Med Surg final exam review by me PDF

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Notes from book and class lecture all in one for first exam as a study guide...

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Med Surg 1 Final Review Handicap: societal participation is used in WHO classification system, instead of handicap, to acknowledge that the environment is always interacting with people to either assist or hinder participation in life activities Functional Independence Measure for Chronically Ill: measures if a patient can do ADLs independently Bleeding precautions: o NO IM injections (minimal injections even Subcut) o Apply pressure for 5 minutes o Use electric razor o Soft bristle toothbrush o No rectal anything o No vigorous sex o No contact sports Neutropenic precautions: o No fresh fruits or flowers, or meats o No raw foods o No crowds o Wash hands!!! o No children o Peel fruits o Talk over the phone instead of having visitors Blood Transfusions: Acute hemolytic reaction o S/S of transfusion reactions: fever, chills, respiratory distress, low back pain, nausea, pain at IV site o Interventions: Determine client’s allergies & previous transfusion reactions o Administer within 30 min. of receiving from blood bank o First 15 minutes: 25-50 mL slowly, after 15 min. increase to 250-500 mL/hr o Never add any meds to blood products o Check crossmatch record with 2 nurses o Infuse each unit over 2-4 hours but no longer than 4 hours o Severe reactions in first 15 min. o Blood tubing changed after 4 hours o If there is a reaction, STOP TRANSFUSION IMMEDIATELY o Maintain IV line (keep vein open) with NS with NEW TUBING at a slow rate o Asses patient (vital signs) for other signs of reaction o Notify HCP & then blood bank & send blood product with tubing back to blood bank o Document o Risks: arm stiffness and ringing in ears are complications of blood transfusions Anemia: o Patho: condition in which the hemoglobin concentration is lower than normal o S/S: fatigue, dyspnea, tachycardia, confusion, weakness, general malaise, pallor of skin & mucous membranes, N/V, anorexia, glossitis, cheilosis (cracks in corners of mouth), smooth sore tongue, pica (craving for ice or clay) o Diet: organ meats, beans, green leafy vegetables (fried liver & spinach) o Interventions: Manage Fatigue o Maintain adequate nutrition (red/organ meats) o Maintain adequate perfusion o Risks: Heart failure, angina, paresthesias, confusion, delirium, injury r/t falls, depressed mood Iron Deficiency Anemia: o Patho: anemia caused by dietary problems (low iron), chronic blood loss, or malabsorption o Most common for women during menstruation; men GI bleeds o Microcytic hypochromic o S/S: smooth sore tongue, brittle & ridged nails, cheilosis (cracks in corner of mouth)

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Diet: increase iron in diet (vitamin C sources enhance iron absorption- ORANGE JUICE) Interventions: Treat underlying cause (bleeding); transfusion of packed RBCs o Give iron supplements (may cause constipation, so give stool softeners) o **Remember: oral liquid form of iron can stain teeth; clients should use a straw or place spoon at back of mouth to take supplement and rinse mouth thoroughly afterward o DO NOT GIVE IRON WITH MILK OR ANTACIDS o Caution client that bowel movement may appear greenish, black, or tarry

Vitamin B12 Deficiency: Pernicious anemia o Patho: anemia from impaired DNA synthesis b/c of lack of Vitamin B12; also r/t faulty absorption in the GI tract from a lack of intrinsic factor (Gastric Surgery); chronic use of PPI’s and metformin o Other risk factors: ulcerative colitis, alcoholism, and vegetarian diets o Macrocytic normochromic o Disrupts the function of peripheral nerves, spinal cord, and brain o S/S: mild jaundice o Mouth and tongue soreness- Beefy red tongue (glossitis) o Neurological manifestations (paresthesias, loss of proprioception) o Diet: organ meats (fried liver & spinach), diary products, eggs & fortified soy milk (for the vegetarian) o Interventions: 24-hour Schilling Test (a vitamin B12 absorption test) o Vitamin B12 replacement o Teach regarding diet & meds; assess for neuro deficits Folate Deficiency: o Patho: anemia caused by a deficiency of folic acid o Found in people w/ poor nutrition, alcoholics, people with celiac disease (malabsorption), meds, anorexia o Macrocytic normochromic o Low folate causes constipation o S/S: mild jaundice, mouth and tongue soreness (glossitis, cheilosis) o Diet: increase folate in diet (green leafy vegetables) o Interventions: administer folic acid 1 mg daily IM Sickle Cell Anemia: o Patho: severe hemolytic anemia; results from inheritance of the HbS gene o Causes sickling of cells o Triggered by: hypoxia, low body temp (being cold), exercise, & high altitude o S/S: jaundice o Chronic anemia: tachycardia, cardiac murmurs, cardiomegaly, ischemia, infarction, late sign= clubbing of fingers o Sickle Cell crisis: hypoxia, inflammation, necrosis (entrapment of erythrocytes in microcirculation) o Acute Chest Syndrome: fever, respiratory distress, new infiltrates on chest x-ray (mimic infection) o Interventions: transfusion therapy o Pain management (first priority, give 02 & hydrate to help w/ blood viscosity) o Adequate hydration (3000 mL) o Supplemental oxygen o Decrease fatigue and inflammation Aplastic Anemia: o Patho: deficiency of all types of blood cells caused by failure of bone marrow development (pancytopenia) o Caused by chromosomal alteration, radiation, chemical agents, toxins, viral/bacterial infections o 50% of cases are idiopathic o Fatty deposits found on bone marrow o S/S: thrombocytopenia, leukopenia, reticulocytopenia o Infections of skin and mucous membranes (WBC deficiency) o Bleeding from gums, nose, vagina or rectum (platelet deficiency) o Purpura & possible retinal hemorrhage o Interventions: implement bleeding precautions o Implement neutropenic precautions

Bleeding Disorders: o Patho: failure of normal hemostatic mechanisms (trauma, platelet factor abnormality, coagulation factor abnormality) o S/S: petechiae, purpura o Interventions: Bleeding precautions o Electric razor o Limit amount of injections; small gauge needles o No Aspirin o Protect from injuries Immune Thrombocytopenic Purpura: o Patho: destruction of platelets by unknown stimulus o S/S: easy bruising, heavy menses, petechiae, mucosal bleeding (increased risk for intracranial bleeding) o Interventions: determine cause of bleeding (NSAIDS) o Neurological assessment o Avoid injections and rectal procedures o Patient education Radiation Therapy: o Used to treat localized lesions, kill tumor, reduce tumor size o Diet: low residual diet (low fiber) o Interventions: Private room, bed rest for 72 hours- log roll if turning o Indwelling urinary catheter o Promote nutrition o Antidiarrheal agents o Time limits for visitors/personnel o Prohibit children and pregnant women visits o Limit visitors to 30 minutes daily and to remain 6 feet from radiation source o Protect yourself with proper PPE o If whatever is implanted dislodges, use forceps & put it in lead container o Risks: fatigue, malaise, anorexia Chemotherapy: o Treats systemic disease o Diet: low residual diet (low fiber) o Interventions: wear gloves, mask and gown o Implement neutropenic precautions o Administer antiemetic (Zofran- ondansetron) 30 min. before chemo o Assess fluid & electrolytes and cognitive status o Protect yourself with proper PPE o Maintain tissue integrity (stomatitis, alopecia, malignant skin lesions) o Promote Nutrition (anorexia, cachexia, malabsorption) o Relieve pain o Decrease fatigue o Assist with improving body image and self-esteem o Risks: N/V, fatigue Multiple Myeloma: o Patho: cancer of the bone marrow; myeloma cells replace bone marrow o S/S: bone pain o Hypercalcemia o BUN elevated b/c of increased uric acid o Bence jones proteins in urine o CRAB- calcium elevated, renal failure, anemia, bone lesions o Interventions: promote hydration AML:

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Patho: defect in hematopoietic stem cell that differentiates into all myeloid cells o Mainly occurs > 60 years of age o Most common non-lymphocytic leukemia o Increased risk in those patients who have received alkylating agents for cancer S/S: WELFS o Weakness o Ecchymosis o Lymphadenopathy o Fever o Splenomegaly

CML: o Patho: mutation in the myeloid stem cell o Pathologic increase in production of blast cells o Philadelphia chromosome o More common in older adults o 10-15% of all leukemia’s o S/S: BLAST o Bone pain o Leukocytosis o Asymptomatic o Splenomegaly o Three stages: chronic, transformation, accelerated (can go from CML to AML) ALL: o

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CLL: o

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Patho: uncontrolled proliferation of immature cells (lymphoblasts) derived from the lymphoid stem cell o B lymphocyte or T lymphocyte precursor o Most common in young children (boys>girls) o Peaks at age 4 o Responsive to treatment o Complete remission achievable S/S: HIIC o Hematopoiesis o Inhibited (reduced number of granulocytes, platelets, erythrocytes) o Immature leukocytes o CNS involvement

Patho: Common in older adults o Most common leukemia o Vietnam War: agent orange o > 20 year survival rate o Most leukemic cells in CLL are fully mature: escape apoptosis o Greater risk for developing other cancers S/S: FAULLSS o Fevers o Asymptomatic o Unintentional weight loss o Lymphocytosis o Lymphadenopathy o Splenomegaly o Sweating

Leukemia: o Patho: Hematopoietic malignancy characterized by unregulated proliferation of leukocytes o Interventions: Monitor lab results, culture results o Prevent/manage infection and bleeding

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Ease pain and discomfort Maintain fluid and electrolyte balance Manage anxiety and grief

Lymphoma: o Patho: neoplasms of cells of lymphoid origin; start in lymph nodes but can spread to spleen, GI tract, liver, or bone marrow Hodgkin’s Lymphoma: FEVER & WEAKNESS W/OUT CHILLS o Patho: originates in a single node o Spreads by contiguous extension along the lymphatic system o Two peaks (15-35 & 55-70) o Caused by infections (Epstein Bar) o Characterized by Reed-Sternberg cells & mediastinal mass o S/S: FFEWUS o Fatigue o Fever o Enlarged lymph nodes o Weakness o Unintentional weight loss o Sweating Non-Hodgkin’s Lymphoma: o Patho: originates outside the lymph o Spread is unpredictable o Most common lymphoma o True localized disease is uncommon o Lymph nodes from multiple sites may be involved o Caused by viral infections o S/S: VCHANSE o Visual disturbance o CNS involvement o Headaches o Abdominal pain o Nausea o Seizures o Enlarged lymph nodes Polycythemia Vera: o Patho: Increased volume of RBC’s due to dehydration o Primary polycythemia- proliferative disorder of the myeloid stem cells (elevated erythrocyte, leukocyte, & platelets) o Secondary Polycythemia- excessive production of erythropoietin because of reduced amount of oxygen (smoking, COPD, CAD, high altitudes, neoplasms) o S/S: Ruddy (dark red) complexion- plethora o Splenomegaly o Symptoms from increased volume- HA, dizziness, tinnitus, fatigue o Symptoms from increased viscosity- angina, claudication, thrombophlebitis o Interventions: PHLEBOTOMY- 500 mL of blood o Educate on risk factors o Risks: Thrombosis (CVA, MI), bleeding due to large & dysfunctional platelets HIV: Priority AIDS patient- one with warm flushed skin & tented skin turgor o Patho: a retrovirus which targets cells with CD4 receptors (expressed on surface of T lymphocytes) o Primary infection: period during which those who are HIV+ test negative on the HIV antibody test. Viral illness for 1-2 weeks; 2-3 weeks: antibodies detected. Characterized by high levels of viral replication, widespread HIV, & drop in CD4 levels=500-1500. o AIDS: 10-20% weight loss  Chronic diarrhea  Chronic weakness  Fever  Protein energy malnutrition  Anorexia, GI malabsorption o Oncologic: Kaposi’s sarcoma (cutaneous lesions), B-cell lymphomas o Neurologic: cognitive defects, peripheral neuropathy, HIV encephalopathy, depression o Integumentary: Herpes zoster, simplex, dermatitis o Gynecological: vaginal candidiasis, genital ulcers, HPV, menstrual abnormalities Diet: small, frequent meals o Avoid foods that act as bowel irritants, such as raw fruits and vegetables, carbonated beverages, spicy foods, and foods for extreme temperatures Interventions: Antiretrovirals o Promote skin integrity (avoid scratching, nondrying soap) o Promote usual bowel patterns (control diarrhea) o Prevent infection (antifungals for candidiasis) o Improve activity tolerance (energy conservation techniques) o Improve airway clearance (semi-fowlers or high-fowler’s, oxygen) o Improve nutritional status o Maintain thought process (use clear, simple language & orient the pt.) o Provide information r/t spread of infection o Pain management

Type 1 Hypersensitivity Reaction (IgE): o Patho: Anaphylactic reaction characterized by vasodilation, increased capillary permeability, smooth muscle contraction, laryngeal stridor, angioedema, hypotension, and bronchial, GI, or uterine spasm. o S/S: hives, asthma, allergic rhinitis (hay fever), ANAPHYLAXIS o Interventions: o Question to ask someone with seasonal rhinitis: What are some symptoms you have that make you think you have an allergy? o Discharge instructions to teach someone with a bee sting allergy: demonstrate use of an epi-pen & make sure they understand how to use it Type 2 Hypersensitivity Reaction (IgG or IgM): o Patho: A cytotoxic reaction that is the result of mistaken identity when the system identifies a normal constituent of the body as foreign & activates the complement cascade o S/S: myasthenia gravis, Goodpasture’s syndrome, pernicious anemia, hemolytic disease, transfusion reaction, and thrombocytopenia Type 3 Hypersensitivity Reaction: o Patho: An immune complex reaction marked by acute inflammation resulting from formation and deposition of immune complexes. The joints and kidneys are susceptible to this kind of reaction. o S/S: Urticaria, joint pain, fever, rash, adenopathy (swollen glands) SLE, serum sickness, nephritis, RA Type 4 Hypersensitivity Reaction: o Patho: A delayed reaction that occurs 1 to 3 days after exposure; results in tissue damage. o S/S: erythema, itching, contact dermatitis, graft-versus-host disease, Hashimoto’s thyroiditis o o

S/S for all hypersensitivity reactions: Mild o Peripheral tingling, warmth o Fullness in mouth/throat o Nasal congestions

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o Periorbital swelling o Pruritus o Sneezing, tearing of eyes Moderate o Flushing/warmth o Anxiety o Itching o Bronchospasm o Airway edema o Dyspnea, cough o Wheezing Severe o Abrupt onset o Bronchospasm, laryngeal edema o Severe dyspnea o Cyanosis o Hypotension o Dysphagia o Abdominal cramps, N/V/D o Seizures o Cardiac arrest o Coma Interventions: Assessment of ABC’s o History of Allergies o Rapid response team o Intubation o Emergency Meds o Pt support

Rheumatoid Arthritis: o Patho: autoimmune, degenerative, inflammatory, & systemic disease; affects joints, muscles, soft tissue o Originates in synovial tissue o RA synovial breaks down collagen: edema, destroys cartilage and erodes the bone causing pannus formation o Loss of articular surfaces & joint motion o Muscle fibers undergo degenerative changes o Tendon/ligament elasticity & contractile power are lost o S/S: pain, joint swelling, limited movement, stiffness, weakness, fatigue o Symmetric joint pain especially in morning o Morning joint stiffness >1 hour o Symmetric swelling and warmth o Bilateral/symmetric stiffness o Spongy/boggy tissue o Immobilization leads to contractures o Deformities of hands (ulnar deviation/swan neck deformity) o Extra-articular features affecting other organs o Sjogren’s syndrome (dry eyes & mouth) o ANA and Rf factor present in diagnostics o Interventions: priority-control acute/chronic pain (protect joints), immunosuppressants o Help them exercise to promote mobility (PT, OT) o Risk: high susceptibility to infectious disease such as flu and pneumonia, Raynaud’s phenomenon o Esp. when on immunosuppressants Systemic Lupus Erythematosus: o Patho: Autoimmune disease where the immune system inaccurately recognizes cell nucleus components as foreign; B cells overproduce antibodies which form antigen-antibody complexes, & antibodies destroy host cells. (Hypersensitivity Type 3)

