ATI Med-Surg – Flashcards
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-high sodium, low potassium, and increased fluids; -small frequent meals to prevent hypoglycemia
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Diet for Addison's Disease
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darkening or bronze pigmentation of skin in both exposed and unexposed parts of the body
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Addison's Disease - skin manifestations
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purple striae on chest and abdomen
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Cushing's disease - skin manifestations
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-frequently occurs after CABG; -in A-Fib the atrial kick is lost and cardiac output is decreased by 30%
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Atrial fibrillation
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Remove stockings 1 to 3 times per day for skin care and inspection
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Anti-embolic stockings
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-when the amount of sodium in fluids outside cells drops [hyponatremia], water moves into the cells to balance the levels. This causes the cells to swell with too much water Water moves from the ECF into the ICF, causing cells to swell (cerebral edema). -client is now in a fluid overload situation: Restrict water intake as prescribed by provider [to keep the blood from becoming more dilute and possibly causing more health problems] -to restore normal ECF volume: Administer isotonic I.V therapy [NS or LR]
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hyponatremia -net gain of water or loss of sodium-rich fluids -sodium levels drop gradually over period of 48 hr or longer -Normal sodium: 135 to 145
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- in acute hyponatremia - sodium levels drop *rapidly* in *< 48 hrs* - water enters brain cells causing them to swell, resulting in deadly cerebral edema; -hypertonic fluids are used to pull water out of the cells and decrease the swelling
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How is *acute* hyponatremia different from the normal hyponatremia [that we treat w/isotonic fluids], and how do we treat it?
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-BUN; -hematocrit [remember this is ratio of cells to volume]; -urine specific gravity and osmolarity; -serum sodium [remember "sodium high, patient dry"]
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fluid volume deficit is reflected in an *increase* of which lab values?
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Hyperosmolarity of the extracellular fluids secondary to hyperglycemia
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A nurse is caring for a client recently diagnosed w/diabetes mellitus (DM). Which of the following is the *physiologic basis for polyuria manifested by individuals with untreated DM*?
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increased urine concentration + increased specific gravity
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Is urine concentration increased or decreased in early-stage renal failure ?
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70 beats per minute is the rate at which the pacemaker will "kick in" to prevent the heart from going slower than this rate; -if patient has a heart rate slower than the set rate there is a problem and HCP needs to be notified
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What does it mean if a pacemaker is set at a ventricular rate of 70 beats per minute?
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a single lead is placed in the ventricle [because the fibrillating atrium cannot be paced]
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If a patient is in chronic atrial fibrillation and the ventricle is going too slow, where is the pacemaker lead placed?
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For clients with COPD the *stimulus to breathe is the low P.a.O2 level* so if this level is increased [with a higher concentration of O2] they won't have the stimulus to breathe
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Why is it important to give COPD patients *low* concentrations [i.e., 2 to 3 liters] of O2?
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-Think *HOLD* - *H*igh alarm = *O*cclusion; *L*ow alarm = *D*isconnection; -examples: occlusion or partial occlusion of ETT tube or ventilator tubing, mucus plug, client biting tube, kinked tube and fluid collection in vent tubing; also if client is "bucking" the vent [fighting it] or coughing
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High pressure alarm for a ventilator
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1) assess NG tube for patency to prevent retention of gastric secretions; 2) secure tube to prevent movement; 3) monitor amount of blood draining from tube; 4) monitor for abdominal distension; *If more than a scant amount of blood or abdominal distension develops - notify surgeon*
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In the immediate postoperative period, what are priority interventions when caring for a client who has had a gastric resection to treat peptic ulcer disease?
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Cover wound with warm saline-soaked gauze
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abdominal stab wound and intestines protruding through the wound
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myocardial ischemia
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What does a significant S.T segment depression or T wave inversion on an ECG indicate?
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pulse oximetry
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best method to monitor for manifestations of atelectasis
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-anxiety, irritability, insomnia, fatigue; -heat intolerance; -weight loss [despite food intake]; -tachycardia, tremors, diaphoresis; -exophthalmos; -diarrhea; -elevated T3 and T3; decreased TSH
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Grave's disease - common manifestations
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-an increase in body temperature of even one degree can signify the onset of a thyroid storm and should be reported to the provider immediately; -other signs of thyroid storm: hypertension, abdominal pain, tachycardia
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Grave's disease - why is it important to monitor for an increase in temp?
