassium ● Nephrotic syndrome ○ Changes to glomerulus that leads to massive leakage of protein in urine ○ Symptoms ■ Massive proteinuria, foamy, frothydarkurine,hypoalbuminemia(lowprotein in blood), edema ○ Treatment ■ Diuretics and IV albumin ■ Low sodium diet ● Chronic Kidney Disease ○ Progressive destruction of the kidney tissue resulting in decreased and a hemostatic function of the kidney ○ Typically irreversible ○ Symptoms include ammonia in the skin and alimentary tract resulting  from bacterial interaction with urea leading to inflammation of mucosal membranes ○ Result in retention of phosphate, decreased calcium, all leading to muscle spasms, tetany, increased parathormone release, and eventually demineralization of bones ○ Also results in waste product retention, which leads to depress bone marrow function, decrease red blood cells, renal tissue hypoxia, decreased erythropoietin production, and eventually further depression of bone marrow functioning ○ Patient teaching ■ Increase fluids to flush the kidneys, check urine for protein, blood, and specific gravity ■ Meticulous perineal care is important ● ● ● ● ● ● ● ■ Low sodium, high calcium, iron, vitamin B, C, D Dehydration ○ Reduced urine output, will lead to elevated specific gravity, indicating concentration of particles from water loss Urinary tract infections ○ Pyridium (OTC Azo) is typically used to treat, teach the patient that it willturnthe urine orange ○ Discouragetheuseofbubblebathsandencourageurinationbeforeandaftersexual intercourse Kidney infection ○ Hallmark sign is flank pain, vomiting Acute glomerulonephritis ○ Inflammatory disease of both kidneys that interfere with glomerular filtration ○ Most commonly caused by repeated streptococcal infections during childhood ○ Symptoms ■ Hematuria and proteinuria ○ Treatment ■ No specific cure, diet include sodium and potassium restriction, but increased protein ■ However, if azotemia is present, protein will be restricted Pyelonephritis ○ Acute or chronic inflammation due to bacterial infection of the parenchyma and pelvis of the kidney ○ Symptoms ■ Kidney pain, impaired sodium reabsorption and protein loss Urolithiasis ○ Presents and formation of stonesintherenalcalculiorpelvisthatpassthroughthe lower regions of the urinary tract ○ Symptoms ■ Severe flank pain (renal colic), pallor, sweating, syncope, shocked, and possible vomiting ○ Strain all urine and check for the presence of stones ○ Encourage decreased calcium and increase fluids (3- 4L/day), increaseambulation to help pass the stones ○ Patient teaching ■ Adhere to a low purine diet Dialysis ○ May be permanent, temporary, stationery, ambulatory ○ Access can be external or internal ○ Effectiveness is measured in a decrease in serumcreatinineandBUNaswellasthe reduction in fluid retention ○ Patients typically will have problems with fluid and electrolyte imbalances Hemodialysis ■ Complications include dialysis disequilibrium syndrome, hypotension, hypertension, arrhythmias, and transfusion reactions ○ Peritoneal dialysis ■ Complications include peritonitis, hypoalbuminemia, bowel or bladder perforation ■ Cloudy dialysate will indicate peritonitis ● Transurethral resection of the prostate (TURP) ○ Removal of prosthetic tissue by instrumentation through the urethra ○ Venous bleeding is common for several days after the procedure ● Perineal prostatectomy ○ Impotence is expected because the procedure involves nerve transaction ● Urinary diversion ○ Via ileal conduit sometimes called the Bricker’s procedure ○ Involves implementation of ureters into a position of the terminal ileum, with the formation of a stoma ○ Complications ■ Paralytic Ileus ■ Changes in urine color, clarity, quantity, smell (mucus in the urine is normal and expected after the surgery) ■ Changes in stoma color to a Dusky or necrotic color is an emergency ● Autonomic dysreflexia ○ Caused by lesion in the thoracic or cervical cord causing hypertension, sweating, and headaches ○ May occur with blockage in the urine catheter or fecal impaction ● Stress