Medical-Surgical Nursing

According to the B-Train

Fall 2007 - Volume I

Brief Overview

Short and sweet explanation of what my purpose is. This is to be updated as much as possible. With notes from class, slides, and the textbook, I hope to come up with some easy to remember study guides to help us get through this class.
I will attempt to continue to update this guide. I, Eina Jane, am the main editor of this project. I have hopes of passing on whatever knowledge I may have accrued over the years. Nursing school is hard. I, for one, admit having difficulty adjusting to the pace of the program. It will take time, but it does happen. If you need help, there are a lot of resources available. Take advantage of our professors’ office hours. If you are determined, it will happen. Ramapo’s nursing program is different from other nursing programs. It provides students a basic foundation of the sciences in order to comprehend the more advanced topics covered in nursing practicum. It provides non-science oriented students access to the basic theories of nursing science. Although nursing may seem far from science, its foundation relies on the laws of physics, the chemistry of compounds, the biology of life, and the many ‘mumbo-jumbo’ that makes the sciences a difficult subject to comprehend. After a two year completion of these pre1

requisites, juniors are now considered to be nursing majors. The curriculum is strict and does not allow for a customized schedule. This is where this guide comes in. It is in no shape or form supposed to replace actual textbook reading and note-taking. This is a supplement. I hope to make this a simpler version of the text book, and more organized than our notes. I will try my best to make this an easy read.

Bergenfield B-Train Chronicles
The crew: Shayne Roselle Aca-Ac, Eina Jane Marie Adlawan, Ton Garcia and Karyn Joy Jaramillo left its mark yet again. Attending Englewood Hospital’s Nursing Program is one of the biggest accomplishments of their lives. Keeping an upbeat outlook in life, they continue to pursue their dreams of becoming nurses. The program tests their ability to adapt and learn new ways of surviving the real world. The real world has forced them to use their special abilities to go out there, work hard, and have fun.

Medical Surgical Nursing: According to the B-Train

Fall 2007 - Volume I

So how do we use this guide?
Essentially this guide is the Powerpoint (C) slides reformatted to an easier to read form. Aside from the slides, additional information from the lecture and textbook are provided if necessary. Sample NCLEX questions are included at the end of each volume. These questions will be from Saunders, ATI, NCLEX Made Easy, and other NCLEX review type books.

Alternate Format Questions will also be featured, along with rationales to the answers.

Important Keep in Mind Refer to Book Online / CD

Eina Jane & Co.
Wandering Fruits, Inc.

MEDICAL SURGICAL NURSING: ACCORDING TO THE B-TRAIN SEES IT Copyright (c) 2007 by Eina Jane & Co. All rights reserved.

Printed in the United States of America


Meet the Candidates
Hey guys! A little something-something about the editors. We are students trying to survive just like you. If you have any questions, don’t hesitate to ask. ^_^


Ateh Karyn


This sexy nurse to be is awesome. Artistic, wonderful, funny and gorgeous. Shiine poses the ability to kick-butt in anything she wants. Pool. Table Table-Tennis. Art. Don’t Mess. The sweet girl transferred to another program, but updates are always an IM or Myspace away. Stay strong, and show those Filipinos how the B-train handles

nursing. Review guides. Chat rooms. Speed Uno. Cooking. Wii. This is how we tackle the stress that comes with the program. jk. HAHAHA. We manage. One exam at a time; that is how we do it. We hope you are enjoying the Philippines!!! We are so jealous. LOL. We miss you! The crew is not the same without you. Keep in touch! Don’t forget to share your nursing school stories with us. HAHAHA. ^_^

Summer 07

Karyn’s 21st



based on lectures by Professor John Fajvan, RN, MSN

First chapter for the senior year.
When you gotta go, you gotta go.