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-*EARLY STAGE*: *hyper*active bowel sounds [because initially, the peristaltic activity in the gut increases in an attempt to overcome the obstruction]; -*LATE STAGE*: *hypo*active bowel sounds
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anticipated bowel sounds for a client with a bowel obstruction
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-direct or indirect lung injury causes capillaries to leak fluid into alveoli; -build up of fluid in alveoli prevents movement of adequate O2 into bloodstream; which means organs aren't getting sufficient O2 to function; -low BP + organ failure usually accompany typical respiratory manifestations
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ARDS
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hypoxemia that doesn't improve w/O2 therapy
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What is the hallmark sign of ARDS?
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-*neutrophil* is the most important infection-fighting WBC; -*normal absolute neutrophil count [ANC]* = 2500 to 6000; -*neutropenia* = ANC below 1000
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neutropenia
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-alopecia; -mucositis / stomatitis; -hematuria; -nausea and vomitting
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common side effects of chemotherapy
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-*CHOLESTEROL*: less than 200; -*HDL*: females 35-80; males 35-65; -*LDL*: less than 130; less than 70 if CVD or DM; -*TRIGLYCERIDES*: females 35-135; males 40-160; older adults 55-220
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Normal lab values for lipid panel
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characterized by: hyperglycemia [blood glucose greater than 300] resulting in the breakdown of body fat for energy and an accumulation of ketones in the blood and urine
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DKA
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-mild pelvic pain; -spotting of blood; -clear vaginal drainage; -no sex or tampons for about 3 weeks; *Instruct client to report any heavy vaginal bleeding, foul-smelling discharge, or fever*
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What are expected findings after a loop electrosurgical excision procedure [LEEP]?
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-wash hair morning of test; -procedure is painless; -no caffeine 8 hr before test
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Patient teaching for an electroencephalogram [EEG]
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*flush with 20-30 mL of sterile or unsterile water* -at least every 4 hours during a continuous feeding; -before and after each intermittent feeding; -before and after drug admin; and -after checking residual volume
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What is used to flush a gastrostomy tube and how often is this done?
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observe the client's facial expressions
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How would you assess the pain level for a client w/dementia?
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-typically used following surgery to insure client's bladder remains clear of sediment and blood clots; -catheter drains urine and allows for instillation of a irrigation of NS or other prescribed irrigating solution; -if abdominal cramping, check catheter for kinks
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What is the purpose of a continuous bladder irrigation?
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-report yellow or green discharge; -report pain accompanied with nausea/vomiting; -avoid rapid, jerky movements such as vacuuming; -wear sunglasses outside
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Patient teaching after cataract surgery
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-*constant bubbling* in water seal chamber = air leak and problem w/the system; -*intermittent bubbling* in water seal chamber and *level flucuates w/respirations* = system functioning properly
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closed water-seal drainage system
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1st stage: defined area of reddened but *intact* skin; 2nd stage: partial thickness skin loss involving epidermis, dermis, or both; 3rd stage: exudate or purulent drainage indicating wound infection
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staging of pressure ulcers
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-peak expiratory flow [PEF] measures 85% above personal best; -absence of asthma manifestations while sleeping or w/increased activity; -forced expiratory volume increased after treatment w/med
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What indicates effectiveness of asthma medication therapy
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H2 receptor antagonists; aspirin; metronidazole [Flagyl]
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warfarin - do not take with
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-bacteriostatic used for TB; -monitor for vision changes - can cause optic neuritis, which can lead to blindness; -instruct client to report changes in vision immediately
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ethambutol [Myambutol]
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-NPO after midnight; -patient will drink beverage containing glucose at start of test; -patient should report dizziness during test; -blood is drawn every 30 minutes;
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oral glucose tolerance test
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-ptosis; -muscle weakness that improves w/rest
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Myasthenia gravis
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-*pernicious* - vitamin B12 anemia; -*megaloblastic* - decrease in RBCs caused by folate deficiency; -*iron deficiency* - decrease in RBCs caused by iron deficiency; -*aplastic* - RBCs, WBCs, and platelets are reduced
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Anemias
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pancytonpenia, fatigue, pale mucous membranes, dyspnea on exertion
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Manifestations of aplastic anemia
