Bullets In Medical Surgical Nursing

BULLETS (Authored from previous board exam questions)

 Chest X ray  painless procedure  Bronchoscopy o AtSO4  Anticholinergic  mimics SNR  Decreases saliva  dry mouth o NPO 6 to 8 hours o Local anesthesia  check gag reflex before feeding  ABG

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Hyperventilation  decreased CO2  increased blood pH  respiratory alkalosis Hypoventilation  increased CO2  decreased blood pH  respiratory acidosis Diarrhea  decreased HCO3  decreased blood pH  metabolic acidosis Vomiting gastric content  decreased HCL  increased blood pH  metabolic alkalosis Vomiting blood  decreased O2  anaerobic metabolism  formation of lactic acid  decreased blood pH  metabolic acidosis o Blood pH  normal 7.35 to 7.45  If increased  alkalosis; If decreased  acidosis o Partial CO2  normal 35 to 45 If increased Respiratory Acidosis; if decreased Respiratory Alkalosis o Partial HCO3  normal 22 to 26  If increased Metabolic alkalosis; If decreased metabolic acidosis

 Cancer of the larynx  CS, alcohol and over usage of voice (choir member) o o o o

A - nterior neck mass B – urning sensation with hot beverages / Bad breath C - hange in the voice (hoarseness) D – ysphagia/dyspnea

 Chronic Obstructive Pulmonary Disease o Chronic Bronchitis  Blue bloater  Excessive mucus production o Asthma  Periods of bronchospasm and bronchoconstriction o Emphysema  Disequilibrium of elastase and antielastase  Pink puffer o Manifestations  A – LTERATION IN • LOC  decreased O2 • Thoracic anatomy  over distention of alveoli  TD = APD  barrel chest • Skin o Temperature  cool clammy skin o Color  pale to cyanotic • ABG  Respiratory acidosis  Increased CO2  B – reathing  difficulty, purse lip  expiration > inhalation  removal of excess CO2 (diet low CHO)  C – ough (mucus production); Chronic hypoxia (2 to 3 lpm of O2 therapy, decreased O2 demand by rest and SFF)  clubbing of the fingers and decreased TP to the kidneys causing polycythemia  D – ecreased Metabolism • Anorexia  weight loss (high calorie diet)  fatigue  weakness  Bronchodilators o Theophylline and aminophylline  Primary effect  stimulates beta 2 receptors  smooth muscle relaxation  bronchodilation  Side effect  stimulates beta 1 receptors  increases cardiac rate  need not to notify the physician

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Adverse effect  hypotension  monitor BP  sign of toxicity Evaluation  check breath sounds

 Acute Respiratory Distress Syndrome o Causes  A – spiration  R – espiratory trauma (embolism) • fracture  embolism  ARDS  D – rug toxicity (ASA)  S – epsis and shock • Vomiting, bleeding, dehydration hypovolemia  shock  ARDS o Syndrome  Severe hypoxia  Bilateral infiltrates  Dyspnea  Pulmonary embolism o Restlessness  earliest sign  Water Seal System o Drainage Bottle → marked the level every shift o Water seal bottle  Presence of fluctuation → normal  Absence of fluctuation → lungs are fully expanded → assess first patient (X ray → confirm) OR presence of obstruction  Intermittent bubbling → normal • Absent → obstruction • Continuous → leakage o Suction Control → continuous bubbling → normal  Risk factors for cardiovascular disorders o R – ace  non modifiable o I – ncreased blood pressure  modifiable o S – tress  SNR  increased BP and CR, vasoconstriction  modifiable o K – nowing sedentary life style  modifiable o F – at foods atherosclerosis  modifiable o A – lcohol (modifiable) / Age  above 40 (non modifiable) o C – igarette smoking  vasoconstriction (nicotine)  modifiable / Contraceptive pills  clotting of blood  thrombus formation o T – ype A behavior (modifiable)  competitiveness, perfectionist  high stress level o O – besity o R – esult of DM  lipolysis  increased fatty acids  atherosclerosis o S – ex gender  males > female (before menopausal because estrogen decreases PVR) after menopausal female eversible}[inverted T wave]  Injury [elevated ST segment] > male

 Decreased TP in heart  Ischemia (Angina) {r necrosis (MI) {irreversible}[pathologic Q wave/permanent in the ECG]

