Med-Surg Final Study Guide PDF

Endocrine: a. Thyroid disorders – Hyperthyroidism (Grave’s): Increased T3 and T4, decreased TSH (high metabolism) Assessment: Hypertension, Tachycardia, exophthalmos, diarrhea, warm / moist skin, weight loss Management: Anti-thyroids: Propylthiouracil (PTU) and Methimazole. Iodine solutions...

Endocrine: a. Thyroid disorders – Hyperthyroidism (Grave’s): Increased T3 and T4, decreased TSH (high metabolism) Assessment: Hypertension, Tachycardia, exophthalmos, diarrhea, warm / moist skin, weight loss Management: Anti-thyroids: Propylthiouracil (PTU) and Methimazole. Iodine solutions Lugol’s Iodine solution (SSKI): decreases size and vascularity of thyroid (before SX) Radioactive iodine 131 (I131): IV administrated to destroy the thyroid tissue Thyroidectomy Increase caloric intake, low-fiber diet Eye care for exophthalmos (eye drops) Monitor weight and VS Thyroid Storm (URGENT): agitation, confusion, hypertension, tachycardia, fever Hypothyroidism (Hashimoto’s): Decreased T3 and T4, increased TSH (low metabolism) Assessment: Weight gain, edema, low metabolism, low energy, alopecia, hypotension, constipation, low mood Management: Levothyroxine or Liothyronine: thyroid replacement hormone, give in morning. CAD may develop. Glucocorticoids: decrease inflammation Anti-lipemic: decrease cholesterol Fluid management (only if no edema) High-fiber, low-calorie diet (slow metabolism) Provide warm environment and frequent rest periods Assess VS, loss of consciousness (do NOT give opioids and sedatives) Myxedema Coma (URGENT): can happen post-thyroidectomy or abruptly stop thyroid. Hypotension, bradycardia, low temperature. Have emergency tracheostomy kit at bedside. b. Parathyroid disorders Hypoparathyroidism: Decreased PTH, decreased Calcium, increased Phosphate Risk factors for Hypoparathyroidism: thyroid surgery, parathyroid surgery, autoimmune Assessment for Hypoparathyroidism: increased neuromuscular irritability (spasms), Trousseau’s sign (hand with blood pressure), Chvostek’s sign (touching face makes cheek spasm), tingling, numbness, seizures Management for Hypoparathyroidism: Give calcium supplement: reduce spasms Thiazide diuretic: promotes calcium reabsorption from kidneys Calcium gluconate + Vitamin D supplements Aluminum-based meds: binds with phosphate High calcium (dark leafy vegs.), low phosphate diet (fruits, pasta) (NO DAIRY!) Respiratory support due to laryngeal spasms, possible stridor. Have tracheostomy kit ready. Hyperparathyroidism: increased PTH, increased calcium (PTH makes bones weak) Assessment of Hyperparathyroidism: decreased neuromuscular irritability, muscle weakness, fatigue, constipation, psych. / bizarre behaviors, fractures, kidney stones, ulcer, pancreatitis Management of Hyperparathyroidism: Hydrate clients to flush out (2 L / day) Furosemide: to get the calcium out Calcitonin: decreases calcium Bisphosphonates: increases bone density Low-calcium diet (chicken, non-green vegs.) Weight-bearing exercise: promotes calcification Parathyroidectomy: removal of the parathyroid (last option) c. Disorders affecting ADH SIADH: increased ADH, decreased sodium (retaining fluid) Assessment: headache, weakness, anorexia, muscle cramps, weight gain, nausea, vomiting, diarrhea, hypertension, seizures, lung congestion (crackles) SIADH Diagnosis: decreased urine output, increased urine specific gravity (1.030), increased urine osmolality, decreased blood serum osmolality. SIADH Management: Tetracycline: stimulates urine flow and excretes fluid. Vasopressin antagonist: promotes water excretion without sodium loss. Furosemide: increases water excretion for kidneys. 