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NSG233 Exam 1 Study Guide
Med-Surg III (NSG 233)
Herzing University
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NSG 233 Med Surg III EXAM 1 STUDY GUIDE Topic Location Student Notes Emergency Surgery Risk Factors
NSG233.01.
Fluid Management of hypovolemic Shock NSG233.01.02 Medical Management: Major goals of treatment 1. Restore intravascular volume 2. Correct underlying cause - 2 large gauge IV lines - Intraosseous if unable to obtain IV - Crystalloid (Normal Saline, actate Ringer) - Blood transfusion - Oxygen Prioritizing Patients in the ED NSG233.01.01 Goal is to assign patient priority to treatment based on patient acuity and need for care Patients with life threatening injuries are given highest priority Different triage systems for different situations (EMS (emergency medical services) vs inpatient) Triage Systems: Basic system three categories: Emergent: highest priority Urgent: serious health problems but not life threatening Nonurgent: episodic illness Emergency severity index (ESI) assigns patients to five levels: Level 1 (most urgent- for example, cardiac arrest) to Level 5 (least urgent – client has hypertension and needs medication). Emergency Severity Index: 1. Resuscitation 2. Emergent 3. Urgent 4. Non-urgent 5. Referred Level 1:
Requires immediate life-saving interventions Unresponsiveness Level 2: Potential major life or organ threat Unsafe to remain in waiting room for any length of time Need for care is immediate High priority and care should be initiated within 10 minutes of arrival Levels 3-5: Level 3 requires 2 or more resources Level 4 requires 1 resource Level 5 requires no resources Priority Emergency Measures: Airway obstruction and establishing an airway and ventilation Hemorrhage Hypovolemic shock Wounds Trauma and multiple trauma Primary Survey: Airway Breathing Circulation Disability Exposure and Environmental control Facilitate adjuncts and family Get resuscitative adjuncts LMNOP Secondary Survey: Starts after the Primary Survey is completed Health history Head-to-toe assessment: reassess airway, breathing, VS Diagnostic and lab testing Monitoring devices: ECG, arterial lines, urinary catheters Splinting of fractures Wound care Other interventions based on condition
Take the family to a private place. Talk to the family together so that they can grieve together and hear the information given together. Reassure the family that everything possible was done; inform them of the treatment rendered. Avoid using euphemisms such as “passed on.” Show the family that you care by touching, offering coffee, water, and the services of a chaplain. Encourage family members to support each other and to express emotions freely (grief, loss, anger, helplessness, tears, disbelief). Avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression. Encourage the family to view the body if they wish; this action helps to integrate the loss. Cover disfigured and injured areas before the family sees the body. Go with the family and do not leave them alone. Show acceptance by touching the body to give the family “permission” to touch. Spend time with the family, listening to them and identifying any needs that they may have for which the nursing staff can be helpful. Allow family members to talk about the deceased and what the person meant to them; this permits ventilation of feelings of loss. Encourage the family to talk about events preceding admission to the emergency department. Do not challenge initial feelings of anger or denial. Avoid volunteering unnecessary information (e., the patient was drinking). Note: These interventions might not be advisable or permitted if “social distancing” prohibitions are in place, such as those prohibitions implemented to thwart transmission of severe acute respiratory coronavirus 2 (SARS-CoV-2) infection during the coronavirus disease (COVID-19) pandemic. Caring for Emergency Personnel NSG233.01.01 ED staff are at an increased risk for exposure to communicable diseases through blood, respiratory droplets, or other body fluids. This risk for exposure to any communicable disease is further compounded because of the common use of a multitude of invasive treatments for patients in the ED. The potential for exposure to highly contagious organisms, hazardous chemicals or gases, and radiation related to acts of terrorism or natural or human-engineered disasters presents additional risks to ED staff. To limit the risk of exposure to airborne diseases, early identification and strict adherence to transmission-based precautions for patients who are
