Study Guide for Med Surg 1 Chapter 1

o o o Delegation is a voluntary function. You are ultimately responsible for deciding if and when to delegate, what to delegate, to whom, and under what circumstances. Look over the different Medicares on page 6.

Chapter 2
o The patient is the primary source of information in the admission process because she knows more about herself than anyone else.

Chapter 3
o o o o Aldosterone and atrial natriuretic peptide (ANP), which regulate the reabsorption of water and sodium ions from the kidney tubules. Normal hematocrit values range from 35 to 54 mL of RBCs. The average range of urine specific gravity is 1.010 to 1.025. Sign and symptoms of hyponatremia are: o Fatigue, lethargy, muscle weakness o Muscle cramps o Abdominal cramps and nausea and vomiting o Headache, confusion, seizures o Decreased blood pressure Potassium is never given IV push. Know the common foods high in Potassium and Sodium page 48. Know the different complications of IV therapy Table 3-7 page 59.

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Chapter 4
o o o o Look over Table 4-1 page 68. The elderly patient is less able to adjust and compensate for the stress of surgery as physiologic reserves (cardiac, respiratory, renal) have declined. Corticosteroids may delay wound healing, can alter fluid and electrolyte balance and affect several metabolic functions in the body. The goals of anesthesia administration are: (MULTI/MULTI) o to prevent pain o to achieve adequate muscle relaxation o to calm fear, ease anxiety, and induce forgetfulness of an unpleasant experience.

Chapter 5
o o o A total score of 9 to 10 indicates criteria for discharge from PACU. Maintaining a patent airway is a priority measure. If any area of the lung remains ateletic (collapse of alveoli in the lungs) for more than 72 hours, hypostatic pneumonia from retained secretions is likely to occur.

Chapter 6
o This normal flora (microorganisms that normally exist in the body and provide natural immunity against certain infections) is most often found on or in body systems that have some form of contact with the outside environment. Look over Table 6-1 Normal Flora of the body page 112.(MULTI/MULTI) Vaccines are suspensions of attenuated or killed microorganisms administered by injection to provide active immunity to infectious disease.

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Pathogens can be transmitted from one person to another through one of three routes: airborne, contact, or droplet. Antibiotics can help prevent a more virulent viral infection from occurring if taken at the first signs of illness. Protozoa are typically found in water and soil. Fungi tend to form spores that are resistant to ordinary antimicrobial agents. The course of treatment must be carried out cautiously and over a long period of time. Look over Box 6-1 page 115. Fever is one of the primary mechanisms the body has to prevent infection from invading microorganisms. Stress can increase blood cortisol levels, which will decrease the anti-inflammatory response of the body. Macrophages are monocytes (large leukocytes) that have left the bloodstream and have migrated into the tissues. Hand hygiene is the primary intervention any health care provider can use to control the spread of infections. Look over Table 6-5 page 121. Personal Protective Equipment (PPE) is the use of some type of barrier to protect a person from exposure to blood-borne pathogens, body fluids, or other potentially infectious materials. Two methods of preventing droplets from spreading to others include teaching people to cover the mouth when sneezing or coughing and turning ones head away to prevent coughing into the face of another. C. difficle (C. diff) the health care worker must use only soap and water to cleanse the hands. The alcohol based sanitizers does not kill the organisms. If the patient is discharged make sure housekeeping staff knows of this so that they can use appropriate cleaning agents to clean the room. Know the differences in medical asepsis and surgical asepsis.

Chapter 7
o o Theory of Pain o Distraction in the form of activity or social interaction produces impulses. o An increase in anxiety seems to open the gate, and a decrease seems to close it. Four Phases of Pain associated with nociceptive pain ( know these phases): o Transduction o Transmission o Perception o Modulation Pain threshold is the point at which pain is perceived. Pain tolerance is the length of time or the intensity of pain a person will endure before outwardly responding to it. When using a pain assessment scale, it is important that the nursing staff uses it consistently and that the patient fully understands how to use it. The need to work through an interpreter or deal with language difficulties when the patient speaks a foreign language compounds the problem of communication. Check all other medications and OTC drugs the patient is receiving when administering doses of acetaminophen. Many OTC drugs consist of a combination containing this drug. Toxicity may occur if more than the total recommended safe dosage is ingested. One of the most common and distressing side effects of pain medication is constipation.

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Chapter 8
o o The word benign indicates a neoplasm that is usually harmless. Benign growths are almost always encapsulated (surrounded by a fibrous capsule). Sarcomas arise from mesenchymal tissues. Carcinomas originate in epithelial tissues.

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The relationship of intense and prolonged exposure to the radiation and the production of cancer cells was first discovered when it was noted that there was high incidence of cancer, particularly leukemia, among people who pioneered studies of x-rays, radium, and uranium. Alcohol is a promoter. Prostate cancer is far more common in black males than in white males. The incidence of cervical cancer is higher in black women than in white women. Breast cancer is more prevalent in white women than in Asian women. Obesity is considered a risk factory in many cancers. Vesicants (chemicals causing tissue damage upon direct contact) should only be administered into veins that have good blood flow. Biologic response modifiers (BRMs) are agents that manipulate the immune system in the hope of controlling or curing a malignancy with little or no toxic effect on normal cells. They essentially make the immune system function better. BRMs stimulate the immune system to recognize cancer cells and to institute action to destroy them. When a patient has fatigue, make sure you prioritize their day. NCLEX Question #5 on page 188.

Chapter 9
o o Do not assign unlicensed personnel to perform tasks for unstable patients. The resident who is immobilized with a security device must be checked visually at least every 30 minutes to ensure that his body is in good alignment and that there are no problems. These checks must be documented. A check of skin color for circulation in the affected body parts is important whenever you are in the room. Residents must be turned or repositioned every 2 hours. Rehabilitation is the process whereby a disabled person is helped to achieve optimal function.

Chapter 10
o o o o o o Inflammation of the inflammatory response occurs with any tissue injury and with any encounter of foreign organisms. Bone marry produces a type of stem cell that is able to produce all types of blood cells, which then differentiate into the cells of the hematologic and immune systems. The thymus gland, located behind the breastbone, is the place that T lymphocytes mature and are released into the bloodstream. The lymph fluid drains into large veins, blending with the plasma circulating in the blood stream. Decreased ciliary action in the respiratory system and gastrointestinal tract results in decreased removal of potentially harmful organisms. The immune response is a remarkable series of complex chemical and mechanical activities that take place in the body. These activities involve: o Constant surveillance o Immediate recognition o Ability to distinguish one kind of foreign agent from another Immune deficiency is a lack of immune bodies and resultant impairment of the immune response to foreign agents. It immediately produces a protein (called an antibody) that is specifically designed to do battle with the antigen. The immediate response is called a humoral response. The cells that mediate the response are the T lymphocytes. Stem cells in the bone marrow and undergo a maturation process that involves bone marrow stromal cells (cells that contribute to the development of multiple tissues and blood cells) and their cytokines (messenger hormones). Look over Table 10-2 page 219. Two types of immunity: o Innate present at birth

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Acquired occurs by actively producing antibodies when the body has been invaded by pathogens, or by receiving an immunization that causes antibodies to a specific pathogen to form. C-Reactive protein (CRP) <1.0 mg/dL purpose is to detect the presence of an inflammatory process. o

Chapter 11
o o o o o o o o o o o The first step in the transmission of this virus is knowledge. Look over Box 11-1 page 235. The ONLY mode of transmission is by exposure to HIV infected blood, body fluids, or tissue. Barrier sex must be practiced with every sexual encounter to prevent transmission of HIV. HIV, a retrovirus that integrates itself into the genetic material of the cell it infects, changing the DNA of the host cell. The primary host cell for HIV is CD4 lymphocyte, the quarterback of the immune system. CD4 T lymphocytes count less than 200 cells/mm3. Reverse transcriptase helps the virus reproduce in the host cell. Opportunistic infections (OIs) organisms commonly found in the environment. Sentinel infections (infections that may indicate underlying immunosuppression), such as oral thrush, recurrent vaginal yeast infection, or a skin disorder. The initial signs and symptoms of AIDS are similar to flulike symptoms: fever, fatigue, diarrhea, and loss of appetite. A negative HIV test after initial exposure is not considered the final word until a second negative test is conducted 1 to 3 months later. The second most common test used to test for HIV is the enzyme-linked immunosorbent assay (ELISA), which is a form of enzyme immunoassay. If the first test is positive, it is followed by the Western blot. After infection with chickenpox, the virus becomes dormant in the base of nerve pathways, and when immune suppression becomes severe enough, it reactivates. The medications for exposure of HIV will need to be taken for 4 weeks. The severity of the condition can range from a mild rash to anaphylaxis (an extreme allergic reaction that is life threatening). Allergens can enter the body in several ways and can have either a local or systemic effect. The tendency to develop allergies, known as atrophy, affects about 10% of the population. Look over anaphylactic reaction and shock on page 263. Know about systemic lupus erythematosus page 266-267. Know about Hodgkins Disease page 268-272.

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Chapter 12
o o o o o o o o The larynx (voice box) is important to the formation of the sounds of speech. The right bronchus angles off to the right; inhaled foreign objects tend to lodge here. Pressure within the pleural cavity is negative. When the diaphragm contracts, it moves downward. If damage to the spinal cord occurs above the level where the respiratory nerves are located (T1), voluntary respiration ceases. Weakness of the respiratory muscles, such as occurs with neuromuscular diseases, also causes decreased lung capacity. Kyphosis (inward curvature and collapse) of the spine constricts the thoracic cavity and restricts the capacity of the lungs to expand fully. Surfactant is secreted by cells in the alveoli; surfactant decreases surface tension on the alveolar wall, allowing it to expand more easily with inspiration and preventing alveolar collapse upon expiration. This provides an adequate surface across which diffusion of O2 and CO2 can take place. When surfactant levels are low, alveoli cannot properly expand O2 and CO2 cannot cross the membrane adequately. When interstitial edema occurs in the lung tissue, the alveolar membrane is thickened and gases cannot diffuse across the membrane as easily. If fluid fills the alveoli, such as occurs with an

