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Med surg 2 blueprint exam 2
Medical-Surgical Nursing II (NSG 223)
Herzing University
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NSG223 Medical-Surgical II
EXAM 2 STUDY GUIDE
Topic Location Student Notes
Pulmonary embolism
- pathophysiology NSG 223.04.
▪ PE: refers to obstruction of the pulmonary artery or one of its branches by a thrombi that originates somewhere in the right side of the heart ▪ Causes: ▪ Trauma ▪ Surgery (orthopedic, abdominal, pelvic,..) ▪ Pregnancy ▪ Heart Failure ▪ Hypercoagulable states Prolonged immobility ▪ Most commonly PE is due to blood clot... can also be due to air, fat, amniotic fluid, sepsis (bacterial vegetation) ▪ Complete or partial occlusion ▪ Little or no blood-flow to distal area ▪ Ventilation/Perfusion impairment ▪ Impaired or no gas exchange ▪ Hemodynamic changes – edema, regional vasoconstriction – increased pressures – can lead to right sided heart failure
Pulmonary embolism - Clinical manifestations
NSG223.04.01 ▪ Depends on the size of the thrombus... ▪ Dyspnea ▪ Tachycardia ▪ Bloody sputum ▪ Cough ▪ Chest pain (pleuritic) ▪ Anxiety ▪ Fever ▪ Diaphoresis ▪ Syncope
Pulmonary embolism - Treatments
NSG223.04.01 ▪ Emergency: ▪ Nasal O2 immediately to relieve hypoxemia, respiratory distress, central cyanosis...
may need to intubate ▪ IV lines for fluids and meds-anticuagulants, vasopressors etc.. ▪ Hypotension – if not improved by IVF – give vasopressors (Dopamine, Dobutamine, Norepinephrine) ▪ Hemodynamic eval, Hypoxemia eval (ABG) and MDCTA ▪ EKG ▪ Labs – electrolytes, CBC, coagulation ▪ Pain and discomfort relief – small doses MS, sedatives if intubated ▪ General management: ▪ Oxygen therapy to relieve hypoxemia ▪ Anti-embolism stockings or SCDs to reduce venous stasis ▪ Elevate legs for venous return ▪ Fluid challenge for hypotension ▪ Anticoagulation therapy: ▪ Suspected PE – tx up to 10 days ▪ After embolic event - long-term tx – 10 days to 3 months ▪ With PE, but hemodynamically stable – LMW Heparin (Lovanox), unfractioned Heparin (sq), or new oral agent such as Dabigatran (Pradaxa), Rivaroxaban (Xarelto) ▪ If pt does not qualify for new oral agents – Coumadin – needs regular blood draws for INR – bleeding precautions – antidote is Vit K ▪ Thrombolytic therapy: ▪ Used in pt with acute PE, hemodynamically unstable, do not have any risk factors for bleeding ▪ Clot busters! – Activase, Streptase ▪ Pt must meet criteria! ▪ Labs done prior to starting tx – PTT, INR, Hematocrit, Platelets ▪ Anticoagulant: Heparin IV if pat doesn’t meet criteria for clot busters
Pulmonary embolism - Prevention
NSG223.04.01 ▪ ID the pt at risk ▪ Prevent thrombus formation ▪ Encourage ambulation ▪ Active and passive leg exercise ▪ Pumping exercise in bed or standing next to bed ▪ Do not sit or lie for prolonged periods ▪ Do not cross legs ▪ Do not wear constrictive clothing
ARDS
- Mechanical Ventilation
NSG223.04.02 ▪ Management almost always includes INTUBATION – mechanical ventilation ▪ PEEP – critical – improves oxygenation by keeping alveoli from collapsing ▪ Goal PaO2 is > 60mmHg, and V/Q balance
ARDS - Nursing Care of Patients on Ventilators
NSG223.04.02 ▪ Watch for and treat hypovolemia ▪ Circulatory support – IVF, inotropic and vasopressor agents ▪ Sedation and paralysis ▪ Prone ▪ Nutrition
Mechanical Ventilators - Medications
NSG223.04.02 ▪ Sedatives – Lorazepam (Ativan), Midazolam (Versed), Propofol (Diprivan) ▪ Neuromuscular blocking agents – Pancuronium (Pavulon), Vecuronium (Norcuron) – often given prior to intubation to relax jaw and vocal cords ▪ Nursing care important – to check effectiveness of these agents – use “train of 4” – 4 consecutive stimuli delivered along nerve, check reaction
Mechanical Ventilators NSG223.04.02 See above***
Medications Pulmonary edema/failure - Nursing interventions
NSG223.04.03 ▪ MANAGEMENT: ID and correct underlying cause – O2, intubate, ventilate
Pulmonary edema/failure - Complications
NSG223.04.03 Respiratory Failure Complications ▪ Respiratory arrest
Pulmonary edema/failure - Treatments
NSG223.04.03 Pulmonary Edema ▪ Treatment: Depending on cause..... (Furesomide)-IV or PO depending on the severity Respiratory Failure Tx ▪ MANAGEMENT: ID and correct underlying cause – O2, intubate, ventilate
Management of Acid-base balance - ABG interpretation
NSG223.05.