potentially infected and contagious is crucial. Complications of rapid IV infusions NSG233.03.01 Care must be taken when rapidly administering isotonic crystalloids to avoid both underresuscitating and overresuscitating the patient in shock. Insufficient fluid replacement is associated with a higher incidence of morbidity and mortality from lack of tissue perfusion, whereas excessive fluid administration can cause systemic and pulmonary edema that progresses to ALI, intra- abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), and MODS (see later discussion). Drugs used in bronchoscopy NSG233.01.01 1. Vecuronium, a non-depolarizing aminosteroid compound, is the prototype. There are several non-depolarizing muscle relaxants. Succinylcholine is the only depolarizing agent used in the United States. Each agent has unique characteristics, and the anesthesia provider makes the appropriate choice based on the health history of the patient as well as the length and type of procedure. Maximum neuromuscular blockade with vecuronium occurs within 3 to 5 minutes, and the duration of action is 25 to 40 minutes. Use with cautions in older Adults, in patients with renal impairmen and with hepatic impairment. Nondepolarizing neuromuscular blocking agents can result in allergic reactions during anesthesia such as anaphylaxis or mild dermatologic conditions such as urticaria or erythema. 2. Depolarizing neuromuscular blocking agent succinylcholine (Anectine, Quelicin) is a rapid onset and short duration muscle relaxant administered by intravenous or intramuscular injection. The depolarization caused by succinylcholine results momentary contractions of the muscles called fasciculation; the patient's entire body may twitch and move for about 5 to 10 seconds. The primary use for succinylcholine is paralysis for tracheal intubation, especially when it is necessary to quickly protect the airway. When tracheal intubation is combined with cricoid pressure to occlude the esophagus, it is referred to as rapid sequence induction. This type of induction is indicated in emergency procedures that reduces the risk of aspiration when an empty stomach cannot be guaranteed. Succinylcholine is also used to relax the vocal cords and terminate a laryngospasm. The adverse effects of succinylcholine include bradycardia, hyperkalemia, and
occur immediately and last for approximately two hours. A second dose may be required because heparin activity lasts approximately four hours. Severe hypotensive and anaphylactoid reactions may result from protamine administration. Thus, the drug should be given in settings with equipment and personnel for resuscitation and management of anaphylactic shock. Reversal of Vitamin K Antagonists Vitamin K (Mephyton) is an antidote for warfarin overdosage. An oral dose of 10 to 20 mg usually stops minor bleeding and returns the INR to a normal range within 24 hours. INR serum levels less than five with no significant bleeding may be managed with withholding of the warfarin based on protocols; INR levels greater than five may require the use of oral vitamin K. Decisions about management of a patient with an INR above the therapeutic range are based on the degree of elevation of the INR serum level, the clinical status of the patient with regard to bleeding, thrombogenic potential, as well as risk factors such as age and presence of concurrent disease. Urgent reversal of warfarin overdosage in adults with acute major bleeding or in need of emergent surgery can be accomplished with PCC (Kcentra). The drug, collected from pooled human plasma, contains therapeutic levels of all four vitamin K–dependent coagulation factors (II, VII, IX, and X), and the antithrombotic proteins C and S. Dosing is based on the most current predose INR value and body weight. The drug should be administered concurrently with vitamin K to maintain factor levels once the effects of PCC have diminished. Resumption of anticoagulation should occur once the risk of thromboembolism outweighs the risk of acute bleeding. Unlike plasma, PCC does not require blood group typing or thawing, so it can be administered more quickly than frozen plasma and at recommended doses is administered in a significantly lower volume than plasma. The FDA has issued a BLACK BOX WARNING ♦ with the use of PCC because reversal of an anticoagulant state in patients being treated with vitamin K– antagonist therapy may predispose the patient to a thromboembolic complication. Benefits of reversal must be weighed against potential risk of a subsequent thromboembolic event. Reversal of Oral Direct Thrombin InhibitorsIdarucizumab (Praxbind) is the antidote for dabigatran, currently the only oral DTI. The drug reverses the
anticoagulant effects of dabigatran for uncontrolled or life-threatening bleeding or for emergency surgery or procedures. In adults, the drug is given intravenously, administered as two separate doses no more than 15 minutes apart. The duration of the effect is about 24 hours. However, if coagulation parameters reelevate within 12 hours of administration, a second dose may be considered. Reversing the effects of dabigatran will subject a patient to an elevated risk of thrombosis, so it is necessary to resume anticoagulant therapy after 24 hours of administering idarucizumab, as appropriate. Reversal of Thrombolytic Agents Aminocaproic acid (Amicar) and tranexamic acid (Cyklokapron) are used to stop bleeding caused by overdoses of thrombolytic