Medical Surgical

Nursing
Bundle
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1- Neuro (Pag 2) 5- Heart Cont. 10- Reproductive (Pag 72)

Stroke Cardiogenic Shock Polycystic Ovarian Syndrome
Multiple Sclerosis Dysrhythmias Endometriosis
Traumatic Head Injury Cardiac Valve Stenosis Pelvic Inflammatory Disease
Meningitis Aortic Valve Regurgitation Varicocele
Seizures Mitral Valve Regurgitation Sterility
Parkinson Disease Angina Erectile Disfunction
Skull Fracture Test Notes 11- Cancer (Pag 73)
GLASGOW COMA SCALE EKG (Pag 44) Carcinoma
Spinal Cord Injury 6- Integumentary (Pag 55) Sarcoma
Seizures Herpes Melanoma
Intracranial Seizure Steven-Johnson Leukemia
Stroke Psoriasis Nursing Interventions
Cranial Nerves Frostbite Lung Cancer
2- Respiratory - Lungs (Pag 17) Pressure Injuries (Pressure Ulcers)
Adventitious Sounds LESSIONs 12- Lab Values (Pag 76)
Pneumonia Burns
COPD Rule of 9’s
13- Bed Positions (Pag 77)
Asthma 7- Renal – Kidneys (Pag 59)
Pleural Effusion Pyelonephritis 14- Acid-Base Balance (Pag 78)
Acute Respiratory Distress Hydronephrosis
Syndrome Benign Prostatic Hypertrophy
Oxygen Therapy Renal Calculi
Chest Tube Polycystic Kidney Disease
Flail Chest Chronic Kidney Disease
Tension Pneumothorax Acute Kidney Injury
3- Endocrine (Pag 27) 8- Musculoskeletal (Pag 62)
Adrenal Hormones Rheumatoid Arthritis
Antidiuretic Hormones Osteoporosis
Growth Hormone Osteoarthritis
Thyroid Hormone Herniated Disk
DIABETES MELLITUS Gout
Type I, II, Patho, Complications Amputation
Insulin Cheat Sheet Join Injuries (Sprain-Strain)
4- Gastrointestinal (Pag 31) Sport Related Injuries
Gastroesophageal Reflux Disease Dislocation / Subluxation
GERD Fractures
Peptic Ulcer Disease Traction
Cholecystitis Cast
IBS – Crohn’s / Ulcerative Colitis 9- Hematologic (Pag 68)
Appendicitis Iron Deficiency
Pancreatitis B12 Deficiency
5- Heart (Pag 36) Sickle Cell Disease
Heart Sounds, Concepts Folic Acid Deficiency Anemia
Cardiac Disorders Aplastic Anemia
Coronary Artery Disease Thrombocytopenia
Aortic Aneurism Blood Products – Transfusion
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NursingStoreRN

P: Neurological Deficit caused by a lack of blood flow to the brain

S/Sx: One side weakness, Facial Drooping, Confusion, Slurred Speech
Dx: CT scan or MRI confirms and identifies type of stroke which determines treatment
R: Atherosclerosis, hypertension, diabetes, stress obesity, oral contraceptives, anticoagulation therapy
N: - Airway is priority - Monitor VS, LOC, pupils + reflexes - Position client on side to prevent aspiration

Types of Strokes
Ischemic: An obstruction of a blood vessel - 87% of stroke cases
Hemorrhagic: A weakened blood vessel ruptures (Risk Factor = Hypertension)
TIA (transient ischemic attack): Temporary clot that resolves on its own (A warning sign for stroke)

P: A central nervous system disease characterized by demyelination of axons

S/Sx: Fatigue, weakness, ataxia, vertigo, tremors, Blurred vision, emotional changes, ↓sensation, Bladder + bowel
disturbances, +Babinski reflex
Dx: Requires extensive neurological testing over many years of a slow onset of disease
N: Provide energy preservation measures, encourage independence while providing safety, Monitor for urinary +
bowel dysfunction
C: Falls, psychological problems, decreased mobility

P: A trauma or blunt force hits the skull causing damage to the brain
S/Sx: Confusion, agitation, visible head injury, sleepiness blown pupils
N: - Assess for neurological changes or change in the level of consciousness, monitor V/S, assess pt. for headache,
nausea/vomiting, check for CSF drainage, Assess pupil size
C: Cerebral bleed, hematoma, ↑intracranial pressure, infection, seizure, ↑CO2 levels, permanent damage
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P: Inflammation of the arachnoid + pia mater of the CNS. Usually caused by bacteria or a virus. CSF
is tested for the pathogen and used to determine the treatment
S/Sx: ↓LOC, Red macular rash, pain with neck flexion
N: Monitor for seizures. Assess cranial nerves

P: Abnormal, sudden electrical activity in the brain

S/Sx: Uncontrollable involuntary muscle movements (convulsions) or Gaze off into the distance with
no response to stimuli. May lose consciousness for seconds or minutes. Usually, the person will not
recall the events leading up to it but they may remember experiencing an aura beforehand.
N: Assess seizure history. Note Time + duration. Prevent injury, but do not restrain. Monitor
behavior before + after episode. Turn Pt. on side at end of seizure to drain secretions
C: Status epilepticus - epileptic spasms without any rest periods which can result in brain damage
R: Genetic Inheritance, Brain trauma, tumors, toxicity, metabolic disorders or infection

P: Decreased dopamine levels in the brain cause neurological + musculoskeletal Sx

S/Sx: Blank facial expression, Slow, monotonous, slurred speech, Rigidity and tremor of extremities and
head, Forward tilt to posture, Reduced arm swinging, Short, shuffling gait
N: Monitor swallowing activity + neuro activity. Assist w/ ambulation. Promote PT + OT to preserve
function, Increase fluid intake to 2L/day
C: Falls, Self-care deficits, depression, constipation and poor posture
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- Motor Vehicle Collision

- Falls
- Fire arms related injuries
- Assaults
- Sport related Injuries
- Recreational Accidents
- War related injuries

Death Can Occur at 3 points in time after injury:

1- Immediately After
2- Within 2 hours after
3- Three Weeks after injury

Scalp Lacerations: Highly Vascular/High Risk of Blood Loss

Simple (linear) fracture: is a break in the continuity of

the bone.
Comminuted skull fracture: a splintered or multiple
fracture line.
Depressed skull fractures: occur when the bones of
the skull are forcefully displaced downward.
Basal skull fracture: A fracture of the base of the
skull.
It allows CSF to leak from the nose and ears

Signs of Basilar Skull: Battle’s Sign and Raccoon Eyes

Dextrostix or Test-Tape Strips

Used to detect glucose found in CSF, however it is
inaccurate if blood is in the sample as there is
glucose in the blood
Halo’s Sign
Allow drainage to leak onto a white gauze pad.
Within a few minutes, blood should gather in the
center and CSF will create a yellow ring around the
blood
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NursingStoreRN
Deep Coma: 3
Comatose: ≤8
Normal: 15
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Initial mechanical disruption of axons as a result of Ongoing, progressive injury that occurs after
stretch or laceration primary injury

Types of Injuries: Complete cord damage r/t auto destruction

- Cord Compression (r/t bone displacement) which occurs during weeks after initial injury
- Interruption of blood flow - Usually starts within 24hrs of injury
- Traction from pulling - Cannot be diagnosed sooner than 72 hrs.
- Penetrating trauma (gun shot, stabbing) after injury

Flexion Skeletal Level Complete Cord

Hyperflexion - Cervical Involvement:
Flexion-Rotation - Thoracic -Total loss of function
Extension-rotation - Lumbar below the level of injury
Compression Neurological Level: The
lowest segment of spinal Incomplete Cord
Most unstable because the cord with normal sensory Involvement:
ligaments structures that and motor function on both -Mixed loss of voluntary and
stabilizes the spine are torn sides of the body sensory functions, leaves
some tracts intact
aka - Quadriplegia
Tetraplegia: All 4 extremities
are paralyzed
Paraplegia: Loss of function of
lower extremities
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C4 or ↑: Loss of system function mechanical ventilation needed

↓C4: diaphragmatic breathing if phrenic nerve if functioning (Hypoventilation)

T6 or ↑: Decrease CNS – Peripheral vasodilation – Bradycardia, Hypotension and Hypovolemia – Decreased Cardiac
Output

Skin breakdown/pressure ulcers

Poikilothermia r/t inability to shiver or sweat below the point of injury
VTE common in 1st 3 months. DVT (difficult to diagnose due to decrease pain sensation)

T5 or ↑: Paralytic ileus, gastric distention (may need gastric suctioning), intraabdominal bleeding (may be hard to
detect due to decreased pain sensation)

Retention (If shock occurs)

A- Complete: No motor or sensory function is preserved in the sacral segment S4-5

B- Incomplete: Sensory but not motor function is preserved below the neurologic level and includes the sacral
segment

C- Incomplete: Motor function is preserved below the neurologic level, and more than half of key muscles below
the neurologic level have muscle grade of less than 3

D- Incomplete: Motor function is preserved below the neurologic level, and at least half of the key muscles below
the neurologic level have a muscle grade of >3.

E- NORMAL: Motor and sensory function are normal.

NursingStoreRN
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Central Cord Syndrome Anterior Cord Syndrome

Damage to the middle of spinal cord Damage to anterior spinal artery.
Typical occurs in cervical area Results in compromised blood flow to anterior spinal
Motor Weakness and sensory loss in both upper and cord
lower extremities Typically caused by hyperflexion injury.
More common in upper extremities Motor paralysis and loss of pain and temp sensation

Lateral Cord Syndrome Posterior Cord Syndrome

Brown-Sequard Syndrome Damage to posterior spinal cord
Damage to half the spinal cord RARE!
Typically results from penetrating trauma Loss of proprioception
Ipsilateral (same side) loss of motor function and
position and vibratory sense, vasomotor paralysis.
Contralateral (opposite side) loss of pain and temp
sensation below level of injury

Conus Medullaris Syndrome Cauda Equina Syndrome

Damage to conus (lowest part of the spinal cord) Damage to cauda equina (lumbar and sacral nerve
Flaccid paralysis of lower limbs and areflexic bladder roots)
and bowel Flaccid paralysis of lower limbs and areflexic bladder
and bowel

Used to realign or reduce injury when skin

traction is not possible Ropes pulls and
weights are used. Traction needs to be
maintained at all times.
Weights must hang freely and the knots in
the rope are tied securely
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Metabolic Causes Intracranial Seizures resulting from

Electrolyte Imbalances Brain tumor metabolic disturbances are NOT
Acidosis Head Injury considered epilepsy if seizure
Hypoglycemia Aneurism stops after underlying condition
ETOH/Barbiturate withdrawals Brain Infection is resolved.
Dehydration / Water toxicity Extracranial
Heart, lungs, kidneys disease. SLE
Diabetes Septicemia

Seizure in Children Seizure in Adults Seizure in Elderly

Birth trauma Head Injury Brain Tumor
Infection ETOH Stroke
Congenital Defects Infection
Fever Stimulants
Med Side Effect

- Increased risk in older adults - Socially Disadvantages 30% Idiopathic Generalized Epilepsy
- Males> females - Parent with epilepsy Changes in the function of astrocytes
- African American - Hx of Alzheimer or CVA my play a role in recurring seizures

Astrocytes release glutamate which triggers synchronized firing of neurons.

Prodromal: Symptoms preceding seizure:

nervousness, lightheaded, etc

Aural: Sensory Warning

Ictal: Actual seizure

Postictal: Altered state of consciousness - Can

last 5-30 min after seizure
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“Grand Mal” -Most Common-

- Synchronized epileptic discharge in both sides of the brain
- No Warning
- Cyanosis, excessive salivation, and tongue/cheek biting may occur

TONIC:
Body Stiffens

CLONIC:
Jerking of extremities

Postictal Phase:
Muscle soreness, fatigue, may
sleep for hours

“ Petit Mal ”
- Common in Children, typically resolve by adulthood
- Precipitated by flashing lights or hyperventilation

- Daydreaming” STARE
- Peculiar behavior during seizure i.e.: Blinking, twitching
- Sometimes loss of postural tone NursingStoreRN
- Confusion after seizure
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- Tonic episode → loss of muscle tone

- Patient usually regains consciousness by the time they fall
- No postictal phase

aka “partial” “partial focal”

- Caused by focal irritation
- Symptoms depend on location of irritation
- Unilateral

Experiences unusually feeling, sudden unexplained emotions, may sense things that are not
there. No loss of consciousness

Strange Behavior. Lip smacking. Repetitive Movement.

Patient doesn’t remember events that occurred during seizure

“Pseudoseizure”. Resembles epileptic seizure

Psychiatric: patient typically suffer from emotional abuse, physical neglect or PTSD

- A continuous seizure or recurrent seizures without regaining consciousness

- Seizure activity can continue even with patients that are sedated and show no physical signs.

ONSET of Seizure: Diazepam, Lorazepam

MAINTENANCE: Dilantin, Phenobarbital
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Normal ICP: 5-15 mmHg

- Arterial Pressure
- Venous Pressure
Elevated ICP: >20 mmHg, sustained
- Intra-abdominal/Intra-thoracic pressure
- Posture
- Temperature
Monro–Kellie doctrine
- Blood Gases
If one component increases, another
decreases to maintain normal ICP

1- Changes in CSF
- Altering the CSF absorption/production
The amount of blood in mm passing through
- Displace the CSF into the spinal subarachnoid space
100g of brain tissue in 1 min
2- Changes in Intracranial Blood Volume
- Collapse of cerebral veins and dural sinuses
- Regional Cerebral vasoconstriction or dilation The atumatic
- Changes in venous flow adjustment in the diameter of the cerebral
3- Changes in brain tissue volume blood vessels by the brain to maintain a
- Distention of dura constant blood flow during changes in arterial
- Compression of brain tissue BP.
Only effective if the MAP is between 70-150
mmHg MAP – Mean Arterial Pressure
Average Pressure exerted against vessel
Stage 1: Total compensation related to autoregulation walls by blood
Stage 2: Decreased compensation, Risk of Increase ICP MAP = Systolyc + 2xDiastolic
3
Stage 3: Failing compensation, clinical manifestation of
ICP appear (Cushing Triad)
Stage 4: Herniation and death likely to occur Treat underlying condition. Adequate Oxygenation
Intubation, Mechanical Ventilation, Surgery – AS
NEEDED
Drug Therapy:
Cushing Triad MANNITOL (Osmitrol) ***
- Increase CBF. Plasma Expansion, Reduces blood
Systolic B/p viscosity, Vascular Osmotic diuretic effect
Hypertonic Saline
Pulse - Move water into blood
Corticosteroids:
Respirations - Vasogenic Edema
PRN Med: Antiseizure, Antipyretics, Sedatives,
Analgesics, Barbiturates
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Sudden interruption of blood flow to part of the brain, killing brain Brain uses 20% of body’s total
cells and destroying or impairing body functions controlled by that oxygen, it has no oxygen reserve.
part of the brain. Anoxia: >2-4 min - Cell Damage
During a stroke, brain tissue fails to receive adequate oxygen, leading 10 mins – Irreversible Damage
to tissue damage and necrosis Glucose is the main source of energy

/
Temporary Loss of neurologic function due to ischemia
S/Sx last less than 24hrs, longer than 1hr
Medical: Antiplatelets,
Depend on vessel involved: Anticoagulants, Vasodilators
Carotid: Slurred speech, aphasia, 1-side weakness
Surgical: Carotid Endarterectomy,
Vertebral: vertigo, diplopia, ataxia
Angioplasty, Stents,
Extracranial/Intracranial Bypass

Inadequate blood flow due to occlusion of an artery

Thrombotic: Embolic:
Occurs in large arteries. Occurs from Clot can be made up of:
injury to a blood vessel wall, formation Blood, fat, bacteria or air.
of a blood cloth Caused when embolus lodges/occludes
Gradual Onset. Typically occurs at cerebral arteries.
night. Commonly precedes by TIA Sudden onset

Sudden onset of symptoms. Progression over minutes to hours because of

ongoing bleeding
- Most commonly caused by Hypertension
- Typically occurs during activity
Symptoms: Severe, sudden headache. N/V, Nuchal rigidity, Rapid deterioration of function, HTN
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by affected Side

Paralysis, weakness on RIGHT side Paralysis, weakness on LEFT side

Right visual field deficit Left visual field deficit
Aphasia
Spatial-Perceptual deficit
- Expressive
- Receptive Increased Distractibility
- Global Impulsive behavior/poor judgment
Altered intellectual ability Lack of awareness of deficits
Slow, cautious behavior Abilities overestimated
Increased level of frustration
Depression

NON-contrast CT/MRI – to determine ischemic or hemorrhagic

Lumbar Puncture, Cerebral Angiography or Angioplasty, Digital Subtraction Angiography,
Transcranial Doppler Ultrasound
PT/INR, PTT

Management of HTN Thrombolytic Therapy

Surgery (based on cause) (Tissue Plasminogen Activator)
- Evaluate hematoma - MUST be given within 3.5-4 hrs of onset
- Clip aneurism - MUST rule out hemorrhage via CT
- Resection - Criteria:
Prevent ICP - BP<185/110 - PT <15, INR < 1.7
Seizure prophylaxis if needed - Not on coumadin - >18 years old
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Smell Visual Acuity Pupillary Constriction (PERRLA)

Pt should be able to ID aromas. Ask Pt to read Snellen’s Chart Assess ocular movements and
-Assess Patency occluding one about 20 ft away. Close one eye at pupil reaction.
nostril at the time. the time. PERRLA: Pupils Equal, Round,
-Close eyes, occlude one nostril and If Pt with Glasses, leave them on. React to Light, and
smell. Remove only reading glasses Accommodation.

Vertical Eye Movement S: Face Sensation Horizontal Eye Movement

Ask Pt to move eyeballs up and Light touch, wipe forehead, cheeks Ask Pt to move eyeballs
down (following object) and chin with cotton (eyes closed) laterally (following object)
M: Mastication Muscles
Palpate Temporal and masseter
muscles as Pt clenches the teeth

S: Taste anterior 2/3 Hearing + Equilibrium S: Taste posterior 1/3

Ask Pt to ID various tastes Hear loud and soft-spoken words. M: Pharynx
placed on the tip and side of the Whispered Voice Test. Gag Reflex
mouth Tuning Fork: Hearing by air and Depress tongue, Pt says
M: Facial Expression bone conduction. WEBER - RINNE “Ahhhh” uvula and soft palate
Ask Pt to do facial expressions, should rise to midline
smile, frown, raise eyebrows

S: Sensation pharynx, viscera, Movement Trapezius and Movement of Tongue

carotid body Sternomastoid Muscles Inspect the tongue. Tongue in
M: Pharynx and Larynx Ask Pt to rotate the head midline as Pt protrudes the
Ask Pt to swallow, Assess Speech against resistance applied to side tongue. Ask Pt to say: “light,
for hoarseness. of chin. tight, dynamite”
Ask Pt to shrug the shoulders
against resistance.

NursingStoreRN
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Tracheal Sound: Harsh, hollow

Bronchial Sound: High pitched, loud, hollow
Bronchovesicular: Low Pitched, hollow,
Anterior and Posterior
Vesicular: Low pitched, blowing
Anterior and Posterior

Crinkle of crackle
R+L lung bases Sudden reinflation of alveoli Fine and short
or fluid in small airways Coarse of Medium
Can be cleared with cough

Trachea Fluid or Secretions in large Loud and low pitched

Bronchi airways Heard on expiration
Fluid through a straw
Can be heard over all lung Narrowed or obstructed High pitched
fields. Usually heard louder Bronchi Prolonged
posteriorly Heard on expiration
Rubbing or grating sound
Lateral Lung Fields Inflamed Pleura heard on inspiration

Disrupted air flow of larynx

Upper lungs or Trachea High pitched, wheezing Mostly
Croup, foreign body in heard on inspiration
airways, infection

NursingStoreRN
✓ Tabaco Use or Smoking ✓ Chronic hoarseness
✓ Persistent cough or sputum ✓ Uncharacteristic Shortness of Breath
production ✓ Family history of TB
✓ Chest Pain
✓ Environmental Exposures
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P: Infection of pulmonary tissue

S/Sx: Chills, fever, tachypnea, rhonchi, wheezes, labored breathing
N: Encourage coughing and deep breathing. Provide O2 therapy or CPT
R: Previous respiratory tract infection, smokers, patients who recently had surgery, elderly, those with a
weakened immune system

P: A progressive disorder of the airway that restricts airflow and alveolar expansion. Exacerbated by
infection. Caused by emphysema or bronchitis
S/Sx: Cough, excess mucus, wheezes, crackles, barrel chest, use of accessory muscles to breathe +
prolonged expiration
N: Administer oxygen therapy as ordered. Monitor pulse oximetry. Monitor sputum color/
characteristics. Place in Fowlers position to aid in breathing. Suction Pt. air way PRN.
E: Avoid extremely hot, cold or spicy foods. Avoid exposure to those with infection. Eat a nutritional
diet. Stop smoking. Use pursed-lip breathing when in distress.

P: Chronic inflammatory disease of airway. Smooth muscles constrict in bronchi

S/Sx: Recurrent episodes of wheezing, breathlessness, chest tightness and cough that is usually brought
on by exercise or triggers
N: Monitor vital signs + pulse oximetry frequently. Administer oxygen as prescribed. Stay with the patient
to reduce anxiety. Administer bronchodilators + corticosteroids as ordered
R: Asthma Triggers: Animal dander, mold, exhaust, pollen, stress, hormonal changes, GERD, chemicals,
plastics, shrimp, potatoes

P: Collection of fluid in pleural space

S/Sx: Progressive dyspnea, dry cough, sharp pain on inspiration. Decreased breath sounds
N: Identify the underlying cause. Prepare for possible thoracentesis. Encourage Cough/deep breathing

P: Respiratory failure caused by an underlying cause like a lung trauma or inflammation. Interstitial
edema causes airway compression
S/Sx: Abnormal ABG values, tachypnea, hypoxemia, pulmonary infiltrates
N: Prepare for intubation or mechanical ventilation
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An infection of the lung parenchyma. Usually your epiglottis, cough reflex, mucous membranes and
bronchoconstriction can protect the lungs from becoming infected, but they can become overwhelmed and
allow bacteria and viruses to grow.

