Med-Surg HESI Review
Med-Surg HESI Review
Perioperative
Cardiovascular
• Risk factors for cardiovascular disease: Age, gender, ethnicity, FH, HTN,
... [Show More] diabetes, Atherosclerosis, high LDL levels, physical inactivity, obesity, smoking, uncontrolled stress.
• Cardiac Catheterization- watch for hemorrhage and decreased blood flow to extremity, patient must be on antiplatelet medication;
• HTN
1. Primary HTN: Usually no identified cause. 90-95% of all cases.
2. Secondary HTN: Caused by congenital narrowing of arteries, renal disease, Endocrine disorders, Neurologic disorders, Cirrhosis, or Sleep Apnea.
3. Both are treated with Beta- blockers, ACE Inhibitors, Ca Channel Blockers, etc.
4. Risk Factors (Primary): Age, Alcohol, cigarette smoking, DM, atherosclerosis, excess sodium levels, gender, Family Hx, Obesity, Ethnicity, Sedentary lifestyle, socioeconomic, stress.
5. Hypertensive Crisis: Severe, abrupt increase in Diastolic BP (>140 mmHg). Often occurs in pts who fail to comply with medications. This is a medical emergency. Can cause cerebral hemorrhage, acute renal failure, MI, HF with pulmonary edema. The Nurse should: monitor cardiac and renal function, neuro checks, determine cause, education to prevent further HTN crisis. Want to bring BP down slowly.
6. Diet/ Lifestyle Modifications: Nutritional therapy, physical activity, home monitoring of BP, tobacco cessation, drug therapy. Weight reduction.
7. DASH Diet, want less than 2.4 g Na per day, moderate alcohol consumption, regular physical activity, stress management.
• Coronary Artery Disease:
1. Risk Factors: Age, gender, ethnicity, Family Hx, Genetic predisposition, elevated serum levels, HTN, tobacco use, physical inactivity, Obesity, Diabetes.
• Myocardial Infarction
1. S/S: Initially, increased HR and BP, then decreased BP; crackles, JVD, abnormal heart sounds, diaphoresis, clammy skin, cool to touch, N&V.
2. Labs: CK, CKMB, and Troponin (look at Troponin the most)
3. Medications: antiplatelet, meds with nitrates, cholesterol meds.
4. IMOAN: IV access, monitor rhythm, Oxygen, Aspirin (CHEW IT) Nitroglycerin (Check BP before giving)
5. Raise HOB
6. Invasive Procedures: Cardiac Cath, PTCA with stent, CABG.
7. After CABG or PTCA: ICU for first 24-36 hours. Floor care focused on: Pain management, monitor pedal pulses and insertion site for bleeding, VS and cardiac monitoring, increased physical activity, monitoring urinary function and electrolytes.
8. Diet/ lifestyle modification teaching needed.
• Heart Failure
1. Left Sided Heart Failure: Most common- caused by left ventricular dysfunction.
2. This causes: Decreased ejection fraction, backup of blood into left atrium and pulmonary veins, pulmonary congestion and pulmonary edema.
3. Right Sided HF (cor pulmonale): caused by Left sided HF.
4. RSHF causes: Backup of blood into the R atrium and venous systemic circulation; JVD; Hepatomegaly; Splenomegaly; Peripheral dependent edema.
5. S/S: SOB, edema, fatigue, nocturia, orthopnea, insomnia, chest pain, tachycardia, JVD, ascites, jaundice, wheezes/ crackles, frothy sputum, cyanosis.
6. Meds: Ace Inhibitors, (EF <40%) Lopressor, Digoxin (increase strength of cardiac meds)
7. Diet and Lifestyle Modification: weight reduction, smoking cessation, Low sodium diet.
• A. Fib
• Dysrhythmias
• Hyper and Hypokalemia
1. Normal Levels: 3.5-5.0
• Peripheral Artery Disease
1. Progressive narrowing and degeneration of arteries of neck, abdomen, and extremities. Atherosclerosis is the leading cause of majority of cases.