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inflammatory process in the lung, the gases cannot diffuse across the membrane. Tumor may black access for gas exchange. The major portion of the O2, about 97%, attaches to the heme portion of the hemoglobin molecule carried by the erythrocytes and form oxyhemoglobin. Lung sounds: o Wheezes whistling, musical, high-pitched sound produced by air being forced through a narrowed airway. o Rhonchi coarse, low-pitched, sonorous, rattling sounds caused by secretions in the larger air passages. o Crackles produced by air passing through moisture in the smaller airways. o Stridor can be heard when there is partial obstruction of the upper air passages; croaking Crackles sound similar to the sounds produced by rubbing hairs between the fingers close to the ear. Look over patient teaching 12-1 page 292. Frequent mouth care also helps remove pathogenic microorganisms from the oral cavity and thereby diminishes the possibility that they will be aspirated deep into the air passages. Suction no longer than 10 to 15 seconds; apply suction only when withdrawing the catheter. A full stomach can contribute to dyspnea by limiting the amount of space available for expansion of the lungs. Small frequent feeding is preferred to three large meals a day. Pursed-lip and diaphragmatic breathing may lessen dyspnea. Hypercapnia (aka hypercarbia) is the retention of excessive amounts of carbon dioxide. It is the result of hypoventilation, during which the usual amount of carbon dioxide is not eliminated by exhalation. Carbon dioxide is a respiratory stimulant; hence the body responds to excessive levels of carbon dioxide by increasing the rate of respirations in an effort to blow off larger quantities of the gas. The heard rate increases to meet the tissues need for more oxygen. Mental confusion and an increase in pulse and heart rate are indicators of inadequate oxygenation of the blood and tissues. It is present when the partial pressure of arterial oxygen (Pao2) is below 50mm Hg and the partial pressure of carbon dioxide (Pco2) is equal to or greater than 50 mm Hg. Know your different breathing patterns on page 294. After each contact with a person with a respiratory disorder that produces airborne or droplet secretions, or with articles contaminated by secretions, the hands should be washed thoroughly. Anorexia and inadequate nutrition are not uncommon in patients with respiratory disorders. Reasons for this include: o The senses of taste and smell may be impaired by nasal congestion. o The patient might be afraid that chewing and swallowing will bring on an attack of coughing o Purulent sputum leaves a bad taste in the mouth and can cause nausea. o Fatigue can deprive the patients of the will to expend the energy needed to feed herself. Deep breathing exercised and coughing techniques should be planned whenever the patient is able to do them with or without some assistance. These activities should be followed by good mouth care and a short period of uninterrupted rest.

Chapter 13
o o o o o A person with a cold is contagious for about 3 days after his symptoms first appear. Treatment of sinusitis is directed at relieving pain, promoting sinus drainage, controlling infection, and preventing reoccurrence. Acute or chronic sinus infection should not be ignored because the infection can cause a variety of complications, including septicemia, meningitis, and brain abscess. The patient should sit forward and apply direct pressure by pinching the soft portion of the nose for 10 to 15 minutes. Pharyngitis = sore throat.

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The inflammation (in pharyngitis) may be caused by a virus, bacteria, or fungus. The majority of cases are viral. Acute follicular pharyngitis, strep throat, is caused by beta-hemolytic streptococcal infection. Laryngitis (inflammation of the larynx with diminished voice or hoarseness) may occur if the infections progresses into the larynx. If the inflammation extends to the epiglottis, epiglottitus occurs, and this usually occurs in children. A throat culture is done before treatment is begun to check for the presence of Streptococcus, which can cause rheumatic fever or glomerulonephritis if not treated promptly. Following tonsillectomy or adenoidectomy, the nurses chief concern is observation for hemorrhage. An ice collar may be placed around the neck to reduce swelling and prevent the oozing of blood from the operative site. Older children may sit up in a semi-Fowlers position after they have recovered from the anesthesia and are often more comfortable this way. Citrus fruits, hot fluids, and rough foods should be avoided until throat has completely healed. Caution against the use of straws because sucking may cause bleeding. Sneezing, coughing, and vomiting are discouraged. The cuffed tracheostomy tube also reduces the chance of aspiration of mucus and fluids by those patients whose protective reflexes in the larynx and trachea are impaired. Tracheostomy care is a sterile procedure. Make sure you know how to provide trach care pages 312-314.

Chapter 14
o o o o o o o o o o o o o o o o Acute bronchitis frequently is an extension of an upper respiratory infection involving the trachea and usually is viral in origin. Causes other than infectious agents are physical and chemical agents inhaled in air polluted by dust, automobile exhaust, industrial fumes, and tobacco smoke. Bacterial pneumonia is often a consequence of influenza. Viral pneumonia tends to be less severe than bacterial pneumonia. Viral pneumonia does not produce exudates; it cause interstitial inflammation. Chest radiography reveals diffuse, patchy areas of density. The first signs of decreasing oxygenation may be restlessness or confusion. The patient should deep breath and cough 5 to 10 times each hour while awake. It is important that the nurse assess for signs of increasing impairment of gas exchange. Confusion often is the most obvious sign of atypical pneumonia in the elderly. It may take 6 to 12 weeks after a bout of pneumonia for the elder to be able to resume normal activities without undue fatigue. Know about TB pages 324-328. The test to test for TB is called tuberculin skin test (TST) rather than PPD test. Obstructive pulmonary disorders are characterized by problems moving air into and out of the lungs. Cor Pulmonale is enlargement of the right side of the heart as a result of pulmonary hypertension cause by constriction of the pulmonary vessels in response to hypoxia. Distended neck veins may occur. Montelukast (singular) Provides both bronchodilation and anti-inflammatory effects. Know patient teaching 14-3, 14-4, and 14-5 pages 336-337. Respiratory failure is defined by arterial blood gases. It has occurred when the Pao2 is less than 50 mm Hg and the partial pressure of carbon dioxide Pco2 is more than 50 mm Hg. Objective criteria for oxygen needs include Pao2 less than 60 mm Hg or Sao2 less than 90%.

