BULLETS IN MEDICAL-SURGICAL NURSING

RESPIRATORY
Chest X-ray  painless procedure
Bronchoscopy
AtSO4
Anticholinergic  mimics SNR
Decreases saliva  dry mouth
NPO 6 to 8 hours
Local anesthesia  check gag reflex before feeding
ABG
Hyperventilation  decreased CO2  increased blood pH  respiratory alkalosis
Hypoventilation  increased CO2  decreased blood pH  respiratory acidosis
Diarrhea  decreased HCO3  decreased blood pH  metabolic acidosis
Vomiting gastric content  decreased HCl  increased blood pH  metabolic alkalosis
Vomiting blood  decreased O2  anaerobic metabolism  formation of lactic acid 
decreased blood pH  metabolic acidosis
Blood pH  normal 7.35 to 7.45  if increased  alkalosis; if decreased
acidosis
Partial CO2  normal 35 to 45  if increased: Respiratory acidosis;
If decreased: Respiratory alkalosis
Partial HCO3  normal 22 to 26  if increased: Metabolic alkalosis;
If decreased: Metabolic acidosis
Cancer of the larynx  CS, alcohol and over usage of voice (choir member)
A –nterior neck mass
B –urning sensation with hot beverages / Bad breath
C –hange in the voice (hoarseness)
D –ysphagia / Dyspnea
Chronic Obstructive Pulmonary Disease
Chronic Bronchitis
Blue bloater
Excessive mucus production
Asthma
Periods of bronchospasm and bronchoconstriction
Emphysema
Disequilibrium of elastase and anti-elastase
Pink puffer
Manifestations:
A –LTERATION IN
LOC  decreased o2
Thoracic anatomy  over distention of alveoli  TD=APD  barrel chest
Skin
Temperature  cool clammy skin
Color  pale to cyanotic
ABG  Respiratory acidosis  Inreased CO2
 B –REATHING  difficulty, purse lip  expiration > inhalation  removal of
excess CO2 (diet low CHO)
C –OUGH (mucus production); Chronic hypoxia (2 to 3 LPM of O2 therapy,
decreased O2 demand by rest and SFF)  clubbing of the fingers and decreased
TP to the kidneys causing polycythemia
D –ECREASED METABOLISM
Anorexia  weight loss (high calorie diet)  fatigue  weakness
Bronchodilators
Theophylline and aminophylline
Primary effect  stimulates beta 2 receptors  smooth muscle relaxation 
bronchodilation
Side effect  stimulates beta 1 receptors  increases cardiac rate  need not to notify
the physician
Adverse effect  hypotension  monitor BP  signs of toxicity
Evaluation  check breath sounds
Acute Respiratory Distress Syndrome
Causes
A – SPIRATION
R –ESPIRATORY TRAUMA (Embolism)
Fracture  embolism  ARDS
D –RUG TOXICITY (ASA)
S –EPSIS AND SHOCK
Vomiting, bleeding, dehydration  hypovolemia  shock  ARDS
Syndrome
Severe hypoxia
Bilateral infiltrates
Dyspnea
Pulmonary Embolism
Restlessness  earliest
Water Seal System
Drainage Bottle  mark the level every shift
Water Seal Bottle
Presence of fluctuation  normal
Absence of fluctuation  lungs are fully expanded  assess patient first
(X-rayconfirm) OR presence of obstruction
Intermittent bubbling  normal
Absent  obstruction
Continuous  leakage
Suction Control  continuous bubbling  normal
CARDIO-VASCULAR
Risk factors for Cardiovascular disorders
R –ACE  non-modifiable
I –NCREASED BLOOD PRESSURE  modifiable
S –TRESS  SNR increased BP and CR, vasoconstriction  modifiable
K –NOWING SEDENTARY LIFESTYLE  modifiable
F –AT FOODS  atherosclerosis  modifiable
A –LCOHOL (modifiable) / AGE above 40 (non-modifiable)
C –IGARETTE SMOKING  vasoconstriction (nicotine)  modifiable / CONTRACEPTIVE
PILLS  clotting of blood  thrombus formation
T –YPE A BEHAVIOR (modifiable)  competitiveness, perfectionist  high stress level
O –BESITY
R –ESULT OF DM  lipolysis increased fatty acids  atherosclerosis
S –EX  GENDER  males > female (before menopausal because estrogen decreases
PVR) after menopausal female irreversible [inverted T wave]  injury [elevated ST
segment]  > male
Decreased TP in heart  Ischemia (Angina) Necrosis (MI) [irreversible]; Pathologic Q
wave/permanent in the ECG
Eating a heavy meal, strenuous exercise, sex, exposure to cold  Decreased blood flow (heart)
 decreased TP (heart)  decreased O2 (heart)  anaerobic respiration  production of
lactic acid  PAIN  management decreased O2 demand by rest and SFF
Angina
Pain relieved by rest and NTG
NTG
Vasodilation  Orthostatic hypotension  move gradually  Monitor BP
Store in a dark and amber container
Effective  tingling sensation  no need to notify physician
Maximum of 3 tablets with 5 minute interval
MI
Pain relieved by Morphine SO4
Narcotic analgesic
Can cause respiratory depression  monitor RR and O2 saturation
Antidote  Narcan
Cardioversion  synchronous
Defibrilation  unsynchronous
Buerger’s disease  CS  vasoconstriction  common in men
Raynauld’s  stress and cold  vasoconstriction  common in female
Congestive heart failure
Left-sided  pulmonary
Dyspnea
Crackles
Polycythemia  due to decrease 02 to the kidneys
Clubbing of the fingers  due to prolonged hyxia
Orthopnea
 Right-sided systemic
Hepatomegaly
Distended neck veins
Edema
Portal hypertension
Ascites  weight gain
Varicose veins
Digoxin
Cardiac glycoside
Positive inotrophic effect  increased strength of myocardial contraction
Negative chronotrophic effect decreased cardiac rate  monitor CR  never
give if CR below 60 bpm
Adverse effect
V –omitting
A –norexia
N –ausea
D –iarrhea
A –bdominal pain
REMEMBER: earliest  GI; late  halo vision
Antidote  Digibind

HEMATOLOGY
Decreased RBC  Activity intolerance, Fatigue, provide rest, Anemia
Decreased Platelets  Prone to bleeding, avoid parenteral injection, apply pressure on
injection site, high risk for injury
Decreased WBC  prone to infection, reverse isolation
Increased WBC  presence of infection
First Day / Newly diagnosed  Knowledge deficit
Diuretic
D –IET
I –NPUT AND OUTPUT
U –NDESIRABLE EFFECT ELECTROLYTE IMBALANCE (K+)
R –ECORD WEIGHT  expected decreased weight
E –LDERLY  special precaution
T –AKE IN THE MORNING (AM) AND WITH FOOD
I –NCREASED ORTHOSTATIC HYPOTENSION  monitor BP and move gradually
C –ANCEL ALCOHOL because of mild diuretic effect
Heparin  anti-coagulant  prevent further enlargement of clot but does not dissolve them 
monitor APTT/PTT  antidote PROTAMINE SO4
Coumadin  anti-coagulant  prevent further enlargement of clot but does not dissolve them
 monitor PT  Vitamin K+ is the antidote
Urokinase/Streptoase  dissolves the clot
Pernicious Anemia  absence of intrinsic factor (gastric surgery)  problem in absorption of
Vitamin B12  beefy red tongue Schilling’s test  definitive test  24 hour urine collection 
life long Vitamin B12

GASTRO-INTESTINAL
Gastritis  LUQ pain
Gastric Ulcer  affected area stomach  pain (precipitated by food intake  increased HCl) 
pain relieved by antacids
Duodenal Ulcer  affected area duodenum  pain (hours after eating)  pain relieved by
food
Ulcers  bleeding  (+) occult blood test (Guiac Test)  high fiber diet, avoid red meat, iron,
steroids, NSAID’s, indomethacin
Vagotomy  resection of vagus nerve  decreased cholinergic stimulation  decreased HCl
and gastric movement
Dumping syndrome  tachycardia and weakness  3 D’s (diarrhea, diaphoresis, and dizziness)
 fluids after meals, lie down after meals and SFF
Appendicitis  RLQ pain  avoid heat pads  cause rupture  signs of ruptured appendix 
sudden cessation of pain, elevation of temperature and WBC
Divertuculitis  LLQ pain  low fiber diet
Diverticulosis  high fiber diet
Ulcerative colitis  bloody diarrhea 20 to 30 times a day  fluid volume deficit
Liver cirrhosis  alcohol and malnutrition (Laanec’s) infection and drugs (post necrotic), RSCHF
(cardiac) and biliary obstruction (biliary)
Portal hypertension can lead to
Blood shifted to the different collateral
Esophageal varices
Spider anginoma (face and neck)
Caput medusa (abdomen)
Hemorrhoids (rectal)
Management avoid rupture  avoid shouting, valsalva maneuver
Increased hydrostatic pressure  fluid shifting  ascites
Decreased albumin  decreased oncotic / colloidal osmotic pressure  fluid shifting 
ascites  management high protein diet
CHON metabolism  by product ammonia  liver cannot convert to urea  increased
level of ammonia in the brain  alteration of LOC and changes of behavior and asterexis
 hepatic encephalopathy  management low CHON diet and lactulose for removal of
ammonia
Hepatitis A  fecal-oral  prone: plumber
Hepatitis B  body secretion  prone: working in a dialysis
Cholecystitis  5 F’s (fair, female, fat, fertile and forty)  RUQ pain  after ingestion of fatty
food  Demerol to relieve pain
Pancreatitis  alcohol  autodigestion  LUQ pain
ENDOCRINE
Anterior Pituitary Gland
Growth hormone
Increased before the closure of the epiphysis of the long bones  gigantism 
tall
Increased after the closure of the epiphysis  acromegaly  big hands (big
gloves), big feet (big shoes) and big head (big hat)
Decreased  dwarfism
Prolactin
Increased  galactorrhea
Decreased  decreased milk production
ACTH
Increased  secondary: Cushing’s Syndrome
Decreased  secondary: Addison’s Disease
TSH
Increased  secondary: Hyperthyroidism
Decreased  secondary: Hypothyroidism
Posterior Pituitary Gland
ADH
Increased  water retention  Oliguria  edema (fluid volume excess) and
weight gain  concentrated urine  increased urine specific gravity
Decreased  water excretion  Polyuria  dehydration (fluid volume deficit
and weight loss)  diluted urine  decreased urine specific gravity
Parathyroid Gland
Parathormone
Increased  increased calcium in the blood and decrease calcium in the bones
 stone formation and decreased bone mass  osteoporosis  management
increased water intake
Decreased  hypocalcemia  calcium supplement
Thyroid Gland
Increased (Hyperthyroidism)
T3 and T4  increased BMR  hyperactive  inability to focus  insomnia 
increased catabolism  weight loss  increased appetite  increased
peristalsis Diarrhea  Fluid volume deficit  increased CR and RR (due to
increased BMR)
Increased T3  heat intolerance
Calcitonin  decreased calcium in the blood  tetany  compensatory 
calcium withdraws from the bones  bone destruction (complication)
PTU  decrease synthesis of TH  watch out for agranulocytosis (fever, skin
rash, and sore throat)
Lugol’s solution  decreased released of TH  before thyroidectomy 
decreased vascularity of the thyroid gland
Decreased (Hypothyroidism)
 T3 and T4  decreased BMR  hypoactive  sleeps a lot  decreased
metabolism  weight gain  anorexia  decreased peristalsis  constipation
 decreased CR and RR due to decreased BMR
T3  cold intolerance
Calcitonin  hypercalcemia  stone formation
Synthroid and Proloid  increased TH

Adrenal Gland
Increased (Cushing’s)
Glucocorticoids hypoglycemia and inability to cope with stress
Mineralcorticoids  decreased aldosterone  sodium excretion and potassium
retention  hyponatremia  hyperkalemia
Hypernatremia  water retention  oliguria  edema (moon face,
buffalo hump, fluid volume excess and weight gain)  concentrated urine 
Increased Urine Specific Gravity  low sodium diet
Hypokalemia  weakness  Prominent U wave  high potassium diet
Epinephrine and Norepinephrine  Increased BP and CR
Sex hormones
Males  gynecomastia and falling of hair
Females  hirsutism and deepening of the voice
Decreased (Addison’s)
Glucocorticoids  hypoglycemia and inability to cope with stress
Mineralcorticoids  decreased aldosterone  sodium excretion and potassium retention 
hyponatremia and hyperkalemia
Hyponatremia  water excretion  polyuria (dehydration, fluid volume deficit
and weight loss)  diluted urine  Decreased Urine Specific Gravity  increased fluids and
Na.