3% NaCl (hypertonic): monitor for fluid overload. Limit oral fluids. Monitor intake and output. Monitor for pulmonary edema, heart failure, altered mental status. Monitor hematocrit and urine specific gravity for reevaluation of patient. DI: Decreased ADH, increased sodium (dehydrated) DI Assessment: polyuria, polydipsia, dehydration, dry mucous membrane, sunken eyes, hypotension, increased heart rate, possible hypovolemic shock. DI Diagnosis: Water Deprivation Test: dehydration is induced by withholding fluids (8-12 hours). Increased urine output, decreased urine specific gravity (1.005), decreased urine osmolality, increased blood serum osmolality. DI Management: Desmopressin / Vasopressin: synthetic ADH (intranasally), IV fluids. Assess vitals, loss of consciousness. Monitor dehydration. Monitor daily weight. Monitor intake and output. d. Adrenal gland disorders Addison’s disease: Decreased ACTH, hyperkalemia Addison’s Disease Assessment: thin (weight loss), dehydration, hyperpigmentation, hyponatremia, hypoglycemia, hypotension. Addisonian crisis: drop in BP due to no steroids. IV push steroids. Management of Addison’s Disease: Fluid replacement: 0.9 NS, D5W, D5NS Steroids: Hydrocortisone, Prednisone (give with food) (at risk to suppress immune system) Vasopressors: Epinephrine and Dopamine (to increase blood pressure) Electrolyte replacement, glucose, antibiotics. Monitor vitals. Monitor intake and output. Monitor weight. Cardiac monitoring. Diet: high carbohydrate, high proteins, high sodium, low- potassium Cushing’s disease: Increased ACTH, hypokalemia. Cushing’s Disease Assessment: Buffalo-Trunk (weight), moon face, hirsutism, acne, purple striae, brittle bones, edema, hypertension, hyperglycemia, hypernatremia. Cushing’s Disease Diagnosis: Dexamethasone suppression test Cushing’s Disease Management: Radiation: to shrink adrenal cortex Hypophysectomy: (removal of pituitary) may lead to DI Adrenalectomy: (removal adrenal glands / cortex) then steroid therapy Adrenal enzyme inhibitors: metyrapone, aminoglutethimide, ketoconazole Diet: High-protein, high-calcium + vitamin D, high potassium, low sodium, low glucose Slowly taper use of steroids, fluid restrictions, prevent infection (due to steroids) Pheochromocytoma: increased epinephrine and nor-epinephrine Tumor of the adrenal medulla. Pheochromocytoma Diagnosis: Clonidine suppression test, elevated metanephrine (MN), and elevated vanillylmandelic acid (VMA) Pheochromocytoma Assessment: hypertension, hyperglycemia, hypermetabolism, hyperhidrosis (excessive sweating), headache, tremors, flushing, anxiety, palpitations. Pheochromocytoma Management: Alpha-adrenergic blocking agents: Phentolamine Calcium Channel Blockers: Nifedipine Vasodilators: Nipride, nitroglycerin Adrenalectomy: removal of adrenal cortex. Monitor VS, Hormonal replacement, hypoglycemia management. Having an organ removed decreases vital signs. Respiratory System: Laryngeal Cancer 1. Causes and Risk Factors: smoking, alcohol, vitamin deficiency, chronic irritation 2. Assessment: Hoarseness of voice (early sign), burning sensation upon ingestion of hot and citrus liquids, lumps on neck, dysphagia, dyspnea, pain. 3. Diagnosis: Laryngoscopy biopsy 4. Management: Laryngectomy (subtotal or total), Altered airway and speech with total laryngectomy. Safety precautions. Radiation: provide skin care for irradiated site. Rest. Chemotherapy: antiemetics prior to chemotherapy. Lung Cancer 1. Causes and Risk Factors: Smoking, chemicals, high fat + low fiber diet, age, genetics, environment, lung lesions from TB or fibrosis 2. Assessment: chronic cough (early sign), chest pain, hemoptysis, dyspnea, increased tactile fremitus (inflamed lung tissue), dull sound on percussion, recurring infection, pleural effusion. 