EXAM 1 MED SURG STUDY GUIDE LATEST

EXAM 1 MED SURG STUDY GUIDE LATEST Unit 1 Specialty practice of medical-surgical nursing Promote, restore, or maintain optimal health for patients 18 years and older Nurses must have knowledge, skills, and attitudes to be Care coordinators Transition managers Caregivers Pt educators Leaders Advocates for the pt and family The joint commission: effective care coordination and transition management Understandable discharge instructions for the patient and family Explanation of self-care activities Ongoing or emergency care information List of community and outpatient resources and referrals Knowledge of the pts language, culture, and health literacy Medication reconciliation Safety The ability to keep the patient and staff free from harm and minimize errors in care Nursing safety priority boxes Critical rescue Action alert Drug alert The join commission: a culture of safety Blame-free approach Patients and families are safety partners w/hcp and organizations Serious events must be reported Teamwork and interprofessional collaboration Collaborate with interprofessional health care team Interprofessional education collaborative competencies Values/ethicsforinterprofessional practice Role-responsibilities Interprofessional communication Teams and teamwork Communication: SBAR Formal method of hand-off communication between two or more health care team members 4 steps s-situation (name, age, dx) b-background (history, home meds, allergies) A-assessment (ivs, v/s, labs) Recommendation/request (plan, pt updates) teamSTEPPS Delegation Process of transferring a selected nursing task or activity to a competent UAP (unlicensed assistive personnel) The nurse is always accountable for the task/activity delegated! Nugget** Make sure they understand, and it is within their scope of practice!! Be specific Prioritization and delegation Physiological, psychological, acute, chronic, unstable,stable, unpredictable, predictable Five rights of delegation Right task Right circumstances Right person Right communication Right supervision Supervision Guidance or direction, evaluation, and followup by the nurse to ensure a task/activity is performed appropriately Evidence-based practice (EBP) Integration of the best current evidence and practices to make decisions about patient care Ethics Considers patient preferences and values Considers one own clinical expertise for delivery of optimal health care Addressesissues and questions about morality Attributes Autonomy Beneficence Nonmaleficence Fidelity Veracity Social justice Common health problems of older adults Concepts The priority concepts are mobility nutrition and cognition Subgroups of late adulthood Young old- 65 to 74 years Middle old 75-84 years Old old – 85 to 99 years Elite old- 100 plus Common health issues and concerns Performance of adls Participation in social activities Losses Health promotion Special considerationsfor older adult clients Decrease tolerance to meds Decrease iv rate to avoid fluid overload Increase risk of: Respiratory depression Pneumonia Disorientation Skin breakdown Problems w/ Circulation Nutrition Constipation Fluid and electrolyte balance Increase balance and decrase falls Sudden increase in confusion Urine infection Hypoxia Electrolyte imbalance Clinical management Treat coexisting medical disorders Cardiac problems Pvd Neurological disorders Nugget** Copd Resp. issues Common health issues and concerns Impaired nutrition and hydration Impaired mobility strokes, risk falls Stress, loss, and coping Accidents Drug use and misuse Impaired cognition Substance use Elder neglect and abuse Nugget** Depression Health need: seeing MD as needed Impaired nutrition and hydration Increased need for calcium, vit a/c/d, fiber Diminished taste and smell, tooth loss, poor dentures can impact nutrition status Constipation concers Loneliness Skin breakdown Nutrition support Avoid friction,shearing Reposition and provide support surfaces Increase mobility and activity Clean skin, use moisture barriers Rehabilitation interprofessional team Nurses, nursing assistants Physicians and physician assistants Advanced practice nurses Physical therapists and assistants OT and assistants Speech-language pathologists and assistants Neuropsychologists Social workers Psychologists