NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Perioperative Care Concepts

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Common Postoperative Complications

Focus topic: Medical–Surgical Nursing

Postoperative Complications

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Postoperative Complications (continued)

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Postoperative Complications

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Postoperative Complications (continued)

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Medical–Surgical Nursing: Respiratory Complications

Focus topic: Medical–Surgical Nursing

Assessment
A. Evaluate complaint of tightness or fullness in chest.
B. Assess for cough, dyspnea, or shortness of breath.
C. Evaluate increased vital signs, particularly temperature and respiratory rate.
D. Observe for restlessness.
E. Assess for decreased breath sounds, crackles.

Implementation
A. Turn, cough, hyperventilate at least every 2 hours.
B. Have client use incentive spirometer to provide motivation and evaluation of sustained inspiration.

  • Inhale deeply and hold 3 seconds.
  • Repeat hourly.
  • Yawning also accomplishes same goal of stimulating surfactant and opening collapsed alveoli.

C. Provide pharmacological therapy (through nebulization or oral route).

  • Antibiotics—to fight infection by causative organism.
  • Bronchodilators—act on smooth muscle to reduce bronchial spasm.
    a. Sympathomimetics (beta2 agonists preferred).
    b. Anticholinergics (atropine sulfate inhalant).
    c. Theophyllines.
  • Adrenocorticosteroids—to reduce inflammation (Deltasone [prednisone]).
  • Enzymes—to liquefy thick, purulent secretions through digestion.
    a. Dornavac.
    b. Varidase (streptokinase).
  • Expectorants—to aid in expectoration of secretions.
    a. Mucolytic agents reduce viscosity of secretion (Mucomyst [acetylcysteine]).
    b. Detergents liquefy tenacious mucus (Tergemist, Alevaire).

D. Medicate for pain to facilitate TCH and use of mechanical devices.

Medical–Surgical Nursing: Pneumonia

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Atelectasis

Focus topic: Medical–Surgical Nursing

Definition: Collapse of pulmonary alveoli caused by mucus plug or inadequate ventilation.

Assessment
A. Assess for clinical manifestations that usually develop 24–48 hours postoperatively. (Most common cause of early postoperative temperature increase.)
B. Assess respiratory symptoms.

  • Observe for asymmetrical chest movement.
  • Auscultate lung sounds. Decreased or absent breath sounds over affected area; crackles; bronchial breathing over affected area.
  • Evaluate shortness of breath.
  • Assess for painful respirations; splinting of diaphragm.

C. Assess for increased vital signs: temperature (fever to 102°F [38.8°C]), respiration, pulse (tachycardia).
D. Observe for anxiety and restlessness.
E. ABGs: decreased PaO2.

Implementation
A. Administer O2 as ordered.
B. Encourage sustained inspiration exercises.
C. Instruct in proper cough technique (splint incision).
D. Turn frequently (every 2 hours) and position to facilitate expectoration.
E. Do clapping, percussion, vibration, if ordered.
F. Do postural drainage every 4 hours.
G. Administer expectorants and other medications, as ordered.
H. Suction as necessary.
I. Encourage oral fluid intake to reduce tenacious sputum and to facilitate expectoration.
J. Place client in cool room with mist mask or vaporized steam.
K. Mobilize client as soon as possible.
L. Medicate for pain to allow for respiratory ventilation.

Medical–Surgical Nursing: Deep Vein Thrombophlebitis

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Pulmonary Embolism

Focus topic: Medical–Surgical Nursing

Definition: The movement of a thrombus from site of origin to lung.

Assessment
A. Assess for mild condition (involves smaller arteries).

  • Signs mimic pleurisy or bronchial pneumonia.
  • Transient dyspnea.
  • Mild pleuritic pain.
  • Tachycardia.
  • Increased temperature.
  • Cough with hemoptysis.

B. Assess for severe condition (involves pulmonary artery).

  • Chest pain.
  • Severe dyspnea leading to air hunger.
  • Shallow, rapid breathing.
  • Sharp substernal chest pain.
  • Vertigo leading to syncope.
  • Hypovolemia.
  • Cardiac arrhythmias.
  • Generalized weakness.
  • Feelings of doom—severe anxiety.
  • Hypotension.

Implementation
A. Prevention.

  • Ambulate as soon as possible after surgery.
  • Range-of-motion exercises.
  • Pneumonic compression boots.