Management of Acid-base balance - Treatments for each ABG Imbalance
NSG223.05.01 Respiratory Acidosis ▪ Treatment aimed at improving ventilation Respiratory Alkalosis ▪ Almost always due to hyperventilation ▪ Manifestations: lightheadedness, inability to concentrate, numbness and tingling, sometimes loss of consciousness ▪ Correct cause of hyperventilation, rebreather mask, breathe into bag Metabolic Acidosis ▪ Causes: Acute: Diabetes, diarrhea ▪ Causes: Chronic – Low Ca levels, Kidney disease ▪ Manifestations: headache, confusion, drowsiness, increased respiratory rate and depth, hyperkalemia, nausea and vomiting, decreased blood pressure, decreased cardiac output, dysrhythmias, shock; if decrease is slow, patient may be asymptomatic until bicarbonate is 15 mEq/L or less ▪ Correct underlying problem, correct imbalance ▪ Serum calcium levels may be low with chronic metabolic acidosis ▪ Must be corrected before treating acidosis ▪ So Bicarbonate may be administered – watch for increased Na levels!) ▪ With acidosis, hyperkalemia may occur as potassium shifts out of cell ▪ As acidosis is corrected, potassium shifts back into cell, potassium levels decrease - Monitor potassium levels
imbalances. Management of Acid-base balance
- Clinical manifestations of the 4 imbalances
NSG223.01.05 See above
Management of Acid-base balance - ABG interpretation
NSG223.05.01 See above
Management of Acid-base balance - Electrolyte imbalances with ABG imbalances
NSG223.05.01 See above
Hepatitis (A,B,C,D,E) - Modes of transmission
NSG223.06.01 Hepatitis A viral infection ▪ Affects mainly the adult population ▪ But, children in day care are at risk ▪ Transmission: oral-fecal route, unsanitary food, poor hygiene, hand to mouth, sexual activity
Hepatitis (A,B,C,D,E) - prevention
NSG223.06.01 vaccination
Hepatitis (A,B,C,D,E) - Risk Factors
NSG223.06.01 Hepatitis B Viral infection ▪ Transmission: Blood ▪ Who is at risk: IV drug users, multiple partners, getting tattoos, teenagers, male homosexual activity, hemodialysis, healthcare workers, close contact with a carrier ▪ Long incubation period – most people recover spontaneously ▪ Clinical manifestations: insidious, flu-like, respiratory, loss of appetite, aches, malaise, liver tenderness.. can last 1 – 6 months.. ▪ Prevention: prevent transmission, vaccination
Hepatitis - Nutrition
NSG223.06.01 Hepatitis B Viral infection ▪ Prevention: prevent transmission, vaccination ▪ Management: Alpha-interferon (inhibits viral replication), entecavir, tenofovir (antiviral agents), antiemetics, monitor liver enzymes, rest, nutritious meals (include
protein and low fat))
Hepatitis - Medication induced
NSG223.06.01 ▪ The most common cause of hepatitis – 50% of cases in the USA ▪ Cause: multiple medications can cause liver damage – Acetaminophen, rheumatic agents, analgesics, antidepressants, anticonvulsants, etc... ▪ Clinical manifestations: fever, rash, nausea, chills, pruritus, arthralgia, anorexia, nausea, jaundice, dark urine, enlarged and tender liver ▪ Management: stop the medication, high-dose corticosteroids, liver transplant
