Medical Surgical Nursing Notes II

ü Risk factors for cardiovascular disorders

o R – ace à non modifiable

o I – ncresed blood pressure à modifiable

o S – tress à SNR à increased BP and CR, vasoconstriction à modifiable

o K – nowing sedentary life style à modifiable

o F – at foodsà atherosclerosis à modifiable

o A – lcohol (modifiable) / Age à above 40 (non modifiable)

o C – igarette smoking à vasoconstriction (nicotine) à modifiable / Contraceptive pills à clotting of blood à thrombus formation

o T – ype A behavior (modifiable) à competitiveness, perfectionist à high stress level

o O – besity

o R – esult of DM à lipolysis à increased fatty acids à atherosclerosis

o S – ex àgender à males > female (before menopausal because estrogen decreases PVR) after menopausal female eversible}[inverted T wave] à Injury [elevated ST segment] à> male

ü Decreased TP in heart à Ischemia (Angina) {r necrosis (MI) {irreversible}[pathologic Q wave/permanent in the ECG]

ü Eating a heavy meal, strenuous exercise, sex, exposure to cold à Decreased blood flow (heart)à decreased TP (heart)à decreased O2 (heart)à anaerobic respiration à production of lactic acid à PAIN à management decreased O2 demand by rest and SFF

ü Angina

o Pain relieved by rest and NTG

o NTG

§ Vasodilation à orthostatic hypotention à move gradually à Monitor BP

§ Store in a dark and amber container

§ Effective à tingling sensation à no need to notify physician

§ Maximum of 3 tablets with 5 minute interval

ü MI

o Pain relieved by Morphine SO4

§ Narcotic analgesic

§ Can cause respiratory depression à monitor RR and O2 saturation

§ Antidote à narcan

ü Cardioversion à synchronous

ü Defibrillation à unsynchronous

ü Buerger’s disease à CS à vasoconstriction à stop CS à common in men

ü Raynaud’s à stress and cold à vasoconstriction à common in female

ü Congestive heart failure

o Left sided à pulmonary

§ Dyspnea

§ Crackles

§ Polycythemia à due to decrease O2 to the kidneys

§ Clubbing of the fingers à due to prolonged hyxia

§ Orthopnea

o Right sided à systemic

§ Hepatomegaly

§ Distended neck veins

§ Edema

§ Portal hypertension

§ Ascites à weight gain

§ Varicose veins

o Digoxin

§ Cardiac glycoside

§ Positive inotrophic effect à increased strength of myocardial contraction

§ Negative chronotrophic effect à decreased cardiac rate à monitor CR à never give if CR below 60 bpm

§ Adverse effect

· V – omitting

· A – norexia

· N – ausea

· D – iarrhea

· A – bdominal pain

· REMEMBER: earliest à GI; late à halo vision

· Antidote à Digibind

ü Decreased RBC ® Activity in tolerance, Fatigue, provide rest, Anemia

ü Decreased Platelets ® Prone to bleeding, avoid parenteral injection, appl pressure on injection site, high risk for injury

ü Decreased WBC ® prone to infection, reverse isolation

ü Increased WBC ® presence of infection

ü First Day/Newly diagnosed ® Knowledge deficit

ü Diuretic

o D – iet à high K diet except aldactone

o I – input and Output à expected increased output

o U – ndesirable effect electrolyte imbalance (K)

o R – ecord weight à expected decreased weight

o E – lderly à special precaution

o T – ake in AM and with food

o I – ncreased orthostatic hypotension à monitor BP and move gradually

o C – ancel alcohol because of mild diuretic effect

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

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

ü Urokinase/Streptoase ® dissolves the clot

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

ü Gastritis à LUQ pain

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

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

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

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

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

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

ü Diverticulitis à LLQ pain ® low fiber diet

ü Diverticulosis ® high fiber diet

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

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

o Portal hypertention can lead to

§ Blood shifted to the different collateral

· Esophageal varices

· Spider angioma (face and neck)

· Caput medusae (abdomen)

· Hemorrhoids (rectal)

· Management avoid rupture à avoid shouting, valsalva maneuver

§ Increased hydstatic pressure à fluid shifting à ascites

o Decreased albumin à decreased oncotic / colloidal osmotic pressure à fluid shifting à ascites à management high protein diet

o CHON metabolism à by product ammonia à liver cannot convert to urea à increased level of ammonia in the brain à Alteration of LOC and changes of behavior and asterexis àhepatic encephalopathy à management low CHON diet and lactulose for removal of ammonia

