Med-Surg Study Guide 2021
Heart Failure (HF) (10)
S/S left HF and S/S right HF
Signs & Symptoms
Left sided failure (blood backing up in
... [Show More] lungs) Right sided failure (blood backing
o up Venus system = edema)
*Dyspnea, orthopnea (shortness of breath while *Jugular vein distention
Lying down), nocturnal dyspnea *Ascending dependent edema (legs,
*Fatigue ankles, sacrum)
*Displaced apical pulse (hypertrophy) *Abdominal distention, ascites
*S3 heart sound (gallop) *Fatigue, weakness
*Pulmonary congestions (dyspnea, cough, *Nausea and anorexia
Bibasilar crackles) *Polyuria at rest (nocturnal)
*Frothy sputum (can be blood-tinged) *Liver enlargement (hepatomegaly)
*Altered mental status and tenderness
*Manifestations of organ failure, such as *Weight Gain
Oliguria (decrease in urine output)
Treatment
o Diuretics
o Ace inhibitors = Valsartan
o ARB’s
o CCB;s
o Digoxin = strengthens heart
o Beta Blockers
o Vasodilators = Nitro
o Warfarin, Plavix, blood thinner
How to monitor HF – patient education
o Daily weight
o Diet = low sodium
o Smoking cessation
o Position: high fowlers
o Monitor VS
o Monitor lab work
o Heart rate = below 60 do not administer digitalis = listen to apical for a full
minute
Nursing actions/interactions associated with monitoring HF
o AROM
o Fluid restriction
o Low sodium diet
o Weights
o I & O
o Medications =
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diuretics
digitalis = increase myocardial contraction which slows conduction
normal 0.5 -2
Ace inhibitors = biggest side effects = cough
Dobutamine for severe heart failure
Digoxin = decrease in potassium
Toxic s/s = halos, vision changes, arrythmias, N/V
Oxygen above 92%
o Monitor labs
o Administer medications
Patient Education
o Low sodium diet
o Emotional support
o Effective breathing techniques
o Daily weight at same time everyday notify dr. if more than 2lbs in a day or 5lb
in a week.
o Report swelling of feet or ankles
o Report shortness of breath
o Common adverse effects of medication
Key assessments with meds associated with HF
o Respiratory assessment
o Auscultation
o Urinary output
o Weight
o I & O
o Blood Pressure
o Ascites
Patient education on meds used to treat HF
o Lisinopril
Hypotension
Increased serum potassium
Worsening renal function
Cough
o Losartan
Hypotension
Increased serum potassium
Worsening renal function
o Hydralazine
Hypotension
o Metoprolol
Decreased heart rate
Hypotension
Dizziness
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Fatigue
o Diuretics
Electrolyte imbalances
Renal dysfunction
Decreased
BP
I & O
Daily weights
Hypokalemia
Hypernatremia
o Spironolactone
Hyperkalemia
Hyponatremia
o Digoxin
Bradycardia
Toxicity
Hemophilia (6)
Both types of hemophilia are inherited as X linked traits so mostly men are
affected
o Hemophilia A (factor VIII deficiency) measured by aPTT (intrinsic Pathway)
o Hemophilia B (Christmas Disease, factor IX deficiency) measured by aPTT
(intrinsic Pathway)
Treatment
o Replacement of the missing factor VIII or IX
o Fresh frozen plasma
o Recumbent (manmade) factor treatment
o aPTT = 30 - 35
Nursing actions/interventions when caring for hemophiliac
o Sign/Symptoms
Lethargy
Joint pain
o Prevent bleeding
o Safety precautions (fall precautions)
o Avoid IM injections
o Avoid meds that may encourage bleeding
o Monitor for internal bleeding
Coffee ground emesis
Cola colored urine
Tarry stools
Patient education on living with hemophiliac
o Can’t take aspirin/NSaids
o Before dentist replace factors
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o Protect from injuries
o Soft bristle tooth brush
o Electric razor
o RICE
o Apply pressure to cuts
o Genetic counseling
Leukemia (AML, ALL, CML, CLL) (10)
Commonalities of all leukemia’s
o Unregulated Proliferation of leukocytes in the bone marrow
o Later stage of proliferation leaves little to no room for normal cell production
o Exposure to radiation or chemicals, certain genetic disorders, and viral infections
Assessment findings of low platelets
o Easy/excessive bruising
o Petechia on lower limbs
o Prolonged bleeding
o Bleeding gums
o Nose bleeds
o Blood in urine or stools
Potential complications associated with leukemia (the TOP potential complications)
o Infection
S/S of each leukemia and treatment regimen for all leukemia’s and complications:
o Acute Myeloid Leukemia results from a defect in the hematopoietic stem
cell that differentiates into all myeloid cells.
Symptoms arise from insufficient production of normal blood cells
Fever, infection
Weakness fatigue
Dyspnea on exertion
Anemia = pallor
Petechiae
Ecchymosis
Bleeding tendencies
Treatment of AML
Aggressive Administration of chemo called induction therapy,
which usually requires hospitalization
Complications:
o Bleeding
o Infection
o Chronic Myeloid Leukemia (CML) arises from a mutation in the myeloid
stem cell
Malaise
Anorexia
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Enlarged/tender liver
Weight loss
Leukocyte above 100,000
Treatment
Tyrosine Kinase inhibitor (Gleevec) blocks signals within
leukemia cells
Complications
o Fatigue
o Anemia
o Acute lymphocytic Leukemia (ALL) results from an uncontrolled
proliferation of immature cells derived from the lymphoid stem cell
Enlarged liver & spleen with pain
Bone pain
Headache, vomiting
Treatment
Chemotherapeutic, dexamethasone, L Asparaginase treatment
Complications
o Tumor lysis syndrome
o Renal failure
o Sepsis
o Bleeding
o Neuropathy
o Encephalopathy
o Chronic lymphocytic Leukemia (CLL) (most common) derived from a
malignant clone of B lymphocytes
Lymphadenopathy
Splenomegaly
Fever
Weight loss
anemia
Treatment
Immunotherapeutic antibody with chemotherapy agents
Complications
o Frequent infections
o Switch to more aggressive cancer
Patient education
o Prescribed medications
o Dx and Tx
o Adverse effects to be looked for
o S/S of infection and bleeding
o Limit contact with infectious people
o Immunizations not good for chemo patients
o No fresh fruits or vegetable
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o No plants
o Low bacteria diet
o Low fever is not good
Induction therapy *acute myeloid leukemia*
o Aggressive [Show Less]