Spiritual care counselors Registered dietitians Pharmacists Cardiovascular and respiratory assessment Assess for decrease in cardiac output Chest pain Weakness and fatigue Plan care to maximize limited energy resources Frequent rest periods Major tasks in morning Determine level of activity that can be done without invoking symptoms Nugget** Fluid in lungs and DVTs SOB Crackles,rhonchi Improving physical mobility Safe patient handling practices Position changes(bed to chair, commode, or wheelchair) Provide assistance w/ transfers Gait training Use of assistive devices/ambulatory aids(canes and walkers) Implementing ROM routines/exercises Coordinate care w/PT and OT Assess pts mobility levels using standardized tool Nugget** look at chart 6-1 Canes and walkers** Cane opposite affected leg (COAL) Walker, with, affected leg (wandering Wilma’s alwayslate) Skin and tissue integrity assessment areas Assessskin integrity Actual or potential interruptions in skin and tissue integrity Pressure injury: asses problem and possible cause Observe for areas of further breakdown and relive the pressures on these Measure depth, diameter of open skin areas Photographs may be taken based upon agency policy and consent obtained Reposition pts every 1-2hrs Maintaining skin integrity Frequent position changes w/ adequate skin care,sufficient nutritional intake (protein) Turn and reposition at least every 1 to 2 hrs Provide adequate skin care Ensure sufficient nutrition Use pressure-relieving or pressure-reducing devices Nugget** Take into consideration Diabetics and geriatrics Sandals Too tight shoes or high tops Pressure ulcer Sustained pressure ofsoft tissue that becomes compressed between bony prominence and external surface for extended period Mechanical forces create ulcers Friction: rubbing together Shear: friction and gravity Pressure ulcerstaging Stage 1: nonblanchable erythema of intact skin, area usually over bony prominence Stage 2: partial thicknessskin loss, ulcer involves epidermis or dermis (skin tear, blister) Stage 3: full thickness, skin loss with subcutaneous damage, ulcer extends down to fascia, presents asshallow center. Bone, tendon, muscle not exposed, may have undermining and tunneling Stage 4: full thickness, skin loss with extensive destruction, tissue necrosis, damage to muscle, bone, tendon or joint capsule (worse case), undermining and tunneling common with sinus tracts possible, slough and eschar often present Laboratory and diagnostic assessment Exposed chronic wounds are colonized w/microorganisms but not alwaysinfected Swab cultures are helping identifying bacteria on surface Infection is diagnosed based on clinical indicators,systemic signs Arterial blood flow studies Prealbumin, albumin, total protein Pressure ulcer: risk factors Medical conditions: DM,stroke, dementia Ams Moisture (sweating, incontinence) Age over 65 h/o pressure ulcers body type/size: obese or very thin immobility anemia ischemia immunosuppression poor nutrition external pressure General principles of wound care Keep wound bed moist (promotes healing) Cleanse would with NS or wound cleanser, pat dry Stage 1: take pressure off the wound, dressing or ointment may not be required Stage 2: clean with NS. DO NOT USE BETADINE OR PEROXIDE. Hydrocolloid dressing (noninfected wounds) Stage 3 or 4: Moisten gauze with NS, gently pack into wound using q-tip Infected wound-wound culture first then antibiotics Wound care products Hydrocolloid dressing Hysept 50 sodium hydrochloride solution: used for infected wounds or prevention of surgical wound infection Wound vac: diabetic, PAD Braden pressure ulcer risk assessment Sensory perception Moisture Activity Mobilty Nutrition Friction or shear Herpes Zoster (shingles) Pathophysiology Varicella-zoster virus Maintains a dormant state for some time Reactivation after a stressful event (orsignificant illness) Follows a dermatome type outbreak Areastypically affected Chest, back, face Risk factors Advanced age, previous varicella exposure, immunosuppression,stressful event Manifestations Severe pain, fluid filled blisters(vesicles), malaise (feeling of unwell), fever, and itching 10-30% increases w/age Rarely crosses midline; band-like pattern Neuropathic pain; treat pt for nerve pain Dx Nature of the pain, dermatome pattern