Med Surge Exam 2 Study Guide latest Update Rated A+, Exams of Nursing

Download Med Surge Exam 2 Study Guide latest Update Rated A+ and more Exams Nursing in PDF only on Docsity! Med Surge Exam 2 Study Guide latest Update Rated A+ Med Surge Exam 2 Study Guide lFluid & Electrolytes & ABG’s o Homeostasis: • Water is the most common fluid, makes up 50-60% of total weight ▪ Needed to deliver dissolved nutrients, electrolytes, and all substances to all organs, tissues, and cells • Water is divided into 2 main compartments: ▪ Extracellular – fluid outside the cell ◆ Also includes interstitial fluid between the cells ▪ Intracellular – fluid inside the cell o Filtration • The movement of fluid (water) through a cell or blood vessel membrane because of water pressure (hydrostatic pressure) differences on both sides of the membrane • The human body constantly seeks equilibrium ▪ Water movement occurs until hydrostatic pressure is equal on both sides of membrane ▪ Blood pressure is an example of hydrostatic filtration. It moves whole blood from the heart to capillaries where filtration can occur to exchange water, nutrients, and waste products between the blood and the tissues o Fluid Balance • Fluid balance is closely linked and affected by electrolytes • Fluid intake is regulated through the thirst drive • Fluid loss occurs via the kidney, skin, lungs, and the intestinal tract ▪ Kidneys – the most important and sensitive water loss route d/t being regulated and adjustable. Volume excreted varies based on intake and body’s need to conserve fluids o Minimum amount of urine per day to excrete toxic waste (400- 600 ml) o The kidney can make either diluted or concentrated urine to maintain balance • Insensible loss occurs via the skin, lungs, and stool as this is not regulated or controlled • **Normal urine output is 30cc/hr** o Renin-Angiotensin • Most critical fluid balance is to maintain blood volume to perfuse tissues/organs ▪ Requires specific hormone levels, kidney function, and blood vessel responses to balance water and sodium • If the kidneys sense BP is low, they secrete Renin that starts hormonal and Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ blood vessel responses to raise the BP to normal Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ * * C r a c k l e s i n l u n g s is a n e a rl y si g n * * ▪ Pale & Cool skin ▪ Altered LOC ▪ Weaknes s, Nausea • Interventions ▪ **Assess pt. q2hr to ensure they do not go into pulmonary edema** ▪ Safety is priority ▪ Give Diuretics ▪ Correct electrolyte imbalance ▪ Fluid restrictions ▪ Low Na Diet ▪ Monitor lung sounds for crackles ▪ Monitor wt. Daily ◆ **+ or – 3 lbs. are indicative of fluid change** • Pt. at risk: ▪ Poor cardiac or Kidney Function ▪ HF ▪ Pulmonary Edema **JVD – if pt. is Tachycardic (1st sign of Hypoxia) if Bradycardic (pt. needs to be intubated) ** **Fluid Retention may not be visible. Rapid wt. gain is the best indicator of fluid retention and overload** o Sodium • **135-145** • Keeping normal levels is vital for: ▪ Skeletal muscle contractions ▪ Cardiac contraction ▪ Nerve impulse transmission (Na – “N” means Nerve impulses) • Balances Fluid – “where sodium goes, water follows” • Highest food sources of sodium are pickled or processed foods • Lowest are fresh fish, poultry and fresh fruits and veggies o Hyponatremia • Less than 135 • S/S: ▪ Lethargy ▪ Headache ▪ Confusion ▪ Apprehension ▪ Seizures & Coma • Pt. that will present with it: ▪ NG tube to low wall suction Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ ▪ Vomiting & Diarrhea ▪ Diuretics ▪ Inadequa te sodium intake or NPO pt. ▪ Excessive ingestion of hypotoni c fluids ▪ **Elderly can be prone to s/s far earlier than others** • Treatment: ▪ Dr ug an d nu tri tio n th era pie s are us ed to res tor e Na levels but are carefully monitored to prevent fluid overload or Hypernatremia ▪ Hourly monitoring for s/s of fluid overload is critical o Hypernatremia • Greater than 145 • S/S: ▪ F – Flushed skin and fever (low-grade) ▪ R – Restless, Irritable, Anxious and Confused ▪ I – Increased BP and Fluid Retention ▪ E – Edema: peripheral and pitting ▪ D – Decreased Urine Output and Dry mouth ▪ S – Skin Flushed ▪ A - Agitation ▪ L – Low-Grade Fever ▪ T – Thirst • Treatment: ▪ Monitoring, ensuring pt. doesn’t become hyponatremic or dehydrated ▪ Na restrictions ▪ Diuretics (Lasix) ▪ Ensure Fluid Intake o Potassium • Normal Levels: 3.5-5 • Everybody system is affected by K+ • Highest Source: Meat, fish, fruits, and veggies • 80% of K+ is exc ret ed via the kid ne ys • Critical for normal cardiac function! Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ • **ANY POTASSIUM out of normal (MAIN intervention is going to be to Monitor the Heart!!) ** • Watch K+ level for Pt. with: ▪ Renal Failure ▪ Hydratio n or Acid- base imbalanc es ▪ Cellular Damage • B u r n s, a c ci d e n ts & s u r g e ry ’s ▪ Diabetics ▪ **If pt. on Digoxin or Diuretics (Loop and Thiazide) (K+ will be Low) ** o Hypokalemia • Lower than 3.5 • S/S: ▪ A - Alkalosis ▪ S – Shallow Respirations ▪ I - Irritability ▪ C - Confusion ▪ W – Weakness, Fatigue ▪ A – Arrhythmias (Tachycardia, Irregular Rhythm and/or Bradycardia) ▪ L - Lethargy ▪ T – Thready Pulse ▪  Intestinal Motility (N/V, ileus, Obstruction) • Causes: ▪ Diuretics (Loop & Thiazide) ▪ Corticosteroids ▪ Cushing Syndrome ▪ Diarrhea & Vomiting ▪ Kidney Disease ▪ Prolonged NG suction • Interventions: ▪ K+ Replacement ◆ IV replacement: o *10 mEq in 100cc given over an hour & we usually give 3* o Rate should not be faster than 10-20 mEq/hr to prevent hyperkalemia and cardiac arrest o Can’t Push! IV infusion can be painful o Don’t add to a hanging bag; must mix well or pt. will get a bolus o IV infusion concentration Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ ▪ Admini ster 10 units of regular insulin; becom es active within 15-60 mins; lasts about 4 hours ◆ **Help K+ and Na go in the cell** ◆ This is given concurrently with hypertonic glucose (10 or 50%) ▪ Give a loop Diuretic ◆ **Sodium polystyrene Sulfonate (Kayexalate)** ⟶ A cation-exchange resin given orally, per NG, or rectally in the form of (many) enemas ⟶ Must give sorbitol along with it as cathartic so the patient gets rid of it ⟶ Potassium is exchanged for sodium • **9-10.5** • Calcium enters the body via dietary intake and absorption via GI tract • Functions: ▪ Maintains bone strength & density ▪ Activates enzymes ▪ Skeletal and cardiac contraction ▪ Nerve impulse transmission ▪ Allows blood clotting activation • Dairy products are commonly high in calcium ▪ Requires Vit D to absorb in GI tract o Hypocalcemia • Less than 9 • S/S: ▪ **Calf pain, Contracture or Severe Charlie Horse** ▪ **Trousseau’s Sign (hand contorts when BP is taken) ** ▪ **Chvostek’s Sign (face contorts when tapping the cheek) ** ▪ C - Convulsions ▪ A - Arrhythmias ▪ T - Tetany ▪ S – Stridor and spasms • Causes: ▪ Inadequate oral intake ▪ Lactose intolerance ▪ Malabsorption ▪ Inadequate intake of Vit D ▪ ESDR ▪ Diarrhea • Treatment: ▪ Vit D Supplements ▪ High Calcium Diet ▪ Reduce stimulation – quiet room Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ ▪ Seizure precaution Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ ▪ ▪ ◆ o Hy pe rc alc e mi a: • G r e a t e r t h a n 1 0.5 • S/S: ▪ Muscle weakness ▪ Decreased Deep – tendon reflexes (DTR’s) ▪ Polyuria, Anorexia ▪ Nausea/Vomiting ▪ Arrythmias ▪ Heart Block ▪ Hypertension • Causes: ▪ Excessive oral intake of Ca ▪ Excessive oral intake of Vit D ▪ Kidney Failure ▪ Thiazide Diuretics ▪ Hyperparathyroidism ▪ Malignancy ▪ Dehydration • Treatment: ▪ Stop any meds that increase Ca levels ▪ Rx: Calcitonin (reduces Ca reabsorption) ▪ Give NS ▪ Cardiac monitoring ▪ Rehydration therapy ▪ Severe: Dialysis o **If Calcium level is high Phosphorus level is LOW (if calcium is high, may give phospho- tab to decrease calcium levels** o Magnesium • **1.5-2.5** • Stored in bones and cartilage • Functions: ▪ Skeletal muscle contractions ▪ Carbohydrate metabolism ▪ Generation of energy stores ▪ Vitamin activation ▪ Blood coagulation ▪ Cellular growth • Regulation occurs in the kidneys and GI tract • **Regulates muscular contraction: acts at the site where the nerves affect the muscle** • **You always measure Mg+ and Albumin together!!** • Mg+ is an intracellular electrolyte Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ o Healthy Eating • Pt. Understanding ▪ Can identify food made up of carbs ▪ Can give an example of balance meal Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ ▪ Correctly identifies carb content on food label ▪ States importance of eating appropriately sized meals throughout the day and states will not skip meals • Red Flags ▪ States he/she can never have anything good or favorite foods again ▪ Advocates for use of fad diets ▪ Only counts “sugars” on label rather than “total carbs” ▪ Eats out excessively ▪ Drinks sugary drinks often o DM Type 1: • **Insulin Dependent** • S/S: ▪ Wt. Loss ▪ Fatigue ▪ Increased frequency of infections ▪ Rapid onset ▪ **Polyuria (𝖳 urination) ** ▪ **Polydipsia (𝖳 thirst) ** ▪ **Polyphagia (𝖳 hunger) ** ▪ **NOT on PO Meds** ▪ **Usually individuals less than 30** o DM Type 2: • Genetic Mutations = Insulin Resistance & familial Tendency • S/S: ▪ Polyuria ▪ Polydipsia ▪ Recurrent Infections ▪ Visual Changes (pretty early on) ▪ Fatigue and decreased energy ▪ 𝖳 HbA1C ▪ Fasting Blood sugar above 126 ▪ **Sedentary Lifestyle, usually in individuals above age 50** ▪ **Takes PO meds (Metformin) ** ◆ When taking Metformin, can cause Abd bloating and “walking farts” ◆ Cannot take it if pt. has Liver issues ◆ If going to have any type of procedure using “dye”, the pt. must stop taking Metformin 48hr before & 48hr after (can cause renal failure) Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ ▪ **Insulin Sensitizers (Thiazolidinediones “glitazones”) ** ◆ Increase cellular use of glucose ◆ If pt. has symptomatic CVD or Heart failure cannot take o Glucose Tolerance Test Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ ◆ Headache, N/V, abd pain, inability to concentrate, fatigue, weakness, vision changes, slow healing of wounds o DKA • Onset over 4-10hr • Lack of Insulin • S/S: ▪ Tachycardia, Hypotension ▪ Acidosis ▪ BS >240 ▪ Hyperkalemia ▪ Polyuria ▪ FRUITY Breath • Nursing Interventions: ▪ H – Hydration ▪ I - Insulin ▪ E – Electrolyte Replacement o Oral Hypoglycemics • Metformin ▪ Reduces production of glucose ▪ Nursing Considerations: ◆ Monitor side effects (flatulence, anorexia, N/V) ◆ Monitor Lactic acidosis (especially in pt. with kidney and liver disorders) ◆ **Stop 48hr before