Nursing Bullets: Medical-Surgical Notes PDF

@RNursingNotes NURSING BULLETS MEDICAL SURGICAL  MEDICAL SURGICAL In a patient with hypokalemia (serum potassium level below 3.5 mEq/L), presenting signs and symptoms include muscle weakness and cardiac arrhythmias. During cardiac arrest, if an I.V. route is unavaila...

@RNursingNotes NURSING BULLETS MEDICAL SURGICAL  MEDICAL SURGICAL In a patient with hypokalemia (serum potassium level below 3.5 mEq/L), presenting signs and symptoms include muscle weakness and cardiac arrhythmias. During cardiac arrest, if an I.V. route is unavailable, epinephrine can be administered endotracheally. Pernicious anemia results from the failure to absorb vitamin B12 in the GI tract and causes primarily GI and neurologic signs and symptoms. A patient who has a pressure ulcer should consume a high-protein, high-calorie diet, unless contraindicated. The CK-MB isoenzyme level is used to assess tissue damage in myocardial infarction. After a 12-hour fast, the normal fasting blood glucose level is 80 to 120 mg/dl. A patient who is experiencing digoxin toxicity may report nausea, vomiting, diplopia, blurred vision, light flashes, and yellow-green halos around images. Anuria is daily urine output of less than 100 ml. In remittent fever, the body temperature varies over a 24-hour period, but remains elevated. Risk of a fat embolism is greatest in the first 48 hours after the fracture of a long bone. It’s manifested by respiratory distress. To help venous blood return in a patient who is in shock, the nurse should elevate the patient’s legs no more than 45 degrees. This procedure is contraindicated in a patient with a head injury. The pulse deficit is the difference between the apical and radial pulse rates, when taken simultaneously by two nurses. To reduce the patient’s risk of vomiting and aspiration, the nurse should schedule postural drainage before meals or 2 to 4 hours after meals. Blood pressure can be measured directly by intra-arterial insertion of a catheter connected to a pressure-monitoring device. A positive Kernig’s sign, seen in meningitis, occurs when an attempt to flex the hip of a recumbent patient causes painful spasms of the hamstring muscle and resistance to further extension of the leg at the knee. In a patient with a fractured, dislocated femur, treatment begins with reduction and immobilization of the affected leg. Herniated nucleus pulposus (intervertebral disk) most commonly occurs in the lumbar and lumbosacral regions. Laminectomy is surgical removal of the herniated portion of an intervertebral disk. 1  MEDICAL SURGICAL Surgical treatment of a gastric ulcer includes severing the vagus nerve (vagotomy) to reduce the amount of gastric acid secreted by the gastric cells. Valsalva’s maneuver is forced exhalation against a closed glottis, as when taking a deep breath, blowing air out, or bearing down. When mean arterial pressure falls below 60 mm Hg and systolic blood pressure falls below 80 mm Hg, vital organ perfusion is seriously compromised. Lidocaine (Xylocaine) is the drug of choice for reducing premature ventricular contractions. A patient is at greatest risk of dying during the first 24 to 48 hours after a myocardial infarction. During a myocardial infarction, the left ventricle usually sustains the greatest damage. The pain of a myocardial infarction results from myocardial ischemia caused by anoxia. For a patient in cardiac arrest, the first priority is to establish an airway. The universal sign for choking is clutching the hand to the throat. For a patient who has heart failure or cardiogenic pulmonary edema, nursing interventions focus on decreasing venous return to the heart and increasing left ventricular output. These interventions include placing the patient in high Fowler’s position and administering oxygen, diuretics, and positive inotropic drugs as prescribed. A positive tuberculin skin test is an induration of 10 mm or greater at the injection site. The signs and symptoms of histoplasmosis, a chronic systemic fungal infection, resemble those of tuberculosis. In burn victims, the leading cause of death is respiratory compromise. The second leading cause is infection. The exocrine function of the pancreas is the secretion of enzymes used to digest carbohydrates, fats, and proteins. A patient who has hepatitis A (infectious hepatitis) should consume a diet that’s moderately high in fat and high in carbohydrate and protein, and should eat the largest meal in the morning. Esophageal balloon tamponade shouldn’t be inflated greater than 20 mm Hg. Overproduction of prolactin by the pituitary gland can cause galactorrhea (excessive or abnormal lactation) and amenorrhea (absence of menstruation). Intermittent claudication (pain during ambulation or other movement that’s relieved with rest) is a classic symptom of arterial insufficiency in the leg. In bladder carcinoma, the most common finding is gross, painless hematuria. 2  MEDICAL SURGICAL Parenteral administration of heparin sodium is contraindicated in patients with renal or liver disease, GI bleeding, or recent surgery or trauma; in pregnant patients; and in women older than age 60. Drugs that potentiate the effects of anticoagulants include aspirin, chloral hydrate, glucagon, anabolic steroids, and chloramphenicol. For a burn patient, care priorities include maintaining a patent airway, preventing or correcting fluid and electrolyte imbalances, controlling pain, and preventing infection. Elastic stockings should be worn on both legs. Active immunization is the formation of antibodies within the body in response to vaccination or exposure to disease. Passive immunization is administration of antibodies that were preformed outside the body. A patient who is receiving digoxin (Lanoxin) shouldn’t receive a calcium preparation because of the increased risk of digoxin toxicity. Concomitant use may affect cardiac contractility and lead to arrhythmias. Intermittent positive-pressure breathing is inflation of the lung during inspiration with compressed air or oxygen. The goal of this inflation is to keep the lung open. Wristdrop is caused by paralysis of the extensor muscles in the forearm and hand. Footdrop results from excessive plantar flexion and is usually a complication of prolonged bed rest. A patient who has gonorrhea may be treated with penicillin and probenecid (Benemid). Probenecid delays the excretion of penicillin and keeps this antibiotic in the body longer. In patients who have glucose-6-phosphate dehydrogenase (G6PD) deficiency, the red blood cells can’t metabolize adequate amounts of glucose, and hemolysis occurs. On-call medication is medication that should be ready for immediate administration when the call to administer it’s received. If gagging, nausea, or vomiting occurs when an airway is removed, the nurse should place the patient in a lateral position with the upper arm supported on a pillow. When a postoperative patient arrives in the recovery room, the nurse should position the patient on his side or with his head turned to the side and the chin extended. In the immediate postoperative period, the nurse should report a respiratory rate greater than 30, temperature greater than 100° F (37.8° C) or below 97° F (36.1° C), or a significant drop in blood pressure or rise in pulse rate from the baseline. Irreversible brain damage may occur if the central nervous system is deprived of oxygen for more than 4 minutes. 3  MEDICAL SURGICAL Treatment for polycythemia vera includes administering oxygen, radioisotope therapy, or chemotherapy agents, such as chlorambucil and nitrogen mustard, to suppress bone marrow growth. A patient with acute renal failure should receive a high-calorie diet that’s low in protein as well as potassium and sodium. Addison’s disease is caused by hypofunction of the adrenal gland and is characterized by fatigue, anemia, weight loss, and bronze skin pigmentation. Without cortisol replacement therapy, it’s usually fatal. Glaucoma is managed conservatively with beta-adrenergic blockers such as timolol (Timoptic), which decrease sympathetic impulses to the eye, and with miotic eyedrops such as pilocarpine (Isopto Carpine), which constrict the pupils. Miotics effectively treat glaucoma by reducing intraocular pressure. They do this by constricting the pupil, contracting the ciliary muscles, opening the anterior chamber angle, and increasing the outflow of aqueous humor. While a patient is receiving heparin, the nurse should monitor the partial thromboplastin time. Urinary frequency, incontinence, or both can occur after catheter removal. Incontinence may be manifested as dribbling. When teaching a patient about colostomy care, the nurse should instruct the patient to hang the irrigation reservoir 18" to 22" (45 to 55 cm) above the stoma, insert the catheter 2" to 4" (5 to 10 cm) into the stoma, irrigate the stoma with 17 to 34 oz (503 to 1,005 ml) of water at a temperature of 105° to 110° F (40° to 43° C) once a day, clean the area around the stoma with soap and water before applying a new bag, and use a protective skin covering, such as a Stomahesive wafer, karaya paste, or karaya ring, around the stoma. The first sign of Hodgkin’s disease is painless, superficial lymphadenopathy, typically found under one arm or on one side of the neck in the cervical chain. To differentiate true cyanosis from deposition of certain pigments, the nurse should press the skin over the discolored area. Cyanotic skin blanches, but pigmented skin doesn’t. A patient who has a gastric ulcer is most likely to report pain during or shortly after eating. Widening pulse pressure is a sign of increasing intracranial pressure. For example, the blood pressure may rise from 120/80 to 160/60 mm Hg. In a burn victim, a primary goal of wound care is to prevent contamination by microorganisms. To prevent external rotation in a patient who has had hip nailing, the nurse places trochanter rolls from the knee to the ankle of the affected leg. 4  MEDICAL SURGICAL Severe hip pain after the insertion of a hip prosthesis indicates dislodgment. If this occurs, before calling the physician, the nurse should assess the patient for shortening of the leg, external rotation, and absence of reflexes. As much as 75% of renal function is lost before blood urea nitrogen and serum creatinine levels rise above normal. When compensatory efforts are present in acid-base balance, partial pressure of arterial carbon dioxide (PaCO2) and bicarbonate (HCO3–) always point in the same direction: pH PaCO2 HCO3– = respiratory acidosis compensated pH PaCO2 HCO3– = respiratory alkalosis compensated pH PaCO2 HCO3– = metabolic acidosis compensated pH PaCO2 HCO3– = metabolic alkalosis compensated. Polyuria is urine output of 2,500 ml or more within 24 hours. The presenting sign of pleuritis is chest pain that is usually unilateral and related to respiratory movement. If a patient has a gastric drainage tube in place, the nurse should expect the physician to order potassium chloride. An increased pulse rate is one of the first indications of respiratory difficulty. It occurs because the heart attempts to compensate for a decreased oxygen supply to the tissues by pumping more blood. In an adult, a hemoglobin level below 11 mg/dl suggests iron deficiency anemia and the need for further evaluation. The normal partial pressure of oxygen in arterial blood is 95 mm Hg (plus or minus 5 mm Hg). Vitamin C deficiency is characterized by brittle bones, pinpoint peripheral hemorrhages, and friable gums with loosened teeth. Clinical manifestations of pulmonary embolism are variable, but increased respiratory rate, tachycardia, and hemoptysis are common. Normally, intraocular pressure is 12 to 20 mm Hg. It can be measured with a Schiøtz tonometer. In early hemorrhagic shock, blood pressure may be normal, but respiratory and pulse rates are rapid. The patient may report thirst and may have clammy skin and piloerection (goose bumps). Cool, moist, pale skin, as occurs in shock, results from diversion of blood from the skin to the major organs. To assess capillary refill, the nurse applies pressure over the nail bed until blanching occurs, quickly releases the pressure, and notes the rate at which blanching fades. Capillary refill indicates perfusion, which decreases in shock, thereby lengthening refill time. Normal capillary refill is less than 3 seconds. Except for patients with renal failure, urine output of less than 30 ml/hour signifies dehydration and the potential for shock. 