ü Hepatitis A à fecal oral à prone plumber

ü Hepatitis B à body secretion à prone working in a dialysis

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

ü Cholecystectomy à T tube à level of the incision site à drain excess bile

ü Pancreatitis à alcohol à autodigestion à LUQ pain

ü Anterior Pituitary gland

o Growth hormone

§ Increased before the closure of the epiphysis of the long bones à gigantism à tall

§ Increased after the closure of the epiphysis à acromegaly à big hands (big gloves), big feet (big shoes) and big head (big hat)

§ Decreased à dwarfism

o Prolactin

§ Increased à galactorrhea

§ Decreased à decreased milk production

o ACTH

§ Increased à secondary cushing’s

§ Decreased à secondary addison’s

o TSH

§ Increased à secondary hypethyroidism

§ Decreased à secondary hypothyroidism

ü Posterior pituitary gland

o ADH

§ Increased à water retention à oliguria à edema (fluid volume excess) and weight gain à concentrated urine à increased urine specific gravity

§ Decreased à water excretion à polyuria à dehydration (fluid volume deficit and weight loss) à diluted urine à decreased urine specific gravity

ü Parathyroid gland

o Parathormone

§ Increased à increased calcium in the blood and decrease calcium in the bones à stone formation and decreased bone mass à osteoporosis à management increased water intake

§ Decreased à hypocalcemia à calcium supplement

ü Thyroid Gland

o Increased (hyperthyroidism)

§ T3 and T4 à increased BMR à hyperactive à inability to focus à insomia à increased catabolism à weight loss à increased appetite à increased peristalsis à Diarrhea à fluid volume deficit à Increased CR and RR (due to increased BMR)

· Increased T3 à heat intolerance

§ Calcitonin à decreased calcium in the blood à tetany à compensatory à calcium withdraws from the bones à bone destruction (complication)

§ PTU à decreased synthesis of TH à watch out for SE (similar to signs and symptoms of hypothyroidism) à watch out for agrunulocytosis (fever, skin rash and sore throat)

§ Lugol’s solution à decreased released of TH à before thyroidectomy à decreased vascularity of the thyroid gland

o Decreased (hypothyroidism)

§ T3 and T4 à decreased BMR à hypoactive à sleeps a lot à decreased metabolism à weight gain à anorexia à decreased peristalsis à constipation à decreased CR and RR due to decreased BMR

§ T3 à cold intolerance

§ Calcitonin à hypercalcemia à stone formation

§ Synthroid and Proloid à increased TH

ü Adrenal Gland

o Incresead (cushing’s)

§ Glucocorticoids à hyperglycemia and decrease wound healing

§ Mineral corticoids à increased aldosterone à sodium retention and potassium excretion à hypernatremia and hypokalemia

· Hypernatremia à water retention à oliguria à edema (moon face,buffalohump, fluid volume excess and weight gain) à concentrated urine à increased urine specific gravity à low sodium diet

· Hypokalemia à weakness à Prominent U wave à high potassium diet

§ Epinephrine and Norepinephrine à Increased BP and CR

§ Sex hormones

· Males à gynecomastia and falling of hair

· Females à hirsutism and deepening of the voice

o Decreased (addisons)

§ Glucocorticoids à hypoglycemia and inability to cope with stress

§ Mineralcorticoids à decreased aldosterone à sodium excretion and potassium retention à hyponatremia and hyperkalemia

· Hyponatremia à water excretion à polyuria (dehydration, fluid volume deficit and weight loss) à diluted urine --. Decreased urine specific gravity à increased fluids and Na

· Hyperkalemia à weakness à tall or peaked T waves à low K diet

§ Epinephrine and Norepinephrine à decreased BP and CR

ü Diabetes Mellitus

o Type I à absolutely no insulin à thin à insulin

o Type II à insufficient insulin à obese à OHA

o Diet à 50% CHO, 30% Fats, 20% CHON

o Exercise à Increased uptake of glucose à Decreased insulin requirement

o Oral hypoglycemic agent (OHA)