3. Diagnosis: Bronchoscopy biopsy, CT, MRI, PET scan, sputum cytology, CXR\ 4. Management: Lung surgery: pneumonectomy, lobectomy, segmentectomy, wedge resection, chest tube post-op (except pneumonectomy) Pleural Effusion 1. A collection of fluid in the pleura space usually secondary to another disease. Filled with fluid, blood or pus. 2. Causes and Risk Factors: iatrogenic due to other medical conditions (infections or tumors) 3. Assessment: symptoms of causing disease, dyspnea, cough, diminished / absent breath sounds, flat / dull percussion, decreased tactile fremitus (air / fluid in pleural space), tracheal deviation on unaffected side 4. Diagnosis: Thoracentesis, pleural fluid analysis, pleural biopsy, chest x-ray 5. Management: Keep client in Semi-Fowler’s position, thoracentesis, pleurodesis, pleurectomy, chest tube, pleuroperitoneal shunt Pulmonary Embolism 1. Causes and Risk Factors: blood clot, DVT, trauma, Fat embolism, heart disease, Atrial Fibrillation. 2. Assessment: sudden onset of dyspnea, chest pain, tachycardia, low oxygen saturation, hemoptysis 3. Diagnosis: Pulmonary angiography, Chest CT, V/Q scan, D-dimer assay 4. Management: Prevention of blood clots, oxygen therapy, morphine for chest pain 5. Medications: Anticoagulants: heparin, warfarin. Monitor labs for heparin (PTT, aPTT) and warfarin (PT, INR). Thrombolytics: alteplase, streptokinase, urokinase. Lab Values for Pulmonary Embolism anticoagulants: PTT: 60 – 70 seconds aPTT: 20-39 seconds PT: 9-12.5 seconds INR: 1. Second Tuberculosis (airborne) 1. Causes and Risk Factors: caused by Mycobacterium tuberculosis, immunosuppression, malnutrition, age, overcrowding, immigration 2. Assessment: low-grade fever, night sweats, persistent cough, diaphoresis, hemoptysis, chest pain, anorexia, weight loss. 3. Diagnosis: PPD + Mantoux Test is positive if greater than 10 mm. If patient is immunocompromised a test greater than 5 mm is positive. Sputum exam: acid fast bacilli (3 morning sputum samples), CXR 4. Management: antibacterial medications: Rifampin (rifadin), Isoniazid, Pyrazinamide, Ethambutol HCl (myambutol). 6–12-month medication therapy. Initial regiment: 8 weeks, continuous regiment: 4-7 months. Negative pressure room. N95 respirator.  Oxygen Therapy: - Assess respiratory status: pulse oximetry, ABG’s, humidify, provide at lowest (depending on patient situation) - Nasal Cannula: 1-6 L/ min, easy-safe, client can talk and eat - Simple Face mask: 5-6 L/min, easy to apply, claustrophobia consideration - Face Tent: 10-15 L/min, provide humidification, useful for facial traumas, burns - Non-rebreather mask: 10-15 L/min, delivers the highest oxygen concentration possible Cardiac System: Hypertension: - Normal blood pressure: less than 120 AND less than 80 - Elevated blood pressure: 120-129 AND less than 80 - Stage 1 Hypertension: 130-139 OR 80-89 - Stage 2 Hypertension: 140+ OR 90+ - Hypertensive Crisis: 180+ AND/OR 120+ Types of hypertensions: - Primary / essential: idiopathic hypertension (kidneys, CNS, emotions) - Secondary hypertension: related to other disease, hyperthyroidism, Cushing’s, pheochromocytoma Assessment: asymptomatic (possible chest pain / stroke), headache (neck pain), palpitation (Cardiac workload), dyspnea, retina blood vessels (blurred vision) Management: - Diuretics (-ide) (affects pre-load): o Furosemide: monitor intake and output, decreases potassium, blood pressure o Hydrochlorothiazide: monitor BP, increases calcium, decreases potassium o Spironolactone: reabsorbs potassium (increases), restrict other potassium - Vasodilators (-zosin) (affects PVR + after load) Alpha-adrenergic blockers: o Prazosin  - Beta-Blocker (-lol): decreases heart rate, listen to apical pulse if it is less than 60 BPM do NOT administer medication o Atenolol o Metoprolol o Labetalol - Calcium-Channel Blocker (-dipine): decreases muscle contraction and how much the heart contracts (decreasing cardiac output decreases blood pressure) o Amlodipine o Nifedipine - ACE-Inhibitors (-pril): can cause angioedema (dry cough, swollen tongue) o Lisinopril or - ARP-blocker (-sartan) o Losartan - Weight management (1 kg weight loss = 1 mmHg) - DASH diet: high fiber, low fat / cholesterol - Reduce sodium 160, HTN, heart murmur, HF, open heart surgery, cardiac diseases, “holiday heart syndrome” 2. Management: Calcium-Channel Blockers: amiodarone (Cordarone), Diltiazem (Cardizem). Beta Blockers (-lol): Propranolol, atenolol, metoprolol. Cardiac glycoside: digoxin. Anti-Coagulants: Warfarin (Coumadin), aspirin. ACE-inhibitors (-pril): Captopril, Enalapril and ARB (-sartan): Losartan both reduce the incidence of A. Fib 3. Most common sustained dysrhythmias. Reduces cardiac output by 25-30%: causing palpitations (symptoms of HF). Do not give BP meds if apical pulse is less than 60 BPM. Monitor potassium levels: Hypokalemia increases the risk for Digoxin toxicity. Monitor INR (2-3) and limit green leafy vegetables if patient is on Warfarin. Atrial Flutter: rapid atrial rate, 250-400 BPM with ventricular rate of 75-150, causing saw-toothed P waves. 1. Causes: conduction defects in the atrium. COPD, pulmonary HTN, valvular disease, thyrotoxicosis, open heart surgery 2. Management: Vagal Maneuvers (to decrease), Adenosine: causes sympathetic block. Cardioversion. Catheter Ablation: treatment of choice. Anticoagulants, Beta-Blockers, Calcium-Channel Blockers, Cardiac glycosides. 3. May cause serious signs such as chest pain, shortness of breath and hypotension. Ventricular Dysrhythmias: Premature Ventricular Contractions (PVC) 1. Causes: Cardiac ischemia or infarction. Caffeine, alcohol, nicotine. Hypoxia, acidosis, electrolyte imbalance (hypokalemia). Increased cardiac workload. 2. Management: Prevent or treat the causative factor. Amiodarone, Sotalol. 3. May be felt as a “skipped beat.” Stable Angina vs. Unstable Angina 1. Stable Angina: Chest discomfort occurs with moderate to prolonged exertion. Causes slight activity limitation. Predictable pattern with same frequency, duration, and intensity of symptoms. Usually relieved by rest. Triggered by cardiac workload (increased activity). Less than 15-minute chest pain. 2. Unstable Angina: Chest discomfort occurs at rest with exertion. Causes severed activity limitation. Increase in number of attacks and intensity of pressure in the chest. Cannot predict. More than 15-minute chest pain. 3. Diagnosis for Angina: Physical exam, history, ECG (ST segment changes, T wave changes) 4. Management for Stable angina vs unstable angina: Rest, Semi-Fowler’s / High-Fowler’s, oxygen therapy to perfuse blood vessels. Reduce activity (rest, anxious, stress). 5. Pharmacological Management to treat/ prevent Angina a. Nitrates (decreases after-load and pre-load): Nitroglycerin: addresses perfusion issue, monitor BP each time, up to 3 doses of nitroglycerin every 5 minutes. If at a home setting, take one tablet and if no pain relief call 911. Caution against Sildenafil (Viagra). Protect medication from light and heat. ^ months good from first day opened. b. Antiplatelets: prevents platelets from clotting. Aspirin: once a day for prevention. Bleeding risk and GI irritation while taking aspirin.  c. Anticoagulants: prevents venous clots from forming. Heparin: SUBQ. If they currently have a clot, treat with Heparin IV Drip. Protamine Sulfate is antidote for heparin. Warfarin (Coumadin): PO medication. Decrease intake of green leafy vegetables due to Vitamin K (antidote). d. Beta-Blockers: Decreased heart rate: Metoprolol / Atenolol. Listen to apical pulse for 1 minute. Do not administer if less than 60 BPM. e. Calcium-Channel Blockers: Amlodipine, Diltiazem 6. Health Promotion for stable / unstable angina : Exercise routine, routine BP and cholesterol level checks, diet low in saturated fats and high in fiber. Angina vs. Acute Myocardial Infarction 1. Angina: caused by stress / exercise. Relieved with rest / nitroglycerin. Symptoms last less than 15 minutes. 