HYperkalemia  weakness  tall or peaked T waves  low K+ diet
Epinephrine and Norepinephrine  decreased BP and CR

Diabetes Mellitus
Type I  absolutely no insulin  thin  insulin
Type II insufficient insulin  obese  OHA
Diet  50% CHO, 30% Fats, 20 % CHON
Exercise  Increased uptake of glucose  Decreased insulin requirement
Oral hypoglycemic agent (OHA)
Stimulates pancreas to produce insulin
Insulin SC; IV if DKA
Never massage the area
Never administer cold insulin
Rotate the site of injection
PREVENTS LIPODYSTROPHY
Mix
Aspirate clear first
 Inject air to cloudy first
Hypoglycemia
W –EAKNESS
H –UNGER PANGS
A –LTERATION OF LOC
T –ACHYCARDIA AND TREMORS
A –BDOMINAL PAIN
B –LURRING OF VISION
C –OOL CLAMMY SKIN
D –IAPHORESIS
G –IVE ORANGE JUICE (SIMPLE SUGARS)
DKA  increased lipolysis increased ketones
Hyperglycemia  polyuria, polydipsia, polyphagia, kussmaul’s breathing, glycosuria, ketonuria
and warm flush skin
Glycosylated hemoglobin  reflect BSL for the past 3 to 4 months  most accurate
Foot care
Podiatrist
Avoid removing corns and calluses
Cut toe nails straight across
Avoid walking barefoot
Hepatitis A  Fecal-oral
Hepatitis B  Body and bloody secretions (hemodialysis)
Pewritoneal Dialysis
Diasylate output is decreased  turn patient from side to side
Complication  Infection  monitor WBC and temperature diasylate is cloudy  board like
and rigid abdomen  peritonitis
Don’t include diasylate solution in the output of the client
Expected  decreased weight  monitor weight before and after  decreased creatinine and
BUN
Heart Block  decreased tissue perfusion
Parkinson’s Disease
Decreased dopamine in the basal ganglia  levodopa to increase dopamine  avoid
Vit. B6 foods
Cardinal signs  tremors (non-intentional)  muscle rigidity  bradykinesia
Pill rolling
Microphonia  ask your client to speak aloud to be aware
Artane and Cogentin  anticholinergic  decreased muscle rigidity
Myasthenia Gravis
Tensilon Test  confirmatory test
Decreased Acetylcholine and increased cholinesterase
Muscle weakness  priority airway
NO tranquilizer, Morphine SO4, muscle relaxant and neomycin
Cholinergics (Mestinom)  increased muscle strength  antidote AtSO4
Undermedication  Myasthenic crisis  give cholinergics
Overmedication  cholinergic crisis  give AtSO4
Multiple Sclerosis
Demyelinization of the myelin sheath
Charcoal’s triad
Intentional tremors
Scanning of speech
Nystagmus
Visual disturbances  diplopia
Pancreatitis  autodigestion  alcohol  bleeding  shock
Elevated amylase
Rheumatoid Arthritis
No specific diagnostic test
NSAID’s and ASA (antipyretic, analgesic and anti-inflammatory)
Synovitis  Pannus formation  fibrous amykylosis (limited joint movement)  bony
ankylosis (joint fixation)
Avoid flexion and promote prone position
Gouty Arthritis
Increased uric acid  allopurinol and avoid organ meats (liver)  tophi (ears)
Osteoarthritis
Most commonrelated with aging
Pain after weight bearing exercise or activity  REST to relieve pain  weight reduction
Diverticulitis  LLQ pain and low fiber diet
Cyclophosphamide (Cytoxan)  can cause hemorrhagic cystitis  to avoid, the client is asked
to increase fluid intake
Vincristine (Oncovin)  increased fiber in the diet
Iron supplement  When is the best time to take? Empty stomach, How is it best taken? With
orange juice
Steroids and NSAID’s
DEATH  inflammation
BIRTH side effects
B –ONE MARROW DEPRESSION  prone to infection  monitor temperature
and WBC
I –NCREASED GASTRIC IRRITATION  take it with food or after meals
R –ENAL TOXICITY
T –INNITUS
H –EPATO TOXIC
Cataract  common cause is aging (senile)  opacity of the lens  position on the unaffected
side
Glaucoma  increased ICP  decreased of peripheral vision first  halo, tunnel and gun barrel
vision  MIOTICS (constricts pupils)  avoid AtSO4 (dilates pupil)
Retinal Detachment  trauma  blood clots  floating spots  dependent position  scleral
buckling
Avoid increased intraocular pressure  PRIORITY
Avoid vomiting, coughing, valsalva maneuver, lifting heavy objects, bending, crying
Meniere’s  Triad  tinnitus, impaired hearing loss and vertigo –> low Na diet
Vertigo imbalance  high risk for injury  decreased vertigo by focusing on one side of the
room  assume a flat or reclining position
Acetyl Salicylic Acid Toxicity  8th cranial nerve damage  tinnitus, impaired hearing loss and
vertigo
Antibiotics  allergic reactions
Normal Values
BUN = 10-20 mg/dl
Calcium = 9 to 10.5 mg/dl
Creatinine = 5 to 1.5 mg/dl
GTT = 70 to 115 mg/dl
02 sat = 97 to 98 %
Signs and symptoms of increased Intracranial Pressure
B –LOOD PRESSURE AND TEMPERATURE are ELEVATED
R –ESPIRATORY AND CARDIAC RATE are DECREASED
A –LTERATION OF LOC
I –RRITABILITY
N –OTE FOR PROJECTILE VOMITING
S- EIZURE