MSI Principles 14th - points to know PDF

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What are the main points for this week? Med/Surg I Week 1

1. Health Care Delivery & Evidence Based Practice Subcutaneous tissue has fewer blood vessels so obesity slows wound healing, increases the risk for infection and delays healing Prevent pressure ulcers by keeping dry skin moist, avoid massaging bony prominences, protect the skin from incontinence or wound drainage, improve mobility, use appropriate support surfaces, administer nutritional supplements as needed, use minimal friction when cleaning and avoid hot water

A. Physiological Integrity A. Physiological Integrity

Chapter 1

1. Health Care Delivery & Evidence Based Practice Health Promotion Conduct a cultural assessment prior to initiating health teaching!

E. Interventions

Teach patients about modifiable (weight, smoking, sex practices and diet) and non-modifiable risk factors (age, genetics and sex) (Page #6) Use the nursing process to provide individualized care that is evidence based (Page #9)

E. Interventions E. Interventions

Safety The quality and safety education for nurses (QSEN) institute seeks to strengthen the knowledge, skills and attitudes o nurses in providing continuous quality improvement in health care (Page #1) The purpose of nursing is to treat the patients response to illness and use evidence based practices to improve outcomes (Page #5) Determine how to prioritize the needs of the patient by using Maslow's hierarchy of needs (physiological integrity, safety and security, belongingness and affection, esteem and self-respect, self-actualization) and remember that physiologic needs (basic need) and life threatening issues are a priority (Page #5) Confirm that physiologic integrity, safety and security, belongingness/affection, esteem/self-respect, and self-actualization are met in that order (Page #6) Healthy People 2020 identifies health promotion and disease prevention goals and lists strategies along with resources in an attempt to improve the nation's health (Page #6) The Institute of Medicine's report on the Future of Nursing recommends ways to strengthen the practice of nursing in order to improve health care. (Page #7) Nurses must comply with their states nurse practice act since it governs nursing practice and is a law that's put in place to protect the public (Page #10) The National Patient Safety Goals lists the top patient safety concerns and includes medication safety, infection prevention surgery-related mistakes, patient identification and improving staff communication. (Page #10)

G. Nursing History A. Physiological Integrity A. Physiological Integrity

E. Interventions A. Physiological Integrity A. Physiological Integrity A. Physiological Integrity A. Physiological Integrity

Chapter 12

3. Pain Management Pain Pain is whatever the patient says it is (Page #225)

B. Assessment Findings

Pain is associated with actual or potential tissue damage (Page #225)

A. Physiological Integrity

The single most reliable indicator of pain is the patient's self-report (Page #225)

A. Physiological Integrity

Pain stimulates the sympathetic nervous system and could result in an increase in blood pressure, heart rate and respirations (Page #226) Unrelieved pain increases glucagon production, decreases insulin secretion, depresses immune function, and can lead to addictive behaviors (Page #229) Prostaglandins initiate inflammation and contribute to tissue swelling and pain (Page #229)

A. Physiological Integrity

A. Physiological Integrity

Tissue damage stimulates the inflammatory response and puts the patient at risk for pain. (Page #229)

A. Physiological Integrity

Manage nociceptive pain with local anesthetics, nonopioids or opioids (Page #230)

E. Interventions

The numeric rating scale ranges from 0 to 10 with 0 representing no pain (Page #230)

C. Diagnostics

The visual analog scale is a 10 cm line that represents no pain to worst pain on opposites sides of the line and the individual places a mark somewhere between the two ends depending on the severity of pain (Page #230) Nerve route injury could lead to allodynia (pain that is associated with a nonnoxious stimulus) (Page #231)

E. Interventions

The visual analog scale is a 10 cm line that represents no pain to worst pain on opposites sides of the line and the individual place a mark somewhere between the two ends depending on the severity of pain (Page #231) The Wong-Baker FACES scale (ages 3 and up) consists of cartoon faces that the patient selects to report their pain. (Page #231) The verbal descriptor scale uses words to help individuals describe the intensity of pain (Page #231) A comprehensive pain assessment includes duration (includes when it started), type (incudes intensity, associated factors, influencing factors (what makes it better or worse), location (Page #231) Nonsteroidal anti-inflammatory medications could lead to acute renal failure in patients with volume depletion or who take it for chronic pain (Page #231) Provide non-pharmacological pain management strategies such as physical modalities, mind-body methods, biologic and energy based therapies (Page #232) Nonsteroidal anti-inflammatory medications could result in gastric ulcers or contribute to cardiovascular events (myocardial infarction or stroke) (Page #234) Provide patient controlled analgesia to help reduce complications related to pain (Page #235)

