MEDICAL – SURGICAL NURSING

BULLETS

 Chest X ray  painless procedure

 Bronchoscopy
o AtSO4
 Anticholinergic  mimics SNR
 Decreases saliva  dry mouth
o NPO 6 to 8 hours
o Local anesthesia  check gag reflex before feeding
 ABG
o Hyperventilation  decreased CO2  increased blood pH  respiratory alkalosis
o Hypoventilation  increased CO2  decreased blood pH  respiratory acidosis
o Diarrhea  decreased HCO3  decreased blood pH  metabolic acidosis
o Vomiting gastric content  decreased HCL  increased blood pH  metabolic alkalosis
o Vomiting blood  decreased O2  anaerobic metabolism  formation of lactic acid 
decreased blood pH  metabolic acidosis
o Blood pH  normal 7.35 to 7.45  If increased  alkalosis; If decreased  acidosis
o Partial CO2  normal 35 to 45 If increased Respiratory Acidosis; if decreased
Respiratory Alkalosis
o 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)
o A - nterior neck mass
o B – urning sensation with hot beverages / Bad breath
o C - hange in the voice (hoarseness)
o D – ysphagia/dyspnea
 Chronic Obstructive Pulmonary Disease
o Chronic Bronchitis
 Blue bloater
 Excessive mucus production
o Asthma
 Periods of bronchospasm and bronchoconstriction
o Emphysema
 Disequilibrium of elastase and antielastase
 Pink puffer
o Manifestations
 A – LTERATION IN
 LOC  decreased O2
 Thoracic anatomy  over distention of alveoli  TD = APD  barrel
chest
 Skin
o Temperature  cool clammy skin
o 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
 D – ecreased Metabolism
 Anorexia  weight loss (high calorie diet)  fatigue  weakness
 Bronchodilators
o 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
o Causes
 A – spiration
 R – espiratory trauma (embolism)
 fracture  embolism  ARDS
 D – rug toxicity (ASA)
 S – epsis and shock
 Vomiting, bleeding, dehydration hypovolemia  shock  ARDS
o Syndrome
 Severe hypoxia
 Bilateral infiltrates
 Dyspnea
 Pulmonary embolism
o Restlessness  earliest
 Water Seal System
o Drainage Bottle  marked the level every shift
o 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
o Suction Control  continuous bubbling  normal
 Risk factors for cardiovascular disorders
o R – ace  non modifiable
o I – ncresed blood pressure  modifiable
o S – tress  SNR  increased BP and CR, vasoconstriction  modifiable
o K – nowing sedentary life style  modifiable
o F – at foods atherosclerosis  modifiable
o A – lcohol (modifiable) / Age  above 40 (non modifiable)
o C – igarette smoking  vasoconstriction (nicotine)  modifiable / Contraceptive pills 
clotting of blood  thrombus formation
o T – ype A behavior (modifiable)  competitiveness, perfectionist  high stress level
o O – besity
o R – esult of DM  lipolysis  increased fatty acids  atherosclerosis
o 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
o Pain relieved by rest and NTG
o 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
o 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