and 48hr after tests with iodine contrast (dye)** ▪ Teaching: ◆ Take with food ◆ Take Vit b12 supplement ◆ **Never crush or chew** o Injection Sites: • **In abdomen (2 inches away from belly button) ** • Back of arm • Rotate site • Pt. Education: ▪ Avoid Alcohol ▪ Wear Medical alert bracelet ▪ Adjust insulin to exercise and diet to avoid hypoglycemia o Rapid Acting Insulin: Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ • Lispro, Aspart ▪ Administer before meals ▪ RAPID (10-30 mins) ▪ **Give within 10 mins of eating** o Short Acting Insulin: • Humulin R or Clear • Administer 30- 60 mins before meals • May be given as sliding scale o Intermediate Acting Insulin: • NPH or Cloudy • Only insulin to mix with rapid-acting (regular) o Long-Acting Insulin: • Glargine or Detemir • Given once a day • No peak • Never Given IV o Mixing Insulin: • Put air in cloudy • Put air in clear • Draw up Clear (regular) • Draw up Cloudy (NPH or intermediate) • **Do not shake bottle, role in hands ** o Glucagon: • Glucagon when the sugar is Gone • Given in upper outer thigh o Dawn Phenomenon: • Usually happens with Type 1 • BS rises with the sun (BS high in AM) • BS Low at night (may give NPH at night due to late peak) o Somogyi Effect: • Insulin peaks in the middle of the night causing Hypoglycemia • Pt. may be sweaty, Ketonuria, Morning Headache • **Important to check BS early in the morning** • **Give low carb snack before bed** • Hyperglycemia in AM (rebound) • Reduce insulin at night (to offset hypoglycemic reaction) o Sick Day Rules: • **Monitor BS every 4hr** • Continue to take insulin or oral hypoglycemia’s • Consume 8-12oz of sugar free, liquid every hour Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ • Test urine for ketones and report to HCP if outside expected range • Get plenty of rest • Eat meals at regular times • Call MD if ▪ BS higher than 240 (tests ketones in urine) ▪ Fever greater than 101.5 (not responding to Tylenol or last longer than 24hr) ▪ Rapid breathing, Diarrhea ▪ Illness lasts longer than 2 days ▪ Inability to tolerate liquids o Exercise • Wear appropriate footwear (examine your feet daily and after exercising) • Stay hydrated • Do not exercise within 1 hour of insulin injection • Do not exercise unless BS is at least 80 and less than 250 • Eat 15-30g of carbs before exercise • Keep simple sugar snack with you • Check BS more often on days of exercise o Foot Care • Proper Fitting shoes • Change shoes every other day • Trim nails across • Wash feet and pat dry especially between toes • Report any open areas • Change clean cotton socks every day • Do not use Hot or Cold water (check temp before stepping into water) • Do not go barefoot • **Moisturize on feet (not in-between toes) ** • **Inspect Feet Daily ** o Diabetic Neuropathy: • Damage to sensory nerve fibers (resulting in numbness and pain) • Nursing Considerations: ▪ Keep BS at normal level ▪ Provide foot care ▪ Encourage annual exams by a podiatrist ▪ Encourage regular follow-up with provider to assess and treat Renal o BUN • Will show toxin • 10-20 Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ ▪ Frequency, Urgency, Incontinence ▪ Weak urinary stream ▪ **Orthostatic Hypotention** • Assess: ▪ Urinary Pattern, nocturia, bladder distention, infection, Calculi and Hematuria • Interventions: ▪ Finasteride, Tamsulosin, Doxazosin ▪ Surgery (TURP) • Education: ▪ Avoid ETOH, Diuretics, caffeine ▪ Void with first urge ▪ Avoid antihistamines and anticholinergics o ED (Erectile Dysfunction) • Inability to achieve or