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-supine w/legs elevated 15 degrees to promote venous return by gravity; -discharge teaching: teach patient importance of periodic positioning of legs above the heart
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post-op position for vein ligation and stripping for varicose veins
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-dyspnea w/rapid respiratory rate; -chest pain will *decrease* when client sits upright or leans forward as this releases pressure in the pericardial sac
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pericarditis - manifestations
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-back pain is cardinal sign; -hypotension; -tachycardia
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dissecting abdominal aneurysm
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-*EARLY* - weight gain 1 kg in 1 day; decreased urine output; hypertension; -*LATE* - pitting edema of +3
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Signs of fluid volume overload
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-plasma rich in clotting factors; -desired effect is decrease in prothrombin time
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fresh frozen plasma [FFP]
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-narrowing of arteries in legs and feet; -causes decreased blood flow to distal extremities; can lead to tissue damage; -*SIGNS*: intermittent claudication, cold or numb feet at rest, loss of hair on lower legs, weakened pulses, thin shiny skin
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arteriosclerosis obliterans
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-hereditary bleeding disorder - caused by deficiency in a clotting factor; -it takes a long time for blood to clot and abnormal bleeding occurs; -treatment is aggressive factor replacement
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hemophilia
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dilates obstructed coronary artery by compressing artherosclerotic plaque against the coronary artery wall with an inflated balloon
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percutaneous transluminal coronary angioplasty [PTCA]
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-promote healing by increasing rate of epithelialization [this is the primary reason]; -act as barrier to prevent contamination; -reduce fluid and protein loss
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purpose of biological dressings during the acute phase of burns
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-*papules* - solid, elevated, w/*distinct borders*, e.g., acne, warts; -*macules* - *flat*, variably shaped, discolored, e.g., freckles; -*wheals* - transient, elevated lesion caused by localized edema, e.g., hives; -*vesicles* - elevated lesion *containing serous fluid*, e.g., chicken pox
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types of skin lesions
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wound w/little or no tissue loss [i.e., a surgical wound that is closed mechanically]
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wound healing by primary intention
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wounds involving loss of tissue [e.g., severe lacerations or pressure ulcers] are left open until filled w/scar tissue
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wound healing by secondary intention
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high in protein and vitamin C
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diet to promote wound healing
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-focuses on preventing the spread of venom; -affected limb should be immobilized below the level of the heart; -also any restrictive clothing and jewelry should be removed; -all snakebites are treated as poisonous until proven otherwise
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emergency management of a snakebite
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-ulceration, bleeding, or exudation; -increasing size
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signs of a mole's potential malignacy
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*ADVERSE EFFECT* - transient leukopenia, appears 2-3 days after treatment begins
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silver sulfadiazine cream [Silvadene]
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surgical excision is treatment of choice for small, superficial lesions; deeper lesions require wide local excision, after which skin grafting may be needed
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malignant melanoma - treatment
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-malignant melanomas; -often cause metastases in bone, liver, lungs, spleen, CNS, lymph nodes
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most serious/lethal type of skin cancer
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-as blood reaches freezing temps, *RBCs clump together*; -this causes *occlusion of small blood vessels* and leads to loss of superficial blood flow; -this causes discoloration of skin that resembles a superficial, partial-thickness burn
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why does frostbitten tissue appear burned?
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-caused by excessive production of somatotropin [a growth hormone]; -results in gradual enlargement of body tissues including bones of the face, jaw, hands, feet, and skull
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acromegaly
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*monitor and report*: -tachycardia and hypertension (could indicate thyroid storm); -laryngeal stridor; -positive Chvostek's sign or positive Trousseau's sign (indicates hypocalcemia)
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post-op thyroidectomy
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-tumor of adrenal glands; caused by excess release of catecholamines: epi and norepi; -urine test for vanillylmandlic acid [VMA] - measures level of catecholamine metabolites in a 24-hr urine sample
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pheochromocytoma
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calcium, phosphorus, and magnesium balance within the blood and bone
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What does the parathyroid hormone regulate?