5  MEDICAL SURGICAL In elderly patients, the most common fracture is hip fracture. Osteoporosis weakens the bones, predisposing these patients to fracture, which usually results from a fall. Before angiography, the nurse should ask the patient whether he’s allergic to the dye, shellfish, or iodine and advise him to take nothing by mouth for 8 hours before the procedure. During myelography, approximately 10 to 15 ml of cerebrospinal fluid is removed for laboratory studies and an equal amount of contrast media is injected. After angiography, the puncture site is covered with a pressure dressing and the affected part is immobilized for 8 hours to decrease the risk of bleeding If a water-based medium was used during myelography, the patient remains on bed rest for 6 to 8 hours, with the head of the bed elevated 30 to 45 degrees. If an oil-based medium was used, the patient remains flat in bed for 6 to 24 hours. The level of amputation is determined by estimating the maximum viable tissue (tissue with adequate circulation) needed to develop a functional stump. Heparin sodium is included in the dialysate used for renal dialysis. Paroxysmal nocturnal dyspnea may indicate heart failure. A patient who takes a cardiac glycoside, such as digoxin, should consume a diet that includes high- potassium foods. The nurse should limit tracheobronchial suctioning to 10 to 15 seconds and should make only two passes. Before performing tracheobronchial suctioning, the nurse should ventilate and oxygenate the patient five to six times with a resuscitation bag and 100% oxygen. This procedure is called bagging. Signs and symptoms of pneumothorax include tachypnea, restlessness, hypotension, and tracheal deviation. The cardinal sign of toxic shock syndrome is rapid onset of a high fever. A key sign of peptic ulcer is hematemesis, which can be bright red or dark red, with the consistency of coffee grounds. Signs and symptoms of a perforated peptic ulcer include sudden, severe upper abdominal pain; vomiting; and an extremely tender, rigid (boardlike) abdomen. Constipation is a common adverse reaction to aluminum hydroxide. For the first 24 hours after a myocardial infarction, the patient should use a bedside commode and then progress to walking to the toilet, bathing, and taking short walks. After a myocardial infarction, the patient should avoid overexertion and add a new activity daily, as tolerated without dyspnea. 6  MEDICAL SURGICAL In a patient with a recent myocardial infarction, frothy, blood-tinged sputum suggests pulmonary edema. In a patient who has acquired immunodeficiency syndrome, the primary purpose of drugs is to prevent secondary infections. In a patient with acquired immunodeficiency syndrome, suppression of the immune system increases the risk of opportunistic infections, such as cytomegalovirus, Pneumocystis carinii pneumonia, and thrush. A patient with acquired immunodeficiency syndrome may have rapid weight loss, a sign of wasting syndrome. If the body doesn’t use glucose for energy, it metabolizes fat and produces ketones. Approximately 20% of patients with Guillain-Barré syndrome have residual deficits, such as mild motor weakness or diminished lower extremity reflexes. Hypertension and hypokalemia are the most significant clinical manifestations of primary hyperaldosteronism. After percutaneous aspiration of the bladder, the patient’s first void is usually pink; however, urine with frank blood should be reported to the physician. A urine culture that grows more than 100,000 colonies of bacteria per milliliter of urine indicates infection. A patient who is undergoing dialysis should take a vitamin supplement and eat foods that are high in calories, but low in protein, sodium, and potassium. In a patient who has chronic obstructive pulmonary disease, the most effective ways to reduce thick secretions are to increase fluid intake to 2,500 ml/day and encourage ambulation. The nurse should teach a patient with emphysema how to perform pursed-lip breathing because this slows expiration, prevents alveolar collapse, and helps to control the respiratory rate. Clubbing of the digits and a barrel chest may develop in a patient who has chronic obstructive pulmonary disease. A stroke (“brain attack”) disrupts the brain’s blood supply and may be caused by hypertension. In a patient who is undergoing dialysis, desired outcomes are normal weight, normal serum albumin level (3.5 to 5.5 g/dl), and adequate protein intake (1.2 to 1.5 g/kg of body weight daily). Intermittent peritoneal dialysis involves performing three to seven treatments that total 40 hours per week. In a patient with chronic obstructive pulmonary disease, the best way to administer oxygen is by nasal cannula. The normal flow rate is 2 to 3 L/ minute. 7  MEDICAL SURGICAL Isoetharine (Bronkosol) can be administered with a handheld nebulizer or by intermittent positive- pressure breathing. Brain death is irreversible cessation of brain function. Continuous ambulatory peritoneal dialysis requires four exchanges per day, 7 days per week, for a total of 168 hours per week. The classic adverse reactions to antihistamines are dry mouth, drowsiness, and blurred vision. Because of the risk of paralytic ileus, a patient who has received a general anesthetic can’t take anything by mouth until active bowel sounds are heard in all abdominal quadrants. The level of alpha-fetoprotein, a tumor marker, is elevated in patients who have testicular germ cell cancer. Clinical manifestations of orchitis caused by bacteria or mumps include high temperature, chills, and sudden pain in the involved testis. The level of prostate-specific antigen is elevated in patients with benign prostatic hyperplasia or prostate cancer. The level of prostatic acid phosphatase is elevated in patients with advanced stages of prostate cancer. Phenylephrine (Neo-Synephrine), a mydriatic, is instilled in a patient’s eye to dilate the eye. To promote fluid drainage and relieve edema in a patient with epididymitis, the nurse should elevate the scrotum on a scrotal bridge. Fluorescein staining is commonly used to assess corneal abrasions because it outlines superficial epithelial defects. Presbyopia is loss of near vision as a result of the loss of elasticity of the crystalline lens. Transient ischemic attacks are considered precursors to strokes. A sign of acute appendicitis, McBurney’s sign is tenderness at McBurney’s point (about 2" [5 cm] from the right anterior superior iliac spine on a line between the spine and the umbilicus). When caring for a patient with Guillain-Barré syndrome, the nurse should focus on respiratory interventions as the disease process advances. Signs and symptoms of colon cancer include rectal bleeding, change in bowel habits, intestinal obstruction, abdominal pain, weight loss, anorexia, nausea, and vomiting. 8  MEDICAL SURGICAL Symptoms of prostatitis include frequent urination and dysuria. A chancre is a painless, ulcerative lesion that develops during the primary stage of syphilis. During the tertiary stage of syphilis, spirochetes invade the internal organs and cause permanent damage. In total parenteral nutrition, weight gain is the most reliable indicator of a positive response to therapy. The nurse may administer an I.V. fat emulsion through a central or peripheral catheter, but shouldn’t use an in-line filter because the fat particles are too large to pass through the pores. If a patient who has a prostatectomy is using a Cunningham clamp, instruct him to wash and dry his penis before applying the clamp. He should apply the clamp horizontally and remove it at least every 4 hours to empty his bladder to prevent infection. If a woman has signs of urinary tract infection during menopause, she should be instructed to drink six to eight glasses of water per day, urinate before and after intercourse, and perform Kegel exercises. If a menopausal patient experiences a “hot flash,” she should be instructed to seek a cool, breezy location and sip a cool drink. Cheilosis causes fissures at the angles of the mouth and indicates a vitamin B2, riboflavin, or iron deficiency. Tetany may result from hypocalcemia caused by hypoparathyroidism. A patient who has cervical cancer may experience vaginal bleeding for 1 to 3 months after intracavitary radiation. Ascites is the accumulation of fluid, containing large amounts of protein and electrolytes, in the abdominal cavity. It’s commonly caused by cirrhosis. Normal pulmonary artery pressure is 10 to 25 mm Hg. Normal pulmonary artery wedge pressure is 5 to 12 mm Hg. After cardiac catheterization, the site is monitored for bleeding and hematoma formation, pulses distal to the site are palpated every 15 minutes for 1 hour, and the patient is maintained on bed rest with the extremity extended for 8 hours. Hemophilia is a bleeding disorder that’s transmitted genetically in a sex-linked (X chromosome) recessive pattern. Although girls and women may carry the defective gene, hemophilia usually occurs only in boys and men. Von Willebrand’s disease is an autosomal dominant bleeding disorder that’s caused by platelet dysfunction and factor VIII deficiency. 9  MEDICAL SURGICAL Sickle cell anemia is a congenital hemolytic anemia that’s caused by defective hemoglobin S molecules. It primarily affects blacks. Sickle cell anemia has a homozygous inheritance pattern. Sickle cell trait has a heterozygous inheritance pattern. Pel-Ebstein fever is a characteristic sign of Hodgkin’s disease. Fever recurs every few days or weeks and alternates with afebrile periods. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited metabolic disorder that’s characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Preferred sites for bone marrow aspiration are the posterior superior iliac crest, anterior iliac crest, and sternum. During bone marrow harvesting, the donor receives general anesthesia and 400 to 800 ml of marrow is aspirated. A butterfly rash across the bridge of the nose is a characteristic sign of systemic lupus erythematosus. Rheumatoid arthritis is a chronic, destructive collagen disease characterized by symmetric inflammation of the synovium that leads to joint swelling. Screening for human immunodeficiency virus antibodies begins with the enzyme-linked immunosorbent assay. Results are confirmed by the Western blot test. The CK-MB isoenzyme level increases 4 to 8 hours after a myocardial infarction, peaks at 12 to 24 hours, and returns to normal in 3 days. Excessive intake of vitamin K may significantly antagonize the anticoagulant effects of warfarin (Coumadin). The patient should be cautioned to avoid eating an excessive amount of leafy green vegetables A lymph node biopsy that shows Reed-Sternberg cells provides a definitive diagnosis of Hodgkin’s disease. Bell’s palsy is unilateral facial weakness or paralysis caused by a disturbance of the seventh cranial (facial) nerve. During an initial tuberculin skin test, lack of a wheal after injection of tuberculin purified protein derivative indicates that the test dose was injected too deeply. The nurse should inject another dose at least 2" (5 cm) from the initial site. A tuberculin skin test should be read 48 to 72 hours after administration. In reading a tuberculin skin test, erythema without induration is usually not significant. Death caused by botulism usually results from delayed diagnosis and respiratory complications. 