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Med Surg HESI II

1. Community Hlth/Medical Surgical- Respiratory COPD- S&S:

cough (chronic intermittent; usually occurs in morning w/ or w/o sputum), sputum production,
dyspnea (progressive; occurs with exertion then becomes present at rest), &/or history of exposure
to risk factors ,Wheezing, chest tightness

2. Critical Care/Fundamentals/Medical Surgical Med Administration/Math IV insulin rate: started

at 0.1 units/kg/hr by continuous infusion

3. Critical Care/Medical Surgical Immune/Hematology PRBC- infusion:

Consent form signed

Typing & crossmatching
VS before admin
Blood should be administered w/in 30 minutes of arrival from blood bank
Remain with pt for first 15 min of infusion; rate should not exceed 2mL/min; VS every 5 for
first 15 min
If no untoward reaction rate can be increased
Observe pt every 30 min
Transfusion should not exceed 4 hours. If pt is not in danger of fluid overload they can receive
1 unit in 2 hours.

4. Fundamentals- Basic nursing skills/hygiene- Postop drainage

-Know the type of wound, the drains inserted and know expected drainage
- Drainage is expected to change from sanguineous (red) to serosanguineous (pink) to serous (yellow). It should
decrease over hours or days, depending on the type surgery.
- Purulent drainage means infection
5. Fundamentals- Basic nursing skills/nutrition- Esophageal varices- diet
- Do not ingest alcohol, aspirin, NSAIDs and irritating foods
6. Fundamentals- med administration/math- IV- Heparin ml/hr
7. Geriatrics/ medSurg- GI/Hepatic/Oncology-Colon cancer-intestinal polyps
Colonoscopy, sigmoidoscopy, barium enema, and CT/MRI colonoscopy are use to discover polyps. Even though the
most common types polyps are nonneoplastics, all polyps are consider abnormal and should be remove; colonoscopy is
proffered since it evaluates the whole colon and remove polyps at same time, sigmoid will only remove the last part. S/S
are non specific ( diarrhea and alternating with constipation and sometimes anemia), and usually appear late in the
disease. The liver is common site of metastasis ( through the portal vein) and then the cancer spreads from the liver to
other sites. People with average risk should have a colonoscopy once a year starting form age 50, African Americans
should start at 45, if high risk should start earlier. --- the book doesn't specify anything about geriatrics but I assume
that since older pt usually have GI/ anemia issues it might be easy to ignore some of the s/s. also the older the higher
risk for any type of cancer.
8. MedSurg-Cardiovascular-Angina-Prophylactic
NItroglycerine tablets, sprays, or ointments may be used prophylactically before emotionally stressful situation, sexual
intercourse, or physical exertion (e.g., climbing a long flight of stairs). Pg. 787.
9. MedSurg-Cardiovascular-MI-Thrombolytics
Thrombolytics to stop an MI should be given as soon as possible and before 6 hours from when the symptoms started.
Fibrinolytics are given IV. Common hospital protocols are -12 lead ECG, draw blood to obtain baseline labs, initiate 2-3
lines for IV therapy. Depending on the drug selected. To asses effectiveness of drug therapy the most reliable marker is
the return of the ST segmented to baseline on the ECG, other markers include resolution of chest pain, and early rapid
rise of the CK-MB enzymes within 3 hours and peaking at 12 hours. To prevent other clots from forming, IV heparin
therapy is initiated. Absolute contraindications: active bleeding, history of aneurism or arteriovenous malformation,
intracranial neoplasm, previous cerebral hemorrhage, recent (within 3 months) ischemic stroke, head or facial trauma
within 3 months, suspected aortic dissection. Caution: recent (within 3 weeks) of surgery, recent (2-3 weeks) internal