- Purulent sputum - Chest pain - Hemoptysis

- Diminished lung sounds - Tachycardia - Respiratory distress
- Fatigue - Sepsis
- Cough - Dyspnea
- Sore throat - Activity
intolerance

- Abdominal/thoracic surgery - Bed rest/immobility

- IV drug use - Tracheal intubation
- Air pollution - Smoking
- Immunosuppressive - Chronic disease
disease/meds - Upper respiratory infection
- Age of 65+ - Exposure to farm animal
- Intestinal/gastric feeding via - Diabetes
NG tube - Lung cancer
- Altered consciousness - CKD
- Malnutrition - Recent antibiotics

Labs Radiology Pharmacology Other Treatment

ABG, CBC, WBC Chest X-Ray Antibiotics (macrolides) - O2 therapy
Blood cultures Chest CT Corticosteroids - IV therapy
Sputum culture Glucocorticoids - chest physiotherapy
- suctioning
- early mobilization
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Lung sounds, VS, SaO2 %, Health - Wash Hands Frequently - Teach good handwashing
Hx, Medications, Recent Surgeries, - Eat A Balanced Diet - Change position frequently
Smoking, Mobility Level, Fatigue - Get Adequate Rest - Promote expectoration
LABs ABGs, Sputum Culture, - Exercise Regularly - Limit visitors to prevent spread of
WBCs - Cough + Sneeze into Elbow infection
- Stop Smoking - Encourage adequate rest
- Avoid Others Who Are ill - Educate pt. to report chest pain,
- Fruits + Vegetables build Immune fever, changes in sputum or altered
System sensorium
- Protein Rich Foods help Repair - Provide comfort for pain
Tissue - Administer antipyretics as ordered
- Drink Plenty of Water and fluid to - Continuously monitor pulse oximetry
Maintain Fluid - Electrolyte Balance - Suction secretion as needed
- Avoid Throat Irritating Foods Like - Encourage early
Milk That Can Cause Excess ambulation/mobilization to speed up
Secretions recovery

Dx: Impaired gas exchange r/t fluid and mucous accumulation

Goal: Improve ventilation and oxygenation of tissues
Interventions:
1- Assess respiratory rate, depth and effort frequently
2- Administer oxygen therapy (Will help maintain PaO2 levels)
3- Assess skin color, mucous membranes + nails for cyanosis (Cyanosis can be a sign of hypoxemia)
4- Monitor Arterial blood gasses (ABGs) + pulse oximetry (helps alert healthcare team to changes in condition)
Dx: Activity intolerance r/t SOB + general fatigue + weakness
Goal: Regain baseline activity levels without complications
Interventions:
1- Evaluate response to activity (Allows you to anticipate the interventions needed)
2- Assist with ambulation + self-care (prevents exhaustion and decrease the likelihood of falls)
3- Turn + reposition every 2 hrs. (Prevents complication like pressure ulcers and fluid accumulation)
4- Group care together (Minimizes exhaustion + conserves oxygen)
5- Ensure pt. is receiving adequate rest (It is important to conserve rest to promote healing + save energy)

Dx: Risk for infection r/t inadequate immune defense

Goal: Recover from infection without complications
Interventions:
1- Educate patient about importance of clearing secretions (sputum accumulation can cause secondary infection)
2- Provide mouth care frequently (keeps bacteria from growing + spreading to lungs)
3- Ensure pt. is practicing good hand hygiene (helps prevent the spread of infection + save energy)
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- COPD is characterized by airflow obstruction that is caused by chronic bronchitis or emphysema

- The obstruction is caused by inflammation which changes the structural function of the lung that makes it harder
to expire CO2
- The air becomes trapped causing the chest to hyper expand and become barrel shaped. This prevents more air
from being expired.
- Because of decreased expiration the pt. will become hypercapnic (↑CO2) and hypoxic (↓O2)
- The excess pressure can damage alveoli further causing a snowball effect of decreased function

Pulmonary Insufficiency - Impaired gas exchange r/t backflow from the Pulmonary Artery to Right ventricle
Acute Exacerbation - Worsening or Symptoms. Tx: Assess ABGs, maintain fowler's position, suction airway if
necessary
Pulmonary hypertension - Excess Pressure in Lungs. Tx: Diuretics, vasodilators, anticoagulants + Calcium Channel
Blockers
Cor Pulmonale - Right Ventricle Hypertrophy. Tx: Treated with diuretics + management of underlying cause

SMOKING - The major risk factor for developing COPD - hyperplasia, ↑mucus, ↓cilia
OCCUPATIONAL - Chemicals + Dusts (Dusts, vapors, irritants, fumes can increase the risk of COPD)
AIR POLLUTION - Urban air pollution coal + biomass fuels used for heating
INFECTION - Recurring infection in childhood are linked to reduced function
GENETICS OR AAT DEFICIENCY - Linked to poor lung function
AGING - Loss of recoil, stiffening of chest wall + impaired gas exchange
ASTHMA - Can be secondary to COPD or contribute to progression of it

Early Stages - History and physical Exam

- Symptoms develop slowly - Spirometry - required
- Chronic intermittent cough - Chest X-Ray
- Dyspnea that increase in severity - A1 - antitrypsin levels (AAT)
- Inability to take a deep breath - Blood gasses - in severe stage
- Prolonged expiration and ↓lung sounds - 6 min walk test
Late Stages
- Dyspnea at rest
- Relies on accessory muscles to breathe
- Wheezing, chest tightness
- Fatigue, weight loss, anorexia

Classification Severity FEV1

↓FEV1 = ↑Obstruction
Stage 1 Mild >80%
FEV1 / FVC < 70% = COPD Stage 2 Moderate 50-80%
FEV1 = Forced Expiratory Volume / 1 Sec Stage 3 Severe 30-50%
Stage 4 Very Severe <30%
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Minimally invasive Pharmacology Surgical Pulmonary rehab

- Smoking cessation - Bronchodilators - Lung - Exercise training (ambulation +
- Airway clearance techniques (↓Dyspnea, ↑FEV1) volume upper limb exercises)
- Hydration (if indicated) - Anticholinergics reduction - Smoking cessation
- Long - term O2 (if indicated) (↓Exacerbations) - Bullectomy - Nutrition counseling
- Exercise Plan (walking + upper - Corticosteroids - Lung - Education (Importance of sleep
body) transplant and good nutrition)

Assessment Planning Diagnosis

Subjective Data Goals - Ineffective breathing
- Hx of exposure to - Prevent disease progression pattern
pollutants/irritants? - Maintain ability to care for self - Impaired gas exchange
- Hx of recent infection or hospital - Relieve symptoms – avoid complications - Ineffective airway clearance
stay?
- Do they use O2 therapy?
Implementation
- Medications they're on?
1) bronchodilators Interventions
2) corticosteroids - Counsel smoking cessation
3) Anticholinergics - Breathing retraining: Pursed-lip (PLB) To prolong expiration. Easier to
4) OTC learn + should be 1st choice in acute situation
- Smoker? Pack years/ quit date - Diaphragmatic breathing: use of abdomen instead of accessory muscles
- Weight Loss or Anorexia?
to prevent Fatigue and slow Respiratory rate
- Exercise / Activity Level?
- Anxiety / Depression? Sleep Pattern? - Airway clearance (ACTs): loosen mucus/secretions then cleared by huff
coughing
Objective Data - Chest Physiotherapy (CPT): Percussion / vibration loosens mucus
General - Postural drainage: Repositioning to drain secretions from specific areas
-Restlessness, Fatigue, Sitting - Nutritional therapy: Increase Kcals and protein
upright
Integument
Cyanosis, poor turgor, clubbing, Education
bruising, edema, thin skin - Encourage Pt. to avoid or control exposure to pollutants
Respiratory - Caution Pt. to avoid others who are sick and practice good hand hygiene
- Rapid + shallow breathing, prolonged - Explain importance of reporting changes in conditions to HCP
exp.,
- Remind Pt. to follow O2 therapy as ordered to prevent oxygen toxicity
- ↓Breath sounds, accessory muscle
breathing - Suggest nutritional meals options
- ↓Diaphragm movement, resp.
acidosis Evaluation
Cardiovascular - Assess need to change flow rate
- Tachycardia, Jugular vein distention, - Evaluate compliance to meds.
edema in feet, dysrhythmias - Monitor for signs of complications
- Determine O2 therapy effectiveness

NursingStoreRN
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– Chronic lung disease that causes narrowing and inflammation of bronchi and bronchioles
Asthma Attack:
1- Sooth muscle constricts = Chest Tightness dyspnea
2- Mucosa lining + goblet cells = more inflamed + excessive mucus production
goblet cells: collect bacteria to prevent going in the airways

Early S/Sx Active S/Sx VERY BAD!

1- Shortness of breath 1- Chest Tight 1- Rescue inhaler doesn’t work
2- Easy fatigue 2- Wheezing 2- Can’t speak
3- Cough at night, trouble sleeping 3- Cough 3- Chest retractions
4- Sneezing, tired, scratchy throat 4- Dyspnea 4- Cyanosis lips/Skin
5- Wheezing 5- ↑HR 5- Sweaty
6- ↓Peak flow best 6- Tachy
6- O2Sat <90%

- Smoke, pollen, pollution, perfume, dander, - V/S

dust, pest, mold, cool and dry air, GERD, - Keep Pt. calm
respiratory infection, exercise, hormonal shift, - High Fowlers
beta blockers/NSAIDS, Aspirin, sulfites - Oxygen / Bronchodilators
Assess: lungs, cyanosis, ease of speak

1- ALBUTEROL – Short Acting, fast relieve 1- CORTICOSTEROIDS – “-sone” “solone”

-NOT for daily Tx- -NOT for acute attack-
2- SALMETEROL – Long Acting 2- MONTELUKAST – Oral – Relaxes smooth muscle, ↓mucus.
-NOT for acute attack- for CONTROL and MAINTENANCE
3- IPRATROPIUM – Short acting -NOT for acute attack-
 24

Lightweight Easily
Nasal 1-6 L/min Inexpensive dislodged, skin
Cannula FiO2 Pt. can talk breakdown
24-44% and eat Mucosal drying

Simple to use, Poor fitting,

Simple 6-10 L/min inexpensive. must remove
Face Mask FiO2 Can have to eat
40-60% humidification

6-12 L/min Warm, poorly

Partial- FiO2 Moderate O2 fitting,
Rebreathing 50-75% Concentration remove to eat

10-15
Non- L/min HIGH FLOW Poorly fitting,
Rebreathing FiO2 O2 remove to eat
80-95 Concentration

MOST
4-10 L/min PRECISE Remove to eat
Venturi FiO2 &
24-60% ACCURATE
 25

Uses:
- Removing Air, Fluid or Blood
- Preventing drained air and fluid from returning to the
pleural space
- Restoring Negative Pressure with the pleural space
to re-expand the lung

Placement:
Mid-anterior axillary line at the 4th or 5th intercostal space on affected side

Complications:
- Bleeding
- Infection
- Air leak / Crepitus
- Clogged tubing – DO NOT MILK / STRIP TUBING
- Tube disconnects from drainage system – Place chest tube in sterile water until new system
is set up

Heimlich Valve:
One-way used with a chest tube to
prevent air from entering the pleural
space

Assessments (q2h):
- Pulmonary Status
- Dressing Status
- Assess for crepitus
- Check tubing
- Keep CDU (Chest Drainage Unit) below patient’s Chest Level
- Monitor Water Levels
- Assess for bubbling in water chamber
- Assess Drainage

NursingStoreRN
 26

Occurs when Rib Cage fractures creating a Symptoms:

“free” segment. - Tachycardia
- Dyspnea/Tachypnea
Causes – Severe Blunt Trauma - Hypotension
- Cyanosis
- Chest Pain
Treatment: - Anxiety
- Oxygenation - Paradoxical Breathing
- Mechanical Ventilation - Diminished Breath Sounds
- IV Hydration
- Possible Surgical Intervention

Life-threatening condition that develops when air

is trapped in the pleural cavity under positive
pressure, displacing mediastinal structures. The
air that enters the chest cavity with each
inspiration is trapped

Symptoms:
- Acute Respiratory Distress
- Hypoxia
- Cyanosis
- Agitation
- Distended Neck Veins
- Drop in BP
- Tracheal Deviation away from the affected side

Treatment:
- Emergency Thoracotomy
- Chest Tube Insertion

Incision in the chest wall at:

4th Intercostal mid-axillary
space
2nd and 3rd space at mid-
clavicular line
Right-Side ONLY NursingStoreRN
 27

Addison’s ↓Cortisol ↓ACTH

S/Sx: Decreased vascular tone, hypotension, bronze skin tone, weight loss and weakness
Tx: lifelong replacement of glucocorticoids or mineral corticoids

Cushing’s ↑Cortisol ↑ACTH

S/Sx: Moon face, weight gain, hypertension, fragile skin
Tx: Glucocorticoid treatment, adrenalectomy with synthetic glucocorticoid replacement therapy for life.

