ATI MEDSURG FINAL EXAM LATEST REVISION GUIDE

ATI MEDSURG FINAL EXAM LATEST REVISION GUIDE 1. INSULIN • Administration o Conventional  going off a set #, takes a certain amount a day – not tight control o Intensive  take based off blood sugar levels and what you're eating o Can be subQ, insulin pens, insulin pumps, IV o Stored in fridge- expiration 28 days from opening outside of fridge • Usually a mix of short acting (regular) and long/ intermediate acting insulin (NPH) ; glargine (Lantus) cannot be mixed with anything • Regular insulin (Humulin/Novolin) is the only insulin given IV • LOOK AT INSULIN HANDOUT FOR ONSET/PEAKS (when you should check your patients) o RAPID ACTING covers insulin needs for meals eaten at same time as the injection; often used with long-acting insulin  Humalog or lispro, NovoLog or aspart, Apidra or glulisine  Onset within 15-30 minutes  Peak within 1 hour  Duration up to 5 hours o SHORT ACTING covers insulin needs for meals within 30-60 minutes  Regular (Humulin R or Novolin R)  Onset within 30 min to 1 hour  Peak within 2-5 hours  Duration is 5-8 hours o INTERMEDIATE ACTING covers insulin needs for half the day or overnight; often combined with short-acting  NPH  Onset within 2 hours  Peak within 4-12 hours  Duration up to 24 hours o LONG ACTING covers insulin needs for one full day; often combined with rapid-or short acting insulin  Lantus (glargine), Levemir (detemir)  Onset within 2 hours  LANTUS HAS NO PEAK  Duration up to 24 hours 2. HYPOGLYCEMIA • Sx: o Sweating, tremors, hunger, tachycardia o Inability to concentrate, slurred speech, memory loss, drowsiness o Seizure, loss of consciousness, death o “T.I.R.E.D.” – Tachycardia, Irritability, Restlessness, Excessive hunger, Diaphoresis/Depression • Management o Give 15g of fast acting concentrated. Carbohydrates (3-4 tablets of glucose or 4-6 oz of juice/regular soda [NOT DIET]) o Retest blood sugar after 15 min. If 70 or sx persist more than 10-15 min retreat. o Provide snack of protein and carbs unless meal is planned within 30-60 min o If patient cannot swallow or is unconscious; subQ/IM injection of 1 mg glucagon OR 25-50 ml of 50% dextrose solution IVP if pt has IV 3. DKA VS HHS • DKA o Absence or inadequate insulin resulting in extremely high blood sugar (300-1,000) o Leads to ketones in the blood & urine o More common in type-1 diabetes o Ketoacidosis leads to low HCO3 and low pH (acidosis) o SX: ketoacidosis, hyperglycemia, kussmal’s, dehydration, hyperkalemia, fruity breath, 3 P’s o Elevated creatinine, BUN, and Hct o TX:  Rehydration with IV fluid initially .9 NS at a fast rate, then .45  IV continuous infusion of regular insulin  After blood sugar at 300 or less change to D5W to decrease chance of hypoglycemia  Rehydration leads to increased plasma volume and decreased K; insulin enhances the movement of K+ from extracellular fluid into the cells  Continuous potassium replacement once potassium levels drop to normal • Only withheld if hyperkalemia is present or if pt is not urinating • HHS o Insufficient insulin leading to hyperglycemia (HIGHER than DKA) 600-1200 o NOT KETONES! o Normal HCO3 o More common in type-2 diabetes o Develops slower o SX:  Hypotension & profound dehydration  Tachycardia  Neurologic sx due to cerebral dehydration o TX:  Rehydrate with fluids • Change to dextrose solution once blood sugar at 300  Administer insulin  Potassium 4. MANAGEMENT OF DM  Complications o Acute complications of DM  hypoglycemia, DKA, HHS o Long term complications:  Macrovascular – atherosclerosis, CAD, cerebrovascular disease, PVD  Microvascular – diabetic neuropathy &nephropathy  Neuropathic – peripheral neuropathy, sexual dysfunction  Neuropathic ulcers! Due to decreased BF, WBC efficiency, & change in arterial wall o Risk for amputation r/t infection and wounds (not in notes but common sense lol)  Patient education o See pediatrist, optometrist, etc. regularly o Take care of your skin o Keep insulin in the fridge. Roll it between hands to warm it before administration (never shake) o Use appropriate syringes o Check glucose level throughout the day  How to and when to use glucagon kit, carry it with them  Check blood sugar many times a day—every 3-4 hours o Rotate injection sites – if you repeat it can lead to “Lipodystrophy” (hardened spots) o Keep HA1C 7% o Promote exercise and nutrition management  Control total calorie intake  Control of blood glucose levels  Normalization of lipids and blood pressure to prevent heart disease • Keep cholesterol levels down to decrease risk of stroke  Sick Day Rules o Take insulin/oral meds as usual o Test blood glucose and ketones q3-4h o Take supplemental (regular) insulin as needed q3-4h o Soft foods 6-8 x day if you cannot tolerate normal meals (gelatin, cream soup, custard, graham crackers) o Take in liquids every ½ to 1 hour to prevent dehydration (regular cola, OJ, sports drink) o Report N/V/D to provider – at risk for extreme dehydration o May be hospitalized for DKA if you cannot hold fluids 5. SIADH • Excessive ADH released from posterior pituitary gland (hyperpituitarism)- see with head trauma • SX: o Fluid retention/water intoxication o Dilutional hyponatremia o Increase intravascular volume o At risk for cerebral edema & seizures! • TX: o Vital signs, daily weights, I&O o Elevate the HOB o Monitor F&E o Fluid restriction  500-1000ml/day o Administer IV fluids but watch for overload! –hypertonic to flush out o Vasopressin antagonist may be given o Loop diuretics – Lasix – to promote diuresis if Na+ is at least 125 mEq/L (replace K+ if you give this) 6. HYPOTHYROIDISM • SX: everything SLOWS down o Lethargy & fatigue o Hair loss & dry skin o Intolerance to cold o Constipation o Puffiness & edema (myxedema – around the eyes) o Cardiomegaly & HF o Bradycardia o Possible goiter o Reduced oxygen level in blood supply • Monitor o Increased TSH o Decreased T4 o Normal T3 • Treatment o AIRWAY IS PRIORITY • Restore metabolic rate by replacing missing hormones o Synthroid or Levothroid  Watch for cardiac sx with thyroid replacement initiated because thyroid hormones enhance the cardiovascular effects of catecholamines  Angina or dysrhythmias- will need to call the provider and discontinue later, when it can be resumed safely, it should be at a lower dosage with close monitoring 7. CUSHING’S • Excessive secretion of adrenal cortex hormones [ACTH] • Commonly caused by use of corticosteroid meds or hyperpituitarism • SX: o “moon” face o Buffalo hump o Osteoporosis because of extra cortisol o Muscle wasting o Subscapular fat pads o HTN o Hyperglycemia o Striae and increased abd fat o Black tarry stools o Emotional instability & insomnia • Labs hypokalemia & hypernatremia and hyperglycemia • Treatment directed at cause—remove tumor, remove corticosteroids 8. INCREASED ICP • Early symptoms o Change in LOC—report to provider o Cheyne-Stokes (hyperventilation then apnea) o Pupil changes- nonreactive o Restlessness o abnormal posturing o Weakness in one extremity or side of the body o Headache that is constant or increasing in intensity • Late symptoms o CUSHINGS TRIAD  bradycardia, HTN, bradypnea o Stupor – coma o Loss of pupil, gag, corneal, and swallow reflex • Nursing interventions o Elevate HOB to 60* o Give 3% NS to dehydrate the brain tissue o Fluid restriction o Drain CSF similar to lumbar puncture o Calm environment o Keep oxygen level 92% o Hyperoxygenate before suctioning o Keep body inline positioning – do not flex hips or Valsalva o Be very worried about infections 9. MENINGITIS • Precautions for meningitis patients o Isolation for 1st 24 hours (bacterial) after antibiotic therapy is initiated o Viral is standard precautions (stool and urine precautions) o SX:  Nuchal rigidity – stiff neck & hard to put chin to chest.  Flu like symptoms (N/V, fever & chills)  Positive Kernig’s (unable to straighten knee at 90*)  Positive Brudzinski (hip & knee flexion with neck flexion)  Seizures due to inflammation  Change in LOC/behavior  Diffuse Janeway Lesions (rash) o Worried about sepsis o Rapid nuero assessment pupils, a+o, Glasgow coma scale • Prevention o Vaccine to youth 11-12, booster at 16 and first year college students or military members 10. CEREBROVASCULAR ACCIDENT • Left CVA o Paralysis/weakness on right side of the body o Right visual field deficit o Aphasia (expressive, receptive, or global) o Altered intellectual ability o Slow, cautious behavior • Right CVA o Paralysis or weakness of left side of the body o Left visual field deficit o Spatial-perceptual deficits o Increased distractibility o Impulsive behavior & poor judgements o Lack of awareness of deficit • Nursing care o IV TpA for ischemic, NOT hemorrhagic  Give within 3-4.5 hours of stroke or within 60 min of arrival to ED  Do NOT give if pt is 80 y.o. or the