bleeding --yes this is what the book says

10. Medical Surgical-Cardiovascular- Pacemaker- assess
*not 100% sure what this question was looking for (pg 837)
Several measures can assess for complications and include prophylactic IV antibiotic therapy
before and after insertion, post insertion chest x-ray to check lead placement and to rule out the
presence of pneumothorax, careful observation of insertion site, and continuous ECG
monitoring of the patient's rhythm. Observe insertion site for signs of bleeding and check that
the insertion is intact. Note any temperature elevation or pain at the insertion site and treat as
ordered. Most patients are discharged the next day if stable. After discharge, patients will need
to check pacemaker function on a regular basis which can involve outpatient visits to a
pacemaker interrogator/programmer, or home monitoring using telephone transmitter devices.
Another method to evaluate pacemaker performance is noninvasive program stimulation, which
is done outpatient in the electrophysiology laboratory.
11. Medical Surgical-Cardiovascular- Right sided heart failure
Causes a backup of blood into the right atrium and venous circulation. Venous congestion in the
systemic circulation results in jugular venous distention, hepatomegaly, splenomegaly, vascular
congestion of the GI tract, and peripheral edema. The primary cause of R-sided heart failure is
left-sided heart failure. In this situation, left-sided failure results in pulmonary congestion and
increased pressure in the blood vessels of the lung (pulmonary hypertension). Eventually,
chronic pulmonary hyptertension (increased R ventricular afterload) results in right-sided
hypertrophy and failure. Cor Pulmonale (R ventricular dilation and hypertrophy caused by
pulmonary disease) can also cause right-sided heart failure. (pg 800)
12. Medical Surgical-Cardiovascular- STEMI- assess thrombolysis
Associated with the deterioration of a once stable atherosclerotic plaque that ruptures, exposing
the intima to blood and stimulating platelet aggregation and local vasoconstriction with
thrombus formation. This unstable lesion is totally occluded by a thrombus(manifesting as a
STEMI). MI occurs because of sustained ischemia, causing irreversible cell death. When a
thrombus develops, perfusion to the myocardium is halted distal to the occlusion, resulting in
necrosis. Treatment of MI with fibrinolytic therapy aims to stop the infarction process by
dissolving the thrombus in the coronary artery and reperfusing the myocardium.
Therapy is given as soon as possible and within the first 6 hours of onset of symptoms. Each
hospital has a protocol for administering TPA (1)chest pain typical of MI (2) 12 lead ECG findings
consistent with acute MI, and (3) no absolute contraindications (table 43-14). (pg 782-3)
13. Med Surge Cardiovascular Electrical Burns (pg. 474)

Dysrhythmias, cardiac arrest, V-fib can result at injury or anytime within 24 hours after injury.
Monitor airway, vital signs, cardiac rhythm, I&O

14. Med Surge Endocrine Diabetes A1c level (pg. 1221, 1223)

At risk for diabetes: 5.7-6.4%

Maintaining an A1c <7% decreases diabetes complications microvascular and neuropathic
Maintaining an A1c <6% may further reduce complications but increases hypoglycemia risk

15. Med Surge Endocrine Graves Disease autoimmune disease marked by diffuse
thyroid enlargement and excessive thyroid hormone secretion. Develop antibodies to TSH
receptor causing release of T3 and T4, excessive amounts of TH develops clinical manifestations
of thyrotoxicosis. Disease is characterized by remissions and exacerbations. Untreated leads to
hypothyroidism treat with Synthroid. (pg. 1264)
16. Endocrine/Physical Assessment Hyperthyroid symptoms:
It is a hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones. This