incontinence ○ Encourage kegel exercises Endocrine System ● Overview ○ System is composed of glands and operates simultaneously with the central nervous system to maintain homeostasis ○ Responsible for the regulation of metabolism, use and storage of energy through the use of hormones ○ Through the use of a negative feedback system, these glands regulate the body's metabolic rate and expenditure of energy ○ Hormones ■ Majority are regulated by trophic, stimulating hormones secreted by the pituitary gland ● ACTH and TSH ■ The pituitary is influenced by hormones secreted by the hypothalamus ○ Glands ○ ■ Thyroid, pituitary, parathyroid, adrenal cortex and medulla, ovaries and testicles, and pancreas ● Pancreas ○ Secretes two hormones- insulin and glucagon that are necessary for carbohydrate metabolism ○ Insulin in specific is required to control fat and protein metabolism ■ Failure of the pancreas toproduceanadequateamountofinsulincanleadto diabetes mellitus, which is characterized by glucose intolerance ○ Diabetes mellitus ■ Polyuria, polyphagia, and polydipsia ■ Family history, age, and weight all also play a factor ■ Also assess for the presence of ketones in the urine, which indicates set the body is using fat as the major source of energy ○ Type 1 diabetes ■ Manageable with daily exercise and a Diet low in fat and simple sugars ■ Encourage the patient to have regular timing and consistency of meals ● Insulin ○ Regular insulin ■ Short-acting, Peaks within 2 to 4 hours ○ NPH insulin ■ Intermediate acting, Peaks within six to twelve hours ○ Ultralente insulin ■ Long-acting, Peaks within 14 to 24 hours ● HBA1C ○ Important index of glucose control becauseitidentifiesaverageglucoselevelsover the past 3 months ● Hypoglycemia ○ Symptoms include diaphoresis, headache, weakness, irritability, and slurred speech ○ Treatment ■ Orange juice or glucose tablet if they are able to swallow ■ IV D50 if unable to swallow/unconscious ● Hyperglycemia ○ Blood glucose levels above 120 ● Diabetic ketoacidosis ○ Complication ofinsulindependentdiabetesmellitus,causedbytheaccumulationof ketones in the blood, leading to metabolic acidosis ○ Symptoms ■ Watch the skin, fast, deep labored breathing, acetone, fruity breath ■ Patient will present with kussmaul's respirations ○ Treatment ■ Fluid replacement, electrolyte replacement, insulin therapy (usually a drip) ● Diabetes insipidus ● ● ● ● ○ Caused by a lack ofantidiuretichormone,whichisresponsibleforthereabsorption of water in the kidneys ○ If ADH is lacking, adequate reabsorption of water is prevented, which leads to diuresis, which leads to concentrated blood and dehydration ○ High sodium, high pee ○ Diagnostic procedure ■ SG will be less than 1.005 SIADH ○ Syndrome of inappropriate antidiuretic hormone ○ Results from too much ADH, causing excess water being reabsorbed by the kidneys ○ Low sodium, low pee ○ Diagnostic procedures ■ Urine and serum levels, as well as osmolality levels Thyroid gland ○ Produces levothyroxine and T3 ○ These hormones affect the speed of chemical reactions, the volume of oxygen consumed, and the amount of heat produced by the cells ○ Hypothyroidism ■ Deficiency of thyroid hormone resulting in decreased body metabolism related to decreased oxygen consumption by the tissues ■ Complication includes myxoedema, a severely hypermetabolic State leading to a coma (characterized by non pitting edema in the periorbital and facial area) ■ Patient will present with decreased metabolic rate, hypoventilation leading to respiratory acidosis, hypothermia, hypotension ■ Patient will be on Synthroid for life ○ Hyperthyroidism ■ Defined as excessive secretion of thyroid hormone commonly caused bythe over functioning of the thyroid gland, most common form is Graves disease ■ Patient will present with goiter and abnormal protrusion of the eyes, called exophthalmos Addison's disease ○ Hypofunction of the adrenal cortex, adrenal insufficiency ○ Symptoms ■ Weakness, fatigue, n/v, hypotension, tachycardia, low BS/sodium, high potassium/calcium ○ Patient