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ATI Med Surg - ATI notes

Intro to Professional Nursing (Holy Family University)

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ATI Med Surg

Ch 1 Health, Wellness, Illness

modifiable variables: smoking, nutrition, exercise, health education and awareness, sexual practices
nonmodifiable variables: cant change = age, gender, developmental level, genetics

Ch 2: Emergency nursing principles and management

emergency nursing – triage: based on acuity
 emergent: life threatening
 urgent: not life threatening
 non urgent: can wait for extended time w/o issues

In mass casualty event, tag diff patients – class 1 red tag, class 2 yellow tag, class 3 green tag, class 4 black tag
 class 1: red tag immediate threat to life ex. respiratory issues, cardiovascular issues like chest pain like a heart attack coming on
 class 2: yellow tag are major injuries that require immediate treatment but maybe aren't life-threatening ex. major fracture
 class 3: green tag is indicates a minor injury that does not require immediate attention ex. abrasion, minor laceration so they need to be seen they're
taken care of at some point but it's definitely not a priority in a mass casualty event
 class 4: black tag when theyre expected to die ex. penetrating head wound - you know you're you're allowing them to die because then unfortunately if
you provide your attention to them they are still likely to die so you're going to divert your attention to those red tag and then to the yellow tag pts patient
is not really going to come back

PRIORITIES aka ABCDE:

 Airway: secure airway! head-tilt chin-lift maneuver unless fracture in cervical spine
 Breathing
 Circulation
 Disability: level of consciousness ex. using Glascow Coma Scale
 Exposure: ex. hypothermia then removes wet clothing, give blanket, increase room temp, warm the IV fluids

Poisoning: if accidental or purposeful poisoning, then

1. activated charcoal
2. gastric lavage
3. whole bowel irrigation
- DO NOT induce vomiting
- DO NOT give syrup of ipecac which produces vomiting

Call rapid response team when patient is rapidly declining

Cardiac emergencies: V-fib or V-tach then initiate BLS or CPR and establish IV access. epinephrine to tx. other meds given p15 (Amiodarone, Lidocaine, Magnesium,
Procainamide, Vasopressin – most are antiarrhythmics) p 16 other meds (alpha 1 receptors, beta 1, beta 2, dopamine receptors)
 alpha 1: skin, mucous membranes, veins vasoconstrict
o meds help congestion, superficial bleeding, raise bp
 beta 1: stimulate heart – activation causes increase HR to treat AV block and cardiac arrest
 beta 2: heart and lungs – activation causes bronchodilation (use for asthma) and relaxation of uterine smooth muscle
Dopamine: activation causes renal blood vessels to dilate – use for shock and HF
 if given more triggers beta 1
 if given more triggers beta 1 and alpha 1
 S/E: dysrhythmias, angina
Epinephrine: triggers alpha 1, beta 1, beta 2; vasoconstriction so increases bp, HR, bronchodilation
 S/E: hypertensive crisis, dysrhythmias, angina
Dobutamine: triggers beta 1 so inc HR – use for HF

Ch 3 Neurologic Diagnostic Procedures

Cerebral angiogram: allows the doctor to visualize the blood vessels up in the brain usually insert the catheter either in the groin or the neck then thread your way up
there
 use contrast dye (with contrast dye, always check if pt is pregnant bc toxic; allergies to iodine or shellfish; renal function, BUN, creatinine to see if elevated
bc if elevated and renal fxn compromised then dye wont be excreted well and can build to toxic levels; pt on anticoagulant bc bleeding risk can increase so
refrain from eating or drinking 4-6hrs prior to procedure and after procedure monitor for bleeding; check insertion site frequently; check pulses distally
from insertion site and make sure circulation is good)
CT scan: contrast dye
EEG: detect seizures or test for sleep disorders and behavioral changes –
 do not have to fast prior
 tell pts to wash hair prior
 be sleep deprived bc the stress can actually trigger seizures or other abnormal brain activity.
 might also expose pts to bright flashing lights or ask them to hyperventilate in order to create activity in brain
 1 hour
Glascow Coma Scale: determine LOC
 highest score 15
 anything less than 8 is associated with severe head injury and coma
 eye opening (1-4), verbal response, motor response
 4 is your best score eyes open spontaneously; 3 if your eyes open to voice commands and you get a 2 if it opens to pain and you get a 1 if you don't open
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 verbal response highest level is 5 conversation is coherent and oriented you get a 4 if conversation is incoherent and disoriented you get a 3 if words are
spoken but inappropriately so they're kind of like garbage and then you get a 2 if sounds are made but there are no words at all and then you get a 1 if
they don't have any vocalization at all
 motor response highest score 6 if they follow your commands they get a 5 if they have a local reaction to pain and they get a 4 if there is a general kind of
withdrawal from pain 3 is for decorticate posturing and then 2 is for decerebrate posturing and then 1 is for like no motor response at all
o decorticate: you're gonna have adduction of the arms and then flexion of the elbows and wrist - flexing those elbows and wrist kind of towards
your core which is how I remember that as decorticate
o decerebrate: extension of your elbows and wrists out versus the flexing
 inter-cranial pressure and ICP monitoring: invasive, for scores 8 and below
o high risk of infection with devices monitoring ICP
o devices which are placed by neurosurgeon are interventricular catherer, subarachnoid screw or bolt, epidural or subdural sensor
o increased ICP: irritability, severe headache, decreased LOC, issues with pupil response, Cheyne-Stokes breathing, abnormal posturing
(decorticate, decerebrate)
o NORMAL ICP 10-15mmHg
lumbar puncture: withdraw a small amount of cerebral spinal fluid to test for certain infections and diseases like meningitis and syphilis
 empty bladder
 lay on side like a cannonball
 apply local anesthetic then insert needle - monitor puncture site
 after procedure, have pt lay flat for several hours
 if no clotting occurs to seal the dura puncture site then cerebral spinal fluid may leak and pt may get spinal headache and need epidural blood patch to
seal hole
 give opioids/pain meds
 increase fluid intake
MRI: may use contrast dye but assess for shellfish allergy; remove jewelry; check for claustrophobia (may need sedation); check for implants containing metal such as
pacemaker orthopedic joints artificial heart valves inner uterine devices or aneurism clips; give ear plugs
PET: nuclear medicine procedure that checks for tumor activity
X-rays: sometimes used with diagnosing neurological issues just bc fractures curvatures dislocations can damage neuro system

Ch 4 pain management
acute pain: temporary, protective and usually resolves with tissue healing
chronic pain: past 6 months & associated with depression, fatigue, and decreased level of functioning
nociceptive pain: damage or inflammation of tissue, throbbing, aching, LOCALIZED
1. somatic: bones, joints, muscles, skin, connective tissue
2. visceral: internal organs or viscera
3. cutaneous: skin or subcutaneous tissue
neuropathic pain: abnormal or damaged pain nerves ex. diabetic neuropathy or phantom limb pain; shooting, burning, pins and needles
 treat with muscle relaxants, antidepressants, or antispasmodic agents
PQRST
 pain location
 quality: dull, sharp, throbbing
 radiating
 severity or intensity: pain scale 1-10
 timing: when did pain start, frequency, duration of pain
 setting: how it affects daily life, what are they doing when symptoms occur
 aggravating v relieving symptoms
nonpharmacological methods:
 imagery acupunctures, relaxation techniques such as transcutaneous electrical nerve stimulation, the application of heat or cold can help with pain,
therapeutic touch or massage
pharmacological methods: pain level 1-3 is mild; 4-6 moderate; 7-10 severe – mild or moderate then NSAIDs, aspirin, salicylates
 NSAIDs: meloxicam, ibuprofen, aspirin, celecoxib, diclofenac, indomethacin, ketoprofen, piroxicam, naproxen
 NSAIDs S/E: gastric upset, bleeding
o aspirin S/E: tinnitus, vertigo, decreased hearing, acid reflux, gastric upset, monitor bleeding time
 acetaminophen: watch for >4g hepatotoxicity – do not give additional Tylenol if taking Vicodin/hydrocodone or/and Percocet/oxycodone
opioids: moderate to severe pain – morphine, hydromorphone (Dilaudid), fentanyl, hydrocodone (Vicodin), oxycodone (Percocet), tramadol, meloxicam
 fentanyl mostly cancer pain or end of life pain
 around the clock on schedule as opposed to PRN – get ahead of pain!
 S/E: constipation, orthostatic hypotension, urinary retention, nausea, vomiting, sedation, respiratory depression
 Narcan/naloxone: reversal agent - when respirations get too low

Ch 5 meningitis
Meningitis: inflammation of the meninges which are membranes that surround the brain or spinal cord – viral or bacterial – viral more common and self resolved –
bacteria is deadly and more dangerous and contagious, requires administration of antibiotics to resolve
 Hib vaccine, meningococcal MCV4 vaccine (when teens – crowded dorm rooms are risk factor)
 symptoms: excruciating headache, stiff neck, photophobia (no bright lights!), fever and chills, N/V, altered level of consciousness, positive turning sign
 positive turning sign and positive brooding skin
 tachycardia, seizures, red macular rash, increased intracranial pressure (keep head of bed elevated 30deg, discourage coughing/sneezing/straining),
irritability
 CSF will look different depending if viral (clear) or bacterial (cloudy)
 increased WBC, elevated protein for both bacterial and viral
 bacterial meningitis: cloudy, decreased glucose
 interventions: droplet antibiotics for 24h then standard, quiet room, HOB 30 degrees, avoid coughing and sneezing, seizure precautions

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 meds: antiseizure, steroids, pain meds

 complications:
o SIADH (inappropriate antidiuretic hormone) – monitor for conentrated urine, dilute blood
o septic emboli

Ch 6 seizures
seizures: abrupt and abnormal uncontrolled electrical charge, decrease LOC, motor and sensory changes
epilepsy: abnormal brain electrical activity and more chronic
causes:
 fever esp under 2y
 genetic
 head trauma, cerebral edema, meningitis, hyponatremia, hypoglycemia, exposure to toxins, brain tumor, hypoxia, drug or alcohol withdrawal, fluid or
electrolyte imbalance
triggering factors: excessive stress, overwhelming fatigue, excess caffeine, flashing lights
types:
 generalized or tonic-clonic
o tonic: maybe aura then stiffening of muscles and loss of consciousness
o clonic: 1-2min + jerk movements of extremities back and forth
o after: confusion, sleepiness
 absent: school-aged children, loss of consciousness lasting a few seconds, spacing out or not paying attention, blank stare, smacking of the lips, eye
fluttering
 myoclonic: brief jerking and stiffening or extremities
 atonic: no tone, usually falling down bc no muscle tone
seizure nursing interventions:
 gently lower them to ground,
 put them on side to prevent aspiration,
 move furniture,
 loosen restrictive clothing,
 do NOT restrain client,
 do NOT put anything in their mouth (no tongue blade, no airway)
- document onset, duration keep in sideline position, check vitals, reorient patient, put on seizure precautions
- meds: antiepileptic (ex. Phenytoin)
- Phenytoin: check lab work bc oral gum overgrowth/gingival hyperplasia, dec effectiveness of oral contraception, warfarin/coumadin
- vagal nerve stimulator inserted (avoid MRI and microwave ovens)
- surgical removal of brain tissue that is causing seizure

- status epilepticus: complications of seizures – prolonged seizure that occurs over 30 minutes so protect airway, establish IV access, EKG monitoring, pulse ox –
Valium, Diazepam, Lorazepam, Phenytoin

Ch 7 Parkinsons disease
affects motor function in your body – balance between dopamine and acetylcholine and in Parkinsons the Ach is too high and dopamine is too low bc substantia nigra
degenerates – Ach overstimulates basal ganglia
symptoms: tremor, muscle rigidity, bradykinesia, postural instability, slow and shuffling type of gait, mask like facial expression, difficulty chewing and swallowing
(careful with aspiration of drool), difficulty with ADLs, mood swings, cognitive impairment
no definitive diagnostic procedure but based on symptoms
nursing care: monitor swallowing, suction available, maintain adequate nutrition, thicken foods, encourage exercise and ROM, yoga, slow walk to reduce risk of
injury, speak slowly, alternate forms of communication
meds: Levodopa (to increase dopamine), Benztropine (anticholinergics to decrease Ach)
complications: pneumonia, aspiration (eat upright, suction equipment, thickening foods)

Ch 8 Alzheimer’s
after age 65
memory loss, personality changes, problems with judgement
risk factors: old age, exposure to metal or toxic waste, herpes virus, previous head injury, genetic predisposition
7 stages – know key points
1. no impairment
2. very mild cognitive decline – little forgetful
3. mild cognitive decline w/ short-term memory loss evident to loved ones
4. moderate cognitive decline w/ personality changes, obvious memory loss
5. moderately severe cognitive decline w/ ADLs help
6. severe cognitive decline w/ frequent episodes of fecal and urinary incontinence
7. very severe cognitive decline w/ loss of ability to speak and move, not able to eat w/o assistance, difficulty swallowing, speech unrecognizable – no
definitive diagnostic
nursing interventions: reorient client, simple calendar w/n clients view, simple short directions w/ consistency and repetition, avoid over stimulation and try to stick
to a routine including routine toilet schedule, you can change schedule but gradually
home safety: no scattered rugs, install door locks that cant be easily opened, good lighting, colored tape at the edge of stairs, remove clutter, mattress on floor
medicine: Donepezil (increases Ach by preventing breakdown, improve cognitive behavior and function)

Ch 9 Tumors
brain tumor: hypothalamus in brain damaged and pressure from tumor, will lead to SIADH or diabetes insipidus

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Ch 10 MS, ALS, Myasthenia gravis

MS: autoimmune disorder, plaque in white matter of the CNS which damages the myelin sheath which interferes with impulse transmission, chronic, no known cure,
usually 20-40y, more common in women, periods of relapsing and periods of remitting
triggers: viruses, too hot or too cold, physical injuries, stress, pregnancy, fatigue
hot baths and showers help
symptoms: DIPLOPIA (double vision) or decreased visual acuity, NYSTAGMUS, TINNITUS/ringing or decreased hearing acuity, dysphagia, slurred and nasal speech,
muscle spasticity and muscle weakness, bowel dysfunction, urinary incontinence, impaired judgement and memory loss, sexual dysfunction
MRI will show plaques in brain and spine
meds: Cyclosporine (immunosuppressive agent) to reduce frequency of relapses, Prednisone (immunosuppressive and anti-inflammatory), muscle relaxants such as
Dantrolene and Baclofen to tx muscle spasticity

ALS: degenerative neurological disorder of upper and lower motor neurons, progressive paralysis starts extremity and moves up towards center of body and affects
respiratory muscles which causes resp failure and then death (w/n 3-5y of onset of symptoms), unknown cause, no cure
COGNITIVE NOT AFFECTED
symptoms: muscle weakness and atrophy, difficulty swallowing, respiratory
nursing: keep patent airway, suction patient and intubation as necessary
meds: glutamate antagonist to help deterioration of motor neurons
complications: pneumonia, resp failure

Myasthenia gravis: autoimmune disorder, muscle weakness d/t antibodies that prevent uptake of Ach at neuromuscular junction; periods of exasperation or
remission d/t fatigue, illness, pregnancy, hot water, infection, hyperplasia of thymus glands
symptoms: muscle weakness, diplopia, difficulty chewing and swallowing, resp function, bowel and bladder dysfunction like incontinence, drooping eyelids
diagnosis: mimic cholinergic crisis! so give pt Edrophonium (Tensilon) which increases Ach if symptoms improve then it was MG, if worsen then it was cholinergic
crisis. Have Atropine on hand bc antidote for Tensilon and if having cholinergic crisis
nursing: patent airway, small frequent high calorie meals, pts sit upright, add thickeners to foods to swallow more easily, lubricating eyedrops bc trouble closing and
blinking eyes and you may need to patch or tape eyelid shut to prevent damage to cornea
meds: Pyridostigmine and Neostigmine to improve muscle strength and inhibit break of Ach, immunosuppressants, plasmapheresis which removes antibodies,
thymectomy

Ch 11 headaches
migraine headaches and cluster headaches
both can be triggered by environmental factors such as allergens, intense odors, bright lights, fatigue, anxiety, stress, hormone changes like menstrual cycle, foods
with tyramine or MSG or nitrites or dairy

migraine: photophobia, sensitivity to loud noises, N/V, UNILATERAL pain usually behind one ear and behind eye
family history, typically 4-72hrs, some ppl get with aura which is like visual disturbance such as flashing lights or tingling of mouth or lips
nursing: cool dark quiet envt, elevate head 30 degrees, NSAIDs, mild antiemetic
for severe: Sumatriptan for vasocontriction to decrease pain; Ergotamine to narrow blood vessels and reduce inflammation for pain

cluster headaches: brief episodes of intense unilateral non throbbing pain that lasts 30min to 2 hrs – intense, NOT throbbing, and happens for SHORTER time. Usually
daily at same time for about 4-12 weeks and usually spring and fall – no aura, no warning signs. Less common than migraines, usually in MEN between 20-50y
symptoms: tearing of eye, RUNNY NOSE, NASAL CONGESTION, drooping eyelid
meds: triptans, ergotamine, NSAIDs

Ch 12 eye disorders
macular degeneration: CENTRAL vision loss over 60y (aging)
types: dry or wet
symptoms: blurred vision, loss of central vision which can cause blindness, no cure
nursing: eat foods high in antioxidants, carotene, vitamin E, vitamin B12; refer pt to community resources to help with ADLs

cataracts: opacity in the lens of the eyes that impairs vision, decreased visual acuity, blurred vision/diplopia, glare and light sensitivity, halo around light.
PROGRESSIVE and painless loss of vision
assessment: no red reflex
care: surgery to remove lens of eye and put replacement lens, correct refractive errors
education post surgery: wear sunglasses outside, report signs of infection including yellow or green discharge, avoid activities that increase intraocular pressure, do
not bend at the waist, avoid sneezing or coughing, avoid hyperflexion head, avoid tilting head when washing hair or anything else, avoid housekeeping and cooking or
rapid jerky movements, avoid driving and sports, avoid carrying over 10 pounds
expect results 4-6 weeks after surgery

glaucoma: optic nerve

1. open angle: decreased aqueous humor outflow d/t partial blockages in eyes drainage system
a. symptoms: mild eye pain, loss of peripheral vision, elevated IOP (normal IOP 10-21 mm Hg)
2. closed angle: complete blockages, IOP rises suddenly – leading cause of blindness
a. symptoms: severe pain, nausea, photophobia, rapid onset of elevated IOP, halos around light, blurred vision
measure IOP
nursing: meds every 12hrs, wait minutes before administering 2nd drops in eyes, don’t touch eye, put pressure on inner corner of eye to allow to absorb
meds: Pilocarpine (constricts pupil), beta blockers, mannitol (diuretic to decrease IOP), Acetazolamide (diuretic for dec IOP)
education: limit activities that increase IOP like bending at wasit, putting head back, straining, coughing, sneezing

retinal detachment: floating dark spots

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Ch 13 ear disorders
otitis media (middle ear): risk factors are recurrent colds, respiratory infections, enlarged adenoids
symptoms: red and inflamed ear canals and tympanic membrane and its bulging and maybe fluid or bubbles behind it

Meniere’s disease: inner ear disorder with 3 main symptoms 1) tinnitus 2) unilateral hearing loss 3) vertigo
inner ear risk factors are viral or bacterial infection which can damage d/t autotoxic meds
symptoms: tinnitus, vertigo, alterations in balance, vomiting

kids: pull down and back

adults: pull up and back

ototoxic meds: gentamycin, metronidazole, furosemide, chemotherapy agents, anticholinergics, antihistamines for vomiting/tinnitus, droperidol for N/V
teaching: avoid caffeine and alcohol, if having severe vertigo then rest and quiet dark envt, space intake of fluids, dec salt intake