 Eating a heavy meal, strenuous exercise, sex, exposure to cold  Decreased blood flow (heart) decreased TP (heart) decreased O2 (heart) anaerobic respiration  production of lactic acid  PAIN  management decreased O2 demand by rest and SFF

 Angina o o

Pain relieved by rest and NTG NTG  Vasodilation  orthostatic hypotension  move gradually  Monitor BP  Store in a dark and amber container

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Effective  tingling sensation  no need to notify physician Maximum of 3 tablets with 5 minute interval

 MI o

Pain relieved by Morphine SO4  Narcotic analgesic  Can cause respiratory depression  monitor RR and O2 saturation  Antidote  narcan

 Cardioversion  synchronous  Defibrillation  unsynchronous  Buerger’s disease  CS  vasoconstriction  stop CS  common in men  Raynaud’s  stress and cold  vasoconstriction  common in female  Congestive heart failure o Left sided  pulmonary  Dyspnea  Crackles  Polycythemia  due to decrease O2 to the kidneys  Clubbing of the fingers  due to prolonged hyxia  Orthopnea o Right sided  systemic  Hepatomegaly  Distended neck veins  Edema  Portal hypertension  Ascites  weight gain  Varicose veins o Digoxin  Cardiac glycoside  Positive inotrophic effect  increased strength of myocardial contraction  Negative chronotrophic effect  decreased cardiac rate  monitor CR  never give if CR below 60 bpm  Adverse effect • V – omitting • A – norexia • N – ausea • D – iarrhea • A – bdominal pain • REMEMBER: earliest  GI; late  halo vision • Antidote  Digibind

 Decreased RBC → Activity in tolerance, Fatigue, provide rest, Anemia  Decreased Platelets → Prone to bleeding, avoid parenteral injection, appl pressure on injection site, high risk for injury

 Decreased WBC → prone to infection, reverse isolation  Increased WBC → presence of infection  First Day/Newly diagnosed → Knowledge deficit  Diuretic o D – iet  high K diet except aldactone o I – input and Output  expected increased output o U – ndesirable effect electrolyte imbalance (K)

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R – ecord weight  expected decreased weight E – lderly  special precaution T – ake in AM and with food I – ncreased orthostatic hypotension  monitor BP and move gradually C – ancel alcohol because of mild diuretic effect

 Heparin  anticoagulant  prevent further enlargement of clot not dissolve them  monitor APTT/PTT  antidote protamine SO4

 Coumadin  anticoagulant  prevent further enlargement of clot not dissolve it  monitor PT  vitamin K is the antidote

 Urokinase/Streptoase → dissolves the clot  Pernicious anemia  absence of intrinsic factor (gastric surgery) problem in absorption of Vitamin B12  beefy red tongue schilling’s test  definitive test  24 hour urine collection  life long Vitamin B12

 Gastritis  LUQ pain  Gastric ulcer  affected area stomach  pain (precipitated by food intake  increased HCl)  pain relieved by antacids

 Duodenal ulcer  affected area duodenum  pain (2 hour after eating)  pain relieved by food  Ulcers  bleeding  (+) occult blood test (guiac) high fiber diet, avoid red meat, iron, steroids, NSAIDs, indomethacin

 Vagotomy  resection of vagus nerve  decreased cholinergic stimulation  decreased HCl and gastric movement

 Dumping syndrome  tachycardia and weakness  3 D’s (diarrhea, diaphoresis and dizziness)  fluids after meals, lie down after meals and SFF

 Appendicitis  RLQ pain  avoid heat pads  cause rupture  signs of ruptured appendix  sudden cessation of pain, elevation of temperature and WBC

 Diverticulitis  LLQ pain → low fiber diet  Diverticulosis → high fiber diet  Ulcerative colitis  bloody diarrhea 15 to 20 times a day  fluid volume deficit, anemia  Liver cirrhosis  alcohol and malnutrition (laennec’s), infection and drugs (post necrotic), RSCHF (cardiac) and biliary obstruction (biliary) o Portal hypertention can lead to  Blood shifted to the different collateral • Esophageal varices • Spider angioma (face and neck) • Caput medusae (abdomen) • Hemorrhoids (rectal) • Management avoid rupture  avoid shouting, valsalva maneuver  Increased hydstatic pressure  fluid shifting  ascites o Decreased albumin  decreased oncotic / colloidal osmotic pressure  fluid shifting  ascites  management high protein diet o CHON metabolism  by product ammonia  liver cannot convert to urea  increased level of ammonia in the brain  Alteration of LOC and changes of behavior and asterexis hepatic encephalopathy  management low CHON diet and lactulose for removal of ammonia