o Left sided  pulmonary
 Dyspnea
 Crackles
 Polycythemia  due to decrease O2 to the kidneys
 Clubbing of the fingers  due to prolonged hyxia
 Orthopnea
o Right sided  systemic
 Hepatomegaly
 Distended neck veins
 Edema
 Portal hypertension
 Ascites  weight gain
 Varicose veins
o 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
 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
o D – iet  high K diet except aldactone
o I – input and Output  expected increased output
o U – ndesirable effect electrolyte imbalance (K)
o R – ecord weight  expected decreased weight
o E – lderly  special precaution
o T – ake in AM and with food
o I – ncreased orthostatic hypotension  monitor BP and move gradually
o 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
 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 (laennec’s), infection and drugs (post necrotic),
RSCHF (cardiac) and biliary obstruction (biliary)
o 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
o Decreased albumin  decreased oncotic / colloidal osmotic pressure  fluid shifting 
ascites  management high protein diet
o 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
o 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
o Prolactin
 Increased  galactorrhea
 Decreased  decreased milk production
o ACTH
 Increased  secondary cushing’s
 Decreased  secondary addison’s
o TSH
 Increased  secondary hypethyroidism
 Decreased  secondary hypothyroidism
 Posterior pituitary gland
o 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
o 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
 oIncreased (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
o 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
o 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
 Sex hormones
 Males  gynecomastia and falling of hair
 Females  hirsutism and deepening of the voice
o 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
o Type I  absolutely no insulin  thin  insulin
o Type II  insufficient insulin  obese  OHA
o Diet  50% CHO, 30% Fats, 20% CHON
o Exercise  Increased uptake of glucose  Decreased insulin requirement
o Oral hypoglycemic agent (OHA)
 Stimulates pancreas to produce insulin
o 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
o 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)
o DKA  increased lipolysis increased ketones
o Hyperglycemia  polyuria, polydipsia, polyphagia, kussmaul breathing, glycosuria,
ketonuria and warm flush skin
o Glycosylated hemoglobin  reflect BSL for the past 3 to 4 months  most accurate
o Foot care
 Podiatrist
 Avoid removing corns and calluses
 Cut toe nails straight across
 Avoid walking bare foot
 Hepatitis A  fecal oral
 Hepatitis B  body and bloody secretions (hemodialysis)
 Peritoneal Dialysis
o Diasylate output is decreased  turn patient from side to side
o Complication  infection  monitor WBC and temperature, diasylate is cloudy 
boardlike and rigid abdomen  peritonitis
o Don’t include diasylate solution in the output of the client
o Expected  decreased weight  monitor weight before and after  decreased
createnine and BUN
 Heart block  decreased tissue perfusion
 Parkinson’s diasease
o Decreased dopamine in the basal ganglia  levodopa to increased dopamine  avoid
Vit B6 foods
o Cardinals signs  tremors (non intentional)  muscle rigidity  bradykinesia
o Pill rolling
o Microphonia  ask your client to speak aloud to be aware
o Artane and Cogentin  anticholinergic  decreased muscle rigidity
 Myasthenia Gravis
o Tensilon test  confirmatory test
o Decreased Acetylcholine and increased cholinesterase
o Muscle weakness  priority airway
o NO tranquilizer, Morphine SO4, Muscle relaxant and neomycin
o Cholinergics (mestinon)  increased muscle strength  antidote ATSO4
 Undermedication  myasthenic crisis  give cholinergics
 Over medication  cholinergic crisis  give ATSO4
 Multiple Sclerosis
o Demyelinization of the myelin sheath
o Charcoat’s triad
 Intentional tremors
 Scanning of speech
 Nystagmus
o Visual disturbances  diplopia
 Pancreatitis  autodigestion  alcohol  bleeding  shock
o Elevated amylase

 Rheumatoid Arthritis
o No specific diagnostic test
o NSAID’s and ASA (antipyretic, analgesic and anti-inflammatory)
o Synovitis  Pannus formation  fibrous ankylosis (limited joint movement)  Bony
ankylosis (joint fixation)
o Avoid flexion and promote prone position
 Gouty Arthritis
o Increased uric acid  allopurinol and avoid organ meats (liver)  tophi (ears)
 Osteoarthritis
o Most common  related with aging
o 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
o DEATH  inflammation
o 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
o Avoid vomiting, coughing, valsalva maneuver, lifting heavy objects, bending, crying
 Meniere’s  Triad  tinnitus, impaired hearing loss and vertigo  low Na diet
o 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
o BUN = 10 – 20 mg/dl
o Calcium = 9 to 10.5 mg/dl
o Creatinine = 5 to 1.5 mg/dl
o GTT = 70 to 115 mg/dl
o O2 sat = 97 to 98%
 Signs and Symptoms of Increased Intracranial Pressure
o B – lood pressure and temperature are elevated
o R – espiratory and cardiac rate are decreased
o A – lteration of LOC
o I – rritability
o N – ote for projectile vomiting
o S – eizure