Ch 14 head injuries
stabilize cervical spine if in car accident until cervical injury ruled out, assess for increased cranial pressure - high ICP: severe headache, deteriorating level of
consciousness (can do Glascow Coma Scale) – IRRITABILITY one of the 1st signs of high ICP, non reacting or fixed pupils, Cheyne-Stoke breathing or apnea, Cushing’s
Triad (increased ICP resulting in triad of increased bp, irregular breathing, bradycardia)
another sign of head injury or inc ICP is leakage from nose or ears that stains sheets like halo or blood surrounded by yellow which is cerebral spinal fluid
ABC: always check breathing and maintain airway
other factors for inc ICP: high CO2 (normal 35-38) so hyperventilate the pt to avoid hypercapnia, avoid suctioning, have pt blow nose, give stool softeners, make sure
catheter isn’t kinked to avoid inc abdominal pressure, maintain bed less than 30 degrees, avoid neck flexing or extending, no restrictive clothing
meds: mannitol – pay attention to electrolyte imbalance, pentobarbital – decreases metabolic demands, phenytoin anticonvulsant to prevent seizures, morphine or
fentanyl for pain
surgery: craniotomy and have bed 30 degrees if supratentorial surgery but FLAT on either side if infratentorial surgery to prevent pressure on that incision site
complications: brain herniation – dilated pupils, dec LOC, irregular respirations, abnormal posturing – pt can get diabetes insidipus or SIADH d/t pressure against
hypothalamus, cerebral salt wasting which can cause hyponatremia or hypovolemia d/t pressure against hypothalamus which is caused by cerebral edema or
hemorrhaging or hematoma

Ch 15 strokes
stroke = cerebral vascular accident
3 types:
1. hemorrhagic: ruptured artery or aneurysm
2. thrombotic: development of blood clot in cerebral artery
3. embolic: blood clot travels to another part of body and ends up in cerebral artery causing the lack of blood flow to the area
risk factors: hypertension, diabetes, smoking, a fib, hyperlipidemia, obesity, lack of physical activity
symptoms: visual disturbances, dizziness, slurred speech, facial drooping, weak extremity or one side of their body becomes weak

*know differences between left and right side strokes

LEFT side symptoms: deficit in LANGUAGE, math, and analytical thinking so expressive and receptive aphasia (inability to speak and understand), difficulty reading or
writing, RIGHT extremity hemiplegia/hemiparesis, hemianopsia (loss of visual field in 1 or both eyes)

RIGHT side symptoms: visual and spatial awareness, poor impulse control and judgement, one sided neglect syndrome which they ignore left side of body, LEFT
hemiplegia/hemiparesis

***LEFT LANGUAGE, RIGHT RECKLESS****

ischemic stroke if systolic over 180 or diastolic over 110, dysphasia – check for gag reflex, speech therapy, thicken foods, sit upright, swallow with neck slightly
forward
teaching: neck forward and flex to be able to swallow, reposition to avoid one sided tissue injuries, prop them up on pillows, heel protector boots, provide safe envt
homonymous hemianopsia: loss of visual field – scanning technique where they turn head from direction of unaffected side to affected side when eating or
ambulating
meds: antiplatelets, anticoagulants, thrombolytics (-plase) give w/n 4-5hrs of initial symptoms of stroke
surgery: carotid artery angioplasty with stent to help retrieve clot and open up carotid artery

Ch 16 spinal cord injuries

injury to cervical region = quadriplegia
injury below T1 = paraplegia
in addition, injury above C4 = respiratory issues d/t phrenic nerve involvement – may need to intubate, mechanical ventilation
other symptoms: inability to feel light touch, differentiate between sharp and dull touch, absent deep tendon reflexes, flaccid muscles, hypotension, neurogenic
shock which causes total loss of voluntary and autonomic function with hypotension, dependent edema, loss of temp regulation from there transitions
 injury to upper motor neurons above L1/L2 will convert to spastic muscles - spastic neurogenic bladder
 injury to lower motor neurons so this is below the level of L1/L2 they will convert to a flaccid type of paralysis and so this carries over to their bladder also
-> flaccid neurogenic bladder
interventions: give that patient daily stool softeners, maintain schedule about urine elimination, may need to do intermittent catheterization
medications: glucocorticoids which is a steroid that helps decrease edema of the spinal cord, vasopressors especially during that neurogenic shock period because
they have that hypotension so things like norepinephrine and dopamine, muscle relaxers for those with spastic muscles ex. Baclofen and Dantrolene
complications: orthostatic hypotension - change the client's position slowly and you may need to give them some thigh-high elastic hose to help with that orthostatic
hypotension. If hypotension give vasopressors; if bradycardia then Atropine; autonomic dysreflexia = injury above the level of T6 (extreme hypertension, sudden
severe headache, pallor, blurred vision and diaphoresis)

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 autonomic dysreflexia: find out CAUSE. autonomic dysreflexia happens because the sympathetic nervous system takes over with inadequate
compensation from the parasympathetic nervous system - you want to sit the client up, you're going to want to notify the provider right away, you're
going to want to check for a distended bladder so if they have a catheter you want to check for kinking, check for fecal impaction and if they're impacted
you may need to get in there and pull that out, check for tight clothing and loosen – give antihypertensives

Ch 17 ABGs
ABG is basically taking arterial blood from the patient's wrist here prior to the blood draw the respiratory therapist who is usually the one who
does the ABG draw should check and do Allen’s Test (compress the ulnar and radial arteries simultaneously and then let one or the other go to determine the
patency of those arteries) prior to doing the blood draw
 Allen’s test is performed prior to the ABG – hold pressure to that site a little longer than you would for like a venous puncture like five minutes normally if
the patient is on blood thinners then you'll need to hold it a little longer like maybe like 20 minutes
 complications: hematoma, air embolism (position that patient on their left side in a Trendelenburg position; symp include shortness of breath, chest pain,
anxiety, air hunger)
bronchoscopy: visualize the lungs for biopsy, remove excess fluid, remove lesions
 patient should be NPO for 8 to 12 hours***
 prior to the procedure you may be asked to administer viscous Lidocaine or some kind of local anesthetic throat spray
 Atropine to reduce secretions
 after the procedure you're gonna want to make sure that their gag reflex returns before you give them anything to eat or drink (~two hours)
 normal findings after procedure: blood-tinged sputum, a dry cough, sore throat
 unexpected findings: bronchospasm and their airway closing
thoracentesis: perforate the chest and you go into the pleural space and you either obtain a specimen, instill medication, or remove
fluid in most cases you're removing fluid or effusion from that pleural cavity
 symptoms: shortness of breath, cough, chest pain
 sit upright and make sure that their arms and shoulders are supported either on pillows or on an over bed table, remain absolutely still during the
procedure to guide that needle into the pleural cavity, amount of fluid that they can remove in one session is limited to 1L if you go over it can result in
cardiovascular collapse, monitor the client's respiratory status very carefully usually hourly for the first several hours at least
 complications: mediastinal shift, bleeding, infection, PNEUMOTHORAX (collapsed lung – symptoms: deviated trachea, pain on the affected side, unequal
movement of chest with inspiration and exhalation or asymmetry, air hunger, tachycardia, very shallow rapid respirations), bleeding internally which can
end up in hypotension, infection

Ch 18 chest tubes
use chest tube if in the pleural space of the patient there's some excess blood, fluid, or air
pneumothorax or excess air in that pleural space the tip of the chest tube will face UP and towards the shoulder
hemothorax or a plural effusion so either blood or excess fluid the tip of the chest tube would be pointed DOWN and towards the posterior
TIP: air rises so it'll be pointing up where as the fluid or blood will settle so that's why the typically pointing down

chest tube: three chambers

1. water seal chamber for drainage collection: 2cm of sterile water which lets excess air come out of the chest out of the pleural space but does not let air go
back pleural space when the patient inhales – tidaling is good – bubbling is bad (bubbling indicates air leak)
2. suction control chamber: pressure of -20cm is most common - be either dry or wet suction, continuous gentle bubbling is good
nursing care: cough and deep breathe every TWO hours, check the water seal level every TWO hours and add fluid if you need to, document the amount and color of
the drainage in the collection chamber HOURLY for the first 24 hours and then at least every eight hours after that so you want to like make a mark on the actual
chest tube apparatus about like at the end of your shift or every eight hours and put the date at the time
***excess drainage: greater than 70 milliliters an hour then contact the provider!!
position the patient upright in a semi or high Fowler's position which helps for lung expansion and drainage of the fluid from the lungs right after the procedure -> x-
ray to ensure that it is placed properly
supplies: enclosed hemostats, sterile water, occlusive dressing
chest tube should only be clamped when ordered by a provider and they're usually done in the case of a suspected air leak or something like that but you never
clamp it yourself without an order and you never strip and never do milk tubing

chest tube drainage system is compromised you can immerse the tip of the tube into sterile water to restore the water seal so if something's not going right with the
unit you can put tip into sterile water to kind of maintain that seal
if the chest tube is accidentally removed from the patient which happens you want to put an occlusive dressing taped on only THREE sides** - you're NOT gonna tape
it on four sides - this allows air to escape and reduces the risk of a tension pneumothorax or use dry dressing
 tension pneumothorax: a kink in the tubing or prolonged clamping of the tubing can cause it - symptoms include tracheal deviation, absent breath sounds
on affected side, respiratory distress, asymmetry of the chest
deep breathe exhale and bear down as the chest tube is being removed, apply airtight sterile petroleum jelly gauze dressing

Ch 19 oxygen and mechanical ventilation

nasal cannula: 1-6 L/min
face mask: 1-6 L/min
partial rebreather mask: 6-11 L/min - not let the reservoir bag deflate fully - adjust the oxygen flow rate to keep it inflated
non-rebreather mask: 10-15L/min - reservoir bag should be 2/3 full and you should perform hourly assessments of the valve and the flap
venturi mask: most precise oxygen concentrations**
aerosol mask or face tent: trauma or burn

EARLY hypoxia: TACHYpnea, TACHYcardia, restlessness, pale skin, HYPERtension, respiratory distress which can be use of accessory muscles, nasal flaring, or
adventitious lung sounds
LATE hypoxia: confusion, stupor, cyanotic skin, BRADYpnea, BRADYcardia, HYPOtension, cardiac dysrhythmias
oxygen toxicity risk: non-productive cough, substernal pain, nasal stuffiness, nausea, vomiting, headache, sore throat and eventually hypoventilation
 keep at lowest

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 normally you're trying to keep people's oxygen between 95-100% but for COPD ok to have at 92%**

no smoking, wear cotton clothing, as opposed to synthetic or wool fabrics which can generate static electricity, no volatile flammable materials

Non-invasive ventilation is the use of airway support administered through a face mask instead of an endotracheal tube
1. CPap: for pt with sleep apnea
2. BPap: sleep apnea but often used to wean a client from a ventilator or prior to putting him on a ventilator they might have amount up by patch
suction the clients tube to clear any secretions out of the airway, frequent gentle skin and oral care, manual resuscitation bag with a face mask and oxygen readily
available at the bedside
after they're extubated you're gonna want to encourage them to cough and deep breathe you're gonna want to monitor their O2 - and their vital
signs like every 5 minutes right after extubation
change positions frequently, cough, deep breath, incentive spirometry to get rid of secretions in lungs

ventilator alarms: difference between low pressure alarms and high pressure alarms what can cause those things so a
low pressure alarm can be caused due to a disconnection, a cuff leak, or tube displacement
 HIGH kink, LOW leak
**high pressure alarm can indicate excess secretions, the client may be biting on the tube, kink in the tubing, the client may be coughing, pulmonary edema,
bronchospasm or a pneumothorax

Ch 20 rhinitis and sinusitis

rhinitis is basically inflammation of the nasal mucosa and it causes a runny nose and congestion it's often due to either an infection either viral
bacterial or allergens
 fluid intake, humidifier, proper cough etiquette like coughing into their shoulder, hand hygiene
 meds: histamines or
 same things apply to sinusitis except for if you have an infection then they're going to treat you with antibiotics as well

influenza: highly contagious viral infection - a severe headache, muscle aches, fever, chills, diarrhea nausea vomiting
treated somewhat with antivirals like Tamiflu but those have to really be started within 24 to 48 hours of the onset of symptoms if it's after that then its effectiveness
is really diminished ---- flu vaccine vaccinations are recommended for anyone over six months of age

pneumonia: if older pts has CONFUSION then can be infection so older people when they get like UTIs pneumonia any other kind of infection kind of the first thing is
that they get really confused
symptoms: fever, chills, shortness of breath, difficulty breathing, sharp chest pain, may hear crackles and wheezing, cough
lab tests: sputum sample - obtain that sample before you start antibiotic therapy to adjust the therapy depending on what the sample comes back with
chest x-ray: show consolidation in the lungs and then possibly if a patient does have pneumonia if you take their pulse ox they'll show readings that are below 95%
high Fowler's position so like 90 degrees that helps them breathe
encourage coughing and deep breathing like mobilize those secretions
O2 and incentive spirometer (breathe in once you suck in you want to kind of hold your breath at the top there for 3-5 seconds before slowly exhaling)
patient will need some additional calories, 2-3L fluid, antibiotics, bronchodilator such as Albuterol, anti-inflammatories such as glucocorticoids (ex. Prednisone)
 with steroids, monitor black tarry stools which can indicate GI bleed, fluid retention, weight gain, canker sores, hyperglycemia d/t dec immunity

Ch 21 asthma
asthma = chronic inflammatory disorder of the airways that is intermittent and reversible
symp: wheezing coughing prolonged exhalation a decreased oxygen saturation barrel chest
dx: pulmonary function tests
peak flow meter with your patient you want to take the highest value out of the three readings (do 3 times)**
sit them upright in a high fowler's position, O2, bronchodilator such as Albuterol (short acting S/E: increased heart rate and some tremors), anticholinergic
Ipratropium (S/E: dry mouth so suck on candies and drink fluids), Theophylline, long-acting beta 2 agonist Salmeterol to prevent but not treat attack, anti-
inflammatories such as glucocorticoids, leukotriene antagonist Singulair
life-threatening episode of airway obstruction can occur which is called Status Asthmaticus - administer oxygen bronchodilators and maybe epinephrine

Ch 22 COPD
a. Emphysema: loss of lung elasticity and hyperinflation of the lung tissue this causes destruction of the alveoli and retention of co2 in the lungs
b. Chronic bronchitis: inflammation of the bronchi
IRREVERSIBLE
risk factors: cigarette smoking, advanced age, exposure to polluted air, alpha-1 antitrypsin deficiency
symp: dyspnea, crackles or wheezing, rapid and shallow respirations, may use their accessory muscles, nasal flaring, may have barrel chest; percussion you may hear
hyperresonance and that is due to the air trapping, dependent edema this is due to right-sided heart failure (distended neck veins, enlarged liver) which can be
caused by COPD, clubbing of fingers, pulse ox below 95% normal (pulse ox 91 or 92 expected)
labs: increased hematocrit level, paO2 <80 and paCO2 >45 (resp acidosis)
nursing: sit the patient up high Fowlers include encourage coughing and deep breathing, incentive spirometer, high calorie high protein
ABDOMINAL BREATHING: lay on their back bend their knees put their hands on their stomach and really take deep breaths from the diaphragm
PURSED LIP BREATHING it's where they breathe in slowly through the nose and then out through their pursed lips
meds: bronchodilator such as Albuterol (S/E: increased heart rate and some tremors), anticholinergic Ipratropium (S/E: dry mouth so suck on candies and drink
fluids), Theophylline, anti-inflammatories such as glucocorticoids, leukotriene antagonists, Acetylcysteine, mucolytic agents such as cough suppressants
complications: respiratory infection and they may end up with right-sided heart failure (d/t air trapping associated with COPD this leads to increased pulmonary
pressures and then this in turn leads to dependent edema an enlarged and tender liver and distended neck veins)

Ch 23 Tuberculosis
AIRBORNE - negative airflow room, n95 mask
risk factors: crowded environment such as a prison or a long-term care facility, low socioeconomic status, immunocompromised

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screen pts: more than three weeks so persistent cough, unexplained weight loss, tired and lethargic, night sweats, purulent sputum
10mm or bigger that is a positive skin test for TB OR compromised immune system such as the chemo patient or somebody with AIDS or HIV then 5mm in duration is
positive
patients international patients typically who have received the BCG vaccine this can cause a false positive - x-ray will likely be ordered which will detect active lesions
in the lungs you can also test their sputum to see if there's acid-fast bacilli (early morning sputum and you want to collect three different samples)
four or more medications for a prolonged period of time for 6-12m – RIPE meds! Rifampin, Isoniazid, Pyrazinamide, Ethambutol
 Rifampin: hepatotoxicity, orange secretions
 Isoniazid: hepatotoxicity, neurotoxicity
 Ethambutol: vision problems
can also give Streptomycin (S/E: ototoxicity)
sputum sample every 2-4 weeks then once they have three negative sputum cultures they are considered no longer infectious

Ch 24 Pulmonary embolism
liquid gas or solid that enters the venous circulation goes into the lungs and blocks blood flow into the lungs
the most common cause of a PE is a DVT
risk factors: oral contraceptive, birth control pills, estrogen therapy, tobacco, obesity, medical situation that causes hypercoagulability, surgery or had a fracture in the
in a long bone, atrial fibrillation
symptoms: anxiety, dyspnea, tachycardia, HYPOtension, tachypnea, PETECHIAE
labs: d-dimer levels are elevated
meds: Enoxaparin (Lovenox), Heparin (monitor PTT), Warfarin (Coumadin) (monitor PT/INR 2-3) - prevent the clot from getting bigger and prevent new clots from
forming however it will not break down that existing clot that's what we're going to use thrombolytic therapy for such as Alteplase (-plase) or Streptokinase (very
slowly in order to prevent hypotension)
warfarin: mobility, wear compression stockings, don’t cross legs, consistent Vit K intake (dark leafy greens), avoid aspirin products, use electric shavers, soft-bristled
toothbrushes, avoid blowing their nose too hard

Ch 25, 26 skip

Ch 27 Cardiac
elevated Troponin T and I elevated levels indicate myocardial infarction
 normal troponin levels 0.00-0.4
 elevated levels will be seen after about three hours but they stay elevated for much long time - troponin I levels will stay elevated for one week whereas
troponin T levels will stay elevated for two to three weeks
elevated myoglobin: myocardial infarction or skeletal muscle damage - first to rise in the bloodstream following an ischemic event so after two hours you'll see
elevated myoglobin levels and that's the quickest out of all of these enzymes but only stays elevated for 24hrs
creatine kinase MB more specific to heart
overall cholesterol level should be under 200
HDL normal level 35-70
LDL normal level <130
triglycerides normal levels <150

echocardiogram: determine the ejection fraction of the heart and it is non-invasive stress testing this is where you could do the stress test one of two ways you can
put the patient on a treadmill and get their heart rate up while they're hooked up to a 12-lead EKG or you can do pharmacological stress testing this is where you give
them a medication such as adenosine to raise their heart rate up while they're hooked up to their EKG
 fast 2 to 4 hours before the procedure they should
 avoid tobacco alcohol and caffeine before the test

hemodynamic monitoring: mostly in the ICU - special indwelling catheter and an arterial line or an a-line and you're monitoring a lot of different pressures in their
system including central venous pressure pulmonary artery pressure pulmonary artery wedge pressure all of those things so the main thing I would really know I
would know the expected values for central venous pressure CVP 1-8 mm
 CVP, pulmonary artery pressures, and wedge pressure are all elevated and their cardiac output is down then that would be indicative of something like
heart failure
a-lines: level the transducer with the phlebostatic access at the fourth intercostal space mid-axillary line, zero the system after you get these lines placed, have a chest
x-ray to confirm catheter placement

coronary angiogram: look at the coronary artery for blockages so they will thread a catheter usually in from the femoral artery but sometimes they can use the
brachial artery up into the coronary artery – invasive –
 NPO for 8 hrs
 no iodine or shellfish allergy d/t contrast dye
 assess renal fxn Bun and creatinine to excrete dye
 post op: monitor their vital signs very frequently every 15 minutes for the first hour then every 30 minutes for the next hour and then every hour for the
next four hours
 LIE FLAT ON BED 4-6 HRS AFTER
 monitor that groin site where they inserted the catheter for bleeding
 make sure that pressure dressing is in place and not bleeding
 check pedal pulse, temp, color frequently to make sure blood flow is happening
give pt antiplatelet or thrombolytics, give pts IV fluids to flush dye
if they've received a stent then the patient will likely be on anti coagulation therapy for six to eight weeks
complication: cardiac tamponade (built up of fluid) – hypotension, jugular vein distension, muffled heart sounds, paradoxical pulse (variance 10mmhg or more when
inhaling and exhaling on systolic) – need pericardiocentesis where they drain the fluid out from that space

