NUR 1234 Medsurg Final Review – Miami Dade College | NUR1234 Medsurg Final Review

Document Content and Description Below

NUR 1234 Medsurg Final Review – Miami Dade College 
 Final Exam Blueprint Impaired Oxygenation Symptoms DX TX Early Restless, fatigue, HA, dyspnea, air hunger, ta... chycardia, and hypertension (Heart is working harder to get oxygen to RBCs) Late Confusion, lethargy, bradycardia, bradypnea, central cyanosis, decrease BP, diaphoresis, and respiratory arrest. VS, SpO2, ABG, CXR, CT, Cultures Correct cause, Supplemental O2, isolate Acute Respiratory Failure 1. PaO2 Less than 50 (Normal: 80-100) 2. PaCO2 Greater than 50 (Normal: 35-45) 3. ****ph less than 7.35 ** Respiratory Acidosis- hypoventilation Symptoms: SOB, fatigue, restless, tachycardia, increased BP Pathophysiology Impaired ventilation mechanisms r/t problems with CNS, MS, COPD, CF, and asthma Impaired perfusion (oxygenation) mechanisms r/t problems with pneumonia, ARDS, heart failure, COPD, PE and restrictive lung diseases Pulmonary Edema • Can result from blood backing up into circulatory system • Abnormal accumulation of fluid in the lung tissue. • Occurs from increased micro vascular pressure from abnormal cardiac function, or fluid overload. Symptoms Management Dyspnea, rales, coughing, pink frothy or blood-tinged secretions, crackles, tachypnea, advances to confusion and respiratory failure. Additional symptom: noisy, moist sounding rapid breathing Correct cause, O2, diuretics (Lasix) RT, intubation. * Be careful when doing blood transfusions, risk for pulmonary edema ARDS Sudden pulmonary edema, infiltrates and hypoxemia which injures alveolar capillary membrane. Pathophysiology Causes Symptoms Management Inflammatory response causes V/Q mismatch from shunting • Alveoli are damaged, collapsed or hemorrhage • Small airways narrow • Atelectasis • Decreased compliance • Refractory hypoxemia Aspiration, OD, prolonged high O2 concentration, smoke, infections, metabolic, shock, trauma, surgery, fat or air embolism, and sepsis Rapid and severe onset of dyspnea and tachypnea. * PaO2 does not respond to supplemental O2. Treat cause, supportive care, supplemental O2, intubation with Positive end expiratory pressure (PEEP), daily CXR, ABG, nutritional support, IV meds, inhaled meds PEEP: Keeps alveoli open • Possible side effects: pneumothorax, hypotension, and is uncomfortable. May need neuromuscular blocking agents • Check BNP levels Pulmonary Embolism Symptom: Sudden onset of chest pain Obstruction of the pulmonary vascular with an embolus. Maybe blood clot, air bubbles, or fat droplets. • Thrombus • Embolus PE often result from deep vein thrombosis (DVT) and is a venous thromboembolism (VTE) Prevention • Implement risk ASSESSment tools, understand, and recognize interventions • Encourage early ambulation, leg exercises • Educate patients on the symptoms of DVT/PE • SCD’s, LMWH Treatment: bedrest, assess skin color and temp (tissue perfusion) Increase HOB- High fowlers DVT Causes Symptoms DX TX • Venous stasis • Hypercoagulability • Venous endothelial disease • Heart disease, trauma, postop, DM and COPD • Advancing age, obesity, pregnancy, BCP, restrictive clothing • Hx of thrombophlebitis and PE • Coagulation conditions: A fib, HF Dyspnea, chest pain, anxiety, tachycardia, Hemoptysis. hypotension, diaphoresis, tachypnea and cyanosis - Redness, warmth, tenderness, pain Gold standard is pulmonary angiography Spiral CT, and D-Dimer, ultrasound * D-miner >2,000 is bad! (0.43-2.33 Normal) Stabilization: Oxygen, fluids, ECG monitoring, vasopressors (constricts- increases BP), percutaneous mechanical thrombectomy, thrombolytic or anticoagulation treatment, Vena cava filter placement and Warfarin * ABCs Anticoagulants Monitoring Reversal Agent LMWH Platelets protamine sulfate Heparin PTT protamine sulfate Warfarin PT/INR vitamin K /FFP PTT- normal 60-80, Therapeutic 90-150 INR- normal <1, Therapeutic 2-3 • Thrombolytics: TPA, streptokinase, alteplase • Educate: Bleeding precautions, s & s bleeding, lab monitoring, avoid invasive procedures, IM injections, avoid too muck vitamin K intake, avoid staining to defecate, and consult HCP before any OTC meds • Home care check list p. 604 avoid sharps to prevent cuts, shave with electric shaver, use soft bristle toothbrush, do not take aspirin or antihistamines while taking Coumadin, report dark tarry stools to health care provider, avoid sitting with legs crossed, change position regularly. Note: Anticoagulants- stops clot from getting bigger (3-6 month therapy) Thrombolytics- dissolve clot Chest Trauma • Causes: (Blunt) MVA and bike crashes & penetrating foreign objects • S/S: Hypoxemia, hypovolemia, decreased lung sounds, tracheal shift, tachycardia, tachypnea, and heart failure • DX: CXR, ABG’s, CT, labs • Can cause: Flail chest, pneumothorax(s), cardiac tamponade, pulmonary contusion, aortic