2. Myocardial infarction: Can occur without cause. Relieved only by opioids (Morphine), symptoms are greater than 30 minutes. MI is associated with nausea, epigastric pain, dyspnea, anxiety, diaphoresis, cold, clammy. Acute Myocardial Infarction 1. Myocardial infarction: Can occur without cause. Relieved only by opioids (Morphine), symptoms are greater than 30 minutes. MI is associated with nausea, epigastric pain, dyspnea, anxiety, diaphoresis, cold, clammy. 2. Assessment: Subjective: Chest pain, anxiety, “impending doom”, nausea, dizziness. Older adults may experience dizziness, disorientation, confusion, new-onset of A-Fib, less chest pain. Objective: Pallor, cool and clammy skin, tachycardia, bradycardia, palpitations, diaphoresis, vomiting, decreased level of consciousness. 3. Diagnostics: EKG, Increased troponin, increased CK-MB. ST Segment changes: ST elevation, non-ST elevation 4. Women experiencing a Myocardial Infarction: dyspnea, pain in the lower chest or upper abdomen, dizziness, extreme fatigue, upper back pain / pressure. “I feel tired.” 5. Patient Centered Care: Assessment and relief of pain. Oxygen administration. Vital Signs every 15 minutes until stable, then every hour. Continuous cardiac monitoring. Promote rest. 2 IV access sites, hourly urine output (30 ml), lab data. We want to decrease cardiac workload! 6. Treatment in order: Oxygen, Aspirin, Nitroglycerin x 3, Morphine. 7. Management: Bed rest, Semi-Fowler’s, deep breathing, oxygen therapy for myocardial tissue, NC 2-4L STEMI vs NSTEMI 1. NSTEMI: has ST depression / T Wave inversion (4-6 hours) 2. STEMI: ST elevation (60-90 minutes) 3. Diagnostics for Myocardial Infarction: a. Cardiac Catheterization / Coronary Angiography (arteriography): assesses arterial circulation within the heart to detect obstruction, narrowing or occlusion, aneurysm. Determines how much percent is occluded. Inserted through femoral artery. Promote bed rest while being supine for 4-6 hours post-procedure and avoid moving around. b. Stress- Test: physical test (treadmill, bicycle) or pharmacological (medication). We want patient to be NPO, no smoking, hold BP medications, no caffeine. Stop if patient is dizzy, has chest pain, SOB, nausea. 80-90% HR is good. 220 – age = max HR c. Echocardiography: Transthoracic (TTE) and Transesophageal (TEE): lie on left side -TTE: closer to heart, better visualization, if obese might be harder -TEE: no food, assess gag reflex, monitor for bleeding, possible chest pain 4. Medical Interventions for NSTEMI / STEMI: Thrombolytics (bursts clots) , anti-platelets and anticoagulants (prevent clots), statins (cholesterol) a. Thrombolytics: dissolve clots (thrombi): Streptokinase, urokinase. Indicated with STEMI if chest pain is unrelieved by nitroglycerin and greater than 30 minutes. Most effective if given 3-6 hours after a coronary event. Start this infusion within 30 minutes of ED admission. Assess for bleeding. Possible internal bleeding if having hypertension crisis (180+). b. ACE-inhibitors (-pril): prevent ventricular remodeling and heart failure. Given within 48 hours if ejection fraction is equal or greater than 40%. Monitor for decreased urine output, hypotension, and cough (angioedema). Assess potassium, creatinine, BUN. c. Beta Blockers (-lol): reduce the size of an infarct, occurrence of dysrhythmias. Slows heart rate and decreases force of contraction. Do not give if apical pulse is less than 60 BPM. Assess for bradycardia, hypotension, reduced LOC, chest pain, wheezes + crackles (may block receptors in lungs), hypoglycemia. d. Prevent Clot Extension: Want normal values to double to be therapeutic. 1. Antiplatelet therapy: Aspirin 325 mg. Inhibits platelet aggregation and reduces clot formation. Assess for bleeding and GI irritation. 2. Anticoagulation therapy: Heparin: monitor PTT (60-70), aPTT (20-39). Antidote: Protamine Sulfate  Warfarin: Monitor PT (9-12.5), INR (1), low Vitamin K consumption e. Statins: reduces cholesterol, LDL goal: