NS4084 Exam Review - Summary Medical-Surgical Nursing PDF

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Summary

This is a very detailed exam review for NS4084. It covers all of med-surg nursing and highlights the important details which are needed when studying for NS4084 and ultimately the NCLEX as well! I used this review to study for my final exam and I received an A - all information needed to pass the c...

Description

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RESPIRATORY SYSTEM Supplemental Oxygen Delivery: Nasal Cannula - For pt with airflow limitation; also used for long term O2 use - 1-6L/min - FiO2 24-44% Simple Face Mask - For short term O2 therapy; also used for emergencies - 5-8L/min - FiO2 40-60% - **Monitor for risk of aspiration Venturi Mask - For pts in acute respiratory failure - 4-10L/min - FiO2 70-90% - Delivers controlled percentages of oxygen - It is the one with different coloured attachments Non-rebreather Mask - For pt with deteriorating respiratory status - Rate of O2 flow needs to keep the bag full - FiO2 60-100% Ventilator Alarms: *** Treat patient first and the ventilator second!! High Pressure - Increased secretions - Tube kink - Pt biting on tube or coughing What to do: - Assess ETT for kinks, reposition, and use a bite block - Check for kinks or condensation in ventilator tubing - Assess oxygenation status, vital signs, breath sounds, and suction airway as needed - Bronchodilators may be ordered to reduce bronchospasm - Assess pt for pain, anxiety, and synchrony with the ventilator - Sedative may be required - Notify physician and RT with deterioration in pt status and/or unable to troubleshoot the cause of the alarm Low pressure - Tube disconnected - Pt stopped breathing What to do: - Check if pt is alive - Check for a disconnection in tubing - Check ETT for placement and cuff leak - Assess the pt for air leakage from the mouth or around the tube

2 of 43 - Notify the physician and RT with deterioration in pt status and/or unable to troubleshoot the cause of alarm Adventitious Lung Sounds Crackles

Fine crackles = high pitched crackling/popping noise heart at end of inspiration Course crackles (worse than fine crackles) = low pitched gurgling sound during inspiration and expiration

Pneumonia Heart Failure Pulmonary edema

Wheeze

High pitched musical sound similar to a squeak Asthma **Relieve broncho-constriction (give short acting bronchodilator - Albuterol)

Ronchi

Low pitched, course, loud, snoring tone during expiration

Pleural friction rub

Low pitched, course, grating sound during inspiration and expiration

Stridor

Harsh, high pitched breathing due to obstruction in upper airway **Life threatening

Chronic bronchitis

Aspiration of foreign object Anaphylaxis Epiglottitis

Now for some common respiratory conditions you should know … COPD - Airflow limitation resulting from small airway disease and parenchyma destruction - Most common cause is smoking!! - Includes emphysema (damaged alveoli) and bronchitis (airway swollen and filled with mucous) - Emphysema = pink puffers - Hyperventilation (puffing to breathe) comes from body trying to compensate for high CO2 levels and low blood O2 levels - Normal O2 levels due to rapid breathing (pink complexion) - Chronic bronchitis = blue bloaters - Cyanotic (blue) comes from hypoxia aka decreased oxygen levels - Hyperinflation of lungs (bloat) comes from air retention bc they cant get all the air out when they breathe - Edema (bloat) eventually comes from right sided heart failure d/t pulmonary hypertension - Happens gradually and is irreversible once developed - S/S: cough, SOB, wheezing, crackles, weight loss, barrel chest, orthopnea, hyperinflation of chest, ABG shows respiratory acidosis and hypoxemia - **Remember that a normal SpO2 is 88-92%; do NOT try to raise the SpO2 level higher than this because a lower SpO2 level is what stimulates a COPD pt to breathe!! - Complications: heart disease, spontaneous pneumothorax (d/t forming of air blebs in lungs), risk for pneumonia, lung cancer - Nutrition = high calorie, protein rich - Biggest health teaching = do not smoke! - Meds: corticosteroids (education = rinse mouth after using inhaled corticosteroids d/t risk for thrush & use corticosteroid inhaler after bronchodilator inhaler), Theophylline, Roflumilast, long acting bronchodilators (to open up the airways so the steroid can get in there and do its job), short acting bronchodilators (used in emergency situations where quick relief is needed) Pulmonary Embolism - Thrombus lodges into branch of pulmonary artery - S/S: sudden onset pleuritic chest pain, cough, SOB, blood tinged sputum, cyanosis, JVD, feeling of impending doom, hypotension, tachypnea, tachycardia