Diabetes Insipidus ↓ADH

S/Sx: Excretion of large amounts of dilute urine. Polydipsia, headache, low specific gravity, dehydration
Tx: Vasopressin therapy, avoiding foods/beverages that are diuretics

Acromegaly ↑GH
S/Sx: Gigantism, long arms and extremities, oily skin, deep voice.
Tx: suppress GH with a GH inhibition medication
Pituitary Dwarfism ↓GH
S/Sx: Short height, reduced cardiac output, moderate obesity
Tx: If caught early, can be cured with GH Supplementation

Hyperthyroidism ↑T3+T4
S/Sx: Tumors, nervousness, tachycardia, weight loss, cramps, diarrhea
Tx: Anti-thyroid medications that inhibit the creation of thyroid hormone
Hypothyroidism ↓T3+T4
S/Sx: Drowsiness, fatigue, excessive hunger, weight gain
Tx: Thyroid hormone replacement therapy based on T3-T4 levels

Type I - Inability to make Insulin

S/Sx: Polyuria, polydipsia, polyphagia, weight loss, blurred vision
Tx: Consistency in food intake, close monitoring + correction of blood glucose
level.
When LOW: eat a carb heavy snack When HIGH: admin insulin or exercise
Type II – Inability to absorb Insulin
S/Sx: Polyphagia, polydipsia, poor wound healing, weight gain
Tx: Exercise, diet changes + weight loss are preferred treatment, but if these
are unsuccessful medications like metformin and Insulin are used
 28

Concepts:
Pancreas: Beta cells produce and secrete Insulin

Glucose [Sugar]: Fuels cells in the body. Will only enter the cells with the help of insulin

Insulin: Secreted by Beta cells to attach glucose so that It can be used to regulate blood sugar

Liver: Stores Excess glucose as glycogen for a later time when your body needs it

Glucagon: Helps increase blood glucose levels. When released, it causes the liver to release glycogen (glucose)

A patient with HIGH Sugar: Pancreas releases Insulin to attach to glucose to enter the cell

A Patient with LOW Sugar: Pancreas releases glucagon to tell the liver to release glycogen-glucose

Diagnosed in Children and Young adult. Insulin-Dependent

1- Immune System attacks beta cells responsible for Insulin production. Treatment:
2- NO Insulin in the bloodstream – Increase glucose Exogenous Insulin
3- Muscle unable to use glucose
4- Glycogen and Protein breakdown cause ketoacidosis

Three Causes:
1- Pancreas doesn’t produce enough Insulin
Treatment:
2- Body doesn’t use Insulin appropriately
1- Nutrition
3- Liver inappropriately produces glucose
2- Insulin
Most common type usually occurs over 35y/o.
80%-90% patients are obese

Develops during pregnancy. Detected at 24-28 weeks of gestation

Usually, glucose levels normalize at 6 weeks post-partum.

RISKs
Increased risk for C-Section, Perinatal death and neonatal complications.
Increased Risk for developing type 2 DM in 5-10 years NursingStoreRN
 29

DKA usually develops rapidly, over 24h period.

Signs/Symptoms
- Blood Glucose >250
- Ketones + Acidosis = pH<7.35
- Dehydration
- Kussmaul Respirations – rapid, deep
breathing, fruity breath
- Abdominal Pain
- Polyuria, Polydipsia, weakness, fatigue and
weight loss

1- Treat Dehydration - 0.9% Normal Saline

>250: IV Regular Insulin only
2- Lower Blood Sugar -Add K+ during IV Insulin
<200 or if Ketones resolve
3- Hourly BG Checks + Heart Monitor SubQ Insulin + IV D5W

Slower onset, NO ketones.

Signs/Symptoms
Blood Glucose >600 (Severe 600-2400mg/dL) Caused by Unmanaged Diabetes, Infection
Dehydration
pH >7.30

1- Treat Dehydration – 0.9% NS IV Regular Insulin, then titrate

2- Lower Blood Sugar with SubQ Insulin + IV D5W
3- Hourly BG Checks
4- Assess Rehydration: Stable BP, Pink skin, warm temp,
Urine Output >30mL/hr
30
 31

Mouth – Amylase breaks down starch

Esophagus - Peristalsis brings foods to Stomach
Stomach - HCL breaks up food + activates enzymes. Pepsin converts proteins
Small Intestine - Duodenum contains bile, pancreatic ducts
Large Intestine - H2O absorption + waste elimination. Vit K synthesis
Pancreas - Maltase – Maltose > monosaccharides
Lactase – Lactose > galactose/glucose
Gallbladder – Stores, Concentrates Bile
Liver - Kupffer cells remove bacteria in the portal venous blood

P: Backflow of gastric and duodenal contents up into the esophagus caused by a dysfunctional lower sphincter
S/Sx: Frequent heartburn and epigastric pain, nausea, dyspepsia, dysphagia, regurgitation
N: Teach pt. to avoid irritants like peppermint, chocolate, coffee, fatty foods, alcohol, smoking. Avoid eating 2
hrs before bedtime. Avoid anticholinergics, NSAIDs. Keep HOB elevated after eating

P: An ulceration that erodes the lining of the stomach or S.I. Caused by irritation, H. pylori, NSAIDs
S/Sx: Sharp pain in left/mid epigastric area after meals 30-60 mins=gastric 90-180mins= duodenal
Rx: Proton pump inhibitors + H2 blockers
Tx: Surgical: resection, vagotomy. Total gastrectomy, pyloroplasty

P: Inflammation of the gallbladder can be caused by slow bile emptying, contracted gallbladder or bacterial invasion
S/Sx: Murphy's sign > can't take deep breath when fingers are placed on the hepatic margin due to pain
Belching, flatulence, RUQ pain
N: Maintain NPO status during exacerbations. Educate pt. to eat small low-fat meals.

P: Inflammatory diseases of the bowel

S/Sx: Diarrhea, abdominal cramps for > 6 weeks
N: Educate about a low FODMAP diet, help decrease triggers and stress, avoid use of NSAIDS to ↓ GI bleeding

P: Acute inflammation of the appendix + surrounding tissue

S/Sx: Sharp, constant, abdominal pain that moves to the RLQ
N: Administer pain meds, prep for imaging or surgery

P: Acute inflammation of pancreas

S/Sx: Nausea, vomiting, diarrhea, diffuse abdominal pain and cramping
N: Pain control, nausea medication administration, limit oral intake NursingStoreRN
 32

A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosa of the stomach,
in the duodenum or in the esophagus.

NursingStoreRN
Everything that reduces the protective mucosa layer:
1- H. Pylori – Bacteria that attacks the mucosa
2- NSAIDs – Inhibit prostaglandins - ↓Bicarbonate, = ↓Defense - ↑Acid
3- Smoking, ETOH, Genetics, STRESS
When damaged: histamine release - parietal cells stimulated to release more HCL acid

-Food makes it worst. Pain occurs IMMEDIATELY after eating.

-Pyrosis vomiting, constipation or diarrhea, and bleeding.
-If bleeding ulcer, hematemesis or melena (black, tarry stools)

-Food makes it better. Pain occurs 2-3 hours after meals.

- Pt. awake with pain during the night.
- Stool- Dark, Tarry

Medication:
- PPI – Proton Pump Inhibitors (-prazole)
- Antibiotics – If confirmed H. Pylori
- Bismuth (Pepto-Bismol)
- H2 Blockers (-tidine)
- Antacids (Mag. Hydroxide, Calcium Carbonate, Sucralfate, Carafate)
 33

Backflow of gastric or duodenal contents into the esophagus, due to a weak/damaged lower
esophageal sphincter (LES)

Endoscopy – Will assess narrowing or ulcers formed

pH Monitoring – Measures the amount of acid in the esophagus

Most Common – Pyrosis (heartburn)

- Epigastric Pain
- Regurgitation
- Dry cough worse at night/ hoarseness
- Nausea
- Difficulty swallowing
- symptoms may mimic those of a heart attack
[Brunner & Suddarth’s Med Surg 14e page 1283]

Lifestyle changes: Small meals NursingStoreRN

- last meal 30min before bedtime
- Sit up 1hr after meals
- Weight loss, smoking cessation
Avoid: fatty, ETOH, coffee, peppermint, acid foods (citrus, tomatoes)
Medication
- Antacids – Interferes with many drugs. Give alone, wait 1-2 hrs before taking another
meds
- Histamine Receptors Blockers – lowers Histamine – Lowers Inflammation
- PPIs – Protect lining of the stomach
- Bethanechol – Protect lining of stomach
Fundoplication Surgery – Reinforces the LES by wrapping a portion of the stomach around
the esophagus
 34

Inflammation or ulceration (or both) of the bowel.

Characterized by periods of remission and exacerbation.
May affect anywhere in the GI. Most common in ileum and the ascending colon.
Scattered patches – Not continuous with cobblestone appearance

1- Right Lower abdominal pain

- Mouth or GI ulcers
- Diarrhea (sometimes with blood, pus, mucus)
- Loss of appetite / weight
- Fissures with anal bleeding
- Abdominal bloating

1- Abscesses: Form in the intestinal wall

2- Fistula: Worsening of abscess may lead to a hollow hole
3-Malnourishment: If affecting the Small Intestine
4- Fissures: If affecting anal area – loss of integrity
5- Strictures: Narrowing, Intestinal Blockage

1- Diet Education – AVOID high fiver, nuts vegies, fruits, dairy, spicy, high fat, gas causing food
Encourage- LOW fiber, HIGH protein, HIGH fluids
2- Medication
1st Line- Mild case: sulfasalazine.
Steroids: ↓Inflammation, NOT long term, ↑ Infection risk
2nd line- Immunosuppressors: ↑risk of infection, cancer, ↓Inflammation
3- Teach Ostomy care if surgery occurs
4- Smoking Cessation
5- In severe cases, TPN for malnourishment – Monitor weight
6- Monitor bowel movement, frequency and characteristics/ Bowel sounds
 35

Chronic ulcerative and inflammatory disease in the INNERMOST lining of the Colon and
Rectum ONLY. (There is NO abscesses, fistulas or fissures -usually)
Continuous - Not Scattered

- Cells of intestinal lining die from ulcers that pus and bleed.
- Intestine can’t absorb water as usual – Watery diarrhea that Includes Pus and Blood
- Urge to defecate frequently
- Periods of remission and exacerbation. Ulcer sites heal, but lining stays damaged, may form
polyps

- Lead-pipe Sign – large intestine starts to

lose its form. Will appear smooth (no Haustra)
- Repeated Ulceration – Rupture of bowels –
peritonitis
- Toxic Megacolon – Large intestine dilates due
to inflammation – Unable to function properly