 Hepatitis A  fecal oral  prone plumber

 Hepatitis B  body secretion  prone working in a dialysis  Cholecystitis  5 F’s (fair, female, fat, fertile and forty)  RUQ pain  after ingestion of fatty food  demerol to relieved pain

 Cholecystectomy  T tube  level of the incision site  drain excess bile  Pancreatitis  alcohol  autodigestion  LUQ pain  Anterior Pituitary gland o Growth hormone  Increased before the closure of the epiphysis of the long bones  gigantism  tall  Increased after the closure of the epiphysis  acromegaly  big hands (big gloves), big feet (big shoes) and big head (big hat)  Decreased  dwarfism o Prolactin  Increased  galactorrhea  Decreased  decreased milk production o ACTH  Increased  secondary cushing’s  Decreased  secondary addison’s o TSH  Increased  secondary hypethyroidism  Decreased  secondary hypothyroidism  Posterior pituitary gland o ADH  Increased  water retention  oliguria  edema (fluid volume excess) and weight gain  concentrated urine  increased urine specific gravity  Decreased  water excretion  polyuria  dehydration (fluid volume deficit and weight loss)  diluted urine  decreased urine specific gravity  Parathyroid gland o Parathormone  Increased  increased calcium in the blood and decrease calcium in the bones  stone formation and decreased bone mass  osteoporosis  management increased water intake  Decreased  hypocalcemia  calcium supplement  Thyroid Gland o Increased (hyperthyroidism)  T3 and T4  increased BMR  hyperactive  inability to focus  insomia  increased catabolism  weight loss  increased appetite  increased peristalsis  Diarrhea  fluid volume deficit  Increased CR and RR (due to increased BMR) • Increased T3  heat intolerance  Calcitonin  decreased calcium in the blood  tetany  compensatory  calcium withdraws from the bones  bone destruction (complication)  PTU  decreased synthesis of TH  watch out for SE (similar to signs and symptoms of hypothyroidism)  watch out for agrunulocytosis (fever, skin rash and sore throat)  Lugol’s solution  decreased released of TH  before thyroidectomy  decreased vascularity of the thyroid gland o Decreased (hypothyroidism)  T3 and T4  decreased BMR  hypoactive  sleeps a lot  decreased metabolism  weight gain  anorexia  decreased peristalsis  constipation  decreased CR and RR due to decreased BMR  T3  cold intolerance  Calcitonin  hypercalcemia  stone formation  Synthroid and Proloid  increased TH  Adrenal Gland o Incresead (cushing’s)  Glucocorticoids  hyperglycemia and decrease wound healing

Mineral corticoids  increased aldosterone  sodium retention and potassium excretion  hypernatremia and hypokalemia • Hypernatremia  water retention  oliguria  edema (moon face,buffalohump, fluid volume excess and weight gain)  concentrated urine  increased urine specific gravity  low sodium diet • Hypokalemia  weakness  Prominent U wave  high potassium diet  Epinephrine and Norepinephrine  Increased BP and CR  Sex hormones • Males  gynecomastia and falling of hair • Females  hirsutism and deepening of the voice Decreased (addisons)  Glucocorticoids  hypoglycemia and inability to cope with stress  Mineralcorticoids  decreased aldosterone  sodium excretion and potassium retention  hyponatremia and hyperkalemia • Hyponatremia  water excretion  polyuria (dehydration, fluid volume deficit and weight loss)  diluted urine --. Decreased urine specific gravity  increased fluids and Na • Hyperkalemia  weakness  tall or peaked T waves  low K diet  Epinephrine and Norepinephrine  decreased BP and CR

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 Diabetes Mellitus o Type I  absolutely no insulin  thin  insulin o Type II  insufficient insulin  obese  OHA o Diet  50% CHO, 30% Fats, 20% CHON o Exercise  Increased uptake of glucose  Decreased insulin requirement o Oral hypoglycemic agent (OHA)  Stimulates pancreas to produce insulin

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Insulin    

SC; IV if DKA Never massage the area Never administer cold insulin Rotate the site of injection • PREVENTS LIPODYSTROPHY  Mix • Aspirate clear first • Inject air to cloudy first Hypoglycemia  W – eakness  H – unger pangs  A – alteration of LOC  T – achycardia and tremors

