Medical-Surgical Nursing PDF

MEDICAL-SURGICAL NURSING nursebossstore.com  ELECTROLYTE IMBALANCE S ODIUM P OTASSIUM C ALCIUM M AGNESIUM 135-145mEq/L 3.5-5.0 mEq/L 8.5-10.5m...

MEDICAL-SURGICAL NURSING nursebossstore.com  ELECTROLYTE IMBALANCE S ODIUM P OTASSIUM C ALCIUM M AGNESIUM 135-145mEq/L 3.5-5.0 mEq/L 8.5-10.5mEq/L 1.5-2.5 mEq/L The Functions The Functions The Functions The Functions Magnesium keeps muscle Sodium is a major electrolyte Potassium is a a major Calcium aids in blood clotting, cells relax after contraction in the extracellular fluid electrolyte in the intracellular Aids in muscle contraction, and + nerve function fluid bone strength Sodium maintains: blood volume + bp + fluid balance. Potassium maintains the heart and muscle contraction. Aids in blood clotting Relaxed after Maintains blood volume contraction Heart contractions Muscle contractions Fluid Balance Muscle contractions Aid in bone strength nursebossstore.com Nerve Function HYPO= Low Level Causes Causes Causes Causes Excessive sweating Medication: potassium Hypoparathyroidism Malabsorption Diuretics, D/V wasting diuretics Celiac’s & Crohn’s syndrome Alkalosis Disease Continuous gastric Increased magnesium NPO suctioning, SIADH,HF Kidney disease excretion Signs and Symptoms Signs and Symptoms Signs and Symptoms Signs and Symptoms ECG changes: ST Positive Trousseau sign, Arrhythmias, Hypotension, Thready depression, flattened T Tachycardia, pulse, Tachycardia, Chvostek sign wave/inverted Risk for fractures High BP Muscle weakness, Thready, weak pulse Chvostek sign, seizures and coma Constipation, Hyporeflexia Tetany, Spasms Positive Lethargy, confusion Trousseau's Hyper= High Level Causes Causes Causes Causes Increased sodium intake Medications: ACE Hyperparathyroidism Magnesium-containing Fluid loss: causes Inhibitors/Potassium Malignancy antacids Sparing Diuretics Increased intake of Antacids or laxatives hemoconcentration Addison's disease. CKD calcium: (excessive use of containing Mg Diabetes Insipidus Renal disease Dehydration Burns and tissue damage oral calcium or Vitamin D supplements) DKA Signs and Symptoms Signs and Symptoms Signs and Symptoms Signs and Symptoms Edema ECG changes: Peaked T Kidney stone formation, Hypotension Increased BP wave, flat P wave, wide Bone pain, Bradycardia QRS complex Decreased DTR Neuro changes Weak pulse Increase DTR Muscle cramps, weakness Bounding pulse Low RR nursebossstore.com  RESPIRATORY DISORDERS P LEURAL EFFUSION h EMOTHORAX P NEUMOTHORAX BLOOD FLUID AIR Pathophysiology Pathophysiology Pathophysiology Accumulation of fluid in the Accumulation of blood in the Air leaks into pleural pleural space. pleural cavity. space. Treatment Causes respiratory distress. Types 1. Thoracentesis Treatment 1. Spontaneous 2. Chest tube insertion 1. Stabilize patient pneumothorax 3. Treatment of underlying 2. Stoppage of bleeding 2. Tension condition 3. Thoracentesis pneumothorax e mpyema: 4. Chest tube insertion 3. Traumatic pneumothorax Empyema is an infection in which Signs and Symptoms Spontaneous pneumothorax pus develops in your SOB/ Cyanosis, Tachycardia pleural space. PUS Asymmetrical chest movement Pus is a thick, Diminished breath sounds on discolored (white, affected side, Chest pain yellow, pink or Tension pneumothorax green) fluid. Tracheal deviation away from nursebossstore.com affected side  RESPIRATORY DISORDERS C OPD a thsma p ULMONARY EMBOLISM Pathophysiology Pathophysiology Pathophysiology Chronic Bronchitis: Inflammation and Pulmonary embolism is the Overproduction of mucus due to hypersensitivity to a trigger obstruction/blockage of a inflammatory response. (stimuli). pulmonary artery mostly BLUE BLOATERS Smooth muscle constriction caused by blood clots (travel of the bronchi. from the deep vein in the 1. Cyanosis us uc M 2. Overweight Signs and Symptoms legs to the lungs). Causes Emphysema 1. Chest tightness Blood clots enlargement of the alveolar. 2. Wheezing Fat, Tumor PINK PUFFERS 3. Shortness of breath Air emboli 4. Cough (due to IV 1. Barrel Chest enlargement of the 5. Restlessness therapy) 2. Hyperventilation alveolar 3. Weight loss Pharmacology Nursing Actions Nursing Actions Anticholinergics 1. Assess lung sounds, SPO2 Anticoagulants: prevent clot formation 2. Adm. 02 (1-2L) Bronchodilators Thrombolytics: dissolve clots 3. Smoking cessation Surgical embolectomy: 4. Purse lips| Diaphragmatic breathing Corticosteroids removal of clot nursebossstore.com nursebossstore.com CARDIOVASCULAR DISORDERS Angina: cardiogenic shockDISEASE PERIPHERAL ARTERIAL Angina is chest pain due to decreased myocardial oxygenation. Type explanation Nursing Actions: Oxygen heart's inability to Medications : Nitro, BB, CCB, Antiplatelets Cardiogenic pump enough blood Shock Myocardial Infarction Hypotension, MI