stroke was 3 hours ago  Check PT/INR or PTT o Safety  need to be close to nursing station, 1 on 1  level of mobility, communication, swallowing-aspiration risk o NPO o Stool softeners o Analgesics and antianxiety meds o Surgery if necessary • TPa Eligibility o 18 but younger than 80 o Ischemia stroke within 3 hours o BP 185/110 o No seizure at onset of stroke o Has not received heparin within 48 hours o No stroke or intracranial surgery within 3 months o No surgical procedure within 14 days o No GI or urinary bleeding within 21 days o No pregnancy • Ischemic Stroke  disruption of blood supply caused by obstruction by thrombus or emboli 11. SEIZURES • Seizure Precautions o Padded side rails o Suction, oral airway, oxygen o Large bore IV • During seizures o IV Ativan/valium to stop seizures abruptly o Provide privacy o Turn patient on their side and move to the floor if possible – if in bed raise siderails o Move furniture or anything they may hurt themselves on o Loosen restrictive clothing or glasses o Do not put anything in their mouth & do not try to restrain • After a seizure o Reorient the patient, establish an airway, and stay away if they get angry • Pt edu about medications for seizures o Medications control rather than cures seizures – if you stopped the meds the seizures would begin again o Do not stop taking abruptly o Seizure meds can be affected by birth control 12. GULLIAN-BARRE SYNDROME • Autoimmune disorder with acute attacks of peripheral nerve demyelination • Commonly follows viral infection, respiratory illness, or gastroenteritis; common after flu shots • SX: start in lower extremities and moves up o Weakness/paralysis/paresthesia o Absent reflexes & other cranial nerve weakness o Tachy/bradycardia o Hyper/hypotension o Pain • Nursing priorities o Preventing DVT – PROM 2xday, turning q2h, compression stockings/SCDs o Bladder and bowel training o Swallowing instructions o RESPIRATORY IS PRIORITY—OXYGEN, AIRWAY, SUCTION o Mental reorientation • Labs  elevated protein in CSF 13. ALZHEIMER’S DISEASE • Long-term and short-term memory loss • Steady decline that eventually leads to a self-care deficit • Testing done before dx is made: o Thyroid, Vit B12 deficiency, ammonia, MBP o MRI and CT to make sure nothing else is going on mimicking it • Nursing interventions o May need a sitter o Provide a safe environment, esp if wanderers o Activities are beneficial to keep them busy 14. SPINAL CORD INJURY • When to call the doctor  with any new loss of function • Body systems we support from injury: o Airway and respiratory o Hold c-spine (head and neck held in neutral position) o Avoid twisting of spinal cord 15. SICKLE CELL DISEASE • Priority interventions o Place patient on oxygen and rehydrate them #1! o Elevate swollen joints o Pain control & infection/DVT prevention • Education to prevent crisis o Avoid dehydration, avoid stress, avoid high altitudes, and pregnancy o Balance exercise and rest o Encourage nutrition and healthy lifestyle o Monitor for infections!! Come in ASAP when you think you have infection 16. ANEMIA • SX: o May be asymptomatic; esp if gradual decline or hypothyroidism o Tachycardia and fatigue with exertion (having to work harder) o Pallor o dizzy o Dyspnea o Chest pain o Muscle pain/cramping • Nursing Care o If due to blood loss – transfusion of RBC o Stem cell transplant or immunosuppressant therapy o Supplement replacements  Iron – take on empty stomach (1 hour ac or 2 hours pc) • Take with stool softeners o Can cause constipation and black stools • IV—always z-track to prevent dying the skin • Oral liquid take with a straw o Supplemental O2 o Balance exercise and rest • Labs  low RBC and Hgb (5-11) with possible low iron, vit B12 &/or folic acid (hypoproliferative) 17. TRANSGENDER • A safe space is represented by pink triangles or rainbow signs! • Estrogen therapy o Watch for DVT & PE o Need to eat more potassium because of loss o Monitor BP • Testosterone therapy o Side effect: weight gain, acne, psychosis, increased LDL/HDL levels o Get regular heart and liver function testing done o Can take up to a year to take affect • If they still have the parts they still need checked: ex—if they still have a uterus they still need pap smears. 