will need replacement therapy for life Cushing's syndrome ○ Patient has a high risk for fluid volume excess ○ Hypersecretions of glucocorticoids ○ Symptoms ■ Moon face, buffalo hump, neck fat, high BS/sodium, low potassium/calcium ● Hypocalcemia ○ Positive signs include trousseau's sign and chvostek's signs ○ Monitor all calcium levels Neurosensory System ● Glasgow Coma Scale ○ Used to assess levels of consciousness and clients with neurological problems ○ Consist of eye-opening, motor response, and verbal response ○ Maximum score of 15 ● Cranial nerves ○ OOOTTAFAGVSH ■ Oh once one takes the airplane flight a great vacation seems heavenly ○ Olfactory (smell) ○ Optic (vision) ○ Oculomotor (pupils/eye movements) ○ Trochlear (eye movement down and medial) ○ Trigeminal (jaw) ○ Abducens (eye side to side) ○ Facial (expressions) ○ Acoustic (hearing/balance) ■ Susceptible to  toxicity to aminoglycosides such as erythromycin and Gentamicin ■ Signs of ototoxicity include tinnitus, dizziness, vertigo, nausea, and vomiting ○ Glossopharyngeal (swallowing, gag reflex) ○ Vagus (swallowing, gag reflex) ○ Accessory/spinal (shoulders) ○ Hypoglossal (tongue and speech) ● Meniere's disease ○ Balance disorder that causes vertigo, hearing loss, and tinnitus ○ Patient teaching ■ Encourage the patient to adhere to a low sodium diet, as well as  avoiding  alcohol, caffeine, and tobacco ● Increased ICP ○ Most significant sign is a decrease in Loc ○ Presentation ■ Widening pulse pressure, lethargy, decrease pulse, increase blood pressure, elevated temperature ■ Sunsetting eyes ○ Nursing care ■ Elevate HOB to 30 degrees ● Retinal detachment ○ Patient will see a veil like curtain individual field as well as flashes of light ○ NOT blindness, NOT painful ● ● ● ● ● ● ● ○ After surgery, patient will need a patch on both eyes and keep the eyes bandaged for 24 hours Cataracts ○ A normally transparent lens becomes cloudy and opaque, leading to Progressive blurring and gradual loss of vision ○ After surgery, teach the patient to avoid increasing intraocular pressure by coughing or rapid head movement Glaucoma ○ Abnormal increase in intraocular pressure that is considered a medical emergency ○ Open-angle ■ Resulting gradual loss of peripheral vision, leading to tunnel vision ○ Narrow-angle ■ hazy/blurred vision Aphasia ○ Complete or partial lossoflanguageskillscausedbydamagetothecorticalareasof the brain's left hemisphere ○ Expressive ■ Provides the patient with a communication board or an alternative way of communication ■ Knowing what you want to say but can’t get it out ○ Global ■ Most severe, when someone is listening to  words/communication but cannot understand Hemianopia ○ Characterized by defective vision or blindness in half of the visual field ○ Seen as a symptom of stroke EEG ○ Avoid stimulants prior to the procedure such as coffee or tea Seizures ○ First nursing priority is to protect the head from injury and move anything in the environment that may enter the patient ○ Avoid restraining the patient and stay with them until the seizure is completed ○ Nursing care ■ Place the patient on their left side to prevent aspiration ■ Dilantin may be used to treat seizures, teach patient that it can cause gum hyperplasia and red colored urine ■ Nothing in the mouth Romberg's test ○ Known as the falling test, assesses the patient's ability to maintain balance and assess vestibular function ○ UsuallyperformedinadditiontotheWeberandRinnetests,whichevaluatehearing acuity ● Kernig's sign and brudzinski's sign ○ Frequently seen in client suffering from meningitis ○ Kernigs’ ■ Present if a lower leg cannot extendduetopainwhenaclientislyingsupine with one leg bent over the abdomen ○ Brudzinski ■ Present if a client's hips and knees Flex when they are lying supine with the head lifted for the chest ● Babinski's reflex ○ When the sole of the foot is stroked from the heel to the ball, the toes should curl downward ( negative) ○ If the toes flare up word this indicates apositivetest,andisabnormalaftertheage of 2 years ■ If