usually occurs in women more than men, with the highest frequency in persons 20-40 years of age. The most common
form is Graves Disease. Other causes include toxic nodular goiter, thyroiditis, excess iodine intake, pituitary tumors, and
thyroid cancer.
Symptoms: Increased circulating thyroid hormone directly increases metabolism causing an increase in appetite with
weight loss, tissue sensitivity to stimulation by the SNS (i.e. nervousness, palpations). A goiter may be present upon
assessment. Auscultation of the thyroid gland may reveal bruits. Exophthalmos (protrusion of the eyeballs), rapid speech,
and intolerance to heat. Pg 1264
17. Endocrine/Respiratory-tracheostomy-parathyroidectomy: Tracheostomy is a surgical incision into the trachea
for the purpose of establishing an airway. A tracheostomy is the stoma (opening) the results from the tracheotomy.
Indications for a tracheostomy: 1. Bypass the upper airway obstruction, 2. Facilitate the removal of secretions, 3. Permit
long-term mechanical ventilation, 4. Permit oral intake and speech in the pt who requires long-term ventilation. Pg 528
Parathyroidectomy- The most effective treatment of primary and secondary hyperparathyroidism is a parathyroidectomy
because it leads to a rapid reduction of high calcium levels. Critera for surgery include calcium levels greater than 12
mg/dL, hypercalciuria (>400 mg/day), markedly reduced bone mineral density, and those under 50 years of age. Nursing
care for a pt with a parathyroidectomy is similar to that for a pt with a thyroidectomy. The major post-op complications
are from hemorrhage and fluid and electrolyte disturbances. Tetany (hyperexcitability associated with a decrease in
calcium levels) is another concern.
18. GI/Hepatic Bariatric surgery-post op care and diet: the initial post-op care focuses on careful assessment and
immediate intervention for cardio pulmonary complications, thrombus formation, anastomosis leaks, and electrolyte
imbalances. During the transfer from surgery, the pts airway should remain stabilized and maintain pain levels. Maintain
the head of the pt at 35-40 degrees to reduce abdominal pressure and increase tidal flow. If the pt is obese, monitor for
rapid O2 desaturation. Early ambulation is essential (the same evening after the surgery). Ted Hose will be placed right
away and passive ROM exercises will be frequent. Low dose heparin might be ordered. Frequent assessment of the skin
to monitor for delayed wound healing, hematomas, wound dehiscence. Keep skin folds clean and dry to prevent
dermatitis and fungal infections. Pain management is critical. Pg 958
During immediate post-op, water and sugar-free liquids are given (30ml every 2 hours). Before discharge instruct pts on
a measured amount of a high protein diet. Teach the pt to eat slowly and stop when feeling full and not to consume
liquids with solid foods. The pt is forced to reduce the oral intake and the ot finds the adherence to a reduced intake is
necessary because of the concern for abdominal distention and diarrhea. The diet should be high in protein and low in
carbs, fat, and roughage and consists of 6 small feedings a day. Fluid restriction of < 1,000 ml/day. Fluids and foods that
are high in carbs promote diarrhea and dumping syndrome.
19. Diverticulitis- NPO
In acute diverticulitis, the goal of treatment is to let the colon rest and the inflammation to subside. At home some
patients are put on antibiotics and a clear liquid diet. If the patient is hospitalized and unable to tolerate oral fluids,
the patient will be kept on NPO status and bed rest, IV fluids and antibiotics will be given. Observe for signs of
abscess, bleeding, and peritonitis. And monitor the WBC count. When the acute attack subsides slowly introduce oral
fluids and then progress the diet to semisolids.
20. GERD- pg 972
Gastrointestinal reflux disease defined as chronic symptoms or mucosal damage secondary to reflux of gastric
contents into the lower esophagus. Heart burn is the most common clinical manifestation, a burning, tightening
sensation felt intermittently beneath the lower sternum and spreading upward into the throat and jaw. Some patients may
also complain of pain in the upper abdomen (Dyspepsia). Noncardiac chest pain is common in older adults with GERD.
Lifestyle modifications- avoid foods that trigger symptoms. weight reduction may helpif the patient is
overweight. Encourage patient to stop smoking
Nutritional therapy- avoid foods that cause reflux. Avoid eating at night before bed.
Drug therapyPPIs Prilosec, Nexium, Protonix, Prevacid, dexilant, aciphex
H2 receptor blockers- Tagamet, Zantac, Pepcid, Axid,
Antiulcer drug- Carafate
21. Hiatal Hernia- pg 975
Herniation of a portion of the stomach into the esophagus through the opening, or hiatus, in the diaphragm. Most
patients are usually asymptomatic. When symptoms to occur they are similar to GERD. Bending over with severe pain.
Pain with large meals, alcohol and smoking.