10  MEDICAL SURGICAL In a patient who has rabies, saliva contains the virus and is a hazard for nurses who provide care. A febrile nonhemolytic reaction is the most common transfusion reaction. Hypokalemia (abnormally low concentration of potassium in the blood) may cause muscle weakness or paralysis, electrocardiographic abnormalities, and GI disturbances. Beriberi, a serious vitamin B1 (thiamine) deficiency, affects alcoholics who have poor dietary habits. It’s epidemic in Asian countries where people subsist on unenriched rice. It’s characterized by the phrase “I can’t,” indicating that the patient is too ill to do anything. Excessive sedation may cause respiratory depression. The primary postoperative concern is maintenance of a patent airway. If cyanosis occurs circumorally, sublingually, or in the nail bed, the oxygen saturation level (Sao 2) is less than 80%. A rapid pulse rate in a postoperative patient may indicate pain, bleeding, dehydration, or shock. Increased pulse rate and blood pressure may indicate that a patient is experiencing “silent pain” (pain that can’t be expressed verbally, such as when a patient is recovering from anesthesia). Lidocaine (Xylocaine) exerts antiarrhythmic action by suppressing automaticity in the Purkinje fibers and elevating the electrical stimulation threshold in the ventricles. Cullen’s sign (a bluish discoloration around the umbilicus) is seen in patients who have a perforated pancreas. During the postoperative period, the patient should cough and breathe deeply every 2 hours unless otherwise contraindicated (for example, after craniotomy, cataract surgery, or throat surgery). Before surgery, a patient’s respiratory volume may be measured by incentive spirometry. This measurement becomes the patient’s postoperative goal for respiratory volume. The postoperative patient should use incentive spirometry 10 to 12 times per hour and breathe deeply. Before ambulating, a postoperative patient should dangle his legs over the side of the bed and perform deep-breathing exercises. During the patient’s first postoperative ambulation, the nurse should monitor the patient closely and assist him as needed while he walks a few feet from the bed to a steady chair. Hypovolemia occurs when 15% to 25% of the body’s total blood volume is lost. Signs and symptoms of hypovolemia include rapid, weak pulse; low blood pressure; cool, clammy skin; shallow respirations; oliguria or anuria; and lethargy. 11  MEDICAL SURGICAL Acute pericarditis causes sudden severe, constant pain over the anterior chest. The pain is aggravated by inspiration. Signs and symptoms of septicemia include fever, chills, rash, abdominal distention, prostration, pain, headache, nausea, and diarrhea. Rocky Mountain spotted fever causes a persistent high fever, nonpitting edema, and rash. Patients who have undergone coronary artery bypass graft should sleep 6 to 10 hours per day, take their temperature twice daily, and avoid lifting more than 10 lb (4.5 kg) for at least 6 weeks. Claudication pain (pain on ambulation) is caused by arterial insufficiency as a result of atheromatous plaque that obstructs arterial blood flow to the extremities. Pacemakers can be powered by lithium batteries for up to 10 years. The patient shouldn’t void for 1 hour before percutaneous suprapubic bladder aspiration to ensure that sufficient urine remains in the bladder to make the procedure successful. Left-sided heart failure causes pulmonary congestion, pink-tinged sputum, and dyspnea. (Remember L for left and lung.) The current recommended blood cholesterol level is less than 200 mg/dl. When caring for a patient who is having a seizure, the nurse should follow these guidelines: (1) Avoid restraining the patient, but help a standing patient to a lying position. (2) Loosen restrictive clothing. (3) Place a pillow or another soft object under the patient’s head. (4) Clear the area of hard objects. (5) Don’t force anything into the patient’s mouth, but maintain a patent airway. (6) Reassure and reorient the patient after the seizure subsides. Gingival hyperplasia, or overgrowth of gum tissue, is an adverse reaction to phenytoin (Dilantin). With aging, most marrow in long bones becomes yellow, but it retains the capacity to convert back to red. Clinical manifestations of lymphedema include accumulation of fluid in the legs. Afterload is ventricular wall tension during systolic ejection. It’s increased in patients who have septal hypertrophy, increased blood viscosity, and conditions that cause blockage of aortic or pulmonary outflow. Red blood cells can be stored frozen for up to 2 years; however, they must be used within 24 hours of thawing. For the first 24 hours after amputation, the nurse should elevate the stump to prevent edema. After hysterectomy, a woman should avoid sexual intercourse for 3 weeks if a vaginal approach was used and 6 weeks if the abdominal approach was used. 12  MEDICAL SURGICAL Parkinson’s disease characteristically causes progressive muscle rigidity, akinesia, and involuntary tremor. Tonic-clonic seizures are characterized by a loss of consciousness and alternating periods of muscle contraction and relaxation. Status epilepticus, a life-threatening emergency, is a series of rapidly repeating seizures that occur without intervening periods of consciousness. The ideal donor for kidney transplantation is an identical twin. If an identical twin isn’t available, a biological sibling is the next best choice. Breast cancer is the leading cancer among women; however, lung cancer accounts for more deaths. The stages of cervical cancer are as follows: stage 0, carcinoma in situ; stage I, cancer confined to the cervix; stage II, cancer extending beyond the cervix, but not to the pelvic wall; stage III, cancer extending to the pelvic wall; and stage IV, cancer extending beyond the pelvis or within the bladder or rectum. One method used to estimate blood loss after a hysterectomy is counting perineal pads. Saturating more than one pad in 1 hour or eight pads in 24 hours is considered hemorrhaging. Transurethral resection of the prostate is the most common procedure for treating benign prostatic hyperplasia. In a chest drainage system, the water in the water-seal chamber normally rises when a patient breathes in and falls when he breathes out. Spinal fusion provides spinal stability through a bone graft, usually from the iliac crest, that fuses two or more vertebrae. A patient who receives any type of transplant must take an immunosuppressant drug for the rest of his life. Incentive spirometry should be used 5 to 10 times an hour while the patient is awake. In women, pelvic inflammatory disease is a common complication of gonorrhea. Scoliosis is lateral S-shaped curvature of the spine. Signs and symptoms of the secondary stage of syphilis include a rash on the palms and soles, erosion of the oral mucosa, alopecia, and enlarged lymph nodes. In a patient who is receiving total parenteral nutrition, the nurse should monitor glucose and electrolyte levels. Unless contraindicated, on admission to the postanesthesia care unit, a patient should be turned on his side and his vital signs should be taken. Edema is treated by limiting fluid intake and eliminating excess fluid. 13  MEDICAL SURGICAL A patient who has had spinal anesthesia should remain flat for 12 to 24 hours. Vital signs and neuromuscular function should be monitored. A patient who has maple syrup urine disease should avoid food containing the amino acids leucine, isoleucine, and lysine. A severe complication of a femur fracture is excessive blood loss that results in shock. To prepare a patient for peritoneal dialysis, the nurse should ask the patient to void, measure his vital signs, place him in a supine position, and using aseptic technique, insert a catheter through the abdominal wall and into the peritoneal space. If more than 3 L of dialysate solution return during peritoneal dialysis, the nurse should notify the physician. Hemodialysis is the removal of certain elements from the blood by passing heparinized blood through a semipermeable membrane to the dialysate bath, which contains all of the important electrolytes in their ideal concentrations. Gangrene usually affects the digits first, and begins with skin color changes that progress from gray- blue to dark brown or black. Kidney function is assessed by evaluating blood urea nitrogen (normal range is 8 to 20 mg/dl) and serum creatinine (normal range is 0.6 to 1.3 mg/dl) levels. A weight-bearing transfer is appropriate only for a patient who has at least one leg that’s strong enough to bear weight, such as a patient with hemiplegia or a single-leg amputation. Overflow incontinence (voiding of 30 to 60 ml of urine every 15 to 30 minutes) is a sign of bladder distention. The first sign of a pressure ulcer is reddened skin that blanches when pressure is applied. Late signs and symptoms of sickle cell anemia include tachycardia, cardiomegaly, systolic and diastolic murmurs, chronic fatigue, hepatomegaly, and splenomegaly. A mechanical ventilator, which can maintain ventilation automatically for an extended period, is indicated when a patient can’t maintain a safe PaO2 or PaCO2 level. Two types of mechanical ventilators exist: negative-pressure ventilators, which apply negative pressure around the chest wall, and positive-pressure ventilators, which deliver air under pressure to the patient. Angina pectoris is characterized by substernal pain that lasts for 2 to 3 minutes. The pain, which is caused by myocardial ischemia, may radiate to the neck, shoulders, or jaw; is described as viselike, or constricting; and may be accompanied by severe apprehension or a feeling of impending doom. The diagnosis of an acute myocardial infarction is based on the patient’s signs and symptoms, electrocardiogram tracings, troponin level, and cardiac enzyme studies. 14  MEDICAL SURGICAL The goal of treatment for a patient with angina pectoris is to reduce the heart’s workload, thereby reducing the myocardial demand for oxygen and preventing myocardial infarction. Nitroglycerin decreases the amount of blood that returns to the heart by increasing the capacity of the venous bed. The patient should take no more than three nitroglycerin tablets in a 15-minute period. Hemodialysis is usually performed 24 hours before kidney transplantation. Signs and symptoms of acute kidney transplant rejection are progressive enlargement and tenderness at the transplant site, increased blood pressure, decreased urine output, elevated serum creatinine level, and fever. After a radical mastectomy, the patient’s arm should be elevated (with the hand above the elbow) on a pillow to enhance circulation and prevent edema Postoperative mastectomy care includes teaching the patient arm exercises to facilitate lymph drainage and prevent shortening of the muscle and contracture of the shoulder joint (frozen shoulder). After radical mastectomy, the patient should help prevent infection by making sure that no blood pressure readings, injections, or venipunctures are performed on the affected arm. For a patient who has undergone mastectomy and is susceptible to lymphedema, a program of hand exercises can begin shortly after surgery, if prescribed. The program consists of opening and closing the hand tightly six to eight times per hour and performing such tasks as washing the face and combing the hair. Signs and symptoms of theophylline toxicity include vomiting, restlessness, and an apical pulse rate of more than 200 beats/minute. The nurse shouldn’t induce vomiting in a person who has ingested poison and is having seizures or is semiconscious or comatose. Central venous pressure (CVP), which is the pressure in the right atrium and the great veins of the thorax, is normally 2 to 8 mm Hg (or 5 to 12 cm H2O). CVP is used to assess right-sided cardiac function. CVP is monitored to assess the need for fluid replacement in seriously ill patients, to estimate blood volume deficits, and to evaluate circulatory pressure in the right atrium. To prevent deep vein thrombosis after surgery, the nurse should administer 5,000 units of heparin subcutaneously every 8 to 12 hours, as prescribed. Oral anticoagulants, such as warfarin (Coumadin) and dicumarol, disrupt natural blood clotting mechanisms, prevent thrombus formation, and limit the extension of a formed thrombus. Anticoagulants can’t dissolve a formed thrombus. 