Medical-Surgical Nursing

BULLETS
 Anemia

• Classifications of anemia
• Renal failure - Renal
• Bone marrow depression - Aplastic
• Lack of nutrition - Nutritional
• Bleeding or RBC structural problems -
Morphologic
 Anemia
• Hallmark: Pallor

• Priority in most anemia: Oxygenation

• Pathognomonic for pernicious anemia:

Red-beefy tongue

• Priority in Sickle-cell anemia: Hydration

 Anemia
• Drug of choice for renal anemia: Epogen

• Drug of choice for Folic acid deficiency anemia: Folic

acid supplement: 1000 mcg

• Drug of choice for iron-deficiency anemia: FESO4

• Best given with Vitamin C

• Only treatment for pernicious anemia: Lifetime monthly

vitamin B12 IM injection
 Anemia
• Confirmatory for pernicious anemia:
Schilling’s test

• The best food source of iron for adults is liver.

• The best food source of iron for children is

egg yolk.
 Anemia

• Crisis in Sickle-cell anemia

• Pain - Sickle-cell crisis
• Infection with parvovirus - Aplastic
• Congestion of major organs - Sequestration
 Aneurysm
• Most common site: AORTA
• Common causes
• Pressure
• Blood vessel damage
• Danger: RUPTURE
• Predisposing factor for rupture:
HYPERTENSION
• Complications:
• Cardiogenic shock
• Hypovolemic shock
 Aneurysm

• Types:
• Affecting 3 walls: FUSIFORM
• Sac on one side: SACCULAR
• Made of tumor or other objects:

PSEUDO-ANEURYSM
• Tear inside: DISSECTING
• Drugs used to prevent rupture: ANTIHYPERTENSIVES
• VASODILATORS
• DIURETICS
 Alzheimer’s Disease
• Exact cause: Unknown

• Depleted neurotransmitter: Acetylcholine

• Hallmark: Dementia

• Priorities: Safety and Security

• DOC: Anticholinesterase
 Appendicitis
• Exact cause: Unknown

• Gender: Male

• Triad:
• Blumberg’s sign
• Low-grade fever
• Leukocytosis
 Appendicitis
• Assessment: (Pain)
• Rebound tenderness on RLQ: Blumberg’s sign
• Palpation on LLQ will cause more pain on RLQ:
Rovsing’s sign
• More pain on lateral hip flexion: Psoas’ sign
• Loss of pain: Rupture
 Appendicitis
• Absolute management: Appendectomy

• Must be done within 24-36 hours

• Anesthesia type: Spinal

• Postop position: Flat on bed (6-8 hours)

• Best indicator of peristalsis return: Presence of

bowel sounds
 Burns

• Most common type: Thermal

• Priority: Airway
 Burns
Shock Diuretic Recovery
(Emergent) (Compensatory) (Rehabilitative)

Time 1st 48 hours 2nd 48 hours 5th day onwards

Fluid imbalances Fluid volume de cit Fluid volume excess None

Hyponatremia Hyponatremia
Electrolyte imbalances
Hyperkalemia Hypokalemia Hypocalcemia

Acid-Base imbalances Metabolic Acidosis Metabolic Acidosis None

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 Cancer Concepts
• Age specific cancers:
• Children : Acute lymphoblastic leukemia
• Adolescents : Acute myolegenous leukemia
• Young adults : Hodgkin’s Disease
• Adults:
• Both gender : Breast
• Males : Breast
• Females : Breast
• Elderly : Colorectal
 Cancer Concepts

• Most common cancer (Gender-specific for males): Prostate

• Most common cancer (Gender-specific for females): Breast

•
 Cancer Concepts

• First sign of bladder cancer: Painless hematuria

• Cell identified in Hodgkin’s lymphoma: Reed-Sternberg Cell

• Virus allegedly causing Hodgkin’s lymphoma: Epstein-Barr

Virus
 Cancer Concepts
• Principles of care for a patient under radiation
therapy
• As low as reasonably achievable
• Safe distance: 6 feet
• Safe shield: Lead
• Safe time exposure: 30 mins / shift
• Absolute contraindications:
• Pregnant
• Children below 12 years old
Benign Prostatic Hyperplasia vs. Prostate Cancer
BPH Prostate Cancer