A. Physiological Integrity

D. Complications E. Interventions C. Diagnostics C. Diagnostics B. Assessment Findings D. Complications F. Drug Therapy D. Complications E. Interventions

What are the main points for this week? Med/Surg I Week 1 Chapter 12

3. Pain Management Pain Provide around the clock administration of analgesics for chronic and postoperative pain, never wait for chronic pain to reoccur (Page #235) Provide aspirin or acetaminophen (mild to moderate pain), non steroidal anti-inflammatory drugs (moderate pain) or morphine (severe pain) to manage pain (Page #235) Nonsteroidal anti-inflammatory medications primarily produce pain relief by preventing prostaglandin formation (Page #235) Acetaminophen does not have anti-inflammatory properties (Page #235)

E. Interventions

Avoid the rectal route for medication administration for patients who are thrombocytopenic (Page #235)

E. Interventions

Wake patients who have chronic pain or who have moderate to severe pain following surgery and administer analgesics as prescribed (Page #235) Acetaminophen use could result in hepatoxicity and should not exceed 4,000 mg/day (Page #235)

E. Interventions

Topical effects produce a local effect whereby the transdermal route produces drug absorption into the systemic circulation (Page #236) Prostaglandin is needed for renal blood flow (Page #237)

F. Drug Therapy

E. Interventions F. Drug Therapy F. Drug Therapy

D. Complications

A. Physiological Integrity

Opioids produce undesirable effects such as constipation, nausea, pupil constriction and respiratory depression (Page #238) Physical dependence and tolerance are not the same as addiction (Page #238)

F. Drug Therapy

Administer medications by starting with the lowest dose and titrating up slowly (Page #240)

E. Interventions

Wong-Baker FACES scale should never be used by the provider to match the patient's facial expression (Page #240)

C. Diagnostics

Never apply heat over transdermal patches since this could increase absorption and result in lethal complications (Page #243) Manage neuropathic pain with adjuvant medications like antidepressants or anticonvulsants (Page #244)

D. Complications

Placebos should not be used in clinical practice since it violates the nurse-patient relationship (Page #245)

F. Drug Therapy

D. Complications

E. Interventions

Chapter 13

4. Electrolytes Acid Base Imbalance Vomiting increases the risk for metabolic alkalosis and diarrhea increases the risk for metabolic acidosis (Page #284)

D. Complications

Calcium Calcium helps to regulate muscle contraction and relaxation (Page #272)

A. Physiological Integrity

Provide a diet high in calcium and low in phosphorus in the setting of hypoparathyroidism (Page #275)

A. Physiological Integrity

Chloride Chloride works with Na to determine osmotic pressure (Page #281)

A. Physiological Integrity

Chloride has an inverse relationship with bicarbonate (if chloride levels drop, bicarbonate is retained and results in hypochloremic metabolic alkalosis) (Page #281)

A. Physiological Integrity

Electrolytes Changes in electrolytes impair action potentials resulting in weakness or excitability (Page #252)

A. Physiological Integrity

Fluid Volume Children have a higher percentage of fluid volume to surface area and small shifts in intravascular volume increases their risk for fluid volume deficit (FVD) (Page #252) Proteins like albumin create an oncotic pressure which pulls fluid from the interstitial compartment into the intravascular compartment to maintain volume. (Page #253) D5W becomes a hypotonic solution as the cells absorb the dextrose and should not be given to patients with a head injury (Page #289)

A. Physiological Integrity A. Physiological Integrity A. Physiological Integrity

Magnesium Magnesium has an inverse relationship with Calcium (low Magnesium stimulates parathyroid hormone secretion) (Page #272) Magnesium helps with carbohydrate and protein metabolism, affects neuromuscular function and produces vasodilation (Page #276) Magnesium sulfate is a calcium antagonist and can be given to relax smooth muscle (Page #277)