1- Surgery – Proctocolectomy ileoanal anastomosis

2- Diet Education – AVOID high fiver, nuts vegies,
fruits, dairy, spicy, high fat, gas causing food
Encourage- LOW fiber, HIGH protein, HIGH fluids
3- Medication:
1st Line- Mild case: sulfasalazine.
Steroids: ↓Inflammation, NOT long term, ↑ Infection risk
2nd line- Immunosuppressors: ↑risk of infection, cancer,
↓Inflammation
Also, Abx during flares up Antidiarrheals
 36

Conducting System Properties of Cardiac Cells

1- Sinoatrial (SA) Node Automaticity: The ability to initiate
[Primary Pacemaker] 60- an impulse
100bpm Excitability: The ability to be
2- Atrioventricular (AV) Node electrically stimulated
[40-60 bpm] Conductivity: The ability to transmit
3- Bundle of His and impulse along a membrane
4- Bundle Branches Contractility: The ability to respond
5- Purkinje Fibers mechanically to an impulse

Cardiac Output = HR x SV Depolarization: When the charges are reversed

CO = 5-7 L (normal) – Heart Muscle Contract –
Mean Arterial Pressure
MAP=(SBP+2DBP)/3 Repolarization: When the cells return to their original State
Normal >60mmHg

Heart Sounds
S1- AV Valves Close – Heard at Apex
-Beginning of Systole Normal
S2- Semilunar Valves close – Heard at Base
-End of Systole, Beginning of Diastole
S3- Heart Failure and Regurgitation
S4- Resistance w/ ventricular filling Abormal

S3- VENTRICULAR GALLOP (Lub-de-dub)

Rapid Rush of Blood from the Atrium to the
Ventricle as it starts relaxing
-Low Pitch
-Early Diastole
-May be Normal in Athlete, Pregnancy, Children
-Normal Up To 30 yrs
-Causes: HF, MI, Cardiomyopathy, HT,

S4- ATRIAL GALLOP

Sudden slowing of blood flow by the ventricle as
the atrium contracts
- Low Intensity sound
- May be a sign of Diastolic HF or Ischemia
- Heard at apex
NursingStoreRN Causes: HF, MI, Cardiomyopathy
 37

Patho: Narrowing or obstruction of a coronary artery due to

plague buildup/ atherosclerosis
Dx: ECG, Catheterization, blood lipids
N: Educate about ↓ Kcal/fat, ↑ fiber diet & exercise
C: ↓ Perfusion, HTN, angina, MI

Patho: Stretching of the medial wall of an artery caused by

vessel weakness
S/Sx: Thoracic - neck, shoulder, ↓back pain, ↑HR, dyspnea
Abdominal - pulsating mass in abdomen, Abd/back pain
Ruptured - severe Abd/back pain, shock, ↓BP
Dx: Ultrasound, CT Scan, arteriography
N: Monitor Vitals, check peripheral pulses, assess for abdominal
tenderness, ask pt. if abdominal or back pain is present

Patho: Reduced cardiac output and tissue perfusion. Usually

caused by a corona artery blockage
S/Sx: Hypotension, pallor, tachy, disorientation, chest pain, cool,
clammy skin
N: Administer O2, morphine sulfate as ordered. Prep for
intubation, Monitor blood gas levels
 38

Patho: Ventricles depolarize in a completely disorganized way

S/Sx: Cardiac output ceases no pulse, BP, Respirations and
Pt. is unconscious
N: Activate Emergency response, Administer CPR,
defibrillate and administer O2 as ordered

Patho: Ventricles contract prematurely due to impulse

initiation by purkinje fibers instead of the SA node
N: Assess O2 saturation. Monitor anticoagulant and
electrolytes as ordered
Bigeminy - PVC every other heartbeat
Trigeminy - PVC every 3rd heartbeat
Quadrigeminy - PVC every 4th heartbeat

Patho: Multiple depolarizations from the atrium occur in a

disorganized way causing the atria to quiver
Dx: ECG - no P wave seen
N: Administer O2 and anticoagulants as ordered. Educate pt.
about therapy.
C: Thrombus formation, stroke

Patho: Cardiac tissue no longer has Oxygen Supply which can

lead to necrosis. Blockage of 1 or more arteries of the heart.
S/Sx: Chest pain, SOB, nausea, low back pain, diaphoresis,
pallor, fear + anxiety
Dx: Troponin levels, CK, CK-MB, Myoglobin, ECG
N: Administer O2, Establish IV access, Obtain 12-lead EKG,
Administer thrombolytic therapy, assess pulses, Monitor for
Blood Pressure Changes
Morphine – Pain and relaxes the heart
Oxygen – ↑O2 in the heart
Nitroglycerin - vasodilates
Aspirin – blood thinner
 39

Normal Mitral Valve Normal Aortic Valve

Mitral Stenosis Aortic Stenosis

Caused by Can lead to Treatment

- Rheumatic disease LV Enlargement - Valvuloplasty
- Strep Infection Right Side Heart - Commissurotomy
(Removal of Scar Tissue)
Failure
- Valve Replacement

Symptoms: Symptoms:
• Fatigue
• Dyspnea
• Chest Pain
• Fatigue
• Shortness of Breath
• Palpitations
• Syncope
• Hemoptysis
• Diastolic Murmur
 40

Blood leaks backward from aorta

unto Left Ventricle

Leads to Left Ventricle enlargement

due to volume overload from
inadequate / incomplete emptying
during systole

Symptoms Causes
Varies depending on cause/severity Congenital Heart Valve
Increased C0 (early compensation) Disease
Paradoxical Nocturnal Dyspnea Age-Related heart
Pulmonary Edema changes
Right Side Heart Failure Endocarditis
Shock – Acute A.R. Rheumatic Fever
Trauma

TREATMENT
- Balloon Valvuloplasty - Annuloplasty
- Commissurotomy - Valve Replacement
 41

Backward of Blood from the

Left Ventricle to Left Atrium
due to an incompetent valve

NursingStoreRN

Symptoms Causes
Weakness Mitral Valve Prolapse
Fatigue Rheumatic Fever
Paradoxical Nocturnal Dyspnea Endocarditis
Murmur Heart Attack
A-Fib Cardiomegaly
Trauma

TREATMENT
- Medication to Increase CO - Annuloplasty
- Valvuloplasty - MV Repair / Replacement
 42

Angina / Chest Pain: A narrowing of the coronary artery that supply the heart
with blood and oxygen. It occurs in times of HIGH demand for Oxygen (Exercise or
Emotional Stress). If it goes untreated, ischemia or myocardial infarction can occur.

Risk Factors: Smoking, diabetes, High BP, High Cholesterol, sedentary lifestyle, obesity,
family history, MEN>45 | WOMEN >55

Dx: Coronary Angiography – CT scan with dye S/Sx: Chest Pain constricting that
to see occlusion radiates, pressure to the jaws, arms,
EKG + Echocardiogram back.
LFT’s Depending on the severity: Nausea,
Lipid Profile – Cholesterol pallor, SOB, diaphoresis, upper GI
Stress test to the heart discomfort
Blood test to see risk for Myocardial Infarction

TREATMENT
1- Immediate relief – Nitroglycerin (dilates heart arteries to ↑ blood flow

For stable angina For Unstable Angina

1 pill q5m (up to 3 doses) Rotate daily
Call 911 if symptoms persist 5 min after 1st
Clean, dry, shaved area
tablet
Heat + Light sensitive. Don’t leave in the car, and Shower ok
keep it in dark bottle Wear gloves
Don’t take with Sidenafil.
HA and flushing are normal

2- Surgical: PCI- Stent in Artery | CABG-reroute around artery

3- Beta Blockers; CCB; -statins, anticoagulants

1- Occurs with exertion or stress 1- Occurs with exertion, stress and REST
2- Short duration – less than 5 min 2- Longer duration - > 30min indicative of Heart
3- Sx of CP relieved by rest or Nitroglycerin attack
4- Predictable 3- Unrelieved by medication or rest
4- Unpredictable
 Test Notes
43

Nursing interventions for dysrhythmias Patient teaching about prevention of atherosclerosis

- Defibrillation for ventricular tachycardia or ventricular fibrillation - Smoking cessation
- Cardioversion for all other dysrhythmias - Maintain an appropriate weight
- CPR for a client who is pulseless or not breathing - Eat a low-fat diet
- Lidocaine IV bolus for a client who has ventricular dysrhythmia

Cardiovascular dysfunctions Holter monitor

- Murmur: sustained swishing or blowing sound caused by turbulent blood - Records and transmits electrical impulses of the
flow through a valve, vessel, or heart chamber heart and alerts the nurse to dysrhythmias,
- S4 (atrial gallop): involves an extra heart sound that occurs before S1, myocardial injury, or conduction defects
resulting from decreased ventricular compliance - Allows the client freedom of movement while
- Pericardial friction rub: scratchy, high-pitched sound associated with cardiac activity is recorded
infection, inflammation, or infiltration and can be a manifestation of
pericarditis Cardiac catheterization
- S3 (ventricular gallop): extra heart sound immediately following S2, - Hematoma formation nursing interventions
and is caused by decreased vascular compliance - Greatest risk = bleeding
- Apply firm pressure to stop bleeding

Cardiac measurements
- Cardiac output: heart rate times stroke volume, measures the amount of blood ejected by the heart over 1 minute
- Echocardiogram: non-invasive ultrasound procedure, evaluates heart valve function and structure
- Telemetry: detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart
muscle
- Cardiac catheterization: measurement of coronary artery blood flow

Cardiac medications
- Dopamine: give to client in cardiogenic shock because produces inotropic effect and improves cardiac output by strengthening
force of contractions
Increases blood pressure by causing vasoconstriction of blood vessels
- Nitroglycerine: vasodilator that decreases cardiac preload and afterload
Decreases blood pressure
- Nitroprusside: vasodilator that decreases cardiac preload and afterload by causing the arterial and venous smooth muscles to
relax
Decreases cardiac output
Decrease blood pressure
- Morphine: opioid analgesic and vasodilator that can decrease cardiac preload and afterload
Decreases blood pressure

Sublingual Nitroglycerin
- Instruct client to allow the tablets to dissolve under the tongue or between cheek and gums
Moisten mouth if dry
- Onset of relief should begin 1-3 minutes after administration
If client’s chest pain has not eased in 5 minutes, client should take another tablet and call 911
- Nitroglycerin is inactivated by heat, light, and moisture
Nurse should instruct the client to keep the medication in its original dark glass container with the lid closed tightly
- Client should take the medication at the onset of angina, regardless of food intake
- Instruct client to lie down after taking the medication because hypotension can occur quickly, leading to dizziness and syncope

Angina Precipitating Factors: 4 E’s Heart Murmur Causes: SPASM

Exertion: physical activity and exercise Stenosis of a valve
Eating Partial obstruction
Emotional distress Aneurysms
Extreme temperatures: hot or cold Septal defect
weather Mitral regurgitation NursingStoreRN
 44

Interpretation

NursingStoreRN
 45

P-wave: Atrial Depolarization

QRS Complex: Ventricular depolarization
T-wave: Ventricular Repolarization Rate: Is it Normal? (60-100) Fast (>100) Slow (<60)
Rhythm: Is it Regular? Irregular?
Normal Sinus Rhythm: 60-100 bpm
Sinus Bradycardia: <60 bpm P Waves: Are they present? Are they 1:1 with the QRS?
Sinus Tachycardia: >100 PR Interval: Is it normal? Does it remain consistent?
Supraventricular Tachycardia: >150 bpm QRS Complex: Is it Normal? Or is it wide? (>10)
QRS Complex: 0.06-0.10 sec
Extra: Are there any extra or abnormal complexes?
PR Interval: 0.12-0.20
 46

Normal Sinus Rhythm Sinus Bradycardia

Sinus Tachycardia Paroxysmal Supraventricular Tachycardia

Atrial Flutter 1st Degree AV Block

2nd Degree AV Block – Type I 2nd Degree AV Block – Type II

3rd Degree AV Block Ventricular Tachycardia

Ventricular Fibrillation

NursingStoreRN
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NursingStoreRN
 55

P: Reactivation of the varicella zoster virus from previous Chickenpox infection

S/Sx: Red skin vesicles along areas of sensory nerves.
N: Isolate patient in contact precautions, prevent scratching - irritation or vesicles. Admin
antivirals as ordered

P: A skin reaction caused by an immunological response to taking certain medications

S/Sx: Vesicles, erosions, flulike symptoms and redness
N: Discontinue the medication that is causing the reaction. Administer antibiotics and
corticosteroids as ordered

P: Chronic, non-contagious inflammation of the skin due to over-keratinization

Ed: Teach client to avoid scratching and wear nonirritating clothing like cotton. Ensure pt.
doesn't use any OTC meds without approval.