Pancreatitis - pathophysiology
NSG223.06.02 ▪ Acute: pancreatic duct becomes obstructed, and enzymes back up, causing autodigestion and inflammation of the pancreas ▪ Chronic: progressive inflammatory disorder with destruction of the pancreas; cells are replaced by fibrous tissue; pressure within the pancreas increases, obstructing the pancreatic and common bile ducts ▪ Mild pancreatitis aka interstitial edematous pancreatitis ▪ Severe pancreatitis aka necrotizing pancreatitis
Pancreatitis - clinical manifestations
NSG223.06.02 ▪ Laboratory tests ▪ Serum amylase level high ▪ Serum lipase level high ▪ Liver enzyme levels high ▪ Triglyceride levels ▪ Glucose level ▪ Bilirubin level ▪ Serum calcium level low ▪ ACUTE: ▪ Severe abdominal pain ▪ mid-epigastric ▪ Acute onset – 24-48 hours after eating or alcohol intake ▪ Abdominal and back tenderness ▪ Abdominal distension ▪ Nausea and vomiting*** ▪ Rigid board-like abdomen – pt in danger of hemorrhaging and peritonitis ▪ Low grade fever ▪ Jaundice ▪ Hypotension
Chronic Pancreatitis - Treatment
NSG223.06.03 ▪ Relief of pain and discomfort ▪ Oral care ▪ Care of NGT ▪ Intake and output ▪ VS ▪ Maintain patient safety – often confused ▪ Respiratory – semi-fowler position ▪ Respiratory assessment ▪ Maintain nutrition – dly weight, enteral/parenteral, high protein - low fat diet ▪ Monitor and prevent complications-peritonitis
Cirrhosis - pathophysiology
NSG223.06.04 • Irreversible, progressive deterioration of the liver - Caused by chronic liver disease - Acute viral hepatitis – necrotic cirrhosis - Chronic hepatitis - Long-term obstruction to biliary flow (gallbladder) – biliary cirrhosis - Alcoholism – alcoholic cirrhosis
Cirrhosis - Treatments
NSG223.06.04 Avoid alcohol, important to rest, diet low Na, restricted fluids, bleeding precautions (soft toothbrush) Cirrhosis
- Clinical manifestations
NSG223.06.04 • May be asymptomatic until severe liver impact - Gradual onset – body compensates... - Early symptoms nonspecific: - Abdominal pain, ankle edema, firm enlarged liver, splenomegaly, intermittent low-grade fever, fatigue, weakness, anorexia, weight loss, spider veins - Decompensated cirrhosis:
- Ascites, continuous mild fever, epistaxis (nose bleeds), hypotension, jaundice, purpura, esophageal varices, hemorrhoids, deficiency of fat-soluble vitamins, especially vitamin K, mental deterioration (encephalopathy)
Cirrhosis - Treatment
NSG223.06.04 • Management based on the severity off the illness to relieve symptoms – permanent damage, cannot heal the liver!
- Antacids, H2 Blockers
- Vitamins and nutritional supplements
- Avoid alcohol, sodium restriction, fluid restriction
- Diuretics (K+ sparing e. Spironolactone)
- Albumin (ascites)
- Mentation changes –ammonia high - Lactulose
- Meds with antifibrotic qualities: colchicine, ACE inhibitors, immunosuppressants,...
