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Medical Surgical Nursing

Chest X ray  painless procedure

Bronchoscopy
AtSO4
Anticholinergic  mimics SNR

Decreases saliva  dry mouth


NPO 6 to 8 hours
Local anesthesia  check gag reflex before feeding

ABG
Hyperventilation  decreased CO2  increased blood pH  respiratory alkalosis
Hypoventilation  increased CO2  decreased blood pH  respiratory acidosis
Diarrhea  decreased HCO3  decreased blood pH  metabolic acidosis
Vomiting gastric content  decreased HCL  increased blood pH  metabolic alkalosis
Vomiting blood  decreased O2  anaerobic metabolism  formation of lactic acid  decreased blood pH 
metabolic acidosis
Blood pH  normal 7.35 to 7.45  If increased  alkalosis; If decreased  acidosis
Partial CO2  normal 35 to 45 If increased Respiratory Acidosis; if decreased Respiratory Alkalosis
Partial HCO3  normal 22 to 26  If increased Metabolic alkalosis; If decreased metabolic acidosis

Cancer of the larynx  CS, alcohol and over usage of voice (choir member)
A - nterior neck mass
B – urning sensation with hot beverages / Bad breath
C - hange in the voice (hoarseness)
D – ysphagia/dyspnea

Chronic Obstructive Pulmonary Disease


Chronic Bronchitis
Blue bloater
Excessive mucus production
Asthma
Periods of bronchospasm and bronchoconstriction
Emphysema
Disequilibrium of elastase and antielastase
Pink puffer

Manifestations
A – LTERATION IN
LOC  decreased O2
Thoracic anatomy  over distention of alveoli  TD = APD  barrel chest
Skin
Temperature  cool clammy skin
Color  pale to cyanotic
ABG  Respiratory acidosis  Increased CO2
B – reathing  difficulty, purse lip  expiration > inhalation  removal of excess CO2 (diet low CHO)
C – ough (mucus production); Chronic hypoxia (2 to 3 lpm of O2 therapy, decreased O2 demand by rest and
SFF)  clubbing of the fingers and decreased TP to the kidneys causing polycythemia
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D – ecreased Metabolism
Anorexia  weight loss (high calorie diet)  fatigue  weakness

Bronchodilators
Theophylline and aminophylline
Primary effect  stimulates beta 2 receptors  smooth muscle relaxation  bronchodilation
Side effect  stimulates beta 1 receptors  increases cardiac rate  need not to notify the physician
Adverse effect  hypotension  monitor BP  sign of toxicity
Evaluation  check breath sounds

Acute Respiratory Distress Syndrome


Causes
A – spiration
R – espiratory trauma (embolism)
fracture  embolism  ARDS
D – rug toxicity (ASA)
S – epsis and shock
Vomiting, bleeding, dehydration hypovolemia  shock  ARDS
Syndrome
Severe hypoxia
Bilateral infiltrates
Dyspnea

Pulmonary embolism
Restlessness  earliest

Water Seal System


Drainage Bottle → marked the level every shift
Water seal bottle
Presence of fluctuation → normal
Absence of fluctuation → lungs are fully expanded → assess first patient (X ray → confirm) OR presence of
obstruction
Intermittent bubbling → normal
Absent → obstruction
Continuous → leakage
Suction Control → continuous bubbling → normal

Risk factors for cardiovascular disorders


R – ace  non modifiable
I – ncresed blood pressure  modifiable
S – tress  SNR  increased BP and CR, vasoconstriction  modifiable
K – nowing sedentary life style  modifiable
F – at foods atherosclerosis  modifiable
A – lcohol (modifiable) / Age  above 40 (non modifiable)
C – igarette smoking  vasoconstriction (nicotine)  modifiable / Contraceptive pills  clotting of blood 
thrombus formation
T – ype A behavior (modifiable)  competitiveness, perfectionist  high stress level

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O – besity
R – esult of DM  lipolysis  increased fatty acids  atherosclerosis
S – ex gender  males > female (before menopausal because estrogen decreases PVR) after menopausal
female eversible}[inverted T wave]  Injury [elevated ST segment] > male
Decreased TP in heart  Ischemia (Angina) {r necrosis (MI) {irreversible}[pathologic Q wave/permanent in
the ECG]
Eating a heavy meal, strenuous exercise, sex, exposure to cold  Decreased blood flow (heart) decreased
TP (heart) decreased O2 (heart) anaerobic respiration  production of lactic acid  PAIN 
management decreased O2 demand by rest and SFF