2. Risk Factors: Cigarette smoking, Hyperlipidemia, HTN, DM.
3. S/S: Muscle ache/ pain with exercise; resolves within 10 minutes or less with rest; shooting or burning pain in extremity; loss of pressure and deep pain sensations.
4. Clinical Manifestations: thin, shiny, and taut skin; Loss of hair on lower legs; diminished or absent pedal/ femoral pulses; Pallor; Reactive Hyperemia (blood flow returning to an area)
5. Complications: Atrophy of skin and underlying muscles; delayed healing; wound infection; tissue necrosis; arterial ulcers; nonhealing arterial ulcers and gangrene are the most serious complications. May result in amputation if blood flow is not adequately restored.
6. Collaborative Care: Smoking cessation; treatment of hyperlipidemia, HTN, and DM. Take antiplatelet therapy; exercise to improve oxygen extraction in the legs and skeletal metabolism (walking)
• Venous Insufficiency/ leg ulcers
1. Caused by bad valves of the deep veins. Hydrostatic pressure increases, making fluid leak from capillaries into the tissue.
2. S/S: Edema; skin discoloration followed by thick, hard, contracted skin (leathery)
3. Interventions: compression (elastic wraps, compression stockings, bandage boot); balanced diet; watch for infection.
• DVT’s
1. Formation of a clot in a vein accompanied by inflammation; commonly found in iliac and femoral veins.
2. S/S: Tenderness with pressure over involved vein; edema; deep reddish color over area; hot to touch.
3. Serious complications: PE, Chronic venous insufficiency.
4. Nursing Interventions: change positions often, walk around at least 3X day; TED hose; SCD; anti- coagulant drugs (Lovenox)
5. Treatment: Initially Heparin, then long term Coumadin therapy. Should not increase foods with Vitamin K
Respiratory
• COPD
Endocrine
• Hypo/ Hyperglycemia
1. Hypoglycemia: Low blood glucose. Occurs when: Too much insulin in proportion to glucose in the blood; Blood glucose level <70 mg/dl; Nurse must respond immediately to prevent syncope, coma, death
2. Common manifestations: Confusion, Irritability, Diaphoresis, Tremors, Hunger, Weakness, Blurry vision, Can mimic alcohol or drug intoxication.
3. Treatment: If alert enough to swallow- 15 to 20 g of a simple carbohydrate; 4 to 6 oz fruit juice; ½ can of regular soft drink. Do not overtreat (no added sugar to juice). Recheck blood sugar Q15 minutes until blood sugar >70 mg/dl. Patient should eat regularly scheduled meal or snack to prevent rebound hypoglycemia. Snack should contain a carb and protein (crackers and peanut butter OR milk) If no improvement after 2 or 3 doses of simple carbohydrate OR patient not alert enough to swallow- Administer 1 mg of glucagon IM or SQ; Buys nurse 15 min of time to start IV or get pt to swallow juice/soda; Side effect=rebound hypoglycemia in 15 min; In acute care settings- 20 to 50 ml of 50% dextrose IV push .
• Regular Insulin, NPH
1. Intermediate-acting (NPH)
2. Injected once or twice a day, am and pm
3. Can be mixed with short-acting
4. Onset 2-4 hours
5. Peak 4-10 hours
6. Duration 10-16 hours
7. 70/30 Humulin or Novolin commonly used rather than mixing insulin
• Oral meds for Diabetes
1. Not insulin
2. Work to improve mechanisms by which insulin and glucose are produced and used by the body
3. Stimulate pancreas to release more insulin
4. Slow rate of glucose production liver
5. Enhance cellular sensitivity to insulin (insulin resistance)
6. Sulfonylureas: ↑ Insulin production from pancreas; ↓ Chance of prolonged hypoglycemia; 10% experience decreased effectiveness after prolonged use Examples: Glipizide (Glucotrol) and Glimepiride (Amaryl).
