ATIMed Surg Review - Nursing PDF

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Med Surg ATI Review Ch. 1 Health, Wellness, and Illness • Variables o Modifiable= can be changed, smoking, nutrition, health edu, sex practices, exercise o Non modifiable= sex, age, developmental level, genetics Ch. 2 Emergency Nursing Principles and Management • Triage o Resuscitation= level one o Emergent= level two o Urgent= level 3 o Less urgent= level four o Nonurgent= level five, non life threatening condition require simple eval and care management • ABCDE o Airway= maintain airway, head tilt/chin lift (do NOT perform if pt has spine injuryà do modified jaw thrust maneuver), bag valve mask w/ 100% O2, nonrebreather w/ 100% O2 use for spontaneous breathers o Breathing o Circulation o Disability= loc o Exposure= clothing • Poisoning= use activated charcoal, gastric lavage (done w/I 1hr) aspiration • Rapid response team= respond to emergency when pt has indications of rapid decline • Cardiac emergency o Vfib= defibrillate, CPR, admin IV antidysrhythmic (epi, amiodarone, lidocaine, magnesium sulfate) o Vtach • Epi= stimulate alpha 1 (vasoconstrict), beta 1 (increase hr), beta 2 (bronchodilate), good for superficial bleeding, increase bp, AV block and cardiac arrest and asthma o s/e= htn crisis, dysrhythmias, angina • Dopamine= renal blood vessel dilation, beta 1 increase hr, good for shock, hf o s/e= dysrhythmias, angina • Dobutamine= beta 1 increase hr, good for hr Ch. 3 Neurologic Diagnostic Procedures • Cerebral angiography= visualization of cerebral blood vessels, assess blood flow within brain, id aneurysms o Do NOT perform if pregnant, don’t eat food or fluids for 4-6hrs prior to procedure, assess for allergy to shellfish or iodine b/c require use of contrast media, ask about anticoag, assess BUN and creatinine; monitor area for clotting after procedure • CT= cross section image • EEG= id seizure activity and sleep disorder o Wash hair b/f procedure, be sleep deprived, expose to flashing lights, hyperventilate for 3-4 min

Glasgow coma scale= determine loc, best score is 15, score less than 8 is associate w/ severe head injury and coma o Eye open (E) § 4= eye open spontaneously § 3= eye open to sound § 2= eye open to pain § 1= eye does not open o Verbal (V) § 5= conversation is coherent and oriented § 4= conversation is incoherent and disoriented § 3= words are spoken but inappropriate § 2= sound made § 1= no sound o Motor (M) § 6= commands followed § 5= local reaction to pain § 4= general w/drawal to pain § 3= decorticate posture (adduction of arms, flexion of elbows and wrists) § 2= decerebrate posture (extension of elbows and wrists) § 1= no motor response • ICP monitoring= performed by neurosurgeon in operating room, used for GCS score of 8, complication of infection o Intraventricular catheter o Subarachnoid screw/bolt o Epidural or subdural sensor • Increased ICP (normal 10-15)= IRRITABILITY first sign, severe headache, decrease loc, dilated/ pinpoint pupils, altered breathing pattern (Cheyne-stokes), hyperventilation, apnea, abnormal posturing • Lumbar puncture= w/draw CSF to diagnose MS, syphilis, meningitis, void b/f procedure, assume cannonball position, monitor puncture site, remain lying still on back after procedure o Complication= headache from leaking csf, give opioids/pain meds, increase fluid intake • MRI= remove jewelry, not claustrophobic, give earplugs o w/ contrast dyes: assess for allergies for shellfish o no jewelry, no metal implants (IUD, aneurysm clip, ortho joint, artificial heart valve, pacemaker) • PET= brain injury, determine tumor activity or response to treatment • X-ray= can reveal fracture or curvature Ch. 4 Pain Management • Acute pain= protective, temporary, self limiting, resolves with tissue healing • Chronic= last longer than 3 months, depression, fatigue, decreased level of function, disability • Nociceptive= damage to or inflame of tissue, throbbing, aching, localized o Somatic= bones, joints, muscles, skin, connective tissue o Visceral= internal organs •