positive, can indicate head trauma ● Parkinson's disease ○ Progressive, degenerative disorder caused by dopamine depletion and result in a decline in muscular functioning ○ Symptoms ■ Tremor at rest, rigidity, slow movements, shuffling gait, mask like face, emotional lability, drooling, and sweating ○ Nursing care ■ Maintain a safe environment ■ levodopa-carbidopa ● Multiple sclerosis ○ Progressive CNS disorder caused by demyelination in the brain and spinal cord ○ Multiple Foci of demyelination are distributed randomly in the white matter of the brain stem, spinal cord, optic nerves, and cerebrum ○ Symptoms ■ First indication is visual problems ○ Nursing care ■ Provide a safe environment and maximize the patient's independence ● Myasthenia gravis ○ Autoimmune disorder causing disturbances in the transmission of impulses from muscles resulting in extreme muscle weakness and fatigue that increases with exertion and improves with rest, eventually this will lead to fatigue without relief from rest ○ Diagnostic test ■ Tensilon test ● Amyotrophic lateral sclerosis (ALS) ○ Progressive, fatal, motor neuron disease causing Progressive muscular atrophy ○ Nursing care ■ Monitor respiratory function and the patient's ability to swallow ● ● ● ● ● ● ● ■ Cause of death is usually pneumonia secretary to an effective respiratory function Bell's palsy ○ Paralysis of  one side of the face, usually  due to inflammation of the 7th cranial nerve ○ Patient teaching ■ Usually lasting only two to eight weeks, the patient should prevent corneal drying by using artificial tears Guillain-Barre syndrome ○ Autoimmune disorder characterized by Progressive ascending paralysis that most often ceases within 4 weeks, with complete recovery around 3 to 6 months ○ Causes motor weakness symmetrically and it is sending fashion ■ Weakness starts in the feet and moves upwards ○ Nursing care ■ Maintain an airway, because the airway is compromised when the disease reaches the diaphragm Huntington's disease ○ Inherited disorder causing progressive atrophy of the basal ganglia andportionsof the cerebral cortex ○ Symptoms ■ Extreme emotional lability, dementia, and uncontrolled limb movements Spinal cord injuries ○ C3 or above are usually fatal because of the muscles used for breathing are now paralyzed ○ Thoracic and lumbar Injuries affect the legs, bladder, and bowel ○ Nursing care ■ Monitor for autonomic dysreflexia, when the patient will experience bradycardia, facial flushing, and severe headache and hypertension; the brain is unable to send those signals to lower the blood pressure due to the spinal cord injury Head injury ○ Hyperthermia of approximately 105 degrees Fahrenheit is observed ○ When testing cerebrospinal fluid, we are looking for glucose, which indicates that the leakage is CSF fluid ○ Deafness and Virgo indicate that cranial nerve #8 is affected Meningitis ○ Droplet precaution ○ Lumbar puncture ■ Patient will lay on their side with their knees curled up toward the chest ■ Following procedure, patient will be on bed rest for 6 to 8 hours Snellen chart ○ Denominator indicates the degree of visual Acuity when the patient is able to read our particular line of letters stand in 20 ft away (numerator) ○ The smaller the denominator, the better the vision Musculoskeletal System ● Overview ○ The skeleton supports and protects the body well the muscles and connective tissue add support and allow for movement ○ The bones story release minerals ○ The bone marrow produces erythrocytes and thrombocytes ● Gout ○ Deposits of uric acid crystals in the synovial joints ○ Gouty arthritis ■ Metabolic disease characterized by urate deposit and pain in the joints, especially in the feet and legs ■ Diagnosis is based on serum uric acid levels, which should be below 8mg/dL ● Purine metabolism ○ Problems with this metabolism results in an increase in uric acid levels in the blood ○ Treatment ■ Allopurinol is the preferred treatment to treat gout ■ Colchicine helps toreducethepainandswellingduringanacutegoutattack, important to