Med-Surg
Hypertension Care: DIURETIC
Daily weight Intake and Output Urine output Response of blood pressure Electrolytes Take pulse Ischemic episodes or TIAs Complications: CVA, CAD, CHR, CRF
Transient Incontinence Causes: DIAPERS
Delirium Infection Atrophic urethra Pharmaceuticals and psychological Excess urine output Restricted mobility Stool impaction
Diverticulosis and Diverticulitis
A high-fiber diet may prevent diverticulosis and diverticulitis by producing stools that are easily passed and thus decreasing pressure within the colon. During acute diverticulitis, a low-fiber diet is prescribed in order to reduce bowel stimulation. Avoid foods with seeds or husks. Clients require instruction regarding diet adjustment based on the need for an acute intervention or preventive approach.
Acute Renal Failure (ARF):
ARF is an abrupt, rapid decline in renal function. It is usually caused by trauma, sepsis, poor perfusion, or medications. ARF can cause hyponatremia, hyperkalemia, hypocalcemia, and hyperphosphatemia. Diet therapy for ARF is dependent upon the phase of ARF and its underlying cause
Clients Who Require Dialysis: AEIOU (The Vowels)
Acid base imbalance Electrolyte imbalances Intoxication Overload of fluids Uremic symptoms
Asthma Management: ASTHMA
Adrenergics: Albuterol and other bronchodilators Steroids Theophylline Hydration: intravenous fluids Mask: oxygen therapy Antibiotics (for associated respiratory infections
Shortness of Breath (SOB) Causes: 4As+4Ps
Airway obstruction Angina Anxiety Asthma Pneumonia Pneumothorax Pulmonary Edema Pulmonary Embolus
Leukemia Signs and Symptoms: ANT
Anemia and decreased hemoglobin Neutropenia and increased risk of infection Thrombocytopenia and increased risk of bleeding
Heart Sounds: All People Enjoy the Movies
Aortic: 2nd right intercostal space Pulmonic: 2nd left intercostal space Erb's Point: 3rd left intercostal space Tricuspid: 4th left intercostal space Mitral or Apex: 5th left intercostal space
Cancer Early Warning Signs: CAUTION UP
Change in bowel or bladder A lesion that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious changes in wart or mole Nagging cough or persistent hoarseness Unexplained weight loss Pernicious Anemia
Cholecystitis:
Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats. Fat intake should be limited to reduce stimulation of the gallbladder. Other foods that may cause problems include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods. Otherwise, the diet is individualized to the client's needs and tolerance.
Shock Signs and Symptoms: CHORD ITEM
Cold, clammy skin Hypotension Oliguria Rapid, shallow breathing Drowsiness, confusion Irritability Tachycardia Elevated or reduced central venous pressure Multi-organ damage
Dealing with Constipation
Constipation is difficult or infrequent passage of stools, which may be hard and dry. Causes include: irregular bowel habits, psychogenic factors, inactivity, chronic laxative use or abuse, obstruction, medications, and inadequate consumption of fiber and fluid. Encouraging exercise and a diet high in fiber and promoting adequate fluid intake may help alleviate symptoms
Hypocalcaemia Signs and Symptoms: CATS
Convulsions Arrhythmias Tetany Stridor and spasms
Hypertension Complications: The 4 C's
Coronary artery disease (CAD) Congestive heart failure (CHF) Chronic renal failure (CRF) Cardiovascular accident (CVA): Brain attack or stroke
Dumping Syndrome
Dumping Syndrome occurs as a complication of gastric surgeries that inhibit the ability of the pyloric sphincter to control the movement of food into the small intestine. This "dumping" results in nausea, distention, cramping pains, and diarrhea within 15 min after eating. Weakness, dizziness, a rapid heartbeat, and hypoglycemia may occur. Small, frequent meals are indicated. Consumption of protein and fat at each meal is indicated. Avoid concentrated sugars. Restrict lactose intake. Consume liquids 1 hr before or after eating instead of with meals (a dry diet).