Cells Benign Malignant

Elevated hormone Estrogen Androgen

Age of onset 40 50

Tumors Multiple, small Single, large

Elevated PSA
(+) PSA
Labs Elevated Acid
(+) Acid Phosphatase
Phosphatase
 Cataract
• Most common cause: Aging

• Type of blindness: Legal

• Main symptom: Blurring of vision

• Treatment: Surgery
 Central Venous Pressure

• Measures the perfusion on the Right Atrium

• Entry point to the body: Subclavian Vein

• Entry point to the heart: Superior Vena Cava

 Central Venous Pressure

• Normal readings
• Manometer = 4-10 cmH20
• Gauge = 7-14 mmHg
• Interpretation:
• High = FVE / CHF
• Low = FVD
 Cholelithiasis / Cholecystitis
The liver can produce 700-1000 cc of bile every 24
hours.

The predisposing factors of gallbladder problems are:

Female
Fat
Forty
Fertile
Fair complexion
Family Planning
 CORONARY ARTERY
DISEASES
• The 4 E’s that predispose the attack of stable
angina are
emotional stress
exercise
extreme temperatures
eating heavy meals
• The pain of angina pectoris should not last more than 15
minutes.

• The drug of choice of angina pectoris is nitroglycerin.

• CAD’s are usually caused by atherosclerosis.

• The waste product of anaerobic glycolysis is lactic acid.

• The most sensitive laboratory test for myocardial
infarction is Troponin I.

• The most indicative laboratory test for myocardial

infarction is CK-MB.

• The most definitive laboratory test for myocardial

infarction is ECG.
• The drug of choice for myocardial infarction is aspirin.

• When giving morphine sulfate, RR must be monitored

because it can cause respiratory depression.

• The antidote for morphine sulfate is Naloxone.

• In MI, LDH flip may indicate multisystem failure.

• The most common complication of MI is dysrhythmias.

 Top 3 drugs in Angina Pectoris
(In order)

• Nitroglycerin

• Beta-Blockers

• Calcium-channel Blockers
ECG readings:
Hyperkalemia : Tall, peaked T-waves
Hypokalemia : Prominent U-Waves
MI, 1 4-24 hours
st : ST Elevation
MI, after 4-24 hours : ST Depression
T-Wave inversion
MI, refractory stage : Deep Q-Wave
 Congestive Heart Failure
• The major therapy in CHF is digitalis therapy.

• Digitalis have (+) inotropic and

(-) chronotropic effects.

• To prevent digitalis toxicity, potassium level must be kept

normal.

• The safest diuretic is the potassium-sparing.

 Congestive Heart Failure
• Bloodless phlebotomy is also known as rotating
tourniquet

• The effect of vasodilator in a client with CHF is that

it decreases the AFTERLOAD.

• The goal of diuretic therapy in CHF is to promote urination,

decreasing the blood volume.
 COPD
Asthma Bronchitis Emphysema

Disorder Allergic In ammatory Autoimmune

Alveolar
Involvement Ventilation Ventilation
diffusion

Productive
Hallmark Wheezing Barrel Chest
Cough

Other name ROAD / RAD Blue Bloaters Pink Puffers

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 COPD
• Oxygen delivery: Low-flow (1-3 LPM)
• Most accurate method: Venturi mask
• Mixes with room air: Nasal cannula

• Diet:
• Consistency: Soft
• Frequency: SFF
 COPD

• The most common side effect of bronchodilators is

tachycardia

• In asthma, the damage to the mast cells by the IgE

can cause release of histamine 1.

• Histamine 1 can cause bronchoconstricton and

vasodilation
 COPD

• The best position to promote maximum lung expansion

is orthopneic.

• In bronchitis, the excessive production of secretion is

caused by the activation of Goblet cells.

• Right-sided CHF secondary to COPD is known as cor

pulmonale.
 COPD

• Permanent alveolar dilation is known as

Emphysema.

• The primary symptoms of the “Blue Bloaters”

are cyanosis and edema.