15  MEDICAL SURGICAL Anticoagulant therapy is contraindicated in a patient who has liver or kidney disease or GI ulcers or who isn’t likely to return for follow-up visits. The nurse can assess a patient for thrombophlebitis by measuring the affected and unaffected legs and comparing their sizes. The nurse should mark the measurement locations with a pen so that the legs can be measured at the same place each day. Drainage of more than 3,000 ml of fluid daily from a nasogastric tube may suggest intestinal obstruction. Yellow drainage that has a foul odor may indicate small-bowel obstruction. Preparation for sigmoidoscopy includes administering an enema 1 hour before the examination, warming the scope in warm water or a sterilizer (if using a metal sigmoidoscope), and draping the patient to expose the perineum. Treatment for a patient with bleeding esophageal varices includes administering vasopressin (Pitressin), giving an ice water lavage, aspirating blood from the stomach, using esophageal balloon tamponade, providing parenteral nutrition, and administering blood transfusions, as needed. A trauma victim shouldn’t be moved until a patent airway is established and the cervical spine is immobilized. After a mastectomy, lymphedema may cause a feeling of heaviness in the affected arm. A dying patient shouldn’t be told exactly how long he’s expected to live, but should be told something more general such “Some people live 3 to 6 months, but others live longer.” After eye surgery, a patient should avoid using makeup until otherwise instructed. After a corneal transplant, the patient should wear an eye shield when engaging in activities such as playing with children or pets. After a corneal transplant, the patient shouldn’t lie on the affected site, bend at the waist, or have sexual intercourse for 1 week. The patient must avoid getting soapsuds in the eye. A Milwaukee brace is used for patients who have structural scoliosis. The brace helps to halt the progression of spinal curvature by providing longitudinal traction and lateral pressure. It should be worn 23 hours a day. Short-term measures used to treat stomal retraction include stool softeners, irrigation, and stomal dilatation. A patient who has a colostomy should be advised to eat a low-residue diet for 4 to 6 weeks and then to add one food at a time to evaluate its effect. To relieve postoperative hiccups, the patient should breathe into a paper bag. 16  MEDICAL SURGICAL If a patient with an ileostomy has a blocked lumen as a result of undigested high-fiber food, the patient should be placed in the knee-chest position and the area below the stoma should be massaged. During the initial interview and treatment of a patient with syphilis, the patient’s sexual contacts should be identified. The nurse shouldn’t administer morphine to a patient whose respiratory rate is less than 12 breaths/minute. To prevent drying of the mucous membranes, oxygen should be administered with hydration. Flavoxate (Urispas) is classified as a urinary tract spasmolytic. Hypotension is a sign of cardiogenic shock in a patient with a myocardial infarction. The predominant signs of mechanical ileus are cramping pain, vomiting, distention, and inability to pass feces or flatus. For a patient with a myocardial infarction, the nurse should monitor fluid intake and output meticulously. Too little intake causes dehydration, and too much may cause pulmonary edema. Nitroglycerin relaxes smooth muscle, causing vasodilation and relieving the chest pain associated with myocardial infarction and angina. The diagnosis of an acute myocardial infarction is based on the patient’s signs and symptoms, electrocardiogram tracings, and serum enzyme studies. Arrhythmias are the predominant problem during the first 48 hours after a myocardial infarction. Clinical manifestations of malabsorption include weight loss, muscle wasting, bloating, and steatorrhea. Asparaginase, an enzyme that inhibits the synthesis of deoxyribonucleic acid and protein, is used to treat acute lymphocytic leukemia. To relieve a patient’s sore throat that’s caused by nasogastric tube irritation, the nurse should provide anesthetic lozenges, as prescribed. For the first 12 to 24 hours after gastric surgery, the stomach contents (obtained by suctioning) are brown. After gastric suctioning is discontinued, a patient who is recovering from a subtotal gastrectomy should receive a clear liquid diet. The descending colon is the preferred site for a permanent colostomy. Valvular insufficiency in the veins commonly causes varicosity. A patient with a colostomy should restrict fat and fibrous foods and should avoid foods that can obstruct the stoma, such as corn, nuts, and cabbage. 17  MEDICAL SURGICAL A patient who is receiving chemotherapy is placed in reverse isolation because the white blood cell count may be depressed. Symptoms of mitral valve stenosis are caused by improper emptying of the left atrium. Persistent bleeding after open heart surgery may require the administration of protamine sulfate to reverse the effects of heparin sodium used during surgery. The nurse should teach a patient with heart failure to take digoxin and other drugs as prescribed, to restrict sodium intake, to restrict fluids as prescribed, to get adequate rest, to increase walking and other activities gradually, to avoid extremes of temperature, to report signs of The nurse should check and maintain the patency of all connections for a chest tube. If an air leak is detected, the nurse should place one Kelly clamp near the insertion site. If the bubbling stops, the leak is in the thoracic cavity and the physician should be notified immediately. If the leak continues, the nurse should take a second clamp, work down the tube until the leak is located, and stop the leak. In two-person cardiopulmonary resuscitation, the rescuers administer 60 chest compressions per minute and 1 breath for every 5 compressions. Mitral valve stenosis can result from rheumatic fever. Atelectasis is incomplete expansion of lung segments or lobules (clusters of alveoli). It may cause the lung or lobe to collapse. The nurse should instruct a patient who has an ileal conduit to empty the collection device frequently because the weight of the urine may cause the device to slip from the skin. A patient who is receiving cardiopulmonary resuscitation should be placed on a solid, flat surface. Brain damage occurs 4 to 6 minutes after cardiopulmonary function ceases. Climacteric is the transition period during which a woman’s reproductive function diminishes and gradually disappears. After infratentorial surgery, the patient should remain on his side, flat in bed. In a patient who has an ulcer, milk is contraindicated because its high calcium content stimulates secretion of gastric acid. A patient who has a positive test result for human immunodeficiency virus has been exposed to the virus associated with acquired immunodeficiency syndrome (AIDS), but doesn’t necessarily have AIDS. A common complication after prostatectomy is circulatory failure caused by bleeding. In right-sided heart failure, a major focus of nursing care is decreasing the workload of the heart. 18  MEDICAL SURGICAL Signs and symptoms of digoxin toxicity include nausea, vomiting, confusion, and arrhythmias. An asthma attack typically begins with wheezing, coughing, and increasing respiratory distress. In a patient who is recovering from a tonsillectomy, frequent swallowing suggests hemorrhage. Ileostomies and Hartmann’s colostomies are permanent stomas. Loop colostomies and double- barrel colostomies are temporary ones. A patient who has an ileostomy should eat foods, such as spinach and parsley, because they act as intestinal tract deodorizers. An adrenalectomy can decrease steroid production, which can cause extensive loss of sodium and water. Before administering morphine (Duramorph) to a patient who is suspected of having a myocardial infarction, the nurse should check the patient’s respiratory rate. If it’s less than 12 breaths/minute, emergency equipment should be readily available for intubation if respiratory depression occurs. A patient who is recovering from supratentorial surgery is normally allowed out of bed 14 to 48 hours after surgery. A patient who is recovering from infratentorial surgery normally remains on bed rest for 3 to 5 days. After a patient undergoes a femoral-popliteal bypass graft, the nurse must closely monitor the peripheral pulses distal to the operative site and circulation. After a femoral-popliteal bypass graft, the patient should initially be maintained in a semi-Fowler position to avoid flexion of the graft site. Before discharge, the nurse should instruct the patient to avoid positions that put pressure on the graft site until the next follow-up visit. Of the five senses, hearing is the last to be lost in a patient who is entering a coma. Cholelithiasis causes an enlarged, edematous gallbladder with multiple stones and an elevated bilirubin level. The antiviral agent zidovudine (Retrovir) successfully slows replication of the human immunodeficiency virus, thereby slowing the development of acquired immunodeficiency syndrome. Severe rheumatoid arthritis causes marked edema and congestion, spindle-shaped joints, and severe flexion deformities. A patient with acquired immunodeficiency syndrome should advise his sexual partners of his human immunodeficiency virus status and observe sexual precautions, such as abstinence or condom use. If a radioactive implant becomes dislodged, the nurse should retrieve it with tongs, place it in a lead- shielded container, and notify the radiology department. A patient who is undergoing radiation therapy should pat his skin dry to avoid abrasions that could easily become infected. 