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2013-09-13 01:29:35

med surg intro
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  1. Percentage of total body weight (fluids)
    • Men have more, especially young
    • babies have more (highest) 80%
    • women hold less.
    • older-less water. 
    • fat-contain less water than lean tissue
  2. Regulation of Fluid Volume
    Hypervolemia (excess fluid volume) in hibits ADH release, aldosterone release inhibited, and thirst inhibited. leads to  increase urine (dilulted)

    Hypovolemia is opposite. 

    • notes:
    • ADH: cause kidney to retain water
    • Renin: convert angiotensin to angiotensin II
    • Angiotensin II: acts on nephron to retain sodium and water and instructs to release adolesterone.
    • Aldosterone: stimulates distal tubules of kidney to reabsorb sodium and excrete potassium, water follows sodium.
  3. Fluid requirements
    • insensible water loss=700 mL/day
    • through breathing, sweating etc.
    • cant be measures.

    body water=60% of patients body weight

    assess: I/O, daily weight, turgor, edema, electrolytes, thirst, protein levels, urine color, skin temp.
  4. Hypertonic vs isotonic vs hypotonic
  5. Hydrostatic and Osmotic pressure and Oncotic Pressure

    Hydrostatic: force created by fluid. blood flows from high-pressure arterial system to low pressure capillaries and veins. pushes water out at capillary level. affected by BP

    Osmotic pressure: power of solution to draw water out of the intracellular space.

    Oncotic (Colloid) Pressure: pressure exerted by proteins or colloids (albumin) in the capillaries. from interstitial to intravascular space.
  6. Osmosis vs. Osmolarity
    osmosis: movement of water across membrane from low to high concentration

    Osmolality: solute concentration. 270-300 mOsmkg

    increased osmolality with stimulate thirst center of brain.
  7. Edema
    accumulation of fluid in the interstitial space caused by:

    ↑ hydrostatic pressure or ↓ plasma oncotic pressure


    ↑ interstitial oncotic pressure or combination
  8. Crystalloid**
    Hypotonic: (.25% NS, .45% NS, 5% D5W) hydrate cells. may worsen hypotension, increase edema, hyponatremia. Use renal, hypertnatremia, intracellular dehydration.

    Isotonic:(.9% NS). no fluid shift, vascular expansion, electrolyte replacement. May cause fluid overload, edema. Use Shock, hemorrhage, severe vomiting/diarrhea, mild hyponatremia, DKA, severe dehydration.  Lactated Ringer

    Hypertonic: ( 3% NS or 5% NS)move water out of cell. Use severe hyponatremia, cerebral edema, volume expander. may cause fluid overload, hypernatremia,  

    Note: D5W is isotnotic in bag, then broken down by body= hypotonic
  9. Colloids
    • volume expanders
    • high oncotic pressure
    • same affect is hypertonic crystalliods
    • risk for fluid overload
    • longer action than crystalloids
  10. Starting an IV
    appropriate IV therapy order:

    • Solution
    • Route 
    • Rate
    • time frame
  11. Pain Module**
    • PCA pump:
    • helps patient deep breathe and ambulate sooner so better than IV or IM 
    • loading dose helps raise levels of med quicker
    • patietn has to be able to press button, no signs of respiratory distress and should be alert and oriented. 
    • set-up requires to RN verify
    • PCA by proxy: someone else pushes the button
    • requires frequent monitoring
    • oversedated can answer questions then will return to oversedated state
    • opiod naive patietns will not get same effect and may go into respiratory distress.
  12. Opioid Antagonist
    Nalozone(narcan) for reversalother options: adjuvant analgesics-anticonvulsants, antidepressants, local anesthetics, topics agents, muscle relaxers, all may reduce use of opiods.
  13. Opiods**
    • relieve pain
    • codeine, hydromorphine fentanyl, methadone (72 hrs), oxycodone, morphine
    • dose may be dependant on size, metabolism, etc. 
    • visceral pain
    • alcohol may require higher dose
    • side effects: nausea, vomiting, constipation
    • and drowsiness. Difficulty urination, dry mouth, sweating, palpitations, bready or tachycardia, rash. large dose: respiratory distress or hypotension.

    for constipation give stimulant (senna) and stool softener (colace). relistor antagonist for opioid constipation.