• Cromolyn sodium is classified as a mast cells

stabilizer.
 COPD

• Pulmonary hypertension may occur for a pressure

exceeding 25 mmHg

• The main purpose of pursed-lip breathing is to

expel more carbon dioxide.
 Cushing’s and Addison’s Disease
• The hormones of adrenal cortex are:
– Glucocorticoids – major is cortisol
• Gluconeogenesis
• Fat distribution
– Mineralocorticoids – major is aldosterone
• Sodium retention
• Potassium excretion
– Sex hormones – androgen, progesterone, estrogen
• Development of secondary sex characteristics
 Cushing’s and Addison’s Disease
• The hypersecretion of adrenal cortex is known as
Cushing’s disease.

• Hypercorticism secondary to administration of

steroids is known as Cushing’s syndrome.

• Fat misdistribution in Cushing’s disorders may

cause thinning of arms and legs, Buffalo hump and
truncal obesity.
 Cushing’s and Addison’s Disease
• Truncal obesity may cause congestion of femoral
veins that may lead to venous thromboembolism.

• Lability of mood in Cushing’s disease is caused by

excessive glucocorticoids.

• Hypertension in Cushing’s disease is caused by

excessive mineralocorticoids.
 Cushing’s and Addison’s Disease
• Primary adrenal hypofunction is known as
Addison’s disease.

• The occurrence of profound weakness, shock and

pains in Addison’s disease is known as
Addisionian crisis.

• The goal to a client with Addison’s disease is to

prevent irreversible shock.
Cushing’s and Addison’s Disease

Diet Cushing’s Addison’s

Potassium High Low

Sodium Low High

Calorie Low High

Fluids Low High

 Diabetes Mellitus
• Upon taking glucose, it will transported to the cells
within 2 hours.

• Insulin lowers blood glucose level by transporting

glucose to the cell and converting excess to become
glycogen.

• The hormone that raises blood glucose level by

converting glycogen to become glucose during
hypoglycemia is Glucagon
 Diabetes Mellitus
• Diabetes mellitus is prolonged hyperglycemia

• Gestational DM is caused by elevation in the hormone

human chorionic somatomammotropin which
antagonizes insulin.

• The closest predisposition of IDDM is heredity.

• The closest predisposition of NIDDM is obesity.

 Diabetes Mellitus
• Cushing’s related DM is related to elevation in the
hormone glucocorticoids.

• Polyuria in DM is secondary to osmotic diuresis.

• Polydipsia in DM is secondary to total dehydration.

 Diabetes Mellitus

• Polyphagia in in DM is caused by cellular starvation.

• The hallmark of DKA is Kussmaul’s breathing

• The only management of DKA is IV insulin.

• The triad of management of DM are

–Diet
–Activity
–Medications

• OHAs are only used to NIDDM.

 Diabetes Mellitus
• The reason for rotating sites for insulin administration is to
prevent lipodystrophy.

• The ideal route of insulin is subcutaneous.

• Rebound hyperglycemia to a client taking insulin is known

as the Somogyi phenomenon.

• The only insulin given IV is the regular insulin.

 Diabetes Mellitus
• Complications of administering IV insulin
• hypokalemia
• hypoglycaemia
• edema

• The most accurate test to determine blood glucose level

is FBS.

• The most accurate test to diagnose DM is glycoslated

hemoglobin.
 Diabetes Mellitus

• Signs of Hypoglycemia
• G ait disturbances (dizziness)
• U nusual perspiration
• T achycardia
• O bivous tremors
• M oodiness
 Diabetic Ketoacidosis

• Common cause: Missed insulin

• Hallmark: Kussmaul's breathing

• Management: IV insulin
 Glaucoma
• Most common cause: Heredity

• Type of blindness: Total

• Main symptom: Eye pain

• Primary Treatment: Miotics

 Guillain - Barre Syndrome
Exact cause: Unknown

Predisposing factor: Postviral exposure

Pathophysiologic basis: Polyneuritis

Classic sign: Ascending paralysis

Priorities: S B A

DOC: Steroids 69
 Hypertension
• Most common type: Primary

• BP of 140/90 or more for 6 months or longer.

• Common complication: Nephropathy

• Drugs used:
• Vasodilators
• Diuretics
71
 Hyperthyroidism and Hypothyroidism
• When taken by oral route, iodine will stay in the
blood for 6 hours before it is utilized by the thyroid
gland.