7. Meglitinides: Increase insulin production from pancreas; Taken 30 minutes before each meal up to time of meal; Should not be taken if meal skipped Examples: Repaglinide (Prandin) and Nateglinide (Starlix).
8. Biguanides: Reduce glucose production by liver; Enhance insulin sensitivity at tissues; Improve glucose transport into cells; Do not promote weight gain Example: Glucophage (metformin). HOLD in pts getting CT scans with dye; Do not use in pts with kidney or liver dx
• Foot care for Diabetes
1. They need to have meticulous foot care.
• Hyper/ Hypothyroidism
1. Hypothyroidism: Fairly common
2. 10% females & 3% males over 65 yo
3. Decreased circulating TSH
4. Iodine deficiency most common type world wide – USA had iodized salt
5. In USA – most common cause is atrophy of thyroid gland
6. Amiodarone & lithium can cause hypothyroidism
7. S/S: Insidious onset, Fatigued, Personality and mental changes, Impaired memory, Constipation, Myxedema - accumulation of hydrophilic mucopolysaccharides in dermis and other tissue – seen as puffiness, periodrbital edema, masklike affect, Cold intolerance, Dry skin, Hair loss.
8. Complications: Myxedema coma – medical emergency. Causes Hypothermic, hypotensive, hypoventilation. Patient needs IV thyroid hormone replacement
9. Treatment: Levothyroxine (Synthroid)-synthetic; peeks 1-2 weeks; Liotrix-synthetic; peak 2-3 days; used in acutely ill patients with hypothyroidism; Armour-natural; dose not standardized. Treatment is life long
• Graves Disease
1. S/S: Exophthalmos , Heat intolerance, Anorexia, Weight loss, Atrial fibrillation, Decreased sleep, Can eat up to 6000Kcal/day and not gain weight, and Visual goiter.
2.
• Thyroidectomy
• Hyperparathyroidism
1. Primary: Increased PTH secretion leading to disorders of calcium, phosphate and bone metabolism; Most common cause-benign neoplasm or single adenoma in parathyroid gland; Leads to hypercalcemia and hypophosphatemia.
2. Secondary: Compensatory response to hypocalcemia; Vitamin D deficiencies, malabsorption, chronic renal failure, and hyperphosphatemia
3. Major symptoms:Weakness, loss of appetite, constipation, increased need for sleep, emotional disorders, and shortened attention span, osteoporosis, nephrolithiasis
4. Serious complications: Renal failure, pancreatitis, collapse of vertebral bodies, cardiac changes, and long bone and rib fractures
5. Surgical therapy: Parathyroidectomy (Open and endoscopic) Autotransplantation of normal parathyroid tissue in the forearm or near sternocleidomastoid muscle; if fails patient will have to take calcium supplements for life.
• Hypoparathryoidism
1. Inadequate circulating PTH or cellular resistance to PTH
2. Uncommon, often associated with hypothyroidism and hypogonadism
3. Most common cause-accidental removal of parathyroids or damage to vascular supply during neck surgery
4. Clinical Manifestations: Due to low serum calcium level- Tetany (Tingling of lips, fingertips, feet), Increased muscle tension leading to paresthesias and stiffness, Chvostek’s sign positive – facial muscle spasm when face tapped below the temple; Trousseau’s sign positive – carpopedal spasm when arterial circulation interrupted; Compromised respiratory function due to accessory muscle involvement
5. Treatment: Goal-maintain normal calcium levels and treat tetany when present; Emergency – IV calcium gluconate over 10-20 min; Calcium salts can cause hypotention and cardiac arrest – SLOW PUSH; High calcium foods – dark green vegetables, soybeans, and tofu
6. Nursing Interventions: Watch for signs of tetany, Trousseau’s sign and Chvostek’s sign; Instruct on foods which reduce calcium absorption; Spinach, rhubarb, bran and whole grains; Calcium carbonate may lead to constipation – stool softeners, fluid, fresh fruits.