19  MEDICAL SURGICAL During radiation therapy, a patient should have frequent blood tests, especially white blood cell and platelet counts. The nurse should administer an aluminum hydroxide antacid at least 1 hour after an enteric-coated drug because it can cause premature release of the enteric-coated drug in the stomach. Acid-base balance is the body’s hydrogen ion concentration, a measure of the ratio of carbonic acid to bicarbonate ions (1 part carbonic acid to 20 parts bicarbonate is normal). Amyotrophic lateral sclerosis causes progressive atrophy and wasting of muscle groups that eventually affects the respiratory muscles. Metabolic acidosis is caused by abnormal loss of bicarbonate ions or excessive production or retention of acid ions. Hemianopsia is defective vision or blindness in one-half of the visual field of one or both eyes. Systemic lupus erythematosus causes early-morning joint stiffness and facial erythema in a butterfly pattern. After total knee replacement, the patient should remain in the semi-Fowler position, with the affected leg elevated. In a patient who is receiving transpyloric feedings, the nurse should watch for dumping syndrome and hypovolemic shock because the stomach is being bypassed. If a total parenteral nutrition infusion must be interrupted, the nurse should administer dextrose 5% in water at a similar rate. Abrupt cessation can cause hypoglycemia. Status epilepticus is treated with I.V. diazepam (Valium) and phenytoin (Dilantin). Disequilibrium syndrome causes nausea, vomiting, restlessness, and twitching in patients who are undergoing dialysis. It’s caused by a rapid fluid shift. An indication that spinal shock is resolving is the return of reflex activity in the arms and legs below the level of injury. Hypovolemia is the most common and fatal complication of severe acute pancreatitis. In a patient with stomatitis, oral care includes rinsing the mouth with a mixture of equal parts of hydrogen peroxide and water three times daily. In otitis media, the tympanic membrane is bright red and lacks its characteristic light reflex (cone of light). In patients who have pericardiocentesis, fluid is aspirated from the pericardial sac for analysis or to relieve cardiac tamponade. Urticaria is an early sign of hemolytic transfusion reaction. 20  MEDICAL SURGICAL During peritoneal dialysis, a return of brown dialysate suggests bowel perforation. The physician should be notified immediately. An early sign of ketoacidosis is polyuria, which is caused by osmotic diuresis. Patients who have multiple sclerosis should visually inspect their extremities to ensure proper alignment and freedom from injury. Aspirated red bone marrow usually appears rust-red, with visible fatty material and white bone fragments. The Dick test detects scarlet fever antigens and immunity or susceptibility to scarlet fever. A positive result indicates no immunity; a negative result indicates immunity. The Schick test detects diphtheria antigens and immunity or susceptibility to diphtheria. A positive result indicates no immunity; a negative result indicates immunity. The recommended adult dosage of sucralfate (Carafate) for duodenal ulcer is 1 g (1 tablet) four times daily 1 hour before meals and at bedtime. A patient with facial burns or smoke or heat inhalation should be admitted to the hospital for 24-hour observation for delayed tracheal edema. In addition to patient teaching, preparation for a colostomy includes withholding oral intake overnight, performing bowel preparation, and administering a cleansing enema. The physiologic changes caused by burn injuries can be divided into two stages: the hypovolemic stage, during which intravascular fluid shifts into the interstitial space, and the diuretic stage, during which capillary integrity and intravascular volume are restored, usually 48 to 72 hours after the injury. The nurse should change total parenteral nutrition tubing every 24 hours and the peripheral I.V. access site dressing every 72 hours. A patient whose carbon monoxide level is 20% to 30% should be treated with 100% humidified oxygen. When in the room of a patient who is in isolation for tuberculosis, staff and visitors should wear ultrafilter masks. When providing skin care immediately after pin insertion, the nurse’s primary concern is prevention of bone infection. After an amputation, moist skin may indicate venous stasis; dry skin may indicate arterial obstruction. In a patient who is receiving dialysis, an internal shunt is working if the nurse feels a thrill on palpation or hears a bruit on auscultation. In a patient with viral hepatitis, the parenchymal, or Kupffer’s, cells of the liver become severely inflamed, enlarged, and necrotic. 21  MEDICAL SURGICAL Early signs of acquired immunodeficiency syndrome include fatigue, night sweats, enlarged lymph nodes, anorexia, weight loss, pallor, and fever. When caring for a patient who has a radioactive implant, health care workers should stay as far away from the radiation source as possible. They should remember the axiom, “If you double the distance, you quarter the dose.” A patient who has Parkinson’s disease should be instructed to walk with a broad-based gait. The cardinal signs of Parkinson’s disease are muscle rigidity, a tremor that begins in the fingers, and akinesia. In a patient with Parkinson’s disease, levodopa (Dopar) is prescribed to compensate for the dopamine deficiency. A patient who has multiple sclerosis is at increased risk for pressure ulcers. Pill-rolling tremor is a classic sign of Parkinson’s disease. For a patient with Parkinson’s disease, nursing interventions are palliative. Fat embolism, a serious complication of a long-bone fracture, causes fever, tachycardia, tachypnea, and anxiety. Metrorrhagia (bleeding between menstrual periods) may be the first sign of cervical cancer. Mannitol is a hypertonic solution and an osmotic diuretic that’s used in the treatment of increased intracranial pressure. The classic sign of an absence seizure is a vacant facial expression. Migraine headaches cause persistent, severe pain that usually occurs in the temporal region. A patient who is in a bladder retraining program should be given an opportunity to void every 2 hours during the day and twice at night. In a patient with a head injury, a decrease in level of consciousness is a cardinal sign of increased intracranial pressure. Ergotamine (Ergomar) is most effective when taken during the prodromal phase of a migraine or vascular headache. Treatment of acute pancreatitis includes nasogastric suctioning to decompress the stomach and meperidine (Demerol) for pain. Symptoms of hiatal hernia include a feeling of fullness in the upper abdomen or chest, heartburn, and pain similar to that of angina pectoris. 21  MEDICAL SURGICAL The incidence of cholelithiasis is higher in women who have had children than in any other group. Acetaminophen (Tylenol) overdose can severely damage the liver. The prominent clinical signs of advanced cirrhosis are ascites and jaundice. The first symptom of pancreatitis is steady epigastric pain or left upper quadrant pain that radiates from the umbilical area or the back. Somnambulism is the medical term for sleepwalking. Epinephrine (Adrenalin) is a vasoconstrictor. An untreated liver laceration or rupture can progress rapidly to hypovolemic shock. Obstipation is extreme, intractable constipation caused by an intestinal obstruction. The definitive test for diagnosing cancer is biopsy with cytologic examination of the specimen. Arthrography requires injection of a contrast medium and can identify joint abnormalities. Brompton’s cocktail is prescribed to help relieve pain in patients who have terminal cancer. A sarcoma is a malignant tumor in connective tissue. Aluminum hydroxide (Amphojel) neutralizes gastric acid. Subluxation is partial dislocation or separation, with spontaneous reduction of a joint. Barbiturates can cause confusion and delirium in an elderly patient who has an organic brain disorder. In a patient with arthritis, physical therapy is indicated to promote optimal functioning. Some patients who have hepatitis A may be anicteric (without jaundice) and lack symptoms, but some have headaches, jaundice, anorexia, fatigue, fever, and respiratory tract infection. Hepatitis A is usually mild and won’t advance to a carrier state. In the preicteric phase of all forms of hepatitis, the patient is highly contagious. Enteric precautions are required for a patient who has hepatitis A. Cholecystography is ineffective in a patient who has jaundice as a result of gallbladder disease. The liver cells can’t transport the contrast medium to the biliary tract. In a patient who has diabetes insipidus, dehydration is a concern because diabetes causes polyuria. In a patient who has a reducible hernia, the protruding mass spontaneously retracts into the abdomen. 22  MEDICAL SURGICAL To prevent purple glove syndrome, a nurse shouldn’t administer I.V. phenytoin (Dilantin) through a vein in the back of thehand, but should use a larger vessel. During stage III of surgical anesthesia, unconsciousness occurs and surgery is permitted. Types of regional anesthesia include spinal, caudal, intercostal, epidural, and brachial plexus. The first step in managing drug overdose or drug toxicity is to establish and maintain an airway. Respiratory paralysis occurs in stage IV of anesthesia (toxic stage). In stage I of anesthesia, the patient is conscious and tranquil. Dyspnea and sharp, stabbing pain that increases with respiration are symptoms of pleurisy, which can be a complication of pneumonia or tuberculosis. Vertigo is the major symptom of inner ear infection or disease. Loud talking is a sign of hearing impairment. A patient who has an upper respiratory tract infection should blow his nose with both nostrils open. A patient who has had a cataract removed can begin most normal activities in 3 or 4 days; however, the patient shouldn’t bend and lift until a physician approves these activities. Symptoms of corneal transplant rejection include eye irritation and decreasing visual field. Graves’ disease (hyperthyroidism) is manifested by weight loss, nervousness, dyspnea, palpitations, heat intolerance, increased thirst, exophthalmos (bulging eyes), and goiter. The four types of lipoprotein are chylomicrons (the lowest-density lipoproteins), very-low-density lipoproteins, low-density lipoproteins, and high-density lipoproteins. Health care professionals use cholesterol level fractionation to assess a patient’s risk of coronary artery disease. If a patient who is taking amphotericin B (Fungizone) bladder irrigations for a fungal infection has systemic candidiasis and must receive I.V. fluconazole (Diflucan), the irrigations can be discontinued because fluconazole treats the bladder infection as well. Patients with adult respiratory distress syndrome can have high peak inspiratory pressures. Therefore, the nurse should monitor these patients closely for signs of spontaneous pneumothorax, such as acute deterioration in oxygenation, absence of breath sounds on the affected side, and crepitus beginning on the affected side. Adverse reactions to cyclosporine (Sandimmune) include renal and hepatic toxicity, central nervous system changes (confusion and delirium), GI bleeding, and hypertension. Osteoporosis is a metabolic bone disorder in which the rate of bone resorption exceeds the rate of bone formation. 