What is that?
In the new NCLEX, they may provide us a picture where we are asked to point and click on the photo. Know what and where these following parts: 1. Abdominal aorta 2. Right renal artery 3. Left renal artery 4. Inferior vena cava 5. Right renal vein 6. Left renal vein 7. Right adrenal gland 8. Right kidney 9. Renal cortex 10. Renal medulla 11. Renal pelvis 12. Renal pyramid 13. Renal papilla 14. Renal hilum [hilus] 15. Ureters 16. Bladder

Clinical Manifestations of Cystitis include:
• burning or pain during urination • frequent urination • cloudy / foul-smelling urine • pain directly above pubic bone • children under 5 - less concrete symptoms [weakness, irritability, reduced appetite, vomiting] • older women - NO symptoms, looks like a part of aging [weakness, falls, confusion, fever] • occasionally, blood in urine

- amoxicillin [Amoxil, Trimox] - ciprofloxacin [Cipro] - nitrofurantoin [Furadantin, Macrodantin] - sulfamethoxazoletrimethoprim [Bactrim, Septra] - trimethoprim [Proloprim, Trimpex]

Interstitial Cystitis
IC causes discomfort / pain in the bladder and abdomen. More common in women than men. Women’s symptoms get worse during periods, pain during intercourse. Natural lining of bladder [epithelium] protected from toxins in urine by a coating of enzymes [mucopolysaccharides] called the GAG [glycoaminoglycan] layer. In IC, protective layer is defective allowing toxins to penetrate into ‘interstitial layers’ of bladder, depolarize nerve endings, thus causing severe irritative voiding symptoms and bladder pain.

Management of Cystitis:
• drink water sufficiently to flush bladder thoroughly • empty bladder completely when urinating [place yourself backwards on the toilet, so you lean against the wall to completely empty bladder - hunching over to read does not work] • cranberry juice / capsules everyday which prevents bacteria from sticking to the bladder wall • urinating immediately after intercourse flushes most bacteria from urethra • urinate at least once every 3hrs • First line of treatment: antibiotics, depends on health of pt and bacteria found in urine. From simple to complex:

Infection of the bladder. BUT it’s usually used to call other infections and irritations in the lower urinary system.

Clinical Manifestations of Interstitial Cystitis include:
• persistent, urgent need to urinate • frequent trickles, sometimes up to 60x a day

• pain in suprapubic [pelvis] or between vagina / anus in women or scrotum / anus in men [perineal] • pelvic pain during intercourse, men have painful ejaculation • chronic pelvic pain

Dimethyl Sulfoxide [DMSO, Rimso-50(R)] - only FDA approved INSTILLATION treatment - instilled through urethra and directly into bladder via catheter - enters bladder wall, reduces inflammation, pain, painful muscle contractions - may be mixed with steroids, or other local anesthetics - may leave garlic taste / smell on skin / breath for up to 72hrs - heparin similar to GAG and may help to repair problems caused by GAG deficiency in bladder - blood, liver, kidney tests required every 6mo. during DMSO therapy

• urethral discharge: fluid may be yellow, green, brown / tinged with blood, production is unrelated to sexual activity • dysuria: localized to meatus or distal penis, worst during first morning void, alcohol consumption • urinary frequency and urgency typically absent; if present, either should suggest prostatitis or cystitis • itching: sensation urethral itching / irritation may persist between voids, some pts have itching instead of pain or burning • orchalgia: men sometimes c/o heaviness in genitals; associated pain in testicles should suggest epididymitis, orchitis, or both • menstrual cycle: women occasionally c/o worsening symptoms during menses • foreign body or instrumentation: pt should be question about recent urethral catheterization or instrumentation, either medical or self-induced [foreign body] causes traumatic urethritis • urethritis following catheterization, occurs up to 20% of pts receiving intermittent catheterization; 10x more likely to occur with latex catheters than silicone catheters