agents. Aminocaproic acid also may be used in other bleeding disorders caused by hyperfibrinolysis (e., in cardiac surgery, blood disorders, hepatic cirrhosis, prostatectomy, neoplastic disorders). Tranexamic acid also is used for short periods (2–8 days) in patients with hemophilia to prevent or decrease bleeding from tooth extraction or menorrhagia. Depending on the indication for administration, aminocaproic acid may be infused as a loading dose over 15 to 60 minutes to reduce the risk of hypotension and dysrhythmias with a rapid bolus. A continuous infusion may be required. Tranexamic acid can be administered orally or intravenously. Tablets should be swallowed whole. A rapid IV bolus can be given, but the drug is usually administered diluted and administered intravenously over 5 to 30 minutes. Dosage of the drug should be re Heat Exhaustion NSG233.01.03 Heat induced injuries: More at risk if not used to heat Most often occur in older adults Goal is to cool patient down as rapidly as possible Frostbite NSG233.01.03 Frostbite: Causes trauma to our vasculature At risk for venous stasis/venous thrombosis Goal is to rewarm area/prevent any further vasoconstriction Suture Care NSG233.01.02 Use a normal saline solution (salt water) or mild soapy water. Tetanus shot Hypothermia Interventions NSG233.01.03 Hypothermia: Core temperature of 35 degrees Celsius or less (95 degrees farenheight or less) Goal is to rewarm patient quickly
Potassium Administration NSG233.01.03 Potassium IV: Dehydrated patients who are experiencing hypokalemia Assess renal function prior to administering any electrolyte Can be uncomfortable at site- warn patient Ingested Poisons NSG233.01.04 Poisoning: Ingestion of pills/products etc. Goals- CALL POISON CONTROL FIRST Goals-give any antidotes, monitor vital organs, stabilize patient, control airway Carbon Monoxide Poisoning NSG233.01.04 Carbon monoxide poisoning: Absorbed VERY rapidly by our hemoglobin Goals- get patient to fresh air, hyperbaric oxygen, assess carboxyhemoglobin levels Medications used to treat medication overdose NSG233.01.04 Substance Abuse/Overdose: Symptoms depend on substance used Narcotic overdose: give Narcan Common OTC products for suicide attempt: aspirin/Tylenol Goals: detoxify patient of substance Alcohol withdrawal treatments NSG233.01.04 Alcohol Withdraw: 1. Closely monitor patient – someone should stay with patient 2. Decrease stimulation 3. Replace fluids Benzodiazepines: Lorazepam Alcohol withdraw Anxiety attacks Treatment of suspected Intimate Partner violence NSG233.01.04 Treating Potential Consequences of Rape After the initial physical examination is completed and specimens have been obtained, any associated injuries are treated as indicated. The patient is given the option of prophylaxis against sexually transmitted infections (STIs) (also referred to as sexually transmitted disease [STDs]). Ceftriaxone given intramuscularly with 1% lidocaine may be prescribed as prophylaxis for gonorrhea. In addition, a single oral dose of metronidazole and either a single oral dose of azithromycin or a 7-day oral regimen of doxycycline may be prescribed as prophylaxis for syphilis and chlamydia (ENA, 2020a). Antipregnancy measures may be considered if the patient is a female of
childbearing age. A postcoital contraceptive medication, such as an oral contraceptive medication that contains levonorgestrel and ethinyl estradiol, may be prescribed after a pregnancy test. To promote effectiveness, the contraceptive medication should be given within 12 to 24 hours and no later than 72 hours after penile-vaginal intercourse. The 21-day package is prescribed so that the patient does not mistakenly take the inert tablets included in the 28-day package. An antiemetic agent may be given as prescribed to decrease discomfort from side effects. A cleansing douche, mouthwash, and fresh clothing are usually offered. Follow-Up Care The patient is informed of counseling services to prevent long-term psychological effects. Counseling services should be made available to both the patient and the family. A referral is made to the National Sexual Assault Hotline (see the Resources section) or directly to a local crisis intervention center. Appointments for follow-up surveillance for pregnancy and for STI and HIV testing also are made (ENA, 2020a). The patient is encouraged to return to their previous level of functioning as soon as possible. When leaving the ED, the patient should be accompanied by a family member or friend. Triage Patients in the ED NSG233.01.01 Triage Systems: Basic system three categories: Emergent: highest priority Urgent: serious health problems but not life threatening Nonurgent: episodic illness Emergency severity index (ESI) assigns patients to five levels: Level 1 (most urgent- for example, cardiac arrest) to Level 5 (least urgent – client has hypertention and needs medication). Emergency Severity Index:
- Resuscitation
- Emergent
- Urgent
- Non-urgent
- Referred Medications for the NSG233.01.04 1. Cephalosporin such as ceftriaxone.