Chapter 15
o o o o o Blood transports water, oxygen, nutrients, hormones, enzymes, and medications to the cells. Blood transports carbon dioxide and other waste products away from the cells. The 4 to 5 L of blood in the body helps regulate fluid volume and electrolyte distribution. The blood regulates the pH and acid-base balance by its buffering ability. Blood assists in regulating body temperature.

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Blood provides clotting factors for homeostasis. Albumin raises osmotic pressure at the capillary membrane, preventing fluid from leaking out into the tissue spaces. 3. The normal range for adults for RBCs is 4.2 to 6.2 million/mm The normal range for hemoglobin in adults is 12.0 to 18.0 g/dL. RBCs live for approximately 120 days. Old, damaged red cells are removed by the spleen and the liver. 3 The normal adult range for total leukocytes (WBCs) is 4500 to 11,000/mm . Granulocytes are divided into neutrophils, eosinphils, and basophils and are produced in the red bone marrow. Neutrophils make up 50% to 70% of the WBC count and work by engulfing and destroying bacteria by the process of phagocytosis. Eosinophils, which make up 1% to 5% of the total WBCs, help detoxify foreign proteins; they increase in number during allergic reactions and in response to parasitic infections. Agranulocytes consist of lymphocytes and monocytes. Lymphocytes comprise 25% of the WBCs and occur as B cells and T cells. B cells synthesize antibodies. Some T cells are killer cells and help B cells destroy foreign proteins. Lymphocytes are produced in the red bone marrow and the lymphatic tissue. Monocytes become macrophages when out in the tissues and are active as phagocytes, fighting infection and ridding the body of foreign substances. A differential blood cell count gives information about the numbers of different types of leukocytes present in the blood and about the types of inflammatory process that is occurring. Platelets, also called thrombocytes, are fragments of megakaryocytes that are produced by the bone marrow. Platelets provide the first line of protection, after vasospasm, to prevent bleeding by promoting clotting when the wall of a blood vessel has been damages. 3 The normal adult platelet count range is 150,000 to 400,000/mm ; the life span of a platelet is about 10 days. Although the body can withstand a substantial drop in the number of platelets, when the platelet count is low, there is rest of spontaneous bleeding into the skin, kidney, brain, and other internal organs. The spleen, located in the upper left abdominal cavity below the diaphragm and behind the stomach, filters the blood, removing pathogens, old blood cells, and debris, and produces lymphocytes. Physical assessment of the hematologic system skin: (MULTI-MULTI) o Color (pale) (check conjunctivae, palms of hands, and roof of the mouth in people with dark skin.)

Chapter 16
o Signs and symptoms of mild anemia: (MULT-MULTI) o Mild headache o Palpitations o Dyspnea upon exertion Common foods high in Iron and Folic Acid: (MULTI-MULTI) o Liver o Dried apricots o Lima beans o Prune juice Aplastic anemia is characterized by bone marrow depression. Treatment of phylcythemia vera is aimed at reducing the number of bloods cells. Phlebotomy, antineoplastic agents, and radiation therapy are used. The leukocytes of the patients with leukemia are abnormal cells that do not function as normal while cells do. In acute leukemia there is a sudden, rapid growth of immature blast or stem cells, rapid progression of the disease, and a short survival if the disease is not treated.

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Acute leukemia treatments consist primarily of chemotherapy with a combination of antineoplastic agents targeted at different phases of the cell cycle. Chemotherapy or palliative radiation is used to combat the disease. Hypocalcaemia and osteoporosis often develop, and patients must be monitored and treated for these complications. Pain assessment and management are crucial to the quality of life for the patient. The more common types of hemophilia, transfusion of the blood factors are used to replace the missing factors and prevent bleeding. The first signs of DIC is usually continued bleeding from an injection from an injection or IV site, extensive bruising in areas of injury, ecchymoses where there has been no trauma, and petechiae. Common signs and symptoms of a reaction are: o Chills o Itching or rash o Headache o Pain in the low back or chest If there is any sign of reaction, the blood transfusion is stopped immediately, saline is started, vital signs are taken, and the physician and charge nurse are notified. Vitamin C is given with iron because it enhances irons absorption.

Chapter 17
o o o o o o o o Low blood levels of good cholesterol appear to be a stronger predictor of heart disease in women than in men, particularly in the over-65 age group. High blood levels of triglycerides are another particular risk factor in women. The sinoatrial (SA) node is located in the right atrium and is called the pacemaker of the heart because it normally initiates the electrical impulses. The ejection fraction is the percentage of blood that is ejected from the heart during systole. Stroke volume equals the amount of blood pumped out of the heart each minute. Diastolic pressure is the pressure when the ventricles are in the relaxation phase, diastole, just before the next contraction of the ventricles. Unmodifiable risk factors cannot change and modifiable risk factors can change. Watch the patient receiving cardiac drugs for postural hypotension; have her hold on to the bedrails and steady herself for a couple of minutes after arising before beginning to walk. Potassium 3.5-5.0 is normal.

Chapter 18
o o o o o o o o o o Hypertension is defined as persistently high blood pressure. Look over Table 18-1 page 434. It is known as the silent killer. There are two types of hypertension o Essential o Secondary The goals of treatment for hypertension include: o Reduction of high blood pressure o Long-term control to decrease the risk of stroke, heart attack, and kidney disease. Patients with symptoms may complain of headache, dizziness, blurred vision, blackouts, irritability, fatigue, and nervousness. Hypertensive crisis is a life-threatening emergency. Embolus is a blood clot or debris that travels and lodges in a blood vessel. The most common etiology of peripheral arterial disorders is atherosclerosis. Intermittent claudication is pain when walking that diminishes at rest. Aspirin is the most commonly used anti-platelet agent. Medications to treat arterial insufficiency may cause serious adverse reactions. The major adverse reaction is bleeding. Observe the patient for and report immediately evidence of

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excessive bruising or bleeding, prolonged clotting after a needle stick, hematuria, changes in vital signs, or changes in neurologic signs. Dressings are changed several times a day, helping to debride (peel away dead tissue) the area. Compression dressings are not used if arterial insufficiency is present. Una boot is an example of a compression dressing. The dressing is changed from 2 to 3 days to every few weeks as needed. Signs and symptoms of PAD include intermittent claudication, pain at rest, and ischemic changes. The 5 Ps are pain, pallor, pulselessness, paralysis, and paresthesia.

Chapter 19
o o o o o o o o o o o o o o Half of patients diagnosed with HF will die within 5 years. Gastroesophageal reflux is the main system in a woman and there may be some persistent pain in the neck and shoulder or the jaw. (MULTI-MULTI) Know Table 19-1 page 464. Implantable cardioverter-defibrillators (ICD) is a device that detects shockable dysrhythmias and delivers a shock to convert the rhythm to normal providing more regular pump action. Angiotension-converting enzyme (ACE) inhibitors may be prescribed to decrease the work load of the heart by causing vasodilatation. Digitalis is used to increase the force of heart contraction and slow the rate thereby increasing cardiac output. Morphine is prescribed if pulmonary edema is present to relieve anxiety and make breathing easier. Eat 5 to 7 servings of fruit and vegetables per day. Know the different heart rhythms on page 473. Coumadin: PT should be 2 to 2 times the control or, if reported as INR, should be between 1.5 and 3.0; hold the medication and report values greater than this to the physician immediately. Automatic implantable cardiac defibrillators (AICD) are sued for patients who have repeated episodes of life-threatening ventricular fibrillation or cardiac asystole (arrest). Untreated strep throat is the most common cause of cardiac inflammation in children who do not have congenital cardiac abnormalities. Small deposits on the valve are called vegetation. Signs and symptoms of mitral valve disorders include: o Cardiac murmur o Progressive fatigue o Exertional dyspnea o Irregular heart rate o Gradual onset of HF Cardiac output falls and venous pressure rises; the arterial blood pressure falls and there is a narrowing pulse pressure accompanied by tachycardia. Cardiogenic chock may occur as a result of hypovolemia or cardiac tamponade caused by trauma.

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Chapter 20
o o Obstruction of blood flow usually is caused by atherosclerosis. Signs and symptoms of CAD: o Chest discomfort, including feeling of tightness, aching, burning o Chest pain (angina pectoris) radiating to the arm, jaw, or back o Dyspnea (shortness of breath) o Palpitations or tachycardia o Nausea and vomiting o Weakness and inability to complete usual activities without chest pain or dyspnea Know Cardiac enzymes Table 20-1 page 490. There are three types of angina: o Stable or exertional triggered by physical activity or stress

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Variant or vasospastic caused by coronary artery spasms that restrict the blood flow to the myocardium o Unstable medical emergency Nitroglycerin is the most common drug for treatment of angina. Alteplase(t-PA, Activase), streptokinase, tenesteplase(TNKase), and reteplase(Retavase) are contraindicated in patients who have sever, uncontrolled hypertension or a history of a hemorrhagic stroke, gastrointestinal (GI) bleed, intracranial or intraspinal surgery within the past 2 months, a brain tumor, arteriovenous malformation, or aneurysm. Look over Table 20-3 and Box 20-1 on page 499. o

Chapter 21
o Protect the nervous system by: o Wearing a helmet o Wearing safety hats or helmets o Have safety precautions when diving o Fasten children seat belts and even make sure adults have their seat belt on o Wear mask, gloves, long pants, and long-sleeved shirt when spraying with insecticide o Refrain from using recreational drugs Sympathetic and parasympathetic nerves have opposite effects on many organs. Once destroyed, cells in the brain cannot be replaced. The brains neurons cannot survive anoxia for more than 4 to 6 minutes. The number of functioning dendrites decreases with age. This decrease causes slower impulse transmission and resultant slower reaction time in the older person. Recent, short-term memory is affected by the aging process, but long-term, distant memory is often not affected. Know Cranial nerves Table 21-2 page 516. Nonpurposeful responses to pain occur in two ways: o Decorticate (flexor) posturing, which is the extension of the legs and internal rotation and adduction of the arms with the elbows bent upward o Decerebrate (extensor) posturing, the arms are stiffly extended and held close to the body, and the wrist are flexed outward Those patients who have difficulty eating are at risk for nutritional disorders and aspiration pneumonia. Patients with dysphagia should be sitting upright or in a high Fowlers position to eat. A bladder training program usually begins with a 2-hour schedule for toileting. Aphasia may be receptive, expressive, or global. The person with receptive aphasia has difficulty interpreting communications to him in either spoken or written form. In expressive aphasia, the person has difficulty expressing himself in speech or writing. Global aphasia is when the person has a combination of receptive and expressive aphasia. Aphasias vary in degree and in type of deficit. NCLEX Question #1 page 538.

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Chapter 22
o o Concussion is term used to describe a closed head injury in which there is a brief disruption in level of consciousness, amnesia regarding the occurrence, and a headache. A coup-countercoup injury, or an acceleration-deceleration injury, occurs when the head is moving rapidly and hits a stationary object. The contents within the cranium hit the inside of the skill (coup) and then bounce back and hit the bony area opposite the site of impact, causing a second injury (countercoup). (MULTI-MULTI) Make sure the head of the bed is raised 30 to 45 degrees with the body in correct alignment. The earliest sign of increasing ICP is lethargy and decreasing consciousness, accompanied by a slowing of speech and delay in response to verbal cues. Normal CCP is 70 to 100 mm Hg. The classic signs of increased ICP, with the first three called Cushings triad, are: o Rising systolic blood pressure

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Widening pulse pressure Bradycardia with a full, bounding pulse Rapid or irregular respirations

Chapter 23
o Seizure producing disorders: (MULTI-MULTI) o Brain injury from a stroke o Pressure from a brain tumor o Infectious diseases with high fever o End stage renal disease with uremia o Toxicity o Epilepsy o Tetanus Partial seizures also are called simple or focal seizures and result from an abnormal localized cortical discharge. Absence of petit mal seizures last only a few seconds. The onset is sudden, with no aura or warning and no postictal symptoms. (MULTI-MULTI) Idiopathic epilepsy has no known cause and symptomatic epilepsy has a known physical cause. Surgery for the prevention of a major stoke is reserved for carotid arteries that are 70% to 90% occluded and involves the removal of plaque deposited on the inner wall of the carotid artery. Astrocytoma are star shaped.

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Chapter 24
o A triad of symptoms are characteristic of PD: tremor, bradykinesia, and rigidity. o The first, tremor, occurs when the body is at rest, decreases when there is voluntary movement, and is absent when the patient is asleep. o Bradykinesia (condition exhibiting slow movement and speech) produces poor body balance, a characteristic gait, and difficult initiating movement. o The third symptom is rigidity affecting the skeletal muscles and contributing to postural changes and difficulty in movement. Giving meperidine to someone taking an MAOI can cause hyperpyrexia (excessive elevation of temperature) and possible death. Safety is a major factor. MS acute attacks are treated with intravenous (IV) methyprednisolone for 5 days followed by oral prednisone in tampering doses. Genetic transmission is by an abnormal gene on the short arm of chromosome 4. It is an autosomal dominant disorder, meaning that 50% of the children of a person who has the disease will inherit it. If a child does not inherit the disease, the gene is not passed on to the next generation. The intestine, bladder, and heart muscles are not affected in Myasthenia Gravis. A smile resembling a snarl if the cranial nerves are involved with Myasthenia Gravis.

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Chapter 27
o o o o o o o o o The transfer of nutrients from the intestine into the blood is referred to as absorption. Peristalsis is the rhythmic squeezing action. Metabolism is the sum of many dispositions of the absorbed nutrients. Anabolism is the need to build, maintain, and repair body tissue. Organs of the gastrointestinal (GI) system are the mouth, pharynx, esophagus, stomach, small intestine, large intestine, rectum and anus. The accessory organs are the liver, gallbladder, and pancreas. The appendix is attached to the cecum and has no known function in the digestive process. Mastication = chewing. Chyme is the mixed food that is broken down further the particles for absorption.

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The large intestine is populated with bacteria that aid in the breakdown of waste products. The gallbladder stores bile. The liver may store between 200 to 400 mL of blood. The pancreas islets of Langerhans secrete the hormones insulin and glucagon into the blood; insulin is essential to the metabolism of carbohydrates. The major pancreatic enzymes are amylase, protease, trypsin, and lipase; these enzymes are essential to the digestion and absorption of nutrients from the small intestine. Excessive stimulation of digestive acid and enzymes can cause a breakdown in the integrity of the mucous membrane lining the digestive tract. The damage to the mucous membrane can result in gastric or duodenal ulcers and chronic colitis. Refraining from eating raw oysters and shellfish from contaminated waters may prevent infection with hepatitis A. When laxatives are administered in liquid form, the patient can drink them more easily if they are chilled or poured over ice. MRI provides better contrast than CT between normal tissue and pathologic tissue. Know about your upper GI Series Table 27-1 page 671. After a liver biopsy, place a small dressing over puncture site; position patients on right side with support to provide pressure over biopsy site for 1-2 hours. Observe for bleeding. Loud, frequent sounds occur when there is excessive motility in the bowel. A resonant sound is heard over areas filled with air and a dull, thudding sound is heard over solid organs. Percussion detects excessive air in the intestinal tract, which occurs with irritation and inflammation. Evaluate the urine for presence of bilirubin, which makes the urine dark or the brown color of tea. Assisting the patient to walk along has traditionally been the nursing intervention for sluggish peristalsis or bloating.

Chapter 28
o o o o o o o o o o o o o o o o o o o Over half of Americans are overweight and 40 million are obese; 3 million Americans are morbidly over (100% over ideal body weight or a body mass index over 40). Circumgastric banding is a restrictive procedure. About a third of patients who undergo bariatric surgery develop gallstones. Watch to see that the larynx rises with each swallow. Gastroesophageal reflux disease (GERD) is a cause of Barretts esophagus, which is a precancerous condition. Care of the patients with Barretts esophagus is focused on encouraging measures to prevent GERD and on regular checkups. Patients should be encouraged not to use tobacco products and not to indulge in heavy alcohol use. Pain, increased temperature, and dyspnea indicate leakage of the feeding into the mediastinum. Ingestion of fats relaxes the sphincter, allowing reflux. Heartburn (dyspepsia) and reflux are the most common symptoms of GERD. Patients with GERD should avoid high fat and spicy foods, including garlic. Also they should stop smoking as it may stimulate gastric acid secretion. Do not administer digoxin with Nexium. The main cause of gastritis is Helicobacter pylori. Gastritis may be acute or chronic in nature. Untreated chronic gastritis may progress ulcer formation and upper GI hemorrhage. The chief cause of peptic ulcer is Helicobacter pylori. Daily dose of acetaminophen over 2g with other NSAIDs increase the risk of upper GI bleeding by twofold. Patients with multiple trauma, burns, or multiple system disorders are subject to physiologic stress ulcers. With a gastric ulcer the pain is diminished in the morning when secretion is low and after meals when food is in the stomach, and is most severe before meals and at bedtime. It takes 4 to 6 hours for the body to shift fluids from other compartments to the intravascular compartment. The shift of fluid changes the ratio of formed elements to fluids in the blood. The

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white cell count may be elevated in massive GI bleeding, probably because of the bodys response to injury or hypovolemia. An elevated level of blood urea nitrogen can indicate digestion of large amounts of blood. Proton pump inhibitors slow the livers ability to metabolize and clear some drugs from the bloodstream; they should be used with caution in patients taking diazepam, phenytoin and warfarin. The three major complications of peptic ulcer are: o Hemorrhage o Perforation o Obstruction Treatments for gastric cancer includes surgical intervention and radiation and/or chemotherapy. If coffee ground-like material is noticed in the tube, the drainage should be tested for presence of blood. Blood that has been in contact with gastric juices looks like coffee grounds.

Chapter 29
o The most common contributing factors in the developments of a hernia are: (MULTI) o Straining to lift heavy objects o Chronic cough o Straining to void o Straining at stools o Ascites The flow of intestinal contents becomes blocked by an incarcerated hernia, and the patient has symptoms of intestinal obstruction. This is an emergency because when the blood supply is restricted, part of the bowel may die. In a hernioplasty, some type of strong synthetic material is sewn over the defect to reinforce the area. The procedure is not most often done on an outpatients basis. Pepto-Bismol will make the stool black or dark red. In diverticula, the intestinal wall becomes irritated and infected, and if it is not treated, perforation and peritonitis may occur. Diverticula tend to develop in people over age 50 that have chronic constipation and/or eat a lowfiber diet. Diverticulitis occurs when the diverticula become inflamed or infected. The condition may be complicated by intestinal obstruction or by peritonitis if the intestinal wall ruptures. Mechanical obstructions include tumors, adhesions, strangulated hernia, twisting of the bowel (volvulus), telescoping of one part of the bowel into another (intussusceptions), gallstones, barium impaction, and intestinal parasites. A diet low-fat, low-fiber foods that have a high protein and caloric content is instituted for patients with Crohns disease. Pain in the lower right side, halfway between the umbilicus and the crest of the ileum, at McBurneys point is the best known symptom of appendicitis. Never use heat to relieve abdominal pain if appendicitis is a possible cause of the pain. An ice pack may be applied. A common complication of peritonitis is paralytic ileus. If the patients passes flatus or feces rectally, this should be recorded on the chart, as it indicates return of peristalsis. A key sign of malabsorption is passage of stool that is bulky, frothy, and found smelling and usually floats in the toilet. Know the different types of ostomies on page 728-729. Although not every patients needing an ileostomy can have a continent ileostomy, it is a safe and effective procedure for many. A noticeable lightening or blanching of the stoma may indicate inadequate blood flow through the tissues of the stoma itself. A deepening of color to a purplish hue may indicate obstruction of blood flow to the stoma.

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Chapter 30

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A return of the characteristic brown color to the stools is an indication that bile is entering the small intestine. Know about the different hepatitis table 30-2 pages 744-746. A definitive diagnosis of cirrhosis of the liver is made by liver biopsy. In cancer of the liver, pain may radiate to the back.

Chapter 35
o o o o o o o o o o o o o o o o o o o The endocrine system is made up of groups of cells whose primary function is to synthesize and release hormones directly into the bloodstream and body fluids. The hormonal need of a target tissue is being satisfied, production or secretion of the hormone will be inhibited is a concept known as negative feedback. Parathormone is produced and secreted by the parathyroid glands. It also acts on bone, causing the release of calcium from the bone into the bloodstream. The adrenal medulla (middle portion) secretes two hormones: o Epinephrine prepares the body to meet stress o Norepinephrine The two major types of hormones secreted by the adrenal cortex are: o Mineralocorticoids o Glucocorticoids Small amounts of androgenic hormones also are secreted, which have effects similar to those of the male and female sex hormones. Aldosterone, which promotes conservation of water by acting on the kidney to retain sodium in exchange for potassium, which is excreted in the urine. Cortisol acts to increase glucose levels in the blood. Cortisol also helps counteract the inflammatory response and helps with stress. The pancreas is both an endocrine and exocrine gland. The beta cells are responsible for producing and secreting insulin. Older adults are at risk for hyperglycemia and the onset of type 2 diabetes. The older adult experiences hypoglycemia more quickly than a younger person and may progress to dangerously low levers of blood glucose before signs and symptoms are obvious. Know table 35-1 and Table 35-2 on pages 878-879. Goiter, an overgrowth of the thyroid, may be prevented by sufficient intake of iodine. Iodine is available in foods grown near the ocean and seafood. Iodized salt is the major source for most people. Oral contraceptives, aspirin, and other drugs may render thyroid hormone assays useless, because they either increase or decrease the levels of thyroid hormones. Laboratory testing for serum calcium and phosphate levels is usually performed to assess parathyroid function. A glucose tolerance test revealing a postprandial glucose greater than or equal to 200, 2 hours after 75g of glucose is administered. In a GTT, the patients is given a set amount of glucose to evaluate insulin secretion and ability to metabolize glucose. Hg A1C is a test that measures blood glucose over a period of many weeks. 4.9%-6.7% is excellent rating for Hg A1C.

Chapter 36
o o o o The pituitary tumors antagonizes (acts against) the effect of the hormone insulin, resulting in an increase in blood glucose and glucose intolerance. A patient with a pituitary tumor should be kept in semi-Fowlers position and closely monitor vital signs and the patients neurologic status. (MULTI) Diabetes Insipidus is usually characterized my more than 2.5L/day of dilute urine. Strict (hourly) intake and output are essential to correct fluid losses and to titrate hypertonic saline infusion.

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If diabetes insipidus is untreated, the patients will demonstrate signs of shock and CNS manifestations progressing from irritability to eventual coma, resulting from hypernatremia and severe dehydration. One type of goiter is caused by a deficiency of iodine in the diet. Although the administration of iodine will not cute goiter, it will stop the continued enlargement of the gland. Iodine preparations should be given well diluted and administered through a straw, as they can stain the teeth. Because iodine circulates in the blood and is excreted by the kidneys, precautions must be taken when handling needles, syringes, and other equipment likely to be contaminated with blood, and bedpans, urinals, and specimen bottles likely to be contaminated by urine. In the subtotal thyroidectomy, two thirds of the glandular mass is removed. The remaining portion of the gland is left intact so production and release of thyroid hormones can continue. If the patients appears nervous, tense, and apprehensive, this should be reported to the surgeon and charge nurse. The patients is placed in the Fowlers position to facilitate breathing and reduce swelling of the operative area. The head may be supported with sandbags on either side to relieve tension on the sutures. A tracheostomy set is kept at the bedside of the postoperative thyroidectomy patients in case severe respiratory complications develop. Parathyroid hormone produces muscle cramps, twitching of the muscles, and, in some cases, severe convulsions. These symptoms represent a medical emergency and must be reported to the physician at once. Thyroid storm, also known as thyroid crisis, is another complication following a thyroidectomy. TS can also be caused by a patient with hypothyroidism who consumes an overdose of levothyroxine. The symptoms of TS are produced by a sudden and extreme elevation of all body processes. The temperature may rise to 106 degree or more, the pulse increases to as much as 200 beats per minute, respirations becomes rapid, and the patients exhibits marked apprehension and restlessness. Myxedema coma is life threatening. Treatment is administration of levothyroxine sodium IV, fluid replacement, maintenance of an airway and respiration, IV glucose administration, corticosteroids, and provision of warmth.