P: Damage to tissue/vessels as a result of prolonged exposure to cold

S/Sx: White plaque around redness, blisters, bluish skin and numbness of extremities
Tx: Rewarm slowly with moist heat + monitor CMS and for signs of compartment syndrome

Pressure against a vessel near the skin prevents adequate blood

flow and causes skin breakdown (especially near pony areas)
- Stage 1: Non-Blanchable but intact/unbroken skin
- Stage 2: partial-thickness injury, extends up to epidermis or
dermis.
- Stage 3: full thickness injury extends past dermis FAT visible.
- Stage 4: full thickness injury extends past subcutaneous/ BONE
visible.
- Unstageable: unable to see thickness layers due to excess
exudate.
- Wound healing is promoted by a diet that is rich in protein and
vitamin C.
 56

NursingStoreRN
 57

Classification of Burns: Cold: Frostbite

Thermal: liquid, steam, fire Radiation: Dun, Radiation
Chemical: powder, gas (inhalation injury) Friction: Road rash
Electric: usually have an entry or exit wound. Injuries may be internal

- Only affect Top Layer (Epidermis)

- No Blister or Scars
- Pink or Red
- May be Tender or Painful
- Some pain, minor Edema, and Erythema

- Epidermis and Dermis

- Raw, mottled, red appearance
- Skin is moist; May blister or need grafting
- Painful, blanching
- Shiny, Scars left behind; 2-6 weeks healing time

- Through all dermal layers; SQ tissue, muscle, bone,

and/or organs involved.
- Nerves burnt away, so, little to no pain.
- May need grafting
- Eschar must be removed

- Ensure patient Tetanus shot if >5-10 years

- Watch for temperature loss = shivering
- Pain control – IV rout (best)
- Wound Care – Premedicate
debridement – remove necrotic tissue
- No pillows for the ear or neck. Use rolled towel under shoulder
- Watch for Webbing
 58

System used to estimate the percentage of body surface involved in a burn injury, and to
estimate the severity of the burn

Posterior 9%
Anterior 9%

Once stablished the total body surface area% burned, we use the Parkland Burn Formula,
for 2nd and 3rd Degree Burn

4mL x TBSA % x Weight (Kg)

1st HALF of the Solution, over the 1st 8 Hours
NursingStoreRN
2nd HALF of the Solution, over the next 16 Hours
*TBSA% - Total Body Surface Area Burned
 59

Patho: Inflammation of the renal pelvis caused by bacterial infection

S/Sx: Fever, chills, tachypnea, nausea, flank pain, frequency, urgency, cloudy urine, hematuria

N: Monitor temperature, Encourage increased fluid intake and decreased protein. Administer analgesics,
antipyretics. Monitor I/O + Weight

Patho: Distension of the renal pelvis caused by an obstruction. Trapping urine proximally

S/Sx: Colicky or dull flank pain that radiates to the grain. Headache + hypertension

N: Monitor vitals, electrolytes, specific gravity, and dehydration

Patho: Slow enlargement of the prostate gland that can compress the urethra

S/Sx: Diminished urinary stream, Nocturia, urgency, hematuria, retention, dysuria, bladder pain

N: Increase fluid intake. (2-3L/day) Encourage patient to decrease caffeine + artificial sweetness intake.
Educate about a timed voiding schedule

Patho: Stones that form in the urinary tract

S/Sx: Severe intermittent pain, nausea, vomiting, low- grade fewer, hematuria

N: Monitor temperature, encourage increased fluids, apply heat to flank area, diet modification

C: Scar tissue formation, infection and obstruction

Patho: Cyst formation and hypertrophy of the kidneys causing scar tissue, infection, nephron damage

S/Sx: Flank or lumbar pain that worsens with activity + improves upon lying down, Hematuria, proteinuria, recurrent UTI

N: Monitor for hematuria which could indicate a rupture. Increase sodium + water intake. Educate about
possible need for surgical interventions
 60

Decrease of Kidney Function >3 months

Patho: Slow progressive loss of kidney function resulting in uremia and hypervolemia - the inability to conserve
sodium and water

S/Sx: Polyuria, decreased skin turgor, edema, diluted urine, proteinuria

N: low protein, potassium, high phosphorus diet. Educate about fluid restriction and possible dialysis treatment

R: Diabetes, Hypertension, AKI, Recurrent Infections, Renal Occlusions

Stage 1: GFR ≥90 mL/min

Stage 2: GFR = 60–89 mL/min
Stage 3: GFR = 30–59 mL/min
Stage 4: GFR = 15–29 mL/min
Stage 5: GFR <15 mL/min
GFR: Glomerular Filtration Rate

Hemodialysis Peritoneal
The Process of filtering the blood Continuous Abdominal Peritoneal
through a dialyzer (Artificial Dialysis (CAPD)
Kidney) Uses Peritoneal Cavity as
Frequency: 3 times a Week / 5-6 “Artificial Kidney”
hrs/day Uses dextrose as osmotic agent
Complications: Hypotension, Muscle Complications: Peritonitis
Cramps, Blood Loss, Hepatitis,
Sepsis, Disequilibrium Syndrome
Nocturnal Hemodialysis: It’s done
5-6 days/week – 2-3 hrs/day
 61

Sudden loss of kidney ability to regulate

- Prolonged Renal Ischemia
volume, remove waste products, release - Nephrotoxic Injury leading to
hormones or maintain body’s acid-base balance. tubular necrosis

Caused by a reduced blood flow to

the kidneys.
Causes:
- Vasoconstriction
Injury occurring from
- Hypotension
disease within the kidneys
- Hypovolemia
Causes:
- Decreased cardiac output
- Acute Tubular Nephritis
- Nephritis
- Nephrotoxic Injury
- Acute Glomerular
Occurs when there is an Nephritis
obstruction of urinary flow causing - Thrombolytic Disorders
intraluminal pressure - Malignant Hypotension
Causes: - SLE
- BPH - Infection
- Bladder Cancer
- Calculi
- Prostate Cancer
- Trauma NursingStoreRN

Initiation Phase: Onset of Injury / Onset of symptoms

Oliguria Phase: Decrease urine output to 400ml/day, usually 1-7 days after injury
Diuretic Phase: Increase urine output to 1-3L/day, caused by inability to concentrate
Risk of hyponatremia, hypokalemia, dehydration

Recovery Phase: Increase in filtration rate, BUN/Creatinine

 62

P: An autoimmune response that causes deformities

S/Sx: Fatigue, anorexia, stiffness, weight loss
Event may trigger: Childbirth, Infection, Stress
Permanent deformity, Symmetrical
D: Rheumatoid factor- Blood Test + - >60 u/mL
↑ Erythrocyte sedimentation rate (ESR) -non specific
CRP, ANA
Radiology showing joint space deterioration
C: Nodular myositis, contractures Sjogren's syndrome, cataracts
Tx: Surgery to restore function

P: Bone demineralization caused by loss of calcium and phosphorus. Bone resorption occurs
faster than bone formation
S/Sx: Loss of bone density and easily fractured bones
N: Encourage a well - balanced diet high in protein, calcium, iron, vit D + C

P: On inflammatory degeneration, gradual loss of articular cartilage. Asymmetrical

R: trauma, aging, obesity, smoking, ↓estrogen, genetic changes
S/Sx: Exacerbated by temperature + climate changes. Joint space narrowing. One leg
shorter than other. Pain is increased after rest
T: Regular exercise -> preventative. Avoid prolonged standing, kneeling and squatting.
Apply cold for inflammation / Heat for stiffness

P: A vertebral disk slips out of place which can

cause pain due to compression of spinal nerve
R: Numbness and tingling in back and
extremities. Severe pain.
Tx: Surgery to realign vertebra, physical
therapy and adjustment by a chiropractor can
alleviate pain but doesn’t fix the herniation
 63

P: Uric acid crystals build up in joints and body tissues. Can

result from poor metabolism of purine
S/Sx: Swelling + inflammation of joints, low grade fever, malaise,
itchiness + pain at joints
N: Low purine diet, increase fluid intake.
Ed: Instruct client to avoid alcohol and excessive use of the joint

1- Transverse: A break that is perpendicular to the long axis

2- Comminuted: The bone fragments into pieces
3- Open / Compound: Part of the bone is through skin
4- Greenstick: The bone is splintered on one side

N: Elevate for 24-48 hours to promote venous drainage. Allow plasters casts to dry for 24-72 Hours
Ed: Instruct client to report skin irritation and hot spot

N: Ensure weights are freely hanging + off the floor. Assess skin integrity frequently with skin traction

Fat Embolism: Altered mental status, impaired respiratory function, decreased perfusion distal
to embolus site.
Compartment Syndrome: Pressure is an extremity that can't escape, i.e., under a cast.
Numbness + tingling, pain that increase with elevation, Pallor, pain W/ Movement

Sprains: The ligament connecting two bones becomes torn or stretched

s rains: The muscle or endon attached to a bone becomes injured or over stretched

Ensure residual limb sock is worn at all times, position is

prone position as prescribed. Educate patient about
cleaning prosthesis socket daily.
Above Knee: Prevent internal and
external rotation of the hip
Below Knee: Discourage long period of
sitting to reduce Flexion.
Don't allow limb to dangle
 64

Active range of motion: Can move joint without assistance

Passive range of motion: Can only move w/ assistance
Goniometer: Measures range of motion of a joint

Muscle Strength Scale

O = No muscle contraction
1 = A barely detectable contraction
2 = Active muscle contraction without gravity
3 = Active muscle contraction against gravity
4 = Active muscle contraction against some resistance
5 = Active movement against full resistance

Diagnostics
X – Ray: Remove any radiopaque obj.
Abnormalities CT scan: Verify no shellfish allergy if
Atrophy: Decrease Size / Strength of a muscle contrast dye is used
Ankylosis: Stiffness at a joint Bone Scan: Ensure bladder is empty
Kyphosis: Thoracic curvature of spine
Myalgia: General Muscle Pain / Tenderness
ASSESS
Scoliosis: Asymmetrical elevation of shoulders
- Joints + muscles for crepitation or
Paresthesia: Pins + Needles
tenderness
Lordosis: Excessive inward curve of spine
- Muscle strength
(pregnancy)
- Range of motion

Fall Prevention
- Eliminate scatter rugs
- Use supportive shoes that have good
grip
- Use a walker or cone for support
 65

Impingement Syndrome
Soft tissue/nerves trapped under coracoacromial arch
Give: NSAIDS, Rest, ROM + Strengthening