B. Maintain patent airway.

  • Place in semi- to high-Fowler’s position if vital signs allow.
  • Administer oxygen as needed (nasal cannula).
  • Assist with intubation as needed.
  • Auscultate breath sounds every 1–2 hours.
  • Obtain arterial blood gases to ascertain acid–base imbalance and/or pulse oximetry to monitor SaO2 level.
  • Turn as directed by physician; do not do percussion or clapping or administer back rubs.
  • Encourage client to cough and deep-breathe every 1–2 hours.

C. Administer medications as ordered.

  • Administer anticoagulants (check lab values each day before administering medication, following initial anticoagulation).
    a. Heparin: 5000–15,000 units IV bolus, then continuous infusion of 1000 units every hour to maintain therapeutic APTT.
    b. Long-term: Coumadin (warfarin sodium) 5–10 mg daily.
  • Give narcotics for pain (watch for respiratory depression).
  • Administer diuretics or cardiotonics, as necessary.
  • Thrombolytic therapy for acute right ventricular failure or refractory hypoxemia.
    a. Immediate dissolution of embolus, but danger of bleeding.
    b. Usual medications: urokinase, tissue plasminogen activator (t-PA), streptokinase.

D. Take vital signs every 2–4 hours.
E. Maintain bed rest; have client avoid sudden movements.
F. Observe for signs of shock.
G. Observe for possible extension of emboli or for occurrence of other emboli.

  • Check urine for hematuria or oliguria.
  • Check legs, especially calf.
  • Check sputum for blood.

H. Prepare for surgical intervention when client is not responsive to heparin therapy.

  • Surgical intervention carries high risk.
  • Types of surgery.
    a. Femoral vein ligation.
    b. Ligation of inferior vena cava.
    c. Pulmonary embolectomy.

Medical–Surgical Nursing: Fat Embolism Syndrome

Focus topic: Medical–Surgical Nursing

Definition: Release of medullary fat droplets into bloodstream following trauma.

Characteristics
A. Embolism occurs after long bone or sternum fractures (particularly from mishandling of client or incorrect splinting of fracture).

  • Fat droplets that are released from the marrow enter the venous circulation and usually become lodged in the lungs.
  • If the fat droplets become lodged in the brain, the embolism is severe and usually fatal.
  • Usually occurs within first 24 hours following injury.

B. Major cause of death from fractures.
C. Prevent by adequate splinting at accident scene and careful handling of fractured extremity.

Assessment
A. Assess for classical sign (occurs 50–60%): petechiae from fat globule deposits across chest, shoulders and axilla. Petechiae do not blanch, but fade out within hours. Can involve conjunctiva.
B. Evaluate related pulmonary signs: shortness of breath, leading to pallor, cyanosis, and hypoxemia.
C. Evaluate related brain involvement.

  • Restlessness (may be first symptom—occurs within 24 to 72 hours), memory loss, confusion.
  • Headache, hemiparesis.

D. Observe for related cardiac involvement.

  • Tachycardia.
  • Right ventricular failure.
  • Decreased cardiac output.

E. Assess for other signs and symptoms.

  • Diaphoresis.
  • Change in level of consciousness.
  • Shock.
  • Increased temperature (if involvement of hypothalamus).

F. Presence of unexplained fever, petechiae, and change in mental status; be alert for possibility of FES.

Implementation
A. Preventive measures important: immobilization of fracture with minimal manipulation.
B. Maintain oxygenation.

  • Position client in high-Fowler’s position to allow for respiratory exchange. Maintain bed rest.
  • Administer oxygen to decrease anoxia and to reduce surface tension of fat globules (incentive spirometer may be needed).

C. Obtain arterial blood gases to maintain sufficient PO2 levels.
D. Physician may intubate and place on respirator if respirations are severely compromised.
E. Institute preventive treatment to avoid further complications, such as shock and heart failure.
F. Monitor administration of medications.

  • Cortisone therapy to reduce inflammation.
  • Restoration of blood volume.

Medical–Surgical Nursing: Adult Respiratory Distress Syndrome

Focus topic: Medical–Surgical Nursing

Characteristics
A. A medical emergency that may have many causes.

  • Can be secondary to bacterial or viral pneumonia.
  • Massive trauma and hemorrhagic shock.
  • Fat emboli.
  • Sepsis.

B. Pathophysiology—damage to pulmonary capillary membrane that produces a leak, diffuse interstitial edema, and intra-alveolar hemorrhage.

  • Decrease in surfactant.
  • Intrapulmonary shunting with decreased oxygen saturation—hypoxia.
  • Decreased lung compliance.