A. Physiological Integrity

The antidote for tetany or hypermagnesemia is calcium gluconate (Page #278)

D. Complications

A. Physiological Integrity A. Physiological Integrity

Phosphorus Phosphorous is required for the formation of ATP and helps to maintain the acid-base balance (Page #279)

A. Physiological Integrity

Potassium Potassium is necessary for neuromuscular and cardiovascular function (Page #268)

A. Physiological Integrity

Hypokalemia lowers the resting membrane potential and makes cells less irritable which could result in an ileus. (Page #268)

A. Physiological Integrity

What are the main points for this week? Med/Surg I Week 1 Chapter 13

4. Electrolytes Potassium Potassium is the ion for repolarization (membranes reset). Tall tented t waves occur with hyperkalemia and inverted t waves occur with hypokalemia (Page #268) Check renal function prior to administering potassium (Page #269)

A. Physiological Integrity

Potassium sparing diuretics should NEVER be used in the presence of renal injury (Page #272)

A. Physiological Integrity

Hydrogen ions are exchanged for potassium ions during alkalosis or acidosis (i.e. metabolic acidosis results in hyperkalemia as H ions are shifted into the cell to raise the pH and potassium leaves the cell and enters the bloodstream) (Page #283)

A. Physiological Integrity

E. Interventions

Sodium Water follows salt so an increase in sodium typically results in an increase in water (Page #252)

A. Physiological Integrity

Sodium is the primary factor for osmolality and intravascular fluid volume (Page #253)

A. Physiological Integrity

Assess patients for electrolyte imbalance in the setting of vomiting, diarrhea or suctioning (Page #259)

B. Assessment Findings

Hyper or hyponatremia can result in neurological changes (Page #265)

A. Physiological Integrity

Clinical manifestations of hyponatremia consist of headaches, seizures, lethargy, tachycardia, decrease in blood pressure, thready pulse, hyperactive bowel sounds and abdominal cramps (Page #265)

B. Assessment Findings

5. Fluid Aspiration Elevate the head of the bed to 30-45 degrees to prevent aspiration in the setting of mechanical ventilation altered consciousness or tube feedings (unless contraindicated) (Page #260)

E. Interventions

Calcium Calcium affects the threshold potential so hypercalcemia contributes to muscle weakness and coma while hypocalcemia contributes to muscle irritability and tetany (Page #272) Chvostek’s and trousseau’s sign are classic signs of hypocalcemia (Page #273)

B. Assessment Findings

Prolonged immobility contributes to shifting of Ca out of the bones leading to osteoporosis (Page #273)

D. Complications

Laryngospasms can occur with low Ca and is a medical emergency (Page #273)

B. Assessment Findings

IV Calcium administration could cause cardiac arrest! (Page #274)

D. Complications

Calcium gluconate is given to reverse central nervous system depression caused by magnesium (Page #278)

D. Complications

B. Assessment Findings

Chemical Agents Antidiuretic hormone (vasopressin) promotes fluid reabsorption by the kidneys (Page #255)

A. Physiological Integrity

The R-A-A cascade (renin, angiotensin & aldosterone) is triggered by a decrease in renal perfusion which results in an increase in blood volume and pressure (increased in perfusion). (Page #255) Aldosterone promotes sodium retention and potassium excretion (Page #255)

A. Physiological Integrity A. Physiological Integrity

Aldosterone, angiotensin and antidiuretic hormone help to prevent lethal drops in perfusion pressure (Page #255)

A. Physiological Integrity

Brain natriuretic peptide (BNP) triggers Na excretion and a decrease in volume. (Page #256)

B. Assessment Findings

Angiotensin is one of the most powerful vasoconstrictors in the body (Page #256)

A. Physiological Integrity

Fluid Volume Intravascular fluid contributes to one's blood pressure or perfusion pressure (Page #252) Hydrostatic pressure moves fluid from the intravascular compartment to the intercellular (Page #253)

A. Physiological Integrity

Edema could result from an increase in hydrostatic pressure or a decrease in oncotic pressure (Page #253)