Dealing with Dysphagia:
Dysphagia is an alteration in the client's ability to swallow. Causes include: Obstruction Inflammation Edema Certain neurological disorders Modifying the texture of foods and the consistency of liquids may enable the client to achieve proper nutrition. Clients with dysphagia are at an increased risk of aspiration. Place the client in an upright or high-Fowler's position to facilitate swallowing. Provide oral care prior to eating to enhance the client's sense of taste. Allow adequate time for eating, utilize adaptive eating devices, and encourage small bites and thorough chewing. Avoid thin liquids and sticky foods
End Stage Renal Disease (ESRD):
ESRD, or chronic renal failure, occurs when the glomerular filtration rate (GFR) is less than 25 mL/min, the serum creatinine level steadily rises, or dialysis or transplantation is required. The goal of nutritional therapy is to maintain appropriate fluid status, blood pressure, and blood chemistries. A high-protein, low-phosphorus, low-potassium, low-sodium, fluid restricted diet is recommended. Calcium and vitamin D are nutrients of concern. Protein needs increase once dialysis is begun because protein and amino acids are lost in the dialysate. Fifty percent of protein intake should come from biologic sources (eggs, milk, meat, fish, poultry, soy). Adequate calories (35 cal/kg of body weight) should be consumed to maintain body protein stores. Phosphorus must be restricted. The high protein requirement leads to an increase in phosphorus intake. Phosphate binders must be taken with all meals and snacks. Vitamin D deficiency occurs because the kidneys are unable to convert it to its active form. This alters the metabolism of calcium, phosphorus, and magnesium and leads to hyperphosphatemia, hypocalcemia, and hypermagnesemia. Calcium supplements will likely be required because foods high in phosphorus (which are restricted) are also high in calcium. Potassium intake is dependent upon the client's laboratory values, which should be closely monitored. Sodium and fluid allowances are determined by blood pressure, weight, serum electrolyte levels, and urine output. Achieving a well-balanced diet based on the above guidelines is a difficult task. The National Renal Diet provides clients with a list of appropriate food choices.
Angina Precipitating Factors: 4 E's
Exertion: physical activity and exercise Eating Emotional distress Extreme temperatures: hot or cold weather
Stroke Signs: FAST
Face Arms Speech Time
Gastroesophageal Reflux Disease (GERD):
GERD leads to indigestion and heartburn from the backflow of acidic gastric juices onto the mucosa of the lower esophagus. Encourage weight loss for overweight clients. Avoid large meals and bedtime snacks. Avoid trigger foods such as citrus fruits and juices, spicy foods, and carbonated beverages. Avoid items that reduce lower esophageal sphincter (LES) pressure, such as alcohol, caffeine, chocolate, fatty foods, peppermint and spearmint flavors and cigarette smoking.
What laboratory values are associated with heparin-induced thrombocytopenia?
Heparin induced thrombocytopenia (HIT) is an immunity mediated clotting disorder that causes unexplained low blood platelet count as a result of treatment with heparin.
Nephrolithiasis (Kidney Stones):
Increasing fluid consumption is the primary intervention for the treatment and prevention of the formation of renal calculi. Excessive intake of protein, sodium, calcium, and oxalates (rhubarb, spinach, beets) may increase the risk of stone formation.
Lactose Intolerance:
Lactose intolerance results from an inadequate supply of lactase, the enzyme that digests lactose. Symptoms include distention, cramps, flatus, and diarrhea. Clients should be encouraged to avoid or limit their intake of foods high in lactose such as: milk, sour cream, cheese, cream soups, coffee creamer, chocolate, ice cream, and puddings
Hypokalemia Signs and Symptoms: 6 L's
Lethargy Leg cramps Limp muscles Low, shallow respirations Lethal cardiac dysrhythmias Lots of urine (polyuria)
A nurse is caring for a client experiencing metabolic acidosis. What are three (3) causes of metabolic acidosis?