occurs due to myocardial tissue damage Tachycardia, weak pulse as a result of oxygen deprivation. cardiac tamponade Nursing actions: ABC, EKG monitoring Accumulation of fluid in the Oxygen, Nitroglycerin, Aspirin, Morphine pericardial cavity Heart Failure Muffled heart sound HF is the inability of the heart muscle to d ria pump enough blood to meet the metabolic sT demands of the body. ck Be L sided Heart Failure R sided Heart Failure JVD Hypotension Edema of the Dyspnea, crackles, extremities, Nursing Actions: IV fluids, tachypnea, abdominal distention, Pericardiocentesis pulmonary JVD, splenomegaly, congestion, dry hepatomegaly, weight Peripheral Vascular Disease cough PAD gain PVD Nursing Actions: High fowler's position, O2 therapy, monitor daily v= PvD v shape weights, intake/output charting, an "a" shape diuretics, low sodium diet a= PAD Inflammation Pericarditis Endocarditis Myocarditis DEEP VEIN THROMBOSIS Deep vein thrombosis (DVT)- Inflammation Inflammation Inflammation thrombus (blood clot) forms mostly of the of the of the in the deep vein of the lower pericadium endocardium myocardium extremities. Elevate extremity,Anti-embolism Hypertension: stockings, thrombolytics Increase in blood pressure (chronic). nursebossstore.com GASTROINTESTINAL DISORDERS gerd Crohns Disease A digestive disorder that occurs due to Inflammation in the the backflow of gastric content. gastrointestinal tract Nursing Actions: Antacid Nursing Actions: Maintain NPO Neutralizes stomach acids status, monitor stool frequency Proton pump inhibitors and characteristics Blocks acid production- reduces pancreatitis stomach acid Inflammation of the pancreas. Histamine H2 antagonist Nursing Actions: Maintain NPO Blocks histamine (decreases status, parenteral nutrition stimulation of stomach acid production). Cholecystitis Gastritis Inflammation of the gallbladder. Gastritis is the inflammation of the gastric Nursing Actions: Maintain NPO mucosa. status, low fat diet, prepare patient for cholecystectomy: Nursing Actions: Maintain NPO status until removal of the gallbladder. symptoms subsides, avoid irritating foods Cholelithiasis APPENDICITIS Gallstones are hard, crystalline Inflammation of the vermiform appendix. structures that abnormally forms and obstruct the gallbladder / bile Nursing Actions: Pre-operative care (NPO + duct. IVF), Avoid palpating area, Appendectomy: surgical removal of the appendix. Cirrhosis Cirrhosis is a chronic progressive Peptic Ulcer Disease disease of the liver characterized Ulceration that erodes the gastric or by fibrosis (scarring). duodenal mucosa. Nursing Actions: Administer Ulcerative Colitis vitamin supplements- KADE, Characterized by the ulceration and obtain daily weights inflammation of the colon and rectum. Diet: low salt, low fat Causes poor nutrient absorption. constipation Nursing Actions: Maintain NPO status, Infrequent bowel movement monitor stool frequency and Nursing Actions: Increase fluids characteristics Diet: high fiber diet nursebossstore.com NEUROLOGICAL DISODERS INCREASED ICP STROKE SEIZURES Pathophysiology Pathophysiology Pathophysiology Increased ICP is a rise in the Stroke is the loss of Seizures is characterized pressure inside the skull. The neurological functions due to by a sudden, uncontrolled normal intracranial pressure is the lack of blood flow to the electrical disturbance in between 5-15 mmHg. brain. the brain. Increased Systolic BP Types Epilepsy: chronic seizure Ischemic Stroke (Clots) activity. ad Hemorrhagic Stroke tri Nursing Actions 's (Bleeding) 1. Assess time and duration ing sh Treatment of seizure activity Cu Decreased RR Decreased HR 1. An IV injection of 2. Provide patient safety Nursing Actions recombinant tissue 3. Turn patient to the side 1. Position: elevate head of bed plasminogen activator 4. Maintain airway to 30 degrees (prevent (tPA)-ischemic stroke 5. Avoid restraining patient flexion of neck & hips) 2. Hemorrhagic stroke: 6. Loosen clothing Patient Education stop bleeding. 7. Administer O2 1. Avoid Valsalva's maneuver Prevention of increased 8. Monitor behavior before 2. Avoid straining activities ICP. and after seizure activity nursebossstore.com RENAL DISORDERS A CUTE KIDNEY INJURY c hronic kidney disease u rinary tract infection CKD UTI AKI Pathophysiology Pathophysiology Pathophysiology Renal cell damage characterized Slow, progressive and UTI is the infection/inflammation of any by a sudden deterioration in irreversible loss of kidney part of the urinary system. kidney function. function. Causes of AKI Stages of CKD pyelonephritis Causes of AKI may be due to 1 (GFR > 90 mL/min) pre-renal injury, intra-renal 2 (GFR = 60-89 mL/min) Acute injury or post-renal injury. 3A (GFR = 45-59 mL/min) Signs and Symptoms 3B (GFR = 30-44 mL/min) Oliguric Phase: