Download Ignatavicius: Medical-Surgical Nursing, 7th Edition

FINAL EXAM STUDY GUIDE: Focus on recognizing the disorders and knowing the treatments and other
management, and know nurse priorities
YELLOW HIGHLIGHTS ARE MAIN NOTES TO KNOW FOR FINAL, BUT STUDENTS SHOULD HAVE LEARNED
MOST OF THE KEYPOINTS
BLOOD PRESSURE MANAGEMENT: Know your medication classifications by suffixes
Essential or Primary Hypertension: recognize suffixes to know classifications of meds
Pre-hypertension SBP 120-139 DBP 80-89? Lifestyle changes
Stage 1: SBP 140-159, DBP 90-99: diuretic ordered first, name a few? Doctor may order an ACEname one? What do ACEs end in usually? What is an adverse effect that would make this med
be discontinued?
Stage 2: SBP >160 or DBP >100: diuretics and may receive a beta blocker: name one? What
does it end in? What VS are you checking in a patient on this? When would you not give this
med? What is an example of an ARB?
What BP is Hypertensive Crisis (Malignant Hypertension) Symptoms & Management
What is a common antihypertensive side effect that makes patients quit their meds? What can
a nurse teach a patient to cope with this?
Dietary:
Sodium: What are the major dietary sources?
The average American gets about 3,400 mg of sodium a day — much more than recommended
(2300 mg) Here are the main sources of sodium in a typical diet:
Processed and prepared foods. The vast majority of sodium in the typical American diet comes
from foods that are processed and prepared. These foods are typically high in salt and additives
that contain sodium. Processed foods include bread, prepared dinners like pasta, meat and egg
dishes, pizza, cold cuts and bacon, cheese, soups, and fast foods.
Reduce sodium, DASH diet Also control diabetes
What should lipid levels be? Total? LDL? Triglycerides? HDL? Which one is “protective”?
A patient who has chest pain after exertion but the pain resolves after resting has experienced:
1. infarction
2. ischemia (intermittent chest pain is called what?)
The primary factor in developing heart disease is:
1. arteriosclerosis
2. atherosclerosis
Recognize peripheral arterial disease signs & symptoms from peripheral venous-refer to
keypoints in the cardiac module for review of arterial versus venous ulcers, for example, if you
don’t recall the info
ACUTE PERIPHERAL ARTERIAL OCCLUSION Signs & Symptoms Below
 Acute arterial occlusions may be sudden and dramatic, usually caused by an embolus from recent
acute myocardial infarction and/or atrial fibrillation.
 Those with acute arterial insufficiency often present with the “six P’s” of ischemia: pain, pallor,
pulselessness, paresthesia, paralysis, and Poikilothermia
 Anticoagulant therapy with unfractionated heparin is usually the first intervention.
HEART FAILURE
 Heart failure, sometimes referred to as pump failure, is a general term for the inability of the heart to
work effectively as a pump.
 The major types of heart failure are left-sided, right-sided, and high-out put failure, but we focused on
Left & Right
 Because the two ventricles of the heart represent two separate pumping systems, it is possible for one
to fail by itself for a short period, however, most heart failure begins with failure of the left ventricle
and progresses to failure of both ventricles.
 Typical causes of left-sided ventricular failure include hypertensive, coronary artery, and valvular
disease involving the mitral or aortic valve.
 Left-sided failure may be acute or chronic and mild to severe.
 When cardiac output is insufficient to meet the demands of the body, compensatory mechanisms
attempt to improve cardiac output.
 Compensatory mechanisms include sympathetic nervous system stimulation, renin-angiotensin system
activation, chemical responses, and myocardial hypertrophy.
 Heart failure is caused by systemic hypertension in the majority of cases.
 The next most common cause includes structural heart changes.
 Assess the patient for manifestations of right- and left-sided HF.
 When obtaining a history, ask about the patient’s perception of his or her activity tolerance, breathing
pattern, urinary pattern, and fluid volume status.
 Impaired perfusion, pulmonary congestion, and edema indicate left ventricular failure.
 Systemic venous congestion and peripheral edema indicate right ventricular failure (Edema in
extremities & JVD)
 Electrolyte imbalance may occur from complications of failure or as side effects of drug therapy, especially
diuretic therapy.
 Echocardiography is the best tool in diagnosing heart failure (election fraction 40% or less is HF) cardiac
valvular changes, pericardial effusion, chamber enlargement, ventricular hypertrophy, and ejection fraction.
 Interventions to improve stroke volume include reducing afterload, reducing preload, and improving
cardiac muscle contractility- meds similar to those for hypertension
 A major role of the nurse is to give medications as prescribed, monitor for their therapeutic and
adverse effects, and teach the patient and family about drug therapy.
 Weigh daily and record intake and output of patients with HF.
 Assess for early signs and symptoms of pulmonary edema (e.g., crackles in the lung bases, dyspnea at
rest, disorientation, confusion), especially in older adults.
HEART FAILURE CONTINUED
 Identify the precise location of crackles and wheezes and whether the wheezes are heard on
inspiration, expiration, or both.
 Assess for symptoms of worsening HF: rapid weight gain (3 lb in a week), a decrease in exercise
tolerance lasting 2 to 3 days, cold symptoms (cough) lasting more than 3 to 5 days, nocturia,
development of dyspnea or angina at rest, or unstable angina.
 Monitor the HF patient on beta blockers carefully for hypotension and bradycardia.
 Monitor the pulse of patients taking digitalis preparations before administration, and report to the
health care provider a pulse that is not within the desired parameters.
 Place the patient in a sitting position and provide oxygen therapy at a high flow rate (unless otherwise
contraindicated) if pulmonary edema is suspected.



Provide teaching about self-management at home for patients with HF.
Monitor older adults who are taking digoxin for manifestations of toxicity.
o Monitor potassium levels to check for hypokalemia.
Teach patients taking ACE inhibitors or ARBs to change positions slowly to avoid
orthostatic hypotension, especially older adults.
Ignatavicius: Medical-Surgical Nursing, 7th Edition
Chapter 32: Care of Patients with Noninfectious Lower Respiratory Problems

Key Points
Lower airway disorders affect gas exchange, oxygenation, and tissue perfusion.

Many problems are chronic and progressive, requiring changes in lifestyle.
CHRONIC AIRFLOW LIMITATION DISORDERS
ASTHMA
Asthma is an intermittent disease with reversible airflow obstruction and wheezing, affecting only the
airways




Status asthmaticus is a severe, life-threatening, acute episode of airway obstruction that intensifies
once it begins and often does not respond to common therapy. It requires immediate emergency
treatment.
With poor control of asthma, chronic inflammation leads to damage and hyperplasia of the
bronchial epithelial cells and smooth muscle.
Airway obstruction can occur as a result of inflammation, which obstructs the lumen of the airways,
or from airway hyper-responsiveness.
Patients have episodes of dyspnea, chest tightness, coughing, wheezing (which is louder on
exhalation), increased mucus production, and accessory muscle use.



Pulse oximetry demonstrates hypoxemia related to the degree of dyspnea.
Laboratory tests include arterial blood gases levels, and sputum cultures
The most accurate tests for asthma are pulmonary function tests
 The goals of therapy are to improve airflow, relieve symptoms, and prevention.
Pharmacologic management includes bronchodilators, anti-inflammatory agents, and leukotriene
inhibitors REFER TO COPY OF THE RESP LECTURE PRE-WORK WORD DOC THAT IS ATTACHED BELOWKNOW WHICH MEDS ARE PREVENTIVE & WHICH ARE RESCUE & CLASS




Daily preventive therapy drugs change airway responsiveness to prevent asthma attacks.
Rescue drugs are those used to stop an attack
Aerobic exercise assists in maintaining cardiac health, enhancing skeletal muscle strength, and
promoting ventilation and perfusion.
Patients must be able to self-assess respiratory status, adjust the frequency and dosage of
prescribed drugs, and determine when to consult the health care provider.