maintain and erection • Causes: ▪ Smoking, stress, DM ▪ Neuro Conditions ▪ Prostatectomy • Assess: ▪ Med HX ▪ Hormone levels ▪ Meds: tadalafil, vardenafil (**Sildenafil**) o Nephrosclerosis: • Thickening of nephron blood vessels (narrowing of vessels), decreased blood flow and hypoxia • Causes: ▪ HTN, atherosclerosis, DM • Assess: ▪ BP, Kidney Function ▪ Give: antihypertensives, diuretics, prevent renal failure o Renal Calculi: (Urolithiasis) • Hard deposits of crystals that form along the lining of kidney and urinary tract • S/S: ▪ Sever Flank Pain ▪ N/V, Pallor, Diaphoresis ▪ Frequent urination/dysuria/Oliguria ▪ Anuria suggest obstruction • Treatment: ▪ **NSAIDS or Opioids (Ketorolac)** ▪ Prevent infection & Urinary obstruction Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ • Interventions and Teaching: ▪ Assess for bladder distention ▪ **Increase Fluid Intake (at least 3L/day) ** ▪ Decrease Sodium/Calcium intake ▪ Monitor Urine pH ▪ Larger stones – surgical procedure may be needed o Kidney Trauma: • S/S: ▪ Hemorrhage, Hematuria, Hematoma ▪ Hx of trauma ▪ Flank or abdominal pain • Assess: ▪ GI ▪ **Abd Distention** ▪ BP, UA, CT and US ▪ Inspect bilateral flanks for bruising ▪ Inspect urine for blood (notify MD before catheter placement) ▪ Monitor HGB and HCT (due to possible bleeding) • Interventions: ▪ Vit K ▪ Platelets, Surgery ▪ IVF ▪ Strict I’s and O’s o Polycystic Kidney Disease: • Genetic Disorder (Cyst formation in nephrons) • S/S: ▪ Abd/flank pain ▪ Increase in abdominal girth ▪ HTN, Constipation ▪ Frequent UTI’s, nocturia ▪ Sodium wasting and inability to concentrate urine in early stage ▪ Progression to kidney failure with anuria • No Treatment • Mange Symptoms • Dialysis for End stage • Measure and record daily BP • Monitor fever/notify MD • Daily wt., monitor abdomen girth • **Avoid potassium/vit k rich foods** o Digital Rectal Exam: • Prostates should be as big as tip of finger Med Surge Exam 2 Study Guide Latest Update Rated A+ Med Surge Exam 2 Study Guide latest Update Rated A+ • If enlarged, they will draw a PSA • Give Cholinergic drugs for BPH o TURP • Continuous or Intermittent Bladder irrigation • Close Observation of drainage system ▪ Increase Bladder distention causes Pain and Bleeding ▪ Maintain Catheter Patency ▪ Control Pain: Analgesics and decrease activity for first 24hr ▪ Avoid Straining with BM’s (High fiber diet and laxatives) ▪ **Q4hr H&H** ▪ If blood clots noted (it is normal) ▪ Strict I’s and O’s • Complications: ▪ **Hemorrhage (Bleeding should gradually decrease to light pink color in 24 hours) ** ◆ Observe for Urethral Stricture (Dysuria, Straining, Weak Stream) ▪ Urinary incontinence (Kegel Exercises) ▪ Infections (Increase Fluids_ ▪ Prevent DVT (Ted hose, low dose Heparin) • Nursing Interventions: ▪ Monitoring and managing potential complication of hemorrhaging ◆ Drainage red to pink (pink within 24hr) ◆ Monitor VS ◆ IV ◆ Blood component treatment/transfusions ◆ I’s & O’s ▪ Management for Potential Catheter Obstructions ◆ Lasix ◆ Increase fluids, assess pain ◆ Decrease BP, increase Pulse • Post/Op Care: ▪ Drink 12 to 14 glasses of water during the day ▪ Avoid Bladder Stimulants (alcohol and spicy foods) ▪ Avoid strenuous exercise for 2-3 weeks o Radical Prostatectomy: o Prostate tumor removed together with prostate gland and neck of bladder o Post/Op Care: ▪ Pain control ▪ Cather care (clean daily with soap and water) ▪ Change Cath drainage bag at least once a week ▪ Do not strain to have BM Med Surge Exam 2 Study Guide Latest Update Rated A+