Conservative therapy- lifestyle modifications, decrease of intra-abdominal pressure, avoid lifting and straining, dont
smoke or drink alcohol, elevate the head of the bed, reduce body weight, use antisecretory agents (PPIs, and H2 receptor
blockers) and antacids
Surgical therapy- herniotomy, herniorraphy, gastropexy
22. GI/hepatic/immune/hematologyCirrhosishematemesis: later symptoms of cirrhosis may be severe and result
from liver failure and portal hypertension. Portal hypertension may cause bleeding esophageal or gastric varices, causing
the pt to have melena or hematemesis. The main tx goal is to prevent bleeding of the varices. Tx of bleeding varices
includes vasopressors, nitroglycerin, beta-blockers, band ligation, endoscopic sclerotherapy, & balloon tamponade.
Supportive measures during a varice bleed include: FFP/packed RBCs, vitamin K, H2 blockers and PPIs, lactulose, and
prophylactic abx. May need a NGT to lavage stomach/get blood out.
23. GI/Hepatic/operativePostop diet: avoidance of hepatotoxins, such as alcohol and Tylenol, is critical. Pt should
avoid spicy and rough foods and activities that increase portal hypertension (straining during BMs, coughing, sneezing,
retching, vomiting). Adequate calories should be ingested (suggest small, frequent high-protein, high-calorie meals).
May be prescribed vitamin K and B complex vitamins.
24. Immune/hematology/integumentary/sensoryShingles pain: herpes zoster/shingles: grouped erythematous skin
and vesicles and pustules appear in a linear distribution along a dermatome. Tx includes antiviral agents (Acyclovir), wet
compresses, & Silvadene to ruptured vesicles. For analgesia, may use mild sedation at bedtime & gabapentin.
25. Musculoskeletal/rheumatoid arthritis- ESR change: Raised erythrocyte sedimentation rate (ESR) signals heart
failure in patients with rheumatoid arthritis. Patients with RA have an increased risk for heart and circulatory conditions
including coronary artery disease, heart attack, atrial fibrillation and stroke. They may also face higher risks for venous
thromboembolism (VTE) and pulmonary embolism
26. Physical assessment of trousseau sign: latent tetany, the occurrence of carpopedal spasm accompanied by
paresthesia elicited when the upper arm is compressed, as in use of a tourniquet or a blood pressure cuff. This is an
objective assessment sign of hypocalcemia
27. Athlete'a foot anti fungal: clotrimazole (lotramin) is an antifungal used to treat yeast infections of the vagina,
mouth, and skin (athletes foot). Use with caution if you have hepatic impairment, monitor LFTs, prey category c
28. Musculoskeletal-Gout medication - Acute gouty arthritis is treated with colchicine and NSAIDs. Because
colchicines have anti-inflammatory effects but no analgesic properties, NSAID is added to the treatment regimen for
pain management. Given PO, pain relief is expected within 24-48 hours. Recurrent gout can be prevented by combining
colchicines with a xanthine oxidase inhibitor like allopurinol or a uricosuric drug like Benemid , Uloric, a selective
inhibitor of xanthine oxidase, is given for long-term mngt of hyperuricemia. If they dont respond to drugs to lower uric
acid, they may be given Krystexxa that metabolizes uric acid and is excreted in urine, given IV. ACTH may also treat
Adequate urine volume w/ normal renal function (2-3L/day) must be maintained to prevent uric acid in the renal tubules.
Give Allopurinol in patients with uric acid stones. Have pt limit alcohol use and consumption of foods high in purine.
29. Musculoskeletal- Skeletal traction-mobility - Skeletal traction, generally in place for longer periods then skin
tractions and is used to align inured bones and joints or to treat joint contractures and congenital hip dysplasia. A pin or
wire is placed into the bone to align and immobilize the injured body part. Wt. for skeletal traction ranges from 5-45 lbs
and must be hanging freely. Prevent external hip displacement by placing a pillow, sandbag, or rolled up draw sheet
along the greater trochanteric region. Pt. should be in the center of the bed in a supine position. Incorrect alignment can
result in increased pain and nonunion or malunion. To offset the problem of immobility, discuss specific patient activity
with the healthcare provider. If exercise is permitted, encourage patient to participate in activities such as frequent
position changes, ROM exercise of unaffected joints, deep-breathing exercises, isometric exercises, and use o the trapeze
bar as permitted
30. Neurological-Lumbar Puncture Position - Lumbar puncture is the most common method of obtaining CSF for
analysis. It is contraindicated in the presence of increased intracranial pressure or infection at site of pucture. Before
procedure have the patient empty bladder. Most commonly, the patient is side-lying or lateral recumbent position.
However, a seated position may also be used. Aim for maximum flexion of the spine (fetal position) but avoid flexion of
the neck. Ensure that the plane of the back is exactly at 90 degrees to the bed and that hips and shoulders are in line.

