Medical-Surgical Nursing Notes

• These notes cover various medical-surgical nursing topics with questions, answers, and rationales.

Initial Assessment of an Old Woman Hit by a Motorcycle

• Prioritize moving the patient to a safer location, particularly if in a dangerous setting like a train railway.
• The old woman's leg being shortened, adducted, and externally rotated suggests a hip fracture (remember "SADDER").
• A hip fracture produces a SHORTENED, ADDUCTED AND EXTERNALLY ROTATED extremity.
• Treatment involves casting the leg in EXTENSION, NEUTRALLY POSITIONED and SLIGHT INTERNAL ROTATION.
• Post Hip replacement, the client's leg should be in FLEXION, EXTERNAL ROTATION and ABDUCTION to prevent dislocation.

Inflammation vs Infection Following Trauma

• Redness, warmth, and swelling in the knee indicate inflammation.
• Inflammation typically starts almost instantly after trauma.
• Infection usually occurs 24-48 hours after fracture.
• Thrombophlebitis develops 4-7 days post-hospitalization due to immobilization.

Osteoporosis

• Hypothyroidism is not a contributing factor to bone demineralization.
• End-stage renal disease, Cushing's disease, and medications like Furosemide and Phenytoin increase bone demineralization

Monitoring Fractured Femur and Pelvis

• Tachycardia and hypotension may indicate hemorrhage due to severed vascular supply from the fracture.

Cane Usage for a Patient with Right Leg Weakness

• Instruct the patient to hold the cane on the left side for reciprocal motion.
• Reciprocal motion: When the right leg moves, the left arm should accompany it for balance.
• The cane should be held 6-10 inches to the side of the foot.
• Intervention is required if the patient moves the cane simultaneously with the right leg.

Mantoux Test (PPD) for Tuberculosis

• Mantoux Test is also known as PPD (purified protein derivative).
• Inject the solution intradermally, creating a wheal to check for TB exposure.
• A positive result is indicated by ≥10 mm induration (redness).
• A 5 mm induration is used for patients with AIDS or who are immunocompromised.
• Clients should return within 2-3 days for reading the results

TB Category Classification

• Category I: Newly diagnosed TB patients with a positive sputum culture.
• Category II: TB patients with relapses.
• Category III: TB patients with a negative sputum culture, but positive chest X-ray.

TB Treatment

• The maintenance phase of TB treatment lasts 4 months for category I patients (2 months intensive, 4 months maintenance).
• Medications during the maintenance include Rifampicin and Isoniazid.
• Ethambutol is only used in the intensive phase.
• The most hazardous period for developing clinical TB is during the first 6-12 months.
• The program to control TB by the DOH is the National Tuberculosis Control Program
• Susceptibility to TB is not increased with diabetes insipidus.

Colostomy Care and Teaching

• Diagnostic tests and treatment are part of secondary prevention.
• Actively participating in daily colostomy care demonstrates the best adaptation to a new colostomy.
• Using tap water indicates the client needs further instruction on colostomy irrigation..
• The colostomy tube should be inserted 3-4 inches for irrigation.
• K-Y Jelly serves as lubricant for the irrigation tube.
• Use an irrigation sleeve to direct drainage into a bedpan or toilet.
• The maximum solution height for colostomy irrigation is 12 inches.
• Agreeing to look at the colostomy in the client is the best first step to caring for it.
• Stop irrigating the colostomy tube if severe cramping occurs.
• A prolapsed stoma presents as protruding with swollen appearance.
• Beet greens and Parsley can lessen the odor of colostomy.
• Other vegetables like Spinach, broccoli, Cabbage, Cucumbers, Patola or bottle gourd may help but are gas-formers.
• The irrigant should be suspended 45 cm above the stoma.
• It requires cone to be inserted 4 cm into the Stoma.