3 of 43 - Priorities: - Elevate HOB - Administer O2 - ABGs - Anticoagulants - For pts at risk for PE, the most effective approach for prevention is to prevent DVT - Complications: cardiogenic shock & right ventricular failure (a sudden increase in pulmonary resistance increases the work of the right ventricle) - Death from PE commonly occurs within 1hr after the onset of symptoms - Assessment: CXR (usually normal, used to r/o other causes), ECG (sinus tachy, PR interval depression, non specific T wave changes), ABGs (may be normal; may show hypoxemia and hypocapnia), pulmonary angiogram (allows for direct visualization of obstruction and accurate assessment of the perfusion deficit), V/Q scan (ventilation and perfusion) - Heparin and warfarin sodium = primary method for managing acute DVT and PE - Thrombolytics are used in pts who are severely compromised - Surgical interventions (if needed) = embolectomy (removal of clot) Asthma - Airway inflammation and hyper-responsiveness to stimuli (allergens, exercise, irritants) leading to smooth muscle constriction, mucus secretion, obstruction of airways, air trapping, respiratory acidosis, and hypoxemia - S/S: wheezing, SOB, coughing, chest tightness, difficulty breathing (especially exhaling), increased respiratory rate - Priorities: - Keep airway patent - Position in high fowlers (helps with ease of breathing) - Administer bronchodilators (open airway to increase airflow) - Administer oxygen - Peak flow meter (ask pt to exhale as hard as they can into the device - measures how much air is exhaled from lungs) - Lung sounds and skin colour ** Status asthmaticus = life threatening emergency - Severe and persistent asthma that does not respond to conventional therapy - Attacks can occur with little or no warning and can progress rapidly to asphyxiation - S/S: wheezing, SOB, coughing, chest tightness, difficulty breathing (especially exhaling), increased respiratory rate - Respiratory alkalosis is the most common finding - ** Rising PaCO2 to normal or higher is a danger sign, signalling respiratory failure - What to do: - Beta-2-adrenergic agonists, corticosteroids, supplemental oxygen, and IV fluids to hydrate pt (note: sedatives are contraindicated) - High flow O2 using a partial or complete non-rebreather mask (PaO2 minimum 92mmHg or O2 sat >95%) - Magnesium sulfate (induces smooth muscle relaxation) - Mechanical ventilation if pt is tiring or in respiratory failure or if condition does not respond to treatment Pneumothorax - Air in pleural space = lung collapses and can push heart and great vessels towards other lung - Open pneumo: opening in chest wall allows air into space - Tension pneumo: no opening in chest wall - S/S: no breath sounds on affected side, cyanosis, SOB, hypotension, sudden onset chest pain (sharp, worse on inspiration), subcutaneous emphysema (crepitus on palpation; feels like rice crispies), sucking sound (if open chest wound), tachycardia, increased RR, hypotension, tracheal deviation to unaffected side (if tension pneumo), unequal expansion of chest rise and fall - Priorities:

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Chest wound dressing Apply O2 Fowlers position Prep for chest tube insertion

Chest Tubes Wet Suction

Dry Suction

Description

Suction regulated by height of water in the suction control chamber

Suction monitor below controls amount of suction

Drainage Chamber

Monitors drainage (colour and amount - normal is 100 = pt is in heart failure (BNP is produced when ventricles stretch from high blood volume and when there are high levels of extracellular fluid) Coronary Artery Disease - Obstruction/narrowing of a coronary artery due to atherosclerosis (can also lead to hypertension, chest pain, and heart failure) - S/S: chest pain, palpitations, SOB, syncope, fatigue, cough - all s/s are especially present during activity - Goal: to prevent further progression of CAD - Lifestyle changes: low fat, low calorie diet, exercise, smoking cessation, weight loss - Meds: antiplatelets (prevents clots from forming/growing; decreases chances of ischemia), nitro (dilates vessels to allow more blood flow to the heart; teach pt to take when having chest pain), statins (helps lower LDL, total cholesterol, lower triglycerides, and increase HDL; educate not to replace diet and exercise), beta blockers (lowers HR and BP which reduces work load on the heart; helps decrease episodes of chest pain), ACE inhibitors (lowers BP which decreases the workload on the heart) Peripheral Artery Disease - Decreased blood flow to lower extremities due to atherosclerosis - S/S: intermittent claudication (muscle pain), hair loss, decreased peripheral pulses, cool and dry skin, gangrene, thick nails, ulcers - Nursing interventions: - Circulation: assess colour of extremities, pain, pulses, sensation - Pain management - Skin integrity focus 6 things to assess and ask the pt to determine if it is arterial or venous disease Arterial Disease