23  MEDICAL SURGICAL The hallmark of ulcerative colitis is recurrent bloody diarrhea, which commonly contains pus and mucus and alternates with asymptomatic remissions. Safer sexual practices include massaging, hugging, body rubbing, friendly kissing (dry), masturbating, hand-to-genital touching, wearing a condom, and limiting the number of sexual partners. Immunosuppressed patients who contract cytomegalovirus (CMV) are at risk for CMV pneumonia and septicemia, which can be fatal. Urinary tract infections can cause urinary urgency and frequency, dysuria, abdominal cramps or bladder spasms, and urethral itching. Mammography is a radiographic technique that’s used to detect breast cysts or tumors, especially those that aren’t palpable on physical examination. To promote early detection of testicular cancer, the nurse should palpate the testes during routine physical examinations and encourage the patient to perform monthly self-examinations during a warm shower. Patients who have thalassemia minor require no treatment. Those with thalassemia major require frequent transfusions of red blood cells. A high level of hepatitis B serum marker that persists for 3 months or more after the onset of acute hepatitis B infection suggests chronic hepatitis or carrier status. Neurogenic bladder dysfunction is caused by disruption of nerve transmission to the bladder. It may be caused by certain spinal cord injuries, diabetes, or multiple sclerosis. Oxygen and carbon dioxide move between the lungs and the bloodstream by diffusion. To grade the severity of dyspnea, the following system is used: grade 1, shortness of breath on mild exertion, such as walking up steps; grade 2, shortness of breath when walking a short distance at a normal pace on level ground; grade 3, shortness of breath with mild daily activity, such as shaving; grade 4, shortness of breath when supine (orthopnea). A patient with Crohn’s disease should consume a diet low in residue, fiber, and fat, and high in calories, proteins, and carbohydrates. The patient also should take vitamin supplements, especially vitamin K. In the three-bottle urine collection method, the patient cleans the meatus and urinates 10 to 15 ml in the first bottle and 15 to 30 ml (midstream) in the second bottle. Then the physician performs prostatic massage, and the patient voids into the third bottle. Findings in the three-bottle urine collection method are interpreted as follows: pus in the urine (pyuria) in the first bottle indicates anterior urethritis; bacteria in the urine in the second bottle indicate bladder infection; bacteria in the third bottle indicate prostatitis. Signs and symptoms of aortic stenosis include a loud, rough systolic murmur over the aortic area; exertional dyspnea; fatigue; angina pectoris; arrhythmias; low blood pressure; and emboli. 24  MEDICAL SURGICAL Elective surgery is primarily a matter of choice. It isn’t essential to the patient’s survival, but it may improve the patient’s health, comfort, or self-esteem. Required surgery is recommended by the physician. It may be delayed, but is inevitable. Urgent surgery must be performed within 24 to 48 hours. Emergency surgery must be performed immediately. About 85% of arterial emboli originate in the heart chambers. Pulmonary embolism usually results from thrombi dislodged from the leg veins. The conscious interpretation of pain occurs in the cerebral cortex. To avoid interfering with new cell growth, the dressing on a donor skin graft site shouldn’t be disturbed. A sequela is any abnormal condition that follows and is the result of a disease, a treatment, or an injury. During sickle cell crisis, patient care includes bed rest, oxygen therapy, analgesics as prescribed, I.V. fluid monitoring, and thorough documentation of fluid intake and output. A patient who has an ileal conduit should maintain a daily fluid intake of 2,000 ml. In a closed chest drainage system, continuous bubbling in the water seal chamber or bottle indicates a leak. Palpitation is a sensation of heart pounding or racing associated with normal emotional responses and certain heart disorders. Fat embolism is likely to occur within the first 24 hours after a long-bone fracture. Footdrop can occur in a patient with a pelvic fracture as a result of peroneal nerve compression against the head of the fibula. To promote venous return after an amputation, the nurse should wrap an elastic bandage around the distal end of the stump. Water that accumulates in the tubing of a ventilator should be removed. The most common route for the administration of epinephrine to a patient who is having a severe allergic reaction is the subcutaneous route. The nurse should use Fowler’s position for a patient who has abdominal pain caused by appendicitis. The nurse shouldn’t give analgesics to a patient who has abdominal pain caused by appendicitis because these drugs may mask the pain that accompanies a ruptured appendix. 25  MEDICAL SURGICAL The nurse shouldn’t give analgesics to a patient who has abdominal pain caused by appendicitis because these drugs may mask the pain that accompanies a ruptured appendix. As a last-ditch effort, a barbiturate coma may be induced to reverse unrelenting increased intracranial pressure (ICP), which is defined as acute ICP of greater than 40 mm Hg, persistent elevation of ICP above 20 mm Hg, or rapidly deteriorating neurologic status. The primary signs and symptoms of epiglottiditis are stridor and progressive difficulty in swallowing. Salivation is the first step in the digestion of starch. A patient who has a demand pacemaker should measure the pulse rate before rising in the morning, notify the physician if the pulse rate drops by 5 beats/minute, obtain a medical identification card and bracelet, and resume normal activities, including sexual activity. Transverse, or loop, colostomy is a temporary procedure that’s performed to divert the fecal stream in a patient who has acute intestinal obstruction. Normal values for erythrocyte sedimentation rate are 0 to 15 mm/hour for men younger than age 50 and 0 to 20 mm/hour for women younger than age 50. A CK-MB level that’s more than 5% of total CK or more than 10 U/L suggests a myocardial infarction. Propranolol (Inderal) blocks sympathetic nerve stimuli that increase cardiac work during exercise or stress, which reduces heart rate, blood pressure, and myocardial oxygen consumption. After a myocardial infarction, electrocardiogram changes (ST-segment elevation, T-wave inversion, and Q-wave enlargement) usually appear in the first 24 hours, but may not appear until the 5th or 6th day. Cardiogenic shock is manifested by systolic blood pressure of less than 80 mm Hg, gray skin, diaphoresis, cyanosis, weak pulse rate, tachycardia or bradycardia, and oliguria (less than 30 ml of urine per hour). A patient who is receiving a low-sodium diet shouldn’t eat cottage cheese, fish, canned beans, chuck steak, chocolate pudding, Italian salad dressing, dill pickles, and beef broth. High-potassium foods include dried prunes, watermelon (15.3 mEq/ portion), dried lima beans (14.5 mEq/portion), soybeans, bananas, and oranges. Kussmaul’s respirations are faster and deeper than normal respirations and occur without pauses, as in diabetic ketoacidosis. Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep, rapid breathing. They occur in patients with central nervous system disorders. Hyperventilation can result from an increased frequency of breathing, an increased tidal volume, or both. Apnea is the absence of spontaneous respirations. 26  MEDICAL SURGICAL Before a thyroidectomy, a patient may receive potassium iodide, antithyroid drugs, and propranolol (Inderal) to prevent thyroid storm during surgery. The normal life span of red blood cells (erythrocytes) is 110 to 120 days. Visual acuity of 20/100 means that the patient sees at 20' (6 m) what a person with normal vision sees at 100' (30 m). Urinary tract infections are more common in girls and women than in boys and men because the shorter urethra in the female urinary tract makes the bladder more accessible to bacteria, especially Escherichia coli. Penicillin is administered orally 1 to 2 hours before meals or 2 to 3 hours after meals because food may interfere with the drug’s absorption. Mild reactions to local anesthetics may include palpitations, tinnitus, vertigo, apprehension, confusion, and a metallic taste in the mouth. About 22% of cardiac output goes to the kidneys. To ensure accurate central venous pressure readings, the nurse should place the manometer or transducer level with the phlebostatic axis. A patient who has lost 2,000 to 2,500 ml of blood will have a pulse rate of 140 beats/minute (or higher), display a systolic blood pressure of 50 to 60 mm Hg, and appear confused and lethargic. Arterial blood is bright red, flows rapidly, and (because it’s pumped directly from the heart) spurts with each heartbeat. Venous blood is dark red and tends to ooze from a wound. Orthostatic blood pressure is taken with the patient in the supine, sitting, and standing positions, with 1 minute between each reading. A 10-mm Hg decrease in blood pressure or an increase in pulse rate of 10 beats/ minute suggests volume depletion. A pneumatic antishock garment should be used cautiously in pregnant women and patients with head injuries. After a patient’s circulating volume is restored, the nurse should remove the pneumatic antishock garment gradually, starting with the abdominal chamber and followed by each leg. The garment should be removed under a physician’s supervision. Most hemolytic transfusion reactions associated with mismatching of ABO blood types stem from identification number errors. Warming of blood to more than 107° F (41.7° C) can cause hemolysis. Cardiac output is the amount of blood ejected from the heart each minute. It’s expressed in liters per minute. 27  MEDICAL SURGICAL Stroke volume is the volume of blood ejected from the heart during systole. Total parenteral nutrition solution contains dextrose, amino acids, and additives, such as electrolytes, minerals, and vitamins. The most common type of neurogenic shock is spinal shock. It usually occurs 30 to 60 minutes after a spinal cord injury. After a spinal cord injury, peristalsis stops within 24 hours and usually returns within 3 to 4 days. Toxic shock syndrome is manifested by a temperature of at least 102° F (38.8° C), an erythematous rash, and systolic blood pressure of less than 90 mm Hg. From 1 to 2 weeks after the onset of these signs, desquamation (especially on the palms and soles) occurs. The signs and symptoms of anaphylaxis are commonly caused by histamine release. The most common cause of septic shock is gram-negative bacteria, such as Escherichia coli, Klebsiella, and Pseudomonas organisms. Bruits are vascular sounds that resemble heart murmurs and result from turbulent blood flow through a diseased or partially obstructed artery. Urine pH is normally 4.5 to 8.0. Urine pH of greater than 8.0 can result from a urinary tract infection, a high-alkali diet, or systemic alkalosis. Urine pH of less than 4.5 may be caused by a high-protein diet, fever, or metabolic acidosis. Before a percutaneous renal biopsy, the patient should be placed on a firm surface and positioned on the abdomen. A sandbag is placed under the abdomen to stabilize the kidneys. Nephrotic syndrome is characterized by marked proteinuria, hypoalbuminemia, mild to severe dependent edema, ascites, and weight gain. Underwater exercise is a form of therapy performed in a Hubbard tank. Most women with trichomoniasis have a malodorous, frothy, greenish gray vaginal discharge. Other women may have no signs or symptoms. Voiding cystourethrography may be performed to detect bladder and urethral abnormalities. Contrast medium is instilled by gentle syringe pressure through a urethral catheter, and overhead X- ray films are taken to visualize bladder filling and excretion. Cystourethrography may be performed to identify the cause of urinary tract infections, congenital anomalies, and incontinence. It also is used to assess for prostate lobe hypertrophy in men. Herpes simplex is characterized by recurrent episodes of blisters on the skin and mucous membranes. It has two variations. 