A – bdominal pain B – blurring of vision C – ool clammy skin D – iaphoresis Give  orange juice (simple sugars) o DKA → increased lipolysis increased ketones o Hyperglycemia  polyuria, polydipsia, polyphagia, kussmaul breathing, glycosuria, ketonuria and warm flush skin o Glycosylated hemoglobin  reflect BSL for the past 3 to 4 months  most accurate o Foot care  Podiatrist  Avoid removing corns and calluses  Cut toe nails straight across  Avoid walking bare foot

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 Hepatitis A → fecal oral  Hepatitis B → body and bloody secretions (hemodialysis)  Peritoneal Dialysis o Diasylate output is decreased → turn patient from side to side o Complication → infection → monitor WBC and temperature, diasylate is cloudy → boardlike and rigid abdomen → peritonitis o Don’t include diasylate solution in the output of the client o Expected → decreased weight → monitor weight before and after → decreased createnine and BUN

 Heart block → decreased tissue perfusion  Parkinson’s diasease o Decreased dopamine in the basal ganglia → levodopa to increased dopamine → avoid Vit B6 foods o Cardinals signs → tremors (non intentional) → muscle rigidity → bradykinesia o Pill rolling o Microphonia → ask your client to speak aloud to be aware o Artane and Cogentin → anticholinergic → decreased muscle rigidity  Myasthenia Gravis o Tensilon test → confirmatory test o Decreased Acetylcholine and increased cholinesterase o Muscle weakness → priority airway o NO tranquilizer, Morphine SO4, Muscle relaxant and neomycin o Cholinergics (mestinon) → increased muscle strength → antidote ATSO4  Undermedication → myasthenic crisis → give cholinergics  Over medication → cholinergic crisis → give ATSO4

 Multiple Sclerosis o Demyelinization of the myelin sheath o Charcoat’s triad  Intentional tremors  Scanning of speech  Nystagmus o Visual disturbances → diplopia

 Pancreatitis → autodigestion → alcohol → bleeding → shock o

Elevated amylase

 Rheumatoid Arthritis o No specific diagnostic test o NSAID’s and ASA (antipyretic, analgesic and anti-inflammatory) o Synovitis → Pannus formation → fibrous ankylosis (limited joint movement) → Bony ankylosis (joint fixation) o Avoid flexion and promote prone position  Gouty Arthritis o Increased uric acid → allopurinol and avoid organ meats (liver) → tophi (ears)  Osteoarthritis o Most common → related with aging o Pain after weight bearing exercise or activity → rest to relieved pain → weight reduction

 Diverticulitis → LLQ pain and low fiber diet  Cyclophosphamide (Cytoxan) → can cause hemorrhagic cystitis → to avoid increased fluid intake  Vincristine (Oncovin) → increased fiber in the diet  Iron supplement →When is the best time to take (empty stomach), How is best taken (with orange juice)  Steroids and NSAID’s o DEATH → inflammation o BIRTH → side effects  B – one marrow depression → prone to infection → monitor temperature and WBC  I – ncreased gastric irritation → take it with food or after meals  R – enal toxicity  T – innitus  H – epato toxic

 Cataract → common cause is aging (senile) → opacity of the lens → position on the unaffected side  Glaucoma → increased IOP → decreased of peripheral vision first → halo, tunnel and gun barrel vision → miotics (constricts pupils) → avoid ATSO4 (dilates pupil)

 Retinal detachment → trauma → blood clots → floating spots → dependent position→ scleral buckling  Avoid Increased Intraocular pressure → PRIORITY o

Avoid vomiting, coughing, valsalva maneuver, lifting heavy objects, bending, crying

 Meniere’s → Triad → tinnitus, impaired hearing loss and vertigo → low Na diet o Vertigo → imbalance → high risk for injury → decreased vertigo by focusing on one side of the room → assume a flat or reclining position

 ASA → 8th cranial nerve damage → tinnitus, impaired hearing loss and vertigo  Antibiotics → allergic reactions

 Normal Values o BUN = 10 – 20 mg/dl o Calcium = 9 to 10.5 mg/dl o Creatinine = 5 to 1.5 mg/dl o GTT = 70 to 115 mg/dl o O2 sat = 97 to 98%  Signs and Symptoms of Increased Intracranial Pressure o B – lood pressure and temperature are elevated o R – espiratory and cardiac rate are decreased o A – lteration of LOC o I – rritability o N – ote for projectile vomiting o S – eizure