• The hormones of the thyroid gland are;

– T3 – metabolism
– T4 – heat production
– TC – PTH antagonist
 Hyperthyroidism and Hypothyroidism
• The most dangerous symptoms of hyperthyroidism are
cardiovascular symptoms.

• To control hypertension and tachycardia in hyperthyroidism,

the drug beta-blockers must be given.

• The most serious side effect of thioamides is bone marrow

depression.
 Hyperthyroidism and Hypothyroidism
• After thyroidectomy, the client must be placed in semi-
Fowler’s position.

• Hypocalcemia after thyroidectomy is caused by possible

damage to the parathyroid glands.

• Signs of tetany are: (+) Chvostek’s sign, (+) Trousseau’s sign

and laryngospasm.
 Hyperthyroidism and Hypothyroidism
• Because of possible laryngospasm after
thyroidectomy, tracheostomy set must be at
bedside.

• The first sign of thyroid crisis is hyperthermia.

• To reverse hypocalcemia, calcium gluconate must

be administered to the client.
 Hyperthyroidism and Hypothyroidism
• Exopthalmos in Grave’s disease is known as the
Dalyrimple’s sign.

• The priority to a client having CNS involvement in

hyperthyroidism is safety.

• The rationale for administering iodides prior to

thyroidectomy is to reduce the size and vascularity
of the thyroid gland.
 Hyperthyroidism and Hypothyroidism
• To assess laryngeal nerve damage after thyroidectomy,
observe for hoarseness of voice.

• Facial twitching upon tapping of facial nerve is known as the

(+) Chvostek’s sign.

• Carpal spasm upon occlusion of brachial nerve is known as

the (+) Trousseau’s sign.
 Hyperthyroidism and Hypothyroidism
• Hypothyroidism for the adults is known as
Myxedema.

• Hypothyroidism for the children is known as

Cretinism.

• Hyperlipidemia and bradycardia in hypothyroidism

often leads to atherosclerosis.
 Hyperthyroidism and Hypothyroidism

• Too little T4 in hypothyroidism may cause cold

intolerance.

• The drug of choice for hypothyroidism is

levothyroxine (synthroid)
 Liver Cirrhosis
• Most common type: Laennec’s

• Primary biliary cirrhosis is caused by

obstruction of the common hepatic duct.

• RSCHF may lead to cardiac cirrhosis.

 Liver Cirrhosis
• Laboratories for liver cirrhosis:

– Most sensitive: Elevated total bilirubin

– Most indicative: Elevated liver enzymes

– Most definitive: Liver biopsy

• After liver biopsy, the client must be placed on the

RIGHT side.
 Liver Cirrhosis
• The waste product that increases in liver
cirrhosis is ammonia.

• Signs of hepatic encephalopathy are:

– Motor: asterixis
– Psychological: Hallucinations, Illusions, delusions
– Neurological: Altered LOC
 Liver Cirrhosis
• The earliest impending signs of encephalopathy
• asterixis
• fetor hepaticus

• To reduce ammonia, management:

• Diet: Giordano Giovannetti
• Lactulose
• Neomycin sulfate

• The management of choice for esophageal bleeding is

Sengstaken-Blakemore tube.
 Liver Cirrhosis

• The balloon is SBT must be released every 15 minutes to

avoid tissue damage.

• Emergency equipment needed in SBT is scissors.

• The most indicative sign of esophageal bleeding is

frequent swallowing.
 Meniere’s Disease

• Also known as: Endolymphatic hydrops

• Exact Cause: Unknown
• Part affected: Inner ear
 Meniere’s Disease
• Triad:
• Tinnitus
• Vertigo
• Sensorineural hearing loss

• Priority: Safety

• Diet: Low-sodium
 Multiple Sclerosis
Exact cause: Unknown

Predisposing factor:
• G enetics
• U nnecessary radiation exposure
• N utrition
• S low acting virus

Pathophysiologic basis: Systemic demyelination

90
 Multiple Sclerosis
Earliest sign: Diplopia

Hallmark: Charcot’s Triad

• Scanning of speech
• Intentional tremors
• Nystagmus

Priorities: S - A - B - A - P
91
92
 Muskulo-Skeletal System
• The hormone the moves calcium from the bone to the blood
is the parathyroid hormone.