28  MEDICAL SURGICAL In type 1, the blisters appear in the nasolabial region; in type 2, they appear on the genitals, anus, buttocks, and thighs. Most patients with Chlamydia trachomatis infection are asymptomatic, but some have an inflamed urethral meatus, dysuria, and urinary urgency and frequency. The hypothalamus regulates the autonomic nervous system and endocrine functions. A patient whose chest excursion is less than normal (3" to 6" [7.5 to 15 cm]) must use accessory muscles to breathe. Signs and symptoms of toxicity from thyroid replacement therapy include rapid pulse rate, diaphoresis, irritability, weight loss, dysuria, and sleep disturbance. The most common allergic reaction to penicillin is a rash. An early sign of aspirin toxicity is deep, rapid respirations. The most serious and irreversible consequence of lead poisoning is mental retardation, which results from neurologic damage. To assess dehydration in the adult, the nurse should check skin turgor on the sternum. For a patient with a peptic ulcer, the type of diet is less important than including foods in the diet that the patient can tolerate. A patient with a colostomy must establish an irrigation schedule so that regular emptying of the bowel occurs without stomal discharge between irrigations. When using rotating tourniquets, the nurse shouldn’t restrict the blood supply to an arm or leg for more than 45 minutes at a time. A patient with diabetes should eat high-fiber foods because they blunt the rise in glucose level that normally follows a meal. Jugular vein distention occurs in patients with heart failure because the left ventricle can’t empty the heart of blood as fast as blood enters from the right ventricle, resulting in congestion in the entire venous system. The leading causes of blindness in the United States are diabetes mellitus and glaucoma. After a thyroidectomy, the patient should remain in the semi-Fowler position, with his head neither hyperextended nor hyperflexed, to avoid pressure on the suture line. This position can be achieved with the use of a cervical pillow. Premenstrual syndrome may cause abdominal distention, engorged and painful breasts, backache, headache, nervousness, irritability, restlessness, and tremors. 29  MEDICAL SURGICAL Treatment of dehiscence (pathologic opening of a wound) consists of covering the wound with a moist sterile dressing andnotifying the physician. When a patient has a radical mastectomy, the ovaries also may be removed because they are a source of estrogen, which stimulates tumor growth. Atropine blocks the effects of acetylcholine, thereby obstructing its vagal effects on the sinoatrial node and increasing heart rate. Salicylates, particularly aspirin, are the treatment of choice in rheumatoid arthritis because they decrease inflammation and relieve joint pain. Deep, intense pain that usually worsens at night and is unrelated to movement suggests bone pain. Pain that follows prolonged or excessive exercise and subsides with rest suggests muscle pain. The major hemodynamic changes associated with cardiogenic shock are decreased left ventricular function and decreased cardiac output. Before thyroidectomy, the patient should be advised that he may experience hoarseness or loss of his voice for several days after surgery. Acceptable adverse effects of long-term steroid use include weight gain, acne, headaches, fatigue, and increased urine retention. Unacceptable adverse effects of long-term steroid use are dizziness on rising, nausea, vomiting, thirst, and pain. After a craniotomy, nursing care includes maintaining normal intracranial pressure, maintaining cerebral perfusion pressure,and preventing injury related to cerebral and cellular ischemia. Folic acid and vitamin B12 are essential for nucleoprotein synthesis and red blood cell maturation. Immediately after intracranial surgery, nursing care includes not giving the patient anything by mouth until the gag and cough reflexes return, monitoring vital signs and assessing the level of consciousness (LOC) for signs of increasing intracranial pressure, and administering analgesics that don’t mask the LOC. Chest physiotherapy includes postural drainage, chest percussion and vibration, and coughing and deep-breathing exercises. Cushing’s syndrome results from excessive levels of adrenocortical hormones and is manifested by fat pads on the face (moon face) and over the upper back (buffalo hump), acne, mood swings, hirsutism, amenorrhea, and decreased libido. To prevent an addisonian crisis when discontinuing long-term prednisone (Deltasone) therapy, the nurse should taper the dose slowly to allow for monitoring of disease flare-ups and for the return of hypothalamic-pituitary-adrenal function. Pulsus paradoxus is a pulse that becomes weak during inspiration and strong during expiration. It may be a sign of cardiac tamponade. 30  MEDICAL SURGICAL Substances that are expelled through portals of exit include saliva, mucus, feces, urine, vomitus, blood, and vaginal and penile discharges. A microorganism may be transmitted directly, by contact with an infected body or droplets, or indirectly, by contact with contaminated air, soil, water, or fluids. A postmenopausal woman who receives estrogen therapy is at an increased risk for gallbladder disease and breast cancer. The approximate oxygen concentrations delivered by a nasal cannula are as follows: 1 L = 24%, 2 L = 28%, 3 L = 32%, 4 L= 36%, and 5 L = 40%. Cardinal features of diabetes insipidus include polydipsia (excessive thirst) and polyuria (increased urination to 5 L/24 hours). A patient with low specific gravity (1.001 to 1.005) may have an increased desire for cold water. Diabetic coma can occur when the blood glucose level drops below 60 mg/dl. For a patient with heart failure, the nurse should elevate the head of the bed 8" to 12" (20 to 30 cm), provide a bedside commode, and administer cardiac glycosides and diuretics as prescribed. The primary reason to treat streptococcal sore throat with antibiotics is to protect the heart valves and prevent rheumatic fever. A patient with a nasal fracture may lose consciousness during reduction. Hoarseness and change in the voice are commonly the first signs of laryngeal cancer. The lungs, colon, and rectum are among the most common cancer sites. The most common preoperative problem in elderly patients is lower-than-normal total blood volume. Mannitol (Osmitrol), an osmotic diuretic, is administered to reduce intraocular or intracranial pressure. When a stroke is suspected, the nurse should place the patient on the affected side to promote lung expansion on the unaffected side. For a patient who has had chest surgery, the nurse should recommend sitting upright and performing coughing and deep- breathing exercises. These actions promote expansion of the lungs, removal of secretions, and optimal pulmonaryfunctioning. During every sleep cycle, the sleeper passes through four stages of nonrapid-eye-movement sleep and one stage of rapid-eye-movement sleep. A patient who is taking calcifediol (Calderol) should avoid concomitant use of preparations that contain vitamin D. 31  MEDICAL SURGICAL A patient should begin and end a 24-hour urine collection period with an empty bladder. For example, if the physician orders urine to be collected from 0800 Thursday to 0800 Friday, the urine voided at 0800 Thursday should be discarded and the urine voided at 0800 Friday should be retained. In a patient who is receiving digoxin (Lanoxin), a low potassium level increases the risk of digoxin toxicity. Blood urea nitrogen values normally range from 10 to 20 mg/dl. Flurazepam (Dalmane) toxicity is manifested by confusion, hallucinations, and ataxia. A silent myocardial infarction is one that has no symptoms. Adverse reactions to verapamil (Isoptin) include dizziness, headache, constipation, hypotension, and atrioventricular conduction disturbances. The drug also may increase the serum digoxin level. When a rectal tube is used to relieve flatulence or enhance peristalsis, it should be inserted for no longer than 20 minutes. Yellowish green discharge on a wound dressing indicates infection and should be cultured. Sickle cell crisis can cause severe abdominal, thoracic, muscular, and bone pain along with painful swelling of soft tissue in the hands and feet. Oral candidiasis (thrush) is characterized by cream-colored or bluish white patches on the oral mucous membrane. Treatment for a patient with cystic fibrosis may include drug therapy, exercises to improve breathing and posture, exercises to facilitate mobilization of pulmonary secretions, a high-salt diet, and pancreatic enzyme supplements with snacks and meals. Pancreatic cancer may cause weight loss, jaundice, and intermittent dull-to-severe epigastric pain. Metastasis is the spread of cancer from one organ or body part to another through the lymphatic system, circulation system, or cerebrospinal fluid. The management of pulmonary edema focuses on opening the airways, supporting ventilation and perfusion, improving cardiac functioning, reducing preload, and reducing patient anxiety. Factors that contribute to the death of patients with Alzheimer’s disease include infection, malnutrition, and dehydration. Hodgkin’s disease is characterized by painless, progressive enlargement of cervical lymph nodes and other lymphoid tissue as a result of proliferation of Reed-Sternberg cells, histiocytes, and eosinophils. Huntington’s disease (chorea) is a hereditary disease characterized by degeneration in the cerebral cortex and basal ganglia. A patient with Huntington’s disease may exhibit suicidal ideation. 32  MEDICAL SURGICAL At discharge, an amputee should be able to demonstrate proper stump care and perform stump- toughening exercises. Acute tubular necrosis is the most common cause of acute renal failure. Common complications of ice water lavage are vomiting and aspiration. Foods high in vitamin D include fortified milk, fish, liver, liver oil, herring, and egg yolk. For a pelvic examination, the patient should be in the lithotomy position, with the buttocks extending 21⁄2" (6.4 cm) past the end of the examination table. If a patient can’t assume the lithotomy position for a pelvic examination, she may lie on her left side. A male examiner should have a female assistant present during a vaginal examination for the patient’s emotional comfort and the examiner’s legal protection. Cervical secretions are clear and stretchy before ovulation and white and opaque after ovulation. They’re normally odorless and don’t irritate the mucosa. A patient with an ileostomy shouldn’t eat corn because it may obstruct the opening of the pouch. Liver dysfunction affects the metabolism of certain drugs. Edema that accompanies burns and malnutrition is caused by decreased osmotic pressure in the capillaries. Hyponatremia is most likely to occur as a complication of nasogastric suctioning. In a man who has complete spinal cord separation at S4, erection and ejaculation aren’t possible. The early signs of pulmonary edema (dyspnea on exertion and coughing) reflect interstitial fluid accumulation and decreased ventilation and alveolar perfusion. Methylprednisolone (Solu-Medrol) is a first-line drug used to control edema after spinal cord trauma. For the patient who is recovering from an intracranial bleed, the nurse should maintain a quiet, restful environment for the first few days. Neurosyphilis is associated with widespread damage to the central nervous system, including general paresis, personality changes, slapping gait, and blindness. A woman who has had a spinal cord injury can still become pregnant. In a patient who has had a stroke, the most serious complication is increasing intracranial pressure. A patient with an intracranial hemorrhage should undergo arteriography to identify the site of the bleeding. Factors that affect the action of drugs include absorption, distribution, metabolism, and excretion. 