Teach patients with chronic airflow limitation how to use a peak flowmeter, since readings
determine if rescue treatment is working KNOW THE ZONE COLORS- Percentage for Green, and
RED
Teach the patient who has a reading in the red zone to immediately use the rescue drugs and seek
emergency help.
Remind patients with asthma to have their rescue inhalers with them at all times
COPD










Emphysema and chronic bronchitis are termed chronic obstructive pulmonary disease, known as
COPD, and result in irreversible and increasingly severe tissue damage.
Pulmonary emphysema involves loss of lung elasticity and hyperinflation of the lung, causing
dyspnea, increased respiratory rate, and, eventually, cardiac failure KNOW THIS TYPE OF HF IS
CALLED COR PULMONALE & IS IT RIGHT SIDED OR LEFT HF? KNOW CHEST REMODELING-WHAT
SHAPE?
Bronchitis is an inflammation of the bronchi and bronchioles caused by chronic exposure to irritants,
especially tobacco smoke, triggering inflammation with vasodilation, congestion, mucosal edema,
and bronchospasm COPD PATIENTS OFTEN HAVE BOTH CHRONIC BRONCHITIS & EMPHYSEMA
Chronic obstructive pulmonary disease is classified from mild to severe. KNOW WHAT GOLD STANDS
FOR
Arterial blood gases identify oxygenation, ventilation, and acid-base status.
Good management strategies help maintain adequate oxygenation and tissue perfusion, as well as
overall health, even with irreversible damage.
COPD Treatment: Careful use of drugs combined with controlled coughing, hydration
The mainstays of nursing management for patients with COPD include airway maintenance,
monitoring, breathing techniques, positioning, effective coughing, oxygen therapy, exercise
conditioning, suctioning, hydration
Remember to assess the airway and breathing for patients who experience shortness of breath or
changes in mental status, and apply oxygen to anyone who is hypoxemic.
Before any intervention, assess the patient to determine the breathing pattern, especially the rate,
rhythm, depth, and use of accessory muscles. The patient with COPD relies more on accessory
muscles than on the diaphragm for breathing.
Ensure proper oxygen flow rate for patients with long-term carbon dioxide retention KNOW WHY














Teach patients to monitor the peak expiratory flow rates at home and adjust drugs.
Teach the patient techniques of pursed-lip breathing, diaphragmatic breathing, coughing and deep
breathing, positioning, relaxation therapy, and energy conservation.
Diaphragmatic or abdominal and pursed-lip breathing may be helpful for managing dyspnea
episodes.
Perform suctioning only when needed, not on a routine schedule. Assess for improved breath
sounds after suctioning.
Maintaining hydration may thin the thick, tenacious (sticky) secretions, making them easier to
remove by coughing.
The patient with COPD often has food intolerance, nausea, early satiety, loss of appetite, and mealrelated dyspnea. KNOW THAT COPD PATIENTS ARE OFTEN THIN
Ensure there are no open flames or combustion hazards in rooms where oxygen is in use.
Assess the degree to which breathing problems interfere with the patient’s ability to perform ADLs,
work, and leisure time activities RECOGNIZE NURSING DIAGNOSIS FOR FATIGUE
Monitor the rate and depth of respiration for any patient with hypercarbia and CO2 narcosis who is
receiving oxygen by mask or nasal cannula Nursing Management: KNOW WHY TOO HIGH
SUPPLEMENTAL 02 MAY DECREASE RESPIRATORY RATE IN A COPD PATIENT-REFER TO RESPIRATORY
DRIVE
Assess the airway and breathing effectiveness for any patient who experiences shortness of breath
or any change in mental status.
Ensure that oxygen therapy delivered to the patient is humidified.
Monitor arterial blood gases and oxygen saturation of all patients receiving oxygen therapy.
Lung transplantation and lung reduction are surgical treatments.
The more common surgical procedure for patients with COPD is lung reduction surgery.
The goal of lung reduction surgery is improved oxygenation after removing hyper-inflated tissue
LUNG CANCER







Tumors in the bronchial tubes can grow and obstruct the bronchus partially or completely, and tumors in
other areas can obstruct the airway by compressing it TYPES: SMALL CELL LUNG CANCER & NON SMALL
CELL LUNG CANCER
Staging of lung cancer based on the TNM system is performed at diagnosis to assess the size and extent of
the disease, which correlates to survival rate KNOW WHAT “T N & M” STAND FOR
Lung cancers occur as a result of repeated exposure to inhaled substances that cause chronic tissue
irritation or inflammation, with cigarette smoking as the major risk factor.
Primary prevention for lung cancer is directed at reducing tobacco smoking.
Manifestations of lung cancer are often nonspecific and appear late in the disease process depending on
the type and location of the tumor BE ABLE TO RECOGNIZE SIGNS, SUCH AS INCREASED COUGHING
Lung lesions are usually first identified on chest x-rays, and then CT scans are used.
Bronchoscopy provides direct visibility of the tracheobronchial tree and procurement of specimens and










