Med Surg Exam 1 - Exam notes from lectures and powerpoint slides PDF

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Exam notes from lectures and powerpoint slides...

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Med Surg Exam 1 

Electrical Conduction System o Sinoatrial Node/SA Node  Located in the right atrium  Heart’s main pacemaker, generating impulses 60-100 times per minute  Is normally the “starting point” for electrical activity

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SA Node o 60-100 AV Node o 40-60 Bundle of His; Bundle Branches o 40-60 Purkinje Network o 20-40

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ECG Breakdown o P-Wave  SA node fires, sends the electrical impulse outward to stimulate both atria and manifests as a P-wave  Represents atrial contraction (depolarizations)  If inverted, impulse does not originate from SA node o PR interval  Time which impulse travels from the SA node to the atria and downward to the ventricles  Measure from start of P-wave to deflection up or down from baseline (starts of QRS)  Normal PRi is 0.12-0.20 seconds (3-4 boxes) o QRS Complex  Impulse from the Bundle of His throughout the ventricular muscles  Ventricular contraction (depolarization)  Located after the PRi, measured from the Q-wave to the ends of the S-wave  Measures less than 0.12 seconds (less than 3 small boxes)  Q-wave represents the first downward from the baseline  R-wave represents the first trend upward form the baseline  Buried within QRS is atrial relaxation (repolarization) o ST Segment  Begins with end of QRS (J point) and ends with the onset of the T-wave  “Elevated” if the segment deviates above the baseline of the PR segment  “Depressed” if the segment deviates below it o T-Wave  Ventricular Repolarization, meaning no associated activity of the ventricular muscle  Resting phase of the cardiac cycles  May be peaked with high potassium o QT Segment  Onset of QRS to end of T  Men have shorter than women  T-wave should end before half-way point between 2 QRS complex  Long QT increases chance for sudden death from arrhythmias  Low magnesium can increase the length of the QT

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Summary of ECG Waves o P-wave  Atrial contraction o PRi  Time from SA node through atrium to ventricle o QRS  Ventricular contraction o T-wave  Ventricular resting o U-wave  After T, rarely seen

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ECG Interpretation o Step 1: heart rate o Step 2: heart rhythm o Step 3: P-wave o Step 4: PR interval o Step 5: QRS Complex

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Sinus Rhythms o Normal Sinus Rhythm Pacemaker site: SA node  Rate: 60-100 bpm  P waves: are upright and all look alike  PR interval: generally constant; 0.12-0.20 sec  R-R interval: usually regular  QRS complexes: usually normal appearing and 0.20 seconds or 5 boxes o R-R interval: usually regular o QRS complexes: usually normal appearing and 50% lung involvement on imaging) 14% o Critical (respiratory failure, shock, sepsis, or multiorgan system dysfunction) 5% o Psychosocial-isolation, depression

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Nursing PPE o PPE before tested: surgical masks and eye protection o PPE when aerosol: fitted N95; surgical mask over; eye protection o ED nurses and COVID floors; fitted N95; surgical mask over; eye protection – in with patient gown, gloves, some caps o R/O (rule out): disposable stethoscope and COVID gear

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Medical Treatment o Proning- done in early stages (self-prone) o High flow O2 cannula- optiflow and BiPap o Ventilator proning- sedate and paralyze o Ventilator: high PEEP; high FiO2; leaving endotracheal tubes in longer than normal o Infusion plasma o Antiviral-Remdesivir o Corticosteroids-dexamethasone o VTE protocol- Enoxaparin o Plasma

Care of Critically Ill Patients with Respiratory Problems 

Pulmonary Embolism o Risk: prolonged immobility o Central venous catheters o Surgery o Obesity o Age o Increased blood clotting o Positive history o Smoking o Estrogen therapy

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Signs and Symptoms o Dyspnea o Chest pain o Anxiety o Impending doom o Cough o Hemoptysis o Tachypnea o Petechiae o Decreased O2 sat

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Assessment o Physical assessment, labs o X-ray, spiral CT o EKG nonspecific

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Hospital Management o Assessment – expected outcomes o Oxygen – ABGs, O2 sat, LOC, color o Surgical management  Vena cava filter

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Medications o Heparin o Alteplase o Enoxaparin o Warfarin o Rivaroxaban

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Laboratory Tests and Medication o See chart p. 622: 32-5 o PTT, PT, INR – common range – want therapeutic  1.5-2.5 times with PE (PTT)  1.5-2 times PT  2.5-3 times INR o Charts p. 623: 32-7 prevention injury – safety during therapy  Using electrics shaver, soft-bristle toothbrush, do not floss  Take stool softeners, do not use enemas or rectal suppositories o Health promotion to prevent injury and bleeding

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Health Promotion and Maintenance o Prevent venous stasis o Prevent VTE o Part of SCIP: evidence-based practice (in hospital) o Lifestyle changes o Medication or inferior vena cava filter

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Acute Respiratory Failure o Ventilatory or oxygenation failure or combination o Patient always hypoxemic o Symptoms are effects of hypoxia, hypercapnia, and acidosis

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Why does respiratory failure occur? o ABG abnormalities o Ventilatory/oxygenation o Asthma o Pneumonia o Influenza o COPD o COVID

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Drug overdose Pulmonary fibrosis Lung injury Infection Cardiac arrest

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History and Assessment o Dyspnea o Orthopnea o Restlessness o Hypoxemia o Pulse oximetry o ABG analysis

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Labs and Tests o SaO2 o ABGs o Bronchoscopy o Sputum C&S o Thoracentesis o Pulmonary function tests o Spiral CT; D-dimer o Pulmonary angiogram

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Arterial Blood Gasses o Respiratory acidosis o Respiratory alkalosis o Metabolic acidosis o Metabolic alkalosis

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ARDS: The most severe form of acute lung injury: complex clinical syndrome o Risk factors  >65  Sepsis  Pneumonia  Multiple trauma  Near-drowning  Aspiration  Transfusions

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ARDS – Life-threatening o Can be from direct pulmonary cause or not o Is systemic inflammatory response

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ARDS o o o o

Hypoxemia although increasing Oxygen given Decreased pulmonary compliance Dyspnea Non-cardiac pulmonary edema

o Dense pulmonary infiltrates 

Management o Early recognition o Mechanical ventilation o High PEEP o Treat underlying cause o Do least harm – conservative o Positioning o Nutritional therapy

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Why Ventilate o Body can’t meet O2 needs through breathing o Body can’t remove CO2 o Acute/chronic conditions o Secretions

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Patient requiring mechanical ventilation o Emergent or not o Different modes of ventilation o Different ways of delivering – artificial airway needed for invasive ventilation

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Ways of delivering o Oral endotracheal tube o Nasal endotracheal tube o Tracheostomy

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Safety: checking for placement of ET tube and stabilizing tube o Chest x-ray o End-tidal CO2 level o Breath sounds o Chest movement o Tube holders – document tube position o Use of restraints

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Ventilator settings o Tidal volume o Amount of air breathed in and out o Rate: number of breaths o Percentage of oxygen – FiO2 o Oxygen toxicity o Peak inspiratory airway pressure (PIP) o Continuous positive airway pressure (CPAP) o Positive and expiratory pressure (PEEP)

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Ventilator Alarms o High pressure – peak pressure – pressure rising o Low pressure – too easy for ventilator to push against pressure o Must keep alarms on

o Priority actions of nurse 

Mouth care and suctioning o Clean with oral kits o As prehospital protocol and as needed o Toothbrush o Suction mouth and ET o Suction ET tube < 10 seconds

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Complications: best practice chart o Barotrauma o VAP/infection o Aspiration o Infections o Nutritional needs o PEEP problems o “bucking” o Communication o Muscle deconditioning o Ventilator dependence

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VAP Bundle: Evidence-Based Practice o HOB elevated o Oral care o Early weaning o Ulcer prophylaxis o CVT protocol o Pulmonary hygiene o Prevent aspiration

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Common medications for the mechanically ventilated patient o Proprofol-Diprovan o Cisatracurium-Nimbex o Dexmedetomidine- Precedex o Diazepam-Valium o Lorazapam-Ativan o Midazolam-Versed o Morphine Sulfate

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Proprofol o Bottle o Expensive o Quick half-life o Green urine o Sedative o Lipid

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Weaning and extubation may not happen at the same time o Weaning methods: table 32-7

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SIMV  The patient breaths between the machine’s preset breaths/min rate  The machine is initially set on an SIMV rate of 12, meaning that the patient receives a minimum of 12 breaths/min by the ventilator  The patient’s respiratory rate will be a combination of ventilator breaths and spontaneous breaths  As the weaning process ensures, the pulmonary health care provider prescribes gradual decreases in the SIMV rate, usually at a decreased of 1 to 2 breaths/min T-piece  The patient is taken off the ventilator for short periods (initially 5 to 10 min) and allowed to breathe spontaneously  The ventilator is replaced with a T-piece or CPAP, which delivers humidified oxygen  The prescribed FiO2 may be higher for the patient on the T-piece than on the ventilator  Weaning progresses as the patient can tolerate progressively longer periods off the ventilator  Nighttime weaning is not usually attempted until the patient can maintain spontaneous respirations most of the day Pressure support  PSV allows the patient’s respiratory effort to be augmented by a predetermined pressure assist from the ventilator  As the weaning process ensues, the amount of pressure applied to inspiration is gradually decreased  Another method of weaning with PSV is to maintain the pressure but gradually decreased the ventilator’s preset breaths/min rate

Extubation o Explain procedure o Gather equipment o Hyperoxygenate o Suction o Rapidly deflate cuff o Remove tube at peak inspiration o Instruct patient to cough o Administer O2 o Monitor patient

Care of the patient with burns 

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Burns o o o o o o

Integumentary system assessment Concept: altered tissue integrity Burn injury classification Rule of nines Aseptic technique/wound care Fluid resuscitation

Classification of Burns o Superficial  Pink to red color

 Mild edema  Healing 3-6 days  Ex. Sunburn, flash burns o Superficial; partial thickness  Pink to red color  Mild to moderate edema  Blisters  Healing ~2weeks  Ex. Scalds, flames, brief contact with hot objects o Deep partial-thickness  Red to white color  Moderate edema  Blisters are rare  Eschar – yes, soft and dry  Healing 2-6 weeks  Grafts can be used if healing is prolonged  Ex. Scalds, flames, prolonged contact with hot objects, tar, grease, chemicals o Full thickness  Black, brown, yellow, white, and red color  Severe edema  Yes and no pain  No blisters  Eschar – yes, hard and inelastic  Healings weeks to months  Grafts required  Ex. Scalds, flames, prolonged contact with hot objects, tar, grease, chemicals, electricity o Deep full thickness  Black color  Absent edema  No pain  No blisters  Eschar – yes, hard and inelastic  Healings weeks to months  Grafts required  Ex. Flames, electricity, grease, tar, chemicals o P. 483 26-2 o Characteristics o Comments Patients in this category should receive o Minor Burns: Partial thickness burns less than 10% TBSA. o emergency care at the scene and should be taken to o Full thickness burns less than 2% TBSA. a hospital emergency department. o No burns of eyes, ears, face, hands, feet, or perineum. o A special expertise hospital or designated o No electrical burns. burn center is usually not necessary. o No inhalation injury. o No complicated additional injury. o Patient is younger than 60 years and has no chronic cardiac, pulmonary, or endocrine disorder. o Patients in this category should receive o Partial thickness burns 15-25% TBSA. emergency care at the scene and be transferred to o Full thickness burns 2-10% TBSA. either a special expertise hospital or a designated o No burns of eyes, ears, face, hands, feet, or perineum. burn center. o No electrical burns. o No inhalation injury.

o No complicated additional injury. o Patient is younger than 60 years and has no chronic cardiac, pulmonary, or endocrine disorder. o Partial thickness burns greater than 25% TBSA. o Full thickness burns greater than 10% TBSA. o Any burn involving the eyes, ears, face, hands, feet, and perineum. o Electrical injury. o Inhalation injury. o Patient is older than 60 years. o Burn complicated with other injuries (e.g., fractures) o Patient has cardiac, pulmonary, or other chronic metabolic disorders.

o Patients who meet any one of the criteria for a major burn should receive emergency care at the nearest emergency department and then be transferred to a designated burn center as soon as possible.

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Vascular changes from burn injuries o Fluid shift occurs in first 12 hours can continue 24-36 hours o Capillary leak both burned and unburned areas if burn extensive o Disruption f and e: hypovolemia, hyperkalemia, hyponatremia  hemoconcentration – increases blood viscosity, reduces blood flow, increases tissue hypoxia o Disruption acid-base balance o Fluid remobilization around 24 hours after injury o Diuretic phase 48-72 hours after  hypokalemia, hyponatremia

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Etiology o Dry heat injuries o Moist heat o Contact burns o Chemical burns o Electrical injuries  Thermal burns, flash burns, true electrical injury o Radiation injury

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Dry heat, moist, contact o Skin damaged by contact with heat  Flame  Scalding liquids/steam  Heat source o Severity of injuries  Duration of contact  Temperature of agent  Amount of tissue exposed  Age of patient

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Chemical Injury o Direct contact with acidic or basic solutions o Severity o Type of agent

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Concentration Mechanism of action Duration