• The mainstay drug in rheumatoid arthritis is aspirin.

• Aspirin is used in arthritis because of its analgesic and anti-

inflammatory properties.
 Muskulo-Skeletal System

• The major goal in any form of arthritis is to prevent joint

deformities.

• The effect Gold compound preparations may be noticed in

3-6 months

• The only anti-arthritis drugs that doesn't cause GI irritation

are the Cox-2 Inhibitors
 Muskulo-Skeletal System
• Relevant hormonal changes in women that predisposes
osteoporosis is decrease in ESTROGEN

• The back brace must be worn 23 hours a day.

• Defined as a break in the continuity of the bone is FRACTURE

 Muskulo-Skeletal System
Types of Fractures

Crack on one side - Greenstick

Bone is fragmented - Comminuted
Caused by twisting force - Spiral
Bone forced to each other - Impacted
Broken bone pressed inward - Depressed
 Muskulo-Skeletal System
6 P’s of Neuromuscular Damage
• Pain
• Paresthesia
• Paralysis
• Pulselessness
• Poikilothermia
• Pallor
 Muskulo-Skeletal System
Emergency Management of Fracture

Rest
Ice
Compression
Elevate
 Muskulo-Skeletal System
Principles of Fracture Management
Immobilization

Reduction

Alignment
 Muskulo-Skeletal System
Osteomyelitis
Common agent - Staphylococcus Aureus

Complication - Septicemia

DOC - Cefazolin (Ancef)

Preventive surgery - Debridement

 Muskulo-Skeletal System

Gouty Arthritis
• Common joint : big toe

• Symmetry : random

• Involvement : systemic

• Hallmark : tophi
 Muskulo-Skeletal System

OSTEOARTHRITIS
• Also known as degenerative joint disease

• Common joints : weight-bearing

• Symmetry : unilateral

• Involvement : local

• Hallmark : osteophytes
 Muskulo-Skeletal System

Rheumatoid Arthritis
• Common joints : small joints

• Symmetry : bilateral

• Involvement : Systemic

• Hallmark : bony ankylosis

 Myasthenia Gravis

Depleted neurotransmitter: Acetylcholine

Hallmark: Muscle weakness

Confirmatory Test: Tensilon Test

DOC: Neostigmine / Pyridostigmine

 Pancreatitis
• Exact cause: Unknown

• Predisposing factors:
• male
• middle-age
• medicine / substance
• meat / heavy meal
• midnight

• Hallmark: Autodigestion
 Pancreatitis
• Drug of choice: morphine sulphate
• Given with antispasmodic drugs

• Laboratories:
• Most sensitive: Elevated lipase
• Most indicative: Elevated amylase
• Most definitive: Autopsy
 Parkinson’s disease
• Exact cause: Unknown

• Depleted neurotransmitter: Dopamine

• Hallmarks:
• Muscle rigidity
• Tremors

• Priority: Safety
 Parkinson’s disease

• Cranial nerves affected:

• Early: 7 and 11
• Late : 9 and 12

• Drugs given
• Dopaminergics
• Anticholinergics
 Peptic Ulcer Disease
• The cells responsible in producing HCl are the parietal cells.

• Stress ulcer is also known as Curling’s ulcer.

• To obtain maximum effect, the drugs for PUD must be taken:

– Antacids – 1-2 hours after meals
– H2 Blockers – with meals
– Cytoprotective drugs – 30-60 mins. before meals.
 Peptic Ulcer Disease
• Diet: Bland

• Surgical management:
• Billroth 1 - Gastroduodenostomy
• Billroth 2 - Gastrojejunostomy

• Complication of Billroth procedures: Dumping

Syndrome
• Peritonitis
– Most common cause: perforated ulcer
– Classic sign: rigid, board-like abdomen
– Complications:
– septicemia
– respiratory depression

• The microorganism which is thought to cause PUD is

H. Pylori.
 Peripheral Vascular Disorders
Raynaud’s Buerger’s

Blood vessels Arteries Arteries & Veins

Extremity Upper Lower

Gender Female Male

 Peripheral Vascular Disorders
• Pain upon dorsiflexion is known as (+) Homan’s
sign.

• The best time to wear the antiembolism stocking is

before arising from bed.

• Buerger’s disease is also known as

thromboangiitis obliterans.
 Peripheral Vascular Disorders
Heparin Warfarin

Route IV / SC Oral

Labs checked PTT PT

Antidote Protamine SO4 Vitamin K

Advantage Fast-acting Long half-life

 Pneumothorax

• Most common type: Secondary

• Type of pain
• Pleuritic - more pronounced on inhalation
• Drug of choice - Codeine SO4
 Pneumothorax

• Best position to promote breathing: Semi-Fowler’s

• Oxygen delivery: Low-flow

• Main management: Chest-Tube Thoracostomy

 PSORIASIS

• Exact cause: Unknown

• Most common type: Vulgaris
• Most serious type: Erythrodermic
• Treatments:
• Coal tars
• Steroids
• Chemotherapy
 Renal Failure
• Acute
• Reversible
• Sudden
• Azotemia
• Chronic
• Irreversible
• Progressive
• Azotemia
 Renal Failure

• Type of azotemia: uremia

• Most accurate diagnostic: Creatinine clearance
• Diet: Giordano Giovannetti
• All electrolytes are elevated except for calcium
• Crisis: hyperkalemia
 Retinal Detachment
• Common cause: Trauma

• Triad
• Floaters
• Flashes of lights
• Curtain-shadow across visual field

• Type of blindness: Spot blindness

• Surgery of choice: Scleral buckling

 Shock
• Problems on 3 P’s
• Pump
• Passenger
• Passageway

• Most common type: Hypovolemic

• Most dangerous: Cardiogenic

 Shock
• Types:
• Hypovolemic - low blood volume
• Cardiogenic - failure of the heart to maintain circulation
• Distributive - systemic vasodilation
• Septic - infection
• Anaphylactic - allergy
• Neurogenic - pain
• Obstructive - physical or mechanical obstruction
 Shock
• Primary compensatory mechanisms
• Tachycardia
• Activation of SNS
• Activation of RAAS

• Best drug to increase BP: Dopamine

 Systemic Lupus Erythematosus

• Exact cause: unknown

• Hallmark: (+) ANA
• Pathognomonic: Butter y rash
• Most common complication: Renal failure
• DOC: Steroids
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 TRAUMATIC HEAD INJURY

Signs of Increased ICP

B P & temp = increased
R R & HR = decreased
A ltered LOC
I rritability
N&V
S eizures
Signs of Increased ICP: Cushing’s Triad

Systolic hypertension

Widened pulse pressure

Bradycardia
Drugs used in treating Traumatic Head Injury

• In ammation or swelling: Steroids

• Cerebral edema: Mannitol
• Bleeding: Vasopressin
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• The priority to a client having seizures is safety.

• The most common sign of autonomic

dysreflexia is pounding headache.

• The normal ICP is 0-15 mmHg

 Triage
Primary goal: To preserve life

Primary Survey: Used to unconscious or unable to respond

Airway
Breathing
Circulation
Disability
Electrolytes
Fluids
 Triage

Secondary Survey: Used to conscious victims

Chief complaint
History
Exact location
Compare
Keep checking
 Triage
• By color
• Immediate - Red
• Expectant - Black
• Delayed - Yellow
• Minimal - Green
 Triage
• By classification:
• Care may be delayed / less chance of
survival: Non-urgent
• Care within 1-2 hours: Urgent
• Without fail: Emergent
 Triage
• Comprehensive critical care:
• Normal ward: Zero
• Multiple organs / systems involved:
Three
• 1 additional support: One
• Single failing organ: Two
 Urinary Tract Infection

• Common pathogen: E. Coli

• Types
• Upper - pyelonephritis
• Lower
• Bladder - cystitis
• Urethra - urethritis
 Urinary Tract Infection

• Classic symptoms of lower UTI:

• Frequency
• Urgency
• Dysuria
• Hallmark of pyelonephritis: CVA
tenderness
 Urinary Tract Infection

• Cause of dysuria: irritation

• DOC: Pyridium

• Cause of suprapubic pain: bladder

spasm
• DOC: Probanthine
 Urinary Tract Infection
• Management:
• Fluid intake = 3-5 liters
• Diet: Acid-ash
• Hygiene (3W’s)
• Wash
• Wear
• Wipe