Rotator Cuff Tear

Rest, NSAIDS + Strengthening + Surgery if Severe

Shin Sprints
Periostitis in calf -> ice, stretching + supportive shoes

Tendonitis
Inflammation of a tendon -> Rest, Ice, NSAIDS, brace, gradual return

Meniscus Injury
Injury to fibrocartilage discs in knee -> R.I.C.E and arthroscopic surgery PRN

NursingStoreRN

Dislocation: Complete displacement or separation of the articular surfaces of a joint

Subluxation: Partial or incomplete dislocation
Nursing Care
Dislocation is an orthopedic emergency r/t the risk of vascular injury. Assist with
realignment and pain management. Physical therapy and Rom exercise are imperative to
achieve full recovery
 66

Colles' Fracture: Fracture of the distal radius

TX: Closed reduction
Long Bone Fracture
TX: Immobilization, traction, int./ext. fixation
Hip Fraction
TX: Hip compression screw, partial replacement or total replacement
N: encourage early ambulation, assess color, temperature, cap refill, pulses, edema,
sensation motor function + pain, do not position on the affected side. Do not allow > 90°
knee flexion
Ed: Teach pt. to avoid crossing legs, internally rotate hip or sit in the low chairs
Stable Vertebral Fracture
TX: Immobilize spine, evaluate existence of cord damage, pain meds, kyphoplasty

Infection: A serious complication

Tx: Antibiotics + surgical debridement
Compartment Syndrome
Swelling causes increased pressure that can compromise
nerves and blood vessels.
S/Sx: pain, pressure, paresthesia pallor, paralysis,
pulselessness. Cool skin at extremities
Tx: Do not elevate or apply cold.
Fat Embolism
Fat globules from the fracture travel to the lungs, blood
vessels or other organs
S/Sx: tachypnea, cyanosis, dyspnea, and low O2 sat.
Tx: Fluid resuscitation, blood transfusion, intubation
N: encourage cough + deep breathe, provide O2 therapy

NursingStoreRN
 67

Pulling force to an affected extremity Skin Traction Skeletal Traction

- Reduces muscle spasm - short term (48-72 hours) - Long term (>72 hours)
- Immobilizes - reduce muscle spasms - alignment of bone
- Reduces a fracture - applied directly to the skin - pins or wires are surgically
- Can treat pathologic joint conditions - 5-10 pounds inserted into the bone
- 5-45 pounds

1. Ensuring traction weights never touch the floor Possible Complications

2. Keep patient in the correct body alignment to enhance traction Atrophy: teach isotonic
muscle strengthening
3. Assess for S/Sx of Compartment Syndrome
Muscle Spasms: heat
4. If pulleys are being used, make sure knots have enough slack application reduces
5. Check skin integrity around pins or skin traction site frequently spasms
6. Apply ice to prevent swelling Contracture: reposition
7. Suggest the use of a hairdryer on cool to help relieve itching frequency + provide ROM
8. Teach pt. importance of keeping proximal joints mobile Pain: determine / treat
underlying cause
9. Ensure pt. never inserts any objects inside the cast

A device used for long term immobilization / Allows freedom to perform most ADLS
Hip spica cast: used for femur fx in children
Body jacket brace: used for stable spiral spinal injury

- Never cover a plaster cast until it's dry because the heat will build up and cause a burn
- Handle with an open palm to avoid denting
- Ensure edges of cast are smooth to avoid skin irritation or breakdown
- Check color, temperature, cap. refill and pulses
- monitor for S/Sx of compartment syndrome
- S cast on a lower extremity should be elevated for the first 24hrs after application
- When a sling is used, ensure the axillary area is well padded.
 68

E: Inadequate diet, malabsorption, blood loss, hemolysis - microcytic & hypochromic

L: ↓Hgb, ↓Hct, ↓MVC, ↓MCH ↓MCHC retic. Serum iron, TIBC
S/Sx: Pallor, glossitis, Cheilitis, black stool
T: Replace iron, transfusion, diet teaching, emphasize compliance
R: Pregnancy, premenopausal women, blood loss, older adults, low socioeconomic backgrounds

E: Impaired DNA synthesis, GI surgery, ETOH, Smoking, *Gastric bypass, PPI use.
L: ↓B12, macrocytic RBCs, MCV >100
S/Sx: Neurological - tingling, paresthesia, beefy tongue, weakness
T: B12 injection or intranasally 1/week

E: Genetically - Autosomal Recessive

L: Sickled RBC
S/Sx: Occlusions, necrosis, ↓perfusion, pain on exertion
T: Avoid ↑Altitude + ↑Temp, bone marrow transplant, O2 therapy

E: Celiac, Crohn's, alcoholism, hemodialysis, malabsorption

L: Macrocytic (MCV > 100) ↓folate
S/Sx: Weakness, fatigue, bruising, No neuro symptoms, weight loss
T: Replacement (green leafy veg) 1 mg/day tablet

E: Infection or Autoimmune
L: ↓RBC ↓WBC ↓Platelets
S/Sx: Respiratory Fatigue, Weakness
T: Transfusion, ↑WBC, Bone Marrow Transplant

L: ↓Platelets ↑INR + ↑PT/PTT

S/Sx: Prolonged bleeding time.
T: Platelet Transfusion, Bone Marrow Transplant or Corticosteroid Treatment.
N: Avoid lacerations - use electric razors, monitor Hgb, Hct and bleeding times.

NursingStoreRN
 69

Antigens on the blood Identifies the cell

Antibodies protect the cell from certain antigens

A antigen Donates to: A, AB

[B antibodies] Receives from: A, O

B antigen Donates to: AB, B

[A antibodies] Receives from: B, O

AB antigen Donates ONLY to: AB

[NO antibodies] Receives from:

NO antigen Donates:
[AB antibodies] Receives ONLY from: O

Contains: Uses
RBC To Increase Oxygen Carrying capacity.
Whole WBC Restoration of Blood Volume
Blood
Platelets
Plasma

NursingStoreRN
 70
Contains: Uses
Fresh Frozen Bleeding, r/t coag. factor deficiencies,
Plasma DIC, Hemorrhage, Vit K Deficiency,
1 Unit=250mL Liver disease, Anticoagulated patients.

Packed RBC Increase RBC mass

Packed 1 Unit=250mL Symptomatic Anemia
RBC Replaces 500mL Loss
Will ↑ HgB 1%,
HcT 3%

Platelets To Prevent / Control Bleeding

Plate-
1 Unit=50mL
lets Rapid Infusion
↑ Platelets by 10,000/
Units

Cryoprecipitate Significant hypofibrinogenemia.

Cryopre 6 pooled units prepared Hemophilia.
cipitate
from Plasma, contains Excessive anticoagulation
clotting factors DIC
von Willebrand's

Adverse Effects
Albumin Hypovolemia - Pulmonary Edema
Moves water – Shock
intravascular space - CHF Precipitation
Burns - HTN
Infuse Slowly
5% Isotonic
Peritonitis - Anaphylaxis
25% Hypertonic Pancreatitis - Hypervolemia
Post-Op Albumin Loss - Tachycardia

Washed RBC Given when there is an anticipated risk of

Washed Rinsed w/ 1-3L of NS Reaction
RBC
 71

Overview
Used to replace blood volume, preserve oxygen-carrying capability, or increase coagulation
capabilities; autologous blood transfusions: donating your own blood before anticipated surgery;
religious considerations.

Initiating a Blood Transfusion

Type and cross-matching; informed consent; infuse each unit of blood within 2 to 4 hours; begin
with normal saline with Y administration set to prime tubing; do not infuse any solution containing
dextrose (causes blood to lyse or be destroyed); inspect for leakage, unusual appearance (bubbles or
purplish color indicate contamination); roller clamp; remain with patient for first 15 to 20 minutes;
after transfusion, flush tubing with normal saline; if giving more than one unit, use fresh tubing.

Blood Transfusion Reactions

- “Not feeling right,” sense of impending doom, chills, fever, low back pain, pruritus (itching),
hypotension, nausea and vomiting, decreased urine output, back pain, chest pain, wheezing, dyspnea
(BRONCO CONSTRICTION) ; stop infusion immediately; infuse normal saline solution with new
tubing then call provider; keep remaining blood product and send it back to pharmacy, lab, or blood
bank for analysis; document all findings; reactions generally happen within first 15 minutes but
some reactions occur 60 to 90 minutes or days to weeks later; asses for circulatory overload.
- LOW BACK PAIN DUE TO KIDNEY PAIN/ENLARGEMENT. (SYSTEM WIDE
INFLAMMATION) LOW BACK PAIN = BAD
- FEVER IS A SIGN OF INFLAMMATION & INFECTION

Nursing Process
Data Collection / Patient Problems
- Assess risk for fluid, electrolyte, and acid-base imbalances and presence of alterations; monitor
vital signs, height, weight, neurological function, intake and output, laboratory studies, past and
present medical history, medication history.
- The RN will choose the patient problem such as “compromised blood flow to tissue,” “inadequate
fluid volume,” etc. The LPN must act accordingly.

Expected Outcomes and Planning / Goal / Outcomes

- Prioritize fluid, electrolyte, and acid-base balance.
- Baseline normal vital signs, normal skin turgor, moist mucous membranes, baseline weight, no
edema, clear breath sounds; normal urine electrolytes ABG’s, intake and output.

Implementation / Evaluation / Goal / Evaluative Measures

- Prevention of fluid, electrolyte, and acid-base imbalances.
- Obtain daily weight, vital signs, intake and output; auscultate lung sounds, check oral mucous
membranes, check tissue turgor, monitor serum electrolyte levels.
 72

P: Abnormalities with the metabolism of androgens and estrogen

S/Sx: Hirsutism, Infertility, Diabetes, Sleep Apnea, Obesity and menstrual dysfunction
Tx: Diet, Exercise, Weight loss, Oral contraceptives, anti-androgens, hypoglycemic agents

P: The endometrium lining the uterus growth in places it should not which can cause
cramping or infertility
S/Sx: Intense pelvic pain. Painful intercourse, diagnosis is confirmed by laparoscopy
Tx: Monitor for S/Sx of anemia during menses, educate about the importance of annual
exams, help patient relieve painful cramp with ordered meds and heat compress

P: Infection of the reportative system usually caused by STDs

S/Sx: Pelvic pain, fever, discharge, cramping, painful menses
Tx: Antibiotics, education about using protection

P: An enlargement of the veins in the scrotum caused by blood pooling in veins

S/Sx: A Dull, recurring pain in the scrotum, visibly large and twisted veins, a lump or swelling
N: Encourage pt to wear supportive underwear or jock strap.