Management of Interstitial Cystitis:
Basic concept of therapy modify diet to help pts avoid foods that irritate the damaged bladder wall. • Avoid alcohol, coffee, tea, herbal tea, green tea, all sodas [especially diet], concentrated fruit juices, tomatoes, citrus fruit, cranberries, B vitamins, vitamin C, monosodium glutamte [MSG], chocolate, potassium rich foods [bananas] Pentosan polysulfate sodium [Elmiron (R)] - only ORAL medication approved by FDA for IC - chemically similar to GAG helps rebuild epithelium by coating bladder wall - take up to 6mo. to provide symptom relief; 25% experience significant relief within 4wks - taken long-term to keep symptoms from recurring - uncommon side fx: GI discomfort, reversible hair loss

Inflammation of the urethra caused by infection. Although irritation of urethra may occur in variety of clinical conditions, it’s a broad term used to describe a syndrome of STDs: gonococcal urethritis [GU] and nongonococcal urethritis [NGU].

Clinical Manifestations of Urethritis include:
• timing: symptoms generally begin 4days to 2wks after contact with infected partner, or patient maybe asymptomatic [assess sexual history]

Management of Urethritis:

objective: treat infection until urine is sterile and at the same time correct underlying cause

Cannot be felt during digital rectal exam and not visible by imaging.

Occurrence of bacterial seeding into blood stream due to an UTI causing generalized infection

Management of Stage I Prostate Cancer:
•watchful waiting[surveillance]

Clinical Manifestations for Urosepsis include:
• UTI - increased frequency of urination • burning sensation on urination • flank pain • blood in urine and fever • increased heart rate [tachycardia] • decreased blood pressure and unconsciousness

Prostate Cancer
Cancer that forms in tissues of prostate. Occurs in older men. Estimated new cases and death from prostate cancer in US in 2007: • New cases: 218,890 • Deaths: 27,050

• radical prostatectomy, usually with pelvic lymphadenectomy, with / without radiation therapy after surgery. May be possible to remove the prostate without damaging nerves that are necessary for an erection • external-beam radiation therapy • implant radiation therapy • clinical trials - high-intensity focused ultrasound - radiation therapy - evaluating new treatment option

Clinical Manifestation of Prostate Cancer include:
weak or interrupted flow of urine • frequent urination [especially at night] • trouble urinating • pain / burning during urination • blood in urine / semen • pain in back, hips, pelvis that does not go away [metastases] • painful ejaculation

What is the Prostate?
Gland in male reproductive system located just below bladder and in front of the rectum. About the size of a walnut. Surrounds part of urethra. Produces fluid that makes up part of the semen.

Stage II Prostate Cancer
More advanced than Stage I. Has NOT spread outside prostate. Could be palpated during digital rectal exam [DRE] or seen during rectal ultrasound examination

Benign Prostatic Hypertrophy [BPH]
Benign [non-cancerous] condition. Overgrowth of prostate tissue pushes against the urethra, blocking flow of urine.

Stage 1 Prostate Cancer
Found in the prostate only.

Management of Stage II Prostate Cancer:
• radical prostatectomy, usually with pelvic lymphadenectomy,


with / without radiation therapy after surgery. May be possible to remove the prostate without damaging nerves that are necessary for an erection • watchful waiting [surveillance] • external-beam radiation therapy with or without hormone therapy • implant radiation therapy • clinical trials - radiation therapy with or without hormone therapy - ultrasound-guided cryosurgery - hormone therapy follwed by radical prostatectomy - evaluating new treatment options

with or without radiation therapy after surgery • watchful waiting [surveillance] • radiation therapy, hormone therapy, transurethral resection of the prostate as palliative therapy to relieve symptoms caused by cancer • clinical trial - ultrasound-guided cryosurgery - hormone therapy followed by radical prostatectomy - evaluating new treatment options

liative therapy to relieve symptoms caused by cancer • watchful waiting [surveillance] • clinical trial of radical prostatectomy with orchiectomy [testoterone driven cancer]

Transurethral Resection of the Prostate [TURP]
Tissue removed from prostate using resectoscope [thin, lighted tub with cutting tool at the end] inserted through urethra. Prostate tissue blocking the urethra is cut away and removed through resectoscope.