CENTRAL LINES:

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1. non tunneled or tunneled percutaneous central catheter

2. PICC line– in place up to a year; long-term antibiotics (ex. vancomycin), TPN, some chemotherapy agents - inserted into the arm and then threaded up to
the superior vena cava and it rests right into the into the lower 1/3 of the superior vena cava - x-ray afterwards to ensure proper placement
a. assess every 8 hrs
b. 10 ml syringe or LARGER to access that line and to flush that line you do not want to use a smaller syringe as that creates two higher pressure in
the in the catheter – BEFORE, BETWEEN, AFTER meds
c. blood sample you want to withdraw 10 milliliters of blood from the PICC line and discard it and then withdraw 10 milliliters of blood for the
sample and then you want to flush with 20 milliliters of normal saline
d. NO BLOOD PRESSURE ON ARM
3. implanted port: usually chemotherapy, non coring Huber needle (chest)**
IV complications:
 phlebitis (warmth, pain, erythema, edema, induration or cord like vein, hardening of vein or red streak – d/c, remove catheter, warm compress)
 infiltration: (swelling around the site, edema, taut, puffiness, sensation of coolness – d/c, hot or cold compress, elevation)
 catheter thrombosis/embolis (coagulates and causes an occlusion you never want to force fluid into like if if it's resisting there may be an emboli and you
don't want to dislodge it by forcing fluid into there – place tourniquet high on extremity and surgery)
 air embolism (patient's sudden shortness of breath you want to place them in a Trendelenburg position on their left side and notify the provider
immediately and give oxygen - positioning helps to prevent air from traveling through the right side of the heart into the pulmonary arteries which leads
to right ventricular outflow obstruction)
 fluid overload: distended neck veins, crackles, edema, inc bp, tachycardia – slow rate on infusion esp if heart problems

EKG: lie still and breathe normally

symptomatic bradycardia: give Atropine***, pacemaker
a fib, supraventricular tachycardia (SVT), or v-tach with a pulse: give anti-arrhythmic such as Amiodarone, Adenosine, or Verapamil, cardioversion
 cardioversion: electrical intervention
o anticoagulation 4-6wks before cardioversion
o stand clear when shock delivered
o assess pts airway, vitals, EKG, monitor for dislodged clot
v-tach without a pulse or v-fib: use antiarrhythmics such as Amiodarone, Lidocaine, or Epinephrine, defibrillation
cardioversion on someone who has a Fed it's important that they be on an anticoagulant for four to six weeks prior to the cardioversion to prevent dislodgement of a
thrombi into the bloodstream - all staff stands clear of the client when the shock is delivered afterwards you're going to want to make sure there they have a patent
airway you're going to let closely monitor their vital signs and obtain an EKG
complications with a cardioversion including an embolism either a pulmonary embolism and then you could also have a CVA or an MI this is if it like a clot is dislodged

Ch 29 pacemakers
two different pacemaker modes one is a fixed rate or a synchronous which is basically the pacemaker fires at a constant rate regardless of what the heart is doing if
the pacemaker is in demand mode which is synchronous it will detect the heart's electrical impulse and fire at a preset rate only if the heart's intrinsic rate falls below
a certain level so it will only fire when it needs to when the heart's not do it's job
reasons to get one: symptomatic bradycardia a complete heart heart block sick sinus syndrome (sinus node not working)
education:
- after the pacemaker is inserted – >pt minimizes their shoulder movement and they will usually provide a sling
- assess the client for HICCUPS if they have hiccups this could mean that the pacemaker is not functioning correctly - pacing the diaphragm instead of heart***
- carry a pacemaker identification card at all times
- they should take their pulse daily
- if they have a pacemaker with a defibrillator built-in then device delivers a shock and anyone touching the patient may feel a slight electrical impulse but they will
not be harmed
- the patient should have no contact sports or heavy lifting for 2m
- never place items that generate a magnetic field directly over their pacemaker such as a strong magnet or garage door opener
- they can still use microwave
- MRIs contraindicated
- pacemakers will set off airport security detectors so they need to notify the TSA agents when they're getting on a flight
complications: an infection, arrhythmias, pneumothorax, hemothorax

Ch 30 MI
percutaneous coronary intervention or PCI: open up that coronary artery so you're either inflating a balloon, inserting a stent, or removing some plaque
if a patient is having an MI then do PCI within NINETY minutes of the MI symptoms
MI symptoms: chest pain like crushing, pain that radiates to jaw, left arm, or shoulder – women have diff symptoms so they get nausea, diaphoresis, dyspnea like
difficulty breathing, fatigue
STEMI: ST elevation on EKG which is more deadly; ST depression or nonspecific ST changes, t-wave inversion
NPO for eight hours, shellfish iodine allergy, renal function, assess the groin site for bleeding, and check their pedal pulses to make sure that there is blood flow going
all the way down
sedated and pain medication during the procedure so the main medications will be midazolam and fentanyl
bedrest for 4-6h flat after the procedure, antiplatelet or thrombolytic agents, administering IV fluids to kind of flush that dye out of their system
avoid strenuous activities, restrict lifting
anticoagulation therapy for usually six to eight weeks
avoid activities that may result in bleeding
***main symptoms of a patient bleeding out or having hemorrhaging include hypotension & tachycardia
- cardiac tamponade: the symptoms of that include hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse

coronary artery bypass graft (CABG): using like the saphenous vein from your leg to help bypass clogged arteries in the heart
 do coughing exercises and deep breathing to prevent pneumonia, incentive spirometer
 have initially an endotracheal tube and mechanical ventilation

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 sternal incision as well as a possible leg incision

 multiple chest tubes and they'll likely have an a-line
 gonna be lowering the client's core temperature to help decrease metabolism and demand for oxygen so they are warmed back up at the end of the
procedure
 chest tube is patent and watch the drain levels again if you see volume exceeding a hundred and fifty milliliters per hour then that is a sign that there's
possible hemorrhaging – call provider!!
 teaching on healthy lifestyle

peripheral bypass grafts: so if a patient has peripheral artery disease then they have some kind of issue or occlusion that prevents blood flow into the extremities and
you need to bypass the affected artery through a bypass graft – use saphenous vein
peripheral arterial symptoms: numbness and burning pain when they exercise that is relieved with rest (claudication) or they may have numbness and burning pain at
rest which is reduced or relieved if they lower their extremities below the level of the heart; decreased or absent pulses to the feet; dry hairless shiny calves;
atrophied muscles, skin will be cold and dark colored, feet and toes may be mottled and dusky which might indicate amputation, thick toenails
 If peripheral artery disease progresses, pain may even occur when you're at rest or when you're lying down (ischemic rest pain). It may be intense enough
to disrupt sleep. Hanging your legs over the edge of your bed or walking around your room may temporarily relieve the pain
interventions:
 NPO for eight hours you want to instruct the client not to cross their legs as this will further occlude the artery and prevent blood flow
 checking their pedal pulses very frequently so your check their pulses their capillary refill your check the skin color and temperature of their extremities
 maintain bed rest for 18 to 24 hours after the procedure and their legs should be kept straight during this time
 use stockings

compartment syndrome: tissue swelling or bleeding within a compartment which reduces or restricts blood flow to the area it's a medical emergency
 worsening pain, swelling, and tense or taut skin => fasciotomy
 5 Ps: pain, pulselessness, paresthesia, paralysis, pallor

Ch 31 Angina and MI
angina <15min, brought on from exertion or stress its relieved by rest or nitroglycerin
stable angina which occurs with exercise but is relieved by rest
unstable angina occurs with exercise or stress but it increases an occurrence severity and duration over time so it just keeps getting worse
variant angina due to coronary artery spasm that often occurs during periods of rest as opposed to exercise
MI: >30min, dyspnea, diaphoresis, feeling of impending doom, chest pain, nausea, cool clammy skin, tachycardia
risks: anxiety, males more common, postmenopausal female, HTN, tobacco, hyperlipidemia, metabolic disorders, stress
EKG: ST elevation (STEMI), ST depression, t-wave inversion, abnormal P waves
angina med: nitroglycerin - orthostatic hypotension - advise them to stop their activity and rest – place under tongue/sublingual and call 911, if pain unrelieved in 5
min take 2nd dose then wait 5 min, take a 3rd dose and that’s it – headache common side effect
other meds: opioid analgesic, beta blockers – check pulse >60, make sure to not give a nonselective beta blocker to someone with asthma bc bronchoconstriction,
thrombolytic agent like streptokinase – w/n 6hrs of onset of symptoms (assess for active bleeding, peptic ulcers, history of a CVA, or a recent trauma or surgery),
antiplatelet like aspirin (tinnitus and GI upset), anticoagulants like heparin or enoxaparin
complications: cardiogenic shock and symptoms can include tachycardia hypotension decreased urine output altered level of consciousness respiratory distress and
like chest pain and then also decrease peripheral pulses

Ch 32 Heart Failure and Pulmonary Edema

path: body to right atrium to the right ventricle then it goes to the lungs and then from the lungs it goes to the left side of the heart and then it goes to the left atrium
left ventricle and then around to the body
right sided heart failure: blood backs up to the rest of your body = edema, distended jugular veins, ascites/abdominal enlargement, liver enlargement
left sided heart failure: blood backs up into the lungs = pulmonary congestion, difficulty breathing, fatigue, crackles, coughing, frothy pink tinged sputum***
labs: elevated BMP (basic metabolic panel)
all their pressures are elevated so their central venous pressure their pulmonary wedge pressure their pulmonary artery pressure
cardiac output will be decreased
decreased normal ejection fraction (normal 50-70%)
transesophageal echocardiography: down the esophagus to visualize the cardiac structures from behind the heart
interventions: DAILY WEIGHTS, track I/Os, oxygen, High Fowlers, assist with ADLs, restrict their fluid***, reduce sodium intake
meds: loop diuretics (S/E hypokalemia eat high potassium foods such as potatoes, dark leafy greens, melon, oranges), ACE inhibitor (-pril) (S/E angioedema, cough,
elevated potassium**), calcium channel blocker (-pine), angiotensin receptor 2 blocker (-sartan), digoxin to improve contractility (pulse >60, S/E fatigue, muscle
weakness, confusion, nausea and VOMITING, and VISUAL changes**), beta blockers as dilators

heart transplant then they will need to be taking an immunosuppressant to prevent rejection of that organ

pulmonary edema same nursing interventions and meds as HF

Ch 33 Valvular Heart Disease

symptoms: stenosis which is narrowing of a valve in the heart or you're having valve insufficiency (leaky valve where blood is regurgitating or moving backwards
instead of forwards)
causes: prolonged hypertension, rheumatic disease like rheumatic fever (caused most likely by a strep infection), infective endocarditis (caused most likely by a strep
infection) = STREP is a big causative agent in getting a valvular heart disease*** (inflammatory disorders strep is also a big cause of those), normal aging you get
fibrotic thickening of the valve and it just becomes stiffer and less compliant, congenital malformation, connective tissue disease such as Marfan syndrome
any time you have a valvular disorder you're often gonna have a murmur!
extra heart sounds, arrhythmias, mitral dysfunction can cause crackles in the lungs
diagnose valve problems with either a chest x-ray, EKG, echocardiogram

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meds: loop diuretics (reduce the preload and heart doesn’t have to work as hard bc of less blood going into it S/E hypokalemia eat high potassium foods such as
potatoes dark leafy greens melon oranges) – K+ administer it no faster than 20 mg/min, ACE inhibitor (-pril) (S/E angioedema, cough, elevated potassium**), calcium
channel blocker, digoxin to improve contractility (pulse >60, S/E fatigue muscle weakness confusion nausea and vomiting and visual changes**), beta blockers
 medication to help with preload – loop diuretics
 medication to help with the afterload – ACE inhibitors beta blockers calcium channel blockers
procedures: percutaneous balloon valvuloplasty which is where you would put a balloon up there and help kind of open up a valve through that balloon insertion or
you can try to do a valve repair or do a prosthetic valve - after you've done some kind of valve repair or replacement that patient will need to take an antibiotic prior
to any dental work or any kind of surgery at all***

Ch 34 inflammatory disorders of the heart

strep infection can cause rheumatic fever and this in turn can cause issues with the heart and inflammation
other risk factors: Iv drug use, overcrowding, low socioeconomic status
pericarditis: chest pressure, chest pain, friction rub, shortness of breath, pain will be relieved when they sit up and lean forward
rheumatic endocarditis: caused by strep it's usually preceded by an upper respiratory infection causes lesions in the heart
 symptoms: murmur, fever, chest pain, shortness of breath, petechiae/rash on the trunk and extremities, friction rub, muscle spasms
infective endocarditis: strep can cause this and it is also common with IV drug users
 symptoms: fever, flu-like symptoms, murmur, petechiae on the skin red dots, red streaks under the nail bed
run blood cultures to check for infection and you'll likely see elevated ESR and CRP and then you can do a throat culture to check for strep
antibiotics to treat the infection, NSAIDs to treat the fever and inflammation, glucocorticoid steroids to help decrease inflammation and then if they are having
pericarditis you may need to do a pericardiocentesis to remove the excess fluid in that space
complications: a cardiac tamponade

Ch 35 peripheral vascular diseases: peripheral arterial disease + peripheral venous disorders ***
peripheral arterial disease (PAD): not getting adequate blood flow through your arteries down into your lower extremities - mostly caused due to atherosclerosis
 risk factors: obesity hyperlipidemia diabetes hypertension sedentary lifestyle and cigarette smoking
 symptoms: when exercising will get burning cramping pain in legs (intermittent claudication) pain is relieved if they hang their legs in a dependent position
or side of the bed or resting - elevating their extremities would hurt!, delayed capillary refill >3s, decreased or non palpable pulses, shiny skin, loss of hair
on the lower calf ankle or foot, dry scaly mottled skin, thick toenails, when elevating leg it will turn pale and when they lower it down into a dependent
position you then red, if really bad then ulcers and possible gangrene of the toes
 nursing: increase the patient's tolerance for exercise so you want to advise them to walk until the point of pain take some rest then walk a little further
and each time we hope they can go a little further without too much pain, avoid crossing their legs, no restrictive garments bc we want to promote blood
flow, warm environment will cause dilation, insulated socks, avoid stress caffeine and nicotine bc causes vasoconstriction
 meds: antiplatelet like aspirin or Clopidogrel reduce blood viscosity so it'll be easier for the blood to make its way down into the lower extremities
 surgical procedures: balloon or stent, break up the plaque, bypass graft
 mark where their pulses are on their feet so that they're easy to find because you're going to be checking them really frequently
 encourage the patient to keep their limbs straight for six to eight hours after the bypass graft
 complications: graft occlusion so if you see diminished pedal pulses increased pain change in color temperature of the extremities, compartment
syndrome which include increased pain tingling numbness and edema with even just kind of passive movement

peripheral venous disorders

1. venous thromboembolism (VTE): blood clot that forms as the result of venous stasis – DVT/deep vein thrombosis is an example and mostly occurs in the
lower extremities but could also happen in the arms
a. virchow's triad: hypercoagulability, impaired blood flow, damage to blood vessels*** -> risk of getting a blood clot
b. if a patient's had hip surgery or total knee replacement they are at higher risk for a DVT
c. other risk factors are heart failure, immobility, pregnancy, and birth control pills
d. DVT symptoms: calf or groin pain, tenderness, sudden onset of edema in that extremity, warmth, hardness over the involved blood vessel - if
that DVT breaks loose and travels up into the lungs then you're looking at a pulmonary embolism (symptoms: chest pain & difficulty breathing)
e. nursing: elevate the extremity above the level of the heart, avoid using pillow under the knees, don't massage the affected area, warm moist
compresses are good, wear thigh high compression socks****
f. meds: heparin or lovenox – monitor aptt levels, S/E: heparin induced thrombocytopenia, antidote is protamine sulfate***
g. meds: Warfarin/Coumadin monitor pt/inr - coumadin takes a number of days to kind of build up so do heparin bridging - vitamin K is the
antidote*** - maintain steady vit K intake
h. meds: thrombolytic agent: dissolve the clot
i. use electric razor versus blade razor and brush their teeth with a soft toothbrush
2. venous insufficiency: incompetent valves in the veins of the lower extremities such that blood is flowing down into the legs but it is having problems
getting back up to the heart -> edema - it can cause venous stasis, ulcers, and it can lead to cellulitis
a. people who sit or stand in one position for a long period of time, obesity
b. symptoms: brown discoloration around the ankles that extends up the calf, edema, stasis ulcers which are usually found around the ankles
c. nursing: elevate legs, wear elastic compression stockings after they have rested for a while with their leg elevated so that the swelling goes
down
3. varicose veins which are enlarged twisted superficial veins in the lower extremities
a. women > men
b. age, pregnancy, obesity, family history
c. symptoms: swollen superficial veins
d. supine position with their legs elevated
e. inject a chemical solution and those to help close the lumen of the vessel over time or they can do vein stripping
assessment findings for a lot of these conditions, the patients will have an aching pain in their lower extremities and a feeling of heaviness
d-dimer test: elevated is bad and can indicate blood clot
venous duplex ultrasound can identify whether there's a DVT present

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Ch 36 hypertension
<120 normal
120-129: prehypertension
130-139 or diastolic 80-90: stage one hypertension
over 140 or diastolic over 90: stage two hypertension
over 180 or diastolic over 120: hypertensive crisis

primary/essential hypertension: no known cause

 African American they are higher risk for having hypertension excess sodium intake obesity physical inactivity high alcohol consumption smoking
hyperlipidemia and stress

secondary hypertension is due to certain diseases such as kidney disease – can damage the heart the eyes the brain and the kidneys if left uncontrolled
 Cushing's disease, pheochromocytoma flaccid
 do not have symptoms!!
 if their blood pressure gets really out of control then they may start having symptoms such as headaches dizziness and visual disturbances

meds: orthostatic hypotension so it's important to tell patients to change their positions very slowly
 hydrochlorothiazide, furosemide -> hypokalemia
 spironolactone -> hyperkalemia
 calcium channel blockers: verapamil amlodipine diltiazem - avoid grapefruit juice***
 ace inhibitors: angioedema cough and elevated potassium
 angiotensin ii receptor antagonists: angioedema, hyperkalemia, heart failure
 aldosterone receptor antagonists: include elevated triglycerides, hyponatremia, hyperkalemia (some salt substitutes have high levels of potassium)
 beta blockers: hypoglycemia can also cause fatigue weakness and sexual dysfunction
 central alpha agonist: sedation or orthostatic hypotension

hypertensive crisis: severe headache they may have blurred vision dizziness - IV antihypertensive therapy such as nitroprusside**

