NUR170 Exam 1 Study Guide Concepts of Medical Surgical Nursing (Galen college), Exams of Nursing

Download NUR170 Exam 1 Study Guide Concepts of Medical Surgical Nursing (Galen college) and more Exams Nursing in PDF only on Docsity!

NUR170 Exam 1 Study Guide

Concepts of Medical Surgical Nursing (Galen College of Nursing)

EXAM 1 STUDY GUIDE

Pain The 5

th

Vital Sign

Characteristics of Acute and Chronic Pain

▪ Acute Pain (sudden onset, trauma, accident) – usually hours to days

o Increased Heart Rate Blood Pressure and Respiratory Rate

o Dilated Pupils and Sweating

o Results from sudden, accidental trauma, surgery; ischemia, inflammation

▪ Chronic Pain (persistent long term) – usually longer than 3 months

o Dull, Burning Sensation

Types of Pain

▪ Nociceptive Pain (normal pain)

o Somatic Pain – Superficial or Subcutaneous Tissue felt by sharp, burning.

o Deep Somatic – Bone, Muscle, Blood Vessel, Connective Tissues.

o Visceral Pain – Organs and Linings of Body Cavities felt by deep cramping,

splitting, sharp.

▪ Neuropathic Pain (abnormal pain) Give Gabapentin

o Nerve Fibers, Spinal Cord, Central Nervous system felt by shooting, fiery, burning,

sharp,

numbness.

o DM, phantom limb pain, HIV

neuropathies How to assess pain

• Wong-Baker faces pain rating scale – 0-10 uses visual appearance of face to determine pain
• Pain scales – 1. Numerical, 2. Descriptive, 3. Visual analog scale
• Non-verbal indicators of pain – moaning, crying, irritability, restlessness, grimacing or

frowning, inability to sleep, rigid posture, increased BP/HR/RR, nausea, diaphoresis

Considerations for Older Adults

o Pain is relative to the person, and it is what they say it is. Always take patients self-report

o Pain is not a part of getting older.

o Never give your patient a placebo.

o Start dose low and titrate slowly.

o Avoid Meperidine (Demerol) because it can cause nephron toxicity and chronic delirium.

o Home safety assessment and teach caregivers to help reduce falls and accidents.

o Do not use an older adults hand for IV’s. A nice plump vein in a younger adult is best.

PQRST Acronym

o P recipitates – what triggers the pain?

o Q uality – what does it feel like?

o R adiate – is the pain localized or referred?

o S everity – how intense is the pain on a scale of 1-10?

o T reatment – what helps it go away and how long?

Non-Opioid Analgesics

o The first-line therapy for mild to moderate pain.

o Assess previous bowel sounds, and movements, administer stool softeners /

laxatives.

• Sedation and Confusion
• Nausea and

Vomiting o Treat with antiemetic (Zofran / Reglan) prophylactically and

prn.

o Watch for other antianxiety meds and hypnotics.

o Watch for caffeine intake and consider opioid rotation.

o If patient is not easily aroused or somnolent, STOP medication and contact provider

• Respiratory Depression

o Monitor respiratory rate, and pulse oximeter

o Decrease dosage if respiratory rate begins to slow, and note that respiratory

depression occurs before sedation

o Resp. assessment is done before arousing sleeping patient – if difficult to arouse,

stop opioid, stay with patient, continue to try to arouse, call for help

o Can cause falls

o (Narcan) Naloxone is the antidote to Opioids

o Flumazenil is antidote for

Benzodiazepines Patient Controlled Analgesic Pump

(PCA)

• Usually with morphine, fentanyl or hydromorphone
• Basal Rate = Continuous Infusion
• On-Demand = Button controlled
• Maxiumum of 10 mg/hr
• Make sure to do frequent vital, neuro, and respiratory checks
• Always continuous pulse oximeter
• STOP and report a 15-20mmHg drop in blood pressure or a respiratory rate less than 9
• Post procedure headache must be reported to surgeon or physician immediately
• Only patient controls device

Epidural

• Respiratory depression can occur – monitor closely with pulse ox
• Infection – mental status changes, pyrexia, nuchal rigidity
• Assess patients receiving epidural for their ability to bend their knees and lift their buttocks

off the mattress – if not prohibited by surgical procedure

• Do not delegate assessment
• No anticoagulants
• Monitor site for REED
• Post procedure headache – REPORT PROMPTLY

TENS unit – physical intervention

• Adjuvant therapy – used in addition to other pain management measures
• Placed directly over or near site of pain – not on bone
• Starts to work immediately

Miscellaneous analgesics

• Dual mechanism – tramadol, ultracet
• Anticonvulsants – carbamazepine, topiramate, gabapentinoids – first line for

persistent neuropathic pain

• ^When used for seizure management produce analgesia by blocking sodium and calcium

channels in the CNS, thereby diminishing the transmission of pain. Increasingly being

added to postop treatment plans to address the neuropathic component of surgical pain.