Stage IV Prostate Cancer
Metastasized [spread] to lymph nodes near or far from prostate, or to other parts of body: bladder, rectum, bones, liver, lungs. Often spreads to bones. Also called Stage D1 Prostate Cancer and Stage D2 Prostate Cancer

Stage III Prostate Cancer
Spread beyond outer layer of prostate to nearby tissues. May be found in seminal vesicles [glands that help produce semen] Also called Stage C Prostate Cancer

Management of Stage III Prostate Cancer:
• external-beam radiation therapy with or without hormone therapy • hormone therapy • radical prostatectomy, usually with pelvic lymphadenectomy,

Management of Stage IV Prostate Cancer
• hormone therapy • external-beam radiation therapy with or without hormone therapy • radiation therapy or TURP of prostate as pal9

Suprapubic Prostatectomy
Surgical procedure that requires a large incision in lower abdomen, through which prostate and nearby

lymph nodes can be removed. Takes 2-3hrs to perform. Followed by 4-6day hospital stay.

may range from tiny to staghorn stones the size of the renal pelvis itself.

Clinical Manifestations of Glomerulonephritis include:
• Initial symptoms: - blood in urine [dark, rustcolored, brown] - foamy urine [beer] • Progressive symptoms: - unintentional weigh loss - nausea / vomiting - malaise / fatigue - headache - frequent hiccups - generalized itching [uric acid irritating skin] - decreased urine output - easy bruising / bleeding - decreased alertness [unfiltered toxins - may lead to eventual coma

Retropubic Prostatectomy
Prostate removed through an incision in the wall of the abdomen. Risk for bleeding / blood clots. Need continuous bladder irrigation [CBI].

Clinical Manifestations of Nephrolithiasis include:
• severe abdominal pain of sudden onset [worse than child birth] unilateral flank pain [one side] • lower abdominal pain • nausea / vomiting

Kidney disease caused by inflammation of internal kidney structures [glomeruli]. May be temporary / reversible condition, or may get worse.

Perineal Prostatectomy
Prostate removed through and incision in the area between scrotum and anus

Progressive glomerulonephritis may result in destruction of kidney glomeruli and chronic renal failure and end stage renal disease May be caused by specific problems with immune system, but precise cause of some cases is unknown • diabetes mellitus • multiple sclerosis • AIDS/HIV Renal failure = NO advil, ibuprofen, motrin, contrast dye • must check BUN / Creatinine levels periodically

Process of forming a stone in the kidney or lower down in the urinary tract. Development of stones related to: • decreased urine volume • increased excretion of stoneforming components such as calcium, oxalate, urate, cystine, xanthine, phosphate Stones form in urine collecting area [pelvis] of the kidney and

Management of Glomerulonephritis:
• treatment varies depending on cause of disorder, type, severity of symptoms • primary treatment goal: control symptoms high blood pressure may be difficult to control - MOST impor-


tant aspect of treatment [avoid stroke] - antihypertensive meds • corticosteroids [too much = damage kidneys], immunosuppressives may be used to treat some causes of chronic glomerulonephritis • dietary restrictions: salt, fluids, protein, other substances to aid control hypertension or kidney failure • dialysis or kidney transplantation may be necessary to control symptoms of renal failure and to sustain life

Management of Nephrotic Syndrome:
• nothing: some cases will improve with time, require no special treatment, others respond to very poorly to any known treatment • oral steroids: [prednisolone] one form of the disease [‘minimal change disease’] very sensitive to steroids; short-term use minimizes potential side-effects immunosuppression: more difficult cases thought to be triggered by own immune system; therapies come as tablets or drips given in the hospital - not commonly used because of toxicitiy - but sometimes effective in some pts

Variety of underlying causes must be identified to stop the progress. Dialysis may be necessary to bridge time gap required for treating fundamental cause.

Three Types of Acute Renal Failure:
• Pre-Renal - decreased blood flow to kidneys leading to ischemia in nephrons [mechanical problems] - prolonged hypoperfusion can lead to tubular necrosis and acute renal failure - caused by: shock, heart failur, pulmonary embolism, anaphylaxis, pericardial tamponade, sepsis • Intrarenal [intrinsic] - actual tissue damage caused by inflammatory or immunologic processes or from prolonged hypoperfusion [physical damage / necrosis] - caused by: acute interstitial nephritis, exposure to nephrotoxins, acute glomerulonephritis, vasculitis, hepatorenal syndrome, acute tubularl necrosis [ATN], renal artery stenosis/ thrombosis [blood clot] • Post-Renal - obstruction of urine collecting system anywhere from calyces to urethral meatus

Nephrotic Syndrome
Disorder where kidneys have been damaged, causing them to leak protein from blood into urine. Proteinuria [>3.5g/day], hypalbumineria, hyperlipidemia, edema.

What is Renal Failure?
Divided into two categories: acute renal failure and chronic renal failure. Type of renal failure determined by trend in serum creatinine. Chronic renal failure generally leads to anemia and small kidney size on ultrasound.

Clinical Manifestations of Nephrotic Syndrome include:
most common sign: excess fluid in the body - takes several forms • puffiness around eyes, especially in the morning pitting edema over legs • fluid in pleural cavity causing pleural effusion • fluid in peritoneal cavity causing ascites

Acute Renal Failure
Rapidly progressive loss of renal function. Oliguria [<400 mL/day] Body water / fluid / electrolyte imbalances.

- obstruction of bladder must be bilateral to cause post-renal failure unless only one kidney is functional - caused by: urethral/bladder cancer, renal/ureteral/bladder stones, atony [decreased muscle tone] of bladder, prostatic hyperplasia / cancer, cervical cancer [metastasis], urethral stricture

- diuresis can result in output of up to 10L [10,000mL] of dilute urine per day - usually occurs 2-6wks after onset of oliguric acute renal failure and continues until BUN level increases to rise • Recovery Phase [Convalescent Phase] - pt begins to return to normal levels of activity - renal function may continue to improve for up to 12mo after oliguric acute renal failure began - pt is particularly vulnerable to additional injury during this time

Many major organs contained in cavity [liver, kidneys, stomach, bowel]. Membrane has many tiny holes and acts as filter, allowing waste products and fluid from blood to pass through.

Phases of Oliguric Acute Renal Failure [<400ml/ day]
• Onset Phase - begins with precipitating event and continues until oliguria develops - can last from hours to several days • Oliguric Phase - Urine output 100-400mL/ day that does not respond to fluid challenges or diuretics - Lasts 8-15days but can last for several wks, especially in older pts or those having preexisting renal insufficiency • Diuretic Phase [High-Output Phase] - often prompt onset with urine flow increasing rapidly over period of several days

Chronic Renal Failure
May develop slowly and show few initial symptoms. Long term result of irreversible acute disease or part of disease progression. Most common cause: diabetes mellitus End-stage renal failure [ESRF] = ultimate consequence, where dialysis is required unless donor for renal transplant is found Holes are too small to allow large molecules to pass through therefore blood and dialysate will never mix. Performed daily at home.

Man-made membrane, or dialyzer. Partly does work of kidneys to filter waste and remove extra fluid. Blood circulates through dialyzer for several hours during treatment, with a machine controlling speed and several safety factors. Most often done 3x/week for 34hrs at a dialysis center.

Peritoneal Dialysis [PD]
Uses the peritoneum, natural membrane that lines cavity of abdomen.