administer with foods and increase fluids while on this medication ● Rheumatoid arthritis ○ Chronic, progressive disease that destroys synovial bone joints and connective tissue ○ Symptoms ■ Joint swelling, low grade fever, fatigue, weakness, paresthesias ■ Can also cause bilateral and symmetrical stiffness in the joints that is worse in the morning ○ Treatment ■ Humira IM ● Osteoarthritis ○ Non-inflammatory degenerative joint disease marked by Progressive pain that is relieved by rest ○ Typically involves the weight-bearing joints and  is characterized by  a loss of cartilage on the articular surfaces of the joints, also spur development ○ Pain will be worse during activity and the patient is usually overweight ● Osteoporosis ○ Most common metabolic Bone disorder, causing decreased bone mass and increased risk of fractures ○ Causes ■ Calcium and estrogen deficiency ● ● ● ● ● ● ● ● ● ● ○ Symptoms ■ Gradual loss in height after menopause Bunions ○ May be congenital or acquired by wearing shoes that are too narrow, high heels ○ All of these increase the pressure on the Bursa at the metatarsal phalangeal joint Carpal tunnel syndrome ○ Patients will exhibit a positive tinel's sign, as well as shock-like pain in reaction to percussion of the median nerve at the wrist ○ Patience will also have a positive phalen's sign, which is characterized by hand tingling and numbness with a cute wrist flexion Lupus ○ Characteristic sign is a butterfly rash over the bridge of the nose Hip replacement surgery ○ Primary goal after surgery is to prevent hip adduction and hyperflexion ■ Prevent the patient from bending at the hips Beyond 90 degrees ■ Use abduction pillows between the legs to reduce the risk of a dislocation ○ Patient teaching ■ Avoid Crossing her legs while sitting ■ Use an abduction pillow, or wedge while laying down Lumbar laminectomy ○ The patient should only be moved by way of log rolling Compartment syndrome ○ Secondary edema that causes an increase in the pressure in a closed spaces ofthe tissue compartment formed by an elastic faccia ○ As the pressure increases, obstruction of the venous circulation and arterial occlusion occur, leading to ischemia ○ Symptoms ■ Progressive pain that is distal to the injury, unrelieved by analgesics ■ Edema, paralysis,  decreased or absent peripheral pulses, delayed capillary refill, colder lamp temperature Fat embolism ○ A serious complication that occurs after a bone fracture, especially the long bones ○ Pulmonary circulation is typicallywherethefatembolibecomesobstructed, which leads dyspnea, chest pain, coughing, tachycardia, and restlessness Pressure ulcers ○ Turn the patient every two hours and elevate bony prominences off the bed to prevent ulcers from occurring ○ Stage 1 ■ A reddened area that does not blanch, treat aggressively Multiple myeloma ○ Bone fractures are a common complication Paget's disease ● ● ● ● ● ● ● ● ● ● ○ Common bone disease that affects middle-aged and elderly people that is marked by inflammation of Bones,  softening and thickening of Bones, excessive bone destruction, and unorganized bone repair, resulting in the Bowing of long bones Phantom limb pain ○ Occurs when an amputee complains of severe pain in the removed body part ○ Nursing care ■ Stump care to promote healing ■ Exercise to maintain the tone of the unaffected muscle ■ Physiological support ■ Never assume that they do nothavepaininkneeremovedlimb,treatallpain aggressively ■ To reduce swelling, the residual limb should be elevated on a pillow for 24 hours, Check the residual inperiodicallytoensurethatitis lyingcompletely flat Cast care ○ Support drain cast on pillows, do not cover ( allow it to air-dry) ○ Frequently assess pulse is, color, movement, and sensation distal to the cast ○ Monitor neurovascular status of the extremity one to two hours after the application of the cast Skin traction ○ Used for relief of painful muscle spasms ○ Bucks and Russell traction ○ Bryant's traction ■ Vertical suspension where the pelvis is elevated from the bay ○ Skeletal