• Antidepressants – TCAs  poor choice for older adults, SSRIs, SNRIs
• ^Relieve pain on the descending modulatory pathway by blocking the body’s reuptake

of the inhibitory neurochemical’s norepinephrine and serotonin.

Pre-Op Teaching

• Fears and Anxieties
• Surgical Procedure
• NPO, Blood Sampling, CHG Bath
• Skin prep – proper cleaning, fresh linens and a fresh gown
• Shaving with electric clippers before bath
• Lower extremity exercises
• Encourage patient to walk (if A&Ox3), turn, cough and deep-breathe after surgery
• D/C plan – never by mouth
• Invasive procedures (IV, catheters, etc) – make sure IV is patent
• Incentive Spirometer and TCDB
• Early Ambulation – prevent DVT and pneumonia
• Anti-Embolism Devices (SCDs, Stockings)
• Pain Management

If you believe patient has not been adequately informed and fully understands the procedure and

all its components, contact the surgeon for clarification and document. DO NOT SIGN CONSENT

UNLESS THIS IS CLEAR!

Intra Op

• Pre-Surgical TIMEOUT is REQUIRED BEFORE PROCEDURE, including the patient’s identity,

correct side and site, patient position, and agreement of procedure must be verified by

ALL members present Circulation nurse makes calls and organizes and initiates

TIMEOUT

• Always pad bony prominences
• Cover patients head and feet to prevent hypothermia during procedure
• Surgical Scrub needs to be at least 3 – 5 minutes

Anesthesia

• Local – Generally topical and brief, very few side effects. Delivered topically or by local

injection. Patient maintains their airway.

• Regional – Blocks multiple impulse nerves offering a regional affect like an epidural, spinal,

nerve block or field block. Pt maintains their airway. Watch vital signs.

• General – Full sedation, reversible loss of consciousness induced by inhibiting nerve

impulses within the CNS (results in analgesia and amnesia). Delivered via IV and gas.

Patient needs oxygen. Watch vital signs.

• Allergic reaction – temperature change
• Ask patient – have you ever had anesthesia? Ever had a reaction? If patient has ever had a

fever with anesthesia, they are at risk for MH.

• Always asses’ patient after for Circulation Movement and Sensation
• Check to see if the area that was once numb, is no longer numb later
• Make sure their airway is patent

Malignant Hyperthermia is an acute emergent complication to anesthesia (life-threatening). Signs

are: Temp > 103, dark urine, muscle rigidity, tachycardia, dysrhythmias, delirium, increased CO

productions, fever, Coca-Cola colored urine, hypotension, and myoglobinuria (muscle protein in

urine). ACIDOTIC.

• Begins when skeletal muscle is exposed to specific agent
• Causes increased metabolism, calcium levels in muscle cells
• Insertion of Foley catheter to monitor output
• Transfer to ICU after stabilization
• Cooling techniques – cooling blanket, ice packs around axillae and groin
• Complications – rhabdo, high blood potassium
• Excessive heat results in metabolic acidosis

POD2) – hyperglycemia delays healing

• Appropriate hair removal – electric razor before washing
• Urinary catheter removed (post op day 1 – 24 hours)
• Recommended VTA (ordered and received)

Drains, dressings and discharge instructions

• First dressing is done by doctor
• lDiet considerations – high is protein, vitamin C, folic acid, and zinc to promote would

healing

• Discharge instructions – very specific to the surgery. And presence of fever, purulent

drainage, and/or pain not relieved by prescribed medication should ALL be reported to

the PCP.

• Any patient going home who will be doing their own dressing change or emptying a

drain and recording the output, make sure you teach and then observe them doing it

properly

Lab Values Know what can happen if they are out of range(Increased HYPER / Decreased HYPO)

Potassium(K) 3.5 – 5 (Dehydration, Renal Failure / NPO status, Vomiting, Diarrhea)

Sodium(Na) 135 – 145 (Cardiac, Renal Failure / Vomiting, Diarrhea, Excessive ADH

usage) Chloride(Cl) 98 – 106 (Dehydrating, Renal Failure / Vomiting, Diarrhea, Excessive

diuretics)

• Calcium(Ca) 9 – 10.5 (Hyperthyroidism Excessive Vitamin D use Hypothyroidism,

Excessive Phosphorus intake, Kidney Disease)

Magnesium(Mg) 1.8 – 3 (Hypothyroidism, Kidney Disease/ Alcoholism, Malnutrition)