C. Multiple organ system failure.

Assessment
A. Assess for clinical manifestations. Usually seen within first 24 hours following shock or injury.
B. Observe for extreme dyspnea, tachypnea, and cyanosis.
C. Assess for pulmonary edema.
D. Auscultate lungs for atelectasis (many small emboli throughout lungs).
E. Evaluate blood gas alterations.

  • PO2 decreased.
  • PCO2 normal or decreased due to tachypnea.
  • pH normal to slightly alkalotic.

Implementation
A. Prevent overhydration in severe trauma cases.
B. Provide early treatment of severe hypoxemia (can be life-threatening).
C. Keep clients “dry,” as they have excess fluids in their lungs. (Restrict fluid intake.)
D . Administer medications.

  • Corticosteroids to reduce inflammation and to prevent further capillary membrane deterioration.
  • Diuretics to decrease fluid overload.
  • Sedatives to prevent client from resisting respirator.
  • Heparin to reduce platelet aggregation.
  • Antibiotics guided by Gram stains of sputum.

E. Maintain adequate ventilation and oxygenation.

  • Provide intubation and mechanical ventilation with volume respirator.
  • Obtain frequent arterial blood gases.
  • Suction frequently with “bagging.” Ambu bag increases alveolar expansion.
  • Prone position improves oxygenation.

F. Provide tracheostomy care, if appropriate, every 4 hours.
G. Provide oral hygiene every 4 hours.
H. Prevent further complications, such as shock and septicemia.
I. Provide adequate nutrition.

Medical–Surgical NursingWound Infections

Focus topic: Medical–Surgical Nursing

Characteristics
A. Usual causative agents.

  • Staphylococcus.
  • Pseudomonas aeruginosa.
  • Proteus vulgaris.
  • Escherichia coli.

: B. Usually occur within 5–7 days of surgery.

Assessment
A. Observe for slowly increasing temperature (greater than 100.4°F [38.8°C]), tachycardia, chills, and malaise.
B. Evaluate pain and tenderness surrounding surgical site.
C. Observe for edema and erythema surrounding suture site.
D. Feel for increased warmth around suture site.
E. Observe for purulent drainage.

  • Yellow if Staphylococcus.
  • Green if Pseudomonas.

F. Elevated white blood count.

Implementation
A. Use meticulous hand hygiene and gloving techniques.
B. Take cultures before starting medication; administer specific antibiotics for causative agent.
C. Irrigate wound with solution as ordered (usually normal saline).

D. Keep dressing and skin area dry to prevent skin excoriation and spread of bacteria.
E. Observe standard precautions. Centers for
Disease Control and Prevention (CDC) is still recommending sterile technique in changing dressings (wet-to-moist).
F. If excoriation occurs, use karaya powder and drainage bags around area of wound.

Medical–Surgical Nursing

Medical–Surgical Nursing: Wound Dehiscence and Evisceration

Focus topic: Medical–Surgical Nursing

Definition: Dehiscence is the splitting open of wound edges. Evisceration is the extensive loss of pinkish fluid (purulent if infection is present) through a wound and the protrusion of a loop of bowel through an open wound. Client feels like “everything is pulling apart.”

Assessment
A. Observe for usual causes.

  • General debilitation.
    a. Poor nutrition.
    b. Chronic illness.
    c. Obesity.
  • Inadequate wound closure.
  • Wound infection.
  • Severe abdominal stretching (by coughing or vomiting).
  • Immunosuppression.

B. Evaluate wound daily. Condition occurs about seventh postoperative day.
C. Assess for sensation of “giving” at the incision, pain, and saturated dressing with clear, pink drainage.
D. Protrusion of viscera through wound edges (evisceration).

Implementation
A. Wound dehiscence.

  • Apply butterfly tapes to incision area.
  • Increase protein in diet.
  • Observe for signs of infection and treat accordingly.
  • Apply abdominal binder when ambulating.
  • Keep client on bed rest.

B. Evisceration.

  • Lay client in supine or low-Fowler’s position.
  • Cover protruding intestine with moist, sterile, normal saline packs; change packs frequently to keep moist.
  • Notify physician.
  • Take vital signs for baseline data and detection of shock.
  • Notify operating room for wound closure.
  • Provide patent IV.
  •  Keep client NPO; place NG tube if ordered.

Medical–Surgical Nursing: Disseminated Intravascular Coagulation

Focus topic: Medical–Surgical Nursing

Definition: Simultaneous activation of the thrombin (clotting) and fibrinolytic system.

Characteristics
A. Excessive intravascular thrombin is produced, which converts fibrinogen to fibrin clot.