Ch 37 hemodynamic shock
hemodynamic shock: inadequate tissue perfusion which can lead to multiple organ failure and death if not treated early
1. cardiogenic shock: cardiac pump failure due to an MI, heart failure, dysrhythmias
a. elevated cardiac enzymes like troponin and ck-mb
b. nitroprusside you can use that to treat cardiogenic shock and that will decrease the after load and preload to help the heart reduce the work
that the heart needs to do
2. hypovolemic shock: excess fluid loss it can be from excessive like diarrhea and vomiting or blood loss if you've had like a trauma or surgery
a. hemoglobin hematocrit will be decreased
3. obstructive shock: blockage of the great vessels it could be like a pulmonary embolism or a tension pneumothorax
4. distributive shock: is characterized by widespread vasodilation and increased capillary permeability
a. septic shock: HYPOtension, TACHYcardia
i. often caused by bacteremia/gram-negative bacteria in the blood stream
ii. in older patients and elderly urosepsis is a big thing – have UTI and that bacteria moves into the bloodstream
iii. blood cultures those will be positive for infection
iv. vancomycin
b. neurogenic shock: trauma or spinal shock so you would see this with like a paraplegic or quadriplegic
c. anaphylactic shock: allergies - wheezing + having trouble breathing
i. give epinephrine
shock symptoms: tachypnea, hypoxia, wheezing, angioedema, HYPOtension (bp down to like 50 or 60), TACHYcardia, decreased urine output
labs: increased lactic acid levels
urine output: less than 30 mL/hour you want to notify the provider**
hypotension: lay them flat with their legs elevated and this will help promote venous return**
vasopressors (dobutamine and norepinephrine) to help strengthen cardiac contraction and increase cardiac output
vasopressin: strengthen cardiac contraction and causes vasoconstriction to bring blood pressure back up
isotonic crystalloids or colloids to help replace their volume
histamines to treat shock
complications: multiple organ dysfunction syndrome MODS or DIC disseminated intravascular coagulation
 MODS: TACHYcardia, TACHYpnea, organ failure
 DIC: body forms microclots all over the body and uses up platelets/clotting factors and so risk for bleeding because they don't have any more of these
clotting factors or platelets left -- transfuse blood products, administer platelets and clotting factors, monitor PT & PTT and look for signs of bleeding

Ch 38 aneurysms
aneurysm: widening or ballooning within the wall of a blood vessel
risk factors: male, smoking, hypertension, aging, atherosclerosis
abdominal aortic aneurysm AAA: flank or back pain, pulsating abdominal mass (do NOT palpate – may rupture)
aortic dissection: sudden feeling of tearing ripping or stabbing in their abdomen or back and they may go into hypovolemic shock (hypotension, tachycardia,
diaphoresis, nausea and vomiting, decrease/absent peripheral pulses)
thoracic aortic aneurysm: severe back pain, cough, shortness of breath, difficulty swallowing
diagnosis: x-ray or CT
patient care: vital signs Q15min, continuously monitor their cardiac rhythm, hemodynamic monitoring, ABG's, hourly urine output, IV access, keep their blood
pressure between 100 and 120 mmHg, anti hypertensive medications to keep bp controlled because if too high then possible rupture and bleeding
surgical interventions: abdominal aortic aneurysm resection - if ruptured emergency surgery very high mortality rate 50% - if hasn't ruptured yet wait until aneurysm
6cm in diameter high mortality 2-5% result in massive hemorrhage, shock and death, greater than 6cm w/ htn are greater risk of death

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Ch 39 Hematologic Diagnostic Procedures

 WBC= 5000-10000
 RBC= 4-6million
 Platelets= 150,000-400,000
 Hgb= 12-18
 Hct= 37-52%
 ApTT= 30-40sec (1.5-3 times control value)
 Pt= 11-12.5 sec
 INR= 1 but 2-3 on warfarin
 Bone marrow biopsy= diagnose blood disorders leukemia and cancer
o Place pt in prone or side lying position to expose iliac crest

Ch 40
blood and blood transfusions so one of the first things mentioned in this chapter are autologous transfusions this is where if you know you're gonna have a procedure
or surgery you can donate your own blood ahead of time to be used in that procedure so the important thing to remember here is that you would want to donate
that blood between five weeks prior to your surgery up until 72 hours prior to your surgery so you can't go longer than that or shorter than that so just kind of know
that window and then let's talk about who can get what type of blood so I've seen questions not only on ATI about this but also NCLEX so this is going to be important
one to know so if you are blood type A that means you have an a antigen on your blood cells and you have antibodies against B so if you're Type A you can receive
blood from types a and O but not from B because again you have those antibodies if you are type B then you have the B antigen and you have antibodies against type
A so if you're type B you can get blood from Type B and Type O but not from type a if you are blood type A at a B then you have a and B antigens you do not have any
antibodies so you can get blood from anybody so if your type a B you can get blood from a B and O and other a B blood types and then if your blood type O then you
have no antigens but you have antibodies against a and B so if your Type O the only type of blood you can get is from another Type O so definitely know this this little
table here additionally Rh positive blood cannot be given to somebody who is Rh negative as this will cause hemolysis so that's important so Rh positive can be given
to rh- in terms of giving blood you're gonna wanna this obviously establish IV access you're gonna want to use a 20-gauge need needle which is a little bigger you
know than some of the choices to make sure it's big enough to receive that blood when you receive the blood from the blood bank you're gonna need to bring
another RN in you can't bring a CNA or somebody else it has to be to our ends and you're gonna come from the clients identity the blood compatibility and the
expiration date of the blood product with that other nurse when you set up the administration of the blood you're gonna set it up with 0.9 sodium chloride so normal
saline that is the only type of hood that you should be setting this up with so sometimes they'll try to trick you like can you set it up with lactating lactated ringers or
something else it always should be 0.9 percent sodium chloride when you start the blood you want to stay with the client for at least 15 minutes sometimes fifteen to
thirty minutes but it will never be less than fifteen minutes because you want to really observe them for any sign of a reaction so let's talk about what the different
reactions could be so one is acute hemolytic reaction to the blood this can be mild or it can be life-threatening some of the symptoms include chills fever low back
pain tachycardia flushing hypotension those type of things they also may have a febrile reaction and this is where they just have some chills and a fever some flushing
and a headache or anxiety and what you would want to do for that is administer an antipyretic so something to bring their temperature down like Tylenol they may
have a mild allergic reaction which is what they have itching utak area or flushing you would give them benadryl for that type of thing and then if they have an
anaphylactic shock you know I'm not shocked but anaphylactic reaction to the blood product they may have reasoning wheezing dyspnea and then and maintaining
Airways gonna be the most important thing giving oxygen and a histamines maybe vasopressors to try to treat that an electric shock so if you see a sign of any of this
reactions or at least most of these reactions you're gonna want to stop the transfusion immediately and you're gonna want to initiate an infusion of the 0.9 sodium
chloride and you're gonna want to initiate it through a separate line because you don't want the rest of that blood product to get in there before the sodium chloride
goes into the patient so you want the sodium chloride to go in right away so you'll need a second line for that and then it's possible that some patients with like heart
failure may have circulatory overload in response to receiving the blood product so they may get symptoms such as dyspnea tachycardia hypertension jugular vein
distension peripheral edema and like crackles in their lungs so the thing you would likely do for that patient is really decrease the rate so when you have a heart
failure patient or someone who's at risk for having circulatory overload you may infuse the blood a little slower so that you don't overwhelm their system and those
are the main points of this chapter and we will pick it up with anemias

Ch. 40 Blood and blood product transfusion*

 Analogous transfusion= pt blood is collect in anticipation of future transfusion, donate 6 weeks prior
 Blood type
o A= a antigen, b antibody
o B= b antigen, a antibody
o AB= AB antigen, no antibodies
o O= no antigens, A and B antibodies
o Rh+ can’t be given to Rh-
 Rhogam if mom is Rh-
 Large bore iv access 18-20 gauge, verify w/ two RN to verify blood produce, pt and #, prime blood admin set w/ 0.9% sodium chloride
 Remain w/ pt 15-30 min
 Complications
o Acute hemolytic reaction= chills, fever, LOW BACK PAIN, tachycardia, flushing, hypotension
 Stop transfusion
o Febrile= chills, increase 1 degree, flushing, shaking, muscle stiffness, headache, nervousness
 Stop transfusion, admin antipyretic
o Allergic= itching, urticaria, flushing
 Stop transfusion, admin antihistamine
o Anaphylactic= bronchospasm, laryngeal edema, shock
 Stop transfusion, admin epi and o2
o Circulatory overload= crackles, dyspnea, jvd, tachy
 Slow infusion

Ch 41
anemia is basically where you have inadequate red blood cells in your body or inadequate hemoglobin or both such that not enough oxygen is being perfused to your
tissues and your organs it can be caused by a number of different things one is blood loss so if you have a patient who's had trauma surgery GI bleed if you have a

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female patient who has really heavy periods like menorrhagia then those can all cause enough blood loss that you end up with anemia also some patients have a
condition which causes bone marrow suppression so if you have patient who has cancer and is getting radiation and chemo often they may end up with bone marrow
suppression such that their bone marrow isn't producing enough red blood cells this would be called a plastic anemia when they have bone marrow suppression
some patients have increased red blood cell destruction and another one to remember is like sickle cell disease in sickle cell their red blood cells are malformed such
that they like clogged up the capillaries and decrease perfusion to to those areas of the body or to different organs and then lastly if a patient is deficient in one of the
necessary components in making red blood cells such as folic acid b12 our iron they can end up with anemia so for children and for pregnant women the most
common form of anemia is iron deficiency anemia so with kids they're always drinking tons of milk milk is really low in iron so if they're drinking a lot of milk and not
eating a lot of food then they often get iron deficient anemia another weird one here to know with a TI is some patients has what's called pica P ICA and this is where
they eat things like chalk or soil just weird things instead of food this can lead to anemia so let's talk about the signs of anemia so a patient may look pale they may
experience fatigue difficulty breathing on exertion so dyspnea they may report numbness and tingling in the extremities they may also have tachycardia dizziness or
syncope and then they may also have nail bed deformities such as spoon-shaped nails if they've been suffering from anemia for a while so the main thing here I would
know is the nursing care for patients with anemia I wouldn't get hung up on the MCB TI b c or any of those things that are discussed on page 460 but i would know
how to take care of a patient has anemia so if it is due to a deficiency in like iron folic acid or b12 then you obviously want to provide a supplement so if they have
iron deficient anemia then you're gonna be giving them ferrous sulfate which is the oral form of iron you want to encourage the patient to take that with a food that
is high in vitamin C to help increase absorption if they have very severe anemia they may need parenteral iron which is iron dextran and you want to always
administer iron dextran through the Z tract method and that's important to know if they have bone marrow suppression or just inadequate numbers of red blood
cells in their body they may be given Ipoh eaten alpha which is a drug that is used to increase the production of red blood cells so that's an important medication to
know for those of you have got pharmacology coming up and if they're on a poet in alpha you're gonna want to closely monitor their hemoglobin and hematocrit
levels usually twice a week in terms of b12 if they have a b12 deficiency it's important to know whether they're not getting enough b12 orally or are they lacking in
the intrinsic factor in their stomach which provides for the absorption of b12 so you can give them all the b12 you can orally and if they can't absorb it due to some
kind of malabsorption syndrome it's not going to help them so if it is a deficiency and their oral intake and their intrinsic factor is fine then you just give them extra
b12 right orally however if they're they don't have enough intrinsic factor and they can't absorb the b12 then you're gonna have to give it to them through an
injection so they would get monthly injections of b12 pretty much for the rest of their life if they have some kind of situation where they don't produce intrinsic factor
in terms of folic acid supplements it's important to know that large amounts of folic acid supplements can mask a vitamin b12 deficiency this is because the folic acid
needs b12 to change it from an inactive form of folic acid to an active form of folic acid so you do require b12 for that too so it's important to know before you
supplement somebody with extra folic acid make sure that they're they're getting enough b12 first in terms of complications heart failure is one possible complication
if a patient suffers from anemia for a long time because your heart when you're not getting of oxygen to your body due to anemia it starts beating harder and faster
to try to compensate for that right to get more oxygen to the tissues and this in turn can lead to heart failure

Ch. 41 Anemias*
 Anemia= low amt of circulating rbc, hgb concentration, low o2
o Causes= blood loss, inadequate rbc production, increased rbc destruction, deficiency of folic acid, iron, b12
o Risk factors= menorrhagia, defective hgb (sickle cell), pica (eating chalk), bone marrow suppression (aplastic anemia decreased rbc)
o Findings= pallor, fatigue, numbness and tingling of extremities, dyspnea on exertion, tachy, dizzy/syncope, nail bed deformity
o Increase dietary intake of iron, vitamin b12, and folic acid
o Meds= ferrous sulfate, iron dextran (use z track), epo (increase production of rbc, monitor hgb and hct 2X a week), b 12 (cyanocobalamin if
lack intrinsic factor can have irreversible malabsorption, receive b12 injections on monthly basis), folic acid (large dose can mask b12 deficiency)
o Edu= take iron with vitamin C to increase oral absorption
o Complications= HF
 Iron deficiency anemia= common in kids, adolescents, pregnant women

Ch 42
coagulation disorders so really there's just two different coagulation disorders that are covered in this chapter one is idiopathic thrombocytopenic purpura or ITP the
second is disseminated intravascular coagulation or di C so ITP it's important to know the difference between these two ITP is an autoimmune disorder such that the
body is decreasing the lifespan of the platelets that are developed so you produce an normal number of platelets but the lifespan of those platelets is decreased due
to an autoimmune disorder with di C this is where your body creates all these little micro clots all over your body it uses up all the clotting factors such that you're at
risk for bleeding so with both these conditions you're at definite risk for bleeding so some of the symptoms include spontaneous leading from the clients gums are
their nose you may see trickling or using of blood from lacerations or incisions they may see you may see petechiae which is like red dots all over the skin or
ecchymosis they may have tachycardia and hypotension and if you run their labs you're likely going to see decreased platelet levels decreased hemoglobin that type
of thing so in terms of nursing care like I said with di C you form all these micro clots so although clotting factors are used up that your risk for bleeding well the other
thing that you're at risk for our micro emboli that basically block the blood flow to your tissues so you may your patient may have like cyanotic nail beds or pain
because they're not getting blood flow to those areas due to those mighty little mini clots so you want to be on the lookout for that you are gonna obviously be
transfusing blood blood products or clotting products as ordered you want to avoid the use of and say you're gonna want to protect the patient from injury again if
they fall or hit themselves on something they are at risk for bleeding out and this can be fatal so again you're gonna want to use bleeding precautions so you're gonna
want to avoid use of needles really minimize how much they're getting poked at the hospital in terms of medications with ITP again that is a autoimmune disorder
you're gonna be administering corticosteroids and immunosuppressants for that condition and then for di C you're actually gonna give the patient heparin which at
first it doesn't seem to make a lot of sense if they're at bleeding risk you would never give somebody heparin but for this patient because of that formation of micro
clots we want to prevent the formation of those micro clots and therefore prevent using up all of the clotting factors and heparin will help do that so again when
you're giving someone heparin what are you monitoring their PTT levels

Ch. 42 Coagulation Disorders*

 Idiopathic thrombocytopenic purpura ITP = autoimmune disorder; life span of platelets is decreased
o Risk factors= female, autoimmune, recent virus (kids)
 DIC= clotting and anticlotting mechanisms occur at same time
 Findings= spontaneous bleeding from gums, oozing/trickling or flow of blood from incisions or lacerations, petechiae, ecchymoses, tachy, hypotension
 Lab tests= decrease hgb, decreased platelet levels

Ch 43 Fluid and Electrolyte Imbalances + Acid-base Imbalances

fluid volume deficits so this can mean either hypovolemia will you lose water and electrolytes or it can mean dehydration where you're losing water but no
electrolytes it's important to know that as we get older the risk of dehydration goes up because when you get older your sense a thirst decrease and also your body
mass decreases in terms of the causes of hypovolemia or dehydration there are many so one is hemorrhaging right if you hemorrhage that you're gonna lose volume

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that is pretty straightforward also if you're vomiting or have diarrhea that's gonna cause you to lose fluid if you're taking diuretics that's a problem profuse sweating
like diaphoresis that can cause hypovolemia if you're a third spacing so with like ascites they would have hypovolemia and if on NPO for a while that can result in
hypovolemia other causes of dehydration include hyperventilation and then diabetic ketoacidosis so in diabetic ketoacidosis they're having those Kussmaul
respirations where they're breathing very deep very rapidly and that can easily cause them to dehydrate other symptoms so if you lose volume you can easily see that
you're probably gonna have lower blood pressure right because there's less volume going through your body and then your pulses are gonna be week or two you'll
have like thready pulses your heart will try to compensate for that lack of volume and will pump a little faster so you'll have tachycardia and you'll also have
tachypnea in addition if you are dehydrated hypovolemia you may experience dizziness thirst illega urea so think about it you're not peeing a lot because you don't
have a lot of extra fluid to pee out you'll have diminished cap capillary refill maybe some cool clammy skin poor skin turgor so and then tenting so it's like you you pull
up on your on your skin there it'll just like stay there it's not very supple it's super dry so it's not gonna fall back in place very well maybe sunken eyeballs those are all
signs of dehydration or hypovolemia in terms of lab work you'll show increased hematocrit increased osmolarity so again because there's not a lot of fluid it will be it
will have a greater osmolarity because it is more concentrated with those electrolytes and you also see an increased vun so and that can show dehydration so when
you're looking at kidney function and you know you look at the creatinine and the B UN the B UN is very sensitive to dehydration so if that's elevated it may not mean
that there's something wrong with the kidneys it may just mean that the patient is dehydrated in addition the urine specific gravity will be increased and let's now
talk about nursing care of someone who is a hypovolemia or dehydration this can include putting them in a shock position so this is on their back with their legs
elevated you'll obviously be replacing fluid and monitoring their intake and output so if their urine output falls below 30 CC's an hour you're gonna want to notify the
provider that's an important number to know and I've mentioned in a couple videos so definitely remember that and then you want to initiate follow precautions
because they may be dizzy and not feeling very well if they go into hypovolemic shock we did talk about that in the previous video obviously you're gonna be
administering oxygen you're gonna do some fluid replacement first before you hit them with any vasoconstrictors so you may give them the colloids or crystalloids
and then you may need to give them a vasoconstrictor and some of those we mentioned in the previous video so that's hypovolemia I'm going to end here and then
I'll start the next video we'll talk about fluid volume excess