Tracheostomy Suctioning

• Suctioning every hour is unnecessary; it should be done on a PRN basis with closed suction systems to minimize infection.
• Use a Fr. 12-18 suction catheter for adults.
• When using a portable suction unit, set the suction to 10-15 mmHg for adults.
• With a wall unit, the suction pressure should be 100-120 mmHg for adults.
• If a tracheostomy becomes dislodged, use an obturator and Kelly clamp to maintain airway patency.
• Two fingers should fit comfortably between the tracheostomy tie and the neck.
• Respiratory rate of 18 indicates adequate air exchange.
• Suctioning should be limited to 10-15 seconds

Acute Close Angle Glaucoma manifestations

• Pain is present in acute close angle glaucoma.
• Nurse uses Tonometry to measure the Intra Ocular Pressure for glaucoma diagnosis..
• Cones in the retina are responsible for color and day vision.
• Aqueous humor (AH) is produced in the ciliary body. Normal intraocular pressure (IOP) ranges from 8-21 mmHg.
• Use Snellen's chart is used to assess Optic nerve acuity (CN II).
• Pilocarpine contracts the ciliary muscle, which widens the angle for increased AH outflow, and decreases IOP in glaucoma.
• Timolol (Timoptic) reduces the production of aqueous humor (AH).
• Bending at the waist should be avoided for patients with glaucoma, as it increases IOP

Eye Angiography

• Mydriatics are required with eye angiography as premedication: After the procedure, reading newsprint is CONTRAINDICATED until the pupil can focus on objects, typically 6 hours-1 day.

Pilocarpine Systemic Toxicity

• In case of pilocarpine systemic toxicity, always have atropine sulfate available.
• Atropine sulfate reverses the effects of systemic toxicity of pilocarpine.

Caloric Testing and Ear Drop Administration

• Rotary nystagmus towards the ear post caloric testing with warm water indicates a normal intact CN VIII (Vestibular branch).
• Ear drops for infants: Pull the pinna DOWN and BACK, directing solution onto the wall of the canal to prevent membrane damage..

Meniere’s Disease plan

• For Meniere's disease, safety is the priority intervention due to incapacitating vertigo.
• Bed rest with the side rails up to prevent injury from falls is required with acute attacks.
• Encourage the client to eat foods low in sodium and to limit fluid intake.
• Client needs to be restricted from fluids and salt, to prevent fluid from accumulating into endolymph.

Post-Mastoidectomy Complications

• Be aware that CN VII (facial nerve) damage is possible after mastoidectomy.

WEBERS TEST.

• If sound is louder in the L ear, client either has conductive hearing loss or have a sensory hearing loss in the right ear

Dietary Needs

• Low sodium and restricted fluid intake is recommended for Meniere’s disease.

Prolonged Vomiting:

• If client demonstrates the sign of furrow tongue and is vomiting it is appropriate to diagnose them with Fluid volume deficit.
• .5kg of acute weightless approximately is 500ml of fluid loss.
• In Postural hypotension, systolic pressure should be greater than 10mmHg when patient changes position from lying to sitting.

Parkinson's Disease

• Levodopa should be avoided in patients taking vitamin B6 rich foods or Pyridoxine.
• Client may complain in difficulty of walking so you should provide a Cane of support.

Dementia

• Dementia is associated with the loss of endurance.
• Aphasia: Patient exhibits difficulty of speaking or understand.
• Use a medium-pitched while communicating for patients with dementia.

Drug Compliance

• Drug Compliance is most important to discuss when clients are dealing with psychoses.
• With clients taking Propantheline, patient should avoid operating machines since it causes dizziness blurred vision etc.
• Peptic ulcer disease is treated with propantheline: Probanthine use to decrease gastric secretion.

CVA

• Patency of airway and the adequacy of respiration is the priority when assessing.
• Suction machine is important to have ready for CVA stroke patents because it can impair swallowing.
• Comatose patents breathe threw their mouth so mouth care prevents cracking or infection to dry mouth.
• To prevent pressure store (Decubitus ulcer) : Turn every 2 hours

Appendicitis

• Client with right side stroke : L lobe = expressive aphasia, careful/slow and right weakness.
• With appendicitis you can expect elevated WBC.
• Nurse should perform a spinal anesthesia for an Appendectomy Diet : As tolerated after fully conscious.