B. Assessment Findings

The higher the concentration of enteral feeding the greater the need for water and the greater the risk for diarrhea (Page #254) Renal function declines as we age and the elderly have a decrease in total body water which puts them at an increased risk for fluid volume deficit. (Page #258) Delirium is a typical sign of dehydration in the elderly (Page #260)

A. Physiological Integrity A. Physiological Integrity

Fever and burns cause an insensible (nonvisible) water loss & contribute to dehydration (Page #260)

A. Physiological Integrity

Assess skin turgor by pinching the skin over the sternum or forehead (Page #260)

E. Interventions

Instruct how to cough and deep breathe and use the incentive spirometer (inhale deeply and slowly) to help remove secretions and promote lung expansion (Page #260) A weight gain of 2.2 pounds is equivalent to a liter of fluid retention (Page #260)

E. Interventions

Changes in fluid volume effect blood volume and contributes to hypotension or hypertension (Page #261)

A. Physiological Integrity

Diuretics are used to treat fluid volume overload but electrolytes are loss along with fluid (Page #261)

F. Drug Therapy

Being in a supine position promotes renal blood flow and the formation of urine (Page #261)

A. Physiological Integrity

Loss of fluid volume could lead to a drop in perfusion, hypovolemic shock and death! (Page #263)

A. Physiological Integrity

Signs of fluid volume deficit include changes in level of consciousness, decreased urinary output, dizziness, dry mucosal membranes, hypotension, tachycardia, (Page #263) The elderly have an impaired thirst mechanism so are at a greater risk for hypernatremia (Page #268

B. Assessment Findings

A. Physiological Integrity

B. Assessment Findings

B. Assessment Findings

D. Complications

What are the main points for this week? Med/Surg I Week 1 Chapter 13

5. Fluid Intravenous Solutions The greater the concentration of a solution the greater the ability to pull fluid in (Page #254)

A. Physiological Integrity

Lactated Ringer's should never be given with metabolic alkalosis, lactic acidosis, or renal failure (Page #260)

A. Physiological Integrity

Infuse 3% NaCl slowly because it could lead to pulmonary edema (emergency use only) (Page #260)

E. Interventions

Never infuse 3% NS rapidly due to risk for fluid volume overload (Page #260)

E. Interventions

Use 0.9% normal saline with blood transfusions (the only solution that can be used with blood transfusions) (Page #285)

E. Interventions

Isotonic fluids cause extracellular fluid (ECF) volume expansion (Page #288)

A. Physiological Integrity

D5W is both isotonic and hypotonic and should NEVER be used in the presence of increased intracranial pressure (Page #289) Use hypotonic solutions to rid the body of waste products (hyperosmolar conditions like diabetic ketoacidosis) (Page #289) Give hypotonic solutions to treat hyperosmolar disorders (Page #289)

A. Physiological Integrity

Give hypotonic solutions to replace intracellular fluid volume (ICF) (true dehydration with water loss, NOT for fluid volume deficit with a loss of electrolytes). (Page #289)

E. Interventions

E. Interventions E. Interventions

IV Therapy Rapid IV solution administration in the elderly increases the risk of pulmonary edema (Page #289)

D. Complications

Obtain an x-ray prior to initiating intravenous therapy on peripherally inserted central catheters (Page #290)

E. Interventions

IV therapy puts the client at risk for circulatory overload (Page #290)

D. Complications

Start intravenous sites at the most distal area of the arm (Page #291)

E. Interventions

Use a 14-18 gauge catheter to administer blood and viscous solutions (Page #291)

E. Interventions

Use smaller size angio-catheters on the elderly patient (Page #291)

E. Interventions

Removing excess hair with a razor increases the risk of infection (Page #291)

D. Complications

Air embolism is treated by placing the client onto their left side in Trendelenburg (Page #291)

E. Interventions

Secure a tourniquet proximal to the IV site and check the flow to confirm an infiltration (Page #291)

E. Interventions

Treat nonvesicant infiltrations with a warm compress and elevate the extremity (Page #291)

E. Interventions

Following an extravasation, neurovascular assessments of the affected extremity should be performed (Page #291)

E. Interventions

Using the leg for IV therapy increases the risk for thromboembolism (Page #293)
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