• Cushing’s
1. Excess corticosteroids secreted from adrenal cortex, particularly glucocorticoids. Most common cause is exogenous cortisol. Adrenal tumors and ectopic ACTH production
2. S/S: Centripedal (truncal) obesity or generalized obesity; “Moon Faces”, Hirsutism; Purplish-red striae on abdomen, breast or buttock; Menstrual disorders; Hypertension; Unexplained hypokalemia.
3. Treatment: Treatment of choice is transsphenoidal surgical removal of adenoma; Mitotane (Lysodren) – suppresses cortisol production, give with meals to reduce GI side effects; Ketoconazole(Nizoral); aminoglutethimide (Cytadren).
4. Nursing Interventions: Watch for S/S of infections; Monitor glucose closely in diabetic patients; QD weight, VS q4hr; don’t stop medications abruptly.
• Addison’s Disease
1. Primary adrenocortical insufficiency – hypofunction of the adrenal cortex; Glucocorticoids, mineralcorticoids, and androgens reduced; Most common cause is autoimmune; Tuberculosis – rare cause
2. S/S: Evident when 90% adrenal cortex destroyed; Insidious onset; Progressive weakness, fatigue, weight loss, anorexia, hypotension, hyponatremia, hyperkalemia, nausea, vomiting, diarrhea; Skin hyperpimentation – esp. palmar creases.
3. Addisonian Crisis: Life-threatening emergency. Triggers: Stress – infection, surgery, trauma, hemorrhage, psychologic distress; Sudden withdrawal of corticosteroid therapy; Adrenal surgery; Sudden pituitary gland destruction.
4. Treatment: Goal – management of underlying cause; Hydrocortisone – has glucocorticoid and mineralocorticoid properties.
5. Nursing Interventions: VS and I&O – q30min-4hours first 24 hours; QD weights; Assistance with daily hygiene; Protect from noise, light, and environmental temperature extremes – can’t tolerate stress
6.
• SIADH
1. Overproduction of ADH; usually caused by malignancy; chronic.
2. S/S: low urine output, increased body weight without edema, low plasma osmolality and sodium, cerebral edema may occur.
3. Treatment: goal= restore normal fluid volume/ osmolality. Fluid restriction (800-1000 ml/day), give 3-5% hypertonic saline solution, give Lasix.
4. Nursing Interventions: daily weights; I&O; fluid restriction; monitor heart and lung sounds; neuro assessment; turn q2h; seizure precautions.
• Growth Hormone excess
1. Overproduction of the GH, usually caused by tumor.
2. Clinical Manifestations: enlargement of hands/feet; thickening of bony and soft tissue; speech difficulties; deep voice; sleep apnea; visual disturbances.
3. Treatment: Surgery, Radiation, Drug therapy, Octreotide, Somavert.
4. Nursing Management: avoid vigorous sneezing, coughing and straining to prevent CSF leakage (surgery); elevate HOB; monitor neuro status; provide oral care q4h; monitor for DI (watch I&O)
• Diabetes Insipidus
1. S/S: polydipsia, polyuria, low urine specific gravity, urine osmolality.
2. Phases of Diabetes Insipidus (DI): Acute phase- abrupt onset of polyuria; Interphase- urine volume normalizes, Third phase- DI is permanent, usually apparent within 10-14 days.
3. Determine cause:
- Central DI
Problem results from an interference with ADH synthesis or release. Multiple causes include brain tumor, head injury, brain surgery, CNS infections.
- Nephrogenic DI
Problem results from inadequate renal response to ADH despite presence of adequate ADH. Caused by drug therapy (especially lithium), renal damage, or hereditary renal disease.
- Primary DI
Problem results from excessive water intake. Caused by structural lesion in thirst center or psychological disorder.
4. Treatment of DI: Goal to maintain fluid and electrolyte balance, ADH (vasopressin)- SQ, IM, IV, IVF- NS and glucose, Acute- IVF at rate to decrease serum NA, Long-term therapy- desmopressin acetate (DDAVP) nasal preparation, PO, IV
5. DI Nursing Interventions: Watch for symptoms in high risk patients; If IV glucose used, check urine for glucose; Daily weights; Accurate I&O, may be hourly; Urine specific gravity; Instruct on medications- how often and side effects; Close follow up with physician; Report signs and symptoms of overdose of medications to physician for medication adjustment.
GI
• NG Tube
• Peg Tube
• G- Tube
• TPN
• Gastroscope
• Peptic Ulcer/ GI bleed
1. Accounts for 50% of UGI bleed
2. R/t H. Pylori bacteria or NSAIDS. Stress can also cause ulcers.
3. Nursing Assessment: LOC; VS q 15-30 min; skin color, cap refill, abdominal distention. Assess for signs of shock.
4. Fluid replacement: preferably 2 IV’s, 16-18 gauge.
5. Endoscopy is primary tool for diagnosing source of bleeding.
• Cirrhosis of the liver
1. Early manifestations: gradual onset, GI disturbance, Abdominal pain, fever, lethargy, weight loss, enlarged liver/ spleen.
2. Late Manifestations: Jaundice, skin lesions, Splenomegaly, bleeding tendencies, Ascites, confusion (Ammonia)
3. Care of patient: Rest; administration of B- complex vitamins; avoidance of alcohol, aspirin, Tylenol, and NSAIDS; prevention of esophageal variceal bleeding; management of ascites.
• Ascites- paracentensis
1. Accumulation of fluid in the peritoneal or abdominal cavity.
2. Paracentensis is to remove the fluid.
3. Nursing Inplementation: patient needs to void immediately before; High Fowler’s or side position; monitor for electrolyte imbalance; monitor dressing for bleeding, apply pressure if needed.
• Esophageal varices- balloon tamponade
• Cholelithiasis/ Cholecystectomy
1. Cholelithiasis is most common disorder of biliary system
2. Gallstones
• Pancreatitis
1. Inflammation of the pancreas.
2. Assessment findings: Abd pain LUQ; pain can radiate to back; sudden onset of pain, deep and piercing; N&V; guarding; low grade fever.
3. Nursing Interventions: NPO at first, NGT with suction; IV fluid for hydration/ TPN; give pain meds, antiemetics, and antacids; monitor VS, I&O; check electrolytes.
• Crohn’s Disease
1. Inflammation of all segments of the GI tract, mouth to anus.
2. Penetrates all layers.
3. Has a cobblestone appearance.
4. S/S: nonbloody diarrhea, Colicky abdominal pain.
5. Diagnostic Studies: Hx/ physical exam; Blood studies and stool cultures; Sigmoidoscopy and colonscopy; double contrast Barium enema.
6. Goals of treatment: NPO initially; control inflammation; combat infection; correct malnutrition; symptomatic relief.
7. Drug therapy: meds for inflammation, infection; corticosteroids; immunosuppresents.
• Ulcerative colitis
1. Inflammation begins in the rectum and spreads up the colon in a continuous pattern; ulcers occur.
2. Autoimmune, tissue damage from sustained immune response.
3. S/S: bloody diarrhea; abdominal pain; rectal bleeding.
4. Diagnostic Studies: same as Crohn’s.
5. Goals of treatment: Crohn’s
6. Drug therapy: Crohn’s
• Colon Cancer
1. Risk Factors: Family history; more common in men and African Americans; Obesity, Smoking, alcohol, large amounts of red meat; IBD.
2. S/S: blood in stool, Melena, Abdominal pain, changes in bowel habits; weakness.
3. Colonoscopy is the “gold standard” for diagnosing colon cancer.
Renal
Male Reproductive
Neuro
Hematology
• Polycythemia vera
1. Caused from chromosomal mutation; usually > 60 yrs when dx; males.
2. Blood becomes too thick organs become congested. Hypercoagulation occurs; splenomegaly and hepatomegaly.
3. Nursing Care: Therapeutic phlebotomy; increase fluids, I&O; meds to reduce platelet count and WBC count; DVT precautions; as much activity as possible; active and passive ROM; after discharge, phlebotomy every 2-3 months.