33  MEDICAL SURGICAL Before prescribing a drug for a woman of childbearing age, the prescriber should ask for the date of her last menstrual period and ask if she may be pregnant. Acidosis may cause insulin resistance. A patient with glucose-6-phosphate dehydrogenase deficiency may have acute hemolytic anemia when given a sulfonamide. The five basic activities of the digestive system are ingestion, movement of food, digestion, absorption, and defecation. Signs and symptoms of acute pancreatitis include epigastric pain, vomiting, bluish discoloration of the left flank (Grey Turner’s sign), bluish discoloration of the periumbilical area (Cullen’s sign), low- grade fever, tachycardia, and hypotension. A patient with a gastric ulcer may have gnawing or burning epigastric pain. To test the first cranial nerve (olfactory nerve), the nurse should ask the patient to close his eyes, occlude one nostril, and identify a nonirritating substance (such as peppermint or cinnamon) by smell. Then the nurse should repeat the test with the patient’s other nostril occluded Salk and Sabin introduced the oral polio vaccine. A patient with a disease of the cerebellum or posterior column has an ataxic gait that’s characterized by staggering and inability to remain steady when standing with the feet together. In trauma patients, improved outcome is directly related to early resuscitation, aggressive management of shock, and appropriate definitive care. To check for leakage of cerebrospinal fluid, the nurse should inspect the patient’s nose and ears. If the patient can sit up, the nurse should observe him for leakage as the patient leans forward. Locked-in syndrome is complete paralysis as a result of brain stem damage. Only the eyes can be moved voluntarily. Neck dissection, or surgical removal of the cervical lymph nodes, is performed to prevent the spread of malignant tumors of the head and neck. A patient with cholecystitis typically has right epigastric pain that may radiate to the right scapula or shoulder; nausea; and vomiting, especially after eating a heavy meal. Atropine is used preoperatively to reduce secretions. Serum calcium levels are normally 4.5 to 5.5 mEq/L. Suppressor T cells regulate overall immune response. Serum levels of aspartate aminotransferase and alanine aminotransferase show whether the liver is adequately detoxifying drugs. Serum sodium levels are normally 135 to 145 mEq/L. 34  MEDICAL SURGICAL Serum potassium levels are normally 3.5 to 5.0 mEq/L. A patient who is taking prednisone (Deltasone) should consume a salt-restricted diet that’s rich in potassium and protein. When performing continuous ambulatory peritoneal dialysis, the nurse must use sterile technique when handling the catheter, send a peritoneal fluid sample for culture and sensitivity testing every 24 hours, and report signs of infection and fluid imbalance. When working with patients who have acquired immunodeficiency syndrome, the nurse should wear goggles and a mask only if blood or another body fluid could splash onto the nurse’s face. Blood spills that are infected with human immunodeficiency virus should be cleaned up with a 1:10 solution of sodium hypochlorite 5.25% (household bleach). Raynaud’s phenomenon is intermittent ischemic attacks in the fingers or toes. It causes severe pallor and sometimes paresthesia and pain. Intussusception (prolapse of one bowel segment into the lumen of another) causes sudden epigastric pain, sausage-shaped abdominal swelling, passage of mucus and blood through the rectum, shock, and hypotension. Bence Jones protein occurs almost exclusively in the urine of patients who have multiple myeloma. Gaucher’s disease is an autosomal disorder that’s characterized by abnormal accumulation of glucocerebrosides (lipid substances that contain glucose) in monocytes and macrocytes. It has three forms: Type 1 is the adult form, type 2 is the infantile form, and type 3 is the juvenile form. A patient with colon obstruction may have lower abdominal pain, constipation, increasing distention, and vomiting. Colchicine (Colsalide) relieves inflammation and is used to treat gout. Some people have gout as a result of hyperuricemia because they can’t metabolize and excrete purines normally. A normal sperm count is 20 to 150 million/ml. A first-degree burn involves the stratum corneum layer of the epidermis and causes pain and redness. Sheehan’s syndrome is hypopituitarism caused by a pituitary infarct after postpartum shock and hemorrhage. When caring for a patient who has had an asthma attack, the nurse should place the patient in Fowler’s or semi-Fowler’s position. In elderly patients, the incidence of noncompliance with prescribed drug therapy is high. Many elderly patients have diminished visual acuity, hearing loss, or forgetfulness, or need to take multiple drugs. 35  MEDICAL SURGICAL Tuberculosis is a reportable communicable disease that’s caused by infection with Mycobacterium tuberculosis (an acid-fast bacillus). For right-sided cardiac catheterization, the physician passes a multilumen catheter through the superior or inferior vena cava. After a fracture, bone healing occurs in these stages: hematoma formation, cellular proliferation and callus formation, and ossification and remodeling. A patient who is scheduled for positron emission tomography should avoid alcohol, tobacco, and caffeine for 24 hours before the test. In a stroke, decreased oxygen destroys brain cells. A patient with glaucoma shouldn’t receive atropine sulfate because it increases intraocular pressure. The nurse should instruct a patient who is hyperventilating to breathe into a paper bag. During intermittent positive-pressure breathing, the patient should bite down on the mouthpiece, breathe normally, and let the machine do the work. After inspiration, the patient should hold his breath for 3 or 4 seconds and exhale completely through the mouthpiece. Flexion contractures of the hips may occur in a patient who sits in a wheelchair for a long time. Nystagmus is rapid horizontal or rotating eye movement. After myelography, the patient should remain recumbent for 24 hours. The treatment of sprains and strains consists of applying ice immediately and elevating the arm or leg above heart level. An anticholinesterase agent shouldn’t be prescribed for a patient who is taking morphine because it can potentiate the effect of morphine and cause respiratory depression. Myopia is nearsightedness. Hyperopia and presbyopia are two types of farsightedness. The most effective contraceptive method is one that the woman selects for herself and uses consistently. To perform Weber’s test for bone conduction, a vibrating tuning fork is placed on top of the patient’s head at midline. The patient should perceive the sound equally in both ears. In a patient who has conductive hearing loss, the sound is heard in (lateralizes to) the ear that has conductive loss. In the Rinne test, bone conduction is tested by placing a vibrating tuning fork on the mastoid process of the temporal bone and air conduction is tested by holding the vibrating tuning fork 1⁄2" (1.3 cm) from the external auditory meatus. These tests are alternated, at different frequencies, until the tuning fork is no longer heard at one position. After an amputation, the stump may shrink because of muscle atrophy and decreased subcutaneous fat. 36  MEDICAL SURGICAL A patient who has deep vein thrombosis is given heparin for 7 to 10 days, followed by 12 weeks of warfarin (Coumadin) therapy. After pneumonectomy, the patient should be positioned on the operative side or on his back, with his head slightly elevated. To reduce the possibility of formation of new emboli or expansion of existing emboli, a patient with deep vein thrombosis should receive heparin. Atherosclerosis is the most common cause of coronary artery disease. It usually involves the aorta and the femoral, coronary, and cerebral arteries. Pulmonary embolism is a potentially fatal complication of deep vein thrombosis. Chest pain is the most common symptom of pulmonary embolism. The nurse should inform a patient who is taking phenazopyridine (Pyridium) that this drug colors urine orange or red. Pneumothorax is a serious complication of central venous line placement; it’s caused by inadvertent lung puncture. Pneumocystis carinii pneumonia isn’t considered contagious because it only affects patients who have a suppressed immune system. To enhance drug absorption, the patient should take regular erythromycin tablets with a full glass of water 1 hour before or 2 hours after a meal or should take enteric-coated tablets with food. The patient should avoid taking either type of tablet with fruit juice. Trismus, a sign of tetanus (lockjaw), causes painful spasms of the masticatory muscles, difficulty opening the mouth, neck rigidity and stiffness, and dysphagia. The nurse should place the patient in an upright position for thoracentesis. If this isn’t possible, the nurse should position the patient on the unaffected side. If gravity flow is used, the nurse should hang a blood bag 3' (1 m) above the level of the planned venipuncture site. The nurse should place a patient who has a closed chest drainage system in the semi-Fowler position. If blood isn’t transfused within 30 minutes, the nurse should return it to the blood bank because the refrigeration facilities on a nursing unit are inadequate for storing blood products. Blood that’s discolored and contains gas bubbles is contaminated with bacteria and shouldn’t be transfused. Fifty percent of patients who receive contaminated blood die. For massive, rapid blood transfusions and for exchange transfusions in neonates, blood should be warmed to 98.7° F (37° C). 37  MEDICAL SURGICAL A chest tube permits air and fluid to drain from the pleural space. A handheld resuscitation bag is an inflatable device that can be attached to a face mask or an endotracheal or tracheostomy tube. It allows manual delivery of oxygen to the lungs of a patient who can’t breathe independently. Mechanical ventilation artificially controls or assists respiration. The nurse should encourage a patient who has a closed chest drainage system to cough frequently and breathe deeply to help drain the pleural space and expand the lungs. Tracheal suction removes secretions from the trachea and bronchi with a suction catheter. During colostomy irrigation, the irrigation bag should be hung 18" (45.7 cm) above the stoma. The water used for colostomy irrigation should be 100° to 105° F (37.8° to 40.6° C). An arterial embolism may cause pain, loss of sensory nerves, pallor, coolness, paralysis, pulselessness, or paresthesia in the affected arm or leg. Respiratory alkalosis results from conditions that cause hyperventilation and reduce the carbon dioxide level in the arterial blood. Mineral oil is contraindicated in a patient with appendicitis, acute surgical abdomen, fecal impaction, or intestinal obstruction. When using a Y-type administration set to transfuse packed red blood cells (RBCs), the nurse can add normal saline solution to the bag to dilute the RBCs and make them less viscous. Autotransfusion is collection, filtration, and reinfusion of the patient’s own blood. Prepared I.V. solutions fall into three general categories: isotonic, hypotonic, and hypertonic. Isotonic solutions have a solute concentration that’s similar to body fluids; adding them to plasma doesn’t change its osmolarity. Hypotonic solutions have a lower osmotic pressure than body fluids; adding them to plasma decreases its osmolarity. Hypertonic solutions have a higher osmotic pressure than body fluids; adding them to plasma increases its osmolarity. Stress incontinence is involuntary leakage of urine triggered by a sudden physical strain, such as a cough, sneeze, or quick movement. Decreased renal function makes an elderly patient more susceptible to the development of renal calculi. The nurse should consider using shorter needles to inject drugs in elderly patients because these patients experience subcutaneous tissue redistribution and loss in areas, such as the buttocks and deltoid muscles. Urge incontinence is the inability to suppress a sudden urge to urinate. Total incontinence is continuous, uncontrollable leakage of urine as a result of the bladder’s inability to retain urine. 38  MEDICAL SURGICAL Protein, vitamin, and mineral needs usually remain constant