All blood is filtered: risk for shock, hypokalemia, low protein/ salt/fluids

Clinical Manifestations of Renal Cancer include:
• Rarely causes s/s in early stages • Disease progression - pain in back, just below ribs that does not go away - weight loss - fatigue - intermittent fever - mass in area of kidneys that’s discovered during a physical exam

Renal Cancer
Forms in tissues of kidney. Renal cell carcinoma: forms in lining of very small tubes in kidney that filter blood and remove waste products. Renal pelvis carcinoma: forms in center of kidney where urine collects. Wilm’s Tumor: kidney cancer that usually develops in children under 5yo [removal of kidney, recurrence = death]. Several types of tumor: benign and malignant may occur Most common type: fluid-filled area called a cyst • Simple cysts do not progress to cancer; requires no follow-up • Complex cysts do not have typical benign appearance and may contain cancer In US, kidney cancer accounts for about 3% of all cancers, approx 12,000 kidney cancer deaths/year Occurs more in males, diagnosed between 50-70yo, but can occur at any age Adults, most common type = renal cancer [renal adenocarcinoma or hypernephroma]

- primary tumor may have spread to renal veins or vena cava, but only spread directly and not out of the local area of kidney • Stage IV - spread to distant sites - invades directly beyond local area - has more than one lymph node involved

Management of Renal Cancer:
• partial or complete nephrectomy - may include removal of adreneal gland, retroperitoneal lymph nodes, possibly tissues involved by direct extension [invasion] of tumor into surrounding tissues - if tumor spread into renal vein, inferior vena cava, possibly right atrium [angioinvasion], portion of tumor can be surgically removed - for metastasis, surgical resection of kidney [cy;todreductiv nephrectomy] may improve survival, as well as resection of solitary metastatic lesion • radiation therapy = not commonly used because not usually successful; may be used to palliate skeletal metastases

Staging of Renal Cancer
• Stage I - primary cancer 7cm [3in] or less - limited to kidney, with no spread to lymph nodes or distant sites • Stage II - primary cancer greater than 7cm [3in] - limited to kidney, with no spread to lymph nodes or distant sites • Stage III - primary cancer less OR greater than 7cm [3in] - spread to SINGLE lymph node

• chemotherapy in some cases, but unlikely cure unless all cancer surgically removed

• significant loss of size in one of testicles • feeling of heaviness in scrotum • dull ache in lower abdomen / groin • sudden collection of fluid in scrotum • pain or discomfort in testicle / scrotum • enlargement / tenderness of breasts

• retroperitoneal lymph node dissection • radiation therapy for seminoma • chemotherapy for nonseminoma - Platinol [cisplatin]: administered in hospital, toxicity of platinum solution - Vepesid / VP-16 [etoposide] - Blenoxane [bleomycin sulfate]: once a month injection at doctor’s office; respiratory toxicity - pulmonary fibrosis • surveillance - CBC - LDH - tumor markers - beta HCG [serum pregnancy test] = determines germ cell carcinoma Iggy Text: Ch. 72-75

Testicular Cancer
Most common type of cancer affecting men 15-35yo. Can strike ANY male, ANY TIME. Almost always curable if found early. Most found by men themselves, either as PAINLESS lump, or hardening or change in size of testicle, or pain in testicle Children born with undescended testicle have increased risk of getting testicular cancer regardless of whether surgery is done to correct problem. However, surgery should still be done to preserve fertility. Can be treated with surgery, radiation therapy, chemotherapy, surveillance, or a combination.

Who is usually affected?
• white males • northern European: Denmark, Finland, Norwegian, etc • No known cause

Staging of Testicular Cancer
• Stage I: cancer confined to testicle • Stage II: spread to retropertoneal lymph nodes, located in rear of body below diaphragm and between the kidneys • Stage III - spread beyond lymph nodes to remote sites in body, including lungs, brain, liver, bones

Clinical Manifestations of Testicular Cancer include:
• enlargement of testicle • painless lump

Management of Testicular Cancer
• inguinal orchiectomy


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