- End stage – Milk Thistle (herb)
- Paracentesis
- Transjugular intrahepatic portosystemic shunt (TIPS)
▪ Prolonged renal ischemia – anemia, transfusion reaction, trauma, burns ▪ Nephrotoxic agents – certain antibiotics, heavy metals, radiopaque contrast mediums ▪ Infectious processes – acute pyelonephritis, glomerulonephritis ▪ Post-renal: ▪ Urinary tract obstruction, BPH, calculi, tumors, strictures
Acute renal failure - Precautions
NSG223.07.01 Medical management ▪ Identify underlying cause key to treatment ▪ Maintain fluid balance – dly weight, I&O, VS, cardiac monitoring, measurements of central pressures, se and urine concentrations, ▪ Maintain electrolyte balances ▪ K+ - if high treat with sodium polystyrene sulphonate (Kayexalate) orally or enema*** ▪ Correct acid-base imbalance ▪ If medications and antibiotics needed – may have to adjust dose ▪ Evaluate need for dialysis ▪ Diet – high carb, low protein, low K, low phos (no bananas, potatoes, citrus fruits, juices, coffee, or soda)** ▪ Fluid restriction
Chronic renal failure - Clinical manifestations
NSG223.07.02 ▪ Neurologic: ▪ Asterixis (uncontrolled hand flap) ▪ Confusion, disorientation ▪ Restless legs, tremors ▪ Seizures ▪ Weakness, fatigue ▪ Skin ▪ Coarse thinning hair ▪ Dry flaking skin ▪ Gray-bronze kin color ▪ Cardiovascular ▪ Pitting edema ▪ Periorbital edema ▪ Engorged neck veins
▪ Hypertension ▪ Increased K+ ▪ Pulmonary ▪ Crackles ▪ Tachypnea, SOB ▪ Thick sputum ▪ GI ▪ Ammonia odor to breath ▪ Anorexia, nausea, vomiting ▪ GI bleed ▪ Hematologic ▪ Anemia ▪ Thrombocytopenia ▪ Musculoskeletal ▪ Bone pain, bone fractures ▪ Muscle cramp
Chronic renal failure - diagnostics
NSG223.07.02 ▪ History and Physical ▪ Glomerular Filtration Rate - As GFR decreases – BUN and Se Cr increases ▪ Na+ and water retention – edema, heart failure, hypertension ▪ Metabolic acidosis – kidneys unable to excrete acids ▪ Anemia – inadequate erythropoietin production ▪ Calcium low and Phosphate high imbalance – as one increases the other decreases, in ESKD kidney is unable to balance ▪ Poor urine output
Chronic renal failure - Nutrition
NSG223.07.02 ▪ Diet ▪ Protein restricted ▪ Fluid restricted (500-600ml/day + prev day uo) ▪ K+ restricted ▪ Na+ restricted ▪ High Carbohydrate
Chronic renal failure - Treatments
NSG223.07.02 ▪ Pharmacologic: ▪ Calcium and Phosphorus binders ▪ Ca Carbonate (Os-cal) tums – binds with Phos
(these can be manipulated according to patient needs) ▪ Excess fluid is removed via osmosis/ultrafiltration ▪ Heparin is used to prevent clotting ▪ Cleaned blood is returned to the body Peritoneal dialysis ▪ For patients unwilling or unable to have hemodialysis ▪ In PD the membrane that covers the abdominal organs and lines the abdominal wall is used as the “dialyzer” ▪ The patient has a peritoneal catheter inserted (stays in permanently) ▪ Dialysate is connected to the catheter (warm with heat pad to body temp)** not microwave ▪ Dialysate (2-3L) is infused (5-10min) – has time to dwell (depends on pt, a few hours to overnight) – drained (10-20min) ▪ Nursing: ▪ Assess abdomen ▪ Assess s/s of infection (peritonitis) ▪ Use strict aseptic technique ▪ Watch for leaks ▪ Assess the drainage (no blood – should be straw colored) ▪ Watch electrolytes
Dialysis - Safety
NSG223.07.03 ▪ Vascular access – double lumen large catheter – in subclavian, jugular or femoral vein - usually short term option ▪ Nursing – only used for dialysis, aseptic technique, watch for infection, protect ▪ Arteriovenous fistula – joining an artery and a vein, takes time to mature and heal ▪ Arteriovenous graft – created by placing a synthetic graft material between the artery and vein ▪ Nursing – assess for patency (bruit/thrill), do not use arm for BP, IV, blood samples, check dressings not too tight, no restraints, jewelry***
Pharmacological treatment - Complications
NSG223.07.
Med surg 2 blueprint exam 2
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
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