1. PREPARE FOR BLOOD ADMINISTRATION FIRST!!!!
- Always do a thorough assessment of the abdomen:
- Bowel sounds
- Increased muscular rigitidy
- Tenderness/guarding
- Decreased hgb with no sugn of bleeding elsewhere Crush injuries NSG233.02.02 Crushing Injury Complications to look out for:
- Rhabdomyolysis
- Acute Tubular necrosis (AKI)
- Fractures
- Compartment syndrome
- Fat embolus Pain control: Morphine PCA PUMP
- ONLY patient should be pressing the button
- Loading dose normally provided
- Nurse should be assessing for:
- Respiratory status
- Level of consciousness
- Pain level
- Opioid tolerance Treatment of shock NSG233.03.01 Specific medical management in the progressive stage of shock depends on the type of shock, its underlying cause, and the degree of decompensation in the organ systems. Use of appropriate IV fluids and medications to restore tissue perfusion by the following methods: Supporting the respiratory system Optimizing intravascular volume Supporting the pumping action of the heart Improving the competence of the vascular system Other aspects of management may include early enteral nutritional support, targeted hyperglycemic control with IV insulin and use of antacids, histamine- (H2) blockers, or antipeptic medications to reduce the risk of GI ulceration and bleeding. Tight glycemic control (i., maintaining serum glucose close to the normal
parameters of 80 to 100 mg/dL) is not recommended in patients who are critically ill because this therapy has been found to result in adverse patient outcomes. Current evidence suggests that maintaining serum glucose less than 180 mg/dL with insulin therapy and close monitoring is indicated in the management of the patient who is critically ill. Stages of Shock NSG233.03.01 Stage 1- Compensatory stage 1 are working harder to compensate 2. Oxygen hungry- can cause agitation 3. Hyperventilation- can cause respiratory alkalosis 4. Tachycardia- compensating for blood pressure 5. Blood pressure normal because compensated for 6. Cool, clammy skin- “I don’t feel very well.” Stage 2- Progressive stage
- Organs are tired- unable to continue compensating
- Heart is still trying -150 BPM and above!
- Marked hypoxia- resp acidosis
- Mental status changes continues
- Renal changes begin Stage 3- Irreversible/Refractory stage
- Organs damage too severe
- Patient unable to survive
- Working with the family and educating for a better understanding Assessing Septic shock NSG233.03.04 Septic Shock Uncontrolled infection widespread Clinical manifestations:
hypotension
tachycardia
fever
Shortness of breath
Lactic acid high Prioritizing orders in the care of sepsis NSG233.03.04 Nursing care management for patients with sepsis or septic shock involves prompt assessment and monitoring of vital signs, fluid resuscitation with intravenous fluids, timely administration of appropriate antibiotics, hemodynamic support with vasoactive medications, ensuring adequate
damage to the lung tissues resulting in hemorrhage and localized edema
may be mild, moderate, or severe
Pt may have decreased breath sounds, tachypnea, tachycardia, chest pain, hypoxemia, and blood-tinged secretions to more severe tachypnea, tachycardia, crackles, frank bleeding, severe hypoxemia (cyanosis), and respiratory acidosis
Control pain
Supplemental oxygen mechanical ventilation may be required Assessing Septic Shock NSG233.03.04 Septic Shock Uncontrolled infection widespread Clinical manifestations:
hypotension
tachycardia
fever
Shortness of breath
Lactic acid high Assessing Hypovolemic Shock NSG233.03.02 Clinical manifestations:
Blood Loss (in most cases)
Low urine output
Pallor
Loss of consciousness
Dizziness
Hypotension
Weak pulse Topic Location Student Notes Assessing Neurogenic Shock NSG233.03.03 Neurogenic Shock Loss of sympathetic tone leading to mass vasodilation Clinical manifestations:
Bradycardia
Hypotension
Flushed lower extremities
Decreased Urine output
Prolonged ATP
Skin warm and dry
Care of Septicemia NSG233.03.04 Septicemia is an infection that occurs when bacteria enter the bloodstream and spread. It can lead to sepsis, the body's reaction to the infection, which can cause organ damage and even death. Septicemia is more common in people who are hospitalized or have other medical conditions. What are the interventions for septicemia? 1. Antibiotics. Treatment with antibiotics begins as soon as possible. Broad- spectrum antibiotics, which are effective against a variety of bacteria, are often used first. 2. Culture. When blood tests results show which germ is causing the infection, the first antibiotic may get switched out for a second one. 3. Fluid resuscitation with intravenous fluids, timely administration of appropriate antibiotics, hemodynamic support with vasoactive medications, ensuring adequate oxygenation and respiratory support Report to HCP if pt’s urine output is 50 mL last 2 hours. Anaphylactic Shock. NSG233.03.03 Anaphylactic Shock Allergic reaction triggers this Three main characteristics: 1. Acute onset of symptoms 2. Presence of two or more symptoms that include respiratory compromise, reduced BP, GI distress, and skin or mucosal tissue irritation 3. Cardiovascular compromise from minutes to hours after exposure to the antigen Assessing MODS NSG233.03.04 While it is not possible to predict MODS, clinical severity assessment tools may be used to anticipate patient risk of organ dysfunction and mortality. These clinical assessment tools include APACHE (Acute Physiology and Chronic Health Evaluation); SAPS (Simplified Acute Physiology Score); PIRO (Predisposing factors, the Infection, the host Response, and Organ dysfunction); and SOFA score. Drop in 2 points or more in SOFA from baseline is suggestive of organ disfunction or sepsis “infection present”. In MODS, the sequence of organ dysfunction varies depending on the patient’s primary illness and comorbidities before experiencing shock. Advanced age, malnutrition, and coexisting disease appear to increase the risk of MODS in
shock 2. Pain - IV morphine for chest pain 3. Oxygen 4. CVP for accurate idea of volume 5. Arterial line for real time BP 6. Meds: - Dobutamine- enhances cardiac output - Nitroglycerin – reduces preload and afterload also enhancing cardiac output - Dopamine for blood pressure (increases cardiac output) - Antiarrhythmics as needed Pain control: Morphine PCA PUMP 1. ONLY patient should be pressing the button 2. Loading dose normally provided 3. Nurse should be assessing for: - Respiratory status - Level of consciousness - Pain level - Opioid tolerance Assessing wounds NSG233.01.02 Risk of infection! Wounds: 1. Cleaning 2. Primary closure 3. Delayed primary closure 4. Tetanus prophylaxis 5. Education Definition of Terms: Wounds Abrasion: denuded skin Avulsion: tearing away of tissue from supporting structures Cut: incision of the skin with well-defined edges, usually longer than deep
Ecchymosis/contusion: blood trapped under the surface of the skin Hematoma: tumorlike mass of blood trapped under the skin Laceration: skin tear with irregular edges and vein bridging Patterned: wound representing the outline of the object (e., steering wheel) causing the wound Stab: incision of the skin with well-defined edges, usually caused by a sharp instrument; a stab wound is typically deeper than long
NSG233 Exam 1 Study Guide
Course: Med-Surg III (NSG 233)
University: Herzing University
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