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Neuropathic= abnormal or damaged pain nerves, phantom limb pain, diabetic neuropathy, shooting, burning, pins and needles; responds to antidepressants, antispasmodic, muscle relaxants Pain assessment= location, quality, measures/intensity/severity, timing/onset/duration, setting/ how it affects daily life, associated manifestations, aggravating/relieving factors Nonpharm pain management= tens, heat, cold, massage, relaxation, imagery Pharm management o Nonopioid= mild-moderate pain, 4g apap, monitor for salicylism (tinnitus, vertigo, decreased hearing), gi upset, bleeding o Opioid= moderate-severe pain, around clock admin, cause constipation, hypotension, urinary retention, n/v, sedation, respiratory depression, have naloxone ready

Ch. 5 Meningitis • Inflam of meninges, viral most common and resolves w/o treatment, bacterial is contagious w/ high mortality • Hib vaccine and MCV4 vaccine, especially in college students • Findings= excruciating constant headache, stiff neck, photophobia, fever and chills, n/v, altered loc, positive kernig sign (resistance and pain w/ extension of pt leg from flexed position) positive Brudzinski sign (flexion of knee and hip w/ deliberate flexion of pt neck), tachy, seizure, red macular rash, irritable • Diagnostics= csf analysis (cloudyàbacterial, clearàviral, increased wbc, increased protein, decreased glucose in bacterial) • Care= isolation precautions, droplet precautions until 24 hrs after antibiotics, decrease environmental stimuli, quiet environment, decrease bright light, bed rest hob 30 degrees, avoid coughing and sneezing, seizure precautions • Meds= antibiotics, anticonvulsant, analgesics • Complications o Increased icp= monitor loc, pupillary changes, impaired eom o Siadh= monitor for dilute blood and concentrated urine o Septic emboli Ch. 6 Seizures and Epilepsy • Seizures= abrupt, abnormal, excessive uncontrolled electrical discharge of neurons w/I brain, altered loc, change in motor and sensory ability/ behavior • Epilepsy= abnormal brain electrical activity w/ 2+ seizures, fever • Risks= febrile state especially in children 30, blurred vision, halos, severe pain, nausea, photophobia o Diagnostics= tonometry (measures iop should be 10-21) o Edu= eye med use every 12hrs, wait 5-10 min between eye drops, avoid touching tip of applicator to eye, apply pressure to punctal occlusion o Med § Pilocarpine= constricts pupil § Bb timolol=decrease iop, first line drug § Acetazolamide= decrease iop by decrease aqueous humor production § Mannitol= osmotic diuretic, used for angle closure, decrease iop quick Ch. 13 Middle and Inner ear disorder • Middle ear= otitis media, redness, bulging tympanic membrane, bubbles behind tm o Risk=recurrent colds and otitis media, enlarged adenoids • Inner ear= meniere disease, vertigo, tinnitus, sensorineural hearing loss, vomiting o Risk= viral or bacterial infection, damage due to ototoxic med • Otoscopy= pull up and back on adult and down and back of auricle on children, light reflex should be visible from center of tm anteriorly • Care= ototoxic meds can cause tinnitus and sensorineural hearing loss o Antibioticsàgentamycin and erythromycin o Diureticsà furosemide, e acid o Nsaidsàaspirin

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o Chemo agentsàcisplatin Meds o Meclizine= antihistamine and anticholinergic effect, treat vertigo o Ondansetron= antiemetic, treat n/v o Diphenhydramine= treat vertigo, cause urinary retention, sedation o Scopolamine= anticholinergic, treat nausea, cause urinary retention and sedation Edu= avoid alcohol and caffeine, rest in quiet dark room, space intake of fluid evenly, decrease intake of salt Stapedectomy= surgical removal of stapes Cochlear implant= treat sensorineural hearing loss, microphone picks up sound and speech processor and transmitter convert sound to electric impulses Labyrinthectomy= surgical treatment for vertigo that removes labyrinthine

Ch. 14 Head Injury • Cervical spine injury should always be suspected when head injury occurs • Findings= CSF leakage from nose and ears (presence of halo sign clear or yellow tinted ring surrounding drop of blood), increased icp (headache, decreased loc, dilated or pinpoint nonreactive pupils, altered breathing pattern, apnea, cushing triadà LATE finding, severe htn, wide pulse pressure, brady) • Diagnostics= cervical spine films, CT, MRI • Care= respiratory status priority, increased icp (should be 10-15, hypercarbia leads to cerebral vasodilation, suction, maintain hob at 30 degrees, avoid extreme flexion/extension, admin o2 to maintain pao2 >60, hyperventilate pt, give stool softener and avoid Valsalva, maintain cervical spinal stability) • Meds o Mannitol= osmotic diuretic to treat cerebral edema; monitor fluid and electrolyte status o Barbiturates= placed in coma to decrease cell metabolic demand o Phenytoin= prophylactically to prevent seizure o Morphine= analgesic to control pain • Craniotomy= decrease cerebral edema, monitor icp, hob 30 degrees, infratentorial keep pt flat and on side for 24-48hr to prevent pressure on neck incision site • Complications= brain herniation (down shift of brain tissue due to cerebral edema) cause fixed dilated pupils, decrease loc, Cheyne stokes respiration, hematoma and intracranial hemorrhage, di or siadh, cerebral salt wasting (hypona and hypovolemia) Ch. 15 Stroke • Hemorrhagic= ruptured artery or aneurysm • Thrombotic= ischemic stroke b/c blood clot in cerebral artery • Embolic= ischemic stroke b/c embolus travel from one part of body to cerebral artery • Risks= htn, dm, smoking • Findings= visual disturbances, dizzy, slurred speech, weak extremity o Left hemisphere= language, math, analytical thinking § Expressive and receptive aphasia (inability to speak and understand language) § Alexia= difficulty reading

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§ Agraphia= difficulty writing § Right extremity hemiplegia § Hemianopsia = loss of visual field in one or both eyes o Right hemisphere= visual and spatial awareness § Overestimate ability § Unilateral neglect= ignore left side § Poor impulse control and judgment § Left hemiplegia § Visual changes Diagnostics= mri, ct, cat Care= notify dr if bp > 180 or 110 means ischemic stroke, monitor vitals, assess swallow and gag reflex, speech language pathologist, have pt eat in upright position w/ neck flexed forward, have suction, maintain skin integrity by reposition and use padding, maintain safe environment and reduce fall risk, homonymous hemianopsia (loss of same visual field in both eyes), instruct pt to use scanning technique (run head from unaffected to affected side) when eating and ambulating Meds= thrombolytic meds w/I 4.5 hr of symptoms Carotid artery angioplasty with stent Complications= dysphagia and aspiration (assess gag reflex, begin w/ thick liquids)

Ch. 16 Spinal Cord Injury • Cervical region result in quadriplegia, paralysis of all four extremities and trunk • Injury below T1 result in paraplegia • C4 and above pose great risk for impaired spontaneous ventilation and phrenic nerve • Findings= inability to feel light tough, inability to discriminate b/w sharp and dull, absent dtr, flaccidity of muscles • Neurogenic shock= monitor for hypotension, dependent edema, loss of temp regulation • Injury above L1 will have spastic muscle tone after neurogenic shock and spastic bladder • Pt who have injury below L1 will convert to flaccid type of paralysis and flaccid bladder • Care= daily stool softener and bowel schedule • Meds o Glucocorticoids= decreased edema of spinal cord o Vasopressors= no epi and dopamine treat hypotension during neurogenic shock o Atropine= treat brady o Baclofen and dantrolene= treat severe muscle spasticity • Complications= orthostatic hypotension (thigh high hose and change position slow), autonomic dysreflexia (stimulation of SNS and inadequate response of PNS, lesion above T6; cause extreme htn, sudden severe headache, pallor below lesion, blurred vision, diaphoresis) Ch. 17 Respiratory Diagnostic Procedures • ABG o pH= 7.35-7.45 o PAO2= 80-100 o PACO2= 35-45 o HCO3= 21-28

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o SAO2= 95-100% Arterial puncture= obtain heparinized syringe for sample collection, perform Allen’s test prior to arterial puncture to verify patent radial and ulnar circulation, compress ulnar and radial arteries simultaneously, pt. often experience pain w/ repeated ABG level check, hold direct pressure over site for at least 5 min or 20 min if on anticoagulant therapy Air embolism= place pt on left side in Trendelenburg position, monitor for SOB, chest pain, anxiety, air hunger Bronchoscopy= visualization of larynx, trachea, bronchi o Biopsy o Aspiration of deep sputum o Maintain pt on NPO 4-8hr o Admin atropine, viscous lidocaine, local anesthetic throat spray o Assess for presence of gag reflex, small amt. of blood tinged sputum is expected Thoracentesis= surgical perforation of chest, instill medication into pleural space and remove fluid o SOB, cough o Position pt sitting upright, instruct pt to remain absolutely still o Amt of fluid removed is limited to 1L at a time, monitor vital signs and respiratory status hourly o Complications § Mediastinal shift § Pneumothorax= collapsed lung, deviated trachea, pain on affected side, increased heart rate § Bleeding= hypotension § Infection

Ch. 18 Chest Tube Insertion and Monitoring • Inserted into pleural space to drain, fluid, blood or air • System o Water seal= sterile fluid to 2cm, allows air to exit from pleural space on exhalation and stops air from entering w/ inhalation, keep chamber upright, TIDALING OF WATER IS EXPECTED, cessation of tidaling signals lung re-expansion or obstruction w/I system, continuous bubbling indicates air leak o Suction= -20cm h20, continuous bubbling • Encourage coughing and deep breathing every 2hr • Check water seal level every 2hr and add fluid as needed • Document amt and color of drainage hourly for first 24hrs and then at least every 8hr, report excess drainage greater than 70 to provider • Monitor chest tube insertion site, position pt in semi-high fowler position, obtain cxr to verify chest placement • Keep two enclosed hemostats, sterile water and occlusive dressing at bedside • Clamp chest tube ONLY when prescribed, do NOT strip or milk tubing • Complications o Monitor water seal chamber for continuous bubbling which means air leak

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o If tubing separates instruct pt to exhale as much as possible and to cough to removes as much air as possible from pleural space o If chest tube drainage system is compromised immerse end of chest tube in sterile water to restore water seal o If chest tube is accidentally removed dress area w/ dry sterile gauze o Tension pneumothorax= prolonged clamping of tubing, assess for tracheal deviation, absent breath sounds on one side, respiratory distress, asymmetry of chest Chest tube removal= deep breath, exhale, bear down (Valsalva), apply airtight sterile petroleum jelly gauze dressing

Ch. 19 Respiratory Management and Mechanical ventilation • Nasal cannula= 1-6L • Simple face mask= 5-8 L • Partial rebreather= 6-11L, must keep reservoir bag inflated • Nonrebreather= 10-15 L, keep reservoir bag 2/3 full, delivers highest o2 concentration, perform hourly assessment of valve and flap • Venturi mask= most precise o2 concentration • Aerosol mask/face tent= facial trauma and burns • O2 therapy need= used for hypoxemia (blood) and hypoxia (tissue) o Early findings= tachy, tachypnea, restless, pale, htn, respiratory distress (accessory muscles, nasal flaring, adventitious breath sounds) o Late= confusion/stupor, cyanotic, brady, bradypnea, hypotension, cardiac dysrhythmias • Complications o O2 toxicity= nonproductive cough, substernal pain, nasal stuffiness, n/v, headache, sore throat, hypoventilation; always use lowest o2 necessary to maintain adequate O2 § Normal for COPD to have O2 of 92% • Edu= no smoking, cotton gown, no volatile flammable materials • CPAP= sleep apnea • BIPAP= COPD, ventilatory assistance • ET tube= inserted through nose or mouth into trachea o Suction oral and tracheal secretions to maintain tube patency o Low pressure alarm= low exhaled volume due to disconnection, cuff leak, tube displacement o High pressure alarm= excess secretions, biting tubing, kinks in tubing, coughing, pulmonary edema, bronchospasm, pneumothorax o Admin analgesics, sedatives, neuromuscular blocking agents, perform frequent gentle skin and oral care o Have manual resuscitation bag w/ face mask and o2 readily available at pt bed, have reintubation equipment at bed o Following extubation assess o2 and vitals every 5 min, encourage coughing and deep breathing, reposition pt to promote mobility of secretions Ch. 20 Acute Respiratory Disorders