    25% of 24 hour total dose
  14. Opioid Respiratory depression
    respirations of <8 per minute, sedation vigorously stimulate patient and wont respond or asleep and sluggish response to vigorous stimulus

    • give narcan
    • give oxygen
  15. Evidence Based Practice
    Evidence-based practice (EBP) in nursing is using and carrying out nursing practices based on the best available knowledge. Evidence-based practice can be thought of as a triad that integrates the nurse’s clinical expertise with the best external research evidence, and takes into account patient preferences in order to deliver quality nursing care.

    Joint Commission (JAHCO) use standards that call for health care providers to implement best practices based on research evidence

    • 1. Identify problem (PICO)-population, intervention, comparison, outcome
    • 2. Review Research/critical appraisal (level of evidence)
    • 3. application and implementation (patient values and preferences) analyze validity etc. 
    • Evaluation (check results)

  16. Quality and Safety
    Quality: practice that is safe and effective, patient centered, timely, efficient and equitable

    Safe: the prevention of harm to the patient

    • culture of safety: systematic approach to preventing harm without blame (nursing role)
    • nurses are the last line of defence, position

    to prevent harm (communicate, anticipate and simulate)
  17. Nurse's guide to pain management
    • -pain often underrated in ethnic minorities, elderly, children and homeless, mentally ill, former substance abusers
    • -pain disrupts concentration, focus and memory
    • -pain threshold: point at which perceived as pain
    • Tolerance: duration of pain patient is willing to endure.
    • -Nonpharmacological: TENS (transcutanous electrical nerve stimulation) for incision pain, heat, cold (more effective than heat), massage, vibration all help relieve pain. use to enhance analgesics. start with analgesic followed 90 minutes later by nonpharm
    • -patient self report is most accurate indicator of pain.
    • -Signs of acute pain: diaphoresis, tachycardia, tachypnea, elevated BP
    • -untreated pain can lead to falls, fatigue, immobility.
  18. Med Nursing Considerations (rights)
    drug, client, dose, time, route, documentation

    reason, to know, refuse

    cross check order with MAR

    3 checks (pull, after pull, bedside)

    PRN needs indication
  19. Adverse effects vs. interactions**
    Adverse effects: side effects, adverse reactions (harmful i.e. hearing loss, etc.), toxic reactions (chemo), allergic reactions, idiosyncratic, cumulative

    Interactions: antagosist (work against effects) synergistic (work with other drugs to get better effects), incompatibilities)

    • Compatibilities: drug-food: grapefruit and BP meds (cyclosoporins)= increase levels in body. Black licorice ingrease digoxin toxicity; MAO inhibiotors and chocolate.
    • st. john: reduce blood levels of drugs
    • Vitamin E disrupt clotting
    • Ginseng disrupt clotting
  20. Enteral Tube Med administration **
    • check placement with 2 menthods
    • follow policty
    • crush med
    • check with med can be crushed
    • flush
  21. Documentation
    • Falsification of Records: documenting care that was not given.
    • Charting by Exception: increase legal risk, doesn't document 24 hour care. 
    • Negligence: failing to provide patient with the standard of care that a reasonably prudent nurse would provide.
    • charting is timely, accurate, truthful and appropriate. document facts.
  22. Pediatric Assessment Triangle (PAT)
    • Appearance: tone, interactive, console, look, speech/cry
    • Breathing : retractions, nasal flaring, airway sounds
    • Circulation: pallor, mottling, cyanosis
  23. Breathing: Auscultation
    • Stridor: upper airway obstruction
    • Wheezing: lower airway obstruction
    • Grunting: poor oxygentation
    • Crackles: fluid, mucus, blood in airway
  24. Focused History
    • sings/symptoms
    • allergies
    • medications
    • past medical history
    • last food/liquid
    • events leading up to injury
  25. Medicating Children:
    • dosage: mg/kg/day
    • Rectal: insert 1/2-1 inch
    • Otic (ear): if less than 3, pull at pinna and down, otherwise pull up and back
  26. Nebulizer vs MDI
    Nebulizer: meds diluted with NS, delivered through mask or mouth piece between lips or close to face