Tx Antivirals(virs) Nurse pain (gabapentin) Nursing care Maintain appropriate precautions, pain medications as prescribed and anti-viral Vaccine Zostavax (live vaccine) Recommending for those 50 and older; prevents shingles in 50% of cases, reduce risk of post-herpetic neuralgia: contraindicated in immunosuppressed individuals Shingx- new vaccine 90% prevent, inactivated vaccine If you received chicken pox vaccine still can get shingles just much less likely Shingles: isolation If patient is immunocompetent and rash islocalized, standard precautions and cover lesions If it is disseminated, standard plus airborne/contact (rash is everywhere, blisters open) Psoriasis Chronic autoimmune, inflammatory disorder Pathophysiology Hyperproliferation (thicken) of cells of epidermis, known as keratinocytes Manifests as erythematous red plaques covered with silvery scales Pruritis Auspitz sign: scratching the scale can lead to bleeding Location Affects extensor surfaces such asthe elbow or knee, also scalp or back of neck Triggers Genetic, 1/3 pts have someone in their family w/psoriasis Injury to the area: sunburn, surgery Cold Infection: strep pharyngitis Medications: beta-blockers, lithium Stress Treatment High potency corticosteroid ointment (betamethasone), vit D3, analog creams. Methotrexate (decrease inflammation), immunomodulating drugs(cause immunosuppression) (test for TB) Helpful: naturalsunlight, active lifestyle, uv radiation Nursing care Trigger education Emotionalsupport Advise against tanning beds Cellulitis Support groups Psoriatic arthritis: complication, as many as 30% of pts. Joints are affected Bacterial infection of the skin and subq tissues Often caused by staphylococcus aureus also GAS Those at high risk are IV drug users, diabetics, PAD, elderly, and immunocompromised, cancer, venous stasis, immobility Manifestations-localized pain, erythema, warmth, edema, pyrexia Treatment-antibiotic, pain control, and supportive care Complications are higher in those who smoke have diabetes, and pad Osteomyelitis Nursing care Administer antibiotics Monitor for response to treatment Warm soaks Elevate extremity Skin cancer Uncontrolled, abnormal growth of cells Basal cell carcinoma: most common,slowest growing, least likely to metastasize; develops from cells in the epidermis; appears small, pearly skin colored bump or nodule Squamous cell carcinoma: second most common; develops from cells in the epidermis known as squamous cells. This type is more dangerous and more likely to reoccur after surgery and to metastasize. Looks like red nodule or rough scaling patch Malignant melanoma: life-threatening skin cancer that develops from melanocytes. Presents as black or brown mole, may appear red, white, blue, or grey, least common but most dangerous Overexposure to sunlight is the leading cause Risk factors-occupation, tanning bed use,skin color, individuals who have a large number of moles and freckles. Also family history Primary prevention-discourse tanning bed use and reinforcement regarding sunblock (spf 30 or higher) hats, light colored clothing and when to go outdoors (11am-3pm) A-asymmetry the mole is irregular B- border the border of the mole is irregular raised or notched c- color the color is dark d- diameter greater than 6mm e evolving mole that looks different from other moles or that is changing in size shape or color is another warning sign of melanoma prevention and management of skin cancer prevention protective clothing (hat,sunglasses) sunblock-apply at least 30 minutes before sun exposure (every 2hrsreapply) body mapping monthly skin self-exam surgical cryosurgery mohssurgery nonsurgical drug therapy 5 fluorouracil cream Topical chemotherapy Melanoma BRAF indication Bedbugs A parasite cimex species; 30 species Larger than scabies Bitesthe host skin prefers nocturnal feeding Bites are painless Skin reaction: Pruritis Erythema Wheal Tx: not usually required, possibly corticosteroid cream or antihistamine Prevention: insecticides, eliminate hiding spots Nursing care- belongings should secured (double bagged) and not confined to a specialized area Client should be bathed Contact precautions Scabies Skin infestation by a mite, parasite that infectsskin, lives I the epidermis, creates tunnels Risk factors- transmitted person to