Angina
Pain relieved by rest and NTG
NTG
Vasodilation  orthostatic hypotention  move gradually  Monitor BP
Store in a dark and amber container
Effective  tingling sensation  no need to notify physician
Maximum of 3 tablets with 5 minute interval

MI
Pain relieved by Morphine SO4
Narcotic analgesic
Can cause respiratory depression  monitor RR and O2 saturation
Antidote  narcan

Cardioversion  synchronous
Defibrillation  unsynchronous
Buerger’s disease  CS  vasoconstriction  stop CS  common in men
Raynaud’s  stress and cold  vasoconstriction  common in female

Congestive heart failure


Left sided  pulmonary
Dyspnea
Crackles
Polycythemia  due to decrease O2 to the kidneys
Clubbing of the fingers  due to prolonged hyxia
Orthopnea
Right sided  systemic
Hepatomegaly
Distended neck veins
Edema
Portal hypertension
Ascites  weight gain
Varicose veins

Digoxin
Cardiac glycoside
Positive inotrophic effect  increased strength of myocardial contraction
Negative chronotrophic effect  decreased cardiac rate  monitor CR  never give if CR below 60 bpm
Adverse effect
V – omitting
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A – norexia
N – ausea
D – iarrhea
A – bdominal pain

REMEMBER: earliest  GI; late  halo vision


Antidote  Digibind
Decreased RBC → Activity in tolerance, Fatigue, provide rest, Anemia
Decreased Platelets → Prone to bleeding, avoid parenteral injection, appl pressure on injection site,
high risk for injury
Decreased WBC → prone to infection, reverse isolation
Increased WBC → presence of infection
First Day/Newly diagnosed → Knowledge deficit

Diuretic
D – iet  high K diet except aldactone
I – input and Output  expected increased output
U – ndesirable effect electrolyte imbalance (K)
R – ecord weight  expected decreased weight
E – lderly  special precaution
T – ake in AM and with food
I – ncreased orthostatic hypotension  monitor BP and move gradually
C – ancel alcohol because of mild diuretic effect

Heparin  anticoagulant  prevent further enlargement of clot not dissolve them  monitor APTT/PTT 
antidote protamine SO4

Coumadin  anticoagulant  prevent further enlargement of clot not dissolve it  monitor PT  vitamin K is
the antidote

Urokinase/Streptoase → dissolves the clot

Pernicious anemia  absence of intrinsic factor (gastric surgery) problem in absorption of Vitamin B12 
beefy red tongue schilling’s test  definitive test  24 hour urine collection  life long Vitamin B12

Gastritis  LUQ pain

Gastric ulcer  affected area stomach  pain (precipitated by food intake  increased HCl)  pain relieved
by antacids

Duodenal ulcer  affected area duodenum  pain (2 hour after eating)  pain relieved by food

Ulcers  bleeding  (+) occult blood test (guiac) high fiber diet, avoid red meat, iron, steroids, NSAIDs,
indomethacin

Vagotomy  resection of vagus nerve  decreased cholinergic stimulation  decreased HCl and gastric
movement

Dumping syndrome  tachycardia and weakness  3 D’s (diarrhea, diaphoresis and dizziness)  fluids
after meals, lie down after meals and SFF

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Appendicitis  RLQ pain  avoid heat pads  cause rupture  signs of ruptured appendix  sudden
cessation of pain, elevation of temperature and WBC

Diverticulitis  LLQ pain → low fiber diet

Diverticulosis → high fiber diet

Ulcerative colitis  bloody diarrhea 20 to 30 times a day  fluid volume deficit

Liver cirrhosis  alcohol and malnutrition (laanec’s), infection and drugs (post necrotic), RSCHF (cardiac)
and biliary obstruction (biliary)

Portal hypertention can lead to


Blood shifted to the different collateral
Esophageal varices
Spider angioma (face and neck)
Caput medusae (abdomen)
Hemorrhoids (rectal)

Management avoid rupture  avoid shouting, valsalva maneuver


Increased hydstatic pressure  fluid shifting  ascites
Decreased albumin  decreased oncotic / colloidal osmotic pressure  fluid shifting  ascites 

management high protein diet


CHON metabolism  by product ammonia  liver cannot convert to urea  increased level of ammonia in the
brain  Alteration of LOC and changes of behavior and asterexis hepatic encephalopathy 

management low CHON diet and lactulose for removal of ammonia

Hepatitis A  fecal oral  prone plumber

Hepatitis B  body secretion  prone working in a dialysis

Cholecystitis  5 F’s (fair, female, fat, fertile and forty)  RUQ pain  after ingestion of fatty food 
demerol to relieved pain

