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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
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)
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
gout.
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.
From hot air or noxious chemicals redness and airway swelling may result, injuries are major
predictor of mortality so rapid assessment is critical
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.
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
spirometer.
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
secretions
patient is in metabolic acidosis. However extensive Kussmaul respirations can lead the patient to develop respiratory
alkalosis.
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.