Metabolic Acidosis Causes: Results from excess production of hydrogen ionsResults in decreased HCO3 and Increased H+ concentrationDiabetic ketoacidosis (DKA)Lactic acidosisStarvationHeavy exerciseSeizure activityFeverHypoxiaIntoxication with ethanol or salicylatesInadequate elimination of hydrogen ionsKidney failureInadequate production of bicarbonateKidney failurePancreatitisLiver failureDehydrationExcess elimination of bicarbonateDiarrhea, ileostomy
Congestive Heart Failure Treatment: MADD DOG
Morphine Aminophylline Digoxin Dopamine Diuretics Oxygen Gasses: Monitor arterial blood gasses
Nephrotic Syndrome:
Nephrotic syndrome results in serum proteins leaking into the urine. The goals of nutritional therapy are to minimize edema, replace lost nutrients, and minimize permanent renal damage. Dietary recommendations indicate sufficient protein and low-sodium intake.
Peptic Ulcer Disease (PUD):
PUD is characterized by an erosion of the mucosal layer of the stomach or duodenum. This may be caused by a bacterial infection with Helicobacter pylori or the chronic use of non-steroidal antiinflammatory drugs (NSAIDs), such as aspirin and ibuprofen. Avoid eating frequent meals and snacks, as they promote increased gastric acid secretion. Avoid alcohol, cigarette smoking, aspirin and other NSAIDs, coffee, black pepper, spicy foods, and caffeine.
Compartment Syndrome Signs and Symptoms: 5 P's
Pain Pallor Pulse declined or absent Pressure increased Paresthesia
Arterial Occlusion: 4 P's
Pain Pulselessness or absent pulse Pallor Paresthesia
A client diagnosed with asthma recently had pulmonary function testing. The client asks the nurse 'What is peak expiratory flow?' What information should the nurse provide?
Peak expiratory flow is the fastest airflow rate reached during exhalation. Pulmonary function tests (PFTs) are the most accurate tests for diagnosing asthma and its severity. Forced vital capacity (FVC) is the volume of air exhaled from full inhalation to full exhalation. Forced expiratory volume in the first second (FEV1) is the volume of air blown out as hard and fast as possible during the first second of the most forceful exhalation after the greatest full inhalation.
A nurse is caring for a client undergoing a phentolamine blocking test to identify a pheochromocytoma. What are the expected findings of this test?
Phentolamine blocking test - Phentolamine (Regitine), an alpha blocker, is administered. Indications - pheochromocytoma Interpretation of Findings - A rapid decrease in systolic blood pressure of greater than or equal to 35 mm Hg and diastolic blood pressure of greater than or equal to 25 mm Hg with the administration of phentolamine is diagnostic for pheochromocytoma.
Pneumothorax Signs: P-THORAX
Pleuretic pain Trachea deviation Hyperresonance Onset sudden Reduced breath sounds (& dyspnea) Absent fremitus X-ray shows collapsed lung
Pre-End Stage Renal Disease (pre-ESRD):
Pre-ESRD, or diminished renal reserve/renal insufficiency, is a predialysis condition characterized by an increase in serum creatinine. Goals of nutritional therapy for pre-ESRD are to: Help preserve remaining renal function by limiting the intake of protein and phosphorus. Control blood glucose levels and hypertension, which are both risk factors. Protein restriction is key for clients with pre-ESRD. Slows the progression of renal disease. Too little protein results in breakdown of body protein, so protein intake must be carefully determined. Restricting phosphorus intake slows the progression of renal disease. High levels of phosphorus contribute to calcium and phosphorus deposits in the kidneys. Dietary recommendations for pre-ESRD: Limit meat intake. Limit dairy products to ½ cup per day. Limit high-phosphorus foods (peanut butter, dried peas and beans, bran, cola, chocolate, beer, some whole grains). Restrict sodium intake to maintain blood pressure. Caution clients to use vitamin and mineral supplements ONLY when recommended by their provider.