P: Inability to reproduce as a result of various causes including low sperm count,

chromosomal abnormalities or inadequate hormones
Tx: Hormone replacement, fertility drugs, surgery, artificial insemination, Psychosocial
counselling to help pt. develop coping methods

P: Inability to keep an erection long enough for sexual intercourse

Tx: Vasodilator or hormone therapy, Smoking Cessation
 73

P: Any cancer originating in the epithelium

S/Sx: A growing lump with a crusty surface, slow growing flat patch of redness
R: Overexposure to sun, repetitive irritation, genetic predisposition, lighter skin, older than
60 years

P: Cancer originating in the connective tissues

S/Sx: Visible lump or mass in the soft tissue
R: Lymphedema. Von Willebrand disease. Genetic predisposition

P: A cancer originating in melanocytes which are located in the basal layer of epithelium
S/Sx: New marks on skin, mole that changes shape or size, new pigments of the skin

P: Cancer of blood-forming cells. Either acute or chronic

S/Sx: Prevent infection by avoiding invasive procedures such as catheterizations and
injections. Prevent excessive bleeding due to possible low platelet count

- Treat nausea, educate about carbohydrate ↓ for prevention

- Maintain meticulous infection control for yourself, the patient and visitors
- Provide non pharmacological and pharm pain control

Surgery: Tumor is removed or destroyed

- Change in bowel/bladder
Radiation: Localized destruction of cancer
- Any sore that doesn't heal
cells. Can cause local irritation + fatigue
- Unusual bleeding/discharge
Chemotherapy: Kills + stops the
- Thickening or lumps
reproduction of neoplastic cells.
- Indigestion
-Skin, hair, nail, GI cells also impacted
- Obvious skin changes
NursingStoreRNbyANA - Nagging cough/hoarseness
 74

- Usually begin in the bronchi

- Spread more quickly than NSCLC
- Early metastasis to Lymph
- Poorest Prognosis
- Survival Rate of 12-18 months
- Staging not useful due to
aggressive nature

Adenocarcinoma Squamous Cell Large Cell

- Associated with scarring - Slow growing - Associated with Tobacco abuse
(chronic fibrosis) - Resectable - Highly metastatic
- Resection attemptable - Often causes Bronchial - High reoccurrence
- Most common in non-smoker Obstructions - Surgery not attempted

Occult-stage:
Cancer cells are found in sputum, but no tumor can be found in the lung by imaging tests or bronchoscopy, or
the tumor is too small to be checked.

Stage 0
Cancer at this stage is also known as carcinoma in situ. The cancer is tiny in size and has not spread into
deeper lung tissues or outside the lungs.

Stage I
Cancer may be present in the underlying lung tissues, but the lymph nodes remain unaffected.

Stage II
The cancer may have spread to nearby lymph nodes or into the chest wall.

Stage III
The cancer is continuing to spread from the lungs to the lymph nodes or to nearby structures and organs, such
as the heart, trachea and esophagus.

Stage IV
The most advanced form of the disease. In stage IV, the cancer has metastasized, or spread, beyond the
lungs into other areas of the body.

NursingStoreRN
 75

Wedge Resection
Removal of “wedge” of lung tissue

Segmentectomy - Segmental Resection

A portion of the lung is removed.
Larger than a wedge, while leaving a
portion of the lobe.

Lobectomy
Removal of a Single Lobe

NursingStoreRN

Pneumonectomy
Removal of the entire lung.
Post Op Consideration – Place pt. on operative
side to facilitate expansion of remaining lung.
 76

Electrolytes: Arterial Blood Gases (ABGs)

Sodium (Na+): 135-145 mEq/L pH: 7.35-7.45
Chloride (Cl-): 98-106 mEq/L PaCO2: 35-45 mmHg
Calcium (Ca2+): 9-10.5 mg/dL PaO2: 80-100 mmHg
Potassium (K+): 3.5-5.0 mEq/L HCO3: 22-26 mEq/L
Phosphate (PO4): 3-4.5 mg/dL SaO2: 95-100%; <95% Indicates Hypoxemia
Magnesium (Mg2+): 1.5-2.5 mEg/L
WBC Differential Count:
Neutrophils: 55-70%
Lymphocytes (T & B Cells): 20-40%
Anticoagulant Therapy Coagulation Times
Monocytes: 2-8%
Therapeutic INR: 2-3 sec
Eosinophils: 1-4%
(Normal Range: 0.8-1.1)
Basophils: 0.5-1.5%
PT: 11-12.5 sec
Platelets: 150,000 - 400,000 mm3 Liver Function Tests
Albumin: 3.5-5.0 g/dL
Liver Enzymes BMI Ranges
Underweight: <18.5 Ammonia: 10-80 mg/dL
ALT: 4-36 u/L
Healthy: 18.5-24.9 Total bilirubin: 0.3-1.0 mg/dL
AST: 0-35 u/L
Overweight: 25-29.9 Indirect/unconjugated bilirubin: 0.2-0.8 mg/dL
ALP: 30-120 u/L
Obese: ≥30 Total protein: 6-8 g/dL;
Prealbumin: 19-38 mg/dL
Blood Glucose Levels Intake & Output [I&O]
Glucose (fasting): 70-110 mg/dL Fluid intake: 2,000-3,000 mL/day
Glycosylated hemoglobin (HbA1c): 4-6% Daily urine output: 1,200-1,500 mL/day
Hourly urine output: ≥30 mL/hour; <30 mL
Thyroid for >2 consecutive hours = CONCERN!!
T3: 70-205 ng/dL Polyuria (consistently high urine volume):
T4: 4-12 mcg/dL >2,000-2,500 mL/day
Thyroid Stimulating Hormone (TSH): 2-10
mU/L Therapeutic Medication Monitoring
Digoxin level: 0.8-2.0 ng/mL
Urinalysis Lithium level: 0.4-1.4 mEq/L
Specific gravity: 1.005-1.030 Phenobarbital: 10-40 mcg/mL
Protein: 0-0.8 mg/dL
Theophylline: 10-20 mcg/mL
Glucose: 50-300 mg/day
pH: 4.6-8 Dilantin: 10-20 mcg/mL
Carbamazepine level: 4-10 mcg/mL
Valproic Acid level: 50-100 mcg/mL

NursingStoreRN
 77

NursingStoreRN
 – 78

1- Look at the pH (7.35 - 7.45)

- If the pH is HIGH, this is ALKALOSIS
- If the pH is LOW, this is ACIDOSIS
2- Look at the PaC02 (35 - 45) - PaC02 – Respiratory
- If PaC02 is HIGH, this is ACIDOSIS
- If PaC02 is LOW, this is ALKALOSIS
3- Look at the HC03 (22 - 26) - HCO3 – Metabolic
- If HC03 is HIGH, this is ALKALOSIS
- If HC03 is LOW, this is ACIDOSIS

Interpret
Step 1: Analyze the pH. It will tell you ACIDOSIS or ALKALOSIS
Step 2: Analyze the PaC02 and the HC03
- Is PaC02 below 35? It is Alkalotic. Above 45 it is Acidic
- Is HC03 below 22? It is Acidic. Above 26 it is Alkalotic
Step 3: Match the PaC02 or the HC03 with the pH
For example, if the pH is acidotic, and the PaC02, then the Acid-Base disturbance is being
caused by the respiratory
system. Therefore, we call it Respiratory Acidosis
Step 4: Does the PaC02 or the HC03 go the opposite direction of the pH?
If so, there is compensation by the systems. For example, if the pH is acidotic, and the
PaC02 is acidotic, and the HC03 is
alkalotic.
If they don’t go the opposite direction, It is UNCOMPENSATED
Step 5: Is the pH in normal range? Fully Compensated / Partially Compensated /
Uncompensated
If there is Compensation, and the pH is in normal range (7.35-7.45), then it is Fully
Compensated
If there is Compensation, and the pH is out of range, then it is Partially Compensated
Step 6: Are the pO2 and the O2 saturation normal?
If they are below normal, there is evidence of Hypoxemia
 – 79

1- Practice Question
A 72 yr. old with pneumonia.
pH - 7.31 (Acidic)
PaC02 – 60 (Acidic)
HC03 - 34 (Alkalotic)
pO2 – 50 (LOW)

#1 – pH is below 35, so It is Acidosis

#2 – Who is doing the same as the pH (Acidic)? PaC02
It is Respiratory
#3 – Does the HCO3 go in opposite direction as the pH? YES – Alkalotic
So, there is Compensation
#4 – Is the pH in normal range? NO
So, it is Partially Compensated
#5 – Is the pO2 in normal range? NO
The patient has Hypoxemia
The full Diagnosis is:
Partially Compensated Respiratory Acidosis with Hypoxemia

2- Practice Question
A 20 years old, acute renal failure
pH - 7.18 (Acidic)
PaC02 – 44 (Normal)
HC03 - 16 (Acidotic) #1 – pH is below 35, so It is Acidosis
pO2 – 92 (Normal) #2 – Who is doing the same as the pH (Acidic)? HC03
It is Metabolic
#3 – Does the PaC02 go in opposite direction as the pH? NO
So, there is NO Compensation
#4 – Is the pH in normal range? NO
So, it is Uncompensated
#5 – Is the pO2 in normal range? YES
The patient doesn’t have Hypoxemia
The full Diagnosis is:
Uncompensated Metabolic Acidosis.
 – 80

1. pH: 7.11 CO2: 51 HCO3: 27

2. pH: 7.39 CO2: 54 HCO3: 38

3. pH: 7.14 CO2: 51 HCO3: 28

4. pH: 7.39 CO2: 53 HCO3: 27

5. pH: 7.45 CO2: 40 HCO3: 22

6. pH: 7.50 CO2: 44 HCO3: 31

7. pH: 7.35 CO2: 20 HCO3: 17

8. pH: 7.12 CO2: 44 HCO3: 14

9. pH: 7.28 CO2: 54 HCO3: 26

10. pH: 7.30 CO2: 35 HCO3: 17

11. pH: 7.19, CO2: 39, HCO3: 18

12. pH: 7.7, CO2: 52, HCO3: 35

13. pH: 7.42, CO2: 54, HCO3: 28

14. pH: 7.84, CO2: 49, HCO3: 30

15. pH: 7.75, CO2: 43, HCO3: 37

16. pH: 7.87, CO2: 26, HCO3: 24

17. pH: 7.37, CO2: 20, HCO3: 15

18. pH: 7.14, CO2: 31, HCO3: 20

NursingStoreRN
19. pH: 7.58, CO2: 50, HCO3: 36

20. pH: 7.43, CO2: 32, HCO3: 12

 – 81

1. pH: 7.11, CO2: 51, HCO3: 27 - Partially Compensated Respiratory Acidosis

2. pH: 7.39, CO2: 54, HCO3: 38 - Fully Compensated Respiratory Acidosis

3. pH: 7.14, CO2: 51, HCO3: 28 - Partially Compensated Respiratory Acidosis

4. pH: 7.39, CO2: 53, HCO3: 27 - Fully Compensated Respiratory Acidosis

5. pH: 7.45, CO2: 40, HCO3: 22 - Normal

6. pH: 7.5, CO2: 44, HCO3: 31 - Uncompensated Metabolic Alkalosis

7. pH: 7.35, CO2: 20, HCO3: 17 - Fully Compensated Metabolic Acidosis

8. pH: 7.12, CO2: 44, HCO3: 14 - Uncompensated Metabolic Acidosis

9. pH: 7.28, CO2: 54, HCO3: 26 - Uncompensated Respiratory Acidosis

10. pH: 7.3, CO2: 35, HCO3: 17 - Uncompensated Metabolic Acidosis

11. pH: 7.19, CO2: 39, HCO3: 18 - Uncompensated Metabolic Acidosis

12. pH: 7.7, CO2: 52, HCO3: 35 - Partially Compensated Metabolic Alkalosis

13. pH: 7.42, CO2: 54, HCO3: 28 - Fully Compensated Metabolic Alkalosis

14. pH: 7.84, CO2: 49, HCO3: 30 - Partially Compensated Metabolic Alkalosis

15. pH: 7.75, CO2: 43, HCO3: 37 - Uncompensated Metabolic Alkalosis

16. pH: 7.87, CO2: 26, HCO3: 24 - Uncompensated Respiratory Alkalosis

17. pH: 7.37, CO2: 20, HCO3: 15 - Fully Compensated Metabolic Acidosis

18. pH: 7.14, CO2: 31, HCO3: 20 - Partially Compensated Metabolic Acidosis

19. pH: 7.58, CO2: 50, HCO3: 36 - Partially Compensated Metabolic Alkalosis

20. pH: 7.43, CO2: 32, HCO3: 12 - Fully Compensated Respiratory Alkalosis