biopsy.
Interventions for the patient with lung cancer are aimed at curing the disease, increasing survival time,
and enhancing quality of life through palliation.
Targeted chemotherapy is now more common in treatment of later-stage lung cancer KNOW NURSING
MANAGEMENT FOR NAUSEA & VOMITING & THE MEDS WERE IN PERI-OP PRE-WORK, EX: ZOFRAN
Radiation therapy can be an effective treatment for locally advanced lung cancers confined to the chest
and is often combined with chemotherapy NURSING MANAGEMENT- SIDE EFFECTS SKIN IRRITATION, ETC
Surgery is the main treatment for early stages in hope of achieving a cure.
Encourage all patients older than 50 years of age and anyone with a respiratory problem to receive a
yearly influenza vaccination.
Teach all patients who smoke the warning signs of lung cancer KNOW A FEW SYMPTOMS, SUCH AS
INCREASED COUGHING
Encourage the patient and family to express their feelings regarding the diagnosis of cancer or the
treatment regimen.
Explain all diagnostic procedures, restrictions, and follow-up care to the patient scheduled for tests.
Help patients use strategies to improve their appearance when alopecia occurs.
Refer patients and family members to local cancer resources and support groups.
PLEURAL EFFUSION







Pleural effusion is a collection of fluid in the pleural space. It is not a disease but rather an
indication of another disease.
Pleural effusion is frequently classified as transudative or exudative according to whether the
protein content of the effusion is low or high, respectively.
A transudate occurs primarily in non-inflammatory conditions and is an accumulation of proteinpoor, cell-poor fluid, such HF
An exudative effusion is an accumulation of fluid and cells in an area of inflammation.
An empyema is a pleural effusion that contains pus.
The type of pleural effusion can be determined by a sample of pleural fluid obtained via
thoracentesis (a procedure done to remove fluid from the pleural space).
The main goal of management of pleural effusions is to treat the underlying cause
CHEST TUBES: Know what the tubes drain and what 3 collection chambers are in drainage system,
how to recognize a “leak” and what to do if a CT is accidentally pulled out of a patient (what site is
covered with)
Recognize classifications of resp meds such as bronchodilator, SABA, LABA, corticosteroid, teaching
regarding inhaler & spacer, what patient needs to do after inhaled corticosteroid, etc.
Respiratory Lecture Pre-Work
(this is the word doc posted in respiratory module)
Asthma Pharm
 Anti-inflammatory agents/corticosteroids: solu-medrol, prednisone,
fluticasone
 Short-acting anticholinergic: ipratropium
 Long-acting anticholinergic: tiotropium
 Anti-IgE: omalizumab
 Leukotriene Modifiers: montelukast
 B2-Adrenergic Agonists: inhaled short-acting-albuterol, levabuterol,
inhaled long-acting-salmeterol
 Methylxanthines: aminophylline
 Combination: fluticasone/salmeterol
COPD
 refer to asthma medications
 oxygen refer to prior lecture notes
Pulmonary Embolism
 anticoagulant: low molecular weight sub-q heparin-enoxaparin, oralwarfarin- refer to prior lecture notes
Pleural Effusion
 treat underlying cause with appropriate meds, for example, HF, but
know what a thoracentesis is
Lung Cancer
 analgesics: narcotic PO or IV-refer to prior lecture notes such as
opioid
 chemo know purpose, side effects-not any specific med
 ABG-refer to prior lecture notes
Diagnostics & Equipment
 Peak Flow Meter- know what it measure and the color zones
 What is a spacer?
 COPD is classified by the Global Initiative for Chronic Obstructive Lung
Disease or “GOLD,” refer to chart on page 617, what level % of
FEV1/FVC is mild COPD?
 Chest xray- refer to prior lecture notes
NEURO:
1. Recognize
2. Recognize
3. Recognize
4. Recognize
epilepsy & management
TIA
CVA types & management
posturing
5. Recognize Neuro Disorders & Management: MG, Parkinson’s, MS,
Bell’s Palsy, Trigeminal Neuralgia, Post-Craniotomy Care, ICP,
Glasgow Coma Scale