31. Neurological- meningitis-step one pg 1452

meningitis- acute inflammation of the meningeal tissues surrounding the brain and spinal cord.
1st step- figuring out if the pt has meningitis and starting them on meds/antibiotics; Diagnosis,
history/psychical, check to see if the pt is presenting S/S (meningitis triad; fever, stiff neck, altered
mental status), pt will get blood culture, CSF sample (lumbar puncture), sputum, and nasopharyngeal
secretions collected before starting antibiotics therapy but after collection before the results are back
they will start the patient on a cocktail of antibiotics.
32. Neurological- Seizure- home care pg 1500
Seizure-paroxysmal, uncontrolled electrical discharge of the neurons in the brain that interrupts normal
Home care- table 59-12
drug compliance
non- drug therapy (e.g. relaxation methods)
be aware of resource in community
risk factors; avoid alcohol, fatigue, loss of sleep
good nutrition habits, snacks when needed

recognize personal limitations

education for care givers (pt safety, first aid)

33. Oncology-Infection- chemo risk pg 280

Neutropenia is most common in pt receiving chemo, places pt at serious risk for infection and sepsis.
Hand hygiene is major with chemo pt.
Pt blood count will be lowest between 7-10 after therapy,making the pt even more susceptible to
infection. Monitoring pt vitals and any sign of infection is crucial. Any sign of fever 100.5 or greater is a
medical emergency.

34. Medical surgical Oncology / Renal Allopurinol Prior to chemotherapy

-Allopurinol is a medication for the treatment of gout that lowers the amount of uric acid in the blood
-Since chemotherapy kills cancer cells, cells break open and spill their contents into the blood stream. This can cause
serious problems such as kidney damage called Tumor lysis syndrome
-Uric acid is formed from the breakdown of these cells, so Allopurinol blocks this process to lower the amount of Uric
acid in the blood
35. Medical surgical Renal ARF-Fluid challenge (Acute Renal Failure)
-Essentially, a large amount of fluid (1-2 liters), or 250mL of colloid (The point is that the kidneys are presented with a
challenge that can be monitored) are infused into a vein while kidney function is monitored for signs of fluid overload. If
overload is observed, further testing can be conducted.
36. Medical surgical Renal Hyperkalemia-dialysis
-Hyperkalemia is common in patients with end-stage renal disease
-IV calcium can be used to stabilize the myocardium
-Mild elevations: Kayexalate and Furosemide
-Point is that dialysis is the ultimate treatment for this, but there are many other ways.
37. Medical Surgical Renal Ileal conduit- post-op complications
Illeal conduit Form of incontinent urinary diversion. In this procedure a 6 to 8 inch segment of the ileum is converted
into a conduit for urinary drainage. The ureters are anastomosed into one end of the conduit, and the other end of the
bowel is brought out through the abdomen to form a stoma.
Risk for impaired skin integrity ensure ostomy appliance fits appropriately to protect skin from urine exposure, monitor
stoma and surrounding tissue, change bag appropriately to prevent urine leakage onto skin, do NOT use alkaline soap on
surrounding skin
General postop complications postop atelectasis and shock, thrombophlebitis, small bowel obstruction, UTI, paralytic
ileus ( will be kept NPO and on NG tube for several days postop since part of the bowel was removed),

38. Medical Surgical Renal Renal lithotripsy- postop care

Lithotripsy procedure used to eliminate calculi from the urinary tract. Postop requires analgesics, hematuria is
common, stent often placed to facilitate shattered calculi.
Postop care dietary modifications (increase water intake, limit colas, coffee, and tea, limit sodium and oxalate rich
foods), monitor urinary elimination (frequency, color, odor, volume, consistency), monitor for UTI, assess and treat pain
39. Medical Surgical Renal/ Reproductive BPH nocturia difficulties
Urinate q 2-3 hours and when first feeling the urge, use a toileting schedule. Continue to drink adequate fluids, but avoid
excess fluid intake before bed. Assess how many times patient gets up to void, whether or not the urge awakens the
patient, and how it interferes with their sleep. Other alternatives include indwelling catheter, drug therapy (5a reductase
inhibitors, a-adrenergic receptor blockers), minimal invasive therapy, or invasive therapy.
40. Reproductive Testicular Cancer:
Rare Cancer, occurs between ages 15-34, 2 types: Seminoma germ cell (not aggressive)
Nonseminoma (very aggressive)
Sx: painless and firm lump on scrotum, scrotal swelling, feeling of heaviness or acheiness, acute
pain only occurs in 10% of patients
Sx of metastasis: back pain, cough, dyspnea, hempotysis, dyshpagia, alterations in vision or
mental status, papilledema and seizues
Dx: Palpation is first test, then an ulatrasound is done
Nursing Care:
Teach pt. testicular self examination: encourage man to preform self examinations once a once;
while in shower (easiest time), use both hands to feel each testis and roll testis between the
thumb and first three fingers until entire surface as been covered. palpate separately. Identify
structures (testes and epididymis) , testes should be round and smooth, and epididymis is not
as smooth as testes. one may be bigger than the other. Look for lumps, irregularities, pain, or a
dragging sensation
Care for Cancer: orchiectomy (removals of affected testes, spermatic cord and regional lymph
nodes) Can be done in conjunction with chemo with patients in late stage cancer.
Px: 95% chance of complete remission if detected in early stages.
Infertility: Prior infertility or impaired fertility is often present at dx time. Chemo can cause
infertility. Talk about cryopreservations of sperm in sperm bank
Ejaculatory dysfunction may occur with removal of the lymph node.
Men may feel less manly and lose self worth. Pg 1396-1397
41. Respiratory: Adequate gas exchange:
The ability of the lungs to oxygenate arterial blood adequately is determined by the examination of the PaO2 (60-80mm
Hg) and SaO2 (above 90%). Tested through ABG's
Sx of Inadequate gas exchange: Change in LOC, tachypnea, dyspnea, use of accessory muscles, retraction of interspaces
on inspiration, pause for breath between sentences and words, tachycardia, mild hypertension, dysrhythmia, hypotension,
cyanosis, cool, clammy skin, decreased urinary output, fatigue
42. Respiratory: Aids in Gas exchange
Treat underlying cause (prevent aspiration, give antibiotics to clear any fluid or mucus in the lungs, remove obstruction
with histamines/epi or TPA to clear clot), , O2 support, deep breathing, incentive spriometer, don't smoke, pursed lip
breathing, huff coughing, acapellas
43. Respiratory Burns Smoke Inhalation

From hot air or noxious chemicals redness and airway swelling may result, injuries are major
predictor of mortality so rapid assessment is critical

Carbon Monoxide Poisoning causes carboxyhemoglobinemia (oxygen displaced from hemoglobin

by carbon monoxide) skin color cherry red and sometimes no burns on skin

Inhalation injury above the glottis (upper airway injury) usually thermally produced by hot air,
steam, or smoke mucosal burns that are red, blistering and edema present. Mechanical
obstruction can occur quickly = medical emergency.

Clues: facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and
nasal membranes, clothing burns around chest and neck.

Inhalation injury below the glottis (lower airway injury) usually chemically produced, tissue
damage related to duration of exposure. Clinical manifestations like pulmonary edema may not
appear until 12-24hrs after burn and may manifest as ARDS

Pts need to be observed closely for resp. distress and transfer to burn center, if carbon monoxide
poisoning suspected, treate with 100% humidified oxygen

Good Table on pg 478: assessment findings rapid, slow respirations; increasing hoarseness;
coughing; singed nasal or facial hair; darkened oral membranes; smoky breath; productive cough
with black or gray sputum; decreased oxygen sat.

44. Respiratory Pneumonia POC

Goals in Treatment: clearer breath sounds, normal breathing patterns, no signs of hypoxia, normal
chest x-ray, no further complications

Nursing Care teach importance of vaccine to at-risk populations, place pt in side-lying position or
upright when decreased LOC, turn and reposition Q2hrs, encourage ambulation, elevate head of
bed to 30-45 degrees for pts with nasogastric tubes and monitor gastric residuals, assist pts who
have difficulty swallowing to prevent aspiration, encourage deep breathing, treat pain to allow
deep breathing and coughing, practice strict medical asepsis, sterile technique when suctioning
trachea. Also teach med compliance at home, adequate rest, continued used of incentive

Prompt culture and initiation of antibiotics are critical

45. Respiratory Suctioning

On vent: deep suctioning only as needed not routinely suctioned, oral cavity frequently

Monitor for complications such as hypoxia, bronchospasm, increased ICP, dysrhythmias mucosal
damage, pain, infection

Indications for need of suctioning: visible secretions in ET tube, sudden onset of respiratory
distress, suspected aspiration of secretions, increased peak airway pressures, auscultation of
adventitious breath sounds over trachea, increased RR, sustained coughing, sudden or gradual
decrease in O2 sat

Closely assess before, during, after procedure. If not tolerating, stop and hyperventilate pt. with
100% oxygen. Limit each pass to 10 seconds or less. Keep pt. adequately hydrated to help with

Chart on pg. 1701 = Suctioning procedures for pt. on mechanical ventilation

46. Medical Surgical- Sensory- Menieres disease

Menieres disease is characterized by symptoms caused by inner ear disease, including vertigo, tinnus and hearing loss.
Disease causes significant disability for patient because of sudden severe attacks of vertigo with the patient because of
n/v and sweating. Sx begin between 30 and 60 yrs old. Nursing interventions include minimizing vertigo and providing
for patient safety. During an acute attack the patient is kept in a quiet dark room in a comfortable position. Teach
patient to avoid sudden head movements and TV or other flickering lights. Provide an emesis basin, raise bed
rails and put bed in low position.
47. Pathophysiology/ Medical Surgical- Cardiovascular- Peripheral arterial disease
PAD involves thickening of the artery walls, which results in a progressive narrowing of the arteries of the upper and
lower extremity. The leading cause of PAD is atherosclerosis, which leads to progressive narrowing of the artery lumen.
Significant risk factors include tobacco use, hyperlipidemia, elevated C-reactive protein, diabetes, HTN, and most
importantly tobacco use.
48. Pathophysiology/ Medical Surgical- Endocrine/ Respiratory- Resp alkalosis- Kussmaul resp
Respiratory alkalosis occurs with hyperventilation. Kussmaul respirations (deep, rapid, breathing) develop when a

patient is in metabolic acidosis. However extensive Kussmaul respirations can lead the patient to develop respiratory
49) Immune/Hematology - HIV CD4 count pathology: CD4 cells (AKA T-helper cells) are a type of white blood
cell that helps fight infection by signaling CD8 killer cells. CD4 cells are made in the spleen, lymph nodes, and thymus
gland, which are part of the lymph system. HIV infection leads to a progressive reduction in the number of CD4 cells.
Medical professionals refer to the CD4 count to decide when to begin treatment during HIV infection. Normal blood
values for CD4 cells range from 500-1200 cells/mm3. CD4 counts are used to assess the immune system of a patient.
Patients often undergo treatments when the CD4 counts reach a level of 350 to 500cpm; people with less than 200 cells
per microliter are at high risk of contracting AIDS defined illnesses.
50) Neurological - CVA Pathology: Cerebrovascular accident (CVA) results from sudden interruption of blood supply
to the brain. Stroke are either ischemic (caused by partial or complete occlusions of a cerebral blood vessel via
thrombosis or embolism) or hemorrhagic. Hemorrhage may occur outside the dura (extradural), beneath the dura mater
(subdural), in the subarachnoid space (subarachnoid), or within the brain substance itself (intracerebral).
51) SBAR - initiate process: Situation Background Assessment Recommendation (SBAR) is a standardized method of
communication used between healthcare staff and physicians to share patient information in a concise and structured
format. It improves efficiency and accuracy.
52. TB- Mantoux test negative - The test is negative if there is no bump (or only a very
small bump) at the spot where the fluid was injected. A negative TB skin test usually means that
you dont have TB. When documenting, the nurse needs to note that there the size of the bump,
if there is one, location, and that it was within 72 hours of the injection.
53. DKA- Hydration - Dehydration is another complication of DKA. High levels of ketones are
associated with high sugar levels in the blood and urine. More water is drawn into the urine,
resulting in frequent urination. Combined with vomiting - from an upset stomach, or possibly
due to a bout of flu or illness - the body quickly loses too much water and electrolytes.
Dehydration can occur rapidly (within hours) and is very serious. Give 0.9% NaCl. Rate is
determined by specific pt need.
54. Renal- pre-op lab - Important for the pt to have adequate fluid intake and normal electrolyte
balance preoperatively.

55. Amputation pain management - As many as 80 percent of all amputees experience pain in
their residual limb or as phantom pain, which feels as if it is in the part of the limb that is missing. 1
Residual limb pain is believed to derive from injuries to nerves at the site of the amputation. At the ends
of these injured nerve fibers, neuromas are formed. These bundles of nerve fibers may send out pain
impulses in a random fashion, or they may give off pain signals when trapped by other tissue, such as
muscle. Doctors usually begin with medications and then may add noninvasive therapies, such as
acupuncture or transcutaneous electrical nerve stimulation (TENS). More-invasive options include
injections or implanted devices. Surgery is done only as a last resort.
Meds: antidepressants, anticonvulsants, narcotics.
Noninvasive therapy: nerve stimulation, electric artificial limb, mirror box, acupuncture.
Minimally invasive: inject pain-killing medications, spinal cord stimulation, intrathecal delivery system.
Surgery: brain stimulation, Stump revision or neurectomy.