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-hypophosphatemia; -hypercalcemia
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hyperparathyroidism is associated with
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*EARLY* manifestations: -drowsiness, weakness, fatigue; -headache, shakiness, nausea; *LATE* manifestations: -tachycardia, diaphoresis; -irritability, anxiety, confusion
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hypoglycemia
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-urinary frequency, anorexia, dry mouth
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hyperglycemia - manifestations
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-inability of kidneys to conserve water appropriately; -polydipsia and polyuria; -large quantity of urine excreted will have a very low specific gravity
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diabetes insipidus
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*Type 1* - pancreas does *NOT* produce insulin; *Type 2* - cells resistant to the effects of insulin [aka insulin resistance]
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diabetes mellitus - patho
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-high blood glucose in the morning after an extremely low level occurring after an untreated insulin reaction during the night; -nighttime glucose levels should be monitored
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What is the Somogyi effect?
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-to compensate for the decrease in cortisol secretion after the surgery; -cortisol is a glucocorticoid
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Why is a glucocorticoid administered after an adrenalectomy?
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-inability to excrete appropriate amount of urine; -caused by excessive release of ADH; -as a result of excessive ADH, the client retains water [fluid retention], which creates dilutional hyponatremia
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syndrome of inappropriate secretion of antidiuretic hormone [SIADH]
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-high genetic risk; -over age of 40; -early menarche; late menopause; -first pregnancy after age of 30; -early or prolonged use of oral contraceptives; -hormone replacement therapy; history of endometrial or ovarian cancer; exposure to low-level radiation; - obesity; cigarette smoking
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Risk factors for breast cancer
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-small, waxy nodule w/superficial blood vessels, well-defined borders; -erythema and ulcerations; -invades local structures such as nerves, bone, cartilage, lymphatic and vascular tissue; -high rate of recurrence
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Characteristics of basal cell skin cancer
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-rough, scaly lesion w/central ulceration and crusting; -localized though may metastasize
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Characteristics of squamous cell skin cancer
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-Manage pain w/analgesics and cold therapy; -Provide catheter care and admin bladder antispasmodics; -If suprapubic surgical approach, suprapubic catheter is inserted [in addition to urethral catheter]; monitor suprapubic catheter output [usually removed when residual urine less than 75 mL];
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prostatectomy post-op nursing interventions
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skin changes, hair loss, and debilitating fatigue
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Adverse effects of radiation therapy
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-*Skin* - blanching, erythema, desquamation, sloughing, hemorrhage; -*Mouth* - mucositis, xerostomia which is dry mouth; -*Neck* - difficulty swallowing; -*Abdomen* - gastroenteritis
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Radiation injury to skin and mucous membranes - what should you monitor for?
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-spicy, salty, acidic foods; -hot foods may not be tolerated
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If mucositis, what foods should be avoided
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-Gently wash skin over irradiated area w/mild soap and water; Dry area thoroughly using patting motions; -Do not wash off radiation "tattoo" markings; -Do not apply powders, ointments, lotions, deodorants, or perfumes to irradiated skin;
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Skin care for radiation therapy
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*risk for infection*; infection is the major cause of death in the 7-10 days following a bone marrow transplant
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priority concern following a bone marrow transplant
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it is transfused just like any other blood component, into a central I.V line
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How does the recipient of a bone marrow transplant receive the harvested marrow?