    MDI: use spacer, dose is measured

    inhale and hold for 5-10 seconds
  27. Childhood Illnesses
    • Chickenpox
    • strep throat
    • UTI
    • Respiratory Infection
    • Otitis Media
  28. Peds Assessment
    • First Impression (general appearance, interaction with parents)
    • Health History (illness, immies, newborn history, birth, hospitalizations, injuries, allergies, meds, social history, family history, pregnancy)
    • developmental milestones
    • vital signs
    • growth
    • Physical exam (palpate last, undress as go, play)
  29. Chest wall
    • Pectus carinatum (pigeon chest) out
    • pectus excavatum funnel chest) in
  30. Immunizations
    should not be vaccinated: allergic reaction, compromised immune system

    possible side effects: mild reaction, mild fever or soreness

    VIS: vaccine information statement
  31. Nasogastric Tube
    indications: gastric decompression (bowel obstruction, GI bleed, surgery), administer meds, feeding (increase energy, burns, trauma)

    contraindication: severe face trauma, nasal surgery, esophageal varices,

    helps cardiac sphincter remain open

    Placement: check orders, check nares, check placement by two methods, gag reflex present, mental status

    verify placement: radiograph (gold standard), ph gasttic content, auscultate, CO2 confirm

    Nursing Intervetions: oral care, skin care around nares, flushing, suction, monitor fluds, monitor color/consistency of output, HOB at 30 degrees, secure tube

    complications: discomfort, epistatis, aspirations, pneumothorax, necrosis of esophagus, electrolyte imbalance
  32. Chest Tubes**
    Indications: pneumothorax (air in pleural space), tension pneumothorax (air in pleual space, lung collapses causing mediastinal shift). post major heart/lung surgery... hemothorax, hemopneumothorax, thoracostomy, VATS, chylothorax, cholotrhorax (bile), pleural effusion

    RN considerations: patient understand, consent, give sedation/analgestic, position, remind patient not to move

    Location: remove air (restore negative pressure) second intercostal anteriorly midclavicular); remove fluid lateral 5th or 6th intercostal mid axillary for VATS; open heart to drain fluid in mediastrum or perdicardial sac front and beneath heart

    problems: air leaks, drain obstruction, disconnected, dislodge, mediastinal shift

    removal: air leak resolved, improved breath sounds, no cluctuatiosn in water seal chamber, pneumothorax resolved on water seal. remove without introducing air
  33. Pneumothorax
    • sings of chest trauma
    • tachypnea, tachycardia
    • shortness of breath
    • diminished air sound
    • ABG: decreased oxygen-respiratory alkalosis
    • x-ray

    • internal origin: bleb rupture, procedural
    • exteranl: any rupture, poke, thoracentesis( needle puncture)
  34. Capnometry
    • measure exhaled CO2
    • 4-6mm <Pa CO2
  35. Suction
    settings: adults: 100-150 mmHg, children 100-120, infant 50-90, preterm 40-60

    Assess/teach: TCDB (turn, cough, deep breathe) or insentive spirometry

    • suction only when necessary
    • for 5-10 seconds, 30 second rest inbetween

    complications: hypoxemia, tachy or bradycardia, bleeding, infections, aspriation RMB, tracheal damange, bronchospasms
  36. trachestomy: passy-muir valve
    • one way valve
    • swallow, smell, talk

    • establish airway: by pass upperairway, removal secretions, eat, mechanical ventilation
    • inflatted cuff protect airway from aspiration, cuff interferes with swallowing
  37. Acute vs chronic pain
    acute: sudden, lasts less than 3 months, mild to severe, resolves over time. increased HR, Resp, BP, urinary retention, diaphoresis

    Chronic: gradual onset, more than 3 months, mild to sever, cause may be unknown, wont go away. decreased movement, flat affect, fatigue, withdrawal
  38. Nociceptive Pain and Tx **
    • NOCICEPTIVE: damage to somatic or visceral:
    • Superficial: from skin, mucous membranes, SQ. Sunburn. Somatic
    • Deep Rise: from muscles, fascia, bones, tendons, radiates. arthritis. Somatic
    • Visceral: from organ. poorly localized, referred. appendicitis. 