person, poor hygiene, dorms, health happens in crowded placessuch as schools and homelessshelters. Treatment with permethrin cream Sx: intense pruritisthis is especially severe at night. Erythematous papules, sites of involvement finger web spaces, flexorsurface of wrist/elbows, axillary folds, beltline, lower buttocks, genitalia, Tx: permethrin or lindane; must also treat contacts and wash all clothes and bedding in boiling hot water Nursing care- belongings should secured (double-bagged) and not confined to a specialized area Client should be bathed Very contagious Contact precautions Pediculosis Head lice Manifested by intense itching Risk factors- hair to hair contact, sharing personal items, occursin people with longer hair Lice attach to hair, lay eggs, feed on blood from scalp Treatment with permethrin or lindane cram Nursing care belongingsshould be secured (double bagged) Educate pt on preventing the transmission wash all clothing and bedding Client should be bathed Contact precautions Nail assessment Dystrophic nails may occur with a serious systemic illness, or local skin disease involving the epidermal keratinocytes Occupation can also have significant impact on the condition of nails (chemical exposure) Examine the nails by looking at the curvature and surrounding tissue. Palpate the nails to assess for sponginess, tenderness or edema Nail disorder Clubbed nail Hypoxia, COPD, CF, chronic HD Spoon nail Iron deficiency, poorly controlled DM, chemical irritants Physiologic defenses Body tissues Phagocytosis Inflammation Immune systems Antibody-mediated Cell-mediated Methods of infection control and prevention Hand hygiene Disinfection/sterilization Standard precautions Transmission-based precautions Airborne Droplet Contact Staff and pt placement and cohorting Isolation precautions Standard Contact Droplet Airborne Reverse isolation Donning your PPE #1 hand hygiene #2 gown #3 respiratory protection #4 eye protection #5 gloves Doffing your PPE #1 gloves #2 eye protection #3 gown #4 respiratory protection #hand hygiene Contact precautions(in addition to standard precautions) Stop visitors: report to nurse before entering Gloves Hand hygiene Gowns Patient transport Limit, ensure pt body are contained and covered Pt care equipment Use disposable or clean Mrsa, vre, pediculosis, scabies, RSV Contact precautions(Clostridium difficile; c. diff) Everything as above just wash hand only with soap and water no alcohol-based sanitizers Droplet precautions Visitor report to nurse before entering Don mask Hand hygiene Private room 3ft away from pts or visitors Patient transport limited; pt to wear mask and follow respiratory hygiene/ cough etiquette Influenza Mumps Pertussis Meningitis(bacterial only, n. meningitides or h. influenza type b) Airborne precautions Visitorsreport to nurse Pt placed in negative pressure room Keep door closed at all times Pt transport pt must wearsurgical mask and follow respiratory hygiene/cough etiquette Hand hygiene Nurses wear n95 or anting higher level when entering room TB Measles Chicken pox (airborne and contact w/open weeping lesions) Shingles(airborne and contact for those w/disseminated lesions) Methicillin-resistant staphylococcus aureus(MRSA) Does not respond to methicillin or other penicillin-based drug Susceptible to vancomycin, linezolid, cefazoline fosamil Spread by Indwelling urinary catheters Vascular access devices Endotracheal tubes Community- associated MRSA Causesinfectionsin healthy non-hospitalized people Heath teaching is important Perform frequent hand hygiene, including use of hand sanitizers Avoid close contact with people with infectious wounds Avoid large crowds Avoid contaminated surfaces Use good overall hygiene Unit 2 Pain defined Official definition an unpleasant sensory and emotional experience associated with actual or potential tissue damage More personal definition pain is whatever the pt says it is existing whenever he or she says it does Pt is the authority on pain Self report is the most reliable indicator Assess pain using a standardized pain assessment tool M-morphine O-oxygen N-nitro A-aspirin If pt refuses morphine due to any condition call MD for new orders Types of pain Acute pain Short-lived: usually hrsto days Resultsfrom sudden, accidental trauma,surgery, ischemia, inflammation