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-empty reservoir bulb attached to drain at least B.I.D; -BP only on unaffected arm; -once incision healed and pain controlled, begin hand and arm exercises (like climbing a wall) to reestablish full ROM; -numbness around incision and along inside of affected arm is common and will resolve over time
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Discharge teaching for a mastectomy
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-caused by rapid death of cells in response to chemo; -*LABS*: high: potassium, uric acid, phosphorus, and low: calcium; -flank pain - symptom caused by strain placed on kidneys to excrete large amounts of intracellular metabolites; -other signs: muscle tetany, oliguria, hypertension
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Tumor lysis syndrome
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difficulty swallowing
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Early sign of esophageal cancer
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bone and joint pain
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Early sign of leukemia and multiple myeloma
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enlarged lymph nodes
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Early sign of Hodgkin's disease
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early state of cancer that is limited to the site of origin
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Cancer in situ
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-partially occluded superior vena cava; -more common for clients w/lung cancer, non-Hodgkin lymphoma, or cancers that spread to the chest; -*EARLY* sign - facial and upper extremity edema; -other signs - difficulty breathing or shortness of breath
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superior vena cava syndrome
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-excessive growth and proliferation of abnormal plasma cells in the lymph nodes and bone marrow; this growth interferes w/production of: -RBCs causing anemia; -WBCs causing increased susceptibility to infection; -platelets (thrombocytopenia) causing bleeding tendencies
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Multiple myeloma
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-t-cells from donor bone marrow attack and destroy vulnerable host cells; -usually occurs between 10 and 100 days following transplant; -*EARLY* signs: temp elevation and rash on hands and feet; -*TREATMENT*: glucocorticoids and cyclosporine
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graft-versus-host-disease
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-drink 4 to 6 full glasses of water just prior to the procedure and do not void
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patient prep for a pelvic ultrasound
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-CEAs are common tumor markers for colorectal cancer; -CEA test is used to monitor clients *who are already being treated for colorectal cancer*; -CEA levels should return to normal following successful treatment
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carcinoembryonic antigen [CEA] test
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-medication remains in bladder for up to 2 hrs; -after infusion, position client on back, abdomen, and each side for 15 min in each position, then standing position for last hour
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intravesical administration of immunotherapy for bladder cancer
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sign of bone marrow suppression which is a common side effect of chemo agents; results in pancytopenia which is a decrease in: RBCs, WBCs, and platelets
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aplastic anemia
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-lowest point that blood counts reach prior to recovery after chemo is given; -occurs approximately 10 days after treatment
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What is "nadir"?
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-private room w/private bath; -hand washing after toilet; flush toilet twice; use separate utensils and towels; wash laundry separate; drink tons of fluids to flush out radioactive iodine; -sit at least 6 feet from client and stay for < 30 min/day during internal radiation therapy; -keep one arm's length distance between client and others who spend more than 2 hr next to client in any 24-hr period; -wear lead shielding apron and always face the radiation source
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Safety precautions for Radiation Therapy
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-*EARLY*: pale skin, elevated BP; -*LATE*: confusion, bradycardia, hypotension
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Manifestation of hypoxemia
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-assess breath sounds every 1 to 2 hr; -monitor ventilator settings hourly; -document tube placement in centimeters *at client's teeth or lips*; -if self-extubation is attempted, soft wrist restraints should be applied
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routine assessment of a client who is receiving mechanical ventilation
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-by decreasing the number of insulin receptors in skeletal muscles and fat cells; -a reduced-calorie diet can reverse this insulin resistance
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How does obesity play a role in the development of diabetes type 2?
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-*serum amylase* - increases within 12 hr, remains increased for 4 days; diagnostic for *ACUTE* pancreatitis; -*serum lipase* - increases slowly after rise in serum amylase but remains increased for up to 2 weeks
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Labs for Pancreatitis
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-*CAUSE*: viral hepatitis; hepatic encephalopathy develops within weeks of onset of disease despite no prior hepatic dysfunction; -*TREATMENT*: liver transplant
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Fulminant hepatic failure
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*surgical connection* between two tubular structures, such as blood vessels or loops of intestine
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What is an anastomosis?
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-monitor prothrombin time [PT] prior to procedure
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Liver biopsy
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low-fiber
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diet for diverticul*itis*
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levels are raised by alcohol and hepatotoxic drugs - useful for monitoring drug toxicity and alcohol abuse
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Gamma-glutamyl transpeptidase [GGT] blood test
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referred pain in the shoulder area
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CO2 injected into the abdomen during laparoscopic procedures can cause what post-procedure?
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-*Postnecrotic*: caused by viral hepatitis or certain medications or toxins; -*Laennec's*: caused by chronic alcoholism; -*Biliary*: caused by chronic biliary obstruction or autoimmune disease
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three types of cirrhosis
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-*EARLY*: anorexia; -*LATE*: jaundice, dark urine, pale feces
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Hepatitis A - manifestations
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*SIGNS*: painful muscle *spasms*, tingling and numbness in hands and feet
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*Hypo*calcemia
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*SIGNS*: muscle *weakness*, decreased DTRs, increased HR, increased BP
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*Hyper*calcemia