    TX: nonopiods (NSAIDS and opiods)
  39. Neuropathic Pain and TX **
    • NEUROPATHIC: damage to peripheral nerve or structures of CNS
    • TX adjuvant analgesics

    • Central: primary lesion of CNS dysfunction (MS, post stroke pain)
    • Peripheral Neuropathy: felt along peripheral nerves (trigeminal neuralgia)
    • Differentiation: loss of input (phantom limb)
    • Sympathetically Maintained: pain secondary to sympathethic nervous system activity (CRPS or RDS)
  40. Pain Managment
    • Nonopiods: ASA, acetaminophen, NSAIDS, Cox-2 inhibitors
    • opiods: agonist and antagonist
    • adjuvant drugs: antidepressants, anti-seizures
  41. Nursing Negligence
    • - duty to provide care to the patient and to follow an acceptable standard of care.
    • -failed to adhere to the standard of care.
    • -failure to adhere to the standard of care caused the patient’s injuries
    • -patient suffered damages as a result of the nurse’s negligent actions
  42. Adjuvant Drugs**
    • given in addition to opiod
    • Corticosteriods: mimic cortisol (stress hormone) prednisone
    • Antidepressants: 
    • Gaba receptor agonist: Baclofen
    • Local anesthetics
    • Mixed Mu agonist opioids: inhibit reuptake of norephinephrine and serotonin (mood). Tramadol, tapentadol
  43. Pain Management and Ethics
    • placebo: no
    • rule of double effects: ethical to give pain relief even if may cause death
    • females, elderly, unattracive, minorities are untreated for pain
  44. Pain
    • actual or potential tissue damage
    • whatever the patient reports it to be
    • emotional component

    • Mechanism:
    • Nociception: physiological process by which information about tissue damage is communicated to the CNS. 
    • 1: transduction: stimulus cause cell damage, release chemicals
    • 2: transmission: actional potential from site of injury to spinal cord to brain
    • 3: conscious experience
    • 4: modulation: release chemicals inhibit nociceptive impulses.
  45. Testicular Cancer
    • common in 15-34yrs
    • clinical Manifestations: slow or rapid onset, painless lumps in scrotum, swelling, heavy feel, nontender and firm, dull ache in lower abd

    Diagnose: palpation (firm mass), visual doesnt transluminate, ultrasound. blood test (lactase dehydrogenase, AFP beta human choronioc gonadotropin hCG)
  46. Benign Prostatic Hyperplasia (BPH)
    • benign enlargement of the prostate gland
    • urological problems due to urethra compression
    • Clinical Manifestations: urinary obstruction (calliber, force, difficult voiding, dribble, intermittent stream) and irritative increase frequency, urgency, dysuria, bladder pain, incontinence. 
    • complications: UTI, incomplete emptying, bladder stones, pain, inability to urinate
    • Diagnose: histroy, physical exam -digital exam, PSA blood level, TRUS (transrectal ultrasound)

    Treatment: relieve symptoms, restore bladder drainage, reduce caffeine sugar spicy, meds to reduce size and relax muscles
  47. TURP and TUIP
    • TURP: trasnurethral resection of prostate: remove prostate tissue ctoscopically
    • TUIP: transurethral incision of prostate: incision into prostate tissue to relieve obstruction.
  48. Prostatic cancer
    malignant tumor of prostate gland (BPH is benign)

    Diagnosis: Anual DRE (digital rectal exam)  and blood test for PSA (increases). Biopsy: TRUS
  49. Oxygen indications
    • respiratory disorders (COPD, etc)
    • cardiovascular disorder (MI)
    • central nervous system disorder (overdose opiod, head injury, sleep apnea)

    humidify if 35% or more

    CO2 drives breathing, so hypoxemia.

    • absorption atelectisis: high concentrations of oxygen, nitrogen replaced by oxygen cause aveoli collapse. 
    • infection with nebulizer

    • breathing exercises:
    • pursed lip breathing: prolong exhalation prevent brochiolar collapse and air trapping
    • diaphragmatic breathing: achieve max inhalation volume, slow respiration rate. 
    • huff coughing:  inhale through mouth, exhale quickly. clears secretions.
  50. Testicular Exam
    • monthly on same date
    • during warm shower
    • feel testes between thub and finger one at a time
    • should feel round, smooth. check for pain and lumps
  51. Erectile Dysfunction
    • causes: diabetes, vascular disease, surgery, trauma, chronic illness, stress, depression, decreased GH. vascular disease is most common
    • Treatment: viagra, cialis, levita (smooth muscle relaxer-increase blood flow)
    •  vacuum, intraurethral devise, penile implants, counseling. 
  52. Death and dying process hmodynamic changes
    • initial low oxygen sats, tachycardia (due to hypoxia
    • BP decrease
    • heart will then brady
  53. Nursing role in death and dying
    • laison
    • palliative care
    • post mortem care, prepare for transport
    • advance directives,, living will, MPA etc
    • Organ/tissue donor
    • Assessment
    • holistic approach
    • opioid for air hunger
  54. Medical Examiner Cases
    • unexpected death of healthy individual
    • death due to injury
    • overdose/poisoning
    • cannot rule out foul play
    • complication of medical treatment
    • shortly after transfer