Sympathetic response, increased b/p, HR, dilated pupils Potential warning sign Chronic (persistent) pain Usually longer than 3 months Ex. Cancer pain, osteoarthritis Gradual onset Can lead to deconditioning Sympathetic nervous system speeds up except for GI Fight or flight response Pain protects Chronic pain can be adaptive NUGGET** Acute up to 3wks Ischemia causes pain-dead tissue Inflammation process-WBC rush to area Can lead to deconditioning -pain and don’t want to move or do anything Chronic pain-assess how pain impacts pt ADLs Categorization of pain by underlying mechanisms Nociceptive Somatic Cutaneous orsuperficial Deep: bone, muscle Visceral Pain that typically originates at the organ level (pancreatitis, appendicitis) Stimulation of nerve cells due to inflammation or injury Sprain, bruise, etc. Neuropathic pain DM, phantom limb pain, HIV, neuropathies , may be described as burning or numbness (shooting, shock like, stabbing) Dysfunctional pain Nerve injury Malfunction of the nervous system due to other disease or injury. Ex. Shingles, vitamin b12 deficiency Pain assessment Nurses role Accept pts self-report Do not label pts, always advocate for proper pain control Assess frequently many pts are reluctant to report pain (older adults) Act promptly to relieve pain Respect values and preferences of patient Family centered approach to gathering information about pain Assess after pain meds IV-15-30mins PO- within 1hr Always use a standardized pain assessment tool Numeric scale most used 1-10 Wong-baker FACES pain rating scale-used in peds Pain assessment in advanced dementia PAINAD PTS who are confused Faces pain scale- similar to wong-baker used for adults Pain assessment in vented pts #1 yes/no signal, thumbs up or down (if awake/alert) #2 communication boards (if awake/alert) Not sedated!!! Pain assessment PQRST acronym (very important) P- what precipitatesthe pain? Exercise? Rest? Q- what is the quality of pain? Dull? Ache? Sharp? used? R- doesthe pain radiate? Referred pain S- severity? What is the severity of the pain on a scale 1-10? Other scales that may be T- what treatment worksfor you usually? When did the pain start? Meds in older adults absorb slower watch pain meds when given can cause resp depression. Pharmacologic management of pain (NUGGET) Basic principles of pain management: prevent and control pain Multimodal analgesia: using two or more classes of analgesia to target different pain mechanisms may allow for lower doses of each drug Post operative pain: combination therapy Pre-medicate before procedures, activity Oral route is preferred, IV can be used if pt is NPO or nauseated, or if pain is severe or escalating Opioids mainstay in management of moderate to severe nociceptive types of pain Mu agonists(morphine like) are first line, ex. Morphine, fentanyl, hydromorphone, oxycodone, hydrocodone The desired outcome of titration isto use the smallest dose that provides satisfactory pain relief w/ the fewest side effects Older adults: start low and go slow, starting dose should be 25-50% lower Meperidine (Demerol) is not recommended for treatment of any type of pain (toxic, used to manage shivers) PCA infusion pump Can deliver pain medication IV or epidural Useful for those requiring ATC pain control Postsurgical Basal rate (automatic dose) Demand dosing Oxygenation concerns v/s education verification; two nurses only the pt should push button to administer medication educate both pt and family ptshould also have Narcan prn ordered (for antidote) used for 24-48hrs Lethargic stop meds Caring for a client with an epidural (ex. Thoracic surgery) Combination therapy ropivacaine and fentanyl Respiratory depression** Monitor pulse oximetry closely Blood pressure changes Hypotension is the most common Report 25% change (15-20 mmHg difference) Infection Mentalstatus changes Pyrexia Nuchal rigidity (neck stiffness) Post procedure headache (CSF leakage) Report promptly Bp drops when inserted-CSF fluid Check v/s-hypotension (give bolus before given) Post procedure headache-losing CSF fluid Assessing the client w/ an epidural Frequent vs Pain intensity rating Sedation score Degree of motor/sensory block Motor assessment: patient should be able to bend knees/lift buttocks Epidural tubing should be yellow lined without injection ports and labeled Monitor insertions site for REED (redness, erythema, edema, drainage), make sure dsg secure Absolutely no anticoagulants!!! May end up w/spinal/epidural hematoma Surgical emergency Severe pain, weakness, numbness, difficulty walking, loss of bowel or bladder control, urinary retention, paralysis Pain intensity rating- check if epidural is working Sedation score-medication effects CNS Opioid concerns: physical dependence, tolerance, and addiction Physical dependence: normal response (rely on med) Tolerance: increased dosesrequired to achieve same effect ( decrease in side effects) Opioid addiction: chronic neurologic and biologic disease (craving and continuous use despite harm) Pseudo addiction: mistaken diagnosis of addictive disease Opioid naïve (not used to taking meds) vs opioid tolerant Sickle cell always in pain Effects of opioids Side effects are dose related - constipation - nausea - urinary retention - vomiting - pruritus - sedation leading to respiratory depression; falls!!! - respiratory depression - reversal agent: naloxone (Narcan) NUGGET** Pain meds slows everything Resp rate 12-20 Safety falls!! Non-opioid pharmacological management Lidocaine Patch and topical cream (on for 12 off for 12) Shingles pain, localized pain Acetaminophen Max dosing (4g) Antidote: acetylcysteine Contraindicated liver disease NSAIDs(ibuprofen, naproxen, Toradol, aspirin) Side effects: increased risk for bleeding/bruising GI bleeding, renal insufficiency Nephrotoxic HTN use cautiously COX-2 inhibitors(Celebrex) Caution w/ heart disease Less side effects Non-pharmacologic interventions Elevation of affected body part RICE Relaxation Distraction (music, TV, visitors, someone to talk too, reading book Heat/cold: do not apply directly to skin use a barrier!! No more than 15-30mins (3 or 4x a day) Never ok to deliver a placebo, violate informed consent laws Physical interventions-TENS Transcutaneous electrical nerve stimulation unit Stimulate nerve fibers thereby stimulating the release of endorphins Client adjuststhe current to a sensation described as pins and needles Disposable electrodes Is an adjuvant treatment (used in addition to other pain management measures) May cause tingling or pins/needles type sensation Placed directly over or near site of pain A minimum of two or up to for pads may be used Startsto work immediately may take up to 30mins for desired effect May be used as long as desired typically 30mins- two hrs May cause some minorskin irritation NUGGETT** Help minimize pain addition to pain medication Working if you feel pins and needles Miscellaneous analgesics Dual mechanism Tramadol Ultracet Neuropathic pain Anticonvulsants Carbamazepine Topiramate (Topamax) gabapentin first line for persistent neuropathic pain antidepressants TCAs poor choice for older adults(orthostatic hypotension) SSRIs SNRIs Considerations for older adults: opioids Start with low doses and titrate slowly More prone to side effects and adverse reactions Polypharmacy concerns and interactions Systematic assessment of pt response Avoiding meperidine (shivering) Teach caregivers measuresto reduce falls and accidents Home safety assessment is recommended Perioperative care Urgency, degree of risk and extent ofsurgery Urgency Elective: hernia repair, cataract removal (non acute problem) Urgent: bone fx, kidney stones (fix within 24-48hrs) Emergent: trauma, AAA, cardiac cath (has to be done now) Degree of risk Minor: biopsy Major: CABG Extent Simple; only most overtly affected area Radical; more extensive Minimally invasive; endoscopic Many different reasons Cosmetic Curative; resolves a health problem Palliative; improve symptoms Diagnostic; lap Pre-operative safety checklist Surgical care improvement project (SCIP)(to reduce complication) Focuses on a safe transition through pre-and post-operative care. Ten core measures are associate with SCIP Prophylactic ABX within a specified time frame. Within one hr prior to surgical incision (do not give send w/pt give in OR) Discontinue 24hrs after administration (up to 48hrs) Hyperglycemia avoidance Less than 200 mg/dL (postop to heal) Post-op urinary catheter removal Within 24-48hrs Do not stop beta-blockers prior to surgery; continue BB post operatively Appropriate VTE prevention: heparin/lovenox, scds