Ch. 43 Fluid Imbalances*

 Hypovolemia causes= vomiting, diarrhea, diaphoresis, diuretics, ascites, np, hyperventilation, DKA
o Risks= older adults b/c diminished thirst reflex
o Findings= tachy, thready pulse, hypotension, tachypnea, dizzy, thirst, oliguria, diminished cap refill, cool clammy skin, sunken eyeballs, poor skin
turgor and tenting
o Lab test= increased hct, increased BUN >25, increased urine specific gravity > 1.025, increased serum osmolarity > 295
o Care= monitor I & O and report < 30 output, admin iv hydration, initiate fall precaution, encourage pt to change position slowly, drink liquids
o Complications= hypovolemic shock (admin o2, colloids, crystalloids, vasoconstrictors)
 Hypervolemia causes= HF, kidney disease, cirrhosis, od sodium, prolonged corticosteroid use
o Findings= tachy, bounding pulse, htn, tachypnea, ascites, crackles, dyspnea, peripheral edema, distended neck veins
o Labs = decreased hct/hgb, serum and urine osmolarity, and BUN
o Care= monitor i&o, monitor daily wt, maintain na restricted diet, fluid restrictions, admin diuretics, position in semi fowlers and reposition
every 2hr to avoid skin breakdown, pressure reducing mattress and assess bony prominence
o Edu= notify provider if gain 1-2lbs in 24hrs or 3lbs in a week
o Complications
 Pulmonary edema= tachy, dyspnea at rest, frothy pink sputum
 Admin o2
Ch 44 Electrolyte Imbalances
sodium is between 135 and 145 I don't have a specific trick for sodium but there are other values that are between like 35 or 45 so blood pH should be between
seven point three five and seven point four five and then paco2 should be between 35 and 45 so I kind of remember sodium because it's similar to those other ranges
I just described potassium so potassium is K right capital K when I think of K I think of a five K which is approximately 3.5 miles it's actually not it's kind of three point
one or two but for our memorization sake let's pretend a five K is three point five miles so the range for potassium is three point five 2 pi chloride when I see chloride
I think of chlorine and I think of my hot tub and let's say I like my hot tub really hot so I like it between 98 and 106 degrees and that's how I remember chloride
calcium the initials for calcium are CA which is also the initials for California so California is due for a big earthquake sometime in the future and if and when that
happens it may register very high on the Richter scale so we may have an earthquake of a magnitude of nine to ten point five so that's how I remember CA
magnesium magnesium is mg and if you've ever seen a little mg car they're not super common but they're really really small so you can only fit between and two
people and your little ng car so the normal range per mg is like 1.2 to 2.1 which is almost 1 to 2 but that's how I kind of remember that range and then lastly
phosphorus so phosphorus is similar to potassium so the potassium level was three point five to five phosphorus is just 0.5 down so instead of three point five to five
it's three to four point five so I kind of remember it that way so those are my tricks let's talk about hyponatremia so this is where the sodium levels are going to be
low they're gonna be below 135 so what are causes of hyponatremia some causes include gi losses so vomiting diarrhea losses through an NG tube those can cause
hyponatremia diuretics often cause electrolyte imbalances including imbalances with sodium kidney disease can cause it SIADH which causes your body to retain a lot
of water which kind of dilutes the blood which results in hyponatremia also different conditions that cause edema such as heart failure cirrhosis can result in
hyponatremia so let's talk about symptoms so some of the symptoms of hyponatremia include hypothermia tachycardia and hypotension also confusion is a big one
especially with older patients if they're really confused I would definitely check their electrolytes because they may have hyponatremia and then the next thing I
would check is their urine to see if they have a urinary tract infection because that will also cause confusion muscle weakness is another sign and then I think it's
really bad that patient may have seizures so in terms of treatment if the patient is suffering from something like heart failure you may need to give them a diuretic to
get rid of the excess fluid you're also going to maybe be giving them hypertonic IV fluids so normal IV fluids have 0.9 sodium chloride so for a patient though who has
hyponatremia you're likely going to give them something like 3% sodium chloride now it's really important that when we're trying to bring up their sodium levels that
we do so slowly so we're gonna definitely infuse this slowly and check their sodium levels very very frequently we're also going to want to encourage the patient to
increase their intake of sodium in their food and again just watch out for seizures and that type of thing until you get their electrolytes into a normal range so let's talk
about hypernatremia so that's a sodium above 145 so what can cause that well excess sodium intake is one kidney failure or Cushing's syndrome can cause
hypernatremia diabetes insipidus this is where you're peeing out tons of dilute urine such that there's not a lot of fluids left so the sodium is more concentrated in the
body's fluids let's talk about symptoms of hypernatremia so unlike hyponatremia which caused hypothermia hypernatremia will cause hyperthermia it will also cause
tachycardia and orthostatic hypotension irritability and muscle twitching are signs and then dry mucous membranes and thirst are other key symptoms so in terms of
treatment so for hyponatremia we wanted to give them fluids which were higher in sodium chloride for hypernatremia we want to give them hypotonic IV fluids so
instead of 0.9 sodium chloride we're going to give them 0.45 percent sodium chloride we're also want to encourage water intake and discourage sodium intake all
right continuing on with chapter 44 we're going to talk about

potassium imbalances so whether your patient has hypokalemia or hyperkalemia the most important thing for you to know is that a potassium imbalance can cause
cardiac arrhythmias or EKG abnormalities so if you don't remember anything else of what I'm about to say definitely remember that so let's talk about causes of

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hypokalemia some causes include gi losses so vomiting diarrhea and g-tube suctioning in addition the use of diuretics specifically furosemide can cause hypokalemia
diaphoresis and wound losses are other causes so in terms of symptoms again the number one symptom that you want to be aware of are issues with the EKG so
arrhythmias beyond that they may experience weakness to the point of respiratory collapse they also may have constipation and an ileus and an ileus is where your
bowel motility basically stops working so in terms of treatment you want to encourage them to increase their intake of potassium rich foods so dark leafy greens
oranges cantaloupe bananas avocados broccoli that type of thing you also may need to give them a potassium supplement so you can give them a oral potassium
supplement or you can give it to them through an IV but keep in mind that IV potassium is a tissue irritant and it can cause phlebitis so often the pharmacy will mix
this with lidocaine to make it a little easier on their veins one thing to keep in the back of your mind is that hypokalemia can increase a patient's risk of digoxin toxicity
and if they have hypokalemia or hyperkalemia you want to do continuous cardiac monitoring
so for hyperkalemia some of the causes include diabetic ketoacidosis DKA or uncontrolled diabetes other causes could be renal failure or the use of potassium sparing
diuretics so medicines like spironolactone which is a potassium sparing diuretic can cause those levels to go too high in terms of symptoms again EKG abnormalities is
the big one the important one but in addition they may have nausea vomiting and increased motility as opposed to an alias that we just talked about with
hypokalemia in terms of nursing care there's a number of things here and I think they're really important to know so definitely take a look at page 4 90 in addition 9.0
if it's addition 10-point know that you're using just look for nursing care of patients with hyperkalemia so one thing you can do to help protect their heart from the ill
effects of hyper cleaning is to give them calcium gluconate so that's a good one to know in addition you're gonna want to restrict potassium in their diet so all those
foods I just talked about you're going to want to have that patient avoid those things if they have like IV fluids running with potassium or scheduled to get oral
potassium you definitely want to hold all that insulin is really helpful to bring potassium from the ECF to the ICF however you need to give it with dextrose so dextrose
and insulin together this is because insulin in addition to moving the potassium into the cells is also gonna be moving glucose into the cells and so the patient would
be at risk for low blood sugar if they didn't get that extra dextrose when you give them the insulin sodium bicarbonate may be used to help help reverse acidosis and
they the patient may also get like a loop diuretic like furosemide so a side effect of first mite of course is hypokalemia but in this case if their potassium levels are too
high this can actually help bring it down and then lastly they may get something called kayexalate which works like a laxative to excrete excess potassium from the
body okay let's talk about calcium so a couple things that are important important to know about calcium is there is an inverse relationship with phosphorus so if
calcium is high phosphorus will be low if phosphorus is high calcium will be low so calcium kind of acts like a gatekeeper in our body for sodium and an action
potential so if your calcium is too high it's harder for those action potentials to happen if your calcium is too low then it's very easy for those action potentials to fire
and this will make sense when we're talking about some of the symptoms of hypocalcemia so let's first talk about some of the causes of hypocalcemia are too low of
calcium so for people who are getting a thyroidectomy sometimes their parathyroid gland can get nicked or damaged in that surgery which the parathyroid gland is
responsible for regulating levels of calcium so if it is damaged then calcium calcium levels will drop and the patient law of hypocalcemia and I definitely seen
questions on that before so just know that they're having thyroid surgery they're at risk for hypocalcemia due to damage to the parathyroid gland so hypo
parathyroid ism is also a cause of hypocalcemia in addition vitamin D deficiency can cause hypocalcemia because vitamin D is needed in order for calcium to be
absorbed into your system and then lastly pancreatitis is one I would know that is associated with hypocalcemia so in terms of the symptoms if a patient has
hypocalcemia where that gate is down and so those so deep that sodium and those action potential can happen a lot so some of the symptoms include muscle
twitches muscle spasms and then two important signs that you need to know are a positive Chi Bostic sign hopefully I'm saying that right and a positive trousseau sign
so a positive chivas dick sign is where you tap on the facial nerve and this triggers facial twitching the way I remember it is is you're kind of like tapping on their cheek
so CH is what the first two letters of Chivas stick sign and then true so sign is where you inflate a blood-pressure cuff and this causes hand and finger spasms the other
symptoms I really wouldn't worry about but I would know about the muscle twitching assassins and I would know about the positive shahboz dick sign and positive
true so say if they have low calcium levels you want to encourage a diet higher in calcium rich foods such as dark green vegetables and dairy products and also making
sure they have adequate vitamin D so lastly we're going to talk about hypomagnesemia so low levels of magnesium causes of hypomagnesemia include alcohol and
Justin ingestion so if people are abusing alcohol their magnesium levels will often be low or malnutrition is another thing in terms of symptoms you'll see increased
nerve impulse transmission they will also demonstrate a positive Chbosky sign and trousseau sign and then in terms of GI they may you may see hypoactive bowel
sounds and a paralytic ileus and then in terms of nursing care you're going to give them magnesium supplements you could do that through IV and oral know that
oral magnesium can cause diarrhea and then again you're going to want to encourage a diet high in magnesium which having also include dairy products and dark
green vegetables similar to calcium so that's it those are like the main points

Ch. 44 Electrolyte imbalances

 Electrolyte levels
o Na= 135-145
o Ca= 9-10.5
o K= 3.5-5
o Mg= 1.3-2.1
o Cl= 98-106
o Ph=3-4.5
o BUN=10-20
 Hypona= na<135
o Risks= diuretics, ng suction, kidney disease, hf, siadh, v/d
o Findings= hypothermia, tachy, hypotension, confusion, muscle weakness, seizures
o Care= PO fluids, Na w/ food and fluids, hypertonic solution admin 3% nacl slowly
 Hyperna= na >145
o Risks= DI, excess Na retention (kidney failure, cushing syndrome)
o Findings= thirst, hyperthermia, tachy, orthostatic hypotension, irritability, muscle twitching, dry mucous membranes
o Care= 0.45%nacl, h20 intake, and decrease na intake
 Hypok
o Risks= loop diuretics, v/d, prolonged ng suctioning, diaphoresis, wound losses
o Findings= ecg disturbances (dysrhythmias), constipation, paralytic ileus
o Care= encourage foods high in k (avocado, broccoli, dairy, dried fruit, cantaloupe, bananas, juices, citrus, oral supplement)
o increases risk of digoxin toxicity
 Hyperk
o Risks= k sparing diuretics, DKA, uncontrolled diabetes, renal failure
o Findings= ecg disturbance, increased motility (diarrhea)
o Care= observe for nausea and colic, avoid foods high in k, receive furosemide, combo of glucose and insulin admin to promote uptake of k by
cells, kayexalate promote k excretion, admin nahco3 to reverse acidosis
 Hypoca= less than 9, inverse to ph

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o Risks= thyroidectomy, hypoparathroidism, vitamin d deficiency, pancreatitis

o Findings= tetany, muscle twitches, painful muscle spasm, positive Chvostek sign (tap cheek and trigger facial twitch), positive trousseau sign
(hand spasm w/ sustained bp cuff inflation)
o Care= encourage foods high in ca, dairy, dark leafy green vegetables
 Hypomagnesemia= less than 1.3
o Risks= malnutrition, ethanol ingestion
o Findings= increase nerve impulse transmission, + Chvostek and trousseau sign, hypoactive bowel sounds, paralytic ileus
o Care= admin oral or iv magnesium sulfate, oral magnesium cause diarrhea, dark green vegetables

Ch. 45 Acid-Base imbalances

 Greater concentration of hydrogen the more acidic and lower the pH
 Buffers
o Chemical protein buffers= first line of defense
o Respiratory buffers= second line of defense, control level of h ions in blood through control of co2 levels
o Kidney buffers= third line of defense, control movement of bicarb; high h ions means bicarb reabsorption, low h ions means bicarb excretion
 Compensation= normal pH 7.35-7.45
 Respiratory acidosis= caused by hypoventilation and obstruction, causes increased CO2
o Manifestations= ineffective, shallow, rapid breathing
o Care= o2, patent airway, ventilatory support, bronchodilators
 Respiratory alkalosis= caused by hyperventilation from fear anxiety or salicylate toxicity, results in decreased co2
o Manifestations= rapid deep respirations
o Care= anxiety reduction and breath into bag (rebreathing technique)
 Metabolic acidosis= results from excess production of h ions, dka, aspirin, kidney failure, diarrhea, decreased hco3
o Manifestations= dysrhythmias, brady, weak peripheral pulses, hypotension, rapid deep respirations (kussmaul respirations), warm dry skin,
hyperk
o Care= admin insulin, admin antidiarrheal, admin nahco3
 Metabolic alkalosis= results from oral ingestion of excess amt of base (antacids), vomiting, ng suction, increased hco3
o Care= antiemetics, fluids and electrolyte replacement
 ABG
o First look at pH, 7.35-7.45
 <7.35=acidic
 >7.45= alkalosis
o PaCO2, 45-35
 >45= respiratory acidosis
 <35= respiratory alkalosis
o HCO3, 22-26
 <22= metabolic acidosis
 >26= metabolic alkalosis
o Uncompensated= pH is outside expected range and so is PaCO2 or HCO3
o Partially compensated= pH, HCO3 and PaCO2 are out of range
o Fully compensated= pH is w/I expected range but PaCO2 and HCO3 are out of range

Ch. 46 Gastrointestinal Diagnostic Procedures

 Liver function tests= expected ALT and AST <40, bilirubin <1
 Pancreatitis= expected amylase <100, lipase <100
 Albumin= 3.5-5; decreased shows malnourished and hepatic disease
 Ammonia= <100, elevated in liver disease
 Fecal occult blood test= test for c diff, gi bleeding, occult blood
o += blood in GI from ulcer, colitis, cancer
 Endoscopy= used for anemia, ab discomfort, ab distention or mass
o Colonoscopy= enter through anus, moderate sedation, left side w/ knee to chest, bowel prep, clear liquid diet (avoid red, purple, orange fluids),
NPO after midnight
o EGD= insertion of endoscope through mouth, NPO 6-8 hr
 Sigmoidoscopy= visualize sigmoid colon, no anesthesia, left side, bowel prep, clear liquid diet 24hr b/f procedure, NPO after midnight
 Complications
o Hemorrhage= tachy, tachypnea, hypotension
o Aspiration
 GI series= done w/ or w/o contrast, drink barium prep
o Clear liquid/low residue diet, NPO after midnight, avoid smoking or chewing gum (increases peristalsis)
o Increase fluid intake to promote elimination of contrast material
o Stools will be white for 24-72hr until barium clears

Ch. 47 Gastrointestinal Therapeutic Procedures

 Enteral feedings= comatose, intubated, difficulty swallowing
o Complications= check residual every 4-6hr, hold for residual volume of 100-200mL
 TPN= through central line, given for inability to absorb nutrition, hypermetabolic state, chronic malnutrition, obtain daily labs, change tubing and solution
bag every 24hr, filter tubing to collect particles from solution, check glucose every 4-6hr for first 24 hrs, keep dextrose 10% in water at bedside
 Complications
o Air embolism= clamp catheter and place pt on left side in Trendelenburg position, admin o2 and notify dr
o Infection= observe central line for local infection (erythema, tenderness, exudate), do NOT use TPN line for other IV bolus fluids and meds

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 Paracentesis= insert needle through ab wall into peritoneal cavity, relief of ab ascites pressure, used for respiratory distress
o Verify pt has signed consent, void, put in upright position, review vitals, wt, measure ab girth, admin sedation
o Check vitals and wt and measure ab girth after procedure, admin iv bolus fluids or albumin
 Bariatric surgery= resume fluids and restrict to 30mL and increase in frequency and volume, provide six small meals a day, observe for dumping syndrome
(cramps, diarrhea, tachy, dizzy, fatigue)
 NG decompression= intestinal obstruction to decompress
o Vomiting, absent bowel sounds (paralytic ileus) or high pitched (obstruction), ab pain, ab distension
o Assess bowel sounds and ab girth after placement, monitor for displacement (Decrease in drainage, increase n/v, distention)
 Ostomies
o Ileostomy= surgical opening in ileum, frequent liquid stools
o Colostomy= surgical opening in large intestine, formed stools
o Stoma should appear pink and moist, empty ostomy bag when ¼ to ½ full
o Complications= ischemia (pale pink or bluish purple stoma, dry)
Ch. 48 Esophageal Disorders
 GERD= content and enzyme backflow into esophagus
o Risks= obesity, old, eat fatty fried foods chocolate caffeine peppermint spicy food tomatoes citrus alcohol, increased ab pressure from obesity,
pregnancy, bending at waist, ascites
o Findings= pain worsens with position of bedding, straining or laying down, pain occurs after eating, throat irritation (chronic cough, bitter taste
in mouth), pain is relieved by drinking water or sitting up or taking antacids
o Diagnostics= egd barretts epithelium (premalignant cells)
o Meds
 PPI= pantoprazole or omeprazole
 reduce gastric acid
 Antacids= aluminum hydroxide
 neutralize excess acid; take 1-3 hrs after eating and at bed, separate from other meds by at least 1hr
 Histamine 2 receptor antagonist= ranitidine, famotidine
 reduce the secretion of acid
 Prokinetics= metoclopramide
 increased motility of esophagus and stomach
 monitor pt for eps
o Therapy
 Fundoplication = wrap fundus of stomach around esophagus
 Avoid offending foods, avoid large meals, sit up, avoid eating b/f bed, avoid tight clothes, lose wt, elevate head of bed
 Esophageal varices= swollen, fragile blood vessels generally found in submucosa, occur as result of portal htn, due to cirrhosis of liver, hemorrhage is
medical emergency
o Findings= hypotension, tachy
o Lab tests= hgb, hct, elevated ammonia
o Diagnostics= endoscopy
o Care= est. iv with large bore needle
o Meds= nonselective bb like propranolol to decrease hr and reduce hepatic venous pressure, vasopressor to vasoconstrict
o Complications= hypovolemic shock (tachy, hypotension)

Ch. 49 Peptic Ulcer Disease

 Erosion of mucosal lining of stomach, esophagus or duodenum, caused by gram – h pylori
 Risks= h pylori, nsaid and corticosteroid use, severe stress
 Findings= heartburn, bloating n/v, pain or burning sensation of mid epigastrium or back, hematemesis, melena (black stools)
 Care= monitor orthostatic changes, tachy, restrict milk, caffeine, decaf coffee, spicy foods, and nsaids
 Meds
o Antibiotics= metronidazole, amoxicillin, clarithromycin, tetracycline
 eliminate h pylori; complete full course of meds
o Histamine 2 receptor antagonist= ranitidine, famotidine
 suppress secretion of gastric acid
o PPI= pantoprazole
 reduce gastric acid, prevent and assist in healing of ulcers
o Antacids= magnesium hydroxide
 1-2hr after meals, give 1-2 apart from other meds
o Mucosal protectants= sucralfate
 coats ulcer and protects from acid, admin on empty stomach 1hr b/f meals and at bed
 Complications= perforation/hemorrhage (severe epigastric pain, ab can become tender and rigid, rebound tenderness), dumping syndrome (limit fluid,
don’t drink w/ meals but 1hr prior and following meal, high protein, high fat, low fiber and low carb diet, avoid milk and sugar)
 Gastric ulcer= pain occur 30-60 min after meal, pain exacerbated by eating
 Duodenal ulcer= pain occurs 1.5-3hr after meal, pain during night, pain relieved by eating or antacid

Ch. 50 Acute and Chronic Gastritis

 Gastritis= inflam in lining of stomach
 Chronic= can lead to pernicious anemia and h pylori
 Risks= h pylori infection, nsaid, corticosteroid, alcohol, smoking, caffeine, excess stress, autoimmune disease
 Findings= upper ab pain or burning can increase or decrease after eating, ab bloating, hematemesis and stools with occult blood, black tarry stools
 Diagnostics= endoscopy
 Care= small frequent meals and encourage eat slow, avoid alcohol/caffeine/foods that cause gastric irritation, reduce stress, monitor for gastric bleeding

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 Meds
o Histamine 2 antagonists= famotidine, take oral dose w/ meals
o Antacids= take on empty stomach, wait 1hr to take other meds
o Ppi= pantoprazole, allow 60 min b/f eating, do not crush or chew
o Prostaglandins= misoprostol, reduce gastric acid secretion don’t take if pregnant
o Mucosal barrier= sucralfate, protective coating over mucosa, allow 30 min b/f or after to give antacid, take on empty stomach
o Antibiotics= eliminate h pylori
 Complications= gastric bleed (fluid replacement, monitor ng tube for blood), dehydration (monitor fluid intake and urine output, electrolytes), pernicious
anemia (need monthly vitamin b12 injections)

Ch. 51 Noninflammatory bowel disorders

 Hernia= displacement of bowel through weakness of ab muscle
 Risks= male, advanced age, increased intra ab pressure from pregnancy or obesity
 Findings= protrusion or lump at site
 Care= avoid coughing, straining and lifting
 Ibs= d/c, consume 2-3l fluid per day, increase fiber intake (30-40g day)
o Findings= cramping pain in ab, change bowel pattern, ab bloating, belching, d/c
o Diagnostics= change bowel pattern, ab distension, feeling defecation isn’t complete and presence of mucus w/ stools
o Care= reduce stress, limit intake of irritating agents (gas foods, caffeine and alcohol), keep food diary
o Meds
 Alosetron= ibsd
 Lubiprostone= ibsc
 Intestinal obstruction
o Mechanical= caused by tumor or postsurgical adhesion, diverticulitis, hernia
o Nonmechanical= paralytic ileus, neurogenic disorder, vascular disorder, electrolyte imbalance
o Small and large= ab distension, high pitch above and hypoactive below obstruction
o Small= profuse, sudden projectile vomiting with fecal odor
o Large= diarrhea or ribbon like stools around impaction
o Diagnostics= ct
o Care= npo
o Therapy=ng tube, oral hygiene every 2hr
o Surgery= colon resection, colostomy; clamp ng and assess tolerance prior to removal, clear liquids, clamp tube after eating