18. RADIATION • Commonly external but can be internally implanted • Internal radiation requires protection for HCP and visitors o Stay 6 ft away as much as possible o No pregnant women or those under 18 o Private room & on bed rest o Decameter (idk how to spell it) to detect amount of radiation exposure o If implant dislodges – grab with metal tongs and put into lead box. Call radiology. • Nursing care o Thorough skin care  Can cause dermatitis, skin opening, hair loss o Rest and exercise balance due to fatigue o Fracture/fall risk – weakens bones; esp iliac crest & sternum o Watch for infections due to neutropenia o Watch for bleeding due to anemia and thrombocytopenia 18. radiation therapy External: -most common. Highly charged radiation beams directed at site of tumor (marked specifically on the pts skin—be sure to educate pt not to mess with markings). Use of CT or other imaging modalities provides images of tumor and neighboring tissues to make the radiation more precise and reduce the risk of radiation-induced toxicity to surrounding normal tissue. Internal: (Brachytherapy)-implantable radiation -intense dose of radiation delivered to a specific/highly targeted area. (more intense then external but more localized—spares normal surrounding tissue). radioactive sources are implanted within/next to the cancer site. -imaging modalities (CT, ultrasound) used with this type as well to help guide placement of radiation sources -safety precautions: -private room. -Educate family members and health care workers to limit exposure time. -Limit number of visitors. -Should remain 6ft from pt. -pregnant women should not be caring for them. (Danielle said in class if they must then nurse needs two dosimeter badges—one for nurse & one for baby). Nurses caring for these pts should wear a dosimeter badge (detects how much radiation you’re being exposed to). - If radiation implant dislodges: have pt lie still, use long-handle forceps to retrieve the radioactive source, put in lead container, and contact radiation oncologist and document. Side effects of radiation: • Dermatitis, open skin wounds (esp with external), hair loss. • GI, skin, and bone marrow are most affected by radiation. (radiation to iliac crest or sternum especially affect bone marrow—may result in decreased WBCs and anemia putting pt at risk for infections and bleeding). • Pts can experience fatigue lasting up to 6 months after radiation. Nursing care: • Promote healing, pt comfort, and quality of life • Good skin care -avoid sunlight -avoid temp extremes -wash gently with soap/water and pat dry • Pt education -esp on special precautions 19. oncologic emergencies *Superior vena cava syndrome : -tumor compressing/invading the SVC s/sx: SOB/dyspnea, facial/neck edema, and epistaxis. Tx: -High-dose chemo/radiation therapy -stent in vena cava -anticoagulants or thrombolytics -supplemental O2 -corticosteroids -diuretics (if fluid overload is present) Nursing care: -monitor pulse and BP -assess for decreased cardiac output if c/o SOB -comfort, positioning for circulation and breathing (semi-fowler’s—promotes venous drainage and promotes breathing) *Tumorlysis syndrome: -chemo-induced cell destruction leads to release of intracellular contents electrolyte imbalances: hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia. -emergent situation/life-threatening. Tx: -May pretreat with Allopurinol to prevent this. (prevents uric acid crystals from forming in the kidneys). -osmotic diuretics -may need dialysis -hydration can prevent this -Kayexalate for hyperkalemia Nursing care: -monitor BUN/creat, electrolyte levels, hematuria, and encourage adequate hydration (3-5L daily). Monitor for dysrhythmias. Spinal cord compression -corticosteroids to reduce inflammation Hypercalcemia -tumor causes calcium to be released from bones -more calcium than the kidneys can excrete and the bones can reabsorb SIADH -may occur but not as common 19. HIV -virus that invades/hijacks the helper T cells (CD4 cells) in the body [defense mechanism/part of our immune system]. Decreases the body’s ability to fight infection—leads to opportunistic infections. An acquired immune deficiency. Bodily fluids with the highest concentration of HIV: blood & semen Diagnosis of HIV: -NAT (nucleic acid tests): expensive. Looks for virus in the blood. Only done when pt has early sx of H ..........................................................................................................................................................DOWNLOAD FOR MORE REVISION TO GRADE A..................