  • After fibrinogen is depleted, circulating thrombin continues to be present and will continue to convert any form of fibrinogen to fibrin.
  • Fibrinogen enters system by transfusion or by body production of fibrinogen. This process intensifies the hemorrhagic state.

B. Disseminated intravascular coagulation (DIC) is associated with extracorporeal circulation seen in obstetric complications and disseminated cancer.
C. Major defect is widespread microvascular thrombosis.

Assessment
A. Observe for excessive bleeding (caused by depletion of clotting factors) through genitourinary tract, following injections, etc.
B. Evaluate lab results for low hemoglobin, low platelets.
C. Evaluate arterial blood gases for acidosis.
D. Observe for skin lesions, such as petechiae, purpura, subcutaneous hematomas.

Implementation
A. Treat cause of DIC symptomatically.

  • Antibiotics for infections.
  • Fluids and colloids for shock.
  • Steroids for endotoxins.
  • Dialysis for renal failure.

B. Administer heparin IV to stop cycle of thrombosis—hemorrhage. Usage is controversial because it often promotes bleeding; used in combination with fluid replacement therapy.

  • Neutralizes free circulating thrombin.
  • Inhibits blood clotting in vivo, due to effect on factor IX.
  • Prevents extension of thrombi.
  • Keep clotting time two to three times normal.
  • Give 10,000–20,000 units every 2–4 hours.

C. Give transfusion of platelets, cryoprecipitate, and fresh frozen plasma to replace clotting factors.

  • Monitor blood transfusion carefully.
  • Be alert for fluid overload—increasing CVP; slow, bounding pulse.

D. Administer oxygen as needed.
E. Take precautions to prevent additional hemorrhage.

  • Avoid chest tube “milking.”
  • Take temperature orally or axillary, not rectally.
  • Avoid administration of parenteral medications if possible.
  • Avoid trauma to mucous membranes.
  • If nasogastric tube inserted, prevent bleeding by administering antacids and keeping NG tube connected to low suction. Do not irrigate unless absolutely necessary.

Medical–Surgical Nursing: Fluid Replacement Therapy

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Fluid Replacement Solutions

Focus topic: Medical–Surgical Nursing

A. Types of IV solutions.

  • Hypertonic solution—a solution with higher osmotic pressure than blood serum.
    a. Cell placed in solution will crenate.
    b. Used in severe salt depletion, very rare.
    c. Used in intracranial pressure therapy—reduces edema by rapid movement of fluid out of ventricles into bloodstream.
    d. Used as a nutrient source (10% dextrose [D]).
    e. Common types of solution: normal saline (NS), dextrose 10% in saline, dextrose 10% in water, and dextrose 5% in saline.
    f. Should not be administered faster than 200 mL/hr.
  • Hypotonic solution—a solution with less osmotic pressure than blood serum.
    a. Causes cells to expand or increase in size.
    b. Used to correct diarrhea and dehydration.
    c. Common types of solution: dextrose 5% in half-strength (0.45%) NS; dextrose 5%; one-third strength (0.33%) NS; and dextrose 5% in water.
    d. Should not be administered faster than 400 mL/hr.
  • Isotonic solution—a solution with the same osmotic pressure as blood serum.
    a. Cells remain unchanged.
    b. Used for replacement or maintenance (expands extracellular volume); especially used to expand circulating intravascular volume.
    c. Common type of solution: lactated Ringer’s solution; 5% dextrose in NS, 5% D in water.

B. Choice of fluid replacement solution—depends on client’s needs.

  • Fluid and electrolyte replacement only.
    a. Saline solution.
    b. Lactated Ringer’s solution.
  • Calorie replacement—dextrose solutions.
  • Restriction of dietary intake, such as low sodium.
  • IV medications that are insoluble in certain IV fluids.
  • Rate of administration of IV solution to correct fluid imbalance.
  • Dextrose plays no part in tonicity. It is metabolized off.

C. Purpose of fluid and electrolyte therapy.

  • To replace previous losses.
  • To provide maintenance requirements.
  • To meet current losses.

Implementation
A. Check circulation of immobilized extremity.
B. Check label of solution against physician’s order.
C. Check rate of infusion.
D. Observe vein site for signs of swelling.
E. Take vital signs at least every 15 minutes for replacement fluid administration.

Intravenous Calorie Calculation

A. 1000 mL D5W provides 50 g of dextrose.
B. 50 g of dextrose provides 4 calories per gram (actually 3.4 calories).
C. 1000 mL D5W provides 200 calories.
D. Usual IV total/day is 2000–3000 mL (400–600 calories/day).

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