Medical-Surgical Nursing Foundation: Unit I Exam Review PDF

M E D I C A L - S U R G I C A L N U R S I N G F O U N D AT O I N S ED AND TRAUMA NURSING F L U I D S , E L E C T R O LY T E S , A C I D - B A S E IMBALANCES I M M U N I T Y, H E M A T O L O G Y, A N D O N C O L O G Y Unit I Review Preparatory Module RECOGNIZE, RESPOND, A...

M E D I C A L - S U R G I C A L N U R S I N G F O U N D AT O I N S ED AND TRAUMA NURSING F L U I D S , E L E C T R O LY T E S , A C I D - B A S E IMBALANCES I M M U N I T Y, H E M A T O L O G Y, A N D O N C O L O G Y Unit I Review Preparatory Module RECOGNIZE, RESPOND, AND GOALS: D EVELO P R E P O RT Clinical judgment Safe delegation- cannot include Critical thinking assessments/evaluation or education Failure to Rescue- failure to recognize Clinical reasoning changes in condition and Systems thinking respond/report appropriately Rapid Response Team vs Code Team- RRT for sudden changes in condition. Code- cardiopulmonary arrest ED Nursing Social determinants of health and vulnerable populations Safety and violence in the ED Priorities of care X, A, B, C, D, E Triage Mechanism of injury Complications of trauma Fluid and Electrolyte Balance Homeostasis Ions move Diffusion Active Transport Water moves Osmosis Filtration Fluid volume imbalances OVER LOAD DEFICIT Weight gain Weight loss Pitting edema Dry, cracked mucosa, tenting turgor Hypertension Hypotension Tachycardia with bounding pulses Tachycardia with thready pulses Jugular vein distention Flat neck veins Crackles, dyspnea, orthopnea Oliguria, Hemoconcentration Bulging fontanels, periorbital edema Sunken fontanels, sunken eyes Fluid balance strategies R E H Y D R AT I O N DIURESIS Oral solutions Safe removal of water Salts and water Electrolyte balance Not concentrated glucose Diuretics IV solutions 20 ml/kg bolus Limit oral salt intake Goal Oral fluid restrictions if CHF or PO: 64 ounces hemodilution Output: 720 ml clear urine Electrolyte imbalances Sodium (natremia) Seizures, confusion, risk for injury Potassium (kalemia) Cardiac dysrhythmias, muscle weakness, GI changes Calcium (calcemia) Neuromuscular changes, cardiac dysrhythmias Magnesium (magnesemia) (mimics other problems) Neuromuscular changes, seizures, respiratory depression, cardiac dysrhythmias Acid-base balance Immunity Hypersensitivity reactions 1 2 3 4 Type I Type II Type III Type IV Histamine and Cellular response to Immune reaction Inflammatory inflammatory foreign proteins Lupus, Serum response response Hemolysis, sickness Contact dermatitis, Allergy, Rhinitis, Transfusion reaction, RA, MS Asthma, Anaphylaxis Graft rejection Immune conditions Lupus Lyme HIV Hematolog y Core concepts of hematology Hematopoiesis Low blood counts Anemia Leukopenia Thrombocytopenia High blood counts Polycythemia Leukocytosis Medications to manage hematologic conditions Iron Erythropoietin alfa (Epogen) Microcytic anemia Increases reticulocytes (become B12 erythrocytes in ~2 days) Do not use if hypertension or normal hgb Pernicious anemia Filgrastim (Neupogen) Folate Increases neutrophils Macrocytic anemia Do not use within 24 hours of chemotherapy DDAVP, TXA, and clotting factors or other myelosuppressants Hemophilia Do not administer during an active infection Vitamin K and Protamine Sulfate Blood and Blood product Transfusions Why? Who? What? Where? When? How? Watch out! Oncology Oncology Benign versus Malignant cells Prevention Diagnosis Management Emergencies