Electrical Injuries

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Lightning Injuries o Direct current o Short duration of exposure o Victim tends to be thrown o Trauma likely o Cardiac dysrhythmias common o Nervous system involvement

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Priorities in Resuscitation Phase o Airway o Fluid replacement  Push fluids; monitor I&O and BP; daily weights o Pain management  Opioids o Prevent infection  Covering with sheet may help contain o Maintain temperature o Psychosocial o See table 26-3 inhalation injury  Factors determining inhalation injury or airway obstruction  Patients who were injured in a closed space  Intra-oral charcoal, especially on teeth and gums  Patients who were unconscious at the time of injury  Patients who singed scalp, hair, nasal hairs, eyelids, or eyelashes  Patients who are coughing up carbonaceous sputum  Changes in voice such as hoarseness or brassy cough  Use of accessory muscles or stridor  Poor oxygenation or ventilation  Edema, erythema, and ulceration of airway mucosa  Wheezing, bronchospasm  Patients with extensive burns or burns of the face

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Resuscitation/Early Phase of Burn Injury o First 24-48 hours – emergent-resuscitative phase  Third spacing and capillary leak syndrome o Profound imbalance of fluid:  Electrolyte, acid-base  Hyperkalemia and hyponatremia  Hemoconcentration o Fluid remobilization after 24 hours  Diuretic stage between 48-72 hours after injury  Hyponatremia and hypokalemia

Inhalation Injury of Airway Obstruction o Assess findings differ greatly in resuscitation phase o Continuous airway assessment is a nursing priority o Direct airway injury – damage depends on:  Fire source  Temperature  Environment  Types of toxic gases o See table 26-4  Carbon Monoxide Poisoning Level  Physiological Effects 1-10% (normal)  Increased threshold to visual stimuli  Increased blood flow to vital organs 11-20% (mild poisoning)  Headache  Decreased cerebral function  Decreased visual acuity  Slight breathlessness 21-40% (moderate poisoning)  Headache  Tinnitus  Nausea  Drowsiness  Vertigo  Altered mental state  Confusion  Stupor  Irritability  Decreased blood pressure, increased and irregular heart rate  Depressed ST segment on ECG and dysrhythmias  Pale to reddish-purple skin 41-60% (severe poisoning)  Coma  Convulsions  Cardiopulmonary instability 61-80% (fatal poisoning)  Death

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Labs – Burn Assessment during Resuscitation o ABGs o CBC o Decreased Sodium o Hyperkalemia

o Increased BUN o Decreased total protein and albumin o CK and myoglobin levels 

Fluid Resuscitation o Parkland Formula: Give ½ fluid in first 8 hours; the rest in remaining 16 hours o Amount ml in 24hr = 4 x pt weight (kg) x BSA% burned o Ex. Person 75 kg with 20% of BSA burned would require?

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Rule of Nines o

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Acute Phase of B o Begins about 36-48 hours after injury o Lasts until wound closure is completed o Care directed toward continued assessment and maintenance of:  CV and respiratory systems  GI and nutritional status  Burn wound care  Pain control  Psychosocial interventions

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Assessment o Cardiopulmonary o Neuro-endocrine o Immune o Musculoskeletal

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Surgical Management o Escharotomy o Fasciotomy o Surgical excision o Wound covering  Skin graft

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Nonsurgical Management o Nonsurgical  IV fluids  Monitor patient response to IV therapy  Drug therapy – see chart 26-5  Silver sulfadiazine  Collagenase

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 Mafenide acetate  Nitrofurazone  Gentamicin sulfate  Polymyxin B-bacitracin  Acticoat  PolyMem  Aquacel Ag  Mepilex Ag CAM therapies Environmental changes Mechanical debridement  Hydrotherapy Enzymatic debridement  Autolysis  Collagenase

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Dressing the Burn Wound o Standard wound dressings o Biologic dressings: figures 28-13,14, p. 500  Homograft – human skin  Heterograft – skin from another species  Amniotic membrane  Cultured skin  Artificial skin o Biosynthetic dressings o Synthetic dressings

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Rehabilitative Phase of Burn Injury o Begins with wound closure o Ends when patient returns to highest possible level of functioning o Emphasis on:  Psychosocial adjustment  Prevention of scars and contractures  Resumption of pre-burn activity o This phase may last years or even a lifetime if patient needs to adjust to permanent limitations o Table 26-7, p. 505

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S.O.A.R Program o Survivors Offering Assistance in Recovery o Peer support program o Patients benefit from “the voice of experience” o Supports patients and families in the hospital and after discharge...