4. Clinical Manifestations: HTN, headache, dizziness, tinnitus, visual disturbances, HF, Thrombophlebitis, SOB.
• Leukocytosis/ leukopenia
1. A reduction in neutrophils.
2. Causes: usually a side effect of Chemo.
3. The biggest problem is infection: fever, (even low grade) chills, weakness, and sepsis/ septic shock.
4. Nursing Management: Administer antibiotics as ordered; strict hand washing; monitor temp q4h; give analgesics PRN; give WBC stimulating medications like Neupogen; reverse isolation.
5. A shift to the left is an increase in the percent of bands. Meaning the bone marrow is releasing less mature cells into circulation in response to a site of injury.
• Iron Deficiency Anemia
1. Decreased available iron- dietary Anorexia, anorexia nervosa or bulimia, vegetarian/ vegan diet. Or caused by malabsorption stomach/ colon cancer or surgery; malabsorption syndromes; chronic blood loss.
2. Diagnostic Tests- Assessment: Low RBC, Hgb, Hct, MCV; Low serum iron, TIBC.
3. If GI bleed is suspected: gastroscopy, stool for occult blood, colonoscopy, occult blood on any emesis.
4. Patient Teaching: with iron supplements, may see dark stools; may experience constipation, may need stool softeners; iron is absorbed best in an acidic environment, taken about an hour before meals; iron absorption is inhanced if taken with Vitamin C.
• Aplastic Anemia
• Macrocytic Anemia
1.
• Thrombocytopenia
1. Clinical S/S: abnormal bleeding; petechia/ purpura; ecchymoses; weakness, fatigue, and anemia.
• Nursing Interventions: monitor for serious bleeding (intercranial hemorrhage, internal abdominal bleed), give platelet infusion as ordered; no IM injections; avoid insertion of NG tubes or urinary catheters; avoid anti- platelet meds; No NSAIDS
• Sickle Cell
1. Hgb S causes the RBC to stiffen and elongates.
2. There is an abnormal form of hemoglobin in the erythrocyte .
3. Patient is chronically low of RBC/ Hgb because of abnormal Hgb. Sickle Cell Crisis occurs when blood is low of oxygen. Can be triggered by infection, stress, surgery, blood loss, high altitude.
4. Sickling Crisis: a severe, painful exacerbation of RBC sickling. Sickled cells cannot fit through small capillaries they pile up and occlude the vessel. Vasospasm occurs. Capillary permeability changes cause plasma volume to be lost. Spleen begins to hemolyze sickled cells.
5. S/S of Sickle cell crisis: pain, fever, swelling, tenderness, tachypnea, HTN, N&V.
6. Nursing Management: Oxygen, rest; increase oral and IV fluids to replace plasma loss; pain management; Antibiotics as ordered; Blood transfusions as ordered; Hydroxyurea (antisickling agent)
7. Patient Teaching: avoid high altitudes, maintain fluid intake, treat infections, pain control.
8. Until now, basically no cure.
• Lymphoma
1. Hodgkins and Non- Hodgkins Lymphoma
2. Malignant neoplasms originating in the bone marrow and lymphatic structures.
3. Cause= unknown. Involves B and T lymphocytes; Spreads to lymph nodes and organs.
4. Clinical Manifestations: enlarged lymph nodes, fever, weight loss, fatigue, weakness, night sweats.
5. Nursing Interventions: Give all meds as ordered; monitor temp; Reverse isolation when indicated; emotional support; family/ patient teaching.
6. Lymphoma treatment: Chemo and radiation
Musc/ Skel
Skin/ Burns
Visual and Auditory
Cancer [Show Less]