rupture, rib fractures, airway obstruction and tracheobronchial diaphragmatic injury ¬ Flail chest: 3 or more free floating ribs from fracture (suction airway secretions) ¬ Open pneumothorax: Wound in the chest wall large enough to allow air to pass freely in and out of thoracic cavity. ¬ Pneumothorax: air between the pleurae • Symptoms- chest pain/SOB, unequal lung expansion, diminished/ absent breath sounds on affected side, (Hyperresonance on percussion) ¬ Blood in the pleural space is a hemothorax. (Dullness on percussion) ¬ Combination of blood and air is hemopneumothorax. Tension pneumothorax: ¬ WILL KILL ¬ Chest wall is intact: Air enters the pleural space from the lung or airway, and it has no way to leave. There is no vent to the atmosphere as there is in an open pneumothorax ¬ Most dangerous when patient is receiving positive pressure ventilation in which air is forced into the chest under pressure ¬ NO BREATH SOUNDS ON AFFECTED SIDE ¬ Mediastinal shift occurs when the pressure gets so high that it pushes the heart and great vessels into the unaffected side of the chest. These structures are compressed from external pressure and cannot expand to accept blood flow. Trachea shifts to unaffected side Chest Tubes • Tube(s) inserted into the pleural space to drain fluid, blood or air. • Removed when lungs reexpanded or condition resolved. May see air leak and some blood post insertion Should resolve! • Pressure in the pleural cavity is normally negative and drainage system connected to it must be sealed so that air or liquid cannot enter the pleural space. Assessment of patient with chest tube Chest tube maintenance Chest tube removal • Respiratory Status: • With pleural chest drainage, the major hazard is tension pneumothorax. The most likely cause is obstructed tubing.   • Subcutaneous emphysema (Crepitus)- Air trapped in tissue under the skin. (Crackling feeling like rice krispies). Mark area with marker, observe, notify MD if expanding, CXR ¬ Indications- post thoracotomy, spontaneous pneumthorax, chest trauma ⎫ Suction control ⎫ Water seal chamber and air leak monitoring ⎫ Recording drainage volume and sampling ⎫ Titling ⎫ Do not clamp or milk tubes ⎫ Check dsg, loops, and connections ⎫ Chest tube drainage system must be lower than the patient. Secured in place. ⎫ Constant bubbling = air leak (check suction) ⎫ Suction level should be – 20cm h20 ⎫ 3 days post op- no fluctuation is normal (lungs expanded) • Daily chest x-ray • Most chest tubes placed to suction after insertion. As drainage slows, suction is discontinued. • Instruct patient to perform valsalva maneuver (bearing down) • Patient in bed, monitor for respiratory distress, SOB, tachypnea. Get stat x-ray, call PCP. Oxygen delivery Systems Non invasive low flow • Nasal cannula fio2 (fraction of inspired o2) 1-6 L:/min add 3-4 % per liter. Dries out nasal passages. • Simple face mask 40 to 60% fio2. (5 to 8 L) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ICP Monitoring Purposes- ID increases in pressure, Measure pressure, Sampling and drain Types of Monitoring • MOST COMMON Ventriculostomy (Intraventricular catheter) - Fine bore cath is inserted into a lateral ventricle (IICP 12mmHg is good) - Aseptic technique, admin antipyretics, freq. oral care • Subarachnoid screw or bolt • Epidural monitor/catheter • Fiberoptic monitor/catheter • NO LUMBAR PUNCTURES Treatment for ICP Craniotomy Monitor labs: • ABG’s, serum osmolarity, electrolytes Meds: • Osmotic diuretics: mannitol.(dehydrates the brain and reduces cerebral edema) Don’t give osmotic diuretic in rehab stage of closed head injury • Loop: furosemide (restrict fluids, monitor UO • Corticosteroids • Stool softeners (Avoid enemas) • VASOPRESSORS- Dobutamine, levophed to maintain CPP greater than 70 Complications Interventions • Brainstem herniation • Diabetes insipidus • SIADH (restrict fluids) • CSF leakage or infection *Aseptic technique • Reduce cellular metabolic demand to improve oxygenation • Frequent monitoring of neuro, respiratory status and lung sounds and measures to maintain a patent airway • Position with head in neutral position and elevation of HOB 0–30° to AS ORDERED • Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP • Maintain a calm, quiet atmosphere and protect patient from stress • Monitor fluid status carefully; every hour, assess for bladder/bowel distension • Cluster nursing care • Cervical color to decrease ICP Intracranial Surgery • Craniotomy: opening of the skull – Purposes: remove tumor, relieve elevated ICP, evacuate a blood clot, control hemorrhage • Craniectomy: excision of portion of skill • Cranioplasty: repair of cranial defect using a plastic or metal plate • Burr holes: circular openings for exploration or diagnosis, to provide access to ventricles or for shunting procedures, to aspirate a hematoma or abscess, or to make a bone flap (relieves