traction ■ Appliance of direct traction to the bone using pins and wires Sprain ○ Soft tissue injury that occurs when a muscle or tendon is excessively stretched Strain ○ Excessive stretching of one or more ligaments that results from twisting movements Heat treatment ○ Increase vasodilation, decrease muscle spasms, joint stiffness, and pain Cold treatment ○ Promote vasoconstriction, decrease swelling, muscle spasms, and pain Cane walking ○ Hold the cane on strong side and advance the cane at the same time as the weak extremity Walker ○ Move walker forward and then step into it Crutches ○ 4-point gait ■ Use when weight-bearing is allowed on both extremities 2-point gait ■ Right crotch moves with the left leg and the leftcrotchmoveswiththeright leg ○ 3-point gait ■ Used when weight-bearing is permitted on one extremity only ○ Swing through gait ■ Used for patients with paralysis of both lower extremities ○ When advancing upstairs, the patient leads with the unaffected leg, and then the crutches and injured leg together Integumentary System ● Overview ○ Priority includes Burns and skin breakdown ○ Composed of hair, skin, nails, sebaceous, and sweat glands ○ Primary nursing interventions include ensuring patient comfort and providing client education regarding medications and procedures ● Skin cancer ○ One out of every seven individuals ○ Leading causes include exposure to the sun, x-rays, Arsenic, and coal ○ Those at highest risk are those with Fair complexion and history of previous  melanomas ● Burns ○ Caused by thermal heat, chemical exposure, and electrical current, and smoke inhalation ■ After a chemical burn, wash with water or normal saline ■ After a thermal burn, the most important goal is to maintain fluid and electrolyte balance is, as well as the acid-base balance to prevent complications such as shocked, dice, respiratory and cardiac failure, and acute tubular necrosis ○ Burns destroy the epidermis, allowing tissue fluid toescapeandleavingthepatient vulnerable to infection ○ Rule of Nines, Palm method ■ Used to determine the extent of the injury ○ Emergent phase ■ Removal from source of burn and stabilization ○ Shock ■ 24 to 48 hours after the injury ○ Diuretic ■ Fluid resuscitation ○ Convalescent ■ Wound care, nutrition, and prevention of gastrointestinal complication ○ Parkland formula ○ ■ In the first eight hours following the injury, give ½of4mLNSSxkgx%body burned ■ In the following 16 hours, give the other ½ ○ Pulmonary compromise ■ Will show in nasal flaring, hoarseness, sputum, and labored respirations ● Pressure ulcers ○ Decubiti ○ Breaks in the skin caused by friction or interference with the blood supply to the tissues ○ prevention includes turning the patient every two hours while on bedrest ● Contact dermatitis ○ Caused by exposure to a physical or chemical allergen ○ Symptoms ■ Itching cosima, raised papules ● Impetigo ○ Contagious superficial skin infection caused by S. Aureus ○ Characterized by a small, red macule that turns into a vesicle that becomes pustular with honey-colored crusts ○ Can lead to glomerulonephritis ● Herpes zoster ○ Highly contagious infection that's transmittedbydirectcontactwithvesicularfluid or Airborne droplets ○ Patient will be in isolation ● Scabies ○ Gray, brown Burrows, epidermal curved or linear ridges and follicular papules ○ Patient will complain of severe itching that occurs mostly at night  Maternity Diagnostic Tests & Reproductive System ● Human chorionic gonadotropin (HCG) ○ Test forthepresenceofhumanchorionicgonadotropin,ahormonesecretedbythe placenta ○ Indicates a positive pregnancy test, increases in a woman's blood and urine until the 15th week of pregnancy ○ Urine test kit from the pharmacy will also test for HCG in the urine ● Radio immunoassay ○ Will be positive up until 8 days after ovulation, or 6 daysbeforescheduledmenses, results are obtained in 1 hour ● Doppler ○ Auscultation of fetal heart rate is usually done at 10 weeks to 12 weeks of gestation ○ Can also help to rule out fetal abnormalities ● Pelvic sonogram