Hypoxia: RAT (signs of early) BED (signs of late)
Restlessness Anxiety Tachycardia and tachypnea Bradycardia Extreme restlessness Dyspnea
Heart Murmur Causes: SPASM
Stenosis of a valve Partial obstruction Aneurysms Septal defect Mitral regurgitation
Hypoglycemia Signs: TIRED
Tachycardia Irritability Restlessness Excessive hunger Depression and diaphoresis
Traction Patient Care: TRACTION
Temperature of extremity is assessed for signs of infection Ropes hang freely Alignment of body and injured area Circulation check (5 P's) Type and location of fracture Increase fluid intake Overhead trapeze No weights on bed or floor
A nurse is caring for a client with a tension pneumothorax. What is a tension pneumothorax and what manifestations should the nurse expect?
• Anxiety • Pleuritic pain • Signs of respiratory distress (tachypnea, tachycardia, hypoxia, cyanosis, dyspnea, and use of accessory muscles) • Tracheal deviation to the unaffected side
A nurse is caring for a client following a hypophysectomy. What postoperative nursing actions should be taken for this client?
• Avoid activities that increase intracranial pressure • Report postnasal drip or increased swallowing • Rinse mouth frequently to minimize effects of mouth breathing • Use oral rinse and flossing to clean teeth. Avoid brushing teeth due to risk of trauma to the operative site • Consume a diet high in fiber to minimize straining to defecate
What are the expected assessment findings for a herniated lumbar disk?
• Back pain, arm or leg pain, intense pain in your buttocks, thigh and calf • Fever and chills • Weakness • Numbness or tingling
What is a potassium hydroxide (KOH) test and what specific nursing actions should be taken when obtaining fungal skin specimens?
• Collect scales using a wooden tongue depressoe and placing the specimen in a clean container to be sent to the laboratory • If a fungal culture is needed because of inconclusive results due to a deeper fungal infection, a punch biopsy is performed • Specimens must be properly labeled and delivered to the laboratory promptly for appropriate storage and analysis
A nurse is caring for a client experiencing metabolic acidosis. What are three (3) causes of metabolic acidosis?
• DKA • Starvation • Excess production from hydrogen ions • Excess diarrhea • Excessive intake of acids • Lactic acidosis can result from: heavy exercise, seizure activity, hypoxia
A mass casualty event has occurred and a nurse is responsible for client triage. What categories should the nurse use and what do these mean? (Review the Nursing Leadership Review Module)
• Emergent category (class I) - Highest priority is given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized. • Urgent category (class II) - Second-highest priority is given to clients who have major injuries that are not yet life threatening and usually can wait 45 to 60 min for treatment. • Non-urgent category (class III) - The next highest priority is given to clients who have minor injuries that are not life threatening and do not need immediate attention. • Expectant category (class IV) - The lowest priority is given to clients who are not expected to live and will be allowed to die naturally. Comfort measures may be provided, but restorative care will not.
A client is diagnosed with Addisonian Crisis. List the lab values that will be affected by this disease process
• Increase K, decreased Na and increased Ca • BUN and creatinine increased • Serum glucose normal to decreased • Serum cortisol decreased
A nurse is caring for a client with Cushing's disease. Would the nurse expect this client's plasma cortisol levels to be increased or decreased?
• Increased
A nurse is caring for a client post-laryngectomy. What three (3) postoperative interventions should be provided?
• Instruct the client to not eat or drink after midnight prior to the procedure
A nurse is caring for a client with Rheumatoid arthritis who is prescribed a non-steroidal anti-inflammatory drug (NSAID) for the treatment of joint pain. Provide three (3) teaching points in client education the nurse should provide regarding this medication therapy?