Cholecystectomy  T tube  level of the incision site  drain excess bile

Pancreatitis  alcohol  autodigestion  LUQ pain

Anterior Pituitary gland


Growth hormone
Increased before the closure of the epiphysis of the long bones  gigantism  tall
Increased after the closure of the epiphysis  acromegaly  big hands (big gloves), big feet (big shoes) and
big head (big hat)
Decreased  dwarfism
Prolactin
Increased  galactorrhea
Decreased  decreased milk production
ACTH
Increased  secondary cushing’s

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Decreased  secondary addison’s
TSH
Increased  secondary hypethyroidism
Decreased  secondary hypothyroidism

Posterior pituitary gland


ADH
Increased  water retention  oliguria  edema (fluid volume excess) and weight gain  concentrated urine
 increased urine specific gravity
Decreased  water excretion  polyuria  dehydration (fluid volume deficit and weight loss)  diluted urine
 decreased urine specific gravity

Parathyroid gland
Parathormone
Increased  increased calcium in the blood and decrease calcium in the bones  stone formation and
decreased bone mass  osteoporosis  management increased water intake
Decreased  hypocalcemia  calcium supplement

Thyroid Gland
Increased (hyperthyroidism)
T3 and T4  increased BMR  hyperactive  inability to focus  insomia  increased catabolism  weight
loss  increased appetite  increased peristalsis  Diarrhea  fluid volume deficit  Increased CR and RR
(due to increased BMR)
Increased T3  heat intolerance
Calcitonin  decreased calcium in the blood  tetany  compensatory  calcium withdraws from the bones
 bone destruction (complication)
PTU  decreased synthesis of TH  watch out for SE (similar to signs and symptoms of hypothyroidism) 
watch out for agrunulocytosis (fever, skin rash and sore throat)
Lugol’s solution  decreased released of TH  before thyroidectomy  decreased vascularity of the thyroid
gland
Decreased (hypothyroidism)
T3 and T4  decreased BMR  hypoactive  sleeps a lot  decreased metabolism  weight gain 
anorexia  decreased peristalsis  constipation  decreased CR and RR due to decreased BMR
T3  cold intolerance
Calcitonin  hypercalcemia  stone formation
Synthroid and Proloid  increased TH

Adrenal Gland
Incresead (cushing’s)
Glucocorticoids  hyperglycemia and decrease wound healing
Mineral corticoids  increased aldosterone  sodium retention and potassium excretion  hypernatremia and
hypokalemia
Hypernatremia  water retention  oliguria  edema (moon face,buffalohump, fluid volume excess and
weight gain)  concentrated urine  increased urine specific gravity  low sodium diet
Hypokalemia  weakness  Prominent U wave  high potassium diet
Epinephrine and Norepinephrine  Increased BP and CR
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Sex hormones
Males  gynecomastia and falling of hair
Females  hirsutism and deepening of the voice
Decreased (addisons)
Glucocorticoids  hypoglycemia and inability to cope with stress
Mineralcorticoids  decreased aldosterone  sodium excretion and potassium retention  hyponatremia and
hyperkalemia
Hyponatremia  water excretion  polyuria (dehydration, fluid volume deficit and weight loss)  diluted urine
--. Decreased urine specific gravity  increased fluids and Na
Hyperkalemia  weakness  tall or peaked T waves  low K diet
Epinephrine and Norepinephrine  decreased BP and CR

Diabetes Mellitus
Type I  absolutely no insulin  thin  insulin
Type II  insufficient insulin  obese  OHA
Diet  50% CHO, 30% Fats, 20% CHON
Exercise  Increased uptake of glucose  Decreased insulin requirement
Oral hypoglycemic agent (OHA)
Stimulates pancreas to produce insulin
Insulin
SC; IV if DKA
Never massage the area
Never administer cold insulin
Rotate the site of injection

PREVENTS LIPODYSTROPHY
Mix
Aspirate clear first
Inject air to cloudy first

Hypoglycemia
W – eakness
H – unger pangs
A – alteration of LOC
T – achycardia and tremors

A – bdominal pain
B – blurring of vision
C – ool clammy skin
D – iaphoresis
Give  orange juice (simple sugars)

DKA → increased lipolysis increased ketones


Hyperglycemia  polyuria, polydipsia, polyphagia, kussmaul breathing, glycosuria, ketonuria and warm flush
skin
Glycosylated hemoglobin  reflect BSL for the past 3 to 4 months  most accurate
Foot care
Podiatrist
Avoid removing corns and calluses
Cut toe nails straight across
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Avoid walking bare foot

Hepatitis A → fecal oral

Hepatitis B → body and bloody secretions (hemodialysis)

Peritoneal Dialysis
Diasylate output is decreased → turn patient from side to side
Complication → infection → monitor WBC and temperature, diasylate is cloudy → boardlike and rigid abdomen
→ peritonitis
Don’t include diasylate solution in the output of the client
Expected → decreased weight → monitor weight before and after → decreased createnine and BUN

Heart block → decreased tissue perfusion

Parkinson’s diasease
Decreased dopamine in the basal ganglia → levodopa to increased dopamine → avoid Vit B6 foods
Cardinals signs → tremors (non intentional) → muscle rigidity → bradykinesia
Pill rolling
Microphonia → ask your client to speak aloud to be aware
Artane and Cogentin → anticholinergic → decreased muscle rigidity

Myasthenia Gravis
Tensilon test → confirmatory test
Decreased Acetylcholine and increased cholinesterase
Muscle weakness → priority airway
NO tranquilizer, Morphine SO4, Muscle relaxant and neomycin
Cholinergics (mestinon) → increased muscle strength → antidote ATSO4

Undermedication → myasthenic crisis → give cholinergics


Over medication → cholinergic crisis → give ATSO4

Multiple Sclerosis
Demyelinization of the myelin sheath

Charcoat’s triad
Intentional tremors
Scanning of speech
Nystagmus
Visual disturbances → diplopia

Pancreatitis → autodigestion → alcohol → bleeding → shock


Elevated amylase

Rheumatoid Arthritis
No specific diagnostic test
NSAID’s and ASA (antipyretic, analgesic and anti-inflammatory)
Synovitis → Pannus formation → fibrous ankylosis (limited joint movement) → Bony ankylosis (joint fixation)
Avoid flexion and promote prone position

Gouty Arthritis
Increased uric acid → allopurinol and avoid organ meats (liver) → tophi (ears)
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Osteoarthritis
Most common → related with aging
Pain after weight bearing exercise or activity → rest to relieved pain → weight reduction

Diverticulitis → LLQ pain and low fiber diet

Cyclophosphamide (Cytoxan) → can cause hemorrhagic cystitis → to avoid increased fluid intake

Vincristine (Oncovin) → increased fiber in the diet

Iron supplement →When is the best time to take (empty stomach), How is best taken (with orange juice)

Steroids and NSAID’s

DEATH → inflammation

BIRTH → side effects


B – one marrow depression → prone to infection → monitor temperature and WBC
I – ncreased gastric irritation → take it with food or after meals
R – enal toxicity
T – innitus
H – epato toxic

Cataract → common cause is aging (senile) → opacity of the lens → position on the unaffected side

Glaucoma → increased IOP → decreased of peripheral vision first → halo, tunnel and gun barrel vision →
miotics (constricts pupils) → avoid ATSO4 (dilates pupil)

Retinal detachment → trauma → blood clots → floating spots → dependent position→ scleral buckling

Avoid Increased Intraocular pressure → PRIORITY


Avoid vomiting, coughing, valsalva maneuver, lifting heavy objects, bending, crying

Meniere’s → Triad → tinnitus, impaired hearing loss and vertigo → low Na diet
Vertigo → imbalance → high risk for injury → decreased vertigo by focusing on one side of the room → assume
a flat or reclining position

ASA → 8th cranial nerve damage → tinnitus, impaired hearing loss and vertigo

Antibiotics → allergic reactions

Normal Values
BUN = 10 – 20 mg/dl
Calcium = 9 to 10.5 mg/dl
Creatinine = 5 to 1.5 mg/dl
GTT = 70 to 115 mg/dl
O2 sat = 97 to 98%

Signs and Symptoms of Increased Intracranial Pressure


B – lood pressure and temperature are elevated
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R – espiratory and cardiac rate are decreased
A – lteration of LOC
I – rritability
N – ote for projectile vomiting
S – eizure

“ I wish you all good luck for your LOCAL BOARD EXAM ….. “

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