§ Stimulates pancreas to produce insulin

o Insulin

§ SC; IV if DKA

§ Never massage the area

§ Never administer cold insulin

§ Rotate the site of injection

· PREVENTS LIPODYSTROPHY

§ Mix

· Aspirate clear first

· Inject air to cloudy first

o Hypoglycemia

§ W – eakness

§ H – unger pangs

§ A – alteration of LOC

§ T – achycardia and tremors

§ A – bdominal pain

§ B – blurring of vision

§ C – ool clammy skin

§ D – iaphoresis

§ Give à orange juice (simple sugars)

o DKA ® increased lipolysis increased ketones

o Hyperglycemia à polyuria, polydipsia, polyphagia, kussmaul breathing, glycosuria, ketonuria and warm flush skin

o Glycosylated hemoglobin à reflect BSL for the past 3 to 4 months à most accurate

o Foot care

§ Podiatrist

§ Avoid removing corns and calluses

§ Cut toe nails straight across

§ Avoid walking bare foot

ü Hepatitis A ® fecal oral

ü Hepatitis B ® body and bloody secretions (hemodialysis)

ü Peritoneal Dialysis

o Diasylate output is decreased ® turn patient from side to side

o Complication ® infection ® monitor WBC and temperature, diasylate is cloudy ® boardlike and rigid abdomen ® peritonitis

o Don’t include diasylate solution in the output of the client

o Expected ® decreased weight ® monitor weight before and after ® decreased createnine and BUN

ü Heart block ® decreased tissue perfusion

ü Parkinson’s diasease

o Decreased dopamine in the basal ganglia ® levodopa to increased dopamine ® avoid Vit B6 foods

o Cardinals signs ® tremors (non intentional) ® muscle rigidity ® bradykinesia

o Pill rolling

o Microphonia ® ask your client to speak aloud to be aware

o Artane and Cogentin ® anticholinergic ® decreased muscle rigidity

ü Myasthenia Gravis

o Tensilon test ® confirmatory test

o Decreased Acetylcholine and increased cholinesterase

o Muscle weakness ® priority airway

o NO tranquilizer, Morphine SO4, Muscle relaxant and neomycin

o Cholinergics (mestinon) ® increased muscle strength ® antidote ATSO4

§ Undermedication ® myasthenic crisis ® give cholinergics

§ Over medication ® cholinergic crisis ® give ATSO4

ü Multiple Sclerosis

o Demyelinization of the myelin sheath

o Charcoat’s triad

§ Intentional tremors

§ Scanning of speech

§ Nystagmus

o Visual disturbances ® diplopia

ü Pancreatitis ® autodigestion ® alcohol ® bleeding ® shock

o Elevated amylase

ü Rheumatoid Arthritis

o No specific diagnostic test

o NSAID’s and ASA (antipyretic, analgesic and anti-inflammatory)

o Synovitis ® Pannus formation ® fibrous ankylosis (limited joint movement) ® Bony ankylosis (joint fixation)

o Avoid flexion and promote prone position

ü Gouty Arthritis

o Increased uric acid ® allopurinol and avoid organ meats (liver) ® tophi (ears)

ü Osteoarthritis

o Most common ® related with aging

o Pain after weight bearing exercise or activity ® rest to relieved pain ® weight reduction

ü Diverticulitis ® LLQ pain and low fiber diet

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

ü Vincristine (Oncovin) ® increased fiber in the diet

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

ü Steroids and NSAID’s

o DEATH ® inflammation

o BIRTH ® side effects

§ B – one marrow depression ® prone to infection ® monitor temperature and WBC

§ I – ncreased gastric irritation ® take it with food or after meals

§ R – enal toxicity

§ T – innitus

§ H – epato toxic

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

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

ü Retinal detachment ® trauma ® blood clots ® floating spots ® dependent position® scleral buckling

ü Avoid Increased Intraocular pressure ® PRIORITY

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

ü Meniere’s ® Triad ® tinnitus, impaired hearing loss and vertigo ® low Na diet

o Vertigo ® imbalance ® high risk for injury ® decreased vertigo by focusing on one side of the room ® assume a flat or reclining position

ü ASA ® 8^th cranial nerve damage ® tinnitus, impaired hearing loss and vertigo

ü Antibiotics ® allergic reactions

ü Normal Values

o BUN = 10 – 20 mg/dl

o Calcium = 9 to 10.5 mg/dl

o Creatinine = 5 to 1.5 mg/dl

o GTT = 70 to 115 mg/dl

o O2 sat = 97 to 98%

ü Signs and Symptoms of Increased Intracranial Pressure

o B – lood pressure and temperature are elevated

o R – espiratory and cardiac rate are decreased

o A – lteration of LOC

o I – rritability

o N – ote for projectile vomiting

o S – eizure