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Rhinitis= inflam of nasal mucosa, caused by virus or allergen o Runny nose (rhinorrhea), nasal congestion o Encourage rest (8-10hr/day) and increased fluid intake (2000mL/day), use cough etiquette and hand hygiene o Antihistamines or decongestant meds Sinusitis= encourage use of steam humidification, nasal decongestants Flu= highly contagious acute viral infection o Severe headache and muscle aches, chills, diarrhea, fever o Antivirals= w/I 24-48hrs after onset of manifestations o Vaccination is encouraged for everyone older than 6 months of age o Complications= pneumonia affects older adults Pneumonia= confusion manifestations in older adult, chills, sob, difficulty breathing, tachypnea, chest pain (sharp), crackles and wheezes, coughing o Lab tests= sputum culture and sensitivity done b/f starting antibiotic therapy, chest xray will show consolidation of lung tissue, pulse ox will be less than 95% o Care= high fowler, admin breathing treatment and meds, o2, deep breathing w/ incentive spirometry, increased work of breathing requires increased calories, encourage fluid intake of 2-3 L/day, antibiotics, bronchodilators (albuterol), anti inflam (glucocorticoids like fluticasone and prednisone) monitor for decreased immunity and hyperglycemia and black tarry stools and fluid retention and wt gain and canker sores

Ch. 21 Asthma • Chronic inflame disorder of airways that results in intermittent and reversible • Risks= smokes, air pollutants (environmental allergies) • Findings= coughing, wheezing, prolonged exhalation, poor o2 saturation, barrel chest • Care= high fowler, o2 therapy, provide rest periods • Meds o Bronchodilators (inhalers) § Short acting beta agonist= albuterol, watch for tremors and tachy § Anticholinergic= ipratropium, observe for dry mouth § Methylxanthines= theophylline, use only when other treatments are ineffective, monitor for toxicity § Long acting beta agonist= salmeterol, asthma attack prevention o Anti-inflam § Corticosteroids= decreased immune function, hyperglycemia, black tarry stools, fluid retention and wt gain § Leukotriene antagonist • Complications= status asthmaticus (life threatening episode of airway obstruction unresponsiveness to common treatment) o Admin IV fluids, o2, bronchodilators, epi Ch. 22 Chronic Obstructive Pulmonary Disease • COPD= emphysema (loss of lung elasticity and hyperinflation of lung tissue) and chronic bronchitis (inflame of bronchi)

Risks= advanced age, smoking, AAT deficiency, air pollution Finding= chronic dyspnea, crackles and wheezes, rapid and shallow respirations, use of accessory muscles, barrel chest, hyperresonance on percussion due to trapped air (emphysema), dependent edema b/c of right sided hf, clubbing of fingers and toes, decreased o2 saturation levels • Labs= increase hct due to low o2, abg (hypoxemia pao2 less than 80, hypercarbia increases paco2 greater than 45), expected pulse ox less than 95% • Care= high fowlers, encourage effective coughing, deep breath incentive spirometer, increased calories, diaphragmatic (abdominal) breathing, lie on back w/ knees, pursed lip breathing (take a breath in through nose and out through lips/mouth) • Meds o Bronchodilators § Short acting beta agonist= albuterol, watch for tremors and tachy § Cholinergic antagonist= ipratropium, observe for dry mouth § Methylxanthine= theophylline, use only when other treatments are ineffective; serum levels for toxicity o Anti-inflam agents § Cor...