Ch. 52 Inflammatory Bowel disease

 Ulcerative Colitis= edema and inflammation in rectum and sigmoid colon, entire length of colon, mucosa and submucosa
o Findings= left lower quadrant pain, fever, 15-20 stools that contain mucus, blood or pus, ab distention, tender
o Tests= decreased hct and hgb, increased ESR, increased wbc, increased c reactive protein, decrease albumin
o Diagnostics= colonoscopy, barium enema, ct
o Therapy= colectomy, ileostomy
 Crohn’s Disease= all bowel layers, entire gi tract from mouth to anus, skips
o Findings= right lower quadrant pain, fever, five loose stools with mucus or pus, ab distention, tender, steatorrhea
o Tests= decreased hct and hgb, increased ESR, increased wbc, increase c reactive protein, decreased albumin
 Diverticulitis= inflammation and infection of bowel mucosa caused by bacteria, food or fecal matter trapped in diverticula
o Findings= pain in left lower quadrant, fever, chills
o Care= consume clear liquid diet, low fiber, add fiber once solid foods are tolerated, avoid seeds or nuts or popcorn
o Therapy= colon resection
 Risks= genes, white, jewish, smoking
 Care=monitor for perforation (fever, severe ab pain, vomiting), npo and tpn, high protein, high cal and low fiber food, avoid caffeine and alcohol, small
frequent meals, monitor electrolytes
 Meds
o 5 aa= sulfasalazine
o Corticosteroids= reduce inflame and pain; risk of infection and hyperglycemia
o Immunosuppressants= cyclosporine, avoid crowds, monitor for infection
o Immunomodulators= suppress immune response infliximab, avoid crowds, increased risk of infection
o Antidiarrheal= loperamide
o Antimicrobial= ciprofloxacin, metronidazole
 Complications= peritonitis (rigid, board like ab, nv, rebound tenderness, tachy) place pt in fowler, admin o2, ng, npo

Ch. 53 Cholecystitis and Cholelithiasis

 Cholecystitis= inflam of gallbladder wall caused by gallstones obstructing bile ducts which causes bile to back up and gall bladder to become inflamed
 Cholelithiasis= presence of stone in gallbladder
 Risks= females, high fat diet, obese, genetics, older
 Findings=sharp pain in right upper quadrant, intense pain after ingestion of high fat food, dyspepsia, eructation (burping), flatulence, clay colored stool,
steatorrhea, dark urine, pruritus
 Labs= increased wbc, inc bilirubin, increased amylase and lipase increased w/ pancreatic involvement
 Diagnostics= ultrasound visualize gallstones, ab x ray or ct visualize calcified gallstones and enlarged gallbladder, hepatobiliary scan
 Therapy
o Lithotripsy= shock waves used to break up stones, used on nonsurgical candidates of normal wt, small cholesterol based stones
o Cholecystectomy= shoulder pain is normal, removal of gallbladder, discharged w/I 24hr if laparoscopic

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 Elevate t tube above level of ab, monitor and record color of drainage, clamp tube 1hr b/f and after meals, assess stools for color
(clay colored until biliary flow reestablished, should return to brown in week and diarrhea is common)
 low fat diet, avoid gas forming foods (beans, cabbage, cauliflower, broccoli)
 Complications= peritonitis

Ch. 54 Pancreatitis
 Secrete digestive enzymes that break down carb, protein and fat which activate prematurely in pancreas
 Chronic pancreatitis leads to fibrosis
 Risks= biliary tract disease, gallstones, alcohol use, gastrointestinal surgery, hyperlipidemia, hyperparathyroidism, trauma, penetrating ulcer, med toxicity
 Findings= severe epigastric pain radiating to back, left flank or left shoulder pain, worse lying down, relieved in fetal position, n/v, wt loss, turner sign
(bruising on flanks), Cullen sign (bruising around umbilicus), jaundice, warm moist skin, fruity breath, ascites, tetany (+ trousseau and Chvostek sign)
 Labs= increased amylase and lipase, increase wbc, decreased Ca and Mg, increase serum liver enzymes and bilirubin (>1), increased glucose
 Care= npo, tpn, bland diet with no caffeine, small frequent meals, antiemetic, no alcohol, no smoking, limit stress, pain management, monitor blood
glucose, insulin, monitor electrolyte and hydration
 Meds
o Opioids
o Pancreatic enzymes= aid w/ digestion of fats and proteins when taken w/ meals and snacks
 Edu= alcohol abuse program
 Complications= pseudocyst (leakage of fluid out of pancreas), dm 1

Ch. 55 Hepatitis and Cirrhosis

Viral hepatitis is most common but can also be caused by drug or toxin
 Viral
o A= transmitted fecal-oral (contaminated food/water or close contact)vaccine preventable
o B= transmitted through blood/body fluids (sex, drugs, mom)vaccine preventable
o C= transmitted through blood/body fluids (sex, drugs)
 Risk for hepatitis= dirty needles, piercings, tattoos, sex, contaminated food, travel in underdeveloped countries, prison or crowded living conditions
 Symptoms hepatitis=flu (fever, vomiting), dark urine, clay stool, jaundice, increased ast and alt >40, increased bilirubin >1
 Diagnose with biopsy
 No cure, antiviral meds, leads to cirrhosis, liver cancer and failure
Cirrhosis= scarring of liver because prolonged inflame
o Post-necrotic= viral hep
o Laennex= chronic alcohol use
o Biliary= chronic biliary obstruction/autoimmune disease
 Risk= alcoholics, hep, drugs
 Symptoms= fatigue, ab pain, ascites, pruritis, confusion, mentation, encephalopathy, gi bleed, esophageal varices, jaundice, petechiae, palmar erythema,
spider angiomas, peripheral edema, asterixis, fetor hepaticus (fruity breath)
 Lab values= elevated alt and ast and bilirubin, protein (less than 6-8) and albumin (less than 3.5-5) will be decreased, decreased hct and hgb and platelets
and rbc, elevated ammonia
 Diagnosis= biopsy, ultrasound, ct scan and mri
 Care= sit upright at 30 degrees with feet elevated, o2, wash with cold water and apply lotion, strict I and O, lactulose (binds ammonia to be excreted for
encephalopathy, cause hypoK), high carb and high protein and low fat and Na, measure ab girth daily, bb, K, void b/f paracentesis, smaller more frequent
meals
 Transplant= pt will be on immunosuppressants

Ch. 56 Renal diagnostic procedures

 Labs
o Creatinine= increases w/ kidney disease
o BUN= dehydration affects it, increased w/ kidney disease
o Urinalysis= collect early morning specimen, observe color, specific gravity (1.01-1.025), drug metabolite, glucose, ketone bodies, protein
 CT complications= dye can cause aki, shellfish allergy or iodine contraindicated, increase hydration after procedure
 Cystoscopy, cystourethroscopy
o NPO after midnight, laxative or enema for bowel prep
 Excretory urography
o Bowel cleanse w/ laxative or enema, NPO after midnight

Ch. 57 Hemodialysis and Peritoneal Dialysis

 Dialysis= rid body of excess fluid and electrolytes, eliminate waste products
 Hemodialysis= vascular access
o Patency of long term devices, presence of bruit, palpable thrill, distal pulses, avoid measuring bp, admin injections, performing venipunctures or
inserting iv on this arm
o Assess vitals, lab values (BUN, creatinine, electrolytes, hct) and wt
o 3x a week for 3-5hr session, two needles, one into artery and other into vein
o Monitor for complications such as hypotension, cramping, vomiting, bleeding, heparin prevent clotting of blood, have protamine sulfate ready
to reverse heparin
o Post= decrease bp and changes in lab values, compare pt pre wt w/ post wt, increase protein intake over pre-dialysis limitations, avoid lifting
heavy objects w/ access arm, avoid carrying objects that compress extremity, avoid sleeping on top of extremity, perform hand exercises that
promote fistula maturation
o Complications

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 Clotting/infection of access site= anticoag prevent blood clots, monitor for hemorrhage, use surgical aseptic technique during
cannulation
 Disequilibrium syndrome= rapid decrease of bun and circulating fluid volume, cerebral edema, increase icp, n/v change in loc,
seizures, agitation; slow dialysis exchange, take anticonvulsant
 Hypotension= infuse iv fluids or colloid, slow dialysis exchange, lower head of bed
 Anemia
 Infectious disease
 Peritoneal dialysis= instillation of hypertonic dialysate solution into peritoneal cavity, dwell, drain dialysate and waste products, use in older adults or
unable vascular access
o Pre= pt feel full when dialysate is dwelling and discomfort
o Intra= record amt of inflow compared to outflow, monitor color (clear to yellow) of outflow, signs of infection (fever, bloody, cloudy frothy
dialysate return), warm dialysate prior to instilling, keep outflow bag lower than pt ab
o Complications
 Peritonitis= fever, purulent drainage, redness, swelling, cloudy or discolored drained dialysate
 Protein loss= increase diet intake of protein over predialysis restriction
 Hyperglycemia= monitor glucose
 Poor dialysate inflow or outflow= obstruction or twisting of tubing, constipation is common cause, milk tubing to break up fibrin
clots, tell pt to avoid constipation and use softener and consume diet high in fiber

Ch. 58 Kidney Transplant

 End stage kidney disease
 Post= assess urine output, should be greater than 30ml, abrupt decrease in urine output indicates rejection, monitor for manifestations of infection
(dyspnea, fever, incisional drainage, redness), rejection (fever, htn, pain at transplant site), encourage pt to turn, cough and deep breathe to prevent
pneumonia, maintain continuous bladder irrigation, admin immunosuppressive meds (cyclosporine) to prevent rejection and monoclonal antibodies
(basiliximab or daclizumab)
 Edu= low fat diet to decrease cholesterol, high fiber to avoid constipation, increase protein, avoid concentrated sugar or carbs to control glycemic factors,
avoid contact sports
 Complications
o Hyperacute= occur w/I 48hrs after surgery, antibody mediated response small blood clots, not reversible
o Acute= 1week to 2 years after surgery, increased doses of immunosuppressive meds
o Chronic= occurs gradually over months to years

Ch. 59 Polycystic Kidney Disease, Acute Kidney Injury, Chronic Kidney Disease
 Acute kidney injury
o Phases
 Oliguria= 100-400ml/24hr for 1-3 weeks
 Diuresis= large amt of fluid occurs and last 2-6 weeks
 Recovery= 12 months
o Types
 Prerenal=reduction of blood flow to kidneys
 Risks= renal vascular obstruction, shock, decreased renal profusion, sepsis, hypovolemia
 Intrarenal= trauma, antibiotics, contrast dye, heavy metals
 Postrenal= stone, tumor, prostate hyperplasia
o Labs
 Creatinine increases
 Bun increases to 80-100 in one week
o Nutrition= implement k, phosphate, na and magnesium restriction, high protein diet
 Chronic kidney disease
o Older adults are at increase risk related to aging, lack of thirst, higher risk for dehydration
o Stages
 1= gfr greater than 90
 2= gfr 60-89
 3= gfr 30-59
 4= gfr 15-29
 5= gfr <15
o Drink at least 2L water daily, stop smoking, control diabetes and htn
o Risks= aki, dm, nephrotoxic meds, htn, autoimmune disorders (sle)
o Findings= lethargy, slurred speech, tremors, jerky movements, jugular distention, hf, sob, tachypnea, crackles, anemia, vomiting, pruritus,
uremic frost
o Labs= hematuria, proteinuria, decrease in specific gravity, increase bun w/ increase creatinine, decreased na and ca, increased k and
phosphorus and mg
o Diagnostics= kub, ct, mri
o Care= 2.2lb wt increase is 1L of fluid retained, restrict na, k, phosphorous and mg, diet high in carbs and moderate in fat, monitor wt gain, skin
care
o Meds= avoid nsaids, contrast dye, epo (stimulate production of rbc), ferrous sulfate, furosemide (loop diuretic to excrete excess fluids)
o Edu= avoid antacids w/ mg, take rest periods from activity

Ch. 60 Infections of Renal and Urinary system

 Uti=caused by ecoli, untreated lead to pyelonephritis and urosepsis

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o Risks= female, short urethra, close proximity of urethra to rectum, sex, pregnancy, synthetic underwear, wt bathing suits, frequent baths or hot
tubs, indwelling urinary catheter, stool incontinence, dm, incomplete bladder emptying
o Findings= lower ab discomfort, nausea, urinary frequency and urgency, dysuria, fever, vomiting, cloudy or foul smelling urine, confusion in older
adults, urosepsis (hypotension, tachy, tachypnea, fever)
o Labs= urinalysis (bacteria, wbc pyuria, positive leukocyte esterase and nitrates)
o Meds= fluoroquinolones (antibiotics), phenazopyridine (bladder analgesic, will turn urine orange)
o Edu= drink at least 3L fluid daily, bathe daily, empty bladder every 3-4hr, urinate b/f and after sex, drink cranberry juice to decrease risk of
infection, wipe front to back, avoid bubble bath, avoid wet bathing suit, avoid tight clothing
 Pyelonephritis
o Findings= nausea, cva tenderness, flank and back pain, fever, tachy, tachypnea, htn, vomiting
o Labs= positive leukocyte esterase and nitrites wbc and bacteria, serum creatinine and bun are elevated, c reactive protein is elevated, esr is
elevated
o Meds= opioid analgesics, antibiotics
o Complications= septic shock, chronic kidney disease, htn
 Glomerulonephritis= can lead to end stage kidney disease, following infection, develop over 20-30 years
o Risks= recent infection (strep), sle
o Findings= oliguria, htn, difficulty breathing, wt gain, pitting edema in lower extremities, red brown colored urine
o Labs= urinalysis shows rbc and protein, throat culture, bun and creatinine increased, antistreptolysin o titer increase, increased esr, increased
specific gravity, increased wbc
o Care= monitor fluids and electrolytes, na restrictions 4g/day, dialysis or plasmapheresis
o Meds= antibiotics, anti-htn, diuretic (decrease excess fluid), corticosteroids (decrease inflame)
o Edu= monitor i&o, monitor daily wt, fluid restriction, protein restriction if azotemia (buildup of nitrogen waste), increased bun
o Complications=pulmonary edema, anemia (decrease epo), give iron and epo

Ch. 61 Renal Calculi

 Urolithiasis= presence of calculi (stones) in urinary tract
 Majority of calculi are composed of calcium phosphate or oxalate or uric acid, most expel calculi w/o invasive procedures
 Risks= males, metabolic defect (increased intestinal absorption or decreased renal excretion of ca), high alkalinity or acidity of urine, urinary stasis, urinary
retention, dehydration
 Findings= sever pain (renal colic), flank pain that radiates to ab, urinary frequency or dysuria, fever, diaphoresis, pallor, n/v, tachy, tachypnea,
oliguria/anuria if calculi obstruct, hematuria
 Diagnostics= x-ray of kidney ureters or bladder, ct or mri
 Care= strain all urine to check for passage of calculus and save calculus for lab analysis, increase oral intake to 3l/day, encourage ambulation to promote
passage of calculus
 Meds= opioid analgesics, nsaids for mild to moderate pain, spasmolytic meds like oxybutynin
 Therapy
o Lithotripsy= use sound, laser or shock wave energy to break calculi into fragments, moderate (conscious) sedation and ecg monitoring during
procedure, strain urine following, bruising is normal, pt will have hematuria
 Edu= limit intake of food high in animal protein and na and reduce ca intake for ca stone, avoid oxalate and limit na intake for oxalate stone, decrease
intake of purine sources and take allopurinol to prevent formation of uric acid in uric acid stone
 Complications
o Obstruction= notify dr immediately
o Hydronephrosis= urine back up and causes distension

Ch. 62 Diagnostic and therapeutic procedures for female reproductive disorders

 Pap test= use to id precancerous and cancerous cells of cervix, start at age 21 to screen for cervical cancer, every 3 years if normal
o Pre= not menstruating, does not use vaginal meds, douch or sex w/I 24hrs, empty bladder
o Post= minimal bleeding
 Biopsy= pap tests that are atypical or abnormal
o Post= rest for first 24 hrs after procedure, abstain from sex, avoid douche, vaginal creams or tampons until discharge has stopped (2 weeks),
avoid lifting heavy object for 2 weeks, report excess bleeding, fever or foul smelling drainage to dr
 Endometrial biopsy= assess for uterine cancer, abnormal bleeding
o Pre= analgesic, discomfort and cramping is expected, empty bladder
o Post= spotting can be present for 1-2 days, abstain from sex, douche until all discharge has stopped (2 weeks), have pt notify dr of heavy
bleeding
 HIV= ELISA test and then western blot to confirm diagnosis
 Mammogram= start at age 40
o Pre= avoid deodorant, lotion, powder, not pregnant
 Hysterectomy= remove uterus b/c uterine cancer, fibroids, endometriosis, genital prolapse
o Post= monitor vitals, monitor breath sounds and bowel sounds, monitor urine output, take thromboembolism precautions, monitor blood loss
o Edu= pt ovaries have been removes watch for menopausal manifestations, restrict activity for 6 weeks, avoid tampons, notify dr of temp over
100, foul smelling drainage from incision, pain redness, swelling in calf or burning on urination

Ch. 63 Menstrual Disorder and Menopause

 Average age of menarche= 12
 Menstrual cycle last 28 days
 Ovulation occurs around day 14
 Menstruation 4-9 days
 Menopause is when ovulation ceases and menstrual cycles stop, around 52
 Menstrual disorders

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o Amenorrhea= common cause is low % of body fat in women who are in sports or strenuous physical activity, anorexia
o Pms= irritability, impaired memory, depression, poor concentration, mood swings, bloating, wt gain, headache, back pain
o Endometriosis= overgrowth of endometrial tissue that extends outside uterus into fallopian tubes, common cause of infertility
 Labs= hgb and hct below range due to excess blood loss, ca125 elevated in ovarian cancer
 Diagnostics= endometrial biopsy (test for uterine cancer), transvaginal ultrasound (uterine fibroids)
 Meds
o Ocp= decrease manifestations of pms, dysmenorrhea and dub
o Diuretic= treat bloating and wt gain
o Leuprolide= treat endometriosis, cause birth defects so use contraception
o Nsaids= pain and discomfort related to pms
o Oral iron supplements= treat anemia associated with dub
o Fluoxetine= treat emotional and physical manifestations of pms
 Menopause= complete when no menses for 12 months
o Findings= hot flashes, atrophic vaginitis, decreased vaginal secretions, mood swings, decreased bone density
o Meds
 Hormone therapy= suppress hot flashes associate with menopause, prevent atrophy of vaginal tissue, reduce risk of fractures due to
osteoporosis
 Adverse effects= coronary heart disease, mi, dvt, stroke, breast cancer
 Edu= quit smoking, avoid knee high stocking and tight clothes, report unilateral leg pain, edema, warmth and redness,
avoid sitting for long periods, stretch legs, mi (pain b/w shoulders)

Ch. 64 Disorders of Female Reproductive Tissue

 Cystocele= protrusion of posterior bladder through anterior vaginal wall
o Risks= obesity, old age, loss of estrogen
o Findings= urinary frequency/urgency, stress incontinence
 Rectocele= protrusion of anterior rectal wall through posterior vaginal wall
o Risks= pelvic structure defects, obesity, constipation
o Findings= constipation, pelvic/rectal pressure/pain
 Risks= females following menopause, constipation
 Care
o Vaginal pessary= removable rubber plastic or silicone devices inserted into vagina to provide support and block protrusion of other organs into
vagina
o Kegal exercises= strengthen pelvic floor, contract circumvaginal and perirectal muscles, increase contraction period to 10 seconds follow each
contraction period w/ relaxation period of 10 seconds
 Fibrocystic breast condition
o Risks= premenopausal
o Findings= tender lumps, palpable rubberlike lumps in upper outer quadrant
o Diagnostics= breast ultrasound to confirm

Ch. 65 Diagnostic Procedures for Male Reproductive Disorders

 Enlargement of prostate gland is benign and called bph, prostate cancer is one common form of cancer in men
 Psa= perform prior to dre b/c rise in psa can occur due to irritation that occurs upon palpation during dre
 Dre= reveals abnormality, location of potentially cancerous prostate lesion is determined by ultrasonography and confirmed by biopsy
 Psa and dre for men older than 50, black and men w/ family history of prostate cancer should begin screening earlier, diminished flow and retention of
urine
 Psa should be 2.5, greater than 4 requires further eval
 Dre= abnormal finding include abnormally large and hard prostate w/ irregular shape or lumps

Ch. 66 Benign Prostatic Hyperplasia

 Prostate gland enlarges in adult males as they age
 Findings= urinary frequency, urgency, hesitancy, incontinence, incomplete emptying of bladder, dribbling post void, nocturia, diminished force of urinary
stream, straining w/ urination, hematuria
 Psa= rule out prostate cancer
 Dre= reveal enlarge smooth prostate
 Transrectal ultrasound w/ needle aspiration biopsy= rule out prostate cancer
 Finasteride= decrease production of testosterone in prostate gland
o Edu= impotence and decrease in libido are possible adverse effects, women who are pregnant should avoid contact w/ tablets and semen of pt
 Tamsulosin= cause relaxation of bladder outlet and prostate gland, cause postural hypotension
 Prostatic stent
 TURP= indwelling three way catheter, rate of cmi is adjusted to keep irrigation return pink or lighter, if it appears ketchup that means bleeding is arterial
w/ clots and nurse should increase cbi rate, if catheter is obstructed (bladder spasms, reduced irrigation outflow) then turn off cbi and irrigate w/ 50ml,
contact surgeon if unable to dislodge clot, balloon will cause pt to feel continuous need to urinate, admin analgesics, antispasmodic, antibiotics, stool
softeners
o Edu= drink 12 8oz glasses of water, avoid bladder stimulants such as caffeine and alcohol, urine becomes bloody stop activity, rest and increase
fluid intake, contact surgeon for persistent bleeding or obstruction

Ch. 67 Musculoskeletal Diagnostic Procedures

 Arthroscopy= allows visualization of internal structures of joint, don’t do if infection or lack of joint mobility
o Apply ice for first 24hr after procedure, elevate extremity for 12-24hrs, notify provider of changes such as swelling, increased joint pain,
thrombophlebitis, infection (redness, swelling, purulent drainage)

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 Nuclear Scans
o Bone scan= radioactive isotope injection 2-3hr b/f scan, bone scans can detect hairline bone fractures, tumors, and diseases of bone
o Gallium and thallium scan= pt receive radionuclide injection 4-6hr b/f scan, scan takes 30-60min and require sedation to help pt lie still during
that time, repeat scan 24,48, 72hrs
o Pre= assess for allergy to radioisotope, explain need to lie still during entire procedure
o Post= encourage pt to drink fluids to increase excretion of radioisotope
 DXA= presence/extent of osteoporosis, baseline at age 40, remove metallic objects
 Emg= determine presence of muscle weakness, place thin needles in muscle under study, record activity during muscle contraction, neuromuscular
disorders, flex muscle during needle insertion

Ch. 68 Arthroplasty
 Arthroplasty= surgical removal of diseased joint and replacing it w/ prosthetic, knees and hips, eliminate pain, restore joint motion, improve pt functional
status and qol, joint crepitus, joint swelling
o c/i= recent or active infection, arterial impairment of affected extremity
o Pre= EPO prescribed several weeks preop to increase hgb for pt who has mild anemia, teach pt about autologous blood donation, remind pt to
scrub surgical site w/ prescribed antiseptic soap night b/f and morning of surgery to decrease bacterial count on skin and lower change of
infection, tell pt to take antihtn and other meds w/ sip of water morning of surgery
 Knee arthroplasty= cpm machine prescribed to promote motion in knee, turn it off during meals, position of flexion of knee are limited to avoid flexion
contractures, avoid knee gatch and pillows placed behind knee, place on pillow under lower calf and foot, apply ice or cold therapy, monitor neuro status
every 2-4hrs
o Meds= analgesics, peripheral nerve blockade, antibiotics, anticoag
 Hip arthroplasty= hgb and hct continue to drop for 48hr after surgery, blood transfusions are common for hgb levels less than 9, early ambulation, place
pillow or abduction device b/w legs when turning to unaffected side, monitor for new joint dislocation (acute onset of pain, pop, shortened affected
extremity)
o Meds= analgesics, antibiotics, anticoagulant
 Edu= elevated seating and raised toilet seat, abduction pillow, externally rotate toes, use extended handles on shoehorns and dressing sticks to prevent
flexion greater than 90 degrees, avoid flexion of hip greater than 90 degrees, do not cross legs, do not internally rotate toes
 Complications= manifestations of pe/dvt (scd while in bed)

Ch. 69 Amputations
 Elective due to complications of pvd, traumatic injury, malignancy
 Findings= altered peripheral pulses (use doppler), differences in temp of extremities (becomes cool), altered color of extremities (gangrene, cyanosis), lack
of sensation in affected extremity
 Traumatic amputation= apply direct pressure, elevate extremity above heart to decrease blood loss, wrap severed extremity in dry sterile gauze and place
in sealed plastic bag, submerge in ice water
 Phantom limb pain= admin bb, admin antiepileptics, recognize pain is real, teach pt how to push residual limb down and support on soft pillow
 Prosthetic= shaped and shrunk residual limb, wrap stump in figure 8, use stump shrinker sock, use air splint, perform limb strengthening exercise
 Complications= contracture (ROM exercises and proper positioning immediately after surgery, have pt lie prone for 20-30min several times a day,
discourage prolonged sitting)

Ch. 70 Osteoporosis
 Low bone density b/c rate of bone resorption (osteoclasts) excess bone formation (osteoblasts), osteopenia is precursor
 Prevention= diet adequate in vitamin d (fish, egg yolks, fortified milk and cereal), calcium (milk, green veggies, fortified orange juice and cereals, red and
white beans), limit carbonated drinks, sun 5-30 min twice a week, wt bearing exercise
 Risks= female, family hist, thin, lean, older than 60, postmenopausal, low ca and vitamin d, smoking, high alcohol, excess caffeine consumption, lack of
physical activity, hyperparathyroidism, long use of corticosteroids and anticonvulsants
 Findings= reduced ht, acute back pain, hist of fractures, kyphosis
 Diagnostics= DXA scan
 Care= ca food, ca and vitamin d supplementation take with food, sun exposure, wt bearing exercise, remove throw rugs, adequate lighting, clear walkways
 Meds
o Calcitonin salmon
o Estrogen= increase risk of breast and endometrial cancer and dvt
o Raloxifene
o Alendronate= risk for esophagitis, take w/ 8oz water in morning b/f eating, remain upright for 30 min after taking
 Therapeutic procedures= orthotic devices; immobilize spine, log roll out of bed, joint repair/ arthroplasty

Ch. 71 Musculoskeletal Trauma

 Closed simple fracture= does not break through skin
 Open compound fracture= disrupts skin integrity, causing open wound and tissue injury w/ risk of infection
 Complete fracture= goes through entire bone
 Incomplete fracture= goes through part of bone
 Comminuted fracture= has multiple fracture lines splitting the bone into multiple pieces
 Displaced fracture= bone fragments that are not in alignment
 Oblique fracture= fracture occurs at oblique angle and across bone
 Spiral fracture= fracture occurs from twisting motion (common w/ physical abuse)
 Risks= post-menopause, osteoporosis, falls, crashes, diseases
 Findings= crepitus, deformity, muscle spasm, edema, ecchymosis
 Care= stabilize, elevate limb above heart and apply ice, initiate and continue neuro checks at least every hour
o Neuro= every hr for first 24hrs, and every 1-4hrs, pain, sensation, skin temp, cap refill, pulses, movement

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o Handle plaster cast w/ palms not fingertips until cast is dry, elevate cast above level of heart during first 24-48hrs, instruct pt to not place
foreign objects inside cast, use hair dryer blowing cool air to relieve itching, report areas under cast that are painful ‘hotspot’ will have
increased drainage, warm to touch have odor and indicate infection
o Traction=promote and maintain alignment of injured area, realign bone fragment
 Bryant= used for congenital hip dislocation in kids
 Bucks= preop for hip fractures
 Assess neuro every hr for 24hrs, avoid lifting or removing wts, ensure wts hang freely and aren’t resting on floor, notify provider if pt
experiences severe pain from muscle spasm unrelieved w/ meds or repositioning, move pt in halo traction as unity, use
heat/massage as prescribed to treat muscle spasms
 Pin site= drainage and redness, loosening of pins, tenting of skin at pin site, pin care is provided once a shift (1-2 times a day)
 Meds=analgesics, muscle relaxants, antibiotics
o External fixations= pins and wires are attached to rigid external frame
o Open reduction and internal fixation= visualize fracture through incision in skin and internal fixation w/ plates, screws, pins, rods and
prosthetics
 Complications
o Compartment syndrome= when pressure w/I one or more muscle compartments compromises circulation resulting in ischemia
 Pain, paresthesia (early manifestation), paralysis (late manifestation), pallor and cyanotic, pulselessness (late manifestation),
palpated muscles are hard and swollen from edema, surgical incision is made through SQ tissue and fascia of affected compartment
to relieve pressure
o Fat embolism= 12-48hrs following long bone fracture or w/ total joint arthroplasty, fat globules from bone marrow released into vasculature
and travel to small blood vessels in lungs, impaired organ perfusion
 Dyspnea, increased RR, respiratory distress, tachy, confusion, petechiae (late manifestation)
o DVT/PE= apply antiembolism stockings, scd, admin anticoags
o Osteomyelitis= bone pain, erythema, edema, fever, leukocytosis, treat w/ 3 months of iv and oral antibiotics, surgical debridement, hyperbaric
o2 treatment can promote healing in chronic cases

Ch. 72 Osteoarthritis and low back pain

 Osteoarthritis= progressive deterioration of articular cartilage, bone spur growth at joint ends, degenerative, pain with activity that improves at rest,
localized, overwt, Heberden’s and bouchards nodes, NOT systemic or symmetric; stop smoking
o Risk= adults > 60, women, repetitive stress on joints, obesity
o Findings= joint pain and stiffness, crepitus, enlarged joint, Heberden’s nodes distal interphalangeal joints, bouchards nodes at proximal
interphalangeal joints
o Edu= balance rest with activity, heat to alleviate pain and ice for acute inflame, splinting, assistive devices, PT
o Meds= apap 4000mg a day, topical nsaids, capsaicin (use gloves, avoid touching eyes or applying over broken skin, burning sensation of skin
after application is normal), glucosamine (makeup cartilage), injections (glucocorticoids treat local inflam, hyaluronic acid)
o Total joint arthroplasty = all else fails, replace total joint
o Monitor kidney function, report black tarry stool
 RA= synovial membrane inflame resulting in cartilage destruction and bone erosion, inflame, pain at rest after immobility (morning stiffness, all joints,
underwt, swan neck and boutonniere deformities of hands, systemic affect lungs, heart skin and extra articular, symmetrical, positive RA factor

Ch. 73 Integumentary Diagnostic Procedures

 Bacterial infection= bathe daily using antibacterial soap, remove crusted exudate so antibacterial topical medication can penetrate into lesion
o Meds= superficial skin infection are treated w/ topical antibacterial cream or ointment, if cellulitis present, treat w/ systemic antibiotic therapy
o Culture and sensitivity should be done b/f antimicrobial therapy, 24-48hr results
 Culture= id pathogen
 Sensitivity= id effect antimicrobial agent have on micro-organism, if microorganism is killed it is sensitive, if not killed it is resistant
 Viral lesion= apply compress of burros solution for 20min, 3x a day to promote formation of crust and healing
o Meds= topical treatment w/ acyclovir
o Tzanck smear= determine if lesion is viral
 Fungal meds= clotrimazole cream is applied to infected skin 2x a day and for 1-2 weeks after lesions are no longer present
o Koh test= determine if lesion is fungal
 Biopsy= confirm or rule out malignancy, punch, shave or excisional biopsy
o Mild discomfort, report excess bleeding or signs of infection

Ch. 74 Skin Disorders

 Psoriasis= skin disorder characterized by scaly, dermal patches and caused by overproduction of keratin, autoimmune disorder w/ periods of exacerbations
and remission, commonly present on elbows, knees, trunk, scalp, sacrum and lateral aspects of extremities
o Findings= scaly patches, bleeding stimulated by removal of scales, lesions on scalp, elbows, knees, sacrum, lateral areas of extremities
o Meds
 Corticosteroids= triamcinolone, use occlusive dressing w/ plastic wrap after applying topical med, leave in place up to 8hrs each day
 Tar prep= can cause staining of skin and hair
 Vitamin d= increased risk of skin cancer
 Methotrexate= monitor liver function test and can cause bone marrow suppression
 Cyclosporine= immunosuppressant, increase risk of infection and nephrotoxicity
o Edu= don’t get live vaccines, report signs of infection
o Therapy= PUVA (give psoralen followed by UV to decrease proliferation of epidermal cells) can cause skin cancer
 Dermatitis= topical steroid therapy

Ch. 75 Burns
 Severity of burns= determined by percentage of total body surface area

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 Rule of nines
o Arm= 9%
o Head= 9%
o Front torso=18%
o Leg= 18%
o Perineum=1%
 Lund and browder= more exact measuring method
 Palmar method= quick method, palm of hand is equal to 1% tbsa
 Phases
o Emergent= 24-48hrs, priorities include securing airway, fluid replacement, managing pain, wound care
o Acute= ends with closure of wound
o Rehabilitative= prevent scars
 Superficial= no blisters
 Superficial partial thickness= damage to entire epidermis and some part of dermis, pink to red, blisters, no eschar
 Deep partial thickness= damage to entire epidermis and deep into dermis, red to white, no blisters, eschar soft and dry
 Full thickness= damage to entire epidermis and dermis, extend into subQ, red black yellow or white, no blisters, severe edema
 Deep full thickness= damage to all layers of skin, extend to muscle, tendons, bone, black no edema
 Inhalation damage= singed nasal hair, eyebrows and eyelashes, sooty sputum, hoarseness, wheezing, edema of nasal septum, smoky smell
 Labs
o Resuscitation
 Elevated hct and hgb b/c loss of fluid volume and fluid shift into interstitial space (third spacing)
 Decreased na due to third spacing
 Potassium increased due to cell destruction
o Fluid remobilizations= begins 48-72hrs
 Hgb and hct decreased
 Decreased na
 Decreased k
 Care= stop burning, flush chemical burns with water, provide warmth, educate family to avoid greasy lotion, tetanus, provide humidified o2, initiate IV
access with large bore needle, admin half of total IV fluid volume w/I first 8hr and remaining volume over next 16hrs, bp is average or low, avoid routes
other than IV, restrict plants and flowers, restrict consumption of fresh fruits and veggies, limit visitors, hypercatabolic state require 5000 calories/day,
double or triple 4-12 days, require enteral therapy or tpn, active and passive rom, apply pressure dressings to prevent contractures and scarring
 Meds
o Silver nitrate= apply with gauze dressing
o Silver sulfadiazine= transient neutropenia
o Skin coverings
 Allograft= human cadaver, partial and full thickness
 Xenograft= animal
 Cultured= grow from small specimen from unburned area
 Artificial= shark cartilage or beef collagen
 Amt of fluid replacement= (4ml)(wt in kg)(% body burned)

Ch. 76 Endocrine Diagnostic Procedures

 Posterior pituitary= secretes ADH, causes kidney to reabsorb water
o Deficiency of ADH= DI, excrete large amts of dilute urine
o Excess ADH= SIADH, kidney retain water, urine becomes concentrated, urinary output decreases
 Water deprivation test= measures kidneys ability to concentrate urine, controlled dehydration, help ID DI
 SIADH= increased urine osmolality, increase in urine specific gravity >1.025
 Adrenal cortex
o Excess production of cortisol= cushing disease
o Lack of cortisol= Addison
 Dexamethasone suppression test
o Screen for cushing disease, no decrease is production of acth and cortisol
o Increase in cortisol after admin of acth is expected but if cortisol does not increase after admin it is + for Addison disease
 Adrenal medulla= hypersecretion of catecholamines from tumor cause pheochromocytoma (tachy, htn, diaphoresis)
 Diabetes
o Fasting blood glucose= fast 8hr prior to blood sampling
 >110= DM
o Oral glucose tolerance test= fast for 10-12hr prior to test, consume specific amt of glucose then obtain blood samples at 30 min, 1 hr, 2hr, 3hr
and 4hr
 >140=DM
o HbA1C= average blood glucose level for past 120 days
 >6.5%= DM
 Thyroid and anterior pituitary gland
o Hyperthyroid= high T3 and T4, low TSH
o Hypothyroid= low T3 and T4, high TSH

Ch. 77 Pituitary Disorders

 DI= results from deficiency of ADH
o Primary= lack of adh b/c defect in hypothalamus or pituitary gland
o Secondary= lack of adh b/c infection, tumor, head trauma or brain surgery

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o Nephrogenic= inherited, renal tubules do not react to adh

o Findings= polyuria (abrupt onset of excess urination), polydipsia (excess thirst), fatigue, dehydration, sunken eyes, tachy, hypotension, absence
of skin turgor, dry mucous membranes
o Labs= decrease urine specific gravity <1.01, decrease urine osmolality <200, increased serum osmolality >300, increased serum na, increased
serum k
o Diagnostics= water deprivation test, vasopressin test (differentiates central from nephrogenic di, admin vasopressin SQ and obtain urine sample
for osmolality)
o Meds= adh replacement (desmopressin and vasopressin)
o Care= monitor wt daily, eat high fiber diet, monitor for dehydration
 SIADH= excess release of ADH
o Risks= tumors, head injury
o Findings= serum na decrease, confusion, seizures, coma, death, fluid volume excess, tachy, htn, crackles in lungs, distended neck veins
o Labs= increased urine na, increased urine osmolarity, decreased serum na, decreased serum osmolarity
o Care= restrict oral fluids to 500-1000mL, monitor I&O, daily wt
o Meds= loop diuretic
o Therapy= hypertonic sodium chloride iv fluid
o Complications= water intoxication, cerebral edema, severe hyponatremia (seizure precautions)

Ch. 78 Hyperthyroidism (video 84)

 Anterior pituitary produces tsh and thyroid produces t3 and t4, caused by graves
 Symptoms= Low tsh, hypermetabolic, nervous, irritable, hot, wt loss, insomnia, diarrhea, warm flushed skin, exophthalmos, sweaty, htn, tachy,
dysrhythmia, high t3 and t4
 Care= Increased calories, monitor wt, tape eyelids closed, avoid palpating thyroid, ptu med, leukopenia, thrombocytopenia, propranolol for tachy, iodine
solutions, radioactive iodine, not pregnant, laxative, don’t share utensils, thyroid replacement, high fowlers, laryngeal nerve damage, monitor for
hypocalcemia (can damage hyperparathyroid gland, muscle twitching, positive Chvostek’s and trousseaus sign, prednisone used to reduce post op edema
 Thyroid storm= sudden surge of hormones, stress infection of surgery
o Symptoms= htn, delirium, tachy, vomiting, chest pain
o Give apap, cool sponge bath, ptu, propranolol

Ch. 79 Hypothyroidism (video 85)

 Not enough t3 or t4, caused by hashimotos, creteinism (infants), common in women
o Primary= thyroid gland is problem
o Secondary= anterior pituitary isn’t producing enough tsh
o Tertiary= hypothalamus isn’t producing enough trh
 Symptoms= cold, fatigue, constipation, wt gain, pale skin, thinning hair, brittle fingernails, depression, brady, hypotension
 Labs= low t3 (70-200) and t4 (4-12), increased tsh, anemia
 Care= frequent rest, dietician, low cal high bulk diet, activity, no fiber laxatives, levothyroxine (start low, take 1-2 hrs b/f breakfast), skin care, extra
clothing, no electric blankets
 Complication=myxedema coma (untreated, stress, low respiration, decreased co, cerebral hypoxia, hypothermia, brady, hypotension)

Ch. 80 Cushing Disease/syndrome (video 86)

 Cushing= too much cortisol
 Hypothalamus produce crhanterior pituitary produce acthadrenal cortex produce cortisol
 Long term glucocorticoid use can cause
 Symptoms= fatigue, joint pain, depression, increased infection, thin skin, htn, dependent edema, tachy, gastric ulcers, truncal obesity, moon face, buffalo
hump, wt gain, fractures and bone pain, hyperglycemia, unusual hair growth, acne
 Lab levels= increased cortisol, decreased Ca and K, increase glucose and Na levels, dexamethasone depression test
 Care= decrease Na in diet and increase K and protein and ca, fall risk, prevent infections, skin care, spironolactone (k sparing diuretic), chemo,
hypophysectomy (surgical removal of pituitary assess drainage for glucose or halo sign (yellow on edge and clear in middle), avoid coughing and blowing
nose and sneezing, straining and bending over at waste, avoid brushing teeth), adrenalectomy (hormone replacement for rest of life, monitor for adrenal
crisis)

Ch. 81 Addison’s Disease (video 87)

 Not enough cortisol, autoimmune
 Symptoms= slow developing, hyperpigmentation, wt loss, craving salt, fatigue, n/v
 Labs= hypona, hyperk, hyperca, hypoglycemia, acth stimulation test (plasma cortisol levels won’t rise in primary)
 Care= monitor fluid and electrolyte, hydrocortisone/prednisone (s/e=hyperglycemia, bone loss, pud, increase risk of infection), insulin, ca, sodium bicarb,
loop diuretic
 Addisonian crisis= discontinued med or caused by infection

Ch. 82 Diabetes (video 88-90)

 Chronic hyperglycemia because inadequate insulin or insulin resistance
 Increased risk of cardiovascular disease, htn, kidney disease, neuropathy, retinopathy, peripheral vascular disease, stroke
 Black, Indian, Hispanic at greater risk for developing diabetes
 Type 1= destruction of b cells because autoimmune disorder
 Type 2= obesity
 Gestational= pregnant
 Risk factors= htn, obesity, inactivity, hyperlipidemia, smoking, elevated crp, genetics
 Symptoms= blood glucose >250, polyuria, polydipsia (dehydration), weak pulse, polyphagia, metabolic acidosis, kussmaul respirations, fruity breath,
headache, n/v, seizures, coma, ab pain, can’t concentrate

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 Diagnosis= casual blood glucose >200, fasting blood glucose >126, oral glucose tolerance test at 2 hrs >200; must have 2 findings on 2 separate days, a1c
<7 is well regulated
 Care= insulin, monitor for hypoglycemia (shaky, confusion, sweating, headache, lack of coordination, blurred vision, seizure)<70 give 15-20g of carb if
conscious, give glucagon if unconscious
o Rapid acting (lispro/Humalog)= onset w/I 15 min, peak 30-1 hr, duration 3-4hr
o Short acting (regular/humalin, novalin)= onset 30-1 hr, peak 2-3 hr, duration 5-7 hr
o Intermediate (nph)= 1-2, 4-12, 18-24; used b/w meals and at bedtime, can be mixed
o Long (glargine)= do NOT mix, 1hr, NO peak, 24hr
o Rotate injection sites, at 90 angle
o Clear before cloudy
 Metformin (biguanide, reduce production of glucose, increase tissue sensitivity to insulin, slow carb in intestines, take with food), glipizide (decrease blood
sugar levels, increase sensitivity to insulin, 30 min b/f meals, avoid alcohol), pioglitazone ( reduce production of glucose, increase tissue sensitivity to
insulin), repaglinide (stimulate insulin release from pancreas 15-30 min b/f meal), acarbose (slow carb absorption, take with first bite of meal)
 Foot care= inspect daily, wash with warm water and mild soap, dry thoroughly, apply lotion NOT between toes, foot powder, podiatrist, trim nails straight
across after shower, wear shoes, cotton or wool socks
 Care= never skip meals, 15g carb is 1g exchange, lose wt, >240 call provider or have fever over 101.5
 Complications= cvd (monitor bp and cholesterol), retinopathy (yearly eye exam), neuropathy, nephropathy (monitor I and O), avoid alcohol apap and
nsaids, 2-3L fluid per day

Ch. 83 Complications of diabetes (video 91)

 DKA= type 1, high sugar levels >300, rapid onset, metabolic acidosis, ketones
o Risk= undertreated, missed dose of insulin, infection
o Symptoms= gi upset, n/v, ab pain, fruity breath, kussmaul respirations
o Care= treat underlying cause, fluid replacement isotonic, insulin, monitor K, sodium bicarb, monitor blood glucose below 200
o Teach to monitor glucose frequently and never skip insulin dose when ill, hydrate, 3L of water, >240 glucose or fever contact provider
 HHS= type 2, >600, gradual onset, dehydration
o Risk= old adults, decreased kidney function, infection, stress

Ch. 84 Immune and Infectious Disorders Diagnostic Procedures

 WBC= 5000-10000
o Leukopenia= <5000, autoimmune disease, overwhelming infection
o Leukocytosis= >10000, infection
o Neutropenia= neutrophil <2000, chemo
o Left shift= increase in immature neutrophils
 Types of WBC
o Neutrophils= increased w/ acute bacterial infection, 55-70%
o Lymphocytes= T & B cells increased w/ chronic bacterial or viral infection (mono, mumps and measles) 20-40%
o Monocytes= increased w/ protozoal infections and viral infections, 2-8%
o Eosinophils= increased w/ allergic reactions, parasitic infections, 1-4%
o Basophils= increased w/ leukemia, 0.5-1%
 Skin testing= intradermal injections or scratching superficial layer
o Avoid taking antihistamines from 48hr – 2 weeks, assess reactions after 15-20 min

Ch. 85 Immunizations
 Vaccines are made from killed viruses or live, attenuated (weakened) viruses
 Immunity
o Active natural= body produces antibodies in response to exposure to live pathogen that enters body naturally
o Active artificial= develops when vaccine is given and body produces antibodies in response
o Passive natural= occurs when antibodies pass from mother to fetus through placenta and breast milk
o Passive artificial immunity= occurs after antibodies in immune globulin are given, immediate protection
 Admin= give antipyretic for fever, apply cool compress for local tenderness and mobilize extremity, document admin of vaccine, date, route, site, type,
manufacturer, lot number, expiration date, pt name address and signature, include nurse name title and address of facility, give IM in deltoid and SQ in
upper arm or thigh
o Tdap= give booster every 10 years
o Mmr
o Varicella= 2 doses
o Pneumococcal vaccine= immunocompromised, chronic diseases, smokers, long term care facilities
o Hep a and b= high risk individuals, health care
o Flu= annually for all adults
o Meningococcal= admin dose to students up to age 21 entering college and living in dorms
o HPV= first dose, then 2 months later second dose, then 6 months after first dose get third dose
o Zoster vaccine= one time dose for all adults older than 60 years
 c/i= anaphylactic reaction to vaccine, common cold and minor illness are NOT c/I, immunocompromised
o MMR= anaphylactic reaction to eggs, gelatin or neomycin
o Varicella= anaphylactic reaction to gelatin or neomycin, pregnant
o Flu= egg allergy, BUT CDC says to still get it
o HPV= latex allergy
 Adverse effects=tenderness at injection site, low fever

Ch. 86 HIV/AIDS

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 HIV= retrovirus that’s transmitted through blood and body fluids, target cd4+ lymphocytes (t cells)
o Stage 1= cd4 t lymphocyte count >500
o Stage 3= AIDS
 Findings= candidiasis, herpes, Kaposi sarcoma, TB, wasting syndrome, cd4 count <200
 Risk factors= unprotected sex, multiple sex partners, occupational exposure, perinatal exposure, iv drug use
 Findings= chills, rash, nausea, wt loss, headache, sore throat, night sweats
 Diagnostics= elisa, w. blot
 Meds= art
 Edu= hand hygiene, avoid raw food, avoid pet litter, safe sex, frequent follow up to monitor cd4 and viral load, ID support system
 Complications= TB, Kaposi sarcoma, cytomegalovirus, herpes, pneumocystis jiravecli pneumonia

Ch. 87 Lupus Erythematosus, Gout, fibromyalgia

 SLE= autoimmune, chronic inflamm and destruction of healthy tissue, connective tissue of multiple organs
 DLE= only affects skin
 Risk factors= women 20-40, black, Asian, native American
 Findings= fatigue/malaise, alopecia, pleuritic pain, joint pain, swelling, tenderness, fever, lymphadenopathy, Raynaud’s, erythematous rash over nose
 Diagnostics= ana, c3 and c4 decrease due to depletion secondary to an exaggerated inflam response, increased bun and creatinine
 Meds= nsaids, corticosteroids, methotrexate, antimalarial
 Edu= avoid sun, use steroid cream
 Complications= kidney transplant, pericarditis, myocarditis

Ch. 88 Rheumatoid Arthritis

 Affects joints bilaterally and symmetrical, wbc attack synovial tissue, becomes inflamed and thick
 Risk= female, 20-50
 Findings= morning stiffness, fatigue, joint swelling, joint deformity is late sign, finger, hands, wrists, knees, foot joints are generally affected, subcutaneous
nodules, fever, reddened sclera, lymph node enlargement
 Diagnostics= ra factor antibody 1:40-1:60, elevated esr, positive c reactive protein, + ana titer, elevated wbc, arthrocentesis (synovial fluid aspiration by
needle, increased wbc and rf present in fluid), x ray determine degree of joint destruction
 Care= hot shower for morning stiffness, cold for edema, safe environment, pt and ot
 Meds= nsaids, antimalarial, methotrexate, plasmapheresis (removes circulating antibodies from plasma which decrease attack on client tissue)
 Complications= sjogrens syndrome (triad of symptoms like dry eye mouth and vagina)

Ch. 89 General Principles of Cancer

 Risks= increased age, race, genes, exposure to chemicals, tobacco, alcohol, diet high in fat and red meat, sun uv light or radiation
 Findings= TNM (tumor, node, metastasis)
 Complications= malnutrition (increased risk for wt loss and anorexia, presence of carcinoma in body increased amt of energy required for metabolic
function, cancer can impair body ability to ingest, digest and absorb nutrients, adverse effects of treatment can affect desire for food or ability to eat N/V,
changes in taste anorexia)

Ch. 90 Cancer screening and Diagnostic Procedures

 Caution
o Change in bowel or bladder habits
o A sore that doesn’t heal
o Unusual bleeding or discharge
o Thickening or lump in breast or elsewhere
o Indigestion or difficulty swallowing
o Obvious change in warts or moles
o Nagging cough or hoarseness
 Biopsy= definitive diagnosis
 Imaging studies used as secondary tools (Ct, mri, pet, ultrasound)

Ch. 91 Cancer treatment options

 Tumor excision
 Chemo= damage cells dna and destroy rapidly dividing cells, unintentional harm done to normal rapidly proliferating cells, such as those found in mucous
membranes of gi tract, hair follicles and bone marrow
o Complications
 Immunosuppression/neutropenia= monitor temp, wbc, fever greater than 37.8 (100) should be reported immediately, anc < 1000
should implement neutropenic private room, restrict ill visitors, avoid invasive procedures, keep dedicated equipment in pt room,
admin filgrastim (CSF) to stimulate wbc production
 Edu=avoid crowds, take temp daily, avoid fresh fruits and vegetables and undercooked meat and fish and eggs pepper
and paprika, avoid yard work gardening or changing pets litter box, avoid fluids that have been sitting at room temp for
longer than 1hr, wash all dishes in hot soapy water or dishwasher, wash glasses and cups after each use, wash toothbrush
daily in dishwasher or rinse in bleach, do NOT share toiletry or personal hygiene items w/ others
 N/V=admin antiemetics b/f chemo and for several days after each treatment, remove vomiting cues, admin megestrol to increase
appetite, perform mouth care prior to serving meals to enhance appetite
 Edu= avoid drinking liquids during meals, pt select foods that are cold, encourage consumption of high protein, high cal
nutrient dense foods and meal supplement
 Alopecia= effect on self image, discuss options, occur 7-10 days after treatment
 Oral effects
 Mucositis= inflame in mucous lining of mouth to stomach

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 Avoid glycerin based mouth wash or mouth swab, use nonalcoholic anesthetic mouth washes, discourage consumption of
salty, acidic or spicy foods, offer oral hygiene b/f and after each meal, use lubricating or moisturizing agents
 Edu= soft bristle toothbrush, soft, bland foods that are high cal
 Anemia= monitor for fatigue, pallor, dizzy and sob, schedule rest periods b/w, admin epo and ferrous sulfate
 Thrombocytopenia= monitor for occult and blood in stools, avoid iv and injections, apply pressure for 10 min after blood is taken,
use electric razor and soft toothbrush, avoid blowing nose, avoid nsaids, prevent injury
 Radiation= tattoos that guide positioning of external radiation source, gently wash skin over irradiated area w/ mild soap and water, dry area thoroughly
using patting motions, do NOT remove or wash off radiation tattoos, do NOT apply powders, ointments, lotions, deodorants, or perfumes to irradiated
skin, wear soft clothing, avoid tight or constricting clothes, do NOT expose irradiated skin to sun
 Hormone therapy= use androgen for estrogen dependent and estrogen for testosterone dependent
o Tamoxifen
 Immunotherapy= biological response modifier
o Interleukins and interferons

Ch. 92 Cancer Disorders

 Skin cancer= sunlight exposure is leading cause
o Squamous cell= epidermis, rough scaly lesion
o Basal cell= small waxy nodule, most common
o Melanoma= new moles, most deadly
o Findings= asymmetry (one side does not match other), borders ( ragged, notched, irregular, blurred edges), color (lack of uniformity in
pigmentation), diameter (width greater than 6mm), evolving change in appearance (shape, size, color, ht, texture)
o Treatment
 Chemo= topical 5 fluorouracil cream
 Cryosurgery= freeze and destroy isolated lesions by applying liquid nitrogen
 Excision
 Leukemias= cancers of wbc, overgrowth of leukemic cells prevents growth of blood components (platelets, rbc, mature leukocytes), infection is leading
cause of death, lack of platelets increase pt risk of bleeding
 Lymphomas= cancer of lymph nodes
o Prevent infection, hand hygiene, restrict raw foods, prevent injury
o Therapy= chemo, radiation, bone marrow transplant (destroy bone marrow, replace w/ healthy stem cells)
 Thyroid cancer = risk include female, diet low in iodine, radiation exposure
o Finding= change in size shape of thyroid, palpable nodules or irregularities
o Monitor airway patency, assess swallowing
o Therapy= rai, thyroidectomy
 Lung cancer= prognosis is poor, cigarette smoking
o Findings= chronic cough, dyspnea
 Colorectal cancer= begins as polyp and is benign in early stages
o Findings= blood in stool
o Recommend annual fobt for pt age 50-75, colonoscopy in age 50 and every 10 years
 Breast cancer= high genetic risk, early menarche, late menopause, prolonged use of ocp, cigarette smoking, hrt, obesity
o Findings= skin changes (peau d orange), dimpling, breast tumors (small, irregular, firm, nontender, nonmobile), nipple discharge, nipple
retraction or ulceration
o Therapy
 Hormone therapy= leuprolide, tamoxifen
 Chemo/radiation
 Surgery= have pt wear sling while ambulating to support arm, avoid admin injections, taking bp or obtaining blood from pts affected
arm and place sign above bed, encourage early arm and hand exercises to regain full rom, do not wear constrictive clothing
 Cervical cancer= infection w/ hpv 90% cases, pap screen by 21 years of age or 3 years following first sex
 Prostate cancer= risks high fat and black
o Findings= urinary hesitancy, recurrent bladder infection, urinary retention, blood in urine and semen (late), significant residual urine after
voiding a small amt of urine
o PSA= greater than 4 indicates possible prostate disease, instruct pt to get prostate screening after 50, insure psa is assess prior to DRE
o Meds= leuprolide

Ch. 93 Pain management for pt who have cancer

 Palliative cancer pain management provides comfort and reduce pains rather than curing cancer, goal of palliative pain management is to reduce pain to
improve qol
 Meds= nonopioid, opioids, antidepressant (reduce depression, decrease neuropathic pain), anticonvulsants, corticosteroids (reduce swelling), skeletal
muscle relaxants (muscle spasms), systemic local anesthetics (infusion pump), topical local anesthetic (lidocaine patch), epidural or intrathecal, regional
nerve blocks
 Alternatives= tens (low voltage electrical impulses), heat or cold, pressure, massage or vibration, acupuncture

Ch. 94 Anesthesia and Moderate Sedation

 General anesthesia= inhalation (NO), IV anesthetic (benzos, Propofol)
o Phases
 Induction= initiation of IV access, preop meds given, secure airway
 Maintenance= performance of surgery, airway maintenance
 Emergence= completion of surgery, removal of assistive airway device
o Meds= opioids, benzos, antiemetics (decrease postanesthetic n/v), anticholinergics, sedatives, neuromuscular blocking agents
o Complications

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 Malignant hyperthermia= tachy first, dysrhythmias, muscle rigidity, hypotension, tachypnea, skin mottling, cyanosis, myoglobinuria
(protein in urine)
 Stop surgery, admin IV dantrolene (muscle relaxant), admin 100% O2, obtain ABGs, infuse iced IV NaCl, apply cooling
blanket
 Moderate sedation= admin sedatives/opioids to point where pt relaxes enough that surgeon can perform minor procedure w/o discomfort for pt, yet pt
retains protective reflexes (gag reflex), is easily arousable and maintains patent airway
 Pre=NPO 6hr prior to procedure, clear liquids up to 2hr b/f surgery, verify pt signed informed consent, remove dentures
 Intra=assess loc, cardiac rhythm, respiratory status and vitals
 Post= monitor and document vitals and loc until pt is fully awake, assessment criteria return to pre-sedation levels
o Discharge= vitals stable for 30-90 min, ability to tolerate orals fluids, ability to urinate, no N/V SOB or dizzy

Ch. 95 Preop Nursing Care

 Verify that informed consent is completed, signed, and witnessed, scheduled meds (antihtn, anticoags, antidepressants) can be held until after surgery,
ensure pt remains NPO for 6hrs for solids and 2hrs for clear liquids b/f surgery, prophylactic antibiotics admin w/I 1hr of surgical incision
 Informed consent= responsibility of PROVIDER to obtain consent after discussing risks and benefits of procedure, the nurse is NOT to obtain consent for
provider UNDER ANY CIRCUMSTANCE, nurse can clarify info that remains unclear but NOT provide any new info, NURSE ROLE is to witness pt signing of
consent form after pt acknowledges understanding of procedure and to notify provider if pt has more questions or appears to not understand info
o Must be 18 or emancipated, mentally capable of understanding risk, NOT under influence of meds that affect decision making or judgment

Ch. 96 PostOp Nursing Care

 Airway=assess blood o2 saturation, assess respiratory pattern, rate, and depth, assess symmetry of breath sounds, auscultate lung sounds, suction
accumulated secretions
 Circulation= observe for internal bleeding, assess for hypervolemia and hypovolemia, assess skin color, temp, sensation, assess and compare peripheral
pulses, monitor ekg, monitor fluid and electrolyte balance
 Vitals= obtain vitals until stable
 I&O= review I& O, urine output less than 30 can indicate hypovolemia
 Surgical wound= check dressings and admin pain meds
 Discharge= stable vitals, no evidence of bleeding, return of reflexes, minimal or absent n/v, wound drainage that is minimal to moderate, urine output at
least 30mL/ hr

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