Phosphorus(Phos) 2 – 4.5 (Hypoparathyroidism, hypocalcemia / Chronis Antacid Use,

Alcoholism)

Glucose(Glu) 70 – 110 (Hyperglycemia, Steroid Use / Hypoglycemia, Excessive Insulin)

Creatinine 0.5 – 1.2 (Renal Insufficiency or Disease, or Acute Damage / Atrophy of muscle

tissue) Blood Urea Nitrogen(BUN) 10 – 20 (Dehydration, Renal Failure / Overhydration,

Malnutrition) Prothrombin Time(PT) 11 – 12.5sec (Coag Deficit Anti-coag Therapy, Vitamin K

Deficiency / Thrombophlebitis, Pulmonary Embolus)

International Normalized Ratio(INR) 0.9 – 1.2sec (Anti-coag Therapy / Extensive Cancer

White Blood Cell(WBC) 5,000 – 10,000 (Infection, Inflammation / Immune Disorder or

Suppressant)

Red Blood Cell(RBC) 4.2 – 6.

Hemoglobulin(Hgb) 12 – 18 (Dehydration, Pulmonary Disease/ Blood Loss, Anemia, Renal

Failure)

Hematocrit(Hct) 37 – 52 (Dehydration, Polycythemia /Blood Loss, Anemia)

Platelet Count(PLT) 150,000 – 400,000 (Thrombocytosis / Anti-Platelet

Therapy)

Fluid and Electrolyte Imbalances

o Fluid Volume Deficit (Hypovolemia)

▪ Hypotension

▪ Thready pulses

▪ Orthostatic hypotension

▪ Increased RR

▪ Lethargy

▪ Constipation

▪ Increased Hemoglobin and Hematocrit

▪ Change in LOC/confusion

▪ Flat neck veins & dry mucous membranes, poor skin turgor

o Interventions

▪ Fluid Replacement with 0.9% NS or 0.45% NS

▪ Assess for Postural Orthostasis

▪ Monitor I&O, and Serum Electrolytes

▪ Monitor Patients WEIGHT do to it being the best indication of fluid status

Assessing for dehydration (lab & diagnostic exams)

o Hemoglobin & hematocrit ^

o Serum osmolarity ^

o BUN ^

o Urine specific gravity^

o Electrolyte imbalances

Fluid Volume Overload (Hypervolemia)

o Causes

▪ Rapid Fluid Replacement with too high of an INFUSION RATE

▪ Heart Failure

▪ Long-Term Corticosteroid Therapy – helps you hold things in

▪ Kidney failure – dialysis

▪ Blood transfusion

o Signs

▪ Increased pulse and blood pressure

▪ Increased shallow respirations with moist crackles in lungs

▪ Juglar Vein Distention (Assess while patient is in low-fowlers position)

▪ Pitting edema and altered mental status or level of consciousness

▪ Decreased H&H, BUN

▪ SOB on exertion

▪ Pulmonary Edema is EMERGENT, and HCP must be notified immediately.

o Interventions/treatments

▪ Loop Diuretics

▪ Fluid restrictions and sodium restrictions

▪ Pressure ulcer formation prevention

▪ Assess Q2 for worsening symptoms, electrolyte imbalances

▪ Keep HOB 30-45 degrees to prevent drowning

▪ REMEMBER – where salt goes, water follows

Hyponatremia; NA=nuero

Causes

• DDDD- Diuretics, diarrhea, dehydration, drains
• VAN- vomiting, anorexia, diarrhea,
• Prolonged diuretic therapy
• Excessive diaphoresis
• Insufficient Na intake
• Kidney disease – the kidneys are our filtering system

Clinical manifestations

• LOC changes/confusion fall risk
• Seizures (severe loss)
• Coma/death (severe – since Na is important for NEURO)
• Muscle weakness
• Diminished DTR’s

Signs/symptoms

• Muscle weakness
• Tachycardia
• Fatigue
• Confusion, headache
• N/V, abdominal cramps
• Ortho hypo

Treatment

• Treat the cause
• Discontinue diuretics
• HYPERTONIC IVF 3 or 5% saline
• Tolvaptan
• Seizure and fall precaution
• High salt diet, decrease fluid intake

Hypernatremia

• Kidney failure
• Corticosteroids
• Excessive PO or IV sodium intake
• Dehydration
• Vomiting/diarrhea
• Diaphoresis
• Major burns
• Hypertonic fluids/tube feedings
• Excessive O2 loss

Assessment

• F – fever (low grade), flushed skin
• R - restless (irritable)
• I – Increased fluid retention and increased BP
• E – Edema (peripheral and pitting)
• D – decreased urine output, dry mouth (membranes) – think salt dries up!
• Muscle twitching, weakness

Causes

• Excessive use of salt substitutes and administration of K+
• Administration of larger qualities of blood that is old
• Hyponatremia (they go together)
• Renal failure

Signs/symptoms

• EKG changes
• Bradycardia
• Hypotension
• Muscle twitching
• Tingling followed by numbness (paresthesia)
• Diarrhea

Treatment

• D50W and regular insulin to facilitate movement into the cells (because K+ likes

to ride the insulin train with glucose into the cell)

• Administer Kayexalate (Na+ polystyrene sulfonate) – oral or rectal – to make them

poop

• Dialysis – urgent step – but remember the time it takes to set it up!
• Cardiac monitoring
• Diuretics – furosemide

Hypocalcemia – found abundantly in the bones

Causes

• Decreased calcium and vit D intake
• Lactose intolerance
• Malabsorption
• Kidney disease
• Diarrhea

Signs/symptoms

• C – Convulsions
• A – Arrythmias
• T – Tetany – involuntary contraction of muscles
• S – Stridor and spasms
• Parasthesia of fingers, toes and face
• Positive Trousseau’s sign (internal rotation and clinch of hand with BP

cuff)/Chvostek’s sign (Cheek twitch)

• Abdominal cramping/diarrhea
• Numbness/tingling around the mouth

Treatment

• Calcium gluconate
• PO calcium supplements
• Minimize stimulations – dark rooms and no noise

Hypercalcemia

• Excessive use of antacids with phosphate-binding
• Excessive vit D intake and calcium intake

• Thiazide diuretics
• Cancer

Signs and symptoms

• B – Bone pain, blood clots in poor flow areas
• A – Arrhythmias
• C – Cardiac arrest – increased blood pressure and heart rate
• K – Kidney stones
• M – Muscle weakness
• E – Excessive urinations
• Decreased GI peristalsis – gut is meant to sing

Treatment

• Loop diuretics
• IV fluids (0.9% NS) – will cause the patient to pee
• Calcitonin
• Phosphorus
• Cardiac monitoring
• Discontinue all meds containing or that can raise Ca+

Hypomagnesemia – important for skeletal muscle contractions

• Hypokalemia’s twin Irish brother
• Malnutrition
• Diarrhea
• Malabsorption issues
• Alcoholism – because of the poor nutrition

Signs/symptoms

• Hypertension
• Dysrhythmias
• Numbness and tingling
• Increased DTR
• Seizure and confusion – severe (also seen in sodium)
• Decreased GI motility

Treatment

• Discontinue magnesium-depleting medications
• Magnesium sulfate IV

Hypermagnesium

Causes

• Increased magnesium intake (like Maalox or MOM)
• Medications
• IV magnesium replacement

Signs/symptoms

• Lethargy and drowsiness
• Depressed neuromuscular activity
• Depressed respirations

o Gastric bypass, crohns and ulcerative colitis patients at high risk for this

o Beefy red tongue called glossitis

o Numbness and tingling in the arms and legs (sign of deficiency), as well as

generalized anemia symptoms, depression, anxiety, memory issues

- Sickle Cell Disease, Give PAIN meds, fluids, oxygen more common

AAmerican Signs and Symptoms of Anemia

• Decreased SPO2 leading to Hypoxemia
• Fatigue / Somnolence
• Dyspnea on Exertion
• Tachycardia and Orthostatic Hypotension
• Pallor and Cool skin to the touch.

Sickle Cell Crisis

• Give O2 therapy, fluids, PAIN meds and loosen clothing
• Check circulation frequently and peripheral pulses
• Give an Isotonic solution or hypotonic solution; NEVER a hypertonic solution

Causes

• Dehydration
• Infection
• Emotional stress
• Pregnancy
• Altitude changes
• Cold weather
• Anesthesia
• Strenuous exercise

Symptoms/signs

• PAIN

• Pallor/cyanosis
• Jaundice – eyes, feet, palms of hands
• Lower extremity ulcers
• Chronic kidney disease
• Cardiovascular issues
• Musculosketal issues

Prevention

• Avoid alcohol, smoking and strenuous activities that make oxygen levels hard to

manage Blood Transfusions

• Can be hung no longer than 4 hours for each blood bag
• Tubing MUST be changed with each bag, NEVER use same tubing
• FIRST step is to TYPE and CROSS
• Check patient’s full vital signs and labs BEFORE infusion
• Remain with the patient for the first 15-30 min to assess for any reactions!
• Asses for hyperkalemia
• Must be administered 30min after receiving it
• Important to know if they have ever had a reaction to a prior transfusion

Compatibility