Venous Disease

Positions that help alleviate the pain

Dangling the legs down (dependent posi- Elevation of the legs decreases swelling and helps with blood flow tion) helps with the pain Dangling legs or standing/sitting for long Elevation makes pain worse periods makes the pain and edema worse

Description of the pain

Sharp (worse at night) Heavy, dull, throbbing, achy “Rest pain” = the pt wakes up from sleep Pain is worse when standing or sitting for with pain (when the legs are in horizontal long periods position it impedes blood flow) and the pt will dangle the extremity off the bed to

10 of 43 alleviate the pain Intermittent claudication: activity causes severe pain in the calf, muscles, thighs, buttocks, etc (because muscle is being deprived of blood flow during activity); pain eases when activity is stopped Description of the skin of lower extremity Cool to the touch Thin, dry/scaly Hairless Thick toenails Dangle legs = turns rubor (dusky red) Elevate legs = turns pale

Warm to the touch Thick, tough skin Brownish coloured

Strength of pulse in lower extremity

Very poor or absent (d/t decreased blood flow going to extremities)

Present, typically normal (issue is with blood leaving extremities not getting there)

Presence of edema

Not common

Yes, tends to be worse at the end of the day

Lesions

Lesions at end of toes, tops of feet (dorsum), lateral ankle region Appearance: Very little drainage Little tissue granulation (pale/very light pink) or necrotic (black) Deep “punched out” with noticeable margins/edges that gives it a round appearance

Lesions on medial parts of lower legs and medial ankle region Appearance: Swollen with drainage Granulation present (deep pink to red) Edges are irregular Depth is shallow

Nursing Interventions for Peripheral Venous Disease - Preventing stasis of the blood (compression stockings and elevation) - Wound care - Preventing infection - Monitoring for clots (red, swollen, painful, warm area) - Helping treat clots Deep Vein Thrombosis (DVT) - Presents as warm skin and calf or groin pain with or without swelling - Risk factors = Virchow’s Triad (decreased flow/stasis, endothelial damage, hyper coagulable state) - Priorities: - Elevate extremity - Avoid pillow under knees - Do not massage the area - Apply anti embolism stockings - Measures circumference of thigh or calf - Apply warm, moist compress as needed - Antithrombolytics - Avoid prolonged sitting Atrial Fibrillation - Increases risk for stroke - Pt needs to be on anticoagulants

11 of 43 - Priorities: - Monitor INR if on warfarin - Monitor changes in heart rate - Monitor circulation Cardiogenic Shock - The heart cannot pump enough blood to meet the perfusion needs of the body - Decreased cardiac output leads to a decrease in tissue perfusion and oxygen supply to organs/tissues/cells - Blood volume is normal - Main cause is acute MI (heart does not pump like it should, cardiac output falls, tissue perfusion decreases) - S/S: pulmonary congestion, crackles, dyspnea, increased RR, increased HR, neck vein distention, high central venous pressure, chest pain (d/t decreased perfusion to heart muscle), hypotension, weak peripheral pulses, confusion, agitation/restlessness, oliguria (40inches, female >35inches) - High triglyceride level (>150mg/dL) - Low HDL (male 30min), muscle atrophy, spongy joints, weight loss, symmetrical parts of body affected - Priorities: - Rheumatoid factor blood test confirms diagnosis - ROM exercises - Balance between rest and activity - Prevent flexion contractures - Avoid weight bearing on inflamed joints - PT and OT - Use chairs with high backs - Use a small pillow when laying down - Do not exercise painful irritated joints (let rest), avoid high impact exercise - Meds: disease-modifying anti-rheumatic drugs, iron/folic acid/vitB12 (for anemia) Osteoarthritis - Deterioration of articular cartilage in peripheral and axial joints - Mostly on weight bearing joints (hips, knees, hands, spine) - Risk factors: older age, being overweight, repeated injuries, strenuous jobs, genetics

27 of 43 - Joint pain due to grating of bones, bone break down, bone spur formation, and cartilage/bone spurs floating into joint space; no inflammation present - No cure, worsens over time - S/S: pain that increases with activity and decreases with rest, pain increases with temp change, Herberden’s (found on distal interphalangeal joint) or Bouchard’s (found on proximal interphalangeal joint) nodes, joint swelling may be minimal, crepitus - Priorities: - Pain and corticosteroid meds - Avoid flexion of knees and hips - Avoid large pillows when laying - Apply cold pack when joint is inflamed - Rest - Balance activity and rest - Limit activity when in pain - Do not exercise painful irritated joints (let rest), avoid high impact exercise - Treatment: topical creams, weight loss (goal BMI...