pressure) Preoperative Care Surgical approaches Postoperative Care • Preoperative diagnostic procedures may include CT scan, MRI, angiography, or transcranial Doppler flow studies • Medications are usually given to reduce risk of seizures • Antibiotics • Diazepam (reduces anxiety) • Obtain baseline neurologic assessment • Assess patient and family understanding of and preparation for surgery. • Provide information, reassurance, and support • Corticosteroids • Fluid restriction Supratentorial (Forebrain) • HOB 30-45 degrees. • Phenytoin prophylactically Infratentorial (Hindbrain) Transphenoidal Through mouth and nasal passages Pituitary gland Avoid coughing, blowing nose and straws post op, monitor nasal packing, diet as ordered - Monitor for post nasal drip (CSF) • Postoperative care is aimed at detecting and reducing cerebral edema, relieving pain, preventing seizures, monitoring ICP, temperature, and neurologic status. • The patient may be intubated and have arterial and central venous lines. • Complications: Increased ICP, bleeding and hypovolemic shock, fluid and electrolyte disturbances, infection, and seizures • Assess for DVT, monitor I&O, passive ROM exercises Seizures Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons • Dysrhythmia in the nerve cells in one section of the brain Classification of seizures Causes of Seizures Plan of Care for a Patient Experiencing a 
Seizure Partial seizures: Begin in one part of the brain • Simple partial: consciousness remains intact • Complex partial: impairment of consciousness Generalized seizures: involve the whole brain (Early- 1-7 days after injury) • Cerebrovascular disease**, hypoxemia, head injury, hypertension, central nervous system infections, metabolic and toxic conditions, brain tumor, drug and alcohol withdrawal, allergies, and epilepsy, menstrual cycle. • Status epilepticus: Series of generalized seizures cause cerebral anoxia and edema. Life threatening • TX: *ABC, Valium, ativan, dipravan, • Meds: Phenytoin, phenobarbital, dilantin, Depakote, neurontin, keppra (give anticonvulsant meds) Phenytoin (Dilantin)- brush teeth after every meal (gingival hyperplasia) - To halt seizures immediately give IV diazepam (Valium), and IV Ativan • AIRWAY, O2, suction, nothing forced into mouth • Do not restrain, maintain safety • Observation and documentation of patient signs and symptoms before, during, and after seizure • After seizure care to prevent complications • Support patient and family • Educate: Med alert bracelet, aura alert, med compliance, avoid stress and triggers • After seizure- side lying position • Side rails padded (2-3) • Ease patient to the floor to prevent injury • Allow pt to sleep after a seizure • EEG- keep pt awake for 24 hrs prior • After seizure patient may be confused Head Injury • A broad classification that includes injury to the scalp, skull, or brain • The most common cause of death from trauma (MVA) • Group at highest risk group for brain trauma is males age 15–24 • Those younger than 5 years and the elderly are also at increased risk • EVERYONE WITH HEAD INJURY IS ASSUMED TO HAVE SPINE INJURY UNTIL RULED OUT • Place cervical collar, and align spine at all times • Get to the ER within 1 hour • Give benzodiapines PRN Scalp wounds – Tend to bleed heavily, and are also portals for infection “ blood vessels constrict poorly” Skull fractures Open or closed – Usually have localized, persistent pain – Open penetrating (skull integrity compromised) closed-blunt (skull integrity maintained) Skull fractures Types Symptoms Nursing Process • Simple: Linear, break in bone • Comminuted: Splintered or multiple fracture line • Depressed: Skull bones displaced downward • Basilar: Fracture at base of skull “ tear in CSF” - You will see raccoon eyes, halo sign, and battle’s sign with Basilar • Bleeding from nose pharynx or ears • Battle’s sign—ecchymosis behind the ear (mastoid bone) “bruising” • CSF leak—halo sign—ring of fluid around the blood stain from drainage • CSF contains glucose • Assessment: Altered LOC, pupillary abnormalities, VS, HA, Seizures • DX: X-rays, CT, MRI • TX: ¬ Linear (Simple) Bed rest, observation ¬ Commuinuted & depressed: Surgical intervention within 24 hrs ¬ Basilar: Sx if CSF leakage, observe for meningitis • Meds: Dexamethasone (decreases edema), antibiotics Nursing responsibilities • Monitor otorrhea, rhinorrhea for Halo sign • Instruct client not to blow nose, cough, inhibit sneeze, and sneeze through open mouth • Keep nasopharynx and external ears clean. Sterile technique • Aseptic technique when changing dressings on head • Call for help if change in LOC, vomiting, blurred vision, slurred speech, prolonged HA, stiff neck, seizures GCS Eye opening 1-4 Best verbal response 1-5 Motor response 1-6 Total- 15 8 or lower usually indicates coma (Lowest score is 3) [Show More]

Last updated: 2 years ago

Preview 1 out of 68 pages