• Instruct the client to take the medication with food or with a full glass of water or milk. If taking routinely, an H2-receptor antagonist can also be prescribed • Instruct the client to observe for GI bleeding (coffee-ground emesis; dark, tarry stools) • Instruct the client tom avoid alcohol, which can increase the risk of GI complications
A client diagnosed with asthma recently had pulmonary function testing. The client asks the nurse 'What is peak expiratory flow?' What information should the nurse provide?
• Peak expiratory flow is the fastest air flow rate reached during exhalation
A nurse is caring for a client undergoing a phentolamine blocking test to identify a pheochromocytoma. What are the expected findings of this test?
• Plasma-free metanephrine test
What laboratory values are associated with heparin-induced thrombocytopenia?
• Platelet levels
A nurse is caring for a client with colorectal cancer who is scheduled for a colectomy. What preoperative and post-operative education should be provided to this client?
• Pre-op education o Educate the client regarding preoperative die (clear liquids several days prior to surgery) o Instruct the client to complete bowel prep with cathartics as prescribed o Inform the client of the administration of antibiotics (neomycin, metronidazole) to eradicate intestinal flora • Post-op education o Teach client regarding turning and deep breathing o Educate the client regarding the care of the incision activity limits, and ostomy care o Provide instructions regarding management of postop complications, including incontinence or sexual dysfunction (most likely to occur with AP resection
A nurse is caring for a client with a history of migraines with auras. What are the stages of this type of migraine?
• Prodromal stage includes awareness of findings for hours to days before onset; irritability, depression, food cravings, diarrhea/constipation, and frequent urination • Aura stage develops over minutes and tingling of mouth, lips, face, or hands; acute confussional state; visual disturbances (light flashes, bright spots) • Second stage; severe incapacitating, throbbing headache the intensifies over several hours and is accompanied by nausea, vomiting, drowsiness, and vertigo • Third stage (4-72 hr.) headaches dull. Older adults can continue with aura and pain subsides (visual migraine) • Recovery with pain and aura subsiding. Muscle aches and contraction of head and neck muscles are common. Physical activity worsens pain, and client might sleep
A nurse finds a client on the floor actively having a seizure. What should the nurse do to keep the client safe?
• Protect the client from injury (move furniture away, hold head in lap if on the floor) • Position the client to provide a patient airway • Be prepared to suction oral secretions • Turn client to the side to decrease the risk of aspiration • Loosen clothing • Do not attempt to restrain • Do not open jaw or put anything inside • Do not use padded tongue blades • Document
A nurse is caring for a client following a bone marrow biopsy. What information should the nurse include in the discharge education?
• Rest for the remainder of the day after the biopsy. • You may feel sore for two or three days after the biopsy. Your caregiver may suggest ice treatments. Ice causes blood vessels to constrict (get small) which helps decrease inflammation (swelling, pain, and redness). Ice is best started after the biopsy and for the next 24 to 48 hours afterwards. Put crushed ice in a plastic bag and cover it with a towel. Place this on the biopsy area for 15 to 20 minutes every hour as long as you need it. Do not sleep on the ice pack because you can get frostbite. • Keep the area clean and dry for 24 hours. Change your bandage any time it gets wet or dirty. If you cannot reach the bandage, ask someone else to help you change it.
Define the following types of urinary incontinence: Stress, urge, overflow, reflex, functional, total.
• Stress: Loss of small amounts of urine from increased abdominal pressure without ladder muscle contraction with laughing, sneezing, or lifting • Urge: Inability to stop urine flow long enough to reach the bathroom due to an overactive detrusor muscle with increased bladder pressure • Overflow: Urinary retention from bladder over distention and frequent loss of small amounts of urine due to obstruction of the urinary outlet or an impaired detrusor muscle • Reflex: Involuntary loss of a moderate amount of urine usually without warning due to hyperreflexia of the detrusor muscle, usually from spinal cord dysfunction • Functional: loss of urine due to factors that interfere with responding to the need to urinate, such as cognitive, mobility and environmental barriers • Total: Unpredictable, involuntary loss of urine that generally dose not respond to treatment