    • leave all invasive lines in
    • chart assessment
  55. Palliative Care
    • care/treatment that reduces the severity of disease symptoms 
    • prevent/relieve suffering
    • improve quality of life

  56. Bereavement and grief
    • Bereavement: state of loss, period of time
    • Grief: normal reaction to loss (anger, guild, anxiety, sad, depression, despair)
  57. Hospice care
    • provides compassion, concern, support for dying
    • end of life care, with emphasis on symptom management
  58. Heart Anatomy
  59. Cardiac conduction and contraction
    • sodium
    • potassium
    • calcium (contraction)

    move in and out of cell=impuslse

    • potassium 3.5-4.5
    • low: extra wave
    • high: tall T wave
  60. Cardiac conduction system

    • sympathetic: acts on A-V node (ventricular)
    • parasympathetic: acts on S-A node (vegal nerve-SA
  61. Myocardial action potential
    • depolarization: contraction, influx of Na and Ca, out K
    • Repolarization: resting state
    • relative Refactory period: contraction can still occur
    • Absolute refractory period: return of cardiac cells to resting state
  62. Components of the EKG
  63. Ventilation vs perfusion
    • Dead space: 150 ml of air never reach alveoli
    • Perfusion: blood flow
    • Oxygenation: process moce oxygen throughout body
    • ventilation: mechanical component of air into and out of lungs
    • respiration: exhange of oxygena nd carbon dioxide. 
  64. oxygen diffusion
    • move from high to low concentration
    • pressure gradient: partial pressure-helps with gas exchange. 
    • Carbon dioxide diffuses 20 times faster than oxygen. 
    • thicker alveoli capillary membrane-slower rate of diffusion (pulmonary edema, fibrosis, ARDS all increase membrane thickness)
  65. Lactate
    • anaerobic respiration
    • normal .5-2.o mmol/L
    • strenous exrecise
  66. Aveoli
    • 3 types of cells:
    • Type I: alveolar epithelial cells surface
    • Type II: surfactant
    • Macrophages: mucus (release peroxide as defense)

    surfactant: lowers surface tension
  67. Oxyhemoglobin Dissociation Curve
    relationship between the PaOand SaO2

    • shift to left (lung)
    • Hgb picks of oxygen easier, but cant give it up
    • tissue hypoxia
    • decrease CO2 and body temp, increase pH, CO poisoning

    • Shift to right (tissue):
    • harder for hgb to bind O2, easy to release, more Ointo cells
    • increased CO2, body temp, decrease pH, anemia.
  68. V/S mismatching
    blood exits heart without gas exchange

    causes: structual failure, inflammation, infection, atelectasis
  69. Signs of impaired gas exchange
    • ABG: impaired oxygenation PaO2 decrease, SaO2 decrease
    • impaired ventilation: PaCO2 increase, decrease pH

    respiratory failure: PaCO2 >50, PaO<60, Ph<7.3
  70. Antitussives
    • suppress cough (opiod and nonopiod)
    • codeine (opioid)
    • dextromethorphan (nonopioid)
  71. Sympathomimetics
    • (decongestant) sudafed
    • reduce nasal congestion
    • vasoconstriction on nasal blood vessels

    rebound congestion if used more than 5 days
  72. Antihistamine
    • zyrtec, allegra, claritin, benadryl
    • for allergic rhinitis
    • for sneezing, rhinorrhea, nasal itching
  73. Glucocorticoids
    • decrease inflammation (athritis, asthma)
    • cortisone, prednisone

    causes osteoporosis, infection, glucose intolerance, fluid imbalance, peptic ulcer if used with NSAIDS
  74. Metered Dose inhaler and spacer
    • metered dose: measured dose
    • spacer: more medciation reaches the lungs
  75. Bronchodialators
    • beta2adrenergic agonists
    • albuterol, 
  76. Glucocorticoid/Laba combination
    • glucocorticoid: anti inflammatory
    • Laba: bronchodialation

    Advair, Dulera, Symbicort
  77. Montelukast
    • Singulair
    • combine with antihistamine to treat asthma and allergies
    • not for acute