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S/S: skin: butterfly rash across bridge of nose and cheeks o Oral ulcers o Arthralgia/arthritis: morning stiffness o Muscle aches o Fever, malaise, weight loss, anorexia o Photosensitivity o Low grade fever o Pericarditis, myocarditis, HTN, valvular incompetence o Nephritis o Psychosis, seizures, cognitive impairment, strokes o Anemia, thrombocytopenia, leukopenia o Raynaud’s phenomenon o Pleural effusions o ANA in diagnostics Interventions: control acute/chronic pain o Teach them to avoid sunlight or limit their exposure & use sunscreen with highest SPF o Pat dry skin gently to prevent skin abrasions o *Prevent loss of organ function* o Monitor CBC for low H/H, platelets, WBC o Manage systemic symptoms (fever, malaise, weight loss, anorexia) o Teach them to stay away from large crowds

**All “Acute Exacerbations” are NPO to rest tissues until symptoms SUBSIDE** Hiatal Hernia:  Patho: Muscle weakness of the diaphragm at the esophageal hiatus  Diet: Small frequent feedings that can pass through esophagus (4-6) o Avoid irritating foods: chocolate, fats, mints, spicy, acidic, carbonated drinks, caffeine, alcohol or smoking  Interventions: 1.Do not recline after meals for at least 1 hour to prevent reflux/movement of hernia o 2. Elevate HOB 4-8 inches o Antacids, PPI, H2 blockers, Fundoplication  Risks: aspiration, nutritional status, pain, GERD GERD:  Patho: Gastric content leakage into esophagus irritating tissue due to weakness in lower esophageal sphincter  S/S: dyspepsia (indigestion), acid reflux, atypical chest pain, pyrosis (heartburn)  Diet: Low fat diet o 4-6 small meals o Avoid irritating foods (caffeine, tobacco, beer, milk, mints, carbonated drinks) o NO eating/drinking 2 hrs before bedtime  Interventions: Elevate HOB 6-8 inches (using pillows, foam wedge) o Educate about no tight clothing, no smoking or alcohol o Antacids, H2, PPI, Prokinetics (b/c delayed gastric emptying can contribute to reflux), fundoplication  Risks: Barrett’s Esophagitis (precursor to cancer), Asthma (related to aspiration), Aspiration, Pneumonia (related to aspiration), Frequent upper resp. sinus/ear infections Gastritis:  Patho: inflammation of stomach related to alcohol, bile reflux, radiation, autoimmune, ulcers, H. pylori  Diet: NPO to rest stomach until symptoms subside then small frequent meals o Avoid irritating foods  Interventions: IV fluids (esp. when NPO) o Monitor F/E o Monitor for bleeding or anemia from bleeding or malabsorption o Vagotomy – cut vagus nerve to decrease stomach acid o Pyloroplasty- pylorus sphincter widened to increase gastric emptying

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Risks: Pernicious anemia due to malabsorption of vit. B12, hemorrhagic gastritis (signs: hematemesis, tachycardia, hypotensive, occult blood in stool)

Gastroenteritis: o Patho: inflammation of the GI tract, involves stomach and small intestine o Caused by bacterial or viral infection o S/S: diarrhea, vomiting, abdominal pain, and cramping o Diet: NPO o Intervention: priority is to rehydrate (major concern is dehydration) o Give antibiotics o Risks: electrolyte imbalance and dehydration Peptic Ulcer Disease:  Patho: erosion of mucosal lining of stomach or duodenum causing dull gnawing epigastric pain o Duodenal ulcers: food takes away pain then returns 1-3 hours after and at night (epigastric pain also!!) o Gastric ulcers: pain 30-60 min after eating and rarely at night o Associated w/ H. Pylori, O Blood Type, acid hypersecretion, NSAIDs, Familial tendency, Zollinger-ellison syndrome  Diet: 3 regular meals (unless symptomatic) to avoid stimulating more acid w/ frequent meals o Avoid irritating foods: caffeine, milk, chocolate, etc.  Interventions: Saline Lavage via NG Tube o Antibiotics (H.Pylori) o H2 blockers, PPI, Antacids, Mucosal Protectants (given in empty stomach) o Test stool for occult blood  Risks: perforation -> peritonitis (emergency situation- hard rigid abdomen & WBC count of 22,000), gastritis, hemorrhage (if bleeding or obstructions: NG tube), pernicious anemia (...